Minor Problems of Pregnancy

Minor Problems of Pregnancy

Backache
Backache is due to the laxity of spinal ligaments and weight of the pregnancy causing an exaggerated lumbar lordosis. Pregnancy can exacerbate the symptoms of a prolapsed intervertebral disc, occasionally leading to complete immobility. Advice should include maintenance of correct posture, avoiding lifting heavy objects (including children), avoiding high-heels, regular physiotherapy and simple analgesia (paracetamol or paracetamol-codeine combinations).


Symphysis pubis dysfunction
This is an excruciatingly painful condition usually occurring in the third trimester. The symphysis pubis joint becomes loose , causing the two halves of the pelvis to rub on one another when walking or moving. The condition will only improve after delivery, and the management revolves around simple analgesia and, under the physiotherapist s direction, a low stability belt may be worn.

Constipation
Constipation is usually blamed on the effect of progesterone in slowing gut motility, but the physical weight of the gravid uterus on the rectum may contribute, as may concomitantly administered iron tablets. A high-fibre diet should be encouraged, increase daily fluid intake and a mild (non-stimulant) laxative such as lactulose may be suggested.








Nausea & vomiting & Hyperemesis Gravidarum:
Nausea & vomiting are common symptoms in early pregnancy affecting over half of pregnant women. The onset of symptoms is around 5-6 weeks gestation & cessation of symptoms occurs at about 16 weeks. It is erroneously referred to as morning sickness. It is worse in multiple pregnancy & is related to high circulating human chorionic gonadotrophin (hCG) level.
Hyperemesis is less common but associated with more morbidity, hospital admission & can be dangerous if not treated appropriately. Nausea & vomiting becomes hyperemesis when the woman is unable to maintain hydration & nutrition because of severity or duration of symptoms. A standard definition of HG is the occurrence of more than three episodes of vomiting per day with ketonuria and more than 3 kg or 5% weight loss.
Risk factors for HG include multiple pregnancy, nulliparity, obesity, metabolic disturbances, a history of HG in a previous pregnancy, trophoblastic disorders, psychological disorders (for example, eating disorders such as anorexia nervosa or bulimia) and a history of migration
It is associated with Mallory-Weiss tears, haematemesis, marked weight loss, muscle waisting, ketonuria, dehydration & electrolyte disturbance including hypokalaemia & metabolic hypochloraemic alkalosis. A common symptom is ptyalism (inability to swallow saliva).
The complications associated with hyperemesis include fetal growth restriction, maternal hyponatraemia & thiamin deficiency leading to Wernicke s encephalopathy.
Markers of severity include weight loss > 10%, abnormal thyroid function test & abnormal liver function.


Management:
Other causes of nausea & vomiting should be excluded, e.g. UTI, gasrtroenteritis & cholecystitis. An US scan is important to exclude hydatidiform mole & to diagnose multiple pregnancy, both of which increase the risk of hyperemesis.
The most important component of management is to ensure adequate rehydration, this should be with normal saline with added potassium chloride. Dextrose-containing fluids are avoided except in patients with diabetes. High concentration of dextrose may precipitate Wernicke s encephalopathy. This is avoided by oral or intravenous administration of thiamine.
Anti-emetics such as metoclopramide & prochlorperazine, are used liberally & safely in pregnancy & should be given on regular doses. For those who do not respond to conventional treatment, a trial of corticosteroid may be considered. In the very worst condition, termination of pregnancy may be considered if the mother is becoming malnourished & dehydrated.


Heart burn:
This is very common. The symptoms are of burning in the chest or discomfort, often on lying down. It occurs more frequently as the pregnancy progresses. Heartburn is caused by the weight effect of the pregnant uterus preventing stomach emptying and the general relaxation of the oesophageal sphincter due to progesterone. It is important to distinguish this symptom from the epigastric pain associated with pre-eclampsia which will usually be associated with hypertension & proteinuria. Management includes simple lifesyle modification such as maintaining upright posture especially after meals, lying with the head propped up at night, stopping smoking, frequent light meals and avoiding fatty foods. Liquid antacid preparations & H2 receptor antagonist are effective. Severe, refractory dyspeptic symptoms warrant gastroenterology referral to exclude a stomach ulcer or hiatus hernia.






Varicose veins and piles:
Haemorrhoids affect 1 in 10 women in last trimester of pregnancy. Both are due to the relaxant effect of progesterone on vascular smooth muscle & the dependent venous stasis caused by the weight of the pregnant uterus on the inferior vena cava.
Neither condition should be treated surgically in pregnancy; piles may be improved with local anesthetic/anti-irritant creams and a high-fibre diet.
Varicose veins of the legs may be symptomatically improved with support stockings, avoidance of standing for prolonged periods and simple analgesia. Thrombophlebitis may occur in a large varicose vein, more commonly after delivery.
Vulval & vaginal varicosities are uncommon but symptomatically troublesome; trauma at the the time of delivery ( episiotomy, tear) may cause considerable bleeding.


Carpal tunnel syndrome:
Compression neuropathies occur in pregnancy due to increased soft-tissue swelling. The most common of these is carpal tunnel syndrome. The median nerve, where it passes through the fibrous canal at the wrist before entering the hand, is most susceptible to compression. The symptoms include numbness, tingling and weakness of the thumb & forefinger. Diuretics are not advised; simple analgesia and splinting of the affected hand usually help. Surgical decompression is very rarely performed in pregnancy.

Oedema:
This is common, there is generalized soft-tissue swelling and increased capillary permeability, which lead to intravascular fluid to leak into the extravascular compartment. The fingers, toes and ankles are worst affected. Oedema is best dealt with by frequent periods of rest with leg elevation; occasionally, support stockings are indicated. Generalized edema may be a feature of pre-eclampsia so remember to check blood pressure & urine for protein. Severe edema may indicate cardiac impairment or nephritic syndrome.