When does a pregnancy become "high risk pregnancy"?

[noorjahan]

I am currently pregnant and so far I don't think I'm in high risk catagory. I just had my first doc visit yesterday and gave blood for some tests. I did end up doing one hour glucose test as diabetes runs in my family.

I don't want to do u/s unless they put me in high risk for whatever reason. And now I am wondering what makes a pregnancy h/r in the first place?

1. Diabetes

2. High blood pressure

3. Advanced maternal age (not sure abt it)

4. Thyroid problem (my friend currently preg is high risk caz of her thyroid problem- my SIL who also has this issue and preg NOT in high risk...so I'm puzzled)

What else?

If I pass the glucose test I'm thinking then I'm okay...and will gladly decline sonogram.

[Snugglebugmom]

Yep, AMA makes you automatically high risk. Not entirely fair, it's not like your risks increase dramatically on the day you turn 35, but I suppose they had to put the cut-off somewhere. 

I also believe that pregnancies that are the result of fertility treatments are considered high risk, as well as pregnancy after repeat losses, or after a second trimester or third trimester loss. 

[finnegansmom]

I've had 3 babies over age 35 and was never told I was high risk.  I have been told for a few midwives,  age alone is not a risk factor.  It might put you at higher risk for some things like diabetes or some fetal chromosomal abnormalities. 

Are you referring to the level II US?

If you are planning a homebirth and want to make sure the baby doesn't have anything glaring that might require immediately hospital care, I would get one.  Just my opinion, I know lots on here deny them. The US is more for the baby and less for the mom (unless you're looking at placenta or for cysts).

If you mean high risk as in risking out of a birth center, I was told when I toured one that PreE, uncontrolled diabetes and sometimes PIH can risk you out.  You would need to ask the birth center their criteria.  I'm sure everyone has different ones.

[Buddhamom]

I think it depends on your dr./midwife.  I am 40 and preg. after 8 years of secondary infertility, although we conceived naturally and certainly weren't trying by any means and I am not considered high risk. Yes, I had a few more US compared to others in the beginning because they were trying to determine viability, but I have passed on everything else except the 20 week US and everyone is fine with it.  However, I am not sure about diabetes as I have never experienced it and am not getting tested.

[Lousli]

I was high risk because of previous preterm deliveries.  Now that I've made it to full term, I'm pretty much not high risk any more (except the AMA thing.)

[nononose]

Originally Posted by Snugglebugmom 

Yep, AMA makes you automatically high risk. Not entirely fair, it's not like your risks increase dramatically on the day you turn 35, but I suppose they had to put the cut-off somewhere. 

I also believe that pregnancies that are the result of fertility treatments are considered high risk, as well as pregnancy after repeat losses, or after a second trimester or third trimester loss. 

AMA does not make one high-risk in Ontario.  Some (most?) OB groups and/or hospitals like to say so though.  I have heard many, many women recite that they are considered high-risk based only on age (all with an OB) - the cut-offs I've heard are 35 (Belleville) and 38 (Ottawa), depending on the hospital.  This is not listed as high-risk according to the SOGC, nor by the College of Midwives, so that leads me to believe that it is hospital specific, and only seems to apply to OB patients.  I am a midwifery client with AMA and a scarred uterus planning a home birth and I'm NOT high risk in Ontario.  I also have thyroid problems, and this does not put me high-risk either (I did do one consult with a high-risk OB as a precaution though - specifically for thyroid - this was not a required consult).  But to be honest, I'm not entirely sure what does put someone as high-risk, other than (pretty serious) pre-existing medical conditions and fertility issues already mentioned.
 

[Smokering]

Placenta previa would make you high-risk; maybe a breech or transverse baby would too (although only once you were in labour, or at least pretty close to it). Multiple births, obviously. VBACs are often considered high-risk, aren't they? Or does that fade away after the first successful VBAC? (My mother had two VBACs that were both quite heavily monitored, but I think that was more because she had GD as well). Pre-eclampsia, definitely.Maybe pre-existing conditions like epilepsy or cystic fibrosis, or paralysis?

I guess there's a distinction between "high-risk" and "we want to keep an eye on you". If you had a previous child with an abnormality they might be worried until you had certain tests or scans, but if you "passed" you presumably wouldn't be considered high-risk for the rest of the pregnancy... right? At my 20-week US they noticed the baby had a twice-wrapped nuchal cord, so they want to do another scan at 32 weeks to see if he's unwrapped himself; I'm not sure I'd technically be considered high-risk even if he hadn't, but it would certainly be a factor to be aware of during labour.

[MarineWife]

IME, there is a huge difference between what is considered high risk with an OB or CNM in a hospital vs. with a homebirth midwife. When I was pg with ds2 and seeing OBs I was not considered high risk for VBAC but was eventually considered high risk for possibly having gestational diabetes. I was required to have constant monitoring in the hospital because I was doing a VBAC. I'm not sure if that was considered high risk, per se.

I saw a CPM for a homebirth when I was pg with ds3 at 36-37. Obviously, still VBAC. I declined the GD testing. She did not consider me high risk. I am currently seeing a CNM for a homebirth and, again, not considered high risk at age 40-41. If I remember correctly, the only things she mentioned that would absolutely preclude me from having a homebirth are pre-E and uncontrolled diabetes. There are some fetal abnormalities that would put one in the high risk category that an u/s should pick up most of the time. But, yeah, AMA alone is not high risk and neither is VBAC.

[mamacolleen]

Just wanting to add that fertility treatments also do not automatically make you high risk. Both my pregnancies were a result of IVF/FET and I have never been considered high risk by either my RE or midwives. (I live in Ontario where midwives are regulated and there's clear guidelines on when they need to consult with an OB and when they need to transfer care to an OB).

Also, I will be attempting VBAC with this baby and this also doesn't make me high risk in Ontario. I have a midwife and am planning an HBAC. I know with how conservative OB's can be, that if VBACS were at all considered high risk, that I would not be allowed to have a home birth (because midwives are a regulated health care professional and have a license to protect).

I haven't seen the Ontario list recently in terms of what things place you in a higher risk category to warrant a consult and possible transfer of care but I believe the things on it are: multiples, baby's position (breech/transverse/etc), age (both much younger and much older), pre-e, GD, history of preterm labour, etc. However, even with some of the high risk categories (multiples and GD for eg), it's not an automatic transfer but may be a consult, making me think that there's an understanding of relative risk. For eg, I believe with GD, a midwife has to consult an OB only, but if the women actually requires insulin, I believe it's an automatic transfer of care to the OB. And I'm pretty sure that midwives are not allowed to take on mum's with Insulin-dependent diabetes.

[Smokering]

age (both much younger and much older)

Why younger? I know the risk of pre-e is higher for younger mums (under 18, or under 21, or something?); but are there other risks?

[noorjahan]

I am having a hospital birth. I mainly wanted to know because I don't want them to force me a sonogram citing high risk thing.

Though don't know what will happen, my 1 hour glucose test came bad, so Monday will have to go for 3 hours. I'm only 17 weeks along, but they are doing it caz diabetes runs in the family! I did ask the nurse if this will mean I'll be high risk, she said no as long as it's under control.

[MarineWife]

Originally Posted by noorjahan 

I am having a hospital birth. I mainly wanted to know because I don't want them to force me a sonogram citing high risk thing.

Though don't know what will happen, my 1 hour glucose test came bad, so Monday will have to go for 3 hours. I'm only 17 weeks along, but they are doing it caz diabetes runs in the family! I did ask the nurse if this will mean I'll be high risk, she said no as long as it's under control.

That's what my MW said. Only uncontrolled GD would make one high risk. I'm not sure about Type I or II diabetes. A lot of women "fail" the 1 hour GTT and pass the 3 hour GTT so I wouldn't worry about that too much at this point. Since diabetes runs in your family, have you or do you have your A1C checked regularly? That will give a more clear picture of whether you are pre-diabetic or diabetic.

As has been said, many hospitals and OBs have different criteria for what they consider high risk. It might behoove you to do your own research on anything you may be told would make you high risk. Also, remember that anything the doctors or hospitals tell you is only a recommendation. They cannot force you to have any procedure, test or treatment that you do not want. They may pressure you and use unethical tactics to try to coerce you but they cannot force you.

[Agatha_Ann]

I'm high risk because I have a history of preterm labor (usually starting at 20 weeks), being underweight, previous losses, I have had 4 c-sections, and I have extreme birth defects in my reproductive organs. I don't know if each of these alone would make me high risk, but the combonation does.

I agree that the definition of high risk totally depends on who you ask. Even when you are considered high risk, it doesn't always cause major changes in your treatment either.

[nononose]

Originally Posted by mamacolleen 

I haven't seen the Ontario list recently in terms of what things place you in a higher risk category to warrant a consult and possible transfer of care but I believe the things on it are: multiples, baby's position (breech/transverse/etc), age (both much younger and much older), pre-e, GD, history of preterm labour, etc. However, even with some of the high risk categories (multiples and GD for eg), it's not an automatic transfer but may be a consult, making me think that there's an understanding of relative risk. For eg, I believe with GD, a midwife has to consult an OB only, but if the women actually requires insulin, I believe it's an automatic transfer of care to the OB. And I'm pretty sure that midwives are not allowed to take on mum's with Insulin-dependent diabetes.

If you are interested, the "rules" are here:

http://www.cmo.on.ca/downloads/communications/standards/G04-Indications%20for%20Mandatory%20Discussion%20Consultation%20and%20Transfer%20Jun00.pdf

Breech is NOT a transfer of care, however most hospital policies overrule that and lay conditions on midwife privileges.  Neither is twins (I think they only tend to be sticky about twins with a primip).  There are many other things that require a consult, but it's just a "chat" really.  I'm still looking into the ways around avoiding a transfer of care.  It is possible.  A woman can still refuse the mandatory transfer, but there are rules protecting the midwife in these cases.

In summary, a transfer of care is required for:

History of

• any serious medical condition, for example:  cardiac or renal disease with failure or insulin dependent diabetes mellitus

Prenatal:

• cardiac or renal disease with failure

• insulin dependent diabetes

• multiple pregnancy (other than twins)

During labour:

• active genital herpes at time of labour

• preterm labour (less than 34 completed weeks)

• abnormal presentation (other than breech)

• multiple pregnancy (other than twins)

• gestational hypertension with proteinuria and/or adverse sequelae

• prolapsed cord or cord presentation

• placenta abruption and/or previa

• severe hypertension

• confirmed non-reassuring fetal heart patterns, unresponsive to therapy         

• uterine rupture

• uterine inversion

• hemorrhage unresponsive to therapy

• obstetric shock

• vasa previa

 

But this is for transfer of care, not necessarily for "high risk".  However, these are the rules that are used when someone would say they've been "risked out of midwifery care".

I hope the 3-hour glucose test goes well.  Lots of women fail the 1 hour one.  I did last time and had no problems with GD at all (and a small baby).  I hope you aren't cornered into doing a sonogram you don't want.  It really is a pain that so many OBs want them for so many things, and not always justified.  Silliness!  Good luck!

[kcparker]

Originally Posted by noorjahan 

I am currently pregnant and so far I don't think I'm in high risk catagory. I just had my first doc visit yesterday and gave blood for some tests. I did end up doing one hour glucose test as diabetes runs in my family.

I don't want to do u/s unless they put me in high risk for whatever reason. And now I am wondering what makes a pregnancy h/r in the first place?

1. Diabetes

2. High blood pressure

3. Advanced maternal age (not sure abt it)

4. Thyroid problem (my friend currently preg is high risk caz of her thyroid problem- my SIL who also has this issue and preg NOT in high risk...so I'm puzzled)

What else?

If I pass the glucose test I'm thinking then I'm okay...and will gladly decline sonogram.

Depends on who you ask (FP doc, OB, midwife, homebirth midwife) and what their perception of and tolerance for risk is.

Uncontrolled diabetes, high blood pressure, thyroid, or other health issue in the mother, multiple gestation, history of unexplained preterm labor, genetic factors, maternal-fetal factors, breech, placental issues (complete previa or velamentous insertion), or a combination of small risk factors that collectively add up to an overall increased risk of complications (for eg. AMA plus two vessel cord, plus GD that isn't well-controlled).

[mamacolleen]

Thanks for posting that list nononose. Really helpful. I'm wondering about how far you're "allowed" to go post-dates with a midwife, because I don't see that on the list anywhere. With my last pregnancy, planning a home birth, once I reached 42 weeks with no sign of labour I was told that I could no longer have a home birth and the midwife needed to consult with the OB. So we went to the hospital and I got talked into a medical induction that ended up in a c-sec 2 days later. I kind of remember being told that if I went to 43 weeks with no labour, that I would be automatically transferred care to an OB and that I wouldn't get any say in the matter. Do you know anything about this particular stipulation? Is there anywhere where that's in writing? And, from what I gather of your post, this time, if I get to 43 weeks and refuse transfer of care my midwife will still care of me and not be penalized?

Sorry to derail the thread.

ETA: sorry, I see where it says a consult is required at 42 weeks but nothing about what happens at 43 weeks. Would a woman have to transfer to an OB at that point?

[Liora]

It definitely depends on where you are too.  I'm in Ohio where MW are very restricted to working under and OB.  Last pregnancy I had to fight to stay with the MW due to GD - controlled with diet.  IVF did not make me high risk AFTER 10 weeks.  I was only monitored more closely while I was on the progesterone and then I was "released" to the midwives.

This pregnancy I'm AMA (funny story- I said "my embryos are from when I was 32, so I'm not AMA" the answer? "AMA for twins is 32." =/ ) and twins (no midwife will delivery twins in Ohio).  I now have GD on insulin, preterm labor, preE, etc. etc. lol.  So I'm certainly high risk now.

[Amy May]

I agree that the term "high risk" is totally subjective. There is also a difference between factors affecting the pregnancy (high blood pressure, protein in the urine, pitting edema, past history etc) and those arrising closer to labor (breech beyond 37 weeks, early rupture of membranes).  Also, while some factors are truly "high risk," there are others that are just high attention.   

A few more to add to the list...

For a homebirth momma, an anemic woman going into labor has a much higher risk of hemorrhage, so if hemocrit & hemoglobin were too low, she'd likely be risked out of a homebirth. 

For a birth center (but not necessarily HB midwives), premature rupture of membranes (longer than 24 hours), as well as any meconium staining would likely risk out a mother from most birth centers.