NCM 109 WEEK 2

NCM 109- Care of Mother
and Child at Risk or with
Problems
(Acute and Chronic)-LECTURE
Wesleyan University –Philippines
Cabanatuan City
CONAMS
Jhonee Balmeo
Instructor

Wesleyan University –Philippines
Cabanatuan City
CONAMS
NCM 109- Care of Mother and Child at Risk or with Problems
(Acute and Chronic)-LECTURE
PRELIM PERIOD

BALIKAN NATIN ANG NAKARAAN T_T
The Nursing Process
What is the process?

I.Care Given to a Mother Experiencing a Pregnancy Complication from a Pre-
existing or Newly Acquired Illness Utilizing the Nursing Care Plan.
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
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 Disease and Pregnancy
A. Cardiovascular Disease 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.

a.1. A Woman with Left Sided Heart Failure:
Occurs in condition 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
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

Signs and Symptoms:
• 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

Signs and Symptoms:
• 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

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

Angelina Gomez is the 22-year-old woman. Suppose
she develops a deep vein thrombosis while in the
hospital on bed rest and is prescribed low-
molecular-weight heparin subcutaneous. What
education will she need in relation to this?
a. Her infant will be born with scattered petechiae
on his trunk.
b. Heparin can cause darkened or nonflexible skin
in newborns.
c. Heparin does not cross the placenta and so does
not affect a fetus.
d. Some infants will be born with allergic symptoms
to heparin.

2.A Woman with Right Sided Heart Failure

a.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

 Signs and Symptoms:
 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.
long-term complication of an unrepaired heart defect that someone was born with (congenital)*

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

True/False?
Congestive heart failure can also cause blood to back up into
the hepatic veins leading to liver enlargement

C.Hematologic Disorders and Pregnancy

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

I. 2.A Woman with Iron-Deficiency Anemia
II. > most common anemia of pregnancy
III. Causes:
IV. * diet low in iron- low socio economic status
V. * heavy menstrual flow
VI. * unwise weight –reducing programs
VII. * getting pregnant less than 2 years before
VIII. the current pregnancy
IX. * 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.

True/False?
Most pregnant women get all the iron they need
from their diets.

Kathy, a new client in the OPD asked you if she
can take FeSO4 tablet with milk? As a Nurse,
what is your best response?
a. It is alright to take FeSO4 with milk to
prevent gastric irritation.
b. You cannot take FeSo4 with milk because it
can interfere with the absorption of Iron .
c. Milk is a good choice actually if there’s no
juice available.

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

• Megaloblastic 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)

• 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)

True/False?
Folic acid is only important during the last few weeks of
pregnancy.

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

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 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.

Diba sir may anemia? So… bakit po wala yung Iron
supplementation as part of our management sa SCA?
• Ehhhh… ano suggestion mo sher? :3

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.

5. The Woman with Thalassemia
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

Which statement by a woman with sickle cell anemia
would alert you she may need further instruction on
prenatal care?
• a. “I understand why folic acid is
important for red cell formation.”
• b. “I’m careful to drink at least eight
glasses of fluid every day.”
• c. “I take an iron pill every day to help
grow new red blood cells.”
• d. “I’ve stopped jogging so I don’t risk
becoming dehydrated.”

C.Coagulation Disorders and Pregnancy
 Most coagulation disorders are sex linked or occur only in males and so have little effect on
pregnancies
1.Von Willebrand disease- a coagulation disorder inherited as an autosomal dominant trait
and occurs in women
 Women have normal platelet counts but bleeding time is prolonged
 Levels of factor VIII-related antigen (VIII-R) and factor VIII coagulations activity (VIII-C) are
both reduced.
 Since childhood, woman with the disorder might have menorrhagia or frequent episodes of
epistaxis
 Cannot diagnose immediately if not severe, until the woman got pregnant and experiences
a spontaneous miscarriage or postpartum hemorrhage.
Management:
> Replacement of the missing factors by blood transfusion of cryoprecipitate or fresh frozen
plasma before labor to prevent excessive bleeding with birth

2.Hemophilia B (Christmas Disease)
Factor IX deficiency, is a sex linked disorder
Occur only in males
Females are carriers and may have a reduced level of factor IX (only 33% of
normal) that results to hemorrhage with labor, or a spontaneous miscarriage
Carriers of the disorder should be identified before pregnancy
Management:
Restoration of factor IX by infusion of factor IX concentrate or frsh frozen
plasma
Maternal serum analysis can be used to detect whether a fetus has a
coagulation disorder during pregnancy

3.Idiopathic Thrombocytopenic Purpura (ITP)
A decreased number of platelets is not inherited
Can occur at anytime in life and can occur during pregnancy
Cause is unknown
Symptoms usually occur shortly after a viral invasion such as an upper
respiratory tract infection
It is assumed to be an autoimmune reaction (an antiplatelet antibody that
destroys platelets is apparently released)
Laboratory analysis reveal a marked thrombocytopenia-platelet count is as low
as 20,000/mm3 from a usual count of 150,000/mm3
If adequate number of platelet, the woman is prone to frequent nosebleeds
and minute petechiae or large ecchymosis appear on her body.

2nd session
• 3 slides were omitted for self study

D. Renal and urinary Disorders and Pregnancy

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

Diagnosis: urine culture – reveal over 100,000 organisms
per milliliter of urine
Therapeutic Management:
 > 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 Pyelomephritis – 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

Which of the following statement by a pregnant
woman with UTI would alert you?
A. Voiding frequently at least every two
hours
B. Wiping from back to front after bowel
movement.
C. Wearing cotton, non synthetic fiber
underwear
D. Voiding immediately after sexual
intercourse

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

Which of the following are factors that can
contribute to chronic kidney disease? SATA
A. Diabetes.
B. High blood pressure.
C. Heart (cardiovascular) disease.
D. Smoking.
E. Obesity.

E.Respiratory Disorders and Pregnancy

1. A Woman with Influenza
 > Caused by a virus identified as type A,B, or C
 > Associated with preterm labor and spontaneous
miscarriage
Signs and Symptoms
• Increased temperature
• Sore throat
Treatment:
• Antipyretic (Acetaminophen/Tylenol) – to control fever
• Oseltamivir (Tamiflu)
• Woman may be immunized against influenza

1. A Woman with Influenza
 > Caused by a virus identified as type A,B, or C
 > Associated with preterm labor and spontaneous
miscarriage
Signs and Symptoms
• Increased temperature
• Sore throat
Treatment:
• Antipyretic (Acetaminophen/Tylenol) – to control fever
• Oseltamivir (Taminflu)
• Woman may be immunized against influenza

2.A Woman with Pneumonia
>Bacteria or viral infection of lung tissue by pathogens such as Streptococcus
pneumoniae, Hemophilus influenzae and Mycoplasma pneumoniae
>Pneumonia is an infection that inflames your lungs' air sacs (alveoli). The air
sacs may fill up with fluid or pus, causing symptoms such as a cough, fever, chills
and trouble breathing

>Bacteria or viral infection of lung tissue by pathogens
such as Streptococcus pneumoniae, Hemophilus
influenzae and Mycoplasma pneumoniae
>Pneumonia is an infection that inflames your lungs'
air sacs (alveoli). The air sacs may fill up with fluid or
pus, causing symptoms such as a cough, fever, chills
and trouble breathing
>after invasion, an acute inflammatory response occurs in
the lung alveoli causing an exudate of RBC, fibrin and
polymorphonuclear leukocytes to flood into the alveoli

>after invasion, an acute inflammatory response occurs in the lung alveoli
causing an exudate of RBC, fibrin and polymorphonuclear leukocytes to
flood into the alveoli
>this process has a helpful effect of confining the bacteria or virus within the segments
of the lobes of the lungs but it has a less helpful effect of filling alveoli with fluid,
blocking off breathing space.

>If the collection of fluid becomes extreme, it can limit the oxygen
available not only for the woman but also for the fetus
>Associated with preterm labor due to oxygen deficit
Treatment;
 Antibiotic and oxygen administration

3.A woman with Asthma
Asthma is a long-term disease of the lungs. It causes your airways to get
inflamed and narrow, and it makes it hard to breathe

>Marked by reversible airflow obstruction, airway
hyperactivity and airway inflammation
>Triggered by an irritant such as an inhaled allergen
(pollen, dust or cigarette smoke)
*with inhalation of these allergen, there is a release
of bioactive mediators such as histamine and
leukotrienes from an immunoglobulin interaction.
*this results in constriction of the bronchial smooth
muscle

> Has the potential to reduce oxygen supply in the fetus
* there is an immediate release of histamine and leukotienes from an IgE;
immunoglobulin interaction – leading to constriction of the bronchial smooth muscle
 Is improved during pregnancy because of high levels of corticosteroid
Signs and Symptoms:
 Marked mucosal, inflammation and swelling
 Production of thick bronchial secretions

 >Difficulty with air exchange
 >High pitched whistling sound (bronchial wheezing)
• if ineffective, inhaled glucocorticoid such as Beclomethasone
(Beclovent/Vancrenase) or fluticasone ( Flovent), an oral corticosteroid such as
prednisone or a mast cell stabilizer such as Intal may be added to the regimen

• 4.A Woman with Tuberculosis
 >Caused by Mycobacterium Tuberculosis –
an acid fast bacillus
Assessment:
 >PPD test (purified protein derivative)
Mantoux Test
 >Follow up CXR with (+) reactions –
abdomen should be covered
 >sputum culture

Signs and Symptoms:
 Chronic cough
 Weight loss
 >Hemoptysis
 >Night sweats
 >Low grade fever
 >Chronic fatigue

Treatment:
 >Izoniazid (INH) – result in peripheral neuritis in women if doesn’t take Pyridoxine
(Vit B12)
 >Ethambutol Hydrochloride ( Myambutol(
* no teratogenic effect
* EMB  main cause optic nerve involvement :
atrophy and loss of green color recognition
* To detect, test woman with Snellen test
* If symptoms continue, discontinue the drug

*Take Calcium – to ensure tuberculosis pockets forms are not broken down
*Wait for 1-2 years after the infection becomes inactive before attempting to conceive
because recent inactive tuberculosis can become active during pregnancy
*Although tuberculosis can be spread by the placenta to the fetus, it usually spread to
the infant after birth
*If with history of tuberculosis, 3 negative sputum culture before she holds or cares for
her infant
*If negative, no need to isolate the infant to the mother

 >If active TB is in the home, the infant is discharge prophylactic INH to prevent
infection, with follow up skin testing at 3 months intervals
 >If infant is to be placed on INH, a mother taking INH should not breastfeed or it
might be toxic to the infant

Pa’no mo nasabi?
Pano po natin malalaman kung sya talaga ay
may TB? Cough* cough*
A. Chest X-ray
B. Sample of sputum
C. Skin or blood test
D. All of the above.

F. Rheumatic Disorders and Pregnancy

*F. 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

Signs and Symptoms:
 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

Your Client in the OPD on her 3rd Trim is currently taking
acetylsalicylic acid (aspirin) for headaches. Why should she limit or
discontinue this toward the end of pregnancy?
a. Salicylates can lead to increased maternal
bleeding at childbirth.
b. Newborns develop withdrawal headaches
from salicylates.
c. Aspirin can lead to deep vein thrombosis
following birth.
d. Newborns develop a red rash from salicylate
toxicity.

G.Gastrointestinal Disorders and Pregnancy

G.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

 >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

 >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

Which of the following Lab Tests may confirm that your client has an
appendicitis?
a. Urinalysis
b. CBC
c. Ultrasound
d. History taking

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: ultrtasound
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 – hepatomagally (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

Tru or fols?
It is safe for a mother infected with hepatitis B virus (HBV) to
breastfeed her infant.

Trot!
Yes mars! Safe na safe!
Also, All infants born to HBV-infected mothers should receive hepatitis B
immune globulin (HBIG) and the first dose of hepatitis B vaccine within 12
hours of birth.

What does Immunoglobulin do to your
body?
a. Immunoglobulins are the antibodies
produced naturally by the body's immune
system, which help fight infection and
disease
b. helps to increase your liver function
c. fights off the bacteria in your body
d. increases globulin production

H. Neurologic Disorders and Pregnancy

H. 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 acetycholine effect and increase
symptoms.
An infant born to a woman with the disease may show symptoms at birth
because of the transfer of antibodies.

Pssstt… sige nga sagutin mo ito?
what is the drug of choice for myasthenia gravis?
A. Acetylcholinesterase (AChE) inhibitors (Pyridostigmine)
B. Atropine
C. Plasmapheresis
D. MgSO4

2. 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

It is a medical procedure where a device or machine separates the cellular
components and plasma from the whole blood.
Ano sa tingin mo ito?

The plasma is then discarded and replaced with a colloid fluid, combined back
with the cellular components, and returned to the same patient.
Nakuha mo ba yung sagot? Good job!

I.Muskuloskeletal Disorders and Pregnancy
1.A Woman with Scoliosis
 Lateral curvature of the spine
 Most common among girls between 12 and 14 years of age
 If not corrected at this time, the curvature progresses until it
can interfere with respiration and heart action because of
chest compression
 If a woman’s spine is extremely curved, epidural anesthesia
may be difficult to administer for pain management in labor

Management:
Preventive Measures:
 Girls can wear body brace during their adolescent years to maintain an erect posture
Surgical management:
 Stainless steel rods implanted on both sides of the vertebrae to strengthen and straighten
the spine
 Rods do not interfere with pregnancy

Side Effects:
> woman may have more than usual back pain
from increased tension on back muscles
If woman’s pelvis is distorted, a caesarean
birth may be scheduled to ensure a safe birth
If vaginal birth, the same management is
applied
Cephalopelvic disproportion can be
recognized during the first stage of labor

YES OR NO
Is it safe to get pregnant if you have scoliosis

OPO!!!
When it comes to getting
pregnant, there is no
evidence
that scoliosis affects fertility,
nor does it affect the
reproductive system in any
way.

J.Endocrine Disorders and Pregnancy

J.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 anovulatory 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

Management and Treatment:
1.Medication
*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

PSSsstt!!
Sabi mo sir rare ito sa
pregnant, right? Bakit?

uwu
So…
kung maayos ang
hormone, will they
get pregnant na?

2.A Woman with Hyperthyroidism
Overproduction of thyroid hormone
Signs and Symptoms:
Rapid heart rate
Exopthalmia-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

What is the drug of choice for
hyperthyroidism?
A.Thioamides (methimazole)
B.propylthiouracil (PTUI)
C.levothyroxine (Synthroid)
D.Iodine

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

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

2. 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

Also known as IDDM
A.Type 1 DM
B.Type 2 DM
C.Type 3 DM
D.Type 4 DM

Also known as Juvenile Onset DM
A.Type 1 DM
B.Type 2 DM
C.Type 3 DM
D.Type 4 DM

Last Question… May
natutunan ka naman
ba?
Kung oo, congrats!
Madami pa tayo pag-
uusapan sa mga
susunod na lingo 

End of discussion
Sir Jhonee Balmeo

NCM 109 WEEK 2

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