in 3rd Trimester
The third trimester is like the last lap of
your journey. It covers the 28th week onwards till delivery.
This period is a crucial phase for baby’s weight
gain. It is also a period where certain obstetric
(pregnancy related) and medical problems can develop.
- Bleed`ing which can be due to
- Placenta praevia
- Abruptio placentae
- Other causes.
- Preterm labour.
- IUGR or foetal growth retardation.
- Post term pregnancy.
- Hypertension in pregnancy, which may or may not be purely
- Gestational diabetes.
- Aggravation of underlying medical condition like anaemia,
cardiac disease, kidney problems, etc.
- You must discuss problems or discomforts you are having with
your doctor to identify any serious problem.
signs for medical disorders include:
- Persistent swelling of feet hands or face.
- Increasing breathless, especially on routine activity.
- Blurring of vision.
- Blackouts or giddiness.
- Fever (temperature > 38 C or 100 F)
- High coloured urine.
- Important obstetric and medical problems are discussed below.
Bleeding in third trimester
- Bleeding in the later part of pregnancy poses a serious threat
to the health and life of both mother and child.
Any amount of bleeding in the late pregnancy
should be reported to your doctor immediately.
Placenta praevia and abruptio placentae make
up 95% of these cases. The causes of bleeding
in the third trimester are:
- Placenta praevia (abnormally located placenta).
- Abruptio placentae (early separation of placenta). .
- Other rare causes such as
- vasa praveia
- Rupture of marginal sinus
- Local lesions.
- Severe fungal or trichomonal infection, varicose veins of
vagina or vulva
- Ployp (local outgrowth) of cervix or vagina
- No discoverable causes – idiopathic.
- Bloody show: reddish discharge at the outset of true labour
In this condition, the placenta is implanted low down in the
uterus and lies over or near the mouth of
the uterus. It is in front of the presenting part
(leading part) of the baby and can cause life
Depending on how low down the placenta is, the different types
of placenta praevia are:
- Total placenta praevia
The placenta covers the entire internal opening
of the cervix.
- Partial placenta praevia
The placenta covers part of the opening of the cervix.
- Marginal Placenta praevia
The placenta extends to the edge of the cervix, but doesn’t
lie over the opening.
- Low lying placenta
The placenta is in the lower uterine segment, but doesn’t encroach
on the internal opening of the cervix.
These grades are important medically, as for
minor degrees of placenta previa, a vaginally
birth may be possible, but is best left to the
judgement of your gynaecologist. Early
or mid-trimester ultrasound may describe the
placenta to be lowlying or praevia in upto 40%
cases. However as the uterus grows and stretches,
the relative location of the placenta changes.
- How often does this occur?
1 in 200 pregnancies.
The causes of placenta praevia are not known
for certain. But the high risk factors are:
- Woman with more than 2 – 3 children.
- Elderly women.
- Smoking habit.
- Previous record of induced abortion, curettage.
- Large placenta as in twins, diabetics, syphilitic infection,
- What do you feel? (warning signals)
Painless vaginal bleeding is the main complaint
of these patients. The blood is usually bright
red, and the amount may range from scanty to
heavy. The bleeding may stop by itself at some
point, but it nearly always recurs days or weeks
- How to arrive at a diagnosis?
- Blood investigation
Tests like haemoglobin levels, packed cell volume
(PCV) Blood grouping and Rh typing are important
to see your capacity to withstand blood loss
if it occurs..
It is most selective and reliable investigation
for the diagnosis of placenta praevia. Up to
98% of cases may be detected accurately.
If the bleeding is severe enough involving the risk of mother’s
life, emergency caesarean operation is undertaken,
irrespective of the maturity of the baby.
If the bleeding has stopped on its own, the further planning
of pregnancy depends upon the stage of pregnancy.
Tocolytic agents in selective patients (which prevents uterine
Once the baby attains maturity, i.e. at 37 completed weeks
decision is usually taken for elective caesarean
The rate of caesarean section being done in placenta praevia
varies between 80 – 90%. Vaginal birth can be
tried for lowlying or marginal praevia. But
if bleeding occurs a caesarean section becomes
This condition, also known as premature separation of the placenta,
involves the detachment of the placenta from the
wall of the uterus. The blood clot (haematoma)
is formed between the placenta and uterus.
Usually the placenta which connects your baby to the uterine
wall and nourishes the foetus, does not separate
until your baby has delivered. Due to some factors
if it seperates from its attachment before the
baby is born, there will be bleeding and risk
to your baby's life as the source of nutrition
and oxygen is affected.
Depending on whether
the bleeding shows externally or not, the various
medical types of placental abruption can be
often does this occur?
This is a little
more common than placenta praevia about 1 in
The exact cause is unknown as yet.
However, woman with multiple children, elderly women are
at risk. Hypertension (blood pressure) in pregnancy.
Over distension of the uterus e.g. in Twin pregnancy and
polyhydramnios (excess amount of amniotic fluid).
- Warning Signs / What do you feel?
In the early stages of premature separation,
there won’t be any clear signs or symptoms.
When symptoms do occur, the most common are:
- Bleeding from the vagina.
- Back or abdominal pain.
- Uterine tenderness.
- Contractions. The uterus may feel hard and rigid.
Depending on the amount of blood loss either inside or outside
the uterus, it can leads to foetal comprise or
death. The bleeding may cause severe fall in blood
pressure, which is dangerous for the life of the
mother. Severe degree of abruption is associated
with disseminated intra-vascular coagulation (DIC),
which is a serious complication endangering life
of the mother.\
- How to arrive at a diagnosis?
Blood Investigations to determine the haemoglobin level and
blood loss haemoglobin levels (Hb levels).
Packed cell volume (PCV levels).
Blood group - Rh factor.
Depending on the severity of abruption, DIC profile is done
First and foremost it differentiates placenta previa from abruptio,
by localizing the placenta. By finding a retro
- placental clot, it confirms the diagnosis.
It can roughly measure the size of the blood
clot and indicate whether the baby is surviving
Blood bottles to be reserved and transfusion given as per
the patient’s conditions.
The decision to go ahead with caesarean section or vaginal
delivery depends upon baby’s health and the
severity of the blood loss. If the baby is alive
or in distress an immediate caesarean can save
the baby's life. Unfortunately, if the baby
is already dead, a vaginal delivery is better
for the mother. Vaginal birth is possible using
The perinatal mortality rate (death rate of babies) is about
30 – 50% in these cases.
- Future implications
The repeat chances of patient developing abruption are about
10%. The good news is that, if patient is closely
monitored and immediate action is taken at the
signs of danger to the baby, most of the babies
and mothers get safely through birth with no
long-term ill effects.
Intrauterine Growth Retardation (IUGR)
The ability to reach an optimal birth weight
results from the interaction between the foetal
growth potential and the in-utero environment.
The growth potential varies from race to race
and from individual to individual. For example:
the mean birth weight of boys in Delhi was 2.7
kg in poor class and 3.2 kg in upper class.
The foetus requires several substrates for normal
growth. The most important are oxygen, glucose
and proteins (amino acids). Persistent and severe
substrate deficiency may threaten the ability
of the foetus to survive.
Intrauterine growth retardation includes newborns
with birth weight less than the 10th
percentile for their gestational age and less
than 2500gms other than babies born out of preterm
How often does this occur?
3 – 10% depending on the type of population.
The causes of intra uterine growth retardation are many and
varied. Often it is difficult to implicate any
single agent. It may be due to some medical
or obstetric condition prevailing in the mother
or due to an abnormal placenta or due to some
problem related to the foetus itself.
Hypertensive disease likes pre-eclampsia. .
and alcohol ingestion
Smoking in pregnancy results in 150 – 200 gms
reduction in birth weight. This is due to the
nicotine causing placental vaso-constriction
and the high carboxy-haemoglobin levels in the
mother and foetus. Maternal addiction to narcotics
and alcohol also has a similar effect on the
maternal nutrition status
Pregnancy weight of 40 kg or below, poor weight gain in pregnancy
– less than six kg,
Anaemia- haemoglobin less than 8gm/dl
in pregnancy are associated with low birth weight
A good quality of prenatal care starting with
the 1st antenatal visit has a beneficial
impact on IUGR.
Decreased placental mass, absolute or relative conditions
that can lead to IUGR are:
- Minor abruption.
Post term pregnancy.
Intrinsic placental defect during formation or implantation
- Foetal Causes
Chromosomal disorders – like Down’s syndrome,other genetic
Congenital anomalies, intrauterine infection like cytomegolovirus,
toxoplasma, rubella etc. can cause IUGR.
- what do you feel?
Because of the high death rate around delivery, early diagnosis
of this condition is important. However, there
is no reliable screening test available to diagnose.
So only one third of infants suspected to be
growth-retarded turn out to be so.
The signs of IUGR are seldom elicited before
28 weeks (7 months) of pregnancy.
The clinical features are:
- Failure of the mother to gain weight during pregnancy (normal
10 – 12 kg – throughout pregnancy, if less than
6 kg – IUGR is likely).
- The fundal height is measured as the distance between pubic
symphysis and the fundus of the uterus.
- In normal pregnancy, the fundal height increases by one cm
/ week during 14 – 32 weeks and later by 0.5
cm / week.
- Approximately, the fundamental height in cms. corresponds to
the weeks of gestation.
For example.: At 30 weeks, the expected fundal height should
be around 30 cm. However, it may vary depending
on the height of the woman and her constitution.
- How to arrive at a diagnosis?
Serial sonography is the most valuable tool in the detection
of growth retardation. Various parameters like
head circumference of baby, Biparietal diameter,
abdominal circumference, length of thighbone
(femur), ratio of head and abdominal circumference
are noted and evaluated.
A previous ultrasonography scan, if done,
is of great benefit for evaluation as the relative
changes in size can be assessed. Doppler studies
reveal adequacy of the blood supply to the foetus.
- Non Stress test .
Which will give the status of foetal
wellbeing in utero and judge how well it is
adjusting to maternal condition.
If another specific test, done via ultrasonography for foetal
assessment and can differentiate a baby who is
doing well from one who is not.
Colour doppler assess
the blood flow to your baby.
- Treatment – Management
The first step in managing suboptimal foetal growth is to
identify those "to be mothers" who are at high
risk. This is done by clincal methods and USG.
The 2nd step is to differentiate the truly malnourished
or IUGR babies from those that are small but
healthy.This is done by tests for foetal well
The 3rd step is to establish adequate methods
of foetal surveillance for patients with IUGR
babies and deliver them under optimal conditions.
It is your attending doctor who is in the right place to
plan your delivery.
Post Term Pregnancy
Pregnancy that advances beyond 42 weeks is post term pregnancy.
Prolonged pregnancy is the one, advancing beyond
the expected date of delivery (EDD).
How often does this occur?
In about 80% of all pregnancies, birth takes place between
38 and 42 weeks. About 10% are preterm i.e. before
37 weeks of pregnancy and the other 10% or so
last beyond 42 weeks.
Often a miscalculated due date is responsible
for a pregnancy being considered post term. When
early ultrasound examination is used to calculate
the due date, the incidence of post term pregnancy
turns out to be 2.6% only when Together, ultrasound
and menstrual history is taken into consideration,
the incidence is only 1.1%
They are largely unknown. Heredity and hormonal factors may
play a role.
What do you feel?
Foetal death during pregnancy, labour delivery or in post delivery
period is very high in post term pregnancies.
As the period increases, the amniotic fluid surrounding
the baby starts decreasing causing umbilical cord
compression during labour and thereby interrupting
oxygen supply to the baby. Another concern is
post term pregnancy is macrosomia (big baby) or
a baby weighing more than 4.5 kg. Such large babies
may have hard time getting safely through the
birth canal during delivery. This is why caesarean
birth is more common in post term pregnancies.
Post term pregnancy also increases the risk of
meconium aspiration syndrome in the baby. In this,
the stool of the baby (meconium) is passed in
the amniotic fluid. This usually causes breathing
difficulty to the baby, leading to pneumonia in
the lungs of the baby. Therefore it is essential
to clear the nose and the mouth (the air passage)
of the baby as soon as delivery occurs.
How to arrive at a diagnosis
It is a reliable investigation, which gives information about
the amniotic fluid volume, nature of placenta,
foetal weight etc. .
The amniotic fluid in which the foetus breathes
in utero is an essential component. In the post
term pregnancy it decreases significantly.
Test for foetal well being: .
Daily foetal kick count.
Non stress test.
Contraction stress test.
Doppler and colour doppler.
These are used appropriately for foetal surveillance. Not all
the tests are required in every case.
Usually the labour is induced artificially after 42 weeks.
The foetus is monitored
caustiously, if there is any deviation from normal,
an immediate decision for caeasarean section is
Most post term babies come safely into the world. How to
best handle your own post term pregnancy and birth
is best decided by you and your doctor, weighing
the benefits and risks of the available options.
Diabetes mellitus and pregnancy
Until recently, getting pregnant was a risky business for a
diabetic woman, and even riskier for her unborn
baby. Today, with expert medical care and guidance
and scrupulous self-care, the diabetic woman has
just about as good a chance of having a successful
pregnancy and healthy baby as any other pregnant
woman does. The commmoner type of situation is,
however where you are diagnosed in pregnancy to
have abnormal sugars.
Making your diabetic pregnancy a success will
take a good deal of effort on your part, but the
reward – a healthy baby – will make it well worth
the effort. Research has proved that the key to
successfully managing diabetic pregnancy is maintaining
euglycemia (normal blood sugar levels).
Carbohydrate Metabolism During
Pregnancy uncovers the diabetic tendencies of symptomatic
women. This is due to the progressive increase
in insulin resistance that occurs during pregnancy.
There is an antagonism to the action of insulin
– (the key hormone, which maintains blood sugar
levels) because of the new hormonal environment
Effect of pregnancy on Diabetes
These patients (women) have high tendencies towards (metabolic)
complications and need frequent glucose monitoring,
strict treatment protocols and highly regulated
life style. Women with a tendency towards Non-Insulin
dependent Diabetes Mellitus may show high blod
sugars for the first time, during pregnancy.
of Diabetes on pregnancy
These women have a greater incidence of complications like
pre-eclampsia (high blood pressure during pregnancy)
infection, post delivery bleeding (PPH) and caesarean
deliveries. The foetuses have high incidence of
congenital anomalies, hypoglycemia (low levels
of glucose), macrosomia (big size baby > 4.5kg),
breathing problems, low levels of calcium (hypocalcemia)
and traumatic deliveries.
Types of Diabetes Mellitus
(i) JUVENILE DIABETES - also called Type I – Insulin
dependent Diabetes Mellitus:
In this, the body doesn’t produce enough insulin.
Also called as ‘Juvenile onset Diabetes Mellitus’.
You would probably be on Insulin from childhood,
and must be taking regular advice and treatment
from a medical specialist or endocrinologist.
Ideally a pregnancy is to be planned when your
sugar levels are well controlled.
(ii) Type II – Non-Insulin dependent Diabetes Mellitus:
In this, the insulin that is produced is not
used effectively by the body. This is the case
in both diabetes that develops during pregnancy
and in adult onset diabetes (diabetes that develops
during adulthood). Women develop this at an older
(iii) Gestational Diabetes also
called as pregnancy diabetes:
Diabetes that develops during pregnancy or
detected during pregnancy is called ‘gestational
In most cases, gestational diabetes causes no
complaints in the mother and poses no immediate
threat to her life. But she has a greater chance
of being diabetic in later part of her life. The
real risk is involved with the baby. The baby
has increased risk of still birth or death as
a newborn, and other problems listed before.
How often does this occur?
About 1 – 3 per 1000 women of reproductive age
have diabetes, but 15 per 1000 show evidence of
glucose intolerance during pregnancy.
High-risk group includes:
Obesity more than 200 pounds or more than 15% of non-pregnant
ideal body weight).
Positive family history of diabetes.
History of still birth.
History of delivery of large infant > 4 kg.
History unexplained neonatal death.
History congenital anomalies.
History of pre term labour.
History high blood pressure (pre eclampsia) in women who
have had multiple deliveries earlier.
Poor reproductive history (more than 3 spontaneous abortions).
Repeated urinary tract infections.
Age > 30 years.
History of diabetes in previous pregnancy.
Glycosuria (excessive loss of glucose in urine).
What do you feel?
Generally, gestational diabetes doesn’t cause any symptoms.
Subtle signs, such as fatigue or excessive thirst
and urination, may sometimes occur. However, blood
glucose test is done to confirm the diagnosis.
How to arrive at a diagnosis?
Ideally, every woman must undergo the screening
test for gestational diabetes. The major step
is to IDENTIFY the problem as it may be silent.
50gms of glucose is given to mothers and blood sugar levels
are measured after 1 hour of ingestion of glucose.
And the results are interpreted.
If blood glucose levels is
More than 140mg / dl – is at risk of gestational diabetes.
Less than 140mg / dl – is not at risk.
Time of screening
Ideally between 24 to 30 weeks of pregnancy.
Patients at High risk may have the test earlier
between 18 to 22 weeks of pregnancy. But, if it
is negative, it should be repeated between 26
– 30 weeks.
Patient with an abnormal screening test should
be given a 3-hour glucose tolerance test (G.T.T)
This is a more specific test for the diagnosis
of gestation diabetes.
In this, 4 samples of blood are collected. First
sample is collected on empty stomach (overnight
fasting). Then 75 gms of glucose is taken orally.
Three samples of blood are collected at the end
of 1 hour, 2 hour and 3 hour, and the values are
measured. The upper limit of normal values is
limit of Normal
||Sketch of test tube
||96 mg / dl
||5.3 m mol / l
||Sketch of test tube
||172 mg /dl
||9.6 m mol / l
||Sketch of test tube
||156 mg / dl
||8.49 m mol / l
||Sketch of test tube
||131 mg / dl
||7.31 m mol / l
If two or more values are more than the values given, the woman
is labelled as diabetic patient. If one value
is abnormal, she is not labelled as diabetic,
but she is at the risk for complications.
Whether you come into pregnancy as a diabetic
or have developed gestational diabetes along the
way. All of the following consideration will be
important in working towards a safe pregnancy
and a healthy baby.
You will probably visit your obstetrician (as well as your
diabetologist) more often than do other expectant
mothers. You will be given many more orders and
will have to be far more scrupulous in following
A diet geared to your personal requirement
should be carefully planned with your physician,
dietician and the obstetrician. The diet will
probably be high in carbohydrates (about half
your daily Calories should come from carbohydrates),
moderate in proteins (20% of Calories intake),
low in cholesterol and fat (30% of Caloric intake)
and contain no sugary sweets; plenty of dietary
fabric is important.
Calories may be restricted, particularly if you
Never fast or skip meals, eating regularly is
essential. If you have trouble getting down three
large meals, take six to eight small ones, regularly
spaced and carefully planned.
Sensible Weight Gain
It is best to try to reach your ideal weight
before becoming pregnant. But if you start your
pregnancy overweight, don’t plan on using the
pregnancy period for slimming down. Getting sufficient
calories is vital to your baby’s well being.
A moderate exercise (brisk walking, swimming
or light stationary skiing) program will give
you more energy, aid in regulating your blood
sugar, and help you get in shape for the delivery.
But it must be planned in conjunction with your
Especially in 3rd trimester, adequate rest is very important. Avoid
overexerting, and try to take some time off during
the middle of the day for napping. If you have
a demanding job, your doctor may recommend that
you begin your maternity leave early.
Medication for blood sugar regulation
If diet and exercise alone do not control your blood sugar,
you will probably be put on insulin. If you had
been taking oral medication for diabetes prior
to pregnancy, you will be switched to injections
of insulin, which is less likely to adversely
affect your foetus, for the duration of your pregnancy.
You may have to test your blood sugar (with a simple finger
prick method) at least 4 – 5 times a day to be
sure it is remaining at safe levels.
Don’t be alarmed if your physician orders great
many tests for you, especially during the 3rd
trimester or even suggest hospitalization for
the final weeks of your pregnancy. This doesn’t
mean something is wrong, only that he or she wants
to be sure that everything stays right. The tests
will primarily be directed towards regular evaluation
of your conditions and that of your baby, in order
to determine the optimal time for delivery and
whether any other intervention is required.
The condition of your baby and placenta will probably
be evaluated through non-stress test, Biophysical
profile, amniocentesis and sonography.
You may be asked to monitor foetal movements
yourself 3 times a day. If you don’t feel movements
during any test period, call your doctor immediately.
Don’t panic if your baby is placed in a neonatal
care unit immediately after delivery. This is
routine procedure in most hospitals for infants
of diabetic mothers.
and mode of pregnancy termination
There is no need to terminate pregnancy before term. Once you
reach your calculated date of delivery, you should
It is not necessary to do caesarean section. More
than 50% can be delivered vaginally (normally)
without many complications.
Gestational diabetes almost always disappears
after delivery. Your blood sugar levels will be
checked immediately after 24 hours of delivery
and later after 6 weeks.
If you have had gestational diabetes in one pregnancy,
your risk of it developing again in subsequent
pregnancy is increased. You may develop ‘overt’
diabetes (diabetes that is present all the time,
not just during pregnancy) as you get older. For
this reason, it is important to follow your doctor’s
advice regarding diet, exercise and blood sugar
Anaemia in Pregnancy
Anaemia has long been recognised as a major public health problem
especially in developing countries like India.During
pregnancy, level of haemoglobin below 11 gms /dl,
is labelled as anaemia.(Before you were pregnant,
you needed about 15 mg of Iron per day, now you
need twice this amount. i.e. approximately 30
mg per day.
How often does this occur?
40 – 60% of are pregnant woman, suffer from anaemia.
During pregnancy, the volume of plasma (fluid portion of blood)
increases dramatically by 45% while the red blood
cells (cells, which contain haemoglobin, i.e.
the iron content) increases by 15% only, causing
a dilution of blood, also called dilutional anaemia
or physiological anaemia.
Iron deficiency is the commonest reason for the development
Deficiency of iron in food, poor reserves of iron
in the body, excessive blood loss, poorly spaced
Prolonged lactation for more than 6 months all
contribute to the occurrence of nutritional anaemia.
Prevention can be achieved by the simple practice
of a well balanced diet and regular intake of
Poor absorption of iron from the intestines is due to worm
infestation like hookworm. There is intestinal
hurry causing less iron absorption.
The average Indian diet would appears adequate in iron content
(20 – 22mg) for a non-pregnant adult woman. But
various factors inhibits iron absorption such
as phytates, deficiency of ascorbic acid (Vit
C), calcium and proteins, which tend to lower
the iron absorption, causing nutritional anaemia.
During pregnancy, there is increased demand of iron. The
iron is taken for:
Expansion of Red Blood cells.
Iron transferred to foetus.
Blood loss at delivery.
Basal Iron requirement.
Chronic infection of gastro intestinal tracts, urinary tract
can cause anaemia.
Deficiency of folic acid and Vit B 12 (Cyano-cobalamine)
leads to megaloblastic anaemia (type of anaemia).
anaemia so common in India?
Besides the physiological demands of pregnancy, other factors
Repeated child bearing. ‘too many, too soon, too close and
Poor bio availability of iron is due to:
- Predominantly vegetarian diet.
- Diet low in Calories, rich in phytates.
- Low in ascorbic acid (Vit C).
- Poor socio economic conditions and protein energy malnutrition.
- Gastro intestinal worm infection.
Improper supplementation in pregnancy and lactation due to:
Late registration for antenatal clinics.
No regularity in taking drugs (non-compliance).
Poor follow up.
What do you feel?
- Loss of appetite.
- Fatigue – weakness.
- Breathlessness – difficulty in breathing.
- Chronic urinary tract infection.
- Oedema – swelling all over the body.
NOTE: These are primarily symptoms of the mother. The foetus is an
excellent parasite. Inspite of low levels of haemoglobin
in blood of the mother, the foetus draws required
amount of iron for himself, putting the mother’s
condition at risk.
How to arrive at a diagnosis?
Haemoglobin estimation is the basic test and gives clue regarding the severity
Levels of haemoglobin
|8.5% gm – 10% gm.
||Mild form of anaemia.
|7.0gms – 8.5 gm.
||Moderate form anaemia.
|Less than 7.0 gm.
||Severe form anaemia.
The severity of anaemia is directly proportional to the occurrence
of complications during pregnancy, (labour) delivery
and in later period.
Peripheral blood smear
It gives information regarding the type of anaemia
and the red blood cells characteristics.
Others tests done are:
Red blood cell count – Normal is 3.5 to 4.5 million / cubic
Packed cell volume – normal more than 32%.
Mean corpuscular haemoglobin concentration (MCHC) more than
Serum iron concentration.
Total Iron-binding capacity (TIBC).
Stool examination to rule out worm infestations.
Ultrasonography to rule out intrauterine growth retardation.amniotic
fluid abnormalities, etc.
Pre-planned pregnancy with adequate antenatal care.
Healthy dietary habits with ingestion of vegetables and fruits
Widely spaced pregnancies, in case of multiple pregnancies.
Treatment of any menstrual problems for example excessive
amount of bleeding during menses (menorrhagia),
bleeding for prolong period of time, etc.
Replenishing the iron stores by taking iron supplementation
during pregnancy and lactation.
Treatment of worm infestations, if any.
Treatment of bleeding through rectum (piles), etc.
Treatment of anaemia consists of taking oral iron pills daily,
usually 2nd half of pregnancy. The common iron preparations are Fefol.2,
Solteron, Autrin, Fecontin etc. Depending upon the severity of anaemia,
the dose of the pills are adjusted as once, twice
or thrice a day. It is advisable to take pills
after meals to reduce the common side effects
like nausea, vomiting, constipation, diarrhoea
occasionally joint pains etc. To prevent Iron
deficiency anaemia, it is generally recommended
that expectant mothers should eat a diet rich
The foods which contain Iron in a rich quantities are:
Ragi, fenugreek (methi), jaggery.
Potatoes in their skin.
Legumes (green peas, lentils).
Soybeans and soy products.
Liver and other organ meats.
Oysters (cooked, don’t eat raw).
Small amounts of iron are found in most of fruits, vegetables,
grains and meats, you eat everyday.
Add your foodstuff with rich calcium and vitamin
C foods, which increase iron absorption from the
Calcium rich foods:
Skim or low fat milk or butter milk.
Low fat cottage cheese / Swiss cheese.
Low fat or not fat yogurt.
Calcium added milk.
Ground sesame seeds.
Soya milk and Soya protein.
Baked goods made with sesame seeds, Soya flour.
Vit. C foods:
Have at least 2 Vit C foods or combination equal to 2 everyday.
Grapefruit / juice.
Orange or orange juice.
Mango, papaya, strawberries.
Tomato, Tomato-juice, raw cabbage.
Cooked cauliflower, etc.
If the woman is not tolerating the oral iron or she is late
to seek medical help, often other modes of treatment
like intramusuclar injections or are advised.,
a blood transfusion of packed red blood cells
is also given. This practice is not very common.
However, oral therapy is best in the interest
of women as this does not have many effects or
involves cumbersome procedure.
If the woman is not responding to iron therapy
for more than 3 – 4 weeks, other causes of anaemia
like megaloblastic anaemia, (type of anaemia where
there is deficiency of iron and folic acid) or
haemoglobinopathies should be investigated for.
(high blood pressure in pregnancy).
High blood pressure complicates approximately
10% of pregnancies and is therefore, the most
common medical problem requiring special attention
during labour and delivery.
Although there is marked regional variation, approximately
75% of these patients have pregnancy induced hypertension
(PIH / pre-eclampsia) and the remaining 25% have
chronic blood pressure of various types. A classification
of hypertension in pregnancy is useful in defining
risks, and in planning for potential complications.
(i) Pregnancy induced Hypertension. Pre-eclampsia mild or severe. Eclampsia.
(ii) Chronic hypertension (preceding pregnancy) of any etiology.
(iii) Chronic hypertension with super imposed pre-eclampsia
(iv) Late or transient hypertension.
Development of hypertension with protein
in the urine with or without oedema after 20 weeks
of pregnancy is known as Pre-eclampsia.
It is pre-eclampsia with convulsions, which are
not due to co-incidental nervous system (brain
and spinal cord) disease.
It is hypertension diagnosed before pregnancy
or before 20 weeks of pregnancy (5 months) and
lasts more than 6 weeks after delivery.
Hypertension that develops in later half of pregnancy or within
24 hours of delivery without proteinuria (protein
in the urine) and disappears within 10 days of
delivery is known as Gestational diabetes.
The essential criteria required to label a woman pre-eclamptic
It is rise in blood pressure, two readings taken 6 hours apart
Systolic Blood pressure > than 140 mm Hg (upper one).
Diastolic Blood pressure > than 90 mm Hg (lower one).
Mean arterial Blood pressure > than 105 mg Hg.
Proteinuria: proteins in the urine:
Loss of proteins (albumin – type of protein) in
urine of more than 0.3 gms / litre.
Swelling of body due to collection of fluids under skin.
How often does this occur?
10% in most parts of India.
The exact cause for pre-eclampsia is not known. However, there
are numerous theories to explain. However, the
risk group has been identified, which are:
Elderly and young primigravida (woman with 1st
Poor people – due to lack of care and poor nutrition.
Pregnancy complications – such as molar pregnancy,
multiple pregnancy, Rh-incompatibility,
incompatibility, poly-hydramnios (excessive
amount of amniotic fluid).
– like Diabetes mellitus, hypertension, renal
What do you feel?
Headache: Located in front or back of head. Lasting for more than 2 hours.
In increasing frequency, duration and regularity.
Diminished urinary output – significant decrease in frequency
and quantity of urine.
Eye problems – loss of clarity of vision, diminished vision.
Oedema – swelling over ankles, legs, which persists on rising
from the bed in the morning or tightening of rings
or bangles. Gradually, the swelling may extend
to face, abdominal wall, and all over body.
Abnormal findings seen by your Obstetrician:
Abnormal weight gain: Rapid gain in weight of more than 5 pounds a month or 1 pounds
a week in later months of pregnancy is abnormal.
Rise of blood pressure: The rise of blood pressure is usually gradual but it may rise
abruptly in few cases.
Growth of baby: The growth of baby may not correspond to the duration of pregnancy.
The baby will be small for the duration of pregnancy.
This is due to the lack of supply of nutrition.
How to arrive at a diagnosis?
A series of investigations are done at regular intervals to
monitor the progression of disease.
The usual blood tests are:
Complete blood count.
Blood grouping and Rh typing.
Serum electrolytes levels.
Serum uric acid levels.
Liver function tests.
Kidney function test
Blood urea nitrogen (BUN).
Serum creatinine (Sr. creat.).
It is done to detect proteins in the urine.
and tests. At regular intervals
to check the growth of the baby inside the uterus,
the quantity of the fluid around the baby, the
It is an eye test for assessing the severity of the disease.
Complication of pre-eclampsia
Immediate – maternal.
Remote – foetal.
Immediate – Maternal – complications
They occur due to poor care and inadequate treatment. However
this disease is unpredictable and may have complication
despite best care.
It is an acute disease, preceeded by severe
pre-eclampsia and characterised by convulsion,
coma, etc. It is one of the major complications
of pregnancy and a principle cause of maternal
death during pregnancy particularly in developing
countries like India, Pakistan, Bangladesh, etc.
Eclampsia is more frequent during the last trimester
and before the onset of labour pains. It is usually
seen in young or elderly 1st time pregnant women and in multiple pregnancies.
The successful prevention of eclampsia depends
upon early recognition, a satisfactory treatment
of pre-eclampsia. Usually, the delivery of the
baby is warranted after eclampsia, irrespective
of the duration of pregnancy.
– premature separation of placenta with bleeding.
Post partum bleeding – (PPH) – excessive bleeding after delivery
causing risk to mother’s life.
‘HELLI’ ‘Syndrome’ – In this, there is breakdown of Red Blood
Cells with high levels of liver enzymes.
Acute renal failure – causing significant lower urine formation
with no urine in the end.
Infection – due to high artificial interference in the process
Immediate foetal complication
Intrauterine foetal death (IUFD) – due to high incidence
of abruptio placentae.
Intrauterine growth retardation (IUGR). IUGR in Complications in Pregnancy.
Pre maturity – either due to preterm onset of labour or due
to premature induction of labour. It may be necessary
to terminate the pregnancy early, in the interest
of the mothers health, if BP becomes uncontrollable
or complications develop.
Hospitalisation – in severe cases is necessary.
Complete bed rest – decrease anxiety.
Daily weight charting.
Record of fluid intake and urine output.
Regular investigation and monitoring of foetal well being.
Regular blood pressure charting.
Control of blood pressure – single or combination of medications
against blood pressure is usually prescribed.
Every attempt is made to prolong the pregnancy in order to
attain healthy baby and healthy mother. However,
if the disease is progressing and involving the
risk to the life of mother, pregnancy is terminated,
irrespective of the duration of pregnancy.
A pregnancy complicated by pre-eclampsia is rarely allowed
to go beyond 40 weeks because of increased risk
to the foetus. The ‘ripeness’ of the cervix (whether
it is beginning to soften, thinned out or open
up) may also be a factor in determining whether
labour will be induced.
After delivery, the blood pressure returns to normal within
2 – 3 weeks. The blood pressure medications are
gradually reduced and taken off. However, the
blood pressure should be recorded regularly and
The risk of recurrence of pre-eclampsia in future
pregnancy is high
If the patient had it at term, the chance of recurrence in
a future pregnancy will be 25%.
If the onset was between 30 – 37 weeks, the recurrence is
If the onset was before 30 weeks of gestation, the chances
of recurrence are approximately 65%.