High-Risk Pregnancy: What puts a pregnancy at risk?

There are various factors which can place a pregnancy at risk. Some develop during pregnancy, whilst others relate to pre-existing conditions that may place the mother or the baby at risk once pregnancy does occur.

Nonetheless a healthy pregnancy and birth are still possible even if you have been diagnosed as high-risk. Sasha Davidson, M.D., FACOG, a Maternal Fetal Medicine Specialist speaks with Dreaming of Baby on the factors behind a high-risk pregnancy, delivery, and the baby’s health.

Introducing Dr. Davidson, M.D., FACOG

Daniela: Good morning, Dr. Sasha Davidson. It’s a pleasure to welcome you on Dreaming of Baby today! Dr. Davidson is an OBGYN and maternal-fetal medicine physician with whom we shall be discussing high-risk pregnancies. For the benefit of our readers, it would be great if you could further introduce yourself as well as your experience in this field.

Sasha Davidson, M.D., FACOG: Good morning. I am a Maternal Fetal Medicine Specialist which is an OBGYN with specialized training to care for women with high-risk pregnancy conditions. Some may have heard the term and refer to me as a perinatologist. I also am trained to perform and interpret ultrasound to identify fetal abnormalities and evaluate the pregnancy and perform diagnostic procedures such as amniocentesis and chorionic villus sampling. I have spent several years practicing as a general Obstetrician and Gynecologist doing both deliveries and gynecologic surgeries. I now practice as a Maternal Fetal Medicine Specialist.

Sasha Davidson, M.D., FACOG: I trained at Johns Hopkins Hospital and Montefiore Medical Center, both of which provided me a breadth and depth of experience that has laid an excellent foundation for how I practice. I currently provide consultations to all women at various stages of their pregnancy and also to those with high-risk medical conditions. I provide genetic counseling and offer screening and diagnostic testing and I detect abnormalities in the developing fetus by performing and/or interpreting ultrasound. I care for two patients (mother and fetus) during the course of the pregnancy. In addition to pregnancy care, I also provide pre-conception counseling to all women planning a pregnancy, especially those undergoing IVF or who may have a condition that needs to be optimized prior to getting pregnant. I collaborate with the woman’s primary care doctor or specialist and create a plan for her future pregnancy.

Sasha Davidson, M.D., FACOG: I’ve been involved with several advisory boards and committees aimed at addressing high-risk issues in pregnancy, particularly preterm labor and infant mortality. I am currently on the March of Dimes advisory board and Maternal Child Health Committee for the state of Florida. I was also the lead investigator in a randomized clinical trial while at Montefiore Medical Center.

What is a high-risk pregnancy?

Daniela: Thank you for this impressive overview, Dr. Davidson. We are certainly in good hands today. As a first question, what classifies a pregnancy as high-risk?

Sasha Davidson, M.D., FACOG: There are several factors that classify a pregnancy as high-risk. There are high-risk conditions involving the mother, the fetus or both. Conditions that impact the mother include diabetes (Type I or Type II), high blood pressure, autoimmune disorders such as Lupus, or infectious diseases such as HIV for example. Then there are women of advanced maternal age (> 35 years old) that are known to have increased pregnancy risks such as genetic abnormalities or fetal growth abnormalities, to name a few. Also, women pregnant with multiples (twins, triplets, etc.) are at high-risk and any abnormal finding on ultrasound that impacts the fetal development classifies the pregnancy as high-risk. For example, I have identified a fetus with a heart defect, growth restriction where the weight was estimated to be small (<10th percentile), or even identified a large mass in the fetal neck or sacrum. These findings increase the pregnancy risk and therefore the woman and her developing fetus need to be monitored closely. I am able to counsel and guide a woman during the pregnancy, recommend a plan and coordinate care with pediatric specialists for care after delivery.

Daniela: What would care look like when a pregnancy is classified as high-risk?

Sasha Davidson, M.D., FACOG: High-risk pregnancy requires more evaluation and surveillance. Most women see their obstetrician 1-2 times per month up until the last trimester of the pregnancy then they are seen weekly until delivery. In addition, most low-risk pregnant women will have maybe 1 or 2 ultrasounds for the entire pregnancy and this is considered to be normal because they are healthy. In the case of high-risk pregnancy, a diabetic mother for example, may be seen weekly to monitor her blood sugar levels and to change her insulin regimen. Also, she will have ultrasound evaluations every 3-4 weeks to make sure her fetus is growing normally and that there are no abnormal findings that jeopardize the health of the fetus. So, most women with high-risk pregnancies are seeing the MFM specialist weekly or 2-3 times per month depending on the clinical situation.

Sasha Davidson, M.D., FACOG: “High-risk pregnancy requires more evaluation and surveillance.”

Daniela: In such cases of a high-risk pregnancy, would there be continuity of care, including the delivery? In other words, would the maternal fetal specialist be also present for the birth?

Sasha Davidson, M.D., FACOG: There are certainly Maternal Fetal Medicine specialists who deliver babies and will therefore “take over” the care of the pregnancy, however this is different in different parts of the country and also depends if you are seeing a doctor at an academic medical institution. For the most part, the majority of MFMs will perform a consultation and provide recommendations and guidance to the general obstetrician caring for the patient. MFMs are available to answer questions when needed or even evaluate a pregnant patient admitted in the hospital if a complication should arise. The MFM is not usually present for delivery but in the event of an emergency will be notified to assist and manage the care with the general obstetrician. There are various models of practice throughout the US. In South Florida, where I practice, there are no MFMs that perform deliveries that I am aware of. I do favor the model of providing prenatal care and performing the delivery for a patient with whom I have been following so closely, as it certainly lends to improved continuity of care for the pregnancy and the patient.

Gestational Diabetes and Gestational Hypertension

Daniela: Thank you for elaborating on this, Dr. Davidson. Going back to conditions associated with a high-risk pregnancy. In terms of diabetes and high blood pressure that is still undiagnosed, what should the mom-to-be stay on the lookout for?

Sasha Davidson, M.D., FACOG: Women can have diabetes or high blood pressure before getting pregnant or can develop these conditions during the pregnancy. In fact, many women become pregnant while on blood pressure medications and various insulin regimens for diabetes. When these two conditions develop during pregnancy we term the phrase “gestational diabetes” or “gestational hypertension”. In regard to being on the look-out, all pregnant women are screened for diabetes between the 24th to 28th week of the pregnancy. I always encourage pregnant women to make good nutritional choices during their pregnancy and minimize their intake of carbohydrates not just before their sugar test. In addition, 30 minutes of low impact exercise such as walking goes a long way. Daily exercise is ideal however 2-3 times a week is acceptable. Women with certain risk factors such as a BMI > 30, family history of diabetes, or who lead a sedentary lifestyle, are highly encouraged to pay close attention to their nutritional choices during pregnancy. Inevitably, a woman may be doing everything right and may still develop gestational diabetes. It is important for these women to know that they are not doing anything wrong and understand that the pregnancy causes her to produce certain hormones that reduces the body’s ability to respond to insulin and she becomes insulin resistant. This is one of many reasons why women develop gestational diabetes (GDM).

Sasha Davidson, M.D., FACOG: With regards to gestational hypertension, this is a disease process that is on a spectrum and many women have heard the term preeclampsia. Preeclampsia is a toxic syndrome that only happens during pregnancy and is sometimes preceded by gestational hypertension (high blood pressure). Preeclampsia is diagnosed when the blood pressure is elevated above a certain level and the body is excreting a lot of protein in the urine. In addition, women may develop certain symptoms such as headaches and visual disturbances (blurry vision, flashes of light). Most women get concerned about the swelling of their feet, however as a physician, I am most concerned about the degree of this swelling or when a woman starts getting swelling in her face and hands where she cannot fit her wedding ring. During every visit in the 3rd trimester, I assess every woman for any signs or symptoms of preeclampsia and so should your obstetrician. If a woman finds herself having these symptoms, she should contact her doctor so that she can get her blood pressure checked and undergo lab evaluation. There are often false alarms, but it never hurts to be proactive and remain safe. Women with gestational hypertension (high-blood pressure) are monitored very closely because they can develop preeclampsia and depending how far along a woman is in the pregnancy, the MFM specialist may recommend delivery of the baby before the symptoms worsen. Delivery is the only way to treat/cure preeclampsia. However, it is not a one size fits all recommendation as there are multiple factors that must be taken into consideration. That is where an MFM specialist like me gets involved if not sooner.

Sasha Davidson M.D., FACOG: “Preeclampsia is diagnosed when the blood pressure is elevated above a certain level and the body is excreting a lot of protein in the urine. In addition, women may develop certain symptoms such as headaches and visual disturbances (blurry vision, flashes of light).”

Daniela: Thank you for this very informative input. With regards to gestational diabetes, are there any symptoms that the mom-to-be can look out for?

Sasha Davidson, M.D., FACOG: Unfortunately, gestational diabetes will not present with any classic symptoms as you would find in the non-pregnant state like having increased urination, thirst, etc. When performing an ultrasound however, I may identify that the amniotic fluid is increased (polyhydramnios) and this is often a clue for me as the physician. Depending on when I identify this during the pregnancy, I will ask the patient, “Did you pass your glucose test?” and if she has not had her glucose screen I then recommend to her and her primary obstetrician to have the sugar test done. In addition, when using ultrasound to estimate the fetal weight in the early to mid-third trimester, if the fetus measures >90th percentile in overall weight or if the fetal abdomen measures > 90 percentile, I start to suspect that there may be some glucose intolerance that has developed. Depending on the findings and how many weeks of the pregnancy, I may have the patient check her daily blood glucose levels for 1 or 2 weeks to assess if she needs to be treated.

Daniela: Thank you for clarifying. Going back to pre-pregnancy, how can a woman reduce her chances of a high-risk pregnancy?

Sasha Davidson, M.D., FACOG: That’s the million-dollar question. I encourage women to eat healthy, exercise regularly and supplement with the right vitamins. This is true for anything but is so important in planning for a pregnancy and during pregnancy. If a woman is overweight, I recommend she try to lose at least 5-10 pounds before she gets pregnant. I’ve actually put together an exercise regimen that I offer and discuss with my patients. In addition, eating right by watching the sugars and carbohydrates in one’s diet is extremely important. This doesn’t mean you can’t enjoy a treat once in a while but in moderation. Folic acid is very important to take before attempting pregnancy because folate (folic acid) helps in the development of the baby’s brain and spinal cord. Some women believe that if they start to take prenatal vitamins as soon as they find out they are pregnant then that will be good enough, however, it is extremely important to start taking supplements with folic acid at least 12 weeks prior to getting pregnant. Keep in mind that not all vitamins are created equal. A lot of the vitamins over the counter and also those prescribed have fillers. I recommend a top of the line, quality brand of prenatal vitamins to take before conception, during pregnancy and in the postpartum period. The research and development behind the supplements I recommend is incredible and it has become a staple in my practice. I am happy to share this information if women are interested.

Sasha Davidson, M.D., FACOG: “I encourage women to eat healthy, exercise regularly and supplement with the right vitamins. This is true for anything but is so important in planning for a pregnancy and during pregnancy.”

Sasha Davidson, M.D., FACOG: There are conditions that may simply just develop during the pregnancy as I previously discussed and that cannot be predicted in advance. There are certainly risk factors that I use to help me identify which woman may be at risk during pregnancy. I recommend that women, especially those with a health condition treated before pregnancy, ask to be referred to an MFM specialist. I also strongly encourage ALL pregnant women to have their fetal anatomy ultrasound with an MFM specialist who is highly trained to detect abnormalities. Ultrasound technology has advanced and we are now able to identify certain women at risk of a preterm delivery for example. The science is constantly improving and recommendations change, so it is important to ask questions to your physician and ensure that you are comfortable with the plan of care.

Would I have to undergo a c-section if my pregnancy is high-risk?

Daniela: Great, many thanks for this insight. A penultimate question if I may, and one which may be of concern to many moms-to-be. Do all high-risk pregnancies end up in a c-section?

Sasha Davidson, M.D., FACOG: NO! I am so passionate about this topic of c-section. Here in South Florida the c-section rate at some hospitals is as high as 50%. There are several reasons why we see this increased rate, but patients need to know that not all high-risk pregnancies require a c-section for delivery. The overall c-section rate in the US is astounding (~32%) and the governing bodies of our specialty are always looking to identify ways to reduce the c-section rate. In fact, my randomized clinical trial examined the c-section rate in a subset of women who needed to be induced. It’s one thing to need an emergency c-section because of the baby’s heart rate or because the cervix stopped dilating during labor, but undergoing an elective c-section without a true indication is entirely something else. I encourage patients to ask their obstetrician questions and inquire as to the clinical reasons for the c-section and to not be afraid to get a second opinion.

Sasha Davidson, M.D., FACOG: “Patients need to know that not all high-risk pregnancies require a c-section for delivery.”

High-risk pregnancy: will my baby be ok?

Daniela: It’s great that you’ve clarified this, Dr. Davidson. On a final note, being classified as high-risk can, of course, be worrying to many moms-to-be, especially when they think of their baby’s health. For the mom-to-be asking if her baby will be ok, what would be your advice?

Sasha Davidson, M.D., FACOG: I try my best to reassure mothers and tell them to “let me do the worrying for them” but I understand that is difficult to do as our minds get the best of us and lead many to still worry. I admit that I encourage meditation. Mindfulness has been shown to be so powerful, especially as it relates to health and wellness. I do remind mothers/parents that our ability to treat and care for babies, manage abnormalities and improve neonatal outcomes is excellent and the science and technology is only getting better. As long as they are compliant with recommendations and the plan of care, we are usually able to get through the pregnancy without any unanticipated issues. My goal is to help pregnant mothers-to-be to enjoy their pregnancy despite the high-risk nature of it. In the end, our goal is always for a healthy baby and a happy mother. It may take a little work to get that but I’m there to guide them through it. I have had the pleasure of seeing moms return to my office with baby in arms and nothing but smiles and appreciation and I am grateful to be a part of that.

Daniela: That’s wonderful, Dr. Davidson. What you have shared with us will help many. I wish to thank you for your time today, it’s been a truly enlightening discussion on this very important subject.

Sasha Davidson, M.D., FACOG: It is my pleasure. Happy to do it and be a part of educating pregnant women.

Are you worried about your pregnancy? Read more about Dr. Davidson and get in touch by clicking here.

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