Medical Conditions 2

MEDICAL
CONDITIONS
HIGH RISK II
RESPIRATORY, RHEUMATIC, GASTRO, NEUROLOGIC, MUSCULOSKELETAL, ENDOCRINE, MENTAL
ILLNESS, CANCER
dcym 2024 medical condition 2
1
OBJECTIVE
S
1. Describe common high
risk medical conditions
disorders.
2. Demonstrate knowledge
on the concepts of caring
and managing maternal
clients with problems
3. Assess a woman with
high risk medical
condition disorders.
4. Integrate the knowledge
of high risk medical
condition disorders with
the interplay of nursing
process, to promote
quality maternal health
nursing care.
2
RESPIRATORY DISORDERS AND PREGNANCY
ACUTE NASOPHARYNGITIS (the common cold)
◦ tends to be more severe during pregnancy - estrogen
stimulation normally causes some degree of nasal congestion.
◦ should not take aspirin as a remedy for a headache,
- this can interfere with blood clotting in both the mother and
fetus and the possibility of prolonged pregnancy at term
(Karch, 2013).
◦ common colds are invariably caused by a virus, antibiotic
therapy is unnecessary except to prevent a secondary
infection
dcym 2024 medical condition 2 3

◦ SIMPLE MEASURES TO COMBAT A COLD, such as:
• Besure to get extra rest and sleep and eat a diet high in vitamin
C (e.g., orange juice and fruit) to help boost the immune system.
• Take acetaminophen (Tylenol) every 4 hours for aches and
pains (up to 3,000 mg/day). Do not take acetylsalicylic acid
(Aspirin) during pregnancy because it can interfere with blood
clotting.
• Use a room humidifier or apply a medicated vapor rub to the
chest, especially at night, to moisten nasal secretions and help
mucus drain.
• Use cool or warm compresses to relieve sinus headaches.

INFLUENZA is caused by a virus, identified as type A, B, or C.
◦ The disease spreads in epidemic form and is accompanied by high fever,
extreme prostration, aching pains in the back and extremities, and
generally, a sore, raw throat.
◦ can be a cause of preterm labor - some studies have shown a link between
influenza during pregnancy and schizophrenia in children born of that
pregnancy.
◦ Treatment includes an antipyretic such as acetaminophen (Tylenol) to
control fever.
- The risk for the woman of not taking oseltamivir (Tamiflu), an oral antiviral
drug that is category C, is greater than if it’s not taken, so it should be
prescribed and begun immediately during pregnancy.
- influenza vaccines are made from inert viruses, women may also be
immunized safely against influenza during pregnancy

PNEUMONIA is the bacterial or viral invasion of lung tissue by pathogens such as S. pneumoniae,
Haemophilus influenzae , and Mycoplasma pneumoniae.
◦ acute inflammatory response occurs in the lung alveoli, causing an exudate of red blood cells, fibrin, and
polymorphonuclear leukocytes to flood into the alveoli.
◦ process has the helpful effect of confining the bacteria or virus within segments of the lobes of the lungs,
but it also has a less helpful effect of filling alveoli with fluid, blocking off breathing space.
◦ If the collection of fluid becomes extreme, it can limit the oxygen available not only to the woman but
also to the fetus.
◦ Therapy involves the use of an appropriate antibiotic and perhaps oxygen administration.
◦ With severe disease, ventilation support may be necessary.
◦ Pneumonia during pregnancy is associated with fetal growth restriction and preterm birth because of
the oxygen deficit
◦ If pneumonia is present during labor, oxygen should be administered so the fetus has adequate oxygen
resources during contractions.
◦ ASTHMA is a disorder marked by reversible airflow obstruction, airway
hyperreactivity, and airway inflammation.
◦ Symptoms are often triggered by an inhaled allergen such as pollen or
cigarette smoke.
◦ With inhalation of the allergen, there is an immediate release of bioactive
mediators such as histamine and leukotrienes from an immunoglobulin
interaction.
◦ This results in constriction of the bronchial smooth muscle, marked mucosal
inflammation and swelling, and the production of thick bronchial secretions.
◦ These three processes cause a woman to have difficulty pulling in air; on
exhalation, she has so much difficulty releasing air she makes a high-pitched
whistling sound (i.e., bronchial wheezing) from air being pushed past the
bronchial narrowing.
◦ Asthma has the potential of reducing the oxygen supply to a fetus leading to
preterm birth or fetal growth restriction if a major attack

TUBERCULOSIS is still one of the leading causes of death.
◦ lung tissue is invaded by Mycobacterium tuberculosis , an acid-
fast bacillus.
◦ Macrophages and T lymphocytes surround the invading
bacillus, but rather than actually killing it, they merely
surround and confine it.
◦ Fibrosis, calcification, and a final ring of collagenous scar tissue
develop, effectively sealing off the organisms from the body and
any further invasion or spread.
◦ The antibodies produced will thereafter cause a woman to have
a positive response to a Mantoux test (purified protein
derivative [PPD]) test.

◦ In high-risk areas, women should undergo skin testing (a PPD test) at their first prenatal visit.
◦ a positive reaction does not necessarily mean they have the disease; it can only mean they
have at some time been exposed to tuberculosis and so have antibodies in their system.
◦ If a woman has a positive reaction, a chest X-ray (which is safe during pregnancy as long
as her abdomen is lead shielded) or a sputum culture for acid-fast bacillus to confirm the
diagnosis will be scheduled.
SYMPTOMS OF TUBERCULOSIS
• A persistent cough (usually more than 3 weeks long) that generates sputum or phlegm;
• Hemoptysis - cough with blood  TB can be spread by the placenta to
• Substantial Weight loss the fetus,
• Low grade Fever  if it is active, it usually is spread to
• Pain in the chest the infant after birth by the
• Weakness and extreme fatigue mother’s coughing.
• Waking at night with night sweats

THERAPEUTIC MANAGEMENT
• Isoniazid (INH), rifampin (RIF), and ethambutol hydrochloride

(Myambutol)—the drugs of choice for tuberculosis—may be given
without apparent teratogenic effects.
• INH, may result in a peripheral neuritis if a woman does not also
take supplemental pyridoxine (vitamin B 6 ).
• Ethambutol has the side effect of causing optic atrophy and loss of
green color recognition in the woman - To detect this, test the
woman’s ability to recognize green at prenatal visits using the color
section of a Snellen (eye test) chart. If symptoms develop, inform
her health provider about possibly discontinuing the drug. A
woman who had tuberculosis earlier in life must be especially
careful to maintain an adequate level of calcium during pregnancy
to ensure the calcium tuberculosis pockets in her lungs are not
broken down and the disease is not reactivated.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- COPD is constriction of the airway associated most often with long-term
cigarette smoking.
- When women had their children between 20 and 30 years of age, COPD
was rarely associated with pregnancy.
- Now that more and more women are waiting until age 35 to 40 years to
have children, it is now possible to see the condition with pregnancy
- Constrictive air disease limits the amount of oxygen that can reach the
lungs, so the condition is associated with fetal growth restriction and
preterm birth.
- may need additional rest during pregnancy because of fatigue and may
need continuous supplemental oxygen during the day.
- If they experience sleep apnea, they may be prescribed continuous
positive airway pressure (CPAP) at night
- short of breath from the exertion needed for pushing that she may be
advised to have a cesarean birth.
◦ CYSTIC FIBROSIS is a recessively inherited disease in which there is
generalized dysfunction of the exocrine glands
◦ This dysfunction leads to mucous secretions, particularly in the pancreas
and lungs, which become so viscid that normal lung and pancreatic
functions become compromised.
◦ disease typically show symptoms of chronic respiratory infection and
overinflation of their lungs from the thickened mucus present;
◦ they have difficulty digesting fat and protein because the pancreas cannot
release amylase.
◦ During a pregnancy, poor pulmonary function can result in inadequate
oxygen supply to the fetus, resulting in an increased risk for growth
restriction, preterm labor, and perinatal death.
◦ Identifying whether the fetus also has the disease can be done by chorionic
villi sampling, amniocentesis, or identification of the abnormal gene on
chromosome 7 in fetal cells obtained from the woman’s blood serum.
◦ Screening for the disorder is included in routine neonatal screening
programs after birth
RHEUMATIC DISORDERS AND PREGNANCY
◦ JUVENILE RHEUMATOID ARTHRITIS (JRA;
sometimes referred to as chronic rheumatoid arthritis), is a disease of
connective tissue marked by joint inflammation and contractures
◦ result of an autoimmune response, the disease pathology involves
synovial membrane destruction, inflammation with effusion, swelling,
erythema, and painful motion of the joints
◦ Untreated, formation of granulation tissue fills the joint space, resulting
in permanent disfigurement and loss of joint motion.
◦ Women with JRA frequently take corticosteroids, hydroxychloroquine,
and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent joint
pain and loss of mobility.
◦ should continue to take oral aspirin therapy during pregnancy to prevent
joint damage

◦ large amounts of salicylates have the potential to lead to increased bleeding at birth or prolonged
pregnancy (salicylate interferes with prostaglandin synthesis, so labor contractions are not
initiated)
◦ The infant may be born with a bleeding defect and may also experience premature closure of the
ductus arteriosus because of the drug’s effects.
◦ woman is asked to decrease her intake of salicylates approximately 2 weeks before term.
◦ women also take low-dose methotrexate, a carcinogen (pregnancy risk category X)
◦ they should stop taking this prepregnancy because of the danger of head and neck defects in the
fetus.
◦ Joint symptoms of the disease may improve during pregnancy because of the naturally increased
circulating level of corticosteroids in the maternal bloodstream during pregnancy.
◦ During the postpartum period, when a woman’s corticosteroid levels fall to prepregnancy levels,
arthritis symptoms will probably recur
◦ In the postpartum period, the determination as to the safety of breastfeeding must be
individualized based on the medication each woman is taking.
◦ Those taking NSAIDs, such as ibuprofen, can breastfeed.
◦ Those taking methotrexate or large doses of aspirin may be advised not to breastfeed because of
the danger to the infant dcym 2024 medical condition 2 14
RHEUMATIC DISORDERS AND PREGNANCY Systemic
Lupus Erythematosus
Systemic lupus erythematosus (SLE) is a multisystem
chronic disease of connective tissue that occurs most
frequently in woman 20 to 40 years of age.
Widespread degeneration of connective tissue
(especially of the heart, kidneys, blood vessels, spleen,
skin, and retroperitoneal tissue) occurs with onset of the
illness.
A marked skin change is a characteristic erythematous
butterfly-shaped rash on the face.
In the kidneys, fibrin deposits develop, plugging and
blocking the glomeruli and leading to necrosis and
scarring.

Systemic Lupus Erythematosus
The thickening of collagen tissue in the blood chief complication of the disorder—acute
vessels can cause vessel obstruction nephritis with glomerular destruction
a. can be life-threatening to a woman if blood a. woman’s blood pressure will rise sharply
flow to vital organs becomes compromised b. develop hematuria, proteinuria with decreased
and urine output, and edema
b. life-threatening to a fetus if blood flow to the Treatment:
placenta is obstructed.
a. combination of NSAIDs,
Many women with SLE have
b. low–molecular-weight heparin,
antiphospholipid antibodies, which increase
the tendency for thrombi to form c. salicylates,
In contrast, marked thrombocytopenia (i.e., d. hydroxychloroquine,

decreased platelet count) may be present, so e. low-dose prednisone, or azathioprine (an
clotting may be deficient immunosuppressant) to reduce disease
symptoms.

continue meds during pregnancy - with caution; to reduce
the dose of salicylates 2 weeks prior to labor to prevent
bleeding in the newborn.
The naturally increased circulation of corticosteroids
during pregnancy may lessen symptoms in some women.
Frequent monitoring of serum creatinine levels will be
necessary to assess if kidney function is adequate.
value is over 1.5 mg/dl and proteinuria and a decreased
creatinine clearance value are present, the fetus is
seriously threatened with growth restriction and the
pregnancy is also threatened to be preterm.

Dialysis to remove excess creatinine or plasmapheresis to replace
platelets may be necessary to guard against hemorrhage in the
woman at birth.
During labor, intravenous hydrocortisone may be administered to
help a woman adjust to stress at this time.
During the postpartum period, there may be an acute exacerbation
of symptoms as corticosteroid levels again fall to normal.
Infants of women with SLE may be born with a lupus-like rash,
anemia, thrombocytopenia (low platelet count), and neonatal heart
block; symptoms last about 6 months and then fade.
If congenital heart block occurs, a newborn pacemaker may be
necessary

GASTROINTESTINAL DISORDERS AND PREGNANCY
APPENDICITIS, or inflammation of the appendix
The change in position of
few hours of nausea, and then an hour or two of generalized abdominal
appendix during pregnancy
discomfort.
typical sharp, peristaltic, lower right quadrant pain of acute
appendicitis.
differentiated pain from that of appendicitis
a. Pain from an overstretched round ligament or a ruptured ectopic
pregnancy may both cause sharp lower quadrant pain, fades almost
instantly; appendicitis pain not only continues, but grows more intense.
b. With an ectopic pregnancy, a woman may experience morning
sickness, and the pain she feels is either diffuse or sharp. With
appendicitis, the nausea and vomiting is much more intense and the
pain is sharp and localized at McBurney point (a point halfway
between the umbilicus and the iliac crest on the lower right abdomen).
c. In the pregnant woman, this can shift higher in the abdomen because
the appendix is often displaced so far up in the abdomen by the uterus
that the pain may resemble the pain of gallbladder disease
GASTROINTESTINAL DISORDERS AND PREGNANCY
 temperature is usually elevated, If the appendix ruptures before surgery, the
 a urine sample reveals ketones, and risk to both mother and fetus increases
 a complete blood count reveals leukocytosis – dramatically.
pregnancy has elevated WBC not a diagnostic of
appendicitis
With ruptured appendix, infected fecal
material escapes into the peritoneum and
 ultrasound or magnetic resonance imaging (MRI) scan
will confirm the inflamed appendix could spread by the fallopian tubes to the
 While waiting for diagnosis, not to eat any food, drink
fetus.
any liquid, or consume any laxatives - increasing Generalized peritonitis is such an
peristalsis could cause an inflamed appendix to rupture
overwhelming infection that it would be
 Management in early pregnancy: difficult for a woman’s body to combat it
a. Removal by laparoscopy effectively and also maintain the pregnancy.
b. Anestheologist – controls O2 level Peritoneal adhesions may develop after an
 Management if near term 37 weeks AOG: appendix ruptures, resulting in future
a. Cesarean section subfertility because of changes in the
b. Removal of inflamed appendix placement of fallopian tubes

Gastroesophageal Reflux Disease or Hiatal Hernia
GASTROESOPHAGEAL REFLUX DISEASE
(GERD) refers to the reflux of acid stomach
secretions into the esophagus
 HIATAL HERNIA is a condition in which a portion
of the stomach extends and protrudes up through
the diaphragm into the esophagus, trapping stomach
acid and causing it to reflux into the esophagus.
Both conditions may generate symptoms for the first
time during pregnancy as the uterus pushes the
stomach up against the esophageal valve and
increases the reflux of acid or the extent of the
hernia.

Gastroesophageal Reflux Disease or Hiatal Hernia
Symptoms include:
In most women, an over-the-counter antacid
• Heartburn, which is particularly extreme or a prescription for a proton pump
when lying supine after a full meal inhibitor such as esomeprazole magnesium
• Gastric regurgitation (Nexium; pregnancy category B) will
effectively dilute or inhibit gastric acid
• Dysphagia (difficulty swallowing) production and so relieve symptoms.
• Possible weight loss because of the stomach Additional measures, advise a woman to
pain wear clothing that is loose around her waist
• Hematemesis (i.e., vomiting of blood) if and to sleep with her head elevated on two
extreme esophageal irritation occurs or more pillows to help confine stomach
secretions.
diagnosed by ultrasound or direct endoscopy
could be used

Cholelithiasis Cholecystitis and Cholelithiasis
CHOLECYSTITIS (gallbladder inflammation) and
CHOLELITHIASIS (gallstone formation)
frequently associated with women older than 40 years of age, who are obese, are
multiparas, and ingest a high-fat diet.
gallstones form from cholesterol, the hypercholesterolemia that naturally occurs
during pregnancy - an increased incidence of gallstone formation during
pregnancy in women prone to these.
Symptoms : constant aching and pressure in the right epigastrium, perhaps
accompanied by jaundice.
Symptoms of acute cholecystitis during pregnancy, diagnosed by ultrasound;
managed by temporarily halting oral intake to rest the gastrointestinal tract and
administering intravenous fluids to provide fluid and nutrients as well as
analgesics for pain.
Medical therapy to prevent both conditions is to lower fat intake; however,
during pregnancy, women should not eliminate it entirely because of the
importance of linoleic acid for fetal brain growth.
Surgery for gallbladder removal by laparoscopic technique may be done during
pregnancy if a woman’s symptoms cannot be controlled by conservative
management
PANCREATITIS - inflammation of the pancreas is a rare disorder that tends to occur in young
adults and so may occur during pregnancy
Experiences severe epigastric pain, nausea, vomiting, anorexia, and

fever.
Diagnosis may be difficult as serum amylase, which rises with
pancreatitis, is also normally elevated during pregnancy; If serum
amylase levels are greater than two times above normal pancreatitis
should be suspected
Treatment: the same during pregnancy and nonpregnant women:
nasogastric suction, bowel rest, analgesia (because pancreatic pain is
sharp), and intravenous hydration through parenteral nutritional
supplementation
The inflammation usually subsides within a week.
Pregnancy loss, however, can occur from acidosis, hypovolemia, and
fetal hypoxia

HEPATITIS liver disease that occurs from invasion of
-
the hepatitis A, B, C, D, or E virus.
With all forms of hepatitis, a woman experiences nausea and vomiting.

Liver area may feel tender to palpation.
Urine will turn dark yellow from excretion of bilirubin;
Stools will be light-colored from lack of bilirubin.
Jaundice occurs as a late symptom.
On physical examination, hepatomegaly (i.e., enlargement of the liver)
The serum bilirubin level is elevated.
Levels of liver enzymes, such as transaminase, are increased.
Specific antibodies against the virus can be detected in the blood serum
Liver biopsy during pregnancy done under local anesthesia

HEPATITIS A Is the result of an infection with the hepatitis A virus (HAV). This type of hepatitis is an acute,
short-term disease.
Hepatitis A is spread mainly by fecal–oral contact

(children in day-care settings have a high incidence) or by
ingestion of fecally contaminated water or shellfish.
It has an incubation period of 2 to 6 weeks.
Pregnant women exposed to hepatitis A may be given
prophylactic - globulin to try to prevent the disease after
exposure.
This form follows a rather benign course and is not
thought to be transmitted to the fetus

HEPATITIS B and C
Hepatitis B
 The hepatitis B virus (HBV) causes hepatitis B. This is
often an ongoing, chronic condition.
Hepatitis C
 comes from the hepatitis C virus (HCV). HCV is among
the most common bloodborne viral infections typically
presents as a long-term condition
Hepatitis B and C are spread by:
a. exposure to contaminated blood or blood products
b. by contact with contaminated semen or vaginal
secretions (and so are considered sexually transmitted
infections [STIs]).
c. can be transmitted to the fetus across the placenta.

HEPATITIS D and E
◦ Hepatitis D
◦ This is a rare form of hepatitis that only

occurs in conjunction with hepatitis B
infection. The hepatitis D virus (HDV) causes
liver inflammation like other strains, but a
person cannot contract HDV without an
existing hepatitis B infection.
◦ Hepatitis D and E are apparently spread by
the same methods as hepatitis B and C, but are
rarely seen in pregnant women.

HEPATITIS MANAGEMENT
 bed rest and encouraged to eat a high-calorie diet Hepatitis during pregnancy may
- liver has difficulty converting stored glycogen into glucose in its diseased lead to spontaneous miscarriage or
state and so hypoglycemia can result preterm labor.
 cesarean at term Unlike most other diseases that
- to reduce the possibility of blood exchange between mother and fetus cause maximum fetal threat in the
first trimester, the later in
 Follow standard infection precautions when you give care to avoid
pregnancy a woman contracts
contact with body fluids.
hepatitis B infection, the greater the
 Use precautions during birth to avoid exposure to maternal body fluids. risk the infant will be affected or
 After birth, a woman may breastfeed as the infection is apparently not develop hepatitis B.
transmitted by breast milk.
If this should occur, it is a serious
 The infant should be washed well to remove any maternal blood consequence because a proportion of
 hepatitis B immune globulin (HBIG) and the first dose of hepatitis B hepatitis B Ag-positive infants will
should be administered develop liver cirrhosis or carcinoma
 The infant then needs to be observed carefully for symptoms of infection later in life
during the first few months of life and for chronic liver disease as he or
she grows older.
Inflammatory Bowel Disease
CROHN DISEASE (i.e., inflammation of the terminal ileus) -
malabsorption, particularly of vitamin B (the absorption of which occurs
almost entirely in the ileum), can occur
ULCERATIVE COLITIS (i.e., inflammation of the distal colon)
occur most often in young adults between ages 12 and 30 years.
Cause is unknown, but an autoimmune process is thought to be
responsible.
Associated with passive and active smoking
The bowel develops shallow ulcers; chronic diarrhea; weight loss; occult
blood in stool and nausea and vomiting.
If extreme, obstruction and fistula formation with peritonitis can occur.
Potential difficulty with absorbing nutrients in both disorders, women
with these disorders need careful monitoring for weight gain during
pregnancy.

MANAGEMENT
CROHNS and UC
Potential for fetal growth restriction if
extreme malabsorption occurs.
Therapy for the disorders is rest for the
gastrointestinal tract by administration of
total parenteral nutrition. Sulfasalazine
(Azulfidine), an anti-inflammatory and a
mainstay of therapy, may be continued during
pregnancy without fetal injury.
Close to birth, the dosage of sulfasalazine,
because of its sulfa base, is reduced because it
may interfere with bilirubin binding sites and
cause neonatal jaundice

NEUROLOGIC DISORDERS AND PREGNANCY
SEIZURE DISORDER
 several causes, such as head trauma or meningitis.
 causes of most recurrent seizures, such as epilepsy, are unknown (i.e., are idiopathic)
 Risk of the following problems:
•Slowing of the fetal heart rate •Preterm labor ; Premature birth
•Decreased oxygen to the fetus •Low birth weight
 Therapeutic Management: The goal of care is to establish the best seizure control
with the fewest possible number of antiseizure drugs prior to pregnancy
 During pregnancy, almost all antiseizure drugs are at least mildly teratogenic,
dosages may have to be decreased even further to protect the fetus, which
unfortunately then increases the risk of seizures
 Be certain women understand the rule “Do not take medication during pregnancy”
does not apply to antiseizure medications, so that they continue to conscientiously
take them despite the nausea or vomiting of early pregnancy.
 It is important the levels of antiseizure drugs be monitored and the doses
SEIZURES adjusted routinely during pregnancy and again after birth.
 As blood volume increases with pregnancy, some women may need their dosage
increased or their serum level will be diluted.
 Common drugs prescribed to control seizures are trimethadione (Tridione;
pregnancy risk category D); valproic acid (sodium valproate and divalproex
sodium; pregnancy risk category D); carbamazepine ( Tegretol; pregnancy risk
category C); ethosuximide ( Zarontin; pregnancy risk category C),
 a drug often used to control absence seizures; and phenytoin sodium (Dilantin;
pregnancy risk category D). Women who have been taking phenytoin
(Dilantin) for some time may have developed chronic hypertension, so a
baseline blood pressure should be established early in pregnancy so any
changes that occur with pregnancy can be interpreted correctly.
 Dilantin is recognized as the cause of a fetal syndrome, including cognitive
impairment, vitamin K deficiency, and a peculiar facial proportion not unlike
that of fetal alcohol sequence.
 To counteract the vitamin K deficiency and prevent hemorrhage in the
newborn, women may be prescribed vitamin K during labor or the last 4 weeks
of gestation.

ABSENCE SEIZURES
Absence seizures (often just a rapid fluttering of the eyelids or a moment’s staring into space)
should have no effect on a woman or fetus.
Tonic–clonic seizures (sustained, full-body involvement) could affect a fetus because spasm of the
woman’s chest muscles could lead to hypoxia.
◦ If a seizure should occur during pregnancy, a woman must be

evaluated to be certain the cause of the seizure was the underlying
seizure disorder, not a beginning sign of gestational hypertension.
◦ Nonpregnant women experiencing tonic–clonic seizures do not need
oxygen administered during a seizure, but in pregnancy, administering
oxygen by mask is a good prophylaxis to ensure adequate fetal
oxygenation.

MYASTHENIA GRAVIS
◦ MYASTHENIA GRAVIS is an autoimmune disorder
characterized by the presence of an IgG antibody against
acetylcholine receptors in striated muscle.
◦ The presence of the antibody causes failure of the striated
muscles to contract, particularly those of the oropharyngeal,
facial, and extraocular groups.
◦ Women with the disorder need to be carefully monitored during
pregnancy as pregnancy can cause major
exacerbations/aggravations of the disease
◦ The disorder is treated with anticholinesterase drugs such as
pyridostigmine (Mestinon) or neostigmine (Prostigmin) and
possibly a corticosteroid such as prednisone.
◦ These medications may be continued during pregnancy, as the
fetus will experience no effects from them.
◦ Atropine is the lifesaving antidote for neostigmine if an overdose
should occur.
◦ Plasmapheresis (i.e., removal of and replacement of plasma) to
MYASTHENIA
remove immune complexes from the bloodstream may be
GRAVIS
prescribed to reduce symptoms.
◦ It must be carried out gradually during pregnancy - to reduce
the risk of fluid overload or hypotension.
◦ Smooth muscle is not affected by the disease, labor should
occur without complications.
◦ Magnesium sulfate (administered to halt preterm labor or treat
hypertension of pregnancy) should be avoided at any point in
pregnancy because it can diminish the acetylcholine effect and
therefore increase disease symptoms.
◦ An infant born to a woman with myasthenia gravis may
demonstrate disease symptoms at birth because of the transfer
of antibodies

MULTIPLE Multiple sclerosis (MS) occurs predominantly in
SCLEROSIS women of childbearing age, usually between 20 and 40
years of age
Nerve fibers become demyelinated and therefore lose
function.
Women develop symptoms of fatigue, numbness,
blurred vision, and loss of coordination.
ACTH (adrenocorticotropic hormone) or a
corticosteroid is commonly given to strengthen nerve
conduction and both can be administered safely during
pregnancy.
In contrast, immunosuppressants such as cyclosporine
(Sandimmune), azathioprine (Imuran), and
cyclophosphamide (Cytoxan), which are also frequently
prescribed, should be used cautiously during pregnancy.

MULTIPLE SCLEROSIS
◦ Women may continue with plasmapheresis (i.e.,

withdrawal and replacement of plasma), during
pregnancy as long as the volume of exchange is well
controlled to prevent hypotension.
◦ Women with the disorder may grow increasingly
fatigued as pregnancy progresses, pregnancy does
not affect the long-term course of MS.
◦ In some women, symptoms may actually improve
during pregnancy because of the increased
circulating corticosteroid levels.
◦ Monitor for UTIs at prenatal visits as these tend to
occur as a poorly defined consequence of the illness.
SCOLIOSIS
 Lateral curvature of the spine begins to be noticed first in girls between 12
and 14 years of age.
 If it is uncorrected at this time, the curvature progresses until it can

interfere with respiration and heart action because of chest compression.
 Girls with scoliosis may wear a body brace during their adolescent years
to maintain an erect posture.
 Once pregnant, Pelvic distortion can interfere with childbirth, especially

at the pelvic inlet.
 If a woman’s spine is extremely curved, epidural anesthesia may be

difficult to administer for pain management in labor.
 Braces cannot be worn during the last half of pregnancy.

MUSCULOSKELETAL DISORDERS AND PREGNANCY
For surgical correction, girls have stainless steel rods surgically
implanted on both sides of their vertebrae to strengthen and straighten
their spine.
Such rod implantations do not interfere with pregnancy; a woman may
notice more than usual back pain, however, from increased tension on
back muscles.
If a woman’s pelvis is distorted, a cesarean birth may be scheduled to
ensure a safe birth.
Vaginal birth, if permitted, requires the same management as for any
woman.
Plot the course of labor on a labor graph so an unusually long first stage,
suggesting cephalopelvic disproportion, can be recognized.

ENDOCRINE DISORDERS AND PREGNANCY
HYPOTHYROIDISM, or underproduction of the thyroid
hormone, is a rare condition in young adults and especially rare in
pregnancy because women with symptoms of untreated
hypothyroidism are often anovulatory and unable to conceive.
A woman who does conceive can then face another obstacle in
that she can have difficulty increasing thyroid functioning to a
necessary pregnancy level, which can then lead to early
spontaneous miscarriage.
Women with hypothyroidism fatigue easily, tend to be obese,
their skin is dry (myxedema), and they have little tolerance for
cold.
It may be associated with an increased incidence of extreme
nausea and vomiting (i.e., hyperemesis gravidarum).

Management:
HYPOTHROIDISM
Increase levothyroxine (Synthroid) 20% to 30% for the duration
of the pregnancy to simulate the increase that would normally
occur in pregnancy to supplement lack of thyroid hormone - high
enough to sustain a pregnancy.
Should take thyroxine at a different time from any medication
containing iron, calcium, or any soy product by about 4 hours to
be certain there is no problem with the absorption of thyroxine.
After the pregnancy, the dose of levothyroxine prescribed for
pregnancy must be gradually tapered back to the pre-pregnancy
level for both her health and so she can breastfeed safely. Be
certain a woman does not continue to take her pregnancy dose -
higher dose could pass beyond normal thyroid function and
develop hyperthyroidism.

HYPERTHYROIDISM
HYPERTHYROIDISM, or overproduction of thyroid hormone,
causes symptoms such as a rapid heart rate, exophthalmos (i.e.,
protruding eyeballs), heat intolerance, heart palpitations, and
weight loss.
Sometimes called GRAVES DISEASE, it is more apt to be seen
in pregnancy than is hypothyroidism.
If undiagnosed, develop heart failure because her heart, already
stressed, cannot manage the increasing blood volume that occurs
with pregnancy.
More prone than the average woman to symptoms of gestational
hypertension, fetal growth restriction, and preterm labor.
Nuclear medicine imaging study involving the radiation
diagnostic procedure should not be used during pregnancy -
possibly resulting in destruction of the fetal thyroid.

HYPERTHYROIDIS Treatment for hyperthyroidism is with thioamides (methimazole
M [Tapazole] or propylthiouracil [PTU]), which reduce thyroid activity.
Methimazole is the preferred drug for pregnant women as it appears to
cross the placenta less easily.
These drugs, cross the placenta and can lead to congenital
hypothyroidism and, consequently, an enlarged thyroid gland (i.e., a
goiter) in the fetus.
If a goiter in the fetus enlarges enough, it can obstruct the airway and
make resuscitation difficult at birth.
If hyperthyroidism is not regulated during pregnancy, an infant may be
born with symptoms of hyperthyroidism; may appear jittery with
tachypnea and tachycardia.
Women receiving smaller or minimal doses of antithyroid drugs may
breastfeed,
Women receiving large doses of these drugs may be advised not to
breastfeed because they are excreted in breast milk.

Diabetes Mellitus
Diabetes mellitus is an endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate body glucose levels.
four new challenges to manage diabetes:
• How to manage both type 1 and type 2 diabetes during pregnancy to
achieve a healthy glucose/insulin balance during pregnancy
• How to protect an infant in utero from the adverse effects of
increased glucose levels
• How to care for the infant in the first 24 hours after birth until the
infant’s insulin–glucose regulatory mechanism stabilizes
• Reproductive planning may be a fourth concern, as women with
diabetes may not be good candidates for oral contraceptives because
progesterone interferes with insulin activity and therefore increases
blood glucose levels.

Classification of Diabetes Mellitus

Diabetes Mellitus
 Infants of women with poorly controlled diabetes high incidence of congenital anomaly:
tend to be large (10 lb)
a. caudal regression syndrome (failure of the lower
- increased insulin the fetus must produce to extremities to develop),
counteract the overload of glucose he or she receives
acts as a growth stimulant. b. spontaneous miscarriage, and stillbirth in
women with uncontrolled diabetes.
 Hydramnios may develop because a high glucose
concentration causes extra fluid to shift and At birth, neonates are more prone to
enlarge the amount of amniotic fluid. hypoglycemia, respiratory distress syndrome,
 A macrosomic infant may create birth problems at hypocalcemia, and hyperbilirubinemia.
the end of the pregnancy: The first trimester of pregnancy is the most
a. cephalopelvic disproportion. important time for fetal development; if a woman
b. combined with an increased risk for shoulder
can be kept from becoming hyperglycemic during
dystocia this time, the chances of a congenital anomaly are
greatly lessened .
c. may make it necessary for infants of women with
diabetes to be born by cesarean birth

Risk factors for developing gestational
diabetes include:
• Obesity
• Age over 25 years
• History of large babies (10 lb or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous
pregnancies
• History of polycystic ovary syndrome
• Family history of diabetes (one close relative
or two distant ones)
• Member of a population with a high risk for
diabetes

Oral Glucose Challenge Test Values (Fasting Plasma Glucose Values) for
Pregnancy Following a 75-g Glucose Solution
Using an insulin pump during pregnancy is

the best assurance that insulin levels will
remain constant

MENTAL ILLNESS AND PREGNANCY
 Mental illness may precede or occur with pregnancy the same as it can at any
point in life; antenatal anxiety, antenatal depression, bipolar disorder in
pregnancy, borderline personality disorder (BPD) in pregnancy
 Schizophrenia tends to have its highest incidence in adolescents and young adults
and so may occur in young pregnant women.
 Depression occurs almost four times more commonly in women than in men, and
often in young adults, making it the most common mental illness seen in pregnant
women.
 Even normal levels of stress make it difficult to use effective coping mechanisms,
so pregnancy or childbirth may be the additional stress that reveals mental
illness for the first time
 Any psychotropic medication taken by a pregnant woman should be evaluated
before pregnancy for possible fetal harm - lithium, a mainstay of therapy for
mood disorders such as bipolar disorder, and serotonin-reuptake inhibitors used
to counteract depression, are potentially teratogenic
 As the care of a newborn requires such a major life change, mental illness may
also occur in the postpartum period
CANCER AND PREGNANCY

•Hodgkin lymphoma stages indicate how far the canc
er has spread
:
•Stage I: The cancer is limited to one lymph node

region or a single organ.
•Stage II: The cancer is in two lymph node regions or
the cancer has invaded one organ and the nearby
lymph nodes. The cancer is either above or below the
diaphragm.
•Stage III: The cancer is in lymph node regions on
both sides of the diaphragm.
•Stage IV: The cancer has spread widely into one or
more organs outside the lymph system

Click icon to add picture
GROUP TWO
1. Review the blood
components and its
functions
2. Identify assessment
finding of Tawnlee
3. Describe diagnostic
procedures to be
done to confirm a
diagnosis for
Tawnlee
2. Prepare a dietary plan with corresponding calories and servings for

breakfast, lunch and dinner.
GROUP ONE
63
Click icon to add picture GROUP THREE
CRITICAL THINKING CARE STUDY
1. Identify assessment
Tawnlee Pawlinsky is a 37-year-old G40030, 30-week finding of Tawnlee
pregnant woman who comes to your high risk prenatal 2. Discuss cardio
clinic for care. She has chronic hypertension and mitral pulmonary
resuscitation on a
valve insufficiency, which cause her to be short of breath if pregnant woman
she hurries up a ladder at her job as a roofer or runs to 3. What rate of
catch a bus after work. respiratory/cardiac
ratio would you use
because she is 30 weeks
Suppose Tawnlee ran from the bus stop into the clinic to pregnant?
avoid being late for her appointment. As soon as she

reached the reception desk, she fell to the floor. You realize
she needs cardiopulmonary resuscitation (CPR).
64
Click icon to add THINKING
CRITICAL picture CARE STUDY GROUP
FOUR
Angelina Gomez, 22 years old, is pregnant with her first 1. Prepare an
child. interprofessional
” She fainted this afternoon while participating in her care map for a
weekly hour-long aerobic class. Angelina had rheumatic woman with
fever with mitral stenosis as a child. She developed multiple threats.
gestational diabetes early in this pregnancy (her serum 2. Describe the
glucose level is 207 mg/dl; her blood pressure (BP) is 100/60 effects of exercise
mmHg. A uterine monitor shows moderate-strength uterine on Angelina’s
present condition.
contractions 7 minutes apart; fetal heart rate (FHR) is 167
beats/min. 3. Discuss the
management for
gestational
diabetes
65

Medical Conditions 2

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Medical Conditions 2

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MEDICAL

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• Isoniazid (INH), rifampin (RIF), and ethambutol hydrochloride

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In contrast, marked thrombocytopenia (i.e., d. hydroxychloroquine,

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Experiences severe epigastric pain, nausea, vomiting, anorexia, and

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the hepatitis A, B, C, D, or E virus.

With all forms of hepatitis, a woman experiences nausea and vomiting.

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Hepatitis A is spread mainly by fecal–oral contact

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◦ This is a rare form of hepatitis that only

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◦ If a seizure should occur during pregnancy, a woman must be

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◦ Women may continue with plasmapheresis (i.e.,

 If it is uncorrected at this time, the curvature progresses until it can

 Once pregnant, Pelvic distortion can interfere with childbirth, especially

 If a woman’s spine is extremely curved, epidural anesthesia may be

 Braces cannot be worn during the last half of pregnancy.

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Using an insulin pump during pregnancy is

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•Stage I: The cancer is limited to one lymph node

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2. Prepare a dietary plan with corresponding calories and servings for

avoid being late for her appointment. As soon as she

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