Minor Ailments During Pregnancy: Genitourinary system changes

BSCN 3014OBSTETRIC &

GYNAECOLOGYMINOR AILMENTS“GENITOURINARY

SYSTEM”Prepared by:

Nur Amira Binti Ahmad3067141001

Bachelor of Science In Nursing (Hons)KPJ Healthcare University College

Lecturer:Madam Norjana

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Learning Objectives:At the end of this presentation, student should be able to:1) Understand the normal anatomy and physiology of genitourinary

system2) Discuss the changes of genitourinary system during pregnancy3) Discuss the expected changes of genitourinary system during

pregnancy4) Explain the minor ailments of genitourinary system changes

during pregnancy5) State the complications of genitourinary changes during

pregnancy6) Discuss the nursing management

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Introduction■ Every pregnancy is a unique experience for that woman and

each pregnancy that the woman experiences will be new and uniquely different.

■ “Davis (1996) has stated that the majority of discomforts experienced during pregnancy can be related to either hormonal changes or the physical changes related to the growing uterus.” (Myles Textbook for Midwives, 14th Edition)

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Anatomy & Physiology of GU systemThe kidneys are powerful chemical factories that perform the following functions:

1. Remove waste products from the body2. Remove drugs from the body3. Balance the body's fluids4. Release hormones that regulate blood

pressure5. Produce an active form of vitamin D that

promotes strong, healthy bones6. Control the production of red blood cells

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Changes of GU system during pregnancy

■ During pregnancy, a striking anatomical changes are seen in the kidneys and ureters. The kidneys increase in weight and lengthen by 1 cm in order to compensate with the increase of the demand to kidney to filter the mother’s waste product and also the fetus.

■ “A degree of hydronephrosis and hydro-ureter exist” (Fetal and Maternal Physiology, 7th Edition).

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Changes of GU system during pregnancy

■ Hydronephrosis is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction.

■ Under the influence of the hormone progesterone, the calyces and renal pelvis dilates. “The ureters also dilate and lengthen in size and are thrown into curves of varying sizes. The dilated collecting system can hold 200 to 300mL of urine, leading to urinary stasis. This will increase the risk of hydronephrosis in pregnant women.” (The National Kidney Foundation, 2017)

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(A) Normal kidneys

(B) Hydroneprosis and hydroureter GU system

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Body system changes ■ Numerous factors affect renal function in pregnancy, including:■ Increased plasma volume, increased glomerular filtration rate (GFR),

increased renal plasma flow and alterations in hormones such as adrenocorticotrophic hormone (ACTH), ADH, aldosterone, cortisol, thyroid hormone and HCG. (Steinfeld & Wax 2001)

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Body system changes cont…■ The increase in blood flow is caused by vasodilation in the urinary tract

(Campbell & Lees 2000). ■ Early in pregnancy renal blood flow increases to levels 25-50% above non-

pregnant values. Although the increase in blood flow is mainly responsible for the 50% increase in GFR, the decrease in plasma oncotic pressure and enhanced permeability also increase glomerular filtration. This cause the pregnant women to urinate more than usual.

■ The GFR returns to non-pregnant values close to term. As tubular reabsorption is unaltered the clearance of many solutes from the bloodstream is increased.

■ The increased GFR coupled with impaired tubular reabsorption capacity for filtered glucose results in excretion of glucose (glycosuria) at some time during pregnancy in 50% women.

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Body system changes cont... ■ The expected changes of the body system during pregnancy is the increase in

bladder pressure and may result in reduced bladder capacity. ■ This can lead to stress incontinence in pregnant women. To compensate for this

problem, the urethra lengthens and intra-urethral pressure increases. ■ The muscles of the internal urethral sphincter relax, which, along with pressure

from the pregnant uterus on the bladder, causes a significant number of women to experience some degrees of stress incontinence.

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Body system changes cont…■ Water and sodium excretion are significantly reduced when the women is in the upright

position or changes from a recumbent to a supine position, owing to reduce venous return to the heart and therefore reduced renal perfusion.

■ Posture does effect the circadian rhythms of sodium excretion. ■ Fluid retained in the legs and feet during the day (edema) is absorbed into the blood

circulation when her legs are raised in bed. The kidneys extract the excess fluid and turn it into urine, so the bladder fills more quickly at night.

■ This reversal of the non-pregnant diurnal pattern of urinary flow causes nocturia and the urine is more dilute because of the excretion of extracellular fluid of relatively low osmolality (Cunningham et al 1997).

■ It follows therefore that increased rest during the day in the recumbent position will lead to excretion of maximum amounts of urine in the middle of the day.

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Minor Ailments■ Frequent urination■ Needing to urinate often is normal, especially in the first and last months of

pregnancy. ■ Growing uterus presses against the bladder. ■ In late pregnancy, a woman often has to get up during the night to urinate,

because fluid retained in the legs and feet during the day (edema) is absorbed into the blood circulation when her legs are raised in bed.

■ The kidneys extract the excess fluid and turn it into urine, so the bladder fills more quickly at night.

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Minor Ailments cont…■ Nocturia, or nocturnal polyuria (Excessive urination during the night)■ During sleep time, body produces less urine that is more concentrated. This

means that most people don’t need to wake up during the night to urinate and can sleep uninterrupted for six to eight hours.

■ Pregnant women will feel the urge to go more often because of hormonal changes and increased blood flow through the kidneys.

■ Antenatal tend to drink more fluids during pregnancy, which may also play a part.

■ Waking up needing micturition is most likely to disturb sleep pattern in the first trimester and third trimester of pregnancy.

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Minor Ailments cont…■ Urinary incontinence ■ This condition often has serious effects on the lives of many

individuals who suffer from embarrassment, stigma, physical discomfort and social isolation.

■ Stress incontinence are most common during pregnancy. It occurs while lifting, exercising, laughing, sneezing and coughing which commonly occurs in women, and presumptively the effect of pregnancy and childbirth; and/or hormonal imbalance during menopausal stage.

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Complication1) Urinary tract infection: Pregnancy increases the risk of urinary tract infection (UTI). Both

progesterone and estrogens levels also increase during pregnancy and these will lead to

decreased ureteral and bladder tone. An incontinence may result which lead to UTI.

Urethrocystitis which is a lower tract infections and pyelonephritis, infection of the upper urinary

tract may develop initially during pregnancy.

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NURSING MANAGEMENT

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1. Teach the mother to lean forward while urinatingLeaning forward will help to empty out the bladder in a

better way and also makes it to the last urine drop by

double-voiding.

2. Emphasize the mother to avoid diuretics beveragesAvoid beverages like tea, coffee or alcohol as they are

diuretic in nature.

3. Explain to the mother to not take excess fluids before bedtimeEducate the mother to cut back on the fluids before going

to bed but make sure to drink more water during the day.

Frequent Urination

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4. Encourage mother to do kegel exercisesKegel exercises help to gain control over the urethra

by strengthening the pelvic floor muscle.

5. Teach the mother to empty the bladderTry to clear out the bladder before going out or sleep.

6. Wear A PadWear a sanitary pad especially if the mother have a

cough or sneeze. Coughing, sneezing or activities like

lifting heavy objects may sometimes cause leakage,

and it may embarrass and lowering self-esteem of

the mother.

Frequent Urination

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1. Assessment for urinary incontinence:

Includes the number of times and frequency of micturation, characteristics of urine, to evaluate urinary

incontinence.

2. Promoting urinary continence:

Initiate bladder training by providing schedule with specified time for the patient to void. Other measures

can be helpful to promote voluntary urination are, suprapubic tapping or stroking of the inner thigh may

produce voiding by stimulating the voiding reflex arc. Listening to running water or perineal wash with

lukewarm water will also help.

3. Promoting hygiene, skin care and preventing infection:

Hygiene and skin care is strictly observed for patients with urinary incontinence. Skin care and perineal care

should be done every after voiding using non-allergenic soap with lukewarm water. Always pat dry the

perineal area.

Urinary Incontinence

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4. Provision of comfort:

When incontinence pads are used, they should wick moisture away from the body to minimize contact of

moisture and excreta with the skin. Wet incontinence pads must be changed promptly, the skin cleansed,

and a moisture barrier applied to protect the skin.

5. Promoting role performance, promoting body image and relieving anxiety and stress:

Privacy should be provided during voiding efforts. Promote positive feedback and optimistic attitude to

reinforce patient’s ego and esteem. Periods of continence and successful voidings are positively reinforced.


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6. Maintaining hydration:

Monitoring intake and output is necessary to assess hydration. Signs and symptoms of good hydration and dehydration

should be assessed and monitored every shift. Sufficient fluid intake (2000 to 3000 mL/day according to patient needs) must

be ensured to maintain hydration.

7. Promoting sleep and rest:

Fluid intake should be consumed before evening to minimize the need to void frequently during the night which can disturb

the time to sleep and rest for the patient.


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Conclusion■ Minor ailments are generally defined as conditions that will resolve on their own and

can be reasonably self-diagnosed. ■ The minor ailments or discomforts experienced by pregnant women such as urinary

frequency, nocturia and incontinency are probably a result of a combination of factors such as the change in sleeping patterns, pressure effects of the enlarging uterus on the bladder, reduced bladder capacity due to increased pressure and most importantly the great effect of the hormonal changes, progesterone which causing vasodilation and cause some internal structures to increase in size, including the uterus.

■ The problems arising can be managed by the common method practiced to decrease the urge of micturition like kegel exercise which help to strengthen the pelvic muscle, emptying the bladder before bed time and the use of sanitary pad for stress incontinence help to preserve the pregnant mother’s self-respect.

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References■ Book1) Fraser, D. and Cooper, M. (2003). Myles textbook for midwives. 14th ed. Edinburgh: Churchill Livingstone.2) Hanretty, K., Ramsden, I. and Callander, R. (2010). Obstetrics illustrated. 1st ed. Edinburgh: Churchill

Livingstone Wordmark.3) Willson, J., Carrington, E., Laros, R., Ledger, W. and Mattox, J. (1991). Obstetrics and gynecology. 1st ed. St.

Louis: Mosby-Year Book. ■ Internet 1) Das, M. and Das, M. (2017). Frequent Urination in Pregnancy - Kegel Exercises, Treatment. [online] Appletail.

Available at: http://appletail.com/articles/frequent-urination-in-pregnancy-kegel-exercises-treatment/ [Accessed 14 Jan. 2017].

2) George A. DeMaagd, T. (2017). Management of Urinary Incontinence. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411204/ [Accessed 14 Jan. 2017].

3) Healthline. (2017). Excessive Urination at Night (Nocturia). [online] Available at: http://www.healthline.com/health/urination-excessive-at-night#Overview1 [Accessed 14 Jan. 2017].

4) NATIONAL ASSOCIATION FOR CONTINENCE | LEARN ABOUT INCONTINENCE CAUSES AND TREATMENTS. (2017). NOCTURIA | CAUSES AND TREATMENTS. [online] Available at: http://www.nafc.org/nocturia/ [Accessed 14 Jan. 2017].

5) Patient. (2017). Stages of Pregnancy. First Stages and More. Pregnancy Info | Patient. [online] Available at: http://patient.info/doctor/physiological-changes-in-pregnancy [Accessed 14 Jan. 2017].

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