Management of Common Antenatal Problems
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Proteinuria
Proteinuria + or more should raise suspicions of pre-eclampsia or urinary tract infection. Check the BP again & ask for repeat testing of a mid-stream urine (MSU) specimen. A high BP in the presence of proteinuria indicates pre-eclampsia, & necessitates hospital admission. If the BP is normal & proteinuria is confirmed, ask the woman if she has symptoms of urinary tract infection & send an MSU specimen to the laboratory for MCS (microscopy, culture & sensitivity). Follow up for results in one week.
Vomiting
Exclude any illness (e.g. appendicitis, hepatitis, pyelonephritis) that may cause vomiting. Mild vomiting in a healthy woman requires no more than reassurance, dietary advice (avoidance of large or very fatty meals), &, if necessary, metoclopramide 10 mg orally 8 hourly when necessary. Vomiting that follows all meals or drinks & causes dehydration (hyperemesis gravidarum) requires hospital admission for investigation, intravenous fluids & anti-emetic therapy.
Heartburn
Heartburn is a very common symptom in pregnancy. Advise on avoiding large & fatty meals. Prescribe available antacid, e.g. aluminium hydroxide 10-20 mL, calcium carbonate or magnesium trisilicate 1 to 2 tablets orally when necessary.
Constipation
Reassure the woman that mild constipation is normal in pregnancy, discourage the use of laxatives, & recommend a high intake of fibre and fluid. If a laxative is required, suggest using natural bran, or prescribe bulk-forming laxatives such as Ispaghula husk. Alternatively lactulose 10 mL 12 hourly may be prescribed. It is best not to prescribe irritants (e.g. senna, bisacodyl) in pregnancy.
Haemorrhoids
Distended veins around the anus are frequent in pregnancy. Suggest measures to prevent constipation & discourage straining at stool. If the haemorrhoids are asymptomatic, reassure but explain that they will persist at least until the pregnancy is completed. Mild pain from thrombosed haemorrhoids can be managed with local anaesthetic creams. Refer severe & difficult cases for surgical opinion.
Urinary incontinence
Mild stress urinary incontinence may occur for the first time in pregnancy. Exclude urinary tract infection by performing dipstick testing &/or sending urine for MCS. Teach pelvic floor (Kegel’s) exercises – squeezing for 3 seconds & releasing for 10, repeated 10 times. This is done 10 times per day.
Striae gravidarum
There are no creams or medications that are known to be effective in preventing striae gravidarum.
Varicose veins
Reassurance & advice on leg elevation may be sufficient. Treat troublesome varicose veins by prescribing elastic stockings.
Nonspecific aches & pains
Try to establish a cause for the pain & advise on adjustments in work and lifestyle. Common causes of pain include low backache, sacroiliac strain, round ligament pain, symphysis pubis pain, painful knees & painful ankles. Prescribe paracetamol 1 g orally when necessary. Sleeping with a pillow between the legs may relieve low backache.
Leg cramps
No specific measures have been proven to prevent cramps. Light exercise & stretching may be of value.
Skin rash
Always consider chickenpox, herpes zoster & syphilis as causes. Seek consultant advice & refer to a dermatologist if necessary. There are a number of pregnancy-specific rashes – polymorphic eruption of pregnancy, popular eruption of pregnancy, pemphigoid gestationis & impetigo herpetiformis. Intrahepatic cholestasis of pregnancy (causing pruritus) is a very rare condition in South Africa.
Domestic violence
This is defined as intentional abuse inflicted on one partner by another in an intimate relationship. This may be physical, psychological or sexual. Pregnant women are at increased risk for undergoing such abuse. Women at particular risk for intimate partner violence may have unwanted or unplanned gestations, or be unbooked or book late in pregnancy (third trimester).
It may be worthwhile to ask women privately if all is well at home and if they are getting all the support they need from their partners. Enquire tactfully about domestic circumstances in women who present frequently with unexplained symptoms or who have multiple trivial injuries. Where domestic violence is reported, the woman must be appropriately counselled and referred to the social work department.
| LIST OF PRE-EXISTING ANTENATAL RISK FACTORS High risk (antenatal care and delivery at hospital) Primigravida aged 35 years or older Previous infertility treatment Previous myomectomy Previous cervical or vaginal surgery, including cerclage Previous surgery for urinary incontinence Previous hysterotomy or classical caesarean section Previous stillbirth or early neonatal death Previous baby with obstetric related cerebral palsy Risk of genetic problems (in women booking at ≤24 weeks)* Last baby preterm delivery at 7 months or less* Last pregnancy severe pre-eclampsia* Three or more previous miscarriages* Two or more mid-trimester miscarriages* Diabetes mellitus Chronic hypertension or renal disease Currently symptomatic asthma Epilepsy on treatment Active tuberculosis Malignant disease, e.g. cervix, breast Heart disease Autoimmune disease, e.g. lupus History of venous thrombo-embolism Psychiatric illness, including previous postpartum depression or psychosis Thyroid disease or thyroidectomy Serious disease or deformity of the spine, pelvis or hip, and paraplegia Any other serious medical condition *These risk factors may fall away as pregnancy advances Intermediate risk (antenatal care at local clinic, delivery at hospital) Previous postpartum haemorrhage requiring blood transfusion Previous lower segment caesarean section† Short stature (<1.5 m) Parity ≥5 †Women with previous caesarean section should be seen at least once by an obstetric doctor during antenatal care, preferably early in the pregnancy |
| LIST OF RISK FACTORS THAT ARISE DURING ANTENATAL CARE Requiring non-urgent referral Anaemia (see Chapter 6: Medical Disorders) Uterus large for dates (>90th centile symphysis-fundal height) Uterus small for dates (<10th centile symphysis-fundal height) Symphysis-fundal height decreasing No maternal weight gain in a woman <60 kg Known or suspected multiple pregnancy Breech or transverse lie at 36 weeks or more Rhesus negative blood group with antibodies Extensive vulval warts that may obstruct vaginal delivery Pregnancy at 41 weeks or more Abnormal glucose tolerance test Mild hypertension without proteinuria Requiring urgent (same day) referral Reduced fetal movements at 28 weeks or more Pre-eclampsia Severe non-proteinuric hypertension (≥160/110 mmHg) Antepartum haemorrhage Prelabour rupture of the membranes Any obstetric emergency Any severe illness, e.g. with pyrexia, shortness of breath or abdominal pain Many of the above categories of patients may be sent back to their local clinics for further antenatal care if their problems are resolved at (examples: suspected breech presentation at term found to be cephalic, or suspected IUGR found to be wrong dates) |