Recently, I was interviewed by Lois M. Collins, a reporter for Deseret News who wrote this great article about high-risk pregnancy that I’d like to share with you. Although I’m listed as a “clinical informatics specialist” which is my new role as a result of completing my studies at Johns Hopkins School of Medicine’s Informatics Program, I’m still very much a board-certified ob-gyn physician.
Pregnancy-related complications are high in the U.S., but doctors say women can help themselves
By Lois M. Collins , Deseret News
Published: Wednesday, July 10 2013 7:35 a.m. MDT
OKLAHOMA CITY, Okla. — Martha Garcia was a healthy 26-year-old when she became pregnant with a baby girl. It was her first pregnancy and she knew her body was undergoing major changes, but she worried even after the doctor said her swollen-like-a-football feet and exhaustion were normal.
Two weeks before her baby was due, Garcia found breathing so hard she felt like she was suffocating. In the emergency room, doctors found her blood pressure was through the roof, she was beginning to bleed and her baby had died, the victim of peripartum cardiomyopathy, a rare complication that results in heart failure and strikes healthy women late in pregnancy or within months after. It most often endangers the moms.
The battle had begun to save Garcia’s life. The doctor handling the emergency was frank. Her blood pressure was so high she could have a seizure and she was bleeding uncontrollably. Garcia would be in intensive care and might need a heart transplant, if she survived. The baby she and husband Joseph had named Michelle was gone, but still had to be delivered.
Three years later, as she tells the story from her home in White Sands, N.M., Garcia cries. She was living a truth that’s often ignored: Pregnancy can be dangerous. In fact, despite world-class medical care, maternal mortality is high in America compared to many industrialized countries. No single source tracks maternal complications, so the real number is unknown, but experts call it cause for concern. Sometimes, as happens with peripartum cardiomyopathy, a mom can do nothing more than get help when she’s in trouble. But much of the time, moms can set the stage for a pregnancy that reduces the risk of complications.
Moving the needle
“The best way to have a healthy pregnancy is to be healthy when you get pregnant,” says Dr. Janyne Althaus, a perinatologist at Johns Hopkins. “If you have health issues you have not maintained well, there’s higher risk of having problems.”
Women with known conditions, like seizure disorders or diabetes, should have them as well-controlled as possible from the beginning of the pregnancy, Althaus said. Any medical condition should prompt discussion with the obstetrician or perinatologist before pregnancy is attempted.
Pregnancy has potential complications even when nothing’s already going wrong, Althaus said.
Something like peripartum cardiomyopathy can come unexpectedly, as can hemorrhaging at delivery and immediately after. “Pregnancy brings its own set of surprises and the healthiest women are at risk of some of the complications, including pre-eclampsia,” a pregnancy-related hypertension that endangers mother or child, Althaus said.
“We’ve tried to see if we could predict those more likely to have surprise complications,” she said. “We are not able to 100 percent. So knowing someone will surprise us, we try to have plans in place to deal with a crisis.”
With all the diligence and effort, she said, “there’s not enough data to show we’ve been able to shift the needle and decrease mortality.” Some countries have a uniform reporting system; the United States doesn’t. “If you want to solve a problem, you first have to know its scope,” Althaus said.
An annual exam is a good time to discuss plans to have children, experts say. It’s a chance to address potential challenges, whether they involve medications that aren’t pregnancy-friendly, structural issues, maternal age or weight, among others.
“The best thing to do is optimize health and create a perfect environment for baby to grow,” Althaus said.
“Obesity is the biggest challenge we’re facing,” said Dr. Flint Porter, director of Maternal-Fetal Medicine at Intermountain Medical Center in Murray. “We’re losing the battle there.”
Obesity brings increased risk of gestational diabetes, preterm birth, need for a cesarean section, toxemia and having a large baby. An obese woman is more likely to have traumatic delivery. C-section is much more complicated. Blood clots, postpartum hemorrhage and preterm labor are also more likely, said Porter. It even makes an ultrasound more difficult. Obesity can mask birth defects that might otherwise be detected. It makes normal symptoms, like back pain, worse.
“Any complication in pregnancy is more common in women who are obese, and it’s more difficult to treat. Prenatal diagnosis is very difficult,” Porter said.
Like Althaus, Porter believes getting as close to an ideal weight as possible, maintaining a good exercise routine and eating healthy are vital.
Things you can’t see
Erin Martineau knows you can’t control all complications, but “you can control how you get educated and what you know.” The Liberty, Mo., mom developed peripartum cardiomyopathy in her second pregnancy, while carrying twins. She, too, had trouble getting the symptoms taken seriously at first. She struggled with the condition afterward for more than a year, but recovered. She and the twins, now 7, are healthy. Some women recover fully, some struggle long-term with symptoms. Some die, usually from delayed diagnosis and treatment, she said.
“With knowledge, you can advocate for your health,” said Martineau, who got a second opinion and diagnosis. “If you’re prepared and knowledgeable, you don’t have to fear. You can go to bat for yourself. I am a big proponent of getting educated.”
Peripartum cardiomyopathy is very rare, says Dr. Ernie Graham, maternal-fetal heart specialist at Johns Hopkins. Most cases are idiopathic, meaning no known cause. High blood pressure or a virus are sometimes associated with the condition. Often, though, the women are very healthy. It’s a diagnosis of exclusion, without known history of heart disease.
Often, women recover and a subsequent pregnancy may not pose significant increased risk. That happened for Garcia, who has a 3-year-old son, Alex. She did her research after recovery and met with a perinatologist before becoming pregnant. A cardiologist monitored her pregnancy, too. She got her heart in shape and adopted an impeccable, pregnancy-friendly diet. Knowledge became her power.
Progress for babies
Great progress has been made for babies in complicated pregnancies, said Dr. Linda Burke-Galloway, a clinical informatics specialist and author of “The Smart Mother’s Guide to a Better Pregnancy.” She cites a cooling blanket that helps reduce brain damage for babies born with very low Apgar scores, which assess the health of an infant right after birth. Many technological successes allow babies to survive and thrive.
Success has been more elusive on the maternal-complication side, said Burke-Galloway, of Orlando, Fla. “I don’t think obstetricians do enough referring to maternal-fetal specialists when a woman needs to be referred.”
General OBs can handle many things, but she thinks women who are older than 35, obese or who have sleep apnea, for instance, should be screened by a maternal-fetal specialist “just to make sure we’re not missing something.” They don’t deliver babies, but look for potential complications.
Women don’t always know what to look for or that it’s OK to get a second opinion or ask whether something’s normal, she said. If a woman has severe back pain, it’s worth ruling out premature labor. If the baby doesn’t move for 30 minutes, moms need to drink something sweet (not soda). If the baby still doesn’t move, she needs to be checked.
Bleeding is also on her don’t-ignore list. After leaving the hospital, baby in tow, she said moms should be examined if they have persistent headache or blood pressure greater than 130/88. Women who had pre-eclampsia are sometimes sent home too soon, since treatment is delivery. Seizures are possible for up to 96 hours. If that bottom number tops 90, seek help, she said.
Gaining a lot of weight right after delivering isn’t normal. If depression develops, she recommends taking an Edinburgh postnatal depression test, available online.
“I strongly encourage women to trust their instincts,” Burke-Galloway said. “I cannot emphasize that enough. We do have an internal barometer that speaks to us, but quite often we ignore it or we let people talk us out of it.”