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.
w
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 please 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 may be very
4. The amount of blood lost is in keeping with
little
the
compared with the subsequent shock
general condition of the patient
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 soft and not tender 7. The uterus is tender and may be hard
8. The foetal parts may be difficult to
8. The foetal parts are easily palpable
palpate
9. The uterine size corresponds to dates 9. The uterus may be larger than dates
of gestation of gestation
10. The presenting part may be displaced into10. The presenting part is usually in the
the iliac fossa 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.