Normal Pregnancy: Common issues in Pregnancy

Question 1

Define anaemia in pregnancy

Answer 1

From RCOG:
Anaemia in pregnancy is defined as first trimester haemoglobin (Hb) less than 110 g/L
second/third trimester Hb less than 105 g/L, and
postpartum Hb less than 100 g/L

From Oxford Handbook:
Hb < 105g/L.

Question 2

Why is physiological anaemia common in pregnancy?

Answer 2

From 10 weeks of gestation, plasma volume rises until 32 weeks by 50+ % .
Red cell volume rises by 18% (if not taking iron supplements) - 32% (if taking supplements).
So, Hb falls due to dilution = physiological anaemia

Question 3

Who is prone to anaemia in pregnancy?

Answer 3

1. Women who start pregnancy anaemic
   e.g from menorrhagia, hookworm, malaria, have haemoglobinopathies
2. Women with frequent pregnancies
3. Women with twin pregnancy
4. Women who have a poor diet

Question 3

Who is prone to anaemia in pregnancy?

Answer 3

1. Women who start pregnancy anaemic
   e.g from menorrhagia, hookworm, malaria, have haemoglobinopathies
2. Women with frequent pregnancies
3. Women with twin pregnancy
4. Women who have a poor diet

Question 4

When should pregnant women be offered antenatal screening for anaemia?

Answer 4

At booking (first visit)
At 28 weeks

Question 5

A pregnant lady comes to her first antenatal screening at LRI. She is a black patient and lived in sub Saharan Africa for over 20 years. She has travelled to live in the UK 2 months ago.
What antenatal screening would you offer her?

Answer 5

• Hb - need to check for anaemia
• Sickle cell tests
• Malaria - thick and thin blood films (the gold standard) or an antigen detection tests.
• Hb electrophoresis for other haemoglobinopathies
• HIV, HepB, syphilis screen should also be offered.

Question 6

What investigations would you do for anaemia in pregnancy?
For each, describe findings that support anaemia in pregnancy

Answer 6

Oxford:
FBC
Ferritin
B12 and Folate

Iron deficiency anaemia - Iron, ferritin are low and Total iron binding capacity (TIBC) is high

Folate deficiency anaemia - MCV is raised, serum and red cell folate are reduced.

Question 7

Symptoms for anaemia in pregnancy?
Distinguish between mild and severe anaemia symptoms

Answer 7

Mild anaemia:
Breathlessness, tiredness, fainting, headaches, palpatations/feel heart beating faster.

Severe anaemia:
The above + feel very unwell with dizziness, breathlessness and chest pain

Question 8

Causes for anaemia in pregnancy?

Answer 8

Iron deficiency - women enter pregnancy with low iron stores
Folate deficiency
Coeliac disease
CKD
Autoimmune disease

Question 9

Treatment for anaemia in pregnancy?

Answer 9

Iron and folate supplements:
Oral iron - ferrous sulfate 200mg BD PO

Parentral iron - used when woman is not tolerating oral iron:
Iron dextran or iron sucrose

Severe late anaemia (Hb < 90g/L) = may need blood transfusion.

Question 10

What advice would you give woman when prescribing oral iron supplements (ferrous sulfate 200mg)?

Answer 10

• Take w/ OJ - vit C helps iron absorb into body
• Avoid taking supplement with tea, calcium or other metal containing supplements
• Alternate day dosing or even twice weekly dosing can help prevent GI SE and improve Hb
• Taking oral iron is a great way to prevent needing blood transfusion later in preganancy (if they can’t do this due to religious beliefs / personal reasons).

Question 11

Differentials for pregnant woman presenting with breathlessness?

Answer 11

Pregnancy related SOB:
* physiological breathlessness of pregnancy
* Amniotic fluid embolism
* Peripartum cardiomyopathy
* Preeclampsia
* HELLP syndrome

Non-pregnancy related SOB:
* Cardiac –> ACS, pericarditis, cardiac tamponade, cardiomyopathies, arrythmias, valvular heart disease, pulmonary arterial HTN
* Pulmonary - PE, pneumonia, asthma exacerbation, pneumothorax
* Blood - anaemia
* GI - GORD
* Other - anxiety, stress

Question 12

By referring to relevent pathophysiology and anatomy, explain why GORD/heartburn is common in pregnancy

Answer 12

Progesterone levels are high during pregnancy.
Progesterone causes relaxation of smooth muscle - this includes relaxation of the lower eosophageal sphincter and the pyloric sphincter.
So irritant bile can reflux into the stomach.

At the same time…
The enlarging fetus presses on the upper GI tract, worsening reflux.
AND there is increased gastrointestinal transit time.

Question 13

What is 1st line management of dyspepsia/GORD in pregnant lady?

Answer 13

NICE:
Lifestyle advice

Question 14

What lifestyle advice would you suggest to a pregnant lady suffering with dyspepsia/GORD?

Answer 14

• Eat smaller meals more frequently (every 3 hours)
• not eat late at night (or less than 3 hours before bedtime)
• avoid known irritants (for example alcohol, caffeine, fruit juices and carbonated drinks, chocolate, and fatty and spicy foods).
• Keep a food diary to identify triggers.
• Try to avoid excessive weight gain and to maintain regular physical activity.
• Try raising the head of their bed by 10–15 cm.
• Try to sleep on the left side rather than on the right side or supine.
• Avoid medications that may cause or worsen symptoms, if appropriate (for example calcium-channel antagonists, anticholinergics, antidepressants, and nonsteroidal anti-inflammatory drugs).
• Stop smoking (if applicable).

Question 15

A pregnant lady has GORD and has tried lifestyle changes you suggested in a previous appt.
What should you offer her now?

Answer 15

• Antacid preparations such as those containing combinations of aluminium and magnesium (co-magaldrox)
  or
• alginate products (for example Gaviscon® Advance) are recommended on an ‘as required’ basis.

Question 16

A pregnant lady has GORD, and you have recently started her on an antacid called co-magaldrox. She is also taking iron and folate supplements for anaemia in pregnancy.

How would you advise her to take these meds?

Answer 16

Advise women to avoid taking antacids within two hours of iron or folate supplements as antacids can affect absorption of other medication.

Question 17

After lifestyle changes and antacids, what is next in line to prescribe to a pregnant lady with heartburn/GORD?

Answer 17

H2 receptor antagonist - famotidine
PPI - omeprazole

Question 18

A pregnant lady’s PC is GORD/heartburn.
Before settling for this Dx, what red flag symptoms should you rule out?

Answer 18

Difficulty swallowing (dysphagia).
Hoarse voice.
Recurring or persistent cough.
Upper or lower gastrointestinal tract bleeding.
Weight loss.
Lymphadenopathy.
Epigastric or supraclavicular mass.

Question 19

A pregnant lady comes to you with heartburn. Your most likely Dx is GORD due to pregnancy. Name 4 other differentials, 2 relating to pregnancy, and two which are non-pregnancy related.

Answer 19

In pregnancy:
* Nausea and vomiting of pregnancy, including hyperemesis gravidarum.
* Pre-eclampsia
* HELLP syndrome (haemolysis, elevated liver enzymes, and low platelets).
* Acute fatty liver of pregnancy (rare).

Disorders unrelated to pregnancy, for example:

• Upper gastrointestinal cancer
• Peptic ulcer disease
• Oesophageal disorders, such as stricture, web or diverticulum, eosinophilic oesophagitis or oesophageal motility disorder.
• Acute Pancreatitis
• Acute Cholecystitis
• IBS
• Infections, including candida or acute viral hepatitis
• Cardiac disease — for example ischaemic heart disease, pericardial disease.

Question 20

What are RF for GORD in pregnancy?

Answer 20

• Symptoms of gastro-oesophageal reflux prior to pregnancy.
• Increasing gestational age.
• Parity

NICE says the following are no longer considered RF: high BMI pre pregnancy, weight gain during pregnancy, higher maternal age

Question 21

What is pelvic girdle pain/dysfunction?

Answer 21

• Pain in front and/or back of pelvis.
• Can also affect hips and thighs.
• Can affect SI joints at back and/or symphisis pubis at front.
• Affects 1 in 5 pregnant women
• Affects mobility and QofL

Question 22

On the following diagram, label:
* coccyx
* sacroiliac joints
* ilium
* iliac crest
* iliac spine
* obturator foramen
* ischium
* pubis/pubic bone
* sacrum

Answer 22

Question 23

Aetiology of pelvic girdle pain?

Answer 23

• In pregnancy, the pelvic joints (sacrococcygeal, lumbosacral, pubic symphysis, and the sacroiliac joints) become stiff or less stable.
• This causes inflammation and pain, which varies in severity.

Question 24

How is the female pelvis adapted for childbirth? (compared to male)

From TeachMeAnatomy

Answer 24

• A wider and broader structure yet it is lighter in weight
• An oval-shaped inlet compared with the heart-shaped android pelvis.
• Less prominent ischial spines, allowing for a greater bispinous diameter
• A greater angled sub-pubic arch, more than 80-90 degrees.
• Sacrum is shorter, more curved and has a less pronounced sacral promontory.
• Sacrotuberous and sacrospinous ligaments can stretch under the influence of progesterone and increase the size of the outlet further.

Question 25

What are symptoms of pelvic girdle pain?

Answer 25

• Pain in pubic region, lower back, hips, groin, thighs or knees
• pain can be mild, moderate or severe
• clicking or grinding in pelvic area
• pain made worse by movement - eg getting out of car, walking on uneven surfaces, during sex, rolling over in bed
• described as deep pain in the pubic area and groin (between the vagina and anus)

Question 26

How is pelvic girdle pain diagnosed?

Answer 26

After appt w/ physio, they make an assessment and make Dx
They look at posture, back and hip movements and rule out other causes of pelvic pain.

Question 27

Differential diagnosis for pelvic girdle pain?

Answer 27

• urinary tract or other infection
• lumbar spine problems (requires physiotherapy referral)
• Braxton Hicks or labour contractions

Other for pelvic pain - see image

Question 28

Conservative treatment options for pelvic girdle pain?

Answer 28

• Pelvic floor muscle exercises
• Hands on treatment - i.e physio/chiro mobileses joints for you
• warm bath, heat packs, ice packs
• hydrotherapy
• acupuncture
• support belt/ use of crutches

Question 29

Medical management for pelvic girdle pain?

Answer 29

paracetamol
may need admitting to antenatal ward for IV analgesia