KOCHI: Seena* was in the 32nd week of her pregnancy when her doctor told the baby was developing complications of anaemia due to blood group incompatibility. She was in a dilemma.
The mother, who is Rh-negative, was carrying a Rh-positive foetus – a condition that causes the mother’s immune system to attack the foetus’s red blood cells – which could lead to serious health problems for the baby.
To treat the condition, intrauterine foetal blood transfusion (IUT) –injecting red blood cells from a donor into a foetus that has anemia through the umbilical vein–was performed. The baby was safely delivered with minimal issues related to prematurity.
According to Dr Sindhu Pudhukudi, consultant in foetal medicine at Aster Medcity, Kochi, advancements in medical sciences and health care have improved the management of high-risk pregnancies. "In this condition, anti-D injection and other treatment options have helped reduce the number of such cases. The risk related to pregnancy, haemorrhages, and hypertension has reduced because of advancements in maternal-foetal care," she said.
With delayed pregnancies, sedentary lifestyles, and comorbid conditions, there is a growing trend of high-risk pregnancies –pregnancies that involve increased risk or complications for the mother or the foetus. Dr Smitha Surendran, consultant gynaecologist at Kinder Hospital, Kochi, said that lifestyle and an imbalanced diet often lead to high-risk pregnancies.
"Sedentary lifestyle, food habits, metabolic diseases, and stress contribute to the condition in several women. Lifestyle modifications, reduced stress, and better and balanced food habits can help decrease the possibility of high-risk pregnancies to an extent," said Dr Smitha.
The possibility of high-risk pregnancy increases with advancing age. As the younger generation opts for late marriages in their 30s, there has been a rise in pregnancies with high-risk factors. "Age is an important contributing factor for high-risk pregnancies.
The presence of comorbid conditions like diabetes and hypertension are commonly seen in older patients, which put them at higher risk during their pregnancy," said Dr Elizabeth Jacob, head of obstetrics and gynaecology at Apollo Adlux Hospital, Angamaly.
She added that increased stress levels in mothers can also affect the growth of the baby, leading to complications during pregnancy and delivery. Maternal mental health issues are a major cause of concern during pregnancy and postpartum. "The rising levels of environmental toxins, alcohol, and substance abuse can also add to higher risk, both to the mother and the baby," she said.
Short birth interval
According to recent studies, the prevalence rate of high-risk pregnancies is around 50% in India. 'High-risk pregnancy in India: Prevalence and contributing risk factors – a national survey-based analysis', published in September 2023 in Global Health Journal, has found that nearly half of all pregnancies in India have one or more high-risk factors, which is a matter of concern, and the risks were higher among the vulnerable population such as non-educated and poorest groups.
"The prevalence of high-risk pregnancies among Indian women was 49.4%, with 33% of women having a single high-risk, and 16.4% having multiple high-risk pregnancies," states the study, which also points to short birth interval (gap between pregnancies), and adverse birth outcomes as leading high-risk factors.
One major contributing factor is the trend of women delaying childbirth beyond the age of 30, according to Dr N Sapna Lulla, lead consultant, obstetrics and gynaecology, Aster CMI Hospital, Bengaluru.
Women in their late 30s are more likely to develop conditions such as hypertension and diabetes, which can complicate pregnancy. “Additionally, lifestyle factors such as obesity—often rooted in childhood—and sedentary habits further elevate the risk. Poor lifestyle choices like alcohol consumption and smoking significantly contribute to the prevalence of high-risk pregnancies,” said Dr Sumana Banerjee, unit head of obstetrics and gynaecology at Aakash Healthcare, Delhi.
“Nearly half of all pregnancies in India have one or more risk factors. The leading cause of high-risk pregnancy is short birthing interval. It would be beneficial to consult with a maternal-foetal medicine specialist if a woman has one or more of the above-mentioned risk factors,” said Dr Padma, head of gynaecology, Meenakshi Mission Hospital and Research Centre, Madurai.
The increase in high-risk pregnancies (46-48%) has been high particularly in the last five years, according to the survey. “Covid-19 has had a significant impact on mental and physical health, contributing to a rise in high-risk pregnancies. Foetal reasons also cause high-risk pregnancies where the foetus has congenital abnormalities, reduced water, etc.,” said Dr Sapna.
"If the baby has a heart disease, the growth is not optimal and any structural or chromosomal abnormalities are also considered a high-risk pregnancy," said Dr Sindu.
Managing high-risk pregnancies
Preconceptual counselling is advisable for young couples to address potential fertility issues early. By seeking counselling before trying to conceive, individuals can identify and address any underlying concerns, thereby improving success rates.
Management of high-risk pregnancy starts in the pre-pregnancy stage. "We need to diagnose the condition at the earliest. Pre-pregnancy care is important, and treatment for comorbid conditions to ensure the safety of the mother and child is crucial," Dr Sindu pointed out. Advancements in diagnosis and treatment have helped in managing the condition and thereby reducing mortality.
"Earlier, if the pregnancies were found to be in the category of high risk - if the mother suffers from diabetes, cardiac diseases, liver, renal disease, hypertension, age, post-chemotherapy - the advice was to avoid it altogether. Now with better medications and treatments, we can manage such pregnancies," said Dr Sindu.
Diabetes has its own risks and management is crucial in pregnant women. Sharing an experience, Dr Smitha said, "Once a woman in her late 20s came to me. She was already diabetic. Pregnancy for a diabetic person involves a lot of risks and the sugar levels may increase during pregnancy. We advised her to follow a proper diet and balanced diet. To tackle the situation, medications and insulin were prescribed. Though the management of such pregnancies is tough, we could control her sugar levels. The child, with the help of supportive care and treatment, was delivered in the ninth month," Dr Smitha said.
Anaemia, thyroid disease, diabetes, hypertension and other factors leading to high-risk pregnancies need to be diagnosed in the pre-pregnancy period. "Folic acid tablets have a protective role in delivering a healthy baby," said Dr Elizabeth, adding that close monitoring is important.
"Regular and frequent ultrasound scanning depending on the condition of the mother and foetus is important," she added. Advancements in technologies have helped in managing high-risk pregnancies after 24 weeks, which would otherwise have led to aborting the child to at least save the mother.
Role Of infertility treatments
With the emergence of in vitro fertilisation (IVF), the number of women opting to get pregnant late has increased. "With the advent of infertility treatments, the maternal age has gone up. Women, who are facing infertility issues are able to conceive in their late 30s and 40s. Though technological advancements help women to conceive, these are considered high-risk pregnancies," said Dr Sindu.
“As age advances there may be a need for fertility treatment which can also contribute to a high-risk pregnancy. Multiple pregnancies, with or without fertility treatment, carry a high risk to both the mother and baby,” added Dr Elizabeth.
Neonatal care
Technological advancements have helped in managing high-risk pregnancies to improve outcomes for both the mother and the baby, even into six months of pregnancy. Level-3 neonatology support is crucial in taking care of premature babies.
"In a case we dealt with recently, the mother was suffering from epilepsy. It was initially a low-risk pregnancy. However, three months into the pregnancy, advanced cervical changes with a very high risk of miscarriage were noticed in the mother. We could manage the pregnancy for another three months by performing a procedure rescue cervical cerclage.
In the sixth month, she went into preterm labour and gave birth to a baby weighing 600g, and after 90 days of dedicated neonatal care, the family left the hospital with a healthy baby weighing 2.5 kg," said Dr Elizabeth. Dr Sindu adds that care doesn’t stop with delivery, as the mothers and baby may face issues and care is essential in the first six months.
“The health condition of the mother and child, and the growth of the infant should be closely monitored,” she added. "A multidisciplinary team approach - cardiac, foetal medicine, neonatology, etc. - is essential for a good outcome in all cases of high-risk pregnancies. The support from a tertiary care neonatology team and the expertise of a foetal medicine specialist can help save babies in complicated pregnancies," added Dr Elizabeth.
Preventive measures
Awareness about polycystic ovarian disease (PCOD) and endometriosis – conditions that impact fertility – and early diagnosis and treatment are crucial in reducing the number of high-risk pregnancies. "By recognising the symptoms of these conditions, individuals can seek appropriate medical care and improve their chances for a healthy pregnancy. Women need to be empowered with knowledge and resources to take charge of their health. Awareness should be created about reproductive health issues and promoting preventive measures. Affordable and quality healthcare services should be accessible through various channels, including workplaces, NGOs, and schools," added Dr Sapna.
(With inputs from Rishita Khanna @Bengaluru, Sinduja Jane @ Chennai, Ashish Srivastava @ New Delhi)