Haemorrhage

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Haemorrhage (bleeding) remains a very serious complication of pregnancy, accounting for a third of maternal deaths in childbirth around the world.

Antepartum Haemorrhage (APH)

Bleeding from 24 weeks up to delivery of the baby. Fortunately, in the majority of cases the amount of bleeding is small and no cause is found. In a small number of women with APH, there may be a serious underlying cause. This is why it is important to seek medical assistance if you experience bleeding. If there is pain associated with the bleeding, you may be having a placental abruption (where the placenta tears away from the womb). This can be life threatening and may require urgent delivery, hence the recommendation about seeking advice early.

Post partum haemorrhage (PPH)

Bleeding after delivery of the baby. We divide PPH into primary (first 24 hours) and secondary (>24 hours and up to 6 weeks), because the causes and management are different. Primary PPH (>500mls) is just as serious as APH. It is most often caused by a lax uterus and can be controlled using drugs that make the womb contract and stop bleeding. Other causes include blood clotting problems (DIC), stuck or retained placenta, uterine tears, cervical tears, vaginal tears. It is important to try and control a PPH as quickly as possible, so forgive the doctors and midwives if they are very busy and don’t talk to you until things are under control.

Secondary PPH is more bleeding than expected, and is usually caused by infection in the womb. This can be treated with antibiotics. Occasionally a hysteroscopy evacuation is required.

Breech presentation

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The breech is the bottom end of the fetus. Prior to the last month of pregnancy, the fetus is very active and assumes many positions. Towards the end of the pregnancy the head presents into the pelvis. In about 3% of pregnancies the baby still presents by the breech, posing a dilemma regarding the route of delivery for the baby. We classify breech into three types, because their management is different.

The extended breech is least likely to turn, whereas the flexed breech is most likely to turn to cephalic, either spontaneously or with the use of external cephalic version (ECV). The footling breech can cause problems if the membranes break, as the foot will not fit the pelvis (and the cord can prolapse down). The most recent randomised studies indicate that the best route for delivering a baby presenting by the breech is by Caesarean Section. Furthermore, as more and more breech deliveries are by Caesarean section, it is important when considering a vaginal approach to ascertain the level of experience of the attending care who will assist you with your breech delivery.

Breech presentation

Chorioamnionitis

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In pregnancy the womb (uterus) can become infected, either through the blood stream or ascending infection from the vagina. This is more common if the membranes have ruptured (see PROM). Although uncommon it is a very serious life threatening complication. The uterus become tender and the mother often has a fever and vaginal discharge. If you experience unusual abdominal pain, especially with a fever or discharge, you should contact your obstetrician or midwife.

Chorioamnionitis is an infection of the membranes (placental tissues) and amniotic fluid. It occurs in about 1 to 2 percent of all pregnancies, but is much more common in preterm births. Chorioamnionitis can cause bacteraemia (blood infection) in the mother and may lead to preterm birth and serious infection in the newborn baby. Other terms for chorioamnionitis include intra-amniotic infection and amnionitis.

The organisms usually responsible for chorioamnionitis are those that are normally present in the vagina, including Escherichia coli (E. coli). Group B streptococcus may also cause the infection. Chorioamnionitis can develop when the membranes (amniotic sac) are ruptured (broken) for an extended period. This allows the vaginal organisms to move upward into the uterus.

Treatment for chorioamnionitis:

Specific treatment for chorioamnionitis will be determined by your physician based on:

  • Your overall health and medical history
  • Extent of the condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Antibiotics are used to treat chorioamnionitis as soon as the infection is diagnosed. Antibiotics are usually continued after delivery as well. Delivery is often necessary to prevent complications in the mother, or if the fetus is in danger.

CMV

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CMV – Cytomegalovirus (CMV) is a virus that can cause a mild flu like illness in the mother, but can lead to serious infection in the fetus. If there is any doubt about this illness in the pregnancy a blood test can tell you if you have been infected recently with this virus.

As there is no vaccine or cure for CMV you should avoid putting yourself at risk so you should use a condom if having sex (outside a monogamous relationship) during pregnancy. You should also avoid saliva from others, particularly children under the age of six. You should also wash your hands with soap when changing nappies or working with children.

DVT

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When we cut our finger and blood is exposed to air, it forms a blood clot, saving us from bleeding. Sometimes we form a form a blood clot within a blood vessel (deep vein thrombosis), which can cause pain and swelling. If some of the blood clot separates it can reach the lung causing a pulmonary embolism.

Management

There are a number of ways to assess the possibility of a DVT, D-dimers and blood flow (Doppler) assess of the legs or area causing concern. If a DVT is diagnosed an anticoagulant is used to reduce the risk of more clots and manage the current DVT.

Failure to thrive in the womb

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Intrauterine growth restriction (IUGR

There are 4 main reasons why a fetus fails to grow or be of a normal size in the womb:

  1. Constitutional: The fetus grows well but is small, because it was meant to be small (typically the parents will be relatively small also)
  2. Maternal: The mother is unwell or undernourished (the most common reason for being born small and growth restricted)
  3. Uteroplacental: The placenta fails to establish a good relationship with the uterus (womb). This leads to problems later in the pregnancy, when the growing fetus demands more and more oxygen and other nutrients from the placenta, which cannot deliver. The fetus fails to thrive to thrive and becomes small and growth restricted (IUGR). Ultrasound can reveal the IUGR and assess the condition of the fetus using biophysical assessment and fetal Doppler (see ultrasound)
  4. Fetal: The fetus may have an abnormality that affects its growth, or it may have an infection. Part of the assessment of the IUGR baby is to look for signs of these and other problems (see ultrasound)

The management and decision regarding delivery of a small, especially growth restricted fetus, is complex and dealt with on an individual basis (see scanning in the second half of pregnancy).

The relationship between maternal psychosocial factors, and low birth weight and preterm delivery is not fully understood. Negative mood states such as anxiety, depression, and/or hostility, and rejection of the pregnancy were more likely to be associated with low birth weight. Emotional support, counselling and strengthening of the woman’s social network and other efforts to improve self-esteem may help to promote the health of the mother and baby.

Group B Streptococcus

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Group B Streptococcus is a normal bacterium that is present in 10-30% of women’s vagina. It becomes important in childbirth for you if you develop signs of an infection, which can be quite nasty (after you’ve delivered). The infection can be of the womb lining (endometritis) or in the wound if you have had a caesarean section.

Much more importantly for your baby is the disease called Early Neonatal Group B Streptococcal Septicaemia (ENGBSS). This occurs after the baby passes through an infected birth canal and the infection spreads to his blood stream. 30% of affected neonates develop meningitis (an infection of the lining of the brain) and half of these babies will be brain-damaged. 20-30% will die. The baby will carry the bug in 35-50% of labours where a swab taken during labour was positive and in 25% where there was a confirmed swab at some point during the pregnancy. Studies from the US indicate that 1-2% of babies that carry the bug develop ENGBSS, whereas in the UK it is only 0.2-0.5%. In the UK, ENGBSS occurs in 0.3/1000 neonates. In the US it is 3/1000.

There are some well identified risk factors for a baby developing ENGBSS. In addition to a positive swab during pregnancy, the following factors lead to a much increased chance of infection (about 50/1000 as compared to 0.3/1000), and should lead to treatment during labour:

  • Prolonged rupture of membranes (>18-24h)
  • Preterm labour (<37w)
  • Rupture of membranes before 37 weeks
  • Temperature during labour
  • GBS found in the urine
  • Previous infant with ENGBSS

Treatment of GBS-carrier mothers with the above risk factors during labour will lead to a 60% reduction in neonatal infection rate and 95% reduction in neonatal death due to this disease.

In the UK, treatment of mothers with a positive swab, but without these risk factors during labour does not significantly reduce the rate of ENGBSS. The difference in numbers between the US and UK mean that it may be worthwhile screening for this bacteria in the US, whereas in the UK because of its rarity, screening is unlikely to have a significant impact on neonatal deaths.

Hepatitis

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Hepatitis refers to a group of viruses (A, B, C) that primarily lead to inflammation in the liver (hepar). Hepatitis B infection is very common (endemic) in some countries, and some women become long-term carriers of the virus. Hepatitis C is most often acquired from blood transfusions. A simple blood test will tell you if you have been exposed to these viruses. If you work in a job where there is an increased risk of contacting Hep B, or are travelling to a country with a high incidence of Hep B, you should be immunised prior to travel. If your blood test is positive for Hep B, there is a risk of transmitting the infection to the baby. The Paediatricians (baby doctors) can give antibodies and immunisation to the baby after birth, so as to reduce the risk of the baby being affected by the infection.

Normally, being pregnant will not affect the course of the hepatitis, unless a woman has hepatitis E, which can worsen severely in some cases. Pregnancy itself will not hasten the disease process or make it worse, although if the liver is already burdened and scarred with cirrhosis, the extra demands of pregnancy may predispose the expectant mother to a condition called acute fatty liver of pregnancy.

Hepatitis A

Hepatitis A is transmitted by the oral-fecal route (such as from contaminated water or diapers, for example). It occurs in roughly 1 in every thousand pregnant women worldwide. It can be diagnosed by checking the levels of IgM anti-HAV antibodies (which can persist for months after the infection). The main treatment is rest and a nutritious diet, and usually the woman will recover within one to two months. If a newborn is exposed, the infection is usually mild and they will have a lifelong immunity to the disease. If a pregnant woman is exposed (such as when traveling or by contact with known carriers) she will be given immune gamma globulin (IG) to help protect her from getting the disease.

Hepatitis B

Hepatitis B is one of the most highly transmitted forms of hepatitis from mother to child around the world, especially in developing countries. Because this virus is highly contagious, and the risk that the newborn infant will develop hepatitis B is 10 to 20% if the mother is positive for the hepatitis B surface antigen, and as high as 90 percent if she is also positive for the HbeAg.

Usually, the disease is passed on during delivery with exposure to the blood and fluids during the birth process. Therefore although the mother will usually become jaundiced during the acute stage, some women have no symptoms of hepatitis, mandatory screening of all women for hepatitis B is recommended during the first prenatal visit.

If a pregnant woman tests positive during her prenatal visits for hepatitis B, she will receive hepatitis B immune globulin, and be told to completely abstain from alcohol. When her infant is born, the newborn will receive hepatitis B immune globulin at birth, and should be vaccinated with a hepatitis B vaccine at one week, one month, and six months after birth.

Most women become pregnant during the years between 20 and 40, which is also the age group in which the incidence of hepatitis C infection is rising most quickly. Any woman with risk factors for hepatitis C (such as exposure to transfusions, contaminated needles, or injected drug use) should be screened for hepatitis C before and during pregnancy. The risk of a pregnant woman passing the hepatitis C virus to her unborn child has been related to the levels of quantitative RNA levels in her blood, and also whether she is also HIV positive. The risk of transmission to the infant is less (0 to 18%) if the mother is HIV negative and if she has no history of i.v. drug use or of blood transfusions. Transmission of the virus to the fetus is highest in women with hepatitis C RNA titer greater than 1 million copies/mL. Mothers without hepatitis C RNA levels detected did not transmit hepatitis C infection to their infants. A pregnant woman with hepatitis will need to be followed by a specialist who can check their liver function tests on a regular basis.

Herpes

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Management of a herpes attack depends on whether it is a first infection or recurrence, because the levels of virus in your body (the viral load) will be different with different associated risk.

1st and 2nd trimester

Confirm diagnosis. Viral isolation and typing should be carried out using ulcer swabbing, viral culture and/or PCR. Testing of paired sera, if a booking specimen is available, may help identify primary from recurrent infection.

Manage symptomatically according to patient need with Aciclovir. Refer the woman to a genito-urinary medicine clinic. Aim for a vaginal delivery.

3rd trimester

When primary infection occurs during the 3rd trimester it carries the greatest risk of neonatal infection. The quoted risk of neonatal herpes, calculated from five studies, when the baby is delivered vaginally was 41%. A Caesarean section should be considered, especially if >34/40 gestation. (The woman can still be shedding the virus at delivery, even if there are no visible lesions.)

Management of recurrent infection

Recurrent genital herpes is associated with a much smaller risk of neonatal herpes. One study reported a transmission rate of 3% while another study reported a rate of 0%. Maternal antibodies will give some protection to the baby but neonatal infection can still occur. Regular viral swabs and culture in late pregnancy do not predict viral shedding at term and are not recommended. Aim for vaginal delivery if there are no genital lesions present at the time of labour. If there are genital lesions present at the onset of labour, current UK practice is that a Caesarean section is performed.

HIV

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An HIV positive woman can transmit the virus to her baby during pregnancy, labour and delivery, and through breastfeeding. If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.

Modern drugs are highly effective at preventing HIV transmission during pregnancy, labour and delivery. When combined with other interventions, including formula feeding, a complete course of treatment can cut the risk of transmission to below 2%. Even where resources are limited, a single dose of medicine given to mother and baby can cut the risk in half.