The Pregnant Patient: Managing Common Acute Medical Problems

David S. Gregory, MD; Velyn Wu, MD; Preyasha Tuladhar, MD

Am Fam Physician. 2018;98(9):595-602.

Abstract and Introduction

Abstract

Women often see their primary care physicians for common acute conditions during pregnancy. These conditions may be caused by pregnancy (obstetric problems) or worsened by pregnancy (obstetrically aggravated problems), or they may require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems). Primary care physicians should know the differential diagnosis for common conditions during pregnancy and recognize the important findings of obstetric and urgent nonobstetric problems. The family physician can evaluate and treat most nonobstetric problems, although obstetric problems require referral to a primary maternity care clinician. A tiered approach, including routinely looking for all-cause red flag symptoms and signs, while remaining aware of estimated gestational age, allows for high-quality care and shared decision making between the family physician and the pregnant patient. When treating common causes of nausea and epigastric pain/gastroesophageal reflux, lifestyle modifications are considered the safest and first-choice therapy, followed by well-established low-risk therapies, such as vitamin B₆ (pyridoxine) and doxylamine for nausea, and antacids not containing salicylates (found in bismuth combination products) for gastroesophageal reflux. Other common conditions during pregnancy are best treated with low-risk therapies, such as using antihistamines or topical steroids for rashes, first-generation cephalosporins or amoxicillin for cystitis, and physical therapy and acetaminophen for low back pain and headaches.

Introduction

Women often see their primary care physicians for common acute conditions during pregnancy, even if they are not the primary maternity care clinician. Some conditions are caused directly by pregnancy (obstetric problems) or are worsened by pregnancy (obstetrically aggravated problems), and others require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems).^[1] Table 1 outlines the causes of common symptoms during pregnancy.

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Abstract and Introduction
General Considerations for Pregnant Patients
Common Symptoms During Pregnancy
References
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Table 1. Causes of Common Symptoms During Pregnancy
Symptom	Important accompanying signs and symptoms	Causes
Nausea and vomiting	General: weight loss, dehydration, high-normal or high serum creatinine level, occurring before four weeks (nonobstetric causes) or persisting after 12 weeks estimated gestational age (molar pregnancy) Nonobstetric: diarrhea, fever, abdominal pain, neck/thyroid pain or enlargement Obstetric: nausea and vomiting of pregnancy, hyperemesis gravidarum, molar pregnancy, multiple gestation	Nonobstetric or obstetrically aggravated: gastroenteritis, appendicitis, cholecystitis, thyroid disease, kidney stones, gallbladder problems Obstetric: vaginal bleeding, large uterus for estimated gestational age, refractory
Abdominal pain	General: nausea and vomiting, epigastric/right upper quadrant pain, weight loss, dehydration, high-normal or high serum creatinine level Nonobstetric: change with eating and drinking, blood in stool or emesis, melena, fever, jaundice Obstetric: headaches, vision changes, low platelet counts, swelling	Nonobstetric or obstetrically aggravated: gastroesophageal reflux disease, peptic ulcer disease, cholecystitis, cystitis, pyelonephritis, appendicitis, kidney stones, constipation, gastritis Obstetric: preeclampsia/HELLP syndrome, acute fatty liver of pregnancy, ectopic pregnancy, spontaneous abortion, abruption, intrauterine fetal demise, round ligament strain, preterm labor
Cough	General: dyspnea, hypoxemia Nonobstetric: wheeze, hemoptysis, fever, myalgia, purulent nasal discharge or sputum	Nonobstetric or obstetrically aggravated: acute/chronic asthma, viral upper respiratory tract infection (including influenza), allergic rhinitis, pneumonia, pertussis Obstetric: physiologic rhinitis of pregnancy
Rash	General: pustules, vesicles/blisters, erythema, pruritus Nonobstetric: condyloma, scaling, lichenification, ulcers, secondary rash on preexisting condition (e.g., eczema, moles) Obstetric: pigmented patches/lines, pruritus with or without papules/blisters, spares the umbilicus (PUPPP)	Nonobstetric or obstetrically aggravated: acne, eczema, psoriasis, cellulitis/abscess, herpes zoster, human papillomavirus infection, fungal infection, scabies, impetigo, folliculitis Obstetric: physiologic pigment change (melasma, linea nigra), striae gravidarum, PUPPP, intrahepatic cholestasis, pustular psoriasis (impetigo herpetiformis), pemphigoid gestationis, atopic eruption of pregnancy (prurigo of pregnancy)
Dysuria	General: dehydration, uterine contractions Nonobstetric: other urinary symptoms; vulvovaginal discharge, itching, or burning; fever; nausea or vomiting; costovertebral angle tenderness; colicky flank pain; gross hematuria; prior urinary tract infection Obstetric: nonspecific (urinary frequency and incontinence common)	Nonobstetric or obstetrically aggravated: cystitis, vulvovaginal candidiasis, pyelonephritis, sexually transmitted urethritis, herpes genitalis, urolithiasis, recurrent urinary tract infection
Low back pain	General: poor function, deconditioning Neurologic red flags: saddle anesthesia, urinary retention, rapidly progressive weakness or numbness Urologic red flags: fever, costovertebral angle tenderness, renal colic Obstetric: history or evidence of an accident/fall/trauma, vaginal bleeding, severe abdominal pain, change in fetal movement, loss of fluid, uterine tenderness, uterine contractions, urinary tract symptoms	Nonobstetric or obstetrically aggravated: musculoskeletal strain, loosening of sacroiliac joint, disc herniation, cauda equina syndrome, sciatic nerve/lumbar plexus pressure, pyelonephritis, urolithiasis, sacroiliitis, joint laxity, herniated nucleus pulposus Obstetric: abruption, intrauterine fetal demise, preterm or term labor
Headache	General: new-onset headache or new headache type, rapidly increasing frequency of headaches Nonobstetric: purulent nasal discharge, nausea and vomiting, focal neurologic signs or symptoms, fever, neck pain/stiffness, sudden thunderclap headache Obstetric: visual disturbance (scotomata), proteinuria, hypertension	Nonobstetric or obstetrically aggravated: tension or migraine headache, meningitis, sinusitis (viral, allergic, bacterial), subarachnoid hemorrhage, brain tumor Obstetric: preeclampsia

HELLP = hemolysis, elevated liver enzymes, and low platelet count; PUPPP = pruritic urticarial papules and plaques of pregnancy.

Table 2. Estimated Gestational Age and Concerning Symptoms to Help Distinguish Obstetric from Nonobstetric Problems
Symptom	Possible obstetric causes by estimated gestational age	Nonobstetric causes
Abdominal pain	0 to 20 weeks Ectopic pregnancy Spontaneous abortion 20 to 40 weeks Abruption Acute fatty liver of pregnancy (epigastric/right upper quadrant pain) Intrauterine fetal demise Preeclampsia/HELLP syndrome (epigastric pain) Preterm labor Round ligament strain	Appendicitis Cholecystitis Constipation Cystitis Gastritis Gastroesophageal reflux disease Kidney stones Peptic ulcer disease Pyelonephritis
Headache	20 to 40 weeks Preeclampsia	Brain tumor Meningitis Sinusitis Subarachnoid hemorrhage Tension or migraine headache
Vaginal bleeding	0 to 20 weeks Ectopic pregnancy Spontaneous abortion 20 to 40 weeks Abruption Cervical change of labor Placenta previa Vasa previa	Cervicitis Nonvaginal sources (hemorrhoid, anal fissure, vulvar varicosity)

HELLP = hemolysis, elevated liver enzymes, and low platelet count.

Table 3. Evaluation and Treatment of Common Symptoms in Pregnancy
Common symptom	Evaluation	Treatment
Nausea and vomiting	For all: weight, blood pressure, pulse, assessment of oral mucous membranes, orthostatic blood pressure measurement, abdominal examination If abdominal pain or tenderness: CBC; consider ultrasonography of gallbladder or appendix If severe, refractory, begins before four weeks, or persists after 12 weeks estimated gestational age^5,6: comprehensive metabolic panel; thyroid-stimulating hormone and beta human chorionic gonadotropin levels; transabdominal ultrasonography; consultation with primary maternity care clinician if evidence of dehydration, poor weight gain, molar pregnancy, or thyroid dysfunction	For nausea and vomiting of pregnancy Lifestyle modifications: frequent small meals; avoidance of high-protein or fatty foods and foods with intense tastes or smells; P6 acupressure^7,8 Medications: vitamin B₆ (pyridoxine), over-the-counter antihistamines (doxylamine), natural ginger (less than 1,500 mg per day)^7–10; antiemetics such as metoclopramide (Reglan) and trimethobenzamide (Tigan) can be used for severe or refractory cases,^9,10 although there are concerns about the use of promethazine near term or during delivery and the use of ondansetron (Zofran) in the first trimester^9–11; intravenous hydration as needed
Epigastric pain/gastroesophageal reflux	For all: temperature, blood pressure, pulse, weight, assessment of oral mucous membranes, UA to check for protein If fever or abdominal pain: CBC, LFTs¹² If nausea, vomiting, colicky pain, positive Murphy sign, or fever: CBC for white blood cell count, lipase, bilirubin, LFTs, right upper quadrant ultrasonography¹² If blood in the stool, emesis, or melena: CBC for hemoglobin and hematocrit, fecal occult blood test¹² If begins after 20 weeks estimated gestational age and there are headaches, vision changes, abdominal pain, high blood pressure, or proteinuria: CBC for platelets, LFTs, consultation with primary maternity care clinician¹²	For gastroesophageal reflux of pregnancy Initial therapy: frequent small meals; avoidance of smoking, caffeine, peppermint, and chocolate¹³ Next choices: over-the-counter antacids that do not contain salicylates (found in bismuth combination products); over-the-counter cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac)^14–16 For severe or refractory cases: proton pump inhibitors, only in consultation with primary maternity care clinician^14–16
Cough	For all: vital signs with pulse oximetry; ears, nose, throat, and lung examination¹⁷ If wheezing, fever, hypoxemia, shortness of breath, hemoptysis: consider chest radiography, CBC¹⁷ If myalgia or fever, or it is influenza season: consider empiric influenza therapy, hospitalization, and consultation with primary maternity care clinician¹⁷	Prevention: hand/cough hygiene, hydration, inactivated influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines^18,19 For specific causes Physiologic rhinitis: nasal saline sprays, nasal opening strips^20,21 Asthma: albuterol, inhaled corticosteroids, oral steroids for exacerbations Allergic rhinitis: antihistamines, nasal steroids^20,21 Influenza: administer oseltamivir (Tamiflu) as soon as possible Pneumonia: antibiotics as indicated Pertussis: azithromycin (Zithromax)
Rash	For all: full examination of rash; note distribution, appearance, associated symptoms, and timing Based on characteristics Blisters: consider Tzanck test or herpes simplex virus polymerase chain reaction testing, consultation with primary maternity care clinician Suspected chickenpox: consider varicella-zoster immune globulin, consultation with primary maternity care clinician Itching but no rash: LFTs, serum bile acids, consultation with primary maternity care clinician Scaly: consider potassium hydroxide skin scraping test Pustular: consider culturing pus If diagnosis still unclear: consider biopsy	Prevention: preconception varicella vaccine (contraindicated during pregnancy) Continue most therapies for chronic conditions,^22–27 except for methotrexate and retinoids (contraindicated in pregnancy) Selective use of acute therapy: topical steroids, antihistamines, topical antifungals, antibiotics Consultation with primary maternity care clinician when considering antivirals for varicella or herpes, or ursodiol (Actigall) for intrahepatic cholestasis of pregnancy^28,29
Dysuria	For all: vital signs, assessment of mucous membranes, examination for abdominal/costovertebral angle tenderness, vulvar inspection, UA with microscopy, urine culture^30,31 If UA results show a substantial number of epithelial cells, physiologic leukorrhea contamination should be suspected unless culture shows more than 100,000 colony-forming units of one organism^32–34 If no clear diagnosis and UA findings are abnormal: vaginal examination with wet mount and urinary gonorrhea/chlamydia testing, empiric antibiotics for urinary tract infection pending urine culture results If costovertebral angle tenderness or fever: CBC, renal ultrasonography, intravenous antibiotics Occurs at more than 20 weeks estimated gestational age: consultation with primary maternity care clinician to monitor for preterm labor and fetal well-being If colicky flank pain or gross hematuria: renal ultrasonography, urology consultation	For cystitis/asymptomatic bacteriuria Initial choice for most: first-generation cephalosporins, nitrofurantoin (avoid at term), penicillins, erythromycins³⁵ Consider if initial choices fail: amoxicillin/clavulanate (Augmentin)³⁵ For vulvovaginal candidiasis Routine, low-risk therapy: oral nystatin, vaginal clotrimazole, vaginal miconazole For refractory cases: other vaginal azoles Avoid oral fluconazole (Diflucan) in a dosage of 400 to 800 mg per day; caution also advised for low-dose oral fluconazole For pyelonephritis Intravenous antibiotics For stones: hydration, pain management, urology consultation If history of asymptomatic bacteriuria or one urinary tract infection: consider prophylactic nitrofurantoin until pregnancy is at term^30,31
Low back pain	If there are urologic red flags (Table 1): UA with culture, consider renal ultrasonography and urology consultation If there are neurologic red flags (Table 1): neurosurgical consultation, magnetic resonance imaging of spine If there are obstetric red flags: consultation with primary maternity care clinician	For musculoskeletal low back pain: low back stretching exercises, water exercises, physical therapy, job and activity modification, warm baths, lumbar traction, supportive devices (prenatal cradles, sacroiliac joint belts), acetaminophen, acupuncture^36,37 If refractory and no red flags: consider epidural steroids^36,37
Headache	For all: blood pressure, UA, neurologic examination, funduscopy, nasal examination³⁸ If headache not relieved with acetaminophen and rest, or there is scotomata, elevated blood pressure, or proteinuria: CBC, LFTs, consultation with primary maternity care clinician If focal neurologic signs or symptoms: shielded noncontrast head CT, neurology consultation; if CT is negative, consider magnetic resonance venography or angiography^39–41 If meningitis or subarachnoid hemorrhage is suspected: shielded noncontrast CT; consider lumbar puncture if CT results are normal^39–41	For sinusitis: amoxicillin For suspected meningitis: third-generation cephalosporins; consider vancomycin, acyclovir, dexamethasone^39–41 For migraine Lowest-risk therapy: acetaminophen; antiemetic; rest in a dark, quiet environment⁴² For severe or refractory migraines significantly affecting nutrition, hydration, or functioning (use these medications with caution, and explain potential risks to patients): sumatriptan (Imitrex), dexamethasone (brief, isolated use; avoid during first trimester), ketorolac (second trimester only)^39–41 Dihydroergotamine is contraindicated in pregnancy

Information from references 5 through 42.

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Sort: Key Recommendations for Practice

Clinical recommendation	Evidence rating	References
Treatment of nausea and vomiting in pregnancy should begin with lifestyle modifications. Other treatments, including P6 acupressure, vitamin B₆ (pyridoxine), doxylamine, and prescription antiemetics, can be added as needed.	B	7, 8, 10
Pregnant women with more than 100,000 colony-forming units of one bacterial species on urine culture should be treated with antibiotics to prevent pyelonephritis.	A	32
Initial choices for treating musculoskeletal back pain in pregnancy include exercise and physical therapy, but additional therapy with acetaminophen, warm baths, acupuncture, support devices, or epidural steroids may be needed.	C	36, 37
Pregnant women with new-onset headaches or a new type of headache should be further evaluated to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches). Preeclampsia must be ruled out if headaches occur after 20 weeks' gestation.	C	40, 42

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.