Nursing Care of the High Risk

Pregnant Client
(Pre-gestional Conditions)
 HIGH-RISK PRENATAL CLIENT
• HIGH-RISK PREGNANCY- is one in
which a concurrent disorder,
pregnancy-related complication, or
external factor jeopardizes the health of
the woman, the fetus, or both
– Mother or fetus has a significant increased chance of
harm, damage, injury, or disability(morbidity), and
loss of life or death(mortality)
 RISK FACTORS

A. Demographic Factors
Age: <16 or over 35 (optimal age: 20-
30yo)
Weight: overweight or underweight
Height: <5 feet
B. Socioeconomic Status
• Inadequate finances
• Overcrowding, poor standards of
housing
• Nutritional deprivation
• Severe social problems
• Unplanned & unprepared
pregnancy, esp. adolescents
C. Obstetric History
• Hx of infertility or multiple gestation
• Grand multiparity
• Previous abortion or ectopic pregnancy
• Previous losses: fetal death, stillbirth,
neonatal deaths
• Previous operative OB: CS, forceps delivery
• Previous uterine/cervical abnormality
• Previous high-risk infant: LBW, LGA, birth
injury or malformation
• Previous hydatidiform mole
D. Current OB Status
• Late or no prenatal care
• Maternal anemia
• Rh sensitization
• Antepartal bleeding; placenta previa, AP
• PIH
• Multiple gestation
• Premature or postmature labor
• Polyhydramnios
• PROM
• SGA, LGA, abnormality in tests and presentation
E. Maternal medical Hx/status
• Cardiac/pulmonary disease
• Metabolic disease: DM, thyroid disease
• Endocrine disorders: pituitary, adrenal
• Chronic renal disease: repeated UTI,
bacteriuria
• Chronic hypertension
• STIs and other infections
• Major congenital anomalies of the
reproductive tract
E. Maternal medical Hx/status cont.
• Hemoglobinopathies
• Seizure disorder
• Malignancy
• Major emotional disorders, mental
retardation
F. Habits/ Lifestyle
• Smoking during pregnancy
• Regular alcohol intake
• Drug use/abuse
 IDENTIFYING CLIENTS AT RISK
• It begins with the 1st prenatal visit &
continues throughout the pregnancy
• It involves subjective as well as objective
assessment techniques such as
screening procedures, laboratory and
diagnostic examinations
 Standard Examinations Done in a Prenatal
Visit
• Complete Blood Count- screens for
anemia
• Edema Check
-normally in LE (if found on leg; in
arms & feet, may indicate pre-
eclampsia)
• Fetal heart Rate (N= 120-160 bpm)
• Fundic Height- measured from 22-34
weeks & correlates with gestational
age with normal pregnancy
• Height- during initial visit
• Leopold’s Maneuver
• Pelvic adequacy examination
• Urinalysis and culture
-screening for asymptomatic
bacteruria as early as 1st prenatal visit; if
(+), culture is done Vital Signs
• Weight- pattern of weight gain/loss is
recorded
• NST
• OCT/CST
• BPP
• X-ray: Lateral pelvimetry
• CVS
• Amniocentesis
• PUBS
 PREGESTATIONAL
CONDITIONS

CARDIOVASCULAR DISEASE
 Effects of Pregnancy on Heart
Disease
1. B BV& Cardiac output
-BV peaks at 24-28 wks
-Cardiac output increases 50%
-heart must contract harder& faster
-postpartum-bld circulating in the uterus &
placenta returns to maternal circulation
*Team approach to care during pregnancy
(internist, OB and nurse)
• Most dangerous period is in weeks
28 to 32, just after the BV peaks,
earlier in more severe cases
 Most Commonly Cause
Difficulty During Pregnancy
• Valve Damage due to Kawasaki
Disease or Rheumatic Fever
• Congenital Anomalies such as
ASD or Uncorrected Coarctation
of Aorta
• Aortic Dilatation
• Marfan Syndrome
 Risk Factors
• Rheumatic fever- 90% of all cases
• Congenital heart defects
• Arteriosclerosis
• MI: pregnancy is generally contraindicated
with previous MI and who have severe L
ventricular damage & heart failure
• Pulmonary disease
• Renal diseases
• Heart surgery
 CLASSIFICATION OF HEART DISEASE
CLASS DESCRIPTION

I-80% Uncompromised. No activity limitation. Ordinary

physical activity causes no discomfort. No
symptoms of cardiac insufficiency & no anginal
pain

II Slightly Compromised. Slight activity limitation.

Asymptomatic at rest but ordinary physical
activity causes excessive fatigue, palpitation &
dyspnea or anginal pain
III Markedly Compromised. Marked limitation.
During less than ordinary activity, woman
experiences excessive fatigue, palpitations,
dyspnea or anginal pain

IV Severely compromised. Marked limitation. Woman

is unable to carry out any physical activity
without experiencing discomfort. Even at rest,
symptoms of cardiac insufficiency or anginal pain
are present
 Prognosis & Management
CLASS Prognosis/Management

Good.Does not interfere with ADLs

Class I &generally do well during pregnancy

Class II Good. Require close supervision. If

symptoms worsen, notify HCP; may
require bedrest & hospitalization if
decompensation occurs
Class Moderate. May require bed rest & digitalis from
III wk 20 to delivery
During labor, hemodynamic monitoring &special
anesthetic mgt

Class Poor. Cardiac condition must be corrected by surgery

IV during pregnancy.
Therapeutic abortion if <14 wks if condition is
uncorrected, then, sterilization.
Hemodynamic monitoring until fetus is viable for
delivery
 Assessment-Diagnostic Tests

• ECG
• Echocardiography
• Echocardiogram(ultrasound of
the heart)
 Criteria for establishing
diagnosis of HD
• Persistent murmurs
• Permanent cardiomegaly
• Severe dysrhythmias
• Severe dyspnea
 Signs of cardiac
decompensation
• moist cough
• Pedal edema: signs of pulmonary edema
• Dyspnea, increasing with activity
• Tachycardia
• Tachypnea
• Chest pains on exertion
• Cyanosis
• Persistent heart murmurs
 Other signs:
• Syncope w/ exertion
• Cyanosis
• Clubbing of fingers
• Neck vein distention
• Cardiomegaly
• Pulmonary hypertension
*Safety alert: presence of severe dyspnea, syncope
with exertion, hemoptysis, nocturnal tachycardia and
angina require prompt evaluation
Management
• A pregnant woman w/ heart ds
should avoid infection, excessive
weight gain, edema and anemia
bec these conditions increase the
workload of the heart
Treatment/Management:individualized
• Frequent prenatal visits
• Rest, physical and mental:
-Sleep at least 8-10 hrs at night & 2 rest
periods during the day
-Instruct client to lie down for 30 mins after
meals
-Allow only light work, no stair climbing, no
exhaustion
-Activity limitation esp for Class 3 & 4
-Severely affected clients may need to be
admitted as early as mid-2nd trimester
 Treatment/Management:individualized
• Digitalis. Withhold if PR <60bpm or >100bpm
• Diuretics. If K-excreting(e.g. Furosemide(Lasix)),
SE: hypokalemia increases the risk for digitalis
toxicity; report signs like bradycardia, N/V,
diarrhea, colored vision(xanthopsia)
• Antibiotics-before any invasive procedure;
prophylaxis vs. RF; treatment of bacterial infection
• Iron supplement- prevent/treat anemia
• Oxygen as necessary
• Anticoagulant-Heparin/Enoxaparin to prevent clot
formation with DVT and Pulmonary Emboli as
complication
• Nitroglycerine- relieves angina by vasodilation
-take: 5 min before effort
-how often: q 5 mins up to 3 tabs, if not relieved
after 15 mins, go to ER
-take tablet while sitting down
-storage: covered, replace q 3 mos
-Side Effects: hypotension, Headache, flushing,
burning & stinging sensation under the tongue
-types: tablet, patch, cream, sublingual
Corticosteroid- help to reduce the formation of
additional antibodies in aPLA
 Intrapartum period goals:
*minimize hemodynamic changes & optimize
perfusion
• Minimize changes in BP & PR
– Lateral position
– Adequate pain relief: regional anesthesia during
labor
– Avoidance of hemorrhage
– Avoidance of infection
 Intrapartum period goals
• Forceps or vacuum extraction to avoid prolonged
Valsalva maneuver & to shorten 2nd stage of
labor (Assess NB for Bell’s Palsy)
• Elective CS in some specific cardiac
complications
 Nursing Implementation
• Encourage early, regular prenatal visits
• Encourage compliance with therapeutic
regimen
• Decrease workload of the heart:
– adequate rest & sleep,
– avoid/treat early anemia and infections,
– prevent exhaustion, fatigue, stress
• Avoid activities that decrease oxygenation: smoking,
overcrowded places, infection
• Avoid constipation: increase fiber and fluids,
exercise(walking is best)
• Proper nutrition
-High in Fe, protein, minerals & vitamins
-Limit sodium intake after 8-12 weeks to
avoid fluid retention
-Weight gain of no more than 24 lbs to
avoid increase in cardiac workload

• Early hospitalization: *Severely affected

clients may need to be admitted as early as
mid-2nd trimester”
 Care during Labor
• Thorough physical assessment- report changes
• Position: lateral, Semi-Fowler’s with hands and
legs supported
• Administer O2 per mask
• Strict asepsis to prevent infection
• Monitor I & O to prevent fluid overload
• Observe NPO
• Provide emotional support
• Continuous cardiac monitoring
*PR is the most sensitive & reliable indicator
of CHF. Report if PR is >200bpm and RR>24/min
 Care during Labor
• Anticipate episiotomy & Forceps delivery
• Prepare for regional anesthesia
• Administer drugs as ordered: digitalis,
diuretics & antibiotics
 Postpartal Care
• Cardiac failure more likely in the early postpartal
period because of: loss of placental circulation,
rapid decrease in intraabdominal pressure lt
vasocongestion and increase in cardiac output
• Monitor blood loss, I & O, & fluid rate flow
• Assess for signs of bleeding, sepsis & CHF
• Provide for non-stressful mom-infant interaction
• Provide other care ant frequent rest periods
• NO Oral contraceptive pills for patient with DVT
 Postpartal Care
• Lower legs promptly to reduce burden of the
heart.
• Promote rest
• Hospitalization until stable
• Early but gradual ambulation
• Meds: antibiotics, stool softeners, sedatives
• Breastfeeding allowed in Class I & II if no
decompensation during pregnancy and labor
• Counsel re sterilization for Class II-IV if not
corrected
 DIABETES MELLITUS
Description:
• An endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate
body glucose levels
• Disorder in CHO, CHON and fat metabolism
• Pregnancy is a diabetogenic state due to the
profound effect of hormones (HPL), which
increases insulin-resistance
 Risk factors of DM

• Family history
• Rapid hormonal changes in
pregnancy
• Tumor/infection of the pancreas
• Obesity
• Stress
 Normal Metabolic changes in
Pregnancy that Affect DM
• Increase insulin antagonistic hormones: cortisol,
E, P and HPL
• Lowered renal threshold for sugar, increased
GFR lt GLYCOSURIA
• Excess glucose crosses placenta lt LGA
• Vomiting decreases CHO intake is link to
metabolic acidosis
• Labor activity requires increased CHO intake
• Hypoglycemia postpartum due to involution &
lactation
 Gestational Diabetes

• This is DM that develops during

pregnancy and spontaneously
resolves after delivery
MATERNAL COMPLICATIONS OF GDM
• Predisposes to PIH, UTI,
• Infections: candidiasis, UTI
• Uteroplacental insufficiency
• Dystocia due to large infant CS delivery
• PTL, CPD
• PP hemorrhage due to uterine atony
• More difficult to control DM-hypo/hyperglycemia
• Maternal mortality
• Diabetic retinopathy
• Diabetic nephropathy
FETAL COMPLICATIONS:
• Macrosomia---birth injuries
• IUGR dt placental insufficiency
• Fetal hypoxia, IUFD, stillbirths
• 1st trimester: spontaneous abortion or fetal
anomalies
• Hydramnios
• Prematurity
• Neonatal hypoglycemia as soon as 1 hr postpartum
• RDS
• Hyperbilirubinemia
• Hypocalcemia
• Birth defects: heart, brain & spine, kidney, GIT
 Assessment Findings
HISTORY
• Family hx of DM, previous GDM
• Previous LGA (4k or more)
• Previous infant with congenital defects, hydramnios
• Spontaneous abortion, fetal deaths, stillbirth
• Obesity
• Frequent candidiasis
• Marked abdominal enlargement (hydramnios &
LGA)
 Assessment Findings
• Signs of hyperglycemia
– Polyphagia
– Polyuria
– Polydipsia
• Weight loss fat and CHON stores used
for energy
• Increased blood and urine glucose
Signs of Hypoglycemia:
• Sweating with cold, clammy skin
• Pallor
• Tremors, shakiness
• Hunger & nausea
• Irritability or impatience, anger
• Confusion, indicating delirium
• Tachycardia
• Nervousness, anxiety
• Sleepiness
• Blurred vision
• Seizures
• unconsciousness
 DIAGNOSIS
• SCREENING TEST
– At 26-28 wks for high-risk women
– 50g oral glucose challenge (if >140 mg/dl, needs 3-hr
GTT)
• GLUCOSE TOLERANCE TEST(GTT)
– 100 g GTT bw wk 28-34
– Glucose levels at 1,2 & 3 hrs
*Results:GDM if FBS>95 or 2 results are high
*Normal: FBS(95 mg/dl)
1h (180 mg/dl)
2h (155 mg/dl)
3h (140 mg/dl)
 DIAGNOSIS
• 2-hr Postprandial Blood Sugar(PPBS)
– Abn Result: >120 mg/dL
*Goals: FBS <105 mg/dL, PPBS <120 mg/dL
• Glycosylated Hemoglobin(HgbA1c)(maternal
hb irreversibly bound to glucose)
– Measures long-term(3 mos) compliance to treatment
– N: 4%-8%
• Urine Glucose monitoring is inaccurate
Treatment of Hypoglycemia
• Consume 15-20 g glucose or simple CHO
– Glucose tabs, 2 tbsp raisins, 4 oz(1/2 c juice or soda),
8 oz nonfat milk, 1 Tbsp sugar, honey or corn syrup,
hard candies, jellybeans or gumdrops
• Recheck blood glucose after 15 mins.
• *emergency drug: GLUCAGON IM into buttock,
arm or thigh to stimulate liver to release stored
glucose into the bloodstream
DO NOT:
Inject insulin
provide food or fluid if unconscious
put hands in mouth
 Nursing Implementation
• Participate in early detection.
• Encourage early prenatal mgt. & supervision
-Regular prenatal check-up
-Record dietary intake & monitor glucose
levels
-Insulin when FBS is not consistent at < 105
mg/dL or 2-hr PPBS is not <120mg/dL
-Serial UTZ- from 28-34 wks if DM poorly-
controlled or with complications
-Hospitalization- if DM is poorly-controlled,
with HPN and infection
 Nursing Implementation
• Provide teaching:
-Nature, effects of DM
– Signs & symptoms of hypo/hyperglycemia
-Exercise to regulate glucose levels
-Insulin regulation/self-administration
-Prompt reporting of danger signs and signs of
infection
• Promote control of DM
– Diet: 1800 to 2,200 cal/day or 35 kcal/kg BW
12%-20& CHON, 40%-45% CHO, 40% from
PUFAs
Use Diabetic food exchange list
Wt gain not > 24 lbs.
 Nursing Implementation
• Exercise: decreases need for insulin but may
cause hypoglycemia if excessive
– No exercise when glucose levels are low or stomach is
empty
– Don’t administer insulin in extremity used in exercise
– Don’t exercise alone
– always carry diabetic ID
 Nursing Implementation
• Insulin Therapy
– No OHA
– Insulin req drops during 1st trimester,
increased in 2nd & 3rd tri(tripled); increased
chance of ketoacidosis
– Regular & NPH(Isophane) insulin; only
regular insulin IV during labor to prevent
ketoacidosis
– Humulin (DOC)- least allergenic
– Split-dose therapy: regular & intermediate
combi; 2/3 daily dose before breakfast at 2:1
ratio(interm to reg);1/3 30 mins before
dinner(1:1)
*DIABETIC KETOACIDOSIS
-diagnosed when glucose >300
mg/dL, (+) serum ketones are at level 1:4
& metabolic acidosis is present
-Causes: poor compliance, infection,
HG, use of drugs like corticosteroids,+
acetone breath
-Fetal effects: 20% perinatal
mortality
 Nursing Implementation
• Prevention of infection, stress, which leads to
hyperglycemia, which increases the need for
insulin
• Encourage assessment of fetal well-being:
ultrasound, amniocentesis(L/S ratio),
phosphatidyl glycerol( fetal lung maturity), NST,
CST, BPP
• Early labor induction or CS in the presence of
fetal distress( 36-37 wks)
 Management

• Maintain normal FBS, Hba1c(N=6%)

– Glycosylated hemoglobin measures the
amount of glucose attached to the RBC &
reflects average measurement of the
glucose levels over the past 4-6 wks
– Good test to assess effectiveness of
treatment
– Abnormal: >7% of total hemoglobin
• Clinic visit every 2 wks up to 36 wks
• Exercise lowers glucose levels
– Ingest protein or complex CHOprior to exercise
• Diet:
– 1800 to 2,200 cal/day or 35 kcal/kg BW
– 12%-20& CHON, 40%-45% CHO, 40% from PUFAs
– Use Diabetic food exchange list
– Wt gain not > 24 lbs.
• Instruct on signs of hypoglycemia(dt excessive
insulin, exercise or insufficient dietary intake):
– Pallor
– Weakness, numbness
– Headache
– Confusion or irritability
– Blurred vision
– Perspiration
– Hunger
– Convulsions, coma
“cold and clammy, need some candy”
Mgt: Give CHO foods like fruit juice, cola, sugar, candy
• Self-monitoring of Blood glucose at least TID
– Desired values:
– before meal: 95 mg/d
– 1 hr after meal: <140 mg/d
– 2 hrs after meal <120 mg/dl
• Fetal Well-being Monitor
– Alphafetoprotein level at 15-17 wks
– Ultrasound at 18-20 weeks and monthly to rule
out deformities, hydramnios,
– NST starting at 34 wks(if abnormal, CST, BPP)
– Daily kick counts from wk 28(N=10/hr); report if
less
– L/S Ratio starting 34-36 weeks (N=2.5-3:1)
– Creatinine clearance to monitor perfusion
 Care During labor & Delivery

• Plan to deliver bw 36-40 wks when fetus is

mature enough but not too large to cause CPD
• L/S ratio should be 2.5-3.5:1
• Vaginal delivery is preferred
• Regular insulin on labor day bec need for insulin
drops immediately pp and may not need insulin
in the 1st 24 hrs pp. Monitor glucose levels.
 Newborn Care
• Keep warm.
• Observe respiration since hydramnios inflates
stomach and may interfere with lung expansion
• Observe for hypoglycemia(shrill cry, tetany,
tremors), BF or give glucose water
• Observe for hypocalcemia(tetany, tremors), give
Calcium gluconate
• Observe for congenital anomalies: esophageal
atresia, NTD
 Contraception

• No IUD- high incidence of PID

• No COCs- P interferes with insulin and E
raises lipid, cholesterol levels & affect
blood coagulation
• Norplant or progestin only pills(minipills)
may be used safely by diabetic women
 ANEMIAS OF PREGNANCY
ANEMIA- is a condition of too few RBCs, or a
lowered ability of the RBCs
Most Common Types during Pregnancy:
• Iron deficiency Anemia
• Vitamin B12 Anemia
• Anemia dt Blood Loss
• Folate Deficiency
 Risk Factors
• Poor nutrition
• Excess alcohol consumption
• Illnesses that reduce absorption of nutrients
• Use of anticonvulsant drugs(tegretol, lithium,
carbamazepine, etc.)
• Previous use of oral contraceptives
• G6PD Deficiency
 Complications of Anemia

• Premature labor
• Intrauterine growth retardation (IUGR)
• Dangerous anemia from normal blood loss
during labor, requiring transfusions
• Increased susceptibility to maternal infection
after childbirth
 IRON DEFICIENCY ANEMIA
• Most common type, develops in the 2 nd & 3rd
trimester when the Fe requirements increase to
compensate for the expanding blood volume
• Predisposing factors:
– Poor diet & poor nutrition
– Heavy menses
– Successive pregnancies w/in 2 yrs or <6 mos interval
– Unwise reducing programs
– Low socioeconomic status
 Signs & Symptoms of IDA
• Easy fatigability
• Sensitivity to cold
• Dizziness
• Brittle, flattened nails
• VS: rise in systolic pressure, tachycardia,
tachypnea
 Diagnosis

Lab findings:
-low hemoglobin <10 g/100ml
-low hematocrit <37% in the 1st trimester,
<35% in the 2nd tri and <33% in the 3rd tri
-Serum ferritin < 100 mg/dl
-Serum Fe level < 30 ug/dl
-Hypochromic, microcytic RBCs
 Effects of Anemia on Pregnancy
• Decreased resistance to infection
• Associated with prematurity & LBW infants
• Predisposes to heavy bleeding during labor &
delivery
• Associated with PICA
 Management
• Promote balance of activity & rest with avoidance of
fatigue
• Oral Fe supplementation:
– 120-180 mg/day.
– Ferrous sulfate is the most absorbable form;
– must be continued 3 mos after anemia has been corrected
• Increase intake of Fe-rich foods:
– Red meats: liver, beef, heart & kidneys, poultry, fish,
– Egg yolk
– GLV
– Dried fruits: raisins
– legumes, yeast, whole grains, nuts, dried beans
• Provide instructions:
– Fe causes tarry stool
– Fe causes constipation: inc fiber & fluids
– Fe causes GI discomfort: take with meals
– Better absorption if taken 1 hr before or 2 hrs
after meal
– Fe is best absorbed in acid medium
– Never take with milk & Ca supplements
– In liquid form, use straw to prevent teeth staining
 Megaloblastic Anemia
Types:
Folic Acid
Deficiency/
(Pernicious anemia)

Vit B12
Deficiency/Addison
Pernicious Anemia)
 Folic acid vs. Folate

Folate is the common form of vitamin B9

present in many whole foods, including
leafy greens, beans, eggs, citrus fruit,
avocados, and beef liver.

Folic acid is a synthesized version of

vitamin B9 that is added to processed foods
and the common version used in
supplements.
 Folic Acid Deficiency Anemia
• Folic Acid is necessary for normal formation of
RBC and in the prevention of NTDs
– Deficiency leads to formation of large & immature
RBCs with shorter lifespan
– FADA develops if diet is mostly meat with little Green
leafy vegetables
Effects on Pregnancy:
-abortion
-abruptio placenta
-NTD
 Most often seen in
• Multiple pregnancies
because of the
increased fetal demand
• Women with secondary
hemolytic illness
• Women who are taking
Hydantoin
• Poor gastric absorption
due to gastric bypass
for morbid obesity
 Signs and Symptoms of FADA

• Nausea
• Vomiting
• Anorexia
 Management of FADA
• Treatment: FA supplements 1 mg/day with oral
FE
• Prevention: 400 ug FA for all women of child-
bearing age & during pregnancy
• Sources:
– Dark green leafy vegetables
– Dried beans & peas
– Citrus fruits & juices and most berries
– Fortified breakfast cereals
– Enriched grain products
 HEMOLYTIC DISEASE

• HDN is caused by either Rh or ABO

incompatibility
• Mother produces antibodies that destroy
RBCs of the fetus; hemolysis results in fetal
anemia and hyperbilirubinemia
 ABO Incompatibility
• Occurs when maternal blood type is O and fetus is
a. Type A- most common
b. Type B- most serious
c. Type AB- rare
• The mother has inborn antibodies vs blood type A
and B in her bloodstream. If fetus has type A or B
blood and if maternal and fetal blood mix, maternal
antibodies will perceive the fetal RBC as an
antigen and will destroy it
• Uncommon during pregnancy since antibodies is
the large IgM type & cannot cross placental
barrier
• During delivery when placenta separates from the
decidua, the barrier is broken allowing maternal
blood to enter the fetal bloodstream .
• Maternal antibodies will then destroy fetal RBCs
after birth
• Thus, signs of hemolytic disease will manifest
several hours after delivery
 RH INCOMPATIBILITY
Rh (D) factor is a protein antigen present on the
surface of some people’s RBC (Rh+)
• Antibodies vs Rh antigen are not naturally-occurring
but are produced when Rh+ blood enters the
bloodstream of an Rh- person
• The Rh + gene is a dominant and therefore if either
the mother or the father or both parents are Rh+, the
baby will be Rh+
 Rh Sensitization/Rh Isoimmunization

• It is the exposure of Rh- blood to Rh+ blood

resulting to production antiRh abs
• It can occur through:
– Sensitization fr previous pregnancy(Rh- mom with
Rh+ baby
– Inadequate response to prophylaxis
– Incompatible blood transfusion
• Insignificant amts of antibodies are formed during
pregnancy thus, 1st baby is not greatly affected.
• Greatest exposure occurs during placental
separation which causes massive production of anti
Rh abs during 1st 72 hrs postpartum
• Rh+ fetuses in future pregnancies will be affected
• Fetal anemia results & to
compensate, fetal bone marrow
produces immature
RBCs(erythroblasts) causing
ERYTHROBLASTOSIS FETALIS
• Fetal anemia may be so profound tha it kills
the fetus
• RBC destruction causes massive production
& accumulaation of bilirubin as the immature
liver is unable to clear them from the body
leading to HYPERBILIRUBINEMIA &
KERNICTERUS
 Fetal Complications of EF

• Anemia
• Splenomegaly & hepatomegaly
• Hyperbilirubinemia
• Hydrops fetalis- as organs are not perfused
properly, the heart will eventually
decompensate; fluid builds up resulting to
edema
• Stillbirth
 Prevention
• Prenatal Screening
– History: past pregnancies, BT, abortion, invasive
diagnostic procedures during pregnancy
– Blood typing & Rh typing
– Coomb’s test (titer >1:16 indicates sensitization);
indirect CT(maternal serum), direct CT(cord blood); if
negative, test at 16 to 20 wks and at 26-27 wks
– Give RhIg aka anti Rho(D) gamma
globulin(RhoGAM) at 28 wks and within 72h after
delivery
• RHOGAM should be given to all Rh- women
who:
– Have delivered Rh+ babies
– Have had untypeable pregnancies such as ectopic
pregnancies, stillbirth & abortion
– Have received ABO compatible Rh+ blood
– Have had invasive dx procedures like
amniocentesis, CVS
 Management
• Amniocentesis q 2wks beginning at 26 wks to
monitor bilirubin
• Percutaneous umbilical blood sampling at 18-
20 wks if bilirubin levels are high
• Intrauterine Blood fetal transfusions(IUFT) at
10-day to 2 week intervals until 34-36 wks
 SUBSTANCE ABUSE
• Substance Abuse- inability to meet major role
obligations, increase in legal problems or risk-
taking behavior, or exposure to hazardous
situations due to an addicting substance
• Substance dependent- if she has withdrawal
symptoms after discontinuation of the substance
• These substances are usually of low
molecular weight & can readily cross the
placenta; the fetus has 50% drug
concentration as that of the mother
• Common substances abused: cocaine,
amphetamines, marijuana, alcohol,
inhalants, opiates, phencyclidine
1. Cocaine-
• most frequently abused drug during pregnancy,
• causes extreme vasoconstriction severely
compromising fetal circulation leading to
premature separation of the placenta resulting
to PTL or fetal death
• Fetal withdrawal symptomsof COCAINE:
– tremulousness,
– irritability,
– muscle rigidity,
– learning defects (later on in life),
– intracranial hemorrhage
• Detected by urinalysis
Cocaine Use
2. Amphetamines-methampetamines
(speed)
• has effects similar to cocaine
• NB symptoms:
– jitteriness,
– poor feeding,
– growth restriction
marijuana
3. Marijuana or hashish
• when smoked causes tachycardia & a sense of
well-being
• Used to counteract nausea in early pregnancy
• Effects:
– loss of short-term memory,
– reduced milk production
– Inc incidence or respiratory infection
– Excretion of drug in breast milk
pcp
4. Phencyclidine (PCP)-
• animal tranquilizer frequently used as a
street drug
• increases cardiac output & gives a sense of
euphoria
• Causes hallucinations(flashback episodes)
• Tends to leave the maternal circulation &
concentrate in fetal cells
5. Narcotic Agonists-
• used for pain (morphine or meperidine), cough
suppression (codeine); is a potent analgesic and
provides euphoric effect.
• HEROIN- main opiate used recreationally & is used
ID(skin-popping), by snorting or IV(shooting)
– Produces immediate but short-lived euphoria followed by
sedation
• Withdrawal symptoms: N/V, diarrhea,
abdominal pain, HPN, restlessness,
shivering, insomnia, body aches, muscle
jerks
• Fetal effects: SGA, increased incidence of
fetal distress & meconium aspiration,
• Management: methadone maintenance
program during pregnancy
6. Inhalants- airplane glue, cooking sprays,
computer keyboard cleaner
– Refer to sniffing or huffing of aerosol drugs
– May lead to severe cardiac and respiratory
irregularities
– May limit fetal O2 supply
7. Alcohol
– FAS, cognitive challenges an memory deficits
 HIV/AIDS
ETIOLOGIC AGENT:
-retrovirus that targets helper T
lymphocytes(T4 cells) that contain the CD4
antigen(which regulates normal immune
response) making the patient susceptible to
opportunistic infections

• Present in infected person’s blood, semen, and

other body fluids
Risk factors:
• Multiple sexual partners of the
individual or sexual partner
• Bisexual partner, MSM
• IV drug use by the individual or partner
• Others: BT, tattoo, etc
 Assessment

Early Symptoms:
• Fatigue
• Anemia
• Diarrhea
• Weight loss
• Lymphadenopathy
• Night sweats
Stages:

• Initial invasion of virus with mild, flulike symptoms

• Seroconversion- production of antibodies vs HIV;
happens in 6 wks to 1 year
• Asymptomatic period for 3 to 11 years
• Symptomatic period with opportunistic infections
& possibly malignancies (CD4 cell count <
200cells/mm3
– Toxoplasmosis , tuberculosis
– Oral & vaginal candidiasis
– GIT illnesses
– Kaposi sarcoma
– P. carinii pneumonia(PCP)- most common
opportunistic infection
– Herpes simplex
– HIV-associated dementia
KAPOSI SARCOMA
PCP
 Assessment
• ELISA test- if (+) 2x then
• Western Blot Test- confirmatory test
• In late infection, CD4+ T cell count
<200cells/ul
• Presence of opportunistic infections
• 20-50% of infants born to untreated HIV +
women will contract the virus & develop
AIDS in the 1st year of life
 Management
• Monitor CD4+ T cell counts.
• Goal: maintain CD4 cell count > 500 cells/ mm3
• Antiretroviral therapy: oral ZVD during pregnancy & IV
during labor & delivery) plus1 or more protease
inhibitors like ritonovir(Norvir) or indinavir(Crivixan) in
conjunction with a nucleoside reverse transcriptase
inhibitor drug.
• Neonate is also given zidovudine
• Breastfeeding is not recommended
• Educate client on safe sex practices, testing
of sex partners
• Monitor client for signs of opportunistic
infection: fever, weight loss, fatigue,
candidiasis, cough, skin lesions
• CS delivery- performed before rupture of
membranes
• If vaginal delivery is unavoidable, no
episiotomy!
Thank you for
listening!