Helencrafter,Jennybrewster

CHAPTER12

Commonproblemsassociatedwithearlyandadvancedpregnancy

HelenCrafter,JennyBrewster

CHAPTERCONTENTS

Themidwife's role222

Abdominalpaininpregnancy222

Bleedingbeforethe24thweekofpregnancy222

Implantationbleed222

Cervicalectropion223

Cervicalpolyps223Carcinoma ofthecervix223Spontaneousmiscarriage224

Recurrentmiscarriage225

Ectopicpregnancy225

Otherproblemsinearlypregnancy226

Inelasticcervix226

Gestationaltrophoblasticdisease(GTD)226

Uterinefibroiddegeneration227

Inducedabortion/terminationofpregnancy227

Pregnancyproblemsassociatedwithassistedconception228

Nausea,vomitingandhyperemesisgravidarum228

Pelvicgirdle pain(PGP)229

Bleedingafterthe24thweekofpregnancy229

Antepartumhaemorrhage229

Placentapraevia230

Placentalabruption233

Bloodcoagulationfailure234

Hepaticdisordersandjaundice235

Obstetriccholestasis235

Gallbladderdisease236

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Viralhepatitis236

Skindisorders236

Abnormalitiesoftheamnioticfluid236

Hydramnios236

Oligohydramnios238

Pretermprelabour ruptureofthemembranes(PPROM)239

Conclusion240

References240

Furtherreading242

Usefulwebsites242

Problems ofpregnancyrangefromthemildlyirritatingtolife-threateningconditions.Fortunatelyinthedeveloped world,thelife-threateningonesarerare because ofimprovementsinthe generalhealthofthepopulation, improved socialcircumstancesandlowerparity.However,aswomendelaychildbearing,theybecomemoreatrisk ofdisorders associatedwithincreasingage,suchasmiscarriage andplacentapraevia.

Regularantenatalexaminationsbeginningearlyinpregnancyareundoubtedlyvaluable.Theyhelpto preventmanycomplicationsandtheirensuingproblems,contribute totimelydiagnosis andtreatment,andenablewomentoformrelationshipswith midwives,obstetriciansandother healthprofessionalswhobecomeinvolvedwiththemin strivingto achievethebestpossiblepregnancyoutcomes.

Thechapteraimsto:

•provideanoverviewofproblemsofpregnancy

•describe the roleofthemidwifeinrelationtotheidentification,assessmentandmanagementofthe more commondisordersofpregnancy

•considertheneedsofbothparents forcontinuingsupportwhenadisorderhasbeendiagnosed.

Themidwife'srole

Themidwife'sroleinrelationtotheproblemsassociatedwithpregnancyisclear.At

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initial andsubsequentencounterswiththepregnantwoman,itis essentialthatanaccuratehealthhistoryisobtained.Generalandspecificphysicalexaminationsmustbecarriedoutandtheresultsmeticulouslyrecorded.Theexaminationandrecordingsenableeffectivereferralandmanagement.Wherethemidwifedetectsadeviationfromthenormwhichisoutsidehersphereofpractice,shemustreferthewoman toasuitable qualifiedhealthprofessionaltoassisther(NMC[NursingandMidwifery Council]2012a).Themidwifewillcontinuetoofferthewomancareandsupportthroughoutherpregnancyandbeyond.Thewomanwhodevelopsproblemsduringherpregnancyisnolessinneedofthemidwife'sskilledafention;indeed,herconditionandpsychologicalstatemaybeconsiderablyimprovedbythemidwife'scontinuedpresence andsupport.Itisalsothemidwife'sroleinsuchasituationtoensurethatthewomanandherfamilyunderstandthesituation;areenabled totakepartindecision-making;andareprotectedfromunnecessaryfear.Astheprimarycaremanager,themidwifemustensurethatalltheafentionthewomanreceivesfromdifferenthealthprofessionalsisbalancedandintegrated–inshort,thewoman'sneedsremainparamountthroughout.

Abdominalpaininpregnancy

Abdominalpainisacommoncomplaintinpregnancy.Itisprobablysufferedbyallwomenatsomestage,andthereforepresentsaproblemforthemidwifeofhowtodistinguishbetweenthephysiologicallynormal(e.g.mildindigestionormusclestretching),thepathologicalbutnotdangerous(e.g.degenerationofafibroid)andthedangerouslypathologicalrequiringimmediatereferraltotheappropriatemedicalpractitionerforurgenttreatment(e.g.ectopicpregnancyorappendicitis).

Themidwifeshouldtakeadetailedhistoryandperformaphysicalexaminationinordertoreachadecisionaboutwhethertoreferthewoman.Treatmentwilldependonthecause(seeBox12.1)andthematernalandfetalconditions.

Box 12.1

Causesofabdominalpaininpregnancy

Pregnancy-specificcauses

Physiological

Heartburn,sorenessfromvomiting,constipationBraxtonHickscontractions

Pressureeffectsfromgrowing/vigorous/malpresentingfetusRoundligamentpain

Severeuterinetorsion(canbecomepathological)

PathologicalSpontaneousmiscarriageUterineleiomyoma

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Ectopicpregnancy

Hyperemesisgravidarum(vomitingwithstraining)Pretermlabour

ChorioamnionitisOvarianpathologyPlacentalabruption

SpontaneousuterineruptureAbdominalpregnancy

Traumatoabdomen(considerundiscloseddomesticabuse)Severepre-eclampsia

Acutefattyliverofpregnancy

Incidentalcauses

Morecommonpathology

Appendicitis

Acutecholestasis/cholelithiasis

Gastro-oesophagealreflux/pepticulcerdiseaseAcutepancreatitis

Urinarytractpathology/pyelonephritisInflammatoryboweldisease

Intestinalobstruction

MiscellaneousRectushaematomaSicklecellcrisis

Porphyria

Malaria

ArteriovenoushaematomaTuberculosis

MalignantdiseasePsychologicalcauses

Source:AdaptedfromCahilletal2011;Mahomed2011a

Manyofthepregnancy-specificcausesofabdominalpaininpregnancylistedinBox

12.1aredealtwithinthisandotherchapters.Formostoftheseconditions,abdominalpainisoneofmanysymptomsandnotnecessarilytheoverridingone.However,anobservantmidwife'sskillsmaybecrucialinprocuringasafepregnancyoutcomeforawomanpresentingwithabdominalpain.

Bleedingbeforethe24thweekofpregnancy

Anyvaginalbleedinginearly pregnancy isabnormalandofconcerntothewomanand

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herpartner,especiallyifthereisahistoryofpreviouspregnancyloss.Themidwifecancomeintocontactwithwomenatthistimeeitherthroughthebookingclinicorthroughphonecontact.Ifbleedinginearlypregnancyoccursawomanmaycontactthemidwife,thebirthingunitoratriagelineforadviceandsupport.Themidwifeshouldbeawareofthelocalpoliciespertainingtoheremploymentandhowtoguidethewoman.InsomeareasoftheUnitedKingdom(UK)womenarereviewedwithinthematernitydepartmentfromearlypregnancy,whereasinothers,theywillbeseenbythegynaecologyteamuntil20weeks'gestation,possiblyinanearlypregnancyclinic.However,womenareohenadvisedtocontacttheirGeneralPractitioner(GP)inthefirstinstance,andmanywillvisitanaccidentandemergencydepartment.

Inallcases,ahistoryshouldbeobtainedtoestablishtheamountandcolourofthebleeding,whenitoccurredandwhethertherewasanyassociatedpain.Fetalwell-beingmaybeassessedeitherbyultrasoundscanor, inthesecondtrimester,usinga hand-heldDopplerdevicetohearthefetalheartsounds.Maternalreportingoffetalmovementsmayalsobeusefulindeterminingtheviabilityofapregnancy.

Therearemanycausesofvaginalbleedinginearlypregnancy,someofwhichcanoccasionallyleadtolife-threateningsituationsandothersoflessconsequenceforthecontinuanceofpregnancy.Themidwifeshouldbeawareofthedifferentcauses ofvaginalbleedinginordertoadviseandsupportthewomanandherfamilyaccordingly.

Implantationbleed

Asmallvaginalbleedcanoccurwhentheblastocystembedsintheendometrium.Thisusuallyoccurs5–7daysaherfertilization,andifthetimingcoincideswiththeexpectedmenstruationthismaycause confusionoverthedatingofthepregnancyif the menstrualcycleis usedtoestimatethe date ofbirth.

Cervicalectropion

Morecommonlyknownas cervicalerosion.Thechangesseenincasesofcervicalectropionareasaphysicalresponsetohormonalchangesthatoccurinpregnancy.Thenumberofcolumnarepithelialcellsinthe cervicalcanalincreasesignificantlyundertheinfluenceofoestrogenduringpregnancytosuchanextentthattheyextendbeyondtothevaginalsurface ofthecervicalos,givingitadarkredappearance.Asthisareaisvascular,andthecellsformonlyasinglelayer,bleedingmayoccureitherspontaneouslyorfollowingsexualintercourse.Normally,notreatmentisrequired,and theectropionrevertsbacktonormalcervicalcellsduringthepuerperium.

Cervicalpolyps

Thesearesmall,vascular,pedunculatedgrowthsonthecervix,whichconsistofsquamousorcolumnarepithelialcellsoveracoreofconnectivetissuerichwithbloodvessels. During pregnancy, the polyps maybe a cause of bleeding, but require no

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treatmentunlessthebleedingissevereorasmeartestindicatesmalignancy.

Carcinomaofthecervix

Carcinoma ofthecervixisthemostcommongynaecologicalmalignantdiseaseoccurring inpregnancywithanestimatedincidenceof1in2200pregnancies(CopelandandLandon2011).Theconditionpresentswithvaginalbleedingandincreasedvaginaldischarge.Onspeculumexaminationtheappearanceofthecervixmayleadtoasuspicionofcarcinoma,whichisdiagnosedfollowingcolposcopyoracervicalbiopsy.

Theprecursortocervicalcanceriscervicalintraepithelialneoplasia(CIN),whichcanbediagnosedfromanabnormalPapanicolaou(Pap)smear.Wherethisisdiagnosedatanearlystage,treatmentcanusually bepostponedforthedurationofthepregnancy.ThePapsmearisnotroutinelycarriedoutduringpregnancy,butthemidwifeshouldensure thatpregnantwomenknowabouttheNationalHealthServiceCervicalScreeningProgramme(2013),recommendingasmear6weekspostnatallyifonehasnotbeencarriedout intheprevious3years.

Treatmentforcervicalcarcinomainpregnancywilldependonthegestationofthepregnancyandthestageof thedisease,andfullexplanationsoftreatmentsandtheirpossibleoutcomesshouldbegiventothewomanandherfamily.Forcarcinomaintheearlystages,treatmentmaybedelayeduntiltheendofthepregnancy,oraconebiopsymaybeperformedundergeneralanaesthetictoremovetheaffectedtissue.However,thereisariskofhaemorrhageduetotheincreasedvascularityofthecervixinpregnancy,aswellasariskofmiscarriage.Wherethediseaseismoreadvanced,andthediagnosismadeinearlypregnancy,thewomanmaybeoffereda terminationofpregnancyinordertoreceivetreatment,as theeffects ofchemotherapyandradiotherapyonthefetuscannotbeaccuratelypredictedatthepresenttime.Duringthelatesecondandthirdtrimestertheobstetricandoncologyteamswillconsidertheoptimaltimeforbirthinordertoachievethebestoutcomesforbothmotherandbaby.

Spontaneousmiscarriage

Thetermmiscarriageisusedtodescribeaspontaneouspregnancylossinpreferencetothetermofabortionwhichisassociatedwiththedeliberateendingofapregnancy.Amiscarriageis seenas thelossoftheproductsofconception priortothecompletionof24weeksofgestation,withanearlypregnancylossbeingonethatoccursbeforethe12th completedweek ofpregnancy(RCOG[RoyalCollegeofObstetriciansandGynaecologists]2006).

Itisestimatedthat10–20%ofclinicallyrecognizedpregnancieswillendinamiscarriage,resultingin50000hospitaladmissionsannually.Approximately1–2%ofsecondtrimesterpregnancieswillresultinamiscarriage(RCOG2011a).Methodsofmanagingpregnancylossarecurrentlyevolving,withmoreemphasisbeingplacedonmedicalinterventionand/ormanagement.

Inallcasesofmiscarriage,thewomanandherfamilywillneedguidanceandsupport

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fromthosecaringforher.Inallareasofcommunication,thelanguageusedshouldbeappropriate,avoidingmedicalterms,andberespectfulofthepregnancyloss.Followingthemiscarriage,theparentsmaywishtoseeandholdtheirbaby,andwillneedtobesupportedindoingthisbythosecaringforthem.Evenwherethereisnorecognizable baby,someparentsarecomfortedbybeinggiventhisopportunity(SANDS[StillbirthandNeonatalDeathSociety2007]).Itisalsoimportanttocreate memoriesfortheparentsintheformofphotographs,and,forpregnancylossesinthesecondandthirdtrimesters,footprintsandhandprintsmaybetaken(seeChapter26).

Forapregnancylosspriorto24weeks'gestation,thereisnolegalrequirementforababy'sbirthtoberegisteredorforaburialorcremationtotakeplace.However,manyNationalHealthService(NHS)facilitiesnowmakeprovisionforaserviceforthesebabies,orparentsmaychoose tomaketheirownarrangements.Inthe case ofcremation,theparentsshouldbeadvisedthatthereareveryfewornoashes.

Following amiscarriage,bloodtestsmaybecarriedoutonthewoman,anddependingongestationalage,theparentsmaybeofferedapostmortemexaminationofthefetalremainsinanefforttotrytoestablish a reasonfor thepregnancyloss.However,inmanycasesthereisnoidentifiablecause.Shouldthisbe thecase,the outlookforfuturepregnanciesisgenerallygood.Manyearlypregnancylossesareduetochromosomalmalformations, resultinginafetusthatdoesnotdevelop. Should a reasonforthemiscarriagebeidentified,itmaybeofsomecomforttothewomanallowingformedicalmanagementtobeput inplacetoenableasubsequentpregnancytobemoresuccessful.

Aspontaneousmiscarriagemaypresentinanumberofways,allassociatedwithahistoryofbleedingand/orlowerabdominalpain.

Athreatenedmiscarriageoccurswherethereisvaginalbleedinginearlypregnancy,whichmayormaynotbeaccompaniedbyabdominalpain.Thecervicalosremainsclosed,andinabout80%ofwomenpresentingwiththesesymptomsaviablepregnancywillcontinue.

Wheretheabdominalpainpersistsandthebleedingincreases,thecervixopensandtheproductsofconceptionwillpassintothevaginainan inevitablemiscarriage.Shouldsomeoftheproductsberetained,thisistermedan incompletemiscarriage.Infectionisariskwithincompletemiscarriageandtherapeuticterminationofpregnancy.Thesignsand symptomsofmiscarriagearepresent,accompaniedbyuterinetenderness, offensivevaginaldischargeandpyrexia.Insomecasesthismayprogresstooverwhelmingsepsis,withtheaccompanyingsymptomsofhypotension,renalfailureanddisseminatedintravascularcoagulation(DIC).Theremainingproductsmaybepassedspontaneouslytobecomeacompletemiscarriage.

Wherethereis amissedorsilentmiscarriageapregnancysacwithidentifiablefetalpartsisseenonultrasoundexamination,butthereisnofetalheartbeat.Theremaybesomeabdominalpainandbleedingbuttheproductsofthepregnancyarenotalwayspassedspontaneously.

Thefirstprioritywithanywomanpresentingwithvaginalbleedingistoensurethatsheishaemodynamicallystable.Profusebleedingmayoccurwheretheproducts ofconceptionarepartiallyexpelledthroughthecervix.

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Humanchorionicgonadotrophichormone(hCG)ispresentinthematernalbloodfrom9–10daysfollowingconception,andassessinghCGlevelsmaybeusedasanindicationofthepregnancy'sviability.Whereawomanhaspersistentbleedingserialreadingscanbetakentoassesstheprogressofapregnancyordistinguishanectopicpregnancyfromacompletemiscarriagewheretheuterusisemptyonanultrasoundscan.ThelevelsofhCGdoubleevery48hoursinanormalintrauterinepregnancyfrom4to6weeksofgestation.

Asapregnancyprogresses,transvaginalultrasoundand/orabdominalultrasoundmaybeusedtoconfirmthepresenceorabsenceofaviablepregnancysac(RCOG2006).Agentlevaginalorspeculumexaminationmayalsobeperformed toascertainifthecervicalosisopen,and toobserveforthepresenceofanyproductsofconceptionwithinthevagina.

Inthecaseofthreatenedmiscarriagewhereviabilityofthepregnancyhasbeenconfirmed,thereisnospecifictreatmentasthelikelihoodofthepregnancyprogressingisusuallygood.Thepracticeofbedresttopreservepregnancyisnotsupportedbyevidencesowomenshouldbeneitherencouragednordiscouragedfromdoingthis.

Foracompletemiscarriage,therealsoisnorequiredtreatmentifthewoman'sconditionisstable,apartfromthesupportandguidancesheandherfamilywillrequireto dealwiththeirloss.

Ifthereareretained productsofconception,anincompleteormissedmiscarriage,theoptionsfortreatmentwillohendependongestationalageandtheconditionofthewoman.Miscarriagesmaybemanagedsurgically,medicallyorexpectantly.Inmanycasestheappropriatemanagementistowaitfortheproductsoftheconceptiontobepassedspontaneously.However womenshouldbeawarethatthiscantakeseveralweeks(RCOG2006).Womenadoptingthisoptionshouldbegivenfullinformationregardingtheprobablesequenceofeventsand beprovidedwithcontactdetailsforfurtheradvice,withtheoptionofadmissiontohospitalifrequired.Itisimportantthatwomenareeducatedtoactivelyobserveforsignsofinfectionandknow whattodoiftheysuspectthis.

Thesurgicalmethod,wheretheuterinecavityisevacuatedoftheretained productsofconception (ERPC)priorto14weeks' gestationissuitableforwomenwhodonotwanttobe managedexpectantlyandwhoare notsuitable formedicalmanagement.Under eitherageneralorlocalanaestheticthecervixisdilatedandasuctioncurefageisusedtoempty theuterus.Theuseofprostaglandinspriortosurgerymakesthecervixeasiertodilate,thusreducingtheriskofcervicaldamage.Between1and2%ofsurgicalevacuationsresultinseriousmorbidityforthewomanwiththemaincomplicationsbeingperforationoftheuterus,tearstothecervixandhaemorrhage.

Medical managementof miscarriagesincludesavarietyof regimesinvolvingthe useofprostaglandins,suchasmisoprostol,andmayincludetheuseofananti-progesteronesuchasmifepristoneforamissedmiscarriage,orprogesteronealoneforanincompletemiscarriage.Thesuccessratesformedicallymanagedmiscarriagesvaryfrom13to96%(RCOG2006)dependingonthegestationandsizeofthegestationalsac.Ohenwomenwillspendtimeathomebetweentheadministrationofthefirstdrugandsubsequent

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treatment,soitshouldbeensuredthattheyhavefullknowledgeofwhatmighthappenanda contactnumberto useatanytime.Althoughthecomplicationsincludeabdominalpainandbleeding,overallthemedicalmanagementofmiscarriagereducesboththenumberofhospitaladmissionsandthetimewomenspendinhospital.

Recurrentmiscarriage

Testsmaybecarriedoutonthewomanandfetusfollowingamiscarriagetotrytoestablishanyunderlyingcause.Thisisespeciallyimportantwherethereisahistoryofrecurrentmiscarriage.Followingahistoryofthreeormoremiscarriagesareferralisusuallymadetoa specialistrecurrentmiscarriageclinic (RCOG2011a),whereappropriateandaccurateinformationandsupportcanbegiven.

Geneticreasonsforthemiscarriagemaybeidentifiedthroughkaryotypingofthefetaltissue,aswellasbothparents.Thiscancausedifficultdilemmastodealwithbutmorerecentgeneticengineeringisofferinghopetosomecouples.Womenshouldalsobetestedforlupusanticoagulantandanticardiolipinantibodies,withtreatmentoflowdoseaspirinandheparinbeinginitiatedifeither ofthese ispresent.Othertreatmentsdependonthecause,orcauses,ofthemiscarriagesbeingidentified.

Ectopicpregnancy

Anectopicpregnancyoccurswhenafertilized ovumimplantsoutsidetheuterinecavity,ohenwithinthefallopiantube.However,implantationcanalsooccurwithintheabdominalcavity(forinstanceonthelargeintestineorinthePouchofDouglas),theovary orinthecervicalcanal.Theincidenceis11.1per1000pregnancies(RCOG2010a),with6deathsafributedtoectopicpregnancyinthe2006–2008SavingMother'sLivesreport(CEMACE[CentreforMaternalandChildEnquiries]2011).

TheconceptusproduceshCG inthesamewayasforauterinepregnancy,maintainingthecorpusluteum,whichleadstotheproductionofoestrogenandprogesteroneandthepreparationoftheuterus toreceivethefertilizedovum.However,followingimplantationinanabnormalsitetheconceptuscontinuestogrowandinthemorecommoncaseofanectopicpregnancyinthefallopiantube,untilthetuberuptures,ohenaccompaniedbycatastrophicbleedinginthewoman,oruntiltheembryodies.

Manyectopicpregnanciesoccurwithnoidentifiableriskfactors.However,itisrecognizedthatdamagetothefallopiantubethroughapreviousectopicpregnancyorprevioustubularsurgeryincreasestherisk,asdopreviousascendinggenitaltractinfections.Furtherriskfactorsincludeapregnancythatcommenceswithanintrauterinecontraceptivedevice(IUCD)insitu orthewomanconceiveswhiletakingtheprogestogen-onlypill.

Ectopic(tubal)pregnanciespresentwithvaginal bleedinganda suddenonsetoflowerabdominalpain,whichisinitially onesided,butspreadsasbloodenterstheperitonealcavity.Thereisreferredshouldertippaincausedbythebloodirritatingthediaphragm.

In25%ofcases,thepresentationwillbeacute,withhypotensionandtachycardia.On

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abdominalpalpationthereisabdominaldistension,guardingandtenderness,whichassistsinconfirmingthediagnosis.However,inthemajorityofcasesthepresentationislessacute,sothereshouldbeasuspicionofectopicpregnancyinanywomanwhopresentswithamenorrheaandlowerabdominalpain.Inthesecasesthepresentationmaybeconfusedwiththatofathreatenedorincompletemiscarriage,thusdelayingappropriatetreatment.

Atransvaginalultrasoundofthelowerabdomenisausefuldiagnostictoolinconfirmingthesiteofthepregnancy.AsinglebloodtestforhCGlevelmaybeeitherpositive(wherethecorpusluteumremainsactive)ornegative,soisoflimiteddiagnosticvalue.Serialtestingisofgreatervalue.

Thebasisoftreatmentintheacute,advancedpresentationissurgicalremovaloftheconceptusandrupturedfallopiantubeasthesethreatenthelifeofthewomanifsheisnotstabilizedandtreatedrapidly.Inthemajorityofcases,surgeryiscurrentlybylaparoscopyasopposedtoalaparotomy,asthisreducesbloodloss,aswellaspostoperativepain. Theectopicpregnancymayeitherberemovedthroughanincisioninthetubeitself,asalpingotomy,orbyremovingpartofthefallopiantube,i.e.asalpingectomy.Althoughasalpingotomywillenableahigherchanceofauterinepregnancyinthefuture,itisassociatedwithahigherincidenceofsubsequenttubalpregnancies(RCOG2010a).

Wherethefetushasdied,hCGlevelswillfallandtheectopicpregnancymayresolveitself,withtheproductseitherbeingreabsorbedormiscarried.Medicalmanagementisalsoachoicewherethediagnosisofanectopicpregnancyismadeandthewomanishaemodynamically stable.Methotrexateisgiveninasingledoseaccordingtothewoman'sbodyweight(RCOG2010a),andworksbyinterferingwithDNA(deoxyribonucleicacid)synthesis,thuspreventingthecontinuedgrowthofthefetus(NHSChoices 2012).Shouldthisbethe treatment choice,the womanshouldbeinformedthatfurthertreatmentmaybeneededaswellashowtoaccesssupportatanytimeshoulditberequired(RCOG2010a).

Womenwhoare Rhesus-negativeshouldbe givenanti-D immunoglobulinasrecommendedbynationalandlocalguidelinesfollowinganyformofpregnancyloss(RCOG2011b).(SeeBox12.2forfurtherinformation.)

Box 12.2

Noteonanti-DimmunoglobulinForallwomenwhoareRhesus-negative,thereisanincreasedriskofsensitizationoccurringduringanyform of pregnancyloss,andthreatenedmiscarriage (NICE2011).Anti-Dimmunoglobulinprophylaxisshouldbeconsideredfornon-sensitizedwomenpresentingwithahistoryofbleedingaher12weeks'gestation.Wherethebleedingpersiststhroughoutthepregnancy,anti-Dshouldberepeatedat6-weeklyintervals.Anti-Dimmunoglobulinshouldalsobeadministeredtoallnon-sensitizedRhesus-negativewomenfollowingmiscarriage,ectopicpregnancyortherapeutictermination

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ofpregnancy(RCOG2011b).

Otherproblemsinearlypregnancy

Inelasticcervix

Formallyknownasincompetentcervix,aninelasticcervixwillleadtosilent,painlessdilatationofthecervixandlossoftheproductsofconception,eitherasamiscarriage,orapretermbirth.Theincidenceis1:100–1:2000pregnancies,thelargevariationbeingduetodifferencesinpopulations(LudmirandOwen2007).

Thecervixconsistsmainlyofconnectivetissue,collagen,elastin,smoothmuscleandbloodvessels,andundergoescomplexchangesduringpregnancy.Theexactmechanismforinelasticcervixisunknown,buttheriskisincreasedwheretherehasbeentraumatothecervixduringsurgicalproceduressuchasadilatationandcurefageorconebiopsy,ortheweaknessmaybeofcongenitalorigin.

Thediagnosisofaninelasticcervixisusuallymaderetrospectivelyonreviewofgynaecologicalandobstetrichistory.Therewillhavebeenapainlessdilatationofthecervixtypicallyataround18–20weeksofgestation,orondigitalvaginalorultrasoundexamination,thelengthofthecervicalcanalmaybe notedtohaveshortenedwithoutanyaccompanyingpain.

Acervicalcerclagemaybe inserted.Howeverthe evidence tosupportthisprocedureisweak,andboththeprocedureandtheimplicationsshouldbefullydiscussedwiththewoman(NICE[NationalInstituteforHealthandClinicalExcellence]2007).Asutureisinsertedfrom14weeks' gestationattheleveloftheinternalos,andremainsinsituuntil38weeks'gestation,unlessthereareearliersignsoflabour.Theassociatedrisksarethatthecervixmaydilatewiththesutureinsitu,leadingtolacerationsofthecervix,andinfection.In3%ofcases,thecervixfailstodilateduringlabour,resultinginacaesareansection(LudmirandOwen2007).

Gestationaltrophoblasticdisease(GTD)

Inthisconditionthere isabnormalplacentaldevelopment,resultingineitheracompletehydatidiformmoleorapartialmoleandthereisnoviablefetus.Thegrape-likeappearanceofthemoleisduetotheover-proliferationofchorionicvilli.Usuallythisisabenignconditionwhich becomesapparentinthesecondtrimester,characterizedbyvaginalbleeding, alargerthanexpecteduterus, hyperemesisgravidarumandohensymptomsofpre-eclampsia.Howeverif amolarpregnancydoesnotspontaneouslymiscarry,twoassociateddisorderscanoccur;gestationaltrophoblastic neoplasia(GTN)wherethemoleremainsinsituandisdiagnosedbycontinuingraisedhCGlevelsandultrasoundscanning,andchoriocarcinoma,whichcanariseasamalignantvariationofthedisease.Itisthoughtthat3%ofcompletehydatidiformmoleswill progresstochoriocarcinoma.

IntheUK,GTDisarareevent,butwomenofAsianoriginareathigherrisk.Ageisalsoariskfactorforbothteenagersandwomenover45yearsofage.However,90%of

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molarpregnanciesoccurinwomenbetweentheagesof18and40years(CopelandandLandon2011).OtherriskfactorsincludeapreviousmolarpregnancyandthosewithbloodtypeGroupA.Treatmentisbyevacuationoftheuterus,followedbyhistology ofthetissuetoenableaccuratediagnosisofmolarpregnancy(RCOG2010b).

Duetotheriskofcarcinomadevelopingfollowinga molarpregnancy,allcasesshouldbefollowedupatatrophoblasticscreeningcentre,withserialbloodorurinehCGlevelsbeingmonitored.IntheUK,thisprogrammehasresultedin98–100%ofcasesbeingsuccessfullytreatedandonly5–8%requiringchemotherapy(RCOG2010b).WherethehCGlevelsarewithin normallimitswithin 56 days of theendof thepregnancy,follow-upcontinuesforafurther6months.However,ifthehCGlevelsremainraisedatthispoint,thewomanwillcontinueto beassesseduntilthelevelsarewithinnormallimits.Followingsubsequentpregnancies,hCGlevelsshouldbemonitoredfor6–8weekstoensurethatthereisnorecurrenceofthedisease(RCOG2010b).

Followingahydatidiform mole,thosewomen whoareRhesus-negativeshouldbeadministeredanti-Dimmunoglobulinasrecommendedbynationaland localguidelines.(SeeBox12.2.forfurtherinformation.)

Uterinefibroiddegeneration

Fibroids(leiomyomas)candegenerateduringpregnancyasaresultoftheirdiminishingbloodsupply,resulting inabdominalpainasthetissuebecomesischaemicand necrotic.Suitableanalgesiaandrestareindicateduntilthepainsubsides,althoughitcanbearecurringproblemthroughouta pregnancy. Notallfibroidsdegenerate duringpregnancyassomemayreceiveanincreasedbloodsupply,causingenlargementwiththeconsequentialimpactofobstructinglabour.

Inducedabortion/terminationofpregnancy

UnderthetermsoftheAbortionAct1967,amendedbytheHumanFertilisationandEmbryologyAct1990, provisionismadeforapregnancytobeterminatedup to 24weeksofpregnancyforanumberofreasonsandwiththewrifenagreementoftworegisteredmedicalpractitionersThemedicalpractitionersmustagreethat,intheiropinion,theterminationisjustifiedunderthetermsofthestatutoryAct(seeBox12.3)IntheUK,in2011,189931terminations of pregnancywere undertaken:themajorityofthese occurringbefore20weeks'gestation(DepartmentofHealth2012).Itshouldbenotedthatthelawin Irelanddoesnotallowforpregnanciestobeterminatedunlessitisto preserve the lifeofthewoman(RCOG2011c).

Box 12.3

Statutorygroundsforterminationofpregnancy

(a)thatthepregnancyhasnotexceededitstwenty-fourthweekandthatthecontinuanceofthepregnancywouldinvolverisk,greaterthanifthepregnancywere

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terminated,ofinjurytothephysicalormentalhealthofthepregnantwomanoranyexistingchildrenofherfamily;or

(b)thattheterminationisnecessarytopreventgravepermanentinjurytothephysicalormentalhealthofthepregnantwoman;or

(c)thatthecontinuanceofthepregnancywouldinvolverisktothelifeofthepregnantwoman,greaterthanifthepregnancywereterminated;or

(d)that there isasubstantialriskthatifthe childwere bornitwouldsufferfromsuchphysicalormentalabnormalitiesastobeseriouslyhandicapped.

AbortionAct1967;amendedbytheHumanFertilisationandEmbryologyAct1990

Themajorityofterminations intheUKarecarriedoutunderclause(a)oftheAbortionAct,meaningthatcontinuingthepregnancywouldinvolveagreatermentalorphysicalrisktothewomanorherexistingfamilythanifthepregnancywereterminated.Priortoanyterminationofpregnancy,thewomanshouldreceivecounsellingtodiscusstheoptionsavailable.Whateverthereasonforthetermination,supportshouldbeofferedbefore,duringandfollowingtheprocedure.Inmanycasesthecareandsupport providedforwomenexperiencingaspontaneousmiscarriagewillalsoapply tothoseundergoingan inducedterminationofpregnancy.Thereasonsfortheterminationmayincludemalformationsofthefetusthatareincompatiblewithlife,oraconditionthatadverselyaffectsthehealthofthewomensuchthatterminatingthepregnancyoffersthebestoptiontoexpediteappropriateandtimelytreatment.

Beforethecommencementofthetermination,itmustbe ensuredthattheHSA1form,whichisalegalrequirementoftheAbortionAct1967 hasbeencompletedandsignedbythetwomedicalpersonnelagreeingtothetermination.Inaddition,itisalsoalegalrequirementthattheChiefMedicalOfficerisnotifiedofallterminationsofpregnancythattakeplace,within14daysoftheiroccurrence(RCOG2011c),bythepractitionerscompletingformHSA4.ThedataonthisformisthenusedforstatisticalpurposesandmonitoringterminationsofpregnanciesthattakeplacewithintheUK.Onlyamedicalpractitionercanterminateapregnancy. However,inpractice,drugsthat areprescribedtoinducetheterminationmaybeadministeredbyregisterednursesandmidwivesworkinginthisareaofclinicalpractice.

Themethodsusedforterminatingthepregnancywilldependonthegestationalage.Priorto14weeks'gestation,thepregnancyisgenerallyterminatedsurgicallybygraduallydilatingthecervixwithaseriesofdilatorsandevacuatingtheuterusviavacuumaspirationorsuctioncurefes.Thismaybecarriedoutundergeneralorlocalanaesthesia.

Terminationsinlaterpregnancy arecarriedoutmedically,usingaregimeofdrugstoprepareanddilatethecervix.Theactualregimeusedmayvaryacrosshealthcareproviders.Thecervixisinitiallypreparedusingmifepristone,whichisaprogesteroneantagonist.Thisisgivenorally,andisfollowed36–48hourslaterbyvaginaland/ororalprostaglandins, such as misoprostol. The woman mayreturn home in between the

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administrationofthetwodrugsandshouldbeprovidedwithclearinformationaboutwhattoexpect,thecontactdetailsofanamedhealthcareprofessionalandthereassurancethatadmissiontohospitalcanbe at anytime.Duringthetermination,analgesiaappropriatetoherneedsshouldbeavailable.

Aterminationofpregnancyshouldnotresultinthelivebirthofthefetus.Tothiseffect,shouldtheproceduretakeplaceaher21weeksand6daysgestation,feticidemaybeperformedpriortothecommencementoftheterminationprocess.Thisinvolvesaninjectionofpotassiumchloridebeinginjectedintothefetalhearttopreventthefetusbeingbornalive(RCOG2011c).

Wherenursesandmidwiveshaveaconscientiousobjectiontoterminationofpregnancy,theyhavetherighttorefusetobeinvolvedinsuchprocedures.However,theycannotrefusetogivelife-savingcaretoawoman,andmustalwaysbenon-judgementalinanycareandcontactthattheyprovide (NMC2012b).

Aswithotherpregnancylosses,thosewomenwhoundergoaterminationofpregnancyandareRhesus-negativewillrequireanti-Dimmunoglobulinasrecommendedbynationalandlocalguidelines.(SeeBox12.2forfurtherinformation.)

Pregnancyproblemsassociatedwithassistedconception

Thereareanumberoftechniquesavailabletoafemptassistedconceptionforwomenandcoupleswhohavefertilityproblems.However,achievingapregnancyisnotalwaystheendofthedifficultiesthatmayoccur.

Aseriousconditionthatmayoccuristhatofovarian hyperstimulationsyndrome.Whenfertilitydrugshavebeentakentostimulatetheproductionoffollicles,massiveenlargementoftheovariesandmultiplecystscandevelop(RCOG2007).Manywomentaking fertilitydrugswillexperienceamild formofthissyndrome,butinaconsiderablepercentage(0.5–5%)thisdevelopstoincludeoliguria,renalfailureandhypovolaemicshock(Mahomed2011b).Thisriskincreaseswhenpregnancyhasbeenachieved.Theconditionitselfsubsidesspontaneously,butmedicalsupportandtreatmentisrequiredforthosewhoareseverelyunwell.

Inassistedconception,theriskofmiscarriageisapproximately14.7%.Thisrateisprobablyassociatedwiththequalityandlengthoffreezingoftheoocytesorembryosthatareused.Howevertherearenodifferencesinthenumberofchromosomalmalformationswhencomparedwithspontaneouspregnancies(Mahomed2011b).

Thenumberofmultiplepregnanciesincreaseswithassistedconception,withratesof27%fortwinsand3%fortriplets(Mahomed2011b).Assistedreproductivetechnologyaccountsfor1%ofallbirths,but18%ofallmultiplebirths;consequentlymultiplebirthinitselfisariskfactorforpregnancy(seeChapter14).Withallpregnanciesresultingfromassistedtechniques,thereisanincreaseintherateofpre-termbirth,smallforgestationalagebabies,placentapraevia,pregnancyinducedhypertensionandgestationaldiabetes.Thereasonsfortheseratesarenotknown,butitisconsideredthattheyrelatetotheoriginalfactorsleadingtotheinfertility(Mahomed2011b).

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Nausea,vomitingandhyperemesisgravidarum

Nauseaandvomiting arecommonsymptomsofpregnancy,affecting approximately70%ofwomen(Gordon2007),withtheonsetfrom4–8weeks'gestationandlastinguntil16–

20weeks(NICE2010).Veryoccasionallythesymptomspersistforthewholeofpregnancy.Fromthewoman'spointofview,nauseaandvomitingisfrequentlydismissedbyothersasbeingacommonsymptomofphysiologicalpregnancysotheimpactthat it mayhave onherlifeandthatofherfamilymaybeignored(Tiran2004).

ThecauseofthesesymptomsisthoughttobeduetothepresenceofhCG,whichispresentduringthetimethatthenauseaand vomitingismostprevalent,althoughoestrogenand/orprogesteronearealsothoughttohavesomeinfluence(Tiran2004;Gordon2007).AccordingtoNICE(2010),gingermaybeofhelpinreducingthesymptoms,asiswristacupuncture,aformoftreatmentfornauseainpregnancyohenchosenbywomenasitisdrug-free.AccordingtoBetts(2006:25), thewristarea isseento‘harmonisethestomach’,thusworkingtoreducenausea.

Hyperemesisgravidarumistheseverestformofnauseaandvomitingandoccursin3.5per1000pregnancies (Gordon2007).Thewomanpresentswithahistoryofvomitingthathasled toweightlossanddehydrationthatmayalsobeassociatedwithposturalhypotension,tachycardia,ketosis andelectrolyte imbalance(WilliamsonandGirling2011).This requirestreatmentinhospital,whereintravenousfluids aregiventore-hydratethewomanandcorrecttheelectrolyteimbalance,withanti-emeticsbeingadministeredtocontrolthevomiting.Veryohenacombinationofdrugswillbeneededinordertoachievethis.Itisimportanttoexcludeotherconditions,suchasaurinarytractinfection,disordersofthegastrointestinaltract,oramolarpregnancy,wherevomitingmayalsobeexcessive.

Theaim of treatmentis notonlytostabilizethewoman'scondition,but alsotopreventfurthercomplications.Continualvomitingduringthepregnancymayleadtovitamindeficiencies,and/orhyponatraemia,whichcanpresentwithconfusionandseizures,leadingultimatelytorespiratoryarrestiflehuntreated(WilliamsonandGirling2011).Forwomenwhoareimmobilizedthroughtheseverity ofthevomiting,deepveinthrombosisisalsoapotentialcomplicationduetothecombinationofdehydrationandimmobility.Incasesofhyperemesisgravidarumthefetusmaybeatriskofbeingsmallforgestationalageduetoalackofnutrients.

Pelvicgirdlepain(PGP)

Duringpregnancytheactivityofthepregnancyhormones,especiallyrelaxin,cancausetheligamentssupportingthepelvicjointstorelax,allowingforslightmovement.Asaconsequence,pelvicgirdlepain(PGP),orformerly knownas symphysispubisdysfunction,occurswhenthisrelaxationisexcessive,allowingthepelvicbonestomoveupanddownwhenthewomaniswalking.Thisleadstopaininthepubicareaaswellasbackache,usuallyoccurringanytimefromthe28thweekofpregnancy.Approximately,1in5 pregnantwomenareaffectedbyPGP(ACPWH[AssociationofCharteredPhysiotherapistsinWomen'sHealth]2011),withsymptomsvaryingfrommildpainand

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discomforttoseveremobilitydifficulties.Somewomenalsoexperiencepainanddiscomfortwhenlyingdownincertainpositionsandonstanding(ACPWH2011).Veryohen,PGPoccurswithoutidentifiableriskfactors,butthesemayincludeahistoryoflowerbackorpelvicgirdlepain,and/orajob thatis physicallyactive.

OnsuspectingthatawomanhasPGP,themidwifeshouldexplaintheconditionandthepossiblecausesto thewomanandorganizea referralto anobstetricphysiotherapist.Thewomanshouldbeadvisedtorestasmuchaspossibleandundertakeactivitiesthatdonotcauseherfurtherpain.Veryohenitismovementthatinvolvesabductingthehipswhich increases thepain anddiscomfort.Aphysiotherapistcan be helpfulin advisingonmobilityandcopingwithdailytasksandinsupplyingaidssuchaspelvicgirdlesupportbeltsandinextremecases,crutches,sothatthepainmaybereduced.

Aplanforbothpregnancyandcareinlabourshouldbedevelopedandrecorded,sothatthemidwivescaringforthewomanduringthebirthareawareofthePGPandanypositions that can bebeneficial,such asbeinguprightandkneelingaswellasthewoman'sanalgesiarequirements.Astheremaybeareductioninhipabduction,themidwifeshouldtakecarewhenperformingvaginalexaminations,andifthelithotomypositionisrequiredduringthebirth,nottocausethewomanunnecessarydiscomfort(ACPWH2011).Followingthebirth,theligamentsslowlyreturntotheirpre-pregnantcondition, butthismaytakesometime. Extrasupportmayberequiredandphysiotherapymayneedtobecontinuedbeyondthepostnatalperiod.

Bleedingafterthe24thweekofpregnancy

Antepartumhaemorrhage(APH)

Antepartum haemorrhage is bleeding from the genital tract aher the 24th week ofpregnancy,andbeforetheonsetoflabour.AsshowninTable 12.1,itiscausedby:

•Bleedingfromlocallesionsofthegenitaltract(incidentalcauses).

•Placentalseparationduetoplacentapraeviaorplacentalabruption.

Table12.1

Causesofbleedinginlate pregnancy

CauseIncidence(%)
Placentapraevia / 31.0
Placental abruption / 22.0
‘Unclassified bleeding’ / 47.0
ofwhich:
Marginal / 60.0
Show / 20.0
Cervicitis / 8.0
Trauma / 5.0

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Vulvovaginal varicosities / 2.0
Genitaltumours / 0.5
Genitalinfections / 0.5
Haematuria / 0.5
Vasapraevia / 0.5
Other / 0.5

Source:AdaptedfromNavtiandKonje2011

Effectonthemother

Asmallamountofbleedingwillnotphysicallyaffectthewoman(unlesssheisalreadyseverelyanaemic)butitislikelytocauseheranxiety.Incasesofheavierbleeding,thismaybeaccompaniedbymedicalshockand blood clofingdisorders.Themidwifewillbeawarethatthewomancandieorbelehwithpermanentmorbidityifbleedinginpregnancyisnotdealtwithpromptlyandeffectively.

Effectonthefetus

Fetalmortalityandmorbidityareincreasedasaresultofseverevaginalbleedinginpregnancy.Stillbirthorneonataldeathmayoccur.Prematureplacentalseparationandconsequenthypoxiamayresultinsevereneurologicaldamageinthebaby.

InitialappraisalofawomanwithAPH

Antepartum haemorrhageisunpredictableandthewoman'sconditioncandeteriorateatanytime.Arapid decisionabouttheurgencyofneedforamedicalorparamedicpresence,orboth,mustbemade,ohenatthesametimeasobservingandtalkingtothewomanandherpartner.

Assessmentofmaternalcondition

•Takeahistoryfromthewoman.

•Assessbasicobservationsoftemperature,pulserate,respiratoryrateandbloodpressure,includingtheirdocumentation.

•Observeforanypallororrestlessness.

•Assessthebloodloss(considerretainingsoiledsheetsandclothesincaseasecondopinionisrequired).

•Performagentleabdominalexamination,whileassessingforsignsoflabour.

•Onnoaccountmustanyvaginalorrectalexaminationbeundertaken,nor shouldanenemaorsuppositoriesbeadministeredtoawomanexperiencinganAPHasthesecouldresultintorrentialhaemorrhage.

Sometimesbleedingthatthewomanhadpresumedtobefromthevaginamaybefromhaemorrhoids.Themidwifeshouldconsiderthisdifferentialdiagnosisandconfirmor

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excludethisassoonaspossiblebycarefulquestioningandexamination.

Assessmentoffetalcondition

•Thewomanisaskedifthe babyhasbeenmovingasmuchas normal

•Anattemptshouldbemadetolistentothefetalheart.Anultrasoundapparatus maybeusedinordertoobtaininformation.Howeverifthewomanis at homeandthebleedingis severe thiswouldnotbeapriority.The midwifewillneedtoensure thewomenistransferredtohospitalassoonas herconditionisstabilizedinorderto givethefetusthebestchanceofsurvival.Speedofactionis vital.

Supportive treatment for moderate or severe bloodloss and/or maternal collapsewouldconsistof:

•providingongoingemotionalsupportforthewomanandherpartner/relatives

•administeringrapidfluidreplacement(warmed)withaplasmaexpander,withwholebloodifnecessary

•administeringappropriateanalgesia

•arrangingtransfertohospitalbythemostappropriatemeans,ifthewomanisathome.

Managementofantepartumhaemorrhagedependsonthedefinitediagnosis(seeTable12.2).

Table12.2

Comparisonofclinicalissuesinplacentalabruptionandplacentapraevia

Placentapraevia

Inthisconditiontheplacentaispartiallyorwhollyimplantedintheloweruterinesegment.Theloweruterinesegmentgrowsandstretchesprogressivelyaherthe12thweekofpregnancy.Inlaterweeksthismaycausetheplacentatoseparateandseverebleedingcanoccur.Theamountofbleedingisnotusuallyassociatedwithanyparticulartypeofactivityandcommonlyoccurswhenthewomanisresting.Thelowplacental

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locationallowsallofthelostbloodtoescapeunimpededandaretroplacentalclotisnotformed.Forthisreason,painisnotafeatureofplacentapraevia.Somewomenwiththisconditionhaveahistoryof asmallrepeatedbloodlossat intervalsthroughoutpregnancywhereasothersmayhaveasuddensingleepisodeofvaginalbleedingaherthe20thweek.However, severehaemorrhageoccursmostfrequentlyaherthe34thweekofpregnancy.Thedegreeofplacentapraeviadoesnotnecessarily correspondtotheamountofbleeding.Atype4placentapraeviamayneverbleedbeforetheonsetofspontaneouslabourorelectivecaesareansectioninlatepregnancy or,conversely,somewomenwithplacentapraeviatype1mayexperiencerelativelyheavybleedingfromearlyintheirpregnancy.

Degreesof placentapraevia

Type1placentapraevia

Themajorityoftheplacentaisintheupperuterinesegment(seeFigs12.1,12.5).Bloodlossisusuallymildandthemotherandfetusremainingoodcondition.Vaginalbirthispossible.

Type2placentapraevia

Theplacenta ispartiallylocatedin thelowersegmentneartheinternalcervicalos(marginalplacenta praevia)(seeFigs 12.2,12.6).Bloodlossisusuallymoderate,althoughtheconditionsof themotherandfetuscan vary.Fetalhypoxia ismorelikelytobepresentthanmaternalshock.Vaginalbirthispossible,particularlyiftheplacentaisanterior.

Type3placentapraevia

Theplacentaislocatedovertheinternalcervicalosbutnotcentrally(seeFigs12.3,12.7).Bleedingislikelytobesevere,particularlywhenthelowersegmentstretchesandthecervixbeginstoeffaceanddilateinlatepregnancy.Vaginalbirthisinappropriatebecausetheplacentaprecedesthefetus.

Type4placentapraevia

Theplacentaislocatedcentrallyovertheinternalcervicalos(seeFigs12.4,12.8)andtorrentialhaemorrhageisverylikely.Caesareansectionisessentialtosavethelivesofthewomanandfetus.

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FIG. 12.1Type1.

FIG. 12.2Type2.

FIG. 12.3Type3.

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FIG. 12.4Type4.

FIGS12.1–12.4Types andpositions ofplacentapraevia.

FIG. 12.5Type1.

FIG. 12.6Type2.

FIG. 12.7Type3.

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FIG. 12.8Type4.

FIGS12.5–12.8Relationofplacentapraeviatocervicalos.

Incidence

Placentapraeviaaffects2.8per1000ofsingletonpregnanciesand3.9per1000oftwinpregnancies(NavtiandKonje2011).Thereisahigherincidenceofplacentapraeviaamongwomenwithincreasingageandparity,inwomenwhosmokeandthosewho havehadapreviouscaesareansection.Furthermore,itisknownthat thereisalsoanincreasedriskofrecurrencewheretherehasbeenaplacentapraeviainaprevious pregnancy.

Management

Immediatere-localizationoftheplacentausingultrasonicscanningisadefinitiveaidtodiagnosis,andaswellasconfirmingtheexistenceofplacentapraeviaitwillestablishitsdegree.Relyingonanearlypregnancyscanat20weeksofpregnancyisnotveryusefulwhenvaginal bleedingstartsinlaterpregnancy,astheplacentatendstomigrateuptheuterinewallas theuterusgrowsinadevelopingpregnancy.

Furthermanagementdecisionswilldependon:

•theamountofbleeding

•theconditionofthewomanandfetus

•thelocationoftheplacenta

•thestageofthepregnancy.

Conservativemanagement

Thisisappropriateifbleedingisslightandthewomanandfetusarewell.Thewomanwillbekeptinhospitalatrestuntilbleedinghasstopped.Aspeculumexaminationwillhaveruledoutincidentalcauses.Furtherbleedingis almostinevitableiftheplacentaencroachesintothelowersegment;thereforeitisusualforthewomantoremainin,orclosetohospitalfortherestofherpregnancy.Avisittothespecialcarebabyunit/neonatalintensivecareunitandcontactwiththeneonatalteammayalsohelptopreparethewomanandherfamilyforthepossibilityofpre-termbirth.

Adecision willbemade withthewomanabouthowandwhenthe birth willbemanaged.Ifthereisnofurtherseverebleeding,vaginalbirthishighlylikelyiftheplacentallocationallows.Themidwifeshouldbeawarethat,evenifvaginalbirthisachieved,thereremainsadangerofpostpartumhaemorrhagebecausetheplacentahasbeensituatedinthelowersegmentwheretherearefewerobliquemusclefibresandtheactionofthelivingligaturesislesseffective.

Immediatemanagementoflife-threateningbleeding

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Severevaginalbleedingwillnecessitateimmediatebirthofthebabybycaesareansectionregardlessofthelocationoftheplacenta. Thisshouldtakeplaceina maternityunitwithfacilitiesfortheappropriatecareofthenewborn,especiallyifthebabyis preterm.Duringtheassessmentandpreparationfortheatrethewomanwillbeextremelyanxiousandthemidwife mustcomfortandencourageher, sharinginformationwith herasmuchaspossible.Thepartnerwillalsoneedtobesupported,whetherheisintheoperatingtheatreorwaitsoutside.

Iftheplacentaissituatedanteriorlyintheuterus,thismaycomplicatethesurgicalapproachasitunderliesthesiteofthenormalincision.Inmajordegreesofplacentapraevia(types3and4)caesareansectionisrequiredevenifthefetushasdiedinutero.Suchmanagementaimstopreventtorrentialhaemorrhageandpossiblematernaldeath.

Complications

Complicationinclude:

•Maternalshock,resultingfrombloodlossandhypovolaemia.

•Anaestheticandsurgicalcomplications,whicharemorecommoninwomenwithmajordegreesofplacentapraevia,andinthoseforwhompreparationforsurgeryhasbeensuboptimal.

•Placentaaccreta,inupto15%ofwomenwithplacentapraevia.

•Airembolism,anoccasionaloccurrencewhenthesinusesintheplacentalbedhavebeenbroken.

•Postpartumhaemorrhage:occasionallyuncontrolledhaemorrhagewillcontinue,despitetheadministrationofuterotonicdrugsatthebirth,evenfollowingthebesteffortstocontrolit,andaligationoftheinternaliliacartery.Acaesareanhysterectomymayberequiredtosavethewoman's life.

•Maternaldeathis rareinthedevelopedworld.

•Fetal hypoxiaanditssequelae duetoplacentalseparation.

•Fetaldeath,dependingongestationandamountofbloodloss.

Placentalabruption

Prematureseparationofanormallysituatedplacentaoccurringaherthe24thweekofpregnancyisreferredtoasaplacentalabruption.Theaetiologyofthistypeofhaemorrhageisnotalways clear,butitmaybeassociatedwith:

•hypertension

•asuddenreductioninuterinesize,forinstancewhenthemembranesruptureorafterthe birth of afirsttwin

•trauma,forinstanceexternalcephalicversionofafetuspresentingbythebreech,aroadtrafficaccidentordomesticviolence,asthesemaypartiallydislodgetheplacenta

•highparity

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•previouscaesareansection

•cigarettesmoking.

Incidence

Placental abruptionoccursin0.49–1.8%ofall pregnancieswith30%ofcases beingclassedasconcealedand70%beingrevealed(NavtiandKonje2011),althoughthereisprobablyacombinationofbothin manysituations(mixedhaemorrhage).Inanyofthesesituationsthebloodlossmaybemild,moderateorsevere,rangingfromafewspotstocontinuallysoakingclothesandbedlinen.

Inrevealedhaemorrhage,asbloodescapesfromtheplacentalsiteitseparatesthemembranesfromtheuterinewallanddrainsthroughthevagina.Howeverin concealedhaemorrhagebloodisretainedbehindtheplacentawhereitisforcedbackintothemyometrium,infiltratingthespacebetweenthemusclefibresoftheuterus.Thisextravasation(seepageoutsidethenormalvascularchannels)cancausemarkeddamageand,ifobservedatoperation,theuteruswillappearbruised,oedematousandenlarged.ThisistermedCouvelaireuterusoruterineapoplexy.Inacompletelyconcealedabruptionwithnovaginalbleeding,thewomanwillhaveallthesignsandsymptomsofhypovolaemicshockandifthebloodlossismoderateorsevereshewillexperienceextremepain.Inpracticethemidwifecannotrelyonvisiblebloodlossasaguidetotheseverityofthehaemorrhage;onthecontrary,themostseverehaemorrhageisohenthatwhichistotallyconcealed.

Aswithplacentapraevia,thematernalandfetalconditionwilldictatethemanagement.

Mildseparationoftheplacenta

Mostcommonlyawomanself-admitstothematernityunitwithslightvaginalbleeding.Onexaminationthewomanandfetusareinastableconditionandthereisnoindicationofshock.Thefetusisalivewithnormalheartsounds.Theconsistencyoftheuterusisnormalandthereisnotendernessonpalpation.Themanagementwouldincludethefollowingplanofcare:

•Anultrasoundscancandeterminetheplacentallocalizationandidentifyanydegreeofconcealedbleeding

•Thefetalconditionshouldbeassessedbyfrequentorcontinuousmonitoringofthefetalheartratewhilebleedingpersists.Subsequentlyacardiotocograph(CTG)shouldbeundertakenonceortwicedaily

•Ifthe woman isnotin labourandthe gestationis lessthan37weeksshe maybe caredforintheantenatalwardforafewdays.Shemayreturnhomeifthereis nofurtherbleedingandtheplacentahasbeenfoundtobeintheupperuterinesegment.Thewomanshouldbeencouragedtoreturntohospitalifthereisanyfurtherbleeding.

•Womenwhohavepassedthe37thweekofpregnancymaybeofferedinductionoflabour,especiallyiftherehasbeenmorethanoneepisodeofmildbleeding

•Furtherheavybleedingorevidenceoffetalcompromisecouldindicatethatacaesarean

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sectionisnecessary.

Themidwifeshouldofferthewomancomfortandencouragementbyafendingtoheremotional needs, includingherneedforinformation.Physicaldomesticabuseshouldbeconsidered bythemidwife,whichthewomanmaybefrightened toreveal.Itshouldalsobenotedthatifthewomanisalreadyseverelyanaemicthenevenanapparentlymildabruptionmaycompromiseherwellbeingandthatofthefetus.

Moderateseparationof theplacenta

Aboutaquarteroftheplacentawillhaveseparatedandaconsiderableamountofbloodmaybelost,althoughconcealedhaemorrhagemustalsobeconsidered.Thewomanwillbeshockedandinpain,withuterinetendernessandabdominal guarding. Thefetusmaybealive,althoughhypoxic,howeverintrauterinedeathisalsoapossibility.

Thepriorityistoreduceshockandtoreplacebloodloss:

•Fluidreplacementshouldbemonitoredwiththeaidofacentralvenouspressure(CVP)line.Meticulousfluidbalancerecordsmustbemaintained.

•ThefetalconditionshouldbecontinuouslyassessedbyCTGifthefetusisalive,inwhichcaseimmediatecaesareansectionwouldbeindicatedoncethewoman'sconditionisstabilized.

•Ifthefetusis ingoodconditionorhas died,vaginalbirthmaybeconsideredas thisenablestheuterustocontractandcontrolthebleeding.Thespontaneousonsetof labourfrequentlyaccompaniesmoderatelysevereplacentalabruption,butifitdoesnotthenamniotomyisusuallysufficienttoinducelabour.Oxytocicsmaybeusedwithgreatcare,ifnecessary.Thebirthofthebabyisoftenquitesuddenafterashortlabour.Theuseofdrugs toattempttostoplabourisusuallyinappropriate.

Severeseparationoftheplacenta

Thisisanacuteobstetricemergencywhereatleasttwo-thirdsoftheplacentahasdetachedand2000mlofbloodormorearelostfromthecirculation.Mostorallofthebloodmaybeconcealedbehindtheplacenta.Thewomanwillbeseverelyshocked,perhapsfarbeyondthedegreetowhichwouldbeexpectedfromthevisiblebloodloss(seeChapter22).Thebloodpressurewillbeloweredbutifthehaemorrhageaccompaniespre-eclampsiathereadingmayliewithinthenormalrangeowingtoaprecedinghypertension.Thefetuswillalmostcertainlybedead.Thewomanwillhaveverysevereabdominalpainwithexcruciatingtendernessandtheuteruswouldhaveaboard-likeconsistency.

Featuresassociatedwithsevereantepartumhaemorrhageare:

•coagulationdefects

•renalfailure

•pituitaryfailure

•postpartumhaemorrhage.

Treatmentisthesameasformoderatehaemorrhage:

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•Wholebloodshouldbetransfusedrapidlyandsubsequentamountscalculatedinaccordancewiththewoman's CVP.

•Labourmaybeginspontaneouslyinadvance ofamniotomyandthemidwifeshouldbealertforsignsofuterinecontractioncausingperiodicintensifyingoftheabdominalpain.

•Ifbleedingcontinuesoracompromisedfetalheartrateispresent,caesareansectionwillberequiredassoonasthewoman'sconditionhasbeenadequatelystabilized.

Bloodcoagulationfailure

Normalbloodcoagulation

Haemostasisreferstothearrestofbleeding,preventinglossofbloodfromthebloodvessels.Itdependsonthemechanismofcoagulation.Thisiscounterbalancedbyfibrinolysiswhichensuresthatthebloodvesselsarereopenedinordertomaintainthepatencyofthecirculation.

Bloodclottingoccursinthreemainstages:

1.Whentissuesaredamagedandplateletsbreakdown,thromboplastinisreleased.

2.Thromboplastinleadstotheconversionofprothrombinintothrombin:aproteolytic(protein-splitting)enzyme.

3.Thrombinconvertsfibrinogenintofibrintoformanetworkoflong,stickystrandsthatentrapbloodcellstoestablishaclot.Thecoagulatedmaterialcontractsandexudesserum,whichis plasmadepletedofitsclottingfactors.This is thefinalpartofacomplexcascadeofcoagulationinvolvingalargenumberofdifferentclottingfactors(simplynamedFactorI,FactorIIetc.inorderoftheirdiscovery).

Itisequallyimportantforahealthypersontomaintainthebloodasafluidinorderthatitcancirculatefreely.Thecoagulationmechanismisnormallyheldatbaybythepresenceofheparin,whichis producedintheliver.

Fibrinolysisisthebreakdownoffibrinandoccursasaresponsetothepresenceofclofedblood.Unlessfibrinolysistakesplace,coagulationwillcontinue.Itisachievedbytheactivationofa seriesofenzymesculminating intheproteolyticenzymeplasmin.Thisbreaksdownthefibrinintheclotsandproducesfibrindegradationproducts(FDPs).

Disseminatedintravascularcoagulation(DIC)

Thecauseofdisseminatedintravascularcoagulation(alsoknownasdisseminatedintravascularcoagulopathy)(DIC)isnotfullyunderstood.Itisacomplexpathologicalreactiontoseveretissuetraumawhichrarelyoccurswhenthefetusisaliveandusuallystartstoresolveaherbirth.Inappropriatecoagulationoccurswithinthebloodvessels,whichleadstotheconsumptionofclofingfactors.Asaresult,clofingfailstooccuratthebleedingsite.DICisneveraprimarydisease,asitalwaysoccursasaresponsetoanotherdiseaseprocess.

EventsthattriggerDICinclude:

•placentalabruption

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•intrauterinefetaldeath,includingdelayedmiscarriage

•amnioticfluidembolism

•intrauterineinfection,includingsepticmiscarriage

•pre-eclampsiaandeclampsia.

Management

TheaimsofthemanagementofDICaresummarizedinBox12.4.

Box 12.4

AimsofthemanagementofDIC

•TomanagetheunderlyingcauseandremovethestimulusprovokingDIC

•Toensuremaintenanceofthecirculatingbloodvolume

•Toreplacetheusedupclottingfactorsanddestroyedredbloodcells

Source:LindowandAnthony2011

ThemidwifeshouldbealertforconditionsthataffectDIC,aswellasthesignsthatclofingisabnormal.Theassessmentofthenatureoftheclotshouldbepartofthemidwife'sroutineobservationduringthethirdstageoflabour.Oozingfromavenepuncturesiteorbleedingfromthemucousmembraneofthewoman'smouthandnosemustbenotedandreported.Bloodtestsshouldincludeassessingthefullbloodcountandtheblood grouping,clofingstudiesandthelevelsofplatelets,fibrinogenandfibrindegradationproducts(FDPs).

Treatmentinvolvesthereplacement ofbloodcells andclofingfactors inordertorestoreequilibrium.Thisisusuallydonebytheadministrationoffreshfrozenplasmaandplateletconcentrates.Bankedredcellswillbetransfusedsubsequently.Managementiscarriedoutbyateamofobstetricians,anaesthetists,haematologists,midwivesandotherhealthcareprofessionalswhomuststrivetoworktogetherharmoniouslyandeffectivelytoachievethebestpossibleclinicaloutcomesforthewoman.

Careby themidwife

DICcausesafrighteningsituationthatdemandsspeedboth of recognitionandofaction.Themidwife has tomaintainherowncalmnessandclarityofthinkingas wellas assistingthecoupletodealwiththesituationinwhichtheyfindthemselves.Frequentandaccurateobservationsmustbemaintainedinordertomonitorthewoman'scondition.Bloodpressure,respirations,pulserateandtemperaturearerecorded.Thegeneralconditionisnoted.Fluidbalanceismonitoredwithvigilance foranysignofrenalfailure.

Thepartnerinparticularislikelytobeconfusedbyasuddenturninevents,whenpreviouslyallseemedtobeundercontrol.Themidwifemustmakesurethatsomeoneisgivinghimappropriateafention,keepinghiminformedofwhatishappening.Allhealth

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professionalsneedtobeawarethatthepartnermayfinditimpossibletoabsorballthatheistoldandmayrequirerepeatedexplanations.Hemaybethebestpersontohelpthewomantounderstandhercondition.Thedeathofthewomanfromorganfailureasaresult ofDICis arealpossibility.

Hepaticdisordersandjaundice

Someliverdisordersarespecificto pregnantwomen,andsomepre-existingorco-existingdisordersmaycomplicatethepregnancy,asshowninBox12.5.

Box 12.5

Hepaticdisordersofpregnancy

Specifictopregnancy

Intrahepaticcholestasisofpregnancy

Acutefattyliverinpregnancy(seeChapter13)Pre-eclampsiaandeclampsia(seeChapter13)Severehyperemesisgravidarum.

Pre-orco-existinginpregnancy

GallbladderdiseaseHepatitis

CausesofjaundiceinpregnancyarelistedinBox12.6.

Box 12.6

Causesofjaundiceinpregnancy

Notspecifictopregnancy

Viralhepatitis–A,B,Care themostprevalent

Hepatitissecondarytoinfection,usuallycytomegalovirus,Epstein–Barrvirus,toxoplasmosisorherpessimplex

GallstonesDrugreactions

Alcohol/drugmisuseBudd–Chiarisyndrome

Pregnancy-specificcauses

Acutefattyliver

HELLP(haemolysis,elevatedliverenzymes,lowplatelets)syndromeIntrahepaticcholestasisofpregnancy

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Hyperemesisgravidarum

Note:Jaundiceisnotaninevitablesymptomofliverdiseaseinpregnancy.

Obstetriccholestasis(OC)

Thisisanidiopathicconditionthatusuallybeginsinthethirdtrimesterofpregnancy,butcanoccasionallypresentasearlyasthefirsttrimester.Itaffects0.7%ofpregnanciesandresolvesspontaneouslyfollowingbirth,butithasuptoa90%recurrencerateinsubsequentpregnancies(WilliamsonandGirling2011).Itscauseisunknown,althoughgenetic,geographicalandenvironmentalfactorsareconsideredtobecontributoryfactors.Itisnotalife-threateningconditionforthe woman,butthereisanincreasedriskofpre-termlabour,fetalcompromiseandmeconiumstaining,andthestillbirthriskisincreasedunlessthereis activemanagementofthepregnancy.

Clinicalpresentation

Thepresentationmayinclude:

•prurituswithoutarash

•insomniaandfatigueas aresult ofthepruritus

•fever,abdominaldiscomfort,nauseaandvomiting

•urinemaybedarkerandstoolspalerthanusual

•afewwomen developmildjaundice.

Investigations

Thefollowinginvestigationsshouldbedone:

•Teststoeliminatedifferentialdiagnosessuchasotherliverdiseaseorpemphigoidgestationalis(arareautoimmunediseaseoflatepregnancythatmimicsOC)includehepaticviralstudies,anultrasoundscanofthehepatobiliarytractandanautoantibodyscreen.

•Bloodteststoassessthelevelsofbileacids,serumalkalinephosphatase,bilirubinandlivertransaminases,whichwouldberaised.

Management

Managementconsistsof:

•Applicationoflocalantipruriticagents,suchasantihistamines.

•VitaminKsupplementsareadministeredtothewoman,10mgorallydaily,asherabsorptionwillbepoor,leadingtoprothombinaemiawhichpredisposeshertoobstetrichaemorrhageifleftuntreated.

•MonitorfetalwellbeingpossiblybyDoppleroftheumbilicalarterybloodflow.

•Considerelectivebirthwhenthefetusismature,orearlierifthefetalconditionappearstobecompromisedbytheintrauterineenvironment,orthebileacidsaresignificantly

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raised,asthisisassociatedwithimpendingintrauterinedeath.

•Providesensitivepsychologicalcaretothewoman.

•Advisethewomanthat herpruritusshoulddisappearwithin3–14days ofthebirth.

•Ifthewomanchooses touseoralcontraceptioninthefuture,sheshouldbeadvisedthatherliverfunctionshouldberegularlymonitored.

Gallbladderdisease

Pregnancyappearstoincreasethelikelihoodofgallstoneformationbutnottheriskofdevelopingacutecholecystitis.Diagnosisismadebyexploringthewoman'sprevioushistory,withanultrasoundscanofthehepatobiliarytract.Thetreatmentforgall bladderdiseaseisbasedonprovidingsymptomaticreliefofbiliarycolicbyanalgesia,hydration,nasogastricsuctionandantibiotics.Ifatallpossible,surgeryinpregnancyshouldbeavoided.

Viralhepatitis

Viralhepatitisisthemostcommonlydiagnosedviralinfectionofpregnancy(Andrews2011).SeeTable12.3forinformationabouthepatitisA,BandCinpregnancy.HepatitisD,EandGhavemore recentlybeendescribedin medicalliteraturebuttheirrelevance topregnancyisnotyet known.

Table12.3

Viralhepatitisinpregnancy

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Skindisorders

Manywomen suffer fromphysiologicalpruritusinpregnancy,particularlyovertheabdomenasitgrowsandstretches.Theapplicationofcalaminelotionisohenhelpful.Howeverprurituscanbeasymptomofadiseaseprocess,suchasOCandpemphigoidgestationalis,anauto-immunediseaseofpregnancywhereblistersdevelopoverthebodyasthepregnancyprogresses.

Womenwithpre-existingskinconditionssuchaseczemaandpsoriasisshouldbeadvisedabouttheuseofsteroidcreamsandapplicationscontainingnutoilderivatives,whichmayadverselyaffectthefetus.

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Abnormalitiesoftheamnioticfluid

Theamountofliquorpresentinapregnancycanbeestimatedby measuring‘pools’ofliquoraroundthefetuswithultrasoundscanning.Thesingledeepestpoolismeasuredtocalculatetheamnioticfluidvolume(AFV). However,wherepossiblea moreaccuratediagnosismaybegainedbymeasuringtheliquorineachoffourquadrantsaroundthefetusinordertoestablishanamnioticfluidindex(AFI).Therearetwoabnormalitiesofamnioticfluid:hydramnios(orpolyhydramnios)andoligohydramnios.

Hydramnios

Hydramniosispresentwhenthereisanexcessofamnioticfluidintheamnioticsac.Causesandpredisposingfactorsinclude:

•twintotwintransfusionsyndrome

•maternaldiabetes

•fetalanaemia(maternalalloimmunization,syphilis/parvovirusinfection)

•fetalmalformationsuchasoesophagealatresia,openneuraltubedefect,anencephaly

•afetalandplacentaltumour(rare).

However,inmanycasesthecauseis unknown.

Types

Chronichydramnios

Thisisgradualinonset, usuallystartingfromabout the30thweekofpregnancy. Itisthemostcommontype.

Acutehydramnios

Thisisveryrare.Itusuallyoccursatabout20weeksanddevelopsverysuddenly.Theuterinesizereachesthexiphisternuminabout3or4days.Acutehydramniosisfrequentlyassociatedwithmonozygotictwinsorseverefetalmalformation.

Diagnosis

Thewomanmaycomplainofbreathlessnessanddiscomfort.Ifthehydramniosisacuteinonset,shemayexperiencesevereabdominalpain.Theconditionmaycauseexacerbationofsymptoms associatedwith pregnancy,suchasindigestion,heartburnandconstipation.Oedemaandvaricositiesofthevulvaandlowerlimbsmayalsobepresent.

Abdominalexamination

Oninspection,theuterusislargerthanexpected fortheperiod ofgestationandisglobularinshape.Theabdominalskinappearsstretchedandshiny,withmarkedstriaegravidarumandsuperficialbloodvessels.

Onpalpation,theuterusfeelstenseanditisdifficulttofeelthefetalparts,butthe

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fetusmaybeballotedbetweenthetwohands. Afluid thrillmaybeelicitedbyplacingahandononeside oftheabdomenandtappingtheothersidewiththefingers.

Ultrasonicscanningisusedtoconfirmthediagnosisofhydramniosandmayalsorevealamultiplepregnancyorfetalmalformation.

Auscultationofthefetalhearmaybedifficultduetothehydramnios.

Complications

Theseinclude:

•maternaluretericobstructionandurinarytractinfection

•unstablelieandmalpresentation

•cordpresentationandprolapse

•prelabour(andoftenpreterm)ruptureofthemembranes

•placentalabruptionwhenthemembranesrupture

•pretermlabour

•increasedincidenceofcaesareansection

•postpartumhaemorrhage

•increasedperinatalmortalityrate.

Management

Carewilldependontheconditionofthewomanandfetus,thecauseanddegreeofthehydramnios andthestageof pregnancy.Thepresenceof fetalmalformationwillbetakenintoconsiderationinchoosingthemodeandtimingofbirth.Ifthereisagrossmalformationpresent,labourmay beinduced.Shouldthefetushaveanoperablecondition,suchasoesophagealatresia,transferwillbearrangedtoaneonatalsurgicalunit.

Mildhydramniosismanagedexpectantly.Regularultrasoundscanswillrevealwhetherornotthehydramniosisprogressive.Somecasesofidiopathichydramniosresolvespontaneouslyaspregnancyprogresses.

Forawomanwithsymptomatichydramnios,anuprightpositionwillhelptorelieveanydyspnoeaandantacidscanbetakentorelieveheartburnandnausea.Ifthediscomfortfrom theswollenuterusissevere,thentherapeuticamniocentesis,oramnioreduction,maybeconsidered.However,thisisnotwithoutrisk,asinfectionmaybeintroducedortheonsetoflabourprovoked.Nomorethan500mlofamnioticfluidshouldbewithdrawnatanyonetime.Itisatbestatemporaryreliefasthefluidwillrapidlyaccumulateagainandtheproceduremayneedtobe repeated.Acutehydramniosmanagedbyamnio-reductionhasapoorprognosisforthefetus.

Labourmayneedtobeinducedinlatepregnancyifthewoman'ssymptomsbecomeworse.Theliemustbecorrectedifitisnotlongitudinalandthemembranesrupturedcautiously,allowingtheamnioticfluidtodrainoutslowlyinordertoavoidalteringthelieandtopreventcordprolapse(seeChapter22).Inaddition,placentalabruptionisalsoariskiftheuterussuddenlydiminishesinsize.

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Labourusuallyprogressesphysiologically, but themidwifeshouldbepreparedforthepossibilityofpostpartumhaemorrhage.Thebabyshouldbecarefullyexaminedformalformationsatbirthandthepatencyoftheoesophagusisascertainedbypassinganasogastrictube.

Oligohydramnios

Oligohydramniosisanabnormallysmallamountofamnioticfluid.Itaffects3–5%ofpregnancies(Bealletal2011).Attermtheremaybe300–500mlbutamountsvaryandtheycanbeevenless.Whendiagnosed inthefirsthalfofpregnancy,oligohydramniosisohenfoundtobeassociatedwithrenalagenesis(absenceofkidneys)orPofer'ssyndrome,inwhichthebabyalsohaspulmonaryhypoplasia.Whendiagnosedatanytimeinpregnancybefore37weeks,oligohydramniosmaybeduetofetalmalformationortopretermprelabourruptureofthemembraneswheretheamnioticfluidfailstore-accumulate.Thelackofamnioticfluidreducestheintrauterinespaceandovertimewillcausecompressionmalformations.Thebabyhasasquashed-lookingface,flafeningofthenose,micrognathia(amalformationofthejaw)andtalipes.Theskinisdryandleatheryinappearance.

Oligohydramnioscanaccompanymaternaldehydration,andsometimesoccursinpost-termpregnancies.

Diagnosis

Oninspection,theuterusmayappearsmallerthanexpectedfortheperiodofgestation.Thewomanmayhavenoticedareductioninfetalmovementsifsheisamultigravidaandhasexperiencedchildbirthpreviously.

Onpalpation,theuterusissmallandcompactandfetalpartsareeasilyfelt.

Ultrasonicscanningwillenabledifferentiationofoligohydramniosfromintrauterinegrowthrestriction(IUGR).Renalmalformationmaybevisibleonthescan.

Auscultationofthefetalheartshouldbeheardwithoutanyunduedifficulty.

Management

Thiswilldependonthegestationalage,theseverityandthecauseoftheoligohydramnios.Inthefirsttrimester thepregnancyislikelyto miscarry.Theconditioncausesthegreatestdilemmasinthesecondtrimesterbutisohenassociatedatthistimewithfetaldeathandcongenitalmalformations.Ifthepregnancyremainsviablethewomanmaywishtoconsideraterminationofpregnancy.Inthethirdtrimestertheconditionismorelikelyassociatedwithpretermprelabourruptureofthemembranes(PPROM)andbirthisusuallyindicated(Bealletal2011).

Liquorvolumewillbeestimatedbyultrasoundscanandthewomanshouldbequestionedaboutthepossibilityofpre-termruptureofthemembranes.Dopplerultrasoundofthe uterinearterymaybeperformedtoassessplacentalfunction,althoughNeilson(2012),inarecentCochranereview,suggeststhisisoflimitedclinicalvalue.Ifthewomanisdehydratedsheshouldbeencouragedtodrinkplentyofwater,oroffered

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intravenoushypotonicfluid.

Wherefetalanomalyisnotconsideredtobelethal,orthecauseoftheoligohydramniosisnotknown,prophylacticamnioinfusionmaybeperformedinordertopreventcompressionmalformationsandhypoplasticlungdisease,andprolongthepregnancy.Lifleevidenceisavailabletodeterminethebenefitsandhazardsofthisinterventionin mid-pregnancy.Iftheoligohydramniosisdueto pretermprelabourruptureofthemembranesandlabourdoes notensue,thewomanshouldbeobservedforuterineinfection(chorioamnionitis),andtreatedaccordinglyifitdevelops.

Incasesofnear-termandtermpregnancy,inductionoflabourislikelytobeadvocated.Alternatively,fetalsurveillancebycardiotocography,amnioticfluidmeasurementwithultrasoundandDopplerassessmentoffetalanduteroplacentalarteriesmaybeofferedtothewomanwhopreferstoawaittheonsetofspontaneouslabour.Regardlessofwhetherlabourcommencesspontaneouslyorisinduced,epiduralanalgesia maybe indicatedbecauseuterinecontractionscan beunusuallypainfulduetothelackofamnioticfluid.Continuousfetalheartratemonitoringisdesirablebecauseofthepotentialforimpairmentofplacentalcirculationandcordcompression.Furthermore,ifmeconiumispassedinuteroitwillbemoreconcentratedandrepresentagreaterdangertoanasphyxiatedfetusduringbirth.

Pretermprelabourruptureofthemembranes(PPROM)

Pretermprelabourrupture ofthe membranes(PPROM)occurs before 37completedweeks'gestation,wherethefetalmembranesrupturewithouttheonsetofspontaneousuterineactivityandtheconsequentialcervicaldilatation.

Itaffects2%ofpregnanciesand placentalabruptionisevidentin4–7%ofwomenwhopresentwithPPROM.Theconditionhasa17–32%recurrencerateinsubsequentpregnanciesofaffectedwomen(Svigosetal2011).ThereisastrongassociationbetweenPPROMandmaternalcolonization(Bacterialvaginosis[BV]),withpotentiallypathogenicmicro-organisms,witha30%incidenceofsubclinicalchorioamnionitis(Hay2012).Infectionmaybothprecede(andcause)orfollowPPROM.Itisalsomorecommoninsmokersandrecreationaldrugusers,for examplecocaineusers.Pretermprelabourruptureofthemembranesisassociatedwith40%ofpretermbirths(RCOG2010c).

RisksofPPROM

RisksassociatedwithPPROMinclude:

•imminentlabourresultinginapretermbirth

•chorioamnionitis,whichmaybefollowedbyfetalandmaternalsystemicinfectionifnottreatedpromptly

•oligohydramniosifprolongedPPROMoccurs

•cordprolapse

•malpresentationassociatedwithprematurity

•antepartumhaemorrhage

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•neonatalsepsis

•psychosocialproblemsresultingfromuncertainfetalandneonataloutcomeandlong-termhospitalization;increasedincidenceofimpairedmotherandbabybondingafterbirth

Management

IfPPROMissuspected,thewomanwillbeadmifedtothematernityunit.Acarefulhistoryistakenandruptureofthemembranesconfirmedbyasterilespeculumexaminationofanypoolingofliquorintheposteriorfornixofthevagina.Saturatedsanitarytowelsovera6-hourperiodwillalsoofferareasonablyconclusivediagnosisifurineleakagehasbeenexcluded.ANitrazinetestmaybeusefultoconfirmthis.A fetalfibronectinimmunoenzymetestisusefulinconfirmingruptureofthemembranes,andultrasoundscanningalsohassomevalue.

Digitalvaginalexaminationshould beavoidedtoreducetheriskofintroducinginfection.Observationsaremadeofthefetalconditionfromthefetalheartrate,asaninfectedfetusmayhaveatachycardia,andalsoamaternalinfectionscreen,temperatureandpulse,uterinetendernessandanypurulentoroffensivelysmellingvaginaldischarge.Adecisiononfuturemanagementwillthenbemade.

Ifthepregnancyislessthan32weeks,thefetusappearstobeuncompromisedandAPHandlabourhavebeenexcluded,itwillbemanagedexpectantly.

•Thewomanisadmittedtohospital.

•Frequentultrasoundscansareundertakentoassessthe growthofthefetusandtheextentandcomplicationsofanyoligohydramnios.

•CorticosteroidsareadministeredtomaturethefetallungsassoonasPPROMisconfirmed,shouldthebabybebornearly.

•Iflabourintervenestheadministrationofatocolyticdrug(suchasatosibanacetate)shouldbeconsideredtoprolongthepregnancy.Inpracticetheseareusuallydiscontinuedafterthecorticosteroidshavehadtimetotakeeffect.

•Knownvaginalinfectionsaretreatedwithantibiotics.Prophylacticantibioticsmayalsobeofferedtowomenwithoutsymptomsofinfection.

•Ifmembranes rupturebefore24weeksof gestationtheoutlookis poorandthewomanmaybeofferedterminationofthepregnancy.

•Ifthewomanis morethan32weeks pregnant,thefetus appears tobecompromisedandAPHorinterveninglabourissuspectedorconfirmed,activemanagementwillensue.Themodeofbirthwillneedtobedecidedandinductionoflabourorcaesareansectionperformed.

Hindwaterleakageofamnioticfluid,andresealingoftheamnioticsacarecurrentlypoorlyunderstoodphenomena.

Conclusion

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Midwiveshaveanimportantroletoplaywhenwomenexperiencepathologicalproblemsintheir pregnancy.Thewomanislikelyto reportsymptomsfirstlyto amidwife, who willthenmakebasicobservationsthatconfirmorexcludethelikelihoodofadeviationfromnormal.Whileexplainingherfindingstothewomanandherpartner,themidwifemustmakeadecisionaboutpossiblediagnoses,whethertotransferhertoahigh-riskobstetricunitandifthiswarrantstransportationbyambulance.Themidwifemayberequiredtostartmanagingthewoman'sconditionpriortoadmissiontohospital.Inhospitalthemidwifeisrequiredtoensurethewoman'scareiscoordinatedwithotherhealthcareprofessionals,whomustbesuppliedwithappropriatebackgroundinformation,thatthewomanandherpartnerreceivepsychologicalsupportandthatcontemporaneousrecordsarekept(NMC2012a).Themidwifemustreportanydeteriorationinawoman'sconditionimmediatelytoanappropriatehealthcareprofessional.Themidwifeisresponsiblefor maintainingcontinualupdating ofher professionalknowledgeandskillsinallareas ofpractice toensure thateverywomanreceivesoptimalmaternitycarethroughoutherpregnancy.

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