Patricia Santiago-Munoz, M.D. Answers Questions On: High-Risk Pregnancy

I treat pregnant women who are considered high-risk because of a problem with either them or the baby. But there is no typical patient.

My primary role is to assist and counsel the patient during pregnancy and the peripartum period. Although most pregnancies will never need a fetal intervention, some babies need in-utero procedures, and in some pregnancies we have to administer drugs to mom so the medicine can cross the placenta. These treatments are typically done by the maternal-fetal medicine specialist. In many other cases, it is mom, not the baby, who is sick: We will manage or co-manage many common maternal complications, and we will take care of mom throughout the postpartum period, especially if she is experiencing postpartum depression.

My other role is to provide pre-conception counseling for patients with pre-existing conditions such as hypertension, diabetes, lupus, multiple sclerosis, and diseases of the lung, liver, or kidney. Ideally, everyone with a pre-existing condition would have a consultation before pregnancy.

We routinely screen all postpartum patients for depression. We use a validated questionnaire called the Edinburgh postnatal depression scale. If a patient is depressed or at risk of becoming depressed, we can start her treatment and then help her coordinate additional care with a psychiatrist or psychologist. And we always follow up to make sure patients are back on track and feeling better.

I think it has to do with the way we do multidisciplinary care. We frequently consult with our colleagues in other disciplines to coordinate the best care for our patients.

For example, we recently had a high-risk patient with a severe liver condition who didn’t think she’d get pregnant again. The patient had a kind of hepatitis that causes the body to fight against its own liver. By the time she was 22 weeks pregnant, she’d already been hospitalized several times with complications that put her at high risk of developing life-threatening infections. We coordinated her care with the liver transplant service, interventional radiology, and other departments to help ensure a healthy delivery.

Endometrial ablation is a procedure we perform on non-pregnant patients who have irregular bleeding with their menstrual cycle. They are typically premenopausal and want to avoid having a hysterectomy. Basically, we destroy the lining of the uterus so they don’t bleed anymore.

However, patients can still become pregnant, and it’s very risky to do so after having this procedure. The placenta can invade the uterus and adjoining structures, such as the bladder or intestines.

Many of these patients will need a hysterectomy at the time of delivery, and they are at high risk of spontaneous loss, bleeding during pregnancy, premature delivery, and heavy blood loss at the time of surgery. Having a frank discussion about these potential outcomes, and doing everything we can to manage them, is critical for patient care.

We are using cell-free fetal DNA screening more frequently. This is a highly accurate test done on the mom’s blood to detect circulating fragments of fetal DNA. It is less invasive than amniocentesis, which is a diagnostic test used to detect fetal chromosomal abnormalities.

This new test is very helpful for patients of advanced maternal age. Though it cannot detect abnormalities in any chromosome, it does provide information about chromosomes 13, 18, and 21. If there’s an extra copy of chromosome 21, for example, that would point to a diagnosis of Down syndrome. If the blood test is positive, then we would recommend the confirmatory test, which is the amniocentesis.