The Pregnant Patient: Managing Common Acute Medical Problems

 

Am Fam Physician. 2018 Nov 1;98(9):595-602.

Author disclosure: No relevant financial affiliations.

Women often see their primary care physicians for common acute conditions during pregnancy. These conditions may be caused by pregnancy (obstetric problems) or worsened by pregnancy (obstetrically aggravated problems), or they may require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems). Primary care physicians should know the differential diagnosis for common conditions during pregnancy and recognize the important findings of obstetric and urgent nonobstetric problems. The family physician can evaluate and treat most nonobstetric problems, although obstetric problems require referral to a primary maternity care clinician. A tiered approach, including routinely looking for all-cause red flag symptoms and signs, while remaining aware of estimated gestational age, allows for high-quality care and shared decision making between the family physician and the pregnant patient. When treating common causes of nausea and epigastric pain/gastroesophageal reflux, lifestyle modifications are considered the safest and first-choice therapy, followed by well-established low-risk therapies, such as vitamin B6 (pyridoxine) and doxylamine for nausea, and antacids not containing salicylates (found in bismuth combination products) for gastroesophageal reflux. Other common conditions during pregnancy are best treated with low-risk therapies, such as using antihistamines or topical steroids for rashes, first-generation cephalosporins or amoxicillin for cystitis, and physical therapy and acetaminophen for low back pain and headaches.

Women often see their primary care physicians for common acute conditions during pregnancy, even if they are not the primary maternity care clinician. Some conditions are caused directly by pregnancy (obstetric problems) or are worsened by pregnancy (obstetrically aggravated problems), and others require special consideration during pregnancy because of maternal or fetal risks (nonobstetric problems).1  Table 1 outlines the causes of common symptoms during pregnancy.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of nausea and vomiting in pregnancy should begin with lifestyle modifications. Other treatments, including P6 acupressure, vitamin B6 (pyridoxine), doxylamine, and prescription antiemetics, can be added as needed.

B

7, 8, 10

Pregnant women with more than 100,000 colony-forming units of one bacterial species on urine culture should be treated with antibiotics to prevent pyelonephritis.

A

32

Initial choices for treating musculoskeletal back pain in pregnancy include exercise and physical therapy, but additional therapy with acetaminophen, warm baths, acupuncture, support devices, or epidural steroids may be needed.

C

36, 37

Pregnant women with new-onset headaches or a new type of headache should be further evaluated to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches). Preeclampsia must be ruled out if headaches occur after 20 weeks' gestation.

C

40, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Treatment of nausea and vomiting in pregnancy should begin with lifestyle modifications. Other treatments, including P6 acupressure, vitamin B6 (pyridoxine), doxylamine, and prescription antiemetics, can be added as needed.

B

7, 8, 10

Pregnant women with more than 100,000 colony-forming units of one bacterial species on urine culture should be treated with antibiotics to prevent pyelonephritis.

A

32

Initial choices for treating musculoskeletal back pain in pregnancy include exercise and physical therapy, but additional therapy with acetaminophen, warm baths, acupuncture, support devices, or epidural steroids may be needed.

C

36, 37

Pregnant women with new-onset headaches or a new type of headache should be further evaluated to distinguish urgent or emergent causes (e.g., meningitis, subarachnoid hemorrhage) from common preexisting conditions (e.g., sinusitis, tension or migraine headaches). Preeclampsia must be ruled out if headaches occur after 20 weeks' gestation.

C

40, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE

The Authors

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DAVID S. GREGORY, MD, is program director of the Centra Lynchburg (Va.) Family Medicine Residency. He is also an associate clinical/adjunct professor at the University of Virginia School of Medicine in Charlottesville, Virginia Commonwealth University School of Medicine in Richmond, and Liberty University College of Osteopathic Medicine in Lynchburg....

VELYN WU, MD, is assistant director of sports medicine at the Centra Lynchburg Family Medicine Residency. She is also an assistant clinical professor in the Department of Family Medicine at the University of Virginia School of Medicine and the Virginia Commonwealth University.

PREYASHA TULADHAR, MD, is a third-year resident at the Centra Lynchburg Family Medicine Residency.

Address correspondence to David S. Gregory, MD, Centra Health, 2323 Memorial Ave. 8, Ste. 10, Lynchburg, VA 24501 (e-mail: runfamdoc@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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