Common Antenatal Problems Flashcards
What are two common sources of chronic pain in pregnancy? Why does this pain occur?
Back and pelvis (PGP)
- During pregnancy the ligaments around the back and pelvis soften causing hyperflexibility and associated pain
What can you suggest to women with chronic backache in pregnancy?
What would warrant further investigation?
Support brace, firm mattress and flat shoes may help
You should do a full peripheral nerve examination - if there are any nerve symptoms then this should warrant further investigation
What manoeuvres exacerbate pelvic girdle pain?
How common is it?
How should it be managed?
Pushing on the pubic symphysis and pushing down on each pelvic brim (rocking pelvis from side to side)
- this can aid diagnosis
VERY COMMON (14-22%)
Usually manage with PCM - can suggest obstetric physiotherapist if severe and discuss C-section over vaginal birth
Other than backache and PGP what other MSK problems are more common during pregnancy?
Carpal tunnel syndrome
What is carpal tunnel syndrome?
Why is it more common in pregnancy?
The compression as it passes under the flexor retinaculum in the anterior part of the wrist
Oedema around the wrist / hands makes carpal tunnel more common during pregnancy
What management can be suggested for carpal tunnel syndrome during pregnancy?
Rest with elevation of the wrist can ease the oedema and thus compression
Hydrocortisone injections into the area or surgical decompression can be offered in extreme cases
What GI problems are common during pregnancy?
Constipation, Haemorrhoids and Reflux / Heartburn are really common
What often makes constipation worse during pregnancy?
Pregnant women are commonly anaemic and iron therapy makes constipation worse
What can be done to manage constipation during pregnancy?
DIETARY ADVICE important (increased fruit, veg and fibre)
Laxatives can be given but bowel stimulants such as senna should be avoided as they can stimulant uterine smooth muscle
Why do haemorrhoids occur during pregnancy?
The weight of the uterus bearing down reduced venous return from the superficial veins around the anus
How are haemorrhoids managed during pregnancy?
Consider local acting creams and always try and treat constipation - straining can increase the chance of haemorrhoids occurring
Why is reflux more likely during pregnancy?
What advice can you give for women with reflux?
Due to increased IAP and relaxation of smooth muscles due to progesterone during pregnancy
Advise avoiding large meals, spicy food, smoking and alcohol
Can advise to sleep in more upright position (lying down makes worse)
What medicines can be offered for reflux in pregnancy?
Magnesium and Aluminium based preparations tend to be the safest
There is also no known teratogenicity to ranitidine or H2 antagonists
PPIs are also quite widely used
What might be the cause of itching in pregnancy?
Depends if the itching is LOCALISED (usually to perineum) - cause is commonly candida infection, or pediculosis pubis)
OR GENERALISED
- Consider obstetric cholestasis, eczema, scabies or urticaria
Causes of itching + rash in pregnancy
Polymorphic eruption of pregnancy (most common)
Prurigo of pregnancy
Pruritic Folliculitis
Pemphigoid gestations
How does obstetric cholestasis present?
Intense itching - particularly bad on soles, palms and abdomen
Upon doing LFTs there is a raised bilirubin with an INTRAHEPATIC PATTERN in 90% but only 20% will have a clinically detectable jaundice
- remember ALP is produced by the placenta anyway so this will always be raised but other LFTS will be raised in OC
What are the risks associated with obstetric cholestasis?
Increased risk of premature birth
How should women with obstetric cholestasis be managed?
usually inducing delivery at 37w
URSODEOXYCHOLIC ACID
VITAMIN K SUPPLEMENTATION
How should leg cramps in pregnant women be managed?
Elevate the foot of bed 20cm
Salt supplements should NOT be used and neither should quinine but calcium appears to help some women
How common is nausea and vomiting in pregnancy?
What is the cause?
VERY COMMON - commonly starts around 6 weeks and should settle by week 12-14
DOES NOT just occur in the morning - can occur throughout the day
Appears to be related to rise and fall of B-hCG
What is excessive vomiting and sickness in pregnancy known as?
Hyperemesis Gravidarum
What are the defining diagnostic criteria for hyperemesis gravidarum?
DIAGNOSTIC TRIAD:
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
What biochemical abnormalities would you see in severe hyperemesis gravidarum?
Electrolyte abnormalities
Low levels of vitamin B
LFT derangement (low albumin and transaminases)
What is the management of hyperemesis gravidarum?
Admission is likely but management is just rehydration (IV fluids)
Can consider anti-emetics but none are licensed during pregnancy
Which anti-emetics are considered safe to use during pregnancy?
NONE ARE LICENSED but most widely used:
- Metoclopramide (10mg TDS)
- Cyclizine (50mg TDS)
- Prochlorperazine (5-10mg BD/TDS)
What happens to vaginal discharge during pregnancy?
Physiological discharge becomes heavier during pregnancy but ALWAYS EXAMINE
Discharge change due to what cause is common during pregnancy?
What are the symptoms?
CANDIDA INFECTION is common during pregnancy (thick, white, creamy discharge) + Itching
- ALWAYS TAKE SWABS
When are women usually able to feel fatal movements?
What will the usual pattern of fetal movements be?
18-20 weeks (possibly earlier in multiparous women)
- Fetal movements will usually increase in strength and frequency up to 32 weeks and at this point they will plateau
- THEY SHOULD NOT DECREASE - the baby should be moving up to the point where it is delivered
What are some caused of reduced fetal movements?
Lack of attention - women might be busy and not register them, encourage them to lie down and be quiet and see if they feel them
- FETAL DEATH
- DRUGS (alcohol, benzodiazepines, methadone)
- FETAL GROWTH RESTRICTION
- SMALL FOR GESTATIONAL AGE
- PLACENTAL INSUFFICIENCY e.g. due to smoking or pre-eclampsia
What are some causes of fetal growth restriction?
can be divided into MATERNAL causes and PLACENTAL FACTORS:
- MATERNAL = Extreme starvation, hypoxia e.g. due to smoking or cardiac disease (compensation via placental hypertrophy will often be seen)
- PLACENTAL = poor trophoblastic invasion
What does it mean if the baby is small for gestation age?
Below the 10th decile for size
What should be done in the first instance if the woman presents with RFM?
DOPPLER - auscultate fetal heart beat / CTG
If not found then arrange for urgent USS
What is PPROM?
Pre-term, Pre-Labour, Rupture of Membranes
How common is PPROM?
Occurs in 2-3% of all pregnancies but occurs in 20-50% of all cases of spontaneous pre-term deliveries
What makes PPROM more common?
Polyhydramnios, twins, vaginal infection
Once PPROM has occurred how likely is the mother to go into spontaneous labour?
75% of those at 28 weeks gestation will deliver within the next 7 days
Of those that don’t go into labour what is the conundrum of management?
The longer the baby stays inside the more developed it will be and the more likely it is to survive after birth
HOWEVER
The longer it stays in the more likely the mother is to contract CHORIOAMNIONITIS - high risk of maternal death and sepsis to mother and baby
What are the risks with PPROM?
Chorioamnionitis
Pulmonary hypoplasia (lungs not developed meaning baby unlikely to survive)
Severe skeletal abnormalities
How should we examine/ivestigate a women with PPROM?
Must only be done if there is strong chance of labour - increases risk of infection and must be done with a sterile speculum
FBC, CRP, Urine analysis
What clinical signs would make us suspect chorioamnionitis?
High maternal temperature Vaginal discharge Abdominal pain Raised WCC Uterine tenderness
How do we manage PPROM?
Regular fetal monitoring for those who do not establish labour
- if woman is discharged home she must take her temperature 4 times a day and if she notices any spikes then she MUST COME BACK
PROPHYLACTIC ERYTHROMYCIN improves fetal outcomes 250mg QDS PO 10/7
MATERNAL CORTICOSTEROIDS given to improve festal lung maturity
DELIVERY AROUND 34-36 weeks seems to suit the compromise
What steroids are given for fetal lung maturation and how?
DEXAMETHASONE
4X6mg doses IM 12hr apart
BECLAMETASONE (only from 34+0 - 36+7w - consultant decision)
2x 12mg IM injections 24h apart
What are some common causes of bleeding during pregnancy?
CERVICAL ECTROPION - very common cause when the cervical neck everts into the vagina INFECTION (UTI) PLACENTAL PRAEVIA PLACENTAL ABRUPTION MISCARRIAGE CERVICAL TENDERNESS VAGINAL SOURCES
What kinds of things are important to ask about during the history for APH?
How much blood is there (how many pads?)
Is it fresh red blood or dark brown blood/
Are there clots and if so how many?
Is there any associated pain and if so when, where and what is it like?
Is the baby moving normally?
Is there any other symptoms (nausea, faintness, breathlessness, discharge, dysuria or pain passing stool)
Is she up to date with her scans and have they all been normal?
How should you investigate APH?
Always do a speculum to try and identify the source of bleeding. Auscultate fetal heart beat / CTG and arrange an USS if any cause for concern
If you suspect praevia then do not do digital exam
BLOODS: Rhesus
What is placenta praevia?
When there is a low lying placenta (either over or near to the cervical os)
How is placenta praevia found?
Usually found incidentally on routine antenatal scanning
- PAINLESS BLEEDING is a common symptom but this usually comes later
How should women with placenta praevia be managed and what advice should be given?
Sexual intercourse might increase risk of bleeding and so sometimes abstinence advice is given but there is poor evidence base for this
INCREASE IN NUMBER OF SCANS: 20, 32 and 36w - if at 36w placenta is still overlying or consultant decision is that woman can’t deliver vaginally then she will be booked for CS at 38-39 weeks
Consider single dose of corticosteroids if between 24-34w as prom delivery is more common
What is placental abruption?
This is when the placenta detaches from the uterine wall causing bleeding, pain and fetal distress
In 20% cases the bleeding is contained
What are the symptoms of placental abruption?
RFx?
Vaginal bleeding
Continuous abdominal pain
OBSTETRIC EMERGENCY (depending on degree of bleeding)
The amount of PV bleeding might not represent how much bleeding is going on within - blood trapped retroplacentally
Hard to palpate fetal HR
Previous abruption and smoking are key RFx
Management of placental abruption
Urgent delivery is required because hypovolaemic shock can occur if the problem is not solved soon - fetal death due to placental insufficiency
What are some RF for placenta praevia?
Prev CS Previous TOP Multiparity Advanced maternal age >40 Smoking Multiple pregnancy
