High-risk pregnancy

Definition

Although as of 2004 there was no formal or universally accepted definition of a "high-risk" pregnancy, it is generally thought of as one in which the mother or the developing fetus has a condition that places one or both of them at a higher-than-normal-risk for complications, either during the pregnancy (antepartum), during delivery (intrapartum), or following the birth (postpartum).

Description

Certain conditions, called risk factors, make a pregnancy high risk. Maternal conditions can be identified with preconception counseling and from the maternal history. Maternal physical and social characteristics that can contribute to a high-risk pregnancy include:

• age younger than 15 years and older than 35 years
• pre-pregnancy weight under 100 lbs (45 kg) or obesity
• height under 5 ft (1.5 m)
• incompetent cervix
• uterine malformations
• small pelvis
• being a single woman
• being a smoker
• using illicit drugs
• having no access to early prenatal care
• using alcohol
• having low socioeconomic status

For women who do not have health insurance, obtaining early prenatal care is extremely difficult, and these same women are often from a socioeconomic level that prevents adequate or appropriate nutritional intake. There is a scoring system that can be used by healthcare professionals to determine the degree of risk for a pregnant woman, but it is difficult to rate risk by degrees. Nevertheless, identification of a high-risk pregnancy helps to ensure that those women who need the most care receive it.

One of the initial factors to consider when evaluating risk is the obstetrical history. If this is not the woman's first pregnancy, outcomes of her previous pregnancies are of importance in relation to the outcome of this one. An obstetrical history with any of the following conditions would be considered high risk:

• previous stillbirth
• previous neonatal death
• previous premature infant
• previous post-term (over 42 weeks) pregnancy
• fetal blood transfusion for hemolytic disease
• repeated miscarriages
• previous infant over 10 lbs (4.5 kg)
• six or more completed pregnancies
• history of preeclampsia
• history of eclampsia
• previous cesarean section
• history of a fetus with anomalies

Next to be considered is the medical history factor. A pregnant woman with any of the following medical conditions would be considered at risk:

• abnormal PAP test
• chronic hypertension
• heart disease (class II-IV, symptomatic)
• insulin-dependent diabetes
• moderate to severe kidney disease
• endocrine gland removal or ablation by autoimmune disease
• sickle cell disease
• epilepsy
• history of tuberculosis
• positive serology for syphilis
• pulmonary disease
• thyroid disease
• family history of diabetes
• HIV
• other chronic diseases
• autoimmune diseases, such as lupus

Current pregnancy risk factors would be considered as follows:

• abnormal fetal position
• mild to severe preeclampsia
• multiple pregnancy
• placenta abruption
• placenta previa
• polyhydramnios or oligiohydramnios
• gestational diabetes
• kidney infection
• Rh sensitization only
• mild (>9g/dl hemoglobin) or severe (<9g/dl hemoglobin) anemia
• vaginal spotting
• bladder infection
• emotional problems
• moderate alcohol use
• smoking more than one pack per day
• infection with parvovirus B19 (fifth disease), cytomegalovirus (CMV), toxoplasmosis , listeria, rubella
• exposure to damaging medications, esp., phenytoin, folic acid antagonists, lithium, streptomycin, tetracycline, warfarin

If prenatal testing indicates the baby has a serious congenital anomaly as a heart defect or spinal cord defect, the mother may need additional testing to determine the extent of the problem. Certain maternal or fetal problems may require the physician to deliver a baby early or to choose a surgical delivery (cesarean section) rather than a vaginal delivery.

Most women will see one healthcare provider during pregnancy, either an obstetrician, a midwife, or a nurse practitioner. Women who have a medical problem may need to see a medical specialist as well. Women diagnosed with a high-risk pregnancy should seek the care of an expert in the field of high-risk obstetrics, called a perinatologist. Perinatologists have additional training beyond the education required for an obstetrician. They care for women who have pre-existing medical problems, women who develop complications during pregnancy, and women whose fetus has problems.

Diagnosis

Labeling a woman with the diagnosis of high-risk pregnancy requires that one of the previous conditions be met. Thus, the diagnosis may be determined during history taking or if it is the fetus, during the morphological ultrasound at 16–19 weeks gestation. A woman with a high-risk pregnancy will need closer monitoring than pregnant women who are not high risk. Such monitoring may include frequent visits with the primary caregiver, tests to monitor the medical problem, blood tests to check the levels of medication, amniocentesis , serial ultrasound examination, and fetal monitoring. These tests are designed to follow the original condition, survey for complications, verify that the fetus is growing adequately, and make decisions regarding whether labor may need to be induced for early delivery of the fetus.

Treatment

Treatment varies widely with the type of disease, the effect that pregnancy has on the disease, and the effect that the disease has on pregnancy. If it is the fetus that has a problem, serial ultrasounds may be performed. Fetal heart rate monitoring may be necessary, or amniocentesis may be required. In addition, it may be essential to give the mother medications to act on the baby.

Prognosis

The prognosis is usually dependent on the specific medical condition. Some medical conditions make it difficult for women to get pregnant and lead to a higher risk of problems in the baby. In thyroid disease, the thyroid gland (located in the neck) may produce too much or too little thyroid hormone. Abnormal levels of this hormone can affect fertility and/or cause problems with the pregnancy and possibly affect the health of the baby. Fortunately, thyroid disease can be treated with medication. As long as the level of thyroid hormone is controlled throughout pregnancy, there should be no problems for mother or baby.

There are other medical conditions that do not interfere with pregnancy but are themselves affected by pregnancy. This group includes asthma , epilepsy, and ulcerative colitis. Some women with ulcerative colitis experience a worsening of their symptoms during pregnancy, while others will have no change or may get better during pregnancy. The same is true of asthma: some women notice that their asthma symptoms are better during pregnancy, some find their asthma worse, and some women notice no change in symptoms. It is not immediately apparent why this discrepancy occurs, but due to the unpredictability of diseases, all women with chronic illnesses should be monitored throughout the course of a pregnancy.

Some autoimmune diseases constitute a group of medical conditions that have a major impact on

KEY TERMS

Ablation —To remove or destroy tissue or a body part, such as by burning or cutting.

Amniocentesis —A procedure performed at 16–18 weeks of pregnancy in which a needle is inserted through a woman's abdomen into her uterus to draw out a small sample of the amniotic fluid from around the baby for analysis. Either the fluid itself or cells from the fluid can be used for a variety of tests to obtain information about genetic disorders and other medical conditions in the fetus.

Amniotic sac —The membranous sac that contains the fetus and the amniotic fluid during pregnancy.

Antepartum —The time period of the woman's pregnancy from conception and onset of labor.

Cytomegalovirus (CMV) —A common human virus causing mild or no symptoms in healthy people, but permanent damage or death to an infected fetus, a transplant patient, or a person with HIV.

Eclampsia —Coma and convulsions during or immediately after pregnancy, characterized by edema, hypertension, and proteinuria.

Endocrine —Refers to glands that secrete hormones circulated in the bloodstream or lymphatic system.

Gestational diabetes —Diabetes of pregnancy leading to increased levels of blood sugar. Unlike diabetes mellitus, gestational diabetes is caused by pregnancy and goes away when pregnancy ends. Like diabetes mellitus, gestational diabetes is treated with a special diet and insulin, if necessary.

Intrapartum —Refers to labor and delivery.

Listeria —An uncommon food-borne, life-threatening pathogen that can cause perinatal infection, which is associated with a high rate of fetal loss (including full-term stillbirths) and serious neonatal disease.

Oligohydramnios —A reduced amount of amniotic fluid. Causes include non-functioning kidneys and premature rupture of membranes. Without amniotic fluid to breathe, a baby will have underdeveloped and immature lungs.

Parvovirus B19 —A virus that commonly infects humans; about 50 percent of all adults have been infected sometime during childhood or adolescence. Parvovirus B19 infects only humans. An infection in pregnancy can cause the unborn baby to have severe anemia and the woman may have a miscarriage.

Perinatal —Referring to the period of time surrounding an infant's birth, from the last two months of pregnancy through the first 28 days of life.

Phenytoin —An anti-convulsant medication used to treat seizure disorders. Sold under the brand name Dilantin.

Polyhydramnios —A condition in which there is too much fluid around the fetus in the amniotic sac.

Postpartum —After childbirth.

Preeclampsia —A condition that develops after the twentieth week of pregnancy and results in high blood pressure, fluid retention that doesn't go away, and large amounts of protein in the urine. Without treatment, it can progress to a dangerous condition called eclampsia, in which a woman goes into convulsions.

Premature labor —Labor beginning before 36 weeks of pregnancy.

Rubella —A mild, highly contagious childhood illness caused by a virus; it is also called German measles. Rubella causes severe birth defects (including heart defects, cataracts, deafness, and mental retardation) if a pregnant woman contracts it during the first three months of pregnancy.

Streptomycin —An antibiotic used to treat tuberculosis.

Tetracycline —A broad-spectrum antibiotic.

Toxoplasmosis —A parasitic infection caused by the intracellular protozoan Toxoplasmosis gondii. Humans are most commonly infected by swallowing the oocyte form of the parasite in soil (or kitty litter) contaminated by feces from an infected cat; or by swallowing the cyst form of the parasite in raw or undercooked meat.

Warfarin —An anticoagulant drug given to treat existing blood clots or to control the formation of new blood clots. Sold in the U.S. under the brand name Coumadin.

pregnancy. Women with lupus (a disease caused by alterations in the immune system that result in inflammation of connective tissue and organs) or kidney disease face serious risks during pregnancy. Pregnancy can cause their symptoms to worsen significantly and lead to severe complications for the mother and the baby. With systemic autoimmune diseases or vasculitis, the mother's blood circulation can be impaired and thus the ability to supply oxygen and nutrients to the baby through the placenta is affected. As a result, fetal intrauterine growth becomes restricted (IUGR). Since chronic hypertension or pregnancy-induced hypertension (preeclampsia, eclampsia) similarly affect blood circulation to the placenta, women with these problems are also at risk for IUGR. If the condition is not determined early enough to provide constant monitoring, there is increased risk of stillbirth. Other autoimmune diseases, (antiphospholipid antibody, APA; anticardiolipin antibody, ACLA) are associated with miscarriages.

Diabetes is a medical condition that is affected by pregnancy and, likewise, affects pregnancy. Diabetes can lead to miscarriages, birth defects, and stillbirths. Women with diabetes should have preconception counseling with a perinatologist. Birth defects can result from the variation in a woman's blood sugar level during the first eight to 12 weeks, which is the time period when the embryo is developing. Cardiac defects are not unusual in the babies of women with abnormal blood sugars during that time. Insulin requirements vary tremendously during pregnancy due to placenta hormones that may inhibit the action of insulin. A perinatologist who specializes in diabetes is well aware of what the pregnant woman needs in each trimester and usually recommends the use of an insulin pump for better control. Women with symptomatic cardiac disease face one of the biggest challenges in pregnancy.

Before the advent of perinatology training, women with medical problems such as chronic hypertension, diabetes, and epilepsy were advised to not get pregnant because they could die. With the advancement of technology, it is in the early 2000s possible for these women to have a baby with just a modicum of risk.

Prevention

Women who have health problems and start specific care before conception have the best chance of a healthy pregnancy. A pre-pregnancy visit with a healthcare provider is, therefore, of the utmost importance for a woman with a medical problem. Together, the perinatologist and the woman can start therapies that will improve the woman's health prior to conception. There may be medications that are safer to take during pregnancy, and the physician can discuss how other women with a specific condition fare during pregnancy. For some diseases, pregnancy can mean increased risk of health problems for mother and baby. In fact, with lupus, preconception counseling is essential to determine the optimum time period for getting pregnant, which is when the disease is in remission. The bottom line is that a woman must always weigh the risks to herself and the baby when deciding whether or not to become pregnant and she can only do this by becoming informed.

See also Amniocentesis; Cesarean section; Electronic fetal monitoring.

Resources

BOOKS

Evans, A. T., and K. R. Niswander. Manual of Obstetrics, 6th ed. Hagerstown, MD: Lippincott Williams & Wilkins, 2000.

Garcia-Pratts, Joseph, et al. What to Do When Your Baby Is Premature: A Parent's Handbook for Coping with High-Risk Pregnancy and Caring for the Preterm Infant. Westminster, MD: Crown Publishing Group, 2000.

Gilbert, Elizabeth S., et al. Manual for High-Risk Pregnancy and Delivery. St. Louis, MO: Mosby, 2002.

High-Risk Pregnancy: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Group International, 2004.

Olds, Sally, et al. Maternal-Newborn Nursing & Women's Health Care, 7th ed. Saddle River, NJ: Prentice Hall, 2004.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street, SW, PO Box 96920, Washington, DC 20090. Web site: <www.acog.org>.

Association of Women's Health, Obstetric and Neonatal Nursing. 2000 L Street, NW Suite 740, Washington, DC 20036. Web site: <www.awhonn.org.

Linda K. Bennington, MSN, CNS

High-risk pregnancy

Definition

A pregnancy that has maternal or fetal complications requiring special medical attention or bed rest is considered to be high-risk. Complications, as used here, mean the risk of illness or death before or after delivery is greater than normal for the mother or baby.

Description

Risk factors in pregnancy are those findings discovered during prenatal assessment that are known to have a potentially negative effect on the outcome of the pregnancy, either for the woman or the fetus. This evaluation determines whether or not the mother has characteristics or conditions that make her or her baby more likely to become sick or die during the pregnancy.

Causes and symptoms

All risk factors do not threaten pregnancy to the same extent. The risk of complications is increased by smoking, poor nutritional habits, drug and alcohol abuse, domestic violence, prepregnancy maternal health status, psychosocial factors, prior health care, the presence of chronic medical problems in the mother, past history of repeated preterm delivery, multiple gestation, and abnormalities of the fetus or placenta. A woman with a high-risk pregnancy may have an earlier labor and delivery depending upon the fetal or maternal complication present and, likewise, present with symptoms dependent upon the condition. Since the placenta supplies the baby with its nutrients and oxygen, any condition that threatens the blood supply to it threatens fetal development .

The threat of a preterm delivery is the most common reason for a referral to a perinatal center, which is linked to obstetric and newborn services that provide the highest level of care for a pregnant woman and her baby. A preterm delivery may occur because of a premature rupture of membranes (the bag of water surrounding the baby breaks) or preterm labor . There is a strong correlation of vaginal or uterine infection with the pregnant woman's water breaking, and there are lab tests that can be predictive of a woman's risk of experiencing preterm labor.

According to a 2001 report from the U.S. Centers for Disease Control and Prevention, there were 29.6 deaths per 100,000 births among African-American women between 1991 and 1997. The rate for women of Hispanic origin was 10.3, and for white women it was 7.3. The rate for Asian women was unavailable. The second most common causes of death in women are problems related to pregnancy and delivery, including blood clots that travel to the lungs , anesthesia complications, bleeding, infection, and high blood pressure complications. A baby dies before, during, or after birth in 16 out of 1,000 deliveries in the United States. Almost 50% of these deaths are stillbirths, which are sometimes unexplained. The rest of the deaths occur in babies up to 28 days old, and the leading cause of these is birth defects, followed by prematurity. Risk factors can be present before pregnancy occurs and others develop during pregnancy.

Diagnosis

A risk-scoring sheet is utilized by many healthcare agencies during the prenatal assessment to establish if a woman may be at risk for complications during her pregnancy. This score sheet is implemented at the first prenatal visit, becomes a part of the woman's record, and is updated throughout the pregnancy as necessary. A

KEY TERMS

Amniocentesis —A procedure that uses ultrasound to guide a needle into the amniotic sac (bag of waters) surrounding the baby and obtain fluid to analyze for genetic abnormalities.

Antepartum —This refers to the time period of the woman's pregnancy from conception and onset of labor.

Perinatal —Refers to the period shortly before and after birth, generally from around the 20th week of pregnancy to one to four weeks after birth.

Perinatologist —A specialist in the branch of obstetrics that deals with the high-risk pregnant woman and her fetus.

Preconceptional —This refers to the time period before pregnancy, i.e., conception, occurs.

Ultrasonographer —The person who performs the radiologic technique of ultrasound in which deep structures of the body are visualized.

woman's age affects pregnancy risk, as girls 15 years old and under are more likely to develop high blood pressure, protein in the urine and fluid accumulation (preeclampsia), or seizures (eclampsia). They also are more likely to have underweight or undernourished babies. A woman 35 or older has a greater risk of developing high blood pressure or diabetes, as well as a much higher risk of having a chromosomal abnormality such as Down syndrome . A woman shorter than five feet or a woman weighing less than 100 pounds before pregnancy has a greater risk of having a small or preterm baby.

Lab data and ultrasound are also utilized to determine high-risk pregnancies by specific blood tests and imaging of the baby. A pregnancy may begin as low risk and change to high risk secondary to complications determined from the ongoing assessment of the pregnant woman. Since many of these complications can be managed with proper treatment, it is essential that a pregnant woman keep her obstetric appointments.

Treatment

Treatment will vary, depending upon the maternal or fetal complication present. Generally, a woman with severe high-risk factors in pregnancy should be referred to a perinatal center to obtain the highest level of care for herself and her baby. Interventions to improve health status might include nutritional assessment, physical examination , teaching modalities for smoking cessation, drug and alcohol programs, prescribing medications related to the condition, or changing pre-pregnancy medications (known to cause problems in the fetus), serial ultrasounds to learn fetal status, amniocentesis , fetal transfusions, fetal surgery, antepartum testing , bed rest, home health care, hospitalization, and early delivery. In a postterm pregnancy (greater than 42 weeks), the death of a baby is three times more likely than that of a normal term pregnancy (37–40 weeks). The treatment in this case would be to induce labor before problems start to occur with an aging placenta.

Prognosis

Advances in the management of complications in high-risk pregnancies have provided women with a means of controlling their risks, which substantially increases the potential for a successful outcome. Since it is impossible to guarantee a good outcome in a normal pregnancy, it is even more difficult to ensure that a high-risk pregnancy will result in a healthy infant and mother. A woman who strictly adheres to the medical regimen established for her, however, will greatly increase her chances of a positive result.

Health care team roles

The pregnant woman's interview at her first visit the health care provider is conducted by the nurse, who obtains the data necessary to begin the high-risk screening. The physician or midwife caring for a pregnant woman should review the prenatal assessment sheet, order lab data, and obtain ultrasounds to determine if any risk factors are present. If it is determined that a woman has a high-risk pregnancy, she should be referred to a perinatologist for advanced care. This is the specialist who establishes and implements the medical regimen needed for the particular maternal/fetal complication and the inter-disciplinary team associated with the perinatal center works in its management. The perinatal team usually comprises a nutritionist, social worker, nurse educators, geneticists, ultrasonographers, and additional nursing staff who are responsible for the monitoring and supervising of ongoing team care of the patient.

Prevention

The early weeks of pregnancy are the most crucial ones for the fetus. Many women do not know they are pregnant until several weeks after conception, so education about the need for preconceptional care is essential. Preconception counseling guides a woman in planning a healthy pregnancy. These are some of the factors to which attention must be paid:

• family history
• medical history
• past pregnancies
• current medications
• lifestyle
• environment
• infections

Cigarette smoking is the most common addiction among pregnant women in the United States, and despite the health hazards of smoking being well-known, only about 20% of these women actually quit during pregnancy. One risk of smoking during pregnancy is having a baby who may die from sudden infant death syndrome (SIDS).

Drugs known to cause birth defects when taken during pregnancy include: alcohol, dilantin (phenytoin), any drug that interferes with the actions of folic acid , lithium, streptomycin, tetracycline, thalidomide, warfarin (Coumadin), and isotretinoin (Accutane), which is prescribed for acne. The number one preventable cause of mental retardation in infants is the abuse of alcohol during pregnancy. Alcohol can cause problems ranging from miscarriage to severe behavioral problems in the baby or developing child even if no obvious physical birth defects are apparent. Fetal alcohol syndrome is seen in about two out of 1000 live births. Infections that may cause birth defects include: herpes simplex, viral hepatitis, the flu, mumps, German measles (rubella), chicken-pox (varicella), syphilis , toxoplasmosis (occurs from eating undercooked meat and handling kitty litter), listeriosis, and infections from the coxsackievirus or cytomegalovirus (CMV). Many adults have been exposed to coxsackievirus and CMV when they were younger, but there are many who have not been. Those who have not been exposed should pay careful attention to any illnesses they have early in their pregnancy, noting the onset, presence of fever , muscle aches and pains, and duration of illness to report to their physician.

Hemolytic disease of the newborn (destruction of the red blood cells) can occur when Rh incompatibility exists between child and mother. The most common cause of incompatible blood types is Rh incompatibility—such as when the mother has Rh-negative blood and the father has Rh-positive blood. The baby may have Rh-positive blood, in which case the mother's body produces antibodies against the baby's blood. Fortunately, the mother can be treated with Rhogham [Rh0(D)immune globulin], which can be given to the mother in the first 72 hours after delivery and at the twenty-eighth week of pregnancy; it will destroy any antibodies produced by her blood and significantly decrease the risk associated with pregnancies with Rh-factor incompatibilities.

There are, however, other incompatible blood factors during the prenatal assessment period that can cause anemia in the fetus and require ongoing monitoring. The greatest gift a woman gives herself is to plan her pregnancy with preconceptional counseling. Many women are frequently deficient in folic acid, a B vitamin used in the synthesis of ribonucleic acid (RNA) and essential, in large quantities, for optimal protein synthesis in the fetus. This is especially true in the early weeks of pregnancy, when all cell division and organ development is occurring. Thus, the best prevention for a high risk pregnancy is good planning.

Resources

BOOKS

Olds, Sally B., London, Marcia L., and Ladewig, Patricia A. Maternal-Newborn Nursing: A Family and Community-Based Approach. Upper Saddle River, NJ: Prentice Hall Health, 2000.

Star, Winifred L., Shannon, Maureen T., Lommel, Lisa L., Gutierrez, Yolanda M. Ambulatory Obstetrics. San Francisco, CA: UCST Nursing Press, 1999.

PERIODICALS

Casimir, Leslie. "Black Maternal Deaths 4 Times the White Rate." The Daily News (June 08, 2001):archives. <http://www.dailynews.com>.

Davis, Lisa J., Okuboye, Simi, Ferguson, Stephanie. "Healthy People 2010: Examining a Decade of Maternal and Infant Health." Lifelines (June/July 2000): 26-33.

Maloni, Judith A. "Preventing Preterm Birth: Evidence-Based Interventions Shift Toward Prevention." Lifelines (August/September 2000): 26-33.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920, Washington, DC 20090-6920. "Preconceptional Care." ACOG Patient Education Booklet. 1999.

Association of Women's Health, Obstetric and Neonatal Nurses. 2000 L Street, N.W., Suite 740, Washington, DC20036. (800) 673-8499. <http://www.awhonn.org>.

OTHER

Sidelines National Support Network. High-risk pregnancy support online. <http://www.sidelines.org>.

Linda K. Bennington, R.N.C., M.S.N., C.N.S.

High-Risk Pregnancy

Definition

A pregnancy that has maternal or fetal complications requiring special medical attention or bed rest is considered to be high-risk. Complications, as used here, mean that the risk of illness or death before or after delivery is greater than normal for the mother or baby.

Description

Risk factors in pregnancy are those findings discovered during prenatal assessment that are known to have a potentially negative effect on the outcome of the pregnancy, either for the woman or the fetus. This evaluation determines whether or not the mother has characteristics or conditions that make her or her baby more likely to become sick or die during the pregnancy.

Causes and symptoms

All risk factors do not threaten pregnancy to the same extent. The risk of complications is increased by smoking, poor nutritional habits, drug and alcohol abuse, domestic violence, prepregnancy maternal health status, psychosocial factors, prior health care, the presence of chronic medical problems in the mother, past history of repeated preterm delivery, multiple gestation, and abnormalities of the fetus or placenta. A woman with a high-risk pregnancy may have an earlier labor and delivery depending upon the fetal or maternal complication present and, likewise, present with symptoms dependent on the condition. Since the placenta supplies the baby with its nutrients and oxygen, any condition that threatens the blood supply to it threatens fetal development.

The threat of a preterm delivery is the most common reason for a referral to a perinatal center, which is linked to obstetric and newborn services that provide the highest level of care for a pregnant woman and her baby. A preterm delivery may occur because of a premature rupture of membranes (the bag of water surrounding the baby breaks) or preterm labor. There is a strong correlation of vaginal or uterine infection with the pregnant woman's water breaking, and there are lab tests that can be predictive of a woman's risk of experiencing preterm labor.

According to a 2001 report from the U.S. Centers for Disease Control and Prevention, there were 29.6 deaths per 100,000 births among African-American women between 1991 and 1997. The rate for women of Hispanic origin was 10.3, and for white women it was 7.3. The rate for Asian women was unavailable. The second most common causes of death in women are problems related to pregnancy and delivery, including blood clots that travel to the lungs, anesthesia complications, bleeding, infection, and high blood pressure complications. A baby dies before, during, or after birth in 16 out of 1,000 deliveries in the United States. Almost 50% of these deaths are stillbirths, which are sometimes unexplained. The rest of the deaths occur in babies up to 28 days old, and the leading cause of these is birth defects, followed by prematurity. Risk factors can be present before pregnancy occurs and others develop during pregnancy.

Diagnosis

A risk-scoring sheet is utilized by many health care agencies during the prenatal assessment to establish if a woman may be at risk for complications during her pregnancy. This score sheet is implemented at the first prenatal visit, becomes a part of the woman's record, and is updated throughout the pregnancy as necessary. A woman's age affects pregnancy risk, as girls 15 years old and under are more likely to develop high blood pressure, protein in the urine and fluid accumulation (preeclampsia), or seizures (eclampsia). They also are more likely to have underweight or undernourished babies. A woman 35 or older has a greater risk of developing high blood pressure or diabetes, as well as a much higher risk of having a chromosomal abnormality such as Down syndrome. A woman shorter than five feet or a woman weighing less than 100 pounds before pregnancy has a greater risk of having a small or preterm baby.

Lab data and ultrasound are also utilized to determine high-risk pregnancies by specific blood tests and imaging of the baby. A pregnancy may begin as low risk and change to high risk secondary to complications determined from the ongoing assessment of the pregnant woman. Since many of these complications can be managed with proper treatment, it is essential that a pregnant woman keep her obstetric appointments.

Treatment

Treatment will vary, depending upon the maternal or fetal complication present. Generally, a woman with severe high-risk factors in pregnancy should be referred to a perinatal center to obtain the highest level of care for herself and her baby. Interventions to improve health status might include nutritional assessment; physical examination; teaching modalities for smoking cessation, drug and alcohol programs; prescribing medications related to the condition or changing pre-pregnancy medications (known to cause problems in the fetus); serial ultrasounds to learn fetal status; amniocentesis; fetal transfusions; fetal surgery; antepartum testing; bed rest; home health care; hospitalization; and early delivery. In a postterm pregnancy (greater than 42 weeks), the death of a baby is three times more likely than that of a normal term pregnancy (37-40 weeks). The treatment in this case would be to induce labor before problems start to occur with an aging placenta.

Prognosis

Advances in the management of complications in high-risk pregnancies have provided women with a means of controlling their risks, which substantially increases the potential for a successful outcome. Since it is impossible to guarantee a good outcome in a normal pregnancy, it is even more difficult to ensure that a high-risk pregnancy will result in a healthy infant and mother. A woman who strictly adheres to the medical regimen established for her, however, will greatly increase her chances of a positive result.

Health care team roles

The pregnant woman's interview at her first visit to the health care provider is conducted by the nurse, who obtains the data necessary to begin the high-risk screening. The physician or midwife caring for a pregnant woman should review the prenatal assessment sheet, order lab data, and obtain ultrasounds to determine if any risk factors are present. If it is determined that a woman has a high-risk pregnancy, she should be referred to a perinatologist for advanced care. This is the specialist who establishes and implements the medical regimen needed for the particular maternal/fetal complication and the interdisciplinary team associated with the perinatal center works in its management. The perinatal team usually comprises a nutritionist, social worker, nurse educators, geneticists, ultrasonographers, and additional nursing staff who are responsible for the monitoring and supervising of ongoing team care of the patient.

Prevention

The early weeks of pregnancy are the most crucial ones for the fetus. Many women do not know they are pregnant until several weeks after conception, so education about the need for preconceptional care is essential. Preconception counseling guides a woman in planning a healthy pregnancy. These are some of the factors to which attention must be paid:

• family history
• medical history
• past pregnancies
• current medications

• lifestyle
• environment
• infections

Cigarette smoking is the most common addiction among pregnant women in the United States, and despite the health hazards of smoking being well-known, only about 20% of these women actually quit during pregnancy. One risk of smoking during pregnancy is having a baby who may die from sudden infant death syndrome (SIDS).

Drugs known to cause birth defects when taken during pregnancy include: alcohol, dilantin (phenytoin), any drug that interferes with the actions of folic acid, lithium, streptomycin, tetracycline, thalidomide, warfarin (Coumadin), and isotretinoin (Accutane), which is prescribed for acne. The number one preventable cause of mental retardation in infants is the abuse of alcohol during pregnancy. Alcohol can cause problems ranging from miscarriage to severe behavioral problems in the baby or developing child even if no obvious physical birth defects are apparent. Fetal alcohol syndrome is seen in about two out of 1,000 live births. Infections that may cause birth defects include: herpes simplex, viral hepatitis, the flu, mumps, German measles (rubella), chickenpox (varicella), syphilis, toxoplasmosis (occurs from eating undercooked meat and handling kitty litter), listeriosis, and infections from the coxsackievirus or cytomegalovirus (CMV). Many adults have been exposed to coxsackievirus and CMV when they were younger, but there are many who have not. Those who have not been exposed should pay careful attention to any illnesses they have early in their pregnancy, noting the onset, presence of fever, muscle aches and pains, and duration of illness to report to their physician.

Hemolytic disease of the newborn (destruction of the red blood cells) can occur when Rh incompatibility exists between child and mother. The most common cause of incompatible blood types is Rh incompatibility—such as when the mother has Rh-negative blood and the father has Rh-positive blood. The baby may have Rh-positive blood, in which case the mother's body produces antibodies against the baby's blood. Fortunately, the mother can be treated with Rhogham [Rh0(D)immune globulin], which can be given to the mother in the first 72 hours after delivery and at the twenty-eighth week of pregnancy; it will destroy any antibodies produced by her blood and significantly decrease the risk associated with pregnancies with Rh-factor incompatibilities.

There are, however, other incompatible blood factors during the prenatal assessment period that can cause anemia in the fetus and require ongoing monitoring. The greatest gift a woman gives herself is to plan her pregnancy with preconceptional counseling. Many women are frequently deficient in folic acid, a B vitamin used in the synthesis of ribonucleic acid (RNA) and essential, in large quantities, for optimal protein synthesis in the fetus. This is especially true in the early weeks of pregnancy, when all cell division and organ development is occurring. Thus, the best prevention for a high risk pregnancy is good planning.

KEY TERMS

Amniocentesis— A procedure that uses ultrasound to guide a needle into the amniotic sac (bag of waters) surrounding the baby and obtain fluid to analyze for genetic abnormalities.

Antepartum— This refers to the time period of the woman's pregnancy from conception and onset of labor.

Perinatal— Refers to the period shortly before and after birth, generally from around the 20th week of pregnancy to one to four weeks after birth.

Perinatologist— A specialist in the branch of obstetrics that deals with the high-risk pregnant woman and her fetus.

Preconceptional— This refers to the time period before pregnancy, i.e., conception, occurs.

Ultrasonographer— The person who performs the radiologic technique of ultrasound in which deep structures of the body are visualized.

Resources

BOOKS

Olds, Sally B., Marcia L. London, and Patricia A. Ladewig. Maternal-Newborn Nursing: A Family and Community-Based Approach. Upper Saddle River, NJ: Prentice Hall Health, 2000.

Star, Winifred L., Maureen T. Shannon, Lisa L. Lommel, Yolanda M. Gutierrez. Ambulatory Obstetrics. San Francisco: UCST Nursing Press, 1999.

PERIODICALS

Casimir, Leslie. "Black Maternal Deaths 4 Times the White Rate." The Daily News (June 08, 2001): archives. 〈http://www.dailynews.com〉.

Davis, Lisa J., Simi Okuboye, and Stephanie Ferguson. "Healthy People 2010: Examining a Decade of Maternal and Infant Health." Lifelines (June/July 2000): 26-33.

Maloni, Judith A. "Preventing Preterm Birth: Evidence-Based Interventions Shift Toward Prevention." Lifelines (August/September 2000): 26-33.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920, Washington, DC 20090-6920. "Preconceptional Care." ACOG Patient Education Booklet. 1999.

Association of Women's Health, Obstetric and Neonatal Nurses. 2000 L Street, N.W., Suite 740, Washington, DC 20036. (800) 673-8499. 〈http://www.awhonn.org〉.

OTHER

Sidelines National Support Network. High-risk pregnancy support online. 〈http://www.sidelines.org〉.

High-Risk Pregnancy

Definition

A high risk pregnancy is one in which some condition puts the mother, the developing fetus, or both at higher-than-normal risk for complications during or after the pregnancy and birth.

Description

A pregnancy can be considered a high-risk pregnancy for a variety of reasons. Factors can be divided into maternal and fetal. Maternal factors include age (younger than age 15, older than age 35); weight (pre-pregnancy weight under 100 lb or obesity); height (under five feet); history of complications during previous pregnancies (including stillbirth, fetal loss, preterm labor and/or delivery, small-for-gestational age baby, large baby, pre-eclampsia or eclampsia ); more than five previous pregnancies; bleeding during the third trimester; abnormalities of the reproductive tract; uterine fibroids; hypertension; Rh incompatability; gestational diabetes; infections of the vagina and/or cervix; kidney infection; fever; acute surgical emergency (appendicitis, gallbladder disease, bowel obstruction); post-term pregnancy; pre-existing chronic illness (such as asthma, autoimmune disease, cancer, sickle cell anemia, tuberculosis, herpes, AIDS, heart disease, kidney disease, Crohn's disease, ulcerative colitis, diabetes). Fetal factors include exposure to infection (especially herpes simplex, viral hepatitis, mumps, rubella, varicella, syphilis, toxoplasmosis, and infections caused by coxsackievirus); exposure to damaging medications (especially phenytoin, folic acid antagonists, lithium, streptomycin, tetracycline, thalidomide, and warfarin); exposure to addictive substances (cigarette smoking, alcohol intake, and illicit or abused drugs). A pregnancy is also considered high-risk when prenatal tests indicate that the baby has a serious health problem (for example, a heart defect). In such cases, the mother will need special tests, and possibly medication, to carry the baby safely through to delivery. Furthermore, certain maternal or fetal problems may prompt a physician to deliver a baby early, or to choose a surgical delivery (cesarean section) rather than a vaginal delivery.

Most women will see one healthcare provider during pregnancy, either an obstetrician, a midwife, or a nurse practitioner. Women who have a medical problem may need to see a medical specialist as well. Women diagnosed with a high-risk pregnancy may also need the expert advice and care of a perinatologist. A perinatologist is a medical doctor (obstetrician) who specializes in the care of women who are at high risk for having problems during pregnancy. Perinatologists care for women who have preexisting medical problems as well as women who develop complications during pregnancy.

Diagnosis

A woman with a high-risk pregnancy will need closer monitoring than the average pregnant woman. Such monitoring may include more frequent visits with the primary caregiver, tests to monitor the medical problem, blood tests to check the levels of medication, amniocentesis, serial ultrasound examination, and fetal monitoring. These tests are designed to track the original condition, survey for complications, verify that the fetus is growing adequately, and make decisions regarding whether labor may need to be induced to allow for early delivery of the fetus.

Treatment

Treatment varies widely with the type of disease, the effect that pregnancy has on the disease, and the effect that the disease has on pregnancy. Additional tests may help determine the need for changes in medication or additional treatment.

Prognosis

The prognosis depends in large part on the specific medical condition. Some medical conditions make it difficult to get pregnant and lead to a higher risk of problems in the baby. An example of this type of condition is thyroid disease. In thyroid disease, the thyroid gland (located in the neck) may produce too much or too little thyroid hormone. Abnormal levels of thyroid hormone can cause problems in pregnancy and affect the health of the baby. Fortunately, thyroid disease can be treated with medication. As long as the level of thyroid hormone is controlled throughout pregnancy, there should be no problems for mother or baby.

There are many medical conditions that usually do not interfere with pregnancy, but are themselves affected by pregnancy. This group includes asthma, epilepsy, and ulcerative colitis. For example, some women with ulcerative colitis experience a worsening of their symptoms during pregnancy, while others will have no change or may get better during pregnancy. The same is true of asthma; some women notice that their asthma symptoms are better during pregnancy, some find their asthma worse, and some women notice no change in symptoms during pregnancy. No one understands why this is so, but due to this unpredictability, all women with chronic illnesses should be monitored carefully throughout pregnancy.

There is also a group of medical conditions that can have a major impact on pregnancy. Women with lupus (disease caused by alterations in the immune system that result in inflammation of connective tissue and organs) or kidney disease face real risks during pregnancy. Pregnancy can cause their symptoms to worsen significantly and can lead to serious illness. Because these diseases can affect the mother's ability to supply oxygen and nutrients to the baby through the placenta, they can cause problems for the baby as well. These babies may not be able to grow and gain weight properly (intrauterine growth retardation ). There is also an increased risk of stillbirth.

Diabetes is a medical condition that is both affected by pregnancy and affects pregnancy. Diabetes can lead to miscarriages, birth defects, and stillbirths. When a woman monitors her blood sugar carefully and treats high levels with insulin, the risk of these negative outcomes drops a great deal. Unfortunately, pregnancy makes diabetes much harder to control. In general, blood sugar and the need for insulin to control it rise throughout pregnancy.

Most medical conditions do not lead to complications in pregnancy. With frequent visits to healthcare providers, and careful attention to medication, women with medical problems usually enjoy healthy, successful pregnancies. There are a few medical conditions that can cause health risks to both mother and baby during pregnancy. Women with these medical problems should consider these risks before deciding to become pregnant. Many of these women will benefit from the care of a perinatologist during pregnancy. Only rarely (in the case of severe heart disease, for example) are the risks to the mother so high that she should not consider pregnancy at all.

Prevention

A pre-pregnancy visit with a healthcare provider is especially important for a woman who has a medical problem. The doctor will discuss how women with this condition usually fare during pregnancy. For some diseases (such as lupus), pregnancy can mean increased risk of health problems for mother and baby.

Sometimes, the medication a woman needs to control a medical condition can cause problems for the baby. There may be another medication available that is safer for use in pregnancy. In some cases there is no other medication, and a woman must weigh the risks to the baby when deciding whether or not to become pregnant.

A woman who has not had a pre-pregnancy visit should contact a healthcare provider as soon as she learns she is pregnant. Often, the provider will schedule the first prenatal visit within a day or two, instead of waiting until eight to 10 weeks of pregnancy. This is because certain medical conditions can increase the risk of miscarriage. The provider will want to be sure that any medication is adjusted properly to increase the chance of having a successful pregnancy.

Resources

BOOKS

Beers, Mark H., et al., editors. "High-Risk Pregnancies." In The Merck Manual of Diagnosis and Therapy. Rahway, NJ: Merck Research Laboratories, 2004.

KEY TERMS

Gestational diabetes— Diabetes of pregnancy leading to increased levels of blood sugar. Unlike diabetes mellitus, gestational diabetes is caused by pregnancy and goes away when pregnancy ends. Like diabetes mellitus, gestational diabetes is treated with a special diet and insulin, if necessary.

Preeclampsia— A disease that only affects pregnant women. The most common signs and symptoms are increased blood pressure, swelling in the hands and feet, and abnormal results on special blood and urine tests.

Premature labor— Labor beginning before 36 weeks of pregnancy.