Pregnancies Needing the Five-Star Treatment

Age and Other Risks

Probably the best age to have a baby from a purely physical point of view is between twenty and twenty-four, but in fact the average age for having a baby in the United Kingdom is around 27–28 years. Of course, that is not always the best time socially or emotionally, but women who have existing illnesses such as diabetes can help to reduce the risks if they have their children during their twenties. Their pregnancies should be well spaced so that the body can recover in between and the mother is not too exhausted with the demands of several very young children.

Younger mothers Under the age of sixteen there is a higher risk of having a small or premature baby, of becoming anaemic and suffering from high blood pressure. Emotionally and socially such very young teenagers are likely to find pregnancy and motherhood much harder to cope with and need a great deal of support.

Older first-time mothers What is the greatest risk to the older mother? ‘Her doctor’s anxiety, I would say,’ said an obstetrician at a London teaching hospital. Certainly, feeling that this may be a woman’s last chance of having a baby, especially if she has had years of fertility treatment to enable her to conceive, may make her doctor more likely to intervene at the first hint of trouble. With careful monitoring, however, there is no reason why older first-time mothers of thirty-five or over should not be just as able to have a normal straightforward birth as a younger woman. The risk most associated with age is having a baby with some chromosomal abnormality, the most common being Down’s syndrome. A woman in her twenties has a chance of only one in several thousand of having such a baby, but by forty the risk is about one in every 110 births, and at forty-five the risk is about one in every 30. Amniocentesis can detect the extra chromosome which results in a Down’s baby. This may be offered routinely to women who are thirty-seven or over or after positive serum screening or nuchal translucency test. Fibroids, high blood pressure and prematurity are all slightly commoner amongst older first-time mothers.

Number of Children

A woman having her first baby is called a ‘primigravida’ and a woman who has already had one baby is called a ‘multiparous’ by doctors. First babies represent a slightly higher risk because the ‘machinery’ is untested and the mother inexperienced. Second and third pregnancies are more often straightforward, provided previous pregnancies have been free of complications. The risks begin to rise again with a fourth and successive pregnancies because the uterine muscles are slacker and less efficient and worn thinner, though this also depends to an extent on age and natural health.

Heart Disease

Pregnancy puts an added strain on the heart anyway – it has to pump about a third more blood round the body, and at a faster rate. It is quite common to feel your heart beating more rapidly or to feel breathless in pregnancy, but existing heart disease is a different matter and relatively unusual. Sometimes a heart condition can be discovered for the first time during pregnancy just because this may be the first time a woman has had a complete medical examination. If it is mild then taking things easy and staying calm may be enough. This could mean giving up work earlier in pregnancy, getting some help with housework or other children, calling on friends and relatives to lend a hand. If your heart condition is more serious, it could involve much closer supervision by the hospital and possibly admission to hospital to monitor your condition. Heart patients should not eat too much, should cut down on their salt intake to help keep their blood pressure down and their weight will be carefully monitored.

Unless there are other problems, they should be able to have a normal labour. An epidural may be suggested because it has the effect of lowering blood pressure and also reducing pain and therefore anxiety, and oxygen will be on hand to relieve breathlessness or chest pain. The effort of pushing as the baby moves down the birth canal is an extra strain on the heart and forceps are often used to avoid a prolonged pushing stage. There is no reason why mothers with heart conditions should not breastfeed, but they must have a longer stay in hospital to make sure they are quite well. Again, pregnancies should be well spaced so that the body has time to recover.

The Rhesus Factor

As well as belonging to one of four different blood groups, your blood can be either rhesus (Rh) positive or rhesus negative. It is Rh-positive if it contains a particular antigen – a substance which stimulates the formation of antibodies – which happens also to be found in the red blood cells of rhesus monkeys. Most people are Rh-positive. Your blood is Rh-negative if it does not have this antigen. Your baby is a mix of genetic information from both parents, and when an Rh-negative woman and an Rh-positive man have a baby, that baby could inherit the blood type of either parent. It is only a problem if he inherits his father’s blood type and is Rh-positive – the opposite to his mother. During pregnancy, and particularly during the birth, some of the baby’s blood cells may become mixed with the mother’s and circulate in her body. This also happens with unsuccessful pregnancies which may be ectopic or end in miscarriage or termination. The mother’s body reacts to these foreign blood cells by producing antibodies to fight them. These antibody molecules are small enough to cross the placenta and go back into the baby to start destroying the baby’s red blood cells. If untreated, this could eventually make him so anaemic he will die.

Usually the level of antibodies is not high enough to do serious damage in a first pregnancy, but they will remain in the mother’s blood and the problem becomes more serious with each successive pregnancy. Fortunately, there is now a way of preventing this, and discovering a way to prevent rhesus babies has been one of the great success stories of obstetrics. If an injection of anti-D globulin is given to the mother within seventy-two hours of the first delivery (and this applies to miscarriages and terminations at whatever stage of pregnancy) it stops her becoming sensitised and making antibodies in future pregnancies.

However, if the woman has already become sensitised, perhaps because of an untreated earlier pregnancy or miscarriage, this injection cannot help. Instead, the level of antibodies in her blood will be monitored carefully through pregnancy, and the baby’s condition may be checked by amniocentesis. The level of a yellowish pigment called ‘bilirubin’ in the amniotic fluid is a rough guide to the degree of anaemia in the baby and several tests may be needed. If the baby is in danger of becoming anaemic he can have a blood transfusion whilst still in the womb. This may be done either by injecting blood into the baby’s abdomen from where it is absorbed into the bloodstream, or transfusing it directly into the umbilical cord blood vessels. Both these procedures are done using expert ultrasound pictures showing where to pass the fine needles. This may have to be done several times during pregnancy until the baby is mature enough to be delivered by Caesarean, and is a complicated procedure which can be done only at a few teaching hospitals. After birth the baby may need another transfusion, although this is a much simpler procedure.

Diabetes

Insulin is a hormone produced by the pancreas gland in the abdomen. Its job is to facilitate transfer of the glucose or sugar in the circulation into the cells where it can be used as a source of energy. Diabetics either do not produce any insulin or not enough. When the body cannot use glucose for fuel it begins to use fat instead and, in the process, substances called ‘ketones’ are produced. A build-up of ketones in the blood upsets the body’s chemistry, making a diabetic feel nauseous or even pass out. The glucose is unused and makes the blood glucose level very high. Because of the high blood level of glucose it begins to be passed out of the body in the urine and this is one of the first signs of diabetes. Diabetes carries a higher risk of miscarriage and some degree of fetal malformation – usually a single defect like a heart or lower spine abnormality – but provided the glucose levels are kept as normal as possible before and during pregnancy the risk is very small indeed. If the father is a diabetic his control before pregnancy does not make any difference to the risk.

Because the key factor in ensuring the successful outcome of a pregnancy for a diabetic woman is control of her diabetes, she should see her doctor or clinic well before she plans to become pregnant. Getting very good control of diabetes may mean three to four injections of insulin a day, usually using a mixture of short and long-acting insulins. Once pregnancy is confirmed, this good control must continue, and because urine tests are not reliable enough, frequent daily blood testing is necessary. During pregnancy the amount of insulin needed changes rapidly and can double in the second half. Diabetic women need to eat especially carefully.

A careful check will also be kept on the baby’s size, for babies of diabetics have a tendency to grow very large. It used to be the practice to deliver the babies of diabetic women early, but this in turn led to problems of prematurity in some cases. When diabetes has been carefully monitored and controlled, it is now often possible to leave such babies until term when they can usually be delivered vaginally. During labour a drip will be set up and insulin can either be added to the fluid which is being given through the drip or administered continuously with a special pump. Immediately after the birth the need for insulin will drop, and the day after the baby has been born the mother should go back to using the dosage and type of insulin she was on before she became pregnant.

Because the babies of diabetics are sometimes larger than average, they may lose a lot of weight in the first few days and seem sleepy, but after that they should develop normally. They will have tests in the first few days to check that their blood sugars are normal. Sometimes they may be immature if they have been delivered early and thus more likely to become hypoglycaemic (very low blood sugar): for this reason they are usually nursed in a special care baby unit for a few days.

Pregnancy Diabetes

Pregnancy predisposes the body chemistry towards diabetes which can occur solely as a condition of pregnancy, disappearing again after the birth. If it happens in one pregnancy, it is more likely to recur in later pregnancies and may occur mildly in later life. It happens more often in older women and the chance of it occurring increases slightly with the number of pregnancies. Treatment is just the same as for existing diabetes – diet and possibly insulin are needed to control the blood sugar levels.

Twins, Triplets and More

Multiple pregnancies, where there is more than one baby, always need special care and monitoring.

Identical twins are the result of one fertilised egg splitting in two. The babies share one placenta and are always the same sex. Anyone has a one in 250 chance of having identical twins, though in unusual cases there may be a family history. Non-identical twins occur when two eggs are released and fertilised by two different sperm and have separate placentas which may, however, fuse together. The babies are no more alike than any brothers and sisters. Non-identical twins are about twice as likely as identical twins in Europe, but there is considerable racial variation in incidence. A family history through the maternal line makes non-identical twins more likely, and the chances are also slightly greater with taller women, older women, women who conceive easily and with successive pregnancies. Triplets, quads, quins and sextuplets can occur spontaneously and can be a mixture of identical and non-identical fetuses. For example, triplets could have started as a non-identical twin pregnancy, but then one twin split to become identical twins.

More usually nowadays these multiple births result from fertility treatment when drugs are used to stimulate ovulation and the ovary over-reacts and produces several eggs. The commonest such drug, Clomiphene, is capable of producing such a response. So-called test-tube treatments (IVF or in vitro fertilisation), when a fertilised egg is implanted back into the uterus, are also likely to produce more than one baby because doctors usually put three embryos back – with the couple’s agreement – in the hope that one will survive. Sometimes more than one can develop, resulting in a multiple birth.

Wider use of ultrasound has made undiagnosed multiple pregnancies rare. The uterus grows more quickly in size, weight gain is faster and the mother often feels the side effects of pregnancy more strongly – sickness, tiredness, aching legs, varicose veins, plus a lot more movement and kicking inside. Now and again, one embryo does not survive and if this happens early in pregnancy it may be re-absorbed back into the body with no ill effects to the remaining embryo. If it happens later in pregnancy, the dead fetus will usually remain in the uterus and be delivered at the time of the birth of the live baby. It is usually much smaller than the surviving twin.

The main risk when there is more than one baby is that they will be born too early and be premature: this becomes a greater risk with the number of babies. Whether you stay at home or need to spend the last weeks in hospital depends on your circumstances and health, but usually women expecting three or more babies will be admitted to hospital. It is also most likely that in cases with three or more babies the delivery will be by Caesarean, but in the case of twins there is no reason – provided both twins are in the head down position and everything else is normal – why they should not be delivered vaginally. The risk of haemorrhage is greater with more than one baby, but medical staff will be well aware of this and take steps to prevent it.

There is no reason why mothers should not totally breastfeed twins and partly breastfeed any number of babies, though naturally this needs great motivation and extra help and support. The Twins and Multiple Births Association is a national organisation which any mother of more than one baby will find helpful.