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Medical Complications
of Pregnancy
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives
 Identify the following medical and surgical conditions in pregnancy and
discuss the potential impact of the conditions on the gravid patient and
the fetus/newborn, as well as the impact of pregnancy (if any) on each
condition, and appropriate initial evaluation:
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Anemia
Endocrine disorders (Diabetes mellitus, Thyroid disease)
Cardiovascular disease
Hypertension
Pulmonary disease
Renal disease
Gastrointestinal disease
Neurologic disease
Autoimmune disorders
Alcohol, tobacco, and substance abuse
Surgical abdomen
Infectious disease, including:
 Syphilis, TORCH, Group B Streptococcus, Hepatitis, HIV, HPV, Parvovirus, Varicella
ANEMIA
Anemia
• In pregnancy, plasma volume expands
proportionally greater than that of RBC mass
• Because Hct reflects proportion of blood
made up primarily of RBCs, Hct demonstrates
a “physiologic” decrease during pregnancy
• Defined as
– Hct <33% for first and third trimesters
– Hct <32% for second trimester
Anemia
• Iron deficiency:
– Pregnancy results in increased iron
requirements
– Standard American diet and endogenous
stores of many women are not sufficient to
provide for increased requirements
– Recommendation: 27mg Fe daily
supplementation for pregnant women
Anemia
• Other anemias
– Sickle cell disease
– Thalassemias
– Hereditary hemolytic anemias
Anemia
• Fetal outcomes such as preterm labor, IUGR
and LBW are more common in women with
hemoglobinopathies – except those with
sickle cell trait
• Antenatal assessment of fetal well-being and
growth is important part of managing these
patients
Anemia
• Evaluation
– Routine prenatal labs:
• Hematocrit or hemoglobin to screen for anemia
• Mean corpuscular volume (MCV) to screen for
thalassemia (MCV <80 fL in the absence of iron
deficiency suggests thalassemia and further testing
with hemoglobin electrophoresis is indicated)
– Further testing for thalassemias and/or other
hemoglobinopathies based on parent history, family
history, ethnic origin
ENDOCRINE DISORDERS
Gestational diabetes
 Pathophysiology
 Placental hormone increases insulin resistance
 Human placenta lactogen (hPL)
 Disease presents like Type II diabetes, but for the
first time in pregnancy
 Diagnosis
 One hour 50gm glucose screening test (O‘Sullivan)
(nl < 140mg/dl)
 3-hour GTT (fasting < 105, 1-hour < 190, 2-hour
<165. 3-hour < 145mg/dl)
Diabetes: Complications
Pregestational
Maternal
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Accelerated retinopathy or nephropathy
More difficult to control glucose levels
• DKA, hyperosmolar coma
• Hypoglycemia
Pregnancy induced hypertension/preeclampsia
Increased risk of infection
Gestational
• Gestational
• Preeclampsia
Fetal
Neonatal
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Spontaneous abortion
Congenital anomalies
• Congenital heart disease (VSD, transposition of the great
arteries)
• Neural tube defects
• Caudal regression
Macrosomia
Polyhydramnios
Preterm birth
Stillbirth (IUFD)
Intrauterine growth restriction (IUGR)
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Morbidity from preterm delivery
Injury from traumatic delivery secondary to macrosomia
Hypoglycemia, hypocalcemia, hyperbilirubinemia
Management of congenital anomalies
Respiratory distress syndrome
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Macrosomia
Intrauterine growth restriction (IUGR)
Stillbirth (IUFD)
Injury from traumatic delivery secondary to
macrosomia
Hypoglycemia, hypocalcemia,
hyperbilirubinemia
Respiratory distress syndrome
Gestational diabetes
 Management
 Tight control essential
 Diet – 30-35 kcal/kg ideal body weight ADA diet
 Glucose testing - fasting and 2-hours following
meals
 FBS <105mg/dl
 1-hour PP <130mg/dl
Thyroid Disease
• Hyperthyroidism
– May suppress fetal and neonatal thyroid function
– Has been associated with fetal goiter
– Thyroid storm – high risk of maternal heart failure
• Hypothyroidism
– Maternal thyroxine requirements increase during
pregnancy
– Adjust levels q4 wks and then check TSH each
trimester
CARDIOVASCULAR DISEASE
Cardiovascular Disease
• Pregnancy results in ~40% increase in cardiac
output
• The risks for mother and fetus are therefore
often profound for women with pre-existing
cardiac disease; ex:
– Rheumatic heart disease
– Acquired infectious valvular disease
Cardiovascular Disease
• Fetal complications
– Fetuses of patients with functionally significant
cardiac disease are at increased risk for LBW and
prematurity
– Patient w/ congenital heart disease is 1-5% more
likely to have a fetus with a congenital heart
disease as well
– High rate of fetal loss in women with rheumatic
heart disease
EvaluationDisease
Cardiovascular
• Evaluation
– Ideally, women with cardiac disease should have
preconception care directed at maximizing cardiac
function and counseling regarding risks that their
particular disease poses in pregnancy
– Serial evaluation of
• Maternal cardiac status
• Fetal well-being and growth
HYPERTENSION
Hypertension
 Classification:
 Chronic – HTN present before 20th week of pregnancy
 Gestational – HTN that develops after 20 wks gestation in
the absence of proteinuria and returns to normal
postpartum
 Preeclampsia – HTN with proteinuria and edema after 20
wks gestation
 Eclampsia – additional presence of convulsions in a woman
with preeclampsia that is not explained by a neuro disease
 HELLP Syndrome – presence of hemolysis, elevated liver
enzymes and low platelets
Hypertension
• Pathophysiology:
– Predominant pathophysiologic finding is maternal
vasospasm
– Potential contributors:
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Endothelial damage
Increased platelet activation and consumption
Increased TXA2 and PGI2
Decreased NO
Hypertension
• Maternal complications:
– Liver dysfunction
– Renal insufficiency
– Coagulopathy
– Convulsions
Hypertension
• Potential Fetal Complications
– IUGR
– PTB
– Abruption
• Studies to evaluate: Ultrasound
– Fetal weight and growth assessment
– Amniotic fluid volume
– Umbilical artery dopplers
Hypertension
• Evaluation:
– Routine measurement of BP
– Compare weight to pregravid weight and previous
weights during pregnancy to monitor for rapid or
excessive gain
– Note excessive, persistent edema (general peripheral
edema is normal)
– Labs
• CBC, platelets
• LFTs
• Serum Cr
PULMONARY DISEASE
Pulmonary Disease
• Asthma – restrictive airway disease
• Effects of pregnancy on asthma are variable
– 1/3 patients improve
– 1/3 worsen
– 1/3 unchanged
Pulmonary Disease
• Women with mild-moderate asthma usually
have excellent maternal and fetal outcomes
• Suboptimal control of asthma during
pregnancy may be associated with increased
risk of
– LBW
– Prematurity
Pulmonary Disease
• Routine evaluation of pulmonary function in
pregnant women w/ persistent asthma is
recommended
• Consider serial ultrasounds starting at 32
weeks for women w/ moderate-severe
asthma during pregnancy
RENAL DISEASE
Renal Disease
• UTIs
• Pre-existing renal disease
UTIs
• Common in pregnancy
• Aysmptomatic bacteruria is more likely to lead to
cystitis and pyelonephritis in pregnant women
– Pregnancy associated urine stasis
– Glycosuria
– ↑ urine pH
• Urine culture should be obtained at first prenatal
visit
Pyleonephritis
• One of the most common medical
complications in pregnancy requiring
hospitalization
• Associated with↑increased risk of preterm
labor
– E. coli produces phospholipase A  promotes
prostaglandin synthesis  ↑ uterine activity
• Treat with IV hydration and antibiotics
Pre-Existing Renal Disease
• Women with significant pre-existing renal
disease (chronic renal failure or transplant)
should be advised of risks involved in
pregnancy during preconception counseling
• Patients with mild renal insufficiency
generally have uneventful pregnancy
Pre-Existing Renal Disease
• Patients with moderate-severe disease are at
risk for worsening renal function, proteinuria
and associated hypertensive complications of
pregnancy
• Women with chronic renal disease also have
increased incidence of IUGR and need serial
assessments of fetal well being and growth
GASTROINTESTINAL DISEASE
GI Disease
• Nausea and vomiting of pregnancy (NVP) – typically
begins ~4-8 wks gestation and stops by 14-16 wks
– Related to ↑ progesterone and hCG, smooth muscle
relaxation of the stomach
• Hyperemesis gravidarum – severe NVP which results
in weight loss, ketonemia or electrolyte imbalance
• GERD – symptoms become more pronounced as
pregnancy advances
– Due to ↑ intraabdominal pressure
GI Disease
• Complications for mom or baby are rare
• Evaluation for mom with persistent vomiting:
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Weight
Orthostatic BPs
Serum electrolytes
Urine ketones
Thyroid function tests
Ultrasound to exclude gestational trophoblastic disease and
multiple gestation, both of which are associated with
hyperemesis
NEUROLOGIC DISEASE
Epilepsy
• Majority of women with epilepsy have
normal pregnancy
• Typically there is not an increased frequency
of seizures during pregnancy
Epilepsy
• Small association with LBW, lower Apgar scores,
preeclampsia, bleeding, placental abruption, and
prematurity
• Increases risk of congenital malformations in fetus
exposed to phenytoin, valproic acid, phenobarbital
and carbamazepine
• Risks to fetus of actual seizures - hypoxia,
abruption, or miscarriage due to maternal trauma
sustained during a seizure; although few studies
have been done to assess
AUTOIMMUNE DISORDERS
SLE
• Prognosis for mom and baby is best when SLE
has been quiescent for at least 6 months
prior to the pregnancy
• Should be seen by OB who is experienced in
management of high risk pregnancies
• Exacerbation of disease can occur
throughout all three trimesters and even in
postpartum period
SLE
• Women with SLE have increased risk of
preeclampsia
• Significant risk of fetal loss in women with
hypertension, active lupus, lupus nephritis,
hypocomplementemia, ↑ anti-DNA antibodies,
↑ aPL or thrombocytopenia
• Mothers should be assessed for disease activity
at least once per semester – more if they have
active lupus
ALCOHOL, TOBACCO AND
SUBSTANCE ABUSE
Alcohol Use
• Leading preventable cause of mental
retardation, developmental delay and birth
defects in the fetus
• Greatest risk – exposure during first trimester
• No established safe level of consumption
Tobacco Use
• Risks to fetus – IUGR, LBW, fetal death
• Safety of nicotine replacement products in
pregnancy has not been documented
Substance Abuse
• Illicit drugs reach fetus via placental transfer or
reach newborn through breast milk
• Opiate-exposed fetus – may have withdrawal
symptoms in utero or after birth
• Universal specimen screening is not
recommended, however all women should be
questioned about and counseled if
appropriate about past and present use of
alcohol, nicotine and other drugs
SURGICAL ABDOMEN
Surgical Abdomen
• Surgical treatment of pregnancy women should
consider maternal and fetal health needs
• Don’t avoid radiographic or other studies because
woman is pregnant, but exercise caution
• Monitor fetal heart tones during surgery to the
extent possible
• Avoid placing patient fully supine if possible –
place in decubitus lateral tilt to prevent supine
hypotensive syndrome
INFECTIOUS DISEASES
ToRCHeS
Infection
Toxoplasma
Transmission
Maternal Disease
Cat feces,
Usually asymptomatic, sometimes
undercooked meat lymphadenopathy
Rubella
Respiratory
droplets
CMV
Sexual contact,
Usually asymptomatic, sometimes
organ transplants mono-like illness
HIV
HSV
Syphillis
Rash, lymphadenopathy, arthritis
Sexual contact
Variable, depending on CD4 count
Skin or mucous
Usually asymptomatic; herpetic
membrane contact lesions
Sexual contact
Primary - chancre, Secondary disseminated rash, Tertiary cardiac/neurologic disease
Neonatal Disease
Triad - chorioretinitis, hydrocephalus,
intracranial calcifications
Triad - PDA (or pulmonary artery
hypoplasia), cataracts, deafness; +/blueberry muffin rash
Hearing loss, seizures; most
asymptomatic; some w/ same triad as
toxoplasma
Recurrent infxns, chronic diarrhea
Temporal lobe encephalitis (seizures),
herpetic lesions
Stillbirth, hydrops fetalis
If child survives - facial abnormalities
(notched teeth, saddle nose, short
maxilla), saber shins, snuffles (bloody
nasal discharge)
GBS
• Asymptomatic lower genital tract
colonization is common
• Without treatment, GBS sepsis can occur
• Infection of newborn – septicemia, septic
shock, pneumonia or meningitis
• Universal screening at 35-37 wks  if
positive, give antibiotic prophylaxis in labor
HIV
• All women exhibit absolute decline in CD4 counts in
pregnancy – thought to be 2/2 hemodilution
• Perinatal transmission w/o prophylaxis is ~25%
• With Zidovudine monotherapy – transmission ~8%
• Combination therapy and undetectable viral load –
transmission ~1-2%
• Universal, voluntary HIV screening should be part of
standard prenatal labs
HPV
• Genital wart lesions often increase in size and area
during pregnancy due to relative immune suppression
• If extensive – c/s delivery may be necessary
• Transmission to infant is rare, but if occurs – manifests
as laryngeal papillomatosis
– c/s delivery does not prevent transmission
Parvovirus
• Can cause devatsating fetal outcomes – SAB, fetal nonimmune
hydrops fetalis, death
• Maternal immune status can be determined by serologic testing –
IgM recent infection, IgG past infection and immunity
– Routine serologic testing not recommended
– Exposed pregnant women should be offered B-19 specific IgM
and IgG serologic testing
• If IgM + confirmed – serial ultrasounds starting at 10 wks to look
for evidence of hydrops, placentomegaly and growth
disturbances
• If hydrops doesn’t develop, long-term outcomes are good
Hepatitis
• Hepatitis A
– Vaccination safety during pregnancy has not been
established
– HAV IG is effective for both pre and post-exposure
prophylaxis and can be used during pregnancy
• Hepatitis B
– Routine testing for HBsAg - if neg w/ risk factors for
HBV infection – offer vaccination during pregnancy
– All infants receive Hep B vaccine
– Infants of mothers who are HBsAg pos should get
vaccine and HBIG w/in 12 hrs of birth
Hepatitis
• Hepatitis C
– Routine screening is not recommended
– Co-infection with HIV is associated with a higher risk of vertical
transmission of HCV
– No known preventative measures to reduce risk of mother to child
transmission
• Hepatitis D
– Infection can only occur along with Hep B infection
– Vertical transmission has been documented but is rare
• Hepatitis E
– Associated with higher rates of fulminant disease and mortality in
pregnant women
– Risk of vertical transmission is low
Bottom Line Concepts
 Maternal medical or surgical conditions can complicate the course of a
pregnancy and/or can be affected by pregnancy
 Important to understand:
 Effect of pregnancy on natural course of disorder
 Effect of disorder on pregnancy
 Change in mgmt of the pregnancy and disorder caused by their coincidence
 Screening for and preventing infectious diseases is an integral part of
routine prenatal care
 Many infectious diseases can have devastating effects for mother, infant
or both
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 17 (p36-37).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 14, 15, 16 (p151182).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 14, 16 (p173-182, 191-218).