Medical Conditions in Pregnancy

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MALARIA IN PREGNANCY

CLINICAL DESCRIPTION

Similar presentation as in non-pregnant woman, however prone to complications:

  • Hypoglycemia, anaemia, miscarriage, fetal growth restriction, low birth weight, preterm delivery

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Fever, malaise, general body pains, low appetite, headache, abdominal pain, nausea, vomiting, symptoms of anaemia, splenomegaly.

INVESTIGATIONS

  • FBC / Check hemoglobin
  • Check MPs and MRDT
  • Check random blood glucose
  • Urinalysis / urine dipsticks

TREATMENT

PHARMACOLOGICAL

  • In 1st trimester of pregnancy give oral Quinine 10mg/kg body weight, administered 8 hourly for 7 days OR
  • In 2ndand 3rdtrimester give Lumefantrine Artemether (LA) 12 hourly for 3 days.

Note: Pregnant women are susceptible to hypoglycemia when taking quinine.

Severe Malaria in Pregnancy

Hypoglycaemia, reduced level of consciousness, anaemia, reduced urine output / cocacola coloured urine, convulsions. 

Refer to the MOH National Malaria Control Program Guidelines for the Treatment of Malaria in Malawi, 5th edition, 2020, for full details of malaria management.

HIV/AIDS IN PREGNANCYRefer to HIV Clinical Management guidelines 2021.

ANEMIA IN PREGNANCY

CLINICAL DESCRIPTION

Anaemia in pregnancy is defined as HB of less than 11g/dl, (severe anemia is HB less than 7g/dl at any gestational age).

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Fatigue
  • Shortness of breath on exertion
  • Headache
  • weakness,
  • heart palpitations
  • dizziness
  • Pallor of the skin and mucous membrane.

INVESTIGATIONS

  • FBC or hemoglobin check if FBC not available
  • MPs and MRDT
  • Urine dipsticks, urine, and stool microscopy
  • Peripheral blood film for hematology if at tertiary level.

TREATMENT

PHARMACOLOGICAL

At Health Centre

If HB is < 8 g/dl or any complications, refer to the hospital 

Prevention

  • Provide all antenatal women with Ferrous Sulphate 325mg 12 hourly
  • Advise on diet rich in green leafy vegetable, liver, fish, eggs, red meat
  • To prevent hook worm, give Albendazole (400 mg stat)
  • To prevent malaria, give 2 doses SP (three tablets each dose) 4 weeks apart, starting after quickening (16 weeks’ gestation)
  • Advise to keep adequate interval between pregnancy > 2 years’ minimum
  • All breastfeeding mothers should take iron supplements

At District Hospital

Prevention (as above in Health Centre)

  • FBC and treat according to the result
  • If HB is < 7g/dl especially if symptomatic, then blood transfusion
  • Transfuse rapidly if anemia due to blood loss.
  • Transfuse slowly and with diuretics if chronic anaemia. (To reduce risk of congestive cardiac failure due to sudden circulatory overload.)
  • Treat with ferrous Sulphate/ folic po bd and recheck HB in 2 to 4 weeks.
  • Treat malaria or schistosomiasis if indicated
  • If Haemoglobinopathy (e.g., sickle cell anemia) is suspected, then refer

 

CARDIOVASCULAR DISEASE IN PREGNANCY

CLINICAL DESCRIPTION

Cardiovascular disease (CVD) is a class of diseases that involve the heart muscle, chambers, valves or blood vessels. These may be congenital or acquired.  It is associated with increased risk of maternal morbidity and mortality.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Severe progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, syncope with exertion, chest pain, palpitations, nocturnal cough, sudden reduction in ability to perform ordinary physical activity, increasing dyspnea on exertion, and hemoptysis are associated with CCF, irregular pulse.

INVESTIGATIONS

  • CXR (shielded), ECG, echocardiogram, ABG where available. 

MANAGEMENT

  • All pregnant patients with cardiac disease should be referred to Central Hospital for management.
  • Preconception counselling for known cardiac disease in order to assess risk and optimize treatment (i.e., preconception surgery, family planning)
  • Explain the cardiac anomaly to the patient and its impact on pregnancy

 Antenatal management 

  • Antenatal care visits: regular visits with obstetrician +/- cardiologist
  • Determine the patient's functional capacity (NYHA)
  • For detailed antenatal management refer to O & G protocols and guidelines

Intrapartum management 

  • Admit for vaginal delivery (Caesarean delivery or induction for obstetric indications only).
  • Consult anesthesiologist immediately so that he/she is aware of high-risk patient.
  • Open partograph, monitor vital signs every 30 minutes, and record fetal surveillance.
  • Semi-recumbent position with lateral tilt.
  • Minimize IV fluids- strict monitoring of fluid intake and urine output.
  • Treat with oxygen at 4-6 L/min as needed.
  • Adequate analgesia with Pethidine 100 mg IV or epidural if available.
  • Treat with X-Penicillin 2.4 MU IV 6 hourly and Gentamicin 240mg IV stat, no need for antibiotic in labour.
  • Second stage of labour: assist delivery with vacuum or forceps.
  • Third stage of labour: AMTSL with Oxytocin 10 IU IM (no ergometrine).

Postnatal management 

  • Avoid PPH, anaemia, sepsis, VTE, development of CCF
  • Keep in HDU until > 24hrs after delivery if no complications
  • Keep in postnatal ward at least 48 hours to monitor for complications
  • For patients on anticoagulation, start heparin 6-12 hours after vaginal delivery or 12-24 hours after caesarean delivery
  • Inform pediatrician of maternal history of cardiac disease so that newborn is evaluated for congenital heart disease (i.e., examination, echocardiogram)
  • Contraception: consider surgical sterilization for life-threatening cardiac disease or intrauterine contraceptive devices, may need to avoid estrogen
  • Review mother and infant at 6-week postnatal visit

 

COVID-19 IN PREGNANCY

CLINICAL DESCRIPTION

Acute respiratory infection caused by SARS-CoV-2 virus. There is growing evidence that pregnant women may be at increased risk of severe illness from COVID-19 compared with non-pregnant women, particularly in the third trimester.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Cough, fever, rhinorrhea, headache, anosmia, malaise, diarrhea

INVESTIGATIONS

  • CXR, FBC, RBS

MANAGEMENT

Prevention

  • Vaccination in pregnancy against COVID-19 is strongly recommended and should be offered to all pregnant women

Antenatal care

  • All women should receive care as per WHO guidelines with appropriate PPE for the health care worker
  • Asymptomatic COVID positive patients
    • Refer to Malawi COVID 19 Guidelines 
  • Severe disease: Refer to district or tertiary hospital
    • Refer to Covid19 treatment manual

 

ASTHMA IN PREGNANCY

CLINICAL DESCRIPTION

Reversible airway inflammation and bronchoconstriction.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Asthma is unpredictable in pregnancy: 1/3 of women report improvement, 1/3 remain the same, and 1/3 worsen.
  • Trigger (often viral), chest tightness, shortness of breath, cough, wheezing, tachypnea

INVESTIGATIONS

  • Peak flow meter or spirometry, pulse oximetry

MANAGEMENT 

  • Avoid triggers and use inhaled corticosteroids to decrease underlying inflammation (for detailed information refer to O & G protocols and guidelines and MSTG respiratory conditions section).
  • Antenatal clinics visit monthly if on regular medication.
  • Avoid GERD in 3rd trimester by using Proton Pump Inhibitor or H2 blocker
  • Peak flow meter every 12hrs (first thing in the morning and 12 hrs later) if available
  • For mild - moderate persistent asthma: salbutamol inhaler 1-2 puffs EVERY 8HRS or corticosteroid inhaler (i.e., beclomethasone)
  • For acute and/or severe exacerbations:
    • Admit to HDU
    • O2 therapy to keep SaO2 >95%
    • inhaled bronchodilator (salbutamol, ipromium bromide and normal saline) through a nebulizer or spacer every 10-20 min until improvement seen
    • IV fluids
    • IV Aminophylline 250 mg over 10 min or MGSO4 2g stat
    • Sit up
    • 4-hourly fetal monitoring
    • Systemic steroids (i.e. hydrocortisone or prednisone IV) for up to 5-7 days
    • Continuously assess response to treatment, complete response is resolution of symptoms and PEFR>80%
      • Incomplete response is continuation of symptoms PEFR<80% personal best
      • Urgent intervention required when PEFR <50% personal best
    • Indication for intubation and ventilation: inability to maintain respiratory drive, worsening hypercapnia, respiratory acidosis, confusion and inability to maintain SpO2> 95% despite high flow oxygen

Intrapartum management

  • Refer if at the health centre
  • continue regular inhaler prn
    • Use of IV hydrocortisone if patient has been on oral steroids >7.5mg/day for >2 weeks 
  • 4-hourly fetal monitoring
  • Misoprostol if indication for labour induction
  • Oxytocin if PPH
  • Avoid use of PGF2 and Ergometrine

 

DIABETES IN PREGNANCY

CLINICAL DESCRIPTION

It is a group of metabolic disease characterized by hypersensitivity from defects in insulin secretion, action or both. Can be gestational or preexisting.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • History: Polyuria, polyphagia, polydipsia. Suspect/screen in macrosomia, unexplained IUD, Family Hx of DM, Maternal obesity, excessive weight gain 

At Health Centre

Refer to the next level

At District hospital

Management

Goal is to maintain FBS at 6 - 8 mmol/l for gestational

INVESTIGATIONS

  • RBS, Hb A1C, ophthalmic examination, baseline urine dipsticks for proteinuria, baseline renal function tests.

Note: (It is advisable to manage only uncomplicated diabetes mellitus)

Pregnancy Care

  • Pregnancy counselling: diet, ideal weight, and sugar levels
  • Switch to insulin if unstable on oral drugs

  Antenatally

  • Continue pre- pregnancy regimen if blood sugar is controlled
  • Consider in patient admission for DMS education and glucose control
  • Antenatal care every 2 weeks until 30 weeks gestation, then weekly until delivery
  • Check FBS. If <6mmol/l (108 mg/dl), patient is managed by diet alone
  • If > 6 mmol/l Insulin must be started
  • If first trimester, total daily dose = weight x 0.7 units
  • If second trimester, total daily dose = weight x 0.8 units
  • If third trimester, total daily dose = weight x 0.9 - 1.0 units
  • Given as 2/3 of total daily dose in the morning at breakfast: 1/3 Soluble Insulin and 1/3 as Long-Acting Insulin
  • Given as 1/3 of total daily dose in the evening at dinner (17 hrs): ½ as Long-Acting Insulin
  • For example, for weight of 72 kgs in third trimester, give 16 units Soluble Insulin and 32 units Long-Acting Insulin at breakfast and 12 units Soluble Insulin and 12 units Long-Acting Insulin at supper
  • Ultrasound every 4 weeks

 Intrapartum Management

  • Elective delivery at 38 -39 weeks
  • No specific treatment if labor progresses normally and quickly
  • For induction, or prolonged labor: add 1/3 of her daily insulin as soluble to 1 L of Dextrose Normal Saline (DNS) and treat 40dpm
  • For caesarean: skip A.M. Insulin, start DNS
  • Place Oxytocin in separate bag of Normal Saline (NS) fluid using separate IV access
  • At 39 weeks’ gestation for women with well controlled blood sugar and no vascular disease
  • At earlier gestation for class D and higher, polyhydramnios, macrosomia, poor blood glucose control, Chronic Hypertension on medication or IUGR and IUD
  • Caesarian delivery for EFW > 4S00 on UD

Postnatal period

  • Breastfeeding infant early and notify pediatric clinician of maternal diabetes
  • Use insulin sliding scale for 5 days post vaginal delivery and then resume pre pregnancy regimen
  • Treat with DNS at 3L daily post C/S until tolerating PO and then use insulin sliding scale
  • Advise mothers to start diabetic diet as soon as possible.

Note: COMPLICATED DIABETES (Refer to central hospital)

DYSFUNCTIONAL LABOR SYNDROME

CLINICAL DESCRIPTION

Labor not progressing according to expectation

Causes:

Consider 3 P's:

  • Passenger: macrosomia, malpresentation, malposition
  • Power: inadequate contractions
  • Passage: inadequate pelvis, rickets, pelvic deformities, cephalopelvic disproportion

CLINICAL FEATURES

INVESTIGATIONS

  • If fetal macrosomia or malpresentation suspected, perform an ultrasound scan if available.

TREATMENT

NON-PHARMACOLOGICAL/PHARMACOLOGICAL

Management

  • Explain findings to the mother
  • Ensure adequate pain relief (PCM, pethidine) and hydration
  • Consult senior or refer as soon as possible if at a health centre
  • If contractions are inadequate, then augment labour (refer to O & G protocol and guidelines)
  • If obstructed labour (caput ++, moulding>++, Cervix poorly applied, Bandls ring, maternal and fetal distress) then C/S (refer to C/S section)