Powerpoint Medical Con Hi Risk Preg

MEDICAL CONDITIONS
HIGH RISK PREGNANCY 1

CARDIO, HEMATOLOGIC,

RENAL
DEMONSTRATE
KNOWLEDGE ON
THE CONCEPTS
OF CARING AND
MANAGING
MATERNAL
CLIENTS WITH
PROBLEMS
dcy 2023 high risk medical conditions 3
HIGH RISK PRENATAL CLIENT

 A high-risk pregnancy is one in which a
concurrent disorder, pregnancy-related
complication, or external factor jeopardizes the
health of the woman, the fetus, or both.
CLASSIFICATION OF HEART DISEASE

Class Description
I Ordinary physical activity causes no
Uncompromised discomfort. No symptoms of cardiac
insufficiency and no anginal pain.
II Slightly Ordinary physical activity causes excessive

compromised fatigue, palpitation, and dyspnea or anginal
pain.
III Markedly During less than ordinary activity, woman

compromised experiences excessive fatigue, palpitations,
dyspnea, or anginal pain.
IV Severely Woman is unable to carry out any physical

compromised activity without experiencing discomfort.
Even at rest, symptoms of cardiac
ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE

• - Nurses major role in the care of pregnant women with cardiovascular
disease :
a. continuous assessment of women’s health status,
b. health education, and
c. health-promotion activities
• ASSESSMENT:
1. Assessment begins with a thorough health history to document pre-
pregnancy cardiac status
2. Document a woman’s level of exercise performance (i.e., what level she
can do before growing short of breath and what physical symptoms she
experiences, such as cyanosis of the lips or nail beds).
3. Ask if she normally has a cough or edema (it’s important that women with
cardiac disease always report coughing during pregnancy because
pulmonary edema from heart failure may first manifest itself as a simple
cough).
• As pulmonary edema becomes severe, a woman

cannot sleep in any position except with her
chest and head elevated (orthopnea) , as
elevating her chest this way allows fluid to settle
to the bottom of her lungs and frees space for
gas exchange.
• She may also notice paroxysmal nocturnal
dyspnea —suddenly waking at night with
shortness of breath. This occurs because heart
action is more effective when she is at rest.

• Documenting edema is also important because the usual innocent
edema of pregnancy must be distinguished from the beginning of
edema from heart failure (serious).
• important difference in the usual edema of pregnancy involves only the
feet and ankles but becomes systemic with heart failure
- It can begin as early as the first trimester, and other symptoms such as
irregular pulse, rapid or difficult respirations, and
- perhaps chest pain on exertion will probably also be present
- NURSES ROLE:
a. Be certain to record a baseline blood pressure, pulse rate, and
respiratory rate in either a sitting or lying position at the first prenatal
visit;
b. At future health visits, always obtain these in the same position for the
most accurate comparison.
c. Make comparison assessments for nail bed filling (should be 5
seconds) and jugular venous distention can also be helpful throughout
pregnancy.
RIGHT-SIDED HEART FAILURE

• Right-sided heart failure occurs when the right ventricle is
overwhelmed by the amount of blood received by the right atrium
from the vena cava.
• It can be caused by an unrepaired congenital heart defect such as
pulmonary valve stenosis, but the anomaly most apt to cause right-
sided heart failure in women of reproductive age is Eisenmenger
syndrome, a right-to-left atrial or ventricular septal defect with an
accompanying pulmonary valve stenosis.
• Pulmonary valve stenosis is a condition where the pulmonary valve, w
hich is responsible for regulating blood flow from the right ventricle t
o the lungs, becomes narrowed
• This narrowing can cause a range of symptoms, including chest pain,
shortness of breath, and fainting
• With this, congestion of the systemic venous circulation and decreased
cardiac output to the lungs occurs.
RIGHT-SIDED HEART FAILURE

• Blood pressure decreases in the aorta because less
blood is able to reach it; in contrast, pressure is high
in the vena cava from back pressure of blood.
• Both jugular venous distention and increased portal
circulation are evident.
• The liver and spleen both become distended.
• Extreme liver enlargement can cause dyspnea and
pain in a pregnant woman because the enlarged liver,
as it is pressed upward by the enlarged uterus, puts
extreme pressure on the diaphragm.
• Distention of abdominal and lower extremity vessels
can lead to exudate of fluid from the vessels into the
peritoneal cavity (i.e., ascites) or peripheral edema.
WOMAN’S HEART DISEASE INVOLVES RIGHT-SIDED HEART FAILURE,
ASSESS LIVER SIZE AT PRENATAL VISITS
Nurses role:
a. Keep in mind that liver assessments can become
difficult and probably inaccurate late in pregnancy
because the enlarged uterus presses the liver
upward under the ribs and makes it difficult to
palpate.
b. For an additional cardiac status assessment,

an electrocardiogram (ECG) or an
echocardiogram may be done at periodic
points in pregnancy.
c. Assure the woman that an ECG merely measures

cardiac electrical discharge and so cannot harm her
fetus in any way. Echocardiography uses ultrasound
and, likewise, will not harm her fetus.

FETAL ASSESSMENT
- maternal blood pressure becomes insufficient

to provide an adequate supply of blood and
nutrients to the placenta, fetal health can be
compromised
- Effects:
a. low birth weights or be small for gestational

age because of acidosis, which develops due
to poor oxygen/carbon dioxide exchange or
not being furnished with enough nutrients.
FETAL ASSESSMENT
b. result in preterm labor, which exposes

the newborn to the hazards of immaturity
as well as low birth weight.
c. If the placenta is not filling well, a fetus

may not respond well to labor (evidenced
by late deceleration patterns on a fetal
heart monitor), and a cesarean birth may
be necessary (an increased risk for both
the mother and fetus
A WOMAN WITH LEFT-SIDED HEART FAILURE

• Left-sided heart failure occurs in conditions such as
mitral stenosis, mitral insufficiency, and aortic
coarctation.
• The left ventricle cannot move the large volume of
blood forward that it has received by the left atrium
from the pulmonary circulation.
 This causes back pressure—the left side of the heart
becomes distended, systemic blood pressure
decreases in the face of lowered cardiac output, and
pulmonary hypertension occurs.
 When pressure in the pulmonary vein reaches a
point of about 25 mmHg, fluid begins to pass from
the pulmonary capillary membranes into the
interstitial spaces surrounding the lung alveoli and
then into the alveoli themselves (pulmonary edema).
A WOMAN WITH LEFT-SIDED HEART FAILURE
 Pulmonary edema produces profound

shortness of breath as it interferes with oxygen–
carbon dioxide exchange
 If pulmonary capillaries rupture under the
pressure, small amounts of blood leak into the
alveoli and the woman develops a productive
cough with blood-speckled sputum.
 Because of the limited oxygen exchange, a
woman with left-sided heart failure is at an
extremely high risk for spontaneous
miscarriage, preterm labor, or even maternal
death.
RELATED INTERVENTIONS WITH CARDIAC DISEASE
- Promote Rest. two rest periods a day (fully resting, not getting up frequently) and a
full night’s sleep (not tossing and turning) to obtain adequate rest.
- Rest should be in the left lateral recumbent position to prevent supine hypotension
syndrome and increased heart effort.
- Women should plan activities so they stop exercising before the point when cardiac
output becomes insufficient to meet systemic body demands causing peripheral and
uterine/placental constriction.
- Be certain they know exactly how much they should limit their exercise. Some
women, for example, may need to discontinue employment early in pregnancy rather
than work until the end.
- A prescription to allow “normally heavy” housework may mean nothing more

strenuous than dusting to some women. To others, it may mean washing windows,
turning mattresses, and shoveling snow.
PROMOTE HEALTHY NUTRITION
A woman with cardiac disease may need closer supervision of

nutrition:
- she must gain enough weight to ensure a healthy pregnancy and
a healthy baby; but she must not gain so much weight that her
heart and circulatory system become overburdened.
- take her prenatal vitamins. These contain an iron supplement to

help prevent anemia. Anemia is important to prevent because it
places an extra burden on the heart because her circulatory
system must circulate blood more vigorously than usual to
distribute oxygen to all body cells.
- If a woman was following a sodium-restricted diet before

pregnancy, this may be continued during pregnancy; although
typically, a woman’s sodium intake is only limited, not severely
restricted, during pregnancy because it’s important to obtain
enough sodium to maintain fluid volume and balance as well as
furnish an adequate supply of blood to the fetus
HEALTH EDUCATION REGARDING
MEDICATION
DIGOXIN
- For those taking digoxin before pregnancy may need
to increase their maintenance dose because of their

expanded blood volume during pregnancy
- For those who is not digoxin dependent before

pregnancy may need such therapy prescribed as
pregnancy advances and her cardiac output has to
be increased or strengthened
Health education:
-To aid a woman in continuing to think of herself as
basically a well person, help her to understand this
does not mean her heart function is weakening, but
rather it is only temporarily being stressed by the
HEALTH EDUCATION REGARDING MEDICATION
- Digoxin also has a unique use during pregnancy

as it can be administered to the woman to slow
the fetal heart if fetal tachycardia is present.
- Arrhythmia agents such as adenosine, -

blockers, and angiotensin-converting enzyme
(ACE) inhibitors to reduce hypertension are safe
to use during pregnancy and are also frequently
prescribed.
- Nitroglycerin, a compound often prescribed for

angina, although not well studied during
pregnancy (a category C drug), is also
considered safe (Karch, 2013).
HEALTH EDUCATION REGARDING
MEDICATION
- Prophylactic penicillin because she had
rheumatic fever as a child (which is often taken
for 10 years after the occurrence of rheumatic
fever, or at least until age 18 years) should
continue to take this drug during pregnancy
because penicillin is not known to be a teratogen
(a category B drug).
- Close to the anticipated day of birth, an

additional course of ampicillin, amoxicillin
(Amoxil), or clindamycin (Cleocin) to prevent
streptococci bacteria from invading the denuded
placental site on the uterus and creating a
subacute bacterial endocarditis.
EDUCATE REGARDING AVOIDANCE OF INFECTION
- Caution women with heart disease, to avoid
visiting or being visited by people with
infections
- alert at the first indication of an upper

respiratory tract infection or urinary tract
infection (UTI) so that, if warranted,
antibiotic therapy can begin early in the
course of the infection
- Monthly screening for bacteriuria with a

clean-catch urine test at prenatal visits
should help detect UTIs.
CARDIOPULMONARY RESUSCITATION DURING PREGNANCY
PURPOSE: TO RESTORE CARDIAC AND RESPIRATORY22
FUNCTION.
PLAN PRINCIPLE
1. Determine the woman is 1. Shaking the shoulders
unconscious and not and shouting are
breathing by shaking effective actions to
and shouting her name determine
unconsciousness and
rouse a woman who
may have fainted or is
asleep.
2. Call for emergency help 2. The woman may need
and have them bring a more than simple
cardiac defibrillator resuscitation
CARDIOPULMONARY RESUSCITATION 23
DURING PREGNANCY
PURPOSE: TO RESTORE CARDIAC AND
RESPIRATORY FUNCTION.
PLAN PRINCIPLE
3. Begin chest compressions. 3. External chest

A second rescuer can deliver compressions
respiratory ventilations at a stimulate the action of
rate of 1 breath every 6 to 8 the heart to maintain
seconds (8 to 10 breaths/ tissue perfusion. Allow
min). chest recoil after each
-Place both hands on the lower compression.
sternum just above the xiphoid
process and compress the chest a
distance of 2 in. at a rate of 100
times a minute
CARDIOPULMONARY RESUSCITATION DURING
24
PREGNANCY
PLAN PRINCIPLE
4. A second rescuer can deliver 4. Ventilation improves
respiratory ventilations at a rate oxygenation.
of 1 breath every 6 to 8 seconds
(8 to 10 breaths/ min).
5. AED is effective at stimulating
5. If an automated external heart action and is not
defibrillator (AED) is necessary, detrimental to pregnancy or a
remove any fetal or uterine fetus
monitors if these are in place.
Follow standard application and
procedure according to agency
protocol.
6. When the emergency rescue 6. A towel placed under one hip
team has arrived and relieved helps to prevent uterine
you as a fi rst responder, place compression on the vena cava
a rolled or folded towel under and helps prevent supine
the woman’s right hip hypotension syndrome
NURSING INTERVENTIONS DURING
25
LABOR AND BIRTH

- Frequently assess a woman’s blood pressure,
pulse, and respirations and monitor fetal heart rate
and uterine contractions during labor for women
with heart disease to be certain their circulatory
system is not failing and the placenta is filling
adequately
- rapidly increasing pulse rate ( 100 beats/min) is an

indication a heart is pumping ineffectively and so
has increased its rate in an effort to compensate.
- advise a woman to assume a side-lying position

during labor to reduce the possibility of supine
hypotension syndrome.
dcy 2023 high risk medical conditions NURSING INTERVENTIONS DURING 26
LABOR AND BIRTH
- If a woman has some pulmonary edema,
elevate her head and chest (a semi-
Fowler’s position) to ease the work of
breathing.
- If this is necessary, be certain to place a

towel under her right hip to shift the uterus
off the vena cava, the same as would
happen with a side-lying position.
- fatigue is a symptom of heart

decompensation
dcy 2023 high risk medical conditions NURSING INTERVENTIONS DURING 27
LABOR AND BIRTH
- Evaluate women carefully, to determine
whether the fatigue is a heart or labor
related. Women
- If with extreme heart disease may need

oxygen administered during labor
because of the need for extra oxygen
due to the exertion of labor;
- continuous hemodynamic monitoring to

monitor heart
dcy 2023 high risk medical conditions
28
NURSING INTERVENTIONS DURING LABOR
AND BIRTH
- shouldnot push with contractions, as

pushing requires more effort than they
should expend
-epidural anesthesia the anesthetic of choice

for women with heart disease because this
decreases the sensation of pushing and can
make both labor and birth less taxing.
Because of the lack of pushing,
-low forceps or a vacuum extractor may be

used for birth.
dcy 2023 high risk medical conditions POSTPARTUM NURSING 29
INTERVENTIONS
The period immediately after birth is a critical
time for a woman with heart disease
because:
- with delivery of the placenta, the blood that

supplied the placenta is released into her
general circulation, increasing her blood
volume by 20% to 40%.
- during pregnancy, the increase in blood

volume that occurred did so over a 6-
month period, so her heart had time to
gradually adjust to this change.
POSTPARTUM NURSING 30
INTERVENTIONS
- after birth, the increase in pressure takes place
within 5 minutes, so the heart must make a
rapid and major adjustment (Easterling & Stout,
2012).
- to compensate for these circulatory changes, a

woman may need a program of decreased
activity and possibly anticoagulant and digoxin
therapy until her circulation stabilizes.
- antiembolic stockings or intermittent pneumatic

compression (IPC) boots may be prescribed to
increase venous return from the legs.
dcy 2023 high risk medical conditions POSTPARTUM NURSING 31
INTERVENTIONS
- If prophylactic antibiotics had not been
started prior to birth, they should be
started immediately after birth to
discourage subacute bacterial endocarditis
caused by the introduction of
microorganisms through the placental site.
- A woman with heart disease is often

interested in close inspection of her baby
immediately after birth because she wants
to know if her infant has a heart defect or
was harmed by any medication she took
during pregnancy.
POSTPARTUM NURSING 32
INTERVENTIONS
- Be certain to point out that acrocyanosis is
normal in newborns so she does not
interpret her baby’s peripheral cyanosis as
cardiac inadequacy.
- In the postpartum period, a stool softener
can be prescribed to prevent straining with
bowel movements.
- Agents to encourage uterine involution,
such as oxytocin (Pitocin), should be used
with caution because they tend to increase
blood pressure, which necessitates
increased heart action.
POSTPARTUM NURSING
33
INTERVENTIONS
- As a rule, women with heart disease can breastfeed
without difficulty.
- Kegel exercises are acceptable for perineal

strengthening immediately, but the woman should
not begin postpartum exercises to improve
abdominal tone until her primary care provider
approves them.
- Before discharge, be certain a woman has thought

through if she will need help at home so she can
continue getting periods of rest.
- Also ensure that she schedules a return

appointment for a postpartum checkup for both her
gynecologic health and her cardiac status
PREGNANT WOMAN WITH AN 34
ARTIFICIAL VALVE PROSTHESIS

- In the past, women with heart valve
prostheses were advised not to become
pregnant for fear the increased blood volume
gained during pregnancy would overwhelm the
artificial valve.
- evidence shows women with a valve

prosthesis can complete a pregnancy safely
(Suri, Keepanasseril, Aggarwal, et al., 2011)
- One potential problem involves the use of oral

anticoagulants women take to prevent the
formation of blood clots at the valve site.
PREGNANT WOMAN WITH AN
35
ARTIFICIAL VALVE PROSTHESIS

- usual maintenance drug for this, sodium
warfarin (Coumadin), increases the risk of
congenital anomalies in infants (pregnancy
risk category D), women are usually placed
on low–molecular-weight heparin therapy
(category C) before becoming pregnant
and during pregnancy.
- Subclinical bleeding from continuous
anticoagulant therapy has the potential to
cause placental dislodgement.
- Nurses role: observe a woman who is
taking an anticoagulant for signs of
petechiae and premature separation of the
placenta during both pregnancy and labor
ASSESSING A PREGNANT WOMAN WITH 36
VENOUS THROMBOEMBOLIC DISEASE
VENOUS THROMBOEMBOLIC DISEASE increases
during pregnancy because of a combination of stasis of
blood in the lower extremities from uterine pressure and
hypercoagulability - the effect of elevated estrogen
deep vein thrombosis (DVT) leading to pulmonary emboli
is highest in women 30 years of age or older because
increased age is yet another risk factor for thrombosis
formation
When the pressure of the fetal head at birth puts
additional pressure on lower extremity veins, damage can
occur to the walls of the veins.
With this triad of effects in place (stasis, vessel damage,
and hypercoagulation), the stage is set for thrombus
formation in the lower extremities
37
CHRONIC HYPERTENSIVE
VASCULAR DISEASE
 Women with chronic hypertensive disease enter pregnancy with
an elevated blood pressure (140/90 mmHg or above).
 Hypertension of this kind is usually associated with
arteriosclerosis or renal disease, making it a problem for the
older pregnant woman.
 Chronic hypertension can be serious because it places both the
woman and fetus at high risk because of poor heart, kidney,
and/or placental perfusion during the pregnancy.
 Management includes a prescription of -blockers and ACE
inhibitors to reduce blood pressure by peripheral dilation to a
safe level, but not to reduce it below the threshold that allows for
good placenta circulation.
 Methyldopa (Aldomet) is a typical drug that may be prescribed.
HEMATOLOGIC DISORDERS AND

39
PREGNANCY
Anemia and Pregnancy
 IRON-DEFICIENCY ANEMIA
 is the most common anemia of pregnancy, complicating as
many as 15% to 25% of all pregnancies
 Many women enter pregnancy with a deficiency of iron
stores resulting from a combination of a diet low in iron,
heavy menstrual periods, or unwise weight reducing
programs.
 Iron stores are also apt to be low in women who were:
- pregnant less than 2 years before the current pregnancy
- those from low socioeconomic levels who have not had iron-
rich diets
HEMATOLOGIC DISORDERS
AND PREGNANCY
 The type of anemia:
a. microcytic (small red blood cell)
b. hypochromic (less hemoglobin than the average red cell)
 occurs when such an inadequate supply of iron is ingested that
iron is not available for incorporation into red blood cells.
 experiences extreme fatigue and poor exercise tolerance because
she cannot transport oxygen effectively.
 mildly associated with low birth weight and preterm birth.
 body recognizes that it needs increased nutrients, some women
with this condition develop pica, or the craving and eating of
substances such as ice or starch
 also associated with restless leg syndrome
HEMATOLOGIC DISORDERS AND PREGNANCY

PREVENTION –take prenatal vitamins containing 27 mg. of iron
as prophylactic therapy during pregnancy
• eat a diet high in iron and vitamins (e.g., green leafy vegetables, meat, and
legumes)
• Women who develop iron-deficiency anemia will be prescribed therapeutic
levels of medication (120 to 200 mg elemental iron per day), usually in the
form of ferrous sulfate or ferrous gluconate.
• Iron is absorbed best in an acid medium
• take iron supplements with orange juice or a vitamin C supplement, which
supplies ascorbic acid.
• Increasing roughage in the diet and always taking the pills with food can
help reduce these symptoms.
• Ferrous sulfate turns stools black, so caution women about this to prevent
them from worrying that they are bleeding internally. If iron-deficiency
anemia is severe and a woman has difficulty with oral iron therapy,
intravenous iron can be prescribed.
HEMATOLOGIC DISORDERS AND
43
PREGNANCY
FOLIC ACID–DEFICIENCY ANEMIA
 Folic acid, or folacin, one of the B vitamins, is necessary for the
normal formation of red blood cells in the woman as well as being
associated with preventing neural tube and abdominal wall defects
in the fetus.
 occurs most often in multiple pregnancies because of the increased
fetal demand;
 in women with a secondary hemolytic illness in which there is
rapid destruction and production of new red blood cells;
 in women who are taking hydantoin, an anticonvulsant agent that
interferes with folate absorption;
44
FOLIC ACID–DEFICIENCY ANEMIA

 in women who have been taking oral contraceptives;
 in women who have poor gastric absorption, such as in those
who have had a gastric bypass for morbid obesity
The anemia that develops is a MEGALOBLASTIC ANEMIA

(enlarged red blood cells).
 Slow to progress, the deficiency may take several weeks to
develop or may not be apparent until the second trimester of
pregnancy.
 Full blown, it may be a contributory factor in early miscarriage
or premature separation of the placenta.
 All women expecting to become pregnant are advised to begin a
supplement of 400 g folic acid daily in addition to eating
folacin-rich foods (e.g., green leafy vegetables, oranges, dried
beans).
SICKLE-CELL ANEMIA
 is a recessively inherited hemolytic anemia caused by an abnormal amino acid
in the beta chain of hemoglobin
 majority of red blood cells are irregular or sickle shaped, so they cannot carry
as much hemoglobin as normally shaped red blood cells can.
 when oxygen tension becomes reduced, as occurs at high altitudes, or blood
becomes more viscid than usual, such as occurs with dehydration, the cells
clump together because of their irregular shape, resulting in vessel blockage
with reduced blood flow to organs.
 the cells then will hemolyse (i.e., be destroyed), thus reducing the number
available and causing a severe anemia.
 sickle-cell trait does not appear to directly influence the course of pregnancy,
preterm birth, growth restriction, miscarriage, or perinatal mortality rates tend
to be higher for women with the homozygous disease-
a. heterozygous - has only one gene in which the abnormal substitution has
occurred
b. homozygous - has two genes in which the substitution has occurred, sickle cell
disease (HbSS) results
SICKLE-CELL ANEMIA
 sickle-cell anemia is a threat to life if vital blood vessels
such as those to the liver, kidneys, heart, lungs, or brain
become blocked.
 in pregnancy, blockage to the placental circulation can
directly compromise the fetus, causing low birth weight
and possibly fetal death.
 A woman with sickle-cell disease have a hemoglobin level
of 6 to 8 mg/100 ml. potentially reducing oxygen to the
fetus.
 hemolytic sickle-cell crisis occurs, a woman’s hemoglobin
level can fall to 5 or 6 mg/100 ml in a few hours, causing
an accompanying rise in indirect bilirubin because the
woman cannot conjugate the bilirubin released from so
many destroyed red blood cells
SICKLE-CELL ANEMIA
 monitor a woman’s nutritional intake to be certain she is
consuming sufficient amounts of folic acid and possibly
an additional folic acid supplement, which is necessary
for replacing red blood cells that have been destroyed.
 Women should not take a routine iron supplement as
sickled cells cannot incorporate iron in the same manner
as non-sickled cells.
 Ensure the woman is drinking at least eight glasses of
fluid daily to be certain she is guarding against
dehydration.
 Early in pregnancy, when she may be nauseated, it is
easy for her fluid intake to decrease, causing dehydration
and a subsequent sickle-cell crisis.
SICKLE-CELL ANEMIA
THERAPEUTIC MANAGEMENT
• If a crisis occurs, controlling pain,
• Interventions to prevent a
administering oxygen as needed,
sickle-cell crisis can include and increasing the fluid volume of
periodic exchange or blood the circulatory system to lower
transfusions throughout viscosity are important
pregnancy to replace sickled interventions
cells with non-sickled cells. • If a woman develops an infection
• An exchange transfusion serves that raises her temperature and
a secondary purpose of causes her to perspire more than
removing a quantity of the usual (which creates dehydration)
or contracts a respiratory infection
increased bilirubin resulting
that compromises air exchange so
from the breakdown of red that her P o2 is lowered,
blood cells as well as restoring hospitalization for observation may
the hemoglobin level be necessary to rule out the
development of a sickle-cell crisis
and subsequent hemolysis of
crowded cells.
THALASSEMIAS
 Are a group of autosomal recessively inherited blood
disorders that lead to poor hemoglobin formation and
severe anemia.
 Symptoms first appear in childhood.
 Treatment focuses on combating anemia through such
measures as folic acid supplementation and perhaps
blood transfusion to infuse hemoglobin-rich red blood
cells.
 Women with thalassemia do not usually take an iron
supplement during pregnancy because they could
receive an iron overload because iron is infused with
blood transfusions.
MALARIA 50
 Is a protozoan infection that is transmitted to people by

Anopheles mosquitoes
 The infection causes red blood cells to stick to the surface of
capillaries causing obstruction of these vessels and resulting
in end-organ anoxia and blood not reaching organs
effectively.
 Make women high risk for blood clotting during pregnancy
- if untreated, can be transmitted to a fetus by mother-to-
fetus transmission.
 The most noticeable symptoms are elevated liver function
tests accompanying fever, malaise, and headache.
 Because of the altered blood cells, thrombocytopenia (i.e.,
low platelet count), anemia, and renal failure can develop. Malaria parasite trapped in a
host cell
MALARIA 51
• Treatment is with a combination of

• Malaria can be prevented by antimalarial drugs, which will both
wearing clothing that covers stop the course of the disease and help
most of the body as well as reduce the incidence of low birth
using an insect repellent when weight and preterm birth.
in an area infested with • Sulfadoxine/pyrimethamine is safe to
mosquitoes, sleeping at night administer during the last trimester of
with a mosquito net, or pregnancy.
keeping windows closed to • Chloroquine is safe to administer all
prevent mosquitoes from
during pregnancy and so is the drug
entering. As further
of choice
prevention, urge women to
• Quinine, Malarone, or tetracyclines,
delay travel to endemic areas
although effective against the disease,
until after pregnancy if
should not be used at any point in
possible.
pregnancy or with women who are
breastfeeding as they are teratogenic.
52
COAGULATION DISORDERS AND

PREGNANCY
VON WILLEBRAND disease, is a coagulation disorder inherited as an
autosomal dominant trait and so does occur in women .
 Women will have normal platelet counts, but bleeding time is
prolonged.
 Levels of factor VIII–related antigen (VIII-R) and factor VIII
coagulation activity (VIII-C) are both reduced.
 From the time she was a child, a woman with the disorder might have
noticed menorrhagia/ heavy menstrual bleeding or frequent episodes
of epistaxis.
 If these symptoms were not severe, - the condition can go undiagnosed
until pregnancy when a woman experiences a spontaneous
miscarriage or postpartum hemorrhage.
 Replacement of the missing coagulation factors by infusion of
cryoprecipitate or fresh frozen plasma may be necessary before labor
to prevent excessive bleeding with birth.
COAGULATION DISORDERS
53
AND PREGNANCY
HEMOPHILIA B (CHRISTMAS DISEASE, FACTOR IX DEFICIENCY)
is a sex-linked disorder, so the actual disease occurs only in males.
 female carriers may have such a reduced level of factor IX (only 33% of
normal) that hemorrhage with labor or a spontaneous miscarriage can
be a serious complication. As with von Willebrand disease, carriers of
the disorder need to be identified before pregnancy. Restoration of
factor IX levels can be quickly restored by infusion of factor IX
concentrate or fresh frozen plasma.
 Restoration of factor IX levels can be quickly restored by infusion of
factor IX concentrate or fresh frozen plasma.
 Before an internal fetal heart rate monitor is attached or fetal scalp
blood sampling is done, it should be determined if the fetus has a
coagulation defect. If one is present, these procedures are
contraindicated because they could result in extensive fetal blood loss.
COAGULATION DISORDERS
AND PREGNANCY
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP), which is a decreased
number of platelets,
 is not inherited, can occur at any time in life, and so occasionally occurs during
pregnancy.
 the cause of the condition is unknown, but because symptoms usually occur
shortly after a viral invasion such as an upper respiratory tract infection, it is
assumed to be an autoimmune reaction (an antiplatelet antibody that destroys
platelets is apparently released)
 a marked thrombocytopenia (platelet count may be as low as 20,000/mm 3 from a
usual count of 150,000/mm 3 ).
 Without an adequate level of platelets, the woman is prone to frequent nosebleeds
and minute petechiae or large ecchymoses appear on her body.
 The illness typically runs a 1- to 3-month limited course, but because a low
platelet count also appears with hypertension of pregnancy with HELLP
( hemolysis, elevated liver enzymes, low platelet count) syndrome, a serious
complication of pregnancy
dcy 2023 high risk medical conditions RENAL AND URINARY 55
DISORDERS AND PREGNANCY

URINARY TRACT INFECTION
 In a pregnant woman, the ureters dilate from the effect of
progesterone, stasis of urine can occur.
 The minimal presence of abnormal amounts of glucose
(GLYCOSURIA) that also occurs with pregnancy provides an ideal
medium for growth for any organisms present.
 Combined, these factors cause asymptomatic urinary tract infections
(UTIs) in as many as 10% to 15% of pregnant women.
 Can progress to pyelonephritis (i.e., infection of the pelvis of the
kidney) and are associated with preterm labor and premature rupture
of membranes.
 Women with known vesicoureteral reflux - backflow of urine into the
ureters tend to develop UTIs or pyelonephritis more often than others.
 The organism most commonly responsible for UTI is Escherichia coli
from an ascending infection.
56
URINARY TRACT INFECTION

 A UTI can also occur as a descending infection or can begin in the kidneys
from the filtration of organisms present from other body infections.
 If the infectious organism is determined to be Streptococcus B, vaginal
cultures should be obtained because streptococcal B infection of the genital
tract is associated with pneumonia in newborns.
 A UTI typically manifests as frequency and pain on urination.
 With pyelonephritis, a woman develops pain in the lumbar region (usually on
the right side) that radiates downward.
 The area feels tender to palpation.
 She may have accompanying nausea and vomiting, malaise, pain, and
frequency of urination.
 Her temperature may be elevated only slightly or may be as high as 103° to
104°F (39° to 40°C).
 The infection usually occurs on the right side because there is greater
compression and urinary stasis on the right ureter from the uterus being
pushed that way by the large bulk of the intestine on the left side.
COMMON MEASURES TO PREVENT UTI 57
• Voidingfrequently (at least every 2 hours)

• Developing a habit of urinating as soon as the need is felt and emptying
the bladder completely when urinating
• Wiping front to back after voiding and bowel movements
• Wearing cotton, not synthetic fiber, underwear
• Voiding immediately after sexual intercourse
• Drinking a glass of cranberry juice daily
Obtain a clean-catch urine sample for culture and sensitivity to assess for
asymptomatic bacteriuria or symptoms of UTI
 Amoxicillin, ampicillin, and cephalosporins are effective against most
organisms causing UTIs and are safe antibiotics during pregnancy.
 The sulfonamides can be used early in pregnancy but not near term
because they can interfere with protein binding of bilirubin, which then
leads to hyperbilirubinemia in the newborn.
 Tetracyclines are contraindicated during pregnancy as they cause
retardation of bone growth and staining of the deciduous teeth
COMMON MEASURES TO PREVENT UTI
58
• The pregnant woman with a UTI needs to take the additional measure
of drinking an increased amount of fluid to flush out the infection from
the urinary tract; 3 to 4 L per 24 hours
• A woman can promote urine drainage by assuming a knee–chest
position for 15 minutes morning and evening; the weight of the uterus is
shifted forward, releasing the pressure on the ureters and allowing urine
to drain more freely.
• the chances are high she will develop another during late in pregnancy,
when urinary stasis tends to grow even greater; be kept on prophylactic
antibiotics throughout the remainder of the pregnancy.
• PYELONEPHRITIS occurs as an extension of a UTI or infection that
originated in or spread to the kidney.
 may be hospitalized for 24 to 48 hours while she is treated with
intravenous antibiotics.
 After this acute episode, she will be maintained on a drug such as oral
nitrofurantoin (Macrodantin) for the remainder of the pregnancy.
 VIT. C is not given during pregnancy because a newborn can develop
scurvy in the immediate neonatal period from vitamin C withdrawal.
RENAL AND URINARY DISORDERS

59
AND PREGNANCY
HYPERACTIVE BLADDER
 refers to a bladder that contracts more frequently
than usual, causing symptoms of frequency, urgency,
and incontinence.
 during pregnancy, these symptoms can increase
greatly because of the additional pressure from the
uterus on the bladder.
 Fesoterodine (Toviaz; pregnancy category C), an
antispasmodic drug frequently prescribed for the
disorder should be used during pregnancy and
breastfeeding only if the risk outweighs the benefit
until it is proven not to be teratogenic
RENAL AND URINARY

60
DISORDERS AND PREGNANCY

CHRONIC RENAL DISEASE
 Women with chronic renal disease need to be monitored carefully during
pregnancy because their diseased kidneys may not produce erythropoietin, a
glycoprotein necessary for red cell formation and so they may develop a
severe anemia.
 The glomerular filtration rate normally increases during pregnancy, a
woman’s serum creatinine level (a measure of kidney function that elevates
when kidneys are under stress) may be actually slightly below normal during
pregnancy or may fall from a usual level of 0.7 mg/100 ml to about 0.5
mg/100 ml.
 Women with kidney disease who normally have a serum creatinine level
greater than 2.0 mg/ dl may be advised not to undertake a pregnancy in case
the increased strain on already damaged kidneys leads to kidney failure.
 Many women with renal disease routinely take a corticosteroid such as oral
prednisone at a maintenance level.
 This drug therapy typically is continued throughout pregnancy.
CHRONIC RENAL DISEASE

61
 Severe renal disease may require dialysis to aid kidney

function during pregnancy.
 With dialysis, there is a risk of preterm labor, - progesterone is
removed with the dialysis.
 Progesterone may be administered intramuscularly before the
procedure.
 If hemodialysis is used, it should be scheduled frequently and
for short durations to avoid acute fluid shifts.
 The heparin administered in connection with hemodialysis is
safe during pregnancy because it does not cross the placenta.
 Even in light of the expanding uterine size, peritoneal dialysis
is actually preferred over hemodialysis because it normally
causes less drastic fluid shifts.
THANK YOU
DAISY COLLEEN YOUNG-MERCADO

RN RM MAN Ph.D

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MEDICAL CONDITIONS

HIGH RISK PREGNANCY 1

HIGH RISK PRENATAL CLIENT

CLASSIFICATION OF HEART DISEASE

II Slightly Ordinary physical activity causes excessive

III Markedly During less than ordinary activity, woman

IV Severely Woman is unable to carry out any physical

ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE

ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE

• As pulmonary edema becomes severe, a woman

ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE

RIGHT-SIDED HEART FAILURE

RIGHT-SIDED HEART FAILURE

b. For an additional cardiac status assessment,

c. Assure the woman that an ECG merely measures

and, likewise, will not harm her fetus.

- maternal blood pressure becomes insufficient

a. low birth weights or be small for gestational

b. result in preterm labor, which exposes

c. If the placenta is not filling well, a fetus

A WOMAN WITH LEFT-SIDED HEART FAILURE

A WOMAN WITH LEFT-SIDED HEART FAILURE

 Pulmonary edema produces profound

- A prescription to allow “normally heavy” housework may mean nothing more

A woman with cardiac disease may need closer supervision of

- take her prenatal vitamins. These contain an iron supplement to

- If a woman was following a sodium-restricted diet before

to increase their maintenance dose because of their

- For those who is not digoxin dependent before

- Digoxin also has a unique use during pregnancy

- Arrhythmia agents such as adenosine, -

- Nitroglycerin, a compound often prescribed for

- Close to the anticipated day of birth, an

- alert at the first indication of an upper

- Monthly screening for bacteriuria with a

3. Begin chest compressions. 3. External chest

LABOR AND BIRTH

- rapidly increasing pulse rate ( 100 beats/min) is an

- advise a woman to assume a side-lying position

- If this is necessary, be certain to place a

- fatigue is a symptom of heart

- If with extreme heart disease may need

- continuous hemodynamic monitoring to

- shouldnot push with contractions, as

-epidural anesthesia the anesthetic of choice

-low forceps or a vacuum extractor may be

- with delivery of the placenta, the blood that

- during pregnancy, the increase in blood

- to compensate for these circulatory changes, a

- antiembolic stockings or intermittent pneumatic

- A woman with heart disease is often

- Kegel exercises are acceptable for perineal

- Before discharge, be certain a woman has thought

- Also ensure that she schedules a return

ARTIFICIAL VALVE PROSTHESIS

- evidence shows women with a valve

- One potential problem involves the use of oral

ARTIFICIAL VALVE PROSTHESIS

HEMATOLOGIC DISORDERS AND

HEMATOLOGIC DISORDERS AND PREGNANCY

FOLIC ACID–DEFICIENCY ANEMIA

The anemia that develops is a MEGALOBLASTIC ANEMIA

 Is a protozoan infection that is transmitted to people by