What is a high risk pregnancy

A high-risk pregnancy is one in which the mother, her fetus, or both are at higher risk for health problems during pregnancy, labor and after delivery than in a typical pregnancy. For example, women who have chronic health problems, such as high blood pressure or diabetes, who become pregnant may be considered to have high-risk pregnancies, even if the condition is well controlled. Other factors, such as infections, injuries, and disorders of pregnancy, can also put a pregnancy at high risk.

Women whose pregnancies are considered high risk may need specialized care from specialists or a team of health care providers or treatment to have healthy pregnancies and deliveries. The specific type of care needed will depend on the specific risk factors, as well as the overall health of the mother and the fetus. Typically, special monitoring or care throughout pregnancy is needed.

Just because a pregnancy is considered high risk does not mean that a problem will occur.

Understand the risk factors for a high-risk pregnancy, and what you can do to take care of yourself and your baby.

Several factors can make a pregnancy high risk, including existing health conditions, the mother’s age, lifestyle, and health issues that happen before or during pregnancy.

Factors present before pregnancy that can increase pregnancy risk may include:

• Being very young or old
• Being overweight or underweight
• Having had problems in previous pregnancies, such as miscarriage, stillbirth, or preterm labor or birth
• Pre-existing health conditions, such as high blood pressure or diabetes
• During pregnancy, problems may also develop even in a woman who was previously healthy. These may include such conditions as gestational diabetes or preeclampsia/eclampsia (dangerously high blood pressure).

If you have a high-risk pregnancy, you might feel reluctant to think about the future and nervous about prenatal visits — for fear that you’ll hear bad news.

Unfortunately, anxiety can affect your health and your baby’s health. Consult your health care provider about healthy ways to relax and stay calm. Some studies suggest that techniques such as imagining pleasant objects or experiences or listening to music can reduce anxiety during pregnancy.

Consult your health care provider about how to manage any medical conditions you might have during your pregnancy and how your health might affect labor and delivery. Ask your health care provider to discuss specific signs or symptoms to look out for, such as:

• Vaginal bleeding
• Severe headaches
• Pain or cramping in the lower abdomen
• Watery vaginal discharge — in a gush or a trickle
• Regular or frequent contractions — a tightening sensation in the abdomen
• Decreased fetal activity
• Pain or burning with urination
• Changes in vision, including blurred vision

Find out which signs or symptoms should prompt you to contact your health care provider and when to seek emergency care.

A high-risk pregnancy might have ups and downs. Do your best to stay positive as you take steps to promote a healthy pregnancy.

Can I have a planned home birth?

It’s often difficult to predict which pregnancies will become high risk or when a high-risk condition might occur. That’s why planned home births typically aren’t recommended.

What makes a pregnancy high risk

Sometimes a high-risk pregnancy is the result of a medical condition present before pregnancy. In other cases, a medical condition that develops during pregnancy for either you or your baby causes a pregnancy to become high risk.

Specific factors that might contribute to a high-risk pregnancy include:

• Teenage pregnancy.
• Advanced maternal age. Pregnancy risks are higher for mothers older than age 35.
• Lifestyle choices. Smoking cigarettes, drinking alcohol and using illegal drugs can put a pregnancy at risk.
• Medical history. A history of chronic hypertension, diabetes, heart disorders, breathing problems such as poorly controlled asthma, infections, and blood-clotting disorders such as deep vein thrombosis can increase pregnancy risks.
• Surgical history. A history of surgery on your uterus, including multiple C-sections, multiple abdominal surgeries or surgery for uterine tumors (fibroids), can increase pregnancy risks.
• Pregnancy complications. Various complications that develop during pregnancy can pose risks. Examples include an abnormal placenta position, fetal growth less than the 10th percentile for gestational age (fetal growth restriction) and Rh (rhesus) sensitization — a potentially serious condition that can occur when your blood group is Rh negative and your baby’s blood group is Rh positive.
• Multiple pregnancy. Pregnancy risks are higher for women carrying twins or higher order multiples.

High risk pregnancy age

• Young age. Pregnant teens are more likely to develop pregnancy-related high blood pressure and anemia (lack of healthy red blood cells) and to go through preterm (early) labor and delivery than women who are older. Teens are also more likely to not know they have a sexually transmitted infection (STI). Some sexually transmitted infections can cause problems with the pregnancy or for the baby ¹. Teens may be less likely to get prenatal care or to keep prenatal appointments. Prenatal care is important because it allows a healthcare provider to evaluate, identify, and treat risks, such as counseling teens not to take certain medications during pregnancy, sometimes before these risks become problems ².
• First-time pregnancy after age 35. Most older first-time mothers have normal pregnancies, but research shows that older women are at higher risk for certain problems than younger women ³, including:
  • Pregnancy-related high blood pressure (called gestational hypertension) and diabetes (called gestational diabetes) ⁴
  • Pregnancy loss ⁵
  • Ectopic pregnancy (when the embryo attaches itself outside the uterus), a condition that can be life-threatening ⁶
  • Cesarean (surgical) delivery
  • Delivery complications, such as excessive bleeding
  • Prolonged labor (lasting more than 20 hours)
  • Labor that does not advance
  • Genetic disorders, such as Down syndrome, in the baby ⁴

Existing health conditions

• High blood pressure. Even though high blood pressure can be risky for the mother and fetus, most women with slightly high blood pressure and no other diseases have healthy pregnancies and healthy deliveries because they get their blood pressure under control before pregnancy. Uncontrolled high blood pressure, however, can damage the mother’s kidneys and increase the risk for low birth weight or preeclampsia ⁷. It is very important for women to have their blood pressure checked at every prenatal visit so that healthcare providers can detect any changes and make decisions about treatment.
• Polycystic ovary syndrome (PCOS). Women with PCOS have higher rates of pregnancy loss before 20 weeks of pregnancy, diabetes during pregnancy (gestational diabetes), preeclampsia, and cesarean section ⁸.
• Diabetes. It is important for women with diabetes to manage their blood sugar levels both before getting pregnant and throughout pregnancy. During the first few weeks of pregnancy, often before a woman even knows she is pregnant, high blood sugar levels can cause birth defects. Even women whose diabetes is well under control may have changes in their metabolism during pregnancy that require extra care or treatment to promote a healthy birth ⁹. Babies of mothers with diabetes tend to be large and are likely to have low blood sugar soon after birth. That is another reason for women with diabetes to keep tight control of their blood sugar.
• Kidney disease. Women with mild kidney disease often have healthy pregnancies. But kidney disease can cause difficulties getting and staying pregnant as well as problems during pregnancy, including preterm delivery, low birth weight, and preeclampsia. Nearly one-fifth of women who develop preeclampsia early in pregnancy are found to have undiagnosed kidney disease ¹⁰. Pregnant women with kidney disease require additional treatments, changes in diet and medication, and frequent visits to their healthcare provider ¹¹.
• Autoimmune disease. Conditions such as lupus and multiple sclerosis can increase a women’s risk for problems during pregnancy and delivery. For example, women with lupus are at increased risk for preterm birth and stillbirth. Some women may find that their symptoms improve during pregnancy, while others have flare-ups and other challenges. Certain medicines to treat autoimmune diseases may be harmful to the fetus, meaning a woman with an autoimmune disease will need to work closely with a healthcare provider throughout pregnancy ¹².
• Thyroid disease. The thyroid is a small gland in the neck that makes hormones that help control heart rate and blood pressure. Uncontrolled thyroid disease, such as an overactive or underactive thyroid, can cause problems for the fetus, such as heart failure, poor weight gain, and brain development problems. Thyroid problems are usually treatable with medicine or surgery ¹³. However, a recent study found that treating mildly low thyroid function during pregnancy did not improve outcomes for mothers or their babies.
• Obesity. Being obese before pregnancy is associated with a number of risks for poor pregnancy outcomes. For example, obesity increases a woman’s chance of developing diabetes during pregnancy, which can contribute to difficult births ¹⁴. Obesity can also cause a fetus to be larger than normal, making the birth process more difficult. Research also found that obesity increases the risk for sleep apnea and disordered sleep breathing during pregnancy. Obesity before pregnancy is associated with an increased risk of structural problems with the baby’s heart. There can also be problems if overweight or obese women gain too much weight during pregnancy. Research has shown that an integrated approach can help obese women to limit their weight gain during pregnancy, leading to better pregnancy outcomes. The Institute of Medicine recommends that overweight women gain no more than 15–25 pounds during pregnancy and that women with obesity gain no more than 11–20 pounds ¹⁵.
• HIV/AIDS. HIV can pass to a fetus during pregnancy, labor and delivery, and breastfeeding. Fortunately, there are effective treatments that can reduce and prevent the spread of HIV from mother to fetus or child. Medications for the mother and for the infant, as well as surgical delivery of the baby before the “water breaks” and feeding formula instead of breastfeeding, can prevent mother-to-child transmission and have led to a dramatic decrease in transmission—to less than 1% in the United States and other developed countries ¹⁶.
• Zika infection. Although scientists and healthcare providers have known about Zika for decades, the link between Zika infection during pregnancy and pregnancy risks and birth defects has only recently come to light. Research has shown that infants born to mothers who were infected with Zika just before and during pregnancy were at higher risk for different problems with the brain and nervous system. The most noticeable is microcephaly, a condition in which the head is smaller than normal. Zika infection during pregnancy can also increase the woman’s risk for pregnancy loss and stillbirth. Researchers are still just learning the possible mechanisms of Zika’s effects on pregnancy.

Lifestyle factors

• Alcohol use. Drinking alcohol during pregnancy can increase the baby’s risk for fetal alcohol spectrum disorders, sudden infant death syndrome, and other problems. Fetal alcohol spectrum disorders are a variety of effects on the fetus that result from the mother’s drinking alcohol during pregnancy. The effects range from mild to severe, and they include intellectual and developmental disabilities; behavior problems; abnormal facial features; and disorders of the heart, kidneys, bones, and hearing. Fetal alcohol spectrum disorders are completely preventable: If a woman does not drink alcohol while she is pregnant, her child will not have an fetal alcohol spectrum disorder ¹⁷. Women who drink also are more likely to have a miscarriage or stillbirth. Currently, research shows that there is no safe amount of alcohol to drink while pregnant. According to one study, infants can suffer long-term developmental problems even with low levels of prenatal alcohol exposure ¹⁸.
• Tobacco use. Smoking during pregnancy puts the fetus at risk for preterm birth, certain birth defects, and sudden infant death syndrome (SIDS). One study showed that smoking doubled or even tripled the risk of stillbirth, or fetal death after 20 weeks of pregnancy ¹⁹. Research has also found that smoking during pregnancy leads to changes in an infant’s immune system ²⁰. Secondhand smoke also puts a woman and her developing fetus at increased risk for health problems ²¹.
• Drug use. Research shows that smoking marijuana and taking drugs during pregnancy can also harm the fetus and affect infant health. One study showed that smoking marijuana and using illegal drugs doubled the risk of stillbirth ¹⁹. Research also shows that smoking marijuana during pregnancy can interfere with normal brain development in the fetus, possibly causing long-term problems ²².

Conditions of pregnancy

• Multiple gestation. Pregnancy with twins, triplets, or more fetuses, called multiple gestation, increases the risk of infants being born prematurely (before 37 weeks of pregnancy). Both giving birth after age 30 and taking fertility drugs have been linked with multiple births. Having three or more infants increases the chance that a woman will need to have the infants delivered by cesarean section. Twins and triplets are more likely to be smaller for their size than single infants. If infants are born prematurely, they are more likely to have difficulty breathing ²³.
• Gestational diabetes. Gestational diabetes occurs when a woman who didn’t have diabetes before develops diabetes when she is pregnant. Gestational diabetes can cause problems for both mother and fetus, including preterm labor and delivery, and high blood pressure. It also increases the risk that a woman and her baby will develop type 2 diabetes later in life. Many women with gestational diabetes have healthy pregnancies because they work with a healthcare provider to manage their condition.
• Preeclampsia and eclampsia. Preeclampsia is a sudden increase in a pregnant woman’s blood pressure after the 20th week of pregnancy. It can affect the mother’s kidneys, liver, and brain. The condition can be fatal for both the mother and the fetus or cause long-term health problems. Eclampsia is a more severe form of preeclampsia that includes seizures and possibly coma.
• Previous preterm birth. Women who went into labor or who had their baby early (before 37 weeks of pregnancy) with a previous pregnancy are at higher risk for preterm labor and birth with their current pregnancy. Healthcare providers will want to monitor women at high risk for preterm labor and birth in case treatment is needed. Research has shown that, among women at high risk for preterm labor and birth because of a previous preterm birth, giving progesterone can help delay birth ²⁴. In addition, women who become pregnant within 12 months after their latest delivery may be at increased risk for preterm birth ²⁵. Women who have recently given birth may want to talk with a healthcare provider about contraception to help delay the next pregnancy.
• Birth defects or genetic conditions in the fetus. In some cases, healthcare providers can detect health problems in the fetus during pregnancy. Depending on the nature of the problems, the pregnancy may be considered high risk because treatments are needed while the fetus is still in the womb or immediately after birth. For example, if certain forms of spina bifida are detected in the fetus, the problems can be repaired before birth. Certain heart problems that are common among infants with Down syndrome need to be corrected with surgery immediately after birth. Knowing a fetus has Down syndrome before birth can help healthcare providers and parents be prepared to give treatment right away.

High risk pregnancy test

If you have a high-risk pregnancy, you might consider various tests or procedures in addition to routine prenatal screening tests. Depending on the circumstances, your health care provider might recommend:

• Specialized or targeted ultrasound. This type of fetal ultrasound — an imaging technique that uses high-frequency sound waves to produce images of a baby in the uterus — targets a suspected problem, such as abnormal development.
• Amniocentesis. During this procedure, a sample of the fluid that surrounds and protects a baby during pregnancy (amniotic fluid) is withdrawn from the uterus. Typically done after week 15 of pregnancy, amniocentesis can identify certain genetic conditions, as well as neural tube defects — serious abnormalities of the brain or spinal cord.
• Chorionic villus sampling (CVS). During this procedure, a sample of cells is removed from the placenta. Typically done between weeks 10 and 12 of pregnancy, chorionic villus sampling can identify certain genetic conditions.
• Cordocentesis. Also known as percutaneous umbilical blood sampling, this is a diagnostic prenatal test in which a sample of the baby’s blood is removed from the umbilical cord for testing. The test can identify certain genetic disorders, blood conditions and infections.
• Ultrasound for cervical length. Your health care provider might use an ultrasound to measure the length of your cervix at prenatal appointments to determine if you’re at risk of preterm labor.
• Lab tests. Your health care provider will test your urine for urinary tract infections and screen you for infectious diseases such as HIV and syphilis.
  Biophysical profile. This prenatal test is used to check on a baby’s well-being. It might involve only an ultrasound to evaluate fetal well-being or, depending on the results of the ultrasound, also fetal heart rate monitoring (nonstress test).

Some prenatal diagnostic tests — such as amniocentesis and chorionic villus sampling — carry a small risk of pregnancy loss. The decision to pursue prenatal testing is up to you and your partner. Discuss the risks and benefits with your health care provider.

High risk pregnancy prevention

Staying healthy before and during pregnancy is a good way to lower your risk of having a difficult pregnancy. Healthcare providers recommend that women who are thinking about becoming pregnant visit a healthcare provider to make sure they are in good preconception health.

Before and during pregnancy, a woman can take steps to help reduce her risk of certain problems.

Whether you know ahead of time that you’ll have a high-risk pregnancy or you simply want to do whatever you can to prevent a high-risk pregnancy, stick to the basics. For example:

• Schedule a preconception appointment. If you’re thinking about becoming pregnant, consult your health care provider. He or she might counsel you to start taking a daily prenatal vitamin with folic acid and reach a healthy weight before you become pregnant. If you have a medical condition, your treatment might need to be adjusted to prepare for pregnancy. Your health care provider might also discuss your risk of having a baby with a genetic condition.
• Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby’s health. Depending on the circumstances, you might be referred to a specialist in maternal-fetal medicine, genetics, pediatrics or other areas.
• Eat a healthy diet. During pregnancy, you’ll need more folic acid, protein, calcium and iron. A daily prenatal vitamin can help fill any gaps. Talk to your health care provider if you have special nutrition needs due to a health condition, such as diabetes.
• Gain weight wisely. Gaining the right amount of weight can support your baby’s health — and make it easier to shed the extra pounds after delivery. Work with your health care provider to determine what’s right for you.
• Avoid risky substances. If you smoke, quit. Alcohol and illegal drugs are off-limits, too. Get your health care provider’s OK before you start — or stop — taking any medications or supplements.

Preconception care

Preconception care is the health care a woman receives before she gets pregnant to help promote a healthy pregnancy.

Taking steps to make sure you are healthy and avoiding exposure to harmful behaviors and toxins before you get pregnant can decrease the chance of problems during pregnancy and improve the health of your child.

Prenatal care

Prenatal care is the health care a woman gets during pregnancy. Prenatal care should begin as soon as a woman knows or thinks she is pregnant. Early and regular prenatal visits are important for the health of both the mother and the fetus.

Research shows that prenatal care makes a difference for a healthy pregnancy. Women who do not seek prenatal care are three times as likely to deliver a low birth weight infant. Lack of prenatal care can also increase the risk of infant death ²⁶.

How is high-risk pregnancy treated?

Treatment for high-risk pregnancy depends on the woman’s specific risk factors.

For example, treatment for a woman whose pregnancy is high risk because of a thyroid problem is usually medication to ensure her body has the right levels of thyroid hormones. Treatment for a woman whose pregnancy is high risk because of cigarette smoking is helping her to quit smoking. Treatment for a woman whose pregnancy is high risk because she is HIV positive would involve antiretroviral treatments during pregnancy, possibly a surgical delivery, and additional medications for her and the baby after birth.

In a high-risk pregnancy, healthcare providers will want to keep a close watch on the woman and the pregnancy to detect any potential problems as quickly as possible so that treatment can start before the woman’s or fetus’s health is in danger. This is particularly true of pregnancies that are high risk because of preeclampsia and previous preterm labor or birth. In these situations, treatment could mean additional days in the womb to allow for fetal development to continue.

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