From Encyclopedia of Sex and Sexuality
Many problems in pregnancy can be prevented by evaluating women for certain risk factors and treating them as soon as their pregnancies are diagnosed. An effective way to pay extra attention to a woman who might need special care in pregnancy is to classify a pregnancy into high risk or low risk categories. This classification can be made either before she becomes pregnant, at the beginning of her pregnancy, or at any time during her pregnancy. Some women already have certain conditions before pregnancy which will make them high risk. It is important for these women to be evaluated and treated well before pregnancy begins so that they can begin their pregnancies expecting the best outcome. Other women may begin their pregnancies as low risk patients, but subsequently be diagnosed as high risk. High risk factors develop either slowly or very quickly during the course of a pregnancy, and it is extremely important to identify them as soon as they occur.
Women who know well beforehand that they will be at high risk during pregnancy should enter their pregnancies in optimal condition to ensure the best outcome for themselves and their babies. It is best for them to have a checkup by a doctor trained in high risk pregnancy before becoming pregnant so as to discuss possible complications and preventive measures. For example, women with diabetes should have their blood sugar levels controlled during the months leading up to their pregnancies. This significantly decreases the major risk to the fetus of developing birth defects.
Women who must take medication should consult their physicians before pregnancy. While most medications are safe for use during pregnancy, there are a few that might present potential problems for the fetus or the mother. Sometimes switching to a safer medication before pregnancy may be better for the mother and the developing fetus. However, no medications should be stopped abruptly because of pregnancy without consulting a physician. Abrupt cessation of medication without consultation with a physician may lead to serious and unexpected problems.
Most women are not aware that they are at risk of developing problems in pregnancy. However, there are several conditions that are indicators that a woman might be in a high-risk category. An adverse outcome in a previous pregnancy places a woman at high risk for future pregnancies. If, for example, the previous pregnancy ended in a miscarriage, a stillborn infant, or premature birth, there is an increased possibility that this might happen again. If a previous baby was too small or too big, if the pregnancy went significantly beyond the due date, if there was a diagnosis of a medical condition such as diabetes, hypertension, or bleeding disorders, or if the woman was unable to deliver vaginally due to a small pelvis, had a prior cesarean section, or gave birth to a baby with a congenital malformation, she is usually at high risk for another adverse outcome.
 High-Risk Factors During Pregnancy
Vaginal bleeding, or spotting, in pregnancy indicates that a patient is at high risk. Whenever a woman experiences bleeding during pregnancy, she should immediately inform her care provider. The first advice given to a pregnant woman who experiences vaginal bleeding is usually to abstain from vaginal intercourse to prevent a potential problem from worsening.
About 20 percent of all women experience minor bleeding during the first few months of pregnancy. While most have a normal baby, vaginal bleeding may also indicate that there is a problem. Reasons for vaginal bleeding during pregnancy are usually classified according to the timing of the occurrence during pregnancy: whether it occurs spontaneously or after sex, whether it is associated with pain, and whether the bleeding is bright or dark red. Pregnancy is divided into three trimesters: the first three months (first trimester), the middle three months (second trimester), and the last three months (third trimester). Bleeding is classified into first-, second-, and third-trimester bleeding. Vaginal bleeding, or spotting, in the first two trimesters of pregnancy is called a threatened abortion or threatened miscarriage. Bleeding in the last three months is simply called third-trimester bleeding.
When a woman complains about vaginal bleeding in pregnancy, the first thing a doctor usually does is to find out whether the bleeding originates outside of the uterus, from the vagina or cervix, or if it comes from inside the uterus. The pregnancy is checked to see whether it is viable and if the fetus is still alive and growing well. If pain accompanies vaginal bleeding early in pregnancy, the doctor will check whether the pregnancy is in the right place within the uterus. A pregnancy outside the uterus is usually located in the fallopian tubes and is called an ectopic pregnancy. Ectopic pregnancy is very serious; if it is not diagnosed in time, it may lead to severe life-threatening internal bleeding.
Vaginal bleeding during or shortly after intercourse during pregnancy is a potentially serious condition. It may be due to a vaginal or cervical infection, a tumor of the cervix, injury to the vagina or cervix, or an abnormal positioning of the placenta.
Vaginal infections are often indicated when the vagina or cervix are reddened and look inflamed, or when there is an abnormal vaginal discharge. Analysis of the discharge with a microscope helps in identifying the organisms responsible for the infection. Treatment of the infection with antibiotics or other specific medication is common. Usually, the sexual partner must be treated too. (During treatment, the partner should wear a condom during sex to prevent reinfection.) Untreated vaginal infections have been implicated in cases of premature birth, infections of newborn infants, and infections of the uterus after delivery. Vaginal sex may be resumed during pregnancy after the vaginal infection has been successfully treated and both partners have been cured.
A tumor of the cervix (cervical neoplasia) is rarely the cause of vaginal bleeding in pregnancy, but it can be very serious if not diagnosed in time. If a woman has a regular PAP test, cervical neoplasia are usually diagnosed very early and treated before vaginal bleeding occurs. The diagnosis of cervical neoplasia is usually made by performing a cervical smear, looking at the cervix directly or with an instrument called a colposcope, or by doing a biopsy, in which a small piece of the cervix is excised. Early diagnosis and treatment of these cervical abnormalities has a nearly 100 percent success rate.
Abnormal placement of the placenta (placenta previa) may be another cause of vaginal bleeding associated with sex. It usually occurs during the last part of the pregnancy. Normally the placenta is located in the top portion of the uterus. In cases of placenta previa, the placenta is abnormally located in the lower part of the uterus, on top of the cervix and between the fetus and the vagina. Bleeding caused by placenta previa is usually painless and bright red in color. The diagnosis of this condition is usually made by ultrasonography (also called ultrasound or a sonogram). If this condition exists, vaginal sex is forbidden for the rest of the pregnancy because it may lead to life-threatening bleeding.
Another reason for bleeding in the last trimester may be the threat of premature birth. Patients with this condition should inform their physician immediately. If there is vaginal bleeding, premature labor with premature contractions of the uterus may also be present. Unfortunately, many women do not feel these contractions, and they may go on for a while before vaginal bleeding is observed. Vaginal spotting, or bleeding, may be the first indicator of premature labor. Doctors usually admit patients with threatened premature birth to the hospital and give them medicine (tocolytics) to stop labor.
Sometime, a woman’s cervix opens even without contractions and pain, leading to vaginal bleeding and the possible loss of a pregnancy. This condition is called an incompetent cervix and usually occurs during the fourth or fifth month of pregnancy. If this condition is diagnosed early enough, or if the woman has had the condition in a previous pregnancy, a stitch (sometimes called cerclage) is placed in the cervix during the fourth month of pregnancy. A diagnosis of incompetent cervix places women in the highest risk of pregnancy loss.
Sexual intercourse may lead to a worsening of uterine contractions because semen contains hormones (prostaglandins) that may induce contractions. In addition, if the cervix has already opened, vaginal intercourse may weaken the fetal membranes, possibly leading to premature rupturing of these membranes. Patients with a history of premature labor should be carefully counseled about sex. Using a condom may prevent semen from entering the vagina, preventing the stimulation of uterine contractions.
Another serious cause of vaginal bleeding is the detachment of the placenta from the uterus. This is called abruptio placentae. Women with this condition usually complain about severe lower abdominal pain associated with passage of dark red blood from the vagina. Abruptio placentae is a potentially life-threatening condition. Immediate admission to the hospital with fetal monitoring and delivery is usually indicated to save both the fetus and the mother.
Diabetes in pregnancy also places the mother and the fetus at high risk. This condition can be diagnosed through special blood tests. A prior big baby or diabetes in a prior pregnancy indicates an increased risk. Pregnancy itself worsens diabetes, but early diagnosis and treatment with diet or insulin injections ensures a good pregnancy outcome in most patients.
High blood pressure during pregnancy constitutes one of the most frequent reasons for defining a woman as being at high risk during pregnancy. Elevated blood pressure may be either long-standing (chronic hypertension), or it may suddenly appear in pregnancy (toxemia or preeclampsia). Toxemia is a condition that usually occurs in women carrying their first pregnancy; it happens in the latter part of the pregnancy. Diagnosis of this condition is usually made by finding an elevated blood pressure (usually over 140/90), diagnosing the appearance of protein in the urine, and sudden weight gain. Woman with toxemia are usually admitted to hospital for bed rest. Possible complications include seizures (eclampsia) and detachment of the placenta (abruptio placentae). Delivery of the baby is considered the best treatment in such cases, especially when the condition occurs close to the due date.