Obstetric Complications
Venous Thromboembolism (VTE)
The risk of this is highest in the postpartum period. Its risk factors in pregnancy are smoking, parity 3+, age 35+, obesity, reduced mobility, multiple pregnancy, pre-eclampsia, thrombophilia, and IVF Pregnancy.
Investigations:
Doppler US if suspected DVT
CXR and ECG if suspected PE
CTPA/VQ scan for a definitive diagnosis
N.B. D-dimer isn't useful in pregnancy as it's usually raised in pregnancy, therefore having little use.
Prophylaxis is with LMWH (Dalteparin, Enoxaparin), and it should be given at:
28 weeks if 3 risk factors
1st trimester if 4+ risk factors
N.B. If anti-coagulation is contraindicated, stockings or pneumatic compression can be used.
Pre-eclampsia (PET)
This is a disorder of the placenta, diagnosed by HTN after 20 weeks on 2 separate occasions at least 4 hours apart PLUS significant Proteinuria. The triad of its symptoms are HTN, Proteinuria, and Oedema. Other symptoms include headache, visual disturbance, N+V, epigastric pain, and reduced urine output.
Pathophysiology:
Disorder of Placentation - Failure of 2nd wave of trophoblastic invasion around 15/16 weeks
Systemic Vasospasm
Systemic Microangiopathy - Endothelial dysfunction leads to Microthrombosis and Infarction of end-organs
Increased Capillary permeability - Movement of fluid into extracellular space
Multi-system disorder - Kidney, Liver, CNS, Coagulation system, Placenta
Risk factors - Pre-existing HTN, DM, CKD, Previous hx or FHx of PET, 40+, BMI >35, 1st pregnancy, Multiple pregnancy
Management:
Labetalol 1st line – Nifedipine 2nd line
Fluid restriction in severe cases to avoid fluid overload
Definitive treatment is done by delivering the placenta
Prophylaxis with Aspirin 5-100mg is given from 12 weeks in high-risk patients.
The eclampsia seizures are prevented and treated with IV Magnesium Sulphate.
Complications:
Eclampsia – seizures due to cerebrovascular vasospasm
Renal disorder - Glomerular dysfunction, Proteinuria = Oedema = Renal failure
Vasospasm, HTN = Encephalopathy, Eclampsia, Cerebral Haemorrhage
Microvascular damage, End-organ disease and Increased vascular permeability = Pulmonary oedema and Acute Respiratory Distress
Foetal symptoms - Reduced placental transfer = Hypoxia, Malnourishment, Placental abruption, and Reduced foetal renal perfusion = Oligohydramnios
The most severe form of PET is HELLP Syndrome, which stands for Haemolysis (H), Elevated Liver enzymes (EL), and Low Platelets (LP). It presents with the features of PET + Epigastric/RUQ pain.
Amniotic Fluid Embolism
Here, amniotic fluid passes into the mother’s blood during labour and delivery, therefore causing a blockage and an immune reaction. Risk factors for it are increased maternal age, Induction of labour, C-section, and multiple pregnancy.
It presents similarly to sepsis, PE, or anaphylaxis - SOB, hypoxia, hypotension, tachycardia, coagulopathy
Placenta Praevia
This is a huge cause of antepartum haemorrhage.
Risk factors - Low-lying placenta, Previous hx, Previous c-sections, Older maternal age, Smoking, IVF pregnancy
It presents with:
Painless PV bleeding, usually > 24 weeks
Bleeding may occur after sex
Complications - Antepartum haemorrhage, Premature birth, Emergency c-section, Maternal anaemia and transfusions, Stillbirth
Management:
Corticosteroids to mature the foetal lungs as there’s risk of prematurity
Planned/Emergency c-section
Vasa Praevia
This is a huge cause of antepartum haemorrhage.
Here, the foetal vessels are exposed outside of the umbilical cord or placenta and pass across the internal os. This makes the vessels more likely to bleed during the rupture of membranes as they’re unsupported by the umbilical cord or placental tissue, therefore leading to severe foetal blood loss and death. The 2 types of this are:
Type 1 – Foetal vessels exposed as a velamentous umbilical cord
Type 2 – Foetal vessels exposed as they travel to an accessory placental lobe
Risk factors - Low lying placenta, IVF pregnancy, Multiple pregnancy
It presents with:
Painless PV bleeding
Rupture of membranes
Foetal distress
Management:
Corticosteroids to mature the foetal lungs as there’s risk of prematurity
Planned/Emergency c-section
Placental Abruption
This is a huge cause of antepartum haemorrhage.
Instead of bleeding out, patients may present with a Concealed Abruption, which is where the cervical os remains closed, so all the blood remains in the uterus, therefore making one underestimate the extent of the bleeding.
Risk factors - Previous hx, PET, Trauma (consider domestic violence), Multiple pregnancy, Smoking, Cocaine/Amphetamine use
It presents with:
Sudden, severe abdominal pain that is continuous
Antepartum haemorrhage
PVB (or not if concealed)
Foetal distress
Shock
O/E - Characteristic “woody” abdomen on palpation
Management:
Corticosteroids to mature the foetal lungs as there’s risk of prematurity
Anti-D prophylaxis for Rh -ve women
Emergency c-section if maternal/foetal compromise – Induction of labour if no compromise
