Complications in Pregnancy

Complications in pregnancy

Whilst most women will remain healthy throughout their pregnancy, some women may develop more serious conditions or complications. In this chapter we will look at some of the more common conditions that you should be aware of. These conditions are not usually self-managed and generally require closer obstetric and/or medical management in conjunction with your obstetrician, another specialist or in hospital.

Bleeding

Vaginal bleeding or spotting can occur at any stage of pregnancy and can have many causes; some serious and others not so serious. Sometimes the cause will not be obvious even after investigation. Regardless of what stage of pregnancy this occurs it should still be investigated, so please contact your obstetrician or hospital early for advice. The management of your bleeding will depend on the stage of your pregnancy, the cause of the bleeding and how much blood you have lost.

• In early pregnancy
• After 20 weeks

High blood pressure and pre-eclampsia

High blood pressure is the most common complication in pregnancy. There is a group of conditions associated with high blood pressure during pregnancy, where the blood pressure may either be high before pregnancy, it may be caused by the pregnancy itself (pre-eclampsia) or it may exist with the pregnancy and resolve in the postpartum period. Pre-eclampsia is the most significant because it may also affect other body systems such as the blood, kidneys, liver, lungs and nervous system in addition to the high blood pressure. All of these conditions are associated with a higher risk of poor pregnancy outcomes for both mother and baby.

High blood pressure is diagnosed when the blood pressure reading is 140/90 (140 over 90) or higher. The cause of pre-eclampsia is not always known, but some risk factors include: family history of high blood pressure, previous pregnancy with high blood pressure, first-time pregnancy, diabetes, kidney disease, blood clotting disorders, older maternal age, higher BMI and obesity, multiple pregnancy, pregnancy with a new partner or a long interval between pregnancies.

If your doctor diagnoses high blood pressure or pre-eclampsia you will need to have further tests. You may also need admission to hospital for these tests, monitoring and medication. The management of high blood pressure and pre-eclampsia and mode of birth will depend on how severe it is, how well it is controlled by medication, the condition of you and your baby, the stage of pregnancy and any other complications.

High blood pressure does not always have any obvious symptoms, but regular antenatal visits with your obstetrician should pick it up early.

Diabetes

For our bodies to function properly we need to convert glucose (sugar) from food into energy. Diabetes is a chronic condition where a hormone called insulin is no longer produced or not produced in sufficient amounts by the body. Insulin is produced by the pancreas and its role is to convert glucose into energy. So when people with diabetes eat glucose, which is contained in foods like breads, cereals, fruit and starchy vegetables, legumes, milk, yoghurt and sweets, it can’t be converted into energy. Instead of being turned into energy the glucose stays in the blood. This is why blood glucose levels are higher in people with diabetes. Glucose is carried around your body in your blood. Your blood glucose level is called glycaemia – a low level is called hypoglycaemia and a high level is called hyperglycaemia.

As with high blood pressure, diabetes may exist prior to pregnancy or it may first appear during pregnancy (gestational diabetes mellitus or GDM). Women with diabetes usually have a normal pregnancy and birth with no effects on the mother’s or the child’s long-term health. However, poorly controlled blood glucose levels during pregnancy can have long term effects for mum and baby, as well as complications during labour and birth. Some of these include: an increased risk of miscarriage or stillbirth, preeclampsia, birthing a large baby with associated difficulties such as shoulder dystocia (difficult birth of the baby’s shoulders) and instrumental delivery or caesarean birth, and the possibility of ongoing diabetes for you and your baby.

There may be no obvious signs or symptoms that you have diabetes but sometimes women with diabetes may experience tiredness, excessive thirst, frequent urination and blurred vision. Most women will have a diabetes screening test at around 24-28 weeks of pregnancy, but some may need earlier testing if there are any risk factors such as a past history of diabetes, a past unexplained stillbirth, previous large babies or older age. If you have diabetes or it is first diagnosed in pregnancy, you will likely have a team of experts caring for you such as your obstetrician, medical specialist, dietician and diabetes educator. Managing diabetes will involve monitoring your blood glucose levels to ensure they remain within normal limits, adopting a healthy eating plan and physical activity. You may be prescribed oral medication or insulin injections, depending on how your blood glucose levels respond to your management plan.

Breech presentation and birth

Most babies will be born head first, but some will be born with their bottom, feet (or both) leading the way. Breech describes the part(s) of the baby coming first such as its bottom or feet or both. While growing, babies can adopt many different positions in the womb because they have so much room to move, but most will turn to lie in a head first presentation by about 37 weeks. Your obstetrician or midwife can diagnose if your baby is breech by feeling your abdomen or performing an ultrasound scan. If your baby is breech near full-term you might feel its hard head under your ribs.

A breech presentation is not considered abnormal but it can sometimes be associated with an increase in risk of complications for you and your baby. You can discuss your options and the risks and benefits of having a breech birth with your doctor. Depending on your discussion with your doctor, it might be advisable you avoid labour altogether and have a caesarean birth or you might be offered a procedure to turn the baby back to a head first presentation (cephalic presentation). This is called External Cephalic Version (ECV). Not all women can have this procedure, particularly those for whom caesarean is better and safer. ECV is performed in a hospital setting from around 37 weeks using equipment such as an ultrasound and fetal heart monitor to check the baby’s position and condition during the procedure. You might also have a uterine muscle relaxant and an injection of anti-D if your blood group is Rhesus negative. If the ECV is successful you can then go on to labour and birth your baby vaginally. If it is unsuccessful, it can be attempted again at a later date or you may choose to have a caesarean birth. Some women have used other techniques to turn their babies, such as adopting a knee-chest position, being treated with a form of acupuncture called moxibustion and talking or playing music to their baby. However, there is not enough good research about these other techniques at present to recommend these as being safe or reliable.

Preterm labour and preterm premature rupture of the membranes

Most pregnancies go to full term which is about 40 weeks. However, nearly 1 in 10 babies will be born before 37 weeks of pregnancy. Going into labour before 37 weeks of pregnancy is called preterm labour. Having a leakage of the amniotic fluid (fluid around the baby) before 37 weeks is called preterm premature rupture of the membranes and this occurs in about 2 in 100 pregnancies. Having preterm labour and/or rupturing the membranes may or may not mean you are about to give birth. About 50% of women with preterm labour will actually go on to give birth within 7-10 days.

The causes of preterm labour or preterm premature rupture of the membranes are not always found and you may have one or the other or both present at the same time. Some risk factors include: previous preterm birth or premature rupture of the membranes, abnormalities of the uterus or cervix, twins (multiple pregnancies have a higher risk of premature labour), excessive amniotic fluid, placental abruption or other bleeding, pre-eclampsia, vaginal infection, smoking and illicit drug use. If preterm labour and/or premature rupture of the membranes are identified and treated early, it may be possible to prevent a preterm birth. Most women’s gut instincts about being in preterm labour are correct so if you think that you have gone into labour early, it is important to seek advice and care from your obstetrician and hospital as soon as possible. These conditions are best managed in a hospital setting where you and your baby can be closely monitored and cared for appropriately. Your care, how long you remain in hospital, and whether or not labour and birth proceed, including the method of birth, will be determined by a range of factors including how many weeks pregnant you are, yours and your baby’s wellbeing, and any other risk factors and causes. Depending on where you are booked to have your baby and how premature your baby is when it is born, you and/or your baby/babies might need to be transferred to a larger hospital with more comprehensive neonatal intensive care facilities. In general, Ramsay Health Care hospitals can care for babies born from 32 weeks onwards.

Please seek advice promptly from your obstetrician and hospital should you experience any of the following signs and symptoms of preterm labour or preterm premature rupture of the membranes: