MODULE 8-10 NM621 study guide Flashcards
Fetal Alcohol Spectrum Disorder
• a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. These effects can range from mild to severe. They can affect each person in different ways and can include physical problems and problems with behavior and learning. (CDC)
FAS fetal alcohol syndrome
• the severe end of FASD spectrum • IS a diagnosis • has three distinct features a. facial abnormalities b. growth deficits c. CNS abnormalties
FAE (fetal alcohol effects)
negatively affect a child’s growth, cognition, physical appearance, and behavior over the lifespan. (Mengel)
incidence of FAS
- 1-3% of live births in the US. “one in 30 women who know they are pregnant reports “risk drinking” (7 or more drinks per week or 5 or more drinks on any one occasion). At least 1 in 10 women will continue to consume alcohol during pregnancy. (LT and Mengel)
• FAS Incidence 0.5-1.5/1000 births; the incidence of FASD is thought to be at least 3X the incidence of FAS (CDC link in LT)
FAS Screening methods
• Quantity/Frequency questions
• days per week of drinking
• average number of drinks per day
• max number of drinks consumed in 1 day during past month
• TWEAK
• Tolerance:
a. How many drinks does it take before you feel high (the first effects of alcohol)? or
b. How many drinks can you hold? (How many drinks does it take before the alcohol makes you fall asleep or pass out? If you never pass out, what is the largest number of drinks you have?)
• Worried: Have your friends or relatives worried about your drinking in the past year?
• Eye opener: Do you sometimes take a drink in the morning when you first get up?
• Amnesia: Are there times when you drink and afterwards can’t remember what you said or did?
• K/Cut Down: Do you sometimes feel the need to cut down on your drinking?
• Receive 2 points if they can hold 5 drinks before passing out, 2 points if yes to “worry”, 1 pt for every other category. Any total score 2 or over=referral for further evaluation/treatment
• T-Ace
- Tolerance: How many drinks does it take to make you feel high?
- Annoyed: Have people ever annoyed you by criticizing your drinking?
- Cut Down: Have you ever felt that you needed to cut down on your drinking?
- Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
- Because of social desirability, some pregnant women, particularly heavy drinkers, may be more likely to reliably report their actual alcohol use in a computerized or “pencil and paper” task rather than through a face-to-face interview.
- Receive 2 points if answer to Tolerance questions is 2 or more drinks, 1 pt for every other category. Any total score 2 or over=referral for further evaluation/treatment
• Know factors associated with drinking alcohol,
- age >30, caucasian, Hx binge drinking or long hx of drinking, college educated, low or high SES, special education population, poor Native Americans, Hx of physical/sexual abuse ever, Hx physical abuse in last year, heavy drinking by male partner or any family member, loss of children to foster/adoptive care, poly-drug use/cigarette smoking, previous child with FAS, major depressive d/o, unmarried, early age of drinking onset.
how to counsel women on drinking alcohol in pregnancy
: assessment first #1
Brief intervention
• Assessment alone seems to reduce alcohol consumption. Among pregnant women, formal screening with tools such as the T-ACE alone, reduces prenatal consumption. Physician advice or written educational information improves patients’ knowledge of the risks of drinking during pregnancy. Providing information alone may reduce the risk of an alcohol-exposed pregnancy through reduced consumption or increased use of effective contraception. Information’s beneficial effects on reducing risk may persist for up to 9 months. It is likely that when coupled with education and advice, assessment may be adequate to prevent further drinking during pregnancy among most patients.
Counsel women: Motivational interviewing (MI) #4
Motivational interviewing (MI), a counseling model developed for health risk behavior, has also demonstrated success in reducing prenatal alcohol use—particularly among heavier drinkers.
counseling women : brainstorming #3
After establishing drinking goals; the patient is encouraged to “brainstorm” environmental triggers (eg, socializing with friends who are drinking) and develop behavioral alternatives for these at-risk periods. Counseling is augmented by written patient educational material such as self-paced workbooks. Keeping a drinking diary, recording the number of alcoholic drinks, and drinking circumstances each day, is often recommended.
counseling women : providing information #2
• After completing an initial screening and providing general information about the risks for drinking during pregnancy, at-risk patients should receive individualized feedback. The physician explains how the patient’s drinking compares with other pregnant women or those of childbearing age. If possible, the physician then describes risks specific to the patient. Next, the physician and patient establish drinking goals, complete cessation of drinking during pregnancy is recommended.
• Know the trends and prevalence of smoking in pregnant women
o Currently, 11% of women in the United States smoke during pregnancy. It is estimated that worldwide up to 30% of pregnant women smoke during pregnancy. The highest rates of smoking during pregnancy occur in underdeveloped and poor countries, where access to prenatal care and education about smoking risks are less likely to be available.
• Know the physiological effects on the placenta, fetus and newborn, and prenatal complications of smoking
o Placenta- previa, abruption, decrease placental weight, adverse morphological changes
o Fetus- Increased FGR and low birth weight, PROM (#1 way to prevent LBW is to increase smoking cessation rates)
o Newborn- Increased risk for SIDS, lower offspring IQ, increased childhood respiratory d/o such as chronic asthma, earaches, learning and behavior problems
o Prenatal complications- Increased first trimester loss, ectopic pregnancy, preterm birth
o CO2 & CO1 decrease available of O2 to fetus, nicotine is neurotoxic to fetal brain, nicotine cause adverse maternal CV changes that results in decreased placental blood flow and ultimately decreased O2/nutrient to fetus.
know the strategies to promote smoking cessation in pregnant women and their families : 5 A’s
o The 5A’s and R’s The 5 A’s: the primary approach to quitting (nurse managed intervention)
• Ask about tobacco use
• Advise to quit- Clear, strong, personalized advice to quit
• Assess willingness to make a quit attempt
. If willing move on to assist
a. If not willing move on to the 5 R’s
• Assist in quit attempt
• Arrange f/u
the 5 R’s
• The 5 R’s: to be used when patients don’t want to quit
• Relevance- have pt identify why quitting might be personally relevant
. ie: children in home, need for money, hx of smoking related illness
• Risks- ask if she knows about risks of smoking during pregnancy, reiterate benefits for her and baby
• Rewards- baby gets more O2 after just 1 day, clothes and hair smell better, she will have more money, food will taste better, she will have more energy
• Roadblocks- negative moods, being around other smokers, triggers and cravings, time pressures
. to overcome: smoke on hard candy, engage in physical activity, express yourself with writing or talking, relax, think about positive pleasant things, ask for support, ask friend to quit with you, ask others not to smoke around you, assign nonsmoking areas, leave room when others smoke, keep hands and mouth busy
a. Cravings will lessen within a few weeks, anticipate triggers, change routine (brush teeth immediately after eating), distract yourself with pleasant activities, change lifestyle to reduce stress, increase physical activity
• Repetition
o Hypnosis-Has not been proven for cessation, may help decrease amount of smoking
o Nicotine replacement- not well studied but considered better than cigarettes b/c of all of the chemicals inhaled with smoking. recommend that nicotine gum, sprays, or inhalers should be used rather than patches; a patch provides a higher total dose because it is on the woman continuously. ACOG states these should only be considered once other interventions have failed and/or those that are heavy smokers (>1ppd)
• Know the trends and prevalence of street drug use in pregnant women
o The common perceptions of substance abuse as a problem of the poor, ethnic minority, and adolescent are inaccurate. These perceptions may often be acted upon by health care professionals in a prejudicial manner. Studies show similar rates of substance abuse during pregnancy by women of all racial, socioeconomic status and age categories. Demographic features are only related to the type of substance used with Black and poorer women most likely to use illicit substances, especially cocaine, while White women and better educated women tend to use alcohol.
o About 1 in 20 women (5%) take street drugs during pregnancy
Marijuana sign and symptoms
tachycardic lung infection trouble paying attention memory problems trouble thinking clearly clumsiness/poor balance
marijuana maternal effects
reduced fertility (street drugs in pregnancy)
marijuana : fetal effects
crosses the placenta, PTB, LBW, unclear evidence, CNS effect in children-changes in brain activity, sleep patterns, and behavior (street drugs in pregnancy)
cocaine signs/ symptoms
affects CNS
• loss of smell r/t (snorting)
• change in eye sight, sound and touch
stomach pain, nausea, anorexia, weight loss, tremors, HA, restless, scared, angry, heart attack, stroke, resp failure
cocaine maternal effects
local anesthetic, CNS stimulant (street drugs in pregnancy
cocaine fetal effects
Placental abruption, preterm birth, lower birth weight, respiratory distress, bowel infarctions, cerebral infarctions, fetal growth restriction and increased risk of seizures, early pregnancy loss, birth defects, CNS problems when the child is older, readily crosses the placenta and metabolizes slowly in the fetus, newborn withdrawl (street drugs in pregnancy)
Amphetamines s/sx
insomnia, tachycardia, sweating, hallucinations, dizziness, brain death/coma, death
amphetamines maternal effects
Stimulant (tachycardia, insomnia, anorexia..). Dextramphetamine (Desoxyn) is rx, appears to carry no risk but no studies in pregnant women (street drugs in pregnancy)
Dextramphetamine is used to treat ADHA, sleep disorders, or as an appetite suppressant→ NOT recommended for use in pregnancy
Amphetamine fetal effects
Preterm birth, LBW, NAS, SAB, FGR, placental abruption, lifetime neuro/cognative issues, neonatal withdrawal, possibly cleft lip and palate (street drugs in pregnancy)
NOTE: It is thought that ecstasy has similar adverse outcomes as amphetamines
heroin maternal effects
affects CNS--itchy, sleepy nausea resp failure infection needle sharing leads to HIV or hepatitis kidney disease, liver disease, coma
heroin fetal effects
abruption PTB, low birthweigh FGR NAS (neonatal abuse syndrome) stillbirth SIDS DO NOT quit “cold turkey” as in doing so you can harm fetus perhaps leading to stillbirth (one of recommend methods to stop heroin is the use of methadone-refer for comprehensive drug treatment program) Heroin is a significant factor for late neuro and developmental problems
when compare METH to Cocaine
METH is:
• Is stronger, last longer, has more toxic effects
• Causes a 3 fold release of dopamine in the brain and has a half-life of 12 hours compared to cocaine’s half life of 1 hour
• Can produce a high for 8-24 hours compared to a 20-30 minute high with cocaine
• Is less expensive than cocaine (street drugs in pregnancy)
Cycle of Domestic Violence (DV)
o Cycle
• (Espinosa, p. 305) Domestic violence has been defined as “a pattern of coercive behavior designed to exert power and control over a person in an intimate relationship through the use of intimidating, threatening, harmful, or harassing behavior
• physical injury often results from the pattern of behavior used by abusers, it does not always occur in relationships affected by domestic violence.
o Scope and factors associated with DV/IPV in pregnancy
Women: more likely to use violence as a means of self-defense or retaliation for violence inflicted by a male partner
Prenatal Care: May start prenatal care late in pregnancy (3rd trimester) due to the controlling behavior of their partners.
• Men: associated with DV
: more likely to use violence as a method of coercion and control
• Younger women associated with DV
more at risk for domestic abuse during pregnancy within a larger context of violence, related to their vulnerability and inexperience with interpersonal relationships; may become involved with males who have dangerous lifestyle behaviors (history of police involvement or use of illegal substances) May lack the life experience that could forewarn them of the seriousness of becoming involved with dangerous or violent individuals. Nonconformist attitudes could also make dangerous behaviors seem attractive; facilitating an adolescent female’s involvement with a violent male
• Substance Abuse associated with DV
cigarette smoking, alcohol use, and history of drug use were associated with a history of domestic violence but were not associated with increased rates of domestic violence during the current pregnancy. Pregnant domestic violence victims were more likely than nonabused pregnant women to report abuse of multiple substances, including alcohol, cigarettes, and other drugs; more likely to continue substance abuse during pregnancy; higher rates of physical abuse for women who smoked cigarettes during the third trimester of pregnancy. Victims of domestic violence may be self-medicating with alcohol and other substances. Increased risk of domestic violence among women whose partners used marijuana, cocaine, had drinking problems, smoked, or had a history of police involvement, and legal problems related to the use of alcohol and other drugs
Prenatal Care associated with DV
May start prenatal care late in pregnancy (3rd trimester) due to the controlling behavior of their partners.
• Depression and Anxiety: as risk factor associated with DV
concurrently experience depression and anxiety. Feel less happy about being pregnant, and to have had a history of depression and attempted suicide.
• Social support: as risk factor associated with DV
Usually nonfamilial support people rather than family members; feel a lack of support during pregnancy; have fewer people with whom they could “get together” or discuss personal issues
• Other factors Associated with DV
low maternal weight gain, infections (including symptomatic bacteriuria, rubella, and cytomegalovirus), anemia, short interpregnancy interval, and bleeding during the first or second trimesters; housing problems and lack of tangible items such as a crib, refrigerator, or the presence of a stove in the home. Less likely to be married, more likely to be participants of WIC, and were more likely to have unintended pregnancies; more likely to seek an elective abortion without the partner being aware or supportive of this option; violent partners sometimes prohibit their partners from using contraceptive methods
primary intervention of DV
o Primary interventions- address the societal underpinnings of domestic violence and include political activism in areas such as welfare reform and child custody legislation, as well as political efforts to end insurance discrimination directed toward victims of domestic violence, efforts to decrease pornography and violence, the promotion of healthy images of women in the media, and support for increased penalization of abusers. Safe options for child care as well as birth control options for women should be advocated, and women should be informed about services available to them. Another way that clinicians can participate in primary prevention is through participation in domestic violence public awareness campaigns.
secondary intervention of DV
o Secondary intervention (screening and treatment)- includes prompt identification of DV and referrals for safe havens and/or treatment. Because many victims of domestic abuse have contact with the health care system only for care related to pregnancy and childbirth, consistent, ongoing, and appropriate screening for domestic violence is an especially important aspect of prenatal care. Secondary intervention strategies also include providing nonjudgmental support to women once situations of domestic violence have been identified, discussing issues of domestic violence with men, encouraging intervention programs for abusive men, and volunteering for services that serve families affected by domestic violence. Lastly, nonjudgmental support is important.
Tertiary intervention of DV
o Tertiary intervention (leaving the abuser)- The process of leaving an abusive relationship is recognized as being complex and challenging for women. It has been described as a four-phase social psychological process of reclaiming self, with the four phases being counteracting abuse, breaking free, not going back, and moving on. Intervention at this level requires that clinicians be educated about domestic violence patterns, as well as the resources available in the community and available to the affected woman specifically. Women who have been identified as victims of domestic violence should be specifically questioned about escalating violence that may put her at risk for serious injury. The priority at this level is to ensure the immediate and long-term safety of the woman and her fetus, as well as any other children the woman may have. Clinicians caring for women who have revealed the presence of domestic violence should maintain consistent and descriptive documentation in the health care record of the violent behavior that is reported by the client.
o Abuse Assessment Screen (AAS)
- One of the most widely used tools for detection of DV
- Consists of 4 questions asked during a routine health hx
- Have you ever been emotionally or physically abused by your partner or someone important to you?
- Within the last year, have you ever been hit, slapped, kicked or otherwise physically hurt by someone?
- Since you’ve been pregnant, have you been slapped, kicked or otherwise physically hurt by someone?
- Within the last year, has anyone forced you to have sexual activities?
- Does not have instructions for scoring or a cutting score (which indicates a problem).
- Serves as a tool to elicit information and open dialogue between clients and providers.
- When using the screen during a health history, providers should ask the questions in such a way that fosters open communication and give plenty of time to answer each question.
- She may not disclose the first time you ask so it is important to ask at each subsequent visit.
o Barriers to diagnosis- DV
providers feel powerless with loss of control, and have a fear of offending the woman, Time constraints in scheduled office visits. Lack of information and training about violence so they are uncomfortable asking if she is a victim of violence. Belief that this is a “private” or family matter rather than a societal problem and health concern; The effects of the provider’s own traumatic experience(s) witnessing or experiencing violence, either past and/or present; Concerns about the legal ramifications of knowing this information; Discomfort with patients expressing emotion and concern about setting time boundaries; Concern about how listening to these experiences will affect them; and feeling helpless to intervene.
BArrier to Disclosing DV
- Fear of increased violence if partner discovers she has disclosed the DV, Fear r/t threats that he will kill her or her children in she leaves, feelings of guilt, embarrassment, self-blame, and fear of not being believed; of being judged and blamed; of not being understood or helped; and of the threat and/or reality of revictimization or retaliation by the perpetrator if they were to seek help.
o Strategies for care
Effective care for women experiencing domestic violence requires collaboration with the woman, social workers, and community resources to develop a safety plan. The woman will need a plan of action, including money, clothes, child care, and a place to go should she decide to leave. Perhaps a neighbor or family member can be identified and incorporated into the safety plan. Extra clinic visits can be scheduled to assist the woman in planning, and in some communities, arrangements can be made for the woman to meet with local shelter personnel at the clinic during a scheduled “prenatal visit.” The health care provider can show the woman where in the telephone directory to find numbers for local shelters and services so that specific written information, which the abuser might find, need not be given. As discussed above, it is important that the clinician not try to “fix” a situation by telling an abused woman what to do. It is the clinician’s role to assist the woman in making her own informed decisions. The health care provider can provide support, information, and appropriate referrals. Providing education about domestic violence can help dispel beliefs that the woman may cling to, such as that the abuser may change or that the abuse will end after the baby is born.
o Physical signs : DV
Mixture of old and new injuries, injuries of the soft tissues and areas usually covered by clothes, trauma to the breasts and abd, characteristically abusive injuries resulting from fingernail scratches, rope burns, or cigarette burns,
o Psychological signs/symptoms/hallmarks- DV
Depression, anxiety, substance abuse, lack of social support (if they did have social support the support tends to NOT be familial),
o Behavior : DV
- Pregnant women in abusive relationships may start prenatal care late in pregnancy due to the controlling behavior of their partners. Less likely to be married, more likely to participate in WIC, more likely to have unintended pregnancies. More likely to seek elective abortion without partner being aware of supportive (often prohibited from using contraception by partner). More likely to abuse multiple substances and continue them throughout pregnancy. More likely to be involved with partners who use marijuana, cocaine, or ETOH
• Know the physical and psychological signs, symptoms, hallmarks and varying behaviors of women who have been victims of CSA, and how to screen for this during prenatal visits.
o it is important for nurses to be aware that there is no typical profile of a CSA survivor, and an almost infinite range of signs and symptoms can be presented by this population.
physical signs : CSA
asthma and respiratory disorders; dizziness and fainting; cardiovascular conditions; irritable bowel syndrome; auto-immune illnesses; chronic pain and fatigue; morbid obesity; sleep disturbances; musculoskeletal disorders; pseudoneurological symptoms; gastrointestinal disorders; and migraine headaches, particularly cluster migraines, sexual dysfunction, breast disease, nausea, chronic menstrual problems, menorrhagia, chronic urinary tract infections, premenstrual syndrome, hyperemesis, prolonged labors, shorter labors, longer pregnancies, and increased rates of postpartum depression, increased rates of abortions, increased rates of complications of pregnancy, more ultrasounds than usual during the pregnancy, and higher birth weights of infants.
o Psychological signs/symptoms/hallmarks- CSA
most often present as a range of posttraumatic responses on a continuum, from a brief stress reaction following a single traumatic event to posttraumatic stress disorder (PTSD), inability to trust, feelings of isolation, affective numbness, low self esteem, anger, eating d/o, compulsive d/o, suicidal ideation/attempts, psych hospitalizations.
Behavior of CSA
younger age at first intercourse, younger age at first pregnancy, multiple sexual partners, negative reaction to or denial of the pregnancy, pseudocyesi, more complaints of stress during pregnancy, difficulty relating in group settings, fear, anxiety or panic attacks, self-injurious behaviors, substance abuse, employment problems, increased potential for revictimization in adulthood, homelessness, survival prostitution.
• Understand potential reactions to prenatal care visits (physical exams) & childbirth in women who are victims of CSA, and midwifery strategies to best help them.
o Pregnancy can be a trigger for a return to the feeling of terror and shame for many women due to the changes in the pregnant body, the feelings of vulnerability that pregnancy naturally brings, and office procedures like vaginal exams. This can take the form of flashbacks of previously repressed memories, nightmares, increased anxiety, and behavior changes. Women who have survived CSA have an increase in pregnancy nausea & vomiting and preterm labor
Two issues essential to caring for women who have survived CSA are #1
• Trust: women need to trust their provider, however this can be a difficult task for CSA survivors. “A provider can say some things a survivor client may need to hear. For example, “I know it may take some time to feel that I am trustworthy. So here are some things about me you can count on. I will keep your confidentiality. I’ll try to remember to ask permission to touch you, and I will keep you informed of your condition” (Sperlich & Seng, pg 68). For women who have not disclosed prior abuse, they may not disclose until they have been asked numerous times or until they can judge that the provider ‘gets it’ and is competent at addressing these issues (Sperlich & Seng, 2008).
Two issues essential to caring for women who have survived CSA are #2
• Control: Almost half of CSA women experience memories of prior abuse when undergoing a medical vaginal exam (Leerners, 2007). Survivors need to be in control of when the exams are done, and when they can be stopped for any reason, without penalty. For those women who have disclosed CSA and even if a client has not disclosed prior abuse, but is showing distress during a pelvic exam, it would be appropriate to say, “I see this is stressful for you - I’m going to stop now. Are you OK? Let me know if I may continue. “ Having control is important to reduce re-traumatization of women during pregnancy care.
o Nurses may assist women during the perinatal period to regain confidence in their bodies, develop knowledge and skills that will increase their abilities for a positive childbirth experience, and contribute to the healing process.
- Knock before entering the room
- Provide private, well lighted exam room
- encourage questions and dialogue
- Reiterate that she is always free to talk about feelings that she thinks may be related to the abuse, or memories that may resurface, even if she doesn’t quite understand or has difficulty articulating them.
- Consider having a female assistant in the exam room for both patient comfort and risk management.
- Relinquish control. Recognize that the woman has the right to control her birth experience to the extent that it is possible.
- Are there fears or triggers he is concerned about?
- Explore with the woman how she has dealt with stressful, difficult, or physically demanding experiences in the past.
incidence of Depression during pregnancy
12-30%
risk factors for depression during pregnancy
family history (genetics may affect up to 37% of an individual developing depression),excessive stress, decreased seratonin- which helps to inhibit the stress response and increased noradrenergic responsiveness to stress- norepinephrine and dopamine. Increased levels of estrogen during pregnancy may decrease seratonin levels, and thyroid dysfunction may predispose mood disorders.
s/sx recognition depression during pregnancy
insomnia or hypersomnia, feeling overwhelmed, fatigue, anxiety, change in sleep or appetite habits, isolation, feeling of hoplessness agitation
maternal outcome of depression during pregnancy
increased risk for preeclampsia, increased substance abuse or risk of suicide, decreased self care and late to seek medical treatment, dysregulation of hypothalmic-adrenal-pituitary axis may lead to disruption of placental blood flow, mental illness during pregnancy is the strongest predictor of mental illness postpartum, preeclampsia
fetal outcomes depression during pregnancy
IUGR, PTB, increased admission to the NICU after birth, bonding is affected, increased risk of miscarriage early on
o Treatment options: depression during pregnancy
: screen for depression and talk about it,- managment either includes lifestyle changes or medication
Psychotherapy considered 1st line, not appropriate are monotherapy for moderate to severe depression but should be used as adjutant in these cases
Social support
Exercise
Diet
• Know appropriate data gathering/evaluation in pregnant women with depression when deciding treatment strategies.
Need to determine the severity of the depression, any family history of depression,
Medications are not appropriate for MILD depression or for those without a diagnosis of depression
• Know the risks of SSRI use in pregnancy.
Paxil has been associated with cardiac defects and should not be used
SSRIs (zoloft) have show an increase in persistent pulmonary HTN of the newborn which is characterized by neonatal jitteriness, hypertonia, feeding difficulties, tachypnea, and rarely seizures and resp. distress, and the rate of this is only 1-2 per 1000 births.
antidepressants
Medications:
TCAs- not used usually because of side effect profile. have not been associated with congenital anomalies, but have been associated with neonatal abstinence effects
Bupropion- not well studied yet but so far has not shown an increase in congenital anomalies
SSRIs-1st line option. Zoloft is often considered 1st (low serum levels, almost undetectable in breast milk). Paxil is avoided d/t increased risk of cardiac defects
• Know alternative treatment therapies for pregnant women with mild depression.
Assess the woman’s social support systems, look for ways to improve diet- especially with omega 3 in the diet because of its role in seratonin function, encourage exercise and sleep, accupuncture and light therapy may be effective.
• Know appropriate medication management for pregnant women with depression: those who are currently taking medications and those who are starting while pregnant
For women already taking medication for depression before pregnancy and if the medication is successfully controlling her depression, usually the medication is not changed because the risk of adverse effects overall in pregnancy is pretty low and changing medications may lead to relapse. If a woman needs to start antidepressants during pregnancy than waiting until after the first trimester is idea. Zoloft is first line but can lead to increased risk of cardiac septal defects (0.2%) but its advantages are that it has lower maternal serum levels than other SSRIs and can be used in breastfeeding.
o Rh sensitization
An individual who lacks a specific red cell antigen can produce antibodies when exposed to that antigen. These antibodies can prove harmful if she receives a blood transfusion or they may be harmful to a fetus during pregnancy. Rh sensitization occurs when an Rh positive baby is born to an Rh negative mother and fetal blood mixes with maternal blood. There are several pathways for this mixing to occur such as during the third stage of labor when the placenta separates. When this occurs antibodies are produced by mom which will affect subsequent Rh positive pregnancies. This can lead to hemolytic disease of the newborn.
o ABO incompatibilities
ABO incompatibility can occur when an infant with A or B blood type is born to a mother with O type blood, or an infant with B or AB blood is born to a mother with type A blood, or an infant with A or AB blood is born to a mother with type B blood. This can lead to ABO incompatibility which is usually treated with phototherapy.
differences between ABO incompatibility & Rh isoimmunization
ABO - effects 1st pregnancy, milder, treat with phototherapy, is considered more of a pediatric concern rather than OB concern, no need to screen during pregnancy for ABO incompatibilities due to only causing mild anemia. Most antibodies of ABO incompatibilities do not cause a problem during preganncy because they are IgM immunoglobulin and do not readily cross the placenta. In addition fetal RBC have less immunogenic properties. It can affect subsequest pregnancies but is NOT PROGRESSIVE
differences between ABO incompatibility & Rh isoimmunization
Rh - effects later pregnancies (after Rh sensitization occurs), fatal, affects subsequent pregnancies and deleterious effects are progressive, we screen for this in pregnancy and it is considered and OB problem. Antibodies readily cross placenta-cause fetal hydrops, anemia, CHF, and death
o Criteria for RhoGAM
RhoGAM is administered after threatened of spontaneous miscarriage later than 12 weeks gestation 50-300mg IM, after procedures or trauma 300mg IM, for prophylaxis at 28-36 weeks 300 mg IM with negative antibody screen. And 300 mg IM or IV Postpartum usually within 72 hours.
• Know the causes of fetomaternal hemorrhage that can induce isoimmunization.
Ectopic pregnancy, SAB, MVA, trauma, termination of pregnancy, amniocentesis, Chorionic villus sampling, external version, placenta previa, abruption, fetal death
• Understand how maternal Kell sensitization can occur
o How it occurs Anti-Kell sensitization can occur after blood transfusion with Kell positive blood; also related to maternal fetal incompatibility. Donated blood in U.S. is NOT routinely screened for kell antibodies (9% of population have Kell antibodies)
how it is detected,
through antibody testing. Use cordocentesis for fetal detection (if Kell antibodies are + in mom and FOB’s status can not be certain), amniocentesis often underestimates Kell isoimmunization/fetal anemia.
potential problems
rapid and severe Fetal anemia.
midwifery actions
ask about hx of blood transfusion and antibody testing done at first visit. If antibody screen is positive for anti-Kell, consult→ Need to determine fetal status (if fetus doesn’t have Kell antibodies it will be no problem)
• PUPPP syndrome
o Definition: benign dermatosis that usually arises late in the third trimester of a first pregnancy, more often occurring in women with multiples or a lot of weight gain during pregnancy, more common in primigravida women giving birth to males infants, or those with maternal hypertension. Seldom reoccurs in future pregnancies; has no adverse affects on the fetus
o S/SX: PUPP
Small vesicles surrounded by a narrow pale halo that appears in the straie of the abdomen but not around the periumbilicus, face, palms, or soles, and in a few days, the eruption spreads to the buttocks and proximal thighs and may generalize. Patients present for a diagnosis of their unusual skin eruption and seek relief from the intense itching. Small vesicles often are noted, but larger bullae, though documented in one case, typically do not occur and would suggest the possibility of herpes gestationis. Less commonly, target lesions and annular and polycyclic wheals may be present. Usually does not affect the face, palms, or soles.
PUPP appropriate data gathering
gravida and para, where is the rash, when did it start, and has she tried any treatments on it
PUPP labs
No blood or urine laboratory tests are diagnostic of pruritic urticarial papules and plaques of pregnancy (PUPPP). However, one large series of cases showed a significant reduction of serum cortisol levels in patients with PUPPP compared with normal pregnant controls. If appropriate consider R/O cholestasis with LFTs/Bile salts, Infection with titers and/or skin biopsy/culture
treatment for PUPP
corticosteroids and antihistamines
usually resolves in 4-6 weeks independent of delivery
symptom alleviation PUPP
may require high-potency topical (class I or II) steroids, such as fluocinonide, or even systemic steroids Prednison
caution with high potency corticosteroids because
could cause systemic absorption if used for greater than 2 weeks time or with open skin, and risk is higher with ointments than with creams or lotions. Use cautiously in those that have DM or HTN
Oral antihistamines
Diphenhydramine, an antihistamine, has a sedative effect that may help patients to sleep better; it is also an effective agent against pruritus resulting from histamine release during inflammatory reactions. Vistaril can also be used and may help
General treatment measures PUPP
include the use of cool, soothing baths; emollients; wet soaks; and light cotton clothing.
• Herpes gestationis AKA: pemphigoid gestationalis
o Definition: pregnancy-associated autoimmune disease most common in caucasians and does not necessarily occur in the first pregnancy. A greater prevalence of premature and small-for-gestational-age (SGA) babies is associated with early onset and the formation of blisters. More common in whites and has a higher relative prevalence in people with other autoimmune diseases, including Hashimoto thyroiditis, Graves disease, and pernicious anemia, which are also associated with HLA-DR3 and DR-4 haplotypes. Can increase maternal long term incidence of Graves Disease.
