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For this assignment you will read Birth Emergency Skills Training chapter 5
1. What is ligament pain? Is it common or does it need attention? What can be done about it?
Round ligament pain is common in pregnancy due to the increasing size of the uterus which these puts stress on the round ligaments which hold the uterus in place. Round ligament pain typically does not need any attention, except to help relieve the pain and discomfort of the woman. Some suggestions to relieve the pain are to splint the painful area with the hand, flex the hip on the affected side(s), apply heat, and wear a maternity belt.
2. How often does appendicitis occur in pregnancy? Explain the symptoms and treatment for it.
Appendicitis is not very common, however it is the most common non-obstetrical surgical emergency during pregnancy, occurring in about 1 per 1,000 pregnancies.
Symptoms of appendicitis:
• dull, poorly localized periumbilical pain that then localizes to a sharp pain in the right lower quadrant
• fever
• chills
• nausea
• vomiting
• involuntary guarding
• rebound tenderness
Treatment for appendicitis is rapid surgical intervention/removal.
3. Define differential diagnosis.
Differential diagnosis refers to a medical term that means a potential diagnosis for a patient based off of their presenting signs and symptoms (subjective and objective information from charting). 2
4. What is the differential diagnosis for appendicitis in pregnancy?
The differential diagnoses for appendicitis in pregnancy are:
• ruptured ovarian cyst
• adnexal torsion
• pelvic inflammatory disease (PID)
• ovarian cancer
• abruption placenta
• chorioamnionitis
• uterine fibroid degeneration
• labor
• ruptured ectopic pregnancy
• Crohn’s disease
• diverticulitis
• ureteral stone
5. What is the difference in an uncomplicated UTI and pyelonephritis?
Uncomplicated UTI Pyelonephritis
Priority 3 Priority 2 or 1 with septicemia
Symptoms include: frequent urination, lower Symptoms include sudden onset of high fever, pelvic cramping (especially while voiding), a shaking chills, hematuria, nausea, vomiting, burning sensation with urination, low-grade fever urinary pain and urgency, flank or low-back pain, costovertebral angle tenderness, and malaise May have no symptoms Often preceded by a UTI
Recognized through lab results Occurs in about 2% of pregnancies 3
6. What is septicemia?
Septicemia means blood poisoning.
7. Kidney infections most often present on which side? Why?
Kidney infections most often present on the right side during pregnancy due to the intestines pushing the uterus to the right which compresses the right ureters and kidney, making a right kidney infection more likely.
8. If left untreated, pyelonephritis can lead to what complications?
If left untreated, pyelonephritis can lead to preterm labor or maternal septicemia and shock.
9. Explain Renal Calculi. What are the symptoms in the kidneys and what are treatments?
Renal calculi (kidney stones) are small solid masses that are produced in the kidneys. They tend to form more easily during pregnancy because of the increased excretion of calcium and urinary stasis (which means the decreased flow of urine). The symptoms of renal calculi include: flank-loin-abdomen distribution of severe pain often with dysuria, hematuria, and nausea. The treatment is mostly focused on easing the pain of passing renal calculi and include: increased hydration, analgesics, and straining the urine for stones.
10. Explain hydronephrosis. How does it occur and what are the symptoms? What can be done about it?
Hydronephrosis is the fluid buildup in the kidneys when urine flow is obstructed in the urinary tract. In pregnancy, hydronephrosis occurs from smooth-muscle relaxation of the ureter due to progesterone and HCG as well as the compression of the ureter at the pelvic brim due to the heavy and increasingly large uterus, which obstructs urine flow. The symptoms are similar to a woman who has pyelonephritis or renal calculi (flank- loin-abdomen distribution of severe pain often with dysuria, shaking chills, hematuria, nausea, vomiting, urinary pain and urgency, flank or low-back pain, costovertebral angle tenderness, and malaise). Depending on the severity of it, there are various treatments/ managements which include narcotic medications and techniques to reduce pressure on the kidneys and ureters (such as urinating in the hands and knees position in the bath tub). 4
11. What are differential diagnoses for renal calculi and hydronephrosis?
The differential diagnoses for renal calculi and hydronephrosis include:
• appendicitis
• bowel obstruction
• cholecystitis
12. Explain ruptured ovarian cysts including symptoms and treatment.
Ovarian cysts are a common finding in pregnancy and they typically do not cause any complications or pain. However, the rupture of an ovarian cyst can cause issues that require treatment. The symptoms of a ruptured ovarian cyst include: mild, chronic lower abdominal pain that suddenly becomes acute, rebound tenderness, and guarding. The treatment for a ruptured ovarian cyst is surgical treatment.
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 an ovary and sometimes a fallopian tube end up getting twisted. This is an uncommon emergency during pregnancy. Typically this occurs when a woman has an ovarian mass (like a dermoid cyst) and it most commonly occurs on the right side. The symptoms of adnexal torsion are: severe pain, nausea, vomiting, and fever. Physical examination does not always show concrete information about the source of the problem and so ultrasound and color Doppler are used to show an absent ovarian flow or peritoneal fluid and an adnexal mass. The treatment for this it either laparoscopy or laparotomy to then either remove the fallopian tube and ovary or to untwist the infundibulopelvic ligament.
14. What are the differential diagnoses for adnexal torsion?
The differential diagnoses for adnexal torsion are:
• ectopic pregnancy
• appendicitis
• endometrioma 5
• degenerating fibroid
15. What are degenerating uterine fibroids? What are the symptoms and how is this treated?
Degenerating uterine fibroids are fibroids that are in the uterus that remain stable or decrease in size with advancing gestation. Often between 12 and 20 weeks gestation, a fibroid may outgrow its blood supply and then begin to degenerate. This can cause the following symptoms: acute onset of significant localized abdominal pain, nausea, vomiting, low-grade fever, and leukocytosis. Because fibroid degeneration is a self- limited process, the treatment typically involves a 48-hour regimen of indomethacin or narcotic analgesia.
16. What are the differential diagnoses for fibroids?
The differential diagnoses for fibroids are:
• appendicitis
• pyelonephritis
• cholecystitis
• placental abruption
17. Define chorioamnionitis. What are the symptoms and what happens if it is left untreated? What are the treatments?
Chorioamnionitis is an infection/inflammation of the fetal membranes due to bacteria. This is a serious condition as it can greatly impact fetal health.
The symptoms of this include: maternal fever (100.4 F), maternal tachycardia (>129 bpm), fetal tachycardia (>160 bpm), foul-smelling amniotic fluid or vaginal discharge, uterine tenderness, increased maternal leukocytosis, and general malaise.
***Note that the fetus typically shows signs of distress, such as tachycardia, before the mother shows any symptoms. 6
If chorioamnionitis is left untreated, it can lead to fetal and neonatal complications, including death. Mothers typically don’t die from chorioamnionitis.
The treatment for chorioamnionitis is antibiotic therapy (since this is caused by bacteria).
18. What are the differential diagnoses of chorioamnionitis and why do they often mimic it?
The differential diagnoses for chorioamnionitis include:
• PID (can mimic chorioamnionitis because it also causes abdominal pain)
• chlamydia or gonorrhea (can mimic chorioamnionitis because these cause foul- smelling vaginal discharge)
19. What are the symptoms of gallbladder issues? Why do these symptoms happen, meaning what are the specific mechanisms that cause the symptoms? How is this condition treated? Why are gallstones problematic in pregnancy? What are the differential diagnoses?
The symptoms of gallbladder issues are: intense dull pain on the right upper quadrant with the pain sometimes radiating out to the shoulder, back, or chest; anorexia; nausea; vomiting; and fever. Some other things to note with symptoms is that the pain begins about an hour or two after eating a meal (especially a fatty meal) and that the pain persists for about 1-5 hours. The pain becomes increasingly worse over a few hours and then after the stone shifts, the pain subsides. This occurs because the gallbladder will contract after a fatty meal and this will then push a stone against the duct which creates the intense pain. There can also be pale or gray stools if the bile duct becomes completely obstructed.
This condition in a pregnant woman is typically treated with expectant management as this is the safest approach during pregnancy. However, surgery may be needed if there is pancreatitis or a bile duct obstruction. In fact, laparoscopic cholecystectomy (which means removal of the gall bladder) is the most common laparoscopic procedure done during pregnancy. However, removing gallstones and/or gallbladder during pregnancy can also potentially cause fetal loss which is why surgery should be delayed until after delivery whenever possible.
The differential diagnoses for gallbladder issues are: 7 appendicitis, hepatitis, pancreatitis, right-sided pneumonia, intra-abdominal abscess, and acute fatty liver of pregnancy
20. Explain pancreatitis. What is happening and why? What are the symptoms? What are the treatments? What can mimic these issues?
Pancreatitis is when the pancreas becomes inflamed. This is often associated with cholecystitis as a gall stone can cause a blockage that inhibits the drainage from the pancreatic duct. The symptoms of this are: sudden and severe pain which starts in the upper abdomen and then radiates toward the back; nausea; vomiting; decreased bowel sounds; and elevated amylase and lipase levels. The treatment is ideally expectant management as the symptoms usually go away after about 5 days with bowel rest, nasogastric suction, pain medication, and IV hydration.
Some other issues can mimic this and these include: gastric or duodenal ulcer, bowel obstruction, ectopic pregnancy, biliary colic, appendicitis, and diverticulitis.
21. What causes small-bowel obstructions? What are the symptoms and treatments? What other conditions can mimic this issue?
Small-bowel obstructions can be caused by adhesions from previous surgeries, neoplasms, volvuli, intussusception, hernia, or pressure from a 3rd trimester uterus. The symptoms of small-bowel obstruction include: poorly localized pain, nausea, foul- smelling vomiting that is persistent, extreme constipation, and abdominal distention. The treatment for this is surgery which involves a midline vertical abdominal incision.
Some other issues can mimic small-bowel obstruction and these include: gastric or duodenal ulcer, pancreatitis, ectopic pregnancy, biliary colic, appendicitis, and diverticulitis.
22. What is AFLP? What causes it and what are the symptoms? What are the treatments and what is it often diagnosed incorrectly as?
AFLP stands for acute fatty liver of pregnancy. This is a rare, but very serious condition in pregnancy as there is a high maternal and fetal mortality rate. This is caused by the accumulation of fat within the liver cells (hepatocytes). This usually occurs in the 3rd trimester and the symptoms include: nausea and vomiting, right-upper quadrant pain, jaundice, and malaise. The treatments for this include: delivery of the fetus, and medical support for the mother for potential maternal coma, respiratory or renal failure, coagulopathy or hemodynamic instability.
This is often misdiagnosed as: severe preeclampsia, HELLP syndrome, or hepatitis 8
23. What are the symptoms of ICP? How is it diagnosed? How is it treated? What can it be misdiagnosed as?
The symptoms of ICP are: severe itching and skin lesions, especially on the palms and soles of the feet. It is diagnosed when severe itching (pruritus) has no other explanation and when abnormal lab results from GGT, ALT, AST or fasting serum total bile acids are found. It is treated through close fetal monitoring and delivery as soon as the fetus hits 37 weeks or sooner if need be due to non-reassuring fetal testing.
It can be misdiagnosed as: dry skin, drug reaction, uremia, iron deficiency, leukemia, thyroid disorders, and diabetes.
24. What is Somatization disorder? What causes it and how is it treated?
Somatization disorder is when there is no physical origin of the presenting symptoms that a person is describing as having. For example, emotional reactions can raise a person’s blood pressure and it can trigger diarrhea or vomiting too. Somatization disorder is typically caused by emotional trauma or other psychological imbalances. It can be treated through psychological therapy, medications (such as serotonin), and alternative treatments such as acupuncture, and myofascial release.