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11.5 Antenatal Care

Table of Contents

11.5.1 Anaemia in Pregnancy

It is hemoglobin levels less than 11 g/dl in early pregnancy and less than 10.5 g/dl in the 2nd and 3rd trimester of pregnancy. Mild anemia– hemoglobin: 8–11g/dl; Severe anemia– hemoglobin<7g/dl. Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery and perinatal mortality. Severe anaemia with maternal hemoglobin levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation and fetal death. Thus, maternal transfusion should be considered for fetal indications.

Diagnostic Criteria

  • Tiredness, weakness, palpitations and dyspnea
  • Exercise intolerance
  • Pallor of skin and mucous membranes
  • Dizziness, faintness, headache
  • Intermittent claudication (ache, cramp, numbness or sense of fatigue)

Note: Some patients with anaemia in pregnancy may be asymptomatic.

Investigations

  • Full blood count and blood cross-match – red cell morphology
  • Red blood cell electrophoresis if haemoglobinopathies suspected
  • Blood smear for malaria
  • Stool and urine analysis
  • HIV test

Non-pharmacological Treatment

  • Iron rich diet (fish, eggs, fruits and vegetables etc.)
  • Prevent and early treatment of malaria
  • Investigate and treat associated worm infestations

Pharmacological Treatment

Prophylaxis in Antenatal Care

AFerrous sulfate (PO) 200 mg 2–3 times per day

AND

A: Folic acid (PO) 5mg once daily

Note:
Ferrous sulfate should be taken in a full stomach and avoid to take it with tea/coffee
Where vomiting is experienced reduce dosage to tolerable level

If Hb is <7g/dl give:

AFerrous sulfate 200mg (PO), 8 hourly until Hb is 12g/dl

Check If Hb>7 to 11 g/dl change dose to:

A: Ferrous sulfate 200mg (PO) 12 houly for 4 weeks

AND

A: Folic acid (PO) 5mg once a day for 4 weeks AND

C: Vitamin B12 tabs (PO) 12 hourly for 4 weeks

Referral

Refer and transfuse in case of signs of severe anemia.

11.5.2 Hypertensive Disorders in Pregnancy

Hypertension is blood pressure (BP) 140/90 mmHg or greater, measured on two occasions at least four hours apart or elevated systolic BP >30mmHg, or diastolic BP 15mmHg from the baseline.

Chronic Hypertension

This is hypertension that is present at the booking visit or before 20 weeks or if the woman is already hypertensive before conception. Most women with chronic hypertension are asymptomatic. New onset chronic hypertension should have further evaluation to find underlying cause e.g. renal artery stenosis, chronic renal disease, Cushing syndrome etc.

Pharmacological Treatment

B: Methyldopa 250–500mg (PO) 8 hourly

AND

C: Nifedipine 10mg (PO) 12 hourly

Pregnancy induced hypertension

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks gestation without the presence of protein in the urine or other signs of preeclampsia.

Non-pharmacological Treatment

  • Adequate rest at home and avoid strenuous activities
  • Eat a normal balanced diet and plenty of oral fluids
  • Schedule antenatal visits every 2 weeks up to 32 weeks and every week thereafter
  • Recommend to deliver in the hospital and should be delivered at 37 completed weeks of gestation

Pharmacological Treatment

For mild hypertension 140–149 mmHg systolic and/or 90–99 mmHg diastolic; Moderate hypertension 150–159 mmHg and/or 100–109 mmHg.

B: Methyldopa 250–500mg (PO) 8 hourly

OR

C: Nifedipine 10mg (PO) 12 hourly

OR

For moderate hypertension you may give:

C: Labetalol 100mg (PO) twice a day

C: Labetalol 100mg (PO) twice a day

Severe hypertension

Severe hypertension is Blood Pressure (BP) of 160/110 mmHg or higher. Admit the patient to hospital until blood pressure is 159/109 mmHg or lower

C: Hydralazine 10mg IV start; recheck the BP after 20 minutes if DBP is more/equal to

110mmHg give another dose of 5–10mg hydralazine IV.

AND

B: Methyldopa 500mg (PO) 8 hourly

OR

C: Nifedipine 20mg (PO) 12 hourly

THEN

C: Labetalol tabs 100mg (PO) twice a day

Referral

Refer to the next level in case there is no improvement

Pre-eclampsia

Is diagnosed when blood pressure is ≥ 140/90 mmHg after 20 weeks of pregnancy plus proteinuria of 300 mg per 24 hours or >2+ on urine dipstick

Diagnostic Criteria

  • Most patients are asymptomatic, but symptoms may include headaches, dizziness, blurred vision, and epigastric pain.
  • Blood pressure of ≥ 140/90 mmHg
  • Proteinuria (≥ 300mg per 24 hours)
  • Generalized edema

Investigations

  • Proteinuria (qualitative/quantitative 24 hour urine collection)
  • Obstetrical Ultrasound and Doppler
  • Urea, creatinine, electrolytes, liver function test and uric acid
  • FBC and clotting profile
  • Funduscopic

Mild pre–eclampsia

This is diagnosed when 90 mmHg ≤ diastolic BP < 110 mmHg; Proteinuria 1+ or 2+

Non–pharmaceutical Management

Pregnancy < 37 weeks of gestation

  • Hospitalization and close monitoring
  • Bed rest
  • Monitoring BP, diuresis, proteinuria, fetal movement and fetal heart beats (every day)
  • Antenatal corticosteroids (dexamethasone Inj. 6mg 12hourly for 48hours) if indicated

Pregnancy >37 weeks of gestation: admission and deliver.

Severe pre-eclampsia (critical care):

This is diagnosed when BP ≥ 160/110 mmHg (especially diastolic ≥110 mmHg),

Proteinuria ≥+++or ≥ 1g/24h, severe headache, epigastric pain, blurring of vision +/_vomiting

Pharmacological Treatment

C: Hydralazine injection: initial dose of 5 mg IV in 10ml sterile water over 4 minutes. Followed by boluses 5–10mg as needed every 20 minutes until when the diastolic BP is less than 110mmHg)

OR

A: Nefedipine: 20 mg (PO) 8 hourly until BP is stabilized

OR

A: Nefedipine: 10 mg (PO) short acting if diastolic blood pressure is ≥ 110mmhg

OR

C: Labetalol if hypertension is refractory to hydralazine

Give 10–20mg intravenously bolus repeat each 10–20 minutes, with doubling doses not exceeding 80 mg in any single dose for maximum total cumulative dose of 300 mg.

Prophylaxis for Seizures

Anti-convulsion treatment of choice is magnesium sulfate (Refer to eclampsia section) LoE=1

Obstetrical Management

If at term deliver immediately when stable, preferably vaginal delivery

11.5.3 Eclampsia

Eclampsia is a condition peculiar to pregnancy and post-partum periods, characterized by elevated BP and tonic-clonic convulsions which are not caused by epilepsy, severe malaria, meningitis, hypoglycemia or other causes of convulsions. It is common in nonwhite nulliparous women from low socioeconomic status. Majority (50%) occur preterm. Eclampsia may occur without prior elevation of BP.

Diagnostic Criteria

  • Signs of severe pre-eclampsia (BP > 160/110mm Hg)
  • Loss of consciousness
  • Tonic-clonic seizures, coma

Investigations

  • Full blood count and cross-match
  • Ultrasound
  • Urea and creatinine + electrolytes
  • Liver enzymes tests
  • 24h urine collection for proteinuria
  • Clotting profile
  • Blood smear to exclude malaria
  • Blood sugar estimation to exclude hypoglycemia.

Pharmacological Treatment

A: Magnesium Sulfate (MgSO4)

  • Loading dose 4g IV slowly using one 20mls syringe
  • Draw 8mls of 50% MgSO4
  • Add 12mls water for injection to make it 20mls of 20% of MgSO4 and
  • Give IV slowly over 5 minutes OR use two 10mls syringes
  • Draw 10mls (5gms) of 50% MgSO4 into each syringe
  • Add 1ml of:

    C: 2% lignocaine in each syringe then give deep IM into each buttock

Maintenance dose for 24hours:

Infusion of MgSO4 1g per hour (in 200–300 ml of Ringer’s Lactate), or 5g undiluted 50% of MgSOinjection (add 1ml of lignocaine 2%) apply deep intra-muscular (IM) injection into each buttock every 4hrs for about 24 hrs after delivery or the last seizure whichever come last.16

  • The infusion should only be given if patellar reflexes are present, respiration rate is ≥ 12 per minute, and urine output is >100mls in 4 hours.
  • Seizure prophylaxis should be continued for 24–48 hours post delivery

If convulsions recur within 15 minutes give;

A: Magnesium sulfate 2g. Draw 4mls of 50% of MgSO4 (2gm), add 6mls of water for injection to make it 10mls of 20% MgSOthen give IV slowly over 5 minutes16.

Antidote for magnesium sulfate toxicity

C: Calcium gluconate 1g slow IV bolus in 2 to 3 minutes

Note: Contra–indications of magnesium sulfate are; myasthenia, respiratory insufficiency, cardiomyopathy, oligo– anuria. Monitor respiratory rate (> 16 breaths/min), urine output, consciousness, deep tendon reflexes and magnesium sulfate serum levels (where possible)

Obstetrical management

Patients with eclampsia should be delivered within 12 hours after the onset of seizures, even if the foetus is premature. Expectant management is contraindicated. If not in labour, induce labour with misoprostol 50µg PO or 25µg vaginally and repeat every 4 hours up to a total of four doses maximum 11, 5

  • If failure of induction, immediate Caesarean section is indicated
  • If the pregnancy is 32–34 weeks and no labor – stabilize and administer IM steroids for lung maturity and vaginal delivery is preferred after 24–48 hours of treatment, give:

A: Dexamethasone 6 mg IM 12 hourly in 48 hours

If the pregnancy is less than 32 weeks Caesarean section is preferred as the success of induction

11.5.4 Antiphospholipid Antibody Syndrome (APLAS) in Pregnancy

It is an autoimmune disease characterized by the presence of maternal circulation of one or more auto antibodies against membrane phospholipids. It is an acquired condition.

Diagnostic Criteria

  • Recurrent pregnancy loss (≥3 unexplained first trimester losses) or ≥1 unexplained second trimester pregnancy loss
  • Unexplained venous or arterial thrombosis or myocardial infarction
  • Autoimmune thrombocytopenia
  • Unexplained Intra Uterine Growth Restriction (IUGR), abruption placenta and severe early preeclampsia (No agreement among experts, remains controversial in all three)7

Diagnosis depends on correct clinical staging and serologic tests.

Investigations

At least 2 tests confirming the presence of circulating antiphospholipid antibodies is required to make the diagnosis of APLAS. Women with recurrent pregnancy loss (≥3 pregnancy losses) before 10 weeks gestation should be screened for APLAS.

Serology tests:

  • Anticardiolipin Antibody (ACL)
  • Lupus Anticoagulant (LAC). (tests include activated PTT test, Dilute Russel viper venom test, Kaolin clotting time)

Pharmacological Treatment

  • Depends on the clinical features. The target international normalized ratio (INR) for vitamin K antagonist (VKA) therapy in APS should normally be 2.5 (target range 2.0–3.0) (1A).
  • For women with APS with recurrent (≥3) pregnancy loss, antenatal administration of heparin combined with low dose aspirin is recommended throughout pregnancy (1B). In general, treatment should begin as soon as pregnancy is confirmed.
  • For women with APS and a history of pre-eclampsia or fetal growth restriction (FGR), low dose aspirin is recommended.
  • Women with aPL should be considered for post-partum thromboprophylaxis (1B).

Recurrent Pregnancy loss

D: Prophylactic Unfractionated Heparin 5000– 10000 SC

OR

D: Low Molecula Weight Heparin (Enoxaparin) 30–40mg SC daily

OR

D: Dalteparin 2500–5000u SC daily starting in first trimester

Patients with Thrombosis such as stroke or pulmonary embolism need therapeutic anticoagulation.

D: Unfractionated Heparin (SC) 5,000 bolus and subsequent 15,000– 20,000 doses at 12 hourly interval

OR

D: Low Molecular Weight Heparin (Enoxaparin) SC 1mg/kg 12 hourly

Note:
The aPTT needs to be checked and is best done midway between the 12–hourly doses, once every 24 hours.
A target of 1.5–2.5 times the control should be aimed

Referral

Refer immediate to a level where monitoring of the treatment through lab testing is available.

11.5.5 Deep Vein Thrombosis in Pregnancy

It is one of the major causes of maternal deaths

Diagnostic Criteria

  • Pain
  • Swelling or redness of the calf or thigh
  • Homan’s sign (pain in the calf in response to dorsiflexion of the foot)

Investigations

  • Venous ultrasound
  • Venography

Pharmacological Treatment

D: Unfractionated heparin (UFH) is the treatment of choice5
Loading dose 100U/kg (or minimum of 5000 U) followed by initial infusion 15-25 U/kg/hour (or minimum of 1000U/hour)

Note: Check PTT every 4 hours and PTT should be maintained at 1.5–2.5 X control. Once steady state has been achieved measure PTT levels daily. Change heparin to SC route after 5–10 days

Referral

Immediate referral to a hospital where monitoring of the treatment through lab testing is available is recommended

11.5.6 Pulmonary Embolism in Pregnancy

It is blockage, usually a blood clot, prevents oxygen from reaching the tissues of the lungs; it can be life-threatening

Diagnostic Criteria

  • Acute onset of shortness of breath (dyspnea)
  • Pleuritic chest pain
  • Cough and/or hemoptysis
  • Low grade fever
  • Tachypnea
  • Diminished oxygen saturation
  • Diminished breath sounds

Investigations

  • Venous ultrasound
  • Pulmonary angiography

Pharmacological Treatment

D: Unfractionated heparin (UFH) is the treatment of choice

  • Loading dose 150 U/kg (or minimum of 5000 U) followed by
  • Initial infusion 15–25 U/kg/hour (or minimum of 1000U/hourly)

Note: Check PTT every 4 hours and adjust infusion to maintained PTT at 1.5–2.5 X control. Once steady state has been achieved measure PTT levels daily. Change heparin to SC route after 5–10 days to avoid formation of hematoma.

Referral

Immediate referral to a health facility where monitoring of the treatment through lab tests is available is recommended

11.5.7 Vomiting in Pregnancy and Hperemesis Gravidarum

It is severe nausea and vomiting in early pregnancy requiring hospital admission and rehydration.

Diagnostic Criteria

  • Weight loss
  • Nausea and vomiting typically in early pregnancy
  • Dehydration
  • Altered general status (fast pulse, restlessness)

Investigations

  • Full blood count
  • Blood for urea, electrolytes and serum creatinine
  • Urinalysis, micro urine and culture, ketonuria
  • Liver function tests
  • Thyroid function tests
  • Obstetric ultrasound

Non-pharmacological Treatment

  • Nil per oral (nothing by mouth) for 24–48 hrs.
  • Input/output for 24–48 hrs.
  • Monitor electrolytes for 24hrs
  • Counselling
  • Reassurance
  • Emotional support
  • Rest
  • Life style adjustment
  • Ensure adequate hydration
  • Frequent small carbohydrate meal

Pharmacological Treatment

A: Ringers Lactate with Normal Saline according to daily needs and severity.

AND

CVitamin B1 (Thiamine100mg per day mix in intravenous rehydration solution

AND

C:Metoclopramide: IM 5–10 mg 8 hourly till vomiting stops.

OR

A: Promethazine (IM) 12.5 mg twice daily

Referral: Depends on the status of the patient, refer to a hospital if vomiting is intractable and if there is a need for high volume replacement.

11.5.8 Heartburn in Pregnancy

Heartburn (also called acid indigestion or acid reflux) is a burning sensation that often extends from the bottom of the breastbone to the lower throat. It is caused by some of the hormonal and physical changes in pregnant women

Management

Pregnant women should avoid:

  • Food and beverages that cause gastrointestinal distress
  • Tobacco and alcohol
  • Do not eat big meals, instead eat several small meals throughout the day
  • Drinking large quantities of fluids during meals
  • Do not eat close to bedtime, they should give themselves 2–3 hours to digest food before they lie down
  • Sleep propped up with several pillows or a wedge. Elevating upper body will help keep the stomach acids where they belong and will aid food digestion.

Pharmacological treatment

A: Omeprazole (PO) 20–40mg per day

OR

D: Pantoprazole 40mg per day

OR

A: Magnesium trisilicate(PO) as needed until when the heartburn subsides.

11.5.9 Other Medical Disorders in Pregnancy

Other medical disorders in pregnancy/other gynecological disorders include diabetes mellitus, glucose intolerance, malaria, HIV/AIDs complications, Pelvic Inflammatory Diseases (PID) etc. All these complications are discussed under specific disease chapters

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