Appendix

15 years or less

Pregnancy may have a detrimental effect on the development of the patient’s personality.

Determine the duration of pregnancy. If 20 weeks or less termination may be indicated.

2

16–19 years

Poor social circumstances.

Pre-eclampsia.

Anaemia.

Refer to social worker for support. Watch for proteinuria and a rise in blood pressure from 28 weeks.

Regular Hb checks.

1

37 years or more

Medical conditions such as hypertension and diabetes are commoner.

Chromosome abnormalities are commoner, e.g. Down syndrome

Carefully look for medical problems at the first visit, and at 26 and 34 weeks.

Motivate for sterilisation.

Determine the duration of pregnancy:

If 13 weeks or less, an ultrasound examination for nuchal thickness is done, followed at 22 weeks looking for structural defects.

Before referral, make sure that the patient will agree to termination of pregnancy, if this is indicated.

*Refer back to level 1 if medical and genetic screening is normal and less than 40 years.

1

Allergies

Penicillin allergy with an anaphylactic reaction is always dangerous, but rarely occurs.

Allergies must always be clearly documented in the Maternity Case Record.

1

Body Mass Index (BMI)

Cephalopelvic disproportion and shoulder dystocia.

Hypertension and diabetes

Use weight, height and attached BMI table.

When reading BMI off table:

With 1st visit in 2nd trimester, subtract 4 kg

With 1st visit in 3rd trimester, subtract 8 kg

Ultrasound examination for accurate gestational age estimation at 18-22 weeks.

Monitor for hypertension and glycosuria.

Glucose profile and umbilical artery Doppler at 26 weeks

BMI above 50

3

Diabetes mellitus (in the patient)

Pregnancy worsens the diabetes.

Insulin requirements increase.

Higher incidence of fetal death.

Large babies with obstructed labour, shoulder dystocia and birth injuries.

Neonatal hypoglycaemia.

Careful control of the diabetes, in order to keep the blood glucose levels as close to normal as possible is absolutely essential.

3

Diabetes mellitus (family history)

There is an increased risk of the patient developing diabetes during pregnancy.

If absent –

If present –

Glucose profile at 26 weeks.

2

Epilepsy

Convulsions may occur more frequently in pregnancy. Some anticonvulsant drugs may cause congenital abnormalities.

The dose of anticonvulsant drugs may need to be increased.

Put the patient on a safe drug before pregnancy (e.g. carbamazepine). The drugs are not changed during pregnancy because of the danger of convulsions.

2

Congenital abnormalities (in the family)

Serious abnormalities tend to recur.

If 13 weeks or less, an ultrasound examination for nuchal thickness is done, followed at 22 weeks looking for structural defects.

If more than 13 weeks, a genetic amniocentesis should be offered between 16 and 22 weeks.

Drugs or medication

Danger of teratogenesis.

Points towards a disease not mentioned in the history.

Get accurate details and consult a doctor.

1

HIV

Mother-to-child transmission of HIV.

With AIDS the mother’s clinical condition may deteriorate.

Commence patient on TLD if no contra-indications.

If contra-indications refer to an antiretroviral (ARV) treatment clinic.

The stage of disease needs to be determined and noted. Check at each visit for symptoms and signs indicating progression at a more advanced stage of disease.

2

Auto-immune diseases

Raised perinatal mortality rate.

Early onset of severe pre-eclampsia.

Get detailed information about the disease and medication.

3

Psychiatric illness

Suicide is commoner.

Illness may become worse during pregnancy.

Get detailed information about the disease and medication.

Termination of pregnancy may be indicated (if duration of pregnancy is less than 20 weeks).

2

Rubella

Congenital abnormalities.

Ask about fever and a skin rash in the first trimester of pregnancy and also about contact with rubella.

Rubella antibody titres can confirm or exclude diagnosis.

1

Thyrotoxicosis (hyperthyroidism)

Thyrotoxicosis and/or goitre in the neonate.

Get detailed information about the illness and medication. Request maternal thyroid hormone levels.

Thyroid hormone levels in cord blood.

2

Respiratory System

Asthma

Prostaglandin F2 alpha is contraindicated.

Asthma usually improves during pregnancy.

Symptomatic and on steroids –

2

Chronic cough more than 14 days. Night sweats, fever and weight loss.

Possible tuberculosis and/or AIDS.

Single X-ray chest with fetus screened off and sputum for GeneXpert or acid fast bacilli.

A rapid test if HIV status unknown.

1

Active tuberculosis

Spread to other family members and the newborn infant.

If stable and on treatment.

The newborn infant must be given isoniazid.

1

Hypertension:

1. Diastolic 90 and/or systolic 140 mm Hg or more.

2. Antihypertensive treatment.

Pre-eclampsia, abruptio placentae, and IUGR or perinatal death.

With diastolic 90 mm Hg or more or systolic 140 mm Hg or more or proteinuria –

3

Dyspnoea and orthopnoea

Symptoms of heart failure.

Underlying heart disease must be excluded or confirmed by the doctor.

2

Rheumatic heart disease

Cardiac output increases with increased risk of cardiac failure and maternal death.

Symptoms and signs of heart failure and/or stenotic heart valve lesions –

3

Varicose veins

May indicate previous venous thrombosis.

Become worse during pregnancy.

Watch for possible thrombosis.

Bed rest and elastic stockings.

1

Thrombo-embolism

Increased incidence in pregnancy with risk of maternal death.

Anticoagulant therapy during pregnancy may have to be considered.

3

Haemorrhoids

May get worse in pregnancy.

May prolapse and thrombose.

Only conservative management needed.

1

Jaundice

Determine if the patient is a carrier of the hepatitis B virus.

Can infect the infant during delivery.

If antigen present (the infant must be given hyperimmune globulin and be immunised) –

2

HIV positive and on FDC or TLD

High risk for serious liver damage

Stop FDC or TLD and refer to an ARV treatment clinic

2

Pyelonephritis

High risk of recurrence.

Midstream urine (MSU) for culture to be sure that the infection is completely treated.

1

Cystitis

Common in pregnancy.

MSU for culture if symptomatic.

Treat with single dose antibiotics

1

Myomectomy

Danger of ruptured uterus.

Elective Caesarean section indicated.

2

Thyroidectomy

Hypothyroidism can develop during pregnancy with the danger of abortion and neurologic impairment of the fetus.

If hyperthyroidism was the indication for surgery, manage as for thyrotoxicosis.

Look carefully for an operation scar.

Thyroid function tests are indicated.

2

Chest surgery

High risk of thrombosis of artificial heart valves in pregnancy.

Warfarin: danger of teratogenesis in the 1st and bleeding in the 3rd trimester.

Correct use of anticoagulant therapy.

3

Abruptio placentae

Tends to recur:

10% chance after previous abruption.

25% chance after 2 previous abruptions.

Deliver at 34 weeks, antenatal steroids for lung maturity must be given.

3

Diabetes mellitus

Recurs in successive pregnancies. Complications already mentioned.

Random blood glucose if there is glycosuria.

Glucose profile at 26 weeks.

2

Ectopic pregnancy

High risk of recurrence.

Gynaecological examination to confirm intra-uterine pregnancy.

Ultrasound is indicated.

1

Grande multiparity (five or more pregnancies have reached viability)

Medical conditions are commoner.

Obstetric complications are commoner: IUGR, multiple pregnancy, abnormal lie, obstructed labour and postpartum haemorrhage.

Motivate for sterilisation.

Look for medical conditions at the first visit.

Look for abnormal lie after 34 weeks.

Additional oxytocin following 3rd stage and observe closely.

2

Infertility

Ectopic pregnancy and multiple pregnancy commoner.

Gynaecological examination to confirm intra-uterine pregnancy and the size of the uterus. (Ultrasound examination is indicated.)

2

Caesarean section(s)

Danger of ruptured uterus with previous vertical uterine incision, or with two or more Caesarean sections.

Get details of the indication and type of incision from old records.

Ultrasound for accurate gestational age.

Elective Caesarean section at 39 weeks if 2 previous Caesarean sections or a vertical incision.

2

Congenital abnormalities

Possible genetic inheritance.

High risk of recurrence.

Genetic counselling.

Determine the duration of pregnancy:

If 13 weeks or less, an ultrasound examination for the nuchal thickness is done, followed at 22 weeks looking for structural defects.

If more than 13 weeks an amniocentesis should be offered between 16 and 22 weeks.

2

Abortion

More than two first trimester abortions.

One or more mid-trimester abortions.

Test parents for chromosomal abnormalities.

If history indicates an incompetent cervix, a MacDonald stitch may be indicated (inserted at 14-16 weeks ).

2

Perinatal death

Highest risk group for another perinatal death to occur (especially when the cause is unknown).

Get a detailed history and the notes from the previous pregnancy.

2

Postpartum haemorrhage and retained placenta

Tend to recur in successive pregnancies.

Deliver in hospital.

Additional oxytocin following 3rd stage and observe closely.

2

Pre-eclampsia

2. Previous pregnancy with pre-eclampsia developing in late 2nd or early 3rd trimester of pregnancy.

High risk of recurrence. Low dose aspirin (Disprin) 150 mg daily from 14 weeks.

2 weekly antenatal clinic visits from 24 weeks.

Calcium 500 mg tablets twice daily.

2

Primigravida

Higher incidence of pre-eclampsia late in pregnancy.

Careful attention to blood pressure and proteinuria.

1

Vacuum extraction or forceps delivery

May indicate cephalopelvic disproportion.

Correct use of the partogram in labour.

1

Preterm labour

High risk of a recurrence in the same pregnancy.

Assess the cervix regularly from 26 to 32 weeks for changes, more regular bed rest, no intercourse in the second half of pregnancy. If there is cervical incompetence, a MacDonald suture at 16 weeks may be indicated.

3

Antepartum haemorrhage

Abruptio placentae and placenta praevia are both serious complications. Local causes, e.g. vaginitis, cervicitis, can also cause bleeding.

If not currently bleeding and there is no fetal distress:

1. Do speculum examination:

No local cause.

2. Ultrasound shows placenta praevia.

3

Asymptomatic bacteriuria

33% incidence of pyelonephritis in these patients.

High risk of preterm labour.

Single dose antibiotics.

Repeat urine culture at next antenatal visit.

1

Diastolic blood pressure of 90 and/or systolic of 140 mm Hg or more

Hypertension or pre-eclampsia.

If diastolic 100 and systolic 150 mm Hg or more or proteinuria, admit to hospital.

2

Reduced fetal movements

Fetal distress or intra-uterine death.

If count remains poor, antenatal fetal heart rate monitoring.

2

Glycosuria 1+ or more

Possible diabetes.

Less than 8 mmol/l is normal.

8 to 11 mmol/l – arrange for glucose profile.

11 mmol/l or more = diabetes.

Admit to hospital for control if diabetes diagnosed.

2

Haemoglobin less than 10 g/dl

Anaemia in pregnancy.

Arrange full blood count.

If confirmed anaemia – Refer.

2

Haematuria

Possible cystitis.

Bilharzia, if endemic in the area.

Urine microscopy and culture. Treat cystitis.

1

Multiple pregnancy

Greater risk of preterm labour.

High incidence of perinatal death and pre-eclampsia.

Anaemia.

Regular vaginal examinations from 26 weeks for cervical effacement and dilatation.

Careful monitoring of proteinuria and rising blood pressure.

Do Hb more frequently.

Ultrasound examination for growth and chorionicity:

Dichorionic (two placentas)

2

Pyelonephritis in current pregnancy

High risk of recurrence.

Follow-up urine culture to ensure that treatment was successful.

2

Polyhydramnios

Congenital abnormalities.

Multiple pregnancy.

Diabetes mellitus.

Rh sensitisation may be present.

Ultrasound examination and glucose profile are indicated. Check blood groups, and possible sensitisation.

Exclude oesophageal atresia in the infant immediately after birth.

2

Proteinuria

Pre-eclampsia or renal disease, e.g. chronic nephritis or nephrosis, may be present.

More than 1 + indicates pre-eclampsia or serious kidney disease. Serum creatinine to assess kidney function.

2

Ruptured membranes

Preterm labour and chorioamnionitis.

If 34 weeks or less transfer to level 2 hospital.

2

Rhesus negative

Rh-sensitisation with hydrops fetalis.

If no antibodies, retest for antibodies at 26, 32 and 38 weeks.

If antibodies present:

Titre less than 1:16.

Titre above 1:16 or more.

3

Preterm labour

Preterm infant.

If less than 34 weeks admit to level 3 hospital. Consider suppression of labour and steroids for lung maturity.

3

Rapid syphilis test positive and

VDRL titre 1:16 or more

Congenital syphilis.

Patient must receive full treatment.

1

Rapid syphilis test positive and VDRL titre less than 1:16

No history of full treatment of woman and partner in past 3 months.

Patient must be fully treated.

1

Uterus larger than dates

Multiple pregnancy.

Polyhydramnios.

Diabetes.

Large fetus.

Incorrect dates.

Arrange for ultrasound and glucose profile.

With a large fetus there is a danger of disproportion.

Be ready to manage shoulder dystocia.

2

Uterus smaller than dates

IUGR.

Oligohydramnios

Fetal death.

Incorrect dates.

Umbilical artery Doppler

Careful measurement of fundal growth and fetal movement counts:

With few or no fetal movements, antenatal fetal heart rate monitoring.

2

Abnormal lie

Breech, oblique or transverse lies suggest possible placenta praevia, multiple pregnancy or disproportion.

Less than 34 weeks, not important.

If more than 34 weeks: exclude the named complications, and refer to a doctor for external cephalic version at 38 weeks, if there are no contraindications.

All others.

2

Umbilical artery Doppler

Placental insufficiency

IUGR

Poor SF growth

≥ 75th and < 95th centile (equal to more thn the 75th centile)

Repeat after 2 weeks

1

≥ 95th centile (equal to more than the 95th centile)

2

Alcohol

Fetal alcohol syndrome.

Counselling: no alcohol should be drunk during pregnancy.

1

Illicit drug use

IUGR

Hypertension

Counselling

Social support

Religion (Customs)

Fear that certain customs will not be fulfilled, e.g. with regard to abortions, placenta, etc.

Counselling: Religious beliefs will be respected.

1

Single mother and/or unwanted pregnancy

Complications of pregnancy are commoner because of usually poorer socio-economic circumstances.

Counsel about termination of pregnancy if less than 14 weeks.

Social support may be needed.

Advise about an effective method of family planning.

Sterilisation may be indicated in a multipara.

1

Smoking

Danger of IUGR.

Advice to the patient: strongly advise her to stop smoking. Encourage her if she stops.

Careful attention to fundal growth.

1

Poor socio-economic circumstances

Pregnancy complications will occur more commonly.

Malnutrition, infection, and anaemia also occur commonly.

Social support necessary.

Advise on effective method of family planning.

Sterilisation may be indicated in a multiparous patient.

1