Maternal complications during pregnancy

Last updated: September 19, 2022

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Nausea and vomiting are common conditions of pregnancy and are typically treated with hydration and nonpharmacological methods. If nausea is refractory to nonpharmacological methods, antiemetics should be started in a step-wise manner. 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. Pregnancy-associated liver diseases occur most frequently in the second and third trimesters and are associated with significant maternal and fetal mortality and morbidity if not managed expeditiously. 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; cervical cerclage may be required. Other maternal complications of pregnancy include peripheral edema, gestational thrombocytopenia, and gestational diabetes.

Overview of maternal complications during pregnancy
Risk factors Clinical features Diagnostics Management
Nausea and vomiting of pregnancy
  • Rehydration
  • Adapt diet and avoid triggers.
  • Ginger tea/capsules
  • Antiemetic therapy
  • Thiamine repletion (in severe recurrent vomiting)
Hyperemesis gravidarum
Cervical insufficiency
Trauma in pregnancy Maternal
  • Almost 1 in 4 pregnant women in the US experiences intimate partner violence [1]
  • Imbalance due to the gravid abdomen (↑ risk of falls)
  • Incorrect use of seatbelts during pregnancy (↑ risk of abdominal trauma)
  • Minor trauma: obstetric surveillance
  • Major trauma: initial stabilization and resuscitation (further assessment in trauma center)
Fetal

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.

Overview [10][11][12]

Overview of liver disease in pregnancy

HELLP syndrome Acute fatty liver of pregnancy Intrahepatic cholestasis of pregnancy Acute viral hepatitis
Trimester
  • Any trimester
Clinical features
Diagnostics
Treatment
  • Stabilization
  • Immediate delivery
  • Supportive care
Complications Maternal
Fetal

Mildly elevated ALP is normal in pregnancy. Pregnant patients with elevated transaminase and/or bilirubin levels should be evaluated for hepatocellular and biliary disease. [10][12]

Acute fatty liver of pregnancy [10][12][15]

Rule out causes of acute liver injury that are unrelated to pregnancy (e.g., acute viral hepatitis, autoimmune hepatitis, drug-induced liver injury, Wilson disease). [10]

It is often difficult to differentiate between AFLP, HELLP, and preeclampsia with severe features, and these conditions can also coexist. Renal failure, hyperuricemia, and hypoglycemia are more common and severe in AFLP than in HELLP and severe preeclampsia. [10]

Supportive care and immediate delivery are the main aspects of AFLP management. There is no role for expectant management. [10]

Intrahepatic cholestasis of pregnancy [10][11][12][14]

Elevated total serum bile acid level (> 10 mcmol/L) in a patient with pruritus in the second or third trimester (without other causes of pruritus) is diagnostic for intrahepatic cholestasis of pregnancy. Elevated transaminases are not required for diagnostic confirmation. [11]

Early initiation of therapy with ursodeoxycholic acid may reduce the risk of preterm birth and stillbirth. [14]

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

Trauma in pregnancy
Maternal Fetal
Clinical features
Diagnostics
Management

Avoid examining the mother in the supine position in order to avoid possible supine hypotensive syndrome.

The mother should be evaluated and treated before the fetus. Early and optimal diagnostics and trauma management of the mother is the best treatment for the fetus.

Supine hypotensive syndrome

Peripheral edema

  • Very common, benign finding
  • Management

Lower back pain

Carpal tunnel syndrome

  • Caused by peripheral edema
  • Usually resolves after delivery

Meralgia paresthetica

Polymorphic eruption of pregnancy (PEP)

Gestational thrombocytopenia [32]

  • 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

Others

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