Module 3 Medical Complications in Pregnancy 2024-2025 PDF

New Era University College of Nursing NCM 109-18 Care of Mother, Child, At Risk or with Problems (Acute and Chronic) S.Y. 2024-2025 | 2nd Semester |Mid Term Modul...

New Era University College of Nursing NCM 109-18 Care of Mother, Child, At Risk or with Problems (Acute and Chronic) S.Y. 2024-2025 | 2nd Semester |Mid Term Module 3: Nursing Care of the High-risk Pregnant Client (Medical Complications in Pregnancy) Description More women enter pregnancy with a pre-existing disorder such as cardiac or respiratory illness that can complicate pregnancy. The utilization of the nursing focuses on close observation of maternal health and fetal well-being, education of a woman and her family about special danger signs to watch for during pregnancy, and actions to minimize complications whenever possible. This module includes information about illnesses and other events that can complicate pregnancy when they occur prior to or during pregnancy. Learning Outcomes LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation and application of appropriate nursing care to mothers with complications during pregnancy to achieve quality maternal and child nursing care. LO2 Apply maternal and child nursing concepts and principles in the prevention of complications during pregnancy that place the woman and her fetus at high risk. holistically and comprehensively. LO3 Assess mothers who is experiencing complication of pregnancy with the use of specific methods and tools to address existing health needs. LO4 Formulate nursing diagnoses to address needs / problems of mothers and her family experiencing complication of pregnancy. LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal outcomes for mothers and her family during a complication of pregnancy. LO7 Evaluate with mothers and family the expected outcomes for the effectiveness and achievement of care. LO8 Institute appropriate corrective actions to prevent or minimize complications during pregnancy. Module Outline I. Cardiovascular Disorder II. Hypertensive Disorders III. HELLP syndrome IV. Diabetes mellitus V. Urinary tract infection VI. Rh incompatibility VII. HIV/AIDS VIII. Substance abuse IX. Nursing Process for a woman with complications during pregnancy 1 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing Module All women desire pregnancy, including those with an underlying disease such as diabetes or heart disease, which can worsen with pregnancy. Some complications lead to early pregnancy loss or preterm delivery. Other complications arise due to specific characteristics of the mother, such as her age or her use of substances. Nursing care for a woman with a pre-existing illness focuses on close observation of maternal health and fetal well-being, education of a woman and her family about special danger signs to watch for during pregnancy, and actions to minimize complications whenever possible. In addition to pre-existing illnesses, the pregnant woman, like any person, may develop a new illness during a pregnancy. When this occurs, the illness can adversely affect not only the woman but also her unborn child. Nursing care for the well, pregnant woman focuses on preventing illness by promoting an especially healthy lifestyle. When accidents and illness occur despite these safeguards, nursing care focuses on: 1. Preventing such disorders from affecting the health of the fetus 2. Helping a woman regain her health as quickly as possible so she can continue a healthy pregnancy and prepare herself psychologically and physically for labor and birth and the arrival of her newborn 3. Helping a woman learn more about her chronic illness so she can continue to safeguard her health during her childrearing years I. Cardiovascular Disorder and Pregnancy The danger of pregnancy in a woman with cardiac disease occurs primarily because of the increase in circulatory volume. The most dangerous time for a woman is in weeks 28 to 32, just after the blood volume peaks. However, if heart disease is severe, symptoms can occur as early as the beginning of pregnancy. A woman’s heart may become so overwhelmed by the increase in blood volume toward the end of pregnancy that her cardiac output falls to the point that vital organs (including the placenta) are no longer perfused adequately. When this happens, neither the oxygen nor nutritional requirements of her cells or those of the fetus can be met. The estimation of whether a woman with cardiovascular disease can complete a pregnancy successfully or not depends on the type and extent of her disease. A. Assessment 1. Signs and symptoms of cardiac decompensation a. Cough and respiratory congestion b. Dyspnea and fatigue c. Palpitations and tachycardia d. Peripheral edema e. Chest pain 2. Signs of respiratory infection 3. Signs of heart failure and pulmonary edema To predict pregnancy outcome, heart disease is divided into four categories based on criteria established (Table 1). A woman with class I or II heart disease can expect to experience a normal pregnancy and birth. Women with class III can 2 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing complete a pregnancy by maintaining almost complete bed rest. Women with class IV heart disease are poor candidates for pregnancy because they are in cardiac failure even at rest and when they are not pregnant. They are usually advised to avoid pregnancy. Table 1. Classification of Heart Disease Class Description I Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no anginal pain. II Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal pain. III Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue, palpitations, dyspnea, or anginal pain. IV Severely compromised. Woman is unable to carry out any physical activity without experiencing discomfort. Even at rest symptoms of cardiac insufficiency or anginal pain are present. B. Interventions 1. Monitor vital signs, fetal heart rate, and condition of the fetus. 2. Limit physical activities and stress the need for sufficient rest. 3. Monitor for signs of cardiac stress and decompensation, such as cough, fatigue, dyspnea, chest pain, and tachycardia; also monitor for signs of heart failure and pulmonary edema. 4. Encourage adequate nutrition to prevent anemia, which would worsen the cardiac status; in addition, a low- sodium diet may be prescribed to prevent fluid retention and heart failure. 5. Avoid excessive weight gain. Excessive weight gain places stress on the heart. In addition, obesity places the client at increased risk for complications during pregnancy. 6. Medications: Digitalis, Iron preparations 7. During labor, prepare to do the following: a. Monitor vital signs frequently. b. Place the client on a cardiac monitor and on an external fetal monitor. c. Maintain bed rest, with the client lying on her side with her head and shoulders elevated. d. Administer oxygen as prescribed. e. Manage pain early in labor. f. Use controlled pushing efforts to decrease cardiac stress. g. Birth is via low forceps or Cesarean section h. Anesthetic choice – caudal anesthesia 8. During postpartum: 3 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing a. Most critical period: immediate postpartum period when 30 – 50% increased blood volume is reabsorbed back in 5 – 10 minutes and the weak heart needs to adjust. b. Ergotrate and other oxytocic, scopolamine, diethylstilbestrol and oral contraceptives are contraindicated because they can cause fluid retention and promote thromboembolism. II. Hypertensive Disorders in Pregnancy - Gestational hypertension is a condition in which vasospasm occurs in both small and large arteries during pregnancy, causing increased blood pressure. Preeclampsia is a pregnancy-related disease process evidenced by increased blood pressure and proteinuria. Preeclampsia affects almost all organs. The vascular spasm, caused by the increased cardiac output required by pregnancy and excess production of thromboxane, a prostaglandin vasoconstrictor, blood pressure increases dramatically. This also causes a reduced blood supply to organs: kidneys (results to proteinuria, lowered urine output and edema), pancreas (results in epigastric pain and elevated amylase-creatinine ratio), liver, brain (seizure/eclampsia), and placenta (Fig. 1). Poor placental perfusion reduces the fetal nutrient and oxygen supply. Figure 1. Physiologic changes with gestational hypertension - Risk Factors 1. Women of color 2. Multiple pregnancy 3. Primiparas younger than 20 years or older than 40 years of age 4. Women from low socioeconomic backgrounds (perhaps because of poor nutrition) 5. Five or more pregnancies 6. Polyhydramnios 7. Women with underlying disease such as heart disease, diabetes, renal disease. - Assessment 4 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing Preeclampsia is classified as preeclampsia without severe features, preeclampsia with severe features, and eclampsia. Table 2 describes each classification and symptoms. Table 2. Classification and symptoms of Gestational Hypertension Hypertension BP PROTEINURIA EDEMA/WT OTHER SYMPTOMS type GAIN Gestational 140/90 or None None None hypertension + 30/15 Preeclampsia 140/90 or 1+, 2+ ↑2lb/wk 2nd tri None without severe + 30/15 ↑1lb/wk 3rd tri features Mild edema of upper extremities Preeclampsia 160/110 3+, 4+ and Extensive Oliguria (400-600ml/24 hr) with severe 5g/24-hour peripheral ↑ serum creatinine, cerebral features edema or visual disturbances (headache, blurred vision) pulmonary and cardiac involvement, hepatic dysfunction (HELLP), thrombocytopenia, epigastric pain Eclampsia Severe classification. Acute cerebral edema leading to grand mal seizure or coma. ↑ maternal mortality, fetal hypoxia, premature separation of the placenta. - Intervention A. Preeclampsia without severe features 1. Usually managed at home with frequent follow-up care and fetal testing. 2. Monitor antiplatelet therapy. A low-dose aspirin is given. 3. Promote bed rest in a later recumbent position to promote sodium excretion and diuresis. 4. Promote good nutrition with adequate protein in diet. 5. Provide emotional support. B. Preeclampsia with severe features 1. Admitted to a health care facility. If greater than 37 weeks, delivery is performed. 2. Support bed rest with decrease stimulus (no bathroom privileges, quiet private room, dim lighted) 3. Monitor maternal wellbeing (BP q 4 hours, CBC, platelet count, renal and liver function, BUN, creatinine) 4. Monitor fetal wellbeing (FHR monitoring, NST, BPP) 5. Provide diet which high in protein and moderate in sodium. 6. IVF to reduce hemoconcentration and hypovolemia. 7. Administer hydralazine (Apresoline) or nifedipine to reduce hypertension. 5 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing 8. Administer magnesium sulfate to prevent seizure. Maintain serum level of 5 to 8mg/dl. Monitor for signs of toxicity (respiratory depression, cardiac arrhythmias, cardiac arrest). Calcium gluconate as antidote at bedside. C. Eclampsia - Eclampsia refers to the occurrence of a seizure. It is a potentially preventable extension of severe preeclampsia; early identification of preeclampsia in a pregnant client allows intervention before the condition reaches the seizure state. - An eclamptic seizure is a tonic-clonic type that occurs in stages. 1. Aura – It is also the preliminary signal that something is happening. 2. Tonic phase – Lasts approximately 20 seconds. All the muscles of the woman’s body contract. Her back arches, her arms and legs stiffen, and her jaw closes so abruptly she may bite her tongue she may bite her tongue. Respirations halt because her thoracic muscles are held in contraction. Woman may grow cyanotic from cessation of respirations. 3. Clonic phase – Lasts up to 1 minute. The woman’s bladder and bowel muscles contract and relax; incontinence of urine and feces may occur. Although a woman begins to breathe during this stage, the breathing is not entirely effective so she may remain cyanotic. 4. Postictal stage – The longest phase, during which the woman is unconscious. - If eclampsia occurs: 1. Remain with the client and call for help. 2. Ensure an open airway, turn the client on her side, and administer oxygen by face mask at 8 to 10 L/minute. 3. Monitor fetal heart rate patterns. 4. Administer medications to control the seizures as prescribed (magnesium sulfate or valium) 5. After the seizure has ended, insert an oral airway and suction the client’s mouth as needed. 6. Prepare for delivery of the fetus after stabilization of the client, if warranted. 7. Document occurrence (duration of seizure), client’s response, and outcome. - During Birth a. If the fetus has reached a point of viability, a decision about birth will be made as soon as a woman’s condition stabilizes, usually 12 to 24 hours after the seizure. b. Cesarean birth is always more hazardous for the fetus than vaginal birth because of the associate of retained lung fluid. A woman with severe high blood pressure is not a good candidate for surgery. She may become hypotensive with regional anesthesia, such as an epidural block. c. The preferred method for birth is vaginal with a minimum of anesthesia. - Postpartum period a. Postpartum preeclampsia may occur up to 10-14 days after birth, although is usually occurs within 48 hours after birth. b. Monitor blood pressure and health care visits and being alert for preeclampsia which occur as late as 2 weeks post birth to detect residual hypertension. 6 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing III. HELLP SYNDROME HELLP syndrome is a variation of PIH named for the common symptoms that occur: A. hemolysis that leads to anemia B. elevated liver enzymes that lead to epigastric pain C. low platelets that lead to abnormal bleeding/clotting and petechia The syndrome occurs in 4% to 12% of patients with PIH. It is a serious syndrome because it results in a maternal mortality rate as high as 24% and an infant mortality rate as high as 35%. - Risk factors a. Primigravids and multigravidas b. Antiphospholipid syndrome or presence of phospholipid syndrome - Assessment 1. Signs of PIH: proteinuria, edema, increased BP 2. Epigastric pain 3. General malaise 4. Right upper quadrant tenderness from liver inflammation occurs 5. Bleeding 6. Laboratory studies: a. Hemolysis of red blood cells b. Thrombocytopenia (a platelet count >100,000/mm3) c. Elevated liver enzyme levels (alanine aminotransferase [ALT] and serum aspartate aminotransferase [AST] - Complications 1. Cerebral hemorrhage 2. Aspiration pneumonia 3. Hypoxic encephalopathy 4. Fetal growth restriction and preterm birth - Interventions 1. Transfusion of fresh-frozen plasma or platelets. 2. If hypoglycemia is present, this is corrected by an intravenous glucose infusion. 3. The infant is born as soon as feasible by either vaginal or cesarean birth. 4. Observe for maternal hemorrhage may occur at birth because of poor clotting ability. 5. Epidural anesthesia may not be possible because of the low platelet count and the high possibility of bleeding at the epidural site. 7 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing IV. Diabetes Mellitus - Pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change. Maternal glucose crosses the placenta, but insulin does not. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions. The newborn of a diabetic mother may be large in size, but has functions related to gestational age rather than size. The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and congenital anomalies. During the first trimester, maternal insulin needs decrease. During the second and third trimesters, increases in placental hormones cause an insulin resistant state, requiring an increase in the client’s insulin dose. After placental delivery, placental hormone levels abruptly decrease, and insulin requirements decrease. - Gestational diabetes mellitus Gestational diabetes occurs in pregnancy (during the second or third trimester) in clients not previously diagnosed as diabetic and occurs when the pancreas cannot respond to the demand for more insulin. Pregnant women should be screened for gestational diabetes between 24 and 28 weeks of gestation. A 3-hour oral glucose tolerance test is performed to confirm gestational diabetes mellitus. Gestational diabetes frequently can be treated by diet alone; however, some clients may need insulin. Most women with gestational diabetes return to a euglycemic state after birth; however, these individuals have an increased risk of developing diabetes mellitus in their lifetimes. A. Predisposing conditions to gestational diabetes 1. Older than 25 years 2. Obesity 3. History of large babies (10 lb or more) 4. History of unexplained fetal or perinatal loss 5. History of anomalies in previous pregnancies 6. History of polycystic ovary syndrome 7. Family history of diabetes B. Assessment 1. Screening for gestational diabetes a. Fasting plasma glucose greater than or equal to 126mg/dl b. Non fasting glucose greater or equal to 200 mg/dl c. 50-g glucose challenge test between 24- and 28-week gestation of 140 mg/dl d. 3-hour glucose tolerance test § Sample for fasting glucose test is obtained § Woman drinks an oral 100-g glucose solution § A venous blood sample is taken for glucose determination at 1, 2, 3 hours later. 8 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing § If two of the four blood samples collected for this are abnormal or fasting value is above 95 mg/dl, a diagnosis is made (Table 3) Table 3. Oral glucose challenge test values after a 100-glucose solution. Test type Pregnant Glucose Level (mg/dl) Fasting 95 1 hr 180 2 hr 155 3 hr 140 2. Excessive thirst 3. Hunger 4. Weight loss 5. Frequent urination 6. Blurred vision 7. Recurrent urinary tract infections and vaginal yeast infections 8. Glycosuria and ketonuria 9. Signs of gestational hypertension C. Complications 1. Maternal effects: uteroplacental insufficiency, risk of dystocia, polyhydramnios, infection 2. Fetal effects: fetal mortality, risk of congenital abnormalities, hypoxia, delayed lung maturity, LGA (macrosomia), hypoglycemia D. Interventions 1. Employ diet, medications (if diet cannot control blood glucose levels), exercise, and blood glucose monitoring. 2. Observe for signs of hyperglycemia, glycosuria and ketonuria, and hypoglycemia. 3. Monitor weight. 4. Increase calorie intake as prescribed, with adequate insulin therapy so that glucose moves into the cells. 5. Assess for signs of maternal complications such as preeclampsia (hypertension and proteinuria). 6. Monitor for signs of infection. 7. Instruct the client to report burning and pain on urination, vaginal discharge or itching, or any other signs of infection. 8. Assess fetal status and monitor for signs of fetal compromise. a. Serum alpha-feto protein level obtained at 15 – 17 weeks to assess for neural tube defects b. Ultrasound at 18 to 20 weeks to detect gross abnormalities, fetal growth, amniotic fluid volume, placental location and biparietal diameter. c. Creatinine Clearance test for each trimester to assess adequate uterine perfusion. d. Weekly Non-stress test or biophysical profile during the last trimester; Movements in an hour = 10 movements 9 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing e. Lecithin – Sphingomyelin ratio f. Phosphatidyl glycerol at amniocentesis is used to assess lung maturity instead of L/S ratio E. Interventions during labor 1. Monitor fetal status continuously for signs of distress and, if noted, prepare the client for immediate cesarean section. 2. Carefully regulate insulin and provide glucose intravenously as prescribed because labor depletes glycogen. F. Interventions during the postpartum period 1. Observe the mother closely for a hypoglycemic reaction because a precipitous decline in insulin requirements normally occurs (the mother may not require insulin for the first 24 hours). 2. Reregulate insulin needs as prescribed after the first day, according to blood glucose testing. 3. Assess dietary needs, based on blood glucose testing and insulin requirements. 4. Monitor for signs of infection or postpartum hemorrhage. V. Rh incompatibility (Isoimmunization) Rh incompatibility occurs when: 1. Mother is an Rh-negative mother (one negative for a D antigen or one with a dd genotype) 2. Fetus with an Rh-positive blood type (DD or Dd genotype). 3. Father of the child must either be homozygous (DD) or heterozygous (Dd) Rh-positive. - If the father of the child is homozygous (DD) for the factor, 100% of the couple’s children will be Rh-positive (Dd). - If the father is heterozygous for the trait, 50% of their children can be expected to be Rh-positive (Dd). Because people who have Rh-positive blood have a protein factor (the D antigen) that Rh-negative people do not, when an Rh-positive fetus begins to grow inside an Rh-negative mother who is sensitized, it is as though her body is being invaded by a foreign agent. Her body reacts in the same manner it would if the invading factor were a substance such as a virus: she forms antibodies against the invading substance. The Rh factor exists as a portion of the red blood cell, so these maternal antibodies cross the placenta and cause red blood cell destruction (hemolysis) of fetal red blood cells. A fetus can become so deficient in red blood cells that sufficient oxygen transport to body cells cannot be maintained. This condition is termed hemolytic disease of the newborn or erythroblastosis fetalis. Theoretically, there is no connection between fetal blood and maternal blood during pregnancy, however that an occasional villus ruptures, allowing a drop or two of fetal blood to enter the maternal circulation. However, fetal blood transfer to maternal blood from a damaged villus when: 1. Amniocentesis or percutaneous umbilical blood sampling 2. As the placenta separates after birth of the first child. Therefore, most of the maternal antibodies formed against the Rh-positive blood are not formed during pregnancy but in the first 72 hours after birth, making them a threat to a second pregnancy. A. Assessment 1. Anti-D antibody titer above 1:8 (antibody to Rh negative) 10 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing 2. Coomb’s test positive – maternal blood showing presence of antibodies. 3. Fetal anemia detected by Doppler velocity. B. Intervention 1. Rh (D) immune globulin (RhIG), a commercial preparation of passive Rh (D) antibodies against the Rh factor, is administered to women who are Rh-negative at 28 weeks of pregnancy and the first 72 hours after birth of an Rh- positive child to further prevent the woman from forming natural antibodies if Coomb’s test is negative. 2. Intrauterine transfusion to treat fetal anemia. VI. Urinary Tract Infection - The pregnant woman is prone to UTI due to: 1. The ureters dilate from the effect of progesterone, stasis of urine occurs. 2. The minimal glucosuria allows more than the usual number of organisms to grow. 3. Vesicoureteral reflux (backflow of urine into the ureters) - E. coli is the usual cause - May cause premature labor and premature rupture of membranes if severe, untreated or pyelonephritis develops. A. Assessment 1. Frequency and urgency of urination 2. Suprapubic pain 3. Flank pain (if kidney involved) 4. Hematuria 5. Pyuria 6. Fever and chills B. Interventions 1. Encourage high fluid intake 2. Provide warm baths to relieve discomfort and promote perineal hygiene 3. Stress good bladder-emptying schedule 4. Monitor for signs of premature labor from severe or untreated infection 5. Administer and monitor intake of prescribed medications (antibiotics, urinary analgesics) VII. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) - HIV is the causative agent of AIDS. Women infected with HIV may first show signs and symptoms at the time of pregnancy or possibly develop life-threatening infections because normal pregnancy involves some suppression of the maternal immune system. Repeated exposure to the virus during pregnancy through unsafe sex practices or IV drug use can increase the risk of transmission to the fetus. - A mother with HIV is managed as high risk because she is vulnerable to infections. 11 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing A. Transmission 1. Sexual exposure to genital secretions of an infected person 2. Parenteral exposure to infected blood and tissue 3. Perinatal exposure of an infant to infected maternal secretions through birth or breast-feeding. B. Diagnosis 1. Tests used to determine the presence of antibodies to HIV include enzyme-linked immunosorbent assay (ELISA), Western blot, and immunofluorescence assay (IFA). 2. A single reactive ELISA test by itself cannot be used to diagnose HIV, and the test should be repeated with the same blood sample; if the result is again reactive, follow-up tests using Western blot or Immunofluorescence antibody test (IFA) should be done. 3. A positive Western blot or IFA is considered confirmatory for HIV. 4. A positive ELISA that fails to be confirmed by Western blot or IFA should not be considered negative and repeat testing should be done in 3 to 6 months. C. WHO disease staging system for HIV infection and disease (September 2005) Stage I: HIV disease is asymptomatic and not categorized as AIDS. Stage II: includes minor mucocutaneous manifestations and recurrent upper respiratory tract infections. Stage III: includes unexplained chronic diarrhea for longer than a month, severe bacterial infections, and pulmonary tuberculosis Stage IV: includes toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma; these diseases are indicators of AIDS. D. Assessment Early 1. Fever 2. Headache 3. Tiredness 4. Enlarged lymph nodes Late 1. Lack of energy 2. Frequent fevers and sweats 3. Persistent or frequent yeast infections (oral or vaginal) 4. Persistent skin rashes or flaky skin 5. Pelvic inflammatory disease in women that does not respond to treatment 6. Short-term memory loss 7. Weight loss E. Interventions 12 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing - Zidovudine is recommended for the prevention of maternal-to-fetal HIV transmission and is administered orally beginning after 14 weeks of gestation, intravenously during labor, and in the form of syrup to the newborn for 6 weeks after birth. Prenatal period 1. Prevent opportunistic infections. 2. Avoid procedures that increase the risk of perinatal transmission, such as amniocentesis and fetal scalp sampling. Intrapartum period 1. If the fetus has not been exposed to HIV in utero, the highest risk exists during delivery through the birth canal. 2. Avoid the use of internal scalp electrodes for monitoring of the fetus. 3. Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal. 4. Avoid the administration of oxytocin because contractions induced by oxytocin can be strong, causing vaginal tears or necessitating an episiotomy. 5. Place heavy absorbent pads under the mother’s hips to absorb amniotic fluid and maternal blood. 6. Minimize the neonate’s exposure to maternal blood and body fluids; promptly remove the neonate from the mother’s blood after delivery. 7. Suction fluids from the neonate promptly. 8. Prepare to administer zidovudine as prescribed to the mother during labor and delivery. Postpartum period 1. Monitor for signs of infection. 2. Place the mother in protective isolation if she is immunosuppressed. 3. Restrict breast-feeding. 4. Instruct the mother to monitor for signs of infection and report any signs if they occur. The newborn and HIV 1. Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after birth; all neonates acquire maternal antibody to HIV infection, but not all acquire infection. 2. The use of antiviral medication, reduced exposure of the neonate to maternal blood and body fluids, and early identification of HIV in pregnancy reduce the risk of transmission to the neonate. 3. Interventions a. Bathe the neonate carefully before any invasive procedure, such as the administration of vitamin K, heel sticks, or venipunctures; clean the umbilical cord stump meticulously every day until healed. b. The newborn can room with the mother. Administer zidovudine to the newborn as prescribed for the first 6 weeks of life. c. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. d. HIV culture is recommended at 1 and 4 months after birth; infants at risk for HIV infection should be seen by the HCP at birth and at 1 week, 2 weeks, 1 month, 2 months, and 4 months of age. 13 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing e. The child may be asymptomatic for the first several years of life and should be monitored for early signs of immunodeficiency. f. Infants at risk for HIV infection need to receive all recommended immunizations on the regular schedule; however, no live vaccines should be administered. VIII. Substance abuse - Substance abuse is defined as the inability to meet major role obligations, an increase in legal problems or risk-taking behavior, or exposure to hazardous situations because of an addicting substance. A person is substance dependent when he or she has withdrawal symptoms following discontinuation of the substance, combined with abandonment of important activities, spending increased time in activities related to substance use, using substances for a longer time than planned, or continued use despite worsening problems because of substance use. - Many women with substance dependency come late in their pregnancy for prenatal care because they are worried their substance use will be discovered and they are worried their substance use will be discovered and they will be reported to authorities. The most abused substances are cocaine, amphetamines, marijuana and hashish, phencyclidine, narcotic agonists, inhalants, alcohol. Substance Forms Effects to the Effects to the Effects to the newborn mother fetus/during pregnancy Cocaine – Powder form Vasoconstrictor Compromised placental Intracranial derived from sniffed or High BP; circulation; abruptio hemorrhage; Erythroxylum smoked in a respiratory and placenta; preterm labor withdrawal syndrome coca pipe; detected cardiac arrest or fetal death; of tremulousness, in the urine irritability, and muscle after 1 week rigidity. use Amphetamines Similar to Neurotoxin; Similar to cocaine Jitteriness and poor cocaine blackened and feeding at birth and infected teeth may be growth restricted. Marijuana and Smoked Tachycardia; Preterm birth; low birth Reduced maternal milk Hashish from sense of weight; fetal production which cannabis wellbeing; short- development affects the nutrition of term memory restrictions the newborn loss and respiratory infection; counteracts nausea. Phencyclidine Street drug in Increased Increased concentration Small for gestational also known as polydrug abuse; cardiac output in the fetal circulation. age and poor muscle angel dust pill; powder or and euphoria. Birth defects control; irritable, (animal crystal form; Long term sensitive to sound; tranquilizer) swallowed or hallucination birth defects injected (flashback episodes); 14 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing Narcotic Intradermal, Potent analgesic, Fetal opiate Preterm birth; severe Agonists inhalation, euphoric effect, dependence; fetal withdrawal symptoms; (morphine, intravenous sedation; PIH; distress; meconium forced maturation of meperidine, Hepa B and HIV aspiration the liver and lungs codeine infection Inhalants Sniffing or Severe Limits fetal oxygen Similar to fetal alcohol (airplane glue; huffing respiratory and supply syndrome cooking sprays; cardiac computer irregularities keyboard cleaner) Alcohol Oral ingestion CNS depressant; Teratogen. Fetal alcohol syndrome drowsiness Growth restrictions. (FAS): cognitive challenges and memory deficit; craniofacial deformities (short palpebral fissures; thin upper lip; microcephaly; cerebral palsy), weak sucking reflex, sleep disturbances; growth deficiency; hyperactivity. Infants are tremulous and irritable. IX. Nursing Process A. Assessment Accurate prenatal assessment of a woman with a preexisting or newly acquired illness requires a thorough understanding of the signs and symptoms of illnesses, such as cardiovascular disease or diabetes mellitus, in addition to an understanding of the course of a normal pregnancy. Assessment techniques include objective measures such as establishing baseline vital signs as well as subjective factors such as the extent of edema or level of exhaustion a woman is experiencing. Such assessment is best made by health care personnel who care for a woman consistently throughout the pregnancy so that subtle changes in data can be recognized. In the absence of a consistent care provider, teach a woman to assess her own health in relation to objective parameters. She could report exhaustion, for example, in relation to daily activity such as, “Two weeks ago I could walk a block without being short of breath. Today I could walk only half a block”; “The last time I was in for a checkup, edema didn’t occur until bedtime. Now I notice it every afternoon by the time my son comes home from school.” B. Nursing Diagnosis Nursing diagnoses developed for a woman with a high-risk pregnancy address her specific, disease-related condition as require. Examples of possible nursing diagnoses are: 1. Ineffective tissue perfusion (cardiopulmonary) related to poor heart function secondary to mitral valve prolapse during pregnancy. 15 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing 2. Social isolation related to prescribed bed rest during pregnancy secondary to concurrent illness. 3. Ineffective role performance related to increasing level of daily restrictions secondary to chronic illness and pregnancy. 4. Knowledge deficit related to normal changes of pregnancy versus illness complications. 5. Fear regarding pregnancy outcome related to chronic illness. 6. Health-seeking behaviors related to the effects of illness on pregnancy. 7. Situational low self-esteem related to illness during pregnancy. C. Outcome Identification and Planning Be certain that expected outcomes established are realistic in light of a woman’s pregnancy and the restrictions placed on her by her health. One family member with illness affects all family members; therefore, outcomes should relate to the entire family’s health. Try to make plans with a woman who has a preexisting medical condition based on the pattern of her life before the pregnancy. A primary goal for a woman with a severe chronic condition might be to maintain her health during pregnancy, so she can remain at home as long as possible, thereby minimizing hospitalization and family disruptions. D. Implementation Nursing interventions for the pregnant woman with a chronic illness may focus on teaching her new or additional measures to maintain health because of the pregnancy. Imaginative solutions to problems may need to be created because a woman may be unable to adjust to the extent of changes she must make. An illness during pregnancy can complicate not only a pregnancy but also a woman’s entire lifestyle and that of her family. Women who think of pregnancy as a time of wellness may have a great deal of difficulty accepting a medical regimen such as daily blood glucose monitoring because this is contradictory to their primary belief about pregnancy. Women in extended families may have an easier time accepting hospitalization during pregnancy than those living in nuclear families, because more people are available to take over their role at home. If the fetus is injured or the pregnancy disrupted, the event may cause a great deal of stress, and a woman and her partner may need counseling to overcome feelings of guilt and anger. Assessing all families individually and asking about the effect on the entire family of an illness during pregnancy helps to identify concerns and can lead to timely solving. E. Outcome Evaluation If evaluation of outcomes at health care visits reveals that an expected outcome is not being met, new assessment, analysis, and planning need to be done. In some instances, an outcome is not met because a woman did not understand the need for an additional pregnancy measure. In another instance, a woman may need better psychological support to continue to follow a health care routine consistently. Nine months is a long time to adhere to restrictions. Make evaluation ongoing to ensure that you know throughout the pregnancy whether interventions are successful. Some examples of outcomes that might be established are: 1. Client states she rests for 2 hours morning and afternoon; dependent edema remains at 1_ or less at next prenatal visit. 16 Module 3 Medical Complications in Pregnancy  New Era University College of Nursing 2. Family members state they are all participating in an exercise program since mother developed gestational diabetes. 3. Client reports no burning on urination or flank pain at next prenatal visit. Integrative Activity Watch the following videos: 1. PIH https://www.youtube.com/watch?v=yta5RRJ-Mg8 2. Rh incompatibility https://www.youtube.com/watch?v=4hCzGhQPrzk 3. Diabetes mellitus in pregnancy https://www.youtube.com/watch?v=UIQgolIGQEU References Silbert-Flagg, J. (2022). Maternal and child health nursing: Care of the childbearing and childbearing family (9th ed.). Philadelphia, PA: WoltersKluwer. Famorca, Z.U., M.A.Nies and M. McEwen. Nursing Care of the Community: A comprehensive text on community and public health nursing in the Philippines (6th ed.). Singapore, Elsevier. Prepared by: MELANIE C. TAPNIO, MAN, RN Assistant Professor 17 Module 3 Medical Complications in Pregnancy