Hyperemesis Gravidarum and Rh Sensitizat

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Information about Hyperemesis Gravidarum and Rh Sensitizat
Science-Technology

Published on January 26, 2009

Author: karamonina

Source: authorstream.com

Hyperemesis Gravidarum and Rh Sensitization : Hyperemesis Gravidarum and Rh Sensitization Prepared by: Cajigas, Teocrine Jitt C. Corpuz, Arjane Ann P. Petallar, May Angeli G. Hyperemesis Gravidarum : Hyperemesis Gravidarum Hyperemesis Gravidarum : Hyperemesis Gravidarum a severe and intractable form of nausea and vomiting in pregnancy. may result in weight loss; nutritional deficiencies; and abnormalities in fluids, electrolyte levels, and acid-base balance. While more common in the first trimester (peak incidence is at 8-12 weeks), it often continues throughout the entire pregnancy. Symptoms usually resolve by week 20 in all but 10% of patients. Fortunately, if caught in time and treated properly, it presents little risk to you or your baby. Distinguishing between Morning Sickness and Hyperemesis Gravidarum : Distinguishing between Morning Sickness and Hyperemesis Gravidarum Factors Causing Hyperemesis Gravidarum : Factors Causing Hyperemesis Gravidarum High levels of hCG (human chorionic gonadotropin). Increased estrogen levels. Gastrointestinal changes. Stress and High-fat diet. Helicobacter pylori. Risk factors : Risk factors Hyperemesis gravidarum is more common in: Trophoblastic disease Multiple pregnancies Those who have had hyperemesis gravidarum in a previous pregnancy Those with a family history of hyperemesis gravidarum Nulliparity Female fetus Maternal obesity Age < 30 years Supportive measures : Supportive measures To reduce nausea A few soda crackers or dry toast when you first wake up, even before you get out of bed in the morning. A small snack at bedtime and when getting up to go to the bathroom at night. Avoiding large meals; instead, snack as often as every 1-2 hours during the day and drink plenty of fluids. Eating foods high in protein and complex carbohydrates, such as peanut butter on apple slices or celery; nuts; cheese; crackers; milk; cottage cheese; and yogurt; avoid foods high in fat and salt, but low in nutrition. Slide 9: Ginger products (proven effective against morning sickness) such as ginger tea, ginger candy, and ginger soda. The first used ginger 250mg four times daily and the second used 1 tablespoon of ginger syrup in 4-8 fluid ounces of water four times daily. Drink and eat little and often. Cold meals reduce smell-related nausea. Avoid caffeine and alcohol as these can enhance dehydration Slide 10: Acupressure wrist bands or acupuncture may help. The pressure point to reduce nausea is located at the middle of the inner wrist, three finger lengths away from the crease of the wrist, and between the two tendons. Locate and press firmly, one wrist at a time for three minutes. Get as much rest as possible Avoid smoking and secondhand smoke. Slide 11: Avoid taking medications for morning sickness. If you do, ask a doctor first. Keep air flowing through rooms to reduce odors. When you feel nauseated, bland foods like gelatin, broth, ginger ale, and saltine crackers can soothe your stomach. When to Contact a Medical Professional : When to Contact a Medical Professional Call your doctor if: Morning sickness does not improve, despite trying home remedies. Nausea and vomiting continue beyond your 4th month of pregnancy. This happens to some women and is usually normal, but have it checked out. You lose more than 2 pounds. Slide 13: You vomit blood or material that looks like coffee grounds. (Call IMMEDIATELY.) You vomit more than 3 times per day or you cannot keep food or liquid down. Diagnostic Tests : Diagnostic Tests Blood tests including CBC and blood chemistry (chem-20) Urine tests Treatment in hospital : Treatment in hospital Because of the potential for severe dehydration, severe cases of hyperemesis gravidarum require hospitalization. Once there, Parenteral fluid and electrolyte replacement: Normal saline or Hartmann's solution should be used as dextrose containing fluids that are rich in carbohydrate may precipitate Wernicke's encephalopathy. After receiving intravenous (IV) fluids for 24 to 48 hours, you may be ready to eat a clear liquid diet and then move on to eating several small meals a day Slide 16: Management of nausea and vomiting symptoms: This should include the general supportive measures recommended drug treatment as detailed above. The intravenous or rectal route of drug administration may be needed initially. Parenteral nutrition: This should be commenced if the woman continues to lose weight. Vitamin supplementation: Thiamine should be given routinely, orally or intravenously, to prevent Wernicke's encephalopathy. Medications: : Medications: Antihistamines ( promethazine, prochlorperazine, metoclopramide): Phenothiazines: Vitamin B6, Antiemetics (Ondansetron) Metoclopramide Short courses of intravenous pulsed hydrocortisone Emotional Support : Emotional Support Because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues. Complications : Complications For the pregnant woman Wernicke's encephalopathy: This is due to thiamine deficiency. Clinical features include diplopia, nystagmus, ophthalmoplegia, ataxia and confusion. Other vitamin deficiencies: Vitamin B12 and vitamin B6 deficiency can cause anemia, peripheral neuropathy , and sub acute combined degeneration of the spinal cord. Slide 20: Mallory-Weiss tears and oesophageal rupture. Hyperthyroxinaemia. Hyponatraemia: This can lead to lethargy, confusion, convulsions and respiratory arrest. Depression: the common 20 complication of HG. For the fetus : For the fetus Prolonged stress, dehydration and malnutrition during pregnancy can put the fetus at risk for chronic disease, such as diabetes or heart disease, later in life, or neurobehavioral issues from birth. Infants born from hyperemetic mother have higher incidence of low in birth weight Prevention : Prevention All women with nausea and vomiting in pregnancy should be reassured of its (usually) benign and normal nature. Self-help measures, dietary modifications and non-drug treatment should be initiated early. Any woman with ketonuria should be commenced on drug treatment with anti-emetics. Frequently Asked Questions : Frequently Asked Questions Q: Can I take steps to prevent this from happening to me? A: Women who start taking prenatal vitamins early in pregnancy seem to be at lower risk of hyperemesis. Once symptoms start, it's important to get care as soon as possible, so that the problem doesn't progress. Q: I am suffering from a mild case of hyperemesis gravidarum. Am I going to be sick like this my whole pregnancy? A: For most women, nausea and vomiting are worse between six and 12 weeks gestation, and will subside and even vanish by the second half of pregnancy. Slide 25: Q: Are there any serious complications with hyperemesis gravidarum? A: Complications are extremely rare, but do happen. Mallory-Weiss tears (tears to the cardiac part of the stomach from excessive vomiting) and Wernicke's encephalopathy (a syndrome related to thiamin deficiency that may cause disorientation, confusion, and coma) have been reported in some rare cases. Miscarriage is extremely rare. In fact, women with bad nausea and vomiting have lower rates of miscarriage than those who breeze through early pregnancy. Rh Sensitization : Rh Sensitization Rh Sensitization : Rh Sensitization There are blood types ABABO. Each of these blood types has specific proteins on the surfaces of their RBCs. Each of the four blood types is additionally classified according to the presence of another protein on the surface of the RBCs that indicates the Rh factor. If you carry this protein, you are Rh positive. If you don’t carry the protein, you are Rh negative. Slide 28: Rh sensitization occurs when a mother with Rh-negative blood is conceives to a man which has Rh-positive blood. If your blood mixes with Rh-positive blood, your immune system will react to the Rh factor by making antibodies to destroy it. This immune system response is called Rh sensitization. Slide 29: The minimum amount of blood mixing necessary to cause sensitization is not known. However, some women who become sensitized do so after becoming exposed to as little as 0.1mL of Rh-positive blood. Rh sensitization in nullipara occurs when: : Rh sensitization in nullipara occurs when: You had a previous miscarriage, abortion, or ectopic pregnancy and you did not receive Rh immune globulin to prevent sensitization. You had a serious injury to your belly during pregnancy. You had a medical test such as an amniocentesis or chorionic villus sampling while you were pregnant, and you did not receive Rh immune globulin. These tests could let your blood and your baby’s blood mix. Slide 31: In the case that you get pregnant again with an Rh-positive baby, the antibodies already in your blood could attack the baby’s red blood cells. This can cause the baby to have anemia, jaundice, or more serious problems. This is called Rh disease. The problems will tend to get worse with each Rh-positive pregnancy you have. Risk Factors : Risk Factors Delivery. Abdominal trauma, such as from a car accident. Abdominal surgery, such as a cesarean section. Placenta abruptio or placenta previa, both of which can cause placental bleeding. External cephalic version for a breech fetus. Obstetric procedures such as amniocentesis, fetal blood sampling, or chorionic villus sampling (CVS). Miscarriage (spontaneous abortion), ectopic pregnancy, or elective abortion (medical or surgical abortion) after 8 weeks of fetal age (when fetal blood cell production begins). Partial molar pregnancy involving fetal growth beyond 8 weeks. Genetic Determinants Of Blood Rh Factor : Genetic Determinants Of Blood Rh Factor Your blood's Rh factor is either positive (Rh+) or negative (Rh-). The Rh+ gene is more common than the Rh- gene, and is dominant. If one of your two Rh genes is Rh+ and the other is Rh-, your blood type is Rh+. It takes a pair of Rh- genes to make your blood type Rh-. Slide 35: When an Rh- woman conceives with an Rh+ man, it is probable that their offspring will be Rh+. If the father has two Rh+ genes, the fetus will inherit an Rh+ gene. That Rh+ gene, paired with the mother's Rh- gene, will result in an Rh+ fetal blood type. If the father has one Rh+ and one Rh- gene, the fetus will inherit one of them, either: An Rh+ gene, resulting in an Rh+ fetal blood type, or An Rh- gene which, when paired with the mother's Rh- gene, results in an Rh- fetal blood type. Diagnosis: : Diagnosis: It doesn't cause any warning symptoms, and a BLOOD TEST is the only way to know you have it or are at risk for it. Blood test results: : Blood test results: If you have Rh-negative blood but are not sensitized: The blood test may be repeated between 24 and 28 weeks of pregnancy. If the test still shows that you are not sensitized, you probably will not need another antibody test until delivery. (You might need to have the test again if you have an amniocentesis, if your pregnancy goes beyond 40 weeks, or if you have a problem such as placenta abruptio, which could cause bleeding in the uterus.) Your baby will have a blood test at birth. If the newborn has Rh-positive blood, you will have an antibody test to see if you were sensitized during late pregnancy or childbirth. Slide 38: If you are Rh-sensitized, your doctor will watch your pregnancy carefully. You may have: Regular blood tests, to check the level of antibodies in your blood. Doppler ultrasound, to check blood flow to the baby’s brain. This can show anemia and how severe it is. Amniocentesis after 15 weeks, to check the baby’s blood type and Rh factor and to look for problems. If you are already sensitized to the Rh factor : If you are already sensitized to the Rh factor If you are already Rh-sensitized or become sensitized while pregnant, close monitoring is important to determine whether your fetus is being harmed. An indirect Coombs' test is done periodically during your pregnancy to see if your Rh-positive antibody levels are increasing. This is the typical course of treatment for most sensitized women during pregnancy. Fetal Doppler ultrasound of blood flow in the brain shows fetal anemia and how bad it is. At a medical center with Doppler experts, this test can give you the same anemia information as amniocentesis, without the risks. Slide 40: Amniocentesis may be done: At or after 15 weeks to check amniotic fluid for signs of fetal problems. To learn the fetal blood type and Rh factor. On a repeated basis to check fetal anemia. This tells how much a fetus is being affected by sensitization. To check serum bilirubin concentration. It should not exceed 200-250 micromole. Repeated every 2-4 weeks if mildly affected, every 1-2 weeks if moderately affected and every week if severely affected Fetal blood sampling (cordocentesis) may be done to directly assess your fetus's health. This procedure is used on a limited basis, usually for monitoring known sensitization problems (as when a mother has had previous fetal deaths, or when other testing has shown signs of fetal distress). Slide 41: Electronic fetal heart monitoring (nonstress test) may be done in the third trimester to check your fetus's condition. Unusual fetal heart rhythms detected during a nonstress test may be a sign that the fetus has anemia related to the sensitization. Fetal ultrasound testing can be used as a pregnancy progresses to detect sensitization problems, such as fetal fluid retention and organ enlargement (a sign of severe Rh disease). Diagnostic Test After Birth : Diagnostic Test After Birth Testing baby’s umbilical cord for blood group, Rh factor, RBC count and antibodies Testing baby’s blood for bilirubin level Coomb’s Test- looks for antibodies that acts against person’s RBC. It has 2 forms: Indirect Coomb’s Test – tests for antibodies that flow freely in the blood serum. More frequently, it is used to determine whether a person might have a reaction after blood transfusion. Direct Coomb’s Test – used to detect antibodies on the surface of the RBC. It is used to diagnose anemia/jaundice. Results: : Results: Normal Results: No agglutination – absence of clumping cells Abnormal Results: Direct: (+) – means the baby has antibodies that acts against his RBC Indirect: (+) – means that the baby has antibodies that the body views as foreign. This may suggest Erythroblastosis Fetalis Types of Rh Disease: : Types of Rh Disease: Mild Rh disease involves limited destruction of fetal red blood cells, possibly resulting in mild fetal anemia. The fetus can usually be carried to term and requires no special treatment but may have problems with jaundice after birth. Mild Rh disease is more likely to develop in the first pregnancy after sensitization has occurred. Moderate Rh disease involves the destruction of larger numbers of fetal red blood cells. The fetus may develop an enlarged liver and may become moderately anemic. The fetus may need to be delivered before term and may require a blood transfusion before (while in the uterus) or after birth. A newborn with moderate Rh disease is watched closely for jaundice. Slide 45: Severe Rh disease (fetal hydrops) involves widespread destruction of fetal red blood cells. The fetus develops severe anemia, liver and spleen enlargement, increased bilirubin levels, and fluid retention (edema). The fetus may need one or more blood transfusions before birth. A fetus with severe Rh disease who survives the pregnancy may need a blood exchange. This procedure replaces most of the infant's blood with donor blood (usually type O, Rh-negative). *A history of pregnancy with Rh disease is a sign that you will need special treatment when you are pregnant with an Rh-positive fetus. Complications: : Complications: Hemolytic anemia – destruction of the RBCs of the neonate by the antibodies produced by the mother Hydrops Fetalis – severe edema of the body which may be associated with heart failure and respiratory problems Kernicterus – neurologic disorder caused by binding of bilirubin with fatty tissue in the brain and CNS, manifested by increased bilirubin levels, extreme jaundice, absent startle reflex, poor suck, and lethargy. Slide 47: Hydrops Fetalis Prevention: : Prevention: If you have Rh-negative blood but are not Rh-sensitized, your doctor will give you one or more shots of Rh immune globulin (such as RhoGAM). This prevents Rh sensitization in about 99 women out of 100 who use it. You may get a shot of Rh immune globulin: If you have a test such as an amniocentesis. Around week 28 of your pregnancy. After delivery if your newborn is Rh-positive. The shots only work for a short time, so you will need to repeat this treatment each time you get pregnant. (To prevent sensitization in future pregnancies, Rh immune globulin is also given when an Rh-negative woman has a miscarriage, abortion, or ectopic pregnancy.) *The shots won't work if you are already Rh-sensitized. Treatment Of A Baby With A Sensitized Mother : Treatment Of A Baby With A Sensitized Mother If you are Rh-sensitized, you will have regular testing to see how your unborn baby is doing. You may also need to see a doctor who specializes in high-risk pregnancies (a perinatologist). Treatment of the baby is based on how severe the loss of red blood cells (anemia) is. If the baby’s anemia is mild, you will have more testing than usual while you are pregnant. Phototherapy may also be used. If anemia is getting worse, it may be safest to deliver the baby early. After delivery, some babies need a blood transfusion or treatment for jaundice. For severe anemia, a baby can have a blood transfusion while still in the uterus. This can help keep the baby healthy until he or she is mature enough to be delivered. You will most likely have an early C-section, and the baby may need to have another blood transfusion right after birth. Slide 50: Exchange transfusion – for moderate to severe hemolytic anemia. It aims to replace all the blood including normal RBCs, bilirubin, antibody, and fetal RBCs coated with maternal antibody with a fresh blood preferably type O blood. Risk for Exchange Transfusion: : Risk for Exchange Transfusion: Infants with visisble jaundice for 12 hours after birth hemoglobin below 10 mg/dl infants with mild to severe Rh disease, those who did not receive intrauterine blood transfusion Nursing Responsibilities: : Nursing Responsibilities: Overall Encourage blood test for all pregnant women Assess pregnant women for possible Rh incompatibility Educate about Rh incompatibility, Rh antibodies/ Rhogam Monitor infants for jaundice Encourage early and frequent breastfeeding Instruct about adequate follow-up For Intrauterine Blood Transfusion : For Intrauterine Blood Transfusion Assess FHR: baseline, variability, accelerations, decelerations and significant changes For Exchange Blood transfusion : For Exchange Blood transfusion Obtain informed consent for exchange transfusion Assess hemoglobin and bilirubin level Monitor cardio-respiratory status and O2 sat Resuscitation equipment and drugs be checked for emergency use Assess for appearance of increased jaundice, change in urinary frequency, pigmentation, and behavioral changes For Phototherapy : For Phototherapy Monitor infant’s temperature Observe meticulous eye care Ensure eye patches are in place over the eyes MIO:assess for DHN, daily weight and skin condition

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