Maternal Disease and Complications –Summary Outline

ProSono Copyright 2006 

Maternal Disease and Complications –Summary Outline 

Maternal Diabetes: Sonography plays an important role in the management of 

a pregnant patient with diabetes. Because of the 3 - 5% rate of fetal mortality 

and the 6 - 12% chance of a major fetal anomaly, careful prenatal monitoring 

and management is indicated to reduce these risks. 

Definition: Diabetes Mellitus (DM) is a spectrum of disorders involving 

carbohydrate, lipid and protein metabolism that is due to an absolute or 

relative lack of insulin. DM may occur spontaneously (90%) or may be 

secondary to pancreatic disease, hormonal imbalances or drug reactions. 

There are two general classifications of spontaneous DM: 

Type I insulin dependent (juvenile onset) 

Type II non-insulin dependent (adult onset, occasionally with insulin 

dependence 

Poorly managed DM or DM which predates the pregnancy is the type of 

diabetes most frequently associated with fetal anatomic anomalies. 

Gestational Diabetes: Hormonal and metabolic changes associated with 

pregnancy can result in a condition referred to as glucose intolerance of 

pregnancy. While the term gestational diabetes is frequently used to 

describe this condition, it does not fit the pathological picture of true diabetes. 

In pregnancy, gestational diabetes is most frequently associated with 

macrosomia. 

Classification: When diabetes and pregnancy coexist, a classification 

system may be employed to help predict the outcome of the pregnancy and 

assist in appropriate medical management. Classification is based on the 

results of a glucose tolerance test, age at onset of diabetes and the presence 

of specific maternal pathologic conditions. Perinatal mortality increases as 

the classification worsens. 

Fetal Complications: Pregnancy in diabetic patients can be complicated by 

a wide variety of problems. The incidence of congenital anomalies is 

increased and may include: 

Caudal regression 

Inguinal hernias 

Neural tube defects 

Clubfoot (talipes) 

Cardiac anomalies 

Maternal Disease and Complications (8)


Single umbilical artery 

Renal anomalies 

Polydactyly 

Gastrointestinal anomalies 

Skeletal anomalies 

Diabetes also has a significant impact on birth weight of the infant. In 

addition to anatomic abnormalities, other fetal complications associated 

with diabetes include: 

Respiratory distress syndrome 

Hypoglycemia (20 - 60%) 

IUGR (with maternal DM pre-dating the pregnancy) 

Macrosomia (with gestational diabetes) 

Hypocalcemia 

Maternal Complications: In addition to fetal complications, associated 

maternal complications of diabetes include: 

Polyhydramnios (31%) 

Preeclampsia (6 - 25%) 

Renal dysfunction (2 - 12%) 

Hypoglycemia 

Peripheral vascular disease 

Increased risk of infection 

Postpartum hemorrhage 

Sonographic Findings: 

Fetal Anatomy 

Presence of an associated anatomic abnormality 

Single umbilical artery 

Oligo or polyhydramnios depending on type of fetal anomaly present 

Placental Changes 

Thickened placenta 

Premature aging 

Growth Related Changes 

IUGR (see section on intrauterine growth restriction) 

Macrosomia (more common in Classes A - C). Defined as: 

Fetal weight > 4,000 grams or 

Birth weight > 90th percentile for gestational age 

Associated with: 

Hydrops fetalis 

Polyhydramnios 

Stillbirth 

Birth trauma 



Hypertensive Disorders: Maternal and fetal complications may result if high 

blood pressure remains uncontrolled during pregnancy. 

Definition: Hypertension is diagnosed when one of the following criteria is 

met: 

Systolic pressure > 140 mmHG 

Increase in systolic pressure of > 30 mmHg (over the pre-pregnant 

state) 

Diastolic pressure > 90 mmHG 

Diastolic pressure increase > 15 mmHG (over the pre-pregnant state) 

Careful monitoring of the blood pressure during pregnancy is important in 

preventing the onset of preeclampsia/eclampsia. Classifications: 

Essential hypertension: the condition exists prior to pregnancy 

P I H D: pregnancy induced hypertensive disorder 

Toxemia: A disorder of pregnancy characterized by proteinuria, hypertension 

and neurological symptoms. Traditionally referred to as "toxemia of 

pregnancy", it is more accurately defined as GEPH - Gestational Edema 

Proteinuria Hypertensive syndrome. It most commonly occurs in 

primigravidas and is more common with multiple gestations. Diagnosis and 

treatment of preeclampsia is necessary to prevent progression into life 

threatening eclampsia. 

Preeclampsia 

Hypertension 

Generalized edema 

Proteinuria 

Eclampsia: In addition to HTN, edema and proteinuria found in 

preeclampsia: 

Coma 

Seizures 

Conditions associated with increased incidence of GEPH include: 

Primigravida 

Multiple gestations 

Vascular disease 


Hydatidiform mole 

Severe undernutrition 

Family history 



Pathology: A broad spectrum of pathologic entities is associated with 

pregnancy induced hypertensive disorder including: 

Abnormal vasospasm leading to hypoxia and/or necrosis 

Premature placental aging 

Renal cellular damage 

Disseminated intravascular coagulopathy (DIC) 

Periportal hemorrhagic necrosis (liver) 

Cerebral edema 

Pulmonary edema 

Clinical Findings: 

Hypertension 

Sudden, excessive weight gain (> 5lb/1week) 

Ankle swelling 

Generalized edema 

Headaches 

Abdominal pain, vomiting 


IUGR 

Oligohydramnios 

Decreased placental volume 

Accelerated placental aging 

Fetal demise 

Sonography is used to monitor the pregnancy and track fetal growth 

Maternal Infections: Any severe, systemic maternal infection may cause 

spontaneous abortion, fetal death and premature labor and delivery. Growth 

restriction may result from chronic infections. Fetal abnormalities can be caused 

by several acute infections. The most common significant in utero infections are 

the TORCH infections: 

Toxoplasmosis 

Other (syphilis, etc.) 

Rubella 

Cytomegalovirus 

Herpes 

Toxoplasmosis: Caused by a protozoa, T. gondii, which is commonly 

found in cat feces and uncooked meat. Maternal infection, which 

crosses the placental barrier and results in fetal infection, may cause: 

CNS calcifications 

Microphthalmia 

IUGR 

Chorio-retinitis 



Microcephaly 

Thrombocytopenia 

Hydrocephaly 

Jaundice 

Thick placenta 

Rubella: Also known as German measles. Extremely teratogenic for 

the fetus. Exposure during the first 5 weeks is most dangerous. 

Defects include: 

Cataracts 

Congenital heart disease 

Deafness 

Mental retardation 

Cytomegalovirus: Most common infection in pregnancy. Thought to 

cause embryonic demise if exposed in the first trimester. May cause: 

Spontaneous abortion 

IUGR 

Fetal ascites 

Fetal death 

Cranial anomalies 

Chest anomalies 

Herpes: The virus is usually transmitted to the fetus during vaginal 

delivery. Cesarean section is frequently performed in women with 

known disease. Infection may cause: 

CNS, eye and visceral infection 

May be asymptomatic 

Generalized multiple organ involvement 

Fetal death 

Parvovirus: A common respiratory viral infection. If there are 

maternal infections during pregnancy, the virus can cross the placental 

barrier and affect the fetus causing: 

Pancytopenia 

Possible development of hydrops, necessitating PUBS/ fetal 

transfusion 

 

Sonographic Findings: Careful examination of the fetal anatomy should be 

performed in any patient presenting with a history of infection during 

pregnancy. Knowledge of the specific defects associated with a particular 

infection is necessary so that attention is focused on the proper organ 

systems. 



Other Maternal Complications 

Incompetent Cervix: also known as painless premature dilatation of the cervix, 

it is the inability of the cervix to prevent the premature expulsion of the uterine 

contents. May be acquired or congenital and is most frequently related to 

cervical trauma. Surgical repair of cervical tears following previous vaginal 

deliveries may be one cause. Habitual abortion in the 2 nd trimester may be the 

only clinical feature. 


Cervical length < 3 cm before 34 weeks 

Cervical width > 2 cm in second trimester - MOST RELIABLE 

Firm diagnosis cannot always be made using sonography 

Diagnosis based on history and clinical findings 

Bulging membranes 

Bladder distention may cause false negative 

Pre-term Labor: Onset of labor before 37 weeks. Etiologies include: 

Previous uterine surgery 

Uterine anomalies 

Maternal stress 

Heavy cigarette smoking 

Multiple gestations 


Antepartum bleeding (from previa, abruption) 

Systemic infections, i.e. appendicitis with sepsis 

Idiopathic 

Premature Rupture of Membranes (PROM): the spontaneous rupture of the 

membranes prior to the on set of labor. If rupture occurs prior to 26 weeks, fetal 

demise is imminent. 

Clinical Signs: passage of a large amount of watery fluid from vagina 



Anemias: The need for increased perfusion to the highly vascularized placenta 

and to the increase in maternal breast mass results in a 40% increase in blood 

volume. Because increased plasma volume accounts for much of this increase, 

hemoglobin (Hb) and hematocrit (Hct) values are normally lower in pregnancy 

than in the non-pregnant state. 

Clinical Signs: 

Hb < 10 g/100 ml 

Hct < 30% 

Types: 

Iron deficiency (95%) 

Folic acid deficiency 



Aplastic anemia 

Drug induced hemolytic anemia 

Uterine Rupture: Rupture of the uterus is a potential obstetric catastrophe 

and a major cause of maternal death. A complete rupture extends across the 

entire thickness of the uterine wall and usually occurs during labor. 

Complications include: 

Hemorrhage 

Shock 

Postoperative infection 

Death of mother and/or child 

Ureteral damage 

Amniotic fluid embolism 

Disseminated intravascular coagulopathy 

Clinical Signs: Reliable signs for impending uterine rupture do not exist. 

Non-specific findings may include: 

Localized pain in uterus 

Small amount of vaginal bleeding 



Large amount of peritoneal fluid 

Coexisting Masses 

Fibroids: also known as leiomyomas, they may increase in size during the 

second and third trimesters due to the effects of hormones, degenerative 

changes or hemorrhage. During delivery, myomas may be responsible for 

decreased intensity of uterine contractions, may cause fetal malpresentation 

and may obstruct delivery. In some cases, cesarean section is indicated.\ 


Fundal height greater than expected for gestational age 

Palpable mass on anterior or lateral uterine wall 

Focal tenderness if degeneration has occurred 


Hypoechoic uterine mass distorting the contours 

Sonolucent center in degenerated masses 

Position of myoma relative to cervix should be ascertained 

Size and location of each myoma should be documented 

May be confused with myometrial contraction 



Ovarian Cysts: Ovarian cystic masses are frequently found in pregnancy. 

Regardless of the type of cysts, if it is large enough it may cause dystocia. 

Two types of cysts are associated with the pregnancy itself: 

Corpus Luteum Cysts produce progesterone and usually regresses 

by 12 to 15 weeks. They may persist and may encourage torsion of 

the ovary. 

Theca Lutein Cysts: occur with gestational trophoblastic disease and 

are usually bilateral. They are frequently large, multiseptated masses. 


Pain, tenderness in the adnexa 

High levels of maternal serum Hcg 

Palpable adnexal mass on pelvic exam 


Presence of cystic mass in adnexa 

May be simple, septated or complex 

Location and size should be documented 

Uterine and cervical contour should be examined for possible distortion 

Masses: Solid masses found in the pelvis during pregnancy may also cause 

dystocia and pain. Common pathologic types of solid masses are usually 

related to the ovary and include dermoids and endometriomas. Anatomical 

variations and abnormalities can also present as coexisting pelvic masses. 

Some causes include: 

Pelvic kidney 

Wandering (ectopic) spleen 

Non-gravid horn of a bicornuate uterus 

Fecal filled colon 

Dilated ureter 


Presence of a solid mass adjacent to the gravid uterus 


Determine nature of mass i.e., ovarian vs. anatomic variant 

Document size and number of masses 

Uterine and cervical contour should be examined for possible distortion 

Sonography can be used to follow masses and detect change in size

Maternal Disease and Complications –Summary Outline

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