Pregnancy-Related Complications

Pregnancy-Related Complications
Introduction

  • Pregnancy-related complications are a leading cause of maternal and fetal morbidity and mortality worldwide.

  • Key complications require prompt identification to prevent progression to life-threatening states.

  • Major focus areas include:

    • Preeclampsia and Eclampsia

    • HELLP syndrome (a sub-category of severe preeclampsia)

    • Hemorrhagic disorders (Abortion, Ectopic Pregnancy, Placental Abruption, Placenta Previa)

    • Coagulation disorders like Disseminated Intravascular Coagulation (DIC)

Hemorrhagic Conditions of Early Pregnancy

  • Abortion (Miscarriage): Termination of pregnancy before the fetus is viable, defined as less than 20 weeks gestation or a fetal weight less than 500 grams.

  • Types of Abortions:

    1. Threatened Abortion: Characterized by vaginal bleeding and cramping, but the cervical os remains closed. Approximately 50\% of these cases result in loss.

    2. Inevitable Abortion: Bleeding increases and the cervix dilates. Membranes often rupture, making the loss unavoidable.

    3. Incomplete Abortion: Some products of conception (usually placental tissue) remain in the uterus. This carries a high risk of hemorrhage and infection (sepsis).

    4. Complete Abortion: All products of conception are expelled; the cervix subsequently closes and bleeding subsides.

    5. Missed Abortion: The fetus dies in utero but is not expelled. If retained for more than 4 weeks, the risk of DIC increases.

    6. Recurrent (Habitual) Abortion: Defined as 3 or more consecutive spontaneous abortions.

Ectopic Pregnancy

  • Definition: Implantation of a fertilized ovum outside the endometrial lining of the uterus. Over 95\% occur in the fallopian tubes (ampullar or isthmus).

  • Risk Factors: Previous ectopic pregnancy, Pelvic Inflammatory Disease (PID), endometriosis, smoking, and prior tubal surgery.

  • Signs and Symptoms:

    • The "Classic Triad": Abdominal pain, delayed menses, and abnormal vaginal bleeding (spotting).

    • Kehr’s Sign: Referred shoulder pain caused by blood irritating the diaphragm (indicates rupture).

  • Diagnosis and Management:

    • Diagnosis: Serial \beta-HCG levels (which fail to double as expected) and transvaginal ultrasound (empty uterus).

    • Medical Management: Methotrexate (a folic acid antagonist) can be used if the mass is small (< 3.5 cm) and unruptured.

    • Surgical Management: Salpingostomy (preserving the tube) or Salpingectomy (removing the tube).

Gestational Trophoblastic Disease (Molar Pregnancy)

  • Pathophysiology: Proliferation of trophoblastic cells resulting in grape-like vesicles.

  • Complete Mole: Fertilization of an egg with no nucleus (all genetic material is paternal). No fetal tissue present.

  • Partial Mole: Fertilization of a normal egg by two sperm (triploidy). Some fetal parts or an abnormal placenta may be present.

  • Clinical Presentation:

    • High \beta-HCG levels resulting in excessive morning sickness (Hyperemesis).

    • Vaginal bleeding often described as "prune juice" color.

    • Uterine size larger than expected for gestational age.

  • Management: Suction curettage followed by serial HCG monitoring for 6-12 months to screen for choriocarcinoma. Patients must avoid pregnancy during this follow-up period.

Disseminated Intravascular Coagulation (DIC)

  • Pathophysiology: A secondary disorder where the clotting cascade is overstimulated, depleting platelets and clotting factors, leading to simultaneous systemic clotting and external/internal bleeding.

  • Obstetric Triggers: Abruptio placentae (most common), HELLP syndrome, retained dead fetus, and Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism).

  • Nursing Interventions: Monitor for bleeding from gums, puncture sites, and epistaxis. Administer blood products (FFP, Cryoprecipitate, Platelets) and \text{O}_{2} at 8-10 L/min via non-rebreather mask.

Late Pregnancy Complications: Previa vs. Abruption

  1. Placenta Previa:

    • Implantation: Lower uterine segment, covering or near the internal os.

    • Cardinal Sign: Painless, bright red vaginal bleeding in the third trimester.

    • Management: No vaginal exams (to avoid puncturing the placenta). If total, a Cesarean section is mandatory.

  2. Placental Abruption (Abruptio Placentae):

    • Definition: Premature separation of the placenta from the uterine wall after 20 weeks gestation.

    • Cardinal Signs: Painful, dark red bleeding, "board-like" rigid abdomen, and uterine tenderness.

    • Risk Factors: Maternal hypertension (primary risk), cocaine use, abdominal trauma, and cigarette smoking.

Hypertension in Pregnancy

  • Preeclampsia:

    • Multisystem vasospastic process characterized by HTN (> 140/90 mmHg) and proteinuria (\ge 0.3 g in 24 hours).

    • Pathophysiology: Generalized vasospasms reduce organ perfusion to the brain, liver, kidneys, and placenta.

  • Eclampsia: Progression of preeclampsia to include tonic-clonic seizures.

  • Management (Magnesium Sulfate):

    • Used for seizure prophylaxis, not primarily for BP control.

    • Therapeutic level: 4-7 mEq/L.

    • Toxicity signs: Diminished Deep Tendon Reflexes (DTRs), respiratory rate < 12/min, and decreased urinary output (< 30 mL/hr).

    • Antidote: Calcium Gluconate must be available at the bedside.

HELLP Syndrome

  • H: Hemolysis (breakdown of RBCs leading to jaundice).

  • EL: Elevated Liver enzymes (ALT and AST increase due to liver ischemia).

  • LP: Low Platelets (less than 100,000/\text{mm}^{3}).

  • Clinical Signs: Epigastric or Right Upper Quadrant (RUQ) pain, malaise, and nausea. It is often misdiagnosed as gallbladder disease or gastritis.

Rh Incompatibility

  • Criteria: Rh-negative mother and Rh-positive fetus.

  • Mechanism: Maternal antibodies cross the placenta and attack fetal RBCs (Erythroblastosis Fetalis).

  • Prevention: Rho(D) Immune Globulin (RhoGAM).

    • Administered at 28 weeks gestation routinely.

    • Administered within 72 hours after delivery if the neonate is Rh-positive.

    • Also given after any potential exposure: trauma, miscarriage, or amniocentesis.