Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions

1. 7
Medical
problems during
pregnancy and
the puerperium
Before you begin this unit, please take the URINARY TRACT
corresponding test at the end of the book to
assess your knowledge of the subject matter. You INFECTION DURING
should redo the test after you’ve worked through PREGNANCY
the unit, to evaluate what you have learned.
Objectives 7-1 Which urinary tract infections
are important during pregnancy?
When you have completed this unit you 1. Cystitis.
should be able to: 2. Asymptomatic bacteriuria.
• Diagnose and manage cystitis. 3. Acute pyelonephritis.
• Reduce the incidence of acute
pyelonephritis in pregnancy. 7-2 Why are urinary tract infections
common during pregnancy
• Diagnose acute pyelonephritis in
and the puerperium?
pregnancy.
• Diagnose and manage anaemia during 1. Placental hormones cause dilatation of the
ureters.
pregnancy.
2. Pregnancy suppresses the function of the
• Identify patients who may possibly have immune system.
heart valve disease. 3. Catheterisation during the first and second
• Manage a patient who develops stage of labour is common.
glycosuria during pregnancy.
A urinary tract infection is the most common
• Manage women needing antiretroviral
infection during pregnancy.
treatment.
7-3 How is cystitis diagnosed?
1. Severe urinary symptoms suddenly appear:
• Dysuria (pain on passing urine).

2. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 125
• Frequency (having to pass urine often). 7-6 Why is asymptomatic bacteriuria
• Nocturia (having to get up at night to during pregnancy important?
pass urine).
1. Between 6 and 10% of pregnant women
2. The patient appears generally well with
have asymptomatic bacteriuria.
normal observations. The only clinical sign
2. One third of these patients with
is tenderness over the bladder.
asymptomatic bacteriuria will develop
3. Examination of the urine under a
acute pyelonephritis during pregnancy.
microscope shows many pus cells and
3. If patients with asymptomatic bacteriuria
bacteria.
are diagnosed and correctly managed, their
A midstream urine sample for culture must risk of developing acute pyelonephritis will
be collected, if possible, to confirm the be reduced by 70%.
clinical diagnosis. Treatment must commence 4. The risk for preterm labour is significantly
immediately without waiting for the results of increased with asymptomatic bacteriuria.
the culture.
The diagnosis and treatment of asymptomatic
7-4 How should you manage bacteriuria will greatly reduce the incidence of
a patient with cystitis? acute pyelonephritis and preterm labour during
pregnancy.
Give 4 adult tablets of co-trimoxazole (e.g.
Bactrim, Co-Trim, Durobac, Mezenol or
Purbac) as a single dose. This is also the drug of 7-7 How and when should patients be
choice for patients who are allergic to penicillin. screened for asymptomatic bacteriuria?
Amoxycillin (Amoxil) 3 g as a single dose If possible, bacterial culture of a midstream
orally could also be used but organisms urine sample should be done at the first
causing cystitis are often resistant to this antenatal visit to screen patients for
antibiotic. The treatment will be more asymptomatic bacteriuria.
successful if 2 amoxycillin capsules (250 mg)
are replaced with 2 Augmentum tablets that If possible, a screening test for asymptomatic
contain an added 125 mg clavulanic acid each. bacteriuria should be done at the first antenatal
A midstream sample should be sent for visit.
culture and sensitivity at the next antenatal
visit to determine whether the management
7-8 Can reagent strips be reliably used
was successful.
to diagnose asymptomatic bacteriuria?
Co-trimoxazole can be safely used during
No. Tests for nitrites (which detect the
pregnancy, including the first trimester.
presence of bacteria) and leukocytes, separately
or together, cannot be used to accurately
7-5 What is asymptomatic bacteriuria? screen for asymptomatic bacteriuria.
It is significant colonisation of the urinary
tract with bacteria, without any symptoms of a 7-9 What is the management of a patient
urinary tract infection. with asymptomatic bacteriuria?
The same as the management of a patient with
cystitis, i.e. 4 adult tablets of co-trimoxazole
(e.g. Bactrim, Septran) as a single dose or
amoxycillin (Amoxil) 3 g as a single dose
orally. Patients who are allergic to penicillin
should be given co-trimoxazole.

3. 126 PRIMAR Y MATERNAL CARE
A midstream specimen of urine should again 6. Paracetamol (Panado) 2 adult tablets,
be sent for microscopy, culture and sensitivity together with tepid sponges, are used to
at the next antenatal visit to determine bring down a high temperature.
whether the management was successful.
Patients with acute pyelonephritis during
7-10 What symptoms suggest pregnancy must be admitted to hospital for
acute pyelonephritis? treatment with a broad-spectrum antibiotic.
1. Most patients have severe general
symptoms: 7-13 Why is acute pyelonephritis a
• Headache. serious infection in pregnancy?
• Pyrexia and rigors (shivering).
Because serious complications can result:
• Lower backache, especially pain over
the kidneys (renal angles). 1. Preterm labour.
2. Only 40% of patients have urinary 2. Septic shock.
complaints. 3. Perinephric abscess (an abscess around the
kidney).
7-11 What physical signs are usually found 4. Anaemia.
in a patient with acute pyelonephritis?
7-14 What should be done at the first
1. The patient is acutely ill.
antenatal visit after the patient has
2. The patient usually has high pyrexia and
been treated for acute pyelonephritis?
a tachycardia. However, the temperature
may be normal during rigors. 1. A midstream urine sample for culture and
3. On abdominal examination, the patient sensitivity must be collected to determine
is tender over one or both kidneys. The whether the treatment has been successful.
patient is also tender on light percussion 2. The haemoglobin concentration must be
over one or both renal angles (posteriorly measured as there is a risk of anaemia
over the kidneys). developing.
7-12 What is the management of a
patient with acute pyelonephritis? ANAEMIA IN PREGNANCY
1. The patient must be admitted to hospital.
2. A midstream urine sample for culture and 7-15 What is the definition of
sensitivity must be collected if possible to anaemia in pregnancy?
confirm the clinical diagnosis, identify the
bacteria and determine the antibiotic of A haemoglobin concentration of less than
choice. 11 g/dl.
3. An intravenous infusion of Balsol or
Ringer’s lactate should be started and 1 litre 7-16 What are the dangers of anaemia?
given rapidly over 2 hours. Thereafter, 1 litre
1. Heart failure which can result from severe
of Maintelyte should be given every 8 hours.
anaemia.
4. An intravenous broad-spectrum antibiotic,
2. Shock which may be caused by a relatively
e.g. cefuroxime (Zinecef) should be given
small vaginal blood loss (antepartum
prior to transfer.
haemorrhage, delivery or postpartum
5. Pethidine 100 mg is given intramuscularly
haemorrhage) in an anaemic patient.
for severe pain while paracetamol
(Panado) 2 adult tablets can be used for
moderate pain.

4. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 127
7-17 What are the common causes • All patients with a haemoglobin
of anaemia in pregnancy? concentration of less than 8 g/dl
who are short of breath or have a
1. Iron deficiency as the result of a diet poor
tachycardia of more than 100 beats per
in iron.
minute (signs of heart failure) must
2. Blood loss during pregnancy (also during
be admitted to hospital for a blood
labour or the puerperium).
transfusion. In addition she must
3. Acute infections (e.g. pyelonephritis),
be treated with 2 tablets of ferrous
chronic infections (e.g. tuberculosis and
sulphate 3 times a day that must be
HIV), and infestations (e.g. malaria,
continued at least one month after the
bilharzia or hook worm) in regions where
baby has been delivered.
these occur.
• If the haemoglobin concentration
4. Folic acid deficiency is less common.
is between 8 g/dl and 10 g/dl, the
The commonest cause of anaemia in pregnancy is patient can be treated with 2 tablets of
ferrous sulphate 3 times a day. If the
iron deficiency.
haemoglobin concentration does not
A full blood count, which is sent to the increase after 2 weeks or the patient is
laboratory, will usually identify the probable 36 weeks pregnant or more, and a full
cause of the anaemia. blood count has not yet been done,
then a full blood count must be done
The size and colour of the red cells indicate the to decide whether the cause of the
probable cause of the anaemia: anaemia is iron deficiency.
1. Microcytic, hypochromic cells suggest iron • If the haemoglobin concentration is
deficiency. 10 g/dl or more, but less than 11 g/dl,
2. Normocytic, normochromic cells suggest the patient can be treated with one
bleeding or infection. tablet of ferrous sulphate 3 times a day.
3. Macrocytic, normochromic cells suggest 2. The management of a patient with iron-
folate deficiency. deficiency anaemia during the puerperium
will depend on whether the patient is
bleeding or not:
7-18 What is the management of
• If the patient is not bleeding, if she
patients with iron deficiency in
has no signs of heart failure, and her
pregnancy or the puerperium?
haemoglobin concentration is 6 g/dl or
1. The management of iron-deficiency more, she can be treated with oral iron
anaemia in pregnancy will depend on tablets. One tablet of ferrous sulphate 3
the haemoglobin concentration and the times daily for a month is sufficient.
duration of pregnancy: • If the patient is not bleeding and she
• If the haemoglobin concentration is has signs of heart failure, or if her
less than 8 g/dl, the gestational age is haemoglobin concentration is less than
less than 36 weeks, and the patient is 6 g/dl, she must be admitted to hospital
asymptomatic, she can be treated with 2 for a blood transfusion to be followed
tablets of ferrous sulphate 3 times a day by oral iron for a month.
and be followed at the antenatal clinic. • If the patient is bleeding, she should
• If the haemoglobin concentration is be managed for a postpartum
less than 8 g/dl and the gestational age haemorrhage.
is 36 weeks or more, the patient must
be admitted to hospital for a blood
transfusion.

5. 128 PRIMAR Y MATERNAL CARE
7-19 Should all patients receive iron HEART VALVE DISEASE
supplements in pregnancy?
IN PREGNANCY AND
1. Well-nourished patients who have
a healthy diet and a haemoglobin THE PUERPERIUM
concentration of 11 g/dl or more, do not
need iron supplements. Heart valve disease consists of damage to,
2. Patients who are poorly nourished, or abnormality of, one or more of the valves
have a poor diet or have a haemoglobin of the heart. Usually the mitral valve is
concentration of less than 11 g/dl need damaged. The cause of heart valve disease in a
iron supplements. developing country is almost always rheumatic
3. Patients from communities where iron fever during childhood.
deficiency is common, or where socio-
economic circumstances are poor, should 7-23 Why is it important during
receive iron supplements. pregnancy to identify patients
Iron tablets are dangerous to small children with heart valve disease?
as even one tablet can cause serious iron 1. A correct diagnosis of the type of heart
poisoning. Therefore, patients must always valve disease and good management of
keep their iron tablets in a safe place where the problem reduces the risk to the patient
children cannot reach them. during her pregnancy.
2. Undiagnosed heart valve disease and
7-20 How are iron supplements inadequate treatment may result in serious
given in pregnancy? complications (e.g. heart failure causing
pulmonary oedema) which may threaten
As 200 mg ferrous sulphate tablets:
the patient’s life.
1. Patients with a haemoglobin 3. A clear family planning plan must be made
concentration of 11 g/dl or higher must during the pregnancy. The patient may
take one tablet daily. have a reduced lifespan and cannot risk
2. Patients who are anaemic must be having a large family.
managed as described in 7-18.
Correct diagnosis and good management reduce
7-21 What side effects can be caused the risk to the patient of heart valve disease in
by ferrous sulphate tablets? pregnancy.
Nausea and even vomiting due to irritation of
the lining of the stomach. 7-24 Which symptoms in a patient’s
history suggest that she may
7-22 How should you manage a have heart valve disease?
patient who complains of side effects 1. Shortness of breath on exercise or even
due to ferrous sulphate tablets? with limited effort.
1. The tablets should be taken with meals. 2. Coughing up blood (haemoptysis).
Although less iron will be absorbed, the 3. Often the patient has previously been told
side effects will be less. by a doctor that she has a ‘leaking heart’.
2. If the patient continues to complain of side 4. Some patients with heart valve disease
effects, she should be given 300 mg ferrous give a history of previous rheumatic fever.
gluconate tablets instead. They cause fewer However, most patients are not aware
side effects than ferrous sulphate tablets. that they have suffered from previous
rheumatic fever.

6. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 129
The cause of heart valve disease in a developing DIABETES MELLITUS
country is almost always previous rheumatic
fever. However, these patients usually do not IN PREGNANCY
know that they have had one or more attacks
of rheumatic fever during childhood.
7-27 Why is it important to diagnose
During the examination of the cardiovascular diabetes if it develops in pregnancy?
system, a cardiac murmur will be heard if the
patient has heart valve disease. Diabetes mellitus is a disorder which is
caused by the secretion of inadequate
amounts of insulin from the pancreas to keep
7-25 How should a patient with heart
the blood glucose concentration normal.
valve disease in pregnancy be managed?
As a result, the blood glucose concentration
1. The patient must be referred to the high- becomes abnormally high. Diabetes may
risk antenatal clinic. often present for the first time in pregnancy,
2. At the high-risk antenatal clinic the type and may then recover spontaneously after
of lesion and correct management will be delivery. The early diagnosis and good
determined. management of diabetes in pregnancy will
3. The follow-up visits will also be at the greatly reduce the incidence of complications.
high-risk antenatal clinic. However, the
patient may be referred to the primary care 7-28 What complications may be caused
antenatal clinic for some ‘inbetween’ visits. by diabetes in pregnancy if it is not
Take care to follow the instructions from diagnosed early and is not well managed?
the high-risk clinic carefully.
4. Patients who are not hospitalised should 1. Throughout the pregnancy infections are
stop work earlier and rest more than usual. common, especially:
5. The patient must be told to report • Candida vaginitis.
immediately if she experiences any • Urinary tract infection.
symptoms of heart failure, e.g. worsening 1. During the first trimester congenital
shortness of breath or tiredness. abnormalities may occur in the developing
6. The patient must at least be delivered at a fetus due to the raised blood glucose
secondary level hospital where specialist concentration.
care is available. 2. During the third trimester pre-eclampsia
and polyhydramnios are common.
3. The fetus may be large, if the patient’s
7-26 What form of family planning should
diabetes has been poorly controlled during
be offered to patients with heart valve
the pregnancy, resulting in problems
disease who have completed their families?
during labour and delivery mainly:
A postpartum sterilisation should be done. • Cephalopelvic disproportion.
Because of the risk of heart failure, the • Impacted shoulders.
procedure must be postponed until the third 1. During the third stage of labour there is an
day after delivery. Patients who are willing increased risk of postpartum haemorrhage.
and are prepared to return for the procedure, 2. The newborn infant is at increased
can have a laparoscopic sterilisation done 6 risk of many complications, especially
weeks after delivery. Meanwhile, an injectable hypoglycaemia and hyaline membrane
contraceptive must be given. disease.

7. 130 PRIMAR Y MATERNAL CARE
7-29 How can complications which concentration, explaining why some patients
commonly occur in diabetics during only become diabetic during their pregnancies.
pregnancy and labour be avoided?
These complications can largely be avoided by: 7-33 How should random blood
glucose measurements be interpreted
1. Early diagnosis. and how do the results determine
2. Good control of the blood glucose further management?
concentration.
A random blood glucose measurement is done
Early diagnosis and good control of the blood on a blood sample taken from the patient at
glucose concentration will prevent most of the the clinic without any previous preparation,
pregnancy and labour complications caused by i.e. the patient does not have to fast. However,
patients who have had nothing to eat during
diabetes.
the past 4 hours should be encouraged to eat
something before the test.
7-30 How can diabetes be diagnosed 1. A random blood glucose concentration
early if it should develop for the of less than 8 mmol/l is normal. These
first time during pregnancy? patients can receive routine primary care.
1. At every antenatal visit all patients should However, if glycosuria is again present, a
routinely have their urine tested for glucose. random blood glucose measurement must
2. A random blood glucose concentration be repeated.
must be measured if the patient has 1+ 2. A random blood glucose concentration of
glycosuria or more at any antenatal visit. 8 mmol/l or more, but less than 11 mmol/l,
may be abnormal and is an indication
Patients with glycosuria during pregnancy must to measure the fasting blood glucose
always be investigated further for diabetes. concentration. The further management of
the patient will depend on the result of the
fasting blood glucose concentration.
7-31 Is a reagent strip accurate 3. A random blood glucose concentration
enough to measure a random of 11 mmol/l or more is abnormal and
blood glucose concentration? indicates that the patient has diabetes.
Yes, if an electronic instrument (Glucometer These patients must be admitted to hospital
or Reflolux) is used to measure the blood to have their blood glucose controlled.
glucose concentration. A reagent strip alone Thereafter, they must remain on treatment
may not be accurate enough. If an instrument and be followed as high-risk patients.
is not available, a sample of blood must be
sent to the nearest laboratory for a blood 7-34 How should fasting blood
glucose measurement. glucose measurements be interpreted
and how do the results determine
7-32 Is it possible that a patient with further management?
an initially normal blood glucose The patient must have nothing to eat or drink
concentration may develop an abnormal (except water) from midnight. At 08:00 the next
concentration later in pregnancy? day a sample of blood is taken and the fasting
Yes. This may be possible due to an increase blood glucose concentration is measured:
in the amount of placental hormones as 1. A fasting blood glucose concentration
pregnancy progresses. Placental hormones of less than 6 mmol/l is normal. These
tend to increase the blood glucose patients can receive routine primary
care. If their random blood glucose

8. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 131
concentration is again abnormal, the that they can have their blood glucose
fasting blood glucose concentration should concentration controlled.
be measured again.
2. Patients with fasting blood glucose
concentrations of 6 mmol/l or more but less HIV INFECTION AND
than 8 mmol/l should be placed on a 7 600
kilojoule (1 800 kilocalorie) diabetic diet. AIDS IN PREGNANCY
A glucose profile should be determined
after 2 weeks and be repeated every 4 weeks
7-37 What is AIDS?
until delivery. Usually the glucose profile
becomes normal on this low kilojoule diet. AIDS is a severe clinical illness caused by
3. Patients with a fasting blood glucose the human immunodeficiency virus (HIV).
concentration of 8 mmol/l or more have Therefore, severe HIV disease is called AIDS.
diabetes. They must be admitted to hospital However, women with HIV infection can
so that their blood glucose concentration remain clinically well for many years before
can be controlled. developing signs of the disease. Patients
with AIDS have a damaged immune system.
A 7 600 kj diabetic diet consists of a normal
They become infected and often die of other
diet with reduced refined carbohydrates (e.g.
‘opportunistic infections’ such as tuberculosis.
sugar, cool drinks, fruit juices) and added high
fibre foods (e.g. beans and wholewheat bread).
7-38 Is AIDS an important
A patient with a normal blood glucose cause of maternal death?
concentration early in pregnancy may develop As the HIV epidemic spreads, the number of
diabetes later during that pregnancy. pregnant women dying of AIDS has increased
dramatically. In some countries, such as South
Africa, AIDS is now the commonest cause of
7-35 How is a glucose profile obtained?
maternal death.
The patient must have nothing to eat or
The Third Report on Confidential Enquiries
drink (except water) from midnight. At 08:00
into Maternal Deaths in South Africa 2002–
the next day a sample of blood is taken and
2004 showed that AIDS was the commonest
the fasting blood glucose concentration is
cause of maternal death. Many additional
measured. Immediately afterwards she has
AIDS deaths may have been missed, as HIV
breakfast (which she can bring with her to
testing is often not done.
the clinic). After 2 hours the blood glucose
concentration is measured again. AIDS is the commonest cause of maternal death
in South Africa.
7-36 How should the glucose profile
be interpreted and how do the results
determine further management? 7-39 Does pregnancy increase the risk
of progression from asymptomatic to
1. A fasting blood glucose result of less than
symptomatic HIV infection and AIDS?
6 mmol/l and a 2 hour result of less than
8 mmol/l are normal. These patients can be Pregnancy appears to have little or no effect
followed up as intermediate risk patients. on the progression from asymptomatic to
2. A fasting blood glucose result of symptomatic HIV infection. However, in
6 mmol/l or more and/or a 2 hour result women who already have symptomatic HIV
of 8 mmol/l or more are abnormal. These infection, pregnancy may lead to a more rapid
patients must be admitted to hospital so progression to AIDS.

9. 132 PRIMAR Y MATERNAL CARE
The progression of HIV infection during 7-42 How are pregnant women with HIV
pregnancy can be monitored by: infection managed at a primary care clinic?
1. Laboratory tests. The management of pregnant women with HIV
2. Clinical signs. infection is very similar to that of non-pregnant
adults. The most important step is to identify
7-40 How is the severity of those pregnant women who are HIV positive.
HIV infection classified? The principles of management of pregnant
1. By assessing the clinical stage of the disease: women with HIV infection at a primary care
• Stage 1: Clinically well. clinic are:
• Stage 2 Mild clinical problems. 1. Make the diagnosis of HIV infection by
• Stage 3: Moderate clinical problems. offering HIV screening to all pregnant
• Stage 4: Severe clinical problems (ie. women at the start of their antenatal care.
AIDS). 2. Take a history and do a clinical assessment
2. By measuring the CD4 count in the blood: to assess the clinical stage of the diease.
A falling CD4 count is an important 3. Assess the CD4 count in all HIV-positive
marker of progression in HIV. It is an women as soon as their HIV status is
indicator of the degree of damage to the known.
immune system. A normal CD4 count is 4. Screen for clinical signs of HIV infection
700 to 1100 cells/μl. A CD4 count below to assess whether the woman has advanced
350 cells/μl indicates severe damage to the to a more severe stage of the disease at each
immune system. antenatal visit.
5. Good diet. Nutritional support may be
The CD4 count is an important marker of HIV
needed.
progression during pregnancy. 6. Emotional support and counselling.
7. Prevention of mother-to-child
7-41 Can an HIV-positive woman be transmission (PMTCT) of HIV.
cared for in a primary care clinic? 8. Start antiretroviral treatment when
indicated.
Most women who are HIV positive are 9. Early referral if there are pregnancy or HIV
clinically well with a normal pregnancy. complications.
Others may only have minor problems (stage
1 or 2). These women can usually be cared 7-43 Which clinical signs suggest
for in a primary care clinic throughout their stage 1 and 2 HIV infection?
pregnancy, labour and puerperium provided
their pregnancy is normal. Women with a 1. Persistent generalised lymphadenopathy
pregnancy complication should be referred to is the only clinical sign of stage 1 HIV
hospital, as would be done with HIV-negative infection.
patients. Women with severe HIV-related 2. Signs of stage 2 HIV infection include:
problems (stage 3 or 4) will need to be referred • Mild weight loss (less than 10% of body
to a special HIV clinic or hospital. weight).
• Repeated or chronic mouth or genital
ulcers.
Many HIV-positive women can be managed at a • Extensive skin rashes.
primary care clinic. • Repeated upper respiratory tract
infections such as otitis media or
sinusitis.
• Herpes zoster (shingles).

10. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 133
Most of these women can be managed at a 1. Clinical signs of stage 3 or 4 HIV infection.
primary care clinic while some may have to 2. A CD4 count below 350 cells/μl.
be referred to an HIV clinic for help with
treatment. These clinical problems are usually 7-47 What patient preparation is
treated symptomatically with simple drugs needed for antiretroviral treatment?
which are not expensive.
Preparing a patient to start antiretroviral
treatment is very important. This requires
7-44 What are the important features
education, counselling and social assessment
suggesting stage 3 or 4 HIV infection?
before antiretroviral treatment can be started.
1. Features of stage 3 HIV infection include: These patients need to learn about their illness
• Unexplained weight loss (more than and the importance of excellent adherence
10% of body weight). (taking their antiretroviral drugs at the correct
• Oral candidiasis (thrush). time every day) and regular clinic attendance.
• Cough, fever and night sweats They also need to know the side effects of
suggesting pulmonary tuberculosis. antiretroviral drugs and how to recognise
• Cough, fever and shortness of breath them. Careful general examination and blood
suggesting bacterial pneumonia. sent for a laboratory hemoglobin concentration
• Chronic diarrhoea or unexplained fever and liver function test (ALT) are also needed
for more than one month. before starting antiretroviral treatment. It
• Pulmonary tuberculosis (TB) usually takes 2 weeks to prepare a patient.
2. Features of stage 4 HIV infection include:
• Severe weight loss. 7-48 What drugs are used for starting
• Severe or repeated bacterial infections, antiretroviral treatment during pregnancy?
especially pneumonia.
• Severe HIV associated (opportunistic) Usually antiretroviral treatment is provided
infections such as oesophageal to pregnant women in South Africa with
candidiasis (which presents three drugs:
with difficulty swallowing) and • D4T 40 mg 12 hourly (or 30 mg 12 hourly
Pneumocyctis pneumonia (which in women weighing less than 60 kg or AZT
presents with cough, fever and 300 mg 12 hourly.
shortness of breath). • 3TC (lamivudine) 150 mg every 12 hours.
• Malignancies such as Kaposi’s sarcoma. • Nevirapine 200 mg daily for two weeks
• Extrapulmonary TB. followed by 200 mg every 12 hours or
efavirenz (EFV) 600 mg in the evening if
7-45 What is antiretroviral treatment? the gestational age is more than 12 weeks.
Antiretroviral treatment (i.e. ART or HAART) This is the current national first line standard
is the use of three or more antiretroviral drugs drug combination used during pregnancy. It
in combination to treat patients with severe may change in future.
HIV infection. The aim of antiretroviral
treatment is to lower the viral load and allow 7-49 What are the side effects of
the immune system to recover. antiretroviral treatment?
Pregnant women on antiretroviral treatment
7-46 What are the indications for
may have side effects to the drugs. These
antiretroviral treatment in pregnancy?
are usually mild and occur during the first
The indications for antiretroviral treatment at 6 weeks of treatment. However, side effects
an HIV clinic are either of the following: may occur at any time that patients are on
antiretroviral treatment. It is important that

11. 134 PRIMAR Y MATERNAL CARE
the staff at primary care clinics are aware CASE STUDY 1
of these side effects and that they ask for
symptoms and look for signs at each clinic
A patient presents at 30 weeks gestation
visit. Side effects with antiretroviral treatment
and complains of backache, feeling feverish,
are more common than with antiretroviral
dysuria and frequency. On examination she
prophylaxis during pregnancy.
has a tachycardia and a temperature of 38.5 °C.
Common early side effects during the first A diagnosis of cystitis is made and the patient
few weeks of starting antiretroviral treatment is given oral ampicillin to take at home.
include:
1. Lethargy, tiredness and headaches. 1. Do you agree with the diagnosis?
2. Nausea, vomiting and diarrhoea. No. The symptoms and signs suggest that the
3. Muscle pains and weakness. patient has acute pyelonephritis.
These mild side effects usually disappear
on their own. They can be treated 2. Is the management of this patient
symptomatically. It is important that adequate to treat acute pyelonephritis?
antiretroviral treatment is continued even if No. The patient should be admitted to hospital
there are mild side effects. and be given a broad-spectrum antibiotic
More severe side effects, which can be fatal, intravenously.
include:
3. Why is it necessary to
1. AZT may suppress the bone marrow
treat acute pyelonephritis in
causing anaemia. There may also be a
pregnancy so aggressively?
reduction in the white cell and platelet
counts. Because severe complications may occur
2. Severe skin rashes with nevirapine. All which can be dangerous both to the patient
patients with severe skin rashes must and her fetus.
urgently be referred to the HIV clinic.
3. Hepatitis can be caused by all antiretroviral 4. What should be done at the first
drugs but especially nevirapine. antenatal visit after the patient
4. Lactic acidosis is a late but serious side is discharged from hospital?
effect, especially with d4T. It presents with
weight loss, tiredness, nausea, vomiting, A midstream urine sample should be
abdominal pain and shortness of breath collected for culture to make sure that the
in patients who have been well on infection has been adequately treated. Her
antiretroviral treatment for a few months. haemoglobin concentration must also be
measured as patients often become anaemic
Staff at primary care clinics must be aware and after acute pyelonephritis.
look out for these very important side effects.
7-50 How should pregnant women on CASE STUDY 2
antiretroviral treatment be managed?
The national protocol should be followed. It is A patient is seen at her first antenatal visit.
very important that staff at the antenatal clinic She is already 36 weeks pregnant and has a
are trained to managed women with HIV haemoglobin concentration of 7.5 g/dl. As
infection. They should work together with the she is not short of breath and has no history
local HIV clinic or infectious diseases clinic of of antepartum bleeding, she is treated with 2
the local hospital. tablets of ferrous suphate to be taken 3 times

12. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 135
a day. She is asked to return to the clinic in tachycardia which suggest heart failure. Again,
one week. a full blood count must be done before the
transfusion is started.
1. Do you agree with the management?
No. The patient is already 36 weeks pregnant
and, therefore, is at great risk of going into
CASE STUDY 3
labour before her haemoglobin concentration
has had time to respond to the oral iron A patient presents for her first antenatal visit
treatment. Therefore, the patient must be and gives a history that she has a ‘leaking
admitted to hospital and be given a blood heart’ due to rheumatic fever as a child.
transfusion. As she has no symptoms and does not get
short of breath on exercise, she is reassured
and managed as a low-risk patient. As she
2. Are any further investigations needed?
remains well with no shortness of breath, she
Yes. The cause of the anaemia must always be is told that she can be delivered by a midwife
looked for. Blood for a full blood count must be obstetric unit (primary perinatal care clinic).
taken before she is given a blood transfusion.
1. Why is the management incorrect?
3. Is a full blood count adequate to
With her history of rheumatic fever and a
diagnose the cause of the anaemia, or
‘leaking heart’, the patient must be examined
should other investigations be done?
by a doctor to determine whether she has
In most cases a full blood count is adequate. heart valve disease. Undiagnosed heart valve
The majority of patients who have anaemia disease can result in serious complications
without a history of bleeding, are iron such as pulmonary oedema.
deficient. A full blood count will confirm the
diagnosis of iron deficiency. 2. What should be done if the patient has a
heart murmur due to heart valve disease?
4. What should be done if a patient
The type of heart valve disease must be
presents before 36 weeks gestation with a
diagnosed. If the patient needs medication, the
haemoglobin concentration below 8 g/dl?
correct drug must be prescribed in the correct
If the patient is not short of breath and does dosage. She must be managed as a high-risk
not have a tachycardia above 100 beats per patient and should be carefully followed up for
minute, she may be managed at a high-risk symptoms or signs of heart failure.
clinic. After blood has been sampled for a
full blood count, she should be prescribed 3. Will most patients with heart
2 ferrous sulphate tablets three times a day. valve disease give a history of
With this treatment the patient should have previous rheumatic fever?
corrected her haemoglobin concentration
before she goes into labour. No. Although most heart valve disease is
caused by rheumatic fever during childhood,
most of these patients are not aware that they
5. What should be done if a patient
have had rheumatic fever.
presents before 36 weeks gestation with
shortness of breath, tachycardia and
a low haemoglobin concentration?
The patient must be admitted to hospital for
a blood transfusion. This is necessary because
the patient has shortness of breath and

13. 136 PRIMAR Y MATERNAL CARE
4. Is it safe to deliver a patient with heart management would depend on the result of
valve disease at a primary care clinic? this test.
No. Special management is needed in at least
a secondary hospital with specialist care 3. Why should a patient be
available. investigated if she has 1+ glycosuria
or more for the first time?
The patient may already be a diabetic with a
CASE STUDY 4 high blood glucose concentration causing the
glycosuria.
An obese 35 year old multiparous patient
presents with 1+ glycosuria at 20 weeks of 4. What should the management have
gestation. At the previous antenatal visit she been if her random blood glucose was
had no glycosuria. A random blood glucose 9.0 mmol/l at 28 weeks gestation?
concentration is 7.5 mmol/l. She is reassured
The patient should be seen the next morning
and followed up as a low-risk patient. At 28
after fasting from midnight. Her fasting
weeks she has 3+ glycosuria. As the random
blood glucose concentration should then be
blood glucose concentration at 20 weeks was
measured.
normal, she is again reassured and asked to
come back to the clinic in 2 weeks.
5. If the patient has a fasting blood
glucose concentration of 7.0 mmol/l, what
1. Do you agree with the management
should her further management be?
at 20 weeks gestation?
The result is abnormal but is not high enough
Yes, the patient was correctly managed when
to diagnose diabetes. She should, therefore,
a random blood glucose concentration was
be placed on a 7600 kilojoule per day diabetic
measured after she had 2+ glycosuria. When
diet. A glucose profile must be obtained after
1+ glycosuria or more is present again,
2 weeks and this should be repeated every 4
later in pregnancy, a random blood glucose
weeks until delivery.
concentration must be measured again.
2. How should the patient have
been managed at 28 weeks?
She should have had another random blood
glucose concentration measurement. Further

14. MEDICAL PROBLEMS DURING PREGNANC Y AND THE PUERPERIUM 137
Hb less than
11 g/dl
Hb less than Hb 8 or more, Hb 10 g/dl
8 g/dl but less than or more
10 g/dl
1. Ferrous sulphate
Full blood count Full blood count
tablets
2. Primary care
Yes Duration of Duration of No 1. Ferrous sulphate
pregnancy 36 weeks pregnancy 36 weeks tablets
or more? or more? 2. Full blood count
two weeks later
No Yes
Admit to hospital Yes Shortness of Yes
for blood breath or
transfusion tachycardia?
No
No
1. Ferrous suplate tablets Increase
2. Clinic for high risk patients in Hb?
Flow diagram 7-I: The management of a patient with iron-deficiency anaemia in pregnancy

15. 138 PRIMAR Y MATERNAL CARE
Random
Random
blood
blood
glucose
glucose
measurement
measurement
Less than
Less than 88or more but
or more but 11 mmol/l
11 mmol/l
88mmol/l
mmol/l less than
less than or more
or more
==normal
normal 11 mmol/l
11 mmol/l ==diabetes
diabetes
1. Routine primary perinatal
1. Routine primary perinatal
care Measure fasting
Measure fasting Admit to hospital for
care blood glucose Admit to hospital for
2. Repeat random blood
2. Repeat random blood blood glucose glucose control
glucose control
glucose ififglycosuria recurs concentration
concentration
glucose glycosuna recurs
Less than
Less than 66or more but
or more but 88mmol/l
mmol/l
66mmol/l
mmol/l less than
less than or more
or more
==normal
normal 88mmol/l
mmol/l ==diabetes
diabetes
Glucose profile
Glucose profile
Follow up at 77600 kj/day
600 kj/day
Follow up at 22weeks later and
weeks later and
special clinic diabetic diet
diabetic diet
special clinic then every 44weeks
then every weeks
Normal Abnormal
Flow diagram 7-II: The management of a patient with glycosuria who has a random blood glucose concen-
tration measured in pregnancy.