CARDIOVASCULAR AND HEMATOLOGIC should stabilize and approach pre-pregnancy numbers by the third trimester.

An abnormal rise in blood pressure could be an indication of preeclampsia,

CHANGES
which involves multiple systems of the patient. (Keep this expected decrease
in SVR in mind when you read the preeclampsia section later in this course.)
Normal and Expected Changes
White blood cell (WBC) counts, especially neutrophils, increase naturally
Maternal circulation changes during pregnancy to accommodate an increase during pregnancy. During active labor there may be another normal increase,
in blood volume of up to 50%. Due to the increase in workload, a split first even in the absence of infection. In nonpregnant patients a normal WBC
sound, a systolic murmur, or even a third heart sound may be heard upon count is somewhere between 5 and 10 (5,00010,000 cells/mm 3), but for
auscultation. The increased blood volume peaks in the third trimester and pregnancy those normal values can be between 6 and 16 in the third
returns to pre-pregnant state somewhere around 612 weeks trimester and may reach 20 to 30 in labor and early postpartum. When
postpartum (Blackburn, 2013). evaluating for infection, therefore, you need to look for other clinical indicators
The increased blood supply includes a 45% to 50% increase in plasma such as increased temperature, bacteriuria, WBC in urine, uterine
volume and 20% to 30% increase in red blood cells. Since these tenderness, and fetal tachycardiaand document them.
percentages are not equal, the subsequent
hemoglobin (HGB)/hematocrit(HCT) will reflect a normal physiologic anemia CHANGES IN CARDIOVASCULAR SYSTEM
of pregnancy. The HCT will appear to fall as the volume increases more than
the packed cell count.
During pregnancy, the systemic vascular resistance (SVR) of the blood Prepregnancy Pregnancy
vessels lowers due to increased levels of hormones. This decreasing SVR is
an expected result of the increasing progesterone and prostaglandin levels,
which relax smooth muscle, producing vasodilatation.
Cardiac output 25-50% increase
As a result of the increased volume and decreased resistance, cardiac output
rises. Therefore, there is a normal lowering of the blood pressure, especially
in the second trimester. This sometimes causes dizziness or feeling faint in
women as they rise to standing during the second trimester. Their pressure
CHANGES IN CARDIOVASCULAR SYSTEM
NORMAL HEMATOLOGIC VALUES

Prepregnancy Pregnancy
Nonpregnan Pregnant
t

Heart Rate 70-80 80-90

Hemoglobin (HGB) 1216 gm/dl 11.515 gm/dl

Blood volume (ml) 4000 5250

Hematocrit (HCT) 36%48% 32%36.5%

RBC mass 4,200,000 4,650,000

Red blood cells (RBC) 45.3 no change

Leukocytes 7,000 20,500

(mm3)
White blood cells (WBC) 410.6 620

Fibringen (mg/dl) 300 450 Pregnancy is typically considered a hypercoagulable statemeaning that
most pregnant women clot more readily than normal and are predisposed to
deep-vein thrombosis or other clot-related conditions. During pregnancy there
is an increase in certain factors in the clotting cascade due to normal The following changes represent abnormal findings:
adaptation (see table). Platelets are usually unchanged in pregnancy, and Diastolic murmur or very loud systolic murmur
increased levels of platelets are rare. Normal levels should be 140,000 to Rising blood pressure before the 20th week (see Preeclampsia
300,000 per mm3. below)
WBC levels above 2030,000 cells/mm3, or shifts in the differential,
NORMAL LEVELS FOR CLOTTING FACTORS especially a larger percentage of bands/stabs appearing, or a sharp
increase in WBC level
A true anemia: HGB <11.5 g/dl and HCT <30%
Nonpregnan Pregnant
ANEMIA
t
To evaluate the genesis of anemia, the following laboratory values are taken
into consideration:
If anemia is from low iron, you will see the following results:
Factor V 50%147% Increased
Microcytic/hypochromic red blood cells (smaller/paler than normal)
Serum ferritin <11 ng/ml (mg/L)
Transferrin saturation level <16%
Protein S 54%160% 30%70% Serum iron <30 mcg/dl
Mean corpuscular hemoglobin concentration (MCHC) <30 g/dl
Iron-binding capacity increased (>400 mcg/dl)
If anemia is from folic acid deficiency, you will see:
Antithrombin 80%130% Should remain stable (a decrease
Enlarged red blood cells, meaning the MCHC will be increased
indicates increased thrombosis risk)
(higher); this is directly opposite of iron-deficiency anemia

INCREASED CLOTTING
Abnormal Changes
Although all pregnant women experience some expected changes in clotting,
there are defective clotting conditions that greatly affect the outcomes of
some pregnancies.
Patients with histories of multiple, unexplained miscarriages or a history of
deep-vein thrombosis are often worked up for clotting conditions, which
include:
Antiphospholipid antibodies
Antithrombin deficiencies
Factor V Leiden mutations
Protein C and S deficiencies
Abnormal increased clotting arises either from abnormal functioning of factors
that assist in clotting or abnormal functioning of factors that control or slow
clotting.
Abnormal Clotting Conditions
Antiphospholipid syndrome (APS). According to Murray &
McKinney (2010), APS is an autoimmune condition characterized by the
production of antiphospholipid antibodies. Patients may experience
thrombosis, fetal loss, preeclampsia, placental insufficiency and preterm
labor. According to Witcher & Hamner (2013), antiphospholipid antibody
syndrome (APS) is characterized by the presence of antiphospholipid
antibodies, lupus anticoagulant (LAC), and anticardiolipin
antibody (ACLA) with arterial and/or venous thrombosis.
Antithrombins (AT) are important regulators of the coagulation cascade
because they inhibit thrombin (clot) formation. Antithrombin
deficiencies can be inherited or pregnancy-induced. Antithrombins work
mainly to inhibit factor Xa and factor IXa, so a deficiency means increased
risk of clotting. Of note: heparin enhances the effect of antithrombin III,
leading to more effective anti-clotting action. Since heparin enhances AT III, if
this factor is not present, heparin may not be an effective anticoagulant for
therapy.
Factor V Leiden mutation is the name of a specific mutation that results in
thrombophilia, or an increased tendency to form abnormal blood clots in blood
vessels. People who have the factor V Leiden mutation are at somewhat
higher-than-average risk for a clot to form in veins such as the deep veins of
the legs (deep-vein thrombosis) or for a clot that travels through the
bloodstream and lodges in the lungs (pulmonary embolism). In a woman
where this mutation is present, clots may form within the placenta, cutting off
nutrition and oxygen to the developing fetus.
Protein S and protein C are important inhibitors of the coagulation cascade,
and a deficiency increases the risk of clots. These protein deficiencies are
usually genetic. Protein C helps to degrade the prothrombotic factor VIII (von
Willebrand factor). Protein S is a co-factor to protein C.
Laboratory Tests
A physician may order the following diagnostic and assessment laboratory
tests in evaluating a patient with frequent miscarriages or history of clotting:
Antiphospholipid syndrome. Medium-to-high positive IgG or IgM
anticardiolipin antibodies or detection of lupus anticoagulant; APTT
(activated partial thromboplastin time), KCT (Kaolin clotting time),
dRVVT (dilute Russells viper venom time), and ELISAs (enzyme
linked immunosorbent assay) for detection of cardiolipin antibodies.
 Thrombosis. Laboratories and panels checking for mutations and Anti-Xa activity level is used for monitoring unfractionated heparin
various clotting factors such as ANT (antithrombin), protein C, protein therapy and low-molecular-weight heparin (Lovenox).
S, dRVVT, LAPTT (LA sensitive PTT), CLABORATORY
(cardiolipin AB panel), HOMO (homocysteine), F5LDNA (factor 5 OPTIMUM RANGES FOR HEPARIN THERAPY
Leiden PCR), F2MUT (factor II mutation), HINTRP (thrombosis panel
intrp), and LINTRP (LLI intrp).
Before starting therapy for clots or deep-vein thrombosis, several panels may Type Therapeutic Prophylactic
be drawn at the same time to assess the patients status or to support a
diagnosis of thrombosis. Ongoing laboratory tests will monitor for therapeutic
goals. Therapy-monitoring laboratory tests include:
Unfractionated 0.30.7 0.10.4
PTT (partial thromboplastin time; looks at the intrinsic or contact
activation pathway) and PT / INR(prothrombin time/international
normalized ratio; the extrinsic or tissue factor pathway). Both monitor
the effects of anti-coagulation therapy. Low molecular-weight 0.51.0 0.20.4
o Normal PTT is 2337 seconds. The PTT used to be the
standard monitoring laboratory test for heparin therapy. Heparin
therapy is now monitored by measuring the unfractionated
Note: All values are given in anti-Xa units/mL plasma.
heparin assay laboratory result (anti-Xa activity), not the PTT.
o Normal PT is 1113 seconds, and normal INR is 0.81.2 IU
(international units). The goal is to increase INR to 23.5 IU.
INCREASED BLEEDING
Warfarin (Coumadin) is used on the extrinsic pathway. (Note:
Those using warfarin should avoid foods with vitamin K due to Patients at increased risk for bleeding are those lacking clotting factors or
their effect on the extrinsic pathway. Pregnant women are not platelets, or whose clotting factors do not function properly.
given warfarin until after delivery, due to its affects on fetal Low platelets may result from:
development and clotting.) HELLP (hemolysis, elevated liver enzymes, and low platelets)
 ITP (idiopathic thrombocytopenia purpura)
TTP (thrombotic thrombocytopenia) VALUES FOR DISSEMINATED INTRAVASCULAR
HUS (hemolytic uremic syndrome) COAGULATION
Platelets may also be lowered due to multiple microclots or for unknown
reasons.
Platelet levels <100,000 per mm3 need to be monitored carefully. Continued Normal DIC
declining levels are suspicious for micro-clotting conditions and disseminated
intravascular coagulation (DIC).
As clots form and break down, clotting factors and fibrinolytic factors are used
up. The presence of fibrin split products and an elevated D-dimer indicate that
clots are being broken down in the body.
DIC occurs if the process is taking place too rapidly for the body to replace
the factors used. Laboratory values will show that clotting has taken place, Platelets 150,000400,000 per mm3
but in DIC there are signs that the process has gotten out of hand, such as
bleeding from intravenous (IV) or injection sites, hemorrhage, and
cardiovascular collapse.
Fibrin split products* <10 mcg/ml

VALUES FOR DISSEMINATED INTRAVASCULAR

COAGULATION
D-dimer** 00.5 mcg/ml

Normal DIC

* Also called fibrin degradation products (FSP or FDP) when clots are
broken down.
Fibrinogen (factor I) 170470 mg/dl
 reabsorption, however. The increase in glucose load during pregnancy is
VALUES FOR DISSEMINATED INTRAVASCULAR often spilled into the urine and not reabsorbed. Therefore, spillage of some
COAGULATION glucose in pregnancy is not always indicative of pathology.
The anatomy of the pregnant uterus causes changes in the location and
pressure of other internal organs. The bladder becomes slightly concave and
Normal DIC is displaced forward and upward. The uterus causes the ureters to become
dilated and more tortuous, especially the right ureter. Detectable
hydronephrosis or hydroureter during pregnancy is considered normal and
may take 3 to 4 months post-delivery to fully resolve.
** D-dimer is made when clots are broken down.

Urinary Tract
Changes
RENAL CHANGES
Normal and Expected Changes Variable Change

The renal system undergoes many changes in pregnancy to accommodate

increased metabolic and circulatory requirements. The system now clears the
body of both maternal and fetal waste and is affected by the increased blood Glomerular Increased by 50%
volume and lowered systemic vascular resistance. As previously mentioned, filtration rate
progesterone has a relaxing effect on vascular tissue, thus enhancing the
renal blood flow and function. The increased plasma flow into the renal
system causes the glomerular filtration rate (GFR)to rise dramatically. BUN Decreased by 25%
Renal clearance of many substances is generally elevated in pregnancy,
causing lower-than-usual serum levels of the renal markers blood-urea-
nitrogen (BUN) and creatinine. Increased filtration does not mean enhanced
 Urinary Tract
Changes NORMAL VALUES FOR RENAL FUNCTION

Variable Change Nonpregnant Pregnant

Renal threshold Decreased to allow slight spillage Serum creatinine 0.61.4 mg/dl 0.530.9 mg/dl
for sugar decrease

Bladder capacity Increased by 1,000 ml Serum BUN 731 mg/dl 810 mg/dl decrease

Diameter of Increased by 25% Serum uric acid 2.48.2 mg/dl 25.8 mg/dl
ureters

Urine Cr 90130 mL/min 150200 mL/min

Frequency of Increased slightly in first trimester, last 2 weeks of clearance
urination pregnany increases to 10-12 times/day

Urine uric acid 150990 mg/24 hrs Increases

 Increased progesterone levels also affect the gastrointestinal (GI) system of
NORMAL VALUES FOR RENAL FUNCTION the pregnant woman. General tone, lower esophageal sphincter tone, and
motility are decreased. This predisposes the woman to increased incidence of
reflux (heartburn) and constipation. As the gravid uterus displaces the internal
Nonpregnant Pregnant organs, this incidence increases.
The liver increases its production of lipids and cholesterol. This change,
combined with delayed gallbladder contraction (due to progesterone-
influenced relaxation), may lead to increased gallstone formation (expected)
or inflammation of the gallbladder (abnormal). The liver also plays a role in
the production of the clotting factors previously discussed.
In addition to increased production of lipids and certain clotting factors, some
Urine glucose 60115 mg/dl Increases enzymes found within the liver are also increased without indicating
pathology. It is important to distinguish a normal rise in these levels from a
pathologic change caused by organ damage or destruction arising, for
Abnormal Changes example, from preeclampsia or hepatitis. In preeclampsia, microclots in the
liver and capsular edema are danger signs, and if clotting factors become
Abnormal values include: affected, the patient is at a high risk for disseminated intravascular
24-hour urinary protein >300 mg coagulation (DIC). Diagnoses are not based upon a single abnormal value.
Serum creatinine rising (indicates renal damage, possibly from
preeclampsia)
WBC >5 from urine sample (high-powered microscopic field)
Bacteria >20 in urine sample (centrifuged urinalysis) (indicates UTI)

GASTROINTESTINAL CHANGES
Normal and Expected Changes

NORMAL HEPATIC VALUES
Liver Enzymes
Alanine transaminase (ALT)
Aspartate
aminotransferase (AST)
Alkaline phosphatase (ALP)
Lactate dihydrogenase (LDH)
Abnormal Changes: Preeclampsia
Preeclampsia is a condition in which high blood pressure and protein in the
urine develop in the late second or third trimester of pregnancy. Preeclampsia
potentially affects every organ of the pregnant patient. Microclots develop
within the vascular tissue, and their effects are typically seen according to
Nonpregnant Pregnant which organ develops the clots.
DIAGNOSING PREECLAMPSIA
Preeclampsia is diagnosed when there is a:
1467 U/L Unchanged
Blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic that
occurs after 20 weeks of gestation in a woman with previously normal
blood pressure
658 U/L Unchanged Proteinuria, defined as urinary excretion of 0.3 g protein in a 24-hour
urine specimen
Severe preeclampsia is diagnosed if one or more of the following are present:
Blood pressure of 160 mm Hg systolic or 110 mm Hg diastolic on
two occasions at least 6 hours apart while the patient is on bed rest
38150 > up to 24 times
Proteinuria of 5 g in a 24-hour urine specimen or 3 g on two random
ImU/ml
urine samples collected at least 4 hours apart
Oliguria of <500 mL in 24 hours
Cerebral or visual disturbances
117224 U/L Upper end of normal to Pulmonary edema or cyanosis
700 U/L Epigastric or right upper-quadrant pain
Impaired liver function
Thrombocytopenia
Fetal growth restriction
ASSESSING FOR COMPLICATIONS AND TREATMENTS Neurological signs. Edema from leaking vascular tissue puts
The following tests, signs, and symptoms are used to assess for pressure on the optic nerve, and patients may report a distortion in
complications or treatments of preeclampsia: their vision. Edema in the brain can cause severe headache and
DIC panel. A patient in severe preeclampsia may develop HELLP potentially life-threatening seizures.
CASE
and/or DIC. (See DIC in the Increased Bleeding section above
and HELLP in the Pregnancy-Specific Diagnoses section below.)
Emergency medical personnel are called to the home of a patient at 35-
Magnesium level. Preeclamptic patients on IV magnesium sulfate
weeks gestation whose husband reports that the patient is having severe
may have laboratory values drawn to establish therapeutic goals.
headaches, blurred vision, and her face seems to twitch. Upon EMSs arrival
o A normal magnesium level in an unsupplemented patient is 1.5
to the home, the patient states that every once in a while I get this really bad
2.5 mg/dl (mEq/L).
pain right here and points to the right, upper quadrant of her abdomen.
o The goal is 47mg/dl (mEq/L) for patients receiving IV
Suddenly, the patient has a seizure. Emergency personnel note tonic-clonic
magnesium therapy.
seizures lasting 60 seconds. Evidence of the rupture of the amniotic
o Magnesium levels >9 mg/dL (mEq/L) are potentially life
membranes is not present. Vital signs are temperature 98.8 F, heart rate 104
threatening.
bpm, RR 24, blood pressure 174/114, pulse ox levels are 90% on 10 L/min of
Liver function panel. Used to assess whether preeclampsia is
oxygen via face mask. Generalized edema and 3+ pedal edema are noted.
causing liver organ damage and/or HELLP syndrome. Assessment of
Fetal heart tones are 110120 beats per minute.
the patient will reveal abdominal pain and tenderness in the upper-right
Discussion
quadrant, which may be caused by microclots and lead to liver
In the presence of severe headache, blurred vision, elevated blood pressure,
capsular edema.
and seizure activity, the patient is most likely experiencing eclampsia.
24-hour urine protein. Assesses whether kidney function is being
Eclampsia may develop in the presence of preeclampsia. Eclampsia is
affected by vascular spasming and microclotting found with
characterized by elevated blood pressure in the presence of seizure activity.
preeclampsia. A level of >300 mg is indicative of mild preeclampsia; a
Initially, patients will present with seizure activity such as facial twitches. Later,
level of >5 gm is indicative of severe preeclampsia. A patient with
the patient may experience tonic-clonic activity. In addition to eclampsia, the
falling urinary output is especially at risk for magnesium overdose if
patient may be experiencing HELLP syndrome (hemolysis, elevated liver
clots from preeclamptic processes are affecting the renal blood flow.
enzymes and low platelets), which often presents with right upper quadrant
abdominal or epigastric pain and/or severe edema.
As a result of uterine irritability, the patients amniotic membranes may rupture
and delivery may be imminent following seizure activity. Therefore,
emergency personnel must be prepared for possible delivery. They should
also follow local protocols to ensure the patients safety during and following
seizure activity. Once at the hospital, orders will be given for a DIC panel, liver
function panel, and 24-hour urine. Orders can also be anticipated for chest
radiography and arterial blood gas to identify aspiration following seizure
activity (Murray & McKinney, 2010).
TRAUMA IN PREGNANCY
A pregnant woman being evaluated after a trauma-related event (e.g., car
wreck, fall, domestic violence) requires immediate, simultaneous assessment
of both maternal and fetal well-being. The woman should undergo the
standard post-trauma focused history and physical exam to determine
whether she has sustained any injuries.
To assess the fetuss heath, the pregnant woman should be asked
immediately about:
Leakage of blood and/or fluid from her vagina
Any traumatic force directed at her abdomen
New-onset abdominal pain
Changes in or absence of previous fetal movements (if indicated by
gestational age)
Further assessment of fetal well-being can be done by fetal monitoring,
ultrasound evaluation, and maternal blood work.
After establishing immediate safety, continued assessment is aimed at
evaluating safety and observing for placental abruption, which is a risk after
traumatic abdominal events.
INTIMATE PARTNER VIOLENCE (IPV)
Pregnancy is a time of increased intimate partner violence. Signs may include
bruises and injuries inconsistent with their explanation, blows or falls visible
on the abdomen, poor weight gain, and frequently missed prenatal
appointments. Every woman should be screened prenatally for risk of
domestic violence and counseled on safety issues. Names and numbers of
local agencies should be made available to the woman should she need help
escaping from violence. Screening should be done in private if at all possible,
as the woman may not feel free to admit to danger in front of her family or the
abuser. To establish privacy, it is sometimes possible to resort to bathroom
facilities.
Bleeding
Maternal bleeding may be indicated by falling hemoglobin and hematocrit or
abnormal CBC (complete blood count); signs and symptoms of placental
abruption (apparent or concealed vaginal bleeding, uterine tenderness,
uterine irritability, abdominal pain, and/or pain in the lower back), which can
be partial and/or hidden; and signs and symptoms of DIC from abruption or
alterations in the normal clotting cascade.
Fetal bleeding may be indicated by electronic fetal monitoring changes such
as tachycardia followed by bradycardia, absent variability, decelerations,
and/or sinusoidal tracing. A Kleihauer-Betke (KB) screen may be ordered to
look for fetal blood cells that have entered maternal circulation; normally there
are none.
CASE
The nurse is caring for a patient at 32-weeks gestation admitted for
abdominal trauma. Upon assessment, the nurse notes a fetal baseline of 165
bpm without accelerations or decelerations. Uterine irritability is present. The
nurse notes a small amount of dark red vaginal bleeding and a board-like
abdomen. Amniotic membranes are intact. Bruises at various stages of
healing are also noted on the wrists and ankles. The patient states, Im so
clumsy. I bumped into the doorknob. Vital signs are temperature 98.9 F,
heart rate 104 bpm, RR 22, and blood pressure 102/66.
Discussion
In the presence of dark red vaginal bleeding, a board-like abdomen, and
uterine irritability, the patient is most likely experiencing abruptio placentae as
a result of abdominal trauma. Bruising at multiple stages of healing and an
explanation that is inconsistent with the level of injury (e.g., walking into a
doorknob) are strong indicators of IPV. Hemoglobin lab testing should be
conducted to determine blood oxygenation levels. A KB screen should also be
ordered to assess for the presence of fetal blood cells in the maternal
circulation. After the patient is stabilized, an IPV screen can be completed in
the absence of the patients family or friends. A social services consult should
be obtained if suspected or confirmed IPV is noted.
PREGNANCY-SPECIFIC DIAGNOSES
Other common tests for the obstetric population include the following:
Fetal Fibronectin (fFn) Test
Fetal fibronectin (fFn) is found in cervicovaginal fluid until about 22 weeks
gestation. It then is absent until it reappears within 2 weeks of term or preterm
delivery. Serial tests done on a woman experiencing preterm contractions or
labor are used as a predictor of preterm delivery. A positive fFn >50 in a
singleton pregnancy is a moderate predictor that delivery will occur within 1 to
2 weeks.
Fetal Maturity Test
The lecithin/sphingomyelin (L/S) ratio is a test of amniotic fluid obtained
through amniocentesis to determine fetal lung maturity. A ratio of 2 or greater
in the presence of phosphatidyl glycerol (PG) is indicative of sufficient lung
surfactant for prevention of neonatal respiratory distress
syndrome (RDS) (Van Leeuwen et al., 2013). A fetal lung maturity test should be
performed before 38 weeks of gestation, or if gestational age is unknown, to
determine the fetuss ability to breathe outside the womb (Murray & McKinney,
2010).
Fetal Anomalies or Fetal Compromise
A patient who has a suspicious fetal heart rate (FHR) tracing on early
monitoring (e.g., sinusoidal tracing, bradycardia, tachycardia) or a patient who
presents with signs of a viral illness, abnormal ultrasounds, or an unexpected
delivery of an infant with anomalies may prompt the provider to order
a TORCH panel. The panel, named for the mnemonic TORCH (see below),
measures the immune system status of the mothers exposure to pathogens
known to cause fetal anomalies or compromise.
TORCH PANEL
Toxoplasmosis Toxoplasmosis can cause eye deformity, eye
infections, and mental retardation by invading
brain tissue. Obtained from raw meat, cat feces
and soil.
Other This includes any additional physician-ordered
tests to screen for other infectious diseases,
such as group B-strep (GBS), HIV, Varicella virus
(Chickenpox), Parvovirus B19 (Fifth disease).
Rubella Infants born with rubella may show signs of heart
defects, retarded growth, ocular defects, or
pneumonia at birth. They may also develop
problems later in childhood, including autism,
hearing loss, brain involvement, immune system
disorders, or thyroid disease. Postpartum
mothers may be immunized if their prenatal
results were rubella non-immune or equivocal in
order to protect future pregnancies. Live virus
vaccines, such as the rubella vaccine, should not
be given to pregnant women.
Cytomegalovirus(CMV Mothers exposed to CMV may have infants who
) suffer from hearing loss (15%) or mental
retardation (30%). Newborns who acquire CMV
during the birth process or shortly after birth may
develop pneumonia, hepatitis, or various blood
disorders.
Herpes Disseminated herpes infections attack the liver,
adrenal glands, and other body organs of the
infant. Without treatment, the mortality rate is as
high as 80%. Mothers with active lesions are
delivered via cesarean section to avoid neonatal
 exposure to lesions.

CONCLUSION
In caring for pregnant women and their unborn infants, it is important for the
healthcare provider to understand the normal physiologic changes that occur
during pregnancy. The provider can utilize various laboratory tests and
diagnostic tools to assess the magnitude of these changes and to identify
abnormal changes.