ANTENATAL OBSTETRIC

COMPLICATIONS
M. Sarmad
17/094
• Minor conditions occur because physiological changes of pregnancy exacerbate irritating
symptoms.
• Common complications include:
 malpresentation
 Rhesus disease
 Abnormalities of amniotic fluid production
 MINOR PROBLEMS OF PREGNANCY:
MUSCULOSKELETAL PROBLEMS:

1. BACKACHE:
• Its extremely common and is caused by hormone induced laxity of spinal ligaments, shifting of center of gravity as the
uterus grows and weight gain.
• There can occur exaggerated lordosis.
• Exacerbation of symptoms of prolapsed intervertebral disc leading to immobility.
• Advice patient to maintain a correct posture, avoid lifting of heavy objects, avoid high heels, physiotherapy and simple
analgesia.
2. SYMPHYSIS PUBIS DYSFUNCTION:

• Painful condition and is common in 3rd trimester.

• Symphysis pubis joint become loose causing
rubbing of two halves of pelvis on one another
when walking or moving.
• This improves after delivery and management
includes simple analgesia and low stability belt
may be worn.
3. CARPAL TUNNEL SYNDROME:
• Increased soft tissue swelling during pregnancy
can lead to compression neuropathies.
• Common one in carpal tunnel in which there is
compression of median nerve.
• Symptoms: numbness, tingling, severe pain at
night and weakness of thumb and forefinger.
• Management: simple analgesia, splinting of
affected hand and rarely surgical decompression.
 GASTROINTESTINAL SYMPTOMS

1. CONSTIPATION:
• Common in pregnancy
• Results from hormonal and mechanical factors that slow gut motility
• Iron tablets can also exacerbate constipation
• Reassurance and women should be advised high fiber diet and if necessary give
lactulose.
2. HYPEREMESIS GRAVIDARUM:
• 70-80% women experience nausea and vomiting in early pregnancy
• It causes imbalance of fluid and electrolytes, disturbs nutritional intake and metabolism, physical
and psychological debilitation and adverse pregnancy outcome.
• Cause is multifactorial but its associated with high levels of HCG, estrogen and thyroxine
• Severe cases can lead to malnutrition and vitamin deficiencies
• Treatment: fluid replacement, thiamine supplements and antiemetics.

3. GASTROESOPHAGEAL REFLUX:
• Causes are weight effect of pregnant uterus and hormone induced relaxation of esophageal
sphincter.
• Management includes lifestyle modification and medications such as H2 receptor antagonists and
proton pump inhibitor.
4. HAEMORRHOIDS:
• Causes are effects of progesterone on vasculature, pressure of gravid uterus on superior rectal
veins increased circulating volume
• Warning symptoms are tenesmus, mucus, blood in stool and back passage discomfort
• Management includes local anesthetic/ anti-irritant creams and high fiber diet

5. OBSTETRIC CHOLESTASIS:
• Multifactorial condition in which there is pruritis and abnormal LFTs
• It can lead to spontaneous and iatrogenic preterm birth, fetal death and maternal morbidity
• Treated with urso-deoxycholic acid (UDCA)
VARICOSE VEINS:
• Either appear 1st time in pregnancy or pre-existing
veins become worse
• Occurs due to effect of progesterone on vascular
smooth muscle and dependent venous stasis caused by
weight of gravid uterus on IVC
• Symptoms improve with support stockings, avoidance
of standing and simple analgesia
• Large veins can lead to thrombophlebitis and bleeding
EDEMA:
• Soft tissue swelling and increased capillary permeability results in fluid leak in extracellular
compartment
• Fingers, toes and ankles are commonly affected
• Management: rest with leg elevation and support stockings
• Generalized edema may be a feature of pre-eclampsia
• Severe edema suggest cardiac impairment and nephrotic syndrome
 PROBLEMS DUE TO ABNORMALITIES OF PELVIC ORGANS:

FIBROIDS ( LEIOMYOMATA):
• Compact masses of smooth muscle that lie in submucous, intramural and subserous.
• Red degeneration is commonest complication which is treated with potent analgesics (opiates and
IV fluids)
• Fibroids grow and become ischemic leading to acute pain, tenderness, frequent vomiting and may
precipitate uterine contractions.
• Diagnosis through history and US scan can help in differentiating subserous pedunculated fibroid
from ovarian cyst.
RETROVERSION OF UTERUS:
• Uterus remains retroverted and fills up the entire pelvic cavity which will stretch the base of
bladder and urethra
• Results in retention of urine, pain and overdistended bladder
• Catherization is essential until position of uterus is changed

CONGENITAL UTERINE ANOMALIES:

• Abnormalities of fusion of Mullerian ducts may give rise to anything from a subseptate uterus
through to a bicornuate uterus and very rarely to a double uterus with two cervices.
The problems associated with bicornuate uterus are:
• miscarriage;
• preterm labor;
• preterm prelabor rupture of membranes (PPROM);
• Abnormalities of lie and presentation;
• higher Caesarean section rate.
OVARIAN CYSTS IN PREGNANCY:
• The most common types of pathological
ovarian cyst are serous cysts and benign
teratomas.
• Incidence of malignancy is uncommon
• Physiological cyst of corpus luteum rarely
require treatment
• Large cysts require surgery
CERVICAL CANCER:
• arise in poor attenders for cervical
screening
• Friable or ulcerated lesion with bleeding
and purulent discharge
• Asymptomatic in early stages but later
present with vaginal bleeding
 URINARY TRACT INFECTION:
Predisposing factors are:
 history of recurrent cystitis;
 renal tract abnormalities: duplex system, scarred kidneys, ureteric damage and stones;
 diabetes;
 bladder emptying problems, for example multiple sclerosis.
• The symptoms of UTI may be different in pregnancy; it occasionally presents as low back pain and general malaise with
flu-like symptoms. The classic presentation of frequency, dysuria and haematuria is not often seen.
• The most common organism for UTI is
• Escherichia coli;
• less commonly implicated are streptococci, Proteus, Pseudomonas and Klebsiella
PYELONEPHRITIS:
• Pyelonephritis is characterized by
dehydration, a very high temperature
(38.5ºC), systemic disturbance and
occasionally shock.
• This requires urgent and aggressive
treatment including intravenous fluids,
opiate analgesia and intravenous
antibiotics (such as cephalosporins or
gentamicin).
• In addition, renal function should be
determined, with at least baseline urea
and electrolytes, and the baby must be
monitored with cardiotocography (CTG).
ABDOMINAL PAIN IN
PREGNANCY:
 VENOUS THROMBOEMBOLISM:
• Venous thromboembolic disease (VTE) is the most
common cause of direct maternal death in the UK.
• Pregnancy is a hypercoagulable state because of an
alteration in the thrombotic and fibrinolytic systems.
• an increase in clotting factors VIII, IX, X and
fibrinogen levels, and a reduction in protein S and
anti-thrombin (AT) III concentrations
• These physiological changes predispose a woman to
thromboembolism
THROMBOPHILIA:
• Changes in coagulation/ fibrinolytic system can be inherited or acquired
• Hereditary form of thrombophilia include: deficiencies of endogenous anticoagulants protein C,
protein S and AT III, abnormalities of procoagulant factors, factor V leiden and prothrombin
mutation G20210A.
• Acquired is associated with antiphospholipid syndrome (APS)
• Presence of thrombophilia with history of thrombotic episodes means prophylaxis should be
considered for pregnancy.
DIAGNOSIS OF ACUTE VENOUS THROMBOEMBOLISM:
• Clinical diagnosis is unreliable
• Women suspected of having deep vein thrombosis and pulmonary embolus should be investigated
promptly
• Deep vein thrombosis: unilateral pain in calf, redness and swelling. Compression ultrasound and
venography should be done.
• Pulmonary embolus: presents as mild breathlessness or inspiratory chest pain with no cyanosis,
tachycardic (>90bpm) and mild pyrexia (37.5). ECG, chest x-ray, arterial blood gases, ventilation
perfusion scan or computed tomography pulmonary angiogram should be done
• Low level of D-dimer suggests absence of DVT or PE.
TREATMENT OF VTE:
• Low molecular weight heparins are treatment of choice
• Following delivery, women use warfarin or LMWH
• Graduated elastic stockings should be used for initial treatment of DVT for 2 years
 SUBSTANCE ABUSE:
• Approximately one-third of adults who access drug
services are women of reproductive age in the UK.
• Opioids, especially heroin, remain the most commonly
used drugs in the UK
• Others are cocaine, tobacco and alcohol
• Intravenous injection of drugs put the users at high risk of
infections.
 OLIGOHYDRAMINOS AND POLYHYDRAMINOS:

OLIGOHYDRAMINOS:
• Amniotic fluid index less than 5th centile for gestation
• AFI is ultrasound estimation of amniotic fluid by adding
together deepest vertical pool in 4 quadrants of abdomen
• History of clear fluid leak from vagina and on palpation
fetal poles are hard with small for dates uterus
• Prognosis depends on cause
POLYHYDRAMINOS:
• Polyhydramnios is the term given to an
excess of amniotic fluid, i.e. AFI 95th centile
for gestation on ultrasound estimation
• On examination, the abdomen will appear
distended out of proportion to the woman’s
gestation (increased SFH).
• abdomen may be tense and tender and the
fetal poles will be hard to palpate.
• Management is to establish the cause,
relieving mother’s discomfort and assessing
risk of preterm labour
 FETAL MALPRESENTATION AT TERM:
• Malpresentation is a presentation that is not cephalic

BREECH PRESENTATION:
• Breech presentation is the most commonly encountered malpresentation and occurs in 3–4 percent
of term pregnancies, but is more common at earlier gestations.
• Commonest is extended (frank) breech.
• Clinically suspected at or after 36 weeks and confirmed by ultrasound scan.
• Management: external cephalic version (ECV), vaginal breech delivery and elective c section.
 POST TERM PREGNANCY:
• Pregnancy that has extended to or beyond 42 weeks gestation
• Aetiology is unknown but it affects 10% of all pregnancies.
• Can lead to increased risk of stillbirth, perinatal death and an increased risk of prolonged labour
and C section.
• Fetal surveillance and induction of labour may reduce the risk of adverse outcomes
• Counselling: no test can guarantee safety of her baby and perinatal mortality is increased
VAGINAL BLEEDING IN PREGNANCY:
• Vaginal bleeding less than 24 weeks gestation is defined as threatened miscarriage.
• Vaginal bleeding from 24 weeks to delivery is defined as antepartum hemorrhage
• Pale, tachycardic, anxious looking woman with painful, firm abdomen, underwear
soaked in fresh blood and reduced fetal movements needs emergency assessment.
Placental causes:
• Placental abruption
• Placenta praevia
• Vasa praevia

Local causes:
• Cervicitis
• Cervical ectropion
• Cervical carcinoma
• Vaginal trauma
• Vaginal infection
 RHESUS ISOIMMUNIZATION:
• Blood groups are defined in 2 ways.
• First is ABO system including blood group O, A, B and AB
• Second is rhesus system consisting of C, D and E antigens
• D is the rhesus antigen
• Mismatch between mother and fetal red blood cells results in sensitization of maternal immune
system to these foreign red blood cells giving rise to hemolytic disease of fetus and newborn
• Potential sensitizing events for rhesus disease are:
 Miscarriage
 Termination of pregnancy
 Antepartum haemorrhage
 Invasive prenatal testing
 delivery
• Rhesus disease does not affect 1st pregnancy as primary response is usually weak and consists
IgM antibodies that do not cross placenta
• Subsequent pregnancy with rhesus positive baby cause maternal resensitization and this time B
cells produce larger response and IgG antibodies which can cross placenta.
• These antibodies result in fetal hemolysis leading to anemia.
• Rhesus isoimmunization can be prevented by IM administration of anti D immunoglobulins
which mop up any circulating rhesus positive cells
 1st trimester: 250 IU
 12-20 weeks: min 250 IU
 After 20 weeks: 500 IU
MANAGEMENT:
• If antibody level rises, fetus should be examined for signs of anaemia
• Bilirubin concentration in amniotic fluid gives indirect measure of fetal hemolysis
• Middle cerebral artery (MCA) dopplers correlate with fetal anaemia
• Fetal blood transfusion with rhesus negative blood is life saving
Signs of Fetal Anemia:
Thank You