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Complications in Pregnancy

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The majority of pregnancy cases proceed without any major problems. However, sometimes major problems happen to the mother, fetus, or birth. Problems in pregnancy like an embryo fail to implant or develop properly, or a problem may occur later when the fetus seems to be developing properly. Problems in pregnancy may due to fetal factors such as genetic or chromosome abnormality or to maternal factors like as n infection or hormonal or anatomical problems.

We will discuss all major complications in this article.

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Miscarriage

This is the spontaneous ending of a pregnancy before 24 weeks. Most occur during the first 14 weeks. Early miscarriages tend to result from a genetic or chromosomal abnormality in the fetus. Later miscarriages may be caused by a problem in the uterus. Other causes include cervical incompetence. maternal infections. Various factors increase the risk of miscarriage, including smoking,
drinking, and drug abuse during pregnancy. The risk of having a miscarriage in early adult life is about 1 in 5 pregnancies (about 20 percent) but the risk increases with age, especially over the age of 40.

There are three main types of miscarriage.

  1. Threatened Miscarriage: In a threatened miscarriage, there is vaginal bleeding but the fetus is alive and the cervix is closed. In an inevitable miscarriage, the cervix is open and the fetus is usually dead.
  2. Missed Miscarriage: In a missed miscarriage, the fetus has died but there is no bleeding. With a threatened miscarriage, the pregnancy may proceed to term.
  3. Inevitable Miscarriage: An inevitable miscarriage may be complete or incomplete, meaning that some tissue remains in the uterus. An incomplete or missed miscarriage may require surgery to empty the uterus.

 

Causes of Miscarriage

There are several causes of miscarriages that are listed below:

1. Inherited

Fetal genetic or chromosomal abnormalities are possible causes, such as the presence of too many or too few chromosomes.

2. Hormonal

Overactivity or underactivity of the thyroid gland, diabetes mellitus, and abnormally low levels of progesterone are possible causes.

3. Immunological

Miscarriage can be caused by rare immune disorders, such as antiphospholipid syndrome (placental clots reducing blood supply to the fetus).

4. Infective

Several infections affecting the mother can cause miscarriage, including rubella and toxoplasmosis (a protozoal infection).

5. Anatomical

Miscarriage can sometimes occur if the uterus is abnormally shaped or has large fibroids; cervical incompetence is another possible cause.

 

Still Birth

A stillbirth is when a fetus dies in the uterus and is born after 24 weeks of pregnancy. Often, the cause of stillbirth is unknown, but it may occur as a result of structural or genetic disorders in the fetus, problems with the placenta, or maternal infection or illness. If the fetus dies late in pregnancy, labor may need to be induced, particularly if the mother’s health is at risk, or it may be possible to wait for labor to start naturally. In either case, a stillbirth can be very distressing, and the mother will be offered various support options. In developed countries, the risk of stillbirth is small – about 1 in 200 pregnancies.

To help minimize the risk, the mother should attend all antenatal appointments and tell the midwife or doctor if the fetus is moving less than normal, or if she develops abdominal pain, vaginal
bleeding, or itching. Other measures include stopping smoking, having flu vaccination during the flu season, going to sleep on one side, keeping a healthy weight, and avoiding alcohol and drugs. Certain foods should also be avoided, including soft cheeses, unpasteurized milk products, pâté, undercooked or raw meat, and uncooked shellfish.

 

Cervical Incompetence

If the cervix is weak (Incompetence), pressure from the growing fetus and amniotic fluid may cause it to open early, resulting in a miscarriage. The weakness of the cervix may follow surgery to the cervix or a number of procedures that require the cervix to be opened (including termination of pregnancy). Cervical incompetence tends to cause miscarriages after 14 weeks’ pregnancy, and often there are no symptoms before a miscarriage occurs. If a woman has had a late miscarriage, an ultrasound may be arranged to check the cervix. In case, the ultrasound confirms cervical incompetence, a stitch may be inserted in the cervix at 12–16 weeks in the next pregnancy (and any subsequent ones) and then removed at 37 weeks ready for the start of labor. If labor begins early, the stitch is removed straight away.

 

Ectopic Pregnancy

In an ectopic pregnancy, the fertilized egg implants outside the uterus so that the embryo cannot develop properly. This condition can be life-threatening for the mother. In most ectopic pregnancies, the fertilized egg implants in the Fallopian tube, although rarely it may implant elsewhere, such as in the cervix, ovary, or abdominal cavity. Possible underlying causes include
previous damage to the Fallopian tube, perhaps due to surgery or an infection such as pelvic inflammatory disease. Using a coil, or intrauterine contraceptive device (IUD), also increases the risk. The symptoms are vaginal bleeding and lower abdominal pain, usually on one side.

To diagnose the condition, a pregnancy test may be arranged, followed by an ultrasound scan if the test is positive. A doctor may also perform a laparoscopy (in which a viewing instrument is passed through the abdominal wall). If an ectopic pregnancy is found, it will be removed during the laparoscopy. If an ectopic pregnancy leads to the rupturing of a Fallopian tube, there will be severe abdominal pain and pain in the shoulder tip. The condition is potentially life-threatening and requires urgent surgery.

 

Molar Pregnancy

This occurs when a sperm fertilizes an egg but the resulting set of chromosomes is abnormal so that a normal pregnancy cannot be developed. In a complete molar pregnancy, a mass of cysts forms in the uterus. In a partial molar pregnancy, an embryo and placenta start to grow, but the embryo does not survive.

Symptoms include vaginal bleeding, which may begin from about six weeks, and nausea and vomiting, which may be severe. A molar pregnancy is treated by opening the cervix (under general anesthesia) so that the tissue can be removed. Rarely, the molar tissue becomes cancerous and further treatment, such as chemotherapy, is necessary.

 

Placenta Previa

If the placenta lies in the uterus low in the uterus and partly or fully covers the opening to the cervix. It can interfere with birth. This condition affects about 1 in 200 pregnancies. Placenta praevia is a common cause of painless vaginal bleeding after the 24th week of pregnancy. Heavy bleeding can be potentially life-threatening for both fetus and mother.

Risk factors include a previous Caesarean section, multiple pregnancies, and several previous pregnancies. It is diagnosed by an ultrasound scan. Often, the placenta will move up as the uterus grows, but if it stays low and bleeding occurs, admission to the hospital is necessary. Hospital admission is also usually recommended from about 30 weeks for all women with complete placenta previa, with a Caesarean section being planned for about 38 weeks. If severe bleeding occurs, an emergency Caesarean section is needed. A Caesarean section is also recommended for women with a partial placenta previa.

 

Placental Abruption

This is a potentially life-threatening condition in which part or all of the placenta detaches itself from the wall of the uterus before the baby is born.

There are two forms of placental abruption:

  1. Revealed abruption, a common cause of vaginal bleeding after 28 weeks.
  2. Concealed abruption, which does not cause bleeding as the blood remains in the uterus.

Risk factors include long-standing high blood pressure, a previous abruption, and several previous pregnancies. Smoking, excessive drinking, and drug abuse also increase the risk. In contrast
to bleeding in placenta previa, placental abruption is always painful.

Amniotic Fluid Problems

The amount of fluid contained in the amniotic sac can be affected by a number of conditions. It results in either an abnormally large volume (Polyhydramnios) or an abnormally small volume (Oligohydramnios). Polyhydramnios can cause maternal discomfort and is associated with premature rupture of the membranes and premature labor. Polyhydramnios also increases the risk of placental abruption, postpartum hemorrhage, Caesarean section, and unstable lie (where the fetal position is constantly changing).

The condition is managed to prolong the pregnancy and prevent complications for the mother and fetus. Where possible, underlying causes are treated. Oligohydramnios is often only noticed during antenatal checks. This condition, caused by the premature rupture of the membranes, is associated with premature labor and fetal growth restriction. Regular assessment of fetal wellbeing should be performed.

Causes of Amniotic Fluid Problems

Excessive amniotic fluid (polyhydramnios) or too little (oligohydramnios) may be associated with factors in the mother or the fetus. Some common factors are below.

Causes of Oligohydramnios

  • Premature rupture of membranes
  • Fetal growth restriction, for example, due to pre-eclampsia
  • A fetal abnormality causing reduced urine production or obstruction of the passage of urine
  • The use of drugs, such as non-steroidal anti-inflammatory drugs
  • Twin–twin transfusion syndrome (an imbalance when one twin receives more blood than the other)
  • Infection
  • Chromosomal abnormalities, such as Down’s syndrome
  • Postmaturity – a baby is overdue

Causes of Polyhydramnios

  • Diabetes mellitus
  • Gastrointestinal (bowel) obstruction
  • Impaired fetal swallowing due to fetal abnormalities, such as anencephaly
  • Heart failure due to congenital reasons or anemia
  • Increased fetal urine production (such as twin-twin transfusion syndrome)
  • Infection, such as syphilis or parvovirus
  • Chromosomal abnormalities, such as Down’s syndrome
  • Achondroplasia (a bone disorder causing short stature).

 

Fetal Growth Restriction

It is also known by the name Intra-Urine Growth Retardation. This condition occurs when a fetus fails to grow sufficiently in the uterus so that it is thin and has a low birth weight (Less than 2.5kg). Fetal growth restriction has many possible causes, including long-standing high blood pressure, pre-eclampsia (see below), or a maternal infection, such as rubella. In some cases, it may occur because the placenta fails to supply sufficient nutrients to the fetus. Inherited fetal disorders, such as Down’s syndrome, are also possible causes. The risk of growth restriction is increased if the mother has a poor diet, smokes, drinks excessively, or abuses drugs. Repeat ultrasound scans, and sometimes Doppler scans of blood flow in the umbilical artery, are used to monitor fetal growth.

Hospital admission for bed rest and monitoring may be needed, and, when possible, any underlying causes are treated. Early delivery may be recommended if there are concerns about the baby’s health.

 

Obstetric Cholestasis

It is also called Intraphetic Cholestasis of Pregnancy. In this condition, there is the abnormally slow flow of bile; a substance that the liver produces to aid digestion. Obstetric cholestasis causes a build-up of bile in the mother’s blood, producing symptoms such as very itchy skin and jaundice. The itching is often most pronounced on the hands and feet but may affect the entire body; it is also often worse at night.

Obstetric cholestasis can increase the risk of premature birth or stillbirth, so it is important that it is recognized and treated early. The cause of the condition is unknown but there may be a genetic link, because it is more common in women of South American, South Asian, or Scandinavian origin, and it can run in families. It is also more common in women who are pregnant with twins or other multiple fetuses. To diagnose obstetric cholestasis, the doctor may ask about the mother’s family history and may order blood tests to assess liver function and levels of bile acids.

The mother may be given a drug called ursodeoxycholic acid to reduce bile acid levels and help to relieve itching. The mother’s liver function and levels of bile acids will be monitored throughout the pregnancy, and the fetus will also be monitored to detect any problems, such as an abnormal fetal heart rate. Severe obstetric cholestasis may interfere with normal blood clotting in the mother; vitamin K may be given to correct this problem. In some severe cases, labor may be induced if the fetus is older than 36 weeks’ gestation, to prevent stillbirth.

 

Pre-Eclampsia and Eclampsia

In pre-eclampsia, the blood pressure increases, fluid is retained, and protein is lost in the urine. Symptoms occur quite late in the condition, including swelling of the hands, face, and feet, headache, visual disturbances, and abdominal pain. If untreated, high blood pressure leads to eclampsia (seizures) in 1 percent of women with pre-eclampsia. For this reason, every pregnant woman has her urine checked for the presence of protein, and her blood pressure measured at each antenatal visit.

Treatment aims to return the blood pressure within the normal range. There may be fetal growth restriction and hospital monitoring and early delivery of the baby may be necessary. Eclampsia is treated urgently and delivery by Caesarean section usually follows once the mother has been stabilized.

 

Risk Factors for Pre-Eclampsia

The underlying cause of pre-eclampsia is not fully understood, although it may be due to a problem with the placenta. However, various factors have been identified that increase the risk of developing the condition, and these are listed below.

  • Being overweight or obese
  • A family or personal history of pre-eclampsia
  • A multiple pregnancies
  • First pregnancy or first pregnancy with a new partner
  • Ten years or more have passed since the last pregnancy
  • Being over the age of 35
  • Pre-existing kidney disease, high blood pressure, and diabetes mellitus
  • Certain autoimmune disorders

 

Gestational Diabetes

Diabetes mellitus can develop in pregnancy if the pancreas cannot meet the increased need for the Blood-Glucose-Regulating Hormone Insulin. Gestational diabetes often causes no symptoms, but if they do occur they may include excessive thirst, tiredness, and passing large amounts of urine. It is diagnosed by blood tests.
Treatment is by dietary control and, in a few cases, insulin injections. The baby may grow very large, which may necessitate a Caesarean section. Gestational diabetes usually disappears after birth but may recur.

 

Hyperemesis Gravidarum

Vomiting in early pregnancy can be so severe that no fluids or food can be kept down. In contrast to women with normal morning sickness who gain weight, those with hyperemesis gravidarum lose weight and may also become dehydrated. The cause is not fully understood, but very high levels of the hormone human chorionic gonadotrophin (hCG), produced in pregnancy, may play a role.

 

Urinary Tract Infection

Bacterial infections of the urinary tract is common during pregnancy due to the delayed clearing of urine. Hormonal changes in pregnancy and the enlarged uterus delay the urine flow, which makes pregnant women susceptible to urinary infections. Symptoms include a burning sensation when urinating, frequent urination, and pain in the lower abdomen, lower back, or on one side. Fever and pain in the kidney area may indicate that the infection has spread up the urinary tract.

A urine test may be done to confirm the diagnosis; treatment is with antibiotics. Untreated, a urinary tract infection may lead to premature labor or a low-birthweight baby.

 

Sciatica

This pain spreads from the buttock down the back of the leg due to pressure on the sciatic nerve. The changes in posture during pregnancy can put pressure on the sciatic nerve, which runs down the back of the leg and divides at the knee to go to the outer border and sole of the foot. As well as pain, sciatica may also make it difficult to stand upright, and even to walk if the condition is severe.

The symptoms tend to be intermittent and usually clear up after birth. In the meantime, they may be alleviated by adopting a good posture, with the shoulders pulled back, the spine kept straight, the bottom tucked under, the abdomen tucked in, and the knees kept relaxed.

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