Maternity - Pregnancy, part 9: Complications: Hyperemesis Gravidarum, Candidiasis, Anemia, UTI

September 13, 2021 Updated: September 23, 2021 7 min read

Full Transcript

Hi, I'm Meris and in this video, I'm going to be talking to you about some complications of pregnancy. We're going to be talking about hyperemesis gravidarum. We're going to be talking about iron deficiency, anemia, candidiasis, and urinary tract infections. I'm going to be following along using our maternity flashcards. These are available on our website, leveluprn.com, if you want to get a set for yourself. I highly recommend it. But if you already have a set and you want to follow along, I would very much invite you to do that so that you can correlate the information on your cards to the stuff that I talk about. Let's get started.

So first up, we're going to be talking about hyperemesis gravidarum, and this is something you may know of because of popular culture. Princess Kate had this with at least one, if not more, of her pregnancies, but two other people you know have had this as well, that would be myself and Cathy Parkes. And this is actually something that we found out about each other early on when we started working together and bonded over immediately because it was such a dramatic and traumatic experience for both of us.

Now, hyperemesis, hyper meaning more than usual, right, elevated, emesis is nausea and vomiting, right, throwing up, and then gravidarum means of pregnancy, so throwing up more than usual in pregnancy. This is not morning sickness. This is not routine nausea and vomiting of pregnancy. This is a very serious condition of pregnancy where your patient is vomiting to the point that they are malnourished, right?

Your patient may have clinical dehydration. They may have electrolyte disturbances, big red flag, right? You got to be thinking, we're worried about the heart, we're worried about the brain, all of those different things. Your patient is also going to be at risk for weight loss. So in a time of pregnancy, I'm supposed to be gaining weight. I should never be losing weight in pregnancy. That is a huge red flag for something being wrong. Now, hyperemesis is going to be really dramatic for most of your patients, and they're going to report, "I'm vomiting dozens of times per day. I can keep no food or fluid down, and I feel very sick," right?

So a big hallmark of hyperemesis is going to be the presence of ketones in the urine. So we call that condition ketonuria. So why do we have ketones in the urine? Well, it can happen because of dehydration, but more specifically, it happens because your patient is not getting the nutrition that they need to live and now their body is breaking down fat, right? It's breaking down this stored energy and we are releasing keto acids through that. Keto acids are a byproduct of breaking down our stored energy. This is not good in pregnancy because this means that we are having to resort to our full backup stores of energy, and this could be deadly for our patient. And it's a really big deal.

So antiemetics are, of course, going to be a good treatment for this. However, most antiemetics are not category A for pregnancy. There is one, which is a combination of vitamin B6 and actually a sleeping medicine, and that one is considered Category A, but it's not as effective as someone with hyperemesis needs. A patient with hyperemesis may be so severely ill that they need to have a Zofran pump. A Zofran pump will actually provide them with continuous levels of Zofran to help control their nausea and vomiting. But this is also not something that everyone can take. I'm allergic to Zofran, so for me, that was not an option, and I had to keep going in for fluids and keep taking-- well, I started with oral medications, right, and then had to proceed to suppositories because I could not keep down my antiemetics. So very, very serious. Personally, my record was 60 times in one day. I threw up anywhere between 30 and 60 times a day every single day until I delivered my baby. It only happened with my daughter. With my son, I did not have that experience. I was so fortunate. But it's very serious and something that should be investigated. If your patient reports weight loss or if you see ketones in their urine, you need to be thinking hyperemesis.

Okay, moving on to candidiasis. Candidiasis is a yeast infection. This is very common in pregnancy because the immune system is a little bit out of whack in pregnancy and the normal flora of the vulva can be disrupted. So this is not an unusual finding, candidiasis.

But the big hallmark, the big sign and symptom that you need to be thinking of for candidiasis is a thick white discharge. They may sometimes describe this as being cottage cheese like in consistency along with intense itching, the fancy medical term is pure rightists, right? So if we have that, we may also have burning with urination, vaginal inflammation but if we have thick white discharge and itching, I've got to be thinking that might be a yeast infection.

The best treatment for this is going to be topical antifungals. Yes, there are oral antifungals that can be taken, however, that would probably not be first line during pregnancy. We would still stick to the topical stuff.

Important patient teaching here is going to have to do with lifestyle modifications. So avoid tight clothing because that's going to hold moisture close to the body. Avoid damp clothing like if you were to go swimming, take your swimsuit off immediately. Don't sit around in it. Do not use douching products, ever. Please don't. You don't need them. Your vagina is self-cleaning. There's no need to douche, but especially in pregnancy, and scented products like scented lotions and things like that are going to be very irritating to the sensitive skin around the vulva, so avoid those. But most importantly, it's going to be wear cotton underwear. It sounds silly, but cotton underwear is going to be more breathable, and it's going to allow for more of that exchange oxygen, less moisture trapping. This is also important because one of the physiologic changes we talked about before in pregnancy is going to be leukorrhea, right? We're going to have increased vaginal discharge as a protective mechanism. So that means increased moisture around the vulva, higher risk for yeast infections. So educate your patients to wear cotton underwear, not synthetic materials.

And then lastly-- oh, I'm sorry, not lastly. Next, we're talking about iron deficiency anemia. Now, remember, I've talked about this in several videos so far. When a patient is pregnant, they have a higher blood volume. In order to make those red blood cells able to carry oxygen, they need to have enough iron to make the hemoglobin to carry the oxygen around. That means that your patient should be increasing their iron intake, right? We talked about that in the nutrition guidance, but sometimes it's just not enough anyway, right? Sometimes your patient is still going to have iron deficiency anemia, and we need to be on the lookout for that.

So signs and symptoms, they may feel fatigued. They may have paler, so they look pale. If it's like me, my doctor would need to know my baseline because I am already pale, right? But they're going to be exceptionally pale. They may report shortness of breath upon exertion. They can't get that oxygenation because of the hemoglobin. And then here's an important one, pica. So pica is the craving or the eating of non-food substances such as dirt, or clay, or laundry detergent. All of those things that aren't food, that means that the body is craving something in particular, and in this instance, we're talking about iron. So if your patient says that they are chewing ice frequently, or that they have this really weird craving for dirt, you need to take that seriously and investigate it.

So, of course, lab findings here, we're going to have a decrease H&H, right. The hemoglobin is going to be low, and the hematocrit is going to be low. That's going to be the hallmark sign here. And then if we did more intense studies, we would see a low iron and/or a low ferritin level. So the treatment is more iron, right? Iron deficiency anemia, we treat it by giving you iron.

Important patient teaching, you want to take it in the morning, with a glass of orange juice, or with a grapefruit or-- well, let's avoid grapefruit in general, but with an orange, because vitamin C increases the absorption of iron. So your patient may also just want to take a vitamin C supplement at the same time as their iron, but increase that fluid and fiber intake because iron is very constipating. And guess what? So is pregnancy.

All right, so let's move on. Lastly, now to urinary tract infections. Now, I know you're thinking, I get it, I get it. UTIs are common and whatever, but UTIs are really important to know about and to assess for in pregnancy because they can lead to uterine irritation and pre-term labor. So this is something that we don't want our patients to have ever, but especially in pregnancy.

So you may have a patient who is asymptomatic. And for this reason, at the initial first trimester visit, many providers will actually send off a urine culture just to rule out a pre-existing UTI. So that we can get that under control.

But if your patient is having symptoms, it would likely be things like dysuria, which is painful urination, they may describe it as burning. They may report frequency and urgency. So frequency meaning, "I'm going more frequently," and urgency, meaning, "I just feel like I have to pee so bad all of the time, and I run to the bathroom," And then they also may say, "but then when I sit down to go to the bathroom, I only get a couple of drops out." So that would be a big sign of a UTI.

Urinalysis is going to be a really good way for us to see if there are white blood cells or the products of bacteria in their urine, but we can also actually send it out for a urine culture and sensitivity, meaning that we can tell exactly what grows and what antibiotics it is susceptible to.

The treatment, of course, antibiotics.

And then we just want to teach our patients that they should increase their fluid intake. They should be wiping from front to back after urination. Urinate after sexual intercourse. So we want to teach them to avoid sitting in wet bathing suits too, wear cotton underwear, all of those things to decrease that moist, warm environment that bacteria enjoy.

All right. I hope that review was helpful for you. If it was, please be sure to like this video and leave me a comment. If you have a better way to remember something, I want to hear it. Thanks so much and happy studying.


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