CMCA Lec Pt. 1

Congenital

defects at birth

What should we do to pregnant mothers in order to prevent possible complications or congenital anomalies?

we must encourage mothers for prenatal check-up or care in order to prevent possibility of complications or congenital anomalies and also in order for them to monitor health for early diagnosis

What do we mean by high risk pregnancy?

it is where the health of the mother or even offspring is jeopardized by a disorder in relation to unique pregnancy

Who are those mothers that are possible for high risk pregnancy in terms of age?

Ages under 17 years old and over 35 years old

what are nonmodifiable risk factors? (AGES)

age

genetics

epigenetics

social determinants of health

Why is aged under 17 possible for high risk pregnancy?

• physically immature (reproductive system)

• in the process of development in terms of emotional, psychological and financial aspects

• impulsive decision making that could harm the baby and even pregnancy

• unhealthy coping mechanism to stress (gives in to abortion / suicide

Why is aged over 35 possible for high risk pregnancy?

• closer to early menopause

• risk for complications like miscarriage, congenital disorders and high blood pressure or diabetes

• fertility starts to decline more rapidly and your chances for complications increase more significantly

• older you get, the fewer eggs you have; eggs you have are more likely to have chromosomal issues that lead to genetic disorders

• *humihina kapit sa matres

• problem in oxgenation; placenta cannot supply baby’s nutrients

How is height a factor for high risk pregnancy? (>140 cm)

• pelvis is proportionate to height

• if less than 140 cm; cephalopelvic disproportion - needs to have cesarean section

Cephalopelvic disproportion

occurs when there’s a mismatch between the size of the fetal head and size of maternal pelvis - “failure progress” in labor

How is weight a factor for high risk pregnancy? (>100 lbs; obese)

• if less than 100 lbs - nutrients for baby is not enough

  • may lead to premature labor

• if obese - prone to / already has heart problem, hypertension or diabetes

  • sometimes may have infertility; too much fats can kill sperm cell (they’re sensitive to heat), can’t penetrate mature ovum

why should we avoid smoking when pregnant?

nicotine hardens blood vessels or accumulation that reduces blood circulation

why should we avoid drinking alcohol when pregnant?

• alcohol deprive satiety center

• baby's brain is developing throughout pregnancy and can be affected by exposure to alcohol at any time

• baby does not have a fully developed liver and cannot process alcohol

Factors Contributing to Increase Rate of Teenage Pregnancy (EILPDR)

• Early menarche (first menstruation)

• Increase in rate of sexual activity among teenagers

• Lack of knowledge about contraceptives

• Proper use of condoms, pills

• Desire to have a child

• Rape

Factors that Influence the Outcome of the Pregnancy (PAIASFSA)

• Physical Development

• Attitudes toward Health

• Interest

• Ability to Seek Prenatal Care (can be hindered by embarrassment)

• Support System

• Financial resources

• Self-Esteem

• Ability to Formulate Personal Goals

GPTPALM

• Gravida- number of pregnancies regardless of outcome

• Para – number of live births

• Term - pregnancies reaching 37 weeks

• Preterm – pregnancies 20-36 weeks

• Abortion – pregnancies that did not reach age of viability (20 weeks)

• Living – number of living children

• Multiple – if there were twins, triplets, etc.

Positive Hegar sign

a non-specific indication of pregnancy characterized by the compressibility and softening of the cervical isthmus (4th or 6th to 12th week)

Chadwick sign

a potential early sign of pregnancy where your vulva, vagina and cervix turn a bluish color. Sometimes, your genitals look purplish or purplish-red.

hydatidiform mole or molar pregnancy

very uncommon affecting around 1 in 1,200 pregnancies

Maternal Serum Alpha-fetoprotein

• Substance produced by the fetal liver

• Present in the amniotic fluid and maternal serum

• protein normally produced by the fetal liver and is present in the fluid surrounding the fetus (amniotic fluid), and crosses the placenta into the mother's blood

AFP test

mainly used to measure the level of alpha-fetoprotein (AFP) in the blood of a pregnant person

Why do we need to have AFP test?

The test checks the baby's risk for having certain genetic problems and birth defects.

When is AFP test usually done?

between 15 and 20 weeks of pregnancy

What happens when a baby has open spinal or abdominal defect?

Spina bifida can happen anywhere along the spine if the neural tube does not close all the way. When the neural tube doesn't close all the way, the backbone that protects the spinal cord doesn't form and close as it should. This often results in damage to the spinal cord and nerves.

Myelomeningocele

open spina bifida

incomplete neural tube closure and a fluid-filled sac that protrudes (sticks out) from your baby's back

What should we do if baby has open spina bifida?

• requires surgery to close the opening in the baby's back within 72 hours of birth

  • Early surgery can help lower the risk of infection associated with the exposed nerves.

• It also may help protect the spinal cord from more trauma

High maternal serum alpha-fetoprotein

increased risk of having a neural tube defect; spina bifida

Low maternal serum alpha-fetoprotein

may indicate that the fetus has a genetic disorder such as Down syndrome

Amniocentesis

• “sac puncture”

• a procedure used to take out a small sample of the amniotic fluid for testing

Purpose of amniocentesis?

to examine a small amount of this fluid to obtain information about the baby, including its sex, and to detect physical abnormalities such as Down syndrome or spina bifida

Amniocentesis is done as early as?

12th to 13th week of pregnancy

Ultrasound

• respond of sound waves against objects

• since there is amniotic fluid, sound is used

Purpose of Ultrasound?

• diagnose pregnancy as early as 6 weeks gestation

• confirm the presence, size, location of the placenta and amniotic fluid

• To determine maturity of placenta, or size of fetus to know gestation (age, sex)

• establish that the fetus is increasing in size and has no gross defect

Transvaginal Ultrasound

• most advisable

• a scanner put in vagina to see reproductive system

• aka Trans V or TVS

• establish the presentation and position of the fetus (sex can be diagnosed if a penis is revealed)

• predict maturity by measurement of the biparietal diameter

• discover complication of pregnancy

• B-mode scanning refer to as sonogram

• allows pattern to merge

• form a picture similar to a black and white television picture called gray scale imaging

Real-time Ultrasound

allow the screen picture to be two dimensional or actually to move

Rhythm Strip Testing

• assessment of the fetal heart rate in term of baseline of long- and short-term variability

• average rate of the fetal heart beat per minute

position when executing rhythm strip testing

woman is placed in a Semi fowlers position (either in a comfortable lounge chair or an examining table or bed with an elevated back rest)

Short term variability (beat-to-beat variability)

denotes the small changes in rate that occur second to second if the parasympathetic nervous system is receiving adequate oxygen and nutrients

Long term variability

• denotes the differences in heart rate that occur over the 20 minute time period

• requires the mother to remain in a fairly fix position for 20 minutes

Nonstress Testing

• most common; much safer

• measures the response of a fetal heart rate to fetal movements

Contraction Stress Testing

• fetal heart rate is analyzed in conjunction with contraction

• contraction was first initiated by the intravenous infusion of oxytocin

best way to administer oxytocin?

“piggyback”

May iv na oxytocin, tas may isa pa na nakaconnect na sabay inject

Contraction Stress Testing negative (normal)

when no fetal heart rate decelerations are present with contraction

Contraction Stress Testing positive (abnormal)

when 50 % or more contraction cause a late deceleration

Associated Medical Conditions

pre-existing medical conditions or coincidental medical condition

Pre-existing

the mother became pregnant despite having a medical condition like cardiac; arrythmia, congenital heart disease, rheumatic heart disease that may affect her pregnancy

Coincidental medical conditions

these are mothers who are apparently well before pregnancy

Class I

• No limitations of physical activity

• No discomfort

• No signs and symptoms of cardiac insufficiency or anginal pain

Class II

• Slight limitations of physical activity

• Ordinary activity causes excessive fatigue palpitations, dyspnea or anginal pain

Class III

• Moderate to marked limitation of activity

• Less than ordinary activity, they experienced excessive fatigue, palpitation, dyspnea or anginal pain

Class IV

• Cannot engage in any physical activity without discomfort

• Symptoms of cardiac insufficiency or anginal pain occur even at rest

Class I & II (indications)

can have normal pregnancy and delivery

Class III (indications)

can complete a pregnancy if they abide complete bed rest (CBR)

Class IV (indications)

poor candidate; not advisable to become pregnant

CBR with bathroom privileges *CBRBP

CBR but mother can use the bathroom to urinate, defecate or even take a bath

CBR w/o bathroom privileges

activities like urination, defecation and even taking a bath will be done while in bed

S/S of heart diseases

• Heart murmurs, palpitations, tachycardia

• Pulmonary edema & hypertension

  • Moist cough

• Edema or ascites

Edema

• swelling caused by too much fluid trapped in the body's tissues

• most likely to show up in the legs and feet

Edema on pregnant mothers

has edema in the afternoon or late in the afternoon

Edema for people with cardiac conditions or renal conditions

edema is present anytime of the day

Ascities

accumulation of fluid in the abdomen or abdominal cavity (more on the GI tract)

Management for pregnant mothers that have S/S of heart disease

• complete bedrest (after 30th week of gestation)

• 10 hours of sleep at night and rest for half hour after each meal

• adequate diet

• sodium restricted diet

• administer digitalis

• iron preparation (feosol)

Why do mothers need CBR after 30th week of gestation?

During pregnancy, blood volume increases by 30% to 50% to nourish the growing baby. The heart also pumps more blood each minute, and the heart rate increases.

Adequate diet

“should gain enough but not too much”

can provide the nutritional needs of the mother or the growing fetus but make sure that the mother should not gain much weight during the course of pregnancy - could lead to obesity that can affect cardiac functioning

Sodium restricted diet

could lead to high blood pressure if too much salt is given on their diet

Example of Digitalis

Digoxin

Digitalis

• increases blood flow and reduces swelling on the hands and arms

• increases myocardial contractions, in order to control the rate and rhythm of heart beat (it reduces the heart rate)

Action mechanism of Digitalis

improves strength and efficiency of the heart

Nursing administration for Digitalis (pregnant)

check the heart rate

*pregnant: administer if more than 100 heart rate

do not administer if below 60

During delivery (when mother can deliver vaginally)

• epidural anesthesia

• class III and IV - semi-setting position

• Episiotomy

• Monitor fetal heart rate, uterine contraction, monitor vital signs especially pulse rate and respiratory rate

Class II and IV - semi-setting position

instead of lithotomy position to prevent experiencing cardiac insufficiency

Why is episiotomy common for primi mothers with cardiac condition?

to hasten the delivery of the baby; no need to push effortlessly because it’s very difficult for the mother to bare down

Management for Post Partum Mothers

• encourage early ambulation

• wearing of antiembolic stockings

• administering prophylactic antibiotics

• administration of methylergonovine maleate (methergine) with CAUTION

Encourage early ambulation

stimulates circulation which can help stop the development of stroke-causing blood clots; getting a patient up and out of bed as soon as it is medically safe to do (prevent DVT)

Prophylactic antibiotics

to prevent the possibility of endocarditis *infection

Example of prophylactic antibiotics

ampicillin

vancomycin

endocarditis

a life-threatening inflammation of the inner lining of the heart's chambers and valves; bacteria, fungi or other germs get into the bloodstream and attach to damaged areas in the heart

Prophylactic antibiotics in the form of penicillin

safe for postpartum mothers who do breastfeeding

Administration of methylergonovine maleate (methergine) with CAUTION

• administered after the delivery of placenta

• before administering, check the blood pressure of the mother

Why do we need to check the blood pressure of the mother before administering methergine?

it tends to increases the BP; even if not pregnant. If elevated BP need to withhold administering oxytocin

Diabetes Mellitus

Chronic hereditary disease which is characterized by hyperglycemia due to a relative insufficiency or lack of insulin from the pancreas which in turn leads to abnormalities in the metabolism of COH, CHON, and fats

*There might be a lack of insulin or insufficient amount to transport the glucose into the cell kaya nag accumulate sa blood yung glucose

What specific area of pancreas is responsible in secretion of insulin and glucagon?

islets of langerhans

Type I and Type II of DM

pre-existing conditions

Type I (IDDM)

• Insulin Dependent Diabetes Mellitus

• Juvenile onset - starts during childhood)

  • Insulin is needed

  • Prone to ketosis or ketoacidosis (DKA)

Type II (NIDDM)

• Non-Insulin Dependent Diabetes Mellitus

• Maturity onset - due to age or generative process; weakening function of pancreas to secrete insulin

• insulin is not necessarily needed; they use oral hypoglycemic agent (dahil hindi need insulin, they can manage with the use of diet)

  • Diet / oral hypoglycemic

  • Less prone to acidosis, ketosis

Oral hypoglycemic agent

help stimulate the pancreas to secrete insulin

Gestational DM

• Diabetes during pregnancy

• Signs and symptoms will fade after pregnancy

Impaired Glucose Homeostasis

State bet Normal and Diabetes which the body is no longer using and/or secreting insulin properly

Diabetogenic Effects of Pregnancy

• Decrease renal threshold for sugar slight glycosuria

• Insulin resistance

  • HPL (human placental lactogen)

  • HCS (human chorionic somatomammotropin)

Why diabetes gets worse during pregnancy?

• The body makes more hormones and goes through other changes, such as weight gain. These changes cause your body's cells to use insulin less effectively, a condition called insulin resistance.

• The effect of pregnancy to renal function - glomerulus becomes permeable to blood glucose leading to decreased renal threshold

• Effect of the HPL and HCS that is present during pregnancy; HPL is insulin resistant - no matter how much insulin is secreted by the pancreas it will have a contradicting effect due to HPL

  • insulin can't perform properly, they can't transport insulin to the cell so it accumulates that leads to hyperglycemia thereby resulting in diabetes mellitus

• Increase production of adrenocorticoids, A.P hormones and thyroxine

  • This increases the secretion of glucose and the amount of glucose in the blood resulting to hyperglycemia that results DM

Classification of DM by White: Class A

• Gestational DM

• Pregestational diabetes (diabetes that existed prior to pregnancy)

• Pregnant women whose glucose tolerance test is only slightly abnormal

• Dietary regulation is minimal

• No insulin required

Classification of DM by White: Class A1

• Abnormal OGTT

• Normal Glucose Levels

• Diet modification

Classification of DM by White: Class A2

• Abnormal OGTT

• Abnormal Glucose levels

• Insulin is required or other medications

Classification of DM by White: Class B

• Disease began at age 20 years or older

• With a duration of less than 10 years

• No vascular involvement

Microangiopathy

effect of insulin to small blood vessels like retina in the eyes

Macroangiopathy

effect of insulin to large blood vessels; disrupted due to the effect of DM to large blood vessels

Classification of DM by White: Class C

• Onset is between 10-19 years old

• Duration of 10 – 19 years

• With minimal vascular involvement

Classification of DM by White: Class D

• Onset before the age of 10 y/o

• With a duration of 20 years or more

• With greater vascular involvement

Class D

• D1 – under age 10 years at onset *before 10

• D2 – more than 20 years duration

• D3 – with beginning retinopathy

• D4 – with calcified vessels of legs

• D5 – HPN is present

Classification of DM by White: Class E

With calcification of the pelvic arteries

Classification of DM by White: Class F

Diabetes has caused nephropathy *affects now your kidney; it leads to hemodialysis