Pre-gestational Conditions-1 PDF

NUR C202 Care of Mother and Child at Risk or with Problems (Acute and Chronic) By Gina M. Dumawal RN, MAN PREGESTATIONAL CONDITION RHEUMATIC HEART DISEASE (RHD) At the end of the discussion, the students will be able to:  PRE-GESTATIONAL CONDITION ❑ Rheumat...

NUR C202 Care of Mother and Child at Risk or with Problems (Acute and Chronic) By Gina M. Dumawal RN, MAN PREGESTATIONAL CONDITION RHEUMATIC HEART DISEASE (RHD) At the end of the discussion, the students will be able to:  PRE-GESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Is the inflammatory response from rheumatic fever, can permanently damage the valves in the heart. > Rheumatic Fever is an acute, nonsuppurative, immunologically mediated, multi- system inflammatory disease. Occurs a few weeks after an episode of group A Streptococcal pharyngitis. Affects: heart, joints, CNS, skin and subcutaneous tissues.  PREGESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Chronic, progressive, permanent heart valve damage that remains after the ARF episode has resolved wherein: - heart has become inflamed - heart valves remain stretched and/or scarred - normal blood flow is interrupted. > Sometimes RHD, especially mitral stenosis, 1st diagnosed during pregnancy or soon after delivery.  PRE-GESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Assessment 1. full history and examination > Risk factors 1. reduced left ventricle systolic function 2. significant aortic or mitral stenosis 3. moderate or severe pulmonary hypertension 4. a history of heart failure 5. symptomatic valvular disease before pregnancy 6. poverty, overcrowding & reduced access to medical care  PREGESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Symptoms 1. Chest pain, heart palpitations 2. Breathlessness on exertion 3. Orthopnea 4. Paroxysmal nocturnal dyspnea 5. Edema 6. Syncope 8. Fever associated with infection of damaged heart valves.  PREGESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Complications during Pregnancy 1. mitral valve stenosis 2. heart arrhythmia 3. heart failure > Diagnostic Tests 1. Chest x-ray 2. Electrocardiogram (ECG) 3. Echocardiogram  PREGESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > Treatment during Pregnancy 1. Diuretics: increase production & excretion of urine, which can help decrease blood volume and BP 2. Beta-blockers: treat & prevent heart arrhythmias. 3. Percutaneous balloon mitral valvuloplasty (PBMV): small balloon is inflated in the mitral valve to help keep it open.  PREGESTATIONAL CONDITION ❑ Rheumatic Heart Disease (RHD) > 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 management during pregnancy but or early in pregnancy, by a cardiologist and obstetrician to establish the safest birth pathway.  GESTATIONAL DIABETES MELLITUS (GDM) Learning Objectives At the end of the discussion, the students will be able to: 1. Define Gestational Diabetes Mellitus. 2. Explain the pathophysiology of Gestational Diabetes. 3. Explain the clinical manifestations of GDM. 4. State the diagnostic evaluation/studies GDM. 5. Explain the nursing assessment 6. State nursing diagnoses 7. Explain the nursing management and interventions and health teachings. 8. Explain the medical management. 9. State the complications of GDM.  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus > appearance of higher-than-expected blood sugars during pregnancy. > form of glucose intolerance with the onset or first recognition during pregnancy (24-28 wks of gestation). > primary problem in controlling balance between insulin and blood glucose levels.  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Etiology Hormonally induced insulin resistance Resulting in hyperglycemia Eventually progresses into diabetes  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Assessment - 3P’s (polyuria, polydipsia, polyphagia) - Dizziness if hypoglycemic - Confusion if hyperglycemic - Possibility of increased monilial infection - Glycosuria - Macrosomia - Hyperglycemia  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Pathophysiology  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Risk Factors for Developing GDM > Obesity > History of large babies > History of unexplained fetal or perinatal loss > Family history of diabetes  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Risks Associated With Diabetes in Pregnancy Maternal Risks Fetal Risks Preeclampsia Birth injuries Increased caesarean delivery Childhood obesity Progression of chronic complications of Hyperbilirubinemia diabetes Hypoglycemia Gestational hypertension Macrosomia Hypoglycemia Shoulder dystocia Infection Respiratory distress syndrome Ketoacidosis Premature birth Polyhydramnios Abnormal birth weight Preterm labor Increased congenital Seizures malformations Doubled spontaneous abortion risk Action of insulin and glucagon on blood Action of insulin and glucagon on glucose levels. (A) High blood glucose is blood glucose levels. (B) Low blood lowered by insulin release. glucose is raised by glucagon release.  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Diagnostic Studies - Fasting plasma glucose level - Random plasma glucose measurement - 2hr OGTT level (drink 75 g of glucose & do not eat anything until blood is drawn) - Fasting blood glucose level - Hemoglobin A1C test: No fasting required - Urine glucose/ketones: fresh urine specimen - Urine microalbumin: fresh urine specimen  High Risk Prenatal Client ❑ Gestational Diabetes Mellitus Components of Diabetes Management 1. Nutritional mgt. 2. Exercise 3. Monitoring 4. Pharmacologic mgt. 5. Education Goals of diabetes management Reduce symptoms Promote well-being Prevent acute complications Delay onset & progression of long-term complications SUBSTANCE ABUSE  Learning Objectives At the end of the discussion, the students will be able to: 1. Define substance abuse and addiction. 2. Outline the acute effects of alcohol, marijuana, and cocaine on the body 3. List several guidelines that can be used to maintain control over alcohol use 4. Outline the behavioral and physiological effects of alcohol as a function of the level of alcohol in the blood 5. Discuss the long-term health consequences of alcohol, marijuana, and cocaine use 6. Describe the addictive properties of tobacco and the impact of prolonged tobacco use on health 7. Describe the acute effects of caffeine on the body 8. Identify ways to reduce your risk of drug use High Risk Prenatal Client ❑ Substance Abuse Use of illegal or inappropriate use of legal drugs to: > produce pleasure, > alleviate stress, or > alter/avoid reality. Addiction > habitual psychological/physical dependence on substance/practice beyond voluntary control. High Risk Prenatal Client ❑ Substance Abuse Commonly Abused Substances Alcohol Illicit drugs including: – marijuana, cocaine, heroin – hallucinogens – inhalants – tranquilizers – stimulants – sedatives High Risk Prenatal Client ❑ Substance Abuse Pathophysiology > mother uses a drug → placenta & umbilical cord → fetus → permanent damage  High Risk Prenatal Client ❑ Substance Abuse Risks of Drug Use During Pregnancy - miscarriage, stillbirth - small gestational age (SGA), low birth weight (LBW) - premature birth, birth defects, sudden infant death syndrome (SIDS) - drug-dependency in the infant Teratogenic Effects of Prenatal Alcohol Exposure Direct toxic effect of alcohol on cells. Hypoxia due to impaired placental/fetal blood flow. Effect on cell migration in the brain. Effect on apoptosis (natural process of cell death). Behavioral disorders Fetal Alcohol Syndrome (permanent birth defect , cause of mental retardation)  High Risk Prenatal Client ❑ Substance Abuse Marijuana Use Marijuana smoking produces higher levels of carbon monoxide than tobacco, a potential mechanism of action of marijuana’s impact on the developing fetus. Long-term use causes psychological dependence/lung damage Effects of Marijuana: MOTHER: - relaxation, hallucination, panic attacks - short-term memory impairment, amnesia FETUS: - Intrauterine growth retardation - Abnormal startle reflexes in newborns - Reduced memory and verbal skills at age 4 years  High Risk Prenatal Client ❑ Substance Abuse Cocaine Exposure: produce direct neurotoxic effects. Prenatal Complications - stillbirth, placental abruption, premature rupture of membranes - fetal distress, preterm delivery, growth retardation Methamphetamine Exposure: produce neurotoxic effects. - premature delivery, placental abruption, cardiac anomalies - fetal growth reduction  High Risk Prenatal Client ❑ Substance Abuse Tobacco Exposure: Cigarette smoke contains; 1. Tar contains substances (lead, cyanide, cadmium, etc.) harmful to the fetus. 2. Nicotine crosses the placenta and distributes freely to the CNS, having effects on neural development. 3. Carbon monoxide causes intrauterine hypoxia and reduced uterine blood flow that leads to growth impairment. * Secondhand smoke contains toxic chemicals. Nicotine Effects on Smokers  Acute effects  Vasoconstriction,  secretions  Chronic effects  Lung disease, heart disease, Increases cancer risk  High Risk Prenatal Client ❑ Substance Abuse Tobacco Exposure: Nicotine Withdrawal on Mother Smoking Effects on Fetus: > craving for tobacco - poor fetal growth/IUGR > irritability, frustration, anger - LBW > anxiety - fetal death > difficulty concentrating - preterm delivery > restlessness - intrauterine hypoxia - spontaneous abortion > depression - placenta previa - SIDS risk >4x higher  High Risk Prenatal Client ❑ Substance Abuse Caffeine > Substance in coffee, tea, soft drinks, chocolate and certain medications. > Stimulates CNS w/in 15 minutes. > Moderate doses (2–4 cups of coffee) increases alertness/provide an energy boost. > Large doses = restlessness & irritability, insomnia, headaches and abnormal heart rhythms. > Creates psychological dependence > Withdrawal symptoms = headache, muscle pain and fatigue. HIV / AIDS  Learning Objectives At the end of the discussion, the students will be able to: 1. Define HIV/AIDS. 2. Identify the signs & symptoms including the causative agent of HIV/AIDS. 3. Discuss the pathophysiology, risk factors and the mode of transmission. 4. Explain the diagnostic exam for the HIV/AIDS. 5. Discuss the treatment/management and preventive measures.  High Risk Prenatal Client ❑ 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 system.  High Risk Prenatal Client ❑ HIV/AIDS Acquired Immune Deficiency Syndrome A = cquired not inherited. I = mmune system weakened. D = eficiency of CD4+ cells in the immune system created. S = yndrome or a group of illnesses taking place at the same time ▪ AIDS is caused by HIV ▪ AIDS diagnosis is made once opportunistic diseases occur.  High Risk Prenatal Client ❑ HIV/AIDS HIV infection -> destroy the immune system -> immune system weakened by HIV -> progresses to AIDS. Causes > Human immunodeficiency virus (HIV) causes HIV infection and AIDS, attacks the immune system. Etiologic Agent (AIDS) > Former names of the virus include: Human T cell lymphotrophic virus (HTLV-III) Lymphadenopathy associated virus (LAV) AIDS associated retrovirus (ARV)  High Risk Prenatal Client ❑ HIV/AIDS HIV continues to reproduce, CD4 count gradually declines from its normal value (500-1200). Once CD4 count drops below 500, HIV infected person is at risk for opportunistic infections. The following diseases are predictive of the progression to AIDS: persistent herpes-zoster infection (shingles) oral candidiasis (thrush) oral hairy leukoplakia Kaposi’s sarcoma (KS) High Risk Prenatal Client ❑ HIV/AIDS Oral Candidiasis (thrush) Oral Hairy Leukoplakia  High Risk Prenatal Client ❑ HIV/AIDS Kaposi’s sarcoma (KS) is a rare cancer of the blood vessels that is associated with HIV. It manifests as bluish-red oval-shaped patches that may eventually become thickened. Lesions may appear singly or in clusters.  High Risk Prenatal Client ❑ HIV/AIDS Opportunistic Infections - do not normally develop in people with a healthy immune system. Common symptoms are: > Fever, Chills > Rash > Sweats (particularly at night) > Swollen lymph glands > Weakness > Weight loss  High Risk Prenatal Client ❑ HIV/AIDS Symptoms - Diarrhea - Headache, Fever, Night sweats - Mouth sores, including yeast infection - Muscle stiffness or aching - Rashes of different types - Swollen lymph glands, sore throat - Chronic fatigue, Unexplained weight loss ▪ There may be no symptoms for up to 10 -12 years until the immune system is suppressed enough to cause problems  High Risk Prenatal Client ❑ HIV/AIDS Transmission of HIV 1. Direct contact; infected bld, semen, vaginal and cervical secretions 2. Sexual contact: oral, anal, or vaginal 3. HIV-infected mothers to infants during pregnancy, delivery and breastfeeding 5. Sharing of hypodermic needles & Blood transfusions (Rare)  High Risk Prenatal Client ❑ HIV/AIDS HIV is not transmitted: > Coughing, Sneezing > Insect bites > Touching, Hugging, Handshakes > Water, food > Kissing > Casual contact > Public baths > Using telephones > Sharing cups, glasses, plates, or other utensils  High Risk Prenatal Client ❑ HIV/AIDS People at Risk: > Injection drug users who share needles. > Infants born to mothers with HIV who did not receive HIV treatment during pregnancy. > People who have unprotected sex. > Sexual partners engaged in high-risk activities.  High Risk Prenatal Client ❑ HIV/AIDS Diagnostic Tests: 1. ELISA tests useful for: Screening blood products. Diagnosing and monitoring patients. Determining prevalence of infection. Research investigations. 2. Western Blot - most popular confirmatory test. 3. CBC and WBC differential 4. Pap smear, Anal pap smear 5. Indirect Immunoflourescence - used to detect both virus and antibody. 6. Polymerase Chain Reaction - looks for HIV DNA in the WBCs of a person. 7. Regular blood tests for CD4 cell count 8. HIV RNA level  High Risk Prenatal Client ❑ HIV/AIDS Treatment > Antiretroviral therapy Common Side Effects > Collection of fat on the back (buffalo hump) and abdomen > General sick feeling ( malaise), Weakness, Headache, Nausea > When used for a long time, increases risk of heart attack, perhaps by increasing levels of cholesterol and glucose (sugar) in the blood.  High Risk Prenatal Client ❑ HIV/AIDS Prevention > 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 High Risk Prenatal Client ❑ HIV/AIDS Prevention (cont.) > Public health strategies to prevent HIV transmission: 1. Screen all blood and blood products. 2. Follow universal precautions. 3. Educate in safer sex practices. 4. Identify & treat STIs/other infections. 5. Provide referral for treatment of drug dependence.  High Risk Prenatal Client ❑ HIV/AIDS When should a client be tested? If a client; 1. have had any STD. 2. shared drug needles. 3. had sex with a prostitute. 4. had sex w/ a man who had sex w/ another man. 5. had unprotected sex w/ 3 or more partners. Remember: Could take 3-6 mos. before antibodies appear in blood. No symptoms during incubation. Wait to be tested until 6 months with no risk behavior.  Rh SENSITIZATION  Learning Objectives At the end of the discussion, the students will be able to: 1. Explain Rh (Rhesus) disorder. 2. Identify the signs & symptoms including the etiology. 3. Discuss the pathophysiology, risk factors and complications of Rh disorder. 4. Explain the diagnostic examinations. 5. Discuss the treatment/management.  High Risk Prenatal Client ❑ Rh SENSITIZATION Rh (Rhesus) Factor - CHON that may be found on the surface of RBC’s, (+) CHON = Rh (+), (-) CHON = Rh (-). Rh Incompatibility - condition that develops when a pregnant woman is Rh(-) blood & the fetus has Rh(+).  High Risk Prenatal Client ❑ Rh SENSITIZATION 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.  High Risk Prenatal Client ❑ Rh SENSITIZATION Risk Factors > Risk for Rh incompatibility include being an Rh(-) pregnant woman who: 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 during/prior to pregnancy with an Rh(+) baby. Symptoms > Symptoms and complications only affect the baby which include: 1. Swelling of the body, which may be associated with heart failure or respiratory problems. 2. Jaundice, Anemia, Low muscle tone and lethargy  High Risk Prenatal Client ❑ Rh SENSITIZATION Possible Complications Include: 1. Brain damage due to high levels of bilirubin (kernicterus) 2. Fluid buildup & swelling in the baby (hydrops fetalis) 3. Problems w/ mental function, movement, hearing, speech, and seizures  Rh Antibodies Antibodies Coated Red Cells Destruction of Fetal Cells by Fetal RES Fetal Anemia Fetal Hypoxia and Stimulate of Erythropoitin Extra Medullary red Cells Synthesis Hepatomegally Hepatic Cell Failure Hypoproteinemia, Increased Intrahepatic Pressure, Portal hypertension Ascetic, Edema, hypoxia, Placental Thickness, Polyhydramnios, Pericardial effusion  High Risk Prenatal Client ❑ Rh SENSITIZATION Diagnostic Exam. 1. Maternal blood type, Rh factor and antibody screening. 2. A (+) direct Coombs test result- to look for the presence of cell-destroying antibodies on the surface of RBC’s. 3. Indirect Coomb’s test - to see if your Rh(+) antibody levels are increasing. > Fetal assessment includes: 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, such as fetal fluid retention. 4. Electronic fetal heart monitoring (nonstress test) – done on the 3rd trimester.  High Risk Prenatal Client ❑ Rh SENSITIZATION Treatment 1. RhoGAM (Rh immunoglobulin) - prevents Rh(-) mother's antibodies from reacting to baby’s Rh(+) RBC’s. Given around 28th wk of pregnancy & within 72 hours after delivery birth. 2. Phototherapy for infants - work by helping to break down bilirubin in the skin. Prevention: RhoGam injections must be given: > During every pregnancy > If they have a miscarriage/abortion > After prenatal tests (amniocentesis) > After injury to the abdomen during pregnancy  ANEMIA IN PREGNANCY Learning Objectives At the end of the discussion, the students will be able to: 1. Define anemia in pregnancy. 2. Identify the types of anemia in pregnancy. 3. Discuss the causes, signs & symptoms including the risk factors. 4. Discuss complications of anemia to the mother & fetus. 4. Explain the diagnostic examinations. 5. Discuss the prevention, treatment/management. © 2014 Pearson Education, Inc.  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Anemia - lack of RBC’s, can lead to lack of O2-carrying ability of the blood, causing unusual tiredness. Types of Anemia During Pregnancy - Iron-deficiency anemia - Folate-deficiency anemia - Vitamin B12 deficiency  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Iron-deficiency anemia (IDA) - the body doesn't have enough iron to produce adequate amounts of hgb. Folate-deficiency anemia - also called folic acid, a type of B vitamin. Folate produces new cells, including healthy RBC’s. Vitamin B12 deficiency - the body needs vitamin B12 to form healthy RBC’s.  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Symptoms: - Pale skin, lips, and nails - Feeling tired or weak - Dizziness or light-headedness - Shortness of breath - Palpitations - Trouble concentrating  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Risk Factors for Developing Anemia in Pregnancy > All pregnant women are at risk for becoming anemic because they need more iron & folic acid than usual, and the risk is higher if you: - are pregnant with multiples - have had two pregnancies close together - vomit a lot because of morning sickness - are pregnant teenager - don't eat enough foods that are rich in iron - had anemia before you became pregnant  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Risks of Anemia in Pregnancy > Severe or untreated IDA during pregnancy can increase the risk of having: - 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.  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY 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.  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Possible Complications - Difficulty in breathing, palpitations and angina - Severe anemia due to loss of blood after the delivery Diagnostic Tests - Hgb test - measures the amount of hgb, an iron-rich CHON in RBC’s that carries O2 from the lungs to tissues in the body. - Hct test - measures the percentage of RBC’s in a sample of blood. Treatment - iron supplement and/or folic acid supplement - vitamin B12 supplement to treat vit B12 deficiency - include more animal foods in a diet, such as meat, eggs and dairy products  High Risk Prenatal Client ❑ ANEMIA IN PREGNANCY Prevention - Eat well-balanced meals - Aim for at least 3 servings a day of iron-rich foods - Vitamin C can help the body absorb more iron - Choose foods that are high in folic acid - Follow your doctor's instructions for taking a prenatal vitamin that contains a sufficient amount of iron and folic acid. End of Slides