The Pregnant Patient: Managing Common Acute Medical Problems

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

Disclosures

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

In This Article

Common Symptoms During Pregnancy

Nausea and Vomiting

About one-half of pregnant women have nausea and vomiting during pregnancy.[43] Nausea and vomiting in pregnancy increases the risk of dehydration, poor function, poor weight gain, and, if severe, acute renal failure and impaired fetal growth. Benign nausea and vomiting of pregnancy is the most common obstetric cause and tends to begin by four weeks estimated gestational age and resolve by the end of 12 weeks estimated gestational age.[5] If it begins or ends outside of these intervals or is severe or refractory, less common obstetric causes (e.g., multiple gestation, molar pregnancy) and nonobstetric causes (e.g., gallbladder problems, thyroid disease) should be considered.[6]

Despite increased availability of prescription therapies for nausea in pregnancy, not all women require prescription antiemetics, and the safety of these therapies is not as clear as conservative treatments.[7,8] First-line treatments include low-risk lifestyle modifications, such as eating frequent small meals throughout the day to keep the stomach from becoming too empty or full, and avoiding foods that further slow gastric emptying (high-protein or fatty foods) or have intense smells or tastes.[7,8] There is modest evidence that P6 acupressure can also be a first-line therapy[7] (a video of this therapy is available at https://www.mskcc.org/cancer-care/patient-education/acupressure-nausea-and-vomiting). If these conservative approaches are ineffective, other therapies, including vitamin B6 (pyridoxine), over-the-counter antihistamines such as doxylamine, and natural ginger (less than 1,500 mg per day), can be added in a stepwise fashion.[7,9,10]

Combination doxylamine 10 mg/pyridoxine 10 mg (Diclegis) is approved by the U.S. Food and Drug Administration for the prevention of nausea and vomiting in pregnancy. The combination may improve compliance because it includes fewer pills but can also be much more expensive than each medication alone.

Prescribed antiemetics such as metoclopramide (Reglan) and trimethobenzamide (Tigan) are reserved for severe or refractory cases.[9,10] However, there are safety concerns with some prescribed antiemetics, such as promethazine, which has a risk of neonatal respiratory depression near term or during labor, and ondansetron (Zofran), which physicians should consider avoiding in the first trimester because of conflicting data on the risk of teratogenicity.[9–11]

Epigastric Pain/Gastroesophageal Reflux

Gastroesophageal reflux disease is common in pregnancy and is attributed to progesterone-mediated relaxation of the lower esophageal sphincter, which increases the frequency and severity of gastric reflux. Other conditions that present as heartburn-like discomfort during pregnancy include peptic ulcer disease, preeclampsia (i.e., HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome),[12] cholecystitis, and acute fatty liver of pregnancy.

If the discomfort is atypical for reflux, persistent, or severe, or if it begins after 20 weeks estimated gestational age in combination with other concerning symptoms (Table 3 [5–42]), the patient should be evaluated for conditions other than reflux.

An elevated alkaline phosphatase level is normal during pregnancy. However, an elevated lipase, bilirubin, or transaminase level requires ultrasound evaluation for cholecystitis, especially in the presence of severe colicky abdominal pain or other suggestive findings (e.g., positive Murphy sign, leukocytosis, fever). Peptic ulcer disease should be considered if results of laboratory tests such as complete blood count, liver panel, and lipase level are normal and reflux therapies are ineffective.

No one therapy for gastroesophageal reflux has been proven superior; therefore, prioritizing therapy depends on relative risks and adverse effects.[13] Initial therapies for gastroesophageal reflux of pregnancy include low-risk lifestyle interventions such as eating frequent small meals and avoiding smoking, caffeine, peppermint, and chocolate. Next choices generally include over-the-counter antacids that do not contain salicylates (found in bismuth combination products) and over-the-counter cimetidine (Tagamet), famotidine (Pepcid), or ranitidine (Zantac). Proton pump inhibitors are reserved for severe or refractory cases because of cautions advised during pregnancy and should be considered only in consultation with a primary maternity care clinician.[14–16] Whatever the suspected cause, an esophagogastroduodenoscopy should be performed only for serious indications, such as significant gastrointestinal bleeding, and is safer in the second trimester compared with the first.[44]

Cough

Apart from physiologic rhinitis of pregnancy, upper respiratory tract conditions are not usually caused by the normal hormonal, anatomic, and circulatory effects of pregnancy.[45] In patients with preexisting chronic conditions, such as asthma, management of the condition is similar during pregnancy, although therapies can be adjusted based on safety data.[46,47] Evaluation of acute cough should consider acute asthma exacerbation, allergic reaction, and viral and bacterial infections.[17] Although cough alone is not indicative of pulmonary embolism, because of the increased risk of pulmonary embolism in pregnancy, the condition should be considered whenever cough is associated with chest pain or shortness of breath.

Common symptoms associated with cough include nasal congestion, rhinorrhea, pharyngitis, shortness of breath, and chest discomfort. In the absence of a concerning diagnosis, the symptoms can be treated with the usual prescription and over-the-counter therapies.[20,21] Prevention of upper respiratory tract illnesses through hand/cough hygiene and the inactivated influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines is essential. Although a case-control study found a possible relationship between the influenza vaccine and miscarriage in a subset of patients, current evidence supports the safety of the vaccine in pregnancy.[18,19]

Rash

Skin conditions that arise or worsen during pregnancy can be due to hormonal and other physiologic changes of pregnancy.[48,49] Most of these conditions do not impact pregnancy outcomes.[50,51] Benign skin conditions of pregnancy include melasma (eFigure A) and striae gravidarum (eFigure B). Signs and symptoms of dermatoses in pregnancy include pruritus, papules, and plaques. Notably, pruritic urticarial papules and plaques of pregnancy spare the umbilicus (eFigure C). Treatment of skin conditions in pregnancy typically involves antihistamines, topical steroids, or oral steroid tapers.[22–27]

eFigure A.

Melasma.
Image used with permission from VisualDx.

eFigure B.

Striae gravidarum (stretch marks).
Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):212.

eFigure C.

Pruritic urticarial papules and plaques of pregnancy. The rash presentation can vary; two examples are shown.
Reprinted with permission from Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):215.

Intrahepatic cholestasis of pregnancy, which causes pruritus without a rash, has been associated with increased fetal mortality, warranting antenatal surveillance in consultation with a primary maternity care clinician. Intrahepatic cholestasis of pregnancy is treated with ursodiol (Actigall) in consultation with a primary maternity care clinician, although the therapy leads to only slightly better fetal and maternal outcomes than placebo. Cholestyramine (Questran) has been used, but it only reduces pruritus.[28] Delivery by 35 to 37 weeks estimated gestational age may be warranted if bile acid levels are more than 16.3 mcg per mL (40 μmol per L).[29]

Dysuria

Although frequency and urgency are normal as the uterus enlarges in the later stages of pregnancy, dysuria may be a result of cystitis, pyelonephritis, or sexually transmitted infections, which can lead to maternal and fetal morbidity.[30,31] In pregnant women who have more than 100,000 colony-forming units of one bacterial species on urine culture, starting antibiotics early is necessary to reduce the risk of pyelonephritis, even in those who are asymptomatic.[32–34]

The choice of an appropriate oral antibiotic (e.g., penicillins, such as amoxicillin; first-generation cephalosporins; erythromycin; nitrofurantoin) is based on known drug risks during pregnancy, patient drug allergies, and bacterial resistance patterns.[35] Nitrofurantoin is not used at term because of the risk of severe hemolytic anemia following birth. Trimethoprim/sulfamethoxazole is generally not recommended for use in pregnancy because of risks of neural tube defects in early pregnancy, as well as methemoglobinemia in the newborn. A systematic review found that of the nonantibiotic measures taken to prevent urinary tract infections during pregnancy, only genital hygiene can be recommended in practice.[52]

Because bacteriuria increases the risk of preterm labor, urinary cultures should be checked after treatment for asymptomatic bacteriuria, cystitis, or pyelonephritis to ensure bacteriuria resolves and does not recur. A follow-up urinary culture should be performed for test of cure. It is prudent to repeat follow-up cultures periodically.

Low Back Pain

Low back pain often occurs during pregnancy because of musculoskeletal strain from increased lordosis and soft tissue laxity. However, urologic and neurologic red flags (Table 1) should be identified and treated. Acute low back pain should be more rigorously evaluated when associated with a history of trauma, vaginal bleeding, severe abdominal pain, loss of fluid, uterine contractions, uterine tenderness, change in fetal movement, or urinary tract symptoms. This evaluation (in consultation with a primary maternity care clinician) should be focused on ruling out obstetric complications of trauma, such as abruption, combined with systematic monitoring for uterine contractions and fetal heart rate, and possibly fetal ultrasonography.[36]

Treatment of back pain in pregnant women targets alleviating musculoskeletal strain with exercises and physical therapy. Additional therapy such as acetaminophen, acupuncture, support devices, warm baths, or epidural steroids may be needed.[36,37] A systematic review found that osteopathic manipulative treatment may improve function and reduce pelvic girdle and low back pain during and after pregnancy.[53]

Headaches

New-onset headaches or a new type of headache in pregnancy warrants further evaluation to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches).[38,40,42] Preeclampsia must be ruled out in all pregnant women with headache who are more than 20 weeks' gestation by monitoring serial blood pressures and assessing urine for protein in consultation with a primary maternity care clinician.[40,42]

Tension and migraine headaches can lead to significant morbidity.[42] Acetaminophen is an initial, low-risk therapy. Other drugs such as sumatriptan (Imitrex), dexamethasone (brief, isolated use; avoid during the first trimester), and ketorolac (second trimester only) can be used with caution, after the potential risks are explained to the patient, for severe or refractory headaches that significantly affect the patient's nutrition, hydration, or functioning. When headaches are associated with sudden onset, focal neurologic symptoms and findings, fever, or neck stiffness, further emergent workup, initially with shielded head computed tomography and possibly lumbar puncture, is warranted.[39–41]

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