90% of participants will understand what these obstetric complications are and how to treat them.
After completing this continuing education course, the participant will be able to:
Although pregnancy, labor, and delivery are normal physiological processes, many complications can arise. Many of these complications are high-risk, low volume, meaning that they are 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 the use of antibiotics and fluid management.
Chorioamnionitis is the most common of all infections, usually occurs during labor, and should be treated. Clinical chorioamnionitis is characterized by acute inflammation of the membranes and chorion of the placenta, generally due to a bacterial infection in women whose membranes have ruptured. It is common and may be associated with potentially serious adverse maternal and neonatal effects.1
Risk factors for chorioamnionitis are longer time of labor and time of ruptured membranes. Multiple vaginal examinations (especially with ruptured membranes), cervical insufficiency, nulliparity, meconium-stained amniotic fluid, internal fetal or uterine contraction monitoring, presence of genital tract pathogens (group B Streptococcus, bacterial vaginosis) are also risk factors.2 The American College of Obstetrics and Gynecology (ACOG) suggests that patients with isolated fever ≥39.0°C (102.2°F) without another clear source of infection should be managed as having suspected chorioamnionitis. Treatment includes both antibiotic therapy and delivery.2 The fetus may experience tachycardia and is at risk for early-onset sepsis.
Acute fatty liver of pregnancy is a third-trimester disease. Inherited genetic mutations in the intramitochondrial fatty acid oxidation pathway lead to microvesicular fat accumulation. Patients experiencing fatty liver may see their provider or come to the hospital with nausea, vomiting, right upper quadrant pain, jaundice, and increased serum aminotransferase levels. Treatment is delivery of the fetus, as well as supportive measures such as mechanical ventilation for coma, dialysis for renal failure, and blood products for coagulopathy. This is a rare but serious complication that requires hospitalization.3
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.4
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.4
With an umbilical cord prolapse, the cord presents ahead of the presenting part of the fetus into the cervical canal or vagina, or beyond. This 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, but 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.5 Cord prolapse usually presents with an abrupt, severe, prolonged fetal bradycardia or moderate to severe variable decelerations. This 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 on a vaginal examination performed to assess labor progress or a patient with ruptured membranes may report seeing or feeling an overt cord prolapse.5
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 the infrequent and urgent nature of this problem. When a cord prolapse is detected, call for assistance, and prepare for an emergency delivery. Initiate maneuvers for intrauterine resuscitation, which are primarily targeted to moving the fetus off of the cord. Intrauterine resuscitation may include maneuvers such as elevation of the presenting part manually or by retrofilling 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, which impacts the urgency of delivery. Minimize manipulating an overtly prolapsed cord and avoid exposing it to the 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, which is typically a cesarean.6
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, and chronic occurs ≥1 month postpartum. Over 80% of cases are acute.7
The reason for uterine inversion is unknown, but the use of excessive cord traction and fundal pressure during the third stage of labor, especially in the setting of 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 are the most common findings that suggest an inversion.
Treatment of 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 all are needed to treat the hemorrhage. The provider should try to replace the uterus manually. Nitroglycerin is a good uterine relaxant and has 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.8 Women who have an induction of labor are at higher risk than women who go into spontaneous labor.9
Some risk factors are increasing maternal age, gestational age >40 weeks, birth weight >4000 grams, 1st pregnancy less than 18 to 24 months prior, and more than one previous cesarean deliveries. 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.
A 35-year-old lady was admitted in early labor. She had had a previous cesarean section for arrest of labor. She was admitted in 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, uterine rupture was noted.
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.