Common problems associated with early and advanced pregnancy

Problems of pregnancy range from the mildly irritating to life-threatening conditions. -the life-threatening ones are rare because of 1- improvements in the general health of the population 2- improved social circumstances 3-lower parity.

women delay childbearing, they become more at risk of disorders associated with increasing age, such as miscarriage and placenta praevia. -Regular antenatal examinations beginning early in pregnancy are valuable because of . 1-help to prevent many complications 2- defined problems, contribute to diagnosis and treatment 3- enable women to form relationships with midwives, obstetricians and other health professionals who become involved with them 4- to achieve the best possible pregnancy outcomes.

The midwife's role 1-accurate health history is obtained. 2- General and specific physical examinations must be carried out and the results recorded. 3-ffective referral and management. 4- the midwife detects a deviation from the norm ,

refer the woman to a suitable qualified health professional to assist her The midwife will continue to offer the woman care and support throughout her pregnancy and beyond. -The woman who develops problems during her pregnancy is no less in need of the midwife's skilled afention; indeed, her condition and psychological state may be considerably improved by the midwife's continued presence and support.

It is also the midwife's role in such a situation to ensure that the woman and her family understand the situation; are enabled to take part in decision-making; and are protected from unnecessary fear. As the primary care manager, the midwife must ensure that all the afention the woman receives from different health professionals is balanced and integrated – in short, the woman's needs remain paramount throughout.

Abdominal pain in pregnancy Abdominal pain is a common complaint in pregnancy. It is probably suffered by all women at some stage, and therefore presents a problem for the midwife of how to distinguish between the physiologically normal (e.g. mild indigestion or muscle stretching), the pathological but not dangerous (e.g. degeneration of a fibroid) and the dangerously pathological requiring immediate referral to the appropriate medical practitioner for urgent treatment (e.g. ectopic pregnancy or appendicitis).

-The midwife should take a detailed history and perform a physical examination in order to reach a decision about whether to refer the woman. - Treatment will depend on the cause ,and the maternal and fetal conditions. C a use s o f a bdo m ina l pa in in pr e g na ncy Pregnancy-specific causes Physiological Heartburn, soreness from vomiting, constipation Braxton Hicks contractions Pressure effects from growing/vigorous/malpresenting fetus Round ligament pain Severe uterine torsion (can become pathological)

Pathological Spontaneous miscarriage Uterine leiomyoma Ectopic pregnancy Hyperemesis gravidarum (vomiting with straining) Preterm labour Chorioamnionitis Ovarian pathology Placental abruption Spontaneous uterine rupture Abdominal pregnancy Trauma to abdomen (consider undisclosed domestic abuse) Severe pre-eclampsia Acute fatty liver of pregnancy Incidental causes More common pathology Appendicitis Acute cholestasis/cholelithiasis Gastro-oesophageal reflux/peptic ulcer disease Acute pancreatitis Urinary tract pathology/pyelonephritis Inflammatory bowel disease Intestinal obstruction

Miscellaneous Rectus haematoma Sickle cell crisis Porphyria Malaria Arteriovenous haematoma Tuberculosis Malignant disease Psychological causes

Many of the pregnancy-specific causes of abdominal pain in pregnancy listed in Box are dealt with in this and other chapters. For most of these conditions, abdominal pain is one of many symptoms and not necessarily the overriding one. However, an observant midwife's skills may be crucial in procuring a safe pregnancy outcome for a woman presenting with abdominal pain.

Bleeding before the 24th week of pregnancy Any vaginal bleeding in early pregnancy is abnormal and of concern to the woman and her partner, especially if there is a history of previous pregnancy loss. -The midwife can come into contact with women at this time either through the booking clinic or through phone contact.

If bleeding in early pregnancy occurs a woman may contact the midwife, the birthing unit or a triage line for advice and support. The midwife should be aware of the local policies pertaining to her employment and how to guide the woman. In some areas of the United Kingdom (UK) women are reviewed within the maternity department from early pregnancy, whereas in others, they will be seen by the gynaecology team until 20 weeks' gestation, possibly in an early pregnancy clinic.

However, women are ohen advised to contact their General Practitioner (GP) in the first instance, and many will visit an accident and emergency department. In all cases, a history should be obtained to establish the amount and colour of the bleeding, when it occurred and whether there was any associated pain. well-being may be assessed either by ultrasound scan or, in the second trimester, using a hand-held Doppler device to hear the fetal heart sounds. Maternal reporting of fetal movements may also be useful in determining the viability of a pregnancy.

-There are many causes of vaginal bleeding in early pregnancy, some of which can occasionally lead to life-threatening situations and others of less consequence for the continuance of pregnancy. - The midwife should be aware of the different causes of vaginal bleeding in order to advise and support the woman and her family accordingly.

Implantation bleed -A small vaginal bleed can occur when the blastocyst embeds in the endometrium. -This usually occurs 5–7 days aher fertilization, and if the timing coincides with the expected menstruation this may cause confusion over the dating of the pregnancy if the menstrual cycle is used to estimate the date of birth.

Cervical ectropion -More commonly known as cervical erosion. The changes seen in cases of cervical ectropion are as a physical response to hormonal changes that occur in pregnancy. -The number of columnar epithelial cells in the cervical canal increase significantly under the influence of oestrogen during pregnancy to such an extent that they extend beyond to the vaginal surface of the cervical os, giving it a dark red appearance. -As this area is vascular, and the cells form only a single layer, bleeding may occur either spontaneously or following sexual intercourse. -Normally, no treatment is required, and the ectropion reverts back to normal cervical cells during the puerperium.

Cervical polyps -These are small, vascular, pedunculated growths on the cervix, which consist of squamous or columnar epithelial cells over a core of connective tissue rich with blood vessels. During pregnancy, the polyps may be a cause of bleeding, but require no treatment unless the bleeding is severe or a smear test indicates malignancy.