Louise Wilkins-Haug, MD, PhD
High-risk pregnancy care differs from typical pregnancy care in that we’re often dealing with women who have chronic medical conditions coming into their pregnancy, or there have been pregnancy complications recognized as the pregnancy goes forward, or there are concerns with the baby that they’re carrying.
In addition to women who have ongoing chronic medical health issues before they come into a pregnancy or concerns with the pregnancy itself, often women come into a high-risk practice if they’re older maternal age, 35 or older, or if they’ve had their pregnancy conceived through IVF in combination with older maternal age. Those would be situations where women would seek high-risk obstetric care for their pregnancy.
We would like to see women who have preexisting medical conditions before they actually consider a pregnancy and are actually pregnant. If women come in for a pre-conception consultation there are alterations to their medical care that we can suggest so that their chronic medical disease such as their diabetes, can be in the best control possible when they enter a pregnancy, or some of their other medical conditions, even an inherited metabolic disease, can be optimally managed for their best pregnancy outcome.
In the middle part of the pregnancy many women will have an ultrasound to evaluate the length of their cervix. If it’s found to be too short or open they might have cervical insufficiency. That would be a situation where they may be transferred into a high-risk practice to be followed more closely or, if they have other risk factors, they may have a cerclage placed.
Certainly other women may have signs on their ultrasounds or have risk factors for having a placenta that may be too adherent to the uterus and have concerns that they are going to have a difficult delivery which may result in blood loss or need for further surgery. A general obstetrician may refer them to our Placenta Accreta Program that Dr. Carusi runs to help coordinate their care and provide them the best surgical support at the time of their delivery.
One of the other concerns that may develop during a pregnancy is a woman may have elevated blood pressure. It may not be significantly elevated that she needs to deliver right at that point in time but she may need ongoing observation. Certainly some of that may be need to be done in a hospital but often it’s not as severe that she needs delivery. In this case, she may be transferred into a high-risk office.
We have the availability of ultrasound in our unit to be able to follow the fetal growth of an infant as it’s developing, to check blood flow through the umbilical cord, to assess the amniotic fluid in a biophysical, as well as being able to do non-stress testing to check how well the infant’s doing at that point in time.
When we have identical twins present we look very carefully, even very early in the first three months, to make sure that the structures of each are normal. Going into the second trimester, identical twins can get into problems because there can be unequal sharing of blood between the two placentas. So we then start following them very carefully to make sure that the blood flow between the two placentas doesn’t disrupt the amniotic fluid between the two and a condition known as twin-twin transfusion doesn’t evolve.
One of the cornerstones of our fetal therapy program has been a collaborative program with Boston Children’s Hospital to treat a certain type of fetal cardiac condition before a baby is born. There is a group of children with hypoplastic left heart in whom halfway through the pregnancy the full manifestations of that hypoplastic left heart have not already developed. What they have at that point is they have a very small narrowing to the outflow trap on the left side. We developed a program about 15 years ago where we are able to go in when the baby is still inside, at about five and a half months, and with a needle, be able to open up the closed valve on the left side of the heart while watching under ultrasound. For about half of the babies where we can get the valve open, they’re able to maintain the left side of their heart.
We are gaining increasing knowledge that the occurrence of a high-risk pregnancy often signals complications or health concerns that are going to be with a woman through the rest of her life. And certainly we recognized for some time that gestational diabetes is one of these concerns that when women come back into care post-partum, they need to have this followed up with additional testing because they’re going to be at increased risk for diabetes later in their life.
I think we’re also recognizing that preeclampsia, and even preterm delivery, place a woman at increased risk for cardiovascular disease later in life. We now have a whole program directed towards trying to identify these women and get them back into primary care and back into programs where their cardiovascular risks are being addressed.
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