Complications in Pregnancy

In pregnancy a number of complications can occur

Early Pregnancy Bleeding

Early pregnancy bleeding is bleeding occuring before 20 weeks, it is common with approximately 20% of women experiencing it, most in first pregnancy

Approximately 60% continue with normal pregnancy, 30% have early pregnancy loss, 9.5% have ectopic pregnancies and 0.5% other causes

Cervical causes

Erosion

Increased proliferation of epithelial cells in cervix due to oestrogen causing blood stained vaginal discharge

Polpys

Small growths which attach to cervix

Carcinoma

Cancer

Genital tract trauma

Can be from something as straight forward as intercourse don’t always jump to assault, falls etc and exclude it.

Caused due to increased vascularity of the genital tract causing increased bleeding

Vaginal infection

Implantation bleed

Implantation into endometrium occurring around the time of expected menstruation

Early Pregnancy Loss

Spontaneous (miscarriage/abortion)

Involuntary loss of foetus less than 20 weeks

Threatened

Cervix remains closed (minimal blood loss)

Strong pain, described as Dysmenorrhoea which is the term for “strong period pain”

70-80% in first trimester can progress to term

Inevitable

Bleeding may be heavy

May contain clots or gestational sac with embryo / foetus

Patient may show signs of shock (due to heavy blood loss)

Incomplete

Remnants of placenta may remain

Heavy blood loss may occur

Will completely pass within 2 weeks with no intervention

Complete

Full passing/removal of pregnancy contents

Ectopic Pregnancy

• Extra-uterine gestation, usually within fallopian tubes but can be elsewhere
• Should be suspected in all sexually active women presenting with pain or PV bleeding
• PV bleed may be minor or significant
• Triad of Sx : Abdominal pain, missed period (Amenorrhoea), vaginal bleeding
• Also consider left shoulder tip pain, pain during defaecation and with movement (caused by irritation of Pouch of Douglas “Kehr’s sign”)

Antepartum Haemorrhage

Defined as bleeding, of greater than 15mls, after the 20th week of gestation from the genital tract.

Placenta abruption

• Placenta is situated normally
• Premature separation of placenta, occuring due to:
  • HTN disorders
  • Trauma
  • Decrease in uterus size
  • Drug use
  • Hx of similar
• Can, depending on location, conceal blood loss behind placenta
  • Visible blood loss may not be congruent with symptoms displayed
• Common cause of third trimester bleeding

Signs & Symptoms

• Painful rigid abdomen
• Little to no visible blood loss due to concealment of blood behind placenta
• Contractions
• Hypovolaemic shock
• Back pain

These patients are also at risk of Post-Partum Haemorrhage and up to 15% will have spontanous labour within 2 weeks (10% pre-term)

Placenta praevia

• Placenta is implanted in lower uterine
• Severe bleeding can occur subject to placement and separation
• Intercourse can cause bleeding
• Bleeding in these patients is an obstertic emergency

High Risk Patients

• High parity
• Multiple pregnancies
• Diabetes
• Smoker
• Previous c-section or uterine surgery
  • This is because placenta can grow along the scar line in these patients
• Age

Signs & Symptoms

• Soft uterus
• Bright red blood
• Painless bleeding

Hypertension

• Hypertension in pregnancy is defined as a SBP > 140mmHg and/or DBP > 90mmHg
• Severe HTN SBP > 170mmHg and/or DBP > 110mmHg

Chronic HTN

• Hypertension that is evident before pregnancy or develops in first 20 weeks
• Can be classified as:
  • Essential
  • No apparent cause
  • Secondary
    • Due to Kidney, Renal, Endocrine or Aorta problems
  • Apparent cause
    • Examples include chronic renal failure or diabetes

Gestational HTN

• Defined a HTN presenting post 20 weeks with no other sign of multi-system dysfunction such as:
  • No proteinuria
  • No liver function problems
  • No platelet problems
• Returns to baseline within 3 months post-partum
• Up to 50% will develop pre-eclampsia, otherwise may have post-partum haemorrhage or small birth weight infants

Pre-eclampsia

• Hypertension developing post 20 weeks with one or more of the following:
  • Proteinuria
  • Liver disease
  • Neurological signs including headaches, flashing lights or convulsions
  • Haematological signs including bruising or derranged platlets
  • Intrauterine growth restrictions

Thromboembolic Disease

• Second leading cause of maternal death and morbidity in Australia (2:100 pregnancies)
• Can occur in all trimesters but more common post-partum
• Amniotic embolism – enters mother via tears in the placental membrane or uterine vein rupture
• Includes:
  • DVT
  • PE
• Occurs due to:
  • Hypercoagulation
  • Venous statis (blood standing still / very low flow)
  • Vascular damage

Supine Hypotensive Syndrome

• Occurs in second half of pregnancy
• Reduces CO by up to 30% (due to pressure on vasculatur
• Relieved by left lateral tilt

Multiple birth

Complications

• Pre-eclampsia
• Anaemia
• Pre-term labour
• Antepartum haemorrhage
• Placenta praevia

Positional issues

In multiple births there’s also four ways the babies can present:

• Cephalic / Cephalic (i.e. head down in both): 50%
• Cephalic / Breech (i.e. head down in one; feet/bottom down in other): 25%
• Breech / Cephalic (reverse of above but the breech is down which causes issues): 10%
• Breech / Breech: Bad… 10%