Obstetrics

High risk pregnancy 

• Pregnancy can be a stressful time, especially if there’s a complication. If you have a complicated pregnancy, your doctor may ask for assistance from Beaumont’s High-Risk Pregnancy Program.
• Our program offers consultations and second opinions to you and your obstetrician. Our goal is to answer questions, explain conditions, provide testing, and help you and your baby from conception to delivery.
• Our prenatal care is extensive. When you come to the program, you’ll meet with a team of specialists including genetic counselors, dietitians, social workers, nurse specialists and pediatric subspecialists.
• The High-Risk Pregnancy Program also is backed by the extensive resources of the hospital. Beaumont has a comprehensive neonatal intensive care unit and more than 25 pediatric specialties to help you and your baby.

As a result, your team is experienced to handle virtually any high-risk pregnancy problem, including:

• diabetes
• heart disease
• kidney disease
• high blood pressure
• cancer in pregnancy
• Rh blood factor problems
• history of pre-term birth
• genetic disease in the mother or family
• quadruplets and other multiple
• births birth defects identified before birth

Diabetes in pregnancy

• Diabetes is the most common medical complication of pregnancy, affecting 2 to 3% of all pregnancies. Ten percent of cases are women who have diabetes before pregnancy, and for these women, the risk of birth defects is four times greater than in women who get diabetes during pregnancy.
• The most common birth defects resulting from a diabetic woman becoming pregnant are problems with the structure of the baby’s heart, spine or kidneys. These outcomes are especially true if the mother has high blood sugars prior to conceiving. Women with pre-pregnancy diabetes are also at higher risk of out-of-control diabetes during pregnancy, which can lead to an increased risk of stillbirth.
• Careful management of diabetes before conception is critical. Women who have normal blood sugars before and when they conceive experience lower risks for birth defects. The risk can even be lowered to near the level of a non-diabetic woman.
• Ninety percent of the cases involving diabetes during pregnancy are classified as gestational diabetes. This is diabetes that is diagnosed or recognized during a pregnancy. Since it develops after the baby’s organs are formed, the risk of birth defects does not increase. Women with gestational diabetes, however, do experience greater incidences of excessive baby growth before birth. This can lead to delivery problems or the need for a cesarean section. Controlling sugars during pregnancy can lower the risk.
• Women with diabetes receive care through the Diabetes in Pregnancy Program at Cedars-Sinai. Our Maternal-Fetal Medicine specialists and certified nurse educator teach each woman how to control her blood sugar. Our nurse educator uses a special diabetic diet for pregnancy (not a weight-reduction diet), and teaches each woman to track her sugars with a home monitor. The patient reviews her sugar log with the nurse at least once every week. As necessary, the Diabetes in Pregnancy Program staff recommends modified diets or medications.
• Patients and referring physicians appreciate our intensive, compassionate approach to managing diabetes in pregnancy, which significantly improves the results of pregnancies that are complicated by this relatively common problem.

Hypertension in pregnancy

• Chronic hypertension in pregnancy is associated with increased rates of adverse maternal and fetal outcomes both acute and long term. These adverse outcomes are particularly seen in women with uncontrolled severe hypertension, in those with target organ damage, and in those who are noncompliant with prenatal visits. In addition, adverse outcomes are substantially increased in women who develop superimposed preeclampsia or abruptio placentae. Women with chronic hypertension should be evaluated either before conception or at time of first prenatal visit. Depending on this evaluation, they can be divided into categories of either “high risk” or “low risk” chronic hypertension. High-risk women should receive aggressive antihypertensive therapy and frequent evaluations of maternal and fetal well-being, and doctors should recommend lifestyle changes. In addition, these women are at increased risk for postpartum complications such as pulmonary edema, renal failure, and hypertensive encephalopathy for which they should receive aggressive control of blood pressure as well as close monitoring.
• In women with low-risk (essential uncomplicated) chronic hypertension, there is uncertainty regarding the benefits or risks of antihypertensive therapy. In my experience, the majority of these women will have good pregnancy outcomes without the use of antihypertensive medications. Antihypertensive agents are recommended and are widely used in these women despite absent evidence of either benefits or harm from this therapy. These recommendations are based on dogma and consensus rather than on scientific evidence. There is an urgent need to conduct randomized trials in women with mild chronic hypertension in pregnancy.

IUGR

The term intrauterine growth restriction (IUGR) is the most common generic term that is used to describe the fetus with a birthweight at or below the 10th percentile for gestational age and sex. This term is often erroneously used as synonymous of small for gestational age (SGA). The IUGR fetus is a fetus that does not reach his potential of growth; whereas the SGA fetus is a fetus who reaches his potential of growth. In other words, a fetus who has a potential of growth at the 50th percentile but because of maternal, fetal, or placental disorders occurring alone or in combination, becomes growth restricted (birthweight <10^th percentile) is a IUGR fetus and he is at risk for adverse perinatal outcome. A fetus with a potential of growth at the 7^th percentile who reaches his potential of growth (7^th percentile) is not a IUGR fetus but a SGA fetus. He is a normal small fetus and he is not at risk for adverse perinatal outcome.

Preterm delivery

Preterm delivery may be affected by gestational weight changes despite prepregnancy weight. Investigators from the U.S. Centers for Disease Control & Prevention report, “The association between excessive gestational weight gain and preterm delivery is unclear, as is the association between low gestational weight gain and preterm delivery among overweight and obese women.

Post term pregnancy

• Last menstrual period is the best physiological land mark to assess the gestational period in pregnancy. However, a few women are sure of their dates and often cause anxiety when they come with postdatism. A post-term pregnancy is the one which extends beyond 42 weeks or 294 days from the first day of the last menstrual period.
• Post-dated pregnancy always poses a high risk, as there is a possibility of foetal distress and death due to progressive foetal hypoxia following plancental insuffiency as a result of its agening. This is however a rare complication as usually there is enough reserve. Although it appears desirable for the pregnancy to be terminated before such a problem arises, it is not always possible to do so as there is a significant number of patients where obstetric dates are not well substantiated; further, when pregnancy reaches 42 weeks, there are patients with a cervix unfavorable for induction and in whom induction results in a high caesarean section rate.

Placenta pravia

• Placenta praevia (also known as low lying placenta) is a complication of pregnancy, when the placenta is in the lower segment of the uterus and covers part or all of the cervix. Between three and six of every 1000 pregnant women have this problem. Bleeding may be a symptom of the condition. As the lower part of the uterus stretches in the second half of pregnancy, the placenta may become detached, causing severe bleeding. The baby cannot be born vaginally if the placenta is totally obstructing the opening from the womb.
• Uncontrolled bleeding (haemorrhage) is life-threatening for both mother and baby, although this is rare. If the bleeding doesn’t stop, or if the mother goes into premature labour, the baby will need to be delivered by caesarean section even if the date on which he was due isn’t for quite a few weeks.

Placenta praevia can be divided into four types, of which the first two are the most common:

• The placenta is positioned low in the womb, but the baby can still be     born vaginally.
• The lower edge of the placenta touches the opening of your cervix, but does not cover it, so the baby can be born vaginally.
• The placenta partially covers the opening of your cervix. The baby will need to be born by caesarean section.
• The placenta completely covers the opening of your cervix. The baby will need to be born by caesarean section.
• If you have an ultrasound scan in early pregnancy and the placenta seems to be near, or even covering the cervix, don’t be too alarmed. It almost certainly is not placenta praevia. As your baby grows, your expanding uterus naturally pulls the placenta away from your cervix. Even if the placenta is still low-lying at your 20-week scan, it may well not present a problem once you are full-term

Twins pregnancy

Obviously, carrying and delivering two babies at once is more of a feat than just producing one, but the fact remains that pregnancy and birth are physiological states, not symptoms of a disease process. Statistically, it is true that there’s an increased likelihood of problems with twins. However, not all complications of single pregnancies occur more frequently in a twin pregnancy, so don’t worry. How twin pregnancies happen Identical twins.
One egg splits after fertilization into two separate cells – each one of these growing into a baby (usually sharing the same placenta). Having developed from the same cell, they are always the same sex and look alike. Non-identical or fraternal twins. Two eggs are fertilized by two different sperm at the same time, (each baby having its own placenta). They can be different sexes and probably will not look any more alike than any brother or sister. Your chance of having twins Twin pregnancies are passed down through the female and are more likely to occur if there are already non-identical twins in the family. The prevalence in the UK is about one in 95 deliveries – and this has been increasing over the past couple of decades. Multiple pregnancies also increase as women get older.

Older mother

• According to figures from the Human Fertility and Embryology Authority (HFEA) is evident that there is an increase in the rates of women attaining motherhood at a later age. Based on statistics it was seen that in 1992, just one baby was born to a mother aged 50 or over. But in 2002, 24 babies were born to women in that age group after IVF treatment. Though rules by the NHS say that IVF should not be done to women over 39 there is no legal IVF age limit. Recently Dr Patricia Rashbrook, of Lewes, East Sussex, became Britain’s oldest mother at the age of 63. She underwent IVF treatment from an Italian fertility doctor Severino Antinori. The HFEA shows that there is an increase both in the number of women seeking IVF and the number of babies born after IVF.
• In 2002, over 7,700 women aged 40 to 44 had IVF, with 524 babies born and among 595 women aged 45 to 49 only 106 live births were seen. The parliament passed laws about fertility treatment but did not mention anything about age limit for IVF treatment. So the doctors had to decide the welfare of any child born to older mother. They should bear in mind that older mothers are at increased risk of stroke, heart attack, pre-eclampsia, diabetes, high blood pressure and multiple births. Dr Allan Pacey, of the British Fertility Society, said that the reason for a surge in older women becoming mothers is mainly due to the NHS waiting list.
• Medindia on Late Pregnancy Women Face The Risk Of Heartbreak, Fertility Problems Clare Brown, chief executive of Infertility Network, Britain, said: “Delaying having children until you are in your thirties is a choice many people make.

FAQ

Q.1.   I am 5 months pregnant and have no problems. However my first baby was born in the 7th month and my doctor after examining me told me that I need to get stitches on the mouth of the womb in order to prevent an early delivery again. I am scared of a surgery in pregnancy. Is it absolutely necessary?

 Ans:   The problem that you have is probably cervical incompetence, where the cervix (mouth of the womb) is weak and begins to open much earlier during pregnancy than it should. If the cervix opens or is short, the chances of premature delivery are high. This condition causes no problems or pain to the patient who is usually unaware that the cervix has opened out. This can be diagnosed only on sonogarphy or on an internal check up by the doctor. As you already have a preterm delivery in the past, it is definitely safer for you to get a cervical stitch taken. This is a simple and safe procedure and takes only a few minutes to do. However you may need to be in hospital for a few days for rest. This simple stitch helps many patients to bear the child till the 9th month and the stitch is cut off a few weeks before delivery.

Q.2.   I am 25 years old and married for 3 years. I have just missed my period by one week and was excited about my pregnancy but my doctor says that I have an ectopic pregnancy and I must get it operated and removed. Are there no alternatives?

Ans:  An ectopic pregnancy is one where the pregnancy gets stuck in the tube or ovary rather than in the womb (uterus). This is diagnosed clinically or on sonography. It is a dangerous condition as the tube can burst and there can be severe bleeding inside the pelvis, therefore treatment has to be done urgently. This can be treated either with special injections of drugs such methotrexate or by key hole surgery (laparoscopic surgery) where the tube can be removed or only the pregnancy is removed and the tube is saved if it looks healthy.