NCM 109 Past Paper PDF - Care of Mother and Child

# NCM 109 - Care of Mother and Child at Risk or with Problems (Acute and Chronic) - LECTURE ## PRELIM PERIOD ### WEEK 2 **Chapter 20-Care Given to a Mother Experiencing a Pregnancy Complication from a Pre-existing or Newly Acquired Illness Utilizing the Nursing Care Plan** ### **I. Illness Utiliz...

# NCM 109 - Care of Mother and Child at Risk or with Problems (Acute and Chronic) - LECTURE ## PRELIM PERIOD ### WEEK 2 **Chapter 20-Care Given to a Mother Experiencing a Pregnancy Complication from a Pre-existing or Newly Acquired Illness Utilizing the Nursing Care Plan** ### **I. Illness Utilizing the Nursing Care Plan.** ### **Nursing Process Overview:** 1. **Assessment** * Focus on the signs and symptoms of the illness: subjective and objective data * Examples: * Subjective Data: woman's level of exhaustion * Objective Data: vital signs, extent of edema 2. **Nursing Diagnosis** * Should be based from the gathered data * Examples: * Ineffective tissue perfusion (cardiopulmonary) related to poor heart function secondary to mitral valve prolapse during pregnancy * Pain related to pyelonephritis secondary to uterine pressure on ureters * Social isolation related to prescribed bed rest during pregnancy secondary to concurrent illness * Ineffective role performance related to increasing level of daily restrictions secondary to chronic illness and pregnancy. 3. **Outcome Identification and Planning** * Outcome should be related to the entire family's health. * Examples: * For chronic illness: To maintain woman's health during pregnancy so she can remain at home as long as possible, thereby minimizing hospitalization and family disruptions. * For new illness: Allowing a woman to choose among alternatives to help her to participate in her own care and also to maintain self-esteem as well as helps her move a step toward parenthood and assuming care for her family. ### **4. Implementation** * Example: Teaching woman on her new or additional measures to maintain health during the pregnancy. ### **5. Outcome Evaluation** * Example: * Patient states she rests for 2 Hours morning and afternoon; dependent edema remains at 1+ or less at next prenatal visit * Family members state they are all participating in an exercise program since mother developed gestational diabetes * Patient reports no burning on urination or flank pain at next prenatal visit. * Patient states she understands the importance of talking daily thyroid medicine for total length of pregnancy. ## Normal Heart * Diagram of the Heart * Superior Vena Cava * Pulmonary Veins from Lungs * Atrial Septum * Tricuspid Valve * Inferior Vena Cava * Pulmonary Valve * Left Atrium * Left Ventricle * Right Atrium * Right Ventricle * Aortic Valve * Mitral Valve * Ventricular Septum * Pulmonary Arteries to Lungs * Pulmonary Veins from Lungs ## **A. Cardiovascular Disease and Pregnancy** * The danger of pregnancy in a woman with cardiac disease occurs primarily due to the increase in circulatory volume. * The most dangerous time for a woman is in 28 to 32 weeks, after the blood volume peaks. ### **a.1. A Woman with Left Sided Heart Failure:** * Occurs in condition such as mitral stenosis, mitral insufficiency and aortic coarctation. * The left ventricle cannot move the volume of blood forward that is received by the left atrium from the pulmonary circulation. ### **a. 2. A Woman with Right Sided Heart Failure** * Causes: * Congenital heart defects - pulmonary valve stenosis and atrial and ventricular septal defects * Occurs when the output of the right ventricle is less than the blood volume received by the right atrium from the vena cava * Back pressure from this results in congestion of the systemic venous circulation and decreased cardiac output to the lungs. * Pulmonary edema - orthopneic * Paroxysmal nocturnal dyspnea - suddenly waking at night with shortness of breath occurs because heart action is more effective when she is at rest ### **Medication:** * Anti hypertensive - to control increased BP * Diuretics to reduce blood volume * Beta blockers - to improve ventricular filling * Diet: low sodium diet * Medical Management: serial UTZ and non stress test after 30 - 32 weeks of pregnancy and monitor FHR. ## **Signs and Symptoms:** * Productive cough of blood-speckled sputum * Risks: * Spontaneous miscarriage - because oxygen is limited * Preterm labor * Maternal death * As oxygen saturation of the blood decreases from dysfunction of the alveoli, chemoreceptors stimulate the respiratory center to increase RR. ## **Signs and Symptoms:** * With rest - increased fatigue * Weaknesses * Dizziness - lack of oxygen in the brain * HR increases * Peripheral constriction occurs in an attempt to increase the systemic BP. ### **a. 3 pregnant patient with peripartum heart disease** * Rare condition happened that can originate in pregnancy in those with no previous history of heart disease. * Cause unknown (stress from being pregnant). * Sign/Symptoms: shortness of breath, chest pain and nondependent edema, cardiomegaly. * Therapy/ mngt: reduce physical activity, diuretic, arrhythmia agent, digitalis therapy, immunosuppressive therapy ### **Management** * Oxygen administration * Frequent arterial blood assessment to ensure fetal growth * During labor - pulmonary artery catheter to monitor pulmonary pressure * Close monitoring to minimize the risk of hypotension after epidural anesthesia ## **Blood pressure decreases in the aorta because less blood is reaching it** * Pressure is high in the vena cava, both jugular distention and increased portal circulation occur ## **Signs and Symptoms:** * Liver and spleen distended - leading to dyspnea and pain in pregnant woman because the enlarged liver, as it pressed upward by the enlarged uterus, puts extreme pressure on the diaphragm * Ascites - distention of abdominal vessels can lead to exudates of fluid from the vessels into the peritoneal cavity * Peripheral edema - fluid also moves from the systemic circulation into lower extremity interstitial spaces * Eisenmenger Syndrome - the congenital anomaly most apt to cause the right sided heart failure in women of reproductive age ## **Iron is made available in the body by absorption from the duodenum into the bloodstream after it has been ingested** * In the bloodstream it is bound for transport to the liver, spleen and bone marrow. * At this site, it is incorporated into hemoglobin or stored as ferritin. ## **SIGNS AND SYMPTOMS:** * Extreme fatigue and poor exercise tolerance. * Reason: woman cannot transport oxygen effectively * Associated with low birth weight and preterm birth * Reason: the body recognizes that it needs increased nutrients, some women with this condition develop *pica # **B. Hematologic Disorders and Pregnancy** * Involves either blood formation or coagulation disorders ## **1. Anemia and Pregnancy** * Because the blood volume expands during pregnancy slightly ahead of the red cell count, most women have a *pseudoanemia* of early pregnancy. This condition is normal and should not be confused with true types of anemia. * True anemia - woman's hemoglobin (hgb) concentration is less than 11 g/dL (hematocrit:hct < 33%) during the first and third trimester of pregnancy * When hgb concentration is &lt; 10.5 g/dL (hematocrit &lt; 32%) during the second trimester ### **2. A Woman with Iron-Deficiency Anemia** * Most common anemia of pregnancy. * Causes: * Diet low in iron- low socio economic status * Heavy menstrual flow * Unwise weight-reducing programs * Getting pregnant less than 2 years before the current pregnancy * Pica ## **Classification of heart disease** * I- uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no angina pain. * II- slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or angina pain. * III- markedly compromised. During less than ordinary activity, patient experiences excessive fatigue, palpitations, dyspnea or angina pain. * IV- severely compromised. Patient is unable to carry out any physical activity without experiencing discomfort. Even at rest, symptoms of cardiac insufficiency or angina pain are present. ## **Megaloblastic anemia - enlarged red blood cells - type of anemia that develops** * Because of the size of the cells, the mean corpuscular volume will be elevated in contrast to the lowered level seen with iron-deficiency anemia ### **Management:** * All women expecting to become pregnant should begin to take 400 ug folic acid daily plus eating folate foods such as: green leafy vegetables, oranges, dried beans) ## **4. A Woman with Sickle-Cell Anemia** * Sickle-Cell Anemia is a recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of hemoglobin. ## **3. A Woman with Folic Acid-Deficiency Anemia** * Folic acid or folate or folacin * One of the B vitamins which is necessary for the normal formation of red blood cells in the woman. * Helps in preventing neural tube and abdominal wall defects in the fetus * Common among: * Multiple pregnancies- increased fetal demands * Women with secondary hemolytic illness, due to rapid destruction and production of new red blood cells * Women taking *hydantoin*, an anticonvulsant agent that interferes with folate absorption * Women who have poor gastric absorption ### **Management for Anemia and Iron-Deficiency Anemia** * Intake of prescribed prenatal vitamins containing 27 mg of iron as prophylactic therapy during pregnancy * Advise woman to eat diet high in iron and vitamins: green leafy vegetables, meat and legumes * Ferrous Sulfate or Ferrous Gluconate- 120-200 mg elemental iron per day * Advise woman to take orange juice or a vitamin c - **Reason**: iron is absorbed in an acid medium * Result: New red blood cells should begin to increase almost immediately or reticulocyte count should rise from 0.5% and 1.5% to 3% and 4% by two weeks ### **Possible Effects:** * Constipation - high fiber diet, increase fluid intake 6-8 glasses per day * Gastric irritation - take oral tablet with full stomach * Turning stools black in color-advice woman that this is normal * If iron deficiency is severe and woman has difficulty in taking oral tablet, Intravenous iron can be prescribed. ### **5. Assess lower extremities for varicosities which can lead to red cell destructions** * Monitor fetal health by an ultrasound examination at 16-24 weeks to assess for intrauterine fetal growth ### **THERAPEUTIC MANAGEMENT** * Periodic exchange or blood transfusions throughout pregnancy to replace sickled cells with non sickled cells- serves as a secondary purpose of removing a quantity of the increased bilirubin resulting from the breakdown of RBC as well as restoring the hemoglobin level. * If crisis occurs, controlling pain, administering oxygen and increasing the fluid volume of the circulatory system to lower viscosity. * If with infection- hospitalization. * If fetus is mature, the time and method of delivery are considered. * Keep the woman well hydrated during labor and delivery. * Epidural anesthesia is the method of choice. ## **The cells will hemolyze (destroyed), reducing the number available and causing severe anemia** * Races usually affected: Blacks has sickle-cell trait or carries a recessive gene for S hemoglobin but asymptomatic. * Effects on pregnancy: blockage to the placental circulation can directly compromise the fetus causing low birth weight and possibly fetal death. ### **Assessment** * Screening at the first pre-natal visit: hemoglobin analysis * Women with the condition - hemoglobin: 6-8 mg/100 ml. * Urinalysis- due to vascular stasis, women are prone to bacteriuria. * Monitor a woman's nutritional intake-if sufficient folic acid is consumed. * Ensure woman is drinking at least 8 glasses of fluid daily to prevent dehydration. ## **If the abnormal amino acid replaces the amino acid saline, sickling hemoglobin results** * If it is substituted for the amino acid lysine, non sickling hemoglobin results. * An individual who is heterozygous (with only one gene in which the abnormal substitution has occurred, has the sickle cell trait. * If the person is *homozygous* (with two genes in which substitution has occurred, sickle cell disease results. * With the disease, the majority of RBC are irregular or sickle shaped, so they cannot carry as much hemoglobin as normally shaped RBC can. * When oxygen tension becomes reduced, as occurs at high altitudes, or blood becomes more viscid than usual, like in dehydration, the cells clump together because of their irregular shape, resulting in vessel blockage with reduced blood flow to the organs. ## **Most coagulation disorders are sex linked or occur only in males and so have little effect on pregnancies** ### **1. Von Willebrand disease- a coagulation disorder inherited as an autosomal dominant trait and occurs in women.** * Women have normal platelet counts but bleeding time is prolonged. * Levels of factor VIII-related antigen (VIII-R) and factor VIII coagulations activity (VIII-C) are both reduced. * Since childhood, woman with the disorder might have menorrhagia or frequent episodes of epistaxis. * Cannot diagnose immediately if not severe, until the woman got pregnant and experiences a spontaneous miscarriage or postpartum hemorrhage. ### **Management:** * Replacement of the missing factors by blood transfusion of cryoprecipitate or fresh frozen plasma before labor to prevent excessive bleeding with birth. ## **5. The Woman with Thalassemia** * Thalassemia are a group of autosomal recessively inherited blood disorders that lead to poor hemoglobin formation and severe anemia. * Most common in Mediterranean, African and Asian populations. * Symptoms first appear in childhood. * Treatment: combating anemia through folic acid supplementation and sometimes, blood transfusion to infuse hemoglobin-rich RBC * Women with the condition usually do not take iron supplementation during pregnancy because they could receive an iron overload because iron is infused with blood transfusions ## **During post partal period: early ambulation, and wearing pressure stockings or IPC boots can help reduce the risk of thromboembolism from stasis in lower extremities** * Parents are generally interested in determining the condition of the infant. * The condition is recessively inherited, if one of the parents has the disease and the other is free, the chance the child will inherit the disease is zero. * If the woman has the disease and her partner has the trait, the chance the child will inherit the disease is 50%. * If both parents has the disease, all their children will have also have the disease. ## **Diagnosis: urine culture - reveal over 100,000 organnisms per milliliter of urine** ### **Therapeutic Management:** * Clean catch urine * Culture and Sensitivity (C & S) - to determine what antibiotic needs to be prescribed. * Examples: Amoxicillin, Ampicillin and Cephalosporins - safe antibiotics during pregnancy. * Sulfonamides - can be used early in pregnancy but not near term because they interfere with protein binding of bilirubin, which can lead to hyperbilirubinemia in newborn. * Tetracyclines are contraindicated in pregnancy - can cause retardation bone growth and staining of the fetal teeth. ## **1.A Woman with Urinary Tract Infection** * Caused by Escherichia coli from an ascending infection. * Can also be a descending infection - can begin in the kidneys from the filtration of organisms present from other body infections. * If caused by Streptococcus B - indicates the woman has an extensive infection. ### **Assessment: Based on signs and symptoms** * Pain on urination. * In case of *Pyelonephritis* - woman develops pain in the lumbar region usually on the right side that radiates downward. * Area is tendered upon palpation * Nausea and vomiting * Malaise * Frequency of urination * Temperature - 103 - 104 degrees F ## **2. Hemophilia B (Christmas Disease)** * Factor IX deficiency, is a sex linked disorder. * Occur only in males. * Females are carriers and may have a reduced level of factor IX (only 33% of normal) that results to hemorrhage with labor, or a spontaneous miscarriage. * Carriers of the disorder should be identified before pregnancy. ### **Management:** * Restoration of factor IX by infusion of factor IX concentrate or fresh frozen plasma. * Maternal serum analysis can be used to detect whether a fetus has a coagulation disorder during pregnancy. ### **2. A Woman with Chronic Renal Disease** * Before, women with this chronic renal disease did not reach childbearing age or were advised not to have children because of their automatic high-risk status during pregnancy. * Today, with conscientious prenatal care, women with this condition, who have had renal transplants can expect to have healthy pregnancies and healthy children. * Pregnancy increases the workload of the kidneys because they must excrete waste products not only for the woman but also for the fetus for 40 weeks. * Can cause severe anemia on women because their diseased kidneys do not produce *erythropoietin*, a glycoprotein necessary for red cell formation and so, they may develop a severe anemia. * The glomerular filtration rate are normally increases during pregnancy, the woman is able to clear waste products from her body for both herself and the fetus with such efficiency that her serum creatinine is slightly below normal during pregnancy. * Normal creatinine level - 0.7 mg per 100 ml of blood. ### **If with Pyelonephritis - hospitalized for 24H - 48H then place on home care and treated with IV antibiotics.** * After this episode - maintained on a drug such as Oral Nitrofurantoin (Macrodanti) for the remainder of the pregnancy. * Acidifying the urine by the use of Ascorbic Acid (Vit. C) which is often recommended in non pregnancy women. * Not recommended during pregnancy because the newborn can develop scurvy in the immediate neonatal period. * After birth - IVP scheduled to help detect any urinary tract abnormality that might be present ### **Precautionary Measures:** * Voiding frequently at least every two hours. * Wiping from front to back after bowel movement. * Wearing cotton, non synthetic fiber underwear. * Voiding immediately after sexual intercourse. * Drinking an increased amount of fluid to flush out the infection from the urinary tract - up to 3 - 4L/24H. ### **Other Measures:** * Knee chest position for 15 minutes morning and evening - the weight of the uterus is shifted forward, releasing the pressure on the uterus and allowing urine to drain more freely. ## **2.A Woman with Pneumonia** * Bacteria or viral infection of lung tissue by pathogens such as Streptococcus pneumoniae, Hemophilus influenzae and Mycoplasma pneumoniae. * After invasion, an acute inflammatory response occurs in the lung alveoli causing an exudate of RBC, fibrin and polymorphonuclear leukocytes to flood into the alveoli. * This process has a helpful effect of confining the bacteria or virus within the segments of the lobes of the lungs but it has a less helpful effect of filling alveoli with fluid, blocking off breathing space. * If the collection of fluid becomes extreme, it can limit the oxygen available not only for the woman but also for the fetus. * Associated with preterm labor due to oxygen deficit. ### **Treatment:** * Antibiotic and oxygen administration. ## **E. Respiratory Disorders and Pregnancy** ### **1. A Woman with Influenza** * Caused by a virus identified as type A, B, or C, * Associated with preterm labor and spontaneous miscarriage. ### **Signs and Symptoms** * Increased temperature * Sore throat. ### **Treatment:** * Antipyretic (Acetaminophen/Tylenol) - to control fever. * Oseltamivir (Taminflu). * Woman may be immunized against influenza. ## **2. A Woman with Asthma** * Marked by reversible airflow obstruction, airway hyperactivity and airway inflammation. * Triggered by an irritant such as an inhaled allergen (pollen, dust or cigarette smoke) * With inhalation of these allergen, there is a release of bioactive mediators such as histamine and leukotrienes from an immunoglobulin interaction. * This results in constriction of the bronchial smooth muscle. * Has the potential to reduce oxygen supply in the fetus. * There is an immediate release of histamine and leukotienes from an IgE; immunoglobulin interaction - leading to constriction of the bronchial smooth muscle. * Is improved during pregnancy because of high levels of corticosteroid. ### **Signs and Symptoms:** * Marked mucosal, inflammation and swelling. * Production of thick bronchial secretions ### **Treatment:** * Corticosteroid * NSAID * Heparin * Salicylates: * To decrease symptoms. * The naturally increased circulation of corticosteroid during pregnancy may lessen symptoms in some women. ### **Complications:** * Acute nephritis with glomerular destruction. * Increased BP. * Develop hematuria and decreased urine output. * PIH - no hematuria. * Diagnosis: frequent creatinine assessment - to assess kidney function ## **F. Rheumatic Disorders and Pregnancy** ### **A Woman with Systemic Lupus Eryrhematosus (SLE)** * Is a multisystem chronic disease of the connective tissue that can occur in women of childbearing age * Widespread degeneration of connective tissue (heart, kidneys, blood vessels, spleen, skin and retroperitoneal tissue) occurs with onset of the illness. ### **Signs and Symptoms:** * Marked skin change is a characteristic erythematous butterfly - shaped rash on the face. * Kidneys - fibrin deposits plugging and blocking the glomeruli and leading to necrosis and scarring * Blood vessels - thickening of collagen tissue cause vessel obstruction. * Life threatening to the woman if blood flow to vital organs is obstructed and also to the fetus. * Woman with SLE have antiphospholipid antibodies, which increases the tendency for *thrombi* to form. ### **To detect, test woman with Snellen test** * If symptoms continue, discontinue the drug. * Take Calcium - to ensure tuberculosis pockets forms are not broken down. * Wait for 1-2 years after the infection becomes inactive before attempting to conceive because recent inactive tuberculosis can become active during pregnancy. * Although tuberculosis can be spread by the placenta to the fetus, it usually spread to the infant after birth. * If with history of tuberculosis, 3 negative sputum culture before she holds or cares for her infant. * If negative, no need to isolate the infant to the mother. * If active TB is in the home, the infant is discharge prophylactic INH to prevent infection, with follow up skin testing at 3 months intervals. * If infant is to be placed on INH, a mother taking INH should not breastfeed or it might be toxic to the infant. ## **If 36 weeks - pregnant - C/S and removed the appendix** * If early pregnancy - laparoscopy. * If appendix ruptured before surgery - risk for both mother and fetus. *With ruptured appendix - infected materials are free in the peritoneum and can spread by the fallopian tubes to the fetus.* ### **Complications:** * Peritonitis * Infertility ## **2. A Woman with Cholecystitis and Cholelithiasis** * Cholecystitis - gallbladder inflammation and Cholelithiasis - gallbladder formation; gallstones are formed from cholesterol. ### **Predisposing Factors:** * Age * Obesity * Multiparity * High fat diet ### **Pregnant woman - the appendix is often displaced so far up in the abdomen that it resembles the pain of gallbladder disease** * CBC - leukocytosis; normal for non pregnant woman to have elevated WBC. * Increased temperature. * Ketones in the urine. ### **Diagnosis:** ultrasound. ### **Management:** * Advise the woman not to take any food, liquid or laxative - increased peristalsis tends to cause an inflamed appendix to rupture. ## **G.Gastrointestinal Disorders and Pregnancy** ### **1.A Woman with Appendicitis** * Inflammation of the appendix. ### **Assessment:** * Begins with few hours of nausea. * After 1-2H - generalized abdominal discomfort. * Vomiting. * Typical sharp, peristaltic, lower right quadrant pain. * If overstretched ligament pain - morning sickness pain is diffuse or sharp. * Non pregnant woman - the sharp localized pain appears at the McBurney's point (a point halfway between the umbilicus and the iliac crest on the lower right abdomen ## **Assessment: all forms of Hepatitis** * Nausea and vomiting. * Liver may feel tender to palpation. * Urine is light - colored from lack of bilirubin. * Jaundice - late symptom. * Physical examination - hepatomegaly (enlargement of the liver). * Bilirubin level increased. * Specific antibodies against the virus can be detected in the blood serum. ### **Management:** * Bed rest. * Increased caloric diet. ## **Hepa A** * Fecal - oral contact (children in day care settings). * Fecally contaminated H20 or shellfish after an incubation period of 2-3 weeks. * Woman may be given prophylactic gamma globulin to prevent the disease and exposure. * Not known to be transmitted to fetus. ## **Hepa B and C** * Exposure to contaminated blood or blood products. * Can be spread by contact with contaminated semen or vaginal secretions. * Considered as STD. * Incubation period - 6 weeks to 6 mos Hepa B. * Can lead to liver cirrhosis. * Hepa C - may demonstrate symptoms for 12 mos. ### **Treatment:** * Immune globulin for prophylaxis. ## **Signs and Symptoms:** * Constant aching and pressure in the right epigastrium. * Jaundice. ### **Diagnosis:** ultrtasound. ### **Management:** * Intake but not free fat diet during pregnancy because of the importance of linoleic acid for fetal grow. * If acute episode - IVF to provide fluid and nutrients and analgesics for pain. * Surgical removal of gallstone - laparoscopic technique. ## **3. A Woman with Hepatitis** * Liver disease that may occur from invasion of A, B, C, D and E virus. ## **Smooth muscle is not affected by the disease, labor should occur without complications** * Magnesium Sulfate - to halt preterm labor or treat hypertension of pregnancy should be avoided because it can diminish the acetycholine effect and increase symptoms. * An infant born to a woman with the disease may show symptoms at birth because of the transfer of antibodies. ## **2. A Woman with Multiple Sclerosis** * Nerve fibers become demyelinated and therefore lose functions. ### **Signs and Symptoms:** * Fatigue * Numbness * Blurred vision * Loss of coordination ## **1. Myasthenia Gravis** ### **H. Neurologic Disorders and Pregnancy** * An autoimmune disorder characterized by the presence of IgG antibody against actylcholine receptors in striated muscle. * Causes failure of the striated muscles to contract, particularly of the oropharyngeal, facila and extraocular groups. * Occurs usually at 20-30 year olds. ### **Treatment:/Management:** 1. **Medications:** * Anticholinesterase drugs such as: pyridostigmine (Mestinon) or neostigmine (Prostigmin)and corticosteroid such as prednisone. * May be continued during pregnancy as the fetus will experienced no effects from them. * Antropine - lifesaving antidote for neostigmine if an overdose should occur. 2. **Plasmapheresis-removal of and replacement of plasma/to remove immune complexes from the bloodstream.** ### **Standard precaution** * After birth - the infant should be washed well to remove any maternal blood and hepa B immune globulin (HBlg) and immunization against Hepa B should be administered. * Advise woman not to breastfeed because HBAg antigens can be removed from bowel movement. ### **Complications:** * Lead to spontaneous miscarriage or preterm labor. * Later in pregnancy - the mother contracts Hepa B, the greater the risk the infant will be affected or develop Hepa B. ## **Side Effects:** * Woman may have more than usual back pain from increased tension on back muscles. * If woman's pelvis is distorted, a caesarean birth may be scheduled to ensure a safe birth. * If vaginal birth, the same management is applied. * Cephalopelvic disproportion can be recognized during the first stage of labor. ## **I. Muskuloskeletal Disorders and Pregnancy** ### **1.A Woman with Scoliosis** * Lateral curvature of the spine. * Most common among girls between 12 and 14 years of age. * If not corrected at this time, the curvature progresses until it can interfere with respiration and heart action because of chest compression. * If a woman's spine is extremely curved, epidural anesthesia may be difficult to administer for pain management in labor. ### **Management:** * **Preventive Measures:** * Girls can wear body brace during their adolescent years to maintain an erect posture. * **Surgical management:** * Stainless steel rods implanted on both sides of the vertebrae to strengthen and straighten the spine. * Rods do not interfere with pregnancy. ### **Treatment and Management:** 1. **Medication:** * ACTH (adrenocorticotropic hormone) or corticosteroid- to strengthen nerve conduction and both can be administered safely during pregnancy. * Immunosuppressant such as cyclosporine (Sandimmune), azathioprine (Imuran), and cyclophosphamide (Cytoxan) which are usually prescribed should be used with caution during pregnancy. 2. **Plasmapheresis** ## **2.A Woman with Hyperthyroidism** * Overproduction of thyroid hormone. ### **Signs and Symptoms:** * Rapid heart rate. * Exopthalmia-protruding eyeballs. * Heat intolerance. * Heart palpitations. * Weight loss. ### **Graves disease- (overactive thyroid) seen mostly in pregnancy than in hypothyroidism** * If undiagnosed, woman may develop heart failure due to her heart already stresses, cannot manage the increasing blood volume that occurs during pregnancy. ### **Management and Treatment:** 1. **Medication** * levothyroxine (Synthroid)-to supplement lack of thyroid hormone. * Advice woman who is taking this medication and planning to conceive to consult her doctor to be certain her dose will be high enough to maintain a pregnancy. * Rule: dose of the medication will need to be increased as much as 20% to 30% for the duration of pregnancy to stimulate the increase that would normally occur in pregnancy. * caution: take the medication at a different time from any medication containing iron, calcium or any soy product by about 4 Hours to be certain there is no problem with the absorption of the drug. * After pregnancy, medication should be tapered back to the pre pregnancy level for both her health and so she can breastfeed safely. ## **J.Endocrine Disorders and Pregnancy** ### **1.A Woman with Hypothyroidism** * Underproduction of the thyroid hormone is a rare condition in late adolescents and especially rare in pregnancy because women with symptoms of untreated hypothyroidism are often anovulatory and unable to conceive. ### **Signs and Symptoms:** * Woman who conceive have difficulty increasing thyroid function to a necessary pregnancy level which can lead to spontaneous miscarriage. * Fatigue easily * Tend to be obese * Skin is dry (myxedema) * Have little tolerance to cold. * Hyperemesis gravidarum. ## **3.A Woman with Diabetes Mellitus** * Is an endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose level. ### **Classification:** * A. Type 1 Diabtetes Mellitus- a disorder that involves an absolute or relatively deficiency of insulin. * Results from immunologic damage to islet cells in susceptible individuals. * If one child in the family has diabetes, sibling will also develop the illness. * Disease Process: * Pancreas produce plenty of insulin (the hormone responsible for "unlocking" cells so that glucose can enter them and provide energy), but a condition known as insulin resistance prevents them from using it effectively. * When insulin doesn't work properly, blood glucose or blood sugar builds up in the bloodstream and gestational diabetes is the result. ### **If hyperthyroidism is not regulated during pregnancy, an infant may be born with symptoms of hyperthyroidism because of the excess stimulation he or she receives in utero.** ### **Signs and Symptoms among Newborn:** * Jittery with tachypnea and tachycardia. ### **Diagnosis:** * An assay of fetal cord blood will reveal the level of thyroxine (T4) and thyroid-stimulating hormone and the need for therapy in the infant. * Women who are taking minimal doses of anti thyroid drugs may breastfeed, if large dose, do not breastfeed because they are excreted in breast milk. * If woman desires other children, surgical treatment can be suggested to reduce the functioning of the maternal thyroid gland. ### **More prone to have gestational diabetes, fetal growth restriction and pre term labor** ### **Diagnosis:** * Using nuclear medicine imaging study involving radioactive uptake of I subtype. * Should not be used during pregnancy because the fetal thyroid would also incorporate this drug, resulting in destruction of the fetal thyroid. ### **Treatment:** * Thioamides (methimazole) or propythiouracil (PTUI)- reduce thyroid activity. * Cross the placenta and can lead to congenital hypothyroidism and enlarged thyroid gland(goiter) in the fetus. * Women should be regulated on the lowest possible dose and advice to keep a record of doses taken so as not to forget or unintentionally duplicate a dose. * *Methimazole* -drug off choice for pregnant women. ## **Among pregnant women:** * Increased thirst * Increased appetite ## **High serum cholesterol and ketoacidosis** * Potassium and Phosphate attempting to serve as buffers, pass from body cells into the bloodstream. ### **Assessment: among children** * Increased thirst * Increased urination * Dehydration that can also cause constipation. ## **From HYPERGLYCEMIA** * If kidneys detect this, it will excrete excess glucose into the urine. ### **Glycosuria** * Polyuria * Polydipsia * The body still needs source of energy, it will break down protein_and fat. * Weight loss and ketone bodies (the acid end product of fat breakdown). ## **Glucose screening Test** * Image of blood glucose test strips, meter and lancet ## **Assessment thru Laboratory Studies:** 1. **Random plasma glucose level greater than 200mg/dL** * Normal range: 70 to 110 mg/dL fasting: 90 to 180 mg/dL not fasting. 2. **Glucose Screening test - between 24 to 48 weeks; may be repeated at 32 weeks if obese or over age 40.** * After the oral 50g glucose load is ingested, a venous blood sample is taken for glucose determination 60 minutes after. * If the result is more than 140mg/dL, patient is scheduled for a 100g 3-H fasting glucose tolerance test. * If two of the four blood samples collected are abnormal or the fasting value is above 95mg/dL, a diagnosis of diabetes can be made. ## **Unusual fatigue**