High Risk Pregnancy

What is a high-risk pregnancy and what makes a pregnancy high risk?

A majority of women will happily have uncomplicated pregnancies. However, between 10 – 15% of women will have pregnancies that will be considered “high risk”. The risk may be related to the woman herself or it can be related to the baby she carries.

In some cases this potential risk will be evident from before or early in pregnancy; if the woman has a medical problem separate to pregnancy (for example hypertension, diabetes, autoimmune disorders, thyroid disease, asthma, mental problems). Or she may have had a medical problem in a previous pregnancy, for example, preeclampsia or gestational diabetes. A woman with a high Body Mass Index (more than 30) is considered “high risk” as this is associated with an increased risk for other complications such as diabetes, hypertension, infection, thrombosis, preterm delivery and caesarean section for delivery. Multiple pregnancies are considered high-risk pregnancies. Women who have delivered prematurely in a previous pregnancy (prior to 34 weeks gestation) are considered high risk.

Problems can occur with the baby which make the pregnancy a high risk. For example, poor growth of the baby (called fetal growth restriction) either diagnosed during the current pregnancy or in a past pregnancy, if a developmental abnormality has been found in the baby on a scan or if the baby develops anaemia because of mismatched mother-baby blood groups (called “rhesus disease”).

Women with a history of infertility are often considered high risk, although this is not always correct. Many women who require infertility treatment to conceive, once pregnant, will have uncomplicated pregnancies which in part relates to the reason for their previous infertility.

It is easy to identify women as high risk if they had problems in a past pregnancy or have a separate medical problem but women who are otherwise well and having their first baby may also become high risk. This will only become apparent during their pregnancy. For this reason careful, experienced antenatal care is important for all women. No woman can be presumed to be at risk.

What age is high risk for pregnancy?

There is no absolute age at which a woman is designated to be “high risk”. In the past women were called (unedifyingly) “elderly primps” (meaning first mother) if they were older than 35 years old during pregnancy. These days a woman aged 35 are considered almost young to be having a baby! A woman who is fit will almost always have a less complicated pregnancy than a woman who is overweight or unfit, regardless of their age. That being said the risk of miscarriage does increase as a woman ages. Miscarriage is mostly due to chromosomal problems in the baby, which can happen to a woman of any age. However, this risk increases over time, so that while the risk for a woman of age 25 is about 1:1000, the risk for a woman of 45 is around 1:20. It is also generally accepted that the risk of developing hypertension and diabetes and possibly needing a caesarean section for delivery is greater in women who are older (more than 40 years old) than in younger women.

Management of high-risk pregnancy

How one can reduce the risk of pregnancy complications?

• Some simple measures will help reduce the risk in your pregnancy. Obvious things are stopping smoking (which is related to growth restriction, bleeding in pregnancy, premature birth, SIDS and childhood asthma in the children of mothers who smoke), not using illicit drugs (which can cause growth restriction, fetal abnormalities, bleeding in pregnancy and premature delivery) and stopping alcohol (which is associated with fetal developmental problems). Making sure you are up to date with your vaccines (rubella, chicken pox, whooping cough, influenza) and observing hygienic hand washing and food preparation will reduce the risk of infection in pregnancy. It is well recognised that of the biggest risk factors for pregnancy is being significantly overweight. A Body Mass Index (BMI) in the ‘obese’ range (more than 30) significantly increases a woman’s risk of hypertension, diabetes, premature delivery, problems in-labour and caesarean section for delivery, haemorrhage after delivery, infection, thrombosis and death. It also increases the risk of growth restriction in the baby. Anyone considering a pregnancy and thinks she might be significantly outside her healthy weight range should consult their GP and possibly a dietitian to help them work toward a healthier weight and to learn and maintain healthy eating habits during pregnancy.
• Other changes can be made, other than lifestyle changes, to modify a woman’s risk during pregnancy. For the most part, these will relate to the underlying cause of her risk. For example, if a woman has hypertension before pregnancy, ensuring she has good blood pressure control prior to pregnancy is important for reducing her chance of pre-eclampsia during pregnancy. It may also be necessary to change or add in medication as part of her care. Women with pre-existing medical problems or problems in a previous pregnancy will find a “pre-pregnancy consultation” with an obstetrician or maternal fetal medicine specialist helpful in making a well-considered plan for a safe pregnancy.

How will your Doctor care for you during high-risk pregnancy?

Changes to “routine’ antenatal care may be necessary if you have a pregnancy with additional risks. This may mean more medical checkups for you and your baby during pregnancy, or more scans or blood tests. Sometimes it is necessary to change or add in additional medication. For a few women it may mean planning to have their baby a bit earlier than their due date, and sometimes (although rarely) it may be prematurely early. A pregnancy that has additional risk doesn’t always need to be delivered by caesarean section, this varies with the associated problem and the timing of delivery. This requires individual assessment and discussion between you and your obstetrician.

Pre-pregnancy check-up or Pre-pregnancy counselling

Overview of “Pre-pregnancy check up”

If you are considering having a baby a pre-pregnancy consultation is valuable and informative preparation. If you have a pre-existing medical condition you can learn how it may affect your pregnancy and how your pregnancy may affect it. You may be pleasantly surprised to find that the risks in pregnancy may not be a serious as you imagined and sometimes there are few changes actually needed different from routine pregnancy care, which will be reassuring. Alternatively, the consultation may flag important risks that require close monitoring of you and your baby, and particular expertise. This will help clarify the caregiver who is best able to provide you with your pregnancy care. If you are taking any medications, their safety can be considered and you will then have a chance to change to different medication more suitable for pregnancy.

A problem you experienced in a previous pregnancy, or that a family member experienced, may cause you concern for a future pregnancy. If you had a complication during a previous birth or an unhappy birth experience, a pre-pregnancy check up is a chance to re-examine that birth and consider ways to improve upon this next time.

A review prior to falling pregnant gives you time to consider changes to your nutrition and weight, find out about testing offered in pregnancy, including genetic testing, discuss the supplements you should be on and when to start them and make sure your vaccines are up to date.

What to expect during a Pre-pregnancy check-up at EMOG

Dr Shelley Rowlands offers a comprehensive pre-pregnancy check up. The consultation covers areas such as:

• Previous and current medical/surgical problems
• Family medical history
• Previous pregnancies and gynaecological history
• Medications and other drug history
• General health, including nutrition and exercise, allergies
• Genetic family history and genetic tests relevant to your pregnancy
• General examination and ultrasound if needed
• Tests may be arranged including, screening for anaemia, vitamin deficiencies, thyroid function and diabetes testing, infection immunity status and ensuring vaccinations are up to date
• Pap smear

The consultation may identify areas of your health that require further assessment by other specialists. Finding the right specialist to see is often difficult and confusing. EMOG is unique to other obstetric practices as we have obstetric physicians who work with us on site in our rooms. We also have strong established relationships with infertility specialists, allied health specialists in nutrition and fitness, genetic counsellors and mental health counsellors that allow ease of further referral.

A pre-pregnancy consultation allows us to understand your particular concerns for a future pregnancy, to identify changes that can be made before pregnancy and to make a plan to ensure you and your baby are healthy and safe, and with which you feel comfortable. Any concerns you have about pregnancy will be addressed fully and sensitively. In addition to the medical discussion, a pre-pregnancy consultation gives you and your family a chance to meet Dr Rowlands and her team at EMOG. Our practice manager will be happy to explain the costs of care and the confusing aspects of health insurance, private or public care and choosing a hospital.