Minor Disorders of Pregnanacy

8/2/2019 Minor Disorders of Pregnanacy

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Minor Ailments

of Pregnancy


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Topics to be covered..

1. Nausea and Vomiting.2. Gastric Reflux (Heartburn).3. Constipation.

4. Respiratory Distress.5. Fatigue and Insomnia.6. Pruritus.7. Oedema and varicose veins.

8.Haemorrhoids.

9. Vaginal discharge.10.Skin Changes.11. Pelvic Pain, Backache and Symphysis pubis dysfunction.12.Peripheral paraesthesia and Leg cramps.


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Nausea and Vomiting (I) Nausea and vomiting of pregnancy (NVP)is

the most common medical disorder inpregnancy

This common symptom occurs in approximately50% of pregnancies and is most marked atgestational weeks 212.

It is usually most severe in the morning(Morning Sickness) but can occur at any timeand may be precipitated by cooking odors and

strong sharp smells. The pathogenesis of NVP is poorly understood

and the etiology is likely to be multifactorial.


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Physiology of Nausea and Vomiting

The vomiting reflex is triggered by stimulation ofchemoreceptors in the upper GI tract andmechanoreceptors in the wall of the GI tract which areactivated by both contraction and distension of the gutas well as by physical damage.

A coordinating center in the central nervous systemcontrols the emetic response. Afferent nerves to the vomiting center arise from

abdominal splanchnic and vagal nerves, vestibulo-labyrinthine receptors, the cerebral cortex and the

chemoreceptor trigger zone (CTZ). The efferent branches of cranial nerves V, VII, and IX,as well as the vagus nerve and sympathetic trunkproduce the complex coordinated set of muscularcontractions, cardiovascular responses and reverseperistalsis that characterizes vomiting.


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Physiology of Nausea and Vomiting

The CTZ containschemoreceptors thatsample both blood andcerebrospinal fluid. Direct

links exist between theemetic center and theCTZ.

The CTZ is exposed toemetic stimuli of

endogenous origin suchas hormones associatedwith pregnancy and tostimuli of exogenousorigin such as drugs .


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Nausea and Vomiting (II)

The nausea probably results fromrapidly rising serum levels ofhumanchorionic gonadotropin- hCG. During

the first trimester, serum hCG levelsmay be as high as 100,000 mIU/mL. Emotional tension may play a role in

the severity of nausea and vomiting.

Extreme nausea and vomiting may bea sign ofmultiple gestation ormolar pregnancy and SHOULD be

distinguished from idiopathic NVP.


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Treatment of NVP

For uncomplicated nausea consists of lightdry foods, small frequent meals, andemotional support.

Some improvement can be seen with theaddition of high-dose B6 therapy and thepreconceptional use of prenatal vitamins.

Alternative therapies, such as gingersupplementation, acupuncture, andacupressure, may be beneficial

Antinauseant drugs ; Promethazine,prochlorperazine and Metoclopramide are

used only as a final measure..


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Nausea and Vomiting (III) Protracted vomiting associated with dehydration

and ketonuria (hyperemesis gravidarum HG)is defined as persistent vomiting that leads to weightloss greater than 5% of pre-pregnancy weight, withassociated electrolyte imbalance and ketonuria.

It usually presents in T1

Management of HG:Admit to hospital.

NPO and apply TPN if severe.

Doxylamine succinate 10mg with vit B6.


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Gastric Reflux (Heartburn)

Gastric reflux commonly occurs as a result ofdelayed gastric emptying, decreased intestinalmotility, and decreased lower esophageal sphincter tone.

Information on lifestyle modification includesawareness of posture, maintaining upright positions

(especially after meals), sleeping in a propped upposition and dietary modifications (e.g. smallfrequent meals, eat slowly, reduction of high-fatfoods and caffeine).

Antacid Preparations containing aluminiumhydroxide are favoured. Both H2 receptorantagonists and proton pump inhibitors have beenshown to be effective and safe in pregnancy but themanufacturers of both drug groups adviseavoidance unless essential.


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Constipation

Constipation during Pregnancy is due to : Reduced motility of large intestine (progesterone

effect). Increased water reabsorption from large intestine

(aldosterone effect). Pressure on the pelvic colon by the pregnant uterus. Sedentary life during pregnancy .

Advice includes drinking plenty of fluids, high fibre foodsand get plenty of exercise.

When fibre supplementation is not effective, stimulantlaxatives have been shown to be more effective butcause more abdominal pain than bulk-forming laxatives.No evidence currently exists for the effectivenessor safety of osmotic laxatives (e.g. lactulose) or

faecal softeners in pregnancy.


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Flash Back!! Laxatives:Surface Acting: Soften and lubricate, ie mineral oils.

Bulk forming: Stimulate peristaltism. ie wheat fibre.

Osmotic Agents: Disturbing iso-osmotic balance insidethe bowel leading to inhibiting the re-absorbtion of thebowel molecules. ie lactulose.

Cathartics:Irritate the bowels mucosa leading tolow re-absorbtion of fluids in the bowel. e senna and

Castor oil.Enemas and Suppositories: ie Saline enema,Glycerin suppositories.

Pote

ncy

Increase


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Respiratory distress I

The enlarged uterus displaces the diaphragm upto 4 cm .This result in :1.The diaphragmatic mobility is reduced and respiration

becomes mainly thoracic .

2.Widen the subcostal angle and increases the transversediameter of the chest.

Overbreathing (deep respiration) occursdue to the effect of excess progesterone.

Shortness of breath (the need to breathbecomes a conscious one) and dyspnea arecommon complaint of the pregnant womenwhich may be due to unfamiliarity with low C02tension in the alveolar capillaries .


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Respiratory distress II

The respiratory rate does not increaseduring pregnancy from its normal rate of14 - 15 / minute.

Theres ahormone-induced 40 percentincrease in tidal volume(amount of gas

inspired or expired in each respiration ) and anattendant PCO2 decrease (normal value

in pregnancy, 30 mm Hg). Functional residual capacity is decreasedbecause of a rise in the level of thediaphragm.


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Fatigue and insomnia

Fatigue is very common in early pregnancy andreaches a peak at the end of the first trimester.Rest, lifestyle adjustment and reassurance are

usually all that is required. Fatigue also occurs inlate pregnancy, when anaemia should beexcluded.

Insomnia is also very common and due to acombination of anxiety, hormonal changes andphysical discomfort. Mild physical exercisebefore sleep may help but drug treatmentshould be avoided.


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Pruritus

Local causes are usually due to infections, e.g. scabies,thrush.

Generalised itching is common in the third trimester

and disappears after delivery. Treatment is with simple emollients but...

Cholestasis of pregnancy needs to be excluded by

checking liver function tests (raised AST/ALT; alkalinephosphatase is increased in normal pregnancy and so anunreliable marker of cholestasis in pregnancy).


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Oedema and Varicose Veins

Oedema and varicose veins in the lower limbs &vulva are due to:

i - Venous pressure .

ii - Relaxation of the smooth muscles in the wall ofthe veins by progesterone

iii - Osmotic pressure in blood .

iv -

Capillary permeability (due toprogesterone and aldosterone).

v - Interstitial pressure (Na retention).


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Varicose Veins treatments

1. Avoid long periods of standing and encourageactive exercise.

2. Avoid constricting clothes.

3. Keep the legs elevated while sitting and duringsleep.

4.Use of elastic stockings:These should be removed at night and applied with

leg elevated before getting out of bed in the morning(empty veins).

5. Stretch panties may be necessary for vulvalvaricosities.


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They occur due to: Mechanical pressure on the pelvic veins. Laxity of the walls of the veins by

progesterone. Constipation.

Treatment for haemorrhoids includes dietmodification, topical soothing preparations andsurgery.

However, surgery is rarely considered anappropriate intervention for the pregnantwoman since haemorrhoids may resolve afterdelivery.

Haemorrhoids :


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Vaginal discharge

Women usually produce more vaginaldischarge during pregnancy. If the dischargehas a strong or unpleasant odour, is associatedwith itch or soreness or associated with

dysuria, then infection needs to be excluded. Trichomoniasis is associated with adverse pregnancyoutcomes, but the effect of metronidazole for itstreatment in pregnancy is unclear.

A topical imidazole is an effective treatment forthrush which is common during pregnancybut the effectiveness and safety of oraltreatments for thrush in pregnancy is uncertainand these should be avoided.


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Skin Changes

Spider telangiectasis & palmarerythema :

Due to increased estrogen or cutaneousvasodilatation.

Hyperpigmentation:Due to increased estrogen ormelanocyte stimulating hormone or

ACTH


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I Chloasma gravidarum :

((mask of pregnancy)) a butterfly pigmentation on thecheeks and nose . It usually disappears few

months after labour .


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II Linea Nigra

Pigmentation in midline below the umbilicus


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III Stria gravidarum

Pigmentation in the lowerabdomen, flanks , innerthighs, buttocks & breastand increase as

pregnancy advances. It starts pink(stria rubra)

then becomes pale tobecome white (striaalbicans) after delivery,

which persists.(Primigravida has striarubra only ,whilemultigravida has both S.Rand S.A).


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Pelvic painAs the uterus grows, pulling and stretchingof pelvic structures causes ligament pain which usuallyresolves by 22 weeks.

Backache Many women develop backache duringpregnancy and it often first develops during the 5th to7th months of pregnancy. Encourage light exercise andsimple analgesia, and consider physiotherapy referral.

Exercising in water, massage therapy and group orindividual back care classes have been shown to beeffective interventions.

Symphysis pubis dysfunction This is a collection of

symptoms of discomfort and pain in the pelvic area,including pelvic pain radiating to the upper thighsand perineum. Discomfort can vary from mild to severepain. There is no evidence for any specific treatment butelbow crutches, pelvic support and prescribed pain reliefmay help.


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Peripheral paraesthesia Fluid retention leads to

compression of peripheral nerves. This often leadsto Carpal Tunnel Syndrome, which can affect upto one half of all pregnancies. Often no specifictreatment is required. Interventions include wristsplints, steroid injections and analgesia, but there is

a lack of research evaluating effective interventions.Other nerves can be affected, e.g. lateral cutaneousnerve of the thigh.

Leg cramps Leg cramps occur in 1 in 3pregnancies. They occur in late pregnancy and areusually worse at night. Massaging the affected legand elevation of the foot of the bed may help.


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Minor Disorders of Pregnanacy

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