Common Problems in Pregnancy
Pregnancy is a unique experience for the mother. While the “new life” is growing inside her womb, she is given to dreaming beautiful dreams. That’s all very fine. “In fact, it is very much desirable,” if I may quote a world-renowned obstetrician.
Like any normal individual with responsibilities pregnancy put extra load on her systems, and she may suffer from certain medical problems. The special significance of these problems is inasmuch as that these may have adverse effect on the progress and outcome of pregnancy.
Anaemia
Believe it or not, on an average, total blood volume during pregnancy shoots up by about 45 per cent. As a result of high dilution of the body blood, ordinary technique of blood examination will show anaemia (apparent) with haemoglobin level between 10 and 11 g/dl.
True, during pregnancy a woman saves about 25 mg of iron since she is no more losing blood in menstrual periods. But then the foetus needs about 400 mg of iron, the placenta 150 mg and lactation 300 mg for the pregnancy and the first three months of lactation. Thus, a pregnant women suffers from iron-deficiency if an extra amount of iron is not administered to her. Such other problems as can accompany pregnancy (poor dietary intake, worm infestations, chronic infections like tuberculosis) usually further aggravate existing anaemia. These factors may cause vitamin B12 and folic acid deficiency in addition, thereby introducing an element of megaloblastic anaemia.
Anaemia during pregnancy causes vague but widespread manifestations. The woman develops pallor of skin, nails and conjunctiva underlying the lids. There is loss of appetite, giddiness and insomnia (sleeplessness). She gets tired easily and has a feeling of being unwell. She may become increasingly conscious of heartbeat (palpitations) which becomes quite fast (tachycardia). Nails may become brittle and flattened (platynechia) or spoon-shaped with a definite concavity (koilonychia).
In advanced cases, she may begin to become breathless on little exertion. Swelling of feet and ankles occur in some anaemic women.
Red and swollen tongue, indigestion and difficulty in swallowing are seen in many a case.
Remember, anaemia can have an adverse effect not only on the mother but on the baby as well. If you neglect it, your baby runs the risk of being a low birthweight infant. And that is not a small risk.
If you are pregnant and anaemic as well, chances are you have not been taking your doctor’s advice seriously. Or, maybe you have not as yet had regular antenatal check-ups. Report to your doctor immediately. He will get your blood and stool (maybe some other things also) tested.
You must cooperate with your doctor in treating your anaemia. He would expect you to take a diet that is rich in iron. But, you also need medicinal iron which he may like to give you as tablets or injection(s). If your anaemia is quite significant and pregnancy is fairly advanced, the doctor may want to raise your haemoglobin through blood transfusion.
Though iron-deficiency plays a pivotal role in causation of nutritional anaemia during pregnancy, folic acid and vitamin B12 deficiencies may also contribute to it. Folic acid needs during pregnancy is twice that of the non-pregnant women. The worst danger of folic acid deficiency is in the form of “neural tube defects” (NTDs) which means the defects of spinal cord in the growing foetus. The neural tube defects occur in the very first four weeks following conception. It is, therefore, advisable that women of child-bearing age drink plenty of orange juice, and eat enough of dried beans, soyabeans, raw spinach and whole-wheat bread. Medicinal folic acid (available as tablets) may also be taken on doctor’s prescription.
Severe and obstinate vomiting
In some nervous and hypersensitive pregnant women, what begins as morning sickness becomes severe and persisting, occurring several times a day. The vomit may contain blood. Too soon the woman stops accepting food and a little later even rejects water. She becomes anorexic and constipated. Excessive thirst, dryness of the mouth and fall in the amount of urine results. The blood pressure falls and the pulse becomes fast and weak.
Treatment of this problem, hyperemesis gravidarum, should be left to the doctor and his team. Hospitalisation is essential.
What the pregnant woman must do to safeguard against the above-mentioned serious condition is to take adequate care of the morning sickness which may be a predecessor to hyperemesis gravidarum. A cup of light tea or a fruit drink together with sweet biscuits should be taken in a recumbent position. She should sit up only after this drink and eat on waking up in the morning. During the day, she should take small amounts of carbohydrate-rich foods at frequent intervals, and avoid fats, fish, meat and soups.
High blood pressure (Hypertension)
In some nervous and hypersensitive pregnant women, what begins as morning sickness becomes severe and persisting, occurring several times a day. The vomit may contain blood. Too soon the woman stops accepting food and a little later even rejects water. She becomes anorexic and constipated. Excessive thirst, dryness of the mouth and fall in the amount of urine results. The blood pressure falls and the pulse becomes fast and weak.
Treatment of this problem, hyperemesis gravidarum, should be left to the doctor and his team. Hospitalisation is essential.
What the pregnant woman must do to safeguard against the above-mentioned serious condition is to take adequate care of the morning sickness which may be a predecessor to hyperemesis gravidarum. A cup of light tea or a fruit drink together with sweet biscuits should be taken in a recumbent position. She should sit up only after this drink and eat on waking up in the morning. During the day, she should take small amounts of carbohydrate-rich foods at frequent intervals, and avoid fats, fish, meat and soups.
High blood pressure (Hypertension)
Pre-eclampsiais by far the commonest manifestation of toxaemias of pregnancy. Its earliest signs are high blood pressure and puffiness of the eyes, gain in weight and swelling over ankles and feet. Generally, swelling of the ankles are found spreading up the leg. Swelling, called oedema, may spread to other parts of the body. In severe cases, even external genitals may become swollen. Examination of urine will show presence of albumin, a protein.
Such a woman may complain of malaise, lassitude, headache, visual disturbances, vomiting and abdominal pain.
Pregnant women who are regularly attending an antenatal clinic should find little difficulty in having pre-eclampsia diagnosed at an early stage. It usually occurs in the second half of pregnancy period.

As a part of its management, your doctor will advise you to have complete bed rest and to reduce your salt intake. He will also prescribe a sedative, a diuretic and an hypotensive drug to get rid of the “water logging” and to bring down the blood pressure.
If you are overweight at the outset of pregnancy, you must reduce it. Also, do not let anaemia develop and see that your blood pressure is within normal range. All this will help you to keep pre-eclampsia at an arm’s length.
Eclampsia includes all the manifestations of pre-eclampsia but in addition there are convulsions and she may go into coma also. It may occur during pregnancy, labour or after childbirth.
The disease is very serious and may prove fatal.
Immediate hospitalisation is a must. Most good hospitals have special eclampsia rooms which have maximum quietness.
Chances of foetal death in eclamptic mothers are 25 per cent higher than in normal women. Also foetal growth retardation is a common observation. The singlemost important contributory factor to the well-being of the newborn in this condition is a good antenatal care. In its absence the progress of the disease remains unchecked, leading to a fatal outcome.
Gestational diabetes
One in 20 pregnant women may develop what is termed “gestational diabetes” during confinement. It can be controlled by consuming high protein, low carbohydrate diet. In other words, the recommended foodstuffs are soyabean or fish, egg and lean meat with restriction of fruit juices, bread and legumes. Some may need insulin as well.
Left untreated, even gestational diabetes may cause serious problems to the growing foetus in the form of a heavy baby weighing over four kg with large deposits of body fat. Such a baby is difficult to deliver by the normal process. There is also a risk of premature delivery and stillbirth, especially if the gestational diabetes is severe enough to need insulin for its control.
Majority of the pregnant mothers with gestational diabetes become all right by six weeks after delivery. Only a small proportion may develop adult-onset diabetes.
Diabetes mellitus
In half or even more of the pregnant women with diabetes the disease is known to be present before pregnancy occurs. The woman must apprise her doctor with this information. Even if she is not aware of it, she should report to him such manifestations as increased thirst, greater frequency of micturition (urination), increased appetite or itching in the region of the vulva. Remember, diabetics are more prone to develop toxaemias of pregnancy.
Management of pregnancy complicated with diabetes is best done by an obstetrician in collaboration with a physician.
Foetus of such a woman runs the risk of dying anytime during pregnancy. This risk is greater during the last month. The baby is likely to be larger and heavier than an average born at full term.
Be mentally prepared if you are such a mother. The chances are that either you would have to undergo a caesarean section or surgical induction of labour. The large, oedematous baby should immediately by examined by a child specialist. He requires special care. Despite his being overweight, he needs to be treated as premature if delivered before term.


Malaria

High-swinging fever as a result of malaria can complicate pregnancy. Abortion, premature labour and foetal death may occur. The mother’s health deteriorates. In malaria, especially when it has caused severe anaemia also, complications in childbirth occur. Anaemia and poor material resistance predisposes to superadded infections.
If your pregnancy has somehow been complicated by malaria, do cooperate with your doctor in curing malaria. Remember pregnancy is not a contraindication for using anti-malarial drugs. Anti-malarial agents do not cause abortion. Risk, if any, is just very slight. At any rate, it is practically zero compared to the dangers involved in not treating the disease. If malaria is left untreated, it can even cause the mother’s death.
Disorders of urinary tract
Cystitis is a bacterial infection of the urinary bladder. Painful micturition (dysuria), episodes of retention of urine and fever should arouse suspicion about the infection.
Your doctor will get the diagnosis confirmed by the presence of red blood cells, pus cells and bacteria (the last-named are grown in culture discs).
He will prescribe chemotherapeutic drug(s) to get rid of the infection. Don’t forget to take plenty of fluids during treatment.

Acute pyelonephritis, in 90 per cent of the instances, shows an infection by a bacteria, E. coli, known to occur in about 2 per cent of the pregnant women. The usual route of infection is from the bladder and uterus to the kidneys.
High fever with chills and rigors, nausea, vomiting, low backache (usually at the junction of the spine with the lowermost rib) should arouse suspicion of this disease, particularly if the onset has been abrupt. Difficult micturition and passing of little blood through urine may occur. Urine contains pus cells. Urine culture shows growth of the causative bacteria and helps in deciding about the chemotherapeutic agent.
Your doctor will prescribe drugs as soon as he is convinced of the diagnosis on urine examination. Later, chemotherapeutic agent may have to be changed if suggested by the culture-sensitivity report on urine. Take adequate bed rest during the acute phase.
As a general rule, pyelonephritis during pregnancy must not be regarded as cured unless and until repeated urine examinations reveal that urine is normal. Inadequate treatment may cause chronic pyelonephritis and renal failure in due course.
In a mild case of chronic pyelonephritis, the patient needs to be hospitalised. Incidence of intra-uterine death is 50 per cent. Those born alive are smaller in size. Many authorities advocate termination of pregnancy whereas others favour caesarean section at the 38th week.
When the disease is severe, outlook for the mother as well as baby is very poor. It is better to terminate the pregnancy.

Acute renal failure during pregnancy is an extremely serious condition. Urine becomes very, very less or nil. Such a woman should immediately be transferred to a good centre.
Intestinal parasitic infestations
Intestinal parasites is a leading cause of ill-health. When one or more of such parasites complicate a pregnancy, it becomes worse. Common parasites infesting Indian women are Entamoebahistolytica, Girardialambia, H. nana (Dwarf tapeworm), hookworm, roundworm and threadworm.
The worst enemy of a pregnant woman is, however, hookworm. A large number of hookworms attach themselves firmly to the upper intestinal mucose, sucking blood. Appetite of an infested woman gets markedly decreased. The patient becomes lethargic and apathetic. Vague abdominal pain and palpitations are common. Ankle swelling (oedema) and breathlessness may occur.
Your doctor would go for one or more stool examinations to confirm the presence of hookworm. Blood and sometimes bone-marrow may also be tested.
Hookworm disease makes prognosis for the child as well as mother unfavourable. The mother may develop pre-eclamptic toxaemia and superimposed bacterial infections. In neglected cases, chances of abortion, premature birth and stillbirth are high.
Fortunately, it is easy to cure the disease. Very effective drugs are now available. Many obstetricians prefer giving anti-hookworm treatment as a routine in early months of pregnancy.

Mind you, the management of hookworm disease does not end with the administration of an anti-hookworm drug. You must follow the doctor’s instructions regarding treatment of accompanying anaemia. If anaemia is mild to moderate, oral iron tablets will do. If it is severe, he may like to give you intravenous or intramuscular iron injections. At times it may become necessary to give a blood transfusion or two to raise haemoglobin speedily.
Heart disease
About one in a hundred pregnant women suffer from one or another heart disease. Most of such diseases have rheumatic origin, monopoly being that of mitral stenosis. The next group is congenital heart disease.
Every woman with a known heart disease must consult her doctor before rushing into pregnancy. Later, she should remain under strict antenatal care. What causes worst difficulties in such cases is the risk of heart failure. A major objective of antenatal check-ups is to prevent it and, if that does not work, at least to diagnose it early so that prompt treatment can be given.
All pregnant women with heart disease should be hospitalised after 34th week in mild cases and 39th week in moderate to advanced cases. If heart problem becomes acute, immediate hospitalisation, irrespective of the stage of pregnancy is recommended. It is a practice on the part of obstetricians to treat such cases in consultation with a physician or a cardiologist.
It is a common experience that complete bed rest, a few weeks before the expected date of delivery, goes a long way in ensuring relatively safe delivery at the time of labour. In most cases, normal vaginal delivery is considered the best.

High blood volume
An important development during pregnancy is the increase in blood volume to provide for the needs of the growing foetus, leading to some undesirable effects.
Bleeding from gums on brushing is another outcome of increased blood volume during pregnancy. If you are otherwise healthy, it need not bother you. Moreover, it shouldn’t become a bottleneck in your maintaining orodental hygiene.
Varicose veins
A common observation during the later months of pregnancy is the development of prominent, enlarged and tortuous veins which protrude out of the skin. The varicose veins are usually seen over the legs. Vulva, rectum, anus and vagina are the other sites.
Heredity is said to play a significant role in the development of varicosity. What seems a striking observation is that most of the women who develop it are the ones who stand or sit for long spans of time.
Among various causes of varicosity are rise in total amount of blood and greater intra-abdominal pressure during pregnancy.
To safeguard against varicosity, you should avoid standing for long hours during pregnancy. Try to sit with feet propped up every now and then. Lying down with feet raised also helps.
Once varicosity develops, it helps to wear elastic stockings.
In order to safeguard against varicosity in the rectum (piles or haemorrhoids) see that you do not have constipation. Take good deal of leafy vegetables and fruits. Taking warm baths and avoiding straining when using the toilet also helps.
Abortion
Abortion means termination of pregnancy before the “little life” in the womb is capable of “viability” which, as a rule, reaches at 28 weeks. Not all pregnancies, because of one or another reason, reach the full term successfully. It is estimated that in around 12 per cent cases abortion occurs.
If a pregnant woman has a slight abdominal pain (colicky), slight bleeding from the birth passage, high frequency of micturition and backache, she appears to be heading for what is termed threatened abortion. The woman should immediately report to the doctor so that he can confirm the diagnosis and take remedial action. Generally speaking, complete bed rest is essential. Sedatives to relieve pain and anxiety are helpful. It will depend on your doctor’s judgement whether he prescribes an oral or intramuscular hormonal preparation, progesterone.
Threatened abortion, if not taken care of, is likely to pass on to either inevitable or incomplete abortion. Its diagnosis is suggested by the fact that pain becomes severer and vaginal bleeding more profuse. A part of products of conception may be protruding through the birth passage.
In most of the cases of inevitable abortion, products of conception are bound to be expelled spontaneously. In others, active interference by a doctor is indicated. The doctor will, under aseptic conditions and anaesthesia, evacuate the womb either digitally or by an instrument.
Missed abortion refers to the condition in which manifestations of abortion do appear but disappear soon. The dead products of conception are retained in the uterus. Abdominal pain and vaginal bleeding also more or less stop. The blood in the uterus clots around this dead ovum which subsequently undergoes lots of changes. The doctor will evacuate the womb. But this should always be done in a hospital.
Therapeutic abortion means induction of planned abortion “in the interest of the mother”. Unfortunately many unscrupulous practitioners and the like are engaged in performing criminal abortion in the name of therapeutic abortion. This practice is responsible for a proportion of maternal mortality and morbidity.

Dr. Suraj Gupte (MD, FIAP, FSAMS (Sweden), FRSTMH (London)
Chairman (Pediatric Education Network- Worldwide) , Principal Advisor, Children’s Health Institute™ (A web based collaboration of World Parenting Organisation (WPO) & International Society for Girl Child & Rights Inc. USA)
Professor & Head (Emeritus), Postgraduate Department of Pediatrics, MMC & Hospitals, Khammam, Telangana, India E-mail: [email protected], www.drsurajgupte.com
Dr Gupte occupies a pride of place for outstanding contribution as a Pediatric educationist, author, researcher and innovator globally. He, besides holding important positions in the Indian Academy of Pediatrics (IAP) is too a recipient of several national and international awards and Visiting Fellowships/ Professorships, Dr.Suraj Gupte figures in most of the national and international Who’s Who volumes, including the Marquis’ Who’s Who (NJ, USA) – a pre-eminent database of outstanding global personalities.

Editor-in-Chief: Recent Advances in Pediatrics (series), The Short Textbook of Pediatrics, Case-based Reviews in Pediatric Emergencies, Problem-solving in Neonatal Emergencies and Intensive Care, Pediatric Emergencies, Neonatal Emergencies, Pediatric Nutrition, Pediatric Gastroenterology, Influenza: Complete Spectrum, Pediatric Infectious Diseases, etc

Author: Instructive Case Studies in Pediatrics, Differential Diagnosis in Pediatrics, Influenza, Perspectives in Influenza, Speaking of Child Care, etc, Textbook of Pediatric Gastroenterology, Hepatology and Nutrition, 2009 (Indo-American Project with Prof Karoly Horvath, USA)

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