Maternal complications during pregnancy

Nausea and vomiting are common conditions of pregnancy and are typically treated with hydration and nonpharmacologic methods. If nausea is refractory to nonpharmacologic methods, antiemetics should be started and added in a step-wise fashion. Hyperemesis gravidarum is a severe form of nausea and vomiting of pregnancy characterized by ketonuria and weight loss, and typically requires inpatient admission, intravenous fluid hydration, and antiemetic therapy. Cervical insufficiency refers to painless cervical dilation that occurs in the absence of uterine contractions and/or labor, usually in the second trimester of pregnancy, and that may require cervical cerclage. Other maternal complications of pregnancy include peripheral edema, gestational thrombocytopenia, and gestational diabetes.

• Epidemiology
  • Occurs in up to 90% of pregnancies
  • Onset at 5–6 weeks' gestation
  • Peaks at 9 weeks' gestation
  • Usually abates by 16–20 weeks' gestation
• Risk factors
  • Nulliparity
  • Migraine
  • Multiple gestation
  • Hydatidiform mole
  • GERD
• Clinical features
  • Nausea and/or vomiting
  • Normal vital signs, lab findings, and normal physical examination
• Differential diagnosis: See the differential diagnosis of nausea and vomiting.
• Treatment ^[1][2][3][4]
  • Rehydration (oral hydration is usually sufficient)
  • Nonpharmacologic options
    • Adapt diet and avoid triggers.
    • Ginger tea/capsules
    • Acupressure , hypnosis
    • Replace iron-containing supplements with folate-containing prenatal vitamins.
  • Antiemetic therapy for nausea and vomiting of pregnancy: If the response to an antiemetic from one class is inadequate, add an antiemetic from another class in a stepwise manner, as shown below. ^[2][5]
    1. Pyridoxine (vitamin B₆) and/or doxylamine
       • Oral pyridoxine (Vitamin B₆)
       • Oral doxylamine
       • Oral pyridoxine/doxylamine combination
    2. For refractory symptoms, add one of the following:
       • Diphenhydramine
       • Dimenhydrinate
       • Prochlorperazine
       • Promethazine
    3. For refractory symptoms despite combination therapy above, add one of the following:
       • Metoclopramide
       • Ondansetron
       • Promethazine
       • Consider also:
         • Change oral dimenhydrinate to IV.
         • Trimethobenzamide
    4. Last resort; : Add chlorpromazine or methylprednisolone.
       • Chlorpromazine
       • Methylprednisolone
  • Thiamine repletion (in patients with severe recurrent vomiting)
• Acute management checklist for uncomplicated nausea and vomiting of pregnancy
  • Rule out alternate etiologies (see differential diagnosis of nausea and vomiting).
  • Identify and treat dehydration (see IV fluids).
  • If dehydration is present, check urine ketones and serum electrolytes to rule out hyperemesis gravidarum.
  • Electrolyte and thiamine repletion (in patients with severe recurrent vomiting)
  • Trial nonpharmacologic options (e.g., dietary changes, ginger tea/capsules)
  • Replace iron-containing supplements with folate-containing prenatal vitamins.
  • Start pyridoxine and/or doxylamine.
  • For refractory emesis, add antiemetic therapy in a stepwise manner (see above).
  • Consider OB/GYN consult.

In pregnant women, a thorough history, examination, and, if necessary, diagnostics are essential to rule out potential causes of nausea and vomiting that are not pregnancy-related.

Because antiemetics are potentially teratogenic, their use should be considered only if nausea and vomiting are refractory to dietary changes and supportive therapy.

• Definition: : severe, persistent nausea and vomiting associated with a > 5% loss of pre-pregnancy weight and ketonuria with no other identifiable cause ^[2]
• Clinical features: nausea, vomiting, physical signs of dehydration, hypersalivation, orthostatic hypotension, malnourishment
• Diagnosis
  • Clinical diagnosis
  • Laboratory analysis
    • Electrolyte disturbances (hypokalemia and hypochloremic metabolic alkalosis)
    • Signs of dehydration (e.g., ↑ hematocrit)
    • Ketonuria
• Treatment:
  • Antiemetic therapy: See antiemetic therapy for nausea and vomiting of pregnancy. ^[2]
    • May require glucocorticoid therapy (see stepwise approach above)
  • IV fluid resuscitation/replacement (see IV fluid therapy)
  • Electrolyte and thiamine repletion
  • Enteral feeding or TPN is recommended in patients with persistent symptoms and weight loss despite antiemetic therapy. ^[2]
• Acute management checklist for hyperemesis gravidarum ^[1][2][3][4]
  • Rule out alternate etiologies (see differential diagnosis of nausea and vomiting).
  • Identify and treat dehydration (see IV fluids).
  • Thiamine repletion
  • Electrolyte repletion
  • IV antiemetic therapy (see antiemetic therapy for nausea and vomiting of pregnancy)
  • Consider enteral tube feeding (nasogastric/nasoduodenal) or TPN.
  • Closely monitor vitals and urine output.
  • Monitor urine ketones, BMP, and body weight daily.
  • Inpatient admission
  • Consult OB/GYN.

• Definition: painless cervical dilation, in the absence of uterine contractions; and/or labor, in the second trimester of pregnancy
• Etiology: Most cases are idiopathic.
• Risk factors
  • Previous mid-trimester pregnancy loss and/or preterm birth
  • Previous obstetric or gynecological trauma (e.g., termination of pregnancy, rapid delivery, multiple gestations, or cervical conization)
  • Cervical connective tissue weakness (e.g., Ehler-Danlos syndrome)
  • Diethylstilbestrol exposure
• Clinical features
  • Painless cervical dilation with or without prolapsed membranes
  • Nonspecific findings
    • Pelvic cramps or backache
    • ↑ Volume, changed color (yellow or blood-stained), and/or thinner consistency of vaginal discharge
• Diagnosis
  • Clinical diagnosis typically before 24 weeks' (may be up to 28 weeks') gestation
  • OR history of ≥ 2 previous mid-trimester pregnancy losses or ≥ 3 preterm births not explained by any other cause, and a transvaginal ultrasound cervical length < 25 mm before 24 weeks' gestation
• Treatment
  • Serial cervical ultrasound monitoring should be commenced in high-risk women (i.e., previous preterm birth) between 16–24 weeks' gestation.
  • Cervical cerclage
    • Definition: placement of a supportive suture in the cervicovaginal junction to prevent early pregnancy loss or preterm birth
    • Methods: McDonald cerclage , Shirodkar cerclage
    • Timing: < 24 weeks gestation; most commonly performed at 13–16 weeks gestation
    • Indications: only in singleton pregnancies
      • Multiple previous preterm births or pregnancy losses in the second trimester
      • A previous preterm birth and current ultrasound diagnosis of a shortened cervix (cervix length < 25 mm) at < 24 weeks gestation
      • Cervical dilation on inspection at < 24 weeks gestation
      • Prior cerclage due to cervical insufficiency at < 24 weeks gestation
    • Contraindications
      • Preterm labor
      • Premature rupture of membranes
      • Chorioamnionitis or vaginal infection
      • ≥ 24 weeks' gestation
      • Unexplained vaginal bleeding
      • Multiple gestations
  • Progesterone supplementation (vaginal or intramuscular): indicated for a short cervical length at < 24 weeks' gestation in the absence of a previous preterm birth
  • Strict bed rest is not recommended.

A shortened cervical length alone is not sufficient to diagnose cervical insufficiency.

References:^{[6][7][8][9][10][11][12][13][14]}

• Supine hypotensive syndrome: Compression of the vena cava and pelvic veins by the uterus may occur during the third trimester of pregnancy as a result of the mother lying in a supine position.
  • Venous return to the heart is impaired → decrease in cardiac output → fetal hypoxia → deceleration (CTG)
  • After repositioning the mother in the left lateral position, the fetal heart rate recovers.
  • In the mother, supine hypotensive syndrome; is characterized by tachycardia, dizziness, and nausea, and occasionally causes syncope.
• Peripheral edema
  • Very common, benign finding
  • Management
    • Rule out DVT and preeclampsia
    • Monitoring; usually no treatment necessary
• Musculoskeletal pain
  • Lower back pain: increased lumbar lordosis caused by relaxation of the ligaments supporting the joints of the pelvic girdle in preparation for childbirth
  • Carpal tunnel syndrome (caused by peripheral edema; usually resolves after delivery)
• Gestational thrombocytopenia ^[15]
  • A benign condition characterized by moderate thrombocytopenia (130,000–150,000/mm³)
  • If thrombocytopenia is more severe, other etiologies should be investigated.
  • Does not require management
• Cephalopelvic disproportion: The fetal size is disproportionately large for the maternal pelvis.
  • Can result in a prolonged second stage of labor
• Others
  • Hypertensive pregnancy disorders
  • Gestational diabetes
  • Pregnancy pyelonephritis
  • Gastrointestinal reflux
  • Bleeding during pregnancy
  • Placenta praevia
  • Polymorphic eruption of pregnancy

References:^{[6][7][8][9][10][11][12][13][14]}

1. Wegrzyniak LJ, Repke JT, Ural SH. Treatment of hyperemesis gravidarum.. Reviews in obstetrics & gynecology. 2012; 5 (2): p.78-84.
2. Committee on Practice Bulletins-Obstetrics.. ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy.. Obstet Gynecol. 2018; 131 (1): p.e15-e30. doi: 10.1097/AOG.0000000000002456 . | Open in Read by QxMD
3. Quigley EMM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001; 120 (1): p.263-286. doi: 10.1053/gast.2001.20516 . | Open in Read by QxMD
4. Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003; 68 (1): p.121-128.
5. Herell EH. Nausea and Vomiting of Pregnancy. Am Fam Physician.. undefined .
6. Ferri FF. Ferri's Clinical Advisor 2017. Elsevier ; 2016 : p. 1345-1346
7. Le T, Bhushan V, Bagga HS. First Aid for the USMLE Step 2 CK. McGraw-Hill Medical ; 2009
8. Smith JA, Refuerzo JS, Ramin SM, Lockwood CJ, Barss VA. Treatment and Outcome of Nausea and Vomiting of Pregnancy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/treatment-and-outcome-of-nausea-and-vomiting-of-pregnancy.Last updated: January 3, 2017. Accessed: June 16, 2017.
9. Ehsanipoor RM, Satin AJ, Lockwood CJ, Barss VA. Normal and Abnormal Labor Progression. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/normal-and-abnormal-labor-progression.Last updated: June 7, 2017. Accessed: June 16, 2017.
10. Refuerzo JS, Smith JA, Ramin SM, Lockwood CL, Barss VA. Clinical Features and Evaluation of Nausea and Vomiting of Pregnancy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-features-and-evaluation-of-nausea-and-vomiting-of-pregnancy.Last updated: January 3, 2017. Accessed: July 7, 2017.
11. American College of Obstetricians and Gynecologists. Practice Bulletin No. 142: Cerclage for the Management of Cervical Insufficiency. Obstet Gynecol. 2014; 123 (2): p.372-379. doi: 10.1097/01.AOG.0000443276.68274.cc . | Open in Read by QxMD
12. Ressel GW. ACOG Releases Bulletin on Managing Cervical Insufficiency. Am Fam Physician. 2004; 69 (2): p.436-439.
13. Norwitz ER, Saade GA, Miller HS, Davidson CM. Obstetric Clinical Algorithms. Wiley-Blackwell ; 2016
14. Berghella V, Lockwood CJ, Barss VA. Cervical Insufficiency. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/cervical-insufficiency.Last updated: January 4, 2017. Accessed: July 7, 2017.
15. Ciobanu et al.. Thrombocytopenia in Pregnancy.. Maedica. 2016; 11 (1): p.55-60.