Problems of Pregnancy
VOMITING OF PREGNANCY
Nausea and / or vomiting in the morning or at other times of the day is the normal symptom of pregnancy.
From about 6th to 12th week of pregnancy. It nearby always stops before the 14th week.
It is due to higher level of chorionic gonadotrophin or an increased sensitivity to it.
It refers to the persistent vomiting of pregnancy, which disturbs the patient’s health.
Occur secondary to vomiting, starvation, dehydration, namely ketosis, electrolyte imbalance and vitamin deficiency.
- Severe weight loss
- Neurological disorder from vitamin – B deficiency and jaundice from hepatic necrosis.
The mainstay of treatment in symptomatic therapy with close attention to the fluid balance.
1) Exclude any other possible causes like
- Intestinal Obstruction
- Infective Hepatitis
- Cerebral Tumor
3) Non – Teratogenic Anti-emetics such as:
- Premethazine (up to 3 times a day) along with Vitamin – B (pyridoxine)
If Vomiting is Severe:
- Admission to the hospital often leads to dramatic & immediate improvement.
- Intravenous fluids
- Vitamin supplement (intravenous multivitamins preparations)
- Oral feeding is begun as soon as possible starting with fluids and progressing to semisolids and eventually to full diet.
- Treatment is regulated by daily studies of the blood chemistry and cessation of vomiting normal urinary output and weight gain are indications of recovery.
This is very common. Symptoms are of burning in the chest or discomfort often lying down.
- Weight effect of the pregnant uterus preventing stomach emptying.
- General relaxation of the esophageal sphincter due to progesterone.
- Liquid antacid preparation
- Stopping smoking
- Reducing alcohol intake.
- Frequent light meals.
- Lying with head propped up at night.
Most probably occurs due to:-
- Effects of progesterone in slowing gut motility
- Weight of gravid uterus on the rectum may contribute
- Administration of Iron intake
A high fiber diet and a mild (non-stimulant) laxative such as lactulose.
VARICOSE VEINS AND PILES
- Relaxant effect of progesterone on vascular smooth muscles.
- Dependent venous stasis caused by the weight of the pregnant uterus on the inferior vena cava.
- Neither condition should be treated surgically in pregnancy.
- Piles may be improved with local anesthetic anti irritant creams and a high fiber diet.
- Varicose veins on the legs may be symptomatically improved with support stocking, avoidance of standing for prolonged periods and simple analgesia.
It is due to the:
- Laxity of spinal ligaments
- Weight of the pregnancy causing an exaggerated lumber lordosis.
Pregnancy can exacerbate the symptoms of a prolapsed interverteberal disc
occasionally leading to complete immobility.
- Maintain of correct posture
- Avoiding lifting heavy objects (including children)
- Avoiding high heals
- Regular physiotherapy
- Simple analgesia (paracetamol or paracetamol-codein combination)
There is a generalized soft tissues swelling and increased permeability which allows intra-vascular fluids to leak into the extra-vascular compartment.
The fingers, toes and ankles are usually worst affected and the symptoms are aggravated by hot weather.
a) Edema is best dealt with by advising frequent periods of rest with leg elevation, occasionally support stockings are indicated.
b) Edema may be a feature of pre-eclampsia , check the women’s blood pressure and urine for protein.
c) Severe edema may suggest under lying cardiac impairment or nephortic syndrome.
CRAMPS IN LEGS
Transient nocturnal painful spasms of the small muscles of the fact or of the pregnancy due to calcium deficiency or temporary circulatory insufficiency.
Improves spontaneously during later pregnancy but can troublesome if it returns during labor.
MEDICAL DISEASES & PREGNANCY
In pregnant women, a systolic blood pressure above 140 mm hg or a diastolic blood pressure above 90 mm hg is considered hypertension.
(Hypertension is diagnosed in pregnancy if there is an increase of 30 mm in systolic or 15 mm in diastolic pressure over the baseline based on two readings taken 6 hours apart)
Hypertension occurring after 20 weeks but not accompanied by proteinuria is termed as gestational hypertension. It was previously called Pregnancy Induced Hypertension. (PIH)
- UCE – Urea , creatinine and electrolytes.
- LFTs – Liver function test
- 24 hours urinary protein / urea creatinine clearance
- Renal Scan
- Auto–antibody Screen
- Complement Studies
- ECG & Echo
If the blood pressure is consistently noted to be in excess of 150/100 mm hg. Anti-hypertensive Medication (preferably methyldopa) is indicated to reduce the risk of intracerebral haemonhage or heart failure.
Anti Hypertension medication should maintain the blood pressure below 160 mm hg systolic and 100 – 110 mm hg diastolic.
Attempt vaginal delivery by induction of labor if the maternal blood pressure is reasonably controlled.
- For delivery before 34 weeks gestation the mother should be given steroids to increase fetal lung maturation
- If there is evidence of rapidly deteriorating maternal or fetal well being then cesarean section is appropriate.
- Magnesium sulphate for seizures in patients with signs of fulminating pre- eclampsia.
- Observation is required in the first 48 hours postnatally because of persisting risk of eclampsia.
- Breast feeding is encouraged and although some anti-hypertensive medication may enter the breast milk, it is not significant.
World Health Organization has defined diabetes mellitus as either a:
Raised fasting blood glucose level of >7.8 mmol / l (140 mg%)
Level of >11.1 mmol / liter (1998 mg%) following a 75 gram glucose load.
Significant hormonal changes affect carbohydrates metabolism during pregnancy. In particular there is an increase in human placental lactogen and cortisol, both of which are insulin antagonists and therefore relative insulin resistance develops in the mother.
These changes are most marked during the third trimester. To balance these changes during normal pregnancy the maternal pancrease secrets increased amount of insulin to maintain carbohydrates metabolism. Typically in pregnancy this will result in a fall in the fasting level of glucose.
Glucose crosses placenta by means of a facilitated diffusion process and the fetal blood glucose level closely follows the maternal level.
1. Pre – Diabetes:
When parous women, discovered to have diabetes give a history of previous very large babies (>4.5 kg) or intrauterine death.
2. Potential Diabetes:
Women who have features in their personal or family history which put them at an increased risk of developing diabetes in pregnancy.
These features include:
- Diabetes in a first degree relative
- Maternal obesity ( e.g > 120% of the ideal body weight)
- Previously large baby (variously considered to be > 4 kg or >4.5 kg.)
- Previous unexplained stillbirths
- Previous abnormal glucose tolerance but not diabetes outside pregnancy.
- Persistent glycosuria
Gestational Diabetes Mellitus (GDM):
- GDM is defined as the state of carbohydrate intolerance that has its onset or first recognition during pregnancy.
- GDM includes type I & type II patients.
- GDM may include a small group of women with previously recognized over diabetes mellitus type I or type II. However, usually the glucose tolerance is mild before pregnancy.
- Diabetes that appears in pregnancy and disappears after delivery, 50% of women with gestational diabetes will be established diabetics 10 years later.
Impaired Glucose Tolerance:
If the 2 hours value in 7.8 – 11.1 mmol /L glucose tolerance is said to be impaired. Impaired glucose tolerance without any symptoms is sometimes referred to as Chemical Diabetes.
- True GDM usually develops in the second trimester or early in third trimester when organogenesis is already complete.
- If GDM is diagnosed in the first trimester then it is imperative to confirm with the help of HbA1C whether it may be overt type I or type II diabetes, which may affect the incidence of congenital malformation.
Selective Screening of women > /=30 years of age 50 gram oral glucose load between 24-28 weeks gestation. Urinary glucose has been shown to be unreliable method of detecting potential diabetes and most screening tests now rely on blood glucose estimation.
Fasting Blood Sugar (FBS):
- Fasting blood glucose of >=7.9 mmol/L or a single blood sugar measurement over 11 mmol/L is diagnostic without the need to delay treatment while a GTT is performed.
- Patient with plasma glucose level >/=140 mg/dl should be evaluated a diagnostic 3-hours Oral Glucose Tolerance Test (OGTT)
Random Blood Sugar (RBS):
Random Blood Sugar at booking, the sensitivity of this test is only about 60%.
When the values at booking are:
- >5.8 mmol / L (2 hours after meals) or
- >6.2 mmol / L (within 2 hours of a meal)
then perform OGTT (Oral Glucose Tolerance Test)
NOTE: This test is repeated at 28 weeks gestational when glucose tolerance is under greater stress because of increased concentration of HPL (Human Placental Lactogen). On further testing 80% of cases are found to be normal.
Testing the Urine for Glucose:
This is not a discriminating test for diabetes in pregnancy. Owing to a decreased renal threshold, glycosuria is common in normal pregnancy so that glucose spills with the urine even though plasma levels are normal. Women with the persistent finding of glucose in the Urine should have a random blood sugar measurement.
- The principle of treatment is to maintain the blood sugar level with a mean 24 hours profile of < 5mmol/L. This will usually require three or four times daily uses of insulin.
- Provided the pregnancy has gone will management would attempt to achieve a vaginal delivery between 38 – 40 weeks gestation.
- Delivery is recommended at no later than 40 weeks gestation in patients requiring insulin therapy and at no later than 42 weeks for diet controlled patients.
- No elective delivery should be performed prior to 39 weeks without establishing lung maturity because of the possibility that even mild GDM can delay lung maturity.
- GDM is not an absolute indication for cesarean section.
- Previous obstetric history and clinical pelvimetry are useful tools in obstetric management.
Timing of Delivery in Women with GDM
The decision about timings of delivery should take into consideration the risk for respiratory distress syndrome (RDS) favorability of cervix for labor, the size of fetus and on going exposure to the risk of stillbirth.
Patient with poorly controlled diabetes & macrosomic features are at greater risk for stillbirth and should be delivered somewhat earlier (37 – 38 weeks) if lung maturity can be assured.
Patients with well-controlled diabetes & normal features are at lower risk for stillbirths and may be allowed to wait later into their pregnancies for cervical maturity.
RH HEMOLYTIC DISEASE
This problem arises when the Rh-negative mother is carrying a Rh positive baby because of the Rh positive blood gp of father.
- The first baby is rarely affected
- The first baby may be affected if the mother had an abortion or blood transfusion with Rh-positive blood group.
Potential Sensitizing Events for Rhesus Diseases:
- Termination of Pregnancy
- Antepartum Hemorrhage
- Invasive prenatal testing (chorionic villous sampling, amniocentesis and cardiocentsis)
- Enlarged fetal heart
- Ascities & pericardial effusion
- Reduced fetal movements
- Abnormal CTG with reduced variability, eventually a “sinusoidal trace”
Clinical Rh hemolytic diseases may manifest as hydrops fetalis or hemolytic anaemia
Management of Rhesus
This depends on clinical scenario, BOTH THE WOMEN & HER BABY’S FATHER is Rh- NEGATIVE: There is no risk that the baby will be Rh – Positive. There is therefore no chance of rhesus (Rh) diseases.
THE WOMEN IS RHESUS NEGATIVE AND THE PARTNER IS RHESUS POSITIVE: She has no Rh antibodies & it is either her first pregnancy or she had not had a pregnancy previously affected by Rh disease.
Monitor atypical antibodies at booking and at 24 – 36 weeks. An increase in antibody titer to > 10 iu /ml requires review in fetal medicine center, so that early signs of fetal edema can be detected by Ultrasound and if appropriate, invasive assessment performed.
Once a women is sensitized to the Rh-antigen, no amount of anti-D will even turn back the clock. In this situation, therefore there is no role whatsoever of anti-D.
Prevention of Rh- Disease:
- Prevention of Rh – disease is by testing women at their first prenatal visit with a blood type and antibody screen.
- In those women who are Rh-negative with a negative antibody screen, 300 ug (one vial) of anti – D globulin (Ig G) is given at 28 weeks of gestation, if the antibody screen has remained negative.
- At the time of delivery, if the newborn Rh – POSITIVE, then anti – D globulin is readministered.
- Administration of anti – D globulin will cause maternal serum antibody titer to be positive to no greater than a titer of 1:4 for seven weeks after administration.
- One vial of anti-D globulin will protect against 30 cc of fetal whole blood or 15 cc of fetal packed red blood cells.
Prevention of Recurrence of Rh Incompatibility
Every Rh-NEGATIVE mother who has given birth to a Rh-POSITIVE baby should be given one ml of anti-D immunoglobulin intramuscularly within 72 hours of delivery.
It is also indicated when:
- Rh – Positive blood is accidentally transfused to a Rh- Negative mother
- Rh – Negative mother who had an abortion.
Anti – D immunoglobulin “mop-up” any circulating rhesus positive cells before an immune response in excited in the mother & then prevents formation to antibodies.
Abortion denotes the expulsion of product of conception before the 24th weeks of pregnancy. The most common time for clinically evident abortion is the termination of pregnancy by any means before the fetus is sufficiently developed to survive.
Types of Abortion:
(Chart from the book)
It means that there is only a threat of abortion, the process has started but it may be arrested. Threatened miscarriage is one of the most common indications (together with suspected ectopic pregnancy) for emergency referral to young women to a causality department. The diagnosis is usually based on clinical examination.
- Sign & Symptoms of Pregnancy
- Characteristically (2-3 months) amenorrhea
- Minimal vaginal bleedings occurs (bright red)
- Internal cervical os is closed
- There is very little and no pain
- U/S findings should confirm pregnancy.
Based on clinical examination:
- Pelvic Examination
- Speculum Examination
- Ultrasound Examination which determines
- The presence of intrauterine gestational sac
- Size of fetus & given fetal cardiac activity
- Give some clue to dilation of cervix
- Reveals any unsuspected abnormality.
- Hormone Estimation:
Diagnostic & prognostic value in 6 – 8 weeks of pregnancy. Soon after missing the periods serum beta HCG level doubles/48 hours.
- Complete bed rest for a few days till all the blood loss stops.
- U/S scan performed which confirms that pregnancy is progressing.
There is no specific treatment for threatened abortion, only complete bed rest, good hygiene and high protein diet would be helpful.
- This means that process has become irreversible
- Expulsion of conceptus is bound to happen & this cannot be prevented or stopped.
- It is usually preceded by threatened abortion
- An inevitable miscarriage can be complete or incomplete depending on the whether or not all fetal & placental tissues have been expelled from the uterus.
Sign & Symptoms of pregnancy + characteristically 2 – 3 months amenorrhea & the following:
- Profuse, intermittentant, heavy vaginal bleeding.
- Dilated internal cervical Os
- Size of uterus corresponds to duration of gestation & uterus is tender.
- Cramping, rhythmical, painful uterine contraction like lower abdominal cramps.
- U/S findings
- Intrauterine gestational sac (>20 mm diameter) with no embryo or with 6mm embryo with no heart beat.
Patient requires admission to hospital, analgesia for pain & evacuation of uterus
(i) < 12 week gestational :
Immediate evacuation of the uterus under general anesthesia
(ii) > 12 week gestational:
Infusion of oxytocin followed by evacuation of retained product of conception.
- Means abortion has taken place but some product of conception are retained in the uterus
- Preceded by inevitable abortion
- If RPOCS are not removed, it results in vaginal bleeding, sepsis & adherence to the uterine wall may get organized to become placental polyp.
Symptoms & signs of pregnancy + amenorrhea ( 2 – 3 months) & the following:
(i) Mild to severe vaginal bleeding occurring along with passage of products of conception often described by the women as “pieces of skin & liver”. Some products are retained.
(ii) Dilatation of internal cervical Os.
(iii) Size of the Uterus, uterus is reduced to the duration of gestation, bulky & softer.
(iv) Cramping, rhythmical, painful uterine contractions.
(v) U/S findings : RPOCS can be seen on ultrasound scanning. Obviously fetal cardiac action is absent.
- Maintain I/V line
- Injection Methergin 02 ampoules (500 ugm) is given immediately intravenously
- 30 units syntocinon in the 1000 cc drip at 30 d / min is to be started
- Prophylactic antibiotic.
- Urgent evacuation of uterus under anesthesia
When all the uterine contents have been expelled spontaneously there is cessation of pain, scanty blood loss and a firmly contracted uterus with closed cervix.
- Symptoms of pregnancy are no longer present and pregnancy test becomes negative
- Minimal vaginal bleeding occurs along with passage of tissues.
- Closed internal cervical os after expulsion
- Cramping, rhythmical, painful uterine contractions but pain is relieved.
- U/S scan shows empty uterine cavity.
If there is no more active bleeding, or if an ultrasound scan shows an empty uterine cavity, no further treatment is required but advise a few days rest.
Anti – D gamma globulin 500 ugm is given 1/M to Rh – Negative women if expulsion occurred within the last 72 hours.
A missed abortion is a gestational sac containing a dead embryo / fetus before 20 weeks gestational without clinical symptoms of expulsion.
This diagnosis is usually made by failure to identify fetal heart activity on ultrasound. The patient after complains of chronic but high vaginal bleeding.
When gestational sac is > 25 mm in diagnosis and no embryonic / fetal part can be seen the term “ BLIGHTED OVUM” or “ANEMBRYONIC PREGNANCY” is used.
Hemorrhage occurs into the choriodecidual space & extends around the gestational sac. The amnion remains intact & becomes surrounded by hillocks of blood clot with a flashy appearance, hence the term “CARNEOUS MOLE” is used.
Amenorrhea ( 4 – 5 months), regression of symptoms and signs of pregnancy plus the following:
- Vaginal bleeding:- Repeated or dark brown vaginal discharge
- Uterine size remains stationary
- Cervix is often TIGHTLY CLOSED
- Serum placental hormone & protein measurements are low & if repeated are shown to be falling
- Ultrasound Scan:
Shows no growth of the fetal (CRL) crown rump measurement & absence of fetal heart activity. In anembryonic pregnancy, no fetus is seen.
Urgent EVACUTION OF THE UTERUS is usually achieved in late cases with a combination of the intra vaginal prostaglandin and an intravenous syntocinon infusion.
All missed abortions would probably be expelled spontaneously in the long term.
Ectopic or Extra Uterine Pregnancy:
An ectopic or extra uterine pregnancy occurs when the fertilized ovum embeds in some site other than the uterine deciduas
An ectopic pregnancy is when the conceptions implant either:
- Outside the uterus (fallopian tube, ovary & abdominal cavity) or
- In an abnormal position within the uterus (cornua or cervix)
- Combined tubal & uterine (hetrotopic) pregnancies are uncommon
Sites of Implementation:
Ectopic sites of implementation are:-
(i) Fallopian tube (ampulla commonest site)
(iv) Rudimentary horn of uterus
(v) Abdominal cavity
Clinical Course & Management:
Symptoms commonly arise after one menstrual period is missed, although they may occasionally begin before this. However, it is rare for ectopic pregnancy to advance beyond 8 weeks without the occurrence of pain & bleeding, a point, which is sometimes helpful in differentiation between the abortion of an intrauterine pregnancy & an ectopic pregnancy.
Symptoms & Signs Associated with Ectopic Pregnancy:
- Pain in 95% of cases
- Gestrointestinal symptoms (80%)
- Amenorrhea with abnormal uterine bleeding (60 – 80%)
- Dizziness or syncope (58%)
Dominate Features is Low Abdominal Pain:
- Pain originates on the side of the ectopic implantation and can be acute or severe
- Dull ache = Unruptured tubal pregnancy
- Sharp Colicky Pain = Hemorrhage in Choriodecidual space
- Severe Pain = Irritation of the under surface of diagram by free blood = shoulder tip pain
- Follows first attack of pain
- Variable continuous to intermittent spotting
- Due to trophoblastic disturbance in tubes =withdrawal of hormones = disintegration of deciduas in uterine cavity.
Profuse, intraperitonal hemorrhage & sever pain will result in sudden shock and collapse of women. This may be fatal unless immediate transfusion & lapartomy are undertaken.
- Serum Beta HCG
- Transvaginal Ultrasound
But both the findings must be interpreted together.
Beta HCG levels : serial estimation shows lower levels to the period of gestation.
Ultrasound Findings (TVS): the presence or obscene of an intrauterine gestational sac is the principle point of distinction between intrauterine & tubal pregnancy.
ULTRASONOGRAPHIC FINDINGS of an extra-uterine sac with an embryo or embryonic remnants in the most reliable diagnosis at ectopic pregnancy.
Speculum or Bimanual Examination must be performed in an environment where facilities for resuscitation are available as this examination may provoke the rupture of tube.
The classical approach to the treatment of ectopic pregnancy has always been Surgical (SALPINGECTOM or SALPINGOTOMY) either by laparotomy or laparoscopy.
Fate of Tubal Pregnancy:
A tubal pregnancy may terminate in the following ways:
- Tubal Male
- Tubal Abortion
- Tubal Pregnancy
- Secondary abdominal pregnancy
- Interstitial (cornual) pregnancy
- Ovarian Pregnancy
- Rupture of pregnant rudimentary horn.
- Cervical Pregnancy.