Hematologic Disorders and Pregnancy

UDANETA CITY UNIVERSITY
1 San Vicente West, Urdaneta City, Pangasinan 2428
 (075) 568-2475 loc. 8110, Fax: (075) 600-1468
COLLEGE OF NURSING
HEMATOLOGIC DISORDERS AND PREGNANCY
PREPARED AND PRESENTED BY:
DAYRIT, NICOLLE ANN M.

ESREBAN, YRA G.
VIJUNGCO, ARISA MAE D.
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PRESENTED TO:
MRS. MYLENE FENULIAR
A. OBJECTIVE
1. To be able to identify and differentiate the different hematological disorders which

may affect the well-being of the mother and the child
2. To be able to identify the signs and symptoms of the different disorders and
know what nursing interventions should be performed
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3. To be able to know the etiology and predisposing factors of the different disorders
in order to provide effective health education and management
B. KEYWORDS
1. Iron deficiency anemia - It is condition in which blood lacks adequate healthy red
blood cells due to insufficient iron.
2. Hemoglobin - part of RBC that gives blood its red color and enables the RBC to
carry oxyginated blood throughout the body
3. Ferritin- blood protein that contains iron and stored in body’s cell until it’s time to
make more RBC
4. Microcytic - small red blood cell
5. Hypochromic - less hemoglobin than the average red cell
6. Megaloblastic - enlargement of red blood cells
7. Dactylitis - The swelling caused by sickle-shaped red blood cells blocking blood
flow to the hands and feet.
8. Thalassemia is a group of inherited diseases of the blood that affect a person's

ability to produce hemoglobin, resulting in anemia.
9. Autosomal dominant- A pattern of inheritance in which an affected individual has

one copy of a mutant gene and one normal gene on a pair of autosomal
chromosomes.
10. Menorrhagia- is the medical term for menstrual periods with abnormally heavy or
prolonged bleeding.
11. Epistaxis- is defined as acute hemorrhage from the nostril, nasal cavity, or
nasopharynx.
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12. Glucocorticoids- these agents are used to treat idiopathic and acquired
autoimmune disorders; they have been shown to increase platelet count in ITP.
13. Hemolysis- This is the breakdown of red blood cells. These cells carry oxygen
from your lungs to your body.
C. NARRATIVE DISCUSSION
ANEMIA
IRON-DEFICIENCY ANEMIA IN PREGNANCY

It is the most common type of anemia in pregnancy. It is condition in which blood
lacks adequate healthy red blood cells due to insufficient iron. Many women who enter
pregnancy with a deficiency of iron resulting from a combination of a diet low in iron,
heavy menstrual periods or unwise weight-reducing programs . It can also be low in
women who were pregnant less than 2 years before the current pregnancy or those from
low socioeconomic levels who have not had iron-rich diet. Iron deficiency anemia is
confirmed by a corresponding low serum iron level (under 30ug/dl) and an increased iron
binding capacity (over400ug/dl).
Iron is made available to the body by absorption from the duodenum into the
bloodstream, it is bound to transferrin for transport to the liver, spleen and bone marrow.
At these sites, it is incorporated into hemoglobin (part of RBC that gives blood its red
color and enables the RBC to carry oxyginated blood throughout the body) or stored as
ferritin (blood protein that contains iron and stored in body’s cell until it’s time to make
more RBC).
This type of anemia is characteristically a microcytic (small red blood cell) and
hypochromic (less hemoglobin than the average red cell) anemia. This occurs when
such as inadequate supply of iron is ingested that iron is not available for incorporation of
red cell. Without iron supplementation in a pregnant women, iron deficiency anemia will
occur and it can affect the pregnancy because their iron stores need to serve their own to
increase the blood volume as well as be a source of hemoglobin for the growing fetus.
RISK FACTORS FOR ANEMIA IN PREGNANCY

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1. Are pregnant with multiples (more than one child)

2. Have had two pregnancies close together
3. Vomit a lot because of morning sickness
4. Are a pregnant teenager
5. Don't eat enough foods that are rich in iron
6. Had anemia before you became pregnant
SYMPTOMS OF ANEMIA DURING PREGNANCY
1. Pale skin, lips, and nails

2. Feeling tired or weak
3. Dizziness
4. Rapid heartbeat
5. Trouble concentrating
RISKS OF ANEMIA IN PREGNANCY
1. A preterm or low-birth-weight baby

2. A blood transfusion (if you lose a significant amount of blood during delivery)
3. Postpartum depression
4. A baby with anemia
5. A child with developmental delays
WAYS TO PREVENT ANEMIA IN PREGNANCY
1. Take prenatal vitamins containing 27 mg of iron as prophylactic therapy during

pregnancy.
2. Eat a diet high in iron and vitamins (meat, green leafy, legumes)
3. Take iron supplements with vitamin C
TESTS FOR ANEMIA

During your first prenatal appointment, you'll get a blood test so your doctor can check
whether you have anemia. Blood tests typically include:
1. Hemoglobin test. It measures the amount of hemoglobin an iron rich protein

in red blood cells that carries oxygen from the lungs to tissues in the body.
2. Hematocrit test. It measures the percentage of red blood cells in a sample of
blood.
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SICKLE CELL ANEMIA
DEFINITION
Sickle cell disease is caused by a mutation in the hemoglobin-Beta gene found on

chromosome 11. Hemoglobin transports oxygen from the lungs to other parts of the
body.
COMPARISON [NORMAL VS. THE CONDITION]

Red blood cells with normal hemoglobin (hemoglobin-A) are smooth and round and
glide through blood vessels.
In people with sickle cell disease, abnormal hemoglobin molecules - hemoglobin S -

stick to one another and form long, rod-like structures. These structures cause red blood
cells to become stiff, assuming a sickle shape. Their shape causes these red blood cells to
pile up, causing blockages and damaging vital organs and tissue.
Sickle cells are destroyed rapidly in the bodies of people with the disease, causing
anemia. This anemia is what gives the disease its commonly known name - sickle cell
anemia.
Sickle cell disease is a blood condition seen most commonly in people of African
ancestry and in the tribal peoples of India. Clinically significant sickle cell syndromes also
occur in people of Mediterranean and Middle Eastern background. The sickle cell
mutation reflects a single change in the amino acid building blocks of the
oxygen-transport protein, hemoglobin. This protein, which is the component that gives
red cells their color, has two subunits. The alpha subunit is normal in people with sickle
cell disease. The beta subunit has the amino acid valine at position 6 instead of the
glutamic acid that is normally present. The alteration is the basis of all the problems that
occur in people with sickle cell disease. The schematic diagram shows the first eight of
the 146 amino acids in the beta globin subunit of the hemoglobin molecule. The amino
acids of the hemoglobin protein are represented as a series of linked, colored boxes. The
lavender box represents the normal glutamic acid at position 6. The dark green box
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represents the valine in sickle cell hemoglobin. The other amino acids in sickle and normal
hemoglobin are identical.
The hemoglobin molecule (made of alpha and beta globin subunits) picks up oxygen
in the lungs and releases it when the red cells reach peripheral tissues, such as the
muscles. Ordinarily, the hemoglobin molecules exist as single, isolated units in the red cell,
whether they have oxygen bound or not. Normal red cells maintain a basic disc shape,
whether they are transporting oxygen or not.
NORMAL
HEMOGLOBIN
MOLECULE (HbA)
SICKLE
HEMOGLOBIN
MOLECULE (HbS)
However, that is not the case with sickle

hemoglobin. Sickle hemoglobin exists as isolated units in the red cells when they have
oxygen bound. When sickle hemoglobin releases oxygen in the peripheral tissues,
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however, the molecules tend to stick together and form long chains or polymers. These
rigid polymers distort the cell and cause it to bend out of shape. While most distorted cells
are simply shaped irregularly, a few have a cresent-like appearence under the microscope.
These cresent-like or "sickle shaped" red cells gave the disorder its name. When the red
cells return to the lungs and pick up oxygen again, the hemoglobin molecules resume
their solitary existence.
CAUSES
The sickle cell gene is passed from generation to generation in a pattern of

inheritance called autosomal recessive inheritance. This means that both the mother and
the father must pass on the defective form of the gene for a child to be affected.
If only one parent passes the sickle cell gene to the child, that child will have the
sickle cell trait. With one normal hemoglobin gene and one defective form of the gene,
people with the sickle cell trait make both normal hemoglobin and sickle cell hemoglobin.
Their blood might contain some sickle cells, but they generally don't have symptoms. But
they are carriers of the disease, which means they can pass the gene to their children.
SIGNS AND SYMPTOMS
Signs and symptoms of sickle cell anemia, which vary from person to person and
change over time, include:
1. Anemia. Sickle cells break apart easily and die, leaving you without enough red
blood cells. Red blood cells usually live for about 120 days before they need to be
replaced. But sickle cells usually die in 10 to 20 days, leaving a shortage of red blood
cells (anemia).
2. Fatigue. Without enough red blood cells, your body can't get the oxygen it
needs to feel energized, causing fatigue.
3. Episodes of pain. Periodic episodes of pain, called crises. Pain develops when
sickle-shaped red blood cells block blood flow through tiny blood vessels to your
chest, abdomen and joints. Pain can also occur in your bones.
4. Aseptic necrosis and bone infarcts. Aseptic necrosis is a bone condition that
results from poor blood supply to an area of bone, causing localized bone death.
5. Painful swelling of hands and feet. The swelling is caused by sickle-shaped
red blood cells blocking blood flow to the hands and feet. (dactilytis).
6. Frequent infections. Sickle cells can damage an organ that fights infection
(spleen), leaving you more vulnerable to infections.
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7. Delayed growth. Red blood cells provide your body with the oxygen and
nutrients you need for growth. A shortage of healthy red blood cells can slow growth
in infants and children and delay puberty in teenagers.
8. Vision problems. Tiny blood vessels that supply your eyes may become
plugged with sickle cells. This can damage the retina — the portion of the eye.
RISK FACTORS
1. Genetics. For a baby to be born with sickle cell anemia, both parents must carry a
sickle cell gene.
2. Race. Sickle cell anemia is most common among people of African descent, but
can also be found in those of Hispanic, Southern European, Middle Eastern or Asian
descent.
LABORATORY TESTS AND DIAGNOSIS
1. Sickle cell blood test. Used to check for hemoglobin S. In adults, a blood sample
is drawn from a vein in the arm. In young children and babies, the blood sample is
usually collected from a finger or heel. The sample is then sent to a laboratory, where
it's screened for hemoglobin S. If the screening test is negative, there is no sickle cell
gene present. If the screening test is positive, further tests will be done to determine
whether one or two sickle cell genes are present.
2. Red blood cell count. If you or your child has sickle cell anemia, a blood test to
check for a low red blood cell count (anemia) will be done. Your doctor might suggest
additional tests to check for possible complications of the disease.
3. Amniocentesis. Sickle cell disease can be diagnosed in an unborn baby by

sampling some of the fluid surrounding the baby in the mother's womb (amniotic fluid)
to look for the sickle cell gene.
4. Chorionic villus sampling. It is a type of prenatal diagnostic test to detect

chromosomal problems that can result in genetic diseases and birth defects. It
involves taking a small sample of part of the placenta (the chorionic villi) where it is
attached to the wall of the uterus.
TREATMENT AND MEDICATIONS
1. Bone marrow transplant. Also known as stem cell transplant, offers the only
potential cure for sickle cell anemia. It's usually reserved for people younger than age
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16 because the risks increase for people older than 16. Finding a donor is difficult,
and the procedure has serious risks associated with it, including death.
2. Blood transfusion. In sickle cell anemia patients, a blood transfusion is used to

provide normal red blood cells to the patient's body. Red blood cell transfusions help
against anemia and to lessen the blood's viscosity, allowing it to flow more freely so
as to easy disease symptoms and prevent complications.
3. Antibiotics. Children with sickle cell anemia may begin taking the antibiotic
penicillin when they're about 2 months old and continue taking it until they're at least
5 years old. Doing so helps prevent infections, such as pneumonia, which can be
life-threatening to an infant or child with sickle cell anemia. As an adult, if you've had
your spleen removed or had pneumonia, you might need to take penicillin throughout
your life.
4. Pain-relieving medications. To relieve pain during a sickle cell crisis, your
doctor might prescribe pain medications.
5. Hydroxyurea (Droxia, Hydrea). When taken daily, hydroxyurea reduces the
frequency of painful crises and might reduce the need for blood transfusions and
hospitalizations. Hydroxyurea seems to work by stimulating production of fetal
hemoglobin — a type of hemoglobin found in newborns that helps prevent the
formation of sickle cells.
6. Assessing stroke risk using a special ultrasound machine (transcranial),
doctors can learn which children have a higher risk of stroke. This painless test, which
uses sound waves to measure blood flow, can be used on children as young as 2
years. Regular blood transfusions can decrease stroke risk.
7. Vaccinations to prevent infections. Your doctor will make sure your child
receives all of the recommended childhood vaccinations. Vaccinations, such as the
pneumococcal vaccine and the annual flu shot, are also important for adults with
sickle cell anemia.
LIFESTYLE AND HOME REMEDIES
Taking the following steps to stay healthy may help you avoid complications of sickle cell
anemia:
1. Take folic acid supplements daily, and choose a healthy diet. Bone
marrow needs folic acid and other vitamins to make new red blood cells. Your doctor
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might recommend a folic acid supplement. Choose a diet that focuses on a variety of
colorful fruits and vegetables, as well as whole grains.
2. Drink plenty of water. Dehydration can increase your risk of a sickle cell crisis.
Drink water throughout your day, aiming for about eight glasses a day. Increase the
amount of water you drink if you exercise or spend time in a hot, dry climate.
3. Avoid temperature extremes. Exposure to extreme heat or cold can increase
your risk of a sickle cell crisis.
4. Exercise regularly, but don't overdo it. Talk with your doctor about how
much exercise is right for you.
5. Use over-the-counter (OTC) medications with caution. Use OTC pain
medications, such as ibuprofen (Advil, Motrin IB, Children's Motrin, others) or
naproxen sodium (Aleve) sparingly, if at all, because of the possible effect on your
kidneys. Ask your doctor before taking OTC drugs.
How does sickle cell disease affect pregnancy?
Generally, women with sickle cell trait do not have problems from the disorder. But they
may have a lot of urinary tract infections during pregnancy. With sickle cell anemia, the
abnormal red blood cells and anemia may result in lower amounts of oxygen going to
your developing baby. This can slow down the baby’s growth.
How is sickle cell disease in pregnancy treated?
Early and regular prenatal care is important if you are pregnant and have sickle
cell disease. Having prenatal visits more often allows your healthcare provider to keep a
close watch on the disease and on the health of developing baby.
Some women may need blood transfusions to replace the sickle cells with fresh
blood. These may be done several times during the pregnancy. Blood transfusions can
help the blood carry oxygen and lower the number of sickle cells. If you get blood
transfusions, you will be screened for antibodies that may have been transferred in the
blood and that may affect your baby. The most common antibodies are to the blood
factor Rh.
What are possible complications of sickle cell disease in pregnancy?
Complications and increased risks may include:

1. Infections, including infection in the urinary tract, kidneys, and lungs
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2. Gallbladder problems, including gallstones

3. Heart enlargement and heart failure from anemia
4. Miscarriage
5. Death
Complications and increased risks for your developing baby may include:
1. Severe anemia
2. Poor fetal growth
3. Preterm birth. This means before 37 weeks of pregnancy.
4. Low birth weight. This means less than 5.5 pounds.
5. Stillbirth and newborn
6. Death
THALASSEMIA
DEFINITION
Thalassemia is a group of inherited diseases of the blood that affect a person's ability
to produce hemoglobin, resulting in anemia. Hemoglobin is a protein in red blood cells
that carries oxygen and nutrients to cells in the body. About 100,000 babies worldwide
are born with severe forms of thalassemia each year. Thalassemia occurs most frequently
in people of Italian, Greek, Middle Eastern, Southern Asian and African Ancestry.
CAUSES
Thalassemia is caused by mutations in the DNA of cells that make hemoglobin — the
substance in red blood cells that carries oxygen throughout your body. The mutations
associated with thalassemia are passed from parents to children.
Hemoglobin molecules are made of chains called alpha and beta chains that can be
affected by mutations. In thalassemia, the production of either the alpha or beta chains
are reduced, resulting in either alpha-thalassemia or beta-thalassemia.
Thalassemia is also categorized into three groups, depending on its severity:

thalassemia major is the most severe form, thalassemia intermedia is a less severe form,
and thalassemia minor may cause no symptoms at all.
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Alpha-thalassemia
Four genes are involved in making the alpha hemoglobin chain. You get two from each of
your parents. If you inherit:
1. One mutated gene, you'll have no signs or symptoms of thalassemia. But you are
a carrier of the disease and can pass it on to your children.
2. Two mutated genes, your thalassemia signs and symptoms will be mild. This
condition might be called alpha-thalassemia trait.
3. Three mutated genes, your signs and symptoms will be moderate to severe.
4. Inheriting four mutated genes is rare and usually results in stillbirth. Babies born
with this condition often die shortly after birth or require lifelong transfusion therapy.
In rare cases, a child born with this condition can be treated with transfusions and a
stem cell transplant.
Beta-thalassemia
Two genes are involved in making the beta hemoglobin chain. You get one from each
of your parents. If you inherit:
1. One mutated gene, you'll have mild signs and symptoms. This condition is called
thalassemia minor or beta-thalassemia.
2. Two mutated genes, your signs and symptoms will be moderate to severe. This
condition is called thalassemia major, or Cooley anemia.
Babies born with two defective beta hemoglobin genes usually are healthy at birth
but develop signs and symptoms within the first two years of life. A milder form, called
thalassemia intermedia, also can result from two mutated genes.
SIGNS AND SYMPTOMS
The signs and symptoms you have depend on the type and severity of your condition.
Thalassemia signs and symptoms can include:
1. Fatigue
2. Weakness
3. Pale or yellowish skin
4. Facial bone deformities
5. Slow growth
6. Abdominal swelling
7. Dark urine
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RISK FACTORS
Factors that increase your risk of thalassemia include:
1. Family history of thalassemia. Thalassemia is passed from parents to

children through mutated hemoglobin genes.
2. Certain ancestry. Thalassemia occurs most often in African Americans and in
people of Mediterranean and Southeast Asian descent.
LABORATORY TESTS AND DIAGNOSIS
1. Red blood cell count. If you or your child has sickle cell anemia, a blood test to
check for a low red blood cell count (anemia) will be done. Your doctor might suggest
additional tests to check for possible complications of the disease.
2. Chorionic villus sampling. Usually done around the 11th week of pregnancy,
this test involves removing a tiny piece of the placenta for evaluation.
3. Amniocentesis. Usually done around the 16th week of pregnancy, this test
involves examining a sample of the fluid that surrounds the fetus.
TREATMENT
Mild forms of thalassemia trait don't need treatment. For moderate to severe thalassemia,
treatments might include:
1. Frequent blood transfusions. More severe forms of thalassemia often require

frequent blood transfusions, possibly every few weeks. Over time, blood transfusions
cause a buildup of iron in your blood, which can damage your heart, liver and other
organs.
2. Chelation therapy. This is treatment to remove excess iron from your blood.
Iron can build up as a result of regular transfusions. Some people with thalassemia
who don't have regular transfusions can also develop excess iron. Removing the
excess iron is vital for your health.
3. Stem cell transplant. Also called a bone marrow transplant, a stem cell
transplant might be an option in some cases. For children with severe thalassemia, it
can eliminate the need for lifelong blood transfusions and drugs to control iron
overload.
Thalassemia in pregnancy
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Women with thalassemia who require blood transfusions often have a higher rate of
infertility. However, some women with the disease are able to become pregnant.
Considerations for the baby’s health
If you have thalassemia and your partner carries the trait for thalassemia, there is a
chance that your baby may inherit the disease. A genetic counsellor can explain the risks
to you and your partner, and offer you testing options to determine if the unborn baby
has been affected.
Considerations for the mother’s health
The stress of pregnancy can make the symptoms of thalassemia worse. The woman’s
heart and liver are most vulnerable during pregnancy, as is the endocrine system, which
secretes hormones in the body. Each of these systems must be closely monitored before
and throughout pregnancy.
During pregnancy, the volume of blood in the mother’s body rises substantially. This
can lead to anemia, which can increase the need for blood transfusion, and makes the
heart work that much harder to push blood to all the body’s tissues. The higher volume of
blood in the mother’s body also adds to the amount of work that the heart has to do.
Therefore, women with thalassemia need to have their heart function checked before
they become pregnant. During pregnancy, they may need to have regular blood
transfusions to lessen the amount of stress on the heart.
People with thalassemia have an increased risk of developing type 1 diabetes. The
stress of pregnancy can worsen this condition. Diabetes needs to be well controlled
before and throughout pregnancy.
MALARIA
DEFINITION
Malaria is an infection caused by single-celled parasites that enter the blood through
the bite of an Anopheles mosquito. These parasites, called plasmodia, belong to at least
five species.
Most human infections are caused by either Plasmodium falciparum or Plasmodium

vivax. Plasmodium parasites infect and multiply inside liver cells and red blood cells.
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Once the parasites are inside your body, they travel to the liver, where they mature. After
several days, the mature parasites enter the bloodstream and begin to infect red blood
cells. Within 48 to 72 hours, the parasites inside the red blood cells multiply, causing the
infected cells to burst open.
Some infected blood cells burst because of the multiplying parasites inside. Many more
infected red blood cells are broken down by your spleen or liver, which filter out and
remove damaged or aging red blood cells from circulation. Both Plasmodium parasites in
the bloodstream and irritants that are released from broken red blood cells cause malaria
symptoms.
Most deaths from malaria are caused by P. falciparum, which causes severe disease.
Before P. falciparum malaria causes a red blood cell to burst, it can make the surface of
the cell stick to other cells like it. This causes the blood to clot within small blood vessels,
which can severely damage organs.
CAUSES
Malaria is caused by a type of microscopic parasite. The parasite is transmitted to humans

most commonly through mosquito bites.
Mosquito transmission cycle
1. Uninfected mosquito. A mosquito becomes infected by feeding on a person who

has malaria.
2. Transmission of parasite. If this mosquito bites you in the future, it can transmit
malaria parasites to you.
3. In the liver. Once the parasites enter your body, they travel to your liver — where
some types can lie dormant for as long as a year.
4. Into the bloodstream. When the parasites mature, they leave the liver and infect
your red blood cells. This is when people typically develop malaria symptoms.
5. On to the next person. If an uninfected mosquito bites you at this point in the
cycle, it will become infected with your malaria parasites and can spread them to the
other people it bites.
Other modes of transmission
Because the parasites that cause malaria affect red blood cells, people can also catch
malaria from exposure to infected blood, including:
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1. From mother to unborn child
2. Through blood transfusions
3. By sharing needles used to inject drugs
SIGNS AND SYMPTOMS
Symptoms of malaria can begin as early as six to eight days after a bite by an infected
mosquito. They include:
1. High fever (up to 105 degrees Fahrenheit) with shaking chills

2. Profuse sweating when the fever suddenly drops
3. Fatigue
4. Headache
5. Muscle aches
6. Abdominal pain and discomfort
7. Diarrhea
8. Nausea, vomiting
9. Feeling faint when you stand up or sit up quickly
10. Convulsions
11. Bloody stools
RISK FACTORS
The biggest risk factor for developing malaria is to live in or to visit areas where the
disease is common. There are many different varieties of malaria parasites. The variety
that causes the most serious complications is most commonly found in:
1. African countries south of the Sahara Desert

2. The Asian subcontinent
3. New Guinea, the Dominican Republic and Haiti
LABORATORY TESTING AND DIAGNOSIS
1. Health history review including any recent travel to tropical climates.

2. Inspection and palpation to etermine if you have an enlarged spleen or liver.
3. If you have symptoms of malaria, your doctor may order additional blood tests to
confirm your diagnosis.
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PREVENTION
If you live in or are traveling to an area where malaria is common, take steps to avoid
mosquito bites. Mosquitoes are most active between dusk and dawn. To protect yourself
from mosquito bites, you should:
1. Cover your skin. Wear pants and long-sleeved shirts.

2. Apply insect repellant to skin and clothing. Sprays containing DEET can be
used on skin and sprays containing permethrin are safe to apply to clothing.
3. Sleep under a net. Bed nets, particularly those treated with insecticide, help
prevent mosquito bites while you are sleeping.
TREATMENT
In the United States, treatment options for uncomplicated chloroquine-resistant P

falciparum and P vivax malaria in pregnant women are limited to mefloquine or quinine
plus clindamycin. Although the limited availability of quinine and increasing resistance to
mefloquine limit these options, strong evidence now demonstrates that
artemether-lumefantrine (Coartem) is effective and safe in the treatment of malaria in
pregnancy. These data are supported by the World Health Organization.
Malaria in Pregnancy
Malaria during pregnancy is very dangerous. Women who become infected

with Plasmodium parasites during pregnancy are far more likely to develop severe
complicated malaria than are non-pregnant women or men who become infected. The
reasons for this are many, but a necessary component cause is that both cell-mediated
and humoral immunity are much reduced in pregnancy.
In addition to the weakened immune system, the biology of the mosquito

contributes to the increased disease burden suffered by pregnant women. Pregnant
women are more likely to be bitten by mosquitoes in all malaria endemic regions because
their higher metabolic rate during pregnancy leads to increased body temperature and
increased release of carbon dioxide while breathing.
In addition to being at higher risk for mosquito bite, pregnant women are also at
higher risk of infection from all Plasmodium species once introduced from the mosquito.
Finally, once infected, pregnant women are at higher risk for severe malaria and death
relative to their non-pregnant and male peers.
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The maternal mortality rate can range between 100 and 1000 per 100,000 live
births.
Adverse outcomes of the pregnancies are also higher in malaria infected women
because there is active infection of the placenta. The combination of placental infection
and the intense host (mother) response to the malaria parasites leads to a high
occurrence of fetal loss, low birth weight, pre-term delivery, and perinatal and infant
mortality. The attributable risk for low birth weight due to malaria infection ranges
between 8% and 14%, 8% and 36% for pre-term delivery, 13% and 70% for fetal
growth retardation, and 3% and 8% for infant mortality.
The greatest risk for malaria infection occurs during the 2nd and 3rd trimesters.
Dramatic reductions in severe complicated malaria can be achieved if infection in the 2nd
and 3rd trimester can be avoided. Even so, the risks are still higher than being malaria
free throughout pregnancy.
If a baby is infected with malaria, the baby may develop symptoms of fever,
irritability, feeding problems, breathing problems, sluggishness, paleness, anemia (low
red blood cell count), an enlarged liver and spleen, jaundice (yellowing of the skin and
eyes), and diarrhea in the weeks after birth.
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COLLEGE OF NURSING
COAGULATION DISORDERS
A. VON WILLEBRAND DISEASE
Von Willebrand disease is a coagulation disorder inherited as an autosomal dominant trait.

Women will have normal platelet count, but bleeding time is prolonged. From the time she was a
child, a woman with the disorder might have noticed menorrhagia or frequent episodes of
epistaxis.
SIGNS AND SYMPTOMS
1. Excessive bleeding from an injury or after surgery or dental work.
2. Nosebleeds that don't stop within 10 minutes.
3. Heavy or long menstrual bleeding.
4. Blood in your urine or stool.
5. Easy bruising or lumpy bruises.
Menstrual signs and symptoms may include:
6. Blood clots greater than 1 inch (2.5 centimeters) in diameter in your menstrual flow
7. The need to change your menstrual pad or tampon more than once an hour
8. The need to use double sanitary protection for menstrual flow
9. Symptoms of anemia, including tiredness, fatigue or shortness of breath
CAUSE
The usual cause of von Willebrand disease is an inherited abnormal gene that controls von
Willebrand factor — a protein that plays a key role in blood clotting.
COMPLICATIONS
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COLLEGE OF NURSING
Rarely, von Willebrand disease can cause uncontrollable bleeding, which can be life-threatening.
Other complications of von Willebrand disease can include:
1. Anemia. Women who have heavy menstrual bleeding can develop iron deficiency
anemia.
2. Swelling and pain. This can be a result of abnormal bleeding in the joints or soft tissue.
PREVENTION
Because von Willebrand disease is usually an inherited disorder, consider having genetic
counseling if you have a family history of this condition and you're planning to have children. If you
carry the defective gene for von Willebrand disease, you can pass it on to your offspring, even if
you don't have symptoms.
Blood tests:
1. Von Willebrand factor antigen. This determines the level of von Willebrand factor in
your blood by measuring a particular protein.
2. Von Willebrand factor activity. There are a variety of tests to measure how well the
von Willebrand factor works in your clotting process.
3. Factor VIII clotting activity. This shows whether you have abnormally low levels and
activity of factor VIII.
4. Von Willebrand factor multimers. This evaluates the structure of von Willebrand
factor in your blood, its protein complexes and how its molecules break down. This
information helps identify the type of von Willebrand disease you have.
B. HEMOPHILIA B
Hemophilia B (Christmas disease) is a sex linked disorder, so the actual disease occurs
only in males. However, female carriers may have such a reduced level of factor IX that
hemorrhage with labor or a spontaneous miscarriage can be a serious complication.
CAUSES
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COLLEGE OF NURSING
When you bleed, a series of reactions take place in the body that helps blood clots form.
This process is called the coagulation cascade. It involves special proteins called coagulation, or
clotting factors. You may have a higher chance of excess bleeding if one or more of these factors
are missing or are not functioning like they should.
Factor IX (nine) is one such coagulation factor. Hemophilia B is the result of the body not
making enough factor IX.
SIGNS AND SYMPTOMS
Signs and symptoms of spontaneous bleeding include:
1. Unexplained and excessive bleeding from cuts or injuries, or after surgery or dental work
2. Many large or deep bruises
3. Unusual bleeding after vaccinations
4. Pain, swelling or tightness in your joints
5. Blood in your urine or stool
6. Nosebleeds without a known cause
7. In infants, unexplained irritability
Screening tests are blood tests that show if the blood is clotting properly. Types of screening tests:
1. Complete Blood Count (CBC). This common test measures the amount of
hemoglobin (the red pigment inside red blood cells that carries oxygen), the size and number
of red blood cells and numbers of different types of white blood cells and platelets found in
blood. The CBC is normal in people with hemophilia. However, if a person with hemophilia has
unusually heavy bleeding or bleeds for a long time, the hemoglobin and the red blood cell
count can be low.
2. Activated Partial Thromboplastin Time (APTT) Test. This test measures how long
it takes for blood to clot. It measures the clotting ability of factors VIII (8), IX (9), XI (11), and
XII (12). If any of these clotting factors are too low, it takes longer than normal for the blood
to clot. The results of this test will show a longer clotting time among people with hemophilia
A or B.
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COLLEGE OF NURSING
3. Prothrombin Time (PT) Test. This test also measures the time it takes for blood to
clot. It measures primarily the clotting ability of factors I (1), II (2), V (5), VII (7), and X (10).
If any of these factors are too low, it takes longer than normal for the blood to clot. The
results of this test will be normal among most people with hemophilia A and B.
4. Fibrinogen Test. This test also helps doctors assess a patient’s ability to form a blood
clot. This test is ordered either along with other blood clotting tests or when a patient has an
abnormal PTExternal or APTT testExternal result, or both. Fibrinogen is another name for
clotting factor I (1).
5. Clotting Factor Tests. Clotting factor tests, also called factor assays, are required to
diagnose a bleeding disorder. This blood test shows the type of hemophilia and the severity.
It is important to know the type and severity in order to create the best treatment plan.
NURSING INTERVENTION
Assess the location, characteristics, and rate of pain (use pain scale).
>Hemarthrosis (bleeding into joint) is the main manifestation of the disease. Common
sites include the elbows, shoulders, hips, knees, and ankle joints.
Assess for joint swelling and ability to move affected limb.
>Bleeding episodes should be managed at the onset of discomfort, which entails a

deficient factor replacement.
Immobilize joints and apply elastic bandages to the affected joint if indicated; elevate affected and
apply a cold compress to active bleeding sites, but must be used cautiously in young children to
prevent skin breakdown.
>Immobilization promotes comfort and decreases joint damage; elastic bandage most
often avoids muscle bleeding; elevation of affected extremity/ joint will minimize swelling; cold
application will promote vasoconstriction.
Provide bed cradle over painful joints and other sites of bleeding.
>Prevents pressure of linens on affected sites, especially joints.
Maintain immobilization of the affected extremity during the acute phase (24 to 48 hours); apply a
splint or sling to the affected extremity if indicated.
>Immobilization of the affected joint helps to decreased bleeding and provide some relief.
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COLLEGE OF NURSING
Perform range of motion 48 hours after the acute bleeding episode and pain has subsided.
Maintains optimal joint movement.
Administer medications as indicated.
>Acetaminophen (Tylenol), propoxyphene, corticosteroids, and codeine are given for pain
management; NSAIDs such aspirin are contraindicated since they impair clotting and can cause
gastric bleeding.
Administer factor VIII or other prescribed factor component immediately.
>Controls the bleeding that is causing the pain.
Educate child about cause of pain and interventions to relieve it; how medications must be
administered via per orem, while injections are not advised; to avoid taking aspirin or aspirin
product for pain.
>Promotes understanding of pain responses and methods to reduce it.
Instruct child to support and protect painful areas and in the importance of immobilization.
> comfort and prevents further bleeding into joints.
C. IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP)
Idiopathic Thrombocytopenic Purpura (ITP) is a condition with decreased number of platelets,

is not inherited, can occur at any time in life, and so occasionally occurs during pregnancy. Cause
is unknown, but because symptoms usually occur shortly after a viral invasion such as an upper
respiratory tract infection, it is assumed to be an autoimmune reaction (an anti platelet antibody
that destroys platelets is apparently released).
CAUSES
Immune thrombocytopenia usually happens when your immune system mistakenly attacks
and destroys platelets, which are cell fragments that help blood clot. In adults, this may be
triggered by infection with HIV, hepatitis or H. pylori — the type of bacteria that causes stomach
ulcers. In most children with ITP, the disorder follows a viral illness, such as the mumps or the flu.
PREDISPOSING FACTORS
ITP is more common among young women. The risk appears to be higher in people who also
have diseases such as rheumatoid arthritis, lupus and antiphospholipid syndrome.
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COLLEGE OF NURSING
SIGNS AND SYMPTOMS
Immune thrombocytopenia may have no signs and symptoms. When they do occur, they may
include:
1. Easy or excessive bruising
2. Superficial bleeding into the skin that appears as pinpoint-sized reddish-purple spots
(petechiae) that look like a rash, usually on the lower legs
3. Bleeding from the gums or nose
4. Blood in urine or stools
5. Unusually heavy menstrual flow
To diagnose immune thrombocytopenia, your doctor will try to exclude other possible causes of
bleeding and a low platelet count, such as an underlying illness or medications you or your child
may be taking. Blood tests can check the levels of platelets. Rarely, adults might need a bone
marrow exam to rule out other problems.
NURSING INTERVENTION
Glucocorticoids and intravenous immunoglobulin (IVIg) are the mainstays of medical

therapy for idiopathic thrombocytopenic purpura (ITP).
D. HELLP (HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET COUNT)

SYNDROME
HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome- is a rare but
serious condition that can happen when you’re pregnant or right after you have your baby. HELLP
syndrome causes problems with your blood, liver, and blood pressure. If left untreated, these
issues can hurt you and your baby.
There may be a link between HELLP syndrome and preeclampsia and eclampsia.
Preeclampsia is when a pregnant woman has high blood pressure and damage to other organs
such as her liver and kidneys. It usually starts after 20 weeks of pregnancy. Eclampsia is a more
severe form of preeclampsia that includes seizures.
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COLLEGE OF NURSING
HELLP syndrome can cause major complications. These include:
1. Seizures
2. Stroke
3. Liver rupture
4. Placental abruption (separation of the placenta from the wall of the uterus before the
baby is born)
5. Placental abruption can cause bleeding, affect your baby’s growth, and lead to
premature birth or stillbirth.
CAUSES
Doctors don’t know what causes HELLP syndrome. Your chance of it is higher if you’ve had
it before. Most women who get it have high blood pressure first. But you can get HELLP with
normal blood pressure.
Experts think your odds may be higher if you:
1. Are older than 25
2. Are Caucasian
3. Have given birth two or more times before
SIGNS AND SYMPTOMS
1. Fatigue
2. Blurred vision
3. Sudden weight gain
4. Swelling, especially in the face and hands
5. Headache
6. Nausea or vomiting
7. Seizures
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COLLEGE OF NURSING
8. Pain in the upper right part of your belly
9. Nosebleed
10. Bleeding that doesn’t stop as quickly as usual
If you have symptoms of HELLP syndrome, talk to your doctor. She’ll do a physical exam and tests
to check for things like:
1. High blood pressure
2. Pain in the upper right side of your belly
3. Enlarged liver
4. Swollen legs
5. Liver function
6. Blood platelet count
7. Bleeding into your liver
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 (075) 568-2475 loc. 8110, Fax: (075) 600-1468
COLLEGE OF NURSING
REFERENCES:
1) https://www.mayoclinic.org/diseases-conditions/sickle-cell-anemia/diagnosis-treatme
nt/drc-20355882
2) https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&Co
ntentID=P02499
3) https://www.medicinenet.com/sickle_cell/article.htm
4) https://www.aboutkidshealth.ca/Article?contentid=368&language=English
5) https://www.mayoclinic.org/diseases-conditions/thalassemia/diagnosis-treatment/drc
-20355001
6) https://www.mayoclinic.org/diseases-conditions/malaria/symptoms-causes/syc-20351
184
7) https://www.healthline.com/health/malaria#diagnosis
8) https://www.mayoclinic.org/diseases-conditions/malaria/symptoms-causes/sy
c-20351184ma
28

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UDANETA CITY UNIVERSITY

1 San Vicente West, Urdaneta City, Pangasinan 2428

 (075) 568-2475 loc. 8110, Fax: (075) 600-1468