High-Risk Pregnancy: Introduction and Risk Factors

There is no formal or universally believed explanation of a high-risk pregnancy. However, a high-risk pregnancy generally involves at least one of the following:

That the probability that the woman or the baby will die or become ill is higher than usual.

That the probability of complications appearing before or after delivery is higher than usual.

Many women with complex, high-risk pregnancy conditions benefit from treatment in a specialized center attended by doctors who specialize in high-risk pregnancies.

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Maternal mortality

Maternal mortality refers to the death of the woman when it is caused by complications of pregnancy and childbirth.

In the United States, in 2017, 19 women died for every 100,000 deliveries. In the United States, nearly half of pregnancy-related deaths occur in African-American women. The maternal mortality rate is higher in the United States than in other Western countries, such as the following:

  • Germany: 7 deaths per 100,000 deliveries
  • Netherlands: 5 deaths
  • Poland: 3 deaths
  • Spain: 4 deaths
  • Sweden: 4 deaths
  • Switzerland: 5 deaths
  • UK: 7 deaths

However, almost all maternal deaths occur in developing countries. More than two-thirds are produced in sub-Saharan Africa (including Nigeria) and almost one-fifth is produced in South Asia (including India). [ Read about: How to prepare for a healthy pregnancy |7 Tips|]

Globally, the maternal mortality rate varies greatly by race and ethnicity. In the United States, the maternal mortality rate is 3 times higher for women of African descent and 2.5 times higher for women of American Indian and Alaska Native descent than it is for women of Caucasian descent. On other hand Brazil, maternal mortality is approximately 5 times higher among women of African descent than among those of Caucasian descent. In the UK it is much higher among women of African descent than among those of Caucasian descent.

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The most frequent causes of death in pregnant women are:

  • Bleeding (hemorrhage), which accounts for more than a quarter of deaths
  • High blood pressure, including preeclampsia (a kind of high blood pressure that emerges during pregnancy)
  • Sepsis (severe generalized [systemic] body response to infection)
  • Miscarriage
  • A pregnancy is located in an abnormal location ( ectopic pregnancy ), that is, it does not occur in its usual location in the uterus.
  • Complications of childbirth (Read Also: 6 Types of childbirth and their characteristics)
  • Pulmonary embolism
  • Conditions that the woman suffered before becoming pregnant (such as obesity and infectious diseases, including HIV infection)

Problems that contribute to death in pregnant women include:

  • The delay in seeking medical attention by the pregnant woman or her relatives when the pregnant woman has a problem.
  • Lack of transportation to a health center.
  • Delay in care in a health center.

About 3 in 5 maternal deaths could be prevented.

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Perinatal mortality

Perinatal mortality refers to the death of fetuses and newborns occurring close to the time of delivery.

In the United States, the perinatal mortality rate is 6 to 7 deaths per 1,000 deliveries.

The most common causes of death in fetuses and newborns are:

  • Complications of childbirth
  • Disorders presented by the mother, such as high blood pressure, diabetes, obesity, or an autoimmune disorder
  • Infections
  • Placenta abnormalities, such as premature detachment of the placenta ( abruptio placentae, abruption placenta, or ablatio placentae ) or a placenta previa ( placenta that is misplaced or displaced )
  • Genetic abnormalities in the fetus
  • Congenital abnormalities
  • Preterm (premature) delivery

Read Also: What is fetal distress and what are its causes?

Risk assessment during pregnancy

A high-risk pregnancy is made up of certain circumstances or characteristics called risk factors. As part of routine pregnancy care, doctors identify these factors to determine the degree of risk for each woman and baby to provide better medical care. Genetic evaluation is particularly important. It consists of evaluating the couple’s family history and, if necessary, testing blood or tissue samples (such as cells from the inside of the cheek). This evaluation is done to determine if a couple is at increased risk of having a baby with an inherited genetic disorder. 

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Factors that can affect risk in women include:

  • Physical characteristics (such as age and weight)
  • Social characteristics (such as marital status)
  • Problems during previous pregnancies
  • Problems that develop during childbirth
  • Disorders that were present before pregnancy, such as chronic high blood pressure (hypertension), diabetes, sexually transmitted diseases, or kidney infections
  • Disorders that appear during pregnancy, such as gestational diabetes or pre-eclampsia
  • Exposure to harmful substances during pregnancy

A high-risk pregnancy requires close monitoring, and women are sometimes referred to a center specializing in the care of these types of pregnancies.

The most common reasons for this referral before delivery are:

  • Preterm (premature) delivery (often due to premature rupture of the membranes )
  • Preeclampsia
  • Vaginal bleeding (gynecology)
  • Disorders that were already present before or developed during pregnancy, such as diabetes, high blood pressure, and severe (morbid) obesity.

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Risk factors for high-risk pregnancy

Some risk factors are present before women become pregnant. These risk factors are:

  • Certain physical characteristics such as the age and social characteristics of women
  • Problems in a previous pregnancy
  • Certain disorders present before pregnancy
  • Exposures that can harm the fetus

Other problems that increase risk can develop during pregnancy and delivery.

The need for surgery during pregnancy (particularly abdominal surgery) increases the risk of premature delivery and miscarriage, especially early in pregnancy. For this reason, the intervention is postponed as long as possible. However, if accurate, surgery should be done without delay and is generally reasonably safe.

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Physical characteristics

The following characteristics of women affect risk during pregnancy.

Age

About 13% of all pregnancies occur in teenagers. These girls are at increased risk of high-risk pregnancy

  • Preeclampsia (a type of high blood pressure that occurs during pregnancy)
  • Premature delivery
  • Anemia

Teen mothers can have low birth weight babies ( small for gestational age ).

In part, this increased risk is due to the lower likelihood that adolescent girls will receive medical care during pregnancy. As a result, they may be unaware of what activities and behaviors (such as smoking, drinking alcohol, and having sex without a condom) can put their pregnancy at risk. Many teens smoke. They are also at a higher risk of contracting a sexually transmitted disease. Using condoms (condoms) can help prevent sexually transmitted diseases.

Women 35 years of age and older are at increased risk of having the following:

  • Having a pre-existing disorder that increases your risk during pregnancy, such as hypertension or diabetes
  • Problems related to pregnancy, such as preeclampsia, gestational diabetes (diabetes that develops during pregnancy), chromosomal abnormalities in the fetus, and stillbirth ( stillbirth )
  • Complications during labor, such as difficult labor, premature detachment of the placenta ( abruptio placentae, abruptio placentae, or ablatio placentae ), or a placenta previa ( placenta that is misplaced or displaced )

As women age, genetic testing for chromosomal abnormalities becomes more important.

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Weight

Women who are very thin, with a body mass index less than 19.8 (see the Determination of Body Mass Index table ), or who weigh less than 100 pounds (45 kg) before becoming pregnant are more likely to

  • Having small, underweight babies

Overweight women (with a BMI between 25 and 29.9 before pregnancy) and obese women (with a BMI greater than 30) are more likely to have the following problems:

  • Very large babies ( large for gestational age ), which can make delivery difficult
  • Low birth weight babies ( small for gestational age )
  • Babies with congenital malformations
  • Miscarriages and stillbirth
  • Gestational diabetes
  • Gestational hypertension (high blood pressure that appears after 20 weeks of pregnancy)
  • Preeclampsia (gestational hypertension accompanied by loss of protein in the urine)
  • Pregnancies lasting 42 weeks or longer ( post-term pregnancy )
  • Need for cesarean delivery

Doctors encourage overweight and obese women to exercise at least 3 times a week for a total of 150 minutes a week. These women should talk to their doctor about which exercises are appropriate for them. Changes to a healthier diet may be recommended. We recommend you to read another article on kidsrush.com which is about How to diet in pregnancy

Height

Women are shorter than 1.50 m are more likely to have a small pelvis, which can make it difficult for the fetus to pass through the pelvis and vagina (birth canal) during delivery. For example, the fetus’s shoulder is more likely to fit against the pubic bone. This complication is called shoulder dystocia. Women of short stature are also more likely to have a premature ( preterm ) delivery and a low birth weight baby (small for gestational age).

Reproductive abnormalities

Structural abnormalities of the uterus or cervix increase the risk of the following:

  • A difficult delivery
  • A miscarriage during the second trimester and preterm labor
  • A fetus in an abnormal position
  • Preterm labor or a premature baby
  • Need for cesarean delivery

Structural abnormalities consist of a double uterus, fibroids in the uterus, and a weak (incompetent) cervix ( cervical insufficiency ) that tends to dilate as the fetus increases in size. Fibroids sometimes cause misplacement of the placenta (called placenta previa ), too early a start of labor ( preterm labor ), and miscarriages. Cervical insufficiency increases the risk of a baby being born too early (preterm labor).

Social characteristics

Being single or belonging to a low socioeconomic group increases the risk of problems during pregnancy. The reason these characteristics increase the risk is not very clear, but it is probably related to other factors that are more frequent among these women. For example, these women may be more likely to smoke, less likely to eat a healthy diet, more likely to have unprotected sex, and less likely to get proper medical care.

Problems in a previous pregnancy

When women have had a problem in one pregnancy, they are more likely to have another problem, often the same, in subsequent pregnancies. These problems include having any of the following:

  • A premature baby
  • A previous miscarriage
  • An underweight baby ( small for gestational age )
  • A baby weighing more than 4.5 kg ( large for gestational age )
  • A baby with birth defects
  • Delivery after the 42nd week of pregnancy ( late, postmature, delayed, or post-term delivery )
  • An Rh incompatibility that requires a blood transfusion to the fetus
  • A delivery that has required a cesarean section
  • A baby who has died shortly before or after birth ( stillbirth, stillbirth )
  • An excess of amniotic fluid in the uterus ( polyhydramnios )
  • A shortage of amniotic fluid in the uterus ( oligohydramnios )
  • A fetus placed in an abnormal position, such as the buttocks first (breech)
  • A baby whose shoulder got caught in the birth canal ( shoulder dystocia )
  • An injury that stretches the nerves in the baby’s shoulder (brachial plexus injury) during delivery
  • Previous pregnancy with more than one fetus ( multiple births )
  • A seizure disorder
  • A baby with cerebral palsy

These women may have a condition that causes the same problem to recur. For example, women with diabetes are more likely to have babies weighing more than 5 kg at birth.

Women who have had a newborn with a genetic disorder or birth defects are more likely to have another baby with a similar problem. Before trying to get pregnant again, it may be appropriate to perform genetic tests on the baby (even stillborn) and the parents. If these women become pregnant again, certain tests, such as high-resolution ultrasound, chorionic villus biopsy, and amniocentesis, may be done to determine if the fetus has a genetic disorder or birth defect. These women can be referred to a specialist.

Being pregnant 5 or more times increases the risk of having premature contractions and excessive bleeding after delivery.

Having twins or more fetuses in one pregnancy increases the risk of the following:

  • Underweight babies
  • Preterm (premature) delivery
  • Placenta separating too soon ( placental abruption )
  • Congenital abnormalities
  • Stillbirth or death of the newborn
  • After delivery, vaginal bleeding from the mother

Disorders present before pregnancy

Before becoming pregnant, a woman may have a disorder that increases the risk of pregnancy problems. These disorders include

  • Arterial hypertension
  • Diabetes
  • Nephropathy
  • Kidney infections
  • heart failure
  • Sickle cell anemia (sickle cell anemia or sickle cell disease)
  • Sexually transmitted diseases

Women with one of these disorders should speak with a doctor to try to be in the best possible physical condition before becoming pregnant. Once they are, they may require special care, often from an interdisciplinary team. The team may consist of an obstetrician (who may also be a specialist in the disorder), a specialist in the disorder, and other health professionals (such as nutritionists).

Disorders during pregnancy

During pregnancy, a problem may arise or a disorder may occur that makes it a high-risk process.

Certain disorders that occur during pregnancy are related to or are complications of pregnancy. Other disorders are not directly related to pregnancy. Certain disorders are more likely to occur because of all the changes pregnancy causes in a woman’s body.

Complications of pregnancy are problems that appear during pregnancy. They can affect the woman, the fetus, or both and occur at different times during pregnancy. For example, complications such as a displaced placenta ( placenta previa ) or your premature detachment of the uterus ( placental abruption ) can cause bleeding into the vagina during pregnancy. Women who bleed heavily are at risk of losing the baby or going into shock and, if not treated right away, dying in childbirth.

Other pregnancy complications include

  • Problems related to amniotic fluid (the fluid that surrounds the fetus in the womb)
  • A weak cervix ( cervical insufficiency ) that tends to open (dilate) as the fetus grows
  • A misplaced pregnancy ( ectopic pregnancy )
  • Vomiting and severe nausea during pregnancy ( hyperemesis gravidarum )
  • An infection of the tissues around the fetus, such as amniotic fluid ( intra-amniotic infection )
  • Spontaneous abortion or stillbirth previous
  • Preeclampsia (a type of high blood pressure that occurs during pregnancy)
  • Rh incompatibility (when the mother has Rh-negative blood and the fetus has Rh-positive blood)

Exposures during pregnancy

During pregnancy, the risk of having a baby with a birth defect can be increased by exposure to the following:

  • Certain infections
  • Certain drugs
  • Radiation and certain chemicals

These types of substances and conditions are called teratogens.

The birth defects are more likely to occur if women are exposed to a teratogen 2 to 8 weeks after becoming pregnant (4 to 10 weeks after their last menstrual period) since the body’s fetus is formed during this period. The risk of miscarriage also increases.

Infections that are particularly dangerous during pregnancy include:

  • Chickenpox
  • Hepatitis
  • Herpes simple
  • Rubella (German measles)
  • Syphilis
  • Toxoplasmosis
  • Infections cytomegalovirus or Coxsackievirus
  • Zika virus infection

Medications and other substances that can increase the risk of birth defects include:

Some prescription drugs (see table Medications That May Cause Problems During Pregnancy )

Exposure to high temperatures (for example, in a sauna) during the first trimester has been linked to spina bifida.

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Mercury in seafood

Consuming too much mercury in fish and shellfish can harm the fetus. However, fish and shellfish contain nutrients that are important for the growth and development of the fetus and breastfed babies. Therefore, the Food and Drug Administration (FDA) recommends that women who are pregnant, could become pregnant, or are breastfeeding:

  • Do not eat tilefish from the Gulf of Mexico, shark, swordfish, bigeye, marlin, and king mackerel.
  • Limit the amount of albacore tuna to 4 ounces (about 113 grams, an average meal) a week.
  • Before consuming fish that come from lakes, rivers, and coastal areas, check the advisories of the local councils on the safety of this type of fish, and if it is not known with certainty if the mercury levels are low or not This information is available, limit the amount consumed to 4 ounces (about 113 grams, an average meal) per week and do not consume other fish or shellfish that are high in mercury during that week.
  • Each week, consume 8 to 12 ounces (between 240 and 360 grams, 2 or 3 medium meals) of a variety of fish and shellfish that are lower in mercury.

Low-mercury seafood includes flounder, shrimp, canned light tuna, salmon, pollock, tilapia, cod, and catfish (see Advice About Eating Fish: For Women Who Are or Might Become Pregnant, Breastfeeding Mothers, and Young Children ). Some authorities ( Consumer Reports: Choose the Right Fish To Lower Mercury Risk Exposure ) advise against consuming any variety of tuna during pregnancy.

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More information

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