IRON DEFICIENCY ANEMIA Definition Anemia is defined as reduction in circulating hemoglobin mass below the critical level. The normal hemoglobin (Hb) concentration in the body is between 12-14 gms %. WHO has accepted up to 11gm% as the normal hemoglobin level in pregnancy. Therefore any hemoglobin level below 11gm% in pregnancy should be considered as anemia. However, in India and most of the other developing countries the lower limit is often accepted as 10 gms %.

Magnitude of the problem Pregnancy anemia is one of the important public health problems not only in India but also in most of the South East Asian countries. About 4 - 16% of maternal deaths are due to anemia. It also increases the maternal morbidity, fetal and neonatal mortality and morbidity significantly.

Incidence Anemia affects nearly half of all pregnant women in the world: 52% in developing countries as compared to 23% of women in the developed countries. The prevalence of Anemia in pregnancy in South East Asia is around 56%. In India: 60 to 88% (about 18 to 26 million) of pregnant and 74% of non- pregnant women are anemic.

Causes 75 Physiological There is disproportionate increase of plasma volume during pregnancy leading to apparent reduction of RBCs, hemoglobin and hematocreit value. Hemoblobin is consequently reduced to a varying extent sometimes as low as 80%. The blood picture in peripheral smear is normochromic and normocytic.

Acquired Nutritional • Iron deficiency anemia (60%) • Macrocytic anemia (10%) due to deficiency of folic acid and / or vitaminB12 • Dimorphic and protein deficiency anemia (30%) both due to deficiency of iron and folic acid and /or vitaminB12 Hemolytic • Hemoglobinopathies • Drug reaction • Infestation with malaria parasites Hemorrhagic • Due to acute blood loss • Chronic blood loss (hook worm, bleeding piles)

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Anemia may be a risk factor for

Fetal, neonatal and infants

Mother

During Antenatal period

• • • • • • •

76

Poor weight gain Pre term labor Pregnancy Induced Hypertension Placenta previa Accidental hemorrhage Eclampsia, Premature rupture of membrane (PROM) etc.

During Intranatal period

• Dysfunctional labor • Intranatal hemorrhage • Shock • Anesthesia risk • Cardiac failure

During Postnatal period

• Postnatal sepsis • Sub involution of uterus • Embolism

• • • • •· •

• • •

Prematurity Low birth weight Poor Apgar score Fetal distress Neonatal distress requiring prolonged resuscitation, Neonatal anemia due to poor reserve. Infants with anemia have higher prevalence of: Failure to thrive Poorer intellectual developmental milestones, Higher rates of morbidity and neonatal mortality than infants without anemia.

A pregnant woman with anemia may present with Vague complaints of ill health Fatigue Weakness/ Tiredness Anorexia Digestive upset Pica Dyspnea Palpitation

On examination Pallor • At palpebral conjunctiva • At tongue/nail beds and /or palms Edema may be present in severe cases

Rule out other causes of dyspnea and palpitation Request for investigations • Hemoglobin estimation • Study of the Peripheral blood smear

Hemoglobin ranges between 7-11g / dl (Moderate anemia)

Microcytic, hypochromic RBCs

• Microcytosis, • Hyper segmentation of neutrophils • Fully hemoglobinised RBCs

If Hemoglobin is less than 7 g / dl (Severe anemia)

• Polychromatic cells • Stippled cells • Target cells

Refer to Obstetrician for assessment and management

77 Iron deficiency anemia

Megaloblastic anemia (B12 / folate deficiency)

• Start appropriate Homoeopathic treatment. • Switch from Prophylactic to Therapeutic dose* of iron therapy. (see next page) • Advise nutritional management. • Get the Hemoglobin tested after 10 days and review the case. • Look for signs of side effects of iron supplements, and if present, provide appropriate Homoeopathic treatment.**

• Improvement in signs and symptoms weakness, appetite, pallor, etc. • Improvement in value of Hemoglobin (Hemoglobin should rise by 1 gm/ dl every 7- 10 days)

• Continue nutritional and therapeutic management. • Review the case every 10 – 14 days with Hemoglobin estimation.

Hemolytic anemia

It is important to rule out • Mal-absorption syndrome

• Advise diet rich in Vitamin B12, iron and folic acid.*** • Continue prophylactic Iron therapy.

Refer for specialized care

• Presence of chronic infection • Loss of iron from the body • Lack of patients compliance • Ineffective release of iron from a particular iron preparation

• Increase Folic acid supplementation to 1 mg per day under supervision of Obstetrician.

• No improvement in signs and symptoms and Hemoglobin percentage. • Continue nutritional and therapeutic management. • Investigate for cause of anemia and treat: ° Stool examination for ova and cysts of helminthes. ° Check for other cause of blood loss such as bleeding piles. • Follow up the case after 7 – 10 days.

Improvement

• No Improvement / worsening of signs and symptoms and /or • No increase in Hemoglobin levels

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*Iron and Folate Supplements Prophylactic dose ( is given to all women):

#

One tablet of 100 mg. elemental iron and 0.5 mg folic acid once a day for at least 100 days. Therapeutic dose:

#

If Hb < 11 g/dl. : 100 mg. elemental iron and 0.5 mg folic acid twice per day for 3 months, i.e. at least 200 tablets. #

As per standard treatment guidelines given by Govt. of India.

** Symptoms of side effects of Iron supplements Nausea Vomiting Abdominal discomfort Constipation Diarrhea Skin rashes Metallic taste in mouth

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Other special laboratory investigations such as total iron binding capacity (TIBC), serum ferritin (SF), serum folic acid, bone marrow studies are not routinely available everywhere and are expensive. Therefore they are not used as routine investigations to diagnose pregnancy anemia.

Important: Iron supplement in hemolytic anemia should be treated with caution under the supervision of obstetrician due to danger of hemosiderosis.

Severe anemia in late pregnancy (after 32 weeks) (may or may not be presenting with heart failure)

Refer the patient for urgent admission to hospital as these patients need complete rest, oxygen therapy and specialized care.

Nutritional management *** Iron rich foods: Cereals, egg, liver, fish, legumes (peas and beans), beet root, green leafy vegetables like spinach, coriander, fenugreek, raisins, etc. It must be emphasized that much of the iron can easily be obtained from many iron rich foods such as jaggary, spinach, roasted grams, etc. which are not expensive and can be easily afforded and consumed. Significant amount of iron may be derived from cooking in iron utensils. Folate rich foods - Fresh green vegetables, legumes, broccoli, asparagus, mushrooms, spinach, lettuce, lemons, bananas, melons, milk, cheese, egg, yeast, meat fish and liver. To prevent loss of folate, foods should not be cooked excessively, especially in large amounts of water. Vitamin B12 rich foods - It is not found in foods of vegetable origin. Liver, meat, kidney are rich sources. Some amount of Vitamin B12 is also found in fish, egg, cheese and milk. To prevent cobalamin (Vitamin B12) deficiency, patients who take vegetarian diets should include dairy products and eggs in their meals.

Timing of oral iron intake in relation to food Foods which interfere with absorption of iron should be avoided along with iron supplement and iron rich foods. These include: •

Phytates (cereals, bran and legumes)

•

Tannins (green and black tea, wine, pomegranates, and coffee)

•

Phosphates, oxalates and carbonates (vegetables, eggs and milk)

Increase intake of Vitamin C rich foods: The absorption of iron from plant foods is improved by the presence of Vitamin C or ascorbic acid. Sources of Vitamin C rich food are guava, lemon, amla, orange, tomato, cabbage, carrots, cauliflower, spinach, germinating pulses, etc.

Prophylaxis It is advisable to build up iron store before a woman marries and becomes pregnant by: Routine screening for anemia for adolescent girls form school days and providing iron supplementation if needed Encouraging iron reach foods Fortification of widely consumed food with iron Regular screening for those with risk factors.

Send for referral if Patient not responding to the above therapy.

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Complicated severe anemia cases e.g. with other co-morbidities like heart failure, palpitations, infections, etc., which might require parenteral iron therapy or blood transfusion. Complications of pregnancy associated with anemia are present (Refer to maternal risk factors )

Important Examine or screen all women for anemia during antenatal visits. Conjunctival inspection in pregnant women may be particularly inaccurate as a result of increased peripheral vasodilatation. Thus, the nail beds, palm and underside of the tongue should also be examined for pallor. Ensure compliance of intake of iron and folic acid supplements.

Homoeopathic management Commonly used medicines with their indications Medicine

General indications

Particular symptoms

Aletris farinosa

Anemic patients who feel tired all the time; have muscular pains; tendency for threatened abortion; disgust for food; least food causes distress, better by passing flatus; worse from loss of fluids; anemic, relaxed condition; both mentally and physically.

• • • •

Cinchona officinalis

Chilly patient; complaints of pregnant women after exhausting discharges and/or intermittent fevers; history of profuse menses and prolonged diarrhea; pale, sickly expression; sensitive to draughts of air, yet wants to be fanned; desire for sour and

• Gradually progressive anemia. • Face pale, hippocratic; eyes sunken and surrounded by blue margins. • Weakness.

Marked anemia due to nutritional disturbances. Fainting spells, with vertigo. Tired, dull, heavy and confused. Suffers from prolapsus uterus, leucorrhea, rectal distress etc.

Contd...

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Calcarea phosphorica

sweet things; intolerance to fruits; aversion to mental and physical exertion; apathetic, indifferent, taciturn, oversensitive to noise, touch and jar; full of care.

• Tinnitus. • Pulsating headache with throbbing of carotids and flushing of the face; worse from slightest jar, motion; better by tight bandage. • May be associated with flatulence with incarcerated flatus; excessive flatulence not relieved by eructations or passing flatus.

Chilly patient; thin, spare, and delicate women; numbness and crawling are characteristic sensations; tendency for easy perspiration; desire for raw salt, bacon and smoked things; dissatisfaction; desire for travel and for change.

• Anemia due to nutritional disturbance, after acute diseases and chronic wasting diseases. • Pale, yellowish face. • Chlorosis with wax like complexion. • Dull headache particularly on the top of the head; head sensitive to jar and pressure.

Ferrum phosphoricum Pale; bright hemorrhages; desire for stimulants and sour; aversion to meat and milk; nervous, sensitive (to touch and jar), easy flushing of face and marked prostration; pulse quick, soft and full; drowsiness and restless.

• Anemic patient with violent local congestion. • Night sweats due to anemia. • Ferrum phosphoricum 3x has been found to be effective in increasing hemoglobin. (Research study conducted by CCRH)

Natrum muriaticum

Hot patient; emaciated (marked on neck), poorly nourished; craving for salt; aversion to bread, wine and fat things; increased thirst; mapped tongue; constipation; great weakness and weariness; oversensitive to all types of influences; awkward, hasty, drops things from nervous weakness; aggravation: noise, music; sad, melancholic, hysterical; weeping alternating with laughing; silent grief; weeping mood, wants to be alone to cry; consolation aggravates.

• Anemic headache, from sunrise to sunset; with pale face, nausea and vomiting. • Dyspnea while ascending stairs or from physical exertion. • Maximum weakness is felt in the morning, in bed. • Tachycardia. • Palpitation, fluttering and intermittent action of the heart.

Kali carbonicum

Chilly patient; intolerance of cold weather; puffiness; weakness, backache and profuse perspiration; aggravation in the morning, 2-4 a.m.; excessive flatulence, distended abdomen as if it would burst; sharp and cutting pains, better by motion; extremely anxious personality; over-sensitive to pain, noise and touch; very irritable with weakness.

• Anemia due to loss of fluids, particularly uterine hemorrhage; constant oozing after copious flow, with violent backache. • Edema of upper eye lids. • Rapid and weak pulse. • Palpitation and burning in the region of heart.

Pulsatilla

Hot patient; marked changeability; thirstless with great dryness of mouth; tongue coated yellow or white; though she feels chilly, she is better in open air; worse in the evening; better by slow , gentle motion; desire for cheese, pungent things, highly seasoned food, sausage; aversion to fatty food, meat, butter, bread, warm foods and drinks and smoking; craving for ice-cream and pastry; mild, gentle, affectionate, yielding; weeping disposition; desire for company.

• Often indicated after abuse or over use of Iron tonics.

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Along with the indicated medicine, ‘Tissue remedies’ can also be used rationally like Calcarea phosphoricum, Kali muriaticum, Kali phosphoricum, Natrum muriaticum, Natrum sulphuricum and Silicea. Other medicines that can be used on symptomatic indications are Lecithin, Vanadium, Manganum aceticum, Ferrum metallicum, Phosphorus, etc.

PEDAL EDEMA Definition Edema is the abnormal and excessive build up of fluid in the body. Dependent edema occurs due to impedance of venous return. It is commonly seen in the feet and ankles, because of the effect of gravity. The swelling is least in the morning on waking but returns later in the day after walking around.

Incidence Mild pedal edema during pregnancy is almost a universal feature and almost always goes away after delivery.

Etiological Factors

Physiological

Pathological

81 Causative factors Retention of fluid due to influence of ovarian, placental and steroid hormones Pressure on the veins of the legs by the growing uterus impairing the return of blood from the lower limbs

Aggravating factors Prolonged standing or sitting

Pre-eclampsia Anemia Cardiac failure Nephrotic syndrome

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A pregnant woman presenting with slight degree of ankle edema which generally disappears / reduces on rest Check blood pressure and other vital signs i.e. pulse, respiration, etc.

> 140/90 mmHg Assess for duration

Of recent origin

82

Severe Anemia: (Hb 110

Proteinuria

+2

Headache

Absent

Present

Visual disturbances

Absent

Present

Epigastric pain

Absent

Present

Oliguria

Absent

Present

Convulsions

Absent

Present (in eclampsia)

Pulmonary edama

Absent

Present

Thrombocytopenia

Absent

Present

Hyperbilirubinemia

Absent

Present

Elevation of liver enzymes

Absent

Present

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Table - 2 : Criteria for Severe Pre-eclampsia Systolic blood pressure: >160 mmHg. Diastolic blood pressure: >110mmHg Proteinuria Oliguria Cerebral or visual disturbances Epigastric pain Pulmonary edema Evidence of microangiopathic hemolysis Hepatocellular dysfunction Thrombocytopenia Intrauterine growth restriction Oligoamnios

Eclampsia Definition

86

Eclampsia is pre-eclampsia complicated by generalized tonic-clonic seizures. May occur before, during or after delivery and labor May cause maternal death

A pregnant woman presenting with B.P. more than 140 / 90 mmHg

Assess gestational age

< 20 weeks

Chronic hypertension

> 20 weeks

Vesicular mole

Mild: Over 140/90 mmHg. Moderate: 150/100 to 170/110 mmHg. Severe: Over 170/110 mmHg. Medical causes of hypertension Essential hypertension Renal vascular hypertension Glomerulonephritis Nephrotic syndrome Pyelonephritis Polycystic kidney disease Pheochromocytoma Primary aldesteronism

Assess for edema and proteinuria

Multiple pregnancy

Refer WITHOUT DELAY to specialist for further assessment and management

Both absent

Either / both present

Medical cause of hypertension

Gestational hypertension or PIH

87 Assess for severity

Mild

Severe

Bed rest on flanks No extra salt intake Avoidence of salt containing foods such as pickles, papad, chutney, etc. Appropriate Homoeopathic treatment Calcium supplement- 2 gm./ day

No improvement

Improvement

Continue same measures

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Homoeopathic management Commonly used medicines with their indications are Medicines

General indications

Particular symptoms

Apis mellifica

Hot patient; intolerance of heat; closed, warm and heated rooms are intolerable; edema; stinging pains, soreness, hypersensitivity to touch; constricted sensation; thirstlessness; aggravation in afternoon; better from cold application; awkward, drops things easily from hands; irritable, jealous, nervous, fidgety and hard to please.

• Ailments from fright, vexation and bad news during pregnancy. • Hypertension due to Renal cause. • Acute inflammation of kidneys and other parenchymatous tissues; urine: suppressed, loaded with casts, high colored. • Puffy swelling: under the eyes. • Edematous swelling of hands and feet; feel too large. • Heat, throbbing, pressing pain in head; better by pressure, worse motion. • Dull, heavy sensation in occiput. • Feet swollen and stiff.

Mercurius corrosivus

Generalized edema with rheumatic tendency; irritable, restless, difficult thinking.

• Hypertension due to renal cause. • Frontal pain with congestion of head. • Albuminuria especially in early pregnancy (Phosphorus for later pregnancy and at full term). • Tenesmus of bladder and rectum. • Headache aggravated looking sideways. • Double vision or objects appear smaller. • Albuminuria during pregnancy, esp. if gout is present.

Cinchona officinalis

Chilly patient; complaints of pregnant women after exhausting discharges and/or intermittent fevers; history of profuse menses and prolonged diarrhea; gradually progressive anemia; face pale, hippocratic; eyes sunken and surrounded by blue margins; pale, sickly expression; sensitive to draughts of air, yet wants to be fanned; desire for sour and sweet things; intolerance to fruits; excessive flatulence not relieved by eructations or passing flatus; apathetic, indifferent, taciturn, oversensitive to noise, touch and jar; aversion to mental and physical exertion, full of care.

• Intense throbbing in head and carotids; sensation as if skull would burst. • Dullness and confusion of head as if blood rushed to the head. • Urine turbid, dark and scanty.

Aurum muriaticum

Hot patient; all discharges suppressed; glandular affections; hypertensive; copious cold sweat; sleeplessness from palpitation; weariness; aversion to work; suicidal disposition; anger when thinking of her ailments, desire for company.

• Ailments from: depressing emotions like grief and fright, anger, disappointed love, contradiction; reserved displeasure. • Persistent, stitching pain in the forehead. • Albuminuria and dropsy of limbs and fingers. • Urine increased and turbid with a peculiar odor and sediments. • Irregular, feeble pulse; sensation as if heart stops and starts again with a thump. • Carotid and temporal arteries throb visibly. • Pain in the region of kidneys.

Helonias dioica

Chilly patient; women enervated and worn out either by indolence and luxury or by hard work, mental or physical; unduly exhausted by frequent pregnancies or abortion; profound melancholia; mental exertion ameliorates; thinking of complaints aggravate; irritable, fault finding; intolerance to contradiction.

• Albuminuria during pregnancy with obstinate vomiting. • Urine profuse and clear. • Often an involuntary passage of urine after the bladder feels emptied. • Dull aching pain and heat in the region of kidneys.

Kali chloricum

Profound prostration, coldness; cheerful alternating with sadness, refuses to eat.

• Albuminuria with hematuria during pregnancy. • Urine scanty and suppressed.

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Contd...

• Coldness of feet with edema. • Edema of ankles in the evening. • Nephritis with stomatitis. Terebinthina

Affections of kidneys; rheumatism; hemorrhagic tendency; drowsiness, tired, loathing of life.

• • • • • •

Hypertension of Renal origin. Dull pain like from a band around the head. Urine scanty and suppressed; albuminuria. Constant tenesmus. Urine smoky with coffee ground sediments. Burning in the region of bladder and urethra when urinating. • Edema especially of hands.

Glonoine

Hot patient; violent pulsating pains all over body; cannot tolerate heat; aggravation by slightest exertion; confusion of mind with irritability, forgetful; time passes slowly.

• Ailments from: heat of sun. • Headache: throbbing, bursting, congestive; cannot lay head on pillow; increases and decreases with sun. • Sensation as if blood is surging to head and heart. • Arterial hypertension. • Nephritis with headache. • Urine: profuse, pale, more frequent at night; albuminuria.

Sepia

Chilly patient; predisposed to take cold at the change of weather; thin built with narrow pelvis; yellow saddle across nose; past history of repeated abortions; sudden prostration with sinking faintness with all complaints; offensive sweat; desire for vinegar, acids, pickles and sour, but sour food aggravates; aversion to food; sad, indifferent even to loved ones, irritable, indolent and quarrelsome.

• Ailments from anger, vexation and over-exertion. • Headache in terrible shocks; worse motion, stooping and mental exertion. • Violent intermittent palpitation, beating in all arteries. • Urine: thick and foul smelling, with red colored sediments. • Involuntary urination, during first sleep.

Apocynum

Anguish look; complaints after abuse of quinine; excretions diminished (especially urine and sweat); bradycardia; excessive vomiting, vomits out least food and drink; great sleepiness and restlessness, but cannot sleep.

• Reduced pulse rate is the prime indication. • Edema associated with great thirst and gastric irritability. • Urine: turbid, hot with thick mucus; burning in urethra, after urinating. • Dribbling of urine. • Associated with nausea, vomiting, drowsiness and difficult breathing. • Pulse: slow, fluttering, irregular or intermittent; may be associated with valvular heart disease. • Can be used as a diuretic to reduce blood pressure.

Belladonna

Sudden, violent effects; fine complexion; flushed face; dryness; bright redness; burning heat; throbbing pain; pains appear and disappear suddenly; great intolerance of light and noise; wildly delirious, restless, sensitive, nervous; starting when closing the eyes or during sleep.

• • • • • • • • • • • •

Ailments from: exposure to sun or cold. Congestive headache with red face. Throbbing headaches with strong pulsations in carotids. Headache worse from slightest jar, noise, motion, light; better by pressure, tight bandaging and rest. Boring of head into pillow; head drawn backwards and rolls from side to side. Headache more on right side; worse when lying down. Photophobia with dilated pupils and red conjunctiva. Rush of blood to head and face. Pulse full, hard and tense. Acute, sudden, severe nephritis. Retention of urine. Urine scanty, dark and turbid or frequent and profuse.

Other medicines which can also be used on symptomatic indications are: Arsenic album, Acetic acid, Helleborus, Digitalis, Veratrum viride, Rauwolfia, Spartium scoparium, etc.

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ABORTION

Abortion

Spontaneous

Induced

Spontaneous abortion: is defined as the loss of pregnancy before fetal viability (22 weeks of gestation) Types of spontaneous abortion may include: Threatened abortion (Incidence 20-30%) (pregnancy may continue) Inevitable abortion ( pregnancy will not continue and will proceed to incomplete or complete abortion) Incomplete abortion (products of conception partially expelled) Complete abortion (products of conception completely expelled) Missed abortion: is a condition when the embryo/ fetus dies but the products of conception are retained in the uterus.

Induced abortion: is defined as a process by which pregnancy is terminated before fetal viability. 90

Septic abortion Is defined as abortion complicated by infection. Sepsis may result from infection if organisms rise from the lower genital tract following either spontaneous or unsafe abortion. It is more likely to occur if there are retained products of conception and evacuation has been delayed. It is a frequent complication of unsafe abortion involving instrumentation. It is manifested by • Fever • Foul smelling vaginal discharge • Pelvic and abdominal pain • Cervical motion tenderness • Peritonitis (varying degree)

Threatened abortion: It is a clinical entity where the process of expulsion of the products of conception has started but has not progressed to the state from where the recovery is impossible. Incidence 25% of pregnant women experience spotting or bleeding early in gestation; 50% of these lose the pregnancy.

Etiology Chromosomal abnormalities are most common reasons occurring in 60% of cases. These include: Autosomal trisomy (most common) 45, X monosomy Triploidy

Tetraploidy Tranlocations Mosaicism Workup for the patient with spontaneous abortion: Detailed history and physical examination Ultrasound- to check the fetal viability and cervical incompetence Thyroid function test and screening for Diabetes mellitus Cervical culture for Ureaplasma urealyticum Screening test for lupus anticoagulant (APLA) and anticardiolipin antibodies (ACA)- done only when there is history of habitual abortion or repeated pregnancy loss.

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A woman in early pregnancy complains of Bleeding per vaginum. Usually painless, may be associated with mild backache or dull pain in lower abdomen

Conduct Bimanual pelvic examination Speculum examination

Light1 bleeding Closed cervix Uterus corresponds to date Cramping lower abdominal pain (may or may not be present

Heavy bleeding Dilated cervix Uterus larger than dates Uterus softer than normal Nausea & vomiting Cramping / lower abdominal pain Partial expulsion of products of conception which resemble grapes

Cervix closed Uterine size bigger than dates (or may be smaller) Beta hCG Ultrasonography

92 Threatened abortion

Molar pregnancy

Fetal heart activity seen

Cervix closed Little or no bleeding Uterine size smaller or equal to dates of LMP

Missed Abortion

Heavy bleeding2 Dilated cervix Uterus corresponds to dates Cramping / lower abdominal pain No expulsion of products of conception Tender uterus Inevitable abortion

Incomplete abortion

Fetal heart activity absent

Advise woman to Avoid sternous activity and sexual intercourse Absolute bed rest is not necessary Start appropriate Homoeopathic treatment under supervision of Obstetrician

Bleeding stops

Heavy bleeding Dilated cervix Uterus smaller than dates Cramping / lower abdominal pain Partial expulsion of products of conception

Refer to Obstetrician for Dilatation and evacuation (D&E) after providing pre referral management

Light bleeding Closed cervix Uterus smaller than dated Uterus softer than normal Light cramping / lower abdominal pain History of expulsion of products of conception

Light bleeding Abdominal pain Closed cervix Uterus slightly larger than normal Uterus softer than normal Fainting Cervical motion tenderness Adenexal mass

Complete abortion

Ectopic pregnancy

Refer to Obstetrician for management

Refer to Obstetrician for immediate laprotomy

Bleeding persists

Ultrasonography

Fetal heart activity seen Continue same measures Reassess if bleeding recurs

Fetal heart activity absent

1

Light bleeding: Takes five minutes or longer for a clean pad or cloth to be soaked.

2

Heavy bleeding: Takes less than five minutes for a clean pad or cloth to be soaked.

Management of shock If shock developes or is suspected Immediately begin treatment

Diagnose shock if the following symptoms and signs are present

Fast, weak pulse (110 per minute or more)

Other symptoms and signs of shock include:

Low blood pressure (systolic less than 90 mm Hg).

Sweatiness or cold clammy skin

Pallor (especially of inner eyelid, palms or around mouth) Rapid breathing (rate of 30 breaths per minute or more) Anxiousness, confusion or unconsciousness Scanty urine output (less than 30 ml per hour).

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Management

Specific management

Immediate management

SHOUT FOR HELP. Urgently mobilize all available personnel. Monitor vital signs (pulse, blood pressure, respiration, temperature). Turn the woman onto her side to minimize the risk of aspiration if she vomits and to ensure that an airway is open. Keep the woman warm but do not overheat her as this will increase peripheral circulation and reduce blood supply to the vital centres. Elevate the legs to increase return of blood to the heart (if possible, raise the foot end of the bed).

Start an IV infusion (two if possible) using a large-bore (16-gauge or largest available) cannula or needle. Collect blood for estimation of hemoglobin, immediate cross-match and bedside clotting (see below), just before infusion of fluids: • Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of 1 L in 15–20 minutes; • Give at least 2 L of these fluids in the first hour. This is over and above fluid replacement for ongoing losses. Note: Avoid using plasma substitutes (e.g. dextran). There is no evidence that plasma substitutes are superior to normal saline in the resuscitation of a shocked woman and dextran can be harmful in large doses. A more rapid rate of infusion is required in the management of shock resulting from bleeding. Aim to replace 2–3 times the estimated fluid loss.

Important: Do not give fluids by mouth to a woman in shock.

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Homoeopathic management Commonly indicated medicines with their indications

94

Medicines

General indications

Particular symptoms

Sabina

Hot patient; hemorrhagic tendency; history of profuse and bright menses, with partly fluid and partly clotted blood; violent pulsations; wants windows open; worse from least motion, warm air; better in cold air; craves lemonade; dislikes music which aggravates; melancholic sadness; sensitive to slightest noise.

• Habitual abortion especially at third month. • Pain from sacrum to pubis, and from below upwards shooting up the vagina. • Hemorrhages where blood is partly fluid and partly clotted. • Atony of uterus.

Secale cornutum

Hot patient; skin feels icy cold to touch yet worse from warm covering; internal burning and external coldness; amelioration from cold; debilitated, thin built, scrawny, feeble, pale with sunken expression; emaciation though appetite and thirst may be excessive; hemorrhagic diathesis; irritable and nervous temperament; anxiety and anguish; fear of death.

• Ailments from: lifting. • Threatened abortion about the third month with copious flow of thin, black and watery blood. • Burning pain in uterus. • Pulse: feeble, rapid and intermittent.

Cimicifuga racemosa (Actea racemosa)

Chilly patient; hysterical, neuralgic and rheumatic subjects; weakness, lassitude and debility; nervousness; incessant talking; great depression with dreams of impending evil; delusion as if going crazy.

• Ailments from: over- exertion. • Tendency to abort at the third month. • Intolerance of pain; pains like electric shocks here and there; pains fly across the pelvis, from side to side and from hip to hip; patient doubling up; sympathetic with ovarian or uterine irritation. • Fainting spells.

Crocus sativus

Hot patient; better in open air; drowsiness and lassitude; • Threatened abortion, especially when hemorrhage is hysterical states; vacillating and changing moods; sings and laughs; dark and stringy. happy and affectionate, then angry; sudden changes from hilarity • Surging of blood to genitals. to melancholy; pleasant mania; anger with violence followed by • Threatened abortion especially when uterine hemorrhage repentance. is dark, clotted in long strings; worse from least movement.

Sepia

Chilly patient; predisposed to take cold at the change of weather; thin built with narrow pelvis; yellow saddle across nose; past history of repeated abortions; sudden prostration with sinking faintness with all complaints; offensive sweat; desire for vinegar, acids, pickles and sour, but sour food aggravates; aversion to food; sad, indifferent even to loved ones, irritable, indolent and quarrelsome.

• Tendency to abort between 5th to 7th month. • Relaxed pelvic organs with bearing down sensation, as if everything will escape from vulva. • Must sit down and cross legs to ameliorate pressure from pelvis. • Terrible itching of vulva.

Helonias

Chilly patient; women enervated and worn out either by indolence and luxury or by hard work, mental or physical; unduly exhausted by frequent pregnancies or abortion; profound melancholia; mental exertion ameliorates; thinking of complaints aggravates; irritable, fault finding; intolerance to contradiction.

• Sensation of weakness, dragging and weight in the sacrum and pelvis, with great languor and prostration. • Weight and soreness in womb. • Atonic uterus. • Dark, foul blood from uterus. • Consciousness of the womb.

Viburnum opulus

Hot patient; tall, slender; spasmodic and congestive affections, originating from ovaries or uterus; hysterical subjects; depressed, irritable, unable to perform mental labor.

• Frequent and very early miscarriage, causing seeming sterility. • Often prevents miscarriage. • Colicky pains in pelvic region. • Consciousness of the womb. • Pains begin in the back and go around from there and end with cramps in the uterus. • Pains from the back to loins, worse early morning.

Other medicines that can also be used on symptomatic indications: Aconitum napellus, Belladonna, Caulophyllum, Chamomilla, Erigerone, Gelsemium, Kali carbonicum, Opium, Pulsatilla, Trillium pendulum, Ustiligo, etc.

INTRA UTERINE GROWTH RESTRICTION / RETARDATION (IUGR) Aim To identify and treat the risks of mortality and morbidity associated with Intrauterine Growth Restriction / Retardation (IUGR).

Introduction Intrauterine Growth Restriction / Retardation (IUGR) is one of the major causes of low birth weight and also results in preterm births (before 37 completed weeks of pregnancy).

Definition Intra uterine Growth Restriction / Retardation is said to be present in those babies whose birth weight is at or below the tenth percentile of the average weight for their gestational maturity.

Incidence IUGR contributes to 2/3rd of Low Birth Weight infants born in India.

Causes

Maternal Causes Poor nutritional status of the mother and frequent pregnancies Mothers with a weight of less than 40 kg and a height of less than 145 cm often give birth to Low Birth Weight(LBW) or Small for Gestational Age(SGA) infants Anemia during pregnancy

Fetal factors Infection with Toxoplasmosis, Rubella, Cytomegalovirus & Herpes simplex (TORCH) agents Congenital malformation

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Chromosomal abnormalities Multiple pregnancy

Maternal diseases associated with pregnancy •

Maternal hypertension

•

Heart diseases

•

Chronic renal diseases

•

Maternal diabetes

•

Thrombophilia

Maternal smoking, alcohol & tobacco use during pregnancy Ingestion of narcotics like cocaine, heroin & drugs like ethanol, hydantoin (phenytoin), coumarin during pregnancy (increased risk of congenital abnormalities)

Placental factors Decreased placental functioning mass due to post term pregnancy or multiple pregnancy Placental insufficiency Placenta previa Abruption of placenta

TYPES of IUGR Classified on the basis of presence or absence of symmetry among different anatomic structure

Symmetrical (Type 1) Refers to symmetrically small fetus with normal head to abdomen ratio

Asymmetrical (Type 2) Abdominal circumference is smaller than head circumference and femur length

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Clinical features and diagnosis As there is high peri-natal morbidity, early diagnosis is important.

Clinical features IUGR infants are often identified at term or near-term in gestation. Ask for History of chronic Hypertension, Pre- eclampsia, Chronic renal diseases, Diabetes, Multiple pregnancies, delivery of IUGR baby Look out for conditions which causes increased risk of IUGR

Look for Signs of IUGR or placental insufficiency Failure of uterus and fetus growth at normal rate over a period of 4 weeks Uterine fundal height is 2cm less than expected for gestational age Diminished fetal movements On examination: check for

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Maternal weight gain: It remains stationary or starts falling Symphysis fundal height (SFH): It is a useful clinical parameter after 24 weeks of gestation. A lag of 4 cm or more from that expected at the gestational age indicates growth restriction Measurement of abdominal girth: showing stationary or falling values Important: In case of any History of Antepartum hemorrhage, avoid pelvic examination & further management should be provided in consultation with the obstetrician.

Suspected case Request for ultrasonography (USG): Most valuable tool to detect growth restriction Must be repeated every 2- 3 weeks

¹ Femur Length: If FL / AC ratio is higher than 24, suggestive of IUGR (Normal value is 22- 24). ¹¹ Amniotic fluid volume: If Amniotic Fluid Volume Index (AFI) is less than 5 indicates IUGR. (Normal value: 5 - 25cm)

Parameters in USG Biparietal diameter of fetal head (BPD) Head circumference (HC) to Abdomen circumference (AC) ratio Length of femur* Amniotic fluid volume* Presence of fetal anomalies

Further medical management should be undertaken in consultation with the obstetrician, at the nearest health facility

Management of IUGR

Ante partum management: Advise: • Adequate bed rest • Intake of nutritious diet (300 extra calories per day) to correct malnutrition • Strict avoidance of smoking and alcohol Start appropriate homoeopathic treatment Monitor daily fetal movement count (The woman lies on her side and counts fetal movements. Perception of 5 distinct movements in a period of up to 1 hour is considered reassuring. If 5 movements have been felt within half an hour, the kick count is complete). Appropriate management of drug abuse Pregnancy is to be monitored more carefully by clinical examination, USG, amniotic fluid determination.

Follow up after 2 weeks 97

Referral criteria Pregnancy associated with medical complications like maternal hypertension, diabetes, heart diseases, chronic renal diseases

If fetal growth improves and reaches to that expected gestational age

If fetal growth does not improves significantly in accordance with gestational age within 2 weeks of homoeopathic treatment

Patient presenting with antepartum hemorrhage IUGR with severe anemia Severe IUGR with Oligohydramnios Abnormal fetal growth Presence of fetal anomalies

Stop homoeopathic treatment and monitor pregnancy till term in consultation with obstetrician

Refer to Obstetrician of nearest health care facility

Need for maternal hyper oxygenation

Important Must look for the condition which can cause Intra Uterine Growth Retardation. Must ask history of illnesses during previous pregnancy. Ensure compliance with advice for adequate nutrition, rest and avoidance of alcohol & smoking.

Homoeopathic management Constitutional homoeopathic treatment can be given on the basis of symptom similarity with emphasis on causative factors.

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MALPOSITION AND MALPRESENTATION Definition Malpositions are abnormal position of the vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex. Malpositions or Malpresentations may result in prolonged or obstructed labor.

General management

Perform rapid evaluation of general condition Check vital signs • Pulse • B.P. • Respiration • Temperature

Provide encouragement and supportive care

Assess fetal condition

Listen to fetal heart immediately after contraction Count the fetal heart rate for full one minute at least once every 5 min. during second stage.

If the membranes have ruptired, note the color of amniotic fluid Presence of thick meconium Absence of fluid / less amniotic fluid

Any fetal heart rate (FHR) abnormality: FHR less than 100 or more than 180/min.

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Suspect fetal distress & manage appropriately

Management of fetal distress No maternal cause identified FHR remains abnormal throughout at least three contractions

Maternal cause e.g. fever, drugs

Give appropriate treatment

Do vaginal examination

Bleeding with intermittent or constant pain

Signs of infection: fever, foul smelling vaginal discharge

If the cord is below presenting part or in the vagina

Suspect Abruptio placentae

Treat appropriately

Manage as Cord prolapse

Refer chapter on "Vaginal bleeding during later pregnancy and labor"

FHR abnormality still persists Additional signs of distress

Cervix fully dilated Fetal head not more than 1/5th above the symphysis pubis

Vacuum extraction or forceps delivery

Refer immediately to Obstetrician / nearest health care facility

Cervix not fully dilated Fetal head is more than 1/5th above the symphysis pubis.

Delivery by Cesarean section

Diagnosis of Malpositions Presentation

On abdominal examination

On vaginal examination

OCCIPUT POSTERIOR POSITION It occurs when the fetal occiput is posterior in relation to the maternal pelvis.

• The lower part of the abdomen is flattened. • Fetal limbs are palpable anteriorly. • The fetal heart may be heard in the flank.

• The posterior fontanelle is towards the sacrum. • The anterior fontanelle may be easily felt if the head is deflexed.

Figure 1

OCCIPUT TRANSVERSE POSITION • It occurs when the fetal occiput is transverse to the maternal pelvis. • If an occiput transverse position persists into the later part of the first stage of labor, it should be managed as an occiput posterior position.

Figure 2

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Diagnosis of Malpresentation Presentation

On abdominal examination

On vaginal examination

BROW PRESENTATION Is caused by partial extension of the fetal head so that the occiput is higher than the sinciput

• More than half the fetal head is above the symphysis pubis and • Occiput is palpable at a higher level than the sinciput.

The anterior fontanelle and the orbits are felt.

Figure 3

Figure 4 FACE PRESENTATION • A groove may be felt between Is caused by hyper-extension of the occiput and the back. the fetal head so that neither the occiput nor the sinciput are palpable on vaginal examination.

The face is palpated, the examiner’s finger enters the mouth easily and the bony jaws are felt.

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Figure 5 COMPOUND PRESENTATION • It occurs when an arm prolapses alongside the presenting part. • Both the prolapsed arm and the fetal head present in the pelvis simultaneously.

BREECH PRESENTATION It occurs when the buttocks and/or the feet are the presenting parts.

• The head is felt in the upper abdomen and the breech in the pelvic brim. • Auscultation locates the fetal heart higher than expected with a vertex presentation.

On vaginal examination during labor: • The buttocks and/or feet are felt. • Thick, dark meconium is normal.

Figure 6

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COMPLETE (FLEXED) BREECH PRESENTATION It occurs when both legs are flexed at the hips and knees.

Figure 7 FRANK (EXTENDED) BREECH PRESENTATION It occurs when both legs are flexed at the hips and extended at the knees.

Figure 8 FOOTLING BREECH PRESENTATION It occurs when a leg is extended at the hip and the knee.

TRANSVERSE LIE AND SHOULDER PRESENTATION • It occurs when the long axis of the fetus is transverse. • The shoulder is typically the presenting part.

• Neither the head nor the buttocks • A shoulder may be felt, but not always. can be felt at the symphysis pubis. • An arm may prolapse and the elbow, • The head is usually felt in the flank. arm or hand may be felt in the vagina.

Figure 9

Management

Determine the presenting part

101 Vertex is presenting part

Vertex is not presenting part

Use landmarks of fetal skull to determine position of fetal head. (See chapter on Normal labor)

Brow presentation

Face presentation

Compound presentation

Refer to Obstetrician for delivery by cesarean section

Refer to Obstetrician for deliver by forceps or cesarean section

Refer to Obstetrician for decision of vaginal delivery or delivery by cesarean section

Breech

Transverse lie and shoulder presentation

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Continued from previous page

Breech

Transverse lie and shoulder presentation

Assess gestational age Woman in early labor Membranes intact > 37 weeks

< 32 weeks

Consult Obstetrician to perform Extra Cephalic Version (ECV) (after excluding contra-indications) Give Homoeopathic medicine

Continue antenatal care

After 37 weeks Consult Obstetrician to perform Extra Cephalic Version (ECV) (after excluding contra-indications) Give homoeopathic medicine

Succeeds

Fails

Normal delivery

Refer to obstetrician for delivery by Cesarean section

102 Succeeds

Fails

Manage as vertex presentation

Refer to obstetrician for Vaginal breech delivery or Cesarean section

Extra Cephalic Version is attempted if: Breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is more likely to spontaneously revert back to breech presentation).

Contraindications for ECV

Refer for Cesarean section in case of:

Multiple pregnancy

Extended head

Antepartum hemorrhage

Cord presentation or prolapse

Placenta previa

Pre-term: 1000-1500gm.

Vaginal delivery is possible.

Ruptured membranes

Membranes are intact and amniotic fluid is adequate.

Previous CS

Previous Lower Segment Cesarean Section (LSCS)

There are no complications (fetal growth restriction, uterine bleeding, previous cesarean delivery, fetal abnormality, twin pregnancy, hypertension, fetal death.

IUGR

Contracted pelvis Placenta previa Fetal heart rate abnormality Primi- breech

Important Ideally every Breech delivery should take place in the hospital with surgical capability.

Homoeopathic management Commonly indicated medicines with their indications Medicines

General indications

Therapeutic use

Pulsatilla 200

Hot patient; marked changeability; thirstless with great dryness of mouth; tongue coated yellow or white; though she feels chilly, she is better in open air; worse in the evening; better by slow, gentle motion; desire for cheese, pungent things, highly seasoned food, sausage; aversion to fatty food, meat, butter, bread, warm foods and drinks and smoking; craving for ice-cream and pastry; desire for company; mild, gentle, affectionate, yielding; weeping disposition.

• Almost specific for malpresentation of the fetus • Transverse lie • Give two doses, each dose at the interval of one week after 28 weeks only when liquor is adequate. (Research study conducted by CCRH).

Other medicines that can also be used on symptomatic indications: Aconitum napellus and Arnica montana, etc.

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FALSE LABOR PAINS Definition False labor pains are contractions, which occur at irregular and unpredictable intervals. The woman feels pain and discomfort in the abdomen. These are more commonly seen in primigravidae than in multiparous women. Pains usually appear prior to the onset of true labor pains, 1-2 weeks before in primigravidae and few days before in multiparous women.

Causes Exact cause is not known. The cause may be: A combination of fetal, placental, and maternal factors. Due to stretching of cervix & lower uterine segment and irritation of neighbouring ganglia. The resistance offered by the cervix & lower uterine segment while ‘taking up’ process which precedes the onset of labor.

Difference between False and True labor pains Type of change

False labor pains

Timing of contractions Often are irregular and do not get closer together

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True labor pains Come at regular intervals and, as time goes on, get closer together. Last for about 30–70 seconds

Change with movement

Contractions may stop when the patient walks or takes rest, Contractions continue, despite movement or change in or may even stop with a change of position position

Strength of contractions

Usually weak and do not get much stronger (may be strong and then weak)

Increase in strength steadily and progressively

Pain of contractions

Dull in nature and are confined to lower abdomen and groin

Pains are felt in front of abdomen & radiate towards the thighs

Related to hardening of uterus & effective dilatation of cervix

No

Yes

Relief

Usually relieved by enema.

Not relieved by any medication and marks the onset of labor

Other symptoms

Generally associated with symptoms of gastric upset

There are no associated symptoms of gastric upset

A pregnant woman presenting with pain in abdomen in later pregnancy Examine for urinary tract or other infection or ruptured membranes

Palpable contractions Blood-stained mucus discharge (show) or watery discharge before 37 weeks Cervical dilatation and effacement Lighta vaginal bleeding Possible preterm labor Refer to Obstetrician

a

Palpable contractions Blood-stained mucus discharge (show) or watery discharge at or after 37 weeks Cervical dilatation and effacement Light vaginal bleeding Possible term labor

Abdominal pain Dysuria Increased frequency and urgency of urination Retropubic / suprapubic pain

Cystitis Refer to chapter on UTI during pregnancy

Refer to chapter on normal labor

Dysuria Abdominal pain Spiking fever / chills Increased frequency and urgency of urination Retropubic / suprapubic pain Loin pain / tenderness Tenderness in rib cage Anorexia Nausea / vomiting

Intermittent or constant abdominal pain Bleeding after 22 weeks gestation (may be retained in the uterus) Shock Tense / tender uterus Decreased / absent fetal movements Fetal distress or absent fetal heart sounds

Watery vaginal discharge Sudden gush or intermittent leaking of fluid Fluid seen at introitus No contractions within 1 hour

Prelabor rupture of membranes

Cervix not dilated No palpable contractions / infrequent contractions False labor Discharge the woman and advise her to return if symptoms of labor occur.

105 Acute pyelonephritis

Abruptio placentae

Refer to Obstetrician

Refer to chapter on vaginal bleeding in later pregnancy

Refer to chapter on PROM

Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.

Homoeopathic management Commonly indicated homoeopathic medicines with their indications Medicines

General indications

Particular symptoms

Belladonna

Sudden, violent effects; flushed face; dryness; bright redness; • False labor pains come and go suddenly. burning heat; throbbing pain; pains appear and disappear suddenly; • Pains usually in short attacks, cause redness of great intolerance of light and noise; wildly delirious, restless, face and eyes. sensitive, nervous; highly irritable.

Caulophyllum

Chilly patient; nervous, hysterical women; easily excitable; depressed; fearful and fretful in nature.

• Intermittent, or erratic or paroxysmal severe pains fly in all directions without progress. • Short, irregular, spasmodic, tormenting pains. Corrects deranged vitality and produces efficient pains, if the symptoms agree. • False labor pains; want of tonicity of womb.

Cimicifuga racemosa (Actea racemosa)

Chilly patient; hysterical, neuralgic and rheumatic subjects; tendency to abort at third month; weakness, lassitude and

• False labor-like pains; sharp pains across abdomen; sleeplessness. Contd...

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debility; nervousness, incessant talking; great depression with dreams of impending evil; mania following disappearance of neuralgia.

• Severe, spasmodic pains, worse by least noise. • When given during last month of pregnancy shortens labor, if symptoms correspond.

Pulsatilla

Hot patient; marked changeability; thirstless with great dryness of mouth; tongue coated yellow or white; though she feels chilly, she is better in open air; worse in the evening; better by slow, gentle motion; desire for cheese, pungent things, highly seasoned food, sausage; aversion to fatty food, meat, butter, bread, warm foods and drinks and smoking; craving for ice-cream and pastry; desire for company; mild, gentle, affectionate, yielding; weeping disposition.

• Pains rapidly shifting from one part to another, accompanied with constant chilliness. • Pains associated with suffocative and fainting spells. • Bearing down sensation worse on lying down.

Nux vomica

Chilly patient; thin, dark complexion; spare, quick, active; prone to indigestion and hemorrhoids; tongue coated yellowish in the posterior part; desire for stimulants; nervous disposition; oversensitive to external impressions, to noise, odors, light or music, etc.; zealous and irritable, impatient, spiteful with violent action; ardent nature.

• False labor pains extend to rectum with frequent desire for stool and urination. • Pains tingling, sticking, aching, worse from motion and contact. • Very irritable, cannot bear to be touched.

Chamomilla

Chilly patient; oversensitive to pain; pain unendurable, associated with numbness and extreme restlessness; complaints from abuse of coffee and narcotics; thirsty; desire for cool air; nervous, excitable temperament; sensitive, peevish, irritable and uncivil behavior; aversion to talking, cannot bear anyone near her, answers snappishly.

• Pains spasmodic, distressing, tearing; extending down the legs. • Drawing pains from sacral region forward; griping and pinching pain in uterus. • Pains pressing upwards. • Dragging pain towards the uterus like labor pains and frequent urging to urinate.

Kali carbonicum

Chilly patient; intolerance of cold weather; puffiness; weakness, backache and profuse perspiration; aggravation in the morning, 2-4 a.m.; excessive flatulence, distended abdomen as if it would burst; sharp and cutting pains, better by motion; over-sensitive to pain, noise and touch; very irritable with weakness.

• False pains; sharp cutting pains across loins; pains stitching and shooting. • Violent backache; wants the back pressed.

Calcarea carbonica

Chilly patient; takes cold easily; fat, fair, flabby, chlorotic, anemic, • False labor pains, running upward. pale and waxy females; diseases arising from defective assimilation; tendency to lymphatic glandular enlargement (scrofulous diathesis); head sweats profusely while sleeping, wetting pillow far around; sour smelling discharges; longing for fresh air; aversion to meat.

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PROLONGED PREGNANCY Definition Pregnancy which has continued for more than 2 weeks beyond expected date of delivery.

It may lead to Functional placental insufficiency because fetus outgrows the placenta. Death of the fetus in uterus before, during and after labor. Higher incidence of meconium aspiration, oxytocin induction, shoulder dystocia, macrosomia, oligohydramnios, fetal heart abnormalities and cesarean section.

Incidence Post term pregnancy occurs in 10% of cases.

Postdatism can be associated with Advance maternal age Primigravida Delayed ovulation Heredity Postdatism in a past pregnancy 107

Anancephaly without hydramnios Trisomy 16 -18.

Features of post-maturity in newborn Macrosomia Head: large, hard skull bones, narrow sutures, small fontanelles, thick margins of cranial bones Nails: long Skin: absence of vernix caseosa, deep sole creases, meconium staining Birth asphyxia Dehydration Hypoglycemia Temperature instability Respiratory distress

Non stress test (NST) It is the most popular method of assessment of fetal wellbeing. If there are at least 2 episodes of fetal movements, each associated with acceleration of fetal heart rate (FHR) by at least 15 beats per minute lasting for at least 15 seconds, NST is said to be reactive and the fetus is said to be well.

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Prolonged pregnancy

Rule out wrong dates

Get Nonstress test (NST) done at 41 weeks

Reactive

Non-reactive

Repeat after 1 week

Repeat after 2 hours

Reactive

Non-reactive

108 Refer to Obstetrician for decision to deliver at the earliest

Induction of labor Appropriate homoeopathic medicines may be used for inducing labor pains in consultation with obstetrician.

Intrapartum monitoring of FHR Scalp blood analysis as required

Fetus remains well

Fetus unwell

Vaginal delivery

Refer to Obstetrician / nearest healthcare facility for immediate delivery

Reactive

Non-reactive

Homoeopathic management Commonly indicated homoeopathic medicines with their indications Medicines

General indications

Particular symptoms

Opium

Hot patient; red and puffed face; hot perspiration all over the body except lower limbs; complaints associated with painlessness and stupor; marked sensitivity to noise; makes no complaints of the sufferings; placid.

• Labor pains wanting.

Caulophyllum

Chilly patient; nervous, hysterical women; easily excitable;

• Extraordinary rigidity of os.

depressed.

• Want of tonicity of womb

Other medicines that can also be used on symptomatic indications: Cimicifuga, Pulsatilla, Nux vomica, Chamomilla, Kali carbonicum, Secale cornutum, Kali phosphoricum, Calcaria carbonica, etc.

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THREATENED PRETERM LABOR Definition Threatened preterm Increased uterine irritability leading to uterine contractions without producing change in the cervix before 37 completed weeks of gestation.

Preterm labor Preterm labor refers to the onset of uterine contractions of sufficient strength and frequency to effect progressive dilatation and effacement of cervix between 20 and 37 weeks or less than 249 days of gestation.

Threatened preterm

Preterm labor

• There are uterine contractions without producing significant changes in the cervix. • Changes like softening of the cervix, do not suggest preterm labor. • Approximately 85% of women with threatened preterm labor will go on to deliver a full-term baby. • About 30% of these women may have contractions again during the same pregnancy, and 50% of them may have preterm labor.

• • •

Pregnancy is between the 20th and 37th week. Uterine contractions are frequent (six or more contractions per hour). The cervix shows significant changes. If the cervical effacement is less than 80% and dilatation is less than 2 cm. repeated monitoring is needed to see the further progress.

Causes of Preterm labor 110

Maternal Previous preterm delivery Low socioeconomic status Maternal age 40 years Preterm premature rupture of the membranes Multiple gestation Maternal history of one or more spontaneous second-trimester abortions Maternal complications (medical or obstetric) • Maternal behaviors • Smoking • Illicit drug use • Alcohol use • Lack of prenatal care Infectious causes • Chorioamnionitis • Bacterial vaginosis • Asymptomatic bacteriuria • Acute pyelonephritis Maternal disease such as Hypertension, Diabetes mellitus, Nephritis etc. Uterine anomalies such as Myomata, Cervical incompetence, etc. Retained IUCD

Placental

Fetal Intrauterine fetal death Intrauterine growth retardation (IUGR) Congenital anomalies

Placenta abruption Placenta praevia

Prevention of Preterm labor Controlling high risk factors such as Hypertension, Diabetes mellitus, Infections etc. Early detection and prophylactic measures • Complete Blood Count (CBC) • Urine: routine, microsopic & culture • Cervicovaginal swab for culture & fibronectin (not done routinely) • Ultrasonography for foetal well being, cervical length and placental localization • Serum electrolytes and glucose levels if patient is on tocolytic agents.

Pregnant woman of gestation age less than 37 weeks presenting with one or more of the following complaints Palpable uterine contractions Watery or bloody discharge Abdominal pain

Assess for the following • Uterine activity • Rupture of membranes • Vaginal bleeding • Presentation • Cervical dilation and effacement Reassess estimate of gestational age Look for precipitating factor

No cervical dilatation Start homoeopathic treatment under the supervision of obstetrician to control the contractions Monitor the contraction every one hour Advise rest

Uterine contractions subside or are reduced

Continue the treatment as required Advise to report if the uterine contractions recur

Cervical dilatation > 2 cm. Effacement > 80% pPROM (Preterm premature rupture of membranes)

111 Refer to Tertiary care centre / Obstetrician as the woman may require Tocolysis

No change in the contractions or Increase in the uterine contractions Increasing cervical dilatation and effacement Rupture of membranes

Refer to Tertiary Care Centre / Obstetrician for management

Important • •

After the 24th week, the presence of fetal fibronectin in cervical and vaginal secretions may indicate detachment of the fetal membranes from the deciduas. Shorter cervix (less than 3 cm.) predicts a higher risk of preterm labor.

Must remember Digital examination should be avoided unless there is a significant possibility of a cord presentation or prolapse, or the cervix cannot be adequately visualised. Instead a speculum examination should be performed with full aseptic technique, not touching the cervix with the speculum.

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Homoeopathic management Commonly used medicines with their indications Medicines

General indications

Particular symptoms

Sabina

Hot patient; hemorrhagic tendency; history of profuse and bright menses with partly fluid and partly clotted blood; violent pulsations; wants windows open; worse from least motion, warm air; better in cold air; craves lemonade; dislikes music which aggravates; melancholic sadness; sensitive to slightest noise.

• Pain from sacrum to pubis, and from below upwards shooting up the vagina.

Sepia

Chilly patient; predisposed to take cold at the change of weather; thin built with narrow pelvis; yellow saddle across nose; past history of repeated preterm labor at later months; sudden prostration with sinking faintness with all complaints; offensive sweat; desire for vinegar, acids, pickles and sour, but sour food aggravates; aversion to food; sad, indifferent even to loved ones, irritable, indolent and quarrelsome.

• Premature labor pains between 5th and 7th months. • Relaxed pelvic organs with bearing down sensation, as if everything will escape from vulva. • Must sit down and cross legs to ameliorate pressure from pelvis.

Cimicifuga racemosa (Actea racemosa)

Chilly patient; hysterical, neuralgic and rheumatic subjects; • Sharp pains across abdomen. tendency to abort at third month; weakness, lassitude and debility; • Severe, spasmodic pains, worse by least noise. nervousness; incessant talking; great depression with dreams of impending evil; mania following disappearance of neuralgia.

Opium

Hot patient; red and puffed face, hot perspiration all over the body except lower limbs; complaints associated with stupor; delirious talking with wide open eyes; marked sensitivity to noise; makes no complaints of the sufferings; placid.

• Premature labor pains due to fright or shock especially in last month of the pregnancy. • Horrible labor like pains in uterus with urging to stool.

Pulsatilla

Hot patient; marked changeability; thirstless with great dryness of mouth; tongue coated yellow or white; though she feels chilly, she is better in open air; worse in the evening; better by slow, gentle motion; desire for cheese, pungent things, highly seasoned food, sausage; aversion to fatty food, meat, butter, bread, warm foods and drinks and smoking; craving for ice-cream and pastry; desire for company; mild, gentle, affectionate, yielding; weeping disposition.

• Pains rapidly shifting from one part to another and are accompanied with constant chilliness. • Pains associated with suffocative and fainting spells. • Premature labor pains at 8th month.

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Other medicines that can also be used on symptomatic indications: Caulophyllum, Cannabis indica, etc.

CHECK YOUR PROGRESS 1.

What is the criterion of diagnosis of Pregnancy induced hypertension (PIH)?

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2.

What are main causes of vaginal bleeding during early pregnancy?

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3.

How is threatened abortion diagnosed?

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4.

What are types of IUGR (Intra uterine growth retardation)?

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5.

Enumerate the differences between true and false labor pains?

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