If Pregnancy Becomes Medically Complicated: Working With a Maternal-Fetal Medicine Physician

If Pregnancy Becomes Medically Complicated: Working With a Maternal-Fetal Medicine Physician

Adriana Lozada: Welcome to Birthful, Mighty Parent or Parent-to-Be! I’m Adriana Lozada.

As we get ready to wrap up our Care Provider series, I wanted to give an insight into the work of Maternal-Fetal Medicine physicians, who are the type of care providers that deal with the most complicated perinatal cases— so, for that reason, you wouldn’t necessarily pick them off the bat to be your care providers unless you or your baby are at high risk for significant complications, although that is certainly a possibility. Regardless, I think it’s a good idea for you to know what they do and how they practice in case you have to consult with them. If that is the case, my hope is that it will make it less daunting for you! 

Okay, so my guest for this is Dr. Loralei Thornburg who is board-certified in both general Obstetrics/Gynecology and in Maternal-Fetal Medicine, and she’s also a Fellow of the American College of [Obstetricians] and [Gynecologists], so ACOG. Dr. Thornburg, along with all that,  is also an associate professor and director of the Maternal-Fetal Medicine division at University of Rochester Medical Center— so yes, she’s in my neck of the woods— and there she supervises residents and fellows, teaches medical students, and cares for higher-risk OB/GYN patients.

One of the things that really stood out to me  from our conversation is that what is considered “higher risk” has so much to do with the risk tolerance of the provider, their experiences, and what resources are available to them as they take care of their patients. And this is an idea that was echoed by other medical providers we’ve had in this series. So what that means then is that your ideal care provider is going to be the one that is well-versed in providing the type of care you want or need for your particular circumstances and chosen place of birth. In other words, if you are going to have a breech delivery, you want someone who is well-versed in breech deliveries. If you are having a homebirth, you want someone well-versed in homebirth, and if you or your baby develop considerable complications, then you want someone who is well-versed in those complications. These differences in risk tolerance and comfort may also be why one provider may give you one recommendation while another one tells you something completely different (or a little different) even if they’re in the same practice.

Of course, another key element to consider is your own risk tolerance since you need to feel safe and comfortable giving birth wherever and with whomever you choose. And if you’ve already had some birth experiences, you might find then that your risk tolerance has changed and maybe you feel more comfortable hanging out at home for longer during early labor, for example, because that’s not so much of an unknown anymore.

I also got the sense that as we venture into more complicated cases, the care and approach become intensely customized to the particular needs of the pregnant person and baby dyad, and likewise it becomes more difficult to find the right answer— because truthfully there isn’t ONE right answer. This is probably why Dr. Thornburg and her colleagues have such involved discussions around the care they provide to their patients, and why it’s also so important that true collaborative care be in place between you and all your care providers so that your thoughts and choices are also part of the conversation. 

So, if you happen to be working with a Maternal-Fetal Medicine physician, you can still keep your BRAIN acronym handy, which I’ll remind you stands for Benefits, Risks, Alternatives, Information or Intuition (for the I), And Nothing or Next for the N— and then use it every time there is a change in your situation and you need to evaluate or even reevaluate the next step in your care so that you can be part of the shared-decision making, as well as understand alternative plans and options.

You’re listening to Birthful. Here to inform your intuition. 

Adriana: Loralei, welcome!

Loralei Thornburg: Thanks for having me. 

Adriana: So happy you’re here! So, before we start, I have a super mundane question to ask you: Can you explain the difference between a resident and a fellow?

Loralei: Sure! We get this a lot. And, in fact, I’ll back up one step further! So, a medical student is somebody who’s in school to learn to be a doctor. A resident is actually somebody who’s a fully-credentialed physician (has an MD) but now is doing additional training. And that training can range anywhere from two years to three years, to seven or eight years in a particular specialty.

So three years of pediatrics, four years of OB/GYN, seven years of neurosurgery, that kind of thing. A fellow is somebody who, after they finish a residency, then says, “You know what? OB/GYN is great, but I want to super sub-specialize, and I’m gonna do an additional fellowship.” So this would be somebody (like me) who does an additional three years in care of high-risk pregnancy, or somebody who does an additional three years in urogynecology and care of incontinence and pelvic organ prolapse. So it’s somebody who specializes beyond the resident level.

Adriana: Okay… So it’s like a second specialization?

Loralei: Yes. So, after medical school I did four years of OB/GYN, and then I did three years of just high-risk training— so a total of seven years of additional training after medical school.

Adriana: Lots and lots!

Loralei: I was in school forever!

Adriana: Yes. And it’s so great to explain it, because when you’re giving birth in a hospital, you’ll— especially if it’s a teaching hospital— you’ll get, y’know, medical students come in, you’ll get residents come in, you’ll get fellows come in, and they all kind have the same coats.

Loralei: They do. We all… We try to have different lengths of coats, so medical students are supposed to have short coats and attendings and full physicians are supposed to have longer coats. And y’know, that hierarchy has disappeared over the years. Just like, y’know, all those things you wear at cap and gown ceremonies all mean something, but I don’t really know what they mean anymore. But they all have meanings, so.

Adriana: Wow. See, I never knew this thing about the length of the coat!

Loralei: Yeah. Yeah, so the short coats are supposed to be medical students, and long coats are supposed to be residents, and then really long coats are attendings. But, y’know, there are also hospitals that color-code, so like at Northwestern, like, I think residents are gray and attendings are blue coats.

Adriana: I’ll have to keep an eye out for that coat length thing next time. Interesting!

Loralei: Yeah, coat length. If it goes beyond, kind of, your fingertips, then it’s an attending coat.

Adriana: Mhm. Very cool. Nobody does floor-length, I’m sure! That’s, like, your whole life in school.

Loralei: I mean, I guess it… y’know, they… the coats kind of come, like, y’know, one size, to some degree. So I guess it depends on your height. Some people that are closer to floor length than others, but…!

Adriana: Okay, so, thank you! And I asked you on the show because you’re pretty much the expert on all of those pregnancy boogiemen that live in the back of an expecting woman’s mind— y’know, constantly bringing up the “What if baby has this?” or “What if this ends up happening?” But for you, this is your day-to-day. And I wanted to try and lessen those worries in the best way that I know how, which is through facts. Let’s start!

Loralei: Absolutely. Absolutely. So the number one thing to know is that most pregnant women don’t need me, right? So, like, most pregnant women are gonna do great. They’re never gonna see me, or they’re gonna see me one time and I’m gonna say, “All is well,” or “You have this little thing that needs follow-up, but no worries,” y’know, “Have a great pregnancy!” 

Or you’re gonna see me and I’m gonna say, “Let’s plan for your pregnancy. Let’s talk about the risks.” But again, you may not ever need me. So in reality, most women will never need me. But the women who do need me really need me.

Adriana: Exactly, and we are so happy you’re there for those not-common cases.

Loralei: Yeah!

Adriana: Starting with the definition, what makes a pregnancy “high-risk”? Why would somebody go see you?

Loralei: So that is… So this is one of the really hard things about our specialty, is “high-risk” is so much in the eye of the beholder. So if your routine obstetrical provider is a midwife or a family practitioner, their threshold for where “high-risk” is may be maybe different than somebody who is an MD in OB/GYN. And maybe that may even be different between two OB/GYN MDs! Somebody who practices at a community hospital without a ton of support services may not be willing to even take anything that’s on the border, versus somebody who’s at a tertiary care center, with lots of support services— even though they’re a general OB/GYN— may have a little more risk tolerance than somebody else.

So one of the really hard things we have when patients come to see me is, “Do they need to see me?” And a lot of times the answer is “No.” Sometimes patients just feel more comfortable because they’ve had a complication in their previous pregnancy. And that’s actually… y’know, one portion of our practice is patients who had something happen last time, and now everything’s great and the pregnancy’s going fabulous.

And I see them and I say, “All is well!” It’s so exciting. And then, y’know, nothing happens and then the baby comes out and it’s great. But because they did have something happen, they just want to be sure that somebody’s watching that little bit more carefully. 

There are some patients that are truly obviously high-risk, that are probably only gonna be cared for by an MFM (or Maternal-Fetal Medicine physician). And those are gonna be your patients with… A patient with a solid organ transplant, so a patient who’s had a heart or a kidney transplant probably is only an MFM that’s gonna be comfortable caring for them in pregnancy. Patients who have really difficult-to-manage diabetes or hypertension. Patients who are very, very obese where special equipment or special considerations are required are probably gonna end up with a Maternal-Fetal Medicine physician. Patients with autoimmune diseases like lupus or Sjögren’s or anticardiolipin antibody syndrome, where things are more complicated, may see a general OB/GYN with us in consultation, or see us. And then patients who have functional heart disease are probably gonna end up with us, or functional neuromuscular disease, functional lung disease. So examples of that would be patients who have artificial heart valves or have a valve that hasn’t been replaced but is leaking or giving abnormal heart rhythms— that might be a patient that a general practitioner would be uncomfortable following in pregnancy.

Adriana: And so we’re talking even not just a pregnancy that’s labeled as “high-risk” for, y’know, things like “Advanced Maternal Age” or underlying conditions that are diabetes or high blood pressure. We’re talking bigger than that, high risks.

Loralei: Yes.

Adriana: Like with a capital H.R.!

Loralei: Yeah, with a big capital H.R., with the patients where even I’m a little uncomfortable. So yeah, and, y’know, “Advanced Maternal Age” certainly might get you a visit to my office and I might be happy to say, “Hey, how are you? Let’s talk about your risks with your age.” But most patients who are labeled with that scary “Advanced Maternal Age”— which we should talk about a little bit— actually don’t need me.

They really… y’know, most patients with “Advanced Maternal Age” really are gonna be fine and are gonna do great. And that “Advanced Maternal Age” wasn’t picked (like I tell them all the time), it’s not like when you hit 35, like, the eggs expire! You know? It’s not like, “Oh no!” that, y’know, your uterus blows up and you can’t have any more babies.

I mean, 35 was picked simply because that’s the age where the risk of— at the time!— invasive procedures, like amniocentesis, the risk of losing a pregnancy from one of those procedures and the risk of having a baby with a genetic condition like Down Syndrome, crossed. So simply that age was picked because it was the number where the risk of having a baby with Down Syndrome is 1 in 300. The risk of the procedure is 1 in 300. So if you’re younger than this, then the procedure’s more risky than the outcome. And if you’re older than this, then the procedure’s less risky than the outcome. That was the only reason that number was picked.

But now we have so many different tests that are available to test for things like Down Syndrome and Turner Syndrome and Trisomy 18 and Trisomy 13, that now we don’t necessarily need to do those invasive tests like we used to, to give a mom a sense of whether she’s at higher or lower risk than women of her age group.

And so the “Advanced Maternal Age”— although women, as they age, have a slightly higher risk of high blood pressure during pregnancy of gestational diabetes during pregnancy, developing complications during the pregnancy and needing early delivery, and, y’know, may have some of those challenges— in general, most women over 35 are gonna do great with a pregnancy and have no issues at all, and so the label has remained, even though 35 is kind of an arbitrary number.

Adriana: Okay, yeah. And because we see more and more every day, more people going into 35-40-45 having kids!

Loralei: Absolutely. And that’s the fastest growing demographic of patients who are having pregnancies. As the teen pregnancy rate has dropped, the pregnancy rate in that later life has risen. And for no other reason than women are delaying childbearing and getting their careers set and, y’know, choosing other time frames to have their children. 

Adriana: And also all the advances in fertility that allow for these pregnancies to even happen.

Loralei: Sure. And, y’know, they’re pros and cons to those kinds of treatments. And most— again, most— women over 35 will get pregnant without any help at all. And, y’know, fertility has ups and downs, and upsides and downsides… but it is widely acceptable now and widely available, and much more [inaudible] than it has been ever before. And so certainly that has extended the options for reproduction beyond where other times in our history have we been able to do that.

Adriana: And I know this is not necessarily specifically to the topic that we’re talking about— but I’m curious: What are those upsides and downsides of fertility that you see?

Loralei: Well, so, I mean, the biggest downside to fertility is (to some degree) we live in a society where the burden of fault for fertility and for complications in the pregnancy (and for children who have challenges) falls to women. Women very much feel that it, y’know, “It’s my fault. I feel very guilty that these things happen to me.”

And so needing fertility [assistance] can be a very stressful event for a couple to have to be in that place. And so I think that’s one thing we have to, y’know, think about when those services are needed. Additionally, I think… y’know, families with multiple children are great, but from my perspective, the complication rate really starts to rise the more children you try to have at a time. And so certainly you want two kids, great. How about one at a time, one right after the other, instead of twins or triplets or quadruplets or quintuplets? And when we start to get into especially those very high-order multiples, the complication rates really start to rise both for mom and baby.

And so, y’know, avoiding those is obviously something that’s ideal, especially if you’re entering pregnancy in a little higher-risk state. And so, fertility does carry a slightly increased risk of having a multiple gestation.

Adriana: Mhm. Have you seen that risk be lowered? It’s my understanding that as fertility has been advancing and it’s gotten more precise, just like you were saying, the tests… Now we have less-invasive tests to determine that risk. It is my understanding that also, the risk of having multiples when you do fertility has also decreased.

Loralei: It has. And so yeah, the fertility groups and the fertility societies have very much taken a very active role in trying to curve back especially higher or multiples. I mean, you’re always gonna have an increased twin risk with any kind of fertility technology. It’s just gonna be hard to avoid! But especially, y’know, quadruplets, quintuplets— y’know, these things should… really, these should be the exception, not the rule. And they’ve really worked hard to try to avoid those kinds of situations because of the neonatal challenges for the babies.

Adriana: You touched upon it a little bit, on the chronic health problems that might get you into that “high-risk” category. What about unexpected—

Loralei: Sure, and…

Adriana: Go ahead! 

Loralei: Oh, I was gonna say… What I didn’t mention is the other group of patients that end up in my practice a lot are moms who are completely and totally healthy, and babies who have a major challenge. So babies who have a prenatally-diagnosed cardiac anomaly or twins where they’re having specific kinds of complications— where they’re not sharing the placenta nicely, and one baby is very large and one baby is very small, and the fluids are abnormal between them, things like that. 

So when the baby is having a complication that now needs management in a high-risk pregnancy clinic— because it’s gonna require more monitoring, more assessment of “When is the right time for this baby to be born?” “Where is the right place for this baby to be born?” and “Who needs to be there and ready for this baby to have the best possible chances after delivery?”— so that’s the other group of patients that I kind of take care of. 

Adriana: And at that point, what are you analyzing? When you’re thinking “When’s the time to be able to thrive and survive and be healthy?” What goes through your mind when you’re looking at each specific case?

Loralei: So, it’s a little combination of things. Y’know, one of the things we have to think about is health of the mother. So if mom is having a complication, like something like preeclampsia (or, high blood pressure of pregnancy with protein in her urine), does the amount of disease that she has, is it such that if we don’t get baby out, mom is going to get sicker and sicker and sicker? Well, then baby needs to come out; we can fix mom. If mom is doing okay, then, y’know, obviously our goal is to get baby as close to full-term as possible. Y’know, 39+ weeks is our goal. If it’s trying to balance those two things: How much more can I let baby cook to get a little bit further, not quite so preemie… While watching mom to make sure she doesn’t get any sicker? And trying to kind of get to that point where I feel like, “Okay, this is the best I can do for baby before mom’s gonna really take a turn.” And so that’s often the balance that we’re playing. 

Sometimes we’re taking the balance of if mom is perfectly well and happy, y’know, we’re trying to go to full-term. Sometimes babies aren’t growing well inside. And so we have to kind of look at the whole curve of “How is baby growing? How is baby’s testing doing? Is baby showing signs that they’re unhappy or their placenta’s not working and they’re not gonna be able continue to grow and develop and get good oxygen? And we have to kind of say, “Okay, would this baby be better out than in?” y’know, where we can feed it an oxygenated outside?

And when you have a really medically-complex baby— where there’s a heart defect or something that needs surgery after delivery— then you’re balancing “How big is the baby? Is it big enough for surgery? Is it mature enough for surgery?” And then balancing that against “How well is it doing inside? How well is it growing inside?”

And then if you add in “How sick is mom? Is she doing okay?” And then you’re trying to balance those three things. And so it’s… You can imagine that we have a lot of heated discussions even among the, y’know, six of us here about, y’know, “Should we do it now? Should we do it next week? Should we try to push it another week?” y’know, that kind of thing.

Adriana: Oh, and it’s such a tricky situation, because you have the facts, but there’s no certainty one way or the other of what is gonna happen in a week. 

Loralei: Absolutely. Absolutely. And, y’know, it’s just like a lot of things in parenthood— y’know, you can’t split your kid in half and be like, “Alright, this half of my kid is gonna take piano lessons and this half of my kid is gonna take guitar lessons, and we’re gonna see which one they’re better at.” We can’t have it both ways. 

So it’s that “grass is always greener”: if we take out a baby and it does terrible, we’re gonna say, “Gosh, I really should’ve let it be inside.” Or maybe “I should’ve let it,” y’know, “be in there a little longer.” “Maybe it would’ve done better if I’d given it another week.” And if we take out baby and it does awesome, we say, “Oh, maybe it’s too well, maybe I should’ve let it cook another week.”

You know what I mean? So we have this balance, and if we don’t deliver a baby, and then the next week it looks even worse, we say, “Gosh, maybe I should have delivered it last week…” So you just gotta make your decisions and go with them. And that’s so much uncertainty. I think that is something that a lot of my moms really struggle with, is it’s gonna be a different kind of pregnancy.

The goal is a healthy mom and the goal as a healthy baby, we have to reorient your plan of, “My baby’s gonna go immediately skin-to-skin and have delayed cord clamping and I’m gonna breastfeed in delivery and I’m…” y’know, “She’s never gonna leave my side!” to, y’know, your baby has a major bowel issue and has got immediately go into a bag to keep it warm and go directly to the NICU and then right to surgery and won’t be able to eat for four or five days and you can’t touch it, because it’s gonna be a high risk of infection. I mean, we just have to reorient what’s best now versus what’s best in the long term. And that can be a big adjustment when you have one vision in your mind for how your pregnancy is gonna go.

Adriana: So, how do you help orient that? How do you help people get through that, y’know, reframing, and…? It’s a big transition to try to have all your dreams switched so radically. 

Loralei: It is. And, y’know, I think everybody experiences this a little bit. I mean, I know when my babies were born, I had this moment where you have, y’know, they announced the baby, “Oh, it’s a girl!” “It’s a boy!” y’know, it’s… whatever. And you have that moment where you’re like, “Oh my God, I’m so glad I have this healthy baby girl!” But then you have that little moment in your mind where you’re like, “Oh, but I pictured what it would be like when my son played baseball, or when my son… When I walked my son down the aisle… Or when I, y’know, saw my son play ice hockey… Or when I saw my son read for the first time”— like, you have, like, a little picture in your mind that you have to kind of let go of.

You have to say, “I can’t really love and appreciate the baby that I got, until I can kind of let go of the image and the story that I’ve told myself about the baby that I was gonna have.” And so part of it is almost a grieving, to kind of let yourself be sad for what you’re not gonna have. You’re not gonna get to have, y’know, the delivery in the forest, with the, y’know, tub of water. And you’re not gonna get to have that. Like, we have to take a step back and say, “Okay, I’m not gonna get to have what my first vision was. Which pieces of that vision can I still have?” 

And so, y’know, sometimes that’s thinking “What’s best in the moment?” but sometimes it’s like, “Okay, so what was really important to me about that delivery that I had pictured in my mind was that my husband was gonna announce the gender. And now I have to have a c-section and my baby has to go right to the NICU and I don’t get to… He doesn’t get to cut the cord. I just have that. But I really still want him to announce the gender. Can we still do that?” and finding little pieces that say, “Let’s take what was really important about this and drill down to some pieces that we can give you some normality. We can give you some pieces of what you wanted, even though you’re gonna have to shift your expectations on other things.”

“I really wanted to breastfeed and I really wanted to have my baby’s skin-to-skin.” Okay, that’s not gonna be possible ‘cause your baby is 28 weeks. You can still breastfeed— y’know, we’re gonna work with lactation to help you do that. Like, it’s gonna be a wonderful thing that you’re gonna do for your child. Let’s still do that goal, but we’re gonna have to reorient how that’s gonna happen.

Adriana: And even with births that are not “high-risk,” we see that happen, because circumstances are like… Y’know, I see it as a doula. I see it happen often, where people had an idea of what was gonna happen, and circumstances change, and you do go through that mourning. And I tell them, “You can’t go down the ‘What if…?’ path. What if I had done this? What if I had…? What…?” ‘cause you don’t know what “if” there is. 

Loralei: You absolutely cannot. You absolutely cannot. You’ll make yourself crazy.

And you’ll do it forever as a parent. “What if I had only walked upstairs one second earlier and my daughter had not pushed my son off the top bunk? What if…?” I mean, you’ll do it forever. You just can’t. You just can’t go down that as a parent, ‘cause you’ll lose your mind.

Adriana: And it’s also about that mindfulness, a little bit of accepting the experience that’s actually happening, instead of trying to fight for the one you had envisioned.

Loralei: Yeah, and that is a hard thing. And so one of the things that we encourage people to do is to write a birth plan. And we have a “high-risk” birth plan— actually, we have a couple of them. We have one that’s specific to the high-risk labor-delivery unit, that’s like, “Let’s talk about some of the monitoring that…” y’know, you planned to have no monitoring? Well, your baby has a major cardiac defect, with only one ventricle. That’s not an option anymore. We gotta do cardiac monitoring, y’know? And that’s just different. It’s just different than a “low-risk” pregnancy. So let’s figure out, “So what was it that you wanted about no monitoring?” “Well, I didn’t wanna be on my back and I didn’t wanna be stuck in bed.” “Absolutely. You don’t have to do any of those things. You can sit on the ball, you can be in the chair, you can stand up, you can walk around. You just have to be within this 10 feet of cord.” “Oh, I don’t have to be in bed…?” y’know, reorienting that— it’s not the monitoring, that’s what it was that was important to you about no monitoring.

Adriana: I also love hearing you say this because that is narrowing it down to what it’s all about. It’s “How can you make this experience better for the mom?” y’know, regardless of what is happening. And “How can you humanize it as much as possible?” and not have it be… y’know, because it is, if you’re “high-risk,” it is a medical event to an extent, but it’s also this amazing life event of your baby being born. And I’m gonna… Would you be able to… Would you be willing to share those “high-risk” birth plans?

Loralei: Sure. Y’know, some of them are a little bit in evolution, but we can, y’know, share where we are with them, y’know. And we redo them periodically to say, “Oh, this doesn’t really work,” y’know? And one of the ones that we use— it’s actually what’s put together by a local organization called Compassion Net— that we use as well in our clinic (even if women aren’t using that service) is a birth plan for the baby that’s not expected to survive. So we have a whole birth process related to that, that we work through with parents. And “What are your goals?” and “What is your plan?” And y’know, how can we take what is both the best and the worst day of your life and make it all that you hope, even though it can’t be what you really want? And so that is always a little bit of a challenge too, to start that conversation. 

And that’s, y’know, to some degree the best and the worst part of my job. But it’s also nice when I get to have that continuity with a patient or even just in the practice with the six of us, to kind of help people work through “This isn’t the plan you had, but let’s get to a plan that works for you and your family.”

Adriana: Mhm. Having that appreciation for what they are going through is key in their healing and moving on and becoming fabulous parents.

Loralei: Yeah, and I think it’s so hard, because I tell my moms all the time, “Everybody’s a parent,” right? Even if your baby’s not with you.

Adriana: Mhm.

Loralei:  So it’s… That can be one of the challenges we have too, because some of our moms don’t take home babies, and to try to help them understand that parenthood is a state you pass into, not a state that defines you, and your children are always with you, whether they are with you or not. And so it’s just such a challenging thing to kind of be in that moment with people, but it’s also just amazing. I mean, what other job is there where I get to do this?

Adriana: And it is very… There’s more awareness about this now, so fortunately there’s more services that address these situations, like the Now I Lay Me Down to Sleep organization, which will come in and take pictures. And you might think, if you’ve never had a baby, you haven’t considered it… You might think, like, that’s a macabre situation, but it goes by in such a blur that later you’ll want those pictures and you’ll appreciate that somebody did that or had… Y’know, there’s so many services that… I know that’s a completely different topic, so I don’t wanna go too far down the road, but it is something that you don’t just have to, like, figure out how to do it on your own.

Loralei: Absolutely, and,  y’know, even if you don’t have the advantage of planning, y’know, there are the labor and delivery nurses— I mean, at least here, are amazing, and we have multiple of them that are certified pregnancy loss specialists and grief counselors, and do all of that. And so it’s just a wonderful, wonderful service and it’s really handled very— I don’t what the word is I want. Tastefully? Sensitively? It’s really beautiful. It’s really nicely done, and of course is an option. 

And so we do get a portion of our practice that is patients who are choosing a palliative approach to an infant with a life-limiting condition. And that’s, y’know, a unique piece of maternal-fetal medicine and one that I think people don’t realize we always do. But those pregnancies also come with considerable maternal risk, often when baby has a major, major problem like that, it puts mother at increased risk for some very unique complications to those pregnancies, and so often a high-risk physician will be involved to make sure that we don’t harm mom in the honoring of her goals for the pregnancy.

Adriana: So now I wanna bring it back to those sort of unexpected circumstances that might happen during pregnancy that can cause it to go into a “high-risk.” So, and I’m gonna go to the very mundane, things that people might be worrying about, like—

Loralei: Let’s go to an easy one!

Adriana: Yes. Let’s go from where we were very deep on the one end, and bring it back to, like, say, experiencing early labor. What may that look like, and what are the next steps you consider?

Loralei: And so that is a great one. So, y’know, oftentimes that’s a real, real quick reorientation of your goals. Y’know, “Here I was planning to deliver at my low-risk community hospital with my midwife, and all of a sudden my water breaks and I’m in labor at 32 weeks. What is happening?” Right? And you’ll get transferred over to the high-risk service. And all of a sudden you have to rethink everything. So that is, y’know, a patient where it’s much more about baby’s needs to be near the NICU and the high-risk NICU physicians, than it is about complications for mom.

But there certainly can be challenges for mom too in an early delivery. So that would be somebody that we would, y’know, sit down and talk about “Okay. Let’s try to figure out if we can stop your labor. Should we stop your labor? Are there signs of complications that baby is better out than in?” things like infection or complications with the placenta, like abruption (that placenta starting to separate early). Or can we try to temporize and get baby a few more weeks inside? Can we give baby medications to be more ready to be on the outside? Things like betamethasone, is a steroid shot that we’ll use to kind of make baby’s lungs and heart and brain and bowel be more ready to be outside than inside. It does not turn a 32 week baby into a full-term baby, but, y’know, can help kind of push baby down the road towards being a little more ready for an air world versus a water world. And then, y’know, can we give antibiotics or things to prevent infection for baby as they’re delivering early and they’re small and they’re, y’know, premature? That’s, y’know, kind of the things that we start to think about when somebody presents with a new challenge in pregnancy.

Adriana: What about another scenario? What about if bleeding… Mom starts experiencing some bleeding in the pregnancy? When should she be concerned?  When is it, yeah… When should she be concerned?

Loralei: So a lot of women will have early bleeding in pregnancy, especially what we call “implantation bleeding,” so kind of in that four to six week range, spotting, a little brown bleeding here or there. And that’s very, very common and probably nothing to worry about. If it’s heavy, if you’re filling pads— that’s something to worry about and you should give your doctor a call. Women who have negative blood, so RH negative— so they’re O-, B-, AB-, something negative— if they have bleeding in pregnancy, they need a special shot called Rhogam to prevent creation of an antibody, essentially, like, an allergy kind of thing against baby’s blood, where it won’t hurt the current pregnancy, but it could hurt future pregnancies. So anytime they have bleeding, they need this special injection to prevent that from happening. 

And then it kind of depends on where you are in the pregnancy. So little spotting here or there in that first part of pregnancy first trimester? Probably not a big deal, as long as ultrasound looks good and baby is continuing to grow well. Heavy bleeding at any point in pregnancy? It can be very concerning and should be checked out, especially more than a pad an hour, we say, that really should bring you in. 

Additionally, bleeding during labor— so, a small amount of bleeding when you’re full-term and laboring, especially with your first pregnancy, is normal. That cervix goes from, y’know, nice and closed, to 10 centimeters. It’s gonna stretch and it’s gonna bleed a little bit, and that’s also a normal thing.

So a little bit depends on where you are and how much it is, whether we’re gonna be concerned. Most of the time when you’re bleeding, you’re gonna come in, we’re gonna do an exam, look inside, see, and if everything looks okay and the bleeding has stopped, we’ll probably at some point do an ultrasound, just make sure there’s nothing collecting inside (especially if you’re in your second or third part of pregnancy). And most of the time it’ll be okay and we’ll just watch it. 

There are a couple of conditions though that do lead to very heavy bleeding, that can be very scary and certainly would probably land you in my office. One of them is called a placenta previa, which is where placenta grows over the cervix— over the door, on the way out. So in that circumstance, the baby can’t get through the cervix. And anytime the cervix starts to open or starts to thin out, the placenta itself will start to bleed— and so you can imagine that that can be life-threatening for mom and baby. 

And the other one is called placental abruption. And that’s when the placenta pulls away from the wall of the uterus early. And that, obviously, that is the organ that is keeping the baby alive inside. And so if enough of it pulls away, the baby can get into trouble. So if we think that’s happening, baby can need additional monitoring to make sure it’s okay. Now the vast majority of abruptions and previas will not have… The abruptions will stabilize and the previas will not have bleeding, and will be fine and everybody will be great. 

The previas will need c-sections because, y’know, someone’s blocking up the door and you have to come out a different way. But, y’know, so even if you have these conditions it does not necessarily mean you’re not gonna be able to have a healthy baby. It just means that you may need more watching, more monitoring.

Y’know, you may go from having the pregnancy where you go in once a month and everything’s great, to having a lot more ultrasounds, a lot more watching, maybe even be in the hospital for a period of time.

Adriana: And that’s reassuring to hear, because you know things like— especially placental abruption, with that big word of “abruption,” it sounds horrible— but the fact that it could be something that just needs more watching and stabilizes, and then you go on to have your regular pregnancy? That’s reassuring.

Loralei: And I’m not saying that everybody with an abruption should say, “Oh, well I heard it on a podcast, so there’s nothing to worry about,” but of course everyone listening knows, right, like, a podcast does not take the place of advice from your doctor. It’s the… The fact remains that there are women who will have abruptions, who will have complications, who will deliver early, who will have very, very scary events happen. Babies can die. Moms can get very sick, y’know, have a lot of blood loss. So there’s not something we wanna blow off, but—

Adriana: Oh, no, absolutely. No.

Loralei: —because you have one doesn’t mean you necessarily are doomed to a lifetime of complications and everything is going to go terrible. So take a deep breath and take a moment, and sometimes these will stabilize and you can do great. 

Adriana: Yeah, exactly. And that’s the first thing we said, is it needs to be monitored. You need to be not just “Stay home and just go on with life as is.” No! 

Loralei: Yeah! 

Adriana: But that doesn’t mean that it’s doom and gloom automatically.

Loralei: Absolutely. Absolutely. 

Adriana: Then the other scenario I wanted to look into was the high blood pressure, because that’s another thing that it’s paid lots of attention to.

Loralei Absolutely. And high blood pressure, there’s no question, is a major complication in pregnancy and one that a lot of people have heard about, right?  But again, the majority of people who have high blood pressure in pregnancy— so this is not people who have high blood pressure before pregnancy, this, “I’ve had normal blood pressure. All of a sudden, in pregnancy, my blood pressure rises. I start to get protein in my urine, develop something called ‘preeclampsia.’”— the majority of that’s gonna happen at term. And although it does sometimes require early delivery and requires evaluation, it does not necessarily mean that you are gonna deliver early or that your baby’s gonna have complications.

So it does need looking into, and it does need more watching: labs, you may end up going for blood work, you may end up going for stress testing on the baby, serial ultrasound exams on the baby, bed rest, or watching your blood pressure really carefully. But again, y’know, it would be something that your doctor will try to balance “When is the right time for a baby to come out?” ‘cause it’s enough cooked that it can do well, before mom gets really sick.

So preeclampsia is… So gestational hypertension is high blood pressure in pregnancy, and then there’s preeclampsia, which is high blood pressure with protein in your urine. And then there’s eclampsia, which is high blood pressure, proteinea, and seizures, and that would require delivery.

Adriana: Right, but the preeclampsia, not necessarily…?

Loralei: Not necessarily, although, I mean, if you are 39 weeks with preeclampsia, odds are you’re getting delivered. If you’re 22 weeks with preeclampsia, well… or 24 weeks, y’know, it’s gonna depend on how sick you are, what your laboratory testing looks like, how the baby’s doing, before we’re gonna deliver you or not deliver you.

Adriana: Perfect. I wanna keep talking with you for hours, but it’s time to end it— it’s time to say goodbye. 

Loralei: Oh no! 

Adriana: I want to thank you so much, Loralei, for being on the show and sharing with us. 

Loralei: Absolutely. Absolutely. Absolutely.

Adriana: Thanks so much. If listeners wanted to follow what you’re doing, how can they do that?

Loralei: I do have a profile on the U of R website and you can kind of see, y’know, what I’ve published and what I’m working on there. If they wanna read more about high-risk pregnancy and, y’know, some of my answers to pregnancy-related questions, I did a Reddit on Ask Me Anything on pregnancy and they’re welcome to go and read, y’know, the 70,000 questions that I think they had me answer Reddit! So— I mean, it wasn’t quite that many, but it felt like it!

Adriana: Very good. And we’ll link to that Reddit on the show notes so that people can find it. 

Loralei: Okay. It’s under the r/science Reddit, y’know, r/science. 

Adriana: Yeah, and then maybe link to those birth plans as well. Thanks!

Loralei: Oh, absolutely. You’re very welcome. This was fun! 

That was Maternal-Fetal Medicine physician and associate professor, Dr. Loralei Thornburg. You can find Dr. Thornburg on Twitter @drloralei (and that’s spelled L-O-R-A-L-E-I)!

And you can connect with us @birthfulpodcast on Instagram.

In fact, if you are not driving, one of the things we love is when you take a screenshot of this episode as you are listening and post it to Instagram, to your stories, sharing your biggest takeaway from the episode. Maybe for this one it was learning how the designation of “Advanced Maternal Age” was arbitrarily created, and how your and your baby’s health matter more than your age. Make sure to tag @birthfulpodcast so we can see it and amplify it.

You can find the in-depth show notes and transcript of this episode at birthful.com, where you can also learn more about my birth and postpartum preparation classes and download your free postpartum preparation plan. Also, if you find this podcast is an invaluable resource for you, the best way to support us is by taking one of my perinatal classes, doula workshops, or trying out any of the wonderful products made by our sponsors. This is what allows us to continue doing this work. 

Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.

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