PRE-GESTATIONAL CONDITIONS

MRS. CATHERINE V. STA.MONICA

Pregnancy stresses your heart and circulatory system. During pregnancy, your blood volume increases by 30 to 50 percent to nourish your growing baby. The amount of blood your heart pumps each minute also increases by 30 to 50 percent. Your heart rate increases as well. These changes cause your heart to work harder.

Risks depend on the nature and severity of the underlying heart condition Heart rhythm issues. Minor abnormalities in heart rhythm are common during pregnancy. Heart valve issues. If you have an artificial heart valve or your heart or valves are scarred or malformed, you might face an increased risk of complications during pregnancy. Mechanical artificial heart valves also pose serious risks during pregnancy due to the need to adjust use of blood thinners and the potential for life-threatening clotting (thrombosis) of heart valves. Congestive heart failure. As blood volume increases, congestive heart failure can get worse. Congenital heart defect. If you were born with a heart problem, your baby has a greater risk of developing some type of heart defect, too. You may also be at risk of premature delivery.

EARLY DETECTION Blood pressure monitoring Urinalysis CBC Echocardiogram, a test that uses sound waves to produce images of the heart Electrocardiogram, a test that records the heart's electrical activity

 Congenital Heart Defects Most commonly seen in pregnant women include:  Atrial septal defect  Patent ductus arteriosus  Coarctation of aorta  Tetralogy of fallot impact of pregnancy depends on the specific defect.if the heart has been surgically repaired & no evidence of heart disease remains, the woman may undertake pregnancy with confidence.-woman with CHD who experience cyanosis should be counseled to avoid pregnancy because the risk to mother & fetus is high.

 Rheumatic Heart Disease  Results from an infection (caused by the bacteria,streptococci) known as rheumatic fever, which starts with a sore throat & leads to the scarring of one or more heart valves. The injured valves are unable to open & close normally, resulting in obstruction to the flow of blood. Is it possible to become pregnant?

 Laboratory tests for detecting RHD: 1. Throat cultures- for group A streptococcus usually are negative by the time symptoms of rheumatic fever or RHD appear. Isolate the organism before the initiation of antibiotic therapy to help confirm a diagnosis of streptococcal pharyngitis & to allow typing of the organism if it is isolated successfully. 2. Rapid Antigen- this test allows rapid detection of group A streptococcal antigen & allows the diagnosis of streptococcal pharyngitis & the initiation of antibiotic therapy while the patient is still in the physicians office.

3. Anti-streptococcal Antibodies -this is useful for confirming previous group A streptococcal infection. Antibody titer should be checked @ 2-week intervals in order to detect a rising titer.

General measures to be followed once you become pregnant:  Make sure to keep your follow-up appointments with your obstetrician throughout your pregnancy.  Plan regular follow-up visits with your cardiologist.  Carefully follow all the recommendations of the cardiologist.  The diet should be nutritious & fluid & sodium intake should be restricted.  Take adequate rest.  Watch your weight.  Avoid alcohol.  Stop smoking.

PRE-GESTATIONAL DIABETES MELLITUS

Diabetes Mellitus An endocrine disorder of carbohydrate metabolism, results from inadequate production or use of insulin. Insulin- produced by B cells of Islets of Langerhans in the pancreas, lowers blood glucose levels by enabling glucose to move from the blood into muscle & adipose tissue cells

METABOLIC CHANGES DURING PREGNANCY  Caloric requirement for a pregnant woman is 300 kcal higher than the non-pregnant woman s basal needs  Placental hormones affect glucose and lipid metabolism to ensure that fetus has ample supply of nutrients  Lipid metabolism:
Increased lipolysis (preferential use of fat for fuel, in order to preserve glucose and protein)

 Glucose metabolism:
Decreased insulin sensitivity Increased insulin resistance

 Increased insulin resistance

 Due to hormones secreted by the placenta that are diabetogenic :
Growth hormone Human placental lactogen Progesterone Corticotropin releasing hormonE

Transient maternal hyperglycemia occurs after meals because of increased insulin resistance

 Baseline hypoglycemia
 Proliferation of pancreatic beta cells (insulinsecreting cells) leads to increased insulin secretion
Insulin levels are higher than in pregnant than nonpregnant women in fasting and postprandial states

 Hypoglycemia between meals and at night because of continuous fetal draw

Blood glucose levels are 10-20% lower

Ist half of pregnancy: Increased insulin production and increased response to insulin 2nd half of pregnancy: Increased insulin resistance and increased glucose tolerance; mother may need 2-3 times the insulin dosage Fetus uses glucose from maternal stores = increased disruption in maternal carbohydrate metabolism Increased maternal lipolysis and ketone production

MANAGEMENT OF PRE-GESTATIONAL DM All women screened at 24-28 weeks Strict glycemic control Oral agents are not recommended ; after 1st trimester, glyburide may be used Lispro or Humalog insulin titrated to caloric intake Delivery at or around week 39; based on BPP

RISKS TO BABY AND MOTHER  Macrosomia  Hypoglycemia  Polycythemia and hyperbilirubinemia  Congenital anomalies  IUGR  Respiratory Distress Syndrome  Hydramnios  Ketoacidosis  Retinopathies  Vaginitis, UTI s

 Three main types of Diabetes: 1.Type I diabetes - results from the body s failure to produce insulin, & presently requires the person to inject insulin. 2.Type II diabetes - results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined wit an absolute insulin deficiency. 3.Gestational diabetes - is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy.

Diabetes on pregnancy outcome The pregnancy of a woman who has diabetes carries a higher risk of complications, especially perinatal mortality & congenital anomalies. Tight metabolic control reduces the risk.

 Management Antepartal Prenatal care- using a team approach to ensure an optimally healthy mother & newborn. - woman needs clear explanations & teaching to gain her cooperation in ensuring a good outcome. - the nurse-educator plays a major role in this counseling.- the woman with pregestational diabetes needs to understand what changes she can expect during pregnancy.

 a. Dietary regulation - the pregnant woman with diabetes needs to increase her caloric intake by 300 kcal/day. - on the first trimester she needs about 35 kcal/day of ideal body weight. Approximately 40% to 50% of the calories came from complex, high fiber carbohydrates,20% from protein, & 30% to 40% from fats. - the food is divided into 3 meals & 3 snacks. Bedtime snack is the most important & should include both protein & complex carbohydrates to prevent nightime hypoglycemia.

b. Glucose monitoring - is essential to determine the need for insulin & to assess glucose control. c. Insulin Administration- Many women with gestational diabetes need insulin to maintain normal glucose levels. Human insulin should be used because it is the least likely to cause an allergic reaction.- given either in multiple injections or by continuous subcutaneous infusion. Oral hypoglycemics- not rarely used

 Intrapartal a. Timing of birth- most pregnant women with diabetes, regardless of the type are allowed to go to term, with spontaneous labor. Some clinicians opt to induce labor in a woman at term to avoid problems related to an aging placenta. Cesarean birth maybe indicated if signs of fetal distress exist.

b. Labor management- maternal glucose levels are measured hourly to determine insulin need. Primary goal is to prevent neonatal hypoglycemia. Often given two IV lines are used, one witH a 50%dextrose solution & one with a saline solution. The saline solution is for piggybacking insulin or if a bolus is needed. IV insulin is discontinued @ the end of the third stage of labor.

Post partal Management First 24 hours postpartum, women wit pre-existing diabetes typically require very little insulin. They are usually managed with a sliding scale specifying dosage based on blood glucose levels. Antihyperglycemics are contraindicated during breastfeeding. The woman should be reassessed 6 weeks postpartum to determine whether her glucose levels are normal. If the levels are normal, she should be reassessed at a minimum of 3 year intervals

Rh INCOMPATIBILITY

 Rh incompatibility results from an antigenantibody reaction (alloimmunization). The fetus develops anemia, jaundice, cardiac failure (hydrops fetalis) and neurological damage (kernicterus).

 Early Diagnosis Pregnancy for Rh incompatibility Hx previous blood transfusions Blood group and Rh status of pregnant woman Rh antibody titer for Rh negative woman at the first pregnancy visit and repeat at 32-38 weeks of pregnancy Normal titer is 0 Minimal ratio 1:8 Chorionic villus sampling in early pregnancy. Amniocentesis and amniotic fluid spectrophotometry for biliribin Regular ultrasound from 14-18 weeks onwards look for fetal ascites and subcutaneous edema (hydrops fetalis)

Prevention for Rh incompatibility Screening for the blood group of all pregnant women. Arrange for further investigations if the woman is Rh negative. Anti D (RhoD or RhoGAM) injection 300g IM for the mother at 28 weeks of gestation. Anti D (RhoD or RhoGAM) injection 300g IM for the mother within 72 hours of an abortion, delivery of Rh positive baby or after procedures like amniocentesis or chorionic villus sampling.

ANEMIA

A low level of hemoglobin (less than 10 gm/dl) during pregnancy. Hemoglobin carries oxygen to body tissues via the red blood cells Anemia in pregnancy is very common and is present in almost 8o% of pregnant women.

CAUSES Poor intake of iron in diet Folic acid deficiency Loss of blood from bleeding hemorrhoids or gastrointestinal bleeding. Even if iron and folic acid intake are sufficient, a pregnant woman may become anemic because pregnancy alters the digestive process. Also the unborn child consumes some of the iron or folic acid normally available to the mother's body.

RISK FACTORS Twin or multiple pregnancy Poor nutrition, especially multiple vitamin deficiencies Smoking, which reduces absorption of important nutrients Excess alcohol consumption, leading to poor nutrition Any disorder that reduces absorption of nutrient

DIAGNOSIS The blood tests determines the red blood cell count, hemoglobin level ,iron and folic acid levels in the blood.

SIGNS AND SYMPTOMS Common Symptoms: Tiredness, weakness or fainting. Paleness Breathlessness Occasional Symptoms: Headache Nausea Inflamed, sore tongue Palpitations or an abnormal awareness of the heartbeat Forgetfulness Jaundice (rare) Abdominal pain (rare)

MEDICATIONS Medications: Iron deficiency anemia is treated with iron tablets, preferably as ferrous sulphate 300 mg, to be taken no more than twice daily. This is because the side effects of iron tablets (stomach upset and constipation) are increased if more than 2 tablets are taken. About 20% of pregnant women fail to ingest or absorb adequate amount of iron and may need to be treated with intra-muscular iron injections. Iron dextran is given every alternate day, in divided doses, for a total of about 1000 mg. over a period of 3 weeks. Iron, folic acid and other supplements may be prescribed. For better absorption, take iron supplements 1 hour before eating, or between meals. Iron will turn bowel movements black, and often causes constipation. It is advisable that most pregnant women should be given supplemental iron (ferrous sulphate 300 to 600mg per day). Even though the hemoglobin is normal at the beginning of pregnancy. This preventive measure prevents depletion of iron reserves and anemia that may occur in case of bleeding or with future pregnancy. Folic acid deficiency anemia is treated with folate tablets.

PREVENTION Eat foods rich in iron, such as liver, beef, whole-grain breads and cereals, eggs and dried fruit. Eat foods high in folic acid, such as wheat germ, beans, peanut butter, oatmeal, mushrooms, collards, broccoli, beef liver and asparagus. Eat foods high in vitamin C, such as citrus fruits and fresh, raw vegetables. Vitamin C makes iron absorption more efficient. Take prenatal vitamin and mineral supplements, especially folic acid

Activity: No restrictions, except rest often until anemia disappears. Diet: Eat well and take prescribed supplements Increase fiber and fluid intake to prevent constipation

POSSIBLE COMPLICATIONS Premature labor Dangerous anemia from normal blood loss during labor, requiring blood transfusions Increased susceptibility to infection after childbirth

SUBSTANCE ABUSE

 Substance Abuse Occurs when a person experiences difficulties with work, family, social relations, & health as a result of alcohol or drug use. Drugs that are commonly misused includes:tobacco, alcohol, cocaine, marijuana, amphetamines,barbiturates, hallucinogens, club drugs, heroin andnarcotics.

 Substances commonly abused during pregnancy 1. Alcohol- is a central nervous system depressant & a potent teratogen. The incidence of alcohol abuse is highest among women ages 20 to 40 years although alcoholism is also seen in teenagers. Chronic abuse of alcohol can undermine maternal health by causing malnutrition, bone marrow suppression, increased incidence of infections, & liver disease.

 Alcohol dependence-result is that a woman may havewithdrawal seizures in the intrapartal period as early as 12 to 48 hours after se stops drinking. Delirium tremens may occur in the postpartal period& the newborn may suffer a withdrawal syndrome. Care includes sedation to decrease irritability &tremors, seizure precautions, IV fluid therapy for hydration & preparation for an addicted newborn.

The effect of alcohol on the fetus may result in a group of signs known as fetal alcohol syndrome (FAS). 2. Cocaine & crack =Nearly 3% of pregnant women use illicit drugs such as cocaine, marijuana, ecstasy, other amphetamines &heroin. Cocaine use during pregnancy tends to affect between1% & 5% of newborns

 Cocaine- acts as the nerve terminals to prevent there uptake of dopamine & norepinephrine, which in turn results in vasoconstriction, tachycardia, & hypertension.T his can be taken by IV injection or by snorting the powdered form. Crack- a form of freebase cocaine that is made up of baking soda, water, and cocaine mixed into a paste and microwaved to form a rock, can be smoked. Smoking crack leads to a quicker, more intense high because the drug is absorbed through the large surface area of the lungs.

 Major adverse maternal effects of cocaine use includes: Hallucinations Pulmonary edema Cerebral hemorrhage Respiratory failure Heart problems

 Women who use cocaine have an increased incidence of spontaneous abortion, abruptio placentae, pretermbirth, and stillbirth. Cocaine crosses into breastmilk and may causes ymptoms in the breastfeeding infant, including extreme irritability, vomiting, diarrhea, dilated pupils, and apnea. Thus, women who continue to use cocaine afte rchildbirth should avoid breastfeeding.

3. Marijuana - is the most widely used illicit drugs among women, both pregnant and non pregnant. More than 25% women of reproductive age admit to current or past marijuana use. Marijuana use is associated with impaired coordination, memory, and critical thinking ability. As a result, the pregnant women or new mother who uses marijuana may be at risk if she tries to perform tasks that require complex mental activities.

 4. MDMA (Ecstasy) Methylenedioxymethamphetamine (MDMA), better known as Ecstasy, is the most commonly used of a group of drugs referred to as club drugs, so called because they have become popular among adolescents and young adults who frequent dance clubs and raves. Is taken by mouth usually as a tablet. It produces euphoria and feelings of empathy for others.

5.Heroin - is an illicit CNS depressant narcotic that alters perception and produces euphoria. It is an addictive drug that is generally administered IV. Pregnancy in women who use heroin is considered highrisk because of the increased incidence in these women of poor nutrition, iron deficiency anemia, and preeclampsia. The fetus of a heroin-addicted woman is at increased risk for IUGR, meconium aspiration, and hypoxia. The newborn frequently show signs of heroin addiction such as restlessness; shrill, high-pitched cry; irritability; fist sucking, vomiting, and seizures.

6.Methadone- is the most commonly used therapy for women dependent on opioids such as heroin. Blocks withdrawal symptoms and reduces or eliminates the craving for narcotics. Crosses the placenta and has been associated with preeclampsia, placental problems, and abnormal fetal presentation. Prenatal exposure to methadone may result in reduced head circumference and lower birth weight.

Management A team approach to the care of the pregnant woman with substance abuse problems ensures the management necessary to provide safe labor and birth for the woman and her child. The management of drug addiction may include hospitalization if necessary to start detoxification. Urine screening is also done regularly throughout the pregnancy if the woman has a known or suspected substance abuse problem. This testing helps to identify the type and amount of drug being abused.

 Little is yet known about the effects of MDMA on pregnancy. However, the timing of ecstasy used by the pregnant woman during fetal brain development may be critical issue. Infants exposed to ecstasy in utero may experience some of the same risks as infants exposed to other amphetamines during pregnancy, including the possibility of withdrawal like symptoms such as drowsiness, jitteriness, and breathing problems.

IV. HIV/AIDS Human immunodeficiency virus infection is one of today s major health concerns. It leads to a progressive disease that ultimately results in acquired immunodeficiency syndrome (AIDS). Women account for about 18% of cases in the U.S.

Pathophysiology HIV-1 enters the body through: Blood Blood Products Or other body fluids such as semen, vaginal fluid and breastmilk It affects T-cells, thereby decreasing the body s simmune responses. This makes the affected person susceptible to opportunistic infections such as Pneumocystis carinii

 Once infected with the virus, the individual develops antibodies that can be detected with the enzyme-linked immunosorbent assay (ELISA) & confirmed with the Western Blot test. Can be detected within 6 mos after exposure. Asymptomatic lasting from a few mos to as long as 17years. Diagnosis of AIDS is made when a person is HIV positive & has one of several specific opportunistic infections.

 Maternal Risks Many women who are HIV positive choose to avoid pregnancy because of the risk of infecting the fetus &the possibility of dying before the child is raised. Women who become pregnant should be advised that pregnancy is not believed to accelerate the progression of HIV/AIDS, that the use of antiretroviral (ARV)therapy during pregnancy significantly reduces the risk of transmitting the HIV-1 to the fetus, and that most medications used treat HIV can be taken during the pregnancy. Fetal-Neonatal Risks HIV/AIDS may develop in infants whose mothers are seropositive, usually due to perinatal transmission. Perinatal transmission occurs transplacentally, at birth when the infant is exposed to maternal blood and vaginal secretions, via breastmilk.

 Management Combination of ARV therapy suppresses viral replication, helps preserve immune function, and reduces the development of resistance. Usually consists of two nucleoside analogues reverse transcriptase inhibitors and a protease inhibitor Zidovudine (ZDV) is perhaps the best known of the nucleoside analogues

 Pregnant women who are currently on ARV therapy should continue their providerrecommended regimen and should receive regular, careful monitoring for pregnancy complications and possible toxicities. Because the fetus is most susceptible to teratogenic effects during the first 10 weeks of pregnancy, and the risks of ARV therapy is not well known, women in 1st trimester might elect to delay therapy until after 12weeks gestation.

 To reduce the risk of perinatal transmission, all pregnant women with HIV infection should be offered the three-part ZDV prophylaxis regimen beginning after the first trimester. This regimen includes: 1.Oral ZDV daily 2.Intravenous ZDV during labor until birth 3.Oral ZDV for the infant starting 8 to 12 hours afterbirth and continuing for 6 weeks.

 At each prenatal visit, asymptomatic, HIV infected women are monitored for early signs of complications, such as weight loss in the second or third trimester or fever. Each trimester the woman should have a visual examination and examination of the retina to detect such complications as toxoplasmosis. In addition to routine prenatal testing, the woman who is HIV positive should be assessed regularly for serologic changes indicating that HIV/Aids is progressing

 A pregnancy complicated by HIV infection, even if asymptomatic, is considered high risk, and the fetus is monitored closely. Women who are HIV positive are at increased risk for complications such as intrapartal or postpartal hemorrhage, postpartal infection, poor wound healing and infections of the genitourinary tract. Thus, they need careful monitoring and appropriate therapy as indicated. HIV positive woman should be cautioned againstbreast feeding her infant