1. Complications of Pregnancy Susanna R. Magee MD MPH Brown University Department of Family Medicine October 15, 2008

2. By Trimester 1st trimester –LMP date to 12 weeks 2nd Trimester –12-24 weeks 3rd trimester –24 weeks to term –term is 37-42 weeks post dates vs. post term

3. 1st trimester Nausea and vomiting Constipation Low Back Pain Bleeding

4. Nausea and Vomiting Very common 1 in 3 pregnancies Likely secondary to high estrogen and high levels of Human Chorionic Gonadotropin –made by the placenta –peaks at 10 weeks then levels off Occasionally needs intensive therapy –loss of more than 10% of body weight –Dehydration –-ketonuria/serum ketones

5. Nausea and Vomiting Treatment varies –dietary options: carbohydrate vs. protein –IV therapy with normal saline or Lactated Ringers to reverse ketosis –vitamin B6, Unisom, Reglan, H2 Blocker or PPI, Ondansetron Counseling –huge psychological component –maternal guilt, family misunderstanding

6. Constipation Very common complication of pregnancy as well Usually starts in 1st trimester Dietary options as well –Increased water! –Fiber –Docusate Sodium –Mineral oil

7. Low Back Pain Usually related to the position of the growing fetus or the stretching uterus Pressure on the sciatic nerve Stretching of the round ligaments PT can be very helpful Pregnancy support belt

8. 1st trimester bleeding Threatened Abortion –bleeding is bright red –usually associated with pain/like menstrual cramping Placental formation/implantation –bleeding is usually brownish or pinkish –usually not painful –occurs at 9-10 weeks –subchorionic hemmorhage

9. 2nd trimester Round Ligament Pain Pre-term Labor Abnormal genetic screening tests

10. Round Ligament Pain Usually in nullips Related to the round ligaments of the uterus that attach to the abdominal wall stretching with fetal growth Can be exquisitely uncomfortable –in differential: appendicitis, colitis, abruption, severe constipation, UTI, etc. –Treat with Pregnancy Support Belt formal and informal types

11. Preterm labor 2 categories –History of preterm labor –Having preterm labor now

12. History of Preterm Labor

13. Pre-term Labor Now Causes –cervicitis, trauma, urinary infection, abruption, drug use, polyhydramnios, multiple gestation Diagnosis –Fetal fibronectin swab –Cerivcal length ultrasound –check for cervicitis, rupture of membranes –check for dilitation –consider urine toxicology screen

14. Pre-term Labor Treatment oral NIFEDIPINE Previously: –Indomethacin (complications) –Bedrest (not effective) –Terbutaline (not effective) IM or PO (not a lot of data for the po-hardly used now) heart rate increases –Magnesium (not effective) IV flushing, nausea, hyporeflexia, need to watch levels

15. AFP testing is now COMPLICATED

16. Genetic Screening Integrated screen –NT ultrasound –PAPP- A serum –Correlate with AFP Quad later Less false positives More sensitive AFP Quad –Blood test with 4 parts Higher false positive Less sensitive

17. Abnormal NT/PAPP-A Referral to MFM –Amniocentesis –Level 2 ultrasound –Decisions on pregnancy outcome before 20 weeks in Rhode Island

18. Abnormal Results AFP Quad Test of maternal serum at 15-22 6/7 weeks optimal at 16-18 weeks screening test--high false positive rate –4-10% 4 hormone levels tested –msAFP, inhibin A, HCG, estradiol If abnormal requires further testing with level 2 u/s or amniocentesis

19. Abnormal AFP Interpretation depends on mothers weight and age Low levels AFP <0.25 MOM: Down’s syndrome –Trisomy 21 High Levels AFP >2.5 MOM: Neural tube defects –spina bifida and anencephaly

20. Abnormal AFP Even with normal screen, baby usually normal –9 times out of 10, the amnio and or level 2 will be normal

21. Abnormal AFP Other issues that it can predict –Abnormal inhibin A IUGR –Abnormal HCG risk IUFD--usually followed with weekly testing

22. 3rd trimester Placenta Previa Gestational Diabetes Pre-eclampsia –(think about all these in second trimester, but usually manifest in third)

23. Placenta Previa Implantation over the cervix –painless vaginal bleeding –vaginal delivery contraindicated –marginal previa next to but not quite covering surface may see a marginal previa on early u/s such as fetal survey at 18-20 weeks needs follow up--as uterus grows, placenta often is dragged up out of the way as muscle stretches

24. Gestational Diabetes All women screened at 26-28 weeks Earlier if risk factors 50 g glucose load Positive: > 130 –non-fasting If positive, 3 hour OGTT –special diet three days before –fasting morning of test –100 g glucose load

25. Gestational Diabetes Once diagnosis confirmed: –FG = 95, 1 hour > 180, 2 hour > 155, 3 hour > 140 Treatment: –glucometer, test strips and lancets pt checks FG and 2 hours postprandial every day –VNA to teach patient diet/exercise –call in sugars after 4 days –needs glyburide or insulin when FG > 95, PP > 120 (20% values abnormal)

26. Gestational Diabetes If insulin is required, usually use one long acting type and one short acting type. NST/AFI weekly Rule of 1/3 At least one injection/day, may be as many as 4 Signs Symptoms hypoglycemia –shaky, sweaty, confused, dizziness, passing out –rare in pregnancy

27. Gestational Diabetes Delivery recommended by 40 weeks May require induction, especially if uncontrolled sugars Risk macrosomia and neonatal hypoglycemia

28. Preeclampsia Triad –edema, proteinuria, hypertension Not before 20 weeks ? Related to abnormal placental implantation Symptoms: –Headache, blurred vision, edema, decreased urine output, nausea and vomiting

29. Pre-eclampsia Exam: –swelling hands face “lion faces” –hyper-reflexia –oliguria

30. Preeclampsia Progression slow or speedy Mild (> 300 mg/24 hour urine) or severe (> 5 grams); no in-between lab tests can be helpful –CBC –Bun/Cr –Uric acid –AST/ALT –UA/24 hour urine for protein

31. Pre-eclampsia Treated when severe with Magnesium sulfate infusion to prevent eclampsia Only cure is delivery –a patient may have to be induced preterm, or undergo a c/s depending on severity –Growth restriction is common

32. Thank You Good Luck Brown MOMS