Obstetric Complications Jonathan Schaffir, MD Associate
Professor Dept. of Obstetrics & Gynecology
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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
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Happy pregnancy
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Complicated pregnancy
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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
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Maternal Mortality Rate worldwide (2010) CIA World FactBook
Maternal Mortality Worldwide
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Trends in PregnancyRelated Mortality in the United States,
19872009 Centers for Disease Control data
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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
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MATERNAL DISORDERS UNIQUE TO PREGNANCY
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Mother vs fetus
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Hypertensive disorders of pregnancy Exacerbation of chronic
hypertension Pregnancy-induced hypertension Pre-eclampsia
eclampsia
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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
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Other symptoms: Headache Epigastric pain Visual disturbances
Oliguria Other signs: Pulmonary edema Fetal growth restriction
Hyperreflexia Signs and symptoms of preeclampsia
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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
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Preventing mortality Treatment Magnesium sulfate to prevent
seizure Fluid management to ensure perfusion Possible bed rest,
antihypertensives Cure Delivery!!
Risk factors Early gestational age Grand multiparity In vitro
fertilization Multiple gestation Previous Cesarean delivery
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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
Treatment Sequelae: Uteroplacental insufficiency Uterine
contractions Maternal anemia and possible coagulopathy Cure:
Delivery
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Uterine atony
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Risk factors Long labor/ induction Intraamniotic infection
Grand multiparity Multiple gestation Polyhydramnios Uterine
fibroids
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Treatment
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Ectopic pregnancy
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Risk factors Salpingitis (PID, chlamydia) Tubal surgery or
ligation Prior ectopic Current use of intrauterine device In vitro
fertilization Smoking
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Treatment Surgical Salpingectomy Salpingostomy Non-surgical
Methotrexate Intraamniotic instillation of K+ or glucose
Observation alone?
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Thromboembolic disease Prevalence: 1/1600 pregnancies Equal
distribution across trimesters Twice as common postpartum Deep
venous thrombosus More common on left Pulmonary embolism Approx of
TED in pregnancy Leading single cause of maternal death in US
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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
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Risk factors
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Outcomes
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Conclusions Pregnancys 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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