NCM 109 Assessment:

Care of Clients Across the Lifespan with Mother, - The presenting symptom of spontaneous
Child and Families miscarriage is almost always vaginal spotting
– at – Risk or with Problems
CI: Mrs. Sanchez Diagnosis:
1.Threatened Miscarriage
- Symptoms begin as a vaginal bleeding initially
Bleeding Disorders During Pregnancy only scant and usually bright red
First Trimester: - Sight cramping, but no cervical dilatation is
 Abortion present on vaginal examination
 Ectopic Pregnancy - Blood may be drawn to test HCG hormone at the
Second Trimester: start of bleeding and again in 48 hours (if the
 Hydatidiform Mole placenta is still intact the level in the blood stream
 Premature Cervical Dilatation should double at this time). If it does not double
Third Trimester: poor placental function is suspected and
 Placenta Previa pregnancy probably will lost
 Abruptio Placenta - Avoidance of strenuous activity for 24-48 hours is
the key intervention
Spontaneous Miscarriage - Complete bedrest may not be necessary
 Abortion – a medical term for any interruption - If spotting is going to stop it usually does so
of a pregnancy before a fetus is viable (able to within 24-48 hours after a woman reduces her
survive outside the uterus if born at that time) activity
 Viable Fetus –is usually defined as a fetus of - Coitus may be restricted for 2 weeks
more than 20-24 weeks of gestation or one
that weighs at least 500 g. A fetus born before 2.Imminent (Inevitable Miscarriage)
this point is considered a miscarriage or is - A threatened miscarriage becomes an Imminent
termed premature or immature birth. miscarriage if uterine contractions and cervical
 Early Miscarriage occurs before week 16 dilatation occur, with cervical dilatation, the loss
 Late Miscarriage occurs between week 16 & of the products of conception cannot be halted
20 - Save any tissue fragments she has passed to
check for abnormality
Common Causes: - If no fetal heart sounds are detected and an
- The most frequent cause of miscarriage is ultrasound reveals an empty gestational sack or
abnormal fetal development due either to a nonviable fetus, her primary health care provider
teratogenic factor or to a chromosomal aberration may offer medication to help the pregnancy pass
- Immunologic factors may be present or rejection or perform Dilatation and Curretage (D&C) OR
of the embryo through an immune response may Dilatation and Evacuation (D&E) to ensure all
occur products of conception is removed
- Implantation abnormalities as up to 50% of
zygotes probably never implant securely because 3.Complete Miscarriage
of inadequate endometrial formation or from an - The entire products of conception (fetus,
inappropriate site of implantation membranes, and placenta) are expelled
- Miscarriage may also occur if Corpus Luteum or spontaneously without any assistance.
the ovary fails to produce enough progesterone - The bleeding usually slows within 2 hours and
to maintain the decidua basalis then ceases within a few days after passage of
- Ingestion of alcohol at the time of conception or the products of conception.
during early pregnancy can contribute to - Because the process is complete, no therapy
pregnancy can contribute to pregnancy loss other than advising the woman to report heavy
because of abnormal fetal growth bleeding is needed.
- Urinary tract infection may be a cause but are
more strongly associated with preterm birth
4.Incomplete Miscarriage
- Systemic infections such as Rubella, Syphillis,
- Part of the conceptus (usually the fetus) is
Poliomyelitis, Cytomegalovirus and
expelled, but the membranes or placenta are
Toxoplasmosis readily cross the placenta and so
retained in the uterus
may also be responsible
- Within an incomplete, there is a danger of
maternal hemorrhage as long as part of the
 conceptus is retained in the uterus because the - Any unusual odor or passing of large clots is also
uterus cannot contract effectively under this abnormal
condition - Oral medication such as Methylergonovine
- The woman will usually have D&C or suction maleate (Methergine) to aid uterine contraction
curettage to evacuate the remainder of the
pregnancy 2.Infection
- The possibility of infection is minimal when
5. Missed Miscarriage pregnancy loss occurs over a short time,
- Also commonly referred to as early pregnancy bleeding is self-limiting and instrumentation is
failure limited
- The fetus dies in utero but is not expelled - Infection is often a reason for excessive blood
- A missed miscarriage is usually discovered at a loss
prenatal examination when the fundal height is - Be certain the woman is familiar with common
measured and no increase in size can be danger signs of infection such as fever higher
demonstrated or when previously heard fetal than 38C, abdominal pain or tenderness and a
heart sounds can no longer be heard foul smelling vaginal discharge
- A woman may have painless vaginal bleeding or - Caution women to always wipe the perineal area
she may have had no prior clinical symptoms from front to back after voiding and defecation to
- D&C or D&E may be done to evacuate the avoid the spread of bacteria
pregnancy - Infection usually involves the inner lining of the
- If pregnancy is over 14 weeks in length and uterus (Endometritis)
therefore these procedures are no longer
possible labor can be induced by a prostaglandin Ectopic Pregnancy
suppository or Misoprostol (Cytotec) introduced
into the posterior fornix of the vagina to cause
dilation
- Followed by Oxytocin stimulation or
administration of Mifepristone techniques used
for elective termination of pregnancy which cause
contractions and birth

6.Recurrent Pregnancy Loss

- In the past woman who had three - Implantation occurred outside the uterine
spontaneous miscarriages were called cavity
“habitual aborters” - The most common site (approx. 95%) is in the
Fallopian Tube
- Of these fallopian tube sites approx.:
Complications of Miscarriage
Ampullar Portion -80%
1. Hemorrhage
Isthmus -12%
- With a complete spontaneous miscarriage,
Interstitial and Fimbrial -8%
serious or fatal hemorrhage is rare
- With most ectopic pregnancy, fertilization is
- With an incomplete miscarriage or in a woman
present, such as an adhesion of the Fallopian
who develops accompanying coagulation defect
Tube from a previous infection (chronic
(usually DIC) major haemorrhage becomes a
Salpingitis or pelvic inflammatory disease)
possibility
- Monitor vital signs for any changes to detect
Causes:
possible hypovolemic shock
- Unfortunately, because an obstruction is
- If excessive vaginal bleeding occurs, immediately
present, such as an adhesion of fallopian tube
position flat and massage the uterine fundus to
from a previous infection (chronic Salpingitis
try to aid contraction
or pelvic inflammatory disease)
- D&C if bleeding does not halt
- Congenital malformations
- Suction curettage to empty the uterus of the
- Scars from tubal surgery
material that is preventing it from contracting and
- Uterine tumor pressing on the proximal end of
achieving hemostasis
the tube
- A transfusion may be necessary to replace blood
- It lodges at the structured site along the tube
loss
and implants there instead of in the uterus
Assessment:
 - No menstrual flow occurs - As the cells degenerate, they become filled
- Nausea and vomiting of early pregnancy with fluid and appear as clear fluid-filled, grape
- Positive pregnancy test for HCG sized vesicles.
- The zygote grows large enough that it - The embryo fails to develop beyond a
ruptures the slender fallopian tube. Tearing primitive start
and destruction of blood vessels and bleeding - Abnormal trophoblast cells are must be
result identified because they are associated with
- Sharp, stabbing pain in one of the lower choriocarcinoma, a rapidly metastasizing
abdominal quadrants at the time of rupture malignancy
followed by scant vaginal spotting (blood may
be expelled in the pelvic cavity rather than into Assessment:
the uterus) - Uterus expands faster than usual. This rapid
- Signs of Hypotension form blood loss: light development is also diagnostic of multiple
headedness, rapid pulse, signs of pregnancy or a miscalculated due date
hypovolemic shock - Strongly positive pregnancy test (1 to 2 million
- Signs of severe shock: rapid, thread pulse, International Units compared with a normal
rapid respirations, falling blood pressure pregnancy level of 400,000 International
- Leucocytosis may be present from trauma and Units)
not from infection - Marked nausea and vomiting
- Temperature is usually normal - Symptoms of Gestational Hypertension
- Rigid abdomen from peritoneal irritation o Increased blood pressure
- Cullen’s sign (bluish tinged umbilicus) o Edema
- Movement of cervix on pelvic examination can o Proteinuria
cause excruciating pain - An ultrasound will show dense growth
- Pain in the shoulders from blood in the (typically a snowflake pattern), but no fetal
peritoneal cavity causing irritation to the growth in the uterus
phrenic nerve - No fetal heart sounds can be heard because
- A tender mass palpable in Douglas cul-de-sac there is no viable fetus
on vaginal examination - Vaginal spotting of dark brown blood
resembling prune juice or as a profuse fresh
Therapeutic Management: flow
- Some Ectopic Pregnancies spontaneously - As bleeding progresses it is accompanied by
end before they rupture and are reabsorbed discharge of clear fluid-filled vesicles
over the next few days requiring no treatment
- Medically treated by intramuscular or less Therapeutic Management:
often oral administration of Methotrexate. - Suction Curettage to evacuate the abnormal
Treated until a negative HCG titer is achieved. trophoblast cells
- The therapy for ruptured Ectopic pregnancy is - Have a baseline pelvic examination and a
Laparoscopy to ligate the bleeding vessels serum test for hCG
and to remove or repair the damaged fallopian - The hCG is analysed every 2 weeks until
tube. normal
- The serum hCG is then assessed every 4
Gestational Trophoblastic Disease weeks for the next 6 to 12 months to see if it is
(Hydatidiform Mole or H-Mole) declining. If the level plateaus or increases, it
suggests a malignant transformation
(Choriocarcinoma) is occurring
- During the waiting time for the hCG to decline,
a woman should use a reliable contraceptive
method such as oral estrogen/progesterone
so that a positive pregnancy test will not be
mistaken with malignancy
- If malignancy should occur, it can be treated
effectively with Methotrexate Dactinomycin a
second agent can be added to the regimen if
- Abnormal proliferation and degeneration of the metastasis occurs
trophoblast villi
 Cervical Insufficiency
(Premature Cervical Dilatation)

- Previously termed as Incompetent Cervix It occurs in Four Degrees:

- Refers to a cervix that dilates prematurely and 1. Low-lying placenta- implantation in the
therefore cannot retain a fetus until term lower rather than in the upper portion of
- Painless dilatation of the cervix the uterus
- First symptom is Show (a pink stained vaginal 2. Marginal Implantation- the placenta edge
discharge) approaches that of the cervical os
- Increased pelvic pressure, followed by rupture 3. Partial Placenta Previa- implantation that
of the membranes and discharge of amniotic occludes a portion of the cervical os
fluid 4. Total Placenta Previa- implantation hat
- Uterine contractions begin and after a short totally obstructs the cervical os
labor, the fetus is born It is associated with:
It is associated with:  Increased parity
o Increased maternal age  Advanced maternal age
o Congenital structural defects  Past Cesarean births
o Trauma to the cervix that might have  Past Uterine Curettage
occurred with a cone biopsy or  Multiple gestation
repeated D & C’s  A male fetus

Management: Assessment:
- Cervical Cerclage a surgical operation can be - The bleeding with placenta Previa doesn’t
performed to prevent this form happening in a usually begin until the lower uterine segment
second pregnancy starts to differentiate from the upper segment
- McDonald procedure a nylon sutures are late in pregnancy and the cervix begins to
placed horizontally and vertically across the dilate
cervix and pulled tight to reduce the cervical - Because the placenta is unable to stretch to
canal to a few millimetres in diameter accommodate the differing shape of the lower
- Shirodkar technique sterile tape is threaded in uterine segment or the cervix, a small portion
a purse string manner under the submucous loosens and damaged blood vessels begin to
layer of the cervix and sutured in place to bleed
achieve a closed cervix - The bleeding is usually abrupt, painless, bright
- After Cerclage surgery; women remain on red and sudden
bedrest (slight or modified Trendelenburg
position) for a few days to decrease pressure Therapeutic Management:
on the new sutures - Place the woman immediately on bedrest in a
- Usual activity and sexual relations can be side lying position to ensure an adequate
resumed in most instances after this rest blood supply to a woman and fetus
period - Inspect the perineum for bleeding and
- The sutures are removed at weeks 37 to 38 of estimate the present rate of blood loss
pregnancy so the fetus can be born vaginally - Obtain baseline vital signs to determine
whether symptoms of hypovolemic shock are
PLACENTA PREVIA present
- A condition of pregnancy in which the placenta - Continue to assess blood pressure every 5 to
is implanted abnormally in the lower part of 5 min
the uterus - Never attempt a pelvic or rectal exam with
- It is the most common cause of painless painless bleeding late in pregnancy because
bleeding in the third trimester of pregnancy any agitation in the cervix might tear the
 placenta further and initiate massive - The separation generally occurs late in
hemorrhage pregnancy: even as late as during the 1st and
- Attach external monitoring equipment to 2nd stage of labor
record fetal heart sounds and uterine - The primary cause of premature separation is
contractions unknown
- Ready for blood replacement if necessary - Predisposing Factors:
- Monitor urine output frequently as often as o High parity
every hour as an indicator her blood volume is o Advanced maternal age
remaining adequate to perfuse her kidneys o Short umbilical cord
- Administer intravenous fluid as prescribe, o Chronic hypertensive disease
preferably with a large-gauge catheter to allow o Hypertension of pregnancy
for blood replacement through the same line o Direct trauma
- A vaginal birth is always safest for the infant.
o Vasoconstriction from cigarette or
But if the previa is under 30% it may be
cocaine use
possible for the fetus to born normal. If over
- Thrombophilic conditions that lead to
30% and the fetus is mature, the safest birth
thrombosis formation
method is Cesarean delivery
- Chorioamnionitis or infection of the fetal
- If only a minimum previa is suspected and
membranes and fluid
may attempt a speculum examination, this
- Rapid decrease in uterine volume such as in
should be done in an Operating Room or a
sudden release of amniotic fluid in
fully equipped birthing room so that if
polyhydramnios
haemorrhage does occur with cervical
manipulation, an immediate caesarean birth is
Assessment:
carried out
- Sharp stabbing pain high in the uterine fundus
- Have oxygen equipment available in case of
as the initial separation occurs
fetal distress
- Tenderness on uterine palpation
- Heavy bleeding, although it may not be readily
Continuing Care Measures:
apparent
- If labor has begun, bleeding is continuing, or
- External bleeding will only be evident if the
the fetus is compromised birth must be
placenta separates first at the edges, so blood
accomplished regardless of gestational age
escapes freely into the uterus and then the
- If bleeding has stopped, the fetal heart sounds
cervix
are of good quality, maternal vital signs are
- If the center of the placenta separates first,
good, and the fetus is not yet 36 weeks of
blood can pool under the placenta and it will
age, a woman is usually managed by
be hidden from view
expectant watching. Typically a woman
- Uterus becomes tense and feels rigid to touch
remains in the hospital bed rest for close
- If blood infiltrates the uterine musculature,
observation for 24 to 48 hours
Couvelaire uterus or uteroplacental apoplexy,
- If bleeding stops, she can be sent home for
forming a hard board like uterus
bedrest
- Assessment of fetal heart sounds and
Therapeutic Management:
laboratory tests, such as haemoglobin and
- Monitor fetal heart sounds externally and
haematocrit are obtained frequently
record maternal vital signs every 5 to 15
- Betamethasone, a steroid that hasten fetal
minutes to establish baselines and observe
lung maturity, may be prescribed for the
progress
mother to encourage the maturity of fetal
- A large-gauge intravenous catheter inserted
lungs if the fetus is less than 34 weeks
for fluid replacement
gestation
- Oxygen by mask to limit fetal anoxia
- Keep woman in lateral, not supine, position to
PREMATURE SEPARATION OF THE PLACENTA prevent pressure on the vena cava and
(ABRUPTIO PLACENTA) additional interference with fetal circulation
- The placenta appears to have been implanted - Do not perform any abdominal, vaginal or
correctly pelvic examination on a woman with a
- Refers to the premature separation of the diagnosed or suspected placental separation
placenta
Premature Separation of the Placenta:
 Degrees of Separation ordinary activity, woman experiences
Grade Criteria excessive fatigue, palpitations, dyspnea,
0 No symptom of separation are apparent or anginal pain
from maternal or fetal signs IV Severely compromised. Woman is unable
1 Minimal separation, but enough to to carry out any physical activity without
cause vaginal bleeding and changes in experiencing discomfort. Even at rest,
the maternal signs; no fetal distress or symptoms of cardiac insufficiency or
hemmorhagic shock occurs anginal pain are present
2 Moderate separation; there is evidence
of fetal distress; the uterus is tense and - A woman with class I or II heart disease can
painful on palpation expect to experience a normal pregnancy and
3 Extreme separation: without immediate birth
inteventions, maternal hypovolemic - Women with class III can complete a pregnancy
shock and fetal death will result by maintaining special interventions such as
bed rest
- Women with class IV heart disease are usually
Nursing Care During Pregnancy Complications advised to avoid pregnancy because they are in
Identifying a High-Risk Pregnancy cardiac failure even at rest and when they are
A high-risk pregnancy is one in which a not pregnant.
concurrent disorder, pregnancy-related complication,
or external factor jeopardizes the health of the A WOMAN WITH CARDIAC DISEASE
woman, the fetus, or both. - Cardiac disease can affect pregnancy in
HYPERGLYCEMIA –increased serum glucose levels different ways depending on whether it
involves the left or the right side of the heart
CARDIOVASCULAR DISORDERS AND
PREGNANCY A Woman with Left Sided Heart Failure
- The number of women of childbearing age who - Left-sided heart failure occurs in conditions
have heart disease is diminishing as more and such as mitral stenosis, mitral insufficiency, and
more congenital heart anomalies are corrected aortic coarctation
in early infancy - In these instances, the left ventricle cannot
- Cardiovascular disease is still a concern in move the large volume of blood forward that it
pregnancy, however, because it can lead to has received by the left atrium from the
such serious complications pulmonary circulation
- It is responsible for 5% of maternal deaths - This causes back pressure- the left side of the
during pregnancy heart becomes distended, systemic blood
- The danger of pregnancy in a woman with pressure decreases in the face of lowered
cardiac disease occurs primarily because of this cardiac output, and pulmonary hypertention
increase in circulatory volume occurs
- The most dangerous time for her is in weeks 28 - Pulmonary edema produces profound
to 32, just after the blood volume peaks shortness of breath as it interferes with oxygen-
- As a rule, a woman with an artificial but well- carbon dioxide exchange
functioning heart valve, a woman with a - If pulmonary capillaries rupture under the
pacemaker implant, and even a woman who pressur, small amounts of blood leak into the
has had a heart transplant can expect to have alveoli and the woman develops a productive
successful pregnancies as long as they have cough with blood-speckled sputum
effective prenatal and postnatal care - Because of the limited oxygen exchange, a
woman with left-sided heart failure is at an
Classification of Heart Disease extremely high risk for spontaneous
CLASS DESCRIPTION miscarriage, preterm labor, or even maternal
I Uncompromised. Ordinary physical activity death
causes no discomfort. No symptoms of - As pulmonary edema becomes severe, a
cardiac insufficiency and no anginal pain. woman cannot sleep in any position except with
II Slightly compromised. Ordinary physical her chest and head elevated (orthopnea), as
activity causes excessive fatigue, elevating her chest this way allows the fluid to
palpitation, and dyspnea or anginal pain settle to the bottom of her lungs and frees
III Markedly compromised. During less than space for gas exchange
- She may also notice paroxysmal nocturnal - An important difference is the usual edema of
dyspnea- suddenly waking at night with pregnancy involves only the feet and ankles but
shortness of breath becomes systemic with heart failure
- This occurs because heart action is more - It can begin as early as the first semester, and
effective when she is at rest other symptoms such as irregular pulse, rapid
- With the more effective heart action, interstitial or difficult respirations, and perhaps chest pain
fluid returns to the circulation on exertion will probably also be present
- This overburdens, her circulation, causing - Be certain to record a baseline blood pressure,
increased left side failure and increased pulse rate, and respiratory rate in either sitting
pulmonary edema or lying position at the first prenatal visit
- At future health visits, always obtain these in
A Woman with Right-Sided Heart Failure the same position for the most accurate
- Right-sided heart failure occurs when the right comparison
ventricle is overwhelmed by the amount of - Making comparison assessments for nail bed
blood received by the right atrium from the vena filling and jugular venous distention can also be
cava helpful throughout the pregnancy
- It can be caused by an unrepaired congenital
heart defect such as pulmonary valve stenosis, A WOMAN WITH CHRONIC HYPERTENSIVE
but the anomaly most apt to cause right-sided VASCULAR DISEASE
heart failure - Women with chronic hypertensive disease enter
- With this, congestion of the systemic venous pregnancy with an elevated blood pressure
circulation and decreased cardiac output to the (140/90 mmHg or above)
lungs occurs - Hypertension of this kind is usually associated
- Blood pressure decreases in the aorta because with arteriosclerosis or renal disease, making it
less blood is able to reach it a problem for the older pregnant woman
- In contrast, pressure is high in the vena cava - Chronic hypertension can be serious because it
from back pressure of blood places both the woman and fetus at high risk
- Both jugular venous distention and increased because of poor heart, kidney, and/or placental
portal circulation is evident perfusion during the pregnancy
- The liver and spleen both become distended - Management includes a prescription of B-
- Extreme liver enlargement can cause dyspnea blockers and calcium channel blockers to
and pain in the pregnant woman because the reduce blood pressure
enlarged liver, as it is pressed upward by the - Methyldopa (Aldomet) is a typical drug that may
enlarged uterus, puts extreme pressure on the be prescribed
diaphragm
- Distention od abdominal and lower extremity A WOMAN WITH VENOUS THROMBOEMBOLIC
vessels can lead to exudate of fluid from the DISEASE
vessels into the peritoneal cavity or peripheral - The incidence of venous thromboembolic
edema diseases increases during pregnancy because
of a combination of stasis of blood in the lower
Assessment of a Woman with Cardiac Disease extremities from uterine pressure and
- Nurses play a major role in the care of pregnant hypercoagulability
women with cardiovascular disease because - When the pressure of the fetal head at birth
continuous assessment of women’s health puts additional pressure on lower extremity
status, health education, and health promotion veins, damage can occur to the walls of the
activities are so essential veins
- Assessment begins with a thorough health - With this triad of effects in place (stasis, vessel
history to document pre-pregnancy cardiac damage, and hypercoagulation), the set is
status stage for thrombus formation in the lower
- Document a woman’s level of exercise extremities
- Ask if she normally has a cough or edema - The likelihood of deep vein thrombosis (DVT)
- Documenting data is also important because leading to pulmonary emboli is highest in
the usual innocent edema of pregnancy must women 30 years of age or older because
be distinguished from the beginning of edema increased age is yet another risk factor for
from heart failure thrombosis formation
 - The risk of thrombus formation can be educed A Woman with Iron-Deficiency Anemia
through common-sense measure such as - Iron-deficiency anemia is the most common
avoiding the use of constrictive knee-high anemia of pregnancy, complicating as many as
stockings, not sitting with legs crossed at the 15% to 25% of all pregnancies
knee, and avoiding standing in one position for
a long period Causes:
- If a thrombus does occur during pregnancy, a - Deficiency of iron stores resulting from a
woman may notice pain and redness usually in combination of a;
the calf of a leg. It is diagnosed by a woman’s  diet low in iron
history and Doppler ultrasonography  heavy menstrual periods
- In order to keep the thrombus from moving and  unwise weight-reducing programs
becoming a pulmonary embolus, a woman will  iron stores are also apt to be low in
be treated with bed rest and intravenous women who were pregnant less than 2
heparin for 24 to 48 hours years before the current pregnancy
- It is generally recommended the lower  those from low socioeconomic levels who
abdomen be used for rotating sites for have not had iron-rich diets
subcutaneous heparin administration. With - Iron is made available to the body by absorption
pregnancy, however, this site is usually avoided from the duodenum into the bloodstream after it
and the injection sites are limited to the arms has been ingested
and thighs - In the bloodstream, it is bound to transferrin for
- The signs of a pulmonary embolism, such as transport to the liver, spleen and bone marrow.
chest pain, a sudden onset of dyspnea, a cough At these sites, it is incorporated into
with hemoptysis, tachycardia or missed beats, haemoglobin or stored as ferritin
or dizziness and fainting need to be recognized
because it is an immediate emergency and Types of Anemia:
measure should be immediately begun - characteristically a microcytic (i.e., small red
- Caution women taking heparin during blood cell) and hypochromic (i.e., less
pregnancy not to take any additional injections haemoglobin than average red cell) anemia,
once labor begins to help reduce the possibility which occurs when such an inadequate supply
of haemorrhage at birth of iron is ingested that iron is not available for
- Women taking heparin are not candidates for incorporation into red blood cells
routine episiotomy or epidural anesthesia for
this same reason unless at least 4 hours has Effects:
passed since the last heparin dose was given - A woman experiences extreme fatigue and poor
exercise tolerance because she cannot
HEMATOLOGIC DISORDERS AND PREGNANCY transport oxygen effectively
Anemia and Pregnancy - The condition is mildly associated with low birth
weight and preterm birth
Pseudoanemia - Because the body recognizes that it needs
- Because the blood volume expands during increased nutrients, some women with this
pregnancy slightly ahead of the red cell count, condition develop pica, or the craving and
most women have a pseudoanemia in early eating of substances such as ice or starch
pregnancy
Prevention:
Normal Hemoglobin count in Women: - To prevent this common anemia, women should
- 120-160g/L take prenatal vitamins containing 27 mg of iron
as prophylactic therapy during pregnancy
True Anemia - They need to eat a diet high in iron and vitamins
- typically considered to be present when a (e.g., green leafy vegetables, meat, and
woman’s haemoglobin concentration is less legumes) so the supplement is truly a
than 11 g/dl (haematocrit <33%) in the first or supplement
third trimester of pregnancy or when the
haemoglobin concentration is less than 10.5 Nursing Responsibility:
g/dl (haematocrit <32%) in the second trimester - Some women report constipation or gastric
irritation when taking oral iron supplements
 - Increasing roughage in the diet and always - The cells then will hemolyze (i.e., be
taking the pills with food can help reduce these destroyed), thus reducing the number available
symptoms and causing a severe anemia
- Ferrous sulfate turns stools black, so caution - Although the sickle-cell trait does not appear to
women about these to prevent them from directly influence the course of pregnancy,
worrying that they are bleeding internally preterm birth, growth restriction, miscarriage, or
- If iron-deficiency anemia is severe and a perinatal mortality, rates tend to be higher for
woman has difficulty with oral iron therapy, women with the homozygous disease
intravenous iron can be prescribed - In pregnancy, blockage to the placental
circulation can directly compromise the fetus,
A Woman with Folic Acid-Deficiency Anemia causing low birth weight and possibly fetal
- Folic acid, or folate or folacin, one of the B death
vitamins, is necessary for the normal function of
red blood cells in the woman as well as being Assessment:
associated with preventing neural tube and - A woman with haemoglobin level of 6 to 8
abdominal wall defects in the fetus mg/100 ml
- Folic acid-deficiency anemia occurs most often
in multiple pregnancies because of the Nursing Responsibility:
increased fetal demand - Throughout pregnancy, monitor a woman’s
nutritional intake to be certain she is consuming
Megaloblastic Anemia: sufficient amounts of folic acid and possibly an
- The anemia that develops is a (enlarged red additional folic acid supplement, which is
blood cells) necessary for replacing red blood cells that
- Slow to progress, the deficiency may take have been destroyed
several weeks to develop or may not be - Women should not take a routine iron
apparent until the second trimester of supplement as sickled cells cannot incorporate
pregnancy iron in the same manner as non-sickled cells
- Full blown, it may be a contributory factor in - Ensure the woman is drinking at least 8 glasses
early miscarriage or premature separation of of fluid daily to be certain she is guarding
the placenta against dehydration

Dosage during Pregnancy: Signs and Symptoms:

- All women expecting to become pregnant are - Early in pregnancy, when she may be
advised to begin a supplement of 400 g folic nauseated, it is easy for her fluid intake to
acid daily in addition to eating folate-rich foods decrease, causing dehydration and a
(e.g., green leafy vegetables, oranges, dried subsequent sickle-cell crisis
beans) - Assess a woman’s lower extremities at prenatal
visits for varicosities or pooling of blood in leg
A Woman with Sickle-Cell Anemia veins, which can lead to red cell destruction
- Sickle-cell anemia is recessively inherited
haemolytic anemia caused by an abnormal Therapeutic Management:
amino acid in the beta chain of haemoglobin - Interventions to prevent a sickle-cell crisis can
- the majority of red blood cells are irregular or include periodic exchange or blood transfusions
sickle shaped, so they cannot carry as much throughout pregnancy to replace sickle-cells
haemoglobin as normally shaped red blood with non-sickle cells
cells can - If a crisis occurs, controlling pain, administering
oxygen is needed, and increasing the fluid
Pathophysiology: volume of the circulatory system to lower
- When oxygen tension becomes reduced, as viscosity are important interventions
occurs at high altitudes, or blood becomes
viscid than usual, such as occurs with A Woman with Diabetes Mellitus
dehydration, the cells clump together because - Diabetes Mellitus is an endocrine disorder in
of their irregular shape, resulting in vessel which the pancreas cannot produce adequate
blockage with reduced blood flow to organs insulin to regulate body glucose levels
 - The disorder affects 3%-5% of all pregnancies Types of Diabetes:
and is the most frequently seen medical 1. In type 1 diabetes, which, although unproven,
condition in pregnancy is probably an autoimmune disorder because
marker antibodies are present, the pancreas
Pathophysiology and Clinical Manifestations: fails to produce adequate insulin for body
- The primary concern for any women with this requirements
disorder is controlling the balance between 2. In type 2 diabetes, there is a gradual loss of
insulin and blood glucose levels to prevent insulin production, but some ability to produce
hyperglycemia or hypoglycemia insulin will still be present
- Infants of women with unregulated diabetes are
5 times more apt to be born large for gestational RISK FACTORS FOR DEVELOPING
age or with birth anomalies GESTATIONAL DIABETES INCLUDE:
- If a woman’s insulin production is insufficient,  Obesity
glucose cannot be used by body cells. The cells  Age over 25 years
register the need for glucose, and the liver  History of large babies (10lb or more)
quickly converts stored glycogen to glucose to  History of unexplained fetal or perenatal loss
increase the serum glucose level. Because  History of congenital anomalies in previous
insulin is still not available, however, the body pregnancies
cells still cannot use the glucose, so the serum  History of polycystic ovary syndrome
glucose levels rise (i.e., hyperglycemia)
 Family history of diabetes (1 close relative or 2
- When the level of blood glucose reaches 150
distant ones)
mg/100 ml (normal level is 80-120 mg/dl), the
 Member of a population with a high risk for
kidneys begin to excrete quantities of glucose in
diabetes (native American, Hispanic, Asian)
the urine (i.e., glycosuria) in an attempt to lower
the level. This cause large quantities of fluid to
Assessment:
be excreted with urine (i.e., polyuria)
- A fasting plasma glucose greater than or equal
to 126 mg/dl or a non-fasting plasma glucose
Effects Of Diabetes During Pregnancy: greater than or equal to 200 mg/dl meets the
- Infants of women with poorly controlled threshold for the diagnosis of diabetes and does
diabetes tend t0 be large (10lb) because the not need confirmation. It is recommended that
increased insulin the fetus must be produce to all pregnant women receive a 50-g glucose
counteract the overload of glucose he/she challenge test
receives acts as a growth stimulant
- Hydramnios may develop because a high Oral Glucose Challenge Test
glucose concentration causes extra fluid to shift - For this, after a fasting glucose sample is
and enlarge the amount of amniotic fluid obtained, the women drinks an oral 100-g
- A macrosomic infant may create birth problems glucose solution; a venous blood sample is then
at the end of the pregnancy because of taken for glucose determination at 1,2,and 3
cephalopelvic disproportion. This, combined hours later
with an increased risk for shoulder dystocia, - If 2 of the four blood samples collected for this
may make it necessary for infants of women test are abnormal or the fasting value is above
with diabetes to be born by cesarean birth 95 mg/dl, a diagnosis of diabetes is made
- There is also a high incidence of congenital - The values that confirmed diabetes are
anomaly, specially caudal regression syndrome reviewed in this table
(failure of the lower extremities to develop), Fasting Plasma Glucose Values
spontaneous miscarriage, and still birth in Test Type Pregnant Glucose Level (mg/dl)
women with uncontrolled diabetes Fasting 95
- At birth, neonates are more prone to
1 hr 180
hypoglycaemia, respiratory distress syndrome,
2 hr 155
hypocalcemia, and hyperbilirubinemia
3 hr 140
- The first trimester of pregnancy is the most
important time for fetal development; if a
woman can be kept from becoming Glycosylated Hemoglobin (HbA 1C)
- a measure of the amount of glucose attached to
hyperglycemic during this time, the chances of
congenital anomaly are greatly lessened haemoglobin, is used to detect the degree of
hyperglycemia present
 - Measuring HbA1c is advantageous not just - Elevated liver enzyme (ALT) alanine
because it offers a present value of glucose, but aminotransferase
because it reflects the average blood glucose - (AST) serum aspartate aminotransferase
level over the past 4-6 weeks (i.e., the time the which are all effects of haemorrhage and
haemoglobin in red blood cells were picking up necrosis of liver
the glucose) - Because of low platelet count women need
- The upper normal level of HbA1c is 6% of total extremely close observation for bleeding, in
haemoglobin addition to observations for necessary for
- A urine culture maybe done each trimester to preeclampsia
detect asymptomatic UTIs as the increased - Therapy for this condition is transfusion of
glucose concentration in urine may lead to fresh frozen plasma or platelets in order to
increased infection an ophthalmic examination improve the platelet count
should be done once during the pregnancy for a
woman with gestational diabetes and at each MULTIPLE PREGNANCY
trimester for women with known diabetes - Is considered a complication of pregnancy
because common background retinal changes because a woman must adjust to the effects of
that are common in diabetes, such as increased more than one fetus
exudate
- Laser therapy to halt these changes can be 1. Identical (Monozygotic) twin
done during pregnancy without risk to fetus  begin with a single ovum and
spermatozoon
Therapeutic Management:  in the process of fusion, or in one of
- Because blood glucose levels near normal the first cell divisions, the zygote
minimize the risk of maternal and fetal divides into two identical individuals
complications, both women with gestational  usually have 1 placenta, 1 chirion, 2
diabetes and those with overt diabetes need amnions, and a 2 umbilical cords
more frequent prenatal visits than usual to  the twins are always of the same sex
ensure close monitoring of their condition and
 they account for 1/3 of thwin births
that of the fetus
- Insulin. Early in pregnancy, a woman with
2. Fraternal (Dizygotic, Nonidentical) twin
diabetes may need less insulin than before
 they account 2/3 of twin births
pregnancy because the fetus is using so much
glucose  the result of the fertilization of two
separate ova by two separate
spermatozoa
HELLP SYNDROME
 have 2 placentas, 2 chorions, 2
- is a variation of gestational hypertension that
amnions, and 2 ummbilical cors
is named for the common symptoms that
occur  the twin may be of the same or
- H – hemolysis that leads to anemia different sex
EL – elevated liver enzymes that lead to
epigastric pain Assessment:
L – low platelets that lead to epigastric pain - uterus begins to increase in size at a rate
- The syndrome occurs in 4-12% of patients faster than usual
who have elevated blood pressure during - AFP levels will also be elevated
pregnancy - At the time of quickening, a woman may report
flurries of action at a different portions of her
Assessment: abdomen rather at one consistent spot
- Proteinuria, edema and increased blood - On auscultation of the abdomen, multiple sets
pressure of fetal heart sounds can be heard
- Nausea, epigastric pain, general malaise - An ultrasound can reveal multiple gestation
- Right upper quadrant tenderness from liver sacs early in pregnancy
inflammation
- Laboratory studies reveal hemolysis of RBC Therapeutic Management:
- Thrombocytopenia (a platelet count below - They are more susceptible to complications of
100,000/mm3) pregnancy such as gestational hypertension,
hydramnios, placemta previa, preterm labor
and anemia
 - Following birth they are more prone to - Maintain bedrest helps to increase
postpartum bleeding because of the additional uteroplacental circulation and reduces
uterine stretching that occurred pressure on the cervix which may help prevent
- Need closer prenatal supervision preterm labor
- A woman carrying more than two foetuses is - Straining to defecate could increase uterine
at greater risk pressure and cause a rupture of membranes-
high fiver
HYDRAMNIOS - Assess vital signs as well as lower extremity
- Usually rhe amniotic fluid volume at term is edema frequently
500-1000ml - Amniocentesis can be performed to remove
- Occurs when there is excess fluid of more some of the extra fluid
than 2000ml or an amniotic fluid index above - If contrractions begin, tocolysis may be
24cm necessary to prevent or halt preterm labor
- Can cause fetal malpresentation because the
additional uterine space can allow the fetus to PSEUDOCYESIS
turn to a transverse lie - False pregnancy
- Can also lead to premature rupture of the - Nausea and vomiting, amenorrhea and
membranes from the increased pressure, enlargement of the abdomen occur in either a
which leads to additional risk to infection, nonpregnant women or man
prolapse cord and preterm birth

Assessment:
- Amniotic fluid is formed by a combination of
the cells of the amniotic membrane and from a
fetal urine
- It is evacuatd by being swallowed by the fetus,
absorbed across the intestinal membrane into
the fetal bloodstream, and transferred across
the placenta
- Accumulation of amniotic fluid suggests
difficulty with the fetus ability to swallow or
absorb, or excessive urine production
- Inability to swallow occurs in infants who are
anencephalic, who have tracheosphageal
fistula with stenosis or who have intestinal
obstruction
- Excessive urine output occurs in the fetuses of
diabetic women (hyperglycemia in the fetus
causes increased urine production)
- Auscultating the fetal heart rate can be difficult
because of the depth of the increased amount
of fluid surrounding the fetus
- An ultrasound is done to document the
presence of hydramnios

Signs and Symptoms:

- Unusually rapid enlargement of the uterus
- The small parts of the fetus become difficult to
palpate because the uterus is unusually tense
- Extreme shortness of breath as the overly
distended uterus pushes up against the
diaphragm
- Lower extremity varicosities and haemorrhoids
- Increased weight gain

Therapeutic Management: