CHAPTER 20 PREEXISTING OR NEWLY ACQUIRED ILLNESS

Conditions especially dangerous to the fetus:  Pulmonary artery catheter inserted during labor to
 Causes changes in fluid and electrolyte imbalance. monitor pulmonary person.
 Causes altered respiratory or cardiac function.  Monitor closely after anesthesia b/c they can
 Causes severe blood loss. become hypotensive.
HIGH RISK PREGNANCY- concurrent disorder, pregnancy related
complication or external factor jeopardizes fetal/maternal health. A woman with PERIPARTUM HEART DISEASE
DEFINITION: Heart condition that originates in pregnancy.
CARDIOVASCULAR DISORDERS AND PREGNANCY
Occurs in African American multiparas most often.
Overall women have less heart issues because of the
Symptoms:
correction of congenital heart disorders and tx of rheumatic fever.
 myocardial failure (SOB, chest pain,
Needs to begin prenatal care within 1 week of missed period. Most
nondependent edema)
dangerous time is at week 28-32 when blood volume peaks.
 Cardiomegaly
Cardiovascular disorders that most commonly complicate
Tx:
pregnancy:
 Sharp reduction of exercise
1) Valve damage cause by rheumatic fever or Kawasaki disease.
 Diuretic, arrhythmia agent, digitalis to maintain
2) Congenital anomalies i.e.. atrial septal defect, coarctation of the
heart function.
aorta.
 Heparin
 Immunosuppressive therapy
4 CLASSES OF HEART DISEASE
Postpartum:
I. Uncompromised. (predict a normal pregnancy)
 Don't get pregnant again.
II. Slightly compromised. Ordinary activity causes
 Don't use oral contraceptives!
excessive fatigue, palpitation, angina. (normal pregnancy)
 May need heart transplant.
III. Markedly compromised. Above symptoms

experienced at less than ordinary activity. (can complete pregnancy
Assessment of Woman with Cardiac disease:
with bed rest and other interventions)
1. Thorough health history.
IV. Severely compromised. Symptoms occur even at rest.
2. Level of exercise.
Unable to do anything without discomfort. (avoid pregnancy)
3. Edema (imp. for distinguishing if it's from heart failure)
4. Baseline vitals, nailbed fillings.
Woman with LEFT-SIDED HEART FAILURE
5. ECG.
Symptoms:
Fetal assessment:
 Pulmonary back-up, edema when vein pressure
Late decelerations indicate issue in labor.
reaches 25mmHg.
 SOB, increased resp rate=orthopnea and
Assessing a pregnant woman with cardiac disease
paroxysmal nocturnal dyspnea.
1. Cough, increased resp. rate.
 Productive cough with bloody sputum if
2. Fatigue, tachycardia.
capillaries rupture.
3. Decreased amniotic fluid and poor fetal heart tone.
 Fatigue, weakness, dizziness.
4. Edema from poor venous return.
 Less blood going to placenta.
Nsg:
 High risk for spontaneous miscarriage, preterm
1. 2 rest periods a day.
labor, death
2. Maintain bp 100/60
Tx:
 Anticoagulant (preferably heparin) to dispel
thrombus formation. NORMAL EDEMA VS HEART FAILURE
 Antihypertensives to control bp. EDEMA
 Diuretics to reduce blood volume. Normal: feet and ankles; Heart failure:
 B-blockers improve ventricular filling.
Diagnostics:
 Week 30, 32: serial US and nonstress tests to rule 3. Remember to take prenatal supplements, esp. iron.
out poor placental perfusion. Cardiac medication instructions:
Q: What is the anticoagulant of choice for early pregnancy and Digoxin: may need to increase dose. Can also be used to
why? slow fetal heart rate.
Heparin. It does not cross the placenta and thus is not Adenosine, b-blockers, ACE inhibitors, nitroglycerin
teratogenic. and safe for pregnancy.
Penicillin for rheumatic fever should be continued through
Woman with RIGHT-SIDED HEART FAILURE pregnancy. May get more antibiotics added on closer to the birth
Symptoms: date.
 Decreased CO to the lungs. No over-the-counter medications unless checked with the
 Jugular vein distention, increased portal doctor.
circulation. Nsg interventions during labor and birth for a woman with cardiac
 Dyspnea and pain from liver enlargement. issue:
 Peripheral edema. 1. Assess vitals, fetal HR, uterine contractions.
Tx: - Oxygen administration.
 Don't get pregnant until this is resolved. - Continuous hemodynamic monitoring via Swan-Ganz
 Oxygen administration. 2. Side-lying position (left)
 Frequent ABG's to measure fetal growth.
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- If she has pulmonary edema, elevate head and chest and  Green leafy veggies, legumes
place towel under right hip.  120-200mg ferrous sulfate/gluconate
3. Don't push with contractions, use of epidural anesthetics
instead! Nsg:
- Low forceps or vacuum extractor used.  Take iron with OJ because it is best absorbed in acid.
Postpartum nursing interventions for a woman with cardiac issues:  Stools may turn black: this is normal.
Circulation  SE of constipation and GI symptoms.
 Program of decreased activity. Type of anemia associated with Iron-deficiency:
 Anticoagulants, stockings. 1. MICROCYTIC: small/stunted RBC.
2. HYPOCHROMIC: less hemoglobin than average cell.
Meds Type of anemia associated with folic-acid deficiency:
 Start prophylactic antibiotics. 1. MEGALOBLASTIC ANEMIA: enlarged red blood cell.
 Give oxytocin with CAUTION! Increases bp. *takes several weeks to develop or not apparent until Tri. 2
Woman with artificial valve prosthesis A woman with FOLIC-ACID DEFICIENCY ANEMIA
NSG: Patho: Folic acid is necessary for formation of RBCs and
 Coumadin is d/c and replaced with heparin before preventing neuro tube/abdominal defects.
pregnancy. Symptoms:
 Observe for petechiae and premature separation of  Can contributes to miscarriage or separation of the
placenta. placenta.
 Stool softeners are okay.  Similar to symptoms in iron-deficiency anemia
Woman with CHRONIC HYPERTENSIVE VASCULAR Tx:
DISEASE  Begin supplement of 400ug folic acid daily.
Symptoms:  Eat folate rich foods (orange, green leafy veggies, dried
 Bp 140/90 or above. beans).
Tx: Q: In what type of woman does folic-acid deficiency anemia occur
 B-blockers and ACE inhibitors. most often in?
 Methyldopa (Aldomet) typically prescribed.  Women having multiple pregnancies.
Woman with VENOUS THROMBOEMBOLIC DISEASE  Women with secondary hemolytic illness.
Symptoms of DVT:  Women taking hydantoin (anticonvulsant interferes with
 Triad of stasis, vessel damage, hypercoagulation occurs. folate absorption).
 Pain and redness in calf  Women taking oral contraceptives.
Symptoms of PE:  Women with poor gastric absorption.
 Chest pain, bloody cough A woman with SICKLE-CELL ANEMIA:
 Sudden dyspnea, tachycardia, Patho: An abnormal amino acid replacing valine. (If lysine
 Dizziness, fainting replaces valine, non-sickling occurs). RBC are sickle shaped, clump
Tx: together.
 Bed rest and IV heparin 24-48 hours, then sub Q heparin Symp:
every day afterwards.  Hemoglobin of 6-8mg/100ml.
 Limit injection side to arms and thighs.  Growth restriction, miscarriage, perinatal mortality of the
 STOP heparin once labor begins. fetus.
 No episiotomy or epidural anesthesia.  Blockage of the placental circulation is possible.
 No OC's postpartum.
Dx: Dopper and history Tx and Nsg considerations:
HEMATOLOGIC  Screen all African American women.
Q: Is anemia a normal finding during pregnancy?  DO NOT take iron (because it can't be incorporated into
 Yes. This is because the blood volume expands ahead of the sickle cell).
the red blood cell count.  Stay hydrated, limit standing.
TRUE ANEMIA  More susceptible to bacteruria (nurse needs to obtain urine
 Hemoglobin less than 11g/dl (33%) in the 1st or third sample).
trimester.  Sickle Cell Crisis: control pain, administer oxygen, lower
 Hemoglobin is less than 10.5 g/dl (32%) in the second viscosity.
trimester.  Hospitalize if the woman develops a fever/infection,
A woman with IRON-DEFICIENCY ANEMIA respiratory issues.
Patho: Iron is absorbed from duodenum into bloodstream.  During labor, use epidural anesthesia.
It then binds transferrin, heads to the liver/spleen/bone marrow and  Postpartum use compression stockings.
is incorporated into hemoglobin or stored as ferritin. Q: How do you determine if your child gets sickle-cell anemia?
 Dx: low serum iron (under 30ug/dl)  Knowing that disorder is recessively inherited.
 Increased iron binding capacity.  Electrophoresis of RBC's obstaiend from maternal serum
Symptoms: or amniocentesis.
 Extreme fatigue, poor exercise intolerance.  Newborn routine serum screening at birth.
 Pica (craving for ice and starch) The woman with THALASSEMIA
 Infants have low birth weight, premature. Patho: autosomal recessive disorder tat results in poor
 Restless leg syndrome. hemoglobin formation and severe anemia occurring most in
Tx: Mediterranean, African, Asians.
 27mg of iron in prenatal vitamins
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Tx: Folic acid, Blood transfusion, NO IRON A woman with HYPERACTIVE BLADDER
supplementation Patho: uterus puts pressure on the bladder.
Symp: frequency, urgency, incontinence.
Tx:
The woman with MALARIA  Fesoterodine (Toviaz) which is an antispasmodic.
Patho: RBC become sticky and obstruct vessels resulting A woman with CHRONIC RENAL DISEASE
in anoxia of organs. Incubation: 12-24 days. Patho: diseased kidneys don't produce erythropoeitin.
Symp: Symp: Elevated bp, proteinuria, Flank pain if she develops
 Elevated LFT pyelonephritis, Anemia, SCR: 0.5,Edema
 Fever, malaise, headache Tx:
 Low platelets, anemia, renal failure  Prednisone (neonates have increased chance of cleft palate
Tx: and may be hyperglycemic).
 Chloroquine is drug of choice. Safe.  Dialysis (risk of preterm labor so progesterone IM given),
 Sulfadoxine/pyrimethamine for the last trimester. preferably peritoneal.
 Teratogenic: Quinine, Malarone, tetracyclines.  Low potassium diet (kidneys don't process this well)
von Willebrand disease RESPIRATORY
Patho: autosomal dominant coagulation disorder that A woman with the COMMON COLD
causes prolonged bleeding times despite normal platelets. This is Patho: estrogen stimulation causes nasal congestion.
because clotting factors (8) are reduced. Mostly caused by a virus.
Symp: menorrhagia or frequent epistaxis Tx:
Tx: Replace missing coagulation factors by infusion of  DO NOT take aspirin. Check before taking OTC.
cryoprecipitate or FFP before birth.  Antibiotics ARE NOT effective.
HEMOPHILIA B  Get extra rest with lots of Vit C
Patho: a sex-linked disorder where there is a reduced level  Tylenol q4h up to 3000mg
of factor 9. In carrier females this could cause miscarriage.  Room humidifier/vapor rub
Tx: Restore factor 9 with concentrate or FFP.  Cool/warm compresses
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP) A woman with INFLUENZA
Patho: decreased platelets that may occur after viral Patho: Caused by a virus (A, B, C)
invasion. Lasts 1-3 months. Symp:
Symp: Thrombocytopenia, Frequent nosebleeds and  High fever
petechiae and large bruises  Extreme prostration
Tx: Oral prednisone, Platelet transfusion, Plasmapheresis.  Aching pains in back and extremities
*all increase platelets count temporarily to decrease chance  Sore, raw throat
of bleed at birth Tx:
RENAL  Antipyretic (Tylenol)
A woman with UTI  Tamiflu (oseltamivir)
Patho: Progesterone causes ureters to dilate, leading to  Vaccination is okay for pregnancy
stasis of urine. Minute amounts of glucose in urine provide feeding A woman with PNEUMONIA
ground for bacteria (esp. E.Coli or Strep B). Path: Bacterial invasion of lung by S. pneumoniae, H.
Symp: influenzae, Mycoplasma pneumoniae. Acute inflammatory response
 Pain and urinary frequency occurs in the lung alveoli.
 Pyelonephritis: Right lumbar pain that radiates downwards Symp:
 N and V, fever, malise.  RBC, fibrin, leukocytes flood the alveoli
 100,000 bacteria/ml on urine culture.  Dyspnea
Tx:  Fetal growth restriction, preterm birth
 Amoxicillin, ampicillin, cephalosporins are safe for use Tx:
during pregnancy.  Appropriate antibiotics
 Sulfonamides: safe for EARLY pregnancy ONLY.  Oxygen therapy
 NO tetracyclines! A woman with ASTHMA
Nsg: Patho: Symptoms triggering by inhalled allergen.
 If Strep B caused it: obtained vaginal cultures to make sure Bronchial smooth muscles are constricted.
it hasn't affected the fetus (associated with pneumonia). Symp:
 Void frequently, wipe front to back, drink cranberry juice.  Mucosal inflammation and swelling.
 15 min knee chest position to promote drainage.  Bronchial wheezing upon exhaling
PYELONEPHRITIS Tx:
Patho: UTI spreads to the kidneys.  Regular corticosteroids she normally takes (check with
Symp: PMD).
 Right lumbar pain that radiates downwards.  IV administration of hydrocortisone during labor b/c of
 N and V, fever, malaise stress.
Tx:  Terbutaline and albuterol need to be tapered close to term
 Hospitalization for 24-48 hours, IV antibiotics. because they may reduce labor contractions.
 For duration of pregnancy: oral Nitrofurantoin A woman with TB
(Macrodantin). Patho: Mycobacterium TB invades lung tissue. Antibodies
 NO vitamin C because neonate may develop scurvy from have a pos. response to PPD test.
vit C withdrawal. Symp:
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 CHAPTER 20 PREEXISTING OR NEWLY ACQUIRED ILLNESS
 Chronic cough, hemoptysis  Polyuria, polydipsia
 Fatigue, weight loss, night sweats Tx:
 Positive PPD (follow with chest x-ray and sputum)  Increase insulin dosage at week 24
Tx: Oral glucose challenge
 Wait 1-2 years after TB inactivate to conceive. Give 75g oral glucose, take blood at 1-2-3 hours.
 Isoniazid (take supp B6 to counter peripheral neuritis) Fasting: 95
 Rifampin 1 hour: 180
 Ethambutol Hcl (may cause optic atrophy) 2 hour: 155
 Maintain Calcium intake 3 hour: 140
A woman with COPD If 2/4 samples are abnormal, diabetes is dx.
Patho: constriction of airway associated with long term GESTATIONAL DIABETES
smoking. Patho: development of insulin resistance midway through
Symp: SOB -fetal growth restriction, preterm birth pregnancy
Tx: Dx: Fasting glucose above 95mg/dl and 2 abnormal
 Additional rest, supp oxygen readings after glucose ingestion
 CPAP for sleep apnea Symp:
 Smoking cessation  Hypoglycemia in 1st and 2nd trimesters, followed by
A woman with CYSTIC FIBROSIS Hyperglycemia peaking at the 6th month.
Patho: Inherited disease where dysfunction of exocrine  Polyuria, polydipsia,
glands causes thick mucus secretions, ruining lung/pancreatic  Metabolic acidosis
health. Nsg:
Symp:  Check for UTIs
 Same as COPD  Eye exams, possible laser therapy
 Thickened mucus Tx:
 Sterility  Diet (20% protein, 40% carbs, 30% fat, fiber)
 Difficulty digesting fat and protein  Bedtime snack of protein and complex carb to prevent
 IUGR, preterm labor (screen by chorionic villi, hypoglycemia.
amniocentesis, abnormal chromosome 7)  3 meals and 3 snacks.
Tx:  Fiber prevents postprandial (after meal) hyperglycemia.
 Pancrelipase Symptoms of hyper and hypoglycemia
 Bronchodilator and antibiotic for symptoms Hyper: Polydipsia, polyuria, polyphagia (fruity breath)
 Daily chest physiotherapy Hypo: nervousness, headache, weakness, irritability
RHEUMATIC Risk factors for gestational diabetes
A woman with RA  Obesity
Patho: Disease of connective tissue marked by joint  Over 25
inflammation and contractures.  Hx of large babies
Symp: Joint symptoms (may actually improve)  Hx of unexplained fetal/perinatal loss, congential
Tx: anomalies
 Corticosteroids, NSAIDS, hydroxychloroquine to improve  Hx of PCOS
mobility.  Family hx of diabetes or Native American, Hispanic, Asian
 Decrease aspirin intake before term. ancestry.
 STOP taking methotrexate (causes head and neck defectS Q: Should Oral hypoglycemics be used during pregnancy? NO!
A woman with SYSTEMIC LUPUS INSULIN IN PREGNANCY
Patho: Chronic disease of connective tissue.  Needs less than normal early in pregnancy
Symp:  MORE needed in late pregnancy
 Butterfly rash of face  Short-acting with intermediate (2/3 at breakfast, 1/3 at
 Vessel obstruction because of thickening of collagen night)
 Thrombocytopenia  Give IM, stretch skin taut, inject at 90deg angle
 Acute nephritis (proteinuria, low UO)  Most prefer the thigh and upper arm site.
Tx: What should you do for hypoglycemia?
 NSAIDS, heparin, salicylates, prednisone, azathioprine.  Milk with crackers.
 Reduce aspirin before term.  Prevents rebound hypoglycemia.
 Dialysis Tests for placental function
 IV hydrocortisone during labor 1. 15-17 weeks: Serum alpha-fetoprotein test (checks neural
NEUROLOGIC tube defects)
A woman with Diabetes Mellitus 2. 18-20 weeks: Ultrasound) (to detect gross abnormalities)
Diagnosis: 3. 36 weeks Lecithin/Sphingomyelin ratio via amniocentesis
-Fasting glucose above 126, nonfasting 200 to determine lung maturity
75-g Glucose Oral challenge 4. Every trimester: Creatinine clearance
Symp: 5. Weekly nonstress test or biophysical profile
 Infants prone to hypoglycemia, hypocalcemia, 6. Fetal kicks
hyperbilirubinemia How do you know if the fetal lungs are mature?
 Hydramnios L/S ratio is 2:1, and you will be able to detect
 Increased risk of HTN, poor fetal heart tone phosphatidylglycerol, an ingredient of lung surfactant.
 Macrosomia (10lb baby) What does hydramnios indicate?
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 CHAPTER 20 PREEXISTING OR NEWLY ACQUIRED ILLNESS
1) GI malformation
2) poorly controlled gestational HTN

*at risk for hemorrhage after delivery because of poor

uterine contraction.
What does oligohydramnios indicate?
1. Fetal growth restriction
2. Fetal renal abnormality
Birth of fetus to a woman with diabetes
1. Week 36-40 are the most dangerous, so induce at 37
weeks.
2. Vaginal delivery is preferred with rupture of membranes or
oxytocin to induce.
3. Avoid use of IV glucose as plasma volume expanded (use
Ringer's lactate or saline instead)
4. Postpartum care of a woman with diabetes
5. 1–2-hour postprandial glucose monitoring
6. Glucose returns to normal at 24 hours if she has gestational
diabetes.
7. If she has IDDM, hold insulin in immediate postpartum but
will need to return to pre-pregnancy requirements

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