What is the definition of a high-risk pregnancy?

Definition of a High-Risk Pregnancy

A high-risk pregnancy is defined as one in which the woman, fetus, or infant is at risk of death or residual injury and that requires additional resources, procedures, or specialized care to optimize outcomes. 1

Key Factors Contributing to High-Risk Pregnancy

Medical Conditions

• Chronic Medical Conditions:

  • Hypertension, preexisting diabetes mellitus, and renal disease (present in approximately 10% of delivery hospitalizations) 1
  • Obesity - increases risk of maternal morbidity and mortality and development of other chronic conditions 1
  • Cardiovascular disease - complicates 1-4% of pregnancies annually and is the leading cause of pregnancy-related mortality in the US 1

• Infectious Diseases:

  • Sexually transmitted infections
  • Hepatitis B and C - risk of vertical transmission and adverse fetal outcomes 1
  • Influenza - pregnant women are at increased risk of complications 1

Other Risk Factors

• Substance Use:

  • Alcohol, tobacco, and illicit drugs can significantly impact maternal and fetal outcomes 1

• Previous Reproductive History:

  • Prior pregnancy complications
  • Previous cesarean deliveries
  • History of preterm birth 1

• Socioeconomic and Geographic Factors:

  • Limited access to healthcare
  • Food insecurity
  • Housing instability
  • Transportation barriers 1

• Racial and Ethnic Disparities:

  • Black and American Indian/Alaska Native women experience disproportionately higher rates of maternal morbidity and mortality 1

Risk Assessment Throughout Pregnancy

Risk assessment should be a continuous process that begins before pregnancy and continues through the postpartum period:

1. Preconception Assessment:

   • Identify and optimize chronic health conditions
   • Assess socioenvironmental and behavioral risks
   • Provide contraception counseling if pregnancy is not desired 1

2. During Pregnancy:

   • Initial assessment at first prenatal visit
   • Continuous reassessment as pregnancy progresses
   • Monitor for development of pregnancy complications (e.g., preeclampsia) 1

3. Delivery Planning:

   • High-risk pregnancies should be managed by multidisciplinary teams
   • Preferably at tertiary care centers with specialized expertise 1

4. Postpartum Period:

   • Continued monitoring for complications
   • Addressing ongoing health needs 1

Important Considerations in Management

• Risk Mitigation:

  • Procedures, medications, and interventions to optimize maternal health should not be withheld solely because a patient is pregnant 1
  • Benefits and risks must be carefully weighed for each intervention

• Coordination of Care:

  • Complex cases should be managed by multidisciplinary teams including gastroenterology, obstetrics, and maternal-fetal medicine specialists 1
  • Collaborative discussions regarding birth planning, location, mode of delivery, and gestational age are essential 1

Common Pitfalls to Avoid

1. Delayed Recognition: Failure to identify high-risk factors early can lead to preventable complications 1

2. Communication Failures: Poor coordination between specialists can compromise care 1

3. Implicit Bias: Acknowledging and combating implicit bias and structural racism is crucial to reducing disparities in maternal outcomes 1

4. Withholding Necessary Interventions: Interventions should not be withheld solely due to pregnancy status if they are medically necessary 1

5. Inadequate Risk Assessment: Risk factors evolve throughout pregnancy and require continuous reassessment 1

The definition and management of high-risk pregnancies require a comprehensive approach that addresses medical, social, and systemic factors to optimize maternal and fetal outcomes.