Genital herpes is a recurrent, lifelong viral infection. The CDC estimates that one out of six people 14 to 49 years old have genital herpes simplex (HSV) infec-tion, with 0.5 million new cases annually
Two serotypes of HSV have been identied: HSV-1 (not sexually transmitted) and HSV-2 (sexually transmitted).
HSV-1 causes the familiar fever blisters or cold sores on the lips, eyes, and face. HSV-2 invades the mucous membranes of the genital tract and is known as her-pes genitalis.
No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes.
Clinical manifestations can be divided into the primary episode and recurrent infections. The first or primary episode is usually the most severe, with a prolonged pe-riod of viral shedding. Primary HSV is a systemic disease characterized by multiple painful vesicular lesions, mu-copurulent discharge, superinfection with candida, fever, chills, malaise, dysuria, headache, genital irritation, in-guinal tenderness, and lymphadenopathy. The lesions in the primary herpes episode are frequently located on the vulva, vagina, and perineal areas. The vesicles will open and weep and finally crust over, dry, and disappear with-out scar formation. This viral shedding process usually takes up to 2 weeks to complete.Recurrent infection episodes are usually much milder and shorter in duration than the primary one. Tingling, itching, pain, unilateral genital lesions, and a more rapid resolution of lesions are characteristics of re-current infections. Recurrent herpes is a localized disease characterized by typical HSV lesions at the site of initial viral entry. Recurrent herpes lesions are fewer in number and less painful and resolve more rapidly
Diagnosis of HSV is often based on clinical signs and symptoms and is conrmed by viral culture of uid from the vesicle
Pap smear is not reliable for diagnosis
Patterns of inheritance demonstrate how genetic abnormalities can be passed on to offspring.
Mendelian or Monogenic Laws of Inheritance:
These patterns occur because a single gene is defective and the disorders that result are referred to as mono-genic or, sometimes, Mendelian disorders.
Monogenic disorders include autosomal dominant, autosomal recessive, X-linked dominant, and X-linked recessive patterns.
If the defect occurs on the autosome, the genetic disorder is termed autosomal; if the defect is on the X chromosome, the genetic disorder is termed X-linked.
Multifactorial Inheritance Disorders:
Many of the common congenital malformations, such as cleft lip, cleft palate, spina bifida, pyloric stenosis, club-foot, congenital hip dysplasia, and cardiac defects, are attributed to multifactorial inheritance these conditions are thought to be caused by multiple gene and environmental factors. That is, a combination of genes from both parents, along with unknown environmental factors, produces the trait or condition.
Nontraditional Inheritance Patterns
Molecular studies have revealed that some genetic disorders are inherited in ways that do not follow the typical patterns of dominant, recessive, X-linked, or multifactorial inheritance.
Examples of nontraditional inheritance patterns include:
Mitochondrial inheritance: Certain diseases result from mutations in the mitochondrial DNA. Mitochondria (the part of the cell responsible for energy production) are inherited almost exclusively from the mother.
In genomic imprinting both the maternal and paternal alleles are present, but only one is expressed; the other is inactive. Genomic imprinting does not alter the genetic sequence itself, but affects the phenotype observed.
As the uterus grows, it presses on the urinary bladder and causes the increased frequency of urination experi-enced during early pregnancy. In addition, the heavy gravid uterus in the last trimester can fall back against the inferior vena cava in the supine position, resulting in vena cava compression, which reduces venous re-turn and decreases cardiac output and blood pressure, with increasing orthostatic stress. This occurs when the woman changes her position from recumbent to sitting to standing. This acute hemodynamic change, termed supine hypotensive syndrome, causes the woman to experience symptoms of weakness, light-headedness, nausea, dizziness, or syncope
These changes are reversed when the woman is in the side-lying position, which displaces the uterus to the left and off the vena cava.
The FDA and the EPA are advising women who may become pregnant, pregnant women, and nursing mothers to do the following:
-Avoid consumption of fish with moderate-to-high mercury levels (e.g., for 6 to 12 months prior to conception and throughout pregnancy).
-Avoid eating shark, swordfish, king mackerel, orange roughy, ahi tuna, and tilefish because they are high in mercury levels.
- Eat up to 12 ounces (two average meals) weekly of low-mercury-level fish such as shrimp, canned light tuna, salmon, pollock, and catfish.
Check local advisories about the safety of sh caught by family and friends in local lakes, rivers, and coastal areas
The nonstress test (NST) is an indirect measurement of uteroplacental function.
The basis for the nonstress test is that the normal fetus produces characteristic fetal heart rate patterns in response to fetal movements. In the healthy fetus there is an ac-celeration of the fetal heart rate with fetal movement. Currently, an NST is recommended twice weekly (after 28 weeks of gestation) for clients with diabetes and other high-risk conditions, such as IUGR, preeclampsia, post-term pregnancy, renal disease, and multifetal pregnancies
Before the procedure the client eats a meal to stimulate fetal activity. Then she is placed in the left lateral recumbent position to avoid supine hypotension syndrome. An external electronic fetal monitoring device is applied to her abdomen. The device consists of two belts, each with a sensor. One of the sensors records uterine activity; the second sensor records fetal heart rate. The client is handed an "event marker" with a button that she pushes every time she perceives fetal movement. When the but-ton is pushed, the fetal monitor strip is marked to identify that fetal movement has occurred. The procedure usually lasts 20 to 30 minutes.
A "reactive" NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. A "nonreactive" NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR. Additional testing, such as a biophysical profile, should be considered
Infections that can cross the placenta have teratogenic affects
-Toxoplasmosis; raw or undercooked meat and handling cat feces. The symptoms are similar to influenza or lymphadenopathy
-Rubella: (German measles) is contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy
-Cytomegalovirus: (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal
-Herpes Simplex: is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions
All of the TORCH infections can affect people of any age or sex. However, the term TORCH is only used when it applies to pregnant women and their unborn or newborn children. As a group, the TORCH infections represent a common cause of birth defects. They can also cause stillbirth, the delivery of a dead baby.
The infection usually causes few, if any, symptoms in the pregnant woman. On the other hand, babies risk serious birth defects if they catch one of these infections during pregnancy or delivery. Babies are usually most severely affected when the mother gets the infection in the first trimester, or first three months of pregnancy. This is the time of pregnancy when the baby's organs are first starting to form.
TEACHING TO PROMOTE SAFE TRAVEL ON PLANES AND IN FOREIGN COUNTRIES
-Bring along a copy of the prenatal record if your travel will be prolonged in case there is a medical emergency away from home.
-When traveling abroad, carry a foreign dictionary that includes words or phrases for the most common pregnancy emergencies. -----Travel with at least one companion at all times for personal safety.
-Check with your health care provider before receiving any immunizations necessary for foreign travel; some may be harmful to the fetus.
-When in a foreign country, avoid fresh fruit, vegetables, and local water.
- Avoid any milk that is not pasteurized.
- Eat only meat that is well cooked to avoid exposure to toxoplasmosis.
-Request an aisle seat and walk about the airplane every 2 hours.
-While sitting on long slights, practice calf- tensing exercises to improve circulation to the lower extremities.
-Be aware of typical problems encountered by pregnant travelers, such as fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, urinary frequency, and hemorrhoids.
-Always wear support hose while flying to prevent the development of blood clots.
-Drink plenty of water to keep well hydrated through-out the flight.
Administer parenteral magnesium sulfate as ordered to prevent seizures.
Diminished or absent reexes occur when the client develops magnesium toxicity. Because magnesium is a potent neuromuscular blockade, the afferent and efferent nerve pathways do not relay messages properly and hyporeflexia develops. Common sites used to assess DTRs are biceps reflex, triceps reflex, patellar reflex, Achilles reflex, and plantar reflex.
Clonus is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms CNS involvement
With magnesium sulfate administration, the client is at risk for magnesium toxicity. Closely assess the client for signs of toxicity, which include a respiratory rate of less than 12 breaths per minute, absence of DTRs, and a decrease in urinary output (>30 mL/hour). Also monitor serum magnesium levels. Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.
As levels increase, the woman is at risk for severe problems:
-10 mEq/L: possible loss of DTRs -15 mEq/L: possible respiratory depression
- 25 mEq/L: possible cardiac arrest
If signs and symptoms of magnesium toxicity develop, expect to administer calcium gluconate as the antidote.
The HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) is a variant of the pre-eclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.
It is a life threatening obstetric complication considered by many to be a severe form of preeclampsia involving hemolysis, thrombocytopenia, and liver dysfunction. Both HELLP and pre-eclampsia occur during the later stages of pregnancy, and sometimes after childbirth. HELLP syndrome is a clinically progressive condition. Early diagnosis is critical to prevent liver distention, rupture, and hemorrhage and the onset of DIC. If the condition presents prenatally, morbidity and mortality can affect both mother and baby.
Women with HELLP usually have fewer signs of abnormalities consistent with the metabolic syndrome and a lower prevalence of thrombophilia as compared with preeclampsia women without HELLP.
Although it has been reported as early as 17 weeks' gestation, most of the time it is diagnosed between 22 and 36 weeks' gestation. It can present prior to the presence of an elevated blood pres-sure. HELLP syndrome leads to an increased maternal risk for developing liver hematoma or rupture, stroke, cardiac arrest, seizure, pulmonary edema, DIC, subendocardial hemorrhage, adult respiratory distress syndrome, renal damage, sepsis, hypoxic encephalopathy, and ma-ternal or fetal death
The mainstay of treatment is lowering of high blood pressure with rapid-acting antihypertensive agents, prevention of convulsions or further seizures with magnesium sulfate, and use of steroids for fetal lung maturity if necessary, followed by the birth of the infant
Magnesium sulfate is used prophylactically to pre-vent seizures. Antihypertensives such as hydralazine or labetalol are given to control blood pressure. Blood component therapy—such as fresh-frozen plasma, packed red blood cells, or platelets—is transfused to address the microangiopathic hemolytic anemia. Birth may be delayed up to 96 hours so that betamethasone or dexamethasone can be given to stimulate lung maturation in the preterm fetus.
A diagnosis of HELLP syndrome is made based on laboratory test results, including:
-Low hematocrit that is not explained by any blood loss
- Elevated LDH (liver impairment) Elevated AST (liver impairment)
-Elevated ALT (liver impairment)
-Elevated BUN Elevated bilirubin level
-Elevated uric acid and creatinine levels (renal involvement) Low platelet count (less than 100,000 cells/mm3)
Cervical insufficiency, also called premature dilation of the cervix, describes a weak, structurally defective cervix that spontaneously dilates in the absence of contractions in the second trimester or in the early third trimester, resulting in the loss of the pregnancy. Since this typically occurs in the fourth or fifth month of gestation before the point of fetal viability, the fetus dies unless the dilation can be arrested.
Premature dilatation of cervix
Cause unknown; possibly due to cervical damage
-Bed rest, pelvic rest, avoidance of heavy lifting
-Pink-tinged vaginal discharge or pelvic pressure
-Cervical shortening via transvaginal -ultrasound
-Continuing surveillance; close -monitoring for preterm labor
Cervical insufficiency may be treated in a variety of ways: bed rest; pelvic rest; avoidance of heavy lifting; or surgically, via a cervical cerclage procedure in the second trimester.
Cervical cerclage involves using a heavy purse-string suture to secure and reinforce the internal os of the cervix
be alert for complaints of vaginal discharge or pelvic pressure. Commonly with cervical insufficiency the woman will report a pink-tinged vaginal discharge or an increase in low pelvic pressure, cramping to vaginal bleeding, and loss of amniotic fluid. Cervical dilation also occurs. If this continues, rupture of the membranes, release of amniotic fluid, and uterine contractions occur, subsequently resulting in delivery of the fetus, often before it is viable.
Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows a provider to avoid obstetric practices that may increase the risk for transmission, and allows an op-portunity to counsel the mother against breastfeeding.
Subsequently, pregnant women who are HIV positive are at risk for preterm delivery, premature rupture of mem-branes, intrapartal or postpartum hemorrhage, postpartum infection, poor wound healing, and genitourinary tract infections.
Perinatal transmission of HIV (from the mother to the fetus or child) also can occur. However, such cases have decreased in the past several years in the United States, primarily due to the use of zidovudine (ZDV) therapy in pregnant women infected with HIV.
Perinatal transmission rates are as high as 35% when there is no intervention (antiretroviral therapy) and below 2% when antiretroviral treatment and appropriate care are avail-able. A recent Cochran meta-analysis review found that ZDV, nevirapine, and birth by elective cesarean section appear to be effective in decreasing the risk of mother-to-child transmission of HIV infection