NURSING CARE OF A FAMILY

EXPERIENCING A PREGNANCY FROM A

PREEXISTING OR NEWLY ACQUIRED
ILLNESS
Identifying a high-risk pregnancy
 A high-risk pregnancy is one in which a concurrent
disorder, pregnancy-related complications, or external
factor jeopardizes the health of the woman, the fetus, or
both.
ASSESSMENT THAT MIGHT CATEGORIZE A
PREGNANCY AS AT RISK
 Obstetric history
 Past illness
 Current obstetric status
 Psychosocial factor
 Demographic factors
 Lifestyle
SIGNS INDICATING POSSIBLE COMPLICATIONS OF
PREGNANCY:
 Vaginal bleeding
 Persistent vomiting
 Chills and fever
 Sudden escape of clear fluid from the vagina
 Abdominal or chest pain
 Gestational hypertension
 Increase or decrease in fetal movement
 Uterine contractions before 37 weeks of pregnancy
The Nursing Role and Nursing Care during Pregnancy
Complication From a Preexisting or Newly Acquired Illness.
CARDIOVASCULAR DISORDERS:
 Cardiac disease
• left-sided heart failure
• right-sided heart failure
 Peripartum Heart disease
 a woman with Artificial Valve prosthesis
 Chronic Hypertensive Vascular disease
 Venous Thromoboembolic Disease

Most common :
 valve damage caused by rheumatic fever or kawasaki disease
 congenital anomaly - ASD or uncorrected coarctation of the aorta
A woman with:

CARDIOVASCULAR DISRODERS AND PREGNANCY

 should visit care provider for preconception care
 should begin prenatal care as soon as she suspects she is pregnant
 The danger of pregnancy in a woman with cardiac disease occurs primarily because of
increase circulatory volume.
 most dangerous time for the pregnant woman is in weeks 28 to 32 - just after the blood
volume peaks.
 If heart disease is severe, symptoms can occur at the very beginning of pregnancy.
 1 II III IV

Physical (-) Slight Marked Severe

limitation

Fatigue (-) With ordinary With less than Even at rest

activity ordinary activity

Palpitation (-) With ordinary With less than Even at rest

activity ordinary activity

Dyspnea (-) With ordinary With less than Even at rest

activity ordinary activity
 Pressure in the heart of a pregnant woman with cardiac problems is due to
increased blood volume, adding strain to the heart. Highest risk is at 28th -
32nd week AOG.
 If cardiomyopathy persists even postpartum, the woman is advised NOT to
get pregnant again.
 Assessment findings are similar to signs of heart failure maternally
 Assessment findings for the fetus include signs of growth retardation and
immaturity, being of low birth weight and late deceleration.
Signs and Symptoms
– Because of increased total cardiac volume during pregnancy, heart murmurs are
observed.
– Cardiac output may become so decreased that vital organs are not perfused adequately ;
oxygen and nutritional requirements therefore are not met.
– Since the left side of the heart is not able to empty the pulmonary vessels adequately, the
latter become engorged, causing pulmonary edema and hypertension. Moist cough in
gravidocardiacs therefore is a danger sign
– Liver and other organs become congested because blood returning to the heart may not
be handled adequately, causing the venous pressure to rise. Fluid then escapes through
the walls of engorged capillaries and cause edema or ascites.

– orthopnea (
– paroxysmal nocturnal dyspnea
Assessment :
 fatigue
 cough
 increased respiratory rate
 poor fetal heart tone
 decrease amniotic luid from intrauterine growth restriction
 edema
Fetal assessment
 low birth weights or small for gestational age
 If the placenta is not filling well , a fetus may not respond well to labor ( evidence by late
deceleration patterns on a fetal heart monitor) - a cesarean birth may be necessary (an
increase risk for both mother and child).
• Management - consider the functional capacity of the
heart
– Bed rest - especially after the 30th week of gestation to
ensure that pregnancy is carried to term or at least 36
weeks gestation
– Diet - should gain enough, but not too much as it would
add to the workload of the heart
Medications
– digitalis
– iron preparations - anemia should be prevented because the body compensates by
increasing cardiac output, thus further increasing cardiac workload.
– Classess III and IV are not placed in lithotomy position during delivery to avoid incresing
venous return. The semi-sitting position is preferred to facilitate easy respirations.
– Anesthetic of choice is caudal anesthesia for effortless, pushless and painless delivery.
Remenber, Gravidocardiacs are not allowed to push with contractions (to prevent
valsalva maneuver which increases venous return to already weak, damaged heart). Low
forceps, therefore is the best method of delivery
Most critical period -
 the period immediately following delivery because the
30%-50% increase in blood volume during pregnancy will
be reabsorbed into the mother's circulation in a matter of
5-10 minutes and the weak heart must make rapid
adjustment to this change.
Antenatal Interventions:
– Ensure the woman has at least two rest periods in a day and a full night's sleep.
– When resting, the woman should be in left lateral recumbent position versus supine hypotension.
Left lateral recumbent position in pregnancy is the most comfortable position for it allows maximum
blood flow to the fetus, uterus, and kidneys).
– Enforce a rest program with specifications concerning degree of work the pregnant woman may
perform.
– Ensure that the woman will gain adequate weight
– Instruct that prenatal vitamins must be taken, especially iron supplementation, to avoid increasing
the workload of the haert for oxygen delivery.
– Advise on following the therapeutic regimen strictly
– Advise the mother on avoiding infections, because it increases bodily demands, causing further
strain to the woman's heart
– Perform life-saving measures in case resuscitation is required. The primary differences in
performing CPR in pregnant woman is the placement of a rolled/folded towel under the woman's
right buttock to avoid inferior vena cava compression and the placement on the hands on the lower
sternum just above the xiphoid process in delivering chest compression .
Anemia: Iron Deficiency and Folic Acid
IRON- DEFICIENCY ANEMIA
 most common anemia of pregnancy (15% to 25 %)
 low serum iron level - (under 30µg/dl)
 increased iron-binding capacity (over 400µg/dl)
TIBC (total iron-binding capacity)
- measures the total amount of iron that can be bound by proteins in the blood
- is a good indirect measurement of transferrin availability
TRANSFERRIN - primary iron-binding protein
IRON- DEFICIENCY ANEMIA
causes: Who are prone:
 diet low in iron  wo were pregnant less
 heavy menstrual flow than 2 years before
 reduction programs current pregnancy
 those from low socio-
economic levels
How does iron get absorbed in the body?
 absobed by the intestinal mucosal in the duodenum and
upper jejunum into the bloodstream
 Bloodstream - bound to transferrin or transpoprt to the
liver, spleen, and bone marrow
 incorporated into the hemoglobin or stored as ferritin
TYPE OF ANEMIA
 microcytic anemia (small red blood cell)
 hypochromic (less hemoglobin than the average red cell)
IRON DEFICIENCY ANEMIA
 causes extreme fatigue and poor exercise tolerance
 effects - low birth weight and preterm birth
 some women - may develop pica (craving or eating of
substances such as ice or starch
 also associated with restless leg syndrome
PREVENTION : IRON-DEFICIENCY ANEMIA
 nutritional changes include taking iron supplementation plus high iron,
high vitamin diet - green leafy vegetables, meat and legumes
 Therapeutic dosage of iron may also be prescribed. 120 to 200 mg of
elemental iron/day
(FERROUS SULFATE OR FERROUS GLUCONATE)
 advise the woman that iron is best taken with vitamin C because its
absorption is increased in an acidic environment
 Instruct the woman to increase roughage in meals to prevent
constipation associated with iron intake.
 instruct the woman to take iron with meals to avoid gastric irritation
FOLIC ACID-DEFICIENCY ANEMIA
(MEGALOBLASTIC ANEMIA)
 is charaterized by red blood cells that are larger than normal
 known as vitamin B-12 or folate deficiency anemia or macrocytic anemia
 slow to progress - may take several weeks to develop or may not apparent
until the second trimester of pregnancy
 contributory factor in early miscarriage or premature separation of the
placenta
All womem expecting to become pregnant are advised to begin a :
 supplement of 400µg folic acid daily
 eat folate-rich foods (green leafy vegetables, oranges, dried beans)
Folic acid/folate/ folacin
 one of the B vitamins necessary for normal formation of red blood cell
 prevent neural tube and abdominal wall defects in the fetus
FOLIC ACID-DEFICIENCY ANEMIA (MEGALOBLASTIC ANEMIA)
occurs most often
 in multiple pregnancies - increased in fetal demand
 in women with a secondary hemolytic illness - rapid destruction and
production of new RBCs
 in women who are taking hydantoin
HYDANTOIN - an anticonvulsant agent that interferes with folate absorption
 in women who have poor gastric absorption - gastric bypass
SICKLE-CELL ANEMIA
 It is a recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta
chain of hemoglobin.
 majority of the RBCs- irregular or sicle-shaped
 cannot carry much hemoglobin
 woman with sickle-cell anemia - normally have a hemoglobin level of 6 to 8 mg/ 100ml -
might reduced oxygen to the fetus
 more susceptible to bacteriuria - periodic clean catch urinalysis is done
 monitor woman’s nutritional intake - rich in folic acid and additional folic acid supplement
 women should not take iron supplement
 water intake up to 8 glasses of fluid daily
 assess for varocosities - that would lead to red cell destruction
 sims position is encourage
 fetal health is usually monitored - by USD (at 16 to 24 weeks) to assess uterine growth
restriction
HEMOLYTIC SICKLE-CELL CRISIS
 It is caused by homozygous inheritance of genes for hemoglobin (Hb) S.
Sickle-shaped red blood cells cause vaso-occlusion and are prone to
hemolysis, leading to severe pain crises, organ ischemia, and other systemic
complications. Acute exacerbations (crises) may develop frequently.
 hemoglobin level - 5 or 6 mg/100 ml
Therapeutic Intervention
 periodic blood transfusion
 if crisis occurs - control pain, O2 administration, increasing fluid volume of the
circulatory sysem to lower viscosity
 if infection develops - hospital admission
 women in labor - well hydrated
 method of delivery - must be individualized
C/s - epidural anesthesia - method of choice
Post partal period
 early ambulation
 wearing of pressure stockings - to reduce the risk of thromboembolism
Hemoglobin electrophoresis
 is a blood test that measures different types of a protein
called hemoglobin in your red blood cells.
 It's sometimes called “hemoglobin evaluation” or “sickle
cell screen.”
COAGULATION DISORDERS AND PREGNANCY
 most coagulation disorders are sex linked or occur only in males - little effect
on pregnancies.
Willebrand disease - is a coagulation disorder inherited as an autosomal
dominant trait - occur in women
 women will have normal platelet counts
 bleeding time is prolonged
 reduced factor VIII-related antigen (VIII-R) and factor VIII coagulation activity
(VIII-C)
COAGULATION DISORDERS AND PREGNANCY
Hemophilia B (factor IX deficiency)
 is a sex-linked disorder
 female carriers - may have reduced level of factor IX
 hemorrhage with labor or a spontaneous miscarriages can be serious
complication
 factor IX levels can be resotred by infusion of factor IX concentrate or fresh
frozen plasma
COAGULATION DISORDERS AND PREGNANCY
• maternal serum analysis - to detect whether a fetus has a
coagulation disorder
• if present - internal fetal heart monitor and scalp blood
sampling is contraindicated
COAGULATION DISORDERS AND PREGNANCY
Idiopathic thrombocytopenia purpura (ITP)
 is an immune disorder in which the blood doesn't clot normally.
 commonly referred as immune thrombocytopenia (ITP).
 ITP can cause excessive bruising and bleeding.
 An unusually low level of platelets, or thrombocytes, in the blood results in ITP
 not inherited.
 usually occur shortly after a viral infection (URTI) - assumed to be an autoimmune reaction

AUTOIMMUNE REaCTION
 an antiplatelet antibody that destroys platelets is released
 Laboratory - marked thrombocytopenia - condition characterized by
abnormally low levels of platelets, also known as thrombocytes, in the blood.
platelet count - may be as low as 20,000/mm³
normal human platelet count - ranges from 150,000 to 450,000 platelets
per microliter of blood.
 woman is prone to frequent nosebleeds and minute petechiae or large
ecchymoses appear on her body
 illness - typically runs 1 to 3 month limited course
 because of a low platelet count - also appears hypertension of pregnancy
with HELLP
HELLP - hemolysis, elevated liver enzymes, low platelet count) syndrome
- a serious complication of pregnancy
The following may be administered temporarily to increase platelet cpount - to
prevent increased bleeding at birth
 oral prednisone - corticosteriods
 platelet transfusion
 plasmapheresis - a process in which the liquid part of the blood, or plasma,
is separated from the blood cells.
CORTICOSTEROIDS
 are a class of drug that lowers inflammation in the body.
 reduce immune system activity
 ease swelling, itching, redness, and allergic reactions
 it resemble cortisol - a hormone naturally produced by the body’s adrenal
glands
CORTISOL
 helps control blood sugar levels, regulates metabolism, help reduce
inflammation
RENAL AND URINARY DISORDERS AND PREGNANCY

URINARY TRACT INFECTION

 4%-10% of nonpregnant women have asymptomatic bacteriuria (organisms are present in
the urine without symptoms of infection)
 asymptomatic infections - dangerous - they can progress to pyelonephritis and are
associated with preterm labor and premature rupture of membranes
 women with known vesico-ureteral reflux (backflow of urine into the ureters) tend to develop
UTIs or pyelonephritis more often than others
 common organism that causes UTI - Escherichia coli from an ascending infection
 can also occur as a descending infection
 if the infectious organism is Streptococcus B. - vaginal cultures should be obtained
 Stroptococcal B infection of the genital tract - is associated with pneumonia in newborns
Assessment
 Frequency and pain in urination
 Pyelonephritis - pain in the lumbar region (usually in the right side that radiates
downward.
 The area is tended to palpation
 Accompanied by nausea, vomiting, and malaise
 Elevated temperature (39° to 40°C)
 Infection usually occurs in the right side - there is greater compression and urinary stasis
on the right ureter from the uterus being pushed
 Urine culture - 100,000 organisms per milliliter of urine - a level diagnostic of infection
PYELONEPHRITIS
 is an infection of the renal pelvis and kidney that usually results from ascent of a
bacterial pathogen up the ureters from the bladder to the kidneys.
THERAPEUTIC MANAGEMENT :
 Obtain a clean catch urine sample for culture and sensitivity - to assess for
asymptomatic bacteriuria or symptoms of UTI.
 A sensitivity test will determine which antibiotic will best combat the
infection.
 Amoxicillin, ampicillin, and cephalosporins are effective against most
organisms - safe antibiotics during pregnancy
 Sulfonamides can be used early in pregnancy but not near term because
they can interfere with protein binding of bilirubin, which then leads to
hyperbilirubinemia in the newborn.
 Tetracyclines are contraindicated during pregnancy as they cause
retardation of bone growth and staining of the deciduous teeth.
A WOMAN WITH HYPERACTIVE BLADDER
 A hyperactive bladder refers to a bladder that contracts more frequently than usual,
causing symptoms of frequency, urgency, and incontinence.
 During pregnancy, these symptoms can increase greatly because of the additional
pressure from the uterus on the bladder.
 Fesoterodine (Tovias; pregnancy category C) - antispasmodic drug
 Should be used during pregnancy and breastfeeding only if the risk outweighs the
benefit until it is proven not to be teratogenic.
A WOMAN WITH CHRONIC RENAL DISEASE
 Women with chronic renal disease need to be monitored carefully during pregnancy because
their diseased kidneys may not produced erythropoietin, a glycoprotein necessary for red
cell formation and so may develop a severe anemia.
 Women with severe renal disease may require dialysis to aid kidney function during
pregnancy
 With dialysis, there is risk of preterm labor - because progesterone is removed with the
dialysis.
 Progesterone may be administered intramuscularly before the procedure.
 For hemodialysis - scheduled for short duration to avoid fluid shifts
 Heparin - does not crossed placenta
 Diet must be on low-potassium - to avoid a buildup of potassium
 Emotional support during pregnancy
CHRONIC RENAL DISEASE
Criteria to be evaluated (whether a woman will be able to
carry pregnancy to term)
 a woman’s general health and the time since the transplant (preferably > 2
years)
 a womans serum creatinine level
 the presence of proteinuria or hypertension or signs of graft rejection
 medications the woman is taking to reduce graft rejection
RESPIRATORY DISORDERS AND PREGNANCY
 Nasopharyngitis
 influenza
 pneumonia
 asthma
 tuberculosis
 COPD (Chronic Obstructive Pulmonary Disease)
 Cystic Fibrosis

Any respiratory disorder can pose serious hazards to the fetus if allowed to process to the point
where the mother’s oxygen-carbon dioxide exchange is altered or the mother or fetus cannot
receive enough oxygen
NASOPHARYNGITIS
 more severe during pregnancy than other times- because estrogen stimulation causes some
degree of nasal congestion
 should not take high-dose aspirin - can interfere with blotting in both the mother and fetus
- can cause fetal constricted ductus arteriosus
 cause by a virus - antibiotic is unnecessary except to prevent a secondary infection
simple measures to combat a cold:
 extra rest and sleep
 eat diet high in vitamin C - to help boost the immune system
 acetaminophen every 4 hours - for aches and pain
 use a room humidifier or apply a medicated vapor rub to the chest -at night
 cool and warm compress - to relieve sinus headache
INFLUENZA
 Influenza is caused by a virus, identified as type A,B, or
C.
 Treatment includes antipyretic such as Acetaminophen to
control fever
 Women may also be immunized safely against influenza
during pregnancy
PNEUMONIA
 Pneumonia is the bacterial or viral invasion of lung tissue by pathogens such as
Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae.
 Therapy involves the use of antibiotic and oxygen administration.
 With severe disease - ventilation support may be necessary
 Pneumonia during pregnancy is associated with fetal growth restriction and preterm birth
because of the oxygen deficit
 If pneumonia is present during labor, oxygen should be administered so the fetus has
adequate oxygen resources during contractions.
ASTHMA
 Asthma is a disorder marked by reversible airflow obstruction, airway hyperreactivity, and
airway inflammation.
 Symptoms are often triggered by an inhaled allergen such as pollen or cigarette smoke
 ASTHMA
inhaled allergens (pollen or cigarette)
↓
released of bioactive mediators (histamines and leukotrienes)
from an immunoglobulin interaction
↓
results in: constriction of the bronchial smooth muscle,
marked mucosal inflammation and swelling,
production of thick brocnhial secretions
↓
dfficulty pulling in air - high pitch whistling sound (bronchial wheezing)

 reduced oxygen supply to the fetus leading to preterm birth or fetal growth restriction (major
attacks)
 some may find that their asthma improves during pregnancy - high circulating levels of
corticosteroids
 A woman should check with primary care provider before pregnancy about the safety of the
medications she routinely takes for this disorder to be certain it will be safe to continue
during pregnancy and breastfeeding.
 Women who have been taking a corticosteroids during pregnancy may need intravenous
administration of hydrocortisone during labor because of the added stress during this time.
 Β-adrenergic agonist such as terbutaline and albuterol may be taken safely during
pregnancy, but because they have potential to reduce labor contractions, the dosage may be
tapered close to term if possible.

B-adrenergic agonist - are medications that relax muscles of the airways, causing widening of
the airways and resulting in easier breathing.
TUBERCULOSIS
 Lung tissue is invaded with Mycobacterium tuberculosis
Mycobacterium tuberculosis, an acid-fast ↓
bacillus lung tissues
Assessment ↓
 Chronic cough macrophages and T lymphocytes surround
 Weight loss the invading bacillus
 Hemoptysis (surrounded and confined)
 extreme fatigue ↓
 night sweats
TUBERCULOSIS
 In high risk area - women should undergo skin
testing (PPD) at their prenatal first visit - a Therapeutic Management:
positive result does not necessarily mean they  Isoniazid (INH) - may result in
have the disease, it can only mean they have at
some time been exposed to tuberculosis (and
peripheral neuritis if not taken
that they have antibody in their system. with supplemental pyridoxine
(Vitamin B6)
 If (+) reaction - chest x-ray or a sputum culture  Rifampoicin (RIF)
for acid-fast bacillus to confirm the diagnosis. (x-  Ethambutol hydrochloride -
ray during pregnancy is safe as long as her
abdomen is lead shielded)
side effect causing optic
atrophy and loss of green
color recognition
MANTOUX TEST
• purified protein derivative (PPD)
RHEUMATIC DISORDERS AND PREGNANCY
 Rheumatoid arthritis
 Systemic lupus erythematous
GASTROINTESTINAL DISORDERS AND PREGNANCY
 Appendicitis
 Gastroesophageal reflux or hiatal hernia
 cholecystitis and cholelithiasis
 Hepatitis
 inflammatory bowel disease