Pregnancy Complications

T​​here are several medical conditions that can complicate a preg​nancy​. Some are more common than others. You should be aware of what these are. 

First Trimester Bleeding 

This is defined as vaginal bleeding or spotting that happens in the first 12 weeks of your pregnancy​. Most of these bleeds are not significant and your baby is not affected in anyway. However, if persistent or associated with pain, it may indicate underlying problems such as a miscarriage or an ectopic pregnancy​ (pregnancy that exists outside the womb). It is imperative that you seek medical attention​ so that the necessary investigations can be performed. 

​In an ectopic pregnancy, the embryo implants into the fallopian tube after fertilisation. It is more common when the fallopian tubes are damaged already. It can cause heavy internal bleeding, resulting in death. Emergency surgery may be required to treat this problem. 

In most cases of early pregnancy bleeding, the baby is unaffected and the scan shows the presence of the fetal heart. In such cases of ‘threatened miscarriage’, the prognosis is good and usually, the baby will be fine. 

Antepartum Haemorrhage (Bleeding) 

This happens when the pregnant mother experiences vaginal bleeding when the baby reaches viability (>24 completed weeks of pregnancy). In most cases, the bleeding is idiopathic, i.e. the cause is unknown and baby is usually well. 

It is important to rule out other more serious conditions such as a low lying placenta (placenta previa) or premature separation of the placenta from the womb (abruption placenta). 

Classically placenta previa has painless bleeds while the latter condition has painful bleeds. Both conditions can be life threatening to either the mother or the baby and may necessitate a Cesarean section​ as a life-saving procedure. It is important to seek prompt medical attention should this symptom occur. 

Important!

​Falls in pregnancy can cause bleeding in the placenta and pre-term labour. This is especially so if there is a direct trauma to the tummy. So seek immediate medical attention if you suffer a serious fall with direct trauma to the womb. 

​Pre-term Labour (PTL) 

It happens when the mother experiences strong labour contractions before 37 completed weeks of pregnancy. In some cases, the symptoms may be subtle and the contractions can feel like mild menstrual cramping or backache. 

The risks to a premature baby include respiratory problems, infections, gut problems and a prolonged intensive care stay.

All these can incur an exorbitant hospitalisation bill. These risks are greater in the more premature babies (e.g. those born before 34 weeks of pregnancy). As such, hospitalisation and medications such as salbutamol or nifedipine may be necessary if you experience preterm labor to help prolong the pregnancy, while steroids (de​xamethasone) administered in the form of intramuscular injections to the mother help accelerate the maturity of the baby’s lungs. 

This condition should be clearly differentiated from Braxton-Hicks contractions — a condition characterised by irregular painless tightenings that happen from about 28 weeks of pregnancy onwards. These are harmless and will not bring about an opening of the cervix and early delivery of baby. 

Pre-term Premature Rupture of Membranes (PPROM) 

PPROM refers to a condition whereby the water bag that surrounds the baby in the womb leaks or ruptures before 37 weeks of pregnancy. When this happens, the risk of a pre-term delivery, infection of the mother and baby, prolapse or compression of the umbilical cord and separation of the placenta from the womb increases. You may experience a sudden gush of fluid from the vagina and the doctor can confirm this after an examination. 

Hospitalisation is required to closely monitor the expectant mother. The aim is to prolong the pregnancy for fetal maturity without compromising the mother’s and the baby’s well being. The mother will be closely monitored for any signs of infection such as fever, and blood tests will be performed at regular intervals. 

Antibiotics will also be given to minimise the risk of an infection. Delivery will be expedited in a pre-term baby should an infection set in, or if the tests indicate that the baby is in distress inside the womb. With the right treatment, both mother and baby will be fine, although the baby may require a stay in the intensive care unit should it be born premature. 

Note:

​If PPROM occurs before six months of pregnancy, the prognosis is guarded. Very often, this will lead to a spontaneous miscarriage. Even if the pregnancy continues, it may cause infection, limb contractures and poor development of the lungs (pulmonary hypoplasia), which could be fatal.

Hypertensive Disorder of Pregnancy/Pre-eclampsia 

This condition is characterised by the development of high blood pressure (>140/90 mmHg), swelling of the extremities and proteins in the urine during pregnancy from >20 weeks of pregnancy onwards. 

Those who are primiparas (never delivered before), above 35 years of age, with twins or triplets or have pre-existing hypertension or diabetes are at a higher risk of developing this condition. In some instances, this condition has been known to arise during labour or after the delivery of the baby. Many other organ systems can also be affected and notably seizures (eclampsia) can occur in severe cases. When the organ systems are severely affected, they can pose a danger to the mother and fetus. 

Treatment entails the delivery of both the baby and the placenta. 

• ​​In mild cases, anti-hypertensives may be prescribed to lower the blood pressure while continuing to follow up the pregnancy closely. The baby’s wellbeing will be checked regularly through a variety of tests to ensure that it is growing properly and receiving adequate oxygen. 
• In severe cases, admission is necessary and a medication known as Magnesium Sulphate may be administered intra-venously to prevent the mother from developing a seizure or fit. 
  

The warning symptoms to this severe condition include severe headaches, visual disturbances, severe nausea and vomiting, and right sided upper abdominal pain. If you suffer from any one of these symptoms after being diagnosed with pre-eclampsia, prompt medical attention is mandatory. 

Gestational Diabetes Mellitus (GDM) 

​​Diabetes​ can happen in pregnancy when the body does not produce adequate amounts of the hormone insulin to deal with sugar control during pregnancy. As a result, the sugar levels may climb. In most cases, the condition disappears after the delivery. 

In others, the condition may persist and long term follow-up and treatment of the diabetes is required. 

A repeat oral glucose tolerance test (OGTT) for diabetes will be performed six weeks after delivery. 

Testing for GDM entails drinking a sweet liquid after a night of fasting, followed by the drawing of blood samples at the onset and two hours later (oral glucose tolerance test) (read the article on Prenatal Ultrasound Scans​).

​​​Once diagnosed, it is essential to control your blood sugar levels during the course of your pregnancy. The various measures include self-monitoring of blood glucose levels, diet and exercise management, insulin injections in more severe cases, and the close monitoring of you and your baby’s well being by an experienced team of caregivers. This minimises the risks to you and your baby. Good control means pre-meal level of 4.4–5.5 mmoL and post-meal level of 5.5–6.6 mmoL. 

Untreated or poorly controlled GDM may result in fetal abnormalities, big babies (>4 kg) causing problems during delivery, premature delivery, an increased chance of cesarean delivery and a slightly increased risk of sudden fetal death. 

Group B Streptococcus (GBS) Infection 

This is a type of bacterial infection that can be found in up to 30–40% of pregnant women’s vagina or rectum (colonisation). It is not a sexually transmitted disease. 

The significance of this is that a small percentage of mothers can pass GBS to their baby during delivery, resulting in severe infection of the lungs and brain resulting in the possible death of the baby within the first few days of birth. A test swab of the vagina can be done at 35–37 weeks during the routine antenatal visits to exclude the presence of GBS colonisation. 

There are other symptoms that may indicate that you are at an increased risk of delivering a baby with GBS infection. These include: 

• Rupture of membrane (forewaters of hindwaters) before 37 weeks or for more than 18 hours duration. 
• Fever during labour ( > 38 degrees Celsius). 
• GBS urinary tract infection during your pregnancy. 
• A previous baby affected with GBS infection. 
  

If your test swab had been positive or if the above risk factors are present, your doctor will administer intravenous antibiotics during your delivery to prevent your baby from becoming infected. 

Asthma in pregnancy 

Asthma has been reported to affect 4%–8% of pregnant women, and is often under-recognised and sub-optimally treated. Generally, the biggest danger to the mother and her fetus comes from poorly controlled or under-treated diseases. Management during pregnancy should include education regarding use of the inhaler and reassurance about the safety of medications used to control asthma. 

The natural course of asthma in pregnancy is very variable and largely unpredictable. The pregnant patient and her immediate family members must be educated on their understanding of the disease, avoidance of asthma triggers, correct inhaler technique and the importance of compliance to treatment. Regular home peak flow monitoring and personalised self-management plans will prove successful in the well-motivated pregnant asthmatic. 

The common warning symptoms are wheezing, shortness of breath, dry coughing, and chest tightness. Nocturnal symptoms also point to poor control of asthma, as are symptoms severe enough to affect the activities of daily living or work. Frequent usage of reliever medications, e.g. salbutamol inhalers is an important warning sign. This is especially so when the usual amount of medication is not able to provide symptomatic relief. Patients should then promptly seek the help of their doctors. 

It must be emphasized that it is safer for pregnant women with asthma to be treated with asthma medications than for them to have asthmatic symptoms and complications (e.g. acute attacks which are potentially fatal in severe cases). 

Pregnant women with more severe asthma have increased risks while those with better-controlled asthma are at lower risk of complications like prematurity and intra-uterine growth restriction (IUGR). 

Bell’s Palsy 

Bell’s palsy​ is a sudden, unilateral facial weakness without a detectable cause. It usually occurs in the age group of 15–45 years. Bell’s palsy is two to three times more common in women than in men. It is three-fold more likely in pregnant than non-pregnant women. Characteristically, it occurs around term, either two weeks before or after delivery. It is present in one in 2000 pregnancies. 

It has no known cause. But it is believed that Bell’s palsy is caused by the inflammation of the facial nerve resulting in a one-sided weakness of the face. They may have facial drooping on the affected half. Some may even complain of excessive tear flow or a reduced sense of taste. It is important to exclude an acute stroke, brain tumor or intracranial bleeding. 

Most patients recover without medication. 85% of patients have full recovery in 6–12 months. 10% may have partial residual facial weakness, while 5% may have severe facial weakness. Some may have reduced or loss of sense of taste permanently. 

The eyes are frequently unprotected in patients with Bell’s palsy. This leaves the eyes at risk for corneal drying and foreign body exposure. Tear substitutes like eyedrops, lubricants, and eye protection with eye shields or glasses will be helpful. 

Treatments with steroids or anti-viral medications have been used, but it is unsure if they hasten the recovery or improve the outcome of Bell’s palsy. 

Macrosomia (Big Baby) 

This condition occurs when the birth weight of the baby is ≥ 4 kg. This is considerably heavier than most babies born at term. 

Although most of these cases have no known predisposing cause, there are a few risk factors associated with macrosomia. The more common factors include poorly controlled diabetes, those with one or more previous deliveries and those with a history of big babies in their previous pregnancies. 

There are certain concerns associated with a big baby: 

• ​The labor can be prolonged or even arrested, needing a Cesarean section. 
• Delivery can be difficult and the baby’s shoulder may be stuck at the birth canal (shoulder dystocia). This is an obstetric emergency and maneuvers will be required to deliver the baby, some of which can injure the baby or result in severe trauma to the perineum. 
• There is an increased risk of baby injury from the shoulder dystocia — this can result in fractures and injuries to nerves especially to those located in the neck region (Erb’s palsy). 
• There is an increased risk of post-delivery bleeding. 
• There is an increased risk of maternal trauma from the birth process. ​

Intrauterine Growth Restriction (IUGR) 

This term is used to describe babies who are smaller than what they should be at their gestational age. The most common cause is a problem in the placenta and this impairs the delivery of nutrition and oxygen to the baby. Smoking and excess alcohol consumption can lead to this. Birth defects and genetic disorders can also cause IUGR. 

Once this problem is detected, it is essential to conduct further tests such as an ultrasound examination to measure the weight and blood flow within the baby. The amniotic fluid level (water-bag) is also assessed and the baby’s heartbeat may be monitored regularly. About 60% of small babies are actually normal and are small because of their genetic make-up. Just like there are different sizes of infants, children and adults, there are also different sizes of babies in the uterus. 

The ultimate timing of the baby’s delivery depends on how well the baby is coping inside the womb. Early delivery is only indicated if the environment inside the womb is deemed too unsafe for the baby. At times, a cesarean section may be carried out to expedite the delivery and prevent the baby from going through the stress of labor. 

Abnormalities of the Amniotic Fluid Levels 

1. Oligohydramnios (Too little fluid surrounding the baby) 

The liquor in the water-bag that surrounds the baby inside the womb is maintained by the balance between the constant production of the baby’s urine and the constant swallowing of the fluid by the baby. It forms a protective environment for the baby. 

If the amniotic fluid level is exceedingly low, it is known as oligohydramnios (usually defined as an Amniotic Fluid index of < 5). There are various reasons for this condition. They include: 

• ​Structural defects in the baby’s urinary system causing less urine production. 
• Intrauterine growth retardation — where the urine production is compromised. 
• Rupture of the amniotic membranes. 
• ​Pregnancy that exceeds 42 weeks gestation (overdue babies). 

The risks associated with this condition depend on the gestation and the underlying cause of the oligohydramnios. When the baby is less than 20 weeks old, this fluid is important for the structural development of the limbs and lungs. A lack of the amniotic fluid can result in limb deformities and lung underdevelopment. 

The treatment for low levels of amniotic fluid is based on gestational age and underlying cause. If the baby is not full term yet, your doctor will monitor you very closely. In certain cases, a termination may be offered if the prognosis is considered very poor in those less than 24 weeks of gestation. 

Further tests may be done to monitor your baby’s activity. If you are close to full term, then delivery is usually recommended. 

2. Polyhydramnios (Too much fluid surrounding the baby) 

When there is an increased production of amniotic fluid, this is known as polyhydramnios. It is usually defined as an Amniotic Fluid Index (AFI) of > 25. 

There are numerous causes. Some of these include uncontrolled diabetes in pregnancy, fetal conditions impairing the ability to swallow and twin-to-twin transfusion in twins with a single placenta. 

In addition to the problems posed by the underlying conditions, the excess fluid can cause the following: 

• ​Pressure symptoms resulting in discomfort and breathlessness. 
  
• Increase risk of premature labour owing to the overdistension of the womb. 
  
• Increase risk of cord prolapse or abruptio placenta (separation of the placenta from the womb) at the time of labour. 
  
• Increase risk of post partum haemorrhage (excessive bleeding) after the delivery of the baby. 
  

​In addition to treating the underlying cause e.g. the medical control of diabetes, amniocentesis may be performed to withdraw the excess fluid to relieve the pressure symptoms and discomfort. ​

Decreased Fetal Movements 

You may first begin to feel your baby move at between 18–24 weeks of pregnancy. The feeling is varied and some have described it as a “wave of bubbles”. This is known as quickening. 

The actual sensation of the baby’s movements varies between individuals and is dependent on factors such as: 

• ​​​Baby’s location. 
• Gestation age. 
• Location of the placenta. 
  

Therefore, although fetal movements are used as a convenient way to assess the baby’s w​ellbeing, there can be pitfalls with this method. In general, fetal kick counts can be recorded in a fetal movement chart — registering the number and time of the kicks. It is considered normal if there are more than ten kicks over a 12-hour period. ​

If there are few or no fetal movements felt, it is prudent to seek medical advice immediately. 

Overdue Babies 

This happens when the pregnancies progress past the expected due date (post dates) or two weeks past the expected due dates (post term). There is a definite concern that such babies pass out meconium during labor and is associated with a higher chance of heart rate abnormalities, meconium aspiration into the lungs, cesarean sections and stillbirth. Most doctors would advocate an induction of labor to avoid these problems. 

Cord Round Neck or Cord Accidents 

The umbilical cord is a vital structure that delivers nutrition and oxygen to the baby. A “cord round neck” situation arises when the cord is wrapped around the baby’s neck. This is usually diagnosed at the time of delivery. In most cases, this does not cause any harm to the baby, but may result in cardiotocograph abnormalities at the time of labour (known as variable decelerations). In most instances, the baby undergoes successful vaginal delivery. 

On the other hand, “cord accidents” refer to a specific situation whereby problem in the cord results in the demise of the baby in-utero (stillbirth). Again, this can only be diagnosed confidently after the delivery of the stillborn, inspection of the cord and the exclusion of other causes. 

​The cord may be found to be knotted resulting in the deprivation of oxygen to the baby. Unfortunately, there is no accurate way of diagnosing this condition antenatally.​ ​

Frequently Asked Questions

​1. Should I continue asthmatic medications during labour? 

Acute attacks of asthma during labor and delivery are extremely rare, and women should be reassured accordingly. Regularly scheduled medications (both inhalers and even steroids) should be continued during labour. For induction of labour, the use of Prostin (Prostaglandin E2), which is a bronchodilator, is safe. Women with asthma may safely use all forms of pain relief in labour, including epidural analgesia and Entonox (see Chapter 37). If cesarean section is required, women should be encouraged to have a regional (spinal or epidural) rather than general anesthesia because of the increased risk of severe bronchospasm and chest infection. 

2. Are there benefits to breastfeeding for asthmatic mothers? 

After childbirth, women with asthma should be encouraged to breastfeed​. The risk of atopic disease developing in the child of an asthmatic woman is about one in 10, or one in 3 if both parents are atopic. Breastfeeding has been shown to reduce this risk. All forms of inhaled preparations and oral steroids are safe when breastfeeding. 

3. Will Hand-Foot-Mouth disease affect my pregnancy? 

Hand, foot and mouth disease​ (HFMD) is a virus usually caused by the Coxsackie A virus. It is infectious and spreads through coughs, sneezes and contact with faeces. It is common in children but rare in healthy adults. The early symptoms are fever and sore throat, followed by sores in the mouth and on the hands and feet. 

The incubation period (time between catching the disease and showing symptoms) is 3–6 days — during which time the virus can be passed on. Treatment is aimed at relieving symptoms. 

There is normally no risk to your baby. However, any viral infections, if serious enough may cause miscarriages although this is very rare. The risk to your baby increases if you catch the virus shortly before delivery. Your baby may be infected and may need hospital treatment to avoid further problems. 

4. Should I induce my labour if my baby is “biggish”? ​

Routine induction of labour is commonly practised but this has not been found to conclusively improve outcomes for both the mother and baby.​​ Moreover, ultrasound estimation of the baby’s weight is not 100% accurate, with measurement error of 20%. On the other hand, routine cesarean sections, with their associated surgical risks, have never been proven to reduce morbidity in babies except in some cases associated with diabetes. 

5. Is it normal to salivate more during my pregnancy? 

It can happen to some women during their pregnancy. There may be various reasons why this arises. Changing hormonal levels during the pregnancy may contribute to increased salivation. Morning sickness causing nausea can also lead to increased production of saliva. Heartburn, resulting from the acidic contents of your stomach, may irritate your salivary glands and worsen this problem. In these situations, over the counter medications (e.g. antacids) can be used to help reduce the salivation. 

6. Is “trigger finger” more common during pregnancy? 

This is a condition characterised by discomfort in the palm during movement of the involved fingers. In some cases, the tendon causes a painful click as the patient flexes and extends the finger. The finger may even be locked in a particular position, usually in flexion, which may need gentle passive manipulation. The problem results from inflammation of tendons located within a protective covering called the tendon sheath. Common causes include repetitive usage of the fingers. It is also associated with medical conditions like diabetes and autoimmune diseases. There is no association with pregnancy. It is important to see a doctor. Treatment can range from simple pain-killers, splinting to local injections. 

7. My heart is beating at a faster rate since pregnancy. Is this normal? 

It is part of the body’s normal physiological response to pregnancy. This is to cope with the demands of increased blood supply to the baby via the placenta. However, if you start experiencing chest pains as well as shortness of breath even at rest, please see your doctor immediately to exclude heart problems.​ 

​8. What happens if I have dengue fever during pregnancy? Will my baby be affected? 

Dengue ​is a mosquito-borne virus infection and is endemic in Southeast Asia. It causes myalgia, high fever and a drop in the blood platelet level with bleeding tendencies. There have been no reports of teratogenic effect of the dengue virus causing fetal malformations in the first and second trimesters. 

Although rare, there have been reports of vertical transmission from the mother to the baby. Those cases occurred at or near the time of delivery. As a result, the affected infants can develop a fever as well as bleeding tendencies due to low platelet levels. 

Acknowledgement

Source: Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John, The New Art and Science of Pregnancy and Childbirth, World Scientific 2008. 

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