High-Risk Pregnancy

Listed below are some of the common conditions that cause a pregnancy to be considered high-risk:

Doctors should recommend that women with diabetes have their blood sugar levels properly managed before trying to become pregnant. Moreover, pregnancy may necessitate different strategies for managing diabetes. Close monitoring by specialized medical professionals is very important for the health of both mother and baby (3).

It is also important to know that many previously non-diabetic women develop diabetes during pregnancy. This is known as gestational diabetes. As with other forms of diabetes, gestational diabetes is characterized by an imbalance between sugar and insulin (a hormone that helps move sugar out of the bloodstream and into cells, where it is used for energy). During pregnancy, a slight change in this balance is normal and healthy. Hormonal changes in pregnancy confer increased resistance to insulin, which allows more glucose in the bloodstream to be passed to the baby. However, some women become too insulin resistant, and develop gestational diabetes (4).

If diabetes or gestational diabetes is not properly managed, the baby can grow abnormally large or macrosomic. This makes vaginal delivery very difficult. Mothers giving birth to babies with macrosomia are at increased risk of genital tract lacerations, postpartum hemorrhage, and uterine rupture, which can be life-threatening. Macrosomic infants are also at risk for serious complications, including shoulder dystocia, brachial plexus injury, bone fractures, and birth asphyxia (5).

Infants of diabetic mothers are also at higher risk of neonatal hypoglycemia, respiratory distress, being small for gestational age, polycythemia, and other complications (6).

There are three types of high blood pressure during pregnancy: chronic hypertension, gestational hypertension, and preeclampsia. Chronic hypertension is high blood pressure that begins prior to pregnancy or in the first 19 weeks of pregnancy. Gestational hypertension is high blood pressure that begins after 20 weeks of pregnancy. Preeclampsia is high blood pressure after the 20th week of pregnancy, in addition to other signs of organ dysfunction, such as proteinuria (an abnormal amount of urine protein). (7).

Hypertension and preeclampsia during pregnancy can cause serious health issues for the mother and baby. These include the following (7, 8, 9, 10):

Maternal complications (it is important to note that these can also cause serious harm to the baby):

• Eclampsia
• Placental abruption
• HELLP syndrome
• Damage to blood and organ systems
• Heart disease

Fetal complications:

• Intrauterine growth restriction (IUGR)
• Low birth weight
• Premature birth
• Oligohydramnios
• Fetal acidosis
• Epilepsy
• Cerebral palsy
• Learning disabilities
• Visual and hearing impairments

With proper medical management, a mother with high blood pressure or preeclampsia may be able to have a safe pregnancy and a healthy baby. However, it is extremely important that she be referred to physicians who are equipped to handle these conditions, and that she receive the monitoring and medical interventions that she needs.

Numerous health problems are associated with obesity during pregnancy. Obesity increases the risk of gestational diabetes, macrosomia, premature birth, hypertension, preeclampsia, and prolonged labor (11). Additionally, women who gain 35 or more pounds during pregnancy often end up having assisted deliveries with forceps or vacuum extractors (12), which increases the risk of infant brain bleeds (intracranial hemorrhages) (13).

It is very important that physicians properly advise expecting mothers of the complications associated with obesity during pregnancy, as well as have a discussion with them about how best to minimize risks.

Multiples (twins, triplets, or more) are often born prematurely, and are more likely to be delivered via cesarean section (C-section). Premature babies are more likely to have issues such as breathing problems (e.g. respiratory distress syndrome, apnea), intraventricular hemorrhage, necrotizing enterocolitis, jaundice, anemia, and infections (14). Preemies are also vulnerable to forms of brain damage that can lead to cerebral palsy — and research shows that multiples are more likely to develop cerebral palsy than are single preterm babies of the same gestational age.

Additional complications associated with multiples birth include intrauterine growth restriction (IUGR), preeclampsia, gestational diabetes, placental abruption, hyperemesis gravidarum, intrahepatic cholestasis of pregnancy (ICP), polyhydramnios, postpartum hemorrhage, twin-twin transfusion syndrome (TTTS), miscarriage, and stillbirth  (15, 16, 17).

Women over the age of 35 are often considered to be of “advanced maternal age,” although the risks associated with age increase more on a continuum basis (18, 19). Older mothers are at an increased risk of developing conditions like preeclampsia and gestational diabetes. They are also more likely to require delivery via C-section. Babies of older women are more likely to have genetic disorders such as Down syndrome, and are at higher risk for being born prematurely or having a low birth weight. Women of advanced maternal age are also at higher risk for having a miscarriage or stillbirth (20). This is not to say that women over the age of 35 cannot deliver healthy babies; just that they require additional monitoring to make sure that serious health problems do not pose a threat to their pregnancies.

Pregnancies may be designated as high-risk if the mother has a health condition such as polycystic ovary syndrome, kidney disease, autoimmune disease, thyroid disease, or HIV/AIDS. Alcohol consumption and cigarette smoking are also very dangerous for the developing baby.

In any pregnancy, medical professionals should conduct regular tests to evaluate the health of the mother and baby. Prenatal assessments may include non-stress tests (NSTs), contraction stress tests (CSTs), ultrasounds for AFI (amniotic fluid index), biophysical profiles (BPPs), Doppler flow studies, and more. These tests can be used to identify a number of fetal risks and pregnancy complications; concerning results may indicate that intervention is necessary.

In high-risk pregnancies, physicians often recommend more frequent and extensive testing. This is critical because careful surveillance can allow sufficient time for medical intervention if the need arises.

In particular, doctors and nurses must be vigilant for signs of fetal distress. These are indications that the baby is not receiving enough oxygen. If a baby is in distress, appropriate interventions may include the administration of oxygen, fluids, and medication to the mother, or a change in the mother’s position. Often, an emergency C-section is required in order to remove the baby from the conditions causing the fetal distress, especially if earlier interventions did not cause fetal heart tones to become reassuring.

For many patients with high-risk pregnancies, it is wise to have a planned early delivery. Physicians should discuss this option with their patients. In order to provide informed consent, patients must understand the risks and benefits of various courses of action.

It is negligence if medical professionals fail to conduct the appropriate prenatal testing for patients with high-risk pregnancies, obtain informed consent, or promptly intervene when necessary. If any of these negligent actions cause harm to a mother or baby, it constitutes medical malpractice.