Anemia During Pregnancy

• Hematologic disorders involve issues with blood formation and coagulation.

Anemia During Pregnancy

• Includes iron-deficiency anemia, folic acid deficiency, and sickle cell anemia

Anemia During Pregnancy Types

• Pseudo anemia results from the expansion of blood volume, causing a dilutional effect.
• True anemia is present when hemoglobin (HGB) is less than 11 g/dL and hematocrit (HCT) is less than 33% during the first trimester.

Normal Blood Values

• HGB: 12-16 g/dL
• HCT: 37-47%
• RBC: 4 to 5.5 million/mm^3

Iron Deficiency Anemia

• The most common anemia during pregnancy, affecting 15-25% of pregnancies
• Characterized by microcytic (small) and hypochromic (less hemoglobin than average red blood cells)

Iron Deficiency Anemia Factors

• Low iron diet
• Heavy menstrual periods
• Weight reducing programs
• HGB lower than 12 g/dL and HCT less than 33%

Iron Deficiency Anemia Effects

• Decreases oxygen transport to the body

Iron Deficiency Anemia Risks

• Low birth weight
• Preterm birth

Iron Deficiency Anemia Symptoms

• Craving or eating starch or ice
• Extreme fatigue
• Poor exercise tolerance

Iron Deficiency Anemia Management

• Includes iron supplementation (e.g., 200mg iron with vitamin C)
• Following a diet rich in iron (green leafy vegetables, legumes, meat)
• Taking juice with Vitamin C for better absorption

Iron Therapy Side Effects

• Constipation, black tarry stool, and gastric irritation require management with fiber-rich foods and taking medication on a full stomach.
• Folic acid is high in demand because it help the body make new cells, including brain cells, blood cells, DNA, and RNA

Folic Acid Deficiency

• Folic acid deficiency is due to deficiency of vitamin B9
• Vitamin B9 is needed for red blood cell formation and prevention of neural tube defects in the fetus

Folic Acid Deficiency Effects

• It occurs mostly among women with multiple pregnancies, secondary hemolytic disease, or those taking anticoagulants, oral contraceptives, or had gastric bypass due to obesity.

Folic Acid Deficiency Anemia Development

• Folic acid deficiency may develop into megaloblastic anemia (enlarged RBCs) over several weeks and manifest in the 2nd trimester.

Sickle Cell Anemia Risks

• Could result to premature separation of the placenta or early miscarriage.
• Prescribe a mother to take 400 to 600 mcg folic acid daily for expectant mothers.
• Eat folate rich foods (Green leafy vegetables; orange and dried beans)

Sickle Cell Anemia

• Normal red blood cells are rounded and disk-shaped, but in sickle cell anemia, they become deformed like sickles used to cut wheat.
• It is a recessively inherited anemia caused by abnormal amino acid in hemoglobin, which results in irregular shaped RBCs that cannot carry much HGB, decreases capacity to transport HGB to the tissues.
• Reduced blood flow to organs results in severe anemias and blockage to placental circulation, compromising the fetus and potentially causing low birth weight or fetal death. Normal HGB is 6-8 mg/100 mL of blood.
• Common among Black women

Sickle Cell Anemia Effects on Pregnancy

• Can cause blockage to placental circulation, which could compromise the fetus causing low birth weight and possible fetal death.

Sickle Cell Anemia Assessment

• Screen for the disease
• Monitor HGB and urine throughout pregnancy.
• Monitor women's diet (must be high in folic acid).
• Increase fluid intake 8 glasses a day and avoid dehydration.
• Assess lower extremities for varicosities

Thrombocytopenia Prevalence

• Defined as platelet count of less than 150,000 to 450,00 microliters of blood, can occur in 7-12% of pregnancies at the time of delivery

First Trimester Bleeding Causes

• Primary causes are uterine abnormalities and chromosomal problems, with unknown causes including infection, deficient progesterone, and metabolic disorders.

First Trimester Bleeding Managment

• Bleeding must stop within 24 hours, and coitus restricted for 2 weeks to prevent infection.

Threatened Abortion Treatment

• Requires bed rest, forbidden sexual life, and progesterone.

Inevitable Miscarriage

• A threatened miscarriage becomes imminent or inevitable if uterine contraction and cervical dilation occur

Inevitable Miscarriage Management

• Must visit the OB for FHB assessment, save tissue for examination.

Clinical Abortion Findings

• Incomplete abortion which is the expulsion of some, but not all, of the products of conception
• Complete abortion which is the expulsion of all the products of conception

Second Trimester Bleeding Complications

• Hydatidiform Mole and premature cervical dilation

Bleeding During the First Trimester

• Classifications include: threatened, imminent (inevitable), missed, incomplete, complete miscarriage, and ectopic pregnancy.

Complete Miscarriage

• The entire product of conception (fetus, membranes, and placenta) are expelled spontaneously without assistance.
• Bleeding slows within 2 hours and stops within a few days.

Incomplete Miscarriage

• Part of the conceptus is expelled, but the membranes are retained in the uterus.

Missed Miscarriage (Early Pregnancy Failure)

• Characterized by fetal death in utero without expulsion
• Discovered during prenatal exams due to lack of fundal height increase and no FHB heard
• Symptoms of threatened abortion may be present or absent
• After 14 weeks, labor may be induced with Cytotec and Oxytocin.

Miscarriage Treatment

• Includes dilation and curettage, estrogen, DIC (disseminated intravascular coagulation), and oxytocin

Abortion complications

• In the third trimester: Placenta previa and Preterm labor

Miscarriage Complications

• Possible hemorrhage with incomplete miscarriage or DIC, potentially leading to hypovolemic shock
• Infection may develop due to pregnancy loss over time and significant blood loss

Septic Abortion

• An infection of the placenta and fetus (product of conception) of a previable pregnancy where infection is centered in the placenta and there is rick of spreading to the uterus
• This causes a pelvic infection and potential damage of distant vital organs.

Septic Abortion Treatment

• Includes isolation, clinical bacteriological identification, antibiotics, monitoring intake/output, and proper disposal pad

Pathology of Abortion in The First 8 Weeks Gestation

• Separation of decidua basalis and expulsion of the ovum

Pathology of Abortion from 8-12 Weeks Gestation

• Rupture of decidua capsularis and expulsion of the product of conception

Pathology of Abortion After 12 Weeks

• Rupture of membranes, hemorrhage, necrosis, uterine contraction, and expulsion of most or all products

Ectopic Pregnancy

• A fertilized ovum implants outside the endometrial lining of the uterus

Risks for Ectopic Pregnancy

• An infection or inflammation in the fallopian tube can partially or completely block it.

Ectopic Pregnancy: Signs and Symptoms

• Develop 6-8 weeks after the last normal menstrual period or throughout the first trimester include pain during intercourse, irregular vaginal bleeding/spotting, cramping/pain on one side, or rapid heartbeat.
• It does not always cause symptoms and may be detected during routine pregnancy scan.

Ectopic pregnancy symptoms Timing

• Tend to develop between the 4th and 12th week of pregnancy.

When to scan

• 6-7 weeks gestation is the time that ultrasound care recommends ultrasound and an early dating scan for high risk pregnancies.

Ectopic Pregnancy Signs

• Abdominal tenderness (80%), adnexal mass (53%), adnexa lump, uterine changes (normal size decreases as gestation progresses), and fever (2%).

Ectopic pregnancy management

• Termination of ectopic pregnancy with rupture and abortion

Ectopic Pregnancy Sites

• 95% occur in fallopian tubes

• 70% ampulla
• 12% isthmic
• 11.1% fimbria
• 3.2% ovarian
• 2.4% interstitial
• 1.3% abdominal

Ruptured Ectopic Pregnancy

• Additional symptoms will immediately warrant an immediate visit to the emergency include sudden pain, dizziness or fainting, pain in the lower back, and pain in the shoulders

Hyperemesis Gravidarum

• Prolonged and severe nausea/vomiting that causes dehydration, weight loss, or electrolyte disturbances during pregnancy

Hyperemesis Gravidarum Cause

• Unknown cause that could be hormonal
• Neurologic
• Metabolic
• Toxic
• Psychosocial factors

Hyperemesis Gravidarum Diagnosis

• Diagnosed through Urine and blood tests, Serum, ultrasound, thyroid.

Hyperemesis Gravidarum Treatment

• Uncontrolled emesis
• Correction of any electrolyte abnormalities and hypovolemia
• IV hydration
• Parental nutrition
• Electrolyte supplement

Treatment for The Termination of The Pregnancy

• Tubal: abortion or missed abortion
• Interstitial, angular, cornual: rupture into the uterine cavity, rupture the broad ligament or the peritoneal cavity.
• Cervical: rupture into the peritoneal cavity
• Ovarian: rupture into the peritoneal cavity

Ectopic Pregnancy: Lab Findings

• Positive in 82.5% cases
• Decreased hematocrit and increased white blood cell count.

Gestational Trophoblastic Disease (GTD)

• the abnormal proliferation and then degeneration of the trophoblastic villi.

GTD Effects

• Degenerating cells filled with fluid form fluid-filled, grape-size vesicles and the embryo fails to develop beyond primitive growth
• If GFD is confirmed, cells must be identified because they are associated with choriocarcinoma and rapidly metastasized

GTD Occurrence

• Occurs in 1 for every 1,500 pregnancies and mostly in women with: low protein intake, older than age 35, Asian heritage, or are a blood type A who marry men with blood group O.

Mole Symptoms

• Symptoms includes vaginal bleeding during the first trimester.
• It may only be diagnosed by use of ultrasound scanning that shows an abnormal appearance.
• A uterus that is too large for the stage of pregnancy can be an indication.

Hydatidiform Mole Definition

• Hydatidiform mole is a pregnancy characterized by vesicular swelling of placental villi and usually the absence of an intact fetus from abnormal gametogenesis and fertilization

Partial Mole Definition

• Chromosomes disorders with 69 chromosomes in which there are three chromosomes (triploid) instead of two for every pair (normal), Two sperm cells penetrated the ovum

Meiosis Definition

• Division of a germ cell involving two fissions of the nucleus and giving rise to four gametes, or sex cells, each possessing half the number of chromosomes of the original cell.

Hydatidiform Note

• Vaginal bleeding does not always indicate a problem

Hydatidiform Mole Diagnosis

• Quantitative beta- HCG and ultrasound is the criterion standard for identifying both complete and partial molar pregnancies.

Hydatidiform benign and malignant moles

• Benign molar pregnancies are complete or incomplete , but malignant molar pregnancies and invasive

GTD examination

• Ultrasound assessment
• Culdocentesis
• Dilation and curettage
• Exploratory laparotomy

Tubal damage

• Chronic salpingitis

GTD Prognosis

• After tubal pregnancy, another tubal pregnancy will occur in 10-20% of patients treated
• Infertility develops in approximately 50% of patients

GTD Treatment

• Tubal factors (Salpingitis, previous tubal surgery)
• Infertility or sterility
• Intestinal obstruction may develop after hemoperitoneum and peritonitis

Invasive Mole

• This term applied to a molar pregnancy in which molar villi grow into the myometrium or its blood vessels, and may extend into the broad ligament and metastasize to the lungs, the vagina or the vulva.

THECA-LUTEIN CYSTS

• Are caused by luteinization and hypertrophy of the thecainternal cell layer in response to excessive stimulation from human chorionic gonadotropin (hCG)

Nursing responsibilities

• A thorough assessment during prenatal visit for any signs of bleeding or leaking of fluid

SnowStorm

• The imaging of choice in a suspected hydatidiform mole is a pelvic ultrasound.

Hydatidiform mole management

• There must be coverages of synctiotrophoblast (syncytial layer)
• Suction dilation and curettage
• The follow-up after evacuation is key necessary
• Chemotherapy may be considered for high-risk patients

complete and partial

• Chromosomes are paternal
• The follow-up after evacuation is key necessary
• Patients with hydatidiform mole are curative over 80% by treatment of evacuation.

Incidence

• Patients have a subsequent greater risk of developing invasive mole or choriocarcinoma