The Nursing Role in Caring for a Family During

Complications of Pregnancy Birth, or the Postpartum

Period (Nursing Care of a Family Experiencing a
Pregnancy Complication from a Pre-existing or Newly
Acquired Illness)
Lesson 2
LESSON: 2
DURATION: 6 hours

NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION

FROM A PRE-EXISTING OR NEWLY ACQUIRED ILLNESS

SPECIFIC OBJECTIVES:

At the end of the lesson, the students should be able to:

1. Define high risk pregnancy, including pre-existing factors that contribute to its development
such as diabetes mellitus or cardiovascular disease.
2. Assess a woman with an illness during pregnancy for changes occurring in the illness
because of the pregnancy or in the pregnancy because of the illness.
3. Formulate nursing diagnosis related to the effect of a preexisting or newly acquired illness
on pregnancy.
4. Identify expected outcomes that will contribute to a safe pregnancy outcome when illness
occurs with pregnancy as well as help families manage seamless transitions across differing
healthcare settings.
5. Implement nursing care for a woman when illness complicates pregnancy, such as teaching
her how to measure blood sugar.
6. Evaluate expected outcomes for achievement and effectiveness of care.

LESSON PROPER:

A. THE NURSING ROLE AND NURSING CARE DURING PREGNANCY

COMPLICATIONS

Nursing Process Overview:

1. Assessment - focus on the signs and symptoms of the illness: subjective and objective data.
Examples:
a. Subjective Data: woman’s level of exhaustion
b. Objective Data: vital signs, extent of edema

2. Nursing Diagnosis
Examples:
 Ineffective tissue perfusion (cardiopulmonary) related to poor heart function secondary
to mitral valve prolapse during pregnancy.
 Pain related to pyelonephritis secondary to uterine pressure on ureters.
 Social isolation related to prescribed bed rest during pregnancy secondary to concurrent
illness.
 Ineffective role performance related to increasing level of daily restrictions secondary
to chronic illness and pregnancy.
  Knowledge deficit related to normal changes of pregnancy versus illness
complications.
 Fear regarding pregnancy outcome related to chronic illness.
 Health – seeking behaviors related to the effects of illness on pregnancy.
 Situational low self-esteem related to illness during pregnancy.

3. Outcome Identification and Planning

Example:
 Outcome should be related to the entire family’s health.
 For chronic illness: To maintain woman’s health during pregnancy so she can remain
at home as long as possible, thereby minimizing hospitalization and family disruptions.
 For new illness: Allowing a woman to choose among alternatives to help her to
participate in her own care and also to maintain self-esteem as well as helps her move
a step toward parenthood and assuming care for her family.

4. Implementation:
Example: Teaching woman on her new or additional measures to maintain health during the
pregnancy.

5. Outcome Evaluation
Example:
 Patient states she rests for 2Hours morning and afternoon; dependent edema remains at
1+ or less at next prenatal visit.
 Family members state they are all participating in an exercise program since mother
developed gestational diabetes.
 Patient reports no burning on urination or flank pain at next prenatal visit.
 Patient states she understands the importance of talking daily thyroid medicine for total
length of pregnancy.

A. CARDIOVASCULAR DISORDER AND PREGNANCY

The danger of pregnancy in a woman with cardiac disease occurs primarily due to the increase
in circulatory volume. The most dangerous time for a woman is in 28 to 32 weeks, after the
blood volume peaks.
1. A Woman with Left Sided Heart Failure:
 Occurs in conditions such as mitral stenosis, mitral insufficiency and aortic coarctation.
 The left ventricle cannot move the volume of blood forward that is received by the left
atrium from the pulmonary circulation.
 The level for the failure is often at the level of the mitral valve.
 The normal physiologic tachycardia of pregnancy shortens diastole (atrial contraction)
and decreases the time available for blood to flow across this valve.
 The inability of the mitral valve to push blood forward causes back-pressure on the
pulmonary circulation, causing it to become distended, systemic blood pressure
decreases in the face of lowered cardiac output and pulmonary hypertension occurs.
  When pressure in the pulmonary vein reaches a point of 25 mm Hg, fluid begins to pass
from the pulmonary capillary membranes into the interstitial spaces surrounding the
alveoli and into the alveoli leads to Pulmonary Edema.
Pulmonary Edema - interferes with oxygen-carbon dioxide exchange because fluid coats
the alveolar exchange space. If pulmonary capillaries rupture under the pressure, small
amounts of blood leak into the alveoli.
Signs and Symptoms:
 Productive cough of blood-speckled sputum
 Increased fatigue
 Weaknesses
 Dizziness – lack of oxygen in the brain
 HR increases.
 Peripheral constriction occurs in an attempt to increase the systemic BP.
 Pulmonary edema
 Orthopneic
 Paroxysmal nocturnal dyspnea (suddenly waking at night with shortness of breath) –
occurs because heart action is more effective when she is at rest.
Risks:
 Spontaneous miscarriage – because oxygen is limited.
 Preterm labor
 Maternal death
As oxygen saturation of the blood decreases from dysfunction of the alveoli, chemoreceptors
stimulate the respiratory center to increase RR.
Medication:
 Antihypertensives – to control increased BP.
 Diuretics – to reduce blood volume.
 Beta blockers – to improve ventricular filling.
Diet: low sodium diet
Laboratory Management: serial UTZ and non-stress test after 30 – 32 weeks of pregnancy
and monitor FHR.
Surgical Management:
 Balloon valve angioplasty to loosen mitral valve adhesions.
 If an anticoagulant is required, heparin is the drug of choice – it does not cross the
placenta.

2. A Woman with Right Sided Heart Failure

Causes:
 Congenital heart defects – pulmonary valve stenosis and atrial and ventricular septal
defects can result in right-sided heart failure.
 Occurs when the output of the right ventricle is less than the blood volume received by
the right atrium from the vena cava.
 Back pressure from this results in congestion of the systemic venous circulation and
decreased cardiac output to the lungs.
 Blood pressure decreases in the aorta because less blood is reaching it
 Pressure is high in the vena cava, both jugular distention and increased portal
circulation occur.
Signs and Symptoms:
 Liver and spleen distended – leading to dyspnea and pain in pregnant woman because
the enlarged liver, as it pressed upward by the enlarged uterus, puts extreme pressure
on the diaphragm.
 Ascites – distention of abdominal vessels can lead to exudates of fluid from the vessels
into the peritoneal cavity.
 Peripheral edema – fluid also moves from the systemic circulation into lower extremity
interstitial spaces.
 Eisenmenger Syndrome – the congenital anomaly most apt to cause the right sided
heart failure in women of reproductive age.
Management:
 Oxygen administration
 Frequent arterial blood assessment to ensure fetal growth.
 During labor – pulmonary artery catheter to monitor pulmonary pressure.
 Close monitoring to minimize the risk of hypotension after epidural anesthesia.

B. HEMATOLOGIC DISORDERS AND PREGNANCY

Involves either blood formation or coagulation disorders.
1. Anemia and Pregnancy
 because the blood volume expands during pregnancy slightly ahead of the red cell
count, most women have a pseudo anemia of early pregnancy. This condition is normal
and should not be confused with true types of anemia.
 true anemia – woman’s hemoglobin (hgb) concentration is less than 11 g/dL
(hematocrit: CT < 33%) during the first and third trimester of pregnancy
* when hgb concentration is < 10.5 g/dL (hematocrit < 32%) during the second trimester

2. A Woman with Iron-Deficiency Anemia

 most common anemia of pregnancy
Causes:
 diet low in iron- low socio economic status
 heavy menstrual flow
 unwise weight –reducing programs
 getting pregnant less than 2 years before the current pregnancy
 pica
Iron is made available in the body by absorption from the duodenum into the bloodstream
after it has been ingested. In the bloodstream it is bound for transport to the liver, spleen
and bone marrow. At this site, it is incorporated into hemoglobin or stored as ferritin.
Signs and Symptoms:
 Extreme fatigue and poor exercise tolerance.
Reason: woman cannot transport oxygen effectively.
 Associated with low birth weight and preterm birth.
Reason: the body recognizes that it needs increased nutrients, some women with this
condition may develop pica.
Management for Anemia and Iron-Deficiency Anemia
1. Intake of prescribed prenatal vitamins containing 27 mg of iron as prophylactic
therapy during pregnancy
 2. Advise woman to eat diet high in iron and vitamins: green leafy vegetables, meat
and legumes
3. Ferrous Sulfate or Ferrous Gluconate- 120-200 mg elemental iron per day
4. Advise woman to take orange juice or a vitamin c – Reason: iron is absorbed in an
acid medium
Result: New red blood cells should begin to increase almost immediately, or reticulocyte
count should rise from 0.5% and 1.5% to 3% and 4% by two weeks
Possible Effects:
1. Constipation – high fiber diet, increase fluid intake 6-8 glasses per day.
2. Gastric irritation – take oral tablet with full stomach.
3. Turning stools black in color-advice woman that this is normal.
 If iron deficiency is severe and woman has difficulty in taking oral tablet, Intravenous
iron can be prescribed.

3. A Woman with Folic Acid-Deficiency Anemia

 Folic- acid or folate or folacin
Importance:
 one of the B vitamins which is necessary for the normal formation of red blood cells in
the woman
 Helps in preventing neural tube and abdominal wall defects in the fetus
Common among:
1. Multiple pregnancies- increased fetal demands
2. Women with secondary hemolytic illness, due to rapid destruction and production of
new red blood cells
3. Women taking hydantoin, -an anticonvulsant agent that interferes with folate
absorption
4. Women who have poor gastric absorption
Megaloblastic anemia – enlarged red blood cells – type of anemia that develops. Because
of the size of the cells, the mean corpuscular volume will be elevated in contrast to the
lowered level seen with iron-deficiency anemia
Management:
 All women expecting to become pregnant should begin to take 400 ug folic acid daily
plus eating folate foods such as: green leafy vegetables, oranges, dried beans)

4. A Woman with Sickle-Cell Anemia

 Sickle-Cell Anemia is a recessively inherited hemolytic anemia caused by an abnormal
amino acid in the beta chain of hemoglobin.
 If the abnormal amino acid replaces the amino acid valine, sickling hemoglobin
(HbS)results.
 If it is substituted for the amino acid lysine, nonsickling hemoglobin (HbC)results
 An individual who is heterozygous (with only one gene in which the abnormal
substitution has occurred, has the sickle cell trait (HbAS)
 If the person is homozygous (with two genes in which substitution has occurred, sickle
cell disease results (HbSS)
 With the disease, the majority of RBC are irregular or sickle shaped, so they cannot
carry as much hemoglobin as normally shaped RBC can.
  When oxygen tension becomes reduced, as occurs at high altitudes, or blood becomes
more viscid than usual, like in dehydration, the cells clump together because of their
irregular shape, resulting in vessel blockage with reduced blood flow to the organs.
 The cells will hemolyze, (destroyed), reducing the number available and causing severe
anemia
Races usually affected: Blacks has the the sickle-cell trait or carries a recessive gene for S
hemoglobin but asymptomatic.
Effects on pregnancy: blockage to the placental circulation can directly compromise the fetus
causing low birth weight and possibly fetal death.
Assessment:
1. Screening at the first pre-natal visit: hemoglobin analysis
 Women with the condition – hemoglobin: 6-8 mg/100 ml
2. Urinalysis- due to vascular stasis, women are prone to bacteriuria
3. Monitor a woman’s nutritional intake-if sufficient folic acid is consumed
4. Ensure the woman is drinking at least 8 glasses of fluid daily to prevent dehydration
5. Assess lower extremities for varicosities which can lead to red cell destructions
6. Monitor fetal health by an ultrasound examination at 16-24 weeks to assess for
intrauterine fetal growth
Therapeutic Management:
1. Periodic exchange or blood transfusions throughout pregnancy to replace sickled cells
with non-sickled cells- serves as a secondary purpose of removing a quantity of the
increased bilirubin resulting from the breakdown of RBC as well as restoring the
hemoglobin level.
2. If crisis occurs, controlling pain, administering oxygen and increasing the fluid volume
of the circulatory system to lower viscosity
3. If with infection- hospitalization
4. If fetus is mature, the time and method of delivery are considered
 keep the woman well hydrated during labor and delivery
 epidural anesthesia is the method of choice
 During post partal period: early ambulation, and wearing pressure stockings or IPC
boots can help reduce the risk of thromboembolism from stasis in lower extremities
Parents are generally interested in determining the condition of the infant.
 The condition is recessively inherited, if one of the parents has the disease and the other is
free, the chance the child will inherit the disease is zero.
 If the woman has the disease and her partner has the trait, the chance the child will inherit
the disease is 50%
 If both parents has the disease, all their children will have also have the disease.

5. The Woman with Thalassemia

 Thalassemia are a group of autosomal recessively inherited blood disorders that lead to
poor hemoglobin formation and severe anemia.
 is an inherited blood disorder that causes your body to have less hemoglobin than normal.
Hemoglobin enables red blood cells to carry oxygen.
 Most common in Mediterranean, African and Asian populations
 Symptoms first appear in childhood
  Treatment: combating anemia through folic acid supplementation and sometimes, blood
transfusion to infuse hemoglobin-rich RBC
 Women with the condition usually do not take iron supplementation during pregnancy
because they could receive an iron overload because iron is infused with blood
transfusions.

D. RENAL AND URINARY DISORDERS AND PREGNANCY

1. A Woman with Urinary Tract Infection
 Caused by Escherichia coli from an ascending infection
 Can also be a descending infection – can begin in the kidneys from the filtration of
organisms present from other body infections
 If caused by Streptococcus B – indicates the woman has an extensive infection
Assessment: Based on signs and symptoms
 Pain on urination
 In case of Pyelonephritis – woman develops pain in the lumbar region usually on the
right side that radiates downward
 area is tendered upon palpation
 nausea and vomiting
 malaise
 frequency of urination
 temperature – 103 – 104 degrees F
Diagnosis: urine culture – reveal over 100,000 organisms per milliliter of urine
Therapeutic Management:
 Clean catch urine
 Culture and Sensitivity (C & S) – to determine what antibiotic needs to be prescribed
 Examples: Amoxicillin, Ampicillin and Cephalosporins – safe antibiotics during
pregnancy
 Sulfonamides – can be used early in pregnancy not near term because they interfere
with protein binding of bilirubin, which can lead to hyperbilirubinemia in newborn
 Tetracyclines are contraindicated in pregnancy – can cause retardation of bone growth
and staining of the fetal teeth
Precautionary Measures:
 Voiding frequently at least every two hours
 Wiping from front to back after bowel movement
 Wearing cotton, non-synthetic fiber underwear
 Voiding immediately after sexual intercourse
 Drinking an increased amount of fluid to flush out the infection from the urinary tract
– up to 3 – 4L/24H
Other Measures:
 Knee chest position for 15 minutes morning and evening – the weight of the uterus is
shifted forward, releasing the pressure on the uterus and allowing urine to drain more
freely.
If with Pyelonephritis – hospitalized for 24H – 48H then place on home care and treated
with IV antibiotics
  After birth – IVP (intravenous pyelogram or ultrasound) scheduled to help detect any
urinary tract abnormality that might be present
 after this episode – maintained on a drug such as Oral Nitrofurantoin (Macrodanti)
for the remainder of the pregnancy
 Acidifying the urine by the use of Ascorbic Acid (Vit. C) which is often
recommended in non-pregnancy women
 Not recommended during pregnancy because the newborn can develop scurvy in
the immediate neonatal period

2. A Woman with Chronic Renal Disease

 before, women with this chronic renal disease did not reach childbearing age or were
advised not to have children because of their automatic high-risk status during
pregnancy.
 Today, with conscientious prenatal care, women with this condition, who have had
renal transplants can expect to have healthy pregnancies and healthy children
Chronic kidney disease (CKD) means your kidneys are damaged and can't filter blood
the way they should. The disease is called “chronic” because the damage to your kidneys
happens slowly over a long period of time. This damage can cause wastes to build up in
your body
What are the problems that might arise?
 Pregnancy increases the workload of the kidneys because they must excrete waste products
not only for the woman but also for the fetus for 40 weeks
 Can cause severe anemia on women because their diseased kidneys do not produce
erythropoietin, a glycoprotein necessary for red cell formation and so, they may develop a
severe anemia
 The glomerular filtration rate are normally increases during pregnancy, the woman is able
to clear waste products from her body for both herself and the fetus with such efficiency
that her serum creatinine is slightly below normal during pregnancy
 normal creatinine level – 0.7 mg per 100 ml of blood
 during pregnancy – 0.5 mg per 100 ml of blood
 if more than 2.0 mg/dL – advise the woman not to get pregnant because it can lead to
kidney failure
 there is a possibility of glucose and protein in the urine during pregnancy because of
increased glomerular permeability
Treatment:
 Corticosteroid (prednisone) – infant may be hyperglycemic at birth because of the
suppression of insulin activity by corticosteroid
 Dialysis - to aid kidney function

E. RHEUMATIC DISORDERS AND PREGNANCY

A Woman with Systemic Lupus Eryrhematosus (SLE)
SLE is an autoimmune disease in which the immune system attacks its own tissues
 Is a multisystem chronic disease of the connective tissue that can occur in women
of childbearing age.
  Widespread degeneration of connective tissue (heart, kidneys, blood vessels,
spleen, skin and retroperitoneal tissue) occurs with onset of the illness
Signs and Symptoms:
 Marked skin change is a characteristic erythematous butterfly – shaped rash on the
face
 Kidneys - fibrin deposits plugging and blocking the glomeruli and leading to
necrosis and scarring
 Blood vessels – thickening of collagen tissue cause vessel obstruction
 Life threatening to the woman if blood flow to vital organs is obstructed and also
to the fetus
 Woman with SLE have antiphospholipid antibodies, which increases the tendency
for thrombi to form
Treatment:
 Corticosteroid
 NSAID
 Heparin
 Salicylates - To decrease symptoms
The naturally increased circulation of corticosteroid during pregnancy may lessen
symptoms in some women
Complications:
 Acute nephritis with glomerular destruction
 Increased BP
 Develop hematuria and decreased urine output
 PIH (pregnancy-induced hypertension) – no hematuria
Diagnosis: frequent creatinine assessment – to assess kidney function

F. GASTROINTESTINAL DISORDERS AND PREGNANCY

1. A Woman with Appendicitis
 inflammation of the appendix
Its incidence is high in young adults so occurs as frequently as 1 in 1500 to 2000
pregnancies (Parangi et al., 2007).
Assessment:
 Begins with few hours of nausea
 After 1-2H – generalized abdominal discomfort
 Vomiting
 Typical sharp, peristaltic, lower right quadrant pain
 If overstretched ligament pain – morning sickness pain is diffuse or sharp
 Non pregnant woman – the sharp localized pain appears at the McBurney’s point (a
point halfway between the umbilicus and the iliac crest on the lower right abdomen
 Pregnant woman – the appendix is often displaced so far up in the abdomen that it
resembles the pain of gallbladder disease
 CBC – leukocytosis; normal for non pregnant woman to have elevated WBC
 Increased temperature
 Ketones in the urine Diagnosis: ultrasound Management:
 Advise the woman not to take any food, liquid or laxative – increased peristalsis tends
to cause an inflamed appendix to rupture
Diagnosis: ultrasound
Management:
 Advise the woman not to take any food, liquid or laxative – increased peristalsis tends
to cause an inflamed appendix to rupture
 If 36 weeks – pregnant – C/S and removed the appendix
 If early pregnancy – laparoscopy
 If appendix ruptured before surgery – risk for both mother and fetus
 with ruptured appendix – infected materials are free in the peritoneum and can spread
by the fallopian tubes to the fetus
Complications:
 Peritonitis
 Infertility

2. A Woman with Cholecystitis and Cholelithiasis

Cholecystitis – gallbladder inflammation and
Cholelithiasis – gallbladder formation; gallstones are formed from cholesterol
Predisposing Factors:
 Age
 Obesity
 Multiparity
 High fat diet
Signs and Symptoms:
 Constant aching and pressure in the right epigastrium
 Jaundice
Diagnosis: ultrasound
Management:
 Intake but not free fat diet during pregnancy because of the importance of linoleic acid
for fetal grow
 If acute episode – IVF to provide fluid and nutrients and analgesics for pain
 Surgical removal of gallstone – laparoscopic technique

3. A Woman with Hepatitis

 liver disease that may occur from invasion of A, B, C, D and E virus

 Hepa A
 Fecal – oral contact (children in day care settings)
 Fecally contaminated H20 or shellfish after an incubation period of 2-3 weeks
 Woman may be given prophylactic gamma globulin to prevent the disease and
exposure
 Not known to be transmitted to fetus

 Hepa B and C
 Exposure to contaminated blood or blood products
 Can be spread by contact with contaminated semen or vaginal secretions
 Considered as STD
 Incubation period – 6 weeks to 6 mos. - Hepa B
  Can lead to liver cirrhosis

 Hepa C – may demonstrate symptoms for 12 mos

Treatment: Immunoglobulin for prophylaxis

Assessment: all forms of Hepatitis
 Nausea and vomiting
 Liver may feel tender to palpation
 Urine is light – colored from lack of bilirubin
 Jaundice – late symptom
 Physical examination – hepatomegaly (enlargement of the liver)
 Bilirubin level increased
 Specific antibodies against the virus can be detected in the blood serum
Management:
 Bed rest
 Increased caloric diet
 Standard precaution
 After birth – the infant should be washed well to remove any maternal blood and hepa
B immune globulin ( HBIg) and immunization against Hepa B should be administered
Complications:
 Lead to spontaneous miscarriage or preterm labor
 Later in pregnancy – the mother contracts Hepa B, the greater the risk the infant will
be affected or develop Hepa B

G. NEUROLOGIC DISORDERS AND PREGNANCY

1. Myasthenia Gravis
 An autoimmune disorder characterized by the presence of IgG antibody against
acetylcholine receptors in striated muscle
 Myasthenia gravis (MG) is a chronic autoimmune disorder in which antibodies destroy
the communication between nerves and muscle.
 Causes failure of the striated muscles to contract, particularly of the oropharyngeal,
facial and extraocular groups
 Occurs usually at 20-30 years’ old
Treatment:/Management:
1. Medications:
 Anticholinesterase drugs (DOC) such as: pyridostigmine (Mestinon) or neostigmine
(Prostigmin)and corticosteroid such as prednisone
 May be continued during pregnancy as the fetus will experienced no effects from them
 Atropine – lifesaving antidote for neostigmine if an overdose should occur
2. Plasmapheresis-removal of and replacement of plasma/to remove immune complexes from
the bloodstream
 Smooth muscle is not affected by the disease, labor should occur without complications
 Magnesium Sulfate – to halt preterm labor or treat hypertension of pregnancy should
be avoided because it can diminish the acetylcholine effect and increase symptoms.
 An infant born to a woman with the disease may show symptoms at birth because of
the transfer of antibodies.
 1. A Woman with Multiple Sclerosis
Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks
myelinated axons in the central nervous system

 Nerve fibers become demyelinated and therefore lose functions

Signs and Symptoms:
 Fatigue
 Numbness
 Blurred vision
 Loss of coordination
Treatment and Management:
1. Medication:
ACTH (adrenocorticotropic hormone) or corticosteroid- to strengthen nerve conduction and
both can be administered safely during pregnancy
Immunosuppressants such as cyclosporine (Sandimmune), azathioprine (Imuran), and
cyclophosphamide (Cytoxan) which are usually prescribed should be used with caution during
pregnancy
2. Plasmapheresis

H. ENDOCRINE DISORDERS AND PREGNANCY

1. A Woman with Hypothyroidism
 Underproduction of the thyroid hormone is a rare condition in late adolescents and
especially rare in pregnancy because women with symptoms of untreated
hypothyroidism are often an ovulatory and unable to conceive.
 The thyroid gland produces hormones that regulate the body's metabolic rate
controlling heart, muscle and digestive function, brain development and bone
maintenance.
Signs and Symptoms:
 Woman who conceive have difficulty increasing thyroid function to a necessary
pregnancy level which can lead to spontaneous miscarriage
 Fatigue easily
 Tend to be obese
 Skin is dry (myxedema)
 Have little tolerance to cold
 Hyperemesis gravidarum
Management and Treatment:
1. Medication
 levothyroxine (Synthroid)-to supplement lack of thyroid hormone
 advice woman who is taking this medication and planning to conceive to consult her
doctor to certain her dose will be high enough to maintain a pregnancy
 Rule: dose of the medication will need to be increased as much as 20% to 30% for the
duration of pregnancy to stimulate the increase that would normally occur in pregnancy
 caution: take the medication at a different time from any medication containing iron,
calcium or any soy product by about 4 Hours to be certain there is no problem with the
absorption of the drug
  After pregnancy, medication should be tapered back to the prepregnancy level for both
her health and so she can breastfeed safely

2. A Woman with Hyperthyroidism

 Overproduction of thyroid hormone
Signs and Symptoms:
 Rapid heart rate
 Exophthalmia-protruding eyeballs
 Heat intolerance
 Heart palpitations
 Weight loss
 Graves’ disease- (overactive thyroid) seen mostly in pregnancy than in
hypothyroidism
 If undiagnosed, woman may develop heart failure due to her heart already stresses,
cannot manage the increasing blood volume that occurs during pregnancy
 More prone to have gestational diabetes, fetal growth restriction and pre term labor
 More prone to have gestational diabetes, fetal growth restriction and pre term labor
Diagnosis:
 Using nuclear medicine imaging study involving radioactive uptake of 131 I subtype.
 Should not be used during pregnancy because the fetal thyroid would also incorporate
this drug, resulting in destruction of the fetal thyroid
Treatment:
 Thioamides (methimazole) or propylthiouracil (PTUI)- reduce thyroid activity
 cross the placenta and can lead to congenital hypothyroidism and enlarged thyroid
gland(goiter) in the fetus
 women should be regulated on the lowest possible dose and advice to keep a record of
doses taken so as not to forget or unintentionally duplicate a dose,
 Methimazole –drug of choice for pregnant women
 If hyperthyroidism is not regulated during pregnancy, an infant may be born with
symptoms of hyperthyroidism because of the excess stimulation he or she receives in
utero.
Signs and Symptoms among Newborn
 Jittery with tachypnea and tachycardia
Diagnosis for fetus: an assay of fetal cord blood will reveal the level of thyroxine (T4) and
thyroid-stimulating hormone and the need for therapy in the infant
 Women who are taking minimal doses of antithyroid drugs may breastfeed, if large
dose, do not breastfeed because they are excreted in breast milk.
 If woman desires other children, surgical treatment can be suggested to reduce the
functioning of the maternal thyroid gland

3. A Woman with Diabetes Mellitus

 Is an endocrine disorder in which the pancreas cannot produce adequate insulin to
regulate body glucose level?

Classification:
A. Type 1 Diabtetes Mellitus- a disorder that involves an absolute or relatively deficiency of
insulin.
 results from immunologic damage to islet cells in susceptible individuals
 If one child in the family has diabetes, sibling will also develop the illness
Disease Process:
 Pancreas produce plenty of insulin (the hormone responsible for “unlocking” cells so
that glucose can enter them and provide energy), but a condition known as insulin
resistance prevents them from using it effectively. When insulin doesn’t work properly,
blood glucose or blood sugar builds up in the bloodstream and gestational diabetes is
the result

From HYPERGLYCEMIA
↓
If kidneys detect this, it will excrete excess glucose into the urine
↓
Gycosuria
Polyuria
Polydipsia
polyphagia
↓
The body still needs source of energy, it will break down protein and fat
↓
Weight loss and ketone bodies (the acid end product of fat breakdown)
↓
High serum cholesterol and ketoacidosis
↓
Potassium and Phosphate attempting to serve as buffers, pass from body cells into the
bloodstream

Assessment: among children

 increased thirst
 increased urination
 dehydration that can also cause constipation
Among pregnant women:
 Increased thirst
 Increased appetite
 Unusual fatigue
 Frequent Urination
Assessment thru Laboratory Studies:
1. Random plasma glucose level greater than 200mg/dL
 Normal range: 70 to 110 mg/dL fasting: 90 to 180 mg/dL not fasting
2. Glucose Screening test – between 24 to 48 weeks; may be repeated at 32 weeks if obese
or over age 40
 After the oral 50g glucose load is ingested, a venous blood sample is taken for glucose
determination 60 minutes’ after
  If the result is more than 140mg/dL, patient is scheduled for a 100g 3-H fasting glucose
tolerance test
 If two of the four blood samples collected are abnormal or the fasting value is above
95mg/dL, a diagnosis of diabetes can be made
 Glucose Screening Test
Fetal Monitoring After Diagnosis of GD:
 Non Stress Test – or periodic ultrasound around 32 weeks to check for the bay’s well
being
 Also called as biophysical profile
 The test measures the baby’s fetal heart rate, both at rest and during movement, by
attaching a monitor to the mother’s abdomen. Monitoring is done for 20 to 30 minutes,
noting any fetal distress.
 If the baby is getting too big – insulin will be started
Maternal Effects:
 Hypoglycemia – during the first trimester
 Hyperglycemia – during the third trimester
 Frequent infection
 Moniliasis
 Polyhydramnios

Dystocia Fetal Effects:

 Hypoglycemia > Preterm Birth
 Hyperglycemia
 Macrosomia

B. Type 2 Diabetes
 The causes of type 2 diabetes are obesity, diet, life styles, smoking, alcohol consuming,
stress etc.
General Management:
1. Depends on how serious the condition is.
2. Glucose monitoring – home glucose meter or strips
 normal blood glucose level –70 to 110 mg/dL fasting: 90 to 180 mg/dL not fasting
3. Balance Diet – based on height, weight and activity level; must have the correct balance
of protein, fats and carbohydrates, proper vitamins, minerals and calories
4. Moderate exercise – walking and swimming; but is not advisable for everyone
5. Insulin therapy – if cannot be controlled with diet and exercise

Effects of Gestational Diabetes to the Fetus

↓
With ↑ glucose in the blood stream of the mother
↓
fetal macrosomia (glucose tend to cross the placenta and enter the bloodstream of the fetus)
↓
Fetus will produce more insulin (to lower its own sugar level)
↓
Fetus will convert the extra sugar into fat stores
 ↓
Additional fat stores→ extra weight gain of the fetus

New Born Effects

↓
Infants born to a Diabetic Mother
↓
Hypoglycemia (due to overproduction of insulin while still inside the uterus and still
present at birth), After delivery, the infant no longer has excess blood glucose from the
mother, but may still have high levels of circulating insulin
↓
Hyperinsulination

Signs and Symptoms:

 shrill, high pitch cry
 Tremors
 Hypocalcemia – less than 7 mg/dL
 Hypocalcemia also may be apparent in the first few hours after birth; symptoms may
include jitteriness or seizure activity.
 Hypocalcemia (levels <7 mg/dL) is believed to be associated with a delay in
parathyroid hormone synthesis after birth.
 Calcemia Tetany – Mgt: Calcium Gluconate
Diagnosis: Heel Stick Test – to check for glucose level

I. MENTAL ILLNESS AND PREGNANCY

How can pregnancy affect my mental health?
Pregnancy is often a very happy and exciting time. But not every woman feels this way. You may
have mixed, or even negative, feelings about being pregnant. You may find it more difficult than
others to cope with the changes and uncertainties which pregnancy brings. Many things can affect
how you feel in pregnancy. These include physical symptoms (e.g. morning sickness), the support
you have (or don’t have), and stressful events in your life.
Women often worry about how they will cope with pregnancy or having a baby. It’s normal to
feel stressed or anxious at times. When you are pregnant, it is common to worry about:
 The changes in your role (becoming a mother, stopping work).
 The changes in your relationships.
 Whether you will be a good parent.
 Fear that there will be problems with the pregnancy or the baby.
 Physical health problems and pregnancy complications.
 Fear of childbirth.
 Lack of support and being alone.
As many as 1 in 5 women have mental health problems in pregnancy or after birth. It can happen
to anyone. Depression and anxiety are the most common mental health problems in pregnancy.
These affect about 10 to 15 out of every 100 pregnant women. Just like at other times in life, you
can have many different types of mental illness and the severity can vary. You may already have
had a mental illness when you became pregnant.
Mental health problems you have had in the past can be worrying because they can increase the
risk of becoming unwell, particularly after birth. However, with the right help this can often be
prevented. You can also develop mental health problems for the first time in pregnancy or after
birth. How your mental health is affected during pregnancy depends on many things. These
include:
 The type of mental illness you have had already.
 Stopping medication for a mental health problem - you have a high risk of relapse if you
do this when you become pregnant. This is more likely if you have had a severe illness 6-7,
several episodes of illness or a recent episode. 8
 Recent stressful events in your life (such as a death in the family or a relationship ending).
 How you feel about your pregnancy - you may or may not be happy about being pregnant.
 Upsetting memories about difficulties in your own childhood.
Symptoms of mental illness in pregnancy are similar to symptoms you have at other times, but
some may focus on the pregnancy. For instance, you may have anxious or negative thoughts about
your pregnancy or your baby. You may find changes in your weight and shape difficult,
particularly if you have had an eating disorder.
Sometimes symptoms caused by your pregnancy can be confused with symptoms of mental
illness. For example, broken sleep and lack of energy are common in both pregnancy and
depression.
What if I have had mental health problems in the past, but am well now?
You should be referred to a mental health service if you are pregnant and have ever had:
 A serious mental illness, like schizophrenia, bipolar disorder, schizoaffective disorder
or severe depression.
 Treatment from mental health services.
 Postpartum psychosis or severe postnatal depression.
 A severe anxiety disorder such as Obsessive Compulsive Disorder.
 An eating disorder, such as anorexia or bulimia.
It is important to get specialist advice even if you are well during this pregnancy. Women who
have had these illnesses have a high risk of becoming unwell after birth. Your midwife or GP can
refer you to a perinatal mental health service if there is one in your area, or otherwise to a
community mental health team. Mental health professionals can discuss care and treatment choices
with you. They will help you make a plan for your care, with your midwife, obstetrician, health
visitor and GP.
If you have had any other mental health problems, talk to your GP. Even if you don’t need to see
a mental health team it helps to get advice and support, so you can stay as well as possible. Often
your GP will be able to advise about care and treatment. This will depend on the illness you have
had and how severe it has been.
What treatment is available for mental health problems during pregnancy?
It’s just as important to have treatment for mental health problems as it is for physical health
problems in pregnancy. The best treatment for you will depend on your illness and how severe it
has been. Both medication and psychological therapies (talking treatments) can help.
Medication
Any woman may need to take medication for many different physical and mental health problems
before, during and after pregnancy. Decisions about whether to continue, change or stop
medications in pregnancy are not straightforward or easy. Some medications have been used in
pregnancy for many years. A few medications, such as Valproate, are known to cause problems in
some babies and so should not usually be used at all in pregnancy. In many cases, we simply do
not have enough information to be absolutely sure that a treatment is safe. It is important to weigh
up the risks and benefits of taking medication in your individual case. Your GP or psychiatrist can
help you decide what is best for you and your baby.
If possible, you should talk to your doctor before you become pregnant. However, many
pregnancies are unplanned. This means it’s common to have to make decisions about medication
when you are already pregnant. In that case, you should see your doctor as soon as possible. It is
very important that you don’t stop your medication suddenly, unless your doctor tells you to.
Stopping treatment suddenly can make you relapse and can cause unpleasant side-effects.
It may be best for you to continue medication during pregnancy. But - there are many things you
need to think about when making decisions about using medication in pregnancy. These include:
 How unwell you have been in the past
 How quickly you become unwell when you stop medication.
 Medications you have taken:
o which treatments have helped you most?
o have some medicines caused side-effects?
 Up-to-date information about the safety of specific medications in pregnancy.
 If you are unwell during pregnancy:
o You might not take good care of yourself.
o You might not attend appointments with your midwife – so you don’t get the care
you need.
o If you use drugs and alcohol, you may use more when unwell. This can harm your
unborn baby.
o You may need a higher dose of medication if you become ill. Sometimes you may
need two or more medications to treat a relapse. This might be riskier for your
unborn baby than if you take a standard dose of medication throughout pregnancy.
o You may need in-patient treatment.
o You may still be unwell when your baby is born. You may then find it more difficult
to care for your baby. It may also affect your relationship with your baby.
o If your illness is not treated, this may be more harmful for your baby than the effect
of medication. Untreated mental illness can cause a number of problems. For
example, some research studies have found babies are more likely to have low
birthweight if their mother has depression in pregnancy. Untreated mental illness
can also affect a baby’s development later on.
o Unfortunately, 2-3 in every 100 babies are born with an abnormality, even when
the mother has not taken any medication.
Psychological therapies
A talking treatment may be helpful. For some women this can be used instead of medication.
Others may need a talking treatment as well as medication.
Psychological therapies services should see you more quickly if you are pregnant. Your doctor can
advise you about referral in your local area.
Which professionals and services will I need to see during my pregnancy and how can they
help me?
A number of services and professionals offer help and support during pregnancy and early
parenthood. They will help you to stay as well as possible and to manage any illness and the
recovery process.
Maternity services
Your midwife will ask questions about your physical and mental health. You should tell your
midwife if you have had mental health problems. She can ensure you get the care and support you
need.
It is important that you attend your antenatal appointments during pregnancy. In some areas
midwives can visit you at home.
Your GP
You should talk to your GP if you are worried about mental health problems in pregnancy. Your
GP can provide information, advice and treatment. He/she can refer you to a mental health or
psychological therapies service if needed.
Improving Access to Psychological Therapies (IAPT)
IAPT offers short-term talking therapies. The types of therapy offered will vary depending on your
local IAPT service. These may include guided self-help sessions with a therapist, cognitive
behaviour therapy, couples therapy and counselling. IAPT services offer individual and group
therapies. Women who are pregnant or have recently had a baby are usually given priority. You
can often bring your baby to appointments. Some IAPT services also have groups just for women
who are pregnant or for new mums. You can self-refer to your local IAPT service. Your GP,
midwife or health visitor can also make a referral for you.
Community Mental Health Teams (CMHTs) and Specialist Perinatal Mental Health Services
If you are already under the care of a CMHT, you should tell your care co-ordinator that you are
pregnant. She/he can tell you about treatment and support available for pregnant women, and new
mothers, in your area.
Perinatal Mental Health Services are specialist mental health services for pregnant and postnatal
women. Often these teams work jointly with CMHTs. Your GP, CMHT,midwife or obstetrician
can tell you whether this type of service is available in your area and refer you.

If you are not under the care of a CMHT, but have been in the past, you should talk to your GP.
Even if you are well, you may need the support of a Perinatal Mental Health Service or CMHT
during pregnancy and for a few months after birth. This will depend on the type of illness you have
had.
Children’s Centres
These offer advice, practical and social support. They host mother and baby groups and drop-in
sessions. This can help you meet other new parents and develop your confidence as a mum.
Children and Families Social Services
In some cases, your doctor, midwife or another professional may want to refer you to Children and
Families Social Services. Social workers from Children and Families Social Services focus on
children’s wellbeing. They provide a range of care and support for children and families. This
depends on the needs of the child and other family members. The professional who wants to refer
you will discuss the reasons for this with you. Having social services help may seem daunting,
but they are there to provide you with help and support.
Health Visitor
Health visitors see all women with new babies. They offer advice about your baby’s health,
feeding, sleep and other issues. In some areas health visitors may see you even before your baby
is born. Your health visitor will ask you about your mental health. She can support you and refer
you to other services for support and treatment if you need it.
Will anyone else be able to help or support me during pregnancy?
Some people have more support than others. Your main support may be your partner, family or
friends. It is helpful if the people closest to you know about your mental health problems. If you
are at risk of becoming unwell, they should know what symptoms to look out for. They also need
to know who to contact for help if they are worried about you. Your partner, family and friends
can also help in practical ways - with cooking and cleaning, for instance.

Many other sources of help and support are available for pregnant women and new mothers. This
will vary depending on where you live. Your midwife and health visitor should be able to tell you
what is available in your area.
Working together and pre-birth planning meetings
All the professionals involved in your care during pregnancy will work together with you and your
family. They will aim to make sure you have all the care and support you need. This will help you
stay as well as possible. It will also mean that you and your family have a plan and know how to
access help and support quickly if you become unwell.
If you have had a severe mental illness, it is helpful to have a meeting to plan your care during
pregnancy. This is called a Pre-Birth Planning Meeting. It can be organised by the perinatal mental
health service or your community mental health team. It usually happens when you are 30-32
weeks pregnant. You can choose who to bring to this meeting – this may be your partner, a family
member or a close friend. All the professionals involved in your care will be invited.
The Pre-Birth Planning meeting helps everyone to understand the care and support you and your
family need. It helps everyone identify how to recognise that you are becoming unwell in case this
happens. You and your family can tell the professionals about any extra support you need so this
can be arranged before your baby is born. Everyone at the meeting can agree a plan for your care
and treatment during pregnancy, delivery, and for the first few months after birth. This plan will
be individual and can include many different things, depending on what you and your family need.
It will usually include:
 Your current treatment and any treatment you plan to start after birth, or if you become
unwell.
 Who will support you at home.
 Key professional contact details.
 Who to contact if you become unwell.
 How to get help quickly.
 Who will visit you after your baby is born and how often.
 Local mother and baby groups in your area.
This plan will be written down and you will be sent a copy. This planning provides reassurance
for you and your family, so you know that you have the care and support you need.
What else can I do to maintain my mental wellbeing during pregnancy?
 Eat a healthy, balanced diet.
 Reduce your alcohol intake. You should stop drinking if possible.
 Stop smoking (ask your midwife or GP about 'stop smoking' services).
 Find some time each week to do something which you enjoy, improves your mood or helps
you to relax.
 Meditation or mindfulness – either through a class or an App such as Headspace
 Let family and friends help you with housework, shopping etc.
 Exercise (ask your midwife about exercise in pregnancy and local exercise classes).
  Discuss any worries you may have with your family, your midwife or GP.
 Get regular sleep.
 Make a Wellbeing Plan – this helps you to start thinking about the support you might need
in your pregnancy and after the birth.

J. CANCER AND PREGNANCY

Cancer during pregnancy is uncommon. Cancer itself rarely affects the growing fetus (unborn
baby). When it does happen, cancer during pregnancy can be more complex to diagnose and treat.
This is because tests to diagnose cancer and treatments can affect the fetus, so each step in your
medical care will be done carefully. It is important to work with a health care team that has
experience treating cancer in pregnancy.

Being diagnosed with cancer or starting cancer treatment during pregnancy can be very stressful
and overwhelming. Throughout this experience, it is important to let your health care team know
how you are feeling so they can help you find the support you need. This may include an in-person
or online support group for other people who have or had cancer during their pregnancy.
What types of cancer occur in pregnancy?
Breast cancer is the most common cancer found during pregnancy. It affects about 1 in 3,000
women who are pregnant. Other cancers that tend to occur during pregnancy are also generally
more common in younger people who are not pregnant, including:
 Cervical cancer
 Gestational trophoblastic disease
 Hodgkin lymphoma
 Melanoma
 Non-Hodgkin lymphoma
 Thyroid cancer

How is cancer during pregnancy diagnosed?

It can be more difficult to detect cancer when a person is pregnant. This is because some cancer
symptoms, such as bloating, headaches, or rectal bleeding, are also common during pregnancy in
general. Breasts typically get larger and change texture during pregnancy and these breast changes
may appear normal. This means that cancer-related changes in pregnant women may be noticed
later and therefore be diagnosed later than women who are not pregnant.
Pregnancy can also sometimes reveal cancer. For example, a Pap test done as a part of standard
pregnancy care can find cervical cancer, or an ultrasound done during pregnancy can find ovarian
cancer.
Some of the tests doctors use to find cancer are safe during pregnancy and for the fetus. Others
could possibly be harmful. Always talk with your health care team about each recommended test
and let the testing staff know you are pregnant. Common tests used in cancer diagnosis include:
X-ray. Research shows that the level of radiation in diagnostic x-rays is too low to harm the fetus.
When possible, a shield is used to cover the abdomen during x-rays.
Computed tomography (CT or CAT) scans. CT scans are like x-rays but are much more exact
because they use more radiation. They can find cancer or show the spread of cancer. CT scans of
the head and chest are usually safe during pregnancy. This is because they do not expose the fetus
to direct radiation. When possible, a shield should be used to cover a pregnant woman's abdomen
during all CT scans. CT scans of the abdomen or pelvis should only be done if there is no other
option. Talk with your health care team about the need for this scan and any risks.
Other tests. Magnetic resonance imaging (MRI), ultrasound, and a biopsy are usually safe during
pregnancy.

How is cancer during pregnancy treated?

Planning cancer treatment during pregnancy requires a multidisciplinary team of different types of
medical and health care providers working together. This includes cancer doctors called
oncologists and high-risk obstetricians. An obstetrician, sometimes called an OB, is a doctor who
cares for women during and after pregnancy.
Your cancer doctors and obstetricians will review and compare the best treatment options for you
and any possible risks. This will involve looking at a number of factors. The stage of your
pregnancy and the type, size, and stage of the cancer are important. Your doctors will also talk
with you about your preferences as you make cancer treatment decisions. Throughout treatment,
they will closely monitor you to make sure the baby is healthy.
Sometimes doctors may recommend delaying or avoiding certain treatments during pregnancy.
For example:
 During the first 3 months of pregnancy, some cancer treatments are more likely to
harm a fetus. So, your doctors may recommend delaying treatment until the second
or third trimester.
 Some treatments can harm the fetus at any time during pregnancy. Doctors try to
avoid using these treatments until after the baby is born. For example, radiation
therapy is a powerful treatment that uses high-energy x-rays to destroy cancer cells.
Depending on the radiation dose and which area of the body needs treatment, there
may be risks to the fetus throughout pregnancy.
 When doctors find cancer later in pregnancy, they may recommend starting
treatment after the baby is born.
 Doctors may recommend waiting to treat some specific types of cancer, such as
early-stage cervical cancer, until after the baby is born.
What cancer treatments can I get during pregnancy?
Some cancer treatments are safer to use during pregnancy than others:
Surgery. During surgery, doctors remove the tumor and some of the healthy tissue around it.
There is usually little risk to the fetus. In general, it is the safest cancer treatment during all stages
of pregnancy.
Cancer medications. Your treatment plan may include the use of medications to destroy cancer
cells, such as chemotherapy. Chemotherapy can only be used during certain times in pregnancy:
 During the first 3 months of pregnancy, chemotherapy carries risk of birth defects
or pregnancy loss. This is when the fetus's organs are still growing.
 During the second and third trimesters, doctors can give several types of
chemotherapy with low risk to the fetus. The placenta acts as a wall protecting the
baby, so some drugs cannot pass through. Other drugs only pass through in small
amounts. Studies suggest that children exposed to chemotherapy during pregnancy
do not show more health issues than children who are not. This includes right after
birth and during the child's growth and development.
  Chemotherapy in the later stages of pregnancy may cause side effects like low
blood counts. This can increase the risk of infection and indirectly harm the baby
during birth or right after birth.
 Your health care team may consider inducing labor early to protect the baby from
your cancer treatment. This is a decision that will be made with you very carefully,
with both your health and your baby's health considered.
 If you receive chemotherapy after the baby is born, you should not breastfeed the
baby. Chemotherapy can transfer to the infant through breast milk.
Does pregnancy affect cancer treatment?
Pregnancy itself does not seem to affect how well cancer treatment works. Finding cancer in a later
stage or not starting treatment right away can affect the results of the cancer treatment. Talk with
your health care team about how different factors may affect your risk from the cancer and how
you recover from treatment.

Questions to ask the health care team

If you are pregnant and recently found out that you have cancer, ask your health care team these
questions:
 How much experience do you have treating pregnant women with cancer?
 How will you work with my obstetrician?
 Do I need to have any special tests done to learn more about the cancer? Could
there be a risk to my baby in having each test?
 What are my cancer treatment options?
 Which treatment plan do you think is best? Why?
 Do I need to start treatment right away, or should I wait?
 Could a delay in my treatment affect how I recover from this cancer?
 Is it safe to continue the pregnancy?
 What are the short- and long-term risks of my treatment to me? To the baby?
 How will my baby's health be monitored during my cancer treatment?
 Will my cancer treatment affect how I give birth?
 Will I be able to breastfeed?
 Is there a counselor, oncology social worker, or other team member who can help
me cope with the emotional side effects of my diagnosis?
 What other support services and other resources are available to me? To my family?

REFERENCES/ADDITIONAL RESOURCES/READINGS:
National Center for Health Statistics. (2016). Child health. Retrieved
from https://www.cdc.gov/nchs/fastats/child-health.htm

Pillitteri, Adele (2018). Maternal and Child Health Nursing, Care of the Childbearing and Childrearing
Family, 8th edition.

Ricci, Susan Scott (2007). Essentials of Maternity, Newborn, and Women’s Health Nursing,
Lippincott Williams and Wilkins