It may be surprising to know that pregnancy-related complications and poor maternal outcomes could be a big problem in a developed country like the United States. But, the statistics are high enough that the National Institutes of Health (NIH) recently funded a robust initiative to address it. Penn Medicine was chosen to be part of that effort.
Alisha Sangal, MD, an obstetrician and gynecologist at Penn Medicine Princeton Health, said during pregnancy, comprehensive perinatal care is not just about checking how the baby is growing. It also means vigilantly screening for and managing any potential problems that could affect the birthing parent or baby.
Sangal stresses how important it is to keep an eye out for potential complications early on. These problems might come from health issues you already have, or they could pop up during pregnancy. The most common health issues are gestational diabetes, high blood pressure, depression, and anemia.
Screening expectant patients for diabetes
“At Princeton Medical Center, because there’s a high prevalence of diabetes among the population in our community, we screen all pregnant patients in the first trimester to check for any underlying sugar-processing issues such as insulin resistance or diabetes,” Sangal said.
Sangal explained that while many Hispanic and Southeast Asian patients are genetically at a higher risk for developing diabetes during their lifetime, she screens all expectant patients with a simple blood test called a hemoglobin A1C.
“We try to catch diabetes before the pregnancy progresses, in order to start treatment and get it under control,” she said.
Patients with a normal screening in the first trimester are screened again at 28 weeks with a one-hour glucose tolerance test. This will often catch any cases of gestational diabetes that develop due to hormones produced by the placenta.
In addition to checking blood sugar four times a day, patients with gestational diabetes are usually able to manage it through lifestyle modifications.
“We have great nutrition and diabetes management providers who will spend time with patients discussing diet and exercise changes,” Sangal said. “If that doesn’t work, we’ll start insulin or other medications.”
Gestational diabetes can cause a baby to grow too large because of excess blood sugar that crosses the placenta. This can lead to the baby getting stuck in the birth canal during a vaginal delivery, putting the birthing parent and baby at risk for injuries or requiring a cesarean section to give birth. Gestational diabetes can also cause the baby to be born early (preterm) and need extra support in the days or weeks after birth.
A proactive approach to high blood pressure
High blood pressure (hypertension) can cause a serious condition called preeclampsia, which can endanger the pregnant person and baby.
There are four categories of hypertension in pregnancy:
- Chronic hypertension—that existed prior to the pregnancy
- Gestational hypertension—that develops during pregnancy
- Preeclampsia—severe hypertension that can cause a variety of symptoms and harm the kidneys and liver
- Eclampsia—an extreme form of preeclampsia that can cause brain seizures
Preeclampsia doesn’t just put the pregnant patient at risk. The condition can restrict blood flow to the baby and slow the baby’s growth, lead to preterm delivery, and (in extreme cases) cause stillbirth.
“One of the theories about why preeclampsia develops is abnormal blood vessels in the uterus and placenta. That’s why, in most cases, the ‘cure’ for preeclampsia is delivering the baby—though some patients develop it postpartum,” said Sangal.
Preeclampsia happens most often after the 20th week of pregnancy, so providers at Princeton Health start preventive measures in the first trimester. Screening for risk factors, monitoring blood pressure throughout the pregnancy, and preventing hypertension with a daily low-dose aspirin can reduce the chances of preeclampsia ever developing.
Mental health matters during pregnancy
Depression, anxiety, and other mental health conditions that aren’t well controlled can worsen during and after pregnancy, as well as lead to adverse outcomes like preterm labor or problems with the baby’s growth.
“The connection between the mind and the body is very evident during pregnancy,” Sangal said.
Penn Medicine offers preconception counseling to patients who plan to become pregnant and have an existing mental health condition. If the condition is well controlled on medication, the care team will recommended that the patient continue the medication during pregnancy, or switch to a drug that’s safer to take during pregnancy and while breastfeeding.
Depression and other conditions can also develop during pregnancy, so Penn Medicine providers screen all of their pregnant patients for mental health disorders in the first trimester. If the patient scores a certain level or higher, the provider will recommend treatment and help coordinate care, whether that’s with medication, in-person or telehealth therapy, or other resources.
Patients are also screened for depression while they are on the postpartum floor, after delivery, and Penn Medicine has even introduced a texting service as part of its Healing at Home program to help detect postpartum depression and support parents after giving birth.
[H2] Staying ahead of anemia and blood loss
Anemia—not having enough healthy red blood cells or hemoglobin (a protein in red blood cells) to carry oxygen to the body—is another complication that can occur in pregnancy. There’s a high prevalence of anemia among many patients of Southeast Asian descent due to genetic predisposition and vegetarian/vegan diets (which can be lower in iron).
In pregnant patients, anemia can cause fatigue, shortness of breath, and lightheadedness and increase the risk of hemorrhaging during childbirth. Severe anemia can also restrict the baby’s growth from a lack of oxygen.
Sangal said in addition to checking the patient’s hemoglobin (Hb) in the first and third trimesters, providers at Princeton Medical Center also test for iron deficiency at 28 weeks.
“The placenta and uterus require a lot of blood and iron to maintain a healthy pregnancy. So even if a patient doesn’t start out with anemia, as the pregnancy progresses, their iron stores can become depleted,” she said.
Treatment for iron deficiency and anemia may be as simple as an oral iron supplement. If the anemia is severe, “we will refer them to our infusion center for intravenous (IV) iron treatments so their bone marrow can start making hemoglobin better,” Sangal said.
In extreme cases, when hemoglobin drops too low, the patient’s organs may not receive enough oxygen. A blood transfusion is sometimes needed after delivery to compensate for blood loss.
Postpartum hemorrhage (excessive blood loss) is a major complication that can occur after delivery—not just in patients with anemia. If a patient’s uterus doesn’t contract properly after giving birth, they can lose too much blood.
“We give every postpartum patient a medication to help the uterus contract,” said Sangal. Nurses also regularly check that the uterus isn’t filling with blood by pressing on the uterus at specific intervals after delivery.
“Penn Medicine has standardized protocols in place so if a patient starts to hemorrhage, we can quickly access the medications we need and, if appropriate, activate blood transfusions without delay,” she added.
Sangal said that whether or not a patient has an underlying medical condition, ideally they will have their general health tuned up prior to becoming pregnant. If you’re thinking of becoming pregnant, a preconception visit with an OB/GYN can help ensure the best possible outcome.