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M6 13-005

Exam 9: Other Complications of Pregnancy

Preventing Fetal Exposure: Environmental Influences Teratogens Mechanical Disruption
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.
Teratogens: Types Infections Ionizing Radiation Maternal Hyperthermia Pollutants Effects of Maternal Disorders -Diabetes -PKU
Infections viruses, bacteria that cross the placenta.
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.
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.
Exposure to harmful influences begins before Conception
Preventing Fetal Exposure: Substantial Lifestyle Changes -Infections -Drugs & other substances -Ionizing radiation -Maternal Hyperthermia
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.
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.
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.
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.  
Mechanical Disruption Forces that interfere with normal prenatal development
Mechanical Disruption include Oligohyramnios Fibrous amniotic Bands
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.
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)
Maternal Effects: Tobacco Decreased placental perfusion Anemia PROM Preterm labor Spontaneous abortion
Fetal Effects: Tobacco Prematurity Low birth weight Fetal demise Developmental delays Increased incidence of SIDS Neurologic problems
Examples of maternal & Fetal Effects -Infant with Fetal Alcohol Syndrome (FAS): -Prenatal and postnatal growth restrictions -CNS impairment -Recognizable combination of facial features
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.
Maternal Effects: Marijuana often used with other drugs. -Tobacco -Alcohol -Cocaine -Increased incidence of anemia and inadequate -weight gain
Fetal Effects: Marijuana unclear, more study needed. -Irritability -Tremors -Sleep problems -Sensitivity to light
Marijuana Most commonly used illicit drug; its active ingredient, THC crosses the placenta and accumulates in the fetus.
Maternal Effects: Cocaine -Hyperarousal state -Generalized vasoconstriction -Hypertension -Increased spontaneous abortion -Abruptio placentae -Preterm labor -Cardiovascular complications (stroke, heart attack) -Seizures -Increased STDs
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
Cocaine second most commonly used illicit drug. Short acting CNS stimulant. 1% of pregnant women use.
Amphetamines produce effects similar to cocaine but are longer acting. (AKA: speed, crystal, ice and ecstasy.)
Maternal Effects: Amphetamines Malnutrition Tachycardia Vasoconstriction
Fetal Effects: Amphetamines Withdrawal symptoms: -Lethargy -Depression IUGR Fetal death
Opioids include drugs such as morphine, heroin, methadone, meperidine, and oxycodone.
Maternal Effects: Opioids Spontaneous abortion PROM Preterm labor Increased incidence of -STDs -HIV exposure -hepatitis
Fetal Effects: Opioids -IUGR -Perinatal asphyxia -Intellectual impairment -Neonatal abstinence syndrome -Neonatal infections -Neonatal death (SIDS, child abuse and neglect)
Substance Abuse: Diagnosis Toxicology Screen. Assessment for STD, Hepatits, HIV. Fetal diagnostic tests. -NST, BPP
Substance Abuse during Pregnancy: Management Monitor weight Nutrition Methadone Relapse prevention Residential treatment Peer support groups
Abuse and Pregnancy Intimate Partner Abuse (IPV) Between 1% and 20 % during pregnancy
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.
Effects of IVP during pregnancy: Infants higher risk of prematurity, low birth weight, admission to neonatal ICU, and neonatal deaths
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
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.
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.
Category A no evidence of risk to the fetus exists.
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.
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.
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.
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.
Diabetes Mellitus During pregnancy Disorder of carbohydrate metabolism caused by partial or complete lack of insulin secretion by the beta cells of the pancreas
Diabetes Mellitus Classification Type I Type II Gestational Diabetes Mellitus (GDM) -A-1: diet controlled -A-2: diet and insulin controlled
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
Fetal or maternal death can be caused by Untreated ketoacidosis
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
Effects of Preexisting Diabetes on the Newborn: 4 Major Compications Hypoglycemia Hypocalcemia Hyperbilirubinemia Respiratory Distress Syndrome
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.
Treatments Identification of Gestational Diabetes Mellitus(GDM)-Done between 24 and 28 weeks -Prenatal screening test
DM Treatments: Insulin-1st trimester pre-existing diabetics may need less insulin
DM Treatments: Insulin-2nd & 3rd Trimester insulin needs increase steadily after the 1st trimester. Begun if fasting glucose > 95 or postprandial exceeds 120
DM Treatments: Insulin- After Delivery insulin needs should rapidly decline, but should still be checked at least 4 times a day.
Care of the Neonate Assess for complications A neonatal nurse and/or neonatologist may attend delivery
Nursing Care: Hypoglycemia Shakiness Sweating Pallor, cold, clammy skin Disorientation Headache Hunger Blurred vision
Nursing Care: Hyperglycemia Fatigue Flushed, hot skin Dry mouth, excessive thirst Frequent urination Rapid, deep respirations Drowsiness, headache Depressed reflexes
Heart Disease During Pregnancy Complicates about 1% of all pregnancies.
Most Common Cardiac Problems During Pregnancy Result from Rheumatic heart disease Congenital heart defects   Mitral valve prolapse (common but benign)
First warning signs of heart disease include: Dyspnea Syncope with exertion Hemoptysis Paroxysmal nocturnal dyspnea Chest pain with exertion
If mother's heart fails... Fetus suffer from reduced placental flow
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
Type of delivery recommended with heart disease Vaginal delivery
Anemia in Pregnancy Hemoglobin concentrations: -Less than 11g/dl in the 1st and 3rd Trimester. -Less than 10.5g/gl in the 2nd Trimester.
Anemia is... One of the most common problems of pregnancy.
Total iron requirement during pregnancy for single fetus is... 1000mg
Iron Deficiency Anemia: Maternal signs and symptoms -Pallor, fatigue, lethargy, and Pica -RBCs are microcytic and hypochromic -Profound maternal anemia reduces fetal oxygen supplies
Folic Acid is essential for synthesis of DNA, cell growth and duplication
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)
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.
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.
Beta Thalassemia Major (Cooley's anemia) trait is inherited from both parents.
Beta Thalassemia Minor trait is inherited from only one parent.
TORCH Toxoplasmosis Other diseases (hepatitis) Rubella Cytomegalovirus Herpes simplex virus
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.
Toxoplasmosis Fetal and Neonatal Effects Spontaneous abortion, still birth or neonatal death. Blindness Retardation Congenital anomalies Enlarged liver and spleen Anemia Low birth weight
Hepatitis B Facts Virus can be transmitted by blood, saliva, vaginal secretion, semen, breast milk, and it readily crosses the placenta.
Hepatitis B Symptoms May be asymptomatic or acutely ill with: -Chronic low-grade fever -Anorexia -Abdominal pain, nausea and vomiting -Jaundice -Joint pain
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.
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.
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
Rubella Transmitted by droplets or direct contact with articles contaminated with nasopharyngeal secretions. The virus can cross the placental barrier.
Rubella: Symptoms May cause mild fever, general malaise, mild lymphedema and a maculopapular rash that begins on the face and migrates over the body.
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
Cytomegalovirus Transmitted by contamination with body fluids containing the virus such as urine, saliva, blood, cervical mucus, semen, breast milk and stool. Usually asymptomatic.
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
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.
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.
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.
Herpes Fetal and Neonatal Effects: S/S Unstable temperature Lethargy Poor feeding Jaundice Seizures Lesions which resemble those of the adult
Syphilis Maternal Effects A chancre is the most common first manifestation
Syphilis Maternal Effects: Secondary Manifestations -Moist, raised gray to pink lesions of the genital or perirectal skin -Enlarged lymph nodes -Fever and fatigue
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
Syphilis Fetal and Neonatal Effects Transmitted transplacentally May produce: Spontaneous abortion Pre-term labor Stillbirth Congenital defects
Syphilis Fetal and Neonatal Effects: Exposure during 3rd Teimester Milder effects, such as: Enlarged liver and spleen Rash Jaundice Pneumonia Hepatitis
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
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. 
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
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).
Gonorrhea Treatment and Nursing Considerations Treat with antibiotics ceftriazone or azithromycin are the most commonly used Prophylactic eye treatment with erythromycin ointment at birth
Chlamydia Most common STD in the United States
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
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
Chlamydia Treatments Erythromycin (during pregnancy)   Tetracycline or azithromycin is used postpartum   Eye prophylactic antibiotics
Trichomoniasis: Incubation Period 4-28 days
Trichomoniasis: Transmission Sexual intercourse Dirty douche nozzles Douche containers Moist washcloths
Trichomoniasis: Maternal Effects Most are asymptomatic Frothy, gray-green, foul vaginal discharge Perineal itching Reddened skin
Trichomoniasis: Fetal and Neonatal Effects Does not cross the placenta; it thrives in vaginal mucosa Neonatal infection is short-lived Associated with premature ROM
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
Condylomata Acuminata (Genital Warts) Caused by the Human Papillomavirus (HPV)
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
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
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
Candidiasis Maternal Effects Change in the vaginal environment that favors growth of fungi.
Candidiasis Maternal Effects: Occurance Pregnancy Diabetes Mellitus when the glucose level increases Radiation, immunosuppressant drugs or antibiotic therapy Oral contraceptive use in nonpregnant woman
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
Candidiasis Neonatal Effects Oral Thrush Diaper rash Edematous nails Edematous tongue
Candidiasis Treatment Includes controlling the underlying condition Miconazole or clotrimazole Oral nystatin
Bacterial Vaginosis (BV): Maternal Effects Profuse vaginal discharge with fishy odor Itching and burning
Bacterial Vaginosis (BV): Neonatal Effects Fetus is usually unaffected
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
Group Beta Streptococcus Infection (GBS) GBS is a nonviral infection that is a leading cause of life-threatening perinatal infections in the U.S.
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.
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.
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.
Urinary Tract Infections (UTIs) Is the presence of microorganisms in the urinary tract. Bacteria is the most common
AIDS breakdown in the immune function caused by the Human Immunodeficiency Virus (HIV).
AIDS Maternal Effects HIV positive women are at an increased risk of preterm labor, premature ROM, IUGR, perinatal mortality and postpartum endometritis.
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.
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
AIDS Fetal and Neonatal Effects: Newborns Prognosis Infected infants have a short survival time, about 4 years
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
Created by: jtzuetrong