PREGESTATIONAL
with a sore throat & leads to
CONDITIONS
I. HEART DISEASE
● Pregnancy results in
increased cardiac output,
heart rate & blood volume.
● Normal heart is able to adapt
to these changes without
difficulty.
● Woman with heart disease
has decreased cardiac
reserve, making it more
difficult for her to handle the
higher workload of
pregnancy.
● Cardiac disease
complicates about 1% of
pregnancies.
1. CONGENITAL HEART DEFECTS
● Most commonly seen in
pregnant women include:
❖ Atrial septal defect
❖ Patent ductus
arteriosus
❖ Coarctation of aorta
❖ Tetralogy of fallot
➢ impact of pregnancy depends on the
specific defect.
➢ if the heart has been surgically
repaired & no evidence of heart
disease remains, the woman may
undertake pregnancy with
confidence.
➢ woman with CHD who experience
cyanosis should be counseled to
avoid pregnancy because the risk to
mother & fetus is high.
2. RHEUMATIC HEART DISEASE
● Results from an infection
(caused by the bacteria,
streptococci) known as
rheumatic fever, which starts
the scarring of one or more
heart valves.
● The injured valves are
unable to open & close
normally, resulting in
obstruction to the flow of
blood.
● Is it possible to become
pregnant?
LABORATORY TESTS FOR DETECTING
RHD:
1. Throat cultures- for group A
streptococcus usually are negative
by the time symptoms of rheumatic
fever or RHD appear.
● Isolate the organism before
the initiation of antibiotic
therapy to help confirm a
diagnosis of streptococcal
pharyngitis & to allow typing
of the organism if it is
isolated successfully.
2. Rapid Antigen- this test allows rapid
detection of group A streptococcal
antigen & allows the diagnosis of
streptococcal pharyngitis & the
initiation of antibiotic therapy while
the patient is still in the physicians
office.
3. Anti-streptococcal Antibodies
● this is useful for confirming
previous group A
streptococcal infection.
Antibody titer should be
checked @ 2-week intervals
in order to detect a rising
titer.
● Causes different types of heart valve
defects.
 ● Commonly causes narrowing of the
valve between the left chambers of
the heart (a condition called mitral
stenosis) in women of child bearing
age.
● If you have mitral stenosis, you ma
develop breathing
difficulty(dyspnea), swelling of the
ankle & feet (edema), & irregular
heartbeats (arrhythmia).
● Can also cause abnormal leaking of
blood through the valve between the
left chambers of the heart ( a
condition called mitral
regurgitation).
General measures to be followed once
you become pregnant:
● Make sure to keep your follow-up
appointments with your obstetrician
throughout your pregnancy.
● Plan regular follow-up visits with
your cardiologist.
● Carefully follow all the
recommendations of the cardiologist.
● The diet should be nutritious & fluid
& sodium intake should be
restricted.
● Take adequate rest.
● Watch your weight.
● Avoid alcohol.
● Stop smoking.
II. DIABETES MELLITUS
● An endocrine disorder of
carbohydrate metabolism, results
from inadequate production or use of
insulin.
● Insulin- produced by B cells of Islets
of Langerhans in the pancreas,
lowers blood glucose levels by
enabling glucose to move from the
blood into muscle & adipose tissue
cells.
PATHOPHYSIOLOGY
● Pancreas- fails to produce insulin or
does not produce enough insulin to
allow necessary carbohydrate
metabolism.
● Without insulin, glucose does not
enter the cells & they become
energy depleted.
● Blood glucose level remains high
(hyperglycemia) & the cells &
breakdown results in a negative
nitrogen balance; fat metabolism
causes ketosis.
SIGN & SYMPTOMS
1. Polyuria ihi ng ihi
2. Polydypsia excessive thirst
3. Polyphagia excessive hunger
4. Weight loss
THREE MAIN TYPES OF DIABETES:
1. Type I diabetes- results from the
body’s failure to produce insulin, &
presently requires the person to
inject insulin.
2. Type II diabetes- results from insulin
resistance, a condition in which cells
fail to use insulin properly,
sometimes combined wit an
absolute insulin deficiency.
3. Gestational diabetes- is when
pregnant women, who have never
had diabetes before, have a high
blood glucose level during
pregnancy.
DIABETES ON PREGNANCY OUTCOME
● The pregnancy of a woman who has
diabetes carries a higher risk of
complications, especially perinatal
mortality & congenital anomalies.
● Tight metabolic control reduces the
risk.
MATERNAL RISKS
1. Hydramnios - increase in the volume
of amniotic fluid, occurs in 10% to
20% of pregnant women with
diabetes.
● a result of excessive fetal
urination because of
hyperglycemia.
● PROM & onset of labor may
occasionally be a problem
with hydramnios.
2. Preeclampsia-eclampsia - occurs
more often in diabetic pregnancies
than in normal pregnancies.
FETAL - NEONATAL RISK
1. Congenital Anomalies - incidence is
5% to 10% & is the major cause of
death of infants born to women with
diabetes.
● Ex. Heart, CNS, skeletal
system
2. Respiratory Distress Syndrome -
appears to result from high levels of
fetal insulin, which inhibit some fetal
enzymes necessary for surfactant
production.
3. Polycythemia - excessive number of
RBCs, due to the diminished ability
of glycosylated hemoglobin in the
mother’s blood to release oxygen.
MANAGEMENT
● ANTEPARTAL
❖ Prenatal care- using a team
approach to ensure an
optimally healthy mother &
newborn.
- woman needs clear explanations &
teaching to gain her cooperation in
ensuring a good outcome.
- the nurse-educator plays a major
role in this counseling.
- the woman with pregestational
diabetes needs to understand what
changes she can expect during
pregnancy.
a. Dietary Regulation
- the pregnant woman with
diabetes needs to increase
her caloric intake by absent
300 kcal/day.
- on the first trimester she
needs about 35 kcal/day of
ideal body weight.
Approximately 40% to 50%
of the calories came from
complex, high fiber
carbohydrates, 20% from
protein, & 30% to 40% from
fats.
- the food is divided into 3
meals & 3 snacks. Bedtime
snack is the most important
& should include both protein
& complex carbohydrates to
prevent nightime
hypoglycemia.
b. Glucose Monitoring
- is essential to determine the
need for insulin & to assess
glucose control.
c. Insulin Administration
- Many women with
gestational diabetes need
insulin to maintain normal
glucose levels. Human
insulin should be used
because it is the least likely
to cause an allergic reaction.
- given either in multiple
injections or by continuous
subcutaneous infusion.
➔ Oral hypoglycemics- not rarely used
 ● INTRAPARTAL
a. Timing of birth- most pregnant
women with diabetes, regardless of
the type are allowed to go to term,
with spontaneous labor.
❖ Some clinicians opt to induce labor
in a woman at term to avoid
problems related to an aging
placenta.
❖ Cesarean birth maybe indicated if
signs of fetal distress exist.
b. Labor management - maternal
glucose levels are measured hourly
to determine insulin need.
❖ Primary goal is to prevent neonatal
hypoglycemia.
❖ Often given two IV lines are used,
one with a 50% dextrose solution &
one with a saline solution.
❖ The saline solution is for
piggybacking insulin or if a bolus is
needed.
❖ IV insulin is discontinued @ the end
of the third stage of labor.
Postpartal Management
● First 24 hours postpartum, women
with pre-existing diabetes typically
require very little insulin.
● They are usually managed with a
sliding scale specifying dosage
based on blood glucose levels.
● Antihyperglycemics are
contraindicated during
breastfeeding.
● The woman should be reassessed 6
weeks postpartum to determine
whether her glucose levels are
normal. If the levels are normal, she
should be reassessed at a minimum
of 3-year intervals.
III. SUBSTANCE ABUSE
● Occurs when a person experiences
difficulties with work, family, social
relations, & health as a result of
alcohol or drug use.
● Drugs that are commonly misused
includes:
➔ tobacco, alcohol, cocaine,
marijuana, amphetamines,
barbiturates, hallucinogens,
club drugs, heroin and
narcotics.
Substances commonly abused during
pregnancy
1. Alcohol- is a central nervous
system depressant & a potent
teratogen.
❖ The incidence of alcohol
abuse is highest among
women ages 20 to 40 years
although alcoholism is also
seen in teenagers.
❖ Chronic abuse of alcohol can
undermine maternal health
by causing malnutrition, bone
marrow suppression,
increased incidence of
infections, & liver disease.
❖ Alcohol dependence- result
is that a woman may have
withdrawal seizures in the
intrapartal period as early as
12 to 48 hours after se stops
drinking.
❖ Delirium tremens may occur
in the postpartal period & the
newborn may suffer a
withdrawal syndrome.
❖ Care includes sedation to
decrease irritability &
tremors, seizure precautions,
IV fluid therapy for hydration
& preparation for an addicted
newborn.
❖ The effect of alcohol on the
fetus may result in a group of
 signs known as fetal alcohol
syndrome (FAS).
2. Cocaine & crack
❖ Nearly 3% of pregnant
women use illicit drugs such
as cocaine, marijuana,
ecstasy, other amphetamines
& heroin.
❖ Cocaine use during
pregnancy tends to affect
between 1% & 5% of
newborns.
● Cocaine- acts as the nerve
terminals to prevent the reuptake of
dopamine & norepinephrine, which
in turn results in vasoconstriction,
tachycardia, & hypertension.
● This can be taken by IV injection or
by snorting the powdered form.
● Crack- a form of freebase cocaine
that is made up of baking soda,
water, and cocaine mixed into a
paste and microwaved to form a
rock, can be smoked. Smoking crack
leads to a quicker, more intense high
because the drug is absorbed
through the large surface area of the
lungs.
Major adverse maternal effects oF
cocaine use includes:
● Hallucinations
● Pulmonary edema
● Cerebral hemorrhage
● Respiratory failure
● Heart problems
❖ Women who use cocaine have an
increased incidence of spontaneous
abortion, abruptio placentae,
preterm birth, and stillbirth.
❖ Cocaine crosses into breastmilk and
may cause symptoms in the
breastfeeding infant, including
extreme irritability, vomiting,
diarrhea, dilated pupils, and apnea.
❖ Thus, women who continue to use
cocaine after childbirth should avoid
breastfeeding.
3. Marijuana - is the most widely used
illicit drug among women, both
pregnant and non pregnant.
❖ More than 25% women of
reproductive age admit to
current or past marijuana
use.
❖ Marijuana use is associated
with impaired coordination,
memory, and critical thinking
ability.
❖ As a result, the pregnant
women or new mother who
uses marijuana may be at
risk if she tries to perform
tasks that require complex
mental activities.
4. MDMA (Ecstasy)
❖ Methylenedioxymethampheta
mine (MDMA), better known
as Ecstasy, is the most
commonly used of a group of
drugs referred to as club
drugs, so called because
they have become popular
among adolescents and
young adults who frequent
dance clubs and “raves”.
❖ Is taken by mouth usually as
a tablet. It produces euphoria
and feelings of empathy for
others.
5. Heroin - is an illicit CNS depressant
narcotic that alters perception and
produces euphoria. It is an addictive
drug that is generally administered
IV.
❖ Pregnancy in women who
use heroin is considered high
 risk because of the increased
incidence in these women of
poor nutrition, iron deficiency
anemia, and preeclampsia.
❖ The fetus of a
heroin-addicted woman is at
increased risk for IUGR,
meconium aspiration, and
hypoxia.
❖ The newborn frequently
show signs of heroin
addiction such as
restlessness; shrill,
high-pitched cry; irritability;
fist sucking, vomiting, and
seizures.
6. Methadone- is the most commonly
used therapy for women dependent
on opioids such as heroin.
❖ Blocks withdrawal symptoms
and reduces or eliminates
the craving for narcotics.
❖ Crosses the placenta and
has been associated with
preeclampsia, placental
problems, and abnormal fetal
presentation.
❖ Prenatal exposure to
methadone may result in
reduced head circumference
and lower birth weight.
MANAGEMENT
● A team approach to the care of the
pregnant woman with substance
abuse problems ensures the
management necessary to provide
safe labor and birth for the woman
and her child.
● The management of drug addiction
may include hospitalization if
necessary to start detoxification.
● Urine screening is also done
regularly throughout the pregnancy if
the woman has a known or
suspected substance abuse
problem. This testing helps to
identify the type and amount of drug
being abused.
● Little is yet known about the effects
of MDMA on pregnancy. However,
the timing of ecstasy used by the
pregnant woman during fetal brain
development may be critical issue.
● Infants exposed to ecstasy in utero
may experience some of the same
risks as infants exposed to other
amphetamines during pregnancy,
including the possibility of withdrawal
–like symptoms such as drowsiness,
jitteriness, and breathing problems.
IV. HIV/AIDS
● Human immunodeficiency virus
infection is one of today’s major
health concerns.
● It leads to a progressive disease that
ultimately results in acquired
immunodeficiency syndrome
(AIDS).
● Women account for about 18% of
cases in the U.S.
PATHOPHYSIOLOGY
● HIV-1 enters the body through:
➔ Blood
➔ Blood products
➔ Or other body fluids such as
semen, vaginal fluid and
breastmilk
● It affects T-cells, thereby decreasing
the body’s immune responses.
● This makes the affected person
susceptible to opportunistic
infections such as Pneumocystis
carinii
● Once infected with the virus, the
individual develops antibodies that
 can be detected with the
enzyme-linked immunosorbent
assay (ELISA) & confirmed with the
Western Blot test.
● Can be detected within 6 mos after
exposure.
● Asymptomatic lasting from a few
mos to as long as 17 years.
● Diagnosis of AIDS is made when a
person is HIV positive & has one of
several specific opportunistic
infections.
MATERNAL RISK
● Many women who are HIV positive
choose to avoid pregnancy because
of the risk of infecting the fetus & the
possibility of dying before the child is
raised.
● Women who become pregnant
should be advised that pregnancy is
not believed to accelerate the
progression of HIV/AIDS, that the
use of antiretroviral (ARV) therapy
during pregnancy significantly
reduces the risk of transmitting the
HIV-1 to the fetus, and that most
medications used treat HIV can be
taken during the pregnancy.
Fetal-Neonatal Risks
● HIV/AIDS may develop in infants
whose mothers are seropositive,
usually due to perinatal
transmission.
● Perinatal transmission occurs
transplacentally, at birth when the
infant is exposed to maternal blood
and vaginal secretions, via
breastmilk.
MANAGEMENT
● Combination of ARV therapy
suppresses viral replication, helps
preserve immune function, and
reduces the development of
resistance.
● Usually consists of two nucleoside
analogues reverse transcriptase
inhibitors and a protease inhibitor.
● Zidovudine (ZDV) is perhaps the
best known of the nucleoside
analogues.
● Pregnant women who are currently
on ARV therapy should continue
their provider-recommended
regimen and should receive regular,
careful monitoring for pregnancy
complications and possible toxicities.
● Because the fetus is most
susceptible to teratogenic effects
during the first 10 weeks of
pregnancy, and the risks of ARV
therapy is not well known, women in
1st trimester might elect to delay
therapy until after 12 weeks
gestation.
● To reduce the risk of perinatal
transmission, all pregnant women
with HIV infection should be offered
the three-part ZDV prophylaxis
regimen beginning after the first
trimester.
● This regimen includes:
1. Oral ZDV daily
2. Intravenous ZDV during labor
until birth
3. Oral ZDV for the infant
starting 8 to 12 hours after
birth and continuing for 6
weeks.
● At each prenatal visit, asymptomatic,
HIV infected women are monitored
for early signs of complications, such
as weight loss in the second or third
trimester or fever.
● Each trimester the woman should
have a visual examination and
 examination of the retina to detect
such complications as
toxoplasmosis.
● In addition to routine prenatal
testing, the woman who is HIV
positive should be assessed
regularly for serologic changes
indicating that HIV/Aids is
progressing.
● A pregnancy complicated by HIV
infection, even if asymptomatic, is
considered high risk, and the fetus is
monitored closely.
● Women who are HIV positive are at
increased risk for complications such
as intrapartal or postpartal
hemorrhage, postpartal infection,
poor wound healing and infections of
the genitourinary tract.
● Thus, they need careful monitoring
and appropriate therapy as
indicated.
● HIV positive woman should be
cautioned against breast feeding her
infant.
RH SENSITIZATION
● All women with Rh-negative blood
should have an anti-D antibody titer
done at a first pregnancy visit. If the
results are normal or the titer is
minimal (normal is 0; a ratio below
1:8 is minimal), the test will be
repeated at week 28 of pregnancy.
● If a woman’s anti-D antibody titer is
elevated at a first assessment (1:16
or greater), showing Rh
sensitization, the well-being of the
fetus in this potentially toxic
environment will be monitored every
2 weeks (or more often) by Doppler
velocity of the fetal middle cerebral
artery, a technique that
● If the artery velocity remains high, a
fetus is not developing anemia and
most likely is an Rh- negative fetus.
● If the reading is low, it means a fetus
is in danger, and immediate birth will
be carried out providing the fetus is
near term. If not near term, efforts to
reduce the number of antibodies in
the woman or replace damaged red
cells in the fetus are begun an
predict when anemia is present or
fetal red cells are being destroyed
(Valcamonico et al., 2007).
THERAPEUTIC MANAGEMENT
● To reduce the number of maternal
Rh (D) antibodies being formed, Rh
(D) immune globulin (RhIG), a
commercial preparation of passive
Rh (D) antibodies against the Rh
factor, is administered to women
who are Rh-negative at 28 weeks of
pregnancy.
● RhIG cannot cross the placenta and
destroy fetal red blood cells because
the antibodies are not the IgG class,
the only type that crosses the
placenta.
● RhIG is given again by injection to
the mother in the first 72 hours after
birth of an Rh-positive child to further
prevent the woman from forming
natural antibodies.
● RhIG cannot cross the placenta and
destroy fetal red blood cells because
the antibodies are not the IgG class,
the only type that crosses the
placenta.
● RhIG is given again by injection to
the mother in the first 72 hours after
birth of an Rh-positive child to further
prevent the woman from forming
natural antibodies.
● Because RhIG is passive antibody
protection, it is transient, and in 2
weeks to 2 months, the passive
antibodies are destroyed.
● Only those few antibodies that were
formed during pregnancy are left.
● For this reason, every pregnancy is
like a first pregnancy in terms of the
number of antibodies present,
ensuring a safe intrauterine
environment for any future
pregnancies.
● Any woman who does not receive a
RhIG injection after an induced
abortion, miscarriage, ectopic
pregnancy, or amniocentesis can
also have antibody formation begin.
● After birth, the infant’s blood type will
be determined from a sample of the
cord blood. If it is
Rh-positive—Coombs’ negative,
indicating that a large number of
antibodies are not present in the
mother—the mother will receive the
RhIG injection.
● If the newborn’s blood type is
Rh-negative, no antibodies have
been formed in the mother’s
circulation during pregnancy and
none will form, so passive antibody
injection is unnecessary.
● To restore fetal red blood cells, blood
transfusion can be performed on the
fetus in utero.
➔ This is done by injecting red
blood cells, by amniocentesis
technique, directly into a
vessel in the fetal cord or
depositing them in the fetal
abdomen where they migrate
into the fetal circulation.
● The mother receives an RhIG
injection after the transfusion to help
reduce increased sensitization from
any blood that might have been
exchanged.
● Transfusion is sometimes done only
once during pregnancy, or it may be
repeated as often as every 2 weeks.
● After birth, the infant may require an
exchange transfusion to remove
hemolyzed red blood cells and
replace them with healthy blood cells
V. ANEMIA
● Iron deficiency anemia is the most
common anemia of pregnancy,
affecting 15% to 50% of pregnant
women. It is identified as physiologic
anemia of pregnancy.
ETIOLOGY
Cause of anemia include:
● Nutritional deficiency (e.g., iron
deficiency or megaloblastic anemia,
which includes folic acid deficiency
and B12 deficiency). This can be a
lot to get your head around, but if
you do a quick search into
something as simple as lactoferrin
anemia, you’ll be able to further your
knowledge in this field. You never
know, this information may come in
handy one day.
● Acute and chronic blood loss
● Hemolysis (e.g., sickle cell anemia,
thalassemia, or
glucose-6-phosphate
dehydrogenase [G-6-PD])
PATHOPHYSIOLOGY
● The hemoglobin level for
nonpregnant women is usually 3.5
g/dL. However, the hemoglobin level
during the second trimester of
pregnancy averages 11.6 g/dL as a
result of the dilution of the mother’s
blood from increased plasma
 volume. This is called physiologic
anemia and is normal during
pregnancy.
● Iron cannot be adequately supplied
in the daily diet during pregnancy.
Substances in the diet, such as milk,
tea, and coffee, decrease absorption
of iron. During pregnancy, additional
iron is required for the increase in
maternal RBCs and for transfer to
the fetus for storage and production
of RBCs. The fetus must store
enough iron to last 4 to 6 months
after birth.
● During the third trimester, if the
woman’s intake of iron is not
sufficient, her hemoglobin will not
rise to a value of 12.5 g/dL and
nutritional anemia may occur. This
will result in decreased transfer of
iron to the fetus.
● Hemoglobinopathies, such as
thalassemia, sickle cell disease, and
G-6-PD, lead to anemia by causing
hemolysis or increased destruction
of RBCs.
ASSESSMENT FINDINGS
● Associated findings. In clients with a
hemoglobin level of 10.5 g/dL,
expect complaints of excessive
fatigue, headache, and tachycardia.
● Clinical manifestations:
● Signs of iron deficiency anemia
(hemoglobin level below 10.5 g/dL)
include brittle fingernails, cheilosis
(severely chapped lips), or a
smooth, red, shiny tongue.
● Women with sickle cell anemia
experience painful crisis episodes.
NURSING MANAGEMENT
● Provide client and family teaching.
Discuss using iron supplements and
increasing dietary sources of iron as
indicated.
● Prepare for blood-typing and
crossmatching, and for administering
packed PBCs during labor if the
client has severe anemia.
● Provide support and management
for clients with hemoglobinopathies.
➔ In a client who has
thalassemia or who carries
the trait, provide support,
especially if the woman has
just learned that she is a
carrier. Also assess for signs
of infection throughout the
pregnancy.
● In a pregnant client with sickle cell
disease, assess iron and folate
stores, and reticulocyte counts;
complete screening for hemolysis;
provide dietary counseling and folic
acid supplements; and observe for
signs of infection.
● In a pregnant client with G-6-PD,
provide iron and folic acid
supplementation and nutrition
counseling, and explain the need to
avoid oxidizing drugs.