Your Maternity Journey Vol. 3

Understanding High-Risk Pregnancy

“High-risk pregnancy” is a scary term to hear from your doctor. After all, the definition of a high-risk pregnancy is one that could be life-threatening for mother, baby, or both. Fortunately, with early and regular prenatal care, many women with high-risk pregnancies have minimal complications and outcomes are better today than ever before. High-risk pregnancies fall under several different categories:

Maternal Age

Pregnancy in teenage girls and women over 35 increases the risk for pre-eclampsia and gestational high blood pressure. Older women also have a higher risk of miscarriage, still birth, and multiple pregnancies. As a woman ages, the baby outgrows the placenta earlier, so delivery is often recommended by the due date.

Multiple Pregnancies

While there’s nothing “unhealthy” about having twins or triplets, such pregnancies do have a higher risk of preterm birth. More than half of twins and over 90% of triplets are born at less than 37 weeks of gestation.

Obesity

Women whose body mass index (BMI) places them in the overweight or obese category have a higher risk of high blood pressure, preeclampsia, gestational diabetes, stillbirth, neural tube defects, and cesarean delivery.

Blood Type Incompatibility

If a fetus’ blood is incompatible with the mother’s, it can lead to serious complications for future pregnancies or if the mother needs a blood transfusion in the future. Blood type incompatibility occurs if the baby’s blood crosses the placenta at some point during pregnancy or during birth. This can cause the mother to become sensitized to her baby’s blood cells and develop antibodies. Blood type incompatibility can be easily avoided if a woman receives an injection.

Pre-Existing Conditions

Certain pre-existing conditions will automatically put your pregnancy in the high-risk category:

• Type 1 and Type 2 diabetes. Diabetes in the mother is one of the most common reasons a pregnancy is considered “high risk.” Whether a woman had diabetes before she got pregnant or develops gestational diabetes in her third trimester, our experts at MarinHealth Braden Diabetes Center can help her monitor her sugars to ensure the best outcome for the baby. Poorly controlled sugars can lead to adverse pregnancy outcomes.
• Cardiovascular conditions. Treating cardiovascular conditions in a pregnant woman is challenging because some procedures and medications used to treat heart disease pose health risks to the fetus. If a pregnant woman has preexisting cardiovascular disease, she needs a cardiologist on her medical team to collaborate with her OB/GYN and perinatologist.
• Thyroid problems. Thyroid levels that are too high (hyperthyroidism) or too low (hypothyroidism) can be dangerous for both the mother and developing baby. A woman who is diagnosed with either condition before or during pregnancy may choose to be monitored by an endocrinologist in addition to her OB/GYN. Thyroid problems are relatively common and can usually be addressed through extra blood tests and adjustments to a woman’s thyroid medication regimen.
• Autoimmune diseases such as lupus or arthritis. Women with autoimmune diseases such as lupus, antiphospholipid syndrome, rheumatoid arthritis, scleroderma, or Sjogren’s syndrome have an elevated risk for pregnancy complications. It is recommended that they achieve and maintain remission for at least six months before conceiving.
• Asthma or other lung problems. Pregnancy reduces a woman’s lung capacity as her baby grows. Meanwhile, her need for oxygen only increases. Even women with perfectly healthy lungs can get short of breath in the later stages of pregnancy. Those with lung conditions often experience new or worsening symptoms.
• Kidney disease. Women with stage 1 or 2 kidney disease, normal blood pressure, and little or no protein in their urine can have a healthy pregnancy. If the kidney disease is rated as moderate to severe kidney disease (stages 3-5), the risk of complications rises considerably. In some cases, pregnancy is simply not advisable.
• Fibroids. Most women will experience no effects from fibroids during their pregnancy. However, fibroids, especially large ones, may restrict fetal growth and increase the risk of miscarriage, breech position, pre-term and/or cesarean delivery and placental abruption.

Careful Monitoring with MarinHealth

Whether your pregnancy was considered high risk from the beginning or you develop a complication over time, you are in good hands with MarinHealth. Thanks to our special collaboration with UCSF Benioff Children’s Hospital, Marin’s mothers and babies have local access to the expertise and resources of one of the nation’s preeminent pediatric hospitals. If your pregnancy is deemed high risk, you and your baby will be closely monitored by both your OB/GYN and a UCSF Health perinatologist—a doctor who specializes in the health of the fetus. UCSF Health neonatologists, doctors who specialize in the care of newborns, are available onsite at our NICU to care for premature, sick, or special-needs babies. Available 24/7 for consultation, these experts divide their time between UCSF Health and MarinHealth, so women with high-risk pregnancies can get the care they need without leaving Marin.

Our high-risk pregnancy patients are seen at an outpatient multispecialty practice in Marin where UCSF Health maternal-fetal medicine specialists offer state-of-the-art ultrasound examinations, consultations for high-risk maternal medical issues, co-management of fetal concerns such as twin gestations, prematurity prevention efforts, and management of unexpected pregnancy complications. Genetic counselors are also available and work closely with MarinHealth patients for prenatal genetic screening and diagnosis. In addition, pregnant women with types 1, 2, or gestational diabetes can get special advice and supervision from our Braden Diabetes Center.

Planning Ahead: Understanding Maternity Leave in California

If you are working, understanding your options for maternity leave is an important consideration. California is one of a small number of states to offer paid family leave. Pregnant women can utilize various types of leave including pregnancy disability, family medical leave, and child bonding leave. Pregnancy disability is designed to protect your job before and after you have given birth and recovered. Child bonding leave is available for both women and men to give them an opportunity to bond with their new baby.

Pregnancy Disability Leave Act (PDL)

The Pregnancy Disability Leave Act (PDL) requires California employers with five or more employees to provide unpaid pregnancy disability leave. (Some companies elect to offer paid maternity leave. Check with your employer’s Human Resources department). Businesses with fewer than five employees have no obligation to preserve your job and may terminate you. Depending on how long you have worked for your employer and how much other protected time off you may have taken, you may be eligible for four months of leave during any period of time you are unable to work due to pregnancy, childbirth, or a related medical condition. This time may be taken before or after your baby’s birth. For example, you can choose to take this time for severe morning sickness, medically necessary bed rest, childbirth and recovery, and any pregnancy-related complications. Routine prenatal or postnatal medical care are included. The amount of time off will depend on your situation. Typically, for an uncomplicated pregnancy and birth, employees may be considered to be disabled for four weeks before giving birth plus six weeks after birth for a vaginal delivery, and eight weeks after birth for a cesarean. If you have a pregnancy-related complication that prevents you from working longer than this, you may be eligible to receive up to four months off.

While your employer is not required to continue paying you during pregnancy disability leave, you can use accrued vacation, sick leave, or paid time off (PTO). You may apply for short-term pregnancy disability benefits through the California State Disability Insurance program, enabling you to receive roughly half of your wages based on a maximum amount set by law each year.

Good to know:

• Your request for maternity leave should be made at least 30 days before the leave is to begin. If you have a medical emergency or unexpected change in your condition that delays the request, make it as soon as you can.
• Your employer may require a doctor’s certification. Information in this medical certification may include a statement that you are unable to work due to a pregnancy-related disability, the date on which you became disabled, and the anticipated length of the disability.
• Denial of leave for an illegitimate reason may be discrimination. If you have questions about pregnancy discrimination, contact the California Department of Fair Employment and Housing.
• An employer must return you to the position you held before taking pregnancy disability. If your position was eliminated for legitimate business reasons, please contact your Human Resources department to discuss your options to find a comparable position within your organization.

Family Medical Leave Act (FMLA) and California Family Rights Act (CFRA)

Like the federal Family Medical Leave Act (FMLA), the California Family Rights Act (CRFA) requires employers with 50 or more employees to provide up to 12 weeks of unpaid leave to bond with a new child. However, you can get paid a percentage of your wages through the state. (If you work in San Francisco, check with Human Resources. San Francisco employers of a certain size are required to provide paid leave under a city ordinance.) Parents who work for businesses with 20-49 employees can obtain this leave under the New Parents Leave Act (NPLA). Family leave is also available for other reasons, such as caring for a sick family member.

You and your spouse or partner may be eligible to take 12 weeks of parental leave within the first year of a child’s arrival by birth, adoption, or foster placement. Because female employees are the only ones who can become pregnant and give birth, they can receive additional time off for pregnancy disability (see above).

To qualify for FMLA/CFRA or for NPLA leave, you must:

• Have worked for a covered employer for at least one year
• Have put in at least 1,250 hours in the 12 months immediately preceding the leave
• Work at a location where your employer has at least 50 employees within a 75-mile radius for FMLA/CFRA and at least 20 employees within a 75-mile radius for NPLA

Getting Paid During Parental Leave

While you take time to get to know your new arrival, you and your partner can receive partial wages from the state. Depending on your income, California pays 60-70% percent of wages for six weeks, up to a weekly maximum set by state law. In addition, you can request—or your employer may require—that your accrued paid vacation, sick leave, or PTO be paid out during your leave. Your employer is obligated to continue your group health coverage during your leave. At the end of your leave, your employer is required to reinstate you to the same job, or a comparable one. If you or your partner or spouse work for an employer with fewer than 20 employees, you are not legally entitled to time off and will not be entitled to job-protected leave. However, you can still receive paid family leave benefits.

Under the FMLA/CFRA, as with pregnancy disability leave, your employer can require at least 30 days’ notice when you have a specific need, such as your due date. If the need for leave is not foreseeable, such as in the case of a medical emergency, you should give notice as soon as you get the chance.