growth restriction

    High blood pressure

    Your blood pressure is checked regularly at your antenatal appointments. Your blood pressure is high if the top number (called ‘systolic’) is over 140 and/or the bottom number (‘diastolic’) is over 90. Sometimes your blood pressure might be raised because you are anxious about something, especially going to see your doctor or being in a medical office or hospital. Sometimes it might be up because you have been smoking or just pushed a pram up the hill.

    After a high blood pressure reading your health professional may ask you to wait and relax before they take another reading. One-off high blood pressure is not of great concern. However, if your blood pressure is consistently high, it can affect your health and that of your growing baby. When blood pressure is high, it may be pregnancy-induced hypertension. If it’s present with other symptoms, it can be a sign of pre-eclampsia.

    Pre-eclampsia

    Pre-eclampsia is a hypertensive disorder of pregnancy. Treated too late, it can develop into eclampsia, a rare but severe complication of pregnancy with seizures or fits. Most cases are mild, but some are dangerous for the baby and the mother.

    Mild pre-eclampsia can be treated with medication to control your blood pressure, with regular blood tests and monitoring of your baby. This surveillance is because as pre-eclampsia worsens, it can affect your liver, kidneys or blood-clotting system. It can also affect your placenta and therefore your baby.

    The only cure for pre-eclampsia is your baby (and the placenta) being born. Once you have pre-eclampsia, it does not go away until this happens. If you have pre-eclampsia, we may recommend induction of labour even if it means baby is a little early. A caesarean section may be indicated if there is significant concern about your or your baby’s health.

    Women with an increased risk of pre-eclampsia include:

    • First-time mums
    • Women with a previous history of high blood pressure or pre-eclampsia
    • Twin pregnancy (or more)
    • High blood pressure before pregnancy
    • Baby has a different father
    • Increasing age
    • Obesity
    • Some pre-existing medical conditions

    Some of the signs and symptoms of pre-eclampsia are (51):

    • Rising blood pressure in mid to late pregnancy
    • Protein in your urine
    • Severe swelling in the ankles, fingers or face
    • Headaches/visual disturbances
    • Severe pain just below the ribs
    • Reduced growth of the baby.

    Routine antenatal screening for pre-eclampsia involves taking your blood pressure and testing your urine (28). Your care provider will let you know what their routines are for this screening. The causes of pre-eclampsia are not fully understood, despite ongoing research into the condition. If you have any of the signs or any concerns speak to your midwife or doctor immediately.

    Gestational Diabetes

    Some women develop diabetes during pregnancy which disappears after baby is born. However, women who get gestational diabetes (GDM) are at higher risk of developing type 2 diabetes later in life. Women are generally screened for GDM about 28 weeks. If you have known risk factors, such as previous GDM or diabetes in the family, we will recommend early testing (28). These women will usually be screened earlier in their pregnancy. If you have GDM, you may need to attend a different antenatal clinic and see a specialist obstetrician.

    Anaemia

    Anaemia is a condition which occurs when there are either not enough red blood cells or haemoglobin in your body. It may be the result of illness, poor diet, severe sickness or extra strain on your body and is reasonably common in pregnancy. From time to time during your pregnancy blood tests will be suggested for routine screening of your ‘blood count’.

    These tests examine the oxygen-carrying capacity of your blood (haemoglobin), how many red (RBC) and white cells (WCC) there are, and how concentrated your blood is (haematocrit). If we find you have low haemoglobin levels, we may order further tests. These look closely at your iron stores and how your body is using them.

    The body’s ability to make haemoglobin depends on the availability of iron. While we recycle some of our iron from the breakdown of red blood cells and muscle tissue, iron consumption via our diet is vital to maintain good health before during and after pregnancy. If you are anaemic, we will provide you with information on changing your diet, and you may be prescribed iron and vitamin C supplements.

    In cases of severe iron deficiency, we may suggest an iron infusion (an iron solution given through a drip into your vein). Anaemia can make you feel tired and lethargic because low haemoglobin results in reduced oxygen delivery to your brain and your muscles. As oxygen performs a significant role in energy production, it is vital for the health of both you (for maintenance) and your baby (for growth).

    Vaginal bleeding

    Bleeding from your vagina during pregnancy is not normal. We may hear from time to time stories of women who continued to have periods during pregnancy. However, these situations are rare, and it is always best to err on the side of caution. Please put on a pad and contact your health care provider straight away. They will ask about how much blood there is, what colour it is and if there was any trauma to your tummy. They will also ask if you had sex in the last 24 hours if it is spotting or constant.

    These are all important answers that will help your midwife or doctor assess the situation and advise you what to do now. Not all instances of bleeding are dangerous. However, we don’t know if that is the case for you until we find out why. Some women do bleed a little, on and off, throughout pregnancy, for a variety of minor reasons and are subject to close monitoring..

    Placenta Previa

    Sometimes the placenta attaches low in the uterus and comes near to or covers the cervix to some degree. In this situation, bleeding is more likely. It may signify that the placenta is coming away from the wall of the uterus. A low placenta is aptly called a low-lying placenta. A placenta praevia covers the cervix to some degree.

    These are usually identified at the 20-week ultrasound if you have one. If your placenta is low lying we will recommend a follow-up scan at about 32 weeks. They will try and see if it has moved out of the way as your uterus has grown. A placenta praevia is not normal and requires careful observation, as bleeding due to this condition can be severe and life-threatening to you and your baby. Women with a placenta praevia of any grade at full term will be advised to birth by caesarean section. Vaginal birth under these circumstances nearly always results in catastrophic blood loss.

    Continued severe morning sickness

    There are various reasons for this, including a twin pregnancy or being particularly sensitive to hormones. If you are unlucky, the morning sickness that usually resolves at around 12-16 weeks continues into later pregnancy. Some women experience this for their entire pregnancy. Very severe cases are not normal – they are known as hyperemesis gravidarum and often need hospital treatment. Hyperemesis is not curable and may persist until your baby is born. Therapy is for support and comfort only and includes medications to help with nausea and IV fluids for dehydration.

    Itching

    Occasionally women develop a severe itching of the skin in pregnancy. This itch is not normal but is usually no more than an irritating discomfort – but sometimes it can be the sign of a condition called obstetric cholestasis. Cholestasis is a condition that affects the flow of bile from the gall bladder. The build-up of bile in the liver results in bile salts entering the bloodstream and entering your bloodstream, causing itching. See your midwife or doctor if your itch persists, or if no treatment helps. Women with confirmed cholestasis are often offered induction early due to the increased health risks for both themselves and their babies.

    Foetal growth restriction

    Your midwife or doctor will keep an eye on your baby’s growth by measuring your tummy at each visit. They compare it with where they would expect it to be at however many weeks you are at the time. Your fundus height in centimetres usually matched how many weeks you are plus or minus 2 cm. Sometimes your tummy is smaller than we expect. This is not normal.

    If this is the case, we will recommend an ultrasound scan to try and figure out the size of your baby. Sometimes small babies are small all over. Their size may be due to genetic factors, such as parents being of short stature. It may be a result of the baby’s environment, such as having a mother who smokes or doesn’t eat a healthy diet.

    SGA vs IUGR

    Some babies are known as Small for Gestational Age (SGA or, small for the number of weeks they are). Babies that are known to be SGA are regularly monitored, and their growth charted at different points in the last trimester. If the baby’s growth drops below that line, they are then known as IUGR (intrauterine growth restricted) babies.

    We monitor these babies very carefully and often induce their labour. This urgency is because a decrease in growth rate suggests the placenta is not working well. If this is the case, your baby will be healthier on the outside, even if they are a bit early. In both cases (SGA and IUGR), the baby often does not tolerate labour as well as a normally grown infant. This intolerance is because they don’t have much in the way of energy (fat) reserves. They sometimes struggle with the physical stress of being born. Continuous monitoring during labour is essential for these babies.

     

    Dr Janelle McAlpine (PhD), Clinical Midwife
    Photo by Tolikoff Photography, used under licence from Shutterstock .com


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