Transcription:
Tips For Managing A High-Risk Pregnancy

Joey Wahler (Host): We've heard the term high risk pregnancy, but what exactly can make a pregnancy riskier than usual? And how are those factors best managed? We're discussing tips for managing a high risk pregnancy. This is Live Greater, a University of Maryland Medical System Podcast. Thanks for listening. I'm Joey Wahler. Our guest Dr. Kerry Lewis. System Medical Director of Women's Health and Specialty Programs. Also Chairman of the Department of Obstetrics and Gynecology and Division Director of Maternal Fetal Medicine at UM Capital Region Health. Dr. Lewis, thanks for joining us.

Kerry Lewis, MD (Guest): Thank you.

Host: Pleasure to have you. So first off, what typically constitutes a high risk pregnancy?

Dr. Lewis: Well, that's great question in the sense that, you know, it confuses a lot of people and it's usually two categories. One is a category of medical comorbidities associated with patient's pregnancy or their own health. So for example, a woman who has hypertension, she has diabetes, she has sickle cell disease. She may have lupus. Those medical conditions can have a significant impact on the pregnancy and the pregnancy can have a significant impact on those comorbidities, so that can actually result in some adverse outcomes to which it's important that we understand those dynamics and manage them appropriately, so that both mother and baby do well. The second category of high risk pregnancies has to do with the pregnancy itself. For example, somebody who has an increased risk of preterm labor, premature rupture of membranes, cervical insufficiency, multiple gestations like having twins and triplets. So all of these are related to the pregnancy. Babies that have fetal anomalies, right? Like anencephaly or have a cardiac defects, that makes the pregnancy high-risk. So, so basically it's those two categories that we look at as it relates to how we identify those risks and then manage the pregnancy to hopefully get the best possible outcome for both mother and baby.

Host: How about family history, genetics, and that type thing?

Dr. Lewis: Yeah. So, so genetic history plays a very interesting role in how we manage pregnancies. We have a number of genetic carrier screening tests that we perform on patients as a routine part of their prenatal care. And that allows us to identify any potential risks that may require, that would require discussion with the partner to determine if they also have a carrier status of any particular kind of a genetic anomaly that may be reflected in the fetus. So for example, one of those genetic disorders is sickle cell disease. So if a mother is a sickle cell carrier and the father is a sickle cell carrier, then there's a 25% risk that the baby could sickle cell disease.

Other diseases include spinal muscular atrophy, which is degenerative muscular disease that carriers are totally asymptomatic and are fine. But if the baby actually receives the genes from both mother and father, then that can create a significant musculoskeletal disorder in the, in the newborn that could actually be life-threatening. So these are the types of genetic disorders that we try and identify during the pregnancy to allow appropriate counseling for both mother and father.

Host: And as you alluded to, there's a lot of testing available nowadays more than ever. Right. And really oftentimes it depends on how deep you want to look into the genetics and the risk factors and how much you're willing to pay and weight. And basically try to leave no stone unturned. Right.

Dr. Lewis: That's exactly right. And, and, and, and in a kind of very common situation is that we have a lot of women who decide to establish their childbearing later in life, usually after the age of 35, which is awesome that they have that opportunity, particularly if they're in good health and have a good, great outcome, but there is the increased incidence of chromosome abnormalities, including Down syndrome, Trisomy 13 and 18, both of which the latter two associated with, with adverse outcomes, that a lot of families want to know prior to the baby's birth, whether or not that's a risk factor for that particular child. And a lot of times it's just for preparation, be prepared, have the initial, the appropriate information, so they can be better prepared for a baby that may have a potential chromosome or genetic anomaly. So now we have a called a cell-free DNA tests and some people call it a non-invasive prenatal testing or NIPT, which allows us to identify genetic material from the fetus while the fetus is still in utero, enters into the maternal blood stream and science has been able to extract and separate the genetic information from the fetus, from that of the mother, and thereby be able to render a risk factor as it relates to this fetus, having a chromosome abnormality, even some other genetic abnormalities.

You can also tell from that, so that avoids a procedure of the amniocentesis, or at least not necessarily avoids it, but reduces the incidence of performing an amniocentesis, which definitely has some complications associated with it when you place a needle into the uterus to get fluid, and it increases the risk of rupture of membranes and adverse outcomes.

And now we have a blood test that reduces the frequency by which we need to perform the amniocentesis. That gives us a very good, I mean, people say 95% sensitivity and specificity regarding the potential for this baby to have a chromosome abnormalities. That technology along with other technologies allows us to get a lot of information about the fetus before it's ever born.

Host: Is there a period during a high-risk pregnancy when those women are most at risk? And is there a time during it when they can start to breathe a little easier?

Dr. Lewis: Ah, interesting question. It kind of depends. Right. You know, again, trying to look at different categories of risk factors that influence the pregnancy outcomes. Of course the genetic disorders, the chromosome abnormalities, those are things that are predetermined. They, they don't change during the pregnancy. So once the conception occurs, if that genetic information is present as an anomaly, then that will follow the fetus throughout. And there's nothing that we can obviously do at least today to change that. Then there are the issues regarding cervical insufficiency. That's when the cervix dilates prior to the onset of labor.

And it's usually not a painful dilation. But it occurs usually in the second trimester. It's usually prior to viability. And in those situations, those pregnancies can be lost at the time prior to viability. And and hopefully we can identify that by close observation of the patients, appropriate ultrasounds and hopefully intervene by a procedure we call either cervical circlage or giving the patient progesterone to reduce the risk of her delivering her fetus prematurely when we've identified this situation where the cervix is actually starting to dilate early. Then we have the diagnosis of like preeclampsia or gestational diabetes, both of which are disorders that manifest themselves later in pregnancy.

Usually about late second, early third trimester. Especially for preeclampsia, which is hypertension in pregnancy. That disorder actually from a physiologic perspective is actually determined very early in pregnancy, but we don't see the clinical manifestations of that until usually the third trimester. And usually we see that as it relates to elevated blood pressures, patients have protein in their urine, or they may have some other laboratory derangements that suggests a potential for an adverse outcome, both for mother and for baby. And fortunately, with that particular diagnosis, we've established a standard of care where we give these patients baby aspirin or low dose aspirin to reduce the risk of them developing preeclampsia and, and such a benign medication as it relates to any side effects or it's tolerance, but it has such a major impact on improving the outcomes of the pregnancy. So some of these risk factors manifest themselves at different times during the pregnancy.

The last one I mentioned about multiple gestations, they're obviously a very high risk for preterm labor. And so we monitor those pregnancies very closely, not only for the onset of labor, but also for growth discrepancies that can occur based upon whether or not one baby gets more blood than the other baby and that results in one baby being sicker than the other.

And so those are the things we monitor very closely throughout the pregnancy that can manifest themselves anytime in relationship to the second or third trimester of pregnancy.

Host: So even though you've hit on a lot of different possibilities there, generally speaking, if possible, what are some of the most effective ways of managing a high risk pregnancy?

Dr. Lewis: Well, as I mentioned a moment ago, baby aspirin, I think has really helped us as a intervention that really reduces the risk of developing preeclampsia. And some studies will show even decrease the risk of growth restriction and maybe even preterm labor, in some studies. The integration of ultrasound has been, is basically, like the hammer is to the contract, to the contractor or the builder, the ultrasound is to the perinatologist, so the high-risk pregnancy expert. Because that's the way we assess not only the baby in terms of any, for example, any anomalies, like we've talked about before or any potential issues regarding the placenta location or amniotic fluid volume, or even looking at the mother for if she has fibroids.

Of course fibroids may affect the pregnancy in relationship to pain, bleeding and the onset of preterm labor. So the ultrasound really is the tool that is essential to allowing us to identify these risks, not only within the baby, but the mother themselves. Of course, even as I mentioned, cervical insufficiency, when the cervix dilates in the absence of uterine contractions, that diagnosis can be identified by the cervix becoming very short and even starting to dilate and how we make that diagnosis is with the ultrasound.

So the ultrasound has been around for many, many years. I think we started back in the sixties or late sixties. But the technology that we now have allows us to see so much more, that we can really identify any potential risks to the pregnancy using that, that information from the ultrasound and what's really helped us also is the institutes, the, the incorporation of anti-hypertensive medications. It used to be when I was trained that there was only one antihypertensive medication that was thought to be safe in pregnancy. And that was called aldomet. Which was not the greatest antihypertensive, but the impression was that was the only safe antihypertensive that you could use in pregnancy.

Now we have a number of different antihypertensives that really allow us to prolong these pregnancies. I remember when I was trained, we would deliver patients with hypertension 24, 26, 28 weeks, because we didn't have the tools to really manage the pregnancy and control the blood pressures. Now we have antihypertensive medications that clearly decreases any adverse outcomes, both in mother and baby, and allows us to prolong those pregnancies to 35 weeks gestation even to full term. And the thing that really came around that really revolutionized particularly the newborn fetus that was born prematurely is antenatal steroids. We give them betamethasone, give them two injections and it significantly reduces the risk of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, all of these potentially life-threatening disorders that occurs in these premature babies that now become very, very infrequent in relationship to initiating antenatal steroids. So all of these technologies, I, I, these medications have come around and actually, since I've finished my fellowship back in the early nineties and that has really those in the incorporation of those medications and tools and technology has really allowed us to really improve the outcomes of both mother and baby.

Host: Certainly sounds like it to say the least. Couple of other things for you. Does pregnancy put a woman at greater risk for COVID-19 complications? I know this has been something of a bone of contention in the medical field, right?

Dr. Lewis: Yes. And, and, you know, the data we have is, is really early data. It's not, it's probably, it's still undergoing investigation, but there are certain things that we do know that because of the science in places like New York and around the country that have really been very deliberate and disciplined about recording their data, we do have some, some knowledge. One, we do know that women who are pregnant and are exposed to COVID-19 or develop the infection are very high risk of embolic disorders, thromboembolisms that particularly characterized by pulmonary embolism, that can be life-threatening. And these patients, they, they, so what we've tried, what we've done in patients who have COVID or symptomatic from COVID, who are pregnant, we'll put them on anticoagulant therapy, because we know that that reduces the risk of them developing a thromboembolic disorder, which could ultimately result in death. And what we've identified is that many of these women who die as a result of COVID usually die as a result of pulmonary complications, either pulmonary edema or the pneumonia associated with COVID and it's clear in our literature and the research that those women who get the vaccine that are adequately vaccinated, do not. The significantly reduction in maternal death and prematurity and adverse perinatal outcomes. So to that extent the, the vaccine has really significantly reduced the risk of adverse outcomes in those women who unfortunately get COVID-19 who have gotten COVID-19. In relationship to COVID-19 or the pregnancy on COVID-19, pregnancy is a relatively immunocompromised state because of the body's ability to reduce the risk of rejection of the pregnancy.

So to that extent, women are very high risk for developing COVID pneumonia when they're pregnant. And so they are at high risk for developing COVID pneumonia. And then if they do develop COVID pneumonia they're at high risk for death. And so, again, I can't emphasize enough the importance and the value of getting the vaccination to reduce the risk of any adverse outcomes, including death.

Host: And then finally doctor for women with high-risk pregnancies in a nutshell, what should they expect that would be different than the norm with postnatal care and any other message you want people to take away from our conversation related to high risk pregnancy?

Dr. Lewis: Great. Thank you for asking me that question. Well, two things. First in relationship to how these patients are managed. As I mentioned before, in a high-risk pregnancy, certain things you would expect, one, you'll probably get more frequent ultrasounds. Two, you'll probably get more visits to your general obstetrician and to the maternal fetal medicine specialist, or also called perinatologist.

You may be, have more frequent admissions to the hospital to look at the, not only to look at the baby, but to monitor blood pressures, for example, or blood sugars in relationship to diabetic patients. You may have a team of people involved with your care, like usually a perinatal nurse and maybe a medical assistant, all of whom are involved with monitoring your wellbeing.

That could be monitoring blood sugars, blood pressures, your weight, anemia, all these things that can that can add on an already high risk pregnancy. And in the postpartum period of course it's important that particularly with the hypertensives and diabetics to continue to maintain adequate control of both of those blood pressures and blood sugars in order to maintain the woman's health to better care for herself and for her baby. And breastfeeding is critical in those situations, particularly if the baby is born prematurely, that we know that breastfeeding and breast milk has a significant impact on the baby's development and growth, particularly when they're premature.

So even when women, if they can't breastfeed because the baby may be in the special care nursery or the NICU, that they can still provide breast milk to the baby so that the baby has the best chance of doing well and having a long and happy life, even in spite of the fact that it's born prematurely. And then the last comment, the second comment I like to make in relationship to the incidence of maternal death that has really some people will call it endemic in this country. It is clearly of, of, of major concern. And I truly believe that as we become more educated meaning the perinatologist, the obstetrician becomes more educated about the factors that contribute to the high incidence of maternal death, many of which are reflected in hypertensive diseases. Women, particularly in the postpartum period will experience elevated blood pressures. They may be delayed going into the emergency department to be evaluated. And even when they enter the emergency department, they may not be recognized as a patient with severely elevated blood pressure, such that it could be life-threatening. And so we, we we're currently educating ourselves across the country about how we manage hypertensive disease in pregnancy. Cause we recognize that that's the number one cause of death. Stroke and heart attack and heart disease associated and cardiomyopathy all associated with hypertensive diseases that we need to be a lot more aggressive about. As a matter of fact, there's a recent article that talks about what a normal blood pressure should be.

And we would, we used to be, we'd be concerned when the blood pressure got above 160 over 110. Now there's good data that suggests even a blood pressure of greater than 140 over 90 should be treated. We always recognized that was associated with elevated blood pressures, but we didn't always treat it. And now we're at a place where we're actually considering that even patients with a slight elevation of blood pressure needs to be treated. So I think as we become more, as we educate ourselves more and become more aggressive in identifying those high risk factors that contribute to maternal death, that we'll be more successful in significantly reduction and in maternal death that's occurring across the country.

Host: All right. Well, a lot of great detailed information there covering a lot of bases. And so folks we trust, you're now more familiar with managing a high risk pregnancy. Dr. Kerry Lewis, thanks so much again.

Dr. Lewis: My pleasure. Thank you so much.

Host: And this episode is sponsored by UM Capital Region Health, the largest healthcare provider in Prince George's County, dedicated to enhancing the health and wellness of the community by providing high quality accessible patient care. UM Capital Region Health, changing up healthcare in Prince George's County. Find more shows just like this one at umms.org/podcast.

That's umms.org/podcast. And thanks for listening to Live Greater. A health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again. Hoping your health is good health. I'm Joey Wahler.