Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

Module #5

Lesson Title: CARE OF THE HIGH-RISK PREGNANT CLIENT Materials:

(PRE-GESTATIONAL CONDITIONS - ANEMIAS OF
PREGNANCY) AND (GESTATIONAL CONDITIONS - Pen, paper, index card, book, and class List
HYPEREMESIS GRAVIDARUM AND ECTOPIC PREGNANCY)

Learning Targets: References:

At the end of the module, students will be able to:
1. Define Anemia, Hyperemesis Gravidarum and Ectopic Pilliteri, Adele and Silbert-Flagg, JoAnne
Pregnancy) its relation to pregnancy, including pre-existing (2018) Maternal and Child Health Nursing, 8th
factors that contribute to its development. Edition. USA: Lippincott Williams and Wilkins
2. Integrate knowledge of Anemia, Hyperemesis Gravidarum and
Ectopic Pregnancy in relation to pregnancy and nursing process
to achieve quality maternal and child health nursing care.

A. LESSON PREVIEW/REVIEW

Instruction: Rh Sensitization/Rh Isoimmunization can occur through:

1. Sensitization from previous pregnancy (Rh- mom with Rh+ baby)
2. Inadequate response to prophylaxis
3. Incompatible blood transfusion

B. MAIN LESSON

ANEMIAS OF PREGNANCY

ANEMIA is a condition of too few RBCs, or a lowered ability of the RBCs

 Many women lack enough iron needed for the second and third trimesters. When the body needs more iron than it
has available, a woman can become anemic.
 Mild anemia is normal during pregnancy due to an increase in blood volume.
 More severe anemia can put the baby at higher risk for anemia later in infancy.

Most Common Types during Pregnancy: Risk Factors

 Iron deficiency Anemia  Poor nutrition
 Vitamin B12 Anemia  Excess alcohol consumption
 Anemia due to Blood Loss  Illnesses that reduce absorption of nutrients
 Folate Deficiency  Use of anticonvulsant drugs (Tegretol, Lithium,
Carbamazepine, etc.)
 Previous use of oral contraceptives
 G6PD Deficiency
Complications of Anemia
 Premature labor
 Intrauterine growth retardation (IUGR)
 Dangerous anemia from normal blood loss during labor, requiring transfusions
 Increased susceptibility to maternal infection after childbirth
IRON DEFICIENCY ANEMIA
 Most common type, develops in the 2nd & 3rd trimester when the Fe requirements increase to compensate for the
expanding blood volume
 Predisposing factors:
 Poor diet & poor nutrition
 Heavy menses
 Successive pregnancies w/in 2 yrs or <6 mos interval
 Unwise reducing programs
 Low socioeconomic status

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 Care of Mother and Child at Risk or with
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Module #5
Signs & Symptoms of IDA Diagnosis
 Easy fatigability Lab findings:
 Sensitivity to cold  low hemoglobin <10 g/100ml
 Dizziness  low hematocrit <37% in the 1st trimester, <35% in the
 Brittle, flattened nails 2nd trimester and <33% in the 3rd trimester
 Changes in Vital Signs: rise in systolic pressure,  Serum ferritin < 100 mg/dl
tachycardia, tachypnea  Serum Fe level < 30 ug/dl
 Hypochromic, microcytic RBCs
Management of Iron Deficiency Anemia Effects of Anemia on Pregnancy
The World Health Organization and most experts  Decreased resistance to infection
recommend prevention of iron deficiency anemia with  Associated with prematurity & LBW infants
prophylactic iron supplementation in pregnancy.  Predisposes to heavy bleeding during labor & delivery
 Associated with PICA
 Pregnancy requires an additional 700–1200 mg of
iron. Of this, 200–300 mg is transferred to the fetus.
 Most of the iron requirements of pregnancy are in the
second half of pregnancy, and they are approximately
5–6 mg/day.
 An average balanced diet will supply only 1–2 mg/day.
 Daily supplementation with 300 mg ferrous sulfate
(which contains 60 mg elemental iron) will satisfy the
pregnancy requirement.

MEGALOBLASTIC ANEMIA

Types:
1. Folic Acid Deficiency/ (Pernicious anemia )
2. Vit B12 Deficiency/Addison Pernicious Anemia

Folic acid vs. Folate

 Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver.
 Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the common version used
in supplements.

1. Folic Acid Deficiency Anemia is necessary for normal formation of RBC and in the prevention of Neural Tube
Defects
 Deficiency leads to formation of large & immature RBCs with shorter lifespan
 develops if diet is mostly meat with little Green leafy vegetables

Effects on Pregnancy: Signs and Symptoms of Folic Acid Deficiency

 abortion  Nausea
 abruptio placenta  Vomiting
 neural tube defect  Anorexia

Most often seen in: Management

 Multiple pregnancies because of the increased  Treatment of patients with pernicious anemia is
fetal demand undertaken with parenteral therapy because oral
 Women with secondary hemolytic illness absorption of vitamin B12 is deficient.
 Women who are taking Hydantoin
 Poor gastric absorption due to gastric bypass for  Daily injections of 200 μg are given for the first week
morbid obesity followed by weekly injections for 3 weeks and then once
a month thereafter.
 Therapy must continue for life to prevent recurrence of
anemia.
 Response to therapy is usually manifested by a brisk
production of reticulocytes within the first few days of
therapy.

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 Care of Mother and Child at Risk or with
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Module #5
2. Vit B12 Deficiency/Addison Pernicious Anemia
 Vitamin B12 deficiency is extremely uncommon during pregnancy.
 Vitamin B12 deficiency (pernicious anemia) is primarily caused by deficiency in oral absorption.

Present in:
 The most common type is that caused by autoimmune atrophic gastritis, which occurs most frequently in patients
of Scandinavian and Northern European ancestry as well as those of Hispanic origins.
 Women between 30 and 40 years of age

Rare causes of vitamin B12 deficiency:

 Infection by the fish tapeworm (Diphyllobothrium latum)
 Chronic conditions such as Crohn’s disease.

Diagnosis
 Patients demonstrating a macrocytic anemia with an abnormally low serum vitamin B12 level.

Management of Vitamin B12 Deficiency is same as Iron Deficiency Anemia

GESTATIONAL CONDITIONS
HYPEREMESIS GRAVIDARUM
 PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY
Extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe (DHN, ketonuria, weight
loss) within the 1st 12 weeks AOG
 Associated with H. pylori
Assessment Management
 Nausea and Vomiting is so severe that nutrition 1. 24-hour Hospitalization. (I & O, blood chemistries &
cannot be maintained, and weight loss is severe rehydration)
 Elevated Hematocrit due to hemoconcentration 2. NPO; IVF ( 3L Ringer’s lactated solution+ vitamin B)
 Reduced Na, K Cl and hypokalemic alkalosis may to control vomiting
occur 3. If no vomiting after the 1st 24h, sips of clear fluid
 Polyneuritis due to deficiency in Vitamin B gradually advanced to a soft, then normal, diet.
 Urine may be (+) for ketones due to breakdown of 4. If vomiting returns, TPN or enteral nutrition may be
protein & fat for cell growth prescribed
 Intrauterine Growth Restriction or preterm birth
 In history taking ask frequency/quantity of vomiting,
how much she eats in a typical day.

Ectopic Pregnancy
 An ectopic pregnancy is one in which implantation occurred outside the uterine cavity. The most common site (in
approximately 95% of such pregnancies) is in the fallopian tube. Of these fallopian tube sites, approximately 80%
occur in the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial (Jurkovic, 2012).

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 Care of Mother and Child at Risk or with
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Module #5

Ectopic Pregnancy Etiology

 It is the implantation of a fertilized ovum outside of the  Salpingitis, tumors, adhesions, or scarring, IUD use,
uterus narrowed oviducts
 Sites: ovary, cervix, peritoneal cavity, fallopian tube
(most common)
Assessment Complication:
1. Missed period, usual signs of pregnancy (Nausea 1. Hemorrhage,
and Vomiting, positive pregnancy test, etc) 2. Shock,
2. Spotting, bleeding (dark red or brownish), possible 3. Peritonitis
signs of hypovolemic shock
3. If at the fallopian tube, by 6 to 12 weeks AOG, slowly
increasing or sudden sharp, stabbing pain in LLQ or
RLQ (due to rupture of fallopian tube), followed by
bleeding, abdominal rigidity
4. Referred shoulder pain (KEHR’S SIGN) due to
blood in the peritoneum irritating the phrenic nerve
5. CULLEN’S SIGN - ecchymosis blueness around the
umbilicus indicating blood pooling in the peritoneum
6. Dizziness, syncope
7. UTZ confirms extrauterine pregnancy & rupture
Management
 Before rupture, oral administration of METHOTREXATE (folic acid antagonist which destroys fast-growing cells)
followed by LEUCOVORIN; treated until hCG is (-); hysterosalpingogram to assess patency of the tube

 After rupture, BT if needed, laparoscopy to ligate bleeding vessels & remove or repair damaged tubes
 Assess for bleeding & pain
 Monitor VS, start IV with 18-gauge needle
 Provide O2 therapy
 Administer RhOGAM if Rh (-)
 Provide emotional support

CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. Berta a pregnant patient was diagnosed with Iron Deficiency Anemia. She asked you what are the other types of
Anemia that can be seen in pregnancy. Which of the following are Anemias of Pregnancy, EXCEPT?
A. Vitamin B12 Anemia
B. Anemia due to Blood Loss
C. Folate Deficiency
D. Thalassemia

2. Cilla a student-nurse who takes care of Berta asked you what are the factors that puts the patient at risk of developing
anemia in pregnancy. All but one are risk factors of Anemia, EXCEPT:
A. Poor nutrition
B. Excess alcohol consumption
C. Illnesses that reduce absorption of nutrients
D. Use of anticonvulsant drugs
E. Elevated hematocrit due to hemoconcentration

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 Care of Mother and Child at Risk or with
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Module #5
3. Cilla a student nurse asked you what the difference between Folic Acid and Folate is. Which of the following are the
correct definition of Folic acid and Folate?
A. Folic Acid is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus
fruit, avocados, and beef liver while Folate is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
B. Folate is the common form of vitamin B9 present in many whole foods, including leafy greens, beans, eggs, citrus fruit,
avocados, and beef liver while Folic acid is a synthesized version of vitamin B9 that is added to processed foods and the
common version used in supplements.
C. Folate is the common form of vitamin B9 present in many synthesized version of vitamin B9 that is added to processed
foods and the common version used in supplements while Folic acid is the common form of vitamin B9 present in many
whole foods, including leafy greens, beans, eggs, citrus fruit, avocados, and beef liver.
D. Folate and Folic Acid is both present in many whole foods, including leafy greens, beans, eggs, citrus fruit, avocados,
and beef liver

4. 4 patients came to the Outpatient Department with Iron Deficiency Anemia EXCEPT:
A. Multiple pregnancies because of the increased fetal demand
B. A woman with secondary hemolytic illness
C. Poor gastric absorption due to gastric bypass for morbid obesity
D. A woman at 36 years of age

5. Erin will be having a case presentation regarding the complications of Anemia in pregnancy. The following are part of
Complications of Anemia in Pregnancy, EXCEPT:
A. Premature labor
B. Intrauterine growth retardation (IUGR)
C. Dangerous anemia from normal blood loss during labor, requiring transfusions
D. Poor diet & poor nutrition

6. Belle is diagnosed with Hyperemesis Gravidarum, which of the following is true regarding Hyperemesis Gravidarum?
A. Extreme nausea and vomiting that is prolonged past week 12 of pregnancy or is so severe
B. Nausea and Vomiting is so severe that nutrition cannot be maintained, and weight loss is severe
C. Urine may be (+) for ketones due to breakdown of protein & fat for cell growth
D. Intrauterine Growth Restriction or preterm birth
E. All of the choices are true

7. Belle was confined to the hospital due to Hyperemesis Gravidarum, The following are part of management for
Hyperemesis Gravidarum, EXCEPT:
A. 24-hour Hospitalization
B. If no vomiting after the first 24 hours, sips of clear fluid gradually advanced to a soft, then normal, diet.
C. If vomiting returns, TPN or enteral nutrition may be prescribed
D. Provide oxygen therapy

8. Karlie is diagnosed with Ectopic Pregnancy. Your instructor ask you which of the following is the common site of
Ectopic Pregnancy?
A. ovary
B. cervix
C. peritoneal cavity

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 Care of Mother and Child at Risk or with
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Module #5
D. fallopian tube

9. Karlie is experiencing sharp shoulder pain. Which of the following conditions is experiencing?
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign

10. As you do physical examination on Karlie, you saw that her abdomen has an ecchymosis blueness around the
umbilicus. You know that its:
A. Cullen’s Sign
B. Charcot’s Sign
C. Kehr’s Sign
D. Leopold’s Sign

C. LESSON WRAP-UP

AL Activity: CAT: 3-2-1 This strategy provides a structure for students to record their own comprehension and
summarize their learning. It also gives the teacher an opportunity to identify areas that need re-teaching, and areas of
student interest

Instructions:

1. As an exit ticket at the end of the class period

2. After the lesson, have each student record three things he or she learned from the lesson.
3. Next, have them record two things that they found interesting and that they’d like to learn more about.
4. Then, have students record one question they still have about the material.
5. Review the students’ responses. You can use this information to help develop future lessons and determine if some
of the material needs to be taught again.

Three things you learned:

1.

3.

Two things that you’d like to learn more about:

1.

2.

One question you still have:

1.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #5

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