PREGESTATIONAL CONDITIONS

•Heart Diseases
•Diabetes Mellitus

•Substance Abuse

•HIV/AIDS

•Rh Sensitization

•Anemia
I. HEART DISEASE
 Pregnancy results in increased cardiac output,
heart rate & blood volume.
 Normal heart is able to adapt to these changes
without difficulty.
 Woman with heart disease has decreased cardiac
reserve, making it more difficult for her to handle
the higher workload of pregnancy.
 Cardiac disease complicates about 1% of
pregnancies.
1.Congenital Heart Defects
 Most commonly seen in pregnant women include:
 Atrial septal defect
 Patent ductus arteriosus
 Coarctation of aorta
 Tetralogy of fallot
-impact of pregnancy depends on the specific defect.
-if the heart has been surgically repaired & no evidence of heart
disease remains, the woman may undertake pregnancy with
confidence.
-woman with CHD who experience cyanosis should be counseled to
avoid pregnancy because the risk to mother & fetus is high.
2. Rheumatic Heart Disease
 Results from an infection (caused by the bacteria,
streptococci) known as rheumatic fever, which
starts with a sore throat & leads to the scarring of
one or more heart valves.
 The injured valves are unable to open & close
normally, resulting in obstruction to the flow of
blood.
 Is it possible to become pregnant?
Laboratory tests for detecting RHD:
1. Throat cultures- for group A streptococcus usually are
negative by the time symptoms of rheumatic fever or
RHD appear.
 Isolate the organism before the initiation of antibiotic therapy to
help confirm a diagnosis of streptococcal pharyngitis & to allow
typing of the organism if it is isolated successfully.
2. Rapid Antigen- this test allows rapid detection of group
A streptococcal antigen & allows the diagnosis of
streptococcal pharyngitis & the initiation of antibiotic
therapy while the patient is still in the physicians office.
3. Anti-streptococcal Antibodies
 this is useful for confirming previous group A
streptococcal infection. Antibody titer should be
checked @ 2-week intervals in order to detect a rising
titer.
RHD
 Causes different types of heart valve defects.
 Commonly causes narrowing of the valve between the
left chambers of the heart (a condition called mitral
stenosis) in women of child bearing age.
 If you have mitral stenosis, you ma develop breathing
difficulty(dyspnea), swelling of the ankle & feet
(edema), & irregular heartbeats (arrythmia).
 Can also cause abnormal leaking of blood through the
valve between the left chambers of the heart ( a
condition called mitral regurgitation).
General measures to be followed once
you become pregnant:
➢ Make sure to keep your follow-up appointments with your
obstetrician throughout your pregnancy.
➢ Plan regular follow-up visits with your cardiologist.
➢ Carefully follow all the recommendations of the
cardiologist.
➢ The diet should be nutritious & fluid & sodium intake
should be restricted.
➢ Take adequate rest.
➢ Watch your weight.
➢ Avoid alcohol.
➢ Stop smoking.
II. Diabetes Mellitus
 An endocrine disorder of carbohydrate
metabolism, results from inadequate production or
use of insulin.

 Insulin- produced by B cells of Islets of Langerhans

in the pancreas, lowers blood glucose levels by
enabling glucose to move from the blood into
muscle & adipose tissue cells.
Pathophysiology
 Pancreas- fails to produce insulin or does not
produce enough insulin to allow necessary
carbohydrate metabolism.
 Without insulin, glucose does not enter the cells &
they become energy depleted.
 Blood glucose level remains high
(hyperglycemia) & the cells breakdown results in
a negative nitrogen balance; fat metabolism causes
ketosis.
Signs & Symptoms
1. Polyuria
2. Polydypsia
3. Polyphagia
4. Weight loss
Three main types of Diabetes:
1. Type I diabetes- results from the body’s failure to
produce insulin, & presently requires the person to
inject insulin.
2. Type II diabetes- results from insulin resistance, a
condition in which cells fail to use insulin properly,
sometimes combined wit an absolute insulin deficiency.
3. Gestational diabetes- is when pregnant women, who
have never had diabetes before, have a high blood
glucose level during pregnancy.
Diabetes on pregnancy outcome
 The pregnancy of a woman who has diabetes
carries a higher risk of complications, especially
perinatal mortality & congenital anomalies.

 Tight metabolic control reduces the risk.

Maternal Risks
1. Hydramnios
-increase in the volume of amniotic fluid, occurs in 10%
to 20% of pregnant women with diabetes.
 a result of excessive fetal urination because of
hyperglycemia.
 PROM & onset of labor may occasionally be a problem with
hydramnios.
2. Preeclampsia-eclampsia
- occurs more often in diabetic pregnancies than in normal
pregnancies.
Fetal-neonatal risk
1. Congenital anomalies
 -incidence is 5% to 10% & is the major cause of death
of infants born to women with diabetes.
 Ex. Heart, CNS, skeletal system

2. Respiratory distress syndrome

- appears to result from high levels of fetal insulin,
which inhibit some fetal enzymes necessary for
surfactant production.
3. Polycythemia
- excessive number of RBCs
 -due to the diminished ability of glycosylated
hemoglobin in the mother’s blood to release oxygen.
 Management
 Antepartal
 Prenatalcare- using a team approach to ensure an
optimally healthy mother & newborn.
- woman needs clear explanations & teaching to gain
her cooperation in ensuring a good outcome.
- the nurse-educator plays a major role in this
counseling.
- the woman with pregestational diabetes needs to
understand what changes she can expect during
pregnancy.
 a. Dietary regulation
 - the pregnant woman with diabetes needs to increase her
caloric intake by absent 300 kcal/day.
 - on the first trimester she needs about 35 kcal/day of
ideal body weight. Approximately 40% to 50% of the
calories came from complex, high fiber carbohydrates,
20% from protein, & 30% to 40% from fats.
 - the food is divided into 3 meals & 3 snacks. Bedtime
snack is the most important & should include both protein
& complex carbohydrates to prevent nightime
hypoglycemia.
b. Glucose monitoring
 - is essential to determine the need for insulin & to assess
glucose control.
c. Insulin Administration
- Many women with gestational diabetes need insulin to
maintain normal glucose levels. Human insulin should be
used because it is the least likely to cause an allergic
reaction.
- given either in multiple injections or by continuous
subcutaneous infusion.
*Oral hypoglycemics- not rarely used
 Intrapartal
a. Timing of birth- most pregnant women with
diabetes, regardless of the type are allowed to go to
term, with spontaneous labor.
 Some clinicians opt to induce labor in a woman at
term to avoid problems related to an aging
placenta.
 Cesarean birth maybe indicated if signs of fetal
distress exist.
b. Labor management
- maternal glucose levels are measured hourly to
determine insulin need.
 Primary goal is to prevent neonatal hypoglycemia.
 Often given two IV lines are used, one wit a 50%
dextrose solution & one with a saline solution.
 The saline solution is for piggybacking insulin or if a
bolus is needed.
 IV insulin is discontinued @ the end of the third stage
of labor.
Post partal Management
 First 24 hours postpartum, women wit pre-existing
diabetes typically require very little insulin.
 They are usually managed with a sliding scale specifying
dosage based on blood glucose levels.
 Antihyperglycemics are contraindicated during
breastfeeding.
 The woman should be reassessed 6 weeks postpartum to
determine whether her glucose levels are normal. If the
levels are normal, she should be reassessed at a minimum
of 3-year intervals.
III. SUBSTANCE ABUSE
 Occurs when a person experiences difficulties with
work, family, social relations, & health as a result of
alcohol or drug use.
 Drugs that are commonly misused includes:
-tobacco, alcohol, cocaine, marijuana,
amphetamines, barbiturates, hallucinogens, club
drugs, heroin and narcotics.
Substances commonly abused during
pregnancy
1. Alcohol- is a central nervous system depressant &
a potent teratogen.
 The incidence of alcohol abuse is highest among
women ages 20 to 40 years although alcoholism is
also seen in teenagers.
 Chronic abuse of alcohol can undermine maternal
health by causing malnutrition, bone marrow
suppression, increased incidence of infections, &
liver disease.
 Alcohol dependence- result is that a woman may
have withdrawal seizures in the intrapartal period
as early as 12 to 48 hours after se stops drinking.
 Delirium tremens may occur in the postpartal
period & the newborn may suffer a withdrawal
syndrome.
 Care includes sedation to decrease irritability &
tremors, seizure precautions, IV fluid therapy for
hydration & preparation for an addicted newborn.
 The effect of alcohol on the fetus may result in a group
of signs known as fetal alcohol syndrome (FAS).

2. Cocaine & crack

 Nearly 3% of pregnant women use illicit drugs such as
cocaine, marijuana, ecstasy, other amphetamines &
heroin.
 Cocaine use during pregnancy tends to affect between
1% & 5% of newborns.
 Cocaine- acts as the nerve terminals to prevent the
reuptake of dopamine & norepinephrine, which in turn
results in vasoconstriction, tachycardia, & hypertension.
 This can be taken by IV injection or by snorting the
powdered form.
 Crack- a form of freebase cocaine that is made up of
baking soda, water, and cocaine mixed into a paste and
microwaved to form a rock, can be smoked. Smoking
crack leads to a quicker, more intense high because the
drug is absorbed through the large surface area of the
lungs.
Major adverse maternal effects of
cocaine use includes:
 Hallucinations
 Pulmonary edema
 Cerebral hemorrhage
 Respiratory failure
 Heart problems
 Women who use cocaine have an increased
incidence of spontaneous abortion, abruptio
placentae, preterm birth, and stillbirth.
 Cocaine crosses into breastmilk and may cause
symptoms in the breastfeeding infant, including
extreme irritability, vomiting, diarrhea, dilated
pupils, and apnea.
 Thus, women who continue to use cocaine after
childbirth should avoid breastfeeding.
3. Marijuana- is the most widely used illicit drug among
women, both pregnant and non pregnant.
 More than 25% women of reproductive age admit to

current or past marijuana use.

 Marijuana use is associated with impaired coordination,
memory, and critical thinking ability.
 As a result, the pregnant women or new mother who

uses marijuana may be at risk if she tries to perform

tasks that require complex mental activities.
4. MDMA (Ecstasy)
 Methylenedioxymethamphetamine (MDMA),
better known as Ecstasy, is the most commonly
used of a group of drugs referred to as club drugs,
so called because they have become popular
among adolescents and young adults who frequent
dance clubs and “raves”.
 Is taken by mouth usually as a tablet. It produces
euphoria and feelings of empathy for others.
5. Heroin- is an illicit CNS depressant narcotic that alters
perception and produces euphoria. It is an addictive drug
that is generally administered IV.
 Pregnancy in women who use heroin is considered high
risk because of the increased incidence in these women of
poor nutrition, iron deficiency anemia, and preeclampsia.
 The fetus of a heroin-addicted woman is at increased risk
for IUGR, meconium aspiration, and hypoxia.
 The newborn frequently show signs of heroin addiction
such as restlessness; shrill, high-pitched cry; irritability; fist
sucking, vomiting, and seizures.
6. Methadone- is the most commonly used therapy for
women dependent on opioids such as heroin.
 Blocks withdrawal symptoms and reduces or eliminates

the craving for narcotics.

 Crosses the placenta and has been associated with
preeclampsia, placental problems, and abnormal fetal
presentation.
 Prenatal exposure to methadone may result in reduced
head circumference and lower birth weight.
Management
 A team approach to the care of the pregnant woman
with substance abuse problems ensures the
management necessary to provide safe labor and birth
for the woman and her child.
 The management of drug addiction may include
hospitalization if necessary to start detoxification.
 Urine screening is also done regularly throughout the
pregnancy if the woman has a known or suspected
substance abuse problem. This testing helps to identify
the type and amount of drug being abused.
 Little is yet known about the effects of MDMA on
pregnancy. However, the timing of ecstasy used by
the pregnant woman during fetal brain
development may be critical issue.
 Infants exposed to ecstasy in utero may experience
some of the same risks as infants exposed to other
amphetamines during pregnancy, including yhe
possibility of withdrawal –like symptoms such as
drowsiness, jitteriness, and breathing problems.
IV. HIV/AIDS
 Human immunodeficiency virus infection is one
of today’s major health concerns.

 It leads to a progressive disease that ultimately

results in acquired immunodeficiency
syndrome (AIDS).

 Women account for about 18% of cases in the U.S.

Pathophysiology
 HIV-1 enters the body through:
Blood
Blood products
Or other body fluids such as semen, vaginal fluid and
breastmilk
- It affects T-cells, thereby decreasing the body’s immune
responses.
- This makes the affected person susceptible to
opportunistic infections such as Pneumocystis carinii
 Once infected with the virus, the individual develops
antibodies that can be detected with the enzyme-linked
immunosorbent assay (ELISA) & confirmed with the
Western Blot test.
 Can be detected within 6 mos after exposure.
 Asymptomatic lasting from a few mos to as long as 17
years.
 Diagnosis of AIDS is made when a person is HIV
positive & has one of several specific opportunistic
infections.
Maternal Risks
 Many women who are HIV positive choose to avoid
pregnancy because of the risk of infecting the fetus &
the possibility of dying before the child is raised.
 Women who become pregnant should be advised that
pregnancy is not believed to accelerate the progression
of HIV/AIDS, that the use of antiretroviral (ARV)
therapy during pregnancy significantly reduces the risk
of transmitting the HIV-1 to the fetus, and that most
medications used treat HIV can be taken during the
pregnancy.
Fetal-Neonatal Risks
 HIV/AIDS may develop in infants whose mothers
are seropositive, usuall due to perinatal
transmission.
 Perinatal transmission occurs transplacentally, at
birth when the infant is exposed to maternal blood
and vaginal secretions, via breastmilk.
Management
 Combination of ARV therapy suppresses viral
replication, helps preserve immune function, and
reduces the development of resistance.
 Usually consists of two nucleoside analogues
reverse transcriptase inhibitors and a protease
inhibitor.
 Zidovudine (ZDV) is perhaps the best known of the
nucleoside analogues.
 Pregnant women who are currently on ARV therapy
should continue their provider-recommended regimen
and should receive regular, careful monitoring for
pregnancy complications and possible toxicities.
 Because the fetus is most susceptible to teratogenic
effects during the first 10 weeks of pregnancy, and the
risks of ARV therapy is not well known, women in 1st
trimester might elect to delay therapy until after 12
weeks gestation.
 To reduce the risk of perinatal transmission, all
pregnant women with HIV infection should be
offered the three-part ZDV prophylaxis regimen
beginning after the first trimester.
 This regimen includes:
1. Oral ZDV daily
2. Intravenous ZDV during labor until birth
3. Oral ZDV for the infant starting 8 to 12 hours after
birth and continuing for 6 weeks.
 At each prenatal visit, asymptomatic, HIV infected
women are monitored for early signs of complications,
such as weight loss in the second or third trimester or
fever.
 Each trimester the woman should have a visual
examination and examination of the retina to detect
such complications as toxoplasmosis.
 In addition to routine prenatal testing, the woman who
is HIV positive should be assessed regularly for
serologic changes indicating that HIV/Aids is
progressing.
 A pregnancy complicated by HIV infection, even if
asymptomatic, is considered high risk, and the
fetus is monitored closely.
 Women who are HIV positive are at increased risk
for complications such as intrapartal or postpartal
hemorrhage, postpartal infection, poor wound
healing and infections of the genitourinary tract.
 Thus, they need careful monitoring and
appropriate therapy as indicated.
 HIV positive woman should be cautioned against
breast feeding her infant.
RH SENSITIZATION
 All women with Rh-negative blood should have an
anti-D antibody titer done at a first pregnancy visit.
If the results are normal or the titer is minimal
(normal is 0; a ratio below 1:8 is minimal), the test
will be repeated at week 28 of pregnancy.
RH SENSITIZATION
 If a woman’s anti-D antibody titer is elevated at a
first assessment (1:16 or greater), showing Rh
sensitization, the well-being of the fetus in this
potentially toxic environment will be monitored
every 2 weeks (or more often) by Doppler velocity
of the fetal middle cerebral artery, a technique that
an predict when anemia is present or fetal red cells
are being destroyed (Valcamonico et al., 2007).
RH SENSITIZATION
 If the artery velocity remains high, a fetus is not
developing anemia and most likely is an Rh-
negative fetus.
 If the reading is low, it means a fetus is in danger,
and immediate birth will be carried out providing
the fetus is near term. If not near term, efforts to
reduce the number of antibodies in the woman or
replace damaged red cells in the fetus are begun
Therapeutic Management
 To reduce the number of maternal Rh (D)
antibodies being formed, Rh (D) immune globulin
(RhIG), a commercial preparation of passive Rh (D)
antibodies against the Rh factor, is administered to
women who are Rh-negative at 28 weeks of
pregnancy.
Therapeutic Management
 RhIG cannot cross the placenta and destroy fetal
red blood cells because the antibodies are not the
IgG class, the only type that crosses the placenta.
 RhIG is given again by injection to the mother in
the first 72 hours after birth of an Rh-positive child
to further prevent the woman from forming
natural antibodies.
Therapeutic Management
 RhIG cannot cross the placenta and destroy fetal
red blood cells because the antibodies are not the
IgG class, the only type that crosses the placenta.
 RhIG is given again by injection to the mother in
the first 72 hours after birth of an Rh-positive child
to further prevent the woman from forming
natural antibodies.
Therapeutic Management
 Because RhIG is passive antibody protection, it is
transient, and in 2 weeks to 2 months, the passive
antibodies are destroyed.
 Only those few antibodies that were formed during
pregnancy are left.
 For this reason, every pregnancy is like a first
pregnancy in terms of the number of antibodies
present, ensuring a safe intrauterine environment
for any future pregnancies.
Therapeutic Management
 Any woman who does not receive a RhIG injection
after an induced abortion, miscarriage, ectopic
pregnancy, or amniocentesis can also have
antibody formation begin.
Therapeutic Management
 After birth, the infant’s blood type will be
determined from a sample of the cord blood. If it is
Rh-positive—Coombs’ negative, indicating that a
large number of antibodies are not present in the
mother—the mother will receive the RhIG
injection.
 If the newborn’s blood type is Rh-negative, no
antibodies have been formed in the mother’s
circulation during pregnancy and none will form,
so passive antibody injection is unnecessary.
Therapeutic Management
 To restore fetal red blood cells, blood transfusion
can be performed on the fetus in utero.
 This is done by injecting red blood cells, by
amniocentesis technique, directly into a vessel in the
fetal cord or depositing them in the fetal abdomen
where they migrate into the fetal circulation.
Therapeutic Management
 The mother receives an RhIG injection after the
transfusion to help reduce increased sensitization
from any blood that might have been exchanged.
 Transfusion is sometimes done only once during
pregnancy, or it may be repeated as often as every
2 weeks.
Therapeutic Management
 After birth, the infant may require an exchange
transfusion to remove hemolyzed red blood cells
and replace them with healthy blood cells
Anemia
Description
 Hemoglobin value of less than 11 mg/dL or
hematocrit value less than 33% during the second
and third trimesters
 Mild anemia (hemoglobin value of 11 mg/dL)
poses no threat but is an indication of a less than
optimal nutritional state.
Anemia
Description
 Iron deficiency anemia is the most common
anemia of pregnancy, affecting 15% to 50% of
pregnant women. It is identified as physiologic
anemia of pregnancy.
Etiology
Causes of anemia include:
 Nutritional deficiency (e.g., iron deficiency or
megaloblastic anemia, which includes folic acid
deficiency and B12 deficiency). This can be a lot to
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Etiology
Causes of anemia include:
 Acute and chronic blood loss

 Hemolysis (e.g., sickle cell anemia, thalassemia, or

glucose-6-phosphate dehydrogenase [G-6-PD])
Pathophysiology
 The hemoglobin level for nonpregnant women is
usually 3.5 g/dL. However, the hemoglobin level
during the second trimester of pregnancy averages
11.6 g/dL as a result of the dilution of the mother’s
blood from increased plasma volume. This is called
physiologic anemia and is normal during
pregnancy.
Pathophysiology
 Iron cannot be adequately supplied in the daily
diet during pregnancy. Substances in the diet, such
as milk, tea, and coffee, decrease absorption of
iron. During pregnancy, additional iron is required
for the increase in maternal RBCs and for transfer
to the fetus for storage and production of RBCs.
The fetus must store enough iron to last 4 to 6
months after birth.
Pathophysiology
 During the third trimester, if the woman’s intake of
iron is not sufficient, her hemoglobin will not rise
to a value of 12.5 g/dL and nutritional anemia may
occur. This will result in decreased transfer of iron
to the fetus.
 Hemoglobinopathies, such as thalassemia, sickle
cell disease, and G-6-PD, lead to anemia by causing
hemolysis or increased destruction of RBCs.
Assessment Findings
 Associated findings. In clients with a hemoglobin
level of 10.5 g/dL, expect complaints of excessive
fatigue, headache, and tachycardia.
 Clinical manifestations:
 Signs of iron deficiency anemia (hemoglobin level
below 10.5 g/dL) include brittle fingernails,
cheilosis (severely chapped lips), or a smooth, red,
shiny tongue.
 Women with sickle cell anemia experience painful
crisis episodes.
Nursing Management
 Provide client and family teaching. Discuss using
iron supplements and increasing dietary sources of
iron as indicated.
 Prepare for blood-typing and crossmatching, and
for administering packed PBCs during labor if the
client has severe anemia.
Nursing Management
 Provide support and management for clients with
hemoglobinopathies.
 Ina client who has thalassemia or who carries the trait,
provide support, especially if the woman has just
learned that she is a carrier. Also assess for signs of
infection throughout the pregnancy.
Nursing Management
 In a pregnant client with sickle cell disease, assess iron
and folate stores, and reticulocyte counts; complete
screening for hemolysis; provide dietary counseling
and folic acid supplements; and observe for signs of
infection.
 In a pregnant client with G-6-PD, provide iron and folic
acid supplementation and nutrition counseling, and
explain the need to avoid oxidizing drugs.