Minor complications of pregnancy

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Chapter 10 Minor complications of pregnancy

CHAPTER CONTENTS

Backache 95
Cervical eversion and discharge 95
Constipation 95
Displacement of the uterus 96

Retroversion 96
Uterovaginal prolapse 96
Dyspnoea 96
Heartburn 96
Haemorrhoids and varicose veins 96
Insomnia 96
Leg cramps 96
Micturition 97

Frequency of micturition 97
Urinary incontinence 97
Nausea and vomiting 97

Mild 97
Moderate 97
Severe 97
Oedema 97
Palpitations, fainting and headaches 98
Placidity and drowsiness 98
Pubic symphysis diastasis 98
Pruritus 98
Sweating 98
Vaginal discharges 98

The physiological and anatomical changes that occur during pregnancy may lead to complications which, although minor in medical terms, may cause considerable distress and discomfort to many pregnant women. They are listed below in alphabetical order.

BACKACHE

Backache is common in late pregnancy and is felt over the sacroiliac joints. It is caused by relaxation of the ligaments and muscles supporting the joints, and is probably also induced by progesterone and, possibly, relaxin. It is usually worse at night and may prevent the woman from sleeping. Wearing flat-heeled shoes, avoiding heavy lifting, gentle exercise (including water-based exercise), physiotherapy and acupuncture are all beneficial.

CERVICAL EVERSION AND DISCHARGE

The high levels of oestrogen in pregnancy may increase the eversion of the endocervical columnar cells so that they appear as a red ring around the external cervical os. The cells may secrete mucus when exposed to the vagina, causing a non-infective vaginal discharge. The condition has erroneously been called a cervical erosion.

CONSTIPATION

The reduced gut motility associated with increased progesterone is aggravated in late pregnancy by the pressure of the enlarged uterus, making constipation common in pregnancy. Treatment consists of increasing dietary fibre (for example by eating wholemeal instead of white bread) and attempting to defecate after a meal. If the constipation is causing discomfort the woman may be prescribed oral sterculia with frangula bark granules (Normacol) or the contact laxative bisacodyl.

DISPLACEMENT OF THE UTERUS

Retroversion

In 10% of women the uterus is normally retroverted; moreover, retroversion of the uterus does not hinder conception, and so when examined vaginally in the early weeks of pregnancy some women will be found to have a retroverted uterus. In nearly all cases the uterus becomes anteverted spontaneously, usually between the 9th and 11th weeks of pregnancy. Very rarely the uterus remains retroverted until after the 14th gestational week and becomes incarcerated in the cul-de-sac. If this occurs the woman complains of frequency of micturition and dysuria. If the position of the uterus is not corrected, the symptoms increase in severity and eventually there is retention of urine and an enormously distended bladder. Finally, retention of urine with overflow occurs. Examination shows a smooth, soft cystic tumour arising in the pelvis and palpable abdominally in the midline. Treatment entails inserting a catheter and decompressing the bladder slowly. When this is done the uterus usually becomes anteverted, but may need to be anteverted using the fingers by pushing up in the posterior fornix and manipulating the uterus to one side of the sacral promontory.

Uterovaginal prolapse

In multiparous women, particularly in the developing countries, uterovaginal prolapse may complicate pregnancy. In the early weeks of pregnancy the prolapse may become more prominent. As the uterus becomes an abdominal organ the pressure on the vagina is relieved to some extent, and the prolapse becomes less obvious. Occasionally a swollen, infected cervix may protrude through the vulva. The prolapse causes few problems during labour and cervical dilatation is usually rapid. Pregnancy after a vaginal repair for prolapse is considered on page 307.

DYSPNOEA

By the 15th week of pregnancy one woman in four complains of dyspnoea on exertion. The proportion increases as pregnancy advances, with the result that, by the fourth quarter of pregnancy, three-quarters of pregnant women are dyspnoeic. The condition is probably due to a lack of adaptation to progesterone-induced hyperventilation. Once pathological causes such as severe anaemia and cardiac disease are excluded, the woman can be reassured that the breathlessness will not harm her or her fetus and that no specific treatment is required.

HEARTBURN

Relaxation of the lower oesophageal sphincter permits the regurgitation of some of the stomach contents, causing irritation of the lower oesophagus. It is also possible that a similar relaxation of the pyloric sphincter permits a reflux of bile into the stomach, which may then be regurgitated into the lower oesophagus. The woman complains of heartburn, which increases as the pregnancy advances.

Treatment is difficult, but frequent small meals, avoidance of spicy food and cigarettes, and the use of antacids may relieve the discomfort. If antacids fail, floating antacids such as a sodium alginate–sodium bicarbonate mixture or the H2 receptor antagonist ranitidine hydrochloride may give relief. If the heartburn occurs predominantly at night, the use of extra pillows to prop up the expectant mother may help.

HAEMORRHOIDS AND VARICOSE VEINS

Haemorrhoids and varicose veins of the legs, and occasionally of the vulva, become increasingly common as pregnancy advances. Haemorrhoids often become larger or may appear for the first time during childbirth. They may persist for several months after the birth and cause pain. Constipation should be avoided and topical treatment prescribed.

Varicose veins increase in size in late pregnancy. Treatment entails the woman lying or sitting with her feet up as much as possible and, if the veins are painful or disfiguring, wearing elastic stockings. The latter should be put on before the woman gets out of bed in the morning. Surgical treatment for either condition is generally contraindicated in pregnancy.

INSOMNIA

Many pregnant women find that their sleep pattern is altered. In early pregnancy they may sleep for longer than usual. In late pregnancy, because of the discomfort of the enlarged uterus, leg cramps and backache, sleep may be disturbed.

LEG CRAMPS

The cause of leg cramps is not known. They tend to occur more frequently in the second half of pregnancy, usually at night. Magnesium (lactate or citrate) 122 mg morning and 244 mg nocte reduces severe cramps in one-third of suffers compared with placebo. Calcium supplements are ineffectual. Some women obtain relief if the foot of the bed is raised about 25 cm.

MICTURITION

Frequency of micturition

Increased frequency of micturition is common in early pregnancy, when it is due to a supranormal excretion of urine by the kidney, and in the last weeks when the pressure of the fetal head causes direct irritation of the trigone.

Urinary incontinence

Urinary incontinence affects over 50% of pregnant women to some extent, and 15% complain that the leakage is troublesome. There is no specific treatment, although pelvic floor exercises may help (see Box 39.1, p. 311). Usually the leakage eases in the puerperium.

NAUSEA AND VOMITING

Nausea due to pregnancy affects over 75% of women and vomiting occurs in half of them. The symptoms usually begin in the sixth gestational week and cease by the 14th, although they may continue throughout the pregnancy. The symptoms are more common in women who have a history of unsuccessful pregnancies, or who are carrying a multiple pregnancy. One-quarter of women who have the symptoms will experience them again in a subsequent pregnancy.

The cause appears to be either the effect of the rising levels of oestrogen, or the high levels of human chorionic gonadotrophin (hCG) acting on the chemoreceptor trigger zone in the midbrain. Once the body has become habituated to the new hormonal environment, the nausea and vomiting usually cease. In addition, psychological factors may act on the emetic centre in the cerebral cortex.

Nausea and vomiting may be graded as mild, moderate or severe.

Mild

Mild nausea (and occasional vomiting) affects 45% of pregnant women and is the most common form. The nausea can occur in the morning (morning sickness), but may occur at any time of the day and can be provoked by emotional stress.

Treatment

The patient should be advised to eat frequent small meals during the day, to take fluid between (not with) meals, and to eat whatever she feels helps her nausea. If the vomiting is distressing she can be prescribed pyridoxine 50 mg 6-hourly or metoclopramide (Maxolon) 10 mg two to three times a day.

Moderate

Moderate nausea and vomiting affects 5% of all pregnant women, and 10% of all women suffering from nausea. The symptoms may occur at any time of the day or night. The patient feels miserable and may become mildly dehydrated.

Severe

This form is uncommon, affecting 1 in 1000 pregnant women. The nausea is continuous and the vomiting frequent. This is the reason for its name – hyperemesis gravidarum. The woman rapidly becomes dehydrated and ketoacidotic.

Treatment

The patient should be admitted to hospital and treatment started urgently to avoid the possibility of liver damage. An intravenous line is established and dehydration and ketosis corrected by infusing 1 L of 5% dextrose, followed by 1 L of Hartmann’s solution if electrolyte disturbance is detected. The infusion should provide 3–4 L/day and is continued until hydration and electrolyte balance have been corrected. The fluid intake and output are recorded, and the urine is checked twice daily for acetone, bile, sugar and specific gravity. Plasma electrolytes are measured daily. If vomiting persists, the patient should be given metoclopramide (10 mg IV or IM) as needed. During the time that the infusion is running the patient can be given ice to suck, and oral feeding should be withheld. Corticosteroids have been used successfully in non-randomized studies. Once the vomiting has ceased the patient is treated in the same way as for the moderate form of nausea. She should remain in hospital for 2 days after the vomiting has ceased and until she has begun to gain weight.

OEDEMA

Oedema, particularly of the legs, is, in the absence of hypertension, a normal physiological adaptation to the pregnant state. The cause is water stored in the ground substance of connective tissue. In pregnancy the increased secretion of oestrogen alters the ground substance from a colloid-rich, water-poor matrix to a colloid-poor, water-rich matrix. In addition, in late pregnancy, increased mechanical obstruction to the venous return from the legs adds to leg oedema. Oedema around the ankles and lower legs is more common towards evening in hot, humid climates, and in obese women. Treatment consists of the woman sitting or lying with her legs elevated. There is no place for diuretics.

Oedema associated with a rise in blood pressure requires further investigation, particularly when the hands or face become oedematous (see Ch. 14).

PALPITATIONS, FAINTING AND HEADACHES

These symptoms are common in pregnancy and are caused by altered cardiovascular dynamics. The patient should be examined and reassured that she has no organic lesion. Auscultation of the heart may reveal a soft systolic murmur, which is due to the hypervolaemic circulation occurring during pregnancy. A murmur of this kind is not a sign of cardiac damage. Some women feel faint when lying on their back in late pregnancy because the pressure of the uterus reduces venous return to the heart (supine hypotension). Pregnant women should avoid lying flat on their backs. Headaches also appear to be due to the altered vascular dynamics.

PLACIDITY AND DROWSINESS

These symptoms are common in pregnancy and are due to the increase in circulating progesterone. This relaxation during pregnancy is enjoyed by some women, but others become frustrated by their inertia. There is no effective treatment available.

PUBIC SYMPHYSIS DIASTASIS (PELVIC OSTEOARTHROPATHY)

In a few women abnormal relaxation of the ligaments surrounding the pubic joint permits the pubic bones to move on each other when the woman walks or exerts herself. This movement may put strain on the sacroiliac joints. Pubic symphysis diastasis may occur during pregnancy or start in the puerperium. The pain may persist for the remainder of the pregnancy or for several weeks after the birth, which makes care of the neonate difficult. The patient complains of severe pubic pain, backache and sacral pain. Examination shows that the pubic joint is very tender when pressed. The diastasis can be confirmed by ultrasound or X-ray examination (Fig. 10.1). Treatment consists of bed rest on a firm mattress, with the patient nursed as far as is possible on one or other side.

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Fig. 10.1 Pelvic symphysis diastasis. The patient is 39 weeks’ pregnant. The sliding movement of the symphysis is shown when (A) the patient stands on her right leg; (B) the patient stands on her left leg.

PRURITUS

After exclusion of a skin rash and abnormal liver function, antihistamines can decrease the skin irritation.

SWEATING

Because of the vasodilatation and increased peripheral circulation, pregnant women ‘feel the heat’ and often sweat profusely, particularly in hot, humid climates. No treatment is available apart from frequent cool showers.

VAGINAL DISCHARGES

In pregnancy the quantity of normal vaginal secretions increases and many women complain of a non-irritant vaginal discharge. Vaginal infections, particularly candidiasis, are more frequent in pregnant women than in non-pregnant women. Vaginal discharges are discussed on pages 260–262.

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