PRE-GESTATIONAL CONDITION | MCN 2
RHEUMATIC HEART DISEASE (RHD) 2. Heart arrhythmia
- Is the inflammatory response from rheumatic
fever, can permanently damage the valves in the
heart.
- Rheumatic Fever is an acute, nonsuppurative,
immunologically mediated, multi-system
inflammatory disease.
o Occurs a few weeks after an episode of
group A Streptococcal pharyngitis.
o Affects: heart, joints, CNS, skin and
subcutaneous tissues
- Chronic, progressive, permanent heart valve
damage that remains after the ARF episode has
resolved wherein:
o Heart has become inflamed
o Heart valves remain stretched and/or
scarred
o Normal blood flow is interrupted
- Sometimes RHD, especially mitral stenosis, 1 st
diagnosed during pregnancy or soon after
delivery
PATHOPHYSIOLOGY
ASSESSMENT
1. Full history and examination
RISK FACTORS
1. Reduced left ventricle systolic function
2. Significant aortic or mitral stenosis
3. Moderate or severe pulmonary hypertension
4. A history of heart failure
5. Symptomatic valvular disease before pregnancy
6. Poverty, overcrowding & reduced access to
medical care
SYMPTOMS
1. Chest pain, heart palpitations
2. Breathlessness on exertion
3. Orthopnea
4. Paroxysmal nocturnal dyspnea
5. Edema
6. Syncope
7. Fever associated with infection of damaged heart
valves
COMPLICATIONS DURING PREGNANCY
1. Mitral valve stenosis
3. Heart failure
DIAGNOSTIC TESTS
1. Chest X-ray
2. Electrocardiogram (ECG)
3. Echocardiogram
TREATMENT DURING PREGNANCY
1. DIURETICS: ↑ production & excretion of urine,
which can help ↓ blood volume and BP
2. BETA-BLOCKERS: treat & prevent heart
arrhythmias
3. PERCUTANEOUS BALLOON MITRAL
VALVULOPLASTY (PBMV): small balloon
inflated in the mitral valve to help keep it open.
MEDICAL MANAGEMENT DURING PREGNANCY
1. Women with moderate or severe rheumatic heart
disease require close supervision, normally at a
tertiary referral centre with cardiology and
intensive care facilities.
2. Women requiring anticoagulation during
pregnancy are at additional risk of complications.
3. Women on secondary prophylaxis should
continue treatment. Any prescribed antibiotic
secondary prophylaxis is safe during pregnancy.
4. Many women with a history of acute rheumatic
fever or mild rheumatic heart disease require no
special management during pregnancy but or
early in pregnancy, by a cardiologist and
obstetrician to establish the safest birth pathway.
GESTATIONAL DIABETES MELLITUS (GDM)
- appearance of higher-than-expected blood
sugars during pregnancy.
- form of glucose intolerance with the onset or first
recognition during pregnancy (24-28 wks of
gestation).
- primary problem in controlling balance between
insulin and blood glucose levels.
ETIOLOGY
ASSESSMENT
 3P’s (polyuria, polydipsia, polyphagia)
 Dizziness if hypoglycemic
 Confusion if hyperglycemic
 Possibility of increased monilial infection
 Glycosuria
 Macrosomia
 Hyperglycemia
PRE-GESTATIONAL CONDITION | MCN 2
PATHOPHYSIOLOGY  2hr OGTT level (drink 75 g of glucose & do not
eat anything until blood is drawn)
 Fasting blood glucose level
 Hemoglobin A1C test: No fasting required
 Urine glucose/ketones: fresh urine specimen
 Urine microalbumin: fresh urine specimen
RISK FACTORS FOR DEVELOPING GDM COMPONENTS OF DIABETES MANAGEMENT
 Obesity 1. Nutritional mgt.
 History of large babies 2. Exercise
 History of unexplained fetal or perinatal loss 3. Monitoring
 Family history of diabetes 4. Pharmacologic mgt.
5. Education
RISKS ASSOCIATED WITH DIABETES IN
PREGNANCY GOALS OF DIABETES MANAGEMENT
Maternal Risks Fetal Risks  Reduce symptoms
 Preeclampsia  Birth injuries  Promote well-being
 Increased  Childhood obesity  Prevent acute complications
caesarean delivery  Hyperbilirubinemia  Delay onset & progression of long-term
 Progression of  Hypoglycemia complications
chronic  Macrosomia
complications of  Shoulder dystocia SUBSTANCE ABUSE
diabetes  Respiratory distress - Use of illegal or inappropriate use of legal drugs
 Gestational syndrome to:
hypertension  Premature birth o produce pleasure,
 Hypoglycemia  Abnormal birth o alleviate stress, or
 Infection weight o alter/avoid reality.
 Ketoacidosis  Increased ADDICTION
 Polyhydramnios congenital - Habitual psychological/physical dependence on
 Preterm labor malformations substance/practice beyond voluntary control.
 Seizures
 Doubled COMMONLY ABUSED SUBSTANCES
spontaneous  Alcohol
abortion risk  Illicit drugs including:
o marijuana, cocaine, heroin
MACROSOMIA PATHOGENESIS o hallucinogens
1. Mother’s blood brings extra glucose to the fetus o inhalants
2. Fetus makes more insulin to handle extra o tranquilizers
glucose o stimulants
3. Extra glucose gets stored as fat and fetus o sedatives
becomes larger than normal
PATHOPHYSIOLOGY
ACTION OF INSULIN AND GLUCAGON ON  mother uses a drug -> placenta & umbilical cord -
BLOOD GLUCOSE LEVES > fetus -> permanent damage
(A) High
blood glucose
is lowered by
insulin release.
(B) Low
blood glucose
is raised by
glucagon
release. RISKS OF DRUG USE DURING PREGNANCY
- miscarriage, stillbirth
DIAGNOSTIC STUDIES - small gestational age (SGA), low birth weight
 Fasting plasma glucose level (LBW)
 Random plasma glucose measurement - premature birth, birth defects, sudden infant
PRE-GESTATIONAL CONDITION | MCN 2
death syndrome (SIDS) NICOTINE EFFECTS ON SMOKERS
- drug-dependency in the infant  Acute effects
 Vasoconstriction, ↑ secretions
TERATOGENIC EFFECTS OF PRENATAL  Chronic effects
ALCOHOL EXPOSURE  Lung disease, heart disease, Increases cancer
 Direct toxic effect of alcohol on cells. risk
 Hypoxia due to impaired placental/fetal blood TOBACCO EXPOSURE:
flow. Nicotine withdrawal Smoking Effects on
 Effect on cell migration in the brain. on Mother Fetus
 Effect on apoptosis (natural process of cell  craving for tobacco  poor fetal
death).  irritability, growth/IUGR
 Behavioral disorders frustration, anger  LBW
 Fetal Alcohol Syndrome (permanent birth defect,  anxiety  fetal death
cause of mental retardation)  difficulty  preterm delivery
concentrating  intrauterine hypoxia
MARIJUANA USE  restlessness  spontaneous
- Marijuana smoking produces higher levels of  depression abortion
carbon monoxide than tobacco, a potential  placenta previa
mechanism of action of marijuana’s impact on the  SIDS risk >4x higher
developing fetus.
- Long-term use causes psychological CAFFEINE
dependence/lung damage - Substance in coffee, tea, soft drinks, chocolate
and certain medications.
EFFECTS OF MARIJUANA: - Stimulates CNS w/in 15 minutes.
 MOTHER: - Moderate doses (2–4 cups of coffee)
- relaxation, hallucination, panic attacks ↑alertness/provide an energy boost.
- short-term memory impairment, amnesia - Large doses = restlessness & irritability,
 FETUS insomnia, headaches and abnormal heart
- Intrauterine growth retardation rhythms.
- Abnormal startle reflexes in newborns - Creates psychological dependence
- Reduced memory & verbal skills at age 4 - Withdrawal symptoms = headache, muscle
years pain and fatigue.

COCAINE EXPORUSE: produce direct neurotoxic HIV / AIDS

effects
 Prenatal Complications
 stillbirth, placental abruption, premature
rupture of membranes
 fetal distress, preterm delivery, growth
retardation
METHAMPHETAMINE EXPOSURE: produce
neurotoxic effects.
 premature delivery, placental abruption,
cardiac anomalies
 fetal growth reduction
TOBACCO EXPOSURE: Cigarette smoke
contains;
1. Tar contains substances (lead, cyanide,
cadmium, etc.) harmful to the fetus.
2. Nicotine crosses the placenta and distributes
freely to the CNS, having effects on neural
development.
3. Carbon monoxide causes intrauterine hypoxia
and reduced uterine blood flow that leads to
growth impairment.
Secondhand smoke contains toxic chemicals.
 Human Immunodeficiency Virus
H= uman beings are only infected.
I= mmunodeficiency virus weakens the immune
system and increases the risk of infection
V= irus that attacks the body
 HIV attacks lymphocytes (WBC’s) called T-
cells.
 The reduction of T-cells results in a weakened
immune system
 Acquired Immune Deficiency Syndrome
A= cquired not inherited.
I= mmune system weakened.
D= efficiency of CD4+ cells in the immune
system created.
S= yndrome or group of illnesses taking place at
the same time
 AIDS is caused by HIV
 AIDS diagnosis is made once opportunistic
diseases occur.
 HIV infection -> destroy the immune system ->
immune system weakened by HIV -> progresses
to AIDS.
 PRE-GESTATIONAL CONDITION | MCN 2
CAUSES
 Human immunodeficiency virus (HIV) causes HIV
infection and AIDS, attacks the immune system.
ETIOLOGIC AGENT (AIDS)
 Former names of the virus include:
- Human T cell lymphotrophic virus (HTLV-III)
- Lymphadenopathy associated virus (LAV)
- AIDS associated retrovirus (ARV)
TRANSMISSION OF HIV
1. Direct contact; infected bld, semen, vaginal and
cervical secretions
2. Sexual contact: oral, anal, or vaginal
3. HIV-infected mothers to infants during
pregnancy, delivery and breastfeeding
4. Sharing of hypodermic needles & Blood
transfusions (Rare)

 HIV continues to reproduce, CD4 count gradually

declines from its normal value (500-1200).
 Once CD4 count drops below 500, HIV infected
person is at risk for opportunistic infections.
 The following diseases are predictive of the
progression to AIDS:
AIDS CANNOT BE SPREAD BY:
o persistent herpes-zoster infection (shingles)
o oral candidiasis (thrush)  Sharing food
o oral hairy leukoplakia  Bed linen, Door knobs, Telephones, Towels,
o Kaposi’s sarcoma (KS) Combs
 Kaposi’s sarcoma (KS) is a rare  Swimming pool
cancer of the blood vessels that is  Travelling, Shaking hands, Living and working
associated with HIV. It manifests as with infected persons
bluish-red oval-shaped patches that may  Kissing, Hugging
eventually become thickened. Lesions  Toilet seat
may appear singly or in clusters.  Mosquitos, flies and other insects

PEOPLE AT RISK
 Injection drug users who share needles.
 Infants born to mothers with HIV who did not
receive HIV treatment during pregnancy.
 People who have unprotected sex.
 Sexual partners engaged in high-risk activities.

DIAGNOSTIC TESTS
1. ELISA tests useful for:
OPPORTUNISTIC INFECTION  Screening blood products.
- do not normally develop in people with a healthy  Diagnosing and monitoring patients.
immune system.  Determining prevalence of infection.
 Research investigations.
COMMON SYMPTOMS ARE: 2. Western Blot - most popular confirmatory test.
 Fever, Chills 3. CBC and WBC differential
 Rash 4. Pap smear, Anal pap smear
 Sweats (particularly at night) 5. Indirect Immunoflourescence - used to detect
 Swollen lymph glands both virus and antibody.
 Weakness 6. Polymerase Chain Reaction - looks for HIV
 Weight loss DNA in the WBCs of a person.
7. Regular blood tests for CD4 cell count
SYMPTOMS 8. HIV RNA level
 Diarrhea
TREATMENT
 Headache, Fever, Night sweats
 Mouth sores, including yeast infection  Antiretroviral therapy
 Muscle stiffness or aching
COMMON SIDE EFFECTS
 Rashes of different types
 Swollen lymph glands, sore throat  Collection of fat on the back (buffalo hump) and
 Chronic fatigue, Unexplained weight loss abdomen
 General sick feeling ( malaise), Weakness,
 There may be no symptoms for up to 10 -12 years until the
immune system is suppressed enough to cause problems
 PRE-GESTATIONAL CONDITION | MCN 2
Headache, Nausea reaction within the body.
 When used for a long time, increases risk of  If blood is Rh(-), it will be tested for antibodies to
heart attack, perhaps by increasing levels of Rh(+) blood. If you have antibodies, you’ve been
cholesterol and glucose (sugar) in the blood. sensitized to Rh(+) blood. The antibodies can kill
Rh(+) RBC’s.
PREVENTION  If you’re pregnant or have miscarried, molar
 Don’t use illegal drugs, do not share pregnancy, or an ectopic pregnancy, you will
needles/syringes. need testing to see if you have been sensitized to
 Avoid contact with another person's blood. Rh(+) blood.
 (+) HIV person should not donate blood, plasma,
body organs, or sperm.
 HIV (+) women who plan to get pregnant should
talk to their health care provider about the risk to
their unborn child.
 BF should be avoided to prevent passing on HIV
to infants through breastmilk.
 Safer sex practices
 Public health strategies to prevent HIV RISK FACTORS
transmission:  Risk for Rh incompatibility include being an Rh(-)
- Screen all blood and blood products. pregnant woman who:
- Follow universal precautions. - Had a prior pregnancy w/ a baby that was
- Educate in safer sex practices. Rh(+).
- Identify & treat STIs/other infections. - Had a prior blood transfusion or
- Provide referral for treatment of drug amniocentesis.
dependence. - Did not receive Rh immunization prophylaxis
during/prior to pregnancy w/ an Rh(+) baby.
WHEN SHOULD A CLIENT BE TESTED? If a client:
1. Have had any STD. SYMPTOMS
2. Shared drug needles.  Symptoms and complications only affect the
3. Had sex with a prostitute. baby.
4. Had sex w/ a man who had sex w/ another man.  Symptoms that can develop in the baby include:
5. Had unprotected sex w/ 3 or more partners. - Swelling of the body, which may be associated
with heart failure or respiratory problems.
REMEMBER:
- Jaundice, Anemia, Low muscle tone and
 Could take 3-6 mos. before antibodies appear in blood.
lethargy
 No symptoms during incubation.
 Wait to be tested until 6 months with no risk behavior.
POSSIBLE COMPLICATIONS INCLUDE:
1. Brain damage due to high levels of
Rh SENSITIZATION bilirubin (kernicterus)
 Rh (Rhesus) Factors – CHON that may be 2. Fluid buildup & swelling in the baby
found on the surface of RBC’s, (+) CHON = Rh (hydrops fetalis)
(+), (-) CHON = Rh (-). 3. Problems w/ mental function, movement,
o The Rh factor describes another surface hearing, speech, and seizures
protein on the RBC. It is named after the
Rhesus Monkey, where it was initially PATHOPHYSIOLOGY
identified.
o If your blood does contain the Rh protein, your
blood is said to be Rh positive (+)
o If your blood does NOT contain the Rh protein,
your blood is said to be Rh negative (-)
 Rh Incompatibility – condition that develops
when a pregnant woman is Rh(-) blood & the
fetus has Rh(+).
 Rh Isoimmunization - Rh(+) blood from the
baby will make the mother's body create
antibodies.
 Rh Sensitization - antigen-antibody immunologic
PRE-GESTATIONAL CONDITION | MCN 2
DIAGNOSTIC EXAMINATION
1. Maternal blood type, Rh factor and antibody
screening.
2. A (+) direct Coombs test result- to look for the
presence of cell-destroying antibodies on the
surface of RBC’s.
3. Indirect Coomb’s test - to see if your Rh(+)
antibody levels are increasing.
FETAL ASSESSMENT INCLUDES:
1. PUBS/Cordocentesis - for monitoring known
sensitization problems.
2. Amniocentesis - to check for the fetus's blood
type and Rh factor.
3. Fetal ultrasound - to detect sensitization
problems, such as fetal fluid retention.
4. Electronic fetal heart monitoring (nonstress
test) – done on the 3rd trimester.
TREATMENT
1. RhoGAM (Rh immunoglobulin) - prevents Rh(-)
mother's antibodies from reacting to baby’s Rh(+)
RBC’s. Given around 28th wk of pregnancy &
within 72 hours after delivery birth.
2. Phototherapy for infants - work by helping to
break down bilirubin in the skin.
PREVENTION: RhoGAM injections must be given:
 During every pregnancy
 If they have a miscarriage/abortion
 After prenatal tests (amniocentesis)
 After injury to the abdomen during pregnancy
ANEMIA IN PREGNANCY
 Anemia – lack of RBC’s, can lead to lack of O2-
carrying ability of the blood, causing unusual
tiredness.
 TYPES OF ANEMINA IN PREGNANCY
o Iron-deficiency anemia
o Folate-deficiency anemia
o Vitamin B12 deficiency
 IRON-DEFICIENCY ANEMIA (IDA) - the body
doesn't have enough iron to produce adequate
amounts of hgb.
 FOLATE-DEFICIENCY ANEMIA - also called
folic acid, a type of B vitamin. Folate produces
new cells, including healthy RBC’s.
 VITAMIN B12 DEFICIENCY - the body needs
vitamin B12 to form healthy RBC’s.
SYMPTOMS
- Pale skin, lips, and nails
- Feeling tired or weak
- Dizziness or light-headedness
- Shortness of breath
- Palpitations
- Trouble concentrating
RISK FACTORS FOR DEVELOPING ANEMIA IN
PREGNANCY
 All pregnant women are at risk for becoming
anemic because they need more iron & folic acid
than usual, and the risk is higher if you:
- are pregnant with multiples
- have had two pregnancies close together
- vomit a lot because of morning sickness
- are pregnant teenager
- don't eat enough foods that are rich in iron
- had anemia before you became pregnant
RISK OF ANEMIA IN PREGNANCY
 Severe or untreated IDA during pregnancy can
increase the risk of having:
- preterm or low-birth-weight baby, blood
transfusion
- postpartum depression, a baby with anemia
- a child with developmental delays
 Untreated folate deficiency can increase the
risk of having a:
- Preterm or low-birth-weight baby
- Baby with a serious birth defect of the spine or
brain (neural tube defects)
 Untreated vitamin B12 deficiency can also
raise the risk of having a baby with neural tube
defects.
CAUSES:
- Increased demand for iron and other vitamins.
- Inadequate dietary intake, a diet low in iron
- Lack of folic acid in the diet, a lack of vitamin B12
- Loss of blood due to bleeding from hemorrhoids
or stomach ulcers.
- A previous pregnancy
- Pregnancies that are close together
- Women carrying twins or triplets.
- A normal recurrent loss of iron in menstrual
blood.
POSSIBLE COMPLICATIONS
- Difficulty in breathing, palpitations and angina
- Severe anemia due to loss of blood after the
delivery
DIAGNOSTIC TESTS
- Hgb test - measures the amount of hgb, an iron-
rich CHON in RBC’s that carries O2 from the
lungs to tissues in the body.
- Hct test - measures the percentage of RBC’s in
a sample of blood.
TREATMENT
- iron supplement and/or folic acid supplement
- vitamin B12 supplement to treat vit B12
deficiency
- include more animal foods in a diet, such as
meat, eggs and dairy products
PRE-GESTATIONAL CONDITION | MCN 2
PREVENTION
- Eat well-balanced meals
- Aim for at least 3 servings a day of iron-rich foods
- Vitamin C can help the body absorb more iron
- Choose foods that are high in folic acid
- Follow your doctor's instructions for taking a
prenatal vitamin that contains a sufficient amount
of iron and folic acid.