 |  | Healthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.) | ||
 |  | Chapter Nine - SERIOUS COMPLICATIONS DURING PREGNANCY | ||
|  | (introduction...) | ||
| | Problems Caused by Pregnancy | ||
| | Existing Problems that Can Be Made Worse by Pregnancy | ||
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During any pregnancy, complications can arise. Some of them are relatively minor, as discussed in the previous chapter. Others, however, can be serious and may require medical attention. These include problems that are caused by pregnancy, as well as conditions that existed before but are made worse by the pregnancy. Some are life threatening, so it is important for women and their families to know which ones are dangerous and which ones are not. They should also know what to expect, and what to do when a problem occurs. This chapter discusses some of the more serious complications of pregnancy.
The problems described in this next section are, for the most part, complications that are caused by pregnancy.
MISCARRIAGE AND ABORTION
Not all pregnancies last the normal nine months (40 weeks) and result in the birth of a baby. In some cases pregnancy ends by itself; this is called a miscarriage or spontaneous abortion. Miscarriages usually occur before the 26th week. In some cases an operation is carried out to end the pregnancy; this is called induced abortion.
MISCARRIAGE OR SPONTANEOUS ABORTION:
Out of every one hundred pregnancies, ten to twenty end in miscarriage. Miscarriage occurs when the pregnancy ends before the baby has any chance of survival. Most miscarriages occur in the first 12 weeks of pregnancy.
What causes a miscarriage? By far the most common reason is that something is wrong with the fertilised egg. When examined under a microscope, 60% of all pregnancies that miscarry show signs of serious problems with the fertilised egg. If the egg had continued to grow and develop, it would have resulted in a baby with severe abnormalities such as deformed or missing organs. Miscarriage, therefore, can sometimes be nature's way of dealing with such problems.
A miscarriage may also result if a woman has a serious illness such as malaria or syphilis, a severe fall, or a problem with her reproductive organs. Some miscarriages occur because the pregnancy was ectopic. This means the fertilised egg was implanted someplace other than the womb, usually in the fallopian tube. Ectopic pregnancies almost always miscarry and can be very dangerous; they are discussed later in this chapter.
THE SIGNS OF A MISCARRIAGE: There are two main signs of a miscarriage: bleeding from the vagina, and pain in the lower abdomen. The bleeding is usually slight to begin with, but gets heavier and soon big clots appear. Both the bleeding and the pain can be quite similar to those accompanying a heavy menstrual period, especially for an early miscarriage. It may therefore be difficult to tell when a miscarriage happens, especially if pregnancy was never suspected.
"COMPLETE" MISCARRIAGES: A miscarriage is described as "complete" when all the tissues of the developing embryo or foetus and the placenta have passed out through the vagina. With a complete miscarriage, the bleeding will stop after a few days. In this case a woman should rest and avoid any heavy lifting or exercise for 2-3 weeks. Sexual intercourse and tub baths should also be avoided during this time, as they increase a woman's chances of getting an infection. To clean herself, she should use a wet cloth or towel instead. A normal miscarriage should not cause any problems, but a woman should go for a check-up at a health clinic in the first week after the bleeding has stopped, even if she feels fine, to make sure no harm has been done. Furthermore, women with any bleeding that is not a menstrual period, whether pregnancy is suspected or not, should be encouraged to have a thorough examination.
INCOMPLETE MISCARRIAGES: A miscarriage is incomplete when part of the foetus or placenta remains inside the womb. A miscarriage is more likely to be incomplete if it happens between the tenth and twentieth week of pregnancy. Bleeding continues and there is a good chance that the dead tissues inside the womb will become infected, which usually causes fever and pain in the abdomen (see Figure 9.1). When a miscarriage is incomplete, the womb must be completely emptied as soon as possible by a trained health worker in a hospital or clinic. If an incomplete miscarriage becomes infected, it can lead to fever and pain in the reproductive organs that does not go away. If the infection is not treated it can cause scarring in the fallopian tubes, which can make a woman infertile. If a woman has any signs of infection after a miscarriage, she should go immediately for a check-up.
After a miscarriage, especially an incomplete one, a woman should wait several months before trying to get pregnant again. During this time a family planning method should be used to avoid pregnancy (see Chapter 17).
REPEATED MISCARRIAGES: Some women have miscarriages again and again. Sometimes it is possible to figure out why this happens. For example, there may be a weakness in the neck of the womb which can be corrected by closing it with a stitch during pregnancy. But often, no medical explanation can be found even after lengthy tests and investigations. After one or two miscarriages early in pregnancy, a woman should be reassured not to worry. Even a woman who has had three or more early miscarriages has a 75% chance of carrying the next pregnancy to term. But after the third or fourth miscarriage, or if a miscarriage occurs late in pregnancy, a woman should be encouraged to have a medical examination to see if any explanation can be found.
INDUCED ABORTION: Miscarriages are also called "spontaneous abortions", which means they start on their own. There are, however, times when a woman ends the pregnancy by an "induced abortion". There are various reasons why a woman might want to end her pregnancy. Some illnesses can make pregnancy dangerous to a woman's health, and an induced abortion may be necessary to preserve her health or even to save her life. In these cases, an abortion can be legally performed by a doctor in most African countries. In some countries, abortion may also be legal if the foetus has a severe abnormality, or if the pregnancy is the result of rape or incest.
A woman may also want to end a pregnancy because she is not married or because her husband has left her. Or, she and her husband may have many children already and feel they cannot afford to take care of any more. If a woman does not want to become pregnant, the best thing for her to do is to use a method of contraception to prevent a pregnancy before it starts. No contraceptive method is perfect, however, and neither are people; so unintended pregnancy does happen. In situations where abortion is legal, the procedure is usually performed early in the pregnancy, during the first three months. The woman is given an injection to reduce the pain, and then a doctor cleans out the womb using instruments that are inserted through the vagina. The operation usually takes about 15 minutes. If it is done by a trained person, with proper equipment and in a clean environment, the operation is not dangerous.
Figure 9.1: Complications of
Miscarriage or Abortion
An incomplete miscarriage or unsafe abortion can result in severe bleeding, infection, and fever. If a miscarriage occurs and any of these signs develop, the woman should go immediately to a hospital or clinic.
Where abortion is not legal, women may still try to end their pregnancies - by themselves, with the help of a traditional healer or birth attendant, or in an illegal abortion clinic. Some of the traditional methods used include inserting a twig into the womb; swallowing a special tea, chemical, or fruit; taking a very large dose of a drug like chloroquine; douching (washing out) the vagina with a harsh chemical like bleach; or having someone massage the abdomen very roughly. Most of these methods are not effective, and many are extremely dangerous to the woman's health. These procedures are often performed in secret and in unclean conditions by untrained people. Even abortions performed by health professionals in medical facilities can be unsafe if they are not done carefully, or if the equipment or the environment is not clean.
If an unsafe method is used to induce an abortion, the woman is likely to have a major infection in her reproductive organs. In some cases, a hole is made in the womb. Both problems are very serious; they can cause death or long-term illness, and are likely to make the woman infertile.
If for some reason a woman has had an induced abortion and she develops any of the signs in Box 9.1 below, she should go to a hospital for treatment immediately. Delay can mean death. The health workers and family members who are helping her should treat her with kindness and sympathy, since she is likely to be frightened and in pain. It is important to gain her trust and reassure her that she will not be punished or blamed. Otherwise she is unlikely to tell the truth about what has happened, which makes it harder to provide the correct medical treatment.
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Box 9.1: Post-Abortion Danger Signs FEVER OR CHILLS |
ANAEMIA
Anaemia is a common complication of pregnancy. In anaemic women, the blood does not have enough iron in it, and is not able to carry enough oxygen to the body. This is often called "weak blood". Even if a woman had a normal amount of iron before pregnancy, more is needed during pregnancy. In fact, two or three times as much is needed to meet the needs of mother and baby. If anaemia existed before pregnancy, the increased need for iron will make the anaemia worse.
Unfortunately, many women start pregnancy with some degree of anaemia. It can be caused by a number of things:
· A diet that is low in iron-rich foods such as liver, eggs, lean meat, and leafy green vegetables. Foods with vitamin C (oranges, pawpaw, mangoes) also help the body absorb iron from other foods.· A parasite (malaria, hookworm, schistosomiasis) in the blood or body that reduces the amount of iron.
· Repeated pregnancies without adequate time in between to recover physically, which uses up iron.
· Sickle cell disease or some other blood disorder.
· Heavy menstrual periods may lead to anaemia over time, since women lose iron during their periods each month.
THE SIGNS OF ANAEMIA: A woman who is anaemic usually feels tired and weak most of the time; she may also feel dizzy and out of breath. Her skin may be unusually pale on the insides of her eyelids (conjunctivae), gums, and tongue, as well as the palms of her hands and the soles of her feet (see Figure 9.2). While these signs can be used as a warning, it is best for her to go to a hospital or clinic that can diagnose the disease through a blood test and find out how serious it is. Blood testing for anaemia may be done more than once during the pregnancy.
WHY IS ANAEMIA SERIOUS? If anaemia is not identified and properly treated early, it will get worse during pregnancy. Very severe anaemia can cause heart failure, miscarriage, or premature labour. Anaemia can also make other problems, like infection or bleeding, even more life-threatening. The blood of an anaemic woman is already weak, and excessive bleeding during an abortion (spontaneous or induced) or following delivery can be very dangerous. Anaemic women also have less ability to fight off infections, especially after an abortion or an operation.
Figure 9.2: Checking for Signs
of Anaemia
If a woman is feeling tired, weak, and dizzy, or if the insides of her eyelids or her palms are especially pale, she might have anaemia. She should go to a hospital or clinic for a test.
WAYS TO PREVENT ANAEMIA: The best way for a woman to avoid severe anaemia is to not be anaemic when pregnancy starts. Eating a diet rich in the foods listed above, and allowing plenty of time between pregnancies (two to three years) will help. Avoiding malaria and other diseases will also help prevent anaemia.
Even if a woman is not anaemic, once she is pregnant she should take iron tablets regularly as prescribed by a trained health worker. Sometimes these tablets will include folic acid or other vitamins. It is best for her to take them with food. Some women find that the tablets make them feel sick, and are therefore reluctant to take them. The benefits of taking the tablets should be carefully and thoroughly explained to them, and they should be advised to take the tablets with food to minimise the discomfort. Iron tablets should not be taken with milk, since milk can prevent the body from using the iron.
TREATMENT OF ANAEMIA: If treatment with iron tablets is started early enough, there is usually time to correct the anaemia before delivery. In severe cases, if there is not enough time for this treatment to work, or if a woman loses a great deal of blood at delivery, it may be necessary to give a blood transfusion. This can be a risky procedure.
PRE-ECLAMPSIA AND ECLAMPSIA
Pre-eclampsia (high blood pressure caused by pregnancy) can occur anytime during pregnancy, but it usually occurs towards the end (after the 28th week). No one knows what causes this serious condition, but it is most common in young women in their first pregnancy. If pre-eclampsia is not treated, it may lead to full-blown eclampsia.
SIGNS OF PRE-ECLAMPSIA: Pre-eclampsia is also known as pregnancy-induced hypertension. It has three major signs:
1. Swelling of the feet, hands and fingers, and face (see Figure 9.3): Some swelling of the ankles during pregnancy is not unusual, especially if a woman has been standing for a while. But if the swelling is present when the woman first wakes up in the morning, or if her shoes are too tight and there is swelling in the face, she should be advised to go to a clinic to see if she has pre-eclampsia. Many women are not aware that such swelling indicates a potentially serious complication. Health education during antenatal care should explain the signs and seriousness of pre-eclampsia in terms that they can understand.2. A rise in the blood pressure: An increase to 140/90 mmHg or above, or an increase in the blood pressure of 30 mmHg systolic and 15 mmHg diastolic in comparison to earlier measures, is a sign of severe hypertension or high blood pressure. This can only be detected by measuring the blood pressure.
3. Protein in the urine: This too can be found only by a test at the clinic.
EFFECTS OF PRE-ECLAMPSIA ON MOTHER AND BABY: In mild cases, a woman may feel no ill effects apart from swelling of the feet, ankles, hands, and face. But if pre-eclampsia is not treated properly and promptly, it can lead to high blood pressure, kidney damage, and increasing amounts of fluid in the body. The baby may not receive enough oxygen and food, and may be small and weak. A woman may develop severe headaches, blurred vision, spots before her eyes, and vomiting. These are signs that the most serious stage of this complication, called eclampsia, may be developing. Eclampsia, in which a woman has fits or convulsions and loses consciousness, is a life-threatening complication for both mother and child. It can occur late in pregnancy, during delivery, or shortly after the baby is born (within two days or 48 hours).
WHAT TO DO: If signs of pre-eclampsia exist, a woman should go to a hospital. Local treatments with herbs and other mixtures are generally not effective. The woman may need total bed rest to prevent pre-eclampsia from getting worse. If resting at home does not work, she may need to enter the hospital for rest and treatment under supervision. Sometimes sedatives or medications are needed to reduce the blood pressure. A woman should understand the danger of the situation so that she knows why these measures are necessary. Sometimes women are reluctant to take these measures because they often feel fine, even though their blood pressure may be dangerously high.
Figure 9.3: Oedema
Swelling in the feet, hands and fingers, as well as the face, is a sign of pre-eclampsia. A woman with these signs should go to a clinic to have her blood pressure and urine checked.
In severe cases, when eclampsia is developing, a woman must get immediate, expert treatment in a hospital. If she starts having fits, she should be prevented from hurting herself, but should not be held down forcibly. The handle of a spoon wrapped in a cloth should be put into her mouth to prevent her from biting her tongue. When the fit is over and she is being taken to the hospital, she should be placed in a lying-down position on her side. It is essential that the baby be delivered as soon as possible; this is necessary to save the lives of both mother and baby. Sometimes an operation is necessary.
SEVERE VOMITING
Morning sickness, sometimes accompanied by vomiting, is a relatively common complaint during the first three months of pregnancy. It is not normal, however, if the vomiting persists or is severe, or if it occurs late in pregnancy or causes weight loss and severe dehydration. A woman should be advised to rest in bed at home or in the hospital for a few days, avoid fatty foods, and not drink too much water at one time. If the vomiting continues in spite of this treatment, she may become very dehydrated. It may be necessary to give fluids and nourishment through a vein in the arm.
TOO MUCH WEIGHT GAIN
During pregnancy, most women put on weight - around 20-30 pounds (10-12 kilos) on average. Most of the weight gain occurs after the fourth month, when women gain roughly four pounds (two kilos) per month. If a woman gains a lot of weight suddenly (more than two pounds or one kilo in a single week) when she has been eating normally, her body may be keeping too much water. This could be a sign of pre-eclampsia; the woman should go to a health facility to have her blood pressure and urine checked, and to be examined by a trained health worker.
NOT ENOUGH WEIGHT GAIN
After the first three months, most women gain weight steadily during the rest of the pregnancy. If the weight gain is less than two pounds (one kilo) per month after the third month, this may be a sign that the baby is not growing as it should. This may be caused by not eating enough or working too hard. It may also be caused by some illnesses, such as tuberculosis or AIDS, or by a placenta that is not carrying enough oxygen and food to the baby. The woman should go see a trained health worker for an examination.
Failure to gain any weight over a number of weeks, or actually losing weight, is an even more serious sign, and needs immediate evaluation by a doctor. Losing weight when eating normally may be a sign that the mother has a serious disease, and may mean that the baby's life is in danger.
BLEEDING EARLY IN PREGNANCY
Slight bleeding from the vagina may occur in early pregnancy (before 26 weeks). A woman who has slight bleeding should lie down and rest for 2-3 days.
Typical causes of this bleeding include implantation bleeding (when the fertilised egg attaches itself to the lining of the womb), an infection in the vagina, irritation caused by herbal douches, and threatened miscarriage. If the bleeding is accompanied by cramps or if it gets worse, the woman should go to a health facility.
BLEEDING LATE IN PREGNANCY
Any bleeding from the vagina during the last four months of pregnancy (after 26 weeks), however slight, must be taken very seriously. A woman should go to a hospital immediately, as she may need a blood transfusion and possibly an operation. Someone should go with her who can donate blood if a transfusion is needed.
Bleeding from the vagina during late pregnancy is called antepartum haemorrhage. It is a sign of two possible problems:
PLACENTA PRAEVIA: Normally, the placenta is attached to the womb high up and out of the way of the baby. Occasionally (in about one out of every 200 pregnancies), the placenta lies low down in the womb, blocking the way the baby has to pass during delivery. This situation is called placenta praevia and frequently causes bleeding in the latter half of pregnancy. In this type of haemorrhage, there are usually small "warning bleeds" earlier in the pregnancy, and the bleeding is not usually accompanied by pain. It may be necessary to deliver the baby by Caesarean section."ACCIDENTAL" HAEMORRHAGE: Bleeding sometimes occurs behind the placenta, even when it is in the normal place, if it separates partially from the womb. The cause of this condition, which is also called abruptio placenta, is not known.
It usually occurs without any "warning bleeds" and is nearly always accompanied by sudden and severe pain in the abdomen and/or back. When the placenta separates, it cuts off food and oxygen to the baby, who may be born dead. Sometimes this separation can happen without any of the blood coming out of the vagina. The only sign in this case may be sudden and severe abdominal pain and tenseness of the womb.
Labour may or may not start soon after an accidental haemorrhage. If the baby is still alive when the mother reaches the hospital, the doctor will try to deliver the baby as soon as possible, sometimes by Caesarean section. A woman who has had this problem runs the risk of postpartum haemorrhage. She should be kept in a hospital and observed for at least 24 hours after delivery.
ECTOPIC OR TUBAL PREGNANCY
Sometimes a fertilised egg does not reach the womb within seven days of being fertilised. It may then attach itself in the tissues surrounding it, often in the fallopian tube. Implantation somewhere other than the inside of the womb is known as ectopic pregnancy. When this happens, the thin walls of the fallopian tube cannot stretch adequately to hold the growing embryo for more than a few weeks. The wall of the tube ruptures or breaks, and severe bleeding occurs inside the body.
SIGNS OF AN ECTOPIC PREGNANCY: At the beginning, an ectopic pregnancy appears similar to a normal pregnancy: menstrual periods stop, and some of the other signs may develop such as the breasts getting bigger. There are two signs that indicate the pregnancy is ectopic rather than normal: bleeding from the vagina, and pain in the abdomen. If a woman has these symptoms, she should go to a doctor immediately for treatment. If the tube ruptures (breaks), she will experience severe, sudden pain and may also vomit or faint. She will need to go to the hospital immediately for surgery, and perhaps a blood transfusion. If possible, someone should go with her who can donate blood for a transfusion in case it is necessary.
PREVENTING ECTOPIC PREGNANCY: Unfortunately, ectopic pregnancies are very common in many areas. Most often they happen because a previous infection of the reproductive organs has damaged the fallopian tube, preventing the egg from reaching the womb. Women who have had a sexually transmitted disease are more likely to have an ectopic pregnancy (see Chapter 18). If a woman has an infection in the reproductive organs, she can reduce her chances of both infertility and ectopic pregnancy by seeking treatment promptly and following instructions carefully.
TWINS (MULTIPLE PREGNANCY)
Having twins is not really a complication. If a woman is carrying twins, however, she is more likely to develop some of the complications described above, such as premature labour, anaemia, or pre-eclampsia. The complications tend to occur earlier than one would expect. Women with twins are also more likely to start labour early. A woman carrying twins should be advised to rest as much as possible during pregnancy in order to avoid or delay the onset of these complications. She should go for antenatal care regularly and often.
A pregnant woman can be affected by an illness just like anyone else. In her case, however, the effects of the illness may be more serious because of the pregnancy. Diseases like malaria and diabetes, for example, become more serious or more difficult to control during pregnancy. Conditions that can be made worse by pregnancy include:
MALARIA
Malaria is a common disease in many parts of Africa that is transmitted through mosquito bites. The symptoms are high fever, severe headaches, and sometimes vomiting. When a pregnant woman suffers an attack of malaria, it can result in miscarriage, premature labour, stillbirth, or an underweight baby. In addition, pregnancy may make women more susceptible to malaria and its complications. Malaria also increases a woman's chances of developing severe anaemia.
It is important, therefore, for pregnant women to take all possible steps to avoid malaria and to get treatment as soon as possible if they do get the disease. Women should be advised to sleep under a mosquito net, stay indoors during the evening, and take anti-malaria tablets if prescribed by a doctor, nurse, or midwife.
DIABETES
Diabetes is a disease marked by the presence of sugar in the urine and blood. It is more difficult to control the disease during pregnancy, and sometimes it is necessary for a pregnant woman with diabetes to be hospitalized. If a woman is diabetic, her infant may be either bigger or smaller than normal, depending on the stage and seriousness of the disease. In both cases the baby can develop problems. Women with diabetes are also more likely to develop complications like pre-eclampsia and urinary tract infections. Some women develop diabetes only during pregnancy, which usually goes away after the baby is born.
A woman with diabetes needs careful supervision throughout pregnancy to check the amount of sugar in her urine and blood. With the correct diet and proper care, serious complications can be avoided or treated. Sometimes it is necessary to start labour a little early. Women with diabetes must have careful antenatal care and deliver in a health facility.
SICKLE CELL DISEASE
This inherited blood disorder is very common in parts of Africa. Its symptoms include frequent attacks of severe pain in the bones, anaemia, and fever, especially during the cold and rainy season. Jaundice can also be a sign. Women with this disorder should go for antenatal care often to make sure that the pregnancy is going well. They should deliver in a hospital if possible, since they might need a blood transfusion and the baby might need special care as well.
There is no known treatment for sickle cell disease. Since attacks are often brought on by fever, infections like malaria should be avoided as much as possible. Women with sickle cell disease should report immediately to a health facility as soon as an attack begins.
Sickle-cell carriers can be diagnosed easily by a simple and reliable laboratory test. Every African woman should have her blood tested for this disorder, ideally before pregnancy. Since sickle cell disease is inherited from both parents (see Chapter 5), it is important that both parents be tested to determine if the baby is likely to be affected. This is especially true if one of them has the disease.
HEART DISEASE
A pregnant woman with heart disease needs careful supervision. Pregnancy requires a lot of extra work for the heart, because the body produces more blood. If a woman has a long and exhausting labour she risks going into heart failure. She should have trained help with delivery, ideally in a hospital. Under proper care and supervision, most women with known heart problems have normal, safe pregnancies and labours.
JAUNDICE
Jaundice is a yellow discolouration of the whites of the eyes, and is a common sign of liver disease. The most common type of liver disease is due to an infection called hepatitis A. The main signs of this disease are fever and chills; nausea and vomiting; abdominal pain; and especially yellowness of the eyes and passing dark urine. It is usually a mild disease which has no serious effects on the mother or the baby. In rare cases, especially when there is high fever and vomiting, it may lead to miscarriage or an early start to labour.
There is no special treatment for infectious hepatitis A. Women should be advised to rest in bed and drink as much liquid as possible. The illness usually clears up in about three to four weeks. Because hepatitis A is easily passed from one person to another through contact with stool or contaminated food or water, women should be counselled on careful hygiene. They should also avoid close contact with anyone who has the disease.
Hepatitis B, a viral infection of the liver, is a chronic, untreatable infection. Often people with this infection will remain in a healthy "carrier" state in which they do not feel sick but may infect others. In some cases, however, it may lead to severe liver damage and death. There is no known cure for the infection, although adults and infants may be protected from the disease by a series of vaccinations. Unlike hepatitis A, hepatitis B is transmitted through contact with blood and body fluids.
TUBERCULOSIS
Tuberculosis is a disease of the lungs, marked by a deep, persistent cough. Women with tuberculosis are more likely to suffer from miscarriage or premature labour, so they need special care during pregnancy. During labour, it is important that a woman with tuberculosis does not become exhausted. She should deliver in a hospital or health facility, and may need to have an assisted delivery (see Chapter 12).
OBESITY
Women who are very overweight may be at higher risk of some complications, especially obstructed labour and high blood pressure (pre-eclampsia). They should go for antenatal care often during pregnancy, and deliver in a health facility if possible.
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Summary: Serious Complications During Pregnancy Some serious complications can be caused by pregnancy. In other cases a woman may have had a condition or disease which is made worse by pregnancy. It is important for women and their families to know the signs of serious complications, and to know what to do. If a woman develops any of the following signs, she should go to a hospital or health centre IMMEDIATELY: High fever If a woman develops any of the following signs, she should visit a health centre as soon as possible because a serious complication may be developing: Pale eyelids, tongue, gums, or palms; always feeling tired and short of breath (anaemia) Not enough weight gain |
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