7b other problems during pregnancy

1
Other Problems During
Pregnancy
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
BEMoC - Presentation 7 (b)
Session 7b
 Urinary Tract Infection
 Hyperemesis Gravidarum
 Retention of Urine
 PROM

OTHER PROBLEMS DURING PREGNANCY
Government of India
2
Session Objectives
 To diagnose and manage other problems
during pregnancy
 Identify the causes
 Base line investigation required for diagnosis
 Management & timely referral

Government of India
3
Urinary Tract Infection
 Cystitis
 Pyelonephritis

Government of India
4
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

Government of India
5
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

Government of India
6
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

Government of India
7
Cystitis Vs Pyelonephritis
Cystitis Involves:
Lower urinary tract
Pyelonephritis Involves :
Upper urinary tract
mainly renal pelvis & the
renal parenchyma

Government of India
8
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.

Government of India
9
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

Government of India
10
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 a
single episode.

Government of India
11
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.

Government of India
12
Complications
 Fetal
• Growth retardation
• Pre term delivery
• Ante Partum fetal distress
 Maternal
• Septic shock
• Pulmonary Injury

Government of India
14
Hyperemesis Gravidarum
Excessive vomiting during pregnancy that affects
the 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

Government of India
15
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

Government of India
16
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.

Government of India
17
Complications
 Wernicke’s encephalopathy
 Peripheral neuritis
 Stress ulcers
 Esophageal tears and rupture
 Jaundice

Government of India
19
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

Government of India
20
Causes: Retention of urine
 During early pregnancy
• Incarcerated retroverted gravid uterus
• Impacted pelvic tumors
 During labour
• Obstructed labour
 During puerperium
• Operative vaginal delivery

Government of India
21
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.

Government of India
22
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

23
Premature Rupture of
Membranes (PROM)

Government of India
24
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

Government of India
25
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.

Government of India
26
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.

Government of India
27
Investigations: PROM
 Full Blood Count
 Urine Routine
 Urine Culture and Sensitivity
 High Vaginal swab for Culture and Sensitivity

Government of India
28
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

Government of India
29
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/cer
vicitis
Bloody vaginal
discharge
 Abdominal pain
 Loss of foetal movements
 Heavy, prolonged vaginal
bleeding
Antepartum
Haemorrhag
e
Blood-stained
mucus or watery
vaginal discharge
 Cervical dilatation and
effacement
 Contractions
Possible
labour (May
be term or
preterm)

Government of India
30
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

Government of India
31
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

Government of India
32
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.

Government of India
33
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

Government of India
34
Complications: PROM
 Increased incidence of pre-term labour and
pre-maturity
 Cord prolapse
 Dry labour
 Foetal pulmonary hypoplasia leading to
Respiratory Distress Syndrome (RDS)

Government of India
35
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

Government of India
36
Key Messages
 Dos & Don’ts of PROM
 Management of problems during pregnancy
 Referral of Pyelonephritis cases to FRU

Government of India
37
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

7b other problems during pregnancy

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (7)

Ähnlich wie 7b other problems during pregnancy

Ähnlich wie 7b other problems during pregnancy (20)

Mehr von Vikram Aditya

Mehr von Vikram Aditya (8)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

7b other problems during pregnancy