This study material has been compiled from a combination of copy-pasted text and an audio lecture transcript.

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📚 Risky Pregnancies - II: Health Issues and Nursing Care

🎯 Purpose & Objectives

This lesson aims to provide comprehensive knowledge about health issues affecting pregnancy and the related nursing care.

By the end of this lesson, students will be able to:

• ✅ Explain potential health issues during pregnancy.
• ✅ Describe nursing care for health issues that may arise during pregnancy.

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1️⃣ Hypertensive Disorders in Pregnancy

Hypertensive disorders are a group of conditions that can significantly impact maternal and fetal health.

📚 Classification

• Gestational Hypertension: High blood pressure developing after 20 weeks of gestation without proteinuria.
• Preeclampsia: Hypertension with proteinuria or other systemic signs of organ dysfunction after 20 weeks.
• Eclampsia: The most severe form, characterized by seizures in a woman with preeclampsia.
• Chronic Hypertension: Hypertension present before pregnancy or diagnosed before 20 weeks of gestation.
• Superimposed Preeclampsia: New-onset or worsening hypertension, proteinuria, or other preeclampsia symptoms in a woman with chronic hypertension.

⚠️ High-Risk Factors for Preeclampsia

• History of preeclampsia
• Multiple pregnancies
• History of hypertension
• Type 1 and 2 diabetes
• Renal disease
• Autoimmune diseases (e.g., Systemic Lupus Erythematosus (SLE), Antiphospholipid Syndrome)
• Nulliparity (first pregnancy)
• Obesity (BMI ≥ 30 kg/m²)
• Family history (mother or sister with preeclampsia)
• Age ≥ 35
• Low socioeconomic status
• Personal history (low birth weight, interval between pregnancies > 10 years)

💡 Preeclampsia: Etiology & Pathophysiology

Preeclampsia results from an interaction of maladaptive cardiovascular and uteroplacental responses to pregnancy. Inadequate insulin leads to high blood glucose, forcing the body to use proteins and fats for energy, which can result in ketosis and cellular dehydration.

📊 Symptoms of Preeclampsia (ACOG, 2020)

Preeclampsia Without Severe Features (Mild Preeclampsia)

• Blood Pressure: ≥ 140/90 mmHg (2 measurements ≥ 4 hours apart)
• Proteinuria: ≥ 300 mg/24 hours OR Protein/creatinine ratio ≥ 0.3 OR Dipstick ≥ 2+
• Other Clinical Features (Not Diagnostic):
  • Urine Output: Normal (> 30 mL/hour)
  • Fetal Growth: Appropriate for gestational age
  • Edema: May be present (not diagnostic), not relieved by rest
  • Nausea/Vomiting: Absent

Preeclampsia With Severe Features (Severe Preeclampsia)

• Blood Pressure: ≥ 160/110 mmHg (2 measurements or urgent need for treatment)
• Proteinuria: Over 300 mg in 24h urine / significant proteinuria (> 5 g/day)
• Thrombocytopenia: Platelets < 100,000/µL
• Creatinine: > 1.1 mg/dL or 2× increase
• Liver Enzymes: ≥ 2× upper limit of normal or persistent right upper quadrant (RUQ)/epigastric pain
• Headache: Severe, persistent, unresponsive to therapy (cerebral symptoms)
• Visual Disturbances: Present (e.g., visual impairment, anxiety, hyperactive reflexes)
• Pulmonary Edema: May present
• Other Clinical Features (Not Diagnostic):
  • Urine Output: < 30 mL/hour (may occur)
  • Fetal Growth: Intrauterine Growth Restriction (IUGR) may be present
  • Edema: May be present (not diagnostic)
  • Nausea/Vomiting: Present

🚨 Eclampsia

Eclampsia is the most severe form of hypertensive disorder, marked by convulsions.

• Prodromal Symptoms: Often include edema, headache, epigastric pain, and visual disturbances.
• Convulsions: Can manifest as tonic and clonic periods, followed by a coma.
  1. Tonic Period: Muscle rigidity.
  2. Clonic Period: Rhythmic muscle contractions and relaxations.
  3. Coma: Post-seizure unconsciousness.
• Symptoms Leading to Convulsions: Nausea, vomiting, epigastric pain, bradycardia, bradypnea, double vision (diplopia), eye floaters, hyperactive reflexes in the ankles.

🏥 Eclampsia Complications

• Maternal Risks: Pulmonary edema, bleeding in internal organs, hepatic and renal insufficiency, HELLP syndrome, ablatio placenta, maternal death.
• Fetal Risks: IUGR, fetal hypoxia, fetal death.

🩸 HELLP Syndrome

A severe variant of preeclampsia, characterized by:

• Hemolysis of red blood cells (due to systemic capillary endothelial damage)
• Elevated Liver enzymes
• Low Platelet count

🩺 Diagnostic Methods

• Routine antenatal checkups: Blood pressure monitoring, edema assessment, weight monitoring.
• Blood and urine tests: To check for proteinuria, liver enzymes, platelet count, creatinine.

💊 Treatment

• Mild Preeclampsia: Antihypertensives.
• Severe Preeclampsia – Eclampsia:
  • Antihypertensives: To control blood pressure.
  • Magnesium Sulfate (MgSO₄):
    • Prevents convulsions.
    • Depresses irritability of the central nervous system.
    • Improves tissue perfusion.
    • Safe for the fetus.
  • MgSO₄ Antidote: Calcium gluconate.

👩‍⚕️ Nursing Care

General Approach

• Activity: Strict bed rest in a quiet, calm environment.
• Diet: High protein and fiber, salt-restricted (6 g/day).
• Patient Follow-up:
  • Vital sign checks (e.g., every 4 hours, or every 15-30 minutes during eclampsia).
  • Daily edema and weight monitoring.
  • Hourly fluid input and output tracking.
  • Continuation of prescribed treatment (e.g., MgSO₄).
  • Observation for convulsions.
  • Monitoring serum Mg level (4.8 - 9.6 mg/dl), respiratory rate (12-16/min), deep tendon reflexes, pulse rate (60/min), urine amount (30ml/hour), state of consciousness.
• Fetal Evaluation: Continuous fetal monitoring.
• Hygienic Care: As needed.
• Education: Informing pregnant women and their families, eliminating worries.
• Laboratory Tests: Follow-up of results.
• Pregnancy Continuation: Preparing for labor if necessary.

In-Natal Nursing Care

• Vaginal birth is preferred if maternal and fetal conditions are stable.
• Oxytocin induction/augmentation may be used with concurrent MgSO₄ therapy.
• Cesarean birth for fetal distress, placental abruption, or failure to progress.
• Epidural anesthesia may be used; spinal anesthesia depends on maternal hemodynamic stability and platelet count.
• Close coordination with NICU is essential.

Postnatal Nursing Care

• Postpartum observation for 24-48 hours.
• Maintenance of MgSO₄ therapy for 24 hours.
• Closely monitor uterine involution and lochia.
• Signs of recovery: Diuresis of 4-6 liters/day and rapid weight loss, reduction in proteinuria, blood pressure returning to normal within two weeks.

Maternal Discharge Education

• Information on postpartum care and baby care (especially for low birth weight or premature infants).
• Adherence to prescribed medications.
• Counseling for a balanced and adequate diet.
• No smoking.
• Avoidance of stress and sadness.
• Regular antenatal checkups for future pregnancies.
• Annual comprehensive physical exam.
• Regular blood pressure checks every two months.
• Family planning counseling.

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2️⃣ Pregnancy and Heart Disease

📈 Cardiovascular System (CVS) Changes in Pregnancy

Pregnancy significantly alters the maternal cardiovascular system:

• Blood volume increases.
• Heart rate increases.
• Coagulation factors increase.
• Physiological anemia may occur.
• Venous stasis is common.
• Systemic vascular resistance decreases.

📚 Classification of Heart Disease in Pregnancy

• Class I: No signs of heart failure during normal activity. Normal activities are not restricted. Pregnancy is usually not a problem.
• Class II: Temporary signs of heart failure during normal activity.
• Class III: Comfortable at rest, but signs of heart failure (tachycardia, dyspnea, chest pain) appear during activity. Pregnancy is not recommended. Bed rest in the hospital if pregnancy is chosen.
• Class IV: Heart failure symptoms present even at rest, unable to perform any physical activity without discomfort. Maternal mortality is HIGH. Pregnancy is extremely dangerous, not recommended.

⚠️ Effects of Heart Disease on Pregnancy

• Threatens maternal and fetal health.
• Adequate placental blood flow is essential for healthy fetal development.
• In cases of heart failure, blood flow to the uterus decreases, endangering the fetus's life.

👩‍⚕️ Nursing Care

• Prenatal:
  • Frequent check-ups.
  • Prevention of infection and anemia.
  • Stress reduction.
  • Balanced diet and prevention of excess weight gain.
• In-Natal:
  • Normal Spontaneous Delivery (NSD) is preferred.
  • Close follow-up for output increase (cardiac).
  • Curing (pushing) is not recommended.
  • Straining is prevented.
  • Stage 2 is shortened.
  • O₂ application if necessary.
• Postnatal:
  • Early mobilization.
  • If there is insufficiency, lactation should be limited.
  • Breastfeeding is not recommended if drugs used pass into the milk.

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3️⃣ Pregnancy and Diabetes

Diabetes in pregnancy is a chronic metabolic disease with a significant 'diabetogenic effect' during gestation, resulting from insufficient insulin secretion or inefficient insulin use.

📚 Classification in Pregnancy

• Gestational Diabetes Mellitus (GDM): Diabetes that develops during pregnancy.
• Pregestational Diabetes: Diabetes present before pregnancy (Type I and Type II).

💡 Pathophysiology

• As a result of insufficient insulin secretion, glucose cannot enter the cells, leading to high blood glucose levels.
• The body meets energy needs from proteins and fats, causing protein breakdown (negative nitrogen balance) and fat breakdown (ketosis).
• High blood glucose causes water to move from cells to blood, leading to cellular dehydration.
• Glucose also appears in urine (glycosuria).

📊 Changing Insulin Requirements During Pregnancy

• First Trimester: Insulin requirements decrease due to increased pancreatic insulin production and heightened peripheral insulin sensitivity. Nausea, vomiting, reduced food intake, and glucose transfer to the embryo/fetus increase the risk of hypoglycemia.
• Second & Third Trimester: Insulin requirements significantly increase (2-4 times) due to placental hormones, cortisol, and insulinase acting as insulin antagonists, reducing insulin effectiveness. Requirements typically stabilize after the 36th week.
• Delivery: Placental separation decreases human placental lactogen (hPL) and insulin needs.
• Breastfeeding Mother: Insulin requirements decrease to approach pre-pregnancy levels.
• Non-Breastfeeding Mother: Insulin requirement returns to pre-pregnancy levels within 7-10 days.

🩺 Gestational Diabetes Mellitus (GDM) Screening

• Urine Test: At each prenatal check-up (glycosuria may indicate need for further testing).
• Oral Glucose Tolerance Test (OGTT): Typically performed between 24-28 weeks.
  • Two-Step Method:
    1. 50-gram OGTT (screening).
    2. If result is over 180 mg/dL and fasting blood glucose is also above 95 mg/dL, GDM can be diagnosed without a 100-gram OGTT.
  • One-Step Method: (Not detailed in source, but implies a single diagnostic OGTT).

⚠️ Effects of Diabetes in Pregnancy

• Effects of Diabetes on Pregnancy:
  • Increased risk of preeclampsia and eclampsia.
  • Increased likelihood of hydramnios (10-20%).
  • Increased risk of large-for-gestational-age baby and preterm birth.
  • Increased risk of difficult labor and cesarean section.
  • Maternal mortality rate.
  • Vascular disease, hypertension, nephropathy, and retinopathy are seen.
  • Ketoacidosis, ketosis, hyperglycemia, hypoglycemia.
• Effects of Pregnancy on Diabetes:
  • Insulin needs INCREASE.
  • Higher likelihood of cardiovascular complications.
  • 1st trimester hPL low - susceptibility to hypoglycemia.
  • Increased hPL raises insulin needs (2-4 times).
  • Placental separation decreases hPL and insulin needs.
• Effects of Diabetes on Fetus and Newborn:
  • Increased risk of congenital anomalies.
  • Metabolic issues (Hypoglycemia, Hypocalcemia, Hypomagnesemia).
  • Hematological issues (Hyperbilirubinemia, Polycythemia).
  • Macrosomia and birth trauma.
  • Respiratory Distress Syndrome (RDS) due to reduced surfactant synthesis.
  • Perinatal mortality rate.

👩‍⚕️ Nursing Care in Diabetes

• Prenatal Monitoring: Diet, exercise, adherence to treatment regimen, blood glucose monitoring, fetal health, and maturity assessment to maintain normoglycemia.
• In-Natal Monitoring: Normal Spontaneous Delivery (NSD) preferred, fetal monitoring, risk of bleeding and infection, possibility of cesarean section, blood glucose monitoring, medical treatment.
• Postnatal Monitoring: Risk of bleeding and infection, DECREASE in insulin requirement, blood glucose monitoring, routine postpartum care, postpartum OGTT.

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4️⃣ Pregnancy and Blood Disorders

🩸 Anemia

Anemia is a common concern in pregnancy.

• Definition: Hemoglobin (Hb) < 11 g/dL in the 1st and 3rd trimesters, and < 10.5 g/dL in the 2nd trimester.
• Causes: Inadequate intake of iron and folic acid, or hereditary conditions like sickle cell anemia or thalassemia.
• Effects of Anemia in Pregnancy: Premature birth, IUGR, infection, delayed maternal recovery.

Iron Deficiency Anemia

• Maternal Effects: Fatigue, weakness, tachycardia, poor appetite, susceptibility to infection, pale mucous membranes and skin.
• Baby Effects: IUGR, premature birth, risk of fetal hypoxia, risk of fetal distress.
• Nursing Care: Nutrition education, adherence to medication regimen, education on iron supplements, providing information about side effects of medication.

Folic Acid Deficiency Anemia

• Importance: Folic acid is essential for DNA, RNA synthesis, and cell proliferation.
• Causes: Commonly associated with poverty, lack of knowledge, chronic diseases, and chronic alcoholism. Often occurs alongside iron deficiency.
• Fetal Effects: Spontaneous abortion, ablatio placenta, fetal anomalies.

Sickle Cell Anemia

• Mechanism: Breakdown of hemoglobin molecules.
• Risks: Maternal and perinatal morbidity and mortality, severe anemia.
• Painful Crises: Severe abdominal pain, leg pain, muscle spasms, joint pain, high fever, neck stiffness, nausea, vomiting. Crises increase especially in the third trimester.

Thalassemia (Mediterranean Anemia) / Major

• Nature: A recessive disease.
• Maternal Risks: Anemia, hypertension, infection, need for blood transfusion.
• Fetal Risks: IUGR, fetal death.

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5️⃣ Pregnancy and Infectious Diseases

The effects of infections on the mother and fetus vary depending on:

• Type of microorganism and mechanism of action.
• Gestational age at infection.
• Mother's immunity.
• Vaccination status.
• Early intervention and treatment.

⚠️ Risks for Mother and Fetus

• Premature Labor
• Congenital Malformation
• Amniotic Fluid Infection
• Intrauterine Growth Restriction (IUGR)

🦠 TORCH Infections

A group of infections that can cause significant harm to the fetus if contracted during pregnancy.

• T - Toxoplasmosis:

  • Type: Protozoa.
  • Maternal Symptoms: Often asymptomatic.
  • Transmission: Via raw or undercooked meat, cat feces.
  • Fetal Effects: Hydrocephalus/microcephaly, anemia, liver/spleen enlargement, low birth weight, neurological damage.

• O - Other:

  • Syphilis:
    • Type: Sexually Transmitted Disease (STD).
    • Symptoms: Small, painless, hard lesions (chancres) appear 2-3 weeks after contact; generalized rashes 3-9 weeks later.
    • Fetal Effects: Prematurity, fetal mortality.
  • HIV:
    • Transmission: Virus can be transmitted to the baby via the placenta, during birth (cervical secretions or blood), and postnatally (breastfeeding).
  • Gonorrhea:
    • Maternal Symptoms: Mostly asymptomatic in women.
    • Newborn Effects: Babies born through an infected birth canal may have eye infections.
    • Prevention: Newborn eye prophylaxis within one hour with 1% tetracycline or 0.5% erythromycin.
  • Chlamydia:
    • Maternal Symptoms: Often asymptomatic.
    • Transmission: To newborns in vaginal delivery.
    • Newborn Effects: May cause conjunctivitis and pneumonia.
  • Human Papillomavirus (HPV):
    • Manifestation: Genital warts.
    • Risk: Warts can grow large enough to obstruct vaginal delivery.

• R - Rubella (German Measles):

  • Type: Teratogenic viral infection.
  • Transmission: Virus crosses the placenta, especially in the 1st trimester.
  • Fetal Effects: Cataracts, hearing impairment, cardiac anomalies, IUGR, prematurity.

• C - Cytomegalovirus (CMV):

  • Transmission: Via respiratory, sexual contact, or personal contact.
  • Maternal Symptoms: Generally asymptomatic; rarely causes chills, leukocytosis.
  • Characteristics: Virus is present in all body fluids.
  • Fetal Effects: IUGR, deafness, blindness, miscarriage, low birth weight, stillbirth, microcephaly, mental retardation.
  • Consideration: Pregnancy termination may be considered if infection is detected before 20 weeks.

• H - Herpes Simplex:

  • Symptoms: Lesions in the genital area appear 2-10 days after contact. Virus remains in the body for life. Symptoms include fever, malaise, burning sensation in the vulva.
  • Management: Active genital lesions necessitate a Cesarean section to prevent transmission to the newborn.

🦠 Hepatitis B Virus

• Transmission: Via contaminated blood/products or sexual contact.
• Placental Transmission: Limited transmission to the fetus via the placenta.
• High Risk: High transmission risk (80-90%) if infection occurs for the first time in the 3rd trimester or during birth (as fetus contacts contaminated blood).
• Prevention: Protection for all newborns via Hepatitis B vaccination.

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6️⃣ Multiple Pregnancies

Multiple pregnancies are classified as high-risk due to elevated rates of morbidity and mortality for both mother and babies. Close antenatal monitoring is essential. Twin pregnancies alone account for a significant portion of neonatal and perinatal deaths.

⚠️ Maternal Risks

• Dyspnea on exertion, back and waist pain.
• Edema in the feet, difficulty walking.
• Increased likelihood of high-risk pregnancy.
• Risk of preterm birth.
• Uterine dysfunction risk.
• Likelihood of dystocia.
• Risk of uterine rupture and amniotic fluid embolism.
• Risk of postpartum hemorrhage.
• Risk of thrombophlebitis.

⚠️ Fetal Risks

• Prematurity and fetal malnutrition.
• Perinatal mortality.
• Intrauterine growth restriction (IUGR).
• Risk of fetal anomaly.
• Presentation, position, and habitus anomalies.
• Risk of cord prolapse.

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7️⃣ Pregnancy and Rh Incompatibility

Rh incompatibility arises when an Rh-negative mother carries an Rh-positive fetus, typically with an Rh-positive father.

💡 Mechanism

1. During events like abortion or birth, fetal Rh-positive blood can enter the mother's circulation.
2. The mother's immune system produces Rh antibodies against the Rh-positive blood cells. These antibodies remain in the mother's circulation.
3. In subsequent pregnancies with an Rh-positive fetus, these maternal Rh antibodies cross the placenta to the fetus, destroying the fetus's Rh cells and erythrocytes.
4. This leads to anemia in the fetus.
5. The fetus compensates by producing more red blood cells, and immature erythrocytes (erythroblasts) enter the fetal circulation.
6. The fetal heart works harder to compensate for the reduced O₂ due to anemia, leading to heart failure.
7. Heart failure + anemia = edema, a severe condition known as Hydrops Fetalis.

🩺 Rh Incompatibility Monitoring

• Indirect Coombs Test: Performed at 24-28 weeks gestation to detect anti-Rh antibodies in the mother's serum.
  • Negative: Repeated every 4 weeks.
  • Positive: Management according to gestational month, potentially requiring Intrauterine (IU) Erythrocyte Transfusion (0 Rh (-) fresh blood).

💊 Prevention & Management

• RhoGAM (Rh Immune Globulin) Administration:
  • At 28 weeks gestation, administer 300 mg RhoGAM (provides 12 weeks of protection).
  • Within 72 hours postpartum, repeat with 300 mg RhoGAM if the baby is Rh-positive.
  • Administer RhoGAM after events such as miscarriage, amniocentesis, antepartum bleeding, abdominal trauma, and fetal demise, as these can expose the mother to fetal blood.