3                                               Hypertensive                                               disorders of   ...
HYPER TENSIVE DISORDERS OF PREGNANC Y          85An abnormally high blood pressure during             1. Whether the hyper...
86    MATERNAL CAREhalf of pregnancy. Pre-eclampsia may present          or second half of pregnancy. If a patient hasduri...
HYPER TENSIVE DISORDERS OF PREGNANC Y           873-12 What are the maternal                              Pre-eclampsia ma...
88     MATERNAL CAREPatients who improve on bed rest should               7. Patients who develop generalised oedema,be ke...
HYPER TENSIVE DISORDERS OF PREGNANC Y        89THE MANAGEMENT                                        3-25 When should you ...
90    MATERNAL CARE                                                     1. Give 4 g slowly intravenously over ten A urinar...
HYPER TENSIVE DISORDERS OF PREGNANC Y       91         mixed with 20 ml of sterile water. Bolus       must be given if mor...
92       MATERNAL CARE3-33 What should you do if the                      patient is fully conscious after the convulsion,...
HYPER TENSIVE DISORDERS OF PREGNANC Y          93   control the blood pressure, if it is decided          viable, growth-r...
94   MATERNAL CAREGESTATIONAL                                        3-39 How should you monitor the fetus                ...
HYPER TENSIVE DISORDERS OF PREGNANC Y      953-42 Will you adjust the medication of               previous visit, and she ...
96   MATERNAL CARECASE STUDY 2                                       of magnesium sulphate has been given.                ...
HYPER TENSIVE DISORDERS OF PREGNANC Y        97used, an ampoule of dihydralazine (25 mg)          3. How can superimposed ...
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Maternal Care: Hypertensive disorders of pregnancy

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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: Hypertensive disorders of pregnancy

  1. 1. 3 Hypertensive disorders of pregnancyBefore you begin this unit, please take the THE HYPERTENSIEVEcorresponding test at the end of the book toassess your knowledge of the subject matter. DISORDERS OF PREGNANCY Objectives When you have completed this unit you 3-1 What is the normal blood should be able to: pressure during pregnancy? • Define hypertension in pregnancy. The normal systolic blood pressure is less than • Give a simple classification of the 140 mm Hg and the diastolic blood pressure hypertensive disorders of pregnancy. is less than 90 mm Hg. During the second trimester both the systolic and diastolic blood • Diagnose pre-eclampsia and chronic pressures usually fall and then rise again hypertension. toward the end of pregnancy. A mild rise in • Explain why the hypertensive disorders blood pressure early in the third trimester can of pregnancy must always be regarded therefore be normal. as serious. • List which patients are at risk of 3-2 What is hypertension developing pre-eclampsia. during pregnancy? • List the complications of pre-eclampsia. Hypertension during pregnancy is defined • Differentiate pre-eclampsia from severe as a diastolic blood pressure of 90 mm Hg pre-eclampsia. or more and/or a systolic blood pressure of 140 mm Hg or more. • Give a practical guide to the management of pre-eclampsia. • Provide emergency management for A diastolic blood pressure of 90 mm Hg or more eclampsia. or a systolic blood pressure of 140 mm hg or more • Manage gestational hypertension and during pregnancy is abnormal. chronic hypertension during pregnancy.
  2. 2. HYPER TENSIVE DISORDERS OF PREGNANC Y 85An abnormally high blood pressure during 1. Whether the hypertension started beforepregnancy is often accompanied by proteinuria. or after the 20th week of pregnancy. 2. Whether or not proteinuria is also present.3-3 What is proteinuria?Proteinuria is defined as an excessive amount The classification of hypertension duringof protein in the urine. Normally the urine pregnancy depends on the time of onset of thecontains no protein or only a trace of protein. hypertension and the presence or absence ofTherefore, just a trace of protein in the urine is proteinuria.not regarded as abnormal.Proteinuria during pregnancy is diagnosed Classifying hypertension is important, as thewhen either of the following is present: cause of the hypertension and the risk to the mother and fetus vary between the different1. 0.3 g or more of protein in a 24-hour urine groups. specimen.2. 1+ or more protein as measured with a The common forms of hypertension during reagent strip (e.g. Albustix, Labstix, Uristix, pregnancy that will be discussed in this unit Multistix, Lenstrip, etc). are:Proteinuria during pregnancy may also be 1. Pre-eclampsia (gestational proteinuriccaused by: hypertension). 2. Gestational hypertension.1. A urinary tract infection or renal disease. 3. Chronic hypertension.2. Contamination of the urine by a vaginal 4. Chronic hypertension with superimposed discharge or leucorrhoea. pre-eclampsia.Patients with proteinuria must be asked to 5. Eclampsia.collect a second sample, as a midstreamspecimen of urine (MSU). The correct NOTE Based on the above criteria,method of collecting an MSU must be hypertension during pregnancy is at presentcarefully explained to the patient. The divided into the following conditions:amount of proteinuria present in the MSU • Gestational proteinuric hypertensionwill be the correct one and must, therefore, (or pre-eclampsia).be recorded in the notes. The further • Gestational hypertension.management will be dictated by the amountof proteinuria in the MSU. • Chronic hypertension and chronic renal disease with hypertension. • Chronic hypertension with 1+ or more protein in the urine is abnormal. superimposed gestational proteinuric hypertension (or pre-eclampsia). • Unclassified hypertension andTHE CLASSIFICATION unclassified proteinuric hypertension (if the patient is seen for the first timeOF HYPERTENSION in the second half of pregnancy, withDURING PREGNANCY hypertension and/or proteinuria). • Eclampsia.3-4 How is hypertension during 3-5 What is pre-eclampsia?pregnancy classified? Pre-eclampsia presents with hypertensionThe classification of hypertension during and proteinuria which develop in the secondpregnancy depends on:
  3. 3. 86 MATERNAL CAREhalf of pregnancy. Pre-eclampsia may present or second half of pregnancy. If a patient hasduring pregnancy, labour, or the puerperium. hypertension without proteinuria when she books during the second half of pregnancy,Pre-eclampsia is also called gestational she is said to have unclassified hypertension.(pregnancy-induced) proteinuric hypertension. However, if she has both hypertension and proteinuria when she books during the3-6 What is gestational hypertension? second half of pregnancy, she is said to have unclassified proteinuric hypertension. MostIn contrast to pre-eclampsia, gestational patients with unclassified hypertensionhypertension is not accompanied by probably have chronic hypertension, whileproteinuria but also presents in the second most patients with unclassified proteinurichalf of pregnancy. Should proteinuria develop hypertension probably have pre-eclampsia.in a patient with gestational hypertension, thediagnosis must be changed to pre-eclampsia. 3-9 What is eclampsia? Eclampsia is a serious complication of pre- Pre-eclampsia presents with hypertension and eclampsia that presents with convulsions proteinuria in the second half of pregnancy. during pregnancy, labour, or the first seven days of the puerperium. Convulsions could also be NOTE The term pre-eclampsia (rather than the result of other causes such as epilepsy, but gestational proteinuric hypertension) will be the possibility of eclampsia must be carefully used, as it is still widely known as such. ruled out whenever convulsions occur.3-7 What is chronic hypertension? PRE-ECLAMPSIAChronic hypertension is hypertension, withor without proteinuria, that presents during Pre-eclampsia is the hypertensive disorder ofthe first half of pregnancy. There is usually a pregnancy which occurs most commonly andhistory of hypertension before the start of the also causes the most problems for the motherpregnancy. and fetus. NOTE Chronic hypertension without Gestational proteinuric hypertension and proteinuria is usually due to essential chronic hypertension with superimposed hypertension. If the chronic hypertension is pre-eclampsia will subsequently be discussed accompanied by proteinuria during the first under the heading ‘pre-eclampsia’ because half of pregnancy, then the hypertension is usually due to chronic renal disease. the management is similar.3-8 What is chronic hypertension with 3-10 How frequently doessuperimposed pre-eclampsia? pre-eclampsia occur?This is hypertension presenting during the In the Western Cape 5–6% of all pregnantfirst half of pregnancy that is complicated women develop pre-eclampsia.by the appearance of proteinuria during thesecond half of pregnancy. In other words it is 3-11 Is pre-eclampsia achronic hypertension that is complicated by danger to the mother?the development of pre-eclampsia. Yes, it is one of the most important causes of maternal death in most parts of southern NOTE Patients who book in the second half of Africa. pregnancy cannot be classified into any of the above types of hypertension, as it is not known whether the hypertension started in the first
  4. 4. HYPER TENSIVE DISORDERS OF PREGNANC Y 873-12 What are the maternal Pre-eclampsia may result in intra-uterine growthcomplications of pre-eclampsia? restriction, fetal distress, preterm delivery andThe two most important complications of intra-uterine death.pre-eclampsia are also important causes ofmaternal death during pregnancy: 3-16 How can the severity of1. Intracerebral haemorrhage. pre-eclampsia be graded?2. Eclampsia. The severity of pre-eclampsia can be graded by: NOTE Other, less common, complications of 1. The diastolic and/or systolic blood pre-eclampsia are pulmonary oedema and the pressure. HELLP (Haemolysis, Elevated Liver enzymes, 2. The amount of proteinuria. and a Low Platelet count) syndrome. Rupture of the liver, renal failure, the adult respiratory 3. Signs and symptoms of imminent distress syndrome, and a generalised disorder eclampsia. of blood coagulation may also occur, but 4. The presence of convulsions. fortunately, those are rare complications. Patients with pre-eclampsia can be divided into four grades of severity:3-13 Which patients are at an increasedrisk of intracerebral haemorrhage? 1. Pre-eclampsia A diastolic blood pressure ofThe risk of intracerebral haemorrhage is 90–109 mm Hg and/or a systolic bloodespecially high if the diastolic blood pressure pressure of 140–159 mm Hg andis 110 mm Hg or more and/or a systolic blood proteinuria.pressure of 160 mm Hg or more. 2. Severe pre-eclampsia Any of the following:3-14 Does eclampsia only occur at a • A diastolic blood pressure ofvery high diastolic blood pressure? 110 mm Hg or more and/or a systolic blood pressure of 160 mm Hg or moreNo, eclampsia can occur at a much lower on two occasions, four hours apart.blood pressure, especially in young patients. • A diastolic blood pressure of 120 mm Hg or more, and/or a systolic3-15 Why is pre-eclampsia a danger blood pressure of 170 mm Hg or more,to the fetus and newborn infant? on one occasion, and proteinuria.Pre-eclampsia is an important cause of 3. Imminent eclampsiaperinatal death because: These patients have symptoms and/or signs that indicate that they are at extremely1. Preterm delivery is often necessary because high risk of developing eclampsia at any of a deterioration in the maternal condition moment. The diagnosis does not depend or the development of fetal distress. on the degree of hypertension or the2. Abruptio placentae is more common in amount of proteinuria present. patients with pre-eclampsia and often 4. Eclampsia results in an intra-uterine death. Eclampsia is diagnosed when a patient with3. Pre-eclampsia is associated with decreased any of the grades of pre-eclampsia has a placental blood flow. As a result of convulsion. decreased placental blood flow the fetus may suffer from: • Intra-uterine growth restriction or If there is any doubt about the grade of pre- wasting. eclampsia, the patient should always be placed • Fetal distress. in the more severe grade.
  5. 5. 88 MATERNAL CAREPatients who improve on bed rest should 7. Patients who develop generalised oedema,be kept in the grade of pre-eclampsia which especially facial oedema.they were given at the initial evaluation onadmission. Further management should be in 3-20 What advice should beaccordance with this grade. given to patients at an increased risk of pre-eclampsia?3-17 What are the symptoms and They must be told about the symptoms ofsigns of imminent eclampsia? imminent eclampsia, and advised to contactThe symptoms are: the clinic or hospital immediately, if these symptoms appear.1. Headache.2. Visual disturbances or flashes of light seen in front of the eyes. 3-21 What special care should be3. Upper abdominal pain, in the epigastrium given to patients at an increased and/or over the liver. risk of pre-eclampsia?The signs are: In the second half of pregnancy, the following must be carefully watched for:1. Tenderness over the liver.2. Increased tendon reflexes, e.g. knee reflexes. 1. A rise in diastolic blood pressure. 2. Proteinuria. 3. Symptoms and signs of imminent The diagnosis of imminent eclampsia is made eclampsia. even if only one of the symptoms or signs is Patients with an obstetric history of pre- present, irrespective of the blood pressure or the eclampsia that developed late in the second amount of proteinuria. trimester or early in the third trimester, must receive 75 mg aspirin (a quarter Disprin)3-18 How common is eclampsia? daily from a gestational age of 14 weeks. This will reduce the risk that pre-eclampsia mayIn the Western Cape, the incidence of develop.eclampsia is 1 per 1000 pregnancies. 3-22 What should you do if a patient develops generalised oedema,PATIENTS AT INCREASED but remains normotensive andRISK OF PRE-ECLAMPSIA does not have proteinuria? 1. She should rest as much as possible. 2. She should be followed up weekly at the3-19 Which patients are at an antenatal clinic and carefully checkedincreased risk of pre-eclampsia? for the development of hypertension and1. Primigravidas. proteinuria.2. Patients with chronic hypertension. 3. She should carefully monitor the fetal3. Patients over 34 years of age. movements.4. Patients with a multiple pregnancy.5. Diabetics.6. Patients with a past history of a pregnancy complicated by pre-eclampsia, especially if the pre-eclampsia developed during the late 2nd or early 3rd trimester.
  6. 6. HYPER TENSIVE DISORDERS OF PREGNANC Y 89THE MANAGEMENT 3-25 When should you deliver a patient with pre-eclampsia?OF PRE-ECLAMPSIA Patients who have a gestational age of 36 weeks or more should have their labour3-23 What should you do if a patient induced on the day that the diagnosis is made.develops pre-eclampsia? If the patient has a favourable (‘ripe’)cervix, a surgical induction can be done.1. A patient with pre-eclampsia must be admitted to hospital. Such a patient may be A patient with an unfavourable (‘unripe’) safely cared for in a level 1 hospital. cervix must be referred to a level 2 hospital.2. Methyldopa (Aldomet) must be prescribed There, labour is induced by first ‘ripening’ the to control the blood pressure. cervix with a very low dose of oral misoprostol (Cytotec) or prostaglandin E2, after which NOTE High doses of methyldopa (Aldomet), the membranes are ruptured. A patient must e.g. 500 mg eight-hourly, must be given. always be carefully monitored for an hour after oral misoprostol or the insertion of the prostaglandin, because overstimulation of the All patients with pre-eclampsia must be uterus may cause fetal distress. admitted to hospital, irrespective of the level of their blood pressure. Patients with a gestation of less than 36 weeks must be managed as described in sections 3-23 and 3-24.3-24 How should you monitor thefetus to ensure fetal wellbeing? 3-26 What should you do if a patientPatients with pre-eclampsia often have placental with pre-eclampsia developsinsufficiency, associated with intra-uterine severe pre-eclampsia?growth restriction. Fetal distress, therefore, 1. If the patient is 34 weeks pregnant or more,occurs commonly. If this is not diagnosed, and labour must be induced.the fetus is not delivered soon, intra-uterine 2. If she is less than 34 weeks pregnant, shedeath will result. These patients are also at high must be managed as indicated in sectionrisk of abruptio placentae, followed by fetal 3-37.distress and frequently also intra-uterine death.The fetal condition must, therefore, be carefullymonitored in all patients with pre-eclampsia. The management of pre-eclampsia is bed rest and careful monitoring, to detect a worsening ofFetal movements must be counted and the pre-eclampsia or the development of fetalrecorded by the patient twice a day. distress. NOTE In level 2 and 3 hospitals antenatal fetal heart rate monitoring (CTG) for fetal 3-27 What special investigations distress must be done at least daily. are indicated in pre-eclampsia? 1. An MSU must be examined Patients with pre-eclampsia are at high risk of microscopically for a urinary tract developing fetal distress. They must, therefore, infection, or sent to the laboratory for be carefully monitored for fetal distress. culture, as a urinary tract infection may be responsible for the proteinuria. 2. A platelet count must be done, if a laboratory is available. A platelet count of less than 100 000 is an indication for referral of the patient to a level 2 hospital.
  7. 7. 90 MATERNAL CARE 1. Give 4 g slowly intravenously over ten A urinary tract infection must be excluded in all minutes. Prepare the 4 g by adding patients with proteinuria in pregnancy. 8 ml 50% magnesium sulphate (i.e. two ampoules) to 12 ml sterile water. 2. Then give 5 g (i.e. 10 ml 50% magnesiumTHE EMERGENCY sulphate) by deep intramuscular injectionMANAGEMENT OF SEVERE into each buttock.PRE-ECLAMPSIA AND A total of 14 g of magnesium sulphate is given.IMMINENT ECLAMPSIA NOTE 300 ml of the intravenous infusion is given rapidly over half an hour. Thereafter, the infusion is given slowly, at a rate of 80 ml per hour.The management of patients with severe pre-eclampsia and imminent eclampsia is the same Step 2and consists of stabilising the patient, followed After the magnesium sulphate has beenby referral to a level 2 or 3 hospital. administered, a Foley catheter is inserted into the patient’s bladder to monitor the urinary3-28 What are the greatest dangers to output.a patient with severe pre-eclampsia? Step 3The two greatest dangers which are a threatto the patient’s life are eclampsia and an After giving the magnesium sulphate, theintracerebral haemorrhage. blood pressure must be measured again. If the diastolic blood pressure is still 110 mg Hg or more and/or the systolic blood pressure3-29 How should you manage a 160 mm Hg or more, oral nifedipine (Adalat)patient with severe pre-eclampsia or dihydralazine (Nepresol) is given as follows:or imminent eclampsia? • Give 10 mg (one capsule) nifedipineThe main aims of management are to: orally or 6.25 mg dihydralazine by1. Prevent eclampsia by giving magnesium intramuscular injection. sulphate. • The patient’s blood pressure is taken2. Prevent intracerebral haemorrhage every five minutes for the next 30 by decreasing the blood pressure with minutes. parenteral dihydralazine (Nepresol) or oral • If the blood pressure drops too much, nifedipine capsules (Adalat). intravenous Balsol or Ringer’s lactate is administered rapidly, until the blood pressure returns to normal. The initial management of severe pre-eclampsia • If the diastolic blood pressure remains and imminent eclampsia is aimed at the 110 mm Hg and/or the systolic blood prevention of eclampsia and intracerebral pressure 160 mm Hg or more after 30 haemorrhage. minutes, patients who received 10 mg nifedipine orally can be given a secondThe steps in the management of severe pre- dose of 10 mg nifedipine orally. Ifeclampsia are: necessary, 10 mg of nifedipine can be repeated half-hourly up to a maximumStep 1 dose of 50 mg.An intravenous infusion is started (Plasmalyte B Oror Ringer’s lactate) and magnesium sulphate is • If dihydralazine was used, an ampouleadministered as follows : of dihydralazine (25 mg) should be
  8. 8. HYPER TENSIVE DISORDERS OF PREGNANC Y 91 mixed with 20 ml of sterile water. Bolus must be given if more than four hours pass doses of 2 ml (2.5 mg) are given slowly after the loading dose. intravenously, at 20-minute intervals, 5. If the blood pressure again rises to until the diastolic blood pressure drops 110 mm Hg and/or the systolic blood to below 110 mm Hg and/or the systolic pressure 160 mm Hg or more while the blood pressure below 160 mm Hg. patient is being transported, you should give a second dose of 10 mg nifedipine orallyNifedipine 10 mg capsules must always be or 6.25 mg dihydralazine intramuscularly.given orally and not given sublingually (under Remember that with every administrationthe tongue). The 10 mg capsules must not be of dihydralazine there is a danger that theconfused with Adalat XL tablets which are patient may become hypotensive. Anotherslowly dissolved and not suitable for rapidly side effect is tachycardia, and if the pulselowering blood pressure. rate rises to 120 beats per minute or above,Step 4 further administration of dihydralazine must be stopped.When the blood pressure is controlled, thepatient is transferred to a level 2 or 3 hospital. 3-31 How and when should you give maintenance doses of Patients with severe pre-eclampsia or imminent magnesium sulphate? eclampsia must always be stabilised before they After the initial loading dose of magnesium are transferred, or until further management is sulphate, the patient will need regular decided upon. maintenance doses until 24 hours after delivery. Magnesium sulphate 5 g is given every four hours by deep intramuscular3-30 What can be done to ensure injection into alternate buttocks. The injectionsmaximal safety for the patient are less painful if the magnesium sulphate isduring her transfer to hospital? injected together with 1 ml 1% lignocaine.1. A doctor or registered nurse or midwife should accompany the patient. 3-32 What are the adverse effects of2. Resuscitation equipment, together with an overdose of magnesium sulphate magnesium sulphate, calcium gluconate and how can they be prevented? and dihydralazine or nifedipine, must be available in the ambulance. Respiration An overdose of magnesium sulphate causes may be depressed if a large dose of respiratory and cardiac depression. Here, the magnesium sulphate is given too rapidly. patellar reflex acts as a convenient warning. Calcium gluconate is the antidote to If the reflex is present, the drug may safely be be given in the event of an overdose of given, as there is no danger of overdosage. If magnesium sulphate. the reflex is absent or very reduced, there is a3. Convulsions must be watched for and danger of overdosage and the next dose must the patient’s blood pressure must also be not be given. carefully observed. Magnesium sulphate is excreted by the kidneys.4. If the patient begins to convulse in the If the urinary output is less than 30 ml per ambulance, she must be given a further 2 g hour, follow-up doses must only be given if of magnesium sulphate intravenously. The there is a definite patellar reflex present. dose may, if required, be repeated once. (Make up the solution beforehand and keep it ready in a 20 ml syringe). Further maintenance doses of magnesium sulphate
  9. 9. 92 MATERNAL CARE3-33 What should you do if the patient is fully conscious after the convulsion,patient develops the effects of an as described in 3-29.overdose of magnesium sulphate? Step 5This is a life-threatening emergency and the The patient must now be urgently transferredfollowing steps must be taken immediately: to a level 2 or 3 hospital.1. The patient must be intubated and ventilated or else temporarily ventilated Eclampsia is a life-threatening condition for with a bag and face mask. External cardiac massage may also be needed. both the mother and the fetus. Immediate2. Give 10 ml of 10% calcium gluconate management is therefore needed. slowly intravenously. This is an antidote for magnesium sulphate poisoning. 3-35 What should you do if the patient convulses again?THE MANAGEMENT If the patient convulses again, after the initial loading dose of 14 g of magnesiumOF ECLAMPSIA sulphate has controlled the first convulsion, a further 2 g of magnesium sulphate should be administered intravenously. This dose can be3-34 What is your immediate repeated once more in the unlikely event ofmanagement if a patient convulses? the patient having yet another convulsion.The management of eclampsia is as follows: The following management is not essentialStep 1 knowledge, but should be read by medical and nursing staff working in level 2 or 3 hospitals.Prevent aspiration of the stomach contents by: • Turning the patient immediately onto her side. THE FURTHER • Keeping the airway open by suctioning MANAGEMENT OF SEVERE (if necessary) and inserting an airway. • Administering oxygen. PRE-ECLAMPSIA ANDStep 2 IMMINENT ECLAMPSIA ATStop the convulsion and prevent further THE REFERRAL HOSPITALconvulsions by putting up an intravenousinfusion of Balsol or Ringer’s lactate and givingmagnesium sulphate as described in 3-30. 3-36 How should you manage the patient further in a level 2 or 3 hospital?Step 3 Further management consists of either deliveryAfter the magnesium sulphate has been or conservative treatment, depending on:given, insert a Foley catheter to monitor theurinary output. 1. The degree to which the patient’s condition stabilises, i.e. the diastolic bloodStep 4 pressure remains below 110 mm HgIf the diastolic blood pressure is 110 mm Hg and/or the systolic blood pressure belowand/or the systolic blood pressure 160 mm Hg 160 mm Hg, and there are no symptomsor more, it must be reduced with dihydralazine or signs of imminent eclampsia. (Oral(Nepresol). Oral nifedipine can be used if the anti-hypertensive drugs must be given to
  10. 10. HYPER TENSIVE DISORDERS OF PREGNANC Y 93 control the blood pressure, if it is decided viable, growth-restricted fetus can present to continue conservative management). with a fundal height of 24, or even 222. The duration of the pregnancy. weeks gestation. Fetal growth must also be3. The condition of the fetus. monitored. 8. Because of the danger of hyalineThe patient must be delivered if any of the membrane disease in a newborn infantfollowing apply: who, though viable, has a gestational1. The patient’s condition does not stabilise. age of less than 34 weeks, steroids2. The fetus is not nearing viability (it is less (betamethasone 12 mg, Celestone- than 26 weeks). Soluspan) must be given intramuscularly3. The duration of pregnancy is 34 or more to the patient, to enhance fetal lung weeks. maturity. A second dose must be repeated4. There is fetal distress. 24 hours later. 9. If the duration of the pregnancy isIf none of the above apply then the patient unknown, and the clinical assessment orcan be managed conservatively until 34 weeks ultrasound size suggests a pregnancy of 34gestation or until the maternal condition weeks or more, the fetus must be delivered.deteriorates or fetal distress develops. 10. If there is no fetal distress and the presentation is cephalic, a medical or The maternal condition must always be stabilised surgical induction of labour must be done first. Thereafter, the condition of the fetus and at 34 weeks gestation. the duration of the pregnancy must be taken 11. If fetal distress is present, or the into consideration in planning the further presentation is abnormal, a Caesarean management of the patient. section must be done. 12. A patient whose condition becomes well stabilised, must be placed on an oral3-37 What is the conservative antihypertensive drug. Alpha methyldopa ismanagement of severe pre-eclampsia? the drug of choice. A high dosage (such as1. Magnesium sulphate must be stopped. 500 mg eight-hourly that can be increased2. The patient must be hospitalised for bed to 750 mg eight-hourly) must be used. rest in a level 2 or 3 hospital. If the diastolic blood pressure remains3. The fetal movements must be monitored at 110 mm Hg and/or the systolic blood daily. pressure 160 mm Hg or higher, a second or4. Antenatal cardiotocography (CTG) is very even a third antihypertensive drug is added. useful and if possible must be done twice NOTE Nifedipine (Adalat) is the drug of choice, or more daily. This is because of the risk if a second antihypertensive drug is required. of fetal distress, as a result of placental Prazosin (Minipress) or labetalol (Trandate) may insufficiency or abruptio placentae. be added, if a third drug is required. This form of5. Urinary tract infection must be excluded. management must take place in a level 3 hospital.6. A platelet count and renal function tests (urea and creatinine) must be done twice If the decision is taken to manage the patient a week. If the platelet count is less than conservatively, the danger of prematurity (if 100 000, liver function tests should be the fetus is delivered) must continually be done. Poor renal function, raised liver weighed against the danger of fetal distress or enzymes or a platelet count that falls abruptio placentae (which could result in an further are indications for delivery. intra-uterine death).7. An ultrasound examination is of value to assess fetal weight, and to assess fetal viability. Remember that a patient with a
  11. 11. 94 MATERNAL CAREGESTATIONAL 3-39 How should you monitor the fetus in order to ensure fetal wellbeing?HYPERTENSION Fetal movements must be counted and recorded twice daily.3-38 What should you do if a patientdevelops gestational hypertension? 3-40 When should you deliver a patient with gestational hypertension?A patient with a slightly elevated bloodpressure (a diastolic blood pressure of If the blood pressure remains well controlled,90 to 95 mm Hg), which develops in the no proteinuria develops, and the fetalsecond half of pregnancy, in the absence of condition remains good, the pregnancy mustproteinuria, may be managed in a level 1 be allowed to continue until 40 weeks whenhospital or clinic. If the home circumstances labour must be induced.are poor, she must be admitted to hospital forbed rest. Where the home circumstances aregood, the patient is allowed bed rest at home, CHRONIC HYPERTENSIONunder the following conditions:1. The patient must be told about the These patients have hypertension in the first symptoms of imminent eclampsia. Should half of pregnancy, or are known to have had any of these occur, she must contact or hypertension before the start of pregnancy. attend the hospital or clinic immediately.2. The patient must be seen weekly at a 3-41 Which patients with chronic high-risk antenatal clinic. In addition, she hypertension should be referred must be seen once between visits, to check to a level 2 or 3 hospital? her blood pressure and test her urine for A good prognosis can be expected if: protein.3. If the patient cannot be seen more 1. Renal function is normal (normal serum frequently, she must be given urinary creatinine concentration). reagent strips to take home. She must then 2. Pre-eclampsia is not superimposed on the test her urine daily and go to the clinic, chronic hypertension. should there be 1+ proteinuria or more. 3. The blood pressure is well controlled (a4. No special investigations are indicated. diastolic blood pressure of 90 mm Hg and/5. Alpha methyldopa (Aldomet) must be or the systolic blood pressure 140 mm Hg prescribed to control her blood pressure. or less) from early in pregnancy. The initial dosage of alpha methyldopa These women can be managed at a level 1 (Aldomet) is 500 mg eight-hourly. hospital. However, women with chronicPatients with a diastolic blood pressure of hypertension should be referred to a level 2 or100 mm Hg and/or a systolic blood pressure 3 hospital for further management if:150 mm Hg or higher must be admitted to 1. Renal function is abnormal (serumhospital and alpha methyldopa (Aldomet) must creatinine more than 120mmol/l).be prescribed. Once the diastolic blood pressure 2. Proteinuria develops.has dropped below 100 mm Hg and the systolic 3. The diastolic blood pressure is 110 mmblood pressure to below 150 mm Hg, they are Hg and/or the systolic blood pressuremanaged as indicated above. 160 mm Hg or higher. 4. There is intra-uterine growth restriction. 5. More than one drug is required to control the blood pressure.
  12. 12. HYPER TENSIVE DISORDERS OF PREGNANC Y 953-42 Will you adjust the medication of previous visit, and she has no proteinuria. Shea patient with chronic hypertension reports that her fetus moves frequently.when she becomes pregnant?Yes, she must change to alpha methyldopa 1. Why is this patient at high risk(Aldomet) 500 mg eight-hourly. Other of developing pre-eclampsia?antihypertensives (i.e. diuretics, beta blockers Because she is a primigravida and hasand ACE inhibitors) must be stopped. developed generalised oedema over the past week. NOTE In pregnancy, beta-blockers are not completely safe for the fetus, while diuretics reduce the intravascular fluid compartment, 2. How should this patient with adverse effects on placental and renal be managed further? perfusion. An ACE inhibitor, such as captopril She should rest a lot. She should also be seen at (Capoten and enalapril (Renitec)), is completely the antenatal clinic again in a week when she contraindicated in pregnancy, as intra-uterine deaths have occurred in patients on this drug. must be carefully examined for a rise in blood pressure or the presence of proteinuria.3-43 What special care is neededfor a patient with chronic 3. What advice should thishypertension during pregnancy? patient be given?1. Any rise in the blood pressure or the She should be told about the symptoms of development of proteinuria must be imminent eclampsia, i.e. headache, flashes of carefully looked for, as they indicate an light before the eyes, and upper abdominal urgent need for referral. pain. She should also be asked to count and2. A Doppler measurement of the blood flow record fetal movements twice a day. If any of the in the umbilical artery should be done to above-mentioned symptoms are experienced, determine placental function. or if fetal movements decrease, she must3. Postpartum sterilisation must be discussed immediately report to the clinic or hospital. with the patient, and is recommended when the patient is a multigravida. 4. When you see the patient a week later she has a diastolic blood pressure of3-44 When should you deliver a 90 mm Hg, but there is still no proteinuria.patient with chronic hypertension? How should she be managed further?The management is the same as that for The patient has pregnancy-inducedgestational hypertension. hypertension. If the home conditions are satisfactory, she can be managed with bed rest at home. The hypertension must be controlledCASE STUDY 1 with alpha methyldopa (Aldomet). She must be seen twice a week and carefully monitored to detect a rise in her blood pressure andA 21-year-old primigravida patient is attending the possible development of proteinuria. Ifthe antenatal clinic. Her pregnancy progresses her blood pressure rises and/or proteinurianormally to 33 weeks. At the next visit at 35 develops, she must be admitted to hospital. Ifweeks, the patient complains that her hands the home conditions are poor, she should beand feet have started to swell over the past admitted to hospital for bed rest.week. On examining her, you notice that herface is also slightly swollen. Her blood pressureat present is 120/80, which is the same as at her
  13. 13. 96 MATERNAL CARECASE STUDY 2 of magnesium sulphate has been given. In that case, no further management is needed for the hypertension. However, ifAt an antenatal clinic you see a patient who is the patient’s blood pressure does not drop39 weeks pregnant. Up until now she has had a after administering the magnesium sulphate,normal pregnancy. On examination, you find 10 mg (one capsule) oral nifedipine (Adalat)that her diastolic blood pressure is 95 mm Hg or intramuscular dihydralazine (Nepresol)and that she has 2+ proteinuria. 6.25 mg should be given.1. How should this patient be managed?She should be admitted to hospital as CASE STUDY 3all patients with 2+ proteinuria must behospitalised. She should also be delivered, as While working at a level 1 hospital youshe is more than 38 weeks pregnant. admit a patient with a blood pressure of 170/120 mm Hg and 3+ proteinuria. She is 322. On examining this patient you observe weeks pregnant. On further questioning andthat she has increased patellar reflexes examination, she has no symptoms or signs ofi.e. brisk knee jerks. How should this imminent eclampsia.observation alter her management?Increased tendon reflexes are a sign of 1. What is the danger toimminent eclampsia. The diagnosis must this patient’s health?be made, irrespective of the degree of The patient has severe pre-eclampsia.hypertension or the amount of proteinuria. Therefore, the immediate danger to herTo prevent the development of eclampsia, the life is the development of eclampsia or anpatient must be given magnesium sulphate. intracerebral haemorrhage.3. What is the danger to this patient’s health? 2. How should this patient be managed?The patient has severe pre-eclampsia. Her clinical condition must first be stabilised.Therefore, the immediate danger to her An intravenous infusion should be started andlife is the development of eclampsia or an a loading dose of 14 g magnesium sulphateintracerebral haemorrhage. must be given. This should prevent the development of eclampsia. A Foley catheter4. How should this patient be managed? must be inserted in her bladder.Her clinical condition must first be stabilised.An intravenous infusion should be started and 3. Following the administration ofa loading dose of 14 g magnesium sulphate magnesium sulphate, the bloodmust be given. This should prevent the pressure is 160/110 mm Hg. Whatdevelopment of eclampsia. A Foley catheter should the further management be?must be inserted in her bladder. Her blood pressure needs to be lowered. 10 mg (one capsule) oral nifedipine (Adalat)5. Is a loading dose of magnesium or intramuscular dihydralazine (Nepresol)sulphate also adequate to control 6.25 mg should be given. If the diastolic bloodthe high blood pressure? pressure remains 110 mm Hg and/or the systolic blood pressure 160 mm Hg or moreNo. Sometimes with severe pre-eclampsia, after 30 minutes, patients who received 10 mgthe blood pressure will drop to below nifedipine orally can be given a second dose of160/110 mm Hg after the loading dose 10 mg nifedipine orally. If dihydralazine was
  14. 14. HYPER TENSIVE DISORDERS OF PREGNANC Y 97used, an ampoule of dihydralazine (25 mg) 3. How can superimposed pre-eclampsiashould be mixed with 20 ml of sterile water. A be diagnosed during pregnancy?bolus doses of 2 ml (2.5 mg) should be given The patient will develop proteinuria and/or aslowly intravenously. rise in blood pressure during the second half of pregnancy.4. Should you continue to managethis patient at a level 1 hospital? 4. Why is it important to detectNo. The patient should be transferred to a level superimposed pre-eclampsia in a2 or 3 hospital for further management. patient with chronic hypertension? Because the risk of complications increases and as a result, a preterm delivery may beCASE STUDY 4 necessary. The patient should, therefore, be transferred to a level 2 or 3 hospital ifA 37-year-old gravida 4, para 3 patient superimposed pre-eclampsia develops.books for antenatal care. She has chronichypertension and is managed with a diuretic. 5. What should be seriously recommendedBy dates and examination she is 14 weeks during the puerperium in this patient?pregnant. A postpartum sterilisation. Postpartum1. Should the management of sterilisation should be discussed with thethe patient’s hypertension be patient during the pregnancy. Postpartumchanged during the pregnancy? sterilisation is particularly important as the patient is a 37-year-old multipara.Yes. The diuretic should be stopped, asthese drugs are not completely safe duringpregnancy. Instead, the patient should betreated with alpha methyldopa (Aldomet).2. What factors indicate a goodprognosis for a patient with chronichypertension during pregnancy?Normal renal function, no superimposedpre-eclampsia and good control of the bloodpressure during pregnancy.

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