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