NURS 2410 Unit 1Nancy Pares, RN, MSN

Metro Community College

Apply basic knowledge of healthy maternal newborn care (recall from PN year)

Describe ethical and legal issues of maternal newborn nursing, current legislation and community resources available.

Demonstrate appropriate therapeutic communication and assessment of high risk pregnancy.

Objective 1 and 2 and 3

Context◦ Who is involved, what is the setting◦ What other information is needed◦ What personal beliefs of the nurse may impact

the situation Clarification of the issues

◦ What are the ethical issues◦ Who should decide the issue

Identification of alternatives and potential outcomes

Ethical decision making model

Ethical reasoning◦ What ethical theories have bearing on the

situation◦ Should some theories be given greater weight in

the decision making process◦ What legal or social constraints are factors ◦ What obligations might be present in the role of

the nurse

Decision making cont

Resolution◦ What is the best action in this situation◦ What strategy should be used to carry out this

action Evaluation

◦ What were the outcomes◦ Should this same action be used in the future for

similar dilemmas

Decision making model cont

Professional Nurse Certified Registered Nurse Nurse Practitioner Clinical Nurse Specialist Certified Nurse Midwife

Maternal-Newborn Nursing Roles

Religion and social beliefs Presence and influence of the extended

family Socialization within the ethnic group Communication patterns Beliefs and understanding about health

and illness Permissible physical contact with

strangers education

Factors Contributing to Family Values

Standards of care:◦ Minimum criteria for competent, proficient,

delivery of nursing care Institutional policies Ethical implications Scope of practice

◦ Defined by state Nurse Practice Act laws

Legal Issues

There was a duty to provide care. The duty was breached. Injury occurred. The breach of duty caused the injury

(proximate cause).

Negligence

Divergence between rights of mother and rights of fetus:◦ Mother may refuse fetal intervention.◦ Fetal intervention may be forced on mother.

Fetal research:◦ Therapeutic vs. non-therapeutic

Maternal-Child Issues

Intrauterine fetal surgery:◦ Therapy for anomalies incompatible with life◦ Health of the mother and fetus is at risk◦ Surrogate, frozen embryo, ◦ Female circumcision

Maternal-Child Issues

Abortion◦Can be performed until point of viability

◦After viability, if mother’s health in jeopardy

Nursing role◦Have right to refuse to assist◦Responsible for ensuring a qualified replacement is available

Maternal-Child Issues

Infertility Human stem cells Cord blood Maternal refusal for c/del Maternal refusal for fetal surgery

Maternal-Child Issues

Womens’ health standards by Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

State Boards Individual facilities policy

Standards of Care

A holistic interpersonal approach Adequate documentation Communication Updated and realistic policies and

procedures Appropriate delegation Question deviations from the standar Follow chain of command

Practicing Safety

Transforms research findings into clinical practice:◦ Efficiency improvement◦ Better outcomes◦ Quality improvement

Benefits ofEvidence-Based Practice

Identify vulnerable periods during which malformations of various organs may occur and describe the resulting anomalies.

Describe the function and structure of the placenta during intrauterine life. (review PN year)

Objective 4 and 5

Mitosis:◦ Exact copies of original cell

Meiosis:◦ Production of new organism

Cell Division (review A&P)

Deletion◦ Loss of chromosome material

Translocation◦ Misplacement

Nondisjunction◦ Chromosomes don’t separate correctly

Karotype◦ Chromosomal make up of an individual

Mosaicismtwo or more genetically different cell populations in an individual

Genetic terms

Figure 11–2 Comparison of mitosis and meiosis.

Interphase Prophase Metaphase Anaphase Telophase

Mitosis

First division:◦ Chromosomes replicate, pair, and exchange

information.◦ Chromosome pairs separate, and cell divides.

Second division:◦ Chromatids separate and move to opposite poles.◦ Cells divide, forming four daughter cells.

Meiosis

Ovary gives rise to oogonial cells. Cells develop into oocytes. Meiosis begins and stops before birth. Cell division resumes at puberty. Development of Graafian follicle.

Oogenesis

Production of sperm First meiotic division:

◦ Primary spermatocyte replicates and divides. Second meiotic division:

◦ Secondary spermatocytes replicate and divide. Produce four spermatids.

Spermatogenesis

Figure 11–3 Gametogenesis involves meiosis within the ovary and testis. A, During meiosis, each oogonium produces a single haploid ovum once some cytoplasm moves into the polar bodies. B, Each spermatogonium, in contrast, produces four haploid spermatozoa.

Uniting sperm and ovum form a zygote Ova are fertile for 12 to 24 hours Sperm are fertile for 72 hours Takes place in the ampulla of fallopian tube

Fertilization

Capacitation:◦ Removal of plasma membrane and glycoprotein

coat◦ Loss of seminal plasma proteins

Acrosomal reaction:◦ Release of enzymes ◦ Allows entry through corona radiata

Changes in Sperm

Figure 11–4 Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of human sperm surrounding a human oocyte (750ﾗ). The smaller spherical cells are granulosa cells of the corona radiata. SOURCE: Used with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.

Zone pellucida blocks additional sperm from entering

Secondary oocyte completes second meiotic division◦ Forms nucleus of ovum

Nuclei of ovum and sperm unite Membranes disappear Chromosomes pair up

After Sperm Entry

Fraternal: two ova and two sperm Identical: single fertilized ovum

- Originate at different stages

Twins

Cleavage Blastomeres form morula Blastocyst:

- develops into embryonic disc and amnion

Trophoblast: - develops into chorion

Pre-embryonic

Occurs 7 to 10 days after fertilization Blastocyst burrows into endometrium Endometrium is now called decidua

Implantation

Primary germ layers:◦ Ectoderm◦ Mesoderm◦ Endoderm

Embryonic Development

Metabolic and nutrient exchange Maternal portion:

◦ Decidua Fetal portion:

◦ Chorionic villi Fetal surface covered by amnion

Placenta

Chorionic villi form spaces in decidua basalis

Spaces fill with maternal blood. Chorionic villi differentiate:

◦ Syncytium: outer layer◦ Cytotrophoblast: inner layer

Anchoring villi form septa

Placental Development

Figure 11–13 Longitudinal section of placental villus. Spaces formed in the maternal decidua are filled withmaternal blood; chorionic villi proliferate into these maternal blood-filled spaces and differentiate into a syncytium layer and a cytotrophoblast layer.

Body stalk fuses with embryonic portion of the placenta

Provides circulatory pathway from chorionic villi to embryo:◦ One vein

Delivers oxygenated blood to fetus:◦ Two arteries

Umbilical Cord

Figure 11–14 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.

Nutrition Excretion Fetal respiration Production of fetal nutrients Production of hormones

Placental Functions

Beginning development of GI tract Heart is developing Somites develop—beginning vertebrae Heart is beating and circulating blood Eyes and nose begin to form Arm and leg buds are present

Fetal Development: Week 4

Trachea is developed Liver produces blood cells Trunk is straighter Digits develop Tail begins to recede

Fetal Development: Week 6

Eyelids are closed Tooth buds appear Fetal heart tones can be heard Genitals are well-differentiated Urine is produced Spontaneous movement occurs

Fetal Development: Week 12

Lanugo begins to develop Blood vessels are clearly developed Active movements are present Fetus makes sucking motions Swallows amniotic fluid Produces meconium

Fetal Development: Week 16

Subcutaneous brown fat appears Quickening is felt by mother Nipples appear over mammary glands Fetal heartbeat is heard by fetoscope

Fetal Development: Week 20

Eyes are structurally complete Vernix caseosa covers skin Alveoli are beginning to form

Fetal Development: Week 24

Testes begin to descend Lungs are structurally mature

Fetal Development: Week 28

Rhythmic breathing movements Ability to partially control temperature Bones are fully developed but soft and

flexible

Fetal Development: Week 32

Increase in subcutaneous fat Lanugo begins to disappear

Fetal Development: Week 36

Skin appears polished Lanugo has disappeared except in upper

arms and shoulders Hair is now coarse and approximately 1 inch

in length Fetus is flexed

Fetal Development: Week 38

Quality of sperm or ovum Genetic code Adequacy of intrauterine environment Teratogens

Factors Influencing Development

Maternal effects:◦ Malnutrition ◦ Bone-marrow suppression◦ Increased incidence of infections◦ Liver disease

Neonatal effects:◦ Fetal alcohol spectrum disorders (FASD)

Alcohol Use in Pregnancy

Figure 19–2 Percentages of pregnant females ages 15 to 44 reporting past month alcohol use, by trimester, 2003–2004. SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). (2005).Results from the 2004 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS Publication No. SMA 05-4062. Rockville, MD: Author.

Seizures and hallucinations Pulmonary edema Respiratory failure Cardiac problems Spontaneous first trimester abortion,

abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth

Cocaine Use in Pregnancy: Maternal Effects

Decreased birth weight and head circumference

Feeding difficulties Neonatal effects from breast milk:

◦ Extreme irritability◦ Vomiting and diarrhea◦ Dilated pupils and apnea

Cocaine Use in Pregnancy: Fetal Effects

Maternal effects:◦ Poor nutrition and iron-deficiency anemia◦ Preeclampsia-eclampsia◦ Breech position◦ Abnormal placental implantation◦ Abruptio placentae◦ Preterm labor

Heroin Use in Pregnancy

Maternal effects:◦ Premature rupture of the membranes (PROM)◦ Meconium staining◦ Higher incidence of STIs and HIV

Fetal effects:◦ IUGR ◦ Withdrawal symptoms after birth

Heroin Use in Pregnancy (cont’d)

Marijuana: difficult to evaluate, no known teratogenic effects

PCP - maternal overdose or a psychotic response

MDMA (Ecstasy) - long-term impaired memory and learning

Substance Use in Pregnancy: Maternal Effects

Figure 19–1 Percentages of females ages 15 to 44 reporting past month use of any illicit drugs, by pregnancy status and age, 2003–2004. SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Results from the 2004 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS Publication No. SMA 05-4062. Rockville, MD: Author.

Identify tests used to detect abnormalities, fetal well being and infertility management.

Discuss age related considerations of pregnancy.

Explain the nursing process as it relates to maternal fetal medical conditions.

Objective 7 and 8 and 9

Favorable cervical mucus Clear passage between cervix and tubes Patent tubes with normal motility Ovulation and release of ova

Essential Components of Fertility: Female

No obstruction between ovary and tubes Endometrial preparation Adequate reproductive hormones

Essential Components of Fertility: Female (cont’d)

Normal semen analysis Unobstructed genital tract Normal genital tract secretions Ejaculated spermatozoa deposited at the

cervix

Essential Components of Fertility: Male

Ovulation Cervix Uterine structures Tubal patency Semen analysis

Preliminary Investigation of Infertility

Figure 12–2 Sequence of events in a normal reproductive cycle showing the relationship of hormone levels to events in the ovarian and endometrial cycles.

Ovulatory:◦ Pharmacologic treatment◦ Donor oocytes

Cervical:◦ THI, IVF, GIFT

Treatment of Infertility Problems

Uterine/Tubal:◦ IVF, GIFT◦ Donor oocytes or gestational carrier

Sperm:◦ THI, IVF, GIFT◦ Micromanipulation

Treatment of Infertility Problems (cont’d)

Figure 12–8 Assisted reproductive techniques.

Marriage may be stressed Relationship affected by intrusiveness Guilt Frustration Anger Shame

Physiologic and Psychological Effects

Loss of control Feelings of reduced competency and

defectiveness Loss of status and ambiguity as a couple A sense of social stigma Stress on the personal and sexual

relationship A strained relationship with healthcare

providers

Physiologic and PsychologicalEffects (cont’d)

Counselor Educator Advocate

Nursing Management of Infertility

Maternal age 35 or over Family history:

◦ Known or suspected Mendelian genetic disorder◦ Birth defects and/or mental retardation

Indications for Preconceptual Genetic Testing

Previous pregnancies:◦ Previous child with chromosomal anomaly◦ Previous child with metabolic disorder◦ Two or more first trimester spontaneous abortions

Indications for Preconceptual Genetic Testing (cont’d)

Parental genetics:◦ Couples with a balanced translocation◦ Couples who are carriers for a metabolic disorder

Abnormal MSAFP Women with teratogenic risk

Indications for Preconceptual Genetic Testing (cont’d)

Multigenerational 50% chance of passing on the gene Males and females equally affected Varying degrees of presentation Diseases

◦ Achondroplasia◦ Marfans◦ Neurofibromotosis

Autosomal Dominant Disorders

Achondroplasia◦ Most common dwarfism, lifespan and IQ WNL

Marfans◦ Connective tissue disorder, triad of ocular,

skeletal and CV alterations Neurofibromotosis (Von Recklinhausen)

◦ Soft tumor development of peripheral nerves

Figure 12–19 Autosomal dominant pedigree. One parent is affected. Statistically, 50% of offspring will be affected, regardless of sex.

Carrier parents 25% chance of passing on abnormal gene 25% chance of an affected child If child is clinically normal, 50% chance

child is carrier Males and females equally affected Diseases: CF, Sickle Cell, PKU, Tay Sachs

Autosomal Recessive Disorders

Figure 12–20 Autosomal recessive pedigree. Both parents are carriers. Statistically, 25% of offspring will be affected, regardless of sex.

No male-to-male transmission 50% chance carrier mother will pass the

abnormal gene to sons (affected) 50% chance carrier mother will pass the

abnormal gene to daughters (carrier) Diseases: Hemophilia A, Duchennes MD,

Trisomies, Klinefelters, Turner’s Cri du chat, Fragile X

X-linked Recessive Disorders

Figure 12–21 X-linked recessive pedigree. The mother is the carrier. Statistically, 50% of male offspring will be affected, and 50% of female offspring will be carriers.

Genetic ultrasound Genetic amniocentesis Chorionic villus sampling Percutaneous umbilical blood sampling MSAFP

Genetic Testing

Figure 12–22 A, Genetic amniocentesis for prenatal diagnosis is done at 14 to 16 weeks’ gestation. B, Chorionic villus sampling is done at 8 to 10 weeks, and the cells are karyotyped within 48 to 72 hours.

Educate about tests Provide support Refer for counseling Resource during and after counseling

Nurse’s Role

Identify the maternal fetal effects of TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes) infections and the corresponding nursing interventions.

Objective 10

Toxoplasmosis Rubella Cytomegalovirus Herpes simplex virus Group B streptococcus Human B-19 parvovirus

Perinatal Infections

Retinochoroiditis Convulsions Coma Microcephaly Hydrocephalus

Fetal Risks: Toxoplasmosis

Congenital cataracts Sensorineural deafness Congenital heart defects

Fetal Risks: Rubella

Neurologic complications Anemia Hyperbilirubinemia Thrombocytopenia Hepatosplenomegaly SGA

Fetal Risks: Chlamydia

Preterm labor Intrauterine growth restriction Neonatal infection

Fetal Risks: Herpes

Respiratory distress or pneumonia Apnea Shock Meningitis Long-term neurologic complications

Fetal Risks: GBS

Spontaneous abortion Fetal hydrops Stillbirth

Fetal Risks: Human B-19 Parvovirus

Discuss pathophysiology, treatment and nursing interventions for pregnant women with:◦ Cardiac Disease, Chorioamnionitis, Gestational

trophoblastic disease, diabetes, Rh sensitivity, pregnancy induced hypertension and HELLP syndrome, HIV, hyperemesis gravidarium .

Objective 11

Endocrine disorder of carbohydrate metabolism

Results from inadequate production or utilization of insulin

Cellular and extracellular dehydration Breakdown of fats and proteins for energy

Pathology of Diabetes Mellitus (DM)

Carbohydrate intolerance of variable severity

Causes:◦ An unidentified preexistent disease◦ The effect of pregnancy on a compensated

metabolic abnormality ◦ A consequence of altered metabolism from

changing hormonal levels

Gestational Diabetes (GDM)

Early pregnancy:◦ Increased insulin production and tissue sensitivity

Second half of pregnancy:◦ Increased peripheral resistance to insulin

Effect of Pregnancy on Carbohydrate Metabolism

Hydramnios Preeclampsia-eclampsia Ketoacidosis Dystocia Increased susceptibility to infections

Maternal Risks with DM

Perinatal mortality Congenital anomalies Macrosomia IUGR RDS Polycythemia

Fetal and Neonatal Risks with DM

Hyperbilirubinemia Hypocalcemia

Fetal and Neonatal Risks with DM (cont’d)

Assess risk at first visit:◦ Low risk - screen at 24 to 28 weeks◦ High risk - screen as early as feasible

Screening for DM in Pregnancy

Age over 40 Family history of diabetes in a first-degree

relative Prior macrosomic, malformed, or stillborn

infant Obesity Hypertension Glucosuria

Risk Factors

One-hour glucose tolerance test:◦ Level greater than 130-140 mg/dl requires further

testing 3-hour glucose tolerance test:

◦ GDM diagnosed if 2 levels are exceeded

Screening Tests

Maintain a physiologic equilibrium of insulin availability and glucose utilization

Ensure an optimally healthy mother and newborn

Treatment:◦ Diet therapy and exercise◦ Glucose monitoring◦ Insulin therapy

Treatment Goals

AFP Fetal activity monitoring NST Biophysical profile Ultrasound

Fetal Assessment

Assessment of glucose Nutrition counseling Education about the disease process and

management Education about glucose monitoring and

insulin administration Assessment of the fetus Support

Nursing Management

Maternal complications:◦ Susceptible to infection◦ May tire easily◦ Increased chance of preeclampsia and postpartal

hemorrhage◦ Tolerates poorly even minimal blood loss during

birth

Iron-deficiency Anemia

Fetal complications:◦ Low birth weight◦ Prematurity◦ Stillbirth◦ Neonatal death

Iron-deficiency Anemia (cont’d)

Prevention and treatment:◦ Prevention - at least 27 mg of iron daily◦ Treatment - 60-120 mg of iron daily

Iron Deficiency Anemia (cont’d)

Maternal complications:◦ Nausea, vomiting, and anorexia

Fetal complications:◦ Neural tube defects

Prevention - 4 mg folic acid daily Treatment - 1 mg folic acid daily plus iron

supplements

Folate Deficiency

Maternal complications:◦ Vaso-occlusive crisis◦ Infections◦ Congestive heart failure◦ Renal failure

Sickle Cell Anemia

Fetal complications include fetal death, prematurity, and IUGR.

Treatment:◦ Folic acid◦ Prompt treatment of infections◦ Prompt treatment of vaso-occlusive crisis

Sickle Cell Anemia (cont’d)

Treatment:◦ Folic acid◦ Transfusion◦ Chelation

Thalassemia

Asymptomatic women - pregnancy has no effect

Symptomatic with low CD4 count - pregnancy accelerates the disease

Zidovudine (ZDV) therapy diminishes risk of transmission to fetus

Transmitted through breast milk Half of all neonatal infections occurs during

labor and birth

HIV in Pregnancy

Intrapartal or postpartal hemorrhage Postpartal infection Poor wound healing Infections of the genitourinary tract

HIV in Pregnancy: Maternal Risks

Infants will often have a positive antibody titer

Infected infants are usually asymptomatic but are likely to be:◦ Premature◦ Low birth weight◦ Small for gestational age (SGA)

HIV Effects on Fetus

Counsel about implications of diagnosis on pregnancy:◦ Antiretroviral therapy◦ Fetal testing◦ Cesarean birth

Treatment DuringPregnancy

Congenital heart disease Marfan syndrome Peripartum cardiomyopathy Eisenmenger syndrome Mitral valve prolapse

Cardiac Disorders in Pregnancy

Rheumatoid arthritis Epilepsy Hepatitis B Hyperthyroidism Hypothyroidism Maternal phenylketonuria

Less Common Medical Conditions in Pregnancy

Multiple sclerosis Systemic lupus erythematosus Tuberculosis

Less Common Medical Conditions in Pregnancy (cont’d)

Tubal damage Previous pelvic or tubal surgery Endometriosis Previous ectopic pregnancy Presence of an IUD High levels of progesterone

Ectopic Pregnancy: Risk Factors

Congenital anomalies of the tube Use of ovulation-inducing drugs Primary infertility Smoking Advanced maternal age

Ectopic Pregnancy: Risk Factors (cont’d)

Methotrexate Surgery

Ectopic Pregnancy: Treatment

Figure 20–2 Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy.”

Assess the appearance and amount of vaginal bleeding

Monitors vital signs Assess the woman’s emotional status and

coping abilities Evaluate the couple’s informational needs. Provide post-operative care

Ectopic Pregnancy: Nursing Care

Vaginal bleeding Anemia Passing of hydropic vesicles Uterine enlargement greater than expected

for gestational age Absence of fetal heart sounds Elevated hCG

Gestational Trophoblastic Disease: Symptoms

Low levels of MSAFP Hyperemesis gravidarum Preeclampsia

Gestational Trophoblastic Disease: Symptoms

D&C Possible hysterectomy Careful follow-up

Gestational Trophoblastic Disease: Treatment

Figure 20–3 Hydatidiform mole. A common sign is vaginal bleeding, often brownish (the characteristic “prune juice” appearance) but sometimes bright red. In this figure, some of the hydropic vessels are being passed. This occurrence is diagnostic for hydatidiform mole.

Monitor vital signs Monitor vaginal bleeding Assess abdominal pain Assess the woman’s emotional state and

coping ability

Gestational Trophoblastic Disease: Nursing Care

Control vomiting Correct dehydration Restore electrolyte balance Maintain adequate nutrition

Hyperemesis Gravidarum: Treatment

Assess the amount and character of further emesis

Assess intake and output and weight. Assess fetal heart rate Assess maternal vital signs Observe for evidence of jaundice or

bleeding Assess the woman’s emotional state

Hyperemesis Gravidarum: Nursing Care

Preeclampsia-eclampsia Chronic hypertension Chronic hypertension with superimposed

preeclampsia Gestational hypertension

Classification of Hypertension in Pregnancy

Maternal vasospasm Decreased perfusion to virtually all organs Decrease in plasma volume Activation of the coagulation cascade Alterations in glomerular capillary

endothelium Edema

Characteristics of Preeclampsia

Increased viscosity of the blood Hyperreflexia Headache Subcapsular hematoma of the liver

Characteristics of Preeclampsia (cont’d)

Figure 20–7 A, In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta. B, In preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.

Figure 20–7 (continued) A, In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta. B, In preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.

Small for gestational age Fetal hypoxia Death related to abruption Prematurity

Hypertensive Effects on Fetus

Monitoring for signs and symptoms of worsening condition

Fetal movement counts Frequent rest in the left lateral position Monitoring of blood pressure, weight, and

urine protein daily NST Laboratory testing

Home Management

Bed rest High-protein, moderate-sodium diet Treatment with magnesium sulfate Corticosteroids Fluid and electrolyte replacement Antihypertensive therapy

Management of Severe Preeclampsia

Scotomata Blurred vision Epigastric pain Vomiting Persistent or severe headache Neurologic hyperactivity

Signs and Symptoms of Eclampsia

Pulmonary edema Cyanosis

Signs and Symptoms of Eclampsia (cont’d)

Assess characteristics of seizure Assess status of the fetus Assess for signs of placental abruption Maintain airway and oxygenation Position on side to avoid aspiration Suction to keep the airway clear

Management of Eclampsia

To prevent injury, raise padded side rails Administer magnesium sulfate

Management of Eclampsia (cont’d)

Hemolysis, elevated liver enzymes, low platelets◦ Hypertension and proteinuria may or may not be

present◦ 90% present with symptoms before 36 wks gest.◦ All with HELLP should deliver

HELLP Syndrome

Rh – mother, Rh + fetus Maternal IgG antibodies produced Hemolysis of fetal red blood cells Rapid production of erythroblasts Hyperbilirubinemia

Rh Incompatibility

Figure 20–10 Rh alloimmunization sequence. A, Rh-positive father and Rh-negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive blood enters the mother’s blood. C, As the placenta separates, the mother is further exposed to the Rh-positive blood. D, The mother is sensitized to the Rh-positive blood; anti-Rh-positive antibodies (triangles) are formed. E, In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of red blood cells in the fetus.

After birth of an Rh+ infant After spontaneous or induced abortion After ectopic pregnancy After invasive procedures during pregnancy After maternal trauma

Administration of Rh Immune Globulin

Mom is type O Infant is type A or B Maternal serum antibodies are present in

serum Hemolysis of fetal red blood cells

ABO Incompatibility

Incidence of spontaneous abortion is increased in first trimester

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

Surgery During Pregnancy

Greater volume of blood loss before signs of shock

More susceptible to hypoxemia with apnea Increased risk of thrombosis DIC Traumatic separation of placenta Premature labor

Trauma During Pregnancy

Psychological distress Loss of pregnancy Preterm labor Low-birth-weight infants Fetal death Increased risk of STIs

Battering During Pregnancy