NMM NCM 109 (PRELIMS) – LESSON 2 1

PREGESTATIONAL CONDITIONS  pregnant women with mechanical valves are a very

Cardiac Diseases high-risk group, in whom all anticoagulation options
Rheumatic Heart Disease / Fever carry maternal and/or fetal risks.
 It is a damage to the heart that remains after the Management of women with RHD
acute ARF episode has resolved.  antenatal care at an appropriate referral centre with
 Acute Rheumatic Fever - is an illness caused by an experienced obstetrician, in collaboration with
a reaction to a bacterial infection with group A an obstetric physician and/or cardiologist and a
streptococcus; it causes an acute, generalized nurse
inflammatory response and an illness that targets  timing, nature and site of planned delivery should
specific parts of the body, including the heart. occur before or early in pregnancy
 It is caused by an episode or recurrent episodes  cease work earlier in pregnancy
of ARF.
 Heart has become inflamed; the heart valves
remain stretched and/or scarred, and normal
blood flow is interrupted.
 Recurrences of ARF may cause further valve
damage, leading to worsening of RHD.
Pregnancy in women with RHD
Normal Pregnancy
◦is associated with a 30–50% increase in blood
volume,
◦reduction in systemic vascular resistance and
corresponding increase in cardiac output.
◦begin during the first trimester, peaking at 28–30
weeks of pregnancy, and are then sustained until
term.
◦increase in heart rate by 10–15 beats per min.
Because of the hyperdynamic circulation.
◦innocent, soft mid-systolic murmurs are common
during pregnancy, particularly along the left sternal
border.
 These circulatory changes of pregnancy will A. Pulmonary Hypertension
exacerbate any pre-existing valvular disease. (due to limited oxygen exchange)
 Sometimes RHD, especially mitral stenosis, is  Increase pressure in the pulmonary arteries.
first diagnosed during pregnancy or soon after  PH causes symptoms such as shortness of breath
delivery when a woman develops symptoms, during routine activity (for example, climbing two
usually dyspnea. flights of stairs), tiredness, chest pain, and a racing
Assessment of women with RHD heartbeat. As the disease worsens, its symptoms
 Ideally, patients with known rheumatic valvular may limit all physical activity.
disease should be properly assessed before
pregnancy.
 Include a full history and examination, and an
echocardiogram
Risk Factors
Predictors of increased maternal and fetal risk in
the pregnant patient
 reduced left ventricle (LV) systolic function
 significant aortic or mitral stenosis
 moderate or severe pulmonary hypertension
 a history of heart failure
 symptomatic valvular disease before pregnancy
 atrial fibrillation, especially when anticoagulation
is require
 NMM NCM 109 (PRELIMS) – LESSON 2 2

B. Pulmonary Edema
 an abnormal build up of fluid in the air sacs of the
lungs, which leads to shortness of breath
 due to pressure in the pulmonary vein, fluid
begins to pass from the pulmonary capillary
membranes into the interstitial spaces
surrounding the alveoli and then into the alveoli
themselves
 Symptoms: anxiety, cough, difficulty of breathing
(paroxysmal nocturnal dyspnea), excessive
sweating, excessive hunger of “air” or “drowning”,
Grunting or gurgling sounds with breathing, pale
skin, restlessness, shortness of breath,
orthopnea, wheezing.
 Additional symptoms that may be associated with
this condition: coughing up blood or bloody froth,
decrease in level of alertness, inability to speak in
full sentences, nasal flaring.

C. Congestive Heart Failure

 is a condition in which the heart can't pump enough
blood to the body's other organs.
This can result from:
narrowed arteries that supply blood to the heart
muscle (coronary artery disease)
past heart attack, or myocardial infarction, with
scar tissue that interferes with the heart muscle's
normal work
high blood pressure
heart valve disease due to past rheumatic fever
or other causes
primary disease of the heart muscle itself
(cardiomyopathy)
heart defects present at birth (congenital heart
defects)
 NMM NCM 109 (PRELIMS) – LESSON 2 3

infection of the heart valves and/or heart muscle

itself (endocarditis and/or myocarditis)
The most common signs and symptoms of heart
failure are:
>Shortness of breath or trouble breathing
>Fatigue (tiredness)
>Swelling in the ankles, feet, legs, abdomen, and,
rarely, the veins in your neck

HEART INTERIOR

HEART EXTERIOR

FIRST WARNING OF HEART FAILURE:

Persistent rales at the base of lungs
Dyspnea on exertion (oxygen saturation of blood)
Cough/hemoptysis (rupture of pulmonary
capillaries)
ADDITIONAL SIGNS:
Progressive edema (as the fall in blood pressure
is registered with the renal angiotensin system both
retention of sodium and water occurs)
Tachycardia (attempt to systemic blood pressure)
 NMM
’ the fetus).
Left Sided Heart Failure (LSFH)
Occurs in conditions such as:
 Mitral stenosis - is a narrowing of the valve
between the two left heart chambers
 Mitral insufficiency - most common form of valvular
heart disease, occurs when the mitral valve does
not close properly, allowing blood to flow
backwards into the heart.
 Aortic coarctation - a birth defect in which a part of
the aorta is narrower than usual. inability of the
mitral valve to push blood forward, inhibiting back-
pressure on the pulmonary circulation, causing it to
become distended
NCM 109 (PRELIMS) – LESSON 2 4
 If an anticoagulant is required, heparin is the drug
of choice for early pregnancy because it does not
have teratogenic effects, as does sodium warfarin
(Coumadin).
 Warfarin can be used after week 12 but a woman
will then be returned to heparin therapy during
the last month of pregnancy so the fetus will not
develop a coagulation disorder at birth
 Heparin does not cross the placenta and enter
Right Sided Heart Failure (RSHF)
 Congenital heart defects such as pulmonary
valve stenosis and atrial and ventricular septal
defects
 Congestion of the systemic venous circulation
and decreased cardiac output to the lungs.
 Jugular venous distention and increased ortal
circulation occur.
 The liver and spleen become distended.
 Liver enlargement can cause extreme dyspnea
and pain in a pregnant woman because the
enlarged liver, as it is pressed upward by the
enlarged uterus, puts extreme pressure on the
diaphragm.
 Distention of abdominal vessels can lead to
exudate of fluid from the vessels into the
peritoneal cavity (ascites).
 Fluid also moves from the systemic circulation
into lower extremity interstitial spaces (peripheral
edema).
Eisenmenger Syndrome
 A cyanotic heart condition that develops when
pulmonary resistance equals or exceeds
systemic resistance to blood flow and a right-to-
left shunt develops.
 Develops when high pressures push the blue
(low oxygen) blood in the right-side circulation
back into the red (oxygenated) left sided
circulation, bypassing the lungs.
 Tissue hypoxia occurs as deoxygenated blood
that should go to the lungs is pushed into the
systemic circulation.
 Several underlying congenital defects may
underlie the equalization of pressures within the
 NMM NCM 109 (PRELIMS) – LESSON 2 5

ventricles (ventricular septal defect or a large

patent ductus arteriosus)
Management:
Operative closure of defects
Delayed surgery - 50% maternal mortality risk
(usually from right ventricular failure)
Mitral Valve Prolapse
Most common cardiac benign condition
Incidence = normal young women is as high as
15%
The leaflets of the MV prolapse into the left atrium
during ventricular contraction
Most are asymptomatic and tolerate pregnancy well
Considered as significant risk for bacterial
endocarditis
Symptoms:
Fatigue Management:
Palpitations >Prophylactic antibiotics (before and during labor
Chest pain and delivery)
Anxiety >Beta blockers (chest pain or dysrhythmias)
Migraine headaches a. Atenolol
b. Metropolol
Peripartum and Postpartum Cardiomyopathy
 heart muscle disease
 the heart muscle becomes enlarged, thick, or
rigid. In rare cases, the muscle tissue in the heart
is replaced with scar tissue.
 Rare condition associated with pregnancy
 Woman have no underlying heart disease but
symptoms of cardiac decompensation appear
during the last week of pregnancy or from 2 to 20
weeks post-partum

Etiology:
-Inherited
-Associated with variety of other cardiac conditions:
a. ASD
b. Marfan’s Syndrome - a genetic disorder of the
connective tissue; typically tall, with long limbs and
long thin fingers
Marfan’s Syndrome

 Etiology:
-Unknown
 Predisposing Factors:
-Effect of pregnancy on the circulatory system
-Undetected heart disease
 Incidence:
-African-American multiparas in conjunction with
HPN of pregnancy
 NMM NCM 109 (PRELIMS) – LESSON 2 6

 Symptoms: (Signs of Congestive Heart  coughing (pulmonary edema from heart failure)
Failure/MI)  edema
Dyspnea  Other signs and symptoms
Edema ◦ irregular pulse
Weakness ◦ rapid or difficult respirations
Chest pain ◦ and perhaps chest pain on exertion
Heart palpitations
 Other sign:
Cardiomegaly
 Management

 Assess nail bed filling (should be less than 5

seconds)
 Jugular distention
 Assess liver size (Right sided heart failure)
 Diagnosis
-From clinical signs and symptoms and physical
 Oral contraceptives are contraindicated due to examination
danger of thromboembolism -Chest x-ray
 Surgery -Electrocardiography (ECG)
 Heart transplant (20% can be saved) -Echocardiography
 Partial recovery with persistent congestive Classification (New York Heart Association
heart failure or other cardiac dysfunction Functional Classification of Heart Disease)
(50%) Class I – Uncompromised
Full recovery (30%)  No limitation of physical activity
Cardiac Disease  Asymptomatic with ordinary activity
Class II – Slightly Compromised
Assessment
Slight limitation of physical activity
1. Thorough health history
Comfortable at rest, but ordinary physical activity
2. Physical assessment / Physical examination
causes fatigue, dyspnea, palpitations or anginal
pain
Class III – Markedly Compromised
Marked limitations of physical activity
Comfortable at rest, but less than ordinary activity
causes excessive fatigue, palpitations, dyspnea, or
anginal pain
Class IV – Severely Compromised
 Inability to perform any physical activity without
discomfort
 Symptoms of cardiac insufficiency even at rest or
anginal pain
Therapeutic Management
Class I or II Heart Disease
 Limit physical activity
 Avoid excessive weight gain
=adequate CHON, calories and sodium
=low-sodium diet (avoid congestive heart failure)
 Prevent anemia (decrease oxygen carrying
capacity of the blood resulting to HR)
=administration of iron and folic acid
 Prevent infection
 Ask about her level of exercise performance (what =immunization for influenza and pneumonia
level she can =prophylactic antibiotics
◦short of breath =avoid contact to person with URI
◦cyanosis of the lips or nail beds).
 NMM NCM 109 (PRELIMS) – LESSON 2 7

 Undergo careful assessment for development of moist rales, and exhaustion); report immediately to
congestive heart failure, pulmonary edema and AP.
cardiac dysrhythmias H. Vaginal delivery is recommended for a woman
=assess signs and symptoms with heart disease unless CS is indicated.
Class III or IV Heart Disease I. Vacuum extraction or outlet forceps are often used
Primary Goal: Prevent cardiac decompensation to minimize Valsalva maneuver and shorten second
and development of congestive heart failure stage of labor.
 Protect fetus from hypoxia and IUGR (due to J. CS may be chosen to limit prolonged labor, which
inadequate placental perfusion) can add to the hemodynamic stress for the woman
 Addition to Class I and II management: with cardiac disease.
=bed rest (esp. late trimester) K. To minimize risk of overloading the heart (fourth
=elastic compression stockings/serial or boot stage):
compression device (risk for thrombus formation) >Avoid abrupt positional changes
=anticoagulant >Uterus should not be massaged to expedite
Drug Therapy separation of the placenta
1. Anticoagulants >Careful assessment of circulatory overload
A. Heparin (subcutaneous) (bounding pulse, distended neck veins and
Careful monitoring of PTT, APTT, and PC peripheral veins, moist rales)
B. Enoxaparin (Lovenox) – low molecular weight
heparin
Less monitoring for bleeding complications
Warfarin (Coumadin) – associated with fetal
malformations; restricted throughout pregnancy
2. Antidysrhythmics
 In addition to controlling dysrhythmias, β-blockers
and calcium channel blockers may be used (control
HPN)
 Digoxin, adenosine, and calcium channel blockers
(appear to be safe)
 β-blockers (atenolol and metoprolol) – do not
cause uterine stimulation
Note: β-blockers have been associated with:
Neonatal respiratory depression, sustained
bradycardia, and hypoglycemia
3. Antiinfectives
For Endocarditis
Prophylactic antibiotics:
-Amoxicillin
-Penicillin
-Gentamicin
Acute Endocarditis
-Ceftriazone or Vancomycin
Intrapartum Management
A. Careful management of IV fluid administration
(prevent fluid overload).
B. Position woman on side, with head and shoulders
elevated. Postpartum Management
C. Oxygen is administered (increase O2 saturation); A. Observe for signs of cardiac decompensation,
monitored by pulse oximetry. infection, hemorrhage, and thromboembolism.
D. Reduce discomfort (anesthesia such as epidural). B. Continue to observe for signs of congestive
E. Keep environment quiet and calm as possible heart failure.
(decrease anxiety; tachycardia). C. Observe urine output.
F. Monitor fetus electronically and uterine D. Make effort to promote contact between the
contraction. mother and significant others and the infant if
G. Monitor maternal signs of cardiac mother cannot assume to take care of infant.
decompensation (tachycardia, rapid respirations, E. BF may vary per clients condition.
 NMM NCM 109 (PRELIMS) – LESSON 2 8

F. Stool softener may be prescribed. Anemia

G. Kegel exercises are acceptable; avoid  Condition in which a decline in circulating blood cell
postpartum exercises. mass occurs.
H. Emphasize importance of postpartum checkup. First and third trimesters = hemoglobin < 11g/dl
Second trimester = hemoglobin is < 10.5 g/dl
 Factors that may cause anemia:
Nutrition
 Hemolysis
 Blood loss
 Most common anemia during pregnancy:
a. Iron-deficiency anemia
b. Folic-acid deficiency anemia
c. Sickle cell disease
d. Thalassemia
A. Iron-Deficiency Anemia
Most common anemia of pregnancy
Complicates 15% to 25% of pregnancies
Characterized by microcytic (small RBC),
hypochromic (less hgb than the average cell)
anemia
Both hct and hgb is reduced (under 33% and
12mg/dl respectively)
Mildly associated with LBW and preterm birth
At risk
>Multifetal pregnancies
>Bleeding complications
>Lack or inadequate iron
>Pregnancy less than 2 years
>Low socio economic status
>Unwise weight - reducing programs
Assessment
1. Nursing History
2. Physical Examination
Signs and Symptoms (maternal effects):
Pallor
Fatigue
Lethargy
Headache
A Woman with an Artificial Valve Prosthesis
Placed on low-molecular-weight heparin therapy Inflammation (lips and tongue)
before becoming pregnant to reduce clot formation Pica (consuming non-food substances)
Heparin does not cross the placenta and so does Fetal and Neonatal Effects:
not interfere with fetal development or fetal Reduced red cell volume, hgb and iron stores
coagulation (category C). Reduce fetal oxygen supply
Observe for Diagnostic Evacuation
Laboratory Result (anemia):
◦signs of petechiae
A. Decreased hct and hgb
◦signs of premature separation of the placenta during
B. Serum transferrin (under100mg/dL)
pregnancy and labor
C. Transferrin saturation level (under 5%)
A Woman with Chronic Hypertensive Vascular
Disease =normal value12-45% (females)
Hypertension diagnosed for the first time before the D. Serum iron hgb concentration (under 30)
20th week of gestation and persists beyond the 42nd E. Increased iron-binding capacity (over 400ug/dL)
day postpartum Nursing Diagnosis
Elevated pressure (140/90 or above) may cause 1. Risk for ineffective tissue perfusion related to
poor placental perfusion maternal anemia during pregnancy
Hematologic Disorders Planning
1. Prevent and minimize ineffective tissue perfusion
 NMM
2. Improve tissue perfusion
Intervention (Therapeutic Management)
1. Iron supplements
Prenatal vitamins containing iron supplement
(60mg elemental iron) as prophylactic
Ferrous sulfate or ferrous gluconate (120 to 180
elemental iron/day) with orange juice or vitamin C
with meals; increase roughage in diet
Parenteral therapy of iron (IM or IV) for severe
IDA
Side effects of Iron supplements:
>constipation
>gastric irritation
2. Diet high in iron and vitamins
Green leafy vegetables, meat, legumes, fruit
Evaluation
1. New RBC’s or in reticulocyte count from a
normal range of 0.5% - 15% to 3% - 4% by 2
weeks
2. Taking pre-natal supplement daily
3. Hemoglobin is above 11mg/dl; FHT is 120 – 160
bpm
B. Folic-Acid Deficiency
Anemia that develops in Megaloblastic Anemia
 Mean corpuscular volume is elevated Folic Acid or
Folacin (one of the vitamin B)
Purpose:
Normal formation of RBC in mother
Prevent neural tube defects in fetus
Cell duplication
Fetal and placental growth
Incidence:
1% to 5% of pregnancies
Risk Factors
Multiple pregnancies
With secondary hemolytic illness
Women taking hydantoin (anticonvulsant agent)
Taking oral contraceptives
Maternal Effects
Reduction in the rate of DNA synthesis and mitotic
activity of individual cells resulting to megaloblast
Nutritional Factors Contribute to Folic-Acid
Deficiency
Hemolytic anemias with increased RBC turnover
Medications such as phenytoin (Dilantin)
Malabsorption
Associated with iron-deficiency anemia
Fetal and Neonatal Effects
Increased risk of spontaneous abortion
Abruptio placenta
Fetal anomalies (neural tube defects)
Assessment
1. Nursing History
At pre-natal visit, ask whether the woman is taking
her prescribed vitamins
2. Physician History/examination
NCM 109 (PRELIMS) – LESSON 2 9
3. Diagnostic Evaluation
Nursing Diagnosis
1. Risk for ineffective tissue perfusion related to
maternal anemia during pregnancy.
Planning
1. Planning and minimize ineffective tissue perfusion
2. Improve tissue perfusion
Interventions (Therapeutic Management)
Eat foods reach in folic acid (liver, kidney beans,
lima beans, fresh dark green leafy vegetables)
Women at childbearing age – take folic acid
supplements (400mcg or 0.4mg) of folic acid daily
Pregnant – 600mcg or 0.6 mg
If had a previous child with neural tube defects – 4
mg for 1 month before and during first trimester of
pregnancy
Prenatal vitamins (1mg of folate)
Evaluation
1. New RBC’s or in reticulocyte count from a
normal range of 0.5% - 15% to 3% - 4% by 2
weeks
2. Taking pre-natal supplement daily
3. Hemoglobin is above 11 mg/dl; FHT is 120 – 160
BPM
C. Sickle Cell Anemia
 An autosomal recessive genetic disorder
 Hemoglobin S gene is inherited from both parents
 The erythrocytes become shaped like a sickle or
crescent failure to pass through small arteries
and capillaries clump together and occlude blood
vessel
Characterized by:
>Chronic anemia
>Increased susceptibility to infection
>Periodic episodes of obstruction of blood
vessels
Incidence
Ancestors from sub-Saharan Africa, South
America, Cuba, Central America, Saudi Arabia,
India and Mediterranean countries
1 in 500 African-American and 1 in 1000 to 4000
Hispanic births in US will result with sickle cell
anemia
Approximately 1 in every 10 African American
has sickle cell trait (i.e. carries a recessive gene S
hemoglobin but is asymptomatic)
Maternal Effects
Conditions (Sickle Cell Crisis):
A. Temporary cessation of bone marrow function
 NMM
B. Hemolysis or hemolytic crisis with massive
erythrocyte destruction resulting in jaundice (rise in
indirect bilirubin level)
C. Severe pain caused by infarctions located in the
joints and major organs
D. Expectant mothers with sickle cell anemia are
prone to pyelonephritis, bone infection, and heart
disease
Fetal and Neonatal Effects
-prematurity
-IUGR
-fetal death
Incidence of Inheritance
A. If one of the parent has the disease and the
other is free of the disease and trait
Chances to inherit the disease are zero
B. If the woman has the disease and her partner
has the trait
Chances are 50%
C. If both parents have the disease
All their children will have the disease
Symptoms of sickle cell disease do not become
clinically apparent until the child’s fetal hemoglobin is
converted to a largely adult pattern in 3 – 6 months
because sickle cell trait is carried on a beta chain
Fetal hemoglobin comprises two alpha and two
gamma chains; adult hemoglobin comprises two
alpha and two beta chains
Pathophysiology
Abnormal amino acid replaces the Amino acid
valine results to Sickle hemoglobin (HbS)
Abnormal amino acid substituted for Amino acid
lysin results to Non-sickling hemoglobin (HbC)
Sickle cell trait (HbAs) – heterozygous individual
(has only one gene in which abnormal substitution
has occurred)
Sickle cell disease (HbSs) – Homozygous
individual
(has two genes in which the substitution occurred)
Assessment
1. Nursing History
A. Ask about the diet throughout the pregnancy:
If consuming sufficient amounts of folic acid
Taking additional folic acid supplement
2. Physical History
A. Assess lower extremities at pre-natal visits for
pooling of blood
B. Fever
C. Lowered PO2 because of respiratory infection
3. Diagnostic Evaluation
A. Screen for sickle cell anemia at first pre-natal visit
a.1. Hemoglobin level should be obtained frequently
If with sickle cell disease (hgb = 6 – 8 mg/100ml)
If there is hemolysis, sickle cell crises occurs (hgb
= fall to 5 – 6 mg/100ml in a few hours; indirect
NCM 109 (PRELIMS) – LESSON 2 10
bilirubin level
a.2. Urinalysis
Clean catch urine sample to detect developing
bacteriuia
a.3. UTZ
Monitor FHR during pregnancy at 16-24 weeks for
IUGR
Weekly non-stress test beginning at 30 weeks
a.4. Measure blood flow velocity
Flow of blood through the uterus and placenta
blood flow velocity = chance of IUGR
a.5. Percutaneous umbilical blood sampling or
amniocentesis
For electrophoresis testing of RBCs that can also
reveal presence of the disease on the few beta
chains present early in pregnancy
Nursing Diagnosis
1. Risk for ineffective tissue perfusion related to
maternal anemia during pregnancy.
Intervention (Therapeutic Management)
Seek preconception or early prenatal care
Frequent evaluation of hgb, CBC, serum iron,
total iron-binding capacity, and serum folate
(degree of anemia and iron and folic acid stores)
Test for infections (HIV, hepatitis, STI’s and TB,
RTI’s)
=hospitalization for observation to R/O sickle cell
crisis
Prevent sickle cell crisis:
=periodic exchange transfusions throughout
pregnancy (to replace sickle cells with normal
cells; remove excess bilirubin and restore hgb
level)
If crisis occurs:
=control pain
=administer oxygen PRN
=increase fluid volume of the circulatory system (to
lower viscosity)
=Administer hypotonic fluid solution (0.45 saline) –
to keep plasma tension low because of the
difficulty concentrating urine to remove large
amounts of fluid
If with sickle cell disease:
=never give iron supplements during pregnancy (to
prevent excessive iron build up)
=give folic acid supplement (to keep new cell
produced from being megaloblastic)
If with pooling of blood in lower extremities:
=Restrict from standing for long periods during the
day
=Advice sitting on chair with legs elevated or
sitting
on the side with modified Sim’s position
=Help woman plan her day to limit long period of
standing
 NMM NCM 109 (PRELIMS) – LESSON 2 11

If infection develops: Tuberculosis

=Hospitalization for observation maybe necessary  maintain an adequate level of calcium during
to rule out the development of a sickle cell crisis pregnancy to ensure that tuberculosis pockets are
and subsequent hemolysis of crowed cells not broken down
Provide comfort measures:  advised to wait 1 to 2 years after the infection
=repositioning becomes inactive before attempting to conceive
=good skin care  a woman with a recent history of TB should have at
=assisting with ambulation and movement in bed least 3 negative sputum cultures before she holds
=assisting women to splint the abdomen (coughing or care for her infant.
or dyspnea) If negative:
Keep well hydrated (prevent dehydration) No need to isolate
Time and method of delivery are individualized Can breast feed the baby
(preterm) Asthma
If CS, receives nerve block rather then GA (avoid  has the potential of reducing the oxygen supply to
hypoxia) a fetus leading to preterm birth or fetal growth
Signs of Sickle Cell Crisis: restriction if a major attack should occur during
>Pain in the abdomen, chest, vertebrae, joints, or pregnancy
extremities  check with her physician or nurse- midwife about
>Pallor the safety of the medications she routinely takes for
>Signs of cardiac failure this
before pregnancy to be certain it will be safe to
continue using them during pregnancy and
D. Thalassemia breastfeeding.
 Group of autosomal recessively inherited blood Endocrine Disorders
disorders that lead to poor hemoglobin formation Thyroid Dysfunction
and severe anemia. Woman with Thyroid Dysfunction
◦Folic acid supplementation and perhaps blood Nursing Diagnosis
transfusion to infuse hemoglobin rich red blood cells. 1. Risk for maternal and fetal injury related to
◦Women do not usually take an iron supplement preexisting thyroid disorder and drug therapy
during pregnancy or they could receive an iron during pregnancy.
overload because of the iron also infused by blood Planning
transfusions 1. Mother and fetus will suffer no adverse effects
Malaria from maternal hormonal imbalance and drug
 The infection causes red blood cells to stick to the therapy.
surface of capillaries causing obstruction of these Evaluation
vessels. 1. No congenital anomalies are present in infant at
This can result in end organ anoxia when blood birth.
cannot reach organs effectively. 2. Apgar score is 7 to 10.
 Chloroquine is the drug of choice. 3. Mother is able to continue pre-pregnancy
Coagulation Disorders activities.
Von Willebrand’s Disease A. Hypothyroidism
-inherited coagulation disorder: symptoms of  Insufficient production of thyroid hormone (T3
menorrhagia and frequent nose bleeding and T4) b the thyroid gland.
Normal platelet count with prolonged bleeding time  Rare condition in young adults and especially in
Hemophilia B pregnancy.
-sex-linked disorder that occurs only in males: female  Woman with hypothyroidism has difficulty
carriers may have the risk of hemorrhage of increasing thyroid functioning to a pregnancy
spontaneous miscarriage level.
Idiopathic Thrombocytopenic Purpura (ITP)  The pregnant woman with hypothyroidism often
-decreased in number of platelets with an unknown has a history of early spontaneous miscarriages.
cause; platelet transfusion necessary Assessment
Disseminated Intravascular Coagulation 1. Physical Examination
(DIC) Signs and Symptoms:
-a paradoxical condition: a bleeding defect exists -Fatigue easily
while the client has increased coagulation -Obese
Respiratory Disorders
 NMM NCM 109 (PRELIMS) – LESSON 2 12

-Myxedema (dry skin)

-Intolerance to cold
-Hyperemesis gravidarum
Diagnosis
1. Blood exam
-high levels of TSH
Effect:
May be associated with hyperemesis gravidarum
Early spontaneous miscarriage
Breech fetal presentation Effect (Pregnant Women)
Treatment/Intervention May develop heart failure (if undiagnosed)
Woman needs to consult with her OB and More prone to symptoms of:
internist when planning on becoming pregnant. a. Hypertension
Early diagnosis and close follow-up (1 week past b. Fetal growth restriction
menstrual period) c. Preterm labor
Levothyroxine (Synthroid) If woman’s thyroid function was not regulated
=thyroid hormone supplement during pregnancy, the infant may be born with
=increase dose to 30% for the duration of symptoms of hyperthyroidism because of the excess
pregnancy (should know the importance of taking stimulation in the utero.
increased dose) Treatment/Intervention
=gradually taper back the dose after pregnancy to 1. Suppressive thyrostatic medications (thioamides)
pre-pregnancy level Methimazole is the preferred drug for pregnant
women as it appears to cross the placenta less
easily Prophylthiouracil (PTU)
=teratogens (congenital hypothyroidism, goiter in
B. Hyperthyroidism fetus)
 Overactive tissue within the thyroid gland, resulting 2. Surgery
in overproduction and thus an excess of circulating Partial or total removal
free thyroid hormones Not the treatment of choice during pregnancy
 Is more apt to be seen in pregnancy than (general anesthesia)
hypothyroidism

Nursing Considerations
Usually diagnosed through nuclear imaging but
should not be used during pregnancy
The woman will be maintained on lowest possible
dose of thioamides or propylthiouracil (PTU) -
these drugs are teratogenic
After pregnancy, the woman may undergo
surgery if she plans to have another child
Women taking large doses of antithyroid drugs
are advised not to breastfeed after birth
Diabetes Mellitus
 an endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate body
glucose levels
>Primary problem is control of the balance
between insulin and blood glucose to prevent
acidosis
>In gestational DM, the patient’s pancreas is
stressed by the normal adaptations to pregnancy,
can’t meet the increased demands for insulin
 A patient may have pre-existing diabetes or may
develop gestational diabetes while she’s
pregnancy
NMM NCM 109 (PRELIMS) – LESSON 2 13

Pancreatic Hormones and Blood Sugar

Signs and Symptoms

- Glycosuria
- Polyuria
- Ketonuria
- Possible monilial infection
- Glucose > 140mg/dl
- Dizziness (hypoglycemic)
- Confusion (hyperglycemic)
Nursing Considerations
Screen pregnant women for gestational diabetes
through an OGTT- oral glucose tolerance test
*Done at 24-28 weeks of pregnancy and repeated at
32 weeks if woman is obese or over 40 years of age
Normal Values
Fasting 95 mg/dl
1 hour 180 mg/dl
2 hours 155 mg/dl
3 hours 140 mg/dl
Glycosylated hemoglobin – used to detect degree
of hyperglycemia: reflects average blood glucose for
the past 4-6 weeks
Provide health education of pregnancy exercises,
dietary control and insulin administration
During early pregnancy, less insulin is needed;
during late pregnancy, increased insulin is needed
Gestational Diabetes Mellitus
Associated with an increased risk of:
a. Congenital anomalies
b. Hydramnios, macrosomia
c. PIH
d. Spontaneous abortion
e. Fetal death
 NMM
f. Increased risk for developing DM
Infant of a Diabetic Mother:
-at risk for developing sacral agenesis
Sacral Agenesis – A congenital anomaly
characterized by incomplete formation of the
vertebral column
Risk Factors
1. Chronic HPN
2. Family history of diabetes (one close relative or
two
distant ones)
3. Gestational diabetes in previous pregnancies
4. Maternal age older than 25
5. Obesity
6. History of large babies (10 lbs or more)
7. History of unexplained fetal or perinatal loss
8. History of congenital anomalies in previous
pregnancies
9. Member of a population with a high risk for
diabetes
Classification
1. Type 1
-Formerly known as insulin-dependent DM (IDDM)
-A state characterized by the destruction of the
beta cells of the islet of langerhans in the pancreas
that usually leads to absolute insulin deficiency
-Can affect children and adults, traditionally termed
juvenile diabetes
A. Immune-mediated DM results from autoimmune
destruction of the beta cells (T-cells)
B. Idiopathic type 1 refers to forms that have no
known cause
2. Type 2
-Formerly known as non-insulin dependent DM
(NIDDM)
-A state that usually arises because of insulin
resistance combined with relatively reduced insulin
secretion
-Most common type
3. Gestational DM
-A condition of abnormal glucose metabolism that
arises during pregnancy
-Resembles type 2 diabetes in several aspects,
involving a combination of relatively inadequate
insulin secretion and responsiveness
-Occurs in about 2% - 5% of all pregnancies
-May improve or disappear after delivery
-Fully treatable but requires careful medical
supervision throughout the pregnancy
-About 20% - 50% of affected women develop type
2 diabetes later in life
4. Impaired Glucose Homeostasis
-A state between “normal and diabetes” in which
the body is no longer using and/or secreting insulin
properly.
NCM 109 (PRELIMS) – LESSON 2 14
A. Impaired fasting glucose: A state when fasting
plasma glucose is 110 but under
126 mg/dl
B. Impaired glucose tolerance test: 140 but under
200 mg/dl in the 2-hour sample
Education Regarding Nutrition During Pregnancy
diabetic diet complemented by an exercise
program as soon as they are diagnosed
1800- to 2400-calorie diet (or one calculated at 30
Kcal per kg of ideal weight), divided into three meals
and three snacks
reduced amount of saturated fats and cholesterol
and an increased amount of dietary fiber
If cannot eat because of vomiting or nausea early
in pregnancy or heartburn in later pregnancy, she
should notify her health care provider
must be extremely nutrition-conscious to maintain
good control and keep her weight gain to a suitable
amount (approximately 25 to 30 lb)
blood glucose level decreases because the
muscles increase their need for glucose
begin her exercise program before pregnancy,
eat a snack consisting of protein or complex
carbohydrate before exercise
30 minutes of walking every day
Therapeutic Management
Administration of insulin - short-acting insulin
(regular) combined with an intermediate type
Human insulin is recommended because it has the
potential for provoking a lesser antibody response
should eat almost immediately after injecting these
short-acting insulins to prevent hypoglycemia before
mealtimes
Oral hypoglycemic agents are not used for
regulation during pregnancy- it cross the placenta
and are potentially teratogenic to a fetus.
absorbed more slowly from the thigh than the upper
arm
Blood Glucose Monitoring
fingerstick technique, using one of her fingertips as
the site of lancet puncture
ingest some form of sustained carbohydrate such
as a glass of milk and some crackers
Human Immunodeficiency Virus Infection
 Cause by a retrovirus that infects and disables T
lymphocytes
 May be contracted through sexual intercourse,
exposure to infected blood, vertical transmission
(placenta to fetus at birth) or breast milk
Nursing Consideration
Women practicing high-risk behavior should be
asked if they want to be screened
Advise women who tested positive not to become
pregnant
Offer the option of caesarean birth
 NMM
Reduce possibility of fetal exposure to maternal
blood (avoid amniocentesis, internal fetal
monitoring, episiotomy, forceps and vacuum
extraction)
Advise the woman not to breastfeed
Zidovudine: Prescribed during pregnancy to help
reduce mother-to-fetal transmission
◦ Given IV during labor
◦ Given to the newborn for 6 weeks after birth
Provide patient education about mode of HIV
transmission and safer sex practices
Use standard precautions to protect against
spread of HIV
Urinary Tracy Infection
Due to minimal glucosuria that is normally
happening in the pregnant woman, growth of
microorganisms is facilitated
Due to the dilated ureters from the effect of
progesterone, stasis of urine occur
Etiology: E. coli
Signs and Symptoms
◦Pain in the lumbar region that radiates downward
◦N/V, malaise, slightly elevated temperature
◦Pain and frequency of urination
Nursing Consideration
Assist or teach the client in obtaining a clean-
catch urine specimen
Amoxicillin, ampicillin, cephalosporins are
commonly used
Sulfonamides may be used only in early
pregnancy
Tetracycline is contraindicated
Rh Incompatibility and Sensitization
 Occurs when an Rh-negative mother is carrying a
fetus with an Rh-positive blood type, with an Rh-
positive father
 Rh (+) fetus Rh (-) mother = antibodies hemolysis
of fetal RBC's (hemolytic disease of the
newborn/erythroblastosis fetalis)
Nursing Consideration
Women with Rh(-) blood should have an antibody
titer done at first visit
Drug of choice: Rhogam given at 28 weeks of
pregnancy
Substance Abuse
 The inability to meet major role obligations, legal
problems and an increase in risk taking behavior
or exposure to hazardous situations
 Substance dependent: a person having
withdrawal symptoms following the
discontinuation of a substance
Commonly Used Drugs in Pregnancy
Cocaine
* Causes extreme vasoconstriction that impedes
placental circulation
NCM 109 (PRELIMS) – LESSON 2 15
* Effects: abruptio placenta, tearing of the placenta,
preterm labor, fetal death
* Newborns born of a cocaine-dependent mother will
manifest tremulousness, irritability and muscle
rigidity; learning defects may also be suspected
Amphetamines
* Has similar effect as cocaine
* Newborns born of mothers using
amphetamine show signs of jitteriness and
poor feeding at birth
Marijuana
• Causes tachycardia and sense of well-being
* Associated with loss of short term memory and
respiratory infection
* Mothers who abused marijuana cannot breastfeed
due to reduced milk production and possibility of
drug excretion through milk
Narcotic Agonists
* Pregnancy complications: PIH, phlebitis, possible
Hep B and HIV
* Withdrawal symptoms: nausea, vomiting, diarrhea,
abdominal pain, hypertension, restlessness and
insomnia
* Effects on fetus: small for gestational age, fetal
distress, meconium aspiration
Nursing Considerations
- Provide anticipatory guidance and support
- Do not encourage breastfeeding after birth
- Appropriate referral
Trauma and Pregnancy
Trauma (injury by force):
Occurs at a high incidence during the childbearing
years (e.g., automobile accidents, homicide, suicide)
During pregnancy, the incidence of trauma is 6% to
7% (as many as 250,000 pregnant women
experience
trauma per year)
High incidence occurs during the last trimester due
to:
a. clumsiness
b. fainting
c. hyperventilation
Orthopedic injuries occur because of altered sense
of balance such as:
a. broken wrist
b. sprained ankle
c. intimate partner abuse
Preventing Accidents:
Pregnancy Counseling – educate about ways to
avoid accidents and trauma
Guidelines on preventive measures to reduce
accidents during pregnancy:
1. Don’t’ stand on stepstools or stepladders (narrow
base)
2. Keep small items out of pathways
3. Use caution stepping in and out of a bathtub
 NMM
4. Do not overload electric circuits
5. Do not smoke.
6. Do not take medicine in the dark so an error is
not apt to occur.
7. Avoid handling any toxic substances at work.
8. Avoid long periods of standing, this can lead to a
drop in BP causing dizziness and fainting.
9. Always use a seatbelt while driving or as a
passenger in an automobile.
10. Refuse to ride with anyone who has been
drinking alcohol or whose judgment might be
impaired.
Assessment
Must be done quickly yet thoroughly
Must include both psychological and physical
status
Attention to fetus health
1. Health History
Brief pregnancy history as well as trauma history
- length of pregnancy or any complication
Ask for fetal heart tones and movements, uterine
contractions and BP
Document circumstances of trauma
- what happened during the time that has passed
since the injury
- signs and symptoms of injury
- action taken
Assess whether the woman’s degree of injury is
proportion to the history
- may indicate partner abuse rather than a simple
accident
Assess awareness to safety precautions
Different Types of Trauma:
1. Open Wounds
A. Laceration (a jagged cut)
-May involve only the skin layer or may penetrate
to deeper subcutaneous tissue or tendons
-Generally bleeds profusely
Management:
>apply the pressure on the site
>clean the area
>suture the area of laceration, a local anesthetic is
necessary
>if laceration is superficial and the woman is
nervous about the use of anesthetic, the edges can
be approximated with a butterfly strip made from a
commercial adhesive strip
>anti-shock trousers should be used with caution to
halt the lower extremity bleed
B. Punctured Wounds
-Result from penetration of a sharp object such as
a nail splinter, nile file, or knife
-Bleed little
-Usually not sutured (would create a sealed,
unoxygenated cavity below the sutures with a
space where tetanus bacilli can grow.
NCM 109 (PRELIMS) – LESSON 2 16
Management:
>administer tetanus toxoid if immunization is
administered within the past 10 years; if did not
receive for the past 10 years tetanus toxoid plus
immune toxoid plus immune tetanus globulin is
administered
>Fistulogram (insertion of a thin catheter into the
wound; the wound is filled with radiopaque solution)
– to determine the depth and extent of the wound
>Celiotomy or an exploratory surgical procedure into
the abdominal cavity may be performed if the
peritoneal cavity is perforated
C. Animal Bites
-are formed of puncture wound
Management
>If bitten by a dog, wash the wound and observe the
dog for 48 hours
>Must be administered with rabies immune globulin
and vaccine
>Should be advised to use caution and avoid contact
with unfamiliar dogs/ stray dogs and animals
2. Blunt Abdominal Trauma
-Occurs generally from automobile accidents, kicking
or punching abdomen
-No visible break is present in the skin
-After the injury, the underlying tissue becomes
edematous; broken underlying blood vessels may
ooze and from ecchymosis or a hematoma at the site
Diagnosis:
1. Peritoneal Lavage
2. Ultrasound
Management:
>Palpate the uterus for any abnormal countours that
would suggest edema or internal bleeding
>Count the fetal heart tones (Doppler)
>Assess for vaginal bleeding or seepage of clear
fluid that would suggest ruptures amniotic fluid
through pelvic examination
>Uterine and fetal monitoring is necessary to
estimate the strength and effect of contractions on
the fetal heart rate and also determine if preterm
labor has begun
3. Gunshot Wounds
Assessment
-Inspection of the point where the bullet entered the
body and bullet exited
Management
>Surgically cleaned and debrided
>Treated with high dose of antibiotics (Ampicillin)
>Report to the Police
>Stay with the woman as necessary
4. Poisoning
Management
 NMM NCM 109 (PRELIMS) – LESSON 2 17

> Managed the same as in any individual

>Should telephone the local poison control center
stating her condition and follow the specific
recommendation of personnel
>Syrup of Ipecac (15ml followed by a glass of
water) is the best emetic to cause vomiting and
discharge of the poison from her body and is safe
for use during pregnancy
>Activated charcoal may also be used
>Investigate carefully the circumstances help the
woman learn about safety with medications or to
discover possible suicidal intent
5. Choking
Management
Chest thrust for the pregnant woman
Purpose
To relieve tracheal aspiration
NMM NCM 109 (PRELIMS) – LESSON 2 18