Complications of pregnancy

Complications of pregnancy are problems that are caused by pregnancy. There is no clear distinction between complications of pregnancy and symptoms and discomforts of pregnancy. However, the latter do not significantly interfere with activities of daily living or pose any significant threat to the health of the mother or baby. In contrast, pregnancy complications may cause both maternal death and fetal death if untreated. Still, in some cases the same basic feature can manifest as either a discomfort or a complication depending on the severity. For example, mild nausea may merely be a discomfort (morning sickness), but if severe and with vomiting causing water-electrolyte imbalance it can be classified as a pregnancy complication (hyperemesis gravidarum).

Maternal problems

The following problems originate mainly in the mother.

Hyperemesis gravidarum

Hyperemesis gravidarum is the presence of severe vomiting and dehydration, which causes the mother to lose weight. It is more severe than the more common morning sickness.

Pelvic girdle pain (PGP)

• Caused by: PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system, altered laxity/stiffness of muscles, laxity to injury of tendinous/ligamentous structures to ‘mal-adaptive’ body mechanics. Musculo-Skeletal Mechanics involved in gait and weight bearing activities can be mild to grossly impaired. PGP can begin peri or postpartum. For most women PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weight bearing activities.
• Treatment: The degree of treatment is based on the severity. A mild case would require rest, rehabilitation therapy and pain is usually manageable. More severe cases would also include mobility aids, strong analgesics and sometimes surgery. One of the main factors in helping women cope is with education, information and support. Many treatment options are available.

Severe hypertensive states

Potential severe hypertensive states of pregnancy are mainly:

• Preeclampsia = gestational hypertension, proteinuria (>300 mg), and edema. Severe preeclampsia involves a BP over 160/110 (with additional signs)
• Eclampsia = seizures in a preeclamptic patient
• HELLP syndrome = Hemolytic anemia, Elevated liver enzymes and low platelet count
• Acute fatty liver of pregnancy is sometimes included in the preeclamptic spectrum.

Deep vein thrombosis

Deep vein thrombosis (DVT) has an incidence of 0.5 to 7 per 1,000 pregnancies, and is the second most common cause of maternal death in developed countries after bleeding.^[1]

• Caused by: Pregnancy-induced hypercoagulability as a physiological response to potential massive bleeding at childbirth.
• Treatment: Prophylactic treatment, e.g. with low molecular weight heparin may be indicated when there are additional risk factors for deep vein thrombosis.^[1]

Anemia

WHO levels of hemoglobin are lower in the third trimesters. According to the United Nations (UN) estimates, approximately half of pregnant women suffer from anemia worldwide. Anemia prevalences during pregnancy differed from 18% in developed countries to 75% in South Asia.^[2] Treatment varies due to the severity of the anaemia, and can be used by increasing iron containing foods, oral iron tablets or by the use of parenteral iron.

Fetal problems

The following problems occur in the fetus or placenta, but may have serious consequences on the mother as well.

Ectopic pregnancy (implantation of the embryo outside the uterus)

• Caused by: Unknown, but risk factors include smoking, advanced maternal age, and prior damage to the Fallopian tubes.
• Treatment: If there is no spontaneous resolution, the pregnancy is usually aborted to prevent injury or death to the mother.

Placental abruption (separation of the placenta from the uterus)

• Caused by: Various causes; risk factors include maternal hypertension, trauma, and drug use.
• Treatment: Immediate delivery if the fetus is mature (36 weeks or older), or if a younger fetus or the mother is in distress. In less severe cases with immature fetuses, the situation may be monitored in hospital, with treatment if necessary.

Multiple pregnancies

Multiples may become monochorionic, sharing the same chorion, with resultant risk of twin-to-twin transfusion syndrome. Monochorionic multiples may even become monoamniotic, sharing the same amniotic sac, resulting in risk of umbilical cord compression and entanglement. In very rare cases, there may be conjoined twins, possibly impairing function of internal organs.

Prenatal infection

The embryo and fetus have little or no immune function. They depend on the immune function of their mother. Several pathogens can cross the placenta and cause (perinatal) infection. Often microorganisms that produce minor illness in the mother are very dangerous for the developing embryo or fetus. This can result in spontaneous abortion or major developmental disorders. For many infections, the baby is more at risk at particular stages of pregnancy. Problems related to perinatal infection are not always directly noticeable.

The term TORCH complex refers to a set of several different infections that may be caused by transplacental infection.

Babies can also become infected by their mother during birth. During birth, babies are exposed to maternal blood and body fluids without the placental barrier intervening and to the maternal genital tract. Because of this, blood-borne microorganisms (Hepatitis B, HIV), organisms associated with sexually transmitted disease (e.g., Gonorrhoea and Chlamydia), and normal fauna of the genito-urinary tract (e.g., Candida) are among those commonly seen in infection of newborns.

General risk factors

Factors increasing the risk (to either the woman, the fetus/es, or both) of pregnancy complications beyond the normal level of risk may be present in a woman's medical profile either before she becomes pregnant or during the pregnancy.^[3] These pre-existing factors may relate to physical and/or mental health, and/or to social issues, or a combination.^[4]

Some common risk factors include:

• Age of either parent
  • Adolescent parents
  • Older parents
    Further information: Paternal age, Maternal age effect, and Pregnancy over age 50
• Exposure to environmental toxins in pregnancy
• Exposure to recreational drugs in pregnancy:
  • Ethanol during pregnancy can cause fetal alcohol syndrome and fetal alcohol spectrum disorder.
  • Tobacco smoking and pregnancy, when combined, causes twice the risk of premature rupture of membranes, placental abruption and placenta previa.^[5] Also, it causes 30% higher odds of the baby being born prematurely.^[6]
  • Prenatal cocaine exposure is associated with, for example, premature birth, birth defects and attention deficit disorder.
  • Prenatal methamphetamine exposure can cause premature birth and congenital abnormalities.^[7] Other investigations have revealed short-term neonatal outcomes to include small deficits in infant neurobehavioral function and growth restriction when compared to control infants.^[8] Also, prenatal methamphetamine use is believed to have long-term effects in terms of brain development, which may last for many years.^[7]
  • Cannabis in pregnancy is possibly associated with adverse effects on the child later in life.
• Exposure to Pharmaceutical drugs in pregnancy.^[4] Anti-depressants, for example, may increase risks of such outcomes as preterm delivery.^[9]
  Further information: Pregnancy category
  • Ionizing radiation
• Risks arising from previous pregnancies:
  • Complications experienced during a previous pregnancy are more likely to recur.
  • Many previous pregnancies. Women who have had five previous pregnancies face increased risks of very rapid labor and excessive bleeding after delivery.
  • Multiple previous fetuses. Women who have had more than one fetus in a previous pregnancy face increased risk of mislocated placenta.^[4]
• Multiple pregnancy, that is, having more than one fetus in a single pregnancy.
• Social and socioeconomic factors. Generally speaking, unmarried women and those in lower socioeconomic groups experience an increased level of risk in pregnancy, due at least in part to lack of access to appropriate prenatal care.^[4]
• Unintended pregnancy. Unintended pregnancies preclude preconception care and delays prenatal care. They preclude other preventive care, may disrupt life plans and on average have worse health and psychological outcomes for the mother and, if birth occurs, the child.^[10][11]
• Height. Pregnancy in women whose height is less than 1.5 meters (5 feet) correlates with higher incidences of preterm birth and underweight babies. Also, these women are more likely to have a small pelvis, which can result in such complications during childbirth as shoulder dystocia.^[4]
• Weight
  • Low weight: Women whose pre-pregnancy weight is less than 45.5 kilograms (100 pounds) are more likely to have underweight babies.
  • Obese women are more likely to have very large babies, potentially increasing difficulties in childbirth. Obesity also increases the chances of developing gestational diabetes, high blood pressure, preeclampsia, experiencing postterm pregnancy and/or requiring a cesarean delivery.^[4]
• Intercurrent disease in pregnancy, that is, a disease and condition not necessarily directly caused by the pregnancy, such as diabetes mellitus in pregnancy, SLE in pregnancy or thyroid disease in pregnancy.

High-risk pregnancy

Some disorders and conditions can mean that pregnancy is considered high-risk (about 6-8% of pregnancies in the USA) and in extreme cases may be contraindicated. High-risk pregnancies are the main focus of doctors specialising in maternal-fetal medicine.

Serious pre-existing disorders which can reduce a woman's physical ability to survive pregnancy include a range of congenital defects (that is, conditions with which the woman herself was born, for example, those of the heart or reproductive organs, some of which are listed above) and diseases acquired at any time during the woman's life.

Low-risk pregnancy

A Dutch 2010 research showed that "low-risk" pregnancy in the Netherlands may actually carry a higher risk of perinatal death than a "high-risk" pregnancy.^[12] A medical news report observed, "Under the Dutch system of obstetric care, women with low-risk pregnancies are supervised by a midwife in primary care, with the choice of a home or hospital delivery, whereas those with potential complicating factors are supervised by an obstetrician throughout their pregnancy and given a hospital delivery".^[13]

See also

• List of obstetric topics
• Dermatoses of pregnancy
• Thyroid in pregnancy
• Reproductive Health Supplies Coalition

Extra Links

• Pregnancy Complications

References