Management of High-Risk Pregnancy

Definition and Identification

High-risk pregnancy is defined as one in which the woman, fetus, or infant is at risk of death or residual injury and requires additional resources, procedures, or specialized care to optimize outcomes, according to the American College of Obstetricians and Gynecologists 1
Early identification of risk factors is essential for reducing maternal morbidity and mortality through timely interventions, as recommended by the American College of Obstetricians and Gynecologists 2
Risk assessment should occur across the reproductive spectrum, including prepregnancy, antenatal, postpartum, and interpregnancy periods, as suggested by the American College of Obstetricians and Gynecologists 1

Cardiovascular diseases, including rheumatic heart valve disease, Marfan syndrome, and Ehlers-Danlos syndrome, are associated with high-risk pregnancy, according to the European Society of Cardiology 3, 4
Hypertensive disorders, including chronic hypertension and preeclampsia, are common risk factors for high-risk pregnancy, as noted by the European Society of Cardiology 5
Diabetes, both pregestational and gestational, is a significant risk factor for high-risk pregnancy, according to the American College of Obstetricians and Gynecologists 2
Previous adverse pregnancy outcomes are a risk factor for high-risk pregnancy, as identified by the American College of Obstetricians and Gynecologists 7
Multiple gestation is a risk factor for high-risk pregnancy, according to the American College of Obstetricians and Gynecologists 2
Substance use is a risk factor for high-risk pregnancy, as noted by the American College of Obstetricians and Gynecologists 7
Socioeconomic and geographic factors can contribute to high-risk pregnancy, according to the American College of Obstetricians and Gynecologists 1

Optimize health before pregnancy through preconception counseling, as recommended by the American Gastroenterological Association 8
Risk stratification and management of medical illnesses are crucial in preconception care, according to the American Gastroenterological Association 8
Discussion of contraception for adequate birth spacing is essential in high-risk women, as suggested by the American College of Obstetricians and Gynecologists 1
Genetic testing, such as for Marfan syndrome, may be necessary in certain cases, according to the European Society of Cardiology 3
Joint cardiac and obstetric management is necessary for women with cardiovascular diseases, as recommended by the European Society of Cardiology 3
Regular echocardiograms are essential for monitoring women with aortic aneurysm risk, according to the European Society of Cardiology 3
Close monitoring of hypertension and arrhythmias is crucial during pregnancy, as noted by the European Society of Cardiology 3
Continuous risk assessment throughout pregnancy is necessary, as conditions may evolve, according to the American College of Obstetricians and Gynecologists 2
Medication management requires careful consideration of maternal and fetal risks/benefits, as suggested by the American Gastroenterological Association 8

Beta-blocker therapy should be continued throughout pregnancy for appropriate conditions, according to the European Society of Cardiology 3
ACE inhibitors should be avoided during the second and third trimesters due to risk of renal dysgenesis, as noted by the European Society of Cardiology 5
For severe hypertension, oral nifedipine, IV labetalol, or IV hydralazine may be used in a monitored setting, according to the American College of Obstetricians and Gynecologists 6
Magnesium sulfate is used for seizure prophylaxis in preeclampsia, as recommended by the American College of Obstetricians and Gynecologists 6
Limiting total fluid intake to 60-80 mL/hour can help avoid pulmonary edema in preeclampsia, according to the American College of Obstetricians and Gynecologists 6
Delivery is the definitive treatment for preeclampsia, as noted by the American College of Obstetricians and Gynecologists 6
Low-dose aspirin may be used for prevention of preeclampsia in high-risk women, according to the American College of Obstetricians and Gynecologists 6

Coordinate birth for patients with complex conditions through a multidisciplinary team, preferably in a tertiary care center, as recommended by the American Gastroenterological Association 8
Determine optimal timing and mode of delivery well in advance, according to the European Society of Cardiology 5
Vaginal delivery is usually advised except in specific cases, such as dilated Marfan aortic roots or aortic dissections, as noted by the European Society of Cardiology 5
Consider epidural anesthesia but avoid vasodilatation in patients with cyanosis or compromised stroke output, according to the European Society of Cardiology 5

Continue close monitoring, especially for cardiovascular conditions, as recommended by the European Society of Cardiology 3
Anticipate potential postpartum hemorrhage in certain conditions, such as Ehlers-Danlos syndrome, according to the European Society of Cardiology 3
Assess physical and mental health risks to identify women needing interventions, as suggested by the American College of Obstetricians and Gynecologists 2
Provide immediate postpartum contraception for women at high risk in future pregnancies, according to the American College of Obstetricians and Gynecologists 2
Schedule follow-up visits to ensure transition to appropriate ongoing care, as recommended by the American College of Obstetricians and Gynecologists 2

Regular echocardiograms are essential for women with Marfan syndrome, according to the European Society of Cardiology 3
Consider elective aortic root replacement prior to pregnancy for high-risk cases of Marfan syndrome, as suggested by the European Society of Cardiology 3
Newborns of women with Marfan syndrome should have careful physical, echocardiographic, and ophthalmic examination, according to the European Society of Cardiology 3
Genetic testing options include chorionic villus biopsy at 13 weeks, amniocentesis, or postnatal testing for Marfan syndrome, as noted by the European Society of Cardiology 3
Close monitoring during pregnancy and delivery is necessary for women with Ehlers-Danlos syndrome, according to the European Society of Cardiology 3
Anticipate increased bruising, hernias, varicosities, or rupture of large blood vessels in women with Ehlers-Danlos syndrome, as suggested by the European Society of Cardiology 3
Be prepared for severe postpartum hemorrhage in women with Ehlers-Danlos syndrome, according to the European Society of Cardiology 3
Use retention sutures for incisions and leave