High Risk Pregnancies
A woman’s medical conditions prior to pregnancy may impact her health or her baby’s health. At times a condition arises during the pregnancy that requires added medical attention. When a woman who had complications with a prior pregnancy becomes pregnant again she may be considered high risk. High-risk pregnancies may require more frequent visits, additional testing and extra surveillance.
Our OB team of providers, prenatal care coordinators, nurses and other specialists meet regularly to discuss and develop a plan of care for our patients with individualized needs. We often utilize the skills and resources of the Division of Maternal-Fetal Medicine at Dartmouth Hitchcock Medical Center in Lebanon for consultations and referrals and work closely with the high-risk OB team there should the need arise.
If screening uncovers health conditions that may affect your pregnancy, our obstetricians will develop a plan of care specific for you and consult with the appropriate specialists.
If you feel your pregnancy may be high-risk or you’ve had a high-risk pregnancy is the past, call the Prenatal Care Coordinator for a preconception appointment at 354-6641. If you are already pregnant call for an appointment as soon as you know you are pregnant.
The following are some of the more common conditions affecting otherwise normal pregnancies:
Preeclampsia (sometimes called Toxemia) affects approximately 10 percent of pregnant women, most often in first pregnancies, pregnancies complicated by other medical illness such as hypertension, and in the extremes of maternal age (younger or older women). Its true cause is still undiscovered, its prevention unknown and its cure still the simple fact of delivery. Signs of preeclampsia, in the late second trimester, s elevated blood pressure, protein in the urine and accumulation of fluid in the body.
Depending upon the gestational age at which preeclampsia becomes evident, its severity, and its effects on the mother or baby, management can range from careful waiting and close monitoring (blood tests, fetal monitoring and ultrasound) to induction of labor to achieve vaginal delivery. In rare cases, immediate delivery by cesarean is indicated. While the actual “cure” for preeclampsia is delivery, treatments are sometimes given to prevent further complications.
During pregnancy, placental hormones act on a mother’s system to provide the fetus needed fats, proteins and sugars. In some women the sugar levels resulting from the effects of pregnancy can be significantly higher. We test for gestational diabetes in pregnancy with the 1-hour glucose tolerance test at 28 weeks. If you have an increased BMI (body metabolism index) or had a previous pregnancy with gestational diabetes, you will be tested at 18 and 28 weeks. A mother with elevated levels of glucose is given the diagnosis of gestational diabetes. This does not necessarily mean that she has diabetes; simply that the pregnancy is pushing her to have higher levels of sugar in her blood. This can lead to the fetus getting too much sugar from the mother and growing too large.
Treatment for gestational diabetes most often involves following a slightly different diet. Occasionally, to bring down the levels of sugar in the blood, insulin is required. In either situation, closer monitoring of the pregnancy is indicated and sometimes earlier delivery is urged.
Women who have diabetes prior to a pregnancy require earlier and more extensive evaluations and commonly obtain care from a number of different physicians including diabetes specialists, nutritionists, and maternal-fetal specialists. Testing is often extensive, and the management of the pregnancy is often dependent upon the severity of the diabetes.
For more information on diabetes and pregnancy go the American Diabetes Association web site www.diabetes.org.
For most women, the placenta functions normally, providing nutrition, fluid and oxygen to the fetus until delivery, when it separates shortly following the delivery of the baby. Occasionally, however, a placenta develops too low thereby covering the opening to the cervix, called placenta previa. Sometimes a placenta partially separates too early, called an abruption. Sometimes a placenta fails to provide adequate nutrition, adequate fluid or adequate oxygen, called placental insufficiency.
At 18 weeks an ultrasound scan is done to determine your placental location and health. In any situation involving the placenta, the fetus is close monitored.
For more information on placental conditions,go to the March of Dimes web site, www.marchofdimes.com, and search for placental conditions.
Intrauterine Growth Restriction (IUGR)
For every gestational age, there is a range of size or weight from the smallest to the largest. A fetus that is measured (by ultrasound) to be somewhere within the midrange and continues its growth throughout pregnancy is reassuring. A fetus who does not appear to be growing well (less than 10 percent) or who falls off the growth curve deserves close observation. While any individual ultrasound measurement or estimate of fetal weight has a margin of error, serial ultrasounds can provide a more accurate diagnosis of IUGR and provide evidence for the presence or absence of fetal growth over time. Sometimes, more specific fetal and placental monitoring is performed and tests for possible causes of poor fetal growth are conducted. Occasionally, treatment for poor fetal growth is initiated. Infrequently, delivery (even preterm delivery) is recommended if there are concerns regarding the safety of continuing the pregnancy.
Some women have had previous pregnancies complicated by preterm labor and perhaps delivery. Other women may develop symptoms of preterm labor for the first time. Early identification will help in the treatment of stopping the labor from progressing.
Advancements in neonatal medicine have improved the care of younger and younger babies to the point that the gestational age of “viability” hovers around 24 weeks gestation. But delivery at this point can result in complications that can make a baby’s survival difficult. With each additional week of gestation, survival increases and the difficulty of that survival decreases, which warrants aggressive efforts to delay delivery.
Treatments to stop preterm labor can include medications that stop contractions. Some treatments are given orally, some by injection and some by intravenous infusion. Bed rest may be recommended for some women at risk for preterm delivery. In some circumstances, a fetal lung-maturing medication is given to hasten fetal lung maturation prior to delivery.
At 34 to 35 weeks, the significant risks of premature delivery diminish and only modest efforts to forestall delivery are employed. Those efforts are proportional to the degree of prematurity risk facing the newborn based upon the gestational age.
For signs and symptoms of preterm labor and treatment go to the March of Dimes web site www.marchofdimes.com.
If you have a seizure disorder and want to become pregnant it is best to see your neurologist prior to becoming pregnant. This gives you an opportunity to check on your seizure medications and their safety in pregnancy as well as get started on additional folic acid recommended for women with seizure disorders. If you are pregnant already, call us for an appointment as soon as you know. We will have you see your neurologist and review your medications.