1.

Define High Risk Pregnancy

A high-risk pregnancy is one that threatens the health or life of the mother or her
fetus. It often requires specialized care from specially trained providers.

Some pregnancies become high risk as they progress, while some women are at
increased risk for complications even before they get pregnant for a variety of
reasons.

Early and regular prenatal care helps many women have healthy pregnancies and
deliveries without complications.

2. What are the different essential high risk factors?

The different essential high risk factors are high blood pressure, tobacco use,
physical inactivity, overweight and obesity, unsafe sex, alcohol use, childhood
underweight, urban outdoor air pollution, suboptimal breastfeeding, unsafe water,
sanitation and hygiene, and illicit drugs.

3. What are the different bleeding disorders of pregnancy?

It is divided into three sections: maternal and fetal thrombocytopenia, thrombotic

microangiopathies and inherited bleeding disorders. The section on maternal and fetal
thrombocytopenia covers gestational thrombocytopenia, thrombocytopenia secondary
to hypertensive disorders of pregnancy, immune thrombocytopenia and neonatal
alloimmune thrombo-cytopenia. The section on thrombotic microangiopathies covers
HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome,
thrombotic thrombocytopenic purpura and disseminated intravascular coagulation.
The section on inherited bleeding disorders covers von Willebrands disease,
haemophilia A and B, factor XI deficiency and acquired haemophilia.

A. MATERNAL AND FETAL THROMBOCYTOPENIA

Maternal platelet counts usually stay in the normal range during pregnancy but
tend to decrease by approximately 10% this decrease being most pronounced in the
third trimester.

 Incidental thrombocytopenia of pregnancy - The thrombocytopenia is mild (70 -

150 x 10^9 per l) and represents a physiological decrease due to platelet
activation in the placental circulation. The timing of onset is usually in the second
trimester, becoming more pronounced at the time of delivery. Incidental
thrombocytopenia of pregnancy is of no clinical significance and requires no
modification of obstetric management.

 Destructive platelet disorders due to hypertensive disorders of pregnancy - Up to

50% of women who develop pre-eclampsia will also develop thrombocytopenia.
The thrombocytopenia tends to be mild^moderate (>75×10^9 per l) but can be
severe, especially in patients with eclampsia or the HELLP (Haemolysis,
Elevated Liver enzymes and Low Platelets) syndrome (see below). The platelets
 are qualitatively abnormal as well as being low in number. The mechanism for
thrombocytopenia is unknown but may be due to increased platelet consumption
with platelets binding to damaged endothelium.The platelet nadir is often after
delivery but usually recovers within a week.

 Immune thrombocytopenic purpura - Immune thrombocytopenic purpura (ITP) is

caused by auto-antibodies directed against platelet surface glycoproteins,
especially Ib/IX and IIb/IIIa. The trigger for antibody development is unknown,
but the antibody is of the IgG subclass and can therefore cross the placenta,
especially during the last trimester of pregnancy. Consequently the
thrombocytopenia can be associated with impaired maternal haemostasis and fetal
or neonatal thrombocytopenia. Most cases are idiopathic but some are secondary
to drugs, human immunodeficiency virus (HIV) infection or connective tissue
disorders.

 Neonatal alloimmune thrombocytopenia - Fetomaternal incompatibility in the

human platelet antigen system (HPAs) may result in maternal sensitization to
foreign fetal platelet antigens inherited from the father.The IgG antiplatelet
antibodies produced as a result can then cross the placenta and may cause severe
fetal and neonatal thrombocytopenia.

B. THROMBOTIC MICROANGIOPATHIES

These conditions are characterized by fragmented red cells on microscopy

(schistocytes), evidence of haemolysis and a low platelet count. Blood ¢lm
examination is an important part of making the diagnosis. Thrombotic
microangiopathies include conditions such as preeclampsia, eclampsia, HELLP
syndrome, thrombotic thrombocytopenic purpura (TTP), haemolytic uraemic
syndrome (HUS) and disseminated intravascular coagulation (DIC). All can be
associated with bleeding.

C. INHERITED BLEEDING DISORDERS

Von Willebrands disease (vWD), haemophilia A and B carriership and factor XI

deficiency will account for approximately 90% of the inherited bleeding disorders
encountered. Obstetric management in women with an inherited bleeding disorder is
directed at ensuring:

1. Haemostasis in the woman in the antenatal, peripartum and postpartum period.

2. Counselling about prenatal diagnosis in carriers of severe haemophilia.

2. Appropriate delivery and neonatal care for an affected or potentially affected

neonate.

 Coagulation factor changes in pregnancy - Pregnancy is normally a procoagulant

state. This is due to the rise in various coagulation factors (factors VIII,VII, X,
fibrinogen and vWF), a fall in natural anticoagulants (especially protein S) and an
inhibition of fibrinolysis. In pregnant women with certain inherited bleeding
disorders the physiological rise in various coagulation factors may be sufficient to
ensure haemostasis during pregnancy and delivery.This is the case for women
 with type 1 vWD and for haemophilia A carriers ^ usually factor VIII levels and
vWF antigen and activity levels rise above haemostatic thresholds.

 Von Willebrand disease - vWD affects 1^3% of the general population and is the
most common inherited bleeding disorder. vWF normally binds to platelets and
subendothelial structures and plays an important role in primary haemostasis. It
also binds factor VIII and prolongs its circulatory half-life. Low levels of vWF
and, consequently, of factor VIII, may result in bleeding. Commonly patients
present with mucocutaneous bleeding e.g. epistaxis, menorrhagia, and bleeding
post-dental extraction.

 Haemophilia A and B - Haemophilia A (factor VIII deficiency) and haemophilia

B (factor IX deficiency) are X-linked recessive conditions. Female carriers are
generally assymptomatic and the majority have factor levels around 50%, but
lower levels secondary to lyonization can result in low factor levels that
phenotypically resemble a mild haemophiliac. Male children of haemophilia
carriers have a 50% chance of being haemophiliacs. Pre-pregnancy these women
should be offered counselling since they are at risk of bleeding as well as of
having a male haemophiliac.

 Factor XI deficiency - is autosomally inherited homozygotes have severe

deficiency and heterozygotes have partial deficiency.

 ACQUIRED HAEMOPHILIA - This is a rare, acquired complication that can

occur during pregnancy or more commonly within 3 months of delivery. It is due
to an acquired inhibitor-an IgG antibody directed against factor VIII.

References:

1. https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/high-risk

2. https://www.who.int/healthinfo/global_burden_disease/
GlobalHealthRisks_report_full.pdf?ua

3. https://www.obstetrics-gynaecology-journal.com/article/S0957-5847(03)90300-3/
pdf

4. https://www.sciencedirect.com/science/article/abs/pii/S0957584703903003