Red flags to look out for in pregnancy, including spine pain, bleeding, headaches, hypertension and higher fever.
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Although GPs have actually not given lead maternity care services for lots of years, studies have actually demonstrated that pregnant women consult their GP much more often compared to non-pregnant women, and that GPs stay necessary providers of care for women throughout maternity. In assessing the pregnant patient, it is necessary to exclude severe conditions that could warrant investigation or referral, from the normal symptoms of pregnancy.
Pregnancy can easily exacerbate medical conditions, including fibroid degeneration, ovarian cysts, urinary tract infections, adnexal masses that persist in pregnancy, gastro-oesophageal reflux and gall bladder disease. Finally, remember labour as a induce of symptoms, especially in first-time pregnancies.
| Red flag symptoms |
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| Possible causes |
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Urgent referral
It is necessary a pregnant woman be urgently referred to the obstetric group if she experiences:
- Severe abdominal, pelvic, or unusual spine pain
- Fainting or lightheadedness
- The baby moving much much less or having sudden violent movements
- A fever and tip of sepsis
- A rapid pulse or lowered BP, indicating shock
- Visual changes, headaches and swelling suggestive of pre-eclampsia
- Acute shortness of breath, along with or devoid of leg swelling and pain
- Rigid/tender uterus
Investigations in primary care
Urinalysis might be done in primary care, depending on the urgency of the situation, to exclude a UTI or highlight proteinuria, suggestive of pre-eclampsia.
Blood examinations can easily be useful, to identify infection or anaemia for example.
USS Doppler of foetal heart price might be performed.
Early vaginal bleeding
One in four pregnancies experience bleeding, most usually between the ninth and twelfth weeks, which can easily be section of a normal pregnancy. Painless spotting throughout early pregnancy is regularly as a result of physiological embryo implantation.
Ectopic pregnancy
Bleeding in the initial trimester can easily likewise be a authorize of an ectopic pregnancy, usually occurring about the sixth week. A woman presenting along with unilateral lower abdominal pain and vaginal bleeding Need to be investigated for ectopic pregnancy.
A history of past ectopic pregnancy, sexually transmitted infections, smoking and fallopian tube surgery raises risk of ectopic pregnancy.
Symptoms including diarrhoea, vomiting, bowel pain and/or referred shoulder suggestion pain (as a result of internal bleeding irritating the phrenic nerve) make the diagnosis much more likely. In women not known to be pregnant, along with a delayed period and bleeding that is different from a normal period (heavier or lighter and regularly darker) an ectopic pregnancy Need to be considered.
Miscarriage
Miscarriage or potential miscarriage (loss of pregnancy prior to 24 weeks gestation) might be indicated by bleeding, passage of clots and especially as soon as combined along with persistent spine or abdominal pain. Most occur in the initial trimester and it could affect up to a fifth of recognised pregnancies.
Antepartum haemorrhage
Antepartum haemorrhage – bleeding from or in to the genital tract that occurs from twenty-four weeks, can easily be as a result of placenta praevia, placental abruption and local causes. Bleeding accompanied by continuous pain along with a hard, tender uterus could indicate placental abruption.
Pre-eclampsia
Pre-eclampsia typically, yet not exclusively, occurs after the twentieth week of gestation, associated along with elevated blood tension and proteinuria in a previously normotensive woman. NICE advice states that blood tension measurement and urinalysis Need to be carried out at each antenatal visit to screen for pre-eclampsia.
Clinical suspicion Need to be aroused along with presenting symptoms including epigastric pain, Significant headaches, Brand-new onset visual issues or sudden onset oedematous swelling.
Hyperemesis gravidarum
Nausea and vomiting are common in pregnancy, affecting up to ninety percent of pregnant women and usually requiring insight and reassurance, Despite the fact that thirty-5 percent of these women could require anti-emetic medication.
The Significant intractable nausea and vomiting of hyperemesis gravidarum, usually between eight and twelve weeks, affects up to 2% of pregnant women, leading to fluid and electrolyte disturbance and marked ketonuria – an indicator for admission for fluid support.
Obstetric cholestasis
Intrahepatic (obstetric) cholestasis generally occurs in the third trimester and affects 0.7% of pregnancies (up to 1.5% of Indian-Asian or Pakistani-Asian origin). Intense pruritis, devoid of accompanying rash, usually affects the hands and soles. Jaundice can easily occur along with pale stools and dark urine, as can easily generalised malaise, along with symptoms regularly preceding unexplained elevated AST, ALT and total bile acid levels (the upper limit of normal is 20% lower compared to non-pregnant levels).
Other sets off of liver dysfunction and itching should be excluded. The condition Need to settle spontaneously complying with delivery. along with increased risk of fetal distress, premature birth and intrauterine death, women along with a present or past history of obstetric cholestasis Need to be managed by a consultant-led team.
Leaking fluid
Leaking of fluid per vagina prior to thirty-seven weeks Need to be assumed to be premature rupture of the membranes and will certainly require monitoring, vigilance over potential infection and preparation for premature delivery. After thirty-seven weeks, clear amniotic fluid leakage would certainly usually be followed by imminent labour.
Contractions
Delivery might be rather imminent along with intense contractions, or the feeling to push or have actually a bowel movement. any kind of of the following, in association along with most likely labour, indicate a potential life-threatening problem along with immediate referral to a consultant led labour ward necessary.
- Heavy vaginal bleeding.
- Ruptured waters along with protrusion of umbilical cord from the vagina or sensation of something in the vagina
- Ruptured waters along with thick, yellow, green or brown fluid
- Cessation of baby movements or violent movements
- Maternal sensation of passing out
Urinary symptoms / vaginal discharge
Urinary infection not responding to antibiotics, refractory candida or Others vaginal discharge Need to all of necessitate swabs because certain vaginal infections are associated along with pre-term birth and reasonable birth-weight babies.
DVT/PE
An index of suspicion Need to be raised toward deep vein thrombosis along with leg swelling, pain, warmth and/or redness – remembering that the Wells score has actually not been validated in pregnancy and referral Need to be based on clinical acumen. any kind of sudden difficulty in breathing, chest pain or tightness, or maternal collapse has actually to contain consideration of a pulmonary embolism along with prompt medical assessment.
Trauma
Most accidental falls and minor traumatic injury in pregnancy are not harmful, however, signs of emotional or bodily distress, such as bleeding, amniotic fluid leak or contractions, Need to prompt obstetric review.
Psychological
If a woman has actually a psychiatric history, they Need to generally be managed by a consultant-led team, including specialist psychiatric review as section of their antenatal programme. Symptoms of depression are regularly reviewed in primary care, and vigilance Need to exist about thoughts of self harm and suicide, along with referral as appropriate.
Fever
A febrile patient Need to prompt investigation and treatment of cause, considering onward referral if signs of sepsis are present, or along with associated haemodynamic instability, deteriorating clinical condition, or non-responsiveness to treatment.
| Box 1: Pyelonephritis and pre-eclampsia |
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Acute pyelonephritis Acute pyelonephritis in pregnancy carries substantial risk to the baby, yet has actually Low in incidence in recent decades. Incidence has actually decreased considerably as a result of screening for asymptomatic bacturia, including urinalysis at each antenatal visit. In Significant cases the mother will certainly have actually higher pyrexia. Babies tolerate fever poorly and death in-utero could occur if the temperature is not brought under control. Premature labour is likewise associated along with higher fevers in the third trimester. The infecting organism is usually a coliform, and antibiotic treatment Need to be commenced empirically. Ascending infection is a common induce of sickle cell crises. Pre-eclampsia Pre-eclampsia is a multisystem disorder having the potential to affect all of the units of the body, including the placenta and the baby. The prime pathology is an abnormal partnership between the maternal system and the trophoblastic system. Its incidence is better in diabetic pregnancies and multiple pregnancies. It is generally a illness of women in their initial pregnancy, and much more common among women aged over 35. Obesity is a risk factor for hypertension, yet not for pre-eclampsia. Women that have actually produced hypertension while taking a combined oral contraceptive are at risk, as are those along with autoimmune disorders. The incidence is lower among women that smoke. |
| Box 2: Hyperemesis treatment options |
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The BMJ Publishing Group’s Clinical Evidence (http://ift.tt/1W12NHv) states antihistamines are `beneficial’ in hyperemesis, while cyanocobalamin (vitamin B12) and dietary ginger are `likely to be beneficial’. Dietary intervention excluding ginger, acupressure, phenothiazines, pyridoxine (vitamin B6), corticosteroids are of unknown effectiveness. |
- Dr Matthew West is a GP in Hertfordshire
