The loss of a pregnancy during the first 13 weeks is called “early pregnancy loss,” “miscarriage” or “spontaneous abortion.” Early pregnancy loss occurs in about 10% to 15% of known pregnancies.
Most early pregnancy losses result from an abnormal embryo (the earliest stage of the baby’s development), not by anything related to the mother or father.
In at least half of the cases, early pregnancy loss is caused by an abnormal number of chromosomes in the embryo. In this instance, the egg or sperm that makes the embryo has the wrong number of chromosomes. This is a random event. Having it happen in one pregnancy does not mean that a couple is at high risk of having it happen in future pregnancies. Other causes of early pregnancy loss involve other embryo problems, including missing genes, extra genes or other abnormalities.
It’s not Your Fault
It is natural for a mother who has experienced an early pregnancy loss to think she did something to cause it. She will often search her memory to find something she did, something she ate, medicine she took or medication she forgot to take just before the loss happened. The loss likely had nothing to do with the mother but involved an abnormal embryo.
Recurrent Early Pregnancy Loss
Most experts define recurrent loss as two or more losses in a row. After one early pregnancy loss, the chance of another loss is about 15%, the same likelihood for someone who has not had a loss. Women with two losses in a row have a slightly higher chance of having another loss, about 20%. After three early losses in a row, the risk of a loss in the next pregnancy is about 30%.
As with single losses, most cases of recurrent loss are caused by abnormalities of the embryo, not by anything concerning the mother or father. However, with recurrent losses, there is a higher chance of finding specific problems in the parents. Therefore, an evaluation, or “workup,” is reasonable if you have had two or more losses in a row.
Components of the standard workup for recurrent early pregnancy loss include patient history, chromosome testing and antiphospholipid antibody testing.
Your physician will review each previous loss with you, including any symptoms you had, findings from ultrasounds, prior procedures (D&C or medical induction), lab results (chromosome testing, pathology studies, blood testing) and gestational age when the loss occurred. Other aspects of the history may include whether you have regular menstrual cycles, prior surgeries of your uterus or cervix, exposure to toxic chemicals, a history of blood clots in the legs or lungs or any family history of recurrent miscarriages in close relatives.
Sometimes, one parent has a chromosome abnormality that produces no findings in the parent but can cause a high pregnancy loss rate. Chromosome testing of both parents is recommended as part of the workup for recurrent pregnancy loss.
Some women have antiphospholipid antibodies (detected through blood tests) that can cause pregnancy loss and produce blood clots. If the antibodies are present and they persist for more than six months, treatment with an anticoagulant (blood thinner) and aspirin may reduce the chance of recurrent miscarriage.
Your doctor may recommend additional tests to detect:
- Anatomical problems, such as an abnormally shaped uterus or fibroids or polyps inside the uterus that may prevent an embryo from implanting normally.
- Thyroid disorder because women with low thyroid hormone levels or certain thyroid antibodies (TPO autoantibodies) can have recurrent miscarriages.
- Diabetes — High blood glucose levels (as reflected by high levels of A1C) in early pregnancy can cause miscarriage or birth defects.
- Immune testing and treatment — Some specialists order blood tests for natural killer cells and other immune components, but the American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine do not recommend such evaluations because treatment of immune problems has not been proven to improve the chances of success in the next pregnancy.
- Problems with ovarian reserve, meaning a limited ability of the ovary to produce healthy egg cells capable of fertilization.
Treatment of Recurrent Early Pregnancy Loss
If the workup reveals a specific abnormality that can be treated, treatment of the abnormality is usually considered. However, in most cases, no abnormality is found on the workup because most cases of pregnancy loss are caused by abnormalities of the embryo, not abnormalities in the parents. If no abnormality is found, there is no need for treatment. Even without treatment, pregnancy success rates of about 80% are found in mothers with two pregnancy losses in a row and 70% in mothers with three losses in a row.
Fetal Growth Restriction
Fetal growth restriction (FGR) refers to a fetus (unborn baby) that is smaller than expected.
It is sometimes called intrauterine growth restriction (IUGR). FGR occurs in about one of every 10 pregnancies.
What Causes FGR?
Several factors may lead to FGR, such as:
- Normal variation — Most fetuses with FGR are healthy, just smaller than average
- Placenta or umbilical cord problems — Not enough blood flow or nutrients to the fetus
- Illness in the mother — High blood pressure, lupus, vascular diseases, preeclampsia
- Issues in the fetus — Birth defects, genetic problems, some infections
- Smoking or vaping — Ask for help to quit
- Alcohol or some medications
- Poor nutrition — Rarely a cause of FGR
How is FGR Managed?
Your health care provider may recommend certain tests once or twice a week, including:
- Amniotic fluid volume via ultrasound
- Doppler ultrasound to check blood flow in the umbilical cord or other blood vessels
- Biophysical profile (BPP) to evaluate the baby’s movements and fluid
- Nonstress test (NST) to monitor the fetal heart rate
Additional actions may be taken depending on individual circumstances, such as:
- An ultrasound in two to three weeks to check fetal growth.
- Checking fetal chromosome count by taking a sample of amniotic fluid (amniocentesis).
- Steroid medicine to help the fetus mature if preterm delivery is planned.
- Admission to the hospital if needed for more frequent monitoring.
- Preterm delivery may be recommended in some circumstances.
What Can You Do?
- Eat a healthy, balanced diet.
- Avoid smoking, vaping, alcohol, marijuana, illicit drugs.
- Pay attention to fetal movements.
- Maintain your normal schedule of exercise and healthy activity. The Society for Maternal-Fetal Medicine does not recommend routine activity restriction for FGR.
- Call your health care provider if the fetus doesn’t seem to be moving as much as usual.
How Does FGR Affect Your Baby’s Future Health?
- Most babies catch up in their growth after birth and go on to have normal lives.
- There may be an increased risk of certain problems after your child becomes an adult (heart disease, high blood pressure, stroke and diabetes).
- This is an active area of research. Ask your pediatrician if your child needs any special testing or follow-up care.
How Does FGR Affect Your Future Health?
FGR may mean an increased risk of metabolic syndrome, a cluster of conditions that occur together, such as:
- High blood pressure
- Heart disease
- Type 2 diabetes
- Excess body fat around the waist
- Abnormal cholesterol and triglyceride levels
- Tell your primary doctor that you had a baby with fetal growth restriction and ask whether you should have annual testing for metabolic syndrome.
You can reduce your risk by:
- Breastfeeding for one to two years, if possible (breastfeeding lowers your risk of diabetes, high blood pressure and heart disease)
- Avoiding tobacco, vaping products, alcohol and recreational drugs
- Staying active and exercising five days a week
- Eating a healthy diet
- Aiming for a healthy body weight
Can You Decrease the Chances of Having Another Baby with FGR?
- The chance for FGR in future pregnancy is about 25% (one out of every four pregnancies).
- The chance may be higher if you have certain illnesses (e.g., lupus or high blood pressure).
Before Your Next Pregnancy
- Quit using tobacco, vaping products, alcohol, marijuana and illicit drugs.
- Discuss with your doctor if you have any chronic health conditions (high blood pressure, diabetes, lupus or other autoimmune disorders).
- Review with your doctor all medicines you take (both prescription and over-the-counter).
- Take a prenatal vitamin daily containing folic acid (800 mcg) before you get pregnant.
- Eat a healthy diet, exercise and aim for a healthy body weight.
During Your Next Pregnancy
- Attend regular prenatal visits to check on blood pressure and fetal growth.
- Ask your doctor whether extra ultrasounds are recommended to check fetal growth.
- Ask your doctor whether you should take low-dose aspirin.
What is Gestational Diabetes?
Diabetes is a disease that happens when too much sugar is in the blood. There are many kinds of sugars in our bodies. The sugar we talk about most often is glucose. Everyone needs a certain amount of glucose in the blood. However, too much glucose is harmful and can cause many serious problems, such as gestational diabetes, during pregnancy.
Why Did I Get Gestational Diabetes?
Anybody can get gestational diabetes caused by pregnancy hormones that raise the amount of glucose in the blood. Several factors increase the risk of getting gestational diabetes, including:
- Age 25 years or older
- African-American, Hispanic, Asian, Pacific Islander or Native American background
- Prior pregnancy with gestational diabetes or delivering a baby with a birth weight of 9 pounds or more
- Family history of diabetes or gestational diabetes
- Pregnancy with more than one fetus (e.g., twins, triplets or more)
- Inactive lifestyle
- High blood pressure or heart disease
- Polycystic ovarian syndrome
While these are the most common risk factors, you can get gestational diabetes even if you don’t have any of the risk factors.
Why Is Gestational Diabetes Important?
Glucose in the mother’s blood feeds the fetus (unborn baby). If there is too much glucose, the fetus gets fed too much. High amounts of glucose can cause the fetus to grow too large, resulting in:
- Increased chance of Cesarean delivery (C-section)
- Risk of birth injury during vaginal delivery
- Risk of jaundice in the baby or other complications requiring intensive care
After delivery, the baby stops getting glucose from the mother. Therefore, glucose levels can fall too low. Babies born too large after a gestational diabetes pregnancy have a higher chance of:
- Diabetes during childhood
- Obesity during childhood
These problems can have life-long harmful effects on the child, which are preventable by keeping your blood glucose levels stable during pregnancy.
What Can I Do to Prevent Harm to My Baby or Myself?
Most people with gestational diabetes can keep glucose levels normal with three simple changes:
- Eating right to prevent blood glucose from going too high
- Walking for 10 to 20 minutes after each meal
- Checking blood glucose levels often
Many foods do not raise blood glucose too high. We recommend eating three healthful meals each day, with a healthy snack between meals. Small meals do not increase your glucose as much as large meals. A snack between meals and at bedtime will help you feel full, so you can eat smaller meals.
We want you to continue gaining weight during your pregnancy. Weight loss during pregnancy is not our goal. Some carbohydrates (starches) are recommended with each meal and snack. It is not our goal to have you avoid all carbs. Keep a written record of what you eat and when you eat.
Activity After Meals
Walking 10 to 20 minutes after each meal will help blood glucose levels. If you have been told not to walk, arm exercises can be done instead.
Blood Glucose Monitoring
Checking glucose levels will help you learn which foods work for you and which do not. Check your glucose as soon as you get up each morning (fasting). Check your glucose after each meal (set a timer as a reminder). That’s a total of four checks each day: fasting and after every meal. Keep a written record of your blood glucose values/levels. To prevent the fetus from growing too large, it is best if glucose values are:
- Usually less than 95 before breakfast (fasting)
- Generally less than 140 at one hour after meals or less than 120 at two hours after meals
It is OK if you go a little over these numbers occasionally. If you go over by a lot, try to figure out what you ate that made your glucose go high and avoid eating that again. If your glucose level is over 250, call your diabetes prenatal care provider for further advice.
If your glucose level remains high after eating right and getting the right amount of activity, your provider may prescribe medication to help lower your glucose level.
Will Gestational Diabetes Go Away After Pregnancy?
For most people, gestational diabetes goes away after pregnancy. However, people with gestational diabetes are likely to get it during future pregnancies. Additionally, people with gestational diabetes have a high chance of getting diabetes later in life. Therefore, you should get tested one to three months after pregnancy to see if you have diabetes or prediabetes.
Tell your primary doctor that you have had gestational diabetes and get yearly check-ups.
Healthful Food Choices for Gestational Diabetes
Lean proteins are needed for fetal growth and help you to feel full.
- Good options include: poultry (chicken, turkey), eggs, fish, greek yogurt, lean red meats (beef, pork), nuts and seeds, legumes (beans, lentils, soy products).
Non-starchy vegetables provide vitamins, minerals and fiber, including:
- Broccoli, cucumbers, green beans, onions, peppers, salad greens.
Healthful fats help you to feel full and provide energy.
- Healthy options include: avocado, nut butter (peanut, almond, cashew), nuts and seeds, olive oil.
Complex carbohydrates (carbs or starches) provide energy, fiber and some nutrients.
- Good choices include: beans and lentils, berries, brown rice, sweet potatoes, whole grain crackers, low-fat dairy (milk, cheese).
Foods to Avoid With Gestational Diabetes
Simple carbohydrates are foods that are high in sugar or foods with starches that your body converts rapidly to sugar, including:
- Sugary beverages (juices, sodas), white rice, white flour (bread, tortillas, roti, cakes, pastries), potato (baked, mashed, French fries, chips), cereals, jams and jellies, honey, sugar added to coffee, tea or other drinks, desserts, sauces and condiments that contain hidden sugars (barbecue sauce, ketchup, teriyaki, syrups, some salad dressings and many others).
Gestational Diabetes (GDM) After Delivery
Does GDM Go Away After Delivery?
Sometimes, glucose values return to normal. Sometimes, they appear normal for a while but then increase again later. Sometimes, they don’t ever completely return to normal.
- Up to one in every three women with GDM (30%) will have prediabetes during the first year after delivery.
- Up to one in every two women with GDM (50%) will have Type 2 diabetes within 10 years.
What Do I Need To Do After a Pregnancy With GDM?
- Before leaving the hospital, ask your health care provider whether you should continue fingerstick glucose testing or continue any diabetes medicines.
- Make an appointment to see your OB provider for routine care and a follow-up visit, including screening for depression and discussing contraception (birth control) options.
- Make an appointment for a glucose tolerance test (GTT) between four to 12 weeks after delivery to determine if you have prediabetes or diabetes. Arrive at the lab after fasting for at least eight hours (water only). Two blood samples will be taken. The first sample is taken while you are fasting. Then you will have a glucose drink, and then blood is drawn again two hours later.
How Can I Decrease My Chances of Getting Diabetes In Future Years?
Lifestyle choices have health benefits for all people who have just delivered a baby, whether or not you have prediabetes:
- Breastfeed — This helps your body use extra calories stored during pregnancy, which helps you lose weight.
- Aim for a healthy weight — You usually lose 10 to 15 pounds with childbirth. After that, aim for 1 pound per week.
- Exercise — Aim for 30 minutes, five days per week. Walking outdoors is an excellent form of exercise. Do the best you can!
- Eat healthful foods (see the Balanced Diet section below).
If you have prediabetes
- Lifestyle choices listed above will delay or prevent the progression from prediabetes to diabetes.
- Referral — We will refer you to a primary care provider to develop a plan to lower the chance you will get diabetes in future years. We recommend that you get checked for diabetes yearly.
- Medicine — Certain oral medications may provide additional benefits in preventing the development of diabetes. They are taken by mouth, not an injection like insulin. Your primary care doctor may start you on oral medicine.
A balanced diet and healthy hints
- Eating well means eating healthy foods that give you the nutrition you need in the right amounts.
- You don’t have to give up your favorite foods completely.
- Have a balance of proteins, fats and carbohydrates.
- Get tips, ideas and a personalized plan using the Choose My Plate program from the U.S. Department of Agriculture (ChooseMyPlate.gov).
- Plan meals ahead of time and stick to the plan.
- Add lemon slices to water instead of drinking juice and sugary drinks.
- Use smaller containers for food and drinks.
- Keep fruit and cut vegetables handy for snacks.
- Use the stairs instead of the elevator.
- Park farther away from building entrances and walk the extra distance.
- Don’t go to the grocery store hungry.
Before Your Next Pregnancy
- Wait at least 18 months before you get pregnant again. Shorter intervals may have an increased risk of miscarriage or preterm birth. Use a reliable method of contraception (birth control).
- Take a prenatal vitamin daily. Folic acid in these vitamins helps prevent some types of birth defects.
- Ask your doctor if you should have an A1C test or repeat GTT before you become pregnant.
- If you have prediabetes or Type 2 diabetes, you can decrease the risk of miscarriage or birth defects by having your blood glucose in good control before you get pregnant. Ask about our preconception diabetes care program.
People who have had GDM have higher chances of developing health problems, such as high blood pressure, heart disease or stroke, sometimes years or decades after pregnancy. To reduce the likelihood of these problems:
- Maintain a healthy weight
- Exercise regularly
- Eat healthful food
- Blood pressure should be checked at least once a year. If you get high blood pressure, follow your provider’s treatment advice and check your blood pressure more often.
- Tell your primary care provider that you have had gestational diabetes and ask if you should be tested yearly to check A1C, cholesterol and triglycerides.
Why Would I Take Low-Dose Aspirin During Pregnancy?
- Low-dose aspirin is used to lower the chances that you will get a disease called preeclampsia.
- Preeclampsia is a serious pregnancy complication that includes very high blood pressure and other problems.
- People with certain risk factors for preeclampsia will benefit from low-dose aspirin.
- Aspirin started during the second trimester of pregnancy reduces the chances of getting preeclampsia during the third trimester by about 15%.
Do I have Risk Factors?
High risk level
- Preeclampsia in a prior pregnancy
- Twin or triplet pregnancy (or more)
- Chronic hypertension
- Kidney disease
- Autoimmune disease
Moderate risk level
- No prior delivery
- 35 years or older
- In vitro fertilization (IVF)
- Your mother or sister had preeclampsia
- African-American ethnicity
- Previous child with low birth weight
- You were born with low birth weight
- Low income
- More than 10 years since your last delivery
Who Recommends Using Low-Dose Aspirin?
The American College of Obstetricians and Gynecologists (ACOG) and the United States Preventive Services Task Force (USPSTF) both recommend that low-dose aspirin should be taken by patients who have:
- Any high-risk factor
- More than one moderate-risk factor
What Dose of Aspirin is Recommended?
- The only dose labelled as “low-dose aspirin” in the United States is 81 mg.
- Both ACOG and USPSTF recommend one tablet daily.
- Some doctors recommend two tablets daily (162 mg).
- Doses of 50, 75 or 100 mg are available in other countries.
- If you have any of these doses, ask your doctor which dose is right for you.
Which Type of Low-Dose Aspirin is Best to Take During Pregnancy?
- Any brand of low-dose aspirin sold in the United States is fine. The FDA requires all manufacturers to meet the same strict standards to guarantee purity and potency.
- It is not known whether “enteric-coated aspirin” is better. The coating is intended to prevent stomach irritation, ulcers and heartburn. However, the coating may also reduce the effectiveness by reducing the amount of aspirin absorbed by your body.
When Should I Start Low-Dose Aspirin?
- The best time to start low-dose aspirin is at 12 to 16 weeks of pregnancy.
- If you are already past 16 weeks, you may start it at any time.
- You may take aspirin at any time of day. It is best to develop a pattern of taking it at the same time every day. For example, take it when you take your prenatal vitamin.
Do I Need a Prescription?
- No prescription is needed.
- Over-the-counter low-dose aspirin should cost less than $10 for a bottle of 200 tablets, enough to last your entire pregnancy.
Can I Wait Until I Show Signs of Preeclampsia to Start Aspirin?
- No. Low-dose aspirin is used to prevent preeclampsia, not to treat it.
- Aspirin has no benefit once preeclampsia appears.
- To be effective, aspirin must be started during the second trimester and best before 16 weeks.
What if I Miss a Dose?
- If you miss a day, just resume taking daily aspirin the next day.
- There is no reason to double-up the dose the next day.
- Don’t miss too many doses. Aspirin is much less effective if you miss more than 10% (1 of every 10).
When Should I Stop Low-Dose Aspirin?
- Aspirin may be continued throughout pregnancy.
- Some doctors recommend stopping once you reach 37 weeks.
Are There Any Other Benefits of Low-Dose Aspirin?
Yes. In addition to reducing the chances of preeclampsia, clinical trials have shown that aspirin also:
- Reduces the chance of a preterm birth by about 20%
- Reduces the chance of a growth-restricted baby (small for gestational age) by about 20%
- Reduces the chances of perinatal death (stillbirth or newborn death) by about 20%
Is Taking Low-Dose Aspirin Safe?
- Low-dose aspirin (81 mg daily) is safe for you and your fetus (unborn baby).
- It has been used safely in tens of thousands of pregnancies without increased bleeding, miscarriage or birth defects.
Are There Any Cautions About Using Low-Dose Aspirin During Pregnancy?
- Make sure your doctor knows about all other medications you are taking.
- Aspirin is not recommended for people who are allergic to aspirin or related medications, such as ibuprofen.
- Aspirin allergy can occur in anyone, but it is more common in people who have had nasal polyps, asthma and hives.
- Seek urgent medical attention if you have signs of an allergic reaction, such as unexplained wheezing, rash or swelling of the lips, face or body.
- Let your doctor know if you have bleeding while taking aspirin. They may recommend stopping aspirin temporarily.
- Some people get mild indigestion after taking aspirin. Taking aspirin with food may help prevent indigestion.
- Low-dose aspirin is not recommended for people who do not have any risk factors for preeclampsia.
Aspirin is NOT for Babies!
- You may hear people use the words “baby aspirin” to describe low-dose aspirin.
- There is no medication in the United States labelled as “baby aspirin.”
- Aspirin in any dose can be dangerous for children and should not be given to a baby, child or teenager without your doctor’s consent.
- Even if aspirin is flavored, chewable or liquid, it does not mean it is intended to be given to babies.
- Low-dose aspirin is for adults only.
- You should find low-dose aspirin in the adult section of the pharmacy, not the children’s section.
- Do not substitute children’s Tylenol (acetaminophen) or other children’s medicine for low-dose aspirin. Only low-dose aspirin prevents preeclampsia.
What Is Periviability?
Periviability, also called borderline viability, is the earliest stage of pregnancy when a baby can be born and survive.
Types of Preterm Birth
There are two types of preterm birth — spontaneous and indicated.
Spontaneous Preterm Birth
“Spontaneous” means the birth process started naturally for reasons such as:
- When the body naturally goes into labor prematurely
- When the mother’s water breaks, called rupture of membranes (ROM)
- When cervical insufficiency is present, called silent cervix dilation
Spontaneous birth often cannot be stopped, even with medication or surgery.
Indicated Preterm Birth
“Indicated” means that your physician has recommended delivery even though you are early in pregnancy because continuing the pregnancy is not safe for you or the baby. Some situations for indicated preterm birth include:
- Medical conditions of the mother (severe high blood pressure, diabetes, obesity)
- Severe fetal growth restriction
- Placenta previa (the placenta partially or completely covers the cervix opening)
- Severe uterus bleeding
- Abnormal fetal heart rate patterns
- Prior surgery of the uterus (C-section, fibroid removal)
- Fetus with a high risk of death if the pregnancy continues
- Infection of the baby or the uterus
- Other serious illnesses of the mother or baby
Can Preterm Birth Be Stopped?
Your care team will do everything possible to prevent preterm birth. However, sometimes we cannot safely delay delivery despite our best efforts.
What Is My Delivery Plan?
Timing of Delivery — Unless you choose to deliver now, we will try to prolong your pregnancy if it is safe to do so. It is difficult to determine exactly when delivery will occur.
Steroid Medication — Injections are given one to seven days before birth to help improve the baby’s chance of survival and reduce many health problems if the baby has reached a “viable” age. We will recommend steroids if we think there is a chance the baby will be born during the next seven days.
Method of Delivery — You can often have a vaginal delivery if the baby is head first and the fetal heart rate is normal. A Caesarean delivery (C-section) is not required just because the baby is premature.
A C-section may be considered for maternal reasons (to benefit the mother), such as a prior C-section, bleeding or uncontrolled blood pressure. A C-section may also be considered for fetal reasons (to benefit the baby), such as if the baby is not head first or the fetal heart rate is abnormal. Although a C-section for fetal reasons may give the baby better chances, it does not guarantee that the baby will survive or be able to sustain life.
A C-section carries serious risks for the mother, including infection, bleeding and a possible need for a C-section in future pregnancies. Therefore, it will only be performed if there is a reasonable chance it will benefit the baby or mother.
Will My Baby Survive If Born This Early?
The chances of survival depend on many factors, including gestational age, birth weight, the reason for delivery and whether you have had steroid shots before delivery.
A neonatologist (specialist in the care of newborn babies) will visit with you about your baby’s overall health based on the information we have about your pregnancy. However, we cannot predict whether an individual baby will survive. Some babies thrive even when the chances are low, and some do not survive even when the chances are high.
If My Baby Survives, Will He or She Be Normal?
Some extremely preterm babies survive “intact,” meaning they have no permanent damage even though they were born extremely early. However, many extremely preterm babies develop serious, permanent complications, including vision loss, hearing loss or damage to portions of the brain, leading to physical disabilities, learning difficulties or profound impairment with a life-long need for full-time care.
Every baby’s outcome is different. A pediatric neonatologist can visit with you about your baby’s chances of surviving without any of these problems based on the gestational age at birth, the estimated fetal weight and various other factors. However, we cannot say whether an extremely preterm baby will develop and thrive like a full-term baby.
What Choices Do I Have Before My Baby Is Born?
When facing the chance of an extremely preterm birth, parents have some important decisions to make.
The first choice is whether to:
- Try to prolong the pregnancy as long as possible, even though it may not be possible to gain much time, and the baby may still be born extremely early.
- End the pregnancy by inducing labor, recognizing that the baby likely will not survive. If you decide to continue the pregnancy, the next choice is whether you will consider the baby viable, meaning that you think the chances of survival are high enough to make it worthwhile to allow interventions, such as a C-section or cardiopulmonary resuscitation (CPR) to improve the baby’s chances.
Some information that may help with your decision-making includes:
- Before 22 weeks, babies are typically not viable and are not likely to survive.
- At 23 to 25 weeks, we ask for your input on whether to consider the baby viable.
- If the baby is considered viable, you will probably want fetal heart rate monitoring to assess the baby’s well-being. You will probably also allow a C-section if needed for fetal reasons.
- After 25 weeks, most babies are viable and more likely to survive.
- If the baby is not considered viable, there is no reason to do interventions, such as fetal heart rate monitoring or a C-section.
What Choices Do I Have After My Baby Is Born?
If the baby is born alive, the next choice is whether to:
- Request all possible treatments to keep the baby alive, including CPR, inserting a breathing tube and using a breathing machine (life support), even if these efforts might not work.
- Select some of these treatments, but not all.
- Select comfort care, meaning you request that the baby not have heroic treatments and life support, allowing the baby to die naturally. We will do our best to keep the baby comfortable during this process.
There are no clear right or wrong answers to these choices. The decision depends on your values, beliefs and desires as you consider the pros and cons of having a baby that:
- May not survive
- May survive but be severely impaired
- Might survive intact
Your doctors can provide information to help you make these choices, but they cannot make the choices for you. You might make one set of choices now but then make different choices in the coming days or weeks as gestational age increases
Preeclampsia Before Delivery
High Blood Pressure in Pregnancy
Health care providers use many words to describe different types of high blood pressure diseases. Following are some of the most common terms. This handout is mainly concerned with hypertensive diseases of pregnancy, but some of the contents are also relevant for chronic hypertension.
- Transient or non-persistent high blood pressure: A single blood pressure measurement is high, but repeat measurement is normal
- White coat syndrome or white coat hypertension: Blood pressure is high in the physician’s office or other clinical settings but normal at other times
- Hypertension: High blood pressure on more than one measurement, either on different days or at least several hours apart
- Chronic hypertension: Hypertension that was present before pregnancy or before 20 weeks of pregnancy
- Gestational hypertension*: Hypertension first seen after 20 weeks of pregnancy
- Preeclampsia*: Gestational hypertension plus abnormalities in at least one body organ system, such as kidney, liver or brain, or blood-clotting factors
- Eclampsia*: Seizure (epileptic fit) in a pregnant person with no history of seizure or no known brain injury to explain a seizure. It is usually associated with preeclampsia but may occur without high blood pressure.
- HELLP syndrome*: A severe form of preeclampsia with a combination of several abnormalities of blood cells and liver enzymes
- *Hypertensive diseases of pregnancy: any of the types above that are marked with an asterisk (*)
Why Did I Get High Blood Pressure?
We do not know all the causes of high blood pressure. Many factors increase the chances of having hypertensive diseases of pregnancy, including:
- High-risk factors: Hypertension in a prior pregnancy, twin pregnancy, diabetes, kidney disease and some autoimmune diseases
- Moderate-risk factors: First pregnancy, age over 35, obesity, in vitro fertilization, Black ethnicity, family history of hypertension, low income Only some people with these risk factors get high blood pressure. Some people get high blood pressure even though they don’t have any risk factors.
Management of Hypertensive Diseases of Pregnancy
Management options depend on a careful evaluation of several questions, such as:
- What type of hypertension is it? — To determine which type of hypertension is present, your physician will order a urine test to see if your kidneys are leaking protein and blood tests to check your liver and blood cell counts.
- Is the condition severe? — Hypertensive diseases are considered “severe” when any of these occurs:
- Very high blood pressure (upper number 160 or more or lower number 110 or more)
- Eclampsia (seizure)
- Very low blood platelets (less than 100,000)
- Elevated liver enzyme blood tests (twice as high as normal)
- Kidney not functioning well (blood creatinine 1.2 or more)
- Fluid in lungs
- New onset unexplained severe headache that does not get better with medicine
- Disturbances in vision
- Is it getting worse, and if so, how fast? — The answer to this question requires blood pressure follow up over hours, days or weeks. Sometimes follow-ups of urine tests and blood tests are needed.
- Should the pregnancy be continued or delivered? — The decision to deliver involves a trade-off of risks to the pregnant person versus risks to the baby. Hypertensive diseases of pregnancy usually get worse over time, so the lowest risk for the pregnant person is to deliver as soon as the problem is discovered. Premature delivery carries risks to the baby. These risks are highest at very early gestational ages and gradually decrease as the pregnancy approaches the due date. Timing
of delivery for hypertensive diseases of pregnancy will depend on your circumstances, but will often follow these general guidelines:
- 37 weeks or more: Delivery is usually recommended
- 34 weeks or more: Delivery is recommended for severe hypertensive disease
- Before 34 weeks: Delivery is recommended for severe hypertensive disease that is getting worse
For chronic hypertension, delivery timing depends on whether your blood pressure is well-controlled and blood pressure medications are being used.
- Can hypertensive diseases of pregnancy be treated with medications? — Medications are often used to reduce blood pressure. But lowering the blood pressure does not prevent or treat abnormalities in organs, such as kidneys, liver or brain, or blood clotting. Magnesium helps reduce the chance of a seizure in severe cases. Magnesium does not reduce blood pressure.
Will My Blood Pressure Improve After Pregnancy?
For most people with hypertensive diseases of pregnancy, blood pressure and other organ changes will return to normal within a few weeks after delivery. Some patients will need medication to reduce blood pressure during this time.
For people with chronic hypertension and some with hypertensive diseases of pregnancy, blood pressure remains high and long-term medication is needed to reduce blood pressure.
Even if your blood pressure returns to normal soon after delivery, it may rise again after you get home. For this reason, blood pressure follow up is essential. Even if your blood pressure returns to normal, patients who had high blood pressure during pregnancy, even if it was not severe, have an increased chance of developing heart conditions, stroke, kidney disease, diabetes and other complications in the future, sometimes years or even decades later.
What Follow-Up is Needed After Delivery?
With severe hypertension, the American College of Obstetricians and Gynecologists recommends that you be seen for a follow-up visit within 72 hours after discharge from the hospital. For non-severe hypertension, follow-up within seven to 10 days is recommended.
Everyone who has had hypertension during pregnancy should establish care with a primary care provider and inform the provider that they have had hypertension during pregnancy. Usually, the primary care provider should screen for risk factors for cardiovascular (heart) disease every year, including checking blood pressure, cholesterol, lipids and a diabetes screen.
Will I have Hypertensive Disease in Future Pregnancies?
Preeclampsia and gestational hypertension recur in about 30% of cases (one in three). The odds of recurrence are higher if you had a preterm delivery or severe preeclampsia. Low-dose aspirin reduces the odds of recurrence. Ask your provider if you should take aspirin during your next pregnancy.
Which Urgent Warning Signs Need Attention?
High blood pressure is sometimes called a “silent killer” because it may not produce any symptoms. If you are taking your blood pressure at home, notify your provider immediately if you get a value of 160 or higher (upper number) or 110 or higher (lower number).
The following symptoms may indicate severe disease, whether or not blood pressure is high and whether you are still pregnant or have already delivered. Notify your provider right away if you have any of the following symptoms:
- Headache that won’t go away or that gets worse over time
- Changes in your vision
- Unexplained pain in your upper abdomen (belly)
- Unexplained shortness of breath
What is Preeclampsia?
Preeclampsia is a disease that occurs during pregnancy or soon after delivery involving high blood pressure plus other health issues, such as protein in the urine, liver problems or blood clotting issues. In severe cases, it may cause seizure, stroke, kidney failure or other serious complications. Preeclampsia affects about 4% of all pregnancies (one out of every 25).
What Causes Preeclampsia?
The exact cause of preeclampsia is unknown. However, it is not your fault. For most people diagnosed with preeclampsia, there was nothing they did to cause it and nothing they should have done to try to prevent it.
The primary treatment for preeclampsia is delivery. Blood pressure, kidney function and liver function usually return to normal in the days or weeks following the delivery of your baby.
When Should I have a Follow-Up Visit After Going Home?
Blood pressure can rise again after you go home from the hospital. For this reason, it is essential to see your obstetrician within a few days.
The American College of Obstetricians and Gynecologists (ACOG) recommends a follow-up visit:
- Within three days of going home, if you had severe high blood pressure
- Within seven to 10 days of going home, if you did not have severe high blood pressure
The purpose of the follow-up visit is to review your blood pressure and any other symptoms you might be having. Medications may be adjusted, and additional follow-up may be suggested during your visit. This can be a “telemedicine” video visit if you monitor your blood pressure at home.
Are There Warning Signs of Post-Delivery Preeclampsia?
Call your doctor’s office right away or seek emergency care if you have any of the following symptoms that may signal that preeclampsia has returned:
- Severe headache or a headache that doesn’t go away
- Vision problems (blind spots, blurred vision, double vision)
- Unexplained pain in your upper belly
- Unexplained shortness of breath
- Blood pressure 160 (upper number) or 110 (lower number) or higher
Will Preeclampsia Happen Again in Future Pregnancies?
Up to one in three women with preeclampsia will get it again during the next pregnancy.
Is There Anything Special I Should do During My Next Pregnancy?
Current recommendations for future pregnancies in people who have had preeclampsia include:
- Low-dose aspirin — Reduces the chance of getting preeclampsia again.
- Lab testing to check your kidney and liver functions early in your pregnancy.
- Ultrasounds to check the growth of the fetus (unborn baby) during the third trimester (last few months of pregnancy).
- Be alert to warning symptoms that may signal that preeclampsia is developing and discuss these with your care provider right away or seek urgent medical attention:
- Severe or persistent headache
- Trouble with vision (blind spots, blurred vision, double vision)
- Unexplained pain in your upper belly
- Swelling of hands or face
- Blood pressure over 140 (upper number) or 90 (lower number) or persistent increase above your normal pressure
- Your prenatal care provider may recommend a consultation with a maternal-fetal medicine specialist (high-risk obstetrician) to discuss an individual care plan for you.
Does Preeclampsia Affect My Long-Term Health?
For most people, blood pressure returns to normal and other problems resolve in the days or weeks after delivery.
However, even though it looks like the disease has gone away, people who have had preeclampsia have a higher chance of developing several diseases later in life. These may occur right away, a few years later or even many decades later, including:
- High blood pressure
- High triglycerides (fat) in the blood
- Low HDL levels (good cholesterol)
- High blood sugar (prediabetes)
- Weight gain (obesity)
It is called metabolic syndrome if you have three or more of these. People with metabolic syndrome are at high risk for diabetes and heart disease.
Healthy lifestyle choices reduce the chances of getting metabolic syndrome:
- Maintain healthful diet
- Maintain a healthy weight (BMI between 21 and 25)
- Moderate exercise 30 minutes five times a week (even light walking is better than nothing!)
- Stop smoking or vaping tobacco or nicotine products
ACOG recommends screening yearly for metabolic syndrome for people who have had preeclampsia. This includes checking the following:
- Blood pressure
- Lab tests for cholesterol, triglycerides and diabetes
It is important to let your primary care doctor know that you have had preeclampsia, so you receive appropriate screening.
After Experiencing a Preterm Birth
What is Preterm Birth?
Preterm birth (PTB) is any birth before 37 weeks of pregnancy and occurs in about one in 10 pregnancies in the United States. The underlying cause of most PTBs is unknown. Most PTBs cannot be prevented.
There are two types of PTB — spontaneous and indicated. Spontaneous PTB results from natural events, including:
- When the body naturally goes into labor prematurely
- When the amniotic membrane (bag of water) breaks, called rupture of membranes (ROM)
- When the cervix dilates silently, called cervical insufficiency
Indicated PTB occurs when the mother or fetus (unborn baby) has a serious health condition that could be harmful to either of them, such as:
- Medical conditions of the mother (severe high blood pressure, diabetes, obesity)
- Fetal growth restriction
- Placenta previa (the placenta partially or completely covers the cervix opening)
- Bleeding from the uterus (womb)
- Abnormal fetal heart rate
- Prior surgery of the uterus (some types of C-section or fibroid removal)
- Certain other reasons
Am I at Risk of Having Another PTB?
If you have had a PTB, there is a chance of another PTB in future pregnancies. Several other factors may put you at higher risk of having a PTB, such as:
- Pregnancy with twins, triplets or more fetuses
- Problems with the cervix or uterus
- Certain health conditions (high blood pressure, malnutrition, obesity, diabetes, vaginal bleeding, infection)
- Mother is over age 40
- Tobacco, drug or alcohol use
- Exposure to environmental pollutants
How can I Reduce My Chances of Another PTB?
There are several steps you can take to improve your overall health that may reduce risks of PTB, such as:
- Wait 18 to 24 months to become pregnant again. Use a reliable form of contraception (birth control) until at least 18 months after giving birth.
- Stop all tobacco products (smoking, vaping, snuff, chewing tobacco).
- Stop marijuana use.
- Stop illicit drug use.
- Aim for a healthy body weight by exercising regularly and eating healthful foods.
- Work with your doctor to manage any medical problems, such as diabetes and high blood pressure, before you get pregnant again.
- Ask your doctor if your current medications are safe during pregnancy.
- Take a prenatal vitamin every day before and during pregnancy.
Your doctor may recommend a consultation with a maternal-fetal medicine (MFM) specialist to help you plan for subsequent pregnancies.
After a Spontaneous PTB
Two ways to reduce the risks of another PTB after a spontaneous PTB include:
- Ultrasounds to check your cervix length. If your cervix is short or showing other changes, your doctor may recommend specific treatments.
- A progesterone supplement (a natural hormone) or similar medication may help reduce the chance of another PTB.
After an Indicated PTB
Common reasons for an indicated PTB are preeclampsia, high blood pressure and fetal growth restriction. If you had one of these, you might need:
- Low-dose aspirin starting at 12 weeks of pregnancy to reduce the risks of preeclampsia, fetal growth restriction and spontaneous PTB. Ask your doctor or MFM specialist if you are a good candidate for low-dose aspirin.
- Ultrasound exams during the last few months of pregnancy to check fetal growth.
If you had another indication for PTB, discuss with your doctor
How does a Preterm Birth Affect My Long-term Health?
Women who have given birth prematurely are at higher risk for certain health problems later in life, sometimes soon after birth, sometimes many years or even decades later. These problems are part of “metabolic syndrome,” which includes one or more of the following:
- High blood pressure
- Heart disease
- Type 2 diabetes
- Excess body fat around the waist
- Abnormal cholesterol and triglyceride levels
How can I Reduce My Risks of Future Health Problems?
- Breastfeed as long as you can — Breastfeeding reduces your risk of diabetes, high blood pressure and heart disease and may help you lose weight after delivery.
- Stay active — Exercise moderately 30 minutes a day, several days a week. Even a 30-minute walk can help.
- Aim for a healthy body weight by eating a healthful diet and exercising.
- Quit using tobacco, vaping products and illicit drugs.
- Make sure your primary care provider is aware of your PTB history. Discuss whether you should have testing every year for blood pressure, diabetes, cholesterol and triglyceride.
Ultrasound During Pregnancy
Routine Pregnancy Ultrasound
Ultrasound is a method to get pictures or videos of the fetus (unborn baby). There are many reasons to perform an ultrasound, including to:
- Help determine the due date
- Find out whether there is only one fetus or multiples (e.g., twins or triplets)
- Determine if the fetus is growing normally
- Identify birth defects or other problems
Ultrasound uses sound waves to generate the images, not X-rays or radiation. It is painless and safe for both the mother and fetus.
Special Ultrasound Exams
Our maternal-fetal medicine physicians have special training and certification to perform certain types of ultrasound that may not be available from a radiology service or a general obstetrician. These exams are performed in certain situations, not in every pregnancy. Special exams include:
- Biophysical profile: An assessment of fetal movements and amniotic fluid (the liquid surrounding the fetus) to check fetal well-being.
- Doppler: A method of measuring blood flow through certain blood vessels, including the umbilical cord, arteries in the fetal brain, veins in the fetal liver and arteries to the mother’s uterus. Blood flow measurements help to check on fetal well-being.
- Fetal echocardiogram: A detailed exam of the fetal heart to look for heart defects.
- 3-D ultrasound: Still pictures that appear 3-dimensional are used to get further detail of certain types of birth defects.
- 4-D ultrasound: Videos that appear 3-dimensional are used to get further detail of certain types of birth defects.