[5 min read] Managing pregnancy complications in primary care

The vast majority of pregnancies progress without any complications. Many minor problems and complications are managed by the general practitioner; however, it is essential to know when referral to secondary care is warranted.

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Some of the most common complications managed in primary care include nausea and vomiting, anaemia, urinary tract infection and musculoskeletal pain.

One of the most common problems in early pregnancy is nausea and vomiting, which affects up to 80% of pregnant women. It can occur as early as week 4 of pregnancy and generally resolves by week 16–20. Non-pharmacological management strategies include rest, maintaining fluid intake, avoiding triggers for nausea and adapting the diet to comprise more bland foodstuffs. Pharmacological management in the form of antiemetics can be utilised in primary care. Referral to secondary care is indicated where there is persistent nausea and vomiting despite primary care management, signs of hyperemesis gravidarum, or if the woman is unable to tolerate oral intake.

Dyspepsia in pregnancy is common and often occurs alongside nausea and vomiting – affecting up to 80% of pregnancies. Symptoms are the same as dyspepsia in the non-pregnant population, and management includes lifestyle and dietary advice, alongside pharmacological management with antacids and alginates.

Routine antenatal tests reveal iron-deficiency anaemia in up to 25% of women, which can usually be managed in primary care. Women with asymptomatic mild iron-deficiency anaemia (haemoglobin of 70–110g/L) should be trialled with oral iron. Where there is no improvement within two weeks or where there are any complications, referral to secondary care should be initiated.

Any infection can occur during pregnancy, however, urinary tract infections (UTI) are significantly more common, with up to 10% of pregnant women experiencing a UTI during pregnancy. UTI in pregnancy increases the risk of serious complications such as preterm labour, so must be promptly treated with antibiotic therapy. Urine culture should be obtained in all cases; however, treatment should be commenced based on typical symptoms without waiting for culture results. In addition, screening for, and treatment of, asymptomatic bacteriuria, should be performed early in pregnancy.

Musculoskeletal pain is common in pregnancy, particularly in the second and third trimesters and may include back pain and pelvic girdle pain. Gentle exercise should be encouraged, alongside simple analgesia. Where mobility is affected, there are any red flag symptoms, or pain is not controlled, referral to secondary care should be initiated.

Presentations which almost always require secondary care input in pregnancy include suspected ectopic pregnancy, vaginal bleeding, abdominal pain, signs of pre-eclampsia (such as hypertension, headache, visual disturbance, peripheral oedema), rupture of membranes, symptoms of thromboembolism and suspected gestational diabetes.

Finally, it is important to remember that any women’s health condition can also occur during pregnancy such as mental health conditions and infections. The general practitioner is also often responsible for jointly managing chronic conditions such as diabetes, thyroid disorders and epilepsy alongside the obstetrician. Often the management is identical, however, some medications are not suitable for use in pregnancy (such as tetracycline antibiotics, systemic antifungals and some anti-epileptic medications).

Dr Samantha Miller, MBChB

Read another article like this one: Managing women’s fertility in primary care


References

  1. Nausea and Vomiting of Pregnancy. The American Family Physician. 2014;89(12):965-970. https://www.aafp.org/pubs/afp/issues/2014/0615/p965.html
  2. National Institute for Health and Care Excellence. Clinical Knowledge Summary: Nausea and Vomiting in Pregnancy. https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/
  3. The Australian Government Department of Health (2020). Clinical Practice Guidelines: Pregnancy Care. https://www.health.gov.au/resources/pregnancy-care-guidelines
  4. The Australian Government Department of Health (2019). Pregnancy Care Guidelines: Anaemia. https://www.health.gov.au/resources/pregnancy-care-guidelines/part-f-routine-maternal-health-tests/anaemia
  5. Australian Journal of General Practice (2019). Anaemia in Pregnancy. https://www1.racgp.org.au/ajgp/2019/march/anaemia-in-pregnancy
  6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2019). Antenatal Care during Pregnancy. https://ranzcog.edu.au/womens-health/patient-information-resources/antenatal-care-during-pregnancy
  7. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2019). Routine Antenatal Care in the Absence of Pregnancy Complications. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Routine-antenatal-assessment-in-the-absence-of-pregnancy-complications-(C-Obs-3b)_2.pdf?ext=.pdf
  8. National Institute for Health and Care Excellence (2016). Antenatal care for uncomplicated pregnancies. https://www.nice.org.uk/guidance/cg62/resources/antenatal-care-for-uncomplicated-pregnancies-pdf-975564597445
  9. National Institute for Health and Care Excellence. Clinical Knowledge Summary: Dyspepsia in Pregnancy. https://cks.nice.org.uk/topics/dyspepsia-pregnancy-associated/
  10. NHS Inform: Ready Steady Baby – Common Problems in Pregnancy. https://www.nhsinform.scot/ready-steady-baby/pregnancy/health-problems-in-pregnancy/common-problems-in-pregnancy

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