NMM NCM 109 (PRELIMS) – LESSON 2 1

PREGESTATIONAL CONDITIONS  pregnant women with mechanical valves are a very

Cardiac Diseases high-risk group, in whom all anticoagulation options
Rheumatic Heart Disease / Fever carry maternal and/or fetal risks.
 It is a damage to the heart that remains after the Management of women with RHD
acute ARF episode has resolved.  antenatal care at an appropriate referral centre with
 Acute Rheumatic Fever - is an illness caused by an experienced obstetrician, in collaboration with
a reaction to a bacterial infection with group A an obstetric physician and/or cardiologist and a
streptococcus; it causes an acute, generalized nurse
inflammatory response and an illness that targets  timing, nature and site of planned delivery should
specific parts of the body, including the heart. occur before or early in pregnancy
 It is caused by an episode or recurrent episodes  cease work earlier in pregnancy
of ARF.
 Heart has become inflamed; the heart valves
remain stretched and/or scarred, and normal
blood flow is interrupted.
 Recurrences of ARF may cause further valve
damage, leading to worsening of RHD.
Pregnancy in women with RHD
Normal Pregnancy
◦is associated with a 30–50% increase in blood
volume,
◦reduction in systemic vascular resistance and
corresponding increase in cardiac output.
◦begin during the first trimester, peaking at 28–30
weeks of pregnancy, and are then sustained until
term.
◦increase in heart rate by 10–15 beats per min.
Because of the hyperdynamic circulation.
◦innocent, soft mid-systolic murmurs are common
during pregnancy, particularly along the left sternal
border.
 These circulatory changes of pregnancy will A. Pulmonary Hypertension
exacerbate any pre-existing valvular disease. (due to limited oxygen exchange)
 Sometimes RHD, especially mitral stenosis, is  Increase pressure in the pulmonary arteries.
first diagnosed during pregnancy or soon after  PH causes symptoms such as shortness of breath
delivery when a woman develops symptoms, during routine activity (for example, climbing two
usually dyspnea. flights of stairs), tiredness, chest pain, and a racing
Assessment of women with RHD heartbeat. As the disease worsens, its symptoms
 Ideally, patients with known rheumatic valvular may limit all physical activity.
disease should be properly assessed before
pregnancy.
 Include a full history and examination, and an
echocardiogram
Risk Factors
Predictors of increased maternal and fetal risk in
the pregnant patient
 reduced left ventricle (LV) systolic function
 significant aortic or mitral stenosis
 moderate or severe pulmonary hypertension
 a history of heart failure
 symptomatic valvular disease before pregnancy
 atrial fibrillation, especially when anticoagulation
is require
 NMM NCM 109 (PRELIMS) – LESSON 2 2

B. Pulmonary Edema
 an abnormal build up of fluid in the air sacs of the
lungs, which leads to shortness of breath
 due to pressure in the pulmonary vein, fluid
begins to pass from the pulmonary capillary
membranes into the interstitial spaces
surrounding the alveoli and then into the alveoli
themselves
 Symptoms: anxiety, cough, difficulty of breathing
(paroxysmal nocturnal dyspnea), excessive
sweating, excessive hunger of “air” or “drowning”,
Grunting or gurgling sounds with breathing, pale
skin, restlessness, shortness of breath,
orthopnea, wheezing.
 Additional symptoms that may be associated with
this condition: coughing up blood or bloody froth,
decrease in level of alertness, inability to speak in
full sentences, nasal flaring.

C. Congestive Heart Failure

 is a condition in which the heart can't pump enough
blood to the body's other organs.
This can result from:
narrowed arteries that supply blood to the heart
muscle (coronary artery disease)
past heart attack, or myocardial infarction, with
scar tissue that interferes with the heart muscle's
normal work
high blood pressure
heart valve disease due to past rheumatic fever
or other causes
primary disease of the heart muscle itself
(cardiomyopathy)
heart defects present at birth (congenital heart
defects)
 NMM NCM 109 (PRELIMS) – LESSON 2 3

infection of the heart valves and/or heart muscle

itself (endocarditis and/or myocarditis)
The most common signs and symptoms of heart
failure are:
>Shortness of breath or trouble breathing
>Fatigue (tiredness)
>Swelling in the ankles, feet, legs, abdomen, and,
rarely, the veins in your neck

HEART INTERIOR

HEART EXTERIOR

FIRST WARNING OF HEART FAILURE:

Persistent rales at the base of lungs
Dyspnea on exertion (oxygen saturation of blood)
Cough/hemoptysis (rupture of pulmonary
capillaries)
ADDITIONAL SIGNS:
Progressive edema (as the fall in blood pressure
is registered with the renal angiotensin system both
retention of sodium and water occurs)
Tachycardia (attempt to systemic blood pressure)
 NMM NCM 109 (PRELIMS) – LESSON 2 4

 If an anticoagulant is required, heparin is the drug

of choice for early pregnancy because it does not
have teratogenic effects, as does sodium warfarin
(Coumadin).
 Warfarin can be used after week 12 but a woman
will then be returned to heparin therapy during
the last month of pregnancy so the fetus will not
develop a coagulation disorder at birth
 Heparin does not cross the placenta and enter
’ the fetus).
Left Sided Heart Failure (LSFH) Right Sided Heart Failure (RSHF)
Occurs in conditions such as:  Congenital heart defects such as pulmonary
 Mitral stenosis - is a narrowing of the valve valve stenosis and atrial and ventricular septal
between the two left heart chambers defects
 Mitral insufficiency - most common form of valvular  Congestion of the systemic venous circulation
heart disease, occurs when the mitral valve does and decreased cardiac output to the lungs.
not close properly, allowing blood to flow  Jugular venous distention and increased ortal
backwards into the heart. circulation occur.
 Aortic coarctation - a birth defect in which a part of  The liver and spleen become distended.
the aorta is narrower than usual. inability of the  Liver enlargement can cause extreme dyspnea
mitral valve to push blood forward, inhibiting back- and pain in a pregnant woman because the
pressure on the pulmonary circulation, causing it to enlarged liver, as it is pressed upward by the
become distended enlarged uterus, puts extreme pressure on the
diaphragm.
 Distention of abdominal vessels can lead to
exudate of fluid from the vessels into the
peritoneal cavity (ascites).
 Fluid also moves from the systemic circulation
into lower extremity interstitial spaces (peripheral
edema).
Eisenmenger Syndrome
 A cyanotic heart condition that develops when
pulmonary resistance equals or exceeds
systemic resistance to blood flow and a right-to-
left shunt develops.
 Develops when high pressures push the blue
(low oxygen) blood in the right-side circulation
back into the red (oxygenated) left sided
circulation, bypassing the lungs.
 Tissue hypoxia occurs as deoxygenated blood
that should go to the lungs is pushed into the
systemic circulation.
 Several underlying congenital defects may
underlie the equalization of pressures within the
 NMM NCM 109 (PRELIMS) – LESSON 2 5

ventricles (ventricular septal defect or a large

patent ductus arteriosus)
Management:
Operative closure of defects
Delayed surgery - 50% maternal mortality risk
(usually from right ventricular failure)
Mitral Valve Prolapse
Most common cardiac benign condition
Incidence = normal young women is as high as
15%
The leaflets of the MV prolapse into the left atrium
during ventricular contraction
Most are asymptomatic and tolerate pregnancy well
Considered as significant risk for bacterial
endocarditis
Symptoms:
Fatigue Management:
Palpitations >Prophylactic antibiotics (before and during labor
Chest pain and delivery)
Anxiety >Beta blockers (chest pain or dysrhythmias)
Migraine headaches a. Atenolol
b. Metropolol
Peripartum and Postpartum Cardiomyopathy
 heart muscle disease
 the heart muscle becomes enlarged, thick, or
rigid. In rare cases, the muscle tissue in the heart
is replaced with scar tissue.
 Rare condition associated with pregnancy
 Woman have no underlying heart disease but
symptoms of cardiac decompensation appear
during the last week of pregnancy or from 2 to 20
weeks post-partum

Etiology:
-Inherited
-Associated with variety of other cardiac conditions:
a. ASD
b. Marfan’s Syndrome - a genetic disorder of the
connective tissue; typically tall, with long limbs and
long thin fingers
Marfan’s Syndrome

 Etiology:
-Unknown
 Predisposing Factors:
-Effect of pregnancy on the circulatory system
-Undetected heart disease
 Incidence:
-African-American multiparas in conjunction with
HPN of pregnancy
 NMM NCM 109 (PRELIMS) – LESSON 2 6

 Symptoms: (Signs of Congestive Heart  coughing (pulmonary edema from heart failure)
Failure/MI)  edema
Dyspnea  Other signs and symptoms
Edema ◦ irregular pulse
Weakness ◦ rapid or difficult respirations
Chest pain ◦ and perhaps chest pain on exertion
Heart palpitations
 Other sign:
Cardiomegaly
 Management

 Assess nail bed filling (should be less than 5

seconds)
 Jugular distention
 Assess liver size (Right sided heart failure)
 Diagnosis
-From clinical signs and symptoms and physical
 Oral contraceptives are contraindicated due to examination
danger of thromboembolism -Chest x-ray
 Surgery -Electrocardiography (ECG)
 Heart transplant (20% can be saved) -Echocardiography
 Partial recovery with persistent congestive Classification (New York Heart Association
heart failure or other cardiac dysfunction Functional Classification of Heart Disease)
(50%) Class I – Uncompromised
Full recovery (30%)  No limitation of physical activity
Cardiac Disease  Asymptomatic with ordinary activity
Class II – Slightly Compromised
Assessment
Slight limitation of physical activity
1. Thorough health history
Comfortable at rest, but ordinary physical activity
2. Physical assessment / Physical examination
causes fatigue, dyspnea, palpitations or anginal
pain
Class III – Markedly Compromised
Marked limitations of physical activity
Comfortable at rest, but less than ordinary activity
causes excessive fatigue, palpitations, dyspnea, or
anginal pain
Class IV – Severely Compromised
 Inability to perform any physical activity without
discomfort
 Symptoms of cardiac insufficiency even at rest or
anginal pain
Therapeutic Management
Class I or II Heart Disease
 Limit physical activity
 Avoid excessive weight gain
=adequate CHON, calories and sodium
=low-sodium diet (avoid congestive heart failure)
 Prevent anemia (decrease oxygen carrying
capacity of the blood resulting to HR)
=administration of iron and folic acid
 Prevent infection
 Ask about her level of exercise performance (what =immunization for influenza and pneumonia
level she can =prophylactic antibiotics
◦short of breath =avoid contact to person with URI
◦cyanosis of the lips or nail beds).
 NMM NCM 109 (PRELIMS) – LESSON 2 7

 Undergo careful assessment for development of moist rales, and exhaustion); report immediately to
congestive heart failure, pulmonary edema and AP.
cardiac dysrhythmias H. Vaginal delivery is recommended for a woman
=assess signs and symptoms with heart disease unless CS is indicated.
Class III or IV Heart Disease I. Vacuum extraction or outlet forceps are often used
Primary Goal: Prevent cardiac decompensation to minimize Valsalva maneuver and shorten second
and development of congestive heart failure stage of labor.
 Protect fetus from hypoxia and IUGR (due to J. CS may be chosen to limit prolonged labor, which
inadequate placental perfusion) can add to the hemodynamic stress for the woman
 Addition to Class I and II management: with cardiac disease.
=bed rest (esp. late trimester) K. To minimize risk of overloading the heart (fourth
=elastic compression stockings/serial or boot stage):
compression device (risk for thrombus formation) >Avoid abrupt positional changes
=anticoagulant >Uterus should not be massaged to expedite
Drug Therapy separation of the placenta
1. Anticoagulants >Careful assessment of circulatory overload
A. Heparin (subcutaneous) (bounding pulse, distended neck veins and
Careful monitoring of PTT, APTT, and PC peripheral veins, moist rales)
B. Enoxaparin (Lovenox) – low molecular weight
heparin
Less monitoring for bleeding complications
Warfarin (Coumadin) – associated with fetal
malformations; restricted throughout pregnancy
2. Antidysrhythmics
 In addition to controlling dysrhythmias, β-blockers
and calcium channel blockers may be used (control
HPN)
 Digoxin, adenosine, and calcium channel blockers
(appear to be safe)
 β-blockers (atenolol and metoprolol) – do not
cause uterine stimulation
Note: β-blockers have been associated with:
Neonatal respiratory depression, sustained
bradycardia, and hypoglycemia
3. Antiinfectives
For Endocarditis
Prophylactic antibiotics:
-Amoxicillin
-Penicillin
-Gentamicin
Acute Endocarditis
-Ceftriazone or Vancomycin
Intrapartum Management
A. Careful management of IV fluid administration
(prevent fluid overload).
B. Position woman on side, with head and shoulders
elevated. Postpartum Management
C. Oxygen is administered (increase O2 saturation); A. Observe for signs of cardiac decompensation,
monitored by pulse oximetry. infection, hemorrhage, and thromboembolism.
D. Reduce discomfort (anesthesia such as epidural). B. Continue to observe for signs of congestive
E. Keep environment quiet and calm as possible heart failure.
(decrease anxiety; tachycardia). C. Observe urine output.
F. Monitor fetus electronically and uterine D. Make effort to promote contact between the
contraction. mother and significant others and the infant if
G. Monitor maternal signs of cardiac mother cannot assume to take care of infant.
decompensation (tachycardia, rapid respirations, E. BF may vary per clients condition.
 NMM NCM 109 (PRELIMS) – LESSON 2 8

F. Stool softener may be prescribed. Anemia

G. Kegel exercises are acceptable; avoid  Condition in which a decline in circulating blood cell
postpartum exercises. mass occurs.
H. Emphasize importance of postpartum checkup. First and third trimesters = hemoglobin < 11g/dl
Second trimester = hemoglobin is < 10.5 g/dl
 Factors that may cause anemia:
Nutrition
 Hemolysis
 Blood loss
 Most common anemia during pregnancy:
a. Iron-deficiency anemia
b. Folic-acid deficiency anemia
c. Sickle cell disease
d. Thalassemia
A. Iron-Deficiency Anemia
Most common anemia of pregnancy
Complicates 15% to 25% of pregnancies
Characterized by microcytic (small RBC),
hypochromic (less hgb than the average cell)
anemia
Both hct and hgb is reduced (under 33% and
12mg/dl respectively)
Mildly associated with LBW and preterm birth
At risk
>Multifetal pregnancies
>Bleeding complications
>Lack or inadequate iron
>Pregnancy less than 2 years
>Low socio economic status
>Unwise weight - reducing programs
Assessment
1. Nursing History
2. Physical Examination
Signs and Symptoms (maternal effects):
Pallor
Fatigue
Lethargy
Headache
A Woman with an Artificial Valve Prosthesis
Placed on low-molecular-weight heparin therapy Inflammation (lips and tongue)
before becoming pregnant to reduce clot formation Pica (consuming non-food substances)
Heparin does not cross the placenta and so does Fetal and Neonatal Effects:
not interfere with fetal development or fetal Reduced red cell volume, hgb and iron stores
coagulation (category C). Reduce fetal oxygen supply
Observe for Diagnostic Evacuation
Laboratory Result (anemia):
◦signs of petechiae
A. Decreased hct and hgb
◦signs of premature separation of the placenta during
B. Serum transferrin (under100mg/dL)
pregnancy and labor
C. Transferrin saturation level (under 5%)
A Woman with Chronic Hypertensive Vascular
Disease =normal value12-45% (females)
Hypertension diagnosed for the first time before the D. Serum iron hgb concentration (under 30)
20th week of gestation and persists beyond the 42nd E. Increased iron-binding capacity (over 400ug/dL)
day postpartum Nursing Diagnosis
Elevated pressure (140/90 or above) may cause 1. Risk for ineffective tissue perfusion related to
poor placental perfusion maternal anemia during pregnancy
Hematologic Disorders Planning
1. Prevent and minimize ineffective tissue perfusion
 NMM NCM 109 (PRELIMS) – LESSON 2 9

2. Improve tissue perfusion 3. Diagnostic Evaluation

Intervention (Therapeutic Management) Nursing Diagnosis
1. Iron supplements 1. Risk for ineffective tissue perfusion related to
Prenatal vitamins containing iron supplement maternal anemia during pregnancy.
(60mg elemental iron) as prophylactic Planning
Ferrous sulfate or ferrous gluconate (120 to 180 1. Planning and minimize ineffective tissue perfusion
elemental iron/day) with orange juice or vitamin C 2. Improve tissue perfusion
with meals; increase roughage in diet Interventions (Therapeutic Management)
Parenteral therapy of iron (IM or IV) for severe Eat foods reach in folic acid (liver, kidney beans,
IDA lima beans, fresh dark green leafy vegetables)
Side effects of Iron supplements: Women at childbearing age – take folic acid
>constipation supplements (400mcg or 0.4mg) of folic acid daily
>gastric irritation Pregnant – 600mcg or 0.6 mg
2. Diet high in iron and vitamins If had a previous child with neural tube defects – 4
Green leafy vegetables, meat, legumes, fruit mg for 1 month before and during first trimester of
Evaluation pregnancy
1. New RBC’s or in reticulocyte count from a Prenatal vitamins (1mg of folate)
normal range of 0.5% - 15% to 3% - 4% by 2
weeks
2. Taking pre-natal supplement daily Evaluation
3. Hemoglobin is above 11mg/dl; FHT is 120 – 160 1. New RBC’s or in reticulocyte count from a
bpm normal range of 0.5% - 15% to 3% - 4% by 2
B. Folic-Acid Deficiency weeks
Anemia that develops in Megaloblastic Anemia 2. Taking pre-natal supplement daily
 Mean corpuscular volume is elevated Folic Acid or 3. Hemoglobin is above 11 mg/dl; FHT is 120 – 160
Folacin (one of the vitamin B) BPM
Purpose: C. Sickle Cell Anemia
Normal formation of RBC in mother  An autosomal recessive genetic disorder
Prevent neural tube defects in fetus  Hemoglobin S gene is inherited from both parents
Cell duplication  The erythrocytes become shaped like a sickle or
Fetal and placental growth crescent failure to pass through small arteries
Incidence: and capillaries clump together and occlude blood
1% to 5% of pregnancies vessel
Risk Factors Characterized by:
Multiple pregnancies >Chronic anemia
With secondary hemolytic illness >Increased susceptibility to infection
Women taking hydantoin (anticonvulsant agent) >Periodic episodes of obstruction of blood
Taking oral contraceptives vessels
Maternal Effects Incidence
Reduction in the rate of DNA synthesis and mitotic Ancestors from sub-Saharan Africa, South
activity of individual cells resulting to megaloblast America, Cuba, Central America, Saudi Arabia,
Nutritional Factors Contribute to Folic-Acid India and Mediterranean countries
Deficiency 1 in 500 African-American and 1 in 1000 to 4000
Hemolytic anemias with increased RBC turnover Hispanic births in US will result with sickle cell
Medications such as phenytoin (Dilantin) anemia
Malabsorption Approximately 1 in every 10 African American
Associated with iron-deficiency anemia has sickle cell trait (i.e. carries a recessive gene S
Fetal and Neonatal Effects hemoglobin but is asymptomatic)
Increased risk of spontaneous abortion Maternal Effects
Abruptio placenta
Fetal anomalies (neural tube defects)
Assessment
1. Nursing History
At pre-natal visit, ask whether the woman is taking Conditions (Sickle Cell Crisis):
her prescribed vitamins A. Temporary cessation of bone marrow function
2. Physician History/examination
 NMM NCM 109 (PRELIMS) – LESSON 2 10

B. Hemolysis or hemolytic crisis with massive bilirubin level

erythrocyte destruction resulting in jaundice (rise in a.2. Urinalysis
indirect bilirubin level) Clean catch urine sample to detect developing
C. Severe pain caused by infarctions located in the bacteriuia
joints and major organs a.3. UTZ
D. Expectant mothers with sickle cell anemia are Monitor FHR during pregnancy at 16-24 weeks for
prone to pyelonephritis, bone infection, and heart IUGR
disease Weekly non-stress test beginning at 30 weeks
Fetal and Neonatal Effects a.4. Measure blood flow velocity
-prematurity Flow of blood through the uterus and placenta
-IUGR blood flow velocity = chance of IUGR
-fetal death a.5. Percutaneous umbilical blood sampling or
Incidence of Inheritance amniocentesis
A. If one of the parent has the disease and the For electrophoresis testing of RBCs that can also
other is free of the disease and trait reveal presence of the disease on the few beta
Chances to inherit the disease are zero chains present early in pregnancy
B. If the woman has the disease and her partner Nursing Diagnosis
has the trait 1. Risk for ineffective tissue perfusion related to
Chances are 50% maternal anemia during pregnancy.
C. If both parents have the disease Intervention (Therapeutic Management)
All their children will have the disease Seek preconception or early prenatal care

Symptoms of sickle cell disease do not become Frequent evaluation of hgb, CBC, serum iron,
clinically apparent until the child’s fetal hemoglobin is total iron-binding capacity, and serum folate
converted to a largely adult pattern in 3 – 6 months (degree of anemia and iron and folic acid stores)
because sickle cell trait is carried on a beta chain Test for infections (HIV, hepatitis, STI’s and TB,
Fetal hemoglobin comprises two alpha and two RTI’s)
gamma chains; adult hemoglobin comprises two =hospitalization for observation to R/O sickle cell
alpha and two beta chains crisis
Pathophysiology Prevent sickle cell crisis:
Abnormal amino acid replaces the Amino acid =periodic exchange transfusions throughout
valine results to Sickle hemoglobin (HbS) pregnancy (to replace sickle cells with normal
Abnormal amino acid substituted for Amino acid cells; remove excess bilirubin and restore hgb
lysin results to Non-sickling hemoglobin (HbC) level)
Sickle cell trait (HbAs) – heterozygous individual If crisis occurs:
(has only one gene in which abnormal substitution =control pain
has occurred) =administer oxygen PRN
Sickle cell disease (HbSs) – Homozygous =increase fluid volume of the circulatory system (to
individual lower viscosity)
(has two genes in which the substitution occurred) =Administer hypotonic fluid solution (0.45 saline) –
Assessment to keep plasma tension low because of the
1. Nursing History difficulty concentrating urine to remove large
A. Ask about the diet throughout the pregnancy: amounts of fluid
If consuming sufficient amounts of folic acid If with sickle cell disease:
Taking additional folic acid supplement =never give iron supplements during pregnancy (to
2. Physical History prevent excessive iron build up)
A. Assess lower extremities at pre-natal visits for =give folic acid supplement (to keep new cell
pooling of blood produced from being megaloblastic)
B. Fever If with pooling of blood in lower extremities:
C. Lowered PO2 because of respiratory infection =Restrict from standing for long periods during the
3. Diagnostic Evaluation day
A. Screen for sickle cell anemia at first pre-natal visit =Advice sitting on chair with legs elevated or
a.1. Hemoglobin level should be obtained frequently sitting
If with sickle cell disease (hgb = 6 – 8 mg/100ml) on the side with modified Sim’s position
If there is hemolysis, sickle cell crises occurs (hgb =Help woman plan her day to limit long period of
= fall to 5 – 6 mg/100ml in a few hours; indirect standing
 NMM NCM 109 (PRELIMS) – LESSON 2 11

If infection develops: Tuberculosis

=Hospitalization for observation maybe necessary  maintain an adequate level of calcium during
to rule out the development of a sickle cell crisis pregnancy to ensure that tuberculosis pockets are
and subsequent hemolysis of crowed cells not broken down
Provide comfort measures:  advised to wait 1 to 2 years after the infection
=repositioning becomes inactive before attempting to conceive
=good skin care  a woman with a recent history of TB should have at
=assisting with ambulation and movement in bed least 3 negative sputum cultures before she holds
=assisting women to splint the abdomen (coughing or care for her infant.
or dyspnea) If negative:
Keep well hydrated (prevent dehydration) No need to isolate
Time and method of delivery are individualized Can breast feed the baby
(preterm) Asthma
If CS, receives nerve block rather then GA (avoid  has the potential of reducing the oxygen supply to
hypoxia) a fetus leading to preterm birth or fetal growth
Signs of Sickle Cell Crisis: restriction if a major attack should occur during
>Pain in the abdomen, chest, vertebrae, joints, or pregnancy
extremities  check with her physician or nurse- midwife about
>Pallor the safety of the medications she routinely takes for
>Signs of cardiac failure this
before pregnancy to be certain it will be safe to
continue using them during pregnancy and
D. Thalassemia breastfeeding.
 Group of autosomal recessively inherited blood Endocrine Disorders
disorders that lead to poor hemoglobin formation Thyroid Dysfunction
and severe anemia. Woman with Thyroid Dysfunction
◦Folic acid supplementation and perhaps blood Nursing Diagnosis
transfusion to infuse hemoglobin rich red blood cells. 1. Risk for maternal and fetal injury related to
◦Women do not usually take an iron supplement preexisting thyroid disorder and drug therapy
during pregnancy or they could receive an iron during pregnancy.
overload because of the iron also infused by blood Planning
transfusions 1. Mother and fetus will suffer no adverse effects
Malaria from maternal hormonal imbalance and drug
 The infection causes red blood cells to stick to the therapy.
surface of capillaries causing obstruction of these Evaluation
vessels. 1. No congenital anomalies are present in infant at
This can result in end organ anoxia when blood birth.
cannot reach organs effectively. 2. Apgar score is 7 to 10.
 Chloroquine is the drug of choice. 3. Mother is able to continue pre-pregnancy
Coagulation Disorders activities.
Von Willebrand’s Disease A. Hypothyroidism
-inherited coagulation disorder: symptoms of  Insufficient production of thyroid hormone (T3
menorrhagia and frequent nose bleeding and T4) b the thyroid gland.
Normal platelet count with prolonged bleeding time  Rare condition in young adults and especially in
Hemophilia B pregnancy.
-sex-linked disorder that occurs only in males: female  Woman with hypothyroidism has difficulty
carriers may have the risk of hemorrhage of increasing thyroid functioning to a pregnancy
spontaneous miscarriage level.
Idiopathic Thrombocytopenic Purpura (ITP)  The pregnant woman with hypothyroidism often
-decreased in number of platelets with an unknown has a history of early spontaneous miscarriages.
cause; platelet transfusion necessary Assessment
Disseminated Intravascular Coagulation 1. Physical Examination
(DIC) Signs and Symptoms:
-a paradoxical condition: a bleeding defect exists -Fatigue easily
while the client has increased coagulation -Obese
Respiratory Disorders
 NMM NCM 109 (PRELIMS) – LESSON 2 12

-Myxedema (dry skin)

-Intolerance to cold
-Hyperemesis gravidarum
Diagnosis
1. Blood exam
-high levels of TSH
Effect:
May be associated with hyperemesis gravidarum
Early spontaneous miscarriage
Breech fetal presentation Effect (Pregnant Women)
Treatment/Intervention May develop heart failure (if undiagnosed)
Woman needs to consult with her OB and More prone to symptoms of:
internist when planning on becoming pregnant. a. Hypertension
Early diagnosis and close follow-up (1 week past b. Fetal growth restriction
menstrual period) c. Preterm labor
Levothyroxine (Synthroid) If woman’s thyroid function was not regulated
=thyroid hormone supplement during pregnancy, the infant may be born with
=increase dose to 30% for the duration of symptoms of hyperthyroidism because of the excess
pregnancy (should know the importance of taking stimulation in the utero.
increased dose) Treatment/Intervention
=gradually taper back the dose after pregnancy to 1. Suppressive thyrostatic medications (thioamides)
pre-pregnancy level Methimazole is the preferred drug for pregnant
women as it appears to cross the placenta less
easily Prophylthiouracil (PTU)
=teratogens (congenital hypothyroidism, goiter in
B. Hyperthyroidism fetus)
 Overactive tissue within the thyroid gland, resulting 2. Surgery
in overproduction and thus an excess of circulating Partial or total removal
free thyroid hormones Not the treatment of choice during pregnancy
 Is more apt to be seen in pregnancy than (general anesthesia)
hypothyroidism

Nursing Considerations
Usually diagnosed through nuclear imaging but
should not be used during pregnancy
The woman will be maintained on lowest possible
dose of thioamides or propylthiouracil (PTU) -
these drugs are teratogenic
After pregnancy, the woman may undergo
surgery if she plans to have another child
Women taking large doses of antithyroid drugs
are advised not to breastfeed after birth
Diabetes Mellitus
 an endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate body
glucose levels
>Primary problem is control of the balance
between insulin and blood glucose to prevent
acidosis
>In gestational DM, the patient’s pancreas is
stressed by the normal adaptations to pregnancy,
can’t meet the increased demands for insulin
 A patient may have pre-existing diabetes or may
develop gestational diabetes while she’s
pregnancy
NMM NCM 109 (PRELIMS) – LESSON 2 13

Pancreatic Hormones and Blood Sugar

Signs and Symptoms

- Glycosuria
- Polyuria
- Ketonuria
- Possible monilial infection
- Glucose > 140mg/dl
- Dizziness (hypoglycemic)
- Confusion (hyperglycemic)
Nursing Considerations
Screen pregnant women for gestational diabetes
through an OGTT- oral glucose tolerance test
*Done at 24-28 weeks of pregnancy and repeated at
32 weeks if woman is obese or over 40 years of age
Normal Values
Fasting 95 mg/dl
1 hour 180 mg/dl
2 hours 155 mg/dl
3 hours 140 mg/dl
Glycosylated hemoglobin – used to detect degree
of hyperglycemia: reflects average blood glucose for
the past 4-6 weeks
Provide health education of pregnancy exercises,
dietary control and insulin administration
During early pregnancy, less insulin is needed;
during late pregnancy, increased insulin is needed
Gestational Diabetes Mellitus
Associated with an increased risk of:
a. Congenital anomalies
b. Hydramnios, macrosomia
c. PIH
d. Spontaneous abortion
e. Fetal death
 NMM NCM 109 (PRELIMS) – LESSON 2 14

f. Increased risk for developing DM A. Impaired fasting glucose: A state when fasting
Infant of a Diabetic Mother: plasma glucose is 110 but under
-at risk for developing sacral agenesis 126 mg/dl
Sacral Agenesis – A congenital anomaly B. Impaired glucose tolerance test: 140 but under
characterized by incomplete formation of the 200 mg/dl in the 2-hour sample
vertebral column Education Regarding Nutrition During Pregnancy
Risk Factors diabetic diet complemented by an exercise
1. Chronic HPN program as soon as they are diagnosed
2. Family history of diabetes (one close relative or 1800- to 2400-calorie diet (or one calculated at 30
two Kcal per kg of ideal weight), divided into three meals
distant ones) and three snacks
3. Gestational diabetes in previous pregnancies reduced amount of saturated fats and cholesterol
4. Maternal age older than 25 and an increased amount of dietary fiber
5. Obesity If cannot eat because of vomiting or nausea early
6. History of large babies (10 lbs or more) in pregnancy or heartburn in later pregnancy, she
7. History of unexplained fetal or perinatal loss should notify her health care provider
8. History of congenital anomalies in previous must be extremely nutrition-conscious to maintain
pregnancies good control and keep her weight gain to a suitable
9. Member of a population with a high risk for amount (approximately 25 to 30 lb)
diabetes blood glucose level decreases because the
Classification muscles increase their need for glucose
1. Type 1 begin her exercise program before pregnancy,
-Formerly known as insulin-dependent DM (IDDM) eat a snack consisting of protein or complex
-A state characterized by the destruction of the carbohydrate before exercise
beta cells of the islet of langerhans in the pancreas 30 minutes of walking every day
that usually leads to absolute insulin deficiency Therapeutic Management
-Can affect children and adults, traditionally termed Administration of insulin - short-acting insulin
juvenile diabetes (regular) combined with an intermediate type
A. Immune-mediated DM results from autoimmune Human insulin is recommended because it has the
destruction of the beta cells (T-cells) potential for provoking a lesser antibody response
B. Idiopathic type 1 refers to forms that have no should eat almost immediately after injecting these
known cause short-acting insulins to prevent hypoglycemia before
2. Type 2 mealtimes
-Formerly known as non-insulin dependent DM Oral hypoglycemic agents are not used for
(NIDDM) regulation during pregnancy- it cross the placenta
-A state that usually arises because of insulin and are potentially teratogenic to a fetus.
resistance combined with relatively reduced insulin absorbed more slowly from the thigh than the upper
secretion arm
-Most common type Blood Glucose Monitoring
3. Gestational DM fingerstick technique, using one of her fingertips as
-A condition of abnormal glucose metabolism that the site of lancet puncture
arises during pregnancy ingest some form of sustained carbohydrate such
-Resembles type 2 diabetes in several aspects, as a glass of milk and some crackers
involving a combination of relatively inadequate Human Immunodeficiency Virus Infection
insulin secretion and responsiveness  Cause by a retrovirus that infects and disables T
-Occurs in about 2% - 5% of all pregnancies lymphocytes
-May improve or disappear after delivery  May be contracted through sexual intercourse,
-Fully treatable but requires careful medical exposure to infected blood, vertical transmission
supervision throughout the pregnancy (placenta to fetus at birth) or breast milk
-About 20% - 50% of affected women develop type Nursing Consideration
2 diabetes later in life Women practicing high-risk behavior should be
4. Impaired Glucose Homeostasis asked if they want to be screened
-A state between “normal and diabetes” in which Advise women who tested positive not to become
the body is no longer using and/or secreting insulin pregnant
properly. Offer the option of caesarean birth
 NMM NCM 109 (PRELIMS) – LESSON 2 15

Reduce possibility of fetal exposure to maternal * Effects: abruptio placenta, tearing of the placenta,
blood (avoid amniocentesis, internal fetal preterm labor, fetal death
monitoring, episiotomy, forceps and vacuum * Newborns born of a cocaine-dependent mother will
extraction) manifest tremulousness, irritability and muscle
Advise the woman not to breastfeed rigidity; learning defects may also be suspected
Zidovudine: Prescribed during pregnancy to help Amphetamines
reduce mother-to-fetal transmission * Has similar effect as cocaine
◦ Given IV during labor * Newborns born of mothers using
◦ Given to the newborn for 6 weeks after birth amphetamine show signs of jitteriness and
Provide patient education about mode of HIV poor feeding at birth
transmission and safer sex practices Marijuana
Use standard precautions to protect against • Causes tachycardia and sense of well-being
spread of HIV * Associated with loss of short term memory and
Urinary Tracy Infection respiratory infection
Due to minimal glucosuria that is normally * Mothers who abused marijuana cannot breastfeed
happening in the pregnant woman, growth of due to reduced milk production and possibility of
microorganisms is facilitated drug excretion through milk
Due to the dilated ureters from the effect of Narcotic Agonists
progesterone, stasis of urine occur * Pregnancy complications: PIH, phlebitis, possible
Etiology: E. coli Hep B and HIV
Signs and Symptoms * Withdrawal symptoms: nausea, vomiting, diarrhea,
◦Pain in the lumbar region that radiates downward abdominal pain, hypertension, restlessness and
◦N/V, malaise, slightly elevated temperature insomnia
◦Pain and frequency of urination * Effects on fetus: small for gestational age, fetal
Nursing Consideration distress, meconium aspiration
Assist or teach the client in obtaining a clean- Nursing Considerations
catch urine specimen - Provide anticipatory guidance and support
Amoxicillin, ampicillin, cephalosporins are - Do not encourage breastfeeding after birth
commonly used - Appropriate referral
Sulfonamides may be used only in early Trauma and Pregnancy
pregnancy Trauma (injury by force):
Tetracycline is contraindicated Occurs at a high incidence during the childbearing
Rh Incompatibility and Sensitization years (e.g., automobile accidents, homicide, suicide)
 Occurs when an Rh-negative mother is carrying a During pregnancy, the incidence of trauma is 6% to
fetus with an Rh-positive blood type, with an Rh- 7% (as many as 250,000 pregnant women
positive father experience
 Rh (+) fetus Rh (-) mother = antibodies hemolysis trauma per year)
of fetal RBC's (hemolytic disease of the High incidence occurs during the last trimester due
newborn/erythroblastosis fetalis) to:
Nursing Consideration a. clumsiness
Women with Rh(-) blood should have an antibody b. fainting
titer done at first visit c. hyperventilation
Drug of choice: Rhogam given at 28 weeks of Orthopedic injuries occur because of altered sense
pregnancy of balance such as:
Substance Abuse a. broken wrist
 The inability to meet major role obligations, legal b. sprained ankle
problems and an increase in risk taking behavior c. intimate partner abuse
or exposure to hazardous situations Preventing Accidents:
 Substance dependent: a person having Pregnancy Counseling – educate about ways to
withdrawal symptoms following the avoid accidents and trauma
discontinuation of a substance Guidelines on preventive measures to reduce
Commonly Used Drugs in Pregnancy accidents during pregnancy:
Cocaine 1. Don’t’ stand on stepstools or stepladders (narrow
* Causes extreme vasoconstriction that impedes base)
placental circulation 2. Keep small items out of pathways
3. Use caution stepping in and out of a bathtub
 NMM NCM 109 (PRELIMS) – LESSON 2 16

4. Do not overload electric circuits

5. Do not smoke. Management:
6. Do not take medicine in the dark so an error is >administer tetanus toxoid if immunization is
not apt to occur. administered within the past 10 years; if did not
7. Avoid handling any toxic substances at work. receive for the past 10 years tetanus toxoid plus
8. Avoid long periods of standing, this can lead to a immune toxoid plus immune tetanus globulin is
drop in BP causing dizziness and fainting. administered
9. Always use a seatbelt while driving or as a >Fistulogram (insertion of a thin catheter into the
passenger in an automobile. wound; the wound is filled with radiopaque solution)
10. Refuse to ride with anyone who has been – to determine the depth and extent of the wound
drinking alcohol or whose judgment might be >Celiotomy or an exploratory surgical procedure into
impaired. the abdominal cavity may be performed if the
Assessment peritoneal cavity is perforated
Must be done quickly yet thoroughly C. Animal Bites
Must include both psychological and physical -are formed of puncture wound
status Management
Attention to fetus health >If bitten by a dog, wash the wound and observe the
1. Health History dog for 48 hours
Brief pregnancy history as well as trauma history >Must be administered with rabies immune globulin
- length of pregnancy or any complication and vaccine
Ask for fetal heart tones and movements, uterine >Should be advised to use caution and avoid contact
contractions and BP with unfamiliar dogs/ stray dogs and animals
Document circumstances of trauma
- what happened during the time that has passed 2. Blunt Abdominal Trauma
since the injury -Occurs generally from automobile accidents, kicking
- signs and symptoms of injury or punching abdomen
- action taken -No visible break is present in the skin
Assess whether the woman’s degree of injury is -After the injury, the underlying tissue becomes
proportion to the history edematous; broken underlying blood vessels may
- may indicate partner abuse rather than a simple ooze and from ecchymosis or a hematoma at the site
accident Diagnosis:
Assess awareness to safety precautions 1. Peritoneal Lavage
Different Types of Trauma: 2. Ultrasound
1. Open Wounds Management:
A. Laceration (a jagged cut) >Palpate the uterus for any abnormal countours that
-May involve only the skin layer or may penetrate would suggest edema or internal bleeding
to deeper subcutaneous tissue or tendons >Count the fetal heart tones (Doppler)
-Generally bleeds profusely >Assess for vaginal bleeding or seepage of clear
Management: fluid that would suggest ruptures amniotic fluid
>apply the pressure on the site through pelvic examination
>clean the area >Uterine and fetal monitoring is necessary to
>suture the area of laceration, a local anesthetic is estimate the strength and effect of contractions on
necessary the fetal heart rate and also determine if preterm
>if laceration is superficial and the woman is labor has begun
nervous about the use of anesthetic, the edges can 3. Gunshot Wounds
be approximated with a butterfly strip made from a Assessment
commercial adhesive strip -Inspection of the point where the bullet entered the
>anti-shock trousers should be used with caution to body and bullet exited
halt the lower extremity bleed Management
B. Punctured Wounds >Surgically cleaned and debrided
-Result from penetration of a sharp object such as >Treated with high dose of antibiotics (Ampicillin)
a nail splinter, nile file, or knife >Report to the Police
-Bleed little >Stay with the woman as necessary
-Usually not sutured (would create a sealed,
unoxygenated cavity below the sutures with a 4. Poisoning
space where tetanus bacilli can grow. Management
 NMM NCM 109 (PRELIMS) – LESSON 2 17

> Managed the same as in any individual

>Should telephone the local poison control center
stating her condition and follow the specific
recommendation of personnel
>Syrup of Ipecac (15ml followed by a glass of
water) is the best emetic to cause vomiting and
discharge of the poison from her body and is safe
for use during pregnancy
>Activated charcoal may also be used
>Investigate carefully the circumstances help the
woman learn about safety with medications or to
discover possible suicidal intent
5. Choking
Management
Chest thrust for the pregnant woman
Purpose
To relieve tracheal aspiration
NMM NCM 109 (PRELIMS) – LESSON 2 18