IN THE NAME OF GOD

THE MOST COMMON DISORDER IN PREGNANCY

E . ZAREAN

OB 3

Bleeding

  Bleeding at any time during pregnancy is serious and potentially life threatening Occurs in 10 – 20% of pregnancies  Amount and timing determine urgency

OB 4

Spontaneous Abortion

 Types     Threatened – bleeding, closed os Incomplete – tissue still present Missed – no bleeding, closed os, embryo/fetus died Inevitable – bleeding, os open  Pathophysiology / Etiology  Chromosomal anomalies  Maternal factors  Environmental factors  Immunological factors  Uterine defects

OB 5

Spontaneous Abortion

 Defined as termination of pregnancy before the point of fetal viability  Gestation less than 20 weeks and conceptus should not weigh more than 500 grams  Commonly called miscarriage

OB 6

Types

 Threatened abortion – possible pregnancy loss, slight bleeding, some cramping, uterine size = dates, cervical os is closed   Inevitable abortion - is a pregnancy that cannot be saved, moderate bleeding and moderate to severe cramping Incomplete abortion – some products of conception are passed, moderate to sever cramping, and heavy bleeding

OB 7

Types

   Complete abortion – all products of conception are expelled, bleeding may be small and contractions should subside Missed abortion – when embryo is not viable, but is retained in utero for at least 6 weeks, no contractions, bleeding may or may not be there Habitual abortion – experience of three or more consecutive spontaneous abortions

OB 8

Subjective data

 Varying amounts of bleeding, low back pain, abdominal cramping and passing of products of conception  Bright red bleeding is significant, dark brown-red (spotting) is less significant  Amount of bleeding and frequency of changing of pads

OB 9

Objective data

 Uterine size < expected gestational size  Fetal heart tones  Cervix dilatation or lack of dilatation  Real-time sonography  Serial B-hCG (at least 2 days apart)  Use of progesterone to determine the presence of viable pregnancy

OB 10

Differential diagnosis

 Malignancy  Cervicitis  Ectopic pregnancy  Gestational trophoblastic disease (Hydatidiform mole)

OB 11

Plan

 Plan – reassurance to client  Health care provider understanding of grief  Progesterone supplementation via vaginal suppositories in luteal phase defect  Bedrest????

 Pelvic rest  Importance of hydration  Watching for signs/symptoms of infection

OB 12

Follow-up

 Danger signs – infection, incomplete evacuation of uterus, fever, foul-smelling lochia, excessive bleeding, back or abdominal pain  Teaching on importance of use of contraception for at least 4 to 6 months to allow for complete healing  If repeated pregnancy loss, refer to infertility specialist

OB 13

Ectopic Pregnancy

 Implantation of a fertilized ovum outside the uterine cavity  Most often occurs in a fallopian tube, but can occur on an ovary, cervix, or abdominal cavity  Potential life threatening disease  Never under diagnose!!!!!

OB 14

Subjective data

 One or two months of amenorrhea, nausea and breast tenderness  Abdominal pain and irregular vaginal bleeding  Unilateral pain  Increases in intensity of pain  Malaise and syncope  Referred pain to the shoulder as hemorrhage becomes extensive and irritates the diaphragm

OB 15

Objective data

      Any woman with missed menses is at risk for an ectopic pregnancy!

Physical examination????

May appear shock like if hemorrhaging Pelvic exam reveals normal appearance, but marked tenderness Vaginal vault may be bloody – brick red to brown in color Tender adnexal mass may be palpated

OB 16

Diagnosis

 Levels of serial B-hCG (will not double every 2-3 days)  Sonogram to determine if pregnancy is intrauterine 

Absence of an intrauterine gestational sac is diagnostic of an ectopic pregnancy

OB 17

Differential diagnosis

 PID, ovarian cyst, ovarian tumor, intrauterine pregnancy, recent spontaneous abortion, early hydatidiform degeneration, acute appendicitis and other bowel-related diseases

OB 18

Plan

 Psychosocial interventions  Refer to obstetrical/gynecology surgeon  Use of contraception post evacuation  Prevention education through screening and client education is essential…..prevent STD’s, and utilization of condoms  Never use an IUD with client with history of ectopic pregnancy

OB 19

Gestational Trophoblastic Disease

 Group of neoplastic disorders:    Hydatidiform mole – most common type, benign neoplasm of the chorion, partial or complete Invasive mole – invasive mole is complete molar gestation and has invaded the myometrium/metastasized to other tissues Choriocarcinoma – rare chorionic malignancy

OB 20

Differential diagnosis

 Normal pregnancy, threatened abortion, error in dates, uterine myomas, polyhydramnios, multiple gestation  Plan – prompt identification and

referral

 Psychosocial support

OB 21

Hyperemesis Gravidarum

 Persistent vomiting of pregnancy differentiated from common nausea and vomiting in pregnancy by a weight loss of more than 5% of prepregnant weight, dehydration, and electrolyte imbalance  Usually peaks around the 4 th or 5 th week of pregnancy and continues to the 12 th week of pregnancy and then dissipates

OB 22

Hyperemesis Gravidarum

   Subjective data – woman reports severe nausea and episodes of uncontrolled vomiting and retching Objective data – None except electrolyte imbalance Differential diagnosis – gastroenteritis, gastroesophageal reflux disease, cholecystitis, pancreatitis, gastric and duodenal peptic disease, irritable bowel disease, hepatitis, pyelonephritis and appendicitis

OB 23

Hyperemesis Gravidarum

 Plan – vitamin B6 and B-Complex prior to pregnancy, Benedectin (formerly removed and now available), dietary counseling including use of salt, glucose and potassium (sports drinks/bouillon), rehydration (1.0 to 1.5 liters of fluid) to prevent dehydration  Alternative therapies: acupuncture, acupressure wrist bands, biofeedback and hypnosis

OB 24

Weight Gain

 Average weight gain – 12.5 kg (28 lbs)   Fetus, placenta, breast/uterine enlargement, fluid retention – 9 kg Maternal fat – 3.5 kg  Institute of Medicine  12.5-18 kg for underweight BMI <19.8

 11.5-16 kg for normal weight BMI 19.9-26.0

 7-11.5 kg for overweight BMI 26-29  >6.8 kg for obese BMI>29

OB 25

Weight Gain

(Cont’d)

 Average 1 pound during 2 nd /3 rd trimester  Weight gain <2 lb. or >6.5 lb. / month warrants review of eating habits, etc.

 Attaining pre-pregnancy weight by 6 months postpartum less long-term weight gain  ½ loss in first 6 weeks

OB 26

Recommended Daily Allowances

 Calories  300 KCal increase singleton   600 KCal increase for multiple gestation Caloric demand of breast feeding – 750 KCal per day – supplement 500 KCal  Folic Acid  400 mcg reduce Neural Tube Defects  4 mg to those of increased risk

 •  CAUSES OF ABDOMINAL PAIN DURING PREGNANCY

(A) Pregnancy Related Pain:

Early pregnancy •

( B)Conditions associated with pregnancy

• o Abortion: Inevitable, incomplete or septic abortions  Rupture of rectus abdominus muscle •

© Non-Pregnancy Related Pain

Gastrointestinal o Acute appendicitis o Vesicular mole: when expulsion starts.  Torsion of the pregnant uterus o o o o Peptic ulcer Gastroenteritis Hepatitis Inflammatory Bowel Complication (Crohn ’ s &Ulcerative Colitis ) o Ectopic pregnancy: pain precedes bleeding.

Later pregnancy  Acute urinary retention due to retroverted gravid uterus MusculoSkeletal ( Pubic Symphysis pain-sacroiliac – back o o Bowel obstruction o Braxton-Hicks Contraction pain ) o o o o Bowel perforation Herniation Meckel diverticulitis Toxic megacolon Pancreatic pseudocyst o Round Ligament Pain Red degeneration of myoma Torsion of pedunculated myoma HepatoBliary o Biliary Stones o Pressure symptoms o Acute Hepatitis Ovarian cyst rupture o Acute Cholecystitis o Cholestasis of pregnancy o Acute pancreatitis o Placental abruption Adnexal torsion  Genitourinary o Ureteral calculus o Placenta percreta o Acute pyelonephritis o o Acute Fatty Liver Acute cystitis o Rupture of renal pelvis o Pre-eclampsia , HELLP o Ureteral obstruction  o o Spontaneous rupture of the liver Uterine rupture Vascular o Superior mesenteric artery syndrome o Thrombosis/infarction - Specifically mesenteric venous thrombosis o Ruptured visceral artery aneurysm o Chorioamnionitis  Respiratory o Pneumonia o Acute Polyhydramnios  o Labor ( Term , Preterm ) Other o Intraperitoneal hemorrhage o Splenic rupture o Abdominal trauma o Acute intermittent porphyria o Diabetic ketoacidosis o Sickle cell disease

Pressure symptoms

• Upper abdominal pressure --- pain due to flaring of the ribs particularly in breech presentation

-

The ribcage expands enormously during pregnancy to help make room for the expanding uterus and to maintain adequate lung capacity. Many pregnant women experience rib discomfort from this expansion, as well as the occasional little foot or knee of fetus that might habitually press against the ribs.

• Mid abdominal pressure --- distension of the abdominal wall ( Twins , polyhydramnios ) • Lower abdominal pressure --engagement of the head

Pressure symptoms

• Upper abdominal pressure --- pain due to flaring of the ribs particularly in breech presentation

-

The ribcage expands enormously during pregnancy to help make room for the expanding uterus and to maintain adequate lung capacity. Many pregnant women experience rib discomfort from this expansion, as well as the occasional little foot or knee of fetus that might habitually press against the ribs.

• Mid abdominal pressure --- distension of the abdominal wall ( Twins , polyhydramnios ) • Lower abdominal pressure --engagement of the head

Sacroiliac strain

of pregnancy

• The

sacroiliac joint

is where the back of the pelvis connects with the sacral vertebrae of the lower spine.

• Most body types display a small dimple on each side of the low back at the sacroiliac joint. Generally, this joint moves very little, however; instability from increased ligament laxity at this joint can occur during the last half of pregnancy and, more commonly, the postpartum period.

• Sacroiliac instability is painful and may cause functional weakness in one or both legs, and low back muscle spasms. Bending, lifting and carrying, sitting with the legs crossed or to one side, prolonged standing/slouching, or walking up a steep hill may aggravate the condition.

Back Pain

•

Factors that influence back pain during pregnancy

• The spine is vulnerable due to the following factors during pregnancy: -Hormone production during pregnancy makes joints less stable (to allow the pelvis to spread as the baby grows) -Typical weight gain of 25-35 pounds during pregnancy, with the majority or extra weight distributed around the abdomen -Increase in postural strain as the body compensates for changes in the pregnant woman ’ s center of gravity

To help prevent or ease back pain

• Try to be aware of how she stands, sits, and moves.

• Wear low-heeled (but not flat) shoes with good arch support. • Ask for help when lifting heavy objects. • When standing for long periods, place one foot on a stool or box. • If her bed is too soft, have someone help her place a board between the mattress and box spring. • Don't bend over from the waist to pick things up pillow behind the low part of her back. her legs for support. lumbar and abdominal regions — • Sit in chairs with good back support, or use a small squat down, bend your knees, and keep her back straight. • Try to sleep on her side with one or two pillows between • Try to wear Maternity Belt comfortably supports the • Apply heat or cold to the painful area or massage it.

Key Points

• Diagnostic delays are more common with surgical disorders in pregnancy, increasing both maternal and fetal morbidity and mortality. • • Physical finding of a surgical abdomen may be more difficult to elicit in pregnancy. • Obstetric causes must always be considered in the pregnant patient with abdominal or pelvic pain, regardless of gestational age. • With any pain in pregnancy think, could this be the onset of labour? • Abdominal pain may be from ligament stretching or from symphysis pubis strain. In early pregnancy remember miscarriage and ectopics Suspected appendicitis is the most common nonobstetric indication for surgery in pregnancy. • Adnexal masses that persist beyond 18 weeks' gestation are rarely functional. • The incidence of gallbladder disease is increased in pregnancy.

• Abdominal pain may complicate pre-eclampsia by liver congestion. Rarely, in severe pre-eclampsia the liver perforates.

• Pancreatitis in pregnancy is rare; but mortality high (37% maternal; 5.6% fetal). Diagnose by urinary diastase in first trimester when amylase may be low • Ultrasound (US) is the most useful imaging tool in the evaluation of abdominal pain in pregnancy. • Do not hesitate to involve a surgeon, obstetrician/gynecologist,

OB 34

Causes of 3rd Trimester Bleeding

 Major   Placenta Previa  Abruption  Ruptured Vasa Previa  Uterine rupture/ laceration Minor  Bloody show  Cervical polyps  Cervical cancer  Cervical ectropion  Vaginal trauma