"...When we know that you are a woman at risk, we can do a much better job at keeping mothers safe..."

Q:  I am unexpectedly pregnant again. At first I was excited to think it could all be different this time.  After seeing three high risk OBs, I am now just scared.  It is pretty much a given I will deliver early, the question is how early, and how much that will impact the baby.  Last time I was only 24 weeks, and our daughter died. One OB says I have a "reasonably good" chance of a baby that survives and is healthy. It is all complicated by my many diseases: diabetes, antiphospholipid antibody syndrome, hypothyroidism and some signs of lupus.  Do you think there is anyone out there who has as many diseases as me and still had a healthy pregnancy?  Or maybe I should just talk to the people who had a baby with severe handicaps, to prepare myself.   I am already on Heparin. I just wanted you to know I am now in the "pregnant and scared to death" group.

A:  I understand how frightening, (and exciting), it can be to be pregnant again.  I have many patients who have multiple complications such as yours.  You are not alone.  Yes, many of them have successful pregnancies.  A few do not.

Some of your problems are very treatable.  Diabetes is a serious life-long disease.  However, in pregnancy, we are very good at controlling the problems.  Blood sugar control is critical.  In most centers that treat women with diabetes during pregnancy, outcomes are achieved that are comparable to normal pregnancies.  It just takes a lot more work.  Hypothyroidism is also very treatable with thyroid replacement.  It is very easy to treat and when treated does not complicate pregnancy.

The antiphospholipid syndrome is a more complicated issue.  If you are a woman who has significant blood clots with a positive lupus inhibitor test, you are at risk for complications that are more difficult to predict or control.  Heparinization is best.  If you have not had blood clots and only have low levels of anticardiolipin antibodies, then the picture is less clear. Your risk profile is probably no worse than a woman who has had preeclampsia at 24 weeks requiring delivery.

Your history of severe, preterm preeclampsia is the most significant risk.  We know that your risk for preeclampsia is between 25 and 60%, (possibly higher).  This does not predict at what gestational age it would happen. If you developed preeclampsia at 33 weeks and delivered a 3 pound baby, I am sure you would consider it a "success."

What can be done to prevent OR DELAY preeclampsia. (Delay is a more realistic concept than prevent).  You are on heparin.  This is a reasonable approach given the positive testing.  It is inconvenient and a bit costly but is not particularly risky.  Heparin therapy has not been clearly tested.  Calcium has been suggested for prevention.  In a large trial, calcium was not found to be helpful.  Aspirin has been suggested.  In clinical trials, there has always been a hint of benefit. Aspirin does not uniformly help prevent preeclampsia.  It may possibly have some effect in a few women.  Vitamin C and E supplementation has been suggested.  The positive data is very limited and did not suggest a prolongation in pregnancies even though preeclampsia seemed to be reduced.  Aggressive blood pressure control has been suggested.  Early BP control clearly reduces the risk of maternal hypertensive crisis.  It may reduce the rate of preeclampsia and improve outcome.  If control is too aggressive, there may be a reduction in fetal growth.  Mothers and their babies may be at some degree of cross purposes. We know that outside pregnancy, blood pressure control in the context of diabetes is very important.  It may be equally important in pregnancy.

When will you know that you will be safe?   On one hand, parenthood, in general, is a condition of never being safe.  With regard to preeclampsia, babies born after 32 weeks do extremely well. A birth at 32 weeks would be a success.  When you know that your baby is normally grown at 22 weeks, you can be feel some reassurance.  (If the baby is normally grown at 22 weeks, it is very unlikely to have a baby with IGR at 24 weeks).  When we see women with BP well controlled at 28 weeks and a baby that is average size or larger, we are very optimistic.

Many, many women have successful pregnancies after one as complicated as yours.   There is certainly a great deal of hope.  Control your blood sugars (not too high, but ALSO not too low).  Take your thyroid replacement.  Report symptoms of headache, nausea and vomiting, abdominal pain to your doctor.  Monitor BP at home if it helps to reassure you.

Since you have seen three specialists, I assume you have chosen one who you can communicate effectively with.  For the next three months you and your baby should be safe.  Try to suppress the worry until 22 weeks.  When we know that you are a woman at risk, we can do a much better job at keeping mothers safe. Be brave.  There are few things in the world as valuable as a healthy baby.  It is worth the struggle.