The High-Risk Pregnancy
Trimester by trimester
Barbie and Ken have left the building.
The “perfect” pregnancy patient gets booted out of the Perfect Pregnancy Club for even the slightest physiologic indiscretion. When I was in school, we used to have a “moderate” risk pregnancy clinic as a joke, to take time off, because there is the normal pregnancy for some and the high-risk for everyone else. There was no such thing as a moderate risk pregnancy; that clinic was empty!
But most patients start out in the Perfect Pregnancy Club until they are ousted for this problem or that. Depending on what your problem is, you may have close to a normal sequence of visits—or in the other extreme, you may be seen every day in the hospital for a serious problem that requires complete bed rest and jeopardizes your baby and/or you.
In the first trimester, problems that can make you high risk include:
- Bleeding (threatened miscarriage)
- Unusual pelvic pain (prompting worries of possible ectopic pregnancy)
- Chronic hypertension
- Pre-existing medical conditions, such as hypertension, heart disease, diabetes, asthma, thyroid disease, etc.
- Medication exposure (either necessary medication for a pre-existing medical condition or exposure to medicines before you knew you were pregnant)
- History of previous miscarriage, preterm labor, premature delivery, congenital abnormalities, stillbirth, or neonatal death
- Family history of congenital abnormality or stillbirth
- Multiple gestation
- Alcohol or drug abuse
- Abnormal Pap
In the second trimester, problems that can make you high risk include:
All of the first trimester concerns, and…
- Incompetent cervix, increasing the risk of pre-term delivery
- Bleeding (due to placental abruption or previa)
- IUGR (Intra-uterine growth restriction—a baby small for the corresponding gestational age
- Gestational diabetes
- Pregnancy-induced hypertension
- Sporadic or non-compliant prenatal care
- Preterm labor
- Kidney infection
- Premature rupture of membranes (or leaking)
- Abdominal tenderness of the uterus (possible infection of the pregnancy)
In the third trimester, problems that can make you high risk include:
All of the first and second trimester concerns, and…
- Decreased fetal movement
- Abnormal amount of amniotic fluid (too much polyhydramnios; too little oligohydramnios)
- Emotional abnormalities (pregnancy is a stress that may fully bring out borderline psychiatric conditions)
- Nausea and/or vomiting—this can’t be looked at as the typical morning sickness of the first trimester. This late in pregnancy, liver problems may be the cause, from a sneaky PIH variant called HELLP which should prompt immediate delivery to a more benign gallbladder problem which can be addressed after delivery.
- Right upper quadrant pain—same as above.
- Decreased “reactivity” on non-stress test, in which the baby’s heart rate does not accelerate after movement, which is the expected norm.
- Abnormal positioning of the baby (breech, transverse, etc.)
Factors in a High Risk Pregnancy
Pre-existing medical conditions can make for tricky pregnancy management since there’s a baby involved. Some treatments may be safe for you but not for your developing baby. Sometimes the risks have to be weighed against the benefits, with trade-offs involved for the fetal as well as for your maternal side.
Another factor that can transform an otherwise healthy pregnancy into a high-risk one is noncompliance with scheduled appointments. Your doctor deals in volume, and it’s hard enough to juggle the caring touch with a full schedule. But a missed appointment is more than just a wasted slot that someone else could have used. It also means your doctor will have to play catch-up at the next appointment. If the next appointment represents an untimely procrastination of concerns that should have been addressed during the missed appointment, windows of opportunity for optimal obstetric care can close. Additionally, many tests in obstetrics are timed to a particular point in the pregnancy, so a missed appointment also creates a scheduling urgency for clerical personnel that is an unfair burden on a doctor’s overhead, which is rising all of the time anyway. In the big scheme of things, missed appointments create an unfair burden on your baby.
Regarding what separates the normal pregnancies from the high-risk ones, every doctor has his or her lists, and these are mine. Pregnancy is a condition in which one can be normal one moment and be blindsided by a disaster the next. For this reason, every doctor has a routine for keeping an eye out for warning signals in each of those “perfect” pregnancies, and then the “high-risk” patients have a series of appointments tailored just for them. In your visits to your obstetrician, you should have all of the screenings that this year has to offer—not last year’s obstetrics. You should expect your doctor to follow your pregnancy appropriately, whether you’re high risk or “normal.” And you should presume that he knows the difference.
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