Infection is a common complication of pregnancy. The impact of infection on pregnancy is dependent on the infectious organ- ism involved. Some infectious agents, such as Trichomonas, are easily treated and affect only the mother. Other infections, such as rubella, can actively infect the fetus during pregnancy.
Infections can be acquired by the fetus transplacentally, such as HIV; may ascend the birth canal; or can be acquired though contact at the time of a vaginal birth, such as herpes. In the fol- lowing section, sexually transmitted diseases and TORCH infections are reviewed, highlighting maternal and fetal effects, treatment, and nursing implications.
Human Immunodeficiency Virus (HIV/AIDS)
The human immunodeficiency virus (HIV) organism is a retrovirus of the lentivirus family that has an affinity for the T-lymphocytes, macrophages, and monocytes. HIV/AIDS is a virus passed from one person to another through blood and sexual contact. The cases of HIV/AIDS among female adults and adolescents >13 years of age increased from 7% in 1985 to 27% in 2007 (Gilbert, 2011). According to the Centers for Disease Control, among female adults and adolescents diag- nosed with HIV/AIDS in 2007, 83% of 10,977 HIV/AIDS cases were attributed to high-risk heterosexual contact, 16%
to injection drug use, and 1% to other risk factors.
Transmission of HIV/AIDS is by exposure to blood or blood products or by-products. Transmission of HIV perina- tally happens through transplacental, intrapartal, and breast milk exposure. Before the use of antiviral therapy in pregnancy, Figure 7–13 Hydatidiform
mole.
C H A P T E R 7 ■ High-Risk Antepartum Nursing Care 165 the risk of infection for a neonate to an HIV seropositive
mother was approximately 25%, ranging from 13%–39%.
However, today most pregnant women are on regular anti- retroviral drug regimen, decreasing their HIV viral load to undetectable. As a result, the rate of maternal-child transmis- sion has decreased to less than 2% (ACOG, 2007).
Factors Associated with Increased Perinatal Transmission
■ Mother with AIDS
■ Preterm delivery
■ Decreased maternal CD4 count
■ High maternal viral load
■ Chorioamnionitis
■ Blood exposure due to episiotomy, vaginal laceration, and forceps delivery
Risks to Fetus and Newborn
■ Risk of transmission is 20%–25% without the use of anti- retroviral drugs but can be as low as 2% with appropriate antepartal drug treatment.
■ Preterm delivery
■ Preterm PROM
■ IUGR
Assessment Findings
■ Physical findings include fever, fatigue, vomiting, diar- rhea, weight loss, generalized lymphadenopathy, oral gin- givitis, vaginitis, and opportunistic infection.
Medical Management
■ Perform routine screening starting at first perinatal visit.
■ Treatment of at least three antiretroviral drugs Nursing Actions in Antepartal Period
■ Provide education and counseling on plan of care.
■ Provide education and counseling on potential conse- quences of pregnancy on HIV disease progress, risk for transmission, and consequences for neonate.
■ Education to facilitate health promotion
■ Adequate sleep
■ Adequate diet as protein deficiency can depress immunity;
adequate zinc and vitamin A for cell growth
■ Avoidance of infection
■ Provide emotional support.
■ If the woman is diagnosed with HIV during pregnancy, she needs extensive and ongoing education and counsel- ing on plan of care and management.
Nursing Actions in Intrapartal Period
■ Avoid using instruments during birth.
■ Leave fetal membranes intact.
■ Avoid fetal scalp electrode.
■ Avoid episiotomy and assisted vaginal delivery.
■ Provide and reinforce education.
■ Provide emotional support.
Sexually Transmitted Infections
Sexually transmitted infections (STIs),sometimes referred to as sexually transmitted diseases (STDs)remain a major public health challenge in the United States. The Centers for Disease Control and Prevention (CDC, 2010) estimates that 19 million new infections occur every year, almost half of them among young people age 15–24 years. STIs affect women of every socioeconomic and educational level, age, race, and ethnicity.
In addition to the physical and psychological consequences, the costs of treating STIs are estimated at more than $17 billion annually (CDC, 2010). Women who are pregnant can become infected with the same STIs as women who are not pregnant.
Pregnancy does not provide protection for the woman or the baby, and consequences of an STI can be serious in pregnancy, even life-threatening for the woman and her baby. Intrauterine or perinatal transmitted STIs can have severely debilitating effects on women, their partners, and their fetuses. All women should be screened for STIs during their first prenatal visit.
Table 7-5 shows the estimated number of women infected with specific STIs annually.
Risks for the Woman
■ STIs can cause pelvic inflammatory disease (Table 7-6).
■ Pelvic inflammatory disease (PID) can lead to infertility, chronic hepatitis, and cervical and other cancers.
■ STIs during pregnancy can lead to PTL, PROM, and uterine infection.
Table 7-7 summarizes information on maternal effects and management of STIs (CDC, 2010).
Risks for the Fetus
■ STIs can pass to the fetus by crossing the placenta; some can be transmitted to the baby during delivery as the baby passes through the birth canal (see Table 7-7).
■ Harmful effects to babies include preterm birth, low birth weight, neonatal sepsis, and neurological damage.
TABLE 7–5 ESTIMATED INCIDENCES OF STIS IN PREGNANT WOMEN ANNUALLY
ESTIMATED NUMBER OF
STI PREGNANT WOMEN
Bacterial vaginosis 1,080,000
Herpes simplex 880,000
Chlamydia 100,000
Trichomoniasis 124,000
Gonorrhea 13,200
Hepatitis B 16,000
HIV 6,400
Syphilis <1,000
Source: Centers for Disease Control and Prevention (CDC) (2010).
TABLE 7–6 PELVIC INFLAMMATORY DISEASE
PELVIC INFLAMMATORY DISEASE (PID)
INCIDENCE CONSEQUENCES
SIGNS AND SYMPTOMS OF PID
TREATMENT
Source: Centers for Disease Control and Prevention (CDC) (2010).
Pelvic inflammatory disease is a general term that refers to an infection of the uterus, fallopian tubes, and other reproductive organs.
It is a common and serious complication of STIs.
Pregnant women with PID are at high risk for maternal morbidity and preterm delivery and should be hospitalized and treated with IV antibiotics.
An estimated more than 1 million women in the United States have an episode of acute PID.
Can lead to infertility, ectopic pregnancy, abscess formation, and chronic pelvic pain.
Scar tissue in fallopian tubes increases the occurrence of ectopic pregnancies.
10%–15% of women with PID become infertile.
Signs and symptoms vary from none to severe including:
Lower abdominal pain, fever, unusual vaginal discharge, painful urination, and irregular menstrual bleeding.
Vague symptoms may go unrecognized.
PID can be cured with antibiotics, but treatment does not reverse damage to reproductive organs.
TABLE 7–7 SUMMARY OF FETAL AND MATERNAL EFFECTS AND MANAGEMENT OF STIS
INFECTION MATERNAL EFFECTS FETAL EFFECTS MANAGEMENT NURSING ISSUES
CHLAMYDIA CHLAMYDIA TRACHOMATIS
GONORRHEA NEISSERIA GONORRHOEAE
GROUP B
STREPTOCOCCUS STREPTOCOCCUS
AGALACTIAE (GBS)
Three-fourths of women have no symptoms, so it is known as a “silent”
disease; may have burning on urination or abnormal vaginal discharge.
Most women have no symptoms but may have burning on urina- tion, increased purulent yellow-green vaginal discharge, or bleeding between periods.
Rectal infection can cause anal itching, dis- charge, and bleeding.
Can lead to PID.
Women are typically asymptomatic carriers.
Symptoms can include abnormal vaginal discharge, urinary tract infections, chorioamnionitis.
Contact at delivery may cause conjunctivitis and/or premature birth.
The efficacy of oph- thalmia neonatorum prophylaxis is unclear.
Contact at birth.
Ophthalmia neonatorum may cause sepsis and/or blindness. To prevent gonococcal ophthalmia neonatorum, a prophy- lactic antibiotic oint- ment should be instilled into the eyes of all newborns.
Transmission rates are low, 1%–2%, but infection can result in invasive GBS with per- manent neurological sequelae.
Antibiotics Amoxicillin Azithromycin Erythromycin
Antibiotics Cephalosporin
If GBS-positive at 35–37 weeks of gestation or GBS status unknown, treat with antibi- otics in labor to prevent neonatal transmission.
Penicillin or ampicillin IV
Can lead to PID.
Treat all infected partners. Retest in 3 weeks.
Can lead to PID.
Complete treatment.
GBS-positive women receive intrapartum antibiotic prophylaxis.
C H A P T E R 7 ■ High-Risk Antepartum Nursing Care 167
TABLE 7–7 SUMMARY OF FETAL AND MATERNAL EFFECTS AND MANAGEMENT OF STIS—cont’d
INFECTION MATERNAL EFFECTS FETAL EFFECTS MANAGEMENT NURSING ISSUES HEPATITIS B (HBV)
HEPATITIS CRNA VIRUS (HCV)
HUMAN PAPILLO- MAVIRUS (HPV) Thirty or more
types infect the genital area.
SYPHILISTREPONEMA PALLIDUM
TRICHOMONAS TRICHOMONAS VAGINALIS
CANDIDIASIS CANDIDA ALBICANS*
50% asymptomatic May have low-grade
fever, anorexia, nausea and vomiting, fatigue, rashes. Chronic infection can lead to cirrhosis of the liver and liver cancer.
80% of persons infected have no symptoms.
Can lead to chronic liver disease, cirrhosis, and liver cancer.
The majority of HPV infections are asympto- matic but can cause genital warts.
Genital warts are flat, papular, or pedunculat- ed growths on the genital mucosa.
Ulcer or chancre, then maculopapular rash advancing to CNS and multiorgan damage.
Malodorous yellow- green vaginal discharge and vulvar irritation.
Can lead to premature rupture of membrane and preterm labor.
Results from a distur- bance in vaginal flora.
Pruritus, vaginal soreness, dyspareunia, abnormal vaginal discharge with a yeasty odor.
90% of infected infants have chronic infection Cirrhosis of the liver Liver cancer
Exposure transplacentally.
Estimated 2%–7% trans- mission rate. Little research on treatment of children.
Route of transmission unclear.
Can cause respiratory papillomatosis.
Transplacental transmission.
Congenital syphilis may cause preterm birth, physical deformity, neurological complica- tions, stillbirth, and/or neonatal death.
Preterm delivery and low birth weight.
Respiratory and genital infection.
No specific treatment
Ribavirin and inter- feron, but are contraindicated in pregnancy.
Warts may be removed during pregnancy.
Treatment reduces but does not elimi- nate HPV infection.
Penicillin
Metronidazole
Topical azole therapies
HBsAg-positive pregnant women should be report- ed to the state or local health department for timely and appro- priate prophylaxis for their infants.
Immunoprophylaxis of all newborns born to HBsAg- positive women.
HBIG to neonate at delivery and hepatitis Βvacci- nation series initiated.
Breastfeeding is not contraindicated.
The presence of genital warts is not an indication for cesarean delivery.
Continued
TABLE 7–7 SUMMARY OF FETAL AND MATERNAL EFFECTS AND MANAGEMENT OF STIS—cont’d
INFECTION MATERNAL EFFECTS FETAL EFFECTS MANAGEMENT NURSING ISSUES BACTERIAL
VAGINOSIS†
HUMAN IMMUNODE- FICIENCY VIRUS (HIV/AIDS)
Source:CDC (2010).
*Not an STI.
† A polymicrobial clinical syndrome
50% of women are asymptomatic.
A fishy odor and/or vaginal discharge.
Can result in preterm labor and/or premature rupture of membranes.
May be asymptomatic for years.
HIV weakens the immune system.
It may manifest as mononucleosis-like symptoms such as fever, fatigue, sore throat, and lymphadenopathy.
Premature rupture of membranes, chorioam- nionitis and/or preterm birth
Early antiretroviral treat- ment has been shown to be effective in reduc- ing maternal–fetal transmissions.
Placental transmission but <2% transmission with maternal treat- ment with antiretroviral medications. 15%–
25% transmission to fetus without maternal treatment.
Antibody screening is not reliable during infancy because of maternally produced IgG antibod- ies to HIV are present up to 18 months.
Metronidazole or clindamycin
Antiviral Cesarean birth may be considered.
Breastfeeding is contraindicated.
Case management follow-up for both the woman and her baby.
Assessment Findings
■ Many STIs in women are “silent” without signs and symp- toms, making routine screening for STIs during the first prenatal visit an important part of routine prenatal care.
■ Physical findings include low-grade temperature, poor personal hygiene, genital warts, purulent urethral or cervical discharge, friable cervix, genital lesions, tender uterus, pain on motion of cervix, inguinal adenopathy, and rash on palms and soles of feet.
■ Positive STI cultures and test results Medical Management (see Table 7-7)
■ Provide routine screening of STIs and HIV at first prenatal visit.
■ Treat bacterial STIs with antibiotics.
■ Prescribe antiviral medications for viral STIs to reduce symptoms.
Nursing Actions (see Table 7-7)
■ Provide information on STIs.
■ Provide emotional support.
■ Instruct the woman on correct administration of medica- tions and other treatments and importance of completing treatment.
■ Instruct the patient on the warning signs of complication (fever, increased pain, bleeding).
■ Provide information on the importance of abstaining from intercourse until the patient and her partner are free of infection.
■ Provide the partner with treatment as indicated.
TORCH Infections
TORCH is an acronym that stands for Toxoplasmosis, Other (hepatitis B), Rubella, and Cytomegalovirus and Herpes simplex virus. TORCH infections are unique in their pathogenesis and have potentially devastating effects on the developing fetus (Table 7-8). Each disease is teratogenic to the developing fetus.
Risk Factors
The risk status for these infections varies based on route of transmission. Some are sexually transmitted diseases, such as
C H A P T E R 7 ■ High-Risk Antepartum Nursing Care 169
TABLE 7–8 TORCH INFECTIONS
MATERNAL PREVENTION AND
INFECTION EFFECTS FETAL EFFECTS MANAGEMENT NURSING ISSUES
TOXOPLASMOSIS TOXOPLASMA GONDII Single-celled
protozoan parasite.
Transplacental transmission
OTHER INFECTIONS HEPATITIS B Direct contact with
blood or body fluid from infected person.
RUBELLA
(GERMAN MEASLES) Nasopharyngeal
secretions Transplacental
CYTOMEGALOVIRUS (CMV)
Virus of herpes group Transmitted by droplet
contact and transplacentally
HERPES SIMPLEX VIRUS (HSV) Chronic lifelong viral
infection
Contact at delivery and ascending infection
Source: Queenan, Hobbins, & Spong (2005).
Most infections are asymptomatic but may cause fatigue, muscle pains, pnuemonitis, myocarditis, and lymphadenopathy.
30%–50% of infect- ed women are asymptomatic.
Symptoms include low-grade fever, nausea, anorexia, jaundice, hepatomegaly, preterm labor, and preterm delivery.
Erythematous mac- ulopapular rash, lymph node enlargement, slight fever, headache, malaise
Most infections are asymptomatic, but 15% of adults may have mononucleo- sis-like syndrome.
Painful genital lesions.
Lesions may be on external or internal genitalia.
Severity varies with gesta- tional age and congenital infection. Can lead to spontaneous abortion, low birth weight, hepatosplenomegaly, icterous, anemia, chorioretinitis, and/or neurological disease.
Incidence of congenital infection is low.
Infants have a 90% chance of becoming chronically infected, HBV carrier, and a 25% risk of developing significant liver disease.
Overall risk of congenital rubella syndrome is 20% for primary maternal infection in the first trimester with 50% if the woman is infect- ed in the first 4 weeks of gestation. Anomalies include deafness, eye defects, CNS anomalies, and severe cardiac malformations.
Infection to fetus is most likely with primary mater- nal infection and timing of infection with first- and second-trimester exposure.
May result in low birth weight, IUGR, hearing impairment microcephaly, and CNS abnormalities.
Transmission rate of 30%–
50% among women who acquire genital herpes near time of delivery and is low (<1%) among women with recurrent genital herpes.
Mortality of 50%–60% if neonatal exposure to active primary lesion is related to neurological complications of massive infection sepsis and neuro- logical complications.
Avoid eating raw meat and contact with cat feces.
Treatment with sulfadiazine or pyrimethamine after the first trimester
Infant receives HBIG and hepati- tis vaccine at delivery.
Primary approach to rubella infection is immunization.
If the woman is pregnant and not immune, she should not receive the vaccine until the postpartum period.
No treatment is available.
No cure available.
Acyclovir to sup- press outbreak of lesions.
Teach women to avoid raw meat and cat feces.
Almost 50% of adults have an antibody to this organism.
Universal screen- ing recommend- ed in pregnancy.
HBV can be given in pregnancy.
If the woman is not immune, she should not receive the vaccine until the postpartum period and be counseled to not become pregnant for 3 months.
Most common viral STI.
Protect the neonate from exposure with cesarean delivery if active lesion.
has decreased oxygen reserves and decreased blood buffering capacity, which leaves the pregnant trauma patient vulnerable to hypoxemia and less able to compensate when acidemia occurs (Ruth & Miller, 2013). Two catastrophic events can occur during pregnancy after blunt trauma to the abdomen:
■ Placental abruption
■ Uterine rupture
Extensive discussion of management and care during trau- ma in pregnancy is beyond the scope of this chapter, but key elements of stabilization of the woman and the fetus and assessments are briefly reviewed. Treatment priorities for injured pregnant women typically are directed as they would be for non-pregnant women. Some important considerations related to pregnancy are presented in the following section.
Assessment Findings
Assessment findings are based on injury. Initial maternal evaluation is the systematic evaluation performed according to the standard Advanced Trauma Life Support (ATLS) pro- tocols. Initial maternal evaluation and resuscitation takes precedence over fetal evaluation. Early recognition of mater- nal compromise and rapid resuscitation reduces maternal mortality, which in turn reduces fetal mortality.
■ Physiological changes in pregnancy might delay the usual vital sign changes of hypovolemia; blood loss of up to 1,500 mL can occur without a change in maternal vital sign changes.
■ Uterine contractions more frequently than every 10 min- utes may be an indication of placental abruption
(Cunningham et al., 2010).
■ Fetal well-being reflects maternal and fetal status, and conversely fetal heart rate changes may indicate maternal deterioration such as hypoxia.
Medical Management
Treatment priorities and medical management for the preg- nant trauma patient are the same as for the non-pregnant woman in the initial evaluation. Admission and continuous fetal monitoring for 24 to 48 hours after stabilization, in par- ticular for abdominal injuries because of the increased inci- dence of placental abruption, is recommended.
Nursing Actions
■ Treatment priorities for injured pregnant women typical- ly are directed as they would be for non-pregnant women.
■ Initial actions in trauma care are focused on maternal sta- bilization.
P
REGESTATIONAL COMPLICATIONSWomen who enter pregnancy with a preexisting disease or chronic medical condition are at increased risk for complication and are considered high-risk. These high-risk pregnancies herpes; others have various routes of transmission to woman
(CDC, 2010).
Risk for the Woman
■ Depends on the infectious agent (CDC, 2010; see Table 7-8)
Risks for the Fetus
■ The usual route of transmission to the fetus is transpla- centally (see Table 7-8).
■ Infections acquired in utero can result in intrauterine growth restriction, prematurity, chronic postnatal infec- tion, and even death.
Assessment Findings
■ Maternal assessment findings vary with the organism (see Table 7-8).
Medical Management
■ Medical management varies based on the organism, trimester of exposure, and clinical evidence of neonatal sequelae (see Table 7-8).
Nursing Actions
■ Nursing considerations vary with the organism (see Table 7-8).
■ Provide emotional support.
■ Instruct woman on treatment plan.
T
RAUMA DURING PREGNANCYTrauma is the leading cause of maternal death during pregnancy and is more likely to cause maternal death than any other com- plication of pregnancy. The most common cause of maternal death by trauma is abdominal injury (resulting in hemorrhagic shock) and head injury. Injury to the pregnant woman can result from blunt or penetrating trauma. The most common cause of blunt injury is motor vehicle accidents. The most common cause of penetrating trauma is from gunshot wounds. The mecha- nisms of maternal and fetal injury, gestational age of the fetus, and secondary complications determine the maternal-fetal response to trauma. Maternal outcome in trauma corresponds to the severity of the injury. Fetal outcome depends on injury and maternal physiological response (Van Otterloo, 2011). It is essential to keep in mind that at term, 15% of maternal cardiac output, that is, 750 mL to 1000 mL/min, flow through the placental bed; unresolved bleeding can lead to maternal exsan- guination in 8 to 10 minutes (Burke-Sosa, 2014).
Pregnancy causes both anatomic and physiological changes that impact the woman’s response to traumatic injury. For example, increased plasma volume by 50% and increased red blood cell volume of 30% can mask hemorrhage. Any condition that results in maternal hypotension, such as hemorrhage or hypovolemia, results in vasoconstriction of the uterine arteries and shunting of blood to vital organs. The shunting of blood from the uteroplacental unit maintains maternal blood pressure at the expense of perfusion to the fetus. The pregnant woman