HIGH RISK

A maternal-fetal medicine specialist explores the intricacies of pregnancy.

Karkowsky (Obstetrics and Gynecology/Albert Einstein Coll. of Medicine) begins her high-risk tales with the account of a pregnant woman over 40 who “had almost no working organs in her body” and was on dialysis three times per week. Through meticulous monitoring and in-hospital care, she had a successful cesarean delivery of a preterm infant who survived intensive care and went home. The author then takes readers through the key elements of each trimester. Initially, it’s often nausea and vomiting that, for an unlucky few, can persist through all nine months. Before IV hydration, such women could die. The second trimester is the time for genetic testing. Amniocentesis is a prime test for Down syndrome, but there are now less invasive tests for many genetic anomalies. An issue here is that false positives or negative rates can be high enough to make decision-making tough. Perils in the third trimester include preterm labor, stillbirths, hemorrhaging, and the soaring maternal blood pressure of potentially fatal preeclampsia/eclampsia. In addition to graphic accounts of complications, Karkowsky also examines how pregnancy care is evolving—not always for the better. She deplores the fact that cesarean deliveries account for one-third of all births in America today (malpractice fears? financial gain?), and she is incensed that maternal mortality is high among white women but three times higher for African American women—and not because of socio-economic factors. She suggests implicit bias is at work. The author believes consent forms are a mess and hates that women seeking a vaginal delivery after a cesarean birth have to sign a consent form to permit it. Overall, Karkowsky urges better communication between doctors and nurses and doctors and patients, especially in conveying tragic news. She also makes frequent references to her own experiences as a wife and mother, subject to some of the risks she describes.

A solid primer on pregnancy risks as well as a cogent plea for progress to make childbirth even less perilous.