What are the common complications and conditions that can develop during pregnancy and their management?

From the Guidelines

Pregnancy complications are common and require careful management to protect both mother and baby, with conditions such as gestational diabetes, preeclampsia, and placenta previa necessitating regular monitoring and possible medical intervention. The management of these conditions is crucial to prevent morbidity, mortality, and to improve quality of life.

Common Complications and Conditions

Some common complications and conditions that can develop during pregnancy include:

• Gestational diabetes, which affects 2-10% of pregnancies and is managed through blood glucose monitoring, dietary changes, exercise, and sometimes insulin therapy 1
• Preeclampsia, characterized by high blood pressure and organ damage after 20 weeks, which requires regular monitoring, possible antihypertensives like labetalol or methyldopa, and may necessitate early delivery if severe 1
• Placenta previa, where the placenta covers the cervix, which requires pelvic rest, monitoring, and often cesarean delivery
• Preterm labor before 37 weeks, which is managed with hydration, bed rest, and tocolytics like nifedipine (10-20mg every 4-6 hours) or magnesium sulfate, plus betamethasone (12mg IM, two doses 24 hours apart) to accelerate fetal lung maturity
• Hyperemesis gravidarum, which involves severe nausea and vomiting requiring IV fluids, antiemetics like ondansetron (4-8mg every 8 hours), and sometimes hospitalization
• Gestational thrombocytopenia, which typically resolves after delivery but requires monitoring
• Intrauterine growth restriction, which necessitates frequent ultrasounds, non-stress tests, and sometimes early delivery
• Cholestasis of pregnancy, which causes intense itching and is treated with ursodeoxycholic acid (10-15mg/kg/day) and may require delivery at 36-37 weeks

Management and Counseling

The management of these conditions is crucial to prevent morbidity, mortality, and to improve quality of life. Women at risk of maternal morbidity and mortality during pregnancy should receive nondirective counseling regarding the potential risks and benefits of pregnancy continuation, including the short- and long-term implications of expectant management or medical intervention for the condition placing her at an increased risk, and the risks and benefits of pregnancy termination 1.

Key Recommendations

Regular prenatal care is essential for early detection and management of these conditions to optimize outcomes. Women with preexisting chronic conditions, new-onset pregnancy-related conditions, and adverse socioeconomic and environmental conditions should receive counseling regarding the potential risks and benefits of pregnancy continuation 1. The use of antihypertensives like labetalol or methyldopa, and the administration of magnesium sulfate for convulsion prophylaxis in women with preeclampsia, are crucial to prevent complications 1.

From the FDA Drug Label

In rodents, rabbits and monkeys, nifedipine has been shown to have a variety of embryotoxic, placentotoxic, teratogenic and fetotoxic effects, including stunted fetuses (rats, mice and rabbits), digital anomalies (rats and rabbits), rib deformities (mice), cleft palate (mice), small placentas and underdeveloped chorionic villi (monkeys), embryonic and fetal deaths (rats, mice and rabbits), prolonged pregnancy (rats; not evaluated in other species), and decreased neonatal survival (rats; not evaluated in other species). Poorly-controlled diabetes mellitus in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth and delivery complications Poorly controlled diabetes mellitus increases the fetal risk for major birth defects, stillbirth, and macrosomia related morbidity. The known effects of indomethacin and other drugs of this class on the human fetus during the third trimester of pregnancy include: constriction of the ductus arteriosus prenatally, tricuspid incompetence, and pulmonary hypertension; nonclosure of the ductus arteriosus postnatally which may be resistant to medical management; myocardial degenerative changes, platelet dysfunction with resultant bleeding, intracranial bleeding, renal dysfunction or failure, renal injury/dysgenesis which may result in prolonged or permanent renal failure, oligohydarmnios, gastrointestinal bleeding or perforation, and increased risk of necrotizing enterocolitis.

Common complications and conditions that can develop during pregnancy:

• Diabetic ketoacidosis
• Pre-eclampsia
• Spontaneous abortions
• Preterm delivery
• Stillbirth
• Delivery complications
• Major birth defects
• Macrosomia related morbidity
• Constriction of the ductus arteriosus
• Tricuspid incompetence
• Pulmonary hypertension
• Nonclosure of the ductus arteriosus
• Myocardial degenerative changes
• Platelet dysfunction
• Intracranial bleeding
• Renal dysfunction or failure
• Renal injury/dysgenesis
• Oligoharmnios
• Gastrointestinal bleeding or perforation
• Necrotizing enterocolitis

These conditions are managed by:

• Controlling blood sugar levels in diabetic patients 2
• Monitoring blood pressure and managing hypertension 3
• Avoiding the use of certain medications, such as indomethacin, during pregnancy 4
• Close monitoring of fetal development and well-being
• Prompt medical attention if any complications arise

From the Research

Common Complications and Conditions During Pregnancy

• Gestational diabetes: requires pharmacologic agents to achieve pregnancy glycemic targets, with insulin being the only FDA-approved medication for use in pregnancy 5
• Preexisting diabetes: management with medications such as metformin and glyburide, in addition to insulin, to achieve glycemic targets 5
• Hypertension: chronic hypertension should be treated to a blood pressure of less than 140/90 mm Hg, and people at risk of preeclampsia should be offered 81 mg of aspirin daily starting at 12 weeks 6
• Periodontal disease: identification and treatment decreases preterm delivery risk 6
• Iron deficiency anemia: treatment decreases the risk of preterm delivery, intrauterine growth restriction, and perinatal depression 6
• Neural tube defects: folic acid supplementation (400 to 800 mcg daily) decreases the risk 6
• Asymptomatic bacteriuria: screening is recommended for all pregnant patients 6
• Sexually transmitted infections: screening is recommended for all pregnant patients 6
• Group B Streptococcus: testing should be performed between 36 and 37 weeks, and intrapartum antibiotic prophylaxis should be initiated to decrease the risk of neonatal infection 6

Management of Complications and Conditions

• Gestational diabetes: screening is recommended between 24 and 28 weeks, and management with medications such as metformin and glyburide, in addition to insulin, to achieve glycemic targets 5, 6
• Hypertension: management with antihypertensive medications such as methyldopa, labetalol, and nifedipine, with consideration of the risks and benefits of each medication 7
• Preterm preeclampsia: metformin use in early gestational or type 2 diabetes in pregnancy was not associated with a significant difference in the occurrence of preterm preeclampsia 8
• Nausea and epigastric pain/gastroesophageal reflux: lifestyle modifications and low-risk therapies such as vitamin B6 and doxylamine for nausea, and antacids not containing salicylates for gastroesophageal reflux 9
• Rashes: treatment with antihistamines or topical steroids 9
• Cystitis: treatment with first-generation cephalosporins or amoxicillin 9
• Low back pain and headaches: treatment with physical therapy and acetaminophen 9