Complications of pregnancy are the symptoms and problems that are associated with pregnancy. .

PRE-EXISTING DISEASES OF PREGNANCY Diabetes Mellitus An endocrine disorder of CHO metabolism, results from inadequate production or use of insulin. Insulin, produced by the beta cells of the islets of Langerhans in the pancreas, lowers blood glucose levels by enabling glucose to move from the blood into muscle & adipose tissue cells. INCIDENCE: May be concurrent disease in pregnancy or may have its first onset in pregnancy RISK FACTORS Family history Rapid hormonal change in pregnancy Tumor/infection of the pancreas Obesity stress Predisposing Factors of Gestational Diabetes: A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia A family history revealing a first degree relative with type 2 diabetes Maternal age a womans risk factor increases as she gets older (especially for women over 35 years of age) Ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from the Indian subcontinent) Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively. A previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g (8 lbs 12.8 oz)) Previous poor obstetric history CARBOHYDRATE METABOLISM Pancreas is enlarged Increased insulin secretion Pregnancy is a diabetogenic state If pre-pregnant mother is diabetic Two to three percent (2% to 3%) chance of having gestational diabetes Placenta COUNTERACTS INSULIN by INSULINASE Insulinase breaks insulin Pathophysiology DM: Endocrine disorder Inadequate production or use of insulin Glucose metabolism is impaired Cells break down stores of fats and protein for energy Result: Negative nitrogen balance and ketosis Cardinal signs and symptoms of DM: Polydipsia excessive thirst Polyuria excessive urination Polyphagia excessive hunger Weight loss

Classification Type 1 diabetes: (IDDM)Absolute insulin deficiency Type 2 diabetes: (NIDDM) Other specific types based on cause Gestational DM Refers to diabetes that develops during pregnancy Screening for GDM Done at 24-28 weeks gestation 1 hour, 50g oral glucose tolerance test used If plasma glucose level exceeds 140 mg/dl, a 3-hour oral glucose tolerance test is necessary Note: some agencies use 130 mg/dl OGTT also referred to as the glucose tolerance test measures the bodys ability to metabolize glucose, or clear it out of the bloodstream. The test can be used to diagnose diabetes, gestational diabetes (diabetes during pregnancy) or prediabetes (a condition characterized by higher-than-normal blood sugar levels that can lead to type 2 diabetes). preparation Those taking the OGTT to diagnose diabetes or prediabetes who are not pregnant should eat a normal, balanced diet the week before taking the test. Experts recommend that this diet include at least 150 to 200 grams of carbohydrates per day. Patients must fast for at least 8 to 12 hours before having the test. After fasting, blood is drawn to establish a fasting glucose level. Next, a patient must quickly drink a sugary (glucose-rich) beverage. Typically, the drink contains 75 grams of carbohydrates, although other amounts are possible. Blood will be drawn at various intervals to measure glucose levels, usually one hour and two hours after the beverage is consumed. The test reveals how quickly glucose is metabolized from the bloodstream for use by cells as an energy source. The normal rate of glucose clearing depends on the amount of glucose ingested. After fasting, the normal blood glucose rate is 60 to 100 mg/dL (milligrams per deciliter). 2 Subtypes of Gestational Diabetes (diabetes which began during pregnancy): Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required Pregestational DM Present before conception Changes in glucose metabolism that result with pregnancy can affect diabetic control & can contribute to possible accelerations of the vascular disease associated with DM Signs & symptoms 1. Hyperglycemia 2. Glycosuria 3 . Polydipsia 4. Weight loss 5. Ketoacidosis

Influence of Pregnancy on Diabetes DM may be difficult to control Insulin requirements vary during pregnancy Risk of ketoacidosis Progression of vascular disorders Hypertension may occur Nephropathy may result from renal impairment Retinopathy may develop Influence of Diabetes on Pregnancy Outcome Maternal Risks Hydramnios Preeclampsia-eclampsia Ketoacidosis Infections Fetal-neonatal risks congenital anomalies Fetal-Neonatal Risks Macrosomia Intrauterine growth restriction (IUGR) Respiratory Distress Syndrome Hyperbilirubinemia Polycythemia Clinical Therapy Goal: Scrupulous maternal plasma glucose control Screening: 1-hour GTT (24 to 28 weeks) Diagnosis: 3-hour oral GTT Blood glucose monitoring Assessment of long-term glucose control Diet and insulin Fetal assessments Screening tests a. Universal screening b. 50 gram oral glucose tolerance test between 24-28 weeks gestation irregardless of the time of the day and meals taken for all pregnant woman. c. If the plasma value is more than 140 mg/dl after one hour, 100 gram three hour oral glucose tolerance test is performed to confirm if the woman is having hyperglycemia. Criteria of 100 gram Oral Glucose Tolerance Test- (Instruct not to eat after midnight) a. Blood tests for sugar by Testape and Clinistix. b. Benedicts test and Clinitest are inaccurate when testing sugar during pregnancy because these test measure all kinds of sugar including lactose which is normally present in the urine of pregnant women, thereby, giving false positive result. C. Urine test for acetone by acetest. 3. Diet a. Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,800 to 2,400 cal/day) but not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50% from carbohydrates, 30% from fats. b. Weight gain should be about 24 lbs. Too much weight gain can lead to large infants and cephalopelvic disproportion. c. Teach and instruct to: Reduce saturated fat Reduce cholesterol Increase dietary fiber Avoid fasting and feasting

d. Have the woman become familiar with food exchange list and caloric values of foods she usually eats to enable her to plan her diet properly and estimate her caloric intake accurately. e. The goal is to maintain a fasting blood sugar level of 90 mg/dl and postprandial blood sugar level of 120mg/dl 4. Exercise A liberal cardiovascular-conditioning exercise and diet therapy is the management for class A or Gestational Diabetes Mellitus Exercise lowers blood glucose levels and decreases the need for insulin. The exercise regimen should be individualized, performed regularly and under supervision. Advise woman to eat complex carbohydrates before exercising to prevent hypoglycemia. 5. Insulin therapy Insulin requirements increase during pregnancy Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia. Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of choice during pregnancy because it is the least allergic 2/3 in the morning, 1/3 at dinner administered subcutaneously hour before meals. Insulin requirement is highest during the third trimester. 6. Home blood glucose monitoringa. Dextrometer b. 4x a day, upon rising in the morning, before breakfast, lunch, dinner c. Normal fasting 90 mg/dl, postprandial - 120mg/dl 7. Observe for urinary and vaginal tract infections particularly candidiasis 8. Fetal wellbeing assessment a. Uteroplacental Function Tests NST and CST b. Amniocentesis to determine fetal lung maturity DIETARY REGULATION: 1. Caloric needs of pregnant women are not altered by diabetes about 30kcal/kg ideal body weight during the 1st trimester & 35-36 kcal/kg IBW during 2nd & 3rd trimester 2. Approx 45% of calories should come from complex CHO, 20% from CHON, & 35% from fat 3. these calories are divided among 3 meals & 3 snacks 4. bedtime snack, w/c should contain both CHON & complex CHO, is most impt b/c of the risk of hypoglycemia during the night GLUCOSE MONITORING 1. Weekly assessment of FBS levels & occasional post prandial checks are indicated 2. Home monitoring of FBS 4-6 times daily 3. Optimal range, AC: 70-100mg/dl 2 hours PP: <120mg/dl INSULIN ADMINISTRATION: 1. Insulin given in multiple injections using human insulin or a fast acting human analog called lispro 2. 4-dose approach often used w/ regular insulin or lispro AC & NPH or Lente insulin added at bedtime 3. Insulin may also be given by continuous subcutaneous infusion Note: oral hypoglycemics are teratogenic & are never used in pregnancy Remember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin: Short acting or regular insulin after 2-3 hours of injection Intermediate or Lente insulin after 6-8 hours of injection Long-acting or ultralente after 16 18 hours of injection

The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision Give a hypoglycemic person a glass of orange juice. Postpartum: 1. Recurrence of diabetes may occur in subsequent pregnancies. 2. Women who develop gestational diabetes have higher tendency to develop overt diabetes later in life. 3. Newborn Care: Keep warm because of poor temperature control mechanisms Observe respiration (stomach aspiration necessary at time of birth, since hydramnios inflates stomach which pushes up and interferes with diaphragm and lung expansion) Observe for signs of hypoglycemia (shrill cry, weakness) give glucose water Observe for signs of hypocalcemia (tetany, tremors) give calcium gluconate Observe for congenital anomalies: esophageal atresia, neural tube defect 4. Contraception: a. IUD and combined oral contraceptives are contraindicated b. Norplant (progestin implant system) and progestin only pill (minipills) may be used safely by diabetic women Cardiac disease Heart Disease Complicates about 1% of pregnancies Pregnancy results in increased Cardiac output Heart rate Blood volume Heart disease Decreased cardiac reserve Diminished capacity to handle pregnancy workload CLASSIFICATION: 1. CLASS I NO LIMITATION,UNCOMPROMISED, NO DISCOMFORT WITH ORDINARY PHYSICAL ACTIVITY. 2. CLASS II SLIGHT LIMITATION, SLIGHTLY COMPROMISED, ORDINARY ACTIVITY CAUSES DYSPNEA, FATIGUE, CHEST PAIN & PALPITATIONS. 3. CLASS III MARKED LIMITATION, LESS THAN ORDINARY ACTIVITY CAUSE EXCESSIVE FATIGUE; PALPITATIONS, CHEST PAIN & DYSPNEA. 4. CLASS IV SEVERE LIMITATION; PATIENT EXPERIENCES SYMPTOMS EVEN AT REST; UNABLE TO PERFORM ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT. Heart Disorders Rheumatic heart disease - mitral stenosis Mitral valve prolapse Peripartum cardiomyopathy

SIGNS & SYMPTOMS:

DIFFICULTY OF BREATHING DYSPNEA, ORTHOPNEA, NOCTURNAL DYSPNEA HEMOPTYSIS SYNCOPE WITH EXERTION CHEST PAIN

CYANOSIS CLUBBING OF FINGERS NECK VEIN DISTENTION SYSTOLIC & DIASTOLIC MURMURS

NURSE ALERT: ** REMEMBER A PREGNANT WOMAN WITH HEART DISEASE SHOULD AVOID INFECTION, EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA BECAUSE THESE CONDITIONS INCREASE THE WORKLOAD OF THE HEART. Clinical Therapy Diagnosis Echocardiogram and chest x-ray Auscultation of heart sounds Sometimes cardiac catheterization Classification of functional capacity Class 1 through 4 Drug therapy Nursing Management Assess the stress of pregnancy on the hearts functioning Limitation of activity Monitor for signs of impending cardiac failure Health teaching Evaluate maternal vital signs Maintain an atmosphere of calm Fetal assessment Family support PRENATAL CARE: 1. PROMOTION OF REST ( CLASS I & CLASS II) *8 HOURS OF SLEEP DURING THE NIGHT & HAVE FREQUENT REST PERIODS DURING THE DAY. * LIGHT WORK IS ALLOWED BUT NO HEAVY WORK, NO STAIR CLIMBING, NO EXHAUSTION. 2. DIET * HIGH IN IRON, PROTEIN,MINERALS & VITAMINS 3. AVOID HIGH ALTITUDES, SMOKING AREAS, UNPRESSURIZED PLANES & OVERCROWDED AREAS. CIGARETTE SMOKING & ALCOHOLIC BEVERAGES ARE STRICTLY PROHIBITED. 4.PREVENTION OF INFECTION * AVOID PERSONS WITH ACTIVE INFECTIONS (COLDS, COUGH). * EARLY TREATMENT OF INFECTIONS 5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF HEART FAILURE: * COUGH WITH CRACKLES IS USUALLY THE FIRST SIGN OF AN IMPENDING HEART FAILURE. * INCREASING DYSPNEA, TACHYCARDIA, RALES, EDEMA MEDICATIONS: IRON SUPPLEMENTATION TO PREVENT ANEMIA DIGITALIS TO STRENGTHEN MYOCARDIAL CONTRACTION AND SLOW DOWN HEART RATE NITROGLYCERINE TO RELIEVE CHEST PAIN ANTIBIOTICS TO PREVENT AND TREAT INFECTION DIURETICS MAY BE PRESCRIBED IN CASE OF HEART FAILURE

INTRAPARTAL CARE EARLY HOSPITALIZATION WOMAN IS HOSPITALIZED BEFORE LABOR BEGINS TO PROMOTE REST, FOR CLOSER SUPERVISION AND PREVENT INFECTION WOMANs POSITION IN LABOR IN SEMI-FOWLERS POSITION OR LEFT LATERAL RECUMBENT POSITION. NO LITHOMY POSITION. VITAL SIGNS VITAL SIGNS ARE MONITORED CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY RATE MORE THAN 24 ARE SIGNS OF IMPENDING CARDIAC DECOMPENSATION. DURING THE FIRST STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES AND MORE FREQUENTLY DURING THE SECOND STAGE EPIDURAL ANESTHESIA IS INSTITUTED FOR PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS USED TO SHORTEN THE SECOND STAGE. PUSHING IS CONTRAINDICATED WOMEN WITH HEART DISEASE ARE POOR CANDIDATE FOR CS DUE TO INCREASED RISK FOR HEMORRHAGE, INFECTION AND THROMBOEMBOLISM POSTPARTUM CARE 1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE POSTPARTUM BECAUSE OF THE SUDDEN INCREASE IN CIRCULATORY BLOOD VOLUME. 2. MONITOR VITAL SIGNS. 3. PROMOTE REST- RESTRICT VISITORS TO ALLOW PATIENT TO REST, THE WOMAN STAYS IN THE HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS STABILIZED. 4. EARLY BUT GRADUAL AMBULATION TO PREVENT THROMBOPHLEBITIS. 5. MEDICATIONS *ANTIBIOTICS *STOOL SOFTENERS TO PREVENT STRAINING AT STOOL CAUSED BY CONSTIPATION. * SEDATIVES MAY BE ORDERED TO PROMOTE REST. 6. BREASTFEEDING IS ALLOWED IF THERE ARE NO SIGNS OF CARDIAC DECOMPENSATION DURING PREGNANCY, LABOR AND PUEPERIUM. Impact on Mother and Pregnancy All women with chronic medical conditions need increased vigilance during pregnancy Most chronic medical conditions Will have some effect on the mother Impact on Newborn Chronic maternal medical conditions May increase risks to the newborn Premature birth Low birth weight Growth retardation

anemia Definition: Hemoglobin (Hb) less than 10 g/dL iron deficiency anemia is the most common anemia of pregnancy affecting 15-50% of pregnant women. also called the physiologic anemia of pregnancy hemoglobin value of less than 11 mg/dL or hematocrit value less than 33% during the 2nd and 3rd trimester. Signs: Paleness Lack of energy Fatigue Implications for the infant: Prematurity Low birth weight Stillbirth Predisposing factors of Anemia: Poor diet and poor nutrition Pregnancies at close intervals; Heavy menses successive pregnancies Unwise reducing programs Types of Anemia Iron deficiency - most common Sickle cell anemia Folic acid deficiency Thalassemia Four types are significant during pregnancy Two are nutritional: Two are genetic disorders: Iron deficiency Sickle cell disease Folic acid deficiency Thalassemia Nutritional Anemias Symptoms Easily fatigued Pounding heart Skin and mucous membranes Rapid pulse (with severe are pale anemia) Shortness of breath Iron Deficiency Anemia RBCs are small (microcytic) and pale (hypochromic) Prevention Iron supplements Do not take iron with milk or antacids Vitamin C may enhance Calcium impairs absorption absorption Treatment Oral doses of elemental iron Continue therapy for about 3 months after anemia has been corrected Folic Acid Deficiency Anemia Large, immature RBCs (megaloblastic anemia) Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals Folate is essential for normal growth and development Prevention Daily supplement of 400 mcg (0.4 mg) Treatment Folate deficiency is treated with folic acid supplementation 1 mg/day (over twice the amount of the preventive supplement) Dose may be higher for women who have had a previous child with a neural tube defect

Multiple pregnancy Twin pregnancy can occur in one of two ways. The more common way (2/3s of cases) is for the two different sperm to fertilize two different eggs resulting in what is called a dizygotic (DZ) twin gestation. These twins are often called fraternal twins. In this type of twinning each twin has its own sac of amniotic fluid and its own placenta (afterbirth). Dizygotic twins have two sets of membranes surrounding their amniotic fluid sacs (one inner amnion layer and one outer chorion layer) and therefore they are known as diamniotic, dichorionic.

Fraternal twin In about 1/3 of twin pregnancies, one sperm fertilizes one egg but this splits into two embryos resulting in what is known as monozygotic (MZ) twins. These twins are often referred to as identical twins since they have the same genetic material. Less than 1% of identical twins (about 1 in 2,400 pregnancies) will have one amniotic sac and one placenta for both twins. This type of twinning is referred to as monochorionic, monoamniotic twinning. These twins are at very high risk for loss of the pregnancy due to entangled umbilical cords.

How Identical Twins are Not Identical? Identical twins share the same DNA - but do not have identical DNA. Characteristics of Siamese twin Identical The siamese twin pairs will always stick together for the whole life except separation process is done. They are actually incomplete identical twin to be. Siamese twin always the same gender. Multiple Gestation Care of woman with more than one fetus includes: Frequent assessment of fetal heart tones of each fetus Education of mother about signs and symptoms of preterm labor Encouragement of mother to rest frequently prior to birth Preparation of equipment needed to care for each individual newborn

German measles Acute viral disease Caused by a mixovirus Low fever and rash Maternal infection is mild but effects on theFetus are severe

Destructive to developing fetus If it occurs early in pregnancy, it can disrupt formation of major body systems If it occurs later in pregnancy, it can cause damage to organs already formed

If woman receives a rubella vaccine prior to pregnancy, then she should not get pregnant for at least 1 month (Bowes, 1996) Not given during pregnancy because vaccine is from a live virus Effects on embryo or fetus: Microcephaly (small head size) Mental retardation Congenital cataracts Deafness Cardiac effects Intrauterine growth restriction (IUGR)

INCUBATION PERIOD - 2-3 weeks PERIOD OF COMMUNICABILITY 7 days before to 5 days after rash appears TRANSMISSION direct & indirect contact ASSESSMENT FINDINGS: Pink maculo-papular rash; starts on face, caudal spread (3-5 days) Slight fever, malaise Nasal catarrh Anorexia Posterior auricular & occipital adenopathy Arthritis/arthralgia

TREATMENT: SYMPTOMATIC Immune serum globulin is given to exposed women to prevent aggravation of maternal symptoms but will not alter fetal infections & will not reverse fetal defects that are already present

SEXUALLY TRANSMITTED DISEASES Refers to diseases ordinarily transmitted by DIRECT SEXUAL CONTACT with an infected individual STDs Common mode of transmission is sexual intercourse Infections that can be transmitted: Syphilis, gonorrhea, chlamydia, trichomoniasis, and condylomata acuminata Vaginal changes during pregnancy increase the risk of transmission

STDs & Pregnancy STDs are viruses, bacteria, or parasites that pose risks or possible death to the baby Be honest and tell your health care provider, if you have or think you have an STD Common STDs include: HIV(AIDS) Gonorrhea Syphilis Chlamydia Genital Herpes Genital Warts Hepatitis

STDs & Pregnancy STDs can cause serious harm to the baby if left untreated During pregnancy, you can be tested for STDs Most STDs can be safely treated during pregnancy Protect yourself and your baby Use condoms Avoid sexual contact with an infected partner Chlamydia Possible effect on baby: 20-50% chance of the baby becoming infected while passing through the birth canal resulting in a pneumonia or eye infection (ophthalmia neonatorum) Symptoms: burning on urination or unusual vaginal discharge. women have no symptoms more than 50% of time Testing: Cervical culture at the time of your initial pap smear Treatment: Antibiotic pills for you, antibiotic ointment to babys eyes at birth Gonorrhea Caused by gonococcus NEISSERIA GONORRHOEAE Causes profuse, purulent & yellowish vaginal discharge & pruritus Possible effect on baby: Baby can get conjunctivitis (redness of the eye), become blind and/or have a serious generalized infection Symptoms: Burning on urination, unusual vaginal discharge or no symptoms at all Testing: Cervical culture at the time of your initial pap smear Treatment: Antibiotic pills for you and an antibiotic ointment for the babys eyes at birth Genital warts Possible effect on baby: Benign tumors Testing: Physical exam, let health care on the vocal cords from the baby provider know if you think you have passing through an infected birth canal warts Symptoms: Skin tags or warts that can Treatment: Delay treatment until after be small or large, soft or hard, raised or delivery flat, single or in clusters like cauliflower

Hepatitis B Transmitted by blood, saliva, vaginal secretions, semen, and breast milk; can also cross the placenta Fetus may be infected transplacentally or by contact with blood or vaginal secretions during delivery Upon delivery, the neonate should receive a single dose of hepatitis B immune globulin, followed by the hepatitis B vaccine

Possible effect on baby: Liver damage and risk of death if passed to baby during the pregnancy Symptoms: Yellowing of the skin and eyes, loss of appetite, nausea, vomiting, stomach and joint pain or extreme tiredness; sometimes there are no symptoms Testing: Blood test at initial visit Treatment: Vaccine, immune globulin, and a baby bath after delivery can help protect baby from getting infection Patients who are on hemodialysis Recipients of multiple blood transfusions or other blood products Household contact with hepatitis carrier or patient on hemodialysis Persons arriving from countries where there is a higher incidence of hepatitis B

Risk Factors for Hepatitis B

Intravenous drug users

Persons with multiple sexual partners Persons with repeated infection with STI Health care workers with occupational exposure to blood products and needle sticks Herpes simplex Caused by herpes simplex virus type 2 May have remission & exacerbation caused by stress, infection & menses Possible effect on baby: Can cause severe disease and death if transmitted to your baby during delivery if you have sores/blisters near your delivery date Symptoms: Fluid-filled sores in the genital area that may itch, burn, tingle or cause pain Testing: Tell your health care provider immediately if you think you have an outbreak (looks like warts); cultures of the blisters can be done Treatment: If active infection occurs at or near your delivery date, you may need a Cesarean Section within 4-6 hours of your water breaking **After birth, herpes can be passed to a baby by receiving a kiss from someone with a cold sore on the mouth (oral herpes) Syphilis Caused by spirochete Treponema Symptoms: Painless sores in genital pallidum area Syphilis chancre Testing: Blood test at first visit Possible effects on baby: Miscarriage, Treatment: Antibiotics for the mother stillbirth or damage to babys bones, teeth and brain Trichomonas Caused by protozoa that thrives best in Symptoms: An increase in odorous, alkaline medium thin or thick, white, yellow-green/gray Acidic douche may be used for control vaginal discharge and itching Causes profuse foamy/frothy white to Testing: Vaginal discharge will be greenish vaginal discharge with pruritus examined under a microscope Possible effects: May increase chance Treatment: Flagyl pills can be given of pre-term labor safely after the first trimester Candidiasis Yeast Infection (Candidiasis) Possible effect on baby: Baby can get a mouth infection (thrush) while passing through an infected birth canal Symptoms: Vaginal itching, burning, or pain, which increases with urination and sex Testing: Your vaginal discharge will be examined under the microscope Treatment: Vaginal creams or suppositories for you, Nystatin for your baby

SUBSTANCE ABUSE Effects of Drug Use: Cocaine and Crack Adverse maternal effects Seizures and hallucinations Pulmonary edema and cerebral hemorrhage Respiratory failure and heart problems Increased incidence of spontaneous abortion Abruptio placentae, preterm birth, and stillbirth

Fetal neonatal effects Increased risk of intrauterine growth restriction (IUGR) Small head circumference Cerebral infarctions Altered brain development Shorter body length Malformations of the genitourinary tract Lower Apgar scores May have neurobehavioral disturbances Marked irritability An exaggerated startle reflex Labile emotions

Newborns exposed to cocaine in utero Increased risk of sudden infant death syndrome (SIDS) Cocaine crosses into breast milk May cause symptoms in the breastfeeding infant Extreme irritability and vomiting Diarrhea, dilated pupils, and apnea Cocaine use after childbirth: Prohibits breastfeeding

Effects of Drug Use: Marijuana Associated with impaired coordination, memory, and critical thinking ability No strong evidence that marijuana is teratogenic Risks are dose related Increased risk of intrauterine growth restriction Sudden infant death syndrome (SIDS) in infants born to heavy users Impact of heavy marijuana use on pregnancy is difficult to evaluate Variety of social factors may influence the results

Effects of Drug Use: Ecstasy MDMA (methylenedioxymethamphetamine) It produces euphoria and feelings of empathy for others Deaths have occurred among users Little is yet known about the effects of MDMA on pregnancy Ecstasy use may be critical issue during fetal brain development

Effects of Drug Use: Heroin CNS depressant narcotic Alters perception and produces euphoria An addictive drug, generally IV-administered Associated with malnutrition Fetus of heroin-addicted woman - increased risk for IUGR and meconium aspiration

Effects of Drug Use: Heroin Hypoxia Restlessness and shrill, high-pitched cry Irritability and fist sucking Vomiting and seizures Signs of withdrawal usually appear within 72 hours May last for several days.

Effects of Drug Use: Methadone Most commonly used for women dependent on opioids Blocks withdrawal symptoms Reduces or eliminates the craving for narcotics Crosses the placenta Associated with pregnancy complications and abnormal fetal presentation Prenatal exposure: Reduced head circumference and lower birth weight Newborn may experience withdrawal symptoms

Effects of Alcohol Use Central nervous system (CNS) depressant Potent teratogen Maternal effects Malnutrition Bone marrow suppression Increased incidence of infections Liver disease Withdrawal seizures

Physical abnormalities Mental abnormalities Newborn may suffer from withdrawal syndrome Excessive alcohol consumption May intoxicate the infant May inhibit the maternal letdown

Human Immunodeficiency Virus (HIV) Virus that causes AIDS Cripples immune system No known immunization or curative treatment

Acquired in one of three ways: Sexual contact Parenteral or mucous membrane exposure to infected body fluids Perinatal exposure

Infant may be infected: Transplacentally Through contact with infected maternal secretions at birth Through breast milk

Possible effect on baby: Infection can be passed to baby while pregnant, during birth or through breast-feeding; it can cause serious complications and death to baby Symptoms: Often there are no symptoms of HIV Testing: Blood test at initial visit Treatment: Medication called AZT (Azidothymidine) can decrease transmission to baby

Human Immunodeficiency Virus (HIV) Infection 18% of cases in the United States are women HIV-1 virus affects specific T cells Suppresses bodys immune responses Affected person susceptible to opportunistic infections The individual develops detectable antibodies Diagnosis Enzyme-linked immunosorbent assay (ELISA) Confirmed with the Western blot test Modes of transmission Exposure to contaminated blood and body fluids Sexual intercourse IV drug abuse: Use of contaminated needles Blood transfusion Placental transmission Breast milk

Maternal Fetal Neonatal Risks Maternal development of AIDS and opportunistic infections Fetal neonatal risk HIV/AIDS disease in the newborn Antiretroviral therapy has decreased infection rates Following birth: Positive antibody titer Reflects the passive transfer of maternal antibodies Does not indicate HIV infection

Clinical Therapy Clinical evaluation of the HIV disease stage Evaluate the risk of disease progression Document history of antiretroviral therapy Discuss risks and benefits of therapy during pregnancy Provide counseling about risk factors Three-part ZDV (Zidovudine) prophylaxis regimen Three-part ZDV prophylaxis regimen Oral ZDV daily Intravenous ZDV during labor and until birth Oral ZDV for the infant Start 8 to 12 hours after birth Continue for 6 weeks

Nursing Management Education Nutrition and ZDV prophylaxis Teaching for self-care

Monitor for signs and symptoms of complications Review laboratory findings May indicate complications May indicate disease progression

Adhere to universal precautions Provide family support and referral to social services

Nursing Care Educate the woman who is HIV positive on methods to reduce the risk of transmission to her developing fetus/infant Pregnant women with AIDS are more susceptible to infection Breastfeeding is contraindicated for mothers who are HIV positive

RH SENSITIZATION The leaking of fetal Rh-positive blood into the Rh-negative mothers circulation, causing her body to respond by making antibodies to destroy the Rh-positive erythrocytes With subsequent pregnancy, the womans antibodies against Rh-positive blood cross the placenta and destroy the fetal Rh-positive erythrocytes before the infant is born Erythroblastosis Fetalis Occurs when the maternal anti-Rh antibodies cross the placenta and destroy fetal erythrocytes Requires RhoGAM to be given at 28 weeks and within 72 hours of delivery to the mother Also given after amniocentesis, and if woman experiences bleeding during pregnancy Fetal assessment tests must be done throughout pregnancy An intrauterine transfusion may be done for the severely anemic fetus Rh Alloimmunization: Causes Rh-negative woman carries an Rh Subsequent pregnancy positive fetus Rh antibodies enter the fetal Fetal red blood cells cross into maternal circulation circulation Result: Hemolysis of fetal red Response: Production of Rh antibodies blood cells and fetal anemia Transfer of RBCs usually occurs at birth The first child is not affected Rh Alloimmunization: Fetal and Neonatal Risks Anemia Hemolytic syndrome Erythroblastosis fetalis Marked fetal edema, called hydrops fetalis Congestive heart failure Marked jaundice Rh Alloimmunization: Prevention Screen for Rh incompatibility and sensitization Take a history Identify Rh-negative woman Antibody screen (indirect Coombs test) Identifies if woman is sensitized Give injection of 300 mcg Rh immune globulin Give Rh immune globulin in the following cases Pregnant Rh-women who have no antibody titer At 28 weeks gestational age Mother whose babys father is Rh positive or unknown After each abortion and within 72 hours postpartum Amniocentesis and placenta previa Invasive procedures that may cause bleeding ABO Incompatibility Cause: Mother has type O blood and infant has A, B, or AB Anti-A and anti-B antibodies occur naturally During pregnancy maternal antibodies cross placenta Cause hemolysis of the fetal red blood cells Unlike Rh incompatibility, first infant is often involved, no evidence of repeated sensitization, no antepartal treatment