Diseases During Pregnancy

DISEASES DURING PREGNANCY •

CARDIOVASCULAR DISEASES

I – UNCOMPROMISED •

No limitation in terms of physical activity

•

Ordinary activity causes no discomfort

•

No angina pain

II – SLIGHTLY COMPROMISED •

Slight limitation of physical activity

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Slight fatigue on ordinary activity

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Slight angina pain

III – MARKEDLY COMPROMISED •

Marked or moderate limitation of physical activity

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Marked or moderate fatigue fatigue

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Marked palpitations

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Marked or moderate angina pain

IV – SEVERELY COMPROMISED •

Severe discomfort when doing any activity

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Severe angina pain even at rest

A ) A WOMAN WITH LEFT SIDED HEART FAILURE •

Increased workload of the heart results in

•

Increase in the size of the hearts chambers especially the ventricles

• During increase in size, it is the STRETCH TISSUES that are predominantly increased and not the Functional Tissue. This results to a •

Diminished left ventricular function

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Left ventricle can no longer pump blood effectively to the systemic circulation

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Causing back pressure on the pulmonary circulation

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Pulmonary vein becomes distended to accommodate the blood

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Increase in pressure in the pulmonary vein ( more than 25 mmHg ) resulting to:

Ø PULMONARY HYPERTENSION •

Limited oxygen supply and poor systemic circulation;

•

When the pulmonary vein pressure reaches 25 mmHg

•

Fluid begins to pass from the pulmonary capillary membranes into the

•

Interstitial spaces and alveoli causing

Ø PULMONARY EDEMA ( check Coughing and Crackles ) •

Increases capillary pressure causing it to rupture ( check Blood-streaked sputum )

• Woman cannot assume any position other than sitting because the left ventricle cannot accommodate increase in increase in venous return •

Fluid moves to the pulmonary system worsening the pulmonary edema

• When resting using sitting position, patient may experience PAROXYSMAL NOCTURNAL DYSPNEA ( suddenly waking at night due to difficulty breathing ) this occurs because the heart is more effective at rest causing temporary shift of fluid back to the circulation • • B ) A WOMAN WITH RIDE SIDED HEART FAILURE

•

Right ventricle is weak so that the blood the blood that the right atrium receives

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Is not efficiently pumped to the pulmonary circulation causing

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Back pressure of blood to the systemic venous circulation resulting to a

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Decrease blood output to the lungs decreasing also the blood to the aorta

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Blood accumulates in the venous system causing

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Increase in pressure of the vena cava resulting to:

Ø Jugular Vein Distention • Accumulation of blood in the venous system also causes an increase in the pressure of the portal vein and later causing enlargement of the spleen and Liver. • Distended abdominal vessels also alters its permeability causing water to shift to the peritoneal cavity causing Ascites. • Fluids from systemic circulation also moves towards the interstitial spaces of the lower extremity causing Peripheral Edema. EFFECTS TO PREGNANCY: • POOR PLACENTAL PERFUSION – INTRAUTERINE GROWTH RESTRICTION – FETAL DEATH ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE •

Starts with obtaining a baseline health history of the mothers pre-pregnant life

• Always alert the woman to report cough during pregnancy ( this is the earliest manifestation of left sided heart failure during pregnancy ) •

Ask the patient what activities would contribute to her dyspnea and chest pain

• Take note of edema ( Normally found in the feet and ankles ), this should not progress to other parts of the body •

HEMATOLOGIC DISORDERS

A ) ANEMIA • Plasma volume normally expands during pregnancy causing pseudoanemia. This should be confused with true anemia that may be present in a woman during pregnancy. 1 ) IRON DEFICIENCY ANEMIA •

The most common form of anemia

• Most common during pregnancy since women do not usually take iron supplement and eat iron rich food and the woman also loses iron during menstruation •

Iron is needed for proper RBC growth and reproduction

• Low supply of iron will lower hemoglobin and thus make a pregnant woman develop easy fatigability MGT: •

Iron supplement of 60 mg ( Prophylaxis )

•

With IDA = 120-180 mg/day in the form of ferrous sulfate )

•

Eat green leafy vegetables, glandular products, and legumes

•

RENAL AND URINARY DISORDERS

A ) URINARY TRACT INFECTION Ø Pregnant women usually have asymptomatic bacteriuria Ø The ureters normally dilate in pregnancy due to progesterone causing urine stasis Ø Because there is sugar in the urine during pregnancy, this allows growth of bacteria •

CHRONIC RENAL DISEASE

Ø Because the kidneys are impaired, the don’t produce erythropotein resulting ANEMIA. Ø The woman may receive synthetic erythropotein. Ø In pregnancy GFR is increased normally i resulting in slightly lower creatinine. But if the if you have chronic renal disease, this may not be the case. Ø Women with CRF usually take Prednisone ( Steroid ) Effects: •

Known to cause cleft palate if used during pregnancy

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Suppresses insulin activity causing hyperglycemia.

•

RESPIRATORY DISORDERS

A ) WOMAN WITH INFLUENZA Ø Caused by Influenza virus identified as A,B, or C. Ø Spreads in epidemic form Ø High fever, extreme prostration, aching pain and soar , raw throat. Treatment of choice: •

Oseltamivir ( TamiFlu )

•

Use cautiously with pregnancy

B ) ASTHMA Ø Reversible airflow obstruction, airway hyperactivity, and airway inflammation. Ø Immediate danger is the reduction of oxygen to the fetus. •

DRUGS FOR ASTHMA DURING PREGNANCY

BEST CHOICE •

Inhalled Corticosteroids

Ø Beclomethasone ( Beclovent and Vancenase ) Ø Budesonide ( Pulmicort and Rhinocort ) C ) TUBERCULOSIS •

Do not breast feed

•

Sputum Exam and PPD

• Mother must have 3 negative sputum cultures if she has a history of tuberculosis before she hold or cares for her infant. E ) CYSTIC FIBROSIS •

AN INHERITED DISEASE THAT A MOTHER MAY PASS TO HER BABY.

• CHILDREN EITHER BE A CARRIER OR ONE WHO WILL MANIFEST THE SYMPTOMS OF THE DISEASE.

• The Implicated cause is the Cystic Fibrosis Transmembrane Conductance Regulator ( CFTR ) which is located on Chromosome No. 7 •

This is an abnormal protein that resembles normal protein

•

However, the abnormal protein lacks PHENYLALANINE

• The lack of this essential amino acid contributes to the characteristic sign of C.F, which is Mucosal Thickening of the Respiratory and Intestinal Tracts. •

RHEUMATOID DISORDERS

A ) JUVENILE RHEUMATOID ARTHRITIS Ø Chronic inflammation of the joints that may lead to permanent loss of joint mobility and function Remember: Aspirin is the Drug of Choice of JRA. What is the implication? •

SYSTEMIC LUPUS ERYTHEMATOSUS

• Chronic Disease that affects connective tissues and has the potential to cause multiorgan failure Dangers: •

Affects oxygenation of the mother and fetus

•

Affects nutrient transport

•

GASTROINTESTINAL PROBLEMS

A ) APPENDICITIS B ) CHOLICYSTITIS and CHOLELITHIASIS •

NEUROLOGIC DISORDERS

•

MYASTHENIA GRAVIS ( weakening )

Ø Neostigmin ( Prostigmin ) Ø Pyridostigmine ( Mestinon )

•

MULTIPLE SCLEROSIS ( demyelination )

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SEIZURE DISORDERS

HIGH RISK NEWBORN •

TOP 8 NEWBORN PRIORITIES IN EARLY DAYS OF LIFE

8 ) DEVELOPMENTAL CARE 7 ) BONDING 6 ) INFECTION PREVENTION 5 ) PROPER WASTE ELIMINATION 4 ) ADEQUATE NUTRITION 3 ) CONTROLLED BODY TEMPERATURE 2 ) PROPER CIRCULATION 1 ) PROPER RESPIRATIONS

PRENATAL VISIT GENERAL CONSIDERATIONS: Ø The PROVISION of prenatal care is the primary factor in the improvement of maternal and infant morbidity and mortality statistics. Duration of Pregnancy: Ø 266-280 days Ø 38-42 weeks ( average is 40weeks ) Ø 9 calendar or 10 Lunar Months • ANY BABY THEREFORE WHO IS BORN BEFORE 38 WEEKS OF GESTATION IS CALLED PRE-TERM

•

ANY BABY BORN AFTER 42 WEEKS IS CALLED

POST-TERM DIAGNOSIS OF PREGNANCY: 1 ) URINE EXAM – to detect HCG Ø HCG is present from the 40th day through the 100th day reaching a peek on the 60th day. COMPONENTS OF PRENATAL VISIT: 1 ) HISTORY TAKING 1.1 PERSONAL DATA

Ø patient’s name Ø Age and address Ø Family diseases Ø Where does she live? Ø Wed or unwed? 1.2 OBSTETRICAL DATA A ) NULLIPARA – never been pregnant B ) GRAVIDA – number of pregnancies a woman has had C ) PARA – number of viable pregnancies regardless of number and outcome D ) TPAL •

T – number of full term babies

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P – remature babies

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A – bortion

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L – iving children

EXAMPLE: 1 ) PATIENT X 2 ABORTIONS DURING HIGHSCHOOL PATIENT X IS 2 MONTHS PREGNANT DURING VISIT GET THE: G –PA T-P-A-L 2 ) PATIENT Y Ø 1 BOY BORN AT 39TH WEEK AOG Ø 1 MISCARRIAGE Ø 1 GIRL BORN AT 36 WEEK AOG Ø 1 STILL BIRTH AT 33 AOG Ø PATIENT Y IS ON HER 3RD WEEK DURING HER VISIT GET THE: G –PA T-P-A-L 1.3 DETERMINE METHODS OF PAST PREGNANCIES Ø NSVD OR C/S? Ø WHERE? AT HOME? IN THE HOSPITAL? Ø RISK INVOLVED? PREMATURITY? TOXEMIA? 2 ASSESSMENT 2.1 PHYSICAL EXAMINATION Ø A review of systems is indicated, especially the teeth because they are usually a source of infection.

2.2 PELVIC EXAMINATION CARDIAN RULE: EMPTY THE BLADDER A ) INTERNAL EXAMINATION ( I.E. ) Ø To determine C / G / H B ) BALLOTEMENT Ø Fetus will bounce when the lower uterine segment is tapped sharply especially during the 5th month of pregnancy. C ) PAPANICOLAU TEST ( Pap Smear ) – cytological examination to diagnose cervical carcinoma. CLASSIFICATION OF FINDINGS: Class 1 : Normal ( Absence of cancer cells ) Class 2 : presence of abnormal cells but no signs of malignancy Class 3 : suggestive of malignancy Class 4 : strongly suggestive of malignancy Class 5 : Conclusive for malignancy CLINICAL STAGES that reflect localization or spread of malignant cervical changes: Stage 1 : Cancer confined to cervix Stage 2 : Cancer extends beyond the cervix into the vagina Stage 3 : Metastasis to the pelvic wall Stage 4 : metastasis from pelvic wall to bladder and rectum D ) LEOPOLD’S MANEUVER’S PURPOSES: Ø To determine presentation, position and attitude Ø Estimate fetal size

Ø Locate fetal parts PREPARATORY STEPS: Ø WARM HANDS Ø PALMS are used, NOT FINGERTIPS Ø DORSAL RECUMBENT Ø Apply gentle but firm motions 1ST MANEUVER Ø Face the HEAD PART of the mother Ø Palpate for fetal part found in the fundus to determine PRESENTATION • HARD, SMOOTH, BALLOTABLE mass at the fundus means the fetus is in BREECH PRESENTATION 2nd MANEUVER Ø PALPATE the sides of the uterus to determine the location of THE FETAL BACK •

The fetal back is the BEST PLACE to hear fetal heart tones

3rd MANEUVER Ø Grasp lower portion of abdomen just above the symphysis pubis to find out degree of ENGAGEMENT. 4th MANEUVER > Facing the feet part of the patient, press fingers downwards on both sides of the uterus to determine ATTITUDE ( DEGREE OF FLEXION OF THE FETAL HEAD ) E ) VITAL SIGNS Ø WEIGHT AND BLOOD PRESSURE SHOLD BE MONITORED CLOSELY. Ø An increase in BP during the 1st trimester usually indicates toxemia. F ) URINE EXAMINATIONS ACETIC – ALBUMIN ( TOXEMIA )

BENEDICT’S - GLUCOSE IMPORTANT ESTIMATES IN PREGNANCY 1 ) ESTIMATING AGE OF GESTATION ( A.O.G. ) A ) NAGELE’S RULE Ø Calculation of expected date of confinement

( EDC ).

Ø Count BACK 3 MONTHS from the first day of the LMP then ADD 7 DAYS. Ø Substitute number for months for easy computation Example of how to use the Nagele’s Rule: LMP = SEPTEMBER 8 SEPTEMBER IS THE 9TH MONTH OF THE YEAR – 3 = 6 ( JUNE ) ADD 7 DAYS TO THE DATE OF LMP (8+7) = 15 EDC = JUNE 15 B ) McDONALD’S METHOD Ø Determines Age of Gestation by measuring from the fundus to the symphysis pubis in CENTIMETERS then DIVIDE by 4. Ø The answer is equivalent to AOG in MONTHS. Ex: FUNDIC HEIGHT IS 16 CM. 16 / 4 = 4 Months AOG or 16 Weeks AOG C ) BARTHOLOMEW’S RULE Ø Estimate AOG by the relative position of the uterus in the abdominal cavity. JUST REMEMBER:

•

By the 3rd LM, the fundus is palpable slightly ABOVE THE SYMPHYSIS PUBIS

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On the 5th LM, fundus is at the level of UMBILICUS

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On the 9th LM, the fundus is BELOW THE XYPHOID PROCESS

D ) HAASE’S RULE Ø Determines the length of the fetus in centimeters TIP: •

MULTIPLY THE 1ST HALF OF PREGNANCY BY 1

•

MULTIPLY THE 2ND HALF OF PREGNANCY BY 5

E ) JOHNSON’S RULE Ø Estimates the weight of the fetus in grams. FORMULA: Fundic Height – “ N “

X

“K“

Where K is constant ( 155 ) N is = 12 ( if fetus in engaged ) = 11 ( if fetus is not engaged ) HEALTH TEACHINGS FOR A PREGNANT WOMAN A ) NUTRITION – most important aspect in health teaching Women who need special attention: Ø Pregnant teenagers Ø Extremes in weighing scale ( Low and High ) Ø Low income women

Ø Successive pregnancies Ø Vegetarians •

Nutritional assessment is based on taking a thorough DIET HISTORY

Ø Food preferences and eating habits Ø Cultural and Religious influences Ø Educational and occupational levels HOW TO COMPUTE CALORIC EQUIVALENTS: CARBOHYDRATES AND PROTEINS = MULTIPLY BY 4 FATS = MULTIPLY BY 9 FOOD SOURCES: PROTEIN-RICH FOODS Ø Meat and Poultry Ø Fish and Cheese Ø Eggs and Beans Ø Milk and Mongo VITAMIN A EGGS, CARROTS, SQUASH, ALL GREEN AND LEAFY VEGETABLES VITAMIN D FISH, LIVER, EGGS AND MILK VITAMIN E Ø FISH AND GREEN LEAFY VEGETABLES

VITAMIN C TOMATOES, GUAVA, PAPAYA, AND CITRUS FRUITS FOLIC ACID Ø BEST SOURCE IS ASPARAGUS Ø NEEDED TO PREVENT MEGALOSBLASTIC ANEMIA, A. PLACENTA AND PREMATURITY REMEMBER: FOLIC ACID TOGETHER WITH IRON AIDS IN HEMOGLOBIN FORMATION. VITAMIN B Ø SAME WITH FOODS RICH IN PROTEIN CALCIUM/PHOSPHORUS Ø MILK AND CHEESE IRON LIVER AND GLANDULAR PRODUCTS, CAMOTE TOPS, KANGKONG, EGG YOLK, AMPALAYA AND MALUNGGAY. Ø Iron is especially needed in the 3rd trimester Ø Iron has low absorption rate, must be given with VITAMIN C Ø Should be given AFTER MEALS RECOMMENDED DAILY ALLOWANCE ( RDA ) A ) CALORIES ( kcal ) Ø 2000 IN NON-PREGNANT WOMEN Ø ADDITIONAL 300-400 DURING PREGNANCY B ) PROTEINS ( g ) Ø 46 grams Ø Additional 30 during pregnancy

C ) VITAMIN A Ø From 4000 IU to 5000 IU during pregnancy D ) VITAMIN D Ø Remains at 400 IU E ) VITAMIN E Ø From 12 IU to 15 IU F ) VITAMIN C Ø From 45 mg to 60 mg G ) FOLIC ACID Ø From 400 mg to 800 mg H ) CALCIUM and PHOSPHORUS Ø From 800 mg to 1200 mg I ) IRON Ø 18 mg to 36 mg J ) MAGNESIUM Ø From 300 mg to 450 mg K ) IODINE Ø 100 ug to 125 ug SMOKING Ø Causes VASOCONSTRICTION, leading to LOW BIRTH WEIGHT DRUGS Ø Most dangerous during the 1st trimester. •

THALIDOMIDES

Ø Causes amelia or phocomelia ( short or no extremities ) •

STEROIDS

Ø Causes CLEFT PALATE and even ABORTION •

IODINE

Ø A common content in OTC drugs, causes enlargement of fetal thyroid gland, leading to tracheal compression and dyspnea ar birth •

ASPIRIN

Ø Bleeding disorders •

STREPTOMYCIN and QUININE

Ø Damage to the 8th Cranial Nerve ( Deafness ) •

TETRACYCLINES

Ø Causes staining of tooth enamel and inhibits growth of long bones SEXUAL ACTIVITY DURING PREGNANCY: Ø SEXUAL DESIRES CONTINUE THROUGHOUT PREGNANCY, BUT LEVELS CHANGE • DURING THE 1ST TRIMESTER, THERE IS DECREASE IN SEXUAL DESIRE BECAUSE THE WOMAN IS MORE FOCUSED TO THE DIFFERENT BODILY CHANGES SHE IS UNDERGOING. • DURING THE SECOND TRIMESTER, THERE IS AN IMPROVEMENT IN SEXUAL DESIRE SINCE THE WOMAN HAS ALREADY ADAPTED TO THE GROWING FETUS. • DURING THE THIRD TRIMESTER, THERE IS A DECREASE AGAIN IN SEXUAL DESIRE BECAUSE THE MOTHER IS AFRAID OF HURTING THE FETUS. GENERAL CONSIDERATIONS WHEN HAVING SEX IF PREGNANT: –

should be done in moderation

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should be done in private place

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mom placed in comfy position, sidelying or mom on top

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avoided 6 weeks prior to EDD

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avoid blowing or air during cunnilingus

Contraindication in sex: 1. vaginal spotting •

1st trimester – threatened abortion

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2nd trimester– placenta previa

2. incompetent cervix 3. preterm labor 4. premature rupture of membrane EMPLOYMENT Ø AS LONG AS THE JOB DOES NOT ENTAIL HANDLING TOXIC SUBSTANCES, OR LIFTING HEAVY OBJECTS, OR EXESSIVE PHYSICAL OR EMOTIONAL STRAIN, THERE IS NO CONTRAINDICATION IN WORKING. Ø AVOID PROLONG SITTING OR STANDING TRAVELING Ø NO TRAVEL RESTRICTIONS BUT POSTPONE TRIP DURING THE LAST TRIMESTER OR HAVE HISTORY OF PREMATURE LABOR AND MISCARRIAGES. Ø ON LONG RIDES, 15-20 MINUTE REST PERIODS EVERY 2-3 HOURS. Ø EMPTY THE BLADDER AND WALK ABOUT EXERCISES CHIEF AIM: TO STRENGTHEN THE MUSCLES USED IN LABOR AND DELIVERY Ø SHOULD BE DONE IN MODERATION Ø SHOULD BE INDIVIDUALIZED

RECOMMENDED EXERCISE: •

SQUATTING AND TAILOR SITTING

Ø Stretches and strengthen the perineal muscles Ø Increases circulation in the perineum Ø Raise buttocks first when standing from squatting position •

PELVIC ROCK

Ø Maintains good posture Ø promotes good posture Ø Relieves low back ache Ø Strengthens abdominal muscles after delivery •

MODIFIED KNEE CHEST POSITION

Ø Relieves pelvic pressure and cramps in the thighs and buttocks Ø Relieves discomfort from hemorrhoids •

SHOULDER-CIRCLING

Ø Strengthens muscles of the chest •

WALKING

Ø Said to be THE BEST EXERCISE •

KEGEL

Ø Relieves congestion and discomfort in the pelvic region CHILDBIRTH PREPARATION • Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience. PSYCHOPHYSICAL

1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature.

Features: •

1.) darkened rm

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2.) quiet environment

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3.) relaxation tech

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4.) closed eye & appearance of sleep

2. Grantly Dick Read Method – fear leads to tension while tension leads to pain PSYCHOSEXUAL 1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s life cycle - flow with contraction than struggle with contraction PSYCHOPROPHYSLAXIS – prevention of pain 1. Lamaze: Dr. Ferdinand Lamaze •

req. disciple, conditioning & concentration. Husband is coach

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Features:

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Conscious relaxation

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Cleansing breathe – inhale nose, exhale mouth

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Effleurage – gentle circular massage over abdominal to relieve pain

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imaging – sensate focus

• CHECK THE TETANUS IMMUNIZATION STATUS: Ø tetanus immunizations – prevents tetanus neonatum

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mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

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TT1 – any time during pregnancy

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TT2 – 4 wks after TT1 – 3 yrs protection

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TT3 – 6 months after TT2 – 5 yrs protection

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TT4 – 1 yr after TT3 – 10 yrs protection

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TT5 – yr after TT4 – lifetime protection

FREQUENCY OF VISITS: •

1st 7 months – 1x a month

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8 – 9 months – 2 x a month

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10 – once a week

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post term 2 x a week

GESTATIONAL DIABETES TO INFECTIONS IN PREGNANCY GESTATIONAL DIABETES Ø Many women who have no evidence of diabetes in the past develop abnormalities of glucose tolerance during pregnancy. •

Decreased renal threshold of sugar because of increase estrogen

•

Increased production of glucocorticoids

• Increased insulin production BUT decreased sensitivity at receptor sites ( normal during pregnancy ) RISKS IF WITH G.D. DURING PREGNANCY: Ø Toxemia Ø Infection Ø Hemorrhage

Ø Polyhydramnios Ø Spontaneous abortion Ø Dystocia DIAGNOSIS: made on the basis of Glucose Tolerance Test ( GTT ) PROCEDURE: Ø NPO after midnight Ø 2 ml. of 50% glucose / 3 kg of PREPREGNANT body weight given IV. WHY NOT ORAL? INTERPRETATION OF RESULTS: •

IF LESS THAN 100 MG – NORMAL

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IF 100-120 MG – POSSIBLE G.D.

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IF MORE THAN 120 MG – G.D.

MGT: A ) DIET Ø Highly individualized Ø Glucose is still needed ( 1800-2200 calories ) to prevent intrauterine growth retardation Ø Consult dietician first before instituting preferred meal plan CATEGORIES: USED TO PREDICT OUTCOME OF PREGNANCY • CLASS A – GTT IS SLIGHTLY ABNORMAL, MINIMAL DIETARY RESTRICTION, INSULIN NOT NEEDED, FETAL SURVIVAL IS HIGH •

CLASS C TO E – HAVE 25% PERINATAL MORTALITY

• )

CLASS F – THERAPEUTIC ABORTION NEEDED ( NOT IN THE PHILIPPINES

2 ) INSULIN REQUIREMENTS

Ø Highly individualized Ø Increase need especially in the 3rd trimesters due to increase effectiveness of hormones Ø Insulin is regulated to keep urine +1 for sugar to prevent acidosis. C )METHOD OF DELIVERY Ø Often by C/S Ø Baby is typically larger of often distress due placental insufficiency Ø Vaginal trauma is likely to occur INFANT OF THE DIABETIC MOTHER (IDM) A ) IS TYPICALLY LONGER AND WEIGHS MORE BECAUSE OF: •

Excessive supply of glucose from the mother

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Increased production of growth hormones by the pituitary gland

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Increase secretion of insulin from the fetal pancreas

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Increase glucorticoids ( favors passage of glucose )

B ) congenital malformations are often seen C ) Cushingoid appearance ( puffy, but limp and lethargic ) D ) usually born premature, Respiratory is common F ) are prone to: •

HYPOGLYCEMIA

Clinical signs: Ø shrill, high-pitched cry Ø lethargy, poor sucking ability Ø Hypothermia CONSEQUENCE:

Ø If hypoglycemia is not treated, will lead to brain damage and even death. TREATMENT: GLUCOSE

I.V.

MULTIPLE PREGNANCY CLASSIFICATION 1 ) MONOZYGOTIC / IDENTICAL Ø Twins begin with a SINGLE OVUM and SPERM Ø In the process of meiosis the zygote divides into two identical BUT separate individuals. CHARACTERISTICS: Ø Describe the sex. Same or different? Ø 2 amnions, 1 chorion, 2 funis and 2 placentas fused as one INCIDENCE: Ø More frequent among non-whites Ø More frequent among young primis and old multis 2 ) DIZYGOTIC / FRATERNAL Ø 2 SEPARATE OVA the same time in the utero.

fertilized by 2 SEPARATE SPERMS. Siblings growing at

CHARACTERISTICS: Ø Same or Different Sexes Ø 2 amnions, 2 chorions, 2 placentas and 2 funis SUSPECT MULTIPLE PREGNANCY IF: Ø Faster rate of increase in uterine size Ø Exagerated quickening

Ø 2 sets of fetal heart tones are heared Ø Marked weight gain, no signs of toxemia or obesity •

MANAGEMENT

BASED ON WHETHER THE FF. IS PRESENT: A)

PIH

B)

PLACENTA PREVIA

C)

PRETERM LABOR

D)

ANEMIA

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DANGERS OF MONOZYGOTIC TWINS

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OVERGWROWTH AND UNDERGROWTH

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CONJOINING OF TWINS

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CONTRACEPTIONS

USUALLY PREFERED BY WOMEN AFTER HAVING TWINS OR MORE. METHODS OF CONTRACEPTION: 1 ) FOLK METHODS 1. PRECOITAL AND POSTCOITAL DOUCHE 2. PROLONGED LACTATION 3. WITHDRAWAL 2) MECHANICAL METHODS 1. CONDOMS B. DIAPHRAGM C. SPONGE 3. CHEMICAL METHOD 4. HORMONAL METHOD

1. CONTRACEPTIVE PILLS TYPES: •

COMBINED

•

SEQUENTIAL

•

MINI PILL 2. INJECTIONS AND IMPLANTS

5 ) SURGICAL METHODS CLASSIFICATIONS: •

AS TO DECISION

•

AS TO PURPOSE

METHODS: 1. TUBAL LIGATION

2. VASECTOMY C. HYSTERECTOMY 6. NATURAL OR BEHAVIORAL METHOD 1. RHYTHM/CALENDAR/OGINO KNAUSSE METHOD • Predicting your first fertile day. If your shortest cycle is 26 days long, subtract 18 from 26. That leaves 8. If day one was the fourth day of the month, the day you will mark X will be the 11th. That's the first day you're likely to be fertile. So on that day, you should start abstaining from sex or start using a cervical cap, condom, diaphragm, or female condom. • Predicting your last fertile day. If your longest cycle is 30 days, subtract 11 from 30. That leaves 19. If day one was the fourth day of the month, the day you will mark X will be the 22nd. That's the last day you're likely to be fertile during your current cycle. So you may start to have unprotected vaginal intercourse after that day. 1. BASAL BODY TEMPERATURE ( BBT )

2. BILLINGS METHOD 3. SYMPTOTHERMAL METHOD 4. SEX DURING MENSTRUATION 7. ABORTIFACIENTS

1. INTRAUTERINE DEVICE

Copper = 10 years Progestasert = 5 years B. MORNING AFTER PILL C. PROSTAGLANDINS D. ANTI-PREGNANCY VACCINE - END INFECTIONS AND PREGNANCY •

CANDIASIS / MONILIASIS

Ø Fungal infection of the vagina commonly caused by Candia albicans Ø One of the most common types of STI seen I women

•

WHY IS IT COMMON IN PREGNANCY?

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Due to increase in ESTROGEN

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Sugar in Pregnancy is usually high

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STEROIDS / ANTIBIOTICS

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SIGNS AND SYMPTOMS

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WHITE, CHEES-LIKE, PATCHES that adhere to the vaginal walls

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Irritatingly itchy vagina

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Discharges are extremely puritic

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Vagina is red and irritated

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MANAGEMENT

• Vaginal Application of an OTC Anti-Fungal Cream: MICONAZOLE ( Monistat ) for 7 days •

Single Dose of Oral FLUCONAZOLE ( Diflucan )

•

Oral or Suppository MYCOSTATIN ( Nystatin ) 100,000 U , BID for 15 Days

•

High sugar level must be corrected

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Avoid intercourse

•

Acidic Vaginal Douche

Ø 15 ml White Vinegar in 1 L of water •

COMPLICATIONS

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If left untreated, may cause Oral Thrush

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Treat with Nystatin applied directly over the area

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TRICHOMONIASIS

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Also known as Trichomonas Vaginalis or Trichomonas Vaginitis

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Commonly spread by coitus

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protozoa

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SIGNS AND SYMPTOMS

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Yello-Gray, FROTHY, Itchy, foul smelling discharge from the vagina

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Vulvar edema

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MANAGEMENT

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Metronidazole ( Flagyl ) PO for 10 days

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Trichomonicidal Suppositories ( Vagisec )

Important Teachings: •

Urine will turn dark brown

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Do not mix with alcohol

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Avoid sex and treat the husband too

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DANGERS

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PRETERM LABOR

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PROM

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POST C/S INFECTION

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BACTERIAL VAGINOSIS

Ø Caused by Gardnerella vaginalis S/S: •

Grayish discharge

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Foul, FISHY ODOR

Mgt: Flagyl •

CHLAMYDIA

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Characterized by heavy gray or white vaginal discharge.

Mgt: Non-Pregnant > Doxycycline ( Vibramycin ) Pregnant > Azithromycin ( Zithromax )

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T.O.R.C.H.

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TOXOPLASMOSIS

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OTHERS ( Hep B, Mumps, Rubeola, Varicella, Gonorrhea and Syphilis )

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Rubella

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Cytomegalovirus

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Herpes Simplex Virus ( Genital Herpes )

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TOXOPLASMOSIS

Ø Classified as a protozoal infection Ø Commonly derived from uncooked meat and CAT STOOL Ø Patients are usually asymptomatic Ø Malaise is the most common symptom if ever there is Mgt: Sulfonamides ( May cause deformities ) If not treated: crosses the placenta •

Central Nervous System Damage

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Hydro/microcephaly

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INSTRUCTIONS

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No need to isolate pet cat if it’s healthy

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Do not buy a new cat

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Do not eat raw meat

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Do not go to a garden where a cat usually defecates

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OTHERS

•

HEPATITIS B

Ø Sexual contact

Ø If the mother is infected, fetus can also be infected •

MANAGEMENT

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Bath the baby ASAP

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Suction gently

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Administer Immune Serum Globulin within 12 hours after birth

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Breast milk AFTER administration of vaccine

•

MUMPS / PAROTITIS

Ø Causative agent: MUMPS VIRUS MGT: Ø Soft Meals Ø Analgesic / Antipyretic • Crosses Placenta and destroys RBC. Early trimester will cause Fetal Death and Late Trimester will cause Anemia. •

SYPHILIS

Ø Caused by Treponema pallidum Ø Sexually transmitted Ø Cannot cross the placenta up to 16th-18th week gestation. Ø Mgt: Penicillin •

DANGERS

• If it crosses the placenta during pregnancy, it may cause deafness, cognitive impairment, osteochondritis and fetal death. •

If not treated, a baby is born with Congenital syphilis:

Ø Congenital anomalies Ø Characteristic syphilictic rash

Ø Hutchinson teeth •

GONORRHEA

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Caused by Neisseria gonorrhea

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Major cause of P.I.D.

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Women are usually ASYMPTOMATIC

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DANGERS

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Women with gonorrhea puts her infant at risk for Ophthalmia neonaorum

S/S: •

Conjunctiva becomes fiery red

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With thick pus

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Edematous eyelids

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MANAGEMENT

•

PROPHYLACTIC ADMINISTRATION OF ERYTHROMICIN

BEFORE: GIVEN IMMEDIATELY NOW: DELAYED ( ACCORDING TO HOSPITAL PPOLICY ) COMPLICATION: BLINDNESS •

RUBELLA / GERMAN MEASLES

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Caused by Rubella virus

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Known as a teratogen

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May cause deafness, mental abnormalities, and has a potential to cause facial clefts.

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MANAGEMENT

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SECURE RUBELLA TITER:

MUST BE GREATER THAN 1:8

INSTRUCTIONS: •

A mother should not receive rubella immunization during pregnancy

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After birth, immunize e mother, instruct not to get pregnant for 3 months.

•

CYTOMEGALOVIRUS ( CMV )

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A member if the herpes virus family

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Also considered as a teratogen

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Droplet transmission

• Crosses the placenta and may cause nuerologic abnormalities and eye damage. Also has the potential to cause chornic liver disease and large petechiae ( BLUEBERRYMUFFIN LESIONS ) •

HERPES SIMPLEX VIRUS

Ø Genital herpes Ø Sexually transmitted Ø Crosses the placenta and will cause Spontaneous abortion on the 1st trimester and Preterm birth on the second trimester. Ø C/S delivery is adviced

Preterm Labor to P.I.H. •

PRETERM LABOR

Ø Labor that begins BEFORE the end of 37 weeks gestation. Ø Braxton-Hicks Contraction is said to be one of the reasons why preterm labor is not commonly diagnosed at an early time. Ø Considered as a type of DYSTOCIA CAUSE: IDIOPATHIC RELATED FACTORS:

A ) DEHYDRATION B ) INFECTIONS Common Symptoms: •

Persistent, dull, LOW backache

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Vaginal Spotting

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Cramping ( Menstrual like )

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Uterine contractions

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Vaginal discharges

FALSE LABOR PAINS: •

REMAIN IRREGULAR

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GENERALLY CONFINED TO THE ABDOMEN

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NO INCREASE IN DURATION, FREQUENCY AND INTENSITY

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OFTEN DISAPPEARS IF THE WOMAN AMBULATE

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ABSENT CERVICAL CHANGES

TRUE LABOR SIGNS STRONG CONTRACTIONS PAIN DOES NOT GO AWAY DILATATION Management: •

If there is NO BLEDDING and CERVICAL DILATATION

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Fetal heart sounds are GOOD; the following can be done:

Ø HYDRATION by I.V. Fluids Ø Vaginal and Cervical Culture

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STOP UTERINE CONTRACTIONS BY:

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ADMINISTERING TOCOLYTICS:

A ) TERBUTALINE ( Brethine ) B ) RITORDINE ( Yutopar ) D ) MAGNESIUM SULFATE * •

POINTS TO REMEMBER WHEN GIVING TOCOLYTICS:

•

ASSESS BASELINE VITAL SIGNS

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USUALLY GIVEN I.V. PIGGYBACK

• COMMONLY INFUSED WITH L.R. AND OTHER FLUIDS WITH NO DEXTROSE • If PREMATURE UTERINE CONTRACTIONS are accompanied by CERVICAL DILATATION and FETAL DESCENT; Preterm Labor is inevitable: Ø Once detected, a woman must begin Steroid Therapy to hasten fetal lung maturity. •

2 doses of 12 mg Betamethasone given IM 24 hours apart or

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4 doses 6 mg Betamethasone given IM 12 hours apart

DURING PREMATURE DELIVERY: •

Pain Medications are kept at a minimum

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Episiotomy not usually performed

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Cord is CUT IMMEDIATELY

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Other Types of DYSTOCIA:

1 )UTERINE INERTIA Ø Sluggishness contractions Causes: •

Too much analgesics

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Excessively large babies

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Fetal positions

TYPES: 1 ) Primary ( Hypertonic ) Uterine Inertia Ø Uterine muscles are tensed so that the latent phase OF THE 1ST PHASE OF LABORis prolonged. Mgt: Sedation of patient STAGES OF LABOR I – STAGE OF DILATATION Ø BEGINS WITH TRUE LABOR PAINS AND ENDS WITH COMPLETE DILATATION OF THE CERVIX. CAUSE: INVOLUNTARY UTERINE CONTRACTIONS PHASES OF DILATATION: 1 ) LATENT – EARLY TIME IN LABOR Ø Cervical dilatation is minimal because effacement is occurring Ø Cervix dilates only 3-4 cm Ø Contractions are of short duration and occur regularly 5-10 minutes apart. Ø Patient is able to communicate Ø Best time to seek hospital admission 2 ) ACTIVE / ACCELERATED Ø Cervical dilatation reaches 4-8 cm Ø Rapid increase in duration, frequency and intensity of contractions Ø Mother fears losing control of herself 3 ) TRANSITION

Ø Cervical dilatation is 8-10 cm Ø Duration is 60-90 seconds, Frequency 2-3 minutes TYPES OF BREATHING TO BE USED: L=C A=A T=P NURSING CARE DURING THE 1ST STAGE: •

PROVIDE PRIVACY AND REASSURANCE FROM THE VERY START

Ø GET PERSONAL DATA Ø GET OBSTETRICAL DATA Ø DETERMINE SHOW AND INTEGRITY OF B.O.W. 2 ) Secondary ( Hypotonic ) Uterine Inertia •

There are good contractions in the start

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Suddenly Stops

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Dilatation stops

Mgt: Induction of labor ( Oxytocin ) •

Or Amniotomy if possible

2 ) PRECIPITATE LABOR Ø Labor that is accomplished in less than 3 hours Causes: •

Multiple pregancy

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Excessive use of oxytocin

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COMPLICATIONS OF PRECIPITATE LABOR:

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EXTREME LACERATIONS

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HEMORRHAGE

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ABRUPTIO PLACENTA

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SHOCK

3 ) PROLONGED LABOR Ø Labor that lasts more than 18 hours May Cause: A ) Maternal exhaustion B ) Uterine Atony C ) Capput Succedaneum 4 ) UTERINE RUPTURE Ø Rupture of uterus due excessive amount of stress R/F: •

Scar from energy

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Oxytocin

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Prolonged labor

Mgt: Hysterectomy •

PREMATURE RUPTURE OF MEMBRANES

• Rupture of membranes leading to a decrease in amount of Amniotic Fluid, which occurs before 37 weeks gestation. • Cause is idiopathic but may be related to inflammation. of the amniotic sac or membranes. IMMEDIATE DANGERS OF P.R.O.M: PRIORITY 1: INFECTION

PRIORITY 2: CORD PROLAPSE PRIORITY 3: POTTER-LIKE SYNDROME MGT: LABOR IS NOT USUALLY HALTED PREGNANCY – INDUCED HYPERTENSION ( P.I.H. ) Ø A type of hypertension that is unique in pregnancy. Ø Formerly known as Toxemia Ø Occurs 20th-24th weeks of gestation up to 2 weeks post partum. Predisposing Factors: 1 ) Age = below 20 and over 30 2 ) Multipara 3 ) L.S.E.S. 4 ) with pre-existing hypertension CLASSIFICATIONS: A ) GESTATIONAL HYPERTENSION B ) MILD PRE-ECLAMPSIA C ) SEVERE PRE-ECLAMPSIA D ) ECLAMPSIA TRIAD OF SYMPTOMS H HYPERTENSION

E EDEMA

GESTATIONAL HYPERTENSION •

Has BP of 140/90 mmHg

P PROTEINURIA

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No proteinuria or edema

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Usually does not require drugs

• MILD PRE-ECLAMPSIA •

BP is 140/90 mmHg taken on 2 occasions at least 6 hours apart

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Proteinuria +1 or +2

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Edema ( upper part is ore significant )

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Weight gain of 2 lb/week during the 2nd trimester

SEVERE PRE-ECLAMPSIA •

BP 160/110

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PROTEINURIA +3 OR +4

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EDEMA PITTING TYPE

+1 PITTING EDEMA = Slight Indentation +2 PITTING EDEMA = Moderate Indentation +3 PITTING EDEMA = Deep Indentation +4 PITTING EDEMA = Indentation is so deep that it remains after the finger is removed.

ECLAMPSIA

SIGNS OF SEVERE PRE-ECLAMPSIA PLUS SEIZURE because of Cerebral Edema

NURSING INTERVENTIONS 1 ) PROMOTE BED REST •

Position in lateral recumbent position

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Best way to help in the excretion of sodium

2 ) PROVIDE PROPER NUTRITION •

Continue the diet required by the O.B.

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Sodium restriction is no longer practiced. Woman is still allowed minimal sodium.

3 ) PROVIDE EMOTIONAL SUPPORT 4 ) ENVIRONMENTAL MANIPULATION •

Dim the light

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Control noise

5 ) STRICT MONITORING OF MATERNAL AND FETAL WEEL BEING. •

IMPORTANT POINTS FOR ECLAMPSIA

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The type of seizure commonly seen in eclampsia is TONIC-CLONIC.

STAGES: •

TONIC

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CLONIC

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POSTICTAL

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MEDICATIONS

MAGNESIUM SULFATE Ø The DRUG OF CHOICE ACTIONS:

Ø CNS Depressant- lessens the possibility of convulsions Ø VASODILATOR – decreases BP Ø CATHARTIC Properties – shifting of fluid from extracellular to intestines for excretion DOSAGE: Ø 10 grams INITIALLY either by slow IV Push over 5-10 minutes Ø Deep IM, 5 grams buttocks Ø Then an IV drip of 1 gram per hour if: •

Deep tendon reflexes are present

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RR at least 12 cpm

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Urine output at least 100 ml in 6 hours

SIGNS OF MAGNESIUM SULFATE TOXICITY: A ) DECREASED URINE OUTPUT B ) DEPRESSED RESPIRATIONS C ) DECREASED CONSCIOUSNESS D ) ABSENCE OF DEEP TENDON REFLEXES •

THE ANTIDOTE IS:

CALCIUM GLUCONATE •

H.E.L.L.P. SYNDROME

•

a variation of PIH named for the common symptoms that occur:

HEMOLYSIS – ELEVATED LIVER ENZYME – LOW PLATELET CAUSE = UNKNOWN

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INITIAL SYMPTOMS

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NAUSEA

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EPIGASTRIC PAIN

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GENERALIZED MALAISE

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RIGHT UPPER QUADRANT TENDERNESS

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COMMON LAB RESULTS

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ELEVATED ALANINE AMINOTRANSFERASE

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SERUM ASPARTATE AMINOTRASNFERASE

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THROMBOCYTOPENIA

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DECREASED RBC DUE TO HEMOLYSIS

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IMMEDIATE MGT:

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IMPROVE CIRCULATING PLATELETS BY PLATELET INFUSION

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CORRECT HYPOGLYCEMIA

( ALT ) AND ( AST )

2ND TRIMESTER BLEEDING 2nd TRIMESTER BLEEDING GESTATIONAL THROPHOBLASTIC DISEASE Ø ABNORMAL proliferation and degeneration of the trophoblastic villi. TYPES OF G.T.D. A ) HYDATIDIFORM MOLE B ) INVASIVE MOLE C ) CHORIOCARCINOMA D ) PLACENTA SITE TROPHOBLASTIC TUMOR

HYDATIDIFORM MOLE •

The MOST COMMON form of GTD

•

Also known as MOLAR PREGNANCY

2 TYPES: A ) COMPLETE ·

The father’s chromosomes are duplicated since the egg of the mother is empty.

· Trophoblastic villi continuous to grow but degenerates due to the absence of the chromosomes. · It will swell and becomes fluid filled resulting to the characteristic Grape-Like structures. B ) PARTIAL •

SOME of the villi form normally BUT it is the Syncitiotrophoblast that is swollen.

•

A partial mole has 69 chromosomes.

INVASIVE MOLE •

Formerly known as CHORIOADENOMA DESTRUENS

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A type of GTD that grows into the MYOMETRIUM (the muscle part of the uterus )

Risks: •

Delayed treatment

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Large uterus

•

History of GTD and over 40 years old

CHORIOCARCINOMA Ø MALIGNANT form of GTD that usually originated from a Complete H. mole

PLACENTAL SITE TROPHOBLASTIC TUMOR Ø Develop on the site where the placenta is implanted Ø Very rare and responds to Chemotherapeutic drugs

ASSESSMENT FINDINGS 1 ) UTERUS Ø Proliferation of trophoblast occurs at a very fast rate and the uterus expands faster that normally. Ø Uterus reaches it landmarks BEFORE its usual time. Usual Time: 12 weeks – over the symphisis pubis 20-24 weeks – at the level of the umbillicus •

VERY HIGH H.C.G. = N/V

Normal Pregnancy: 400,00 IU GTD: 1-2 IU Continuous to rise even on the 100th day! • S/S of PIH NORMALLY APPEARS AT 20 WEEKS IN PREGNANCY BUT IN GTD: LESS THAN 20 WEEKS OR EARLIER MANAGEMENT 1 ) EVACUATION OF MOLE THROUGH 2 ) PHROPHYLAXIS: METHOTREXATE •

Antineoplstic

• 15-30 mg PO/IM daily for 5 days, repeated after 1 week. ( Avoid Sunlight. May cause alopecia ) •

MONITORING OF hCG LEVELS

IMPORTANT REMINDERS • A WOMAN SHOULD USE A CONTRACEPTIVE AGENT FOR 12 MONTHS AFTER G.T.D. Q: WHAT IS THE RATIONALE FOR THIS? AFTER 6 MONTHS, IF HCG LEVELS ARE STILL NEGATIVE, WOMEN IS FREE OF THE RISKS FOR MALIGNANCY CONTINUE TO MONITOR, BY THE END OF 12 MONTHS,WOMAN CAN GET PREGNANT AGAIN

INCOMPETENT CERVICAL OS • Also known as: PREMATURE CERVICAL DILATATION OR INCOMPETENT CERVIX Ø Refers to a cervix that dilates prematurely before term making it impossible to hold a fetus. Causes: Connective tissue structure around the cervix is not strong enough to maintain closure. MOTHER of patient used DES during her pregnancy.

SIGNS AND SYMPTOMS PAINLESS CERVICAL DILATATION PINK-STAINED VAGINAL DISCHARGE PELVIC PRESSURE IS INCREASED

MANAGEMENT AFTER THE LOSS OF ONE CHILD, AN OPERATION IS PERFORMED TO PREVENT THE EVENT FROM HAPPENING AGAIN. THIS IS CALLED: CERVICAL CIRCLEAGE IF THE COUPLE WANTS TO HAVE A BABY AGAIN, THEY MUST CONSULT A PHYSICIAN FOR SPECIFIC INSTRUCTIONS: ON THE 12TH-14TH WEEK OF GESTATION SUTURES ARE PLACED IN THE CERVIX TO PREVENT PREMATURE DILATATION. THIS IS CALLED: McDonald – temporary sutures – vaginal delivery Shirodkar – Permanent Sutures – C/S PLACENTA PREVIA Ø Defined as low implantation of the placenta so that it is in the way of the presenting part. Types: •

LOW IMPLANT

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PARTIAL ( Marginal ) IMPLANT

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TOTAL ( Complete ) IMPLANT

Causes: •

Increasing Parity

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Advanced Maternal Age

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Past C/S

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Multiple Gestation

SIGNS AND SYMPTOMS

PAINLESS, BRIGHT RED VAGINAL BLEEDING MGT: •

CBR

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MONITOR VITAL SIGNS OF BOTH PATIENTS

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PREPARE OXYGEN AND BLOOD

I.E. is NOT USUALLY done! If ever it should be done, must be double set up! IMMEDIATE DANGERS OF PLACENTA PREVIA: •

The site of bleeding, the decidua, places the mother at risk for hemorrhage

•

The placenta is loosened:

Ø Compromised oxygenation Ø Preterm labor • An APT or Kleihauer-Betke Test may be used to check if the blood is of fetal or maternal origin. ABRUPTIO PLACENTA •

Defined as the PREMATURE SEPARATION of the placenta.

Predisposing Factor: •

Maternal hypertension or toxemia

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Increasing parity and maternal age

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Sudden release of amniotic fluid

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Trauma

Signs and Symptoms: •

Severe, Sharp, Knife-Like, Stabbing Pain High In The Fundus

•

Hard, Boardlike uterus, Rigid Abdomen

MGT: HYSTERECTOMY since the UTERUS CAN NO LONGER CONTRACT