NURSING CARE OF THE HIGH RISK PREGNANT CLIENT (PRE-GESTATIONAL CONDITIONS)

Maternal and Child Health Nursing

L E C T U R E

HIGH-RISK PRENATAL CLIENT • STIs and other infections

• Major congenital anomalies of the reproductive
High-Risk Pregnancy – is one in which a tract
concurrent disorder, pregnancy-related • Hemoglobinopathies
complication, or external factor jeopardizes the
• Seizure disorder
health of the woman, the fetus, or both
• Malignancy
Mother and fetus has a significant increased chance • Major emotional disorders, mental retardation
of harm, damage, injury, or disability (morbidity), and
loss of life or death (mortality).
F. Habits/ Lifestyle
• Smoking during pregnancy
RISK FACTORS • Regular alcohol intake
• Drug use/abuse
A. Demographic Factors
Age: <16 or over 35 (optimal age: 20- 30yo) IDENTIFYING CLIENTS AT RISK
Weight: overweight or underweight
Height: <5 feet
• It begins with the 1st prenatal visit & continues
throughout the pregnancy
B. Socioeconomic Status
• It involves subjective as well as objective
• Inadequate finances
assessment techniques such as screening
• Overcrowding, poor standards of housing
procedures, laboratory and diagnostic
• Nutritional deprivation
examinations
• Severe social problems
• Unplanned & unprepared pregnancy, esp.
STANDARD EXAMINATIONS DONE IN A PRENATAL
adolescents
VISIT
C. Obstetric History
• Hx of infertility or multiple gestation • Complete Blood Count- screens for anemia
• Grand multiparity • Edema Check
• Previous abortion or ectopic pregnancy -normally in LE (if found on leg; in arms
• Previous losses: fetal death, stillbirth, neonatal & feet, may indicate preeclampsia)
deaths • Fetal heart Rate (N= 120-160 bpm)
• Previous operative OB: CS, forceps delivery • Fundic Height- measured from 22-34 weeks &
• Previous uterine/cervical abnormality correlates with gestational age with normal
• Previous high-risk infant: LBW, LGA, birth pregnancy
injury or malformation • Height- during initial visit
• Previous hydatidiform mole • Leopold’s Maneuver
• Pelvic adequacy examination
D. Current OB Status • Urinalysis and culture
• Late or no prenatal care -screening for asymptomatic bacteruria
• Maternal anemia as early as 1st prenatal visit; if (+),
• Rh sensitization culture is done Vital Signs
• Antepartal bleeding; placenta previa, AP • Weight- pattern of weight gain/loss is recorded
• PIH • NST
• Multiple gestation • OCT/CST
• Premature or postmature labor • Biophysical profile test (BPP)
• Polyhydramnios • X-ray: Lateral pelvimetry
• PROM • Cord Villi Sampling (CVS)
• SGA, LGA, abnormality in tests and • Amniocentesis
presentation • Percutaneous Umbilical Blood Sampling
(PUBS)
E. Maternal medical Hx/status
• Cardiac/pulmonary disease PREGESTATIONAL CONDITIONS
• Metabolic disease: DM, thyroid disease CARDIOVASCULAR DISEASE
• Endocrine disorders: pituitary, adrenal
• Chronic renal disease: repeated UTI, Effects of Pregnancy on Heart Disease
bacteriuria 1. Increase BV & Cardiac output
• Chronic hypertension -BV peaks at 24-28 weeks

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 NURSING CARE OF THE HIGH RISK PREGNANT CLIENT (PRE-GESTATIONAL CONDITIONS)
Maternal and Child Health Nursing
L E C T U R E

-Cardiac output increases 50% • Heart surgery

-heart must contract harder& faster
-postpartum-bleed circulating in the CLASSIFICATION OF HEART DISEASE
uterus & placenta returns to maternal
circulation
CLASS DESCRIPTION
Team approach to care during pregnancy
I – 80% Uncompromised. No activity limitation.
Ordinary physical activity causes no
(internist, OB and nurse) discomfort. No symptoms of cardiac
insufficiency & no angina pain
Most dangerous period is in weeks II Slightly Compromised. Slight activity
28 to 32, just after the BV peaks, limitation. Asymptomatic at rest but
earlier in more severe cases ordinary physical activity causes
excessive fatigue, palpitation & dyspnea
or anginal pain
Most Commonly Cause
III Markedly Compromised. Marked
Difficulty During Pregnancy limitation.
• Valve Damage due to Kawasaki Disease or During less than ordinary activity, woman
experiences excessive fatigue,
Rheumatic Fever palpitations, dyspnea or anginal pain
• Congenital Anomalies such as ASD or IV Severely compromised. Marked
Uncorrected Coarctation of Aorta limitation. Woman is unable to carry out
• Aortic Dilatation any physical activity without experiencing
discomfort. Even at rest, symptoms of
• Marfan Syndrome cardiac insufficiency or anginal pain are
present

PROGNOSIS & MANAGEMENT

CLASS PROGNOSIS / MANAGEMENT

CLASS I Good. Does not interfere with ADLs
& generally do well during pregnancy
CLASS II Good. Require close supervision. If
symptoms worsen, notify HCP; may
require bedrest & hospitalization if
decompensation occurs
CLASS III Moderate. May require bed rest & digitalis
from week 20 to delivery. During labor,
hemodynamic monitoring & special
anesthetic management
CLASS IV Poor. Cardiac condition must be corrected
by surgery during pregnancy. Therapeutic
abortion if <14 weeks if condition is
uncorrected, then, sterilization.
Hemodynamic monitoring until fetus is
viable for delivery.

ASSESSMENT-DIAGNOSTIC TESTS
• ECG
• Echocardiography
• Echocardiogram (ultrasound of the heart)

CRITERIA FOR ESTABLISHING DIAGNOSIS OF

HEART DISEASE
• Persistent murmurs
• Permanent cardiomegaly
Risk Factors • Severe dysrhythmias
• Rheumatic fever- 90% of all cases • Severe dyspnea
• Congenital heart defects
• Arteriosclerosis SIGNS OF CARDIAC DECOMPOSITION
• MI: pregnancy is generally contraindicated with • Moist cough
previous MI and who have severe L ventricular • Pedal edema: signs of pulmonary edema
damage & heart failure • Dyspnea, increasing with activity
• Pulmonary disease
• Tachycardia
• Renal diseases

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Maternal and Child Health Nursing
L E C T U R E

• Tachypnea -types: tablet, patch, cream, sublingual

• Chest pains on exertion
Corticosteroid- help to reduce the formation of
• Cyanosis additional antibodies in a PLA
• Persistent heart murmurs
Other signs: INTRAPARTUM PERIOD GOALS
• Syncope w/ exertion Minimize hemodynamic changes & optimize perfusion
• Cyanosis
• Clubbing of fingers • Minimize changes in BP & PR
• Neck vein distention – Lateral position
• Cardiomegaly – Adequate pain relief: regional
• Pulmonary hypertension anesthesia during labor
Safety alert: presence of severe dyspnea, syncope – Avoidance of hemorrhage
with exertion, hemoptysis, nocturnal tachycardia and – Avoidance of infection
angina require prompt evaluation
• Forceps or vacuum extraction to avoid
prolonged Valsalva maneuver & to shorten 2nd
MANAGEMENT
stage of labor (Assess NB for Bell’s Palsy)
• Elective CS in some specific cardiac
A pregnant woman w/ heart dieases should avoid complications
infection, excessive weight gain, edema and anemia
because these conditions increase the workload of
the heart NURSING IMPLEMENTATION
• Encourage early, regular prenatal visits
Treatment/Management: Individualized • Encourage compliance with therapeutic
• Frequent prenatal visits regimen
• Rest, physical and mental: • Decrease workload of the heart:
-Sleep at least 8-10 hrs at night & 2 rest – adequate rest & sleep,
periods during the day – avoid/treat early anemia and
-Instruct client to lie down for 30 mins infections,
after meals – prevent exhaustion, fatigue, stress
-Allow only light work, no stair climbing, • Avoid activities that decrease oxygenation:
no exhaustion smoking, overcrowded places, infection
-Activity limitation esp for Class 3 & 4 • Avoid constipation: increase fiber and fluids,
-Severely affected clients may need to exercise (walking is best)
be admitted as early as mid-2nd • Proper nutrition
trimester -High in Fe, protein, minerals & vitamins
• Digitalis. Withhold if PR <60bpm or >100bpm -Limit sodium intake after 8-12 weeks to
•Diuretics. If K-excreting (e.g. Furosemide avoid fluid retention
(Lasix)) -Weight gain of no more than 24 lbs to
SE: hypokalemia increases the risk for digitalis avoid increase in cardiac workload
toxicity; report signs like bradycardia, N/V, • Early hospitalization: *Severely affected clients
diarrhea, colored vision (xanthopsia) may need to be admitted as early as mid-2nd
•Antibiotics- before any invasive procedure; trimester”
prophylaxis vs. RF; treatment of bacterial
infection CARE DURING LABOR
• Iron supplement- prevent/treat anemia • Thorough physical assessment - report
• Oxygen as necessary changes
• Anticoagulant-Heparin/Enoxaparin to prevent • Position: lateral, Semi-Fowler’s with hands and
clot formation with DVT and Pulmonary Emboli legs supported
as complication • Administer O2 per mask
• Nitroglycerine- relieves angina by vasodilation • Strict asepsis to prevent infection
-take: 5 min before effort • Monitor I & O to prevent fluid overload
-how often: q 5 mins up to 3 tabs, if not • Observe NPO
relieved after 15 mins, go to ER • Provide emotional support
-take tablet while sitting down • Continuous cardiac monitoring
-storage: covered, replace q 3 mos PR is the most sensitive & reliable indicator of CHF.
-Side Effects: hypotension, Headache, Report if PR is >200bpm and RR>24/min
flushing, burning & stinging sensation • Anticipate episiotomy & Forceps delivery
under the tongue • Prepare for regional anesthesia

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Maternal and Child Health Nursing
L E C T U R E

• Administer drugs as ordered: digitalis, diuretics lactation

& antibiotics

POSTPARTAL CARE
• Cardiac failure more likely in the early
postpartal period because of: loss of placental
circulation, rapid decrease in intraabdominal
pressure lt vasocongestion and increase in
cardiac output
• Monitor blood loss, I & O, & fluid rate flow
• Assess for signs of bleeding, sepsis & CHF
• Provide for non-stressful mom-infant
interaction GESTATIONAL DIABETES
• Provide other care ant frequent rest periods This is DM that develops during pregnancy and
• NO Oral contraceptive pills for patient with DVT spontaneously resolves after delivery
• Lower legs promptly to reduce burden of the
heart. MATERNAL COMPLICATIONS OF
• Promote rest GESTATIONAL DM
• Hospitalization until stable • Predisposes to PIH, UTI,
• Early but gradual ambulation • Infections: candidiasis, UTI
• Meds: antibiotics, stool softeners, sedatives • Uteroplacental insufficiency
• Breastfeeding allowed in Class I & II if no • Dystocia due to large infant CS delivery
decompensation during pregnancy and labor • PTL, CPD
• Counsel re sterilization for Class II-IV if not • PP hemorrhage due to uterine atony
corrected •More difficult to control DM-hypo/hyperglycemia
• Maternal mortality
DIABETES MELLITUS • Diabetic retinopathy
Description: • Diabetic nephropathy
• An endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate FETAL COMPLICATIONS
body glucose levels • Macrosomia---birth injuries
• Disorder in CHO, CHON and fat metabolism • IUGR dt placental insufficiency
• Pregnancy is a diabetogenic state due to the • Fetal hypoxia, IUFD, stillbirths
profound effect of hormones (HPL), which • 1st trimester: spontaneous abortion or fetal
increases insulin-resistance anomalies
• Hydramnios
RISK FACTORS OF DM • Prematurity
• Family history • Neonatal hypoglycemia as soon as 1 hr
• Rapid hormonal changes in pregnancy postpartum
• Tumor/infection of the pancreas • RDS
• Hyperbilirubinemia
• Obesity
• Hypocalcemia
• Stress
• Birth defects: heart, brain & spine, kidney, GIT

NORMAL METABOLIC CHANGES IN

PREGNANCY THAT AFFECT DM

• Increase insulin antagonistic hormones:

cortisol, E, P and HPL
• Lowered renal threshold for sugar, increased
GFR lt GLYCOSURIA
• Excess glucose crosses placenta lt LGA
• Vomiting decreases CHO intake is link to
metabolic acidosis

• Labor activity requires increased CHO intake

• Hypoglycemia postpartum due to involution &

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 NURSING CARE OF THE HIGH RISK PREGNANT CLIENT (PRE-GESTATIONAL CONDITIONS)
Maternal and Child Health Nursing
L E C T U R E

– 50g oral glucose challenge (if >140 mg/dl,

needs 3-hr GTT)

• Glucose Tolerance Test (GTT)

– 100 g GTT bw week 28-34
– Glucose levels at 1,2 & 3 hrs
*Results:GDM if FBS>95 or 2 results are high
*Normal: FBS(95 mg/dl)
1h (180 mg/dl)
2h (155 mg/dl)
3h (140 mg/dl)

• 2-hr Postprandial Blood Sugar (PPBS)

– Abn Result: >120 mg/dL
*Goals: FBS <105 mg/dL, PPBS <120 mg/dL

• Glycosylated Hemoglobin(HgbA1c)
(maternal hb irreversibly bound to glucose)
– Measures long-term(3 mos)
ASSESSMENT FINDINGS compliance to treatment
HISTORY – N: 4%-8%
• Family hx of DM, previous GDM • Urine Glucose monitoring is inaccurate
• Previous LGA (4k or more)
• Previous infant with congenital defects, TREATMENT OF HYPOGLYCEMIA
hydramnios • Consume 15-20 g glucose or simple CHO
• Spontaneous abortion, fetal deaths, stillbirth – Glucose tabs, 2 tbsp raisins, 4 oz (1/2
• Obesity c juice or soda), 8 oz nonfat milk, 1 Tbsp
• Frequent candidiasis sugar, honey or corn syrup, hard
• Marked abdominal enlargement (hydramnios & candies, jellybeans or gumdrops
LGA) • Recheck blood glucose after 15 mins.
• Signs of hyperglycemia
– Polyphagia Emergency drug: GLUCAGON IM into buttock,
arm or thigh to stimulate liver to release stored
– Polyuria glucose into the bloodstream
– Polydipsia
• Weight loss fat and CHON stores used for DO NOT:
energy Inject insulin
provide food or fluid if unconscious
• Increased blood and urine glucose put hands in mouth

SIGNS OF HYPOGLYCEMIA NURSING IMPLEMENTATION

REMEMBER: “Cold and Clammy need some Candy” • Participate in early detection.
• Sweating with cold, clammy skin • Encourage early prenatal management &
• Pallor supervision
• Tremors, shakiness -Regular prenatal check-up
• Hunger & nausea -Record dietary intake & monitor
• Irritability or impatience, anger glucose levels
• Confusion, indicating delirium -Insulin when FBS is not consistent at <
• Tachycardia 105 mg/dL or 2-hr PPBS is not
• Nervousness, anxiety <120mg/dL
• Sleepiness -Serial UTZ- from 28-34 weeks if DM
• Blurred vision poorly controlled or with complications
• Seizures -Hospitalization- if DM is poorly-
• unconsciousness controlled, with HPN and infection
• Provide teaching:
DIAGNOSIS - Nature, effects of DM
• Screening Test – Signs & symptoms of
– At 26-28 weeks for high-risk women hypo/hyperglycemia
-Exercise to regulate glucose levels

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Maternal and Child Health Nursing
L E C T U R E

-Insulin regulation/self-administration – Good test to assess effectiveness of

-Prompt reporting of danger signs and treatment
signs of infection – Abnormal: >7% of total hemoglobin
• Promote control of DM
– Diet: 1800 to 2,200 cal/day or 35 • Clinic visit every 2 weeks up to 36
kcal/kg BW 12%-20& CHON, 40%-45% weeks
CHO, 40% from Polyunsaturated fatty • Exercise lowers glucose levels
acids (PUFAs) – Ingest protein or complex
Use Diabetic food exchange list CHO prior to exercise
Weight gain not > 24 lbs. • Diet:
• Exercise: decreases need for insulin but may – 1800 to 2,200 cal/day or 35
cause hypoglycemia if excessive kcal/kg BW
– No exercise when glucose levels are – 12%-20& CHON, 40%-45%
low or stomach is empty CHO, 40% from PUFAs
– Don’t administer insulin in extremity – Use Diabetic food exchange
used in exercise list
– Don’t exercise alone – Weight gain not > 24 lbs.
– always carry diabetic ID • Instruct on signs of hypoglycemia (due to
• Insulin Therapy excessive
– No OHA insulin, exercise or insufficient dietary intake):
– Insulin req drops during 1st trimester, – Pallor
increased in 2nd & 3rd tri(tripled); – Weakness, numbness
increased chance of ketoacidosis – Headache
– Regular & NPH(Isophane) insulin; only – Confusion or irritability
regular insulin IV during labor to prevent – Blurred vision
ketoacidosis – Perspiration
– Humulin (DOC)- least allergenic – Hunger
– Split-dose therapy: regular & – Convulsions, coma
intermediate combi; 2/3 daily dose Management: Give CHO foods like fruit juice, cola,
before breakfast at 2:1 ratio (interm to sugar, candy
reg);1/3 30 mins before dinner(1:1) • Self-monitoring of Blood glucose at least TID
– Desired values:
DIABETIC KETOACIDOSIS – before meal: 95 mg/d
-diagnosed when glucose >300 – 1 hr after meal: <140 mg/d
mg/dL, (+) serum ketones are at level – 2 hrs after meal <120 mg/dl
1:4 & metabolic acidosis is present • Fetal Well-being Monitor
-Causes: poor compliance, infection, – Alphafetoprotein level at 15-17 wks
HG, use of drugs like corticosteroids,+ – Ultrasound at 18-20 weeks and
acetone breath monthly to rule out deformities,
-Fetal effects: 20% perinatal mortality hydramnios,
– NST starting at 34 wks(if abnormal,
• Prevention of infection, stress, which leads to CST, BPP)
hyperglycemia, which increases the need for – Daily kick counts from wk 28(N=10/hr);
insulin report if less
• Encourage assessment of fetal well-being: – L/S Ratio starting 34-36 weeks
ultrasound, amniocentesis(L/S ratio), (N=2.5-3:1)
phosphatidyl glycerol( fetal lung maturity), NST, – Creatinine clearance to monitor
CST, BPP perfusion
• Early labor induction or CS in the presence of
fetal distress ( 36-37 weeks) CARE DURING LABOR AND DELIVERY
• Plan to deliver bw 36-40 weeks when fetus is
MANAGEMENT mature enough but not too large to cause CPD
• Maintain normal FBS, Hba1c(N=6%) • L/S ratio should be 2.5-3.5:1
– Glycosylated hemoglobin measures • Vaginal delivery is preferred
the amount of glucose attached to the • Regular insulin on labor day because need for
RBC & reflects average measurement of insulin drops immediately pp and may not need
the glucose levels over the past 4-6 insulin in the 1st 24 hrs pp. Monitor glucose
weeks levels.

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Maternal and Child Health Nursing
L E C T U R E

NEWBORN CARE – Low socioeconomic status

• Keep warm. SIGNS AND SYMPTOMS OF IDA
• Observe respiration since hydramnios inflates • Easy fatigability
stomach and may interfere with lung expansion • Sensitivity to cold
• Dizziness
• Observe for hypoglycemia (shrill cry, tetany, • Brittle, flattened nails
tremors), BF or give glucose water • VS: rise in systolic pressure, tachycardia,
• Observe for hypocalcemia (tetany, tremors), tachypnea
give Calcium gluconate
• Observe for congenital anomalies: esophageal DIAGNOSIS
atresia, NTD Lab findings:
-low hemoglobin <10 g/100ml
CONTRACEPTION -low hematocrit <37% in the 1st
• No IUD- high incidence of PID trimester, <35% in the 2nd tri and <33%
• No COCs- P interferes with insulin and E in the 3rd triimester
raises lipid, cholesterol levels & affect blood -Serum ferritin < 100 mg/dl
coagulation -Serum Fe level < 30 ug/dl
• Norplant or progestin only pills (minipills) -Hypochromic, microcytic RBCs
may be used safely by diabetic women
EFFECTS OF ANEMIA DURING PREGNANCY
ANEMIAS OF PREGNANCY • Decreased resistance to infection
ANEMIA - is a condition of too few RBCs, or a • Associated with prematurity & LBW infants
lowered ability of the RBCs • Predisposes to heavy bleeding during labor &
delivery
Most Common Types during Pregnancy: • Associated with PICA
• Iron deficiency Anemia
• Vitamin B12 Anemia
MANAGEMENT
• Anemia due to Blood Loss
• Promote balance of activity & rest with
• Folate Deficiency
avoidance of fatigue
• Oral Fe supplementation:
RISK FACTORS – 120-180 mg/day.
• Poor nutrition – Ferrous sulfate is the most absorbable
• Excess alcohol consumption form;
• Illnesses that reduce absorption of nutrients – must be continued 3 months after
• Use of anticonvulsant drugs (tegretol, lithium, anemia has been corrected
carbamazepine, etc.) • Increase intake of Fe-rich foods:
• Previous use of oral contraceptives – Red meats: liver, beef, heart &
• G6PD Deficiency kidneys, poultry, fish,
– Egg yolk
COMPLICATONS OF ANEMIA – GLV
• Premature labor – Dried fruits: raisins
• Intrauterine growth retardation (IUGR) – legumes, yeast, whole grains, nuts,
• Dangerous anemia from normal blood loss dried beans
during labor, requiring transfusions • Provide instructions:
• Increased susceptibility to maternal infection – Fe causes tarry stool
after childbirth – Fe causes constipation: inc fiber &
fluids
IRON DEFICIENCY ANEMIA – Fe causes GI discomfort: take with
• Most common type, develops in the 2nd & 3rd meals
trimester when the iron requirements increase to – Better absorption if taken 1 hr before
compensate for the expanding blood volume or 2 hrs after meal
• Predisposing factors: – Fe is best absorbed in acid medium
– Poor diet & poor nutrition – Never take with milk & Ca
– Heavy menses supplements
– Successive pregnancies w/in 2 yrs or – In liquid form, use straw to prevent
<6 mos interval teeth staining
– Unwise reducing programs

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 NURSING CARE OF THE HIGH RISK PREGNANT CLIENT (PRE-GESTATIONAL CONDITIONS)
Maternal and Child Health Nursing
L E C T U R E
MEGALOBLASTIC ANEMIA SIGNS AND SYMPTOMS OF FADA
Types: • Nausea
Folic Acid Deficiency/ • Vomiting
(Pernicious anemia) • Anorexia

Vit B12 Deficiency/ MANAGEMENT OF FADA

(Addison Pernicious Anemia) • Treatment: FA supplements 1 mg/day with oral
FE
• Prevention: 400 ug FA for all women of
childbearing age & during pregnancy
• Sources:
– Dark green leafy vegetables
– Dried beans & peas
– Citrus fruits & juices and most berries
– Fortified breakfast cereals
– Enriched grain products

FOLIC ACID VS FOLATE HEMOLYTIC DISEASE

Folate is the common form of vitamin • HDN is caused by either Rh or ABO
B9 present in many whole foods, incompatibility
including leafy greens, beans, eggs, • Mother produces antibodies that destroy
citrus fruit, avocados, and beef liver. RBCs of the fetus; hemolysis results in fetal
anemia and hyperbilirubinemia
Folic acid is a synthesized version of
vitamin B9 that is added to processed
foods and the common version used in
supplements.
Vitamin B12 is essential for:
Red Blood Cell formation
Neurological function
DNA synthesis
FOLIC ACID DEFICIENCY ANEMIA
• Folic Acid is necessary for normal formation of
RBC and in the prevention of NTDs
– Deficiency leads to formation of large
& immature RBCs with shorter lifespan
– FADA develops if diet is mostly meat ABO INCOMPATIBILITY
with little green leafy vegetables • Occurs when maternal blood type is O and
Effects on Pregnancy: fetus is
-abortion a. Type A- most common
-abruptio placenta b. Type B- most serious
-NTD c. Type AB- rare
Most often seen in: • The mother has inborn antibodies vs blood
• Multiple pregnancies because of the increased type A and B in her bloodstream. If fetus has
fetal demand type A or B blood and if maternal and fetal blood
• Women with secondary hemolytic illness mix, maternal antibodies will perceive the fetal
• Women who are taking Hydantoin RBC as an antigen and will destroy it
• Poor gastric absorption due to gastric bypass • Uncommon during pregnancy since antibodies
for morbid obesity is the large IgM type & cannot cross placental
barrier
• During delivery when placenta separates from
the decidua, the barrier is broken allowing
maternal blood to enter the fetal bloodstream .
• Maternal antibodies will then destroy fetal
RBCs after birth
• Thus, signs of hemolytic disease will manifest
several hours after delivery

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the mother or the father or both parents are Rh+,

the baby will be Rh+

Rh Sensitization/ Rh Isoimmunization

• It is the exposure of Rh- blood to Rh+ blood

resulting to production antiRh abs
• It can occur through:
– Sensitization fr previous pregnancy
(Rh- mom with Rh+ baby)
– Inadequate response to prophylaxis
– Incompatible blood transfusion

• Insignificant amounts of antibodies are formed

during pregnancy thus, 1st baby is not greatly
affected.
• Greatest exposure occurs during placental
CLINICAL MANIFESTATIONS
separation which causes massive production of
Clinical features of Hemolytic Disease
anti Rh abs during 1st 72 hours postpartum
• Rh+ fetuses in future pregnancies will be
Clinical Features Rh ABO
affected
Frequency Unusual Common
Anemia Marked Minimal • Fetal anemia results & to compensate, fetal
Jaundice Marked Minimal to bone marrow produces immature RBCs
Moderate (erythroblasts) causing ERYTHROBLASTOSIS
Hydrops Common Rare FETALIS
Hepatosplenomegaly Marked Minimal
Kernicterus Common Rare

• Fetal anemia may be so profound tha it kills

the fetus
RH INCOMPATIBILITY • RBC destruction causes massive production &
Rh (D) factor is a protein antigen present on the accumulation of bilirubin as the immature liver is
surface of some people’s RBC (Rh+) unable to clear them from the body leading to
• Antibodies vs Rh antigen are not naturally- HYPERBILIRUBINEMIA & KERNICTERUS
occurring but are produced when Rh+ blood
enters the bloodstream of an Rh- person
• The Rh + gene is a dominant and therefore if
either

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SUBSTANCE ABUSE
• 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: cocaine,
amphetamines, marijuana, alcohol, inhalants,
opiates, phencyclidine
FETAL COMPLICATIONS OF
ERYTHROBLASTOSIS FETALIS COCAINE
• Anemia • most frequently abused drug during pregnancy,
• Splenomegaly & hepatomegaly • causes extreme vasoconstriction severely
• Hyperbilirubinemia compromising fetal circulation leading to
• Hydrops fetalis- as organs are not perfused premature separation of the placenta resulting
properly, the heart will eventually to PTL or fetal death
decompensate; fluid builds up resulting to • Fetal withdrawal symptomsof COCAINE:
edema – tremulousness,
• Stillbirth – irritability,
PREVENTION – muscle rigidity,
• Prenatal Screening – learning defects (later on in life),
– History: past pregnancies, BT, – intracranial hemorrhage
abortion, invasive diagnostic procedures • Detected by urinalysis
during pregnancy
– Blood typing & Rh typing AMPHETAMINES-METHAMPETAMINES (SPEED)
– Coomb’s test (titer >1:16 indicates has effects similar to cocaine
sensitization); indirect CT(maternal • NB symptoms:
serum), direct CT(cord blood); if – jitteriness,
negative, test at 16 to 20 wks and at 26- – poor feeding,
27 weeks – growth restriction
– Give RhIg aka anti Rho(D) gamma
globulin(RhoGAM) at 28 wks and within MARIJUANA OR HASHISH
72h after delivery when smoked causes tachycardia & a sense of
• RHOGAM should be given to all Rh- women well-being
who: • Used to counteract nausea in early pregnancy
– Have delivered Rh+ babies • Effects:
– Have had untypeable pregnancies – loss of short-term memory,
such as ectopic pregnancies, stillbirth & – reduced milk production
abortion – Inc incidence or respiratory infection
– Have received ABO compatible Rh+ – Excretion of drug in breast milk
blood
– Have had invasive dx procedures like PHENCYCLIDINE (PCP)
amniocentesis, CVS • animal tranquilizer frequently used as a street
MANAGEMENT drug
• Amniocentesis q 2 weeks beginning at 26 wks • increases cardiac output & gives a sense of
to monitor bilirubin euphoria
• Percutaneous umbilical blood sampling at 18 • Causes hallucinations (flashback episodes)
20 weeks if bilirubin levels are high • Tends to leave the maternal circulation &
• Intrauterine Blood fetal transfusions(IUFT) at concentrate in fetal cells
10-day to 2 week intervals until 34-36 weeks
NARCOTIC AGONISTS
• used for pain (morphine or meperidine), cough

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L E C T U R E

suppression (codeine); is a potent analgesic and • Diarrhea

provides euphoric effect. • Weight loss
• HEROIN- main opiate used recreationally & is • Lymphadenopathy
used ID(skin-popping), by snorting or IV • Night sweats
(shooting)
– Produces immediate but short-lived STAGES
euphoria followed by sedation • Initial invasion of virus with mild, flulike
symptoms
• Seroconversion- production of antibodies vs
HIV; happens in 6 weeks to 1 year
• Asymptomatic period for 3 to 11 years
• Symptomatic period with opportunistic
infections & possibly malignancies (CD4 cell
count <200cells/mm3
– Toxoplasmosis tuberculosis
– Oral & vaginal candidiasis
– GIT illnesses
• Withdrawal symptoms: N/V, diarrhea,
– Kaposi sarcoma
abdominal pain, HPN, restlessness, shivering,
– P. carinii pneumonia (PCP)- most
insomnia, body aches, muscle jerks
common opportunistic infection
• Fetal effects: SGA, increased incidence of
– Herpes simplex
fetal distress & meconium aspiration,
– HIV-associated dementia
• Management: methadone maintenance
program during pregnancy
KAPOSI SARCOMA
A cancer that develops from the cells that line
INHALANTS
lymph or blood vessels. It usually appears as
airplane glue, cooking sprays, computer
tumors on the skin or on mucosal surfaces such
keyboard cleaner
as inside the mouth, but these tumors can also
– Refer to sniffing or huffing of aerosol drugs
develop in other parts of the body, such as in the
– May lead to severe cardiac and respiratory
lymph nodes (bean-sized collections of immune
irregularities
cells throughout the body), the lungs, or
– May limit fetal O2 supply
digestive tract.

ALCOHOL
FAS, cognitive challenges an memory deficits

HIV / AIDS
ETIOLOGIC AGENT:
- retrovirus that targets helper T
lymphocytes (T4 cells) that contain the
CD4 antigen (which regulates normal
KS is caused by infection with human
immune response) making the patient
herpesvirus-8 (HHV-8). Most people infected
susceptible to opportunistic infections
with HHV-8 don't get KS. It usually happens in:
• Present in infected person’s blood, semen, and
other body fluids
- People with weak immune systems, due
to HIV/AIDS, drugs taken after an organ
RISK FACTORS
transplant, or another disease
• Multiple sexual partners of the individual or
- Older men of Jewish or Mediterranean
sexual partner
descent
• Bisexual partner, MSM
- Young men in Africa
• IV drug use by the individual or partner
-
• Others: BT, tattoo, etc
PNEUMOCYSTIS CARINII PNEUMONIA
Pneumocystis carinii pneumonia (PCP) is an
ASSESSMENT
opportunistic infection that occurs in
Early Symptoms:
immunosuppressed populations, primarily
• Fatigue
patients with advanced human
• Anemia
immunodeficiency virus infection.

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 NURSING CARE OF THE HIGH RISK PREGNANT CLIENT (PRE-GESTATIONAL CONDITIONS)
Maternal and Child Health Nursing
L E C T U R E

ASSESSMENT
• ELISA test- if (+) 2x then
• Western Blot Test- confirmatory test
• In late infection, CD4+ T cell count <200cells/ul
• Presence of opportunistic infections
• 20-50% of infants born to untreated HIV +
women will contract the virus & develop
AIDS in the 1st year of life

MANAGEMENT
• Monitor CD4+ T cell counts.
• Goal: maintain CD4 cell count > 500 cells/mm3
• Antiretroviral therapy: oral ZVD during
pregnancy & IV during labor & delivery) plus1 or
more protease inhibitors like ritonavir (Norvir) or
indinavir (Crivixan) in conjunction with a
nucleoside reverse transcriptase inhibitor drug.
• Neonate is also given zidovudine
• Breastfeeding is not recommended
• Educate client on safe sex practices, testing of
sex partners
• Monitor client for signs of opportunistic
infection: fever, weight loss, fatigue, candidiasis,
cough, skin lesions
• CS delivery- performed before rupture of
membranes
• If vaginal delivery is unavoidable, no
episiotomy!

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