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BEST Ch. 5 - Hw 4 Gianny Navas BEST ch. 5 - hw 4 1. What is ligament pain? Is it common or does it need attention? What can be done about it? There are different ligaments connecting the uterus to the pelvis: round ligaments, broad ligament, uterosacral ligaments, and more. Pain is usually associated with the round ligaments, which are two ligaments running vertically from the superior, lateral parts of the uterus, to the pubic bone. They help support the uterus, allowing it to move forward and backward. Round ligament pain is very common, especially starting at 18 weeks gestation. At around this time, the ligaments are stretching as much as possible due to the weight and forward leaning motion of the uterus, causing them to tighten, cramp, and spasm. It's especially common to feel the pain on the right side. This pain can feel sharp and severe. Pregnant women can apply a warm compress, wear a maternity belt, avoid pelvic anterior tilts, and practice side bend stretches to ease the pain. 2. How often does appendicitis occur in pregnancy? Explain the symptoms and treatment for it. Appendicitis occurs in about 1 pregnancy per 1,000. Symptoms for a pregnant woman are similar to a nonpregnant woman, being: dull periumbilical pain at first and leading to right lower quadrant pain, nausea, vomiting, turning a greenish hue, fever, chills, rebound tenderness, and involuntary guarding. Treatment is immediate surgery before the appendix ruptures. A pregnant woman's infected appendix is more likely to rupture; fetal loss before rupture is 5-10%, increasing to 20-30% if it does rupture. 3. Define differential diagnosis. Differential diagnosis is a list of possible diseases and conditions that share similar symptoms made to rule out every possible option when diagnosing a patient. 4. What is the differential diagnosis for appendicitis in pregnancy? Adnexal torsion, ruptured ovary, ruptured ectopic pregnancy, placental abruption, ovarian cancer, labor, diverticulitis, uterine fibroid degeneration, kidney stone, chorioamnionitis, PID, and Crohn’s disease. 5. What is the difference between an uncomplicated UTI and pyelonephritis? UTIs can be common during pregnancy and when it doesn't lead to an infection of the bladder (cystitis), or infection of the kidney (pyelonephritis), it is asymptomatic. Usually a UTI can be solved through home remedies, or antibiotics. Symptoms are: severe urge to urinate, burning sensation when urinating, strong smelling urine, cloudy urine, dark or bloody urine, passing little urine, and pelvic pain. Cystitis displays all these similar symptoms, along with a low grade fever, and lower pelvic cramping while voiding. Pyelonephritis on the other hand precedes cystitis and occurs in just 2% of pregnancies. Symptoms are: high fever, chills, nausea, vomiting, urinary pain and urgency, flank pain, malaise, and costovertebral angle tenderness. 6. What is septicemia? Septicemia is bacteria entering the bloodstream due to an infection and inflammation within the body. For instance, an infected kidney will be septic (inflamed) and then lead to septicemia. The inflammation can lead to leaky blood vessels and blood clots, which is how the bacteria enters the bloodstream. Septicemia is also known as bacteremia or blood poisoning. 7. Kidney infections most often present on which side? Why? During pregnancy, the right side often has more kidney infections because the enlarged uterus is pushed up and to the right by the intestines. When this happens, the uterus compresses the right ureters and kidneys which cause kinks in their already smooth muscle lining (due to relaxin), making bacteria and urine be backed up. 8. If left untreated, pyelonephritis can lead to what complications? Pyelonephritis can lead to septicemia, shock, and preterm labor if left untreated. 9. Explain Renal Calculi. What are the symptoms in the kidneys and what are treatments? Renal calculi (kidney stones or nephrolithiasis) are hard deposits made of minerals and salts, like calcium, that form in the kidneys and travel down the ureters, into the bladder, and out the urethra. Kidney stones are very painful, and depending on the location of the stones and where it's traveling, the pain can be dull, aching, sharp, or severe. They form more easily during pregnancy because of elevated calcium excretion and urinary stasis. Symptoms include: nausea, hematuria (blood in urine), dysuria (painful urination), flank pain (due to obstruction in the upper ureteral segment), labia pain (due to obstruction in the lower ureteral segment), and fever if there is a kidney Gianny Navas BEST ch. 5 - hw 4 infection. They can be avoided by staying hydrated, reducing sodium intake and avoiding foods high in oxalates, and purines. Oxalate-rich foods are chocolate, leafy greens, coffee, nuts, tea, and beets. Purine-rich foods are red meats, fish, chicken, beef, fish, and peanuts. 10. Explain hydronephrosis. How does it occur and what are the symptoms? What can be done about it? Hydronephrosis is a buildup of fluid in the kidneys due to the urinary tract, or ureters being obstructed and not allowing urine to escape. During pregnancy, the hormone relaxin, progesterone, and HCG are released, causing smooth muscles, ligaments, and connective tissue to soften up and “relax” to allow the body to expand and allow room for the fetus to grow. The smooth muscles of the ureters soften, and are easily kinked, which can be the reason for an obstruction. Like causing a kink in a water hose, the urine can not pass to or out of the bladder. This causes the fluid build up in the kidneys which leads to them swelling. Symptoms are: severe flank pain, dysuria, and urinary stasis. Most of the time women are asymptomatic. If it causes pain and difficulty in the pregnant woman's life, then narcotic medication is prescribed, and positions to urinate to relieve pressure on the kidneys and ureters are taught (like hands and knees in the tub). 11. What are differential diagnoses for renal calculi and hydronephrosis? Appendicitis, cholecystitis, and bowel obstruction. 12. Explain ruptured ovarian cysts including symptoms and treatment. An ovarian cyst is a fluid-filled sac that grows on the ovaries, and may rupture due to trauma, a fall, sexual intercourse or spontaneously. Ovarian cysts are common, especially during pregnancy, and if it ruptures, it would need surgical treatment. Symptoms are: mild, chronic to then acute pain in the lower abdomen, fluid filling the cul-de-sac (seen by ultrasound), rebound tenderness, and guarding. 13. Explain adnexal torsion. How does it happen and what are the symptoms? How is it diagnosed? How is it treated? Adnexal torsion is when the ovary, and sometimes fallopian tube, gets twisted. This interrupts blood supply and can cause ischemia. It is more common when there is a dermoid cyst on the ovary, because this can make it heavier on one side or unbalanced, causing torsion. It is also common in women who have undergone infertility treatment because their ovaries become hyperstimulated and very large (about the size of golfballs). Torsion usually occurs on the right side, leading to misdiagnosis of appendicitis. Symptoms are: nausea, vomiting, severe pain in the RLQ (right lower quadrant),fever, and rebound tenderness. It is diagnosed by ultrasound, and treated by either removing the ovary/tube completely, or untwisting the infundibulopelvic (suspensory) ligament by laparotomy. 14. What are the differential diagnoses for adnexal torsion? Appendicitis, ectopic pregnancy, endometrioma, and degenerating fibroid. 15. What are degenerating uterine fibroids? What are the symptoms and how is this treated? Uterine fibroids are noncancerous growths in the uterus that grow in the myometrium. A degenerating uterine fibroid is one that grows so large it cuts off its own blood supply. This causes the fibroid tissue to die, shrinking back to a smaller state that gains blood supply again. This dying tissue causes acute, localized abdominal pain, nausea, vomiting, low-grade fever, and a high white blood cell count. Treatment consists of a 48 hour regimen of narcotic analgesia or indomethacin. So basically, medications that reduce pain and swelling until the fibroid shrinks. 16. What are the differential diagnoses for fibroids? Appendicitis, pyelonephritis, cholecystitis, and placental abruption. 17. Define chorioamnionitis. What are the symptoms and what happens if it is left untreated? What are the treatments? Chorioamnionitis (intra-amniotic infection) is a condition in which bacteria ascends from the vagina into the uterus, affecting the fetal membranes and causing infection. Prolonged rupture of membranes, too many vaginal exams, and cerclage are common causes of this. Symptoms include: fever, maternal and fetal tachycardia, foul smelling vaginal discharge or amniotic fluid, increased maternal leukocytosis, uterine tenderness, and malaise. If left untreated, there will be complications for both the mother and baby. The mother will eventually have pelvic infections Gianny Navas BEST ch. 5 - hw 4 requiring drainage, intra-abdominal infections, thrombosis of pelvic vessels, and pulmonary embolisms. It can also initiate placental abruption, uteroplacental bleeding, and a precipitous delivery. The baby will undergo septic shock, pulmonary hypertension, respiratory failure, and meningitis. Antibiotics are given as treatment (clindamycin, and aminoglycoside). 18. What is the differential diagnosis of chorioamnionitis and why do they often mimic it? PID (pelvic inflammatory disease) is also an infection of
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