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
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