Common Antenatal Problems (inc PROM/hyperemisis) 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 on median nerva 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?
- Increased abdominal pressure
- Progesterone relaxes smooth muscles
Advice
- 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?
- 1st line: Magnesium and Aluminium antiacids safest
- 2nd line: Ranitidine (H2) or omeprazole (not lansoprazol)
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
- LFTS (increased ALT/bile/GGT)
- remember ALP is always raised (placenta)
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 causes hyperemesis gravidarum?
What are the defining diagnostic triad for hyperemesis gravidarum?
Other symptoms?
Hyperemesis gravidarum is caused by beta-hcg
DIAGNOSTIC TRIAD:
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
Others: muscle wasting/ptyalism (cant swallow saliva)
What blood tests would you do hyperemesis gravidarum (and what may you see)?
Other investigations?
Bloods
FBC (increased heamatocrit-increased RBC ratio due to dehydration)
Us and Es
-Electrolyte abnormalities (reduced K+ and Na+ as vomited it all up)
LFTs
-LFT derangement (low albumin and transaminases)
B vitamines
-Low levels of vitamin B1 (thiamine)
Urinalysis-check for ketones and exclude UTI
USS-to rule out multiple pregnancies and molar pregnancies (more b-hcg=higher risk of HG)
When would you admit a patient with hyperemesis gravidarum?
What is the management?
Hyperemesis gravidarum
-Admit if ketones+ or not tolerating oral intake (fluids/antiemetics)
Managment
- IV fluids
- antiemetics (1st line: cylazine/2nd line metoclopramide)
- electrolyte replacement (K+) if required
- NBM for 24 hours then introduce light diet
- Daily UsEs
- Give thiamine
- if antiemetics dont work can give steroids
*avoid glucose in fluids as can precipitate wernikes
Which anti-emetics are considered safe to use during pregnancy?
NONE ARE LICENSED but most widely used:
- PROMETHAZINE or CYCLIZINE 1st line (Histamine H1)
- Metoclopramide or Prochlorperazine 2nd line
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?
Reduced fetal movements
1st line: DOPPLER - auscultate fetal heart beat
2nd line: CTG
What is PPROM?
What is os like?
What weeks?
Pre-term, Pre-Labour, Rupture of Membranes (os is closed)
weeks 24-37 weeks
What are the causes of PPROM
‘castle analogy’
Too many people inside
-multiple pregnancies
-polyhydraminos
Have to escape for survival
-pre eclampsia/IUGR/abruption
Something bad has got in
-STI/chorioamnionitis/neonatal sepsis/UTI
Poorly designed castle walls
-fibroids/congenital problems
Weak castle door
-cervical incompetence
PPROM vs PROM?
PPROM has no labour
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? (what would you see)
Must only be done if there is strong chance of labour - increases risk of infection and must be done with a sterile speculum> pooling of fluid in posterior fornex
FBC, CRP, Urine analysis
What clinical signs would make us suspect chorioamnionitis?
What is the treatment?
High maternal temperature Vaginal discharge Abdominal pain Raised WCC Uterine tenderness
Treatment: prompt DELIVERY and maternal IV AB
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
- 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?
Steroids given 24-34 weeks
BECLAMETASONE
2x 12mg IM injections 24h apart
(can give magnesium sulfate-needs to be 12 hours before birth)
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 are complications of hyperemesis gravidarum?
Hyperemesis gravidarum
Maternal complications
- Thiamine (B1) defficiency>Wernikes
- Hyponatreamia and rapid reversal of hyponatreamia (causing central pontine myelinosis)
- Liver and renal failure in severe cases
Fetal complications
- IUGR
- Fetal death due to wernikes
What would you prescribe for UTI in pregnancy?
UTI in pregnancy
-1st line: Nitrofurantoin (avoid at term and egfr <45)
-2nd line: Amoxicillin (if sensitive) or cefalexin
Sudden onset itching with no lesions visible-what is it?
Intra hepatic cholestasis of pregnancy
-jaundice (hands and feet) abnormal LFTs
What is the prophylaxis for Antiphospholipid syndrome in pregnancy?
Antiphospholipid syndrome in pregnancy:
- aspirin ASAP
- LMWH (when you know theres a fetal heartbeat)
