Pregestational Conditions PDF

Rheumatic Heart Disease (RHD) 5. Edema 6. Syncope > Is the inflammatory response from rheumatic fever, 8. Fever associated w/ infection of damaged heart valves. can permanently damage the valves in the heart. > Rheumat...

Rheumatic Heart Disease (RHD) 5. Edema 6. Syncope > Is the inflammatory response from rheumatic fever, 8. Fever associated w/ infection of damaged heart valves. can permanently damage the valves in the heart. > Rheumatic Fever is an acute, nonsuppurative, > Complications during Pregnancy immunologically mediated, multi-system inflammatory 1. mitral valve stenosis disease. 2. heart arrhythmia Occurs a few weeks after an episode of group A 3. heart failure Streptococcal pharyngitis. Affects: heart, joints, CNS, skin and subcutaneous > Diagnostic Tests tissues 1. Chest x-ray 3. Echocardiogram > Chronic, progressive, permanent heart valve damage 2. Electrocardiogram (ECG) that remains after the ARF episode has resolved wherein: > Treatment during Pregnancy - heart has become inflamed 1. Diuretics: increase production & excretion of urine, - heart valves remain stretched and/or scarred which can help decrease blood volume and BP - normal blood flow is interrupted. 2. Beta-blockers: treat & prevent heart arrhythmias. > Sometimes RHD, especially mitral stenosis, 1st 3. Percutaneous balloon mitral valvuloplasty (PBMV): diagnosed during pregnancy or soon after delivery. small balloon is inflated in the mitral valve to help keep it open. > Medical Management during Pregnancy 1. Women with moderate or severe rheumatic heart disease require close supervision, normally at a tertiary referral centre with cardiology and intensive care facilities. 2. Women requiring anticoagulation during pregnancy are at additional risk of complications. 3. Women on secondary prophylaxis should continue treatment. Any prescribed antibiotic secondary prophylaxis is safe during pregnancy. 4. Many women with a history of acute rheumatic fever or mild rheumatic heart disease require no special > Assessment management during pregnancy but or early in pregnancy, 1. full history and examination by a cardiologist and obstetrician to establish the safest > Risk factors birth pathway. 1. reduced left ventricle systolic function 2. significant aortic or mitral stenosis High Risk Prenatal Client 3. moderate or severe pulmonary hypertension Gestational Diabetes Mellitus 4. a history of heart failure 5. symptomatic valvular disease before pregnancy > appearance of higher-than-expected blood sugars 6. poverty, overcrowding & reduced access to medical during pregnancy. care > form of glucose intolerance with the onset or first recognition during pregnancy (24-28 wks of gestation). > Symptoms > primary problem in controlling balance between insulin 1. Chest pain, heart palpitations and blood glucose levels. 2. Breathlessness on exertion Etiology 3. Orthopnea Hormonally induced insulin resistance → 4. Paroxysmal nocturnal dyspnea Resulting in hyperglycemia → Eventually progresses into diabetes Assessment - 3P’s (polyuria, polydipsia, polyphagia) - Dizziness if hypoglycemic - Confusion if hyperglycemic - Possibility of increased monilial infection - Glycosuria - Macrosomia - Hyperglycemia Pathophysiology Risk Factors for Developing GDM > Obesity > History of large babies > History of unexplained fetal or perinatal loss > Family history of diabetes Diagnostic Studies Risks Associated with Diabetes in Pregnancy - Fasting plasma glucose level Maternal Risks Fetal Risks - Random plasma glucose measurement Preeclampsia Birth injuries - 2hr OGTT level (drink 75 g of glucose & do not eat Increased caesarean Childhood obesity anything until blood is drawn) delivery Hyperbilirubinemia - Fasting blood glucose level Progression of chronic Hypoglycemia - Hemoglobin A1C test: No fasting required complications of diabetes Macrosomia - Urine glucose/ketones: fresh urine specimen Gestational hypertension Shoulder dystocia - Urine microalbumin: fresh urine specimen Hypoglycemia Respiratory distress Infection syndrome Components of Diabetes Management Ketoacidosis Premature birth 1. Nutritional mgt. Polyhydramnios Abnormal birth weight 2. Exercise Preterm labor Increased congenital Seizures malformations 3. Monitoring Doubled spontaneous High Risk Prenatal Client 4. Pharmacologic mgt. abortion risk 5. Education Goals of diabetes management Reduce symptoms Promote well-being Prevent acute complications Delay onset & progression of long-term complications Substance Abuse FETUS: - Intrauterine growth retardation Use of illegal or inappropriate use of legal drugs to: - Abnormal startle reflexes in newborns > produce pleasure, - Reduced memory & verbal skills at age 4 years > alleviate stress, or > alter/avoid reality. Cocaine Exposure: produce direct neurotoxic effects. Addiction - habitual psychological/physical dependence Prenatal Complications on substance/practice beyond voluntary control. - stillbirth, placental abruption, premature rupture of membranes Commonly Abused Substances - fetal distress, preterm delivery, growth retardation Alcohol Illicit drugs including: Methamphetamine Exposure: produce neurotoxic – marijuana, cocaine, heroin – tranquilizers effects. – hallucinogens – stimulants - premature delivery, placental abruption, cardiac – inhalants – sedatives anomalies - fetal growth reduction Pathophysiology > mother uses a drug → placenta & umbilical cord → Tobacco Exposure: Cigarette smoke contains; fetus → permanent damage 1. Tar contains substances (lead, cyanide, cadmium, etc.) harmful to the fetus. Risks of Drug Use During Pregnancy 2. Nicotine crosses the placenta and distributes freely to - miscarriage, stillbirth the CNS, having effects on neural development. - small gestational age (SGA), low birth weight (LBW) 3. Carbon monoxide causes intrauterine hypoxia and - premature birth, birth defects, sudden infant death reduced uterine blood flow that leads to growth syndrome (SIDS) impairment. - drug-dependency in the infant * Secondhand smoke contains toxic chemicals. Teratogenic Effects of Prenatal Alcohol Exposure Nicotine Effects on Smokers Direct toxic effect of alcohol on cells.  Acute effects Hypoxia due to impaired placental/fetal blood flow. Vasoconstriction,  secretions Effect on cell migration in the brain.  Chronic effects Effect on apoptosis (natural process of cell death). Lung disease, heart disease, Increases cancer risk Behavioral disorders Fetal Alcohol Syndrome (permanent birth defect, Tobacco Exposure: cause of mental retardation) Nicotine Withdrawal on Mother > craving for tobacco > anxiety Marijuana Use > irritability, frustration, anger > restlessness Marijuana smoking produces higher levels of carbon > difficulty concentrating > depression monoxide than tobacco, a potential mechanism of action of marijuana’s impact on the developing fetus. Smoking Effects on Fetus: Long-term use causes psychological dependence/lung - poor fetal growth/IUGR - intrauterine hypoxia damage - LBW - spontaneous abortion - fetal death - placenta previa Effects of Marijuana: - preterm delivery - SIDS risk >4x higher MOTHER: - relaxation, hallucination, panic attacks - short-term memory impairment, amnesia Caffeine > Substance in coffee, tea, soft drinks, chocolate and certain medications. The following diseases are predictive of the > Stimulates CNS w/in 15 minutes. progression to AIDS: > Moderate doses (2–4 cups of coffee) increases persistent herpes-zoster infection (shingles) alertness/provide an energy boost. oral candidiasis (thrush) > Large doses = restlessness & irritability, insomnia, oral hairy leukoplakia headaches and abnormal heart rhythms. Kaposi’s sarcoma (KS) > Creates psychological dependence > Withdrawal symptoms = headache, muscle pain and fatigue. HIV/AIDS Human Immunodeficiency Virus H = uman beings are only infected. I = mmunodeficiency virus weakens the immune system and increases the risk of infection. V = irus that attacks the body. ▪ HIV attacks lymphocytes (WBC’s) called T-cells. ▪ The reduction of T-cells results in a weakened immune Kaposi’s sarcoma (KS) system. is a rare cancer of the blood vessels that is associated Acquired Immune Deficiency Syndrome with HIV. It manifests as A = cquired not inherited. bluish-red oval-shaped I = mmune system weakened. patches that may eventually D = eficiency of CD4+ cells in the immune system created. become thickened. Lesions S = yndrome or a group of illnesses taking place at the may appear singly or in same time clusters. ▪ AIDS is caused by HIV ▪ AIDS diagnosis is made once opportunistic diseases Opportunistic occur. Infections - do not normally develop in people with a healthy immune HIV infection -> destroy the immune system -> immune system. system weakened by HIV -> progresses to AIDS. Common symptoms are: > Fever, Chills > Rash Causes > Sweats (particularly at night) > Weakness > Human immunodeficiency virus (HIV) causes HIV > Swollen lymph glands > Weight loss infection and AIDS, attacks the immune system. Symptoms Etiologic Agent (AIDS) - Diarrhea > Former names of the virus include: - Headache, Fever, Night sweats Human T cell lymphotrophic virus (HTLV-III) - Mouth sores, including yeast infection Lymphadenopathy associated virus (LAV) - Muscle stiffness or aching AIDS associated retrovirus (ARV) - Rashes of different types - Swollen lymph glands, sore throat HIV continues to reproduce, CD4 count gradually - Chronic fatigue, Unexplained weight loss declines from its normal value (500-1200). Once CD4 count drops below 500, HIV infected person is at risk for opportunistic infections. ▪ There may be no symptoms for up to 10 -12 years until the immune system is suppressed enough to cause Common Side Effects problems > Collection of fat on the back (buffalo hump) and abdomen Transmission of HIV > General sick feeling (malaise), Weakness, Headache, 1. Direct contact; infected bld, semen, vaginal and cervical Nausea secretions > When used for a long time, increases risk of heart 2. Sexual contact: oral, anal, or vaginal attack, perhaps by increasing levels of cholesterol and 3. HIV-infected mothers to infants during pregnancy, glucose (sugar) in the blood. delivery and breastfeeding 5. Sharing of hypodermic needles & Blood transfusions Prevention (Rare) > Don’t use illegal drugs, do not share needles/syringes. > Avoid contact with another person's blood. > (+) HIV person should not donate blood, plasma, body organs, or sperm. > HIV (+) women who plan to get pregnant should talk to their health care provider about the risk to their unborn child. > BF should be avoided to prevent passing on HIV to infants through breastmilk. > Safer sex practices > Public health strategies to prevent HIV transmission: People at Risk: 1. Screen all blood and blood products. > Injection drug users who share needles. 2. Follow universal precautions. > Infants born to mothers with HIV who did not receive HIV 3. Educate in safer sex practices. treatment during pregnancy. 4. Identify & treat STIs/other infections. > People who have unprotected sex. 5. Provide referral for treatment of drug dependence. > Sexual partners engaged in high-risk activities. When should a client be tested? If a client; Diagnostic Tests: 1. have had any STD. 1. ELISA tests useful for: 2. shared drug needles. Screening blood products. 3. had sex with a prostitute. Diagnosing and monitoring patients. 4. had sex w/ a man who had sex w/ another man. Determining prevalence of infection. 5. had unprotected sex w/ 3 or more partners. Research investigations. 2. Western Blot - most popular confirmatory test. Remember: 3. CBC and WBC differential Could take 3-6 mos. before antibodies appear in blood. 4. Pap smear, Anal pap smear No symptoms during incubation. 5. Indirect Immunoflourescence - used to detect both Wait to be tested until 6 months with no risk behavior. virus and antibody. 6. Polymerase Chain Reaction - looks for HIV DNA in the Rh SENSITIZATION WBCs of a person. 7. Regular blood tests for CD4 cell count Rh (Rhesus) Factor - CHON that may be found on the 8. HIV RNA level surface of RBC’s, (+) CHON = Rh (+), (- ) CHON = Rh (-). Treatment Rh Incompatibility - condition > Antiretroviral therapy that develops when a pregnant woman is Rh(-) blood & the fetus has Rh(+). Rh Isoimmunization – Rh (+) blood from the baby will make the mother's body create antibodies. Rh Sensitization - antigen-antibody immunologic reaction within the body. If blood is Rh (-), it will be tested for antibodies to Rh (+) blood. If you have antibodies, you’ve been sensitized to Rh (+) blood. The antibodies can kill Rh (+) RBC’s. If you’re pregnant or have miscarried, molar pregnancy, or an ectopic pregnancy, you will need testing to see if you have been sensitized to Rh (+) blood. 1. PUBS/Cordocentesis - for monitoring known sensitization problems. 2. Amniocentesis - to check for the fetus's blood type and Rh factor. 3. Fetal ultrasound - to detect sensitization problems, Risk Factors such as fetal fluid retention. > Risk for Rh incompatibility include being an Rh (-) 4. Electronic fetal heart monitoring (nonstress pregnant woman who: test) – done on the 3rd trimester. 1. had a prior pregnancy w/ a baby that was Rh (+). 2. had a prior blood transfusion or amniocentesis. 3. did not receive Rh immunization prophylaxis Treatment during/prior to pregnancy 1. RhoGAM (Rh immunoglobulin) - prevents Rh(-) w/ an Rh (+) baby. mother's antibodies from reacting to baby’s Rh(+) RBC’s. Given around 28th wk of pregnancy & within 72 hours after Symptoms delivery birth. > Symptoms and complications only affect the baby. 2. Phototherapy for infants - work by helping to break > Symptoms that can develop in the baby include: down bilirubin in the skin. 1. Swelling of the body, which may be associated with heart failure or respiratory problems. Prevention: RhoGam injections must be given: 2. Jaundice, Anemia, Low muscle tone and lethargy > During every pregnancy > If they have a miscarriage/abortion Possible Complications Include: > After prenatal tests (amniocentesis) 1. Brain damage due to high levels of bilirubin (kernicterus) > After injury to the abdomen during pregnancy 2. Fluid buildup & swelling in the baby (hydrops fetalis) 3. Problems w/ mental function, movement, hearing, speech, and seizure ANEMIA IN PREGNANCY Diagnostic Exam. Anemia - lack of RBC’s, can lead to lack of O2-carrying 1. Maternal blood type, Rh factor and antibody screening. ability of the blood, causing unusual tiredness. 2. A (+) direct Coombs test result- to look for the presence Types of Anemia During Pregnancy of cell-destroying antibodies on the surface of RBC’s. 3. Indirect Coomb’s test - to see if your Rh(+) antibody Iron-deficiency anemia (IDA) - the body doesn't levels are increasing. have enough iron to produce adequate amounts of hgb. > Fetal assessment includes:  Folate-deficiency anemia - also called folic acid, a Possible Complications type of B vitamin. Folate produces new cells, including - Difficulty in breathing, palpitations and angina healthy RBC’s. - Severe anemia due to loss of blood after the delivery Vitamin B12 deficiency - the body needs vitamin B12 to form healthy RBC’s. Diagnostic Tests - Hgb test - measures the amount of hgb, an iron-rich Symptoms: CHON in RBC’s that carries O2 from the lungs to tissues - Pale skin, lips, and nails - Feeling tired or weak in the body. - Dizziness or light-headedness - Palpitations - Hct test - measures the percentage of RBC’s in a - Trouble concentrating - Shortness of breath sample of blood. Risk Factors for Developing Anemia in Pregnancy Treatment > All pregnant women are at risk for becoming anemic - iron supplement and/or folic acid supplement because they need more iron & folic acid than usual, and - vitamin B12 supplement to treat vit B12 deficiency the risk is higher if you: - include more animal foods in a diet, such as meat, eggs - are pregnant with multiples and dairy products - have had two pregnancies close together - vomit a lot because of morning sickness Prevention - are pregnant teenager - Eat well-balanced meals - don't eat enough foods that are rich in iron - Aim for at least 3 servings a day of iron-rich foods - had anemia before you became pregnant - Vitamin C can help the body absorb more iron - Choose foods that are high in folic acid Risks of Anemia in Pregnancy - Follow your doctor's instructions for taking a prenatal > Severe or untreated IDA during pregnancy can increase vitamin that contains a sufficient amount of iron and folic the risk of having: acid. - preterm or low-birth-weight baby, blood transfusion - postpartum depression, a baby with anemia - a child with developmental delays > Untreated folate deficiency can increase the risk of having a: - Preterm or low-birth-weight baby - Baby with a serious birth defect of the spine or brain (neural tube defects) > Untreated vitamin B12 deficiency can also raise the risk of having a baby with neural tube defects. Causes: - increased demand for iron and other vitamins. - inadequate dietary intake, a diet low in iron - lack of folic acid in the diet, a lack of vitamin B12 - loss of blood due to bleeding from hemorrhoids or stomach ulcers. - a previous pregnancy - pregnancies that are close together - women carrying twins or triplets. - a normal recurrent loss of iron in menstrual blood.