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Managing High-Risk Pregnancies: Insights from Perinatologists

Perinatology, also referred to as maternal-fetal medicine, is the care of mother and fetus across all stages of pregnancy, including postpartum — with a focus on high-risk pregnancies.

Jordan Knight, DO, a perinatologist at Allegheny Health Network

Jordan Knight, DO, a perinatologist at Allegheny Health Network

“High-risk” means that extra care and attention may be needed to have a healthy and successful pregnancy — from conception to delivery, and beyond. This can include many subsets of care, and a broad spectrum of urgency. A risk may involve the mother, the fetus, or both. It could be related to a woman’s pre-existing health condition, or something that develops during pregnancy. Some risks are nothing to fear, they just require extra care — other risks are life-threatening.

Allegheny Health Network (AHN) has an integrated, interdisciplinary Maternal-Fetal Medicine program that assists mothers and families in identifying and navigating high-risk pregnancies. To learn more about different risks and how they are managed, I sat down with AHN perinatologists Marta Kolthoff, MD, and Jordan Knight, DO.

High-Risk Pregnancy: Risk Factors

Emily Laubham (EL): How would you describe high-risk pregnancy?

Dr. Marta Kolthoff: High-risk pregnancy can include fetal issues, maternal issues, or some combination of the two. As a geneticist, I have cared for women with genetic disease, but I’m looking at genetic risk to the fetus more often. In general, our role is to learn whether or not there is a specific disorder based on ultrasound results, other testing, and family history.

Dr. Jordan Knight: Pregnancy is a great unmasker of chronic medical conditions. From the maternal health standpoint, the question is, how does a chronic disease affect a pregnancy and vice versa. There can also be certain conditions unique to pregnancy such as multiple gestation and gestational diabetes, or adverse pregnancy conditions such as preeclampsia. Roughly 10 percent of all pregnancies are considered high risk.

EL: Are multiple risk factors the rule or the exception during a high-risk pregnancy?

Dr. Knight: It’s the rule and becoming even more so. Obesity and high blood pressure are two of the most common comorbidities, as well as diabetes. Age, unfortunately, is another thing that gets lumped into that group, as it can put both mom and baby at a unique risk.

EL: At what age do perinatologists consider a pregnancy to be high-risk?

Dr. Knight: Historically, advanced maternal age for pregnancy, at least in the U.S., is considered 35 and older. Older moms tend to have additional medical conditions like the ones I mentioned, such as high blood pressure or obesity, and that can make pregnancy riskier. From a genetic standpoint, the risk of chromosomal abnormalities or miscarriage is also higher.

EL: And multiple gestation — what risks come with carrying twins or triplets or more?

Dr. Knight: It’s important to recognize multiple gestation early on. The most important thing is to know whether or not the babies share a placenta. Sharing isn’t abnormal — but it could come with more inherent risk of structural defect.

Genetic Counseling

EL: How important is genetic counseling for hopeful parents?

Dr. Kolthoff: You could make the argument that every family needs a genetic counseling session before or during pregnancy. If people would sit down with us for an hour, it could be so beneficial.

EL: At what point should someone come in for a genetic counseling session?

Dr. Kolthoff: Preconception is ideal. That way we have time to discuss and consider risks without a time constraint. That said, the majority of patients we see are already pregnant.

EL: What does genetic counseling involve? What does the process look like for patients?

Dr. Kolthoff: Typically, they are referred to a counselor by their OB/GYN or primary physician based on an issue. Testing may be performed, and then they’ll likely interact with their counselor again when results come back. They can visit multiple times if they have additional questions.

If we identify an issue or see something on the ultrasound, such as a birth defect, we will stay in touch throughout the entire pregnancy. The patient will have regular ultrasounds and recurring visits to discuss ongoing questions and concerns along with the development of a delivery plan.

EL: Are there misconceptions about genetic counseling and high-risk pregnancy that you want to address?

Dr. Kolthoff: There is a prevalent misconception that if you’re not, say, 40 years old when you’re pregnant, or not at risk for a specific genetic disorder or fetal anomaly, then you shouldn’t worry about genetic counseling and testing. In reality, the American College of Obstetrics and Gynecology and American College of Medical Genetics recommend that all women be offered screening for genetic disorders and chromosomal conditions. There is a potential risk with every pregnancy. The absence of a family history, or the fact that you’ve had a former pregnancy without issue does not mean there won’t be a problem. You could still be at risk for passing along a genetic disorder.

Dr. Knight: I’d also tell people to keep in mind that it’s not always bad when we have to come into the room. Just because your doctor recommends seeing us does not mean it’s going to be a negative outcome. It’s more about proper instruction, making a plan, and reassurance. That often gets lost in the shuffle when patients hear the words “high-risk pregnancy.” To put it another way, saying you’re at risk doesn’t necessarily mean you’ll be affected.

Dr. Kolthoff: Very true. Going back to age as a risk factor, I want to make patients aware that you can have an advanced maternal age pregnancy that is completely healthy. The majority of women in a higher age bracket are going to have healthy babies. The same goes for many other high-risk pregnancy conditions.

EL: Dr. Kolthoff, you have a master’s degree in bioethics in addition to your medical training. What are some of the ethical issues within maternal-fetal medicine?

Dr. Kolthoff: There is a lot we can test for, and with that information come an assortment of ethical issues. One of the biggest principles is informed consent. We need to be sure that the patient fully understands what they or their baby is being tested for, and then what the test does and doesn’t mean.

So, for example, there are a lot of non-invasive tests for chromosomal conditions — some tell us a lot and some tell us a little. Having a patient think that everything is OK because of a negative test result, and then finding out something is wrong later — we don’t want that.

And then, how do you manage the pregnancy once a diagnosis has been made? There is a lot of debate about the right thing to do if someone receives a diagnosis that is likely not compatible with a long life after birth.

Miscarriage and Postpartum Care

EL: I feel like miscarriage is an issue that often gets swept under the rug. How common is it for a pregnancy to end in miscarriage?

Marta Kolthoff, MD, a perinatologist at Allegheny Health Network

Marta Kolthoff, MD, a perinatologist at Allegheny Health Network

Dr. Knight: In general, up to 20 percent of pregnancies end in miscarriage, with that number increasing with the patient’s age.

Dr. Kolthoff: Another statistic you’ll see is that 1 in 4 women will experience some type of pregnancy loss during their lifetime. But it’s only now being recognized what the impact of that loss is for women and their families. I’m very interested in perinatal loss, and trying to provide the best care possible. It’s a passion of mine.

I like to give examples of how other cultures deal with perinatal loss. In Japan, women receive a symbolic statue — it’s called Jizo — if they’ve encountered any type of perinatal loss. They have a sort of memorial for these statues. I’ve seen pictures where there are just thousands of statues, and women gather to dress and decorate them with shirts or scarves. This whole process of acknowledging loss doesn’t yet exist in our country. But that’s changing — a growing number of organizations are working to make perinatal loss known and understood.

Having something like our Perinatal Palliative Care program is so important to provide that extra emotional, spiritual, social, and symptom support when someone receives difficult news and goes through the experience of loss.

EL: In the case of loss, or even when pregnancy is successful, do you believe, on a national level, that we provide enough postpartum support to mothers and families?

Dr. Knight: To go back to the phrase you used — “swept under the rug” — it’s common, but not openly discussed, that a lot of the medical and genetic conditions we see come with increased risk for postpartum depression and anxiety. I think that’s where AHN has been outstanding in women’s behavioral health — in recognizing these issues and helping moms from a mental health standpoint throughout the entire pregnancy experience.

Dr. Kolthoff: Throughout AHN, the primary OB/GYN will screen for postpartum conditions, but if we get a patient who we think is at particular risk, we can suggest they see a behavioral health expert even before they deliver. This comes up again and again with patients who experience pregnancy loss, or who have a baby with some kind of life-threatening condition. These women are especially at risk, and so we try to make sure they have that referral.

“We’re here for the patient — that’s the bottom line”

EL: What are you most excited for in the future of perinatal medicine?

Dr. Kolthoff: I’m probably most excited by the possibility of fetal treatment. We do a lot of diagnosis but not much intervention.

Dr. Knight: I think AHN has done a particularly good job recognizing the importance of maternal morbidity and mortality, specifically in relation to hemorrhage. To be able to prevent future catastrophic events is so important.

Also, we’re starting to improve continuity of care. For example, with preeclampsia, there’s a risk later in life for certain comorbid conditions like cardiovascular disease. Another example is gestational diabetes, which is diagnosed during pregnancy and effectively “cured” by giving birth. However, over the next 10 to 25 years, a good portion of these women will develop type 2 diabetes. In the future, I want to get them risk stratified and potentially treated under modified activity and diet right from the start. So, overall, we need to keep the plug connected, so to speak, and recognize when pregnancy increases a risk for health complications in the future.

EL: Are you concerned about anything in the future of your field?

Dr. Knight: First and foremost, we are patient advocates. Unfortunately, there are restrictions, such as certain legal legislation, that define what we can and cannot offer or talk about. That concerns me because I believe it’s our obligation to discuss every option with patients and be as informative as possible. At the same time, the place for advocacy in our field excites me. I’m happy for the opportunity to know some of the people involved and to be involved myself.

Dr. Kolthoff: I agree. There is a sanctity to the doctor-patient relationship, and a need for privacy to maintain that relationship. It’s scary how legislation, politics, and media can interfere. Here’s the thing to remember: For one reason or another, we will all be patients someday. Decisions are being made without thought of how it will affect the relationship we would all want with our doctor.

Dr. Knight: It’s the simple thing of being able to communicate a concern on an ultrasound, and then talk about the options we have to ensure the safety of both mom and baby. People putting their trust in you — I find that reaffirming. We’re here for the patient — that’s the bottom line.

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