Complications in 3rd Trimester

The third trimester is like the last lap of your journey. It covers the 28^th 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.

These include:

Obstetric problems

• Bleed`ing which can be due to
• Placenta praevia
• Abruptio placentae
• Other causes.
• Preterm labour.
• IUGR or foetal growth retardation.
• Post term pregnancy.     

Medical problems

• Hypertension in pregnancy, which may or may not be purely pregnancy related.
• 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.
• Warning signs for medical disorders include:
• Persistent swelling of feet hands or face.
• Increasing breathless, especially on routine activity.
• Headaches.
• 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 pains.

Placenta Praevia

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 threatening bleeding.

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.
  

• Causes:
  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, Rh-sensitisation.

• 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 later.

• 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..
• Ultrasonography:
  It is most selective and reliable investigation for the diagnosis of placenta praevia. Up to 98% of cases may be detected accurately.

• Treatment:
  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.
  Bed rest.
  Tocolytic agents in selective patients (which prevents uterine contractions).
  Once the baby attains maturity, i.e. at 37 completed weeks decision is usually taken for elective caesarean section.
  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 necessary.

Abruptio Placentae

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.

• Types
  Depending on whether the bleeding shows externally or not, the various medical types of placental abruption can be
  Revealed
  Concealed
  Mixed

• How often does this occur?
  This is a little more common than placenta praevia about 1 in 150 pregnancies.

• Causes
  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 which includes:

• Ultrasonography
  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 or not.
• Treatment
  Immediate admission.
  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 ammniotomy.
  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 10^th percentile for their gestational age and less than 2500gms other than babies born out of preterm delivery.

How often does this occur?

3 – 10% depending on the type of population.

• Causes
  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.

• Maternal
  Hypertensive disease likes pre-eclampsia.    .
  Chronic hypertension.
  Gestational diabetes.     

• Smoking 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 baby.

• Poor 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 babies.
  A good quality of prenatal care starting with the 1^st antenatal visit has a beneficial impact on IUGR.

• Placental causes

Decreased placental mass, absolute or relative conditions that can lead to IUGR are:

• Minor abruption.
  Infarction.
  Post term pregnancy.
  Multiple pregnancy.

Intrinsic placental defect during formation or implantation causes IUGR.

• Foetal Causes
  Chromosomal disorders – like Down’s syndrome,other genetic defects.
  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?

• Ultrasonography:
  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.

•  Biophysical Profile

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 2^nd 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 being
  The 3^rd 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%

Causes
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 

Ultrasonography
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.
Biophysical profile.
Doppler and colour doppler.

These are used appropriately for foetal surveillance. Not all the tests are required in every case.

Treatment
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 taken.

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

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 of pregnancy.

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. 

Effect 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 age, usually.

(iii) Gestational Diabetes also called as pregnancy diabetes:
Diabetes that develops during pregnancy or detected during pregnancy is called ‘gestational diabetes’.
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.

The 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).     
Chronic hypertension.
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.

Screening test
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 given below:

Upper limit of Normal

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.

Treatment
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.

Doctors Orders
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 them.

Good Diet       
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 are overweight.
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.

Exercises
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 medical team.

Rest
Especially in 3^rd 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. 

Careful Monitoring
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 3^rd 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. 

Timing and mode of pregnancy termination
There is no need to terminate pregnancy before term. Once you reach your calculated date of delivery, you should be delivered.
It is not necessary to do caesarean section. More than 50% can be delivered vaginally (normally) without many complications.

Future risks:
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 examination regularly.

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.

Causes:

Physiological 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.

Nutritional anaemia:

Iron deficiency is the commonest reason for the development of anaemia.
Deficiency of iron in food, poor reserves of iron in the body, excessive blood loss, poorly spaced pregnancies.
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 iron.

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).

Why is anaemia so common in India?
Besides the physiological demands of pregnancy, other factors are

Repeated child bearing. ‘too many, too soon, too close and too late’.

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.
  
• Malaria.
  
• Kalaazar.
  
• Worms.
  
• Amoebiasis.
  

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.
  
• Restlessness.
  
• 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 of anaemia.      

Levels of haemoglobin

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 mm.
Packed cell volume – normal more than 32%.
Mean corpuscular haemoglobin concentration (MCHC) more than 30%.
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.

Treatment

Pre-planned pregnancy with adequate antenatal care.

Healthy dietary habits with ingestion of vegetables and fruits daily.

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 in iron.    

The foods which contain Iron in a rich quantities are:

Ragi, fenugreek (methi), jaggery.
Pumpkin.
Potatoes in their skin.
Spinach.
Spiruline (seaweed).
Legumes (green peas, lentils).
Soybeans and soy products.
Dried fruits.
Duck.
Beef.
Liver and other organ meats.
Oysters (cooked, don’t eat raw).
Sardines.

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 intestines.

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.
Almonds, peanuts.
Dried fruits.
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.

Hypertension in Pregnancy

(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.

Classifications:

(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 or eclampsia.

(iv) Late or transient hypertension.

Pre-eclampsia:
Development of hypertension with protein in the urine with or without oedema after 20 weeks of pregnancy is known as Pre-eclampsia.

Eclampsia:
It is pre-eclampsia with convulsions, which are not due to co-incidental nervous system (brain and spinal cord) disease.

Chronic Hypertension:
It is hypertension diagnosed before pregnancy or before 20 weeks of pregnancy (5 months) and lasts more than 6 weeks after delivery.

Gestational Hypertension:
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 are:

Hypertension:
It is rise in blood pressure, two readings taken 6 hours apart at rest.
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.

Oedema:
Swelling of body due to collection of fluids under skin.

How often does this occur?
10% in most parts of India.

Causes:
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 1^st time pregnancy).
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).
Medical disorders – like Diabetes mellitus, hypertension, renal diseases. Hereditary.

  What do you feel?

Headache: Located in front or back of head. Lasting for more than 2 hours.
In increasing frequency, duration and regularity.
Disturbed sleep
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.).

Urine test
It is done to detect proteins in the urine.

Ultrasonography  
Investigations and tests. At regular intervals to check the growth of the baby inside the uterus, the quantity of the fluid around the baby, the placenta, etc.

Fundoscopy:
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.

Eclampsia
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 1^st 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.

Abruptio placenta    – 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 of delivery.

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.

Treatment:

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.

Implications

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 frequently.
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 40%

If the onset was before 30 weeks of gestation, the chances of recurrence are approximately 65%.