High Risk Pregnancy (Perinatology)

Pregnancy is a very special process. Each day of this period, which is programmed as nine months, 40 weeks or 280 days, is important and open to surprises.

In the past, it was written in the Obstetrics and Gynecology books that pregnancy was a normal, physiological phase of a woman's life, and it was most likely a healthy and problem-free period.

However, according to the data accumulated since the 1900s, when modern medicine began to keep the statistical records on human health more robustly, almost half of the pregnancies are faced with one or more problems, that is, if we put it in medical language, complications are encountered and pregnancy is not very common, it is very open to risks. It turned out to be a special period.

About 10% of pregnancies result in early miscarriage, that is, they end before reaching the 10th week. In 10% of ongoing pregnancies, premature birth occurs. The fetus, that is, the baby, is born at a stage where it cannot breathe, feed and maintain its vital functions in the external environment, and the newborn needs intensive care. Again, in 10% of pregnancies, high blood pressure (preeclampsia and pregnancy-induced hypertension) develops in the mother, and in 10% of pregnancies, gestational diabetes (gestational diabetes) develops, and if these complications are not managed well, they carry vital risks for the health of the mother and baby.

Again, in 1% of pregnancies, the fetus has chromosomal number or structure disorders or defects at the gene level, and tests routinely performed in each pregnancy (double, triple or quadruple tests) to detect these may yield risky results and require further research.

Organ development defects, which are expressed as structural defects, can be detected in 1% of fetuses, and it is necessary to investigate the relationship of these structural defects with genetic abnormalities and to provide large-scale consultations regarding their prognosis, namely prenatal and postnatal outcomes.

In 1-2% of pregnancies, a significant systemic disease is present in the pregnant woman before pregnancy, special care and protective measures such as drug change or drug dosage adjustments should be taken during pregnancy.

The growth and development of fetuses is not at the expected level in 1% of pregnancies. In these cases, which may be due to placental (also known as baby partner) insufficiency, the circulatory status of the fetus is evaluated with sequential and frequent measurements with color Doppler, and a sensitive follow-up process and a well-defined delivery timing are required.

Multiple pregnancies, especially pregnancies obtained with assisted reproductive techniques and technologies, and IVF pregnancies constitute another important category of risky and specialty pregnancies. In the follow-ups that start with the distinction between monozygotic and fraternal twins and not less than once every two weeks, it is investigated whether there is a need for laser applications, which is the most vital and most advanced intervention for babies in the mother's womb.

When we bring all these top headings together, almost half of the pregnancies fall into the risky pregnancy category. Perinatology is a specialized field focused on determining which pregnancy is prone to these problems and taking the necessary protective and preventive measures in these pregnancies with risk. It is known as Risky Pregnancy Specialization, but its main goal is to identify the risks before the disease occurs and to start the interventions to prevent the development of complications as early as possible.

So, when and how is risk analysis done in pregnancies?
In fact, ideal evaluation should be done before pregnancy in couples planning pregnancy. However, the ideal pre-pregnancy evaluation could not be established because most of the pregnancies in our country are unplanned pregnancies. Obtaining information about the general health status, smoking habits, body mass index and weight status of the woman who is planning a pregnancy, the drugs she uses and has to use, and other personal characteristics, and providing lifestyle changes for these, greatly affects and improves the risk situation during pregnancy.

In order to correct obesity before conception, losing weight and approaching the ideal weight, quitting or reducing smoking, discontinuing drugs that may have disruptive effects on organ development in the first 8 weeks, which is the most critical stage of the baby's development, or switching to another drug that may have a less negative effect, seem like small details. arrangements that can bring great benefits.

A partially successful pre-pregnancy treatment in our country is folic acid supplementation. However, we see that daily 400 micrograms of folic acid supplementation is often started when we learn that she is pregnant, not at the ideal time, that is, 2 months before the planned pregnancy. In this case, open neural tube defects (severe defects in the baby's skull bones, spine and brain development), which are as common as Down Syndrome, cannot be prevented.

 

The second important period in pregnancies that cannot have a planned start before pregnancy is the 11-14th week of pregnancy. An evaluation by perinatology specialists during these weeks provides very valuable information beyond a routine pregnancy examination. Important information can be obtained about the genetic structure of the fetus. The most basic measurements in the 11-14th week examination are the baby's CRL (head-rump distance measurement). This measurement provides confirmation of the gestational week and the estimated delivery date. However, it is necessary not to stay with CRL measurements and other measurements that give information about the genetic health of the fetus. These include nuchal thickness measurement (NT), nasal bone measurement (NB), currents in the vein coming from the cord and going to the heart (DV), investigation of leakage current in the valve in the right heart part of the heart (TR), symmetric evaluation of the development of the fetal head in the posterior area (open neural tube defect). indirect findings) are the most important. It is also possible to investigate the organ development and structural defects of the fetus; Evaluation of brain, heart structure, stomach, bladder, umbilical cord entrance, arm, leg, foot integrity, spine and face can be achieved to a great extent. Observation of the placement of the placenta (baby partner), Evaluation of the complications (negative course and consequences) of pregnancy by measuring bilateral right and left currents in the uterus vessels (uterine arteries), Evaluation of which complications (negative course and results) are prone to, and Cardiac axis in which the four chambers and three vessels of the heart are evaluated with color Doppler, and Basic fetal echo evaluation combined with other information is also possible in these weeks if a good ultrasonography device, a competent specialist and sufficient time are allocated.

A very good 11-14 week examination provides 3 big gains.

First, it is ensured that dual testing can be performed with a sensitivity and accuracy of 90%. Thus, if necessary, further steps such as maternal blood DNA test (NIPT) or diagnostic interventions such as chorionic villus biopsy/amniocentesis can be selected more accurately.

Second, nearly half of the infant's structural defects are recognized early and a better pre-screening is performed for anomaly screening at 18-23 weeks. An effective 11-14 week ultrasound examination provides a reassuring start for 18-23 weeks.

A third and not the last great advantage is the detection of risky pregnancies in which aspirin will be started and preventive treatment for placental insufficiency will be started by measuring the currents in the uterine vessels. Because strong scientific evidence shows that when aspirin is started after the 16th week, it either has no effect on placental function or its effect is very limited.

18-23. Detailed ultrasound, also known as fetal anomaly screening, is still the gold standard examination in the evaluation of the baby during pregnancy in some respects.

Because some structures in the brain cannot be seen clearly before the 17th or 18th week according to our current technology and knowledge, and the diagnosis of developmental defects of these organs or parts can only be possible with full certainty after the 18th week. And again, many unique structures of the heart become visible only in these weeks and allow the normal-abnormal distinction.

Again, by measuring the length of the cervix (cervix) within the scope of this examination, pregnancies with a short cervix length with a risk of premature birth can be detected and treated.

Thus, we see that we can divide the risks in pregnancy into 2 big categories; the risks that existed before pregnancy and the risks that arise in the later weeks of pregnancy.

When we look at the risks that may arise in the following weeks of pregnancy, the importance of cooperation between the Gynecology and Obstetrics Specialist and the Perinatology Specialist emerges, in addition to regular follow-ups and screening tests during pregnancy.

A gestational diabetes study at 22-24 weeks of pregnancy will reveal a whole new risk, gestational diabetes. Again, fetal biometric measurements evaluating the growth, weight gain and development of the baby, especially at the 32nd week and later, will reveal the pre-diagnosis of fetal growth restriction and the risk of placental insufficiency.

From here, the following conclusion can be easily drawn; Every day of pregnancy is important, every examination is important and can reveal new findings and diagnoses of its own.

Every day, every moment is important, specific and a whole, until the baby's healthy birth and from the delivery room to the mother's room safely and securely.

A good pre-pregnancy planning provides great benefits, but it cannot replace the 11-14th screening. A very well done double test or a good result of the DNA test in the maternal blood does not make the 18-23 week ultrasound scan unnecessary. The fact that the detailed ultrasound examination is reported with the usual findings does not guarantee that an organ anomaly will not develop in the later weeks of pregnancy, does not make the follow-up of the baby's growth with meticulous and sensitive biometric measurements unimportant. All these inspection tools should be viewed as a whole. All together, it constitutes the sum of the works and procedures for the birth of a healthy baby in the planned way from a pregnancy that has reached beyond the 37th week and for the mother to protect her health in this process.

As in all medical practices, patient-physician communication and trust are fundamental in Gynecology and Obstetrics and Perinatology. All interviews, examinations, tests, treatments, interventions and follow-ups are planned and performed on this solid foundation of trust. What a pregnant couple needs to do from the very beginning is to decide to follow up with a physician that they feel can find this trusting relationship and to continue these follow-ups regularly. Physicians will provide connections and ways that will enable the pregnant and baby to receive the most accurate test and treatment, by helping with their colleagues, when necessary, and with higher institutions and organizations, within the organization of the Health family in which they are involved.

In my opinion, the biggest risks in pregnancy are irregular pregnancy follow-up, not performing the tests recommended by the physicians, and changing the following physician two or more times. For this reason, trust and good communication are strong + protective factors as well as knowledge, technological opportunities and experience against the risks in pregnancy.

Assoc. Dr. Semir KÖSE / Gynecology, Obstetrics and Perinatology Specialist / Ä°RENBE