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Every expectant mother knows that pregnancy harbors both the highest of hopes and the deepest of fears. Of course, most pregnancies proceed normally and result in a healthy baby. But what if something goes wrong? The most important step in ensuring a safe and healthy pregnancy is identifying women at risk of complications and the best time to identify them is before they get pregnant. Factors such as lifestyle, family health history and the mother's overall health offer important information about potential risks. For instance, women over age 35 are considered at higher risk than younger women for pregnancy-related complications. Chronic health problems such as asthma, diabetes, heart problems, lupus and Rh disease also require particular care during pregnancy.

But some women don't fall into a high-risk category until they become pregnant. Pregnancy also can induce conditions, such as cholestasis, HELLP syndrome, preeclampsia, and pregnancy induced hypertension. Multiple births, an increasingly common occurrence because of fertility medication, are also considered high-risk.

Some factors, such as the mother's advanced age, anemia, bleeding in pregnancy, and group B strep (GBS) are considered low-risk enough for a generalist to handle. More complicated risk factors, such as intrauterine growth retardation (IUGR), placenta abruption, placenta previa, and premature rupture of membranes (PROM) sometimes require the services of high-risk specialists.

But every woman can bolster her odds of a healthy pregnancy by maintaining a healthy lifestyle, particularly by eating well and refraining from non-prescription drugs, including alcohol and receiving regular medical care.

Anemia

Anemia is a condition of too few red blood cells, or a lowered ability of the red blood cells to carry oxygen or iron. Tissue enzymes dependent on iron can affect cell function in nerves and muscles. Anemia is usually discovered during a prenatal examination through a routine blood test for hemoglobin or hematocrit levels. Diagnostic procedures for anemia may include additional blood tests and other evaluation procedures. The fetus is dependent on the mother’s blood and anemia can cause poor fetal growth, preterm birth, and low birth weight.

Signs of anemia in pregnancy: women with anemia of pregnancy may not have obvious symptoms unless the cell counts are very low. The following are the most common symptoms of anemia. However, each woman may experience symptoms differently. Symptoms may include: pale skin, lips, nails, palms of hands, or underside of the eyelids, fatigue, vertigo or dizziness, labored breathing and/or rapid heartbeat (tachycardia).

Requirements for quality care: depends on the type and severity of anemia. Treatment for iron deficiency anemia includes iron supplements. Some forms are time-released, while others must be taken several times each day. Eating a healthy and balanced diet during pregnancy helps maintain the levels of iron and other important nutrients needed for the health of the mother and growing baby.

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Asthma

Asthma during pregnancy may worsen under certain conditions. During asthma attacks treatment should ensure that oxygen concentration in the blood does not drop to levels which may endanger the fetus or provoke preterm labor even though the mother may feel better. A maternal-fetal medicine specialist experienced with asthma may provide the input needed to properly guide treatment. Fetal growth should be followed regularly.

Signs of worsening asthma: using inhalers increasingly often, diminishing effect of inhalers and other medications, wheezing, unable to clear secretions, severe cough and congestion, working to breathe.

Requirements for quality care: experience with severe asthmatics in pregnancy, monitoring of mother's oxygen saturation during acute attacks, availability of fetal growth monitoring.

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Bleeding in Pregnancy

Bleeding may occur at various times in pregnancy. Although bleeding is alarming, it may or may not be a serious complication. The time of bleeding in the pregnancy, the amount, and whether or not there is pain may vary depending on the cause.

Bleeding in the first trimester of pregnancy is quite common and may be due to the following: miscarriage (pregnancy loss), ectopic pregnancy (pregnancy in the fallopian tube), gestational trophoblastic disease or molar pregnancy (a rare condition that may be cancerous in which a grape-like mass of fetal and placental tissues develops), implantation of the placenta in the uterus or infection.

Bleeding in late pregnancy (after about 20 weeks) may be due to the following: placenta previa (placenta is near or covers the cervical opening), placental abruption (placenta detaches prematurely from the uterus) or an unknown cause.

Requirements for quality care: in early pregnancy usually nothing is required because a miscarriage will happen with or without medical intervention. with ectopic or molar pregnancies, surgery is always needed to removed the pregnancy. In later pregnancy bed rest, limited activity, or an immediate delivery is needed.

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Cholestasis

Cholestasis of pregnancy is a condition in which the normal flow of bile in the gallbladder is slowed or stopped resulting in itching and jaundice (yellowing of the skin, eyes, and mucous membranes). Although it may begin in early pregnancy, cholestasis is more common in the last trimester of pregnancy and usually goes away within a few days after delivery. Cholestasis of pregnancy occurs in about one to two women out of 1,000 overall, but it is more likely in Swedish and Chilean populations, and possibly in multiple pregnancies. It has a high risk of reoccurrence in future pregnancies. It is also known as intrahepatic (in the liver) cholestasis of pregnancy and pruritus gravidarum (severe itching).

Signs of cholestasis of pregnancy: overall itching, dark urine color, light coloring of stools (bowel movements), and/or jaundice (yellow coloring of skin, eyes, and mucous membranes). Cholestasis may increase the risks for fetal distress, preterm birth, or stillbirth. It may also increase the mother’s risk of postpartum hemorrhage (severe bleeding following delivery).

Requirements for quality care: in addition to a complete medical history and physical examination, generalized severe itching without a rash is often the first clue to diagnosis. Blood tests for liver function, bile acids, and bilirubin often show changes which may also aid in the diagnosis. The goals of treating cholestasis of pregnancy are to relieve the itching and prevent complications. Itching may be treated with topical anti-itch medications or with corticosteroids. Medication is sometimes used to help decrease the concentration of bile acids. Vitamin K may also be used if blood clotting factors are abnormal. Fetal monitoring tests may used to check the well-being of the fetus. If cholestasis of pregnancy endangers the well-being of the mother or fetus, then an early delivery may be necessary.

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Diabetes

Diabetes poses a particularly high-risk to the developing fetus and to the health of the pregnant woman. Diabetes must be tightly controlled before pregnancy begins to prevent fetal malformations. Advanced fetal ultrasonography, including echocardiography (ultrasound of the heart) is needed to verify normal development as early as possible. If blood sugars are too high, there can be damage to the placenta, resulting in miscarriage or fetal loss in late pregnancy. High blood sugars can also cause excessive fetal growth which places the baby at risk for birth injury.

Pregnancy always worsens diabetes. Requirements for insulin increase as the fetus matures. If these requirements are not met, the mother is at risk for coma and shock. Poorly controlled diabetes may damage her kidneys, retina and heart. Proper management of diabetes during pregnancy requires enormous commitment on the part of both mother and doctor. Successful pregnancies result in a healthy mother and baby with no impact on the future health of either.

Gestational Diabetes, or diabetes arising during and because of pregnancy, must also be properly managed in order to avoid an excessively large baby. Fortunately most women require only dietary measures to control blood sugars. 10-15% of cases are more severe and require insulin to avoid the more dangerous complications.

Signs of worsening diabetes: increased urine production and thirst, retinal damage with worsening vision, extremely large uterus due to amniotic fluid overload or dangerous fetal size, in some cases arrest of fetal growth.

Requirements for quality care: Diabetic teaching, dietary counseling, monitoring of glycosylated hemoglobin levels, advanced early fetal ultrasound including transvaginal ultrasound, amniocentesis, umbilical artery Doppler, fetal biophysical profile testing, fetal lung maturity testing.

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Group B Strep (GBS)

Group B streptococcus (GBS) are bacteria that can be found in the digestive tract, urinary tract, and genital area of adults. Although GBS infection usually causes no problems in healthy women before pregnancy, it can cause serious illness for the mother and baby during pregnancy and after delivery. One out of every four or five pregnant women carries GBS in her rectum or vagina. In the pregnant mother, GBS infection may cause chorioamnionitis (a severe infection of the placental tissues) and postpartum (after birth) infection. Urinary tract infections caused by GBS can lead to preterm labor and birth. Newborn babies contract the GBS during pregnancy, or from the mother’s genital tract during labor and delivery. GBS is the most common cause of life-threatening infections in newborns, including pneumonia and meningitis. About one out of every 100 to 200 babies whose mothers carry GBS develop symptoms of GBS disease. Premature babies are more susceptible to GBS infection than full-term babies.

Signs of Group B Strep: all women are tested for GBS which can be cultured from the mother’s vagina or rectum with a swab during a pelvic examination. GBS can also be cultured from a mother's urine. Cultures are usually done between 35 and 37 weeks of pregnancy and may take a few days to complete. Cultures collected earlier in pregnancy do not accurately predict whether a mother will have GBS at delivery.

Requirements for quality care: A positive GBS culture means that the mother carries GBS. It does not mean that she or her baby will definitely become ill. However, the decision to treat GBS must be balanced with certain risk factors. Most health care providers will recommend treating women with positive GBS cultures with intravenous (IV) antibiotics during labor to reduce the risk of transmission of the infection to the baby.

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HELLP Syndrome

HELLP, or hemolysis, elevated liver enzymes, and low platelet count, Syndrome occurs in tandem with preeclampsia, but because HELLP Syndrome's symptoms may happen before preeclampsia's three findings of high blood pressure, protein in the urine, and swelling, they may be misdiagnosed as symptoms of gastritis, disseminated intravascular coagulation (DIC), acute hepatitis, gall bladder disease, and other conditions. As a result, the mother may not get the right treatment, leaving both mother and baby that much more at risk.

Requirements for quality care: immediate delivery of the fetus regardless of the gestational age, maternal death rate is high if left untreated.

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Heart Problems

The valves of the heart (aortic, mitral, tricuspid, pulmonic) may function improperly or the mother may have been born with an abnormal heart (sometimes having been repaired surgically). Although the woman may feel well when she is not pregnant, careful medical attention is needed during pregnancy due to the tremendously increased demands on the heart. In some cases pregnancy can be life-threatening. Many women with heart problems have been told they should not get pregnant or that they should abort a pregnancy. In most cases, if a woman is treated properly by skilled and experienced personnel in an advanced-care hospital, a woman can have a successful pregnancy outcome with a healthy baby with no adverse effects on the woman's health.

Signs of worsening heart disease: Frequent episodes of shortness of breath, severe fatigue, diminishing tolerance of exercise or regular daily activities.

Requirements for quality care: Full maternal cardiology services including echocardiography, EKG, cardiac catheterization, monitoring of fetal growth and development by ultrasound and fetal echocardiography, fetal biophysical profile testing, advanced obstetrical anesthesia services, advanced labor-room intensive care services, cardiac surgery or invasive cardiology if needed.

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Intrauterine Growth Retardation (IUGR)

Intrauterine growth restriction (IUGR) is a term used to describe a condition in which the fetus is smaller than expected for the number of weeks of pregnancy. Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as small for gestational age (SGA). A fetus with IUGR often has an estimated fetal weight less than the 10th percentile. This means that the fetus weighs less than 90 percent of all other fetuses of the same gestational age. A fetus with IUGR also may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks).

Signs of IUGR: Intrauterine growth restriction results when a problem or abnormality prevents cells and tissues from growing or causes cells to decrease in size. This may occur when the fetus does not receive the necessary nutrients and oxygen needed for growth and development of organs and tissues, or because of infection. Maternal factors include high blood pressure, chronic kidney disease, advanced diabetes, heart or respiratory disease, malnutrition, anemia, infection, substance abuse (alcohol, drugs) or cigarette smoking. Factors involving the uterus or placenta that may contribute to IGR include decreased blood flow in the uterus and placenta, placental abruption (placenta detaches from the uterus), placenta previa (placenta attaches low in the uterus) or infection in the tissues around the fetus.

Requirements for quality care: management of IUGR depends on the severity of growth restriction, and how early the problem began in the pregnancy. Generally, the earlier and more severe the growth restriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGR and ongoing testing may be needed. Although it is not possible to reverse IUGR, some treatments may help slow or minimize the effects. Some studies have shown that increasing maternal nutrition may increase gestational weight gain and fetal growth. Bed rest in the hospital or at home may help improve circulation to the fetus. If IUGR endangers the health of the fetus, then an early delivery may be necessary.

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Lupus

Women with lupus have a 33% risk of a lupus flare during pregnancy. Care is aimed at prevention and early detection of impending flares. Due to the potential for serious complications, the mother will benefit from having a team of experienced health care workers available should complications arise.

Lupus places the fetus at very high risk. Ongoing assessments of fetal health are needed to prevent a loss by determining if early delivery is needed. Selection of the right medications for pregnancy is also needed. An experienced maternal-fetal medicine specialist is essential for care of pregnant women with lupus.

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Preeclampsia

Preeclampsia is a condition occurring exclusively during pregnancy affecting 7% of all women. Findings initially consist of rising blood pressure, edema (tissue swelling), and increasing protein excretion in urine which may be discovered during prenatal care. If allowed to progress it may damage maternal organs such as the kidney, liver, brain, lung and heart.

Signs of advancing preeclampsia: include headaches, seizures, visual disturbances, abdominal pain and bloody urine.

Requirements for quality care: preeclampsia necessitates delivery of the infant in order to stop the disease process. If caught early, the process is reversible and full recovery is expected. The infant of a preeclamptic mother is frequently sick, however, often due to prematurity but also because preeclampsia adversely affects the health of the newborn. Delivery in an advanced-care setting is frequently necessary and desirable. In the worst cases, premature separation of the placenta occurs (abruptio placenta) often with resulting death of the fetus and dire consequences for the mother due to severe blood loss.

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Pregnancy Induced Hypertension

High blood pressure compromises the blood supply to the placenta. This can affect your baby's growth and development. A mother with poorly controlled blood pressure can also develop preeclampsia, placing her own health at risk. To avoid complications it is often necessary to take medications to control blood pressure. However these medications must be properly selected and the dose must be carefully adjusted to avoid low blood pressure which may also affect the baby's growth. The doctor must have experience with hypertension during pregnancy and the many anti-hypertensive medications.

Signs of worsening hypertension: headache, visual disturbances, poor fetal growth.

Requirements for quality care: renal ultrasound, tests of renal function, EKG, fetal growth monitoring by ultrasound, fetal umbilical artery Doppler velocimetry, fetal biophysical profile testing, monitoring for signs of preeclampsia.

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Placenta Abruption

Placental abruption is the premature separation of a placenta from its implantation in the uterus. Within the placenta are many blood vessels that allow the transfer of nutrients to the fetus from the mother. If the placenta begins to detach during pregnancy, there is bleeding from these vessels. The larger the area that detaches, the greater the amount of bleeding. Placental abruption occurs about once in every 120 births. It is also called abruptio placenta. Other than direct trauma to the uterus such as in a motor vehicle accident, the cause of placental abruption is unknown. Placental abruption is dangerous because of the risk of uncontrolled bleeding (hemorrhage).

Signs of a placenta abruption: most common symptom of placental abruption is dark red vaginal bleeding with pain during the third trimester of pregnancy. It also can occur during labor. Other signs include vaginal bleeding, abdominal pain, uterine contractions that do not relax, blood in amniotic fluid, nausea, thirst, faint feeling or decreased fetal movements.

Requirements of quality care: as there is no treatment to stop placental abruption or reattach the placenta, once placental abruption is diagnosed, a woman's care depends on the amount of bleeding, the gestational age, and condition of the fetus. Cesarean delivery is performed for most cases of placental abruption and emergency delivery may be needed if hemorrhage occurs. Severe blood loss may require a blood transfusion.

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Placenta Previa

Normally, the placenta is located near the top of the uterus (the fundus). In women with placenta previa, the placenta is situated either very near or partially or completely covering the opening of the cervix. The placenta placement causes a risk of hemorrhage excessive bleeding) which can threaten the well being of the mother and the baby. In 4-8% of women, the placenta is found to be in a low lying position in early pregnancy (and even as late as early in the third trimester). However, in most cases, the placenta moves up toward the top of the uterus as the pregnancy approaches term. Less than 10% of women with a low lying placenta are diagnosed with placenta previa.

There are three classifications of placenta previa:

Marginal previa: The edge of the placenta is very near the opening of the cervix. When the cervix dilates during labor, the placenta may move upward or it may partially block the birth canal. Marginal previa presents a risk of hemorrhage during labor and delivery. While a vaginal delivery is possible in some circumstances, a c-section is more likely.

Partial previa: The placenta partly covers the cervical opening. Normal labor and delivery would probably result in hemorrhage as the placenta is damaged by pressure from the baby. The physician will perform a cesarean.

Total previa: The placenta completely covers the cervical opening. The baby will need to be delivered by cesarean.

Requirements of quality care: management of placenta previa depends upon the type (marginal, partial or complete), the maturity of the fetus, and the presence of active bleeding. If a woman is diagnosed with placenta previa but not actively bleeding, the physician may continue the pregnancy to allow the preterm fetus to mature. The pregnant woman may be placed on bed rest at home. She will be instructed to call the physician if any bleeding occurs. Additionally, she will be instructed to avoid stimulating the cervix; she must abstain from sex, vaginal manipulation, and douching. If a woman is bleeding, the physician will try to assess the maturity of the fetus and the degree of blood loss. The mother may be treated with intravenous fluids to maintain fluid volume, blood or plasma transfusions to replace loss. The mother will receive oxygen since blood loss reduces blood oxygen levels and places the fetus at risk for insufficient oxygenation. Fetal monitoring will be used to gauge fetal well being. If hemorrhage is severe, the baby will be delivered by c-section even if the lungs are immature. The hemorrhaging placenta cannot nourish the baby and the severe blood loss places the mother at risk. If an fetus’ lungs are mature, a woman with partial or complete placenta previa will require a cesarean. In some instances, a woman with a marginal previa may be able to deliver vaginally. Whenever possible, the woman should deliver at a hospital facility that has intensive care services for mother and newborn.

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Premature Rupture of Membranes (PROM)

Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins. If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PROM). PROM occurs in about 10 percent of all pregnancies. PROM (before 37 weeks) occurs in about 2 percent of all pregnancies.

Signs of PROM: most common symptom is a leaking or a gush of watery fluid from the vagina or having a constant wetness in your underwear. If you notice any symptoms of PROM, be sure to call your physician as soon as possible.

Requirements of quality care: includes hospitalization, expectant management (in some cases of PROM, the membranes may seal over and the fluid may stop leaking without treatment), monitoring for signs of infection such as fever, pain, increased fetal heart rate, and/or laboratory tests, giving the mother medications called corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major problem of premature babies), antibiotics (to prevent or treat infections), giving tocolytics (medications used to stop preterm labor) or delivery (if PROM endangers the well-being of the mother or fetus, then an early delivery may be necessary to prevent further complications).

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Rh Disease

Rh disease or erythroblastosis fetalis. occurs during pregnancy when there is an incompatibility between the blood types of the mother and baby. When an Rh negative mother has a baby that is Rh positive, problems can develop if the baby’s red blood cells cross to the Rh negative mother. This usually happens at delivery when the placenta detaches. It may also happen, however, anytime blood cells of the two circulations mix such as during a miscarriage or abortion, with a fall, or during an invasive prenatal testing procedure such as an amniocentesis or chorionic villus sampling. The mother’s immune system sees the baby’s Rh positive red blood cells as foreign. Just as when bacteria invade the body, the immune system responds by developing antibodies to fight and destroy these foreign cells. The mother’s immune system keeps the antibodies in case the foreign cells appear again, even in a future pregnancy. The mother is now Rh sensitized. In a first pregnancy, Rh sensitization is not likely. Usually it only becomes a problem in a future pregnancy with another Rh positive baby. During that pregnancy, the mother’s antibodies cross the placenta to fight the Rh positive cells in the baby’s body. As the antibodies destroy the red blood cells, the baby can become anemic. The anemia can lead to other complications including jaundice and organ enlargement.

Signs of Rh Disease: A mother has no physical signs of Rh disease, but her Rh positive baby can have problems if the mother has developed antibodies. Early identification of the Rh negative mother is very important. Then, the risks for the baby can be determined by blood testing of both parents (Rh negative mother, Rh positive father). The disease may be diagnosed if a previous pregnancy resulted in an Rh positive baby.

Requirements of quality care: nearly all women with Rh negative blood are identified in early pregnancy by blood testing. If a mother is Rh negative, she will be tested for Rh antibody titers. If she has not been sensitized, she is usually given a drug called Rh immunoglobulin (RhIg), also known as RhoGAM. This is a specially-developed blood product that can prevent an Rh negative mother’s antibodies from being able to react to Rh positive cells. Many women are also given RhIg around the 28th week of pregnancy. After the baby is born, a woman should receive a second dose of the drug within 72 hours. RhIg destroys any anti-Rh antibodies that enter in the mother’s circulation before her immune system becomes sensitized. This helps protect a future Rh positive baby.

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