ABNORMAL

PREGNANCY

1. RISK FACTORS IN
PREGNANCY
Hyperemesis Gravidarum

This is a condition where vomiting is severe and continuous throughout the

day. The woman vomits everything she has eaten. This usually leads to
severe dehydration and ketoacidosis. She becomes malnourished. If
treatment is not started quickly, liver and kidney damage may result.
Anaemia may develop as a result of lack of vitamin B, folic acid and iron.

Can you think of three conditions that are associated with

hyperemesis gravidarum?

Did you think of these?

Hyperemesis gravidarum occurs in very few women. It is usually associated
with multiple pregnancies, hydatidiform mole and/or a history of habitual
abortions.

Management of Hyperemesis Gravidarum

If in a health centre or dispensary, the patient should be referred to a
hospital as soon as the diagnosis is made. In the hospital, the following
should be done:
• Intravenous infusion of five percent dextrose alternating with normal
saline will be given to correct the dehydration.
• Anti emetics like promethazine hydrochloride (phenergan) or
metoclopromide hydrochloride (plasil) are given usually parenterally to
control the vomiting.
• Multivitamin supplements are given.
• The patient is reassured and her visitors restricted.
 • Routine nursing care and observations of vital signs are maintained
twice daily or as necessary.
The patient should be discharged at least two to three days after vomiting
has ceased. The case should be followed up in the antenatal clinic.

Polyhydramnios

This is a condition in which the quantity of amniotic fluid exceeds 1500mls. It

may not become apparent until it reaches 3000mls. It is a fairly rare
condition.
Polyhydramnios is associated with the following conditions:
• Oesophageal atresia
• Open neural tube defect
• Multiple pregnancy, especially in monozygotic twins
• Maternal diabetes mellitus
• Rarely in rhesus isoimmunisation
• Severe foetal abnormalities
There are two types of polyhydramnios: chronic and acute.

Chronic Polyhydramnios
This occurs gradually, usually from about the 30th week
of pregnancy.
It is the most common type.

Acute Polyhydramnios
This is a rare type, which occurs at about 20 weeks and comes on very
suddenly. The uterus reaches the xiphisternum in about three to four days. It
is associated with monozygotic twins or severe foetal abnormality.
Polyhydramnios can be recognised in the following ways:
• The mother may complain of breathlessness
and discomfort.
• If the condition is acute in onset, she may complain of severe
abdominal pain.
• The condition may aggravate other symptoms associated with
pregnancy such as indigestion, heartburn, constipation, oedema,
varicose veins of the vulva and lower limbs.
• On abdominal inspection, the uterus is larger than expected for the
period of gestation and is globular in shape. The abdominal skin
appears stretched and tight with marked striae gravidurum and
marked superficial blood vessels.
• On palpation, the uterus is tense and it is difficult to feel foetal parts.
• The abdominal girth is much more than expected for the period of
gestation.
• Auscultation of the foetal heart is difficult because of the free
movement of the foetus.
 • Where possible an ultrasonic scan should be done to confirm the
diagnosis. It may also reveal multiple pregnancy or foetal abnormality
if these are present

Management of Polyhydramnios
The mother is admitted to hospital and, where possible, the cause of the
condition is determined. The subsequent care will be determined by the
condition of the mother, the cause and the period of gestation.
If there is foetal abnormality, the method and timing of delivery will depend
on the severity. If there is gross abnormality, induction should be started.
The nursing care should include rest in bed in sitting position to relieve
dyspnoea. Assist the patient with personal hygiene and routine prenatal
observations.
If abdominal discomfort is severe, abdominal amniocentesis may be
considered. If it is done, infection prevention measures must be observed
and only 500ml should be withdrawn at a time. Labour may be induced in
the case of late pregnancy. Before the membranes are ruptured, the lie must
be determined and the membranes ruptured cautiously allowing the fluid to
flow slowly. This is to avoid cord prolapse, alteration of the lie and abruptio
placenta which may occur after sudden reduction of uterine size.

Complications of Polyhydramnios
There are several complications associated with polyhydramnios. These
include:
• Increased foetal mobility leading to unstable lie
and malpresentation
• Cord presentation and cord prolapse
• Premature rupture of the membranes
• Placenta abruptio when the membranes rupture
• Premature labour
• Postpartum haemorrhage

Oligohydramnios

In this condition there is an abnormally small amount of amniotic fluid. It

may be 300 to 500ml at term but amounts vary and it may be much less. It
is associated with absence of kidneys or Potter's syndrome in which the
foetus has pulmonary hypoplasia.
The lack of amniotic fluid reduces intrauterine space and causes deformities
of the foetus due to compression. The baby's skin is dry and leathery in
appearance and the nose may be flat. It may have talipes and a squashed-
looking face.
The following characteristics will help you recognise the presence
of oligohydramnios:
• The uterus is smaller than expected for the period
of gestation
 • The mother notices reduced foetal movements if she has had a
previous normal pregnancy
• On palpation the foetal parts are easily felt and the uterus is small and
compact

Management
The woman should be admitted for investigations, usually in the form of an
ultrasound scan. If there are no foetal abnormalities, the pregnancy will be
allowed to continue. Labour may be induced early to avoid placental
insufficiency.
Analgesics are given during labour because the contractions are usually very
painful. However, be aware that impaired circulation may cause foetal
hypoxia. After delivery the baby is examined carefully for abnormalities.

Bleeding in Late Pregnancy (Antepartum Haemorrhage

Bleeding in late pregnancy refers to any bleeding from the genital tract from
the 28th week of gestation and before the birth of the baby. It is usually
known as antepartum haemorrhage.

Remember:
Never perform a vaginal examination on a woman with antepartum
haemorrhage. This may lead to severe bleeding which can be fatal.

The two most important causes of bleeding in late pregnancy are placenta
praevia and abruptio placentae. You will now look at each of
these separately.

Placenta Praevia
This is bleeding from a partially separated placenta, which is wholly or
partially situated in the lower uterine segment. It might be covering either
part or the entire internal os.
It is more likely to occur with increasing maternal age. It is more common in
women aged 35 and above. It is also associated with increasing parity, and is
twice as common in multigravida as in primigravida.
Placenta praevia is divided into four types or degrees.

Type 1
The placenta lies in the upper segment and only the lower margin dips into
the lower uterine segment.

Type II
The placenta is partially situated in the lower uterine segment with the lower
margin of the placenta reaching the edge of the internal os but does not
cover it. It is known as marginal placenta praevia.

Type III
The placenta covers the internal os when closed up to three to four
centimetres dilatation. This is known as partial or incomplete placenta
praevia.

Type IV
The placenta lies centrally over the internal os and covers the os even when
the cervix is fully dilated.
Signs and Symptoms of Placenta Praevia
The signs and symptoms of placenta praevia include painless vaginal
bleeding which starts when at rest or sleeping. It starts suddenly, usually
from the 32nd week of gestation because of Braxton Hicks contractions.
Additionally, because the placenta occupies the lower uterine segment, the
foetal head remains high, which results in malpresentation and unstable lie.
If bleeding is severe, the blood pressure is low, the pulse and respirations are
high, and there is shock corresponding with the amount of bleeding.

The Management of Placenta Praevia

If in a health centre or dispensary, refer all pregnant women with vaginal
bleeding to hospital. Ensure there is a running intravenous drip of saline or
dextrose before transferring the patient to the hospital. A nurse should
always accompany the patient to
the hospital.
In the hospital the type of management will depend on the amount of blood
loss, the condition of the mother and foetus, the location of the placenta and
the gestation period.
The aim of management is to control haemorrhage and to try to conserve
the pregnancy up to 38 weeks gestation when the foetus
is mature.
Where there is slight vaginal bleeding, conservative treatment is started if
the pregnancy has not reached 38 weeks of gestation. The patient is
admitted for complete bed rest and total care.
Measures to be Taken in the Case of Placenta Praevia
• Blood is taken for HB, grouping and cross matching
• She is put on mild sedation like phenobarbitone
• No abdominal palpation is done as it may trigger severe bleeding
• Save all pads to assess blood loss
• Give high protein diet
• Take two hourly vital signs
• On the third day speculum examination is done to exclude incidental
haemorrhage
• At 34 weeks scanning is carried out to assess progress and to confirm
diagnosis
• The patient should be retained in hospital until the 37th week when
Examination Under Anaesthesia (EUA) is done in theatre ready for
caesarean section in case of
severe bleeding
• In placenta praevia type one and two and if placenta is anterior, the
membranes are ruptured and spontaneous delivery awaited. Labour is
induced with oxytocin drug
• In placenta praevia type two with placenta posteriorly situated and in
type three and four, caesarean section is performed
In the case of moderate to severe vaginal bleeding, you should
set up intravenous infusion and prepare for immediate caesarean section.
Blood for HB grouping and cross matching should be taken, and physical and
psychological preparation of the mother
is done.

Complications of Placenta Praevia

The following are some complications of placenta praevia:
• Post partum haemorrhage
• Foetal hypoxia
• Puerperal sepsis
• Anaemia
• Maternal and foetal death

Abruptio Placentae (Accidental

Haemorrhage)
This is bleeding from premature separation of a normally situated placenta
occurring after the 28th week of gestation. It is associated with the following
conditions:
• Hypertensive conditions and pre-eclampsia
• High parity
• Trauma
• Sudden release of polyhydramnious
• High fever
• Traction of abnormally short umbilical cord during labour
• External cephalic version
 • Fright or sudden shock, for example, bad news

Types of Abruptio Placentae

There are three clinical presentations.

Mixed or combined, where bleeding is partly revealed and partly

concealed.

Concealed, where the blood is trapped between the placenta, membranes

and the uterine wall. There is no visible bleeding.

External or revealed, which is where there is free (visible) vaginal

haemorrhage.

Signs and Symptoms of Abruptio Placentae

In the revealed type, there is slight to severe vaginal bleeding. On abdominal
palpation there may or may not be pain and tenderness. The pulse is raised
and there is low blood pressure or hypertension.
In the concealed type, there is severe abdominal pain and the patient is in
shock. There is no vaginal bleeding and the uterus is very tender and is
board like. The foetal parts cannot be palpated and there are no foetal heart
sounds. The pulse is raised and there may be oliguria and proteinuria.
In the combined type, the patient has both features of revealed and
concealed bleeding. The degree of shock is higher than the visible blood loss.
The uterus is tender and rigid and pain is constant.

Management of Abruptio Placentae

Refer the patient to hospital if in a health centre or dispensary. She should
be started on intravenous drip. Inform the hospital if possible. Take a
specimen of blood for grouping cross matching before starting the drip and
take it with the patient when she is transferred. In the hospital, admit the
patient and call the doctor immediately. Give emotional support and physical
care. Relieve pain with IM morphine 15mg or pethidine 100mg. If there is
severe bleeding treat for shock and prepare for caesarean section.
Take vital signs, such as blood pressure and pulse, quarter to half hourly and
temperature four hourly. Raise the foot of the bed to prevent vena cava
occlusion by gravid uterus. Maintain a urine output chart and test urine for
protein. You should also test blood for coagulation defects and take clotting
time at intervals for monitoring. Prepare for reception and resuscitation of
the baby. Usually, the baby is still born. A blood transfusion should be given
where necessary.
Conservative Management
This occurs in cases of mild separation of the placenta. When the mother and
baby are in good condition, intra-uterine scanning is done to assess the
degree of haemorrhage and continuous foetal monitoring is done to assess
foetal condition.
If both mother and baby are well and gestation is under 37 weeks, she may
be discharged and seen weekly at the antenatal clinic.
At 37 weeks gestation you should readmit the mother for induction. The
membranes should be ruptured and she should be started on oxytocin drip
and monitored half hourly for onset of labour. In case of foetal distress,
Caesarean section should be performed.

Complications of Abruptio Placentae

These can be very serious and include the following:
• Failure of blood clotting mechanisms, leading to excessive
haemorrhage in concealed bleeding
• Renal failure or hypovoleamia
• Puerperal sepsis
• Anaemia
• Maternal death
• Foetal death
• Anterior pituitary gland necrosis. Thrombosis of pituitary gland may
occur in severe bleeding and if the mother stays in shock for long
Other causes of antepartum haemorrhage include:
• Rupture of small vessels at the edge of the placenta
• Cervical erosion
• Cancer of cervix
• Severe cervicitis
• Infected cervical polyp
For any of these conditions, refer the patient to the hospital for
management. You will learn their specific management in unit three.

The Differences between Placenta Praevia and Abruptio Placentae

Placenta Praevia Abruptio Placentae

1. Painless vaginal bleeding 1. Painful vaginal bleeding
2. Recurrent
2. Non recurrent bleeding
bleeding
3. The blood lost is bright red 3. The blood lost is dark red
4. The amount of blood lost is in keeping 4.The amount of blood lost may be
with the very little
general condition of the patient compared with the subsequent
 shock and/or anaemia
5. Signs of pre-eclampsia may be
5. No signs of pre-eclampsia
present
6. The foetus is most often alive 6. The foetus is dead in most cases
7. The uterus is tender and may be
7. The uterus is soft and not tender
hard
8. The foetal parts may be difficult
8. The foetal parts are easily palpable
to palpate
9. The uterine size corresponds to dates 9. The uterus may be larger
of gestation than dates of gestation
10. The presenting part may10. The presenting part is usually
be displaced into the iliac fossa in the normal place

Pre-eclampsia

Can you think of five conditions that may predispose a mother to

pre-eclampsia?

Pre-eclampsia is a condition peculiar to pregnancy and occurring usually

after the
28th week of gestation. It is characterised by the presence of hypertension,
oedema and proteinuria or any two of the three. It is more common in the
following conditions:
• Primigravida, especially the too young or over 35 years
• Multiple pregnancy
• Diabetes mellitus
• Hydatidiform mole
• Essential hypertension
• Polyhydramnios
• Mothers with past history of pre-eclampsia
• Obese mothers
As you can see, it is important to take a good history as it will enable you to
detect this condition early.
The cause of pre-eclampsia is not known, but there are various theories
relating to its possible causes, which are endocrine in nature, metabolic or
immunological.

Diagnosis of Pre-eclampsia
The diagnosis of pre-eclampsia is not easy since the mother has no obvious
complaints. There are three cardinal signs.

Hypertension
There is a rise in diastolic pressure of 15 to 20mm/hg above the mother's
normal diastolic pressure, or an increase above 80 to 90mm/hg on two
occasions. A marked increase in systolic pressure above that expected for
the mother's age is important to note, for example, 140 to170 where the
mother's normal pressure is between 90/60 and 120/70mm/hg.

Proteinuria
This is important in the absence of urinary tract infection. It may be detected
in testing a midstream specimen of urine, which should be followed by
laboratory investigation. The amount of protein in the urine indicates the
severity of pre-eclampsia.

Oedema
Oedema of ankles is common in late pregnancy but it disappears overnight.
This is known as physiological oedema. Any generalised oedema is
significant and occult oedema is suspected in cases of excess weight gain
above what is expected for the gestation. Clinical oedema may be mild or
severe. The oedema puts on pressure and is found in the following areas:
Feet, ankles, and pretibial region; lower abdomen; vulva, which is
uncomfortable and distressing to the mother; sacral area in a mother
confined to bed; facial puffiness of the face and eye lids, fingers.
Pre-eclampsia can be classified as mild, moderate or severe.

Mild Pre-eclampsia
This is detected when, after resting, the diastolic pressure is 15 to 20mm/hg
above the basal blood pressure recorded in early pregnancy or a diastolic
above 80 to 90mm/hg, for example, BP 130/80 to 140/90. Oedema of feet,
ankles and pretibial region may also be present.

Moderate Pre-eclampsia
This is diagnosed when there is marked rise in both systolic and diastolic
pressure - 140/100 to 160/100mm/hg, proteinuria of 0.5gm/litre with no
evidence of urinary tract infection and
generalised oedema.

Severe Pre-eclampsia
Symptoms include the blood pressure exceeding 160/110mm/hg and an
increased proteinuria over 1gm/litre. There may be marked generalised
oedema, frontal headache and visual disturbances.
The effects of severe pre-eclampsia on the mother include:
• Abruptio placenta
• Condition may worsen, leading to eclampsia
• The kidneys, lungs, heart and liver may be seriously damaged due to
haematological disturbance
• The capillaries within the fundus of the eye may be irreparably
damaged causing blindness
The effects on the foetus are:
• Low birth weight due to reduced placental function
• Increased incidence of hypoxia during prenatal and
intranatal periods
• Placenta abruptio leading to hypoxia and later death
• Prematurity if the baby is delivered early delivery due to placenta
abruptio or worsening of the condition
The midwife plays an important role in detecting pre-eclampsia. There
should always be
vigilant antenatal care to enable early detection and management.
You should also ensure a thorough history taking to detect the mothers at
risk early in pregnancy.
Follow up should include monitoring of weight and blood pressure and urine
testing on every subsequent visit.
Factors that may predispose the patient to pre-eclampsia, such as multiple
pregnancies and obesity should be noted early.

Management of Pre-eclampsia
The method of management will depend on the severity of the condition. The
main principles of care are:
• Provide adequate rest and monitoring of observations to avoid
eclampsia
• Prolong the pregnancy until the baby is mature enough to survive
• Safeguard the life of the mother

Mild Pre-eclampsia Management

The mother should be advised on bed rest at home and she is seen weekly to
assess her condition. She should be given
anti-hypertensive drugs such as aldomet 500mg. Sedatives such as valium
or phenobarbitone should also be administered to help her rest and she
should be advised to report to the hospital in case of any problem.

Moderate Pre-eclampsia Management

The patient should be admitted to hospital for bed rest. She should only be
allowed to go to the toilet. She should be nursed in sitting position or lying on
the side to encourage uterine blood flow. Bed rest will reduce oedema by
improving the renal circulation, facilitating kidney filtration and producing
diuresis. It also lowers the blood pressure.
The patient's diet should be rich in protein, fibre and vitamins and low in
carbohydrates and salt. Her weight should be recorded twice a week.
Observe for oedema daily. Urine should be tested for protein and Ketones.
Esbach setting is done daily to assess level of protein loss. Twenty four hour
urine collection should be done to estimate oestriol level as an indication of
placental function.
Fluid intake and output should be maintained strictly to monitor renal
function.
Sedatives, such as phenobarbitone, may be given to ensure rest and sleep.
Give antihypertensive drugs like aldomet to lower blood pressure. Take vital
signs: blood pressure, temperature, pulse and respirations four hourly.
The foetal heart rate should be taken four hourly or two times daily,
depending on the condition. A kick chart to monitor foetal movement should
also be kept.
When the mother's condition improves, she can be discharged to attend
clinic weekly until she goes into spontaneous labour. Otherwise, she should
be admitted at 38 weeks for induction of labour. If, in spite of the above care,
the condition does not improve, caesarean section should be performed.

Management of Labour
Remain with the mother throughout labour. Maintain close vigilant
observations of:
• Presence of oedema
• Urinary output
• Urinalysis results
• Blood pressure
Report any deviations to the doctor immediately. Take vital signs as follows:
blood pressure and pulse rate half hourly, temperature four hourly, unless
otherwise indicated.
Perform abdominal examination and observe for contractions and foetal
heart rate half hourly. At the same time, observe for signs of second stage of
labour and immediately alert both the obstetrician and paediatrician.
After delivery, monitor blood pressure four hourly for 24 hours. Urinalysis
should be done twice a day. You should maintain a urinary output chart and
continue with antihypertensive drugs and normal postnatal or caesarean
section care.

Active Management of Severe Pre-eclampsia

Admit the mother in a quiet, dimly lit room on complete bedrest. In the room
there should be an emergency tray and an epileptic tray in case of a fit. The
aim of care is to prevent convulsions and control hypertension to prevent
death of the mother and foetus.
Place the mother on lateral position to improve foetal circulation and to
prevent vena cavae compression by the uterus. Remain with the mother and
maintain vigilant observations. On admission you should take all
observations and note them on a chart and continue half hourly or as
prescribed by the doctor.
The doctor will prescribe antihypertensive drugs like hydrolysing
5-10mg which is administered slowly and blood pressure monitored
every five minutes until it stabilises. Diazepam is also given 10mg stat
followed by 40mg in 5% dextrose. Lasix 20 to 80mg may be given as a
diuretic. Antibiotics may be prescribed if necessary. Strict monitoring of
blood pressure should be done.
Maintain a strict intake and output chart and test all urine that is passed. In
some cases an indwelling catheter may be passed. Fluid intake is restricted
to one to two litres in 24 hours. Esbach should be set daily. The weight
should also be measured daily or on alternative days.
Administer medication as prescribed. Observe for signs of onset of labour
and signs of impending eclampsia. If protenuria and high blood pressure
persist, the doctor should induce labour by artificial rupture of membranes
followed by syntocinon drip. Unless there is some obstetric contra-indication
a caesarean section will be done.
You have seen that mothers with severe pre-eclampsia can
proceed to eclampsia. The following are warning signs of impending
eclampsia:
• A sharp rise in blood pressure
• Diminished urinary output
• Increased proteinuria
• Severe persistent frontal occipital headache
• Drowsiness or confusion (due to cerebral oedema)
• Blurring of vision or flashing lights (due to retinal oedema)
• Nausea and vomiting
• Epigastric pain which the mother may interpret as indigestion (due to
oedema of the liver)
Should a mother present to your clinic with these signs, give her an
anticonvulsant and refer to hospital immediately for further management. In
the hospital, the midwife should summon the
doctor immediately.

Care During Labour

Treatment for severe pre-eclampsia should be continued. Perform a vaginal
examination to assess the progress of labour. During the second stage,
episiotomy should be performed to shorten the phase and the doctor will use
vacuum extractor to prevent the mother from pushing. Ergometrine is
avoided because of its
vaso-constrictive effect and instead syntocinon 5 IV in a drip or
intramuscularly is given. A Caesarean section may be performed if the
condition does not improve or there is obstetric contra-indication for vaginal
delivery.

Post Delivery Care for Pre-eclampsia Cases

Sedate the mother and continue observations of vital signs. Continue and
adjust drugs as necessary.
Eclampsia

Eclampsia is an acute condition characterised by convulsions and coma. The

incidence of eclampsia is 0.2 to 0.5% of all pregnancies. It can occur in the
antenatal period at the rate of about 20%; during the intrapartum period at
the rate of about 25% and during the postnatal period within the first few
hours after delivery (35%).

Signs and Symptoms of Eclampsia

The prodromal signs of eclampsia are those we have described as serious
signs of pre-eclampsia. The more immediate precursors of eclampsia are
vomiting, intense headache and epigastric pain.
There are four stages of an eclampsia fit.

Premonitory stage, which lasts 10 to 20 seconds. The mother is restless

and rapid eye movements can be noted. The head may be drawn to one
side, twitching of the facial muscles may occur, and the mother is not aware
of
what is happening.

The tonic stage lasts 10 to 20 seconds. The muscles of the mother's body
go into spasms and become rigid. The back may become arched and her
teeth become tightly clenched. The eyes appear like they are staring and her
diaphragm goes into spasm. Respirations cease and cyanosis occurs.

The chronic stage lasts 60 to 90 seconds. There is violent contraction and

intermitted relaxation of the mother's muscles causing convulsive
movements. There is increased salivation and foaming at the mouth.
The mother's face becomes congested and bloated while her features
become distorted. The mother becomes unconscious and breathing is
stertorous while the pulse full and bounding. The convulsions subside
gradually.
In the stage of coma stertorous breathing continues and the coma may
persist for minutes or hours. Further convulsions may occur before the
mother
regains consciousness.
Now move on to look at the management of eclampsia

Management of Eclampsia
The main principle of management is to stop convulsions and deliver the
pregnant woman by the quickest and safest method. The mother's welfare is
of paramount importance and the foetus is the secondary consideration as it
is already in great danger.
Steps taken at the health centre
· Stop convulsions by giving intravenous diazepam or phenobarbitone or
paraldehyde.

· Insert a mouth gag to prevent the mother from biting her tongue.

· Place the mother in semi-prone position to facilitate drainage of saliva and

vomitus.

· Aspirate to remove mucus and to maintain clear airway and administer

oxygen as necessary.

· Transfer the patient to hospital by quickest means and accompany her.

· Take a delivery and emergency tray with drugs and mucus extractor, the
patient's notes and records.

· Inform the hospital before you leave.

Steps taken in the hospital

· Call the doctor and, meanwhile, put up intravenous drip of 5% dextrose for
nutrition and drugs.

· IV diazepam 10mg is given followed by 40mg in 5% dextrose 500ml IV drip

at 60 drops/minute.

· IV hydralazine 10mg is given to reduce the blood pressure. It should be

given slowly and blood pressure checked every five minutes.

· The doctors will perform careful assessment to determine the method of

delivery. Vaginal delivery is preferred unless there is
contra-indication.
· Once the blood pressure is under control, labour is induced by artificial
rupture of membranes and syntocinon drip commenced.

· Insert a urethral catheter and maintain continuous urine drainage.

· If vaginal delivery is not possible she is delivered by caesarean section.

The patient should be nursed in a darkened, quiet room. At this point you
should take the following steps:
• Take observations of vital signs and uterine contractions
half hourly.
• Protect from injury from the cot sides and nurse in
semi-prone position to encourage saliva and
mucus drainage.
• Do not restrict convulsive movements.
 • Ensure catheter care and keep the airway clear.
• Prepare for delivery or caesarean section as appropriate.
After a fit continue oxygen therapy and, do not give oral fluids. Intravenous
fluids should be restricted to 2000ml in 24 hours. Maintain strict fluid intake
and output chart. Observe for signs of labour. Delivery is by vacuum
extraction and sedation is continued. The baby should be nursed in the
special care baby unit (nursery).

Complications that may arise

· Cerebral haemorrhage
· Mental confusion
· Thrombosis
· Acute renal failure
· Liver necrosis
· Many develop myocardial infarction due to
pulmonary oedema
· Bronchopneumonia
· Temporary blindness
· Injuries or fractures may result if the patient falls or movement is restricted
during a fit
· She may bite her tongue
· Foetal hypoxia, prematurity, still birth

2. Medical Conditions that

may Complicate a Pregnancy
There are several medical conditions that may complicate a pregnancy.
These include:
• Cardiac disease
• Anaemia
• Diabetes
• Malaria
• Tuberculosis
• Urinary Tract Infections
You will now cover these in more detail.

Cardiac Disease in Pregnancy

There are changes that occur in the cardiac system during pregnancy due to
the increased demand in the foeto-placental unit. These changes increase
the workload of the heart. The major changes are:
• Blood volume increases by 35%
• Cardiac output increases by 40%, that is from
4.5 to 6l/min
The extra work that the heart has to do is reduced by the decreased blood
viscosity and lowered peripheral resistance. The pulse rate rises slightly in
order to pump out the extra blood around the body. Oxygen consumption is
raised. The heart is displaced upwards during the last trimester by the gravid
uterus. During the third stage of labour 300 to 400ml of blood is added to the
circulating volume by the contracting uterus.
These changes commence in early pregnancy and gradually reach their
maximum at the 30th week and are maintained until term.

Risk Factors for Heart Disease

The following factors predispose patients to heart disease:
• Anaemia, which should be avoided and if present,
vigorously treated.
• Infections, the most common of which are upper respiratory infections.
These should be treated with antibiotics.
• Obesity should be avoided. Controlled weight gain should be
encouraged to avoid extra strain on the heart.
• Hypertension and pre-eclampsia should be admitted
and controlled.
• Smoking mothers should be advised to control their habits.
• Multiple pregnancies should be well monitored.
• Strain of any form should be avoided and mothers should be
encouraged to have enough rest and adequate sleep.
• Exercises that induce breathlessness should
be discouraged.
• Fatigue of any kind should be avoided.

Cardiac disease in pregnancy has been classified in four grades. These are:

Cardiac Grade I

In this grade, there are no symptoms but a heart murmur is discovered on

general examination.

Cardiac Grade II
There are symptoms during ordinary physical activity (breathlessness) but
no symptoms when at rest.

Cardiac Grade III

There are symptoms during mild physical activity. The mother is unable to
perform ordinary daily activity. On slight exertion she gets exhausted and
severely dyspnoeic and has anginal pain.

Cardiac Grade IV

There are symptoms even at rest. There are signs of cardiac disease and
heart failure.
Effects of cardiac disease in pregnancy
• The increase in blood volume and body weight causes strain on the
already impaired heart.
• The increased cardiac output reaches maximum at 30 weeks when the
output is 25% above normal and, therefore, there is greater need
for rest.
• The normal venous dilation, which accompanies pregnancy, slows the
venous return to the heart and, therefore, increases the difficulty in
maintaining adequate output.
This results in an increased risk of thromboemboli and bacterial endocarditis
and raised maternal mortality when blood flow is impaired. There also also
risks to the foetus and these include intrauterine growth retardation, raised
incidence of congenital heart disease, and raised risk of foetal loss.

Management of Heart Disease

The mother is followed up by obstetrician, cardiologist, haematologist and
anaesthetist for effective management. The main aim of management is to
maintain and improve
the physical and psychological well being of both the mother and the foetus
and to
prevent complications.
Prenatal management for mild cardiac disease (Grades I & II) should include:
• Good history taking and a careful examination of the mother should be
done on the first visit.
• The mother is seen fortnightly until 32 weeks, then weekly until term.
Ideally, she should be admitted between 29 to 32 weeks for rest.
• All infections should be prevented and, if present, treated promptly.
• Anaemia should be treated effectively and prevented by extra iron HB.
Therefore, check regularly for anaemia.
• Health messages on the importance of a balanced diet, avoiding
excess weight, adequate rest and sleep, need for house help, and the
effects of smoking, should be shared.
 • Tooth extraction is possible under antibiotic cover but should be
discouraged.
• Drugs like digoxin, diuretics such as lasix to reduce oedema, and
sedatives may be taken as prescribed.
• At 38 weeks gestation, the patient should be admitted for complete
bed rest.

Management of Heart Disease (Grades I and II)

In first stage labour, follow normal admission procedure. You should:
• Inform the obstetrician and the cardiologist
• Vigilant observations quarter to half hourly, especially of pulse,
respirations, colour and foetal heart rate
• Administer prophylactic antibiotics
• Mild sedation

In the second stage of labour the following steps should be taken:

• The patient should avoid exhaustion
• Paediatrician to be around
• The mother should be placed in the dorsal position or the position in
which she feels most comfortable
• Episiotomy and vacuum extraction may
be performed

In the third stage of labour:

• No ergometrine should be given
• The cord should be delivered by controlled
cord traction

During the puerperium, the following measures should be taken:

• The patient may need to rest and may
require sedatives
• Keep her under strict observation half hourly until stable then two to
four hourly
• Treat any infections promptly
• If there are no complications, discharge on the tenth day post delivery
Management of Heart Disease (Grade III and IV)
When managing a patient with severe cardiac disease, the following steps
should be taken in the prenatal stage.
The patient should be nursed as a cardiac failure patient. She should be
admitted on first contact for complete bed rest. The strain is greatest
between the 23rd and 32nd weeks and so total nursing care should be given
during that period. There should always be two nurses present to perform
any procedure.
A very sick mother should be nursed in the propped up position and
preferably in a cardiac bed. You should monitor foetal heart and foetal
placental blood flow. Administer a diet low in salt and ensure adequate rest,
through the use of sedatives if necessary. Maintain good hygiene. Administer
drugs as prescribed by the doctor and treat anaemia. Ensure that there is
social care and support by family members and social workers.
In terms of psychological care, it is very important to reassure the patient
about her condition. Attend to her emotional needs and give counselling on
reproductive health.

Intrapartum management usually involves an easy delivery due to hypoxia.

Take the following measures:
• Avoid exhaustion
• Prop up in bed to prevent orthopnoea
• Give oxygen continuously
• Give analgesics but avoid inhalation
• Observations should be taken quarter hourly
In the second stage, avoid pushing and give episiotomy and vacuum
extraction. No ergometrine should be administered. If there is any post
partum haemorrhage, give syntometrine.

Puerperium management involves nursing in Intensive Care Unit (ICU) for 48

hours. You should take the following steps:
• Ensure that the patient has complete bed rest and total nursing care
• Observations half hourly until stable, then four hourly
• Withhold breast feeding if mother is in heart failure
• Admit the baby in a special care unit

Remember:
Carry out a thorough first examination to rule out congenital heart
condition. Continue antibiotics and sedatives for two weeks.
Discharge when condition is satisfactory.
Always keep in mind the following complications, which may arise:
• Congestive cardiac failure
• Pulmonary oedema
• Cardiac arrest
• Puerperal sepsis as a result of lowered resistance
to infection
• Deep venous thrombosis, pulmonary embolus, which may lead to
death
• Postpartum haemorrhage due to anaemia
• Bacterial endocarditis
• Myocardial infarction

Acute Heart Failure

The following are signs of acute heart failure:
• Cyanosis
• Rapid irregular pulse rate
 • Cold sweating extremities
• Cough with blood (haemoptysis)
• Pulmonary oedema, which is sudden with tachycardia, intense
dyspnoea, bronchospasm, cough, frothy mucus
The mother is nursed propped up in bed. Her diet should be low in salt.
Restrict fluid intake and maintain fluid intake and output chart strictly.
Rehydrate slowly. The patient should be kept warm and she should avoid
exertion. Exercises, such as passive leg movements should be encouraged.
Observe the vital signs quarter hourly, report severe breathlessness,
cyanosis, raised pulse rate above 110 per minute and respiration above 24
per minute.

Management of Labour for Acute Heart Disease Cases

First Stage
• Prop up in bed
• Valium 5 to 10mg in early labour to allay anxiety
• Morphia for pain
• Observations quarter hourly
• Rehydrate slowly

Second stage
• Usually short and easy
• Sit up or lie in the most comfortable position
• Give continuous oxygen
• No pushing
• Episiotomy is performed under pudendal nerve block
• No ergometrine
• Syntometrine is given only if Postpartum Haemorrhage (PPH) occurs

Third Stage
Patient may collapse when uterus contracts returning more blood into
circulation thus overloading the heart. To avoid this, the right hand is placed
on the abdomen firmly above the umbilicus to decrease abdominal pressure.
Discourage mother from over breathing because it draws more blood to the
heart. If syntocinon is given, it should be continuous infusion with a syringe
pump
(10 to 20 units). Lasix should be given half hour before commencing the drip.
This also applies if blood is to be transfused.

Puerperium
Heart failure may occur suddenly during puerperium, especially if the patient
has incompetence of the aortic valve.
The patient should be nursed on complete bed rest. Ensure adequate
breathing and leg exercises to prevent embolism. Ambulate on the fourth to
fifth day. You should continue antibiotics for two weeks
Breastfeeding is encouraged unless there is actual heart failure.
The following family planning methods are advised:
• Natural family planning
• Barrier methods with spermicides
• Progesterone only pill
The mother will require adequate health information messages concerning
contraceptives and her condition in order to make an informed choice.

Anaemia in Pregnancy

Anaemia is a deficiency in the quality or quantity of red blood cells with the
result that the oxygen carrying capacity of the blood is reduced. The normal
haemoglobin level in a female is 12 to 14gm per deciliter. Anaemia is
diagnosed in pregnant women when the haemoglobin level is below 10gm
per deciliter.
The following are some of the signs and symptoms of anaemia:
• Pallor of mucous membranes
• Breathlessness
• Dizziness
• Fatigue and lethargy
• Fainting attacks
• Headaches due to lack of sufficient oxygen to brain cells
• Anorexia and vomiting

Anaemia affects the patient in several ways. With regard to the mother,
anaemia has the following effects:
• It reduces enjoyment of pregnancy due to fatigue
• It reduces resistance to infection caused by impaired cell mediated
immunity
• Predisposition to postpartum haemorrhage
• Potential threat to life
• Problems caused by treatment and side effects
like constipation
Anaemia also affects the foetus in the following ways:
• High perinatal mortality if maternal haemoglobin level is below
8gm/decilitre
• Increased risk of intra uterine hypoxia and growth retardation and
severe asphyxia in severe anaemia
• Increased sudden infant death when maternal haemoglobin is below
10gm/decilitre

Degrees of Anaemia
These are classified according to the severity in pregnancy:
 • Mild anaemia is when haemoglobin level is between
8.1gm/dl to 9.9gm/dl
• Moderate anaemia is when the haemoglobin level is between
5.1gm/dl to 8gm/dl
• Severe anaemia is when the haemoglobin is less than
5gm/dl

In severe anaemia there is:

• Renal hypoxia resulting in retention of sodium
and electrolytes
• Myocardial hypoxia leading to heart failure
• Mental confusion
• Cough, especially with congestion in lungs
You will now look at the types of anaemia commonly seen
in pregnancy.

Physiological Anaemia
During pregnancy the blood plasma volume increases by 15% by the 10th
week of gestation and 50% by the 32nd to the 35th week
of pregnancy.
The red cells mass increases by 30%. These result in increased cardiac
output from five to seven litres per minute.
These changes result in apparent anaemia but as this
represents the normal pregnancy state, they should not
be regarded as pathological.

Iron Deficiency Anaemia

During pregnancy approximately 1400gm of iron is needed during the entire
period. Please note that this is given in small doses of about 200gm three
times a day. This is necessary for:
• The increased number of red blood cells
• The foetus and the placenta
• Replacement of blood lost during delivery
• Lactation

Remember:
Absorption of iron is usually hindered by tea or coffee consumption,
thus ascorbic acid is given to hasten iron absorption if one cannot
stop taking tea or coffee.

Folic Acid Deficiency Anaemia

Folic acid is required for the increased cell growth of both the mother and
the foetus. The main causes of folic acid deficiency
anaemia are:
• Low dietary intake
• Reduced absorption
 • Interference with utilisation like in substance abuse,
anti-convulsant drugs and sulphonamides which are
folate antagonists
• Excessive demand and loss like in haemolytic anaemia

Management of Anaemia in Pregnancy

The management of a woman with anaemia depends on the type and
severity of anaemia, and the duration of pregnancy.

Mild Anaemia
This is characterised by haemoglobin between 8.1 to 9.9gm/decilitre. At a
gestation of 20 to 29 weeks, the woman is given heamatinics and a diet rich
in protein and iron.
At 30 to 36 weeks, the haemoglobin levels are checked, diet is emphasised
and haematinics continued. These include oral iron, for example, ferrous
sulphate 200mg three times daily.
Investigations are carried out to establish the cause of the anaemia, for
example, malarial parasites, hookworms, sickle cell disease. The mother is
given health messages on nutrition, rest and taking drugs as prescribed.

Moderate Anaemia
This is characterised by haemoglobin levels of between 5.1 to 8gm per
decilitre. At gestation of 29 to 30 weeks investigations are carried out to
establish the cause and institute treatment.
Haematinics are given and a total dose of parenteral inferon 50 mgs/mililitre
is given in a slow intravenous infusion of normal saline after a test dose to
rule out sensitivity.
Intramuscular iron in the form of sorbital 50mg/ml is also administered. The
dose is 1.5mg/kg body weight weekly. Haemoglobin levels are monitored
regularly starting on the third day after commencement of treatment and
then monthly. The injection should not be given in conjunction with oral iron
as this enhances toxic effects.
At 30 to 36 weeks of gestation the woman is given total dose inferon and
transfused with no more than 500ml whole blood. The blood is given slowly
under close supervision. After transfusion, the woman will be put on folic
acid. At 37 weeks blood transfusion is given again as above.
Parenteral iron is contraindicated for women who have liver or renal
conditions.

Severe Anaemia
This is characterised by haemoglobin below 5gm per decilitre. This is an
emergency where the mother is admitted and put on complete bed rest to
reduce cardiac workload as she could go into cardiac failure.
Investigations are carried out to establish the cause. Meanwhile, she is
nursed in left lateral position to prevent compression of the vena cava by the
gravid uterus. Vital observations are taken quarter hourly and the foetal
heart rate is monitored.
Transfuse three units of packed cells slowly. Monitoring is continued quarter
hourly. Administration of haematinics is continued.
In case of malaria, hookworm or sickle cell disease, the root cause of the
anaemia
is treated.
Health messages are shared on diet and general prevention.

Management During Labour

Blood is cross-matched and the patient is started on transfusion of packed
cells only to avoid cardiac overload. Emergency drugs are kept ready. In the
second stage of labour, oxygen is given and a vacuum extraction is carried
out. Intravenous lasix is given. Syntocinon 40 to 60 units in half litre of 5%
dextrose is given
by pump.

Remember:
Ergometrine is contra-indicated because it causes vaso-constriction.

Blood loss should be minimised by rubbing the uterus to contract it.

Controlled cord traction is used to deliver the placenta. The mother should
avoid any exertion.

Post Natal Care

The mother is given antibiotics to prevent infection, and put on haematinics
for three months. The haemoglobin is checked on the third and sixth week.
Family planning and good nutrition are encouraged.
If a pregnant woman has folic acid deficiency, you should give folic acid
supplements and oral Iron. If she has vitamin B12 deficiency she should be
given a weekly dose of 100mg of vitamin B12 injections until the condition is
reversed.

Prevention of Anaemia in Pregnancy

The prevention of anaemia in pregnancy involves taking the
following steps.

Health Education
You should advise mothers in the antenatal clinic about a balanced diet.
Green vegetables should not be overcooked as this destroys the folic acid.
Teach them about proper disposal of faeces to avoid hookworm infestation.
Encourage the practice of child spacing to avoid frequent pregnancies so as
to give the woman's body time to replenish her body stores. In addition
encourage her to continue coming to antenatal clinic.

Prophylactic Medication
Give the following supplements to the women throughout pregnancy:
• Ferrous sulphate 200mg three times a day
• Folic acid 5mg daily
• Prophylactic anti malarial medication
Ensure early detection and adequate treatment of malaria, anaemia,
antepartum and postpartum haemorrhage.

Diabetes in Pregnancy

Diabetes mellitus is not a new terminology and module one will be frequently
referred to.
Diabetes is a metabolic disorder due to partial or total lack of insulin,
characterised by hyperglycaemia. This may seriously complicate a
pregnancy as you will see later on.

Primary Diabetes
Diabetes can be primary which involves abnormality of the pancreas and is
sometimes called juvenile diabetes.

Secondary Diabetes
The other type of diabetes is known as secondary diabetes. It occurs later in
life and could be due to a disease in the pancreas such as tumours or
infection interfering with the normal production of insulin by the islets of
Langerhan's. It can also first appear during pregnancy.

Classification of diabetes mellitus in pregnancy

Insulin Dependent Diabetes Mellitus is where the patient has abnormal

blood sugar and is on insulin therapy to control the blood sugar levels.

Non Insulin Dependent Diabetes Mellitus is where the patient has

abnormal blood sugar but it is controlled by diet alone.

Gestational Diabetes Mellitus is where the patient develops abnormal

glucose
during pregnancy.

Potential Diabetic is where the individual has an increased tendency to

develop the disease during pregnancy, due to having delivered an unduly
large baby (4.5kg or more), family history of diabetes, chronic obesity or
glycosuria.

Carbohydrate Metabolism in Pregnancy

Do you remember the functions of insulin, digestion and metabolism of
carbohydrate which was covered in module one?
To understand what happens during pregnancy you must know what
happens normally.
If you need to do so, go back and review this section in module one.
There are a lot of changes, which occur due to pregnancy and some of these
changes will be covered now.

Fall in fasting blood sugar

The foetus obtains glucose from its mother via the placenta by the process of
diffusion. From the 10th week of pregnancy there is progressive fall in
maternal fasting glucose from 4 to 3.6 mmol/l.

Ketoacidiosis
During the third trimester the mother begins to utilise fat stores laid down in
the first and second trimester. This results in free fatty acids and glycerol in
the blood stream and the woman becomes ketotic more easily.
Hormonal Effect
The foeto-placental unit alters the mother's carbohydrate metabolism to
make glucose more readily available. Human Placental Lactogen hormone
(HPL), manufactured by the placenta, causes resistance to insulin in the
maternal tissues. The blood remains raised for a longer period than in the
non-pregnant state.
The extra demands on the pancreatic beta cells can precipitate glucose
intolerance or overt diabetes in those whose capacity for producing insulin
was just adequate prior to pregnancy. If the mother was already diabetic
before pregnancy, her insulin need will be further increased.

Glycosuria in Pregnancy
Glycosuria in pregnancy is not diagnostic of diabetes because there is:
• An increase in glomerular filtration rate as it passes through the
proximal convoluted tubule faster than the re-absorption
• Lowered renal threshold to glucose for the diabetic, which leads to
more glucose in the glomerular filtrate
• Renal tubular damage interferes with glucose re-absorption and may
be revealed for the first time during pregnancy
You will now cover the different grades of diabetes.

Potential Diabetes
Potential diabetes is indicated by various criteria, for example, one or both
parents are diabetic,
or the mother has previously borne an unduly
large baby. Usually, there is marked chronic obesity and glycosuria.

Chemical
Chemical diabetes is characterised by
abnormal Glucose Tolerance Test (GTT) but is without symptoms.
Overt or Clinical
This is indicated by abnormal GTT with symptoms and raised fasting blood
glucose level.

The Effects of Pregnancy on Diabetes

When the mother has diabetes and then becomes pregnant, there will be
further increase in insulin demand and even a mother who had only been on
a controlled diet, without need for medication, may now require insulin
supplements. This is due to low renal threshold to glucose and also low
glucose intake by mother due to nausea and vomiting.
The mother easily gets ketoacidosis as the fat is broken down. In late
pregnancy, insulin requirements are still high as there is reduced sensitivity
of the tissues to due to the Human Placental Lactogen hormone. Those with
juvenile diabetes may progress to nephropathy hence kidney failure and
retinopathy leading to blindness.

The Effects of Diabetes on Pregnancy

It is important to know what happens to the mother and foetus in relation to
glucose and insulin control and the effects.

Effects of Diabetes on the Mother

Unrecognised or a badly treated diabetes leads to complications in both the
mother and the baby. If well controlled, then the effects to pregnancy may
be minimal.
Maternal complications include:
• Urinary tract infection
• Candidiasis of vulva and vagina
• Reduced fertility, spontaneous abortion, pregnancy
induced hypertension
• Hydramnios
• Pre-term labour
The foetal and neonatal complications occur when the blood sugar is not
controlled and are mainly due to glucose being attached to the haemoglobin
(glycosulated haemoglobin). This results into impaired oxygen carrying
capacity resulting in the following conditions.

Macrosoma
Glucose crosses the placental barrier easily but insulin does not.
Hyperglycaemia in the mother is reflected by foetal hyperglycaemia in late
pregnancy. The foetal pancreas responds by producing excess insulin, which
cannot cross back into the maternal circulation. The insulin converts excess
glucose into glycogen, which is stored as fat deposits in the tissues resulting
in a big baby.

Foetal Hypoxia
Intrauterine hypoxia is caused by vascular changes on the maternal side of
the placenta, and increased oxygen consumption by the placenta and foetus.
The foetal haemoglobin is glycosurated hence there is an increase in the red
blood cells count (polycythaemia) in order to compensate for the demand of
oxygen by the foetus. The baby is red due to polycythaemia.

Congenital Malformations
Poor control of sugar in the first seven weeks of pregnancy leads to
congenital malformation. The most common occurrence is sacral agenesis
which includes anencephaly and spina bifida. The cardiovascular system will
have ventricular septal defects and transposition of the great vessels.
Other conditions that may transpire include intra uterine death as a result of
too severe maternal ketosis. There may be increased perinatal death soon
after birth from hypoglycaemia and respiratory distress syndrome in the
newborn.
The babies are also prone to jaundice and hypocalcaemia. Birth trauma is
also possible due to their large size and all these increase the risk of
perinatal mortality if not well managed. Perinatal mortality is high in mothers
who have developed nephropathy and retinopathy. Such women should
avoid pregnancy.
This topic will be discussed in more detail in unit three of module two, which
deals with care of the baby of a diabetic mother.

Risk Factors of Diabetes Mellitus

At this point you will deal with those who are predisposed to diabetes in
pregnancy.
Certain women are at risk of developing gestational diabetes during
pregnancy and may be identified when the history reveals one or more of
the following:
• Diabetes in a close family member
• Recurrent abortion
• Unexplained still birth
• Congenital abnormality
• Large baby above 4.2kg
• Previous gestational diabetes or impaired glucose
tolerance test
• Persistent glycosuria
• Excess of normal weight gain approximately 20%

Diagnosis of Diabetes During Pregnancy

Diagnosis of diabetes includes assessing the obstetric history of the patient
which may include
• Unduly large babies
• One or more still births
• Neonatal death
• Polyhydramnios
The potential diabetic state of the woman should also be assessed. Checking
for glycosuria two hours after a meal involves the use of reagent strips or
tablets if approximately 6.7mmol/1 (20mg/dl) GTT. A full GTT involves:
• Fasting blood sample for glucose level
• Glucose load of 50gm oral glucose
(If one hourly, blood glucose level is equal to or approximately
7.7mmol/l or higher.)
The aim of GTT is to assess body response to a glucose load. The level of
glucose should gradually decrease in the blood as follows:
• Fasting blood glucose: 5.8mmol/l
• One hour after ingestion of 80 to 100mg 75mg glucose
equal to11.0mmols/l (195mg/dl)
• Two hours after ingestion of 80 to 100mg 9.0mmols/l
equivalent to 150mg/dl
• Three hours after ingestion of 80 to 100mg 7.0mmols/l
equivalent to 120mg/dl
After ingestion, the blood glucose rises initially but returns to normal within a
given length of time. At 28 to 34 weeks gestation, if after giving glucose and
testing of venous sample, you find two out of four samples exceed the
above, then a diagnosis can be made.
So far you have gone through the definition, classifications of diabetes, the
effects of diabetes on pregnancy and pregnancy on diabetes, those at risk
and how to diagnose the disease. Now you will go through the management
prenatally, intrapartally and postnatally.

Pre Natal Care of the Diabetic Case

A mother who is at risk of developing diabetes during her pregnancy should
be taken care of by the diabetic specialist, obstetrician, dietician and
midwife. Ideally preconception counselling is done and the mother is
stabilised. If she has nephropathy or retinopathy, pregnancy should be
avoided. The aim of prenatal care is the control of blood sugar. To avoid
hypoglycaemia and hyperglycaemia adjust the insulin dose.

Remember:
Maintain blood glucose level within the normal range of 4.0 -
5.5mmol/l.
Ensure that post-delivery the blood sugar does not exceed
7.2mmols/l.
Prolong the pregnancy to ensure foetal viability.

Once diagnosed, the mother should be followed up keenly by the two doctors
fortnightly up to 32 weeks gestation and then weekly up to term.

Admission may be undertaken at 12 weeks and 32 weeks for stabilisation

when hormonal changes may affect the mother. Hospitalisation is also done
in case any complication or
infection occurs.

Stabilisation
This is the care given to the admitted mother to bring the blood sugar down
and maintain it. A daily urinalysis should be carried out six hourly using
dextrostix, and also when necessary. Blood sugar should be measured twice
weekly or daily if high.
Short acting insulin subcutaneously given on a sliding scale (measure) helps
to avoid gross foetal abnormality. Scanning is done to assess the foetal
maturity/growth and an x-ray may be carried out after 30 weeks gestation.
The foetal wellbeing is also monitored by the mother noting the frequency of
the foetal kicks.
Any infection, for example urinary tract infections, has to be detected early
and appropriate treatment given. At term a pelvimentry is done to assess
pelvic adequacy.

Once the mother is stabilised, she is discharged to continue with prenatal

clinic fortnightly or weekly depending on the gestation.
The mother is readmitted at 37 to 38 weeks for induction of labour if she has
not gone into spontaneous labour.

Weight Monitoring
A dietician should be consulted but diet with high fibre produces a more
constant blood glucose as carbohydrate is released for absorption more
slowly. The need for carbohydrate increases as the foetus grows and must be
reviewed.

Can you think of four health messages concerning diabetes you

would give to a pregnant mother?

Did you think of these?

Diet, self injection, use of diabetic kit for testing, reading and accurate
recording of the blood sugar level, signs and symptoms of
hypo/hyperglycaemia and what to do.

Management of the Diabetic Case During Labour

After the good care prenatally you still have to maintain observation during
labour and delivery. The mothers who are at risk, for instance those with a
bad obstetric history, the elderly primigravidae, the mother with pre-
eclampsia and a baby that is too big, should not deliver vaginally.
At 36 to 38 weeks the mother is admitted for elective Caesarean section. On
the day of operation, the morning dose of insulin is omitted. However, if the
operation is performed at a late hour then one third or half of the
intermediate acting dose of insulin should be given in the morning before
starting the drip.
Premature delivery is not necessary if the diabetes is well controlled. If
labour starts spontaneously prematurely, then dexamethasone is given to
aid in lung maturity or salbutamol (ventolin) to relax the uterus. The drugs
are given with care as they increase insulin requirements.
Aim at controlling blood sugar between 4 to 5mmol/l.
Hyperglycaemia increases foetal insulin production, which usually causes
neonatal hypoglycaemia. The patient may be allowed a light breakfast or nil
by mouth. In some cases subcutaneous insulin is given to mothers with
insulin dependent diabetes mellitus.

Regimen in Management of Diabetes During Labour

Induction of Labour in a Diabetic Mother

To induce labour, artificial rupture of the membranes is done and oxytocin is
put in normal saline, which is regulated depending on the uterine
contractions.
For the nutritional needs and to prevent hypoglycaemia, a drip of 10%
dextrose is set up and regulated at 20 drops per minute.
Soluble insulin is given by syringe pump at six units in 60ml of normal saline.
This is regulated depending on the blood sugar levels. Throughout labour the
blood sugar is checked hourly. If the results are lower than 4mmol/l, reduce
the insulin dose by half.
If they are higher, double the dose and check blood sugar every
30 minutes.

Remember:
Long acting insulin is NOT given during induction of labour because
the insulin requirements fall by about 50 percent once the placenta
is delivered.

Vigilant observations of the general condition of the mother, uterine

contractions, foetal heart rate, maternal pulse half hourly, blood pressure,
vaginal examination four hourly, and urinalysis two hourly (or more
frequently) are made and charted on the partograph accordingly every half,
two and four hours. Any deviation from the normal should be noted and the
doctor informed.
Sedatives and analgesics, which could depress the foetal respiratory centre,
should be avoided. The physical care of the mother is maintained. The drips
are regulated accurately. If the mother has not delivered within eight hours,
she is re-assessed and caesarean section is performed.

During delivery a paediatrician should be present to take care of the baby

immediately after birth. The principles of managing the baby after birth
involve clearing the airway, providing warmth, giving oxygen and preventing
hypoglycaemia and hypocalcaemia. The baby is admitted in the baby unit for
management after the resuscitative measures are carried out.

Postnatal Care of the Diabetic Mother

The care of a diabetic mother after delivery is very important as it enhances
the previous care. You will note that after delivery of the placenta the
carbohydrate metabolism returns to normal almost immediately. Thus, the
insulin dose has to be reduced by half immediately to avoid hypoglycaemia.
The intravenous infusion is maintained until the next meal. Meanwhile, the
blood sugar has to be constantly checked and levels controlled within the
normal range and the insulin dose adjusted accordingly. When she is breast
feeding, the mother will need increased intake of carbohydrate by 50gm a
day. Small amounts of insulin enter the breast milk but these are destroyed
in the baby's stomach.
A diabetic mother is more prone to infection so care should be exercised to
prevent it. On discharge, the health messages shared with the mother should
include: diet, insulin administration, post natal and diabetic check up,
personal hygiene, baby care and immunisation and so on.
Now you have gone through diabetes in pregnancy you must have realised
that, if well managed, the risk to both mother and baby can be minimised.
Throughout pregnancy, labour and delivery, the blood sugar should be
controlled between 4-6mmols/l.
Attendants should be very keen to identify complications and manage the
woman appropriately. You should also be able to decide the mode of
delivery, which is either per vaginal or elective caesarean section. If the
mother has not gone into spontaneous labour at term, induction of labour
should be done under the supervision of an obstetrician, a diabetician and a
paediatrician.

Malaria in Pregnancy

As you know, malaria is a very common condition in Kenya. You will cover
malaria in detail later in the course.
In this unit you will cover the effects malaria may have on the course of
pregnancy as it affects the health of the mother.
Malaria can cause the following in a pregnant woman and the foetus:
• Haemolysis of red blood cells, causing anaemia and jaundice
• Hyperpyrexia (very high fever), which may cause abortion or preterm
labour
• Malaria parasites have affinity for the placenta and this interferes with
nutrition of the unborn baby and may cause intra-uterine growth
retardation, stillbirth or abortion

Management of Malaria in Pregnancy

The aim of treatment is to reduce the pyrexia and bring the attack to an end
as quickly as possible. The following steps should
be taken:
• Give a full course of fansidar three tablets stat.
It is given as a single dose
• Administer a mild analgesic such as paracetamol
• Folic acid 5mg daily
In order to prevent of malaria in pregnancy, the following steps should be
taken:
• Use of chemoprophylaxis
• Give all pregnant women two presumptive treatments for malaria at
the beginning of second trimester and beginning of third trimester
• Encourage mothers to take other preventive measures including taking
ferrous sulphate and folic acid, clear bushes around the home, drain all
stagnant water near the home, use of insecticide treated mosquito
nets and insecticides
at night

Tuberculosis in Pregnancy

Tuberculosis will be covered in more detail later in the course. In this unit
only the effects of tuberculosis on pregnancy will be covered.
The incidence of pulmonary tuberculosis in Kenya seems to be on the
increase because of its association with the HIV and AIDS epidemic.
How does tuberculosis present in a pregnant woman?
Clinical presentation of pulmonary tuberculosis in pregnancy may be
asymptomatic but typical symptoms include:
• Night sweats
• Fever in the evenings
• Weight loss
• General weakness
• Loss of appetite
• Productive cough
• Occasionally haemoptysis
Women with advanced pulmonary tuberculosis are often anaemic and may
go into premature labour. Some of them will present with severe
breathlessness secondary to pleural effusion or empyema thoracis. Those
who are anaemic will not respond to haematinics until the tuberculosis
infection is brought under control.
Diagnosis of tuberculosis in pregnancy can be done by:
• Sputum smear
• Chest x-ray
• Mantoux test

Management of Tuberculosis in Pregnancy

The aim of treatment is to make the mother sputum negative by the time the
baby is born. A sputum positive mother can transmit the disease to her baby.
The mother is admitted until the disease is controlled. This is mandatory.
Chemotherapy is commonly used. Other therapies include:
• Streptomycin and thiazina (TH). Streptomycin is given for
60 days (intramuscularly injection) and TH for 18 months.
• An alternate short term therapy regime may be preferred and the
commonly used one is a combination of rifampicin, ethambutol,
isoniazid and Para AminoSalicycin acid (PAS) for a period of six to nine
months.
During labour necessary steps should be taken to observe infection
prevention measures to avoid development of puerperal sepsis. Care should
be taken to avoid post partum haemorrhage, which may lead to anaemia
during puerperium.
The mother is encouraged to breastfeed but remember to protect the baby
from tuberculosis by giving prophylactic Isoniazid (INAH, 25mg per kg per
day). INAH resistant BCG should be given since ordinary BCG may be
inhibited by INAH. If INAH resistant BCG is not available, the baby should be
given ordinary BCG at birth and separated from its mother for two weeks.
If the baby still gives a negative reaction to tuberculosis at six to eight
weeks, it should be re-vaccinated with INAH resistant BCG and prophylaxis
should be maintained with INAH for a further six weeks until mantoux
conversion occurs.

Urinary Tract Infections

Although Urinary Tract Infections (UTI) also occur to women who are not
pregnant, it is a common problem among pregnant women. In a pregnant
woman, this infection presents in different forms, some of which are serious,
and others of mild consequence. The common conditions of urinary tract
infection in pregnancy are:
• Asymptomatic bacteriuria
• Acute cystitis
• Acute pyelonephritis
Asymptomatic bacteriuria is more common in pregnant women than in non-
pregnant women. The condition is also twice as common in pregnant women
with sickle cell trait and three times in those with diabetes as compared to
normal pregnant women.
A woman with asymptomatic UTI may feel nothing except a slight pain when
passing urine. She may also have offensive smelling urine. If the condition
remains untreated during pregnancy, about
25 to 35% of these women will develop acute pyelonephritis.
Acute pyelonephritis occurs in two percent of all pregnant women and its
effect may be fatal to the mother and/or her foetus. This occurs in those
women with previous asymptomatic bacteriuria.
Acute cystitis is less common in pregnancy than asymptomatic bacteriuria.
However, it causes more concern because of
its symptoms.
As stated earlier, urinary tract infection occurs more frequently in pregnancy.
This is because:
• The pregnant uterus causes pressure on the ureters and the bladder
which delays emptying.
• The action of hormones on the smooth muscles of the ureters and
bladder also causes them to relax and dilate easily. This causes urine
to move more slowly down the dilated tubes and infection lodges in
them easily.
• Normally the urinary tract mucosa is highly sensitive to invading
organisms and the ureters go into spasmodic contractions to get rid of
such invaders.

Clinical Presentation of Urinary Tract Infection in Pregnancy

Asymptomatic bacteriuria is usually diagnosed based on laboratory
investigations. E-coli is the most common organism causing this condition
and accounts for 80% of the cases.
Acute cystitis presents with urinary frequency and urgency, dysuria,
suprapubic discomfort, urine is cloudy with offensive smell and if cultured,
bacteria cells are identified.
In acute pyelonephritis, the patient will present with the
following symptoms:
• Fever
• Nausea and vomiting
 • Headache
• Urinary frequency
• Dysuria
• Shivering or chills
• Lower abdominal pain
• Dehydration if vomiting has been severe
• Renal angle tenderness on examination

Management of Urinary Tract Infections

Where possible, refer all suspected cases for further investigations and
management to an obstetrician in hospital. In case this is difficult, give the
patient a broad spectrum antibiotic such as ampicillin 500mg, six hourly for
two weeks and assess her regularly to make sure that the pus cells are
cleared.
If there is no improvement within 48 hours, refer the patient to hospital. In
the hospital, a urine specimen will be collected for culture and sensitivity.
The appropriate antibiotics will
be prescribed.

Advise the patient to clean the vulva area from front to back to avoid
contamination with faecal matter from the rectum.
Remember:
Fever in a pregnant woman may induce abortions, premature labour
and intra uterine foetal death.
It should be controlled and the underlying cause treated.

Pregnancy and HIV

Effects of Pregnancy on HIV

Pregnancy is a very important and emotional period for a woman. There are
many issues and concerns that HIV/AIDS presents to pregnant mothers, their
partners, their families and health care workers during this period.
In the early asymptomatic phase of HIV disease, pregnancy does not seem to
have any significant effect on the progress of HIV. However, pregnancy will
greatly affect women whose defence mechanism has already been
destroyed. Pregnancy in such women will make the disease progress rapidly
to full blown AIDS.

Effects of HIV on Pregnancy

HIV infection on the other hand, does not usually appear to seriously affect
the pregnancy. However, HIV infection may cause an increased likelihood of
intra uterine growth retardation, prematurity, still births and congenital
infection.
An HIV positive woman has about 30% chance of transmitting the HIV virus
to her infant. This may occur during pregnancy, at childbirth, or during
breastfeeding.
HIV Screening During Pregnancy
HIV screening during pregnancy needs careful sensitive consideration. The
decision to screen a woman for HIV infection is a joint consideration between
the health worker and the woman, but the woman herself should make the
final decision.
Any HIV testing must be accompanied by careful and adequate pre test
counselling with proper post test counselling and support. Confidentiality of
the results is important. There are many advantages of knowing whether a
woman is HIV positive during her pregnancy.

Advantages
· t will help to monitor important HIV related infections/conditions, to make
important management decisions during pregnancy, childbirth and
postpartum period.
· It will then be possible to monitor the newborn for possible infections and
manage
problems accordingly.
· Some women may also choose to terminate the pregnancy and to prevent
future pregnancies.
· A decision can be made to test her partner if she is found to be positive
and to adjust to safer sexual practices.
However, antenatal HIV testing can also result in serious problems.
· Severe emotional and psychological disturbances and marital or
relationship problems.
· Crises and problems associated with discovering the HIV infection for the
first time.
The possibility of transmitting the infection to the foetus will raise many
other problems and considerations for the mother and her partner.

These consist of the following:

• The choice of terminating the pregnancy
• The difficulties of diagnosing HIV infection in newborns
• The possibility of caring for a sick and dying infant
• The possible feelings of guilt, sadness and fear
If the HIV infection is newly diagnosed, the woman is under a lot of stress
and will need a lot of support and counselling.
The health care services and the health workers should make a great effort
to establish good support and care structures to manage women, their
partners and their newborns. Support and care will need to be considered for
the family.

Remember:
Women with HIV need extra care during pregnancy. They should be
seen more frequently than usual.
It is very important to be on the look out for the development of any HIV
related conditions, especially for infections such as vaginal and oral thrush
and other opportunistic infections such as herpes. Other infections which
should be treated are respiratory infections, diarrhoea, skin infections,
sexually transmitted diseases and Kaposis sacroma.
It is important to provide counselling for encouragement and support to the
HIV positive mother and her partner throughout the pregnancy. It is also
important to start preparing them for possible problems that may occur after
the pregnancy, that is, whether to breast or bottle feed the baby, possibility
of HIV diagnosis in the baby and the care and treatment that may be
necessary.
During delivery, every effort should be made to avoid even minor trauma to
the baby before birth as this may promote transmission of the virus to the
baby. All injection sites on the newborn must be properly cleaned before
inserting the needle to make sure the mothers' blood is not on the skin.
Breastfeeding should be avoided if the mother can safely feed her infant with
other milk feeds. BCG immunisation should be given to the newborn as
usual, unless the infant is very ill. The usual postpartum care should be given
to the mother.