Education Family Health Pregnancy

#42: Introduction to High-Risk Pregnancy with Dr. Shannon Clark, Founder of BabiesAfter35

Shannon is originally from Kentucky. She settled in the Houston area as a practicing maternal-fetal medicine specialist. She’s been working at a large academic center as an educator and researcher since 2004. Her patients consist largely of high-risk pregnant women who have various medical, surgical or fetal complications.

She met her husband at age 38 and they got married when she was 39. Unfortunately, they had very little luck in starting their family. They have undergone IVF procedure but failed for 5 times. So they decided to try an egg donor and they successfully conceived on their 2nd try with their egg donor. Dr. Shannon delivered twins at the age of 42.

Shannon had some complications during her pregnancy. She was hospitalized at 22 weeks due to a short cervix and preterm labor. Her twins were delivered at 31 weeks and spent 5-6 weeks in NICU. Both babies are healthy and now 18-month old.

A high-risk pregnancy is a pregnancy that either has maternal and/or fetal complications. That can be anything from medical issues to surgical issues to genetic complications. Typically, depending on what those complications are and whether or not they involve the mom and/or the baby, additional testing may be required. Sometimes, medical treatments or surgical interventions may be needed to treat or assess the pregnancy as it progresses.

A high-risk pregnant woman may require more frequent visits to her doctor and increase fetal surveillance either thru ultrasounds or non-stress tests (NST). They may require a planned delivery that may either be a C-section or induction. They may require an early delivery or could have treatments if the mom needs it. A lot of times, depending on where the mom is located and what the abilities are of her medical care provider, she may need either full treatment or consultations routinely with a maternal-fetal specialist like myself throughout her pregnancy.

High-risk is not always designated at the very beginning. Sometimes a woman can start her pregnancy without complications, but she may develop something that makes her high-risk. Routine prenatal care and knowing any risk factors you may have either prior to or during your pregnancy are very important to keep in mind.

Common complications that make a pregnancy high-risk:

  • Maternal medical conditions. These can be pre-existing medical conditions like being an older first-time mom or an older mom in general, having diabetes, high blood pressure, asthma, blood-clotting disorders, any cardiovascular disease, kidney disease, auto-immune disease like lupus which is a very common one, thyroid disease, obesity is also very common, having any kind of infectious disease like HIV or hepatitic C.
  • Pregnancy-related maternal medical conditions. These can be preterm labor, pre-eclampsia, having a short cervix, having a placenta previa where the placenta covers the opening of the cervix, gestational diabetes or gestational hypertension.
  • Surgical complications. Women that had multiple C-sections in the past can be high-risk. If you’ve had a prior uterine surgery, a fibroid surgery or any other prior abdominal surgery could make you high-risk as well.
  • Fetal complications. The most common is growth abnormalities where the baby is not growing like it should or it’s growing too big. This also includes any kind of genetic defect that may have found or there is a family medical history that puts the baby at high-risk. Another thing is any congenital birth defect that may have picked up on an ultrasound like a heart defect, brain defect, or cleft palate. Multiple gestations are also considered high-risk though it is very common. Twin pregnancy, even if the mother is completely healthy, is a high-risk pregnancy.
  • Drug use, abuse, and smoking.

Obesity. Obese women a lot of times will come in with pre-existing medical conditions that are often times sub-optimally controlled like diabetes and high blood pressure. When an obese woman is pregnant and she has a medical condition that is not optimally controlled, you need to get her condition controlled while she’s pregnant. Pregnancy weakens the body due to physiological changes that occur. Sometimes it is a lot harder to get those conditions under control when you’re pregnant and obese. You also have to worry about weight gain and how you’re going to deliver. It is not always as easy for an obese patient to have a normal delivery. A lot of times, those patients end up with a C-section. Recovering from that can be very difficult due to a more increased risk for infection.

Multiple C-sections. Twofold – first is how your uterus was interred during a C-section because there are different ways to make an incision on a uterus and second is the number of times you’ve had a uterine incision increases your risk of having abnormal placentation or an abnormal placental attachment to the lining of the uterine wall. A lot of times, the placenta might attach over that old uterine scar. If a woman had a C-section for multiple times, the area where the scar is becomes weaker and it can allow the placenta to grow into the uterus and won’t come off. This is called placenta accreta. There is also a complication called placenta percreta where the placenta can even go through the uterus and to surrounding organs. Placenta previa means the placenta is attached over the cervix. For women with multiple C-sections, they have increased risk of having placenta accreta and placenta previa which makes them a very high surgical risk once they deliver.

Multiple gestations. A uterus is designed for one baby and you have two or three or more so the uterus gets overextended. You have an increased risk for preterm labor, short cervix, miscarriage, gestational diabetes, and preeclampsia. Genetic issues are also something to watch out for. When you have twins or more, you also have increased risk for birth defects.

Why is 35 seen as the age of high-risk pregnancy? So many women are having babies later in life, after age 35 or even 40, and they don’t feel that their age should make them high-risk. However, there are reasons why they are high-risk.

A woman over age 35 is considered high-risk based on her age alone. We know that women over age 35 have an increased risk of having a child with chromosomal abnormalities like Down syndrome. The reason why there’s so much focus on Down syndrome specifically is that there is a small percentage of Down syndrome babies who have completely normal anatomy ultrasounds. For this reason, especially on women over age 35, we offer and recommend antenatal screening like a quad screen or a first-trimester screening to assess her risk for having a baby with Down syndrome.

We also want her to have a detailed fetal anatomy ultrasound at 18-20 weeks to look for any signs of fetal birth defects. There are other chromosomal or genetic abnormalities that can occur after age 35 but they are a little more likely to have abnormal ultrasounds. If her quad screen is negative and fetal ultrasound is normal and she has no other reason to be considered high-risk other than her age, then she could be considered to have a normal pregnancy and she may no longer need to be labeled high-risk.

Another reason why it is an age considered high-risk is if the mother has pre-existing medical conditions, her pregnancy may have additional complications especially if those pre-existing conditions are not optimally controlled. Her medical conditions should be closely monitored during pregnancy and ideally controlled before she gets pregnant.

Women over age 35 have increased risk of developing certain complications of pregnancy just based on age. Any of these complications can place her into the high-risk category – gestational diabetes, blood pressure issues, having multiple gestations, delivering pre-maturely, increased risk of having a large baby or low birth weight baby, increased risk for requiring a C-section, increased risk of developing placenta previa or experiencing pregnancy loss. For all these reasons, women over age 35, even if they may not feel that they are high-risk, they should be managed or co-managed by someone who is versed in delivering women later in life and know the potential complications she may have.

Precautions. These are some things that women who are over age 35 should consider:

  1. Make sure any pre-existing medical conditions are optimally managed.
  2. Early onset and routine prenatal care.
  3. Make sure to take a prenatal vitamin before pregnancy.
  4. Controlled weight gain is important.
  5. Compliance with any medical management that’s needed while you’re pregnant whether it be to treat any condition you have coming into the pregnancy or to treat any condition that develops during your pregnancy.
  6. Deliver at an institution that’s equipped to handle potential maternal and neonatal complications especially if you deliver pre-maturely (depends on the availability of healthcare). It is very important to be somewhere where they are able to take care of the baby.

Personal advice. You have to be realistic. It is important to educate yourself by talking to your doctor about any concerns. I would suggest to stay off the internet and the chatrooms where people ask random questions because you will hear so many things that will just scare you to death. Establishing a good relationship with your physician and being able to ask questions about your concerns is very ideal. Unless you know where the information is coming from and that it is backed by somebody who knows what they’re talking about, you can really get some bad information on the internet.

The struggle of a high-risk pregnancy. Shannon’s sister just naturally conceived and had a 34-week baby at age 43. She and her husband didn’t think they could get pregnant and out of the blue, they got pregnant. She, having seen what Shannon went through, knew all these stuff to worry about and was so stressed out. The one thing she said to her sister and it’s a piece of advice she wished she had done for herself:

“No matter what complications you have, no matter what you’re worried about occuring or all the things that could occur, you need to be sure and enjoy and celebrate your pregnancy as much as possible. Because being racked with worry and thinking about that all the time, takes away from the bonding you have as a pregnant woman with your child and the developing baby.

I didn’t bond as early as I should have because I was so afraid of losing them. I was afraid of getting too close. I wasted a lot of time stressed out that I was gonna lose them that I didn’t enjoy the time that I have them when I was pregnant. So no matter what’s going on, you need to enjoy and celebrate your pregnancy as much as possible in order to be able to bond with your baby.”

Ways to bond with your baby. Having a high-risk pregnancy, you need to talk about it. Once you’re ready to announce, let your family know. Let people do things for you if they want to buy you things for the baby. Do what you’re comfortable with. Talk to your babies. Take baby bump photos even if it’s a selfie in the bathroom. These are little things women can do to celebrate their pregnancy.

Shannon’s experience at the NICU was tough so she suggests to have a good relationship with people taking care of your babies. She also suggests to not be at the NICU all day because you got to have time to heal yourself and be ready for your babies when they come home. Being there all day is not always good for you. Ask the NICU staff when it’s time for their first bath, when it’s time for footprints, when it’s time for baby pictures, when it’s time for some of those what we call “firsts” to make sure that they let you know so that you can try to be there. The NICU staff are actually so good about that stuff. You just got to ask them what you need to know to bond as much as you can with your baby and they will tell you.

How to contact Dr. Shannon Clark:

Website: www.babiesafter35.com

Facebook: https://www.facebook.com/babiesafter35/

Instagram: https://www.instagram.com/babiesafter35/

Twitter: https://twitter.com/babiesafter35

 

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