ANTENATAL AND POSTNATAL COMPLICATIONS AND THEIR REMEDIES

Prof. K. Bharathi

Head

Department of Prasutitantra & Striroga

National Institute of Ayurveda, Jaipur.

Antenatal complications

• Pregnancy is a dynamic state and mother adapts anatomic, physiological and endocrinological changes to accommodate and support the foetus throughout gestation, for delivery and lactation.

• Because of these adaptations pregnant women suffer with minor to major problems.

Minor problems:

• DIGESTIVE SYSTEM - Nausea and vomiting, Constipation, Acidity and heartburn, Excessive salivation (Ptyalism), Abdominal discomfort, Pica

NAUSEA AND VOMITING:

• Especially in the morning, soon after getting out of bed
• Usually common in primigravidae
• 50% women have both nausea and vomiting, 25% have nausea only and 25% are unaffected
• Most commonly occurs during the first 10 weeks
• Related to higher levels of hcg

MANAGEMENT

• Dietary changes
• Behavior modification
• Hospitalization may be necessary to correct fluid and electrolyte imbalance
• Explanation, reassurance, and symptomatic relief are sufficient.

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Avoid: Disagreeable odors and rich, spicy, or greasy foods

Drink water or other fluids between meals to avoid dehydration and acidosis

Medication: well-known over-the-counter drugs should be administered only when absolutely indicated and prescribed.

CONSTIPATION: �Quite common ailment �Atonicity of the gut due to the effect of progesterone, diminished physical activity and pressure of the gravid uterus on the pelvic colon, sluggish bowel function are the possible explanations.��MANAGEMENT:�Regular bowel habit may be restored�Emphasize ample fluids and laxative foods and prescribe a stool softener�Purgatives should be avoided because of the possibility of inducing labor. �Exercise and good bowel habits are helpful.

ACIDITY AND HEARTBURN�Due to relaxation of the esophageal sphincter & hiatus hernia�Heartburn (pyrosis, acid indigestion) results from gastroesophageal reflux disease (GERD) in almost 10% of all gravidas.�In late pregnancy, this may be aggravated by displacement of the stomach and duodenum by the uterine fundus.�Most likely to occur when the patient is lying down or bending over��

MANAGEMENT

• To avoid over eating and not to go to bed immediately after the meal.
• Liquid antacids may be helpful
• Sleeping in semi-reclining position with high pillows
• This hernia is reduced spontaneously after delivery
• Symptomatic treatment is recommended
• Hot tea and change of posture are helpful.
• Calcium-containing antacids & the histamine H2- receptor antagonists are pregnancy category B (e.g., Tums) to reduce gastric irritation�

MUSCULO-SKELETOL SYSTEM

1. Fatigue 2. Backache 3. Leg cramps 4. Round ligament pain

FATIGUE

• The pregnant patient is more subject to fatigue during the last trimester of pregnancy because of altered posture and extra weight carried.
• Management: Anemia and other systemic diseases must be ruled out.
• Frequent rest periods are recommended.

BACKACHE

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• Common problem (50%) in pregnancy
• Physiological changes that contribute to backache are: joint ligament laxity (relaxin, estrogen), weight gain, hyperlordosis and anterior tilt of the pelvis.
• May be due to faulty posture and high heel shoes, muscular spasm, urinary infection or constipation.
• Fatigue, muscle spasm, or postural back strain most often is responsible
• MANAGEMENT:
• Excessive weight gain should be avoided.
• Rest with elevation of the legs to flex the hips may be helpful.
• Improvement of posture, well-fitted pelvic girdle belt which corrects the lumbar lordosis during walking and rest in hard bed

BACKACHE

• Improvement in posture is often achieved by the wearing of low-heeled shoes.
• To achieve proper posture, the abdomen should be flattened, the pelvis tilted forward, and the buttocks tucked under to straighten the back.
• Massaging the back muscles, analgesics and rest
• Back exercises under the supervision of a rehabilitation physician, an orthopedist, or a physical therapist.
• Recommend sleep on a firm mattress.
• Apply local heat and light massage to relax tense, taut back muscles.
• Give acetaminophen 0.3–0.6 g orally or equivalent.
• Obtain orthopedic consultation if disability results.
• Note neurological signs and symptoms indicative of prolapsed intervertebral disk syndrome, radiculitis.

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LEG CRAMPS

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• Quite common, usually in the leg.
• Worse at night.
• The cause of leg cramps in pregnancy is not known but it may be due to deficiency vitamin b1 and of diffusible serum calcium or elevation of serum phosphorus.
• It may due to ischemia and changes in ph or electrolyte status.
• MANAGEMENT:
• Supplementary calcium therapy in tablet or syrup after the principal meals may be effective.
• Massaging the leg, application of local heat and intake of vitamin B1 (30 mg) daily may be effective.
• Sleep with the foot end elevation by 20 to 25 cm. once the cramps is occur gentle kneading is effective.

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Early pregnancy complications

• Abortion
• ECTOPIC PREGNANCY: Pregnancy outside uterine cavity, In fallopian tube (fimbrial, ampullary, isthmic, interstitial) , in the ovary, In the abdominal cavity, In the cervical site

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Medical problems

GESTATIONAL DIABETES:

• Gestational diabetes is a type of diabetes that occurs only during pregnancy.
• Like other forms of diabetes, gestational diabetes affects the way the body uses blood sugar (glucose).
• As a result, the blood sugar level is too high.
• If untreated or uncontrolled, gestational diabetes can result in a variety of health problems to fetus and mother.
• The controlling the blood sugar can helps ensure a healthy pregnancy and a healthy start for the baby.
• It usually occurs about the 20th to 24th week of pregnancy and can be measured by the 24th to 28th week of pregnancy.
• After the baby is born and placental hormones disappear from the bloodstream, blood sugar levels should quickly return to normal.

PREGNANCY-INDUCED HYPERTENSION PREECLAMPSIA

PREGNANCY-INDUCED HYPERTENSION [PIH]

Hypertension (BP ≥ 140/90 mm Hg) during pregnancy can be classified as chronic or gestational.

Chronic hypertension is BP that is high before pregnancy or before 20 wk gestation. Chronic hypertension complicates about 1 to 5% of all pregnancies.

Gestational hypertension develops after 20 wk gestation (typically after 37 wk) and remits by 6 wk postpartum; it occurs in about 5 to 10% of pregnancies, more commonly in multifetal pregnancy. 

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• Preeclampsia is a common problem during pregnancy, affecting up to one in seven pregnant women around the world.
• This condition is defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy.
• It may also be called toxemia or pregnancy-induced hypertension.
• It can lead to serious, even deadly complications for the pregnant woman and the unborn baby. 

• Globally, preeclampsia and other high blood pressure disorders during pregnancy are a leading cause of maternal and infant illness and death.
• The only cure for preeclampsia is delivery of the baby. After the baby is born, blood pressure usually returns to normal within a few days.
• So delivery is the obvious solution when preeclampsia is found near the end of pregnancy, which is typically the case.
• However, if diagnosed earlier, treatment is trickier.

Eclampsia

• Eclampsia is pre eclampsia with convulsion and or coma Or Development of Convulsions and/or unexplained coma during pregnancy or postpartum inpatients with signs and symptoms of preeclampsia
• Incidence :o 1:500 to 1: 30 & Common in Primigravida (75%) than multigravida (25%)o In 80% cases it is proceeded by severe preeclampsiao
• Commonly occurs between 36th week to term
• Types a) Antepartum -50%b) Intrapartum-30%c) Postpartum-20% (Early & Late)d) Intercurrent-Rare 3

Eclampsia

CAUSES OF CONVULSION

• Cerebral anoxia : spasm of cerebral vessel due to hypertension-increase cerebrovascular resistance-decrease oxygen consumption-convulsion
• Cerebral edema –irritation
• Cerebral dysarhythmia: increases following edema & anoxia

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MANAGEMENT

• General 1). Maintenance of airway 2) Oxygen administration 3) Fluid Management 4) Organization of investigation
• Control of Convulsions
• Control of BP
• Obstetric Management
• Complication Management
• Postpartum Care��

Garbhini Vishishta Vyadhi

• Hrillasa – Bhunimba with honey
• Garbhaja Vamana – Rice water mixed with sugar, honey, flour of parched paddy; Bilva majja, lajambu
• Kikkisa – Madhuragana sadhita navanita (internal); candana & mrinala (external)
• Garbhini jvara
• Garbhini udavarta
• Garbhini atisara
• Garbhini parikartika

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Puerperium

• It is the period following childbirth during which the body tissues, specially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically.

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• Involution is the process whereby the genital organs revert back approximately to the state as they were before pregnancy.

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General principles of treatment

• Use of soft, sweet, cold, pleasing and gentle drugs, dietetics and behaviour.
• Emetics, purgatives, sternutatory drugs, bloodletting should not be done
• Asthana and Anuvasana vasti should not be used frequently
• After eighth month gentle emesis can be done
• Use of pungent drugs, exercise and coitus should be avoided.

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PUERPERAL PROBLEMS – Sutika Vyadhi

Sutika vyadhi according to Ayurveda

• Sutika jvara
• Yoni bheda
• Yoni sopha
• Yoni vedana
• Yonishula
• Katishula
• Yonibhramsha
• Makkalla
• Mutrasanga
• Stanaroga
• Malarodha etc.

Puerperal Problems

• Puerperal pyrexia
• Puerperal sepsis
• Subinvolution
• Urinary complications
• Breast complications
• Puerperal venous thrombosis & pulmonary embolism
• Puerperal emergencies
• Psychiatric disorders

General principles of treatment

• Nidana parivarjana
• Congenial diet and oleaginous substances
• Massage, anointment, irrigation and ghee, oil or decoction prepared with bhautika, jivaniya drugs, brimhaniya, madhura, vatahara drugs along with specific drugs
• Rice gruel treated with appetizing drugs

Puerperal Pyrexia

• A rise in TPR above 100.4°f or more on two separate occassions at 24 hours apart (excluding first 24 hrs) within first 10 days following delivery.

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• Puerperal Sepsis or infection

An infection of the genital tract which occurs as a complication of delivery.

Predisposing causes

• Home births in unhygienic conditions
• Low socioeconomic status
• Anemia
• Malnutrion
• Multiple vaginal examinations in labour
• Prolonged labour & prolonged rupture of membrane
• Trauma to the genital tract (vaginal,perineal & cervical lacerations)
• Caesarian Section

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Clinical Features

• Genital tract infection
• Rise in temparature
• Septicemia
• General peritonitis
• Salpingo-oophoritis and cellulitis
• Pelvic abscess
• pyemia

Grades of puerperal infection

• Grade I : infection involving the lower genital tract & the uterus
• Grade II : grade I plus infection involving the adnexa
• Grade III : grade II plus entire pelvic involvement
• Grade IV : septicemia

complications

• Maternal & fetal
• Maternal : septicemia,endotoxic shock, peritonitis, or abscess formation leading to surgery and compromised future fertility
• Fetal : neonatal septicemia & pneumonia

D.D of puerperal fever

• Site of puerperal infection :
• Endometrium: endometritis & parametritis
• Pelvis :pelvic abscess
• Lungs : respiratory infections
• Urinary tract : urinary tract infections
• Wound: C.S , episiotomy, vaginal/ cervical lacerations
• Veins: septic thrombophlebitis
• Breasts : mastitis

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investigations

• Blood culture
• Urine culture & sensitivity
• Vaginal swab culture
• USG of pelvis
• X-ray chest
• Blood urea and serum electrolytes

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Management

• In mild cases of pelvic infection :oral antibiotics
• In moderate to severe cases : parenteral therapy with broad –spectrum antibiotics
• First line of treatment is ampicillin + gentamycin
• Patients with more serious infections or infections following cesarean delivery : to anerobic cover metronidazole.
• Commonly used regimen : clindamycin, gentamycin + ampicillin.

Urinary complications

• Urinary Tract Infection
• Retention of urine
• Incontinence of urine
• Suppression of urine.

Breast complications

• Breast engorgement
• Cracked & retracted nipple
• Mastitis & breast abscess
• Lactation failure

Venous thromboembolic diseases

• DVT
• Thrombophlebitis
• Pulmonary embolism

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Puerperal emergencies

• Immediate:
• Postpartum hemorrhage, 2) shock, 3)postpartum eclampsia, 4) Pulmonary embolism, 5) inversion
• Early (within one week):

1) Urinary tract infection, 2) Puerperal sepsis, 3) breast engorgement, 4) pulmonary infection.

• Delayed:

1) Secondary PPH, 2) Psychosis

3) Pulmonary embolism, thrombophlebitis

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Psychiatric disorders

• Puerperal blues
• Postpartum depression
• Postpartum psychosis (schizophrenia)