To appreciate the causes and management of minor complications of
pregnancy.
To be able to provide a differential diagnosis for abdominal pain in pregnancy
and a management plan.
To understand the risk factors, presentation and management of venous
thromboembolic disease in pregnancy.
To understand the complications of drug abuse in pregnancy.
To understand the causes, complications and management of oligohyramnios
and polyhydramnios.
To understand the causes and management of malpresentation in late
pregnancy.
To understand the causes, prevention and treatment of haemolytic disease of
the fetus and newborn.
There are a variety of maternal and fetal complications that can arise during
pregnancy. Some of these ‘minor’ conditions arise because the physiological
changes of pregnancy exacerbate many irritating symptoms that in the normal non-
pregnant state would not require specific treatment. While these problems are not
dangerous to the mother, they can be extremely troublesome and incapacitating.
Some of the more major fetal and maternal complications are discussed in detail
in other chapters. Here we discuss common complications, including
malpresentation, rhesus disease and abnormalities of amniotic fluid production.
Musculoskeletal problems
Backache
Backache is extremely common in pregnancy and is caused by:
Hormone induced laxity of spinal ligaments.
A shifting in the centre of gravity as the uterus grows.
Additional weight gain.
They cause an exaggerated lumbar lordosis. Pregnancy can exacerbate the
symptoms of a prolapsed intervertebral disc, occasionally leading to complete
immobility. Advice should include maintenance of correct posture, avoiding
lifting heavy objects (including children), avoiding high-heels, regular
physiotherapy and simple analgesia (paracetamol or paracetamol–codeine
combinations).
Symphysis pubis dysfunction
This is an excruciatingly painful condition most common in the third trimester,
although it can occur at any time during pregnancy. The symphysis pubis joint
becomes ‘loose’, causing the two halves of the pelvis to rub on one another when
walking or moving. The condition improves after delivery and the management
revolves around simple analgesia. Under a physiotherapist’s direction, a low
stability belt may be worn.
Carpal tunnel syndrome
Compression neuropathies occur in pregnancy due to increased soft-tissue
swelling. The most common of these is carpal tunnel syndrome. The median nerve,
where it passes through the fibrous canal at the wrist before entering the hand, is
most susceptible to compression. The symptoms include numbness, tingling and
weakness of the thumb and forefinger, and often quite severe pain at night. Simple
analgesia and splinting of the affected hand usually help, although there is no
realistic prospect of cure until after delivery. Surgical decompression is very
rarely performed in pregnancy.
Gastrointestinal symptoms
Constipation
Constipation is common in pregnancy and usually results from a combination of
hormonal and mechanical factors that slow gut motility. Concomitantly
administered iron tablets may exacerbate the condition. Women should be given
clear explanations, reassurance and advice regarding the adoption of a high-fibre
diet. Medications are best avoided but if necessary, mild (non-stimulant) laxatives
such as lactulose may be suggested.
Hyperemesis gravidarum
Nausea and vomiting in pregnancy are extremely common; 70–80% of women
experience these symptoms early in their pregnancy and approximately 35% of all
pregnant patients are absent from work on at least one occasion through nausea
and vomiting. Although the symptoms are often most pronounced in the first
trimester, they are by no means confined to it. Similarly, despite common usage of
the term ‘morning sickness’, in only a minority of cases are the symptoms solely
confined to the morning. Nausea and vomiting in pregnancy tends to be mild and
self-limited and is not associated with adverse pregnancy outcome.
Hyperemesis gravidarum, however, is a severe, intractable form of nausea and
vomiting that affects 0.3–2.0% of pregnancies. It causes imbalances of fluid and
electrolytes, disturbs nutritional intake and metabolism, causes physical and
psychological debilitation and is associated with adverse pregnancy outcome,
including an increased risk of preterm birth and low birthweight babies. The
aetiology is unknown and various putative mechanisms have been proposed
including an association with high levels of serum human chorionic gonadotrophin
(hCG), oestrogen and thyroxine. The likely cause is multifactorial. Severe cases
of hyperemesis gravidarum cause malnutrition and vitamin deficiencies including
Wernicke’s encephalopathy and intractable retching predisposes to oesophageal
trauma and Mallory–Weiss tears. Treatment includes fluid replacement and
thiamine supplementation. Antiemetics such as phenothiazines are safe and are
commonly prescribed. Other proposed treatments including the administration of
corticosteroids have not yet been adequately proven and remain empirical.
Gastroesophageal reflux
This is very common. Altered structure and function of the normal physiological
barriers to reflux, namely the weight effect of the pregnant uterus and hormonally
induced relaxation of the oesophageal sphincter, explain the extremely high
incidence in the pregnant population. For the majority of patients, lifestyle
modifications such as smoking cessation, frequent light meals and lying with the
head propped up at night are helpful. When these prove insufficient to control
symptoms medications can be added in a stepwise fashion, starting with simple
antacids. Histamine-2 receptor antagonists and proton pump inhibitors have a
good safety record in pregnancy and can be used.
Haemorrhoids
Several factors conspire to render haemorrhoids more common during pregnancy
including the effects of circulating progesterone on the vasculature, pressure on
the superior rectal veins by the gravid uterus and increased circulating volume. A
conservative approach is usually advocated including local anaesthetic/anti-
irritant creams and a high-fibre diet. Never overlook the ‘warning’ symptoms of
tenesmus, mucus, blood mixed with stool and back passage discomfort that may
suggest rectal carcinoma; a rectal digital examination should be carried out if
these symptoms are suggested.
Obstetric cholestasis
Obstetric cholestasis (also referred to as intrahepatic cholestasis of pregnancy)
affects 0.7% of pregnancies with some ethnic variation. It normally presents in the
second half of pregnancy with pruritus and abnormal liver function tests (LFTs),
neither of which has an alternative cause and both of which resolve after birth.
The clinical importance of obstetric cholestasis lies in the potential fetal risks,
which may include spontaneous preterm birth, iatrogenic preterm birth and fetal
death. There can also be maternal morbidity in association with the intense
pruritus and consequent sleep deprivation. It is normally treated with
ursodeoxycholic acid (UDCA), which improves pruritus and liver function but has
not been proven to improve fetal and neonatal outcomes. Women with obstetric
cholestasis are therefore normally offered delivery after 37 weeks’ gestation.
Varicose veins
Varicose veins may appear for the first time in pregnancy or pre-existing veins
may become worse. They are thought to be due to the relaxant effect of
progesterone on vascular smooth muscle and the dependent venous stasis caused
by the weight of the pregnant uterus on the inferior vena cava (IVC).
Varicose veins of the legs may be symptomatically improved with support
stockings, avoidance of standing for prolonged periods and simple analgesia.
Thrombophlebitis may occur in a large varicose vein, more commonly after
delivery. A large superficial varicose vein may bleed profusely if traumatized; the
leg must be elevated and direct pressure applied. Vulval and vaginal varicosities
are uncommon but symptomatically troublesome; trauma at the time of delivery
(episiotomy, tear, instrumental delivery) may also cause considerable bleeding.
Oedem
a
This is common, occurring to some degree in approximately 80% of all
capillary pregnancies. There is generalized soft-tissue swelling and increased
vascularapermeability, which allows intravascular fluid to leak into the extr
and the compartment. The fingers, toes and ankles are usually worst affected
frequent symptoms are aggravated by hot weather. Oedema is best dealt with by
re indicated.aperiods of rest with leg elevation; occasionally, support stockings
lleryeExcessively swollen fingers may necessitate removal of rings and jew
rather than)before they get stuck. It is important to remember that generalized
check the lower limb) oedema may be a feature of pre-eclampsia, so remember to
ema maydwoman’s blood pressure and urine for protein. More rarely, severe oe
.suggest underlying cardiac impairment or nephrotic syndrome
Other common ‘minor’ disorders
Itching.
Urinary incontinence.
Nose-bleeds.
Thrush (vaginal candidiasis).
Headache.
Fainting.
Breast soreness.
Tiredness.
Altered taste sensation.
Insomnia.
Leg cramps.
Striae gravidarum and chloasma.