Pregnancy symptoms

Question 1

What is the definition of hyperemesis gravidarum?

Answer 1

Severe N+V (intractable) > than normal for pregnancy that leads to dehydration, electrolyte disturbance, weight loss >=5% pre-pregnancy weight or requires hospital admission

Question 2

What are risk factors for hyperemesis?

Answer 2

Anything that causes high B-hCG

• Multiple pregnancy
• Molar pregnancy

Past history

Ethnicity - higher in asian population

Question 3

What is the natural hx of hyperemesis?

Answer 3

Symptoms generally started by 5W, peak ~11-12W and 80% will resolve by end of 1T - some continue through until 2nd or 3rd T

Question 4

What are the features of hyperemesis?

Answer 4

• Occurs frequently throughout the day, any time
• Typically worse in the afternoon/evening (often b/c of fatigue)
• Worse with stress
• Weight loss, dehydration (headache, dizziness, postural hypotension), thiamine deficiency (rarely) - ataxia, confusion, opthalmoplegia

Question 5

What are important features on history for patient with hyperemesis?

Answer 5

Antenatal history and past obstetric hx

• Multiple pregnancy
• Hx molar pregnancy
• Previous hyperemesis

Vomiting

• Frequency, volume, blood, bile
• Exacerbating - time of day, fatigue, stress, smells, certain foods
• Tried anything - pharm or non-pharm

Input hx - Fluid intake

Associated features (exclude non-obs cause)

• Abdo pain, distention, constipation
• Pruritis, jaundice, pale stools, dark urine
• fever, diarrhoea, travel hx, sick contacts
• urinary symptoms

Psychosocial impact, functional impact

PMHx, medications, allergies, social hx

Question 6

What are important examinations for patient with hyperemesis?

Answer 6

Fluid status - postural BP, cap refil, vitals (tachycardia)
Neurological exam - if concerned about thiamine deficiency
Abdominal examination - exclude surgical cause
Urine dipstick - infection

Question 7

What Ix for patient with hyperemesis?

Answer 7

Must Ix for possible cause of hyperemesis and complications

U&Es, LFTs, FBE, CRP
Urine MCS
Ultrasound

Question 8

What is the Rx of hyperemsis?

Answer 8

• Admit if require resus/TPN
• IV fluids, monitor U&E and replace K+ if required
• IV antiemetics - metoclopramide, ondanestron
• Thiamine if required
• Dietitian referal if require TPN
• Non-pharm Rx - rest to avoid excess fatigue, avoid triggers, stress management techniques, small frequent meals

Question 9

What are the medication options for Rx of N+V in pregnancy?

Answer 9

1st = B6
2nd = Metoclopramide
3rd = Ondanesteron (class B)

Question 10

What are DDx for abdominal pain in pregnancy?

Answer 10

Round ligament pain
Pain associated with stretching of rectus abdominus muscle 
Placental abruption
Labour 
Miscarriage 

Non-obstetric

• Biliary colic - increased risk of gall stones in pregnancy
• Obstruction
• Hepatic cause
• UTI, GIT infection
• Ovarian pathology

Question 11

What are the features of round ligament pain?

Answer 11

Start from the 2nd trimester
Lower abdominal pain usually into groin
Usually unilateral, left side particularly common
Occurs from prolonged standing, sudden change in movement i.e. standing from seated position, coughing, sneezing
Often worse at end of the day

Due to stretching of round ligament as uterus is enlarging

Question 12

What are key features on history for women presenting with abdominal pain in pregnancy?

Answer 12

• Antenatal hx and past obstetric hx (issues with placenta, growth of baby)
• PV bleeding, foetal movements
• Acute or recurrent/chronic issue
• Location of pain, radiation, quality, severity, triggers/exacerbating factors (end of day, prolonged standing, coughing/sneezing, standing up, movement, worse with breathing), relationship to meals
• Associated symptoms - N+V, fever, distention, diarrhoea, constipation, urinary symptoms, pale stools, dark urine, pruritis
• Travel history, sick contacts
• PMHx - gallstones, pelvic surgeries, liver problems, CVD, HTN, diabetes, clots
• FHx - gallstones, clots
• Medications, allergies
• Social hx

Question 13

What pharmacological Rx can be used for constipation in pregnancy?

Answer 13

Bulking agents (metamucil)
Osmotic laxative (Magnesium hydroxide)
Stimulant laxatives (senna)

Question 14

What medications can be used for reflux in pregnancy?

Answer 14

Antacids - can use ‘liberally’
Elevation of head at night, minimise fluids 2-3hr before bed
H2-antagonist safe in pregnancy
PPI can be used but less known about effects in pregnancy so only if refractory case

Question 15

Why do you get constipation in pregnancy?

Answer 15

Progesterone - relaxant effect on smooth muscle of GI
Immobility
Dehydration - vomiting
Iron supplements

Question 16

Why do you get reflux in pregnancy?

Answer 16

Progesterone causes relaxation of the oesophageal sphincter

Later in pregnancy the gravid uterus puts pressure on the stomach