7b other problems during pregnancy
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
395
On Slideshare
395
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
14
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. 1Other Problems DuringPregnancyMaternal Health DivisionMinistry of Health & Family WelfareGovernment of IndiaBEMoC - Presentation 7 (b)Session 7b Urinary Tract Infection Hyperemesis Gravidarum Retention of Urine PROM
  • 2. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India2Session Objectives To diagnose and manage other problemsduring pregnancy Identify the causes Base line investigation required for diagnosis Management & timely referral
  • 3. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India3Urinary Tract Infection Cystitis Pyelonephritis
  • 4. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India4Signs & Symptoms: UTI Fever, may be high grade, i.e. >38 °C; may beaccompanied with chills and rigors Burning on urination Increased frequency and urgency of urination Abdominal pain Flank tenderness
  • 5. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India5Signs & Symptoms: Cystitis & PyelonephritisTypically Present Sometimes Present Probablediagnosis• Dysuria• Increasedfrequency &urgency ofurination• Retropubic/ suprapubicpain during or afterurination• Lower abdominal pain(radiating form flanks toloin)Cystitis• Above PLUS• SpikingFever/Chills• Abdominal pain• Retropubic/ suprapubicpain during or afterurination• Loin pain/ Tenderness• Tenderness in the rib cage• Anorexia• Nausea/ VomitingAcutePyelonephritis
  • 6. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India6Signs & Symptoms: Cystitis & PyelonephritisCystitis:Involves lower urinarytract Dysuria Increased frequency &urgency of urination Lower abdominal pain(Radiating from flanksto loin)Pyelonephritis:Involves upper urinary tract,mainly renal pelvis & the renalparenchyma Spiking fever with chills &rigor Toxic look Loin pain (costo-vertebralangle tenderness) Dysuria Nausea Vomiting
  • 7. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India7Cystitis Vs PyelonephritisCystitis Involves:Lower urinary tractPyelonephritis Involves :Upper urinary tractmainly renal pelvis & therenal parenchyma
  • 8. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India8Investigations Microscopy: WBCs, bacteria, sometimes RBC’s Urine culture and sensitivity: identify the organismand its antibiotic sensitivity PS for mp to differentiate from malaria Blood culture HaemogramNote: These tests can determine if UTI is present, but will notdifferentiate between cystitis & acute pyelonephritis Urine examination requires a clean-catch mid-streamsample to minimize the possibility of contamination.
  • 9. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India9General Management Encourage bed rest in lateral supine position Physical activity should be moderate Encourage increased fluid intake by mouthlike water, juice, soups etc. Use a fan or tepid sponge to help decreasethe body temperature Antipyretics/Analgesics if required Sodium intake may require adjustments if pt ishypertensive
  • 10. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India10Management: 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 3days 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 thepregnancy up till two weeks postpartum as under:• Co-trimoxazole 1 tablet (160/800 mg) OD at bedtime OR• Amoxicillin 250 mg OD at bedtimeNOTE: Prophylaxis is indicated only after recurrent infections, and NOT after just asingle episode.
  • 11. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India11Management: Pyelonephritis Should be aggressive to avoid complication endotoxicshock (keep a watch on tachycardia & hypotension) If shock is present or suspected, initiate immediatetreatment Start an IV infusion and infuse IV fluids @ 150 ml perhour Start the woman on antibiotics and refer her to an FRUfor further management. Give:• Ampicillin 2 g IV 6 hourly PLUS• Gentamicin 80 mg IM 12 hourly Give Paracetamol, 500 mg orally as needed to controlthe pain and lower the body temperature.
  • 12. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India12Complications Fetal• Growth retardation• Pre term delivery• Ante Partum fetal distress Maternal• Septic shock• Pulmonary Injury
  • 13. 13Hyperemesis Gravidarum
  • 14. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India14Hyperemesis GravidarumExcessive vomiting during pregnancy that affectsthe day to day activity and health of the mother Common in: Primigravidas, Multiplepregnancy, Molar Pregnancy On examination:• Dehydration (dry tongue, loss of skin turgor,oliguria in severe cases)• Tachycardia• Ketonuria
  • 15. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India15Differential Diagnosis: Hyperemesis Gravidarum Exclude the following conditions which mayresult in vomiting when present duringpregnancy:• Jaundice• Meningitis• Diabetic coma• Uremic Coma• Peritonitis due untreated septic abortion• Intestinal obstruction
  • 16. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India16Management: Hyperemesis Gravidarum Admit & reassure the woman and her family. Counsel them regarding the harmless nature of thecondition. Start IV fluids slowly, either R/L or dextrose saline. Repeat urine examination every four hours till it becomesnegative for ketone bodies. USG optional – rule out twins and vesicular mole Give an anti-emetic such as Inj. Stemetil to control thevomiting & 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.
  • 17. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India17Complications Wernicke’s encephalopathy Peripheral neuritis Stress ulcers Esophageal tears and rupture Jaundice
  • 18. 18Retention of Urine
  • 19. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India19Retention of urineCauses: During the late first trimester, dysuria maypresent due to pressure of the retrovertedgravid uterus on the bladder, though usuallythis does not present with any symptoms. A retroverted uterus expanding in the pelvismay exert pressure on the bladder neckcausing retention if it persists in this positionbeyond 12 weeks The woman will present with urinary retentionand a distended bladder
  • 20. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India20Causes: Retention of urine During early pregnancy• Incarcerated retroverted gravid uterus• Impacted pelvic tumors During labour• Obstructed labour During puerperium• Operative vaginal delivery
  • 21. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India21Diagnosis: Retention of urine On abdominal examination:• Cystic swelling is palpable in the lowerabdomen arising from the pelvis.• Swelling may be large enough to reachabove the umbilicus. On vaginal examination:• The cervix is high up behind the symphysispubis and directed downward and forward.• The uterus is retroverted, more than 12weeks in size and is felt below the cervix.• There is a cystic mass in the anterior fornix.
  • 22. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India22Management: Retention of urine Management involves keeping the bladder empty with aurinary catheter for 48 to 72 hours allowing the uterus torise above the pelvic brim Under all aseptic precautions, insert a self retainingFoley’s catheter and collect urine for microscopy (thismeasure allows the uterus to rise above the pelvic brim) OR Put the woman in prone position so that the uterusbecomes anteverted Drain the urine continuously for 48 hrs These measures allow the uterus to rise above thepelvic brim Once the uterus is palpable P/A, remove the catheter Ensure that the woman voids urine
  • 23. 23Premature Rupture ofMembranes (PROM)
  • 24. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India24PROM Spotaneous rupture of membranes (bag of water)any time beyond 28 weeks of pregnancy butbefore onset of labour is called PROM Diagnosed by passage of watery discharge fromvagina either in the form of sudden gush or slowleakage Diagnosis is confirmed by per speculum exam withaseptic precautions Avoid per vaginal examination
  • 25. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India25Signs & Symptoms: PROM On Inspection:• Profuse watery discharge with the typical odourof the amniotic fluid may be seen at the introitus Signs and symptoms:• P/S examination (done aseptically): A pool ofamniotic fluid lying in the vagina, or amnioticfluid coming out of the cervix, particularly whenthe woman is made to cough.• A sterile pad placed over the vulva andexamined after an hour may show the padsoaked with amniotic fluid.
  • 26. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India26Tests in PROM If the facilities are available, the following tests may also becarried out. Nitrazine test:• Normal vaginal secretions are acidic and the amniotic fluidis alkaline.• Touching a nitrazine paper to the pool of fluid collected ona speculum from the vagina will change it from yellow toblue if the fluid is alkaline, indicating rupture of themembranes. Ferning test:• Amniotic fluid, when dried, crystallizes and leaves a fern-leaf pattern.• Spread some fluid pooled in the vagina on a glass slideand let it dry.• Examine under a microscope for ferning.
  • 27. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India27Investigations: PROM Full Blood Count Urine Routine Urine Culture and Sensitivity High Vaginal swab for Culture and Sensitivity
  • 28. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India28D/D of vaginal Discharge during pregnancySymptoms andsigns typicallypresentSymptoms and signssometimes presentProbablediagnosisWatery vaginaldischarge Sudden gush orintermittent leaking of fluid Fluid seen at the introitus No contractions within 1hourPROM Foul-smellingwatery vaginaldischarge after 22weeks of gestation Fever/chills Abdominal pain History of loss of fluid Tender uterus Rapid foetal heart rate Light vaginal bleedingAmnionitis
  • 29. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India29D/D of vaginal Discharge during pregnancySymptoms andsigns typicallypresentSymptoms and signssometimes presentProbablediagnosis Foul-smellingvaginal discharge No history of lossof fluid Itching Frothy/curdy discharge Dysuria Abdominal painVaginitis/cervicitisBloody vaginaldischarge Abdominal pain Loss of foetal movements Heavy, prolonged vaginalbleedingAntepartumHaemorrhageBlood-stainedmucus or wateryvaginal discharge Cervical dilatation andeffacement ContractionsPossiblelabour (Maybe term orpreterm)
  • 30. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India30Management: PROM < 37 wks w/o infection Managed conservatively under strict monitoring for signs ofchorioamnionitis At the earliest signs of chorioamnionitis pregnancy needs tobe terminated in a FRU set up Before referral administer triple antibiotic and the first dose ofsteroids for fetal lung maturity:• Ampicillin 1 gm PLUS Metronidazole 400 mg orally PLUSInj Gentamycin 80 mg IM• Inj Betamethasone 12 mg IM OR Inj Dexamethasone 6 mgIM If palpable contractions and a blood-stained mucus discharge:suspect preterm labour & manage accordingly If in labor : Manage as preterm labor
  • 31. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India31Management: PROM < 37 wks with infection Refer to FRU after the first dose of tripleantibiotics & stabilizing the woman Signs of Infection:• Fever• Tachycardia• Leucocytosis• Lower Abdominal Pain• Foul Vaginal Discharge• Uterine Tenderness• Hot vagina• Fetal Tachycardia
  • 32. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India32Management: 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 asrequired after giving her the first dose of the tripleantibiotics.
  • 33. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India33Management: PROM > 37 wks with Infection At the earliest signs of chorioamnionitis pregnancyneeds to be terminated If in 1ststage of labor:• Refer to FRU for induction or a caesareansection as required after giving her the firstdose of the triple antibiotics. If in active labor & delivery imminent :• Conduct Normal Delivery with AMTSL aftergiving her the first dose of the triple antibiotics.• Referral to higher health facility for specializedneonatal care
  • 34. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India34Complications: PROM Increased incidence of pre-term labour andpre-maturity Cord prolapse Dry labour Foetal pulmonary hypoplasia leading toRespiratory Distress Syndrome (RDS)
  • 35. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India35Dos & Don’ts: PROMDo’s Aseptic Per SpeculumExamination Nitrazine Test Ferning test Referral to higher healthfacility for specializedneonatal care If vaginal bleeding withintermittent or constantabdominal pain, suspectabruptio placentaeDon’ts If a woman complains ofbleeding after 20 weeks ofgestation, do NOT do adigital vaginal examination A digital examination (P/V) inno way helps to establish thediagnosis of PROM Instead it may add to thecomplication by way ofintroducing infection Don’t give Corticosteroids inthe presence of frankinfection
  • 36. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India36Key Messages Dos & Don’ts of PROM Management of problems during pregnancy Referral of Pyelonephritis cases to FRU
  • 37. OTHER PROBLEMS DURING PREGNANCYMaternal Health DivisionMinistry of Health & Family WelfareGovernment of India37Case 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 Trainers guide
  • 38. 38Thank you