A woman who is Substance Dependent/Abuse

RH Sensitization & HIV/AIDS

Anemia
DAY 2
Substance Abuse
• inability to meet major role obligations, increase in legal
problems or risk-taking behavior, or exposure to hazardous
situations due to an addicting substance.
Substance dependent
• if she has withdrawal symptoms after discontinuation of the
substance ,these substances are usually of low molecular
weight & can readily cross the placenta; the fetus has 50%
drug concentration as that of the mother
Common substances abused:
• 1. cocaine(extreme vasoconstriction of fetal circulation leading
premature separation of placenta)
• 2. amphetamines (cause LBW, prematurity, maternal and fetal mortality)
• 3. marijuana(cause abnormal neurological development)
• 4. alcohol ( cognitive challenges and memory deficits)
• 5. inhalants(delayed growth and problems with speech and motor skills)
• 6. opiates (behavioral problems, learning disabilities, birth defects and
stillbirth)
• 7. phencyclidine(more abnormal neurological and behavioral findings)
• A woman who is substance dependent presents a unique challenge for
healthcare providers during pregnancy
• Encouraging her to decrease or halt her substance intake to safeguard the
health of the fetus is a short term goal.
• Addressing her need to decrease her substance intake
• The fetus of a woman who is substance dependent is at high risk because of
the direct effects of the substance and the indirect effects of an unhealthy
lifestyle.
• Woman should be encourage to join substance reduction/maintenance
program if possible to reduce fetal risk.
 HEMOLYTIC DISORDERS of PREGNANCY

Description

• Hemolytic disease of the fetus and newborn is an immune reaction of

the mother’s blood against the blood group factor on the fetus RBCs.
• When RhoGAM (Rh immune globulin) became available in the 1960’s
to treat isoimmunization in Rh-negative women, the incidence of
hemolytic disease in the fetus and newborn dropped significantly.
Etiology

• Hemolytic disease occurs most frequently when the mother does not
have the Rh factor present in her blood but the fetus has this factor.
Another common cause of hemolytic disease is ABO incompatibility.
• In most cases of ABO incompatibility, the mother has blood type O and
the fetus has blood type A. It may also occur when the fetus has blood
type B or AB.
• Hemolysis is occasionally caused by maternal anemias, such as
thalassemia or from other blood group antigens (anti-D).
Pathophysiology

• This disorder occurs when the fetus has a blood group antigen that the mother
does not posses. The mother’s body forms an antibody against that particular
blood group antigen, and hemolysis begins. The process of antibody formation is
called maternal sensitization.
• The fetus has resulting anemia from the hemolysis of blood cells. The fetus
compensates by producing large numbers of immature erythrocytes, a condition
known as erythroblastosis fetalis, hemolytic disease of the newborn, or hydrops
fetalis. Hydrops refers to the edema and fetalis refers to the lethal state of the
infant.
• In Rh incompatibility, the hemolysis usually begins in utero. It may not affect the
first pregnancy but all pregnancies that follow will experience this problem. In ABO
incompatibility, the hemolysis does not usually begin until the birth of the newborn .
Hemolytic Disease
Assessment Findings
1. Clinical manifestations
 The hemolytic response in ABO incompatibility usually begins at birth
with a resulting newborn jaundice.
 Rh incompatibility may lead to:
 Hydramnios in the mother

 Excess bilirubin levels in the amniotic fluid.

 Varying degrees of hemolytic anemia (erythroblastosis) in the fetus. If the condition

is left unmanaged, 25% of affected infants may die or suffer permanent brain
damage.
 2.Laboratory and diagnostic study findings

 The indirect Coombs test can aid in the search for agglutination of Rh-positive RBCs to
determine if antibodies are present.

 Amniocentesis is used to determine optical density and estimate fetal hemolysis.

Spectrophotometer readings are made of the amniotic fluid collected. The readings are
obtained to determine fluid density. They are plotted on a graph and correlated with
gestational age. The amount of bilirubin resulting from the hemolysis of red blood cells
can then be estimated.

 An antibody titer should be drawn at the first prenatal visit on all Rh-negative women. It
should also be drawn at 28 and 36 weeks of pregnancy and again at delivery or abortion.
The normal value is 0. The result is usually reported as a ratio; normal is 1:8. If the titer
is absent or minimal (1:8), no therapy is needed. A rising titer indicates the need for
RhoGAM and vigilant monitoring of fetal well-being.
Nursing Management
1. Administer RhoGAm to the unsensitized Rh-negative client as appropriate
 Administer RhoGAM at 28 weeks’ gestation, even when titers are negative, or after any invasive
procedure, such as amniocentesis. RhoGAM protects against the effects of early transplacental
hemorrhage (as recommended by the American College of Gynecologists).

 When the Rh-negative mother is in labor, crossmatch for RhoGAM, which must given within 72
hours of delivery of the newborn.

2. Provide management for the sensitized Rh-negative mother and Rh-positive fetus.

 Focus management of the sensitized Rh-negative mother on close monitoring of fetal well-being,
as reflected by Rh titers, amniocentesis results, and sonography.

 If there is evidence of erythroblastosis, notify the perineal team of the possibility for delivery of a
compromised newborn.
3. Provide management for ABO incompatibility.
 Phototherapy usually can resolve the newborn jaundice associated with
ABO incompatibility.
 In addition, initiation of early feeding and exchange blood transfusions
may be immediate measures required to reduce indirect bilirubin levels.
 Provide client and family teaching.
HIV /AIDS
 HIV INFECTION AND AIDS
• HIV is slowly replicating retrovirus and has two main division HIV1 and HIV 2 followed
by variety of subtypes.

• The virus acts by attacking the lymphoreticular system (particularly CD4-bearing

helper T lymphocytes).

• The virus enters the cell, substitute its own RNA and DNA for the cells DNA, and
begins to replicate, destroying the lymphocytes in the process as well as their ability
to initiate an effective lymphocyte response.

• There is no effective way to destroy the HIV , so it remains in the body for life and can
activate if the immune system becomes depressed.
Transmission
• HIV infection is spread by exposure to blood and/or other body secretions through;
• Sexual contact, sharing of contaminated needles for injection, transfusion of
contaminated blood or blood products, perinatally from mother to fetus and possibly
through breastfeeding.

• Children - sexual maltreatment

• Healthcare providers – needle puncture
• The transmission of HIV from mother to child by placental spread is still the most
common reason for childhood HIV infection
Assessment

• Incubation period
• Adults – 10 years
• Progress more rapidly in children and infants, however those who receive the
virus via placental transmission ( if mothers do not receive treatment).

• These children are usually HIV positive by 6 months and develop clinical signs
of the disease by 1-3 years of age.
• Children who receive the virus from another source usually convert to HIV
positivity by 2-6 weeks or at least 6 months after exposure. During the pre-
conversion time child may display preliminary symptoms like:

• Poor resistance to infection

• Fever
• Swollen lymph nodes
• Respiratory tract infection
• Oral candidiasis.
• All infants born to infected mothers test positive for antibodies to the virus at birth
because of passive antibody transmission (which persist about 18 months).

• The disease is diagnosed by recovery of HIV antigen in children under this age and
antibodies to the virus in children over this age.

• Test to detect antigen are termed Polymerase chain reaction ( PCR) test
• For antibody are termed enzyme-linked immunsorbent/immunoassay ( ELISA) or
Western blot confirmation.

• CD4 count are used to document the disease status and predict disease progression.
( CD4 -500 cells/mm3 to 1,500 cell/mm3) is a healthy count.
 Classification of HIV infection in children has 3 categories:

• Category A – mildly symptomatic. Two or more symptoms such as enlarge lymph

nodes, hepatomegaly or splenomegaly or recurrent or persistent URTI, sinusitis or otitis
media.

• Category B – moderately symptomatic. Oro pharyngeal candidiasis, bacterial

meningitis, pneumonia, sepsis, cardiomyopathy, cystomegalovirus (CMV) infection,
hepatitis, herpes simplex virus ( HSV), bronchitis, pneumonitis, esophagitis, herpes
zoster ( shingles)lymphoid interstitial pneumonia ( LIP) pulmonary lymphoid hyperplasia
or toxoplasmosis are present.

• Category C – severely symptomatic ( AIDS). Serious bacterial infections such as

septicemia, mycobacterial pneumonia, meningitis, bone or joint infection, abscess of an
internal organ or body cavity, candidiasis, encephalopathy, herpes simplex lasting over
1 month, histoplasmosis, lymphoma, tuberculosis. Pneumocystisis jiroveci pneumonia a
form of pneumonia caused by a yeast like fungus and Kaposi sarcoma a malignancy that
causes large purple/blue tumors to grow from the lining of the capillaries.
• Therapeutic management
• Because of advances in general health care, Increase birth control education
focused on the needs of woman who are HIV positive

• Availability of antiretroviral medication, the number of infants born with HIV

infection are decreasing.
 Pregnant Woman with HIV infection
Early symptoms of pregnancy
Fatigue, Anemia, Diarrhea, Weight loss
• Without therapy, HIV infection progressive more slowly in adults than it does in
children, the pregnant woman with HIV passed through a multiple number of stages:
• 1. The initial invasion of the virus – mild flu-like symptom
• 2. Seroconversion- the woman converts from having no HIV antibodies in her blood
serum ( HIV serum negative) to having antibodies against HIV (HIV serum positive)
happens 6 weeks to 1 year after exposure.
• 3. Asymptomatic period – disease free except for symptoms like weight loss and
fatigue. The virus continues to replicate during this time, 3-11 years.
• 4. A symptomatic period – develop opportunistic infections possibly malignancy
including oral vaginal candidiasis, gastrointestinal illness, herpes simplex, candida
esophagitis, Kaposi sarcoma, HIV associated dementia. CD4 count is below 200
cells/mm3
 A woman with HIV infection may also have contracted other and STI’s like
syphilis, gonorrhea, chlamydia and Hepatis B, should be screened for these
diseases including tuberculosis.
• If a woman found HIV positive during pregnancy through an ELISA antibody
reaction or a Western blot analysis, the issue of safer sex practices, testing
sexual contacts and treatment during pregnancy need to be addressed.
• HIV infection is associated with both preterm births and low birth weight.
 Therapeutic Management

• Goal of therapy during pregnancy is to maintain the CD4 cell count at greater than
500cells/mm3 by administering oral zidovudine, which helps to halt maternal fetal
transmission.
• Kaposi sarcoma is treated with chemotherapy. Chemo is contraindicated in early
pregnancy but can be used later in pregnancy to halt malignant growth.

• Thrombocytopenia (low platelet count) part of HIV disease, woman may need
platelet transfusion before birth.
• To reduce the risk of mother to newborn transmission, cesarean birth is
recommended.
• Follow-up testing of the newborn being treated with zidovudine for the first 6
weeks of life is important because if the child has two negative HIV test for 4
months of age HIV infection can be excluded.
ANEMIAS OF PREGNANCY
 ANEMIAS OF PREGNANCY
 Iron-deficiency anemia is the most common anemia among pregnant women,
mainly because many women enter pregnancy already deficient in iron
stores because of low intake of iron. (resulting from combination of diet low in
iron, heavy menstrual period & unwise reducing program).
 A hemoglobin level below 12mg/dl with hematocrit below 33% is a possible
sign of iron deficiency.

Hemoglobin Male: 13.2-16.6 grams/dL***

(132-166 grams/L)
Female: 11.6-15 grams/dL
(116-150 grams/L)

Hematocrit Male: 38.3-48.6 percent

Female: 35.5-44.9 percent
 Iron-deficiency anemia is a microcytic (small red blood cells), hypochromic
anemia (less hemoglobin) because when inadequate iron is ingested, it would
be unavailable for incorporation into red blood cells.
 Iron-deficiency anemia is mildly associated with low birth weight and preterm
birth.
 Extreme fatigue and poor exercise tolerance because she cannot transport
oxygen effectively.
 Advise the woman to take prenatal vitamins containing an iron supplement of
60 mg ( 27mg) elemental iron.
 Instruct her to eat a diet high in iron such as green leafy vegetables, meat,
legumes, and fruit.
 When a pregnant woman has developed anemia during pregnancy, she will be
prescribed with 120 to 200 mg elemental iron per day in the form of ferrous
sulfate or ferrous gluconate.
 Iron is best absorbed in an acidic medium, so advise the woman to take her
iron supplements with orange juice or a vitamin c supplement.
 Side effects of iron therapy include constipation and gastric irritation.
 Ferrous sulfate turns stool black so caution women with this side effect.
• Folic Acid-Deficiency Anemia
 Folic acid is vital for the normal formation of red blood cells in the mother.
 It also prevents neural tube defects in the fetus.
 Folic acid anemia is a megaloblastic anemia wherein the mean corpuscular volume is
elevated.
 This anemia is most apparent during the second trimester of pregnancy and may
contribute to early miscarriage or premature separation of the placenta.
 Women who are expecting to be pregnant are advised to take 400 µg of folic acid
daily.
 Advise the woman to take folacin rich foods such as green leafy vegetables, oranges,
and dried beans.