High Risk Pregnancy + Antenatal Care

Hypertension in pregnancy

Hypertension means high BP. High BP which develops during the pregnancy is called pregnancy induced hypertension (PIH). Some women have high BP prior to conceiving, this is called chronic hypertension. Women with chronic hypertension may already be on drugs while conceiving and may develop a superimposed PIH later during their pregnancies.

About 1 in 10 pregnant women has problems with high blood pressure.

About 1 in 20 pregnant women has pre-existing high blood pressure.

If you are pregnant you should have regular blood pressure checks. Most women will not develop any problems with their blood pressure during pregnancy. However, in some women, high blood pressure can develop. It is often mild and not serious. But in some cases, high blood pressure can become severe and can be harmful to both the mother and baby.

High-Risk-Pregnancy

Pregnancy induced Hypertension

Some women can develop new high blood pressure during their pregnancy. This is called pregnancy-induced high blood pressure (or hypertension) or gestational high blood pressure (or hypertension).

Gestational high blood pressure is high blood pressure that develops for the first time after 5 months of pregnancy. Women with a family history of hypertension or history of PIH in previous pregnancies have a higher incidence of developing it. Also women who are overweight or obese prior to pregnancy and women who tend to gain too much weight during pregnancy are at high risk of developing PIH.

 

Chronic hypertension

Women having high blood pressure prior to conceiving or if a high BP is recorded prior to 5th month of pregnancy, fall in the category of chronic hypertension. These women have a risk of developing superimposed PIH and thereby hold a higher risk compared to women with only PIH. A team work of gynecologists and physicians is needed to manage such patients.

 

Complications due to hypertension in pregnancy

Complications are rare if hypertension is picked up at the right time and treated correctly. However if neglected, hypertension in pregnancy can cause problems like

Maternal: In well controlled cases maternal complication are rare however in neglected cases it can lead to maternal convulsion and multi organ damage. These complications are seen in women who do not receive adequate antenatal care during their pregnancy. We hardly come across these complications in our practice.

Fetal: Abortion, preterm delivery, intrauterine growth retardation (IUGR), Low birth weight babies and even intrauterine fetal death (IUFD) in severe cases. All these problems can be avoided if treatment is taken at the right time.

Neonatal: Need for NICU care, Multiple investigations, Problems of prematurity and rarely neonatal death.

 

Warning symptoms

There are some symptoms that you should look out for that could be signs of uncontrolled BP. If you develop any of these, you should see your doctor urgently so that they can check your blood pressure and do other investigation. They include:

  • Severe headaches that do not go away.
  • Problems with your vision, such as blurred vision, flashing lights or spots in front of your eyes.
  • Abdominal (tummy) pain. The pain that occurs with hypertension tends to be mainly in the upper part of the abdomen, just below your ribs, especially on your right side.
  • Vomiting later in your pregnancy (not the morning sickness of early pregnancy).
  • Sudden swelling or puffiness of your hands, face or feet.
  • Not being able to feel your baby move as much.
  • Just not feeling right.

 

Prevention

  • To have adequate weight loss before you conceive.
  • Avoid excessive weight gain during pregnancy. Normal weight gain allowed during pregnancy is 11-15 kg. Too much gain or too rapid gain can predispose to Hypertension.
  • Adequately controlled BP on safe medications before one conceives.
  • Regular BP check up if family history of Hypertension.
  • Zinc and calcium supplements have shown to prevent hypertension according to some studies.
  • Low dose Aspirin given in high risk cases have successfully shown to prevent Hypertension and its complication during pregnancy.

 

Treatment

Depends on how high is the blood pressure and in what stage of pregnancy has it been diagnosed.

  • Mildly high blood pressure is blood pressure between 140/90 and 149/99 mm Hg.
  • Moderately high blood pressure is blood pressure between 150/100 and 159/109 mm Hg.
  • Severely high blood pressure is blood pressure of 160/110 mm Hg or higher.

Mild hypertension may need no treatment. There is usually little risk. But it is important to regularly monitor BP and report on development of warning symptoms. Regular checks to see how your pregnancy is progressing may be all that is needed until the natural time of birth. Checks may include blood tests and an ultrasound scan to look at how your baby is growing and to check the blood flow from the placenta to the baby (Doppler). Sometimes a low dose anti- hypertensive drug is started to prevent further exacerbation.

In case of moderate to severe hypertension, there are risks to both, the mother and the baby. Blood tests may be suggested to check to see how much your blood pressure is affecting you. The wellbeing of your baby may also be checked using ultrasound scanning and doppler. A recording of your baby’s heart rate may be carried out. Many a times the only cure is to deliver your baby. This may be fine if your pregnancy is near to term. The birth can be induced, or your baby can be born by Caesarean section if necessary. However, a difficult decision may have to be made if high blood pressure is detected earlier in your pregnancy. Medication, one or more, to lower the blood pressure may be prescribed for a while. This may allow your pregnancy to progress further before delivering your baby.

In short presence of hypertension before or after pregnancy should be taken seriously as, if uncontrolled it has drastic consequences on both mother and baby.

 

Diabetes in pregnancy

Pregnant women who have high blood sugar (glucose) levels during pregnancy, but did not have diabetes before pregnancy are said to have gestational diabetes (GDM). The abnormally high blood sugar appears to be caused by hormones produced by the placenta that block the action of the mother’s own insulin. Because insulin is required for sugar to enter cells, the sugar rises in her blood. Gestational diabetes usually develops in the second trimester as the placenta is getting larger. If your diabetes was diagnosed in the first half of your pregnancy, it’s possible you had diabetes even before you conceived.

 

High risk for diabetes

Following women have high risk of diabetes:

  • Family history of diabetes.
  • Increased weight gain during pregnancy.
  • Overweight or obese prior to pregnancy.
  • Polycystic ovarian disease

 

Testing for diabetes

If you are at risk for developing GDM certain tests will be performed. You will need to give your fasting blood sugar followed by a glucose syrup drink. After an hour your blood is tested for excessive sugar (1 hour oral glucose tolerance test). If the sugar level is too high ( > 140 mg/dl ) you will need to take an additional three-hour test . From 3% to 12% of all pregnancies are diagnosed with diabetes.

 

Consequences of Diabetes

Women who are diabetic even when they are not pregnant are called pregestational diabetics. In pregestational diabetics fasting blood sugars persistently greater than 120 mg/dl in early pregnancy can cause miscarriage and birth defects. Mothers who are diabetic only when they are pregnant (GDM) do not have higher rates of birth defects, but may have a higher chance for a stillbirth if their sugars are not controlled well.

Later in pregnancy the excessive sugar in either type of diabetic crosses the placenta to the baby. The consequences are the baby grows, and grows, and grows. As the baby’s size increases its risk for birth injuries with a vaginal delivery increases. These injuries may include a fractured collar bone, a fractured arm, or paralysis of the upper arm. Fortunately, these conditions are usually temporary. Very rarely, an infant may be so large it fails to deliver in a timely manner and suffers brain damage from prolonged lack of oxygen. If your baby is too large for you to safely attempt a vaginal delivery, a cesarean delivery is the best option.

Babies born to mothers with poorly controlled diabetes are also at higher risk for low blood sugar , jaundice, polycythemia ( high numbers of red blood cells) , low calcium levels, and an increased risk for fetal death during the last months of pregnancy. Lastly uncontrolled diabetes places the mother at risk for developing polyhydramnios (excessive amniotic fluid) and pre-eclampsia (high blood pressure with protein in the urine). Also there is a high risk of developing infections during pregnancy and wound infection after delivery.

 

Treatment

The first step in treatment is usually a change in diet. If you are diagnosed with GDM you may initially be instructed to:

  • Avoid sugars and sweets.
  • Avoid instant foods.
  • Avoid rice and other similar products.
  • Do not drink fruit juices.
  • Eat 3 meals and snacks daily. Wait 2 to 3 hours between meals and snacks.
  • Do not eat fruit for breakfast. Eat fruit for snacks.
  • Do not eat dry cereal (like cornflakes) for breakfast.
  • Eat more cooked or raw vegetables.

In addition a minimum of three episodes of exercise per week is also recommended. The sugar lowering effect of exercise may not be seen for 2 to 4 weeks.
If diet and exercise don’t keep blood sugar controlled, then you will likely be prescribed insulin. If your blood sugar is only mildly elevated you may be offered an oral medication called metformin or glyburide. Approximately 15% to 20% of women with gestational diabetes will require insulin therapy. The major side effect of these medications is possible low blood sugar (hypoglycemia).

 

The Risk of Developing Diabetes Later in Life

Most women diagnosed with gestational diabetes may expect their blood sugars to return to normal after they have delivered. Whether a woman develops diabetes later in life seems to be predicted to some degree by her fasting blood sugar levels. If her fasting glucose levels during pregnancy are 105 to 130 mg/dl, 50% of mothers may be expected to become diabetic after pregnancy. 86 % of women with fasting blood sugars greater than 130 mg/dl may be expected to become diabetic.

It is recommended that women with gestational diabetes be retested for diabetes six weeks after delivery. It is important that this follow up be done, so that women with diabetes may be effectively treated to avoid the harmful effects of neglected diabetes on the mother’s health and her future pregnancies.

 

Twin gestation

Twin or multiple pregnancies(triplets or quadruplets) are common especially when you are pregnant after treatment with ovulation induction, IUI, Or IVF. Journey through a twin pregnancy can be challenging. Multiple pregnancies account for one in every 80 pregnancies conceived naturally. With fertility treatment, the incidence of multiple pregnancies increases to one in every four pregnancies resulting from treatment.

To start with if one has more than two fetus in the womb, there is an option wherein the pregnancy can be reduced to two by a procedure called embryo reduction. This procedure is done by fetal medicine experts. It is an invasive procedure with its own risks and complications; you may discuss the options with your Obstetrician. This is mainly done because it is difficult to carry more than two fetus till full 9 months and there are very high chance of complications, like fetal and neonatal deaths, increased maternal problems like high BP, anemia, Blood loss, to name a few.

This is usually diagnosed when you attend for your dating scan between 7 and 8 week. Early diagnosis is also possible if your obstetrician is monitoring your blood beta-HcG levels and the values more than double in consequent readings.

 

Problems associated with twin pregnancies :

  • Minor problems such as morning sickness, heartburn or acidity, ankle swelling, varicose veins(dilated veins on the feet and legs), backache and tiredness can be increased
  • Anaemia (low iron) : As the Iron requirement is high you may need additional iron in form of tablets or injections depending upon the hemoglobin levels.
  • Pre-eclampsia (high blood pressure with protein in urine)
  • Gestational diabetes (pregnancy related diabetes)
  • Ante-partum and post-partum hemorrhage (bleeding before and after delivery)
  • Fetal growth restriction (Small size baby).
  • Preterm labour and delivery. (Delivery before 8 months of pregnancy).
  • Problems with babies delivering prematurely.

 

Antenatal care

A good and regular (3-4weekly) follow is utmost important in women with twin pregnancy. This not only helps to monitor the growth of the babies, but also enables to pick up early complications and therefore helps in management.

Ultrasonography are done as in normal pregnancy i.e. at 11-12 weeks, at 20 weeks, at 32-34 weeks. Additional sonography may be advised if the obstetrician suspects some abnormalities. A Doppler sonography wherein the blood flow to the babies is evaluated may be done one or two times between 28-34 weeks or as suggested by the obstetrician.

Other than monitoring the growth of the babies some things which sonography may help in is the location of placenta (After births), position of babies (Head down or feet down), and cervical length( length of mouth of uterus)Blood tests may be done more frequently almost every 11/2 to 2 months for early detection of anemia, deranged blood sugar etc.

 

Prevention of complications

  • Regular antenatal check ups, frequent Ultrasonography and blood tests.
  • Oral supplements for iron, vitamins, calcium and proteins. Very rarely if the women does not respond to medical management, supplements may be given in intravenous form.
  • Cervical os tightening (Stitch taken at the mouth of uterus) in certain selected cases where in there are high chances of mouth of uterus opening very early in pregnancy.
  • Prophylactic betamethasone injections at 7-8 moths to facilitate fetal lung maturity in case of premature birth and thereby reduce fetal morbidity.
  • Additional drugs like L-Argine or ecosprin low dose to prevent PIH.

 

Planning delivery

If all goes well, delivery is usually planned around 36-37 weeks. If a cervical knot is taken, then the most suitable time to cut it is around 36 weeks. Mode of delivery whether normal or cesarean depends upon the gestation period, location of placenta, the weights and condition of babies and position of babies. Depending upon all these factors the obstetrician will sketch a plan after discussing with you and your partner. It is always better to deliver at a place where NICU facilities are available as one orbothe the babies may need some initial care.

 

Preterm labour and PROM

Pregnancies after Infertility treatment have higher risk of preterm labour and PROM (Premature rupture of membranes). 8% of women who have undergone IVF or ICSI have a risk of delivering prematurely as against 5%of women with natural conception. Part of this risk may be associates with more incidence of twin pregnancies in IVF treatment.

 

Causes of preterm labour and PROM:

  • Infection in pregnancy is the most common cause. Infection may reach the uterus via the vagina or spread from other body parts like dental infection, urinary tract infection, bowel infection (Diarrhoea), respiratory tract infection or hepatitis.
  • Higher order pregnancy for eg: twins or more may be an important cause.
  • Weakness of the cervix or mouth of uterus is responsible for extreme prematurity. This may be inherent or induced by various surgeries on the uterus or cervix prior to conceiving.
  • Gaining too much or too little weight during pregnancy. Optimal weight gain during pregnancy is between 12-16 kg. The amount of weight gain also depends on prenatal weight of the mother.
  • Development of anemia (low hemoglobin levels), hypertension or diabetes in pregnancy may lead to induced preterm where there is no option but to deliver the baby prematurely to avoid serious complication.

 

Complication of preterm delivery:

Mainly preterm delivery may lead to increased morbidity and mortality in the new born babies.

There is an increased risk of NICU admission. The baby may have difficulty in breathing, develop infection and need IV drugs.

There is an increased risk of jaundice in such babies. The baby may also have difficulty in breast feeding. All this increases the parental stress in addition to financial burdun.

 

Prevention:

  • Avoiding or early treatment of any infection with antibiotics. Use of prophylactic prebiotics and probiotics can significantly reduce the incidence of vaginal and bowel infections. A short course of vaginal antibiotics one or two times between 24-34 weeks may treat any bacterial vaginal infection and thereby preventing it to ascend up into the uterus.
  • Try to reduce higher birth order pregnancy i.e. triplets and quadruplets to twins or singleton pregnancy.
  • To take a prophylactic cervical stitch at 14-18 weeks in women with a history of operative procedure done on the uterus.
  • To take regular nutritional supplements like iron, folic acid and calcium to avoid deficiencies and thereby preventing complications like anemia or hypertension.
  • Regular monitoring of cervical length by trans vaginal scan so as to pick up early shortening of cervix and treating it with either vaginal progesterone or cervical stitch.
  • Regular blood checks up to detect anemia or diabetes in pregnancy.
  • Prophylactic doses of injection betamethasone at 28-32 weeks in certain high risk women to ensure fetal lung maturity and prevent neonatal morbidity and need of NICU.

 

IUGR

As such pregnancies after treatment of infertility are not at a very high risk of developing IUGR as compared to normal pregnancies. IUGR stands for intrauterine growth restriction which means that the baby is slow in growth and therefore low birth weight. However there might be slight increase in growth restriction of the fetus in following situations:

  • Twin pregnancy where in either one or both the twins may have growth restriction.
  • Women with preexisting hypertension or who develop moderate to severe PIH during pregnancy.
  • Women with preexisting diabetes mellitus or those who develop gestational diabetes in pregnancy. Incidence is particularly higher if the sugars are uncontrolled.
  • Women with preexisting chronic liver, lung or kidney diseases as commonly found in women above 40 years of age. Mothers with thalassemia minor or sickle cell disease may also develop a growth restricted baby.
  • Dietary deficiencies like anemia or protein inadequacy may lead to IUGR.
  • Infections like malaria, hepatitis, multiple times Urinary tract infection may also lead to IUGR.

All the above situations mainly lead to IUGR because they affect the placenta i.e. the organ supplying blood to fetus from the mother. The mechanism may be different but the effect is same i.e. IUGR

 

Complication of IUGR:

IUGR mainly affects the fetus and may lead to increased morbidity and mortality in the newborn baby. Complications like preterm baby, difficulty in breathing, need for IV drugs and need for NICU care increase in such babies.

Also there is a high chance that the mother may need to undergo a cesarean section as these babies do not take the stress of labour very well.

 

Prevention:

  • Regular monitoring of high risk pregnancy with USG and Doppler studies to pick up early IUGR, which can be treated with drugs or IV medicines.
  • Prenatal control of blood pressure and diabetes to avoid them worsening during pregnancy.
  • Adequate dietary supplementation with Iron, multivitamins, calcium and proteins to obatain adequate growth of the baby.
  • Early diagnosis and treatment of infection.