HIGH RISK PREGNANCY QUIZ

You may be considered a “high risk pregnancy” if:

True or False Conditions Rationale

1. You have a medical condition such as diabetes, high  For women with chronic medical
blood pressure, heart/vascular disease, asthma, conditions, pregnancy may worsen the
rheumatic disease (like lupus), kidney disease, or condition or the disease may complicate
thyroid disease for which you take medications. the pregnancy, or both. Pre-pregnancy
True
counseling and special monitoring during
pregnancy can improve the chances for a
healthy Mom and Baby.

2. You have had a blood clot in your leg, lung or brain.  Women with a prior blood clot anywhere
in their body are more likely to have a
recurrence in pregnancy and may need
specially-dosed medications to prevent
True
clotting or bleeding. Certain blood thinners
can damage the Baby’s development.

3. You have previously delivered a baby with severe  Some blood conditions may not be a
anemia or a bleeding disorder. problem for Mom, but can injure the
True baby’s blood cells, causing anemia and
even brain hemorrhage. These conditions
can be treated.

4. You have a seizure disorder or other significant  Women with seizures and other
neurologic problem. neurologic problems, especially if they
require medications are more likely to
have a baby with a birth defect. Changing
True
medications may decrease this risk and a
special ultrasound may detect these
problems

5. You will be 35 years or older during a future pregnancy  Women over age 35 have an increased
risk for miscarriage, pre-term birth, fetal
True anomalies and other complications.

6. You have had 2 or more prior early pregnancy losses or  Women who have had previous
a single loss at more than 15 weeks of gestation pregnancy loss(es) are at higher risk for
(stillbirth or fetal death). subsequent losses and may need
evaluation before and specialized care
True
during another pregnancy. Evaluation and
specific treatment may improve your
 chances for a good outcome

7. You developed high-blood pressure, pre-eclampsia,  If you developed hypertension, pre-
gestational diabetes or other health problems in a eclampsia, diabetes or other medical
True problems in a prior pregnancy, you are at
previous pregnancy.
risk for a recurrence of greater severity.
This requires more frequent, specialized
care next time.

8. You have had a prior preterm delivery?  Women who delivered a “premie” baby in
the past are more likely to do so again and
True may require closer monitoring and
treatment to prevent a recurrence.

9. You are carrying more than one baby.  Women with multiple gestations have
multiple pregnancy risks and require an
True accurate diagnosis; 3 or more is especially
risky, and special treatments may become
necessary.

10. You have a history of infertility or gynecological  Women with infertility may have other
problems such as large symptomatic fibroids, surgery risk factors for poor outcome.
True
on the cervix or cancer

11. You have a sexually transmitted disease (STD), If you have an STD, especially HIV, you
including HIV, that could be transmitted to your baby may be at risk for transmitting the
True infections to your newborn. Careful
during pregnancy or at the time of birth.
management of the delivery and newborn
can prevent this.

True 12. You became pregnant while with an IUD in place  If you conceived with an IUD in place, you
are at risk for miscarriage or preterm
birth.

13. You have a child with a genetic disorder or are a carrier If you have a child with a genetic disorder
for a genetic disorder or carry an abnormal gene you may take
advantage of UAB’s unique genetic
counseling and diagnostic services.
True
Depending on test results you may benefit
from management by UAB’s maternal-
fetal-medicine specialists

14. You are very overweight or underweight, or have had Being overweight or underweight
increases the risk of preterm birth or other
 True gastric bypass surgery to lose weight. complications of pregnancy and may
require additional monitoring. Prior
Gastric bypass surgery carries special risks.

15. You have had multiple prior cesareans or a prior Women with multiple prior cesareans may
cesarean with a classical-vertical incision have an abnormal placental attachment
True and severe hemorrhage at birth.

16. You have abnormal antibodies in your blood that can  Certain antibodies in Mom can attack the
hurt the placenta, the baby’s blood cells or even the placenta or cross over into the Baby’s
True bloodstream and affect its blood or heart
baby’s heart
development

17. You leak amniotic fluid or have had significant bleeding Leaking vaginal fluid or bleeding may be a
in your current pregnancy symptom of a serious complication that
True requires immediate evaluation.

18. You have too much or too little amniotic fluid in this  Pregnancies with too much or too little
pregnancy. amniotic fluid require special diagnostic
True procedures and management to improve
the Baby’s chances for a good outcome.

True 19. You have too much or too little amniotic fluid in this  A high fever can be the first sign of a
pregnancy. serious infection that can harm the baby

20. You have persistent vomiting and weight loss in this  Persistent vomiting, especially with
pregnancy. weight loss, may complicate the
True pregnancy; it may be from other serious
conditions not even related to pregnancy-
nausea or “morning sickness.”

Specific Pregnancy Problems and Related Risk Factors

Polyhydramnios Oligohydramnios

Symptoms Signs and symptoms of oligohydramnios

The signs and symptoms of oligohydramnios vary from

Polyhydramnios symptoms result from pressure being
exerted within the uterus and on nearby organs. Mild person to person. Some of the most common signs and
polyhydramnios may cause few — if any — signs or
symptoms. Severe polyhydramnios may cause: symptoms of a lowered amniotic fluid volume are:
  Leaking of the amniotic fluid
 Shortness of breath or the inability to breathe
 Low amniotic fluid on an ultrasound
 Swelling in the lower extremities and abdominal
 Measurements of size smaller than
wall
what is normal for gestational age
 Uterine discomfort or contractions
 Low maternal weight gain
 Fetal malposition, such as breech presentation
 Prelabor Rupture of membranes
Your health care provider may also suspect  Abdominal discomfort
polyhydramnios if your uterus is excessively enlarged and
 Sudden drop in fetal heart rate
he or she has trouble feeling the baby.
 Little to no fetal movement, or
Causes
decreasing fetal movement

 Abnormal findings on a fetal monitor,

Some of the known causes of polyhydramnios include:
including fetal distress
 A birth defect that affects the baby's
gastrointestinal tract or central nervous system

 Maternal diabetes Oligohydramnios can occur any time during pregnancy,

but is most commonly diagnosed in the third trimester.

 Twin-twin transfusion — a possible complication of
identical twin pregnancies in which one twin receives Oligohydramnios is typically caused by the following:
too much blood and the other too little
 Placental issues: If the placenta isn’t
 A lack of red blood cells in the baby (fetal anemia)
providing enough nutrients for the baby, then
 Blood incompatibilities between mother and baby
the baby may stop recycling fluid, therefore
 Infection during pregnancy
lowering the amniotic fluid.
Often, however, the cause of polyhydramnios isn't clear.  Birth defects: Certain birth defects

Complications cause problems in the fetal urinary tract and

kidneys, leading to insufficient urine

Polyhydramnios is associated with: production.

 Premature rupture of membranes

 Premature birth
PROM: When the water breaks before labor
 Premature rupture of membranes — when your
begins.
 water breaks early
 Leaking of amniotic fluid: A tear in the
 Placental abruption — when the placenta peels membrane can cause a gush or a trickle of
away from the inner wall of the uterus before
amniotic fluid to leak.
delivery
 Post-date pregnancy: A pregnancy that
 Umbilical cord prolapse — when the umbilical cord
goes past 42 weeks is at risk of
drops into the vagina ahead of the baby
oligohydramnios because the amniotic fluid
 C-section delivery
can decrease by half after this time.
 Stillbirth
Moreover, one study of 3050 uncomplicated
 Heavy bleeding due to lack of uterine muscle tone
pregnancies with singleton fetuses between
after delivery
40- and 41.6-weeks’ gestation found that 11%
The earlier that polyhydramnios occurs in pregnancy and
of them presented with oligohydramnios (2).
the greater the amount of excess amniotic fluid, the higher
 Maternal problems: Maternal
the risk of complications.
conditions, such as diabetes,

dehydration, hypertension and

preeclampsia have an effect on
  amniotic fluid levels.
Risk factors for oligohydramnios
 
In some cases, women who develop oligohydramnios
 
have no identifiable risk factors. Because of this, it is
 
crucial for physicians to monitor amniotic fluid levels
 
throughout pregnancy. However, many pregnant
 
women do have risk factors for oligohydramnios.
 
Risk factors for oligohydramnios include:
 
 Maternal hypertension/preeclampsia
 
 Maternal diabetes

 Maternal dehydration

 Maternal hypoxia

 Placental issues
 Complications of oligohydramnios

Oligohydramnios can cause the following injuries and

complications:

 Increased chance of miscarriage or

stillbirth

 Compression of fetal organs that can

lead to birth asphyxia or hypoxic-ischemic

encephalopathy (HIE)

 Premature birth

 Intrauterine growth restriction

 Cord compression

 Cerebral palsy

 Preterm birth

 Meconium aspiration

   

Intrauterine Growth Restriction (IUGR) Chromosomal Abnormalities

When a baby in the womb fails to grow at the expected The most common chromosomal defect in the group
rate during the pregnancy. In other words, at any point in referred at < 26 weeks' gestation was triploidy; in those
the pregnancy, the baby is not as big as would be expected referred at > or = 26 weeks, it was trisomy 18. The
for how far along the mother is in her pregnancy (this incidence of fetal autosomal chromosome aberrations
timing is referred to as an unborn babies "gestational increased, whereas the incidence of triploidy did not
age"). Babies who have IUGR often have a low weight at change, with maternal age. Ninety-six percent of
birth. If the weight is below the 10th percentile for a baby's chromosomally abnormal fetuses had multisystem fetal
gestational age (meaning that 90% of babies that age defects that were characteristic of the different types of
weigh more) the baby is also referred to as "small for chromosomal abnormalities. Compared with those
gestational age," or SGA. The two types of IUGR are: fetuses with a normal karyotype, the chromosomally
Symmetrical IUGR, in which a baby's body is proportionally abnormal group had a higher mean head
small (meaning all parts of the baby's body are similarly circumference/abdominal circumference ratio, a higher
small in size). Asymmetrical IUGR, which is when the baby incidence of normal or increased amniotic fluid volume,
has a normal-size head and brain but the rest of the body is and normal waveforms from the uterine or umbilical
small. arteries or both.

Maternal Causes

Women at extremes of reproductive age, especially young

maternal age, are at increased risk for IUGR. Similarly,
advanced maternal age has been associated with low birth
weight. Several environmental and behavioral risk factors
are known to cause IUGR. The common risk factors include
maternal causes (hypertension, diabetes, cardiopulmonary
disease, anemia, malnutrition, smoking, drug use).

Fetoplacental Causes

Fetal factors can vary from genetic causes, congenital

malformations, fetal infection, or other causes, including
Fetal causes (genetic disease including aneuploidy,
congenital malformations, fetal infection, multiple
pregnancies), and placental causes (placental insufficiency,
placental infarction, placental mosaicism).

  

MAJOR USES OF ULTRASONOGRAPHY DURING PREGNANCY

First Trimester Second Trimester Third Trimester

 In the first trimester of pregnancy  In the second trimester (12 to 24  In the third trimester (24 to 40 weeks
(weeks one to 12), ultrasounds may weeks) an ultrasound may be done or birth), an ultrasound may be done
be done to: to: to:

 confirm pregnancy  monitor the fetus’ growth  monitor the fetus’ growth and
 check the fetal heartbeat and position (breech, position (breech, transverse,
 determine the gestational transverse, cephalic, or cephalic, or optimal)
age of the baby and estimate optimal)  determine the baby’s sex
a due date  determine the baby’s sex  confirm multiple pregnancies
 check for multiple  look at the placenta to check
 pregnancies  confirm multiple pregnancies for problems, such as placenta
 examine the placenta,  look at the placenta to check previa (when the placenta
uterus, ovaries, and cervix for problems, such covers the cervix)
 diagnose an ectopic as placenta previa (when the and placental abruption (when
pregnancy (when the fetus placenta covers the cervix) the placenta separates from
does not attach to the and placental the uterus prior to delivery)
uterus) or miscarriage abruption (when the  check for characteristics
 look for any abnormal placenta separates from the of Down syndrome (normally
growth in the fetus uterus prior to delivery) done between 13 and 14
 check for characteristics weeks)
of Down syndrome (normally  check for congenital
  done between 13 and 14 abnormalities or birth defects
weeks)  examine the fetus for
   check for congenital structural abnormalities or
  abnormalities or birth blood flow problems
defects  monitor the levels of amniotic
   examine the fetus for fluid
  structural abnormalities or  determine if the fetus is
blood flow problems getting enough oxygen
   monitor the levels of  diagnose problems with the
  amniotic fluid ovaries or uterus, such as
 determine if the fetus is pregnancy tumors
  getting enough oxygen  measure the length of the
 diagnose problems with the cervix
 
ovaries or uterus, such as  guide other tests, such
  pregnancy tumors as amniocentesis
 measure the length of the  confirm an intrauterine death
 
cervix
You may get ultrasounds, just as you
   guide other tests, such
have in previous weeks, to confirm the
as amniocentesis
  baby’s position, growth, and health.
 confirm an intrauterine
Electronic fetal heart rate monitoring
death
checks to make sure the baby’s heart
A second trimester ultrasound can is beating properly.
confirm or change the menstrual
dating and the stage of your
pregnancy to within 10 to 14 days. A
second trimester ultrasound will also
be able to check fetal anatomy, the
placenta, and the amniotic fluid.

 
CLINICAL CASE APPLICATION:

Case 1:

HPI:  37 yo pregnant female of 32 weeks and 4 days gestation presents to the emergency room because
of significant vaginal bleeding over the past hour.  The patient also reports some contractions, but
denies any continuing abdominal pain. She denies any recent trauma.

Past Obsetrical History:

-G3 P2002 (3 gestations, 2 full term, 0 pre-term, 0 miscarriages, 2 currently living)

-2 previous SVD’s (spontaneous vaginal delivery)

-Last birth was 9 years ago by SVD, weighed 3800 grams

-No previous obstetrical complications or morbidity

Past Medical History:  None

Past Surgical History:  None

Family History:  Unremarkable, no history of twins or multiple gestations

Social History:  Patient lives with her husband in the Santiago district of Cuzco.  Denies any smoking,
alcohol or other drug use during her pregnancy.  Denies any spousal abuse. Completed elementary
school, currently works as a housewife.  Low economic status.

Current Gestational History:

-G3 P2002

-Date of Last Menstration:  4/11/11

-Estimated Date of Delivery:  1/22/12

-Estimated Gestational Age (based on dates):  32 4/7 weeks

-No prior antenatal care

Physical Exam:

Vital Signs:  Stable (BP – 110/70, P – 72)

General Appearance:  No apparent distress, appeared clinically stable

Skin:  Elastic, capillary reflex < 2 seconds

Uterine Height:  30 cm

Fetal Lie: Longitudinal

Contractions:  Present
Fetal Heart Tones:  144 x minute

Cervical Exam:  Deferred

1. Based on this patient’s clinical presentation, what clinical condition would you suspect the
patient has? 

 Based on this patient’s clinical presentation, placenta previa was suspected. Placenta
previa is defined as the presence of placental tissue over or adjacent to the cervical os,
and can be described within a variety of possibilities: Total placenta previa—the
internal os is covered completely by placenta. Partial placenta previa—the internal os is
partially covered by placenta. Marginal placenta previa—the edge of the placenta is at
the margin of the internal os. Low-lying placenta—the placenta is implanted in the
lower uterine segment such that the placental edge does not reach the internal os, but
is in close proximity to it. Vasa previa—the fetal vessels course through membranes and
present at the cervical os.

2. What are the identifying signs of this condition?

Bleeding is the primary symptom of placenta previa and occurs in the majority (70%-80%) of
women with this condition.

 Vaginal bleeding after the 20th week of gestation is characteristic of placenta previa.

 Usually the bleeding is painless, but it can be associated with uterine contractions

and abdominal pain.

 Bleeding may range in severity from light to severe.

3. What diagnostic tool/s can be used to further confirm your diagnosis?

 An ultrasound examination is used to establish the diagnosis of placenta previa. Either a

transabdominal (using a probe on the abdominal wall) or transvaginal (with a probe

inserted inside the vagina but away from the cervical opening) ultrasound evaluation

may be performed, depending upon the location of the placenta. Sometimes both types

of ultrasound examination are necessary. It is important that the ultrasound

examination be performed before a physical examination of the pelvis in women with

 suspected placenta previa, since the pelvic physical examination may lead to further

bleeding.

4. What is/are the reason/s why cervical exam was “deferred” for this patient?

 A cervical examination was deferred in our patient, as appropriate management.

Because of the risk of provoking life-threatening hemorrhage, a digital examination is
absolutely contraindicated until placenta previa is excluded. Such digital cervical
examination is never permissible unless the woman is in an operating room with all the
preparations for immediate cesarean delivery even the gentlest digital examination can
cause torrential hemorrhage.

5. Briefly discuss some differential diagnosis related to the given case.

Placenta previa is an important cause of antenatal hemorrhage; but it is not the most common.
Differential diagnoses to consider include:

 Placental abruption – where a part or all of the placenta separates from the wall of the
uterus prematurely.
 Vasa previa – where fetal blood vessels run near the internal cervical os. It is
characterized by a triad of (i) Vaginal bleeding; (ii) Rupture of membranes; and (iii) Fetal
compromise.

 The bleeding occurs following membrane rupture when there is rupture of the
umbilical cord vessels, leading to loss of fetal blood and rapid deterioration in
fetal condition.

 Uterine rupture – a full-thickness disruption of the uterine muscle and overlying serosa.
This usually occurs in labour with a history of previous caesarean section or previous
uterine surgery such as myomectomy.

 Local genital causes:

 Benign or malignant lesions – e.g. polyps, carcinoma. cervical

ectropion (common).
 Infections – e.g. candida, bacterial vaginosis and chlamydia.
References:

https://www.uab.edu

https://www.mayoclinic.org/diseases-conditions/polyhydramnios/symptoms-causes

https://www.abclawcenters.com

https://kidshealth.org

https://link.springer.com

https://www.ncbi.nlm.nih.gov

https://www.healthline.com

http://www.peru-zo.com

https://www.medicinenet.com

https://teachmeobgyn.com