Week 2 and 3 Reviewer PDF

Pre- existing or Newly Acquired “Care Given to a Mother Experiencing a If pulmonary capillaries rupture under Pregnancy Complication from a Pre- existing the pressure, small amounts of blood or Newly Acquired” leak into the alveoli...

Pre- existing or Newly Acquired “Care Given to a Mother Experiencing a If pulmonary capillaries rupture under Pregnancy Complication from a Pre- existing the pressure, small amounts of blood or Newly Acquired” leak into the alveoli Pulmonary edema – orthopneic A.Cardiovascular Disease and Pregnancy Paroxysmal nocturnal dyspnea – ⮚ The danger of pregnancy in a woman suddenly waking at night with with cardiac disease occurs primarily shortness of breath – occurs because due to the increase in circulatory heart action is more effective when she volume is at rest ⮚ The most dangerous time for a woman Medication: is in 28 to 32 weeks, after the blood Anti hypertensive – to control increased volume peaks. BP A 1. Woman with Left Sided Heart Failure: Diuretics – to reduce blood volume Beta blockers – to improve ventricular Occurs in condition such as mitral filling stenosis, mitral insufficiency and aortic coarctation. The left ventricle cannot Diet: move the volume of blood forward that Low sodium diet is received by the left atrium from the pulmonary circulation Medical Management: The level for the failure is often at the Serial UTZ and non stress test after 30 – level of the mitral valve 32 weeks of pregnancy and monitor FHR The normal physiologic tachycardia of Surgical Management: pregnancy shortens diastole ( atrial ⮚ Balloon valve angioplasty to loosen contraction) and decreases the time mitral valve adhesions available for blood to flow across this valve ⮚ If an anticoagulant is required, heparin is the drug of choice – it does not cross The inability of the mitral valve to push the placenta blood forward causes back-pressure on the pulmonary circulation, causing it A 2. Woman with Right Sided Heart Failure to become distended, systemic blood Causes: pressure decreases in the face of lowered cardiac output and pulmonary Congenital heart defects hypotension occurs. Pulmonary valve stenosis and atrial When pressure in the pulmonary vein and ventricular septal defects reaches a point of 25 mm Hg, fluid Occurs when the output of the right begins to pass from the pulmonary ventricle is less than the blood volume capillary membranes into the received by the right atrium from the interstitial spaces surrounding the vena cava alveoli and into the alveoli leads to Back pressure from this results in Pulmonary Edema congestion of the systemic venous circulation and decreased cardiac Pulmonary Edema output to the lungs Interferes with oxygen-carbon dioxide exchange because fluid coats the alveolar exchange space  Pre- existing or Newly Acquired ⮚ Blood pressure decreases in the aorta Sign/Symptoms : because less blood is reaching it Shortness of breath, chest pain and ⮚ Pressure is high in the vena cava, both nondependent edema, cardiomegaly jugular distention and increased portal Therapy/Management: circulation occur Reduce physical activity, diuretic, Signs and Symptoms: arrhythmia agent, digitalis therapy, ⮚ Liver and spleen distended – leading to immunosuppressive therapy. dyspnea and pain in pregnant woman _______________________________ because the enlarged liver, as it pressed upward by the enlarged uterus, Classification of heart disease puts extreme pressure on the Uncompromised diaphragm Ordinary physical activity causes no ⮚ Ascites – distention of abdominal discomfort. No symptoms of cardiac vessels can lead to exudates of fluid insufficiency and no angina pain. from the vessels into the peritoneal cavity Slightly compromised ⮚ Peripheral edema – fluid also moves Ordinary physical activity causes from the systemic circulation into lower excessive fatigue, palpitation, and extremity interstitial spaces dyspnea or angina pain. Eisenmenger Syndrome Markedly compromised The congenital anomaly most apt to During less than ordinary activity, cause the right sided heart failure in patient experiences excessive fatigue, women of reproductive age. palpitations, dyspnea or angina pain. Management: Severely compromised Oxygen administration Patient is unable to carry out any Frequent arterial blood assessment to physical activity without experiencing ensure fetal growth discomfort. Even at rest, symptoms of During labor – pulmonary artery cardiac insufficiency or angina pain are catheter to monitor pulmonary present. pressure B. Hematologic Disorders and Pregnancy Close monitoring to minimize the risk of hypotension after epidural anesthesia ⮚ Involves either blood formation or coagulation disorders A 3. pregnant patient with peripartum HD Anemia and Pregnancy Rare condition happened that can originate in pregnancy in those with no Because the blood volume expands previous history of heart disease. during pregnancy slightly ahead of the red cell count, most women have a Cause: pseudoanemia of early pregnancy. This Unknown ( stress from being pregnant) condition is normal and should not be confused with true types of anemia.  Pre- existing or Newly Acquired True anemia – woman’s hemoglobin (hgb) 3. Ferrous Sulfate or Ferrous Gluconate- concentration is less than 11 g/dL 120-200 mg elemental iron per day (hematocrit:hct < 33%) during the first and 4. Advise woman to take orange juice or a third trimester of pregnancy when hgb vitamin c – Reason: iron is absorbed in concentration is < 10.5 g/dL (hematocrit < 32%) an acid medium during the second trimester Result: Woman with Iron-Deficiency Anemia New red blood cells should begin to Most common anemia of pregnancy increase almost immediately or Causes: reticulocyte count should rise from 0.5% and 1.5% to 3% and 4% by two weeks Diet low in iron- low socio economic status Possible Effects: Heavy menstrual flow Constipation – high fiber diet, increase Unwise weight –reducing programs fluid intake 6-8 glasses per day Getting pregnant less than 2 years Gastric irritation – take oral tablet with before the current pregnancy full stomach Pica Turning stools black in color-advice ⮚ Iron is made available in the body by woman that this is normal absorption from the duodenum into the * If iron deficiency is severe and woman has bloodstream after it has been ingested difficulty in taking oral tablet, Intravenous iron ⮚ In the bloodstream it is bound for can be prescribed. transport to the liver, spleen and bone Woman with Folic Acid-Deficiency Anemia marrow. ⮚ Folic- acid or folate or folacin ⮚ At this site, it is incorporated into hemoglobin or stored as ferritin. IMPORTANCE: SIGNS AND SYMPTOMS: One of the B vitamins which is necessary for the normal formation of ⮚ Extreme fatigue and poor exercise red blood cells in the woman tolerance Helps in preventing neural tube and Reason: abdominal wall defects in the fetus Woman cannot transport oxygen Common among: effectively Multiple pregnancies- increased fetal ⮚ Associated with low birth weight and demands preterm birth. Women with secondary hemolytic illness, due to rapid destruction and ⮚ The body recognizes that it needs production of new red blood cells increased nutrients, some women with Women taking hydantoin, an this condition develop pica anticonvulsant agent that interferes “Management for Anemia and IDA” with folate absorption Women who have poor gastric 1. Intake of prescribed prenatal vitamins absorption containing 27 mg of iron as prophylactic therapy during pregnancy 2. Advise woman to eat diet high in iron and vitamins: green leafy vegetables, meat and legumes  Pre- existing or Newly Acquired Megaloblastic anemia – enlarged red blood Races usually affected: cells – type of anemia that develops Blacks has sickle-cell trait or carries a Because of the size of the cells, the recessive gene for S hemoglobin but mean corpuscular volume will be asymptomatic elevated in contrast to the lowered level Effects on pregnancy: seen with iron-deficiency anemia Blockage to the placental circulation Management: can directly compromise the fetus ⮚ All women expecting to become causing low birth weight and possibly pregnant should begin to take 400 ug fetal death folic acid daily plus eating folate foods Assessment: such as: green leafy vegetables, oranges, dried beans) Screening at the first pre-natal visit: hemoglobin analysis Woman with Sickle-Cell Anemia -Women with the condition – hemoglobin: 6- Sickle-Cell Anemia is a recessively 8 mg/100 ml inherited hemolytic anemia caused by an abnormal amino acid in the beta Urinalysis- due to vascular stasis, chain of hemoglobin. women are prone to bacteriuria If the abnormal amino acid replaces Monitor a woman’s nutritional intake-if the amino acid saline, sickling sufficient folic acid is consumed hemoglobin results Ensure woman is drinking at least 8 If it is substituted for the amino acid glasses of fluid daily to prevent lysine, non sickling hemoglobin results dehydration An individual who is heterozygous (with Assess lower extremities for varicosities only one gene in which the abnormal which can lead to red cell destructions substitution has occurred, has the sickle Monitor fetal health by an ultrasound cell trait examination at 16-24 weeks to assess If the person is homozygous (with two for intrauterine fetal growth genes in which substitution has THERAPEUTIC MANAGEMENT: occurred, sickle cell disease results With the disease, the majority of RBC Periodic exchange or blood are irregular or sickle shaped, so they transfusions throughout pregnancy to cannot carry as much hemoglobin as replace sickled cells with non sickled normally shaped RBC can. cells- serves as a secondary purpose of When oxygen tension becomes removing a quantity of the increased reduced, as occurs at high altitudes, or bilirubin resulting from the breakdown blood becomes more viscid than usual, of RBC as well as restoring the like in dehydration, the cells clump hemoglobin level. together because of their irregular If crisis occurs, controlling pain, shape, resulting in vessel blockage with administering oxygen and increasing reduced blood flow to the organs the fluid volume of the circulatory The cells will hemolyze, (destroyed), system to lower viscosity reducing the number available and If with infection- hospitalization causing severe anemia If fetus is mature, the time and method of delivery are considered  Pre- existing or Newly Acquired *keep the woman well hydrated during labor Von Willebrand disease and delivery A coagulation disorder inherited as an *epidural anesthesia is the method of choice autosomal dominant trait and occurs in women During post partal period: early ambulation, and wearing pressure ⮚ Women have normal platelet counts stockings or IPC boots can help reduce but bleeding time is prolonged the risk of thromboembolism from ⮚ Levels of factor VIII-related antigen stasis in lower extremities (VIII-R) and factor VIII coagulations Parents are generally interested in activity (VIII-C) are both reduced. determining the condition of the infant ⮚ Since childhood, woman with the The condition is recessively inherited, if disorder might have menorrhagia or one of the parents has the disease and frequent episodes of epistaxis the other is free, the chance the child ⮚ Cannot diagnose immediately if not will inherit the disease is zero. severe, until the woman got pregnant If the woman has the disease and her and experiences a spontaneous partner has the trait, the chance the miscarriage or postpartum child will inherit the disease is 50% hemorrhage. If both parents has the disease, all their children will have also have the disease. Management: The Woman with Thalassemia Replacement of the missing factors by blood transfusion of cryoprecipitate or ⮚ Thalassemia are a group of autosomal fresh frozen plasma before labor to recessively inherited blood disorders prevent excessive bleeding with birth that lead to poor hemoglobin formation and severe anemia. 2.Hemophilia B (Christmas Disease) ⮚ Most common in Mediterranean, ⮚ Factor IX deficiency, is a sex linked African and Asian populations disorder ⮚ Symptoms first appear in childhood ⮚ Occur only in males ⮚ Treatment: combating anemia through ⮚ Females are carriers and may have a folic acid supplementation and reduced level of factor IX (only 33% of sometimes, blood transfusion to infuse normal) that results to hemorrhage hemoglobin-rich RBC with labor, or a spontaneous miscarriage ⮚ Women with the condition usually do not take iron supplementation during ⮚ Carriers of the disorder should be pregnancy because they could receive identified before pregnancy an iron overload because iron is infused Hemophilia B (Christmas Disease) with blood transfusions ⮚ Factor IX deficiency, is a sex linked C. Coagulation Disorders and Pregnancy disorder ⮚ Most coagulation disorders are sex ⮚ Occur only in males linked or occur only in males and so have little effect on pregnancies ⮚ 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  Pre- existing or Newly Acquired ⮚ Carriers of the disorder should be Assessment: Based on signs and symptoms identified before pregnancy Pain on urination Management: In case of Pyelonephritis – woman develops ⮚ Restoration of factor IX by infusion of pain in the lumbar region usually on the right factor IX concentrate or fresh frozen side that radiates downward plasma Area is tendered upon palpation ⮚ Maternal serum analysis can be used to Nausea and vomiting detect whether a fetus has a Malaise coagulation disorder during pregnancy Frequency of urination Temperature – 103 – 104 degrees F Idiopathic Thrombocytopenic Purpura (ITP) Diagnosis: ⮚ A decreased number of platelets is not inherited Urine culture – reveal over 100,000 organnisms per milliliter of urine ⮚ Can occur at anytime in life and can occur during pregnancy Therapeutic Management: ⮚ Cause is unknown ⮚ Clean catch urine ⮚ Symptoms usually occur shortly after a ⮚ Culture and Sensitivity (C & S) – to viral invasion such as an upper determine what antibiotic needs to be respiratory tract infection prescribed ⮚ It is assumed to be an autoimmune ⮚ Examples: Amoxicillin, Ampicillin and reaction (an antiplatelet antibody that Cephalosporins – safe antibiotics destroys platelets is apparently during pregnancy released) ⮚ Sulfonamides – can be used early in ⮚ Laboratory analysis reveal a marked pregnancy but not near term because thrombocytopenia-platelet count is as they interfere with protein binding of low as 20,000/mm3 from a usual count bilirubin, which can lead to of 150,000/mm3 hyperbilirubinemia in newborn ⮚ If adequate number of platelet, the ⮚ Tetracyclines are contraindicated in woman is prone to frequent nosebleeds pregnancy – can cause retardation of and minute petechiae or large bone growth and staining of the fetal ecchymosis appear on her body. teeth D. Renal and urinary Disorders and Precautionary Measures: Pregnancy ⮚ Voiding frequently at least every two Woman with Urinary Tract Infection hours ⮚ Caused by Escherichia coli from an ⮚ Wiping from front to back after bowel ascending infection movement ⮚ Can also be a descending infection – ⮚ Wearing cotton, non synthetic fiber can begin in the kidneys from the underwear filtration of organisms present from ⮚ Voiding immediately after sexual other body infections intercourse ⮚ If caused by Streptococcus B – ⮚ Drinking an increased amount of fluid to indicates the woman has an extensive flush out the infection from the urinary infection tract – up to 3 – 4L/24H  Pre- existing or Newly Acquired Other Measures: The glomerular filtration rate are normally increases during pregnancy, Knee chest position for 15 minutes the woman is able to clear waste morning and evening – the weight of products from her body for both herself the uterus is shifted forward, releasing and the fetus with such efficiency that the pressure on the uterus and allowing her serum creatinine is slightly below urine to drain more freely. normal during pregnancy If with Pyelonephritis – hospitalized for 24H – normal creatinine level – 0.7 mg per 100 48H then place on home care and treated with ml of blood. IV antibiotics During pregnancy – 0.5 mg per 100 ml of blood Ater this episode – maintained on a If more than 2.0 mg/dL – advise the drug such as Oral Nitrofurantoin woman not to get pregnant because it (Macrodanti) for the remainder of the can lead to kidney failure pregnancy There is a possibility of glucose and Acidifying the urine by the use of protein in the urine during pregnancy Ascorbic Acid (Vit. C) which is often because of increased glomerular recommended in non pregnancy permeability women Not recommended during pregnancy Treatment: because the newborn can develop Corticosteroid (prednisone) – infant scurvy in the immediate neonatal may be hyperglycemic at birth period because of the suppression of insulin After birth – IVP scheduled to help activity by corticosteroid detect any urinary tract abnormality Dialysis - to aid kidney function that might be present E. Respiratory Disorders and Pregnancy Woman with Chronic Renal Disease Woman with Influenza ⮚ before, women with this chronic renal disease did not reach childbearing age ⮚ Caused by a virus identified as type A,B, or were advised not to have children or C because of their automatic high-risk ⮚ Associated with preterm labor and status during pregnancy. spontaneous miscarriage ⮚ Today, with conscientious prenatal Signs and Symptoms care, women with this condition, who have had renal transplants can expect ⮚ Increased temperature to have healthy pregnancies and ⮚ Sore throat healthy children Treatment: ⮚ Pregnancy increases the workload of the kidneys because they must excrete ⮚ Antipyretic (Acetaminophen/Tylenol) – waste products not only for the woman to control fever but also for the fetus for 40 weeks ⮚ Oseltamivir (Taminflu) ⮚ Can cause severe anemia on women ⮚ Woman may be immunized against because their diseased kidneys do not influenza produce erythropoietin, a glycoprotein necessary for red cell formation and so, they may develop a severe anemia  Pre- existing or Newly Acquired Woman with Pneumonia Signs and Symptoms: Bacteria or viral infection of lung tissue ⮚ Marked mucosal, inflammation and by pathogens such as Streptococcus swelling pneumoniae, Hemophilus influenzae ⮚ Production of thick bronchial secretions and Mycoplasma pneumoniae After invasion, an acute inflammatory ⮚ Difficulty with air exchange response occurs in the lung alveoli ⮚ High pitched whistling sound (bronchial causing an exudate of RBC, fibrin and wheezing) polymorphonuclear leukocytes to flood into the alveoli ⮚ If ineffective, inhaled glucocorticoid This process has a helpful effect of such as Beclomethasone confining the bacteria or virus within the (Beclovent/Vancrenase) or fluticasone segments of the lobes of the lungs but ( Flovent), an oral corticosteroid such as it has a less helpful effect of filling prednisone or a mast cell stabilizer alveoli with fluid, blocking off breathing such as Intal may be added to the space regimen If the collection of fluid becomes Woman with Tuberculosis extreme, it can limit the oxygen available not only for the woman but ⮚ Caused by Mycobacterium also for the fetus Tuberculosis – an acid fast bacilus Associated with preterm labor due to Assessment: oxygen deficit ⮚ PPD test Treatment; ⮚ Follow up CXR with (+) reactions – ⮚ Antibiotic and oxygen administration abdomen should be covered A woman with Asthma Signs and Symptoms: ⮚ Marked by reversible airflow ⮚ Chronic cough obstruction, airway hyperactivity and ⮚ Sudden Weight loss airway inflammation ⮚ Hemoptysis ⮚ Triggered by an irritant such as an ⮚ Night sweats inhaled allergen (pollen, dust or ⮚ Low grade fever cigarette smoke) ⮚ Chronic fatigue *With inhalation of these allergen, there is a Treatment: release of bioactive mediators such as ⮚ Isoniazid (INH) – result in peripheral histamine and leukotrienes from an neuritis in women if doesn’t take immunoglobulin interaction. Pyridoxine (Vit B6) *This results in constriction of the bronchial ⮚ Ethambutol Hydrochloride smooth muscle (Myambutol) ⮚ Has the potential to reduce oxygen ⮚ Rifampicin supply in the fetus * No teratogenic affect *There is an immediate release of histamine and leukotienes from an IgE; immunoglobulin * Main cause optic nerve involvement: atrophy interaction – leading to constriction of the and loss of green color recognition bronchial smooth muscle. Is improved during pregnancy because of high levels of corticosteroid  Pre- existing or Newly Acquired ⮚ To detect, test woman with Snellen test ⮚ Life threatening to the woman if blood ⮚ If symptoms continue, discontinue the flow to vital organs is obstructed and drug also to the fetus ⮚ Take Calcium – to ensure tuberculosis ⮚ Woman with SLE have antiphospholipid pockets forms are not broken down antibodies, which increases the ⮚ Wait for 1-2 years after the infection tendency for thrombi to form. becomes inactive before attempting to conceive because recent inactive Treatment: tuberculosis can become active during ⮚ Corticosteroid pregnancy ⮚ Although tuberculosis can be spread by NSAID (nonsteroidal anti-inflammatory the placenta to the fetus, it usually drugs) spread to the infant after birth ⮚ Heparin ⮚ If with history of tuberculosis, 3 negative sputum culture before she holds or ⮚ Salicylates cares for her infant To decrease symptoms ⮚ If negative, no need to isolate the infant ⮚ The naturally increased circulation of to the mother corticosteroid during pregnancy may *If active TB is in the home, the infant is lessen symptoms in some women discharge prophylactic INH to prevent Complications: infection, with follow up skin testing at 3 months intervals ⮚ Acute nephritis with glomerular destruction *If infant is to be placed on INH, a mother ⮚ Increased BP taking INH should not breastfeed or it might be ⮚ Develop hematuria and decreased toxic to the infant urine output F. Rheumatic Disorders and Pregnancy ⮚ PIH – no hematuria Woman with Systemic Lupus Eryrhematosus Diagnosis: (SLE) ⮚ Frequent creatinine assessment – to ⮚ Is a multisystem chronic disease of the assess kidney function connective tissue that can occur in Gastrointestinal Disorders and Pregnancy women of childbearing age Woman with Appendicitis ⮚ Widespread degeneration of connective tissue ( heart, kidneys, blood ⮚ Inflammation of the appendix vessels, spleen, skin and retroperitoneal Assessment: tissue) occurs with onset of the illness ⮚ Begins with few hours of nausea Signs and Symptoms: ⮚ After 1-2H – generalized abdominal ⮚ Marked skin change is a characteristic discomfort erythematous butterfly – shaped rash on the face ⮚ Vomiting ⮚ Kidneys - fibrin deposits plugging and ⮚ Typical sharp, peristaltic, lower right blocking the glomeruli and leading to quadrant pain necrosis and scarring ⮚ If overstretched ligament pain – ⮚ Blood vessels – thickening of collagen morning sickness pain is diffuse or tissue cause vessel obstruction sharp  Pre- existing or Newly Acquired ⮚ Non pregnant woman – the sharp Signs and Symptoms: localized pain appears at the ⮚ Constant aching and pressure in the McBurney’s point (a point halfway right epigastrium between the umbilicus and the iliac crest on the lower right abdomen. ⮚ Jaundice ⮚ Pregnant woman – the appendix is Diagnosis: often displaced so far up in the abdomen that it resembles the pain of ⮚ Ultrasound gallbladder disease Management: ⮚ CBC – leukocytosis; normal for non pregnant woman to have elevated ⮚ Intake but not free fat diet during WBC pregnancy because of the importance ⮚ Increased temperature of linoleic acid for fetal grow ⮚ Ketones in the urine ⮚ If acute episode – IVF to provide fluid and nutrients and analgesics for pain Diagnosis: ⮚ Surgical removal of gallstone – ⮚ Ultrasound laparoscopic technique Management: Woman with Hepatitis ⮚ Advise the woman not to take any food, ⮚ Liver disease that may occur from liquid or laxative – increased peristalsis invasion of A, B, C, D and E virus tends to cause an inflamed appendix to Hepa A rupture ⮚ Fecal – oral contact (children in day ⮚ If 36 weeks – pregnant – C/S and care settings) removed the appendix ⮚ Fecally contaminated H20 or shellfish ⮚ If early pregnancy – laparoscopy after an incubation period of 2-3 weeks ⮚ Woman may be given prophylactic ⮚ If appendix ruptured before surgery – gamma globulin to prevent the disease risk for both mother and fetus and exposure * with ruptured appendix – infected materials ⮚ Not known to be transmitted to fetus are free in the peritoneum and can spread by Hepa B and C the fallopian tubes to the fetus Exposure to contaminated blood or Complications: blood products ⮚ Peritonitis Can be spread by contact with ⮚ Infertility contaminated semen or vaginal secretions Woman with Cholecystitis and Considered as STD Cholelithiasis Incubation period – 6 weeks to 6 mos - Cholecystitis Hepa B Can lead to liver cirrhosis ⮚ Gallbladder inflammation and Hepa C – may demonstrate symptoms Cholelithiasis – gallbladder formation; for 12 mos gallstones are formed from cholesterol Treatment: Predisposing Factors: Immune globulin for prophylaxis ⮚ Age ⮚ Obesity ⮚ Multiparity ⮚ High fat diet  Pre- existing or Newly Acquired Assessment: all forms of Hepatitis Treatment:/Management: Nausea and vomiting Medications: Liver may feel tender to palpation ⮚ Anticholinesterase drugs such as: Urine is light – colored from lack of pyridostigmine (Mestinon) or bilirubin neostigmine (Prostigmin)and Jaundice – late symptom corticosteroid such as prednisone Physical examination – hepatomegaly (enlargement of the liver) ⮚ May be continued during pregnancy as Bilirubin level increased the fetus will experienced no effects Specific antibodies against the virus from them can be detected in the blood serum ⮚ Antropine – lifesaving antidote for Management: neostigmine if an overdose should occur Bed rest Increased caloric diet Plasmapheresis: Standard precaution Removal of and replacement of plasma/to remove immune complexes After birth – the infant should be from the bloodstream washed well to remove any maternal Smooth muscle is not affected by the blood and hepa B immune globulin ( disease, labor should occur without HBIg) and immunization against complications Hepa B should be administered Magnesium Sulfate – to halt preterm Advise woman not to breastfeed labor or treat hypertension of because HBAg antigens can be pregnancy should be avoided because removed from bowel movement it can diminish the acetycholine effect Complications: and increase symptoms. An infant born to a woman with the Lead to spontaneous miscarriage or disease may show symptoms at birth preterm labor because of the transfer of antibodies. Later in pregnancy – the mother contracts Hepa B, the greater the Woman with Multiple Sclerosis risk the infant will be affected or Nerve fibers become demyelinated and develop Hepa B therefore lose functions H. Neurologic Disorders and Pregnancy Signs and Symptoms: Myasthenia Gravis Fatigue ⮚ An autoimmune disorder characterized Numbness by the presence of IgG antibody Blurred vision against actylcholine receptors in Loss of coordination striated muscle Treatment and Management: ⮚ Causes failure of the striated muscles Medication: to contract, particularly of the oropharyngeal, facila and extraocular ⮚ ACTH (adrenocorticotropic hormone) groups or corticosteroid- to strengthen nerve conduction and both can be ⮚ Occurs usually at 20-30 year olds administered safely during pregnancy.  Pre- existing or Newly Acquired ⮚ Immunosuppressant such as ⮚ Cephalopelvic disproportion can be cyclosporine (Sandimmune), recognized during the first stage of azathioprine (Imuran), and labor. cyclophosphamide (Cytoxan) which J.Endocrine Disorders and Pregnancy are usually prescribed should be used with caution during pregnancy Woman with Hypothyroidism Plasmapheresis: ⮚ Underproduction of the thyroid hormone is a rare condition in late I. Muskuloskeletal Disorders and Pregnancy adolescents and especially rare in Woman with Scoliosis pregnancy because women with symptoms of untreated ⮚ Lateral curvature of the spine hypothyroidism are often anovulatory ⮚ Most common among girls between 12 and unable to conceive. and 14 years of age Signs and Symptoms: ⮚ If not corrected at this time, the ⮚ Woman who conceive have curvature progresses until it can difficulty increasing thyroid function interfere with respiration and heart to a necessary pregnancy level action because of chest compression which can lead to spontaneous ⮚ If a woman’s spine is extremely curved, miscarriage epidural anesthesia may be difficult to ⮚ Fatigue easily administer for pain management in ⮚ Tend to be obese labor ⮚ Skin is dry (myxedema) ⮚ Have little tolerance to cold Management: ⮚ Hyperemesis gravidarum Preventive Measures: Management and Treatment: ⮚ Girls can wear body brace during their Medication adolescent years to maintain an erect posture ⮚ Levothyroxine (Synthroid)-to supplement lack of thyroid hormone Surgical management: ⮚ Advice woman who is taking this ⮚ Stainless steel rods implanted on both medication and planning to conceive sides of the vertebrae to strengthen to consult her doctor to be certain her and straighten the spine dose will be high enough to maintain a ⮚ Rods do not interfere with pregnancy pregnancy Side Effects: *Rule: dose of the medication will need to be increased as much as 20% to 30% for the ⮚ Woman may have more than usual duration of pregnancy to stimulate the back pain from increased tension on increase that would normally occur in back muscles pregnancy ⮚ If woman’s pelvis is distorted, a *Caution: take the medication at a different caesarean birth may be scheduled to time from any medication containing iron, ensure a safe birth calcium or any soy product by about 4 Hours ⮚ If vaginal birth, the same management to be certain there is no problem with the is applied absorption of the drug ⮚ ⮚  Pre- existing or Newly Acquired ⮚ *Methimazole –drug of choice for ⮚ After pregnancy, medication should pregnant women be tapered back to the pre ⮚ If hyperthyroidism is not regulated pregnancy level for both her health during pregnancy, an infant may be and so she can breastfeed safely born with symptoms of Woman with Hyperthyroidism hyperthyroidism because of the excess stimulation he or she receives in utero. ⮚ Overproduction of thyroid hormone Signs and Symptoms among Newborn Signs and Symptoms: ⮚ Jittery with tachypnea and tachycardia ⮚ Rapid heart rate ⮚ Exopthalmia-protruding eyeballs Diagnosis: ⮚ Heat intolerance ⮚ An assay of fetal cord blood will reveal ⮚ Heart palpitations the level of thyroxine (T4) and thyroid- ⮚ Weight loss stimulating hormone and the need for Graves disease- (overactive thyroid) seen therapy in the infant mostly in pregnancy than in hypothyroidism ⮚ Women who are taking minimal doses of anti thyroid drugs may breastfeed, if ⮚ If undiagnosed, woman may develop large dose, do not breastfeed because heart failure due to her heart already they are excreted in breast milk. stresses, cannot manage the ⮚ If woman desires other children, increasing blood volume that occurs surgical treatment can be suggested to during pregnancy reduce the functioning of the maternal ⮚ More prone to have gestational thyroid gland diabetes, fetal growth restriction and pre term labor Woman with Diabetes Mellitus Diagnosis: ⮚ Is an endocrine disorder in which the pancreas cannot produce adequate ⮚ Using nuclear medicine imaging study insulin to regulate body glucose level involving radioactive uptake of I subtype Classification: ⮚ Should not be used during pregnancy A. Type 1 Diabtetes Mellitus because the fetal thyroid would also incorporate this drug, resulting in ⮚ A disorder that involves an absolute or destruction of the fetal thyroid relatively deficiency of insulin. Treatment: ⮚ Results from immunologic damage to islet cells in susceptible individuals Thioamides (methimazole) or propythiouracil (PTUI)- reduce thyroid ⮚ If one child in the family has diabetes, activity sibling will also develop the illness ⮚ 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,  Pre- existing or Newly Acquired Disease Process: ⮚ If two of the four blood samples collected are abnormal or the fasting ⮚ Pancreas produce plenty of insulin ( the value is above 95mg/dL, a diagnosis of hormone responsible for “unlocking” diabetes can be made cells so that glucose can enter them and provide energy), but a condition Fetal Monitoring After Diagnosis of GD: known as insulin resistance prevents ⮚ Non Stress Test – or periodic ultrasound them from using it effectively. When around 32 weeks to check for the bay’s insulin doesn’t work properly, blood well being glucose or blood sugar builds up in the bloodstream and gestational diabetes ⮚ Also called as biophysical profile is the result. ⮚ The test measures the baby’s fetal From HYPERGLYCEMIA heart rate, both at rest and during movement, by attaching a monitor to ⮚ If kidneys detect this, it will excrete the mother’s abdomen. Monitoring is excess glucose into the urine done for 20 to 30 minutes, noting any ⮚ Glycosuria fetal distress. ⮚ Polyuria ⮚ Polydipsia ⮚ If the baby is getting too big – insulin will ⮚ The body still needs source of energy, it be started will break down protein and fat Maternal Effects: ⮚ Weight loss and ketone bodies (the acid end product of fat breakdown) ⮚ Hypoglycemia – during the first trimester Assessment: among children ⮚ Hyperglycemia – during the third ⮚ Increased thirst trimester ⮚ Frequent infection ⮚ Increased urination ⮚ Moniliasis ⮚ Dehydration that can also cause ⮚ Polyhaydramnios constipation ⮚ Dystocia Assessment thru Laboratory Studies: Fetal Effects: Random plasma glucose level greater than ⮚ Hypoglycemia 200mg/dL ⮚ Preterm Birth ⮚ Hyperglycemia ⮚ Normal range: 70 to 110 mg/dL fasting: ⮚ Macrosomia 90 to 180 mg/dL not fasting Type 2 Diabetes Glucose Screening test – between 24 to 48 weeks; may be repeated at 32 weeks if obese ⮚ The causes of type 2 diabetes are or over age 40 obesity, diet, life styles, smoking, alcohol consuming, stress etc. ⮚ After the oral 50g glucose load is ingested, a venous blood sample is General Management: taken for glucose determination 60 ⮚ Depends on how serious the condition minutes after is. ⮚ If the result is more than 140mg/dL, ⮚ Glucose monitoring – home glucose patient is scheduled for a 100g 3-H meter or strips. normal blood glucose fasting glucose tolerance test level –70 to 110 mg/dL fasting: 90 to 180 mg/dL not fasting.  Pre- existing or Newly Acquired ⮚ Balance Diet – based on height, weight GESTATIONAL DIABETES and activity level; must have the correct A condition of abnormal glucose balance of protein, fats and metabolism that arises during carbohydrates, proper vitamins, pregnancy. minerals and calories Possible increase risk of type 2 DM later ⮚ Moderate exercise – walking and in life. swimming; but is not advisable for IMPAIRED GLUCOSE HOMEOSTASIS everyone State between normal and diabetes in ⮚ Insulin therapy – if cannot be controlled which the body is no longer using or with diet and exercise secreting insulin properly Signs and Symptoms: Impaired fasting glucose- a state when fasting plasma glucose is at least 110 ⮚ Shrill, high pitch cry but under 126mg/dl ⮚ Tremors Impaired glucose tolerance-a sate ⮚ Hypocalcemia – less than 7 mg/dL when results of the oral glucose ⮚ Hypocalcemia also may be apparent in tolerance test are at least 140 but under the first few hours after birth; symptoms 200 mg/dl in the 1hour sample. may include jitteriness or seizure activity. Hypocalcemia (levels Irreversible shock infection that get worse very quickly. It can arise from infections throughout >Waterhouse-Friderichesen syndrome the body, including infections in the >Adult respiratory distress syndrome lungs, abdomen, and urinary tract (ARDS) Septicemia can rapidly lead to septic Ectopic Pregnancy shock and death. Septicemia Occurs when gestation is located associated with some organisms outside the uterine cavity/tubal (germs) such as meningogococci can pregnancies lead to shock, adrenal collapse, and disseminated intravascular Causes: coagulopathy, a condition called Fallopian tube damage often from Waterhouse-Friderichsen syndrome infection-can block the fertilized egg’s Signs and Symptoms: path to the uterus causing it to implant and grow in the tube Fever (sudden onset, often spiking) Chills Surgery Toxic looking (looks acutely ill) Endometriosis Changes in mental state Smoking Irritable Previous ectopic pregnancy Lethargic Anxious  Sudden Pregnancy Complication Pelvic infection – chlamydia or Future Pregnancies: gonorrhea 30% who have had ectopic pregnancy Fertility drugs that increase egg will have difficulty becoming pregnant production again Pelvic or abdominal surgery If the fallopian tube has been spared, Risks: the chances of a future successful Can damage the fallopian tube pregnancy are 60%. Even if one fallopian tube has been removed, the Signs and Symptoms: chances of having a successful Normal signs of pregnancy pregnancy with the other tube can be Pain- first red flag sign greater than 40%. Other Signs and Symptoms: High Risk Women: Vaginal spotting or bleeding Age – 35 and 44 y/o Dizziness or fainting (caused by With PID – Pelvic Inflammatory blood loss) Disease Low blood pressure (caused by Previous Ectopic Pregnancy blood loss) Surgery on fallopian tube Lower back pain Infertility problems or medication to stimulate ovulation Unruptured: Nursing Care: Missed period Abdominal pain within Vital Signs 3-5 weeks Administer IVF Scant, dark brown vaginal bleeding Monitor vaginal bleeding Vague discomfort umbilicus Monitor I&O Prepare for Culdocentesis- Tubal Ruptured: Result: Sudden sharp severe pain shoulder pain (indicative of intraperitoneal To determine if clotting or non clotting bleeding that If clotting – negative for ectopic Extends to diaphragm and Phrenic pregnancy nerve) If non – clotting – positive for ectopic Cullen's sign - bluish tinged pregnancy Diagnostic Test: Culdocentesis - is a procedure in which peritoneal fluid is obtained from the cul de sac Urine pregnancy test of a female patient. It involves the introduction If (+) pregnancy test – quantitative of a spinal needle through the vaginal wall into HCG test the peritoneal space of the pouch of Douglas. Pelvic exam B. BLEEDING DISORDER DURING THE SECOND Ultrasound TRIMESTER OF BLEEDING Culdocentesis Hydatidiform Mole ( H-Mole) Treatment: An abnormal proliferation and degeneration Vary depending on its size and of the trophoblastic villi location Injection of methotrexate Surgery Laparoscopy  Sudden Pregnancy Complication Molar pregnancy Early Signs: Gestational Trophoblastic Disease Vesicles passed thru the vagina Bunch of Grapes Hyperemesis gravidarum Hydatid – means drop of water; Fundal height – rapidly increases mole – means spot Vaginal bleeding (scant or profuse) Types: Pre-eclampsia at about 12 weeks a. Partial Molar – pregnancy that Late Signs includes an abnormal embryo (a HPN before 20th week fertilized egg that has begun to grow) Vesicles look like a ‘snowstorm” on but does not survive sonogram b. Complete Molar –pregnancy in which Anemia there is small cluster of clear blisters or Abdominal cramping pouches that don’t contain an embryo Serious Late Complications Etiology: Unknown Hyperthyroidism Other Causes: Pulmonary embolus Problems with the chromosome Diagnosis: Problem with the nutrition – low protein intake suspect until 3rd month or later if fetal Problem with the ovaries and uterus heartbeat is present with bleeding and severe Mole sometimes can develop from a nausea and vomiting placental tissue that is left behind in Physician will examine the woman’s the uterus after a miscarriage or abdomen feeling for any strange childbirth humps or abnormalities in the uterus Signs and Symptoms Tubal pregnancy will be ruled out (+) pregnancy test Abnormally increased HCG level with Symptoms for the first 3-4 months vaginal bleeding; (-) FHB and unusually Uterus grow abnormally fast large uterus will indicate a molar End of 3rd month-woman will pregnancy experience vaginal bleeding ranging from scant spotting to excessive Ultrasound – confirm no living fetus bleeding Treatment Presence of hyperthyroidism (overproduction Often, the tissue is naturally expelled by of thyroid hormone) leads to: the fourth month of pregnancy. In some Weight loss instances, the physician will give the Increase appetite woman a drug called oxytocin to trigger Intolerance to heat the release of the mole that is not Grapelike cluster of cells itself will be spontaneously aborted shed with the blood during this time If this does not happen, a vacuum Nausea and vomiting due to increase aspiration can be performed to remove HCG and progesterone the mole (-) fetal movement (-)fetal heart rate  Sudden Pregnancy Complication 1.D&C Uterine contraction. Woman is given anesthetic CERVICAL CERCLAGE Cervix is dilated and the contents of the a treatment that involves uterus is gently sanctioned out. temporarily sewing the cervix closed After the mole has been mostly with stitches prior to child loss or removed, gentle scraping of the uterus cervix hold a pregnancy in the lining is usually performed. uterus at 2nd trimester to prevent If the woman is older and does not want preterm labor. any more children, the uterus can be surgically removed (hysterectomy) After surgery patient needs to instead of a vacuum aspiration remain on bed rest for a days to because of the higher risk of cancerous decrease pressure on the new moles in this age group sutures. Monitoring the patient for at least 2 C. BLEEDING DISORDERS DURING THE THIRD months after the end of a molar TRIMESTER OF PREGNANCY pregnancy for HCG level. >Hcg level will be checked every 2 Placenta Previa weeks – if don’t return to normal by that Occurs when the placenta is improperly time, the mole may have become implanted in the lower uterine segment, cancerous sometimes covering the cervical os If HCG level is normal, the woman’s HCG will be tested each month for 6 months Signs and Symptoms and every 2 months for a year Frank, bright red, painless vaginal If mole become cancerous, treatment bleeding includes removal of the cancerous Engagement (usually has not tissue and chemotherapy occurred) If cancer spread to other parts of the Fetal distress body, radiation will be added Presentation (usually abnormal) – Woman should not be pregnant within baby is breech or in transverse position a year after HCG levels have returned to Uterus measures larger than it should normal according to gestational age If woman got pregnant within that time, Types: it is difficult to tell whether the resulting high levels of HCG were caused by the a. Partial Placenta Previa – a portion of pregnancy or as a cancer from the the cervix is covered by the placenta mole b. Complete Placental Previa/Total – Cervical insuffiency cervical opening is completely covered (premature cervical dilatations) c. Marginal Placenta Previa – extends Termed as incompetent cervix just to the edge of the cervix Cervix that dilates prematurely and Management therefore cannot retain a fetus until term Bed Rest - If the patient presents with mild bleeding before the fetal lungs are Signs and Symptom: mature painless blood show pelvic pressure Discharge amniotic fluid  Sudden Pregnancy Complication Depending on the gestational age; Signs and Symptoms: steroid shots may be given to help Painful vaginal bleeding mature the baby’s lungs Severe abdominal pain If the bleeding cannot be controlled, an Concealed bleeding immediate caesarean delivery is (retroplacental) usually done regardless of the length of Rigid abdomen pregnancy Couvelaire uterus (caused by Near term, fetal lung maturity may be bleeding into the myometrium) assessed by amniocentesis and the Dropping Coagulation factor ( a preferred method is C/S potential for DIC) ◼ Some marginal previas can be delivered vaginally Other Signs and Symptoms: ◼ Complete or partial previous would Uterine hypertonous require a C/S Back pain Preterm labor Avoid intercourse Hypovolemic shock Limit or no travelling Non reassuring fetal heart tracking's Avoid pelvic exams/internal exams and fetal demise – can cause profuse bleeding Severe Cases Predisposing Factors Maternal hypotension Old Age Uterine hypertonicity Smoking Fetal distress Intake of alcoholic beverages Death History of placenta previa in the past Clotting abnormalities pregnancy Cause: unknown Surgical Management: C/S with blood transfusion based on blood loss Predisposing Factors: Abruptio Placenta Mechanical factors such as: abdominal trauma – car accident of Premature separation of the placenta fall from the implantation site. It usually Sudden loss in uterine volume as occurs after the 20th week of pregnancy occurs with rapid loss of amniotic Bleeding into the decidua basalis (the fluid or the delivery of a first twin layer between the placenta and Abnormally short umbilical cord myometrium) compresses and Hypertension compromises the function of adjacent Pre-eclampsia placenta Multiparity Rupture of membranes more than Other Names: 24H Premature Separation of Placenta Signs and Tests: Accidental Hemorrhage Ablatio Placenta During a physical examination, Placental Abruption uterine tenderness and or increased uterine tone may be noticed CBC – decreased hematocrit and hemoglobin and platelets Prothrombin time test  Sudden Pregnancy Complication Partial thromboplastin time test Anti coagulant is also given which Fibrinogen level test precaution Ultrasound Fetal and newborn assessment is equally important to evaluate the Treatment and Management: efficiency of the placental IVF circulation in light of the increase clotting. Blood Transfusion D. Pregnancy Induced Hypertension Check for presence of shock and fetal distress A form of increased blood pressure in pregnancy Emergency C/S – for fetal distress or Also called toxemia or pre – maternal bleeding eclampsia Immature fetus with small placental Eclampsia is a severe form of PIH separation – hospitalization – for accompanied with seizures observation – release after several HELLP Syndrome – Hemolysis with days if no evidence of progressing Elevated Liver Enzymes and abruption occurs. If mature fetus – Decreased Platelet Counts- is a vaginal delivery if maternal and fetal complication of severe pre- distress is minimal C/S – to protect the eclampsia or eclampsia mother and child Signs and Symptoms of HELLP Syndrome: General Nursing Care Breakdown of RBC Infuse IVF, prepare to administer Changes in the liver blood Decreased platelets (cells found in Type and cross match blood the blood that are needed to help components (PRBC) the blood to clot in order to control Monitor FHR bleeding) Insert foley catheter THREE PRIMARY CHARACTERISTICS: Measure blood loss – count pads Report signs and symptoms of DIC Increased blood pressure, reading Monitor V/S greater than 140/90 mmHg or a Strict I & O significant increased in one or both pressures DISSEMINATED INTRAVASCULAR Protein in the urine – proteinuria COAGULATION Edema – swelling of face and fingers Acquired disorder of blood clotting Cause : unknown in which the fibrinogen level falls to below effective limits. Predisposing Factors: Symptoms are easy bruising, Pre – existing HPN (increased BP) bleeding in IV site >PIH with previous pregnancy It occurs when there is such extreme Kidney disease bleeding and so many platelets and Mother’s age younger than 20 or fibrin from the general circulation Diabetes older than 40 rush to the site that there is not Multiple gestation (twins/triplets) enough left in the rest of the body. DIC is an emergency because it can result to excessive blood loss A blood platelet transfusion is needed.  Sudden Pregnancy Complication Note: Route: IM/IV * PIH should be treated immediately since with Site: increased BP, there is also an increased in the 1st dose – IV; 2nd dose – buttocks resistance of blood vessels. This may hinder blood flow in many different organ systems in Nursing Considerations: an expectant Consider the rights in giving Other Problems: medications Check the expiration date of the Occurrence of placental abruptio medication Fetal problems such as intrauterine Check for proper color of the growth restriction (poor fetal medication growth) and stillbirth Check the patient’s BP before and after Signs and Symptoms: giving of medication Insert foley catheter as per doctor’s May experience symptoms differently order Increased BP Before giving the 2nd dose: check for the Proteinuria following: Edema on face and fingers Sudden weight gain BP – increased or decreased Blurring or double vision Urine output – 30 cc/H; if less than Nausea and vomiting 30 cc/H, hold the 2nd dose, notify the Right sided upper abdominal pain or physician at once and document pain around the stomach the findings Decreased urine output Check for knee jerk – (+) or (-), if (-), Changes in liver or kidney function hold the 2nd dose, notify the test physician at once (-) knee jerk is a sign of MgSo4 Diagnosis: toxicity BP assessment Give antidote: Calcium Gluconate Urine testing 3. Fetal Monitoring – to check for the health of Assessment of edema the fetus when the mother has PIH Frequent weight measurement Eye examination to check for retinal Include the following changes Fetal movement counting – Liver and kidney function test increased or decreased – fetal Blood clotting tests distress Treatment: Non stress testing test – tests that measure the fetal HR in response to Goal: to prevent the condition from becoming fetus’ movements worse and to prevent other complications Biophysical profile – test that 1. Bed rest – either at home or in the hospital combine nonstress test with ultrasound to observe the fetus 2. Magnesium Sulfate (MgSO4) – drug of Doppler waves – to measure the choice flow of blood through a blood vessel Action: CNS Depressant/ Anti Convulsive Drug  Sudden Pregnancy Complication 4. Continued laboratory testing of urine and B – BP decreased blood U – urine output decreased 5. Medications called corticosteroids that may R – RR less than 12/min help mature the lungs of the fetus P – patellar reflex absent 6. Delivery of the baby ( if treatment do not control the PIH, if the fetus or the mother is in Note: if one of these is present, hold the 2nd danger), C/S is recommended dose, report the findings to the physician, document the findings and actions taken For The General Nursing Care, remember this acronym: PEACE GENERAL NURSING CARE: P – PROMOTE BED REST Prevent convulsion by nursing measures: seizure precautions Quiet and calm environment Minimal handling Avoid jarring the bed Provide tongue guard – to prevent biting the tongue in case of seizure attack All side rails up (at all times) – to ensure the safety of the client Prepare the following at bed side: Suction machine Oxygen Suction tip NSS Note: make sure all machine and equipment are functioning well and in good status, this is considered as one of the nurse’s responsibilities. During seizure attack – stay with the patient; do not restrict movements of extremities to prevent contracture deformity; ensure patient’s safety (prevent patient from falling) After the attack – turn patient to side E - NSURE HIGH PROTEIN INTAKE ( 1 G/KG/DAY) A – NTIHYPERTENSIVE DRUG : HYDRALIZE C - NS DEPRESSANT (MGSO4) ANTICONVULSANT DRUG E – VALUATE PHYSICAL PARAMETERS FOR MAGNESIUM SULFATE TOXICITY Sudden Pregnancy Complication