High-Risk Pregnancy: Risk Factors, Conditions & Treatments (podcast)

Dr. Daneshmand: A high-risk pregnancy is a pregnancy where there are more risk factors than usual that predispose the mom and the baby to complications.

These may be extremes, such as age, increased body mass index, pre-existing conditions, such as high blood pressure or chronic hypertension. Endocrine disorders can also be a factor, such as thyroid abnormalities, or someone who may be low on their thyroid or elevated in their thyroid activity.

Diabetes diagnosed during pregnancy is known as gestational diabetes. Diabetes could happen because a patient may have an increased body mass index, a patient can have genetic risk factors. Patients who are 35 and older have a high risk of having diabetes. Patients who are having twins or triplets, have an increased risk....

Gestational diabetes in pregnancy is more of an insulin-resistant state. When you’re entering your third trimester in the 24 to 28 week period, we screen patients for gestational diabetes because your body becomes more insulin-resistant. The cells need sugar, and when the cells become more resistant, sugar is not getting into the cells, so your blood contains more sugar, and that carries complications for both mom and baby.

The Scripps Whittier Diabetes Institute offers outpatient and inpatient diabetes services. Any patient who has diabetes can receive management and counseling services. They also have behavioral health. If a patient is struggling with their diabetes, and they need help managing anxiety, they offer services for that.

Dr. Daneshmand: If the patient has hypertension, there are multiple risks that can affect both mom and baby.

With mom, she is at an increased risk of developing preeclampsia, which is a condition in pregnancy where blood pressures are elevated. Patients with hypertension can also develop fetal growth restriction, which happens when the baby is not growing. They could also have the placenta separated from the uterine wall if their pressures are too high, a condition called placental abruption.

Moms could also have strokes and heart attacks. When a patient is seen initially, we review the patient’s history and their risk factors. If they have hypertension, we manage the patient accordingly based on those risk factors.

Dr. Daneshmand: Not necessarily, but you certainly have a higher risk. A patient who’s had a history of a preterm delivery, that’s the biggest risk factor for having subsequent preterm deliveries.

If a patient has had that history, say someone went into spontaneous labor at 32 or 33 weeks, that patient is going to be managed differently than someone who went full-term.

Fernandes: There can be a genetic component to developing things like diabetes and high blood pressure. A lot of times, the gestational diabetes that develops during pregnancy is more a product of the pregnancy environment, but there’s always genetics at play. Someone who has a family history of those conditions may be at a higher risk if they have a lot of the environmental factors that impact the risk as well.

Dr. Daneshmand: Preconception counseling can be very important when it comes to knowing whether you have a high-risk pregnancy.

If a patient is planning on getting pregnant, it’s imperative that they speak to their health care provider because they will review their family history. If a patient has a mom who delivered her or her sibling and had preeclampsia, she is at risk for developing preeclampsia, which is an elevation in her blood pressure.

They will review environmental toxin exposures, including whether the patient smokes or is on any medications, such as anti-epileptic medications or seizure medications that may predispose the fetus to complications, such as structural abnormalities like spina bifida, openings in the baby’s spine and heart defects.

There are certain medications for depression that impose an increased risk for the baby. It’s really important for patients who are planning on conceiving to speak to their health care provider and just to go over everything. That way, at least, they can meet with the appropriate people and have it planned as much as possible.

Dr. Daneshmand: It depends on the condition. If a patient has elevated blood pressures, we tend to run some basic labs, like your cell blood count. We want to make sure that your platelet counts are normal. We check your chemistry panel, which includes your sodium, potassium, your renal function, which is a serum creatinine. We do a 24-hour urine collection. We assess the protein, because patients that develop preeclampsia may have protein that they spill in their urine, which is typically not done in a non-pregnant patient.

Patients get an ultrasound usually with their physician, and then they may come see us for an ultrasound called a nuchal translucency screening, which is looking behind the baby’s neck, between the skin and the soft tissue. They also get their anatomy scan between 18 to 20 weeks.

If a mom has diabetes or has a baby with a congenital heart defect, or she herself has had heart disease or heart defect, then they get a fetal echocardiogram, which is looking at the heart in detail with ultrasound. They get serial growth scans just to make sure that the baby is growing appropriately, the fluid levels are fine. Once they reach about 33, 34 weeks, that’s when we start more intense monitoring, because that’s when babies really start putting on the weight, and we want to make sure babies are doing well.

Dr. Daneshmand: A perinatalogist is a consultant to obstetricians, midwives and family practitioners. We are viewed as fetal imaging doctors. We are radiologists for the baby when mom is pregnant, and also serve as consultants and as internal medicine physicians for pregnancy. We basically assist our obstetricians, our midwives, family practitioners with any questions they may have. If there are any issues with mom that predispose the baby or mom to complications, that’s when we get involved.

You could go see a perinatologist first if you think you have a high-risk pregnancy, but you can also go to your regular OB-GYN. It is very much a team approach which includes your obstetrician, your family practitioner, your internal medicine, your internal fetal medicine specialist, nurses, midwives, nutritionists, genetic counselors and sonographers. We all work very closely together and communicate very well with one another.

Fernandes: A genetic counselor is someone who has advanced training in genetics and training in counseling and decision-making techniques. We screen for a few conditions pretty commonly, and routinely across the board.

Anyone who is pregnant, particularly women over 35, are offered screening for different chromosome conditions, such as Down syndrome and a condition called trisomy 18. Typically we have 46 chromosomes, and these chromosomes are like the instructions that tell our body how to grow and develop. People with a chromosome condition have 47 rather than 46. Down syndrome is an extra copy of the chromosome pair number 21, and then trisomy 18 is an extra copy of 18.

Another common test we screen for during pregnancy, but also before pregnancy, is something called carrier screening. Some people can be a carrier of a genetic disease, and that just means that they are healthy themselves, but they have the potential to have a child with that condition, such as cystic fibrosis, which is a genetic lung disease. Another test that is frequently recommended is for a condition called spinal muscular atrophy, which is a muscle disease.

There are conditions where both parents would need to be carriers before we would worry about them having a child with the condition. There are other genetic diseases that can run in the family that only one parent needs to be a carrier for before they have the chance to have a child with it. People who find that they are at risk to have a child with these genetic conditions because one or both of them are carriers have options that we discuss with them. Some people choose to go through IVF, which is in-vitro fertilization, where they take the egg and sperm outside the body and create an embryo in a lab. We can test some cells from that embryo to see if that embryo would be affected with that genetic condition. Some couples may go through this process and choose to only transfer embryos that are unaffected. It is a very time-consuming and expensive process. But it is one option. Other people might choose to use a donor, a genetic donor who is not a carrier. Other people might choose adoption.

Fernandes: Amniocentesis is a test where ultrasound guidance is used to monitor the baby. The physician inserts a needle through the abdomen, and collect some of the fluid that is around the baby. In that fluid is the baby’s skin cells. They take those skin cells in the lab, and culture them, which lets them grow. We get a large sample of cells and we can test for different things we’re concerned about. We can look at the chromosomes to make sure there aren’t extra. We can test for genetic diseases that parents might be carriers for or that might be running in the family.

Dr. Daneshmand: When a patient has diabetes, there are certain labs that are drawn. One is called a hemoglobin A1C, which assesses the patient’s glycemic control over the past several months. If that is elevated, the patient may be admitted to the hospital for diabetes care.This patient may require medications orally to bring down their blood sugars, or they may require insulin.

Some of these patients have prediabetes, or are maybe on an insulin pump. We manage these patients with help from the Scripps Whittier Diabetes Institute team, with the endocrinologists and the diabetes educators and the nutritionists. This patient will require frequent ultrasounds throughout the pregnancy because babies that are exposed to moms with diabetes could also be growth-restricted or could also be very big.This carries a risk to the pregnancy. These patients are just followed very closely.

In the third trimester, we do a non-stress test, which is listening to the baby’s heartbeat twice a week. That has a very good negative predictive value, which means that when you see accelerations in the baby’s heart rate during the monitoring that tells you the baby is happy because movements increase heart rates.

Dr. Daneshmand: We follow patients with high blood pressure very closely. We do some baseline labs. We ask the patients to check their blood pressure routinely themselves as well.

For us, it’s very intensive monitoring, frequent visits to the office, checking if the patients' blood pressure is elevated and placing them on anti-hypertensive medications or high blood pressure medications.

Dr. Daneshmand: Lupus, or systemic lupus erythematosus or rheumatoid arthritis are examples of autoimmune disorders. Sjogren's disease is another one.

For a patient with lupus, it depends on which organs are affected. If a patient has lupus that affects her kidneys, then that predisposes the patient to an increased risk for preeclampsia or toxemia in pregnancy. It puts the baby at an increased risk for growth restriction and increases the risk for premature labor and delivery. These patients, get baseline labs and are followed very closely with frequent ultrasound, consultations with the perinatologist and with routine visits with their obstetrician.

Dr. Daneshmand: Women pregnant with twins have an increased risk for developing preeclampsia, gestational diabetes and premature births. Twins, on average, deliver at around 36 weeks, but they can deliver earlier. There is also an increased risk for anemia because a lot of iron is used to increase the mom’s red blood cell mass.

The main thing with twins during pregnancy is the number of placentations, or how many placentas the babies have. The placenta is the connection between mom and baby. It’s where everything happens. Without a healthy placenta, we don’t have healthy pregnancies.

The number of placentations is very important as far as how you manage a patient with multiples. If a patient has one placenta with twins, then that increases the risk for something called twin-to-twin transfusion syndrome, which is one baby giving a lot more blood to the other than is receiving back. That carries an increased risk for the pregnancy.

Fernandes: Once we find out that the baby has a genetic disease, we have very sensitive conversations with the couple. Not every couple will make the same choice when faced with these sorts of situations, but we strive to create a space where people can talk through their options and feel safe and supported in whatever they decide to do.

Some people use this time to decide what they want to do going forward with the pregnancy. Other people use the time to start to build their support networks, learn more about what their life will be like going forward, or what their life will look like going forward. We help guide them down the path, help them choose which path is right for their family, and get them started on whichever direction they need to go.

Dr. Daneshmand: The best thing to do prepare for a pregnancy is preconception counseling. Meet with your provider, go through your history, your family history and be prepared.

Be as informed as possible before you get pregnant. There are certain things in the first trimester that you can avoid that can have long-lasting effects on your pregnancy, such as alcohol and smoking.

Taking folic acid at least a month prior to conceiving is beneficial for reducing the risk of spina bifida, or any openings in the baby’s spine. That’s probably the time when we can have the most amount of impact on our moms and our babies.

Fernandes: From a genetic standpoint, the carrier screening will help to see if a parent is carrier for a genetic disease and can be performed before a pregnancy. It’s really the ideal time to find out about these sorts of things. That’s something that people can discuss with their primary care physicians or their obstetricians. If they have very detailed questions about it or a family history of a genetic disease, they can come and see a genetic counselor to discuss it as well....

When a woman becomes pregnant, she is going to be offered a lot of different testing options. It can get very overwhelming and confusing. When needed, Scripps prenatal genetic counselors are here to act as interpreters for people, to get through all of that complex medical data.