1. Common Problems in Pregnancy Deidre Young, PGY-2

2. Overview • Why this topic? • Nausea and Vomiting • Constipation • Heartburn • Common Cold • Urinary Tract Infections

3. Why this topic? • Personal interest • Lots of prenatals • Lots of morbidity from these problems • Fear and uncertainty about medications in pregnancy

4. Nausea and Vomiting • How big a problem? • 50 – 90% of pregnancies affected • 35% lose time from work • Cited as a reason for terminating pregnancies • Severity can be comparable to that of cancer patients receiving chemotherapy

5. What can we do about it? • Lifestyle and Dietary Modifications • Ginger • Accupuncture and Accupressure • Pharmacological Interventions

6. Lifestyle and Dietary Modifications • No proven benefit but lots of anecdotal evidence • Patient should be encouraged to eat what she can, when she can • Encourage folic acid, even if other prenatal vitamins not well-tolerated • Small, bland meals often encouraged • Avoid sensory stimuli, e.g. strong odors • Avoid fatigue, can exacerbate symptoms

7. Ginger • Has been shown in an RCT to be effective but its safety has not been thoroughly tested • Large quantities (>1000 mg/day) of ginger should not be recommended in pregnancy

8. Accupuncture and Accupressure • Stimulation of the P6 point, three finger breadths proximal to the wrist has been used for thousands of years • No concerns about safety • Accupressure (seabands) has been shown to work in non-RCT trials

9. Pharmacological • If non-pharmacological interventions have not succeeded, therapy should be initiated as soon as possible to alleviate symptoms • The SOGC has developed an algorithm for the treatment of nausea and vomiting in pregnancy, based on evidence-based treatments

10. Constipation • Common in first and third trimesters • Can be extremely uncomfortable • Can lead to hemorrhoids due to straining

11. Constipation • Encourage patient to drink lots of water, can be a problem with N/V • Exercise regularly, just walking can be beneficial • Stop iron supplements if necessary • Eat a high-fibre diet • Try prunes, flax seed • Colace doesn’t help much, try to avoid laxatives

12. Heartburn • Occurs in late second and third trimesters • Due to relaxation of the esophageal sphincter • Lifestyle modifications include: avoiding spicy foods, smaller meals, extra pillows • Antacids are generally recommended with the liquid kind generally giving better relief than tablets • If necessary, can progress to Ranitidine

13. Common Cold • Pretty common! • Can usually go without treatment but if symptoms lead to fatigue – can exacerbate other problems of pregnancy • Try usual non-pharmacological approaches such as fluids, rest, humidified air

14. Pharmacological • Decongestants – Pseudoephedrine OK in second and third trimesters, beware of other ingredients (e.g. Advil Cold and Sinus contains ibuprofen) • Antihistamines – chlorpheniramine (Sinutab) considered the antihistamine of choice • Antitussives – Dextromethorphan appears to be safe but limited data, use with caution

15. Urinary Tract Infections • UTIs in pregnancy can lead to complications such as low birth weight, preterm labour, pre-eclampsia • Prompt treatment important • E. coli most commonly responsible

16. Antimicrobial Treatment for the Pregnant Patient with Bacteriuria • Amoxicillin 500 mg three times a day • Ampicillin 250 mg four times a day • Cephalosporin 250 mg four times a day • Nitrofurantoin 100 mg four times a day • Sustained release nitrofurantoin 100 mg two times a day • The agent of choice should be given for a 3- to 7-day course. A repeat urine culture is recommended 2 weeks after the treatment has been completed.