URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

urdanetacityuniversity@yahoo.com
(075) 568-7612 / (075) 568-2475 loc. 110
E-mail: ucu.reg@gmail.com

SCHOOL OF MIDWIFERY

Established in 1973
Level II Accreditation Status-ALCU-COA

MID 104-CLINICAL MANAGEMENT-OBSTETRICAL EMERGENCIES HIGH RISK

PREGNANCY MANAGEMENT
Name: FRIDALYN A. MOJICA
Date: SEPTEMBER 30, 2016
LEARNING ACTIVITY 2

1. GESTATIONAL DIABETES MELLITUS (GDM)- is when a women without diabetes,

develop high blood sugar levels during pregnancy. Gestational diabetes generally results in
few symptoms. It; however, increases the risk of pre-eclampsia, depression, and requiring a Caesarean
section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of being too
large, having low blood sugar after birth, and jaundice. If untreated, it can also result in stillbirth. Long
term, children are at higher risk of being overweight and developing type 2 diabetes.
A. Macrosomia- which literally means "big body," is sometimes confused with Large for gestational age.
Macrosomia is used to describe a newborn with an excessive birth weight (birth weight > 4000 g).
B. Screening - Two other sets of criteria are available for diagnosis of gestational diabetes, both based on
blood-sugar levels.

*Criteria for diagnosis of gestational diabetes, using the 100 gram Glucose Tolerance Test,
according to Carpenter and Coustan:
Fasting 95 mg/dl
1 hour 180 mg/dl
2 hours 155 mg/dl
3 hours140 mg/dl

*Criteria for diagnosis of gestational diabetes according to National Diabetes Data Group:
Fasting 105 mg/dl
1 hour 190 mg/dl
2 hours 165 mg/dl
3 hours 145 mg/dl

Results of GDM

Fasting plasma glucose (measured before the OGTT begins) should be below 6.1 mmol/L (110 mg/dL).
Fasting levels between 6.1 and 7.0 mmol/L (110 and 125 mg/dL) are borderline ("impaired fasting
glycaemia"), and fasting levels repeatedly at or above 7.0 mmol/L (126 mg/dL) are diagnostic of diabetes.
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A 1 hour GTT (Glucose Tolerance Test) glucose level below 10 mmol/L (180 mg/dL) is considered
normal.
For 2 hour GTT (Glucose Tolerance Test) with 75g intake, a glucose level below 7.8 mmol/L
(140 mg/dL) is normal, whereas higher glucose levels indicate hyperglycemia. Blood plasma glucose
between 7.8 mmol/L (140 mg/dL) and 11.1 mmol/L (200 mg/dL) indicate "impaired glucose tolerance",
and levels above 11.1 mmol/L (200 mg/dL) at 2 hours confirm a diagnosis of diabetes.
C. Post prandial blood sugar(PPBS)- . The word postprandial means after a meal; therefore, PPG
concentrations refer to plasma glucose concentrations after eating. PPBS is a blood glucose test that
determines the amount of a type of sugar, called glucose, in the blood after a meal . A 2-hour postprandial
blood sugar measures blood glucose exactly 2 hours after you start eating a meal timed from the start of
the meal. This is not a test used to diagnose diabetes. This test is used to see if someone with diabetes is
taking the right amount of insulin with meals. The purpose of PPBS is to Check for diabetes that occurs
during pregnancy gestational diabetes.
D. Glycosylated hemoglobin- Hemoglobin is the substance inside red blood cells that carries oxygen to
the cells of the body. Glucose (a type of sugar) molecules in the blood normally become stuck to
hemoglobin molecules - this means the hemoglobin has become glycosylated (also referred to as
hemoglobin A1c, or HbA1c). As a person's blood sugar becomes higher, more of the person's hemoglobin
becomes glycosylated. The glucose remains attached to the hemoglobin for the life of the red blood cell,
or about 2 to 3 months. Hemoglobin A1c, HbA1c, A1C, or Hb1c; sometimes also referred to as being
Hb1c or HGBA1C) is a form of hemoglobin that is measured primarily to identify the three-month
average plasma glucose concentration. The test is limited to a three-month average because the lifespan of
a red blood cell is four months (120 days). But RBCs do not all undergo lysis at the same time, so HbA1C
is taken as a limited measure of 3 months.

D. Management (With focus on Midwifery Interventions)

Advice pt. that Treatment of GDM with diet and insulin reduces health problems mother and
child.

Health teaching of how to manage appropriate meal planning, increased physical activity and properlyinstituted insulin treatment. Advice pregnant pt. that Insulin is not harmful for the baby.

Meals Cut down sweets, eats three small meals and one to three snacks a day, maintain proper
mealtimes, and include balanced fiber intake in the form of fruits, vegetables and whole-grains.
Increased physical activity - walking, swimming/aquaerobics, etc.

Monitor blood sugar level frequently, The blood sugar level should be below 95 mg/dl
(5.3 mmol/l) on awakening, below 140 mg/dl (7.8 mmol/l) one hour after a meal and below
120 mg/dl (6.7 mmol/l) two hours after a meal.

Each time when checking the blood sugar level, keep a proper record of the results and present to
the midwife for evaluation and modification of the management. If blood sugar levels are above
targets, a perinatal diabetes pt. may suggest doctors referral for proper medication and management.

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Women with GDM should be encouraged to breastfeed as soon after birth as possible in order to
avoid neonatal hypoglycemia.

Neonatal glucose monitoring is recommended at two hours after birth or whenever symptoms of
hypoglycemia present. For at risk infants, blood glucose should be >2.6 mmol/L.

2. HEART DISEASE in Pregnancy

Physiological considerations- Cardiac diseases complicate 1% to 4% of pregnancies in women without
pre-existing cardiac abnormalities. A working knowledge of the normal physiology of pregnancy is often
helpful in the management of patients with heart disease. Patients with pre-existing cardiac lesions should
be counsels in advance about the risk of pregnancy.PhysiologicalconsiderationsareMajor hemodynamic
changes occur during pregnancy, labor and delivery, and the postpartum period. These changes begin in
the first 5 to 8 weeks of gestation and peak late in the second trimester. In patients with preexisting CVD,
cardiac decompensation often coincides with this peak. Blood volume increases 40% to 50% during
normal pregnancy and outweighs the increase in red blood cell mass, contributing to the fall in
hemoglobin concentration otherwise known as anemia of pregnancy. Similarly, cardiac output rises 30%
to 50% above baseline, peaking at the end of the second trimester and re aching a plateau until delivery.

Clinical indicators of heart disease during pregnancy- Findings resembling heart failure (eg, mild
dyspnea, systolic murmurs, jugular venous distention, tachycardia, mild cardiomegaly seen on chest xray) extreme fatigue typically occur during third semester of pregnancy, extreme swelling or weight gain,
fainting, persistent cough, chest pain or fast heartbeat, severe shortness of breath especially when lying
down. Congenital heart disease (CHD) being the most common preexisting condition and hypertension
the most common acquired condition. cardiovascular risk factors (obesity, diabetes, and hypertension,)
Diagnostic studies- Clinical evaluation usually echocardiography. Diagnosis is usually based on clinical
evaluation and echocardiography. Because genetics can contribute to the risk of heart disorders, genetic
counseling and fetal echocardiography should be offered to women with congenital heart disease.
Clinical classification: ACQUIREDCARDIOVASCULARDISORDERSDURINGPREGNANCY
A. Hypertension in Pregnancy Hypertension during pregnancy is defined as a systolic pressure of
140 mm Hg or higher, a diastolic pressure of 90 mm Hg or higher, or both. Hypertension during
pregnancy can be classified into three main categories-chronic hyper tension, gestational
hypertension, and preeclampsia, with or without preexisting hypertension.
B. Peripartum Cardiomyopathy Peripartum cardiomyopathy (PPCM) is defined as the
development of idiopathic left ventricular systolic dysfunction (demonstrated by
echocardiography) in the interval between the last month of pregnancy up to the first 5
postpartum months in women without preexisting cardiac dysfunction. The exact cause of PPCM
is unknown, although viral myocarditis, autoimmune phenomena, and specific genetic mutations
that ultimately affect the formation of prolactin have been proposed as possible causes.
C. CoronaryArteryDisease coronary artery disease in female patients is increasing due to
changing lifestyle patterns including cigarette smoking, diabetes and stress. Since women are
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delaying childbearing until older age, acute coronary syndrome will more frequently occur during
pregnancy. The changes in the cardiac, hemodynamic, hemostatic and hormonal situation during
pregnancy and in the puerperium form a broad spectrum of causes of ACS.
D. For women with some types of heart disorders, pregnancy is inadvisable because it greatly
increases the risk of death. These disorders include 1.Pulmonary hypertension (high blood
pressure in the arteries of the lungs)2.Certain heart birth defects, including Eisenmenger
syndrome (a complication of some heart defects) and sometimes coarctation of the aorta
3.Sometimes Marfan syndrome (a hereditary connective tissue disorder)4.Severe aortic stenosis
(narrowing of opening of the aortic heart valve)5.Heart damage ( cardiomyopathy) that occurred
in a previous pregnancy
Management-labor and delivery ;puerperium (With focus on Midwifery Interventions) The main
midwife management are:

Early risk assessment, optimization, regular monitoring for deterioration, planning of delivery,
and surveillance for deterioration in the immediate post-partum period.
Vaginal delivery with low-dose regional analgesia (intravenous analgesics or epidurals) and
careful fluid management is the preferred delivery mode in most cases. Midwife should carefully
and closely monitor pt. during labour and delivery.
If patient encounter chest pain, difficulty in breathing, high bp during labor refer and transfer the
patient immediately in the nearest hospital.

3. ACUTE PYELONEPHRITIS (APN)- Is an inflammation of the kidney tissue, calyces, and renal
pelvis. It is commonly caused by bacterial infection that has spread up the urinary tract or travelled
through the bloodstream to the kidneys. Acute pyelonephritis results from bacterial invasion of the renal
parenchyma. Bacteria usually reach the kidney by ascending from the lower urinary tract. Pyelonephritis
is the most common non-obstetric cause for hospital admission of pregnant women.

Clinical presentation- The classic presentation in acute pyelonephritis is the triad of fever,
costovertebral angle pain, and nausea and/or vomiting. These may not all be present, however, or they
may not occur together temporally. Symptoms may be minimal to severe and usually develop over hours
or over the course of a day. Infrequently, symptoms develop over several days and may even be present
for a few weeks before the patient seeks medical care. Symptoms of cystitis may or may not be present to
varying degrees. These may include urinary frequency, hesitancy, lower abdominal pain, and urgency.
Gross hematuria (hemorrhagic cystitis) is present in 30-40% of pyelonephritis cases in females, most
often young women. Gross hematuria is unusual in males and should prompt consideration of a more
serious cause. Pain may be mild, moderate, or severe. Flank pain may be unilateral or sometimes bilateral.
Discomfort or pain may be present in the back (lower or middle) and/or the suprapubic area. Patients may
describe suprapubic symptoms as discomfort, heaviness, pain, or pressure. Upper abdominal pain is
unusual, and radiation of pain to the groin is suggestive of a ureteral stone. Fever is not always present.
When present, it is not unusual for the temperature to exceed 103F (39.4C). The patient may
demonstrate rigor, and chills may be present in the absence of demonstrated fever. Malaise and weakness
may also be present.

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Management of pregnant woman with APN (With focus on Midwifery Interventions)

A. Antibiotic therapy is essential in the treatment of acute pyelonephritis and prevents progression of
the infection.
B. Midwife should monitor urine test (Urine culture and sensitivity testing) should always be
performed, and empirical therapy should be tailored to the infecting uropathogen.
C. Health teaching of proper hygiene for pregnant women and advice pt. to Avoid of dehydration is
important for both patient well-being and kidney function. When under stress, men typically
drink only enough liquid to replace two thirds of the loss.
D. Ask pt. of Bedrest in semi-Fowler's position, Place on side opposite affected Kidney.

4. ACUTE RENAL FAILURE- Acute kidney failure happens when your kidneys suddenly lose the
ability to eliminate excess salts, fluids, and waste materials from the blood. This elimination is the core of
your kidneys main function. Acute renal failure in pregnancy can be induced by any of the disorders
leading to renal failure such as acute tubular necrosis. Acute kidney injury (AKI) is the abrupt loss of
kidney function, resulting in the retention of urea and other nitrogenous waste products and in the
dysregulation of extracellular volume and electrolytes. There are certain conditions associated with
pregnancy which vary between the first and second halves of gestation. Early in pregnancy, the most
common problems are prerenal disease due to hyperemesis gravidarum or acute tubular necrosis, resulting
from a septic abortion.
Prevention- Primary strategies to prevent Acute Renal Failure still include adequate hydration,
maintenance of mean arterial pressure, and minimizing nephrotoxin exposure. Diuretics and dopamine
have been shown to be ineffective in the prevention of ARF or improving outcomes once AFR occurs.
Increasing insight into mechanisms leading to ARF and the importance of facilitating renal recovery has
prompted investigators to evaluate the role of newer therapeutic agents in the prevention of Acute Renal
Failure. Having a healthy lifestyle that includes regular physical activity and a sensible diet can help to
prevent kidney failure.

Factors associated with acute renal failure during pregnancy- Acute kidney injury (AKI) is a serious
problem during pregnancy. Once occurred, it brings about devastating maternal and fetal outcomes. Acute
kidney failure can occur for many reasons. Among the most common reasons are:
Acute tubular necrosis (ATN), severe or sudden dehydration, urinary tract obstruction.
Toxic kidney injury from poisons or certain medications
Autoimmune kidney diseases, such as acute nephritic syndrome and interstitial nephritis
You have a condition that slows blood flow to your kidneys
You experience direct damage to your kidneys, urinary tract obstruction
Your kidneys' urine drainage tubes (ureters) become blocked and wastes can't leave your body through
your urine.
Management (With focus on Midwifery Interventions)- Pregnant patients with kidney disease are
often under the care of a maternal-fetal specialist who has advanced training in high-risk obstetrics.
Advice pregnant patient to receive frequent obstetric follow-up that includes careful blood
pressure monitoring, renal function testing, and 24-hour urine protein collections.
Midwife must advice pregnant to Consultation with a nephrologist often occurs, particularly for
patients with more advanced disease and those with progressive renal failure. Almost all patients
with significant renal disease and/or hypertension in late pregnancy, or when the likelihood of
fetal viability is very high, are delivered and they can be managed as non-gravid patients. If
progressive renal failure occurs either in early pregnancy or before fetal viability can be assured,
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however, dialysis may need to be considered.

Midwife must advice pregnant patient to undergo urine test like urinalysis that may reveal
abnormalities that suggest kidney failure.
Health teaching for healthy diet and proper nutrition avoid salty food, enough water and
hydration, healthy life style.

5. NEPHROTIC SYNDROME OR NEPHROSIS - Is a syndrome comprising signs of nephrosis,

chiefly proteinuria, hypoalbuminemia, and edema. Nephrotic syndrome is a group of symptoms that
include protein in the urine, low blood protein levels in the blood, high cholesterol levels, high
triglyceride levels, and swelling.

Physiological change- Renal disease can affect the outcome of pregnancy, pregnancy can affect the
progression of pre-existing renal disease, and pregnancy can itself cause renal impairment. The renal
system undergoes significant physiological and anatomical changes during a normal pregnancy: A change
in tubular function with increased glycosuria also occurs. The anatomical changes are mainly in the
collecting system. A dilatation of the ureters and pelvis occurs, which can lead to urinary stasis and an
increased risk of developing urinary tract infections (UTIs). There is also an increase in overall kidney
size by about 1-1.5 cm. In general, the physiological changes peak by the end of the second trimester and
then start to return to pre-pregnancy levels; anatomical changes generally take up to three months
postpartum to subside.
Physiological changes in pregnant

Significant proteinuria= 150 300mg/d in pregnancy glomerular and tubular proteinuria

Nephrotic syndrome >3g/d, albumin < 30g/L, oedema hypercholesterolemia, lipiduria

Nephrotic range proteinuria >3g/d, usually glomerular proteinuria

Most common cause = preeclampsia After 20wks GA : R/O preeclampsia until proven otherwise

Proteinuria with hypertension: Hematuria, red cell casts, creatinine

Maternal consideration impact of nephrosis are Acute kidney injury Chronic renal failure /
ESRD, Gestational hypertension, Preeclampsia / severe preeclampsia, Maternal renal and life
expectancy.
Fetal consideration impact of nephrosis are fetal growth restriction most likely related to reduced
utero-placental perfusion / low colloid osmotic pressure and reduction in effective blood volume

Prematurity Stillbirth, Fetal anasarca, Polyhydramnios.

Causes
Nephrotic syndrome is caused by different disorders that damage the kidneys. This damage leads
to the release of too much protein in the urine.
The most common cause in children is minimal change disease. Membranous glomerulonephritis
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is the most common cause in adults. In both diseases, the glomeruli in the kidneys are damaged.
Glomeruli are the structures that help filter wastes and fluids.
Management
1. Midwife should monitor the sign of edema, Oedema: Stockings / Leg elevation, Salt restriction
<100mmol/day (2.3g of sodium) Water restriction 1.5L/day.
2. Blood pressure control BP goal 110-140/80-90 no data on best threshold balance between
maternal BP and uteroplacental blood flow Antihypertensives drugs, when hypervolemia present:
salt and water restriction / diuretics
3. Health teaching for intake/nutritional needs weight gain monitoring as surrogate of nutritional
status may be misleading when excess of edema, proper diet like low salt diet and moderate
protein diet (1gram only)
4. Advice patient to take vitamin D supplement if nephrotic syndrome is long-term and is not
responding to treatment.
Pregnancy after renal transplantation (With focus on Midwifery Interventions)

Midwife/Obstetric management of pregnant transplant recipients includes the following:

Frequent evaluations, preferably every 2 weeks
Vaginal delivery (preferred): Usually delayed until labor onset unless maternal/fetal indications for
induction exist; cesarean delivery is only indicated for obstetric reasons (in such cases, avoid injury to the
allograft by knowing its exact location)
Antibiotic prophylaxis for all surgical procedures. Increased steroid dose at labor onset to overcome the
stress of labor and prevent postpartum transplant rejection.
Advice patient to have Low dose estrogenprogesterone oral contraceptive preparations 6 months after
delivery of baby. The risk of infection from the use of intrauterine devices is increased in
immunocompromised patients. The efficacy of IUDs may be reduced because of the antiinflammatory
properties of immunosuppressive agents.
Midwife care must be taken to avoid fluid overload and infection. At the time of delivery, instrumentation
should be minimized. Patients with renal insufficiency may be particularly at risk of water retention
secondary to oxytocin.
Advice patient that getting pregnant and having a child is possible. But you should not become pregnant
for at least one year after your transplant, even with stable kidney function and right birth control
measures and any consideration of pregnancy should be discus.

6.PNEUMONIA- An infection of one or both the lungs refers to Pneumonia. The major causes of
pneumonia are germs like bacteria, virus, and fungi. The inflammation of alveoli (air sacs) of an infected
persons lungs are inflated with fluids or pus making it difficult to breathe. Pneumonia can make a person
very sick or even cause death. Although the disease can occur in young and healthy people, it is most
dangerous for older adults, babies, and people at all ages with other diseases or impaired immune
systems.
Streptococcus pneumoniae is the most common cause of bacterial pneumonia. People who suffer
from chronic obstructive pulmonary disease (COPD) or alcoholism most often get pneumonia from
Klebsiella pneumoniae and Hemophilus influenzae. Atypical pneumonia, a type of pneumonia that
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typically occurs during the summer and fall months, is caused by the bacteria Mycoplasma pneumoniae.
Sign & Symptoms: Cough, Rusty or green mucus (sputum) coughed up from lungs, Fever, Fast breathing
and shortness of breath, Shaking chills, Chest pain that usually worsens when taking a deep breath
(pleuritic pain), Fast heartbeat, Fatigue and feeling very weak, Nausea and vomiting, Diarrhea, Sweating,
Headache, Muscle pain, Confusion or delirium, Dusky or purplish skin color (cyanosis) from poorly
oxygenated blood.
Management (With focus on Midwifery Interventions)
a) Midwife health teaching to pregnant woman about the sign & symptoms, causes and how can
acquired pneumonia and inform that prevention is better than cure and vaccines help to prevent
certain types of (bacterial and viral) pneumonia.
b) Advice safe oral antibiotics that is safe for pregnant woman, rest, simple analgesics, and fluids
usually suffice for complete resolution. Midwife should inform the patient If the symptoms
worsen, the pneumonia does not improve with home treatment, or complications occur, or if there
is a drop in blood pressure hospitalization may be required.
c) Inform pregnant patient that Bacterial pneumonias are usually treated with antibiotics, whereas
viral pneumonias are treated with rest and plenty of fluids. Fungal pneumonias are usually treated
with antifungal medications.
d) Health teaching of proper hygiene (especially of regular hand washing), proper ventilation of
house, proper nutritious and healthy foods to strengthen the immune system of pregnant patient.

Prevention- Ensure your safety by following these preventive measures:

Get vaccinated, There are two vaccines that are available to prevent pneumococcal disease the
pneumococcal conjugate vaccine (Prevnar) administered as part of the normal infant
immunization procedure and is recommended for children less than 2 years of age or between two
and four years with certain medical conditions. and pneumococcal polysaccharide vaccine
(Pneumovax) is provided for adults who are at increased risk of developing pneumococcal
pneumonia, such as the elderly.

Give attention to personal hygiene, especially the hands. Avoid or limit contact with the sick. Eat
well and eat healthy food, exercise sleep well and build strong immunity. Refrain from smoking,
and stay away from sputum or cough particles from others with pneumonia.

7. VIRAL PNEUMONIA- is a complication of the viruses that cause colds and the flu. The virus
invades your lungs and causes them to swell and block your flow of oxygen. A case of viral pneumonia in
pregnant women can be more dangerous. The viral respiratory infections can be varicella, influenza, and
an acute respiratory syndrome. The infants who are born to such women are feared to have low birth
weight and increased preterm birth. Serious complications can occur to the mother also in the form of
respiratory failure. However, antiviral and respiratory therapies can reduce maternal morbidity and death
rates. It would be good to take an influenza vaccination in pregnancy as a preventive measure, especially
during the influenza season.
There are a number of viruses that can lead to viral pneumonia, including:
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adenoviruses, which can also cause the common cold and bronchitis
chickenpox
flu respiratory syncytial virus, which causes cold-like symptoms
Prevention (With focus on Midwifery Interventions)

Recommends that all pregnant women with persistent upper respiratory distress have a chest
radiograph.
Midwife should be alert to any pregnant woman reporting cough, phlegm, nasal stuffiness or
discharge, or shortness of breath. This last symptom dyspnea is a confounding factor because
dyspnea is often physiologic and normal in pregnancy.
Educate pregnant women on labor room of proper push during labor to avoid Aspiration that is
most common cause of Postpartum pneumonia during labor and delivery.
Inform pregnant patient that choice of antibiotic therapy in the pregnant patient with pneumonia
is dictated by the same principles as in the non-pregnant patient.
Educate pregnant patient to Recognize the Symptoms of Viral Pneumonia The symptoms occur
when your lungs become inflamed as they try to fight off the viral infection. This inflammation
blocks the flow of oxygen.
Practice good hygiene by washing your hands after using the bathroom or public transportation,
or after youve been anywhere that has a high risk of contamination
Get adequate amounts of rest, exercise and eat healthy
Practice courteous and safe sneezing and coughing by using the inner crook of your elbow when
you sneeze or cough
Dont smoke because smoking damages your lungs ability to fight off infection.
Get influenza vaccinations before you conceive.

Treatment of Viral Pneumonia

Treatment has two goals. It will help ease the symptoms of infection and rid your body of underlying
infection. Depending on the type of infection you have, your doctor may prescribe an antiviral
medication. Antiviral medication doesnt work against most pneumonias, but it may be helpful if flu or
herpes viruses cause your pneumonia.

8. ASTHMA- Is a common long term inflammatory disease of the airways of the lungs. It is
characterized by increased responsiveness of the tracheobronchial tree to multiple stimuli. It is the most
common chronic condition in pregnancy and by variable and recurring symptoms, reversible airflow
obstruction, and bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness,
and shortness of breath. These episodes may occur a few times a day or a few times per week. Depending
on the person they may become worse at night or with exercise.
During pregnancy, asthma not only affects you, but it can also cut back on the oxygen your fetus
gets from you.
Minor effects on pregnancy outcome- Although women with mild asthma are unlikely to have
problems, patients with severe asthma are at greater risk of deterioration. In fact, severe and/or poorly

uncontrolled asthma during pregnancy can produce serious maternal and fetal complications.

Maternal complications include preeclampsia, gestational hypertension, hyperemesis gravidarum, vaginal

hemorrhage, toxemia, and induced and complicated labors.
Fetal complications include increased risk of perinatal mortality, intrauterine growth retardation, preterm
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birth, low birth weight, still birth and neonatal hypoxia.

Management of Chronic Asthma- Most asthma treatments and antiasthma drugs are safe to use when
you are pregnant and during breastfeeding.

Monitoring and making appropriate adjustments in therapy may be required to maintain

lung function and, hence, blood oxygenation that ensures oxygen supply to the fetus.
Inhaled medications are generally preferred because they have a more localized effect with only
small amounts entering the bloodstream.

Medication use is limited in the first trimester as much as possible when the fetus is forming.

Inadequate control of asthma is a greater risk to the fetus than asthma medications are.

Proper control of asthma symptoms should enable a woman with asthma to maintain a
normal pregnancy with little or no risk to her or her fetus. Avoid or control asthma
triggers like stay away or stop smoking, allergic irritants like pet fur.

The midwife should be involved in asthma care, including monitoring of asthma status
during prenatal visits.

Steps therapy of Chronic Asthma during Pregnancy

Mild Intermittent Asthma
No daily medications, albuterol as needed
Mild Persistent Asthma
Preferred Low-dose inhaled corticosteroid
Alternative Cromolyn, leukotriene receptor antagonist, or theophylline (serum level 5 to 12
mcg/mL)
Moderate Persistent Asthma
Preferred Low-dose inhaled corticosteroid and salmeterol or medium-dose inhaled
corticosteroid or (if needed) medium-dose inhaled corticosteroid and salmeterol
Alternative Low-dose or (if needed) medium-dose inhaled corticosteroid and either
leukotriene receptor antagonist or theophylline (serum level 5 to 12 mcg/mL)
Severe Chronic Persistent Asthma
Preferred High-dose inhaled corticosteroid and salmeterol and (if needed) oral
corticosteroid
Alternative High-dose inhaled corticosteroid and theophylline (serum level 5 to 12
mcg/mL) and oral corticosteroid if needed

Management of Acute Asthma

Acute asthma management is based on:
Assessing severity (mild/moderate, severe or life-threatening) while starting bronchodilator treatment
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10

immediately
Administering oxygen therapy, if required, and titrating oxygen saturation to target of 9295% (pregnant
women)
Completing observations and assessments (when appropriate, based on clinical priorities determined by
baseline severity)
Administering systemic corticosteroids within the first hour of treatment
Repeatedly reassessing response to treatment and either continuing treatment or adding on treatments,
until acute asthma has resolved, or patient is transferred to an intensive care unit or admitted to hospital
observing the patient for at least 1 hour after dyspnea/respiratory distress has resolved, providing postacute care and arranging follow-up.
Management of labor and delivery (With focus on Midwifery Interventions)
During labor and delivery asthma patients should monitor carefully especially fetal monitoring is
very important, fetal assessment can be accomplished by 20 minutes of electronic monitoring (the
admission test). Intensive fetal monitoring with careful observation is recommended for patients
who enter labor and delivery with severe asthma.
Always prepare oxygen if asthma attack happen during labor and delivery.
The patient's regularly scheduled asthma medications should be continued during labor and
delivery.
If your asthma gets worse, you will be referred appropriately

Preterm Labor
A patient already receiving asthma medication has a risk of dangerous drug interactions. During an
asthma exacerbation, uterine contractions are common and usually do not progress to preterm labor.
Successful treatment of the exacerbation will usually abate the contractions. If tocolytic therapy is
necessary, care should be taken to avoid the use of more than one type of b 2-agonist. Magnesium sulfate is
recommended to treat uterine contractions if the patient is already taking a systemic b 2-agonist for her
asthma.
Pain Control
Narcotic analgesics that cause histamine release should be avoided; fentanyl is a preferred agent. Lumbar
epidural analgesia reduces oxygen consumption and minute ventilation during first and second stages of
labor, which offers patients with asthma considerable benefit. If a general anesthetic is necessary,
preanesthetic use of atropine and glycopyrrolate may provide bronchodilatory effect. For induction of
anesthesia, ketamine is the agent of choice. Low concentrations of halogenated anesthetics can provide
bronchodilation to the patient with asthma.
Labor Induction
Oxytocin is the drug of choice. Prior to term, the use of 15 methyl prostaglandin F2-alpha should be
avoided because it may cause bronchospasm; use of prostaglandin E2 suppositories or gel has not been
reported to cause bronchospasm.
Postpartum Hemorrhage
Oxytocin is the recommended agent. If additional agents are required, methylergonovine as well as
ergonovine should be avoided if possible because they may cause bronchospasm. If their use is
unavoidable, pretreatment with methylprednisolone is recommended. If prostaglandin treatment is
necessary, the safest analog is E2, which is less likely to cause bronchospasm.

9.

TUBERCULOSIS-

Is an infectious disease caused by the bacterium Mycobacterium

tuberculosis (MTB). Tuberculosis generally affects the lungs, but can also affect other parts of the body.
Most infections do not have symptoms, known as latent tuberculosis.
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11

Sign/Symptoms of Active TB- are chronic cough with blood-containing sputum, fever, night sweats,
chills, loss of appetite, fatigue and weight loss. Infection of other organs can cause a wide range of
symptoms. Tuberculosis is spread through the air when people who have active TB in their lungs cough,
spit, speak, or sneeze. People with latent TB do not spread the disease. Active infection occurs more
often in people with HIV/AIDS and in those who smoke. Diagnosis of active TB is based on chest X-rays,
as well as microscopic examination and culture of body fluids. Diagnosis of latent TB relies on
the tuberculin skin test (TST) or blood tests.
Orally Prescribed regimen for Pregnant Women (With focus on Midwifery Interventions)

Pregnant women with active TB should be treated, even in the first stage of pregnancy. Isoniazid,
Rifampin, and Ethambutol may be used. Pyrazinamide is reserved for women with suspected
multidrug-resistant TB (MDR-TB). Elsewhere in the world, pyrazinamide is commonly used in
pregnant women with TB.

Streptomycin should not be used, because it has been shown to have harmful effects on the fetus.

The initial treatment regimen should consist of INH, RIF, and EMB. Although all of these drugs
cross the placenta, they do not appear to have teratogenic effects. PZA can probably be used
safely during pregnancy and is recommended by the World Health Organization (WHO) and the
International Union Against Tuberculosis and Lung Disease (IUATLD). If PZA is not included in
the initial treatment regimen, the minimum duration of therapy is 9 months.

Health teaching to recommend that pregnant or breast-feeding women take vitamin B6

(pyridoxine) during treatment for TB. Women being treated for active TB with first-line
medicines can continue to breast-feed. The small amounts of medicine that get into the breast
milk do not appear to harm a baby.

Health teaching of personal hygiene especially of hand washing, advice to take healthy foods as
this is the first line of defense to boost the immune system of pregnant women, live a healthy
lifestyle and exercise.

Prepared by:
DR. AMELIA C. FERNANDO
University Physician

Noted by:
DR. CHRISTOPHER R. BAEZ
Dean

Fridalyn Mojica 3rd Year BSM

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Submitted by:
Fridalyn Mojica
3rd year BSM

Fridalyn Mojica 3rd Year BSM

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