2 reasons we’re seeing more high-risk pregnancies in D.C.

We care for about 3,500 pregnant women every year. While that number has remained fairly steady over the past decade, the number of those women with high-risk pregnancies increases every year.  

Because “high-risk pregnancy” is a catch-all term that includes factors such as age and chronic health problems, it can be difficult to determine exactly how many of these women there are. But my colleagues and I can tell you that we’re treating more women who fall into this category than ever before.  

The most severe pregnancy complications – such as eclampsia, heart failure and hemorrhage – are referred to as severe maternal morbidity. The Centers for Disease Control and Prevention reports that the severe maternal morbidity rate has more than doubled from 2000 to 2010, and now affects 650,000 women in the United States every year.  

Many factors contribute to this increase, but the two we see most often in the District of Columbia are obesity and advanced maternal age. 

1. How obesity can complicate pregnancy  

Nearly one in four U.S. women was considered obese when they became pregnant in 2014. While the rate of pre-pregnancy obesity in D.C. was lower than the national average at about one in five women, we still feel the effects of this epidemic.

 Obesity is defined as having a body mass index greater than 29.9, and it can increase the risk of problems during pregnancy, including:

  • Birth defects
  • Gestational diabetes
  • Preeclampsia
  • Preterm birth or stillbirth  

Excess body fat also can make it difficult to analyze an ultrasound and monitor fetal heart rate.  

Obesity also increase a person’s risk for health problems such as diabetes, high blood pressure and heart conditions. Our patients are not nearly as healthy going into pregnancy as they once were. I commonly find myself caring for patients with a condition that requires me to collaborate with a specialist such as a cardiologist.  

The number one thing you can do to decrease the risk of obesity-related pregnancy complications is to lose weight before you become pregnant. Talk with your doctor about lifestyle changes you can make to reach a healthier weight.  

Also, talk to your Ob/Gyn or a maternal-fetal medicine specialist before you become pregnant about what to expect if you have a heart condition or another chronic health problem such as obesity. 

2. More D.C. women delaying pregnancy until 35 or older

Not even 15 years ago, I would have exclaimed, “Whoa! You have a 45-year-old patient who’s pregnant?” These days, we don’t blink an eye at a pregnant woman in her 40s.  

The District of Columbia is somewhat unique in that we have more professional women who delay having children until they are older.  

  • The birth rate for D.C. women age 35 to 39 was 72.7 births per 1,000 women in 2015, compared with 51.8 nationwide.
  • The birth rate for D.C. women age 40-44 was 21.8 births per 1,000 women in 2015, compared with 11 nationwide.
  • The birth rate for D.C. women age 45-49 was 2.5 births per 1,000 women in 2015, compared with 0.8 nationwide.  

It’s wonderful to have the option to wait to have children until you’re in your late 30s and early 40s. However, it does increase certain risks for mom and baby, including:

  • Birth defects
  • Gestational diabetes
  • High blood pressure  
  • Miscarriage
  • Premature birth  

We may recommend additional testing and screening if you are 35 and older to detect certain birth defects. The best thing you can do if you’re 35 or older and want to get pregnant is to talk with your Ob/Gyn about your specific risk factors and how to go into pregnancy as healthy as possible. 

Reduce and manage pregnancy risks

Obesity and advanced maternal age are just two factors for the increase in high-risk pregnancies. Thanks to advances in science, we’re also caring for more women who are having multiples (twins or more), have had organ transplants or are cancer survivors. We also see a number of pregnant women who have HIV.  

With proper preparation, we’re better able to manage the increased risks of these health factors. Request an appointment with an Ob/Gyn or maternal-fetal medicine specialist to discuss your unique challenges. The doctor can help you prepare for pregnancy and manage your and your baby’s health during pregnancy, labor and delivery.  

Don’t be afraid to ask your doctor questions. These can include:

  • How can I get healthier before I become pregnant?
  • What type of prenatal testing will be done?
  • Should I stop or adjust my medications?
  • Will I need extra ultrasounds to monitor my baby’s health?
  • Will I need additional prenatal appointments?  

We may care for high-risk pregnancies more often, but each pregnancy is different and comes with its own challenges. We want the same thing for every woman: to go home with a healthy baby.  

What to expect during pregnancy if you have a heart condition

Common tests during pregnancy include ultrasounds and blood sugar screenings. But heart tests – such as electrocardiograms (EKGs) – are also sometimes necessary.

Obstetricians discuss and evaluate their pregnant patients’ heart health to gain knowledge of a woman’s family history and risk factors. In cases of prior heart problems, we need to take special care to manage heart health during pregnancy.

As little as 15 years ago, a woman with a condition such as a congenital heart defect would have been advised to never get pregnant. We just didn’t think her heart could handle pregnancy, labor and delivery. But thanks to advances in medicine, growing expertise and doctors from multiple specialties – and facilities – working together, more and more of these women are able to safely give birth.

I’ve cared for a woman who had a heart valve replacement when she was 26. She became pregnant and delivered a healthy baby a year later. There’s no getting around it, such pre-existing conditions add complications to a pregnancy. But in many cases, the staff and resources are available to care for these high-risk patients and help them plan for safe, healthy pregnancies and deliveries.

The January 2017 guidelines issued by the American Heart Association agree, recommending that women with serious congenital heart defects work closely with their cardiologist and maternal-fetal medicine specialist before, during and after pregnancy. The guidelines also recommend giving birth at a larger medical center with specialists who have the necessary expertise to manage such a delivery.

Planning for pregnancy with a heart condition

Before you become pregnant, sit down for a discussion with a cardiologist and a maternal-fetal medicine specialist. It’s important that everyone is aware of your health history and the potential risks involved.

We’ll also want to evaluate:

  • Medications: Some medications can harm a baby during pregnancy, so we’ll want to discuss changing a medication or adjusting the dosage.
  • Potential procedures: Certain conditions should be fixed before pregnancy. This could include repairing a hole in your heart or opening a blocked valve.
  • Genetics testing: This can determine your baby’s risk of inheriting a congenital heart defect.

Your family doctor or general obstetrician may not have the expertise to plan for or manage such a complex pregnancy. It takes a unique understanding to optimize the care and outcomes for these women.

We’ll help connect you with an experienced team through our Special Moms/Special Babies program, which offers coordinated care for moms with congenital health problems. We also partner with Children’s National Health System, with whom we share a campus, to care for pregnant women in their adult heart clinics.

Learn more about our Special Moms/Special Babies program or call 202-877-3627.

There are still some circumstances in which we may advise you to not become pregnant. If this is the case, talk to your doctor about reliable birth control options.

Managing a heart condition during pregnancy

Every pregnancy causes the heart to work overtime. For example, the amount of blood it pumps can increase by as much as 50 percent to sustain a growing baby.

Physical changes during pregnancy affect which stressors the maternal heart faces. And when an underlying cardiac problem is in play, we become more worried about the potential for heart failure, heart attack and pulmonary hypertension, among other things.

Your care team likely will include a maternal-fetal medicine specialist, obstetrician, cardiologist, neonatologist and other specialists as needed.

Together, we’ll help you manage your heart health with medication, diet and exercise. You’ll likely need regular tests such as blood tests and EKGs to evaluate your heart function.

And, of course, we’ll keep an eye on your baby. For example, we know that if mom has an arrhythmia, the baby can develop it as well, so we’ll monitor for that.

Going into labor and delivery

Your team will collaborate with you on a plan for labor and delivery based on your health. This will include deciding whether certain specialists need to be present, in which case we may plan to induce labor.

We’ll monitor your and your baby’s hearts throughout the process. Pushing can put additional stress on the heart, so we might limit how long you push, or give you additional assistance using forceps or a vacuum extractor. In some cases, a cesarean section may be necessary.

If you decide you would like to have another baby, talk with your cardiologist and maternal-fetal medicine specialist before you get pregnant again. Your heart health may have changed since your first pregnancy. And even if it hasn’t, every pregnancy is different. We want to prepare for all possibilities.

With proper planning and precautions, more and more women who thought they could never give birth due to a heart condition are realizing their dreams and taking home healthy babies.