Primary Maternal Care: Medical problems during pregnancy and the pueperium
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Primary Maternal Care: Medical problems during pregnancy and the pueperium

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Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from ...

Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions

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Primary Maternal Care: Medical problems during pregnancy and the pueperium Primary Maternal Care: Medical problems during pregnancy and the pueperium Document Transcript

  • 7 Medical problems during pregnancy 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. You INFECTION DURINGshould redo the test after you’ve worked through PREGNANCYthe unit, to evaluate what you have learned. Objectives 7-1 Which urinary tract infections are important during pregnancy? When you have completed this unit you 1. Cystitis. should be able to: 2. Asymptomatic bacteriuria. • Diagnose and manage cystitis. 3. Acute pyelonephritis. • Reduce the incidence of acute pyelonephritis in pregnancy. 7-2 Why are urinary tract infections common during pregnancy • Diagnose acute pyelonephritis in and the puerperium? pregnancy. • Diagnose and manage anaemia during 1. Placental hormones cause dilatation of the ureters. pregnancy. 2. Pregnancy suppresses the function of the • Identify patients who may possibly have immune system. heart valve disease. 3. Catheterisation during the first and second • Manage a patient who develops stage of labour is common. glycosuria during pregnancy. A urinary tract infection is the most common • Manage women needing antiretroviral infection during pregnancy. treatment. 7-3 How is cystitis diagnosed? 1. Severe urinary symptoms suddenly appear: • Dysuria (pain on passing urine).
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 125 • Frequency (having to pass urine often). 7-6 Why is asymptomatic bacteriuria • Nocturia (having to get up at night to during pregnancy important? pass urine). 1. Between 6 and 10% of pregnant women2. The patient appears generally well with have asymptomatic bacteriuria. normal observations. The only clinical sign 2. One third of these patients with is tenderness over the bladder. asymptomatic bacteriuria will develop3. Examination of the urine under a acute pyelonephritis during pregnancy. microscope shows many pus cells and 3. If patients with asymptomatic bacteriuria bacteria. are diagnosed and correctly managed, theirA midstream urine sample for culture must risk of developing acute pyelonephritis willbe collected, if possible, to confirm the be reduced by 70%.clinical diagnosis. Treatment must commence 4. The risk for preterm labour is significantlyimmediately without waiting for the results of increased with asymptomatic bacteriuria.the culture. The diagnosis and treatment of asymptomatic7-4 How should you manage bacteriuria will greatly reduce the incidence ofa patient with cystitis? acute pyelonephritis and preterm labour during pregnancy.Give 4 adult tablets of co-trimoxazole (e.g.Bactrim, Co-Trim, Durobac, Mezenol orPurbac) as a single dose. This is also the drug of 7-7 How and when should patients bechoice for patients who are allergic to penicillin. screened for asymptomatic bacteriuria?Amoxycillin (Amoxil) 3 g as a single dose If possible, bacterial culture of a midstreamorally could also be used but organisms urine sample should be done at the firstcausing cystitis are often resistant to this antenatal visit to screen patients forantibiotic. The treatment will be more asymptomatic bacteriuria.successful if 2 amoxycillin capsules (250 mg)are replaced with 2 Augmentum tablets that If possible, a screening test for asymptomaticcontain an added 125 mg clavulanic acid each. bacteriuria should be done at the first antenatalA midstream sample should be sent for visit.culture and sensitivity at the next antenatalvisit to determine whether the management 7-8 Can reagent strips be reliably usedwas successful. to diagnose asymptomatic bacteriuria?Co-trimoxazole can be safely used during No. Tests for nitrites (which detect thepregnancy, including the first trimester. presence of bacteria) and leukocytes, separately or together, cannot be used to accurately7-5 What is asymptomatic bacteriuria? screen for asymptomatic bacteriuria.It is significant colonisation of the urinarytract with bacteria, without any symptoms of a 7-9 What is the management of a patienturinary tract infection. with asymptomatic bacteriuria? The same as the management of a patient with cystitis, i.e. 4 adult tablets of co-trimoxazole (e.g. Bactrim, Septran) as a single dose or amoxycillin (Amoxil) 3 g as a single dose orally. Patients who are allergic to penicillin should be given co-trimoxazole.
  • 126 PRIMAR Y MATERNAL CAREA midstream specimen of urine should again 6. Paracetamol (Panado) 2 adult tablets,be sent for microscopy, culture and sensitivity together with tepid sponges, are used toat the next antenatal visit to determine bring down a high temperature.whether the management was successful. Patients with acute pyelonephritis during7-10 What symptoms suggest pregnancy must be admitted to hospital foracute pyelonephritis? treatment with a broad-spectrum antibiotic.1. Most patients have severe general symptoms: 7-13 Why is acute pyelonephritis a • Headache. serious infection in pregnancy? • Pyrexia and rigors (shivering). Because serious complications can result: • Lower backache, especially pain over the kidneys (renal angles). 1. Preterm labour.2. Only 40% of patients have urinary 2. Septic shock. complaints. 3. Perinephric abscess (an abscess around the kidney).7-11 What physical signs are usually found 4. Anaemia.in a patient with acute pyelonephritis? 7-14 What should be done at the first1. The patient is acutely ill. antenatal visit after the patient has2. The patient usually has high pyrexia and been treated for acute pyelonephritis? a tachycardia. However, the temperature may be normal during rigors. 1. A midstream urine sample for culture and3. On abdominal examination, the patient sensitivity must be collected to determine is tender over one or both kidneys. The whether the treatment has been successful. patient is also tender on light percussion 2. The haemoglobin concentration must be over one or both renal angles (posteriorly measured as there is a risk of anaemia over the kidneys). developing.7-12 What is the management of apatient with acute pyelonephritis? ANAEMIA IN PREGNANCY1. The patient must be admitted to hospital.2. A midstream urine sample for culture and 7-15 What is the definition of sensitivity must be collected if possible to anaemia in pregnancy? confirm the clinical diagnosis, identify the bacteria and determine the antibiotic of A haemoglobin concentration of less than choice. 11 g/dl.3. An intravenous infusion of Balsol or Ringer’s lactate should be started and 1 litre 7-16 What are the dangers of anaemia? given rapidly over 2 hours. Thereafter, 1 litre 1. Heart failure which can result from severe of Maintelyte should be given every 8 hours. anaemia.4. An intravenous broad-spectrum antibiotic, 2. Shock which may be caused by a relatively e.g. cefuroxime (Zinecef) should be given small vaginal blood loss (antepartum prior to transfer. haemorrhage, delivery or postpartum5. Pethidine 100 mg is given intramuscularly haemorrhage) in an anaemic patient. for severe pain while paracetamol (Panado) 2 adult tablets can be used for moderate pain.
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 1277-17 What are the common causes • All patients with a haemoglobinof anaemia in pregnancy? concentration of less than 8 g/dl who are short of breath or have a1. Iron deficiency as the result of a diet poor tachycardia of more than 100 beats per in iron. minute (signs of heart failure) must2. Blood loss during pregnancy (also during be admitted to hospital for a blood labour or the puerperium). transfusion. In addition she must3. Acute infections (e.g. pyelonephritis), be treated with 2 tablets of ferrous chronic infections (e.g. tuberculosis and sulphate 3 times a day that must be HIV), and infestations (e.g. malaria, continued at least one month after the bilharzia or hook worm) in regions where baby has been delivered. these occur. • If the haemoglobin concentration4. Folic acid deficiency is less common. is between 8 g/dl and 10 g/dl, the The commonest cause of anaemia in pregnancy is patient can be treated with 2 tablets of ferrous sulphate 3 times a day. If the iron deficiency. haemoglobin concentration does notA full blood count, which is sent to the increase after 2 weeks or the patient islaboratory, will usually identify the probable 36 weeks pregnant or more, and a fullcause of the anaemia. blood count has not yet been done, then a full blood count must be doneThe size and colour of the red cells indicate the to decide whether the cause of theprobable cause of the anaemia: anaemia is iron deficiency.1. Microcytic, hypochromic cells suggest iron • If the haemoglobin concentration is deficiency. 10 g/dl or more, but less than 11 g/dl,2. Normocytic, normochromic cells suggest the patient can be treated with one bleeding or infection. tablet of ferrous sulphate 3 times a day.3. Macrocytic, normochromic cells suggest 2. The management of a patient with iron- folate deficiency. deficiency anaemia during the puerperium will depend on whether the patient is bleeding or not:7-18 What is the management of • If the patient is not bleeding, if shepatients with iron deficiency in has no signs of heart failure, and herpregnancy or the puerperium? haemoglobin concentration is 6 g/dl or1. The management of iron-deficiency more, she can be treated with oral iron anaemia in pregnancy will depend on tablets. One tablet of ferrous sulphate 3 the haemoglobin concentration and the times daily for a month is sufficient. duration of pregnancy: • If the patient is not bleeding and she • If the haemoglobin concentration is has signs of heart failure, or if her less than 8 g/dl, the gestational age is haemoglobin concentration is less than less than 36 weeks, and the patient is 6 g/dl, she must be admitted to hospital asymptomatic, she can be treated with 2 for a blood transfusion to be followed tablets of ferrous sulphate 3 times a day by oral iron for a month. and be followed at the antenatal clinic. • If the patient is bleeding, she should • If the haemoglobin concentration is be managed for a postpartum less than 8 g/dl and the gestational age haemorrhage. is 36 weeks or more, the patient must be admitted to hospital for a blood transfusion.
  • 128 PRIMAR Y MATERNAL CARE7-19 Should all patients receive iron HEART VALVE DISEASEsupplements in pregnancy? IN PREGNANCY AND1. Well-nourished patients who have 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 7-23 Why is it important during receive iron supplements. pregnancy to identify patientsIron tablets are dangerous to small children with heart valve disease?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 ofkeep their iron tablets in a safe place where the problem reduces the risk to the patientchildren cannot reach them. during her pregnancy. 2. Undiagnosed heart valve disease and7-20 How are iron supplements inadequate treatment may result in seriousgiven in pregnancy? complications (e.g. heart failure causing pulmonary oedema) which may threatenAs 200 mg ferrous sulphate tablets: the patient’s life.1. Patients with a haemoglobin 3. A clear family planning plan must be made concentration of 11 g/dl or higher must during the pregnancy. The patient may take one tablet daily. have a reduced lifespan and cannot risk2. Patients who are anaemic must be having a large family. managed as described in 7-18. Correct diagnosis and good management reduce7-21 What side effects can be caused the risk to the patient of heart valve disease inby ferrous sulphate tablets? pregnancy.Nausea and even vomiting due to irritation ofthe lining of the stomach. 7-24 Which symptoms in a patient’s history suggest that she may7-22 How should you manage a have heart valve disease?patient who complains of side effects 1. Shortness of breath on exercise or evendue to ferrous sulphate tablets? with limited effort.1. The tablets should be taken with meals. 2. Coughing up blood (haemoptysis). Although less iron will be absorbed, the 3. Often the patient has previously been told side effects will be less. by a doctor that she has a ‘leaking heart’.2. If the patient continues to complain of side 4. Some patients with heart valve disease effects, she should be given 300 mg ferrous give a history of previous rheumatic fever. gluconate tablets instead. They cause fewer However, most patients are not aware side effects than ferrous sulphate tablets. that they have suffered from previous rheumatic fever.
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 129The cause of heart valve disease in a developing DIABETES MELLITUScountry is almost always previous rheumaticfever. However, these patients usually do not IN PREGNANCYknow that they have had one or more attacksof rheumatic fever during childhood. 7-27 Why is it important to diagnoseDuring the examination of the cardiovascular diabetes if it develops in pregnancy?system, a cardiac murmur will be heard if thepatient has heart valve disease. Diabetes mellitus is a disorder which is caused by the secretion of inadequate amounts of insulin from the pancreas to keep7-25 How should a patient with heart the blood glucose concentration normal.valve disease in pregnancy be managed? As a result, the blood glucose concentration1. The patient must be referred to the high- becomes abnormally high. Diabetes may risk antenatal clinic. often present for the first time in pregnancy,2. At the high-risk antenatal clinic the type and may then recover spontaneously after of lesion and correct management will be delivery. The early diagnosis and good determined. management of diabetes in pregnancy will3. The follow-up visits will also be at the greatly reduce the incidence of complications. high-risk antenatal clinic. However, the patient may be referred to the primary care 7-28 What complications may be caused antenatal clinic for some ‘inbetween’ visits. by diabetes in pregnancy if it is not Take care to follow the instructions from diagnosed early and is not well managed? the high-risk clinic carefully.4. Patients who are not hospitalised should 1. Throughout the pregnancy infections are stop work earlier and rest more than usual. common, especially:5. The patient must be told to report • Candida vaginitis. immediately if she experiences any • Urinary tract infection. symptoms of heart failure, e.g. worsening 1. During the first trimester congenital shortness of breath or tiredness. abnormalities may occur in the developing6. The patient must at least be delivered at a fetus due to the raised blood glucose secondary level hospital where specialist concentration. care is available. 2. During the third trimester pre-eclampsia and polyhydramnios are common. 3. The fetus may be large, if the patient’s7-26 What form of family planning should diabetes has been poorly controlled duringbe offered to patients with heart valve the pregnancy, resulting in problemsdisease who have completed their families? during labour and delivery mainly:A postpartum sterilisation should be done. • Cephalopelvic disproportion.Because of the risk of heart failure, the • Impacted shoulders.procedure must be postponed until the third 1. During the third stage of labour there is anday after delivery. Patients who are willing increased risk of postpartum haemorrhage.and are prepared to return for the procedure, 2. The newborn infant is at increasedcan have a laparoscopic sterilisation done 6 risk of many complications, especiallyweeks after delivery. Meanwhile, an injectable hypoglycaemia and hyaline membranecontraceptive must be given. disease.
  • 130 PRIMAR Y MATERNAL CARE7-29 How can complications which concentration, explaining why some patientscommonly occur in diabetics during only become diabetic during their pregnancies.pregnancy and labour be avoided?These complications can largely be avoided by: 7-33 How should random blood glucose measurements be interpreted1. Early diagnosis. and how do the results determine2. Good control of the blood glucose further management? concentration. A random blood glucose measurement is done Early diagnosis and good control of the blood on a blood sample taken from the patient at glucose concentration will prevent most of the the clinic without any previous preparation, pregnancy and labour complications caused by i.e. the patient does not have to fast. However, patients who have had nothing to eat during diabetes. the past 4 hours should be encouraged to eat something before the test.7-30 How can diabetes be diagnosed 1. A random blood glucose concentrationearly if it should develop for the of less than 8 mmol/l is normal. Thesefirst time during pregnancy? patients can receive routine primary care.1. At every antenatal visit all patients should However, if glycosuria is again present, a routinely have their urine tested for glucose. random blood glucose measurement must2. A random blood glucose concentration be repeated. must be measured if the patient has 1+ 2. A random blood glucose concentration of glycosuria or more at any antenatal visit. 8 mmol/l or more, but less than 11 mmol/l, may be abnormal and is an indication Patients with glycosuria during pregnancy must to measure the fasting blood glucose always be investigated further for diabetes. concentration. The further management of the patient will depend on the result of the fasting blood glucose concentration.7-31 Is a reagent strip accurate 3. A random blood glucose concentrationenough to measure a random of 11 mmol/l or more is abnormal andblood glucose concentration? indicates that the patient has diabetes.Yes, if an electronic instrument (Glucometer These patients must be admitted to hospitalor Reflolux) is used to measure the blood to have their blood glucose controlled.glucose concentration. A reagent strip alone Thereafter, they must remain on treatmentmay not be accurate enough. If an instrument and be followed as high-risk patients.is not available, a sample of blood must besent to the nearest laboratory for a blood 7-34 How should fasting bloodglucose measurement. glucose measurements be interpreted and how do the results determine7-32 Is it possible that a patient with further management?an initially normal blood glucose The patient must have nothing to eat or drinkconcentration may develop an abnormal (except water) from midnight. At 08:00 the nextconcentration later in pregnancy? day a sample of blood is taken and the fastingYes. This may be possible due to an increase blood glucose concentration is measured:in the amount of placental hormones as 1. A fasting blood glucose concentrationpregnancy progresses. Placental hormones of less than 6 mmol/l is normal. Thesetend to increase the blood glucose patients can receive routine primary care. If their random blood glucose
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 131 concentration is again abnormal, the that they can have their blood glucose fasting blood glucose concentration should concentration controlled. be measured again.2. Patients with fasting blood glucose concentrations of 6 mmol/l or more but less HIV INFECTION AND than 8 mmol/l should be placed on a 7 600 kilojoule (1 800 kilocalorie) diabetic diet. AIDS IN PREGNANCY A glucose profile should be determined after 2 weeks and be repeated every 4 weeks 7-37 What is AIDS? until delivery. Usually the glucose profile becomes normal on this low kilojoule diet. AIDS is a severe clinical illness caused by3. Patients with a fasting blood glucose the human immunodeficiency virus (HIV). concentration of 8 mmol/l or more have Therefore, severe HIV disease is called AIDS. diabetes. They must be admitted to hospital However, women with HIV infection can so that their blood glucose concentration remain clinically well for many years before can be controlled. developing signs of the disease. Patients with AIDS have a damaged immune system.A 7 600 kj diabetic diet consists of a normal They become infected and often die of otherdiet with reduced refined carbohydrates (e.g. ‘opportunistic infections’ such as tuberculosis.sugar, cool drinks, fruit juices) and added highfibre foods (e.g. beans and wholewheat bread). 7-38 Is AIDS an important A patient with a normal blood glucose cause of maternal death? concentration early in pregnancy may develop As the HIV epidemic spreads, the number of diabetes later during that pregnancy. pregnant women dying of AIDS has increased dramatically. In some countries, such as South Africa, AIDS is now the commonest cause of7-35 How is a glucose profile obtained? maternal death.The patient must have nothing to eat or The Third Report on Confidential Enquiriesdrink (except water) from midnight. At 08:00 into Maternal Deaths in South Africa 2002–the next day a sample of blood is taken and 2004 showed that AIDS was the commonestthe fasting blood glucose concentration is cause of maternal death. Many additionalmeasured. Immediately afterwards she has AIDS deaths may have been missed, as HIVbreakfast (which she can bring with her to testing is often not done.the clinic). After 2 hours the blood glucoseconcentration is measured again. AIDS is the commonest cause of maternal death in South Africa.7-36 How should the glucose profilebe interpreted and how do the resultsdetermine further management? 7-39 Does pregnancy increase the risk of progression from asymptomatic to1. A fasting blood glucose result of less than symptomatic HIV infection and AIDS? 6 mmol/l and a 2 hour result of less than 8 mmol/l are normal. These patients can be Pregnancy appears to have little or no effect followed up as intermediate risk patients. on the progression from asymptomatic to2. A fasting blood glucose result of symptomatic HIV infection. However, in 6 mmol/l or more and/or a 2 hour result women who already have symptomatic HIV of 8 mmol/l or more are abnormal. These infection, pregnancy may lead to a more rapid patients must be admitted to hospital so progression to AIDS.
  • 132 PRIMAR Y MATERNAL CAREThe progression of HIV infection during 7-42 How are pregnant women with HIVpregnancy can be monitored by: infection managed at a primary care clinic?1. Laboratory tests. The management of pregnant women with HIV2. Clinical signs. infection is very similar to that of non-pregnant adults. The most important step is to identify7-40 How is the severity of those pregnant women who are HIV positive.HIV infection classified? The principles of management of pregnant1. By assessing the clinical stage of the disease: women with HIV infection at a primary care • Stage 1: Clinically well. clinic are: • Stage 2 Mild clinical problems. 1. Make the diagnosis of HIV infection by • Stage 3: Moderate clinical problems. offering HIV screening to all pregnant • Stage 4: Severe clinical problems (ie. women at the start of their antenatal care. AIDS). 2. Take a history and do a clinical assessment2. By measuring the CD4 count in the blood: to assess the clinical stage of the diease. A falling CD4 count is an important 3. Assess the CD4 count in all HIV-positive marker of progression in HIV. It is an women as soon as their HIV status is indicator of the degree of damage to the known. immune system. A normal CD4 count is 4. Screen for clinical signs of HIV infection 700 to 1100 cells/μl. A CD4 count below to assess whether the woman has advanced 350 cells/μl indicates severe damage to the to a more severe stage of the disease at each immune system. antenatal visit. 5. Good diet. Nutritional support may be The CD4 count is an important marker of HIV needed. progression during pregnancy. 6. Emotional support and counselling. 7. Prevention of mother-to-child7-41 Can an HIV-positive woman be transmission (PMTCT) of HIV.cared for in a primary care clinic? 8. Start antiretroviral treatment when indicated.Most women who are HIV positive are 9. Early referral if there are pregnancy or HIVclinically well with a normal pregnancy. complications.Others may only have minor problems (stage1 or 2). These women can usually be cared 7-43 Which clinical signs suggestfor in a primary care clinic throughout their stage 1 and 2 HIV infection?pregnancy, labour and puerperium providedtheir pregnancy is normal. Women with a 1. Persistent generalised lymphadenopathypregnancy complication should be referred to is the only clinical sign of stage 1 HIVhospital, as would be done with HIV-negative infection.patients. Women with severe HIV-related 2. Signs of stage 2 HIV infection include:problems (stage 3 or 4) will need to be referred • Mild weight loss (less than 10% of bodyto a special HIV clinic or hospital. weight). • Repeated or chronic mouth or genital ulcers. Many HIV-positive women can be managed at a • Extensive skin rashes. primary care clinic. • Repeated upper respiratory tract infections such as otitis media or sinusitis. • Herpes zoster (shingles).
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 133Most of these women can be managed at a 1. Clinical signs of stage 3 or 4 HIV infection.primary care clinic while some may have to 2. A CD4 count below 350 cells/μl.be referred to an HIV clinic for help withtreatment. These clinical problems are usually 7-47 What patient preparation istreated symptomatically with simple drugs needed for antiretroviral treatment?which are not expensive. Preparing a patient to start antiretroviral treatment is very important. This requires7-44 What are the important features education, counselling and social assessmentsuggesting stage 3 or 4 HIV infection? before antiretroviral treatment can be started.1. Features of stage 3 HIV infection include: These patients need to learn about their illness • Unexplained weight loss (more than and the importance of excellent adherence 10% of body weight). (taking their antiretroviral drugs at the correct • Oral candidiasis (thrush). time every day) and regular clinic attendance. • Cough, fever and night sweats They also need to know the side effects of suggesting pulmonary tuberculosis. antiretroviral drugs and how to recognise • Cough, fever and shortness of breath them. Careful general examination and blood suggesting bacterial pneumonia. sent for a laboratory hemoglobin concentration • Chronic diarrhoea or unexplained fever and liver function test (ALT) are also needed for more than one month. before starting antiretroviral treatment. It • Pulmonary tuberculosis (TB) usually takes 2 weeks to prepare a patient.2. Features of stage 4 HIV infection include: • Severe weight loss. 7-48 What drugs are used for starting • Severe or repeated bacterial infections, antiretroviral treatment during pregnancy? especially pneumonia. • Severe HIV associated (opportunistic) Usually antiretroviral treatment is provided infections such as oesophageal to pregnant women in South Africa with candidiasis (which presents three drugs: with difficulty swallowing) and • D4T 40 mg 12 hourly (or 30 mg 12 hourly Pneumocyctis pneumonia (which in women weighing less than 60 kg or AZT presents with cough, fever and 300 mg 12 hourly. shortness of breath). • 3TC (lamivudine) 150 mg every 12 hours. • Malignancies such as Kaposi’s sarcoma. • Nevirapine 200 mg daily for two weeks • Extrapulmonary TB. followed by 200 mg every 12 hours or efavirenz (EFV) 600 mg in the evening if7-45 What is antiretroviral treatment? the gestational age is more than 12 weeks.Antiretroviral treatment (i.e. ART or HAART) This is the current national first line standardis the use of three or more antiretroviral drugs drug combination used during pregnancy. Itin combination to treat patients with severe may change in future.HIV infection. The aim of antiretroviraltreatment is to lower the viral load and allow 7-49 What are the side effects ofthe immune system to recover. antiretroviral treatment? Pregnant women on antiretroviral treatment7-46 What are the indications for may have side effects to the drugs. Theseantiretroviral treatment in pregnancy? are usually mild and occur during the firstThe indications for antiretroviral treatment at 6 weeks of treatment. However, side effectsan HIV clinic are either of the following: may occur at any time that patients are on antiretroviral treatment. It is important that
  • 134 PRIMAR Y MATERNAL CAREthe staff at primary care clinics are aware CASE STUDY 1of these side effects and that they ask forsymptoms and look for signs at each clinic A patient presents at 30 weeks gestationvisit. Side effects with antiretroviral treatment and complains of backache, feeling feverish,are more common than with antiretroviral dysuria and frequency. On examination sheprophylaxis during pregnancy. has a tachycardia and a temperature of 38.5 °C.Common early side effects during the first A diagnosis of cystitis is made and the patientfew weeks of starting antiretroviral treatment is given oral ampicillin to take at home.include:1. Lethargy, tiredness and headaches. 1. Do you agree with the diagnosis?2. Nausea, vomiting and diarrhoea. No. The symptoms and signs suggest that the3. Muscle pains and weakness. patient has acute pyelonephritis.These mild side effects usually disappearon their own. They can be treated 2. Is the management of this patientsymptomatically. It is important that adequate to treat acute pyelonephritis?antiretroviral treatment is continued even if No. The patient should be admitted to hospitalthere are mild side effects. and be given a broad-spectrum antibioticMore severe side effects, which can be fatal, intravenously.include: 3. Why is it necessary to1. AZT may suppress the bone marrow treat acute pyelonephritis in causing anaemia. There may also be a pregnancy so aggressively? reduction in the white cell and platelet counts. Because severe complications may occur2. Severe skin rashes with nevirapine. All which can be dangerous both to the patient patients with severe skin rashes must and her fetus. urgently be referred to the HIV clinic.3. Hepatitis can be caused by all antiretroviral 4. What should be done at the first drugs but especially nevirapine. antenatal visit after the patient4. Lactic acidosis is a late but serious side is discharged from hospital? effect, especially with d4T. It presents with weight loss, tiredness, nausea, vomiting, A midstream urine sample should be abdominal pain and shortness of breath collected for culture to make sure that the in patients who have been well on infection has been adequately treated. Her antiretroviral treatment for a few months. haemoglobin concentration must also be measured as patients often become anaemicStaff at primary care clinics must be aware and after acute pyelonephritis.look out for these very important side effects.7-50 How should pregnant women on CASE STUDY 2antiretroviral treatment be managed?The national protocol should be followed. It is A patient is seen at her first antenatal visit.very important that staff at the antenatal clinic She is already 36 weeks pregnant and has aare trained to managed women with HIV haemoglobin concentration of 7.5 g/dl. Asinfection. They should work together with the she is not short of breath and has no historylocal HIV clinic or infectious diseases clinic of of antepartum bleeding, she is treated with 2the local hospital. tablets of ferrous suphate to be taken 3 times
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 135a day. She is asked to return to the clinic in tachycardia which suggest heart failure. Again,one week. a full blood count must be done before the transfusion is started.1. Do you agree with the management?No. The patient is already 36 weeks pregnantand, therefore, is at great risk of going into CASE STUDY 3labour before her haemoglobin concentrationhas had time to respond to the oral iron A patient presents for her first antenatal visittreatment. Therefore, the patient must be and gives a history that she has a ‘leakingadmitted to hospital and be given a blood heart’ due to rheumatic fever as a child.transfusion. As she has no symptoms and does not get short of breath on exercise, she is reassured and managed as a low-risk patient. As she2. Are any further investigations needed? remains well with no shortness of breath, sheYes. The cause of the anaemia must always be is told that she can be delivered by a midwifelooked for. Blood for a full blood count must be obstetric unit (primary perinatal care clinic).taken before she is given a blood transfusion. 1. Why is the management incorrect?3. Is a full blood count adequate to With her history of rheumatic fever and adiagnose the cause of the anaemia, or ‘leaking heart’, the patient must be examinedshould other investigations be done? by a doctor to determine whether she hasIn most cases a full blood count is adequate. heart valve disease. Undiagnosed heart valveThe majority of patients who have anaemia disease can result in serious complicationswithout a history of bleeding, are iron such as pulmonary oedema.deficient. A full blood count will confirm thediagnosis of iron deficiency. 2. What should be done if the patient has a heart murmur due to heart valve disease?4. What should be done if a patient The type of heart valve disease must bepresents before 36 weeks gestation with a diagnosed. If the patient needs medication, thehaemoglobin concentration below 8 g/dl? correct drug must be prescribed in the correctIf the patient is not short of breath and does dosage. She must be managed as a high-risknot have a tachycardia above 100 beats per patient and should be carefully followed up forminute, she may be managed at a high-risk symptoms or signs of heart failure.clinic. After blood has been sampled for afull blood count, she should be prescribed 3. Will most patients with heart2 ferrous sulphate tablets three times a day. valve disease give a history ofWith this treatment the patient should have previous rheumatic fever?corrected her haemoglobin concentrationbefore she goes into labour. No. Although most heart valve disease is caused by rheumatic fever during childhood, most of these patients are not aware that they5. What should be done if a patient have had rheumatic fever.presents before 36 weeks gestation withshortness of breath, tachycardia anda low haemoglobin concentration?The patient must be admitted to hospital fora blood transfusion. This is necessary becausethe patient has shortness of breath and
  • 136 PRIMAR Y MATERNAL CARE4. Is it safe to deliver a patient with heart management would depend on the result ofvalve disease at a primary care clinic? this test.No. Special management is needed in at leasta secondary hospital with specialist care 3. Why should a patient beavailable. investigated if she has 1+ glycosuria or more for the first time? The patient may already be a diabetic with aCASE STUDY 4 high blood glucose concentration causing the glycosuria.An obese 35 year old multiparous patientpresents with 1+ glycosuria at 20 weeks of 4. What should the management havegestation. At the previous antenatal visit she been if her random blood glucose washad no glycosuria. A random blood glucose 9.0 mmol/l at 28 weeks gestation?concentration is 7.5 mmol/l. She is reassured The patient should be seen the next morningand followed up as a low-risk patient. At 28 after fasting from midnight. Her fastingweeks she has 3+ glycosuria. As the random blood glucose concentration should then beblood glucose concentration at 20 weeks was measured.normal, she is again reassured and asked tocome back to the clinic in 2 weeks. 5. If the patient has a fasting blood glucose concentration of 7.0 mmol/l, what1. Do you agree with the management should her further management be?at 20 weeks gestation? The result is abnormal but is not high enoughYes, the patient was correctly managed when to diagnose diabetes. She should, therefore,a random blood glucose concentration was be placed on a 7600 kilojoule per day diabeticmeasured after she had 2+ glycosuria. When diet. A glucose profile must be obtained after1+ glycosuria or more is present again, 2 weeks and this should be repeated every 4later in pregnancy, a random blood glucose weeks until delivery.concentration must be measured again.2. How should the patient havebeen managed at 28 weeks?She should have had another random bloodglucose concentration measurement. Further
  • MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 137 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 YesAdmit 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 7-I: The management of a patient with iron-deficiency anaemia in pregnancy
  • 138 PRIMAR Y MATERNAL CARE Random Random blood blood glucose glucose measurement 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 22weeks later and weeks later and special clinic diabetic diet diabetic diet special clinic then every 44weeks then every weeks Normal AbnormalFlow diagram 7-II: The management of a patient with glycosuria who has a random blood glucose concen-tration measured in pregnancy.