Care of the client across the Lifespan with Mother, child and Family at Risk or With Problems

I. Mother
A. High Risk prenatal client
a. Identifying clients at risk

High risk pregnancy- is one in which a concurrent disorder, pregnancy-related complication or

external factor jeopardizes the health of the mother and/or fetus

Objectives
1. Define high risk pregnancy, including pre-existing factors that contribute to its
development
2. Describe common illnesses such as cardiovascular disease, diabetes mellitus, or renal
and blood disorders that can result in complications when they exist with pregnancy
3. Use critical thinking to analyze ways that nursing care plan can remain family centered
when a pre-existing or newly acquired illness develops during pregnancy
4. Assess a woman with an illness during pregnancy for changes occurring in an illness
because of the pregnancy
5. Implement nursing care specific to a woman who has developed a complication of
pregnancy such as teaching her how to recognized symptoms of preterm labor

Assessment of risk factors

A. Factors arising from the woman’s characteristics and lifestyle

 AGE <15 and >35 years old
 NUTRITIONAL HABITS AND STATUS
 STATURE <5 ft
 ABUSE OF TOBACCO, ALCOHOL, DRUGS
 HOSTILE ENVIRONMENT AT HOME OR AT WORK, WITH EXPOSURE TO TERATOGENS

B. Factors arising from the health status and lifestyle of the father of the baby
 ABUSE OF DRUGS, ALCOHOL, TOBACCO- passive smoke exposure of mothers around the
time of conception – likely due to fathers’ smoking – is associated with a significantly
higher incidence of serious congenital heart defects in infants.
 HARMFUL SEXUAL PRACTICES (multiple sex partners)
 EXPOSURE TO ENVIRONMENTAL HAZARDS

C. Preexisting health problems

 Health problems present prior to the onset of pregnancy

 Pregnancy effects the health problem and the health problem effects the pregnancy
 Preconception care and counseling is critical

D. Health problems that arise during pregnancy

 Includes: PIH, anemia, hyperemesis gravidarum, hemorrhage, gestational diabetes

 Occur as a result of ineffective adaptation to the changes that occur with pregnancy
 More likely to occur among women who are already at risk

E. Obstetrical –gynecological factors

 Number of pregnancies (gravid) and birth (para)

 Pelvic and uterine malformation and abnormalities
 History of STDs and pelvic inflammatory disease (PID)
 History of complications with previous pregnancies (abortion, hemorrhage)
 History of infertility
 Exposure to DES (diethylstilbestrol)as a fetus

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 The daughters of women who used DES while pregnant—commonly called DES
daughters—have about 40 times the risk of developing clear cell adenocarcinoma of the
lower genital tract than unexposed women. However, this type of cancer is still rare;
approximately 1 in 1,000 DES daughters develops it.

F. Psychosocial risk factors

 Instability of family relationship

 Inadequate economic resources
 Limited access to nearby culturally sensitive prenatal care or a high risk pregnancy
center
 Minority status in terms of race-ethnicity-experience higher rates of maternal-infant
morbidity as well as low birth weight (LBW)
 History of mental health disorders including depression and psychosis
 Diagnostic Tests and Laboratory Exams

 Complete blood count

 Hemoglobin, hematocrit and red cell index- determine the presence of
anemia
 Hemoglobin- 120-180 G/L
 Hematocrit- 0.37-0.54
 WBC count-to determine infection
 WBC 4.5-11X10/L
 Platelet count- to estimate clotting ability
 Platelet Count- 150-450X10/L
 Sickle cell anemia screen-to detect sickle cell trait or disease

2. VDRL-Venereal Disease Research Laboratory

Screening test for syphilis

The venereal disease research laboratory (VDRL) test is designed to assess whether or not you
have syphilis, a sexually transmitted infection (STI). Syphilis is caused by the
bacteria Treponema pallidum. The bacteria infects by penetrating into the lining of the mouth
or genital area.
The VDRL test doesn’t look for the bacteria that causes syphilis. Instead, it checks for the
antibodies your body makes in response to antigens produced by cells damaged by the
bacteria. Antibodies are a type of protein produced by your immune system to fight off
invaders like bacteria or toxins. Testing for these antibodies can let your doctors know whether
you have syphilis.

3. Blood typing (Rh factor)-to determine blood type and Rh status of mother

4. MsAFP (Maternal serum alfa feto protein- to screen for open neural tube defects

MSAFP (maternal serum alpha-fetoprotein): The presence of AFP, a plasma protein normally

produced by the fetus, in the mother's blood. The MSAFP serves as the basis for some valuable
tests.
AFP is manufactured principally in the fetus's liver and, also, in the fetal gastrointestinal (GI)
tract and the yolk sac, a structure temporarily present during embryonic development. The
level of AFP is typically high in the fetus's blood, goes down in the baby's blood after birth, and
by a year of age is virtually undetectable.

During pregnancy, AFP crosses the placenta from the fetal circulation and appears in the
mother's blood. The level of AFP in the mother's blood (the maternal serum AFP) provides a
screening test for a number of disorders including:
 Open neural tube defects (anencephaly and spina bifida); and
 Down syndrome (and other chromosome abnormalities).

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The maternal serum AFP (MSAFP) tends to be:

 High with open neural tube defects such as anencephaly and spina bifida
(meningomyelocele); and
 Low with Down syndrome (trisomy 21, an extra chromosome number 21).

5. Indirect Coomb’s test

Indirect Coomb’s test determines whether there are antibodies to the rH factor in the
mother’s blood.

A normal (negative) result means that the mother has not developed antibodies against
the fetus's blood. A negative Coomb’s test indicates that the fetus is not presently in danger
from problems relating to Rh incompatibility.

An abnormal (positive) result means that the mother has developed antibodies to the fetal
red blood cell and is sensitized. However, a positive Coomb’s test only indicates that an Rh-
positive fetus has a possibility of being harmed. A positive test cannot indicate the amount of
fetal harm that has occurred or is likely to occur.

6. Rubella Titer

A rubella blood test detects antibodies that are made by the immune system to help kill
the rubella virus. The test for IgG antibodies is most common and is the test done to see if a
woman who is pregnant or planning to get pregnant is immune to rubella.

7. Hepatitis B surface antigen (HBsAG)- to screen for hepatitis B infection (non-reactive)

8. HIV test- to screen for HIV. General recommendations for screening includes women who

1. have used or are using intravenous drugs

2. have engaged in sex with multiple partners
3. have sexual partners who are infected or are at risk
4. received a blood transfusion between 1977 and 1985

In general, antibody tests that use blood can detect HIV slightly sooner after infection

than tests done with oral fluid. It can take 3 to 12 weeks (21-84 days) for an HIV-positive
person's body to make enough antibodies for an antibody test to detect HIV infection. This is
called the window period.

9. Oral glucose tolerance test (OGTT)- to screen for gestational diabetes

The oral glucose tolerance test (OGTT) measures the body's ability to use a type of sugar,
called glucose, that is the body's main source of energy. An OGTT can be used to diagnose
prediabetes and diabetes. An OGTT is most commonly done to check for diabetes that occurs
with pregnancy (gestational diabetes).

The OGTT involves fasting overnight and then having your blood checked early in the morning.
You will then drink a special glucose drink and have your blood tested again after 2 hours.
Sometimes blood sugar levels are also checked at other times such as 1 hour, 3 hours, or 4
hours after the glucose drink.

10. Urinalysis- to determine the presence of bacteria, albumin and glucose in the urine

11. Tuberculin skin test/Purified Protein Derivative test- to screen for tuberculosis.

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A tuberculin skin test (also called a Mantoux tuberculin test) is done to see if you have ever
been exposed to tuberculosis (TB). The test is done by putting a small amount of TB protein
(antigens) under the top layer of skin on your inner forearm.

How is the TST Administered?

The TST is performed by injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the
inner surface of the forearm. The injection should be made with a tuberculin syringe, with the
needle bevel facing upward. The TST is an intradermal injection. When placed correctly, the
injection should produce a pale elevation of the skin (a wheal) 6 to 10 mm in diameter.

How is the TST Read?

The skin test reaction should be read between 48 and 72 hours after administration. A patient
who does not return within 72 hours will need to be rescheduled for another skin test.

The reaction should be measured in millimeters of the induration (palpable, raised, hardened
area or swelling). The reader should not measure erythema (redness). The diameter of the
indurated area should be measured across the forearm (perpendicular to the long axis).

12. Ultrasonography- to confirm the pregnancy length or document healthy fetal growth.
Ultrasound is used during pregnancy to check the baby's development, the presence of a
multiple pregnancy and to help pick up any abnormalities. 

13. Pap smear- A Pap smear (also called a Pap test) is a screening procedure for cervical cancer.
It tests for the presence of precancerous or cancerous cells on the cervix, the opening of the
uterus. It's named after the doctor who determined that this was a useful way to detect signs of
cervical cancer, Georgios Papanikolaou.

14. Testing of cervical and vaginal secretions- to screen for reproductive tract infection

Cardiac disease in Pregnancy

Pregnancy places stress on the cardiovascular system as a result of plasma volume expansion
which increases cardiac output and workload

Classification of Cardiac disease

Class I- Women have no limitation of physical activity. Ordinary physical activity causes no
discomfort. They have no symptoms of cardiac insufficiency and no anginal pain

Class II- Women have slight limitation of physical activity. Ordinary physical activity causes
excessive fatigue, palpitation, dyspnea or anginal pain

Class III- Women have a moderate to marked limitation of physical activity. During less than
ordinary activity, they experience excessive fatigue, palpitation, dyspnea or angina pain

Class IV- Women are unable to carry out any physical activity without experiencing discomfort.
Even at rest they experience cardiac insufficiency or anginal pain

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Signs and symptoms
-fatigue
-cough
-tachycardia
-increased RR
-poor fetal heart tone variability
-decreased amniotic fluid
-edema

Management:

Antepartal period

1. adequate nutrition
2. promotion of rest
3. protection from infection
4. drug therapy
5. restriction of activity
6. continuous monitoring of pregnancy
7. psychological support

Intrapartal period

1. continuous monitoring of vital signs

2. assessment of pulmonary function
3. proper positioning (side lying)
4. supportive therapies
5. assistance during delivery
6. psychological support

Postpartal period
1. assessment of post delivery heart status
2. proper positioning
3. planning of scheduled activity
4. psychological support
5. education and assistance of mother in infant care
6. preparation for discharge

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Gestational Diabetes

1. occurs in pregnancy (during the second or third trimester) in clients not previously diagnosed
as diabetic and occurs when the pancreas cannot respond to the demand for more insulin

2. pregnant women should be screened for gestational diabetes between 24 to 28 weeks of

pregnancy
3. A 3 hour OGTT is performed to confirm gestational diabetes mellitus

4. gestational diabetes frequently can be treated by diet alone, however some clients may need
insulin

5. Most women with gestational diabetes return to euglycemic state after delivery, however,
these individuals have an increased risk of developing DM in their lifetimes

Predisposing conditions to gestational diabetes

1. older than 35 years

2. obesity
3. multiple gestation
4. family history of diabetes mellitus

Assessment

-excessive thirst
-hunger
-weight loss
-frequent urination
- blurred vision
-recurrent UTI and vaginal yeast infection
-glycosuria and ketonuria
-signs of gestational hypertension
-polyhydramnios
-large fetus for gestational age

Interventions

1. employ, diet, insulin (if diet cannot control blood glucose levels), exercise, and blood glucose
determinations to maintain blood glucose levels between 65 mg/dL and 130 mg/dL
2. Observe for signs of hyperglycemia, glycosuria and ketonuria and hypoglycemia
3. Monitor weight

4. Increase calorie intake as prescribed, with adequate insulin therapy so that glucose moves
into the cells

5. assess for signs of maternal complications such as preeclampsia (hypertension, proteinuria,

and edema)

6. monitor for signs of infection

7. Instruct the client to report burning and pain on urination, vaginal discharge or itching, or any
other signs of infection to the health care provider

8. assess fetal status and monitor for signs of fetal compromise

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Woman who is drug dependent

Substance abuser- is one who uses drugs for pleasure

Drug dependent-someone who craves a particular drug for psychological and physical well-
being
Drugs that a pregnant woman takes during pregnancy can affect the fetus in several ways:
They can act directly on the fetus, causing damage, abnormal development (leading to birth
defects), or death.
They can alter the function of the placenta, usually by causing blood vessels to narrow
(constrict) and thus reducing the supply of oxygen and nutrients to the fetus from the mother.
Sometimes the result is a baby that is underweight and underdeveloped.
They can cause the muscles of the uterus to contract forcefully, indirectly injuring the fetus by
reducing its blood supply or triggering preterm labor and delivery.
They can also affect the fetus indirectly. For example, drugs that lower the mother's blood
pressure may reduce blood flow to the placenta and thus reduce the supply of oxygen and
nutrients to the fetus.

Characteristics if a drug dependent woman

-woman is in the youngest age group

-they may have less traditional lifestyle than others
-they may come late for prenatal care
-they may have difficulty following prenatal instructions

Management

1. Anticipatory guidance and nursing support during pregnancy

2. interdisciplinary team approach
3. discouraged breastfeeding (drugs is secreted in breastmilk)

Drugs Commonly used during pregnancy

Cocaine

Common slang names: bump, toot, C, coke, crack, flake, snow, and candy

What happens when a pregnant woman consumes cocaine? Cocaine crosses the placenta and

enters your baby’s circulation. The elimination of cocaine is slower in a fetus than in an adult.
This means that cocaine remains in the baby’s body much longer than it does in your body.

Marijuana

Common slang names: pot, weed, grass and reefer

What happens when a pregnant woman smokes marijuana? Marijuana crosses the placenta to

your baby. Marijuana, like cigarette smoke, contains toxins that keep your baby from getting
the proper supply of oxygen that he or she needs to grow.
Smoking marijuana during pregnancy can increase the chance of miscarriage, low birth weight,
premature births, developmental delays, and behavioral and learning problems.

Heroin

Common slang names: horse, smack, junk, and H-stuff

What happens when a pregnant woman uses heroin? Heroin is a very addictive drug that
crosses the placenta to the baby. Because this drug is so addictive, the unborn baby can
become dependent on the drug

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Using heroin during pregnancy increases the chance of premature birth, low birth weight,
breathing difficulties, low blood sugar (hypoglycemia), bleeding within the brain
(intracranial hemorrhage), and infant death

PSP and LSD (Phenylcyclidine a lysergic acid diethylamide)

What happens when a pregnant woman takes PCP and LSD? PCP and LSD are hallucinogens.
Both PCP and LSD users can behave violently, which may harm the baby if the mother hurts
herself.

How can PCP and LSD affect my baby? PCP use during pregnancy can lead to low birth
weight, poor muscle control, brain damage, and withdrawal syndrome if used frequently.
Withdrawal symptoms include lethargy, alternating with tremors. LSD can lead to birth defects
if used frequently.

Methamphetamine

Common slang names: meth, speed, crystal, glass, and crank

What happens when a pregnant woman takes methamphetamine? Methamphetamine is

chemically related to amphetamine, which causes the heart rate of the mother and baby to
increase.

How can methamphetamine affect my baby: can lead to low birth weight.
Methamphetamine can also increase the likelihood of premature labor, miscarriage, and
placental abruption. Babies can be born addicted to methamphetamine and suffer withdrawal
symptoms that include tremors, sleeplessness, muscle spasms, and feeding difficulties. 

Sexually transmitted diseases and pregnancy

The woman with candidiasis

Signs and symptoms

Itchiness, irritation, soreness, burning, and redness in the vagina and labia (and sometimes
swelling)
An odorless vaginal discharge that's often white, creamy, or cottage-cheesy
Discomfort or pain during sex
Burning when you urinate (when the urine hits your already irritated genitals)

Candidiasis-causes vaginal infection spread by the fungus Candida

Risk factors:

-women being treated with an antibiotic for another infection

-women with gestational diabetes
-women with HIV

Management

1. treat the infection during pregnancy

2. local application of an antifungal cream: Miconazole (Monistat) or Clotrimazole (Gyne-

Lotrimin)

3. Caution the women to telephone their primary health care provider before using over the
counter preparation for candidiasis
The woman with Trichomoniasis vaginalis

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Trichomonas vaginalis

is a very common sexually transmitted disease (STD) that is caused by infection with a
protozoan parasite called Trichomonas vaginalis.

Signs and symptoms

itching, burning, redness or soreness of the genitals, discomfort with urination, or a thin
discharge with an unusual smell that can be clear, white, yellowish, or greenish.

Failure to treat trichomoniasis

Trichomoniasis during pregnancy may result in preterm birth, low birth weight, and other
adverse fetal outcomes.

Effect of trichomoniasis vaginalis in pregnancy

Preterm delivery
Low birth weight

Management

1. assess for the presence of trichomoniasis infections

2. administer medication. Metronidazole (Flagyl), topical Clotrimazole

The woman with bacterial vaginosis

Bacterial vaginosis
is a local infection of the vagina by the invasion, most commonly of Gardnerella organisms

Signs and symptoms

 gray and fish-like odor discharges
intense pruritus

Management

1. metronidazole

The Woman with Chlamydia trachomatis

Chlamydia infection

is one of the most common type of vaginal infections seen during pregnancy. It is caused by
gram-negative intracellular parasite

Signs and symptoms

-heavy gray-white vaginal discharge

Management

1. administration of erythromycin or amoxicillin

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The woman with syphilis

Syphilis is a systemic disease caused by the spirochete treponema pallidum

Signs and symptoms

-painless ulcer (chancre) on the vulva or vagina

-placenta appears impervious to the disease organism before 18 weeks of pregnancy

Management

1. infection of benzathine penicillin G is the drug of choice for the treatment of syphilis
during pregnancy. After therapy, the woman may experience a sudden episode of
hypotension, fever, tachycardia and muscle aches, this is called a JARISCH-HERXHEIMER
reaction

The woman with a Herpes infection

Genital herpes infection-is a sexually transmitted disease caused by the herpes simplex virus
(HSV) type 2

Signs and symptoms

-painful, small, pinpoint vesicles surrounded by erythema on the vulva or in the vagina 3 to 7
days after exposure

Management:

1. hot sitz bath

2. application of warm, moist tea bags to the lesions
3. administration of acyclovir (Zovirax) in an ointment or oral form
4. women with active lesions from a primary infection may be scheduled for a ceasarean birth.

If no lesion are present, a vaginal birth is preferable

The woman with Gonorrhea

Gonorrhea-
is a sexually transmitted disease caused by the gram-negative coccus Neisseria gonorrhoeae

Signs and symptoms

-yellow green vaginal discharge

Management

1. traditionally been treated with amoxicillin and probenecid, the incidence of penicillinase-
producing strains has made this traditional therapy ineffective
2. oral cefixime and ceftriaxone sodium IM are now the drug of choice
3. sexual partner should be treated as well to prevent reinfection

The woman with Human papilloma virus infection

Human papilloma virus-

causes fibrous tissue overgrowth on the external vulva (condyloma acuminatum)

Signs and symptoms

-lesion appear as discrete papillary structure
-large culiflower-like lesions

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Management

1. application of trichloroacetic acid (TCA) or bichloroacetic acid (BCA) to the lesions weekly
2. large lesions may be removed by laser therapy, cryocautery or knife excision
3. Hot sitz bath and application of lidocaine cream maybe soothing during the postpartal period
4. caesearean delivery maybe performed when vulvar lesion is present at the time of birth
5. women who have had one episode of infection should be conscientious about having yearly
papsmear for the rest of their lives

The woman with a group B streptococci infection

Streptococcus B infection perhaps occurs at a higher incidence during pregnancy than herpes
type 2 or gonorrhea. Infection develops within the cervix or vagina and the mother usually
experiences no symptoms. Consequences can be urinary tract infection and intra-amniotic
infection.

Management

1. women are screened for the infection at 35 to 38 weeks of pregnancy by a vaginal culture
and treated with broad spectrum penicillin such as ampicillin
2. women who experience rupture of membranes at less than 37 weeks of pregnancy are
treated with intravenous IV ampicillin

The woman with Human Immunodeficiency virus infection

A. Description

1. HIV is the causative agent of AIDS

2. Women infected with HIV may first show symptoms at the time of pregnancy or possibly
develop life-threatening infections because normal pregnancy involves suppression of the
maternal immune system
3. Zidovudine (Retrovir) is recommended for the prevention of maternal-to-fetal HIV
transmission and is administered orally beginning after 14 weeks gestation, intravenously
during labor, and in the form of syrup to the newborn for 6 weeks after birth

B. Transmission

1. Sexual exposure to genital secretions of an infected person

2. Parenteral exposure to infected blood and tissue
3. Perinatal exposure of an infant to infected maternal secretions through birth or breast-
feeding

C. Risk to the mother: a mother with HIV is managed as high risk because she is vulnerable to
infections

D. Diagnosis

1. Test used to determine the presence the presence of antibodies to HIV include enzyme-
linked immunosorbent assay (ELISA), western blot and immunofluorecence assay (IFA)
2. A single reactive ELISA test by itself cannot be used to diagnose HIV and the test should be
repeated with the same blood sample, if the result is again reactive, follow up tests using
Western blot or IFA should be done
3. Positive western blot or IFA is considered confirmatory for HIV
4. A positive ELISA that fails to be confirmed by western blot or IFA should not be considered
negative and repeat negative and repeat testing should be done in 3 to 6 months

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Stage 1
-fever
-headache
-lymphadenopathy
-myalgia

Stage 2

-infection is active but asymptomatic and may remain so far years

-clients may experience outbreak of herpes zooster (shingles)
-client may experience transient thrombocytopenia

Stage 3
-client is symptomatic
-immune dysfunction is evident
-all body systems can show signs of immune dysfunction
-integumentary and gynecological problems are common

Stage 4
-advanced infection
-client vulnerable to common bacterial infections
development of opportunistic infections
-serious immune compromise

Interventions

- prevent opportunistic infections

-avoid procedures that increase the risk of perinatal transmission, such as amniocentesis and
fetal scalp sampling
-if the fetus has not been exposed to HIV in utero, the highest risk exist during delivery through
the birth canal

The newborn and HIV

Neonates born to HIV positive clients may test positive because antibodies received from the
mother may persist for 18 months after birth, all neonates acquire maternal antibody to HIV
infection, but not all acquire infection

Interventions:
-bath the baby carefully before any invasive procedure, such as the administration of vitamin K,
heel sticks, or venipunctures, clean the umbilical cord stump meticulously every day until
healed
-the newborn can room with the mother
administer zidovudine to the newborn as prescribed for the first 6 weeks of life

• Rh incompatibility
•  is a condition that occurs during pregnancy if a woman has Rh-negative blood and her
baby has Rh-positive blood. "Rh-negative" and "Rh-positive" refer to whether your
blood has Rh factor. Rh factor is a protein on red blood cells. If you have Rh factor,
you're Rh-positive.
• When you're pregnant, blood from your baby can cross into your bloodstream,
especially during delivery. If you're Rh-negative and your baby is Rh-positive, your body
will react to the baby's blood as a foreign substance.

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• Your body will create antibodies (proteins) against the baby's Rh-positive blood. These
antibodies usually don't cause problems during a first pregnancy. This is because the
baby often is born before many of the antibodies develop.
• However, the antibodies stay in your body once they have formed. Thus, Rh
incompatibility is more likely to cause problems in second or later pregnancies (if the
baby is Rh-positive).
• RH incompatibility occurs when a pregnant woman has Rh-negative blood and the
fetus has Rh-positive blood.
•  Rh incompatibility can result in destruction of the fetus’s red blood cells, sometimes
causing anemia that can be severe.
• The fetus is checked periodically for evidence of anemia.
• If anemia is suspected, the fetus is given blood transfusions.
• To prevent problems in the fetus, doctors give injections to women with Rh-negative
blood late in the pregnancy, after delivery, and after certain procedures
• prevention
• As a precaution, women who have Rh-negative blood are given an injection of Rh
antibodies at 28 weeks of pregnancy and within 72 hours after delivery of a baby who
has Rh-positive blood, even after a miscarriage or an abortion. They are also given an
injection after any episode of vaginal bleeding and after amniocentesis or chorionic
villus sampling. The antibodies given are called Rh0(D) immune globulin. This treatment
works by making the woman's immune system less able to recognize the Rh factor on
red blood cells from the baby, which may have entered the woman’s bloodstream. Thus,
the woman's immune system does not make antibodies to the Rh factor. Such
treatment reduces the risk that the fetus's red blood cells will be destroyed in
subsequent pregnancies from about 12 to 13% (without treatment) to 1 to 2%.
• Anemia in pregnancy
• Iron deficiency anemia-is characteristically a microcytic and hypochromic anemia
• Microcytic anemia
•  is defined as the presence of small, often hypochromic, red blood cells in a peripheral
blood smear and is usually characterized by a low MCV (Mean Corposcular Volume),
(less than 83 micron 3). Iron deficiency is the most common cause of microcytic anemia.
• Causes

1. diet low in iron

2. heavy menstrual period
3. short period between pregnancies
4. women from low socio-economic status
• Signs and symptoms

1.Pica-eating non nutritious food results to low fetal birth weight and preterm birth
2. extreme fatigue
3. poor exercise tolerance
4. decreased hemoglobin (below 11 mg/dL
• Risks of Anemia in Pregnancy
• Severe or untreated iron-deficiency anemia during pregnancy can increase your risk of
having:
• A preterm or low-birth-weight baby
• A blood transfusion (if you lose a significant amount of blood during delivery)
• Postpartum depression
• A baby with anemia
• A child with developmental delays
• Management
1. take 120 to 180 mg of elemental iron per day
2. eat foods high in iron
3. increase roughage in diet
• Folic acid deficiency anemia
• Having too little folate (vitamin B9) in your blood causes folic acid deficiency
anemia. Folate is necessary for your body to make new red blood cells.

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• Your baby may be at higher risk of developing serious birth defects like spina bifida if
you have folic acid deficiency anemia during pregnancy.
• What are the symptoms?
Anemia may make you:
• Feel weak and tired.
• Feel lightheaded.
• Be forgetful.
• Feel grouchy.
• Loss of appetite and weight loss
• Have trouble concentrating.
• Risk factors

1. multiple pregnancies
2. women with a secondary hemolytic disease
3. women who are taking hydantoin- drug that interferes with folic acid absorption
• Complications

1. early abortion
2. abruptio placenta
• Management
1. take a supplement of 400ug of folic acid daily
2. eat foods rich in folic acid
• Sickle cell disease
• The term sickle cell disease (SCD) describes a group of inherited red blood cell disorders.
People with SCD have abnormal hemoglobin, called hemoglobin S or sickle hemoglobin,
in their red blood cells.
• Causes of sickle cell disease
• Abnormal hemoglobin, called hemoglobin S, causes sickle cell disease (SCD).
• The problem in hemoglobin S is caused by a small defect in the gene that directs the
production of the beta globin part of hemoglobin. This small defect in the beta globin
gene causes a problem in the beta globin part of hemoglobin, changing the way that
hemoglobin works. 
• How Is Sickle Cell Disease Inherited?
• When the hemoglobin S gene is inherited from only one parent and a normal
hemoglobin gene is inherited from the other, a person will have sickle cell trait. People
with sickle cell trait are generally healthy.
• Only rarely do people with sickle cell trait have complications similar to those seen in
people with SCD. But people with sickle cell trait are carriers of a defective hemoglobin S
gene. So, they can pass it on when they have a child.
• If the child’s other parent also has sickle cell trait or another abnormal hemoglobin gene
(like thalassemia, hemoglobin C, hemoglobin D, hemoglobin E), that child has a chance
of having SCD.
• Signs and symptoms
• Painful swelling of the hands and feet, known as dactylitis
• Fatigue or fussiness from anemia
• A yellowish color of the skin, known as jaundice, or whites of the eyes, known
as icteris, that occurs when a large number of red cells hemolyze
• Signs and symptoms
• -RBC’s are irregular or sickle shape
-hemoglobin level of 6-8 mg/100 mL
-increase indirect bilirubin
-asymptomatic bacteriuria
• Complications:

1. direct fetal compromise with low birth weight

2. death
• Management

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1. MIO
2. proper positioning
3. exchange transfusion periodically
4. administer IVF
5. administer folic acid supplement, avoid iron supplement
6. administer oxygen
7. administration of meds (acetaminophen, NSAIDS, narcotics)
• Gestational condition
• Hyperemesis gravidarum-
• is nausea and vomiting of pregnancy that is prolonged past 12 weeks of pregnancy
• is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte
disturbance
• It is believed that this severe nausea is caused by a rise in hormone levels;
• however, the absolute cause is still unknown. The symptoms of HG usually appear
between 4-6 weeks of pregnancy and may peak between 9-13 weeks.
• Most women receive some relief between weeks 14-20, although up to 20% of women
may require care for hyperemesis throughout the rest of their pregnancy. 
• Signs and symptoms
• Severe nausea and vomiting
• Food aversions
• Weight loss of 5% or more of pre-pregnancy weight
• Decrease in urination
• dehydration
• headaches
• Confusion
• Fainting
• jaundice
• Extreme jaundice
• Low blood pressure
• Rapid heart rate
• Loss of skin elasticity
• Secondary anxiety/depression
• treatments
• In some cases hyperemesis gravidarum is so severe that hospitalization may be
required.
• Hospital treatment may include some or all of the following:
• Intravenous fluids (IV) – to restore hydration, electrolytes, vitamins, and nutrients
• Tube feeding:
• Nasogastric – restores nutrients through a tube passing through the nose and to
the stomach
• Percutaneous endoscopic gastrostomy – restores nutrients through a tube
passing through the abdomen and to the stomach; requires a surgical procedure
• Medications – metoclopramide, antihistamines, and antireflux medications*
• Other treatments may include:
• Bed rest –This may provide comfort, but be cautious and aware of the effects of muscle
and weight loss due to too much bed rest.
• Acupressure – The pressure point to reduce nausea is located at the middle of the inner
wrist, three finger lengths away from the crease of the wrist, and between the two
tendons. Locate and press firmly, one wrist at a time for three minutes. Sea bands
also help with acupressure and can be found at your local drug store.
• herbs– ginger or peppermint
• Homeopathic remedies are a non-toxic system of medicines. Do not try to self medicate
with homeopathic methods; have a doctor prescribe the proper remedy and dose.
• Hypnosis
• Ectopic pregnancy
• pregnancy in which implantation occurs outside uterine cavity
• causes

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• inflammation and scarring of the fallopian tubes from a previous medical condition,
infection, or surgery
• hormonal factors
• genetic abnormalities
• birth defects
• medical conditions that affect the shape and condition of the fallopian tubes and
reproductive organs
• classification
• Tubal pregnancy (95%)
• May implant in ampulla (73.3%), isthmus (12.5%), fimbria (11.6%), and interstitium and
cornua (2.6%).
• Ovarian pregnancy (1% to 3%)
• Unlike tubal pregnancy, not associated with IUD use or genital infection (strict
histopathological diagnostic criteria apply).
• Cervical pregnancy (<1%)
• Often presents with profuse and painless bleeding.
• Interstitial pregnancy (2%)
• Trophoblast implants at junction of proximal fallopian tube and muscular wall of the
uterus.
• Hysterotomy scar pregnancy (<1%)
• Occurs in 6% of ectopic pregnancies among women with a previous caesarean delivery.
• Abdominal pregnancy (1.4%)
• May be primary from direct implantation of the blastocyte or secondary from expulsion
of the embryo from the fallopian tube.
• Heterotopic pregnancy (1:4000)
• Two concurrent pregnancies, one intrauterine and the other ectopic. Incidence is rising,
approaching 1% among women undergoing IVF.
• Signs and symptoms
• sharp waves of pain in the abdomen, pelvis, shoulder, or neck
• severe pain that occurs on one side of the abdomen
• light to heavy vaginal spotting or bleeding
• dizziness or fainting
• rectal pressure
• Management
1. careful history taking
2. record amount of blood discharge
3. monitor v/s
4. position patient for shock
5. pelvic exam
6. Culdocentesis (a procedure in which peritoneal fluid is obtained from the cul de sac of
a female patient. It involves the introduction of a spinal needle through the vaginal wall
into the peritoneal space of the pouch of Douglas)
• 7.Laparotomy( surgical incision into the abdominal cavity, for diagnosis or in preparation
for surgery)

8. Ultrasonography
• 9. Salpingostomy (is a surgical incision into a fallopian tube. This procedure may be done
to repair a damaged tube or to remove an ectopic pregnancy (one that occurs outside of
the uterus).

10. Salphingectomy (surgical removal of the fallopian tubes.)

11. Blood transfusion

• Gestational Trophoblastic disease/Hydatidiform
• mole-is a proliferation and degeneration of the tropoblastic villi as the cells degenerate,
they degenerate, they become fluid filled with fluid, appearing as fluid, appearing as
fluid-filled, grape sized vesicles
• causes

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• Hydatidiform mole, or molar pregnancy, results from too much production of the tissue
that is supposed to develop into the placenta. The placenta feeds the fetus during
pregnancy. With a molar pregnancy, the tissues develop into an abnormal growth,
called a mass.
• There are 2 types of these masses:
• Partial molar pregnancy. There is an abnormal placenta and some fetal development.
• Complete molar pregnancy. There is an abnormal placenta and no fetus.
• Symptoms of a molar pregnancy are:
• Abnormal growth of the uterus, either bigger or smaller than usual
• Nausea and vomiting that may be severe enough to require a hospital stay
• Vaginal bleeding during the first 3 months of pregnancy
• Symptoms of hyperthyroidism, including heat intolerance, loose stool, rapid heart
rate, restlessness or nervousness, warm and moist skin, trembling hands,
or unexplained weight loss
• Symptoms similar to preeclampsia that occur in the first trimester or early second
trimester, including high blood pressure and swelling in the feet, ankles, and legs (this is
almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare
this early in a normal pregnancy)
• Exams and Tests
• A pelvic exam may show signs similar to a normal pregnancy. But the size of the womb
may be abnormal and there may be no heart sounds from the baby. There may be some
vaginal bleeding.
• A pregnancy ultrasound will show an abnormal placenta, with or without some
development of a baby.
• Tests may include:
• hcg (quantitative levels) blood test
• Chest x-ray
• CT or MRI of the abdomen (imaging tests)
• Complete blood count (CBC)
• Blood clotting tests
• Kidney and liver function tests
• Treatment
• If your health care provider suspects a molar pregnancy, a dilation and curettage (D and
C) will most likely be recommended.
• Sometimes a partial molar pregnancy can continue. A woman may choose to continue
her pregnancy in the hope of having a successful birth and delivery. However, these are
very high-risk pregnancies. Risks include bleeding, problems with blood pressure, and
premature delivery (having the baby before it is fully developed). Also, the condition
may become worse. Women need to thoroughly discuss the risks with their health care
provider before continuing the pregnancy.
• A hysterectomy (surgery to remove the uterus) may be an option for older women who
do not wish to become pregnant in the future.
• After treatment, your hCG level will be followed. It is important to avoid another
pregnancy and to use a reliable contraceptive for 6 to 12 months after treatment for a
molar pregnancy. This time allows for accurate testing to be sure that the abnormal
tissue does not grow back. Women who get pregnant too soon after a molar pregnancy
are at high risk of having another molar pregnancy.

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