Complications of Pregnancy

Susanna R. Magee MD MPH

Brown University Department of Family Medicine

October 15, 2008

By Trimester

• 1st trimester– LMP date to 12 weeks

• 2nd Trimester– 12-24 weeks

• 3rd trimester– 24 weeks to term– term is 37-42 weeks

• post dates vs. post term

1st trimester

• Nausea and vomiting• Constipation• Low Back Pain• Bleeding

Nausea and Vomiting

• Very common 1 in 3 pregnancies• Likely secondary to high estrogen and high levels

of Human Chorionic Gonadotropin– made by the placenta– peaks at 10 weeks then levels off

• Occasionally needs intensive therapy– loss of more than 10% of body weight– Dehydration– -ketonuria/serum ketones

Nausea and Vomiting

• Treatment varies– dietary options: carbohydrate vs. protein– IV therapy with normal saline or Lactated Ringers to

reverse ketosis– vitamin B6, Unisom, Reglan, H2 Blocker or PPI,

Ondansetron

• Counseling– huge psychological component– maternal guilt, family misunderstanding

Constipation

• Very common complication of pregnancy as well

• Usually starts in 1st trimester• Dietary options as well

– Increased water!– Fiber– Docusate Sodium– Mineral oil

Low Back Pain

• Usually related to the position of the growing fetus or the stretching uterus

• Pressure on the sciatic nerve

• Stretching of the round ligaments

• PT can be very helpful

• Pregnancy support belt

1st trimester bleeding

• Threatened Abortion– bleeding is bright red– usually associated with pain/like menstrual cramping

• Placental formation/implantation– bleeding is usually brownish or pinkish– usually not painful– occurs at 9-10 weeks– subchorionic hemmorhage

2nd trimester

• Round Ligament Pain

• Pre-term Labor

• Abnormal genetic screening tests

Round Ligament Pain

• Usually in nullips

• Related to the round ligaments of the uterus that attach to the abdominal wall stretching with fetal growth

• Can be exquisitely uncomfortable– in differential: appendicitis, colitis, abruption, severe

constipation, UTI, etc.– Treat with Pregnancy Support Belt

• formal and informal types

Preterm labor

• 2 categories– History of preterm labor– Having preterm labor now

History of Preterm Labor

Pre-term Labor Now

• Causes– cervicitis, trauma, urinary infection, abruption, drug

use, polyhydramnios, multiple gestation

• Diagnosis– Fetal fibronectin swab– Cerivcal length ultrasound– check for cervicitis, rupture of membranes– check for dilitation– consider urine toxicology screen

Pre-term Labor

• Treatment oral NIFEDIPINE

• Previously:– Indomethacin (complications)– Bedrest (not effective)– Terbutaline (not effective)

• IM or PO (not a lot of data for the po-hardly used now)• heart rate increases

– Magnesium (not effective)• IV

• flushing, nausea, hyporeflexia, need to watch levels

AFP testing is now COMPLICATED

Genetic Screening

• Integrated screen– NT ultrasound– PAPP- A serum– Correlate with AFP Quad later

• Less false positives• More sensitive

• AFP Quad– Blood test with 4 parts

• Higher false positive• Less sensitive

Abnormal NT/PAPP-A

• Referral to MFM– Amniocentesis– Level 2 ultrasound

– Decisions on pregnancy outcome before 20 weeks in Rhode Island

Abnormal Results AFP Quad

• Test of maternal serum at 15-22 6/7 weeks

• optimal at 16-18 weeks

• screening test--high false positive rate– 4-10%

• 4 hormone levels tested– msAFP, inhibin A, HCG, estradiol

• If abnormal requires further testing with level 2 u/s or amniocentesis

Abnormal AFP

• Interpretation depends on mothers weight and age

• Low levels AFP <0.25 MOM: Down’s syndrome– Trisomy 21

• High Levels AFP >2.5 MOM: Neural tube defects– spina bifida and anencephaly

Abnormal AFP

• Even with normal screen, baby usually normal– 9 times out of 10, the amnio and or level 2 will

be normal

Abnormal AFP

• Other issues that it can predict– Abnormal inhibin A

• IUGR

– Abnormal HCG• risk IUFD--usually followed with weekly testing

3rd trimester

• Placenta Previa

• Gestational Diabetes

• Pre-eclampsia– (think about all these in second trimester, but

usually manifest in third)

Placenta Previa

• Implantation over the cervix– painless vaginal bleeding– vaginal delivery contraindicated

– marginal previa• next to but not quite covering surface• may see a marginal previa on early u/s such as fetal survey

at 18-20 weeks• needs follow up--as uterus grows, placenta often is

dragged up out of the way as muscle stretches

Gestational Diabetes

• All women screened at 26-28 weeks

• Earlier if risk factors

• 50 g glucose load

• Positive: > 130– non-fasting

• If positive, 3 hour OGTT– special diet three days before

– fasting morning of test

– 100 g glucose load

Gestational Diabetes

• Once diagnosis confirmed:– FG = 95, 1 hour > 180, 2 hour > 155, 3 hour > 140

• Treatment:– glucometer, test strips and lancets

• pt checks FG and 2 hours postprandial every day

– VNA to teach patient diet/exercise– call in sugars after 4 days– needs glyburide or insulin when

• FG > 95, PP > 120 (20% values abnormal)

Gestational Diabetes

• If insulin is required, usually use one long acting type and one short acting type.

• NST/AFI weekly• Rule of 1/3• At least one injection/day, may be as many as 4• Signs Symptoms hypoglycemia

– shaky, sweaty, confused, dizziness, passing out– rare in pregnancy

Gestational Diabetes

• Delivery recommended by 40 weeks

• May require induction, especially if uncontrolled sugars

• Risk macrosomia and neonatal hypoglycemia

Preeclampsia

• Triad– edema, proteinuria, hypertension

• Not before 20 weeks

• ? Related to abnormal placental implantation

• Symptoms:– Headache, blurred vision, edema, decreased

urine output, nausea and vomiting

Pre-eclampsia

• Exam:– swelling hands face

• “lion faces”

– hyper-reflexia

– oliguria

Preeclampsia

• Progression slow or speedy• Mild (> 300 mg/24 hour urine) or severe (> 5

grams); no in-between• lab tests can be helpful

– CBC – Bun/Cr– Uric acid– AST/ALT– UA/24 hour urine for protein

Pre-eclampsia

• Treated when severe with Magnesium sulfate infusion to prevent eclampsia

• Only cure is delivery– a patient may have to be induced preterm, or

undergo a c/s depending on severity– Growth restriction is common

Thank You

Good Luck Brown MOMS