Maternity - Pregnancy, part 9: Complications: Hyperemesis Gravidarum, Candidiasis, Anemia, UTI
by Meris Shuwarger BSN, RN, CEN, TCRN September 13, 2021 Updated: December 07, 2022 5 min read
This article continues our discussion of the various complications of pregnancy, focusing on hyperemesis gravidarum, iron-deficiency anemia, candidiasis, and urinary tract infections.
This series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Patients with hyperemesis gravidarum suffer from severe nausea and vomiting that extends beyond the first trimester of pregnancy.
“Hyper” means more than usual, and “emesis” means nausea and vomiting, so hyperemesis means throwing up more than usual — more than the common morning sickness. It is a serious condition of pregnancy, which, if left untreated, could result in the patient vomiting to the point that they become malnourished.
Signs and symptoms of hyperemesis gravidarum
Signs and symptoms of hyperemesis gravidarum, in addition to nausea and vomiting, include dehydration, electrolyte imbalances, and weight loss. These could lead to major complications of the heart and brain, for example.
Pregnancy is a time for gaining weight, so losing weight during pregnancy is a sign something is not right.
Another sign of hyperemesis is the presence of ketones in the urine, a condition called ketonuria. Ketones appear in the urine because of dehydration, and, more specifically, because the patient is not getting the nutrition that they need. This means the body has to break down fat for energy, and in the process of breaking down its fat (its stored energy), keto acids are released. For a pregnant patient, this is potentially deadly if the body has to resort to burning its full backup stores of energy for nourishment.
Treatment of hyperemesis gravidarum
Treatment for hyperemesis gravidarum includes prescribing antiemetics (e.g., ondansetron, metoclopramide, promethazine). Note that most antiemetics are not considered category A (safe to use) for pregnancy.
One antiemetic that is category A is pyridoxine (a combination of vitamin B6 and sleeping medicine), though its efficacy may be limited for a patient suffering from hyperemesis.
If the patient has refractory hyperemesis (the condition is not readily responding to treatment), the provider may prescribe corticosteroids.
A patient with hyperemesis may be so severely ill that they need to have a Zofran pump. A Zofran pump provides a continuous level of Zofran to help control nausea and vomiting. However, some patients are allergic to Zofran, eliminating it as a treatment option.
Nursing care for hyperemesis gravidarum
In terms of nursing care for hyperemesis gravidarum, administer IV fluids and electrolytes as ordered. Monitor their Is and Os and their weight.
Encourage the patient to eat small, frequent meals, and dry or bland foods.
Remember, hyperemesis is going to be a dramatic experience for most patients. They’ll report, “I’m vomiting dozens of times per day. I can keep no food or fluid down, and I feel very sick.” This is an unpleasant, even frightening condition, especially for a pregnant patient.
Candidiasis is a fungal infection caused by Candida albicans (better known as a “yeast infection”). It is common during pregnancy due to changes in vaginal pH and the flora of the vulva, and because the patient’s immune system is not working as it normally does.
Signs and symptoms of candidiasis
The most obvious and common sign/symptom for candidiasis is a thick white discharge, sometimes described as being like cottage cheese in consistency, and an intense itching, known as pruritus. The patient may also experience burning with urination as well as vaginal inflammation.
Treatment of candidiasis
Candidiasis may be treated with topical antifungal agents, (e.g., clotrimazole, miconazole).
Patient teaching for candidiasis
Patient teaching for someone with candidiasis involves lifestyle modifications.
Patients should avoid wearing tight clothing, which holds moisture close to the body. They should also avoid damp clothing or bathing suits for the same reason.
Patients should not use douching products. Teach them that the vagina is self-cleaning, so there's never a need to douche, which is especially true during pregnancy. Similarly, it is important to avoid using scented feminine products (e.g., scented lotions), which can be irritating to the sensitive skin around the vulva.
Most important, the patient should wear cotton underwear, which is more breathable, allowing for a greater exchange of oxygen while trapping less moisture.
This is also important because one of the physiologic changes of pregnancy is leukorrhea, an increased vaginal discharge, which acts as a protective mechanism. But it also means increased moisture around the vulva (and, therefore, a higher risk for yeast infections). The natural cotton fibers may help to alleviate this.
Iron-deficiency anemia is anemia due to inadequate iron stores and/or insufficient intake of iron-rich foods. When a patient is pregnant, they have a higher blood volume. In order to allow their red blood cells to carry the oxygen they require, they need to have enough iron to allow the hemoglobin to carry that increased oxygen load. That means the patient should be increasing their iron intake, and their caregivers need to be aware if they are iron deficient, which can cause anemia.
Signs and symptoms of iron-deficiency anemia
The signs and symptoms of iron-deficiency anemia include fatigue, shortness of breath, pallor (paleness), and pica (the craving to consume non-food substances, such as clay, dirt, ice, even laundry detergent). Pica is the body’s way of saying it is not getting the nutrients it needs.
Labs for iron-deficiency anemia
Labs will show a decrease in H&H — that is, low levels of hemoglobin and hematocrit (a measurement of the proportion of red blood cells in the blood).
Further labs will indicate low levels of iron and ferritin (a protein that stores and releases iron).
Treatment of iron-deficiency anemia
Treatment for iron-deficiency anemia is simply increasing the patient’s intake of iron. This includes taking ferrous sulfate, which should be taken with vitamin C (to increase absorption).
Nursing care for iron-deficiency anemia
In addition to taking ferrous sulfate, patients should be advised to increase their intake of iron-rich foods (e.g., meat, fish, chicken, liver, green leafy vegetables).
It is also important for the patient to increase their fluid and fiber intake when taking iron supplements (to prevent constipation).
Urinary tract infection (UTI)
A urinary tract infection (UTI) is a bacterial infection in any part of the urinary tract. A UTI should be treated seriously, as it may lead to uterine irritation and preterm labor.
UTI risk factors
Signs and symptoms of UTI
It is possible that a patient with a UTI is asymptomatic. For this reason, at the initial first trimester visit, many providers will send off a urine culture to screen for a pre-existing UTI.
For a patient with symptoms of a urinary tract infection, those may include dysuria (painful urination that might be described as burning), and/or frequent and urgent urination (often with only a couple of drops coming out).
Other symptoms include cloudy and/or malodorous urine, fever, chills, fatigue, and suprapubic (above the pubic bone) pain.
Labs and diagnostics for UTI
Urine may also be sent to the lab for a culture, allowing the provider to know exactly what bacteria may be growing and what antibiotics it is susceptible to. Additional labs include RBC, nitrites, and leukocyte esterase (a screening test used to detect white blood cells in the urine).
Treatment of UTI
Antibiotics are administered to treat a UTI.
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 pruritus, 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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