Pregnancy can be an exciting journey. However, beyond the themed baby showers, gender reveals, and carefully curated nursery designs it’s also important to look at the ugly side of getting pregnant. It’s important to be aware that as you cross milestones for the next nine months, there are also factors that can complicate this journey. Get to know 13 of them, below.
Hypertension, or high blood pressure, is fairly common in Singapore where it affects less than 1 in 4 between the ages 30-69. This is well within the age of conception in a lot of women in the country. If uncontrolled, this can result in a number of complications for you and your baby
Preeclampsia is one of the complications of hypertension, and it is described as a sudden increase in blood pressure after the 20th week of pregnancy. Initially, it will not show any symptoms, but early signs include high blood pressure and the presence of protein in your urine (proteinuria). If the condition progresses, the woman may experience fluid retention evidenced by swelling in the face, hands, ankle, and feet. The baby will also be smaller than expected (growth retarded) with low amniotic fluid levels.
Experts are not sure why preeclampsia occurs, but it was surmised that this may be linked to problems with the development of the placenta. The blood vessels that supply it are narrower than normal, which means blood flow is limited and it may also respond differently to hormones.
If left untreated, preeclampsia can develop into eclampsia which bears serious consequences like seizures, severe bleeding, stroke, coma, placental separation from the uterus, or even death. There can also be abnormal kidney, liver and platelet function that affects the ability to clot. Although uncommon, complications from preeclampsia can be prevented if blood pressure levels are controlled and a mother commits to her scheduled prenatal appointments.
Preeclampsia can be cured if the baby is delivered, but in rare occasions where it starts early in pregnancy, delivery will not be a suitable solution. How the treatment proceeds will depend on the severity of your case.
So if you’ve experienced this in the past, you must take your doctor visits seriously because it can reoccur in a succeeding pregnancy. In such cases, medications like antihypertensives, anticonvulsants, and steroids for fetal lung maturation will be recommended.
With good management, you can recover well from preeclampsia. Most women improve within a day or two after delivery, and blood pressure levels revert to its pre-pregnancy rate around 1-6 weeks postpartum.
Check your symptoms!
- Swelling of the face or hands
- A headache that will not go away
- Seeing spots or changes in eyesight
- Pain in the upper abdomen
- Nausea and vomiting (in the second half of pregnancy)
- Sudden weight gain
- Difficulty breathing
2. Gestational Diabetes
Another condition you don’t want complicating your pregnancy is Gestational Diabetes Mellitus (GDM). It’s a category of diabetes that develops in the middle or towards the end of pregnancy and then resolves after giving birth. This is common in Singapore affecting about one in five women.
Those with persisting diabetes even after pregnancy probably had underlying diabetes, to begin with. Furthermore, even in women whose condition resolve after giving birth are at an increased risk of developing diabetes later in life.
Since it’s so common and some women who develop GDM don’t show any symptoms, it became necessary that an Oral Glucose Tolerance Test (OGTT) is done between the 24th to 28th week of pregnancy. The blood tests are conducted at fasting, 1 hour and 2 hours after a pregnant woman has consumed a specific sugar load or a drink with high sugar content.
Proper diagnosis and treatment can help women with gestational diabetes have healthy pregnancies and babies. But when it is poorly managed, it can result in complications that can affect you and your baby.
GDM can be controlled with diet and exercise. If you are diagnosed with GDM, you will be taught how to monitor your blood sugar levels at home using a glucometer. However, if it’s unresponsive to lifestyle changes and an ultrasound scan revealed that the baby is larger than expected, you may be prescribed oral tablets or hormonal injections.
Check your symptoms!
- Being unusually thirsty all the time.
- Frequent urination in large amounts.
- Feeling tired or nauseous (which can be confused with early pregnancy symptoms).
- Sugar detected in urine tests (conducted during a prenatal visit with the gynaecologist).
- Blurred vision
3. Preterm Labor
A typical pregnancy is 40 weeks and its conclusion is marked by labour where the uterus regularly tightens and the cervix thin and open. But, when your body starts getting ready for birth too early in your pregnancy (usually around 37 weeks) it is considered preterm labour. However, preterm delivery doesn’t always follow. Regardless, this requires immediate medical attention to ensure that you and your baby are safe.
While no one knows for certain what the main cause is behind preterm labour, there are known factors that raise a woman’s risk. These include:
- Being under 20 years or over 35 years old
- Long-term illness such as heart or kidney disease
- The use of illegal drugs such as cocaine
- Abnormally shaped uterus
- Cervix unable to stay closed
- Having a preterm birth in the past
- A placenta that separates from the uterus early
- The placenta is in an abnormal position
- A placenta that does not work as well as it should
- Early breaking of the sac around the baby (premature rupture of membranes)
- Birth defects in the baby
- Problems with fetal growth
- Having more than one baby in the womb
To check if you’re indeed going into premature labour, cervical exam or a transvaginal ultrasound scan will be done by your OB to check. Tests may also be ordered to check the amniotic fluid or fetal fibronectin or phIGFBP-1 (proteins found between the amniotic membrane and uterine lining).
The management of preterm labour will be based on your OB’s assessment of your case. If your baby will benefit from a delay in delivery, medications can be given to reduce the risk of complications, help the organs mature, prevent infection, and stall the delivery. A cervical cerclage, which is a procedure where the cervix is stitched closed, may also be done especially if it is weak and unable to stay closed. Bed rest may also be advised. However, if these treatments are unsuccessful at preventing preterm labour or the safety of your baby is compromised, delivery may ensue.
Check your symptoms!
- Painful abdominal cramps, with or without diarrhoea
- A change in the type of vaginal discharge (watery, bloody, or with mucus)
- An increase in the amount of discharge
- Regular or frequent contractions or uterine tightening
- Your water breaks with a gush or a trickle of fluid (indicates ruptured membranes)
4. Premature Rupture of Membranes (PROM)
Sometimes, the membranes that surround the growing fetus breaks before a woman goes into labour, this is called premature rupture of membranes (PROM). But, if the sac ruptures earlier than 37 weeks of pregnancy, it is referred to as preterm premature rupture of membranes (PPROM), and it comes with a higher risk of complications for you and the baby.
Rupture of membranes occurs naturally in the process of labour as the amniotic sac weakens with the force of the contractions. However, the cause is not known with PROM, but triggering factors include:
- Infection of the vagina, cervix, or uterus
- Cigarette smoking during pregnancy
- Too much stretching of the amniotic sac due to having too much fluid or more than one baby putting pressure on the membranes
- Having been pregnant before and had PROM or PPROM
- Surgeries or biopsies of the cervix
PROM can be detrimental because it exposes placental tissues to infection, which puts you and your baby in danger. It is also linked to other complications such as compression of the umbilical cord, early detachment of the placenta from the uterus (placental abruption), a cesarean birth, and postpartum infection. PPROM, on the other hand, poses a significant risk because the baby can be born within a few days after membrane rupture. This is why you must alert your OB right away once you notice any symptom.
The treatment for PPROM will involve hospitalisation, monitoring and treatment of infection, medications to help the baby’s organs develop, and drugs to prevent premature labour. If the baby is more than 34 weeks, labour can be induced. Meanwhile, expectant management is done if the baby is below 34 weeks.
Check your symptoms!
- Leaking of fluid from your vagina
- A feeling of wetness in your vagina or underwear
5. Pregnancy Loss or Miscarriage
Also called a spontaneous abortion or miscarriage, this is a non-viable pregnancy up to 20 weeks gestation. It occurs in up to 1 in every 4-5 pregnancies, where most happen during the first trimester and is referred to as early pregnancy loss. This type of miscarriage happens so early on that some women may not even be aware that they are pregnant. However, it may also occur between 12-24 weeks which is called a late miscarriage.
About half of early pregnancy losses are due to genetic or chromosomal defects. Smoking, alcohol, and caffeine have also been identified as possible causes. Maternal age is also a factor as the likelihood of a miscarriage increases in older women.
Pregnancy loss beyond the first trimester of pregnancy may be caused by factors like underlying health conditions in the mother or infections that can lead to the bag of water breaking prematurely before any pain or bleeding. Miscarriages can also occur when the neck of the womb opens too soon.
Losing a baby at any time in pregnancy can be physically and emotionally hard for a mother, and even for other members of the family. Counselling and support can help the family cope through this difficult time. For those who are still planning to start a family, it’s important that you seek professional care especially if you think you are among those high-risk women.
Check your symptoms!
- Vaginal bleeding
- Mild to severe back pain
- Sudden decrease in the signs of pregnancy
- White or pink mucus discharge from the vagina
- Weight loss
Globally, stillbirth is among the most common adverse pregnancy outcomes. It is defined as fetal death or pregnancy loss that occurs after 20 weeks of pregnancy, either before or during delivery. In Singapore, it affects two in every one thousand births. While these numbers are among the lowest in the world, it’s not reason enough to keep your guard down from potential risk factors.
Identified factors that increase the likelihood of stillbirths include, birth defects, problems with the placenta, a mother’s medical condition (obesity, preexisting diabetes, chronic hypertension), or her lifestyle choices (e.g. smoking, alcohol). Adding to that, advanced maternal age, twin pregnancies, and pregnancy that used assisted reproductive technology also heightens the risk.
Not all causes of stillbirth are currently known, but if you know aggravating factors, the signs to look out for, and when to seek help, you can reduce the chances of this happening.
Check the symptoms!
- Spotting or heavy bleeding
- Stopping of fetal movement and kicks
- Absence of fetal heartbeat when you check through a stethoscope or doppler
7. Ectopic Pregnancy
In our efforts to get pregnant, we assume that the embryo that develops will soon burrow into the uterus. However, there are cases where the egg that is fertilised by the sperm in the Fallopian tube grows outside the uterus, especially if the tube is scarred, damaged, or distorted. In 1% of pregnancies, these fertilised eggs end their journey in the fallopian tube, This is called a tubal ectopic pregnancy, which is a non-viable, high-risk condition because fallopian tubes are not designed to hold a growing baby.
There is no measure that can help save an ectopic pregnancy, and it can never turn into a normal one. If the fertilised egg continues to grow in the fallopian tube, it can damage or burst resulting in heavy bleeding. Hence, this requires urgent medical attention.
To diagnose an ectopic pregnancy, your OB will perform a pelvic exam, and a transvaginal ultrasound scan will confirm it. A blood test may also be done to check for pregnancy hormones.
After an ectopic pregnancy diagnosis is confirmed, treatment options may include medical, surgical, and expectant management. The surgical approach is advised for patients who are medically unstable or are experiencing life-threatening haemorrhage. It is also preferable if the bhcg levels are very high or the ectopic is large especially if there is positive fetal heart activity. For others, management can be based on the patient’s preference after the risks, benefits, and monitoring requirements of other treatment approaches have been discussed.
Medicine can be used if the pregnancy is found early and the tube has not been damaged. To spare the removal of the fallopian tube, a chemotherapeutic drug used to treat it can also end the pregnancy. It may let you steer clear from surgery, but it also comes with side effects. You may also have to undergo blood tests to make sure that the treatment worked.
Check your symptoms!
- Abnormal vaginal bleeding
- Low back pain
- Mild pain in the abdomen or pelvis
- Mild cramping on one side of the pelvis
8. Placental Abruption
Placental abruption is a relatively rare complication of pregnancy due to the partial or complete separation of the placenta from the lining of the uterus before the baby is delivered. It may cause you to bleed and it also heightens the odds of stillbirth.
This complication occurs when the blood vessels that run between the uterus and the maternal side of the placenta are torn and the placenta shears off. This can be dangerous because these structures deliver oxygen and nutrients to the baby.
Factors like hypertension or substance abuse can stretch the uterus which is an elastic muscle. In the event that the uterine tissue suddenly stretches the placenta remains stable and the vascular structure that connects the two gets torn away. This damage causes bleeding, and when blood accumulates, it further separates the placenta from the uterine wall.
If you show symptoms of placental abruption, the doctor usually does a physical exam, an ultrasound and a CTG that monitors the fetal heart rate pattern. If the doctor finds that this is a severe case, treatment would be to deliver the baby, usually through an emergency C-section. Unfortunately, delivery doesn’t always guarantee that the baby can survive. For those that do, they often face complications associated with prematurity and oxygen deprivation.
While it’s impossible to prevent placental abruption, the risks can be reduced. It mostly has something to do with lifestyle changes where you should avoid smoking, never use illegal drugs, and have your high blood pressure under control.
Check your symptoms!
- Vaginal bleeding (although there might not be any in some cases)
- Sudden Abdominal pain
- Reduced fetal movements
- Uterine tenderness or rigidity
- Uterine contractions, often coming one right after another
- Blood stained amniotic fluid (if membranes are ruptured)
9. Cervical Insufficiency
Also referred to as an incompetent cervix, this means that your cervix is unable to retain a pregnancy by opening up too early even in the absence of pain and uterine contractions. While the reason behind it is not well-understood, it is believed to involve a combination of structural abnormalities and biochemical factors (e.g. infection, inflammation) which are either acquired or genetic.
The tricky part about cervical insufficiency is that it can only be identified until a woman delivers a baby too early. This can be confirmed through a transvaginal ultrasound.
To keep the cervix from opening, doctors place stitches around or through the cervix which is called a cervical cerclage. It is done during the 12-14 th week if the risk of cervical insufficiency is high eg previous history of incompetence, previous cervical surgery or early delivery less than 32 weeks and a shortened cervical length is detected on ultrasound. It can also be done during the second trimester if the cervix is shortening on ultrasound surveillance or as a ‘rescue’ attempt if the patient presents with a dilated cervix before 24 weeks.
Check your symptoms!
- Mild abdominal cramps
- A sensation of pelvic pressure
- A change in vaginal discharge (volume, color, consistency)
- Light vaginal bleeding
- Braxton-Hicks-like contractions
10. Placenta Previa
This is an obstetric complication where the placenta lies low in the uterus and partially or completely covers the cervix. The placenta may separate from the uterine wall as the cervix begins to open up during labor. This classically presents as painless vaginal bleeding in the third trimester.
Like most of the complications in this list, the cause behind placenta previa is unknown. However, the risk is higher in women over the age of 35, in those who have a history of uterine surgery, women pregnant with multiples, or those who had more than four pregnancies.
Without proper intervention, placenta previa can lead to:
- Major bleeding on the maternal end
- Shock from blood loss
- Fetal distress due to lack of oxygen
- Blood loss for the baby
- Health risks to the baby, if born prematurely
- Premature labour or delivery
- Emergency caesarean delivery
- Hysterectomy, (removal of the womb) if the placenta fails to separate from the uterus (placenta accreta)
A diagnosis of placenta previa can dampen the anticipation of a healthy delivery. You can expect bed rest and activity restrictions. Medication, intravenous fluids, and blood transfusions may also be needed depending on the severity of your condition. While this can make the journey challenging, there is hope in knowing that some women go on to deliver healthy babies.
Check your symptoms!
- Light to severe bleeding after the 20th week of pregnancy
- Painless vaginal bleeding during the third trimester
- Premature contractions
11. Molar Pregnancy
This type of pregnancy is also known as a hydatidiform mole. Receiving this diagnosis can be distressing and it crushes expectations when you learn that the growing baby is actually just a fluid-filled mass of cells. These cells are called trophoblasts which is why a molar pregnancy is also called trophoblastic disease.
Developing a molar pregnancy is a chance event. But the possibility of mole formation is higher in older women and in those who had a previous molar pregnancy. While there are usually no signs of a molar pregnancy, it can be spotted during a routine ultrasound scan at 8-14 weeks, or through tests carried out after a miscarriage.
This type of pregnancy can be treated with a simple procedure to remove the growth of cells from the womb. In cases where some get left behind, further treatment will be needed to remove it.
Check your symptoms!
- Dark brown to bright red spotting or bleeding
- Severe nausea and vomiting
- Early preeclampsia
- Pelvic pressure or pain
- Rapid uterine growth
- Vaginal passage of grape-like cysts
Infections cover a wide scope, and you are more vulnerable to certain infections when you’re pregnant and it may even complicate your pregnancy if left untreated.
Intrauterine infections occur when the environment where the baby develops (womb and amniotic fluid) become infected. The usual suspects are the natural bacteria that many women carry on the skin or vagina, which are normally harmless, but have migrated to other parts of the body where they shouldn’t be. The vagina and cervix have been tagged as common sites of infection, but it can also find its way to the placenta via the fallopian tubes or through an invasive procedure such as an amniocentesis.
Infections can be treated without leaving complications at its wake, but in some cases, it can also lead to preterm labor, birth defects, or a miscarriage. It poses serious risks to a point where it can be life-threatening to you and your baby. Therefore, no matter how small, these must be taken seriously.
Some infections pose problems mainly for moms, such as vaginitis, urinary tract infections, or postpartum infection. Meanwhile, some are troublesome for your little bun in the oven, such as toxoplasmosis, cytomegalovirus, and parvovirus.
To ensure that you avoid the potential dangers of an infection, make sure to reach out to your doctor whenever you feel ill. As preventive measures, you may also get the necessary immunisations which will be advised to you during your prenatal check-ups.
13. SGA Babies
Small for gestational age (SGA) is used to describe babies who are smaller than the usual number of weeks of pregnancy. Their weight lies below the 10th percentile, which means they are smaller than other babies for their age.
Some babies are small simply because of genetics, or their parents are small. However, most SGA babies are the way they are due to fetal growth problems that occur during pregnancy. If ultrasound shows poor fetal growth while in the womb, the baby may also be described to have “IUGR” or intrauterine growth restriction. This condition means that the baby is small because it’s not growing at a normal rate inside the womb. It occurs when the fetus isn’t getting enough oxygen and the key nutrients for proper growth and development.
Infants who are small for gestational age are at an increased risk for morbidity and mortality. It is a concern because not only does this involve their size, but their overall body and organ growth. It also follows that their tissues and organ cells may also be compromised.
Except for those factors that are uncontrollable, expectant moms can minimise the chance of having SGA babies by making lifestyle changes. For instance, you should avoid recreational drugs and smoking especially once you are aware that you are pregnant. It also helps that antenatal care is started early on in pregnancy. Improved management for those who fall under high-risk pregnancies can also prevent IUGR.
We all want a healthy pregnancy, but we can’t brush potential dangers aside. By knowing what may complicate a pregnancy is a step in the right direction. So, when you plan to start a family, or if you have a little one on the way, you must learn to take the good with the bad. Enjoy the exciting milestones for the next nine months, while keeping an eye out for red flags.
You may have some questions brewing after reading this. If you wish to discuss them more in detail, you may schedule a consultation with Dr Pamela Tan today. Work on a healthy pregnancy with the right help.
Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.