COMPLICATIONS IN PREGNANCY

Most pregnancies are healthy and free from complications, but sometimes problems do arise. In most cases, risks to the mother and the baby are decreased if warning signals are recognised and dealt with early. So, it is important to know about them to recognize them early and take the help of specialized care.

Complications in 1st Trimester

Bleeding

Spotting or bleeding through vagina is a frequent phenomenon during 1^st trimester of pregnancy. It is rather difficult to say which of the cases may land up in a problem and which may not. However, bleeding, unless proved otherwise, should be considered a symptom of impending abortion  .   The patient must call on the doctor immediately.

How often does bleeding occur?

20 to 25% of women have spotting to bleeding. through the vagina. However, the possibility of spontaneous abortion is relatively small (2.5% to 3%) and the most likely outcome of the pregnancy will be normal.

What can cause bleeding?

• Minimal spotting particularly at the expected time of menses or just prior to that is rather normal, which usually occurs at the time of implantation of the zygote  .

• Under influence of estrogen the inner lining of the cervix overgrows causing spotting. This is medically known as 'Erosion' of cervix and can give rise to spotting particularly following deep intercourse in early pregnancy.

• Infection of vagina, cervix – like candidal (fungal) or trichomonal infection. 

• Threatened abortion to complete abortion – all cause bleeding which is definite sign.

• Unless proved otherwise, all bleeding cases should be considered as cases of abortions and carefully investigated.

How to arrive at the diagnosis?

A thorough clinical (physical) and internal examination to rule out the above causes.

1. Blood investigation:

• CBC – complete blood count.
• Blood grouping and Rh typing.

2. Specific investigations :

For the health of foetus:

• Beta hCG levels.
• Serum progesterone levels.

For causes of problems

• TORCH titres.
• Fasting and post lunch sugar.
• VDRL for sexually transmitted disease.
• Thyroid function tests.
• Urine for infection.
• Others as suggest by your doctor.

Ultrasonography

This gives very important information as to whether this bleeding is an indicator of a serious problem.   .   . It can tell you whether the pregnancy is growing well or not, whether it is an abnormally located pregnancy (ectopic). If the heart beat is seen at 8 weeks, the risk of having a miscarriage is not more than 2%.

Treatment:

• Bed rest.
• Sedation.
• Healthy nutritious diet.     
• Folic acid supplementation.     
• Hormonal support: A Woman having low levels of hormone–serum Beta hCG and serum progesterone, can be supplemented from outside, however its role is still questionable.   
• Specific treatment of any cause identified.

Hyperemesis Gravidarum / Severe Vomiting

Hyper – means ‘over’ emesis means- vomiting, gravidarum means – ‘pregnant state’ so Hyperemesis gravidarum means excessive vomiting during pregnancy. This is because B-hCG hormone (hormone of pregnancy), which has stimulating effect on the center of vomiting in brain. (CTZ center in brain).      
More or less all pregnant women experience the complaint of vomiting. When the vomiting becomes persistent, frequent and severe, it leads to health problems. It may keep the mother from getting the nutrition and fluids she needs. If it is not treated in time, it may cause danger to your life and that of the foetus, too.

How often does severe vomiting occurs?
The severe form of vomiting occurs in one in every 300 pregnant women.

What can cause severe vomiting?

• It is not known for certain but probably related to the high level of hCG hormone and estrogen.
• It is more common in multiple pregnancies        and during first pregnancy.

• Molar pregnancy, is associated with high levels of hCG hormone, causing excessive vomiting.

How to arrive at the diagnosis?

Blood Investigation:  .   

• CBC – complete blood count.
• Blood group and Rh typing.

Specific:

• Serum Beta hCG levels.
• Serum electrolytes may be abnormal.
• Serum thyroid tests.
• Urine test: urine test for ketone bodies, a sign of starvation.
• Liver function tests (may be abnormal)
• Blood sugar level (may be low).

Ultrasonography:
For confirmation of pregnancy and to rule out molar pregnancy.

Treatment:

• After ruling out molar pregnancy and gastro-intestinal disturbances and hepatitis depending on the severity of the problem, your obstetrician will treat you.
• For mild cases, rest and antacid treatment will do.
• For moderate cases, rest, antacid and occasionally anti-emetic like dicyclomine or Vit. B6 (pyridoxine) is given. Adequate amount of fluids must be ingested. It is advisable to have juices, lemon water in good quantity.
• Severe cases need hospitalisation where the pregnant woman needs to be given fluids and nutrition through intravenous line.

Miscarriage or early pregnancy loss /    spontaneous abortion

Human reproduction is a relatively inefficient process. Recently, investigators have demonstrated overall pregnancy loss of 31% with 22% occurring before the pregnancy, which is implanted in the uterine cavity. Pregnancy termination, when it is not induced voluntarily before the period of viability i.e. 28 weeks, is known as spontaneous abortion.

How often does the abortions occur?
The risk of spontaneous abortion for a woman with no history of reproductive wastage is about 15%.The risk increases gradually with prior history of spontaneous abortion.

Types of Spontaneous Abortion:
Habitual Abortion                                Threatened Abortion
Inevitable / incomplete Abortion            Missed Abortion

Threatened Abortion
Vaginal bleeding of varied severity, lower abdominal cramps with backache are classical symptoms with threatened abortion. The ultra sonography shows a live baby corresponding to the period of amenorrhoea. Bed rest and sedation to decrease anxiety is the most logical treatment. Hormonal support given without conformation has questionable role.

Inevitable Abortion and Incomplete Abortion
These are considered together because, although clinically they are two distinct entities, they are present similar problems and are treated similarly. An abortion is considered incomplete, when some fragments of products of conceptions have been expelled earlier. A quick curettage of the uterine cavity prevents excessive blood loss, and prevents lethal complications.

Missed Abortion
Retention of the products of conception in the uterus for four weeks or longer after the death of the foetus is classified as missed abortion. Clinical evaluation with ultrasonagraphy clinches diagnosis. However with easy availability of USG, once it is identified that the foetus has no heartbeat, depending on the clinical picture your doctor may suggest that removal of the products even if you have no symptoms. Monitoring of clotting factors with evacuation of uterine cavity is the treatment.

Septic Abortion
Any abortion associated with fever, lower abdominal pain and foul smelling vaginal discharge should be considered as septic abortion. Treatment with higher antibiotics, removal of origin of sepsis is the treatment of choice.

Habitual Abortion
This means three or more consecutive spontaneous abortions. Incidence of this condition is believed to be less than 1%. Investigations and treatment of habitual abortion should begin between pregnancies.A thorough systemic examination with cytogenetic studies should be helpful to arrive at a diagnosis.

Pathology / Causes

Genetic Causes   (in 50% to 60% of cases) 
Chromosomal abnormalities are found in approximately 80% of blighted ovum and 5% to 10% of the abortions in which a foetus is present.

Endocrine Causes      (10% to 15% of cases)

• Progesterone hormone, required for the maintaining of pregnancy, is deficient.

• Diabetes: Uncontrolled diabetes can have a significantly increased risk of spontaneous abortion.

• Thyroid Deficiency : Rarely decreased or increased secretion causes spontaneous abortion.

• Polycystic ovarian syndrome: In this, the elevated levels of leutinising hormone (LH) may have deleterious effect on pregnancy.

• Infection: Viral infection by rubella, toxoplasmosis, parvovirus, herpes simplex, chlamydia and mycoplasma can lead to miscarriage.Acute infectious fever may lead to abortion.

• Abnormalities of the genital tract: Congenital structural abnormalities of the uterus and adhesion or fibrous bands within the uterus may give rise to recurrent abortions.

• ¨     Sub-chorionic haematomas and chorio-amniotic separation :
  Collection of blood clot between the foetal sac and the uterine wall. This is a frequent cause of 1^st trimester vague bleeding, but an uncommon cause of pregnancy loss. This clot usually gets absorbed over a period of time, approximately by 4 - 6 weeks. During this time one may observe continuous altered dark brown discharge from the vagina, which is the collected blood being expelled.

• Immunological causes:
  There is a possibility of an immunological rejection of the foetus by the mother’s immune system. This is a frequent cause of recurrent pregnancy loss.

• Abnormal placental implantation : 
  This is seen in pre-eclampsia, severe foetal growth retardation and preterm labour.

How to arrive at the diagnosis?

If you have had 3 or more abortion you are said to have recurrent / habitual abortion. If so, it is advisable to go to a gynaecologist  who will order a battery of test to be done before conception so that adequate treatment can be given.

The investigations are: 

Blood investigations:

• CBC with ESR.
• VDRL to rule out syphilis (one type of sexually transmitted disease).
• Blood group with Rh factor to rule out Rh – incompatibility.       
• Blood sugar levels: to rule out diabetes, which causes early pregnancy losses.     
• Beta-hCG levels in blood : very sensitive tests of blood for confirmation of pregnancy levels correspond to week of gestation with doubling time less than 48 hours.

Specific test done in selected cases:

• TORCH titres: done to rule out infections like toxoplasmosis, cytomegalovirus, rubella, herpes group and other.
• Serum thyroid levels – to rule out thyroid hormone imbalance.
• Serum prolactin levels – to rule out hyperprolactinemia.
• Karyotyping of parents: this is done to diagnose any genetic abnormality in either parents or its occurrence in the foetus.

Urine tests:
Urine routine test with culture – to rule out infection of urinary tract.

Ultrasonography

It is most specific and informative test regarding abortion. It gives information regarding:

• Foetal viability.
• Stage of abortion.
• Congenital abnormalities of uterus like septum, fibroids, etc.
• Bleeding inside the uterine cavity, or in the abdominal cavity (as in ectopic).
• Status of other pelvic organs condition of the ovaries. Presence of any cyst.

Chromosomal Studies
In cases of habitual abortions, chromosomal studies of either of the partners and of the products of conception may be done. Your obstetrician is the ideal person to decide about it.

Treatment for Habitual Abortion
Ideally, with prior record of abortion, you should be investigated before she becomes pregnant.

When pregnant, you should have:

• Bed rest.
• Avoid intercourse particularly in 1st trimester.
• Good nutritious diet   . .
• Mental and physical rest.
• Folic acid supplementation: Around conception time, folic acid is believed to prevent congenital abnormalities of the brain in the foetus. It also may reduce placental separation.
• Depending on any specific conditions identified, your doctor will suggest special further treatment.

       Ectopic Pregnancy

Ideally, a pregnancy should be implanted in the uterine cavity, but on occasions it gets implanted outside the uterine cavity, called as ectopic (ecto-outside) pregnancy. Of these in 95% of the time, the ectopic pregnancy gets implanted in the fallopian tube, known as tubal pregnancy. Ectopic pregnancy per se is an emergency, which must be dealt under specialized supervision in a hospital set up. It can get implanted at various other sites like: outside the uterus like cervix, ovary, abdominal cavity. This is quite rare, however.

How often does this occur? 

• 1 in 150 to 1 in 500 pregnancies.
• Incidence is increasing, although the risk of maternal death is decreasing due to early diagnosis and better medical facilities.

Causes:

1. Pelvic inflammatory disease (PID):
   Global increase in incidence of sexually transmitted diseases and pelvic inflammatory diseases leads to defective transport of fertilised egg (zygote) to the uterine cavity.        .   Thus the fertilized egg gets implanted into the tube.

• The tube is naturally meant for transport and not to support the growing egg. Physiology of reproduction in Sexual Activity. 

• It gets stretched upto a certain point and gives way, causing rupture and bleeding in the abdominal cavity.

• At this point, the woman gets acute pain.

• Depending on the severity of bleeding and the physical status the woman might experience fainting episodes, giddiness over a period of time.

2. Tubal microsurgery:
   Causing narrowing of tubal lumen at the site of surgery, causing obstruction to the passage of the fertilised egg. 

3. IUD: (Intra Uterine Device)
   The chances of an ectopic pregnancy are relatively more in an IUD user. The IUD protects more against an intrauterine than an extra uterine pregnancy. However, the overall incidence of ectopic pregnancy is much less in IUD user as compared to non-IUD users.

What you feel?

Absence of menses (amenorrhoea) : can last from days to weeks.Up to 15% may not have history of amenorrhoea.

Abdominal pain

• Mainly in lower abdomen on left or right side A sudden onset of cramping may occur with giddiness and fainting.
• May have repeated attacks of pain before acute pain followed by fainting due to rupture of ectopic pregnancy.

Vaginal bleeding
Many patients may have irregular scanty altered bleeding through the vagina. This is another reason why you may not realise that the period has been missed.

Other symptoms may include:

• Increased urinary frequency.
• Burning sensation during urination.
• Low grade fever.
• Feeling of motion (rectal tenesmus).

What does the doctor see?

• Pale look on the face.
• Increased pulse rate (normal pulse rate =60-100 beats / minute )
• Decrease in blood pressure (hypotension).
• Tenderness in lower abdomen.
• Internal examination will be very painful.

Investigations:

1. Blood investigations:

• Haemoglobin estimation, which shows fall in haemoglobin levels due to internal bleeding.
• Serum hCG  estimation: Normally, hCG         hormone doubles its previous value in 48 hours, in 1^st 10weeks of pregnancy. In ectopic pregnancy, the rate increase much slower, in fact it may not increase at all.

• Serum Progesterone: Is another hormone that can be measured to help in the diagnosis of ectopic pregnancy, low levels of this hormone may indicate that the pregnancy is abnormal.

3. Ultrasonography:
   Particularly, the trans-vaginal method can diagnose ectopic pregnancy early and more accurately.

4. Culdocentesis:
   Procedure by which needle aspiration of the most dependent part of abdominal (pouch of Douglas) cavity is done for diagnostic purpose. This is done by vaginal route, to check for any free blood in abdomen (peritoneal cavity) for confirmation of ruptured ectopic pregnancy. This clinical test is done in emergency cases when facility or time for special tests is not available. It is positive only if the ectopic is ruptured or leaking.

5. Laproscopy:
   Can be used as a confirmatory procedure when there is a high suspicion of an ectopic pregnancy. 'Seeing is believing' and by this technique the doctor actually looks at the pelvic structures, under anaesthesia. If possible corrective surgery may be done at the same sitting.

Treatment:
With modern techniques, ectopic pregnancy may be diagnosed at a very early stage: Some cases of ectopic pregnancy may not need any intervention at all – resolve spontaneously. But theoretically, it gives false sense of security and misleads.
Serial follow–ups by monitoring vital parameters serum hCG levels, serum progesterone is a must for ectopic pregnancy, when medical or surgical interventions are withheld.

1. Surgery:

• Either by laparoscopy or by laparotomy i.e. opening the abdomen surgically. However, laparoscopy is the preferred option. if possible

• The surgery could be conservative like – salphingostomy (making an incision on the unruptured ectopic pregnancy site and milking out the disease).

• Partial salphingectomy: removing only the diseased part of the tube.

• Radical surgery: complete removal of the fallopian tube on the affected site. The advantages of surgical treatment is that it is a one step procedure that will take care of the ectopic, without any later risks.

2. Medical treatment:
   In this, the agents which dissolves the ectopic pregnancy are used like:

•  Injection methotrexate – locally or intramuscular.

• Injection KCL – locally.

These are used kill the pregnancy under sonographic guidance or laproscopically. A drug called RU 486 given orally can also act on the pregnancy to destroy it. These methods however require serial follow up.

Molar Pregnancy
(gestational trophoblastic tumours)

Technically called hydatidiform mole (hydatid – means ‘A drop of water’ mole means ‘spot’). The molar pregnancy occurs due to abnormal development of cells of placenta. They form grape like watery clusters, which cannot support a growing embryo.They are hence called 'drakshagarbha' in local language in India.

How often does this occur?
0.5 to 8.3 per 1000 live births. The incidence is 7 to 10 times greater in Asian countries as compared to North America or Europe.

Causes:
Molar pregnancy is caused by chromosomal problem in either the sperm that fertilises the egg or the egg itself or both.  

Risk factors:

• Age more than 40 years, the risk increases by 200 times.
• Ethnic group: Asians / blacks / Caucasians. Asians have greater risks than blacks. Blacks have more risk than Caucasians.
• Socioeconomic status : Risk is higher in poor group probably due to malnutrition and protein deficiency.
• Previous occurrence of hydatidiform mole: repeat mole in 0.5 – 2%.

Women who have had a molar pregnancy are at a risk of developing neoplasm (rapid growth of new cells) or invasive disease inside the uterus. Some of these, are highly metastatic (likely to spread to other parts of body). Although, it is rare and its cure rate is high, any woman who has had a molar pregnancy is at risk for invasive disease. Hence proper follow up is necessary.

What do you feel?

• Amenorrhoea (Irregularity of menses): usually for 3 to 4 months.
• Bleeding:  It is the first symptom in almost 95% of cases. Occasionally, altered brownish ‘prune – juice’ like discharge.
• Excessive vomiting: probably due to high levels of hormone hCG.
• Passage of grape like vesicles: spontaneous expulsion of a part or complete molar pregnancy can occur.

Others:  Some other complaints which are not very specific include

• Palpitation.
• Intolerance to heat.
• Increased appetite.
• Fatigue.
• Swelling of legs.

What the doctor sees?

• Increase in the size of uterus, which doesn’t correspond to the duration of pregnancy.
• Increase in the heart rate and the pulse rate.
• Increase in the blood pressure.
• Pallor

Early diagnosis and prompt meticulous treatment prevents complications.

How to arrive at a diagnosis?

Blood Investigations:

• CBC (complete blood count).
• Blood grouping and Rh typing.
• Serum electrolyte (sodium, chloride and potassium) levels.

Special investigations:

• Serum Beta-hCG levels: they are very high as compared to normal pregnancy levels, usually in lakhs. Serial Beta-hCG levels are done regularly for the management as they reflect disease activity.
• Serum thyroxin and thyroid stimulating hormone levels.

Ultrasonography:
This is an extermely important test as it Clinches diagnosis: It will show absence of foetus with ‘snow storm’ appearance.

Treatment:
Dilatation and evacuation: In this, under suitable anaesthesia, the cervix (mouth of uterus) is dilated (opened with mechanical force) and the contents are gently removed by suction. A medication called oxytocin / prostaglandin may be given at the same time for contraction of uterus. Before evacuation your gynaecologist may ask for reserving 1 bag of blood in the blood bank.

Follow up:
Usually, the above treatment is adequate in most of the cases. But it is advisable to monitor your blood levels of Beta-hCG hormone to rule out chances of invasive diseases. As these can manifest even months after evacuation. Most women are advised not to become pregnant for at least 6 months. The relatively rare form of malignant disease that may follow a molar pregnancy are managed by chemotherapy (specialized treatment for cancer). The success rate of treating these tumors is very high – almost 100%.if picked up early.

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