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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