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

1. 3
Hypertensive
disorders of
pregnancy
Before you begin this unit, please take the THE HYPERTENSIEVE
corresponding test at the end of the book to
assess your knowledge of the subject matter. DISORDERS OF
PREGNANCY
Objectives
3-1 What is the normal blood
When you have completed this unit you pressure during pregnancy?
should be able to: The normal systolic blood pressure is less than
• Define and diagnose the hypertensive 140 mm Hg and the diastolic blood pressure is
disorders of pregnancy. less than 90 mm Hg.
• Give a simple classification of the
hypertensive disorders of pregnancy. 3-2 What is hypertension
during pregnancy?
• Diagnose pre-eclampsia and chronic
hypertension. Hypertension during pregnancy is defined
• Explain why the hypertensive disorders as a diastolic blood pressure of 90 mm Hg
or more and/or a systolic blood pressure of
of pregnancy must always be regarded
140 mm Hg or more.
as serious.
• List which patients are at risk of A diastolic blood pressure of 90 mm hg or more
developing pre-eclampsia. and a systolic blood pressure of 140 mm hg or
• List the complications of pre-eclampsia. more during pregnancy is abnormal.
• Differentiate pre-eclampsia from severe
During pregnancy an abnormally high blood
pre-eclampsia.
pressure is often accompanied by proteinuria.
• Provide emergency management for a
patient with pre-eclampsia. 3-3 What is proteinuria?
• Provide emergency management for
Proteinuria is defined as an excessive amount
eclampsia.
of protein in the urine. Normally the urine
• Manage gestational hypertension and contains no protein or only a trace of protein.
chronic hypertension during pregnancy.

2. 76 PRIMAR Y MATERNAL CARE
Therefore, a trace of protein in the urine is not 3-6 What is chronic hypertension?
regarded as abnormal.
Chronic hypertension is hypertension, with
Proteinuria during pregnancy is diagnosed or without proteinuria, that presents during
when 1+ or more protein as measured with a the first half of pregnancy. There is usually a
reagent strip (e.g. Albustix, Labstix, Uristix, history of hypertension before the start of the
Multistix, Lenstrip, etc). pregnancy.
Proteinuria during pregnancy may also be
caused by: 3-7 What is chronic hypertension with
superimposed pre-eclampsia?
1. A urinary tract infection.
2. Renal disease. This is hypertension presenting during the
3. Contamination of the urine by a vaginal first half of pregnancy that is complicated
discharge. by the appearance of proteinuria during the
second half of pregnancy. In other words it is
Patients with proteinuria must be asked to chronic hypertension that is complicated by
collect a second sample, as a midstream the development of pre-eclampsia.
specimen of urine (MSU). The correct
method of collecting an MSU must be
3-8 What is eclampsia?
carefully explained to the patient. The
amount of proteinuria present in the MSU Eclampsia is a serious complication of pre-
must be recorded in the notes. The further eclampsia that presents with convulsions
management will be dictated by the amount of during pregnancy, labour or the first 7 days
proteinuria in the MSU. of the puerperium. Convulsions can also be
the result of other causes, e.g. epilepsy, but the
1+ or more protein in the urine is abnormal. possibility of eclampsia must be carefully ruled
out whenever convulsions occur.
3-4 What is pre-eclampsia?
Pre-eclampsia presents with hypertension PRE-ECLAMPSIA
and proteinuria which develop in the second
half of pregnancy (20 weeks or more). Pre- Pre-eclampsia is the hypertensive disorder of
eclampsia may present during pregnancy, pregnancy which occurs most commonly and
labour or the puerperium. also causes most problems for the mother
Pre-eclampsia is also called gestational and fetus.
(pregnancy induced) proteinuric hypertension. Gestational proteinuric hypertension and
chronic hypertension with superimposed
3-5 What is gestational hypertension? pre-eclampsia will be discussed under
In contrast to pre-eclampsia, gestational the heading ‘pre-eclampsia’ because the
hypertension is not accompanied by management is similar.
proteinuria but also presents in the second
half of pregnancy. Should proteinuria develop 3-9 How frequently does pre-
in a patient with gestational hypertension, the eclampsia occur?
diagnosis must be changed to pre-eclampsia. In the Western Cape of South Africa 5–6% of
all pregnant women develop pre-eclampsia.
Pre-eclampsia presents with hypertension and
proteinuria in the second half of pregnancy.

3. HYPER TENSIVE DISORDERS OF PREGNANC Y 77
3-10 Is pre-eclampsia a Pre-eclampsia may result in intra-uterine growth
danger to the mother?
restriction, fetal distress, preterm delivery and
Yes, it is one of the most important causes intra-uterine death.
of maternal death in most parts of southern
Africa.
3-15 How can the severity of
3-11 What are the maternal pre-eclampsia be graded?
complications of pre-eclampsia? The severity of pre-eclampsia can be graded by:
The most important complications of pre- 1. The diastolic blood pressure and/or
eclampsia are also important causes of systolic.
maternal death during pregnancy: 2. The amount of proteinuria.
1. Intracerebral haemorrhage. 3. Signs and symptoms of imminent
2. Eclampsia. eclampsia.
4. The presence of convulsions.
3-12 Which patients are at an increased Patients with pre-eclampsia can be divided
risk of intracerebral haemorrhage? into 4 grades of severity:
The risk of intracerebral haemorrhage is 1. Pre-eclampsia.
especially high if the diastolic blood pressure A diastolic blood pressure of 90 to
is 110 mm Hg or more and/or a systolic blood 109 mm Hg and proteinuria, and/or a
pressure of 160 mm Hg or more. systolic blood pressure of 140 to 159 mm
Hg, plus proteinuria.
3-13 Does eclampsia only occur at a 2. Severe pre-eclampsia.
very high diastolic blood pressure? Any of the following:
• A diastolic blood pressure of
No, eclampsia can occur at a much lower 110 mm Hg or more and/or a systolic
blood pressure, especially in young patients. blood pressure of 160 mm Hg or more
on 2 occasions, 4 hours apart, plus
3-14 Why is pre-eclampsia a danger proteinuria.
to the fetus and newborn infant? • A diatolic blood pressure of
Pre-eclampsia is an important cause of 120 mm Hg or more and/or a systolic
perinatal death because: blood pressure of 170 mm Hg or more
on 1 occasion, plus proteinuria.
1. Preterm delivery is often necessary because 3. Imminent eclampsia.
of a deterioration in the maternal condition These patients have symptoms and/or signs
or the development of fetal distress. that indicate that they are at extremely
2. Abruptio placentae is more common in high risk of developing eclampsia at any
patients with pre-eclampsia and often moment. The diagnosis does not depend
results in an intra-uterine death. on the degree of hypertension or the
3. Pre-eclampsia is associated with decreased amount of proteinuria present.
placental blood flow. As a result of 4. Eclampsia:
decreased placental blood flow the fetus Eclampsia is diagnosed when a patient with
may suffer from: any of the grades of pre-eclampsia has a
• Intra-uterine growth restriction or convulsion.
wasting.
• Fetal distress.

4. 78 PRIMAR Y MATERNAL CARE
6. Patients with a past history of a pregnancy
If there is any doubt about the grade of pre-
complicated by pre-eclampsia, especially
eclampsia, the patient should always be placed
if the pre-eclampsia developed during the
in the more severe grade. late 2nd or early 3rd trimester.
7. Patients who develop generalised oedema,
Patients who improve on bed rest should be especially facial oedema.
kept in the grade of pre-eclampsia which they
were given at the initial evaluation. Further
3-19 What advice should be given to
management should be in accordance with
patients at increased risk of
this grade.
pre-eclampsia?
3-16 What are the symptoms and They must be told about the symptoms of
signs of imminent eclampsia? imminent eclampsia, and advised to contact
the clinic or hospital immediately, if these
The symptoms are: symptoms appear.
1. Headache.
2. Visual disturbances or flashes of light seen 3-20 What special care should be given to
in front of the eyes. patients at increased risk of pre-eclampsia?
3. Upper abdominal pain, in the epigastrium
In the second half of pregnancy, the following
and/or over the liver.
must be carefully watched for:
The signs are:
1. A rise in diastolic blood pressure.
1. Tenderness over the liver. 2. Proteinuria.
2. Increased tendon reflexes, e.g. knee reflexes. 3. Symptoms and signs of imminent
eclampsia.
The diagnosis of imminent eclampsia is made
even if only one of the symptoms or signs is Patients with an obstetric history of pre-
eclampsia that developed late in the second
present, irrespective of the blood pressure or the
or early in the third trimester, must receive
amount of proteinuria. 75 mg aspirin (a quarter Disprin) daily from
a gestational age of 14 weeks. This will reduce
3-17 How common is eclampsia? the risk that pre-eclampsia may develop.
In the Western Cape of South Africa
3-21 What should you do if a patient
the incidence of eclampsia is 1 per 1000
develops generalised oedema,
pregnancies.
but remains normotensive and
does not have proteinuria?
PATIENTS AT INCREASED 1. She should rest as much as possible.
2. She should be followed up weekly at the
RISK OF PRE-ECLAMPSIA antenatal clinic and carefully checked
for the development of hypertension and
proteinuria.
3-18 Which patients are at an 3. She should carefully monitor the fetal
increased risk of pre-eclampsia? movements.
1. Primigravidas.
2. Patients with chronic hypertension.
3. Patients over 34 years.
4. Patients with a multiple pregnancy.
5. Diabetics.

5. HYPER TENSIVE DISORDERS OF PREGNANC Y 79
THE MANAGEMENT The initial management of severe pre-eclampsia
OF PRE-ECLAMPSIA and imminent eclampsia is aimed at the
prevention of eclampsia and intracerebral
haemorrhage.
3-22 What should you do if a patient
develops pre-eclampsia? The steps in the management of severe pre-
eclampsia are:
1. A patient with pre-eclampsia must be
admitted to hospital. Such a patient may Step 1
safely be cared for in a level 1 hospital.
An intravenous infusion is started (Balsol or
2. Methyldopa (Aldomet) must be prescribed
Ringer’s lactate) and magnesium sulphate is
to control the blood pressure.
administered as follows :
All patients with pre-eclampsia must be 1. Give 4 g slowly intravenously over 10
admitted to hospital, irrespective of the level of minutes. Prepare the 4 g by adding 8 ml
the blood pressure. 50% magnesium sulphate (i.e. 2 ampoules)
to 12 ml sterile water.
2. Then give 5 g (i.e. 10 ml 50% magnesium
sulphate) by deep intramuscular injection
THE EMERGENCY into each buttock.
MANAGEMENT OF SEVERE A total of 14 g of magnesium sulphate is,
PRE-ECLAMPSIA AND therefore, given.
IMMINENT ECLAMPSIA Step 2
After the magnesium sulphate has been
The management of patients with severe pre- administered, a Foley’s catheter is inserted
eclampsia and imminent eclampsia is the same into the patient’s bladder, to monitor the
and consists of stabilising the patient, followed urinary output.
by referral to a level 2 or 3 hospital.
Step 3
3-23 What are the two greatest dangers to After giving the magnesium sulphate the
the patient with severe pre-eclampsia? blood pressure must be measured again.
Magnesium sulphate may cause a slight
The two greatest dangers, which are a threat drop in blood pressure. If the diastolic blood
to the patient’s life, are eclampsia and an pressure is still 110 mg Hg or more and/or the
intracerebral haemorrhage. systolic blood pressure 160 mm Hg or more,
oral nifedipine (Adalat) or dihydralazine
3-24 How should you manage a (Nepresol) is given as follows:
patient with severe pre-eclampsia
or imminent eclampsia? • Give 10 mg (one capsule) nifedipine
orally or 6.25 mg dihydralazine by
The main aims of management are to: intramuscular injection.
1. Prevent eclampsia, by giving magnesium • The patient’s blood pressure is taken
sulphate. every 5 minutes for the next 30 minutes.
2. Prevent intracerebral haemorrhage, by • If the blood pressure drops too much,
decreasing the blood pressure with oral intravenous Balsol or Ringer’s lactate
nifedipine capsules (Adalat) or parenteral is administered rapidly, until the blood
dihydralazine (Nepresol). pressure returns to normal.

6. 80 PRIMAR Y MATERNAL CARE
• If the blood pressure does not drop, 3. Convulsions must be watched for and
patients who have received 10 mg the patient’s blood pressure must also be
nifedipine can be given a second carefully observed.
dose of 10 mg nifedipine orally if 4. If the patient begins to convulse in the
the diastolic blood pressure remains ambulance, she must be given a further 2 g
110 mm Hg or more after 30 minutes. of magnesium sulphate intravenously. The
If necessary, 10 mg nifedipine orally dose may, if required, be repeated once.
can be repeated half hourly up to a (Make up the solution beforehand and
maximum dose of 50 mg. keep it ready in a 20 ml syringe). Further
Or maintenance doses of magnesium sulphate
must be given if more than 4 hours pass
• If dihydralazine was used an ampoule
after the loading dose.
of dihydralazine (25 mg) should be
5. If the blood pressure again rises to
mixed with 20 ml of sterile water. Bolus
110 mm Hg or more while the patient
doses of 2 ml (2.5 mg) are then given
is being transported, you should give a
slowly intravenously, at 20 minute
second dose of 10 mg nifedipine by mouth
intervals, until the diastolic blood
or 6.25 mg dihydralazine intramuscularly.
pressure drops below 110 mm Hg.
Remember that, with every administration
Nifedipine 10 mg capsules must always be of dihydralazine, there is a danger that the
given orally in pregnancy and not given patient may become hypotensive. Another
sublingually (under the tongue). The 10 mg side-effect is tachycardia, and if the pulse
capsules must not be confused with Adalat rate rises to 120 beats per minute or above,
XL tablets which are slowly dissolved and not further administration of dihydralazine
suitable for rapidly lowering the blood pressure. must be stopped.
Step 4
When the blood pressure is controlled, the THE MANAGEMENT
patient is transferred to a level 2 or 3 hospital.
OF ECLAMPSIA
Patients with severe pre-eclampsia or imminent
eclampsia must always be stabilised before they
are transferred. 3-26 What is your immediate
management if a patient convulses?
3-25 What can be done to ensure The management of eclampsia is as follows:
maximal safety for the patient Step 1
during her transfer to hospital?
Prevent aspiration of the stomach contents by:
1. A doctor or registered nurse/midwife
should accompany the patient. • Turning the patient immediately on her
2. Resuscitation equipment, together with side.
magnesium sulphate, calcium gluconate • Keeping the airway open by suctioning
and nifedipine or dihydralazine, must be (if necessary) and inserting an airway.
available in the ambulance. Respiration • Administering oxygen.
may be depressed if a large dose of Step 2
magnesium sulphate is given too rapidly.
Calcium gluconate is the antidote to Stop the convulsion and prevent further
be given in the event of an overdose of convulsions by putting up an intravenous
magnesium sulphate. infusion of Balsol or Ringer’s lactate and giving
magnesium sulphate.

7. HYPER TENSIVE DISORDERS OF PREGNANC Y 81
Step 3 are good, the patient is allowed bedrest at
home, under the following conditions:
After the magnesium sulphate has been
given, insert a Foley’s catheter to monitor the 1. The patient must be told about the
urinary output. symptoms of imminent eclampsia. Should
any of these occur, she must contact or
Step 4
attend the hospital or clinic immediately.
If the diastolic blood pressure is 110 mm Hg 2. The patient must be seen weekly at a high-
or more and/or the systolic blood pressure risk antenatal clinic. In addition, following
160 mm Hg or more, it must be reduced with the initial diagnosis, she must be seen once
dihydralazine (Nepresol). Oral nifedipine can between visits, to check the blood pressure
be used if the patient is fully conscious after and test the urine for protein.
the convulsion. 3. If the patient cannot be seen more
frequently, she must be given urinary
Step 5
reagent strips to take home. She must then
The patient must now be urgently transferred test her urine daily and go to the clinic,
to a level 2 or 3 hospital. should there be 1+ proteinuria or more.
4. No special investigations are indicated.
Eclampsia is a life-threatening condition for 5. Alpha methyldopa (Aldomet) must be
both the mother and the fetus. Immediate prescribed to control the blood pressure.
management is, therefore, needed. The initial dosage is 500 mg 8 hourly.
Patients with a diastolic blood pressure of
3-27 What should you do if the 100 mm Hg or more and/or a systolic blood
patient convulses again? pressure of 160 mm Hg or more, must be
admitted to hospital and alpha methyldopa
If the patient convulses again, after the (Aldomet) must be prescribed. Once the
convulsions had initially been controlled by diastolic blood pressure has dropped below
the total loading dose of 14 g of magnesium 100 mm Hg, they are managed as indicated
sulphate, a further 2 g of magnesium sulphate above.
should be administered intravenously. This dose
can be repeated once more in the unlikely event
3-29 How should you monitor the fetus,
of the patient having yet a further convulsion.
in order to ensure fetal wellbeing?
Fetal movements must be counted and
GESTATIONAL recorded twice daily. A Doppler measurement
of the blood flow in the umbilical artery to
HYPERTENSION determine placental function should be done.
3-28 What should you do if a patient 3-30 When should you deliver a patient
develops gestational hypertension? with gestational hypertension?
A patient with a slightly elevated blood If the blood pressure remains well controlled,
pressure (a diastolic blood pressure of no proteinuria develops and the fetal
90 to 95 mm Hg), which develops in the condition remains good, the pregnancy must
second half of pregnancy, in the absence of not be allowed to continue until 40 weeks
proteinuria, may be managed in a level 1 when induction of labour must be done.
hospital or clinic. If the home circumstances
are poor, she must be admitted to hospital,
for bedrest. Where the home circumstances

8. 82 PRIMAR Y MATERNAL CARE
CHRONIC HYPERTENSION 3-33 What special care is needed
for a patient with chronic
hypertension during pregnancy?
These patients have hypertension in the first
half of pregnancy, or are known to have had 1. Any rise in the blood pressure or the
hypertension before the start of pregnancy. development of proteinuria must be
They do not have superimposed pre-eclampsia. carefully looked for, as they indicate an
urgent need for referral.
3-31 Which patients with chronic 2. A Doppler measurement of the blood
hypertension should be referred flow in the umbilical artery to determine
to a level 2 or 3 hospital? placental function should be done.
3. Postpartum sterilisation must be discussed
A good prognosis can be expected if: with the patient, and is recommended
1. Renal function is normal (normal serum when the patient is a multigravida.
creatinine concentration).
2. Pre-eclampsia is not superimposed on the 3-34 When should you deliver a
chronic hypertension. patient with chronic hypertension?
3. The blood pressure is well controlled (a
The management is the same as that for
diastolic blood pressure of 90 mm Hg or less
gestational hypertension.
and a systolic blood pressure of 140 mm Hg
or less) from early in pregnancy.
Therefore, these women can be managed at a CASE STUDY 1
level 1 hospital. However, women with chronic
hypertension should be referred to a level 2 or
A 21 year old primigravid patient has attended
3 hospital for further management if:
the antenatal clinic and her pregnancy
1. Renal function is abnormal (serum progresses normally to 33 weeks. At the next
creatinine more than 120 μmol/l). visit at 35 weeks, the patient complains that
2. Proteinuria develops. her hands and feet have started to swell over
3. The diastolic blood pressure is 110 mm Hg the past week. On examination, you notice
or higher more and systolic blood pressure that her face is also slightly swollen. Her blood
160 mm Hg or more. pressure is 120/80, which is the same as at her
4. There is intra-uterine growth restriction. previous visit, and she has no proteinuria. She
5. More than one drug is required to control reports that her fetus moves frequently.
the blood pressure.
1. Why is this patient at high risk
3-32 Will you adjust the medication of of developing pre-eclampsia?
a patient with chronic hypertension
Because she is a primigravida and has
when she becomes pregnant?
developed generalised oedema over the past
Yes, she must be put onto alpha methyldopa week.
(Aldomet) 500 mg 8 hourly. Other
antihypertensives (i.e. diuretics, beta blockers 2. How should this patient
and ACE inhibitors) must be stopped. be managed further?
She should rest a lot. She also should be seen at
the antenatal clinic again in a week when she
must be carefully examined for a rise in blood
pressure or the presence of proteinuria.

9. HYPER TENSIVE DISORDERS OF PREGNANC Y 83
3. What advice should this 2. On examining this patient you observe
patient be given? that she has increased patellar reflexes,
i.e. brisk knee jerks. How should this
She should be told about the symptoms of
observation alter her management?
imminent eclampsia, i.e. headache, flashes of
light before the eyes, and upper abdominal Increased tendon reflexes are a sign of
pain. She should also be asked to count and imminent eclampsia. The diagnosis must
record fetal movements twice a day. If any of the be made, irrespective of the degree of
above-mentioned symptoms are experienced, hypertension or the amount of proteinuria.
or if fetal movements decrease, she must To prevent the development of eclampsia, the
immediately report to the clinic or hospital. patient must be given magnesium sulphate.
4. When you see the patient a week later 3. What is the danger to
she has a diastolic blood pressure of this patient’s health?
90 mm Hg, but there is still no proteinuria.
The patient has severe pre-eclampsia.
How should she be managed further?
Therefore, the immediate danger to her
The patient has pregnancy-induced life is the development of eclampsia or an
hypertension. If the home conditions are intracerebral haemorrhage.
satisfactory, she can be managed with bedrest
at home. The hypertension must be controlled 4. How should this patient be managed?
with alpha methyldopa (Aldomet). She must
be seen twice a week, and carefully monitored, Her clinical condition must first be stabilised.
to detect a rise in the blood pressure and An intravenous infusion should be started and
the possible development of proteinuria. If a loading dose of 14 g magnesium sulphate
the blood pressure rises and/or proteinuria must be given. This should prevent the
develops, she must be referred to hospital for development of eclampsia. A Foley’s catheter
admission. If the home conditions are poor, must be inserted in her bladder.
she should be admitted to hospital for bed rest.
5. Is a loading dose of magnesium
sulphate also adequate to control
CASE STUDY 2 the high blood pressure?
No. Sometimes with severe pre-eclampsia, the
At an antenatal clinic you see a patient who is diastolic blood pressure will drop to below
39 weeks pregnant. Up until now she has had a 110 mm Hg after a loading dose of magnesium
normal pregnancy. On examination, you find sulphate has been given. In that case, no further
that her diastolic blood pressure is 95 mm Hg management is needed for the hypertension.
and that she has 2+ proteinuria. However, if the patient’s blood pressure does
not drop after administering the magnesium
1. How should this patient be managed? sulphate, 10 mg (one capsule) oral nifedipine
(Adalat) or intramuscular dihydralazine
She should be transferred to hospital as (Nepresol) 6.25 mg should be given.
all patients with 2+ proteinuria must be
hospitalised.
CASE STUDY 3
While working at a level 1 hospital you admit
a patient with a diastolic blood pressure of
120 mm Hg and 3+ proteinuria. She is 32