Oxford Handbook of Midwifery (48 page)

• Raised respiratory rate—tachypnoea
  
• Tiredness
  
• Dizziness
  
• Fainting—syncope.
  

  The woman should be examined at every visit for:
  

• Cyanosis
  
• Pallor
  
• Prominent neck veins
  
• Peripheral oedema
  
• Rapid weight gain
  
• Blood pressure, heart rate, and rhythm
  
• Auscultation of heart sounds to record type and grade of murmurs
  
• Auscultation of the lung bases to detect pulmonary oedema.
  

  Investigations
  

• Electrocardiogram.
  
• Echocardiogram.
  
• 12 and 20 week scans.
  

  CARDIAC CONDITIONS
  

  183
  

Most maternal cardiac conditions present a high risk for intrauterine growth restriction (IUGR) and pre-eclampsia so the midwife should continue normal antenatal surveillance. Drug therapy will continue during the pregnancy and may involve the use of anticoagulants in some conditions. Regimens should be monitored closely with individual drugs considered for their likely effect on pregnancy and the fetus.

Recommended reading

Boyle M, Bothamley J (2009). Cardiac disorders: care during pregnancy, labour and the puerperium.
Midwives
October/November
, 36–7.

1
Lewis, G (ed.) (2007).
The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer
—
2003–2005
. The 7th report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.

CHAPTER 10
Medical conditions during pregnancy

184‌‌

Diabetes

• Diabetes during pregnancy can be classified into three forms:
  
  • Insulin-dependent diabetes, which is present prior to pregnancy (type 1 diabetes)
    
  • Non-insulin dependent diabetes (type 2 diabetes)
    
  • Gestational diabetes (GDM) or impaired glucose tolerance, which arises as a result of pregnancy and then resolves after the birth. The incidence is between 3% and 12% of the pregnant population. Overt diabetes will develop in 20–30% of women with GDM within 5 years.
    ¹
    
• Non-diabetic pregnant women are offered a glucose challenge screen to detect GDM if any two of the following risk factors are present:
  
  • Glycosuria on two occasions on testing at an antenatal visit (early morning sample)
    
  • History of diabetes in a close relative
    
  • Obesity, BMI >27
    
  • Previous baby weighing more than 4.5kg
    
  • Previous unexplained perinatal death
    
  • Previous baby with congenital malformations
    
  • Unexplained severe polyhydramnios (excess amniotic fluid in the uterus).
    
• Maternal complications which might arise in the pregnant diabetic client are related to poorly controlled glucose levels in the maternal serum:
  
  • Urinary tract infection
    
  • Vaginal infection
    
  • Polyhydramnios
    
  • Pregnancy-induced hypertension
    
  • Fetal macrosomia leading to shoulder dystocia.
    

    Fetal complications
    

• Congenital abnormality—four times higher than in non-diabetic women
  

  •
  Prematurity associated with delayed lung maturity
  

• Perinatal death (due to the above conditions)
  
• 1:100 risk of the child themselves becoming diabetic.
  

  Carbohydrate metabolism during pregnancy (non diabetic)
  

• Pregnancy itself is said to be diabetogenic as a result of changes due to the action of the pregnancy hormones.
  
• The fetal/placental unit alters glucose metabolism in the following ways:
  
  • From the 10th week fasting blood sugar progressively falls from 4 to
    
    1. mmol/L
       
  • The placenta produces a hormone called human placental lactogen, which increases the maternal tissue resistance to insulin
    
  • Blood glucose levels therefore are higher after meals and remain so for longer than in the non-pregnant state.
    
  • More insulin is required by the body and output of insulin in the pancreas increases by three to four times the normal rate.
    

DIABETES

185

Management of diabetes/GDM
²

If the mother is already diabetic, her insulin requirements will be increased during pregnancy and her pregnancy will be monitored carefully. If it is safely achievable, women with diabetes should aim to keep fasting blood glucose between 3.5 and 5.9 mmol/L and 1h postprandial blood glucose

<7.8 mmol/L during pregnancy.

Women with type 2 diabetes may form the largest population of pre- pregnancy diabetics and be exposed to the same levels of risk related to pregnancy outcomes. Their condition may indeed be diagnosed for the first time during pregnancy due to screening for GDM. Careful monitoring of glycaemic control, provision of insulin as a replacement or in addition to metformin therapy could improve outcomes.

For women who develop GDM a careful assessment of their insulin needs is required and therapy commenced in accordance with the need to control blood glucose levels in the prescribed range.

Women with insulin-treated diabetes should be advised of the risks of hypoglycaemia and hypoglycaemia unawareness in pregnancy, particularly in the first trimester. During pregnancy, women with insulin-treated diabetes should be provided with a concentrated glucose solution and women with type 1 diabetes should also be given glucagon; women and their partners or other family members should be instructed in their use.

General principles of care for women with diabetes in pregnancy

12 months, it should be offered as soon as possible after the first contact in pregnancy in women with pre-existing diabetes.

12 months in women with preexisting diabetes, it should be arranged at the first contact in pregnancy. If serum creatinine is abnormal

(120 micromol/L or more) or if total protein excretion exceeds 2g/day,

CHAPTER 10
Medical conditions during pregnancy

186

referral to a nephrologist should be considered (estimated glomerular filtration rate (eGFR) should not be used during pregnancy). Thrombo- prophylaxis should be considered for women with proteinuria above

5 g/day (macroalbuminuria).

• Careful screening for urinary tract and vaginal infection, with prompt treatment.
  
• Discuss the need for fetal anomaly scan in light of the increased risk of malformations.
  
• Careful monitoring of fetal growth by regular ultrasound scans.
  
• At 36 weeks’ gestation a discussion will take place with the mother regarding mode of delivery and the options available. A
  

recommendation of induction of labour or elective caesarean section will be made should the maternal or fetal condition warrant this.

1. Peters RK, Kjos SL., Xiang A., Buchanan TA (1996). Long-term diabetogenic effect of single pregnancy in women with previous gestational diabetes mellitus.
   International Journal of Gynecology and Obstetrics
   54
   , 213–13.
   
2. Royal College of Obstetrics and Gynaecologists (2008).
   Diabetes in Pregnancy: Management of Diabetes and its Complications From Preconception to the Postnatal Period
   . Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.
   

EPILEPSY

187‌‌

Epilepsy

It is estimated that 1 in 250 of all pregnancies in the UK are in women with epilepsy. These women face unique problems when it comes to control- ling their epilepsy during a pregnancy.

Women with epilepsy taking antiepileptic drugs (AEDs) have a two to three times greater risk of having a child with a major congenital malformation than women without epilepsy. Nevertheless, it is still overwhelmingly likely that a woman with epilepsy will have a normal pregnancy and give birth to a healthy child.

The pregnancy should be identified early so adjustments to anticonvul- sive therapy can be made and a higher dose of folic acid (5mg) can commence. Some AEDs have been associated with altered concentrations of folate and an increased incidence of neural tube defects.

The main problems in pregnancy are related to the number of seizures experienced. During pregnancy some women notice a reduction in the number of seizures, but others may experience an increase.

Generalized convulsive seizures may cause metabolic alterations in the mother's body, increase her blood pressure, and change her circulation pattern. There is also an increased risk of injury to the fetus from falls.

Management

Recommendations for management during pregnancy:
^1,2