Common Discomforts of Pregnancy Flashcards
1
Q
VARICOSITIES
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- Progesterone relaxes vessel walls and valves
- Gravid uterus → pressure on pelvic vessels → vein engorgement
- Vulvar varicosities usually disappear by 4 weeks postpartum (leg ones usually dont go away but might get a little better)
Associated symptoms
- Legs
- pain, night cramps, numbness/tingling in affected area
- Vulva
- Vulvovaginal swelling, sensation of heaviness, pressure, and pain with prolonged standing.
- Pruritis, dysparunia, discomfort while walking
Trimester
- Vulvar: after 24 weeks
Risk factors
- Increased age
- Family hx of varicose veins
- Obesity
- Prolonged standing
- Existing leg trauma
- Multigravida (for vulvar)
Differential Dx
- DVT
- Arterial or venous disease
Associated complications
- Worsening of preexisting varicose veins on leg and vulva
- Constant itching
- Pigmentation or ulcers around ankles
- Mild swelling of feet
- Infection of vein
- Thrombosis/bleeding of vulvar varicosities rare
Relief Measures
- Preventative measure: exercise
- Elevate legs as often as possible
- Lie on left with legs elevated
- Avoid prolonged standing
- Dont cross legs
- Gain appropriate amount of weight for BMI
- Compression stockings with pressure gradient for legs or bike shorts for vulva
2
Q
BACKACHE
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiology
- Progesterone/relaxin soften ligaments and joints, center of gravity change
- Upper back: increased breast size, postural, prolonged sitting
- Lower back: lumbar lordosis counteracts growing uterus
Associated Symptoms
- Worsens over pregnancy (esp 3rd)
Risk Factors
- Older age
- Higher parity
- Occupations with heavy lifting/standing
Relief Measures
- Pelvic floor (kegels) and pelvic tilt exercises
- Swimming
- Chiropractic
- Acetaminophen
3
Q
BREAST TENDERNESS AND TINGLING
- Physiologic Basis
- Trimester
- Risk factors
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Increased estrogen and progesterone stimulates milk ducts to develop
- Increased blood flow
Trimester
- Begins 4-6 weeks until mid 2nd trimester
Risk Factors
- Primigravidas
Differential Dx
- Mastitis, fibrocystic breasts, benign breast mass, breast cancer
- Normal pregnancy should affect both sides
- Warning signs: dimpling, puckering, peeling, retraction, suspicious mass in breast/axilla
Relief Measures
- Adequate breast support, no underwire. Cotton.
- Cool cloth
- Avoid stimulation during sex
- Pat dry, don’t rub
- Bra at night
4
Q
CARPAL TUNNEL SYNDROME
(Tingling and numbness of fingers)
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Assessment
- Associated complications
- Relief Measures
A
Physiologic Basis
- Increased fluid volume → compression of median nerve
Associated symptoms
- Numbness/tingling in thumb, index finger, and middle fingers
- Wrist pain
- Loss of grip strength and dexterity
- More pronounced after a period of rest or repetative hand movements or sleeping in flexed position
Trimester
- Typically 3rd
Risk factors
- Primigravida
- Older age
- Preeclampsia
- Excessive weight gain
- Edema
Assessment
- Examiner applies direct pressure over median nerve at the carpal tunnel for 30 seconds ⇒ paresthesias
- Flex wrist downward while holding elbow straight ⇒ paresthesias within 60 seconds
Associated complications
- Symptoms can persist post partum after 1 year in 50%
Relief Measures
- Hand splint in neutral position at night or during day prn
- Avoid extreme flextion or extension of wrist
- Decrease vibrating tools (ie lawnmower)
- Decrease repetative wrist/hand motions
- Masagge and gentle finger/wrist stretches
- Acetominophen 325-650 mg po q4-6 hours. Max 3000 mg/day
5
Q
CONSTIPATION
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Progesterone → slows peristalsis
- Altered fluid reabsorption
- Gravid uterus displaces intenstines
Associated symptoms
- Hemorrhoids and anal fissures
- Abdonimal pain, nausea, poor appetite
Trimester
- Common early in pregnancy
Risk factors
- Iron supplementation
- History of constipation
- Low fiber intake
- Low physical activity level
Differential Dx
- Opioid use, other GI diseases (i.e. IBS), preterm labor
- Warning signs: severe abdominal pain, fever, weight loss
Relief Measures
- Increase fluid ( 8 - 12 cups liquid)
- Increase fiber (25 - 30 g of dietary fiber)
- Exercise routinely
- Decrease (q3days) /change (plant based fiber like Floradix)/stop iron supplements
- Defacate after meals
- Avoid valsalva (hemorrhoid prevention)
- Bulking agents (2-3 days to see effect)
- 2-4 tbs bran or psyllium
- Osmotic and stimulant laxitives (2nd line)
- Fleet enema
6
Q
DIZZINESS
- Physiologic Basis
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- Increased vascular resistance, vasodilation and venous pooling in legs → decreased C.O. → decreased BP → decreased cerebral blood flow
Risk factors
- Standing long periods
- Standing up too fast
Differential Dx
- Hypoglycemia
- Heart disease
- Warning signs: chest pain, significant SOB, syncope
Relief Measures
- Get up slowly
- Avoid extended standing and sitting
- Walk in place when standing is unavoidable
- Eat small meals/snacks every few hours
- Hydration
- Consider compression stockings if in a standing profession
- Avoid overheating and closed-in areas with limited ventillation
7
Q
PEDAL EDEMA
- Physiologic Basis
- Trimester
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Increase in body fluid in extracellular space
- Uterus interferes with venous return in lower extremities
Trimester
- Later in pregnancy
Differential Dx
- Preeclampsia
- Warning signs: rapid onset edema, blurry vision, hypertension, proteinuria
Relief Measures
- Water immersion for at least 20 min
- Exercise like walking/swimming
- Apply compression stockings 1st thing in AM
- Avoid constrictive clothing
- Elevate legs periodically during day
- Hydration
- Avoid salted foods
8
Q
FATIGUE
- Physiologic Basis
- Trimester
- Risk factors
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Progesterone
Trimester
- 1st especially (5-7 weeks), usually relief by around 12 weeks
- Can return during 3rd
Differential Dx
- Anemia (weakness, SOB, dizziness, HA, cold hands/feet, pale skin)
- Depression (decreased energy, motivation, excessive sleeping, irritability, inability to concentrate/decisions, sadness/apathy)
- Thyroid dysfunction
- Sleep apnea
- Virus
Relief Measures
- Reassurance
- Encourage rest (daytime nap if possible, get enough sleep)
- 30 min exercise
- Delegate household chores
- Adequate protein and iron intake
- Eat every few hours
9
Q
FLATULENCE
- Physiologic Basis
- Trimester
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- Progesterone → slowed GI transit time → more gas formation in gut
- Expanding uterus in 3rd trimester → more pressure on intestines and rectum → decreased muscle control
Trimester
- Any
Differential Dx
- Dietary sensitivities/food intolerance
- Celiac, IBS, other bowel disease
- Warning signs: pain not relieved with passing gas, worsening pain, along with other warning sign like fever, change in stool color (ie black tarry), diarrhea, rectal bleeding should be evaluated ASAP
Relief Measures
- Avoid gas producing foods
- May have added fiber too fast or without enough hydration…back off and restart more slowly
- Eat 6 smaller meals to avoid overload
- Avoid artificial sweeteners
- Food diary
- Eat slow and no straws (decrease air swallowing)
- Cook vegetables (raw harder to digest)
- Probiotic
- Fresh ginger, carrot, apple and celery juice may calm GI tract
- Massage abdomen clockwise
- Side lying position, knee chest position, elevating hips above head (hot air rises)
- Brisk walk to mobilize gas
- Yoga
- OTC gas relieve like simethicone
10
Q
HEADACHE
- Physiologic Basis
- Risk factors
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Muscle tension
Risk factors
- Abruptly eliminating caffiene
- Migraines usually less frequent/severe
Differential Dx
- Sinus congestion
- Allergies
- Low blood sugar
- Dehydration
- Warning signs: new onset HA with neuro signs, severe HA doesnt respond to comfort measures or analgesics, sudden severe onset, or if accompanied by increased BP, proteinuria, or papilledema
Relief Measures
- Acetaminophen 325-650mg q 4-6 hours prn up to 3000 g daily
- Massage head, neck, back
- Acupuncture
- Warm compress at base of head, neck, forehead
- Relaxation exercises
- Increased rest
- Regular exercise (ie walking)
- Avoid triggers (food, environmental)
11
Q
HEARTBURN
- Physiologic Basis
- Trimester
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- Increased estrogen and progesterone → LES relaxation → acid reflux
- Growing uterus crowds stomach and increases pressure
Trimester
- Increases as pregnancy goes on
Risk factors
- Greasy, fatty foods, caffinated drinks, onion, garlic, spicy food, certain meds, overfilling stomach, eating too fast, lying down after eating
Differential Dx
- Warning signs: heart burn that returns as soon as the antacid wears off, heartburn that disrupts sleep, difficulty swallowing, weight loss, spitting up blood, black stools
- Hiatal hernia, peptic ulcer disease, cholecystitis, pancreatitis
- Chest pain ⇒ rule out cardiac: PE, asthma
- Epigastric pain ⇒ rule out preeclampsia
Associated complications
- Serious complications uncommon
Relief Measures
- Lifestyle/diet modifications:
- Smaller meals
- Avoid: spicy/fatty food, caffeine, large meals, lots of fluids with meals
- Use low fat or skim milk
- Dont lie down after meals
- Antacids with magnesium hydroxide or trisilicate (Maalox, Mylanta)
- Avoid Alka-seltzer
- Dont take with iron or PNV with iron
- H2 receptor antagonists (ranitidine)
12
Q
HEMORRHOIDS
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- Decreased venous return
- Pressure of growing uterus
- Decreased GI motility due to progesterone
- Increased valsalva during defecation
Associated symptoms
- Itching, burning, bleeding with passage of stool
Trimester
- Common in 3rd
Risk factors
- Constipation
Differential Dx
- Warning signs: severe or worsening pain (could be thrombosed hemorrhoid), abdominal pain, changes in stool color, diarrhea, rectal bleeding
Associated complications
- Can progress to thrombosis, secondary infection, ulceration, abscess, and fecal incontinence
Relief Measures
- Constipation treatment
- Avoid prolonged toilet sitting
- Practice proper anal cleansing
- OTC pain relief after BM (ie preparation H)
- Topical hydrocortisone
- Kegel exercises to promote pelvic floor blood flow/tone
13
Q
LEUKORRHEA
- Physiologic Basis
- Associated symptoms
- Trimester
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Increase in pelvic blood flow
- Estrogen ⇒ conversion of glycogen to lactic acid by lactobacilli
Associated symptoms
- Clear to white, thin/watery to viscous, nonirritating, mild non-offensive odor
Trimester
- Can start in 1st, typically presents in 2nd
Differential Dx
- Rule out STIs
- Warning signs: itching, foul odor, pain
Relief Measures
- Reassurance
- Avoid douching and OTC treatment
- Wear absorbent cotton underwear and change several times a day
- Daily perineal hygeine
- Nonscented panty liners prn
14
Q
LEG CRAMPS
- Physiologic Basis
- Associated symptoms
- Trimester
- Differential Dx
- Relief Measures
A
Physiologic Basis
- Unknown. Possibly build up of lactic/pyruvic acid due to impaired blood flow
Associated symptoms
- Often at night or after period of inactivity
Trimester
- More common 2nd and 3rd
Differential Dx
- Restless leg
- Musculoskeletal disorders
- Endocrine or renal disorders
- DVT
Relief Measures
- Reassure
- Stand up and stretch affected leg, dorsiflex foot. ***Both during cramp and at night before bed
- Exercise
- Hydration
- Avoid sitting or standing for long periods
- Warm bath before bed
15
Q
NAUSEA/VOMITING
- Physiologic Basis
- Associated symptoms
- Trimester
- Risk factors
- Differential Dx
- Associated complications
- Relief Measures
A
Physiologic Basis
- hCG and estrogen
- Progesterone slows GI
- H. pylori implicated in worsening
Associated symptoms
- Lower rates of miscarriage, preterm birth, low birth weight, congential anomaly, and stillbirth
- Use Pregnancy Unite Quantification of Emesis and Nausea (PUQE) scoring system) to assess severity
- <6 = mild, 7-12 = moderate, >13 = severe
Trimester
- Typical onset 6 weeks, peaks 9-10 weeks, subsides by 12-14 weeks
- Absent by 20 weeks for most women
Risk factors
- Family history of NVP
Differential Dx
- Hyperemesis (1-2% of people) - persistant N/V, can’t keep anything down, weight loss, ketonuria, dehydration
- Hydatidaform mole
- Thyroid disease
- Other GI disorders: GERD, PUD, cholecystitis, gastroenteritis
Associated complications
- Significant dehydration and poor nutrition
Relief Measures
- Non-pharm
- Small frequent meals, sip clear carbonated or sour liquids, small amounts of liquids throughout day
- Avoid: fatty, spicy, strong-smelling food, PNVs (switch to just folic acid)
- Eat: more protein, bland foods, whatever appeals, before bed and before getting out of bed. Suck on candy
- Brush teeth between meals, not right after
- Ginger 1 g (250mg qid), various forms
- Acupressure at P6
- Exercise
- Acupuncture or hypnosis
- OTC Pharm
- Vitamin B6 (pyridoxine) 10 - 25 mg p.o tid-qid
- alone or with Doxylamine 12.5 mg
- Vitamin B6 (pyridoxine) 10mg/Doxylamine 10 mg combination (Diclegis) 2 tabs po qHS
- can take up to 4 tabs daily (add 1 tab morning and midday)
- Vitamin B6 (pyridoxine) 20mg/Doxylamine 20mg combined product 1 tab qHS
- can take up to 2 daily (add one in AM)
- Vitamin B6 (pyridoxine) 10 - 25 mg p.o tid-qid
- Prescription Pharm
- Ondensetron (Zofran) 8 mg po bid (Cat B)
- Promethazine (Phenergan) 12.5-25 mg po q4-6 (Cat C)
