Medical Conditions In Pregnancy

Medical Conditions In Pregnancy

Anaemia In Pregnancy 

Anemia is a major intercurrent disease during pregnancy in the tropics. Patients usually have hemoglobin lower than the World Health recommended level of 11.59%. In the tropics any woman with a hemoglobin level of less than 100% is anemic. The level of 10g% though less than the WHO standard is considered adequate in this environment due to poverty, environmental hazards, and poor nutrition. Patients are usually asymptomatic.

Causes of anemia in pregnancy in our environment:

1. Iron deficiency;
2. Sickle cell disease;
3. Folate deficiency;
4. Duodenal ulcer;
5. Hook worm infestation;
6. Renal and liver problems.
7. Malaria;

Deficiency Anaemia 

Iron deficiency occurs when the iron loss is greater than absorption and utilization. Such patients usually give a history of inadequate meat in their diet, bleeding of the gastrointestinal tract, and hookworm infestation

Clinical presentation:-

Although patients are unusually asymptomatic, some features are noticeable

(a) Conjunctival pallor;

(b) Brittle and dry hair;

(c) koilonychia and sometimes atrophic glossitis.

If a sample of the blood is sent to the laboratory the scientist usually sends back the following results;

1. Microcytosis; 
2. Poikilocytosis;
3. Hypochromic;
4. Low serum ferritin;
5. Anisocytosis
6. The haemoglobin will be low.

Treatment:-

A high protein diet, multivitamins and de-worming of the patient is recommended. Antimalaria is also necessary. Specific treatment is by the use of interferon put in 5% Dextrose water. The doctor will determine the quantity of interferon required based on the level of haemoglobin. Alternatively, Intramuscular Jectopher is used. The dosage is  Jectopher 2ml x 7 interferon drip may cause an anaphylactic reaction.

B. FOLATE DEFICIENCY

Folate is concerned with the biosynthesis of purine from amino acids.in hemolytic conditions such as malaria and sickle cell disease, the body,s requirement for folate increases. Patients who present with folate deficiency may give a history of taking canned food, overcooked vegetable, and maybe on drugs such as a phenytoin-an antiepileptic drug. Laboratory Finding:-Beside low hemoglobin the blood show

(a)macropinocytosis;

(b) Normochromic;

(d) Low serum folate.

(c) Some degree of anisocytosis and poikilocytosis;

Treatment:

High protein diets, vegetables, and antimalarial are recommended. A folic acid supplement of 5mg daily is required. In folate deficiency the appropriate dose is 10mg TDS x “s2 then 5mg TDS x 1152 and then 5mg daily supplement for another two weeks. If the patient is vomiting and cannot take orally give intramuscular sodium foliate 15mg daily for ten days.

C/Hook-Worm Infection

The patient gives a history of colicky abdominal pain, nausea, and vomiting with most of the time passage of worm in stool. Weight loss is a feature.

Treatment:- Mebendazole, or Alcopar

In all these cases, if the hemoglobin is too low, blood transfusion is indicated. The general thinking is that patients should not be transfused during or immediately postpartum to avoid circulatory overload. This is because there is pumping of blood from the uterus into the general circulation due to contraction and retraction. It is advised to wait for about twelve hours. This is not usually done in private practice.

Ergometrine is not given to anaemic patients postpartum except if there is postpartum hemorrhage. It is believed that ergometrine shunts blood from the uterus into the general circulation leading to hyper circulation. This too is not done in private practice. Anaemic patients tend to go into heart failure in the puerperium especially if secondarily infected. It is therefore recommended that they be given prophylactic antibiotics.

Sickle Cell Diseases In Pregnancy 

The detailed study of sickle cell diseases is treated later in this article. In pregnancy, they usually present with weakness, lassitude, recurrent attack of jaundice, and bone pain. On examination, they almost always have conjunctival pallor, jaundice, Chronic leg ulcers, prominent facial bone and of course body habitus pointing to that of a sickler. Repeat the patient’s blood group and genotype.

Management:-

The patient is seen in the clinic fortnightly until the 28th week of pregnancy and thereafter weekly till delivery. At each visit to the clinic, history is taken to find out if she has fever, cough, frequency of micturition and dysuria, and also bone pain. Examine for pallor and jaundice. If she has a cough, listen to the chest with a stethoscope to see if there is a chest infection. Palpate the abdomen for liver and spleen and also for the fetus. The doctor will do all these.

If she has frequency and dysuria take midstream urine for microscopy, culture, and sensitivity. Do routine hemoglobin and urinalysis at each visit. Measure the blood pressure too and record.

Treatment:

Routine drug: Folic acid † TDS Daraprint Wkly Broad-spectrum antibiotics for chest infection Urinary antiseptics for urinary tract infection. If a sickler has no problem she is never admitted but where there is severe anaemia and bone pain crises they are admitted. There are three main problems that sicklers face during pregnancy and these are:

1. Anaemia
2. Sequestration crises
3. Bone pain crises

If the blood level falls below 69% especially in the 3rd trimester they should be transfused with AA blood. Packed cells are preferred. If the hemoglobin is less than 48% in the public hospitals, exchange blood transfusion is done but in the majority of private hospitals normal blood transfusion is carried out. In both cases, intramuscular

administration of 40 mg Lasix is advised to avoid transfusion overload. Sickle cells may be sequestrated in the liver and spleen especially during the last month of pregnancy, in labor, and about the fourth day postpartum. This action reduces the haemoglobin by as much as 5g% in twenty-four hours. The best way of replacing the blood is by exchange blood transfusion (EBT) but as usual, the majority of the private clinics will transfuse the patient the normal way. For bone, pain crisis gives aspirin tablets. If this does not relieve the pain, give intramuscular pethidine or tramal. 

Broadspectrum antibiotics are added to the treatment. Check the hemoglobin too to see if she requires a blood transfusion. This is the treatment before the term However at term or shortly before labor, a different regimen is used If she complains of severe bone pain, do measure the blood pressure

and check the urine for protein. Usually, the blood pressure will be and will usually lead to Bone marrow embolism. If this happens, the high and there will be proteinuria. This is known as pseudotoxaemia pregnancy is terminated preferably by cesarean section. Detail of what is done before the pregnancy is terminated especially the place of heparin in the management of the labor is beyond the scope of this content Except for the above, management of the sickler in labor is not significantly different from other labors.

Diabetes in Pregnancy 

If a patient has features suggestive of Diabetes, an oral glucose tolerance test is done early in the first trimester. The patient may be an established diabetic or gestational diabetic where she is diabetic only during pregnancy. She may also be a potential diabetic. Features of potential diabetic are:

1. Gross obesity
2. First-degree family history of diabetes
3. History of big baby
4. Unexplained intrauterine death.

Pregnancy is diabetogenic and therefore insulin requirements increase during pregnancy. Patients who were controlled on diet. And oral hypoglycaemic drugs may now require insulin. This is so because pregnancy produces insulin antagonists such as progesterone, estrogen, cortisol, human placental lactogen, growth hormone, and glucagon.

The following are the effects of diabetes on pregnancy:-

1. Increased incidence of pre-eclamptic toxemia
2. Increased incidence of fetal abnormality
3.  Intrauterine death.
4. Big baby
5. Hydramnios
6. High incidence of operative delivery.

MANAGEMENT

Ensure good control of diabetes. The patient should be regular at the antenatal clinic. She should be seen fortnightly until the 28th week of pregnancy and thereafter weekly till delivery.

• Strict diabetic diet
• At each visit measure the blood pressure and weight. Urinalysis is done to check for sugar and protein
• Fasting blood sugar is done at regular interval
• A weekly blood glucose profile is advised. The blood sugar should never be more than 160mg% in a 5 point glucose profile at 7:30am 11pm, 6pm, and 12 midnight.
• Adequate fetal monitoring.