Common problems associated with early and advanced pregnancy

1. Common problems associated with early and advanced pregnancy

2. The chapter aim s to: • provide an overview of problems of pregnancy • describe the role of the midwife in relation to the identification, assessment and management of the more common disorders of pregnancy • consider the needs of both parents for continuing support when a disorder has been diagnosed.

3. The midwife's role • it is essential that an accurate health history is obtained. • General and specific physical examinations must be carried out and the results recorded. • The examination and recordings enable effective referral and management. • Where the midwife detects a deviation from the norm which is outside her sphere of practice, she must refer the woman to a suitable qualified health professional to assist her • The midwife will continue to offer the woman care and support throughout her pregnancy and beyond.

4. the midwife's continued presence and support. • the midwife's role to ensure that the woman and her family understand the situation; • are enabled to take part in decision-making

5. Abdominal pain in pregnancy • a common complaint in pregnancy. • suffered by all women at some stage, and therefore presents a problem for the midwife of how to distinguish between • 1- the physiologically normal (e.g. mild indigestion or muscle stretching) • 2- the pathological but not dangerous (e.g. degeneration of a fibroid) • 3- the dangerously pathological requiring immediate referral to the appropriate medical practitioner for urgent treatment (e.g. ectopic pregnancy or appendicitis).

6. The midwife should take a detailed history and perform a physical examination in order to reach a decision about whether to refer the woman. • Treatment will depend on the cause ,and the maternal and fetal conditions.

7. Causes of abdominal pain in pregnancy • Pregnancy-specific causes • Physiological • Heartburn, soreness from vomiting, constipation Braxton Hicks contractions • Pressure effects from growing/vigorous/malpresenting fetus, Round ligament pain • Severe uterine torsion (can become pathological)

8. Pathological • Spontaneous miscarriage • Uterine leiomyoma • Ectopic pregnancy • Hyperemesis gravidarum (vomiting with straining) Preterm labour • Chorioamnionitis • Ovarian pathology Placental abruption • Spontaneous uterine rupture • Abdominal pregnancy • Trauma to abdomen (consider undisclosed domestic abuse) • Severe pre-eclampsia • Acute fatty liver of pregnancy

9. Incidental causesMore common pathology • Appendicitis • Acute cholestasis/cholelithiasis • Gastro-oesophageal reflux/peptic ulcer disease • Acute pancreatitis • Urinary tract pathology/pyelonephritis Inflammatory bowel disease • Intestinal obstruction

10. Miscellaneous • Rectus haematoma • Sickle cell crisis • Porphyria • Malaria • Arteriovenous haematoma • Tuberculosis • Malignant disease • Psychological causes • Note:abdominal pain is one of many symptoms .

12. Bleeding before the 24th week of pregnancy • Any vaginal bleeding in early pregnancy is abnormal and of concern to the woman and her partner, especially if there is a history of previous pregnancy loss. • The midwife can come into contact with women through the booking clinic or through phone contact.

13. In all cases, a history should be obtained to establish the amount and colour of the bleeding, when it occurred and whether there was any associated pain. • Fetal well-being may be assessed either by ultrasound scan or, in the second trimester, using a hand-held Doppler device to hear the fetal heart sounds.

14. Maternal reporting of fetal movements may also be useful in determining the viability of a pregnancy. • There are many causes of vaginal bleeding in early pregnancy, some of which can occasionally lead to life-threatening situations and others of less consequence for the continuance of pregnancy. • The midwife should be aware of the different causes of vaginal bleeding in order to advise and support the woman and her family accordingly.

15. Implantation bleed • A small vaginal bleed can occur when the blastocyst embeds in the endometrium. This usually occurs 5–7 days after fertilization, • the timing coincides with the expected menstruation this may cause confusion over the dating of the pregnancy if the menstrual cycle is used to estimate the date of birth.

16. Cervical ectropion • known as cervical erosion • changes seen are as a physical response to hormonal changes that occur in pregnancy. • The number of columnar epithelial cells in the cervical canal increase significantly under the influence of oestrogen during pregnancy ,they extend beyond to the vaginal surface of the cervical os • giving it a dark red appearance. • this area is vascular, and the cells form only a single layer, bleeding may occur either spontaneously or following sexual intercourse.

17. Normally, no treatment is required, and the ectropion reverts back to normal cervical cells during the puerperium. • Cervical polyps • small, vascular, pedunculated growths on the cervix • consist of squamous or columnar epithelial cells over a core of connective tissue rich with blood vessels.

18. During pregnancy, the polyps may be a cause of bleeding • no treatment unless the bleeding is severe or a smear test indicates malignancy.