Disease Associated With
Pregnancy
Pregnancy produces a degree of altered immune responsiveness which helps
to prevent fetal resection but predisposes the woman to infection. Infection in
pregnancy will affect the fetus as well as the mother.
Transmission of infection to the fetus can occur as:
·
Via the transplacentally for example the human immunodeficiency virus
(HIV) and rubella
·
By ascending via the vagina after rupture of the membranes
·
As the baby passes through the birth canal
If the woman contracts an infection investigations of the cause of
infection include blood culture and culture of a high vaginal swab should be
assessed.
Antimicrobial therapy is undertaken with care over use of broad –
spectium antibiotics has produced resistant organisms and some antibiotics are
contraindicated in pregnancy because of their effect on the fetus
The over all effect is to debilitate the woman, making her less able to
cope with pregnancy and her existing family.
Transplacentally, infection of the fetus is rare but possible and there
is a suggestion that the risk of abortion may beincreased. The woman’s poor
state of health may affect fetal growth.
If there are clinical signs of tuberculosis or the woman is known to
have been in contact with tuberculosis a chest x-ray is performed during the
third month, at term and 6 months after delivery. Sputum specimens are taken
and any plural effusions may be aspirated to help identify the organism.
Most treatment is given on an out patient basis although the woman may
be admitted to an isolation unit if her sputum test is positive as the disease
is communicated by droplet infection. Treatment is usually with isoniazid and
ethambutol during the first trimester; rifampicin may be used after that.
If the mother is infectious she should be allocated a single room during
her stay in hospital. Problems in labour stem from fatigue and reduced lung
function.
Episiotomy and forceps delivery may be advocated to reduce the strain of
the second stage. Unnecessary blood loss can be avoided by careful management
of the third stage.
Separation of the baby from his family is not always necessary. The baby
can be vaccinated with an isoniazid resistant BCG while being protected from
the disease by the prophylactic use of isoniazidFamily pranning advice.
The work load of the heart increases quite significantly during
pregnancy. These changes commence in early pregnancy and gradually reach a
maximum at the 30th
week, where they are maintained until term. Oestrogens and prostaglandins are though
to be the mediators of the alterations in haemodynamics during pregnancy. These
changes are associated with several clinical signs.
Based on exercise tolerance is useful for describing the extent of the
immediate problem but has little predictive valve:
·
No symptoms during ordinary physical activity
·
Symptoms during ordinary physical activity
·
Symptoms during mild physical activity
· Symptoms at rest
Diagnosis of cardiac disease in some women may only make during antenatal vists. The aim of management is to maintain or improve the physical and psychological well being of mother and fetus. This involves keeping a steady haemodynamic state and preventing complication.
The least stressful labour for a woman with cardiac disease will be
spontaneous in on set and result in a vaginal delivery. Blood may be
cross-matched in case of need. Oxygen and resuscitation equipment should be
available and functioning.
·
Pulse ,blood pressure and fetal condition should be monitored and
recorded
·
Administration of prophylaxis antibiotic to prevent endocarditis
·
Positioning – encouraged to adopt a position in which she is comfortable
· Maintain fluid balance
The second stage should be short and with out undue exertion on the part
of the mother. She advised to avoid holding her breath and follows her natural
desire to push;giving several short pushes during each contraction. Provide
oxygen if necessary.
Syntocinon may be used in order to prevent haemorrhage as it has less
effect on blood vessels than ergometrine.
During the first 48 hours following delivery the heart must cope with
the extra blood from the uterine circulation and it is important to monitor the
woman’s condition closely.
When the woman has discussed the implications of future pregnancies, she
will decide on her condition with the cardiologist and obstetrician.
The extra demands on the pancreatic beta cells can precipitate glucose
intolerance in women whose capacity for producing insulin was only just
adequate prior to pregnancy. If a mother was already diabetic before pregnancy,
her insulin needs will be increased.
When it is well controlled its effect in one pregnancy many be minimal.
If the control is inadequate ther may be complications.
·
Maternal haemoglobin can be irreversibly bounded to glucose
·
There is an increased risk of spontaneous abortion, stillbirth and fetal
abnormality
·
The perinatal mortality rate is 2 or 3 times higher for diabetic mother
·
Diabetic mother are more prone to urinary tract infection
·
Diabetic mother has a greater susceptibility to candidida albicans.
·
The incidence of preeclampsia and polyhydraminous is increased.
·
Neural tube defects in babies of diabetic mothers
·
Should be seen at a combined antenatal and diabetic clinic
·
Should attend (visit) antenatal clinic every tow week until 28 weeks
gestation and then weekly until term
·
Fetal growth and anomaly must be observed for the risk of either growth
retardation, macrosomia or fetal abnormality
·
Should be assessed for any sign of diabetic complication
·
Labour should be allowed to commence spontaneously at term in well
controlled diabetic
·
Maternal hyperglycemia should be controlled thus leads to an increase in
fetal insulin production which will cause neonatal hypoglycmeia
·
Monitor fetal condition through out the labour
·
A pediatrician should be present during delivery especially if labout
has been induced or labour is premature
Carbohydrate metabolism returns to normal very quickly after delivery of
the placenta and insulin requirements will fall rapidly, often she needs no
insulin during the immediate post natal period then she will return to her non
pregnant insulin requirement
·
Careful observation for PPH if there is polyhydraminos
·
A diabetic mother who is breast feeding may need to increase her
carbohydrate intake
·
Since diabetic mother is prone to infections advice her, to change her
pads frequently keeps any wound clean and dry.
·
The woman with gestational diabetes will usually demonstrate normal
glucose values by 24 hours after birth and need no further diet or insulin
therapy
·
Be certain the woman has contraceptive information as appropriate
·
Examine carefully as there is an increased risk of congenital
abnormality
·
The baby should be fed soon after delivery to prevent hypoglycemia as
the baby continues to produce insulin than he needs.
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