Problems of Pregnancy

Chapter 12 Problems of Pregnancy



Abdominal pain in pregnancy


Abdominal pain is a common complaint in pregnancy. It is probably suffered by all women at some stage, and therefore presents a problem for the midwife of how to distinguish between:



image the physiologically normal (e.g. mild indigestion or muscle stretching)


image the pathological but not dangerous (e.g. degeneration of a fibroid)


image the dangerously pathological requiring immediate referral to the appropriate medical practitioner for urgent treatment (e.g. ectopic pregnancy or appendicitis).


The midwife should take a detailed history and perform a physical examination in order to reach a decision about whether to refer the woman. Treatment will depend on the cause (Box 12.1) and the maternal and fetal conditions.



Box 12.1 Causes of abdominal pain in pregnancy




Pregnancy-specific causes



Physiological




• Heartburn, excessive vomiting, constipation


• Round ligament pain


• Severe uterine torsion


• Braxton Hicks contractions


• Miscellaneous discomfort in late pregnancy



Pathological




• Ectopic pregnancy


• Miscarriage


• Uterine fibroids


• Placental abruption


• Preterm labour


• Severe pre-eclampsia


• Uterine rupture



Incidental causes (consider domestic abuse)



Common pathology




• Appendicitis


• Intestinal obstruction


• Cholecystitis


• Inflammatory bowel disease


• Peptic ulcer


• Renal disease


• Ovarian pathology, e.g. torsion


• Acute pancreatitis


• Urinary tract infection


• Malaria


• Tuberculosis (may be associated with HIV infection)



Rare pathology




• Rectus haematoma


• Sickle-cell crisis


• Porphyria


• Arteriovenous haemorrhage


• Malignant disease



Uterine fibroid degeneration


Uterine fibroid degeneration may cause recurrent acute pain during pregnancy and is due to a diminished blood supply that may cause central core necrosis of a fibroid or fibroids.



Management




image Rest and analgesia are required.


image Be aware that enlargement of the fibroid may occasionally impede the progress of labour and lead to rupture of the uterus.



Severe uterine torsion


Severe uterine torsion refers to rotation of the uterus by more than 90°, which may cause pain in the latter half of pregnancy.



Management




image Bed rest is necessary, altering the maternal position to correct the torsion spontaneously


image Analgesia is required.


image In severe cases a laparotomy will need to be performed in order for a clear diagnosis to be made.


image Delivery by caesarean section may be performed, either preceded or followed by manipulation of the uterus.



Symphysis pubis dysfunction (Pelvic girdle pain [PGP])


This refers to abnormal relaxation of ligaments, causing increased mobility of the pubic joint. The woman may complain of pain at any time from the 28th week of pregnancy.



Management




image Reduce non-essential weight-bearing activities and avoid straddle movements that abduct the hips, e.g. squatting.


image A supportive panty girdle or ‘tubigrip’ and comfortable shoes may help when the woman is up and about.


image Refer to an obstetric physiotherapist for advice and treatment.


image In severe cases, bed rest on a firm mattress may be necessary.


image Postnatal physiotherapy will aid the strengthening and stabilisation of the joint.



Antepartum haemorrhage (APH)


Antepartum haemorrhage is bleeding from the genital tract after the 24th week of gestation and before the onset of labour.




Effect on the fetus


Fetal mortality and morbidity are increased as a result of severe vaginal bleeding in pregnancy. Stillbirth or neonatal death may occur. Premature placental separation and consequent hypoxia may result in severe neurological damage in the baby.



Effect on the mother


If bleeding is severe, it may be accompanied by shock and disseminated intravascular coagulation (DIC). The mother may die or be left with permanent ill health.



Types of APH (Table 12.1)




image Bleeding from local lesions of the genital tract (incidental causes).


image Placental separation due to placenta praevia or placental abruption.


Table 12.1 Causes of bleeding in late pregnancy













































Cause Incidence (%)
Placenta praevia 31.0
Placental abruption 22.0
‘Unclassified bleeding’, e.g.: 47.0
Marginal  
Show  
Cervicitis  
Trauma  
Vulvovaginal varicosities  
Genital tumours  
Genital infections  
Haematuria  
Vasa praevia  
Other  


Initial appraisal of a woman with APH


APH is unpredictable and the woman’s condition can deteriorate rapidly at any time. A rapid decision about the urgency of need for a medical or paramedic presence, or both, must be made, often at the same time as observing and talking to the woman and her partner.



Assessment of physical condition



Maternal condition




image Take a history from the woman.


image Observe pulse rate, respiratory rate, blood pressure and temperature.


image Look for any pallor or breathlessness.


image Assess the amount of blood lost.


image Perform a gentle abdominal examination, observing for signs that the woman is going into labour.


image On no account must any vaginal or rectal examination be done; nor may an enema or suppository be given to a woman suffering from an APH.



Fetal condition




image The mother should be asked if the baby has been moving as much as normal.


image Attempt to auscultate the fetal heart; ultrasound apparatus may be used in order to obtain information.



Factors to aid differential diagnosis


The location of the placenta is perhaps the most critical piece of information that will be needed in order to make a correct diagnosis; initially, the midwife may not have this fact at her disposal. However, if she is able to elicit the information listed in Box 12.2 from her observations and from talking to the woman and her partner, then this will help her to arrive at a provisional diagnosis.



Box 12.2 Diagnosis of antepartum haemorrhage



Pain




• Did the pain precede bleeding and is it continuous or intermittent?



Onset of bleeding




• Was this associated with any event such as abdominal trauma or sex?



Amount of visible blood loss




• Is there any reason to suspect that some blood has been retained in utero?



Colour of the blood




• Is it bright red or darker in colour?



Degree of shock




• Is this commensurate with the amount of blood visible or more severe?



Consistency of the abdomen




• Is it soft or tense and board-like?



Tenderness of the abdomen




• Does the mother tense on abdominal palpation?



Lie, presentation and engagement




• Are any of these abnormal when account is taken of parity and gestation?



Audibility of the fetal heart




• Is the fetal heart heard?



Ultrasound scan




• Does a scan suggest that the placenta is in the lower uterine segment?



Supportive treatment




image Provide emotional reassurance.


image Give rapid fluid replacement (warmed) with a plasma expander, and later with whole blood if necessary.


image Give analgesia.


image If at home, arrange transfer to hospital.


image Subsequent management depends on the definite diagnosis.



Placenta praevia


In this condition the placenta is partially or wholly implanted in the lower uterine segment on either the anterior or posterior wall.


The lower uterine segment grows and stretches progressively after the 12th week of pregnancy. In later weeks this may cause the placenta to separate and severe bleeding can occur.



Degrees of placenta praevia


See Box 12.3 and Figs 12.1–12.8.



Box 12.3 Degrees of placenta praevia



Type 1 placenta praevia




• The majority of the placenta is in the upper uterine segment


• Blood loss is usually mild and the mother and fetus remain in good condition


• Vaginal birth is possible



Type 2 placenta praevia




• The placenta is partially located in the lower segment near the internal cervical os


• Blood loss is usually moderate, although the conditions of the mother and fetus can vary


• Vaginal birth is possible, particularly if the placenta is anterior



Type 3 placenta praevia




• The placenta is located over the internal cervical os but not centrally


• Bleeding is likely to be severe


• Vaginal birth is inappropriate



Type 4 placenta praevia




• The placenta is located centrally over the internal cervical os


• Torrential haemorrhage is very likely


• Caesarean section is essential



Fig. 12.1–12.4: Types of placenta praevia.


image

Fig. 12.1: Type 1.


image

Fig. 12.2: Type 2.


image

Fig. 12.3: Type 3.


image

Fig. 12.4: Type 4.



Fig. 12.5–12.8: Relation of placenta praevia to cervical os.


image

Fig. 12.5: Type 1.


image

Fig. 12.6: Type 2.

< div class='tao-gold-member'>

Related posts:

  1. The Placenta
  2. Prolonged Pregnancy and Disorders of Uterine Action
  3. The Third Stage of Labour
  4. Antenatal Care

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 11, 2016 | Posted by in MIDWIFERY | Comments Off on Problems of Pregnancy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access