A pregnancy that has maternal or fetal complications requiring special medical attention or bed rest is considered to be high-risk. Complications, as used here, mean the risk of illness or death before or after delivery is greater than normal for the mother or baby.
Risk factors in pregnancy are those findings discovered during prenatal assessment that are known to have a potentially negative effect on the outcome of the pregnancy, either for the woman or the fetus. This evaluation determines whether or not the mother has characteristics or conditions that make her or her baby more likely to become sick or die during the pregnancy.
Causes and symptoms
All risk factors do not threaten pregnancy to the same extent. The risk of complications is increased by smoking, poor nutritional habits, drug and alcohol abuse, domestic violence, prepregnancy maternal health status, psychosocial factors, prior health care, the presence of chronic medical problems in the mother, past history of repeated preterm delivery, multiple gestation, and abnormalities of the fetus or placenta. A woman with a high-risk pregnancy may have an earlier labor and delivery depending upon the fetal or maternal complication present and, likewise, present with symptoms dependent upon the condition. Since the placenta supplies the baby with its nutrients and oxygen, any condition that threatens the blood supply to it threatens fetal development.
The threat of a preterm delivery is the most common reason for a referral to a perinatal center, which is linked to obstetric and newborn services that provide the highest level of care for a pregnant woman and her baby. A preterm delivery may occur because of a premature rupture of membranes (the bag of water surrounding the baby breaks) or preterm labor. There is a strong correlation of vaginal or uterine infection with the pregnant woman's water breaking, and there are lab tests that can be predictive of a woman's risk of experiencing preterm labor.
According to a 2001 report from the U.S. Centers for Disease Control and Prevention, there were 29.6 deaths per 100,000 births among African-American women between 1991 and 1997. The rate for women of Hispanic origin was 10.3, and for white women it was 7.3. The rate for Asian women was unavailable. The second most common causes of death in women are problems related to pregnancy and delivery, including blood clots that travel to the lungs, anesthesia complications, bleeding, infection, and high blood pressure complications. A baby dies before, during, or after birth in 16 out of 1,000 deliveries in the United States. Almost 50% of these deaths are stillbirths, which are sometimes unexplained. The rest of the deaths occur in babies up to 28 days old, and the leading cause of these is birth defects, followed by prematurity. Risk factors can be present before pregnancy occurs and others develop during pregnancy.
A risk-scoring sheet is utilized by many healthcare agencies during the prenatal assessment to establish if a woman may be at risk for complications during her pregnancy. This score sheet is implemented at the first prenatal visit, becomes a part of the woman's record, and is updated throughout the pregnancy as necessary. A
Antepartum—This refers to the time period of the woman's pregnancy from conception and onset of labor.
Perinatal—Refers to the period shortly before and after birth, generally from around the 20th week of pregnancy to one to four weeks after birth.
Perinatologist—A specialist in the branch of obstetrics that deals with the high-risk pregnant woman and her fetus.
Preconceptional—This refers to the time period before pregnancy, i.e., conception, occurs.
Ultrasonographer—The person who performs the radiologic technique of ultrasound in which deep structures of the body are visualized.
woman's age affects pregnancy risk, as girls 15 years old and under are more likely to develop high blood pressure, protein in the urine and fluid accumulation (preeclampsia), or seizures (eclampsia). They also are more likely to have underweight or undernourished babies. A woman 35 or older has a greater risk of developing high blood pressure or diabetes, as well as a much higher risk of having a chromosomal abnormality such as Down syndrome. A woman shorter than five feet or a woman weighing less than 100 pounds before pregnancy has a greater risk of having a small or preterm baby.
Lab data and ultrasound are also utilized to determine high-risk pregnancies by specific blood tests and imaging of the baby. A pregnancy may begin as low risk and change to high risk secondary to complications determined from the ongoing assessment of the pregnant woman. Since many of these complications can be managed with proper treatment, it is essential that a pregnant woman keep her obstetric appointments.
Treatment will vary, depending upon the maternal or fetal complication present. Generally, a woman with severe high-risk factors in pregnancy should be referred to a perinatal center to obtain the highest level of care for herself and her baby. Interventions to improve health status might include nutritional assessment, physical examination, teaching modalities for smoking cessation, drug and alcohol programs, prescribing medications related to the condition, or changing pre-pregnancy medications (known to cause problems in the fetus), serial ultrasounds to learn fetal status, amniocentesis, fetal transfusions, fetal surgery, antepartum testing, bed rest, home health care, hospitalization, and early delivery. In a postterm pregnancy (greater than 42 weeks), the death of a baby is three times more likely than that of a normal term pregnancy (37–40 weeks). The treatment in this case would be to induce labor before problems start to occur with an aging placenta.
Advances in the management of complications in high-risk pregnancies have provided women with a means of controlling their risks, which substantially increases the potential for a successful outcome. Since it is impossible to guarantee a good outcome in a normal pregnancy, it is even more difficult to ensure that a high-risk pregnancy will result in a healthy infant and mother. A woman who strictly adheres to the medical regimen established for her, however, will greatly increase her chances of a positive result.
Health care team roles
The pregnant woman's interview at her first visit the health care provider is conducted by the nurse, who obtains the data necessary to begin the high-risk screening. The physician or midwife caring for a pregnant woman should review the prenatal assessment sheet, order lab data, and obtain ultrasounds to determine if any risk factors are present. If it is determined that a woman has a high-risk pregnancy, she should be referred to a perinatologist for advanced care. This is the specialist who establishes and implements the medical regimen needed for the particular maternal/fetal complication and the inter-disciplinary team associated with the perinatal center works in its management. The perinatal team usually comprises a nutritionist, social worker, nurse educators, geneticists, ultrasonographers, and additional nursing staff who are responsible for the monitoring and supervising of ongoing team care of the patient.
The early weeks of pregnancy are the most crucial ones for the fetus. Many women do not know they are pregnant until several weeks after conception, so education about the need for preconceptional care is essential. Preconception counseling guides a woman in planning
- family history
- medical history
- past pregnancies
- current medications
Cigarette smoking is the most common addiction among pregnant women in the United States, and despite the health hazards of smoking being well-known, only about 20% of these women actually quit during pregnancy. One risk of smoking during pregnancy is having a baby who may die from sudden infant death syndrome (SIDS).
Drugs known to cause birth defects when taken during pregnancy include: alcohol, dilantin (phenytoin), any drug that interferes with the actions of folic acid, lithium, streptomycin, tetracycline, thalidomide, warfarin (Coumadin), and isotretinoin (Accutane), which is prescribed for acne. The number one preventable cause of mental retardation in infants is the abuse of alcohol during pregnancy. Alcohol can cause problems ranging from miscarriage to severe behavioral problems in the baby or developing child even if no obvious physical birth defects are apparent. Fetal alcohol syndrome is seen in about two out of 1000 live births. Infections that may cause birth defects include: herpes simplex, viral hepatitis, the flu, mumps, German measles (rubella), chicken-pox (varicella), syphilis, toxoplasmosis (occurs from eating undercooked meat and handling kitty litter), listeriosis, and infections from the coxsackievirus or cytomegalovirus (CMV). Many adults have been exposed to coxsackievirus and CMV when they were younger, but there are many who have not been. Those who have not been exposed should pay careful attention to any illnesses they have early in their pregnancy, noting the onset, presence of fever, muscle aches and pains, and duration of illness to report to their physician.
Hemolytic disease of the newborn (destruction of the red blood cells) can occur when Rh incompatibility exists between child and mother. The most common cause of incompatible blood types is Rh incompatibility—such as when the mother has Rh-negative blood and the father has Rh-positive blood. The baby may have Rh-positive blood, in which case the mother's body produces antibodies against the baby's blood. Fortunately, the mother can be treated with Rhogham [Rh0(D)immune globulin], which can be given to the mother in the first 72 hours after delivery and at the twenty-eighth week of pregnancy; it will destroy any antibodies produced by her blood and significantly decrease the risk associated with pregnancies with Rh-factor incompatibilities.
There are, however, other incompatible blood factors during the prenatal assessment period that can cause anemia in the fetus and require ongoing monitoring. The greatest gift a woman gives herself is to plan her pregnancy with preconceptional counseling. Many women are frequently deficient in folic acid, a B vitamin used in the synthesis of ribonucleic acid (RNA) and essential, in large quantities, for optimal protein synthesis in the fetus. This is especially true in the early weeks of pregnancy, when all cell division and organ development is occurring. Thus, the best prevention for a high risk pregnancy is good planning.
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Star, Winifred L., Shannon, Maureen T., Lommel, Lisa L., Gutierrez, Yolanda M. Ambulatory Obstetrics. San Francisco, CA: UCST Nursing Press, 1999.
Casimir, Leslie. "Black Maternal Deaths 4 Times the White Rate." The Daily News (June 08, 2001):archives. <http://www.dailynews.com>.
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American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920, Washington, DC 20090-6920. "Preconceptional Care." ACOG Patient Education Booklet. 1999.
Association of Women's Health, Obstetric and Neonatal Nurses. 2000 L Street, N.W., Suite 740, Washington, DC20036. (800) 673-8499. <http://www.awhonn.org>.
Sidelines National Support Network. High-risk pregnancy support online. <http://www.sidelines.org>.
Linda K. Bennington, R.N.C., M.S.N., C.N.S.