High-risk pregnancy

High-risk pregnancy
Ultrasound during Pregnancy
Ultrasound during pregnancy
SpecialtyObstetrics, midwifery
Risk factorsHigh blood pressure, diabetes, heart disease, renal disease, autoimmune disease, fetal growth restriction, multiple gestations, congenital fetal abnormalities
Diagnostic methodBased on symptoms, imaging, screening

A high-risk pregnancy is one where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies, however there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes.[1] These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.[2]

In 2012, the CDC estimated that there were approximately 65,000 pregnancies deemed "high-risk" in the United States.[3]

Causes

Pregnancies could be considered high risk if the mother has certain pre-existing health conditions. These include:

  • Age
    • Older age - Pregnancies in women over the age of 35 are considered "advanced age". First-time pregnant women in this age group may have normal pregnancies, but research indicates that these women are at increased risk of having: first trimester miscarriage, chromosomal abnormalities in the fetus, and fetal growth restriction (FGR).[4] Advanced age is associated with a higher risk for fetal chromosomal abnormalities such as Down Syndrome (Trisomy 21) and Trisomy 13.[4] Some of these chromosomal abnormalities are further associated with an increased risk of miscarriage in the first trimester.[5] It is not yet well-understood how older age leads to increased risk of FGR, but studies have suggested that it could be related to placenta dysfunction.[4][6]
    • Younger age - Pregnant teenagers are more likely to develop anemia, have preterm births, and have low birth weight babies.[7]
  • Chronic high blood pressure - The CDC estimates the rate of chronic hypertension in the US as 166.9 per 100,000 hospital deliveries.[8] Hypertension is considered a risk factor for high-risk pregnancy because it leads to an increased risk of pre-eclampsia, restricted fetal growth, and preterm birth.[9][10] It is not yet well-understood how hypertension leads to increased risk of these outcomes. However, it is thought that hypertension leads to decreased blood flow to the placenta.[10] Decreased blood flow to the fetus could lead to restricted growth and trigger other changes that increase the risk of pre-eclampsia, restricted fetal growth, and pre-term birth.[11]
  • Pre-existing diabetes - Pre-existing diabetes that is not managed during pregnancy is associated with increased risk of spontaneous abortions in the first few weeks of pregnancy and increased risk of congenital malformations such as congenital heart defects and neural tube defects.[12][13] The mechanism through which hyperglycemia results in these malformations is still an area being studied, but increased oxidative stress resulting from hyperglycemia is a potential contributor. Pre-existing diabetes is also associated with an increased risk of high birth weight or macrosomia and preterm birth. Macrosomia can put the fetus at risk of brachial plexus injury due to shoulder dystocia during vaginal delivery.[12][13]
  • Cardiac/heart disease - During pregnancy, there is an increase in the volume of circulating blood.[14] In women with cardiac disease, this increased blood volume can worsen/exacerbate existing heart disease.[15]
  • Autoimmune disease

In some pregnancies, certain conditions that arise in the developing fetus or fetuses can put a pregnancy into a high risk category. In these situations, special care must be taken during the pregnancy to address these factors while the fetus is still in the womb to reduce the chances of morbidity and mortality. Common fetal related factors that can create a high risk pregnancy include:

Other reasons a pregnancy may be classified as high-risk include if the mother develops a medical condition during pregnancy or if complications occur during pregnancy.

  • Conditions developed during pregnancy:
    • Preeclampsia: Preeclampsia is a syndrome marked by a sudden increase in the blood pressure of a pregnant woman after the 20th week of pregnancy. It can affect the mother's kidneys, liver, and brain. When left untreated, the condition can be fatal for the mother and/or the fetus and result in long-term health problems.[16]
    • Eclampsia: Eclampsia is a more severe form of preeclampsia, marked by seizures and coma in the mother.[6][17]
    • HELLP Syndrome[18]
    • Gestational diabetes: Gestational diabetes (GDM) is diabetes that first develops when a woman is pregnant. Many women can have healthy pregnancies if they manage their diabetes, following a diet and treatment plan from their health care provider. Uncontrolled gestational diabetes increases the risk for adverse perinatal outcomes such as preterm labor and delivery, preeclampsia, and other hypertension-related conditions in pregnancy. Additionally, some evidence suggests that GDM is associated with long-term outcomes such as development of type 2 diabetes in the mother and future obesity in the infant.[19][20][21]
  • Timing of pregnancy:
  • Placenta - The placenta is a structure within the uterus that facilitates exchange of nutrients, oxygen, and waste products between the mother and the fetus. When this connection between mother and fetus is abnormally positioned, the pregnancy is more complicated and requires careful delivery technique.
  • Infections - Different types of infections may be spread from mother to fetus, predisposing adverse pregnancy outcomes. An existing infection in the mother may be passed along to the fetus during pregnancy through the placenta. A newborn infant is also directly exposed to pathogens during delivery through the vaginal canal or breastfeeding. Fetal infections that develop during pregnancy may trigger spontaneous abortion or affect typical fetal growth and development.[31] Several infections that are notably associated with pregnancy include Group B streptococcus,[32] Bacterial vaginosis,[33] yeast infections,[34] and Zika virus.[35] Some of these infections may be rare but are associated with significant infant morbidity and mortality, particularly if the infection spreads throughout the fetal nervous system. Early evidence shows that COVID-19 maternal infection in pregnancy may increase adverse outcomes such as preeclampsia.[36][37]
  • Twin-to-twin transfusion syndrome[38]

Management

Management of high risk pregnancy is dependent on the specific etiology and situation of each particular pregnancy. Some examples of management for certain conditions include:

  • Diabetes: To manage diabetes, self-monitoring using finger stick blood glucose monitoring is recommended.[39] Medical nutritional therapy and insulin therapy, as well as anti-hyperglycemic oral medications are also recommended.[39]
  • Chronic hypertension: Anti-hypertensive agents that are safe to use during pregnancy should be used to manage hypertension during pregnancy.[40] ACOG also recommends low dose aspirin in pregnant women who have chronic hypertension and other pre-eclampsia risk factors.[41]
  • Congenital defects: The management of congenital defects in the fetus depends on the specific condition. For example, certain cardiac anomalies must be corrected to avoid irreversible damage during the gestational period, such as using fetal cardiac catheterization to correct pulmonary atresia with intact ventricular septum.[42] Spina Bifida is another common condition that can be repaired before birth.[43] Other anomalies, such as hypoplastic left heart syndrome, can be monitored throughout the pregnancy and treated with surgery soon after birth.[44]
  • Multiple gestations: Although conditions that are more common in multiple gestations, such as preterm birth, should be monitored properly during the pregnancy, there is currently limited evidence to evaluate the ability of specialized antenatal care on improving outcomes for the parent or infant.[45]
  • Infections: Early and regular prenatal care is important. A provider should be consulted about options including prevention via medication prophylaxis or vaccines,[46] and treatment such as appropriate use of antibiotics (ex. for congenital syphilis) or antifungals. Another option for prevention of transmission includes delivery via Caesarian delivery.[47][48][49]

Anxiety surrounding "high-risk pregnancy" label

The concept of a high risk pregnancy has been shown to elicit a strong emotional response in some pregnant women, including fear, anger, and guilt.[50] In addition, some studies show that a pregnancy labeled "high risk" may lead to more unnecessary testing than without the label, increasing these fears and reducing the pregnant woman's sense of control over the situation.[51] Managing anxiety in pregnancies deemed high risk has been deemed an important focus in research, although there is currently limited high quality studies on the issue.[52]

References

  1. ↑ Alfirevic, Zarko; Stampalija, Tamara; Gyte, Gillian M. L. (2013-11-12). "Fetal and umbilical Doppler ultrasound in high-risk pregnancies". The Cochrane Database of Systematic Reviews (11): CD007529. doi:10.1002/14651858.CD007529.pub3. ISSN 1469-493X. PMC 6464948. PMID 24222334.
  2. ↑ "High-Risk Pregnancy: Overview". www.nichd.nih.gov. Retrieved 2017-11-07.Public Domain This article incorporates text from this source, which is in the public domain.
  3. ↑ Holness N (June 2018). "High-Risk Pregnancy". The Nursing Clinics of North America. 53 (2): 241–251. doi:10.1016/j.cnur.2018.01.010. PMID 29779516.
  4. 1 2 3 Frick AP (January 2021). "Advanced maternal age and adverse pregnancy outcomes". Best Practice & Research. Clinical Obstetrics & Gynaecology. 70: 92–100. doi:10.1016/j.bpobgyn.2020.07.005. PMID 32741623. S2CID 220942573.
  5. ↑ Frick AP (January 2021). "Advanced maternal age and adverse pregnancy outcomes". Best Practice & Research. Clinical Obstetrics & Gynaecology. 70: 92–100. doi:10.1016/j.bpobgyn.2020.07.005. PMID 32741623. S2CID 220942573.
  6. 1 2 "What are the factors that put a pregnancy at risk?". www.nichd.nih.gov. Retrieved 2017-11-08.Public Domain This article incorporates text from this source, which is in the public domain.
  7. ↑ Jeha D, Usta I, Ghulmiyyah L, Nassar A (March 2015). "A review of the risks and consequences of adolescent pregnancy". Journal of Neonatal-Perinatal Medicine. 8 (1): 1–8. doi:10.3233/NPM-15814038. PMID 25766198.
  8. ↑ "Data on Pregnancy Complications | Pregnancy | Maternal and Infant Health | CDC". www.cdc.gov. 2019-02-28. Retrieved 2021-09-13.
  9. ↑ Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC (April 2014). "Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis". BMJ. 348 (apr15 7): g2301. doi:10.1136/bmj.g2301. PMC 3988319. PMID 24735917.
  10. 1 2 Braunthal S, Brateanu A (2019). "Hypertension in pregnancy: Pathophysiology and treatment". SAGE Open Medicine. 7: 2050312119843700. doi:10.1177/2050312119843700. PMC 6458675. PMID 31007914.
  11. ↑ Braunthal S, Brateanu A (January 2019). "Hypertension in pregnancy: Pathophysiology and treatment". SAGE Open Medicine. 7: 2050312119843700. doi:10.1177/2050312119843700. PMC 6458675. PMID 31007914.
  12. 1 2 Loeken MR (September 2020). "Mechanisms of Congenital Malformations in Pregnancies with Pre-existing Diabetes". Current Diabetes Reports. 20 (10): 54. doi:10.1007/s11892-020-01338-4. PMC 7803009. PMID 32918152.
  13. 1 2 Kitzmiller JL, Buchanan TA, Kjos S, Combs CA, Ratner RE (May 1996). "Pre-conception care of diabetes, congenital malformations, and spontaneous abortions". Diabetes Care. 19 (5): 514–41. doi:10.2337/diacare.19.5.514. PMID 8732721. S2CID 11516620.
  14. ↑ Sanghavi M, Rutherford JD (September 2014). "Cardiovascular physiology of pregnancy". Circulation. 130 (12): 1003–8. doi:10.1161/CIRCULATIONAHA.114.009029. PMID 25223771.
  15. ↑ Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJ, et al. (June 2007). "Outcome of pregnancy in women with congenital heart disease: a literature review". Journal of the American College of Cardiology. 49 (24): 2303–11. doi:10.1016/j.jacc.2007.03.027. PMID 17572244.
  16. ↑ Backes, Carl H.; Markham, Kara; Moorehead, Pamela; Cordero, Leandro; Nankervis, Craig A.; Giannone, Peter J. (2011). "Maternal Preeclampsia and Neonatal Outcomes". Journal of Pregnancy. 2011: 214365. doi:10.1155/2011/214365. ISSN 2090-2727. PMC 3087144. PMID 21547086.
  17. ↑ Fishel Bartal, Michal; Sibai, Baha M. (2020-09-24). "Eclampsia in the 21st century". American Journal of Obstetrics and Gynecology. doi:10.1016/j.ajog.2020.09.037. ISSN 1097-6868. PMID 32980358.
  18. ↑ Kongwattanakul, Kiattisak; Saksiriwuttho, Piyamas; Chaiyarach, Sukanya; Thepsuthammarat, Kaewjai (2018-07-17). "Incidence, characteristics, maternal complications, and perinatal outcomes associated with preeclampsia with severe features and HELLP syndrome". International Journal of Women's Health. 10: 371–377. doi:10.2147/IJWH.S168569. ISSN 1179-1411. PMC 6054275. PMID 30046254.
  19. ↑ Alfadhli, Eman M. (1 Jan 2015). "Gestational diabetes mellitus". Saudi Medical Journal. 36 (4): 399–406. doi:10.15537/smj.2015.4.10307. ISSN 0379-5284. PMC 4404472. PMID 25828275.
  20. ↑ McIntyre, H. David; Catalano, Patrick; Zhang, Cuilin; Desoye, Gernot; Mathiesen, Elisabeth R.; Damm, Peter (2019-07-11). "Gestational diabetes mellitus". Nature Reviews. Disease Primers. 5 (1): 47. doi:10.1038/s41572-019-0098-8. ISSN 2056-676X. PMID 31296866. S2CID 195893390.
  21. ↑ Szmuilowicz, Emily D.; Josefson, Jami L.; Metzger, Boyd E. (2019-09-01). "Gestational Diabetes Mellitus". Endocrinology and Metabolism Clinics of North America. 48 (3): 479–493. doi:10.1016/j.ecl.2019.05.001. ISSN 1558-4410. PMC 7008467. PMID 31345518.
  22. ↑ Platt, M. J. (2014-05-10). "Outcomes in preterm infants". Public Health. 128 (5): 399–403. doi:10.1016/j.puhe.2014.03.010. ISSN 1476-5616. PMID 24794180.
  23. ↑ Frey, Heather A.; Klebanoff, Mark A. (2016-01-11). "The epidemiology, etiology, and costs of preterm birth". Seminars in Fetal and Neonatal Medicine. 21 (2): 68–73. doi:10.1016/j.siny.2015.12.011. PMID 26794420.
  24. ↑ Tchirikov, Michael; Schlabritz-Loutsevitch, Natalia; Maher, James; Buchmann, Jörg; Naberezhnev, Yuri; Winarno, Andreas S.; Seliger, Gregor (2018-07-26). "Mid-trimester preterm premature rupture of membranes (PPROM): etiology, diagnosis, classification, international recommendations of treatment options and outcome". Journal of Perinatal Medicine. 46 (5): 465–488. doi:10.1515/jpm-2017-0027. ISSN 1619-3997. PMID 28710882. S2CID 8674143.
  25. ↑ Sim, Winnie Huiyan; Araujo Júnior, Edward; Da Silva Costa, Fabricio; Sheehan, Penelope Marie (2017-01-01). "Maternal and neonatal outcomes following expectant management of preterm prelabour rupture of membranes before viability". Journal of Perinatal Medicine. 45 (1): 29–44. doi:10.1515/jpm-2016-0183. ISSN 1619-3997. PMID 27780154. S2CID 19665179.
  26. ↑ Boettcher, Lillian B.; Clark, Erin A. S. (2020-10-07). "Neonatal and Childhood Outcomes Following Preterm Premature Rupture of Membranes". Obstetrics and Gynecology Clinics of North America. 47 (4): 671–680. doi:10.1016/j.ogc.2020.09.001. ISSN 1558-0474. PMID 33121652. S2CID 225144816.
  27. ↑ "Management of Late-Term and Postterm Pregnancies". www.acog.org. Retrieved 2021-09-20.
  28. ↑ Downes KL, Grantz KL, Shenassa ED (August 2017). "Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review". American Journal of Perinatology. 34 (10): 935–957. doi:10.1055/s-0037-1599149. PMC 5683164. PMID 28329897.
  29. ↑ Jauniaux E, Bunce C, Grønbeck L, Langhoff-Roos J (September 2019). "Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis" (PDF). American Journal of Obstetrics and Gynecology. 221 (3): 208–218. doi:10.1016/j.ajog.2019.01.233. PMID 30716286. S2CID 73415025.
  30. ↑ Downes KL, Grantz KL, Shenassa ED (August 2017). "Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review". American Journal of Perinatology. 34 (10): 935–957. doi:10.1055/s-0037-1599149. PMC 5683164. PMID 28329897.
  31. ↑ Giakoumelou S, Wheelhouse N, Cuschieri K, Entrican G, Howie SE, Horne AW (2016-01-01). "The role of infection in miscarriage". Human Reproduction Update. 22 (1): 116–33. doi:10.1093/humupd/dmv041. PMC 4664130. PMID 26386469.
  32. ↑ "Group B streptococcus", Infections Affecting Pregnancy and Childbirth, CRC Press, pp. 156–169, 2015-01-15, doi:10.1201/b20750-9, ISBN 9780429091902, retrieved 2021-09-19
  33. ↑ Reiter S, Kellogg Spadt S (January 2019). "Bacterial vaginosis: a primer for clinicians". Postgraduate Medicine. 131 (1): 8–18. doi:10.1080/00325481.2019.1546534. PMID 30424704. S2CID 53302848.
  34. ↑ Schuster HJ, de Jonghe BA, Limpens J, Budding AE, Painter RC (August 2020). "Asymptomatic vaginal Candida colonization and adverse pregnancy outcomes including preterm birth: a systematic review and meta-analysis". American Journal of Obstetrics & Gynecology MFM. 2 (3): 100163. doi:10.1016/j.ajogmf.2020.100163. PMID 33345884. S2CID 225655391.
  35. ↑ Britt WJ (April 2018). "Adverse outcomes of pregnancy-associated Zika virus infection". Seminars in Perinatology. 42 (3): 155–167. doi:10.1053/j.semperi.2018.02.003. PMC 7442220. PMID 29523447.
  36. ↑ Narang K, Enninga EA, Gunaratne MD, Ibirogba ER, Trad AT, Elrefaei A, et al. (August 2020). "SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review". Mayo Clinic Proceedings. 95 (8): 1750–1765. doi:10.1016/j.mayocp.2020.05.011. PMC 7260486. PMID 32753148.
  37. ↑ Papapanou M, Papaioannou M, Petta A, Routsi E, Farmaki M, Vlahos N, Siristatidis C (January 2021). "Maternal and Neonatal Characteristics and Outcomes of COVID-19 in Pregnancy: An Overview of Systematic Reviews". International Journal of Environmental Research and Public Health. 18 (2): 596. doi:10.3390/ijerph18020596. PMC 7828126. PMID 33445657.
  38. ↑ Murgano D, Khalil A, Prefumo F, Mieghem TV, Rizzo G, Heyborne KD, et al. (March 2020). "Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis" (PDF). Ultrasound in Obstetrics & Gynecology. 55 (3): 310–317. doi:10.1002/uog.21889. PMID 31595578. S2CID 203985163.
  39. 1 2 Kitzmiller JL, Block JM, Brown FM, Catalano PM, Conway DL, Coustan DR, et al. (May 2008). "Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care". Diabetes Care. 31 (5): 1060–79. doi:10.2337/dc08-9020. PMC 2930883. PMID 18445730.
  40. ↑ WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneva, Switzerland: World Health Organization. 2011. ISBN 978-92-4-154833-5. OCLC 781290959.
  41. ↑ "Low-Dose Aspirin Use During Pregnancy". www.acog.org. Retrieved 2021-09-14.
  42. ↑ Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, et al. (May 2014). "Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association". Circulation. 129 (21): 2183–242. doi:10.1161/01.cir.0000437597.44550.5d. PMID 24763516. S2CID 39191574.
  43. ↑ "What are some factors that make a pregnancy high risk?". National Institute of Child Health and Human Development (NICHD). Retrieved 2021-09-13.
  44. ↑ CDC (2019-11-19). "Congenital Heart Defects - Facts about Hypoplastic Left Heart Syndrome". Centers for Disease Control and Prevention. Retrieved 2021-09-13.
  45. ↑ Dodd JM, Dowswell T, Crowther CA, et al. (Cochrane Pregnancy and Childbirth Group) (November 2015). "Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes". The Cochrane Database of Systematic Reviews (11): CD005300. doi:10.1002/14651858.CD005300.pub4. PMC 8536469. PMID 26545291.
  46. ↑ Fortner KB, Nieuwoudt C, Reeder CF, Swamy GK (June 2018). "Infections in Pregnancy and the Role of Vaccines". Obstetrics and Gynecology Clinics of North America. 45 (2): 369–388. doi:10.1016/j.ogc.2018.01.006. PMID 29747736.
  47. ↑ Rogan SC, Beigi RH (June 2019). "Treatment of Viral Infections During Pregnancy". Clinics in Perinatology. 46 (2): 235–256. doi:10.1016/j.clp.2019.02.009. PMID 31010558. S2CID 128361368.
  48. ↑ Fortner KB, Nieuwoudt C, Reeder CF, Swamy GK (June 2018). "Infections in Pregnancy and the Role of Vaccines". Obstetrics and Gynecology Clinics of North America. 45 (2): 369–388. doi:10.1016/j.ogc.2018.01.006. PMID 29747736.
  49. ↑ Noguchi LM, Beigi RH (March 2017). "Treatment of infections during pregnancy: Progress and challenges". Birth Defects Research. 109 (5): 387–390. doi:10.1002/bdr2.1005. PMID 28398676.
  50. ↑ Isaacs NZ, Andipatin MG (May 2020). "A systematic review regarding women's emotional and psychological experiences of high-risk pregnancies". BMC Psychology. 8 (1): 45. doi:10.1186/s40359-020-00410-8. PMC 7197168. PMID 32362285.
  51. ↑ Holness N (June 2018). "High-Risk Pregnancy". The Nursing Clinics of North America. 53 (2): 241–251. doi:10.1016/j.cnur.2018.01.010. PMID 29779516.
  52. ↑ Isaacs NZ, Andipatin MG (May 2020). "A systematic review regarding women's emotional and psychological experiences of high-risk pregnancies". BMC Psychology. 8 (1): 45. doi:10.1186/s40359-020-00410-8. PMC 7197168. PMID 32362285.
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