Medical disorders in Pregnancy & Complications in pregnancy Tutorial.
COMPLICATIONS OF PREGNANCY
-
Upload
graiden-frederick -
Category
Documents
-
view
39 -
download
3
description
Transcript of COMPLICATIONS OF PREGNANCY
COMPLICATIONSCOMPLICATIONS
OFOF
PREGNANCYPREGNANCY
Revised October 2009Revised October 2009Debbie Perez RN, MSN, CNSDebbie Perez RN, MSN, CNS
Risk Factors
Age – under 17 over 35Gravida and ParitySocioeconomic statusPsychological well-beingPredisposing chronic illness –
diabetes, heart conditions, renal, etc.
Pregnancy related conditions – hyperemesis gravidarum, PIH
Goals of Care for High Risk Pregnancy
Provide optimum care for the mother and the fetus
Assist the client and her family to understand and cope through education
Gestational Onset Disorders
Take report: Mrs. R. admitted to L&D• Initial Data
– Chief complaint: moderate amount vaginal bleeding
– Vital Signs: T. 98.4; P. 100, R. 22, B/P 100/66– G 1 P 0– Last menstrual period: 8/12; EDC: May 19– Allergies: none known– Nauseated– Mild pain– HCG levels – WNL for pregnancy
Bleeding DisordersBleeding Disorders
AbortionsAbortions
Termination of pregnancy at any time before the fetus has reached the age of viability
Either: spontaneous – occurring
naturally induced – artificial
Etiology / Predisposing FactorsEtiology / Predisposing Factors
• Chromosomal abnormalities - Faulty germ plasm -- imperfect ova or sperm, genetic make-up (chromosomal disorders), congenital abnormalities
• Faulty implantation
• Decrease in the production of progesterone
• Drugs or radiation
• Maternal causes -- infections, endocrine disorders, malnutrition, hypertension, cervix disorder
Assessment Types of Abortions Threatened
Assessment Types of Abortions Threatened
• Signs and Symptoms– vaginal bleeding, spotting– Mild cramps, backache– Cervix remains CLOSED– Intact membranes
• Treatment and Nursing Care– Bed rest, sedation, – Avoid stress and intercourse– Progesterone therapy– A period of “watchful waiting”
Imminent Abortion Imminent Abortion
• Signs and Symptoms– Loss is certain– Bleeding is more profuse– Painful uterine contractions– Cervix DILATES
• Treatment and Nursing Care– Assess all bleeding. Save all pads. (May
need to weigh the pads)– Use the bedpan to assess all products
expelled– Treated by evacuation of the uterus usually
be a D & C or suction
• Provide Psychological Support
Complete AbortionComplete Abortion
• All products of conception are expelled
• No treatment is needed, but may do a D & C
Incomplete Abortion Incomplete Abortion
• Parts of the products of conception are expelled, placenta and membranes retained and intact
• Treated with a D & C or suction evacuation
• Provide support to the family
Missed Abortion Missed Abortion
• The fetus dies in-utero and is not expelled
• Uterine growth ceases• Breast changes regress• Maceration occurs• Treatment:
– D & C – Hysterotomy
Question???
• What are two main complications related to a missed abortion?
• 1.
• 2.
Recurrent / Habitual Abortion Premature Cervical Dilation
Recurrent / Habitual Abortion Premature Cervical Dilation
• Abortion occurs consecutively in _____ or more pregnancies
• Usually due to an Incompetent Cervical Os
• Occurs most often about 18-20 weeks gestation.
Habitual Abortion Habitual Abortion
• Treatment
–Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state
Nursing Care post cerclage
• Bedrest in a slight trendelenburg position
• Teach:– Assess for leakage of fluid, bleeding– Assess for contractions– Assess fetal movement and report
decrease movement– Assess temperature for elevations
Delivery options:
• When time for delivery there are several options:– physician will clip suture and allow
patient to go into labor on her own– induce labor– cesarean delivery
Key Concepts to Remember!! Key Concepts to Remember!!
• If a woman is Rh-, RhoGam is given within 72 hours
• Provide emotional support. Feelings of shock or disbelief are normal
• Encourage to talk about their feelings. It begins the grief process
Bleeding Disorders Ectopic Pregnancy Bleeding Disorders Ectopic Pregnancy
• Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus
(5) Cervicalovary
Etiology / Contributing Factors Etiology / Contributing Factors
• Salpingitis• Pelvic Inflammatory Disease, PID• Endometriosis• Tubal atony or spasms• Imperfect genetic development
Assessment Ectopic Pregnancy Assessment Ectopic Pregnancy
• Early:• Missed menstruation followed by vaginal
bleeding (scant to profuse)• Unilateral pelvic pain, sharp abdominal pain• Referred shoulder pain• Cul-de-sac mass
• Acute:• Shock – blood loss poor indicator• Cullen’s sign -- bluish discoloration around
umbilicus• Nausea, Vomiting• Faintness
Diagnostic Tests Ectopic Pregnancy Diagnostic Tests Ectopic Pregnancy
• Diagnosis:•Ultrasound•Culdocentesis•Laparoscopy
Treatment Options / Nursing Care• Combat shock / stabilize cardiovascular
• Type and cross match • Administer blood replacement • IV access and fluids
• Laparotomy
• Psychological support
• Linear salpingostomy
• Methotrexate – used prior to rupture. Destroys fast growing cells
Question 4
Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy
Etiology
Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy
Etiology A DEVELOPMENTAL
ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI
As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.
Assessment: Assessment:
• Vaginal Bleeding -- scant to profuse, brownish in color (prune juice)
• Possible anemia due to blood loss• Enlargement of the uterus out of
proportion to the duration of the pregnancy• Vaginal discharge of grape-like vesicles• May display signs of pre-eclampsia early• Hyperemesis gravidarium• No Fetal heart tone or Quickening• Abnormally elevated level of HCG
Question 6
Interventions and Follow-UpInterventions and Follow-Up
• Empty the Uterus by D & C or Hysterotomy
• Extensive Follow-Up for One Year• Assess for the development of
choriocarcinoma• Blood tests for levels of HCG frequently• Chest X-rays• Placed on oral contraceptives• If the levels rise, then chemotherapy started
usually Methotrexate
Critical Thinking Exercise
• A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her.
• How should the nurse respond?
Placenta PreviaPlacenta Previa• Low implantation of the placenta in the
uterus• Etiology
• Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors
• Three Major Types:• Low or Marginal• Partial• Complete
Question 8
Abruptio PlacentaAbruptio Placenta
Premature separation of the placenta from the implantation site in the uterus
Etiology: Chronic Hypertension Sudden decompression of an over-distended
uterus Trauma Injudicious use of Pitocin Smoking / Caffeine / Cocaine Vascular problems
Placenta PreviaPlacenta Previa• PAINLESS vaginal
bleeding• Bright red bleeding• First episode of
bleeding is slight then becomes profuse
• Signs of blood loss comparable to extent of bleeding
• Uterus soft, non-tender
• Fetal parts palpable; FHT’s countable
• Blood clotting defect absent
Abruptio PlacentaAbruptio Placenta Bleeding accompanied Bleeding accompanied
Abruptio by PAINAbruptio by PAIN Dark red bleedingDark red bleeding First episode of bleeding First episode of bleeding
usually profuseusually profuse
Signs of blood loss out Signs of blood loss out of proportion to visible of proportion to visible amount amount
Uterus board-like, Uterus board-like, painfulpainful
Fetal parts non-palpable, Fetal parts non-palpable, FHT’s non-countable FHT’s non-countable
Blood clotting defect Blood clotting defect (DIC) likely(DIC) likely
Signs of Concealed Hemorrhage
Increase in fundal heightHard, board-like abdomenHigh uterine baseline tone on
electronic fetal monitoringPersistent abdominal painSystemic signs of hemorrhage
Interventions and Nursing Care Interventions and Nursing Care
Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to
deliver vaginally Cesarean delivery for All other types
of previa
Treatment and Nursing Care
Abruptio Placenta Cesarean delivery immediately Combat shock – blood replacement /
fluid replacement Blood work – assessment for
complication of DIC
Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking
Mrs. A., G3 P2, 38 weeks gestation is admitted to L & D with bleeding. What is the priority nursing intervention at this time?A. Assess the fundal height for a decreaseB. Place a hand on the abdomen to assess if
hard, board-like, tetanicC. Place a clean pad under the patient to
assess the amount of bleedingD. Prepare for an emergency cesarean
delivery
Disseminated Intravascular Coagulation (DIC) Disseminated Intravascular Coagulation (DIC)
Anti-coagulation and Pro-coagulation
effects existing at the same time.
EtiologyDefect in the Clotting Cascade EtiologyDefect in the Clotting Cascade
• An abnormal overstimulation of the coagulation process
Activation of Coagulation with release of thromboplastin Thrombin (powerful anticoagulant) is produced
Fibrinogen fibrin which enhances platelet aggregation Widespread fibrin and platelet deposition in
capillaries and arterioles
Resulting in Thrombosis (multiple small clots)
Excessive clotting activates the fibrinolytic system
Lysis of the new formed clots create fibrin split products
These products have anticoagulant properties and inhibit normal blood clotting
A stable clot cannot be formed at injury sites Hemorrhage occurs Ischemia of organs follows from vascular
occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and
can result in death
Disseminated Intravascular Coagulation (DIC)Disseminated Intravascular Coagulation (DIC)
Precipating Factors: Abruptio placenta PIH Sepsis Retained fetus (fetal demise) Fetal placenta fragments Amniotic embolism Maternal liver disease Septic abortion HELLP and preeclampsia
Assessment Signs and Symptoms Assessment Signs and Symptoms
Spontaneous bleeding -- from gums and Epistaxis, and injection and IV sites, incisions
Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis
Tachycardia, diaphoresis, restlessness, hypotension
Hematuria, oliguria, occult blood in stool
Altered LOC if brain affected.
Diagnostic Tests
Lab work reveals: PT – Prothrombin time is prolonged PTT – Partial Thromboplastin Time increased D-Dimer – increased Product that results
from fibrin degradation. More specific marker of the degree of fibrinolysis
Platelets -- decreased Fibrin Split Products – increase
An increase in both FSP and D-Dimer are indicative of DIC
DICInterventions and Nursing Care DICInterventions and Nursing Care
Remove Cause Evaluate vital signs Replace blood and blood products Fluid replacement
May give Heparin
Question 9-D: E
HYPEREMESIS GRAVIDARIUMHYPEREMESIS GRAVIDARIUM
**Pernicious vomiting during **Pernicious vomiting during PregnancyPregnancy
Hyperemesis GravidariumHyperemesis Gravidarium
EtiologyEtiology
Increased levels of HCGIncreased levels of HCG
AssessmentAssessment
Persistent nausea and vomitingWeight loss from 5 - 20 poundsMay become severely dehydrated with
oliguria AEB increased specific gravity, and dry skin
Depletion of essential electrolytesMetabolic alkalosis -- Metabolic
acidosisStarvation
Nursing Care / InterventionsHyperemesis GravidariumNursing Care / InterventionsHyperemesis Gravidarium
Control vomiting
Maintain adequate nutrition and electrolyte balance Allow patient to eat whatever she wants If unable to eat – Total Parenteral Nutrition
Combat emotional component – provide emotional support. Mouth care
Weigh daily
Check urine for output, ketones
PREGNANCY INDUCED HYPERTENSION
A hypertensive disease of pregnancy. Known as pre-eclampsia and eclampsia.
Pre-eclampsia = hypertension, edema
proteinuria, Eclampsia = other signs plus
convulsions
It develops between the 20th and 24th week of gestation and resolves after the tenth day postpartum
PREDISPOSING FACTORSPREDISPOSING FACTORS
PRIMIGRAVIDA MULTIPLE PREGNANCY
VASCULAR DISEASE
UNDER 17 AND OVER 35
LOWER SOCIOECONOMIC STATUSSevere malnutrition, decrease Protein intake
Inadequate or late prenatal care
FAMILY HISTORY
HYDATIFORM MOLE
Diabetes, renal
PATHOLOGICAL CHANGESPIH is due to:
GENERALIZED ARTERIOLAR
CYCLICVASOSPASMS
INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW( in blood pressure)
Endothelial CELL DAMAGE
Intravascular Fluid Redistribution
(decrease in diameter of blood vessel)
Decreased Organ Perfusion
Multi-system failure DiseaseMulti-system failure Disease
Clinical Manifestation
HYPERTENSIONHYPERTENSION
Earliest and The Most Earliest and The Most Dependable IndicatorDependable Indicator of PIHof PIH
Hypertension
B/P = 140 / 90 if have no baseline. 1. 30 mm. Hg. systolic increase or a 15 mm. Hg. diastolic increase (two occasions four to six hours apart)
2. Increase in MAP > 20 mm.Hg over baseline or >105 mm. Hg. with no baseline
Rationale for HYPERTENSIONThe blood pressure rises due to: ARTERIOLAR VASOSPASMS AND
VASOCONSTRICTION causing
(Narrowing of the blood vessels)
an increase in peripheral resistance
fluid forced out of vessels
HEMOCONCENTRATION
Increased blood viscosity = Increased hematocrit
Key Point to Remember !
HEMOCONCENTRATION develops because:
Vessels became narrowed forcing fluid to shift
Fluid leaves the intracellular spaces and moves to extracellular spaces
Now the blood viscosity is increased (Hemocrit is increased)
**Very difficult to circulate thick blood
Test Yourself !
Which of these readings indicates hypertension in the patient whose blood pressure normally is 100 / 60 and MAP of 77?
a. 120 / 76; MAP 96 b. 110 / 70; MAP 83 c. 130 / 80; MAP 98 d. 125 / 70; MAP 88
Proteinuria With Renal vasospasms, narrowing of
glomular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate (damage to glomeruli)
PROTEINURIA
Spilling of 1+ of protein is significant to begin treatment
Oliguria and tubular necrosis may precipitate acute renal failure
Significant Lab WorkChanges in Serum Chemistry
• Decreased urine creatinine clearance (80-130 mL/ min)
• Increased BUN (12-30 mg./dl.)
• Increased serum creatinine (0.5 - 1.5 mg./dl)
• Increased serum uric acid (3.5 - 6 mg./dl.)
Weight Gain and Edema
• Clinical Manifestation:
– Edema may appear rapidly– Begins in lower extremities and
moves upward– Pitting edema and facial edema are
late signs
– Weight gain is directly related to accumulation of fluid
WEIGHT GAIN AND EDEMA
Rationale:• Albumin is lost due to the damage to the
tubules allowing larger solutes to pass in the urine
• This leads to a decreased colloid osmotic pressure
• A in COP allows fluid to shift from from intravascular to extravascular by osmosis
• Fluid accumulates in the extravascular space• Increased angiotensin and aldostersone
triggers retention of sodium and water
The difference between dependent edema and generalized edema is important.
The patient with PIH has generalized edema because fluid is in all tissues.
The Nurse Must Know
Placenta
Due to Vasospasms and Vasoconstriction of the vessels in the placenta.
Decreased Placental Perfusion and Placental Aging
Fetal Growth is retarded - IUGR, SGA
Positive OCT / __________Decelerations
With Prolonged decreased Placental Perfusion:
Condition is
Worsening
Condition is
Worsening
•Oliguria – 100ml./4 hrs or less than 30 cc. / hour
•Edema moves upward and becomes generalized (face, periorbital, sacral)
•Excessive weight gain – greater than 2 pounds per week
Central Nervous System Changes
• Cerebral edema -- forcing of fluids to extracellular
–Headaches -- severe, continuous
–Hyper-reflexia–Level of Consciousness changes – changes in affect
–Convulsions / seizures
Visual Changes
Retinal Edema and spasms leads to:
• Blurred vision
• Double vision
• Retinal detachment
• Scotoma (areas of absent or depressed vision)
• Nausea and Vomiting
• Epigastric pain –often sign of impending coma
Pre-Eclampsia Mild Severe
B/P 140/90 160/110Protein 1+ 2+ 3+ 4+Edema 1+, lower legs 3+ 4+Weight <1 lb. / week >2lb. / week Reflexes 1+ 2+ brisk 3+ 4+ (Hyperreflexia) Clonus presentRetina 0 Blurred vision, Scotoma
Retinal detachmentGI, Hepatic 0 N & V, Epigastric pain, changes in liver enzymesCNS 0 Headache, LOC changes
Fetus 0 Premature aging of placenta IUGR; late decelerations
Interventions and Nursing Care• Home Management
– Decrease activities and promote bed rest • Sedative drugs• Lie in left lateral position• Remain quiet and calm – restrict visitors and phone calls
– Dietary modifications • increase protein intake to 70 - 80 g/day• maintain sodium intake• Caffeine avoidance
– Weigh daily at the same time
– Keep record of fetal movement - kick counts
– Check urine for Protein
Hospitalization• If symptoms do not get better, patient
needs to be hospitalized for further evaluation
• Common lab studies:– CBC, platelets; type and cross
match– Renal blood studies -- BUN,
creatinine, uric acid– Liver studies -- AST, LDH, Bilirubin– DIC profile -- platelets, fibrinogen,
FSP, D-Dimer
Hospital ManagementNursing Care Goal
1. Decrease CNS Irritability
2. Control Blood Pressure
3. Promote Diuresis
4. Monitor Fetal Well-Being
5. Deliver the Infant
Decrease CNS Irritability Provide for a Quiet Environment and
Rest 1. MONITOR EXTERNAL STIMULI
Explain plans and provide Emotional Support
Administer Medications1. Anticonvulsant -- Magnesium Sulfate2. Sedative -- Diazepam (Valium)3. Apresoline (hydralazine)
Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available
Magnesium SulfateACTION
CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter release
ROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours
• Prior to administration:– Insert a foley catheter with urimeter
for assessment of hourly output
Magnesium SulfateNURSING IMPLICATIONS 1. Monitor respirations > 14-16; < 12 is critical
2. Assess reflexes for hyporeflexia -- D/C for hyporeflexia
3. Measure Urinary Output >100cc in 4 hrs.
4. Measure Magnesium levels – normal is 1.5-2.5 mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl; Cardiac arrest is > 15 mg/dl.
• Have Calcium Gluconate available as antagonist
Test Yourself !
A Woman taking Magnesium Sulfate has a
respiratory rate of 10. In addition to discontinuing the medication, the nurse should:
a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids
Nursing Care: Hospital Management
1. Decrease CNS Irritability
2. Control Blood Pressure
3. Promote Diuresis
4. Monitor Fetal Well-Being
5. Deliver the Infant
Control Blood Pressure• Check B / P frequently.
• Give Antihypertensive Drugs– Hydralzine ( apresoline)– Labetalol – Aldomet– Procardia
• Check Hemocrit
•Do NOT want to decrease the B/P too low or too rapidly. Best Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. to keep diastolic ~90.
•WHY?WHY?
Nursing Care: Hospital Management
1. Decrease CNS Irritability
2. Control Blood Pressure
3. Promote Diuresis
4. Monitor Fetal Well-Being
5. Deliver the Infant
Promote Diuresis
**Don’t give Diuretic, masks the symptoms of PIH
• Bed rest in left or right lateral position
• Check hourly output -- foley cath with urimeter
• Dipstick for Protein
• Weigh daily -- same time, same scale
Nursing Care: Hospital Management1. Decrease CNS Irritability
2. Control Blood Pressure
3. Promote Diuresis
4. Monitor Fetal Well-Being
5. Deliver the Infant
Monitor Fetal Well-Being
FETAL MONITORING-- assessing for late decelerations.
NST -- Non-stress test
OCT --oxytocin challenge test
If all else fails ---- Deliver the baby
Key Point to Remember !
SEVERE COMPLICATIONS OF PIH:PLACENTAL SEPARATION - ABRUPTIO PLACENTA;
DIC
PULMONARY EDEMA
RENAL FAILURE
CARDIOVASCULAR ACCIDENT
IUGR; FETAL DEATH
HELLP SYNDROME
HELLP Syndrome
•A multisystem condition that is a form of severe preeclampsia - eclampsia
•H = hemolysis of RBC
•EL = elevated liver enzymes
•LP = low platelets <100,000mm (thrombocytopenia)
Etiology of HELLP
Hemolysis occurs from destruction of RBC’s
Release of bilirubin
Elevated liver enzymes occur from blood flow that is obstructed in the liver due to fibrin deposits
Vascular vasoconstriction endothelial damage platelet aggregation at the sites of damage low platelets.
HELLP Syndrome Assessment:1. Right upper quadrant pain and tenderness2. Nausea and vomiting3. Edema4. Flu like symptoms5. Lab work reveals – a. anemia – low Hemoglobin b. thrombocytopenia – low platelets. < 100,000. c. elevated liver enzymes: -AST asparatate aminotransferase (formerly SGOT) exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L. - LDH – when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L/
HELLP
• Intervention:• 1. Bed rest – any trauma or increase in
intra- abdominal pressure could lead to rupture of the liver capsule hematoma.
• 2. Volume expanders
• 3. Antithrombic medications
Urinary Tract Infection
Most common infection complicating Pregnancy
EtiologyPressure on ureters and bladder
causing Stasis with compression of ureters
RefluxHormonal effects cause decrease tone
of bladder Assessment
Dysuria, frequency, urgency lower abdominal pain; costal
vertebral pain fever
InterventionsMonthly culturesOral Sulfonamides; Amoxicillin,
Ampicillin, Cephalosporins, NO tetracyclines
Increase fluid intake to 3 – 4 liters / day
Knee chest positionComplication
Premature labor
T O R C H A Infections
T = ToxoplasmosisO = Other Syphilis, Gonorrhea, Chlamydial,Hepatitis A or B
R = RubellaC = CytomegalovirusH = HerpesA = Aids
ToxoplasmosisEtiology
Protozoan infection. Raw meat and cat litter
Maternal and Fetal Effects Mom - flu-like symptoms,
lymphadenopathy Fetus – stillborn, premature birth,
microcephaly; mental retardationInterventions / Nursing Care
* Instruct to cook meat thoroughly* Avoid changing cat litter* Advise to wear gloves when working in the garden Treatment: Sulfa drugs
Syphilis
• Etiology•Spirochete – Treponema Pallium
• Maternal and Fetal Effects• May pass across the placenta to fetus
causing spontaneous abortion. Major cause of late,second trimester abortions
• Infant born with congenital anomalies
Syphilis
• Intervention:•1. Penicillin
•2. Advise to return for prenatal visits monthly to assess for reinfection.
•3. Advise that if treated early, fetus may not be infected
GonorrheaEtiology – Neisseria GonorrhoeaeMaternal and Fetal Effects:
May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infant
Mom will experience dysuria, frequency, urgency
Major cause Pelvic Inflammatory Disease which leads to infertility.
Treated with RocephinSpectinomycin
Treat partner!!Treat partner!!
Chlamydia Three times more common than
gonorrhea. Etiology - Chlamydia trachomatis Maternal and Fetal Effects
Mom – pelvic inflammatory disease, dysuria, abortions, pre-term labor
Fetus -- Stillbirth, Chylamydial pneumonia
Interventions Erythromycin, doxycycline, zithromax Advise treatment of both partners is
very important
Hepatitis A or B
• Highly contagious when transmitted by direct contact with blood or body fluids
• Maternal and Fetal Effects:• All moms should be tested for Hep B during
pregnancy• Fetus may be born with low birth weight and
liver changes\• May be infected through placenta, at time of
birth, or breast milk
• Intervention:• Recommend Hepatitis B vaccination to both
mother and baby after delivery.
Rubella
EtiologySpread by droplet infection or through
direct contact with articles contaminated with nasopharyngeal secretions.
Crosses placenta Maternal and Fetal Effects
Mom– fever, general malaise, rashMost serious problem is to the fetus--
causes many congenital anomalies (cataracts, heart defects)
InterventionDetermine immune status of mother. If
titer is low, vaccine given in early postpartum period
CYTOMEGALOVIRUSEtiology -- Member of the Herpes virus
• Crosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milk
Effects on Mom and Fetus• Mom – no symptoms, not know until after
birth of the baby• Fetus -- Severe brain damage; Eye
damage
InterventionNo drug available at this timeTeach mom should not breast feed babyIsolate baby after birth
Herpes Simplex Type 2 Maternal and Fetal Effects
Painful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeks
Culture lesions to detect if Herpes, No cure
If mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth
*Virus is lethal to fetus if inoculated at birth Intervention:
Zivorax
AIDS
• Etiology: Human Immunodeficiency Virus, HIV
• Transmission of HIV to the fetus occurs through:– The placenta; birth canal– Through breast milk
**The virus must enter the baby’s bloodstream to produce infection.
Maternal and Fetal Effects:
– Mom - brief febrile illness after exposure to with symptoms of fatigue and lymphadenopathy
– Fetus has a 2-5% chance of being infected. No symptoms until about 1 year of age
Diagnosis:• ELISA test – identifies antibodies specific to HIV. If
positive = person has been exposed and formed antibodies
• Western Blot – used to confirm seropositivity when ELISA is positive.
• Viral load - measures HIV RNA in plasma. It is used to predict severity – lower the load the longer survival.
• CD4 cell count – markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system.
Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count.
Nursing Care:
• **Provide Emotional Support
• **Teach measures to promote wellness AZT
oral during pregnancy IV during labor liquid to newborn for 6 weeks.
• **Provide information about resources
Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath
Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath
DEFINITION: Death of a fetus after the age of
viability
Assessment: 1. First indication is usually NO fetal movement
2. NO fetal heart tones Confirmed by ultrasound
3. Decrease in the signs and symptoms of
pregnancy
Treatment:
• Deliver the fetus
• How???
Pre-Gestational Onset Disorders
Diabetes in Pregnancy
Diabetes creates special problems which affect pregnancy in a variety of ways.
Successful delivery requires work of the entire health care team
Endocrine Changes During
Pregnancy
There is an increase in activity of maternal pancreatic islets which result in increaseincrease production of insulin.
Counterbalanced by:a. Placenta’s production of Human
Chorionic Somatomammotropin (HCS)
b. Increased levels of progesterone and estrogen--antagonistic to insulin
c. Human placenta lactogen – reduces effectiveness of circulating insulin
d. Placenta enzyme-- insulinase
GESTATIONAL DIABETESDiabetes diagnosed during pregnancy,
but unidentifable in non-pregnant woman
Known as Type III Diabetes - intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after delivery
Glucose tolerance test:1 hr oral GTT – if elevated, do 3 hour GTTGestational diabetes if:
Fasting – 95 mg / dl1 hour - 180 mg/ dl2 hour - 155 mg/ dl3 hour – 140mg/dl
Treatment for the patient with Gestational Diabetes:•
• Treatment - controlled mainly by diet
• No use of oral hypoglycemics
Effects of Diabetes on the Pregnancy
MATERNAL Increase incidence of INFECTION
Fourfold greater incidence of Pre-eclampsia
Increase incidence of Polyhydramnios
Dystocia – large babies
Rapid Aging of Placenta
FETAL COMPLICATIONSFETAL COMPLICATIONS
Increase morbidity
Increase Congenital Anomalies neural tube defect (AFP)Cardiac anomalies
Spontaneous Abortions
Large for Gestation Baby, LGA
Increase risk of RDS
Effects of Pregnancy on the Diabetic
Insulin Requirements are AlteredFirst Trimester--may drop slightlySecond Trimester-- Rise in the
requirementsThird Trimester-- double to quadruple by
the end of pregnancy
Fluctuations harder to control; more prone to DKA
Possible acceleration of vascular diseases
Key Point to Remember!
If the insulin requirements do not rise as pregnancy progresses that is an indication that the placenta is not functioning well.
Test Yourself?
Mrs. R.’s is 31 weeks gestation and her insulin requirements have dropped. What additional test could be performed to assess fetal well-being? a. L/S ratio b. Estriol levels c. Oxytocin Challenge Test
Interventions /Nursing Care
I. I. Diet TherapyDiet Therapy– dietary management must be based on
BLOOD GLUCOSE LEVELS – Pre-pregnant diet usually will not work– Need ~300kcal/day– Divide among three meals and three
snacks
II. Insulin RegulationII. Insulin Regulation– maintaining optimal blood glucose levels
require careful regulation of insulin. Sometimes placed on insulin pump.
III. Blood Glucose MonitoringIII. Blood Glucose Monitoring– teach how to keep a record of results of home
glucose monitoring
IV. EXERCISE– A consistent and structured exercise program is O.K.
V. MONITOR FETAL WELL-BEING– The objective is to deliver the infant as near to
term as possible and prevent unnecessary prematurityNSTUltrasoundL / S ratio
Heart Disease in
Pregnancy
Cardiac Response in All Pregnancies
Increase in Cardiac Output 30% - 50%
Expanded Plasma Volume
Increase in Blood (Intravascular) Volume
Every Pregnancy affects the cardiovascular system
A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications
Effects of Heart Disease on Pregnancy
Growth Retarded Fetus
Spontaneous Abortion
Premature Labor and Delivery
Effects of Pregnancy onHeart Disease
The Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure).
The effect may be varied depending upon the classification of the disease
Classification of Heart Disease
Class 1 Uncompromised No alteration in activity No anginal pain, no symptoms with activity
Class 2 Slight limitation of physical activity Dyspnea, fatigue, palpitations on ordinary
exertion comfortable at rest p. 328
Class 3 Marked limitation of physical activity Excessive fatigue and dyspnea on minimal exertion Anginal pain with less than ordinary exertion
Class 4 Symptoms of cardiac insufficiency even at rest Inability to perform any activity without discomfort Anginal pain Maternal and fetal risks are high p. 328
Nursing Care - Antepartum
Decrease Stress– Teach the importance of REST! – watch weight– assess for infections - stay away from
crowds– assess for anemia– assess home responsibilities
Teach signs of cardiac decompenstion
Key Point to RememberSigns of Congestive Heart Failure
Cough (frequent, productive, hemoptysis)
Dyspnea, Shortness of breath, orthopnea
Palpitations of the heart
Generalized edema, pitting edema of legs and feet
Moist rales in lower lobes, indicating pulmonary edema
Teach about diet
high in iron, proteinlow in sodium and calories ( fat )
Watch weight gain
Teach how to take their medicine– Supplemental iron– Heparin, not coumarin – monitor lab work– Diuretics – very careful monitoring– Antiarrhythmics –Digoxin, quinidine, procainamide. *Beta-blockers are
associated with fetal defects.
Reinforce physicians care
Key point to remember !
Never eat foods high in Vitamin K while on
an anticoagulant!
( raw green leafy vegetables)
Nursing Care: Intrapartum
Labor in an upright or side lying position Restrict fluids On O2 per mask throughout labor and
cardiac monitoring. Sedation / epidural given early Report fetal distress or cardiac failure
Stage 2 - gentle pushing, high forceps delivery
Nursing Care Postpartum The immediate post delivery period is the
MOST significant and dangerous for the mom with cardiac problems
Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion
Cardiac output increases, blood volume increases
Strain on the heart! Watch for cardiac failure
Test Yourself !• Mrs. B. has mitral valve prolapse.
During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time?
a. Class I b. Class II c. Class III d. Class IV
The End