01.2 Pregestational Conditions

CARE OF MOTHER AND CHILD SEM 02 | 01
LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON
NCM 0109 MODULE 01.2 – HIGH-RISK PRENATAL CLIENT (PREGESTATIONAL CONDITIONS)

● Done to provide sufficient levels of glucose
OUTLINE to the fetus
I Pregestational Conditions ● This resistance to or destruction of insulin is
A Diabetes Mellitus helpful in a healthy pregnancy as it
B Substance Abuse
C Human Immunodeficiency Virus prevents the patient’s blood glucose from
D RH Sensitization falling to dangerous limits
E Anemia ● Patients with DM are not candidates for oral
F Pregnancy-induced Hypertension
contraceptives and IUD
○ Prone to infections (UTI), candidiasis, and
PREGESTATIONAL CONDITIONS fungal infections
○ Progesterone may interfere with insulin activity
A. DIABETES MELLITUS → increased blood glucose
● A pure progesterone pill antagonizes insulin
● Endocrine disorder in which the pancreas cannot ○ Glucose in the urine is a good medium for
produce adequate insulin to regulate glucose levels microorganisms to thrive
○ GESTATIONAL DIABETES MELLITUS: any degree ○ Insertion of IUD is invasive → risk for
of glucose intolerance or abnormal glucose contamination/wound = slow wound healing
metabolism with the onset/first recognition ○ Can increase blood glucose
occurring during pregnancy
○ When is insulin released?
● ❓ IS IT POSSIBLE TO BECOME DIABETIC DURING
PREGNANCY EVEN THOUGH YOUR BLOOD GLUCOSE
● When the sugar level of the blood is high, LEVELS ARE NORMAL PRE-PREGNANCY?
insulin is released to regulate blood glucose ○ Yes. Less than 5% (2–3%) of patients who are
level and absorb blood sugar towards the non-diabetic pre-pregnancy develop GDM.
cell in order to release energy ○ However, the signs and symptoms of GDM are
● Ang pagkain ng cell ay ang sugar na not permanent and would fade at the end of
kinakain mo; ipapasok ng insulin yung pregnancy, but there is still a 50–60% chance of
sugar in the blood papunta sa cell so the developing Type 2 DM later in life.
cell can utilize it as a form of your energy
● If hindi makakapasok ang sugar from the MAJOR EFFECTS OF GESTATIONAL DIABETES MELLITUS
blood towards the cell, the cells cannot be
MATERNAL RISKS
utilized and would get hungry always
EFFECT PROBABLE CAUSE
● Usual concern is hyperglycemia
○ Sugar would be accumulating in the blood Hypertension
Renal and vascular impairment;
GOAL OF TREATMENT and/or
● vessels are vasoconstricted
preeclampsia
○ Controlling balance between insulin and blood
glucose to prevent hyper/hypoglycemia As the urine of pts with GDM is
sweet, there is an increased
● Bakit may hypoglycemia? UTI
bacterial growth in nutrient-rich
○ Pregnant clients with GDM need to
increase their insulin dosage to prevent urine
hyperglycemia. However, due to the ● Uncontrolled hyperglycemia or
constant use of glucose by the fetus, infection
● Body becomes acidic due to
there is a risk for hypoglycemia and Ketoacidosis
the presence of ketones
ketoacidosis (byproduct fat and protein
● WHY DOES GDM HAPPEN? metabolism)
○ Resistance to insulin: caused by effect of Labor
● Hydramnios d/t fetal osmotic
maternal hormones (HPL, catecholamines, dystocia/obstru
diuresis caused by
cortisols, progesterone, etc.) on beta cells of the cted delivery,
hyperglycemia (may cause
pancreas CS, uterine
atony)
atony
● When the stress hormone cortisol is ● Kapag mataas ang sugar level
(insufficient
released, blood sugar elevates ni fetus, lagi siyang iiihi, then
uterine
the urine would go in the
contraction)
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MODULE 01.2 – HIGH-RISK PRENATAL CLIENT (PREGESTATIONAL CONDITIONS)
with amniotic fluid which ● Encourage breastfeeding if

postpartum contributes to its volume blood sugar levels are
hemorrhage ● Overstretched uterus abnormal
(increased blood sugar = Compensating from poor
polyuria) Polycythemia placental perfusion = hypoxia =
Fetal macrosomia = labor dystocia (increased RBC) increased RBC production making
= CS the blood more viscous
Hematoma and
lacerations ● Breakdown of excessive RBC
D/t dystocia and/or fundal after birth (related to
pushing polycythemia)
FETAL AND NEONATAL RISKS ● Pathologic Jaundice: detected
Hyperbilirubine within 24 hours after delivery
EFFECT PROBABLE CAUSE mia ● Physiologic Jaundice: normal;
may be seen after 3 days of
Hyperglycemia during
delivery; neonate is exposed to
organogenesis
sunlight to break down excess
Congenital ● Prompts hyperinsulinemia and
bilirubin underneath the skin
anomalies excessive growth
● Caudal-regression syndrome: ● Transfer of calcium abruptly
undeveloped lower extremities stopped after birth d/t
decreased parathyroid
● Poor placental perfusion d/t Hypocalcemia
hormone or anoxia
maternal vascular impairment ● Monitor airway or laryngeal
● Post-term deliveries are not spasm (DOB; high-pitched cry)
recommended (sobrang laki na
Perinatal death
ng fetus = mas maraming Respiratory ● Delayed maturation of lungs d/t
nutrients ‘yung need despite distress preterm delivery or cortisol
narrowing of blood vessels; syndrome release
baka mamatay ‘yung baby)
● Stimulates production of insulin I. ASSESSMENT
(hyperinsulinemia) to
metabolize carbohydrates
● Insulin stimulates production of CLASSIFICATIONS OF DIABETES MELLITUS
growth hormone TYPE 1
● Once the fetus detects na
mataas ang sugar level ni ● A state characterized by the destruction of the
Macrosomia beta cells in the pancreas that usually leads to
mother, the fetus can produce
(4000g) absolute insulin deficiency (zero production).
its own insulin
● The fetus is not dependent on ● Immune-mediated diabetes mellitus results from
the maternal insulin autoimmune destruction of the beta cells.
● Lahat ng sugar na na-receive ● Idiopathic type 1 refers to forms that have no
ng baby mula sa mother, known cause.
ipapasok ng fetal insulin sa ● MANAGEMENT: Dependent on the administration
fetal tissues and cells of synthetic insulin
Intrauterine TYPE 2
growth Maternal vascular impairment =
● A state that usually arises because of insulin
retardation poor placental perfusion
resistance combined with a relative deficiency
(IUGR)
(not enough) in the production of insulin.
Preterm labor
Overdistention of uterus ● MANAGEMENT: Dependent on oral hypoglycemic
and/or PROM agents and synthetic insulin together with diet and
● Macrosomia and shoulder exercise
dystocia (hindi makakagalaw
Birth injury nang maayos kasi masyadong GESTATIONAL DIABETES
malaki) ● A condition of abnormal glucose metabolism that
● Large fetal size arises during pregnancy
● Neonatal hyperinsulinemia ● Possible signal of an increased risk for type 2
after birth diabetes later in life
● The baby is already in the
extrauterine environment but IMPAIRED GLUCOSE HOMEOSTASIS
Hypoglycemia ● A state between “normal” and “diabetes” in which
their body still produces too
much insulin, kaya lang, wala the body is no longer using or secreting insulin
ng sugar coming from the properly
mother ● Impaired fasting glucose: a state when fasting
plasma glucose is at least 110 but under 126 mg/dL
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● Impaired glucose tolerance: a state when results of ● History of polycystic ovary syndrome
the oral glucose tolerance test are at least 140 but ○ Insulin production is affected (development of
under 200 mg/dL in the 1-hour sample insulin resistance)
● History of abnormal glucose tolerance
A. GENERAL ASSESSMENT
● Family history of diabetes (one close relative or two
distant ones; first-degree relative)
MATERNAL HYPOGLYCEMIA
● Member of a population with a high risk of diabetes
○ Native American, Hispanic, and Asian descent
● Shaking/tremors (sympathetic nervous system
● Presence of glucose in urine [(+) glycosuria]
stimulation; converts glycogen to glucose)
● >36-day menstrual cycle (due to PCOS; hormonal
● Sweating
imbalance; increased progesterone level)
● Pallor and cold, clammy skin
● High dietary fat intake
● Disorientation, irritability, and headache
● Low levels of physical activity (blood sugar
● Hunger
decreases with exercise)
● Blurred vision
● Type 1 Diabetes and multiple gestation = high-risk
pregnancy
MATERNAL HYPERGLYCEMIA
● Fatigue (dahil kumain siya nang kumain, kulang na C. SIGNS AND SYMPTOMS
yung insulin kaya nasa blood lang yung sugar, thus
● HYPERGLYCEMIA
there’s inability to absorb energy because of lack of
○ Insulin insufficiency
insulin)
○ Elevation of serum glucose
● Flushed, hot skin
● Normal: 80–120 mg/dL
● Dry mouth and excessive thirst (dahil ihi nang ihi,
● Danger: 150 mg/100 mL
nade-dehydrate and then iinom rin nang iinom)
○ Presence of human placental lactogen (HPL)
● Frequent urination (polyuria; nilalabas yung excess
and high levels of maternal hormones may
sugar/glucose [solute] through urine)
cause the woman to develop an insulin
● Rapid, deep respirations and acetone breath (fruity
resistance
or acetone-smell breath d/t ketoacidosis)
● The body would try to look for other sources
○ When fats are digested, the end product is
of glucose; there is high glucose level
ketones and fatty acids. These would be
because of resistance
dispersed in the bloodstream, then the patient
○ Ketoacidosis due to fat breakdown
would have acidosis. This will signal the
● Nabe-breakdown ‘yung fat kasi hindi
respiratory system and the pt would have rapid,
nagagamit ng body ‘yung glucose d/t
deep respirations to eliminate excess acid
insufficient insulin production
● Drowsiness and headache (gutom ang brain cells
● RESULT: Increased serum glucose levels
dahil walang sugar na papasok because of lack of
○ Nag-i-increase siya kasi hindi available
insulin)
‘yung insulin
● Depressed reflexes (lack of sugar = mabagal ang
● GLYCOSURIA
reflexes natin)
○ COMPENSATORY MECHANISM: kidneys begin to
excrete quantities of glucose in the urine in an
B. RISK FACTORS
attempt to lower serum glucose levels
● Obesity (BMI 25–40) ○ Occurs when serum glucose level rises to 150
○ Increased risk for thromboembolic events mg/100 mL
○ Too much fat in the body ○ NOTE: In all pregnancies, the glomerular filtration
● Age over 25 years of glucose is increased (the glomerular excretion
● History of macrosomic/large babies (10 lb or more) threshold is lowered), causing slight glycosuria
● History of previous birth outcomes often associated ● POLYURIA
with GDM (e.g., neonatal macrosomia, maternal ○ Increased urination due to polydipsia
HPN, fetal death) ○ Osmotic action of glucose in the urine decreases
● History of unexplained fetal loss or death fluid absorption in the kidneys
● History of congenital anomalies in previous ● Causes large quantities of fluid to be lost in
pregnancies urine (polydipsia)
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○ METABOLIC ACIDOSIS: release of potassium and ● As cells die, they release potassium and
sodium due to cell death sodium, which is lost from the body in the
extensive polyuria
1 Osmotic action due to glucose in the urine ● VASCULAR NARROWING
○ Long-term effects
2 Large quantities of fluid are lost in the urine ○ Leads to kidney, heart, and retinal dysfunction
Patient becomes dehydrated, causing ● Has decreased blood flow to the kidneys
3 lower plasma serum levels (depletion of ● Higher blood flow = increased urine output
fluid volume) ● Lesser blood flow = decreased urine output
Increased hematocrit levels (lower plasma ● If the kidneys continuously compensates in
4 levels increase the ratio of red blood cells eliminating the sugar level, it affects the
to blood volume) filtration rate
Since there is not enough fluid in the body, ● INCREASED BLOOD PRESSURE
5 blood volume and blood flow decrease as
well II. DIAGNOSIS
6 No blood circulating = no oxygen
Anaerobic metabolism = increased lactic ● PROCEDURE
7 acid (contributes to acidosis) ○ A blood sample is taken
○ Blood is put on a monitor to check glucose levels
● POLYDIPSIA ○ If glucose levels are too high, insulin is
○ Excessive thirst administered; if glucose levels are too low,
○ Can lead to dehydration d/t polyuria carbohydrates are ingested
● POLYPHAGIA ○ Fasting is done for 8 hours and not exceeding 12
○ Eating excessive amounts of food hours
○ Tissue breakdown; cells do not use blood ● Do not drink or eat until kinuhanan ka na ng
glucose (d/t insufficient insulin production) dugo
● WEIGHT LOSS
○ Use of fat and muscle for energy DIAGNOSTIC VALUES
○ Since sugar cannot be used for energy FBG 2-HR POST-
metabolism, fats and proteins are used instead (Fasting Blood PRANDIAL NON-FASTING
Glucose) (after eating)
● METABOLIC ACIDOSIS
○ Blood pH is lowered and occurs because of 2 <95–100
NORMAL <120 mg/dl
mg/dl
phenomena
○ Breakdown of fat and protein stores for energy = PRE- 101–125
DIABETIC mg/dl
vascular narrowing
● FAT METABOLISM FOR ENERGY: levels of DIABETIC >126 mg/dl >200 mg/dl
glucose present in the bloodstream cannot
be readily used by the body as a source of BLOOD GLUCOSE MONITORING
energy. Fat is then metabolized from fat
sources to produce energy causing an ● Fingerstick technique
outpour of large amounts of ketone bodies ● One of their fingertips serve as the site of lancet
and fatty acids in the bloodstream puncture
● LACTIC ACID PRODUCTION: dehydration ○ Place a drip of blood on the test strip
causes concentration of the blood serum, ○ Insert strip into glucose meter and determine
consequently resulting in an overall glucose level
decrease in the blood volume. With the ● NURSING RESPONSIBILITIES
reduced blood flow, cells do not receive ○ Wash hands before puncturing
adequate oxygenation and the body resorts ○ Hanging arm down for 30 seconds but DO NOT
to anaerobic metabolism massage
○ Protein metabolism is also involved in metabolic ○ Use sides of fingers instead of ends to decrease
acidosis sensation of pain
● Protein stores are tapped in a final attempt ○ Wipe away the first drop of blood as it might
to find a source of energy = reduced supply contain tissue fluid and debris
of protein to cells = cell death
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ORAL GLUCOSE CHALLENGE TEST ● Decreased consumption of food: during the

first trimester, the fetus uses too much
● No fasting glucose for rapid cell growth but the mother
● Done at 24–38 weeks AOG to check for risk of GDM consumes less food (d/t morning sickness)
● Confirms diagnosis of diabetes in clients who have ● Increased estrogen and progesterone: these
a fasting serum glucose of 126 mg/dL or above, or a hormones stimulate normal insulin
non-fasting serum glucose of 200 mg/dL or above production
● PROCEDURE ○ NOTE: Since both ‘yung nag-i-increase,
○ A client ingests a 50-g glucose load; serum normal insulin production takes place.
glucose is determined after 1 hour Hindi lang kasi progesterone. Mayro’ng
○ If result at 1 hour is >140 mg/dL, client is gumaganang insulin naturally.
scheduled for a 100-g, 3-hour fasting glucose ● Decreased hPL (released by the placenta)
tolerance test and prolactin (insulin antagonists pero dahil
● Venous blood sample is then drawn for konti pa lang sila, it would not affect much
glucose determination the normal insulin level)
○ LATE PREGNANCY: higher synthetic insulin
SUBSEQUENT SERUM GLUCOSE ● Increased glucose used by woman and fetus
FASTING (rapid growth)
PREGNANT GLUCOSE LEVEL (mg/dl)
HOURS ● Increased hPL from placental maturation
Fasting >95 (antagonists)
1 hour >180
ADMINISTERING INSULIN
2 hours >155
3 hours >140 ● Diet aside from insulin administration
If after 1, 2, and 3 hours, 2/4 abnormal blood samples ● STARTING INSULIN DOSE
are abnormal OR fasting value is >95 mg/dl, the client ○ 2/3 of the amount is given in the morning
is (+) GDM ○ 1/3 is given in the evening
● Be certain a woman is using an injection technique
GLYCOSYLATED HEMOGLOBIN (HbA1C) for insulin
○ Use subcutaneous route (no need to aspirate;
● Detects the degree of hyperglycemia by reflecting
abdominal area is discouraged especially during
the average glucose level over the past 4–6 weeks
last trimester of pregnancy)
● Measures the amount of sugar attached to the
○ The woman should maintain a consistent rotating
hemoglobin
injection routine
● The upper normal level of HbA1C is at 6% of total
○ An insulin syringe has an orange cap
hemoglobin; a value higher than this indicates
● Administered 30 minutes before meals such as
diabetes
during breakfast in a ration of 2:1 (intermediate to
○ ↑ glucose attached to hemoglobin = ↑ blood
regular) and again before dinner in a ratio of 1:1
sugar
● Advise client to eat immediately after administration
of regular insulin kasi babagsak ‘yung glucose level
III. MEDICAL MANAGEMENT
● Use a 90-degree angle since insulin syringes have
short needles
● Before insulin was produced synthetically in 1921,
people with type 1 diabetes died before reaching
childbearing age, were subfertile, or had
spontaneous miscarriages early in pregnancy
INSULIN ADMINISTRATION
● Gold standard for management of diabetes

● Short-acting (regular) insulin combined with
intermediate type
● REASONS FOR HIGH/LOW INSULIN LEVELS
○ EARLY PREGNANCY: lower synthetic insulin
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● Avoid use of oral hypoglycemic agents (OHA); these
can cross the placenta and teratogenic ACTION
TYPE/
TIME ONSET
PEAK AND
APPEARANCE DURATION
DRAWING INSULIN Before After

breakfas mealtime
● Inject air to intermediate insulin (neutral protamine Regular t (2–3
Short 1/2–1
hagedorn) first, then to regular insulin (Humulin R) insulin hours)
acting hour
[clear]
● Insulin is drawn from regular insulin first, then from Duration:
Evening
intermediate insulin 3-6 hrs
NURSING RESPONSIBILITIES After

Before
lunch
breakfas
● Do not administer cold insulin (4–10
t
○ Causes pain and irritation hours)
Intermediat
○ Warm at room temperature e insulin/ Next day
● Do not freeze but keep it away from heat and Interm NPH before
2–4
sunlight as it may lose its potency ediate (Neutral breakfast
hours
● Rotate injection sites or administer them 1 inch apart acting Protamine (4–10
Hagedorn) hours)
○ Prevents lipodystrophy and formation of scar Evening
[cloudy]
tissue
○ Not on the arm Duration:
● Insulin Leakage 10-16 hrs
○ Tissue pinch causes insulin leakage from
subcutaneous tissue
● Release pinch upon insertion of needle INSULIN PUMP THERAPY
● Stretch skin tight (taut)
○ SQ (insulin absorbed more slowly; gradual ● Mimics healthy pancreas
lowering of the blood sugar) ● Continuous subcutaneous insulin infusion; more
● Regular insulin: only insulin which can be comfortable
given through SQ and IV infusion ● Given to patients if diet and exercise is no longer
● Do not inject into the muscles as the working
medication can be absorbed more rapidly ● Automatic pump (cellphone) + syringe of regular
and would lead to sudden hypoglycemia insulin in pump chamber → small gauge needle
○ Inject insulin slowly (2-4 seconds) to allow tissue implanted into SC tissue of woman’s thigh/abdomen
expansion and minimize pressure, causing insulin → day and night continuous infusion (1 unit per hour)
leakage
○ 90 degree angle (insulin syringe have short
needles) but 45 angle if using a regular syringe
○ Withdraw needle quickly to prevent formation of
track that permits insulin leakage
● Do not aspirate since there is little to no blood
vessels on the subcutaneous areas of the body
● Help the woman plan her day based on the time
interval her insulin takes to reach its peak
○ Alert them of the time of day when they are most
suitable to hypoglycemia
○ Make sure to immediately eat after injecting NURSING RESPONSIBILITIES
short-acting or regular insulin
● Fast-acting; reaches onset/peak ● Site cleaned daily and covered with sterile gauze
immediately ● Site changed 24–48 hours
● TWO ORAL HYPOGLYCEMIC AGENTS WHICH CAN BE ○ Also replaced/changed if misplaced or exposed
AN ALTERNATIVE FOR INSULIN IN TREATING GDM to outside environment
○ Metformin: biguanide ● The pump should not get wet
○ Glyburide: non-sulfonylurea
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○ Remove complete apparatus if going for a swim ○ Prevents contamination from skin debris and
or taking a bath tissue fluids
○ Should not be disconnected for more than 1 hour
● Check if pump is delivering insulin by monitoring NURSING RESPONSIBILITIES
blood glucose
○ Monitor blood glucose 4x/day ● Wash hands before puncturing the finger
● Ex. if magfa-fasting sa gabi, take the blood ● Hang arm down for 30 seconds to increase blood
glucose sa umaga, then 1 hour after each flow to the finger and to prevent infection
meal ● Instruct the woman on how to do blood glucose
● PATIENTS WITH HYPOGLYCEMIA monitoring using finger stick technique
○ Provide a glass of milk and crackers ● If a woman discovers an elevated blood glucose
○ Do not give orange juice with complex level, she should assess her urine for ketones and
carbohydrates (rice, pasta, noodles, potatoes, inform her healthcare provider
cassava, oats) as these will cause rebound ○ Acidosis in pregnancy leads to fetal anoxia
hypoglycemia (easily spike blood sugar level) because of inability to use oxygen while maternal
○ Give 1 tbsp of honey cells are acidotic
BLOOD GLUCOSE MONITORING IV. ADDITIONAL MONITORING

TESTS FOR PLACENTAL FUNCTION AND FETAL
● To determine whether hyperglycemia or
WELL-BEING
hypoglycemia exists
● The patient is usually subjected to finger stick ● ALPHA-FETOPROTEIN LEVEL
technique
○ Assess for neural tube defect; done at 15–17
● Instruct the patient on how to do blood glucose weeks
monitoring using finger stick technique
○ Those with GDM have a higher risk of fetal or
○ Hypoglycemia: ingest some form of sustained congenital anomalies
carbohydrate
● ULTRASOUND
○ Hyperglycemia: assess her urine for ketones and ○ Detects gross abnormalities, and determines fetal
inform her healthcare provider growth; done at 18–20 weeks gestation
● Acidosis in pregnancy leads to fetal anoxia because ○ Repeated 28 weeks (7 months)
of inability to use oxygen while maternal cells are
○ Repeated again at week 36-38
acidotic
● Checks for the growth (macrosomia), AF
volume (fluid shift = fetal polyuria =
PROCEDURE
hydramnios), placental location (abruptio
placenta), biparietal diameter of the fetal
● Twist the round object to open the lancet
head (appropriateness of weight to AOG; a
● Open the top portion of the pen then attach the
mature fetus has a 9.5-9.8 cm
lancet. Secure it with the cap afterwards.
measurement)
● Note the number attached to the pen.
○ ABNORMAL HYDRAMNIOS
○ The higher the number, the deeper the prick =
● Oligo: little amount of amniotic fluid; there
fast release of blood in the finger
might be fetal growth restriction/fetal renal
● #4–#5 is usually used for those with thick
abnormality
layers of skin
● Poly: large amounts of AF; GI tract
○ Always start with #1
malformation/poorly controlled disease
● Retract the part of the pen to push the lancet
○ The baby might have a
● Ask the client to wash their hands
tracheoesophageal fistula (esophagus
● Put cotton and wipe the area in a circular motion
does not open or is cut off kaya sa
● Once the finger is dry, insert the strip in the
pag-swallow niya ng AF, it cannot reach
glucometer and wait for it to load
the fetal abdomen, then babalik ulit yung
● Prick the side of the tip of the finger
swinallow niyang fluid sa original volume
○ This area is recommended since the topmost tip
ng AF, thus contributing to the large
causes more pain d/t presence of nerve endings
amount of AF)
● After pricking, wipe the first blood with clean cotton
● CREATININE CLEARANCE TEST
ball
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○ May be ordered each trimester ● Do not induce labor (hindi na pinatatagal
○ Normal: 0.7-1 mg/dL kasi lalong lalaki ‘yung fetus)
○ A normal creatinine clearance test suggests that ○ The membranes are artificially ruptured and
a woman’s vascular system is intact, normal oxytocin is administered to stimulate
kidney functioning, and uterine perfusion is contractions, leading to cervical ripening
adequate ○ DYSTOCIA: since the baby is macrosomic, there
● NST WEEKLY OR BPP DURING THE LAST TRIMESTER might be difficulties in fetal delivery
○ To assess placental functioning ○ NURSING RESPONSIBILITIES
● DAILY FETAL MOVEMENT COUNT ● IV infusion of short-acting or regular insulin
○ 10–12 movements per hour with frequent blood glucose assays
○ Repeated for the next hour if <10 movements are ● Monitor labor contractions and FHT
recorded; proceed with reporting to HCP if <10 ● IV fluid infusion (LRS or PNSS: isotonic solution;
movements are still noted walang D5 kasi ‘yon ‘yung sugar)
● LECITHIN-SPHINGOMYELIN RATIO BY AMNIOCENTESIS
○ Determines fetal lung maturity POSTPARTUM ADJUSTMENT
● Elevated maternal blood glucose delays fetal
lung maturation d/t absence of surfactant ● NORMALIZATION OF GLUCOSE LEVELS
stabilizer (phosphatidylglycerol), which ○ After delivery, maternal glucose levels usually
prevents lung collapse/total lung recoil, return to normal which is why OHAs and insulin
resulting in delayed surfactant production (LS are not administered 24 hours after birth
Ratio remains at 1:2, signifying immaturity) ● Careful administration of insulin may be done
○ Corticosteroids are used to hasten fetal lung as recommended
maturity among premature infants but it is NOT ● DM PRE-PREGNANCY
recommended because it impairs release of fetal ○ A woman who came into pregnancy with
insulin (insulin antagonists) diabetes must undergo another readjustment of
● They also have altered glucose metabolism, if insulin regulation
given, altered metabolism would exacerbate ● Risk (50-60%) for developing Type 2 DM later
● Promotes hyperglycemia in life
○ Week 36: delayed production of ○ Nawawala na ‘yung symptoms pero at
phosphatidylglycerol for LS stabilization risk pa rin sila
● It is expected that L:S ratio is present even if ○ Monitor blood glucose level
the baby is less than 35 weeks ● BREASTFEEDING: may be done because insulin is not
○ Assess fetal maturity expressed in the breast milk
● LS Ratio is 1:2 (abnormal/immature) ● HYDRAMNIOS: monitor closely since uterine
● They are called “fragile giants” because they contraction is poor, increasing risk for hemorrhage
are big (macrosomic) but they are at risk for (check for bleeding)
RDS (immature fetal lungs)
V. NURSING MANAGEMENT
TIMING FOR BIRTH (Possible Nursing Diagnoses)
● Individualized for the patient based on assessment ● Risk for ineffective tissue perfusion related to
results (e.g., NST) reduced vascular flow
● VAGINAL BIRTH: preferred method of delivery ○ GDM affects the micro- and macro- vascular
○ WHY? Cesarean birth poses higher risks. system
● Might exacerbate hyperglycemia d/t cortisol ● Imbalanced nutrition, less than body requirements,
release related to inability to use glucose
● CS birth is still possible but must be done at ○ Kahit na kumain sila, hindi nagagamit ‘yung
37 weeks to prevent fetal loss/death d/t sugar kasi wala/kulang ‘yung insulin
placental insufficiency ● Risk for ineffective coping related to required
○ Not done during 36-40 weeks, except at change in lifestyle
37th week, because the baby is drawing ○ Constant monitoring and diet modifications are
up large amount of maternal nutrients due necessary as it is not curable
to its large size, leading to complications ● Risk for infection related to impaired healing
accompanying conditions
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○ High glucose in blood makes it viscous which ● Mothers are most vulnerable to
results in poor wound healing (mabagal or hindi hypoglycemia at night because of
kaagad nakakapag-circulate ‘yung blood kasi continuous fetal use of glucose during sleep
masyado siyang thick) time
● Deficient fluid volume related to ○ Allow slow digestion during the night
polyuria-accompanying disorder ● Foods recommended include: rice, breads,
○ Ihi nang ihi yung patient oats, spaghetti, cassava, potatoes, egg, whole
● Deficient knowledge related to difficult and complex grain toast, hummus, and whole grain
health problems crackers
○ Affects multiple organ systems
○ Most people die because of DM complications EXERCISE DURING PREGNANCY
and not of DM itself
● Health seeking behaviors related to voiced need to ● DECREASE IN BLOOD GLUCOSE LEVELS: exercises
learn home glucose monitoring lower blood sugar, therefore decreasing the need for
○ Poorly monitored glucose level: must monitor at insulin
least 4x a day ○ Also helps with weight control, glucose
● Risk for injury related to possible complications metabolism, cardiopulmonary benefits
secondary to hypoglycemia or hyperglycemia ● HYPOGLYCEMIA DURING EXERCISE: prevented by
○ Abnormal blood glucose affects ability to do ADLs eating a snack consisting of protein or complex
(e.g., fatigue, depressed reflexes, etc.) carbohydrate
● Interrupted family processes related to the need for ○ Muscles increase their need for glucose (energy)
hospitalization secondary to diabetes mellitus during exercise
● ADDITIONAL REMINDERS
VI. PATIENT EDUCATION ○ Maintain a consistent exercise program (e.g. daily
30-minute walking)
NUTRITION DURING PREGNANCY ● Extreme exercise will cause hyperglycemia
and ketoacidosis
● DIETARY CONTROL ○ Uterine Contractions: stop walking, drink 2–3
○ Maintaining adequate glucose intake: prevents glasses of water (hydration stops contractions),
hypoglycemia and rest in a side-lying position for 1 hour
○ Reduced amount of saturated fats and ● If persistent even after an hour, call HCP
cholesterol (difficult to digest), and increased
fiber
B. SUBSTANCE ABUSE
○ Becoming nutrition-conscious individuals
● Keep weight gain at 25-30 lbs to limit size of ● 20-30% of pregnant women use illegal drugs during
fetus and make NSD possible pregnancy
● Food intake should not be less than 1800 ● Inability to meet major role obligations, increase in
calories (magkakaroon ng fat breakdown → legal problems or in risk taking behavior
ketoacidosis) (stealing/killing), or exposure to hazardous situations
● CALORIES because of an addicting substance
○ 1800–2400-calorie diet divided into 3 meals and ● RISK FACTOR: Younger age group
3 snacks (20% CHON, 40–50% CHO, 30% fats; 30
kCal/kg) SUBSTANCES
● BMI >30 = 25 kcal/kg (weekly monitoring of
CAFFEINE
ketonuria) (coffee, cola, chocolate, cold remedies, analgesics;
● EATING PATTERNS one cup/day is allowed)
○ Nausea, vomiting, heartburn: may be unable to MATERNAL EFFECTS FETAL EFFECTS
eat; inform HCP immediately to start IV infusion of
● Stimulates CNS ● Crosses placental
glucose and fluids
(tremors and barrier and stimulates
○ Night snacks: encourage CHON and complex
anxiety) and cardiac fetus
CHO at night to prevent hypoglycemia, do not
function ● Teratogenic effects are
consume simple sugars from concentrated
(tachycardia) documented
sweets (candy, coke, cookies, juice)
NCM 0109|9
● Vasoconstriction and
mild diuresis
TOBACCO
(nicotine, tar, carbon monoxide, even cyanide)
● 30% prematurity
● 200g > LBW and length
○ Smoking could alter
● Low maternal the food intake
perfusion = ● Neurodevelopmental
decreased blood problems
flow = decreased ○ Carbon monoxide MARIJUANA
oxygen = fetal can attach to (reduced milk production and excretion of drug into
distress hemoglobin and breast milk)
● Decreased oxygen
● Abruptio Placenta displaces the
available to fetus ● Neurobehavioral
● Placenta Previa oxygen =
● Do not breastfeed; problems (tremors,
● Anemia (tar) decreased oxygen
expressed in breast sleep disturbances)
● PROM to mother and baby
milk
● Preterm labor ○ 20x faster than
COCAINE
● Spontaneous oxygen in attaching
(short-acting stimulant)
abortion to hemoglobin
● Hyperarousal state
● 1.4-3x die due to SIDS ● Euphoria
(Sudden Infant Death
● Generalized
Syndrome) vasoconstriction ● Hypoxia, pulmonary
ALCOHOL (HPN, Tachycardia) edema
(beer, wine, mixed, after-dinner drinks; easily crosses
placental barrier) ● Increased STIs r/t ● Tachycardia
● Fetal demise hyperarousal state ● Stillbirth
● IUGR (baby is smaller (Prostitution) ● Prematurity
than normal) ● Increased ● Irritability
● FASD ([fetal alcohol spontaneous ● Sleep followed by
spectrum disorder] abortion agitation
physical and mental ● Abruptio placenta ● Poor response to
abnormalities) (vasoconstriction of comforting or
● FAS placental vessels) interaction (unusual
● Spontaneous ● Pre-eclampsia agitation)
(neurodevelopmental
abortion ● PROM, preterm labor, ● Long-term: possible
disorder = growth
● Abruptio placenta precipitous delivery attention and
restriction, CNS
● Malnutrition due to induced language problems
impairment, facial
(interferes with folic uterine contractions
features)
acid and thiamine ● Anemia
○ CNS = intellectual
absorption) ● Anorexia
impairment,
learning disabilities, AMPHETAMINES AND METHAMPHETAMINES
short attention (long-acting stimulant)
● Increased risk IUGR
span, poor ● Vasoconstriction
(due to poor placental
short-term memory ● Tachycardia
perfusion
○ Facial = ● HPN
[vasoconstriction])
dysmorphic ● Spontaneous
● Prematurity
features abortion
● Cleft palate
● Preterm labor
● Abnormal sleeping
● Abruptio placenta
patterns
● Pre-eclampsia
● Agitation
● Retroplacental
● Poor feeding
hemorrhage
○ Failure to thrive
NCM 0109|10
● Vomiting ● Leads to poor nutrition; they choose drugs

OPIOIDS over food
(heroine, morphine) ● No money to buy vitamins and iron
● Malnutrition supplements
● Anemia ○ Inconsistent follow-through with recommended
● Inc. incidence of STIs care
● IUGR
○ HIV exposure ● Busy doing substance abuse
● LBW
○ Hepatitis ○ Impatient (r/t anger, apathy, and severe mood
● Perinatal asphyxia
● Thrombosis swings)
● MAS (meconium
(hematoma) ● Afraid of withdrawal symptoms
aspiration syndrome)
○ These drugs are ● Excited to take drugs at home
● Fetal/Neonatal death
injected ● PHYSICAL FACTORS
● SIDS
● Cardiac disease ○ Fetal abnormalities and preterm birth
● Child abuse or neglect
● Spontaneous ○ Hepatitis or HIV if method of drug administration
abortion is through IV
● Preterm labor ○ Poor grooming and inadequate weight gain
○ Needle puncture, thrombosed veins (parang may
I. ASSESSMENT namamaga/certain bump), cellulitis
● PSYCHOLOGICAL FACTORS
A. GENERAL ASSESSMENT
○ Defensive or hostile behaviors
○ Anger or apathy regarding pregnancy
● Presence of withdrawal symptoms
○ Severe mood swings
○ Due to sudden stop of using substances
MEDICAL AND OBSTETRIC HISTORY PREVALENT AMONG
WITHDRAWAL SYMPTOMS THOSE WHO USE DRUGS
● Insomnia
● Nausea and vomiting ● Hepatitis, STIs, cellulitis, seizures, hypertension,
● Body aches
● Diarrhea depression, and suicide attempts
● Muscle jerks
● Abdominal pain
● Nervousness ● Check history: spontaneous abortions, premature
● HPN
● Seizures deliveries, AP, stillbirths
● Shivering
● Restlessness
● Check current condition: vaginal bleeding, inactive
or hyperactive fetus, IUGR
● Abandonment of important activities
● Check emotional response: anger, apathy, negative
○ Spending more time with those related to
feelings
substance use
● Check patterns of drug use: occasional, binges
● Using substance for a longer period of time than
planned II. NURSING MANAGEMENT
○ Continued use despite worsening problems (Possible Nursing Diagnosis)
B. RISK FACTORS ● Risk for injury to self and fetus related to chronic
substance abuse
● Women in younger age groups (easily influenced) ● Ineffective health maintenance related to lack of
○ Starts with inhalant use followed by binge knowledge of the effects of substance abuse on self
drinking (nagiging habit na) and fetus
○ Sometimes, the mother is not aware that
C. ADDITIONAL ASSESSMENT substance abuse is harmful to her and her baby
● PRENATAL CARE
III. NURSING INTERVENTIONS
○ Seek care late in pregnancy due to fear of being
deemed unable to care for the child (natatakot
● GENUINE CONCERN
silang mahuli na gumagamit ng drugs)
○ Maintain feelings of concern without becoming
○ Difficulty following prenatal instructions (proper judgmental/punitive to the pregnant woman
nutrition and supplemental vitamins)
● Refer them to HCPs who can help them with
● Failure to keep prenatal appointments their condition
○ Display patience and genuine concern for them
NCM 0109|11
● Huwag nang sabayan ‘yung mood swings ○ If a woman is still abusing a drug by the time she
nila begins labor, her infant may experience
○ Ask about stressors in her life that may be withdrawal symptoms after birth
contributing to her substance abuse ● FETAL EFFECTS
● Develop health education programs to ○ Fetal liver matures faster than normal
manage stressors ● Hyperbilirubinemia rare problem
● Some have poor coping mechanisms ending ○ More mature fetal lung tissue
up to substance abuse ● Even if premature = decreased RDS
○ Allow woman to express guilt ○ Breastfeeding is usually not encouraged for
○ Acknowledge weight problems and concerns women with substance abuse
during prenatal check-ups
● SUPPORT AND GUIDANCE C. HUMAN IMMUNODEFICIENCY VIRUS OR
○ In-service education, professional consultation, ACQUIRED IMMUNODEFICIENCY SYNDROME
and peer support
● Infection with the human immunodeficiency virus
○ Provide anticipatory guidance and nursing
(HIV), the organism responsible for acquired
support all during pregnancy
immunodeficiency syndrome (AIDS), is the most
● Require long time to change lifestyle
serious of the STIs because it can be fatal to both
● Have few effective support people who they
mother and child
can open up
● HIV AND AIDS: They are but one.
○ Encourage to engage in a formal substance
○ Start with the initial symptoms of HIV; if left
abuse treatment program
untreated, it progresses to AIDS
● With good support and active participation
● AIDS: severe, life-threatening syndrome that
● Pregnancy become stimulus for drug
represents the late clinical stage of infection
withdrawal
with HIV
● ADDICTION RECOVERY GROUPS
○ Acquired: neither hereditary nor in-born;
○ Share experiences during drug addiction, what
transmitted from person-to-person
they did to recover, and the reason why they
○ If a patient diagnosed with HIV starts having signs
stopped
of pneumocystis carinii pneumonia (PCP) and
○ New members having a hard time stopping may
kaposi sarcoma, this indicates that it has
adapt the methods used by others
become full-blown AIDS
● PATHOPHYSIOLOGY [HIV]
● Alcoholics
○ The disorder is caused by a slow growing
Anonymous (AA)
● Nicotine Anonymous retrovirus that infects and disables T
● Cocaine Anonymous
(NicA) lymphocytes
(CA)
● Narcotics Anonymous ○ The virus enters the bloodstream, substitutes its
● Heroin Anonymous
(NA) own RNA and DNA for the cell’s DNA, and
(HA)
● Pills Anonymous (PA) replicates in these lymphocytes, destroying them
● Marijuana
in the process
Anonymous (MA)
● Papalitan ang DNA ng T4 cells with HIV RNA
and DNA
● LABOR ROOM
● T4 cells are critical in the immune process
○ Electronic fetal monitoring
○ It results in the loss of CD4 lymphocytes and the
● Monitor contractions, FHT, and movement
ability to initiate effective B-lymphocyte
○ Oxygen therapy
response (T4 cells die)
○ Seizures precaution with cocaine usage
● This consequently affects antibody formation
● Bed in low, locked position
and reduces function of the immune system
● Pad side rails, always up to prevent injury
○ When CD4 count falls below 500 cells/mm3 or the
● Suction equipment (too much saliva would
viral load rises above 5000 copies/mL,
obstruct the airway)
opportunistic infections start to appear
● Reduce environmental stimuli (lights and
○ NOTE: HIV is not curable (no effective means to
noise stimulate seizures, place in dark room)
destroy the virus)
NCM 0109|12
● There are two types of HIV: Type II is less
transmissible and lesser chances of A.2. ASYMPTOMATIC PERIOD
becoming AIDS than Type I
● The only thing you can do is decrease the ● Woman appears to be disease-free except for
viral load/keep it at a minimum symptoms such as unexpected/unexplained weight
● HIV AND PREGNANCY loss and fatigue (wasting syndrome)
○ 2% of 1000 women giving birth are HIV+ ● Virus can be replicating at this time (takes 3–11
○ Pregnancy does not accelerate/exacerbate the years)
progression of the disease
● However, if left untreated, 20-50% of infants A.3. SYMPTOMATIC PERIOD
will develop AIDS in the 1st year of life
● NOTE: Women that are HIV+ but do not ● Women develop opportunistic infections and
receive ART (antiretroviral therapy) have possibly malignancies (e.g., oral and vaginal
15–35% possibility of transmitting the virus to candidiasis, herpes simplex, P.carinii pneumonia.
the infant (maternal-fetal transmission) Kaposi sarcoma, toxoplasmosis, cytomegalovirus)
○ Anti-virals: keeps the viral load at a ○ Opportunistic infections: microorganisms are
minimum (<500 copies/mL); makes the normally present in the body, but causes harm
disease less transmissible when the person is immunocompromised
○ ZDV (zidovudine): administered during the ● Oral and vaginal candidiasis (caused by
14th week with antiviral therapy beginning yeast-like fungi)
with birth ● GI illness (diarrhea)
○ Nevirapine: used to prevent perinatal ● Herpes simplex (mouth sores)
transmission of HIV ● PCP (pneumocystis carinii [present in healthy
○ HIV infection in pregnant women is associated lungs] pneumonia; comes from a yeast-like
with low birth weight and preterm birth fungi)
○ No breastfeeding when in antiretroviral ● Candida esophagitis (fungal infection)
therapy/CS ● Kaposi sarcoma (purplish cancerous tumors
● Latest trends encourage breastfeeding since caused by human herpesvirus 8)
benefits outweigh risk of maternal-child ○ When combined with PCP, the patient
transmission already suffers from full-blown AIDS
● HIV-associated dementia
I. ASSESSMENT ● ↑ VIRAL LOAD AND ↓ CD4 COUNT = RISK FOR O.I.
○ If the viral load is <5000/mL, there is lesser
● Reduced immune system functioning chances for the patient to have opportunistic
○ Without therapy, the infection may progress infections
through the following stages: ○ CD4 count is usually <200 cells/mm3 and has
greater chances for opportunistic infections
A.1. EARLY SYMPTOMS ● Para hindi magkaroon ng OI, dapat higher
‘yung CD4 count
● Early symptoms are more subtle and difficult to
determine; mimics early pregnancy manifestations B. RISK FACTORS
○ Fatigue
○ Anemia ● Multiple sexual partners (sexual intercourse)
○ Diarrhea ○ Increases exposure to body secretions
○ Progressive weight loss ● Bisexual partners
○ Malaise ● IV drug use with shared needles
○ Lymphadenopathy (swollen glands) ○ Common among those who use opioids, heroins,
● Mild flu-like symptoms in the initial invasion of virus or morphines (these are injected into the system)
○ Low-grade fever, joint pain, coughs and colds ● Blood transfusion (rare)
● SEROCONVERSION (6 weeks to 1 year after exposure) ○ Exposure to infected blood
○ Woman converts from having no HIV antibodies ○ Rare because of the screening process in BT
to having detectable antibodies (HIV serum ● Vertical transmission (mother-child transmission;
positive) breastfeeding/placental route)
○ HIV is a slow-growing retrovirus ● Body secretions (semen, vaginal fluids, breastmilk)
NCM 0109|13
○ HIV cannot be passed through saliva (sobrang ● Mataas na CD4 cell count and mababang
baba lang ng presence ng virus sa saliva) viral load ang goal
● Utensils may be shared ● To maintain these levels, take ART
consistently and adequately
ADDITIONAL ASSESSMENT ○ Possible Problems: Hindi nakakapag-take
MATERNAL consistently ‘yung patient kasi masyadong
FETAL SIGNS/SYMPTOMS marami; they get tired of taking the
COMPLICATIONS
● Poor resistance to medications or hindi nasu-sustain d/t
infection (HIV affects financial problems
CD4 cells; impairs ● POLYMERASE CHAIN REACTION — ANTIGEN
immune system) ○ Checks for the level of antigens in the blood
● Fever ● ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) —
● Swollen lymph nodes ANTIBODIES
● Intrapartum and PP ● Recurrent respiratory ○ The most commonly used screening test
hemorrhage tract infection ○ (+) HIV antibodies, test is repeated
● PP infection ● Recurrent GI/GU ● Baka kaya nag-positive sa una kasi may
● Poor wound healing infections existing STI pero ‘di siya HIV
● GU infections ● Oral candidiasis ○ If the screening test is positive, a confirmatory
● Preterm births test such as the Western blot analysis or indirect
● Small for gestational fluorescent antibody test is usually performed
age ● Antigen detection procedures detect an HIV antigen
● Failure to thrive known as p24
● Enlarged spleen and ● WESTERN BLOT TEST
liver ○ Confirmatory test to validate whether the patient
is an HIV/AIDS patient or not
○ Done after 2 (+) ELISA
II. DIAGNOSTIC PROCEDURES
● INDIRECT IMMUNOFLUORESCENCE ASSAY (IFA)
● HISTORY TAKING ○ Checks level of antibodies
○ High-risk sexual behavior ● Specifically checks the antibodies’ ability to
● Multiple sexual partners and unprotected sex react to the antigen on the infected cell
● Other STIs: Syphilis, Gonorrhea, Chlamydia,
Hepatitis B III. MEDICAL MANAGEMENT
○ Dito usually nagsa-start; mayro’n silang
ganito before pa man ma-diagnose with ● Goal of management is to maintain the CD4 cell
HIV count at greater than 500 cells/mm3
○ High risk to develop toxoplasmosis,
cytomegalovirus infections, and TB d/t A. ANTIVIRALS
immunocompromised state
● TORCH infections ● Prevents progressive deterioration of the immune
○ Ask for cat ownership (because of cat system and acts as prophylaxis against
litter) and ingestion of raw meats as these opportunistic infections due to increased CD4 cell
are risk factors count and decreased viral load copies
● History of recurrent TB ● If a child has 2 (-) HIV cultures at 4 months of age =
○ Immunocompromised state puts them at (-) HIV
risk for acquiring TB ● ZIDOVUDINE
○ Ask permission if they can be HIV screened ○ 100 mg 5x/day
● CD4 CELL COUNT/T4 LYMPHOCYTE COUNT (VIRAL ○ Child: 2 mg/kg PO q6 after birth
LOAD) ○ Administered to a woman beginning with the 14th
○ Check how many T4 cells are present and week of pregnancy and the newborn receives the
functioning drug for 6 weeks after birth
○ Normal: >500 T4 cells/mm3 and decrease viral ○ NURSING RESPONSIBILITIES:
load of 5000 copies/mL ● Check for possible adverse effects
○ Nausea, loss of appetite, change in taste,
paresthesia (numbness or tingling
NCM 0109|14
sensation), headache, fever, IV. NURSING MANAGEMENT
agranulocytopenia (severely decreased (Possible Nursing Diagnosis)
WBC), thrombocytopenia (decreased
platelets; possibility of bleeding) ● Risk for infection (opportunistic) related to
● Infuse drug IV over 60 minutes dysfunction of the immune system secondary to
○ Volumetric control chamber is used since invasion of HIV
the drug cannot be infused rapidly ● Risk for compromised family coping related to
● Administer round the clock to sustain diagnosis of HIV infection in child
maximum effect ● Ineffective health maintenance r/t lack of
● SFF to combat loss of appetite and change in information about HIV/AIDS and its long term
taste implications for the woman, unborn child, and family
● Make sure to ensure client safety to prevent
injury (d/t paresthesia) V. NURSING INTERVENTIONS
● TRIMETHOPRIM WITH SULFAMETHOXAZOLE
● Provide health teachings
(BACTRIM)
○ Importance of religiously taking prescribed drugs
○ For clients who develop Pneumocystis carinii
● Prescribed drugs to help prevent
pneumonia
opportunistic infections
○ Take note of possible effects especially if given
○ Mode of transmission and safer sex practices
during the first trimester of pregnancy
● Can still transmit even being treated with
○ Trimethoprim may be teratogenic in early
antivirals
pregnancy; sulfamethoxazole may lead to
increased bilirubin levels in the newborn
ABCDE NG STD AT HIV PREVENTION
(kernicterus)
● Outweigh risks and benefits AYOKO
● ADDITIONAL DRUGS
A
Abstinence
○ Ritonavir (Norvir) or Indinavir (Crixivan): BASTA IKAW AT AKO LAMANG
protease inhibitor B Be mutually faithful with your partner
○ Pentamidine (Pentam): non-pregnant clients
with PCP CONDOMS GAMITIN NANG TAMA AT PALAGIAN
○ Acyclovir (Zovirax): herpes simplex
C Consistent and correct use of condoms
○ Clotrimazole (Mycelex): oral thrush DAPAT PANG-INJEKSYON LAGING BAGO
○ Pyrimethamine (Daraprim) and sulfadiazine:
D Do not use drugs and reuse needles for
toxoplasmosis medication administration
EDUKASYON AT TAMANG KAALAMAN
B. ADDITIONAL MANAGEMENT E Early detection and education
● CHEMOTHERAPY
○ For treatment of Kaposi sarcoma (rare ○ Use of standard precautions to prevent spread of
malignancy that occurs with AIDS) HIV
○ May cause potential fetal injury when used in ● Gloves and gown: body secretions; change
early pregnancy diapers
● PLATELET TRANSFUSION ○ Only remove gloves once maternal blood
is totally removed
○ To restore coagulation ability because of severe
thrombocytopenia (occurs as part of the disease ● Goggles at birth: splash amniotic fluid to
pathology or effect of ZDV therapy) mucous membrane of the eyes
○ Performed when nearing birth ● Avoid blood sampling/injections
○ RISK OF BLEEDING D/T SEVERE LOW PLATELET CT ○ Done only after first bath or once cleansed
from maternal blood
● No epidural injection as anesthesia during
labor ● Frequent handwashing
● No episiotomy ● Avoid close contact between child and
anyone who has respiratory infection
● CESAREAN SECTION BIRTH
(immunocompromised)
○ Decreases maternal-fetal transmission
○ Make sure to follow protocol (double gloving/PPE) ● Bathing the child: warm water/mild soap
bath
NCM 0109|15
● Body fluid spills: household bleach diluted would open the circulation between the
with water 1:10 at least 30 sec mother and fetus
● Avoid fetal exposure to maternal blood ● Pag-form ng second pregnancy, the formed
○ Avoid amniocentesis (invasive) maternal antibodies would now target the
○ Avoid forceps delivery (lesions at fetal scalp) fetal red blood cells
○ Avoid episiotomy ○ WHAT IF THE MOTHER IS RH+ WHILE THE BABY IS
○ Avoid scalp blood sampling RH-?
● During pregnancy and at birth, active interventions ● No reaction will take place since the baby’s
are necessary blood—Rh-—does not contain any D antigens.
● Breastfeeding is avoided (make sure to weigh Therefore, the mother does not have to
benefits and risks) produce antibodies.
○ Transmit HIV
○ Increased risk of mastitis
○ Exhausting debilitated woman
D. RH SENSITIZATION (Isoimmunization)
● Occurs only when an Rh-negative mother is

carrying a fetus with an Rh-positive blood type
○ When an Rh-positive fetus begins to grow inside a
mother who is sensitized, it is as though her body
is being invaded by a foreign agent
● WHAT HAPPENS TO THE BODY?
○ Body of the mother reacts in the same manner it
SUMMARY
would for a virus and bacteria—she would form
antibodies Rh- mother carries Rh+ fetus (Rh+ blood has
● This is because Rh+ blood contains the D
1 Rhesus factor [D antigen], while Rh- blood does
not)
antigen, causing an immune response
As the Rh+ fetus grows inside the Rh- mother,
○ Hemolytic Disease of the Newborn 2 their blood start to mix
(Erythroblastosis Fetalis): these maternal Maternal immune system starts forming
antibodies cross the placenta and cause RBC 3 antibodies against the fetus, the invading
destruction (hemolysis) of fetal RBCs (agad substance
namamatay or nade-destroy ‘yung RBCs) 4 The antibodies cross the placenta
● A fetus can become so deficient in RBCs that
Since the Rh factor is part of the RBC, maternal
sufficient oxygen transport to body cells
cannot be maintained
5 antibodies destroy those without Rh factor =
hemolysis of fetal RBC
● PREGNANCY AND FETAL/MATERNAL BLOOD
Due to lack of RBC, there is a decrease in the
○ During pregnancy, there is no connection
6 amount of oxygen circulating the body (body
between fetal and maternal blood; there is no cells cannot be maintained = HDN
active exchange Since there are already antibodies present,
○ However, during delivery, as the placenta 7 succeeding pregnancies (Rh+ fetus) may be
separates after birth of the first child, there is an harmful
active exchange of fetal and maternal blood
from ruptured villi FETAL EFFECTS
○ WHAT HAPPENS TO THE FORMED ANTIBODIES?
● Most of the maternal antibodies formed ● HEMOLYSIS
against Rh-positive blood occurs in the first ○ Enlarged liver and spleen
72 hours after birth, making it a threat to a ● Happens in an attempt
second pregnancy to destroy lysed RBCs
● Kapag na-deliver na ang first pregnancy, ○ Because there is an
nagkakaroon na ng breakage of the increase in
chorionic villi during placental delivery that erythroblastic
activity, the liver compensates leading to
NCM 0109|16
hepatomegaly and impaired liver function
(na-o-overwork ‘yung liver) B. DOPPLER VELOCITY OF FETAL MIDDLE CEREBRAL
ARTERY
○ Vascular hypertonicity (there is more serum than
blood components) ● Used to predict fetal anemia or destruction of fetal
● Fluid shift: extreme edema RBCs
○ Caused by escape of albumin into ● GOAL: decrease number of maternal antibodies
interstitial spaces, leading to decreased ● MANAGEMENT: administration of Rh immune
oncotic pressure globulin (RhIG) at 28 weeks of AOG
● Congestive heart failure ● RESULTS
○ There is too much workload in the heart, ○ High (increased) artery velocity: no anemia;
increasing its size (cardiomegaly) fetus is likely Rh- (hindi na-a-activate ‘yung
● Hydrops fetalis: fetal; liver swelling maternal antibodies)
(hepatomegaly), ascites, hydramnios d/t ○ Low (decreased) artery velocity: fetus is in
impaired swallowing danger; immediate birth; intrauterine blood
● Anemia infusion (takes place when there is severe
● HYPERBILIRUBINEMIA (bilirubin is not excreted by the anemia but the fetus is still too young to be
system since it is delivered)
indirect/unconjugated)
○ Jaundice within 24 C. DELTA OPTICAL DENSITY
hours of life
(pathologic in nature) ● Determines bilirubin in amniotic fluid
○ Bilirubin-induced ● RESULTS
neurologic damage ○ Decreased: normal
(Kernicterus ○ Increased: hemolysis
(permanent brain
damage); bilirubin moves from the bloodstream II. MEDICAL MANAGEMENT
into the brain tissue)
A. RH IMMUNE GLOBULIN (RhIG; RhoGAM)
● Normal: 3 mg/dl
○ 20 mg/dl in term babies or 12 mg/dl in
● A commercial preparation of passive antibodies
preterm babies lead to kernicterus
against the Rh factor
● Start management if levels are at 7–10 mg/dl
● Passive artificial immunity; can be received again
○ Early breastfeeding or phototherapy
● “Tricks” the body; will not produce own antibodies
(cover eyes and genitalia)
○ Rather, it prevents the mother from forming
natural antibodies
I. ASSESSMENT
● Does not cross the placenta as it is not an IgG =
A. ANTI-D ANTIBODY TITER cannot destroy fetal RBCs
● ADMINISTRATION
● All women with Rh- blood should have antibody titer ○ ROUTE: 300 mcg IM (deltoid)
done at the first prenatal visit ○ TIMING
● RESULTS ● Rh- women at 28 weeks of pregnancy
○ Normal: 0 ● Rh- women carrying Rh+ fetus in the first 72
○ Minimal: ratio below 1:8 hours after birth
● The test will be repeated at the 28th week of ○ SHOULD AN RH- MOTHER RECEIVE RHOGAM AFTER
pregnancy for normal and minimal results; ABORTION WITH AN RH+ FETUS?
no therapy is needed if normal ● Yes, as there is still a possibility of the abortus
○ Elevated: ratio 1:16 or above clot mixing with the maternal blood
● Indicates Rh sensitization ● TRANSIENCE: CHARACTERISTIC OF RHOGAM
● Titer will be monitored approximately every 2 ○ Because RhIG is passive antibody protection, it is
weeks by Doppler velocity of the fetal middle transient
cerebral artery to check for fetal anemia ● Must be injected again after delivery of the
○ Fetal RBC are destroyed; the fetus will not Rh+ child
automatically die ● In 2 weeks–2 months, the passive antibodies
○ Intrauterine blood infusion may be done are destroyed
NCM 0109|17
○ Ginagamit siya ng body; it is not (no change in the number of RBCs, they just become
naturally-occurring hemodiluted)
● Only those few antibodies that were formed ○ The concentration of hemoglobin and
during pregnancy are left erythrocytes may decline (hemodilution) but
○ Every pregnancy is like a first pregnancy in terms there is no decrease
of the number of antibodies present, ensuring a
safe intrauterine environment for any future E.1. IRON-DEFICIENCY ANEMIA
pregnancies
● IRON: made available to the body by absorption
AFTER BIRTH from the duodenum into the bloodstream after it has
been ingested
● Determine infant’s blood type through sample of ○ In the bloodstream, it is bound to transferrin for
cord blood transport to the liver, spleen, and bone marrow
● At these sites, it is incorporated into
COOMBS RH FACTOR RHOGAM hemoglobin or stored as ferritin
- + ✔ ● Most common anemia of pregnancy (15–25% of
pregnancies)
+ - ✘
○ Many enter pregnancy with a deficiency of iron
stores resulting from a combination of a diet low
B. INTRAUTERINE INFUSION in iron, heavy menstrual periods, or unwise
weight-reducing programs
● Blood type of the baby will be determined through ● Characteristically a microcytic (i.e., small red blood
PUBS cell), hypochromic (i.e., less hemoglobin/oxygen
● Inject RBC directly into a vessel in the fetal cord than the average red cell) anemia
○ Done by amniocentesis technique directly into a ○ Occurs when an inadequate supply of iron is
vessel in the fetal cord or depositing them in the ingested, iron is unavailable for incorporation into
fetal abdomen where they migrate into the fetal red blood cells
circulation ● Mildly associated with low birth weight and preterm
● Given when the hematocrit levels are less than 30% birth
intravascularly/intraperitoneally
● Done only once I. ASSESSMENT
● PURPOSE: restore fetal RBCs
● BLOOD TYPE A. SIGNS AND SYMPTOMS
○ Use fetus’ own type (if PUBS was done)
○ Type O- to sustain plasma volume of the pt PERIOD LABORATORY VALUES
● Universal donor; given only under extreme HEMOGLOBIN HEMATOCRIT SERUM IRON
circumstances 1ST <11 g/dL <33%
○ 75–150 mL of washed red cells are used
2ND <10.5 g/dL <32% <30 mcg/dL
● COMPLICATIONS
○ Lacerations in cord blood vessel (may cause 3RD <11 g/dL <33%
contractions d/t uterine irritation)
○ Preterm labor (d/t contractions) ● Extreme fatigue and poor exercise tolerance
● POST-PROCEDURE ○ Happens due to lack of oxygen (kulang sa iron
○ Monitor FHT and uterine activity which affects hemoglobin)
○ Administer RhIG ○ Increased risk for infection, pre-eclampsia,
hemorrhage, and delayed healing of
episiorrhaphy or incision
E. ANEMIA
● Pallor, fatigue, lethargy, and headache
● DECLINE IN CIRCULATING RBCS: low capacity to carry (hypotension, tachycardia, tachypnea)
oxygen to vital organs of mother or fetus ○ Earliest sign is tachycardia because the system
● Because the blood volume expands during will compensate to increase cardiac rate
pregnancy slightly ahead of the red cell count, most ● Pica: eating of non-food substances like ice, starch,
individuals have pseudoanemia in early pregnancy clay, dirt, soil, cigarette butts and ashes, hair, paper,
paint chips, stones, paper clips
NCM 0109|18
○ Persistent craving and compulsive eating of IV. NURSING INTERVENTIONS
non-food substances
○ Body recognizes that it needs more nutrients ● Advise women to take iron supplements with orange
juice or a vitamin C supplement (500 mg)
B. RISK FACTORS ○ Drink with meals to prevent GI discomfort
○ Best absorbed in acidic environment; do not take
● Diet low in iron (poor nutrition)
with milk as this prevents iron absorption
● Heavy menstrual periods (normal: 40-80 ml)
● Eat a diet high in iron and vitamins
● Unhealthy weight reduction programs (limited iron
○ Organ meats, shellfish, spinach, egg, legumes,
intake)
green leafy vegetables, fish
● Women from low socioeconomic communities (no
● Increase roughage in diet and increase fluid intake
iron-rich diets)
(to prevent constipation)
● Women who experience a short period between
● Inform the client that a common side effect is
pregnancy (less than 2 years)
melena (black stools; not a sign of internal bleeding)
○ The body has insufficient time to recover from the
● May have IM or IV prescription if there is difficulty
blood loss during delivery
taking oral iron therapy
● Blood loss
C. EFFECTS TO PREGNANCY E.2. FOLIC ACID-DEFICIENCY ANEMIA
● Low birth weight (not enough oxygen and nutrients) ● FOLIC ACID/FOLACIN/FOLATE
● Preterm birth ○ Aids in the formation of maternal RBC
● Restless leg syndrome ○ Prevents neural tube and abdominal wall defects
○ Linked to abnormal iron utilization by the brain in the fetus (SAAbd)
○ Irresistible urge to move legs ● Happens in 1–5% of pregnancies; common during
○ Described as itchy, pins and needles, creepy, and the 2nd trimester
crawly ● Megaloblastic anemia: enlarged RBC but with less
● Worst at rest (sitting or lying) hemoglobin; premature
● Fetal death (lesser oxygen and nutrients) ○ Because of the size of the cells, the mean
● Hypoxia (lack of oxygen) during labor corpuscular volume will be elevated in contrast to
the lowered level seen with iron-deficiency
II. MEDICAL MANAGEMENT anemia
MATERNAL
● IRON SUPPLEMENTATION FETAL EFFECTS
COMPLICATIONS
○ Ferrous sulfate/gluconate
○ 27 mg as prophylactic therapy during pregnancy; ● Spontaneous
for those without IDA ● Large yet immature abortion
○ 120–200 mg per day if with iron-deficiency erythrocytes ● Abruptio placenta
anemia ● Neural tube defects
○ Highest need of the baby for iron is during the
third trimester (nagre-reserve na bago siya I. ASSESSMENT
lumabas)
A. RISK FACTORS (related to impairment in folic acid
○ Not given during the 1st trimester of pregnancy as absorption)
it can aggravate nausea and vomiting
● When a pregnant patient begins to take a ● Occurs in multiple pregnancies (increases fetal
prescribed iron supplement, new red blood cells demand)
should begin to increase almost immediately ● Secondary hemolytic effects (causes destruction
and production of RBCs)
III. NURSING DIAGNOSIS ● Hydantoin intake (anticonvulsant that interferes with
folic acid absorption)
● Risk for ineffective tissue perfusion related to ● Women taking oral contraceptives
maternal anemia during pregnancy ● Women who had gastric bypass for morbid obesity
(iron absorbed in the GI tract)
NCM 0109|19
II. MEDICAL MANAGEMENT ○ Occurs as a result of vasoconstriction from

reduced responsiveness to vasopressors
● 400 mcg folic acid daily for those planning to get Increased cardiac output = vascular
pregnant; 800 mcg for those currently pregnant 1 spasm of the mother
● For those with pregnancy history of child with neural Vasoconstriction and injury to endothelial
tube defects, take 4 mg of folic acid for 1 month 2 cells of arteries
before and during first trimester Increase in BP passing through the
● Eat folacin acid-rich foods 3 vasoconstricted vessel para makadaan
sa narrow opening
○ Fresh dark green leafy vegetables, oranges, dried
Due to the injury, platelets are released.
beans, red meat, fish, and poultry 4 These may coagulate and cluster
Cardiac system becomes overwhelmed
F. PREGNANCY-INDUCED HYPERTENSION and the heart is forced to pump against
● Previously known as toxemia

5 increased vascular resistance (d/t
vasospasm) leads to a decreased
● Condition in which vasospasm (narrowing) occurs cardiac output
during pregnancy in both small and large arteries Decrease in blood supply to the organs
6 (kidneys, pancreas, liver, brain, placenta)
○ Narrowing of the blood vessels
○ May be caused by increased cardiac output
○ 2 HORMONES PRODUCED BY THE LIVER
required by pregnancy
● Prostacyclin: potent prostaglandin
○ Since the body needs to supply more blood to the
vasodilator but d/t endothelial damage, its
baby and placenta (increased circulatory
action is reduced = hypertension
activity) → vasospasm → hypertension → lumiliit
● Thromboxane: potent vasoconstrictor and
‘yung lumen
stimulant of platelet aggregation; damage to
● Signs and symptoms start at 20 weeks
endothelial cells increases its production
○ CLINICAL MANIFESTATIONS: hypertension,
proteinuria, and edema
ACTION OF KIDNEYS LEADING TO ECLAMPSIA
● Kahit na isang manifestation lang ‘yung wala,
Increased tubular reabsorption of Na =
the mother can still be diagnosed with PIH
1 retention of fluid [where Na goes, water
○ Normalized 48 hours postpartum follows]
○ Cure: after birth of infant Edema or vasospasm occurs (decrease in
● Occurs in 5–7% of pregnancies 2 perfused blood), leading to decreased GFR
● RESEARCH ON PREGNANCY-INDUCED HYPERTENSION Hindi nagfa-function normally, leading to
○ Cause remains unknown decreased urinary output and increased
○ In 2018, eclampsia was reported to be the leading 3 creatinine (product of metabolism which
cause of maternal death comprising 17.6% of becomes toxic when accumulated)
total maternal deaths (Philippine Health Statistics, Increased blood flow resistance =
2018)
4 increased permeability in the glomerulus
Escape of albumin and globulin into
I. ASSESSMENT 5 interstitial fluid (hindi naman dapat
lumalabas; not normal) = proteinuria
A. SIGNS AND SYMPTOMS
6 Decreased osmotic pressure
Fluid diffuses to interstitial spaces to
VASOSPASM HAS THE FOLLOWING EFFECTS: 7 equalize pressure = extreme edema
Vasoconstriction leads to high blood
VASCULAR Cerebral and pulmonary edema (umaabot
pressure and poor organ perfusion
na sa upper parts ng body ‘yung fluid) =
The decreased GFR and increased
permeability causes ↑ serum blood
8 seizures = eclampsia
RENAL ● Ask for presence of epigastric pain,
urea nitrogen, creatinine, ↓ urine headache, and blurring of vision
output, and proteinuria
Due to escape of protein, fluid goes to ● Reduced fetal nutrient and oxygen supply
INTERSTITIAL
the interstitial spaces causing edema ○ Fetal heart is forced to pump against rising
peripheral resistance that results to a reduced
● Hypertension placental perfusion, and consequently nutrient
NCM 0109|20
and oxygen supply; possibly leads to a SGA baby ● Those who have underlying disease such as heart
or fetal death disease, diabetes with vessel/renal involvement, and
● Epigastric pain and elevated amylase-creatinine essential hypertension
ratio ● ADDITIONAL RISK FACTORS
○ From ischemia in the pancreas ○ Large placental mass (multiple gestation and
● There is decreased in blood supply to H-mole)
pancreas ○ Rh incompatibility
● Vision changes ○ Normotensive in previous pregnancy; conceive
○ From vasospasm of arteries in the retina with new partner
○ If retinal hemorrhage occurs, blurring of vision ○ In-vitro fertilization
and blindness (if not corrected) may happen
● Proteinuria COMPLICATIONS
○ Degenerative changes in the glomeruli causes
MATERNAL RISKS FETAL RISKS
increased permeability; this allows escape of
● CNS changes
protein in the urine
(hyperreflexia,
● Lowered urine output and creatinine clearance
headaches, and
○ Degenerative changes in the kidneys (d/t back
seizures)
pressure) results in decreased glomerular
● Renal failure
filtration
● Abruptio placenta
● Edema ● Small for gestational
● Disseminated
○ Results from increased reabsorption of sodium; age d/t decreased
intravascular
additionally, because of proteinuria, osmotic placental perfusion
coagulation (no more
pressure decreases causing fluid to escape into (leads to fetal hypoxia
circulating platelets
the interstitial spaces and malnutrition)
[thrombocytopenia],
○ Extreme edema can lead to cerebral and ● Prematurity
generalized blood
pulmonary edema and seizure (signs of
clotting leading to
eclampsia)
bleeding)
○ Measured by the amount of hematocrit level;
● Ruptured liver
<40% suggests edema
● Pulmonary embolism
● Thrombocytopenia
(moving clot)
○ Platelets cluster in the site of endothelial damage
resulting to a decreased circulating platelet
II. CLASSIFICATION
○ Vasospasm → endothelial damage → bleeding →
platelet clusters at the site of damage to try and GESTATIONAL HYPERTENSION
stop the bleeding
● Increased hematocrit (↑40%; hemoconcentration) ● Elevated BP 140/90 mmHg but has no proteinuria
○ Significant fluid loss to interstitial spaces/extent of and edema
edema leads to vascular dehydration ○ Increase in systolic: >30 mmHg and diastolic: >15
○ Plasma loss to interstitial space mmHg from baseline (pre-pregnancy) values
● No drug therapy is needed as BP returns to normal
B. RISK FACTORS postpartum
● Women of color (native Black Americans) NURSING RESPONSIBILITIES

● With a multiple pregnancy (increased placental
mass) ● Continuously monitor the blood pressure
● Primiparas younger than 20 years of age or older ● Delivery is recommended when this occurs at/after
than 40 years 37 weeks AOG d/t increased risk of adverse
● Women from low socioeconomic background pregnancy outcomes
(inadequate nutrition) ● Observe closely for progression to preeclampsia
● Those who have had 5 or more pregnancies
MILD PREECLAMPSIA
● Those who have hydramnios (increased fluid volume
= increased blood pressure) ● Abnormal assessment results taken on two
occasions, at least 6 hours apart
NCM 0109|21
● HIGH BLOOD PRESSURE: BP of 140/90 mmHg (systolic ○ Assess if pitting or non-pitting
BP >30 mmHg and diastolic BP >15 mmHg above ● Pitting: edematous tissue can be indented
pre-pregnancy values)
SCORE DEFINITION
○ The diastolic value of blood pressure best
indicates the degree of peripheral arterial spasm 1+ slight indentation
present 2+ moderate indentation
● Consistent increase may indicate that
3+ deep indentation
preeclampsia is worsening
● PROTEINURIA: proteinuria 1+ or 2+ (represents loss of remains after removal of
4+
finger/pitting
protein at a level of 1–2g/L)
○ 1g/24 hr urine collection
○ Orthostatic Proteinuria: if the client has been long ● Non-pitting: edematous tissue cannot be
standing, and urinalysis is collected = proteinuria indented with finger pressure; brought about
is collected (no proteinuria during bedrest) but is by excess lymphatic fluid
not related with mild preeclampsia ● ADDITIONAL S/SX
● The best time to tell the mother to collect ○ Reduced urine output/oliguria (400–600 mL per
urine to rule out proteinuria = first sample of 24 hours)
urine in the morning (transport urine for 30 ● Due to decreased perfusion of blood supply
min–1 hr is also okay if there is no receptacle) to kidneys = cannot form urine
● MILD EDEMA ● Edema d/t fluid shifting
○ D/t protein loss and Na reabsorption (lowered ● Normal urine output is 720 mL
GFR = glomerular permeability increases and ○ Severe epigastric pain, nausea, and vomiting
allows escape of proteins) ● May indicate abdominal edema and
ischemia to pancreas and liver because of
○ Fluid accumulation in the upper extremities/face
reduced blood flow
● Normally, edema is present in the lower
extremities d/t pressure from the uterus ○ Shortness of breath, coughing, DOB from
pulmonary edema
○ Weight gain of >2 lb/week in the second trimester
or 1 lb/week in the third trimester ● Fluid pools or remain in the lungs
● Normal weight gain is 25–30 lbs for the whole ○ Visual disturbances
pregnancy ● Blurred vision, seeing spots d/t cerebral
edema/spasmic arteries of the retina
SEVERE PREECLAMPSIA ○ Severe headache, hyperreflexia and ankle
clonus from cerebral edema and continued
● Abnormal assessment results taken on two motion of the foot
occasions, at least 6 hours apart at bed rest ● ANKLE CLONUS: rapid dorsiflexion of the foot,
○ BP is usually taken during bed rest as it is at its hold with slight tension, then release it and
lowest, but with clients with severe preeclampsia, check if it jerks over 5x = clonus reaction
their BP remains elevated even during bed rest ○ Condition that results in involuntary spasm
● HIGH BLOOD PRESSURE: BP of 160/110 mmHg or above and indicates neurological conditions
○ Diastolic pressure is 30 mmHg above ○ Similar procedure can be conducted on
pre-pregnancy level the wrist as well if the patient undergone
● PROTEINURIA: 3+ or 4+ spinal anesthesia
○ 5g/24h urine collection ○ LABORATORY VALUES
○ 2 random samples taken 4h apart ● Platelet Count: <100,000
○ Orthostatic proteinuria is not ruled out anymore ● Elevated liver enzymes (above 2x thee normal
● EXTREME EDEMA upper limit)
○ Proteinuria of 3+/4+ = severe depletion of ● Serum Creatinine: >1.1 mg/dL
albumin in the blood
○ Palpated over bony prominences (cheekbones, ECLAMPSIA
ulna of forearms, tibia in anterior leg)
○ Puffiness in face, eyelids and upper extremities ● Most severe stage of PIH
(hands) ○ High maternal mortality rate of 20% (cerebral
hemorrhage [rupture of blood vessels], renal
● They have difficulty opening their eyes and
cannot wear their ring due to edema
NCM 0109|22
failure, and circulatory collapse = respiratory ○ Assess pulse and BP before/after administration
arrest) ● Do not administer if the diastolic is
● TONIC-CLONIC (GRAND MAL) SEIZURE AND COMA 80-90mmHg
○ Acute cerebral edema ● FUROSEMIDE (Lasix)
○ Aura that “something is about to happen” ○ Diuretic to correct edema (pulmonary edema)
○ All muscles of the body contract ○ Fluid shifting to the intestine to promote maximal
○ Tonic Phase: back arches, extremities stiffen, jaw excretion and absorption in that area
clenches, respirations halt; lasts approximately 20 ○ Decreases chance of seizures and helps lower BP
seconds ● MAGNESIUM SULFATE
○ Clonic Phase: bladder and bowel muscles ○ Drug of choice to prevent preeclampsia
alternately contract and relax, may become ○ Antihypertensive, promotes fluid excretion, and
cyanotic; lasts up to 1 minute CNS depressant
● Poor fetal prognosis because of hypoxia and ● Classified as cathartic: reduces edema by
acidosis due to seizure; abruptio placenta causing a shift in fluid into the intestine
(premature separation d/t severe vasospasm) from ● Has a CNS depressant effect: lessens
extreme vasospasm possibility of seizure
● Relaxes smooth muscles: correcting HPN
III. MEDICAL MANAGEMENT ○ Administered as loading dose IM (buttocks); then,
as continuous IV infusion
● ANTIHYPERTENSIVE DRUGS: promotes vasodilation ● 4-6 g initially (loading dose)/1-2 g IV in 100 mL
● Before administering medications, take note of the fluid over 15–20 min
blood pressure (hypotension indicates decreased ● Therapeutic Range (ito ‘yung
placental perfusion; no diastolic 80–90 mmHg) mine-maintain): 5–8 mg/dl
and pulse rate (there should be no tachycardia) ● Administer if RR = ↑ 12 cpm; UO = ↑ 30cc/hr;
(+) DTR
● 5–10 mg/IV
○ Administered slowly to prevent sudden fall in BP ○ 📌REMEMBER: If the drug is given 2 hours before
birth, alert the pediatrician as it can cross the
placenta and cause respiratory depression on
● HYDRALAZINE (Apresoline)
the part of the baby (drug crosses placenta)
○ Reduces blood pressure mainly by direct effect
○ Important Interventions:
on vascular smooth muscles of
● Urine output should be above 25–30 mL/hr
arterial-resistance vessels
○ Less extraction of urine can lead to toxicity
● NIFEDIPINE
● Respirations should be above 12 cpm
○ Calcium channel blocker
○ May lead to bradypnea if lesser than 12
● LABETALOL (Normodyne)
● Deep tendon reflexes should be present
○ Antihypertensive medications used to lower BP by
○ Knee-jerk reflex is checked to assess CNS
peripheral dilation
function
○ Can cause maternal tachycardia
○ Therapeutic Effects
● Assess pulse and BP before and after
● Normal Levels: slurring of speech and
administration
decreased appetite
○ Maintain diastolic pressure at 90 mmHg; pressure
● SE: flushing, thirst, and increased warmth
below 80 mmHg could lead to inadequate
throughout the body
placental perfusion
● Toxicity: absence of DTR, respiratory
○ Non-selective beta blocker (blocks B1 and B2)
depression, cardiac arrhythmias, decreased
● Cannot be given to those with asthma or
UO, cardiac arrest, difficulty swallowing, and
heart failure
drooling
○ Causes bronchospasm effect, triggering or
worsening the symptoms of asthma MAGNESIUM SULFATE TOXICITY
● METHYLDOPA
BLOOD PRESSURE DECREASED
○ Long-term control of mild-moderate HPN in
pregnancy
● The px is manifesting hypotension
○ 5–10 mg/IV B already, nag-rerelax na yung blood
● Administer slowly to prevent sudden
vessels ng body
hypotension
NCM 0109|23
● Hook to a cardiac monitor for regular V. NURSING INTERVENTIONS

taking of blood pressure (usually every
5–15 minutes) A. MILD PIH
URINE OUTPUT DECREASED (Oliguria) ● Promote bed rest at home

● Urine output less than 30cc/hr
U ● Monitor urine output by inserting a
○ Lateral recumbent position and raise side rails
for safety purposes
catheter for accuracy ○ Avoid uterine pressure on vena cava to prevent
RESPIRATORY DEPRESSIONS <12 SHS
R ● Apnea or bradypnea
● The respiratory center is found in the
○ Na is excreted faster = correction of edema
● Promote good nutrition: continue usual pregnancy
medulla oblongata diet
PATELLAR REFLEX ABSENT ● Monitor antiplatelet therapy
P ● MagSul is a CNS depressant ○ Administering low-dose aspirin may help
delay/prevent the development of preeclampsia
● Long-term effect: osteoporosis (affects ● Note that there is an increased risk for
calcium absorption) platelets to cluster along arterial walls
○ Calcium Gluconate ● Provide emotional support
● Antidote for magnesium toxicity ○ They may feel socially-isolated
● Kept at bedside
B. SEVERE PIH
● 1 g/L
● DIAZEPAM (Valium)
● Admit to health care facility to support bed rest
○ Can control seizures and has sedative effect
○ Visitors are restricted to support person
(hindi nasi-stimulate so no seizures)
(husband, mother, older children)
● AMOBARBITAL
○ No unlimited phone calls
○ CNS depressant; anticonvulsant; barbiturate;
○ Avoid too loud noise (may precipitate seizures);
sedative-hypnotic
admit the patient to a private room
○ Used for seizures not controlled by magnesium
○ Raise side rails; darken the room (make sure that
sulfate (stronger than magnesium sulfate)
there is still enough light for assessment) and
● Works by increasing the threshold for motor
avoid sudden stimulation to light
cortex stimuli
○ Provide clear explanations to prevent stress
○ Given 5–10 mg/IV
● Monitor maternal well-being
● ASPIRIN
○ Monitor BP every 4 hours
○ 50–80/150 mg starting at 16 weeks AOG
○ Obtain blood studies as ordered to assess renal
○ Mild antiplatelet agent (suppresses
and liver function test
thromboxane)
● CBC, Hct (determine severity of anemia),
○ Removes platelets clustered in the area of
platelet count (thrombocytopenia), liver
endothelial damage (prevents danger of
function, BUN/BUA, creatinine, fibrin
embolism and obstruction of major vessels)
degradation, DIC, plasma estriol levels (tests
○ Delays development of pre-/eclampsia, IUGR,
placental function)
and preterm birth
○ Obtain daily weights to assess edema
○ WOF maternal bleeding
● Best to be taken every morning, wear the
same type of clothes and check in the same
IV. NURSING DIAGNOSES
time of the day; same weighing scale to
check fluid retention
● Ineffective tissue perfusion r/t vasoconstriction of
blood vessels ○ Monitor I&O
● Deficient fluid volume r/t fluid shift from IV to ● In-dwelling foley catheter provides accurate
extravascular space secondary to vasospasm measurement of urine output
● Risk for fetal injury r/t reduced placental perfusion ● Normal = >600mL/24hrs; 30mL/hour
secondary to vasospasm ● Mg excreted in urine
● Risk for injury r/t possibility of seizure secondary to ● Monitor fetal well-being
cerebral vasospasm/edema ○ FHR and oxygenation
● Social isolation r/t prescribed bed rest
NCM 0109|24
● Maintain adequate fetal oxygen and prevent ○ Decreased RR since thoracic muscles are held in
fetal bradycardia by providing oxygen contraction = cyanotic
inhalation to mother ● Cyanosis may cause longer tonic phase
○ Doppler auscultation at 4-hour intervals ● Maintain patent airway (remove tongue blade)
○ If pregnancy is greater than 34 weeks, labor ○ Do not put a tongue blade between a woman’s
should be induced to prevent compromising fetal teeth during the seizure
health ● Best time to insert tongue blade is when
● Support nutritious diet seizure warnings are present
○ Moderate to high protein: compensate lost ○ Broken teeth = aspiration or fractured jaw
protein in urine ● Administer oxygen by face mask to protect fetal
○ Moderate sodium: manage edema oxygenation
● No sodium may trigger RAAS which can ● Assess oxygen saturation via pulse oximeter
increase BP ● Pad side rails or put a pillow between the woman
● 80-100g/day and side rails
● Na should not exceed 6g/day and must ● Turn a woman on her side
distributed for the whole day ○ Prevents aspiration (allows secretions to drain
● Monitor newborn for respiratory depression from the mouth)
○ Magnesium during delivery ○ Aids in placental circulation
● Alert neonatal care personnel about this ● Seizures may announce the beginning of labor
possibility (r/t MagSul toxicity) (monitor contractions)
● Monitor for loss of heartbeat variability ● Monitor fetal condition
○ Delay breastfeeding until the drug is discontinued ● Check for vaginal bleeding (detect premature
since the drug is expressed in the breast milk abruptio placenta)
(12–24 hours → tapered → discontinue)
1.C. CLONIC PHASE: lasts for 60 seconds
● Administer medications to prevent eclampsia
○ Hydralazine, labetalol, and magnesium sulfate
● All the muscles of the body contract and relax
● Initiate IVF
repeatedly (jerking)
○ Administer fluids to correct hypovolemia and
○ Incontinence of urine and feces d/t muscles of
increased hematocrit (dehydration)
bladder/bowel contraction and relaxation
○ Emergency route for drug administration
○ Ineffective breathing (cyanotic pa rin si pt)
○ Fluid intake may be oral to prevent fluid overload
● Magnesium sulfate and diazepam may be
C. ECLAMPSIA: TONIC (muscular contraction) CLONIC administered intravenously as an emergency
(contraction and relaxation) SEIZURE measure at this time
● Administer oxygen inhalation since there is
1.A. PRELIMINARY SEIZURE: warning signs ineffective breathing pattern
● Premonition or aura (seeing floating spots, unusual 1.D. POST-ICTAL STATE: cannot be aroused except by
feeling, abnormal sensations, and déjà vu) painful stimuli for 1–4 hours
○ Allows HCP to prepare for seizure
● Third stage of seizure
○ Would not stop the seizure from occurring
● The woman is semi-comatose
● Blood pressure rises suddenly from additional
● Precautions on seizure; this may lead to placental
vasospasm
separation
● High temp (39.4–40℃) d/t increased cerebral
● Keep the woman on her side to drain secretions from
pressure
mouth
● Blurring of vision, severe headache, epigastric pain
● Keep on NPO (if pinakain, baka ma-aspirate)
(vascular congestion), nausea, hyperactive reflexes
● Continuously assess FHR and uterine contractions
○ If labor begins during this period, the patient will
1.B. TONIC PHASE: lasts for 20 seconds
be unable to report the sensation of contractions
○ Painful stimulus of contractions may initiate
● All the muscles of the body will contract another seizure
○ Back arches, arms and legs stiffens, jaw closes ● Check for vaginal bleeding every 15 minutes
abruptly (may bite tongue)
NCM 0109|25
● Close observation (seizure may cause premature b. Administer the drug only in the morning
separation of placenta → labor → may also initiate c. Follow physician instructions
seizure again) d. Administer half of the drug dose before
● Coma (hearing is the last sense lost and 1st sleeping
regained) 4. Caloric needs of pregnant client with DM should
○ Only say things you want the client to hear mainly consist of:
a. Protein
2.A. DELIVERY
b. Carbohydrates
c. Fats
● NORMAL SPONTANEOUS DELIVERY
d. Water
○ Even if the patient has proteinuria, edema and
5. Which age group is at risk of substance abuse
hypertension, she can deliver via NSD
during pregnancy?:
● CS is more harmful as it could affect the CV
a. Middle adults who lost a job
system due to low blood volume
b. Late adults who married at a later time
○ Inducing Contractions
c. Young adults with abusive parents
● Artificial rupture of the membrane
d. Middle adults with financial stability
(amniotomy)
6. The confirmatory test in the diagnosis of HIV:
● Oxytocin (monitor BP)
a. Western blot test
● Place client in a side-lying or semi-sitting
b. ELISA
position
c. CD4 count
● CESAREAN SECTION
d. Elevated lymphocyte count
○ Only done when no contractions take place after
7. For RhIG to be effective in protecting the
ROM and oxytocin administration
succeeding pregnancy, it should be administered:
○ Low blood volume
a. Only at the 28th week of pregnancy
● CS affects the vascular system as it can also
b. During the first 24 hours prior birth
result in blood loss (>500mL)
c. Three months prior to the next planned
○ Sudden hypotension from regional anesthesia
pregnancy
● Dangerous for mother and baby
d. In the first 72 hours after delivery
○ Mature lungs even in preterm babies d/t
8. Which health teaching will benefit a pregnant
intrauterine stress
client taking iron supplements?
● The baby experiences the same amount of
a. Take the iron supplements 30 minutes before
stress experienced by the mother
meals
● Faster production of lung surfactant
b. Ingest cold milk while taking in the iron
● POSTPARTUM HYPERTENSION
capsules
○ May occur 10–14 days after delivery
c. Avoid ingesting foods high in fiber during iron
○ Usually occurs in the first 48 hours after birth
therapy
○ NI: Monitor BP
d. Take the iron tablets with orange juice
9. The following are triad symptoms of PIH except:
POSTTEST a. Proteinuria
b. Edema
1. Which of the following is a sign of DM?
c. Hypertension
a. Weight gain
d. Seizure
b. Metabolic alkalosis
10. The drug of choice in PIH:
c. Hypoglycemia
a. Magnesium sulfate
d. Polydipsia
b. Hydralazine
2. Which test is a more accurate procedure used in
c. Diazepam
the diagnosis of DM?
d. Calcium gluconate
a. Fasting blood glucose
11. Which intervention is appropriate when a pregnant
b. Random blood glucose
client with PIH experiences seizures?
c. HbA1C
a. Turn the head to the side
d. Urinalysis
b. Insert a sterile padded tongue blade in the
3. Which health teaching with regard to insulin use is
mouth
most useful for a pregnant client with DM?
c. Restrain the client
a. Rotate injection sites
NCM 0109|26
d. Keep the head in neutral position
ANSWER KEY: D, C, A, B, C, A, D, D, D, A, A
Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Navarro,

Paras, Tapnio | BSN 2025
REFERENCES
Synchronous Lecture: 09–10 Feb 2023
Module: NCM 0109 High-Risk Prenatal Client
Book: Maternal and Child Health Nursing
Practice Questions:
A. Question Bank 1
B. Question Bank 2
NCM 0109|27

01.2 Pregestational Conditions

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01.2 Pregestational Conditions

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CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

NCM 0109 MODULE 01.2 – HIGH-RISK PRENATAL CLIENT (PREGESTATIONAL CONDITIONS)

with amniotic fluid which ● Encourage breastfeeding if

ORAL GLUCOSE CHALLENGE TEST ● Decreased consumption of food: during the

● Gold standard for management of diabetes

DRAWING INSULIN Before After

NURSING RESPONSIBILITIES After

BLOOD GLUCOSE MONITORING IV. ADDITIONAL MONITORING

● Vomiting ● Leads to poor nutrition; they choose drugs

● Occurs only when an Rh-negative mother is

C. EFFECTS TO PREGNANCY E.2. FOLIC ACID-DEFICIENCY ANEMIA

II. MEDICAL MANAGEMENT ○ Occurs as a result of vasoconstriction from

● Previously known as toxemia

● Women of color (native Black Americans) NURSING RESPONSIBILITIES

● Hook to a cardiac monitor for regular V. NURSING INTERVENTIONS

URINE OUTPUT DECREASED (Oliguria) ● Promote bed rest at home

Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Navarro,

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