Pocket ObGyn – Common Prenatal Complaints
See Abbreviations
Nausea and Vomiting (Obstet Gynecol 2004;103:803)
- NVP: 70–85% of hCG & estrogen ® NVP.Typically presents <9 w ± abdominal pain. If abd pain & fever ® broader diff. 50% resolves by 14 w; 90% by 22 w (Am J Obstet Gyn 2000;182:931).
Therapy: Small, frequent meals w/ bland low-fat foods (BRAT diet). Use of ginger can be effective. Encourage hydration.
1st-line meds: Vit B6 (10–15 mg TID-QID) & antihistamines (doxylamine)
2nd-line meds: Promethazine, metoclopramide, then ondansetron
- Hyperemesis Gravidarum (HEG): NVP significant enough to cause dehyd, metabolic alkalosis, ketonuria, weight loss (>5%), <1% of pregnancies. Risks: Multi gest, FHx, or personal Hx in prior Preg.
- W/u: Labs may show elevated transaminases (<300), Amy, & lipase; hypochloremic metabolic alkalosis; suppressed TSH & thyroxine; ketones on UA
- Therapy: IV hydration (w/ dextrose ± thiamine), enteral nutrition (eg, tube feeding), hospitalization for monitoring & suppl as above
Carpal Tunnel Syndrome (CTS) (Muscle Nerve 2006; 34:559)
- Incid btw 2 & 35%; most often in 3rd Risks: H/o CTS in prior Preg, age
>30, nulliparous, edema. Caused by compression of median nerve related to edema in Preg. Sx include numbness, pain, paresthesias of thumb, index, & middle fingers, often worse at night. Exacerbated by flexion or extension of wrist, improved by mvmt of hands.
- Exam: ± median nerve sensory Phalen test: Pain reproduced w/ prolonged (>60 s) flexion of wrists. Tinel test: Pain reproducible w/ percussion at wrist over median nerve.
- Rx: Low salt diet, physical therapy, wrist bracing, Tylenol ® consider Cort injections for refrac Surgical intervention generally not indicated, sx improve w/i 1 y of deliv (4–50% persist at 1 y).
Round Ligament Pain
- Anatomy: Origin at uterine fundus ® inguinal canal, terminates in labia
- Presentation: Lower abdominal pain (more common in right lower quadrant). Exacerbated by mvmt, often reported as “shooting pain into ” Case reports of association w/ endometriosis, lipomas, & varicosities. Dx depends on ruling out other etiologies (eg, torsion, appendicitis, preterm labor).
- Rx: Typically self-limited. Advise acetaminophen, rest, & Belly-band can be helpful.
Lower Extremity Edema
- Physiologic changes in Preg predispose to edema SVR ¯, venous return impeded by gravid uterus. Water retention mediated by ¯ plasma osmolality due to osmolar reset of vasopressin & thirst thresholds (Br J Obstet Gynaecol 1985;92:1131).
- Rx: Elevation of feet & support Counsel women to report nonsymmetric edema or nondependent edema as these can be signs of pathology such as DVT or preeclampsia.
Low Back Pain (Obstet Gynecol 2004;104:65)
- Up to 70% report LBP during Risks: LBP outside of Preg, in a prev Preg, or w/ menstruation.
- Presentation: Attributed to changes in posture & joint Pain exacerbated by mvmt, relieved by rest. ± assoc neurologic sx.
- Exam: Eval motor/sensory fxn & reflexes to detect Paraspinal or joint tenderness to palpation & ¯ range of motion. Imaging not indicated in the absence of progressive neuro signs or trauma.
- Rx: Avoid excessive weight gain, lifting heavy objects, prolonged standing, bending from Recommend shoes w/ arch support & sleeping on side w/ pillow btw knees. Use of good body mechanics when lifting & getting out of vehicles is critical. Exercise, acupuncture, support belts may be helpful adjuncts (Cochrane Database Syst Rev 2007;18(2)).
Lower Extremity Varicosities
- Pathophysiology: Femoral venous pres in Preg up to 24 mm Hg secondary to uterine compression on Pressures closer to 8 mm Hg (pregravid state) in lateral recumbent position (Surg Gynecol Obstet 1950;90:481).
- Presentation: Sx vary from cosmetic complaints to a range of Throbbing pain that may worsen w/ advancing Preg, weight gain, & standing.
- Rx: Periodic elevation of feet & support Surgical correction during Preg generally avoided unless sev sx.
Vulvar Varicosities
- Pathophysiology: 4% lifetime prevalence, most often occurring during Preg b/c of
venous pressures & pelvic bld flow.“Vulvar veins lack valves”
- Presentation: Often asymptomatic & noted only on Pelvic discomfort & swelling worsened with standing or intercourse.
- Mgmt: Reassurance – most vulvar varicosities regress postpartum.Vulvar support belt for sev sx or local excision for Vaginal deliv not contraindicated despite theoretical risk of hemorrhage w/ laceration.
Hemorrhoids
- Pathophysiology: Arise w/i plexus of inferior & superior hemorrhoidal venous pressures in Preg ® engorgement both internally & externally ® venous stasis ® thrombosis & pain/swelling.
- Presentation: Painless bleeding w/ defecation or anal pruritus. Sev pain or complaints of a palpable lump can occur w/ thrombosis. External hemorrhoids visualized as dilated veins; thrombosis felt on palpation during rectal
Rx: Supportive w/ local anesthesia, hydration, & stool softeners. Topical anesthetics or steroid creams along w/ warm soaks can provide local relief.Thrombosis can be treated w/ excision under local anesthesia