7b other problems during pregnancy

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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



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Session Objectives

To diagnose and manage other problems during pregnancy

Identify the causes Base line investigation required for diagnosis Management & timely referral




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Urinary Tract Infection

Cystitis

Pyelonephritis




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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




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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




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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




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Cystitis Vs Pyelonephritis

Cystitis Involves:

Lower urinary tract

Pyelonephritis Involves :

Upper urinary tract

mainly renal pelvis & the renal parenchyma




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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.




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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




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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.




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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.




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Complications

Fetal

• Growth retardation

• Pre term delivery

• Ante Partum fetal distress Maternal

• Septic shock

• Pulmonary Injury

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Hyperemesis Gravidarum




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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




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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




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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.




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Complications

Wernicke’s encephalopathy Peripheral neuritis Stress ulcers Esophageal tears and rupture Jaundice

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Retention of Urine




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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




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Causes: Retention of urine

During early pregnancy

• Incarcerated retroverted gravid uterus

• Impacted pelvic tumors During labour

• Obstructed labour During puerperium

• Operative vaginal delivery




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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.




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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

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Premature Rupture of Membranes (PROM)




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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




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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.




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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.




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Investigations: PROM

Full Blood Count Urine Routine Urine Culture and Sensitivity High Vaginal swab for Culture and Sensitivity




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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




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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)




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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




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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




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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.




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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




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Complications: PROM

Increased incidence of pre-term labour and pre-maturity

Cord prolapse Dry labour Foetal pulmonary hypoplasia leading to

Respiratory Distress Syndrome (RDS)




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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




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Key Messages

Dos & Don’ts of PROM

Management of problems during pregnancy

Referral of Pyelonephritis cases to FRU




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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

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Thank you

7b other problems during pregnancy

Health & Medicine