C H A P T E R 1 2 Common problems associated with early and advanced pregnancy

1. C H A P T E R 1 2Common problems associated with early and advanced pregnancy

2. CHAPTER CONTENTS • The midwife's roleAbdominal pain in pregnancy • Bleeding before the 24th week of pregnancy • Implantation bleed • Cervical ectropionCervical polyps • Carcinoma of the cervix • Spontaneous miscarriage • Recurrent miscarriage • Ectopic pregnancy • Other problems in early pregnancy • Inelastic cervix • Gestational trophoblastic disease (GTD) • Uterine fibroid degeneration • Induced abortion/termination of pregnancy • Pregnancy problems associated with assisted conception • Nausea, vomiting and hyperemesis gravidarum

3. Pelvic girdle pain (PGP) • Bleeding after the 24th week of pregnancy • Antepartum haemorrhage • Placenta praevia • Placental abruption • Blood coagulation failure • Hepatic disorders and jaundice • Obstetric cholestasis • Gall bladder diseaseViral hepatitis • Skin disorders • Abnormalities of the amniotic fluid • HydramniosOligohydramnios • Preterm prelabour rupture of the membranes (PPROM)

4. Problems of pregnancy range from the mildly irritating to life-threatening conditions. Fortunately in the developed world, the life-threatening ones are rare because of improvements in the general health of the population, improved social circumstances and lower parity. However, as women delay childbearing, they become more at risk of disorders associated with increasing age, such as miscarriage and placenta praevia.

5. Regular antenatal examinations beginning early in pregnancy are undoubtedly valuable. They help to prevent many complications and their ensuing problems, contribute to timely diagnosis and treatment, and enable women to form relationships with midwives, obstetricians and other health professionals who become involved with them in striving to achieve the best possible pregnancy outcomes.

6. The chapter aim s to: • provide an overview of problems of pregnancy • describe the role of the midwife in relation to the identification, assessment and management of the more common disorders of pregnancy • consider the needs of both parents for continuing support when a disorder has been diagnosed.

7. The midwife's role • The midwife's role in relation to the problems associated with pregnancy is clear. At initial and subsequent encounters with the pregnant woman, it is essential that an accurate health history is obtained. General and specific physical examinations must be carried out and the results meticulously recorded.

8. The examination and recordings enable effective referral and management. Where the midwife detects a deviation from the norm which is outside her sphere of practice, she must refer the woman to a suitablepregnancy and beyond.

9. The woman who develops problems during her pregnancy is no less in need of the midwife's skilled afention; indeed, her condition and psychological state may be considerably improved by the midwife's continued presence and support. It is also the midwife's role in such a situation to ensure that the woman and her family understand the situation;

10. are enabled to take part in decision-making; and are protected from unnecessary fear. As the primary care manager, the midwife must ensure that all the afention the woman receives from different health professionals is balanced and integrated – in short, the woman's needs remain paramount throughout.

11. Abdominal pain in pregnancy • Abdominal pain is a common complaint in pregnancy. It is probably suffered by all women at some stage, and therefore presents a problem for the midwife of how to distinguish between the physiologically normal (e.g. mild indigestion or muscle stretching), the pathological but not dangerous (e.g. degeneration of a fibroid) and the dangerously pathological requiring immediate referral to the appropriate medical practitioner for urgent treatment (e.g. ectopic pregnancy or appendicitis).

12. The midwife should take a detailed history and perform a physical examination in order to reach a decision about whether to refer the woman. Treatment will depend on the cause (see Box 12.1) and the maternal and fetal conditions.

13. C a use s o f a bdo m ina l pa in in pr e g na ncy • Pregnancy-specific causes • Physiological • Heartburn, soreness from vomiting, constipation Braxton Hicks contractions • Pressure effects from growing/vigorous/malpresenting fetus Round ligament pain • Severe uterine torsion (can become pathological) • Pathological Spontaneous miscarriage Uterine leiomyoma

14. Ectopic pregnancy • Hyperemesis gravidarum (vomiting with straining) Preterm labour • Chorioamnionitis Ovarian pathology Placental abruption • Spontaneous uterine rupture Abdominal pregnancy • Trauma to abdomen (consider undisclosed domestic abuse) Severe pre-eclampsia • Acute fatty liver of pregnancy • Incidental causes

15. More common pathology • Appendicitis • Acute cholestasis/cholelithiasis • Gastro-oesophageal reflux/peptic ulcer disease Acute pancreatitis • Urinary tract pathology/pyelonephritis Inflammatory bowel disease • Intestinal obstruction • Miscellaneous Rectus haematoma • Sickle cell crisis • Porphyria • Malaria • Arteriovenous haematoma Tuberculosis • Malignant disease • Psychological causes

16. Many of the pregnancy-specific causes of abdominal pain in pregnancy listed in Box • are dealt with in this and other chapters. For most of these conditions, abdominal pain is one of many symptoms and not necessarily the overriding one. However, an observant midwife's skills may be crucial in procuring a safe pregnancy outcome for a woman presenting with abdominal pain.

17. Bleeding before the 24th week of pregnancy • Any vaginal bleeding in early pregnancy is abnormal and of concern to the woman andher partner, especially if there is a history of previous pregnancy loss. The midwife can come into contact with women at this time either through the booking clinic or through phone contact. If bleeding in early pregnancy occurs a woman may contact the midwife, the birthing unit or a triage line for advice and support. The midwife should be aware of the local policies pertaining to her employment and how to guide the woman. In some areas of the United Kingdom (UK) women are reviewed within the maternity department from early pregnancy, whereas in others, they will be seen by the gynaecology team until 20 weeks' gestation, possibly in an early pregnancy clinic. However, women are ohen advised to contact their General Practitioner (GP) in the first instance, and many will visit an accident and emergency department.

18. In all cases, a history should be obtained to establish the amount and colour of the bleeding, when it occurred and whether there was any associated pain. Fetal well-being may be assessed either by ultrasound scan or, in the second trimester, using a hand-held Doppler device to hear the fetal heart sounds. Maternal reporting of fetal movements may also be useful in determining the viability of a pregnancy. • There are many causes of vaginal bleeding in early pregnancy, some of which can occasionally lead to life-threatening situations and others of less consequence for the continuance of pregnancy. The midwife should be aware of the different causes of vaginal bleeding in order to advise and support the woman and her family accordingly.

19. Implantation bleed • A small vaginal bleed can occur when the blastocyst embeds in the endometrium. This usually occurs 5–7 days aher fertilization, and if the timing coincides with the expected menstruation this may cause confusion over the dating of the pregnancy if the menstrual cycle is used to estimate the date of birth.

20. Cervical ectropion • More commonly known as cervical erosion. The changes seen in cases of cervical ectropion are as a physical response to hormonal changes that occur in pregnancy. The number of columnar epithelial cells in the cervical canal increase significantly under the influence of oestrogen during pregnancy to such an extent that they extend beyond to the vaginal surface of the cervical os, giving it a dark red appearance. As this area is vascular, and the cells form only a single layer, bleeding may occur either spontaneously or following sexual intercourse. Normally, no treatment is required, and the ectropion reverts back to normal cervical cells during the puerperium.

21. Cervical polyps • These are small, vascular, pedunculated growths on the cervix, which consist of squamous or columnar epithelial cells over a core of connective tissue rich with blood vessels. During pregnancy, the polyps may be a cause of bleeding, but require no • treatment unless the bleeding is severe or a smear test indicates malignancy.

22. Carcinoma of the cervix • Carcinoma of the cervix is the most common gynaecological malignant disease occurring in pregnancy with an estimated incidence of 1 in 2200 pregnancies (Copeland and Landon 2011). The condition presents with vaginal bleeding and increased vaginal discharge. On speculum examination the appearance of the cervix may lead to a suspicion of carcinoma, which is diagnosed following colposcopy or a cervical biopsy.

23. The precursor to cervical cancer is cervical intraepithelial neoplasia (CIN), which can be diagnosed from an abnormal Papanicolaou (Pap) smear. Where this is diagnosed at an early stage, treatment can usually be postponed for the duration of the pregnancy. The Pap smear is not routinely carried out during pregnancy, but the midwife should ensure that pregnant women know about the National Health Service Cervical Screening Programme (2013), recommending a smear 6 weeks postnatally if one has not been carried out in the previous 3 years.

24. Treatment for cervical carcinoma in pregnancy will depend on the gestation of the pregnancy and the stage of the disease, and full explanations of treatments and their possible outcomes should be given to the woman and her family. For carcinoma in the early stages, treatment may be delayed until the end of the pregnancy, or a cone biopsy may be performed under general anaesthetic to remove the affected tissue.

25. However, there is a risk of haemorrhage due to the increased vascularity of the cervix in pregnancy, as well as a risk of miscarriage. Where the disease is more advanced, and the diagnosis made in early pregnancy, the woman may be offered a termination of pregnancy in order to receive treatment, as the effects of chemotherapy and radiotherapy on the fetus cannot be accurately predicted at the present time. During the late second and third trimester the obstetric and oncology teams will consider the optimal time for birth in order to achieve the best outcomes for both mother and baby.