Obstetric Complications

Although pregnancy, labor, and delivery are normal physiological processes, many complications can arise. Many of these complications are high-risk and low volume, meaning they can be devastating, but do not occur often. Some of these complications will be discussed below.

Obstetrical infections may require ICU admission, especially if there is severe sepsis or septic shock. These infections are a significant cause of maternal morbidity and mortality. There are different types and causes of infection. Antenatal infections occur before delivery and include intraamniotic infection (chorioamnionitis), pyelonephritis, and cases of pneumonia caused by streptococcus pneumoniae and influenza.

Postpartum infection can also occur. The most common postpartum infection is endometritis. Other postpartum infections include wound infections, necrotizing fasciitis, toxic shock syndrome, pelvic abscess, gas gangrene of the myometrium, septic pelvic thrombophlebitis, pyogenic sacroiliitis, and clostridium difficile colitis. The management of sepsis should be similar to that of the nonpregnant patient and use the same targets, including antibiotics and fluid management.

Acute fatty liver of pregnancy is a third-trimester disease. Inherited genetic mutations in the intramitochondrial fatty acid oxidation pathway led to micro vesicular fat accumulation. Patients experiencing fatty liver may see their provider or visit the hospital with nausea, vomiting, right upper quadrant pain, jaundice, and increased serum aminotransferase levels. Treatment is delivery of the fetus and supportive measures such as mechanical ventilation for coma, dialysis for renal failure, and blood products for coagulopathy. This rare but serious complication requires hospitalization (ACG, 2019).

Liver disease may occur in women with preeclampsia or eclampsia. These include the HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), hepatic hematoma, and hepatic failure. Therapy for these preeclampsia-related liver diseases is supportive care and delivery of the fetus. Rupture of a hepatic hematoma is likely to require surgical intervention (Liver disease in pregnancy, 2019).

Viral hepatitis may occur during pregnancy and lead to liver failure. The woman usually has a fever, nausea, right upper quadrant pain, and markedly elevated transaminases. Herpes simplex virus (HSV) can cause severe hepatitis and should be suspected in the presence of vesicular lesions of the skin. The diagnosis of HSV hepatitis is important because treatment with antiviral agents may be beneficial. The treatment of hepatitis C during pregnancy with direct-acting antivirals is not recommended because there is a lack of safety and efficacy data (Liver disease in pregnancy, 2019).

With an umbilical cord prolapse, the cord presents ahead of the presenting part of the fetus into the cervical canal or vagina. This prolapse is an obstetrical emergency because the prolapsed cord can be compressed, leading to umbilical vein occlusion and umbilical artery vasospasm, which can compromise fetal oxygenation. Membranes are usually ruptured before this occurs. Cord prolapse is rare, and the cause is not always known. However, some factors that increase the risk are malpresentation (breech, transverse, oblique, or unstable lie), prematurity, low birth weight, low lying placentation, uterine malformations/tumors, multiparity, polyhydramnios, long umbilical cord, and unengaged presenting part (UpToDate, 2019). Cord prolapse usually presents with an abrupt, severe, prolonged fetal bradycardia or moderate to severe variable decelerations. This complication usually occurs after membrane rupture or an obstetric intervention that dislodges the presenting part. The provider or nurse also may palpate a pulsating cord incidentally during a vaginal examination performed to assess labor progress, or a patient with ruptured membranes may report seeing or feeling an overt cord prolapse (UpToDate, 2019).

The optimal obstetric management of acute cord prolapse is prompt delivery to avoid fetal compromise or death from compression of the cord between the presenting fetal part and the birth canal. There are no data from prospective studies or randomized trials on which to base management recommendations because of this problem's infrequent and urgent nature. When a cord prolapse is detected, call for assistance, and prepare for an emergency delivery. Initiate maneuvers for intrauterine resuscitation, primarily targeted at moving the fetus off the cord. Intrauterine resuscitation may include maneuvers such as manually elevation of the presenting part or retro filling the bladder, placing the patient in Trendelenburg or knee-chest position, and administering a tocolytic may reduce pressure on the cord. Monitor the fetal heart rate to determine whether resuscitative interventions are effective, impacting the delivery urgency. Minimize manipulating an overtly prolapsed cord and avoid exposing it to a cold environment. Instead, gently replace an overtly prolapsed cord in the vagina and keep it moist with wet gauze. Perform emergency delivery by the most rapid and safe route, typically a cesarean (UpToDate, 2019b).

Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery, but when it occurs, it is a life-threatening obstetric emergency. If not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock, resulting in maternal death. There are 3 types of uterine inversion: acute occurs within 24 hours of delivery; subacute occurs more than 24 hours but less than four weeks postpartum. Moreover, chronic occurs ≥1 month postpartum. Over 80% of cases are acute (UpToDate, 2019b).

The reason for uterine inversion is unknown, but excessive cord traction and fundal pressure during the third stage of labor, especially in an atonic uterus with fundal implantation of the placenta, may increase the risk of uterine inversion. A vaginal exam revealing "something" in the vagina and severe hemorrhage is the most common findings that suggest an inversion.

Treating uterine inversion means replacing the uterus, treating hemorrhage, and preventing reoccurrence. Uterotonic medications should be discontinued because the uterus needs to relax to be put in. Emergency call for assistance, including anesthesia, is important. A 2nd IV, blood products, and fluids are needed to treat the hemorrhage. The provider should try to replace the uterus manually. Nitroglycerin is a good uterine relaxant with a short half-life, which is useful in women with severe hemorrhage and hemodynamic instability. Terbutaline or magnesium sulfate are other options for uterine relaxation. Surgical intervention is the last option. Once the uterus is replaced, the provider can hold it in place until the uterus is firm and in place. Uterotonic medications must then be given to treat the uterine atony. These medications include Pitocin, Methergine, Hemabate, and misoprostol. Antibiotics may also be given.

Uterine rupture is a life-threatening pregnancy complication for both mother and fetus. Most uterine ruptures in developed countries are associated with a trial of labor after cesarean delivery (TOLAC), although the risk is very low. The women with the highest risk are those with previous uterine rupture or previous fundal or high vertical hysterotomy (UpToDate, 2019c).

Women who have an induction of labor are at higher risk than women who go into spontaneous labor (ACOG, 2017).

Some risk factors are increasing maternal age, gestational age >40 weeks, birth weight >4000 grams, first pregnancy less than 18 to 24 months prior, and more than one previous cesarean delivery. Signs of rupture may include abnormal fetal heart rate, abdominal pain, vaginal bleeding, loss of station of the fetal presenting part, or change in contraction pattern. Unstable patients should be stabilized with fluids and blood transfusion, as appropriate, and prepared for cesarean delivery. The rupture may require a hysterectomy, although repair could be possible.

Case Study (Revicky, 2012).

A 35-year-old lady was admitted to early labor. She had had a previous cesarean section for the arrest of labor. She was admitted to spontaneous labor. She progressed to full dilation. An hour later, fetal monitoring recorded prolonged atypical variable decelerations (Fig. 1). Emergency cesarean section was decided upon as instrumental delivery was not considered appropriate. During surgery, the uterine rupture was noted.

Fig.1

1. What was the first sign that there could be uterine rupture?
   
   The fetal heart tracing is extremely abnormal, indicating a possible uterine rupture.
    
2. Should the patient have been managed differently?
   
   No, appropriate care was given. She was a candidate for a trial of labor after cesarean.
    
3. If the patient was pushing, what other sign may have been seen?

A patient who is fully dilated and pushing may have a loss of presenting part when uterine rupture occurs. If the head was at 0 station and all of a sudden is floating, this should signal a possible rupture.

• ACG Clinical Guideline: Liver Disease and Pregnancy. Accessed December 6, 2019. Visit Source.
• ACOG's 2017 VBAC GUIDELINES: WHAT MOTHERS NEED TO KNOW. A woman-centered, evidence-based resource. Accessed December 6, 2019. Visit Source.
• Liver disease in pregnancy. Accessed December 6, 2019. Visit Source.
• Kawakita T, Huang C-C, Landy H. Risk Factors for Umbilical Cord Prolapse at the Time of Artificial Rupture of Membranes. American Journal of Perinatology Reports. 2018;08(02). doi:10.1055/s-0038-1649486.
• Obstetrics & Gynecology, Committee Opinion No. 712. . 2017;130(2). doi:10.1097/aog.0000000000002236.
• Revicky V, Muralidhar A, Mukhopadhyay S, Mahmood T. A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice. The Journal of Obstetrics and Gynecology of India. 2012;62(6):665-673. doi:10.1007/s13224-012-0328-4.
• UpToDate. Intra-amniotic infection. Accessed December 6, 2019. Visit Source.
• UpToDate. Umbilical cord prolapse. Accessed December 6, 2019. Visit Source.
• UpToDate. Puerperal uterine inversion. Accessed December 6, 2019b. Visit Source.
• UpToDate. Uterine rupture: After previous cesarean delivery. Accessed December 6, 2019c. Visit Source.