Maternity Monday: Expecting the Unexpected — High-Risk Pregnancy

Laura Aimone’s pregnancy was progressing along normally, although she did feel tired in her second trimester, which she didn’t expect. “I just kind of figured that’s what me being pregnant was,” she says. Her baby was measuring small, but doctors at University Physicians for Women at Northridge were monitoring it.

Headaches: A Warning Sign

Due on August 28, 2013, Aimone began experiencing bad headaches in July. “I didn’t know that was a sign of anything,” she says. Headaches can, in fact, indicate preeclampsia, a serious pregnancy-related condition characterized by high blood pressure. It can cause poor growth, placental abruption (separation of the placenta from the uterus) and damage to the mother’s organs.

Preeclampsia is diagnosed by testing for protein in the urine. But when Aimone next went to her doctor, a test didn’t find any protein. While her blood pressure was elevated to 130/95, her baby looked fine during an NST (non-stress test), which measures a baby’s heart rate and movements. Aimone was ordered to take it easy, but she admits she didn’t understand what that meant. She took a yoga class that night that which left her with a horrible headache; when she called UVA’s Labor and Delivery Department, the staff had her come in.

Aimone’s blood pressure was high but it went down after resting and there still wasn’t any protein in her urine. Tests again showed the baby was in good condition. “They said, “We’re not going to deliver the baby tonight. I think my husband and I said, ‘Well, no, we’re not going to deliver the baby tonight! We have six weeks to go and I’m going to be late because first pregnancies are late.’”

Aimone was scheduled to do a 24-hour urine test, which more accurately measures the amount of protein in the urine, but without those results doctors still weren’t prepared to officially diagnose her. Still, at this point she learned what taking it easy really meant when doctors told her she could get out of bed to use the bathroom.

What is a High-Risk Pregnancy?

Aimone’s pregnancy had quickly progressed from normal to high-risk. A high-risk pregnancy means there are complications that could affect the mother, the fetus or both.

Women with a high-risk pregnancy often see a maternal-fetal medicine specialist (MFM). Other names for this type of doctor, who has specialized training in treating high-risk pregnancies, are:

• High-risk obstetrician
• Perinatologist

“Fortunately, the vast majority of pregnancies proceed along fairly normally and don’t really need to be seen by someone who’s a high-risk obstetrician. Most women are low risk,” says Donald Dudley, MD, division director of the Division of Maternal-Fetal Medicine at the University of Virginia. “But for moms-to-be who are high risk, at UVA, we have a team of maternal-fetal medicine specialists who treat women at our Maternal and Fetal Medicine Clinic at the new Battle Building.“

Women with high-risk pregnancies usually spend more time with the doctor and are seen as often as twice a week throughout their pregnancy. They also need additional blood tests, ultrasounds and possibly specialist visits. For women for whom these additional visits become a hard to manage, UVA doctors often set up programs with local care providers and use the telemedicine program, making appointments less of a burden.

Diagnosis of Preeclampsia

After her visit to Labor and Delivery, Aimone had a scheduled appointment for a special ultrasound called a biophysical profile, which is used in high-risk pregnancies to measure the baby’s breathing, movement, amniotic fluid, muscle tone and heart rate. It showed the baby was in great condition. The results of the 24-hour urine test were in, though, and they showed Aimone did have preeclampsia, so Megan Bray, MD, sent Aimone back to Labor and Delivery for an assessment.

“She was very direct,” Aimone says. “She said, ‘At the point where your health risks outweigh the baby’s health risks, that’s when we deliver the baby, because that’s how we fix your preeclampsia.’ I wanted to make it to 37 weeks, but she said it wouldn’t be any longer than that. I was kind of bummed about that. I really wanted to go into labor naturally.”

After bedrest, more headaches and another trip to Labor and Delivery, Aimone’s water broke at 35 weeks, 5 days. She delivered her daughter Waverly, who weighed 3 lbs, 15 oz, on July 29. Waverly spent 10 days in UVA’s NICU (neonatal intensive care unit). Aimone’s doula assisted at the birth and Aimone had the opportunity to hold her daughter before she went to the NICU. Waverly is now a healthy, happy little girl who keeps her mom and dad Ben busy.

Who Has a High-Risk Pregnancy?

Anyone who gets pregnant can have a high-risk pregnancy, but most women won’t, says Dudley. A lot of rare conditions can cause high-risk pregnancies, but some of the most common risk factors include:

• Multiples (twins, triplets or higher)
• Previous history of diabetes
• Blood pressure issues, such as pre-eclampsia
• Lupus
• Fetuses with birth defects
• Previous history of preterm birth
• Women at risk for preterm birth for any number of reasons, including, cervical insufficiency

In many cases, these risk factors mean there’s a risk for preterm labor and/or preterm birth. Dudley says preterm birth is a significant problem in the U.S and the leading cause of neonatal infant mortality worldwide. “Having babies in the NICU is really what we want to avoid. We want to have babies go home with the mom right away. That’s the optimal outcome.”

Other factors that put a pregnancy in the high-risk category: Going past the due date and the mother having late-onset high blood pressure are examples.

What About Gestational Diabetes?

Having gestational diabetes doesn’t mean you necessarily need to see a maternal-fetal medicine specialist. Dudley says it depends on the comfort level of your provider. Gestational diabetes is a common pregnancy condition that affects many women. If you’re seeing a midwife or a nurse practitioner, you should see a high-risk doctor, he says. “Most good general obstetricians can manage you, but most of them would want you seen by a high-risk obstetrician to confirm the management plan and to have that kind of insurance.”

Preventing a High-Risk Pregnancy

It’s not always possible to prevent a high-risk pregnancy, especially if you already have an underlying health condition or you’re pregnant with multiples. But here are a few steps you should take:

Before you get pregnant:

• Eat a healthy diet
• Don’t be overweight
• Maintain a healthy lifestyle
• Exercise regularly
• Take prenatal vitamins containing folic acid
• Stop smoking and taking drugs unless prescribed

Once you’re pregnant:

• Get early prenatal care
• Continue prenatal vitamins
• Continue a healthy diet with green, leafy vegetables and include extra calcium and extra protein
• Do some aerobic exercise  (check with your doctor first!)
• Minimize chemical and drug exposures
• Don’t smoke, take drugs or drink alcohol

Worried About the Risks?

If you have underlying health conditions, you may want to consider preconception counseling. Dudley says MFM doctors prefer women with high-risk conditions like lupus, complex high blood pressure, kidney disease, diabetes, seizure disorders and other conditions see a high-risk doctor for preconception counseling.

“We can go over a plan for what we’re going to do when they achieve pregnancy, make sure they’re on medications that are safe for pregnancy as best we can, and that way when they’re pregnant they’re already in an optimal condition,” he says. Women with lupus have a higher risk of preeclampsia, fetal death and other problems; however, if they have their babies while in remission and on medication they usually have good outcomes, Dudley says.

Preconception counseling isn’t the norm because at least half of all pregnancies are surprises. But ideally, a woman with a serious health condition will call an MFM first, Dudley says. This is critical, because maternal mortality rates in the U.S. are increasing. “It’s driven a lot by women who have underlying heart conditions achieving pregnancy and then having problems toward the end of their pregnancy.

“We love to do preconception counseling. It helps us provide a strategy that hopefully will ensure the best possible outcome from the very beginning.”

Choosing a Hospital to Minimize Risk

Worried about a high-risk pregnancy, though you don’t have underlying conditions? Choosing a hospital with a NICU might be your best bet.

“Mainly you need a NICU if there’s going to be some need for specialized care. The main one is preterm birth, but if you have a baby that is delivered at term that has a heart defect or spina bifida or some other problem, you would still need a NICU,” says Dudley.

Sometimes, it’s actually care for the mother that’s just as important, if not more so. “There are high-risk maternal conditions where the baby will do fine. For example, the baby’s at term and the mother develops severe preeclampsia. Then the mother needs to be in a place with high-risk maternal care and adult care, but the baby doesn’t always need anything special. You really want a hospital that has comparable levels of care for the mom and the baby. It’s the combination of the two.”

Even without the risks that could affect their pregnancy, some women choose the safety net of a hospital with a NICU to avoid last-minute emergencies.

Aimone expected to have a normal pregnancy and did until the very end. She planned to have her baby at UVA in part because of convenience, but also because of the care UVA provides. UVA is right around the corner from her house. “God forbid anything happen, we wanted to be at UVA. Everyone was like, ‘Oh nothing will happen. It’ll be fine.’ But it did.”