Obstetric Complications Jonathan Schaffir, MD Associate Professor Dept. of Obstetrics & Gynecology

Learning Objectives  Discuss causes of maternal morbidity and mortality unique to pregnancy  Define statistics related to maternal mortality  Describe the clinical features of preeclampsia and the HELLP syndrome, including its pathophysiology, clinical symptoms, treatment and possible sequelae.  Describe conditions associated with catastrophic bleeding in pregnancy, including placenta previa, placental abruption, and uterine atony; discuss their risk factors and clinical implications.  Discuss the risk factors, clinical presentation and sequelae of ectopic pregnancy  Discuss thromboembolic disease associated with pregnancy, and its risk factors

Happy pregnancy

Complicated pregnancy

Definitions  Maternal mortality: Death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to the pregnancy  Direct maternal death: result of a complication of the pregnancy or delivery  Indirect maternal death: due to preexisting or new health problem unrelated to pregnancy

Maternal Mortality Rate worldwide (2010) – CIA World FactBook Maternal Mortality Worldwide

Trends in Pregnancy–Related Mortality in the United States, 1987–2009 Centers for Disease Control data

Top 5 causes of maternal mortality Developing world  Hemorrhage  Infection  Hypertensive disorders of pregnancy  Unsafe abortion  Obstructed labor United States  Hypertensive disorders of pregnancy  Infection  Cardiomyopathy  Thromboembolic disease  Other concurrent medical diagnoses

MATERNAL DISORDERS UNIQUE TO PREGNANCY

Mother vs fetus

Hypertensive disorders of pregnancy  Exacerbation of chronic hypertension  Pregnancy-induced hypertension  Pre-eclampsia  eclampsia

Risk factors Excessive placentation: Multiple gestation Hydatidiform mole Insufficient blood supply: Vascular disease Thrombosis Older women Immunologic factors: First pregnancy New partner Family or personal history Pathophysiology of preeclampsia

Other symptoms: Headache Epigastric pain Visual disturbances Oliguria Other signs: Pulmonary edema Fetal growth restriction Hyperreflexia Signs and symptoms of preeclampsia

Sequelae of pre-eclampsia Pre-eclampsia D isseminated I ntravascular C oagulopathy H emolysis E levated L iver enzymes L ow P latelets blood liver

Preventing mortality  Treatment  Magnesium sulfate to prevent seizure  Fluid management to ensure perfusion  Possible bed rest, antihypertensives  Cure  Delivery!!

Hemorrhage in pregnancy  Placental disorders  Placenta previa  Placental abruption  Uterine atony  Ectopic pregnancy

Placenta previa

Risk factors  Early gestational age  Grand multiparity  In vitro fertilization  Multiple gestation  Previous Cesarean delivery

Treatment  Delivery is by Cesarean section  Scheduled at 36 weeks  Earlier if bleeding jeopardizes health of mother/ fetus  Often associated with additional postpartum bleeding  Need for uterotonics, blood bank availability

Placental abruption Concealed (occult) abruption

Risk factors  Hypertension  Trauma  Vasoconstrictive meds (cocaine)  Smoking  Polyhydramnios  Prolonged rupture of membranes

Treatment  Sequelae:  Uteroplacental insufficiency  Uterine contractions  Maternal anemia and possible coagulopathy  Cure:  Delivery

Uterine atony

Risk factors  Long labor/ induction  Intraamniotic infection  Grand multiparity  Multiple gestation  Polyhydramnios  Uterine fibroids

Treatment

Ectopic pregnancy

Risk factors  Salpingitis (PID, chlamydia)  Tubal surgery or ligation  Prior ectopic  Current use of intrauterine device  In vitro fertilization  Smoking

Treatment  Surgical  Salpingectomy  Salpingostomy  Non-surgical  Methotrexate  Intraamniotic instillation of K+ or glucose  Observation alone?

Thromboembolic disease  Prevalence: 1/1600 pregnancies  Equal distribution across trimesters  Twice as common postpartum  Deep venous thrombosus  More common on left  Pulmonary embolism  Approx ¼ of TED in pregnancy  Leading single cause of maternal death in US

Clotting in pregnancy  Necessary to prevent intrapartum hemorrhage  Progressive increase in clotting factors I, II, VII, VIII, IX, and X  Decrease in Protein S  Increase in resistance to activated Protein C

Risk factors

Outcomes

Conclusions  Pregnancy’s adaptations can pose benefits as well as dangers  Be cognizant of the warning signs and risk factors that may predispose to adverse pregnancy outcomes  Many if not most serious pregnancy-related disorders are treatable and preventable

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