High Risk Pregnancy 03/19/03 -- Amos Grunebaum, MD. -- 03/19/03
By Amos Grunebaum
Are you pregnant but facing a higher-than-normal risk? Ob-gyn Amos Grunebaum, MD, joined us on March 19, 2003 to talk about working with your doctor and the treatment options you have for managing a high-risk pregnancy.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Grunebaum: Hello everybody.
Member: Hi doctor, I am 36 weeks pregnant, and have been having pre-term labor since 24 weeks. Yesterday, at my routine ob-gyn visit, they did an NST and the baby's heartbeat was over 200 (the highest it went was 213). They immediately sent me over to the hospital for IV fluids, and blood work. I also am running a fever of 102 at that time. While at the hospital the baby's heartbeat went down to 160 and stayed there for the next four to five hours until they sent me home. What does this mean for my baby? Is there a problem with her? I am still running a fever today, and my stomach is very sore, it actually hurts when the baby moves. I am very concerned about my baby at this point.
Grunebaum: The interpretation of the fetal heart tracing requires more than just a description. I would have to actually see the tracing before I can know what's going on. For example, a faster than usual fetal heart rate can be normal under certain circumstances as can be a slower than average heart rate. The heart rate can also go up when the mother's temperature goes up. The most important question that needs to be answered is why the temperature went up in the first place. If it was just a cold, then there is less to worry about.
Member: When does someone need a cerclage that requires surgery through the abdomen versus inserting it through the vagina? And what kind if risks do both pose to the fetus?
Grunebaum: An abdominal cerclage is very rarely done. And most doctors are not trained enough to do it. Indications for doing it are very rare and include prior incompetent cervix pregnancy losses that were not helped by the usual McDonald vaginal cerclage. In addition indications include when there is little cervix left, for example after surgery and when vaginal there isn't enough cervix left to place a cerclage.
Member: Are people who get pregnant by Clomid considered high risk?
Grunebaum: Clomid in and by itself doe not make you high risk. But it also depends on why you took the Clomid and your age. So it needs to be decided on a case-by-case instance.
Member: I had a drastic LEEP a few years ago. (I'm not yet pregnant.) I've been told that my cervix is very small and that I will need a cerclage, but that there is very little cervix left to put the stitch into. What are my options and what do you think my chances are of having a successful pregnancy?
Grunebaum: This is a question only your doctor can answer. It's because the vaginal examination is important in making the decision. Often after such surgery there is still enough of the cervix left for a vaginal cerclage. I hope you are seeing a high-risk obstetrician (maternal-fetal medicine specialist). They are best trained to provide you with the assistance you need.
Member: I'm not yet pregnant but my husband and I are seriously considering having one more child. We have four beautiful children but have always wanted a large family. All my pregnancies have been relatively normal except for my last one. My cervix opened at 24.5 weeks and could not be stopped by the time I got to my doctor's office. Needless to say I had my daughter who was in the hospital for the next three and a half months. Today she is a normal 5 1/2-year-old child. Will I need a cerclage and if so, does that mean total bed rest or only for a little while?
Grunebaum: It all depends on why your cervix opened. If it opened because of labor then a cerclage won't make likely a difference, but if the cervix opened without labor, then this may be an indication for a cerclage. You may want to have your doctor measure the cervix in pregnancy and find out if a cerclage may make a difference.
Member: I wanted to know if I could have a baby again after my third C-section.
Grunebaum: This all depends on whether there were major complications during your surgery. I have seen many women who have had four, five, or even more cesareans. In and by itself there is no contraindication for a fourth pregnancy. But again, it depends on your prior surgical and medical history.
Member: Dr. Grunebaum, I have recently had a miscarriage at 15 weeks after a nasty flu with heavy vomiting and retching. I had slight bleeding on and off from the seventh week on, and the combination of the two events appears to have caused the miscarriage (the baby was healthy). I have one son already (17 months old) and had early bleeding with him. I have tested very borderline for a clotting disorder and they have talked about putting me on blood thinners. I am very scared to go through another miscarriage as difficult as this one. What am I looking at, and how high risk am I?
Grunebaum: The answer to your question depends on many unknowns to me. What clotting disorder is present? How did the miscarriage happen? It's clear that a miscarriage means the loss of a pregnancy, but there are many different ways it can happen. For example, someone with an incompetent cervix can have the cervix open without labor and then lose the pregnancy because the water breaks. In another pregnancy the fetus can die inside the uterus without any labor. And then you can also lose the fetus after heavy bleeding and placental problems. Each incidence may have different etiologies and requires different approaches in the next pregnancy.
Member: I cannot remember the name of the blood disorder; it is the presence of antibodies that interfere with membrane structures (too easily clotting). The miscarriage happened after a week of heavier bleeding and cramping, and after passing a very large clot.
Grunebaum: I suggest you see a high-risk doctor to look over the history, and review the actual test results. This will help you find out more about the possible reasons. Women who lose a fetus because of an abnormal clotting problem usually have so-called "intrauterine demise." That means the fetus dies first before any other symptoms. In those cases a pathological examination of the placenta will help find the reason for this problem.
Member: Would you recommend a C-section for a mother with a previous fetal demise at full term and history of shoulder dystocia? Both complications were from the same pregnancy. Shoulder dystocia was secondary to stillbirth due to cord accident.
Grunebaum: I suggest you have a high-risk obstetrician review the complete medical record. It's very important to review meticulously what happened. There are many different kinds of cord accidents. There could be a cord prolapse, a true knot, or a ruptured cord. Each of these is different but they are all called a cord accident, and the weeks of the pregnancy, the size of the baby, and many other factors are important. Only a careful review of your records can help you answer this question. In addition, a review of the labor and why shoulder dystocia occurred will help answer your very, very important question.
Member: Dr. Grunebaum, I was recently discovered to have severe dysplasia on my cervix. My doctor believes that this issue can be tackled after the birth. I am now in my 14th week of pregnancy and don't want this condition to worsen while the pregnancy continues, nor do I want to endanger the baby. Any thoughts? Would this condition also explain occasional spotting? My doctor doesn't seem to be alarmed by it.
Grunebaum: Most doctors believe that severe dysplasia diagnosed by colposcopy and biopsy is a slow progressing problem. And if the dysplasia was clearly diagnosed then many doctors suggest waiting until after delivery to reevaluate it and then decide how to treat it. In addition, many doctors also repeat the colposcopy late in the second trimester to see what's going on and make sure it did not get worse.
Member: Should I adjust my activities in any way as in a high-risk pregnancy?
Grunebaum: The term high-risk pregnancy is a very unclear term and I usually do not use it per se. What I explain to my patients is that there are many different risks. And each risk requires a different approach. If, for example you have twins, you are at risk for different problems. One is the risk of preterm delivery and rest is often a treatment to prevent preterm delivery. But having cervical dysplasia does not increase the risk for preterm delivery. So any limitation of activity wouldn't change this.
Member: When does the risk for preterm delivery in twins start setting in?
Grunebaum: Anytime before 37 weeks. That's how preterm delivery is defined: a delivery before 37 weeks.
Member: I have been diagnosed with homozygosity for MTHFR mutation (two previous early miscarriages) and have been told to take baby aspirin and high doses of folic acid, B6, B12 vitamins. Isn't heparin usually prescribed for this, too?
Grunebaum: You are correct. Many high risk doctors prescribe heparin for this condition, especially if you already had several miscarriages in the past.
Member: For my MTHFR diagnosis, should heparin therapy start before pregnancy starts or after a positive pregnancy test?
Grunebaum: Many doctors start it as soon as pregnancy is diagnosed.
Member: One more question about MTHFR. What do you think my chances are for having a healthy pregnancy taking just the baby aspirin and supplements (without heparin)? Would the supplements reduce homocysteine levels, thus reducing blood clots?
Grunebaum: Chances with and without heparin are very good having a healthy baby. You also should probably see a high-risk obstetrician who can advise you best about the possible outcome. Good luck.
Member: Dr G., when I was about 30 weeks I couldn't take my multivitamins because anytime I did I had to throw up and it made me feel really miserable, so I stopped completely; do you think this could affect my baby?
Grunebaum: If you eat regular food then this is unlikely to affect the pregnancy. I am now going to tell you a very big secret: No study has ever shown that pregnancy outcomes significantly improve in women who take vitamins in pregnancy. The most important vitamin to take is folic acid before and the first months of the pregnancy. Folic acid, of course, decreases fetal malformations. But if you otherwise have a balanced diet, adding vitamins has not shown to significantly improve pregnancy outcomes.
Member: Dr. Grunebaum, I am currently 17-weeks pregnant with my first child. I am 26 years old and have never had an abnormal PAP until now. It came back ASCUS and they did a DNA test for HPV. It turns out that I have contracted a high-risk type of HPV. This comes as a surprise since I waited to have sex until I was 20 years old and I've only had two partners. Anyway, my concern is that my doctor wants to do a colcopscopy and I don't know if this could possibly harm my baby. Also if she finds abnormal cells she said she would like to remove them. Is this safe during pregnancy? Also are there any effects that having HPV could have on my baby?
Grunebaum: All it takes is one partner to get a sexually transmitted disease like HPV. HPV increases the risk of cervical dysplasia and cancer, so it's important to get a regular PAP smear with or without being pregnant. I am unsure what your doctor means by abnormal cells, but the best test to check out an abnormal PAP smear is a colposcopy. It's a test where your doctor looks at the cervix with an enlarging glass similar to a microscope. During this procedure a small sample of the cervix (biopsy) is taken and sent for pathologic examination. This test can be done also during pregnancy and will tell you exactly how to treat the abnormal cells.
Member: Can you ever be cured of HPV?
Grunebaum: There is no real cure for HPV. It's always with you. It requires regular PAP smear.
Member: Doctor, while I was in the hospital yesterday, they ran numerous tests, and I was diagnosed with another UTI and vaginal infection. I just completed medication for both of these about two weeks ago. This is my fourth UTI and second vaginal infection. I seem to never get the UTI cleared up. What are the effects for the baby with having these UTIs? I have heard that it can cause brain damage, is this true?
Grunebaum: It really depends on how the UTI is diagnosed, what the organism is, and how it's treated. I am not aware that if treated correctly UTI will lead to brain damage. Brain damage of the fetus is very rare, and most of the time we cannot find a specific reason. Untreated UTI can lead to a kidney infection and treating it will prevent this from happening.
Member: The test always comes back as "borderline" and never a full-blown UTI. Does that help?
Grunebaum: I am unsure what you mean by "borderline." Borderline for what?
Member: They keep telling me that the urine looks suspicious, and when they return with the results it's "borderline" for a UTI.
Grunebaum: Either you have a UTI or not. UTI is diagnosed with a positive urine culture and a specific bacterium is usually found and treated. You need a specific diagnosis, borderline means very little without more and clearer information.
Member: Would a high white blood cell count cause problems with pregnancy? What causes it?
Grunebaum: A high white count can be normal because of the pregnancy. And it depends how high it is. With an infection there is often an elevated white count. In and by itself it doesn't necessarily mean much unless you find out why it's elevated and how much it's elevated.
Member: I was on Methadone for a couple of years for back pain. I got pregnant in February while I was only taking 20 mg at night. I was completely off of it by the end of my fourth week; is there a big chance of birth defects?
Grunebaum: Methadone is not a teratogenic agent. It's not known to increase the risk of fetal malformations. Babies born to mothers who take methadone are also dependent on it, and need close observation after delivery, but it does not increase the risk of malformations.
Member: I have high blood pressure; is that a reason not to get pregnant?
Grunebaum: There is an increased risk of several pregnancy complications with hypertension. They include preterm delivery, preeclampsia, and smaller babies. The real risk depends on the medical exam, what and how many drugs you take, and how high the pressure is. You should have a high-risk doctor look at all factors to advise you about specific risks.
Member: I am currently 27 weeks and am considered high risk because of a blood clot. I take 200 mg of Lovenox a day. For the past week I have been having dizzy spells, even when just sitting down relaxing. Is this something I should be worried about? I didn't have these with my first son.
Grunebaum: You must see a doctor right away. Dizzy spells can be normal or not. Only an examination by your doctor can tell what it is.
Moderator: Thanks for joining us, everyone. If Dr. Grunebaum wasn't able to answer your question, check our live event calendar for his next high risk chat, or try posting in his message boards here at WebMD. Best of luck in your journeys to parenthood!
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