NMT 06101

CARE OF A WOMAN WITH

ABNORMAL PREGNANCY,
LABOUR AND PUERPERIUM
CARE OF A WOMAN WITH HYPEREMESIS
GRAVIDARUM AND DISORDERS OF AMNIOTIC FLUID
(POLYHYDRAMNIOS AND OLIGOHYDRAMNIOS)
BY
B. MWAIPASI
BSc Mw – UDOM
mwaipasi64@gmail.com
Learning Tasks
At the end of this session, a learner is
expected to be able to:
1. Define hyperemesis gravidarum
2. Explain causes and diagnosis of hyperemesis
gravidarum
3. Outline signs and symptoms of hyperemesis
gravidarum
4. Describe the management of a pregnant woman
with hyperemesis gravidarum
Definition of Hyperemesis
Gravidarum
Hyperemesis gravidarum
Is an excessive nausea and vomiting that
start between 4-10 weeks gestation, and
resolve before 20 weeks
Causes and Diagnosis of
Hyperemesis Gravidarum
The causes of hyperemesis is uncertain, with
multi-factorial causes such as:
Hormonal /Endocrine
• High human chorionic ganadotrophin (hCG)
stimulates the chemoreceptor trigger zone
in the brain stem including the vomiting
center.
• Allergy to the corpus luteum or the
released hormones.
Cont……..
Nervous and psychological due
psychological rejection of an unwanted
pregnancy
Deficiency of:
• Adrenocortical hormone and /or,
• Vitamin B6 and B1
Cont……..
Hyperemesis occur more often where
mothers have a multiple pregnancy, or a
hydatidiform
Simultaneously occurrence of
hyperthyroidism and hyperemesis suggest
transient thyroid dysfunction as a possible
cause
Sign and Symptoms of
Hyperemesis Gravidarum
The patient cannot retain anything in her
stomach.
• Vomiting occurs through the day and night
even without eating.
 Thirst, constipation and oliguria.
 In severe cases, vomitus is bile and/ or
blood stained.
Finally, there are manifestations of
Werniche’s encephalopathy as drowsiness,
Cont……..
Manifestations of starvation and dehydration:
• Loss of weight.
• Sunken eyes.
• Dry tongue and inelastic skin.
• Pulse: rapid and weak.
• Blood pressure: low.
• Temperature: slight rise
Care of a Pregnant Woman with
Hyperemesis Gravidarum
The woman should be hospitalized for
observation and fluid therapy
Nil per oral (nothing by mouth) for24–48 hrs.
Calm reassurance and sensitive
information-giving should be accompanied
by competent attention to physical needs.
On arrival in hospital blood will be taken to
determine the plasma electrolytes.
Cont……..
The potassium and sodium levels will be
corrected by intravenous infusion( Ringers
lactate)
The infusion will continue until hydration
and electrolytes return to normal.
Vitamins B12 and C, folic acid and iron will
be required to correct anaemia.
Cont……..
The pregnant woman should be given
Promethazine (IM) 12.5 mg 12hourly a day if
vomiting persists and a sedative may be
given to produce rest.
Advice the woman to take small quantity
of meals frequently.
Monitor vital signs at least 4 hourly
Test urine twice for specific gravity,
acetone, sugar and protein
Cont……..
Monitor and record the intake and output
of fluids including vomitus. 24- 48 hrs
Once vomiting has ceased for a period of
24 hrs, oral fluids may be commenced and
if these are tolerated a light diet may
follow.
Normal food is gradually introduced and
intravenous therapy discontinued
Cont……..
Note
Very occasional the disorder fails to
improve with the treatment outlined above
and
The mother will subside into coma and be
in danger of dying.
Pharmacological Treatment
• Compound sodium lactate with 5% dextrose and 0.9%sodium chloride
according to daily needs and severity.
• AND
• Vitamin B1 (IV)100mg 24hourly mix in intravenous rehydration
solution AND
• Metoclopramide (IM) 5–10 mg 8hourly till vomiting stops. OR
• Promethazine (IM) 12.5 mg 12hourly a day
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Learning Tasks
At the end of this session a learner is expected to
be able to:
1. Define the terms polyhydramnios and
oligohydramnios
2. State causes and predisposing factors of
polyhydramnios and oligohydramnios
3. Describe the management of a pregnant woman with
polyhydramnios and oligohydramnios
4. State the complications associated with
polyhydramnios and oligohydramnios
Definition of Polyhydramnios
and Oligohydramnios
Polyhydramnios (hydramnios) is an
excessive amount of amniotic fluid.
• Is defined as the amount of amniotic fluid
which exceeds 1500 ml.
• It may not be clinically apparent until it
reaches 3000 ml.
Oligohydramnios is an abnormally small
amount of amniotic fluid.
Causes and Predisposing
Factors of Polyhydramnios and
Oligohydramnios
Causes and predisposing factors of
polyhydramnios
Most polyhydramios is of unknown
etiology.
The following conditions are more likely to
result into polyhydramnios:
• Multiple pregnancy (especially with
monozygotic twins)
• Diabetes
Cont……..
• Erythroblastosis
• Fetal malformations (especially of the
gastrointestinal tract—e.g.,
tracheoesophageal fistula—or central
nervous system—e.g., anencephaly,
meningomyelocele)
Causes and predisposing factors
of oligohydramnios
• The condition is frequently caused by
uteroplacental insufficiency, which there by
means that a decreased fluid volume may
be associated with a marked increase in
perinatal mortality.
• The following conditions are more
likely to result into oligohydramnios:
Cont……..
Congenital anomalies (e.g., renal agenesis,
Potter’s syndrome)
Viral diseases
Intrauterine growth restriction (IUGR)
Uteroplacental insufficiency
Early rupture of the fetal membranes (24
to 26 weeks)
Cont……..
Response to indocin as a tocolytic
Fetal hypoxia
Meconium-stained fluid and meconium
aspiration
Postmaturity syndrome
Care of a Woman with
Polyhydramnios
Assessing the woman thorough
On history taking the woman will complain
of
Breathlessness and discomfort
Abdominal pain in severe cases
Exacerbation of associated symptoms of
pregnancy such as; indigestion, heartburns
and constipation.
Lower swelling and varicosities of vulva and
Cont……..
Abdominal examination
Inspection
• The uterus is larger than expected for the
period of gestation and is globular in shape
• Abdominal skin appears stretched and
shiny with marked stripe gravidarum and
obvious superficial blood vessels
Cont……..
Palpation
• Uterus feels tense and is difficult to feel the
Fetal parts
• Fetal ballottement between the two hands
• Fluid thrill may be elicited by placing a
hand on one side of the abdomen and
taping the other side with fingers
Cont……..
• Measurement of abdominal girth
• In cases of acute hydramnios it is done in order
to observe the rate of increase
Auscultation
• May be difficult if the quantity of fluid
allows the foetus to move away from the
stethoscope
Ultrasound
• Is used to confirm the diagnosis of
Management of polyhydramnios
• The aim of management is to relieve
maternal symptoms and optimize the
length of gestation, prolonging it if safe.
• When the cause is already determined
The mother will usually be admitted to a
consultant obstetric unit.
Cont……..
Subsequent care will depend on the
mother’s condition, the cause of the
polyhydramnios and the stage of
pregnancy.
The mother should rest in bed. An upright
position will help to relieve any dyspnea
and she may be given antacids to relieve
heartburn and nausea.
Acute polyhydramnios is managed by
Cont……..
The mother may need to have labor
induced in late pregnancy if the symptoms
become worse.
Labor is usually normal but the midwife
should be prepared for the possibility of
postpartum hemorrhage.
Cont……..
The baby should be carefully examined for
abnormalities and a wide orogastric tube
must be passed for about 10-12cm. in
order to confirm the patency of the
oesophagus
Care of a Woman with
Oligohydramnios
Assessment of the mother
History taking
The woman who had a previous normal
pregnancy may have noticed a reduction in
fetal movements.
History of vagina leakage
Cont……..
Abdominal Examination
• Inspection
The uterus appears smaller than expected for the
period of gestation.
• Palpation
The uterus is small and compact and fetal parts
are easily felt
Breech presentation is possible.
• Auscultation is normal
Diagnosis
Ultrasonic scan will exclude
• Intra-uterine growth restriction.
• Renal abnormality.
• Coexisting fetal or placental conditions or
complications.
Screen for diabetes and Rh iso-
oimmunization
Care of woman with
oligohydramnios
The woman should be admitted for
investigations which will include placental
function tests.
If there is no fetal abnormality the
pregnancy will be allowed to continue
Labor may begin early or may be induced
because of the possibility of placental
insufficiency.
Epidural analgesia may be indicated
Cont……..
Impairment of placental circulation may
result in fetal hypoxia.
Constriction rings are a possibility due to
the small amount of amniotic fluid.
 In rare cases the membranes may adhere
to the fetus.
Reassure the woman and the partner on
the condition
Complications of Polyhydramnios
and Oligohydramnios
Polyhydramnios complications
Preterm labor (due to over distention of
the uterus)
Maternal dyspnea and shortness of breath
Fetal malpresentations
Abruptio placenta
Cord prolapse
Cont……..
Uterine dysfunction during labor (due to
over distention of the uterus)
Immediate postpartum hemorrhage as a
result of uterine atony from over distention
Cont……..
Oligohydramnios complications
Lack of amniotic fluid reduces the intra-
uterine space and causes compression
deformities.
The baby has a squashed-looking face,
flattening of the nose, micrognathia and
talipes.
The skin is dry and leathery in appearance
Key points
• Polyhydramnios (hydramnios) is an excessive amount of amniotic
fluid.
• The woman needs emotional support especially if congenital
anomalies are present.
• Women with severe polyhydramnios have a number of mechanical
difficulties and discomforts for which the midwife can provide relief
measures.
• Oligohydramnios is an abnormally small amount of amniotic fluid.
• Oligohydramnios is a significant finding suggestive of post-maturity
syndrome in a postdate pregnancy.
Any question
Session Evaluation
1. What are the differences between polyhydramnios and
oligohydramnios?
2. What are the complications of polyhydramnios?
3. What are the complications of Oligohydramnios?
THE END