ANTEPARTUM *Pseudoanemia in pregnancy

- drop in Hct during pregnancy

-plasma volume increase 50% where as
High-Risk Prenatal Client RBC count increase 30%

- Life of mother/fetus is jeopardized by a 1. Iron-deficiency Anemia

disorder coincidental with or unique in - most common anemia of pregnancy
pregnancy - 15 to 25% of all pregnancies
- From prepartum to 30 days after birth - Hgb <12.5g/dl; low serum iron

Causes:
Factors that make a pregnancy high-risk - Low iron in diet
Biologic factors - Heavy menstrual periods
- Weight reducing programs
1. Genetic considerations - Getting pregnant <2 years before
- May interfere with normal fetal or current pregnancy
neonatal development whihcih results in - Low socioeconomic levels who have not
congenital anomalies or create had iron-rich diets
difficulties for the mother
- Multiple gestations, large fetal size, Assessment:
transmissible inherited disorders - Easy fatigability
2. Nutritional status - Pallor
- Young age, 3 pregnancies in 2 years, - Exercise intolerance
inadequate dietary intake because of - Dizziness
chronic illness or food fads, excessive or - Pica
inadequate weight gain, Hct < 33%, - Laboratory findings
tobacco, drug or alcohol abuse
Effects:
3. Medical & Obstetric Disorder
- Decreased resistance to infection
- Preterm labor, polyhydramnios, IUGR - Predispose heavy bleeding during labor
Psychosocial factors and puerperium
- Associated with prematurity and LBW
1. Smoking infants
2. Caffeine
3. Alcohol
4. Psychologic status Prevention:

Socio-demographic factors - Take prenatal vitamins containing an

iron supplement of 27mg elemental iron
1. Low income as prophylactic therapy during
2. Lack of prenatal care pregnancy
3. Age - Eat a diet high in iron and vitamin C
4. Residence (green leafy vegetables, meat, legumes
and fruit)
Pre-gestational Conditions - Therapeutic levels of medications of
120-200mg elemental iron/day usually in
 Anemia the form of ferrous sulfate/gluconate
- when Hgb is concentrations is - Take iron supplement with orange juice
<11g/dl (Hct is <33%) in the 1st & 3rd or vitamin C to allow faster absorption
trimester - Take on hours of sleep
- <10.5 g/dl (Hct is <32%) in the 2 nd - Constipation/GI irritation, increase
trimester roughage in diet and oral fluid intake
- CBC is done and always take pills with food
- supplemental amount of iron - If severe, or woman has difficulty with
- if not, therapeutic preps of iron; IM therapy, IM or IV iron dextran can be
prescribed
 2. Folic Acid Deficiency Anemia
- 1 to 5 % in pregnancies
- Folic acid/folacin is necessary for the
normal formation of RBC in mother as
well as prevent neural tube defects in
the fetus
- Formation of large and immature blood
cells
*Megaloblastic anemia – enlarged RBCs
Occurs most often:
- Multiple pregnancies – increased fetal
demand
- Women with secondary hemolytic illness
– rapid destruction and production of
new RBCs
- Women taking hydantoin – interferes
with folate absorption
- Women who have poor gastric
absorption – gastric bypass for morbid
obesity
Management:
- 400 mcg folic acid daily and 600 mcg
during pregnancy
- Eating a diet high in folic acid (beans
and legumes, citrus fruits and juices,
green leafy vegetables, pork, poultry,
shellfish, wheat bran)
Possible Nursing Diagnosis
1. Risk for Ineffective Tissue Perfusion
2. Impaired oral mucos membrane
3. Imbalanced nutrition
4. Constipation/diarrhea
5. Deficient knowledge
6. Fatigue
7. Fear
8. Ineffective Coping
 Diabetes Mellitus
– an endocrine disorder in which the
pancreas cannot produce adequate
insulin tor egulate body glucose
levels
*Gestational Diabetes – abnormal glucose
metabolism that arises during pregnancy
Assessment:
- Polyuria
- Polydipsia
- Polyphagua
- Involuntary weight loss
Risk factors:
- Obesity
- History of large babies (10lbs or more)
- History of unexplained fetal or perinatal
loss
- Family history or a population with a
high risk of diabetes (Native Americans,
Hispanic, Asian)
Diagnostic tests:
- Urinalysis
- Fasting Blood Sugar (FBS)
- Oral Glucose Tolerance Test (OGTT)
Negative Maternal Health Outcomes:
- Greater increase in CS deliveries (22 to
30% for mothers with DM; 17% for those
without GDM)
- Higher risk for 3rd or 4th degree perineal
laceration
- Polyhydramnios
- PIH
- Increased risk for GDM in succeeding
pregnancies
- Increased risk for preeclamplsia
Monitoring:
- Meet her OB before she gets pregnant
- Ophthalmic exam once for a woman
with GDM, and each trimester for a
woman with known DM
- Retinal changes such as increased
exudate is experienced
- Urine culture maybe done each
trimester to detect asymptomatic UTI as
increased glucose concentration in urine
lead to infection
- Stricter diabetic diet complement by
exercise
Management:
1. Diet – 1800 to 2400 calories/day;
weight gain should be about
24lbs; teach women to be familiar
with food exchange list; maintain
FBS WNL
2. Exercise – individualized;
performed regularly with
supervision
3. Insulin therapy – less insulin in
early pregnancy; insulin required
is higher during 3rd trimester; oral
hypoglycemics are
contraindicated; Humulin is the
 insulin of choice; 2/3 at morning,
1/3 at dinner; SQ; 30 minutes
before meals
Self-administered (IM @ 90
degree angle)
Sites – upper thigh, outer arm
and abdomen
Consistent rotating injection
routine
FBS at 95-100mg/dl below and
2hr post-prandial level below
120mg/dl
4. Stress Management – teach
coping techniques and provide
additional support if needed
To test for placental function and fetal well-
being
1. Creatinine clearance test – each month;
normal CC suggests that the woman’s vascular
system is intact because kidney function is
normal (88-128 mL/min)
2. Self-monitor fetal well-being – 10kicks/hr;
uTZ at 28 weeks and 36-38 weeks to
determine fetal growth, amniotic fluid volume
and placental position
Postpartum Adjusment
- Normal glucose levels within 24hrs after
birthe and need no further diet and
insulin therapy
- Routine FBS every 6 months
Nursing Diagnosis
1. Risk for fetal injury
2. Altered nutrition, risk for less than body
requirements
3. Knowledge deficit
4. Risk for maternal injury
5. Risk for Ineffective Tissue Perfusion
6. Risk for Infection
7. Ineffective coping
8. Deficient fluid volume
 Substance Abuse in Pregnancy
- Inability to meet major role obligations;
an increase in legal problems or risk-
taking behavior because of an addicting
substance
- Illicit drugs readily cross the placenta
- Substance-abusing women typically do
not seek prenatal care until late
pregnancy
*Amphetamines – Ice, a rock type of
methamphetamine that is smoked can produce
high concentration of drugs in maternal
circulation
Newborns -> jitterness and poor feeding at
birth and maybe growth restricted
*Marijuana & Hashish – hemp plant, Cannabis;
tachycardia and sense of well-being; some
women use it to counteract nausea in early
pregnancy; may not be able breastfeed
because of reduced milk production from
excretion of drug to the milk
*Phencyclidine (PCP) – animal tranquilizer, a
street drug in polydrug abuse; increase cardiac
output and sense of euphoria; cause of long-
term hallucinations; leave maternal circulation
and concentrate in fetal cells which maybe
injurious to a fetus
*Inhalants – sniffing/huffing of aerosol drugs;
airplane glue, cooking sprays, computer
keyboard cleaner, rugby; effects are similar to
alcohol abuse
Signs and Symptoms
Physical Signs
- Slow weight gain
- Unexplained fluctuations in BP & HR
- Altered sleep pattern
- Needle marks at different parts of the
body
Psychological Signs
- Euphoria to depression
- Rapid mood swings, paranoia, panic
attacks
- Narcotics -> lethargy, stupor and coma
Ways on how to help the woman stop:
1. Make information available on the effects of
substance to herself and to the fetus
2. Motivate woman to make lifestyle changes
3. Refer patient to professionals
Nursing Diagnosis
1. Altered nutrition
2. Denial, Ineffective coping
3. Chronic, situational low self-esteem
 Rheumatic fever
- an inflammatory connective tissue
disease which may develop in untreated
group A-B hemolytic Streptococcal
infections
- it can involve heart, joints, CNS, SQ
tissue
 RHD
- Results when recurrent inflammation from
bouts of rheumatic fever causes scarring
formation in the valves resulting to stenosis
and regurgitation
Classification of Functional Capacity
Class I – Asymptomatic; no limitation of
physical activity
Class II – Slight limitation; asymptomatic at rest
and symptoms occur with ordinary physical
activity
Class III – Marked limitation; comfortable at
rest but symptomatic during less than ordinary
physical activity
Class IV – inability to carry on any physical
activity without discomfort; discomfort
increases with any physical activity
Nursing Care:
- Woman and her family should
understand her condition
- Nurse explains the purposes of the
dietary and activity changes required
- During the 1st half of pregnancy, woman
should assess cardiac status every two
weeks
Intrapartum period
- Nurse should evaluate maternal VS
frequently to determine woman’s
response to labor
- Semi-fowler’s or left side-lying position
with her head and shoulders elevated is
assumed
- Continuous fetal electronic monitoring to
provide ongoing assessment of the fetal
response to labor
Postpartum period
- Woman remains at the hospital longer
- Nurse gives woman opportunity to
discuss her birth experience and helps
her deal with any feelings of concern
that distress her
- Nurse should ensure that woman and
her family understands the sign of
possible problems of her heart disease
and other postpartal conditions
Nursing Diagnosis
1. Decreased cardiac output
2. Activity Intolerance
 Hyperemesis Gravidarum
- Excessive vomiting all throughout the
day
- Begins during first 10 weeks of
pregnancy
- hCG levels below 1,200 mIU/mL usually
doubles every 48-72hrs and increases
by at least 60% every two days
- associated with nulliparous women,
have increased body weight, have
history of migraine, pregnant with
twins/Hmole
Clinical Manifestations
- Significant weight loss and dehydration
- Decreased BP
- Increased HR
- Poor skin turgor
- Frequently unable to keep down clear
liquids by mouth
- Lab test may reveal electrolyte
imbalance
Possible causes
- Increased levels of estrogen
- High hCG levels
- Transient maternal hypothyroidism
- Stress
- Interrelated psychosocial components
Collaborative care
- Thorough assessment to determine
severity of the problem (frequency,
severity, and duration of N/V episodes;
approximate amount and color of
vomitus)
- Woman’s weight and VS are measured
with complete PE (fluid and electrolytes,
nutritional status; CBC, urinalysis,
electrolytes, bilirubin levels and liver
enzymes)
- Psychosocial assessment -> anxiety,
fears, and concerns r/t her own health
and effects of pregnancy outcome
- Family should also be assessed for
anxiety and with regard to their role in
providing support for the woman
- IV therapy for correction of fluid and
electrolyte imbalance
- Should be kept on NPO status until
dehydration has been resolved and for
at least 48 hours after vomiting has
stopped to prevent rapid recurrence of
the problem
Medications
- Pyridoxine (B6) in combination with
doxylamine (Unisom)
- Promethazine (Phenergan)
- Metoclopramide (Reglan)
Management:
- Psychotherapy and stress reduction
techniques
- Accurate measurement of I&O; amount
of emesis
- Oral hygiene while woman is on NPO to
help allay associated discomfort
- Assistance with positioning and
providing a quiet, restful environment,
free from odors may increase woman’s
comfort
- Limited amounts of oral fluids and bland
foods such as crackers, toast or baked
chicken is begin
- Assist in coordinating treatment periods
and episodes of visitation to provide
opportunity for rest periods
Nursing Diagnosis
1. Risk for deficient fluid volume
2. Imbalanced nutrition
 Incompetent Cervix
- It opens too early because of the
pressure exerted by the growing fetus
- Can be treated by stitching the cervix
closed during the second trimester or by
bed rest for the last several months of
pregnancy
Causes
- Cervical trauma
- Infection
- Congenital cervical/uterine anomalies
- Increased uterine volume
Nursing Priorities
- Evaluate the client and fetal status
- Assist with efforts to maintain pregnancy
- Provide emotional support
- Provide accurate information
Discharge goals
- Client/fetal condition stable following
procedure
- Uterine contractions absent
- Therapeutic needs and concern
understood
Nursing Diagnoses
- Anxiety
- Risk for maternal injury
- Risk for fetal injury
- Knowledge deficit
 Abortion
- Related to chromosomal abnormalities
- Inevitable; spontaneous
- Occurs mostly before 14th week of
pregnancy
Possible Causes
- Teratogenic drugs
- Faulty implantation due to abnormalities
of female reproductive tract
- Weakened cervix
- Placental abnormalities
- Chronic maternal disease
- Endocrine imbalances
Classification
 Threatened abortion
- Embryo or fetus is jeopardized by
unexplained bleeding and cramping
- Cervix is closed
- Bleeding persists for days
 Imminent Abortion
- Increased bleeding and cramping
- Internal cervical os dilates
- Membranes may rupture
 Complete Abortion
- All products of conception are expelled
 Missed Abortion
- Fetus die in utero but was not expelled
- Uterine growth ceases, breast changes
regress and report brown vaginal
discharge
 Recurrent pregnancy loss
- Habitual abortion
- Occurs consecutively in 3 or more
pregnancy
 Septic abortion
 - Presence of infection
- May occur with prolonged unrecognized
rupture of membrane, pregnancy with
IUD in utero, attempts of unqualified
individuals to terminate a pregnancy
Causes of bleeding
First Trimester
- Threatened Miscarriage -> unknown;
probably chromosomal abnormalities;
vaginal spotting, slight cramping
- Imminent Miscarriage -> vaginal
spotting, cramping, cervical dilation
- Missed miscarriage -> vaginal spotting,
slight cramping, no apparent loss of
pregnancy
- Incomplete miscarriage -> vaginal
spotting, cramping, cervical dilation, but
incomplete expulsion of uterine contents
- Complete miscarriage -> vaginal
spotting, cramping, cervical dilation, and
complete expulsion of uterine contents
- Ectopic (Tubal) Pregnancy ->
implantation of zygote at site other than
uterus; tubal constricture and adhesions
associated; sudden unilateral lower
abdominal pain; minimal vaginal
bleeding; possible signs of shock or
hemorrhage; may occur again if tubal
scarrings are bilateral
Second Trimester
- H mole (Hydatidiform mole) or
gestational trophoblastic disease ->
abnormal proliferation of trophoblast
tissue, fertilization, division defect;
overgrowth of uterus, highly positive
hCG test; no fetus present on
sonogram; bleeding from vagina of
old/fresh blood accompanied by cyst
formation; may become malignant
(choriocarcinoma); follow up for 6
months or 1 year with hCG testing
- Premature cervical dilation -> cervix
begins to dilate and pregnancy is lost
about 20 weeks; unknown cause but
cervical trauma from D&C maybe
associated; painless bleeding leading to
expulsion of fetus
- Can have cervical sutures placed to
ensure second pregnancy
Clinical Therapy
- Pelvic cramping and backache are more
reliable indicators
- UTZ scanning maybe used to detect
presence of gestational sac or cardiac
activity if cause of bleeding is unclear
- Hgb and Hct are obtained to assess
blood loss
- Bed rest, sedation, abstinence from
coitus
- IV therapy, blood transplant to replace
fluid; D&C or suction evacuation to
remove remainder products of
conception
- Missed abortions -> products of
conception is expelled spontaneously;
diagnosis is based on history, pelvic
exam, pregnancy test and UTZ
- If products of conception is not expelled,
within 4-6 weeks of embryo or fetal
death, hospitalization is necessary
- 1st Tri -> D&C is done; 2nd Tri -> Induced
labor/D&C
Nursing Diagnosis
- Acute pain
- Anticipatory grieving
- Risk for infection
- Fluid volume deficit
- Anxiety
 Ectopic Pregnancy
- Implantation outside the uterine cavity
- May occur in the surface of the
uterus/cervix
- Fallopian tube is the most common site
(approximately 95%)
- 2% of pregnancies
- 2nd most frequent cause of bleeding
- If a tube is removed, a woman is
theoretically, 50% fertile
Causes
- Adhesion of fallopian tube from previous
infection (PID or chronic salpingitis)
- Congenital malformations
- Surgery scars
- Uterine tumor
S/Sx
- Abdominal/pelvic pain or tenderness
sometimes accompanied by N/V
- Vaginal spotting/bleeding (red/brown)
- Pain that gets worse when active or
bowel movement or coughing
- Signs of shock, decreased pulse, pale,
clammy skin, dizziness/fainting
- Shoulder pain when lying down
 - Overdue period - Vaginal bleeding during first three
- Positive pregnancy test months
- Fainting - Symptoms of hyperthyroidism
- Symptoms similar to preeclampsia that
occur in 1st trimester
Diagnostic Test
- Gynecological exam
Therapeutic Management - UTZ
- Placental hormone blood tests (hCG
- Methotrexate, a folic acid antagonist, test)
attacks and destroys fast growing cells,
until negative hCG is achieved Can be mistaken as:
- Mifepristone – abortificent; causing
- Ectopic pregnancy
sloughing off of the tubal implantation
- Pregnancy
site
- Ovarian cancer
- Laparoscopy – ligate the bleeding
vessel and remove/repair damaged Symptoms
fallopian tube; one week to recuperate
- Multiple placental cyst
- Vaginal bleeding
- Cyst in vaginal discharge
 Gestational Trophoblastic Disease
- Excessive nausea, breast tenderness
(Hydatidiform Mole)
and enlarged uterus
- Abnormal proliferation then
- Lack of fetal movement
degeneration of the trophoblastic villi
- Increased hCG
- As cells degenerate, they become filled
with fluids and appear as clear fluid- Therapeutic Management
filled grape-sized vesicle
- Suction curettage/ D&C
- Abnormal cluster of cells
- Baseline pelvic exam, chest radiograph,
- 1 of 1500 pregnancies
a serum test for beta subunit of hCG
Incidence - hCG is analyzed every 2 weeks until
levels are again normal; 4 weeks for the
- Women with low protein intake
next 6 to 12 months (after 6 months,
- Women > 35 years of age
theoretically free; after 12 months, can
- Women of Asian heritage
have 2nd pregnancy)
- Blood group A who married blood group
- MTX for choriocarcinoma
O men
- Woman need opportunity to expres
2 Types of Molar Growth anger and sense of unfairness at this
type of event
1. Complete mole
Nursing Diagnosis
- all trophoblastic villi swell and become cystic
- Acute pain
- dies early in 1-2mm size with no fetal blood - Activity intolerance
present at villi - Disturbed sleeping pattern
2. Partial mole - Hyperthermia
- Anxiety
- some of villi form normally, however swollen
and mishapen
- macerated embryo of approximately 9 weeks  Pregnancy Induced Hypertension
AOG maybe present - Most common complication of
pregnancy
- Significant contributor to maternal and
S/Sx perinatal morbidity and mortality
- Complicates approximately 9-22% of
- Abnormal uterine growth pregnancies
- N/V - Increase in BP
- >30mmHg systolic, >15mmH diastolic
 - >140/90mmHg on two consecutive
readings assessed at least 6 hours
apart
1. Gestational Hypertension
- onset of HPN without proteinuria after 20
weeks of pregnancy
- development of mild hypertension during
pregnancy without proteinuria or pathologic
edema

2. Gestational Proteinuria
- development of proteinuria after 20 weeks of
gestation without hypertension

3. Preeclampsia
- development of HPN and proteinuria after 20
weeks AOG or in an early postpartum period
- in presence of H mole, it can develop before
20 weeks AOG

Assessment
- Interview (admission, prenatal record,
family history of HPN, DM, note unusual
frequent/severe headache, visual
disturbances, or epigastric pain)
- Physical examination (consistent BP
taking, assess edema, assess fetal
status)
Management
- Routine monitoring of blood pressure
- Advise client that ACE inhibitors,
Angiotensin receptor blockers, and
diuretics are not safe in pregnancy and
should not be taken
- Ensure maternal safety
- Provide emotional support