Explaining common pregnancy complications

Yes, There’s potential for problems in pregnancy, but no, you don’t need to panic. Dr Nick Walker talks us through common complications.

Congratulations on your pregnancy! You’ve done several tests at home, possibly been for an early scan, and seen black and white images of your baby. Your life is now full of hope and expectation … until your positivity is moderated by a pregnancy complication. While it’s important, for obvious reasons, to stay positive – complications can and do occur, and having some knowledge of them is equally important.

THE FIRST TRIMESTER: different degrees of nausea
The first complication many women notice is morning sickness, which can manifest itself in a variety of symptoms ranging from mild queasiness and avoidance of certain foods, to significant nausea and inability to tolerate anything but dry/plain foods, and right through to daily vomiting and a total inability to take any food or even fluids. This last category is known medically as hyperemesis gravidarum. 

Mild and moderate cases will usually benefit from listening to your body. Simply follow your instincts about what to avoid eating (or indeed the opposite – following a craving) and understand that the nutritional requirements in early pregnancy are minimal. As long as you entered into the pregnancy with a balanced healthy diet, including the recommended prenatal supplements of folic acid and iodine, you can be reassured that the self-limiting nature of morning sickness means that you’re not going to be depriving the developing baby of necessary nutrients. During most pregnancies, symptoms will disappear between 12 and 16 weeks gestation, and after that there’s plenty of time to return to healthy eating. Another important aspect of managing morning sickness is social and psychological support. Taking time for rest is important, and an ounce of sympathy is worth more than a tonne of medication. As far as natural remedies go, it’s worth trying ginger and its derivatives (tea, tablets, even ginger ale).

Hyperemesis gravidarum is another matter. Vomiting and dry retching can be persistent and severe, with very little respite, so women can easily become dehydrated. The continual absence of food in the digestive system can lead to the body burning through its own fat and muscle stores to provide energy, and this, combined with dehydration, can lead to noticeable weight loss. Upper gastric problems from vomiting include oesophageal tears and bleeding; lower intestinal problems like constipation often occur due to lack of food and medication side effects. It is also extremely psychologically challenging – the constant feelings of being unwell and lethargic frequently lead to a depressed mental state.

Due to these factors, patients with hyperemesis often require inpatient hospital management. Intravenous fluid rehydration is the cornerstone of treatment. Often electrolytes such as potassium have been depleted and need to be replaced also. In many cases, once rehydration is achieved, the patient will feel better enough to start tolerating oral fluids and even food again. Because fluid hydration can be performed within several hours, admission to hospital is seldom necessary, and the patient can return every few days for a top-up of fluids – rather like filling up a car with petrol! In very rare cases, a patient is so depleted of nutrition that not just fluids but fats, proteins and sugars can be given intravenously (known as total parenteral nutrition, or TPN).  Admission to hospital in this circumstance is mandatory, as other health specialists, such as dieticians, need to contribute to the care of the patient.

THE SECOND TRIMESTER: testing times

The next major milestone of a normal pregnancy involves a panel of blood tests between 24 and 28 weeks gestation. Your blood is tested for the presence of red-cell antibodies, which if present, may cross through the placenta and cause your baby’s red blood cells to be destroyed. Management of this complication is by sub-specialist obstetricians based in large tertiary hospitals. Maternal anaemia and iron deficiency are also tested for – if these are detected, then iron supplementation in the form of tablets or intravenous injections can be offered.

GESTATIONAL DIABETES

Finally, this panel of tests also aims to detect the presence of gestational diabetes. Most women who have been pregnant will remember this test due to the requirement to drink a bottle of liquid glucose syrup as part of the testing process! Even those who claim to have a sweet tooth are usually challenged by this. Gestational diabetes is not uncommon, and there are no particular symptoms which give a clue to its presence (unlike anaemia), which is why it is recommended that all pregnancies are screened.

As the name implies, gestational diabetes is specific to pregnancy and due to a metabolic imbalance between the placental function of increasing blood sugar levels and the maternal response to normalise them. The problem is that, whether blood sugar levels are on average 7.5 (high) or 5.0 (normal), the mother cannot tell the difference, but the baby gets exposed to a constantly high blood sugar level and can consequently grow too large and have other metabolic problems.

There is a non-fasting screening test that takes one hour and most people do this first.  If that test is positive, the person is at increased risk of gestational diabetes and proceeds to a more in-depth two-hour fasting glucose-challenge test. Women at high risk of diabetes may opt to go straight to the two-hour test.

Gestational diabetes is managed by a multidisciplinary team of midwives, dieticians, physicians and obstetricians. The pregnant mother may need to use tablets or even insulin injections to keep her blood sugar within the normal range. As the placenta is the cause of gestastional diabetes, the ‘cure’ is baby being delivered. Due to this, and other risks particular to gestational diabetes, delivery prior to the due date is almost always advised.

PLACENTA PRAEVIA

Placenta praevia is another condition, which though uncommon, has important implications for pregnancy management. At the standard 20-week anatomy scan of the baby, the position of the placenta is also detailed. The placenta randomly attaches to somewhere on the inside wall of the uterus. The problem of placenta praevia arises when that attachment is very close to, or even covering, the exit point of the uterus. Imagine the uterus as a room – you can see that, if the placenta is covering the ‘doorway’, then it is impossible for the baby to get out. Fortunately, with the use of ultrasound, placenta praevia can be easily diagnosed, though the management of each case must be individualised depending on the clinical particulars.  In general, women may stay at home, though are advised against travel to remote areas due to the possibility of sudden and heavy bleeding. As and when bleeding occurs, admission to hospital for observation is sensible, with the goal of getting as far towards the due date as possible. Even if all goes well, delivery must be by Caesarean section, and even then, the potential for losing lots of blood must be kept in mind. Obstetric operating theatres are well equipped to handle all eventualities to ensure the safe arrival for both the mother and her baby. 

OTHER PLIGHTS

As pregnancy progresses, a number of more minor complaints can become evident. Heartburn, also known as gastric reflux, can cause discomfort and loss of sleep. You should report this to your LMC, as treatment is readily available and safe to use. Your pharmacy is the best place to start – using antacid tablets or liquids will often help. If your symptoms remain a problem, medications such as ranitidine and omeprazole (usually used by non-pregnant patients) are very effective, but need to be prescribed by your doctor. 

Vaginal thrush, though it won’t cause harm to your pregnancy, is very irritating but can be treated in much the same way as when non-pregnant. Varicose veins may become swollen and painful, you should report these to your LMC as an underlying blood clot may give rise to these symptoms. Similarly, constipation and haemorrhoids are common, and though they’re not really classified as complications, they’re certainly a nuisance and are also treatable with no risk to the baby. Musculoskeletal pains are extremely common, due to not only the physical stretch of the growing uterus, but also due to the hormonal effects which loosen and soften the ligaments and joints of the body. Interestingly, this effect is not just confined to the pelvic joints; low back, hip, rib, and even small finger joints can become painful!

THE THIRD TRIMESTER: three things we track

In the third trimester, antenatal visits move to fortnightly then weekly in the lead-up to your due date. The three main goals of frequent monitoring are to check: one, the position of the baby; two, the size of the baby (too small is more concerning than too big); and three, your blood pressure. Experienced LMCs will use clinical estimation in determining points one and two. Where there may be any concern, the use of ultrasound has again been found to be a highly useful and accurate tool for checking baby’s growth and position, as well as checking the amniotic fluid level.

PRE-ECLAMPSIA

Checking maternal blood pressure is vitally important as a way to detect the complication known as pre-eclampsia. Pre-eclampsia remains an incompletely understood condition in terms of its causation. It is thought that the placenta starts to release toxins that have various effects on maternal organ systems. Fortunately, most of these effects can be measured by blood and urine tests.  Elevation of the blood pressure (defined as 140/90mmHg) can be the first indication, and protein found in the urine is a common additional finding. Pre-eclampsia can also cause liver, kidney and blood clotting problems, and detecting these certainly requires lots of blood tests. Similar to gestational diabetes, the cure is delivery of the placenta and baby, though the management algorithms are far more complicated due to the wide-ranging severity of individual cases of pre-eclampsia. Once again, with pre-eclampsia being a common and potentially very serious problem, maternity hospitals are well placed to provide the best care, and result in the best outcome for the mother and baby. 

Dr Nick Walker is a specialist obstetrician working in both public practice at National Women’s Hospital and private practice in Mt Eden, Auckland. He divides his time between these roles and helping his wife in caring for their four young children.