SECTION II: MANAGEMENT OF DISORDERS AND SPECIAL SITUATIONS
MINOR DISORDERS - ADVICE
Morning Sickness and Heartburn
- Eat a light sweet meal before getting out of bed e.g. glass of milk with sugar and biscuits.
- Have several smaller meals rather than large meals
- Avoid fatty and highly seasoned foods.
- Correct with diet (adequate intake of fluids i.e. 8-10 cups per day, high fiber diet, increase intake of fruits, vegetables) and regular physical activity
- Laxatives should be considered only if dietary measures fail
- If due to side effects of iron supplements, consider reducing the dosage
- Try to establish regular toilet routine
- Rest when possible during the day
- Walking, physical activity, wear flat shoes
- Lie on a comfortable bed with a firm mattress or on the floor on the back with pillows under legs or on the side with pillows between legs
- See physiotherapist or doctor, if backache persists
- No tight bands or garters around the waist or leg which may impede the circulation. A support panty hose may be used.
- Avoid constipation
- Apply cold compresses, then soothing haemorrhoidal ointment/cream in mild cases Refer to doctor if there is bleeding which is not relieved by the above treatment.
- Follow-up at six weeks postpartum visit - refer if necessary.
- Sponge the skin with a solution of bicarbonate of soda, 2 teaspoonfuls to 1 litre of water
- Apply calamine lotion, zinc cream
- If a rash or ‘blebs’ on the skin, seek medical advice
Personal and Genital Hygiene
- Check for abnormal vaginal discharge
- Advise on good personal hygiene
- Test urine for sugar and proteinuria
- Advise against douching
- Apply warm compresses
- Elevate legs and do gentle massage/physical activity
- Increase milk intake (calcium)
This usually presents with a thick, white, itchy discharge – usually odourless. It is common in pregnancy and is more common in diabetics.
- Apply appropriate anti-fungal treatment in consultation with the doctor
- Cool underwear
- Vinegar washes
- This usually presents with a watery, greenish, itchy discharge.
- Appropriate anti-protozoal treatment e.g. Metronidazole (do not use before 2nd trimester).
- It is important to also treat partner, in consultation with the doctor.
Bleeding in early pregnancy can be due to
- Threatened miscarriage
- Ectopic pregnancy
- Septic miscarriage
- Cervical erosion/polyps
Bleeding in late pregnancy (Antepartum haemorrhage) may be due to:
- Bleeding in late pregnancy
- Abruptio placenta
- Placenta previa
- Localized lesions (vagina, cervix, uterus)
Pregnancy Induced Hypertension (PIH) / Pre-Eclampsia / Eclampsia
Pregnancy Induced Hypertension (PIH) is defined as the development of hypertension with proteinuria or oedema after the 20th week of pregnancy, without any other known etiology. PIH is also known as pre-eclampsia and gestational hypertension. PIH can be mild or severe depending on the level of hypertension. Eclampsia is coma or seizures occurring in the same period in a patient with PIH.
In this state, the blood pressure is between 130/90 mm/Hg - <160/110 mm/Hg. The proteinuria measures <5g/24 hr or <0.3 g/dL or + on routine urine testing.
Management of this patient also depends on the gestation age of the fetus. Where the gestational age is 36 weeks or more, delivery should be considered. At a gestational age less than 36 weeks, delivery may be delayed in order to achieve fetal maturation.
Management of this condition includes:
- Bed Rest - If patient can have bed rest at home she can be treated as an outpatient.
Note that such patients should also have facilities to monitor the blood pressure; otherwise it may be safer to admit them in hospital. This mode of management may be considered for patients where the blood pressure is marginally elevated and with minimal edema and proteinuria.
- Use of Drugs - A sedative is not usually necessary. The patient can be advised to lie on the left side. Restriction of salt intake has been found to be unnecessary. Diuretics are contraindicated. The patient should be reviewed weekly. If the blood pressure does not return to normal, the patient should be referred to the obstetric team to be evaluated for the initiation of anti-hypertensive therapy.
- Delivery - Delivery should be effected by the 37th week. If there are signs of fetal compromise, assess the patient and expedite delivery. The pregnancy should not be allowed to go beyond dates, that is, expected date of delivery even if the BP has normalized.
- Diet – Sodium restriction or supplementation usually has no place in the management of preeclampsia
Remember: Normalization of the blood pressure may be an indication that fetal demise is imminent.
- In this state, the blood pressure is >160/110 mm/Hg. Proteinuria is >5g/24 hours (urine albumin shows ++or more). These patients may also have epigastric pain, central nervous system disorders (visual disturbance, headache) and oliguria. Such patients can also be classified as having Impending Eclampsia.
- Patients should be admitted to hospital immediately. Ideally, patients with severe preeclampsia should be delivered immediately regardless of the fetal age, as the risk of serious maternal morbidity is high. In a tertiary hospital setting, expectant management can be considered in some cases for a short period, in order to stabilize the clinical situation and possibly to achieve better fetal pulmonary maturity.
Eclampsia is said to occur when a patient with PIH/ Pre eclampsia experiences epileptic fits or convulsions, which are typically of the “grand mal” type. This is a very serious complication which can occur during pregnancy, labour and within the first week post partum. The condition may be associated with prodromal features such as headaches, visual disturbances (blurred vision, flashing lights), epigastric pain (from liver capsule oedema) and generalized oedema, especially relevant in non-dependent areas such as the face and lumbosacral areas. The principles of managing such patients are clear airway, control/prevent convulsions, control extreme hypertension and expedite delivery. The patient must be delivered immediately.
- Maintain a clear airway through proper positioning of the patient and suctioning of any mucous or vomit
- Catheterize patient and record urinary output and colour; test for proteinuria, set up IV infusion 500 ml Ringer’s lactate
- Take blood for CBC, group and cross-matching, BUN, creatinine, serum electrolytes, PT/PTT, platelet count, liver enzymes
Treatment of Fits/Prevention of Further Convulsions
- Administer magnesium sulphate as indicated for pre-eclampsia. If not available use diazepam IV- 10 mg IM/IV stat (caution as per eclampsia)
- Diazepam 40 mg in 500 ml, 5% Dextrose to run at 20 - 40 drops per minute.
Treatment of Hypertension
- Hydralazine is the drug of choice if BP diastolic >110 mmHg and above
- Hydralazine 10 mg IV stat; repeat in 30 minutes if diastolic BP 110 or above.
Management of Labour and Delivery
- The mode and timing of the delivery depend on the clinical condition of the mother, fetus and the state of the cervix.
- Vaginal delivery should be the goal if conditions are suitable; otherwise Caesarean Section after the BP is stabilized and favourable anaesthetic assessment.
- During labour, blood pressure should be monitored ½ to 1 hourly until delivery
- Anticonvulsants are used during labour
- The second stage should be assisted by means of forceps or vacuum extraction
- The patient should be closely monitored in the post-partum period; as convulsions can occur after delivery; thus anticonvulsive treatment should be continued.
- All "high risk" women must be monitored closely after delivery until discharged from the institution.
- All women should have their blood pressure recorded immediately or shortly after delivery and every 4 hours until discharge.
- Patients who have PIH should be managed by specialist teams and discharged when vital signs return to normal, with appropriate follow-up.
- Women who had severe pre-eclampsia and eclampsia should be seen at home within one week and at post-natal clinic after 2 to 4 weeks and have their blood pressure recorded.
- Patients who had severe pre-eclampsia and eclampsia should be advised on contraception and future pregnancies.
Guidelines for Secondary Prevention of PIH
Preconception counseling is ideally provided for women known to have hypertension to achieve best control before conception. This advice should also be given at postpartum or family planning clinics.
- Pregnant women should be advised to start prenatal clinic after missing their second menses
- All women should have their blood pressure recorded on every antenatal clinic visit
- All women should have their urine tested for protein every visit
- All women detected to have an increase of their blood pressure by 30 mmHg of systolic and or 15 mmHg diastolic from their baseline blood pressure, or those found to have blood pressure 130/90 mmHg or above should be flagged. (The presence of protein in Mid -Stream Urine (MSU) is significant)
- All women found to have proteinuria, should have urine microscopy to exclude urinary tract infection. If found to be hypertensive, the patient should be treated for PIH
- All patients with hypertension, proteinuria and edema should be referred to an obstetrician.