Medical illness in pregnancy

Manage now— do this, in order

• Ask what you would do if she were not pregnant, then decide what genuinely needs to change — usually very little: withholding effective treatment causes more foetal harm through maternal deterioration than most drugs do directly. Do not reduce doses out of caution — pregnant women usually need the same or higher doses. Position her left lateral or with manual uterine displacement from mid-pregnancy.
• Severe hypertension (160/110 mmHg or more) requires prompt reduction to cut stroke risk: intravenous labetalol and intravenous hydralazine are first-line, oral nifedipine where IV access is not established, transitioning to oral agents once controlled; treat to a target below 140/90 mmHg.Doctor / Nurse
• Magnesium sulphate for eclamptic seizures and for prophylaxis once severe pre-eclampsia is diagnosed and delivery planned: loading 4 g IV over 5–20 minutes (some regimens 4–6 g), then 1 g/hour for 24 hours (alternatives 2–3 g/hour). A recurrent seizure despite magnesium warrants a further 2 g IV bolus. Monitor tendon reflexes, respiratory rate and urine output — loss of reflexes precedes respiratory depression — and keep calcium gluconate 1 g IV to hand as the antidote.Doctor / NurseNot available at your setup — Infusion pump.
• Restrict fluid in pre-eclampsia even in the face of oliguria: low colloid osmotic pressure and capillary leak make pulmonary oedema the danger — do not give repeated fluid challenges; the acute kidney injury is usually rapidly reversible after delivery.
• Corticosteroids for foetal lung maturity where preterm birth between 24 and 34 weeks is anticipated: betamethasone 12 mg IM every 24 hours for two doses, or dexamethasone 6 mg IM every 12 hours for four doses — but do not delay delivery for steroids in unstable severe pre-eclampsia.Doctor / Nurse
• Delivery is the definitive treatment: without severe features at or beyond 37 weeks, deliver; before 37 weeks manage expectantly with close surveillance; with severe features, deliver — unless before 34 weeks with a stable mother in a setting able to offer expectant management.
• Prophylaxis: low-dose aspirin from 12 weeks until delivery in women at high risk or with more than one moderate risk factor — 75 mg, 81 mg or 150 mg once daily (higher end favoured by recent evidence), usually stopped 10 days to 4 weeks before planned delivery; calcium supplementation where dietary intake is low; folic acid 5 mg daily from before conception in diabetes and epilepsy.
• Treat infection and VTE with safe agents: penicillins, cephalosporins and macrolides are safe; oseltamivir 75 mg twice daily for 5 days for suspected influenza without waiting for testing; aciclovir 800 mg four times daily for 5–7 days for chickenpox started within 24 hours of rash. Anticoagulate established VTE with weight-based LMWH (or unfractionated heparin), avoiding DOACs and warfarin. Never use D-dimer to exclude VTE — V/Q scan first-line with a normal chest radiograph, CTPA where abnormal or unstable.Doctor / Nurse
• Stop ACE inhibitors and angiotensin receptor blockers (fetotoxic — contraindicated), and avoid diuretics for hypertension (they reduce placental perfusion, though appropriate for pulmonary oedema). Never withhold indicated imaging or surgery: ultrasound, echocardiography and chest radiography are safe at any gestation, MRI is not contraindicated, CT can be performed with counselling, and appendicectomy and cholecystectomy have been done safely in all trimesters.