Pregnancy complications

Bleeding in early pregnancy can be very distressing but it does not always mean you are having a miscarriage. It affects one in four women, and many will go on to have a healthy baby.

If you are bleeding in early pregnancy (the first 12 weeks), talk to your GP or midwife as soon as possible.

Early Pregnancy Assessment Clinic (EPAC)

You may be referred to EPAC at Waikato Hospital, a specialist service for women experiencing pain and bleeding in early pregnancy, when the pregnancy is of an unknown location.

Women with gestational trophoblastic disease (GTD), also known as molar pregnancy, and women with a confirmed miscarriage are also patients at the clinic.

The EPAC service includes early pregnancy ultrasound, diagnostic tests, counselling and management planning. This service is an outpatient clinic and is open Monday to Friday.

The cause of bleeding

The cause of the bleeding is often not found and the pregnancy will continue as normal.

If the bleeding is being caused by a miscarriage, unfortunately there is no treatment or therapy that can stop the miscarriage from happening.

Ectopic pregnancy can also cause bleeding and pain. This is when the pregnancy is growing outside the uterus – usually in the fallopian tube. Between 1-2 per cent of all pregnancies are ectopic, and without treatment they can seriously impact your health and fertility.

If you are experiencing severe pain, or your bleeding is very heavy, with large clots accompanied by crampy abdominal pains, you need urgent care and should attend the nearest emergency department to you – either at Waikato Hospital or one of the rural hospitals. 

Early bleeding that is not an ectopic pregnancy, a molar pregnancy or does not lead to miscarriage will not have caused your baby any harm.

If you are pregnant and have pre-existing type 1 or 2 diabetes, talk to your GP or midwife as soon as possible. You will be referred to the Diabetes in Pregnancy team, which is made up of specialist doctors, diabetes nurse specialists and a diabetes specialist midwife.

The team will work with you to manage your blood sugar levels well, to reduce the chance of developing complications during your pregnancy.

You will also see the obstetrics team at the hospital at around 16 weeks, then regularly from approximately 24 weeks of pregnancy. The obstetrics team will monitor the progress of your pregnancy and work with you to plan for care around the birth of your baby.

Potential complications

• Labour might start too early (premature labour).
• Increased chance of developing high blood pressure and pre-eclampsia.
• Increased chance of gum disease, bladder and other infections.
• Worsening of any problems related to your diabetes such as eye, kidney, heart or nerve problems.
• Increased chance of miscarriage or stillbirth.
• Larger baby (which may cause problems during birth).
• Baby being smaller than expected.
• Baby having difficulty breathing at birth.
• Baby having jaundice following birth.
• Baby having abnormalities like heart problems. 

Diabetes antenatal clinic

The Diabetes in Pregnancy team runs a joint clinic with the obstetrics team on a Tuesday at Waikato Hospital. This is a ‘one stop shop’ and can be a long afternoon, where you will have any scans or tests needed and see the diabetes nurse, midwife and doctor to monitor your diabetes.

As your pregnancy progresses, you will also see the obstetric doctor who will review your scans to monitor the progress of your pregnancy and the baby’s growth and development.

If you are not already on insulin, you may be started on insulin. You will receive support and education about insulin from the diabetes midwife or nurse.

During labour and delivery

Pregnant women with diabetes are advised to birth at Waikato Hospital and you will be able to plan your birth together with your midwife and doctor.

An induction of labour will be offered at around 38 weeks of pregnancy due to the increased chance of complications.

Your blood glucose levels will be monitored regularly while in labour. You may be advised to have a drip with glucose and insulin to help manage your levels in labour. The Diabetes

in Pregnancy team will ensure that the plan for your diabetes medication management is well documented in your notes for when your baby is born, as your insulin requirements will change.

Once born, your baby’s blood glucose will need to be checked a number of times. This is to check for low blood glucose levels, not diabetes, as babies born to mothers with diabetes are more likely to have low blood glucose levels at birth and it is important to manage this promptly.

The Diabetes in Pregnancy team will be able to answer any questions you have about the management of your diabetes after your baby is born.

Gestational diabetes (GDM) is when a pregnant woman who is not known to have diabetes before pregnancy develops high blood glucose levels during pregnancy.

GDM affects about 4-8 per cent of all pregnant women. Left untreated, it can lead to problems for both you and your baby. Treatment includes healthy eating and exercise, and possibly use of medication or insulin.

GDM usually goes away after your baby is born, however it can come back in future pregnancies and there is also a higher chance of developing type 2 diabetes later in life.

How do you find out if you have gestational diabetes?

Every pregnant woman is offered a blood test that measures their average blood glucose levels over the previous three months (HbA1c). This is a routine part of booking antenatal blood tests in early pregnancy and identifies women with an increased chance of developing GDM.

At 24-28 weeks of pregnancy, all women are offered another screening test to check for GDM.

If you are found to have GDM you will be referred to the Diabetes in Pregnancy team who will work with you to manage your blood sugar levels well to reduce the chance of developing complications during your pregnancy.

If you’ve had gestational diabetes in a previous pregnancy you should be screened for GDM as soon as a new pregnancy occurs – talk to your GP or midwife about this as soon as you can.

Who is at higher risk of gestational diabetes?

• Women who are overweight or obese.
• Women who have gained excessive weight during pregnancy.
• Women with Asian, Indian, Maori or Pacific Island heritage.
• Women with a family history of diabetes.
• Women with pre-diabetes.
• Women over 30 years of age.
• Women who have a previous history of gestational diabetes. If you’ve had gestational diabetes in a previous pregnancy you should be screened for GDM as soon as a new pregnancy occurs – talk to your GP or midwife about this as soon as you can.
• Women who have an obstetric history of an unexplained stillbirth or miscarriage.
• Women who have had a previous large baby or babies.
• Women with hormonal conditions like polycystic ovarian syndrome or endometriosis. 

GDM can also occur in women who have none of these risk factors.

Potential complications

If left untreated, the high sugar (and fat) in the blood of a woman with GDM can overfeed the baby while it is in the womb, leading to macrosomia (a large baby).

Large babies lead to higher rates of difficult births and a need for assisted delivery (forceps or ventouse), or a caesarean section.

Women with GDM also have a higher risk of:

• premature birth (baby being born before 37 weeks)
• high blood pressure in pregnancy
• pre-eclampsia
• developing type 2 diabetes within five years of delivery.

 Stillbirth rates (baby dying before birth) are also higher.

Diabetes antenatal clinic

Treatment for GDM includes eating a healthy diet and being active every day, aiming for at least 30 minutes of activity. If this doesn't keep your blood sugars within the target range, then medication or insulin may be recommended.

You will receive support and education about diet and activity from the Diabetes in Pregnancy team. The team includes nurses, a midwife and dietitians who are all passionate about supporting women with GDM to achieve healthy outcomes with their pregnancies.

You are likely to have frequent scans during your pregnancy to check on the baby’s growth and development, and to pick up any problems.

You may be offered appointments to come to the joint antenatal diabetes clinic, where you will be able to see both the obstetric team and the diabetes team in one afternoon.

During labour and delivery

Pregnant women with diabetes are advised to birth at Waikato Hospital and you will be able to plan your birth together with your midwife and doctor.

Once born, your baby’s blood glucose will need to be checked a number of times. This is to check for low blood glucose levels, not diabetes, as babies born to mothers with diabetes are more likely to have low blood glucose levels at birth and it is important to manage this promptly.

Once both you and your baby are considered to be stable and there are no other complications you may be able to transfer to one of the local birth centres.

Having GDM can be challenging but the Diabetes in Pregnancy team is here to support you all the way.

Sometimes your unborn baby may be diagnosed as being large for gestational age (or large for dates), which means your midwife or doctor has felt or measured the baby to be bigger than expected for the number of weeks of pregnancy.

There is no strict definition of what a large baby is, but it generally means your baby is expected to weigh more than 4.5kg at birth.

However, whether your baby is large for you will depend upon your own individual characteristics, which are used to draw a customised growth chart to plot your baby’s estimated weight.

Who is more likely to have a larger than usual baby?

You are more likely to have a large baby if you:

• have diabetes
• have had a previous baby weighing over 4.5kg at birth
• are obese
• have gained an excessive amount of weight in pregnancy
• were a large baby yourself.

If your baby is estimated to be large for dates, you will be offered a glucose tolerance test (GTT) to check for diabetes in pregnancy (gestational diabetes). If this test has already been done, but it was more than four weeks ago, the test may be repeated.

How do you know your baby is larger than usual?

During your antenatal appointments your midwife or doctor measures your uterus (womb) size with a tape measure and plots the measurement on a chart made particularly for you. A large baby is suspected if these measurements are larger than expected, or you have certain characteristics that might make you more likely to having a large baby (listed above).

Having a scan is the main way to confirm whether a baby is large. However, using a scan to take the baby’s measurements and estimate its weight is not very precise.

On average, the scan estimate of your baby’s weight may have a margin of error of 10-15 per cent. For example, a baby that is estimated to weight 4kg may weigh anything between 3.6kg and 4.4kg.

Unfortunately there is no way to know exactly how much a baby is going to weigh until after the baby is born. 

Potential complications

It is important to remember that although the risk of complications is increased by having a large baby, most women and babies do not have complications.

Having a large baby increases the risk of:

• having a caesarean or assisted/instrumental delivery (ventouse or forceps)
• difficulty in delivering the baby’s shoulders (shoulder dystocia) with associated risks of damage to the baby’s shoulder or arm when trying to deliver the baby, or of the baby being deprived of oxygen (however, most babies do not have shoulder dystocia)
• having a large amount of blood loss after the birth (postpartum haemorrhage)
• having a severe tear of your perineum (the area between your vagina and anus).

Recommended birth plan

Early induction of labour is not routinely offered if your baby is thought to be larger than usual, as there have been no studies performed in New Zealand, or a similar population, suggesting better outcomes with early planned birth. Induction of labour prior to 39 weeks may have a negative impact on your baby’s health and is likely to lead to the baby needing more interventions.

Because of the potential complications, you will be advised to birth at Waikato Hospital where your midwife will have the support of the hospital midwives and doctors if needed.

Your midwife will regularly check the progress of your labour and the wellbeing of you and your baby. If there any concerns at all, your midwife will ask a doctor to assess your situation and make a plan for your ongoing care. 

After your baby is born, we recommend that you have the oxytocin injection offered to help with firm contraction of the uterus and delivery of the placenta, as it can help prevent a large amount of bleeding.

Please talk to your midwife or doctor if you have further questions about having a large baby.

Sometimes your unborn baby may be diagnosed as being small for gestational age (also called SGA or small for dates), which means your midwife or doctor has felt or measured the baby to be smaller than expected for the number of weeks of pregnancy.

An unborn baby is small if, at that stage of pregnancy, its size or estimated weight on scan is in the lowest 10 per cent of babies. This means the smallest 10 out of every 100 babies.

What affects my baby’s birth weight?

• Your height and weight – taller, heavier women tend to have heavier babies and shorter, lighter women tend to have smaller babies.
• Whether you were a small baby at birth.
• Your ethnicity – for example, South Asian women tend to have smaller babies.
• The number of babies you have had – babies tend to become heavier with each pregnancy.
• Whether your baby is a boy or a girl – boys tend to be heavier.

Why is my baby small?

Some babies will be smaller just because it runs in their genes. They are called constitutionally small. These babies generally don’t have any health problems due to their small size.

However, some other babies are small because they do not grow as well as expected. This is called being growth restricted. This might be abbreviated to IUGR, which stands for Intra Uterine Growth Restriction.

Causes of growth restriction include:

• the placenta not working as well as it should
• very rarely, it is related to having a baby with a developmental or genetic problem.

What increases the risk of my baby being growth restricted?

Lifestyle choices such as smoking, using cocaine, over-exercising or not eating healthily are all linked to the placenta not working as well as it should, and an increased chance of a baby being growth restricted.

You are more at risk of having a growth restricted baby if you:

• have an existing health condition or pregnancy complications
• are over 40 years old
• smoke cigarettes
• have used cocaine during pregnancy
• had a low pre-pregnancy weight and have poor nutrition
• are obese
• have high blood pressure
• have kidney problems or diabetes complications
• have lost a baby late in pregnancy or had a growth restricted baby in the past
• have placenta or uterine abnormalities
• conceived with IVF.

Heavy vaginal bleeding, especially in the second half of pregnancy, can also affect the way your baby grows.

Potential complications

The outcome depends on why your baby is small. If your baby is small but healthy, and not growth restricted, there is no increased risk of complications.

Unfortunately, growth restricted babies have higher risk of stillbirth and this is the reason why close monitoring during pregnancy is essential.

Growth restricted babies are also more likely to have:

• complications after birth
• illness around the time of birth due to a lack of oxygen
• inhaled meconium (the baby’s first poo) during labour
• difficulty maintaining their temperature
• abnormal blood sugar or calcium levels
• jaundice
• feeding difficulties or intolerance
• late-onset sepsis (a severe immune response to an infection)
• other, rarer complications.

Growth restricted babies may also have behaviour and development issues, poor growth and increased susceptibility to adult-onset diseases as a child and teenager, including obesity, type 2 diabetes and cardiovascular disease.

The earlier in pregnancy and the more severely your baby’s growth is affected, the more likely it is that your baby will have a poor outcome. Babies whose growth is affected later in pregnancy have a better outcome.

If my baby is small or not growing, what tests may I be offered?

If your baby is small or not growing, you will be offered a range of tests to monitor its progress during pregnancy.

• Growth scans, normally every 2-3 weeks.
• Umbilical artery doppler to measure the flow of blood through the umbilical cord and sometimes other vessels. The frequency of this test varies but could be twice weekly if the results are abnormal.
• Cardiotocograph (CTG), this is a tracing of your baby’s heart rate.
• Measuring the amount of amniotic fluid around your baby.
• Your blood pressure will be checked frequently as high blood pressure is linked to having a small baby.
• You may also have extra blood tests.

We will also ask you to monitor your baby’s movements. If your baby’s movements decrease in number, it is important to get help as soon as possible. Call your midwife or come in to the Women’s Assessment Unit at Waikato Hospital that day.

When is the best time for my baby to be born?

This will depend on how affected your baby’s growth appears to be, and on the doppler measurements.

Scans will help your team decide whether it is better for your baby to be born early, or safer for you and your baby to continue your pregnancy longer.

If your baby is growing and the doppler tests are normal, it is usually best to wait until you are at least 37 weeks pregnant, as premature birth has its own risks.

If you go into labour, your waters have broken, or you have had any bleeding before the date that you have been advised to have your baby, you should contact your midwife and come to the Women’s Assessment Unit at Waikato Hospital straight away.

Is there any other treatment I should have?

Depending on the timing of birth and how you are going to have your baby, you may be offered a course of corticosteroids over a 24–48 hour period.

This is to help your baby’s development and reduce the chance of breathing problems after birth.

How will I have my baby?

If there are no other complications, you may be able to have a vaginal birth. Your baby will be monitored closely during labour.

However, if the umbilical artery doppler measurements are severely abnormal, your doctor may recommend that your baby be born by caesarean section.

Where should I have my baby?

If your baby is growth restricted, you will be advised to have your baby at Waikato Hospital where there is a neonatal unit.

Whether your baby will need to be looked after in the neonatal unit will depend on how small your baby is, at what stage of pregnancy your baby is born and the condition of your baby at birth.

If your baby is likely to need special care, you should have an opportunity to talk to the neonatal team during pregnancy. You and your partner may also wish to visit the neonatal unit ahead of time.

Concerns or further questions?

If you have concerns or further questions talk to your midwife in the first instance. You can also ask to speak to your team of midwives and doctors at Waikato Hospital.

Multiple pregnancy includes twins, triplets, quadruplets and more, and occurs in 5 per cent (or five in 100) of pregnancies.

Having a multiple pregnancy is different to having one baby, and it’s important that you take a few steps to ensure a healthy pregnancy.

Based on information from The New Zealand Multiple Birth Association.

Types of multiple pregnancy

There are two main types of multiple pregnancy.

• Fraternal – two or more eggs, fertilised separately. Fraternal multiples can be the same sex, or different sexes.
• Identical – one fertilised egg, which splits after conception. Identical multiples are always the same sex and share the same genes.

Triplets or higher multiples can be fraternal or identical, or a mixture of both.

At your first scan the sonographer will check what type of multiples you are carrying, and how many placentas and amniotic sacs there are. This information helps determine whether there are increased risks to the health of you and your babies, and the type of monitoring you will need during pregnancy.

Having a multiple pregnancy is different

Having a multiple pregnancy is different to having one baby, here are a few things to think about.

• Twins are usually born at 38 weeks and triplets at 33 weeks.
• If you are having identical multiples there are increased risks and you will need careful monitoring and regular ultrasound scans.
• Although multiples are not always born preterm, you need to be mentally prepared for this possibility.
• You will get bigger earlier, your morning sickness may be worse, you may get tired more easily, and you may be hungrier.
• You will need to be very mindful of eating well, drinking water and getting plenty of rest to ensure you grow healthy babies.
• You will need to finish work earlier.

Find a midwife as soon as possible

If you are pregnant with more than one baby, you will need to find a midwife with experience in multiple pregnancies as soon as possible, to ensure you get the right care.

If you live in a rural area you may need to travel to find a midwife with suitable experience.

Specialist care

Having twins (or more) is considered to increase the risk of pregnancy complications. Your midwife will recommend that you are referred to the antenatal clinic or high risk pregnancy service at Waikato Hospital. For more information on referral and “transfer of care” look under the topic heading: Referral to the Waikato Hospital Antenatal Clinic.

Support services

The New Zealand Multiple Birth Association provides networking, education, support and advocacy for families with multiples.

The association runs clubs throughout New Zealand, which provide moral support, information and playgroups. Some also provide antenatal education, hire equipment and library resources.

Join a club as soon as possible so you can access information and support throughout your pregnancy and once your babies have arrived.  

Visit www.multiples.org.nz or call 0800 4TWINS (0800 489 467).

Pre-eclampsia is a very serious complication that affects 3-7 per cent of women, usually late in pregnancy, but sometimes as early as 20 weeks. Pre-eclampsia can also occur up to two or three weeks after your baby is born.

If pre-eclampsia is not treated quickly, both your health and your baby’s health is at risk.

Who can get pre-eclampsia?

Anyone can get pre-eclampsia during pregnancy and the exact cause of the condition is unknown. However, your risk is higher if you:

• are having your first baby
• are having your first baby with a new partner
• have had pre-eclampsia in a previous pregnancy – it is important to register early with a midwife and tell her you have had pre-eclampsia before
• have several existing medical problems, including diabetes, high blood pressure, kidney disease, blood or clotting disorders
• are having a multiple birth
• have a family history of pre-eclampsia – it is important to let your midwife know if your mother or sisters have experienced pre-eclampsia in their pregnancies.

The risks of pre-eclampsia

In pre-eclampsia your blood pressure rises, which decreases blood supply to the organs in your body. This can affect your brain, kidneys and liver, and in severe cases lead to convulsions, kidney and liver failure – although this is rare in New Zealand today.

Decreased blood supply to your placenta can decrease the supply of food and oxygen to your baby. This can affect the growth of your baby, and in severe cases the baby will need to be born early.

Pre-eclampsia may also be referred to as pre-eclamptic toxaemia (PET) or toxaemia. If left untreated, severe pre-eclampsia can turn into eclampsia – seizures which can sometimes result in death.

Very occasionally pre-eclampsia can cause early separation of the placenta from the uterine wall, which endangers the health of both you and your baby.

Identifying pre-eclampsia

The signs of pre-eclampsia can be hard to spot, and you may feel perfectly well with no noticeable symptoms in the early stages.

It is important that pre-eclampsia is identified early. Your midwife will regularly check your blood pressure and screen your urine for protein throughout your pregnancy. Raised blood pressure and protein in your urine may suggest pre-eclampsia. 

What can you do?

• Know the six warning signs (below) and get in touch with your midwife as soon as possible if you experience any of them.
• Ensure you attend all of your regular appointments with your midwife to identify any issues early.
• Rest as much as possible.
• Remember to always be aware of your baby’s movements and contact your midwife if your baby’s movements are less or changed from usual. 

The six major warning signs of pre-eclampsia

If you are past 20 weeks pregnancy and start having even one of these warning signs, contact your midwife as soon as possible – do not wait until the following day. She will arrange for you to be checked out.

1. Upper abdominal pain.
2. Headaches. 
3. Feeling unwell, nauseous or throwing up.
4. Blurry vision or seeing flashing lights.
5. Swollen hands and face (not the very normal mild ankle and finger swelling that most women get late in pregnancy).
6. Reduced baby movement or changes in your baby’s movement pattern.

If you are worried and can’t contact your midwife or doctor, you can contact the Women’s Assessment Unit (WAU) at Waikato Hospital, phone 07 839 8800.

Treatment for pre-eclampsia

Treatment will depend on the severity of your symptoms, but usually includes:

• frequent monitoring of your blood pressure, urine checks and blood tests
• frequent monitoring of the wellbeing of your baby
• rest, as this can help lower blood pressure (but won’t make it go away)
• medication may be given to help lower blood pressure.

If you have high blood pressure but don’t have protein in your urine, you’ll usually receive regular blood pressure and urine checks outside of hospital.

If you have developed pre-eclampsia you may be admitted to hospital for close monitoring and extra care from a specialist doctor to ensure everything goes as smoothly as possible. The aim is to keep your condition stable so that your baby can keep growing.

The only treatment for severe pre-eclampsia is the delivery of your baby. This may be necessary even if your baby is not full-term yet.

For more information about pre-eclampsia visit the NZ Action on Pre-eclampsia website.

Breech presentation means that from 36 weeks your baby is lying with its bottom or feet coming down first, instead of the usual head-first position.

About 3-4 per cent (three or four in every 100) of babies will remain in a breech position by the time your pregnancy reaches full term (after 37 weeks). Babies who remain in the breech position are at a higher risk of complications during birth, and many will be delivered by caesarean section.

If your baby is in a breech position at 36 weeks, it is recommended that your midwife sends a referral for consultation with a specialist obstetrician, where individual assessment and a discussion can take place with you, your midwife and the obstetrician about delivery options.

The obstetrician will talk to you about external cephalic version (ECV) which is a technique used to turn your baby head down. You will also have a discussion on how your baby will be born if your baby does not turn following ECV, or if you do not wish to have an ECV.

Why is your baby breech?

There are many reasons why your baby may be breech.

• Not enough fluid around your baby, making it harder for them to turn head down.
• Too much fluid around your baby, making it easy for them to turn around a lot.
• The placenta lying low in your uterus and getting in the way of your baby’s head.
• The shape of your pelvis or uterus encourages baby to sit in this position.
• Your baby may just adopt this position.

Important considerations for a breech birth

• Is your baby’s bottom or feet presenting? There are higher risks for vaginal birth for babies who are feet presenting.
• Is there a doctor or midwife available who is skilled in vaginal breech birth?

The doctor and your midwife will discuss with you the risks and benefits of either a vaginal birth or a planned caesarean section, dependent on your individual circumstances.

Information about ECV

The chance of successfully turning your baby with ECV is only around 50 per cent, but if successful it’s more likely your baby will be born by normal vaginal delivery, rather than a caesarean section.

An ECV is usually only considered after 36 weeks, because before that many breech babies turn around by themselves. All ECV procedures at Waikato Hospital are done by doctors who are experienced in ECV, or under their direct supervision.  Your doctor and midwife will discuss with you how the ECV is performed and the risks and benefits associated with an ECV.

Other issues related to babies in the breech position

Babies who lie in the breech position are at higher risk of development dysplasia of the hip (DDH). This is a condition where the hip joint does not form normally, causing the top of the thigh bone to slip out of the hip socket (dislocate) easily, regardless of the type of birth.

When your baby is born they will have an examination to check their hips. If this initial exam is abnormal, or there is uncertainty, your baby will be referred to the paediatric team for assessment. If DDH is diagnosed, they will receive treatment. 

If the initial examination at birth is normal an x-ray of your baby’s hips between 4-6 months is recommended, with a copy sent to your GP. If the x-ray is abnormal your GP will refer your baby to the paediatric team.

With early diagnosis and treatment, the majority of babies develop normally and have a full range of movement in their hips.

Obstetric cholestasis is a disorder that affects your liver during pregnancy, causing a build-up of bile salts in your body.

The main symptom is itching of the skin but there is no skin rash. The symptoms get better when your baby has been born.

Cholestasis is uncommon, with rates varying around the world from 1 in 1,000 (0.1 per cent) to 15 in 100 (15 per cent) of pregnant women. It is more common in women from some ethnicities, for example women from South America and India.

In New Zealand about 450 women a year might be expected to get this condition. If you’ve had it with one pregnancy, you’re more likely to get it again in another pregnancy.

What causes cholestasis?

The cause of obstetric cholestasis is not yet understood, but it is thought that hormones and genetic and environmental factors (for example diet) may be involved.  

Hormones such as oestrogens, levels of which are higher in pregnancy, may affect the way your liver works and cause obstetric cholestasis.

It also tends to run in families so if your mother or sister have had cholestasis, you might be more likely to get it too.

How is obstetric cholestasis diagnosed?

You may be diagnosed with obstetric cholestasis if you have unexplained itching in pregnancy with abnormal blood tests (liver function and bile salts tests) – both of which get better after your baby is born.

Cholestasis is a diagnosis that is made once other causes of itching and abnormal liver function have been ruled out.

What cholestasis means for your baby

The effects of obstetric cholestasis on your baby are still not clear.

There is an increased chance that your baby may pass meconium (move its bowels) before being born. This makes the amniotic fluid around your baby a green or brown colour, and may mean your baby needs help at birth.

There is also an increased chance of premature birth. One in 10 women with obstetric cholestasis will have their baby before 37 weeks of pregnancy (including women who have their labour induced).

Small research studies many years ago suggested that stillbirths may be more common among women with obstetric cholestasis and as a result labour was induced early. Recent research has shown that the risk of stillbirth is the same as in women without obstetric cholestasis (0.6 per 100). We do not know whether the reduction in stillbirth rate in women with obstetric cholestasis is because of a general improvement in pregnancy and newborn  care, a general improvement in women’s overall health, or early induction of labour.

What cholestasis means for you

Obstetric cholestasis can be a very uncomfortable condition, but it does not have any serious consequences for your health.

Itching

Itching can start any time during pregnancy, but usually begins after 28 weeks. Although it often starts on the palms of your hands and the soles of your feet, it may spread over your arms and legs and, less commonly, may occur on your face, back and breasts.

The itching can vary from mild to intense and persistent, and can be very distressing. The itching tends to be worse at night and can disturb sleep, often making you feel tired and exhausted during the day.

There is no rash, but some women scratch so intensely that their skin breaks and bleeds.

The itching gets better after birth and causes no long-term health problems.

Jaundice

A few women with obstetric cholestasis develop jaundice (yellowing of the skin owing to liver changes). Some women feel unwell and lose their appetite.

Jaundice can also cause dark urine and pale bowel movements.

Extra care for you and your baby

Once diagnosed with obstetric cholestasis, you will be under the care of an obstetric team and have your baby in a hospital with a neonatal unit.

Depending on your circumstances, you may be recommended to have extra antenatal checks. You are likely to have liver function blood tests, usually once or twice a week, until you have had your baby.

Additional monitoring of your baby may include monitoring your baby’s heart rate (cardiotocography or CTG), ultrasound scans for growth and measuring the amount of fluid around your baby.  

You might also have a scan of your liver, to rule out any problems causing the itch. When you are in labour, you will be offered continuous monitoring of your baby’s heart rate.

Your unborn baby is surrounded by a sac of amniotic fluid or ‘waters’. In most cases, this sac breaks during labour.

In two per cent (two in 100) pregnancies there is premature prelabour rupture of membranes (PPROM) – when your waters break before labour begins and more than three weeks before your due date.

You may notice a gush of fluid, a slow leak or a trickle from your vagina. Contact your midwife or doctor straight away if this happens.

What causes PPROM?

The cause of PPROM is unknown, however there is an increased risk of PPROM if:

• you smoke cigarettes
• you have had bleeding or an infection during pregnancy
• your waters broke before you went into labour in a previous pregnancy.

Contractions, too much amniotic fluid (known as polyhydramnios), or infections can also cause your membranes to weaken and break.

Treatment for PPROM

After PPROM you and your doctor will talk about whether it would be better for your baby to be born now or to continue growing inside you, depending on how far along in pregnancy you are.

After PPROM amniotic fluid will continue to leak from your vagina when you get up. Do not worry. Your baby will keep making amniotic fluid during the pregnancy.

If you have backache, pelvic pressure, abdominal pain, vaginal bleeding, or your baby is moving less often, you must tell your midwife or doctor immediately. Your baby may need to be delivered soon.

Less than 24 weeks

PPROM very early in pregnancy (less than 24 weeks) may be treated at home, with you returning to the hospital at around 24 weeks.

If your membranes have ruptured at less than 20 weeks, the outlook for your baby can be very poor. Some women, after counselling, choose not to continue the pregnancy and have a termination of pregnancy.

After 24 weeks

If your membranes break after 24 weeks and your due date is not close, you will probably need to be monitored at the hospital. Sometimes it may be possible to go home and have a check up 2-3 times a week at the hospital.

Treatment in hospital may include:

• monitoring of your baby’s heartbeat
• antibiotics to prevent infection
• steroid injections to help the baby’s lungs develop, and lessen the chance of breathing problems after birth.

Premature delivery

It is likely your baby will be delivered prematurely, and delivery within one week of PPROM is common. There is no way to tell how long the pregnancy will continue after your membranes break. If all goes well, your labour will be induced around 34-36 weeks.  

No matter when your due date is, if you or your baby show signs of infection or other problems, the baby will need to be delivered.

Unless there are other problems with your health or your baby’s health, you can deliver your baby vaginally. A caesarean delivery will be needed if the umbilical cord is born before the baby or may be needed if the baby is not in a head down position.

Potential complications

PPROM can lead to other problems such as premature labour, infections of the mother or baby (chorioamnionitis), kinking of the umbilical cord, delivery of the umbilical cord before the baby (prolapsed cord) and poor growth of the baby’s lungs.

The sac around your baby helps to protect the baby from bacteria that normally live in the vagina. When this sac breaks, these bacteria can cause an infection in the mother and/or baby. This is called chorioamnionitis.

If the baby’s lungs are too small (this is called pulmonary hyperplasia), it may be hard or impossible for the baby to breathe after birth. This problem is more likely when PPROM has occurred before 24 weeks.

After your baby is born

The biggest risk to your baby after PPROM is prematurity. Infection can also be a problem.

If there is a chance your baby will need specialised care after birth, the staff from the Newborn Intensive Care Unit (NICU) will be at your delivery to care for your baby if needed.

Your baby will probably need antibiotics and may need help breathing. How much special care your baby needs depends on many factors such as your baby’s gestational age, the length of time your membranes were ruptured and whether your baby has an infection.

If your baby is born at or near your due date and has no problems, you can expect the baby to go home with you. Many premature babies go home when they reach about 36 weeks. Some babies go home before or after this time.

During your pregnancy your midwife may refer you to see doctors at the Waikato Hospital Antenatal Clinic for a pre-existing health condition or complication that has occurred during your pregnancy. 

Depending on your health condition there are two types of referrals.

• Consultation referral – depending on the outcome of the consultation, either your midwife will receive advice and information from the hospital but continue making decisions with you about your care, or your care might be transferred to the hospital team.
• Transfer of care referral – when your midwife transfers your care to the hospital team, which takes on monitoring your pregnancy and making decisions with you about your care.

Consultation referrals

Consultation referrals take place at an outpatient clinic. You will be seen by an obstetrician, which is a doctor with specialist training and experience in complicated pregnancy care. 

Depending on your condition, the doctor may assess your health needs, discuss them with you and write to your midwife about your ongoing care requirements and plans.

• Your midwife will continue to make decisions with you about your care and birth plan and will consult with the hospital team as needed.
• You may return to the clinic for ongoing appointments, scans and other tests, but still be under the care of your midwife, who will remain your main point of contact.
• Your midwife will provide your care during labour and birth. If you birth at Waikato Hospital the hospital midwifery team may also provide support to your midwife.

Following a consultation referral, in some circumstances a discussion will be had with you about making the decision to transfer your care to the hospital team.

Transfer of care referrals

For some women with complex health needs or pregnancies, their care will be transferred directly to the hospital medical team. For example, women with type 1 diabetes. 

You will have an initial appointment with an obstetrician, which is a doctor with specialist training and experience in complicated pregnancy care.    

After your health needs have been assessed you will be monitored regularly by the antenatal clinic.

• If you have had a transfer of care the hospital medical team will become the main health professional making decisions with you about your care and birth plan. You should still contact your midwife for any urgent concerns during pregnancy.
• If your situation changes, or after your baby is born, your care can be transferred back to your midwife.
• Depending on your condition you may attend one of the hospital clinics or services frequently to monitor your pregnancy.
• Sometimes your care may be shared between the hospital and your midwife in the community.
• Your midwife will remain your main point of contact.
• Depending on your condition, the hospital midwives or your midwife (or a combination of both) will provide care during labour and birth, with the oversight of the medical team.

Women who have had a consultation at the Waikato Hospital Antenatal Clinic may need frequent monitoring by a midwife. This may be more than your own midwife in the community can provide.

If this is the case you may be asked to attend the Waikato Hospital Day Assessment Unit for follow up. You will be given an appointment to attend the clinic, which is open Monday – Friday, 8.30am – 2.30pm.

At the clinic you will be seen by a midwife who will review any tests and/or monitoring you need. Depending on your needs you may have your blood pressure taken, blood tests, urine tests or be on a monitor to listen to your baby’s heart rate and movements. If anything is not in the expected range she will discuss your ongoing care with a doctor and a new plan of care will be made.

You will continue to attend the clinic for as long as your doctor has requested and the frequency of your attendance will depend on your condition.

In most situations you will have another appointment with the doctors at a later date.