LET’S BEGIN!

UNIT 1: Framework for Maternal and Child Health Nursing (MCN)

focusing on At- Risk, High Risk, and Sick Clients

Intended Learning Outcomes (ILO)

At the end of the unit, you are expected to:

1. Define common statistical terms used in the field, such as infant and
maternal mortality.
2. Identify 2020 National Goals related to genetic disorders that nurses
can help the nation achieve.
3. Formulate nursing diagnosis related to genetic disorder.
4. Established expected outcomes that meet the needs of the family
undergoing genetic assessment and counseling as well as manage
seamless transitions across differing healthcare settings.
5. Implement nursing care such as counseling a family with a genetic
disorder.
6. Evaluate expected outcomes for achievement and effectiveness of
care.

Introduction

The care of childbearing and childrearing families is a major focus of

nursing practice, because to have healthy adults you must have healthy
children. To have healthy children, it is important to promote the health
of the childbearing woman and her family from the time before children
are born until they reach adulthood.

Unlocking of Difficulties

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Let’s define some terms that you will encounter in this lesson…

Allele - is one of a pair of genes that appear at a particular location on a

particular chromosome and control the same characteristic, such as
blood type or color blindness.
Autosome - is any chromosome that is not a sex chromosome.
Child - a young human being below the age of puberty or below the legal
age of majority.
Childbearing - the process of giving birth to children.
Childrearing - the process of bringing up a child or children.
Cytogenetics - is the study of chromosomes by light microscopy and the
method by which chromosomal aberrations are identified.
Dermatoglyphics - the study of surface markings of the skin.
Fetal death - refers to the spontaneous intrauterine death of a fetus at any
time during pregnancy.
Genes - are the basic units of hereditary that determine both the
physical and cognitive characteristics of people.
Genetics - is the study of the way such disorders occur.
Goals - is an idea of the future or desired result that a person or a group
of people envision, plan and commit to achieve.
Infant mortality is the death of an infant before his or her first birthday.
Infant mortality rate - is the number of infant deaths for every 1,000 live
births
Inheritance - is the process by which genetic information is passed on from
parent to child.
Maternal - relating to a mother, especially during pregnancy or shortly
after childbirth.
Maternal Mortality -  is defined as "the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of
the duration and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from accidental
or incidental causes.

Lecture Notes

NATIONAL HEALTH SITUATION ON MATERNAL AND CHILD NURSING

INFANT MORTALITY
 The 2018 infant death rate increased by 5.9 percent from 11.9 infant
deaths per 1000 live births in 2017 to 12.6 infant deaths per 1000
live births in 2018.

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 The 21,019 infant deaths comprised 3.6 percent of the total deaths
(590,709) reported during the year.
 This represented a daily average of 57 infant deaths or two infant
deaths every hour. Statistics showed a decreasing IMR between ten-
year-period intervals, although there were minimal increases at
some point.
MATERNAL MORTALITY
 In 2018, the number of registered maternal deaths reached a total of
1,616. There were more than 132 maternal deaths registered in 2018
than in 2017 (1,484). The 2018 Maternal Mortality Ratio (MMR) is
1.0 per one thousand live birth. This was an 11.1 percent increase in
MMR from 2017.
 Eclampsia was the leading cause of maternal death in 2018 with 284
deaths and comprised 17.6 percent of maternal deaths. This was
followed by Gestational hypertension with significant proteinuria
with 198 deaths and was 12.3 percent of the total maternal deaths.
FETAL DEATHS
 Two out of five of fetal deaths (3,603; 41.9%) died of unspecified
cause.
 The next two leading causes of fetal death recorded were Fetus and
newborn affected by complication of placenta, cord and membrane
(1,736; 20.2%) and Birth asphyxia (1,301; 15.1%).
 Most number of fetal deaths occurred to mothers in age-group 25-
29 years, with 1,884 reported deaths or 21.9 percent of total fetal
deaths.
 High numbers of fetal deaths were also registered to mothers of
ages 20-24 years (1,750; 20.4%) and 30-34 years old (1,748; 20.31%).
However, statistics show that older mother (40-44, and 45-49 years
old) had the highest fetal death ratio as compared to other age-
groups of mother. Their corresponding FDR were 10.5 and 10.4 fetal
deaths per one thousand live births, respectively.
MORTALITY AMONG LOWER AGE GROUPS
 The 2018 ten leading causes of mortality among lower age groups,
specifically to age groups 1-4; 5-9; 10-14 years were presented.
 Pneumonia was the most common cause of death among children
age 1-4 years. In this age-group, Pneumonia recorded the highest
age-specific death rate (14.5 deaths per 100,000 of age-group
population).
 Deaths from diseases of nervous system and diarrhea and
gastroenteritis of infectious origin were also high among this age

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 group with seven and 6 deaths per 100,000 of age-group population,
respectively.
 Statistics also showed that deaths due to accidental drowning and
submersion were still common cause of deaths of children of age-
group 5-9 and 10-14 years old. It was the second leading cause of
death in both age-groups.
MORTALITY AMONG IMMUNIZABLE DISEASES
 The highest number of deaths was due to all forms of Tuberculosis,
which did not only include respiratory TB but also TB of other sites,
with 466 deaths.
 It was then followed by Measles with 323 deaths. The number of
deaths from Measles among 0-14 years old, is 17 times higher as
compared to last year, with 18 deaths only.
 Death from Acute poliomyelitis (1) was lower compared to last year,
with two deaths.

STATISTICS ON MATERNAL AND CHILD

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https://doh.gov.ph/sites/default/files/publications/2018%20Philippine%20Health
%20Statistics.pdf date retrieved: January 18, 2021

5
https://doh.gov.ph/sites/default/files/publications/2018%20Philippine%20Health
%20Statistics.pdf date retrieved: January 18, 2021

https://doh.gov.ph/sites/default/files/publications/2018%20Philippine%20Health
%20Statistics.pdf date retrieved: January 18, 2021

6
https://doh.gov.ph/sites/default/files/publications/2018%20Philippine%20Health
%20Statistics.pdf date retrieved: January 18, 2021

GENETIC AND GENETIC COUNSELING

Genetic Disorders

 Inherited or genetic disorders are disorders that can be passed from

one generation to the next because they result from some disorder
in the gene or chromosome structure.
 Genetic disorders occur in some ethnic groups more than others
because people tend to marry within their own cultural group.
 Some genetic disorders may occur due to occupational hazards, such
as toxic substance in the environment of workplaces.
 Genetic disorders occur at the the moment an ovum and sperm fuse

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 when the chromosome count is halved from 46 to 23.
 90% of first trimester spontaneous miscarriages may occur as the
result of chromosomal disorders.
 Other genetic disorders do not affect life in utero, so the result of the
disorder only becomes apparent at the time of fetal testing or after
birth.

Cytogenetics

 is the study of chromosomes by light microscopy and the method by

which chromosomal aberrations are identified.

Nature of Inheritance

 Genes are the basic units of hereditary that determine both the
physical and cognitive characteristics of people. Composed of
segments of DNA, they are woven into strands in the nucleus of all
body cells to form chromosomes.
 Humans (except sperm and ovum) - contains 46 chromosomes (44
autosomes and 2 sex chromosomes)
 Spermatozoa and ova each carry only half of the chromosome
number (23chromosomes).
 For each chromosomes in a sperm cell, there is a like chromosome of
similar size, shape, and function in the ovum (two like genes or
alleles)
 A person’s phenotype refers to his or her outward appearance or the
expression of genes.
 A person’s genotype refers to his or her actual gene composition.
 A person’s genome is the complete set of genes present (about
50,000 - 100,000)
 A normal genome is abbreviated as 46XX or 46XY.
 If a chromosomal aberration exists, it is listed after the sex
chromosome pattern.
Ex. 46XX5p
 In Down syndrome, the person has an extra chromosome 21, so this
is abbreviated as 47XX21+

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Genetic Counseling

 Genetic counseling can result in making individuals feel “well” or free

of guilt - if they discover a disorder they were worried about is not
an inherited one but rather occurred by chance.
 Genetic counseling can result in informing individuals they are
carriers of a trait responsible for a child’s condition.
 The ideal time for discussing whether the possibility of a genetic
disorder exist is before a first pregnancy at a preconception health
visit.
 If a couple did not receive counseling before a first pregnancy, it is
best if they receive it before a second pregnancy.

Genetic Information Nondiscrimination Act of 2008

 bars employers from using individuals’ genetic information when

making hiring, firing, job placement, or promotion decisions.
 Also prohibits group health plans and health insurers from denying
coverage to a healthy individual or charging that person higher
premiums based solely on a genetic predisposition to developing a
disease.

Assessment for Genetic Disorder:

History
 Obtain information and document diseases in family members for a
minimum of three generations - physical examination of both the
parents, includes half brothers and half sisters or anyone related in
any way as family.
 Include the mother’s age - some disorders increase in incidence with
age.
 Laboratory assays of blood, amniocentesis
 Family’s ethnic background - certain disorders occur more commonly
in some ethnic groups than others
 Any spontaneous miscarriages or children in the family who died at
birth - many instances, these children died of unknown
chromosomal disorders.
 Extensive prenatal history - to determine whether environmental
conditions could account for the condition.

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Physical Assessment
Pay particular attention to certain body areas:
 Space between the eyes
 Height
 Contour and shape of ears
 Number of fingers and toes
 Presence of webbing
 Dermatoglyphics - helpful because unusual fingerprints, abnormal
palmar creases, hair whorls, or coloring of hair are also present with
some disorder.
 Infants born at less than 35 weeks gestation- infants with multiple
congenital anomaly.
 Parents who have had other children with chromosomal disorders.

Screening and Diagnostic Test

 DNA analysis or karyotyping of both parents and an already affected

child - provides a picture of the family’s genetic pattern and can be
used for prediction in future problems.
 First trimester nuchal transparency and hormonal screening
 cfDNA testing
 Quadruple test analysis
 CVS
 Amniocentesis
 Percutaneous umbilical blood sampling (PUBS)
 Sonography

Reproductive Alternatives

1. Alternative insemination by donor (AID) - if the genetic disorder is

one inherited by the male partner or is a recessively inherited
disorder carried by both partners.
2. Surrogate embryo transfer - if the inherited problem is from the
female partner.
 an oocyte is donated by a friend or relative or provided by an
anonymous donor, which is then fertilized by the male partner;s
sperm in the laboratory and implanted into a woman’s uterus.
3. Use of a surrogate mother (a woman who agrees to be alternately
inseminated by the male partner’s sperm, and bear a child for the
couple)

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4. Adoption

Legal and Ethical Aspects of Genetic Screening and Counseling

 Participation by couples or individuals in genetic screening must be

elective.
 People desiring genetic screening must sign an informed consent for
the procedure
 Results must be interpreted correctly yet provided to the individuals
as quickly as possible
 The results must not be withheld from the individuals and must be
given only to those persons directly involved
 After genetic counseling, persons must not be coerced to undergo
procedures such as abortion or sterilization.
Failure to heed these guidelines could result in charges
 of invasion of privacy
 Breach of confidentiality
 Psychological injury caused by “labeling” someone or imparting
unwarranted fear and worry about the significance of the disease
or carrier state.

Common Chromosomal Disorders resulting in Physical or Cognitive

Development Disorders

TRISOMY 13 SYNDROME (47XY13+ OR 47XX13+)

 Patau syndrome
 The child has an extra chromosome 13 and is severely cognitively
challenge
 Incidence of the syndrome is low (approximately 0.45 per 1,000 live
births.
 Midline body disorders such as cleft lip and palate
 heart disorders (particularly ventricular septal defects)
 Abnormal genitalia are present.
Other common findings:
 Microcephaly with disorders of the forebrain and forehead
 Eyes that are smaller than usual (micropthalmos) or absent
 Low-set ears
 Most of these do not survive beyond early childhood.

TRISOMY 18 SYNDROME (47XY18+ or 47XX18+)

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 Edwards syndrome)
 Children with trisomy 18 syndrome have three copies of
chromosome 18.
 Incidence is approximately 0.23 per 1,000 live births
 Severely cognitively challenged and tend to be small for gestational
age
 Markedly low-set ears, a small jaw,congenital heart defects, and
usually misshapen fingers and toes (the index finger deviates or
crosses over other fingers)
 Sole of their feet are often rounded instead of flat (rocker-bottom
feet)
 Most of these children do not survive beyond infancy.

CRI-DU-CHAT SYNDROME (46XX5P OR 46XX5P)

 Is the result of a missing portion of chromosome 5

TURNER SYNDROME (45X0)

 Turner syndrome (gonadal dysgenesis) has only one functional X
chromosome.
 The child is short in stature and has only streak (small and
nonfunctional ) ovaries.
 She is sterile and, with the exception of pubic hair, secondary sex
characteristic do not develop at puberty.
 The hairline at the nape of the neck is low set and the neck may
appear to be webbed and short.
  low-set ears, hands and feet that are swollen or puffy at birth, and soft
nails that turn upward.

KLINEFELTER SYNDROME (47XXY)

 Children with Klinefelter syndrome are males with an extra X
chromosome.

FRAGILE X SYNDROME
 It is an an X-linked disorder in which one long arm of an X
chromosome is defective, which results in inadequate protein
synaptic responses.

DOWN SYNDROME (TRISOMY 21)

(47XY21 OR 47XX21)
 The most frequently occurring chromosomal disorder.

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CHILDHOOD TUMORS
 Retinoblastoma (chromosome 13)
 Wilms tumor (chromosome 11)
 Neuroblastoma (chromosome 1 or 11)

Focus Questions

Instructions: Answer the following questions and submit your answers

thru Email on or before the scheduled prelim exam.

Amy Alvarez is pregnant with twins. One twin fetus is diagnosed as

having Down Syndrome and the other is not. How would the nurse
counsel her if she wanted abort the affected child when the procedure
also might endanger the child without the disorder?

Related Readings

https://doh.gov.ph/sites/default/files/publications/2018%20Philippin
e%20Health%20Statistics.pdf

https://www.nature.com/scitable/topicpage/gregor-mendel-and-the-
principles-of-inheritance-593/

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infant
mortality.htm#:~:text=Infant%20mortality%20is%20the%20death,for
%20every%201%2C000%20live%20births.

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3363315

Learning/Assessment Activities

Direction: Answer the multiple choice quiz in schoology. Choose the best
answer and tick your answer.

References

JoAnne Silbert-Flagg, DNP, CPNP, IBCLC, FAAN, and Adele Pillitteri, PhD,
RN, PNP (2018). Maternal and Child Health Nursing. Care of the
Childbearing and Childrearing Family. Eigth Edition.Wolters Kluwer

13
Dar, S., Lazer, T., Swanson, S., et al. (2015). Assisted reproduction
involving gestational surrogacy: An analysis of the medical, psychological
and legal issues: Experience from a large surrogacy program. Human
Reproduction. 30(2), 345-352

Contractor, A., Klyachko, V.A., &Portera-Cailliau, C. (2015). Altered

neuronal and circuit excitability in fragile X syndrome. Neuron, 87(4),
699-715

The Philippine Health Statistic

https://doh.gov.ph/sites/default/files/publications/2018%20Philippine
%20Health%20Statistics.pdf

UNIT II: Care of At Risk/High Risk and Sick Mother and Child

Intended Learning Outcomes (ILO)

At the end of the unit, you are expected to:
1. Define high-risk pregnancy, including preexisting factors that
contribute to its development such as diabetes mellitus or
cardiovascular disease.
2. Assess a woman with an illness during pregnancy for changes
occurring in the illness because of the pregnancy or in the pregnancy
because of the illness.
3. Formulate nursing diagnoses related to the effect of a preexisting or
newly acquired illness on pregnancy.
4. Implement nursing care for a woman when illness complicates
pregnancy.
5. Evaluate expected outcomes for achievement and effectiveness of
care.

Introduction

This unit addresses the nursing role and care provided to families
with pregnancy complications. It focuses on pregnant women with a
chronic condition, such as cardiovascular or kidney disease, and those
who experience unintentional injury or develop a chronic illness during
pregnancy.

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Unlocking of Difficulties

Autoimmune - relating to disease caused by antibodies or lymphocytes

produced against substances naturally present in the body.
High-risk pregnancy - is one that threatens the health or life of the
mother or her fetus.
Hyperglycemia - is the technical term for high blood glucose (blood sugar)
Glycosuria - a condition characterized by an excess of sugar in the urine,
typically associated with diabetes or kidney disease.
Pyelonephritis - is an infection of the renal pelvis and kidney that usually
results from ascent of a bacterial pathogen up the ureters from the
bladder to the kidneys.
Pica - is a condition in which pregnant women compulsively eat nonfood
items (over the course of at least a month) that don’t have any
nutritional value, like dirt and clay.
Teratogenic - is - of, relating to, or causing developmental
malformations.
Teratogens - are substances that may produce physical or functional
defects in the human embryo or fetus after the pregnant woman is
exposed to the substance.

Lecture Notes

CARE OF A WOMAN WITH PREEXISTING OR NEWLY ACQUIRED ILLNESS

NURSING PROCESS

Assessment

 Obtaining baseline vital signs

 Subjective factor such as the extent of edema or level of exhaustion
 Teach a woman how to assess for her own health

Nursing Diagnosis

 Nursing diagnoses - address her specific, disease-related condition as

well as therapeutic restrictions her condition might require.
Examples:
 Ineffective tissue perfusion (cardiopulmonary) related to poor heart
function secondary to mitral valve prolapse during pregnancy

15
 Pain related to pyelonephritis secondary to uterine pressure on
ureters
 Knowledge deficit related to normal changes of pregnancy versus
illness complications.
 Fear regarding pregnancy outcome related to chronic illness.

Outcome Identification and Planning

 When making plans with a woman who has preexisting medical

condition, base them on the pattern of her life before pregnancy.
 Primary goal - maintaining the health of the pregnant woman during
pregnancy
 Be careful not to make plans for her, instead give the woman an
alternative.

Implementation

 Focus on teaching her new or additional measures to maintain

health during pregnancy.

Outcome Evaluation

Examples
 Patient states she rests for 2 hours morning and afternoon;
dependent edema remains at 1+ or less at next prenatal visit
 Family members state they are all participating in an exercise
program since mother developed gestational diabetes.
If expected outcome is not being met, a new assessment, analysis, and
planning need to be done.

Identifying a high-risk pregnancy

 A high-risk pregnancy is one in which a concurrent disorder,
pregnancy-related complications, or external factor jeopardizes the
health of the woman, the fetus, or both.

ASSESSMENT THAT MIGHT CATEGORIZE A PREGNANCY AS AT RISK

1. Obstetric history

 Existing uterine or cervical anomaly

 History of subfertility

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 Last pregnancy less than 1 year previous
 History of abnormal papsmear
 Previous premature cervical dilatation, preterm labor, preterm birth,
low-birth weight infant, or ceasarean birth
 Previous macrosomic infant or multiple gestation
 Previous abnormal gestational trophoblastic disease
 Previous ectopic pregnancy or stillborn/neonatal death
 Previous infant with neurologic deficit, birth injury, or congenital
anomaly

2. Past illness

 A chronic disease such as diabetes mellitus, heart disease, renal

disease, or chronic hypertension
 Emotional disorder or cognitive challenge
 Family history of severe inherited disorders
 Fibroid tumors or previous surgeries on reproductive organs
 Maternal reproductive tract anomalies or malignancy
 Seizure disorders
 Sexually transmitted infections
 Surgery required during pregnancy

3. Current obstetric status

 Abnormal fetal surveillance test

 Abnormal presentation; fetal version necessary
 Premature separation of the placenta
 Cervical cerclage
 Limited prenatal care
 Maternal weight loss or weight gain less than 10 lb by midpregnancy
 Multiple gestation or hydramios
 Gestational hypertension or preeclamsia
 Premature rupture of membranes or preterm labor
 Rh sensitization
 Sexually transmitted infection

4. Psychosocial factor

 Attempt or ideation of self injury

 Dangerous occupation

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 Lack of support people
 Inadequate finances; inadequate nutrition or poor housing
 Lack of acceptance of pregnancy

5. Demographic factors

 Maternal age under 16 years or over 40 years

6. Lifestyle

 Alcohol use during pregnancy

 Smoking greater than 10 cigarettes a day or living with person who
smokes this much
 Heavy lifting or long periods of standing
 Recreational drug use
 Unusual stress

SIGNS INDICATING POSSIBLE COMPLICATIONS OF PREGNANCY

 Vaginal bleeding
 Persistent vomiting
 Chills and fever
 Sudden escape of clear fluid from the vagina
 Abdominal or chest pain
 Gestational hypertension
 Increase or decrease in fetal movement
 Uterine contractions before 37 weeks of pregnancy

The Nursing Role and Nursing Care during Pregnancy Complication

From a Preexisting or Newly Acquired Illness.

I. CARDIOVASCULAR DISRODERS AND PREGNANCY

 Most common cause:

 valve damage concerns caused by rheumatic fever or Kawasaki
disease
 congenital anomalies such as atrial septal defect or uncorrected
coarctation of aorta
 Aortic dilatation
 Coronary artery disease

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  Varicosities
 A woman with cardiovascular disease should visit care provider for
preconception care - so her state of health and baseline data when
she is not pregnant can be established
 She should begin prenatal care as soon as she suspects she is
pregnant (1 week after the first missed menstrual period or as soon
as she has a positive pregnancy test) - so her general condition and
circulatory system can be monitored from the beginning of
pregnancy.
 The danger of pregnancy in a woman with cardiac disease occurs
primarily because of increase circulatory volume.
 The most dangerous time for the pregnant woman is in weeks 28 to
32 - just after the blood volume peaks.
 If heart disease is severe, symptoms can occur at the very beginning
of pregnancy.
 Toward the end of pregnancy, heart may become so overwhelmed
by the increase in blood volume that cardiac output falls to the point
vital organs (including the placenta) can no longer be perfused
adequately - oxygen and nutritional requirement of cells of both
mother and fetus are not met.
 The estimation of whether a woman with cardiovascular disease can
complete a pregnancy successfully depends on the type and extent
of her disease
 A woman with an artificial but well-functioning heart valves, those
with pacemaker implant, and heart transplant - can expect to have a
successful pregnancies as long as they have effective prenatal and
post natal care.

A WOMAN WITH CARDIAC DISEASE : Left-sided Heart Failure or Right-

sided Heart failure

 Left-sided heart failure happens when the left ventricle cannot shunt
the blood forward that it received by the left atrium from the
pulmonary circulation.
 Right-sided heart failure happens when the output of the right
ventricle is less than the blood volume received by the right atrium
from the vena cava.
A WOMAN WITH PERIPARTUM HEART HEART DISEASE

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 An extremely rare condition, peripartal cardiomyopathy, can
originate in pregnancy in women with no previous history of heart
disease. This occurs because of the stress of the pregnancy on the
circulatory system

Assessment of a woman with Cardiac Disease:

 Document a woman’s level of exercise performance

 Ask if she normally has a cough or edema
 Document baseline blood pressure, pulse rate and respiratory rate in
either sitting or lying position at the first prenatal visit; at future
health visits
 Make comparison assessments for nail bed filling (should be <5
seconds) and jugular venous distention
 If with right-sided heart failure - assess liver size at prenatal visits.
 ECG may be done at periodic points in pregnancy - assure the
woman that an ECG cannot harm the fetus.

ASSESSING A PREGNANT WOMAN WITH CARDIAC DISEASE:

 Fatigue
 Cough
 Increased respiratory rate
 Tachycardia
 Decreased amniotic fluid from intrauterine growth restriction
 Poor fetal heart tone variability from poor tissue perfusion
 Edema from poor venous return

Fetal assessment

 Infants tend to have low birth weights or small for gestational age -
because of acidosis, which develops due to poor oxygen/carbon
dioxide exchange or not being furnished with enough nutrients.
 This can result to preterm labor, which exposes the newborn to the
hazards of immaturity
 If the placenta is not filling well , a fetus may not respond well to
labor ( evidence by late deceleration patterns on a fetal heart
monitor) - a cesarean birth may be necessary (an increase risk for
both mother and child).

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Nursing Intervention During Labor and Birth

 Frequently assess a woman’s blood pressure, pulse, and respirations

 Monitor fetal hear rate and uterine contractions during labor
 A rapidly increasing pulse rate is an indications a heart is pumping
ineffectively (an effort to compensate)
 Advise a woman to assume a side-lying position during labor to
reduce the possibility of supine hypotension syndrome
 If with pulmonary edema - elevate her head and chest (semi-
Fowler’s position) to ease the work of breathing
 Evaluate women carefully to determine whether the fatigue is heart
or labor related.
 May need oxygen administration - need of extra oxygen due to the
exertion of labor
 A Swan-Ganz catheter to monitor heart function may be prescribed.
 Epidural anesthesia to decreases the sensation of pushing - pushing
requires more effort.
 Low forceps or a vacuum extractor may be used - because of lack of
pushing due to epidural anesthesia
 A woman may be disappointed (labor is not “natural”) - stress that
these measures may not be what she anticipated, but they can help
her achieve her ultimate goal, a healthy newborn and a mother able
to care for her new baby.

Postpartum Nursing Interventions:

 After birth, the increase in pressure takes place within 5 minutes, so

the heart must make a rapid and major adjustment
 May need to decrease activity
 Anticoagulant and digoxin therapy may be needed until circulation is
stabilized
 Antiembolic stockings or intermittent pneumatic compression (IPC)
boots - to increase venous return from the legs.
 Prophylactic antibiotics - must be started immediately after birth to
discourage subacute bacterial endocarditis caused by the
introduction of microorganisms through the placental site.
 Inform the mother that acrocyanosis is normal in newborns.
 Stool softener may be prescribed - to prevent form straining
 oxytocin must be used with caution - tend to increase blood pressure
 Women with heart disease can breastfeed without difficulty.

21
 Kegel exercise should not begin until approved by the primary care
provider.
 schedule a post partum check up for both gynecologic health and
cardiac status.

A WOMAN WITH AN ARTIFICIAL VALVE PROSTHESIS

 In patients with prosthetic heart valves (PHV), pregnancy is

associated with the risks of warfarin embryopathy in patients with
mechanical PHV and of structural valve deterioration (SVD), both
early and late, in patients with biological PHV.

A WOMAN WITH CHRONIC HYPERTENSIVE VASCULAR DISEASE

 Women already diagnosed with chronic hypertensive vascular

disease already has an elevated blood pressure (140/90 mmHg and
above) in pregnancy.
 Usually associated with arteriosclerosis or renal disease.
 Chronic hypertension can be serious cause it places both the woman
and fetus at high risk because of poor heart, kidney, and or placental
perfusion during the pregnancy.
 Management: Beta- blockers and calcium channel blockers 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.
 Drugs: Labetalol (Trandate) and nifedipine

A WOMAN WITH VENOUS THROMBOEMBOLIC DISEASE

 Venous thromboembolic disease happens more likely in pregnant

women because of the stasis of blood in the lower extremities due to
uterine pressure and the effect of elevated estrogen on the
hypercoagulability of the woman.
 The triad of stasis, vessel damage, and hypercoagulation results in
thrombus formation in the lower extremities.
 Women who are 30 years and older have an increased risk of
developing deep vein thrombosis leading to pulmonary emboli.
 Pain and redness in the calf of the leg usually signal thrombus
formation.
 Thrombus formation can be prevented by avoiding the use of
constrictive knee-high stockings.

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 Advise the woman not to sit with her legs crossed at the knee and to
avoid standing in one position for a long time.
 A thrombus that occurred during pregnancy is diagnosed by Doppler
ultrasonography and a woman’s history.
 The woman will be placed on bed rest and intravenous heparin
administration for 24 to 48 hours.
 Women who are taking heparin during pregnancy are not candidates
for routine episiotomy or epidural anesthesia to prevent
hemorrhage.
 PTT determination should be continued during labor.
 A breastfeeding woman cannot take heparin or Coumadin, or
Coumadin should be used cautiously.
 The main danger of thrombophlebitis is pulmonary embolism or a
clot that lodges in the pulmonary artery, blocking the circulation to
the lungs and heart.

II. HEMATOLOGIC DISORDERS AND PREGNANCY

 Involve either blood formation or coagulation disorder

IRON-DEFICIENCY ANEMIA

 Prevention:

 Prenatal vitamins - containing 27 mg of iron (as prophylactic

therapy)
 Diet high in iron and vitamins ( green leafy vegetables, meat, and
legumes)
 For iron-deficiency anemia - 120-200 mg elemental iron per day -
ferrous sulfate or ferrous gluconate
 Advise women to take iron supplements with orange juice or a
vitamin C supplement (ascorbic acid) - iron is best absorbed in an
acid medium

 Some women report constipation or gastric irritation when taking

oral iron supplements. Increasing roughage in the diet and always
taking the pills with food can help reduce these symptoms.
 Ferrous sulfate turns stool black, so caution women about this to
prevent them from worrying that they are bleeding internally.

FOLIC ACID-DEFICIENCY ANEMIA

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 Folic acid - necessary for the normal formation of red blood cells in
the woman as well as being associated with preventing neural tube
abdominal wall defects in the fetus.

 All women expecting to become pregnant are advise to begin a

supplement of 400 µg folic acid daily in addition to eating folate-rich
foods (e.g. green leafy vegetables, oranges and dried beans).

SICKLE-CELL ANEMIA

 It is a recessively inherited hemolytic anemia caused by an abnormal

amino acid in the beta chain of hemoglobin.
Assessment:
 Screening for sickle-cell anemia at a first prenatal visit
 Obtain hemoglobin levels
 Periodic collection of a clean catch urine sample during pregnancy- to
detect developing bacteriuria while asymptomatic
 Monitoring of nutritional intake - to be sure enough folic acid intake
 Should not take iron supplement
 Ensure increase fluid intake - at least 8 glasses a day - guard against
dehydration
 Assess for lower extremities for varicosities or pooling of blood in leg
veins - can lead to red cell destruction - encourage sitting on a chair
with the legs elevated or lying on the side in a modified Sims position
 Ultrasound examination at 16 to 24 weeks to assess for intrauterine
gorwth restriction then weekly USD at 30 weeks.

Therapeutic Management:
 Periodic exchange or blood transfusion
 If crisis occurs - controlling pain, administering oxygen as needed, and
increasing the fluid volume of the circulatory system to lower
viscosity
 Hospitalization if there is infection
 Keep the woman well hydrated while in labor and help resist
strenous exertion
 Epidural anesthesia is the method of choice if operation is needed.
 Post-partal period - early ambulation and wearing of pressure
stockings or IPC boots can help reduce the risk of thromboembolism.

THALASSEMIA

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 Are a group of autosomal recessively inherited blood disorders that
lead to poor hemoglobin formation and severe anemia
 Treatment focuses on combating anemia through folic acid
supplementation and blood transfusion to infuse hemoglobin-rich
red blood cells.

MALARIA

 is a protozoan infection that is transmitted to people by Anopheles

mosquitoes.
 Treatment: antimalarial drugs, which will both stop the coarse of the
disease and help reduced the incidence of low birth weight and
preterm birth
 Sulfadoxine/pyrimethamine - safe to administer during the last
trimester
 Choloroquine - safe during all pregnancy (drug of choice)
 Quinine, atovaquone, and proguanil, or tetracyclines - should not be
used at any point in pregnancy or with women who are
breastfeeding as they are teratogenic.

III. COAGULATION DISORDERS AND PREGNANCY

 VON WILLEBRAND DISEASE - Replacement of the missing

coagulation factor by infusion of cryoprecipitate or fresh frozen
plasma (FFP) may be necessary before labor to prevent excessive
bleeding with birth.

 HEMOPHILIA B (factor IX deficiency) - Restoration of factor IX levels -

restored by infusion of factor IX concentrate or fresh frozen plasma.
 IDIOPATHIC THROMBOCYTOPENIA PURPURA - Oral prednisone or a
platelet transfusion or plasmapheresis may be administered - to
temporarily increase the platelet count to prevent increased
bleeding at birth.
IV. RENAL AND URINARY DISORDERS AND PREGNANCY

A WOMAN WITH A URINARY TRACT INFECTION

Assessment
 Frequency and pain in urination

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 Pyelonephritis - pain in the lumbar region (usually in the right side
that radiates downward.
 The area is tended to palpation
 Accompanied by nausea, vomiting, and malaise
 Elevated temperature (39° to 40°C)
 Infection usually occurs in the right side
 Urine culture - 100,000 organisms per milliliter of urine - a level
diagnostic of infection

Therapeutic Management:

 Obtain a clean catch urine sample for culture and sensitivity - to

assess for asymptomatic bacteriuria or symptoms of UTI.
 A sensitivity test will determine which antibiotic will best combat the
infection.
 Amoxicillin, ampicillin, and cephalosporins are effective against most
organisms - safe antibiotics during pregnancy
 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 decidous teeth.

A WOMAN WITH HYPERACTIVE BLADDER

 A 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 (Tovias; pregnancy category C) - antispasmodic drug
 Should be used during pregnancy and breastfeeding only if the risk
outweighs the benefit until it is proven not to be teratogenic.

A WOMAN WITH CHRONIC RENAL DISEASE

 Women with chronic renal disease need to be monitored carefully

during pregnancy because their diseased kidneys may not produced
erythropoietin, a glycoprotein necessary for red cell formation and
so may develop a severe anemia.

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 Women with severe renal disease may require dialysis to aid kidney
function during pregnancy
 With dialysis, there is risk of preterm labor - because progesterone is
removed with the dialysis.
 Progesterone may be administered intramuscularly before the
procedure.
 For hemodialysis - scheduled for short duration to avoid fluid shifts
 Heparin - does not crossed placenta
 Diet must be on low-potassium - to avoid a buildup of potassium
 Emotional support during pregnancy
 Provide extra time with their infant at birth for bonding
V. RESPIRATORY DISORDERS AND PREGNANCY

 Any respiratory condition can worsen in pregnancy because the

rising uterus compresses the diaphragm, thus reducing the size of
the thoracic cavity and available lung space.

A WOMAN WITH ACUTE NASOPHARYNGITIS

 Should not take high-dose aspirin - can interfere with blood clotting
in both the mother and fetus
 Urge women to use simple measures to combat a cold such as:

 Extra rest and sleep and eat a diet high in vitamin C to help boost
the immune system
 Take acetaminophen )Tylenol) every 4 hours for aches and pains.
No Aspirin during pregnancy
 Apply medicated vapor rub to the chest
 Use cool or warm compresses to relieve sinus headaches

A WOMAN WITH INFLUENZA

 Influenza is caused by a virus, identified as type A,B, or C.

 Treatment includes antipyretic such as Acetaminophen to control
fever
 Women may also be immunized safely against influenza during
pregnancy

A WOMAN WITH PNEUMONIA

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 Pneumonia is the bacterial or viral invasion of lung tissue by
pathogens such as Streptococcus pneumoniae, Haemophilus
influenzae, and Mycoplasma pneumoniae.
 Therapy involves the use of antibiotic and 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.

A WOMAN WITH ASTHMA

 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
 A woman should check with primary care provider before pregnancy
about the safety of the medications she routinely takes for this
disorder to be certain it will be safe to continue during pregnancy
and breastfeeding.
 Women who have been taking a corticosteroids during pregnancy
may need intravenous administration of hydrocortisone during labor
because of the added stress during this time.
 Β-adrenergic agonist such as terbutaline and albuterol may be taken
safely during pregnancy, but because they have potential to reduce
labor contractions, the dosage may be tapered close to term if
possible.

A WOMAN WITH TUBERCULOSIS

 Lung tissue is invaded with Mycobacterium tuberculosis, an acid-fast

bacillus

Assessment

 Chronic cough
 Weight loss
 Hemoptysis
 Night sweats
 In high risk area - women should undergo skin testing (PPD) at their
prenatal first visit - a positive result does not mean does not

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 necessarily mean they have the disease, it can only mean they have
at some time been exposed to tuberculosis (and that they have
antibody in their system.
 If (+) reaction - chest x-ray or a sputum culture for acid-fast bacillus
to confirm the diagnosis. (x-ray during pregnancy is safe as long as
her abdomen is lead shielded)

Therapeutic Management:

 Isoniazid (INH) - may result in peripheral neuritis if not taken with

supplemental pyridoxine (Vitamin B6)
 Rifampoicin (RIF)
 Ethambutol hydrochloride - side effect causing optic atrophy and loss
of green color recognition
 If had tuberculosis earlier - 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.
 A woman is usually advise to wait 1 to 2 years after the infection
becomes inactive before attempting to conceive - as pressure on the
diaphragm form the enlarging uterus changes the shape of the lung
and can break open recently calcified pockets more readily than
well-calcified lesions.
 Pockets may also break open during labor from the increase
intrapulmonary pressure of pushing.
 Tuberculosis can be spread by the placenta to the fetus, it usually is
spread to the infant after birth by the mother’s coughing.
 Urge the woman to continue taking the her tuberculosis medication
as prescribed during breastfeeding - only small amount s of these are
secreted in breast milk

A WOMAN WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

 COPD is constriction of the airway associated most often with long-

term cigarette smoking.
 Constricted air disease limits the amount of oxygen that can reach
the lungs - associated with fetal growth restriction and preterm birth
 Women may need additional rest because of fatigue and may need
supplemental oxygen therapy during the day.
 If with sleep apnea- may be prescribed continuous positive airway
pressure (CPAP) at night.
 During labor - she may be advise to have cesarean birth

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 Stop smoking - to provide smoke-free environment for her baby

A WOMAN WITH CYSTIC FIBROSIS

 Cystic fibrosis is a recessively inherited disease in which there is

generalized dysfunction of the exocrine glands.
 Leads to mucus secretions, particularly in the pancreas and lungs ,
which become so viscid that normal lung and pancreatic functions
become compromised.
 Fertility may be lessen in women because sperm cannot migrate
through viscid cervical mucus - may need to have alternative
insemination or in vitro fertilization necessary for conception
 Symptoms: symptoms of chronic respiratory infection and
overinflation of their lungs from the thickened mucus present;
difficulty digesting fat and protein because the pancreas cannot
release amylase .
 During pregnancy - poor pulmonary function can result in
inadequate oxygen supply to the fetus, resulting in an increased risk
of 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 form the
woman’s blood sample.
 Screening for the disorder - included in the routine neonatal
screening.

Therapy:

 administration of pancrelipase (Pancrease) - to supplement

pancreatic enzymes. - pregnancy risk category C drug .- it does not
appear to affect the fetus - caution women to continue to take this
even with nausea of early pregnancy.
 Bronchodilator or antibiotic - to reduce pulmonary symptoms.
 Chest physiotherapy daily - to reduce buildup of lung secretions - this
should continue during pregnancy.
 Monitor hydration status during labor

Modification for Pregnancy:

 Pancrealipase may interfere with iron absorption - needs iron

supplement

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 Higher incidence of diabetes mellitus - needs close monitoring of
serum glucose levels at prenatal visits to detect development of
gestational diabetes
 Chest physiotherapy - may need to plan more frequent and shorter
sessions in modified positions (other than prone) during pregnancy.
 Fetal health - may be monitored by ultrasound and nonstress tests to
identify intrauterine growth restriction.

Modification for the Post Partum Period

 Advised not to breastfeed - because milk of nursing mother with

cystic fibrosis is high in sodium (risk of hypernatremia)
VI. RHEUMATIC DISORDERS AND PREGNANCY

A WOMAN WITH RHEUMATOID ARTHRITIS

 Women with JRA frequently take corticosteroids,

hydroxycholoroquine, and nonsteriodal anti-inflammatory drugs to
prevent joint pain and loss of mobility. Some women may be taking
oral aspirin therapy - potential to lead to increased bleeding at birth
or possibly prolonged pregnancy.
 Salicylate interferes with prostaglandin synthesis - so labor
contractions are not initiated.
 Infant may be born with bleeding defect and may alsoexperience
premature closure of the ductus arteriosus - because of the drug’s
effects
 Some women are taking methotrexate - a carcinogen (pregnancy risk
category X) - they should stop taking medication during pregnancy -
because of the danger of head and neck defects in the fetus
 Breastfeeding - must be individualized based on the medication each
woman is taking

A WOMAN WITH SYSTEMIC LUPUS ERYTHEMATOSUS

 Systemic lupus erythematosus is a multisystem chronic disease of

connective tissue that occurs most frequently in woman 20 to 40
years of age.
 Prior to pregnancy, a woman with SLE may be taking NSAIDS, low-
molecular weight heparin, salicylates, hydroxycholoroquine, low-
dose prednisone, or azathioprine (an immunosuppresant) to reduce

31
 disease symptoms -can continue taking this medication during
pregnancy but with caution. - may reduce of salicylates 2 weeks prior
to labor to prevent bleeding in the newborn and premature closure
of the ductus arteriosus.
 Increase in the blood pressure due to nephritis (chief complication of
the disorder) -will develop hematuria, proteinuria, with decreased
urine output, and edema.
 Frequent monitoring of serum creatinine levels
 if value is over 1.5 mg/dl , and proteinuria, and a decreased
creatinine clearance value are present - fetus is seriously threatened
with growth restriction, may have preterm pregnancy.
 Dialysis may be necessary
 During labor - intravenous hydrocortisone may be administered
 Infants of women with SLE may be born with a lupus-like rash,
anemia, thrombocytopenia, and neonatal heart block - symptoms
last for 6 months and then fade.

VII. GASTROINTESTINAL DISORDERS AND PREGNANCY

A WOMAN WITH APPEDNDICITIS

Assessment:
 Appendicitis usually begins with a few hours of nausea and then an
hour or two of generalized abdominal discomfort, then a typical
sharp peristaltic, lower right quadrant pain of acute appendicitis.
 Pain from an overstretched round ligament or rupture ectopic
pregnancy may both cause sharp lower quadrant pain - needs to be
differentiated from that of appendicitis
 Major difference - pain of an overstretched round ligament fades
almost instantly while pain form appendicitis is continuous and
grows more intense.
 Temperature is usually elevated
 urine sample reveals ketones
 CBC - leukocytosis
 MRI - confirmed the inflamed appendix
 Advise woman while at the emergency room not to eat, drink liquid,
or consume any laxatives because increasing peristalsis could cause
an inflamed appendix to rupture.
Therapeutic Management:
 Cesarean birth - if near term (past 37 weeks)

32
 If early in pregnancy - laparoscopy

A WOMAN WITH HEPATITIS

Assessment:
 Nausea and vomiting
 Liver area may feel tender to palpation
 Urine - dark yellow from excretion of bilirubin
 Stools - light-colored from lack of bilirubin
 Jaundice occurs as a late symptoms
 PE: hepatomegaly
 Serum bilirubin is elevated
 Liver enzymes - transaminase are increases
 Specific antibodies against the virus can be detected in the blood
serum - routine screening
 Liver biopsy - if necessary for diagnosis - can be performed under
local anesthesia (safe)
Therapeutic Management:
 Bed rest
 Encourage to eat high-calorie diet
 A cesarian birth may be planned at term to reduce the possibility of
blood exchange between mother and fetus.
 Follow standard precautions when give care to avoid contact with
body fluids.
 After birth - may breastfeed - infection not transmitted by breastmilk
 Infant - should be washed well to remove any maternal blood.
 Hepatitis B immune globulin (HBIG) and the first dose of hepatitis B
should be administered to the infant
 Infant needs to be observed for symptoms of infection during the
first few months of life and for chronic liver disease as he or she
grows older

Focus Questions

Instructions: Choose the correct answer of the given questions. Write

the correct letter of your choice and submit thru messenger.
1. Christina develops a DVT while in the hospital on bed rest and is
prescribed low-molecular-weight heparin. The nurse identifies which
action as important when planning care for her?
A. Showing her how to self-administer the drug as a rectal
suppository .

33
 B. Cautioning her that her hemoglobin level will be closely
monitored during therapy.
C. Allowing her to choose a subcutaneous site for the injection.
D. Monitoring her white blood cell count daily for decrease
coagulation.
2. Christina is friends with a woman in the clinic who has sickle- cell
anemia, and they often talk together about their care. Which
statement would alert the nurse that her friend may need further
instruction on prenatal care?
A. “I understand why folic acid is important for red cell formation.”
B. “I’m careful to drink at least eight glasses of fluid everyday.”
C. “I take an iron pill every day to help grow new red blood cell.”
D. “I’ve temporarily stopped jogging so I don’t risk becoming
dehydrated.”
3. While reviewing antenatal electronic records, the charge nurse of a
prenatal clinic notes that a high number of pregnant women seen in
the clinic, including Christina, have developed UTIs during their
pregnancies. The nurse should emphasize the need for staff nurses
to do which of the following?
A. Ensure that the housekeeping department is adequately cleaning
the toilet.
B. Suggest all women be prescribed a prophylactic antibiotic during
their first trimester.
C. Educate women on the need for sound perinatal care during
pregnancy.
D. Urge women to restrict fluid to keep their urine acidic and
concentrated.

Related Readings

https://www.mayoclinic.org/diseases-conditions/gestational-
diabetes/symptoms-causes/syc-20355339#:~:text=Gestational
%20diabetes%20is%20diabetes%20diagnosed,pregnancy%20and
%20your%20baby's%20health.

https://www.escardio.org/Journals/E-Journal-of-Cardiology-
Practice/Volume-17/hypertension-in-pregnancy#:~:text=The%20target
%20BP%20should%20be,their%20antihypertensive%20medication
%20%5B2%5D.

34
Learning/Assessment Activities

Direction: Answer the multiple choice quiz in schoology. Choose the best
answer and tick your answer.

References

Au, C. P., Raynes-Greenow, C. H., Turner, R. M., et al. (2016). Antenatal

Management of gestational diabetes mellitus can improve neonatal
outcomes. Midwifery, 34, 66-71

Basta, P., Bak, A., & Roszkowski, K. (2015). cancer treatment in pregnant
women. Contemporary Oncology, 19(5), 354-360.

JoAnne Silbert-Flagg, DNP, CPNP, IBCLC, FAAN, and Adele Pillitteri, PhD,
RN, PNP (2018). Maternal and Child Health Nursing. Care of the
Childbearing and Childrearing Family. Eigth Edition.Wolters Kluwer

https://www.mayoclinic.org/diseases-conditions/gestational-
diabetes/symptoms-causes/syc-20355339#:~:text=Gestational
%20diabetes%20is%20diabetes%20diagnosed,pregnancy%20and
%20your%20baby's%20health.

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