Medical Disorders in Pregnancy A Manual for Midwives

S. Elizabeth Robson is Principal Lecturer in Midwifery at De Montfort University, Leicester, UK. With 25 years of experience as a midwifery lecturer, she leads a module on medical disorders for student midwives with a particular interest in immunology. Her link lecturer areas comprise a high-risk maternity ward and community team. She has presented nationally, and has a number of publications.

Jason Waugh is Consultant in Obstetrics and Maternal Medicine at the Royal Victoria Infirmary, Newcastle Upon Tyne, UK. He has published extensively in the fields of hypertension and renal and cardiovascular disease in pregnancy as well as producing national guidelines for the management of pre-eclampsia and renal disease. He is President of the UK’s Macdonald Obstetric Medicine Society.

Contributors ix

Acknowledgements xi

Acronyms, Abbreviations and Cardiac Terms xiii

Foreword xvii

Foreword to the First Edition xix

Preface xxi

1 Midwifery Care and Medical Disorders 1

S. Elizabeth Robson

Pre-conception Care 2

Antenatal Care 2

Intrapartum Care 5

Postnatal Care 6

General Considerations 7

Emergency Management 9

Preventing Maternal Mortality 9

Back to Basics Campaign 12

Patient Organisations and Essential Reading 13

References 14

Appendix 1.1 UK Maternal Deaths – Causes

and Risk Factors 15

Appendix 1.2 Daily Vitamin and

Mineral Dietary Intake for Pregnancy

and Lactation 16

2 Skin Disorders 17

Catherine Gittins and Rhoda Cowell

2.1 Physiological Skin Changes in Pregnancy 18

2.2 Dermatoses Specifi c to Pregnancy 19

2.3 Eczema 20

2.4 Psoriasis 22

Patient Organisations and Essential Reading 24

References 25

Appendix 2.2.1 Emollients and Steroid Creams 26

3 Hypertensive Disorders 27

Sophia Webster, Claire Dodd and Jason Waugh

3.1 Chronic Hypertension 28

3.2 Pre-eclampsia 34

3.3 Severe Pre-eclampsia and Eclampsia 36

3.4 HELLP Syndrome 38

Patient Organisations and Essential Reading 40

References 41

4 Heart Disease 43

Moira McLean, Frances A. Bu’Lock and

S. Elizabeth Robson

4.1 Mild Structural Heart Disease 44

4.2 Moderate Structural Heart Disease 48

4.3 Severe Structural Heart Disease 51

4.4 Rheumatic and Valvular Heart Disease 54

4.5 Marfan’s Syndrome 56

4.6 Functional Heart Disease: Cardiomyopathy 58

4.7 Functional Heart Disease: Arrhythmias 60

4.8 Ischaemic Heart Disease: Angina and

Myocardial Infarction 62

4.9 Pulmonary Hypertension and

Eisenmenger’s Syndrome 64

4.10 Heart Transplant 66

Patient Organisations and Essential Reading 68

References 69

Appendix 4.3.1 Drugs for Cardiac

Disease – An Overview for Midwives 74

5 Respiratory Disorders 75

Jane Scullion, Christopher Brightling and

Michelle Goldie

5.1 The Breathless Pregnant Woman 76

5.2 Asthma 78

5.3 Pneumonia and Chest Infections 80

5.4 Tuberculosis 82

5.5 Cystic Fibrosis 84

5.6 Sarcoidosis 86

Patient Organisations and Essential Reading 88

References 89

Appendix 5.2.1 Asthma in Pregnancy:

An Information Leafl et for Pregnant Women 90

6 Renal Disorders 91

Nigel J. Brunskill and Andrea Goodlife

6.1 Urinary Tract Infections 92

6.2 Chronic Kidney Disease 94

6.3 Dialysis in Pregnancy 96

6.4 Renal Transplantation 98

6.5 Nephrotic Syndrome 100

Patient Organisations and Essential Reading 102

References 103

Appendix 6.3.1 Replacement of Renal Function

by Dialysis 104

7 Endocrine Disorders 105

Robert Gregory and Diane Todd

7.1 Hypothyroidism 106

7.2 Thyrotoxicosis 108

7.3 Type 1 Diabetes Mellitus 110

7.4 Type 2 Diabetes Mellitus 113

7.5 Gestational Diabetes Mellitus 115

7.6 Addison’s Disease (Adrenal Insuffi ciency) 118

7.7 Prolactinoma 120

Patient Organisations and Essential Reading 122

References 123

Appendix 7.3.1 Diabetes Mellitus 124

8 Neurological Disorders 125

Fionnuala McAuliffe, Eleanor Burns-Kent,

Deborah Frost and Edmund S. Howarth

8.1 Migraine and Headaches 126

8.2 Epilepsy 128

8.3 Cerebrovascular Disease and Stroke 132

8.4 Bell’s Palsy 137

8.5 Carpal Tunnel Syndrome 140

8.6 Myasthenia Gravis 142

8.7 Multiple Sclerosis 144

Patient Organisations and Essential Reading 147

References 148

Appendix 8.2.1 Drugs Used for Neurological

Conditions 152

9 Musculoskeletal Disorders 153

S. Elizabeth Robson, Marie C. Smith,

Edmund S. Howarth and Javed Iqbal

9.1 Back and Pelvic Pain 154

9.2 Diastasis Recti Abdominis 156

9.3 Pregnancy Related Pelvic Girdle Pain 158

9.4 Hypovitaminosis D 160

9.5 Osteoporosis 163

Patient Organisations and Essential Reading 165

References 166

Appendix 9.1.1 Pain Therapy Ladder for

Pregnancy 169

10 Gastrointestinal Disorders 171

Rosemary Lydall, Manjiri Khare, Caroline Farrar and

S. Elizabeth Robson

10.1 Gastro-oesophageal Refl ux and

Hiatus Hernia 172

10.2 Coeliac Disease 176

10.3 Ulcerative Colitis 178

10.4 Crohn’s Disease 180

10.5 Irritable Bowel Syndrome 182

10.6 Haemorrhoids 184

10.7 Anal Sphincter Disorders 186

10.8 Obstetric Cholestasis 188

10.9 Gall Bladder and Pancreatic Disease 190

Patient Organisations and Essential Reading 192

References 193

Appendix 10.3.1 Care of a Stoma 197

Appendix 10.5.1 Management Algorithm of

Irritable Bowel Syndrome 198

11 Autoimmune Disorders 199

S. Elizabeth Robson and Julie Goddard

11.1 Rheumatoid Arthritis 200

11.2 Raynaud’s Phenomenon 202

11.3 Systemic Lupus Erythematosus 204

11.4 Antiphospholipid (Hughes) Syndrome 206

Patient Organisations and Essential Reading 209

References 210

Appendix 11.1.1 Drugs for Autoimmune

Disease – An Overview for Midwives 213

12 Infectious Conditions 215

Karen Watkins, Veronica Johnson-Roffey,

Juliet Houghton and S. Elizabeth Robson

12.1 Viral Hepatitis 216

12.2 Human Immunodefi ciency Virus 218

12.3 Malaria 220

12.4 Chickenpox 223

12.5 Toxoplasmosis 226

12.6 Listeriosis 228

12.7 Herpes Simplex Virus 230

12.8 Streptococcal Sepsis 232

Patient Organisations and Essential Reading 234

References 235

Appendix 12.1.1 The ABC of Hepatitis 238

Appendix 12.2.1 Other Infectious Viral Diseases 239

Appendix 12.2.2 Other Infectious Bacterial

Diseases 240

13 Metabolic Disorders 241

Rowena Doughty and Jason Waugh

13.1 Obesity 242

13.2 Phenylketonuria 244

13.3 Hyperemesis Gravidarum 246

13.4 Acute Fatty Liver of Pregnancy 248

Patient Organisations and Essential Reading 250

References 251

Appendix 13.1.1 Body Mass Index 253

14 Haematological Disorders 255

Abena Addo, Christina Oppenheimer and

S. Elizabeth Robson

14.1 Iron Defi ciency Anaemia 256

14.2 Megaloblastic Anaemia 260

14.3 Disseminated Intravascular Coagulation 262

14.4 Von Willebrand’s Disease and

Other Bleeding Disorders 264

14.5 Thrombocytopenia in Pregnancy 266

14.6 Thalassaemia 268

14.7 Sickle Cell Disorders 270

Patient Organisations and Essential Reading 273

References 274

Appendix 14.1.1 Blood and Blood Products

Overview 277

15 Thrombo-embolic Disorders 279

Daksha Elliott and Sue Pavord

15.1 Thrombophilia and Inherited Clotting

Disorders 280

15.2 Deep Vein Thrombosis 282

15.3 Pulmonary Embolism 287

15.4 Thromboprophylaxis 290

Patient Organisations and Essential Reading 294

References 295

Appendix 15.4.1 Thrombo-embolic

Disease Stockings 297

16 Addictive Disorders 299

Paul Moran and Madeleine Findlay

16.1 Substance Misuse 300

16.2 Alcohol Addiction 302

16.3 Tobacco and Cannabis Use 304

16.4 Cocaine Addiction 306

16.5 Opiate Addiction 308

16.6 Stimulant Addiction 310

Patient Organisations and Essential Reading 312

References 313

Appendix 16.1.1 Applying a Formal

Assessment Framework 315

Appendix 16.3.1 Preventing SIDS: Advice to

Parents 316

Appendix 16.4.1 Care of the Baby who

Experiences Withdrawal 317

17 Psychiatric Disorders 319

Renuka Lazarus and Kathryn Gutteridge

17.1 Antenatal Psychiatric Disorders 320

17.2 Postnatal Psychiatric Disorders 322

17.3 Eating Disorders 324

17.4 Post-Traumatic Stress Disorder 326

Patient Organisations and Essential Reading 328

References 329

Appendix 17.1 Treatment Guidance for

Depression 331

18 Neoplasia 333

Caroline Farrar and Francis J. E. Gardner

18.1 Gestational Trophoblastic Disease

(Hydatidiform Mole and Choriocarcinoma) 334

18.2 Cervical Cancer 336

18.3 Cervical Screening 340

18.4 Breast Cancer 342

18.5 Non-Hodgkin’s Lymphoma 344

18.6 Hodgkin’s Lymphoma 346

18.7 Ovarian Neoplasia 348

18.8 Malignant Melanoma 351

Patient Organisations and Essential Reading 354

References 355

Index 357

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