Normal pregnancy and complications

Common complications of pregnancy

- Majority of pregnancies are completely straightforward and low risk.
- Nearly all women exp minor troublesome symp to some degree
- Some women describe enormous wellbeing.
- Pregnancy women can experience all other medical problems aswell

Minor symptoms include

- Tiredness
- N+V
- Constipation
- Heartburn
- Breast tenderness
- Freq backache
- Piles
- Headache
- Heat intolerance
- “scramble brain”
- Emotional lability
Note: abnormality depends on degree of symp
- DIFFICULTY IS SPOTTING THE PATHOLOGY = ‘NEEDLE IN THE HAYSTACK’

Physiological changes
- Huge changes in short time
- Mediated principally by the effects of steroids:
o Oestrogens
o Progesterone
o Cortisol
o Human placental lactogen

Common complications of pregnancy

- First trimester
o Miscarriage (15% all preg)
o Ectopic preg (0.5-2%)
 Occurs when a fertilized egg implants and grows outside the main
cavity of the uterus
o Hyperemesis gravidarum (2-5%)
 Excessive N + V
- Second and third trimesters (maternal)
o UTI
o Anaemia (common)
o Pre – eclampsia (4-5%)
o Gestational diabetes (variable -5%)
o Antepartum haemorrhage
 - Second and third trimesters (Fetal)
o Premature labour (delivery <37 completed weeks)
o Intrauterine growth restriction (IUGR)
 Failure to reach growth potential or <2500g at term
o Macrosomia (>4500g at term)

Urinary tract infection

- Increased throughout pregnancy cf. non preg women
- Relative urinary stasis – mass effect + progesterone leading to smooth muscle
relaxation (leading to .. hydro-uterus/nephrosis)
o Presses on bladder / presses on uterus
o If leave urine in preg (i.e. don't go toilet and hold it) your more likely to get
UTI
- Immuno - suppression
- Symptoms can be mild or absent
- UTIs associated with obstetric problems esp pre term delivery
- Can cause pre term labour
- Can cause sepsis
- TEST urine EVERY visit

Anaemia in pregnancy
- Non pregnant females Hb 12 – 16g/dl
- Pregnant range Hb 10.5 – 13g/dl
o Conc is reduced in preg
- Normal physiology:
o Circulating volume increase from 4.5l – 6l
o Increased plasma volume > increased red cell volume
o Physiological dilution of Hb concentration
o Maximal dilution at 28 – 30 weeks
- Investigate as for all anaemia if Hb <10.5g/dl
- Common causes: Fe deficiency
- Sickle cell or thalassaemia trait
o (Genetics)
- Vit B12 + folate deficiency
- Blood dyscrasias e.g. leukaemias etc
- Management
o Check Hb at booking 28 / 36 weeks
o Investigate for cause of anaemia e.g. serum ferritin / B12 / folate /
electrophoresis
o Treat underlying cause if Hb < 10.5 e.g. ferrous sulphate
o Transfuse if Hb < 7 or symptomatic

Diabetes in pregnancy
- Gestational diabetes – DM diagnosed or recognised for the first time > 20/40
(recognised beyond 20 weeks) gestation (true GDM and pre existing DM)
- Pre – existing IDDM / NIDDM – already diagnosed pre preg or recognised < 20 / 40 (if
we find out before / on 20 weeks then diabetes was already there)
 - Diabetic pregnancy is associated with:
o Increased perinatal morbidity + mortality
o Increased maternal morbidity
o Small increase maternal mortality
 High risk obstetrics

Why do we get gestational diabetes?

- Some people in preg may not become diabetic because they overcome the insulin
resistance by producing more insulin
- GDM only usually occurs in already susceptible women:
o Obese
o FH DM
o Previous GDM
o Previous baby > 4.5kg
o PCOS
o Older
o Asian?
- SCREEN / TEST high risk groups at booking SCREEN everyone 28/40

- These shows having hyperglycaemia is a

problem in pregnancy
Problem with mum being hyperglycaemic , the glucose crosses the placenta easily = mum
hyperglycaemic , baby hyperglycaemic
- Baby can therefore produce a lot of insulin , can get big pancreas , can get Bb cell
hyperplasia in islet of Langerhans
- If loads of sugar and insulin = this has got to go somewhere.. where this it go??
o Into fat
o Liver
o Muscle
o Baby can bulky up = macrosomic = chunky baby
- Another problem , insulin inhibits surfactant so when breathe aveoli may not work as
well (respiratory problems)
- When born due to baby being hyperglyacemia in tummy , when cut the ‘cord’ when
baby born = no more sugar going in therefore baby can easily become hypoglycaemic
- A lot of sugar in circulation = too much sugar in kidney = drags water in through
osmosis = poly hydramnios (excessive water)
REFER TO PIC BELOW
 APH – antepartum
haemorrhage
PPH – post partum
haemorrhage
RDS – respiratory distress
syndrome

Principles of management
- Pre pregnancy counselling for known DM
- Achieve normoglycaemia (HBGM q.d.s) (fasting < 5.0 mmol/l, 1 hr pp < 7.0 – 7.5
mmol/l)
- Diet +/-
- Metformin
- Insulin (obstetrician plus diabetologist)
o We don't like to necessarily use insulin in preg but sometimes we need to
Pre-eclampsia (PET)
- PET is significant rise in BP or BP 140/90 > 20/40 gestation on 2 separate occasions at
least 4 hours apart PLUS significant proteinuria
o E.g. If high blood pressure at 12 weeks ( 12/40) already hypertensive but
didn’t know it
- There may also be evidence of other end organ disease
- Significant change from the booking BP (before 20 weeks)
o >/= 30 (systolic)
o >/= 20 (diastolic)
- Oedema – normal finding up to 80% of preg women
o Therefore tends to more significant if sever or in unusual site e.g. facial or
sacral

Problem = PIH can induce PET

 - Normally in pregnancy blood
pressure goes down

Aetiology of PET is poorly understood:

- Aka yucky little vessel disease LOOOL
- Disorder of placentation – failure of 2nd wave of trophoblastic invasion at around 15 –
16 / 40
- Overriding pathology is systemic VASOSPASM (tight)
- Systemic small (sticky) – vessel abnormalities (microangiopathy) – increased
endothelial cell wall activation of platelets + coagulation factors resulting in micro –
thrombosis and infarction of end organs
- Increased capillary permeability (leaky) – movement of fluid into the extracellular
space
- Multi system disorder – involving any organ of the body but particularly the kidneys,
liver, CNS, coagulation system and placenta
- TIGHT, STICKY, LEAKY
- hypertension goes up quickly in preg
i.e. over a number of days/weeks
compared to someone with normal
hypertension which will go up
through a number of years this is a
problem (refer to photo on right)
o Can cause stroke

- Baby look skinny

- Because using up all the
reserves as placenta not
working problem
- Baby has under perfusion of
kidneys = oligohydramnios
- Can give blood pressure drugs to help
o E.g. labetolol, nfidepine
o Obviously, cant use all drugs we have on offer to the wider population with
hypertension as these women are pregnant