complications of pregnancy complications of pregnancy complications of pregnancy are health problems that are related to, or arise during pregnancy. complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. while some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality. complications of pregnancy810 women die every day from preventable causes related to pregnancy and childbirth. 94% occur in low and lower middle-income countries.specialtyobstetricscomplicationsnumerous biological and environmental complicationsrisk factorsnumerous biological and environmental conditions common complications of pregnancy include anemia, gestational diabetes, infections, gestational hypertension and pre-eclampsia. presence of these types of complications can have implications on monitoring lab work, imaging, and medical management during pregnancy. severe complications of pregnancy, childbirth, and the puerperium are present in 1.6% of mothers in the us, and in 1.5% of mothers in canada. in the immediate postpartum period (puerperium), 87% to 94% of women report at least one health problem. long-term health problems (persisting after six months postpartum) are reported by 31% of women. in 2016, complications of pregnancy, childbirth, and the puerperium resulted globally in 230,600 deaths, down from 377,000 deaths in 1990. the most common causes of maternal mortality are maternal bleeding, postpartum infections including sepsis, hypertensive diseases of pregnancy, obstructed labor, and unsafe abortion. complications of pregnancy can sometimes arise from abnormally severe presentations of symptoms and discomforts of pregnancy, which usually do not significantly interfere with activities of daily living or pose any significant threat to the health of the birthing person or fetus. for example, morning sickness is a fairly common mild symptom of pregnancy that generally resolves in the second trimester, but hyperemesis gravidarum is a severe form of this symptom that sometimes requires medical intervention to prevent electrolyte imbalances from severe vomiting. maternal problems the following problems originate in the mother, however, they may have serious consequences for the fetus as well. gestational diabetes gestational diabetes is when a woman, without a previous diagnosis of diabetes, develops high blood sugar levels during pregnancy. there are many non-modifiable and modifiable risk factors that lead to the devopment of this complication. non-modifiable risk factors include a family history of diabetes, advanced maternal age, and ethnicity. modifiable risk factors include maternal obesity. there is an elevated demand for insulin during pregnancy which leads to increased insulin production from pancreatic beta cells. the elevated demand is a result of increased maternal calorie intake and weight gain, and increased production of prolactin and growth hormone. gestational diabetes increases risk for further maternal and fetal complications such as development of pre-eclampsia, need for cesarean delivery, preterm delivery, polyhydramnios, macrosomia, shoulder dystocia, fetal hypoglycemia, hyperbilirubinemia, and admission into the neonatal intensive care unit. the increased risk is correlated with the how well the gestational diabetes is controlled during pregnancy with poor control associated with worsened outcomes. a multidisciplinary approach is used to treat gestational diabetes and involves monitoring of blood-glucose levels, nutritional and dietary modifications, lifestyle changes such as increasing physical activity, maternal weight management, and medication such as insulin. hyperemesis gravidarum hyperemesis gravidarum is the presence of severe and persistent vomiting, causing dehydration and weight loss. it is similar although more severe than the common morning sickness. it is estimated to affect 0.3–3.6% of pregnant women and is the greatest contributor to hospitalizations under 20 weeks of gestation. most often, nausea and vomiting symptoms during pregnancy resolve in the first trimester, however, some continue to experience symptoms. hyperemesis gravidarum is diagnosed by the following criteria: greater than 3 vomiting episodes per day, ketonuria, and weight loss of more than 3 kg or 5% of body weight. there are several non-modifiable and modifiable risk factors that predispose women to development of this condition such as female fetus, psychiatric illness history, high or low bmi pre-pregnancy, young age, african american or asian ethnicity, type i diabetes, multiple pregnancies, and history of pregnancy affected by hyperemesis gravidarum. there are currently no known mechanisms for the cause of this condition. this complication can cause nutritional deficiency, low pregnancy weight gain, dehydration, and vitamin, electrolyte, and acid-based disturbances in the mother. it has been shown to cause low birth weight, small gestational age, preterm birth, and poor apgar scores in the infant. treatments for this condition focus on preventing harm to the fetus while improving symptoms and commonly include fluid replacement and consumption of small, frequent, bland meals. first-line treatments include ginger and acupuncture. second-line treatments include vitamin b6 +/- doxylamine, antihistamines, dopamine antagonists, and serotonin antagonists. third-line treatments include corticosteroids, transdermal clonidine, and gabapentin. treatments chosen are dependent on severity of symptoms and response to therapies. pelvic girdle pain pelvic girdle pain (pgp) disorder is pain in the area between the posterior iliac crest and gluteal fold beginning peri or postpartum caused by instability and limitation of mobility. it is associated with pubic symphysis pain and sometimes radiation of pain down the hips and thighs. for most pregnant individuals, pgp resolves within three months following delivery, but for some it can last for years, resulting in a reduced tolerance for weight bearing activities. pgp affects around 45% of individuals during pregnancy: 25% report serious pain and 8% are severely disabled. risk factors for complication development include multiparity, increased bmi, physically strenuous work, smoking, distress, history of back and pelvic trauma, and previous history of pelvic and lower back pain. this syndrome results from a growing uterus during pregnancy that causes increased stress on the lumbar and pelvic regions of the mother, thereby, resulting in postural changes and reduced lumbopelvic muscle strength leading to pelvic instability and pain. it is unclear whether specific hormones in pregnancy are associated with complication development. pgp can result in poor quality of life, predisposition to chronic pain syndrome, extended leave from work, and psychosocial distress. many treatment options are available based on symptom severity. non-invasive treatment options include activity modification, pelvic support garments, analgesia with or without short periods of bed rest, and physiotherapy to increase strength of gluteal and adductor muscles reducing stress on the lumbar spine. invasive surgical management is considered a last-line treatment if all other treatment modalities have failed and symptoms are severe. high blood pressure main article: hypertensive disease of pregnancy potential severe hypertensive states of pregnancy are mainly: pre-eclampsia – gestational hypertension, proteinuria (>300 mg), and edema. severe pre-eclampsia involves a bp over 160/110 (with additional signs). it affects 5–8% of pregnancies. eclampsia – seizures in a pre-eclamptic patient, affect around 1.4% of pregnancies. gestational hypertension can develop after 20 weeks but has no other symptoms, and later rights itself, but it can develop into pre-eclampsia. hellp syndrome – hemolytic anemia, elevated liver enzymes and a low platelet count. incidence is reported as 0.5–0.9% of all pregnancies. acute fatty liver of pregnancy is sometimes included in the pre-eclamptic spectrum. it occurs in approximately one in 7,000 to one in 15,000 pregnancies. venous thromboembolism deep vein thrombosis (dvt), a form of venous thromboembolism (vte), has an incidence of 0.5 to 7 per 1,000 pregnancies, and is the second most common cause of maternal death in developed countries after bleeding. caused by: pregnancy-induced hypercoagulability as a physiological response in preparation for the potential bleeding during childbirth. treatment: prophylactic treatment, e.g. with low molecular weight heparin may be indicated when there are additional risk factors for deep vein thrombosis. anemia levels of hemoglobin are lower in the third trimesters. according to the united nations (un) estimates, approximately half of pregnant individuals develop anemia worldwide. anemia prevalences during pregnancy differed from 18% in developed countries to 75% in south asia. treatment varies due to the severity of the anaemia, and can be used by increasing iron containing foods, oral iron tablets or by the use of parenteral iron. infection main article: susceptibility and severity of infections in pregnancy further information: neonatal infection a pregnant woman is more susceptible to certain infections. this increased risk is caused by an increased immune tolerance in pregnancy to prevent an immune reaction against the fetus, as well as secondary to maternal physiological changes including a decrease in respiratory volumes and urinary stasis due to an enlarging uterus. pregnant individuals are more severely affected by, for example, influenza, hepatitis e, herpes simplex and malaria. the evidence is more limited for coccidioidomycosis, measles, smallpox, and varicella. mastitis, or inflammation of the breast, occurs in 20% of lactating individuals. some infections are vertically transmissible, meaning that they can affect the child as well. peripartum cardiomyopathy peripartum cardiomyopathy is a heart failure caused by a decrease in left ventricular ejection fraction (lvef) to <45% which occurs towards the end of pregnancy or a few months postpartum. symptoms include shortness of breath in various positions and/or with exertion, fatigue, pedal edema, and chest tightness. risk factors associated with the development of this complication include maternal age over 30 years, multi gestational pregnancy, family history of cardiomyopathy, previous diagnosis of cardiomyopathy, pre-eclampsia, hypertension, and african ancestry. the pathogenesis of peripartum cardiomyopathy is not yet known, however, it is suggested that multifactorial potential causes could include autoimmune processes, viral myocarditis, nutritional deficiencies, and maximal cardiovascular changes during which increase cardiac preload. peripartum cardiomyopathy can lead to many complications such as cardiopulmonary arrest, pulmonary edema, thromboembolisms, brain injury, and death. treatment of this condition is very similar to treatment of non-gravid heart failure patients, however, safety of the fetus must be prioritized. for example, for anticoagulation due to increased risk for thromboembolism, low molecular weight heparin which is safe for use during pregnancy is used instead of warfarin which crosses the placenta. hypothyroidism main article: thyroid disease in women hypothyroidism (commonly caused by hashimoto's disease) is an autoimmune disease that affects the thyroid by causing low thyroid hormone levels. symptoms of hypothyroidism can include low energy, cold intolerance, muscle cramps, constipation, and memory and concentration problems. it is diagnosed by the presence of elevated levels of thyroid stimulation hormone or tsh. patients with elevated tsh and decreased levels of free thyroxine or t4 are considered to have overt hypothyroidism. while those with elevated tsh and normal levels of free t4 are considered to have subclinical hypothyroidism. risk factors for developing hypothyroidism during pregnancy include iodine deficiency, history of thyroid disease, visible goiter, hypothyroidism symptoms, family history of thyroid disease, history of type 1 diabetes or autoimmune conditions, and history of infertility or fetal loss. various hormones during pregnancy affect the thyroid and increase thyroid hormone demand. for example, during pregnancy, there is increased urinary iodine excretion as well as increased thyroxine binding globulin and thyroid hormone degradation which all increase thyroid hormone demands. this condition can have a profound effect during pregnancy on the mother and fetus. the infant may be seriously affected and have a variety of birth defects. complications in the mother and fetus can include pre-eclampsia, anemia, miscarriage, low birth weight, still birth, congestive heart failure, impaired neurointellectual development, and if severe, congenital iodine deficiency syndrome. this complication is treated by iodine supplementation, levothyroxine which is a form of thyroid hormone replacement, and close monitoring of thyroid function. fetal and placental problems the following problems occur in the fetus or placenta, but may have serious consequences on the mother as well. ectopic pregnancy ectopic pregnancy is implantation of the embryo outside the uterus caused by: unknown, but risk factors include smoking, advanced maternal age, and prior surgery or trauma to the fallopian tubes. risk factors include untreated pelvic inflammatory disease, likely due to fallopian tube scarring. treatment: in most cases, keyhole surgery must be carried out to remove the fetus, along with the fallopian tube. if the pregnancy is very early, it may resolve on its own, or it can be treated with methotrexate, an abortifacient. miscarriage miscarriage is the loss of a pregnancy prior to 20 weeks. in the uk, miscarriage is defined as the loss of a pregnancy during the first 23 weeks. approximately 80% of pregnancy loss occurs in the first trimester, with a decrease in risk after 12 weeks gestation. spontaneous abortions can be further categorized into complete, inevitable, missed, and threatened abortions: complete: vaginal bleeding occurs followed by the complete passing of conception products through the cervix. inevitable: vaginal bleeding occurs; the cervical os