Maternal Care: Medical problems during pregnancy, labour and the puerperium

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Medical problems during pregnancy, labour and the puerperium

  1. 1. 13 Medical problems during pregnancy, labour and the puerperiumBefore you begin this unit, please take the URINARY TRACTcorresponding test at the end of the book toassess your knowledge of the subject matter. INFECTION DURING PREGNANCY Objectives 13-1 Which urinary tract infections When you have completed this unit you are important during pregnancy? should be able to: 1. Cystitis. • Diagnose and manage cystitis. 2. Asymptomatic bacteriuria. • Reduce the incidence of acute 3. Acute pyelonephritis. pyelonephritis in pregnancy. • Diagnose and manage acute 13-2 Why are urinary tract infections pyelonephritis in pregnancy. common during pregnancy and the puerperium? • Diagnose and manage anaemia during pregnancy. 1. Placental hormones cause dilatation of the ureters. • Identify patients who may possibly have 2. Pregnancy suppresses the function of the heart valve disease. immune system. • Manage a patient with heart valve disease during labour and the A urinary tract infection is the most common puerperium. infection during pregnancy. • Manage a patient with diabetes mellitus.
  2. 2. 244 MATERNAL CARE13-3 How should you diagnose cystitis? 13-6 Why is asymptomatic bacteriuria during pregnancy important?1. These severe urinary symptoms suddenly appear: 1. Between 6 and 10% of pregnant women • Dysuria (pain on passing urine). have asymptomatic bacteriuria. • Frequency (having to pass urine often). 2. One third of these patients with • Nocturia (having to get up at night to asymptomatic bacteriuria will develop pass urine). acute pyelonephritis during pregnancy.2. The patient appears generally well with 3. If patients with asymptomatic bacteriuria normal observations. The only clinical sign are diagnosed and correctly managed, their is tenderness over the bladder. risk of developing acute pyelonephritis will3. Examination of the urine under a be reduced by 70%. microscope shows many pus cells and bacteria. The diagnosis and treatment of asymptomaticA midstream urine sample for culture must bacteriuria will greatly reduce the incidence ofbe collected, if possible, to confirm the acute pyelonephritis during pregnancy.clinical diagnosis. Treatment must commenceimmediately without waiting for the results ofthe culture.. 13-7 How and when should patients be screened for asymptomatic bacteriuria?13-4 How should you manage If possible, bacterial culture of a midstreama patient with cystitis? urine sample should be done at the first antenatal visit to screen patients forGive four adult tablets of co-trimoxazole (e.g. asymptomatic bacteriuria.Bactrim, Cotrim, Durobac, Mezenol or Purbac)as a single dose. This is also the drug of choice NOTE A culture medium prepared by afor patients who are allergic to penicillin. laboratory, or a commercially prepared cultureAmoxycillin (Amoxil) 3 g as a single dose medium, is inoculated with urine and then incubated for 12 to 24 hours to determineorally could also be used but organisms whether bacteriuria is present or not.causing cystitis are often resistant to thisantibiotic. The treatment will be moresuccessful if two amoxycillin capsules (250 mg) If possible, a screening test for asymptomaticare replaced with two Augmentin tablets that bacteriuria should be done at the first antenatalcontain 125 mg clavulanic acid each. visit.A midstream sample should again be sentfor microscopy, culture, and sensitivity at the 13-8 Can reagent strips be reliably usednext antenatal visit to determine whether the to diagnose asymptomatic bacteriuria?management was successful. No. Tests for nitrites (which detect theCo-trimoxazole can be safely used during presence of bacteria) and leukocytes, separatelypregnancy, including the first trimester. or together, cannot be used to accurately screen for asymptomatic bacteriuria.13-5 What is asymptomatic bacteriuria?It is significant colonisation of the urinary 13-9 What is the management of atract with bacteria, without any symptoms of a patient with asymptomatic bacteriuria?urinary tract infection. The same as the management of a patient with cystitis, i.e. four adult tablets of co- trimoxazole (e.g. Bactrim, Cotrim, Durobac,
  3. 3. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 245Mezenol or Purbac) as a single dose or eight-hourly. All antibiotics must beamoxycillin (Amoxil) 3 g as a single dose. given intravenously until the patient’sPatients who are allergic to penicillin should temperature has been normal for 24be given co-trimoxazole. hours. Oral cefuroxime (Zinnat) can then be given until a course of ten days ofA midstream specimen of urine should again antibiotics has been completed.be sent for culture at the next antenatal visit 5. Pethidine 100 mg is given intramuscularlyto determine whether the management was for severe pain while paracetamolsuccessful. (Panado) two adult tablets can be used for moderate pain.13-10 What symptoms suggest 6. Paracetamol (Panado) two adult tablets,acute pyelonephritis? together with tepid sponges, are used to1. Most patients have severe general bring down a high temperature. symptoms • Headache. NOTE If the bacterial culture from the urine is positive, the antibiotic may need to be changed, • Pyrexia and rigors (shivering). depending on the sensitivity of the bacteria. • Lower backache, especially pain over the kidneys (renal angles).2. Only 40% of patients have urinary Patients with acute pyelonephritis during complaints. pregnancy must be admitted to hospital for treatment with a broad-spectrum antibiotic.13-11 What physical signs are usually foundin a patient with acute pyelonephritis? 13-13 Why is acute pyelonephritis a1. The patient is acutely ill. serious infection in pregnancy?2. The patient usually has high pyrexia and Because serious complications can result: a tachycardia. However, the temperature may be normal during rigors. 1. Preterm labour.3. On abdominal examination, the patient 2. Septic shock. is tender over one or both kidneys. The 3. Perinephric abscess (an abscess around the patient is also tender on light percussion kidney). over one or both renal angles (posteriorly 4. Anaemia. over the kidneys). Septic shock usually presents with continuing hypotension in spite of adequate intravenous13-12 What is the management of a fluids. There is also failure of the clinical signspatient with acute pyelonephritis? of acute pyelonephritis to improve rapidly1. The patient must be admitted to hospital. within the first 72 hours of treatment. If septic2. A midstream urine sample for microscopy, shock is diagnosed, intravenous gentamicin culture and sensitivity must be collected, if 80 mg must be given immediately, followed by possible, to confirm the clinical diagnosis, a further 80 mg every eight hours. Gentamicin identify the bacteria and determine the (Garamycin) must be added to any other antibiotic of choice. antibiotic already given. The patient must also3. An intravenous infusion of Balsol or be transferred to a level 3 hospital. Ringer’s lactate should be started and one litre given rapidly over two hours. Thereafter, one litre of Maintelyte should be given every eight hours.4. Broad-spectrum antibiotics must be given, i.e. cefuroxime (Zinecef) 750 mg
  4. 4. 246 MATERNAL CARE13-14 What should be done at the first The size and colour of the red cells indicate theantenatal visit after the patient has probable cause of the anaemia:been treated for acute pyelonephritis? 1. Microcytic, hypochromic cells suggest iron1. A midstream urine sample for culture and deficiency. sensitivity must be collected to determine 2. Normocytic, normochromic cells suggest whether the treatment has been successful. bleeding or infection.2. The haemoglobin concentration must be 3. Macrocytic, normochromic cells suggest measured as there is a risk of anaemia folate deficiency. developing. 13-18 What is the management of patients with iron deficiency inANAEMIA IN PREGNANCY pregnancy or the puerperium? 1. The management of iron-deficiency13-15 What is the definition of anaemia in pregnancy will depend onanaemia in pregnancy? the haemoglobin concentration and theA haemoglobin concentration of less than duration of pregnancy.11 g/dl. • If the haemoglobin concentration is less than 8 g/dl, the gestational age is less than 36 weeks, and the patient is13-16 What are the dangers of anaemia? asymptomatic, she can be treated with1. Heart failure, which can result from severe two tablets of ferrous sulphate three anaemia. times a day and be followed at the2. Shock, which may be caused by a relatively antenatal clinic. small vaginal blood loss (antepartum • If the haemoglobin concentration is haemorrhage, delivery or postpartum less than 8 g/dl and the gestational age haemorrhage) in an anaemic patient. is 36 weeks or more, the patient must be admitted to hospital for a blood13-17 What are the common causes transfusion.of anaemia in pregnancy? • All patients with a haemoglobin concentration of less than 8 g/dl who1. Iron deficiency as the result of a diet poor are short of breath or have a tachycardia in iron. of more than 100 beats per minute2. Blood loss during pregnancy (also during (signs of heart failure) must be admitted labour or the puerperium). to hospital for a blood transfusion.3. Acute infections (e.g. pyelonephritis), • If the haemoglobin concentration is chronic infections (e.g. tuberculosis and between 8 g/dl and 10 g/dl, the patient HIV), and infestations (e.g. malaria, can be treated with two tablets of bilharzia or hook worm) in regions where ferrous sulphate three times a day. If these occur. the haemoglobin concentration does4. Folic-acid deficiency is less common. not increase after two weeks or the patient is 36 weeks pregnant or more, The commonest cause of anaemia in pregnancy is and a full blood count has not yet been iron deficiency. done, then a full blood count must be done to decide whether the cause of the anaemia is iron deficiency.A full blood count, which is sent to the • If the haemoglobin concentration islaboratory, will usually identify the probable 10 g/dl or more, but less than 11 g/dl,cause of the anaemia.
  5. 5. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 247 the patient can be treated with one tablet keep their iron tablets in a safe place where of ferrous sulphate three times a day. children cannot reach them. In the case of the first three points above, a full blood count must be done. The size 13-20 How are iron supplements and colour of the red blood cells will help given in pregnancy? in determining the cause of the anaemia.2. The management of a patient with iron- As 200 mg ferrous sulphate tablets. deficiency anaemia during the puerperium 1. Patients with a haemoglobin will depend on whether the patient is concentration of 11 g/dl or higher must bleeding or not. take one tablet daily. • If the patient is not bleeding, if she 2. Patients who are anaemic must be correctly has no signs of heart failure, and her managed. haemoglobin concentration is 6 g/dl or more, she can be treated with oral 13-21 What side effects can be caused iron tablets. One tablet of ferrous by ferrous sulphate tablets? sulphate three times daily for a month is sufficient. Nausea and even vomiting due to irritation of • If the patient is not bleeding and she the lining of the stomach. has signs of heart failure, or if her haemoglobin concentration is less than 13-22 How should you manage a 6 g/dl, she must be admitted to hospital patient who complains of side effects and given a blood transfusion to be due to ferrous sulphate tablets? followed by oral iron for a month. 1. The tablets should be taken with meals. • If the patient is bleeding, she should Although less iron will be absorbed, the be managed for a postpartum side effects will be less. haemorrhage. 2. If the patient continues to complain of sideThe management of a patient with iron- effects, she should be given 300 mg ferrousdeficiency anaemia during the puerperium is gluconate tablets instead. They cause fewersummarised in flow diagram 13-1. side effects than ferrous sulphate tablets.13-19 Should all patients receiveiron supplements in pregnancy? HEART VALVE DISEASE1. Well-nourished patients who have IN PREGNANCY AND a healthy diet and a haemoglobin THE PUERPERIUM concentration of 11 g/dl or more, do not need iron supplements. Heart valve disease consists of damage to,2. Patients who are poorly nourished, or abnormality of, one or more of the valves have a poor diet or have a haemoglobin of the heart. Usually the mitral valve is concentration of less than 11 g/dl need damaged. The cause of heart valve disease in a iron supplements. developing country is almost always rheumatic3. Patients from communities where iron fever during childhood. deficiency is common, or where socio- economic circumstances are poor, should 13-23 Why is it important during receive iron supplements. pregnancy to identify patients withIron tablets are dangerous to small children heart valve disease in pregnancy?as even one tablet can cause serious iron 1. A correct diagnosis of the type of heartpoisoning. Therefore, patients must always valve disease and good management of
  6. 6. 248 MATERNAL CARE Hb less than 11 g/dl Hb less than Hb 8 or more, Hb 10 g/dl 8 g/dl but less than or more 10 g/dl 1. Ferrous sulphate Full blood count Full blood count tablets 2. Primary care Yes Duration of Duration of No 1. Ferrous sulphate pregnancy 36 weeks pregnancy 36 weeks tablets or more? or more? 2. Full blood count two weeks later No Yes Admit to hospital Yes Shortness of Yes for blood breath or transfusion tachycardia? No No 1. Ferrous suplate tablets Increase 2. Clinic for high-risk patients in Hb?Flow diagram 13-1: The management of a patient with iron-deficiency anaemia in pregnancy
  7. 7. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 249 the problem reduces the risk to the patient 3. The follow-up visits will also be at the during her pregnancy. high-risk antenatal clinic. However, the2. Undiagnosed heart valve disease and patient may be referred to the primary-care inadequate treatment may result in serious antenatal clinic for some ‘in between’ visits. complications (e.g. heart failure causing Take care to follow the instructions from pulmonary oedema) which may threaten the high-risk clinic carefully. the patient’s life. 4. Patients who are not hospitalised should3. A clear family-planning plan must be made stop work earlier and rest more than usual. during the pregnancy. The patient may 5. The patient must be told to report have a reduced lifespan and cannot risk immediately if she experiences any having a large family. symptoms of heart failure, e.g. worsening shortness of breath or tiredness. 6. The patient must be delivered at least in a Correct diagnosis and good management reduce secondary level hospital where specialist the risk to the patient of heart valve disease in care is available. pregnancy. 13-26 How should patients with13-24 Which symptoms in a heart valve disease be managedpatient’s history suggest that she in the first stage of labour?may have heart valve disease? 1. All patients must be delivered in hospital1. Shortness of breath on exercise or even because of the risk of pulmonary oedema. with limited effort. 2. The patient should lie on her side with2. Coughing up blood (haemoptysis). her upper body raised with pillows to3. Often the patient has previously been told 45 degress. by a doctor that she has a ‘leaking heart’. 3. Good analgesia is important to ensure that4. Some patients with heart valve disease the patient does not become exhausted. give a history of previous rheumatic fever. 4. A slow intravenous infusion of However, most patients are not aware 200 ml saline should be started, using a that they have suffered from previous minidropper to make sure that not too rheumatic fever. much fluid is given. 5. Ampicillin 1 g and gentamicin 80 mgThe cause of heart valve disease in a developing are given intravenously as prophylaxiscountry is almost always previous rheumatic against infective endocarditis. Thesefever. However, these patients usually do not antibiotics should be repeated eight-hourlyknow that they have had one or more attacks for another two doses. Patients who areof rheumatic fever during childhood. allergic to penicillin should be givenDuring the examination of the cardiovascular erythromycin 500 mg instead of ampicillin.system, a cardiac murmur will be heard if thepatient has heart valve disease. 13-27 How should patients with heart valve disease be managed13-25 How should a patient with heart in the second stage of labour?valve disease in pregnancy be managed? 1. The patient must be managed with her1. The patient must be referred to the high- upper body raised with pillows to 45 risk antenatal clinic. degrees.2. At the high-risk antenatal clinic the type 2. There should be good progress with of lesion and correct management will be effective maternal effort to ensure a short determined. and easy second stage. Otherwise, an assisted delivery must be done.
  8. 8. 250 MATERNAL CARE3. If indicated, an episiotomy should be done There is a high risk of pulmonary oedema in the to ensure a short and easy second stage. third stage of labour and for the first 24 hours4. The patient’s legs must not be placed in the normal lithotomy position as this may of the puerperium in patients with heart valve cause pulmonary oedema. If the lithotomy disease. position is needed, the patient should place her feet on two chairs which are at a lower 13-30 What form of family planning should level than the bed. be offered to patients with heart valve disease who have completed their families?13-28 How should patients with A postpartum sterilisation should be done.heart valve disease be managed Because of the risk of heart failure, thein the third stage of labour? procedure must be postponed until the thirdThis is a very dangerous time for a patient with day after delivery. Patients who are willingheart valve disease as there is an increased and are prepared to return for the procedure,risk of pulmonary oedema. Therefore, careful can have a laparoscopic sterilisation done sixattention must be paid to the following: weeks after delivery. Meanwhile, an injectable contraceptive must be given.1. Syntometrine or ergometrine must not be given as they increase the risk of pulmonary oedema.2. Oxytocin may be given. Ten units are given DIABETES MELLITUS intramuscularly. IN PREGNANCY3. The third stage of labour should be actively managed. 13-31 Why is it important to diagnose diabetes if it develops in pregnancy? Any drug containing ergometrine is absolutely contraindicated in the third stage of labour and Diabetes mellitus is a disorder which is caused the first 24 hours of the puerperium if the patient by the secretion of inadequate amounts of has heart valve disease. insulin from the pancreas to keep the blood glucose concentration normal. As a result, the blood glucose concentration becomes13-29 What is important in the puerperium abnormally high. Diabetes may often presentin patients with heart valve disease? for the first time in pregnancy, and may thenThe risk of pulmonary oedema during the first recover spontaneously after delivery. The early24 hours of the puerperium is great. Therefore, diagnosis and good management of diabetes inattention must be paid to the following: pregnancy will greatly reduce the incidence of complications.1. During the first 24 hours of the puerperium the patient must be carefully observed for signs of pulmonary oedema, The early diagnosis and good management of i.e. tachypnoea (breathing fast), dyspnoea diabetes in pregnancy will greatly reduce the (shortness of breath) and crepitations in incidence of complications. the lungs.2. The course of prophylactic antibiotics must 13-32 What complications may be caused be completed. by diabetes in pregnancy if it is not diagnosed early and is not well managed? 1. Throughout the pregnancy infections are common, especially:
  9. 9. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 251 • Candida vaginitis. Patients with repeated or marked glycosuria • Urinary tract infection. during pregnancy must always be investigated2. During the first trimester congenital abnormalities may occur in the developing further for diabetes. fetus due to the raised blood glucose concentration. 13-35 Is a reagent strip accurate1. During the third trimester pre-eclampsia enough to measure a random and polyhydramnios are common. blood glucose concentration?2. The fetus may be large if the patient’s Yes, if an electronic instrument (Glucometer diabetes has been poorly controlled during or Reflolux) is used to measure the blood the pregnancy, resulting in problems glucose concentration. However, a reagent during labour and delivery, mainly: strip alone may not be accurate enough. • Cephalopelvic disproportion. Therefore, a sample of blood must be sent • Impacted shoulders. to the nearest laboratory for a blood glucose5. During the third stage of labour there is an measurement, if an instrument is not available. increased risk of postpartum haemorrhage.6. The newborn infant is at increased risk of many complications, especially 13-36 Is it possible that a patient with hypoglycaemia and hyaline membrane an initially normal blood glucose disease. concentration may develop an abnormal concentration later in pregnancy?13-33 How can complications which Yes. This may be possible due to an increasecommonly occur in diabetics during in the amount of placental hormones aspregnancy and labour be avoided? pregnancy progresses. Placental hormones tend to increase the blood glucoseThese complications can largely be avoided by: concentration, explaining why some patients1. Early diagnosis. only become diabetic during their pregnancies.2. Good control of the blood glucose concentration. 13-37 How should random blood glucose measurements be Early diagnosis and good control of the blood interpreted and how do the results glucose concentration will prevent most of the determine further management? pregnancy and labour complications caused by A random blood glucose measurement is done diabetes. on a blood sample taken from the patient at the clinic without any previous preparation, i.e. the patient does not have to fast. However,13-34 How can diabetes be diagnosed patients who have had nothing to eat duringearly if it should develop for the the previous four hours should be encouragedfirst time during pregnancy? to eat something before the test.1. At every antenatal visit all patients should 1. A random blood glucose concentration routinely have their urine tested for glucose. of less than 8 mmol/l is normal. These2. A random blood glucose concentration patients can receive routine primary care. must be measured if the patient has 1+ However, if glycosuria is again present, a glycosuria or more at any antenatal visit. random blood glucose measurement must be repeated. 2. A random blood glucose concentration of 8 mmol/l or more, but less than 11 mmol/l, may be abnormal and is an indication
  10. 10. 252 MATERNAL CARE to measure the fasting blood glucose A patient with a normal blood glucose concentration. The further management of concentration early in pregnancy may develop the patient will depend on the result of the fasting blood glucose concentration. diabetes later during that pregnancy.3. A random blood glucose concentration of 11 mmol/l or more is abnormal and 13-39 How is a glucose profile obtained? indicates that the patient has diabetes. The patient must have nothing to eat or These patients must be admitted to hospital drink (except water) from midnight. At 08:00 to have their blood glucose controlled. the next day a sample of blood is taken and Thereafter, they must remain on treatment the fasting blood glucose concentration is and be followed as high-risk patients. measured. Immediately afterwards she has breakfast (which she can bring with her to13-38 How should fasting blood the clinic). After two hours the blood glucoseglucose measurements be interpreted concentration is measured again.and how do the results determinefurther management? 13-40 How should the glucose profileThe patient must have nothing to eat or drink be interpreted and how do the results(except water) from midnight. At 08:00 the next determine further management?day a sample of blood is taken and the fasting 1. A fasting blood glucose result of less thanblood glucose concentration is measured: 6 mmol/l and a two hour result of less than1. A fasting blood glucose concentration 8 mmol/l are normal. These patients can be of less than 6 mmol/l is normal. These followed up as intermediate-risk patients. patients can receive routine primary 2. A fasting blood glucose result of care. If their random blood glucose 6 mmol/l or more and/or a two hour concentration is again abnormal, the result of 8 mmol/l or more are abnormal. fasting blood glucose concentration should These patients must be admitted to be measured again. hospital so that they can have their blood2. Patients with fasting blood glucose glucose concentration controlled. concentrations of 6 mmol/l or more but less The management of patients with an abnormal than 8 mmol/l should be placed on a 7 600 random blood glucose concentration is kilojoule (1 800 kilocalorie) diabetic diet. A summarised in flow diagram 13-2. glucose profile should be determined after two weeks and be repeated every four weeks until delivery. Usually the glucose profile becomes normal on this low kilojoule diet. CASE STUDY 13. Patients with a fasting blood glucose concentration of 8 mmol/l or more have A patient presents at 30 weeks gestation diabetes. They must be admitted to hospital and complains of backache, feeling feverish, so that their blood glucose concentration dysuria and frequency. On examination she can be controlled. has a tachycardia and a temperature of 38.5 °C. A diagnosis of cystitis is made and the patientA 7600 kj diabetic diet consists of a normal is given oral ampicillin to take at home.diet with reduced refined carbohydrates (e.g.sugar, cool drinks, fruit juices) and added highfibre foods (e.g. beans and wholewheat bread). 1. Do you agree with the diagnosis? No. The symptoms and signs suggest that the patient has acute pyelonephritis.
  11. 11. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 253 Random Random blood blood glucose glucose measurement Less than Less than 88or more but or more but 11 mmol/l 11 mmol/l 88mmol/l mmol/l less than less than or more or more ==normal normal 11 mmol/l 11 mmol/l ==diabetes diabetes 1. Routine primary perinatal 1. Routine primary perinatal care Measure fasting Measure fasting Admit to hospital for care blood glucose Admit to hospital for 2. Repeat random blood 2. Repeat random blood blood glucose glucose control glucose control glucose ififglycosuria recurs concentration concentration glucose glycosuna recurs Less than Less than 66or more but or more but 88mmol/l mmol/l 66mmol/l mmol/l less than less than or more or more ==normal normal 88mmol/l mmol/l ==diabetes diabetes Glucose profile Glucose profile Follow up at 77600 kj/day 600 kj/day Follow up at two weeks later and 2 weeks later and special clinic diabetic diet diabetic diet special clinic then every four weeks then every 4 weeks Normal AbnormalFlow diagram 13-2: The management of a patient with glycosuria who has a random blood glucoseconcentration measured in pregnancy
  12. 12. 254 MATERNAL CARE2. Is the management of this patient 1. Do you agree with the management?adequate to treat acute pyelonephritis? No. The patient is already 36 weeks pregnantNo. The patient should be admitted to hospital and, therefore, is at great risk of going intoand be given a broad-spectrum antibiotic labour before her haemoglobin concentrationintravenously. has had time to respond to the oral iron treatment. Therefore, the patient must be3. Why is it necessary to admitted to hospital and be given a bloodtreat acute pyelonephritis in transfusion.pregnancy so aggressively? 2. Are any further investigations needed?Because severe complications may occurwhich can be dangerous both to the patient Yes. The cause of the anaemia must always beand her fetus. looked for. Blood for a full blood count must be taken before she is given a blood transfusion.4. What two complications shouldyou watch for after admitting 3. Is a full blood count adequate tothis patient to hospital? diagnose the cause of the anaemia, or should other investigations be done?1. Preterm labour.2. Septic shock. In most cases a full blood count is adequate. The majority of patients who have anaemia5. How will you recognise that the without a history of bleeding are iron deficient.patient has developed septic shock? A full blood count will confirm the diagnosis of iron deficiency.The patient will become hypotensive in spite ofreceiving adequate intravenous fluid. 4. What should be done if a patient presents before 36 weeks gestation with a6. What should be done at the first haemoglobin concentration below 8 g/dl?antenatal visit after the patientis discharged from hospital? If the patient is not short of breath and does not have a tachycardia above 100 beats perA midstream urine sample should be collected minute, she may be managed at a high-riskfor culture to make sure that the infection has clinic. After blood has been sampled for abeen adequately treated. Her haemoglobin full blood count, she should be prescribedconcentration must also be measured as two ferrous sulphate tablets three times a day.patients often become anaemic after acute With this treatment the patient should havepyelonephritis. corrected her haemoglobin concentration before she goes into labour.CASE STUDY 2 5. What should be done if a patient presents before 36 weeks gestation withA patient is seen at her first antenatal visit. shortness of breath, tachycardia andShe is already 36 weeks pregnant and has a a low haemoglobin concentration?haemoglobin concentration of 7.5 g/dl. Asshe is not short of breath and has no history The patient must be admitted to hospitalof antepartum bleeding, she is treated with for a blood transfusion. This is necessarytwo tablets of ferrous sulphate to be taken because the patient has shortness of breaththree times a day. She is asked to return to the and tachycardia, which suggest heart failure.clinic in one week. Again, a full blood count must be done before the transfusion is started.
  13. 13. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 255CASE STUDY 3 must be given. An assisted delivery may be necessary.A patient presents for her first antenatal visitand gives a history that she has a ‘leaking 5. Is the danger over onceheart’ due to rheumatic fever as a child. As the infant is born?she has no symptoms and does not get short No. The third stage of labour and the first 24of breath on exercise, she is reassured and hours of the puerperium are also dangerous.managed as a low-risk patient. As she remains Ergometrine or Syntometrine must not be givenwell with no shortness of breath, she is told and the patient must be closely observed forthat she can be delivered by a midwife at the signs of heart failure. Oxytocin should be givenprimary perinatal-care clinic. and the third stage must be actively managed.1. Why is the management incorrect?With her history of rheumatic fever and a CASE STUDY 4‘leaking heart’, the patient must be examinedby a doctor to determine whether she has An obese 35-year-old multiparous patientheart valve disease. Undiagnosed heart valve presents with 1+ glycosuria at 20 weeksdisease can result in serious complications gestation. At the previous antenatal visit shesuch as pulmonary oedema. had no glycosuria. A random blood glucose concentration is 7.5 mmol/l. She is reassured2. What should be done if the patient has a and followed up as a low-risk patient. At 28heart murmur due to heart valve disease? weeks she has 3+ glycosuria. As the random blood glucose concentration at 20 weeks wasThe type of heart valve disease must be normal, she is again reassured and asked todiagnosed. If the patient needs medication, the come back to the clinic in two weeks.correct drug must be prescribed in the correctdosage. She must be managed as a high-risk 1. Do you agree with the managementpatient and should be carefully followed up for at 20 weeks gestation?symptoms or signs of heart failure. Yes, the patient was correctly managed when3. Will most patients with heart a random blood glucose concentration wasvalve disease give a history of measured after she had 2+ glycosuria. Whenprevious rheumatic fever? 1+ glycosuria or more is present again, later in pregnancy, a random blood glucoseNo. Although most heart valve disease is concentration must be measured again.caused by rheumatic fever during childhood,most of these patients are not aware that they 2. How should the patient havehave had rheumatic fever. been managed at 28 weeks?4. Is it safe to deliver a patient She should have had another random bloodwith heart valve disease at a glucose concentration measurement. Furtherprimary perinatal-care clinic? management would depend on the result of this test.No. Special management is needed in at leasta secondary hospital with specialist careavailable. The patient must be closely observedfor signs of heart failure, good pain reliefis needed during labour and prophylacticantibiotics against infective endocarditis
  14. 14. 256 MATERNAL CARE3. Why should a patient be 5. If the patient has a fasting bloodinvestigated if she has 2+ glycosuria glucose concentration of 7.0 mmol/l, whatof more for the first time? should her further management be?Because the patient may already be a diabetic The result is abnormal but is not high enoughwith a high blood glucose concentration to diagnose diabetes. She should, therefore,causing the marked glycosuria. be placed on a 7600 kilojoule per day diabetic diet. A glucose profile must be obtained after4. What should the management have two weeks and this should be repeated everybeen if her random blood glucose was four weeks until delivery.9.0 mmol/l at 28 weeks gestation?The patient should be seen the next morningafter fasting from midnight. Her fastingblood glucose concentration should then bemeasured.

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