Oxford Handbook of Midwifery (46 page)

1
Nair M, Kumar G (2009). Uncomplicated monochorionic diamniotic twin pregnancy.
Journal of Obstetrics and Gynaecology
29
, 90–3.

CHAPTER 9
Pregnancy complications

172‌‌

Obstetric cholestasis

Obstetric cholestasis, also known as intra-hepatic cholestasis of pregnancy is a disorder of the liver where the flow of bile is reduced, resulting in increased levels of bile acids in the mother’s bloodstream. This is thought to be caused by sensitivity to the hormone oestrogen and tends to affect up to 1% of pregnant women.
¹

Women with a family history of the disorder and those with multiple pregnancy are more at risk.

Symptoms

• Itching: due to the excess bile salts in the bloodstream, begins in the palms of the hands and soles of the feet then spreads to the limbs before becoming generalized.
  
• Jaundice: a rare symptom, indicating problems with the synthesis of bilirubin.
  
• Loss of appetite.
  
• Insomnia.
  
• Meconium staining in the amniotic fluid.
  
• Fetal heart rate changes: bradycardia or tachycardia.
  
• Preterm labour.
  
• Postnatal bleeding: due to underproduction of clotting factors by the liver.
  

  Management
  

• Serum screening for bile acids and liver function tests.
  
• Ultrasound scan to exclude maternal gallstones that may be causing reduction of the flow of bile.
  
• Drug treatment may improve the condition, but the drug used, ursodeoxycholic acid, is unlicensed and can only be given with the
  

  woman’s full consent and in the knowledge that the drug has
  not
  been tested on pregnant women.
  

• There is a small risk that babies whose mothers have cholestasis may be stillborn, and some obstetricians prefer to induce labour at 38 weeks’ gestation or earlier if there are signs of fetal compromise. There is at present insufficient data to support or disprove the value of this intervention.
  
• The mother may be prescribed oral vitamin K daily until delivery to prevent postnatal bleeding.
  
• Betamethasone may be given to mature the fetal lungs if preterm delivery is anticipated.
  
• The baby will require vitamin K at delivery to prevent bleeding.
  
• The mother may be advised follow-up liver function tests and a further scan to exclude gallstones.
  
• She should make a full recovery with return of normal liver function.
  
• The condition may re-appear in subsequent pregnancies.
  

  1
  Royal College of Obstetrics and Gynaecologists (2006).
  Obstetric Cholestasis
  . Guideline 43. London: RCOG Press.
  

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  CHAPTER 9
  Pregnancy complications
  

  174‌‌
  

  Pregnancy-induced hypertension
  

  Hypertensive disorders of pregnancy affect 1 in 10 pregnancies overall and 1 in 50 severely. Pregnancy-induced hypertension (PIH) is the second leading cause of maternal death with 18 deaths in the latest CEMACH report.
  ¹
  

  There is also an impact on perinatal mortality as the condition is associated with placental abruption, intrauterine growth restriction in otherwise normal fetuses, and preterm birth; 500–600 babies a year die as a result of PIH.
  

  Aetiology
  

• Unknown, but thought to be linked to genetic and immunological influences.
  
• Begins in early pregnancy and is related to disorders of the developing placenta. The invading trophoblast cells of the fertilized ovum are normally able to restructure the maternal spiral arteries in the decidual lining of the uterus to create a low-pressure, high-flow blood supply to the developing fetus.
  
• Placental development is completed by around 18 weeks’ gestation, and if this has not progressed normally, the spiral arteries supplying the placental bed remain narrow, and retain their responses, causing generalized vasospasm and ischaemia.
  
• After 20 weeks gestation the mother’s blood pressure rises in response to this, causing generalized endothelial damage in her circulatory system, leading to vasoconstriction, platelet activation, and placental insufficiency.
  
• In the end stage of PIH, sometimes referred to as pre-eclampsia, end- organ damage affects the renal and hepatic systems, with symptoms such as proteinuria, disruption of the clotting mechanism, and disturbed
  

  fluid distribution, leading to generalized oedema.
  

• This is a progressive condition and multisystem disease, relieved only by delivery of the baby and placenta. Rarely, eclampsia develops, characterized by convulsions, loss of consciousness, and severe hypertension.
  

  Diagnosis and clinical features
  

• Blood pressure: systolic >20–25mmHg over the baseline; diastolic
  

  >15mmHg over the baseline. These changes persist for two readings more than 4h apart.
  

• Proteinuria: >0.30g protein daily, or dipstick showing 2+ protein from clean-catch mid-stream urine sample (MSU).
  
• Oedema: rapid weight gain before oedema noted. The oedema will involve the upper extremities.
  

  Severe: maternal criteria
  

• Systolic >160mmHg; diastolic >110mmHg
  
• >5g proteinuria in 24h (4+ on stick)
  
• Altered liver function—epigastric pain
  
• Persistent headache
  
• Hyperreflexia
  

PREGNANCY-INDUCED HYPERTENSION

175

Severe: fetal criteria

Management

Midwives play a critical role in screening and identification of women who are developing pregnancy induced hypertension. During each antenatal care appointment the midwife measures the blood pressure, tests the woman’s urine for protein, and observes for signs of excessive oedema.

If the midwife detects mild hypertension without proteinuria an increased level of surveillance will be required and the woman asked to attend more frequently to have her blood pressure and urine monitored. Collaborative care provides the most effective management and after referral to the consultant for investigation the woman can often resume her care in the community provided her condition does not deteriorate.

Once protein appears in the urine the woman should be referred to consultant led antenatal care and this may take place on an outpatient basis, in a day care setting or the woman may be referred to triage with a view to further management. Admission to hospital is required when the mother and fetus require more monitoring and evaluation than can be provided in a day care setting.

Antihypertensives may be prescribed mainly to prevent severe hypertension developing which protects the mother from the risk of cerebral haemorrhage. Methyldopa is a centrally acting antihypertensive safe for use in pregnancy in doses up to 1g daily. Labetalol, a B-blocking drug is also commonly used for this purpose.

The midwife’s role is to provide whatever emotional and supportive
care is appropriate for the practice setting. Once admitted to hospital

the woman will have a daily antenatal examination including urinalysis and the condition of the fetus is monitored by daily cardiotocograph. Blood pressure recording will be undertaken at least every 4h during the day and if the mother wakes during the night.

FBC, renal and hepatic chemistry, plasma proteins, and clotting factors will be monitored closely and any deterioration in the maternal or fetal condition will lead to the decision to deliver the baby either by induction of labour or caesarean section.

1
Lewis, G (ed.) (2007).
The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer
—
2003–2005
. The 7th report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.

CHAPTER 9
Pregnancy complications

176‌‌

The impact of obesity during pregnancy and beyond

Recent figures suggest that in the UK the rising rate of obesity within the general population will have a major impact on public health. For the childbearing population this is already having an impact. Obesity repre- sents one of the greatest and growing overall threats to the childbearing population of the UK.

Obesity in pregnancy is usually defined as a BMI of 30kg/m
²
or greater at booking.
¹
In the UK national statistics about the prevalence of obesity during pregnancy suggest that 50% of women of childbearing age are overweight or obese.
²

The predominance of obese women among those who died from thromboembolism, sepsis, and cardiac disease recorded in the latest CEMACH report
³
means that early multidisciplinary planning regarding mode of delivery and use of thromboprophylaxis for these women is essential.

Pre-pregnancy counselling and weight loss, together with wider public health messages about optimum weight should help to reduce the number of obese women who become pregnant.

Risks of obesity in pregnancy

Obesity in pregnancy is associated with increased risks of complications for both mother and baby. Women with obesity in pregnancy also have higher rates of induction of labour, caesarean section and PPH and there is an increased risk of post-caesarean wound infection.
⁴

There is also evidence that babies of obese women have significantly increased risks of adverse outcomes, including fetal congenital anomaly, prematurity, stillbirth and neonatal death.
⁴

Risks for the mother

• Maternal death or severe morbidity
  
• Cardiac disease
  
• Spontaneous first trimester and recurrent miscarriage
  
• Pre-eclampsia
  
• Gestational diabetes
  
• Thromboembolism
  
• Post-caesarean wound infection
  
• Infection from other causes
  
• Postpartum haemorrhage
  
• Low breastfeeding rates.
  

  Risks for the baby
  

• Stillbirth and neonatal death
  
• Congenital abnormalities
  
• Macrosomia
  
• Prematurity.
  

  Pre-pregnancy care
  

• Women of childbearing age should have the opportunity to optimize their weight prior to pregnancy.
  

THE IMPACT OF OBESITY DURING PREGNANCY AND BEYOND

177