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

1. 13
Medical
problems during
pregnancy,
labour and the
puerperium
Before you begin this unit, please take the URINARY TRACT
corresponding test at the end of the book to
assess your knowledge of the subject matter. INFECTION DURING
PREGNANCY
Objectives
13-1 Which urinary tract infections
When you have completed this unit you are important during pregnancy?
should be able to: 1. Cystitis.
• Diagnose and manage cystitis. 2. Asymptomatic bacteriuria.
• Reduce the incidence of acute 3. Acute pyelonephritis.
pyelonephritis in pregnancy.
• Diagnose and manage acute 13-2 Why are urinary tract infections
pyelonephritis in pregnancy. common during pregnancy
and the puerperium?
• Diagnose and manage anaemia during
pregnancy. 1. Placental hormones cause dilatation of the
ureters.
• Identify patients who may possibly have
2. Pregnancy suppresses the function of the
heart valve disease. immune system.
• Manage a patient with heart valve
disease during labour and the
A urinary tract infection is the most common
puerperium.
infection during pregnancy.
• Manage a patient with diabetes mellitus.

2. 244 MATERNAL CARE
13-3 How should you diagnose cystitis? 13-6 Why is asymptomatic bacteriuria
during pregnancy important?
1. These severe urinary symptoms suddenly
appear: 1. Between 6 and 10% of pregnant women
• Dysuria (pain on passing urine). have asymptomatic bacteriuria.
• Frequency (having to pass urine often). 2. One third of these patients with
• Nocturia (having to get up at night to asymptomatic bacteriuria will develop
pass urine). acute pyelonephritis during pregnancy.
2. The patient appears generally well with 3. If patients with asymptomatic bacteriuria
normal observations. The only clinical sign are diagnosed and correctly managed, their
is tenderness over the bladder. risk of developing acute pyelonephritis will
3. Examination of the urine under a be reduced by 70%.
microscope shows many pus cells and
bacteria.
The diagnosis and treatment of asymptomatic
A midstream urine sample for culture must bacteriuria will greatly reduce the incidence of
be collected, if possible, to confirm the acute pyelonephritis during pregnancy.
clinical diagnosis. Treatment must commence
immediately without waiting for the results of
the culture.. 13-7 How and when should patients be
screened for asymptomatic bacteriuria?
13-4 How should you manage If possible, bacterial culture of a midstream
a patient with cystitis? urine sample should be done at the first
antenatal visit to screen patients for
Give four adult tablets of co-trimoxazole (e.g.
asymptomatic bacteriuria.
Bactrim, Cotrim, Durobac, Mezenol or Purbac)
as a single dose. This is also the drug of choice NOTE A culture medium prepared by a
for patients who are allergic to penicillin. laboratory, or a commercially prepared culture
Amoxycillin (Amoxil) 3 g as a single dose medium, is inoculated with urine and then
incubated for 12 to 24 hours to determine
orally could also be used but organisms
whether bacteriuria is present or not.
causing cystitis are often resistant to this
antibiotic. The treatment will be more
successful if two amoxycillin capsules (250 mg) If possible, a screening test for asymptomatic
are replaced with two Augmentin tablets that bacteriuria should be done at the first antenatal
contain 125 mg clavulanic acid each. visit.
A midstream sample should again be sent
for microscopy, culture, and sensitivity at the 13-8 Can reagent strips be reliably used
next antenatal visit to determine whether the to diagnose asymptomatic bacteriuria?
management was successful.
No. Tests for nitrites (which detect the
Co-trimoxazole can be safely used during presence of bacteria) and leukocytes, separately
pregnancy, including the first trimester. or together, cannot be used to accurately
screen for asymptomatic bacteriuria.
13-5 What is asymptomatic bacteriuria?
It is significant colonisation of the urinary 13-9 What is the management of a
tract with bacteria, without any symptoms of a patient with asymptomatic bacteriuria?
urinary tract infection. The same as the management of a patient
with cystitis, i.e. four adult tablets of co-
trimoxazole (e.g. Bactrim, Cotrim, Durobac,

3. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 245
Mezenol or Purbac) as a single dose or eight-hourly. All antibiotics must be
amoxycillin (Amoxil) 3 g as a single dose. given intravenously until the patient’s
Patients who are allergic to penicillin should temperature has been normal for 24
be given co-trimoxazole. hours. Oral cefuroxime (Zinnat) can
then be given until a course of ten days of
A midstream specimen of urine should again
antibiotics has been completed.
be sent for culture at the next antenatal visit
5. Pethidine 100 mg is given intramuscularly
to determine whether the management was
for severe pain while paracetamol
successful.
(Panado) two adult tablets can be used for
moderate pain.
13-10 What symptoms suggest 6. Paracetamol (Panado) two adult tablets,
acute pyelonephritis? together with tepid sponges, are used to
1. Most patients have severe general bring down a high temperature.
symptoms
• Headache. NOTE If the bacterial culture from the urine is
positive, the antibiotic may need to be changed,
• Pyrexia and rigors (shivering).
depending on the sensitivity of the bacteria.
• Lower backache, especially pain over
the kidneys (renal angles).
2. Only 40% of patients have urinary Patients with acute pyelonephritis during
complaints. pregnancy must be admitted to hospital for
treatment with a broad-spectrum antibiotic.
13-11 What physical signs are usually found
in a patient with acute pyelonephritis?
13-13 Why is acute pyelonephritis a
1. The patient is acutely ill. serious infection in pregnancy?
2. The patient usually has high pyrexia and
Because serious complications can result:
a tachycardia. However, the temperature
may be normal during rigors. 1. Preterm labour.
3. On abdominal examination, the patient 2. Septic shock.
is tender over one or both kidneys. The 3. Perinephric abscess (an abscess around the
patient is also tender on light percussion kidney).
over one or both renal angles (posteriorly 4. Anaemia.
over the kidneys).
Septic shock usually presents with continuing
hypotension in spite of adequate intravenous
13-12 What is the management of a fluids. There is also failure of the clinical signs
patient with acute pyelonephritis? of acute pyelonephritis to improve rapidly
1. The patient must be admitted to hospital. within the first 72 hours of treatment. If septic
2. A midstream urine sample for microscopy, shock is diagnosed, intravenous gentamicin
culture and sensitivity must be collected, if 80 mg must be given immediately, followed by
possible, to confirm the clinical diagnosis, a further 80 mg every eight hours. Gentamicin
identify the bacteria and determine the (Garamycin) must be added to any other
antibiotic of choice. antibiotic already given. The patient must also
3. An intravenous infusion of Balsol or be transferred to a level 3 hospital.
Ringer’s lactate should be started and
one litre given rapidly over two hours.
Thereafter, one litre of Maintelyte should
be given every eight hours.
4. Broad-spectrum antibiotics must be
given, i.e. cefuroxime (Zinecef) 750 mg

4. 246 MATERNAL CARE
13-14 What should be done at the first The size and colour of the red cells indicate the
antenatal visit after the patient has probable cause of the anaemia:
been treated for acute pyelonephritis?
1. Microcytic, hypochromic cells suggest iron
1. A midstream urine sample for culture and deficiency.
sensitivity must be collected to determine 2. Normocytic, normochromic cells suggest
whether the treatment has been successful. bleeding or infection.
2. The haemoglobin concentration must be 3. Macrocytic, normochromic cells suggest
measured as there is a risk of anaemia folate deficiency.
developing.
13-18 What is the management
of patients with iron deficiency in
ANAEMIA IN PREGNANCY pregnancy or the puerperium?
1. The management of iron-deficiency
13-15 What is the definition of anaemia in pregnancy will depend on
anaemia in pregnancy? the haemoglobin concentration and the
A haemoglobin concentration of less than duration of pregnancy.
11 g/dl. • If the haemoglobin concentration is
less than 8 g/dl, the gestational age is
less than 36 weeks, and the patient is
13-16 What are the dangers of anaemia? asymptomatic, she can be treated with
1. Heart failure, which can result from severe two tablets of ferrous sulphate three
anaemia. times a day and be followed at the
2. Shock, which may be caused by a relatively antenatal clinic.
small vaginal blood loss (antepartum • If the haemoglobin concentration is
haemorrhage, delivery or postpartum less than 8 g/dl and the gestational age
haemorrhage) in an anaemic patient. is 36 weeks or more, the patient must
be admitted to hospital for a blood
13-17 What are the common causes transfusion.
of anaemia in pregnancy? • All patients with a haemoglobin
concentration of less than 8 g/dl who
1. Iron deficiency as the result of a diet poor are short of breath or have a tachycardia
in iron. of more than 100 beats per minute
2. Blood loss during pregnancy (also during (signs of heart failure) must be admitted
labour or the puerperium). to hospital for a blood transfusion.
3. Acute infections (e.g. pyelonephritis), • If the haemoglobin concentration is
chronic infections (e.g. tuberculosis and between 8 g/dl and 10 g/dl, the patient
HIV), and infestations (e.g. malaria, can be treated with two tablets of
bilharzia or hook worm) in regions where ferrous sulphate three times a day. If
these occur. the haemoglobin concentration does
4. Folic-acid deficiency is less common. not increase after two weeks or the
patient is 36 weeks pregnant or more,
The commonest cause of anaemia in pregnancy is and a full blood count has not yet been
iron deficiency. done, then a full blood count must be
done to decide whether the cause of the
anaemia is iron deficiency.
A full blood count, which is sent to the
• If the haemoglobin concentration is
laboratory, will usually identify the probable
10 g/dl or more, but less than 11 g/dl,
cause of the anaemia.

5. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 247
the patient can be treated with one tablet keep their iron tablets in a safe place where
of ferrous sulphate three times a day. children cannot reach them.
In the case of the first three points above,
a full blood count must be done. The size 13-20 How are iron supplements
and colour of the red blood cells will help given in pregnancy?
in determining the cause of the anaemia.
2. The management of a patient with iron- As 200 mg ferrous sulphate tablets.
deficiency anaemia during the puerperium 1. Patients with a haemoglobin
will depend on whether the patient is concentration of 11 g/dl or higher must
bleeding or not. take one tablet daily.
• If the patient is not bleeding, if she 2. Patients who are anaemic must be correctly
has no signs of heart failure, and her managed.
haemoglobin concentration is 6 g/dl
or more, she can be treated with oral 13-21 What side effects can be caused
iron tablets. One tablet of ferrous by ferrous sulphate tablets?
sulphate three times daily for a month
is sufficient. Nausea and even vomiting due to irritation of
• If the patient is not bleeding and she the lining of the stomach.
has signs of heart failure, or if her
haemoglobin concentration is less than 13-22 How should you manage a
6 g/dl, she must be admitted to hospital patient who complains of side effects
and given a blood transfusion to be due to ferrous sulphate tablets?
followed by oral iron for a month.
1. The tablets should be taken with meals.
• If the patient is bleeding, she should
Although less iron will be absorbed, the
be managed for a postpartum
side effects will be less.
haemorrhage.
2. If the patient continues to complain of side
The management of a patient with iron- effects, she should be given 300 mg ferrous
deficiency anaemia during the puerperium is gluconate tablets instead. They cause fewer
summarised in flow diagram 13-1. side effects than ferrous sulphate tablets.
13-19 Should all patients receive
iron supplements in pregnancy?
HEART VALVE DISEASE
1. Well-nourished patients who have
IN PREGNANCY AND
a healthy diet and a haemoglobin THE PUERPERIUM
concentration of 11 g/dl or more, do not
need iron supplements. Heart valve disease consists of damage to,
2. Patients who are poorly nourished, or abnormality of, one or more of the valves
have a poor diet or have a haemoglobin of the heart. Usually the mitral valve is
concentration of less than 11 g/dl need damaged. The cause of heart valve disease in a
iron supplements. developing country is almost always rheumatic
3. Patients from communities where iron fever during childhood.
deficiency is common, or where socio-
economic circumstances are poor, should 13-23 Why is it important during
receive iron supplements. pregnancy to identify patients with
Iron tablets are dangerous to small children heart valve disease in pregnancy?
as even one tablet can cause serious iron 1. A correct diagnosis of the type of heart
poisoning. Therefore, patients must always valve disease and good management of

6. 248 MATERNAL CARE
Hb less than
11 g/dl
Hb less than Hb 8 or more, Hb 10 g/dl
8 g/dl but less than or more
10 g/dl
1. Ferrous sulphate
Full blood count Full blood count
tablets
2. Primary care
Yes Duration of Duration of No 1. Ferrous sulphate
pregnancy 36 weeks pregnancy 36 weeks tablets
or more? or more? 2. Full blood count
two weeks later
No Yes
Admit to hospital Yes Shortness of Yes
for blood breath or
transfusion tachycardia?
No
No
1. Ferrous suplate tablets Increase
2. Clinic for high-risk patients in Hb?
Flow diagram 13-1: The management of a patient with iron-deficiency anaemia in pregnancy

7. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 249
the problem reduces the risk to the patient 3. The follow-up visits will also be at the
during her pregnancy. high-risk antenatal clinic. However, the
2. Undiagnosed heart valve disease and patient may be referred to the primary-care
inadequate treatment may result in serious antenatal clinic for some ‘in between’ visits.
complications (e.g. heart failure causing Take care to follow the instructions from
pulmonary oedema) which may threaten the high-risk clinic carefully.
the patient’s life. 4. Patients who are not hospitalised should
3. A clear family-planning plan must be made stop work earlier and rest more than usual.
during the pregnancy. The patient may 5. The patient must be told to report
have a reduced lifespan and cannot risk immediately if she experiences any
having a large family. symptoms of heart failure, e.g. worsening
shortness of breath or tiredness.
6. The patient must be delivered at least in a
Correct diagnosis and good management reduce secondary level hospital where specialist
the risk to the patient of heart valve disease in care is available.
pregnancy.
13-26 How should patients with
13-24 Which symptoms in a heart valve disease be managed
patient’s history suggest that she in the first stage of labour?
may have heart valve disease?
1. All patients must be delivered in hospital
1. Shortness of breath on exercise or even because of the risk of pulmonary oedema.
with limited effort. 2. The patient should lie on her side with
2. Coughing up blood (haemoptysis). her upper body raised with pillows to
3. Often the patient has previously been told 45 degress.
by a doctor that she has a ‘leaking heart’. 3. Good analgesia is important to ensure that
4. Some patients with heart valve disease the patient does not become exhausted.
give a history of previous rheumatic fever. 4. A slow intravenous infusion of
However, most patients are not aware 200 ml saline should be started, using a
that they have suffered from previous minidropper to make sure that not too
rheumatic fever. much fluid is given.
5. Ampicillin 1 g and gentamicin 80 mg
The cause of heart valve disease in a developing
are given intravenously as prophylaxis
country is almost always previous rheumatic
against infective endocarditis. These
fever. However, these patients usually do not
antibiotics should be repeated eight-hourly
know that they have had one or more attacks
for another two doses. Patients who are
of rheumatic fever during childhood.
allergic to penicillin should be given
During the examination of the cardiovascular erythromycin 500 mg instead of ampicillin.
system, a cardiac murmur will be heard if the
patient has heart valve disease. 13-27 How should patients with
heart valve disease be managed
13-25 How should a patient with heart in the second stage of labour?
valve disease in pregnancy be managed?
1. The patient must be managed with her
1. The patient must be referred to the high- upper body raised with pillows to 45
risk antenatal clinic. degrees.
2. At the high-risk antenatal clinic the type 2. There should be good progress with
of lesion and correct management will be effective maternal effort to ensure a short
determined. and easy second stage. Otherwise, an
assisted delivery must be done.

8. 250 MATERNAL CARE
3. If indicated, an episiotomy should be done
There is a high risk of pulmonary oedema in the
to ensure a short and easy second stage.
third stage of labour and for the first 24 hours
4. The patient’s legs must not be placed in
the normal lithotomy position as this may of the puerperium in patients with heart valve
cause pulmonary oedema. If the lithotomy disease.
position is needed, the patient should place
her feet on two chairs which are at a lower 13-30 What form of family planning should
level than the bed. be offered to patients with heart valve
disease who have completed their families?
13-28 How should patients with
A postpartum sterilisation should be done.
heart valve disease be managed
Because of the risk of heart failure, the
in the third stage of labour?
procedure must be postponed until the third
This is a very dangerous time for a patient with day after delivery. Patients who are willing
heart valve disease as there is an increased and are prepared to return for the procedure,
risk of pulmonary oedema. Therefore, careful can have a laparoscopic sterilisation done six
attention must be paid to the following: weeks after delivery. Meanwhile, an injectable
contraceptive must be given.
1. Syntometrine or ergometrine must not
be given as they increase the risk of
pulmonary oedema.
2. Oxytocin may be given. Ten units are given DIABETES MELLITUS
intramuscularly. IN PREGNANCY
3. The third stage of labour should be actively
managed.
13-31 Why is it important to diagnose
diabetes if it develops in pregnancy?
Any drug containing ergometrine is absolutely
contraindicated in the third stage of labour and Diabetes mellitus is a disorder which is caused
the first 24 hours of the puerperium if the patient by the secretion of inadequate amounts of
has heart valve disease. insulin from the pancreas to keep the blood
glucose concentration normal. As a result,
the blood glucose concentration becomes
13-29 What is important in the puerperium abnormally high. Diabetes may often present
in patients with heart valve disease? for the first time in pregnancy, and may then
The risk of pulmonary oedema during the first recover spontaneously after delivery. The early
24 hours of the puerperium is great. Therefore, diagnosis and good management of diabetes in
attention must be paid to the following: pregnancy will greatly reduce the incidence of
complications.
1. During the first 24 hours of the
puerperium the patient must be carefully
observed for signs of pulmonary oedema, The early diagnosis and good management of
i.e. tachypnoea (breathing fast), dyspnoea diabetes in pregnancy will greatly reduce the
(shortness of breath) and crepitations in incidence of complications.
the lungs.
2. The course of prophylactic antibiotics must
13-32 What complications may be caused
be completed.
by diabetes in pregnancy if it is not
diagnosed early and is not well managed?
1. Throughout the pregnancy infections are
common, especially:

9. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 251
• Candida vaginitis.
Patients with repeated or marked glycosuria
• Urinary tract infection.
during pregnancy must always be investigated
2. During the first trimester congenital
abnormalities may occur in the developing further for diabetes.
fetus due to the raised blood glucose
concentration. 13-35 Is a reagent strip accurate
1. During the third trimester pre-eclampsia enough to measure a random
and polyhydramnios are common. blood glucose concentration?
2. The fetus may be large if the patient’s
Yes, if an electronic instrument (Glucometer
diabetes has been poorly controlled during
or Reflolux) is used to measure the blood
the pregnancy, resulting in problems
glucose concentration. However, a reagent
during labour and delivery, mainly:
strip alone may not be accurate enough.
• Cephalopelvic disproportion.
Therefore, a sample of blood must be sent
• Impacted shoulders.
to the nearest laboratory for a blood glucose
5. During the third stage of labour there is an
measurement, if an instrument is not available.
increased risk of postpartum haemorrhage.
6. The newborn infant is at increased
risk of many complications, especially 13-36 Is it possible that a patient with
hypoglycaemia and hyaline membrane an initially normal blood glucose
disease. concentration may develop an abnormal
concentration later in pregnancy?
13-33 How can complications which Yes. This may be possible due to an increase
commonly occur in diabetics during in the amount of placental hormones as
pregnancy and labour be avoided? pregnancy progresses. Placental hormones
tend to increase the blood glucose
These complications can largely be avoided by:
concentration, explaining why some patients
1. Early diagnosis. only become diabetic during their pregnancies.
2. Good control of the blood glucose
concentration. 13-37 How should random
blood glucose measurements be
Early diagnosis and good control of the blood interpreted and how do the results
glucose concentration will prevent most of the determine further management?
pregnancy and labour complications caused by A random blood glucose measurement is done
diabetes. on a blood sample taken from the patient at
the clinic without any previous preparation,
i.e. the patient does not have to fast. However,
13-34 How can diabetes be diagnosed
patients who have had nothing to eat during
early if it should develop for the
the previous four hours should be encouraged
first time during pregnancy?
to eat something before the test.
1. At every antenatal visit all patients should
1. A random blood glucose concentration
routinely have their urine tested for glucose.
of less than 8 mmol/l is normal. These
2. A random blood glucose concentration
patients can receive routine primary care.
must be measured if the patient has 1+
However, if glycosuria is again present, a
glycosuria or more at any antenatal visit.
random blood glucose measurement must
be repeated.
2. A random blood glucose concentration of
8 mmol/l or more, but less than 11 mmol/l,
may be abnormal and is an indication

10. 252 MATERNAL CARE
to measure the fasting blood glucose
A patient with a normal blood glucose
concentration. The further management of
concentration early in pregnancy may develop
the patient will depend on the result of the
fasting blood glucose concentration. diabetes later during that pregnancy.
3. A random blood glucose concentration
of 11 mmol/l or more is abnormal and 13-39 How is a glucose profile obtained?
indicates that the patient has diabetes.
The patient must have nothing to eat or
These patients must be admitted to hospital
drink (except water) from midnight. At 08:00
to have their blood glucose controlled.
the next day a sample of blood is taken and
Thereafter, they must remain on treatment
the fasting blood glucose concentration is
and be followed as high-risk patients.
measured. Immediately afterwards she has
breakfast (which she can bring with her to
13-38 How should fasting blood the clinic). After two hours the blood glucose
glucose measurements be interpreted concentration is measured again.
and how do the results determine
further management?
13-40 How should the glucose profile
The patient must have nothing to eat or drink be interpreted and how do the results
(except water) from midnight. At 08:00 the next determine further management?
day a sample of blood is taken and the fasting
1. A fasting blood glucose result of less than
blood glucose concentration is measured:
6 mmol/l and a two hour result of less than
1. A fasting blood glucose concentration 8 mmol/l are normal. These patients can be
of less than 6 mmol/l is normal. These followed up as intermediate-risk patients.
patients can receive routine primary 2. A fasting blood glucose result of
care. If their random blood glucose 6 mmol/l or more and/or a two hour
concentration is again abnormal, the result of 8 mmol/l or more are abnormal.
fasting blood glucose concentration should These patients must be admitted to
be measured again. hospital so that they can have their blood
2. Patients with fasting blood glucose glucose concentration controlled.
concentrations of 6 mmol/l or more but less
The management of patients with an abnormal
than 8 mmol/l should be placed on a 7 600
random blood glucose concentration is
kilojoule (1 800 kilocalorie) diabetic diet. A
summarised in flow diagram 13-2.
glucose profile should be determined after
two weeks and be repeated every four weeks
until delivery. Usually the glucose profile
becomes normal on this low kilojoule diet. CASE STUDY 1
3. Patients with a fasting blood glucose
concentration of 8 mmol/l or more have A patient presents at 30 weeks gestation
diabetes. They must be admitted to hospital and complains of backache, feeling feverish,
so that their blood glucose concentration dysuria and frequency. On examination she
can be controlled. has a tachycardia and a temperature of 38.5 °C.
A diagnosis of cystitis is made and the patient
A 7600 kj diabetic diet consists of a normal is given oral ampicillin to take at home.
diet with reduced refined carbohydrates (e.g.
sugar, cool drinks, fruit juices) and added high
fibre foods (e.g. beans and wholewheat bread). 1. Do you agree with the diagnosis?
No. The symptoms and signs suggest that the
patient has acute pyelonephritis.

11. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 253
Random
Random
blood
blood
glucose
glucose
measurement
Less than
Less than 88or more but
or more but 11 mmol/l
11 mmol/l
88mmol/l
mmol/l less than
less than or more
or more
==normal
normal 11 mmol/l
11 mmol/l ==diabetes
diabetes
1. Routine primary perinatal
1. Routine primary perinatal
care Measure fasting
Measure fasting Admit to hospital for
care blood glucose Admit to hospital for
2. Repeat random blood
2. Repeat random blood blood glucose glucose control
glucose control
glucose ififglycosuria recurs concentration
concentration
glucose glycosuna recurs
Less than
Less than 66or more but
or more but 88mmol/l
mmol/l
66mmol/l
mmol/l less than
less than or more
or more
==normal
normal 88mmol/l
mmol/l ==diabetes
diabetes
Glucose profile
Glucose profile
Follow up at 77600 kj/day
600 kj/day
Follow up at two weeks later and
2 weeks later and
special clinic diabetic diet
diabetic diet
special clinic then every four weeks
then every 4 weeks
Normal Abnormal
Flow diagram 13-2: The management of a patient with glycosuria who has a random blood glucose
concentration measured in pregnancy

12. 254 MATERNAL CARE
2. Is the management of this patient 1. Do you agree with the management?
adequate to treat acute pyelonephritis?
No. The patient is already 36 weeks pregnant
No. The patient should be admitted to hospital and, therefore, is at great risk of going into
and be given a broad-spectrum antibiotic labour before her haemoglobin concentration
intravenously. has had time to respond to the oral iron
treatment. Therefore, the patient must be
3. Why is it necessary to admitted to hospital and be given a blood
treat acute pyelonephritis in transfusion.
pregnancy so aggressively?
2. Are any further investigations needed?
Because severe complications may occur
which can be dangerous both to the patient Yes. The cause of the anaemia must always be
and her fetus. looked for. Blood for a full blood count must be
taken before she is given a blood transfusion.
4. What two complications should
you watch for after admitting 3. Is a full blood count adequate to
this patient to hospital? diagnose the cause of the anaemia, or
should other investigations be done?
1. Preterm labour.
2. Septic shock. In most cases a full blood count is adequate.
The majority of patients who have anaemia
5. How will you recognise that the without a history of bleeding are iron deficient.
patient has developed septic shock? A full blood count will confirm the diagnosis
of iron deficiency.
The patient will become hypotensive in spite of
receiving adequate intravenous fluid.
4. What should be done if a patient
presents before 36 weeks gestation with a
6. What should be done at the first haemoglobin concentration below 8 g/dl?
antenatal visit after the patient
is discharged from hospital? If the patient is not short of breath and does
not have a tachycardia above 100 beats per
A midstream urine sample should be collected minute, she may be managed at a high-risk
for culture to make sure that the infection has clinic. After blood has been sampled for a
been adequately treated. Her haemoglobin full blood count, she should be prescribed
concentration must also be measured as two ferrous sulphate tablets three times a day.
patients often become anaemic after acute With this treatment the patient should have
pyelonephritis. corrected her haemoglobin concentration
before she goes into labour.
CASE STUDY 2 5. What should be done if a patient
presents before 36 weeks gestation with
A patient is seen at her first antenatal visit. shortness of breath, tachycardia and
She is already 36 weeks pregnant and has a a low haemoglobin concentration?
haemoglobin concentration of 7.5 g/dl. As
she is not short of breath and has no history The patient must be admitted to hospital
of antepartum bleeding, she is treated with for a blood transfusion. This is necessary
two tablets of ferrous sulphate to be taken because the patient has shortness of breath
three times a day. She is asked to return to the and tachycardia, which suggest heart failure.
clinic in one week. Again, a full blood count must be done before
the transfusion is started.

13. MEDICAL PROBLEMS DURING PREGNANC Y, LABOUR AND THE PUERPERIUM 255
CASE STUDY 3 must be given. An assisted delivery may be
necessary.
A patient presents for her first antenatal visit
and gives a history that she has a ‘leaking 5. Is the danger over once
heart’ due to rheumatic fever as a child. As the infant is born?
she has no symptoms and does not get short No. The third stage of labour and the first 24
of breath on exercise, she is reassured and hours of the puerperium are also dangerous.
managed as a low-risk patient. As she remains Ergometrine or Syntometrine must not be given
well with no shortness of breath, she is told and the patient must be closely observed for
that she can be delivered by a midwife at the signs of heart failure. Oxytocin should be given
primary perinatal-care clinic. and the third stage must be actively managed.
1. Why is the management incorrect?
With her history of rheumatic fever and a CASE STUDY 4
‘leaking heart’, the patient must be examined
by a doctor to determine whether she has An obese 35-year-old multiparous patient
heart valve disease. Undiagnosed heart valve presents with 1+ glycosuria at 20 weeks
disease can result in serious complications gestation. At the previous antenatal visit she
such as pulmonary oedema. had no glycosuria. A random blood glucose
concentration is 7.5 mmol/l. She is reassured
2. What should be done if the patient has a and followed up as a low-risk patient. At 28
heart murmur due to heart valve disease? weeks she has 3+ glycosuria. As the random
blood glucose concentration at 20 weeks was
The type of heart valve disease must be normal, she is again reassured and asked to
diagnosed. If the patient needs medication, the come back to the clinic in two weeks.
correct drug must be prescribed in the correct
dosage. She must be managed as a high-risk 1. Do you agree with the management
patient and should be carefully followed up for at 20 weeks gestation?
symptoms or signs of heart failure.
Yes, the patient was correctly managed when
3. Will most patients with heart a random blood glucose concentration was
valve disease give a history of measured after she had 2+ glycosuria. When
previous rheumatic fever? 1+ glycosuria or more is present again,
later in pregnancy, a random blood glucose
No. Although most heart valve disease is concentration must be measured again.
caused by rheumatic fever during childhood,
most of these patients are not aware that they 2. How should the patient have
have had rheumatic fever. been managed at 28 weeks?
4. Is it safe to deliver a patient She should have had another random blood
with heart valve disease at a glucose concentration measurement. Further
primary perinatal-care clinic? management would depend on the result of
this test.
No. Special management is needed in at least
a secondary hospital with specialist care
available. The patient must be closely observed
for signs of heart failure, good pain relief
is needed during labour and prophylactic
antibiotics against infective endocarditis

14. 256 MATERNAL CARE
3. Why should a patient be 5. If the patient has a fasting blood
investigated if she has 2+ glycosuria glucose concentration of 7.0 mmol/l, what
of more for the first time? should her further management be?
Because the patient may already be a diabetic The result is abnormal but is not high enough
with a high blood glucose concentration to diagnose diabetes. She should, therefore,
causing the marked glycosuria. be placed on a 7600 kilojoule per day diabetic
diet. A glucose profile must be obtained after
4. What should the management have two weeks and this should be repeated every
been if her random blood glucose was four weeks until delivery.
9.0 mmol/l at 28 weeks gestation?
The patient should be seen the next morning
after fasting from midnight. Her fasting
blood glucose concentration should then be
measured.