NCM 109 - Bleeding During Pregnancy PDF

NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) BLEEDING DURING PREGNANCY CALATI, KELLY KEITH JANN & GADDAO, CRISTIAN RAY MR. ALLAN PAULO BLAQUERA, RN ATTENDANCE: SCHEDULE:...

NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) BLEEDING DURING PREGNANCY CALATI, KELLY KEITH JANN & GADDAO, CRISTIAN RAY MR. ALLAN PAULO BLAQUERA, RN ATTENDANCE: SCHEDULE: BUENAVENTURA, NIÑO KAE C. 09/25-26 (STUDY OWN TOPIC & MAKE OUTLINE) CABAYA, DANIEL VAN DER S. 09/27 (FIRST SGL) CALATI, KELLY KEITH JANN R. CALIGUIRAN, MARIA ERIKA C. 09/28 (FINALIZATION OF HYPOTHESIS) CASTILLO, MICHELLE T. 09/28-30 (PATHOPHYSIOLOGY MAKING) COLLADO, DIANA NICOLE D. 09/30 – 10/02 (NCP MAKING) CORTEZ, ELLYZA L. 10/03 (FINALIZATION OF PATHOPHYSIOLOGY AND NCP) DAYAG, CEE JAR MARIE G. 10/06-7 (PLENARY FOR SCENARIO 2) FABELLAR, AIDON JOSH B. GADDAO, CRISTIAN REY I. Vaginal bleeding during pregnancy is always a deviation from Miscarriage may also occur if the corpus luteum on the the normal, is always potentially serious, may occur at any ovary fails to produce enough progesterone to maintain point during pregnancy, and is always frightening. the decidua basalis. Ingestion of alcohol at the time of conception or during I. SPONTANEOUS MISCARRIAGE early pregnancy can contribute to pregnancy loss because – Occurs in 15% to 30% of all pregnancies and arises from of abnormal fetal growth. natural causes. Urinary tract infections may be a cause but are more strongly as Systemic infections such as rubella, syphilis, ABORTION poliomyelitis, cytomegalovirus, and toxoplasmosis readily – Is a medical term for any interruption of a pregnancy cross the placenta and so may also be responsible. With before a fetus is viable (i.e., able to survive outside the an infection, if the fetus fails to grow, estrogen and uterus if born at that time). progesterone production by the placenta falls and leads to – A viable fetus is usually defined as a fetus of more than endometrial sloughing. With the sloughing, prostaglandins 20 to 24 weeks of gestation or one that weighs at least are released; uterine contractions and cervical dilatation 500 g. along with expulsion of the products of the pregnancy – A fetus born before this point is considered a begin associated with preterm birth. miscarriage or is termed a premature or immature birth. Nx Notes: MISCARRIAGE Early miscarriage is largely not preventable because it is Early miscarriage if it occurs before week 16 of caused by such things as abnormal chromosome formation pregnancy or poor uterine implantation—things over which we have no Late miscarriage if it occurs between weeks 16 and 20. control. Eating a nutritious diet, in order to enter a For the first 6 weeks of pregnancy, the developing pregnancy in good health and avoiding cigarette smoking placenta is tentatively attached to the decidua of the or drinking alcohol are sensible recommendations to uterus; during weeks 6 to 12, it is moderately attached. reduce the risk of miscarriage. If there is extensive blood After week 12, the attachment is penetrating and deep. loss with your miscarriage, be certain to eat iron-rich foods Because of these degrees of attachment achieved at (such as meat and green vegetables) to help restore red different weeks of pregnancy, it is important to attempt to blood cells for a second pregnancy. establish the week of the pregnancy at which bleeding has become apparent. THERAPEUTIC MANAGEMENT Bleeding before week 6 is rarely severe; bleeding after Depending on the symptoms and the description of the E week 12 can be profuse because the placenta is bleeding, a woman’s primary healthcare provider will decide whether she needs to be seen and, if so, whether she should 3 implanted so deeply. be seen in an ambulatory setting or the hospital. Fortunately, at this time, with such deep placental implantation, the fetus tends to be expelled as in natural DIAGNOSIS – childbirth before the placenta separates. Uterine contractions, however, then help to control placental bleeding as they do postpartally. 1. THREATENED MISCARRIAGE 2 For some women, then, the stage of attachment between – A threatened miscarriage is where there is weeks 6 and 12 can lead to the most severe, even life- vaginal bleeding during pregnancy. It does not threatening bleeding. always mean that you will go on to have a miscarriage. COMMON CAUSES – There is an 83% chance of pregnancy The most frequent cause of miscarriage in the first continuing. If the pregnancy continues, the trimester of pregnancy is abnormal fetal development, due bleeding will not cause any harm to the baby, either to a teratogenic factor or to a chromosomal even if the bleeding is heavy. aberration. In other miscarriages, immunologic factors may be present SYMPTOMS: or rejection of the embryo through an immune response Vaginal Bleeding (initially only scant and usually bright may occur. red) Another common cause of early miscarriage involves Slight cramping, but no cervical dilatation is present implantation abnormalities, as up to 50% of zygotes on vaginal examination probably never implant securely because of inadequate Mild period-type pain (not always present). endometrial formation or from an inappropriate site of implantation. With inadequate implantation, the placental circulation does not develop adequate enough to support the pregnancy. TEST NEEDED – It is usually discovered at a prenatal examination Assessment of fetal heart sounds when the fundal height is measured and no Ultrasound performed to evaluate the viability of the increase in size can be demonstrated, or fetus previously heard fetal heart sounds cannot be Blood may be drawn to test for human chorionic heard. gonadotropin (hCG) hormone at the start of bleeding – A sonogram can establish the fetus is dead. and again in 48 hours – Often the embryo actually died 4 to 6 weeks before the onset of miscarriage symptoms and failure of WHAT CAUSES A THREATENED MISCARRIAGE? growth was noted. In many cases there is no known cause for the bleeding but – Disseminated intravascular coagulation (DIC) may likely causes may be: – result if the fetus remains too long in the utero. The placenta is trying to burrow itself into the lining of the womb, causing some blood vessels to bleed. 6. RECURRENT PREGNANCY LOSS Damage to the cervix. Even slight damage can cause – It is when a women had three spontaneous bleeding because during pregnancy the tissues miscarriages that occurred at the same time become softer and have a richer blood supply for a gestational age. They were formerly termed as vaginal infection. "habitual aborters" Small blood clot around the amniotic sac. – A thorough investigation is done to discover the cause of the loss and help ensure the outcome of a future 2. IMMINENT (INEVITABLE) MISCRARIAGE pregnancy. – Although many occur for unknown reasons, possible – A threatened miscarriage becomes an imminent causes include: (i.e., inevitable) miscarriage if uterine contractions o Defective spermatozoa or ova and cervical dilation occur as, with cervical o Endocrine factors such as lowered levels of dilation, the loss of the products of conception protein- bound iodine (PBI), butanol-extractable cannot be halted. iodine (BEl), and globuline-bound iodine (GBI), – This usually happens before 20 weeks, typically poor thyroid function, or luteal phase defect in the 1st trimester. o Deviations of the uterus, such as septate or bicornuate uterus SIGNS AND SYMPTOMS o Infection Heavy spotting - a light or trace amount of pink, red, or o Autoimmune disorders such as those involving dark brown (rust-colored) blood. lupus anticoagulant and antiphospholipid Vaginal bleeding antibodies Discharge of tissue or fluid from your vagina Severe abdominal pain or cramping COMPLICATION OF MISCARRIAGE Mild to severe back pain 1. HEMORRHAGE TEST NEEDED – With a complete spontaneous miscarriage, serious Pelvic exam or fatal hemorrhage is rare. With an incomplete Ultrasound miscarriage or in a woman who develops an Blood Tests accompanying coagulation defect, major Tissue Tests hemorrhage is a possibility. Chromosomal Tests – Vaginal bleeding can occur frequently in the first trimester of pregnancy and may not be a sign of 3. COMPLETE MISCARRIAGE problems. But bleeding that occurs in the second E – The entire products of conception (fetus, and third trimester of pregnancy can often be a sign of a possible complication. Bleeding can be caused 3 membranes, and placenta) are expelled by a number of reasons. spontaneously without any assistance. The bleeding usually slows within 2 hours and then 2. INFECTION – ceases within a few days after passage of the products of conception. – It tends to occur in women who have lost appreciable amounts of blood, most likely from the 2 4. INCOMPLETE MISCARRIAGE debilitating effect of blood loss. – Part of the conceptus (usually the fetus) is – UTI or urinary tract infection (UTI) is a bacterial expelled, but the membrane or placenta is retained inflammation in the urinary tract which is more in the uterus. common during pregnancy because of changes in – There is a danger of maternal hemorrhage as long the urinary tract. The uterus sits directly on top of as part of the conceptus is retained in the uterus the bladder. As the uterus grows, its increased because the uterus cannot contract effectively in weight can block the drainage of urine from the bladder, causing an infection. this condition. – Dilatation & Curettage (D&C) or suction curettage is usually performed to evacuate the remainder of WHAT IS GOING ON IN THE BODY? the pregnancy from the uterus. The bladder and the urine it holds are normally free from – Inform the patient that pregnancy was already lost bacteria and other organisms. A urinary tract infection and that all procedures are to clean the uterus and occurs when organisms are introduced into the bladder. prevent further complications. Bacteria from the skin may enter through the urethra. The urethra is the tube that carries urine from the bladder 5. MISSED MISCARRIAGE to the outside of the body. Organisms can also enter the bladder on urinary catheters. – Also known as "early pregnancy failure" – wherein the fetus dies inside the utero but is not SIGNS AND SYMPTOMS expelled.  Pain or burning (discomfort) when urinating 4. POWERLESSNESS OR ANXIETY The need to urinate more often than usual – A medical condition that leads to intense feelings of A feeling of urgency when you urinate sadness or despair. These feelings don't go away Blood or mucus in the urine on their own. They are not necessarily related to a Cramps or pain in the lower abdomen particular life event. Pain during sexual intercourse – Spontaneous miscarriage can be particularly Chills, fever, sweats, leaking of urine (incontinence) heartbreaking for an older woman because she Waking up from sleep to urinate realizes her window of childbearing is limited. Change in amount of urine, either more or less Urine that looks cloudy, smells foul or unusually strong Pain, pressure, or tenderness in the area of the bladder When a bacterium spreads to the kidneys you may experience: back pain, chills, fever, nausea, and vomiting A urinalysis and a urine culture can detect a UTI throughout pregnancy. 2.A SEPTIC ABORTION – A septic abortion is a spontaneous or therapeutic/artificial abortion complicated by a pelvic infection. But more frequently it occurs in women who have tried to self-abort or were aborted illegally using a nonsterile instrument such as a knitting needle. A SEPTIC ABORTION MAY BE CAUSED BY ANY OF THE FOLLOWING FACTORS: The membranes surrounding the fetus have ruptured, sometimes without being detected the woman has a sexually transmitted disease an intrauterine device (IUD) was left in place during the pregnancy Tissue from the fetus or placenta is left inside the uterus after a miscarriage or abortion Attempts were made to end the pregnancy, often illegally, by inserting tools, chemicals, or soaps into the uterus. SIGN AND SYMPTOMS Fever Crampy abdomen Uterus feels tender to palpation 3. ISOIMMUNIZATION (RH INCOMPATIBILITY) E – Blood types are determined by the types of 3 antigens on the blood cells. Antigens are proteins on the surface of blood cells that can cause a response from the immune system. The Rh factor – is a type of protein on the surface of red blood cells. Most people who have the Rh factor are Rh- positive. Those who do not have the Rh factor are 2 Rh-negative. WHAT MAY HAPPEN IF THE PREGNANT WOMAN IS RH- NEGATIVE? – If you are Rh-negative you may develop antibodies to an Rh-positive baby. If a small amount of the baby's blood mixes with your blood, which often happens, your body may respond as if it were allergic to the baby. Your body may make antibodies to the Rh antigens in the baby's blood. This means you have become sensitized and your antibodies can cross the placenta and attack your baby’s blood. They break down the fetus's red blood cells and produce anemia. This condition is called hemolytic disease or hemolytic anemia. It can become severe enough to cause serious illness, brain damage, or even death in the fetus or newborn.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) ECTOPIC PREGNANCY CALATI, KELLY KEITH JANN & GADDAO, CRISTIAN RAY MR. ALLAN PAULO BLAQUERA, RN ECTOPIC PREGNANCY POINTS TO REMEMBER: – An ectopic pregnancy is one in which implantation Ectopic pregnancies are diagnosed because a woman occurred outside the uterine cavity. has an early pregnancy ultrasound to date the – The most common site (in approximately 95% of pregnancy such pregnancies) is in the fallopian tube. If not revealed by an ultrasound, at weeks 6 to 12 of – Of these fallopian tube sites, approximately 80% pregnancy (2 to 8 weeks after a missed menstrual occur in the ampullary portion, 12% occur in the period), the zygote grows large enough that it ruptures isthmus, and 8% are interstitial or fimbrial. the slender fallopian tube. o Tearing and destruction of blood vessels and bleeding result. If implantation was in the interstitial portion of the tube (where the tube joins the uterus), rupture can cause severe intraperitoneal bleeding because of the large blood vessels in that part of the tube. Fortunately, the incidence of tubal pregnancies is highest in the ampullary area (the distal third), where the blood vessels are smaller and profuse hemorrhage is less likely. o Constant, continued bleeding from this area, however, may result in a large amount of blood loss over time. o Therefore, a ruptured ectopic pregnancy is serious regardless of the site of implantation. A woman usually experiences: sharp, stabbing pain in one of her lower abdominal quadrants at the time of rupture scant vaginal spotting amount of bleeding evident with a ruptured ectopic pregnancy usually does not reveal the actual amount With most ectopic pregnancies, fertilization occurs as present, however, because the products of conception usual in the fallopian tube. from the ruptured tube and the accompanying blood Unfortunately, because an obstruction is present, may be expelled into the pelvic cavity rather than into such as an adhesion of the fallopian tube from a the uterus previous infection (chronic salpingitis or pelvic inflammatory disease), congenital malformations, At the point the placenta dislodges, progesterone scars from tubal surgery, or a uterine tumor pressing secretion will stop and the uterine decidua will begin to on the proximal end of the tube, the zygote cannot slough, causing additional vaginal bleeding. As soon as travel the length of the tube. It lodges at a structured the woman becomes hypotensive from blood loss, she site along the tube and implants there instead of in will experience light-headedness and a rapid pulse, the uterus. signs of hypovolemic shock. E Approximately 2% of pregnancies are ectopic, and because at least minimal bleeding occurs, it is the Any woman with sharp abdominal pain and vaginal 3 second most frequent cause of bleeding early in spotting needs to be evaluated by her healthcare pregnancy. The incidence of ectopic pregnancy provider to rule out the possibility of ectopic pregnancy. appears to be increasing, possibly because of the – increasing rate of pelvic inflammatory disease, which can lead to tubal scarring. WHAT TO CHECK WHEN A WOMAN WITH SYMPTOMS OF ECTOPIC PREGNANCY ARRIVES AT THE HOSPITAL: 2 Women who have one ectopic pregnancy have a higher she may already be in severe shock, as evidenced by a chance of having a subsequent ectopic pregnancy. This is rapid, thready pulse because salpingitis generally leaves scarring, which is rapid respirations bilateral. Congenital anomalies such as webbing (fibrous falling blood pressure bands) that block a fallopian tube may also occur in both Leukocytosis may be present, not from infection but tubes. For unknown reasons, oral contraceptives used from the trauma. before pregnancy reduce the incidence of ectopic Temperature is usually normal. pregnancy A transvaginal ultrasound will demonstrate the ruptured tube and blood collecting in the peritoneum. ASSESSMENT falling hCG or serum progesterone level suggests No menstrual flow occurs since the corpus luteum of the pregnancy has ended. the ovary continue to function as if the implantation A laparoscopy or culdoscopy can also be used to were in the uterus visualize the fallopian tube if the symptoms alone do A woman may begin to experience the usual nausea not reveal a clear picture of what 1182 has happened. and vomiting of early pregnancy and a pregnancy test for hCG will be positive.  If a woman waits for a time before seeking help, her SIDE NOTE: abdomen gradually becomes rigid from peritoneal irritation. Her umbilicus may develop a bluish-tinged WHAT DOES IT MEAN IF YOU HAVE RH-POSITIVE hue (Cullen sign) BLOOD? She may have continuing extensive or dull vaginal and – Having an Rh negative blood type is not an illness, and abdominal pain it usually does not affect your health. But it can affect movement of the cervix on pelvic examination can pregnancy. During pregnancy, problems can happen if cause excruciating pain you're Rh negative and your baby is Rh positive. She may feel pain in her shoulders as well from blood Usually, your blood doesn't mix with your baby's blood in the peritoneal cavity causing irritation to the phrenic during pregnancy. nerve. – If you're Rh negative and your baby is Rh positive, your A tender mass is usually palpable in Douglas cul-de- body might produce proteins called Rh antibodies if sac on vaginal examination. your blood and the baby's blood mix. Those antibodies aren't a problem during the first pregnancy. But If the diagnosis of ectopic pregnancy is in doubt, a primary problems can happen if you become pregnant again. healthcare provider may insert a needle through the posterior vaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. THERAPEUTIC MANAGEMENT When an ectopic pregnancy is revealed by an early ultrasound, the woman is shown the sonogram, and after her agreement that therapy could be lifesaving, she is usually medically treated by the intramuscular or less often, oral, administration of methotrexate. o Methotrexate - This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4– 6 weeks. This does not require the removal of the fallopian tube. Women are treated until a negative hCG titer is achieved. o A hysterosalpingogram or ultrasound is usually performed after this to assess that the pregnancy is no longer present and also whether the tube appears fully patent. If an ectopic pregnancy is not discovered early, but rather, only when it ruptures, it creates an emergency situation The amount of blood evident with a ruptured ectopic pregnancy is a poor estimate of the actual blood loss. o A blood sample needs to be drawn immediately for hemoglobin level, typing and cross-matching, and possibly the hCG level for immediate E pregnancy testing, if pregnancy has not yet been confirmed. 3 Intravenous fluid using a large-gauge catheter to restore intravascular volume will be prescribed. The therapy for ruptured ectopic pregnancy is – laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. 2 A rough suture line on a fallopian tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube will be done with microsurgical technique. As with miscarriage, women with Rh-negative blood should receive RhIG/RhoGAM after an ectopic pregnancy for isoimmunization protection in future childbearing. o RhIG / RhoGAM - RhoGAM is one brand of Rh immunoglobulin (RhIg). o RhIG is an injectable drug given to women with Rh-negative blood during pregnancy. The main purpose of RhIG is to prevent problems in case a baby has Rh-positive blood.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) GESTATIONAL TROPHOBLASTIC DISEASES (H-MOLE) CALATI, KELLY KEITH JANN & GADDAO, CRISTIAN RAY MR. ALLAN PAULO BLAQUERA, RN GESTATIONAL TROPHOBLASTIC DISEASE – is abnormal proliferation and then degeneration of the by two sperm or an ovum fertilized by one sperm in trophoblastic villi. As the cells degenerate, they which meiosis or reduction division did not occur). become filled with fluid and appear as clear fluid-filled, – This could also occur if one set of 23 chromosomes grape-sized vesicles. The embryo fails to develop was supplied by one sperm and an ovum that did beyond a primitive start. Abnormal trophoblast cells not undergo reduction division supplied 46. must be identified because they are associated with – partial moles rarely lead to choriocarcinoma. choriocarcinoma, a rapidly metastasizing malignancy. ASSESSMENT Because proliferation of the abnormal trophoblast cells grow so rapidly, the uterus tends to expand faster than usual or the uterus reaches its landmarks (just over the symphysis brim at 12 weeks, at the umbilicus at 20 to 24 weeks) before the usual time. This rapid development is also diagnostic of multiple pregnancy or a miscalculated due date, however, so this finding must be evaluated carefully. Because hCG is produced by the trophoblast cells that are overgrowing, a serum or urine test of hCG for pregnancy will be strongly positive (1 to 2 million International Units compared with a normal pregnancy level of 400,000 International Units). The nausea and vomiting of early pregnancy is usually marked, probably because of the high hCG level present. HYDRATIDIFORM MOLE (H-MOLE) Symptoms of gestational hypertension, such as – A rare complication of pregnancy characterized by the increased blood pressure, edema, and proteinuria, are abnormal growth of trophoblasts, the cells that ordinarily not present before week 20 of pregnancy. normally develop into the placenta With gestational trophoblastic disease, they may appear before this time. An ultrasound will show dense Trophoblastic villi - Villous trophoblasts have two cell growth (typically a snowflake pattern) but no fetal populations: undifferentiated cytotrophoblasts and fully growth in the uterus. No fetal heart sounds can be differentiated syncytiotrophoblasts. The heard because there is no viable fetus. syncytiotrophoblasts are a continuous, specialized layer of At approximately week 16 of pregnancy, if the structure epithelial cells. They cover the entire surface of villous was not identified earlier by ultrasound, it will identify trees and are in direct contact with maternal blood. itself with vaginal bleeding. o may begin as spotting of dark-brown blood – The condition tends to occur most often in: resembling prune juice or as a profuse fresh women who have a low-protein intake flow. women older than 35 years of age o As the bleeding progresses, it is accompanied women of Asian heritage, and by discharge of the clear fluid-filled vesicles. blood group A women who marry blood group o The presence of clear fluid-filled cysts changes E O men the diagnosis from a simple miscarriage to 3 gestational trophoblastic disease. TWO TYPES OF MOLAR GROWTH Can be identified by chromosome analysis THERAPEUTIC MANAGEMENT – – Therapy for gestational trophoblastic disease is suction A. COMPLETE MOLAR PREGNANCY curettage to evacuate the abnormal trophoblast cells. – all trophoblastic villi swell and become cystic. – Following extraction, women should have a baseline 2 – No formation of fetal tissue pelvic examination and a serum test for the beta – If an embryo forms, it dies early at only 1 to 2 mm in subunit of hCG. The hCG is then analyzed every 2 size, with no fetal blood present in the villi. weeks until levels are again normal. – although the karyotype is a normal 46XX or 46XY, – The serum hCG level is then assessed every 4 weeks this chromosome component was contributed only for the next 6 to 12 months to see if it is declining (half by the father or an “empty ovum” was fertilized and of women will still have a positive reading at 3 weeks; the chromosome material was duplicated one fourth still have a positive test result at 40 days). – If the level plateaus or increases, it suggests a B. PARTIAL MOLAR PREGNANCY malignant transformation (i.e., choriocarcinoma) is occurring. – Some of the villi form normally – During the waiting time for the hCG level to decline, a – a fetus develops but it will be abnormal and cannot woman should use a reliable contraceptive such as survive. At most, the fetus might survive for around oral estrogen/progesterone so that a positive three months. pregnancy test (the presence of hCG) resulting from a – syncytiotrophoblastic layer of villi (swollen and new pregnancy will not be confused with the increasing misshapen) level that occurs with a developing malignancy. – mole has 69 chromosomes (69XX or 69XY) (a – After 6 months, if hCG levels are still negative, a triploid formation in which there are three woman is theoretically free of the risk of malignancy. chromosomes instead of two for every pair: one set supplied by an ovum that apparently was fertilized – Some primary healthcare providers give women who have had gestational trophoblastic disease a prophylactic course of methotrexate. However, because the drug interferes with white blood cell formation (i.e., leukopenia), prophylactic use must be weighed carefully – If malignancy should occur, it can be treated effectively in most instances with methotrexate at that. A second agent such as dactinomycin can be added to the regimen if metastasis occurs. – Dactinomycin - type of antibiotic that is only used in cancer chemotherapy. It works by slowing or stopping the growth of cancer cells in your body. 2 – 3 E  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) PLACENTA PREVIA CASTILLO, MICHELLE T. & CABAYA, DANIEL VAN DER S. MR. ALLAN PAULO BLAQUERA, RN PLACENTA PREVIA THERAPEUTIC MANAGEMENT – a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus, IMMEDIATE CARE MEASURES is the most common cause of painless bleeding in the To ensure an adequate blood supply to a woman and third trimester of pregnancy fetus, place the woman immediately on bed rest in a – is a problem during pregnancy when the placenta side-lying position. completely or partially covers the opening of the Assess for: uterus (cervix). o Duration of the pregnancy o Time the bleeding began IT OCCURS IN FOUR DEGREES: o Woman’s estimation of the amount of blood— o Implantation in the lower rather than in the upper ask her to estimate in terms of cups or portion of the uterus (low-lying placenta), tablespoons (a cup is 240 ml; a tablespoon is 15 o Marginal implantation (the placenta edge approaches ml) that of the cervical os), o Whether there was accompanying pain o Implantation that occludes a portion of the cervical os o Color of the blood (red blood indicates bleeding (partial placenta previa), is fresh or is continuing) o Implantation that totally obstructs the cervical os (total o What she has done, if anything, for the bleeding placenta previa). (if she inserted a tampon to halt the bleeding, there may be hidden bleeding) The degree to which the placenta covers the internal cervical o Whether there were prior episodes of bleeding os is generally estimated in percentages: 100%, 75%, 30%, during the pregnancy and so forth. o Whether she had prior cervical surgery for premature cervical dilatation Normal placement of placenta is in the superior portion of the Inspect the perineum for bleeding and estimate the uterus present rate of blood loss. o Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss. Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff. Monitor urine output frequently, as often as every hour, as an indicator her blood volume is remaining adequate to perfuse her kidneys. ASSOCIATED WITH PLACENTIA PREVIA A vaginal birth is always safest for an infant. It is essential, Increased parity therefore, to determine the placenta’s location as advanced maternal age accurately as possible in the hope that its position will past cesarean births make vaginal birth feasible. o If the previa is under 30% by abdominal or past uterine curettage intravaginal ultrasound, it may be possible for the E multiple gestation fetus to be born past it. perhaps a male fetus 3 o If over 30%, and the fetus is mature, the safest birth method for both mother and baby is often a – There is a possibility an increase in congenital fetal cesarean birth anomalies or fetal restricted growth could occur if the – low implantation does not allow optimal fetal nutrition or oxygenation, but in actual practice, this rarely CONTINUING CARE MEASURES If labor has begun, bleeding is continuing, or the fetus is 2 happens being compromised (measured by the response of the ASSESSMENT FHR to contractions), birth must be accomplished Placenta previa is often detected during pregnancy regardless of gestational age. through a routine sonogram done to date the A woman remains in the hospital on bed rest for close pregnancy. observation for 24 to 48 hours. If the bleeding stops, Low-lying placentas detected on early ultrasounds she can be sent home with a referral for bed rest and migrate upward to a noncervical position home care. Assessments of fetal heart sounds and o Bleeding with placenta previa doesn’t usually laboratory tests, such as hemoglobin or hematocrit, are begin, however, until the lower uterine segment obtained frequently. starts to differentiate from the upper segment late in pregnancy (approximately week 30) and Betamethasone, a steroid that hastens fetal lung maturity, the cervix begins to dilate. may be prescribed for the mother to encourage the maturity o The bleeding is usually abrupt, painless, bright of fetal lungs if the fetus is less than 34 weeks gestation red, and sudden enough to frighten a woman. o Placenta is unable to stretch to accommodate the differing shape of the lower uterine segment or the cervix, a small portion loosens and damaged blood vessels begin to bleed.  BIRTH If the pregnancy was past 37 weeks at the time of the initial bleeding, and an amniocentesis analysis for lung maturity shows a positive result (a favorable, lecithin/sphingomyelin ratio) If the fetus is not mature, the pregnancy will be allowed to continue to the point bleeding occurs again, labor begins, the fetus shows symptoms of distress, or the fetus is mature. Offer firm support if the birth will be an emergency situation. If the placenta previa is found to be total, birth through the cervix which is covered by the placenta is impossible and the baby must be born by cesarean birth. If the placenta previa is partial, the amount of the blood loss, the condition of the fetus, and a woman’s parity will influence the birth decision. Any woman who has had a placenta previa is more prone than normal to postpartum hemorrhage because the placental site is in the lower uterine segment, which does not contract as efficiently as the upper segment. 2 – 3 E  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTAE) CASTILLO, MICHELLE T. & CABAYA, DANIEL VAN DER S. MR. ALLAN PAULO BLAQUERA, RN ABRUPTIO PLACENTAE RISK FACTORS – defined as the premature separation of the placenta Factors that can increase the risk of placental abruption from the uterus. Patients with abruptio placentae, also include: called placental abruption, typically present with Placental abruption in a previous pregnancy that bleeding, uterine contractions, and fetal distress. wasn't caused by abdominal trauma – It occurs when the placenta partly or completely Chronic high blood pressure (hypertension) separates from the inner wall of the uterus before Hypertension-related problems during pregnancy, delivery. This can decrease or block the baby's supply including preeclampsia, HELLP syndrome or of oxygen and nutrients and cause heavy bleeding in eclampsia the mother. A fall or other type of blow to the abdomen – It can lead to extensive bleeding and the most frequent Smoking cause of perinatal death. Cocaine uses during pregnancy Early rupture of membranes, which causes leaking CERTAIN PREDISPOSING FACTORS: amniotic fluid before the end of pregnancy High parity Infection inside of the uterus during pregnancy Advanced maternal age (chorioamnionitis) Short umbilical cord Being older, especially older than 40 Chronic hypertensive disease Hypertension of pregnancy THERAPEUTIC MANAGEMENT Direct trauma (as from an automobile accident or Since the situation is a threat to both the woman and the intimate partner violence) fetus, separation of the placenta is immediately an Vasoconstriction from cocaine or cigarette use emergency situation. Thrombophilic conditions that lead to thrombosis A woman needs a large-gauge intravenous catheter formation inserted for fluid replacement and oxygen by mask to limit fetal anoxia. May also be caused by chorioamnionitis or infection of the Monitor fetal heart sounds externally and record fetal membranes and fluid maternal vital signs every 5 to 15 minutes to establish baselines and observe progress Another possible cause is a rapid decrease in uterine Do not perform any abdominal, vaginal, or pelvic volume, such as occurs with sudden release of amniotic examination on a woman diagnosed or suspected fluid as can happen with polyhydramnios. Usually, the placental separation. fetal head is low enough in the pelvis that when The degrees of placental separation can be graded membranes rupture, this prevents loss of the total for better prediction of fetal and maternal outcomes volume of the amniotic fluid at one time, so normally a With the worst outcome, a hysterectomy might be rapid reduction in amniotic fluid does not occur. necessary to prevent exsanguination. PREMATURE SEPARATION OF THE PLACENTA: DEGRESS OF SEPARATION GRADE CRITERIA 0 No symptoms of separation are apparent from maternal or fetal signs; the diagnosis E is made after birth, when the placenta is examined and a segment of the placenta 3 shows a recent adherent clot on the maternal surface. 1 Minimal separation, but enough to cause – vaginal bleeding and changes in the maternal vital signs; no fetal distress or 2 hemorrhagic shock occurs, however. ASSESSMENT 2 Moderate separation; there is evidence of A woman experiences: fetal distress; the uterus is tense and Sharp, stabbing pain high in the uterine fundus as the painful on palpation. initial separation occurs 3 Extreme separation; without immediate If labor begins with the separation, each contraction interventions, maternal hypovolemic will be accompanied by pain over and above the pain shock and fetal death will result. of the contraction Tenderness can be felt on uterine palpation Fetal prognosis depends on the extent of the placenta Heavy bleeding separation and the degree of fetal hypoxia o External bleeding will only be evident if the Maternal prognosis depends on how promptly treatment placenta separates first at the edges, so blood can be instituted escapes freely into the uterus and then the Death can occur from massive hemorrhage leading to cervix shock and circulatory collapse or renal failure from o If the center of the placenta separates first, circulatory collapse blood can pool under the placenta, and although bleeding is just as intense, it will be hidden from view  Any woman who has had bleeding before birth is more prone to infection after birth than the average woman. A woman with a history of premature separation of the placenta, therefore, needs to be observed closely for the development of infection in the postpartum period. 2 – 3 E  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) DISSEMINATED INTRAVASCULAR COAGULATION (DIC) CASTILLO, MICHELLE T. & CABAYA, DANIEL VAN DER S. MR. ALLAN PAULO BLAQUERA, RN DISSEMINATED INTRAVASCULAR COAGULATION FROM LECTURIO: – Is an acquired disorder of blood clotting in which the fibrinogen level falls to below effective limits ETIOLOGY – Early symptom: Easy bruising or bleeding from an Sepsis – especially E. coli and Neisseria Meningitidis intravenous site Malignancy – could be any cancer, but especially – Conditions such as premature separation of the common in acute promyelocytic leukemia placenta, hypertension of pregnancy, amniotic fluid Obstetrical complications (e.g., eclampsia) embolism, placental retention, septic abortion, and Trauma – especially crush injuries and burns retention of a dead fetus are all associated with its Snake bites development. Cancer o Pancreatic à Trousseau phenomenon Normally, platelets quickly form a seal over a point of bleeding to prevent further loss of blood. Intrinsic PATHOGENESIS and extrinsic clotting pathways then activate and strengthen this plug with fibrin threads to produce a Widespread activation of the coagulation system firm, fixed structure. Leads to extensive thrombus formation in the To prevent too much clotting from occurring, at the microvascular same time the clot is being formed, thrombin o Obstruction of flow – tissue hypoxia and damage activates fibrinolysin, a proteolytic enzyme, which o Consumption of clotting factors and platelets – begins digestion of excess fibrin threads increased risk of bleeding (anticoagulation). This lysis results in the release of o Activation of the fibrinolytic system – production fibrin degradation products. of D-dimers CLINICAL PATHOLOGY – DIC occurs when there is such extreme bleeding and so many platelets and fibrin from the general circulation Elevated PT, PTT, INR rush to the site that there is not enough left in the rest of Thrombocytopenia the body Microangiopathic hemolytic anemia (schistocytes) – This is an emergency because it can result in extreme Elevated D-dimers blood loss Causes bleeding – petechiae, purpura, mucosal – Blood needs to be drawn for a: bleeding, etc. o Platelet count (will be decreased to = 126 mg/dl (fasting plasma glucose) and >= 200 Test Type Pregnant Glucose Level mg/dl (nonfasting plasma glucose) meets the threshold (mg/dl) for the diagnosis of diabetes and does not need Fasting 95 confirmation. 1 hr 180 It is recommended that all pregnant women receive a 2 hr 155 50-g glucose challenge test between 24 and 28 3 hr 140 weeks’ gestation to determine if they are at risk for gestational diabetes. If the result for that test is 140 mg/dl (some providers use 130 mg/dl as the cutoff) then the woman will need to do a three hour glucose tolerance test A urine culture may be done each trimester to detect MONITORING A WOMAN WITH DIABETES asymptomatic UTIs as the increased glucose Measurement of glycosylated hemoglobin (HbA1c) concentration in urine may lead to increased infection. – a measure of the amount of glucose attached to An ophthalmic examination should be done once during hemoglobin the pregnancy for a woman with gestational diabetes – used to detect the degree of hyperglycemia is and at each trimester for women with known diabetes present because common background retinal changes that are – measuring HbA1c is advantageous not just common in diabetes, such as increased exudate dot because it offers a present value of glucose, but hemorrhage, and macular edema, can progress or because it reflects the average blood glucose over originate during pregnancy. the past 4 to 6 weeks – the upper normal level of HbA1c is 6% of total hemoglobin THERAPEUTIC MANAGEMENT Description Methods Precautions Insulin Needed by pregestational and Short-acting insulin may be used Early in pregnancy, insulin needs may Therapy gestational diabetics who are alone or with an intermediate type. be less. Later in pregnancy, increased uncontrolled with diet or oral Two thirds of daily insulin needs are insulin may be needed. Women should therapy. Necessary for the given before breakfast and one third eat immediately after injecting insulin to cells to take glucose from the before dinner. Insulin should be avoid hypoglycemia. Different body bloodstream given subcutaneously and at a 90- areas take up insulin at different rates. E degree angle to the skin. The Rotate within the same type of injection 3 injection site should generally be the site. same each injection (arms OR legs OR abdomen). – Blood Completed four times a day by The patient should obtain fasting If the patient is hypoglycemic, she glucose the patient. The patient pricks and 1-hour postprandial values. Her should have some carbohydrate rich monitoring her finger and uses a goals include fasting number that food, like crackers, and a protein, like 2 glucometer to determine her are 90 and below and postprandial milk. Simple sugars can create blood glucose. She should values that are less than 140 hyperglycemia and rebound track these numbers with a hypoglycemia chart and bring it to her OB visits. Her provider will determine if any adjustments in her insulin or oral diabetic regimen are needed Insulin An insulin pump is an A continuous rate (basal) of insulin The patient should clean the site daily Pump automatic pump with thin is given to the patient through the and cover it with a dressing to keep it Therapy tubing, which is placed pump, and the patient can program clean. The site also needs to be subcutaneously, most often on the pump to give extra doses as changed every 24-48 hours to ensure the woman’s abdomen. Insulin boluses prior to meals or optimal absorption and decrease is given through this tube and correlational doses related to her infection. injection of insulin is therefore blood glucose values after meals. eliminated TEST FOR PLACENTAL FUNCTION AND FETAL WELL- BEING A woman will have a serum alpha-fetoprotein level obtained at 15 to 17 weeks to assess for a neural tube defect An ultrasound examination performed at approximately 18 to 20 weeks to detect gross abnormalities A creatinine clearance test may be ordered each trimester o A normal creatinine clearance rate suggests a woman’s vascular system is intact because kidney function is normal o By default, this also implies uterine perfusion is also adequate Placentals functioning may also be assessed by a weekly nonstress test or biophysical profile during the last trimester of pregnancy if a woman is in good control, or a daily nonstress test if her regulation is poor In addition, a woman may be asked to self-monitor fetal well-being by recording how many movements occur an hour (usually about 10 fetal kicks) An ultrasound examination may be taken at week 28 and then again at weeks 36 to 38 to determine fetal growth, amniotic fluid volume, placental location, and biparietal diameter. o Oligohydramnios (i.e., a small amount of amniotic fluid) may indicate fetal growth restriction or a fetal renal abnormality o Polyhydramnios (i.e., an excessive amount of amniotic fluid) may indicate gastrointestinal malformation or poorly controlled disease. A lecithin/sphingomyelin ratio by amniocentesis is usually performed by week 36 of pregnancy to assess fetal maturity. o In pregnancies complicated by diabetes, this ratio tends not to show maturity as early as in other pregnancies because the synthesis of phosphatidylglycerol, the compound that stabilizes surfactant, is delayed is hyperglycemia is present. o Because lung surfactant does not appear to form as early in these fetuses as in others, the presence of phosphatidylglycerol, an ingredient of surfactant, at amniocentesis is used to indicate lung maturity for these infants. 3 E TIMING FOR BIRTH Among the most hazardous times for a fetus during a diabetes-involved pregnancy are weeks 36 to 40 of – pregnancy, when the fetus is drawing large stores of maternal nutrients because of his or her large size Cesarean birth was chosen because it is difficult to 2 induce labor this early in pregnancy because the cervix is not yet ripe or responsive to labor contractions o babies of women with diabetes are large, making vaginal birth difficult; o and a fetus suffering placental dysfunction or insufficiency did not do well in labor.  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) IRON-DEFICIENCY ANEMIA FABELLAR, AIDON JOSH MR. ALLAN PAULO BLAQUERA, RN IRON DEFICIENCY ANEMIA 80% of total body iron is in the hemoglobin of RBCs Many women enter pregnancy with a deficiency of iron IRON METABOLISM stores resulting from a combination of a diet low in iron, heavy menstrual periods, or unwise weight-reducing programs Iron-deficiency anemia is confirmed by a corresponding low serum iron level (under 30 μg/dL) and an increased iron-binding capacity (over 400 μg/dL) Iron is made available to the body by absorption from the duodenum into the bloodstream after it has been ingested. In the bloodstream, it is bound to transferrin for transport to the liver, spleen, and bone marrow. At these sites, it is incorporated into hemoglobin or stored as ferritin. The type of anemia is characteristically: o Microcytic anemia (small red blood cell) o Hypochromic anemia (less hemoglobin than the average red cell) o They occur when such an inadequate supply of iron is ingested that iron is not available for incorporation into red blood cells. This condition is mildly associated with low birth weight and preterm birth. When the body recognizes that it needs nutrients, some women with this condition develop pica, or the craving and eating of substances such as ice or starch A woman may experience extreme fatigue and poor exercise tolerance because she cannot transport oxygen effectively. TREATMENT Take prenatal vitamins containing 27mg of iron (prophylactic therapy) Eat diet high in iron and vitamins (i.e., green leafy vegetable, meat, and legumes) Prescribed therapeutic levels of medication (120 to 200 mg elemental iron per day) usually in the form of ferrous sulfate and ferrous gluconate Take iron supplements with orange juice or a Vitamin C supplement (Iron is best absorbed best in an acid medium) E Increase roughage in the diet 3 Take the supplements with food to help reduce constipation or gastric irritation – When women begin to take a prescribed iron supplement, new red blood cells should begin to increase almost immediately, or their reticulocyte count should rise from a 2 range of between 0.5% and 1.5% to 3% and 4% by 2 weeks. If iron-deficiency anemia is sever and a woman has difficulty with iron oral therapy, intravenous iron can be prescribed. FROM LECTURIO IRON DEFICIENCY ANEMIA Iron is very important in maintaining many body functions o Production of hemoglobin (molecules in the blood that carries oxygen Iron is also necessary to maintain healthy cells, skin, hair, and nails IRON 20% of iron is stored as ferritin in the bone marrow, the liver, the spleen, and muscles  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) FOLIC ACID DEFICIENCY (MEGALOBLASTIC ANEMIA) DAYAG, CEE JAY MARIE MR. ALLAN PAULO BLAQUERA, RN FOLIC ACID DEFICIENCY to death several years after onset of symptoms (Leung, – Folate-deficiency anemia is the lack of folic acid in 2019). the blood. Folic acid is a B vitamin that helps your body make red blood cells. If you don't have enough red blood cells, you have anemia. Red blood cells carry B. ASSESSMENT AND DIAGNOSTIC FINDINGS oxygen to all parts of your body. – A folate test measures the amount of folate in the – Anemias associated with vitamin B12 or folic acid blood. deficiency cause the same bone marrow and – Serum levels of folic acid are analyzed peripheral blood changes because both are needed for – Small amounts of folate can increase the serum normal DNA synthesis. folate level; therefore, measurement of the amount – Folic acid is stored in the body as compounds known as of folate within the red blood cells is a more folates. Folate stores are smaller than those of sensitive test to determine true folate deficiency vitamin B12 and can be depleted within months if although it is not commonly performed. dietary intake of folate is deficient (Green, 2016). – They might also order blood tests and a complete – Folate is found in green vegetables and liver. blood count (CBC) test to measure the number and – Folate deficiency is rarely seen in patients who appearance of your red blood cells. If you have a consume uncooked vegetables. lack of folate, your red blood cells look large and – Alcohol ingestion increases folic acid requirements immature. and it is not uncommon for those with alcohol abuse – You may also have a barium study if a digestive disorder to have a diet deficient in folate and other problem is the cause. nutrients. – B12 and folate levels may be ordered when a complete – Folic acid requirements are also higher in those with blood count (CBC) and/or blood smear, done as part liver disease, chronic hemolytic anemias, and in of a health checkup or an evaluation for anemia, shows women who are pregnant because erythrocyte a low red blood cell (RBC) count, decreased production is increased with these conditions. hemoglobin and hematocrit, and the presence of – Small bowel diseases such as celiac disease may large RBCs. interfere with normal absorption of folic acid (Green, 2016). C. MEDICAL MANAGEMENT – A deficiency of folic acid combined with vitamin C – Folate deficiency is easily treated in most cases by deficiency produces an anemia in which the increasing the amount of folic acid in the diet and erythrocytes grow abnormally large. There is often taking 1 mg of folic acid daily as a supplement. accompanying neutropenia and thrombocytopenia. – Folic acid can be given intramuscularly to those people with conditions associated with Folic acid deficiency in pregnancy can lead to midline closure malabsorption defects such as neural tube disorders. Nurses can help the – Folate deficiency anemia is prevented and treated nation achieve these goals by urging women to plan their by eating a healthy diet. pregnancies so they can enter the pregnancy in good health o This includes foods rich in folic acid, such as and with an optimum folic acid level. Educating women about nuts, leafy green vegetables, enriched the importance of attending prenatal care is another breads and cereals, and fruit. important role. While many multivitamin supplements contain folic acid, the A. CLINICAL MANIFESTATIONS amount may not be enough to replace body stores E – because the onset and progression of the anemia are completely. When folate deficiency is associated with alcohol so gradual, the body can compensate well until the abuse, supplementation should continue as long as the 3 anemia is severe, so the typical manifestations of patient is consuming alcohol. anemia (weakness, listlessness, fatigue) may not be apparent initially. D. NURSING MANAGEMENT – – Patients with pernicious anemia develop a smooth, – Assessment of patients who have or are at risk for sore, red tongue and mild diarrhea. megaloblastic anemia includes inspection of the skin, 2 o Pernicious - having a harmful effect, especially tongue, and mucous membranes. in a gradual or subtle way. – Mild jaundice may be evident and is best seen in the – They are extremely pale, particularly in the mucous sclera with natural lighting membranes – Vitiligo and premature graying of the hair are – They may become confused; more often, they have frequently present in those with pernicious anemia. paresthesias in the extremities (particularly numbness – Careful neurologic assessment is important to and tingling in the feet and lower legs). identify neurologic complications. o Paresthesia - a burning or prickling sensation – Assessment should include tests of position, that is usually felt in the hands, arms, legs, or vibration sense, and cognitive function. feet, but can also occur in other parts of the – The nurse should pay close attention to the patient’s body gait and stability with ambulation. – They may have difficulty maintaining their balance o Safety is a concern when gait, coordination and because of damage to the spinal cord, and they also position sense are affected. lose position sense (proprioception) – Physical and occupational therapy referrals may be needed to assist in obtaining assistive devices and These symptoms are progressive, although the course of making sure patients are instructed in their use. illness may be marked by spontaneous partial remissions – When sensation is impaired, patients should be and exacerbations. Without treatment, heart failure instructed to avoid excessive heat and cold. associated with severe anemia may result, often leading Mouth and tongue soreness may impair nutritional intake. The nurse may instruct the patient to choose soft bland foods that are less likely to cause further discomfort. Promoting Home, Community-Based and Transitional Care Education for patients with pernicious anemia must include the chronic nature of this condition and the necessity of monthly vitamin B12 injections or daily oral vitamin B12 supplements even when symptoms have resolved Patients or a family caregiver can be taught to administer injections The risk for gastric cancer is increased in patients with gastric atrophy associated with pernicious anemia making it important that patients understand the need for ongoing follow-up care and screening 2 – 3 E  NCM 109 – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC) INFECTIONS DURING PREGNANCY (VIRAL AND NON-VIRAL) DAYAG, CEE JAY MARIE MR. ALLAN PAULO BLAQUERA, RN I. VIRAL AND NONVIRAL INFECTIONS MALARIA ON FETUS DURING PREGNANCY Abortion – Viral infections in pregnancy are major causes of Stillbirth maternal and fetal morbidity and mortality. Congenital infection TERATOGENIC MATERNAL INFECTIONS – involve viral, bacterial, or protozoan organisms, MALARIA ON NEWBORN which cross the placenta from mother to fetus Low birth weight – most infections that may detract from a healthy Prematurity pregnancy outcome cause relatively mild, flu-like Intrauterine growth restriction symptoms in the woman but can have much more Malarial illness serious effects on a fetus or newborn Mortality TERATOGENS PREVENTION – drugs, chemicals, or even infections that can cause Wearing clothing that covers most of the body as well abnormal fetal development as using an insect repellent when in an area infested – there are billions of potential teratogens, but only a with mosquitoes few agents are proven to have teratogenic effects Sleeping at night with a mosquito net o these effects can result in a baby being born keeping windows closed to prevent mosquitoes from with a birth defect entering As further prevention, urge women to delay travel to E. MALARIA endemic areas until after pregnancy if possible. – caused by intraerythrocytic protozoa of the genus Women who will be visiting an area known to be Plasmodium transmitted to humans by the bite of an epidemic for malaria can begin treatment as infected female Anopheles mosquito. prophylaxis up to 2 weeks before travel – During pregnancy, women can transmit malaria to a fetus o It’s important to consider during pregnancy as MEDICATION it can not only make women high risk for blood Treatment is with a combination of antimalarial clotting during pregnancy but also, if untreated, drugs, which will both stop the course of the disease can be transmitted to a fetus by mother-to- and help reduce the incidence of low birth weight fetus transmission. and preterm birth. – The infection causes red blood cells to stick to the First Trimester: Chloroquine (Aralen) surface of capillaries causing obstruction of these o Chloroquine is safe to administer all during vessels and resulting in end-organ anoxia and blood pregnancy and so is the drug of choice not reaching organs effectively. Second Trimester: Mefloquine (Lariam) Third Trimester: Mefloquine, SIGNS AND SYMPTOMS Sulfadoxine/pyrimethamine Quinine, atovaquone and proguanil (Malarone), or tetracyclines, although effective against the disease, should not be used at any point in pregnancy or with E women who are breastfeeding as they are teratogenic. 3 F. URINARY TRACT INFECTION – In a pregnant woman, because the ureters dilate from the effect of progesterone, stasis of urine can occur. – o Stasis - a period or state of inactivity or equilibrium. 2 – The minimal presence of abnormal amounts of glucose (glycosuria) that also occurs with pregnancy provides The most noticeable symptoms are elevated liver function an ideal medium for growth for any organisms present. tests accompanying fever, malaise, and headache. – Asymptomatic infections are potentially dangerous Because of the altered blood cells, thrombocytopenia (i.e., because they can progress to pyelonephritis (i.e., low platelet count), anemia, and renal failure can develop. infection of 1108 the pelvis of the kidney) and are associated with preterm labor and premature rupture of MALARIA ON MATERNAL membranes. Parasitemia – Women with known vesicoureteral reflux (i.e., backflow Morbidity of urine into the ureters) tend to develop UTIs or o Anemia pyelonephritis more often than others. o Febrile illness – The organism most commonly responsible for UTI is o Cerebral malaria Escherichia coli from an ascending infection. o Hypoglycemia – A UTI can also occur as a descending infection or can o Puerperal sepsis begin in the kidneys from the filtration of organisms Mortality present from other body infections o Severe disease o Hemorrhage  o If the infectious organism is determined to the ureters and allowing urine to drain be Streptococcus B, vaginal cultures more freely. should be obtained because streptococcal If a woman has one UTI during pregnancy, the B infection of the genital tract is associated chances are high she will develop another late in with pneumonia in newborns. pregnancy, when urinary stasis tends to grow even greater. Adequate kidney function is important for a successful o She may, therefore, be kept on pregnancy outcome because a woman is excreting waste prophylactic antibiotics throughout the products not only for herself but also for the fetus. remainder of the pregnancy When women have pain and symptoms of urinary ASSESSMENT frequency, they usually take medication – A UTI typically manifests as frequency and pain on consistently. urination. After birth, a woman who developed more than one – With pyelonephritis, a woman develops pain in the UTI may have an ultrasound scheduled to detect lumbar region (usually on the right side) that radiates any urinary tract abnormality that might be present, downward such as vesicoureteral reflux, to help prevent future o Area feels tender to palpation infections. – She may have accompanying nausea and vomiting, malaise, pain, and frequency of urination Pyelonephritis occurs as an extension of a UTI or infection – Her temperature may be elevated only slightly or may that originated in or spread to the kidney. If this develops, a be as high as 103° to 104°F (39° to 40°C) woman may be hospitalized for 24 to 48 hours while she – The infection usually occurs on the right side is treated with intravenous antibiotics. After this acute because there is greater compression and urinary episode, she will be maintained on a drug such as oral stasis on the right ureter from the uterus being pushed nitrofurantoin (Macrodantin) for the remainder of the that way by the large bulk of the intestine on the left pregnancy. Acidifying urine by the use of ascorbic acid side. (vitamin C), which is often recommended in nonpregnant – A urine culture will reveal over 100,000 organisms per women, is not usually recommended during pregnancy milliliter of urine, a level diagnostic of infection. because a newborn can develop scurvy in the immediate neonatal period from vitamin C withdrawal. THERAPEUTIC MANAGEMENT (and Medication) G. ACUTE NASOPHARYNGITIS – Obtain a clean-catch urine sample for culture and – generally called as “common colds” sensitivity to assess for asymptomatic bacteriuria or – is basically the swelling of nasal passages and the symptoms of UTI back of the throat o A sensitivity test will then determine which – tends to be more severe during pregnancy than at antibiotic will best combat the infection. other times because, during pregnancy, estrogen – Amoxicillin, ampicillin, and cephalosporins are stimulation normally causes some degree of nasal effective against most organisms causing UTIs and are congestion safe antibiotics during pregnancy o This means that even with a minor cold, a – Sulfonamides can be used early in pregnancy but woman can find it difficult to breathe not near term because they can interfere with protein binding of bilirubin, which then leads to hyperbilirubinemia in the newborn MEDICATION o Bilirubin - a yellowish pigment that is made Because common colds are invariably caused by a during the normal breakdown of red blood cells virus, antibiotic therapy is unnecessary except to o Hyperbilirubinemia - a condition in which prevent a secondary infection there is too much bilirubin in your baby's Take acetaminophen (Tylenol) every 4 hours for E blood. aches and pains (up to 3,000 mg/day). Do not take 3 Tetracyclines are contraindicated during pregnancy acetylsalicylic acid (Aspirin) during pregnancy as they cause retardation of bone growth and because it can interfere with blood clotting. staining of the deciduous teeth o Women should not take high-dose aspirin as – a remedy for a headache, which commonly PREVENTION AND INTERVENTION accompanies an upper respiratory infection. o It can interfere with blood clotting in both the 2 Voiding frequently (at least every 2 hours) mother and fetus as well as cause fetal Developing a habit of urinating as soon as the need is constricted ductus arteriosus felt and emptying the bladder completely when urinating o Ductus arteriosus - a normal blood vessel that Wiping front to back after voiding and bowel connects two major arteries — the aorta and the movements pulmonary artery — that carry blood away from Wearing cotton, not synthetic fiber, underwear the heart. The lungs are not used while a fetus is Voiding immediately after sexual intercourse in the womb because the baby gets oxygen Drinking a glass of cranberry juice daily directly from the mother's placenta Drinking an increased amount of fluid to flush out the Although most simple cough syrups don’t contain infection from the urinary tract. ingredients that would make them unsafe for use o Do not simply tell her to “push fluids” or “drink during pregnancy, women should check with lots of water.” Give her a specific amount to their healthcare provider before taking any over- drink every day the-counter medication other than honey and A woman can promote urine drainage by assuming lemon lozenges a knee–chest position for 15 minutes morning and evening o In this position, the weight of the uterus is shifted forward, releasing the pressure on  PREVENTION AND INTERVENTION o It has an incubation period of 2 to 6 weeks Be sure to get extra rest and sleep and eat a diet high HEPATITIS B in vitamin C (e.g., orange juice and fruit) to help boost – occurs about 1 in every 2,000 pregnancies the immune system – It has an incubation period of 6 weeks to 6 Use a room humidifier or apply a medicated vapor rub months. to the chest, especially at night, to moisten nasal – It occurs in both an acute and chronic form, secretions and help mucus drain leading to liver cell necrosis with scarring and an Use cool or warm compresses to relieve sinus inability to convert indirect to direct bilirubin or to headaches excrete direct bilirubin. – Women exposed to the virus receive immune H. INFLUENZA globulin for prophylaxis; a hepatitis B vaccine can be administered to those who are at high – a viral infection that attacks your respiratory system — your nose, throat and lungs risk, such as women who handle blood products, to prevent the illness. – caused by a virus, identified as type A, B, or C – spreads in epidemic form and is accompanied by HEPATITIS C high fever, extreme prostration, aching pains in the – demonstrates few symptoms, and these may not back and extremities, and generally, a sore, raw be present for 12 months after exposure. throat – It is, however, the most common cause of – Contrary to early reports, influenza infection has not chronic liver disease and liver transplantation in been clearly correlated with congenital anomalies