Brine + De x RH FACTOR - special proteins present on their red blood cell surface. The big deal is that people who are Rh-negative blood (Rh factor is ABSENT from their red blood cell surface) can ONLY receive other Rh- negative blood. They should never receive Rh-positive blood into their circulation because the body will create antibodies and ATTACK the Rh- positive red blood cells. However, a person with Rh-positive blood CAN receive both Rh-negative and positive blood without any problems. NOTE So with that in mind, if the baby’s blood (who is Rh-positive) mixes with the mother’s blood (who is Rh-negative) the mother’s body wall create antibodies that will attack Rh-positive blood...hence attack fhe baby’s RBCs. | |- Remember that since she is Rh-negative she should ONLY receive Rh- negative bload in her system. So, if the baby was Rh-negative it wouldn’t matter OR if the mother was Rh-positive and the baby was Rh-negative it wouldn’t matter as well because the mom can receive BOTH Rh-positive and Rh-negative in her blood. - Mixing of blood: It most likely occurs during delivery when the placenta is detaching....therefore, the child of the first pregnancy is gone and not present for the antibodies to attack their red blood cells However, a child of a first pregnancy can be affected if the mother has some type of complication like abruptio placentae etc. or invasive procedure like amniocentesis etc. The baby will still be in the wom for the antibodies to attack.How does RhoGAM work? - It stops the immune system from creating antibodies against the baby’s Rh positive blood. * **Given with subsequent pregnancies when the baby is Rh+ * Given intramuscular (IM)....if mom already has the antibodies created RhoGAM isn’t effective. ‘Home rer + a8 a x Second pregnancy: Rh incompatibility will occur during the second pregnancy IF the child again is Rh-positive (this won't be an issue if the child is Rh-negative). There is a high probability of this happening if an Rh-positive father and Rh-negative mother have another child. How is this prevention done? PRENATAL CARE The mother’s blood type will be assessed...if Rh+...needs nothing... if Rh- will needa * RhoGAM shot at 28 weeks and then * within 72 hours AFTER delivery of the baby if the baby is Rh+ (aby will be checked).NOTE: ¥ Insignificant number of antibodies are formed during pregnancy thus, Ast baby is not greatly affected v Greatest exposure occursduring placental separation which causes massive production of anti Rh abs during 1st 72 hrs postpartum ¥ Rh+ fetuses in future pregnancies will be affected ¥ Fetal anemia results & to compensate, fetal bone marrow produces immature RBCs(erythroblasts) causing Erythroblastosis Fetalis ( |Erythroblastosis fetalis Type of anemia in which the red blood cells (erythrocytes) of a fetus are destroyed in a maternal immune reaction resulting from a blood group incompatibility between the fetus and its mother. This incompatibility arises when the fetus inherits a certain blood factor from the father that is absent in the mother. Y Two blood group systems, Rh and ABO, primarily are associated Y The Rh system is responsible for the most severe form of the disease, which can occur when an Rh-negative woman (a woman whose blood cells lack the Rh factor) conceives an Rh-positive fetus. ¥ Sensitization of the mother’s immune system (immunization) occurs when fetAll red blood cells that carry the Rh factor (an antigen in this context) cross the, placental barrier and enter the mother’s bloodstream. They stimulate the production of antibodies, some of which pass across the placenta into fetal circulation and lyse, or break apart, the red blood cells of the fetus (hemolysis)+ =@ GED - 0 « ana Severity varies depending on the degree of hemolysis: v Anemia sdue to immature red blood cells (erythroblasts) Y Jaundice - resulting from a buildup of bilirubin (a breakdown product of hemoglobin from red blood cells). v Enlarged liver(Hepatomegaly) and spleen( spleenomegaly) v Hydrops fetalis extreme edema (abnormal accumulation of serous fluid) and congestive heart failure. ¥ Death9 + ° = ax COMPLICATIONS v kernicterus- caused by deposition of bilirubin in the brain Y Hearing loss ¥ mental retardation, or v death PROCEDURES to avert these consequences: AMNIOCENTESIS- to measure bilirubin concentrations and predict the severity of the disease If levels are elevated, intrauterine transfusions of Rh-negative blood can be given until premature delivery can be induced. These measures, together with the use of Rh immunoglobulin, have almost eliminated the incidence of erythroblastosis fetalis in developed countriesNeural tube defect Any congenital defect of the brain and spinal cord as a result of abnormal development of the neural tube (the precursor of the spinal cord) during early embryonic life, usually accompanied by defects of the vertebral column or skull, Degree is the basic defect underlying ¥ spina bifida v meningocele v myelocele ¥ meningomyelocele.Types of spina bifida peat perple naw trough Ro open Ome sucrre 6# their 9 10 form a cys? na.‘oh Heme BI tote + ne SE—E> - TYPES OF SPINA BIFIDA ., v Myelocele- the spinal cord is exposed so that nerve tissue lies exposed on the surface of the back without even a covering of skin or of the meninges, the membranous tissue surrounding the brain and spinal cord v Meningocele- occurs when these meninges protrude through the vertebral defect, forming a fluid-filled sac. , ¥ Meningomyelocele- is a compound defect in which the protruding4 sac contains some nervous tissue as well. j /Anemia During Pregnancy v¥ Anemia is when you don’t have enough red blood cells to carry oxygen throughout your body. When your body doesn’t get enough oxygen from your blood, it can’t function properly. A person who has anemia during pregnancy is considered anemic. ¥ The red blood cells (RBCs) contain an important protein called hemoglobin. This protein holds oxygen and helps your red blood cells carry oxygen from your lungs to your body. It also helps carry carbon dioxide from your body to your lungs so you can breathe it out.tome | i + Ze = al x * To produce RBCs and hemoglobin, your body needs a consistent supply of iron and vitamins. Without that supply, your body won't produce enough hemoglobin to properly carry oxygen to your organs. It’s common for women to become anemic during pregnancy because they don’t have enough iron and other vitamins. What are the types of anemia affecting pregnant women? There are more than 400 types of anemia. Some are more common during pregnancy, including: ¥ Iron-deficiency anemia(IDA)- from a lack of iron. v Folate-deficiency anemia(FDA)- from a lack of folic acid ¥ Vitamin B12 deficiency anemia- from a lack of vitamin B12. / | poBriton Fa =e Who is most likely to have anemia during pregnancy? NOTE: Throughout pregnancy, the amount of blood in your body increases by 20% to 30%, That means your body needs more iron for more red blood cells. You may be at higher risk for anemia during pregnancy if you are: v Pregnant with multiples. b ¥ Not consuming enough iron v Having back-to-back pregnancies with minimal time between. wv Experiencing a heavy menstrual flow before pregnancy. ¥ Vomiting often because of morning sickness.stems BE tte + ne =a x How does anemia affect the baby during pregnancy? v The developing fetus relies on you to get enough iron, vitamin B12 and folic acid. Anemia can affect the growth of the fetus, especially during the first trimester. ¥ If anemia goes untreated, your baby is at higher risk of having anemia after birth, which can lead to developmental problems. Also, anemia increases the risk of delivering your baby early and having a low-weight baby. f |SIGNS AND SYMPTOMS: You may not notice any symptoms of mild anemia at first. Over time, you may feel ¥ Fatigue Yoo, * ¥ Shortness of breath. Other symptoms include: Y Dizziness or weakness Y Fast heartbeat(Tachycardia) v Headache. ¥ Pale, dry or easily bruised skin Y Sore tongue. v Unintended movement in the lower leg (restless legs syndrome).Diagnosis and Tests Y Regular Prenatal Check-Up Ya, V How is anemia treated in pregnancy? Treatment for anemia during pregnancy depends on the severity. If you have: Y¥ Mild to moderate anemia: Your provider will usually treat it with a daily prenatal vitamin or iron supplement. This gives your body healthy amounts of iron, vitamin B12 and folic acid, v _ Severe anemia: You may need a blood transfusion.of rome rte + ne =a x How can | treat anemia at home while pregnant? v Make sure you're getting enough iron, B12 and folic acid, ¥ Diet - green leafy vegetables, Meat, Organ meat ¥ Food that are high in vitamins that help your body absorb iron (like vitamin C) are important as well, including citrus fruits, tomatoes and peppers.What does untreated anemia do to the body? Untreated anemia can get worse over time. Having too little oxygen in the blood can damage your organs. It also forces the heart to work harder, increasing the risk of: * Arrhythmia (irregular heartbeat) * Enlarged heart. * Heart failure.i seme | as rs BO How can | prevent anemia during pregnancy? ¥ The best thing you can do for anemia prevention is to eat at least 30 milligrams (three servings) of iron each day. If you can’t get that much iron in your diet, talk to your provider about taking an iron supplement. v You should also take a prenatal vitamin daily. If possible, you should start taking renatal vitamins before you get pregnant. Some prenatal vitamins don’t have enough iron in them. So, talk to your healthcare provider to determine which type of prenatal vitamin is best for you Y Keep in mind that you can do all the right things and still get mild anemia durig pregnancy. That’s because of the natural increase in blood volume. If you feel tired, dizzy or have any other symptoms, talk to your provider.GESTATIONAL CONDITIONS + HYPEREMESIS GRAVIDARUM - PERNICIOUS or PERSISTENT VOMITING OF PREGNANCY ¥ Hyperemesis gravidarum (HG) is when extreme, persistent nausea and vomiting occur during your pregnancy. It can lead to weight loss and dehydration. Hyperemesis gravidarum is sometimes called severe morning sickness. v Hyperemesis gravidarum causes you to vornit several times per day. This can eventually lead to weight loss and dehydration. Symptoms of HG often last longer than morning sickness, You might need treatment in a hospital with I\f fluids (fluids given intravenously, or through your vein) if you become dehydrated, ,Symptoms and Causes What are the symptoms of hyperemesis gravidarum? - usually occurs during the first trimester of your pregnancy (beginning around 6 to 12 weeks of pregnancy). Symptoms can last weeks, months or up until delivery. They can be debilitating, preventing you from doing your normal activities. > The most comman symptomsof hyneremesis gravidarum are: ¥ Severe nausea. ¥ Vomiting more than three times per day. Y Losing more than 5% of your pre-pregnancy weight, ¥ Not being able ta keep foed or liquids down. ¥ Dehydration + Feeling dizzy or lightheaded. ¥ Peoing less than normal “ txtreme tiredness, ¥ Fainting, HeadachesWhat causes hyperemesis gravidarum? * Experts don’t know for sure what causes hyperemesis gravidarum. However, rising hormone levels are most likely what causes it. Specifically, HCG (human chorionic gonadotropin), which your body makes during pregnancy — very quickly and in large amounts, HCG levels peak around 10 weeks of pregnancy, which is when most people report having the most severe symptoms. Estrogen, another hormone that increases during pregnancy, may also play a role in causing nausea and vomiting.¥ Lifestyle changes: These changes might include wearing a pressure-poing wristband (acupressure bands) or eating ginger chews and drinking ginger tea for nausea ¥ Dietary changes: Small, frequent meals (every two hours) of bland, dry food can help with nausea and vomiting. *Crackers, toast, white potatoes or rice are good examples. ¥ avoid greasy or spicy foods, High fat food ¥ Avoiding triggers: You may notice certain things make you more nauseated, like specific smells or riding in a car. Try to avoid activities, that make you feel this way.Moderate to Severe hyperemesis gravidarum * Prescription medication: There are several prescription medications that can relieve nausea and vomiting. Your provider will start with a prescription that combines doxylamine and B6. The most common prescription medications for nausea and vomiting are promethazine _and metoclopramide. Ondansetron is another drug that can help with nausea and vomiting. Some of these medications are available through an IY, injection or rectal suppository if you can’t take them by mouth * Intravenous fluids + Tube feeding * Total parenteral intravenous nutrition (TPN)Ectopic Pregnancy * ectopic pregnancy is one in which —_ implantation occurred outside the uterine cavity(uterus) Cd Most common site: Fallopian Tube -80% - ampulla | -12% - isthmus -8% interstitial or fimbrial ‘Other Sites: ovary, cervix, peritoneal cavityAssessment ¥ Missed period, usual signs of pregnancy (Nausea and Vomiting, positive pregnancy test, etc) ¥ Spottingpbleeding (dark red or brownish), possible signs of hypovolemic shock ¥ Sharp stabbing pain IN La or RRa ¥ abdominal rigidity ¥ Referred shoulder pain (KEHR’S SIGN) due to blood in the peritoneum irritating the phrenic nerve ¥ CULLEN'S SIGN - ecchymosis blueness a‘ound the umbilicus indicating blood pooling in the peritoneum ¥ Dizziness, syncope Y 7. UTZ confirms extrauterine pregnancy & ruptureBev tom Assessment V Missed period, usual signs of pregnancy (Nausea and Vomiting, positive pregnancy test, etc) Y Spotting, bleeding (dark red or brownish), possible signs of hypovolemic shock v Sharp stabbing pain IN LLq or RRq ¥ abdominal rigidity ¥ Referred shoulder pain (KEHR’S SIGN) due to blood in the peritoneum irritating the phrenic nerve v CULLEN’S SIGN - ecchymosis blueness around the umbilicus indicating blood pooling in the peritoneum Y Dizziness, syncope Y 7. UTZ confirms extrauterine pregnancy & ruptureManagement * Before rupture, oral administration of METHOTREXATE (folic acid antagonist which destroys fast-growing cells) ‘ ¥ followed by LEUCOVORIN; treated until hCG is (-) ¥ Hysterosalpingogram to assess patency of the tube Y After rupture, BT if needed, laparoscopy to ligate bleeding vessels & remove or repair damaged tubes Y Assess for bleeding & pain ¥ Monitor VS, start IV with 18-gauge needle v Provide O2 therapy ¥ Administer RROGAM if Rh (-) Y Provide emotional supportComplication: v Hemorrhage ¥ Shock v Peritonitis * Etiology ¥ Salpingitis ¥ tumors v adhesions, or scarring v IUD use, ¥ narrowed oviducts y iGESTATIONAL TROPHOBLASTIC DISEASE/HY DATIDIFORM MOLE/MOLAR PREGNANCY (H-MOLE)¥ Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic vill ¥ It happens when grape-like cysts grow in your uterus instead of a placenta or a fetus, You may feel pregnant and get a positive pregnancy test, but find no baby growing during a prenatal ultrasound, The positive pregnancy test is due to the pregnancy hormone made inside the placenta. Two Types of H Mole 1. Complete Mole - All trophoblastic villi swell & become cystic; embryo dies early{ May lead to choriocarcinoma) f 2. Partial Mole - Some of the villi form normally(Rarely leads tof choriocarcinoma)deme Brin + Ze = a| x Assessment — Uterus expands faster than normal ' — No fetal heart sounds — hCG test is strongly positive (1 to 2 million IU) dt overgrowing trophoblast cells & remains positive after the 100th day of gestation — Marked N/V due to high hCG levels (1-2 Million |U/24hrs) — Positive pregnancy test — Abdominal pain — contain grapelike vesicles “ UTZ shows dense growth (snowflake pattern) but no f fetal growthDiagnosis ¥ Passage of vesicles- 1st sign — TRIAD SIGNS. Y Big uterus ¥ Vaginal bleeding: brownish, intermittent ¥ HCG >1 million 1U/24 hrs (NV: 400,000 !U/24hrs) + Ultrasound: no fetal sac, no fetal parts + XRAY: no fetal skeleton Therapeutic Management Y Monitor for signs of hemorthage, PIH, or other complications such as HELLP Syndrome H-EMOLYSIS E-LEVATED L-IVER ENZYME Low P-LATELETE COUNT ¥ Suction & curettage to evacuate the mole ¥ hCG is analyzed every 2 weeks until levels are normal. Afterwards, q 4 weeks for 6 to 12 months (increasgs suggests malignancy) fHELLP Syndrome Fatigue Fluid retention and excess weight gain H- eL-- ip Headache Worsening Nausea and vomiting Upper right abdomen pain * 10-20% of severe Pre- Blurry vision eclampsia and Nosebleed or other ; bleeding that won't stop Eclampsia easily (rare) + 1-2/1900 normal Seizures or convulsions pregnancies (rare)NOTE: Y¥ Should not get pregnant within 1 year of diagnosis because signs of pregnancy can mask signs of choriocarcinoma v Chest X-ray to detect early lung metastasis — if malignant, Methotrexate is the Drug of Choice ¥ Provide RHOGAM if Rh (-) ¥ Address emotional & psychosocial needs.ene FH + CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION/INCOMPETENT CERVIX) v cervix that dilates prematurely and cannot hold a fetus until term cause of habitual abortion v It usually at week 20 when the fetus is still too immature to survive. ¥ associated with : maternal age, congenital structural defects & trauma to the cervix (cone biopsy, repeated D & C) ¥ The dilatation is usually painless*** * — Ast symptom is usually - SHOW - increased pelvic pressure, - rupture of membranes & discharge of Amniotic Fluid ¥ Uterine contractions begin & after a short labor, the fetus is bornBerson + MANAGEMENT: ¥ Ultrasound - to confirm that the fetus is healthy weeks 12 to 14, by ¥ CERVICAL CERCLAGE- purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia ~- Sutures strengthen the cervix & prevents it from dilating. * After surgery v bed rest ¥ Position : slight or modified Irendelenburg position - to decrease pressure in the new sutures When to remove Sutures? v at weeks 37 to 38 so that the fetus can be born vaginally.Bev ene + TWO TYPES OF CERCLAGE 1. McDonald's cerclage 2. Shirodkar Procedure — Nylon sutures are placed — Sterile tape is threaded in horizontally & vertically a purse-string manner under across the cervix & pulled the submucous layer of tight to reduce the cervical _the cervix & sutured in place canal to a few millimeters in to achieve a closed diameter cervix. — Usually, temporary — Maybe permanent _+ ae GESTATIONAL CONDITIONS-SPONTANEOUS MISCARRIAGE “SPONTANEOUS MISCARRIAGE ® ABORTION is any interruption of a pregnancy before a fetus is viable (> 20 to 24 weeks & weighs at least 500 g} ~ ELECTIVE ABORTION — medical termination of a pregnancy ¥ MISCARRIAGE - spontaneous interruption of a pregnancy — Early miscarriage occurs: <16weeks — Late miscarriage :between 16 and 24 weeks1. Threatened Miscarriage Y Bleeding (+): scant, Bright Red ¥ No Cervical Dilatation(-)** Slightt Cramping/backache Management: ¥ Ultrasound and Fetal Heart Tone(FHT) v Assess amount of bleeding ¥ Monitor Vital signs; assess far impending shock( HYPO, TACHY, TACHY ) ¥ Provide emotional support Vv hCG titer at start of bleeding & after 24h (if viable, hCG doubles) ¥ Complete bed rest for 24 to 48 hours ¥ Avoid stress ¥ NO SEX FOR 2 WEEKS AFTER BLEEDING ***2. Imminent or Inevitable Miscarriage v Vaginal Bleeding (+) ¥ uterine contraction (+) ¥ Cervical Dilatation (+) Management ¥ assess bleeding ¥ save any tissue fragments passed © initiate IVT with an 18-gauge needle v If (-) FHT & UTZ reveals empty uterus or nonviable fetus, D&E ¥ after D & E monitor bleeding (saturating > 1 pad/hour is heavy bleeding) ¥ RhOGAM as necessary ¥ Provide psychological supportSIS nn + =e 3. Complete Miscarriage 4. Incomplete Miscarriage Symptoms: Symptoms: ¥ the entire products of conception (fetus, ¥_ Bleeding, cramping & part of the placenta, membranes) are expelled conceptus (usually the fetus) is expelled ¥ Bleeding, cramping & expulsion of but the rest are retained conceptus ‘ ¥ Bleeding slows within 2 hours then stops Y cervix is dilated within a few days after passage of conceptus ¥ danger of hemorrhage because the ¥ The cervix is closed & the uterus contracts Uterus cannot contract effectively Management: Management: ¥ Advise the woman to report heavy bleeding. YD & Cor suction curettage v/ No therapy needed since the process of is complete due to spontaneous expulsion of the entire products of conception.Borie + 5. Missed Miscarriage/ Early Pregnancy Failure Symptoms: ¥ the fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy ¥ Cervixis clased*** Dark brawn vaginal discharge ¥ Pregnancy test (-) Y Fundal height does not increase in sizeS Management: ¥ UIZ to establish fetal death Vv DRE ¥ IF> 14 wks AOG, Prostaglandin suppository of misaprostal (Cytotec} to dilate the cervis, fall deed by oxytocin or ¥ mifepristone, ¥ Miscarriage usually occurs spontaneously within 2 weeks Wf IFeancentus remains in the terns > S weeks risk far NIC and sensisDeve + 6, Recurrent Pregnancy Loss/Habitual Abortion V Three Spontaneous miscarriage that occurred at the same gestational age Causes: V Defective spermatozoa or ova ¥ Poor Thyroid Function ¥ Septate or Bicornuate Uterus ¥ Resistance to uterine artery blood flow ¥ Chorioamnionitis or uterine infection ¥ Autoimmune disorders such as Lupus Anticoagulant and Anti Phospholipid Antibodies yfComplications of Miscarriage Hemorrhage ¥ complete spontaneous miscarriage-serious or fatal hemorrhage is rare ¥ incomplete miscarriage or ina woman who develops an accompanying coagulation defect (usually DIC)- major hemorrhage becomes a possibility *"* Disseminated intravascular coagulation (DIC) abnormal blood clotting throughout the body's blood vessels. You may develop DIC if you have an infection or injury that affects the body's normal blood clotting process. Management ¥ Monitor VS v¥ Position flat on bed ¥ Blood replacement if necessary ¥ D&Ceens | Blo tne 2. Infection v fever v¥ abdominal pain or tenderness ¥ foul-smelling vaginal discharge », Management v Wipe perineal are : front-back after each voiding and defecation ¥ {X) use of tampon