Minor Problems of Pregnancy د.نادية مضر الحلي
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, 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.
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 marked weight loss, muscle waisting, ketonuria, dehydration & electrolyte disturbance including hypokalaemia & metabolic hypochloraemic alkalosis. A common symptom is ptyalism (inability to swallow saliva).
The risks 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 are used liberally & safely in pregnancy & should be given in regular doses. For those who do not respond to conventional treatment, a trial of corticosteroid may be considered.
Heart burn:
This is very common. The symptoms are of burning in the chest or discomfort, often on lying down. 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. Management includes liquid antacid preparations, stopping smoking, frequent light meals and lying with the head propped up at night. Severe, refractory dyspeptic symptoms warrant gastroenterology referral to exclude a stomach ulcer or hiatus hernia.
Varicose veins and piles:
These become worse in later 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.
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. Severe edema may indicate cardiac impairment or nephritic syndrome.