Complications During Complications During PregnancyPregnancy

Chapter 5Chapter 5

Characteristic Causes of Characteristic Causes of High-Risk PregnanciesHigh-Risk Pregnancies

Can relate to the pregnancy itselfCan relate to the pregnancy itself Can occur because the woman Can occur because the woman

has a medical condition or injury has a medical condition or injury that complicates the pregnancythat complicates the pregnancy

Can result from environmental Can result from environmental hazards that affect the mother or hazards that affect the mother or her fetusher fetus

Can arise from maternal Can arise from maternal behaviors or lifestyles that have behaviors or lifestyles that have a negative effect on the mother a negative effect on the mother or fetusor fetus

Assessment of Fetal Assessment of Fetal HealthHealth

The Goal of fetal assessmentThe Goal of fetal assessment Positive outcomesPositive outcomes

Nursing responsibilitiesNursing responsibilities Preparing the patientPreparing the patient Explaining procedures/testsExplaining procedures/tests Clarifying and interpreting resultsClarifying and interpreting results Collaboration with other healthcare Collaboration with other healthcare

providersproviders Psychosocial supportPsychosocial support

Danger Signs in Danger Signs in PregnancyPregnancy

Sudden gush of fluid from the vaginaSudden gush of fluid from the vagina Vaginal bleedingVaginal bleeding Abdominal painAbdominal pain Persistent vomitingPersistent vomiting Epigastric painEpigastric pain Edema of face and handsEdema of face and hands Severe, persistent headacheSevere, persistent headache Blurred vision or dizzinessBlurred vision or dizziness Chills with fever over 38.0Chills with fever over 38.0° ° C (100.4C (100.4° ° F)F) Painful urination or reduced urine outputPainful urination or reduced urine output

Pregnancy-Related Pregnancy-Related ComplicationsComplications

Hyperemesis GravidarumHyperemesis Gravidarum Excessive Nausea and vomitingExcessive Nausea and vomiting

Electrolyte/acid base imbalanceElectrolyte/acid base imbalance Significant weight lossSignificant weight loss Decreased turgorDecreased turgor Decreased urine outputDecreased urine output High hematocritHigh hematocrit

TreatmentTreatment Correct dehydration and inadequate nutritionCorrect dehydration and inadequate nutrition

Nursing Care for Nursing Care for HyperemesisHyperemesis

Patient EducationPatient Education Reduce factors that trigger nausea Reduce factors that trigger nausea

and vomitingand vomiting Keep accurate I&OKeep accurate I&O Frequent, small mealsFrequent, small meals

Easley digested carbohydratesEasley digested carbohydrates Eliminate foods with strong ordersEliminate foods with strong orders Drinking liquids between mealsDrinking liquids between meals Reduce stressReduce stress

Bleeding Disorders of Early Bleeding Disorders of Early Pregnancy Pregnancy

Abortion Abortion Spontaneous (non-intentional) Spontaneous (non-intentional)

AbortionAbortion A pregnancy that ends before 20 weeksA pregnancy that ends before 20 weeks

Threatened AbortionThreatened Abortion Light spotting; cervix is closed & no tissue Light spotting; cervix is closed & no tissue

is passedis passed Inevitable AbortionInevitable Abortion

Increased bleeding & cervix dilatesIncreased bleeding & cervix dilates Incomplete AbortionIncomplete Abortion

Bleeding dilation of cervix & passage of Bleeding dilation of cervix & passage of tissuetissue

Management for Threatened Management for Threatened AbortionAbortion

Avoid strenuous activities for Avoid strenuous activities for

24-48 hours24-48 hours

Complete bed restComplete bed rest

Talk in a sympathetic and Talk in a sympathetic and

supportive manner.supportive manner.

If bleeding stops, restrict If bleeding stops, restrict

coitus to prevent infection and coitus to prevent infection and

to avoid inducing further to avoid inducing further

bleeding.bleeding.

Inevitable AbortionInevitable Abortion

Instruct patient that she should save Instruct patient that she should save any fragment she has passed.any fragment she has passed.

If there is no fetal heart sound or If there is no fetal heart sound or sonogram reveals an empty uterus or sonogram reveals an empty uterus or nonviable uterus, the physician may nonviable uterus, the physician may perform VACUUM EXTRACTION.perform VACUUM EXTRACTION.

Be certain the woman has been told Be certain the woman has been told that pregnancy was already lost and that pregnancy was already lost and that all procedures to be done are to that all procedures to be done are to clean the uterus and to prevent further clean the uterus and to prevent further complications such as infection.complications such as infection.

Instruct patient that she should save Instruct patient that she should save any fragment she has passed.any fragment she has passed.

If there is no fetal heart sound or If there is no fetal heart sound or sonogram reveals an empty uterus or sonogram reveals an empty uterus or nonviable uterus, the physician may nonviable uterus, the physician may perform VACUUM EXTRACTION.perform VACUUM EXTRACTION.

Be certain the woman has been told Be certain the woman has been told that pregnancy was already lost and that pregnancy was already lost and that all procedures to be done are to that all procedures to be done are to clean the uterus and to prevent further clean the uterus and to prevent further complications such as infection.complications such as infection.

Bleeding Disorders of Early Bleeding Disorders of Early Pregnancy (continued)Pregnancy (continued)

AbortionAbortion CompleteComplete

Passage of all products of conception, Passage of all products of conception, cervix closes and bleeding stopscervix closes and bleeding stops

Missed Missed Fetus dies in utero but is not expelled, Fetus dies in utero but is not expelled,

uterine growth stops and spetis is uterine growth stops and spetis is possiblepossible

Recurrent Recurrent 2 or more consecutive spontaneous 2 or more consecutive spontaneous

abortions abortions

ManagementManagement After sonogram, D & C most After sonogram, D & C most

commonly will be done.commonly will be done. If pregnancy is over 14 If pregnancy is over 14

weeks, induction of weeks, induction of prostaglandin suppository or prostaglandin suppository or misoprostol to dilate cervix, misoprostol to dilate cervix, followed by oxytocin followed by oxytocin stimulation or mifepristone is stimulation or mifepristone is done.done.

Induced AbortionsInduced Abortions

Therapeutic AbortionTherapeutic Abortion Intentional termination of Intentional termination of

pregnancy before age of viability to pregnancy before age of viability to preserve the health of the motherpreserve the health of the mother

Elective AbortionElective Abortion Intentional termination of Intentional termination of

pregnancy for reasons unrelated to pregnancy for reasons unrelated to mothers healthmothers health

AbortionAbortion

Document amount and character of Document amount and character of bleedingbleeding

Save anything that looks like clots or Save anything that looks like clots or tissue for evaluation by a pathologisttissue for evaluation by a pathologist

Perineal pad count with estimated Perineal pad count with estimated amount of blood per pad, such as 50% amount of blood per pad, such as 50% (could weight pads before/after)(could weight pads before/after)

Monitor vital signsMonitor vital signs If actively bleeding, woman should be If actively bleeding, woman should be

kept NPO in case surgical intervention is kept NPO in case surgical intervention is neededneeded

Nursing Care of Early Nursing Care of Early Pregnancy Bleeding DisordersPregnancy Bleeding Disorders

Post-Abortion TeachingPost-Abortion Teaching

Report increased bleedingReport increased bleeding Take temperature every 8 hours for 3 daysTake temperature every 8 hours for 3 days Take an oral iron supplement if prescribedTake an oral iron supplement if prescribed Resume sexual activity as recommended by Resume sexual activity as recommended by

the health care providerthe health care provider Return to health care provider at the Return to health care provider at the

recommended time for a checkup and recommended time for a checkup and contraception informationcontraception information

Pregnancy can occur before the first Pregnancy can occur before the first menstrual period returns after the abortion menstrual period returns after the abortion procedureprocedure

Emotional CareEmotional Care

Spiritual support from someone Spiritual support from someone of the family’s choice and of the family’s choice and community support groups may community support groups may help the family work through help the family work through the grief of any pregnancy lossthe grief of any pregnancy loss

Review effective and ineffective Review effective and ineffective communication techniquescommunication techniques

Effective CommunicationEffective Communication

Ectopic PregnancyEctopic Pregnancy

95% occur in fallopian tube95% occur in fallopian tube Scarring or tubal deformity may result from:Scarring or tubal deformity may result from:

Hormonal abnormalitiesHormonal abnormalities InflammationInflammation InfectionInfection AdhesionsAdhesions Congenital defectsCongenital defects EndometriosisEndometriosis

Ectopic Pregnancies Ectopic Pregnancies (Continued)(Continued)

ManifestationsManifestations Lower abdominal pain, may have Lower abdominal pain, may have

light vaginal bleedinglight vaginal bleeding If tube ruptures:If tube ruptures:

May have sudden severe lower May have sudden severe lower abdominal painabdominal pain

Vaginal bleedingVaginal bleeding Signs of hypovolemic shockSigns of hypovolemic shock Shoulder pain may also be feltShoulder pain may also be felt

Ectopic Pregnancies Ectopic Pregnancies (Continued)(Continued)

TreatmentTreatment Pregnancy testPregnancy test Transvaginal ultrasoundTransvaginal ultrasound Laparoscopic examinationLaparoscopic examination Priority is to control bleedingPriority is to control bleeding Three actions can be taken:Three actions can be taken:

No actionNo action Treatment with methotrexate to inhibit Treatment with methotrexate to inhibit

cell divisioncell division Surgery to remove pregnancy from the Surgery to remove pregnancy from the

tubetube

Signs and Symptoms of Signs and Symptoms of Hypovolemic ShockHypovolemic Shock

Changes in fetal Changes in fetal heart rate heart rate (increased, (increased, decreased, less decreased, less fluctuation) fluctuation)

Rising, weak pulse Rising, weak pulse (tachycardia)(tachycardia)

Rising respiratory Rising respiratory rate (tachypnea)rate (tachypnea)

Shallow, irregular Shallow, irregular respirations; air respirations; air hungerhunger

Falling blood Falling blood pressure pressure (hypotension)(hypotension)

Decreased or absent Decreased or absent urinary output urinary output (usually less than 30 (usually less than 30 ml/hr)ml/hr)

Pale skin or pale Pale skin or pale mucous membranesmucous membranes

Cold, clammy skinCold, clammy skin FaintnessFaintness ThirstThirst

Hydatidiform Mole Hydatidiform Mole (Molar Pregnancy)(Molar Pregnancy)

Also known as Gestational Trophoblastic Also known as Gestational Trophoblastic DiseaseDisease Occurs when chorionic villi Occurs when chorionic villi

abnormally increase and develop abnormally increase and develop vesiclesvesicles

May cause hemorrhage, clotting May cause hemorrhage, clotting abnormalities, hypertension, and abnormalities, hypertension, and later development of cancerlater development of cancer

More likely to occur in women at age More likely to occur in women at age extremes of the reproductive lifeextremes of the reproductive life

Hydatidiform Mole Hydatidiform Mole (Continued)(Continued)

ManifestationsManifestations BleedingBleeding Rapid uterine growthRapid uterine growth Failure to detect fetal heart activityFailure to detect fetal heart activity Signs of hyperemesis gravidarumSigns of hyperemesis gravidarum Unusually early development of GHUnusually early development of GH Higher than expected levels of hCGHigher than expected levels of hCG A distinct “snowstorm” pattern on ultrasound with A distinct “snowstorm” pattern on ultrasound with

no evidence of a developing fetusno evidence of a developing fetus TreatmentTreatment

Uterine evacuationUterine evacuation Dilation and evacuationDilation and evacuation

Bleeding Disorders of Bleeding Disorders of Late PregnancyLate Pregnancy

Placenta previaPlacenta previa Abnormal implantation of placentaAbnormal implantation of placenta Bright bleeding occurs when cervix dilates, Bright bleeding occurs when cervix dilates,

resulting in resulting in painlesspainless bleedingbleeding Abruptio placentaeAbruptio placentae

Normal implantation of placentaNormal implantation of placenta Dark bleeding with Dark bleeding with painpain and enlarging uterus and enlarging uterus

suggest blood is accumulating within the cavitysuggest blood is accumulating within the cavity

Placenta Previa/Abruptio Placenta Previa/Abruptio PlacentaePlacentae

Complications or RisksComplications or Risks

Placenta previaPlacenta previa Infection, because of vaginal organismsInfection, because of vaginal organisms Postpartum hemorrhage, because if lower segment Postpartum hemorrhage, because if lower segment

of uterus was site of attachment, then there are of uterus was site of attachment, then there are fewer muscle fibers so weaker contractions may fewer muscle fibers so weaker contractions may occuroccur

Abruptio placentaeAbruptio placentae Predisposing factorsPredisposing factors

HypertensionHypertension Cocaine or alcohol useCocaine or alcohol use Cigarette smoking and poor nutritionCigarette smoking and poor nutrition Blows to the abdomenBlows to the abdomen Prior history of abruptio placentaePrior history of abruptio placentae Folate deficiencyFolate deficiency

Disseminated Disseminated Intravascular Coagulation Intravascular Coagulation

(DIC)(DIC) A Pathologic form of coagulation A Pathologic form of coagulation

in which clotting factors are in which clotting factors are consumed to such extent that consumed to such extent that generalized bleeding can occur, generalized bleeding can occur, usually associated with abruptio usually associated with abruptio placentae, eclampsia, placentae, eclampsia, intrauterine fetal demise, amiotic intrauterine fetal demise, amiotic fluid embolism and hemorrhage..fluid embolism and hemorrhage..

Risk Factors for Risk Factors for Gestational Hypertension Gestational Hypertension

(GH)(GH) First pregnancyFirst pregnancy ObesityObesity Family history of GHFamily history of GH Age over 40 years or under 19 Age over 40 years or under 19

yearsyears Multifetal pregnancyMultifetal pregnancy Chronic hypertensionChronic hypertension Chronic renal diseaseChronic renal disease Diabetes mellitusDiabetes mellitus

Manifestations of GHManifestations of GH

HypertensionHypertension EdemaEdema ProteinuriaProteinuria Central nervous Central nervous

systemsystem EyesEyes

Urinary tractUrinary tract Respiratory Respiratory

systemsystem Gastrointestinal Gastrointestinal

system and liversystem and liver Blood clottingBlood clotting Vasospasms of Vasospasms of

the arteriesthe arteries

Management of GHManagement of GH

Depends on severity of the hypertension Depends on severity of the hypertension and on the maturity of the fetusand on the maturity of the fetus

Treatment focuses on:Treatment focuses on: Maintaining blood flow to the Maintaining blood flow to the

woman’s vital organs and to the woman’s vital organs and to the placentaplacenta

Preventing convulsionsPreventing convulsions Safe delivery of the fetusSafe delivery of the fetus

Conservative TreatmentConservative Treatment

Activity Activity restrictionrestriction

Maternal Maternal assessment of assessment of fetal activityfetal activity

Blood pressure Blood pressure monitoringmonitoring

Daily weightDaily weight Checking urine Checking urine

for proteinfor protein

Drug therapyDrug therapy Magnesium Magnesium

sulfatesulfate Calcium Calcium

gluconategluconate AntihypertensiveAntihypertensive

ss

Nursing Care FocusNursing Care Focus

Assisting the woman in obtaining prenatal Assisting the woman in obtaining prenatal carecare

Helping her cope with therapyHelping her cope with therapy Caring for acutely ill womanCaring for acutely ill woman

Know what signs/symptoms to Know what signs/symptoms to monitor for and when to intervenemonitor for and when to intervene

Administering medications as prescribedAdministering medications as prescribed

Bleeding Bleeding IncompatibilitiesIncompatibilities

Rh-negative blood type is an Rh-negative blood type is an autosomal recessive traitautosomal recessive trait

Rh-positive blood type is a Rh-positive blood type is a dominant traitdominant trait

Rh incompatibility can only occur Rh incompatibility can only occur if the woman is Rh-negative and if the woman is Rh-negative and the fetus is Rh-positivethe fetus is Rh-positive

IsoimmunizationIsoimmunization

The leaking of fetal Rh-positive blood The leaking of fetal Rh-positive blood into the Rh-negative mother’s into the Rh-negative mother’s circulation, causing her body to circulation, causing her body to respond by making antibodies to respond by making antibodies to destroy the Rh-positive erythrocytesdestroy the Rh-positive erythrocytes

With subsequent pregnancy, the With subsequent pregnancy, the woman’s antibodies against Rh-woman’s antibodies against Rh-positive blood cross the placenta and positive blood cross the placenta and destroy the fetal Rh-positive destroy the fetal Rh-positive erythrocytes before the infant is bornerythrocytes before the infant is born

Erythroblastosis FetalisErythroblastosis Fetalis

Occurs when the Occurs when the maternal anti-Rh maternal anti-Rh antibodies cross the antibodies cross the placenta and destroy placenta and destroy fetal erythrocytesfetal erythrocytes

Requires RhoGAM to Requires RhoGAM to be given at 28 weeks be given at 28 weeks and within 72 hours of and within 72 hours of delivery to the motherdelivery to the mother Also given after Also given after

amniocentesis, and if amniocentesis, and if woman experiences woman experiences bleeding during bleeding during pregnancypregnancy

Fetal assessment Fetal assessment tests must be tests must be done throughout done throughout pregnancypregnancy

An intrauterine An intrauterine transfusion may transfusion may be done for the be done for the severely anemic severely anemic fetusfetus

Pregnancy Complicated Pregnancy Complicated by Medical Conditionsby Medical Conditions

Diabetes MellitusDiabetes Mellitus Type 1 diabetes mellitusType 1 diabetes mellitus

Physiological disorder of the pancreas Physiological disorder of the pancreas resulting in insulin deficiencyresulting in insulin deficiency

Type 2 diabetes MellitusType 2 diabetes Mellitus Insulin resistanceInsulin resistance Familiar predispositionFamiliar predisposition

Gestationa diabetes mellitus (GDM)Gestationa diabetes mellitus (GDM) Glucose intolerance with the onset of Glucose intolerance with the onset of

pregnancypregnancy

Effects of Diabetes in Effects of Diabetes in PregnancyPregnancy

Maternal EffectsMaternal Effects Spontaneous abortionSpontaneous abortion Gestational hypertensionGestational hypertension Preterm labor and premature rupture of Preterm labor and premature rupture of

the membranesthe membranes Hydramnios/ployhydramnios (excessive Hydramnios/ployhydramnios (excessive

amniotic fluid)amniotic fluid) Infections (vaginitis, UTI)Infections (vaginitis, UTI) Large for gestational age (LGA) fetusLarge for gestational age (LGA) fetus KetoacidosisKetoacidosis

Effects of Diabetes in Effects of Diabetes in Pregnancy (Continued)Pregnancy (Continued)

Fetal/Neonatal effectsFetal/Neonatal effects Congenital abnormalitiesCongenital abnormalities MacrosomiaMacrosomia Intrauterine growth restriction (IUGR)Intrauterine growth restriction (IUGR) Birth injuryBirth injury Delayed lung maturityDelayed lung maturity Neonatal: hypoglycemia, hypocalcemia, Neonatal: hypoglycemia, hypocalcemia,

hyperbilirubinemia/jaundice and hyperbilirubinemia/jaundice and polycythemiapolycythemia

Perinatal deathPerinatal death

Gestational DiabetesGestational Diabetes

If woman cannot increase her insulin If woman cannot increase her insulin production, then she will have periods of production, then she will have periods of hyperglycemiahyperglycemia

Because fetus is continuously drawing Because fetus is continuously drawing glucose from the mother, she will also glucose from the mother, she will also experience hypoglycemia between meals experience hypoglycemia between meals and during the nightand during the night

During 2nd and 3rd trimester, fetus is at During 2nd and 3rd trimester, fetus is at risk for organ damage from risk for organ damage from hyperglycemia because fetal tissue has hyperglycemia because fetal tissue has increased tissue resistance to maternal increased tissue resistance to maternal insulin actioninsulin action

TreatmentTreatment

DietDiet Monitoring blood glucose levelsMonitoring blood glucose levels Ketone monitoringKetone monitoring ExerciseExercise Fetal assessmentFetal assessment

Care During Labor of the Care During Labor of the Woman With GDMWoman With GDM

Intravenous infusion of dextrose Intravenous infusion of dextrose may be neededmay be needed

Regular insulinRegular insulin Assess blood glucose levels Assess blood glucose levels

hourly and adjust insulin hourly and adjust insulin administration accordinglyadministration accordingly

Care of the Neonate of a Care of the Neonate of a Woman With GDMWoman With GDM

May have the following occur:May have the following occur: HypoglycemiaHypoglycemia Respiratory distressRespiratory distress

Injury related to macrosomiaInjury related to macrosomia Blood glucose monitored closely for at least Blood glucose monitored closely for at least

the first 24 hours after birththe first 24 hours after birth Breastfeeding should be encouragedBreastfeeding should be encouraged

Heart DiseaseHeart Disease

ManifestationsManifestations Increased levels of clotting factors Increased levels of clotting factors Increased risk of thrombosisIncreased risk of thrombosis

If woman’s heart cannot handle increased If woman’s heart cannot handle increased workload, then congestive heart failure workload, then congestive heart failure (CHF) results(CHF) results

Fetus suffers from reduced placental blood Fetus suffers from reduced placental blood flowflow

Signs of CHF During Signs of CHF During PregnancyPregnancy

Persistent coughPersistent cough Moist lung Moist lung

soundssounds Fatigue or Fatigue or

fainting on fainting on exertionexertion

Difficulty Difficulty breathing on breathing on exertionexertion

Orthopnea Orthopnea

Severe pitting Severe pitting edema of the lower edema of the lower extremities or extremities or generalized edemageneralized edema

PalpitationsPalpitations Changes in fetal Changes in fetal

heart rateheart rate Indicating Indicating

hypoxia or hypoxia or growth growth restrictionrestriction

TreatmentTreatment

Under care of both obstetrician and Under care of both obstetrician and cardiologistcardiologist

Priority care is limiting physical activityPriority care is limiting physical activity Drug therapyDrug therapy May include beta-adrenergic blockers, May include beta-adrenergic blockers,

anticoagulants, diureticsanticoagulants, diuretics Vaginal birth is preferred because it carries Vaginal birth is preferred because it carries

less risk for infection or respiratory less risk for infection or respiratory complicationscomplications

AnemiaAnemia

Anemia is the reduced ability of the blood to Anemia is the reduced ability of the blood to carry oxygen to the cellscarry oxygen to the cells

Four types are significant during pregnancyFour types are significant during pregnancy Two are nutritional:Two are nutritional:

Iron deficiencyIron deficiency Folic acid deficiencyFolic acid deficiency

Two are genetic disorders:Two are genetic disorders: Sickle cell diseaseSickle cell disease Thalassemia Thalassemia

Nutritional AnemiasNutritional Anemias

SymptomsSymptoms Easily fatiguedEasily fatigued Skin and mucous membranes are Skin and mucous membranes are

palepale Shortness of breathShortness of breath Pounding heartPounding heart Rapid pulse (with severe anemia)Rapid pulse (with severe anemia)

Iron Deficiency AnemiaIron Deficiency Anemia

RBCs are small (microcytic) and pale RBCs are small (microcytic) and pale (hypochromic)(hypochromic)

PreventionPrevention Iron supplementsIron supplements Vitamin C may enhance absorptionVitamin C may enhance absorption Do not take iron with milk or Do not take iron with milk or

antacidsantacids Calcium impairs absorptionCalcium impairs absorption

Iron Deficiency AnemiaIron Deficiency Anemia (continued)(continued)

TreatmentTreatment Oral doses of elemental ironOral doses of elemental iron Continue therapy for about 3 Continue therapy for about 3

months after anemia has been months after anemia has been correctedcorrected

Folic Acid Deficiency Folic Acid Deficiency AnemiaAnemia

Large, immature RBCs (megaloblastic Large, immature RBCs (megaloblastic anemia)anemia)

Anticonvulsants, oral contraceptives, sulfa Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption drugs, and alcohol can decrease absorption of folate from mealsof folate from meals

Folate is essential for normal growth and Folate is essential for normal growth and developmentdevelopment

PreventionPrevention Daily supplement of 400 Daily supplement of 400 mcmcg (0.4 g (0.4

mg)mg)

Folic Acid Deficiency Folic Acid Deficiency Anemia (continued)Anemia (continued)

TreatmentTreatment Folate deficiency is treated with Folate deficiency is treated with

folic acid supplementationfolic acid supplementation 1 mg/day (over twice the amount of 1 mg/day (over twice the amount of

the preventive supplement)the preventive supplement) Dose may be higher for women who Dose may be higher for women who

have had a previous child with a neural have had a previous child with a neural tube defecttube defect

Genetic AnemiasGenetic Anemias

Sickle cell anemiaSickle cell anemia Autosomal recessive disorderAutosomal recessive disorder Abnormal hemoglobin Abnormal hemoglobin Causes erythrocytes to become distorted and sickle Causes erythrocytes to become distorted and sickle

(crescent) shaped during hypoxic or acidotic episodes(crescent) shaped during hypoxic or acidotic episodes Abnormally shaped blood cells do not flow smoothlyAbnormally shaped blood cells do not flow smoothly Can clog small blood vesselsCan clog small blood vessels Pregnancy can cause a crisisPregnancy can cause a crisis Massive erythrocyte destruction and vessel occlusionMassive erythrocyte destruction and vessel occlusion Risk to fetus if occlusion occurs in vessels that supply Risk to fetus if occlusion occurs in vessels that supply

the placentathe placenta Can lead to preterm birth, growth restriction, and fetal Can lead to preterm birth, growth restriction, and fetal

demisedemise Oxygen and fluids are given continuously throughout Oxygen and fluids are given continuously throughout

laborlabor

Genetic Anemia's Genetic Anemia's (Continued)(Continued)

ThalassemiaThalassemia Pregnancy can cause a crisisPregnancy can cause a crisis Massive erythrocyte destruction and vessel occlusionMassive erythrocyte destruction and vessel occlusion Risk to fetus if occlusion occurs in vessels that supply Risk to fetus if occlusion occurs in vessels that supply

the placentathe placenta Can lead to preterm birth, growth restriction, and fetal Can lead to preterm birth, growth restriction, and fetal

demisedemise Oxygen and fluids are given continuously throughout Oxygen and fluids are given continuously throughout

laborlabor Genetic trait causes abnormality in one of two chains of Genetic trait causes abnormality in one of two chains of

hemoglobin hemoglobin

Thalassemia (continued)Thalassemia (continued)

ββ chain seen most often in United States chain seen most often in United States Can inherit abnormal gene from each parent, causing Can inherit abnormal gene from each parent, causing ββ--

thalassemia major thalassemia major If only one abnormal gene is inherited, then infant will If only one abnormal gene is inherited, then infant will

have have ββ-thalassemia minor-thalassemia minor Woman with Woman with ββ-thalassemia minor has few problems, -thalassemia minor has few problems,

other than mild anemiaother than mild anemia Fetus does not appear affectedFetus does not appear affected Iron supplements may cause iron overloadIron supplements may cause iron overload Body absorbs and stores iron in amounts that are Body absorbs and stores iron in amounts that are

higher than usualhigher than usual

Nursing Care for Women With Nursing Care for Women With Anemias During PregnancyAnemias During Pregnancy

Teach woman which foods are high in iron and folic Teach woman which foods are high in iron and folic acidacid

Teach woman how to take supplementsTeach woman how to take supplements Do not take iron supplements at the same time Do not take iron supplements at the same time

when drinking milkwhen drinking milk Do not take antacids with ironDo not take antacids with iron When taking iron, stools will be dark green to blackWhen taking iron, stools will be dark green to black

The woman with sickle cell disease requires close The woman with sickle cell disease requires close medical and nursing caremedical and nursing care Teach her to prevent dehydration and activities Teach her to prevent dehydration and activities

that cause hypoxiathat cause hypoxia Teach her to avoid situations where exposure to Teach her to avoid situations where exposure to

infections are more likelyinfections are more likely Teach her to promptly report any signs of infectionsTeach her to promptly report any signs of infections

InfectionsInfections

Acronym Acronym TORCHTORCH is used to describe is used to describe infections that can be devastating to the infections that can be devastating to the fetus or newbornfetus or newborn TToxoplasmosisoxoplasmosis OOther infectionsther infections RRubellaubella CCytomegalovirusytomegalovirus HHerpeserpes

Viral InfectionsViral Infections

No effective therapyNo effective therapy Immunizations can prevent Immunizations can prevent somesome

infectionsinfections

Cytomegalovirus (CMV)Cytomegalovirus (CMV)

Infected infant may Infected infant may havehave Mental Mental

retardationretardation SeizuresSeizures BlindnessBlindness DeafnessDeafness Dental Dental

abnormalitiesabnormalities PetechiaePetechiae

TreatmentTreatment No effective No effective

treatment is treatment is knownknown

Therapeutic Therapeutic abortion may be abortion may be offered if CMV offered if CMV infection is infection is discovered early discovered early in pregnancyin pregnancy

SyphilisSyphilis

• Treponema pallidum (spirochete)Treponema pallidum (spirochete)• Transmitted via sexual contactTransmitted via sexual contact• Placental transmission as early as 6wks Placental transmission as early as 6wks

gestationgestation• Typically occurs during second halfTypically occurs during second half• Mom with primary or secondary syphilis more Mom with primary or secondary syphilis more

likely to transmit than latent diseaselikely to transmit than latent disease• Large decrease in congenital syphilis since Large decrease in congenital syphilis since

late 1990slate 1990s• In 2002, only 11.2 cases/100,000 live births In 2002, only 11.2 cases/100,000 live births

reportedreported

Congenital SyphilisCongenital Syphilis

• 2/3 of affected live-born infants are 2/3 of affected live-born infants are asymptomatic at birthasymptomatic at birth

• Clinical symptoms split into early or late Clinical symptoms split into early or late (2 years is cutoff)(2 years is cutoff)

• 3 major classifications:3 major classifications:• Fetal effectsFetal effects• Early effectsEarly effects• Late effectsLate effects

Clinical ManifestationsClinical Manifestations

• Fetal:Fetal:• StillbirthStillbirth• Neonatal deathNeonatal death• Hydrops fetalisHydrops fetalis

• Intrauterine death in 25%Intrauterine death in 25%

• Perinatal mortality in 25-30% if Perinatal mortality in 25-30% if untreateduntreated

Clinical ManifestationsClinical Manifestations

• Early congenital (typically 1Early congenital (typically 1stst 5 weeks): 5 weeks):• Cutaneous lesions (palms/soles)Cutaneous lesions (palms/soles)• HSMHSM• JaundiceJaundice• AnemiaAnemia• SnufflesSnuffles• PeriostitisPeriostitis and metaphysial dystrophy and metaphysial dystrophy• Funisitis (umbilical cord vasculitis)Funisitis (umbilical cord vasculitis)

Periostitis of long bones Periostitis of long bones seen in neonatal syphilisseen in neonatal syphilis

Clinical ManifestationsClinical Manifestations

• Late congenital:Late congenital:• Frontal bossingFrontal bossing• Short maxillaShort maxilla• High palatal archHigh palatal arch• Hutchinson teethHutchinson teeth• 88thth nerve deafness nerve deafness• Saddle nose Saddle nose • Perioral fissuresPerioral fissures

• Can be prevented with appropriate treatmentCan be prevented with appropriate treatment

Hutchinson teeth – late result of Hutchinson teeth – late result of congenital syphiliscongenital syphilis

Diagnosing SyphilisDiagnosing Syphilis(Not in Newborns)(Not in Newborns)

• Available serologic testingAvailable serologic testing• RPR/VDRL: nontreponemal testRPR/VDRL: nontreponemal test

• Sensitive but NOT specificSensitive but NOT specific• Quantitative, so can follow to determine disease activity Quantitative, so can follow to determine disease activity

and treatment responseand treatment response• MHA-TP/FTA-ABS: specific treponemal testMHA-TP/FTA-ABS: specific treponemal test

• Used for confirmatory testingUsed for confirmatory testing• Qualitative, once positive always positiveQualitative, once positive always positive

• RPR/VDRL screen in ALL pregnant women RPR/VDRL screen in ALL pregnant women early in pregnancy and at time of birthearly in pregnancy and at time of birth• This is easily treated!!This is easily treated!!

CDC Definition of Congenital CDC Definition of Congenital SyphilisSyphilis

• Confirmed if T. pallidum identified in skin Confirmed if T. pallidum identified in skin lesions, placenta, umbilical cord, or at lesions, placenta, umbilical cord, or at autopsyautopsy

• Presumptive diagnosis if any of:Presumptive diagnosis if any of:• Physical exam findingsPhysical exam findings• CSF findings (positive VDRL)CSF findings (positive VDRL)• Osteitis on long bone x-raysOsteitis on long bone x-rays• Funisitis (“barber shop pole” umbilical cord)Funisitis (“barber shop pole” umbilical cord)• RPR/VDRL >4 times maternal testRPR/VDRL >4 times maternal test• Positive IgM antibodyPositive IgM antibody

TreatmentTreatment

• Penicillin G is THE drug of choice for Penicillin G is THE drug of choice for ALL syphilis infectionsALL syphilis infections

• Maternal treatment during pregnancy Maternal treatment during pregnancy very effective (overall 98% success)very effective (overall 98% success)

• Treat newborn if:Treat newborn if:• They meet CDC diagnostic criteriaThey meet CDC diagnostic criteria• Mom was treated <4wks before deliveryMom was treated <4wks before delivery

RubellaRubella

Mild viral diseaseMild viral disease Low fever and rashLow fever and rash Destructive to developing fetusDestructive to developing fetus

If it occurs early in pregnancy, it can disrupt If it occurs early in pregnancy, it can disrupt formation of major body systemsformation of major body systems

If it occurs later in pregnancy, it can cause If it occurs later in pregnancy, it can cause damage to organs already formeddamage to organs already formed

If woman receives a rubella vaccine prior to If woman receives a rubella vaccine prior to pregnancy, then she should not get pregnancy, then she should not get pregnant for at least 3 monthspregnant for at least 3 months

Not given during pregnancy because Not given during pregnancy because vaccine is from a live virusvaccine is from a live virus

Rubella (continued)Rubella (continued)

Effects on embryo or fetus:Effects on embryo or fetus: Microcephaly (small head size)Microcephaly (small head size) Mental retardationMental retardation Congenital cataractsCongenital cataracts DeafnessDeafness Cardiac effectsCardiac effects Intrauterine growth restriction Intrauterine growth restriction

(IUGR)(IUGR)

HerpesvirusHerpesvirus

Two typesTwo types Type 1: Likely to cause fever Type 1: Likely to cause fever

blisters or cold soresblisters or cold sores Type 2: Likely to cause genital Type 2: Likely to cause genital

herpesherpes After primary infection, herpesvirus lies After primary infection, herpesvirus lies

dormant in the nerves and can reactivate at dormant in the nerves and can reactivate at any timeany time

Initial infection during first half of pregnancy Initial infection during first half of pregnancy may cause spontaneous abortion, IUGR, and may cause spontaneous abortion, IUGR, and preterm laborpreterm labor

Herpesvirus (continued)Herpesvirus (continued)

Infant can be infected in one of two ways:Infant can be infected in one of two ways: Virus ascends into the uterus after Virus ascends into the uterus after

the membranes rupturethe membranes rupture Infant has direct contact with Infant has direct contact with

infectious lesions during vaginal infectious lesions during vaginal deliverydelivery

Neonatal herpes Neonatal herpes Can be either localized or Can be either localized or

disseminated (widespread)disseminated (widespread) High mortality rateHigh mortality rate

Herpesvirus (continued)Herpesvirus (continued)

Treatment and Nursing CareTreatment and Nursing Care Avoid contact with lesionsAvoid contact with lesions

If woman has active genital herpes If woman has active genital herpes when membranes rupture or labor when membranes rupture or labor beginsbegins

Cesarean delivery may be required Cesarean delivery may be required if lesions are present at time of if lesions are present at time of deliverydelivery

Mother and infant do not need to be Mother and infant do not need to be isolated as long as direct contact isolated as long as direct contact with lesions is avoidedwith lesions is avoided

Hepatitis BHepatitis B

Transmitted by blood, saliva, vaginal Transmitted by blood, saliva, vaginal secretions, semen, and breast milk; secretions, semen, and breast milk; can also cross the placentacan also cross the placenta

Fetus may be infected transplacentally Fetus may be infected transplacentally or by contact with blood or vaginal or by contact with blood or vaginal secretions during deliverysecretions during delivery

Upon delivery, the neonate should Upon delivery, the neonate should receive a single dose of hepatitis B receive a single dose of hepatitis B immune globulin, followed by the immune globulin, followed by the hepatitis B vaccinehepatitis B vaccine

Risk Factors for Hepatitis Risk Factors for Hepatitis BB

Intravenous drug usersIntravenous drug users Persons with multiple sexual partnersPersons with multiple sexual partners Persons with repeated infection with STIPersons with repeated infection with STI Health care workers with occupational Health care workers with occupational

exposure to blood products and needle sticksexposure to blood products and needle sticks Patients who are on hemodialysisPatients who are on hemodialysis Recipients of multiple blood transfusions or Recipients of multiple blood transfusions or

other blood productsother blood products Household contact with hepatitis carrier or Household contact with hepatitis carrier or

patient on hemodialysispatient on hemodialysis Persons arriving from countries where there is Persons arriving from countries where there is

a higher incidence of hepatitis Ba higher incidence of hepatitis B

Human Human Immunodeficiency Virus Immunodeficiency Virus

(HIV)(HIV) Virus that causes Virus that causes

AIDSAIDS Cripples immune Cripples immune

systemsystem No known No known

immunization or immunization or curative curative treatmenttreatment

Acquired in one of three Acquired in one of three ways:ways: Sexual contactSexual contact Parenteral or mucous Parenteral or mucous

membrane exposure membrane exposure to infected body to infected body fluidsfluids

Perinatal exposurePerinatal exposure Infant may be infected:Infant may be infected:

TransplacentallyTransplacentally Through contact with Through contact with

infected maternal infected maternal secretions at birthsecretions at birth

Through breast milkThrough breast milk

Nursing CareNursing Care

Educate the woman who is HIV Educate the woman who is HIV positive on methods to reduce positive on methods to reduce the risk of transmission to her the risk of transmission to her developing fetus/infantdeveloping fetus/infant

Pregnant women with AIDS are Pregnant women with AIDS are more susceptible to infectionmore susceptible to infection

Breastfeeding is contraindicated Breastfeeding is contraindicated for mothers who are HIV positivefor mothers who are HIV positive

Nonviral InfectionsNonviral Infections

ToxoplasmosisToxoplasmosis A parasite acquired by contact with cat feces or raw meatA parasite acquired by contact with cat feces or raw meat Transmitted through the placentaTransmitted through the placenta Congenital toxoplasmosis includes the following possible signs:Congenital toxoplasmosis includes the following possible signs:

Low birth weightLow birth weight Enlarged liver and spleenEnlarged liver and spleen JaundiceJaundice AnemiaAnemia Inflammation of eye structuresInflammation of eye structures Neurological damageNeurological damage

Nonviral InfectionsNonviral Infections

ToxoplasmosisToxoplasmosis TreatmentTreatment

Therapeutic abortionTherapeutic abortion Preventive measuresPreventive measures

Cook all meat thoroughlyCook all meat thoroughly Wash hands and all kitchen surfaces Wash hands and all kitchen surfaces

after handling raw meatafter handling raw meat Avoid uncooked eggs and Avoid uncooked eggs and

unpasteurized milkunpasteurized milk Wash fresh fruits and vegetables wellWash fresh fruits and vegetables well Avoid materials contaminated with cat Avoid materials contaminated with cat

fecesfeces

Group B Streptococcus Group B Streptococcus (GBS) Infection(GBS) Infection

Leading cause of Leading cause of perinatal infection with perinatal infection with high mortality ratehigh mortality rate

Organism found in Organism found in woman’s rectum, woman’s rectum, vagina, cervix, throat, vagina, cervix, throat, or skinor skin

The risk of exposure to The risk of exposure to the infant is greater if the infant is greater if the labor is long or the the labor is long or the woman experiences woman experiences premature rupture of premature rupture of membranesmembranes

GBS significant cause of GBS significant cause of maternal postpartum maternal postpartum infectioninfection Symptoms include: Symptoms include:

Elevated Elevated temperature within temperature within 12 hours after 12 hours after delivery, rapid heart delivery, rapid heart rate, abdominal rate, abdominal distentiondistention

Can be deadly to the Can be deadly to the infantinfant

TreatmentTreatment PenicillinPenicillin

Sexually Transmitted Sexually Transmitted Infections (STI)Infections (STI)

Common mode of transmission is sexual Common mode of transmission is sexual intercourseintercourse

Infections that can be transmitted:Infections that can be transmitted: Syphilis, gonorrhea, chlamydia, Syphilis, gonorrhea, chlamydia,

trichomoniasis, and condylomata trichomoniasis, and condylomata acuminata acuminata

Vaginal changes during pregnancy increase Vaginal changes during pregnancy increase the risk of transmissionthe risk of transmission

Urinary Tract InfectionsUrinary Tract Infections

Pregnancy alters Pregnancy alters self-cleaning self-cleaning action due to action due to pressure on pressure on urinary structuresurinary structures

Prevents bladder Prevents bladder from emptying from emptying completelycompletely

Retained urine Retained urine becomes more becomes more alkalinealkaline

May develop cystitisMay develop cystitis Burning with urinationBurning with urination Increased frequency Increased frequency

and urgency of and urgency of urinationurination

Normal or slightly Normal or slightly elevated temperatureelevated temperature

PyelonephritisPyelonephritis High feverHigh fever ChillsChills Flank pain or Flank pain or

tendernesstenderness Nausea and vomitingNausea and vomiting

Environmental Hazards Environmental Hazards During PregnancyDuring Pregnancy

Bioterrorism and the pregnant womanBioterrorism and the pregnant woman Three basic categoriesThree basic categories

A — Can be easily transmitted from A — Can be easily transmitted from person to personperson to person

B — Can be spread via food and B — Can be spread via food and waterwater

C — Can be spread via C — Can be spread via manufactured weapons designed to manufactured weapons designed to spread diseasespread disease

Environmental Hazards Environmental Hazards During Pregnancy During Pregnancy

(continued)(continued) Substance abuseSubstance abuse

Questions should focus on how the Questions should focus on how the information will help nurses and information will help nurses and physicians provide the safest and physicians provide the safest and most appropriate care to the most appropriate care to the pregnant woman and her infantpregnant woman and her infant

AlcoholAlcohol A single episode of consuming two A single episode of consuming two

alcoholic drinks can lead to the loss alcoholic drinks can lead to the loss of some fetal brain cellsof some fetal brain cells

Trauma During Trauma During PregnancyPregnancy

3 leading causes of traumatic 3 leading causes of traumatic deathdeath Automobile accidentsAutomobile accidents HomicideHomicide Suicide Suicide

BatteringBattering Burses in various stages of healingBurses in various stages of healing

Nursing TipNursing Tip

If a woman confides that she is being If a woman confides that she is being abused during pregnancy, this abused during pregnancy, this information must be kept absolutely information must be kept absolutely confidentialconfidential

Her life may be in danger if her Her life may be in danger if her abuser learns that she has told abuser learns that she has told anyone anyone

She should be referred to local She should be referred to local shelters, but the decision to leave her shelters, but the decision to leave her abuser is hers aloneabuser is hers alone

Effects of a High-Risk Effects of a High-Risk Pregnancy on the FamilyPregnancy on the Family

Disruption of usual rolesDisruption of usual roles Financial difficultiesFinancial difficulties Delay attachment to the infantDelay attachment to the infant Loss of expected birth Loss of expected birth

experienceexperience

Interventions for the Interventions for the Grieving ProcessGrieving Process

Allow parents to remain together in Allow parents to remain together in privacyprivacy

Accept behaviors related to grievingAccept behaviors related to grieving Develop a plan of care to provide Develop a plan of care to provide

support to the familysupport to the family Offer a memento such as a footprintOffer a memento such as a footprint Offer parents an opportunity to hold Offer parents an opportunity to hold

the infant, if they choosethe infant, if they choose

Interventions for the Interventions for the Grieving Process Grieving Process

(continued)(continued) Prepare parents for the Prepare parents for the

appearance of the infantappearance of the infant Provide parents with educational Provide parents with educational

materials and referrals to materials and referrals to support groupssupport groups

Discuss wishes concerning Discuss wishes concerning religious and cultural ritualsreligious and cultural rituals

Interventions for the Interventions for the Grieving Process Grieving Process

(continued)(continued) Prepare parents for the Prepare parents for the

appearance of the infantappearance of the infant Provide parents with educational Provide parents with educational

materials and referrals to materials and referrals to support groupssupport groups

Discuss wishes concerning Discuss wishes concerning religious and cultural ritualsreligious and cultural rituals