Is my pregnancy high risk? This question comes up numerous times in conversation with both patients at the office and in social conversation. As a fellowship trained maternal fetal medicine obstetrician who has been practicing for 30 years, one would think I am ideally situated to easily answer that question. And yes, in many instances where the history is specific and clear, the designation is easy but oftentimes the answer is tricky.
My good friend Jason who is an Ivy league trained litigator makes the bold claim that he can become proficient in any profession in seven days. I challenged Jason, who has absolutely no background or knowledge of medicine, with his ability to practice obstetrics after a seven-day crash course. He confidently assured me that not only would he be able to practice obstetrics but by default he would be a “high-risk obstetrician.” He explained his reasoning. “Anybody who’s using me as their provider would be at high risk of an untoward outcome.” I must admit that his logic is hard to argue with. So in the unlikely event Jason hangs an obstetrical shingle and is posed this title question by a patient, his answer would always be an unequivocal yes!
Surprisingly, there is no official definition of “high-risk pregnancy” put forward by the American College of OB-GYN, the Society for Maternal Fetal Medicine, or any governing medical organization. It is universally agreed that the designation can be applied to three categories. First are patients with a pre-existing medical condition complicating pregnancy such as diabetes, hypertension, kidney disease or any major medical malady. The second, patients with a history of preterm delivery, cervical insufficiency, obstetrical hemorrhage, late loss, cholestasis of pregnancy, poor obstetrical outcome and severe preeclampsia are also appropriately designated as “high-risk” in future pregnancies. The third category of “high-risk pregnancy” relates to issues of the baby or placenta in the current pregnancy. Hence, twins, triplets, fetal growth restriction, babies with structural anomalies, placenta previa, overabundance or near absence of amniotic fluid, are all common reasons for the designation of HRP.
My own definition of a HRP falls between Jason’s hard “yes” and the somewhat regimented criteria provided in textbooks. I believe the designation of “low risk” cannot be the default. All pregnant women should be considered high risk unless history has proven otherwise. Think about it, if you apply for a jumbo mortgage without having had any credit cards or loan history, will any bank consider you “low risk” as you were never late or missed a payment? Is it a “low risk” gamble if an NFL team drafts a quarterback based on his never having thrown an interception or having been sacked if he never set foot on a football gridiron?
Likewise, a woman should never be considered “low risk” unless she has carried a previous pregnancy to term without complication, delivered normally, and experienced no significant postpartum complications. An example of a pregnancy complication that does occur in a small number (1%) of women is cervical insufficiency. This is an unfortunate diagnosis usually made when a woman loses a pregnancy in the second trimester after painless cervical dilation. Placing a cerlage (a purse string suture) around a cervix that is starting to open in the second trimester often leads to a healthy birth. Another example of an obstetrical complication that often occurs in pregnancy is fetal growth restriction, or poor growth of the baby in utero. This may be associated with chronic hypertension or diabetes but often it occurs to women with no underlying risk factors. Undiagnosed, it can proceed to fetal death or a long-term disability. When the diagnosis is made and the baby is subsequently delivered early, the disease process has less long-term implications. Early delivery may even be the difference between an otherwise healthy child and a pregnancy loss.
Standards of obstetrical practice do not call for cervical length screening in the second trimester or regular fetal growth ultrasounds throughout pregnancy in patients who have no history of cervical insufficiency or fetal growth restriction, respectively. First-time moms undergo an early ultrasound to confirm viability and dating. An anatomy scan is routinely performed mid-pregnancy. Most women will not have an indication for more ultrasound unless they go overdue or a complication arises. It is assumed that the cervix is competent and will stay closed and the baby will grow at an appropriate rate.
Instituting cervical monitoring early in the second trimester can detect cervical insufficiency with enough time to place a pregnancy-saving cerclage. Losing a pregnancy to an undiagnosed cervical insufficiency or having an unhealthy growth restricted child is way too high a price to pay to attain the designation of “high-risk pregnancy” and receive the associated surveillance, fetal monitoring and office visits that said designation indicates.
Similarly, how many women underwent an unanticipated and unwelcomed primary cesarean delivery when they were first found to be carrying breech in labor. Current guidelines do not require weekly ultrasounds at term to confirm fetal presentation. An astute obstetrician might suspect the baby is breech by palpating the pregnant belly. Sometimes it is not found until it is too late to attempt an external cephalic version (turn the baby) or seek out a specialist willing to allow a breech vaginal delivery.
Having familiarity, I can fortunately say that the majority of local obstetrical practices provide excellent care and are more than capable of taking care of low- and high-risk issues. These practices generally do have ultrasound capability in the office and employ it frequently to assess fetal growth and position at term or along the way if there is any concern. It would be nice to end on a high note. And it is undoubtedly bad form to disparage one’s competition, especially in the arena of medicine. I must recommend to avoid being delivered by Jason.
Dr. Yaakov Abdelhak is a board-certified OB/GYN who also completed an additional fellowship in perinatology (high-risk obstetrics) and has been a Maternal-Fetal Medicine doctor since 2002. He is a firm supporter of natural and vaginal birth whenever safe for the mother and baby. He is the founder of Maternal Resources, a thriving boutique style practice, with offices in Hackensack, Jersey City, Hoboken, Howell and NYC.
