Hyper / Hypo Disorders

1
COMPLICATIONS OF PREGNANCY
Jeanie Ward
2
Risk Factors

• Age under 17 over 35
• Gravida and Parity
• Socioeconomic status
• Psychological well-being
• Predisposing chronic illness diabetes, heart
  conditions, renal, etc.
• Pregnancy related conditions hyperemesis
  gravidarum, PIH, etc.

3
High Risk Pregnancy Goals
of Care

• Provide with optimum care for the mother and the
  fetus
• Assist the patient and her family to understand
  and cope with the variations in a High Risk
  Pregnancy and cope with her feelings

4
Gestational Onset Disorders
5
Take report Mrs. R. admitted to LD

• Initial Data
• Chief complaint moderate amount vaginal bleeding
• Vital Signs T. 98.4 P. 100, R. 22, B/P 100/66
• G i P 0
• Last menstrual period 8/12 EDC May 19
• Allergies none known
• Nauseated
• Mild pain
• HCG levels normal for pregnancy

6
Bleeding Disorders
7
Abortions

• Termination of pregnancy at any time before the
  fetus has reached the age of viability
• Either
• spontaneous occurring naturally
• induced artificial

Question 1
8
Etiology / 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

9
Assessment Types of
Abortions Threatened

• Signs and Symptoms
• vaginal bleeding, spotting
• Mild cramps, backache
• Cervix remains CLOSED
• Treatment and Nursing Care
• Bed rest, sedation,
• Avoid stress and intercourse
• Progesterone therapy
• A period of watchful waiting

10
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

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Complete Abortion

• All products of conception are expelled
• No treatment is needed, but may do a D C

12
Incomplete Abortion

• Parts of the products of conception are expelled,
  with placenta and membranes retained
• Treated with a D C or suction evacuation
• Provide support to the family

13
Missed Abortion

• The fetus dies in-utero and is not expelled
• Uterine growth ceases
• Breast changes regress
• Maceration occurs
• Treatment
• D C
• Hysterotomy

14
Question???

• What are two main complications related to a
  missed abortion?
• 1.
• 2.

15
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.

16
Habitual Abortion

• Treatment
• Cerclage procedure -- purse-string suture
  placed around the internal os to hold the cervix
  in a normal state

17
Nursing Care

• Bedrest in a slight trendlenburg position to
  decrease the pressure on the new sutures
• Teach
• Assess for leakage of fluid, bleeding
• Assess for contractions
• Assess fetal movement and report decrease
  movement (if old enough)
• Assess temperature for elevations

18
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

19
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

20
Bleeding Disorders
Ectopic Pregnancy

• Implantation of the blastocyst in ANY site other
  than the endometrial lining of the uterus

ovary
(5) Cervical
Question 2
21
Etiology / Contributing Factors

• Salpingitis
• Pelvic Inflammatory Disease, PID
• Endometriosis
• Tubal atony or spasms
• Imperfect genetic development

Question 3
22
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
• Cullens sign -- bluish discoloration around
  umbilicus
• Nausea, Vomiting
• Faintness

23
Diagnostic Tests Ectopic
Pregnancy

• Diagnosis
• Ultrasound
• Culdocentesis
• Laparoscopy

24
Treatment Options / Nursing Care

• Combat shock / stabilize cardiovascular
• Draw blood for type and cross match
• Give blood replacements
• IVs.
• Laparotomy
• Psychological support
• Linear salpingostomy
• Methotrexate used prior to rupture. Destroys
  fast growing cells

Question 4
25
Gestational Trophoblastic DiseaseHydatiform
Molar PregnancyEtiology

• 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.

Question 5
26
Assessment

• Vaginal Bleeding -- scant to profuse, brownish in
  color (prune juice)
• 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 levels of HCG

Question 6
27
Interventions and Follow-Up

• Empty the Uterus by D C or Hysterotomy
• 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

Question 7
28
Critical Thinking Exercise

• A woman who just had an evacuation of a
  hydatiform mole tells the nurse that she doesnt
  believe in birth control and does not intend to
  take the oral contraceptives that were prescribed
  for her.
• How should the nurse respond?

29
Placenta 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
30
Abruptio 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

31

• Placenta 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 FHTs countable
• Blood clotting defect absent

• Abruptio Placenta
• Bleeding accompanied Abruptio by PAIN
• Dark red bleeding
• First episode of bleeding usually profuse
• Signs of blood loss out of proportion to visible
  amount
• Uterus board-like, painful
• Fetal parts non-palpable, FHTs non-countable
• Blood clotting defect (DIC) likely

32
Signs of Concealed Hemorrhage

• Increase in fundal height
• Hard, board-like abdomen
• High uterine baseline tone on electronic fetal
  monitoring
• Persistent abdominal pain
• Systemic signs of hemorrhage

Question 8-C
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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
• Abruptio Placenta
• Deliver by cesarean delivery immediately
• Combat shock blood replacement / fluid
  replacement
• Blood work assessment of DIC

34
Critical Thinking

• Mrs. A. , G3 P2, 38 weeks gestation is admitted
  to L D with bleeding. What is the priority
  nursing intervention at this time?
• Assess the fundal height for a decrease
• Place a hand on the abdomen to assess if hard,
  board-like, tetanic
• Place a clean pad under the patient to assess the
  amount of bleeding
• Prepare for an emergency cesarean delivery

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Disseminated Intravascular Coagulation (DIC)

• Anti-coagulation and Pro-coagulation
• effects existing at the same time.

Question 9
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EtiologyDefect in the Clotting
Cascade

• An abnormal overstimulation of the
  
• coagulation process
• Activation of Coagulation with
• release of thromboplastin
• ê
• Thrombin (powerful anticoagulant) is produced
• ê
• Fibrinogen ?fibrin which enhances platelet
  aggregation
• ê
• Widespread fibrin and platelet deposition in
  capillaries and arterioles

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• 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

38
Disseminated Intravascular Coagulation (DIC)

• Precipating Factors
• Abruptio placenta
• PIH
• Sepsis
• Retained fetus (fetal demise)
• Fetal placenta fragments

39
Assessment Signs and
Symptoms

• Spontaneous bleeding -- from gums and Epistasis,
  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
• Mental changes if brain affected.

Question 9-C
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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

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DICInterventions and Nursing
Care

• Remove Cause
• Evaluate vital signs
• Replace blood and blood products
• Fluid replacement
• May give Heparin

Question 9-D E
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Hyperemesis Gravidarum
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HYPEREMESIS GRAVIDARIUM
Pernicious vomiting during
Pregnancy
Question 10
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Hyperemesis Gravidarium
Etiology Increased levels of HCG
45
Assessment

• Persistent nausea and vomiting
• Weight loss from 5 - 20 pounds
• May become severely dehydrated with oliguria
  increased specific gravity, and dry skin
• Depletion of essential electrolytes
• Metabolic alkalosis -- Metabolic acidosis
• Starvation

46
Nursing Care / InterventionsHyperemesis
Gravidarium

• Control vomiting
• Maintain adequate nutrition and electrolyte
  balance
• Allow patient to eat whatever she wants
• If unable to eat Hyperalimentation
• Combat emotional component provide emotional
  support
• Weigh daily
• Check urine for output, ketones

Question 11 12
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Pregnancy Induced Hypertension
48
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 disappears after the tenth day
  postpartum

Question 13
49
MULTIPLE PREGNANCY
PRIMIGRAVIDA
UNDER 17 AND OVER 35
HYDATIFORM MOLE
PREDISPOSING FACTORS
FAMILY HISTORY
VASCULAR DISEASE
Diabetes, renal
LOWER SOCIOECONOMIC STATUS
Severe malnutrition, decrease Protein intake
Question 14
Inadequate or late prenatal care
50
PATHOLOGICAL CHANGES
PIH is due to
INCREASED PERIPHERAL RESISTANCE
IMPEDED BLOOD FLOW ( in blood pressure)
GENERALIZED
ARTERIOLAR CYCLIC VASOSPASMS
Endothelial CELL DAMAGE
Intravascular Fluid Redistribution
(decrease in diameter of blood vessel)
Decreased Organ Perfusion

Question 15
Multi-system failure Disease
51
Clinical Manifestation


HYPERTENSION
Earliest and The Most Dependable Indicator
of PIH
52
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 gt 20 mm.Hg over baseline or gt105
mm. Hg. with no baseline
Positive Roll Over Test
53
Rationale for HYPERTENSION

• The 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

54
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

55
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

56
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
57
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.)

Question 17
58
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

59
WEIGHT GAIN AND EDEMA

• Rationale
• Decreased blood flow to the kidneys causes a loss
  of plasma proteins and albumin
• This leads to a decreased colloid osmotic
  pressure.
• A ? in COP allows fluid to shift from from
  intravascular to extravascular.
• Now there is an accumulation of fluid in the
  tissues.
• Increased angiotensin and aldostersone triggers
  retention of sodium and water.

60
The Nurse Must Know

• The difference between dependent edema and
  generalized edema is important.
• The patient with PIH has generalized edema
  because fluid is in all tissues.

61
Placenta

• With Vasospasms and Vasoconstriction of the
  the vessels in the placenta.
• Decreased Placental Perfusion and Placental Aging

Positive OCT / __________Decelerations
With Prolonged decreased Placental Perfusion
Fetal Growth is retarded - IUGR, SGA
62

• Condition
• is
• Worsening

63

• 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

64
Central Nervous System Changes

• Cerebral edema -- forcing of fluids to
  extracellular
• Headaches -- severe, continuous
• Hyperreflexia
• Level of Consciousness changes changes in
  affect
• Convulsions / seizures

65
Visual Changes

• Retinal Edema and spasms leads to
• Blurred vision
• Double vision
• Retinal detachment
• Scotoma (areas of absent or depressed vision)

66

• Nausea and Vomiting
• Epigastric pain often sign of impending coma

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Pre-Eclampsia Mild
Severe

• B/P 140/90
  160/110
• Protein 1 2
  3 4
• Edema 1, lower legs
  3 4
• Weight lt1 lb. / week
  gt2lb. / week
• 
  
• Reflexes 1 2 brisk
  3 4 (Hyperreflexia)
  
• 
  Clonus present
• Retina 0
  Blurred vision, Scotoma
  
• 
  Retinal detachment
• GI, Hepatic 0
  N V, Epigastric pain,
• 
  changes in liver enzymes
• CNS 0
  Headache, LOC changes
• Fetus 0
  Premature aging of placenta
• 
  IUGR late decelerations
• 
  

Question 16
68
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

Question 18
69
Hospitalization

• If symptoms do not get better then the patient
  needs to be hospitalized in order to further
  evaluate her condition.
• Common lab studies
• CBC, platelets type and cross match
• Renal blood studies -- BUN, creatitine, uric acid
• Liver studies -- AST, LDH, Bilirubin
• DIC profile -- platelets, fibrinogen, FSP, D-Dimer

70
Hospital ManagementNursing Care Goal

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

71
Decrease CNS Irritability

• Provide for a Quiet Environment and Rest
• 1. MONITOR EXTERNAL STIMULI
• Explain plans and provide Emotional Support
• Administer Medications
• 1. Anticonvulsant -- Magnesium Sulfate
• 2. Sedative -- Diazepam (Valium)
• 3. Apresoline (hydralazine)
• Assess Reflexes
• Assess Subjective Symptoms
• Keep Emergency Supplies Available

72
Magnesium Sulfate

• ACTION
• 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

73
Magnesium Sulfate

• NURSING IMPLICATIONS
• 1. Monitor respirations gt 14-16 lt 12 is
  critical
• 2. Assess reflexes for hyporeflexia -- D/C for
  hyporeflexia
• 3. Measure Urinary Output gt100cc in 4 hrs.
• 4. Measure Magnesium levels normal is 1.5-2.5
  mg/dl
• Therapeutic is 4-8mg/dl. Toxicity -
  gt9mg/dl
• Absence of reflexes is gt10 mg/dl
• Respiratory arrest is 12-15 mg/dl
• Cardiac arrest is gt 15 mg/dl.
• Have Calcium Gluconate available as antagonist

74
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

75
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

76
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 to keep diastolic 90.
• WHY?

77
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

78
Promote Diuresis

• Dont 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

79
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

80
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

81
Key Point to Remember !

• SEVERE COMPLICATIONS OF PIH
• PLACENTAL SEPARATION - ABRUPTIO PLACENTA DIC
• PULMONARY EDEMA
• RENAL FAILURE
• CARDIOVASCULAR ACCIDENT
• IUGR FETAL DEATH
• HELLP SYNDROME

82
HELLP Syndrome

• A multisystem condition that is a form of severe
  preeclampsia - eclampsia
• H hemolysis of RBC
• EL elevated liver enzymes
• LP low platelets lt100,000mm
  (thrombocytopenia)

Question 19
83
Etiology of HELLP

• Hemolysis occurs from destruction of RBCs
• 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.

84
HELLP Syndrome Assessment

• 1. Right upper quadrant pain and tenderness
• 2. Nausea and vomiting
• 3. Edema
• 4. Flu like symptoms
• 5. Lab work reveals
• a.  anemia low Hemoglobin
• b.  thrombocytopenia low platelets. lt
  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 gt 20 u/L.
•   - LDH when cells of the liver
  are lysed, they spill
• into the bloodstream and there is
  an increase in
• serum gt 90 u/L/

85
HELLP

• Intervention
• 1. Bedrest any trauma or increase in intra-
  
• abdominal pressure could lead to rupture
• of the liver capsule hematoma.
• 2. Volume expanders
• 3. Antithrombic medications

86
Infections
87
Urinary Tract Infection

• Most common infection complicating Pregnancy
• Etiology
• Pressure on ureters and bladder causing Stasis
  with compression of ureters
• Reflux
• Hormonal effects cause decrease tone of bladder
• Assessment
• Dysuria, frequency, urgency
• lower abdominal pain costal vertebral pain
• fever

88

• Interventions
• Monthly cultures
• Oral Sulfonamides Amoxicillin, Ampicillin,
  Cephalosporins, NO tetracyclines
• Increase fluid intake to 3 4 liters / day
• Knee chest position
• Complication
• Premature labor

89
T O R C H A Infections

• T Toxoplasmosis
• O Other
• Syphilis, Gonorrhea,
• Chlamydial,Hepatitis A or B
• R Rubella
• C Cytomegalovirus
• H Herpes
• A Aids

Question 20
90
Toxoplasmosis

• Etiology
• Protozoan infection. Raw meat and cat litter
• Maternal and Fetal Effects
• Mom - flu-like symptoms, lymphadenopathy
• Fetus stillborn, premature birth,
  microcephaly mental retardation

Interventions / Nursing Care
Instruct to cook meat thoroughly Avoid
changing cat litter Advise to wear gloves when
working in the garden Treatment Sulfa
drugs
91
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

92
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

93
Gonorrhea

• Etiology Neisseria Gonorrhoeae
• Maternal 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

Rocephin Spectinomycin
Treat partner!!
94
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

95
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.

96
Rubella

• Etiology
• Spread by droplet infection or through direct
  contact with articles contaminated with
  nasopharyngeal secretions.
• Crosses placenta
• Maternal and Fetal Effects
• Mom fever, general malaise, rash
• Most serious problem is to the fetus--causes many
  congenital anomalies (cataracts, heart defects)
• Intervention
• Determine immune status of mother. If titer is
  low, vaccine given in early postpartum period

97
CYTOMEGALOVIRUS

• Etiology -- 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
• Intervention
• No drug available at this time
• Teach mom should not breast feed baby
• Isolate baby after birth

98
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

99
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 babys
  bloodstream to produce infection.

100

• 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
• The mother can be diagnosed by the ELISA test
  and confirmed using the Western Blot.
• Assessment of viral load, CD4 cell count
• Goal reduce viral load to below 50 copies
  /ml. and increase the CD4 cell count.

Question 21
101
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.

102
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

103
Fetal Demise / Intrauterine Fetal
Death

• DEFINITION
• Death of a fetus after the age of
  viability

104

• 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

105
Treatment

• Deliver the fetus
• How???

106
Pre-Gestational Onset Disorders
107
Substance Abuse

• Drugs that commonly misused are
• Tobacco
• Alcohol
• Cocaine
• Marijuana
• Amphetamines, barbiturates , hallucinogens
• Heroin
• Others
• Effects vary depending on the drug, time
  exposed, etc. See table 14-1.

108
Substance Abuse

• Patient Teaching
• Very dangerous to use any drugs during the first
  8 weeks of gestation
• Drugs that cross the placenta may cause possible
  problems in the infant
• mental retardation
• Microcephaly
• FAS
• IUGR
• Congenital heart defects

109
Diabetes in Pregnancy
110
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

111
Endocrine Changes During
Pregnancy

• There is an increase in activity of maternal
  pancreatic islets which result in increase
  production of insulin.

112

• Counterbalanced by
• Placentas production of Human Chorionic
  Somatomammotropin (HCS)
• Increased levels of progesterone and
  estrogen--antagonistic to insulin
• Human placenta lactogen reduces effectiveness
  of circulating insulin
• d. Placenta enzyme-- insulinase

113
GESTATIONAL DIABETES

• Diabetes 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
• 3 hr oral gtt check levels at 1,2,3 hours
• Gestational diabetes if
• Fasting 95 mg / dl
• 1 hour - 180 mg/ dl
• 2 hour - 155 mg/ dl
• 3 hour 140mg/dl

114
Treatment for the patient with Gestational
Diabetes

• Treatment - controlled mainly by diet
• No use of oral hypoglycemics

115
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

116

• FETAL COMPLICATIONS

• Increase morbidity
• Increase Congenital Anomalies
• neural tube defect (AFP)
• Cardiac anomalies
• Spontaneous Abortions
• Large for Gestation Baby, LGA
• Increase risk of RDS

117
Effects of Pregnancy on the Diabetic

• Insulin Requirements are Altered
• First Trimester--may drop slightly
• Second Trimester-- Rise in the requirements
• Third Trimester-- double to quadruple by the end
  of pregnancy
• Fluctuations harder to control more prone to DKA
• Possible acceleration of vascular diseases

118
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.

119
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
120
Interventions /Nursing Care

• I. Diet Therapy
• dietary management must be based on BLOOD GLUCOSE
  LEVELS
• Pre-pregnant diet usually will not work
• II. Insulin Regulation
• maintaining optimal blood glucose levels require
  careful regulation of insulin. Sometimes
  placed on insulin pump.
• III. Blood Glucose Monitoring
• teach how to keep a record of results of home
  glucose monitoring

121

• 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 prematurity
• NST
• Ultrasound
• L / S ratio

122

• ?Heart Disease in
• Pregnancy

123
Cardiac Response in All Pregnancies
Every Pregnancy affects the
cardiovascular system

• Increase in Cardiac Output 30 - 50
• Expanded Plasma Volume
• Increase in Blood (Intravascular) Volume

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
124
Effects of Heart Disease on Pregnancy

• Growth Retarded Fetus
• Spontaneous Abortion
• Premature Labor and Delivery

125
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

126
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. 669

127

• 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. 669

128
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

129
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
• 
  

130

• Teach about diet
• high in iron, protein
• low 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

131
Key point to remember !
Never eat foods high in Vitamin K while
on an anticoagulant!
( raw green leafy vegetables)
132
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

133
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

134
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

135
The End