7b other problems during pregnancy
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1
Other Problems During Pregnancy
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
BEMoC - Presentation 7 (b)
Session 7b
Urinary Tract Infection Hyperemesis Gravidarum Retention of Urine PROM
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
2
Session Objectives
To diagnose and manage other problems during pregnancy
Identify the causes Base line investigation required for diagnosis Management & timely referral
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
3
Urinary Tract Infection
Cystitis
Pyelonephritis
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
4
Signs & Symptoms: UTI
Fever, may be high grade, i.e. >38 °C; may be accompanied with chills and rigors
Burning on urination
Increased frequency and urgency of urination
Abdominal pain
Flank tenderness
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
5
Signs & Symptoms: Cystitis & Pyelonephritis
Typically Present Sometimes Present Probable diagnosis
• Dysuria• Increased
frequency & urgency of urination
• Retropubic/ suprapubic pain during or after urination
• Lower abdominal pain (radiating form flanks to loin)
Cystitis
• Above PLUS• Spiking
Fever/Chills • Abdominal pain
• Retropubic/ suprapubic pain during or after urination
• Loin pain/ Tenderness• Tenderness in the rib cage• Anorexia• Nausea/ Vomiting
Acute Pyelonephritis
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
6
Signs & Symptoms: Cystitis & Pyelonephritis
Cystitis:
Involves lower urinary tract Dysuria Increased frequency &
urgency of urination Lower abdominal pain
(Radiating from flanks to loin)
Pyelonephritis: Involves upper urinary tract, mainly renal pelvis & the renal parenchyma Spiking fever with chills &
rigor Toxic look Loin pain (costo-vertebral
angle tenderness) Dysuria Nausea Vomiting
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
7
Cystitis Vs Pyelonephritis
Cystitis Involves:
Lower urinary tract
Pyelonephritis Involves :
Upper urinary tract
mainly renal pelvis & the renal parenchyma
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
8
Investigations
Microscopy: WBCs, bacteria, sometimes RBC’s Urine culture and sensitivity: identify the organism
and its antibiotic sensitivity PS for mp to differentiate from malaria Blood culture Haemogram
Note: These tests can determine if UTI is present, but will not
differentiate between cystitis & acute pyelonephritis Urine examination requires a clean-catch mid-stream
sample to minimize the possibility of contamination.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
9
General Management
Encourage bed rest in lateral supine position Physical activity should be moderate Encourage increased fluid intake by mouth
like water, juice, soups etc. Use a fan or tepid sponge to help decrease
the body temperature Antipyretics/Analgesics if required Sodium intake may require adjustments if pt is
hypertensive
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
10
Management: Cystitis
Treat with antibiotics• Cap Amoxicillin, 500 mg orally, TDS for 3 days; OR• Nitrofurantoin 50 to 100mg Qid for 10 days; OR• Cefadroxil 500 mg BD for 10 days; OR• Tab Co-trimoxazole (160/800 mg) 1 tablet or ally BD for 3
days If No response: Refer to FRU If the infection recurs two or more times:
• Refer to an FRU for urine culture and sensitivity tests;• For prophylaxis, give antibiotics for the remainder of the
pregnancy up till two weeks postpartum as under:• Co-trimoxazole 1 tablet (160/800 mg) OD at bedtime OR• Amoxicillin 250 mg OD at bedtime
NOTE: Prophylaxis is indicated only after recurrent infections, and NOT after just asingle episode.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
11
Management: Pyelonephritis
Should be aggressive to avoid complication endotoxic shock (keep a watch on tachycardia & hypotension)
If shock is present or suspected, initiate immediate treatment
Start an IV infusion and infuse IV fluids @ 150 ml per hour
Start the woman on antibiotics and refer her to an FRU for further management. Give:• Ampicillin 2 g IV 6 hourly PLUS • Gentamicin 80 mg IM 12 hourly
Give Paracetamol, 500 mg orally as needed to control the pain and lower the body temperature.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
12
Complications
Fetal
• Growth retardation
• Pre term delivery
• Ante Partum fetal distress Maternal
• Septic shock
• Pulmonary Injury
13
Hyperemesis Gravidarum
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
14
Hyperemesis Gravidarum
Excessive vomiting during pregnancy that affectsthe day to day activity and health of the mother Common in: Primigravidas, Multiple
pregnancy, Molar Pregnancy On examination:
• Dehydration (dry tongue, loss of skin turgor, oliguria in severe cases)
• Tachycardia
• Ketonuria
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
15
Differential Diagnosis: Hyperemesis Gravidarum
Exclude the following conditions which may result in vomiting when present during pregnancy:
• Jaundice
• Meningitis
• Diabetic coma
• Uremic Coma
• Peritonitis due untreated septic abortion
• Intestinal obstruction
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
16
Management: Hyperemesis Gravidarum
Admit & reassure the woman and her family. Counsel them regarding the harmless nature of the
condition. Start IV fluids slowly, either R/L or dextrose saline. Repeat urine examination every four hours till it becomes
negative for ketone bodies. USG optional – rule out twins and vesicular mole Give an anti-emetic such as Inj. Stemetil to control the
vomiting & Multi-vitamins Once the vomiting stops and the dehydration is corrected,
discharge after 24 hours. Advise the woman to take small, frequent, carbohydrate-
rich meals.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
17
Complications
Wernicke’s encephalopathy Peripheral neuritis Stress ulcers Esophageal tears and rupture Jaundice
18
Retention of Urine
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
19
Retention of urine
Causes: During the late first trimester, dysuria may
present due to pressure of the retroverted gravid uterus on the bladder, though usually this does not present with any symptoms.
A retroverted uterus expanding in the pelvis may exert pressure on the bladder neck causing retention if it persists in this position beyond 12 weeks
The woman will present with urinary retention and a distended bladder
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
20
Causes: Retention of urine
During early pregnancy
• Incarcerated retroverted gravid uterus
• Impacted pelvic tumors During labour
• Obstructed labour During puerperium
• Operative vaginal delivery
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
21
Diagnosis: Retention of urine
On abdominal examination:• Cystic swelling is palpable in the lower
abdomen arising from the pelvis.• Swelling may be large enough to reach
above the umbilicus. On vaginal examination:
• The cervix is high up behind the symphysis pubis and directed downward and forward.
• The uterus is retroverted, more than 12 weeks in size and is felt below the cervix.
• There is a cystic mass in the anterior fornix.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
22
Management: Retention of urine
Management involves keeping the bladder empty with a urinary catheter for 48 to 72 hours allowing the uterus to rise above the pelvic brim
Under all aseptic precautions, insert a self retaining Foley’s catheter and collect urine for microscopy (this measure allows the uterus to rise above the pelvic brim) OR
Put the woman in prone position so that the uterus becomes anteverted
Drain the urine continuously for 48 hrs These measures allow the uterus to rise above the pelvic
brim Once the uterus is palpable P/A, remove the catheter Ensure that the woman voids urine
23
Premature Rupture of Membranes (PROM)
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
24
PROM
Spotaneous rupture of membranes (bag of water) any time beyond 28 weeks of pregnancy but before onset of labour is called PROM
Diagnosed by passage of watery discharge from vagina either in the form of sudden gush or slow leakage
Diagnosis is confirmed by per speculum exam with aseptic precautions
Avoid per vaginal examination
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
25
Signs & Symptoms: PROM
On Inspection:
• Profuse watery discharge with the typical odour of the amniotic fluid may be seen at the introitus
Signs and symptoms:
• P/S examination (done aseptically): A pool of amniotic fluid lying in the vagina, or amniotic fluid coming out of the cervix, particularly when the woman is made to cough.
• A sterile pad placed over the vulva and examined after an hour may show the pad soaked with amniotic fluid.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
26
Tests in PROM
If the facilities are available, the following tests may also be carried out.
Nitrazine test: • Normal vaginal secretions are acidic and the amniotic fluid
is alkaline. • Touching a nitrazine paper to the pool of fluid collected on
a speculum from the vagina will change it from yellow to blue if the fluid is alkaline, indicating rupture of the membranes.
Ferning test: • Amniotic fluid, when dried, crystallizes and leaves a fern-
leaf pattern. • Spread some fluid pooled in the vagina on a glass slide
and let it dry.• Examine under a microscope for ferning.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
27
Investigations: PROM
Full Blood Count Urine Routine Urine Culture and Sensitivity High Vaginal swab for Culture and Sensitivity
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
28
D/D of vaginal Discharge during pregnancy
Symptoms and signs typically
present
Symptoms and signs sometimes present
Probable diagnosis
Watery vaginal discharge
Sudden gush or intermittent leaking of fluid
Fluid seen at the introitus No contractions within 1
hour
PROM
Foul-smelling watery vaginal discharge after 22 weeks of gestation
Fever/chills Abdominal pain
History of loss of fluid Tender uterus Rapid foetal heart rate Light vaginal bleeding
Amnionitis
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
29
D/D of vaginal Discharge during pregnancy
Symptoms and signs typically
present
Symptoms and signs sometimes present
Probable diagnosis
Foul-smelling vaginal discharge
No history of loss of fluid
Itching Frothy/curdy discharge Dysuria Abdominal pain
Vaginitis/cervicitis
Bloody vaginal discharge
Abdominal pain Loss of foetal movements Heavy, prolonged vaginal
bleeding
AntepartumHaemorrhage
Blood-stained mucus or watery vaginal discharge
Cervical dilatation and effacement
Contractions
Possible labour (May be term or preterm)
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
30
Management: PROM < 37 wks w/o infection
Managed conservatively under strict monitoring for signs of chorioamnionitis
At the earliest signs of chorioamnionitis pregnancy needs to be terminated in a FRU set up
Before referral administer triple antibiotic and the first dose of steroids for fetal lung maturity:
• Ampicillin 1 gm PLUS Metronidazole 400 mg orally PLUS Inj Gentamycin 80 mg IM
• Inj Betamethasone 12 mg IM OR Inj Dexamethasone 6 mg IM
If palpable contractions and a blood-stained mucus discharge: suspect preterm labour & manage accordingly
If in labor : Manage as preterm labor
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
31
Management: PROM < 37 wks with infection
Refer to FRU after the first dose of triple antibiotics & stabilizing the woman
Signs of Infection:• Fever• Tachycardia• Leucocytosis• Lower Abdominal Pain• Foul Vaginal Discharge• Uterine Tenderness• Hot vagina• Fetal Tachycardia
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
32
Management: PROM > 37 wks w/o Infection
If the membranes have been ruptured for more than 18 hours, give prophylactic antibiotics:• Ampicillin 1 g orally every 6 hourly PLUS• Metronidazole 400 mg every 8 hourly PLUS• Inj. Gentamicin 80 mg IM every 12 hourly
Assess the cervix• Favourable cervix(soft, thin and partly dilated):
could signify the beginning of labour. Deliver the woman under antibiotic cover. If there are no signs of infection after delivery,
discontinue the antibiotics.• Unfavourable cervix :
Refer to FRU for induction or a caesarean section as required after giving her the first dose of the triple antibiotics.
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
33
Management: PROM > 37 wks with Infection
At the earliest signs of chorioamnionitis pregnancy needs to be terminated
If in 1st stage of labor:
• Refer to FRU for induction or a caesarean section as required after giving her the first dose of the triple antibiotics.
If in active labor & delivery imminent :
• Conduct Normal Delivery with AMTSL after giving her the first dose of the triple antibiotics.
• Referral to higher health facility for specialized neonatal care
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
34
Complications: PROM
Increased incidence of pre-term labour and pre-maturity
Cord prolapse Dry labour Foetal pulmonary hypoplasia leading to
Respiratory Distress Syndrome (RDS)
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
35
Dos & Don’ts: PROM
Do’s Aseptic Per Speculum
Examination Nitrazine Test Ferning test Referral to higher health
facility for specialized neonatal care
If vaginal bleeding with intermittent or constant abdominal pain, suspect abruptio placentae
Don’ts If a woman complains of
bleeding after 20 weeks of gestation, do NOT do a digital vaginal examination
A digital examination (P/V) in no way helps to establish the diagnosis of PROM
Instead it may add to the complication by way of introducing infection
Don’t give Corticosteroids in the presence of frank infection
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
36
Key Messages
Dos & Don’ts of PROM
Management of problems during pregnancy
Referral of Pyelonephritis cases to FRU
OTHER PROBLEMS DURING PREGNANCY
Maternal Health DivisionMinistry of Health & Family
WelfareGovernment of India
37
Case Studies: Session...7b
Case studies 24 to 27 at:
Page No……91 of Trainee’s Handbook
Answers to Case study:
Page No….…43-50 of Trainer's guide
38
Thank you