Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

Module #4

Lesson Title: CARE OF THE HIGH-RISK PREGNANT CLIENT Materials:

(PRE-GESTATIONAL CONDITIONS- RH SENSITIZATION AND
HIV/AIDS) Pen, paper, index card, book, and class List

Learning Targets:
At the end of the module, students will be able to: References:
1. Define Rh sensitization in relation to pregnancy, including pre-
existing factors that contribute to its development. Pilliteri, Adele and Silbert-Flagg, JoAnne
2. Integrate knowledge of Rh Sensitization in relation to pregnancy (2018) Maternal and Child Health Nursing, 8th
and nursing process to achieve quality maternal and child health Edition. USA: Lippincott Williams and Wilkins
nursing care.
3. Identify the difference HIV/AIDS and its effect to pregnancy,
including preexisting factors that contribute to its development.
4. Integrate knowledge of HIV/AIDS to nursing process to achieve
quality maternal and child health nursing care.

A. LESSON PREVIEW/REVIEW

Instruction: Identify the following based on its description.

1. The most frequently abused drug during pregnancy Cocaine

2. When smoked causes tachycardia & a sense of well-being. Marijuana or Hashish

3. A potent analgesic and provides euphoric effect. Narcotic Agonists

4. Animal tranquilizer frequently used as a street drug Phencyclidine (PCP

5. Causes cognitive challenges and memory deficits Alcohol

B. MAIN LESSON.

HEMOLYTIC DISEASE OF THE NEWBORN

 Is caused by either Rh or ABO incompatibility
 Mother produces antibodies that destroy RBCs of the fetus; hemolysis results in fetal anemia and
hyperbilirubinemia
 Occurs when fetal red blood cells (RBCs) which possess an antigen that the mother lacks
 Cross the placenta into the maternal circulation, where they stimulate antibody production.
 The antibodies return to the fetal circulation and result in RBC destruction.

DIFFERENTIAL DIAGNOSIS of hemolytic anemia in a newborn infant:

 Isoimmunization
 RBC enzyme disorders (e.g., G6PD, pyruvate kinase deficiency)
 Hemoglobin synthesis disorders (e.g., alpha-thalassemia)
 RBC membrane abnormalities (e.g., hereditary spherocytosis, elliptocytosis)
 Hemangiomas (Kasabach Merritt syndrome)
 Acquired conditions, such as sepsis, infections with TORCH or Parvovirus B19 (anemia due to RBC aplasia) and
hemolysis secondary to drugs.

ISOIMMUNIZATION
1. ABO Incompatibility 2. RH INCOMPATIBILITY

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #4
 Occurs when maternal blood type is O and fetus is. Rh (D) factor is a protein antigen present on the surface of
a. Type A- most common some people’s RBC (Rh+)
b. Type B- most serious
c. Type AB- rare 1. Antibodies vs Rh antigen are not naturally occurring
but are produced when Rh+ blood enters the
1. The mother has inborn antibodies vs blood type A and bloodstream of an Rh- person.
B in her bloodstream. If fetus has type A or B blood 2. The Rh + gene is a dominant and therefore if either
and if maternal and fetal blood mix, maternal the mother or the father or both parents are Rh+, the
antibodies will perceive the fetal RBC as an antigen baby will be Rh+
and will destroy it.
2. Uncommon during pregnancy since antibodies is the Rh Sensitization/Rh Isoimmunization- It is the exposure
large IgM type & cannot cross placental barrier. of Rh- blood to Rh+ blood resulting to production anti-Rh
3. During delivery when placenta separates from the abs
decidua, the barrier is broken allowing maternal blood
to enter the fetal bloodstream. It can occur through:
4. Maternal antibodies will then destroy fetal RBCs after  Sensitization from previous pregnancy (Rh- mom with
birth Rh+ baby)
5. Thus, signs of hemolytic disease will manifest several  Inadequate response to prophylaxis
hours after delivery  Incompatible blood transfusion

CLINICAL PRESENTATION  Insignificant number of antibodies are formed during

 Generally, less severe than with Rh disease. pregnancy thus, 1st baby is not greatly affected.
 Greatest exposure occurs during placental
LABORATORY FINDINGS separation which causes massive production of anti
 Smear: micro spherocytosis Rh abs during 1st 72 hrs postpartum
 Mean Corpuscular Volume (MCV) <95, microcytic for  Rh+ fetuses in future pregnancies will be affected
a newborn (normal for adult)  Fetal anemia results & to compensate, fetal bone
 Direct Coombs test is often weakly +. marrow produces immature RBCs(erythroblasts)
causing Erythroblastosis Fetalis
MANAGEMENT
A. Preparation prior to delivery should include: ERYTHROBLASTOSIS FETALIS
 Blood: type O Rh negative packed RBCs, cross-  Fetal anemia may be so profound that it kills the
matched against the mother. fetus
 For severe HDN, have blood in the Resuscitation  RBC destruction causes massive production &
Room to correct severe anaemia immediately accumulation of bilirubin as the immature liver is
after birth by partial exchange transfusion (ExTx). unable to clear them from the body leading to
 Anticipate need for later ExTx for HYPERBILIRUBINEMIA & KERNICTERUS
hyperbilirubinemia and have additional blood for
these. Fetal Complications of Erythroblastosis Fetalis
 Surfactant, if infant is preterm. 1. Anemia
 Catheters (e.g., angiocaths) for immediate 2. Splenomegaly & hepatomegaly
drainage of hydropic fluid. 3. Hyperbilirubinemia
4. Hydrops fetalis as organs are not perfused
B. Resuscitation properly, the heart will eventually decompensate;
 Obtain cord blood for bilirubin (total & direct), fluid builds up resulting to edema
albumin, blood type & Rh, Direct Coombs test, 5. Stillbirth
CBC, platelets, reticulocyte count and nucleated
RBCs.
 assisted ventilation with oxygen. If ventilation is
difficult, drain pleural and ascitic fluid; during
o paracentesis, take care to avoid
puncturing the enlarged liver and spleen.
 Insert umbilical arterial (UAC) and venous
catheters (UVC) and immediately measure blood
pressures, arterial pH and blood gas tensions,
hematocrit (Hct) and blood sugar.
 Correct metabolic acidosis with alkali, but only if
giving assisted ventilation

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #4
 Correct anemia, which is essential for effective
resuscitation.
 Do not infuse packed RBCs or blood through UAC
because of risk of damage to spinal cord from
emboli.

Complications of Exchange Transfusion (ExTx):

 Hypocalcaemia due to Ca++ binding by citrate.
 Give Ca-gluconate 100 mg after every 100 mL of
blood exchanged.
 Hypoglycaemia particularly after the ExTx, due to
dextrose load from anticoagulant of donor blood and
hyperinsulinism in HDN.
 Thrombocytopenia and granulocytopenia due to
washout with the ExTx.
 Hyperkalaemia, especially with older units of blood.
 Hypothermia, associated with inadequate warming
of blood.
Prevention
1. Prenatal Screening
 History: past pregnancies, BT, abortion, invasive diagnostic procedures during pregnancy
 Blood typing & Rh typing
 Coomb’s test (titer >1:16 indicates sensitization); indirect Coomb’s Test (maternal serum), direct Coomb’s Test
(cord blood); if negative, test at 16 to 20 wks. and at 26-27 wks.
 Give RhIg aka anti Rho(D) gamma globulin(RhoGAM) at 28 wks. and within 72h after delivery

2. RHOGAM should be given to all Rh- women who:

 Have delivered Rh+ babies
 Have had pregnancies such as ectopic pregnancies, stillbirth & abortion
 Have received ABO compatible Rh+ blood
 Have had invasive dx procedures like amniocentesis or Chorionic Villi Sampling

Management
1. Amniocentesis q 2wks beginning at 26 wks. to monitor bilirubin
2. Percutaneous umbilical blood sampling at 18-20 wks. if bilirubin levels are high
3. 3Intrauterine Blood fetal transfusions (IUFT) at 10-day to 2-week intervals until 34-36 wks.

HIV/AIDS
 HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
 HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
 The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
 The virus enters the cell, substitutes its own RNA and DNA for the cell’s DNA, and begins to replicate, destroying the
lymphocytes in the process as well as their ability to initiate an effective B-lymphocyte response.

ETIOLOGIC AGENT:
1. retrovirus that targets helper T lymphocytes (T4 cells) that contain the CD4 antigen (which regulates normal immune
response) making the patient susceptible to opportunistic infections
2. Present in infected person’s blood, semen, and other body fluids

Risk factors: Assessment

 Multiple sexual partners of the individual or Early Symptoms:
sexual partner  Fatigue
 Bisexual partner, MSM  Anemia
 IV drug use by the individual or partner  Diarrhea
 Others: BT, tattoo, etc  Weight loss

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 Care of Mother and Child at Risk or with
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Module #4
 Lymphadenopathy
 Night sweats
Stages:
 Initial invasion of virus with mild, flulike symptoms
 Seroconversion- production of antibodies vs HIV; happens in 6 weeks to 1 year
 Asymptomatic period for 3 to 11 years
 Symptomatic period with opportunistic infections & possibly malignancies (CD4 cell count < 200cells/mm3)
 Toxoplasmosis, tuberculosis
 Oral & vaginal candidiasis
 GIT illnesses
 Kaposi sarcoma
 P. carinii pneumonia (PCP)- most common opportunistic infection
 Herpes simplex
 HIV-associated dementia
KAPOSI SARCOMA - is a cancer that causes patches PCP (Pneumocystis Carinii Pneumonia) - a life-
of abnormal tissue to grow under the skin, in the lining of threatening lung infection that can affect people with
the mouth, nose, and throat, in lymph nodes, or in other weakened immune systems, such as those infected with
organs. These patches, or lesions, are usually red or HIV, the virus that causes AIDS.
purple.

Assessment Management
 ELISA test- if (+) 2x then  Monitor CD4+ T cell counts.
 Western Blot Test- confirmatory test  Goal: maintain CD4 cell count > 500 cells/ mm3.
 In late infection, CD4+ T cell count <200cells/ul  Antiretroviral therapy: oral Zidovudine during
 Presence of opportunistic infections pregnancy & IV during labor & delivery) plus1 or more
 20-50% of infants born to untreated HIV + women protease inhibitors like ritonavir (Norvir) or indinavir
will contract the virus & develop AIDS in the 1st year (Crivixan) in conjunction with a nucleoside reverse
of life transcriptase inhibitor drug.
 Neonate is also given zidovudine
 Breastfeeding is not recommended
 Educate client on safe sex practices, testing of sex
partners
 Monitor client for signs of opportunistic infection: fever,
weight loss, fatigue, candidiasis, cough, skin lesions
 CS delivery-performed before rupture of membranes
 If vaginal delivery is unavoidable, no episiotomy!

CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. A 26-week pregnant client was diagnosed with ABO incompatibility. She asked you what her diagnosis means. Which
of the following is incorrect regarding ABO incompatibility?
A. The mother has inborn antibodies vs blood type A and B in her bloodstream.
B. Uncommon during pregnancy since antibodies is the large IgM type & cannot cross placental barrier

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #4
C. During delivery when placenta separates from the decidua, the barrier is broken allowing maternal blood to enter the
fetal bloodstream.
D. Antibodies vs Rh antigen are not naturally occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.

2. An 18-week pregnant client ask you what Rh incompatibility is. Which of the following is correct regarding Rh
Incompatibility? EXCEPT:
A. Rh (D) factor is a protein antigen present on the surface of some people’s RBC (Rh+)
B. Antibodies vs Rh antigen are not naturally occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.
C. The mother has inborn antibodies vs blood type A and B in her bloodstream.
D. The Rh + gene is a dominant and therefore if either the mother or the father or both parents are Rh+, the baby will be
Rh+

3. Kyra a client who gave birth to a female newborn and was diagnosed as having ABO incompatibility. Which of the
following is incorrect for the laboratory findings of a newborn with ABO incompatibility?
A. Blood Smear result is microspherocytosis
B. <95, microcytic for a newborn
C. Direct Coombs test is often weakly +
D. Direct Coombs test is often weakly –

4. Kyra’s child was ordered to have Exchange Transfusion. She asked you what the possible complications of the
procedure are. The following are complications of Exchange Transfusion, EXCEPT:
A. Hypothermia
B. Hypocalcemia
C. Hyperkalemia
D. Hypoglycemia
E. Hypernatremia

5. A patient was diagnosed with Habitual Abortion due to Rh incompatibility and had a fetal complication of
Erythroblastosis Fetalis. She asked you what the complication will be if she will get pregnant again. The following are
complications of Rh Incompatibility, EXCEPT:
A. Anemia
B. Splenomegaly & hepatomegaly
C. Hyperbilirubinemia
D. Wilms Tumor
E. Hydrops fetalis

6. The following are true regarding HIV/AIDS, EXCEPT:

A. HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
B. HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
C. The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
D. HIV/AIDS is spread through saliva.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #4

7. Remi a pregnant client asked you what the risk factors are for having HIV/AIDS. The following are risk factors of
HIV/AIDS, EXCEPT:
A. Multiple sexual partners of the individual or sexual partner
B. Bisexual partner
C. IV drug use by the individual or partner
D. Deep, open mouth kissing without mouth sores

8. A patient asked you regarding HIV/AIDS on what is Seroconversion. You know that Seroconversion is:
A. Seroconversion is the production of antibodies versus HIV that happens in 5 weeks to a year.
B. Seroconversion is the production of antibodies versus HIV that happens in 6 weeks to a year.
C. Seroconversion is the production of antibodies versus HIV that happens in 7 weeks to a year.
D. Seroconversion is the production of antibodies versus HIV that happens in 4 weeks to a year.

9. A pregnant client was admitted with a lung infection that can affect people with weakened immune systems, such as
those infected with HIV, the virus that causes AIDS. Which of the following condition pertains to the client’s condition?
A. Hospital Acquired Pneumonia
B. Community Acquired Pneumonia
C. Pneumocystis Carinii Pneumonia
D. Fungal Pneumonia

10. You were conducting a physical examination to a pregnant client. Upon examining the skin of the patient you saw red
to purplish skin patches and was told that she is taking Zidovudine. You know that the patient is having:
A. Angiosarcoma
B. Fibroblastic Sarcoma
C. Kaposi’s Sarcoma
D. Leiomyosarcoma

C. LESSON WRAP-UP

AL Activity: Formative Assessment

Formative assessment (assessment FOR learning) is the collection of information prior to or during instruction, that can be
used by the instructors to make instructional decisions and in-flight adjustments. This can improve student learning,
especially those who are struggling. This activity focuses on the assessment after a lesson. The student must answer the
following questions:

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #4

1. What specific part of the Main Lesson for this session do you find the most confusing?
2. What makes your answer in #1 confusing? What is the question in your mind?
3. Since that is your most confusing lesson, what are the interventions that you must do to understand the topic?

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