Coping with a High-Risk Pregnancy

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What being "high risk" means to you and your baby . Chronic conditions that can place a pregnancy at risk . Conditions that can develop during pregnancy . Coping with your anxiety . Staying sane while you're on bed rest

Coping with a High-Risk Pregnancy
There's nothing warm and fuzzy about the term high-risk pregnancy. In fact, it can be downright scary. What many people don't realize, however, is that the term high-risk pregnancy is a catch-all term that's used to describe women who are on the risk continuum at any point during their pregnancy: women who are at a slightly higher-than-average risk of experiencing complications during pregnancy or birth, or giving birth to a baby with a minor birth defect; and those who have the odds of a happy outcome firmly stacked against them, but who are willing nonetheless to take their chances at starting a family.

If you are at the low end of the risk continuum, your pregnancy may be, for all intents and purposes, perfectly normal. If, on the other hand, you're at high risk of experiencing complications, your pregnancy will be a major commitment—one that will change virtually every aspect of your life during the months ahead.

In this chapter, we talk about what being high risk is likely to mean to you and your baby. Then we discuss both chronic conditions that require special management during pregnancy and conditions that can arise during pregnancy and plunge a low-risk pregnancy into the high-risk category in the blink of an eye. We wrap up the chapter by discussing what it feels like to experience a high-risk pregnancy and offering some practical tips on staying sane during bed rest—one of the biggest challenges many women face during a high-risk pregnancy.

" Your perfect pregnancy—the one we're brought up to believe every woman gets to experience—has now become that other thing you read about in magazines. You are now in the high-risk category. Everyone, from your obstetrician to your own mother, is behaving differently toward you.
—Laurie A. Rich, When Pregnancy Isn't Perfect: A Layperson's Guide to Complications in Pregnancy "

What being high risk means to you and your baby
The term high risk is used to describe pregnancies in which the mother, the baby, or both are at higher-than-average risk of experiencing complications. You are likely to be classified as high risk if you have

a chronic medical condition that may affect your pregnancy,


a history of previous pregnancy-related complications or pregnancy-related complications during your current pregnancy,


a history of pregnancy loss.
As you can see from the following checklist, there are a number of reasons why your pregnancy may be classified as high risk.

CHECKLIST: IS YOUR PREGNANCY HIGH RISK?
Your pregnancy may be treated as high risk if

you are over 35 years old and are therefore at increased risk of giving birth to a child with a chromosomal anomaly;


you are under 17 and are therefore at increased risk of experiencing intrauterine growth restriction;


you are carrying more than one baby and are therefore at risk of experiencing a number of pregnancy-related complications, including preterm labor;


you have a chronic health condition such as diabetes, heart problems, or a blood-clotting disorder that has the potential to affect your pregnancy;


you have a history of gynecological problems such as pelvic inflammatory disease (PID), endometriosis, or large symptomatic fibroids;


you have a history of pregnancy loss (miscarriage, ectopic pregnancy, or stillbirth) or premature birth;


you have an STD, including HIV, that could be transmitted to your baby during pregnancy or at the time of birth;


you are pregnant as a result of assisted reproductive technologies (something that may put you at increased risk of having a multiple pregnancy);


you have had two or more second-trimester abortions (which may increase your chances of having problems with an incompetent cervix);


your mother took DES during her pregnancy (which may increase your chances of having difficulty carrying a pregnancy to term);


you conceived while using an IUD (something that increases your chances of experiencing a miscarriage);


you have a child with a genetic disorder or are a carrier for a genetic disorder (something that may increase your risk of giving birth to a child with that particular genetic disorder).

Watch Out!
Any pregnancy can become high risk. Although the occurrence of any of the following symptoms may not necessarily indicate a problem, you should call your caregiver immediately if you experience

vaginal bleeding or spotting

swelling in the face or fingers

a leakage of fluid or increased vaginal discharge

severe or persistent headaches

pain in the abdomen or shoulder

persistent vomiting that is not related to morning sickness

chills or a fever

a noticeable change in the frequency or strength of your baby's movements

painful or urgent urination

dizziness or faintness
" Because of my heart murmur, I need to take antibiotics before any procedure in which I will bleed. I was striving for a natural delivery, so I wasn't thrilled at the prospect of having to be attached to an IV pole, but as it turned out, the IV pole was not a hindrance at all. I was able to walk around, change positions, even get in the shower.
—Tracy, 30, mother of one "

If your doctor or midwife lacks the specialized expertise to deal with someone with your particular risk factors, you may need to switch to a high-risk-pregnancy specialist. You may find this upsetting if you've established a good rapport with your current caregiver, but switching caregivers is probably the best option for you and your baby. Candace Hurley, the founder of Sidelines (a national support group for moms on bed rest) put it this way in a recent interview with the Los Angeles Times: "You're not a Ford anymore, you're a Ferrari. You need a mechanic who works on Ferraris."

Regardless of who your caregiver is, however, your pregnancy will be more closely monitored than it would be if your pregnancy were classified as low-risk. Consequently, you may be required to make more frequent visits to the doctor, and your doctor may recommend additional tests. If complications do arise—or seem likely to arise—your doctor may prescribe certain types of medications or bed rest.

Chronic conditions that place a pregnancy at risk
Advances in obstetrical medicine have made motherhood a possibility for large numbers of women who might have been discouraged from starting a family a generation ago. Not everyone, however, is able to have a baby. Some chronic conditions place such a tremendous burden on the body that pregnancy is unlikely to occur in the first place, or if it does, the odds of miscarriage, stillbirth, or neonatal loss are extremely high. In certain situations, a woman with a serious medical condition who manages to beat the odds and become pregnant will be encouraged to terminate her pregnancy because the risks to herself or her baby, or both, are simply far too high.

If you are dealing with such a condition, the time to weigh the risks and benefits of a pregnancy is before you become pregnant. Set up an appointment with your doctor to discuss how your pregnancy may affect your condition, how your condition may affect your pregnancy, how past treatments (chemotherapy, radiation therapy, surgery, and so on) for your condition may affect your pregnancy and delivery, what warning signs you need to be aware of, what prenatal tests you may wish to consider, and what—if anything—can be done to minimize the risks to you and your baby.

Bright Idea
If you are at risk of experiencing blood-pressure problems during pregnancy, purchase a blood-pressure gauge at your local drugstore or medical supply store so that you can keep track of your blood pressure between prenatal checkups.





High blood pressure
There's high blood pressure—and then there's really high blood pressure.
If you have mild or moderate hypertension (that is, your blood pressure is from 140/90 to 160/105) and it is not complicated by other factors such as kidney disease or heart disease, your odds of developing preeclampsia are just 10%, and your chances of having a healthy baby are excellent.

If, however, you suffer from severe chronic hypertension (that is, your blood pressure is over 160/105 or your condition is complicated by either kidney disease or heart disease), having a baby will be a fairly risky venture for you. You have a 50% chance of developing preeclampsia and a 10% chance of experiencing a placental abruption, and you are at increased risk of intrauterine growth restriction, premature delivery, and maternal complications such as stroke and cardiovascular problems.

You are at highest risk of experiencing blood-pressure-related problems during your pregnancy if

you are over 40;


you have a lengthy history of hypertension (you've had problems with your blood pressure for more than 15 years);


your blood pressure is higher than 160/110 early on in your pregnancy;


you have diabetes, cardiomyopathy (a disease of the heart muscle caused by either hypertension or other problems), kidney disease, or connective tissue disease (for example, lupus);


you have previously experienced blood-clot complications;


you developed severe preeclampsia early on in a previous pregnancy;


you experienced a placental abruption in a previous pregnancy.


Watch Out!
Don't stop taking your medications without talking to your doctor first. Although certain medications (for example, epilepsy drugs) may be harmful to your baby, the risks of not taking your medications may be even higher. Only your doctor can help you decide whether it's safe to discontinue your medications during pregnancy and, if so, how you can safely wean yourself off them.



Women with extremely complicated cases of hypertension typically spend 15 days in the hospital during their pregnancies. What's more, they have a 50% chance of requiring a cesarean section, a 50% chance of experiencing major complications such as deteriorating kidney function, and a 50% chance of developing preeclampsia—with a 25% chance that the baby will die.

Heart disease
The increased blood volume during pregnancy means that your heart already has to work 50% harder than usual. That's why women with preexisting heart problems can run into difficulty during pregnancy.

Unofficially…
Heart disease is the third-leading cause of maternal death during pregnancy, exceeded only by hemorrhage and infection.



Here are the facts on some common types of heart disease and pregnancy:

Rheumatic heart disease: Rheumatic heart disease is caused by rheumatic fever—an autoimmune response to an infection (typically, untreated strep throat). If it results in mitral stenosis—a particular form of heart-valve damage—the rate of maternal mortality during pregnancy is high. Women affected by this condition require intensive monitoring and multiple cardiac drugs during labor.


Congenital heart diseases: Although the majority of congenital heart defects are mild or repair themselves spontaneously during childhood, some more serious types of congenital heart diseases can endanger a pregnant woman and her baby. Some of these diseases have maternal mortality rates of 50% and fetal mortality rates of 25% to 50%. What's more, babies who survive are also at increased risk of developing congenital heart defects themselves. Women with Eisenmenger's syndrome and primary pulmonary hypertension are advised to avoid pregnancy because of the high rates of maternal mortality associated with these problems. Women with mitral valve prolapse (a disorder in which the heart valve clicks and murmurs) don't face any significant risk during pregnancy, although some caregivers will prescribe antibiotics during labor to prevent potential complications.
Lung disorders
Like the heart, the lungs have to work harder during pregnancy. Although most pre-existing lung diseases (for example, tuberculosis and sarcoidosis) don't cause problems during pregnancy, asthma warrants special monitoring and care.

According to the U.S. Department of Health and Human Services, approximately 1% of pregnant women have chronic asthma, and another 1% will develop the disease as a complication of pregnancy.

Some women with asthma will experience an improvement (25%), others will experience a deterioration (25%), and others will find that their condition remains stable (50%). Unfortunately, there's no way to predict in advance what will happen to any particular woman.

If you are asthmatic and become pregnant, you should

avoid substances that tend to trigger asthma attacks,


minimize your exposure to colds, flus, and respiratory infections,


consider having a flu shot (particularly if you will be pregnant during flu season),


continue to take your allergy shots (with your doctor's approval),


continue to use your asthma medications (with your doctor's approval),


treat asthma attacks immediately to avoid depriving your baby of oxygen.
Kidney disease
The kidneys—which are responsible for filtering the blood—are also required to work harder during pregnancy because they must contend with the waste products that the baby releases into the mother's blood stream, as well as the increased volume of blood.

Here are the facts on kidney disease and pregnancy:

Women with mild kidney disease experience very few problems during pregnancy, but those who have more severe forms of the disease are at risk of developing pyelonephritis (an acute kidney infection that can cause permanent damage), experiencing a premature delivery, or having a baby with intrauterine growth restriction.
Watch Out!
An untreated urinary-tract infection can spread to the kidneys, causing kidney damage or premature delivery.



Women who have both chronic kidney disease and high blood pressure have a 50% chance of developing severe hypertension during pregnancy.


Women who are on dialysis prior to pregnancy will require dialysis treatments more frequently during pregnancy.


Women who are pregnant after a kidney transplant will continue to require medications to prevent rejection of the kidney. They have a 33% chance of developing preeclampsia, a 50% chance of experiencing a premature delivery, an increased risk of having a baby with intrauterine growth restriction, and a higher risk of cesarean due to pelvic bone disease or narrowing of the birth canal.
Note: To maximize their chances of giving birth to a health baby, women who have had a kidney transplant should wait two to five years before attempting a pregnancy. Women who have minimal protein in their urine, normal blood pressure, and no evidence of kidney rejection are considered to be the best candidates for a pregnancy.



Liver disorders
The liver plays a role in a number of important bodily functions. It produces substances the body needs in order to metabolize fats, vitamins, minerals, proteins, and carbohydrates; it controls blood sugar level and lipids; it stores essential vitamins, minerals, and glucose; and it detoxifies substances such as drugs, alcohol, and chemicals.

Although most forms of hepatitis do not appear to worsen during pregnancy and therefore don't appear to pose a significantly increased risk to the mother, certain liver disorders can endanger the fetus (for example, it's possible that a woman with hepatitis B or C could transmit the disease to her baby).

Some women develop a particular form of jaundice during pregnancy (intrahepatic cholestasis). It tends to develop during the third trimester, and it results in severe itching and mild jaundice. It disappears spontaneously within two days of delivery.
Note: Some studies have shown that women who experience jaundice during pregnancy may be at increased risk of experiencing a premature delivery or a stillbirth.

" If you have previously given birth to a premature baby, make sure you see a high-risk- pregnancy specialist during your next pregnancy. Ask for every test available, particularly if they don't know the cause of your first premature labor.
—Susan, 33, mother of two boys who were each premature "



Diabetes mellitus
Pregnancy can be risky for a woman with diabetes. Hormonal changes cause an increase in insulin requirements that a diabetic woman's body can't meet. If a pregnant woman does not manage to keep her blood sugars under control, she is at increased risk of experiencing miscarriage, stillbirth, or fetal death, or of giving birth to a baby with heart, kidney, or spinal defects. She is also more likely to give birth to an extremely large baby—something that can lead to problems during the delivery or necessitate a cesarean section.

Watch Out!
A family history of diabetes is one of the factors that increases your risk of developing gestational diabetes during your pregnancy.



A diabetic woman is likely to experience the best possible outcome if she manages to tightly control her blood sugars during the two months prior to becoming pregnant, as well as through her pregnancy. Blood sugar levels of 70 to 140 milligrams/deciliter in the months prior to pregnancy and an average of 80 to 87 milligrams/deciliter during pregnancy are associated with positive pregnancy outcomes. A diabetic woman can find out how well her blood sugars are under control by taking a glycosylated hemoglobin (hemoglobin Alc) test at two to three months of pregnancy. A favorable result on the test indicates that she is at no greater risk of giving birth to a baby with birth defects than any other pregnant woman.

Most of the damage that causes birth defects occurs during the first trimester. Some of the problems that can result are minor and correctable; others can be fatal. That's why it's important for a diabetic pregnant woman to check her blood levels up to six or seven times daily using a home glucose monitor and to report any problems in controlling her blood sugar levels to her caregiver. If blood sugar levels cannot be controlled through diet alone, insulin doses may be required. (Women with pre-existing diabetes—as opposed to gestational diabetes—always need insulin.)

A diabetic woman may require additional tests during pregnancy to check on the status of her eyes, her kidneys, the placenta, and the baby. What's more, her baby may need to be checked over in the neonatal intensive care unit after delivery to be observed for both respiratory problems and hypoglycemia.

Thyroid disorders
The thyroid is responsible for regulating the body's metabolic processes.

Watch Out!
The leading cause of maternal death during pregnancy is motor-vehicle accidents.

If it is overactive—a condition known as hyperthyroidism—the metabolism speeds up; the heart rate increases; and such symptoms as muscle weakness, nervousness, anxiety, heat sensitivity, flushed skin, bulging eyes, weight loss, and goiter are experienced. Pregnant women with hyperthyroidism can develop thyroid storm—a severe form of the disorder—during pregnancy. Thyroid storm is associated with an increased risk of premature delivery and low birthweight.

If the thyroid is underactive—a condition known as hypothyroidism—the metabolism slows down, causing lethargy, aching muscles, intolerance to cold, constipation, weight gain, voice deepening, facial puffiness, and dry skin.

Thyroid function needs to be monitored closely in pregnant women with either type of disorder, and where appropriate, medication should be prescribed.

Parathyroid disorders
The parathyroid is located behind the thyroid gland. It plays a role in regulating calcium levels in the body.

Too much parathyroid—a condition known as hyperparathyroidism—results in fatigue, muscle weakness, abdominal pain, bone pain and fractures, frequent urination, thirst, kidney stones, pancreatitis, stomach ulcers, and constipation. Pregnant women with this disorder are at slightly increased risk of experiencing a stillbirth or neonatal death or of giving birth to a baby with tetany (severe muscle spasms and paralysis caused by inadequate levels of calcium).

Too little parathyroid—a condition known as hypoparathyroidism—can cause bone-weakening disorders in the developing baby. Consequently, women with this disorder will be prescribed calcium and vitamin D supplements.

Pituitary disorders
The pituitary gland is responsible for regulating the flow of hormones in the body. A couple of pituitary-related disorders can cause problems during pregnancy:

Pituitary tumors: Some women have undetected pituitary tumors. Pregnancy hormones can cause these tumors to grow, causing severe headaches and visual-field disturbances (that is, spots before the eyes or obstructions to vision). If this occurs, the pregnant woman will need to be monitored by a team of specialists, including an obstetrician, an endocrinologist, and an opthamologist.


Diabetes inspidus: Diabetes inspidus is a rare condition caused by a deficiency in an antidiuretic hormone manufactured by the pituitary gland. This disorder causes increased thirst and a correspondingly increased output of urine. The condition tends to get worse during pregnancy but can be controlled through medication.


Pituitary insufficiency: Pituitary insufficiency—a deficiency in overall pituitary function—can be caused by damage from a tumor, surgery, radiation, or complications from a previous pregnancy. If the condition is not corrected during pregnancy, a woman has only a 54% chance of having a healthy baby. Women who have had previous surgery or radiation in the pituitary region or who have experienced a severe hemorrhage during a previous pregnancy—particularly if the hemorrhage was followed by an inability to lactate—should be tested for pituitary insufficiency.
Bright Idea
Read up on high-risk pregnancy at the Johns Hopkins Health Information Web site: www.intellihealth.com.

Adrenal gland disorders
The adrenal glands are responsible for maintaining the correct levels of salt in the body, for producing sex steroids (hormones), and for manufacturing other hormones known as glucocorticoids. Two types of adrenal gland disorders tend to cause problems during pregnancy:

Cushing's syndrome—the result of too much cortisone—is associated with a high rate of premature delivery and stillbirth. The syndrome is characterized by muscle weakness and wasting; thinning and reddening of the skin; an accumulation of excess fat on the face, neck, and torso; and excessive hair growth. Later stages of the syndrome may also result in high blood pressure, diabetes mellitus, and an increased susceptibility to various infections. It is difficult to diagnose during pregnancy because many of the symptoms are also associated with pregnancy: weakness, weight gain, edema, stretch marks, high blood pressure, and diabetic tendencies.


Addison's disease—the result of inadequate adrenal production—can result in life- threatening infections. It is characterized by fatigue, loss of appetite, nausea, dizziness, fainting, skin darkening, and abdominal pain.


Blood disorders
The following five blood disorders can cause problems during pregnancy:

Anemia: Anemia—a blood disorder that is caused by deficiencies in iron, vitamin B12, and folic acid—can result in fatigue; weakness; shortness of breath; dizziness; tingling in the hands and feet; a lack of balance and coordination; irritability; depression; heart palpitations; a loss of color in the skin, gums, and fingernails; jaundice of the skin and eyes; and—in particularly serious cases—heart failure. Because many women become anemic during pregnancy, you're at increased risk of experiencing these types of difficulties if you are anemic prior to pregnancy.


Sickle-cell anemia: Sickle-cell anemia is a hereditary blood disease. Women with sickle-cell anemia who become pregnant have a 25% chance of miscarriage, an 8% to 10% chance of stillbirth, and a 15% chance of neonatal death. They have a 33% chance of developing high blood pressure and toxemia and also tend to have problems with urinary tract infections, pneumonia, and lung tissue damage. Sickle-cell crises—painful episodes that can lead to organ damage due to the lack of proper blood flow into the fine capillaries—are more likely to occur during pregnancy. As if that weren't enough, a pregnant woman runs the risk of passing along sickle-cell anemia to her baby if her partner also happens to carry the gene for the disease.


Thalassemia: Thalassemia is another hereditary blood disease. Although most people with Cooley's anemia (alpha-thalassemia) die before they reach childbearing age, the handful of women who do live long enough to become pregnant often suffer severe anemia and congestive heart failure requiring blood transfusions. Those pregnant women who have the less-severe form of thalassemia (beta- thalassemia) may require blood transfusions during pregnancy and run the risk of giving birth to a baby with the disease if their partner is also a carrier.


Thrombocytopenia: Women with thrombocytopenia—a deficiency of blood platelets—are at increased risk of requiring a cesarean section. Babies born vaginally to mothers with severe thrombocytopenia may have decreased platelet counts and problems with hemorrhaging— particularly around the brain.


Von Willebrand's disease: Von Willebrand's disease is an inherited disorder that affects the blood's capability to clot. It can lead to severe blood loss during surgery, accidents, or delivery, which is why pregnant women with this disease need to be treated with intravenous clotting factors.
Autoimmune disorders
Autoimmune disorders occur when the body's immune system develops antibodies to its own body tissue, resulting in damage to its own major organs.

Here are the facts on four of the most common autoimmune disorders and pregnancy:

Lupus: A generation ago, women with lupus were advised not to have any children because of the risks to both the mother and the baby. Today, a growing number of women with the disorder are trying to have children. This is not to say that it's an easy journey to make: according to the Lupus Foundation of America, although 50% of women with lupus can expect to enjoy a normal pregnancy, 25% will experience either stillbirth or a miscarriage, and another 25% will experience preterm labor. What's more, 20% of women with lupus develop preeclampsia, and 3% give birth to babies with "neonatal lupus"—a form of the disease that lasts until the baby is six months old and that may cause a permanent heart abnormality. Women with moderate-to-severe involvement of the central nervous system, lungs, heart, kidneys, or other internal organs are advised to avoid pregnancy.
Unofficially…
Babies born before 25 weeks who weigh more than two pounds have a 50% chance of survival if they're born in a hospital that is equipped to deal with a baby who is this premature. On the other hand, babies who weigh in at three pounds or more have a 95% chance of survival.



Rheumatoid arthritis: Rheumatoid arthritis is a common form of arthritis. Its symptoms include joint pain and swelling, and stiffness (especially in the morning). Almost all women with rheumatoid arthritis go into remission during pregnancy. Unfortunately, the disease recurs in 90% of women after they give birth—25% within a month of the delivery.


Scleroderma: Scleroderma is a progressive connective tissue disorder that can cause lung, heart, kidney, and organ damage and that is characterized by both joint inflammation and reduced mobility. In 40% of cases the disease worsens during pregnancy, in another 40% there is no change, and in the remaining 20% of cases the condition actually improves. Pregnant women with the disorder face an increased risk of premature delivery and stillbirth, but the majority of babies born to mothers with scleroderma are born healthy.


Myasthenia gravis: Myasthenia gravis is an autoimmune disease that causes skeletal muscle weakness and easy fatigability. Thirty percent of women with the condition experience no change to their condition during pregnancy, 40% experience a worsening of symptoms, and 30% go into remission. There is a 25% rate of premature delivery associated with the disorder and a 10% to 20% chance that the baby will experience a temporary case of myasthenia gravis within two days of delivery.
Gastrointestinal disorders
Here's what you need to know about chronic gastrointestinal disorders and pregnancy:

Peptic ulcers: Peptic ulcers are chronic sores that protrude through the gastrointestinal tract lining and can penetrate the muscle tissue in the duodenum, stomach, or esophagus. Forty-four percent of women with peptic ulcers experience an improvement during pregnancy because the high levels of progesterone in the body stimulate the production of mucus, which can help to provide a protective shield in the stomach lining. Another 44% experience no change in their condition, however, and the remaining 12% actually report a deterioration.


Ulcerative colitis: Ulcerative colitis is an inflammatory disease of the colon and rectum. It can lead to bloody stools, diarrhea, cramping, abdominal pain, weight loss, and dehydration. It can also be linked to fever, anemia, and a high white-blood-cell count. A woman whose colitis is inactive when she becomes pregnant has a 50% to 70% chance of having it remain inactive during pregnancy—good news for both her and her baby. The condition tends to be a significant problem only if emergency surgery is required, because this type of surgery can cause premature labor or necessitate a cesarean delivery.


Crohn's disease: Crohn's disease is similar to ulcerative colitis, but it affects the entire gastrointestinal tract (that is, from the mouth to the anus), although it tends to be focused in the intestines. If Crohn's disease is active at the time of conception, a pregnant woman faces 50% odds of miscarrying. If, however, she is in remission, she has an 85% chance of having the remission continue during her pregnancy.


Bright Idea
You can reduce the likelihood of experiencing problems with your epilepsy if you take your medications as prescribed. Studies have shown that women who take their epilepsy medications as directed have an 85% to 90% chance of giving birth to a healthy baby. If morning sickness is making it difficult for you to keep your medications down, try taking them at times when your nausea is less severe or with plain crackers and a drink of milk.

Neurological disorders
Here's what you need to know about neurological disorders and pregnancy:

Epilepsy and seizure disorders: Pregnancy is risky business for a woman with epilepsy. Many of the drugs used to control the disorder are linked to birth defects; facial, skull, and limb deformities; fatal hemorrhages in newborns; unusual childhood cancers; cleft palate or lip; congenital heart disease; spina bifida; intrauterine growth restriction; and fetal death. Women with epilepsy also have a 1 in 30 chance of giving birth to a child with a seizure disorder. Not everyone faces an equal risk of running into problems;
however: women who experience frequent seizures prior to becoming pregnant are four times as likely to experience problems during pregnancy as women who don't.


Migraines: Nearly one in five pregnant women suffers from migraine headaches. Fortunately, 80% find that their condition improves during pregnancy, and others are able to avoid problems by avoiding such dietary triggers as MSG (found in Chinese food), sodium nitrates and nitrites (found in cured meats), and tyramine (found in strong cheese).


Watch Out!
If you're subject to migraines, don't allow yourself to get too hungry. Low blood sugar can trigger migraines .



Multiple sclerosis: Multiple sclerosis is a disease in which the insulating material covering the body's nerve fibers is destroyed, causing weakness in the legs, vision problems, poor coordination and balance, spasticity or trembling in one hand, loss of bladder control, and other difficulties. Women with multiple sclerosis are able to give birth to perfectly healthy babies since there is only a 1% to 5% chance that the baby will develop the disease. Women with a lack of sensation in their lower bodies are monitored closely during the ninth month in case they are unable to detect the onset of labor. They also may require a forceps or vacuum-assisted delivery since the disorder can affect their ability to push.


Cerebrovascular disease
Pregnancy can pose a significant risk to women with a history of strokes, hemorrhages, and blood clots. If a pregnant woman has a known blood-vessel disorder of the brain, such as an arteriovenous malformation, she has a 33% chance of dying during pregnancy.

Malignant diseases
As a rule of thumb, women with cancer should delay becoming pregnant until they are reasonably sure that a recurrence won't occur during pregnancy. This is because women who are diagnosed with cancer during pregnancy are often advised to terminate their pregnancy so that they can obtain the medical treatment they need. Delaying treatment can, in many cases, reduce their odds for long-term survival.



Bright Idea
You and your doctor can obtain the latest information on the effects of chemotherapeutic agents on pregnancy through the Registry of Pregnancies Exposed to Chemotherapeutic Agents. The database contains details on the known effects of cancer drugs during specific stages of pregnancy. Contact the Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA 15261, 412-624-9951, bgettig@helix.hgen.pitt.edu.



Phenylketonuria (PKU)
Phenylketonuria is a genetically transmitted disorder that can cause severe mental retardation in the newborn if it is undetected within two days of birth. People with PKU are deficient in a particular liver enzyme needed to metabolize phenylalanine, an amino acid found in most foods. Pregnant women with PKU face a higher risk of miscarriage and tend to give birth to more children with microcephaly, heart defects, mental retardation, growth restriction, and low birthweight. Women with PKU must follow a special diet during pregnancy. Studies have shown, however, that women who begin following the diet prior to becoming pregnant have better outcomes.

Group B beta-hemolytic strep
Group B Beta-hemolytic strep is a strain of bacteria that is carried by somewhere between 20% and 40% of pregnant women. Two percent of babies born to women who are infected with the bacteria develop Group B strep disease—a serious condition with a 6% mortality rate. Group B strep is more likely to be a problem if a baby is premature, if the membranes have been ruptured for more than 30 hours when labor commences, or if the woman had a previous baby who contracted a Group B strep infection. Most caregivers screen for Group B strep when a woman is 35 to 37 weeks' pregnant and prescribe antibiotics during labor to women who are carriers or who have other risk factors. (See Chapter 16).

Sexually transmitted diseases
Nearly two million pregnant women experience STDs each year. (See Table 10.1.) If you or your partner has had unprotected sex with someone since your last STD screening, you should be retested. STDs can occur at any time—even during pregnancy—and can be harmful to the unborn baby. Fortunately, there are treatments available to minimize the risk to the baby. Consider the facts for yourself:

Babies of HIV-positive mothers who have been treated with AZT prior to birth and who are delivered by cesearean section have, for example, a less than 1% chance of developing HIV, according to the National Institute for Child Health and Human Development. Babies born to women who do not receive any form of treatment, on the other hand, have a 20% to 32% chance of developing the disease.


Babies whose mothers test positive for hepatitis B can usually avoid developing the disease if they are given hepatitis B vaccine and immune globulin within 12 hours of birth. These treatments are repeated one month and six months later.
Unofficially…
According to a recent study in the British Journal of Obstetrics and Gynaecology, women with hepatitis C have an excellent chance of giving birth to perfectly healthy babies. Pregnancy doesn't worsen the disease, and it has not been linked with any pregnancy-related complications.

Psychiatric illness
Psychiatric illness is relatively common in women of reproductive age. Between 8% and 10% of women of childbearing age experience depression and approximately 1% are schizophrenic.

Although certain drugs used to treat psychiatric illness have been linked with birth defects, others are considered to be relatively safe for use during pregnancy (although, ideally, you will want to avoid taking any drug during your first trimester). Your obstetrician or your psychiatrist will be able to provide you with information on the use of your medication during pregnancy.

If you suffer from an eating disorder, you may find it difficult to allow yourself to gain weight during pregnancy. You may wish to continue with an existing treatment program or seek the services of a professional to ensure that you are able to give your baby the best possible start in life.



Unofficially…
Pregnant women are particularly susceptible to diabetes because the placenta produces hormones that counteract the effects of insulin. As a result, a pregnant woman's body needs to produce 30% more insulin than normal.


TABLE 10.1: THE NUMBER OF PREGNANT WOMEN IN THE U.S. WITH STDS EACH YEAR
STD Estimated Number of Pregnant
Women Who Get the Disease Each Year

Bacterial vaginosis 800,000

Herpes simplex 800,000

Chlamydia 200,000

Trichomoniasis 80,000

Gonorrhea 40,000

Hepatitis B 40,000

HIV 8,000

Syphilis 8,000

Total 1,976,000

Source: Goldenberg et al., 1997

Conditions that can develop during pregnancy
As we mentioned earlier, any pregnancy can change from low risk to high risk in the blink of an eye. That's why it's important to be prepared to spot the warning signals of the most common pregnancy-related complications.

Risk factors:

subsequent pregnancy,

family history of diabetes,

have previously given birth to a baby over 9 lbs.,

have experienced unexplained pregnancy losses,

overweight,

high blood pressure,

recurrent yeast infections.
You may be admitted to a hospital if your blood sugar remains high despite efforts to control your sugar levels through diet. You may require insulin injections.


Symptoms of early-stage preeclampsia include swelling of hands and feet, sudden weight gain, high blood pressure (140/90 or higher), increased protein in the urine, and headaches. Most likely to occur in:

first-time mothers,

women carrying multiples,

women with chronic high blood pressure, diabetes, kidney disease, or a family history of preeclampsia.
Mild cases can be treated through bed rest. Severe cases require hospitalization for treatment with antihypertensive drugs. The condition is cured when the baby is born, although the danger period extends to approximately 24 hours after delivery. Labor may be induced or cesarean performed if the condition progresses to a certain point.


Condition What Can Happen Risk Factors and
Warning Signs Treatment

Hyperemesis gravidarum (severe morning sickness)
Can lead to malnutrition and dehydration.
Occurs in 1/200 pregnancies. More common in first-time mothers, women carrying multiples, and mothers who have experienced the disorder during a previous pregnancy.
You will usually be hospitalized so that intravenous drugs and fluids can be administered.


Chorioamnionitis (an infection of the amniotic fluid and fetal membranes)
Can lead to premature rupture of the membranes or premature labor.
Occurs in 1/100 pregnancies. Often there are no symptoms early on except a rapid heartbeat and a fever over 100.4° F.
Treatment options include antibiotics and/or prompt delivery.


Gestational diabetes
Can lead to excessive fetal growth. An overly large baby may have to be delivered by cesarean section and may have difficulties at birth. The diabetes may continue after delivery or recur later in life.


Preeclampsia (also known as toxemia)
Associated with increased risk of placental abruption and fetal distress. In severe forms, it can cause a life-threatening condition that includes blood clotting problems, liver dysfunction, stroke, and possibly even the death of the mother or baby. When seizures are present, it is known as eclampsia.


Intrauterine growth restriction (IUGR) (also known as intrauterine growth retardation)
Can result in low-birthweight babies or infants who are less alert and responsive.
Diagnosed when the developing baby consistently measures small for dates. Most likely to occur in:

women with chronic health problems or an unhealthy lifestyle,

women with high blood pressure,

women carrying multiples,

woman having first or fifth (or later) pregnancy,

a fetus with chromosomal abnormalities.
Bed rest and/or hospitalization. Labor may be induced if it is felt that the baby will do better in the nursery than in the relatively hostile uterine environment.


Amniotic fluid-level problems: polyhydramnios (too much fluid) or oligohydramnios (too little fluid)
Polyhydramnios may indicate Rh-incompatibility problems, diabetes, or the presence of multiple fetuses. Oligohydramnios may indicate a malfunction or absence of fetal kidneys or leakage of amniotic fluid due to premature rupture of the membranes.
Suspected when a woman measures too large or too small for dates; diagnosed via ultrasound.
Polyhydramnios: If severe and causes significant symptoms or fetal compromise, can be treated by removing excess liquid through amniocentesis. Oligohydramnios: This is a serious condition that is generally treated by delivering the baby as soon as it is considered safe to do so.


Condition What Can Happen Risk Factors and
Warning Signs Treatment

Premature labor
Health of premature newborn is determined by week of gestation, type of neonatal care available, birthweight, and general health.
Contractions accompanied by cervical dilation, vaginal bleeding or discharge, or vaginal pressure between the 20th and 37th week of pregnancy. Other symptoms include menstrual-like cramps, with possible diarrhea, nausea, or indigestion. Risk factors include smoking, urinary tract infections, poor general health, diabetes or thyroid problems, bacterial infections or STDs, placental problems, physical trauma (car accident, spouse abuse), a history of premature labor, multiple fetuses, abdominal surgery during pregnancy, or a history of two second trimester miscarriages.
Bed rest, intravenous fluids, and/or the prescription of drugs to prevent labor. Note: Medications are generally effective only if your cervix is dilated less than three centimeters and is not yet effaced.


Placenta previa (placenta covering the cervical opening)
The baby cannot pass out of the mother's body without dislodging the placenta and disrupting its own blood supply. A postpartum hemorrhage may occur after the birth of the baby.
Bleeding can be triggered by coughing, straining, or sexual intercourse. More common in women who have had several children. Occurs in 1/200 pregnancies.
Bed rest, monitoring, and/or hospitalization. A cesarean section may be required.Note: If placenta previa is diagnosed n 2nd trimester, the condition may correct itself by the time you deliver.


Placental abruption (placenta prematurely separates from uterus, either partially or wholly)
Can be harmful—even fatal—to mother and baby.
Warning signs include heavy vaginal bleeding, premature labor, contractions, uterine tenderness, and lower back pain. More common in women who have had two or more children, who smoke, who have high blood pressure, or who have had a previous placental abruption. Sometimes caused by the trauma of an automobile accident. Occurs in 1/150 pregnancies.
Bed rest and careful monitoring. If fetus goes into distress, an emergency cesarean section may be necessary.


Placental insufficiency
Can result in a low-birthweight baby.
Can be caused by abnormal development, restricted blood flow due to a clot, a partial abruption, a placenta that is too small or poorly developed, a pregnancy that is postdate, or maternal diabetes.
Sometimes warrants the delivery of the baby before term.


Bright Idea
Check out the online guide to gestational diabetes at www.mediconsult.com/pregnancy/shareware/gest/.

Coping with the stress of a high-risk pregnancy
Nine months can seem like an impossibly long time when you're dealing with the stress of a high-risk pregnancy. If your pregnancy has been categorized as high risk, you may be dealing with a lot of conflicting emotions. "At some point during your confinement, you can expect to feel angry at your baby (for keeping you in bed), your husband (for getting you into bed in the first place), your doctor (for not fixing the problem), and everyone else you can think of," explains Laurie A. Rich, author of When Pregnancy Isn't Perfect: A Layman's Guide to Compli-cations in Pregnancy.