NCM107 Lecture

Teratogenic Maternal Infection

Teratogen
- is any factor, chemical or physical that
adversely affects the fertilized ovum, Prenatal Diagnosis
embryo or fetus
 Placental thickening with a "frosted glass"
appearance.
Factors Affecting the Amount Can Cause
 Cerebral ventricular dilatation, usually
 Strength
symmetrical and bilateral and leads, to
 Timing - before implantation - zygote is hydrocephalus
destroyed/appear unaffected
 Hyper-echogenic fetal bowel.
- 2nd to 8th weeks - very vulnerable to injury
 Hepato-splenomegaly and hepatic densities,
- Last trimester - potential harm decreases pleural, pericardial effusions and ascites
 Teratogens affinity for specific tissue  If diagnosis is established serum analysis during
- Lead - attacks and disables nervous tissue pregnancy sulfonamides is precribed
- Tetracycline - enamel deficiencies, long bone pyrimethamine- antiprotozoal agent
deformities
Management
 Remove cat from the home during pregnancy is
not necessary as long as its healthy
 Taking new cat is unwise
 Avoid undercooked meat
 Avoid changing cat litter box or work in soil
area whre cats may defecate.

Rubella (German Measles)

- Causes mild rash and mild systemic illness but
can bring devastating effects to the fetus which
includes:
 Deafness
 Mental and motor challenges
 Cataracts
TORCH  Cardiac defects (PDA, pulmonary stenosis)
- Group of teratogenic maternal infection which
 Retarded IUG
can involve either sexually transmitted or
systemic infection is described collectively as:  Thrompocytopenic purpura
 Dental and facial clefts
o T-oxoplasmosis
o O-ther disease (Syphilis)
o R- rubella
o C-ytomegalovirus
o H-erpes Simplex

All these infection are known to cross the placenta

and affect the fetus.

TORCH SCREEN
- Immunologic survey that determine whether these
infections exist in either the pregnant women or
the newborn.

Toxoplasmosis
 Protozoan infection Mode of Transmission
 Spread commonly through handling cat stool in  Rubella virus is transmitted, through person-to-
soil or cat litter person contact or droplets shed from the
 Almost no symptoms except for body malaise respiratory secretions of infected people.
and posterior lymphadenopathy  Infection can be communicated 7days before
 May cause CNS damage, hydrocephalus, and 4 days after appearance of rash.
microcephaly, intracerebral calcification, retinal  Rash appears 2-3 weeks following exposure &
deformities. persist for three days.

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 If a woman is infected with rubella virus during Herpes Simplex Virus
pregnancy, the virus can cross the placenta and  Virus spread into the bloodstream (viremia) and
infect the fetus crosses the to the fetus
 Infection takes place in the 1st tri- spontaneous
DIAGNOSIS: Rubella Titer (1st Prenatal Visit) miscarriage, severe congenital anomalities • 2nd
 Greater than 1:8- immunity to rubella or 3rd tri- premature birth, IUGR
 Less than 1:8- susceptible to viral invasion  For women with history of genital herpes and
 Initially extremely high- recent infection has existing genital lesions, CS birth is often advised
occurred to reduce the risk of neonatal infection
 Intravenous or oral acyclovir (Zovirax) can be
Management administered t women during pregnancy.
 Woman who is not immunized before pregnancy
cannot be immunized during pregnancy
 After immunization women is advised not to get
Syphilis
pregnant for at least 3 months  Causative agent- Treponema pallidum
 All women with low rubella titer's should be  Can extremely damage the fetus after 16th to
immunized to protect against rubella in future 18th wk of intrauterine life
pregnancies.  Transmitted via sexual contact

Diagnosis
Cytomegalovirus
 Serologic screening (VDL or plasma reagin) on
 Member of herpes virus
the 1st prenatal visit
 Transmitted through droplet inection from
person-to person Clinical Manifestations
 Infant may be born:  Fetal:
o Neurologically challenge (hydrocephalus, o Stillbirth
microcephaly) o Neonatal death
o Eye damage ( optic atrophy, chorioretinitis) o Hydrops fetalis
o Deafness
 Intrauterine death in 25%
o Chrionic liver disease
o Blueberry muffin lesions  Perinatal mortality in 25-30% if untreated
 Early congenital (typically 1st 5 weeks):
o Cutaneous lesions (palms/soles)
o HSM
o Jaundice
o Anemia
o Snuffles
o Periostitis and metaphysial dystrophy
o Funisitis (umbilical cord vasculitis)
 Late congenital:
o Frontal bossing
o Short maxilla
o High palatal arch
o Hutchinson teeth
o 8th nerve deafness
Diagnosis o Saddle nose
 Isolation of CMV antibodies in serum o Perioral fissures
 Can be prevented with appropriate treatment
CMV - Prenatal USG
 Oligo-hydramnios Treatment
 Poly-hydroamnios  Penicillin G is THE drug of choice for ALL syphilis
 IUGR infections
 Fetal ascites, Hyperechogenic bowel  Maternal treatment during pregnancy very
effective (overall 98% success)
 Microcephaly, ventriculomegaly
 Treat newborn if:
 Intracranial calcification
 Mother was treated <4wks before delivery
 Hepatomegaly
 Maternal titers do not show adequate response
Prevention (less than 4-fold decline)
 Thorough hand washing before eating
 Avoid crowds of young children RH sensitization
 There are blood types A,B,AB,O. Each of these
NO TREATMENT FOR THE INFECTION EXIST. blood types has specific proteins on the surfaces
of their RBCs. Each of the four blood types is
additionally classified according to the presence
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 of another protein on the surface of the RBCs (D Management
factor) that indicates the Rh factor.
 If you carry this protein, you are Rh positive. If  RhIG (commercial preparation of passive
you don't carry the protein, you are Rh negative. antibodies against Rh factor) is administered to
women at 28 wks of pregnancy.
 Rh incompatibility occurs ONLY when an Rh-  •After birth, infants blood type will be
negative mother is carrying a fetus with an Rh- determined by Coomb's test.
positive blood type. If this occur, the father of  -If it is Rh-positive/Coomb's negative, indicating
the child muat either be homozygous (DD) or that a large number of antibodies are not
heterozygous (Dd) Rh positive. present in the mother, the mother will recieve
 Father is homozygous - 100% the baby will be RgIG injection. -If it is Rh-negative baby, no
Rh positive (Dd) antibodies have been formed during pregnacy,
 Father is heterozygous - 50% the baby will be antibody injection is unnecessary.
Rh positive (Dd)
 When Rh-positive fetus grow inside an Rh- Anemia
negative mother, it is as though her body is • Anemia is the common medical disorder during
being invaded bya foreign agent. pregnancy
 As a result: • Greek meaning "without blood"
 She forms antibodies against invading substance • Iron deficiency anaemia is the most common type
 Entire RBC is destroyed (Rh factor exist in the of anemia during pregnancy
RBC). It crosses the placenta and causes • 25% direct maternal deaths
hemolysis.
 Fetus become deficient of oxygen (hemolytic IRON DEFICIENCY ANEMIA
disease of the newborn or erythroblastosis  occurs as many as 15-20% of all pregnacies
fetalis).  When the hemoglobin level is below 10mg/dl,
IDA is suspected
Risk Factors  Causes:
 Abdominal trauma, such as from a car accident. o Diet low in iron
 Abdominal surgery, such as a cesarean section. o Heavy menstrual period
 Placenta abruptio or placenta previa, both of o Unwise weight reducing programs
which can cause placental bleeding.
Characteristic
 External cephalic version for a breech fetus.
 Microcytic and hypochromic RBC
 Obstetric procedures such as amniocentesis, fetal
blood sampling, or chorionic villus sampling  Reduced hemoglobin and hematocrit level (under
(CVS). 33% and 10mg/dl)
 Miscarriage (spontaneous abortion), ectopic  Serum tranferrin- under 100mg/dl
pregnancy, or elective abortion (medical or
surgical abortion) after 8 weeks of fetal age
(when fetal blood cell production begins). Effects on the baby
 Partial molar pregnancy involving fetal growth  Low birth rate
beyond 8 weeks.  Preterm birth

Diagnosis Effects on the mother

 All women with Rh-negative blood should have  Extreme fatigue
an anti-D antibody titer done at 1st pregnancy  Poor exercise tolerance
visit.
o Result is normal/ titer is minimal (normal is 0,1:8 Management
is minimal) test will be repeated at 28 wks of  Iron supplement of 60mg as prophylactic
pregnancy. No therepy is needed. therapy against iron-deficiency anemia
o Result is elevated (1:16 or greater) titer should  Advise the women to take supplements with
be monitored approximately every 2wks during orange juice or Vit. C supplement
the remainder of pregancy. Amniocentesis is  Eat a diet high in iron and vitamins (green leafy
done every 2 weeks veg, meat, legumes, fruits)
 Increase roughage in the diet and take pills with
 Spectrophotometer readings are made (reveal food to avoid constipation and gastric irritation
fluid density)
o Low fluid density (zone1)- no distress, Rh Iron Requirement in Pregnancy
negative fetus  2.5mg/day in early pregnancy
o Moderate (zone 2)- preterm birth by  5.5mg/day from 20 -32 weeks
induction of labor at fetal maturity is  6-8 mg/day after 32 weeks
indicated
 Average 4 mg/day
o High (zone 3)- immediate birth will be
carried out or IU transfusion begun
Made by MIjelyn V. Bantigue
 FOLIC ACID DEFICIENCY ANEMIA/ 250mg four times daily and the second used 1
MEGALOBLASTIC ANEMIA tablespoon of ginger syrup in 4-8 fluid ounces of
 Folactin, one of the B vitamins, necessary for water four times daily.
formation of red blood cells in the mother has  Drink and eat little and often.
been associated in preventing neural tube  Cold meals reduce smell-related nausea.
defects in the fetus  Avoid caffeine and alcohol as these can enhance
 Seen in 1-5% of pregnancies dehydration
 May cause early miscarriage/ premature
separation of the placenta Effect on The Fetus
 Prolonged stress, dehydration and malnutrition
Management during pregnancy can put the fetus at risk for
 Women expecting to become pregnant should chronic disease, such as diabetes or heart
be advised to take a vitamin suplement disease, later in life, or neurobehavioral issues
 Eat folacin rich foods (glv, oranges, dried beans) from birth.
 All women of child bearing age should take  Infants born from hyperemetic mother have
supplement of 400ug folic acid daily higher incidence of low in birth weight

Ectopic Pregnancy
Hyperemesis Gravidarum  Pregnancy that develops outside a woman's
 pernicious vomiting uterus (womb).
 may result in weight loss; nutritional deficiencies;  This happens when the fertilized egg from the
and abnormalities in fluids, electrolyte levels, ovary does not implant itself normally in the
and acid-base balance. uterus. Instead, the egg develops somewhere
else in the abdomen. The products of this
Factors Causing Hyperemesis Gravidarum conception are abnormal and cannot develop
 High levels of hCG (human chorionic into fetuses.
gonadotropin).  Ectopic pregnancy is usually found in the first 5-
 Increased estrogen levels. 10 weeks of pregnancy.
 Gastrointestinal changes.
PLACE
 Stress and
 The most common place that ectopic pregnancy
 High-fat diet.
occurs is in one of the fallopian tubes.
Distinguishing between Morning Sickness and  Ectopic pregnancies also can be found on the
Hyperemesis Gravidarum outside of the uterus, on the ovaries, or attached
to the bowel.

Common conditions that increase the risk of ectopic

pregnancy include the following:
 Previous tube infections (salpingitis), such as
pelvic inflammatory disease (PID), chlamydia
and gonorrhea.
 Previous surgery inside the abdomen, especially
involving the fallopian tubes, ovaries, uterus,
lower abdomen, or bowels
 Use of fertility medications at the time of
conception
Management
 The use of an intrauterine device (IUD) does not
 A few soda crackers or dry toast when you first
increase the risk of ectopic pregnancy. However,
wake up, even before you get out of bed in the
a normal pregnancy is unlikely with an IUD in
morning.
place, so if a woman becomes pregnant while
 A small snack at bedtime and when getting up to using an IUD, it is more likely the pregnancy is
go to the bathroom at night. not inside the uterus.
 Avoiding large meals; instead, snack as often as  Prior history of tubal pregnancy
every 1-2 hours during the day and drink plenty
of fluids. Symptoms
 Eating foods high in protein and complex  Symptoms of an ectopic pregnancy are often
carbohydrates, such as peanut butter on apple confused with those of a miscarriage or pelvic
slices or celery; nuts; cheese; crackers; milk; inflammatory disease.
cottage cheese; and yogurt; avoid foods high in
 The most common symptoms are sharp
fat and salt, but low in nutrition
abdominal and pelvic pain and vaginal
 Ginger products (proven effective against bleeding.
morning sickness) such as ginger tea, ginger
 A ruptured ectopic pregnancy is a true medical
candy, and ginger soda. The first used ginger
emergency.
Made by MIjelyn V. Bantigue
 Common symptoms of a ruptured ectopic condition embryo fails to develop beyond a
pregnancy include the following: primitive start.
 dizziness, pale complexion, sweaty, fast  Mostly likely to occur on women of extreme age
heartbeat (over 100 beats per minute)
Abdominal or pelvic pain so severe that you Types of Mole
can't even stand up  Complete mole
 Partial mole
Diagnosis
 An ectopic pregnancy should be considered in
any woman with abdominal pain or vaginal
bleeding who has a positive pregnancy test.
 An ultrasound showing a gestational sac with
fetal heart in the fallopian tube is clear evidence
of ectopic pregnancy.
 An abnormal rise in blood hCG levels may also
indicate an ectopic pregnancy
 A laparoscopy or laparotomy can also be
performed to visually confirm an ectopic
pregnancy. A laparoscopy in very early ectopic
pregnancy rarely shows a normal looking
fallopian tube.
 A less commonly performed test, a culdocentesis,
may be used to look for internal bleeding. In this
test, a needle is inserted into the space at the
very top of the vagina, behind the uterus and in
front of the rectum. Any blood or fluid found
there likely comes from a ruptured ectopic
pregnancy.
 Cullen's sign can indicate a ruptured ectopic
pregnancy. (Cullen's sign is blue-black bruising
of the area around the umbilicus.)

Management
 The primary treatment for hydatidiform mole is
suction D&C.
 After the surgical evacuation of a hydatidiform
mole, all patients should be monitored as follows
o hCG level should be measured 48 hours
after evacuation.
Surgery o hCG level should be determined weekly until
results are normal for 3 consecutive weeks,
 Surgery is the final possibility in treatment of an then monthly until results are normal for 6 to
ectopic pregnancy. 12 consecutive months
 The therapy for ruptured ectopic pregnancy is  Pelvic examinations should be performed to
laparoscopy to ligate the bleeding vessels and monitor the involution of pelvic structures (e.g.,
to remove or repair the damaged tube. ovaries, uterus) and to aid in early detection of
metastasis.
Chances of Future Pregnancy
 Repeat chest radiograph if the hCG titer
 The chance of future pregnancy depends on the plateaus or rises
status of the adnexa left behind. The chance of
recurrent ectopic pregnancy is about 10% and
depends on whether the affected tube was
repaired (salpingostomy) or removed
(salpingectomy).

Hydatidiform Mole
 Gestational trophoblastic disease is the
proliferation and degeneration of the
trophoblastic villi.
 As cells degenerate they become filled with fluid
appear to be as grape size vesicles. With this

Made by MIjelyn V. Bantigue

 NCM107 Lecture The areas to be assessed in acceptance of
Psychological Changes in pregnancy:
Pregnancy  Extent to which the pregnancy was planned and
wanted by the woman and her partner.
 Amount of time the woman in happy versus
Psycho-Socio Cultural Aspects in Pregnancy
depressed using the pregnancy
 Amount of reported discomfort during
 Pregnancy is an experience full of growth, pregnancy and the woman's response to the
change, enrichment, and challenge. discomfort
 Fears and expectations about becoming parents.  Extent to which the woman accepts or rejects in
 Emotions in both mother and father. her body
 Pregnancy and child birth are events that touch
nearly every aspect of human experience. Second Trimester Adaptations
 Biologic, psychological, social and culture  Role assumption
individual adaptations to child bearing on each  Self-image and body image during pregnancy
of these levels may be quite different
depending on age, health, socio-economic status  Maternal role attainment
and cultural background of the women and her
family. Role Assumption
 Assuming and adopting to the role of mother are
parts of a long term process.
First Trimester Adaptations
 The psychological changes a woman undergone
 Ambivalence during pregnancy that enable her assume the
 Introversion or narcissism maternal role actually build a lifelong process of
 Acceptance of pregnancy informal socialization of learning a feminine
 Need extra emotional support from family identify
members
Self-Image and Body Image during Pregnancy
Ambivalence  Psychological change a woman undergoes
 Most of half of the pregnancies are unintended during pregnancy are self-image and body
and unexpected image.
 Once the pregnancy is confirmed many women  Self-image and body image will be different,
have conflict feeling is known as ambivalence. depending on the woman's trimester of
 Pregnancy cause permanent life changes for pregnancy.
woman  Three interdependent spheres of self that
 Primi mothers feel unsure of their ability to be a influence the psychological transition to role of
good parent mother
 Multi para may be apprehensive about 1. the ideal self,
pregnancy which will affect her relationship with 2. the self-image, and
her children. 3. the body image

Introversion/Narcissism  Ideal self is composed of all the attributes,

 Many women become increasingly concerned qualities and images a person would like to
about their ability to protect and provide for the have and hope to include the self.
fetus.  Self-image refers to the more reality oriented
 Undue preoccupation with oneself is narcissism active self, it is the self that interfaces with real
 Concentration on the self and body is world, here and now.
introversion  Body image during pregnancy has to do
 Selecting right foods to eat woman’s perception of her size, how she
woman's moves and her own physical beauty or
 Primi mothers wonder about the infant and looks ugliness.
baby pictures and eager to hear stories what
they were like as infants Maternal Role Attainment
 Multi paras know more about infants but they
 Maternal role attainment, that acquisition of the
are concerned with child's acceptance by siblings
mothering role, is described as process that
begins prenatally and ends with formation of a
Acceptance of Pregnancy
maternal identify during the infants first years.
 Accepting the pregnancy is one of the first  For first time mothers, it is a process in which the
changes a women must make for a successful mother achieves competence in the role and
transition in life style. integrates the mothering behaviors in to her
 A woman who cannot accept the pregnancy will established role set, so that she is comfortable
find it very difficult to accept the changes with their identify as a mother
necessitated by pregnancy, child birth and
interaction with the new born.

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 Third Trimester Adaptations - So cold goods such as milk and milk products
 Lack of knowledge and preparation for sour foods and vegetables are encouraged. Hot
maternal role foods such as chilies, ginger and animal products
 Establishing a relationship with the fetus are believed to cause miscarriage and fetal
abnormalities
 Fantasy during pregnancy
Activity and Rest
Lack of Knowledge and Preparation for Maternal
Role  Must cultures encourage a pregnant women to
maintain normal activities, excluding strenuous
 In modern nuclear family, guidelines for works, although some encourage more rest
parenting are confusing and role models less during pregnancy
apparent than in some other family types
stressors include the lack of guidelines for  Norms for sexual activity during pregnancy are
successful parenting. more variable ranging from no change to strict
prohibition of sexual intercourse through the
 Some women may feel they have trouble second half of pregnancy
concentrating or focusing on learning new
material or skills at this time  Postpartum period is characterized by more
restrictions on maternal activity. Most cultures
 Teaching should be clear and concise to help encourage a period for rest. Some as long as 40
women learn most easily. days, during which time the mother is confined to
her home, often to her bed.
Establishing a Relationship with the Fetus
 Some cultures regard the post-partum woman as
 During the course of pregnancy and the
unclean and prohibit her participation in
transition to a new life style and the maternal religious activities when this is the case, there is
roles a mother needs to establish a relationship usually provision for a ritual cleansing for both
with the infant to be. mother and infant at the end of the confinement
 The relationship with fetus is through to be the period
first stage in establishing a relationship with the
new-born and then the child. Preparation for Birth
 Preparations for the actual birth may include
Dreams/Fantacies during Pregnancy
intensive preparation of the house and actual
 Experience strange dreams about childbirth, new physical preparations of the mother through
born baby, and life as a new mother. specific exercises, religious practices or diet.
 Baby's sex and nightmares.  Some cultures view preparation in advance of
 Fantasy is an important factor in assumption of the event as potentially dangerous. Advance
the maternal role and transition in to the life preparation or even referring to the fetus by
style of women and child. name may be seen as tempting fate and making
 Fantasies during pregnancy allow a women to the mother and fetus vulnerable to evil
have a "dress rehearsal" for labor and delivery influences.
and mothering of an infant.
 Realistic fantasies of potential problems that Cultural Assessment
might occur during pregnancy and labor and  Question to help the nurse understand the family
delivery can help the women prepare herself to belief about appropriate care during pregnancy
cope with these problems or complications, include:
should they occur - How will you and your family prepare for the baby?
- What concerns do you have about the pregnancy?
Cultural Aspects in Pregnancy - What would provide the greatest assistance
- Where do you obtain most health care information?
Diets - What foods are encouraged or discouraged?
 Cultures encourages the pregnant women to - Who will be with you during labor and birth of the
maintain a diet to generally consider a normal baby?
one for that is generally considered a normal - Who will help you at home during pregnancy and
one for that culture. after birth?
 Food taboos are common, usually reflecting a
cultural belief that certain foods are unclean or CULTURAL NEGOTIATION
fears that ingesting certain food will produce  Cultural negotiation also involves sensitivity to
undesirable physical characteristic in the new specific concerns.
born. o Nurses must be aware about Islamic law
- For example pregnant women avoid eating governing modesty when caring Muslim
chicken crab, eggs drank, rabbit and blemished women.
fruits as those may harm baby's appearance  CONCLUSION
some cultures that subscribe to hot and cold o Psychological changes that occur during
theory of illness such as the Hindus, view pregnancy will help both expectant mothers
pregnancy as a hot state and expectant fathers to understand
themselves and their partners better.

Made by MIjelyn V. Bantigue