P2.1.pdf

Nursing Care Related to Assessment of a Pregnant Family John Marco L. Segobre, RN, MAN-CN, DipHM LEARNING OBJECTIVES: After mastering the content of this Chapter, you should be able to: Describe the areas of health assessment commonly included in prenatal visits. Assess the readiness for...

Nursing Care Related to Assessment of a Pregnant Family John Marco L. Segobre, RN, MAN-CN, DipHM LEARNING OBJECTIVES: After mastering the content of this Chapter, you should be able to: Describe the areas of health assessment commonly included in prenatal visits. Assess the readiness for parenthood and the health status of a pregnant woman and her family. DEFINITION OF TERMS Antepartal, prenatal or antenatal period Period of pregnancy or period before labor Postpartal, or postnatal period Refers to period of six weeks following delivery  PRENATAL CARE (ANTENATAL CARE) Refers to the systematic assessment and anticipatory guidance of a pregnant woman. Is a time for health promotion, pregnancy education, and encouraging a pattern of healthy behaviors for the family to use in the future.  PRENATAL CARE (ANTENATAL CARE) Purposes: – To establish a baseline of present health. – To determine the gestational age of the fetus. – To monitor fetal development and maternal well-being. – To identify women at risk for complications. – Minimize the risk of possible complications by anticipating and preventing problems before they occur. – To provide education about pregnancy, lactation, and newborn care.  PRENATAL CARE (ANTENATAL CARE) VISITS Prenatal Visits Period of Pregnancy 1st visit As early in pregnancy as possible before four months or during the first trimester. 2nd visit During the 2nd trimester 3rd visit During the 3rd trimester Every 2 weeks After 8th month of pregnancy until delivery  COMPONENTS OF THE HEALTH HISTORY Demographic data this include the name, age, address, telephone number, e-mail address, religion, ethnicity, type and place of employment, and health insurance information.  COMPONENTS OF THE HEALTH HISTORY Chief concern is the reason the woman has come to the health care setting – in this instance, the fact that she is or thinks she is pregnant. – Document the date of her last menstrual period (LMP). – Elicit information about the usual signs that occur with early pregnancy, such as nausea, vomiting, breast changes, or fatigue. – Ask if she is feeling any discomfort with her pregnancy, such as constipation, backache, or frequent urination. – Ask also about any danger signs of pregnancy, such as bleeding, abnormal pain, continuous headache, visual disturbances, or swelling of the hands and face. COMPONENTS OF THE HEALTH HISTORY History of the past illnesses Questions about a woman’s past medical history are important because a past condition can become active during or immediately following pregnancy. Representative diseases that pose potential difficulty during pregnancy include kidney disease, heart disease (coarctation of the aorta and heart valve problems cause concern most often), hypertension, sexually transmitted infections (including hepatitis B and C, herpes, and HIV), diabetes, thyroid disease, recurrent seizures, gallbladder disease, urinary tract infections, varicosities, phenylketonuria, tuberculosis, and asthma. COMPONENTS OF THE HEALTH HISTORY History of the past illnesses It is also important to ask whether a woman had childhood diseases such as chickenpox (varicella), mumps (epidemic parotitis), measles (rubeola), German measles (rubella), and poliomyelitis or if she has had immunizations against these illnesses. – A woman cannot be immunized with the oral Sabin poliomyelitis vaccine or with the vaccine against measles, mumps, or rubella because the vaccines for these contain live viruses that could be harmful to the fetus if the virus crossed the placenta. COMPONENTS OF THE HEALTH HISTORY Tobacco Consumption – Smoking during pregnancy increases the rate of preterm birth and IUGR Alcohol Consumption – Alcohol predisposes fetus to Fetal Alcohol Spectrum Disorder COMPONENTS OF THE HEALTH HISTORY Medication and Herbal Therapy – Tetracycline an antibiotic for facial acne, causes long bone defects in the fetus. – Ginger can cause anticoagulation  OBSTETRIC HISTORY Gravida = means the number of pregnancies a woman has experienced, including the current one, regardless of their outcomes. Gravid means “pregnant”. The prefix nul means none, prim, means first, multi means many or at least more than one. – Nulligravida = is a woman who has never been pregnant. – Primigravida = is a woman who is having her first or has had one pregnancy. – Multigravida = is a woman who has had more than one pregnancy – Grand multigravida = is a woman who has been pregnant five times or more, irrespective of outcome.  OBSTETRIC HISTORY Para is used for the number of completed pregnancies that have resulted in viable birth, alive or stillborn, vaginally or by cesarean section. Age of viability = the earliest age at which fetus survive if they are born is generally accepted as 24 weeks, or at the point a fetus weighs more than 500-600 g. – Nullipara = is a woman who has never delivered a viable child. – Primipara = is a woman who has completed one pregnancy of a viable age. – Multipara = is a woman who has completed two or more viable pregnancies. – Grand multipara = a woman who has had five or more viable births.  OBSTETRIC HISTORY Term = refers to the number of full-term infants born at 37 weeks or after (must be resulted to birth) Preterm = refers to the number of preterm infants born before 37 weeks. Abortion = refers to the number of spontaneous miscarriages or therapeutic abortions. Any births before the age of viability (before 20 to 24 weeks) would result to abortion because the fetus cannot definitely survive. Living = refers to the number of living children Multiple pregnancies = refers to the number of twins, triplets, quadruplets, etc. OBSTETRIC HISTORY Example: A pregnant woman has the following past history: a boy at 39 weeks gestation, alive and well; a girl born at 40 weeks gestation, alive and well; and a girl born at 33 weeks gestation, alive and well. How would you summarize her obstetric history? OBSTETRIC HISTORY Example: A 39 year old female is currently 18 weeks pregnant. She has two sets of twin daughters that were born at 38 and 39 weeks gestation and an 11 year-old son who was born at 32 weeks gestation. She has no history of miscarriage or abortion. What is her GTPAL? PRACTICE EXERCISE: A pregnant client has delayed her first prenatal visit, coming to the clinic only after she starts to experience edema of the feet and hands.You take a history and perform a physical examination. The client’s response to one of your questions is, “This is my third pregnancy. I miscarried twice, the first time I was 8 weeks pregnant and the last time I was 26 weeks.” You correctly record Mrs. Barton’s pregnancy status as A. Gravida 2 P0. B. Gravida 2 P1. C. Gravida 3 P1. D. Gravida 3 P0.  WEIGHT GAIN “Weight gain during pregnancy is healthy” – Normal: 30 – 40 lbs FEMALE PELVIS  PELVIS Also known as the “pelvic girdle”, a basin-shaped cavity, is a bony ring between the movable vertebrae of the vertebral column which it supports, and the lower limbs that it rests on. PELVIS Functions of the Pelvis: – It provides protection to the organs found within the pelvic cavity – It provides attachment to muscles, fascia and ligaments. – It supports the uterus during pregnancy. – It serves as birth canal. TYPES OF PELVIS T YPES OF PELVIS  Types of Pelvis Gynecoid the female type of pelvis that is most ideal for childbirth. The inlet of this type of pelvis is round shaped with transverse diameter larger than AP diameter. It has wide pubic arch. This type of pelvis is found in about 50% of women. Android - The male type pelvis has heart shaped inlet. Irregular, represents the most difficulty during childbirth as the fetal head has difficulty getting out of this pelvis. Its AP diameter is wider than its transverse diameter. This type of pelvis is found in only 20% of women. Anthropoid - The ape-like pelvis which is which is the deepest type of pelvis. Its inlet is oval shaped with AP diameter wider than transverse diameter. The size does not conform to the head of the baby. Found in 25 % of women. Platypelloid - Flat pelvis and most shallow pelvic type. Its transverse diameter is wider than its AP diameter. Its difficult for the fetal head to rotate. The rarest type of pelvis found only in about 5% of women.  PARTS OF THE PELVIS Innominate bones - these bones form the anterior and lateral aspects of the pelvis: 1. Ilium 2. Ischium 3. Pubes  INNOMINATE BONES A. Ilium The upper flaring portion which is the largest bone of the pelvis. Iliac crest = the upper border, forms the hip bone Helps support the uterus during pregnancy. B. Ischium Portion located below the hip joint Tuberosity Spine  ISCHIUM 1. Ischial tuberosities Projections at the lower portion that support the body in sitting position 2. Ischial spines Small projections that delineate the midpoint of the cervix and functions as an important obstetrical landmarks when performing pelvic measurement and calculating degrees of fetal descent.  ISCHIUM Pubes The front bones Are connected by the symphysis pubis.  PARTS OF THE PELVIS Sacrum Is a triangular shaped bone forming the posterior portion of the pelvis. It is composed of 5 sacral vertebrae. PARTS OF THE PELVIS Sacrum The first sacral vertebra, is called sacral promontory An important obstetrical landmark used in measuring pelvic diameter. PARTS OF THE PELVIS Coccyx Lowest posterior portion of the pelvis composed of 5 fused vertebrae. Sacrococcygeal joint allows the coccyx to some degree of movement. When the fetus descends into the pelvic canal, the coccyx moves slightly backward to give more room for the fetal head. DIVISION OF PELVIS False pelvis It is the upper flaring portion, the ilia. Functions: to provide support to the uterus during pregnancy and to direct the fetus to the true pelvis during labor. DIVISION OF PELVIS True pelvis Forms the passageway of the fetus during labor. It has the wider transverse diameter and appears heart shaped when viewed from the top. TRUE PELVIS Inlet of pelvic brim Entrance to the true pelvis INLET (AP DIAMETERS) Diagonal Conjugate It is the distance between the midpoint of sacral promontory and the lower margin of symphysis pubis. Measured by IE. 12.5 cm  INLET Obstetric Conjugate The distance between the midpoint of sacral promontory and the midline of symphysis pubis. Measures as 1 – 1.5 less than diagonal conjugate  INLET True Conjugate (Conjugata Vera) Distance between the midpoint of sacral promontory and the upper margin of symphysis pubis 10.5 – 11 cm INLET Transverse diameter 13.5 cm Right and left oblique diameter 12.75 cm PELVIC CANAL Is situated between inlet and outlet at the level of the ischial spines. It controls the speed of descent of fetal head. ✓rapid descent causes rupture of cerebral arteries Interspinous diameter ✓The smallest diameter of the pelvic canal\ ✓10 cm OUTLET Marked by the coccyx and sacrotuberous ligament at the back, ischial tuberoisities at the sides, and the pubic arch infront which forms 90 degrees OUTLET Transverse or bi-ischial diameter: The distance between the two ischial spines 11 cm AP diameter: It is measured from the apex of the pubic arch to the sacrococcygeal joint 9.5 – 11 cm PELVIC ARTICULATIONS Joints ▪ serve as points of attachment between pelvic bones ▪ They allow the bones some degree of movement 1. Symphysis pubis ✓Joins the two pubic bones 2. Sacroiliac joints ✓Joins sacrum and iliac 3. Sacrococcygeal joints ✓Joins the sacrum and coccyx EFFECTS OF HORMONES ✓Progesterone causes relaxation and softening of pelvic joints that results in increased mobility of the pelvic bones. CONTRACTED PELVIS Refers to a pelvis with a measurement Vaginal delivery of the less than 1.5 – 2 cm fetus not possible. in any of its important diameters. CONTRACTED PELVIS Manifestations: Lightening has not yet taken place after 37 weeks in primiparas. History of stillbirth, dystocia, and previous forceps delivery in multiparas. Girls below 14 years old are more likely to have contracted pelvis than older women. LABORATORY ASSESSMENT Urinalysis Abnormal results: ✓Proteinuria (protein in urine) ✓Glycosuria (glucose in urine) ✓Nitrites (bacteria in urine) ✓Pyuria (WBC in urine suggesting an infection) LABORATORY ASSESSMENT Blood Serum Studies: – CBC Hgb, hct, and RBC index is used to determine the presence of anemia WBC is used to determine infection Platelet count is use to estimate clotting ability LABORATORY ASSESSMENT Blood Serum Studies: – Serologic test for syphilis VDRL or plasma reagent test LABORATORY ASSESSMENT Blood Serum Studies: – Blood typing including RH factor determination. Blood Serum Studies: – MSAFP and Plasma Protein A Elevated = NTD and abdominal defect Decreased = chromosomal anomaly Scheduled at 16 to 18 weeks or pregnancy to be accurate Amniocentesis will be scheduled if levels are elevated or decreased. LABORATORY ASSESSMENT Blood Serum Studies: – Indirect Coomb’s test = determination of whether Rh antibodies are present in an Rh-negative woman If the RH-negative woman’s titer is not elevated, she will be offered RhIg (RhoGAM) at 28 weeks and within 72 hours after delivery Procedure that might cause placental bleeding: – Amniocentesis – External version LABORATORY ASSESSMENT Blood Serum Studies: – Serum antibody titers for rubella, hepa B (HBsAg), hepa C, varicella (chickenpox) – HIV screening: High risk criteria Woman using IV drugs Have engaged in sex w/ multiple partners Have had sexual partners who are infected or at risk because they are bisexual Have partner who are IV drug users Have hemophiliac partner NURSING CARE TO P R O M O T E F ETA L A N D M AT E R N A L H E A LT H BATHING Sweating tends to increase because a woman excretes waste products for both herself and the fetus. There is an increase vaginal discharge. Daily showers are recommended. – Tub baths should be contraindicated when membranes ruptures or vaginal bleeding is present. – There would be danger of contamination of uterine contents. BREAST CARE Wear a supportive bra with wide straps to spread breast weight across the shoulder. – 16 week of pregnancy, colostrum secretion begins in the breasts. – Put a gauze squares or breast pads, and change them frequently to maintain dryness. Wash the breasts with clear tap water with no soap. – Because it could cause drying and cracking of her nipples. – Dry the nipples by patting them with soft towel. DENTAL CARE There is a strong correlation between poor oral health and preterm birth, so maintaining good oral health during pregnancy is important. – No dental x-ray during pregnancy. PERINEAL HYGIENE Due to increased vaginal discharge should the woman need to maintain good perineal hygiene. Wipe front to back after voiding to prevent bringing contamination forward from the rectum. Douching is contraindicated. – The force of the irrigating fluid could cause the solution to enter the cervix, leading to uterine infection. – It can alter the pH of the vagina, leading to an increased risk for vaginal bacterial growth. CLOTHING Avoid garters, extremely firm girdles with panty legs, and knee-high stockings during pregnancy. Wear a moderate-to-low heel. SEXUAL ACTIVITY No coitus for women whose membranes have ruptured or who have vaginal spotting. No partner oral-female genital contact – air embolism. Side-by-side position or a woman in a superior position. Nonmonogamous male partner should be advised to wear condoms to prevent transmission of STD. EXERCISE No contact sports during pregnancy: football or soccer. Exercise 3x weekly for 30 consecutive min. Walking = best exercise during pregnancy. – Yoga Jogging is contraindicated; extra weight of pregnancy places on the knees. – Swimming Diving, long-distance swimming should be avoided. – Dancing High-impact aerobic is contraindicated. A woman who has complicated pregnancy should consult their doctor before beginning an exercise. SLEEP Drink a glass of milk before bedtime. Relaxation exercises Sleeping position: left-sided Sims position, with the top leg forward. – This position puts the weight of the fetus on the bed, not on the woman, and allows good circulation in lower extremities. TRAVEL Traveling during pregnancy is not contraindicated, not until late in pregnancy. Take a rest or stretch periods with a long trip. – Get out of the care every 2 hours, and walk a short distance. – This would help varicosities, hemorrhoids, and thrombophlebitis. MINOR BODY CHANGES OF PREGNANCY: THE FIRST TRIMESTER BREAST TENDERNESS Most noticeable on exposure to cold air. Management: encourage a woman to wear a bra with a wide shoulder strap for support and to dress warmly to avoid cold drafts if cold increases symptoms. PALMAR ERYTHEMA Or palmar pruritus, occurs in pregnancy and is probably caused by increases estrogen levels. Management: calamine lotion FATIGUE Is extremely common in early pregnancy, probably because of increased metabolic requirements. Management: – Increasing the amount of rest and sleep. MUSCLE CRAMPS Cause: – Decrease serum calcium levels – Increase serum phosphorus levels – Interference with circulation MUSCLE CRAMPS Management: – Best relieved if a woman lies on her back momentarily and extends the involved leg while keeping her knee straight and dorsiflexing the foot until the pain disappears. MUSCLE CRAMPS – She may take magnesium lactate or citrate once in the morning and again the evening as these bind phosphorus in the intestinal tract and thereby lower its circulating level. MUSCLE CRAMPS Elevating lower extremities frequently during the day to improve circulation and avoid full leg extension, such as stretching with the toes pointed, may also be helpful.  SUPINE HYPOTENSION SYNDROME Is a symptom that occurs when a woman lies on her back and the uterus presses on the vena cava, impairing blood return to her heart. Manifestation: irregular heart rate, hypotension, difficulty breathing  SUPINE HYPOTENSION SYNDROME Management: place the client in left side lying  VARICOSITIES The development of tortuous leg veins, commonly form in pregnancy because the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities. This causes blood pooling and vessel distension. VARICOSITIES Management: – Resting in a Sim’s position or on the back with the legs raised against the wall (with a small firm pillow under their right hip) or elevated on a footstool for 15 to 20 minutes twice a day is a good precaution.  VARICOSITIES – Caution women not to sit with their legs crossed or their knees bent and to avoid constrictive knee-high hose or garters.  VARICOSITIES Apply elastic support stockings for relief of varicosities in pregnancy. – Urge the woman to put them on before she arises in the morning because once she is on her feet, blood pooling begins, and the stockings will be less effective. – When applied appropriately the stockings should reach an area above the point of distension. COMPRESSION STOCKINGS  VARICOSITIES To increase circulation, advise women to break up these long periods of sitting or standing with a “walk break” at least twice a day. Increase vitamin C because it is necessary for the formation of blood vessel collagen and endothelium.  HEMORRHOIDS Varicose of the rectal veins, occurs in pregnancy because of pressure on these veins from the bulk of the growing uterus. Management: – Daily bowel evacuation to prevent constipation, drinking adequate fluid, eating adequate fiber, and resting in a modified Sims position are all helpful measures to both prevent these and relieve pain.  HEMORRHOIDS Assuming a knee-chest position for 10 to 15 minutes is an excellent way to reduce the pressure on rectal veins. – Because the weight of the uterus is shifted forward, this position promotes free flow of urine from the kidneys (preventing urinary stasis and infection) and better circulation in the rectal area (preventing hemorrhoids).  HEMORRHOIDS Stool softeners such as Docusate sodium (Colace) may be recommended if a woman already has hemorrhoids when she enters pregnancy. Applying witch hazel, a cold compress, are other helpful measures to relive pain. Hydrocortisone-pramoxine (Proctofoam) is a prescription medication that is also helpful and is safe for the fetus.  HEART PALPITATIONS Probably due to circulatory adjustments necessary to accommodate her increased blood supply. Management: gradual slow movement FREQUENT URINATION Cause: because of growing uterus that presses on the anterior bladder. This sensation lasts about 3 months, beginning as early as the first or second missed menstrual period, and then returns in late pregnancy as the fetal head presses against the bladder. The sensation of frequency will probably return after lightening (the settling of fetal head into the inlet of the pelvis at pregnancy’s end).  FREQUENT URINATION Management: advise the woman not to wait but to void as often as necessary, as urine stasis can lead to infection. ✓Ask her about any burning or pain on urination or whether she has noticed any blood in her urine, which are signs of a urinary tract infection. ✓Women should not restrict their fluid intake to diminish frequency of urination, as fluids are necessary to allow their blood volume to double. ✓Suggest a woman to reduce the amount of caffeine she consumes in coffee or cola drinks may be helpful. ✓Doing Kegel exercise (alternately contracting and relaxing perineal muscles) not only helps strengthen urinary control but also directly strengthens perineal muscles for birth.  KEGEL EXERCISE: Kegel exercises are exercises designed to strengthen the pubococcygeal muscles. Each is a separate exercise and should be done about three times per day. Squeeze the muscles surrounding the vagina as if stopping the flow of urine. Hold for three seconds. Relax. Repeat this sequence 10 times. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 to 25 times. KEGEL EXERCISE: Imagine you are sitting in a bathtub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds. Relax. Repeat this action 10 times. It may take as long as 6 weeks of exercise before pubococcygeal muscles are strengthened. In addition to strengthening urinary control and preventing stress incontinence, Kegel exercises can lead to increased sexual enjoyment because of tightened vaginal muscles and can help avoid tearing of the perineum with childbirth. ABDOMINAL DISCOMFORT When a woman stands up quickly, she may experience a pulling pain, sometimes sharp and frightening, in her right or left lower abdomen from tension on a round ligament. – She can prevent this from happening by always rising slowly from a lying or a sitting or from a sitting to a standing position. LEUKORRHEA A whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen level and increased blood supply to the vaginal epithelium and cervix in pregnancy. LEUKORRHEA Managements: – A daily bath or shower to wash away accumulated secretions and prevent vulvar excoriation usually controls this problem – Wearing cotton underpants and sleeping at night without underwear can be helpful to reduce moisture and possible vulvar excoriation. – Caution women not to use tampons because this could lead to stasis of secretions and subsequent infection. LEUKORRHEA Managements: – Caution women not to douche; douching is contraindicated throughout pregnancy because fluid could be forced into the uterine cervix. – Avoiding tight underpants and pantyhose may help prevent vulvar and vaginal infections, particularly yeast infections. MINOR BODY CHANGES OF PREGNANCY: SECOND AND THIRD TRIMESTERS  MUSCULOSKELETAL DISCOMFORT Lumbar lordosis develops and postural changes necessary to maintain balance lead to backache. Management: – Wearing shoes with low-to-moderate heels reduces the amount of spinal curvature necessary to maintain an upright posture. – Encouraging a woman to walk with her pelvis tilted forward (i.e., putting pelvic support under the weight of the fetus) is also helpful. MUSCULOSKELETAL DISCOMFORT Apply local heat from a heating pad may aid in relieving backache. Advise the woman to squat rather than bend over to pick up objects. Also encourage the woman to always lift objects by holding them close to the body.  MUSCULOSKELETAL DISCOMFORT Pelvic rocking helps relieve backache during pregnancy and early labor by making then lumbar spine more flexible. – A woman arches her back, trying to lengthen or stretch her spine. She holds the position for 1 minute, then hollows her back. MUSCULOSKELETAL DISCOMFORT – If a woman does this at the end of the day about five times, it not only increases flaexibility but also helps relieve back pain and make her more comfortable during the night.  MUSCULOSKELETAL DISCOMFORT Acetaminophen (Tylenol) is considered to be safe and effective for relieving back pain during pregnancy. Acupuncture can also be effective. Caution women not to take herbal remedies, muscle relaxants, or other analgesics (or any other medication) for back pain without first consulting their primary health care provider. HEADACHE Cause: from the expanding blood volume, which puts pressure on cerebral arteries. Managements: – Trying to reduce any possible causative situations, such as eye strain or tension, may lessen the number of headaches they experience. – Resting with an ice pack on the forehead and taking a usual adult dose of acetaminophen usually furnishes adequate relief. HEADACHE – Caution women that if a headache seems unusually intense or continuous, they should report it to their primary care provider as a continuous sharp headache may be a sign of high blood pressure, a danger sign of pregnancy.  DYSPNEA Cause: the expanding uterus puts pressure on the diaphragm, lung compression and shortness of breath result. – A woman will notice this primarily at night if she lies flat. DYSPNEA Management: – Advise the woman to sleep with her head and chest elevated so the weight of the uterus falls away from her diaphragm. As pregnancy progresses, she may require two or more pillows to sleep at night and she may need to limit her activities during that day to prevent exertional dyspnea. ANKLE EDEMA Some swelling of the ankles and feet during late pregnancy would be most noticeable at the end of the day. As long as proteinuria and hypertension are absent, ankle edema is a normal occurrence of pregnancy. It is probably caused by general fluid retention and reduced blood flow circulation in the lower extremities because of uterine pressure.  ANKLE EDEMA Management: – Can be relieved by resting in a left side-lying position because this increases the kidney’s glomerular filtration rate and also allows for good venous return. – Sitting for half an hour in the afternoon and again in the evening with the legs elevated is also helpful. – Caution women to avoid wearing constricting clothing such as panty girdles or knee-high stockings because these impede lower extremity circulation and venous return.  BRAXTON HICKS CONTRACTIONS Beginning 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. – Middle or late pregnancy, the contractions become so strong. – Needs to report to the physician if there is rhythmic pattern and persistent contractions – beginning sign of preterm labor. P R E V E N T I N G F E TAL EXPOSURE TO T E R AT O G E N S TERATOGEN Is any factor, chemical or physical, that adversely affects the fertilized ovum, embryo, or fetus. “TORCH” TOXOPLASMOSIS OTHER INFECTIONS RUBELLA CYTOMEGALO VIRUS HERPES TERATOGENIC MATERNAL INFECTIONS TOXOPLASMOSIS OTHER INFECTIONS RUBELLA CYTOMEGALO VIRUS HERPES “TORCH”  TOXOPLASMOSIS A protozoan infection, is spread most commonly through contact with uncooked meat, although it may also be contracted through handling cat stool in soil or cat litter. Prevention: – Discourage taking a new cat at home. – Instruct pregnant women to avoid undercooked meat and also not to change a cat litter box or garden in soil in an area where cats may defecate to avoid exposure to the disease. – Reinforce proper hand hygiene after handling uncooked meat. OTHER INFECTIONS Malaria Syphilis Chickenpox Measles Influenza Viral hepatitis MALARIA Is caused by Plasmodium transmitted to humans by the bite of an infected female Anopheles mosquito. During pregnancy, women can transmit malaria to the fetus. – Treatment: Chloroquine or artesunate Mefloquine SYPHILIS Is a sexually transmitted infection that places a fetus at risk for intrauterine or congenital syphilis. – Cause: spirochete bacteria, Treponema pallidum – Prevention: safe sex practices (e.i., one partner only) – Diagnosis: rapid plasma reagin or Venereal Disease Research Laboratory (VDRL) – Treatment: intramuscular benzathine penicillin SYPHILIS Complication to newborn: congenital anomalies, extreme rhinitis (sniffles), and a characteristic syphilitic rash, Hutchinson teeth (oddly-shaped teeth) when the baby’s primary teeth come in. RUBELLA German Measles cause only a mild rashes and mild systemic illness in a woman Complications to the newborn: – hearing impairment – cognitive and motor challenges – cataracts – cardiac defect (commonly patent ductus arteriosus and pulmonary stenosis) – restricted intrauterine growth (i.e., small for gestational age) – thrombocytopenic purpura – dental and facial clefts, such as cleft lip and palate  RUBELLA A woman who is not immunized before pregnancy cannot be immunized during pregnancy because the vaccine contains a live virus that would have effects similar to those occurring with a subclinical case of rubella. After rubella immunization, a woman is advised not to become pregnant for about 3 months, until the rubella virus is no longer active. RUBELLA – Prevention: all women should avoid contact with children with rashes of unknown cause. – A titer greater than 1:8 suggests immunity. A titer of less than 1:8 suggests a woman is susceptible to viral invasion. CYTOMEGALOVIRUS Is not a sexually transmitted infection but spreads from person to person by droplet infection such as occurs with sneezing. – Complications to the newborn: Severe neurologic challenges (such as hydrocephalus, microcephaly, or spasticity) Eye damage (e.i., optic atrophy or chorioretinitis) Hearing impairment Chronic liver disease Large petechiae on the skin CYTOMEGALOVIRUS Treatment: none Prevention: advise women to wash hands thoroughly before eating and to avoid crowds of young children at daycare or nursery school settings to help prevent exposure HERPES SIMPLEX VIRUS TYPE 2 (Genital Herpes Infection) is a sexually transmitted infection spread by intimate contact. – Complications to the newborn: First trimester: severe congenital anomalies or spontaneous miscarriage can occur. Second trimester: premature birth, intrauterine growth restriction, neurologic disease. HERPES SIMPLEX VIRUS TYPE 2 – Preventions: Cesarean birth is usually advised to reduce the risk of this route of infection Intravenous acyclovir (Zovirax) or valacyclovir (Valtrex) TERATOGENIC DRUGS: Two principles always govern intake during pregnancy: – Any drug or herbal supplement, under certain circumstances, may be detrimental to fetal welfare. Therefore, during pregnancy, women should not take any drug or supplement not specifically prescribed or approved by their primary health care provider. – A woman of childbearing age should not take any drug other than one prescribed by a primary health care provider to avoid exposure to a drug should she become pregnant. TERATOGENIC DRUGS: – Thalidomide, prescribed for cancer therapy, causes limb defects (phocomelia – partial absence of extremities, or Amelia – total absence of extremities) – Cocaine can cause severe vasoconstriction in the mother, thus compromising placental blood flow and perhaps dislodging the placenta. Its use is associated with spontaneous miscarriage, preterm labor, meconium staining, and intrauterine growth restriction. – Narcotics such as Meperidine (Demerol) and heroin have long been implicated to fetal growth restriction and preterm labor. TERATOGENECITY OF ALCOHOL – Evidence confirms high incidence of characteristic congenital craniofacial deformities including short palpebral fissures, a thin upper lip, an upturned nose, as well as cognitive impairment (fetal alcohol spectrum) when woman consumes large quantities of alcohol during pregnancy. – Prevention: advise women to abstain from alcohol completely for the remainder of the pregnancy. TERATOGENICITY OF TOBACCO – Low birth weight in infants of smoking mothers result from vasoconstriction of the uterine vessels, an effect of nicotine. This limits the blood supply to a fetus. – Secondary smoke, or inhaling the smoke of another person’s cigarettes, may be as harmful as actually smoking. – The best way to urge women to discontinue smoking is to educate them about the risks to themselves and their fetus at the first prenatal visits and then offer a support program to help them throughout the pregnancy. MATERNAL AND CHEMICAL HAZARDS – Pesticides and carbon monoxide, such as automobile exhaust, should be avoided as these are examples of chemical teratogens. – Arsenic, a byproduct of copper and lead smelting, used in pesticides, paints, and leather processing; formaldehyde, used in paper manufacturing; and mercury, used in the manufacture of electrical apparatuses and found in high proportions in swordfish and tuna, are all teratogens that can be found at work sites. – Lead poisoning may lead to both cognitively and neurologically challenged fetus. RADIATION – The most damaging time for exposure and subsequent damage is from implantation to 6 weeks after conception (a time when many women are not yet aware they are pregnant). The nervous system, brain, and retinal innervation are rapidly growing at this time and so are most affected. – Prevention: use pelvic shield or lead apron should radiation exposure is needed.