Recognition and Presentation 1
This GI discomfort peaks in the first trimester and affects 50–80% of pregnant people. What hormone is this related to?
Nausea and vomiting of pregnancy. While the exact cause remains unknown, it is thought to relate to hCG and hormonal changes.
A pregnant person at 9 weeks is vomiting every few hours and is only able to keep down sips of water. Her skin turgor is poor and mucous membranes are dry. What should you recommend at this time?
IV fluids and labs to rule out electrolyte imbalances
For a pregnant person with mild nausea and vomiting, your first-line counseling includes non-prescription options before recommending prescription medications. Name three over-the-counter agents that have evidence for managing mild nausea and vomiting in pregnancy.
Vitamin B6 (pyridoxine); Unisom (doxylamine); ginger
Eating five to six small meals throughout the day instead of three large meals reduces nausea. Explain the physiologic mechanism: why does this approach decrease nausea in pregnancy?
Small, frequent meals keep blood glucose stable and prevent both hypoglycemia and gastric distention, which can trigger nausea and vomiting
Relaxin
A pregnant person at 16 weeks reports palpitations and a racing heart "out of nowhere." She has had no prior cardiac history. What is the likely physiologic cause of this?
Sinus tachycardia related to cardiovascular changes: - increased blood volume and cardiovascular return to heart.
- Progesterone causes vasodilation
During your assessment of a person with vomiting, you note blood in the vomitus. This red flag suggests you should rule out one of these two gastrointestinal conditions.
Peptic ulcer disease OR esophagitis (from repeated vomiting)
Doxylamine, diphenhydramine, and prochlorperazine all belong to this drug class. They may cause drowsiness as a side effect but can help manage mild to moderate nausea and vomiting of pregnancy.
Antihistamines (or anticholinergic agents)
Ginger is a commonly recommended herbal remedy for nausea in pregnancy. Describe the paradoxical physiologic effects of ginger: one mechanism that helps nausea and one that potentially worsens another discomfort.
Ginger stimulates gastric motility and decreases nausea; however, it also relaxes the lower esophageal sphincter, which increases acid reflux and heartburn
Both dependent edema and varicosities occur in pregnancy due to a combination of hormonal effects and mechanical pressure. Name the hormone that relaxes venous walls and increases venous distensibility, and explain the mechanical factor from the enlarging uterus.
Progesterone relaxes smooth muscle in venous walls, increasing venous compliance and distensibility. The enlarged uterus increases pressure on the inferior vena cava and veins in the lower extremities, impairing venous return and elevating venous pressure.
A patient presents with persistent nausea and vomiting onset before 7 weeks. She has lost 10lbs, which is greater than 5% of her baseline. What condition should you be most concerned about?
Hyperemesis gravidarum
A pregnant person at 28 weeks complains of persistent leg swelling, but on exam you note the swelling is unilateral (only one leg) and accompanied by warmth, erythema, and calf tenderness. She assumed this was normal "dependent edema." What serious condition must you rule out, and what is the first-line imaging?
Deep vein thrombosis; compression ultrasound (or duplex ultrasound) of the affected leg
Ondansetron (Zofran) is the only anti-emetic agent used in pregnancy with this specific mechanism of action: it directly targets serotonin receptors in the chemoreceptor trigger zone in the brain. What unique advantage does this central mechanism offer compared to antihistamines?
It works directly on the nausea-vomiting center in the brain rather than on peripheral receptors, making it effective for moderate to severe nausea when other agents have failed. May also be combined with other agents. Also comes in dissolving format
To manage pregnancy-related constipation, dietary interventions (fluids, fiber) are first-line. When pharmacologic intervention is needed, identify a laxative agent that is safe in pregnancy and one that should be used with caution.
Safe: bulk-forming laxatives, stool softeners, glycerin suppositories. Unsafe (contraindicated): stimulant laxatives such as senna; castor oil (can cause uterine contractions)
A patient with allergies reports new onset of nose bleeds during pregnancy. What hormone is this associated with?
Estrogen
You ask a pregnant person at 28 weeks whether her shortness of breath began gradually or suddenly. This question matters because sudden onset with vital sign changes might suggest this alternative diagnosis.
Pulmonary embolism
A pregnant person at 9 weeks with admitted with severe vomiting has these lab results: AST 90, ALT 130. Before attributing elevated liver enzymes to hyperemesis gravidarum, what other labs should you order to rule out a serious alternative diagnosis?
Hepatitis Panel
A pregnant person with moderate nausea and vomiting is on a combination of metoclopramide (Reglan), promethazine (Phenergan), and ondansetron (Zofran) because monotherapy failed. What serious cardiac complication is she at risk for with this polypharmacy approach, particularly related to ondansetron?
Prolonged Q-T interval and cardiac arrhythmias; ondansetron carries a black box warning about Q-T prolongation, and combining multiple anti-emetics increases this risk
A pregnant person at 26 weeks has progressive low back pain affecting daily function. She wants to avoid pain medications. Varney's recommends a combination of interventions: proper body mechanics for lifting, specific exercises, and an external support device. Name the recommended external support device and describe how the exercises differ between upper back pain and lower back pain.
External support: maternity support belt or sacroiliac belt. Upper back pain: supportive bra and chest exercises; Lower back pain: pelvic rock exercises, pelvic tilt exercises, and external abdominal support
A patient at 32 weeks has reported increased vaginal discharge for the last 3 visits. A wet prep followed by a vaginal PCR swab has ruled out all infectious causes. What is this called and what hormone would you educate her on that causes this?
Leukorrhea of pregnancy r/t estrogen
A pregnant person at 10 weeks carries a spit bottle and large cup of ice everywhere. She notes vomiting 2-3 times a day, and lab work shows microcytic anemia. What are your differential diagnoses?
- Ptyalism
- Pica
A pregnant person at 10 weeks cannot urinate despite a full bladder. She reports severe lower abdm pain and difficulty voiding. What complication of early pregnancy is she experiencing, and what intervention is indicated?
Incarcerated uterus; catheterization may be necessary to relieve acute urinary retention, followed by referral for possible manual reduction with or without anesthesia depending on severity
This anti-emetic carries an FDA black box warning about agitation, anxiety, and dystonic reactions. It is a second-line agent for moderate nausea and vomiting of pregnancy when antihistamines alone are insufficient.
Metoclopramide (Reglan)
A pregnant person at 16 weeks with lower back pain that is inhibiting her daily function. She has no neurologic deficits. What types of referrals would be appropriate?
- PT
- Accupuncture
- Chiropractor (Webster technique)
- Massage therapy
Dyspnea is a common discomfort in pregnancy that typically increases as pregnancy progresses. Other than the physiologic growth of the uterus - Explain the hormonal basis.
Progesterone causes relaxation of the smooth muscle in the upper airway and increases airway edema (hyperemia), narrowing the airway. Additionally, progesterone increases sensitivity of the respiratory center in the medulla to carbon dioxide, causing a hyperventilation response.