1

N0RSINu CARE 0F TBE BIuB RISK

PRENATAL CLIENT
HIGH RISK
O Is onc in wIicI a concurrcni disordcr, rcgnancy rclaicd comlicaiion, or
cicrnal facior jcoardizcs iIc IcaliI of iIc woman, iIc fcius or loiI.
O Povcriy
O Lacl of suori colc circumsianccs iIai
O Poor coing mccIanisms causcs womcn io lc
O Ccnciic inIcriiancc IigI- risl
O Pasi Iisiory of rcgnancy comlicaiions

O SIould lc sccn morc frcqucnily for rcnaial carc


IDENTIFYING CLIENTS T RISK

1 SSESSMENT OF RISK FCTORS
Factors EIIects
DemograpbIc Iactors
1. Agc (<16 or >35 ycars}




2. Povcriy

3. Muliiiariiy ( >4 rcgnancics}
Lcss iIan 18. incrcascd risl for LDW and
rcicrm lalor, PIH, ancmia,CS for CPD.

Morc iIan 35 ycars. incrcascd risl of
cIromosomal alnormaliiics, PIH

Associaic wiiI LDW, rcicrm infanis

HcmorrIagc, CS and fcial loss

!ersonaI -socIaI IactorsJIIIestyIe
1. WcigIi

2. HcigIi ( <5 fcci}

3. Smoling

4. AlcoIol/illcgal drug usc
<100 lls. associaicd wiiI LDW
>200 lls. PIH, LCA infanis, difficuli lalor, CS
duc io CPD
Incrcascd risl for CS duc io CPD

LDW, rcicrm liriI

Congcniial anomalics, fcial wiiIdrawal
syndromc, fcial alcoIol syndromc



ObstetrIc Iactors
1. DiriI of rcvious infani wiiI wcigIi
>8.5 lls

Incrcascd risl for CS, liriI injury, maicrnal
gcsiaiional dialcics and nconaial
Iyoglyccmia



2. Prcvious siillliriI


3. FI scnsiiizaiion

4. Ccrvical insufficicncy

5. Muliilc gcsiaiions
Incrcascd risl of maicrnal sycIological
disircss

Incrcascd risl for fcial ancmia,
cryIrollasiosis and lcrnicicrus
Associaicd wiiI dclivcry of rcviallc fcius

Associaicd wiiI nuiriiional ancmia,
rccclamsia, rcicrm lalor, malrcscniaiion,
CS, osiarium IcmorrIagc
ExIstIng medIcaI condItIons
1. DM


2. HyoiIyroidism



3. Cardiac discasc




4. Fcnal discasc



5. Concurrcni infcciion




6. Scizurc disordcrs



7. Livcr discasc
Incrcascd risl of PIH. CS, LCA, SCA ,
nconaial Iyoglyccmia, fcial or nconaial
dcaiI, congcniial anomalics

Incrcascd risl of soniancous aloriion,
congcniial anomalics, congcniial
IyoiIyroidism

Incrcascd risl of fcial or nconaial dcaiI
WaicI oui for signs of worscning Icari discasc
sucI as cdcma, cracllcs, aciiviiy iniolcrancc,
SOD , irrcgular Icari raic.

Associaicd wiiI maicrnal rcnal failurc,
rcicrm dclivcry, inirauicrinc growiI
rciardaiion

Scvcrc fcial cffccis if maicrnal discasc occurs
in iIc firsi irimcsicr
Incrcascd risl for soniancous aloriion and
congcniial anomalics

Incrcascd risl of fcial malformaiion, incrcascd
incidcncc of ccrclral alsy, scizurc disordcr
and mcnial rciardaiion in offsring

Prcicrm and siillliriIs


EnvIronmentaI agents Imair fcriiliiy, inicrfcrc wiiI normal laccnial
funciion and may lc ioic io iIc fcius lcading
io fcial dcaiI
MedIcatIons

2 DIGNOSTIC ND SCREENING !ROCEDURES
a. UTZ. aldominal, iransvaginal, Dolcr
l. urinalysis
c. Amnioccnicsis- donc lciwccn 16-18 wccls
a. Invasivc roccdurc for amnioiic fluid analysis io asscss fcial lung maiuriiy donc
aficr 14 wccls gcsiaiion

d. NST
a. Fcaciivc icsi 3 accclcraiions of FHF 15 lcais/min alovc lasclinc FHF lasiing
for 15 scc. Or morc, ovcr 20 minuics


l. Non rcaciivc icsi no accclcraiions or accclcraiion lcss iIan 15 lcais/ minuic
alovc lasclinc FHF. May indicaic fcial jcoardy.

c. AFI } amnioiic fluid indc} iIc sum of iIc amnioiic fluid in iIc quadranis of iIc
uicrus
f. Kicl couni asscssmcni iool. Sandovsly or Cardiff mciIod- usually donc aficr mcal
- 10 movcmcnis cr Iour

g. AFP ( amnioiic fcioroicin} io dcicci ncural iulc dcfccis, donc ai 15-20 wccls
I. Dialciic scrccning- donc ai 24-28 wccls
i. Pcrcuiancous llood samling/ cordoccnicsis
j. MSAFP- maicrnal scrum alIa fcioroicin donc io dcicci ncural iulc dcfccis or
ocn aldominal wall dcfccis
- Donc lciwccn 16-18 wccls
l. Sicllc ccll icsi donc io dcicci rcscncc of sicllc Icmoglolin in ai risl womcn.
l. Crou D lcia sirciococcus ( ccrvical and Iaryngcal swals} donc io dcicci
carricrs or aciivc grou D lcia sirciococcus.
m. DioIysical rofilc- uscs ulirasonograIy and NST io asscss 5 lioIysical variallcs
in dcicrmining fcial wcll lcing.
- Pcrformcd during a 30 minuic iimc framc
1. NST asscssing fir FHF accclcraiion in rclaiion io fcial movcmcnis
2. Amnioiic fluid indc asscssning for onc or morc oclcis of amnioiic fluid
mcasuring incI ( 2 cm} or morc in 2 crcndicular lancs.
3. Cross fcial lody movcmcnis- onc or morc cisodcs lasiing ai lcasi 30
scconds.
4. Fcial jusclc ionc onc or morc aciivc cicnsion wiiI rciurn io flcion of
sinc, Iand or limls.
n. lASIC LAD TESTS.
a. llood scrccning for rI facior
l. vdrl for scdonc ai 32 wccls
c. urinc icsiing
d. a's smcar for sid
c. siool culiurc for ova and
arasiics,
f. io icsi for IigI risl aiicni

Danger sIgns oI pregnancy
SIgns Jsymptoms !otentIaI medIcaIJsurgIcaI compIIcatIons
1. 'aginal soiiing or llccding Lalor, laccnia rcvia, alruiion laccnia,
ccioic rcgnancy, Iydaiidiform molc
2. Suddcn gusI of vagina fluid Fuiurc of mcmlrancs, imcnding lalor and
rouic for asccnding infcciion
3. Uicrinc ain Lalor, alruiion laccnia, UTI
4. HcadacIc wiiI llurrcd vision, ucr
aldominal ain, Icad and facial swclling,
suddcn wcigIi gain
Prcgnancy induccd Iycricnsion, UTI
5. 'aginal discIargc Infcciion
6. Flu lilc symioms Infcciion
7. Eosurc io communicallc discascs Possillc infcciion
8. Dysuria wiiI frcqucni flanl ain UTI
9. Suddcn lowcr aldominal ain, vaginal
llccding, confusion, allor, iacIycardia and
scvcrc sIouldcr ain
Possillc ccioic rcgnancy
10. Family Iisiory of dialcics, dizzincss,
confusion, glucosuria, olyuria
DM


SuraL nCM 10 lec

FCTORS THT CTEGORI2ES !REGNNCY S HIGH RISK
!sycboIogIcaI SocIaI !bysIcaI
!repregnancy O Hisiory of drug
dccndcncc (
including alcoIol}
O Hisiory of
iniimaic arincr
alusc
O Hisiory of mcnial
illncss
O Hisiory of oor
coing
mccIanisms
O Cogniiivcly
cIallcngcd
O Survivor of
cIildIood scual
alusc

O Occuaiion
involving Iandling
of ioic,
sulsianccs (
including
radiaiion and
ancsiIcsia gascs}
O Environmcnial
coniaminanis ai
Iomc
O Isolaicd
O Lowcr cconomic
lcvcl
O Poor acccss io
iransoriaiion for
carc
O HigI aliiiudc
O HigIly molilc
lifcsiylc
O Poor Iousing
O Lacl of suori
colc
O 'isual or Icaring
cIallcngcs
O Pclvic inadcquacy
or missIac
O Uicrinc
incomcicncy,
osiiion or
siruciurc
O Sccondary major
illncss ( Icari
discasc, dialcics
mclliius, lidncy
discasc,
Iycricnsion.
CIronic infcciion
sucI as
iulcrculosis,
Icmooiciic or
llood disordcr,
malignancy}
O Poor gynccologic
or olsiciric
Iisiory
O Hisiory of
rcvious oor
rcgnancy
ouicomc (
miscarriagc,
siillliriI,
inirauicrinc fcial
dcaiI}
O Hisiory of cIild
wiiI congcniial
anomalics
O Olcsiiy ( DMI >30}
O UndcrwcigIi (
DMI <18.5}
O Pclvic
inflammaiory
discasc
O Hisiory of
inIcriicd disordcr
O Small siaiurc
O Poicniial of llood
incomaiililiiy
O oungcr iIan agc
18 ycars or oldcr
iIan 35 ycars
O Cigarciic smolcr
O Sulsiancc aluscr



SuraL nCM 10 lec

!regnancy O Loss of suori
crson
O Illncss of a family
mcmlcr
O Dccrcasc in sclf
csiccm
O Drug alusc (
including alcoIol
and cigarciic
smoling}
O Poor accciancc
of rcgnancy
O Fcfusal of or
ncglccicd rcnaial
carc
O Eosurc io
cnvironmcnial
icraiogcns
O Disruiivc family
incidcni
O Concciion lcss
iIan 1 ycar aficr
lasi rcgnancy
O Suljcci io irauma
O Fluid or
clccirolyic
imlalancc
O Inialc of
icraiogcn sucI as
a drug
O Muliilc gcsiaiion
O A llccding
disruiion
O Poor laccnial
formaiion or
osiiion
O Ccsiaiional
dialcics
O Nuiriiional
dcficicncy of iron,
folic acid, or
roicin
O Poor wcigIi gain
O Prcgnancy-
induccd
Iycricnsion
O Infcciion
O Amnioiic fluid
alnormaliiy
O Posimaiuriiy





Labor and bIrtb O Scvcrcly
frigIicncd ly
lalor and liriI
ccricncc
O Inaliliiy io
ariiciaic
lccausc of
ancsiIcsia
O Scaraiion of
infani ai liriI
O Lacl of scaraiion
for lalor
O DiriI of infani
wIo is
disaoiniing in
somc way ( sucI
as sc,
acarancc, or
congcniial
anomalics}
O Illncss in ncwlorn
O Lacl of suori
crson
O Inadcquaic Iomc
for infani carc
O Unlanncd
ccsarcan liriI
O Lacl of acccss io
coniinucd IcaliI
carc
O Lacl of acccss io
cmcrgcncy
crsonncl or
cquimcni
O HcmorrIagc
O Infcciion
O Fluid and
clccirolyic
imlalancc



SuraL nCM 10 lec

C 'ULNERLE GROU!S OF !REGNNT WOMEN:
1. Adolcsccni
2. Mcnially ill
3. 18 y/o and lclow
4. Womcn ovcr 40 y/o
5. PIysically and cogniiivcly cIallcngc
6. Woman wIo is a sulsiancc dccndcni

D MEDICL CONDITIONSFFECTING !REGNNCY OUTCOMES ( !RE-
GESTTIONL CONDITIONS)

1 ssessment oI a woman wItb CRDIC DISESE:
O TIorougI IcaliI Iisiory---io documcni Icr rcrcgnancy cardiac siaius
Asl Icr lcvcl of ccrcisc crformancc
Asl if sIc Ias cougI or cdcma
Insiruci iIc woman io rcori cougIing during rcgnancy---lcc ulmonary
cdcma from Icari failurc may firsi manifcsi iisclf as a simlc cougI.
Normal cdcma of rcgnancy involvcs only iIc fcci and anllcs
Edcma of rcgnancy induccd Iycricnsion usually lcgins aficr wccl 20.

SIgn oI beart IaIIure.
4 Edcma
4 Irrcgular ulsc
4 Faid or difficuli rcsiraiions
4 CIcsi ain on ccriion
Maling comarison asscssmcni for nail lcd ( sIould lc <5 scconds}
ugular vcnous disicniion
Asscss livcr sizc ( Icari dss involvcs rigIi sidcd Icari failurc}- difficuli io
asscss, sincc iIc uicrus rcsscs iIc livcr uward undcr iIc rils and difficuli io
alaic.
EcIocardiograIy
CIcsi radiograI----- aldomcn is covcrcd wiiI lcad aron during cosurc
ECC------ lcss accuraic lccausc iy
iHc cnlargc uicrus rcsscs uward on iIc diaIragm and dislaccs iIc Icari

Four categorIes oI beart dIsease:
1. CIass 1 and II can ccci io ccricncc a normal rcgnancy and liriI.
2. CIass III can comlcic a rcgnancy ly mainiaining almosi comlcic lcd
rcsi.
3. CIass I' arc oor candidaics for rcgnancy lccausc iIcy arc in cardiac
failurc cvcn ai rcsi and wIcn iIcy arc noi rcgnani.
- Adviscd io avoid rcgnancy.
HE!RIN drug of cIoicc for carly rcgnancy . Aniicoagulani
- No icraiogcnic cffcci
- Docs noi cross iIc laccnia and iIc fcius


SuraL nCM 10 lec

SODIUM WRFRIN (COUMDIN} can lc uscd aficr wccl 12 lui a woman will rciurncd io
Icarin iIcray during iIc lasi moniI of rcgnancyfor iIc fcius noi io dcvclo a
coagulaiion disordcr ai liriI.
FetaI assessment
Cardiac failurc affcci fcial growiI
4 Maicrnal llood rcssurc lccomcs insufficicni io rovidc an adcquaic suly of
llood and nuiricnis io iIc laccnia.
4 Low liriI wcigIi
4 acidoiic fcial cnvironmcni
4 Prcicrm lalor
4 Immaiuriiy
4 Infani may noi rcsond io lalor ( laic dccclcraiions}

Noic. WIcn cardiac ouiui is noi cnougI io mcci sysicmic lody dcmands---criIcral
vasoconsiriciion occurs lccausc iIc uicrus is a criIcral organ iIai causcs iIc
uicrinc/laccnial consiriciion.
InterventIons:
1. Promoic IcaliIy nuiriiion
O Musi gain wcigIi lui noi so mucI wcigIi ( lurdcn io Icr Icari}
2. Talc iron sulcmcnis io rcvcni ancmia
3. Educaic rcgarding mcdicaiion
O DIgoxIn adminisicrcd io a woman during rcgnancy io slow iIc Fcial Icari if fcial
iacIycardia is rcscni
O denosIne beta bIockers and angIotensIn convertIne enzyme ( CE) InbIbItors
io rcducc Iycricnsion, safc during rcgnancy
O NItrogIycerIn a comound oficn rcscrilcd for angina, safc
O A valid ccciion io iIc rulc No mcdicinc during rcgnancy"

4. Educaic rcgarding iIc avoidancc of infcciion
O Cauiion a woman wiiI Icari discasc io avoid visiiing or lcing visiicd ly colc
wiiI infcciion

InterventIons durIng Iabor and bIrtb
1. Moniir FHF and uicrinc comniraciions in all womcn wiiI Icari dss
2. Asscss DP, ulsc and FF frcqucnily
O A raid incrcasing PF ( >100 lcais/min} is an indicaiion iIai a Icari is uming
incffcciivcly and Ias incrcascd iis raic in an cffori io comcnsaic.
O Advisc iIc woman io assumc a sidc lying osiiion io rcducc iIc ossililiiy of
suinc Iycricnsion syndromc
O If sIc Ias ulmonary cdcma Iavc Icr cIcsi and Icad clcvaicd ( scmi-fowlcr's } io
casc iIc worl of lrcaiIing.
O Faiiguc is a symiom of Icari dccomrcssion
3. Oygcn adminisiraiion
4. Swan ganz caiIcicr- io moniior iIc Icari funciion
5. Eidural ancsiIcsia
O If cidural ancsiIcsia is uscd, low forcc or vacuum ciracior can lc uscd for liriI


SuraL nCM 10 lec

6. SIould noi usI wiiI coniraciions

InterventIons durIng postpartum
1. Dccrcascd aciiviiy
2. Aniicoagulani and digoin iIcray
3. Aniicmlolic sioclings and amlulaiion may lc nccdcd io incrcasc vcnous rciurn from
iIc lcgs
4. If roIylaciic aniilioiics Iad noi lccn siaricd rior io liriI, iIcy will lc siaricd
immcdiaicly aficr liriI io discouragc sulacuic lacicrial cndocardiiis
5. Closc inscciion of iIc laly
Acrocyanosis normal in ncwlorn
6. Oyiocin (iiocin} for uicrinc involuiion, uscd wiiI cauiionicnd io incrcasc DP
7. Kcgcl ccrcisc for crincal sircngiIcning lui NOT osiarium ccrciscs io imrovc
aldominal ionc.waii for iIc dr or midvivc's ordcr.
8. Siool soficncr
As a rulc, woman wiiI Icari discasc can lrcsifccd wiiIoui difficuliy

RHEUMTIC ENDOCRDITISJRHEUMTIC HERT DISESE
O Is an acuc, rccurrcni inflammaiory discasc iIai causcs damagc io iIc Icari as a
scqucl io grou.
O A lcia Icmolyiic sirciococcal infcciion, ariicularly iIc valvcs, rcsuliing in valvc
lcalagc ( insufficicncy} and or olsiruciion ( narrowing or sicnosis}.
O TIcrc arc associaicd comcnsaiory cIangcs in iIc sizc of iIc Icari's cIamlcrs and
iIc iIiclncss of cIamlcr walls.
!atbopbysIoIogy and etIoIogy
O FIcumaiic fcvcr is a scqucl io grou A sirciococcal infcciion iIai occur in
aloui 3% of unircaicd infcciions. Ii is a rcvcniallc discasc iIrougI iIc
dcicciion and adcquaic ircaimcni of sirciococcal Iaryngiiis.
O Conncciivc iissuc of iIc Icari, llood vcsscls, joinis and sulcuiancous iissucs
can lc affccicd.
O Lcsions in conncciivc iissuc arc lnown as ascboII bodIes wIicI arc localizcd
arcas of iissuc nccrosis is surroundcd ly immunc cclls.
O Hcari valvcs arc affccicd, rcsuliing in valvc lcalagc and narrowing
O Comcnsaiory cIangcs in iIc cIamlcr sizcs and iIiclncss of cIamlcr walls
occur.
O Hcari involvcmcni ( cardiiis} also includcs cricardiiis, myocardiiis and
cndocardiiis.
Myocardiiis inflammaiory roccss involving iIc myocardium
Pcricardiiis inflammaiion of iIc cricardium, iIc mcmlranous sac cnvcloing
iIc Icari






SuraL nCM 10 lec

CIInIcaI manIIestatIons
1. Symioms of sirciococcal Iaryngiiis may rcccdc rIcumaiic symioms
a. Suddcn onsci of sorc iIroai, iIroai rcddcncd wiiI cudaic
l. Swollcn, icndcr lymI nodcs ai anglc of jaw
c. HcadacIc and fcvcr 101 -104 F ( 38.9 -40C}
d. Aldominal ain ( cIildrcn}
c. Somc cascs of sirciococcal iIroai infcciion arc rclaiivcly asymiomaiic
2. Warm and swollcn joinis ( olyariIriiis}
3. CIorca ( irrcgular jcrly, involuniary, unrcdiciallc muscular movcmcnis}
4. EryiIcma marginaium (iransicni mcsIlilc mascular rasI on irunl an dcircmiiics in
aloui 10% of aiicnis}
5. Sulcuiancous nodulcs ( Iard, ainlcss nodulcs ovcr cicnsor surfaccs of circmiiics }
6. Fcvcr
7. Prolongcd PF inicrval dcmonsiraicd ly ECC
8. Hcari murmurs, lcural and cricardial ruls
DIagnostIc evaIuatIon
1. TIroai culiurc io dcicrminc rcscncc of sirciococcal organisms
2. Scdimcniaiion raic, WDC couni and diffcrcniial, and CFP incrcascd during acuic
Iasc of infcciion
3. Elcvaicd aniisirciolysin O ( ASO} iiicr
4. ECC rolongcd PF inicrval or Icari llocl
Management
1. Aniimicrolial iIcray- cnicillin is iIc drug of cIoicc
a. Noic iIai misscd doscs of aniilioiics duc io iIc aiicni's unavailaliliiy wIilc off of
iIc unii for diagnosiic icsis arc givcn aficr rciurn io iIc unii.
l. Misscd aniilioiic doscs may Iavc irrcvcrsillc dclcicrious conscqucnccs.
c. Noiify IcaiI acrc rovidcr if doscs will lc misscd io malc surc iIai aroriaic
alicrnaiivc mcasurc arc ialcn.
2. Fcsi io mainiain oiimal cardiac funciion
3. Salicylaics or NSAIDS io conirol fcvcr and ain
4. Prcvcniion of rccurrcni cisodcs iIrougI long icrm cnicillin iIcray for 5 ycars aficr
iniiial aiiacl in mosi adulis, criodic roIylais iIrougIoui lifc if valvular damagc.
CompIIcatIons
1. 'alvular Icari discasc
2. CardiomyoaiIy
3. Hcari failurc
NursIng ssessment
1. Asl aiicni aloui symioms of fcvcr or iIroai or joini ain.
2. Asl aiicni aloui cIcsi ain, dysnca, faiiguc
3. Olscrvc for slin lcsions or rasI on irunl and circmiiics.
4. Palaic for firm, nonicndcr movallc nodulcs ncar icndons or joinis.
5. Ausculiaic Icari sounds for murmurs and ruls
NursIng DIagnosIs
1. HycriIcrmia rclaicd io discasc roccss.
2. Dccrcascd cardiac ouiui rclaic io dccrcascs cardiac coniraciiliiy
10

SuraL nCM 10 lec

3. Aciiviiy iniolcrancc rclaicd io joini ain and casy faiigaliliiy.
NursIng InterventIons
ReducIng Fever
1. Adminisicr cnicillin iIcray as rcscrilcd io cradicaic Icmolyiic sirciococcus ; an
alicrnaiivc drug may lc rcscrilcd if aiicnis is allcrgic io cnicillin or scnsiiiviiy
icsiing and dcscnsiiizaiion may lc donc.
2. Civc salicylaics/NSAIDS as rcscrilcs io surcss rIcumaiic aciiviiy ly conirolling
ioic manifcsiaiions. To rcducc fcvcr and io rclicvc joini ain.
3. Asscss for cffcciivcncss of drug iIcray
a. Talc and rccord icmcraiurc cvcry 3 Iours.
l. Evaluaic aiicni's comfori lcvcl cvcry 3 Iours.
MaIntaInIng adequate cardIac output
1. Asscss for signs and symioms of acuic rIcumaiic cardiiis.
a. Dc alcri io aiicni's comlaini of cIcsi ain, aliiaiions, and or rccordial
iigIincss"
l. Moniior for iacIycardia ( usually crsisicni wIcn aiicni slccs} or lradycardia.
c. Dc alcri io dcvclomcni of sccond dcgrcc Icari llocl or wenckebacb's dIsease (
acuic rIcumaiic cardiiis causcs PF inicrval rolongaiion}.
2. Ausculiaic Icari sounds cvcry 4 Iours.
a. Documcni rcscncc of murmur or cricardial friciion rul.
l. Documcni cira Icari sounds ( S3 gallo, S4 gallo}.
3. Moniior for dcvclomcni of cIronic rIcumaiic cndocardiiis, wIicI may includc valvular
discasc and Icari failurc.
MaIntaInIng ctIvIty
1. Mainiain lcd rcsi for duraiion of fcvcr or if signs of aciivc cardiiis arc rcscni.
2. Providc FOM ccrcisc rogram.
3. Providc divcrsuonal aciiviiics iIai rcvcnis ccriion.
4. Discuss nccds for iuiorial scrviccs wiiI arcnis io Icl cIild lcc u wiiI scIool worl.
!atIent educatIon and beaItb maIntenance
1. Counscl aiicni io mainiain good nuiriiion.
2. Counscl aiicni on Iygicnic raciiccs.
a. Discuss rocr Iand wasIing, disosal of iissucs, laundcring of IandlcrcIicfs (
dccrcasc risl of cosurc io microlcs}
l. Discuss iIc imoriancc of using aiicni's own iooiIlrusI, soa and wasIcloiIs
wIcn living in grou siiuaiions.
3. Counscl aiicni on imoriancc of rccciving adcquaic rcsi.
4. Insiruci aiicni io sccl ircaimcni immcdiaicly sIould sorc iIroai occur.
5. Suori aiicnis in long-icrm aniilioiic iIcray io rcvcni rclasc ( 5 ycars for mosi
adulis}
6. Insiruci aiicni wiiI valvular discasc io usc roIylaciic cnicillin iIcray lcforc
ccriain roccdurcs and surgcry.
7. Elorc wiiI aiicni Iis aliliiy io ay for mcdical ircaimcni. If aroriaic, coniaci
social scrviccs for aiicni.


11

SuraL nCM 10 lec


2 DIETES MELLITUS
O Is an cndocrinc d/o in wIicI iIc ancrcas cannoi roducc adcquaic insulin io
rcgulaic lody glucosc lcvcls.
O NOT a good candidaic for oral coniracciivc
lccausc progesterone inicrfcrcs wiiI insulin aciiviiy and iIcrcforc incrcascs
llood glucosc lcvcls
estrogen Ias iIc oicniial incrcasing liid and cIolcsicrol lcvcls and llood
coagulaiion
O NOT a candidaic for using IUD
Associaicd wiiI IigIcr raics of Pclvic inflammaiory discasc
Havc rollcms figIiing infcciions
O Sulcuiancous imlanicd or IM injcciions of rogcsiin may lc good cIoicc
CIInIcaI !resentatIon
O Polyuria
O Polydysia
O PolyIagia
O WcigIi loss
O Frcqucni UTI
O Largc fcius

CIassIIIcatIon oI DIabetes MeIIItus
Type DescrIptIon
Tyc 1 O Formcrly lnown as insulin dccndcni
dialcics mclliius
O A siaic cIaracicrizcd ly iIc dcsiruciion
of iIc lcia cclls in iIc ancrcas iIai
usually lcads io alsoluic insulin
dcficicncy.
O A. immunc mcdiaicd dialcics mclliius
rcsulys from auioimmunc dcsiruciion
of iIc lcia cclls.
O D. IdioaiIic iyc I rcfcrs io forms iIai
Ias no causc
Tyc 2 O Formcrly lnown as non-insulin
dccndcni dialcics mclliius.
O A siaic iIai usually ariscs lccausc of
insulin rcsisiancc comlincd wiiI a
rclaiivc dcficicncy in iIc roduciion of
insulin
Ccsiaiional dialcics

Fisl faciors.
O Olcsiiy
O Agc ovcr 25 ycars
O H of largc lalics (10 ll or morc}
O H of unclaincd fcial or crinaial
O A condiiion of alnormal glucosc
mcialolism iIai ariscs during
rcgnancy. ( 24
iI
-28
iI
wccls}
1

SuraL nCM 10 lec

loss
O H of congcniial anomalics in
rcvious rcgnancics
O H of olycysiic ovary syndromc
O Family I of dialcics ( onc closc
rclaiivc or iwo disiani oncs}
O Mcmlcr of a oulaiion wiiI a IigI
risl for dialcics
Imaircd glucosc Iomcosiasis O A siaic lciwccn normal" and
dialcics" in wIicI iIc lody is no
longcr using and or sccrciing insulin
rocrly.
O A. imaircd fasiing glucosc- a siaic
wIcn fasiing lasma glucosc is ai lcasi
110 lui undcr 126mg/dl
O D. imaircd glucosc iolcrancc- a siaic
wIcn iIc rcsulis of iIc oral glucosc
iolcrancc icsi arc ai lcasi 140 lui
undcr 200 mg/dl in iIc 2 Iour samlc.

CompIIcatIons
MaternaI FetaI
PIH Macrosomia
Infcciion ( cardiasis} Congcniial anomalics
PolyIydramnios ( IigIcr urinc roduciion
causcd ly Iycrglyccmia
SiillliriIs
Soniancous aloriion

TEST
1 g oraI gIucose cbaIIenge test
O To confirm dialcics fasiing lasma glucosc of 126 mg/dl or alovc or a
nonfasiing lasma glucosc of 200 mg/dl or alovc wiiI dialcics
O Aficr iIc oral 50 g glucosc load- a vcnous samlc is ialcn for glucosc
dcicrminaiion 60 minuics laicr.
O Donc during iIc firsi rcnaial visii and rccai ai 24-28 wccls AOC
2. If ncgaiivc. usc 1g GIucose ToIerance test ai 32-34 wccls
O If iIc scrum glucosc lcvcl ai 1 Iour is morc iIan 140 mg/dl, iIc woman is
scIcdulcd for a 100 g , 3 Iour fasiing glucosc iolcrancc icsi.
O If 2 of iIc 4 llood samlcs collccicd for iIis icsi arc alnormal or iIc fasiing
valuc is alovc 95 mg/dl dialcics is rcscni

OraI gIucose cbaIIenge test vaIues (IastIng pIasma gIucose vaIues) Ior pregnancy
Test type !regnant gIucose IeveI
(mgJdI) by carpenter
and coustan
Fasiing 95
1 Iour 180
2 Iours 155
1

SuraL nCM 10 lec

3 Iours 140
Following a 100 g glucosc load. Faic is alnormal if iwo valucs arc cc
NursIng care and management:
1 Comlcic aiicni daialasc and documcni icsi rcsulis during rcgnancy
2. Educaic loiI iIc aiicni and Icr family
O Asscss aiicni's undcrsianding of Icr condiiion and iic cffccis on daily lifc
O Discuss and dcmonsiraic sclf adminisiraiion of insulin
O Dcmonsiraic sclf moniioring of llood glucosc lcvcl lcforc mcals and ai lcdiimc.
O Sircss iIc imoriancc of rccording
llood glucosc lcvcls
insulin dosc
diciary inialc
criods of ccrcisc
criods of Iyoglyccmia
lind and amouni of ircaimcni
urinc icsi rcsulis daily
3. Elain imoriancc of coniinucd cvaluaiion cvcn during iIc osiarium criod (
moniior glucosc lcvcls cvcry 4-6 Iours for 24 Iours, adminisicr insulin sulcuiancously
wIcn nccdcd} and cvcn wIcn llood glucosc lcvcls arc normal.
4. Arrangc for aiicnis consuliaiion wiiI a diciician
Dici. 20% CHON, 40-50% CHO, 30% fais
5. Encouragc rcgular ccrcisc ( 3-4 /wccl, duraiion of 15-30 minuics, HF mainiains
lciwccn 130-160 lm}
6. Aiicnd io aiicni's cmoiional and sycIological nccds and rovidc assurancc.
7. Ensurc aiicni's rcaraiion for inicnsivc and rcgular iniraariun asscssmcni.
Fcial moniioring
Iniravcnous glucosc
Insulin and oyiocin infusion
Evaluaiion for dialciic Icioacidosis
I'F rclaccmcni
Invasivc maicrnal cardiac moniioring
8. Idcniify and rcfcr iIc aiicni and Icr family io ossillc suori grous and rcsourccs
9. Advisc coniracciion in dialciic womcn
10. Moniior DP and liid lcvcls
11. Woman wIo is iyc 1 0r 2 sIould mcci wiiI Icr olsicirician lcforc sIc lccomcs
rcgnani.
12. Usc Iomc icsi lii io dcicrminc if sIc is rcgnani io lnow ii ai carlicsi iimc.
13. Clycosylaicd Icmoglolin is uscd io dcicci iIc dcgrcc of Iycrglyccmia
O Clucosc circulaics in iIc llood, linds io a oriion of Icmoglolin in iIc llood.
O Mcasuring glycosylaicd Icmoglolin is advaniagcous lccausc ii rcflccis iIc
avcragc llood glucosc lcvcls ovcr iIc asi 4-6 wccls ( iIc iimc iIc FDC wcrc
icling u glucosc}
14. OIiIalmic caminaiion is donc during rcgnancy
15. Urinc culiurc may lc donc cacI irimcsicr io dcicci asymiomaiic UTI as iIc incrcascd
glucosc conccniraiion in urinc lcads io incrcascd infcciion.
TberapeutIc management
1. Insulin
O Fcgular sIori aciing insulin ( Lisro or insulin asari}
O 2/3 givcn in iIc morning
O 1/3- cvcning
1

SuraL nCM 10 lec

O Sclf adminisicrcd 30 minuics lcforc lrcalfasi in araiio 2.1 ( inicrmcdiaic io
rcgular}
O Again lcforc dinncr. raiio 1.1
O Human insulin is rccommcndcd lcc ii Ias lcsscr aniilody rcsonsc iIan lccf or
orl insulins.
2. Dlood glucosc moniioring
O To dcicrminc if Iyoglyccmia or Iycrglyccmia cisis


SIgns and symptoms oI bypogIycemIs and bypergIycemIa

HypogIycemIa= common In tbe 2
nd
and
rd

montbs
HypergIycemIa= common In tbe 6
tb

montbs
Swcaiing
Pallor, cold, clammy slin
Disoricniaiion, irriialiliiy
IcadacIc
Iungcr
llurrcd vision
ncrvousncss
wcalncss, faiiguc
sIallow lrcaiIing, lui normal PF
urinc ncgaiivc for glucosc and lcioncs
llood glucosc lcvcl <60 mg/dl

Faiiguc
FlusIcd, Ioi slin
Dry mouiI, cccssivc iIirsi
Frcqucni urinaiion
Faid, dcc lrcaiIing, fruiiy lrcaiI
odor
Dcrcsscd rcflccs
Drowsincss, IcadacIc






SUSTNCE USE
O Inaliliiy io mcci major rolc olligaiions , an incrcasc in lcgal rollcms or risl
ialing lcIavior or cosurc io Iazardous siiuaiions lccausc of an addiciing
sulsiancc.
O SUDSTANCE DEPENDENT
wIcn Ic or sIc Ias wiiIdrawal symioms following disconiinuaiion of
iIc sulsiancc comlincd wiiI alandoncmcni of imoriani aciiviiics,
scnding incrcascd iimc in aciiviiics rclaicd io sulsiancc usc
using sulsianccs for longcr iimc iIan lanncd
coniinucd usc dcsiic worscning rollcms lccausc of sulsiancc usc.
Usually youngcr agc grou
MAFK.
4 laic in rcnaial carc lccausc sIc s afraid Icr drug usc will lc
discovcrcd and lc rcoricd io auiIoriiics.
4 Cannoi waii long ai IaliI carc faciliiy io lc sccn for an
aoinimcni
4 Difficuliy following insiruciions for rocr nuiriiion
4 Prcfcr io luy drugs iIan food
EFFECTS
Fcial alnormaliiics
Prcicrm liriI
Hcaiiiis if using injccicd drugs D
or HI'
OUTCOMES:
1

SuraL nCM 10 lec

Havc fcw cffcciivc suori colc
Fcquirc a muliidiscilinary icam aroacI noi only from rcgnancy HCP lui
sulsiancc alusc ircaimcni rovidcrs
Siill using drug wIcn lalor lcgins--------infani will Iavc drug wiiIdrawal symioms
aficr liriI
O Ncrvousncss
O Irriialiliiy/lciIargy
O Possilly scizurcs
NOTE:
reastIeedIng Is not encouraged lccausc drugs arc lcing carricd and ccrcicd
inio lrcasi mill.
Womcn rccciving METHDONE as ari of iIcir drug ircaimcni can breastIeed
as only a small amouni of iIis drug is ccrcicd in lrcasi mill
COMMON SUSTNCES USED DURING !REGNNCY
COCINE
O Dcrivcd from EryiIroylum coca
O WIcn sniffcd-alsorlcd in iIc mucous mcmlranc affcciing iIc ccniral ncrvous
sysicm------------ vasoconsiriciion occurs.
O FF , DP and HF incrcascs raidly in rcsonsc io vasoconsiriciion
O Immcdiaic dcaiI may rcsuli from cardiac failurc
O If iIcrc is vasoconsiriciion, laccnial insufficicncy rcmaiurc of iIc
laccnia rcicrm lalor or fcial dcaiI
O INFANT will suffcr iniracranial IcmorrIagc and a wiiIdrawal syndromc of
ircmulousncss, irriialiliiy and musclc rigidiiy.
O Long icrn cffccis. lcarning dcfccis
M!HETMINES
O MciIamIciaminc ( sccd}
O Smolcd
O Ncwlorns sIow jiiicrncss, oor fccding ai liriI, growiI rcsiricicd.
C MRIJUN ND HSHISH
O Oliaincd from iIc Icm lani CANNADIS
O WIcn smolcd roducc iacIycardia and scnsc of wcll lcing
O Associaicd wiiI sIori icrm mcmory and incrcascd rcsiraiory infcciion in adulis
O Frcqucni uscr may NOT nc allc io lrcasifccd lccausc of rcduccd mill
roduciion and iIc risl of iIc ncwlorn from ccrciion of iIc drug in iIc mill.
D !HENCYCLIDINE
O an animal iranquilizcr iIai is frcqucnily uscd sircci drug in olydrug alusc.
O Causcs incrcascd cardiac ouiui and scnsc of cuIoria, long icrm Iallucinaiion
( flasIlacl cisodcs}
O Tcnd io lcavc iIc maicrnal circulaiion and conccniraic in fcial cclls-----injurious
io a fcius.
E NRCOTIC GONISTS
O Uscd for iIc ircaimcni of ain
O Mccridinc, morIinc
O HEROIN
a raw oiaic, sIori aciing narcoiic
inaciivc uniil ii crosscs iIc llood lrain larricr
adminisicrcd ID, I' and inIalaiion
roduccs a sIori livcd fccling of cuIoria followcd ly scdaiion.
CompIIcatIon:
1

SuraL nCM 10 lec

4 PIH
4 PIlcliiis
4 sulacuic lacicrial cndocardiiis,
4 Icaiiiis D
4 HI'
WItbdrawaI symptoms may begIn as soon as 6 bours aIter tbe Iast
drug
4 Nausca
4 'omiiing
4 DiarrIca
4 Aldominal ain
4 Hycricnsion
4 Fcsilcssncss
4 SIivcring
4 Insomnia
4 Dody caIcs
4 Musclc jcrls
EIIects oI opIates to InIants.
4 SCA
4 Fcial disircss
4 Mcconium asiraiion
4 WiiIdrawal symioms aficr liriI
NOTE. lccausc iIc fcius is coscd io drugs iIai musi lc roccsscd ly iIc livcr during
rcgnancy, iIc fcial livcr is forccd io maiurc fasicr iIan normally.Fcial lung iissuc also
acars io maiurc from iIc sircss of inirauicrinc drug cosurc, iIus lcing lorn in
rcicrm
Management.
1 MciIadonc mainicnancc rogram
2 DurcnorIinc if noi ircaicd wiiI mciIadonc
Suloonc (comlinaiion of naloonc and lurcnorIinc}- an analgcsic similar io
morIinc

F INHLNTS
O Sniffing/Iuffing
O Can lcad io rcsiraiory and cardiac irrcgulariiics
G LCOHOL
O Dcirimcnial io fcial growiI
O Fcial alcoIol syndromc significani facial fcaiurcs, cogniiivc cIallcngc and
mcmory dcficiis











1

SuraL nCM 10 lec



4 Rb SENSITI2TION
O II you are Rh-negative, your red blood cells do not have a marker called Rh Iactor on
them. Rh-positive blood does have this marker.
O II your blood mixes with Rh-positive blood, your immune system will react to the Rh
Iactor by making antibodies to destroy it.
O The immune system response is called Rh sensitization.
Wbat causes Rb sensItIzatIon durIng pregnancy?
O Rh sensitization can occur during pregnancy iI you are Rh-negative and pregnant with an
unborn baby (Ietus) who has Rh-positive blood.
In most cases, your blood will not mix with your baby`s blood until delivery. It
takes a while to make antibodies that can aIIect the baby, so during your Iirst
pregnancy, the baby probably would not be aIIected.
iI you get pregnant again with an Rh-positive baby, the antibodies already in your
blood could attack the baby`s red blood cells.
cause the baby to have:
4 anemia
4 aundice
4 more serious problems.
This is called Rh disease.
The problems will tend to get worse with each Rh-positive pregnancy you have.
uring your Iirst pregnancy, your baby could be at risk Ior Rh disease iI you were
sensitized beIore or during pregnancy. This can happen iI:
ou Iad a rcvious miscarriagc, aloriion, or ccioic rcgnancy and you did noi
rcccivc FI immunc glolulin io rcvcni scnsiiizaiion.
ou Iad a scrious injury io your lclly during rcgnancy.
ou Iad a mcdical icsi sucI as an amnioccnicsis or cIorionic villus samling wIilc
you wcrc rcgnani, and you did noi rcccivc FI immunc glolulin. TIcsc icsis could
lci your llood and your laly's llood mi.
FI scnsiiizaiion is onc rcason ii's imoriani io scc your docior in iIc firsi irimcsicr of
rcgnancy. Ii docsn'i causc any warning symioms, and a llood icsi is iIc only way io
lnow you Iavc ii or arc ai risl for ii.
O If you arc ai risl, FI scnsiiizaiion can almosi always lc rcvcnicd.
O If you arc alrcady scnsiiizcd, ircaimcni can Icl roicci your laly.
Wbo gets Rb sensitization during pregnancy?
O FI scnsiiizaiion during rcgnancy can only Iacn if a woman Ias FI-ncgaiivc llood
and only if Icr unlorn laly Ias FI-osiiivc llood.
If iIc moiIcr is FI-ncgaiivc and iIc faiIcr is FI-osiiivc, iIcrc is a good cIancc iIc
laly will Iavc FI-osiiivc llood. FI scnsiiizaiion can occur.
If loiI arcnis Iavc FI-ncgaiivc llood, iIc laly will Iavc FI-ncgaiivc llood. Sincc
iIc moiIcr's llood and iIc laly's llood maicI, scnsiiizaiion will noi occur.
1

SuraL nCM 10 lec

If you Iavc FI-ncgaiivc llood, your docior will rolally ircai you as iIougI iIc
laly's llood is FI-osiiivc no maiicr wIai iIc faiIcr's llood iyc is, jusi io lc on
iIc safc sidc.
ll pregnant women get a blood test at their Iirst prenatal visit during early pregnancy.
This test will show iI you have Rh-negative blood and iI you are Rh-sensitized.
II you bave Rb-negatIve bIood but are not sensItIzed:
O TIc llood icsi may lc rccaicd lciwccn 24 and 28 wccls of rcgnancy. If iIc icsi siill
sIows iIai you arc noi scnsiiizcd, you rolally will noi nccd anoiIcr aniilody icsi
uniil dclivcry. (ou migIi nccd io Iavc iIc icsi again if you Iavc an amnioccnicsis, if
your rcgnancy gocs lcyond 40 wccls, or if you Iavc a rollcm sucI as laccnia
alruiio, wIicI could causc llccding in iIc uicrus.}
O our laly will Iavc a llood icsi ai liriI. If iIc ncwlorn Ias FI-osiiivc llood, you will
Iavc an aniilody icsi io scc if you wcrc scnsiiizcd during laic rcgnancy or cIildliriI.

II you are Rb-sensItIzed, your doctor wIII watcb your pregnancy careIuIIy You may bave:
O Fcgular llood icsis, io cIccl iIc lcvcl of aniilodics in your llood.
O Dolcr ulirasound, io cIccl llood flow io iIc laly's lrain. TIis can sIow ancmia and
Iow scvcrc ii is.
O Amnioccnicsis aficr 15 wccls, io cIccl iIc laly's llood iyc and FI facior and io lool
for rollcms.

How Is Rb sensItIzatIon prevented
If you Iavc FI-ncgaiivc llood lui arc noi FI-scnsiiizcd, your docior will givc you onc or morc
sIois of FI immunc glolulin (sucI as FIoCAM}. TIis rcvcnis FI scnsiiizaiion in aloui 99
womcn oui of 100 wIo usc ii.
1

ou may gci a sIoi of Rb Immune gIobuIIn.
O If you Iavc a icsi sucI as an amnioccnicsis.
O Around wccl 28 of your rcgnancy.
O Aficr dclivcry if your ncwlorn is FI-osiiivc.

Tbe sbots onIy work Ior a sbort tIme, so you will nccd io rccai iIis ircaimcni cacI
iimc you gci rcgnani. (To rcvcni scnsiiizaiion in fuiurc rcgnancics, FI immunc
glolulin is also givcn wIcn an FI-ncgaiivc woman Ias a miscarriagc, aloriion, or
ccioic rcgnancy.}
TIc sIois won'i worl if you arc alrcady FI-scnsiiizcd.
How Is It treated?
If you arc FI-scnsiiizcd.
a. rcgular icsiing io scc Iow your unlorn laly is doing.
l. nccd io scc a docior wIo sccializcs in IigI-risl rcgnancics (a crinaiologisi}.
Trcaimcni of iIc laly is lascd on Iow scvcrc iIc loss of rcd llood cclls (ancmia} is.
O If iIc laly's ancmia is mild, you will jusi Iavc morc icsiing iIan usual wIilc you arc
rcgnani. TIc laly may noi nccd any sccial ircaimcni aficr liriI.
1

SuraL nCM 10 lec

O If ancmia is gciiing worsc, ii may lc safcsi io dclivcr iIc laly carly. Aficr dclivcry, somc
lalics nccd a llood iransfusion or ircaimcni for jaundicc.
O For scvcrc ancmia, a laly can Iavc a llood iransfusion wIilc siill in iIc uicrus. TIis
can Icl lcc iIc laly IcaliIy uniil Ic or sIc is maiurc cnougI io lc dclivcrcd. ou
will mosi lilcly Iavc an carly C-scciion, and iIc laly may nccd io Iavc anoiIcr llood
iransfusion rigIi aficr liriI.

NEMI
O NormaIIy: llood volumc cands during rcgnancy ( scudo ancmia}
O True anemIa
1
st
and
rd
trImester: Icmoglolin conccniraiion is lcss iIan 11g/dl (
Icmaiocrii <33%}
2
nd
trImester: Icmoglolin is lcss iIan 10.5g/dl (Icmaiocrii <32%}
a Iron deIIcIency anemIa
O A microcyiic ( small rcd llood ccll}, IyocIromic ( lcss Icmoglolin iIan iIc
avcragc rcd ccll} ancmia lccausc wIcn an inadcquaic suly of iron is
ingcsicd, iron is unavailallc for incororaiion inio rcd llood cclls.
O Mosi common ancmia of rcgnancy
O Hcmoglolin lcvcl is lclow 12 mg/dl
O Hcmaiocrii <33%
O Low scrum iron lcvcl confirms iron dcficicncy ancmia
O Incrcascd iron linding caaciiy
O Causes:
4 Dici low in iron
4 Hcavy mcnsirual flow
4 Unwisc wcigIi rcduciion rograms
4 Prcgnani lcss iIan 2 ycars
4 Low socio cconomic lcvcls
O Madc availallc io iIc lody ly alsoriion from iIc duodcnum
inio iIc lloodsircam aficr ii is ingcsicd.
O In iIc llood sircam------iransfcrrin----for iransori io iIc
livcr, slccn and lonc marrow------------and incororaicd inio
Icmoglolin or siorcd as fcrriiin.

O EIIects:
4 LDW
4 Prcicrm liriI
4 Pica ( food craving} lilc icc or siarcI
Management:
1. Womcn sIould ialc rcnaial viiamins
O Iron sulcmcni of 60 mg
2. Dici IigI in iron and viiamins grccn lcafy vcgciallcs, mcai, lcgumcs , fruii}
3. TIcracuiic lcvcls of mcdicaiions 120-200 mg clcmcnis iron/day}in iIc form of
Fcrrous sulfaic or fcrrous gluconaic
Iron is lcsi alsorlcd from an acid mcdium
SIde eIIects.
4 Consiiaiion
4 Casiric irriiaiion
Mgt: incrcasc rougIagc dici
Always ialc iIc ills wiiI food
0

SuraL nCM 10 lec

O If iron dcficicncy ancmia is scvcrc and a woman Ias difficuliy wiiI oral iron iIcray, IM or
I' iron dciran can lc rcscrilcd.

b FoIIc acId deIIcIency anemIa
O Folic acid/ folacin- D viiamins ncccssary for iIc normal formaiion of rcd
llood cclls in iIc moiIcr.
O Associaicd wiiI rcvcniing ncural iulc dcfccis in iIc fcius.
O HIgb- rIsk:
Occurs mosi in muliilc rcgnancics lcc of incrcascd fcial dcmand
Womcn wiiI sccondary Icmolyiic illncss---iIcrc is raid dcsiruciion
and roduciion of ncw rcd llood cclls
Womcn ialing bydantoIn - an aniiconvulsani agcni iIai inicrfcrcs
wiiI folaic alsoriion
Womcn ialing oral coniracciivcs
Womcn wIo Iad gasiric lyass for morlid olcsiiy
O Mcgalollasiic ancmia cnlargcd rcd llood cclls
Ancmia common in iIis iyc
TIc mcan coruscular volumc will nc clcvaicd in conirasi io iIc
lowcrcd lcvcl sccn wiiI iron dcficcicncy
Talc scvcral wccls io dcvclo
Aarcni during 2
nd
irimcsicr
A coniriluiory facior in carly miscarriagc or rcmaiurc scaraiion of
iIc laccnia.
O Occur in iIc 1
si
fcw wccls of fcial dcvclomcni
Adviscd iIc woman io lcgin 400 microgram folic acid daily
Eai folacin food (grccn lcafy vcgciallcs, orangcs, dricd lcans.
O During rcgnancy
Folic acid rcquircmcni incrcascs io 600 microgram daily
c. Sicllc ccll ancmia
O An inIcriicd Icmolyiic ancmia causcd ly alnormal aminmo acid in iIc lcia
cIain of Icmoglolin.
O If an alnormal amino acid rclaccs iIc amino acid valinc, sicllc Icmoglolin
(HlS} rcsulis
O If ii is sulsiiiuicd for iIc amino acid lysinc, nonsiclling Icmoglolin ( HlC}
rcsulis.
O An individual is Icicrozygous ( Ias only onc gcnc in wIicI iIc alnormal
sulsiiiuiion Ias occurrcd} Ias iIc sicllc ccll iraii ( HlAS}
O If iIc crson in Iomozygous ( Ias 2 gcncs in wIicI iIc sulsiiiuiion Ias
occurrcd} sicllc ccll discasc rcsulis. ( HlSS}
O Majoriiy of iIc rcd llood cclls arc irrcgular or sicllc sIacd------cannoi carry
as mucI Icmoglolin as a normally sIacd rcd cclls do.
oygcn
lld lccomcs viscid ( dcIydraicd} cclls clum

Icmolysis llood flow io organs vcsscl lloclagc

dccrcasc = of FDC scvcrc ancmia

1

SuraL nCM 10 lec

EIIects oI bomozygous dIsease:
1. Prcmaiuriiy
2. Miscarriagc
3. Pcrinaial morialiiy
4. Incrcascd incidcncc of asymiomaiic lacicriuria rcsuliing in incrcasc incidcncc of
ycloncIriiis.

O Sicllc ccll ancmia is a iIrcai io lifc if viial llood vcsscls sucI as iIosc io iIc livcr, lidncys,
Icari, lungs or lrain lccomc lloclcd.
O In rcgnancy, lloclagc io iIc laccnial circulaiion can dirccily comromisc iIc fcius,
causing low liriI wcigIi and ossilly fcial dcaiI.
ssessment:
1. Moniior Icmoglolin lcvcl
2. Clcan caicI urinc samlc
O Sincc iIcy arc suscciillc io lacicriuria
3. Moniior dici iIrougIoui rcgnancy
4. Fluid inialc carcfully moniiorcd
O SIould consumc ai lcasi 8 glasscs of fluids daily
O If nauscaicd ----dccrcasc fluid inialc, dcIydraiion iIcn sicllc ccll crisis occurs.
5. Asscss for rcscncc of varicosiiics during rcnaial visiis
O Duc io uicrinc rcssurc during rcgnancy/ooling of llood in lcg vcins
O Pooling and rcssurc can lcad io rcd llood ccll dcsiruciion
O Sianding for long iimc causcs iIis rcssurc
6. Encouragc woman io clcvaic lcgs wIilc siiiing
7. Sim's osiiion io cncouragc vcnous rciurn from iIc lowcr circmiiics
8. Moniior fcial IcaliI ly
a. UTZ ai 16-24 wccls io asscss for inirauicrinc growiI rcsiriciion
l. NST ly wcclly lcginning ai 30 wccls
c. Dlood flow vclociiy io mcasurc llood flow io iIc uicrus and laccnia
O If rcduccd ------ inirauicrinc growiI rcsiriciion
TberapeutIc Management:
1. Pcriodic ccIangc iransfusion iIrougIoui rcgnancy----io rclacc sicllcd cclls wiiI non
sicllcd cclls
2. O2 adminisiraiion
3. Incrcasc fluid volumc
O Hyoionic (0.45 salinc}---io lcc lasma icnsion low lccausc of iIc
difficuliy of a woman conccniraiing urinc io rcmovc largc amounis of
fluids.
As a rulc womcn wiiI sicllc ccll ancmia arc noi givcn iron sulcmcni during
rcgnancy
O Sicllc cclls cannoi incororaic wiiI iron samc manncr as non sicllcd ccll
ccll can, so cccssivc iron luildu may rcsuli
4. Hosiializaiion
O If wiiI fcvcr io rulc oui iIc dcvclomcni of sicllc ccll crisis
O WiiI infcciion and Icmolysis
If a woman Ias iIc discasc and Icr arincr Ias iIc iraii----50% cIild lorn wiiI iIc
dss, and all of iIcir cIild will Iavc iIc discasc.


SuraL nCM 10 lec

Symioms of sicllc ccll discasc do noi lccomc aarcni uniil an infani's fcial
Icmoglolin convcris io a largcly aduli aiicrn ( in 3 -6 moniIs}.
Fcial Igl 2 alIa 2 gamma cIains
Aduli Igl 2 alIa 2 lcia cIains
Dcc sicllc ccll iraii is carricd on iIc lcia cIain, symioms will lc manifcsicd uniil iIis
cIain acars.
5. ElcciroIorcsis of FDC---oliaincd iIru crcuiancous umlilical llood
samling/amnioccnicsis----can rcvcal iIc rcscncc of iIc discasc.
ND Iavc 15% aduli Igl ai liriI-----so clcciroIorcsis ai liriI can rcvcal if iIc
dss is rcscni.

6 HI'
RIsk Iactors:
O Muliilc scual arincrs of iIc individual or scual arincr
O Discual arincrs
O Iniravcnous drug uscd ly iIc individuals or scual arincr
ssessment:
a. Fcroduciivc iraci irriiaiion
l. Mild flu symioms
c. Scroconvcrsion- in wIicI a woman convcris from Iaving no HI' aniilodics in Icr llood
scrum ( HI' scrum ncgaiivc} io Iaving aniilodics againsi HI' } HI' scrum osiiivc
O Hacns 6 wccls io 1 ycar aficr cosurc
d. WcigIi loss
c. faiiguc
IigIcr risl of dcvcloing ioolasmosis and cyiomcgalovirus infcciions
HI' osiiivc woman may invadc iIc ccrclrosinal fluid and causc circmc
ncurologic involvcmcni.
f. Tulcrculis
ELIS or Western bIot anaIysIs
2IdovudIne ( Z'D}- adminisicrd io iIc woman lcginning wiiI iIc 14
iI
wccl of rcgnancy
And ncwlorns rcccivcs aniiviral iIcray lcginning wiiI liriI. And a follow- u of 6wccls .

TberapeutIc Mgt:
1. Adviscd noi io lc rcgnani
2. TrimciIorin wiiI sulfamciIoazolc (lacirim}- wiiI ncumonia
O Tcraiogcnic in carly rcgnancy
O SulfamciIoazolc ( ganianol}- may lcad io incrcasc lilirulin lcvcls in ncwlorn if
adminisicrcd laic in rcgnancy
3. CIcmoiIcraIy for iIosc wiiI Kaosi's sarcoma- coniraindicaicd during carly
rcgnancy lcc of oicniial for fcial injury lui can lc uscd laicr in rcgnancy io Iali iIc
malignani growiI.
4. Cs dclivcry

EIIects:
O Low liriI wcigIi
O Prcicrm liriI



SuraL nCM 10 lec

uESTATI0NAL C0NBITI0NS AFFECTINu
PREuNANCY 00TC0NES S0CB AS:

1. ECTOPIC PREGNANCY- 1
st
trimester
O mplantation occurs outside the uterine cavity either in the surface of the
ovary or the cervix.
O Common site is the fallopian tube
80% in the ampulla
12% in the isthmus
8% in the interstitial/fimbria
Assessment:
1. Amenorrhea triad
2. Sharp knife stabbing pain in the lower abdominal OF
quadrants ( Unilateral)
symptoms

3. Scant vaginal spotting
symptoms
4. Shock
Rapid, thread pulse
Rapid RR
Falling BP
5. Leukocytosis -----due to trauma and not from infection
O f delayed in seeking care:
Rigid abdomen
Umbilicus develop a bluish tinge ( cullen's sign)
Extensive or dull vaginal and abdominal pain
Movement of the cervix and pelvis exam cause excruciating pain
Shoulder pain due to the irritation of the phrenic nerve
Tender mass palpated in Douglas cul de sac on vaginal exam.
6. No gestational sac in the UTZ
Risk factors:
1. Obstruction like adhesion in the fallopian tube from previous infection
2. Congenital malformations
3. Scars from tubal surgery
4. Uterine tumor
===makes the zygote unable to travel into the tube
Management
2. Unruptured ectopic pregnancy
a. Oral administration of methotrexate-----destroys fast growing cells
O Treatment continued till hcg is negative


SuraL nCM 10 lec

l. Hysterosalpingogram or UTZ is perforemed after chemotherapy to
assess whether the tube is fully patent.
c. Mifepristone ------an abortifacient , causing sloughing of the tubal
implantation
O Advantage : the tube is left intact, with no surgical scarring that could cause a 2
nd
ectopic
implantation.
3. Ruptured ectopic pregnancy
O Blood sample be drawn immediately for
Hemoglobin level
Typing and cross matching
HCG level for for immediate pregnancy testing
O VF using a large gauge catheter to restore intravascular volume
O Administer blood
O Therapy:
Laparoscopy---to ligate the bleeding vessels and to remove or
repair the damaged fallopian tube.
Rh (D) immune globulin (RhG) after an ectopic pregnancy for
isoimmunization for future pregnancy .
O How is cuIdocentesis done:
a. Consent
b. Lithotomy position
c. Prepare perineum
d. Speculum introduced
e. Spinal needle directed to the posterior portion of the cervix
f. Aspirate:
4 f blood is present in the cul de sac, it is a RUPTURED ECTOPC
PREGNANCY
4 Blood is placed in a test tube / disk and observed for clotting
4 f NON-CLOTTNG OR LAKED BLOOD
t comes from ectopic pregnancy
4 f BLOOD CLOTS -----t is maternal blood
The products of conception from the ruptured tube and the accompanying blood
may be expelled to the pelvic cavity rather than in the uterus.







SuraL nCM 10 lec


. HYPEREMESIS GRAVIDARUM
O Pernicious or persistent vomiting
O s nausea and vomiting of pregnancy that is prolonged past week 12 of pregnancy or is
so severe that dehydration, ketonuria and significant weight loss occur within the 12
weeks of pregnancy.
O Have increased thyroid function because of thyroid stimulating properties of human
chorionic gobadotropin
O Associated with helicobacter pylori- bacteria that causes peptic ulcer
Assessment
O Severe nausea and vomiting
O Elevated hct- bec unable to retain fluid resulted to hemoconcentration
O Low Na, K and chloride bec of her low intake
O Hypokalemic due to vomiting
O Polyneuritis bec of vitamin B deficiency
O Weight loss
O Urine test positive for ketones- evidence that a woman is breaking down fats and
protein for cell growth
O Poor skin turgor
O f left untreated=====associated with intrauterine growth restriction, preterm birth if the
woman is dehydrated and can no longer provide a fetus with essential nutrients for growth.
Therapeutic mgt:
O Hospitalization for 24 hours to monitor intake and output, blood chem. And to restore
hydration.
O Withheld oral food and fluid
O VF ( 3000 LR with added Vit B)
O Antiemetic metoclopramide ( raglan)-to control vomiting
O Measure intake and outpu and amount of vomitus
O f no vominting within 24 hours===may start small amounts of clear fluid
O Dry crackers, dry toast or cereal and be added every 2 or hours then advanced to soft diet-
then to normal diet.
O f vomiting returns==== TPN is used
Nursing care mgt:
1. Ensure that the client has no oral intake until vomiting stops.
2. Administer VF
3. Record fluid intake and output
4. Advise small frequent meals once vomiting has subsided.
5. Administer antiemetics as prescribed
6. Attends to client's emotional and psychological needs by providing reassurance and
allowing the client and her family to freely communicate their fears and concers among
themselves.



SuraL nCM 10 lec


. GESTATIONAL TROPHOBLASTIC DISEASE / H-
MOLE- (
nd
semester)
O An abnormal proliferation and then degeneration of the trophoblastic villi.
O As the cells degenerate, they become filled with fluid and appear as clear fluid filled,
grape sized vesicles.
O Associated with choriocarcinoma- a rapidly metastasizing malignancy.

Risk factors:
a. Low protein intake
b. Women older than 35 years old
c. Blood group A who marry group O men
Types of moIar growth:- identified by chromosome analysis
a. Complete mole
O All trophoblastic villi swell and become cystic
O f embryo forms, it dies early at 1 to 2 mm in size, with no fetal blood present in
the villi.
O Empty ovum---the sperm enters empty egg and its chromosomes replicates
b. Partial mole
O Some of the villi form normally
O Syncytiotrophoblastic layer of villi is swollen and misshapen.
Or syncytial layer==the outer ring of the chorionic villi that produces
placental hormones ( somatomammotrophin ( HPL), E and P
O A macerated embryo of approx 9 weeks gestation may be present and fetal
blood may be present in the villi.
O Has 69 chromosome
O Rarely lead to choriocarcinoma
Assessment:
O Uterus tends to expand faster than normally.- just over the symphysis pubis brim at 12
weeks, umbilicus at 20-24 weeks)====also diagnostic of multiple pregnancy or
miscalculated due date
O +urine test of HCG ( 1-2 M U compared with a normal pregnancy level of 400,000U)
Highly positive results can be a characteristic of multiple pregnancies with more
than one placenta



SuraL nCM 10 lec

O Marked nausea and vomiting- due to high level of HCG
O UTZ ----show dense growth ( snowflake pattern) but no fetal growth in the uterus
O No fetal heart sounds are heard bec there is no viable fetus.
O Vaginal bleeding ( approx at 16 weeks)====begin spotting of dark brown or a profuse
fresh flow
As bleeding progresses==accompanied by discharge of clear fluid filled vesicles
nstruct the woman to carry/bring with her any clots or tissue passed
O Early s/s of preeclampsa/eclampsia ( proteinuria, edema, hypertension) before 20
th
week

Therapeutic mgt:
1. Suction curettage- to evacuate the mole
2. Pelvic exam
3. Chest radiograph
4. Serum test for the beta unit of HCG==analyzed every 2 weeks
5. Use oral contraceptive method for 12 months
-HCG should be negative
6. Methothrexate===drug of choice for choriocarcinoma
O nterferes with WBC formation (leucopenia)
O DACTNOMYCN- added regimen if metastasis occur
7. Encourage women to express their anger and sense of unfairness

. INCOMPETENT CERVIX/Premature cervicaI
diIatation (
nd
trimester)
O inability of the cervix to support growing weight of pregnancy associated with repeated
spontaneous 2
nd
trimester abortion.
O Painless dilatation of the cervix in the absence of uterine contraction due to cervical
trauma.
Assessment:
O Bloody Show ( pink stained vaginal bleeding) -1
st
symptom
O ncreased pelvic pressure/low abdominal pressure
O Followed by rupture of membranes and discharge of amniotic fluid
O Uterine contractions begins and a short labor the fetus is born
O Occurs approx week 20 of pregnancy
O Progressive dilation of the cervix
O Urinary frequency
Risk factors
O Maternal age
O Congenital structural defects
O Trauma to the cervix---due to repeated D&C, cone biopsy
Diagnosed after the pregnancy was lost.


SuraL nCM 10 lec

Treatment
O Cervical cerclage- performed between 14-16 weeks of pregnancy
Sew the cervix and removed between 36-38
th
weeks
O Mc Donald/Shirodkar procedure- purse string sutures are placed in the cervix by the
vaginal route under regional anesthesia
the suture used to strengthen the cervix and prevent it from dilating.
nylon sutures are placed horizontally and vertically across the cervix and pulled
tight to reduce the cervical canal to a few millimeters in diameter.
a sterile tape is threaded in a purse string manner under the submucous layer of
the cervix and sutured in place to achieve a closed cervix.
sutures are removed at weeks 37-38 of pregnancy so the fetus can be born
vaginally.
SHRODKAR = cervix is closed but menstrual flow is allowed to come out,
delivery via CS
Nursing mgt:
1. modified trendelenburg position- to decrese pressure on the new sutures
2. bed rest
3. coitus is temporarily restricted
4. tocolytic therapy is employed if there is contraction ( ritodrin, terbutaline is administerd to
stop contraction)

5. SPONTANEOUS ABORTION
Abortion - medical term for any interruption of pregnancy before a fetus is viable
ViabIe fetus-fetus of more than 20-24 weeks of gestation, weighs at least 500g
EarIy miscarriage - occurs before 16
th
week
Late miscarriage- occurs between 16
th
and 24 weeks
1
st
6 Week - developing placenta is tentatively attached to the deciduas of the uterus
6 weeks - 12- a moderater degree of attachment to the myometrium is present
After week 1 - attachment is penetrating and deep
BIeeding before 6 week- severe
BIeeding after week 1- can be profuse because the placenta is implanted so deeply, the
fetus tends to be expelled as in natural childbirth before the placenta separates.
Causes of spontaneous miscarriage
1. Abnormal fetal development-
2. mplantation abnormalities- because of enadequate endometrial formation or from
inappropriate site of implantation===causing to poor placental circulation resulting to
poor fetal nutrition
3. Corpues luteum on the ovary fails to produce enough progesterone
4. Systemic infection ( UT)
5. ngestion of teratogenic drug eg isotretinoin ( accutane), drug to treat acne
O f taken early in pregnancy can lead to miscarriage or fetal abnormality
6. ngestion of alcohol
Assessment:
1. Vaginal spotting- notify HCP
2. Lower abdominal cramps
3. Fever and body malaise


SuraL nCM 10 lec

4. Signs of infection



Types:
Types S/s Txt
1. Threatened



Scant bright red vaginal
bleeding
Slight cramping
Cervix closed

* without the passage of
conception and rupture of
membrane
a. ask to come to the clinic to
have FHT be checked or UTZ
to evaluate the viability of the
fetus
b. hcg test at the start of
bleeding and repeat in 48
hours to check if the placenta
is still intact= should be
double at this time. f it does
not double===poor placental
function
c. avoid strenuous activity for
24-48 hours
c. once bleeding stops , she
can resume her activity
d. Coitus is restricted for 2
weeks after the bleeding
episodes to prevent infection
and avoid inducing further
bleeding
e. for dilatation and
evacuation
. Imminent ( Cervical dilatation and uterine a. Ask to come to the clinic
0

SuraL nCM 10 lec

InevitabIe) contraction
Moderate Vaginal bleeding
Severe /painful cramping
Cervix dilated

And bring tissue
fragments to be examined
b. Vacuum extraction (
dilatation and evacuation)
if no FHT and UTz
reveals empty uterus
O To ensure that all
products of conception
are removed
c. After dischargedask the
woman to assess vaginal
bleeding by recording the
number of pads she uses.
==saturation more than
one pad/hr heavy
bleeding
. CompIete The entire products of
conception (fetus, membranes
and placenta) are expelled
spontaneously without any
resistance

Bleeding slows within 2 hours
and then ceases within few
days after passage of the
products of conception

. IncompIete Part of the fetus ( usually the
fetus) is expelled but the
membrane or placenta is
retained in the uterus

Danger of maternal
hemorrhagebec the uterus
cannot contract effectively at
this time
D &C ( dilation and
curettage) or suction
curettage to evacuate the
remainder of pregnancy
5. Missed/earIy
pregnancy faiIure
Fetus die in the uteru but s
not expelled.

Determine when: fetus does
not increase in size, no FHT

Have s/s of threatened
abortion or no symptoms

Fetis died at 4-6 weeks before
the onset of miscarriage
symptoms or failure of growth
UTZ

D &E

Prostaglandin suppository
or misoprostol ( cytotec) if
pregnancy is over 14
weeks, to dilate the cervix

Oxytocin stimulation or
administration of
mifepristone

O DC ( disseminated
intravascular
1

SuraL nCM 10 lec

coagulation)
COAGULATON
Defect, will result if
fetus remains TOO
LONG N UTERU
6. Recurrent pregnancy
Ioss/habituaI
Causes:
O Defective spermatozoa
or ova
O Endocrine factors as
lowered levels of protein
bounf iodine (PB),
butanol-extractable
iodine (BE) and globulin
bound iodine ( GB);
poor thyroid function or
luteal phase defect
O Deviations of the uterus
such as setate or
bicornuate uterus
O Resistance to uterine
artery blood flow
O Chorioamnionitis or
uterine infection
O Autoimmune disorders


CompIications:
1. Hemorrhage
2. nfection
3. Septic abortion- those who tried self abort
Had symptoms of fever
Crampy abdominal pain
Uterus feels tender to palpation
O f left untreated===infection can lead to toxic shock syndrome, septicemia, kidney failure,
death.
O Need immediate attention
4 CBC
4 Serum electrolytes
4 Serum creatinine
4 Bld type and cross match
4 Cervical, vaginal and urine cultures
4 FC can be inserted to monitor urine output hourly to assess kidney failure
4 VF to restore fluid volume
4 Antibiotic---- combination of penicillin and gentamicin and clindamycin
4 D&c/D &E
4 Tetanus toxoid subq
4 Dopamine and digitalis to maintain sufficient cardiac output
4 O2


SuraL nCM 10 lec

4. soimmunization
5. Powerlessness or anxiety

Nursing care and management:
1. Perform the appropriate management and prevent complications
2. Monitor vital signs, bleeding and pain
3. Document VF, lab test results and prepare for emergency surgical intervention when
needed.
4. Prepare administration of RhoGAM to Rh negative mother as advised.
5. Advise iron supplements and increased iron intake to prevent anemia
6. Educate both client and family
7. Provide anticipatory guidance regarding recovery, importance of rest and delay of next
pregnancy until full recovery is ensured.
8. Suggest refraining from sexual intercourse until next menses and advise use of barrier
contraception
9. Explain the most cases of spontaneous abortions have no identified causes.

6. PLACENTA PREVIA
O s a condition of pregnancy in which the placenta is implanted abnormally in the
uterus.
O Painless bleeding in the third trimester of pregnancy.
O Placenta is the presenting part
O Delivered via CS
O No internal exam done
O there is less blood supply in the lower segment thus the placenta tends to grow
larger than it would normally.

TYPES OF PLACENTA PREVIA

a. Iow Iying pIacenta- implantation in the lower lower rather than the upper portion of the
uterus
b. MarginaI impIantation - the placenta edge approaches that of cervical os
c. PartiaI pIacenta previa- implantation that occludes a portion of the cervical os

d. TotaI pIacenta previa- implantation that totally obstructs the cervical os


SuraL nCM 10 lec

The degree to which the placenta covers the internal cervical os is generally estimated in
percentages: 100%, 75%, 30% ..


Predisposing factors
O ncreased parity
O Advanced maternal age
O Past CS
O Uterine curettage
O Multip;e gestations
O Male fetus
An increased in congenital anomalies may occur if the low implantation does not allow
optimal fetal nutrition or oxygenation.

Assessment
O Abrupt, painless, bright red bleeding
Bleeding starts when the lower uterine segments starts to differentiate from the upper
segment late in pregnancy ( approx week 30) and cervix begins to dilate.
Bleeding results from the inability of the placenta to stretch to accommodate the
differing shape of the lower uterine segment of the cervix.
Therapeutic management:
1. Bed rest in a side lying position/trendelenburg for at least 72 hrs.
2. Ask the following:
Duration of pregnancy
Time of bleeding began
Woman's estimation of the amt of bleeding ( in cups of tbsp) 1 cup= 240 ml, 1
tbsp= 15 ml
Pain
Color of the blood ( red= bleeding is fresh and continous)
What she has done for the bleeding ( if she inserted a tampon to halt the
bleeding)
Prior episodes of bleeding during pregnancy
Prior cervical surgery for premature cervical dilatation
3. nspect the perinem
Estimate the present rate of blood loss.
Weigh perineal pad before and after use and calculate the difference by
substraction
Use Ieihauer Betke test ( test strip procedure)- to detect whether the blood is
of fetal or maternal origin
4. No pelvic or rectal examination- agitation of the cervix causing massive hemorrhage
5. Obtain v/s- to determine shock
BP every 5-15 minutes or continuously with an electronic cuff
Attach external monitoring equipment to monitor FHT/ sounds, uterine
contractions
nternal monitor is contraindicated


SuraL nCM 10 lec

7. VF therapy using a large gauge catheter
8. Monitor urine output every hour- indicator of blood volume adequacy
9. Assess hgb, hct, prothrombin time, partial prothrombin time, fibrinogen, platelet count, cross
match, antibody screen- to detect possible disorders and ready for blood replacement if
necessary
10. Determine the placental location thru UTZ
Previa is under 30% - possible for the fetus to be born pass it.
Over 30% and the fetus is mature CS
11. Abdominal assessment- reveal the fetal head is not engaged of the interfering placenta
Gives little indication of how much of the placenta is obscuring the os and
preventing the head from engaging.
F NO PREVA speculum exam of the vagina and cervix to rule out another
ccause of bleeding
12. Double set-up
vaginal exam is done in the OR- if causes hemorrhage due to manipulation-
immediate CS can be carried out to remove the baby and the bleeding placenta
have O2 available just in case FHT is decrease
if labor has begun and bleeding is continuous- birth may be accomplished regardless of
gestational age
if bleeding stops- FHt is good, maternal v/s is good, fetus is not yet 36 weeks of age-
managed bye expectant watching
remains in the hospital on bed rest for close observation for 48 hours
careful exam of FHT, lab test ( hgb and hct) are frequently obtained.
BETHAMETHASONE a steroid that hastens fetal lung maturity may be prescribed for the
mother to encourage the maturity of fetal lungs if the fetus is less than 34 weeks gestation.
-a corticosteroid that acts as an anti inflammatory and immunosuppressive agent
- given to a pregnant woman 12 to 24 hours before birth to hasten fetal lung maturity if a
fetus is less than 34 weeks gestation and help prevent respiratory distress syndrome in the
newborn.
- 12-12.5 mg M initially, may be repeated in 24 hours and again 1-2 weeks

Side effects:
Burning
tching
rritation at the injection site
Swelling
Tachycardia
Headache
Dizziness
Weight gain
Sodium and fluid retention
ncreased risk of infection
If the cIient is aIso receiving a tocoIytic agent
be alert for possible cardiac decompression as a result of drug-drug
interaction
observe for signs of increased pulse, decreased BP and edema
s/s of possible infection




1. ABRUPTIO PLACENTA/PREMATURE
SEPARATION OF THE PLACENTA
O Other name: abIation pIacenta


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O The placenta appears to have been implanted correctly, suddenly it begins to separate and
bleeding results.
O Early separation of the placenta prior to delivery of the fetus
O Premature separation of the placenta
NORMALLY: separation of the placenta occurs in the 3
rd
stage of labor
May occur late as during the first or second stage of labor


Predisposing factors:
1. High parity
2. Advanced maternal age
3. Short umbilical cord
4. Chronic hypertensive disease
5. PH
6. Direct trauma ( automobile accident/partner abuse)
7. Vasoconstriction from cocaine or thrombosis such as autoimmune antibodies
Assessment:
1. Sharp stabbing pain high in the uterine fundus
2. Uterine Tenderness
3. Heavy bleeding
Concealed hemorrhage
4. Rigid and tense uterus
5. Abdominal rigidity
Blood infiltrates in the uterine musculature=== COUVELARE UTERUS/
uteroplacental apoplexy===hard, boardlike uterus with no apparent, bleeding
occurs.
6. Hypotension, tachycardia, pallor
As bleeding progresses, a woman's reserve blood fibrinogen may be used
up in her body's attempt to accomplished clot formation and disseminated
intravascular coagulation (DC) can occur.



SuraL nCM 10 lec


Therapeutic Management:
1. VF
2. Oxygen by mask- to limit fetal anoxia
3. Monitor fetal heart sounds externally
4. Record maternal v/s every 5-15 minutes
5. LateraI position not supine to prevent pressure on the vena cava and additional
interfere with fetal circulation
6. No abdominal, vaginal and pelvic exam not to disturb the placenta
7. f placental grade is 2 -3, terminate the pregnancy-because the fetus cannot obtain
adequate oxygen and nutrients
8. CS is the birth method of choice
9. ntravenous administration of fibrinogen- to elevate a woman's fibrinogen priopr to and
concurrently with surgery
10. Hysterectomy- to prevent exsanguinations
Premature Separation of the PIacenta degrees of Separation
Grade Criteria
0 No symptom,s of separation were apparent from maternal or fetal signs; the diagnosis
that a slight separation did occur is made after birth, when the placentais examined and a
segment of the placenta shows a recent adherent clot on the maternal surface
1 MinimaI separation, nut enough to cause vaginal bleeding and changes in the maternal
vital signs; no fetal distress or hemorrhagic shock occurs
Moderate separation; there is evidence of fetal distress; the uterus is tense and painful
on palpitation
Extreme separation; without immediate interventions, maternal shock and fetal death
will result.



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1. PREMATURE RUPTURE OF MEMBRANES
O Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37
th

weeks
O Associated with infection of membranes ( chorioamnionitis)
O f rupture occurs early in pregnancy---major threat to fetus and after rupture=== the
seal to the fetus is lost and uterine an dfetal infection may occur.
O CompIications:
a. Chorioamnionitis
b. Cord proplapse- apt to occur when the fetal head is still too small to fit the cervix
firmly.
Position the client in trendelenburg /NCHE'S position
Do not re-insert the cord
Moisten OS with NSS and cover
Transport client to OR
Provide O2
c. Potter like syndrome/distorted facial features
d. pulmonary hypoplasia from pressure
e. preterm labor
f. infection
Assessment
1. sudden gush of clear fluid from her vagina
2. constant wetness of underwear
. nitrazine paper
O bIue- amniotic fIuid (aIkaIine rxn)
O yeIIow- urine ( acidic rxn)
4. ferning- typical appearance of high estrogen fluid on microscopic exam ( urine does not
show this)
5. presence of high AFP in the vagina
6. UTZ =t o assess the amniotic fluid index
7. Blood culture

Therapeutic Management
1. Bed rest
2. Corticosteroids-to hasten lung maturity
3. Antibiotics- to delay onset of labor and reduce risk of infection
4. V of penicillin/ampicillin if positive for Sterptococcus B
5. Tocolytic agent if with no signs of infection
6. Amnioinfusion- to reduce pressure on the fetus or cord and allow a term birth
7. Endoscopic intrauterine procedure- sealed by a fibrin






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15. PREGNANCY INDUCED HYPERTENSION
O Condition in which vasospasm occurs during pregnancy in both small and large
arteries.
O s/s
hypertension
proteinuria=== serum proteins albumin and globulin to escape into the urine
due to the vasosapam of the kidneys--------- decrease renal output due to
decreased glomerular filtration
edema=====increased absorption of sodium
O Sodium retains fluid
O Edema is increased because more protein is lost-----osmotic pressure
of the circulating blood falls and fluid diffuses from the circulatory
system into the denser interstitial spaces to equalize the pressure.
O Extreme edema can lead to cerebral and pulmonary edema and
seizures ECLAMPSIA
O Measure hct to assess the extent of edema
O related to the presence of antiphospholipid syndrome /antibodies
O called toxemia== spread of bacteria in the blood, spread of foreign protein of the
growing fetus
O occurs anytime after the week of gestation up to 2 weeks postpartum

Predisposing factors:
O muItipIe pregnancy
O primiparas
O age younger than 20 and older than 40
O low socio economic-poor nutrition
O 5 or more pregnancies
O Hydramnios
O With underlying disease== heart dss., DM, renal involvement, essential HPN
Assessment
1. Vision changes
2. Hypertension classic signs of PH------occurs before 20 weeks of pregnancy
3. Proteinuria
4. Edema-----------------------due to protein loss, sodium retention, lowered glomerular
filtration rate

CIassification of PIH
1. GestationaI HPN-
O develops an elevated BP (140/90 mmHg)
O systolic pressure elevate at 30mmHg, diastolic elevated at 15 mmHg
O BP returns to normal after birth
O no proteinuria or edema.
O Develop after 20 weeks
. MiId pre-ecIampsia
O BP 140/90


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O Systolic elevated at 30 mmHg, diastolic elevated at 15 mmHg above pre pregnancy
level
O Proteinuria +1, +2 on a random sample
O Weight gain over 2 lb per week in 2
nd
tri and 1 lb /wk in 3
rd
tri
O Mild edema in upper extremities or face
. Severe pre-ecIampsia
O BP of 160/110
O Proteinuria +3, +4 on a random sample
O Oliguria ( 500 ml or less in 24 hrs)
O Elevated serum creatinine more than 1.2 mg/dl
O Cerebral or visual disturbance ( headache, blurred vision)
O Pulmonary or cardiac involvement
O Extensive peripheral edema------SOB
O Cerebral edema--------ankIe cIonus ( continued motion of the foot)
Mild2 movt
Moderate= 3-5 mov't
Severe= over 6 mov't
O Hepatic dysfunction
O Thrombocytopenia -------lowered platelet count
O Epigastric pain------------due to ischemia of the pancreas( due to reduced blood
supply to the pancreas)
O +1 ===slightly indented pitting edema
O +2 ====moderately indented
O +3 ====deep indention
O +4====so deep that it remains after removal of the finger
4. Eclampsia
O Seizure or coma accompanied by s/s of pre eclampsia

NURSING INTERVENTIONS FOR A WOMAN WITH :
MILD HPN:
O Monitor antiplatelet therapy===bec of the increased tendency of platelet to cluster along
arterial walls
Low dose aspirin (50-150mg)----prevent or delay development of pre-
eclampsia
O Promote bed rest- lateral recumbent position to avoid uterine pressure on the vena cava
and prevent supine hypotension syndrome
O Promote good nutrition-----give little sodium
-----if no sodium---it could activate the rennin angiotensin aldosterone system and
result in the increased of BP
Provide emotional support
SEVERE HPN
O Support bed rest
O Hospitalization
No visitors---can trigger seizure initiating eclampsia
Private room
0

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Raised side rails to prevent injury
Darken the room----light can trigger seizure
No shining of flashlight into the woma's eyes
O Monitor maternal well-being
Take BP frequently ( at least every 4 hours)
Obtain blood studies-----bec high risk of premature separation of the placenta
Daily hct monitoring-----to determine blood concentration
-----will rise if increased fluid is leaving the bloodstream for
interstitial tissue ( edema)
Anticipate the need for frequent plasma estriol levels ( a test of placental
function) and electrolyte levels
Assess optic function daily ------to assess for arterial spasm, edma or
hemorrhage
Obtain daily weights at the same time each day wearing the same amount
of clothing----- to determine fluid retention and not to alter/influence change
nsert FC------should be 600 ml/24 hours ( more than 30 ml/hr)
24 hour sample urine is taken-----for pretein and creatinine clearance
determination to evaluate kidney function
O Monitor fetal well-being
Doppler with 4 hr interval
Assess FHT continuously
Non stress test daily -----to assess uteroplacental sufficiency
Oxygn administration to the mother------to maintain the adequate oxygenation and
prevent fetal bradycardia
O Support nutrition diet
High protein an dmoderate in sodium-----to compensate for CHON loss in the
urine.
VF
O Administer medications to prevent eclampsia
Hydralazine ( apresoline)
Labetalol ( Normodyne) to reduce HPN
Nifedipine causes maternal tachycardia=====assess firstBP
and PR before and after administration

Diastolic pressure should not be lowered 80-90
mmHg or inadequate placental perfusion could
occur.
Magnesium suIfate -----drug of choice to prevent ecIampsia
-----given firsts V for 15 minutes ----bolus dose
-----acts as an anticonvulsant
s/s of overdose of MG SO4:
4 Decreased urine output
4 Decreased RR
4 Reduced consciousness
4 Decreased deep tendon reflex
------urine output should be monitored closely to ensure adequate
elimination
-------BEFORE administering:
urine output should be 25 -20 ml/hr with a specific gravity of 1.010
or lower
1

SuraL nCM 10 lec

RR should be above 12 breaths/min
Ankle clonus should be minimal
Deep tendon reflex should be present---- paterllar reflex
Assessment should be every hour if a continuous VF infusion is being used.
CaIcium GIuconate------antidote for Magnesium suIfate
-------shouId be at bedside
Osteoporosis -----Iong term effect of Mg SO
No BF
ECLAMPSIA
O Happens late in pregnancy upto 48 hours after birth
a. Tonic cIonic seizure
Preliminary signal/aura
All muscles contracts
Back arches, her arms and leg stiffen, jaw closes, RR stops ( bec her thoracic
muscles are held in contraction)
Last 20 secs
cyanotic
During the
nd
cIonic stage:
4 BIadder and boweI contracts and reIax
4 ncontinence of urine and feces
4 Begins to breathe but not entirely effective
4 Rrmain cyanotic
4 Last up to 1 minute
Management:
to maintain a patent airway
administer oxygen by face mask---- to protect the fetus
turn woman to her side-----to prevent aspiration, and allow drainage
Magnesium sulfate/diazepam (valium) via V as an emergency measure
Assess oxygen saturation
Apply external heart monitor
Assess FHT and uterine contractions
Check vaginal bleeding-----to detect placental separation

During the
rd
stage of seizure (prostictaI state)
O Semicomatose
O Cannot be roused except by painful stimuli for 1-4 hours
O Close observation is important-----can caused premature separation of the placenta---
labor BUT the woman will be unable to report sensation of contractions.
Management:
Keep the woman on her side
Give her nothing by mouth
Limit conversation
Continuously monitor FHT
Check vaginal bleeding very 15 minutes



SuraL nCM 10 lec

f pregnancy is >24 weeks----decision will be made as soon as her condition
stabilizes usually 12-24 hours.
Terminate the fetus coz it does not continue to grow
Fetal lung maturity is advanced with PH
CS is more hazardous for the fetus bec of the association of retained lung fluid
Woman with eclampsia is not a good candidate for surgery----bec her vascular
system is low in volume----may become hypotensive with regional anesthersia
Vaginal the preferred birth
d labor does not begin spontaneously-----can rupture the membrane or can
induct labor with oxytocin via V
f ineffective----- CS is indicated bec the fetus is in danger

HELLP SYNDROME
O Variation of PH
O H-hemolysis that leads to anemia
O E- eIevated Iiver enzymes that leads to epigastric pain
O L- Iow platelets that leads to abnormal bleeding/clotting and petichiae
O Occurs both in primis nd multigravidas
O Complication of severe pre-eclampsia
O s/s
proteinuria
edema
hypertension
nausea
epigastric pain
general malaise right upper quadrant tenderness from liver ionflammation
O need close observation for bleeding
O compIications:
4 liver hematom,a
4 hyponatremia
4 renal failure
4 hypoglycemia
effects to the mother
O cerebral hemoprrhage
O aspiration pneumonia
O hypoxic encephalopathy
fetaI effects
O growth restriction
O preterm birth
mgt:
1. implrove the platelet ct- BT of fresh frozen plasma or platelets
2. intravevous glucose infusion----treat hypoglycemia
3. CS or vaginal