Pregnancy Complications

Hyperemesis Gravidarum

Hyperemesis gravidarum is excessive vomiting during pregnancy. Persistent, frequent and severe vomiting can lead to dehydration and weight loss but can often be relieved with medications but sometimes hospital admission is indicated. If you are concerned, very thirsty or unable to keep fluids down, you have to seek medical attention.

Bleeding during pregnancy

Vaginal bleeding or spotting is common during the first trimester of pregnancy. In most cases the pregnancy will continue without any negative consequences. It could also be a sign of something more sinister like a miscarriage, ectopic pregnancy or a molar pregnancy.

In later pregnancy bleeding can be due to a shortening of the cervix, from a low lying placenta(previa) or a placenta that comes away from the wall of the uterus (abruption). In late pregnancy  a “show” which is mucus mixed with blood, is normal and happens when the cervix is opening up and preparing for labour. A show often happens after the start of labour.

All vaginal bleeding must be discussed with your doctor or midwife and you will often be asked to present to POGS or the hospital. You will usually get an ultrasound but you may also need an internal/speculum examination, BHCG levels or a CTG. Women with a negative blood group will usually get an Anti-D injection.

Miscarriage (Spontaneous abortion)

A miscarriage is the loss of a pregnancy before 20 weeks. This is unfortunately  very common and around 20 percent of pregnancies will end in a miscarriage. It happens more often in early pregnancy, is more common in older women, women with a high BMI and in certain medical conditions eg diabetes but can happen to anyone.

It is uncommon after the 12th week of pregnancy. If a miscarriage is confirmed, treatment options include a wait and see approach, medications or a suction D&C under anaesthetic.

Ectopic pregnancy

An ectopic pregnancy is where an embryo implants outside the uterine cavity. Most ectopic pregnancies are in the Fallopian tubes but it can be anywhere outside the uterus. It happens in 1% of all pregnancies and in 10% of pregnancies in women who have had a previous ectopic pregnancy.  An ectopic pregnancy can only grow for a few weeks before it runs out of room and cause pain and/or bleeding. Most but not all women will have pain when they have an ectopic pregnancy. Ectopic pregnancies can be dangerous because they can rupture and cause internal bleeding.  A slow rise in BHCG levels is another sign of an ectopic pregnancy. A large amount of blood can be lost into the abdominal  cavity without any outward signs of bleeding. Ectopic pregnancies  can be difficult to diagnose because it may present like a miscarriage and it is not always visible on an ultrasound scan.  

Ectopic pregnancies can be treated with a medication called Methotrexate or with laparoscopic (key-hole) surgery and rarely with a laparotomy (large cut in abdomen).

It is important that women with vaginal bleeding and pain in early pregnancy seek medical attention, especially if she has not had a scan to prove that the pregnancy is inside the uterus.

Molar pregnancy

A molar pregnancy is a genetically abnormal pregnancy and is also referred to as gestational trophoblastic disease (GTD). It causes vaginal bleeding that can occasionally be very severe. The BHCG levels are often very high which in turn  can cause severe nausea and vomiting. A molar pregnancy is treated with a  suction D&C and the BHCG levels are then followed for weeks or months till it becomes undetectable before a woman can fall pregnant again because there is a small risk that it can persist or even spread outside the uterus.

Placenta previa (low lying placenta)

The placenta can attached itself to the front wall, back wall or fundus (top) of the uterus or combinations of any of these. If it is attached low ie near or over the cervix, it is called a low lying placenta or placenta previa. Low lying placentas that are diagnosed on the anatomy scan at 19 weeks, often move out of the way by full term. If it does not, a woman cannot give birth vaginally as it may cause life threatening bleeding so the only option is a caesarean section. Placenta previa can also cause bleeding before birth and some women have to be hospitalised as a result. Bleeding from a placenta previa is usually bright red and painless.

Placental abruption

Abruption of the placenta is where the placenta lifts away from the wall of the uterus causing bleeding under the placenta and often also vaginal bleeding. Depending on how much of the placenta comes away, it can cause fetal distress  when we have to deliver the baby immediately. It usually causes a lot of pain and it can bring on labour. Bleeding is usually dark red with clots.

Diabetes and gestational diabetes

Diabetes is a condition where the body cannot manage the blood sugar levels due to a relative or absolute shortage of insulin. Diabetes that is diagnosed in pregnancy is called gestational diabetes. All women that were not already diagnosed with diabetes will have a  glucose tolerance test (GTT)  done at 28 weeks gestation. High-risk women will also have a GTT done in early pregnancy.

In diabetes, blood glucose levels are monitored. If diabetes is well controlled it is less likely that the pregnancy will be affected but we have to monitor pregnancy in all women with diabetes closely as there can be adverse effects on pregnancy such as a miscarriage,  macrosomia (an abnormally big baby), growth restriction, and birth complications such as fetal distress or shoulder dystocia (where there is difficulty delivering the shoulders).Treatment with insulin is prescribed with blood glucose levels are out of control. We usually recommend that women with diabetes do not go past their due date or have the baby sooner if there are complications.

Pre-eclampsia and high blood pressure

High blood pressure (hypertension) is not uncommon in pregnancy. High blood pressure can be due to pre-existing hypertension, renal disease or it can be pregnancy-related. We divide pregnancy-related hypertension into 2 groups:

• Gestational hypertension- where a woman with a previously normal blood pressure develops high blood pressure during pregnancy
• Pre-Eclampsia – where the hypertension is associated with other signs and symptoms such as protein in the urine, abnormal blood tests, headaches, abdominal pain, visual changes or growth restriction in the fetus. It can come on suddenly and can sometimes progress very quickly. The only way to resolve it is to deliver the baby, sometimes prematurely. The good news is that women usually recover fully and quickly once the baby is delivered. Unfortunately if may recur in future pregnancies.

Preterm rupture of membranes

If membranes rupture before 37 weeks it is called preterm rupture of membranes. It could be caused by  infection or an incompetent cervix, but often no cause is found. Once the membranes rupture, the baby is at risk of infection and women often go into labour. Women are given antibiotics to reduce the infection risk and the baby is delivered 34-36 weeks or sooner if there are signs of infection.

Preterm labour

Is when labour starts before 37 weeks gestation. Medications to stop  labour  is given if there are no other risk factors. It is not always successful. In preterm labour before 34 weeks a medication called Celestone is used that helps to mature the baby’s lungs and other organs.

Short cervix

A short cervix puts a woman at risk of preterm delivery. All women have a measurement of the cervix done at the 19 weeks anatomy scan. If the cervix is short, ie less than 25mm, treatment is indicated, usually in the form of vaginal progesterone pessaries.  In some cases a suture around the cervix is needed to prevent it from opening, also called a cerclage. It is also called an incompetent cervix.

Intra Uterine Growth Restriction (IUGR)

When a Cetus is not growing as expected it is called IUGR. (Babies with IUGR is usually, but not always, small but not all small babies have IUGR, some are normal. A small baby that is growing normally does not have IUGR.) IUGR is usually caused by a placenta that is not functioning optimally. The baby does not get enough nutrients from the placenta and therefore the growth slows down. Babies with IUGR have to be monitored closely, often by twice-weekly assessments with CTGs and weekly ultrasounds.  On ultrasound we monitor the movements, fluid around the baby and the blood flow through the placenta. We often have to deliver babies with IUGR early, before the point where the placenta can no longer provide sufficient oxygen to the baby, but we will not let it go past 39 weeks gestation.

Cholestasis

In cholestasis the bile becomes thickened which prevents it from flowing normally through the small bile ducts in the liver.  The build up of bile acids in the blood usually leads to itchy palms and soles and can also cause abnormal liver function tests. It can be treated with medications that will improve the itch but the baby has to be delivered by 37 weeks because the bile acids can affect the baby’s heart rhythm.