High-Risk Pregnancy

For the vast majority of women, pregnancy follows a routine course. Some women, however, have medical difficulties related to their health or the health of their baby. These women experience what is called a high-risk pregnancy. High-risk complications occur in only 6 percent to 8 percent of all pregnancies. These complications can be serious and require special care to ensure the best possible outcome. While some problems are unavoidable, UCSF perinatologists obstetricians with special training and board certification in high-risk pregnancy care work to minimize complications and help you achieve the healthiest pregnancy possible. Each year, we deliver hundreds of high-risk pregnancies. Our team of doctors, nurses and support staff coordinates all aspects of pregnancy care, from consultation, diagnosis and delivery, to long-term follow-up care for mothers and their babies
High-Risk Pregnancy
What causes a high-risk pregnancy?
Before a woman becomes pregnant, it is important for her to have good nutrition and a healthy lifestyle. Good prenatal care and medical treatment during pregnancy can help prevent complications. But there are factors that can be present before a woman becomes pregnant, that can cause a high-risk pregnancy. Risk factors for a high-risk pregnancy can include: Young or old maternal age Being overweight or underweight Having had problems in previous pregnancies Pre-existing health conditions, such as high blood pressure, diabetes, or HIV Health problems can also develop during a pregnancy that can make it high-risk. Such problems may occur even in a woman who was previously healthy.

What are some conditions that may cause a high-risk pregnancy?

Preeclampsia and Eclampsia - Preeclampsia is a syndrome that includes high blood pressure, urinary protein, and changes in blood levels of liver enzymes during pregnancy. It can affect the mothers kidneys, liver, and brain. With treatment, many women will have healthy babies. If left untreated, the condition can be fatal for the mother and/or the baby and can lead to long-term health problems. Eclampsia is a more severe form of preeclampsia that can cause seizures and coma in the mother. Gestational Diabetes Mellitus (or gestational diabetes) is a type of diabetes that only pregnant women get. If a woman gets diabetes when

she is pregnant, but never had it before, then she has gestational diabetes. Many women with gestational diabetes have healthy pregnancies and healthy babies because they follow a treatment plan from their health care provider. HIV/AIDS kills or damages cells of the body's immune system, progressively destroying the body's ability to fight infections and certain cancers. The term AIDS applies to the most advanced stages of HIV infection. Women can give HIV to their babies during pregnancy, while giving birth, or through breastfeeding. But, there are effective ways to prevent the spread of mother-to-infant transmission of HIV. Preterm Labor is labor that begins before 37 weeks of pregnancy. Because the baby is not fully grown at this time, it may not be able to survive outside the womb. Health care providers will often take steps to try to stop labor if it occurs before this time. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth. Other medical conditions like high blood pressure, diabetes, or heart, breathing, or kidney problems can become more serious during a womans pregnancy. Regular prenatal care can help ensure a healthier pregnancy for a woman and her baby.

What can a woman do to promote a healthy pregnancy?

Many health care providers recommend that a woman who is thinking about becoming pregnant see a health care provider to ensure she is in good preconception health. During pregnancy, there are also steps a woman can take to reduce the risk of certain problems: 1. Getting at least 400 micrograms of folic acid every day if she thinks she could become pregnant, and continuing folic acid when she does get pregnant Getting proper immunizations Maintaining a healthy weight and diet, getting regular physical activity, and avoiding smoking, alcohol, or drug use Starting prenatal care appointments early in pregnancy

2. 3. 4.

The term "high-risk pregnancy" describes a case where a pregnant woman has one or more factors that could put her or the fetus at risk for health problems.

In general, a pregnancy may be considered high risk if the pregnant woman:

is 35 years old or older is 15 years old or younger is underweight or overweight prior to becoming pregnant is pregnant with more than one fetus has gestational diabetes has gone into premature labor

has had a premature baby has had a baby with a birth defect, especially heart or genetic problems has high blood pressure, heart disease, diabetes, lupus, asthma, a seizure disorder, or another longstanding medical problem

Risk Factors for High-Risk Pregnancy Reasons that a pregnancy may be considered high risk include: Maternal Age. One of the most common risk factors for a high-risk pregnancy is the age of the mother-to-be. Women who will be under 17 or over 35 when their baby is due are at greater risk of complications than those between their late teens and early 30s. The risk of miscarriage and genetic defects further increases after age 40. Medical conditions that exist before pregnancy. Conditions such as high blood pressure; breathing, kidney, or heart problems; diabetes; autoimmune disease; sexually transmitted diseases (STDs); or chronic infections such as human immunodeficiency virus (HIV) can present risks for the mother and/or her unborn baby. A history of miscarriage, problems with a previous pregnancy or pregnancies, or a family history of genetic disorders are also risk factors for a high-risk pregnancy. If you have a medical condition, it's important to consult your doctor before you decide to become pregnant. Your doctor may run tests, adjust medications, or advise you of precautions you need to take to optimize the health of you and your baby. Medical conditions that occur during pregnancy. Even if you are healthy when you become pregnant, it is possible to develop or be diagnosed with problems during pregnancy that can affect you and your baby. Two of the more common pregnancy-related problems are: Preeclampsia is a syndrome that includes high blood pressure, urinary protein, and swelling; it can be fatal for the mother and/or baby if not treated. With proper treatment, however, many women who develop preeclampsia have healthy babies. Gestational diabetes is a type of diabetes that develops during pregnancy. Women with gestational diabetes may have healthy pregnancies and babies if they follow the treatment plan from their health-care provider. Usually the diabetes resolves after delivery. However women with gestational diabetes are at increased risk of developing type 2 diabetes.

Pregnancy-related issues. Often a pregnancy is classified as high risk because of issues that arise from the pregnancy itself and that have little to do with the mother's health. These include: Premature labor is labor that begins before the 37th week of pregnancy -- the point at which the baby is deemed full-term. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth. Multiple births means you are carrying more than one baby (twins, triplets, quadruplets, etc.). Multiple pregnancies, which are more common as women are using more infertility treatments, increase the risk of premature labor, gestational diabetes, and pregnancy-induced high blood pressure.

Placenta previa is a condition in which the placenta covers the cervix. The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, the doctor may schedule a cesarean section to reduce bleeding risks to the mother and baby. Fetal problems, which can sometimes be seen on ultrasound. Approximately 2% to 3% of all babies have a minor or major structural problem in development. Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected.

WebMD Editors Picks: News and Trends in Pregnancy

Your Pregnancy Week by Week: What to Expect Photos: See Your Baby's Development Pregnancy Calendar: Daily Tips for You and Your Baby

Note: Clicking these links will take you to a site outside of KidsHealth's control.

Common risk factors Some common factors include:

Age of either parent

Adolescent parents

Further information: Teenage_pregnancy#Medical_outcomes

Older parents

Further information: Paternal age, Maternal age effect, and Pregnancy over age 50 Drug use or addiction Height. Pregnancy in women whose height is less than 1.5 meters (5 feet) correlates with higher incidences of preterm birth and underweight babies. Also, these women are more likely to have a small pelvis, which can result in such complications during childbirth as shoulder dystocia.[MMHE 2]

Medication(s).[MMHE 3] Anti-depressants, for example, may increase risks of such outcomes as preterm delivery.[2]

Further information: Pregnancy category

Risks arising from previous pregnancies:

Complications experienced during a previous pregnancy are more likely to recur.

Many previous pregnancies. Women who have had five previous pregnancies face increased risks of very rapid labor and excessive bleeding after delivery.

Multiple previous fetuses. Women who have had more than one fetus in a previous pregnancy face increased risk of mislocated placenta.[MMHE 4]

Further information: multiple births

Social and socioeconomic factors. Generally speaking, unmarried women and those in lower socioeconomic groups experience an increased level of risk in pregnancy, due at least in part to lack of access to appropriate prenatal care.[MMHE
5]

Weight

Low weight: Women whose pre-pregnancy weight is less than 45.5 kilograms (100 pounds) are more likely to have underweight babies.

Obese women are more likely to have very large babies, potentially increasing difficulties in childbirth. Obesity also increases the chances of developing gestational diabetes, high blood pressure, preeclampsia, experiencing postterm pregnancy and/or requiring a cesarean delivery.[MMHE 6]

[edit] Disorders and diseases Pre-existing disorders and/or congenital defects can increase the usual risks involved in pregnancy. In such circumstances, women who wish to continue with a pregnancy require extra medical care, often from an interdisciplinary team. Such a team might include (besides an obstetrician) a specialist in the disorder and other practitioners (for example, maternal-fetal specialists, nutritionists, etc.).[MMHE 7] These conditions include:

Cancer[MMHE 8] Chronic hypertension[MMHE 9] Cirrhosis[MMHE 10] Congenital disorders that may be passed on to offspring Diabetes[MMHE 11] Heart defects, especially primary pulmonary hypertension and Eisenmenger's syndrome[MMHE 12] Hyperthyroidism[MMHE 13] Hypothyroidism[MMHE 14] Kidney disorders[MMHE 15] Lupus[MMHE 16] Mental health.

Depression has been linked to higher rates of preterm delivery.[3]

Respiratory disorders and diseases (associated, for example, with placental abruption)[4]

Asthma[5][6]

Seizure disorders[MMHE 17] Structural abnormalities in the cervix Structural abnormalities in the uterus Valvular heart disease Viral hepatitis[MMHE 18]

Sign up for o ur f ree weekly eNewslette rs he re

Identification of a High-Risk Pregnancy

A high-risk pregnancy is one in which the mother or fetus has a significantly increased chance of death or disability (Hobel, 1979). In order to achieve optimal perinatal outcome, all factors contributing to mortality and Socioeconomic Factors Socioeconomic Status. The many social factors that place a fetus at greater risk are interrelated. Such conditions as overcrowding poor standards of housing and hygiene, and poor nutrition are closely associated with high Parental Occupation. Occupation of the father, as a reflection of socioeconomic status, is related to profound differences in the incidence of prematurity and infant mortality. Kessner and Colleagus (1973) have reported that the lowest incidence of perinatal loss occurs in cases in which the father is in a professional or managerial position, where as the highest rates of loss are rates of infant and child morbidity and mortality. Poverty and low educational status are at root of these problems, and in countries where social and economic improvement has occurred, there has also been a decrease in perinatal mortality (Chea et al, 1977). seen in situations in which the father is absent altogether. It has further been demonstrated that a correlation exists between the occupation of the mothers father and the incidence of perinatal loss; that is, women from a higher socioeconomic background have a lower incidence of perinatal loss than those from a less affluent one (Kessner et al, 1973). morbidity in a particular pregnancy must be identified and acted upon early. The factors may be divided into the categories of socio-economic, demographic, and medical

Social Environment. The effects of maternal social environment on the outcome of pregnancy are recognized to be both multiple and profound. Social environment itself is described as the summation of numerous factors, including the familys standards of health and hygiene, housing and financial status, emotional and social support and so on. The environment itself was grossly unhygienic. Recurrent infections and poor health were frequently noted within the family. Educational needs were, for the most part, unmet and ignored. The adverse influences of this history of social, emotional, nutritional and financial deprivation on reproductive outcome were numerous. Demographic Factors

Psychological High-Risk factors. When a woman becomes pregnant the entire family prepares for change. The support and guidance that the family receives during this preparation period will influence the familys ability to cope with the stress of this pregnancy and with its changes in family structure, as well as with other life stresses in the future. Therefore, it is important to identify psychological maladaptation to pregnancy. Maladaptations may increase anxiety, and it has been suggested increased anxiety can cause physical complications during pregnancy, including preterm labour (Crandon, 1979; Creasy, 1981).

Maternal Age. The relationship between maternal age and pregnancy outcome has long been recognized. Studies have been shown that the optimal age for childbearing is between 20 and 30 years, with a steadily increasing risk of perinatal mortality when the woman is over 30 years of age. Children of mothers 19 years and younger and the first born of mothers 35 years of age and older are at an increased risk for prematurity and other pregnancy complications such as pregnancy-induced hypertension (PIH) and congenital anomalies. Additionally, babies born to women over 35 years of age have an increased risk of genetic abnormalities (Crandall et al, 1986). Maternal Education. Correlations have been indicated between the number of years of schooling completed by a pregnant woman and perinatal death rate, birth weight, and the rate of neurologic abnormalities seen in the child at 1 year of age. As the length of the mothers education increases, perinatal morbidity and mortality rates drop significantly. Maternal Height. Short stature of the mother (less than 5 ft) has been associated with increased perinatal morbidity and mortality in several studies. The primary reason suspected for this association is that short maternal stature may be a reflection of adverse environmental conditions and poor nutrition as a child. Because stature relates to pelvic dimensions, short women have a higher incidence of operative delivery, including cesarean section because of cephalopelvic disproportion. Maternal weight and Weight Gain. Women who are underweight or overweight for height and age at the beginning of pregnancy are at risk for poor perinatal outcome (Abrams and Laros, 1986). Both of these parameters reflect previous nutritional status of the mother. Women who are underweight and or fail to gain the recommended 28 to 35 lb during pregnancy are at risk for having low-birth- weight babies. Women who are overweight and or gain more than 35 lb during pregnancy are at risk for developing preeclampsia and having large- for gestational age babies. Fetuses weighing more than 4000 g are frequently associated with an increased likelihood of dystocia during labour, fetal distress, maternal and infant birth trauma, and consequently, an increased incidence of perinatal morbidity and mortality. Previous Obstetric Problems In women who have had an obstetric complication or a perinatal loss, there is a tendency for the problem to repeat in a subsequent pregnancy. This is true for all of the factors listed in the high-risk pregnancy classification. History of Infertility. Conceptions following medical or surgical treatment of infertility carry a considerable high-risk factor. There is a high prevalence of multiple gestation and associated preterm labour in women treated for infertility, and, therefore, an increase in the perinatal morbidity and mortality rates. Previous Ectopic Pregnancy and Spontaneous Abortion. The incidence of infertility in patients who have had an ectopic pregnancy is high, as is the chance of a repeat ectopic conception (Kadar and Romero, 1990). In women who have had two or more spontaneous abortion, the risk of a repeat abortion is significantly increased. Previous Stillbirth or Neonatal Death. A history of a previous perinatal death, especially if the cause is unknown, is an indication of high-risk status. Uterine/Cervical Abnormality. Abnormalities of the uterus/ cervix such as a bicornuate uterus, uterine septum, and incompetent cervix are frequently associated with repeated spontaneous abortions and premature labour.

Previous Premature Labour. Premature labour is one of the most challenging problems facing perinatal health care providers (Mc Cormick, 1985). A woman who has had a previous premature labor has a significantly higher chance of delivering prematurely with a subsequent pregnancy. Depending on the etiology of the preterm birth, the history of one previous preterm birth is associated with a risk of recurrence of 25 to 50 percent, and the risk increases with each subsequent preterm birth (Creasy, 1990). There is also an increased chance that the patient will have a stillbirth or neonatal death. Previous Macrocosmic Infant. A macrocosmic infant is one who, at term, weighs more than 4000 g or is large for his or her gestational age. A woman who has previously had, or is suspected of carrying, a large infant is at risk for having or developing diabetes during pregnancy, with all its concomitant problems. The infants themselves are at increased risk for morbidity (including low newborn blood sugars) and mortality as a result of unstable maternal metabolic condition, placental insufficiency, and even if the mother is not diabetic, birth trauma due to difficult delivery, shoulder dystocia, and other complications. Grandmultiparity. Increasing parity increases the risk of pregnancy wastage both in terms of higher mortality rates and an increased risk of neurologic anomaly. In general, the lowest perinatal mortality rate and incidence of obstetric complication occurs in second and third pregnancies, and the highest in fifth and subsequent pregnancies. The frequency of anemia, hypertensive disease of pregnancy, antepartum and postpartum hemorrhage, as well as the number of cesarean sections, almost doubles for each of these complications in women of lower parity. Maternal Medical History/Status. Certain maternal disease diagnosed prior to pregnancy, at the time of initial physical examination or at any time during the pregnancy, may have a significant for both fetus and mother. These are: Maternal Cardiac Disease. The diagnosis of organic heart disease includes: rheumatic heart disease hypertensive heart disease and congenital heart disease. Fetal death rates are substantially increased in women with any of these diagnosis; in fact, the stillbirth rate is doubled compared with that in women without organic heart disease. The presence of organic heart disease also significantly increases the risk of delivery of a low-birth-weight infant (< 2500 g). Maternal Pulmonary Disease. Bronchial asthma is a rather common respiratory disease; pregnancy does not seem to have any consistent effect on it. * The effect of pregnancy on asthma generally follows the rule of thirds: one third of patients improve during pregnancy, one third remain unchanged, and one third deteriorate. * The fetuses may be at increased risk for intrauterine growth retardation, preterm delivery, stillbirth, or neonatal death (Benedetti, 1990). Diabetes Mellitus. Diabetes is deleterious to pregnancy in a number of ways. The adverse maternal effects that are likely to be encountered are as follows: 1. 1. The likelihood of preeclampsia/eclampsia is increased fourfold.

2. 2. Infection occurs more often and is likely to be more severe. 3. 3. The fetus frequently is macrocosmic, and its size may lead to difficult delivery with injury to the infant and the birth canal. 4. 4. The tendency for fetal condition to substantially deteriorate prior to the onset of labor, as well as the possibility of dystocia, increases the frequency of cesarean section with its incumbent maternal risk. 5. 5. Postpartum hemorrhage is more common 6. 6. Polyhydramnios is common Maternal diabetes also affects the fetus/neonate in a variety of ways: 7. 7. Perinatal death rate is considerably higher. 8. 8. Morbidity as a result of birth trauma or respiratory distress syndrome is common. 9. 9. Congenital anomalies, including sacral agenesis or anencephaly, open spinabifida, and cardiac anomalies, are more frequent. 10.10.The infant is more likely to inherit diabetes. 11.11.Persistent maternal hyperglycemia probably contributes to the increased risk of intrauterine death, respiratory distress syndrome, hypoglycemia, and other morbidity (Gabbe, 1991) Maternal Thyroid Dysfunction. Thyroid disease appears to have an adverse effect on pregnancy outcome. Hypothyroidism results primarily in an increase in the stillbirth rate. Hyperthyroidism shows a slight association with increased neonatal mortality rate, a significant increase in the frequency of delivery of low-birth-weight infants, and an overall drop in the mean birth weight. Once the diagnosis of thyroid disease is made in pregnancy, therapy may be complicated by the presence of the fetus. Drugs that may be beneficial to the mother can be harmful to the fetus, and this must be taken into account when a therapeutic decision is made (Burrow and Ferris, 1982). Gastrointestinal/Hepatic System Diseases. With the exception of hepatitis and appendicitis, maternal gastrointestinal diseases does not generally cause any increased risk in pregnancy. Hepatitis appears to be associated with an increase in low-birth-weight infants and an increased incidence of infection of the infant. Appendicitis appears to increase the rate of premature labor, fetal death, and lowbirth-weight infants most probably as a result of infection, regardless of whether surgery is performed. Chronic Hypertension In most cases of chronic hypertension, high blood pressure is the only demonstrable finding. Frequently, the babies of mothers with chronic hypertension show evidence of intrauterine growth retardation. The incidence of abruptio placenta and PIH also has been noted to be increased. Renal Disease / Urinary Tract Disease Renal diseases such as glomerulonephritis, nephrotic syndrome, polycystic disease of the kidney, and previous nephrectomy/renal transplant vary in their effect on pregnancy outcome, depending on the severity of the disease. Most commonly, they are associated with increased risk for * premature labor,

* intrauterine growth retardation, and * placental insufficiency leading to antepartum fetal distress. Acute urinary tract infection, if undiagnosed or untreated, may lead to premature labor (Pritchcard et al, 1985). Current Obstetric Status Late or No Prenatal Care Prenatal care that is inadequate, late is the single greatest predictor of poor perinatal outcome, particularly in regard to low-birth-weight infants (Sachs et al, 1987). Antepartum Bleeding. Antepartum Bleeding. Antepartum bleeding is defined as bleeding from the vagina after the 28th week of gestation and prior to the onset of labor. The etiology includes 1.Placenta previa, 2.abruptio placenta, 3.local causes such as cervical polyps or erosions, and 4.unknown etiology in which a specific cause cannot found. Placenta previa, and consequent bleeding from a placenta partly or wholly attached to the lower uterine segment, is a complication frequently associated with multiparity and older gravidas. Women who gave had a placenta previa tend to repeat this complication in subsequent pregnancies. Overall incidence of placenta previa is 1 in 200 pregnancies at term. Incidence increases significantly with maternal age, parity, previous placenta previa, and most importantly, previous uterine surgery (Bender, 1987). Maternal mortality associated with placenta previa has been reduced to less than 1 percent, but maternal morbidity from this complication is still high as 20 percent (Astrash et al, 1990; Cavanagh, 1982). Prematurity is the prevalent cause of perinatal mortality associated with placenta previa. Despite the availability of neonatal intensive care, the perinatal mortality rate remains as high as 20 percent, with intrauterine hypoxia and developmental anomalies also complicated the situation. Abruptio placenta is described as the premature separation of normally implanted placenta from the uterine implantation site. Abruption of the placenta is most commonly associated with hypertension of any origin, including preeclampsia. High parity and history of previous abruption have been implicated. Other factors implicated as possible causes of abruption are trauma, sudden uterine decompression (particularly with polyhydramnios), short umbilical cord, and uterine leiomyomas and anomalies. Recurrence rates of placental abruption range from 1 in 6 to 1 in 18 pregnancies (Patterson, 1979). Maternal mortality in abruptio placenta ranges from 2 to 10 percent in severe cases with associated fetal death. Perinatal mortality approaches 35 percent, the major determinats being length of gestation and fetal condition at the time of presentation (Clark, 1990). In general, antepartum bleeding is associated with significantly increased risks for premature labor and delivery, intrauterine growth retardation, fetal and maternal anemia, and perinatal death (Clark, 1990). Multiple Gestation.

Perinatal mortality in twins is 2 to 3 times higher than in single births. The predominant cause of perinatal death is prematurity. Other major complications include * placenta previa, * intrauterine growth retardation, * twin to twin transfusion, * prolapsed cord, * premature separation of the second placenta, and * malformations. Women with a multiple gestation have an increased incidence of * preeclampsia, * anemia, * polyhydramnios, and * postpartum hemorrhage. Pregnancy-Induced Hypertension (PIH) PIH is one of the hypertensive disorders of pregnancy, and a major contributor to maternal, fetal, and neonatal morbidity and mortality and mortality. Complications of PIH are the second most common cause of maternal deaths (Atrash, 1990). The incidence of PIH is approximately 6 to 8 percent. PIH seems to be higher in blacks for each age and parity group, and it runs in families. The incidence is also higher in young, primiparous women and in women with twins, diabetes, chronic hypertension, polyhydramnios, and hydatidiform mole. Approximately one third develop it in subsequent pregnancies (Burrow and Ferris, 1982). Maternal effects of PIH range from relatively transient to serious morbidity, such as * renal damage or * cerebral vascular accident, to death of the mother or fetus, or both. Fetal problems include increased incidence of * intrauterine growth retardation, * abruptio placenta, * preterm birth, * stillbirth, and * mental retardation in surviving offspring. At present, it is not possible to prevent PIH. It is possible, however, to identify patients who are especially prone to develop the disease. Conditions that predispose a woman to develop PIH include: 1.First pregnancy 2.Multiple pregnancy 3.Chronic hypertension 4.Hydatidiform mole 5.Chronic renal disease 6.Malnutrition 7.Diabetes 8.Hydrops fetalis 9.History of PIH in family or in previous pregnancy 10.Age less than 20 or greater than 30 11.Patients developing polyhydramnios Premature Rupture of the Membranes

Premature rupture of the membranes, that is, rupture prior to the onset of labor, is a major perinatal complication and is responsible for at least 30 percent of preterm deliveries (Garite, 1990; Kaltreider, 1980). The incidence of premature rupture of the membranes is reported to be 8 to 10 percent of all pregnancies that extend beyond 20 weeks gestation (Garite, 1990; Gunn et al, 1970). It is associated with a high perinatal mortality rate, attributable primarily to delivery of premature, low-birth-weight infants. Depending on management, premature rupture of the membranes can also be associated with significant perinatal morbidity, including * premature delivery, * maternal and/or fetal infection, and * fetal respiratory distress syndrome. Other problems, such as * breech presentation, * prolapsed cord, * transverse lie, * a plastic lungs, and * positional limb deformities of the fetus due to the lack of cushioning normally provided by amniotic fluid, have also been reported. It is felt by several authors that preexisting infection may contribute significantly to premature rupture of the membranes. Intrauterine Growth Retardation Intrauterine growth retardation (IUGR) complicates approximately 3 to 7 percent of all pregnancies. Babies born at or below the 10th percentile of mean weight for gestation are at greater risk of antepartum death, perinatal asphyxia, neonatal morbidity, and later developmental problems. Babies with IUGR have a perinatal mortality rate that is 8 times that of normal infants(Butler and Alberman, 1969). Two types of fetal growth retardations * asymmetric and * symmetric have been described In asymmetric IUGR, there is increasing disproportion in head-to-body ratios. This type of IUGR is the more common and is known as brain sparing, because the last organ to be deprived of essential nutrients is the brain. Asymmetric IUGR is most commonly caused by adverse effects applied during the later part of pregnancy. A common example is placental insufficiency resulting from such conditions as PIH, chronic hypertension, smoking, and alcoholism. Symmetric IUGR is non-brain sparing, occurs less commonly, and can be the result of an acute maternal infection, chromosomal abnormalities in the fetus, maternal drug addiction, or maternal malnutrition.

Table 1 Factors Causing fetal Growth Retardation

Maternal Factors Causing fetal Growth Retardation Chronic lung disease

Cyanotic heart disease Severe anemias Malnutrition Low calorie consumption Malabsorption conditions surgical bypass procedures Smoking Drug addiction Placental Factors Causing fetal Growth Retardation Small placenta in hypertensive women Circumvallate placenta Abnormal implantation site Abruptio placenta Fetal Factors Causing fetal Growth Retardation Congenital anomalies Trisomies Intrauterine infections AIDS (Acquired immunodeficiency syndrome) TORCH) Toxoplasmosis, Rubella, Cytomegalovirus Rh Isoimmunization The simple step of determining a womans Rh status should be done at the initial examination for all pregnant women. Every Rh-negative woman carrying a child fathered by an Rh-positive man should be tested for antibodies in every pregnancy, starting with the first prenatal visit. Past history should include the following: 1.History of transfusion incompatible blood 2.Outcome of previous pregnancies a) a) Rh factors of infants b) b) Severity of hemolytic disease c) c) Gestational age at intrauterine death, if any 3. 3. Existing conditions implicated in predisposition to Rh isoimmunization a) a) PIH b) b) External version c) c) Abruptio placenta Once this information is obtained, appropriate measures: amniocentesis, cordocentesis, intrauterine fetal transfusion, and planning for possible early delivery can be instituted. Prevention is the key to eradicating this disease. Prolonged Pregnancy. Prolonged pregnancy is a common obstetric problem with potentially profound consequences. Three definitions are important at the onset: 1. 1. Postdatism- the pregnancy has gone beyond the expected date of birth. 2. 2. Prolonged pregnancy- the length of gestation has exceeded 42 weeks. 3. 3. Postmaturity- a pediatric diagnosis based on neonatal examination.

The incidence of prolonged pregnancy ranges from 7 to 12 percent, with an average of approximately 10 percent. The perinatal impact of prolonged pregnancy may be severe: Perinatal mortality for these infants is increased 2 to 3 times relative to term infants, 7 times. Morbidity includes birth trauma, meconium aspiration, and hypoglycemia. Developmental defects in surviving infants have been identified. Habits / Habituation Smoking during Pregnancy. Cigarette smoking during pregnancy has been demonstrated to be detrimental to the fetus. Table 2 Categorization of High Risk Pregnancy Factors Socioeconomic Factors 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. Inadequate finances Poor housing Severe social problems Unwed, especially adolescent Minority status Nutritional deprivation

Demographic Factors 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. maternal age under 16 or over 35 years overweight or underweight prior to pregnancy Height less than 5 feet Maternal education less than 11 years Family history of severe inherited disorders

Medial Factors A. A. Obstetric History 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 9. 9. 10. 10. 11. 11. 12. 12. 13. 13. 14. 14. History of infertility Previous ectopic pregnancy or spontaneous abortion Grandmultiparity Previous stillborn or neonatal death Uterine / cervical abnormality Previous multiple gestation Previous premature labour delivery Previous prolonged labor Previous cesarean section Previous low-birth-weight infant Previous macrosomic infant Previous midforceps delivery Previous baby with neurologic deficit, birth injury, or malformation Previous hydatidiform mole or choriocarcinoma

B. B. Maternal Medical History / Status

1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 9. 9. 10. 10. 11. 11. 12. 12. 13. 13. 14. 14. 15. 15.

Maternal cardiac disease Maternal pulmonary disease Maternal metabolic disease-particularly diabetes mellitus, thyroid disease Chronic renal disease, repeated urinary tract infections, repeated bacteriuria Maternal gastrointestinal disease Maternal endocrine disorders (pituitary, adrenal) Chronic hypertension Maternal hemoglobinopathies Seizure disorder Venereal and other infectious diseases Weight loss greater than 5 pounds Malignancy Surgery during pregnancy Major congenital anomalies of the reproductive tract Maternal mental retardation, major emotional disorders

C. C. Current Obstetric Status 1. 2. 3. 4. 5. 6. 7. 8. 9. Late or no prenatal care Rh sensitization Fetus inappropriately large or small for gestation Premature labor Pregnancy-induced hypertension Multiple gestation Polyhydramnios Premature rupture of the membranes Antepartum bleeding a) a) Placenta previa b) b) Abruptio placenta 10. 10. Abnormal presentation 11. 11. Postdatism 12. 12. Abnormality in tests for fetal well-being 13. 13. Maternal anemia D. D. Habits / Habituation 1. 1. Smoking during pregnancy 2. 2. Regular alcohol intake 3. 3. Drug use 1. 2. 3. 4. 5. 6. 7. 8. 9.