Chapter 30: Medical-Surgical Disorders

Skin conditions that may be aggravated by pregnancy

- Acne vulgaris (in the first trimester) - Neurofibromatosis (von Recklinghausen disease) - Pruritic urticarial papules and plaques - Intrahepatic cholestasis

Multiple sclerosis in pregnancy

- Exacerbations reduced later trimesters but increased postpartum period. - Breastfeeding reduces PP exacerbation. - Rest and support important. - Slight lower birth weight and some genetic predisposition. - Need genetic counseling.

Thalassemia therapy

- Folic acid (no iron supplements) - transfusion - chelation: administration of chelating agents to remove heavy metals from the body - management: education and genetic counseling

Maternal sickle cell disease risks

- Higher risk of nephritis, bacteriuria, hematuria, anemia - Vaso-occlusive crisis - Infections

Class III and IV classification of cardiovascular disease

- Hospitalized before onset of labor - Vaginal birth with low-dose regional analgesia - Forceps, vacuum-assisted birth

Sickle cell disease treatment

- Hydroxyurea (fetal hemoglobin) - Folic acid - Prompt treatment of infections and vaso-occlusive crisis - rehydration - oxygen - antibiotics - analgesics - monitor FHR

Lupus in pregnancy

- Immunosuppressive medications not recommended during pregnancy - Efforts are aimed at reducing the risk of infection

Fetal sickle cell disease risks

- Incidence of fetal death decreased greatly - Prematurity - IUGR

What cardiovascular changes occur during pregnancy that affect women with cardiac disease?

- Increased intravascular volume - Decreased systemic vascular resistance - Cardiac output changes during labor and birth - Intravascular volume changes that occur just after childbirth

Complications of CPR in pregnancy

- Lacerations of liver or spleen - Fracture of sternum or ribs - If CPR is not effective within 4 to 5 minutes, consider perimortem cesarean birth.

Neonatal risks with anemia

- Low birth weight - Prematurity - Stillbirth - Neonatal death

Normal skin conditions in pregnancy

- Melasma (chloasma) - Vascular "spiders" - Palmar erythema - Striae gravidarum

Chlamydia in pregnancy

- Most common STI. - Silent and destructive. - ½ of infants will develop opthalmia neonatorum, or pneumonia from exposure. - Easily treated with Azithromycin 1 gm in pregnancy. - NO DOXYCYCLINE in PREGNANCY. - Routine screening in pregnancy and may rescreen at term. - Retest 3 weeks after treatment.

Hepatitis B infection in pregnancy

- Now recommend testing for all prenatal patients - prophylactic treatment for babies of all positive or unknown mothers (HBIG) - routine vaccination of all infants. - Vaccines given 0, at 1-2 months, 6-18 months (All doses by 6 months if mom positive. Delayed doses if preterm.) - Breastfeeding not contraindicated when baby gets vaccine. - Precautions if mom is positive.

Clinical therapy for folic acid deficiency anemia

- Prevention: 400-600mcg of folic acid daily - Iron deficiency anemia almost always coexists

Special considerations for surgery during pregnancy

- Shield fetus from radiation - Insert nasogastric tube prior to surgery - Insert indwelling catheter - Encourage patient to use support stockings - Assess fetal heart tones - Position to maximize utero-placental circulation - Spinal or epidural anesthesia preferred - Blood loss monitored carefully

Maternal risks with anemia

- Susceptible to infection, poor healing - fatigue - Increased preeclampsia and postpartal hemorrhage - Minimal blood loss during birth poorly tolerated

Common causes of cardiac arrest in pregnancy

- Trauma - Cardiac abnormalities - Embolism - Magnesium overdose - Sepsis - Intracranial hemorrhage - Anesthetic complications - Eclampsia - Uterine rupture

Specific modifications for CPR during pregnancy

- Uterine displacement in second half of pregnancy - Defibrillation paddles must be placed one rib space higher.

Postpartum care for cardiovascular disorders

- Woman may remain in hospital longer - Nurse gives opportunity to discuss birth - Only concern with lactation related to medications - Stress follow-up Plan gradual activity schedule

What is sickle cell disease characterized by?

Acute, reoccurring episodes of tissue, abdominal, and joint pain.

Folic acid deficiency anemia

Anemia caused by deficiency of Folic acid in diet. Associated with neural tube defects (NTDs) - more prevalent with twins - N/V, anorexia

Iron deficiency anemia

Anemia caused by inadequate iron intake.

What is the most common lung disease in pregnancy?

Asthma

What is monitored for those with systemic lupus erythematosus during pregnancy

BP proteinuria placental blood flow

What is the fetus at risk for if the mother is taking anticonvulsants?

Congenital anomalies

Epilepsy in pregnancy

Failure to take medications is a common factor. - Avoid valproic acid - Encourage Folic acid and Vitamin D - Exacerbation may occur with N/V, lack of compliance with medications, sleep deprivation

What is the most common cause of megaloblastic anemia during pregnancy?

Folic acid deficiency anemia

What can you not give to pregnant women with asthma?

Hemabate

Diagnosis of iron deficiency anemia

Hemoglobin <12 g/dl nonpregnant Hemoglobin <11 g/dl in pregnant woman

Thalassemia

Inherited defect in ability to produce hemoglobin. Group of autosomal recessive disorders (Thalassemia major and minor)

Causes of anemia in pregnancy

Insufficient hemoglobin production Hemoglobin destruction

What is the most common medical complication of pregnancy?

Iron deficiency anemia

What would you do if tuberculosis is active in the mother at the time of birth?

Keep the infant and mother separated until noninfectious.

Myasthenia gravis in pregnancy

Muscle weakness in the eyes, face, neck, limbs, and respiratory muscles. - Women with MG usually tolerate labor well - May require forceps or vacuum delivery

What is the goal for anemia during pregnancy?

PREVENTION! Iron rich diet, iron supplements, stool softeners to combat constipation (stool will be black)

What are common comorbidities for those with systemic lupus erythematosus during pregnancy

Preeclampsia Prematurity IUGR stillbirth neonatal lupus congenital heart blocks Increased learning disabilities

Sickle cell disease (SCD)

Recessive autosomal disorder - Hemoglobin S (HbS) causes red blood cells (RBCs) to be sickle-shaped - RBCs are distorted, causing low oxygenation

What makes anemia worse?

Smoking

Class I and II classification of cardiovascular disease

Spontaneous natural labor with adequate pain relief

Trichomonias in pregnancy

Treated with Metronidazole 2 Gm PO X 1 dose

How can HIV transmission to the fetus be avoided?

Elective cesarean before rupture of membranes (ROM) with prophylactic ART

Battery during pregnancy

Frequent onset or increased during pregnancy

Cystic fibrosis

- exocrine glands produce excessive viscous secretions - problems with respiratory and digestive system - severe cases with pregnancy are complicated with chronic hypoxia and pulmonary infections

How many people are living with HIV/AIDS in the US?

1.2 million - 1 in 8 with HIV are not aware

HIV clinical therapy in pregnancy

- ART administered orally beginning at 14 weeks - IV AZT (Retrovir) in labor, and in form of syrup to infant for 6 weeks after - Possible C-section (scheduled)

Trauma during pregnancy

- Accidents and injury leading cause of death in women of reproductive years - Normal physiological changes increase potential for injury - Maternal mortality from head trauma or hemorrhage

Drug therapy for cardiovascular disorders during pregnancy

- Antibiotic prophylaxis not indicated - Heparin for anticoagulant therapy (Avoid Coumadin in Pregnancy) - Thiazide diuretics, furosemide for congestive heart failure (CHF) - Digitalis glycosides

Maternal HIV in pregnancy

- Antiretroviral therapy (ART) increases life expectancy - For women with no access/noncompliant ART, AIDS defining symptoms more common

Herpes in pregnancy

- Can be passed to fetus in utero if primary infection or from passing through birth canal if lesions present. - No cure. - Symptom management only. - HPV+ moms are placed on acyclovir at 35-36 weeks.

Syphilis in pregnancy

- Can be primary or secondary infection. - Screened early in pregnancy and again at term or hospital admission. - IM benzathine Penicillin G is treatment. - Problems if she is allergic-may need desensitized. - Can be directly transmitted to fetus through placenta.

Bacterial vaginosis in pregnancy

- Can cause PTL - Treated with Metronidazole 500mg PO BID x 7 days

Most common reasons for surgery during pregnancy

- appendicitis - cholecystitis - bowel obstruction - melanoma - ovarian disorders - breast or cervical disease - trauma

Gonorrhea in pregnancy

- Can cause Premature Rupture Of Membranes, preterm birth, Chorioamnionitis, neonatal sepsis, intrauterine growth restriction, postpartum sepsis. - Can also cause ophthalmia neonatorum or blindness. - Easily treated with cephtriaxone (Rocephin) 250mg IM. - Also treat for chlamydia at same time. - Screening done early prenatal and repeated at term if high risk. - Test of cure 3-4 weeks after treatment.

How can you identify a battered pregnant woman?

- Chronic psychosomatic symptoms - Old scars - Bruising - Decreased eye contact, nervousness - History

HIV counseling guidelines

- Discuss HIV testing during prenatal assessment: No testing without knowledge, no written consent needed - Provide private, comfortable environment - Provide woman with HIV information - Posttest counseling - No breastfeeding in developed countries

Complications of HIV in pregnancy

- Hemorrhage - Infection - Poor healing - UTI

Signs and symptoms of thalassemia

- mild anemia - hepatosplenomegaly - bony malformations - minor: small RBCs - major: severe anemia and risk for CHF

Results for battery in pregnancy

- psychological distress - loss of pregnancy - PTL - Low birth weight - injury to fetus - fetal death

If a pregnant women presents with abdominal pain that may require surgery, it is important for the nurse to understand that:

...

Incidence of physical trauma complications during pregnancy

1 in 12

When is the cardiovascular disease classification determined at?

3 months and again at 7 or 8 months of gestation as progression may occur

When can HIV be transmitted to the fetus from the mother?

In pregnancy Breast milk Majority happens during labor and birth.

What does asthma put pregnant women at more of a risk for?

Preeclampsia Growth restriction PTL/birth Hemorrhage