Programs, Trends, and Issues in Maternal
Health Populations and Development
Introduction
• In 1990s
– Every minute, a woman dies in
childbirth or from complications
of pregnancy
– > 500,000 women die each
year; almost all (95%) occur in
developing countries
– For every woman who dies as
many as 30 others suffer chronic
illness or disability
– Maternal mortality is the health
indicator with the most disparity
between developed and
developing countries
• The cumulative lifetime
risk of dying as a result
of pregnancy is 1:2800
in developed versus
1:16 in developing
countries
Introduction
– Maternal mortality trends are
unacceptable, but not
insurmountable because the
major causes are known and
avoidable
• Nearly 2/3 of maternal
deaths are due:
– Hemorrhage
– Obstructed
labor
– Pregnancy-
induced
hypertension
– Sepsis/infection
– Complications
of unsafe
abortion
– Interventions can be made
available even in resource-poor
settings
1987 – Safe Motherhood Initiative
1990 – World Summit for Children
1994 – International Conference on
1995 – 4th World Conference on Women
2000 – Millennium Summit/Declaration
• Why aim for maternal survival?
1. Moral imperative
– The death of a woman during
pregnancy or childbirth is a
violation of her rights to life and
health
– Governments must promote
dignity and equity for women
within the health-care system
– Social implications
• Maternal death or
disability can plunge
families into poverty
and deeper despair;
surviving children esp.
those < 5 years old are
at risk of dying since no
one will attend to their
needs
• The loss may
reverberate throughout
an entire community
• Maternal death
• Ways in measuring progress in reducing
maternal mortality
• Methodological issues in
measuring maternal mortality
1. It is a rare event and therefore its
number may not be large enough to
detect statistically significant changes
over time
2. Underreporting – especially if most occur
outside of health facilities (in the
absence of health personnel to report
them)
3. Misreporting because of the complicated
definition requiring also its cause and
timing OR sometimes done intentionally
to avoid legal action
• Trend in MMR
• Lessons learned
 • Most maternal deaths and disabilities Lack of support people
would be averted if...
PSYCHOLOGICAL FACTOR
– All pregnancies are wanted and
Cognitively challenge
planned
Single / Separated mothers
– All pregnancies are adequately
managed throughout its course Victims of Abuse, domestic violence, rape,
incest
– All births are attended by
skilled health professionals Mental Retardation
(ideally facility-based)
Environmental factors
– All complications are managed
in adequately-staffed and Exposure to Teratogens due to employment
equipped facilities offering
Environmental contaminants at home
emergency obstetric care
Poor Housing
• Strategies to reduce maternal mortality
CARING FOR A WOMAN WHO DEVELOPS A
1. Universal access to contraceptive
COMPLICATION OF PREGNANCY:
services to reduce unintended
pregnancies Assessment
2. Skilled attendance at all births Provide enough time for a thorough health
history.

Problems such as headache, blurred vision,

Nursing care of the High Risk Pregnant Client vaginal spotting should be discovered and
investigated thoroughly
High risk pregnancy
Common nursing diagnosis
One in which a concurrent disorder,
pregnancy related complications or external Anxiety related to guarded pregnancy
factor jeopardize the health of the woman, outcome
the fetus or both
Risk for infection related to incomplete
Risk factors miscarriage
Physiological Deficient knowledge related to signs and
symptoms of possible complications.
Socio demographic
Risk for ineffective tissue perfusion related to
Psychological
pregnancy-induced hypertension.
Environmental
Ineffective role performance related to
Physiologic increasing level of daily restrictions
secondary to chronic illness and pregnancy
Concurrent illness
IMPLEMENTATION
Malnutrition
Interventions for woman experiencing a
Physically challenged complication of pregnancy include measures
to maintain number of different areas.
Frequent pregnancies
Continued healthy fetal growth
Socio demographic
A woman’s and family‘s psychological health
Poverty
Continuation of the pregnancy as long as
Unemployment possible
Lack of education

Age

Poor access to transportation for care

Evaluation CAUSES:

Client’s BP is maintained within acceptable Terratogenic factor

parameters
Chromosomal aberrations/abnormal fetal
Couple states they feel able to cope with development
anxiety associated with the pregnancy
complication Implantation abnormalities

Client accurately verbalizes crucial signs and Failure to produce enough progesterone
symptoms to report to the health care
Infection
provider immediately.
Presenting symptom
SUDDEN PREGNANCY COMPLICATION
Vaginal bleeding/spotting
In few women, unexpected deviations or
complications from the normal course of Should consult attending Obstetrician so that
pregnancy happens instructions may be given
Sudden pregnancy complications Threatened miscarriage
Bleeding during pregnancy Vaginal bleeding,scant, bright red usually,
slight cramping
Ectopic pregnancy
No cervical dilatation
Gestational trophoblastic disease
MANAGEMENT:
Premature cervical dilatation
Fetal heart assessment
Placenta previa
Utz
Abruptio placenta
hCG determination
Disseminated intravascular coagulation
Avoid strenuous activity
Preterm labor
Coitus usually restricted for 2 weeks
Preterm rupture of membranes
Spotting usually stops within 24-48 hours
Pregnancy induced hypertension
Imminent (inevitable) miscarriage
HELLP Syndrome
Uterine contractions and cervical dilatation
Multiple pregnancy
occurs
Abnormal amniotic fluid volume
Loss of product of conception cannot be
Isoimmunization halted

Bleeding during pregnancy If no FHT and UTZ reveals empty uterus-

dilatation and evacuation may be
Bleeding during pregnancy performed

Always a deviation from the normal Complete miscarriage

Summary of primary causes of bleeding Entire products of conception are expelled

during pregnancy spontaneously without assistance

Abortion Incomplete miscarriage

Medical term for any interruption of a Part of the conceptus is expelled, but the
pregnancy before a fetus is viable membrane or placenta is retained

Spontaneous miscarriage MANAGEMENT:

Early miscarriage if it occurs before 16th Dilatation and curettage or suction

week curettage

Late between 16-24 weeks Recurrent pregnancy loss

 Women who had 3 spontaneous Pain in shoulders
miscarriages
Management
Defective spermatozoa or ova
Unruptured –methotrexate followed by
Endocrine factors leucovorin, mifepristone (abortifacient)

Deviations of the uterus Ruptured –emergency situation

Uterine infections Laparoscopy-ligate the bleeding vessels and

remove/repair fallopian tube
Autoimmune disorders
CBC
Complications of miscarriage
Administration of fluids
Hemorrhage
Abdominal pregnancy
Infection
Woman may report sudden lower quadrant
Risk for isoimmunization pain
Process of shock because of blood loss Fetal outline is easily palpable
Signs and symptoms of hypovolemic shock Danger is infiltration of large blood
vessel,bowel perforation, poor nutrient
Ectopic pregnancy
supply to the fetus
Implantation occurs outside the uterine cavity
Infant must be born through laparotomy
Ovary or cervix
Rate of survival
Most common is fallopian tube
60%
Due to fallopian tube scarring that slows the
Gestational trophoblastic disease
travel of the zygote
(hydatidiform mole)
Woman still experiences the signs of
Abnormal proliferation and then
pregnancy
degeneration of the trophoblastic villi

Cells become filled with fluid and appears

ECTOPIC PREGNANCY
as fluid filled grape sized vesicles
Missed period
1 in every 1500 pregnancies
Signs and symptoms of pregnancy is
Two types:
experienced by the woman
Complete mole-all trophoblastic villi swell
(+) pregnancy test
and become cystic
Ruptured ectopic pregnancy
Partial mole-some of the villi form normally
Sharp stabbing pain in lower abdominal
Assessment:
quadrant
Uterus tends to expand faster
Vaginal spotting
Strong (+) result of hCG- 1 to 2 M IU
Amount of bleeding not evident
compared to a normal of 400,000IU)
May lead to shock
Symptoms of pregnancy induced
Falling hcg level hypertension may appear before the 20th
week
Utz –provides clear cut picture
Ultrasound-no fetal growth and fetal heart
If the woman does not seek help at once sound

Cullen’s sign

Dull, vaginal abdominal pain

Movement of cervix cause excruciating pain

Assessment Shirodkar

Marked nausea and vomiting Sterile tape is threaded in a purse string

Dark brown blood, profuse flesh flow(16
weeks) with clear fluid filled vessicles
Therapeutic management
Suction curettage
Post-Surgery:
Pelvic examination, chest radiograph,hCG
level
hCG monitoring
Half of woman positive at 3 weeks
¼ positive result at 40 days
Assess every 2 weeks until normal
Every 4 weeks for the next 6 to 12 months
manner under the submucous layer of the
cervix
Placenta previa
Placenta is implanted abnormally in the
uterus
Most common cause of painless bleeding in
the third trimester of pregnancy
Occurs in 4 degrees
Low lying- implantation in the lower rather
than in the upper portion of the uterus
Marginal –the placenta edge approaches
that of the cervical os
Partial-implantation that totally obstructs the
cervical os

Should use reliable contraceptive method Total placenta previa- totally obstructs the
cervical os
Plan pregnancy at 12 months if hcg is normal
Assessment
Prophylaxis
Bleeding is abrupt, painless, bright red and
Methotrexate sudden

Dactinomycin Immediate care measures:

Premature cervical dilatation Place the woman immediately on bedrest in

a side lying position
Old name-Incompetent cervix
Associated with:
Cervix that dilate prematurely,cannot hold a
fetus until term Increased parity

Painless Advanced maternal age

Pink-stained vaginal discharge(1st symptom) Past CS

Followed by Rupture of membrane, Past uterine curettage

discharge of amniotic fluid
Multiple gestations
Uterine contractions-birth of the fetus
Male fetus
Associated with:
Assess:
Increased maternal age
Duration of pregnancy
Congenital structured defect
Time the bleeding began
Trauma to cervix
Estimate amount of blood loss
Management:
Accompanying pain
Cervical cerclage-purse-string sutures are
placed in the cervix by vaginal route Color of the blood

Mc Donald Procedure What has she done?

Nylon sutures are placed vertically and Prior episodes of bleeding

horizontally across the cervix and pulled
Prior cervical surgery
tight to reduce the cervical canal
Therapeutic management
 Never attempt a pelvic or rectal examination Therapeutic management:
with painless bleeding late in pregnancy
Emergency situation
Obtain baseline VS
Large gauge IV catheter
IVF therapy
Oxygen by mask
I and O monitoring
FHT and maternal VS monitoring
External monitoring equipment
Lateral position
Complete blood count
No abdominal, pelvic or vaginal examination
Blood typing and crossmatching
Unless separation is minimal, pregnancy must
How is the fetus delivered? be TERMINATED

Depends on the percentage of previa and Degrees of premature placental separation

the condition of the pregnancy
Premature separation of the placenta/
abruptio placenta
Placenta appears to be implanted correctly
Disseminated intravascular coagulation
(DIC)
Acquired disorder of blood clotting,
fibrinogen level falls to below effective limits

Begins to separate and bleeding results Conditions associated with its development:

Cause is unknown Premature separation of placenta

Predisposing factors: PIH

High parity Amniotic fluid embolism

Advanced maternal age Placental retention

Short umbilical cord Septic abortion

Chronic hypertensive disease Retention of dead fetus

Pregnancy induced hypertension dic

Direct trauma Extreme bleeding causes many platelets and

fibrin from the general circulation rush to the
Vasoconstriction site, not enough are left for the rest of the
body
Autoimmune antibodies
Test clotting time
Chorioamnionitis
Test tube-clot must form
Assessment:
Platelet assessment - less than or equal to
Sharp stabbing pain high in the uterine
100,000/uL
fundus
Prothrombin –low
If labor begins, each contraction will be
accompanied by pain over and above the Thrombin-elevated
pain of contraction
Fibrinogen –less than 150 mg/dL
Heavy bleeding - evident if separation
occurs at the edges Management:

Couvelaire uterus (uteroplacental Halt the underlying insult

apoplexy)
IV administration of Heparin
- Hard board like uterus with no apparent or
Blood or platelet transfusion
Minimally apparent bleeding
Preterm labor
Disseminated Intravascular Coagulation (DIC)
may occur Labor that occurs before the end of the 37
weeks of gestation
 Persistent uterine contractions, cervical
effacement over 80% and dilation over 1cm
Unknown cause
Conditions associated:
Dehydration
UTI
Periodontal disease
Chorioamnionitis
Inadequate prenatal care
Assessment:
Persistent, dull, low backache
Vaginal spotting
Pelvic pressure or abdominal tightening
Menstrual like cramping
Ways to predict which pregnancy will end
early:
Analyze change in vaginal mucus
Presence of fetal fibronectin (protein
produced by trophoblast cells)
-preterm contractions are ready to occur
Absence of fetal fibronectin
- labor will not occur at least 14 days
Therapeutic management:
Woman usually admitted
Bed rest
IV fluids – hydration may stop contractions
Tocolytic agent - halt labor (terbutaline)
Advise to limit strenuous activities
Fetal assessment - count to 10 test
Administration of terbutaline:
Mixed with lactated Ringer’s
Piggy back
Microdrip
Check blood pressure and pulse rate
If contractions are halt, oral terbutaline may
be given
Drug administration:
Steroid(betamethasone) - to hasten lung
maturity
Effects after 24 hours and lasts 7 days
Labor that cannot be halted
Membranes have ruptured
Cervix more than 50% effaced and 3-4 cm
dilated
If fetus is very immature -CS
Method of delivery:
If very immature – CS delivery to reduce
pressure on the fetal head
Cord is clamped immediately – extra
amount of blood could overburden the
circulatory system
Preterm rupture of the membranes
Rupture of fetal membranes with loss of
amniotic fluid during pregnancy before 37
weeks
Threats to fetus:
Uterine and fetal infections
Increased pressure on the umbilical cord
(cord prolapse)
Potter –like syndrome - distorted facial
features and pulmonary hypoplasia from
pressure
Assessment:
Sudden gush of clear fluid from vagina
Test with nitrazine paper-turns blue (alkaline)
Therapeutic management:
If labor does not begin, and fetus is at point of
viability:
Woman is placed on bed rest and receives
corticosteroid
Administration of broad –spectrum antibiotics
Membranes resealed by fibrin-based
commercial sealant
Pregnancy induced hypertension
Vasospasm occurs during pregnancy in both
small and large arteries
Used to be called toxemia
Occurs most frequently in women:
Of color
Multiple pregnancy Assess FHT

Primiparas younger than 20 years or older Check for vaginal bleeding

than 40 years
HELLP SYNDROME
Low socioeconomic backgrounds – poor
nutrition Variation of PIH

Who have had five or more pregnancies H-emolysis

Hydramnios EL-evated liver enzymes

Underlying disease – heart dse, diabetes, L-ow P-latelet count

renal involvement
Increased BP, edema, proteinuria+
CLASSIFICATIONS:
Nausea, epigastric pain, general malaise,
Gestational hypertension RUQ tenderness

Mild eclampsia Management:

Severe eclampsia Improve platelet count by transfusion of fresh

frozen plasma or platelets
Eclampsia
Multiple pregnancy
Assessment:
A woman’s body must adjust to the effects of
Hypertension more than one fetus

Proteinuria MONOZYGOTIC TWINS:

Edema Single ovum and spermatozoon, zygote

divides into two identical individuals
Symptoms of pregnancy induced
hypertension One placenta, one chorion, 2 amnions,

Management: mild pre eclampsia 2 umbilical cords

Promote bed rest DIZYGOTIC(FRATERNAL/NON IDENTICAL):

Anti-platelet therapy Double ova-2 placentas, 2 chorions,

2 amnions, 2 umbilical cord
Promote good nutrition
ASSESSMENT:
Provide emotional support
Uterus increase in size at a rate faster than
Management for severe pre eclampsia: usual

Support bed rest Alpha-fetoprotein levels elevated

Monitor maternal well being Quickening - flurries of action at different

portions of abdomen
Monitor fetal well being
Reveals by ultrasound
Support nutritious diet
Therapeutic management:
Administer medications to prevent eclampsia
Closer prenatal supervisions
Management of eclampsia:
hydramnios
Tonic-clonic seizures
Normal amniotic fluid volume 500-1000mL
Maintain patent airway
Fluid index above 24 cm or more than 2000
Administer oxygen mL
Turn to side Suggests difficulty with the fetus’ ability to
swallow
Administer Magnesium sulfate or diazepam
(Valium) Unusual enlargement of uterus
 Difficult to auscultate FHT Passive Rh (D) antibodies against the Rh
factor is administered to women who are Rh-
Shortness of breath negative at 28 weeks
Increase weight gain Given in the 1st 72 hours after birth
Hemorrhoid Cord blood is tested - if Rh positive (Coombs’
negative) – large amount of antibodies are
Varicosities
not present in the mother, mother will receive
Management RhIG injection

Bed rest If Rh negative - injection not necessary

Assess VS and edema Intrauterine transfusion

NSAID Injection of RBC directly into the vessel of the

fetal cord or depositing them in the fetal
Amniocentesis- almost daily abdomen

oligohydramnios Fetal death

Pregnancy with less than the average
amount of amniotic fluid
Caused by bladder or renal disorder
Fetus is cramped for space
Uterus fails to meey expected growth rate
If labor does not begin, it will be induced by
a combination of prostaglandin gel such as
misoprostol (Cytotec) and oxytocin
NURSING CARE OF A FAMILY EXPERIENCING
PREGNANCY COMPLICATIONS FROM A PRE
EXISTING OR NEWLY ACQUIRED ILLNESS

Mgt: amniotransfusion Cardio vascular disorders and pregnancy

Post term pregnancy Concerns:

Pregnancy that exceeds 42 weeks Can a woman get pregnant?

If there is evidence of placental insufficiency If the couple decides to get pregnant, how will it
affect the health condition of the woman and the
Common in receiving salicylates growing fetus?

Mgt: oxytocin to initiate labor or CS is How does it affect the decision making of the
performed couple?

isoimmunization Cardiac disease

Occur when an Rh negative mother carries a Variety of health conditions both congenital and
fetus with an Rh positive blood( D antigen) acquired that complicate pregnancy

Maternal antibodies may cross the placenta Cardiac output

causing:
Rises significantly
Hemolytic disease of the newborn or
Erythroblastosis fetalis (RBC destruction, Plateau is 28-32 weeks
decreased O2 supply) Factors increasing cardiac output
Assessment Blood volume
Anti D antibody titer-done at 1st pregnancy Hormonal influences
visit
Autonomic nervous system
If normal (0) or minimal (below 1:8) - test
repeated in the 28th week Blood volume

If normal - no therapy Increases by plasma volume expansion and RBC

multiplication
If elevated (1:16) - fetal condition monitored
every 2 weeks Heart rate increases and dilated systemic
vasculature is maintained
Therapeutic management:
Hormonal influences
Autonomic nervous system
Cardiovascular system is hyperfilled from
increased blood volume and hyperdynamic
Pt will likely report signs and symptoms that
mimic cardiac disease
Affects the valves of the heart secondary to
previous exposure to beta hemolytic
streptococcus
assessment
History of pre pregnancy cardiac status
Level of exercise performance

Dyspnea Physical assessment

Orthopnea Diagnostic tests

Edema Fetal assessment

Syncope Criteria for establishing a diagnosis of cardiac

disease in pregnancy
Palpitations
Persistent murmur
Risk factors
Permanent cardiomegaly
Rheumatic fever 90%
Severe dysrhythmias
Congenital defects
Severe dyspnea prior to stage of pressure on the
Arteriosclerosis diaphragm
Myocardial infections Signs of cardiac decompensation
Pulmonary diseases Moist cough
Renal diseases Pedal edema
Heart surgery Dyspnea
Examples of cardiac diseases Tachycardia
Left sided heart failure Tachypnea
Right sided heart failure Chest pain on exertion
Cardiomyopathy Cyanosis
Hypertensive vascular disease Persistent heart murmur
Thromboembolic disease Maternal effects
Rheumatic heart disease Patients with valvular problems causing atrial
fibrillation-susceptible to embolic episodes
Classification of heart disease
Cyanotic heart disease-increase the maternal
Left sided heart failure
mortality by 50%
Right sided heart failure
Fetal and neonatal effects

Usual medical management and protocols for

Peripartal Cardiomyopathy
nurse practitioners
No previous history of heart disease
General management
Shortness of breath
Team approach
Chest pain
Adjust cardiac medications
Edema
Bed rest/restricted activity
Rheumatic heart disease
Prophylactic antibiotic

Careful titration of fluid volume

Advance planning for route of delivery Oxygen per mask

Drug therapy Forceps or vaccuum extraction

Heparin –anticoagulant Elective CS

Warfarin-pulmonary embolism/prosthetic valves Primary goal:

Furosemide-diuretic Reduce risks for complications

Digitalis-crosses placental barrier Achieved by:

Tocolytics Education

Beta blockers-treat hypertension Routine assessment

Nursing implementations Proper referral

Nursing implementations Facilitation of patient participation in decision

Encourage early, frequent and regular prenatal Being an advocate and coordinator for the
visits multidiciplinary team approach

Encourage compliance with therapeutic regimen Hematologic disorders and pregnancy

Decrease workload of the heart anemia

Adequate rest and sleep Decrease in oxygen carrying capacity of the

blood due to decrease hemoglobin in the blood
Treat early anemia
Risk factors:
Prevent exhaustion, fatigue , stress
Decrease nutritional intake
Avoid activities that decrease oxygenation
Heredity
Smoking
Increased demands as in pregnancy and
Overcrowded place adolescence
Avoid constipation Poor absorption
Daily fruits Iron deficiency anemia
Vegetables Most common
Regular bowel movement Diet low in iron
Regular exercise Heavy menstrual period
Proper nutrition Unwise weight reduction program
Well balanced diet Woman experiences fatigue and poor exercise
tolerance
Adequate protein
Rbc’s are:
Low sodium, fats and carbohydrates
Microcytic – exceptionally small RBC
No junk foods and stimulants
Hypochromic – decreased hemoglobin in the
Intrapartum period goals
RBC
Minimize changes in pulse and blood pressure:
Assessment findings
Lateral position
Pale skin and mucous linings
Adequate pain relief
Pearl white sclera
Avoidance of hemorrhage
Brittle flattened nails
Avoidance of infection
Low Hgb( less than 10g/dl)
Intrapartum period goals
Low hematocrit( less than 33%) not addressing increased folic acid needs of
certain age groups
Serum iron ( < 65ug/100 ml blood)

May lead to May conribute to

Low birth weight Early miscarriage
Preterm birth Early separation of placenta
Increased incidence of abortion and premature Prevention/management
labor
400 ug of folic acid daily before getting
Prevention/management pregnant
Pre natal vitamins containing iron supplement of Folacin rich food: green leafy vegetables,
60 mg elemental iron oranges, dried beans
Diet high in iron such as green leafy vegetables, During pregnancy: 600 ug/day
meat, legumes and fruits
Sickle cell anemia
If with deficiency: 120-200 mg /day
Caused by abnormal amino acid in the beta
Severe anemia - IV iron dextran (substitute for chain of hemoglobin
blood plasma or transfussion)
Recessively inherited
Nursing implementations
Majority of RBCs are irregular or sickle shaped
Promote a balance of activity and rest with and cannot carry much hemoglobin
avoidance of fatigue
If amino acid valine is replaced-sickle
Provide dietary instructions hemoglobin (Hbs)
Encourage regular intake of ordered hematinics
If amino acid lysine is replaced- non sickling
(ferrous sulfate)
May result to:
Folic acid deficiency
Blockage to placental circulation
Folic acid-B vitamin necessary for the normal
formation of red blood cells Low birth weight
Leads to megaloblastic anemia Fetal death
Becomes apparent in the 2nd trimester of Therapeutic management
pregnancy
Exchange transfusion
More common in multiple pregnancy
Administering oxygen
causes
Controlling pain
alcohol abuse (alcohol prevents absorption of
several nutrients especially the B vitamins) Increasing fluid volume

poor diets (common in alcoholics, the elderly,
those living alone or in poverty, and infants,
especially those with infections or diarrhea)
impaired absorption because of intestinal
dysfunction
The chances of passing it to the offspring
depends on genetic composition of the parents
Renal and urinary disorders
Renal and urinary disorders

bacteria competing for available folic acid Urinary tract infection (UTI)

overcooking of food, destroying valuable water- Chronic renal failure

soluble nutrients, including a high percentage of
incidence
folic acid
Infection-1-5% of pregnancies
limited storage capacity in infants
Chronic kidney disease- 6 to 12 cases per
prolonged drug therapy, especially from
10,000 pregnancies
anticonvulsants and estrogens
kidneys Wearing cotton underwear

Excrete water, electrolytes and nitrogenous Voiding immediately after sexual intercourse
waste product
Nursing implementations
Acid –base balance
Advise 3-4 L of water/day
Secretes erythropoietin – kidney hormone that
increases the number of RBC in cases of anemia Knee chest position – to promote urine drainage

Renin-angiotensin-aldosterone system Compliance to medications

Renin– hormone released in the kidney in Chronic renal disease

response to either decrease BP or plasma sodium
Results in accumulation of waste products in the
concentration
blood, electrolyte abnormalities and anemia
Accounts 20-25 % of the cardiac output
CBC may indicate anemia
Urinary tract infection
Chronic renal disease
Ureters dilate from the effect of progesterone -
May develop severe anemia
urine stasis/ stagnation
Increased glomerular filtration rate/creatinine
Minimal glucosuria - growth of microorganisms
level
Ascending infection
Medical management
Caused by Escherichia coli
ACE inhibitor-preserves kidney function but
Descending infection fetotoxic

Streptococcus B Low dose aspirin

Assessment Urine output monitoring

Frequency and pain on urination Ultrasound every 2 weeks from 24 wks of

gestation
Pain in the lumbar region
Non stress test
Nausea and vomiting
Care of the woman with chronic renal disease
Malaise
If undergoing dialysis, peritoneal (removal of
Temperature elevation fluid from the abdominal cavity) is more
preferred
Maternal effects
-monitor for preterm labor
May lead to preterm labor
Nutrition consultation
Bacteremia causing septic shock
Emotional support
Therapeutic mgt
Nursing interventions
Urine C & S
Monitor I and O
Administration of antibiotics
Evaluate degree of edema
Amoxicillin and ampicillin are safe to administer
Make referral to a dietitian
trimethoprim
Teach home blood pressure monitoring
Folic acid antagonist (neutralizes the effect of
another drug) Teach pt signs and symptoms of preterm labor

Must not be given on the first trimester Educate on the importance of drinking variety of
fluids
Prevention of uti
Empty bladder at least every 2 hours
Void frequently
Perineal hygiene from front to back
Wiping perineal area from front to back
Respiratory disorders and pregnancy Effect on fetus

Respiratory conditions Preterm birth

Acute Nasopharyngitis Growth restriction

Influenza management

Pneumonia Beclomethasone

Asthma Budesonide

Tuberculosis Terbutaline & Albuterol – tapered, close to term

because they may reduce labor contractions
Acute nasopharyngitis/common colD
Cromolyn sodium

Woman experiences nasal congestion due to Montelukast sodium

estrogen
Nursing interventions
If viral , no medication is needed
Review various asthma medications
influenza
Teach importance of avoiding environmental
Caused by virus allergens

High fever Pollens

Body aches Molds

Sore throat Dusts

May receive immunization Nuts

Anti pyretic Fish

Tami Flu (new anti-viral drug) Tuberculosis

Asthma
Asthma is a disorder marked by reversible
airway obstruction, airway hyperactivity and
airway inflammation
Trigerred by allergens-release of histamine-
bronchial smooth muscle constriction
Lung tissue invaded by mycobacterium
tuberculosis
Calcification and scarring of the lungs
assessment
Mantoux test /purified protein derivative (PPD)

asthma - If positive, should undergo chest radiograph

Most serious medical condition to complicate Sputum culture confirms the diagnosis
pregnancy
Assessment
asthma
Chronic cough
Difficulty releasing air
Weight loss
High pitched whistling sound(wheezes)
Coughs out blood (hemoptysis)
Chest tightness
Night sweat
Sputum production
Low grade fever
Maternal effects
Chronic fatigue
Adequately controlled-risk of complication is no
greater than non asthmatic Therapeutic management

Poorly controlled - increased risk of hypertension Isoniazid (INH) and ethambutol hydrochloride
and hyperemesis gravidarum (excessive (Myambutol)
vomiting)
-drugs of choice
Treatment regimen Rash on face,scalp,ear ,arms, chest

With active disease in pregnancy: Photosensitivity

Isoniazid (INH) 300 mg combined with rifampin( Oral ulcers

RIF) 600 mg and ethambutol 1 gram daily for 2
months Arthritis

RIF and INH for additional 7 months Pericarditis

Pyrodoxine (vitamin B6) taken with INH - to Renal disorder

prevent peripheral neuritis
Neurologic disorder
Ethambutol – may cause optic atrophy & loss of
Hematologic disorder
green color recognition. Monthly, Snellen chart
test – if with s/s, discontinue the drug. Immunologic disorder
Health education: ANA positive titer (Anti-Nuclear Antibody)
Maintain an adequate intake of calcium – to Maternal effects
ensure that tuberculosis pockets form or are not
broken down. If SLE is active during conception, exacerbation is
common
Wait 1 to 2 years to be negative of infection
before deciding to conceive If pt has renal insufficiency before pregnancy,
disease deterioration is common
Woman with history of tuberculosis should have
three negative sputum culture before she can Fetal and neonatal effect
hold/cares for her infant
Increase risk of spontaneous abortion
If with active infection-INH prophylaxis
Intrauterine growth restriction
AUTOIMMUNE RHEUMATIC DISEASES
Still birth
AUTOIMMUNE RHEUMATIC DISEASES
General management
Result from the body’s immune system inability to
distinguish “self” from “non self” Counselling

Body manufactures T cells and antobodies Planning pregnancy

directed against its own cells At least 6 months on remission
Most common examples Drug therapy
Systemic lupus erythematosus Corticosteroids-prednisone
Anti phospholipid syndrome Low dose aspirin
Systemic lupus erythematosus Anti malaraialagents(hydroxychloroquine)
Suppression of the body’s normal immunity Cytotoxic agent
Targets skin, joints, kidneys, lungs, cardiac and Nursing interventions
nervous system
Emphasize frequent pre natal visits
In pregnancy , causes inflammation of the
connective tissue of the decidua resulting to Assess weight gain
problem in implantation and functioning
Measure BP each day
Signs and symptoms
Balance between activity and rest
Depends on the target organ
Teach prevention and recognition of preterm
Most common are fever, malaise, fatigue, weight labor
loss, skin rashes and polyarthralgia
Instruct on skin care
11 criteria
Fetal surveillance
Butterfly rash
Evaluate fetal growth by UTZ every 3-4 weeks Collaborate with medical management plan
after 24 weeks AOG
Reinforce preconceptual counselling
Fetal movement counting
Interpret clinical information in lay terms
Assess coping styles and ability to cope with
chronic illness Be vigilant in physical and psychosocial
assessment
Anti phospholipid syndrome
Nursing interventions for APL
Antibodies formed against plasma protein
leading to a pro coagulant state Discuss medical and pregnancy risks

Superficial thrombophlebitis Pre natal visits

Deep vein thrombosis Screen for pre eclampsia and pre-term labor

Pulmonary embolism Teach self adminsitration of prescribed

Maternal effects
May lead to life threatening event for the
mother(pulmonary emboli, stroke)
Fetal and neonatal effects
medications
If heparin is used,take 1000mg of calcium,
Vitamin D and weight bearing exercises
Serial ultrasound every 3 to 4 weeks starting 17
to 18 weeks AOG

Increases pregnancy loss 32 weeks- daily fetal movement and BPS

(Bronchopulmonary Sequestration)
Recurrent spontaneous abortion and unexplained
2nd and 3rd trimester fetal death Teach prevention and recognition of preterm
labor
Increased risk in cardiac or neurologic anomalies
diabetes
Clinical criteria
diabetes
Vascular thrombosis
Disease characterized by the inability to produce
Venous or use sufficient endogenous insulin to metabolize
glucose properly
Arterial
3 types
Fetal loss
Type 1-absolute insulin deficiency
One or more unexplained fetal death beyond
10 weeks AOG Type 2-receptor sites are resistant to insulin
One or more preterm birth before 34 weeks Type 3- Gestational Diabetes mellitus
AOG
Gestational diabetes mellitus
3 or more unexplained consecutive spontaneous
abortion without hormonal or chromosomal Carbohydrate intolerance that is first recognized
abnormalities during pregnancy particularly in the 3rd
trimester
Laboratory criteria
Impaired fasting blood glucose (IFG)
Anticardiolipin antibody
FBS level that is 100 mg/dL or higher but lower
Lupus anticoagulant than 126 mg/dL
General management Impaired glucose tolerance
Low dose aspirin ( 81 mg) 2 hour post prandial blood sugar level higher
than 140 mg/dL but lower than 200 mg/dL
Heparin
Signs and symptoms of GDM in a previous
Prednisone
pregnancy
Nursing management
Prior delivery of an infant weighing more than 9
Provide adequate information pounds
Previous stillbirth of an infant with congenital Increase growth and fat deposition
defects
Birth trauma
Polyhydramnios
Intrauterine growth retardation
Hx or recurrent monilial vaginitis
placentalinsuffiency or vascular disease
Signs of gdm in the current pregnancy
Delayed lung maturity
Recurrent monilial vaginitis
Interfere with production of phosphatidyl
Macrosomia of the fetus on ultrasound glycerol

Polyhydramnios (fetal surfactant)

Maternal effects Neonatal hypoglycemia

Risk is directly related to glucose control initiated At birth, the supply of increased glucose is
before and throughout pregnancy suddenly cut off, but insulin is still produced

Risks: Learning disabilities

Spontaneous abortion Fetal brain cell damage and decresaed brain

growth
Pre eclampsia
Low intelligence quotient (IQ)
Preterm labor
Childhood obesity and TYPe 2 dm later in life
Polyhydramnios
70% chance of developing type 2 DM and
Infection obesity
Diabetic ketoacidosis Establishing diagnosis
Cesarean or instrumental birth and induction Criteria for the diagnosis of GDM
risks criteria
Retinopathy Fasting plasma glucose (FPG) 126 mg/dl or
greater after 8 hour fasting
Hypoglycemia
Two hour post prandial glucose >200 mg/dl
Fetal and neonatal effects
after 75 g glucose load
Hypoglycemia
Polyuria, polydypsia and unexplained weight
Hyperglycemia loss

hyperglycemia Two-step approach: glucose challenge test

Congenital defects Give 50 g of oral glucose, test blood sugar level

after 1 hour
Risk is 3 to 5 times more often
139 mg/dL or less rules out GDM
Directly affects the yolk sac development
More than 139 to 199 mg/dL –follow up with
Neural tube defects OGTT

Congenital cardiac anomalies If 200mg/ dL or greater, treat as GDM

GI and renal anomalies Two or three hour glucose tolerance test

Directly related to diabetic control in the 3 1. 150 g of complex carbohydrates should be

months before conception and the 1st 2 months eaten for 3 days
of pregnancy
NPO 8 hours before the test
macrosomia
Draw an FBS sample
Elevated fetal glucose
Start timer, pt drinks 100 g of glucose solution
Fetal hyperinsulinemia within 10 minutes
Blood samples are drawn 1, 2, and 3 hours Calculation guidelines for insulin during
pregnancy
Normal serum blood glucose values
Diet management
Antepartum glycemic management
In consideration to pre pregnancy weight,
Blood glucose monitoring general health status, dietary habits, activity
level and insulin therapy
Urine testing
Exercise recommendations
Insulin management
Exercise can lead to improved sensitivity to
Exercise recommendations
insulin after 4 weeks
Antepartum fetal surveillance
Antepartal fetal surveillance
Blood glucose monitoring
Ultrasound
Daily self-monitoring of blood glucose-3 to 10
Maternal alpha-fetoprotein
times per day
Fetal biophysical tests
Capillary blood glucose samples are taken
before meals and snacks, 60-90 minutes after Amniocentesis
meals, at bed time, ocassionally between 2 -4
AM Gastrointestinal disorders and pregnancy

HbA1c tests every 4-6 weeks GASTRO ESOPHAGEAL REFLUX

DISEASE/hiatal hernia
Urine testing
GERD - Reflux of acid stomach secretions into the
Ketones esophagus
Sugar HIATAL HERNIA - portion of the stomach
extends and protrudes up through the
Insulin management
diaphragm into the chest cavity
Usual type is biosynthetic human insulin (Humulin)
symptoms
Classification:
Heartburn
A. Rapid acting: lispro(Humalog) and aspart
Gastric regurgitation
( Novolog)
Dysphagia – impaired swallowing
B. Short acting: regular (Humulin R)
Possible weight loss
Intermediate acting: neutral protamine
Hematemesis
hagedorn( NPH, Humulin N)
management
Rapid acting insulin
Antacids
Works within 10-15 minutes
Histamine receptor antagonist(ranitidine)
Shorter duration (3-5 hours)
Proton pump inhibitor (esomeprazole-Nexium)
Must eat as soon as injection is administered
Loose clothing
Good for high glycemic index foods: bread, rice
and potatoes Sleep with head elevated
Short acting PANCREATITIS
Onset is 30 minutes or longer Inflammation of the pancreas
Duration of 6-8 hours Nasogastric suction
Snacks are essential in the morning, afternoon Bowel rest
and bedtime
Analgesia – pancreatic pain is sharp
Comparsionchart for human insulins
Intravenous hydration
hepatitis Common drugs:

Liver disease that may occur from invasion of the Trimethadione (Tridione)
A,B,C, D or E virus
Valproic acid
Hepatitis A
Carbamazepine
Spread by fecal-oral contact
Phenytoin
Ingestion of fecally contaminated water or
shellfish MUSCULOSKELETAL DISORDERS AND
PREGNANCY
May be given prophylactic gamma globulin
SCOLIOSIS
Hepatitis b & C Spread by exposure to
contaminated blood or blood products Lateral curvature of the spine

Can be spread by contaminated semen or Noticed in girls between 12-14 years old
vaginal secretions
SCOLIOSIS
Assessment

Experiences nausea and vomiting

ASSESSMENT
Liver is tender on palpation
Visible curve fails to straighten when the child
Dark yellow urine bends forward and hangs arms down toward
feet
Hepatomegaly
Hips, ribs and shoulders are asymetrical
Jaundice
Apparent leg length discrepancy
THERAPEUTIC MANAGEMENT
SCOLIOSIS CAN INTERFERE
Bed rest
With respiration and heart action because of
High calorie diet chest compression

CS delivery Pelvic distortion can interfere with childbirth

Standard infection precautions MANAGEMENT

Inflammatory bowel disease BRACES

Crohn’s disease – inflammation of the terminal Usually worn 16-23 hours a day
ileus
Inspect skin for breakdown
Ulcerative colitis – inflammation of the distal
colon Keep skin clean

Inflammatory bowel disease Advise to wear soft non irritating clothes under
the brace
Bowel develops shallow ulcers
Unless modified it cannot be worn during the last
Woman develops chronic half of pregnancy
diarrhea,weightloss,occult blood in stool, nausea
and vomiting Brace for scoliosis

Fetal effects Boston Brace

Interferring with fetal growth Surgical Management

Total rest for GI tract IMPLEMENTATION POST OPERATIVELY

Sulfasalazine (Azulfidine) Maintain proper alignment

NEUROLOGIC DISORDERS AND PREGNANCY Logroll when turning

SEIZURE DISORDER Neurovascular assessment of lower extremity

function
May be due to head trauma or meninigitis
Monitor for Mesenteric Artery Syndrome
Disorder – mechanical changes in the position of
abdominal contents during surgery (emesis,
abdominal distention)

Cancer and pregnancy

incidence

1 in 1000 pregnancies

First trimester option

Delay treatment or

End pregnancy