Exam 9: Other Complications of Pregnancy
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| Preventing Fetal Exposure: Environmental Influences | Teratogens
Mechanical Disruption
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| Teratogens | Agents in the fetal environment that either cause or increase the likelihood that a birth defect will occur. Most agents cross the placenta and affect the developing fetus.
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| Teratogens: Types | Infections
Ionizing Radiation
Maternal Hyperthermia
Pollutants
Effects of Maternal Disorders
-Diabetes
-PKU
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| Infections | viruses, bacteria that cross the placenta.
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| Ionizing radiation | for urgent procedures during pregnancy, the lower abdomen should be shielded with a lead apron if possible. Dose is kept as low as possible to reduce fetal exposure.
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| Maternal Hyperthermia | nurses should caution pregnant women to avoid deliberate exposure to heat sources such as saunas and hot tubs. The important factor is how high the woman’s body temperature rises and for how long, not just the sauna or hot tub.
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| Exposure to harmful influences begins before | Conception
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| Preventing Fetal Exposure: Substantial Lifestyle Changes | -Infections
-Drugs & other substances
-Ionizing radiation
-Maternal Hyperthermia
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| Substantial Lifestyle Changes: Infections | rubella immunization before getting pregnant eliminates the risk of infection and damage to the fetus. For infections that cannot be prevented by immunizing, the nurse can counsel the woman to avoid risky situations where they could acquire the disease.
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| Substantial Lifestyle Changes: Drugs and other substances | Some drugs are harmful to the fetus. Illicit drugs can cause
prenatal damage. They are unlikely to be pure and substances to dilute them may be harmful. The mother must eliminate use of non-therapeutic drugs and substances such as alcohol.
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| Substantial Lifestyle Changes: Maternal hyperthermia | mother’s temperature may rise unavoidably during illness. Important factor is how high the woman’s body temperature rises and for how long, not just the sauna or hot tub temperature.
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| Substantial Lifestyle Changes: Ionizing radiation | Limit non-urgent radiologic procedures. For urgent procedures, the lower
abdomen should be shielded with a lead apron if possible.
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| Mechanical Disruption | Forces that interfere with normal prenatal development
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| Mechanical Disruption include | Oligohyramnios
Fibrous amniotic Bands
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| Oligohydramnios | an abnormally small volume of amniotic fluid reduces the cushion surrounding the fetus and may result in deformations. Prolonged oligohydramnios can interfere with fetal lung development.
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| Fibrous amniotic bands | may result from tears in the inner sac (amnion) of the fetal membranes and can result in fetal deformations or intrauterine limb amputations (sometimes confused with birth defects)
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| Maternal Effects: Tobacco | Decreased placental perfusion
Anemia
PROM
Preterm labor
Spontaneous abortion
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| Fetal Effects: Tobacco | Prematurity
Low birth weight
Fetal demise
Developmental delays
Increased incidence of SIDS
Neurologic problems
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| Examples of maternal & Fetal Effects | -Infant with Fetal Alcohol Syndrome (FAS):
-Prenatal and postnatal growth restrictions
-CNS impairment
-Recognizable combination of facial features
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| Fetal Alcohol Syndrome: Features | Small Head.
Low Nasal Bridge.
Epicanthal folds.
Small Eye openings.
Flat Midface.
Short nose.
Smooth philtrum.
Thin Upper lip.
Underdeveloped jaw.
"Railroad track" ears.
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| Maternal Effects: Marijuana | often used with other drugs.
-Tobacco
-Alcohol
-Cocaine
-Increased incidence of anemia and inadequate -weight gain
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| Fetal Effects: Marijuana | unclear, more study needed.
-Irritability
-Tremors
-Sleep problems
-Sensitivity to light
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| Marijuana | Most commonly used illicit drug; its active ingredient, THC crosses the placenta and accumulates in the fetus.
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| Maternal Effects: Cocaine | -Hyperarousal state
-Generalized vasoconstriction
-Hypertension
-Increased spontaneous abortion
-Abruptio placentae
-Preterm labor
-Cardiovascular complications (stroke, heart attack)
-Seizures
-Increased STDs
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| Fetal Effects: Cocaine | -Risk for intracranial bleeding
-Stillbirth
-Prematurity
-IUGR
-Irritability
-Decreased ability to interact with -environmental stimuli
-Poor feeding reflexes
-N/V/D
-Decreased intellectual development
-Prune-belly caused by absence of ABD muscle
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| Cocaine | second most commonly used illicit drug. Short acting CNS stimulant. 1% of pregnant women use.
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| Amphetamines | produce effects similar to cocaine but are longer acting. (AKA: speed, crystal, ice and ecstasy.)
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| Maternal Effects: Amphetamines | Malnutrition
Tachycardia
Vasoconstriction
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| Fetal Effects: Amphetamines | Withdrawal symptoms:
-Lethargy
-Depression
IUGR
Fetal death
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| Opioids | include drugs such as morphine, heroin, methadone, meperidine, and oxycodone.
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| Maternal Effects: Opioids | Spontaneous abortion
PROM
Preterm labor
Increased incidence of
-STDs
-HIV exposure
-hepatitis
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| Fetal Effects: Opioids | -IUGR
-Perinatal asphyxia
-Intellectual impairment
-Neonatal abstinence syndrome
-Neonatal infections
-Neonatal death (SIDS, child abuse and neglect)
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| Substance Abuse: Diagnosis | Toxicology Screen.
Assessment for STD, Hepatits, HIV.
Fetal diagnostic tests.
-NST, BPP
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| Substance Abuse during Pregnancy: Management | Monitor weight
Nutrition
Methadone
Relapse prevention
Residential treatment
Peer support groups
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| Abuse and Pregnancy | Intimate Partner Abuse (IPV)
Between 1% and 20 % during pregnancy
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| Effects of IVP during pregnancy | Multiple injury sites (ABD, Face & breast).
Increased risk of STDs & HIV.
Late prenatal care, missed appts.
Vaginal bleeding, V/D, kidney or UTI, low weight gain, anemia, use of ETOH and drugs increase.
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| Effects of IVP during pregnancy: Infants | higher risk of prematurity, low birth weight, admission to neonatal ICU, and neonatal deaths
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| Prevention of abuse | Nurses should be familiar with national resources that are designed to provide health care workers with technical assistance, training materials, and relevant articles
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| Prevention of abuse: Interventions | -Assist developing a personal safety plan
-She is not to blame
-Provide referrals to community agencies such as local police, legal services, community shelters, counseling services and social service agencies; mental health referral if necessary.
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| FDA Risk Categories | Depending on fetal effects of nearness of birth, drugs may carry different risk categories at different points during pregnancy. Categories include:
Category A, B, C, D, X.
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| Category A | no evidence of risk to the fetus exists.
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| Category B | animal reproduction studies have not demonstrated a risk to the fetus. No adequate and well-controlled studies have been done in pregnant women.
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| Category C | animal reproduction studies have shown an adverse effect on the fetus, but no adequate, well-controlled studies have been done in humans. Potential benefits may warrant use of drug in pregnant women despite fetal risks.
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| Category D | is positive evidence of human fetal risk based on adverse reaction data, but potential benefits may warrant use of drug despite fetal risks.
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| Category X | positive evidence of human fetal risk based on animal or human studies and/or adverse reaction date. Risks of using drug clearly outweigh potential benefits.
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| Diabetes Mellitus During pregnancy | Disorder of carbohydrate metabolism caused by partial or complete lack of insulin secretion by the beta cells of the pancreas
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| Diabetes Mellitus Classification | Type I
Type II
Gestational Diabetes Mellitus (GDM)
-A-1: diet controlled
-A-2: diet and insulin controlled
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| Effect of Pregnancy on Preexisting Diabetic Mother | Increased incidence of:
-Spontaneous abortions
-Preeclampsia is two to three times more -likely
-UTIs
-premature rupture of membranes
-Shoulder dystocia and Injury to the birth -canal
-Increased Cesarean birth rate
-postpartum hemorrhage
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| Fetal or maternal death can be caused by | Untreated ketoacidosis
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| Effects of Preexisting Diabetes on the Fetus | Depends on the timing and severity of maternal hyperglycemia and vascular impairment.
Congenital malformations:
-Neural tube defects
-Caudal regression syndrome
Variations in fetal size
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| Effects of Preexisting Diabetes on the Newborn: 4 Major Compications | Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Respiratory Distress Syndrome
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| Goals for GDM | Maintain a normal blood glucose level (euglycemic).
Facilitate the birth of a healthy baby.
Avoid common complications of diabetics to include damage to major organs and impairment of blood vessels.
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| Treatments | Identification of Gestational Diabetes Mellitus(GDM)-Done between 24 and 28 weeks
-Prenatal screening test
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| DM Treatments: Insulin-1st trimester | pre-existing diabetics may need less insulin
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| DM Treatments: Insulin-2nd & 3rd Trimester | insulin needs increase steadily after the 1st trimester. Begun if fasting glucose > 95 or postprandial exceeds 120
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| DM Treatments: Insulin- After Delivery | insulin needs should rapidly decline, but should still be checked at least 4 times a day.
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| Care of the Neonate | Assess for complications
A neonatal nurse and/or neonatologist may attend delivery
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| Nursing Care: Hypoglycemia | Shakiness
Sweating
Pallor, cold, clammy skin
Disorientation
Headache
Hunger
Blurred vision
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| Nursing Care: Hyperglycemia | Fatigue
Flushed, hot skin
Dry mouth, excessive thirst
Frequent urination
Rapid, deep respirations
Drowsiness, headache
Depressed reflexes
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| Heart Disease During Pregnancy | Complicates about 1% of all pregnancies.
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| Most Common Cardiac Problems During Pregnancy Result from | Rheumatic heart disease
Congenital heart defects
Mitral valve prolapse (common but benign)
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| First warning signs of heart disease include: | Dyspnea
Syncope with exertion
Hemoptysis
Paroxysmal nocturnal dyspnea
Chest pain with exertion
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| If mother's heart fails... | Fetus suffer from reduced placental flow
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| Heart Disease Treatments | Frequent antepartum visits
Monitor weight
Limit Na+
Adequate diet with iron
Frequent rest
Oxygen is administered during labor to increase blood oxygen saturation
Antiarrhythmics, diuretics, heparin and prophylactic antibiotics as ordered by the pro
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| Type of delivery recommended with heart disease | Vaginal delivery
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| Anemia in Pregnancy | Hemoglobin concentrations:
-Less than 11g/dl in the 1st and 3rd Trimester.
-Less than 10.5g/gl in the 2nd Trimester.
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| Anemia is... | One of the most common problems of pregnancy.
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| Total iron requirement during pregnancy for single fetus is... | 1000mg
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| Iron Deficiency Anemia: Maternal signs and symptoms | -Pallor, fatigue, lethargy, and Pica
-RBCs are microcytic and hypochromic
-Profound maternal anemia reduces fetal oxygen supplies
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| Folic Acid is essential for | synthesis of DNA, cell growth and duplication
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| Folic Acid Deficiency Anemia | -Maternal needs double during pregnancy
-A deficiency in folic acid results in a decrease in rate of DNA synthesis resulting in the presence of large immature RBCs (megaloblasts)
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| Sickle Cell Anemia | Abnormal hemoglobin that causes their erythrocytes to become distorted in a sickle cell shape, or crescent shape, with low oxygen concentration, acidosis and dehydration worsening the process.
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| Thalassemia | Genetic disorder where there is an abnormality in one of two chains of hemoglobin, the alpha or the beta chain which leads to alterations in the RBC membrane and decreases the lifespan of the RBC.
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| Beta Thalassemia Major (Cooley's anemia) | trait is inherited from both parents.
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| Beta Thalassemia Minor | trait is inherited from only one parent.
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| TORCH | Toxoplasmosis
Other diseases (hepatitis)
Rubella
Cytomegalovirus
Herpes simplex virus
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| Toxoplasmosis Facts | Caused by a protozoan, toxoplasma gondii, which is acquired by contact with cat feces, raw meat, or through the placenta. The woman usually has mild symptoms.
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| Toxoplasmosis Fetal and Neonatal Effects | Spontaneous abortion, still birth or neonatal death.
Blindness
Retardation
Congenital anomalies
Enlarged liver and spleen
Anemia
Low birth weight
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| Hepatitis B Facts | Virus can be transmitted by blood, saliva, vaginal secretion, semen, breast milk, and it readily crosses the placenta.
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| Hepatitis B Symptoms | May be asymptomatic or acutely ill with:
-Chronic low-grade fever
-Anorexia
-Abdominal pain, nausea and vomiting
-Jaundice
-Joint pain
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| Hepatitis B Fetal and Neonatal Effects | The infant is at risk for developing many infections at birth.
Prematurity, low birth weight, chronic liver disease and neonatal death are common effects of active maternal hepatitis B.
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| Hepatitis B Prevention | All pregnant women should be screened for hepatitis B during prenatal visits.
Screening should be repeated during the 3rd trimester for women in high-risk groups especially if the first screen was negative.
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| Hepatitis B Treatments | Infants born to women who are positive for hepatitis receives hepatitis B immune globulin followed by hepatitis B vaccine within 12 hours of birth. Infant must be bathed prior to any injections to decrease the possibilities of transmitting the disease
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| Rubella | Transmitted by droplets or direct contact with articles contaminated with nasopharyngeal secretions. The virus can cross the placental barrier.
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| Rubella: Symptoms | May cause mild fever, general malaise, mild lymphedema and a maculopapular rash that begins on the face and migrates over the body.
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| Rubella Fetal and Neonatal Effects | Greatest risk to the fetus is during the first trimester.
Spontaneous abortion
Deafness
Mental retardation
Congenital cataracts
Heart defects
Growth retardation
Microcephaly
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| Cytomegalovirus | Transmitted by contamination with body fluids containing the virus such as urine, saliva, blood, cervical mucus, semen, breast milk and stool.
Usually asymptomatic.
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| Cytomegalovirus: Fetal and Neonatal Effects | -A primary infection is likely to cross the placenta
-Mental retardation
-Blindness
-Seizures
-Deafness
-Enlarged spleen and liver
-Jaundice
-IUGR
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| Cytomegalovirus Prevention & Treatments | No immunization or effective treatment is currently available.
Isolate infected infants because they continue to shed the virus in urine and saliva.
Prevent by good handwashing and avoiding contact with infected people.
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| Herpes | Transmitted by direct contact with infected lesions.
Painful blisters appear on external genitals and can involve the cervix.
Virus becomes latent in the nerves and reactivated later as a recurrent infection.
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| Herpes Fetal and Neonatal Effects | Spontaneous abortion, growth retardation, or preterm labor may occur if the mother has her first infection during pregnancy.
Infections at birth may result in generalized infection, with a 50% mortality rate.
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| Herpes Fetal and Neonatal Effects: S/S | Unstable temperature
Lethargy
Poor feeding
Jaundice
Seizures
Lesions which resemble those of the adult
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| Syphilis Maternal Effects | A chancre is the most common first manifestation
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| Syphilis Maternal Effects: Secondary Manifestations | -Moist, raised gray to pink lesions of the genital or perirectal skin
-Enlarged lymph nodes
-Fever and fatigue
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| Syphilis Maternal Effects: Late Stage Manifestations | -CV syphilis where the heart and blood vessels are involved
-Neurosyphilis where the CNS is involved
-Tabes dorsalis (a slow, progressive wasting of the nervous system)
-Paresis
-Various psychoses may result
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| Syphilis Fetal and Neonatal Effects | Transmitted transplacentally
May produce:
Spontaneous abortion
Pre-term labor
Stillbirth
Congenital defects
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| Syphilis Fetal and Neonatal Effects: Exposure during 3rd Teimester | Milder effects, such as:
Enlarged liver and spleen
Rash
Jaundice
Pneumonia
Hepatitis
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| Syphilis Treatment & Nursing Considerations | Screening during prenatal care is standard
Treatment with penicillin before 18 weeks can prevent fetal infection
Sexual partners should be notified
Reinfection during pregnancy is possible
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| Gonorrhea | It almost exclusively follows sexual contact; it is primarily an infection of the genital or rectal mucosa but is not limited to the genital organs; it can infect the mother, throat and eyes.
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| Gonorrhea Maternal Effects | Most women remain asymptomatic
Vaginal greenish-yellow discharge profuse and purulent
Itching and burning of the vulva
Painful urination
Abdominal pain and distention
Tonsillitis
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| Gonorrhea Fetal and Neonatal Effects | Cannot be transmitted via the placenta; transmitted during birth by direct contact with infected birth canal.
Eye infection may cause blindness (ophthalmia neonatorum).
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| Gonorrhea Treatment and Nursing Considerations | Treat with antibiotics
ceftriazone or azithromycin are the most commonly used
Prophylactic eye treatment with erythromycin ointment at birth
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| Chlamydia | Most common STD in the United States
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| Chlamydia: Maternal Effects | Usually asymptomatic
Increased yellow vaginal discharge
Painful, frequent urination
Dull pelvic pain
Irregular bleeding
May cause infertility by blocking the fallopian tubes
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| Chlamydia Fetal and Neonatal Effects | Transmitted to the infant's eyes during birth resulting in neonatal conjunctivitis
Associated with pre-term labor, premature rupture of the membranes, and chorioamnionitis
Pneumonia
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| Chlamydia Treatments | Erythromycin (during pregnancy)
Tetracycline or azithromycin is used postpartum
Eye prophylactic antibiotics
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| Trichomoniasis: Incubation Period | 4-28 days
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| Trichomoniasis: Transmission | Sexual intercourse
Dirty douche nozzles
Douche containers
Moist washcloths
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| Trichomoniasis: Maternal Effects | Most are asymptomatic
Frothy, gray-green, foul vaginal discharge
Perineal itching
Reddened skin
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| Trichomoniasis: Fetal and Neonatal Effects | Does not cross the placenta; it thrives in vaginal mucosa
Neonatal infection is short-lived
Associated with premature ROM
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| Trichomoniasis Treatments and Nursing Considerations | Avoid treatment until after the 1st trimester
Clotrimazole during the 1st trimester provides symptomatic relief
Metronidazole given during the 2nd and 3rd trimesters
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| Condylomata Acuminata (Genital Warts) | Caused by the Human Papillomavirus (HPV)
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| Genital Warts: Maternal Effects | Pregnancy can cause proliferation of lesions associated with cervical dysplasia and cancer
Appear like dry cauliflower-like growths which itch and are commonly located on the vagina, labia, cervix and perineal area
Vulva pain and vaginal discharge
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| Genital Warts: Fetal and Neonatal Effects | Associated with epithelial tumors of the mucous membranes of the larynx.
Laryngeal papillomas cause:
Abnormal cry
Voice change
Hoarseness
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| Genital Warts Treatments and Nursing Considerations | The goal of treatment is to remove the warts because they facilitate transmittal of the virus back and forth
Trichloroacetic acid applied topically to the growths
Cryotherapy in the 2nd and 3rd trimesters
Laser or electrocautery
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| Candidiasis Maternal Effects | Change in the vaginal environment that favors growth of fungi.
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| Candidiasis Maternal Effects: Occurance | Pregnancy
Diabetes Mellitus when the glucose level increases
Radiation, immunosuppressant drugs or antibiotic therapy
Oral contraceptive use in nonpregnant woman
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| Candidiasis Signs and Symptoms | Scaly skin, erythematous rash, itching of the vagina, vulva, & perirectal area
Urination & sexual intercourse may be painful
Cheesy, tenacious white vaginal discharge
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| Candidiasis Neonatal Effects | Oral Thrush
Diaper rash
Edematous nails
Edematous tongue
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| Candidiasis Treatment | Includes controlling the underlying condition
Miconazole or clotrimazole
Oral nystatin
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| Bacterial Vaginosis (BV): Maternal Effects | Profuse vaginal discharge with fishy odor
Itching and burning
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| Bacterial Vaginosis (BV): Neonatal Effects | Fetus is usually unaffected
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| Bacterial Vaginosis (BV): Treatment & Nursing Consideration | Flagyl
Clindamycin intravaginal cream
Antibiotics for the sexual partner
Warm sitz baths, followed by dry heat from a hair dryer on a low setting
100% cotton underwear
Avoid panties or pantyhose with nylon inserts
Do not wear tight fitting jeans
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| Group Beta Streptococcus Infection (GBS) | GBS is a nonviral infection that is a leading cause of life-threatening perinatal infections in the U.S.
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| Group Beta Streptococcus Infection (GBS): Can cause | UTIs.
Chorioamnionitis.
Metritis.
Most respond quickly to antimicrobial therapy but potentially fatal maternal complications can occur if mother is infected at time of birth.
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| Group Beta Streptococcus Infection (GBS): Fetal and Neonatal Effects | GBS disease during the 1st wk after birth, often within 48 hrs. Sepsis, pneumonia, and meningitis are primary infections.
Late-onset GBS disease occurs after the 1st week of life, and meningitis is the most common clinical manifestation.
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| Group Beta Streptococcus Infection: Treatments | Optimal identification of GBS carrier status is obtained by vaginal/rectal culture between 35 and 37 weeks.
Penicillin is the first-line agent for prophylactic antibiotic treatment of infected women during labor.
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| Urinary Tract Infections (UTIs) | Is the presence of microorganisms in the urinary tract. Bacteria is the most common
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| AIDS | breakdown in the immune function caused by the Human Immunodeficiency Virus (HIV).
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| AIDS Maternal Effects | HIV positive women are at an increased risk of preterm labor, premature ROM, IUGR, perinatal mortality and postpartum endometritis.
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| AIDS Fetal and Neonatal Effects | Infant maybe infected by perinatal exposure of the infant to infected maternal secretions through birth.
Infants born to HIV positive women who do not receive treatment during pregnancy have a higher risk of becoming infected.
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| AIDS Fetal and Neonatal Effects: Newborns | Asymptomatic at birth, but signs usually obvious during the first year of life
They include:
Enlargement of the liver and spleen
Lymphadenopathy
Failure to thrive
Persistent thrush
Presence of chronic bacterial infections such as meningitis & pneum
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| AIDS Fetal and Neonatal Effects: Newborns Prognosis | Infected infants have a short survival time, about 4 years
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| AIDS Treatments | Antiviral therapy:
After 14 weeks, the mother can take Zidovudine (prolongs woman's life and decreases transmission of virus to fetus)
It can also be given in lower doses to the newborn for 6 weeks beginning 8 to 12 hours after birth
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