CHAPTER 20: NURSING CARE OF FAMILY occur even at rest.

Unable to do anything
EXERIENCING A PREGANANCY COMPLICATION without discomfort. (avoid pregnancy)
FROM PRE-EXISTING OR NEWLY ACQUIRED
ILLNESS A woman with class I or II heart disease can
expect to experience a normal pregnancy
and birth. Women with class III can
complete a pregnancy by maintaining
IDENTIFYING A HIGH-RISK PREGNANCY special interventions such as bed rest.
Women with class IV heart disease are
A high-risk pregnancy is one in which a concurrent usually advised to avoid pregnancy because
disorder, pregnancy-related complication, or external they are in cardiac failure even at rest and
factor jeopardizes the health of the woman, the fetus, when they are not pregnant.
or both.
CARDIOVASCULAR DISORDERS AND
CONDITIONS ESPECIALLY DANGEROUS TO THE PREGNANCY
FETUS
-overall women have less heart issues
-causes changes in fluid and electrolyte imbalance because of the correction of congenital heart
-causes altered respiratory or cardiac function disorders and tx of rheumatic fever
-causes severe blood loss -needs to begin prenatal care within 1 week
of missed period.
2020 NATIONAL HEALTH GOALS REDUCING
-most dangerous time is at week 28-32
COMPLICATION OF PREGNANCY
when blood volume peaks.
1. reduce rate of fetal deaths
- both the blood volume and cardiac output
2. reduce rate of maternal deaths
increases approximately 30% (and up to as
3. reduce rate of maternal complications and illness
much as 50%) during pregnancy. Half of this
during pregnancy
increase occurs by 8 weeks; it is maximized
by midpregnancy
By educating women to enter pregnancy at optimal
health, helping diabetes understand pre-pregnancy
-the increased blood flow past valves,
care, support those with chronic diseases to follow
functional (innocent) or transient murmurs
regimen.
can be heard in many women without heart
disease during pregnancy.
CARDIOVASCULAR DISEASE AND PREGNANCY
A WOMAN WITH LEFT-SIDED HEART
1) valve damage cause by rheumatic fever or
FAILURE
Kawasaki disease.
2) congenital anomalies ie atrial septal defect,
SYMPTOMS:
coartation of the aorta
- back pressure—the left side of the heart
becomes distended, systemic blood
4 classes of heart disease
pressure decreases in the face of lowered
cardiac output, and pulmonary hypertension
I. Uncompromised. (predict a normal
occurs., pulmonary edema when vein
pregnancy)
pressure reaches 25mmHg. Produces
profound shortness of breath as it interferes
II. Slightly compromised. Ordinary activity
with oxygen–carbon dioxide exchange
causes excessive fatigue, palpitation,
-SOB, increased resp rate=orthopnea (s
angina. (normal pregnancy)
elevating her chest this way allows fluid to
settle to the bottom of her lungs and frees
III. Markedly compromised. Above
space for gas exchange.) and paroxysmal
symptoms experienced at less than
noctural dyspnea (suddenly waking at night
ordinary activity. (can complete pregnancy
with shortness of breath.)
with bed rest and other interventions)
-productive cough with bloody sputum if
capillaries rupture
IV. Severely compromised. Symptoms
-fatigue, weakness, dizziness.
-less blood going to placenta. maintain heart function
-high risk for spontaneous miscarrage, -heparin
preterm labor, death -immunosuppressive therapy
-peripheral edema
Postpartum:
TREATMENT(Tx) -Don't get pregnant again
-anticoagulant (preferably heparin) to dispel -Don't use oral contraceptives!
thrombus formation -may need heart transplant.
-antihypertensives to control bp
-diuretics to reduce blood vlume Assessment of Woman with Cardiac disease
-B-blockers improve ventricular filling
1. thorough health history
DIAGNOSTIC: 2. level of exercise
3. edema (imp. for distinguishing if it's from
-Week 30, 32: serial US and nonstress tests heart failure)
to rule out poor placental perfusion. 4. baseline vitals, nailbed fillings.
5. ECG
What is the anticoagulant of choice for early
pregnancy and why? FETAL ASSESSMENT

-Heparin (It does not cross the placenta and 1. late decelerations indicate issue in labor
thus is not teratogenic.)
What is the most dangerous time for a
A WOMAN WITH RIGHT-SIDED HEART woman with cardiac disorders?
FAILURE
Week 28-32 (This is where the blood
Symptoms: volume peaks.)
-decreased CO to the lungs.
-jugular vein distention, increased portal
circulation
-dyspnea and pain from liver enlargement
-peripheral edema
Assessing a pregnant woman with cardiac
Tx: disease
-don't get pregnant until this is resolved
Symptoms:
-Oxygen administration
-Frequent ABG's to measure fetal growth -cough, increased resp. rate
-pulmonary artery catheter inserted during -fatigue, tachycardia
labor to monitor pulmonary person. -decreased amniotic fluid and poor fetal
-monitor closely after anesthesia b/c they heart tone.
can become hypotensive. -edema from poor venous return

A woman with peripartum heart disease  maternal blood pressure is

maintained above 100/60 mmHg
Definition: heart condition that originates in and fetal heart rate at 110 to 160
pregnancy. Occurs in African American beats/min.
multiparas most often.  2 days rest / should be in the left
lateral recumbent position to prevent
Symptoms: supine hypotension syndrome and
-myocardial failure (SOB, chest pain, increased heart effort.
nondependent edema)  Be certain they know exactly how
-cardiomegaly much they should limit their
exercise.
Tx:  Be certain she is remembering to
-sharp reduction of exercise take her prenatal vitamins / help
-diuretic, arrhythmia agent, digitalis to prevent anemia.
  Digoxin/ before pregnancy may -continuous hemodynamic monitoring via
need to increase their maintenance Swan-Ganz
dose because of their expanded -epidural anesthesia the anesthetic of
blood volume during pregnancy. it choice for women with heart disease
can be administered to the woman
to slow the fetal heart if fetal 2. side-lying position (left)
tachycardia is present -if she has pulmonary edema, elevate head and
 Not Digoxin Dependent / may need chest and place towel under right hip.
such therapy prescribed as
pregnancy advances and her 3) don't push with contractions, use of epidural
cardiac output has to be increased anesthetics instead!
or strengthened. -low forceps or vacuum extractor used.
 Antihypertensive and arrhythmia
agents such as adenosine, β
blockers, and calcium channel
blockers to reduce hypertension are
safe to use during pregnancy and
are also frequently prescribed. Postpartum nursing interventions for a woman
 Nitroglycerin, a compound often with cardiac issues
prescribed for angina
 penicillin prophylactically because 1)Circulation
she had rheumatic/ should continue -program of decreased activity
to take this drug during pregnancy -anticoagulants, stockings
because penicillin is not known to
be a teratogen 2)Meds
 ampicillin, amoxicillin (Amoxil), or -start prophylactic antibiotics.
clindamycin (Cleocin)/ prevent - Give oxytocin with CAUTION! Increases bp.
streptococci bacteria from invading -stool softeners are okay
the denuded placental site on the
uterus and creating a subacute Woman with artificial valve prosthesis
bacterial endocarditis.
NSG:
 systemic infection / avoid visiting or -Coumadin is d/c and replaced with heparin
being visited by people with before pregnancy.
infections and to alert healthcare -observe for petechiae and premature
personnel at the first indication of an separation of placenta
upper respiratory tract infection or
urinary tract infection (UTI) so that, if Woman with chronic hypertensive vascular
warranted, antibiotic therapy can disease
begin early in the course
 women with heart disease Symptoms:
overexert/ they may need -bp 140/90 or above.
supplemental oxygen or cardiac
resuscitation. Tx:
-B-blockers and ACE inhibitors.
Normal Edema vs Heart Failure Edema -Methyldopa (Aldomet) typically prescribed.

normal: feet and ankles Woman with Venous Thromboembolic Disease

heart failure: systemic
Symptoms of DVT:
Nsg interventions during labor and birth for a -triad of stasis, vessel damage, hypercoagulation
woman with cardiac issues occurs
-pain and redness in calf
1. assess vitals, fetal HR, uterine
contractions Symptoms of PE:
-oxygen administration -chest pain, bloody cough
-sudden dyspnea, tachycardia,
-dizziness, fainting 2) hypochromic: less hemoglobin than
average cell.
Tx:
-bed rest and IV heparin 24-48 hours, then sub Q Type of anemia associated with folic-acid
heparin every day afterwards deficiency
-limit injection side to arms and thighs 1) megaloblastic anemia: enlarged red
blood cell.
-STOP heparin once labor begins.
-No epsiotomy or epidural anesthesia.
*takes several weeks to develop or not
-No OC's postpartum. apparent until Trimester 2

A woman with folic-acid deficiency anemia

Dx: Dopper and history
Patho: Folic acid is necessary for formation of
Is anemia a normal finding during pregnancy? RBCs and preventing neuro tube/abdominal
defects.
Yes.
This is because the blood volume expands ahead Symptoms:
of the red blood cell count. -can contributes to miscarriage or separation of
the placenta.
True anemia -similar to symptoms in iron-deficiency anemia

Hemoglobin less than 11g/dl (33%) in the 1st or
third trimester.
Hemoglobin is less than 10.5 g/dl (32%) in the
second trimester
A woman with Iron-Deficiency Anemia
Patho: Iron is absorbed from duodenum into
bloodstream. It then binds transferrin, heads to
the liver/spleen/bone marrow and is
incorporated into hemoglobin or stored as
ferritin.
Dx: low serum iron (under 30ug/dl)
-increased iron binding capacity.
Tx:
-begin supplement of 400ug folic acid daily
-eat folate rich foods (orange, green leafy
veggies, dried beans)
In what type of woman does folic-acid deficiency
anemia occur most often in?
1) women having multiple pregnancies
2) women with secondary hemolytic illness
3) women taking hydantoin (anticonvulsant
interferes with folate absorption)
4) women taking oral contraceptives
5) women with poor gastric absorption

Symptoms:
-extreme fatigue, poor exercise intolerance
-pica (craving for ice and starch)
-infants have low birth weight, premature.
-restless leg syndrome.
Tx:
-27mg of iron in prenatal vitamins
-green leafy veggies, legumes
-120-200mg ferrous sulfate/gluconate
Nsg:
-take iron with OJ because it is best absorbed in
acid.
-stools may turn black: this is normal.
-SE of constipation and GI symptoms.
Type of anemia associated with Iron-deficiency
1) microcytic: small/stunted RBC
A woman with sickle-cell anemia
Patho: An abnormal amino acid replacing valine.
(If lysine replaces valine, non-sickling occurs).
RBC are sickle shaped, clump together.
Symp:
-hemoglobin of 6-8mg/100ml.
-growth restriction, miscarriage, perinatal
mortality of the fetus
-blockage of the placental circulation is possible.
Tx and Nsg considerations:
-screen all African American women
-DO NOT take iron (because it can't be
incorporated into the sickle cell)
-stay hydrated, limit standing
-more susceptible to bacteruria (nurse needs to
obtain urine sample)
-Sickle Cell Crisis: control pain, administer
oxygen, lower viscosity.
-hospitalize if the woman develops a
fever/infection, respiratory issues.
-during labor, use epidural anesthesia.
-Postpartum use compression stockings.
How do you determine if your child gets sickle-
cell anemia?
-knowing that disorder is recessively inherited.
-electrophoresis of RBC's obstaiend from
maternal serum or amniocentesis
-newborn routine serum screening at birth.
The woman with thalassemia
Patho: autosomal recessive disorder tat results
in poor hemoglobin formation and severe
anemia occurring most in Mediterranean,
African, Asians.
Tx:
-folic acid
-blood transfusion
-NO IRON supplementation
The woman with malaria
Patho: RBC become sticky and obstruct vessels
resulting in anoxia of organs. Incubation: 12-24
days.
Symp:
-elevated LFT
-fever, malaise, headache
-low platelets, anemia, renal failure
Tx:
-Chloroquine is drug of choice. Safe.
-Sulfadoxine/pyrimethamine for the last
trimester.
-Teratogenic: Quinine, Malarone, tetracyclines
von Willebrand disease
Patho: autosomal dominant coagulation disorder
that causes prolonged bleeding times despite
normal platelets. This is because clotting factors
(8) are reduced.
Symp:
-menorrhagia or frequent epistaxis
Tx:
-replace missing coagulation factors by infusion
of cyroprecipitate or FFP before birth.
Hemophilia B
Patho: a sex-linked disorder where there is a
reduced level of factor 9. In carrier females this
could cause miscarriage
Tx:
-restore factor 9 with concentrate or FFP
Idiopathic thrombocytopenic purpura (ITP)
Patho: decreased platelets that may occur after
viral invasion. Lasts 1-3 months.
Symp:
-thrombocytopenia
-frequent nosebleeds and petechiae and large
bruises
Tx:
-oral prednisone
-platelet transfusion
-plasmapheresis
*all increase platelet count temporarily to
decrease chance of bleed at birth
A woman with UTI
Patho: Progesterone causes ureters to dilate,
leading to stasis of urine. Minute amounts of
glucose in urine provide feeding ground for
bacteria (esp. E.Coli or Strep B).
Symp:
-pain and urinary frequency
-Pyelonephritis: Right lumbar pain that radiates
downwards. N and V, fever, malise.
-100,000 bacteria/ml on urine culture.
Tx:
-Amoxicillin, ampicillin, cephalosporins are safe
for use during pregnancy.
-Sulfonamides: safe for EARLY pregnancy
ONLY
-NO tetracyclines!
Nsg:
-if Strep B caused it: obtained vaginal cultures to
make sure it hasn't affected the fetus (assoc with
pneumonia)
-Void frequently, wipe front to back, drink cran
juice
-15 min knee chest position to promote drainage
Pyelonephritis
Patho: UTI spreads to the kidneys.
Symp:
-Right lumbar pain that radiates downwards.
-N and V, fever, malaise
Tx:
-hospitalization for 24-48 hours, IV antibiotics
-for duration of pregnancy: oral Nitrofurantoin
(Macrodantin)
-NO vitamin C because neonate may develop occurs in the lung alveoli.
scurvy from vit C withdrawal
Symp:
A woman with hyperactive bladder -RBC, fibrin, leukocytes flood the alveoli
Patho: uterus puts pressure on the bladder. -dyspnea
-fetal growth restriction, preterm birth
Symp: frequency, urgency, incontinence.
Tx:
Tx: -appropriate antibiotics
-Fesoterodine (Toviaz) which is an -oxygen therapy
antispasmodic.
A woman with chronic renal disease A woman with asthma
Patho: diseased kidneys don't produce Patho: Symptoms triggering by inhalled allergen.
erythropoeitin. Bronchial smooth muscles are constricted.

Symp: Symp:
-elevated bp, proteinuria -mucosal inflammation and swelling
-flank pain if she develops pyelonephritis -bronchial wheezing upon exhaling
-anemia
-sCR: 0.5 Tx:
-edema -regular corticosteroids she normally takes
(check with PMD).
Tx: -IV administration of hydrocortisone during labor
-prednisone (neonates have increased chance b/c of stress
of cleft palate and may be hyperglycemic) -Terbutaline and albuterol need to be tapered
-dialysis (risk of preterm labor so progesterone close to term because they may reduce labor
IM given), preferably peritoneal. contractions.
-low potassium diet (kidneys don't process this
well) A woman with RB
Patho: Mycobacterium TB invades lung tissue.
A woman with the common cold Antibodies have a pos. response to PPD test.
Patho: estrogen stimulation causes nasal
congestion. Mostly caused by a virus. Symp:
-chronic cough, hemoptysis
Tx: -fatigue, weight loss, night sweats
-DO NOT take aspirin. Check before taking -Positive PPD (follow with chest x-ray and
OTC. sputum)
-Antibiotics ARE NOT effective.
-Get extra rest with lots of Vit C Tx:
-Tylenol q4h up to 3000mg -Wait 1-2 years after TB inactivate to conceive.
-room humidifier/vapor rub -Isoniazid (take supp B6 to counter peripheral
-cool/warm compresses neuritis)
A woman with Influenza -Rifampin
Patho: Caused by a virus (A, B, C) -Ethambutol Hcl (may cause optic atrophy)
-Maintain Calcium intake
Symp:
-high fever A woman with COPD
-extreme prostration Patho: constriction of airway associated with
-aching pains in back and extremities long term smoking.
-sore, raw throat
Symp:
Tx: -SOB
-antipyretic (Tylenol) -fetal growth restriction, preterm birth
-Tamiflu (oseltamivir)
-vaccination is okay for pregnancy Tx:
-additional rest, supp oxygen
A woman with pneumonia -CPAP for sleep apnea
Path: Bacterial invasion of lung by S. -smoking cessation
pneumoniae, H. influenzae, Mycoplasma
pneumoniae. Acute inflammatory response A woman with cystic fibrosis
Patho: Inherited disease where dysfunction of
exocrine glands causes thick mucus secretions,
ruining lung/pancreatic health.
Symp:
-same as COPD
-thickened mucus
-sterility
-difficulty digesting fat and protein
-IUGR, preterm labor (screen by chorionic villi,
amniocentesis, abnormal chromosome 7)
Tx:
-Pancrelipase
-bronchodilator and antibiotic for symptoms
-daily chest physiotherapy
A woman with Rheumatoid arthritis
Patho: Disease of connective tissue marked by
joint inflammation and contractures.
Symp:
-joint symptoms (may actually improve)
Tx:
-corticosteroids, NSAIDS, hydroxychloroquine to
improve mobility
-decrease aspirin intake before term
-STOP taking methotrexate (causes head and
neck defects)
A woman with systemic lupus Erythematosus
Patho: Chronic disease of connective tissue.
Symp:
-butterfly rash of face
-vessel obstruction because of thickening of
collagen
-thrombocytopenia
-acute nephritis (proteinuria, low UO)
Tx:
-NSAIDS, heparin, salicylates, prednisone,
azathioprine
-Reduce aspirin before term
-dialysis
-IV hydrocortisone during labor
A woman with appendicitis
Appendicitis usually begins with a few hours of
nausea and then an hour or two of generalized
abdominal discomfort. Then, comes the typical
sharp, peristaltic, lower right quadrant pain of
acute appendicitis.
Symptoms:
-Pain from an overstretched round ligament or a
ruptured ectopic pregnancy may both cause
sharp lower quadrant pain/ grows more intense.
-morning sickness for ectopic pregnancy
Nausea and vomiting from pain at the McBurney
point (a point halfway between the umbilicus and
the iliac crest on the lower right abdomen)
-urine samples reveals ketones
-elevated white blood cell (WBC)
Tx
-Advise a woman in an emergency room that
while she is waiting to be evaluated for possible
appendicitis not to eat any food, drink any liquid,
or consume any laxatives because increasing
peristalsis could cause an inflamed appendix to
rupture.
Therapeutic management:
-If a woman is near term (past 37 weeks) and
the fetus is believed to be mature, a cesarean
birth may be performed along with removal of
the inflamed appendix at the same time.
- If appendicitis occurs early in pregnancy, the
inflamed appendix is usually removed by
laparoscopy.
A WOMAN WITH GASTROESOPHAGEAL
REFLUX DISEASE OR HIATAL HERNIA
- refers to the reflux of acid stomach
secretions into the esophagus
- Hiatal hernia is a condition in which a
portion of the stomach extends and
protrudes up through the diaphragm into
the esophagus, trapping stomach acid
and causing it to reflux into the
esophagus.
Symptoms
- for the first time during pregnancy as the
uterus pushes the stomach up against
the esophageal valve and increases the
reflux of acid or the extent of the hernia.
- Heartburn, which is particularly extreme
when lying supine after a full meal •
Gastric regurgitation • Dysphagia
(difficulty swallowing) • Possible weight
loss because of the stomach pain •
Hematemesis (i.e., vomiting of blood) if
extreme esophageal irritation occurs
Diagnose
ultrasound, although direct endoscopy could be
used
TX and nursing management:
- an over-the-counter antacid or a
prescription for a proton pump inhibitor
such as esomeprazole magnesium
(Nexium; pregnancy category B) will
effectively dilute or inhibit gastric acid
production and so relieve symptoms
- advise a woman to wear clothing that is
loose around her waist and to sleep with
her head elevated on two or more
 pillows to help confine stomach
secretions.
- Esomeprazole magnesium
A woman with Cholecystitis and Cholelithiasis
- gallstones form from cholesterol, the
hypercholesterolemia that naturally
occurs during pregnancy may be the
reason an increased incidence of
gallstone formation occurs during
pregnancy in women prone to these.
Symptoms:
constant aching and pressure in the right
epigastrium, perhaps accompanied by jaundice.
Medical Therapy
-lower fat intake
- temporarily halting oral intake to rest the
gastrointestinal tract and administering
intravenous fluids to provide fluid and nutrients
as well as analgesics for pain.
- Surgery for gallbladder removal by
laparoscopic technique may be done during
pregnancy if a woman’s symptoms cannot be
controlled by conservative management
A woman with Pancreatitis
- a rare disorder that tends to occur in late
adolescents and so may occur during
pregnancy
Symptoms
- severe epigastric pain, nausea,
vomiting, anorexia, and fever
Diagnosis
If serum amylase levels are greater than two
times above normal, however, pancreatitis
should be suspected.
Treatment :
The disorder is treated the same during
pregnancy as in nonpregnant women:
nasogastric suction, bowel rest, analgesia
(because pancreatic pain is sharp), and
intravenous hydration through parenteral
nutritional supplementation
A woman with Hepatitis
- a liver disease that occurs from invasion
of the hepatitis A, B, C, D, or E virus.
- Hepatitis A is spread mainly by fecal–
oral contact (children in day-care
settings have a high incidence) or by
ingestion of fecally contaminated water
or shellfish. It has an incubation period
of 2 to 6 weeks. Pregnant women
exposed to hepatitis A may be given
prophylactic γ-globulin to try to prevent
the disease after exposure.
- Hepatitis B and C are spread by
exposure to contaminated blood or
blood products or by contact with
contaminated semen or vaginal
secretions (and so are considered
sexually transmitted infections [STIs]).
These can be transmitted to the fetus
across the placenta. Hepatitis B It
occurs in both an acute and chronic
form, leading to liver cell necrosis with
scarring and an inability to convert
indirect to direct bilirubin or to excrete
direct bilirubin. ( receive immune
globulin for prophylaxis; a hepatitis B
vaccine can be administered to those
who are at high risk)
- Hepatitis D and E are apparently
spread by the same methods as
hepatitis B and C but are rarely seen in
pregnant women.
Symptoms :
-experiences nausea and vomiting.
- liver area may feel tender to palpation.
- Urine will turn dark yellow from excretion of
bilirubin; stools will be light-colored from lack of
bilirubin. Jaundice occurs as a late symptom.
- , hepatomegaly (i.e., enlargement of the liver)
is noted.
-serum bilirubin level is elevated.
- Levels of liver enzymes, such as transaminase,
are increased.
Therapeutic management
- prescribed bed rest and encouraged to
eat a high-calorie diet because her liver
has difficulty converting stored glycogen
into glucose in its diseased state and so
hypoglycemia can result.
- A cesarean birth may be planned at
term to reduce the possibility of blood
exchange between mother and fetus.
- a woman may breastfeed as the
infection is apparently not transmitted by
breast milk.
- Avoid blood
- infant should be washed well to remove
any maternal blood; hepatitis B immune
globulin (HBIG) and the first dose of
hepatitis B should be administered
A woman with Inflammatory Bowel Disease
-Crohn disease (i.e., inflammation of the terminal
ileus) and ulcerative colitis (i.e., inflammation of
the distal colon) occur most often in late
adolescents between ages 12 and 30 years. The
cause of these diseases is unknown, but an
autoimmune process is thought to be
responsible.
-experiences chronic diarrhea, weight loss,
occult blood in stool, and nausea and vomiting.
If extreme, obstruction and fistula formation with
peritonitis can occur. With Crohn disease,
malabsorption, particularly of vitamin B (the
absorption of which occurs almost entirely in the
ileum), can occur.
-potential for fetal growth restriction if extreme
malabsorption occurs.
-Sulfasalazine (Azulfidine), an anti-inflammatory
and a mainstay of therapy, may be continued
during pregnancy without fetal injury. Close to
birth, the dosage of sulfasalazine, because of its
sulfa base, is reduced because it may interfere
with bilirubin binding sites and cause neonatal
jaundice (Karch, 2015). Infliximab (IFX) and
adalimumab (ADA) are other attractive treatment
options,
A woman with seizure disorder
-Recurrent seizures have several causes, such
as head trauma or meningitis. However, the
causes of most recurrent seizures, such as
epilepsy, are unknown
- establish the best seizure control with the
fewest possible number of antiseizure drugs
prior to pregnancy
-continue to conscientiously take antiseizure
medications
-monitor the levels of antiseizure drugs
-Common drugs prescribed to control seizures
are trimethadione (Tridione; pregnancy risk
category D); valproic acid (sodium valproate and
divalproex sodium; pregnancy risk category D);
carbamazepine (Tegretol; pregnancy risk
category C); ethosuximide (Zarontin; pregnancy
risk category C), a drug often used to control
absence seizures; and phenytoin sodium
(Dilantin; pregnancy risk category D).
-Phenytoin (Dilantin) is recognized as the cause
of a fetal syndrome, including cognitive
impairment, vitamin K deficiency, and a peculiar
facial proportion not unlike that of fetal alcohol
sequence
A woman with Myasthenia gravis
- Myasthenia gravis is an autoimmune
disorder characterized by the presence
of an IgG antibody against acetylcholine
receptors in striated muscle. The
presence of the antibody causes failure
of the striated muscles to contract,
particularly those of the oropharyngeal,
facial, and extraocular groups. The
disorder usually occurs in 20- to 30-
year-olds,
- treated with anticholinesterase drugs
such as pyridostigmine (Mestinon) or
neostigmine (Prostigmin) and possibly a
corticosteroid such as prednisone.
These medications may be continued
during pregnancy, as the fetus will
experience no effects from them
- Plasmapheresis (i.e., removal of and
replacement of plasma) to remove
immune complexes from the
bloodstream may be prescribed to
reduce symptoms.
- Magnesium sulfate (administered to halt
preterm labor or treat hypertension of
pregnancy) should be avoided at any
point in pregnancy because it can
diminish the acetylcholine effect and
therefore increase disease symptoms.
A woman with sclerosis
-Multiple sclerosis (MS) occurs predominantly in
women of childbearing age, usually between 20
and 40 years of age
-With MS, nerve fibers become demyelinated
and therefore lose function. Women develop
symptoms of fatigue, numbness, blurred vision,
and loss of coordination. ACTH
(adrenocorticotropic hormone) or a
corticosteroid is commonly given to strengthen
nerve conduction and both can be administered
safely during pregnancy
-, immunosuppressants such as cyclosporine
(Sandimmune), azathioprine (Imuran), and
cyclophosphamide (Cytoxan), which are also
frequently prescribed, should be used cautiously
during pregnancy
-plasmapheresis (i.e., withdrawal and
replacement of plasma)
-Monitor for UTIs at prenatal visits as these tend
to occur as a poorly defined consequence of the
illness.
A woman with scoliosis
-Scoliosis (i.e., lateral curvature of the spine)
begins to be noticed first in girls between 12 and
14 years of age. If it is uncorrected at this time,
the curvature progresses until it can interfere
with respiration and heart action because of
chest compression.
-y wear a body brace during their adolescent
years to maintain an erect posture.
-e stainless steel rods surgically implanted on
both sides of their vertebrae to strengthen and
straighten their spine.
-If a woman’s pelvis is distorted, a cesarean
birth may be scheduled to ensure a safe birth.
A woman with thyroid dysfunction
……
A woman with Diabetes Mellitus
Diagnosis:
-fasting glucose above 126, nonfasting 200
-75-g Glucose Oral challenge
Symp:
-infants prone to hypoglycemia, hypocalcemia, -hx of large babies
hyperbilirubinemia
-hydraamnios -hx of unexplained fetal/perinatal loss,
-increased risk of HTN, poor fetal heart tone congential anomalies
-macrosomia (10lb baby)
-polyuria, polydipsia -hx of PCOS

Tx: -family hx of diabetes or Native American,

-increase insulin dosage at week 24 Hispanic, Asian ancestry.

Oral glucose challenge Should oral hypoglycemics be used during

Give 75g oral glucose, take blood at 1-2-3 pregnancy?
hours. NO!

Fasting: 95 Insulin in pregnancy

1 hour: 180 -needs less than normal early in pregnancy
2 hour: 155 -MORE needed in late pregnancy
3 hour: 140
-short-acting with intermediate (2/3 at breakfast,
If 2/4 samples are abnormal, diabetes is dx. 1/3 at night)
-give IM, stretch skin taut, inject at 90deg angle
Gestational Diabetes -most prefer the thigh and upper arm site.
Patho: development of insulin resistance
midway through pregnancy What should you do for hypoglycemia?
Milk with crackers.
Dx: Fasting glucose above 95mg/dl and 2 Prevents rebound hypoglycemia.
abnormal readings after glucose ingestion
Tests for placental function
1) 15-17 weeks: Serum alpha-fetoprotein
Symp: test (checks neural tube defects)
-hypoglycemia in 1st and 2nd trimesters,
followed by hyperglycemia peaking at the 6th 2) 18-20 weeks: Ultrasound) (to detect
month. gross abnormalities)
-polyuria, polydipsia,
-metabolic acidosis 3) 36 weeks Lecithin/Sphingomyelin
ratio via amniocentesis to determine
Nsg: lung maturity
-check for UTIs
-eye exams, possible laser therapy 4) Every trimester: Creatinine clearance

Tx: 5) Weekly nonstress test or biophysical

-diet (20% protein, 40% carbs, 30% fat, fiber)
- bedtime snack of protein and complex carb to
prevent hypoglycemia.
-3 meals and 3 snacks.
-fiber prevents postprandial (after meal)
hyperglycemia.
Symptoms of hyper and hypoglycemia
Hyper: Polydipsia, polyuria, polyphagia (fruity
breath)
Hypo: nervousness, headache, weakness,
irritability
Risk factors for gestational diabetes
-obesity
profile
6) Fetal kicks
How do you know if the fetal lungs are mature?
L/S ratio is 2:1, and you will be able to detect
phosphatidylglycerol, an ingredient of lung
surfactent.
What does hydramnios indicate?
1) GI malformation
2) poorly controlled gestational HTN
*at risk for hemorrhage after delivery
becuase of poor uterine contraction.

-over 25 What does oligohydramnios indicate?

1) fetal growth restriction
2) fetal renal abnormality
Birth of fetus to a woman with diabetes
-Week 36-40 are the most dangerous, so induce
at 37 weeks.

-Vaginal delivery is preferred with rupture of

membranes or oxytocin to induce.

-Avoid use of IV glucose as plasma volume

expanded (use Ringer's lactate or saline
instead)

Postpartum care of a woman with diabetes

-1-2 hour postprandial glucose monitoring

-glucose return to normal at 24 hours if she has

gestational diabetes.

-if she has IDDM, hold insulin in immediate

postpartum but will need to return to pre-
pregnancy requirements