Complications of Pregnancy

Dana Farabaugh, M.D.

Link to Full Video (90 minutes long)

Objectives:
1. Identify medical conditions that predate pregnancy and their effect on pregnancy
2. Identify medical complications that are induced by pregnancy and their
management
3. Discuss the complications that are specific to pregnancy

Overview: Link to Overview and Pre-existing Conditions (37 minutes)

Types of Complications:
Medical complications predating pregnancy
Medical complications induced by pregnancy
Medical complications that lead to pregnancy specific syndromes
Specific obstetrical complications

Pre-Existing Medical & Surgical Conditions Complicating Pregnancy

HIV Infection
1. Most pediatric HIV infection are the result of vertical transmission
2. Treatment in pregnancy
a. Treat prenatally, in labor, newborn
b. Antiretroviral therapy
3. Rapid HIV test in labor
4. Minimize invasive procedures
a. Artificial rupture of membranes
b. Operative vaginal delivery
c. Fetal scalp electrodes
5. Postpartum – No breastfeeding

Asthma
1. One of the most common medical conditions in pregnancy
2. Management complicated by
3. Effect of pregnancy on asthma is variable
4. Potential effect of medications used to treat
5. Adverse effects of asthma on fetus and pregnancy progression
6. Goal to prevent acute exacerbations and optimize pulmonary function

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Thyroid Disease
1. Second most common endocrine disease in pregnancy
2. T4 important in fetal brain development until 18-20 weeks after which fetal thyroid
takes over
3. Hypothyroid
a. Most common etiologies
i. Hashimoto’s thyroiditis
ii. Post ablative therapy
b. Diagnosis
i. Overt: elevated TSH and low free T4
ii. Subclinical: elevated TSH and normal free T4
c. Treatment: levothyroxine
i. Pregnancy increases dose requirements
ii. Check TFTs every 4 wks while adjusting
iii. Check every trimester when stable
d. Complications
i. neuropsychological impairment of fetus
ii. preeclampsia
iii. placental abruption
iv. preterm delivery
v. postpartum hemorrhage
4. Hyperthyroid
a. Etiology – Grave’s Disease in 90% of cases
b. Diagnosis – Low TSH concentration and elevated free T4
c. Treatment
i. Primarily medical: PTU and Methimazole
1. Both cross placenta and can cause fetal hypothyroidism
2. Methimazole as teratogen
3. Maternal liver toxicity of PTU
4. Lowest dose to maintain free T4 in high normal range
5. Avoid methimazole in first trimester
ii. Thyroidectomy in refractory cases
iii. Ablation contraindicated in pregnancy
d. Complications
i. Miscarriage
ii. Preterm labor
iii. Low birth weight
iv. IUFD
v. Preeclampsia
vi. Heart failure
vii. Thyroid Storm
1. Life threatening
a. Nausea, vomiting, fever, tachycardia, delirium
b. Treat in ICU, high dose PTU, steroids, propranolol

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Venous Thromboembolism
1. General
a. Includes deep venous thromboembolism (DVT) and pulmonary embolus (PE)
b. Rate of these is 4-50X higher in pregnant versus non pregnant women
c. Higher incidence postpartum than antepartum
d. Higher incidence following cesarean section than for vaginal delivery
e. Pregnancy promotes all the components of Virchow’s Triad
f. Those with inherited thrombophilias have a significantly increased risk VTE
suring and outside of pregnancy
2. Diagnosis
a. Difficult as signs/symptoms mimic normal pregnancy
i. Low extremity swelling
ii. Dyspnea
b. Labs
i. ABG-low sensitivity and specificity
ii. D dimer high sensitivity but low specificity
c. Imaging
i. Lower extremity Doppler U/S- DVT
ii. MRI- DVT
iii. V/Q Scan- PE
iv. CT angio- PE
3. Treatment
a. Anticoagulation
b. Duration of therapy
i. At least 6 months after diagnosis and 6 weeks postpartum
ii. Can be transitioned to Coumadin postpartum
4. Prophylaxis
a. Women at high risk
i. History of VTE
ii. Cardiac valves
iii. Thrombophillias
iv. Morbid obesity
v. Prolonged immobility
b. Therapy
i. Depending on indication- duration of pregnancy and postpartum
ii. Heparin or Low Molecular Weight Heparin, prophylactic doses

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Seizure Disorder
1. Most frequent neurologic complication of pregnancy
2. Pregnancy may increase seizure frequency
a. Decrease in levels of antiepileptic drugs (AEDs)
i. Change in clearance, protein binding, volume of distribution
b. Decrease in compliance
c. Sleep deprivation
3. Concerns
a. Increased risk of malformations with all AEDss
i. Depakene (valproic acid)- neural tube defects
ii. Dilantin (phenytoin)- hydantoin syndrome
4. Management
a. Consultation with neurologist
i. Are meds needed?
b. AED- lowest dose, newer meds, monotherapy
c. Avoid valproate if possible
d. Monitor drug levels
e. Folic acid supplementation 4mg/day
f. Malformation screening
i. Ultrasound
ii. MSAFP

Surgical Conditions in Pregnancy

1. Adverse pregnancy outcomes from complications of condition- not surgery itself
2. Fetal health should be considered, but need for maternal evaluation and treatment
supercedes
3. Trauma
a. Penetrating trauma –
b. More likely to injure fetus than maternal abdominal structures
c. Blunt trauma
i. Non viable fetus- less than 24 wks
1. Assess maternal blood type and administer rhogam
ii. Viable fetus- greater than 24 weeks
1. Monitor for evidence of abruption
4. Appendicitis
a. Most common surgical condition in pregnancy
b. Location of the appendix can be altered in pregnancy
c. Imaging: attempt ultrasound first, but CT scan as needed
d. Outcomes worse if perforation occurs
e. Surgical approach- laparoscopy vs. open- depends on gestation

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Medical Conditions Induced by Pregnancy (11 minutes)

Hyperemesis Gravidarum
1. Severe nausea and vomiting of pregnancy
a. Electrolyte abnormalities- hypokalemia
b. Starvation ketosis
c. Weight loss from pre-pregnancy (>5%)
2. Mostly during first trimester
3. Affects 2% of pregnancies
4. Unclear etiology- possible related to elevated hCG levels
5. Differential Diagnosis- anything that causes N/V
6. Rarely results in severe adverse maternal or fetal effects
7. Management
a. Hospitalization
b. Anti-emetics, vitamin B6
c. IVF until able to tolerate meals
d. If persistent weight loss- PICC line and TPN

Intrahepatic Cholestasis of Pregnancy

1. Elevated serum bile acid concentration and severe itching- palms and soles
2. Second and third trimester
3. Variable incidence (1-15%)- higher in Latin ethnic groups
4. Genetic link, but thought to be related to estrogen effect on bile acids
5. Differential Diagnosis- other liver or biliary diseases
6. No adverse maternal effects
7. Increased risk of fetal death and respiratory distress syndrome
8. Management
a. Actigall (ursodiol)- improves bile flow
b. Benadryl for pruritus
c. Fetal testing with delivery between 36-38 weeks

Gestational Thrombocytopenia
1. Low platelet count during pregnancy
a. Mild (>70K), most are >120K
b. Women are asymptomatic
c. No history of platelet abnormality predating pregnancy
d. Returns to normal postpartum
2. Occurs in third trimester
3. Roughly 5% of pregnancies
4. Unclear etiology
a. Anti-platelet antibodies present similar to ITP
b. Accelerated platelet consumption
5. Differential Diagnosis – ITP, TTP, Preeclampsia/HELLP syndrome
6. No significant fetal or maternal effects
7. Some anesthesiologists will not place epidural with low platelets
8. No specific management

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Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPs)
1. Erythematous and itchy papules and plaques that develop striated areas
2. Third trimester and postpartum
3. Etiology:
a. Stretching of skin causes inflammatory response
b. Fetal DNA found in some lesions
4. Differential Diagnosis
a. Bed bugs bites, IHCP, Eczema
5. Rash and itching can be uncomfortable but no severe fetal or maternal effects
6. Management- symptomatic treatment
a. Topical corticosteroids
b. Oral antihistamines
c. Systemic steroids if severe

Pre-Existing medical conditions & Pregnancy Specific Syndromes (33 minutes)

Chronic Hypertension (CHTN)

1. Diagnosis
a. BP > 130/80, prior to 20th week of pregnancy, 2 separate occasions
b. Known diagnosis of CHTN prior to pregnancy
c. Increases risk of fetal death, growth restriction, placental abruption, and the
risk of developing a hypertensive disorder of pregnancy
2. Initial Evaluation
a. history of age of onset, duration, and severity of disease
b. may need more extensive work up depending on above
3. Labs/ Studies
a. EKG, echocardiogram, ophthalmologic exam
b. BMP- electrolytes, particularly kidney function
c. 24 hour urine collection- protein
d. CBC, LFTs, Uric acid
4. Antenatal Testing
a. baseline U/S at 18-20 weeks- anatomy
b. repeat U/S every 4 wks starting at 28 wks- growth
c. Non stress test and/or Biophysical Profile weekly starting at 32 wks
5. Management
a. Mild to Moderate Hypertension (140-159/90-109)
i. no proven benefit in clinical trials to prevent progression to
preeclampsia, growth restriction, neonatal death, or preterm
birth
ii. therapy instituted for BP >150/90
b. Severe Hypertension (>160/110)
i. Prevention of intracerebral hemorrhage, hypertensive
encephalopathy, and decreases risk of maternal death
c. Acute management (>170/110)
ii. Labetalol
iii. Hydralazine

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 iv. Procardia
v. Sodium Nitroprusside
vi. Titrate BP to no less than 140/90- applies to CHTN and HTN
disorders of pregnancy
d. Chronic management
vii. Nifedipine
viii. Labetalol
ix. methyldopa

Hypertensive Syndromes of Pregnancy

1. Gestational Hypertension
a. Systolic BP >140 or Diastolic BP >90 on 2 occasions 6 hours apart
b. After 20 weeks of gestation
c. No other signs or symptoms
2. Preeclampsia
a. Diagnosis
i. Gestational hypertension AND
ii. Proteinuria > 300mg in a 24 hour collection or persistent 1+ on
dipstick
b. Cause is unknown
c. Incidence in the US is roughly 5%
d. Classification: dependent on the severity of signs and symptoms
i. Non Severe or Severe
e. Criteria for Severe
i. BP > 160/110 on two occasions while on bedrest (either/or)
ii. Proteinuria need not be present
iii. Oliguria <500ml in 24 hours
iv. Cerebral or visual disturbances
v. Pulmonary edema or cyanosis
vi. Epigastric or RUQ pain
vii. Evidence of hepatic dysfunction
viii. Thrombocytopenia
f. In non severe preeclampsia outcomes are similar to normal pregnancy
g. In severe preeclampsia risks are increased compared to normal
pregnancies
3. Superimposed Preeclampsia
a. Complicates 25% of those with CHTN
b. CHTN plus new onset proteinuria or
c. Onset of CNS symptoms or evidence of HELLP syndrome
d. Sudden increase in BP or proteinuria from baseline
4. HELLP Syndrome
a. Hemolysis, Elevated Liver enzymes, and Low Platelets in women with
preeclampsia
5. Eclampsia
a. Seizures in women with preeclampsia not attributable to other causes

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Diabetes- Pregestational and Gestational
1. Hormones of pregnancy lead to increasing insulin resistance as pregnancy
progresses
2. Prevalence of DMII is increasing
3. 90% of diabetes in pregnancy is gestational
4. Pregestational
a. Evaluate for history of DM or undiagnosed pre-existing DM
b. If history of pre-existing assess for end organ damage
i. Cardiovascular
ii. Renal
iii. Ophthalmologic
iv. HgbA1c
c. If no history screen for gestational or consider testing for type II
5. Gestational
a. Risk factors- age, race, obesity, family history, prior GDM
b. Diagnosis
i. Screening: 50 gram glucose load- check BS at one hour
1. >135 considered elevated and need further testing
ii. Diagnostic: 100 gram glucose load- check FBS, one hour, two hour,
and three hour BS
1. Abnl values are greater than: 90/180/155/140
2. At least two abnl values qualifies for diagnosis of GDM
iii. Classifications of DM
1. A1/A2- gestational
2. B/C/D/F/R/H- pregestational
c. Pregnancy complications
i. Maternal
1. Diabetic complications may worsen- renal, eyes, DKA
2. Spontaneous abortion
3. Preeclampsia
ii. Fetal
1. Congenital anomalies
2. IUFD
3. Macrosomia and birth injury
4. Growth restriction
5. Neonatal cardiomyopathy
6. Respiratory distress syndrome
7. Neonatal hypoglycemia
8. Increased risk of childhood obesity
d. Management
i. Diet and Exercise- A1
1. BS goal: fasting < 95, 2 hr PP < 120
2. Measure BS 4 times daily
ii. Oral medications – Glyburide or metformin

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 iii. Insulin
1. Many regimens available
2. Insulin requirements increase through pregnancy
3. 2/3 and 1/3 rule
iv. Imaging
1. First trimester
a. Date and assess viability
2. Second trimester
a. Anatomy 18-20 wks
b. Fetal echo 22 wks
3. Third trimester
a. Growth scans every 4 wks
v. Testing
1. NST/BPP twice weekly
vi. Delivery
1. Glycemic control
2. Fetal size
3. Amniocentesis
vii. Postpartum
1. Screen at 6 wks to assess for non-gestational diabetes

Pregnancy Specific Complications (8 minutes)

Preterm delivery
Delivery prior to 37 completed weeks of gestation
12% of births in the US
Consequences: death, respiratory distress syndrome, intraventricular
hemorrhage, necrotizing enterocolitis, cerebral palsy, visual and hearing
impairment

1. Cervical Insufficiency
a. Structural weakness of the cervical tissue that leadsto pregnancy loss
i. Asymptomatic- cervix opens without feeling contractions
ii. Recurrent
iii. Occurs during second trimester
iv. Congenital versus acquired
b. If history in a prior pregnancy
i. Follow with u/s- cervical length
ii. Cervical cerclage
2. Preterm Labor
a. Uterine contractions causing dilation of the cervix
b. Unclear etiology
c. Management
i. Tocolysis- stop contractions
ii. Steroids- fetal lung maturity, minimize risks of PTD
iii. Magnesium sulfate- neuroprotection- decrease risk of CP

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 d. Prevention
i. 17 alpha hydroxyprogesterone acetate- IM injection
ii. Decreases risk of recurrent preterm birth
3. Preterm Premature Rupture
a. Rupture of amniotic sac prior to labor in a preterm gestation
b. Etiology is unclear
c. Management
i. Antibiotics- prolongs the latency to delivery
ii. Steroids
iii. Magnesium sulfate
d. Prevention – 17 alpha hydroxyprogesterone acetate

Abnormal Placentation
1. Placenta Previa
a. Placenta covers the internal cervical os
b. 1 in 200 pregnancies
c. Labor or digital exam can lead to massive bleeding
d. Symptoms- painless vaginal bleeding in second/third trimester
e. Diagnosis via ultrasound
f. Requires delivery by cesarean section
g. May be indication for preterm delivery if significant bleeding
2. Placental Abruption
a. Premature separation of the placenta from the uterus
b. Bleeding occurs between the uterine decidua and placenta
c. 1 in 100 births
d. Symptoms- bleeding with painful uterine contractions- bleeding can be
concealed
e. Management
i. Close monitoring of mother and fetus
ii. May require transfusion of blood products
iii. Timing of delivery
1. Can wait if preterm and bleeding is limited
2. If massive delivery regardless of gestational age
iv. Mode of delivery
1. Can attempt vaginal delivery is bleeding is minimal
2. May require cesarean section
3. Placenta Accreta
a. Abnormal implantation of placenta
b. Attached directly to myometrium instead of endometrial decidual layer
c. Abnormally adherent to uterus. Does not separate following delivery
d. Attempts to separate can lead to massive hemorrhage
e. Incidence varies depending on obstetric history
i. Prior cesarean section
ii. Prior D&E
iii. Multiparity
iv. Thought to be caused by damage to endometrial/decidual layer

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 f. Diagnosis
i. Ultrasound, confirmed by MRI antenatally
g. Different degrees
i. Accrete- attaches to the myometrium
ii. Increta- invades the myometrium
iii. Percreta- penetrates through the myometrium
h. Management
i. Prepare for massive transfusion
ii. Multidisciplinary approach
iii. Plan for cesarean hysterectomy

I have no financial relationships with manufacturers related to this lecture to disclose. –

Dana Farabaugh, M.D.

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