Complications During Pregnancy

Hemoglobinopathies-Sickle Cell Disease

A woman with SCD is more likely to have problems during pregnancy that can affect her health and the health of the unborn baby than a woman without SCD. During pregnancy the disease can become more severe, and pain episodes can occur more often. A pregnant woman with SCD is at a higher risk of preterm labor, having a low birth weight baby or other complications. However, with early prenatal care and careful monitoring throughout pregnancy, a woman with SCD can have a healthy pregnancy. Sickle cell disease during pregnancy Sickle cell disease often becomes more severe - and pain episodes more frequent - during pregnancy, particularly in the third trimester. A pregnant woman with sickle cell disease is more likely to have a miscarriage, preterm labor, or a low-birth-weight baby.

Abruptio Placentae Now you can.....describe the difference between placenta previa and abruptio placentae

Abruptio Placentae aka Placental abruption premature separation of a normally implante placenta from the uterine wall. an abruption results in hemorhage between the unterine wall and the placenta 50% of abruptions occur befor labor and after 30 weeks. S/S: grade 1: slight vaginal bleeding and some utering irritability grade 2: exteranl utering bleeding is absent to moderate, uterus is irritable and tetanic or very frequent contraction may be present grade 3: bleeding is moderat to severe

Cardiovascular Disease- Acquired Cardiac Disease

Acquired heart disease is heart disease that develops after birth. There are two major types of acquired heart disease in children: Rheumatic heart disease Kawasaki disease Symptoms of rheumatic heart disease may include: Chest pain Heart palpitations Shortness of breath Flaring of the nostrils Swelling in the ankles, feet, legs, and abdomen Fatigue Symptoms of Kawasaki disease may include: Fever Rash Red eyes Swollen hands and feet Red lips and tongue Swollen lymph nodes

Treatment of ectopic pregnancy

Methotrexate (anti-metabolic: stops things from growing) unruptured, 3-4cm or less Salpingotomy: surgical incision of a uterine tube Salpingectomy: surgical removal of the fallopian tubes Emotional Support

Preeclampsia (progressive NOT sudden) P. 305

Multisystem, vasopressive (like pressure on a hose) targets CV, hematological, hepatic, renal and CNS (worry about clotting) Disease of the placenta (preeclampsia) incomplete arterial transformation acute atherosis (a maternal vascular lesion observed regularly in cases of pre-eclampsia and idiopathic intrauterine growth retardation) vasospasm and endothelial cell damage Morbidity and mortality Management: delivery of fetus only cure pharmaceuticals (beta blockers, anti-hypertiensives) teaching for home management P. 305 ULTIMATE CURE FOR PREECLAMPSIA=DELIVERY

Cervical Insufficiency/Incompetence

Painless dilation and cercical effacement 2nd trimester Management: Transvaginal ultrasound cervical lenth assessment Cerclage (sewing shut) Bedrest

Antibiotics (preterm labor?)

Penicillin G Ampicillin Cefazolin Clindamycin Erthromycin Vancomycin

Early Pregnancy Complications Now you can...... name 3 signs and symptoms associated with spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease?

Perinatal loss Ectopic pregnancy Gestational trophoblastic disease Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy. S/S : vaginal bleeding, excessive N/V, abdomianl pain, size/date discrpancy Management: remove uterin contents

Perinatal loss

Pg. 293

Now you can ......... name three intial steps in the management of the bleeding pregnang patient....

Placenta Previa -stabilization involves the administering of IV fluids -laboratory workup that includes CBC -Prothrombin time (PT) and partial thromboplastin time (PTT) -blood type and cross match (kleihauer-Betke blood test may be orered to determine if there has been a trasfer of fetal blood cells Abruptio placentae -potential for DIC, hemorrhage, fteral hypozia may potentiate the need for early delivery -if delivery not necessary: hospitalization labwork -CBC continuous monitory Betamethasone may be given to woman to promote fetal lun maturity when deliver is not imminent (promote fetal lung development) I&O electronic fetal monitoring

Hemorrhagic Disorders

Placenta Previa: S/S: painless vaginal bleeding Management: stabilization, fetal monitoring Abruptio placentae S/S: 3rd trimester bleeding associated with severe abdominal pain Management: monitoring, delivery Complications: Baby: lack of nutrition, lack of oxygen, hypoxia, braind damage, cerebral palsy (general term for brain damage) Mom: blood loss

Infections: UTI

UTI: Urinary Tract Infection During Pregnancy Urinary tract infection (UTI) is the most common type of bacterial infection during pregnancy. A UTI, with or without symptoms, can lead to dangerous kidney infection. Kidney infection during pregnancy can endanger both mother and fetus. Many women with a UTI have no symptoms but have high levels of bacteria in their urinary tract. During your first prenatal exam, your doctor will test your urine sample for bacteria. If your results show that you have a UTI, you will be treated with antibiotics. Pregnancy increases your risk of having a urinary tract infection (UTI). UTIs are more common in multiple pregnancies than in pregnancies with one fetus. A UTI during pregnancy can be difficult to distinguish from the usual symptoms of pregnancy (such as bladder pressure, frequent urination, or back pain). Some pregnant women who have UTIs have no symptoms at all. Symptoms of a urinary tract infection are: Frequent urination. A feeling of burning during urination. Pain or itching during urination.

Diagnostic procedures for suspected ectopic pregnancy

Urine pregnancy test Beta-human chorionic gonadotrophin concentrations: (hCG) is a hormone produced by the embryo after implantation Transvaginal ultrasound Serum progesterone concentrations: Serum progesterone is a test to measure the amount of progesterone in the blood. Progesterone is a hormone produced mainly in the ovaries. Progesterone plays a key role in pregnancy. It helps make a woman's uterus ready for a fertilized egg to be implanted Dilatation and curettage Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a therapeutic gynecological procedure as well as the most often used method of first trimester abortion Laparoscopy

Placenta Previa Now you can.....describe the difference between placenta previa and abruptio placentae

*implantation of the placenta in the lower uterine segment, near or over the internal cervical os *accounts for 20% of all antepartum hemorrhages Three variations: 1-Complete (total) placenta previa the placenta covers the entire cervical os associated with the greatest amount of blood loss, presents the most serious risk 2-partial Previa: describes a placenta that partially occludes the cervical os 3-marginal Previa is characterized by the encroachment of the placenta to the margin of the cervical os Placenta accreta, percreta, and increta are placentas with abnormally fir attachment to the uterine wall may be associated with conditions that cause scarring of the uterus S/S: painless vaginal bleeding premature deliver is resonsible for 60% of pernatal deaths associated with placenta previa

Antenatal glucocorticoids

Antenatal glucocorticoid therapy decreases the incidence of several complications among very premature infants Used: In cased of preterm labor Between 24 and 34 weeks gestation To optimize fetal status by speeding up lung development Betamethasone 12 mg IM q 12 h x 2 Requires 24 hours to become effective Do not give in cases of chorioamnionitis chorioamnionitis also known as intra-amniotic infection (IAI) is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.

Infection: Tuberculosis

Anyone diagnosed with tuberculosis needs treatment to keep the TB infection from becoming a deadly disease, and pregnant women are no exception. Treatment gets trickier during pregnancy, however, because some medications commonly used to treat tuberculosis infection can harm a developing fetus or a breastfeeding newborn. Safe Tuberculosis Treatment for Pregnant Women It's perfectly safe for mothers-to-be to undergo a skin test for TB during pregnancy. It's important to get an early diagnosis so that treatment can begin right away, even during pregnancy. Treating a pregnant woman for tuberculosis may be a little complicated, but it's not nearly as dangerous as leaving the infection untreated. If untreated, active tuberculosis can cause problems for the fetus. Many babies born to mothers with untreated TB have low birth weight; in rare cases, the child may also have TB. For mom, leaving the disease untreated could kill her. The right treatment combination poses little risk to baby while helping to save mom's life. Cholesterol Medication treating-ldlc.com Get Info About an Rx Drug To Help Lower Your Bad Cholesterol. Treatment for Latent TB If possible, a pregnant woman diagnosed with latent TB — meaning there are no symptoms yet — should hold off on treatment until about two or three months after she's had her baby. However, there are certain circumstances under which a pregnant woman may need to undergo treatment for latent tuberculosis infection. If so, she can be safely treated with isoniazid, or INH. These pills need to be taken once a day or twice a week for about nine months. When taking INH for latent tuberculosis infection, it's important that women also take vitamin B6 (pyridoxine) supplements so that the fetus gets the necessary vitamins. Treatment for Active Tuberculosis Active tuberculosis disease is treated with a combination of TB drugs, including INH. Pregnant women with active tuberculosis also need to take Myambutol (ethambutol) and rifampin (RIF) each day for two months. Following that round, daily doses (or two times per week) of INH and RIF are recommended for another seven months, bringing the total treatment time to nine months. Pregnant women who have active tuberculosis need to be treated right away to prevent serious complications. Pregnant women who are HIV-positive and have been diagnosed with TB also need immediate treatment. Pregnant women with HIV also need treatment with rifamycin and possibly also PZA (pyrazinamide), though the risks these two antibiotics pose to the fetus are not yet understood. Tuberculosis Medications to Avoid Certain antibiotics and medications sometimes used to treat TB should not be used during pregnancy. These include: Kanamycin Cycloserine Ethionamide Streptomycin Amikacin Ciprofloxacin Ofloxacin Sparfloxacin Levofloxacin Capreomycin Tuberculosis and Breastfeeding New mothers who choose to breastfeed and are still undergoing treatment for tuberculosis can safely do so. Mothers taking INH to treat their tuberculosis will pass only very small amounts of the medication to the baby in breast milk — amounts that have not been found to be harmful. Breastfeeding is always best even while taking tuberculosis treatment medications, and breastfeeding moms taking INH should also continue taking a vitamin B6 supplement. If the baby is born with TB, the tiny amount of INH in mom's breast milk is not enough to treat the baby's infection. Infants will need their own treatment regimen and cannot rely on mom's supply. A woman's health is more important than ever during pregnancy — taking care of your own health means your baby is taken care of as well.

Respiratory complications - Asthma

Asthma medicines and pregnancy A review of the animal and human studies on the effects of asthma medicines taken during pregnancy found few risks to the woman or her fetus. It is safer for a pregnant woman who has asthma to be treated with asthma medicines than for her to have asthma symptoms and asthma attacks.1 Poor control of asthma is a greater risk to the fetus than asthma medicines are.1Budesonide is labeled by the U.S. Food and Drug Administration (FDA) as the safest inhaled corticosteroid to use during pregnancy. One study found that low-dose inhaled budesonide in pregnant women seemed to be safe for the mother and the fetus.3 Never stop taking or reduce your medicines without talking to your doctor. You might have to wait until your pregnancy is over to make changes in your medicine.

Spontaneous abortion Now you can...... name 3 signs and symptoms associate with spontanous abortion, epctopci pregnancy, and gestational trophoblastic disease?

Before 20 weeks gestation S/S: bleeding, cramping, abdomial pain, decreased symptoms of pregngncy Management: D&C

Mild HTN or preeclampsia

CAN'T READ ON PPT.

Severe preeclampsia

CAN'T READ ON PPT.

TEST TEST TEST TEST TEST p. 305

CAN'T READ ON PPT. flowchart of pathophysiological changes of preeclampsia

Now you can..... identify five symptoms of preterm labor

Cervical chnages Regualr unterine contraction between 20-37 weeks backache pelvic aching menstrual-like cramps increased vaginal discharge, pelvic pressue urinary frequency intestinal crapmping with or without diarrhea

Hyperemesis gravidarum gravidarum: latin for pregnancy

Criteria: persistent vomiting, measure of acute starvation, weight loss, dehydration, electrolyte loss Management: rest small frequent meals (dry, bland food) high-protein snacks (protein=building blocks) P. 297

Respiratory Complications- Cystic Fibrosis

Cystic fibrosis (CF) is a condition that affects breathing and digestion. It's caused by very thick mucus that builds up in the body. Mucus is a fluid that normally coats and protects parts of the body. It's usually slippery and slightly thicker than water. But In CF, the mucus is thicker and sticky. It builds up in the lungs and digestive system and can cause problems with how you breathe and digest food. With proper management, women with cystic fibrosis (CF) can experience uncomplicated pregnancies that result in healthy babies. In general, women with CF have better pregnancy outcomes when pregnancy is planned and preparations are made to keep their doctor involved in monitoring the progress along the way. How to Manage Pregnancy When You Have Cystic Fibrosis Before you get pregnant, you should have good nutritional status, be at your target weight, and have at least 40% lung function. During the planning stages, your partner should have genetic testing to determine if he is a carrier of cystic fibrosis. For a smooth and worry free pregnancy, may doctors recommend that you keep the following management tips in mind: 1. Maintain Adequate Nutrition Nutrition demands will increase during pregnancy, and you will probably be advised to take supplements such as nutrition shakes to be sure that you're getting enough calories. Sometimes, women with CF are not able to get enough nutrition from foods and supplements. If that happens, you may have to go to the hospital to get intravenous nutrition called TPN through a long-term IV called a central line. 2. Fight Respiratory Infections Aggressively Respiratory infections should be treated with antibiotics as soon as the first symptom appears, because they can get out of hand very quickly in people with CF and reduce the amount of oxygen that is delivered to the body. Low oxygen is a problem for you and for your baby since he or she is counting on you to meet his or her oxygen needs. 3. Continue Chest Physiotherapy (CPT) Chest Physiotherapy is an important part of your daily treatment and must be done even when you are pregnant. It will not harm your baby. 4. Continue Your CF Medications Most oral and inhaled medications that are prescribed to women with cystic fibrosis are safe for the baby. Discuss your pregnancy with your CF doctor. Then review your medication list with your obstetrician at the first visit and he or she will tell you if any adjustments are needed. 5. Be Prepared for Hospital Admission You may need to stay in the hospital for a while during your pregnancy for treatment or observation. This is most likely to happen sometime in the last three months when your body may begin to have problems handling the demands of pregnancy. 6. Decide Whether You Want to Breastfeed Women with cystic fibrosis can breastfeed their babies, and their milk contains sufficient amounts of protein and sodium. If you do choose to breastfeed, you will need to meet with your nutritionist to develop a plan that will provide enough extra calories for you and your baby. 7. Plan for the Future Despite modern advances in treatment, cystic fibrosis is still a life-shortening disease. Some people live longer, but the average life expectancy of people with CF in the United States is about 40 years. It is unpleasant to think about the possibility of not being able to raise your child to adulthood, but it is a possibility that must be considered. Discuss this possibility with your partner and begin making plans for the care of your child. Another option that may be considered in future planning is the possibility of lung transplantation or new therapies. Not everybody with CF will qualify for a transplant, but those that do can be successful in lengthening their lives. A lung transplant is risky, but it can offer you a chance to improve your health and extend your life. So far, more than 1600 CF patients have received lung transplants. Most of them were still living one year later and about half of them were doing well five years after the transplant.

Now you can....... Explain why it may be difficult to identify an early maternal hemmorrhage

Dduring prgnancy, the woman's blood volume increases 50% and in the case of multiple gestation as high as 100%. Due to this expanded blood volu, the patient may be asymptomatic and exhibit vital signs that rmain within normal parameters despite a large amoun of blood loss. Blood pressure is a very poor indicator of blood volume deficit. The maternal pulse (tachycardia) and/or fetal heart reat (bradycardia or tachycardia) may be the first indicator of maternal instability

Dilation/Effacement

Dilation, the opening of the cervix (measured in centimeters), and effacement, the thinning of the cervix (measured in percentage),

Desseminated Intravascular Coaguopathy (DIC)

External or internal bleeding Nursing Care Meticulous maternal and fetal assessment Place indwelling catheter (don't want mom to get up, Limit stress on the kidneys) Side lying (left side) Oxygen: rebreathing mask Blood and blood products Emotional support From Wiki: Disseminated intravascular coagulation (DIC), also known as disseminated intravascular coagulopathy or less commonly as consumptive coagulopathy, is a pathological process characterized by the widespread activation of the clotting cascade that results in the formation of blood clots in the small blood vessels throughout the body

Premature rupture of membranes (at term)

Ferning test A ferning test may be performed on fluid that has leaked from the vagina during pregnancy in order to determine if it is amniotic fluid

Cardiovascular Disease- Mitral Valve Prolapse

From book: common condition that affects 2-3% of reproductive aged women. howeverr it generally does not affect pregnancy. Hemodynamic changes may alleviate the murmur of MVP. In rare cases, pts experience chest discomfort or rhythm disturbance beta blockers may be inititated in highly symptomatic pts. From web: Mitral valve prolapse (MVP) occurs when the valve between your heart's left upper chamber (left atrium) and the left lower chamber (left ventricle) doesn't close properly. During mitral valve prolapse, the leaflets of the mitral valve bulge (prolapse) upward or back into the left atrium as the heart contracts. Mitral (MY-trul) valve prolapse sometimes leads to blood leaking backward into the left atrium, a condition called mitral valve regurgitation. In most people, mitral valve prolapse isn't life-threatening and doesn't require treatment or changes in lifestyle. Some people with mitral valve prolapse, however, require treatment. Although mitral valve prolapse is usually a lifelong disorder, many people with this condition never have symptoms. When diagnosed, people may be surprised to learn that they have a heart condition. When signs and symptoms do occur, it may be because blood is leaking backward through the valve (regurgitation). Mitral valve prolapse symptoms can vary widely from one person to another. They tend to be mild and develop gradually. Symptoms may include: A racing or irregular heartbeat (arrhythmia) Dizziness or lightheadedness Difficulty breathing or shortness of breath, often when lying flat or during physical activity Fatigue Chest pain that's not caused by a heart attack or coronary artery disease

Infection: Group B Streptoccoccus

Group B streptococcus - pregnancy Group B streptococcus (GBS) is a type of bacteria that some women carry in their intestines and vagina. It is not passed through sexual contact. Most of the time, GBS is harmless. However, GBS can be passed to a newborn during birth. Most babies who come in contact with GBS during birth will not become sick. But the few babies who do become ill can have severe problems. GBS Infection in Newborn Babies After your baby is born, GBS can lead to infections in: The blood (sepsis) The lungs (pneumonia) The brain (meningitis) Most babies who get GBS will start having problems during their first week of life. Some babies will not get sick until later. Symptoms can take as long as 3 months to appear. The infections caused by GBS are serious and can be fatal. Yet prompt treatment can lead to complete recovery. Preventing GBS Infections in Babies Women who carry GBS often don't know it. You are more likely to pass the GBS bacteria to your baby if: You go into labor before week 37. Your water breaks before week 37. It has been 18 or more hours since your water broke, but you haven't had your baby yet. You have a fever of 100.4°F (38°C) or more during labor. You have had a baby with GBS during another pregnancy. You have had urinary tract infections that were caused by GBS. When you are 35 to 37 weeks pregnant, your doctor may do a test for GBS. The doctor will take a culture by swabbing the outer part of your vagina and rectum. The swab will be tested for GBS. Results are often ready in a few days. Some doctors do not test for GBS. Instead, they will treat any woman who is at risk for having their baby be affected by GBS. Treating and Preventing GBS Infections in Pregnant Women There is no vaccine to protect women and babies from GBS. If a test shows that you carry GBS, your doctor will give you antibiotics through an IV during your labor. Even if you are not tested for GBS but have risk factors, your doctor will give you the same treatment. There is no way to avoid getting GBS. The bacteria are widespread. People who carry GBS often have no symptoms. GBS can come and go. Testing positive for GBS does not mean you will have it forever. But you will still be considered a carrier for the rest of your life. Note: Strep throat is caused by a different bacterium. If you have had strep throat, or got it while you were pregnant, it does not mean that you have GBS. Alternative Names

HELLP Syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets Complication of severe preeclampsia Treatment: Improve platelets with fresh-frozen plasma (FFP) Delivery of fetus as soon as feasible Oftern goes hand and hand with preeclampsia

Multiple Gestation

High-risk pregnancy Morbidity and mortality 7% vs. 0.5% (maternal morbidity) Monochorionicity-Monoamniotic twins are always monozygotic (identical twins) Growth restriction Prematurity Cerebral Palsy (CP) 4x more in twins; 17 x more in triplets Management: Delivery at level III facility

Nursing Assessments: Preeclampsia

Identify hypertension Proteinuria Edema CNS alterations: Eclampsia: seizures

hemoglobinopathies- ABO

In ABO hemolytic disease of the newborn (also known as ABO HDN) maternal IgG antibodies with specificity for the ABO blood group system pass through the placenta to the fetal circulation where they can cause hemolysis of fetal red blood cells which can lead to fetal anemia and HDN. In contrast to Rh disease, about half of the cases of ABO HDN occur in a firstborn baby and ABO HDN does not become more severe after further pregnancies. The ABO blood group system is the best known surface antigen system, expressed on a wide variety of human cells. For Caucasian populations about one fifth of all pregnancies have ABO incompatibility between the fetus and the mother, but only a very small minority develop symptomatic ABO HDN.[1] The latter typically only occurs in mothers of blood group O, because they can produce enough IgG antibodies to cause hemolysis. Although very uncommon, cases of ABO HDN have been reported in infants born to mothers with blood groups A[2][3] and B.[4]

Ectopic Pregnancy

In fallopian tube On fallopian tube On ovary On cervix On the abdomial wall On the bowel

Cardiovascular Disease-Congenital Cardiac Disease

The symptoms of congenital heart disease in infants and children may include: A bluish tint to the skin, fingernails, and lips (doctors call this cyanosis). Fast breathing and poor feeding. Poor weight gain. Congenital heart disease is a problem with the heart's structure and function that is present at birth. There are several types of congenital heart disease. The most common types include: Holes between the heart's chambers Heart valve problems Defects in major blood vessels A combination of the above

Hemoglobinopathies- RHo (D) isoimmunization

Rh disease (also known as rhesus isoimmunisation, Rh (D) disease, rhesus incompatibility, rhesus disease, RhD hemolytic disease of the newborn, rhesus D hemolytic disease of the newborn or RhD HDN) is a type of hemolytic disease of the newborn (HDN). The disease ranges from mild to severe, and typically occurs only in some second or subsequent pregnancies of Rh negative women where the fetus's father is Rh positive, leading to a Rh+ pregnancy. During birth, the mother may be exposed to the infant's blood, and this causes the development of antibodies, which may affect the health of subsequent Rh+ pregnancies. In mild cases, the fetus may have mild anaemia with reticulocytosis. In moderate or severe cases the fetus may have a more marked anaemia and erythroblastosis fetalis (hemolytic disease of the newborn). When the disease is very severe it may cause hydrops fetalis or stillbirth. Rh disease is generally preventable by treating the mother during pregnancy or soon after delivery with an intramuscular injection of anti-RhD immunoglobulin (Rho(D) immune globulin).

SPASMS P. 306

S-significant BP changes P-proteinuria A-arterioles affected by vasospasm S-significant lab changes (increase LFTs and platelet count) M-multiple organ system involvement S-symptoms AFTER 20 weeks gestation

Premature rupture of membranes

S/S: gush/trickle of fluid from vagina Management factors: establish gestational age ultrasound to assess fetus assess for advanced labor, infection if advanced labor or infection, deliver fetus Risk of infection

Factors implicated in ectopic pregnancy

Tubal pathology-problem inside the tube Previous tubal surgery-endometriosis? Ashermans? abortion? ALL because of scar tissue Infertility Genital or pelvic inflammatory disease Use of some reproductive technologies Previous miscarriage Previous induced abortion Use of an intrauterine contraceptive device Previous ectopic pregnancy Sterilisation Smoking Douching Exposure to diethylstilboestrol : terrible drug that has since been withdrawn

Inflammatory Disease and Pregnancy Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders that affect women during their childbearing years. Signs and symptoms Typical clinical signs and symptoms of SLE include the following: Fatigue Fever Arthritis Photosensitive rash Serositis Raynaud phenomenon Glomerulonephritis Vasculitis Hematologic abnormalities In general, pregnancy does not cause flares of SLE. When flares do develop, they often occur during the first or second trimester or during the first few months after delivery. The most common symptoms of these flares include arthritis, rashes, and fatigue, and they are often easily treated. Signs and symptoms of normal pregnancy that must be differentiated from those of SLE exacerbations include the following: Chloasma versus malar rash Proteinuria secondary to preeclampsia versus proteinuria due to lupus nephritis Preeclampsia versus renal disease due to an exacerbation of lupus (may be difficult to differentiate) Thrombocytopenia in pregnancy (ie, hemolysis, elevated liver enzyme levels, and low platelet counts syndrome) versus thrombocytopenia of lupus exacerbation (ie, thrombotic thrombocytopenic purpura or idiopathic thrombocytopenic purpura) Pedal edema and fluid accumulation in joints (especially the knees) in the late stages of pregnancy versus the arthritis of SLE Diagnostic evaluation Laboratory testing The following laboratory studies are recommended with the first visit after or when pregnancy is confirmed: Renal function tests, including determination of the glomerular filtration rate (GFR), urinalysis, and tests of the urinary protein-to-creatinine (P/C) ratio Complete blood count Test for anti-Ro/SSA and anti-La/SSB antibodies Lupus anticoagulant and anticardiolipin antibody studies Anti-double-stranded DNA (anti-dsDNA) test Complement studies (CH50 or C3 and C4) During the first 2 trimesters, a monthly platelet count or CBC is recommended. In addition, the following studies are recommended at the end of each trimester of pregnancy: Determination of the GFR and measurement of the urinary P/C ratio Anticardiolipin antibody measurement Complement studies (CH50 or C3 and C4) Anti-dsDNA study In pregnant patients with renal disease, renal biopsy should be performed to differentiate preeclampsia from active lupus nephritis when differentiation on clinical grounds is not possible. Imaging studies Ultrasonography: At first prenatal visit to accurately estimate the gestational age Serial fetal echocardiography: To detect fetal heart block at an early stage Management In general, an integrated team consisting of a rheumatologist, an obstetrician experienced with high-risk care, and a nephrologist (if renal disease is present or if it develops later) manages care of a pregnant patient with SLE. Nonpharmacotherapy Before initiating therapy, perform preconception counseling, including discussions of teratogenicity and adverse effects of SLE medications as well as contraception once therapy is begun. Pharmacotherapy None of the medications used in the treatment of SLE is absolutely safe during pregnancy. Therefore, whether to use medications should be decided after careful assessment of the risks and benefits in consultation with the patient. During the first trimester, most of the drugs should be avoided. Overview Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders that affect women during their childbearing years. Typical clinical symptoms of SLE include fatigue, fever, arthritis, a photosensitive rash, serositis, Raynaud phenomenon, glomerulonephritis, vasculitis, and hematologic abnormalities. Flares of SLE are uncommon during pregnancy and are often easily treated. The most common symptoms of these flares include arthritis, rashes (see the image below), and fatigue. Classic malar rash (also known as butterfly rash) Classic malar rash (also known as butterfly rash) of systemic lupus erythematosus, with distribution over cheeks and nasal bridge. Note that fixed erythema, sometimes with mild induration as seen here, characteristically spares nasolabial folds. SLE increases the risk of spontaneous abortion, intrauterine fetal death, preeclampsia, intrauterine growth retardation, and preterm birth. Prognosis for both mother and child are best when SLE is quiescent for at least 6 months before the pregnancy and when the mother's underlying renal function is stable and normal or near normal. Lupus nephritis can get worse during pregnancy.[1, 2, 3, 4, 5] The mother's health and fetal development should be monitored frequently during pregnancy. In addition, an obstetrician with experience in high-risk care should conduct the follow-up of pregnant women with SLE.

Hypertensive Disorders

TEST TEST TEST TEST P. 304 CAN NOT READ SLIDE ON P. 7 *problem with HTN: doesn't circulate blood, vasospasm

Infection: TORCH

TORCH testing (sometimes called TORCHES testing) includes tests for a group of infectious diseases that can infect pregnant women and cause birth defects or death in their infants. TORCHES is an acronym for the following infectious diseases: Toxoplasma gondii (toxoplasmosis)- a parasite that can be acquired from ingesting cysts from the feces of infected cats, drinking unpasteurized milk, or eating undercooked contaminated meat. Infection early in pregnancy can cause miscarriage. Later in pregnancy it can cause eye infections, and mental retardation. Other- Other infections that may be screened for at the same time include Parvovirus B19 and sometimes varicella zoster virus (chicken pox). Rubella (German Measles)-Infection early in pregnancy can cause birth defects such as heart disease, growth retardation, and eye defects. It can also cause problems later in childhood such as hearing loss. Following the introduction of the vaccine in the 1970s, the incidence of Rubella has now dropped to approximately 1 in 10,000 births. Cytomegalovirus (CMV)- This virus is transmitted through body secretions (including breast milk) as well as sexual contact. Infection can cause death, hearing loss and mental retardation. Herpes simplex virus (HSV)- is a common infection that is spread by oral and genital contact. Most infections are spread to infants during the birth process. Infected infants may have localized infections of the mouth, eyes or skin, and some may have disseminated infection. Infant mortality from neonatal infection can be very high. Syphilis (Treponema pallidum) - this bacterial infection can cause stillbirth or infant death shortly after birth. Untreated babies may become developmentally delayed, have malformations, seizures, or die. In practice, TORCH testing in the United States is most commonly targeted toward high-risk groups, or women from areas where the prevalence of the diseases is high. In these situations, the screening serves to identify women with active infection as well as those who lack immunity to the diseases. Those who aren't immune can be vaccinated or more specifically counseled to limit risk of exposure. The use of TORCH testing to diagnose these infections is becoming less common since more specific and sensitive tests, that don't rely on the detection of antibodies are available. Note that false positive results are possible and all positive TORCH tests should be followed-up with more specific confirmatory tests. Routine screening of pregnant women for underlying infectious disease or immunity is consistently performed to identify: Chronic carriers of hepatitis B virus HIV infection Group B streptococcal colonization Immunity to Rubella virus Syphilis In fact, the CDC 2010 "Sexually Transmitted Diseases Treatment Guidelines" recommend that pregnant women be screened on their first prenatal visit for sexually transmitted diseases which may include Hepatitis B, HIV, Syphilis as well as Gonorrhea & Chlamydia. I

Hemoglobinopathies- Thalassemia

Thalassaemia is an inherited (genetic) blood disorder. It happens when mutated genes affect the body's ability to make healthy haemoglobin, the iron-rich protein found in red blood cells. Haemoglobin carries oxygen to all parts of the body, and carbon dioxide to the lungs to be exhaled. When genes are mutated it means that they are permanently altered. So thalassaemia is a lifelong condition. If you and your partner have been diagnosed with thalassaemia trait, a diagnostic test will tell you for sure whether your baby has inherited it. You may be offered one of the following tests: Chorionic villus sampling involves taking a small sample of the placenta for DNA testing at about 11 weeks to 14 weeks of pregnancy. Amniocentesis, in which the amniotic fluid surrounding your baby is tested after 15 weeks of pregnancy. Fetal blood sampling, during which a blood sample is taken from the umbilical cord between 18 weeks and 21 weeks. When a baby is affected by alpha thalassaemia major and has a very low chance of survival, some parents consider ending the pregnancy. This is because, very sadly, the baby may not have a good quality of life, even if they have complex treatments. An early diagnosis will be better for you and your family, to give you time to make your decision. The results are confidential, and if they are positive, a counsellor will explain your options before you and your partner decide what to do.

Infections: STI's

What are sexually transmitted infections and how can they affect my pregnancy? A sexually transmitted infection (STI)—sometimes referred to as a sexually transmitted disease (STD)—is a bacterial or viral illness that you can get from having genital, oral, or anal sex with an infected partner. STIs can have serious health consequences for you and your baby. Sex isn't the only way some of these infections are transmitted. For example, you can also become infected with the hepatitis B virus - which can survive outside the body for at least a week—from contact with contaminated needles or other sharp instruments, contact with the blood or open sores of an infected person, or even by sharing household items like a toothbrush or razor. Some infections can pass to your baby through the placenta or be transmitted during labor and delivery or when your water breaks. Newborn infections can be very serious (even life threatening), and some may lead to long-term irreversible health and developmental problems. What's more, some STIs raise your risk of miscarriage, preterm premature rupture of the membranes (PPROM), preterm birth, uterine infection, and stillbirth. Some of the most common STIs include: Chlamydia Genital herpes Gonorrhea Hepatitis B HIV/AIDS HPV Syphilis Trichomoniasis

Warning signs of possible rupture (ectopic pregnancy) Now you can...... name 3 signs and symptoms associated with spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease?

dizziness/syncope fever passage of tissue from vagina shortness of breath shoulder pain sudden, sharp and/or severe abdominal pain tachycardia vaginal bleeding (especially if heavy)

Gestational Trophoblasitc Disease Now you can...... name 3 signs and symptoms associated with spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease?

is a group of rare tumors that involve abnormal growth of cells inside a woman's uterus. GTD does not develop from cells of the uterus like cervical cancer or endometrial (uterine lining) cancer do. Instead, these tumors start in the cells that would normally develop into the placenta during pregnancy. (The term gestational refers to pregnancy.) Common type: hydatidiform mole Incidence: 1/1200 pregnancies S/S: vaginal bleeding, excessive nausea/vomiting, abdominal pain, size/date discrepancy Mangagement: remove uterine content Does not contain fetal contents, false pregancy, some HCG but not as high, aka-molar pregnancy D&C necessary Pg. 294 Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic diseas

Preterm Labor

occurs between 20-37 weeks morbidity and mortality subtle signs/symptoms screening biochemical markers management goals: inhibit/reduce contraction strength/frequency pharmacueticals: Betamethasone, Terbutaline Mag/Sulfate optimize fetal status

Respiratory Complications- pneumonia

penicillins, cephalosporins, and macrolides (excluding erythromycin estolate, because it has been associated with hepatotoxicity in mothers during the second half of pregnancy) are safe Current antibiotics available for treatment of community-acquired pneumonia include fluoroquinolones, macrolides, and beta-lactams, as well as aminoglycosides, tetracyclines, and some miscellaneous agents such as trimethoprim-sulbactam.

Tocolytics Tocolytics (also called anti-contraction medications or labor repressants) are medications used to suppress premature labor (from the Greek tokos, childbirth, and lytic, capable of dissolving). They are given when delivery would result in premature birth drugs include: beta-adrenerci agonist, mag sulfate, prostaglandin synthetiase inhibitor and calciu channel blockers P. 3-2 Now you can.......use of tocolytics in preterm labor

slows & weakens strength of contraction Magnesium Sulfate (why give??????) Neuromuscular depressant complications antidote: calcium gluconate Terbutaline beta2-adrenergic agonist Nifedipine calcium channel blocker Indomethacin Role of tocolyitics????????