Hyper / Hypo Disorders

1
COMPLICATIONS OF PREGNANCY
Revised October 2009 Debbie Perez RN, MSN, CNS
2
Risk Factors

• Age under 17 over 35
• Gravida and Parity
• Socioeconomic status
• Psychological well-being
• Predisposing chronic illness diabetes, heart
  conditions, renal
• Pregnancy related conditions hyperemesis
  gravidarum, PIH

3
Goals of Care for High Risk Pregnancy

• Provide optimum care for the mother and the fetus
• Assist the client and her family to understand
  and cope through education

4
Gestational Onset Disorders
5
Take report Mrs. R. admitted to LD

• Initial Data
• Chief complaint moderate amount vaginal bleeding
• Vital Signs T. 98.4 P. 100, R. 22, B/P 100/66
• G 1 P 0
• Last menstrual period 8/12 EDC May 19
• Allergies none known
• Nauseated
• Mild pain
• HCG levels WNL for pregnancy

6
Bleeding Disorders
7
Abortions

• Termination of pregnancy at any time before the
  fetus has reached the age of viability
• Either
• spontaneous occurring naturally
• induced artificial

8
Etiology / Predisposing Factors

• Chromosomal abnormalities - Faulty germ plasm --
  imperfect ova or sperm, genetic make-up
  (chromosomal disorders), congenital abnormalities
• Faulty implantation
• Decrease in the production of progesterone
• Drugs or radiation
• Maternal causes -- infections, endocrine
  disorders, malnutrition, hypertension, cervix
  disorder

9
Types of Abortions Threatened

• Signs and Symptoms
• vaginal bleeding, spotting
• Mild cramps, backache
• Cervix remains CLOSED
• Intact membranes
• Treatment and Nursing Care
• Bed rest, sedation
• Avoid stress and intercourse
• Progesterone therapy
• A period of watchful waiting

10
Imminent Abortion

• Signs and Symptoms
• Loss is certain
• Bleeding is more profuse
• Painful uterine contractions
• Cervix DILATES
• Treatment and Nursing Care
• Assess all bleeding. Save all pads. (May need
  to weigh the pads)
• Use the bedpan to assess all products expelled
• Treated by evacuation of the uterus usually be a
  D C or suction
• Provide Psychological Support

11
Complete Abortion

• All products of conception are expelled
• No treatment is needed, but may do a D C

12
Incomplete Abortion

• Parts of the products of conception are expelled,
  placenta and membranes retained and intact
• Treated with a D C or suction evacuation
• Provide support to the family

13
Missed Abortion

• The fetus dies in-utero and is not expelled
• Uterine growth ceases
• Breast changes regress
• Maceration occurs
• Treatment
• D C
• Hysterotomy

14
Question???

• What are two main complications related to a
  missed abortion?
• 1.
• 2.

15
Recurrent / Habitual Abortion
Premature Cervical Dilation

• Abortion occurs consecutively in _____ or more
  pregnancies
• Usually due to an Incompetent Cervical Os
• Occurs most often about 18-20 weeks gestation.

16
Habitual Abortion

• Treatment
• Cerclage procedure -- purse-string suture
  placed around the internal os to hold the cervix
  in a normal state

17
Nursing Care post cerclage

• Bedrest in a slight trendelenburg position
• Teach
• Assess for leakage of fluid, bleeding
• Assess for contractions
• Assess fetal movement and report decrease
  movement
• Assess temperature for elevations

18
Delivery options

• When time for delivery there are several options
• physician will clip suture and allow patient to
  go into labor on her own
• induce labor
• cesarean delivery

19
Key Concepts Related to Bleeding Disorders

• If a woman is Rh-, RhoGam is given within 72
  hours of abortion
• Provide emotional support. Feelings of shock or
  disbelief are normal
• Encourage to talk about their feelings. It
  begins the grief process

20
Bleeding Disorders
Ectopic Pregnancy

• Implantation of the blastocyst in ANY site other
  than the endometrial lining of the uterus

ovary
(5) Cervical
21
Etiology / Contributing Factors

• Salpingitis
• Pelvic Inflammatory Disease, PID
• Endometriosis
• Tubal atony or spasms
• Imperfect genetic development
• History of sexually transmitted disease

22
Contributing Factors

• Failed tubal ligation
• Intrauterine device
• Multiple induced abortions
• Maternal age gt 35 years
• History of previous ectopic

23
Assessment Ectopic
Pregnancy

• Early
• Missed menstruation followed by vaginal bleeding
  (scant to profuse)
• Unilateral pelvic pain, sharp abdominal pain
• Referred shoulder pain
• Cul-de-sac mass
• Acute
• Shock blood loss poor indicator
• Cullens sign -- bluish discoloration around
  umbilicus
• Nausea, Vomiting
• Faintness

24
Diagnostic Tests Ectopic
Pregnancy

• Diagnosis
• Ultrasound
• Culdocentesis
• Laparoscopy

25
Treatment Options / Nursing Care

• Combat shock / stabilize cardiovascular
• Type and cross match
• Administer blood replacement
• IV access and fluids
• Laparotomy
• Psychological support
• Linear salpingostomy
• Methotrexate used prior to rupture. Destroys
  fast growing cells

26
Gestational Trophoblastic DiseaseHydatiform
Molar PregnancyEtiology

• A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH
  DEGENERATION OF THE CHORIONIC VILLI
• As cells degenerate, they become filled with
  fluid and appear as fluid filled grape-size
  vessicles.

27
Assessment

• Vaginal Bleeding -- scant to profuse, brownish in
  color (prune juice)
• Possible anemia due to blood loss
• Enlargement of the uterus out of proportion to
  the duration of the pregnancy
• Vaginal discharge of grape-like vesicles
• May display signs of pre-eclampsia early
• Hyperemesis gravidarium
• No Fetal heart tone or Quickening
• Abnormally elevated level of HCG

Question 6
28
Interventions and Follow-Up

• Empty the Uterus by D C or Hysterotomy
• Extensive Follow-Up for One Year
• Assess for the development of choriocarcinoma
• Blood tests for levels of HCG frequently
• Chest X-rays
• Placed on oral contraceptives
• If the levels rise, then chemotherapy started
  usually Methotrexate

29
Critical Thinking Exercise

• A woman who just had an evacuation of a
  hydatiform mole tells the nurse that she doesnt
  believe in birth control and does not intend to
  take the oral contraceptives that were prescribed
  for her.
• How should the nurse respond?

30
Placenta Previa

• Low implantation of the placenta in the uterus
• Etiology
• Usually due to reduced vascularity in the upper
  uterine segment from an old cesarean scar or
  fibroid tumors
• Three Major Types
• Low or Marginal
• Partial
• Complete

Question 8
31
Abruptio Placenta

• Premature separation of the placenta from the
  implantation site in the uterus
• Etiology
• Chronic Maternal Hypertension
• Short umbilical cord
• Trauma
• History of previous delivery with separation
• Smoking / Caffeine / Cocaine
• Vascular problems such as with diabetes
• Multigravida status
• Defined as marginal, partial or complete

32
Recently Identified Risk Factor

• Autoimmune antibodies including resulting in
  various coagulopathies
• Anticardiolipin
• Lupus anticoagulant

33

• Placenta Previa
• PAINLESS vaginal bleeding
• Bright red bleeding
• First episode of bleeding is slight then becomes
  profuse
• Signs of blood loss comparable to extent of
  bleeding
• Uterus soft, non-tender
• Fetal parts palpable FHTs countable and uterus
  is not hypertonic
• Blood clotting defect absent

• Abruptio Placenta
• Bleeding accompanied by PAIN
• Dark red bleeding
• First episode of bleeding usually profuse
• Signs of blood loss out of proportion to visible
  amount
• Uterus board-like, painful and low back pain
• Fetal parts non-palpable, FHTs non-countable
  and high uterine resting tone (noted with IUPC)
• Blood clotting defect (DIC) likely

34
Signs of Concealed Hemorrhage

• Increase in fundal height
• Hard, board-like abdomen
• High uterine baseline tone on electronic fetal
  monitoring
• Persistent abdominal pain and low back pain
• Systemic signs of hemorrhage

35
Interventions and Nursing Care

• Placenta Previa
• Bed-rest
• Assessment of bleeding
• Electronic fetal monitoring
• If it is low lying, then may allow to deliver
  vaginally
• Cesarean delivery for All other types of previa

36
Treatment and Nursing Care

• Abruptio Placenta
• Cesarean delivery immediately
• Combat shock blood replacement / fluid
  replacement
• Blood work assessment for complication of DIC

37
Critical Thinking

• Mrs. A., G3 P2, 38 weeks gestation is admitted to
  L D with scant amoutn of dark red bleeding.
  What is the priority nursing intervention at this
  time?
• Assess the fundal height for a decrease
• Place a hand on the abdomen to assess if hard,
  board-like, tetanic
• Place a clean pad under the patient to assess the
  amount of bleeding
• Prepare for an emergency cesarean delivery

38
Disseminated Intravascular Coagulation (DIC)

• Anti-coagulation and Pro-coagulation
• effects existing at the same time.

39
EtiologyDefect in the Clotting
Cascade

• An abnormal overstimulation of the
  
• coagulation process
• Activation of Coagulation with
• release of thromboplastin into
  maternal bloodstream
• ê
• Thrombin (powerful anticoagulant) is produced
• ê
• Fibrinogen ?fibrin which enhances platelet
  aggregation and clot formation
• ê
• Widespread fibrin and platelet deposition in
  capillaries and arterioles

40

• Resulting in Thrombosis (multiple small clots)
• Excessive clotting activates the fibrinolytic
  system
• Lysis of the new formed clots create fibrin split
  products
• These products have anticoagulant properties and
  inhibit normal blood clotting
• A stable clot cannot be formed at injury sites
• Hemorrhage occurs
• Ischemia of organs from vascular occlusion of
  numerous fibrin thrombi
• Multisite hemorrhage results in shock and can
  result in death

41
Disseminated Intravascular Coagulation (DIC)

• Precipating Factors
• Abruptio placenta
• PIH
• Sepsis
• Retained fetus (fetal demise)
• Retained fetal placenta fragments
• Amniotic embolism
• Maternal liver disease
• Septic abortion
• HELLP and preeclampsia

42
Assessment Signs and
Symptoms

• Spontaneous bleeding -- from gums and nose
  (Epistaxis), injection and IV sites, incisions
• Excessive bleeding -- Petechiae at site of blood
  pressure cuff, pulse points. Ecchymosis
• Tachycardia, diaphoresis, restlessness,
  hypotension
• Hematuria, oliguria, occult blood in stool
• Altered LOC if cerebral bleeding or significant
  blood loss

43
Diagnostic Tests

• Lab work reveals
• PT Prothrombin time is prolonged
• PTT Partial Thromboplastin Time increased
• D-Dimer increased Product that results from
  fibrin degradation. More specific marker of the
  degree of fibrinolysis
• Platelets -- decreased
• Fibrin Split Products increase
• An increase in both FSP and D-Dimer are
  indicative of DIC

44
DICInterventions and Nursing
Care

• Remove Cause
• Evaluate vital signs
• Replace blood and blood products
• Fluid replacement
• May give Heparin Why?

Question 9-D E
45
Hyperemesis Gravidarum
46
HYPEREMESIS GRAVIDARIUM
Pernicious vomiting during
Pregnancy
47
Hyperemesis Gravidarium
Etiology Increased levels of HCG
48
Assessment

• Persistent nausea and vomiting
• Weight loss from 5 - 20 pounds
• May become severely dehydrated with oliguria AEB
  increased specific gravity, and dry skin
• Depletion of essential electrolytes
• Metabolic alkalosis -- Metabolic acidosis
• Starvation

49
Nursing Care / InterventionsHyperemesis
Gravidarium

• Control vomiting
• Maintain adequate nutrition and electrolyte
  balance
• Allow patient to eat whatever she wants
• If unable to eat Total Parenteral Nutrition
• Combat emotional component provide emotional
  support and outlet for sharing feelings
• Mouth care
• Weigh daily
• Check urine for output, ketones

50
Hypertenison during pregnancy
51
Classification of HTN in Pregnancy

• Gestational HTN Systolic BP gt or equal to
  140/90 after 20 weeks (replaces term of PIH),
  protein negative or trace
• Pre-eclampsia BP gt or equal to 140/90 after
  20 weeks, proteinuria, edema considered
  nonspecific
• Eclampsia other signs plus convulsions not
  attributable to other causes
• Chronic HTN BP gt or equal to 140/90 that
  was known to exist before pregnancy or does
  not resolve after 6 weeks after delivery

52
MULTIPLE PREGNANCY
PRIMIGRAVIDA
UNDER 17 AND OVER 35
HYDATIFORM MOLE
PREDISPOSING FACTORS
FAMILY HISTORY
VASCULAR DISEASE
Diabetes, renal
LOWER SOCIOECONOMIC STATUS
Severe malnutrition, decrease Protein intake
Inadequate or late prenatal care
53
PATHOLOGICAL CHANGES
PIH is due to
INCREASED PERIPHERAL RESISTANCE
IMPEDED BLOOD FLOW ( in blood pressure)
GENERALIZED
ARTERIOLAR CYCLIC VASOSPASMS
Endothelial CELL DAMAGE
Intravascular Fluid Redistribution
(decrease in diameter of blood vessel)
Decreased Organ Perfusion

Multi-system failure Disease
54
Clinical Manifestation


HYPERTENSION
Earliest and The Most Dependable Indicator
of PIH
55
Hypertension
B/P 140 / 90 if have no baseline. 1. 30
mm. Hg. systolic increase or a 15 mm.
Hg. diastolic increase (two occasions
four to six hours apart) 2. Increase in
MAP gt 20 mm.Hg over baseline or gt105
mm. Hg. with no baseline
56
Rationale for HYPERTENSION

• The blood pressure rises due to
• ARTERIOLAR VASOSPASMS AND
• VASOCONSTRICTION causing
  
• (Narrowing of the blood
  vessels)
• an increase in peripheral resistance
• fluid forced out of vessels
• HEMOCONCENTRATION
• Increased blood viscosity Increased hematocrit

57
Key Point to Remember !

• HEMOCONCENTRATION develops because
• Vessels became narrowed forcing fluid to shift
  out of the vascular space
• Fluid leaves the intravascular space
• and moves to extravascular spaces
• Now the blood viscosity is increased
• (Hematocrit is increased)
• Very difficult to circulate thick blood

58
Proteinuria

• With renal vasospasms, narrowing of glomerular
  capillaries which leads to decreased renal
  perfusion and decreased glomerular filtration
  rate
• PROTEINURIA

Spilling of 1 of protein is significant to
begin treatment Oliguria and tubular
necrosis may precipitate acute renal failure
59
Significant Lab WorkChanges in Serum Chemistry

• Decreased urine creatinine clearance (80-130 mL/
  min)
• Increased BUN (12-30 mg./dl.)
• Increased serum creatinine (0.5 - 1.5 mg./dl)
• Increased serum uric acid (3.5 - 6 mg./dl.)

60
Weight Gain and Edema

• Clinical Manifestation
• Edema may appear rapidly
• Begins in lower extremities and moves upward
• Pitting edema and facial edema are late signs
• Weight gain is directly related to accumulation
  of fluid

61
WEIGHT GAIN AND EDEMA

• Albumin is lost due to the damage to the tubules
  allowing larger solutes to pass in the urine
• This leads to a decreased colloid osmotic
  pressure
• A ? in COP allows fluid to shift from from
  intravascular to extravascular by osmosis
• Fluid accumulates in the extravascular space
• Activation of angiotensin and release of
  aldostersone retention of sodium and water and
  vasoconstriction

62
The Nurse Must Know

• The difference between dependent edema and
  generalized edema is important.
• The patient with PIH has generalized edema
  because fluid is in all tissues.

63
Placenta

• Due to Vasospasms and Vasoconstriction of the
  vessels in the placenta.
• Decreased Placental Perfusion and Placental Aging

Positive OCT / __________Decelerations
With Prolonged decreased Placental Perfusion
Fetal Growth is retarded - IUGR, SGA
64
Condition is Worsening
65

• Oliguria 100ml/4 hrs or less than 30 cc. / hour
• Edema moves upward and becomes generalized (face,
  periorbital, sacral)
• Excessive weight gain greater than 2 pounds per
  week

66
Central Nervous System Changes

• Cerebral edema -- forcing of fluids to
  extracellular
• Headaches -- severe, continuous
• Hyper-reflexia
• LOC changes changes in affect
• Convulsions / seizures

67
Visual Changes

• Retinal Edema and spasms leads to
• Blurred vision
• Double vision
• Retinal detachment
• Scotoma (areas of absent or depressed vision)

68

• Nausea and Vomiting
• Epigastric pain often sign of impending coma

69
Pre-Eclampsia Mild
Severe

• B/P 140/90
  160/110
• Protein 1 2
  3 4
• Edema 1, lower legs
  3 4
• Weight lt1 lb. / week
  gt2lb. / week
• 
  
• Reflexes 1 2 brisk
  3 4 (Hyperreflexia)
  
• 
  Clonus present
• Retina 0
  Blurred vision, Scotoma
  
• 
  Retinal detachment
• GI, Hepatic 0
  N V, Epigastric pain,
• 
  changes in liver enzymes
• CNS 0
  Headache, LOC changes
• Fetus 0
  Premature aging of placenta
• 
  IUGR late decelerations
• 
  

70
Interventions and Nursing Care

• Home Management
• Decrease activities and promote bed rest
• Sedative drugs
• Lie in left lateral position
• Remain quiet and calm restrict visitors
• and phone calls
• Dietary modifications
• increase protein intake to 70 - 80 g/day
• maintain sodium intake
• Caffeine avoidance
• Weigh daily at the same time
• Keep record of fetal movement - kick counts
• Check urine for Protein

71
Hospitalization

• If symptoms do not get better then the patient
  needs to be hospitalized in order to further
  evaluate her condition.
• Common lab studies
• CBC, platelets type and cross match
• Renal blood studies -- BUN, creatinine, uric acid
• Liver studies -- AST, LDH, Bilirubin
• DIC profile -- platelets, fibrinogen, FSP, D-Dimer

72
Hospital ManagementNursing Care Goal

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

73
Decrease CNS Irritability

• Provide for a Quiet Environment and Rest
• 1. MONITOR EXTERNAL STIMULI
• Explain plans and provide Emotional Support
• Administer Medications
• 1. Anticonvulsant -- Magnesium Sulfate
• 2. Sedative -- Diazepam (Valium)
• 3. Apresoline (hydralazine)
• Assess Reflexes
• Assess Subjective Symptoms
• Keep Emergency Supplies Available

74
Magnesium Sulfate

• ACTION
• CNS Depressant, reduces CNS irritability
• Calcium channel blocker- inhibits cerebral
• neurotransmitter
  release
• ROUTE
• IV effect is immediate and lasts 30
  min.
• IM onset in 1 hour and lasts 3-4 hours
• Prior to administration
• Insert a foley catheter with urimeter for
  assessment of hourly output

75
Magnesium Sulfate

• NURSING IMPLICATIONS
• 1. Monitor respirations gt 14-16 lt 12 is
  critical
• 2. Assess reflexes for hypo-reflexia -- D/C if
  hypo-refexia
• 3. Measure Urinary Output gt100cc in 4 hrs.
• 4. Measure Magnesium levels normal is 1.5-2.5
  mg/dl
• Therapeutic is 4-8mg/dl. Toxicity -
  gt9mg/dl
• Absence of reflexes is gt10 mg/dl
• Respiratory arrest is 12-15 mg/dl
• Cardiac arrest is gt 15 mg/dl.
• Have Calcium Gluconate available as antagonist

76
Test Yourself !

• A Woman taking Magnesium Sulfate has a
• respiratory rate of 10. In addition to
  discontinuing the medication, the nurse should
• a. Vigorously stimulate the woman
• b. Administer Calcium gluconate
• c. Instruct her to take deep breaths
• d. Increase her IV fluids

77
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

78
Control Blood Pressure

• Check B / P frequently.
• Give Antihypertensive Drugs
• Hydralazine
• Labetalol
• Nifedipine
• Check Hematocrit
• 
  

• Do NOT want to decrease the B/P too low or too
  rapidly. Best to keep diastolic 90.
• WHY?

79
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

80
Promote Diuresis

• Dont give Diuretic, masks the symptoms of
  PIH
• Bed rest in left or right lateral position
• Check hourly output -- foley catheter with
  urimeter
• Dipstick for Protein
• Weigh daily -- same time, same scale

81
Nursing Care Hospital Management

• 1. Decrease CNS Irritability
• 2. Control Blood Pressure
• 3. Promote Diuresis
• 4. Monitor Fetal Well-Being
• 5. Deliver the Infant

82
Monitor Fetal Well-Being

• FETAL MONITORING-- assessing for late
  decelerations.
• NST -- Non-stress test
• OCT --oxytocin challenge test
• BPP biophysical profile
• If all else fails ---- Deliver the baby!!

83
Key Point to Remember !

• SEVERE COMPLICATIONS OF PIH
• PLACENTAL SEPARATION - ABRUPTIO PLACENTA DIC
• PULMONARY EDEMA
• RENAL FAILURE
• CARDIOVASCULAR ACCIDENT
• IUGR FETAL DEATH
• HELLP SYNDROME

84
HELLP Syndrome

• A multisystem condition that is a form of severe
  preeclampsia - eclampsia
• H hemolysis of RBC
• EL elevated liver enzymes
• LP low platelets lt100,000mm
  (thrombocytopenia)

85
Etiology of HELLP

• Hemolysis occurs from destruction of RBCs
• Release of bilirubin
• Elevated liver enzymes occur from blood flow that
  is obstructed in the liver due to fibrin deposits
• Vascular vasoconstriction ? endothelial damage ?
  platelet aggregation at the sites of damage ? low
  platelets.

86
HELLP Syndrome Assessment

• 1. Right upper quadrant pain and tenderness
• 2. Nausea and vomiting
• 3. Edema
• 4. Flu like symptoms
• 5. Lab work reveals
• a.  anemia low Hemoglobin
• b.  thrombocytopenia low platelets. lt
  100,000.
• c.  elevated liver enzymes
•    -AST asparatate aminotransferase
  (formerly
• SGOT) exists within the liver cells
  and with
• damage to liver cells, the AST
  levels rise gt 20 u/L.
•   - LDH when cells of the liver
  are lysed, they spill
• into the bloodstream and there is
  an increase in
• serum gt 90 u/L/

87
HELLP

• Intervention
• 1. Bedrest any trauma or increase in intra-
  
• abdominal pressure could lead to rupture
• of the liver capsule hematoma.
• 2. Volume expanders
• 3. Antithrombic medications

88
Infections
89
Urinary Tract Infection

• Most common infection complicating Pregnancy
• Etiology
• Pressure on ureters and bladder causing Stasis
  with compression of ureters
• Reflux
• Hormonal effects cause decrease tone of bladder
• Assessment
• Dysuria, frequency, urgency
• lower abdominal pain costal vertebral pain
• fever

90

• Interventions
• Monthly cultures
• Oral Sulfonamides Amoxicillin, Ampicillin,
  Cephalosporins, NO tetracyclines
• Increase fluid intake to 3 4 liters / day
• Knee chest position
• Complication
• Premature labor

91
T O R C H A Infections

• T Toxoplasmosis
• O Other
• Syphilis, Gonorrhea,
• Chlamydial,Hepatitis A or B
• R Rubella
• C Cytomegalovirus
• H Herpes
• A Aids

92
Toxoplasmosis

• Etiology
• Protozoan infection. Raw meat and cat litter
• Maternal and Fetal Effects
• Mom - flu-like symptoms, lymphadenopathy
• Fetus stillborn, premature birth,
  microcephaly mental retardation

Interventions / Nursing Care
Instruct to cook meat thoroughly Avoid
changing cat litter Advise to wear gloves when
working in the garden Treatment Sulfa
drugs
93
Syphilis

• Etiology
• Spirochete Treponema Pallium
• Maternal and Fetal Effects
• May pass across the placenta to fetus causing
  spontaneous abortion. Major cause of late,
  second trimester abortion
• Infant born with congenital anomalies

94
Syphilis

• Intervention
• 1. Penicillin
• 2. Advise to return for prenatal visits monthly
  to assess for re-infection
• 3. Advise that if treated early, fetus may not
  be infected

95
Gonorrhea

• Etiology Neisseria Gonorrhoeae
• Maternal and Fetal Effects
• May get infected during vaginal delivery causing
  Ophthalmia neonatorium (blindness) in the infant
• Mom will experience dysuria, frequency, urgency
• Major cause Pelvic Inflammatory Disease which
  leads to infertility.
• Treated with

Rocephin Spectinomycin
Treat partner!!
96
Chlamydia

• Three times more common than gonorrhea.
• Etiology - Chlamydia trachomatis
• Maternal and Fetal Effects
• Mom pelvic inflammatory disease, dysuria,
  abortions, pre-term labor
• Fetus -- Stillbirth, Chylamydial pneumonia
• Interventions
• Erythromycin, doxycycline, zithromax
• Advise treatment of both partners is very
  important

97
Hepatitis A or B

• Highly contagious when transmitted by direct
  contact with blood or body fluids
• Maternal and Fetal Effects
• All moms should be tested for Hep B during
  pregnancy
• Fetus may be born with low birth weight and liver
  changes\
• May be infected through placenta, at time of
  birth, or breast milk
• Intervention
• Recommend Hepatitis B vaccination to both mother
  and baby after delivery.

98
Rubella

• Etiology
• Spread by droplet infection or through direct
  contact with articles contaminated with
  nasopharyngeal secretions.
• Crosses placenta
• Maternal and Fetal Effects
• Mom fever, general malaise, rash
• Most serious problem is to the fetus--causes many
  congenital anomalies (cataracts, heart defects)
• Intervention
• Determine immune status of mother. If titer is
  low, vaccine given in early postpartum period

99
CYTOMEGALOVIRUS

• Etiology -- Member of the Herpes virus
• Crosses the placenta to the fetus or contracted
  during delivery. Cannot breast feed because
  transmitted through breast milk
• Effects on Mom and Fetus
• Mom no symptoms, not know until after birth of
  the baby
• Fetus -- Severe brain damage Eye damage
• Intervention
• No drug available at this time
• Teach mom should not breast feed baby
• Isolate baby after birth

100
Herpes Simplex Type 2

• Maternal and Fetal Effects
• Painful lesions, blisters that may rupture and
  leave shallow lesions that crust over and
  disappear in 2-6 weeks
• Culture lesions to detect if Herpes, No cure
• If mom has an outbreak close to delivery, then
  cannot deliver vaginally. Must deliver by
  Cesarean birth
• Virus is lethal to fetus if inoculated
• at birth
• Intervention
• Zovirax

101
HIV/AIDS

• Etiology Human Immunodeficiency Virus, HIV
• Transmission of HIV to the fetus occurs
  through
• The placenta birth canal
• Through breast milk
• The virus must enter the babys
  bloodstream to produce infection.

102

• Maternal and Fetal Effects
• Mom - brief febrile illness after exposure to
  with symptoms of fatigue and lymphadenopathy
• Fetus has a 2-5 chance of being infected. No
  symptoms until about 1 year of age

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Diagnosis

• ELISA test identifies antibodies specific to
  HIV. If positive person has been exposed and
  formed antibodies
• Western Blot used to confirm seropositivity
  when ELISA is positive.
• Viral load - measures HIV RNA in plasma. It is
  used to predict severity lower the load the
  longer survival.
• CD4 cell count markers found on lymphocytes to
  indicate helper T4 cells. HIV kills CD4 cells
  which results in impaired immune system.
• Goal reduce viral load to below 50 copies
  /ml. and increase the CD4 cell count.

104
Nursing Care

• Provide Emotional Support
• Teach measures to promote wellness
• AZT
• oral during pregnancy
• IV during labor
• liquid to newborn for 6 weeks.
• Provide information about resources

105
Fetal Demise / Intrauterine Fetal
Death

• DEFINITION
• Death of a fetus after the age of
  viability

106

• Assessment
• 1. First indication is usually NO fetal
• movement
• 2. NO fetal heart tones
• Confirmed by ultrasound
• 3. Decrease in the signs and symptoms of
• pregnancy

107
Treatment

• Deliver the fetus
• How???

108
Pre-Gestational Onset Disorders
109
Diabetes in Pregnancy
110
Diabetes in Pregnancy

• Diabetes creates special problems which affect
  pregnancy in a variety of ways.
• Successful delivery requires work of the entire
  health care team

111
Endocrine Changes During
Pregnancy

• There is an increase in activity of maternal
  pancreatic islets which result in increase
  production of insulin.

112

• Counterbalanced by
• Placentas production of Human Chorionic
  Somatomammotropin (HCS)
• Increased levels of progesterone and
  estrogen--antagonistic to insulin
• Human placenta lactogen reduces effectiveness
  of circulating insulin
• d. Placenta enzyme-- insulinase

113
GESTATIONAL DIABETES

• Diabetes diagnosed during pregnancy, but
  unidentifable in non-pregnant woman
• Known as Type III Diabetes - intolerance to
  glucose during pregnancy with return to normal
  glucose tolerance within 24 hours after delivery
• Glucose tolerance test
• 1 hr oral GTT if elevated, do 3 hour GTT
• Gestational diabetes if
• Fasting 95 mg / dl
• 1 hour - 180 mg/ dl
• 2 hour - 155 mg/ dl
• 3 hour 140mg/dl

114
Treatment for the patient with Gestational
Diabetes

• Treatment - controlled mainly by diet
• No use of oral hypoglycemics

115
Effects of Diabetes on the
Pregnancy

• MATERNAL
• Increase incidence of INFECTION
• Fourfold greater incidence of Pre-eclampsia
• Increase incidence of Polyhydramnios
• Dystocia large babies
• Rapid Aging of Placenta

116

• FETAL COMPLICATIONS

• Increase morbidity
• Increase Congenital Anomalies
• neural tube defect (AFP)
• Cardiac anomalies
• Spontaneous Abortions
• Large for Gestation Baby, LGA
• Increase risk of RDS

117
Effects of Pregnancy on the Diabetic

• Insulin Requirements are Altered
• First Trimester--may drop slightly
• Second Trimester-- Rise in the requirements
• Third Trimester-- double to quadruple by the end
  of pregnancy
• Fluctuations harder to control more prone to DKA
• Possible acceleration of vascular diseases

118
Key Point to Remember!

• If the insulin requirements do not rise as
  pregnancy progresses that is an indication that
  the placenta is not functioning well.

119
Interventions /Nursing Care

• I. Diet Therapy
• dietary management must be based on BLOOD GLUCOSE
  LEVELS
• Pre-pregnant diet usually will not work
• Need 300kcal/day
• Divide among three meals and three snacks
• II. Insulin Regulation
• maintaining optimal blood glucose levels require
  careful regulation of insulin. Sometimes
  placed on insulin pump.

120

• III. Blood Glucose Monitoring
• teach how to keep a record of results of home
  glucose monitoring
• IV. EXERCISE
• A consistent and structured exercise program is
  O.K.
• V. MONITOR FETAL WELL-BEING
• The objective is to deliver the infant as
  near to term as possible and prevent
  unnecessary prematurity
• NST
• Ultrasound
• L / S ratio

121

• ?Heart Disease in
• Pregnancy

122
Cardiac Response in All Pregnancies
Every Pregnancy affects the
cardiovascular system

• Increase in Cardiac Output 30 - 50
• Expanded Plasma Volume
• Increase in Blood (Intravascular) Volume

A woman with a healthy heart can
tolerate the stress of pregnancy,but a
woman with a compromised heart is
challenged Hemodynamically and will have
complications
123
Effects of Heart Disease on Pregnancy

• Growth Retarded Fetus
• Spontaneous Abortion
• Premature Labor and Delivery

124
Effects of Pregnancy onHeart Disease

• The Stress of Pregnancy on an already
  weakened heart may lead to cardiac
  decompensation (failure).
• The effect may be varied depending upon the
  classification of the disease

125
Classification of Heart Disease

• Class 1
• Uncompromised
• No alteration in activity
• No anginal pain, no symptoms with activity
• Class 2
• Slight limitation of physical activity
• Dyspnea, fatigue, palpitations on ordinary
  exertion
• comfortable at rest
• 
  

126

• Class 3
• Marked limitation of physical activity
• Excessive fatigue and dyspnea on minimal exertion
• Anginal pain with less than ordinary exertion
• Class 4
• Symptoms of cardiac insufficiency even at rest
• Inability to perform any activity without
  discomfort
• Anginal pain
• Maternal and fetal risks are high
• 
  

127
Nursing Care - Antepartum

• Decrease Stress
• teach the importance of REST!
• watch weight
• assess for infections - stay away from crowds
• assess for anemia
• assess home responsibilities
• Teach signs of cardiac decompensation

128
Key Point to RememberSigns of Congestive Heart
Failure

• Cough (frequent, productive, hemoptysis)
• Dyspnea, Shortness of breath, orthopnea
• Palpitations of the heart
• Generalized edema, pitting edema of legs and
  feet
• Moist rales in lower lobes, indicating pulmonary
  edema
• 
  

129

• Teach about diet
• high in iron, protein
• low in sodium and calories ( fat )
• Watch weight gain
• Teach how to take their medicine
• Supplemental iron
• Heparin, not coumarin monitor lab work
• Diuretics very careful monitoring
• Antiarrhythmics Digoxin, quinidine,
  procainamide. Beta-blockers are associated with
  fetal defects.
• Reinforce physicians care

130
Key point to remember !
Never eat foods high in Vitamin K while
on an anticoagulant!
( raw green leafy vegetables)
131
Nursing Care Intrapartum

• Labor in an upright or side lying position
• Restrict fluids
• On O2 per mask throughout labor and cardiac
  monitoring.
• Sedation / epidural given early
• Report fetal distress or cardiac failure
• Stage 2 - gentle pushing, high forceps delivery

132
Nursing Care Postpartum

• The immediate post delivery period is the MOST
  significant and dangerous for the mom with
  cardiac problems
• Following delivery, fluid shifts from
  extravascular spaces into the blood stream for
  excretion
• Cardiac output increases, blood volume increases
• Strain on the heart! Watch for cardiac failure

133
Test Yourself !

• Mrs. B. has mitral valve prolapse. During the
  second trimester of pregnancy, she reports
  fatigue and palpitations during routine
  housework. As a cardiac patient, what would her
  functional classification be at this time?
• a. Class I
• b. Class II
• c. Class III
• d. Class IV

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The End