Pregnancy Complications

Hyperemesis Gravidarum

Hyperemesis gravidarum is a condition of excessive vomiting during pregnancy.

Vomiting is a common complaint during pregnancy, but persistent, frequent and severe vomiting, can lead to dehydration and weight loss. It can often be relieved with medications and 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 a common problem that can occur during the first trimester of pregnancy. In most cases, the pregnancy will continue without any negative consequences but the bleeding could be a sign of something more sinister like a miscarriage an ectopic pregnancy or a Molar Pregnancy. The bleeding can also come from the cervix.

In later pregnancy, the bleeding can again arise from the cervix (especially if it comes on after sexual intercourse) but can be due to a shortening of the cervix (which is normal in late pregnancy) or the placenta if it is low lying or if it is coming away from the wall of the uterus (abruption).

In late pregnancy, you may have a “show” which is mucus mixed with blood. It 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 healthcare provider and you will often be asked to come in for an assessment. Assessments usually mean an ultrasound but you may also need a speculum examination and may need serial BHCG levels done

If you have a negative blood group, you will usually need an Anti-D injection.

Miscarriage (Spontaneous Abortion)

A miscarriage is the loss of a pregnancy before 20 weeks gestation. It is very common with around 20 per cent of pregnancies ending in a miscarriage. It is more common in older women, women with a high BMI, in certain medical conditions eg diabetes.

It is more common in early pregnancy and when a fetal heart is visible the miscarriage risk reduces to 10%. It is uncommon after the 12th week of pregnancy.

If a miscarriage is confirmed, treatment options include a wait and see approach, medications or an anaesthetic and a suction D&C under anaesthetic.

Ectopic Pregnancy

An ectopic pregnancy happens when an embryo implants outside the uterine cavity. It happens in 1% of pregnancies but in 10% of pregnancy of women who had a previous ectopic pregnancy.

Most ectopic pregnancies are in the Fallopian tubes but they can be anywhere outside the uterus.

An ectopic pregnancy can only row in the tube for a few weeks before it will run out of room and cause pain and/or bleeding. It can be very difficult to diagnose an ectopic pregnancy because it may look like a miscarriage. It is not always visible on ultrasound scan either. We often diagnose it when we cannot see a pregnancy in the uterus when it should be big enough to see.

A slow rise in BHCG levels is another sign of an ectopic pregnancy.

Most but not all women will have pain when they have an ectopic pregnancy.

An ectopic pregnancy is a potentially serious complication of pregnancy because it can rupture and cause internal bleeding. A woman with an ectopic pregnancy can lose a large amount of blood into her abdomen without any outward signs of bleeding.

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

It is important that women with 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 often leads to bleeding but can occasionally cause severe haemorrhage. The BHCG levels are often very high and it 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 attaches to the uterine wall, it can the front wall, the back wall or the top of the uterus or combinations of the above. If it attaches itself near or over the neck of the womb, it is called a placenta previa. If it is diagnosed on the anatomy scan at 19 weeks, it may move out of the way by full term, but if it does not, a woman cannot give birth vaginally as it may cause life-threatening bleeding so she has to have 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 painless.

Abruptio placenta

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. There is usually p depending on how much of the placenta come away it can cause fetal distress and rarely life-threatening blood loss in the mother. It can also bring on labour.

Diabetes and Gestational Diabetes

Diabetes is a condition where the body is not handling glucose well 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.

If you are diagnosed with diabetes you have to monitor your blood glucose levels and may need insulin. 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. Diabetes can have 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). We usually recommend that women with diabetes do not go over their due date or 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 because of pre-existing hypertension or 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 – is a condition that is unique to pregnancy. Here 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 a preterm rupture of membranes. It could happen because of infection or an incompetent cervix, but often no cause is found. Once the membranes rupture the baby is at risk of infection and there is also an increased risk of labour. We would usually give women antibiotics to reduce the infection risk and deliver the baby 34-36 weeks or sooner if there are signs of infection.

Preterm labour

Preterm labour is where a woman goes into labour before 37 weeks gestation. We have medications that we can use to suppress labour if there are no other risk factors. It is not always successful. If a woman goes into labour before 34 weeks we will usually give her an injection of a medication called Celestone that help to mature the baby’s lungs and other organs.

Short cervix

A short cervix put a woman at risk of preterm delivery. All women will have a cervical measurement done at the 19 weeks anatomy scan. It the cervix is short, ie less than 25mm, they need treatment, usually in the form of vaginal progesterone pessaries but they may need a cervical suture, also called a cerclage. If a cervix opens up in the second trimester of pregnancy, it is also called an incompetent cervix.

Intra Uterine Growth Restriction (IUGR)

Is where a baby is not growing as expected. (Babies with IUGR is usually, but not always, small but not all small babies have growth restriction. If a baby is small but growing normally, it does not have IUGR.). IUGR usually means that the placenta is not functioning optimally so that the baby is not getting enough nutrients from the placenta and therefore not growing normally. We have to monitor these babies closely sometimes women need twice-weekly assessments with CTGs and weekly ultrasounds. We monitor the baby’s movements, the fluid around the baby and the blood flow through the placenta and have to deliver them early before the point where the placenta can no longer provide sufficient oxygen to the baby

Cholestasis

Cholestasis is a condition where the bile becomes thickened so it does not flow through the small bile ducts in the liver so that bile acids build up in the blood. This usually leads to itchy palms and soles. It can also cause abnormal liver function tests. It can be treated with medications that will improve the itch and we have to deliver the baby by 37 weeks because the bile acids can affect the baby’s heart rhythm.