Minor do of px

CHAPTER ONE

ABNORMAL PREGNANCY

BY GEBREMARYA TEMESGEN BSC MW 1

MINOR DISOEDERS OF PREGNANCY

BY GEBREMARYA TEMESGEN BSC MW2

Minor Disorders of Pregnancy

• Are only minor and are not life threatening

• But may escalate and becomes serious. complications of pregnancy( e.g. hyperemisis gravidarum can arise from morning sickness).

Causes of minor disorders can be divided in to:

1. Hormonal changes: e.g. Nausea & vomiting

2. Accommodation change: e.g. frequency of micturition

BY GEBREMARYAM TEMESGEN BSC MW 3

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3. Metabolic changes: e.g. pica and

4. Postural changes: e.g. back ache

Note: Every system of the body adjusts and is affected by pregnancy

A. Digestive System

1. Nausea & Vomiting (Morning Sickness)

– Complicates about 70% of all pregnancies.

– Present b/n 4th and 16th week of pregnancy


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- Associated with high level of human chorionic gonaodotropin hormone (hCG), estrogen and progestron.

- Not confined to early morning, can occur at any time in the day

- Can persist and become hyperemisis gravidarum.

NB: Beware to rule out other causes of vomiting e.g. appendicitis.


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Treatment of Nausea & Vomiting

• Reassure the mother that the symptoms will soon settle.

• Advise to eat small and frequent meals and to avoid fatty foods.

• Advise to eat dry foods before getting out of bed. E.g. ‘Kollo’

• Avoid liquid with meals.

• Rise slowly from lying or sitting.


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2. Heart Burn

Is a burning sensation in the mediastianal region resulted from:

• Relaxation to smooth GI muscles and cardiac sphincter of the stomach allowing gastric reflux of stomach contents to the lower esophagus.

• Displacement of stomach and duodenum by enlarging uterus (30 – 40 weeks)


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Treatment of Heart burn

• If the heart burn is occasional advise the woman to:– Avoid bending over while house keeping

– Avoid kneeling to clean the bath

– Eat small and frequent meals

– Seep with extra pillows

– Avoid fried or spicy foods

– Avoid citrus fruits


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Treatment of Heart burn cont..• If the heart burn is persistent:

– The above advise plus anti acids e.g. MTS(Magnesium trisilicate). Do not give Al2(OH) as it can cause or exacerbate constipation.

3. ConstipationCause: Relaxed gut smooth muscles due to the

effect of the hormone progesterone decreased peristalsis delay in emptying much water is re absorbed constipation.

Oral iron can exacerbate


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Treatment of constipation

• Increase intake of water(6 – 8 glasses per day)

• High residue diet(fresh vegetables)

• A glass of warm water in the morning

• Exercise. E.g. walking

NB: Constipation can aggravate hemorrhoids


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4. Excessive Salivation (Ptyilsm)

Cause: Difficulty in swallowing caused by the nausea and not because of the excess production of saliva

• Occurs from 8 weeks

Treatment:

- Practice good oral hygiene - Suck hard candy

- Avoid excessive starch intake

- Eat Kollo


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5. Pica:

Is a persistent carving and compulsive consumption of substances such as coal, soup, or clay etc.

Causes: Many theories

1. Nutritional deficiency

2. Cultural

Rx: Advise the mother that the act can harm her and her fetus( electrolyte imbalance, metabolic disturbance may occur)


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6. Gingivitis

Cause:

Hypertrophy of gums due to estrogen effect

Rx:

• Tooth brush

• Oral hygiene

• Reassurance


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7. Hemorrhoids

Cause: Progesterone related

Treatment: Avoid constipation

B. Musculoskeletal System

1. Back ache

Cause: Softened ligaments due to progesterone and relaxin effect.


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Treatment of back ache

• Correction of posture( advise to sleep on a firm mattress and sit on upright chair).

• Avoid high heeled shoes.

• Use leg muscle while lifting objects.

• Avoid lifting heavy objects.

• Reassurance and rest.

NB: Rule out UTI and onset of labour.


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2. Leg Cramps:

Cause: Unknown may be de to change in PH

Management: Advise the mother to:

• Raise the foot of the bed about 25 cm.

• Keep legs warm.

• Get regular exercise, walking.

• Stand on the affected leg to strengthen muscles.


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C. Genitourinary System

1. Frequency of maturation:

• Occurs early pregnancy from 6 – 12 weeks and in late pregnancy after lightening has occurred.

Cause: Pressure on the urinary bladder from the growing utters or fetal head.

Rx: Reassure the woman

NB: exclude other causes. E.g. UTI.


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Genitourinary cont..2. Leucorrhoea: This is a term used to describe increased,

white, non offensive, non itchy vaginal discharge in pregnancy.

Cause: Desquamation of the superficial cells of the vagina.

Rx: -Reassurance- Personal hygiene, washing with plain water 2x per

day. Do not use soap.- Cotton underwear , avoiding tights, exclude other

causes.


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D. Circulatory System1. FaintingCause: i. In early pregnancy: Vasodilatation before the

compensatory increase in blood volumeii. In late pregnancy: laying flat on back( Supine

hypotensive syndrome)Rx: - Avoid long period of standing

-Avoid laying on back except during abdominal exam


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1. Management of fainting cont…

- Turn the mother quickly to the left lateral side when she feels faint during abdominal examination.

- Avoid sudden change in position.


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Circulatory cont…

2. Varicosities:

Cause:

• Progesterone relaxes the smooth muscles of the veins and results in sluggish circulation.

• The valves of the dilated veils becomes inefficient + pressure from the gravid uterus and results in varicosities.


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Usual sites of Varicose vein:

• Legs

• Anus (Hemorrhoids)

• Vulva

- Hemorrhoids can be complicated by constipation

- Woman with family history of varicose vein, and those doing work which demands long period of standing or sitting are at high risk to develop varicosities.


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Management of Varicosities:

• Avoid long period of standing

• Elevate legs when sitting

• Wear support tights or stockings

• Avoid sitting on the edge of the bed or chair

• Hospital delivery for vulval and hemorrhoids.


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• E. Intrigumentary System

1. Skin Changes

– Linea nigra

– Chloasma

– Areola

Management

- Reassure the mother that they are signs of pregnancy and settle soon after delivery


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Intrigumentary cont…

2. Itching of the skin

• Often starts over the abdomen

• May be due to the liver hormones responding to pregnancy hormones

• Clear as soon as the baby born

Rx: Antihistamines e.g. chloropheniramine.

For vulval itching R/O candidiasis


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F. Nervous System

1. Carpal tunnel Syndrome/CTS/

• Is a sensation of numbness and pins’ and needles’ in the fingers and hands.

Cause: Pregnancy hormone(progestron) fluid retention edema pressure on the median nerve numbness.


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Management of CTS

1. Anti pain

2. Wearing of split at night with hands resting high on two or three pillows may bring relief.

3. Diuretics may e needed

It usually resolves spontaneously following delivery.


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CNS Cont..2. Insomnia(Sleeplessness) Causes:A. Physical Reasons

– Nocturnal frequency– Difficulty in getting comfortable in bed b/s of the

growing uterus

B. Psychological reasons: AnxietyC. Hormonal reasons: May contribute to

depression


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Management of Insomnia

• Never dismiss lightly

• Ask what she has been dreaming and discuss and reassure

• Small pillow under the abdomen and lying in the lateral position

• Consider psychiatric unit if it seems ‘abnormal’


Hyperemesis gravidarum (HEG)

30BY GEBREMARYA TEMESGEN BSC MW

Hyperemisis gravidarum

• Hyper emesis gravidarum

Definition: Vomiting that starts before 20th

week of pregnancy, severe enough to cause electrolyte, metabolic and nutritional imbalance in known as hyperemisis gravidarum

• It is a rare case but can cause

– Dehydration

– Electrolyte imbalance

– Keto - acidosis

– Weight loss. 31

BY GEBREMARYA TEMESGEN BSC MW

HEG Cont..

Incidence:1 in 1000 pregnant women.

Causes:• The cause is unknown but can be associated with

condition of high HCG and estrogen level – Multiple pregnancy – Hydatidiform mole – A history of unsuccessful pregnancy and – First pregnancy

Note - A women who experience hyper emesis gravidarum will have a recurrence in subsequent pregnancy.


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Assessing the mother condition

• Ask the women whether normal diet has been resumed & tolerated.

• Identify any event producing stress or anxiety as these may exacerbate any vomiting.

• Ascertain whether the nausea or vomiting is accompanied by pain of the location of any pain should be elicited.


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• Dryness or inelasticity of the skin

• The mothers weight will be less than expected for gestation

• The pulse rate will be weak & rapid & the blood pressure will be low.

• Urine will be scant & dark in color & contain acetone


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S/S of HEG:• Rapid pulse rate• Low BP• Dry and furred tongue• Her breath smells like Acetone • The pt becomes weak• Sunken eyes• Elevated HCT• Ketonuria• Wt loss• Inelastic skin teeth covered by sordes


HEG Cont...

Management: • Keep the woman NPO • Reassurance • Correct the electrolyte imbalance by intravenous fluid therapy (Na+

& K+ level) continuous the infusion until hydration & electrolyte returns to normal.

• Glucose to correct Ketoacidosisis• Anti emetics like promethazine may be used if vomiting persists• Sedatives to produce rest• Administer vitamin B12, C, Folic acid & iron to correct the anemia. • Observe the BP, Pulse rate & To at least 4hrly


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• Order urine test twice/ day for - specific gravity – Acetone, – Sugar &– Protein

• Measure intake & out put of fluid, includes vomits Note:• If vomiting is ceased for 24 hrs oral fluid can be started

& if this is tolerated a high carbohydrate diet may follow

• Then normal food is gradually introduced & IV therapy will be discontinued.


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DDx:

• UTI, Appendicitis acute polyhydramnious, preeclampsia, acute intestinal obstruction, torsion of the ovarian cyst etc…

NB: Beware to exclude obstetric causes like

• Multiple pregnancy and

• Hydati form mole


Health & Medicine

Minor do of px