ANTENATAL

OBSTETRIC
COMPLICATIONS

MASAB AZEEM
2018/018
 MINOR PROBLEMS OF PREGNANCY

MUSCULOSKELETAL PROBLEMS
BACKACHE
• Exaggerated lumbar lordosis caused by:
• Hormone induced laxity of spinal ligaments
• Centre of gravity shifts as uterus grows
• Additional weight gain

• Treatment: correct posture, avoid heavy

lifting & high heels, physiotherapy, analgesia
 MINOR PROBLEMS OF PREGNANCY

MUSCULOSKELETAL PROBLEMS
SYMPHYSIS PUBIS DYSFUNCTION
• Painful, most commonly in 3rd trimester
• Symphysis pubis joint becomes ‘loose’

Two halves of the pelvis rub on one another while

walking
• Simple analgesia, improves after delivery;
low stability belt
 MINOR PROBLEMS OF PREGNANCY

MUSCULOSKELETAL PROBLEMS
CARPAL TUNNEL SYNDROME
• Increased soft tissue swelling

Compression neuropathies
• Most common: MEDIAN NERVE
• Numbness, tingling, weakness, pain of
thumb and forefinger
 MINOR PROBLEMS OF PREGNANCY

GASTROINTESTINAL SYMPTOMS
CONSTIPATION
• Hormonal – relax gut muscles
• Mechanical – pressure by expanding uterus on
intestines
• Exacerbated by iron supplements
• High fiber diet
• Mild non-stimulant laxative if necessary (Lactulose)
 MINOR PROBLEMS OF PREGNANCY

GASTROINTESTINAL SYMPTOMS
HYPEREMESIS GRAVIDARUM
• Nausea/vomiting common, 70-80%; 1st trimester
• HG  severe intractable form, 0.3-2.0%
• Fluid/electrolyte imbalance; weight loss
• Increased risk of preterm birth and low birthweight babies
• HIGH levels of hCG
• Treatment: fluid replacement, thiamine supplementation,
anti-emetics (phenothiazine)
 MINOR PROBLEMS OF PREGNANCY

GASTROINTESTINAL SYMPTOMS
GASTROESOPHAGEAL REFLUX
• Weight of gravid uterus + hormone induced relaxation of
esophageal sphincter
• Lifestyle modifications – light meals, sleep propped up,
smoking cessation
• If necessary – antacids, H2 receptor antagonists, PPIs
 MINOR PROBLEMS OF PREGNANCY

GASTROINTESTINAL SYMPTOMS
HAEMORRHOIDS
 High levels of progesterone causes relaxation of blood vessels,
pressure on the superior rectal veins by the gravid uterus and
increasing circulating volume
 Prescribe a local anesthetic/anti-irritant creams and high fiber diet
 Never overlook the ‘warning’ symptoms of tenesmus, mucus, blood
mixed with stool and back passage discomfort that may suggest rectal
carcinoma; a rectal digital examination should be carried out if these
symptoms are suggested.
 MINOR PROBLEMS OF PREGNANCY

GASTROINTESTINAL SYMPTOMS
OBSTETRIC CHOLESTASIS
 Also referred to as intrahepatic cholestasis of pregnancy

 Presents in the second half of pregnancy

 Pruritus(itching) and abnormal liver function tests (LFTs)

 Risk of spontaneous preterm birth, iatrogenic preterm birth and fetal death

 Maternal morbidity in association with the intense pruritus and sleep deprivation

 Treatment: Ursodeoxycholic acid (UDCA) – does not improve fetal outcomes

 MINOR PROBLEMS OF PREGNANCY

VARICOSE VEINS
 Due to relaxant effect of progesterone on the vessels
and venous stasis caused by the weight of the gravid
uterus on IVC.
 Varicose veins of legs: support stockings, avoid
standing for prolonged periods
 MINOR PROBLEMS OF PREGNANCY

OEDEMA
• Generalize soft tissue swelling + increased capillary
permeability  intravascular fluid to leak into
extravascular space.
• Extremities are usually worst affected.
• Frequent periods of rest with leg elevation,
occasionally stockings are indicated.
• Generalized edema !  pre-eclampsia so check BP
and urine for protein.
 OTHER MINOR PROBLEMS OF PREGNANCY

• Itching • Sore Breasts

• Urinary Incontinence • Tiredness
• Nose Bleed • Altered Taste
• Thrush • Insomnia
• Headache • Leg Cramps
• Fainting • Striae Gravidarum & Chloasma
 PROBLEMS DUE TO ABNORMALITIES OF THE
PELVIC ORGANS
FIBROIDS (LEIOMYOMATA)
• Benign growths that develop in the uterus.
• Can be submucous, intramural, subserous
• Can dramatically increase in size during pregnancy.
• If at cervix, may obstruct vaginal delivery
• Red degeneration: ischemic fibroid leading to acute pain,
tenderness, vomiting
Risk of preterm labour or miscarriage. Treat with potent analgesics and
IV fluids.
 PROBLEMS DUE TO ABNORMALITIES OF THE
PELVIC ORGANS
RETROVERSION OF THE UTERUS
 Remains in retroversion and fills up the pelvic cavity
 Base of bladder and urethra are stretched
 Presents with urine retention (classically at 12 – 14
weeks)
 Catheterization is essential until the position of the
uterus has changed
 PROBLEMS DUE TO ABNORMALITIES OF THE
PELVIC ORGANS
CONGENITAL UTERINE ANOMALIES
• Abnormal fusion of mullerian ducts
• Problems associated with bicornuate
uterus:
• miscarriage;
• preterm labour;
• preterm prelabour rupture of membranes (PPROM);
• abnormalities of lie and presentation;
• higher Caesarean section rate.
 PROBLEMS DUE TO ABNORMALITIES OF THE
PELVIC ORGANS
OVARIAN CYSTS IN PREGNANCY
 Most common are serous cysts and benign teratomas
 Asymptomatic cysts may be followed up by clinical
and ultrasound examination
 Large cysts may undergo torsion, hemorrhage and
rupture causing acute abdominal pain which may lead
to pre-term labour or miscarriage
 Requires an emergency surgery where a midline
incision is given to remove the cyst
 URINARY TRACT INFECTIONS
• Most females have asymptomatic bacteriuria. If left untreated, leads to UTI
• Associated with low birth weight and preterm delivery
• Predisposing factors: history of recurrent cystitis, renal tract abnormalities, diabetes, bladder emptying
problems
• The most common organism is E. coli
• Presents as low back pain, general malaise and flu-like symptoms (the classic presentation of increased
frequency, dysuria and hematuria are not often seen)
• O/E: tachycardia, pyrexia, dehydration and loin tenderness
• Order CBC and Mid-Stream Urine (MSU) for microscopy and C/S
• Antibiotics (amoxicillin or 1stgen cephalosporins), high water intake, simple analgesia
 POST TERM PREGNANCY
• A pregnancy that has extended to or beyond 42 weeks of gestation
• Associated with increased risks to both
• Fetus: increased risk of stillbirth and perinatal death
• Mother: increased risk of prolonged labour and caesarean section

• An U/S scan may give temporary reassurance

• CTG should be performed at and after 42 weeks
• Fetal surveillance
• Induction of labour
 ABDOMINAL PAIN IN PREGNANCY
• Distinguish ‘pathological’ from ‘physiological’ pain
• Obstetric causes:
• Early pregnancy (<24 weeks): ligament stretching, miscarriage, ectopic pregnancy, active urinary
retention due to retroverted gravid uterus
• Later pregnancy (>24 weeks): labour, placental abruption, HELLP syndrome, uterine rupture
• Non-obstetric causes
• Uterine/Ovarian causes: torsion of fibroid, ovarian cyst
• Urinary tract disorders: UTI, renal colic
• GI disorders: acute appendicitis, acute pancreatitis, acute gastroenteritis, intestinal obstruction or
perforation, gastric/duodenal ulcer
 VENOUS THROMBOEMBOLISM
• Pregnancy is a hyper-coagulable state due to an alteration in the thrombotic and fibrinolytic systems to
reduce chances of hemorrhage following delivery.
 increase in clotting factors VIII, IX, X and fibrinogen levels,
 decrease in protein S and antithrombin (AT) III
• This is further exacerbated by immobility and venous stasis in lower limbs due to the weight of the gravid
uterus placing pressure on IVC in late pregnancy
 VENOUS THROMBOEMBOLISM
• Pregnancy is associated with 6 to 10 times more risk of VTE
• Risk factors:
 Pre-existing: increase maternal age, thrombophilia (inherited/acquired), obesity, severe varicose veins,
smoking, malignancy
 Specific to pregnancy: multiple gestation, pre-eclampsia, grand multiparity, prolonged bed rest,
emergent cesarean section
• The incidence of nonfatal pulmonary embolism (PE) and deep vein thrombosis (DVT) in pregnancy is high following
delivery and further increases following emergency caesarean section

• Clinical diagnosis of VTE is difficult so all patients suspected of DVT and PE are to be investigated for VTE
 VTE: Deep Venous Thrombosis
• Pain in the calf with varying degrees of redness or swelling.
• Women’s legs are often swollen during pregnancy, therefore unilateral symptoms should ring alarm bells.
• It is mandatory to ask about symptoms of PE as a woman with PE might present initially with a DVT.
• Compression ultrasound and Venography
 VTE: Pulmonary Embolism
• Missing the diagnosis could have fatal implications
• Mild breathlessness or inspiratory chest pain, slight tachycardia (>90 bpm) with a mild pyrexia
(37.5°C)
• Rarely, massive PE may present with sudden cardiorespiratory collapse
• ECG, chest X-ray and ABGs to exclude other respiratory diagnoses
• Ventilation perfusion (V/Q) scan or computed tomography pulmonary angiogram (CTPA)
• Investigate the lower limbs for evidence of DVT by ultrasound, and if positive treat with a
presumptive diagnosis of PE
 VENOUS THROMBOEMBOLISM
• D-dimer test cannot be used to screen for VTE in pregnancy because D-dimer levels are already high in
pregnancy
• Treatment of choice includes Low Molecular Weight Heparin (LMWHs):
 Easy to administer (women can do it on their own)
 Does not cross the placenta
 Lower chances of hemorrhagic complications
• Graduated elastic stockings: for initial treatment of DVT and should be worn for 2 years following a DVT
to prevent post-thrombotic syndrome.
• Warfarin is contraindicated in pregnancy as it crosses the placenta and causes facial and limb defects
in the fetus
 SUBSTANCE ABUSE IN PREGNANCY

• Coexistent addictions
• Malnutrition, especially iron, Vit B and C
• Risk of viral infections (Hep B, Hep C, HIV)
• Management: Stabilize mother’s drug-taking habits, contact social workers/psychiatric
• IMP! Don’t reduce opiate dose too rapidly in pregnancy  fetal distress and stillbirth

Drug Fetal & neonatal risk

Tobacco FGR, Placental abruption
Alcohol FGR, Fetal Alcohol Syndrome
Opiates Preterm labour, Neonatal withdrawal syndrome
Cocaine Placental abruption, FGR, Preterm labour
 OLIGOHYDRAMNIOS

• Defined as amniotic fluid index (AFI) <5th centile for gestation

• History of clear fluid leaking from the vagina; this may represent PPROM
• On abdominal palpation the fetal poles may be very obviously felt and ‘hard’ with a small for dates uterus.
• Causes: renal agenesis, bilateral multicystic kidneys, urinary tract obstruction, placental insufficiency,
maternal drugs (NSAIDs), leakage due to rupture of membranes
• Complications: pulmonary hypoplasia & limb deformities
• Poor prognosis
 POLYHYDRAMNIOS

• Defined as amniotic fluid index (AFI) >95th centile for gestation

• Presents with severe abdominal swelling and discomfort
• Causes: Diabetes mellitus, AV fistula, multiple gestation, oesophageal atresia, duodenal atresia, neuromuscular
fetal condition and anencephaly
• Identify the cause of polyhyroamnios, relieve the discomfort of the mother (via amniodrainage) and assess the
risk of pre-term labour
• In case of maternal DM, polyhyrdamnios corrects itself when the mother’s glycemic control is optimized
 FETAL MALPRESENTATION AT TERM

• Presentation that is not cephalic

• Breech presentation is the most commonly encountered malpresentation
• There are 3 types of breech:
• Extended/frank breech: most common
• Flexed/complete breech: less common
• Footling breech: least common (foot presents at cervix)

• Other types of fetal malpresentations: Transverse and Oblique

 FETAL MALPRESENTATION AT TERM

FRANK (EXTENDED ) FLEXED (COMPLETE) FOOTLING TRANSVERSE LIE OBLIQUE

LIE
 BREECH PRESENATATION

Risk Factors:  Fetal and placental:

 Maternal: -Multiple gestation
-Fibroids -Prematurity
-Congenital uterine abnormalities -Placenta previa
-Uterine surgery -Anencephaly
-Fetal neuromuscular condition
-Oligohydramnios
-Polyhydramnios
 BREECH PRESENATATION

• Confirm breech presentation via U/S by 37th week

• Management:

1. External Cephalic Version (ECV):

2. Vaginal Breech Delivery
3. Elective LSCS (best method is planned elective LSCS)
 OTHER FETAL MALPRESENATATIONS

• A transverse lie occurs when the fetal long axis lies perpendicular to that of the maternal long axis and
classically results in a shoulder presentation
• An oblique lie occurs when the long axis of the fetal body crosses the long axis of the maternal body at an
angle close to 45°
• Both carry a potential risk of cord prolapse and prolapse of the hand, shoulder or foot once in labour.
• Abdomen often appears asymmetrical, Symphsio-fundal height may be less than expected, and on palpation
the fetal head or buttocks may be in the iliac fossa. Palpation over the pelvic brim will reveal an ‘empty’
pelvis.
• Deliver by cesarean section if the unstable lie does not correct itself
 VAGINAL BLEEDING IN PREGNANCY
Threatened Miscarriage:
Vaginal bleeding before 24 weeks of gestation

Antepartum Hemorrhage:
Vaginal bleeding from 24 weeks to the delivery of the baby
• Placental causes:
• Placental Abruption: premature separation of the placenta
• Placenta Previa: placenta covering or encroaching on the cervical os
• Local causes: cervicitis, cervical ectropion, cervical carcinoma, vaginal trauma, vaginal infection
 How to manage a case of APH?
Key questions:
1. Is the bleeding placental?
2. Is the bleeding compromising the mother and/or fetus?

HISTORY EXAMINATION
 How much bleeding?  Pulse, BP
 Triggering factors (e.g. post-coital bleeding)?  Is the uterus soft/tender/firm?
 Any pain or contractions?  Fetal heart auscultation/CTG
 Is the baby moving?  Speculum vaginal examination to identify the
cause of bleeding (after having established that
 Last cervical smear (normal or abnormal)?
placenta is not a previa)
 How to manage a case of APH?
• Investigations:
 CBC, clotting, cross-match 6 units of blood
 Ultrasound scan

Management:
 If localized vaginal bleeding: symptomatic treatment
 If bleeding is placental: admit the patient and monitor both mother and fetus
 Decision has to be made regarding immediate delivery irrespective of gestational age, steroid injection can
be administered
 The woman must be kept under observation for 48 hours as the risk of re-bleeding is high within this time
frame
 RHESUS ISOIMMUNIZATION

• Mismatch between the rhesus blood group systems b/w fetus and mother
• When fetal red cells (Rh +ve) pass across the maternal circulation (Rh –ve), sensitization of the maternal immune
system to these “foreign” red cells may occur and subsequently give rise to hemolytic disease of the fetus and
newborn (HDFN)
• Rhesus disease does not affect the first pregnancy as the primary response is usually weak and consists of IgM
antibodies that do not cross the placenta.
• In subsequent pregnancy with a Rh +ve baby, the Rh +ve red cells cause maternal re-sensitization and production
of IgG antibodies that can cross the placenta and cause fetal hemolysis. This leads to Erythroblastosis Fetalis
causing severe anemia and the fetus may die unless transfusion is performed.
 RHESUS ISOIMMUNIZATION

Potential sensitizing events:

 Miscarriage
 Termination of pregnancy
 Antepartum hemorrhage
 Invasive prenatal testing
 Delivery
 RHESUS ISOIMMUNIZATION

• Prevention: Intramuscular administration of anti-D immunoglobulins to mother. Anti-D immunoglobulins

‘mop up’ any circulating rhesus-positive cells before an immune response is excited in the mother.
 Administer anti-D within 72 hours of a potential sensitizing event
 All rhesus-negative pregnant women who have not been previously sensitized should be offered routine
antenatal prophylaxis with anti-D at 28 and 34 weeks’ gestation
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