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Physiology of the Newborn The neonatal or newborn period is the

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					                      Physiology of the Newborn

The neonatal or newborn period is the first 28 days of life during which the infant
undergoes amazing growth and change.


Respiratory Changes :
During a vaginal birth, approximately one third of the fetal lung fluid is expelled due
to the “thoracic squeeze” that occurs during passage through the birth canal.
Infants of cesarean births are at a higher risk for pulmonary transitional difficulties
because they do not receive the lung compression benefits associated with a vaginal
birth.
Lung expansion after birth stimulates the release of surfactant.
Initiation of respiration: a combination of physical, sensory and chemical factors:
      1. Chemical: ↓O2, ↓pH and ↑ CO2 level (stimulate the respiratory center in the
         brain to initiate breathing).
      2. Sensory: maximum effort is required to expand the lungs and fill the collapsed
        alveoli. (When leaving a familiar, comfortable, warm environment to enter into
        an extremely sensory overloaded one—filled with visual and auditory stimuli.
        These sensory experiences aid in the initiation of respirations).
      3. Thermal factors The drastic change in temperature (from the warm intrauterine
        [37º] to cooler environment outside the womb) helps to stimulate the initiation
        of respirations. (to prevent cold stress and respiratory depression, immediately
        dry the infant).
      4. Mechanical factors: Removal of fluid from the lungs with the subsequent
        replacement of air constitutes the primary mechanical factors involved in the
        initiation of respirations.




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Several factors may interfere with the neonate’s ability to initiate respirations
(prematurity, birth asphyxia can be due to birth trauma, maternal medications, and the
mode of delivery) can interfere with normal pulmonary transition.
Neonates less that 36 weeks gestation are subject to RDS.
* Normal respiration :
           - Irregular in depth, rate and rhythm.
           - 40 - 60 breath \ minute
           - Affected by such things like crying.
           - Accomplished mainaly by the diaphragm and abdominal muscles.
           - Dyspnea or cyanosis may indicate anomaly or pathology.
       The breathing pattern may include brief pauses that last 5 to 15 seconds.
       Termed periodic breathing, this pattern is usually not associated with any
       change in skin color or heart rate and it has no prognostic significance.

Circulatory Changes:
    Anatomic changes :
     - Umbilical arteries and vein contract and close.
     - Ductus arteriosus close within 24 hours.
     - Ductus arteriosus and ductus venosus are converted to fibrous tissue
        (ligaments ) within 2 - 3 months.
     - When the pressure in the left atrium exceeds than that of right atrium
     Formen Ovale closes.




    Blood Volume for full term neonate: 80 - 90 ml \ kg at birth.
     Holding the neonate below the level of the placenta and delaying the clamping
     of the cord may allow up to a 100 mL/kg increase in the neonate’s total blood
     volume. The increase in blood volume may facilitate an improved transition due
     to enhanced pulmonary perfusion and the gain of additional iron stores. A
     disadvantage of this practice concerns the increased risk of jaundice due to the
     higher volume of erythrocytes and possible resultant polycythemia.
    Peripheral Circulation: residual cyanosis in hands and feet.
    Pulse Rate: 120 - 160 beat \ minute, apical rate is more accurate.
    Blood Pressure: 70\40 mmhg at birth, 100\50 mmhg by the 10th day.



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    Blood Elements : (Hb 16 - 22 gm/ Hb consists of fetal Hb and Adult Hb. Fetal
     Hb has more affinity to oxygen than adult Hb), (average leukocytes18,000 but
     range from 9,000- 30,000\ ml)
    Neonate’s RBC is higher than the adults but have a shorter lifespan (60-70 days
     in full term) which leads later on for physiological anemia (persist for 2-3
     months)
    Blood Coagulation :
     - Coagulability is temporarily diminished because of lack of bacteria in the
         intestinal tract that contribute to the synthesis of vitamin K.
     - Coagulation time 3 – 4 minutes.
     - Bleeding time 2 - 4 minutes.
     - Prothrombin 50% decreasing to 20% - 30%.

Temperature Regulation:

At birth temperature is as mother’s temperature. The newborn has poor ability to
regulate his body temperature because of:
      - He has little fat insulation.
      - He has large body surface (but their normal position of flexion facilitates
          maintenance of body heat).
      - He has a relatively poor circulation.
      - He doesn’t yet sweat or shiver.
      When the infant is exposed to a cold environment, several physiological
      adaptations help him to increase heat production. These include increasing the
      basal metabolic rate and muscle activity to generate heat, peripheral
      vasoconstriction to conserve heat, and nonshivering (or chemical) thermogenesis
      (NST) (heat production). Unlike children and adults, newborns are unable to
      shiver to generate heat.




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Basal Metabolism:
-   Surface area of the infant is large in comparison with body surface.
-   Basal metabolism per kg of body is higher than that of adult.
-   Caloric requirements are high (117 calorise \ kg day).

Renal Funcion:
 - At birth the kidney’s function 30 % - 50% of the adult’s capacity and are
   not yet mature enough to concentrate urine. With a low GFR, the newborn’s
   kidneys are unable to dispose of fluid rapidly and tend to reabsorb excess
   sodium.
 Term newborns are unable to adequately concentrate urine (reabsorb water
   back into the blood). This alteration may lead to an inappropriate loss of
   substances such as amino acids and glucose.
- Neonate usually voids immediately after birth or within few hours, but it may
   take up to 24 hours.


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    - Anuria should be reported.
    - Increase uric acid will stain in the diaper.
     - Not functioning well yet in maintaining acid-base balance.
     - GFR rapidly increases during the first 4 months, but reaches adult’s function
       after 2 years.

Hepatic Function :
    -   Limited because of decrease of GIT activity and decrease blood supply.
    -   Decrease ability to conjugate bilirubin will lead to jaundice.
        This condition occurs in approximately 60% of full-term infants and in up to
        80% of preterm infants (becomes visible when the total serum bilirubin level
        is greater than 5 mg to 7 mg/dL)
        Physiologic jaundice may start 1-2 days after birth, peak at 5-7 days, &
        decline after 10-14 days.
        Elevated blood levels of unconjugated bilirubin can be toxic and result in
        kernicterus, a life-threatening condition caused by the deposition of
        unconjugated bilirubin in the brain and spinal cord.




    -   Decrease ability to regulate glucose will lead to hypoglycemia (90% of the
        stored glycogen is converted to glucose in the first 3 hours). The serum


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         blood glucose level drops during the first 3 hours of life and then gradually
         rises over the next 3 to 4 hours to reach a steady state of 40 to 80 mg/dL.
         The blood glucose of a term infant should be 70% to 80% of the maternal
         blood glucose level.




     -   Decrease production of prothrombin will lead to hemorrhage.
     -   Adequate maternal iron intake during pregnancy ensures that a sufficient
         amount of iron is available in the infant to last up to 6 months of age.
         Beginning at 6 months, all infants should receive iron supplements or iron-
         rich foods to prevent anemia

Endocrine Function:
Disturbances are most often realated to maternally provided hormones which can
cause the following:
     - Vaginal discharage \ bleeding in famale infant.
     - Enlargement of mammary glands in both sexes.
     - Disturbance related to maternal endocrine pathology ( D. M )
GI system:
     The neonate’s stomach capacity is approximately 6 mL/kg at birth and by the
     end of the first week of life, the capacity has increased to hold approximately 90
     mL.
     A decrease of pancreatic amylase makes it difficult for infants to digest fats
     efficiently. Newborns also have a decreased production of pancreatic lipase and
     bile acids, which further limits their ability to absorb fats.
     No salivation for the first 3 months.
     Cardiac sphincter is immature (leads to regurgitation)
     Compared to size, small intestines are long which increase rate of absorption.
     Infants born at term generally pass their first meconium stool within 8 to 24
     hours of life.
     Absence of passage of a bowel movement by 72 hours of age may be indicative
     of an obstructive bowel problem.


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Immunological Adaptation
     IgG is the only immunoglobulin able to pass through the placenta before birth.
      Placental transfer of IgG occurs primarily during the third trimester. At birth,
      full-term infants have already acquired immunity to tetanus, diphtheria,
      smallpox, measles, mumps, poliomyelitis, and a host of other bacterial and
      viral diseases. Preterm infants born before 34 weeks of gestation are at a
      greater risk for infection. Passive acquired immunity typically disappears by 6
      months of age.
     Colostrum and breast milk are important sources of IgA (which is important in
      protecting the infant against gastrointestinal and respiratory infections.




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Physical Findings:

    Posture:

     -   Full term newborn assumes symmetric posture, face turned to side, flexed
         extrermities, hands tightly fisted with thumb covered by fingers.
     -   Asymmetric posture may be caused by fracture of clavicle or humerus or
         never injury.




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Figure The full-term infant assumes a flexed position.




 ● Length: 45 - 55 cm
  Birth weight: On average, a term newborn infant weighs 3400 grams, with a
   normal range of 2500 to 4300

    Skin:
     - Hair distribution, lango hair over the back.
 -       Color : ( cyanosis - acrocyanosis), (pallor - cold, anemia or heartfailure),
     ( jaundice - physiologic )
     - Turgor: full term should have good skin turgor.
     - Dryness feeling: sign of post term.
     - Vernix: in skin folds. (vernix caseosa, a whitish, cheesy substance, present
         between skin folds)
     - Milia: enlarged sebaceous glands on face, decreased by 2 weeks. (small
         white papules or sebaceous cysts on the infant’s face that resemble pimples)




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      Mangolian spots: blue pigmentation on lower back, decreased by 4 years. (are
      areas that appear gray, dark blue, or purple and are most commonly located on
      the back and buttocks, although they may also be found on the shoulders,
      wrists, forearms, and ankles)




  -    Petechiae: pinpoint hemorrhage, decreased within 24 - 48 hours.
  -    Edema: around eyes, face, legs, scrotum, labia and hands.



 Head :


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     -   Caput succedaneum: swelling of soft tissue of the scalp.




     -   Cephalhematoma: subperiosteal hemorrhage.
     -   Molding: overlapping of skull bones.
     -   Examine symmetry of facial movement.
     -   Head circumference: 33 - 38 cm (2 cm larger than chest ).
     -   Fontanels: (enlarged = increased intracranial pressure), (sunken =
         dehydration).
     -   Size of fontanels : (posterior 2 – 3 months \ molding ), ( anterior 12- 18
         months ).

  Face :

     - Eyes: color, hemorrhage, lid edema, conjunctivitis, jaundice, pupils.
     - Nose: patency and discharge (nasal breathing)
     - Ears : hearing, position, cartilage.
     - Mouth: size, palate, size of the tongue, teeth, epestinpearls (white nodules ),
frenulum linguae, oral thrust.


  Neck :
     -   Mobility, lymph nodes, fractures.
     -   Skin folds: increased in trisomy 21.
     -   Stiffness: trauma or infection.




 ●    Chest :

      - Circumference : 30 - 33 cm.
     - Breast enlargment.

   ● Abdomen :




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       - Protrudes slightly, moves with chest in respiration.
       - Examine umbilical cord for number of vessels, signs of infection,
         umbilical hernia, usually falls within 7 - 10 days.

  Genitalia:

       - Female genitalia: vaginal discharge, labia majora cover labia
         minora.
       - Male genitalia: testes in scrotal sac, examine glans penis for
         urethral open
         (Open ventrally = hypospadias), ( open dorsally = epispadias)

  Back :

       - Spinal column for normal curvature and closure.
       - Anal area.

  Muscloskletal:

       - Extremities for fractures.
       - Fingers and toes for number (if extra digit: polydactyly)
         (if fused digit: syndactyly).
       - Hips for dislocation: clicking sounds.


   *    Neurologic: muscle tone, head control and reflexes.




                        Nursing Care of Newborn
In some hospitals the newborn infant is transferred from delivery room to traansitional
nursery for intensive observation. When stabilized, the infant is admitted to a regular
nursery or mother’s room. Infants designated as high risk are admitted to an ICU.
The immediate care of the newborn infant after arrived in the nursery room:



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      1. Cleansing and assessment:
-   Baby’s hair is frequently matted with dried blood; the body may have areas
    with a heavy deposits of vernix caseosa.
-   Just remove the excess of vernix and sponge away the dried blood.
-    This called dry-skin care to reduce heat loss and potential damage to
    delicate skin.
-   General assessment beside axillary temperaure, respiration and pulse are
    measured at this time.
-   Prevent undue exposure, provide warn enviroment.

      2. Weighing and measuring:

-   The newborn is weighed after arrival to nursery.
-   The scales are balanced with a protective paper on which the naked infant is
    placed.
-   Great care is taken to protect the infant from falling off the scales.
-   Accuracy is vital, since it is a part of the baseline data.
-   5% - 10% weight loss is normal.
-   After 3 – 5 days the baby begins to gain weight and reach their birth weight
    after 2 weeks.
-   Measurement of the head and chest cirumferences and length.




      3. Estimation gestational age:

-   Ability to survive is affected by the maturity of the infant.
-   Accurate assessment of gestational age is vital to effective care planning.
-   Ggestational age is determined by standarized measuremeants of physical
    growth as: (preterm, term, post term), (SGA, AGA, LGA).
    The Ballard Gestational Age by Maturity Rating tool includes a
    neuromuscular maturity and a physical maturity component

      4. Cord care:



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-   About 2 inches (5cm) of umbilical cord usually is extending from the
    abdomen with some type of clamp....
-   In few days (7 - 10 days) the cord shrinks and falls off.
-   Observe for signs of hemohrrge, other clamp may be used.
-   Protect from infection.
-   As a precaution against such an infection, the area around the umbilicus
    stump is scrubbed and 70% alcohol may be applied.


     5 .Clothing and cover:

-   It is not desirable to constrict their movement with heavy clothes or blankets.


      6. Positioning and enviroment ;
-   The baby is placed in a preheated incubator usually on the side with head
    slightly lower than the rest of the body; this help drains any remaining
    amniotic fluid or mucus from the stomach and nasophrynx.
-   Provide warm enviroment 24 – 27C◦.
-   Never leave the infant alone.
-   Extra oxygen is not administered unless indicated because retrolental
    fibroplasia, a condition producing blindness, may result from excessively
    high oxygen concentration.

      7. Recording and identifying:
-   All the observations, measurements and care given to the newborn should be
    carefully recorded on the chart.
-   It is important to label the incubator with a clearly marked card having the
    mother’s name, room number, baby’s sex, birth time and date and the
    physician’s name.
-   It is customary to give the card to the mother when she takes her baby home.

      8. Feeding and rest:
-   After birth the primary need is for rest, so infant is kept NPO for 4 – 6 hours.
-   Test blood glucose, infant may be hypoglaycemic and require feeding sooner
    than usual.

      9. Discharge planning:
-   The nurse takes the baby to the mother’s bedside.
-   The mother watches the nurse – cut off the baby’s ID. band and together
    they check the number against the mother’s band.
-   Give instructions about :

      ● Cord care.
      ● Follow up.


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          ● Bathing, diapering.
          ● Breast and formula feeding.
          ● Measuring body temperature.
          ● Recogizing reportable signs and symptoms " pallor, cyanosis,
    vomiting, diarrhea, abdominal respiration, fever, hypothermia….".

    -     Encourage the parents to ask questions and participate in discussion.




                  Complications of pregnancy


Pregnancy is a normal funtion of the body, not a disease. Several factors
can complicate pregnancy. However including preexisting conditions
and those that develop during pregnancy. Pregnancy (s) that threaten the
health of the fetus or the mother need special care (before, during and
after delivery).

High Risk pregnancies :

□   Complications of previous pregnancies:
-   Prolonged labor.                              - Cesarean birth    -PIH
-   Bleeding                                      - Abnormal fetal position.

□    Anatomical abnormalities:
-       Small pelvis.                              - Incompetent cervix.

□   Metabolic and endocrinological disorders:
-    Diabetes.                                     - Thyroid disorders.

□   Cardiovascular disorders:
-   Hypertension                                   - Congenital heart disease.

□   Kidney disorders:
-   Acute pyelonephritis.                         - Acute cystitis.

□   Hemoatological disorders:
-   Anemia.                                        - Sickle cell anemia.


□   other factors :

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-     Age: under 16 or over 35 years.
-     Weight: less than 45 kg or over 90 kg.
-     Syphilis.
-     Tuberculosis.
-     Smoking.
-     Drug addiction.

                        Preexisting medical conditions
                               Diabetes mellitus
Diabetes is an endocrine disorder characterized by high blood levels of glucose in the
urine. diabetes results from inadequate production or use of insulin. Pregnancy
imposes an additional physiological stress on a diabetic woman. Successful delivery
of a healthy infant requires much teaching, support, adherence to dietary control and
work of the entire health care team.
Effects of pregnancy on diabetes:
   1. Pregnancy is an insulin-resistant state.
   2. Placental hormones (HPL(Human placental lactogen) , Placental
      insulinase) have anti-insulin effect result in increasing the
      incidence of ketoacidosis { Spare glucose for fetal use while
      mobilizing lipids for maternal energy use}.
   3. Increase peripheral resistance to insulin.
   4. Nausea and vomiting of pregnancy may further compound the
      problem of blood glucose regulation.
   5. Insulin dose increases (except in first trimester).
   6. Oral hypoglycemic must not be used.
   7. During labor and early postpartum period, insulin should be
      stopped since HPL is decreased.
   8. Glucosuria is common during pregnancy because of decreased
      renal threshold or nephropathy.
Effects of Diabetes on Pregnancy:
    1. Gestational diabetes: " 90% of all diabetics seen by obstetrician ".
    2. Insulin-dependent Diabetes.
     Maternal problems:
           1. Hypoglycemia: usually occurs in the first half of pregnancy
              and needs to adjust insulin dose based on caloric intake.
           2. hyperglycemia : Tends to occur in second half of pregnancy.
           3. Urinary tract and other infections:
           - pregnancy predisposes to urinary tract colonization.
           - Obtain urine cultures at first visit and at 32 weeks or if
              symptoms develop.
           4. Hypertension : diabetic woman are at higher risk for
              hypertensive disorders of pregnancy.




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            5. Hydramnios: May occur in 10-20% of diabetic pregnancies
               probably result of fetal polyuria resulting from fetal
               glucosuria.
            6. Retinopathy.
            7. Postpartum hemorrhage.
        Infant problems:
    1.    Abortion: Frequency increased in patients with poor control.
    2.    Congenital anomalies: Threefold increase overall in anomaly rate.
    3.    Neonatal hypoglycemia: Monitor infant closely after delivery.
    4.    Macrosomia: usually defined as infants greater than 4000 or
          4500g. High incidence of birth trauma.
    5.    Perinatal mortality.
    6.    Hypocalcemia.
    7.    Hyperbillirubinemia.
    8.    Respiratory distress.
    Assessment:
 History:
     - Family history.
     - Obstetric history of preeolmpsia , abortion , congenital
        anomalies or birth of over 4 kg babies.
 Screening for Diabetes during Pregnancy:
     - High –risk patient: screen at the first visit.
     - All mothers: screen by end of second trimester (26 weeks).
 Screening Examination:
     - 50g oral glucose load, plasma glucose checked 1 hour later.
     - Less than 140mg/dl →normal.
     - Greater than 140mg/dl → perform oral glucose tolerance test
        (GTT).
     - Greater than 200mg/dl → probably doesn't need GTT →
        (positive).
 Glucose Tolerance Test:
     - Begins after 3 days of good diet. (250 calories of
        carbohydrate daily).
     - Fast for 10 hours prior to test is ingested.
     - 100 g oral glucose solution.
     - Perform blood level tests at fasting, 1, 2 and 3 hours after
        drinking solutions.
 Follow-up:
     - Two or more abnormal values, define gestational diabetes.
     - One abnormal value, repeat GTT in one month.
 Pregnancy Oral Glucose Tolerance Test by using a 100 gm
  load:


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                  Upper limits for Normal Glucose Levels (mg/dl)

                 Sample   Fasting    1h     2h    3h
                 Blood      90      165    145    125
                 Plasma    105      190    165    145

           - Assess the woman's ability to monitor blood sugar levels,
               insulin regulation throughout pregnancy.
           - Urine test for glucosuria.
           - Assess the woman's understanding of diabetes and changes
               that may occur during pregnancy.
           - Assess the woman's support system.
  Interventions:
Diabetic woman needs continuous medical and nursing supervision
during pregnancy, therefore prenatal visits are scheduled every 1-2 weeks
for the first 32 weeks, then weekly until delivery.
     interventions are based on Identifying Problems as follow:
 1. Dietary Regulation Need:
           - Recommended diet is 35 calories/ kg of ideal body weight.
           - 250 g of carbohydrates, 125 g protein , 60-80 g fat.
           - Mother should not gain more than 1.3-1.6 kg /month.
 2. Insulin Need:
           - Insulin dosage is based on blood and urine glucose levels.
           - Oral hypoglycemics are not used because they are fetotoxic
               (teratogenic) and don't provide adequate control.
           - Mothers need to learn how to test for glucose and administer
               correct amount of insulin.
           - They need to know the symptoms of hypoglycemia and
               hyperglycemia and appropriate emergency management of
               each.
 3. Preeclampsia potential:
           - there is a potential susceptibility to PIH.
           - Monitor blood pressure frequently.
           - If signs of PIH appear, treatment is begun at once.
 4. Infection potential:
           - vaginitis and UTI are common.
           - If symptoms appear , diagnosis and medical treatment are
               begun at once.
 5. Inadequate rest: Mothers need to lie down and rest frequently during
    the day.
 6. Hydramnios:
           - Size of mother's uterus and signs of respiratory distress are
               evaluated.


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        - Sometimes amniotony may be performed to remove
          excessive fluid.

7. Labor Induction:
        - At about 37 weeks if fetal lungs have mature enough , labor
            may be induced . Blood glucose levels and fetal conditions
            are monitored closely.
        - to evaluate the fetal status , observe how FHR varies in
            relation to fetal movement . Variations are limited in
            prematurity or sedative taking but variations increase with
            mature autonomic nervous system. Observation for 30
            minutes by continuous F.H.M. after ingestion of 30 g
            glucose.
8. Postpartum Considerations:
        - The mother's insulin need is monitored closely.
        - She is watched carefully for signs of hemorrhage caused by
            uterine relaxation, which often follows hydramnios.
        - If the infant was placed in a special care unit, efforts are
            made to assist the parents with infant bonding.
        - Postpartum Family Planning:
        Usually recommend barrier contraception, IUD may also be a
        good choice in selected patients. Low-dose oral contraception
        pills may be used.




                                  127
                              Heart Disease
Every pregnancy places extra demands on the cardiovascular system
especially on the heart. Blood volume and cardiac output are increased
40%-45% and the rate is accelerated. The normal heart is well able to
compensate for the added work but the damaged or diseased one may
not.
The signs of Cardiac Decompensation are:
         - Increasing fatigue and breathlessness with usual exertion.
         - Episodes of murmures, palpitation and tachycardia.
         - Hemoptysis.
         - Progressive generalized edema.

Incidence:
      o 0.5%-2% of pregnant woman.
      o 4.5% these with rheumatic heart disease.
      o 3% of these with congenital heart disease.

Classification:
Woman with heart disease are classified into 4 groups according to the
level of activity tolerated without symptoms. Medical and nursing care is
adjusted accordingly.
Class 1
No limitation of physical activity, no symptoms of cardiac insufficiency
or anginal pain with ordinary physical activity.
Class 2
Slight limitation of physical activity, comfortable at rest, excessive
fatigue, palpitation, dyspnea or anginal pain with heavy physical activity.
Class 3
Marked limitation of physical activity, comfortable at rest, excessive
fatigue, palpitation, dyspnea or anginal pain with less than ordinary
physical activity.
Class 4




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Inability to perform any physical activity without discomfort, cardiac
insufficiency signs possible at rest, discomfort increased with physical
activity.

Patients classified as NYHA I and II generally do well during pregnancy,
but those classified as III or IV have a significantly increased risk of
morbidity and mortality with pregnancy.

Effects of pregnancy on heart disease:
   1. Increase volume of circulation 40-45%.
   2. Increase cardiac output.
   3. Increase body weight (edema).
   4. Increase coagulation tendency.
   5. Salt and water retention.
Effects of heart disease on pregnancy:
   1. Prematurity.
   2. IUGR.
   3. Placental insufficiency.
   4. Intrauterine fetal death.
Assessment:
   - History.
   - Cardiac status of women should be evaluated very early in
      pregnancy if not before {chest X-ray, ECG}.
   - Cardiac status and functional capacity are monitored carefully
      throughout pregnancy.
   - Monitor for signs of cardiac decompensation {cyanosis, dyspnea,
      tachycardia, edema, hemoptysis, and cough…}.
Nursing diagnosis:
      - Potential for fetal distress related to uteroplacental
          insufficiency.
      - Potential for infection "endocarditis".
      - Alteration of fluid volume "excess" related to hypervolemia.
      - Alteration of comfort level.
      - Fear and anxiety.
      - Knowledge deficit.

Interventions:
1.    Rest is most important; 10 hours sleep per night and rest
         throughout the day.
2.    Physical exertion is to be avoided since it is an important cause of
         heart failure.
3.    Emotional as well as physical stress is to be avoided.
4.    Infection must be avoided and if contracted treat immediately.


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5.    A well balanced diet, high in protein, iron, vitamins and minerals is
          recommended to prevent anemia.
6.    Hospitalization prior to delivery is usual for women with classes 1
          or 2 cardiac disease to evaluate cardiac status before labor;
          women in class 3 are hospitalized somewhat earlier.
7. Any woman showing signs of cardiac failure during pregnancy is
          hospitalized and may remain hospitalized for the duration of
          pregnancy.
8. For classes 3 and 4 therapeutic abortion may be indicated,
          sterilization surgery may be recommended for those who
          attempt pregnancy of the 4th class, absolute bed rest,
          hospitalization and intensive care are necessary.
9. During labor and delivery:
      - The woman`s vital signs and fetal heart tones are monitored
          continuously, don`t leave the woman alone and decrease
          anxiety.
      - The woman may receive oxygen during the course of labor.
      - Regional anesthesia may be used to reduce pain.
      - To avoid having the mother push, forceps delivery may be used.
   o Cesarean delivery is avoided because of (grater blood loss, risk of
      infection, risk of thromboemboism ).
   - Second stage of labor is shortened to reduce stress on the mother`s
      heart as much as possible.
10. During postpartum:
   - Monitor carefully for postpartum hemorrhage, infection or
      thromboemboism.
   - Restrict visitors; promote rest and gradual resumption of activities.
   - Ambulate to avoid thromboemboism.
   - Prophylactic antibiotic may be used to avoid infection.
   - Methergin and estrogen are contraindicated because they increase
      fluid retention and blood clotting.
   - Diluted oxytocin may be administered continuously to shorten
      second stage of labor and control postpartum bleeding.
   - Stool softeners to prevent straining.
   - Careful monitoring of vital signs.
   - Preparation for discharge planning (care of the baby, bed rest,
      medications, future pregnancy and contraception).
Note:
- If there is a need for anticoagulant, heparin is used, oral anticoagulant
   are contraindicated.
- Breast-feeding is too strenuous and not recommended for class 3 & 4.




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            Medical conditions associated with pregnancy
                           Anemia in pregnancy
Normal hematological events associated with pregnancy:
- During pregnancy there is an increase of 40 up to 45% in the blood
   volume , the maximum is reached at 34 weeks gestation.
- The plasma volume increases 47-50% and the RBCs mass increases
   only 17% and reaches its maximum at term.
- There is relative hemodilution throughout pregnancy, and this reaches
   its maximum at 28-34 weeks.
- This dilution effect lowers the Hb, HCT and RBCs count; it causes no
   change in the mean corpuscular volume (MCV) {the average red
   blood cell volume that is reported as part of a standard complete blood
   count} or in the mean Corpuscular Hb concentration (MCH).
Definition:
- Hb value below the lower limits of normal not explained by the state
   of hydration.
- Anemia during pregnancy 11 or 10.5 g/dl . Anemia is defined as a
   reduction in the total circulating red blood cell mass.
- 20-60% of prenatal patients will be found to be anemic at sometimes
   during pregnancy.
Causes of anemia during pregnancy:
1. Acquired:
- Iron deficiency anemia.
- Anemia caused by acute blood loss.
- Anemia of inflammation or malignancy.
- Megaloblastic anemia.
- Acquired hemolytic anemia.
- Aplastic or hypoplastic anemia.
Hereditary:
- Thalassemia.
- Sickle-cell hemoglobinopathies.
- Other hemoglobinopathies.
- Hereditary hemolytic anemia.

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Red blood cell disorder during pregnancy:
1. Decreased erythrocyte production:
- Iron deficiency.         - Thalassemia.             - Chronic disease.
- Bone marrow failure. - Folate deficiency.           - Malignancy.
- Inflammatory process.                      - Vitamin B12 deficiency.
2. Increased erythrocyte loss:
- Hemorrhage.                   – Parasites.
3. Increased erythrocyte destruction:
- Hemoglobinopathies.        - Hemolytic anemia. - Chemical toxicity.


Clinical presentation:
Symptoms caused by anemia are those resulting from:
    1. Tissue hypoxia: fatigue, lightheadness , weakness , pallor and
        exertional dyspnea.
    2. Cardiovascular system attempts to compensate for the anemia:
        palpitation and tachycardia (hyperdynamic circulation).
    3. An underlying disease:
- Chronic infection.                  - Chronic liver disease.
- Chronic renal disease.               - Multiple pregnancies.
Note:
In obstetric patients anemia is discovered because CBC is obtained as
part of laboratory evaluation at the initial prenatal visit or at repeat
screening at 28-32 weeks.
Severe anemia is associated with:
    o Congestive heart failure.
    o Multi-organ failure.
    o Tissue hypoxia.
                           Iron Deficiency Anemia
Is a hypochromic microcytic anemia that occurs when iron stores are
inadequate to support normal erythropoiesis.
WHO standard: anemia during pregnancy is defined as Hb < 11g/dl.
It is the most common nutritional anemia worldwide and accounts for
75% of all anemia diagnosed during pregnancy.
Almost all pregnancies are associated with some degree of iron depletion.
If iron depletion becomes severe; iron deficiency anemia occurs.
The major reason for poor iron stores is thought to be menstrual loss.
Pregnancy places large demands on iron balance and can`t be met with
usual diet. In absence of iron supplementation, iron deficiency develops.
High-risk Populations for Iron-Deficiency Anemia:
- Low socioeconomic status.
- Limited education.
- Women with a history of menorrhagia.


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-   Diet deficient in meat and ascorbic acid.
-   Regular use of aspirin.
-   Adolescent pregnancy.
-   Multiple pregnancies.
-   Successive pregnancies (less than 2 years a part).




Factors affecting Iron absorption:
1. Iron content of the meal.
2. The chemical form of iron (iron is absorbed in the ferrous state in the
    duodenum and proximal small intestine).
3. The iron status of the individual.
4. Composition of ingested food.
Effects of pregnancy on Iron Metabolism:
- Iron requirements increase throughout pregnancy.
- During the first half of pregnancy, iron requirements are minimally
    elevated. During the last 20 weeks, requirements increase
    dramatically.
On average 2.5 mg of iron are required to meet these demands per day. In
the third trimester the requirements may rise to as much as 7.5 mg per
day and dietary iron absorption increases each trimester to meet these
increased requirements. During the first trimester, approx 10% of the
dietary iron is absorbed; this increases to 25-30% in the second and in the
third trimester.
- Pregnancy complications such as hypermesis will compromise the
    availability of iron absorption.
Effects of Iron Deficiency Anemia on Pregnancy:
1. Maternal effects:
- Symptoms associated with iron deficiency anemia include fatigue,
    irritability, palpitations, dizziness, headaches, breathlessness, glossitis
    and stomaitis.
- In severe cases, high output congestive heart failure.
- Pica: the ingestion of various substances that have no dietary value is
    a striking manifestation of iron deficiency. { Pagophagia (ice),
    geophagia (clay) and amyophagia ( starch) } are common examples of
    pica. Pica is noted in over 50% of patients diagnosed with iron
    deficiency anemia, mostly occur after 20 weeks of gestation.
- Maternal anemia has been associated with placental gigantism.
2. Fetal and neonatal effects:


                                      133
- Controversy exists.
- An increase in the frequency of preterm delivery, low birth weight
  infants and stillbirth. The outcome is related to the gestational age
  when maternal iron deficiency is diagnosed.
- The fetus stores enough iron to meet requirements for 3-6 months after
  birth.


                           Megaloblastic Anemia
Is the second most common nutritional anemia seen during pregnancy
Folate deficiency is the cause but a deficiency in vitamin B12 must be
considered.
Folate:
Folic acid, a water-soluble vitamin is widely available in diet. Folate is
absorbed in the proximal jejunum. Pancreatic conjugates reduce folate to
monoglutamate before its absorption. Conjugate activity is reduced by:
1. Anticonvulsants                   2. Alcohol
3. Oral contraceptives                4. Sulfa drugs
Because adequate folate intake before and during the first weeks of
pregnancy may reduce the occurrence of neural tube defects, all women
considering to become pregnant should consume 400 mcg/day of folate.
Vitamin B12:
Abundantly available in the diet bond to animal proteins. Its absorption
requires HCL and pepsin to free the cobalamin molecule from protein.
Most of the vitamin B12 is stored in the liver and most people have a 2-3
years store available.
Diagnosis of Anemia:
- Anemia is not a diagnosis, but rather a sign as fever.
- Is the patient anemic?
- What is the morphology of the anemia? CBC and reticulocyte is
    helpful.
- What is the mechanism of anemia?
- Is there an underlying disease?
- History.
- Family history.               - History of tonics.
- History of GI bleeding and melena.
- Exposure to oxidant drugs ( Risk of G6PD) e.g. sulfonamides, PASA.
- Peripheral blood smear.
- Serum iron value (less than 30 mcg/dl indicates IDA).
- The gold standard to determine iron stores is a bone marrow biopsy,
    which is rarely indicated in pregnancy patients.
Treatment:



                                    134
o Preventable by routine use of iron supplementation. When not given
  supplemental iron, 80% of normal pregnant women will have Hb
  value less than 11 g /dl at term.
o Correct the underlying cause.




Nursing intervention:
o To improve Nutritional status:
1. Provide a well-balanced diet high in iron.
2. Administer iron supplementation if prescribed.
3. With iron supplementation, increase intake of foods high in fiber and
   fluids to prevent constipation. Increase intake of foods high in vitamin
   C to enhance iron absorption.
4. For folic acid deficiency anemia, provide folic acid supplement and
   diet high in animal protein and green leafy vegetables.
5. In severe anemia, IM iron or transfusion of packed RBCs may be
   necessary.
o To improve Fetal Nutrition and Oxygenation:
1. Provide diet rich with vitamin and mineral supplementation.
2. Oxygenation to fetus can be improved by:
       a. Improving maternal Hb level.
       b. Avoidance of maternal infection, which increases BMR and
          oxygen consumption.




                                    135
                         Hyperemesis Gravidarum
Is exaggerated nausea and vomiting during pregnancy, persisting past the
1st trimester.
About 70-85% of all women experience a mild form of nausea in early
pregnancy called morning sickness usually disappear by about 12th week,
however vomiting persist causing serious dehydration and starvation.
Such a condition is called hyperemesis gravidarum which means
"excessive vomiting of pregnancy".
Causes:
1. Hormonal changes of pregnancy: increase hCG hormone level.
2. Emotional factors, insecurity, anxiety.
Risk Factors
     increased placental mass associated with multiple gestation
     a history of hyperemesis gravidarum in a previous pregnancy, and
        a history of motion sickness or migraine headaches.
     Daughters and sisters of women who experienced hyperemesis
        gravidarum
     women who are pregnant with a female child
Incidence: 3,5 in 1000 pregnancies.
Clinical manifestations:
- Begin with morning sickness and become increasingly severe.
- Frequent vomiting when mention, sight or smell food.
- Loss of weight (5% of the pre-pregnancy weight).
- Dehydration.
- Tachycardia.
- Thirst.
- Scanty concentrated urine.
- Jaundice caused by liver damage.
- Blindness caused by retinal hemorrhage.
- Convulsions.
- Death.
Note:
If the fetus dies and is expelled, nausea usually stops immediately but
damage to major organs of the mother may be permanent.

                                  136
Nursing diagnosis:
- Alteration in comfort level…
- Impaired skin integrity…
- Alteration in nutritional status…
- Fluid volume deficit…
- Knowledge deficit…
- Potential for complication…
Nursing interventions:
- Treatment of hyperemesis gravidarum should begin before damage
   occurs.
- Maintaining fluid and Electrolyte Balance:
1. If vomiting is severe, the woman is hospitalized and oral intake is
   restricted for 24-48 hours. I.V. fluids are administered.
2. Oral liquid intake is resumed slowly, usually high in carbohydrate of
   the type preferred by the woman.
3. Vitamin B complex to combat nausea.
4. Sedative and antiemetic as prescribed.
- Improve Nutritional Status:
1. Offer small and frequent meals, high in carbohydrates.
2. Avoid strong food odors.
3. Avoid greasy foods.
4. Give vitamin supplementation as prescribed.
- Developing Coping Abilities:
   1. Have the woman discuss her perception of the problem.
   2. Discuss possible resolutions to problems identified.
   3. Hospitalization usually removes the woman from pressure.
   4. Restriction of visitors usually relieves stress.




                                   137
                  Hypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension (PIH):
The term Preeclampsia has replaced the term Toxemia. The hypertensive
disorders complicate 5% -10 of all pregnancies (the second leading cause
of maternal death in the United States). Delay of diagnosis and
uncertainty of treatment can lead to significant maternal and fetal
morbidity and mortality.
Hypertension:
Defined as blood pressure of at least 140/90 mmHg or a rise of 30 mmHg
diastolic. Blood pressure usually falls during second trimester.
Pregnancy induced Hypertension. (PIH) has two stages; Preeclampsia
and Eclampsia. In Preeclampsia hypertension, proteinuria and excessive
fluid retention develop with resultant edema and weight gain. Symptoms
may be mild or severe. In Eclampsia, convulsive seizures and coma
develop.
The only cure for PIH is termination of pregnancy.
Etiology:
1. Unknown: described in 1916 as “a disease of theories" and still true
    today.
2. Theories include:
    a) Uterine ischemia.
    b) Autoimmune disease.
    c) Deficiency of dietary protein.
    d) Organism called "hydatoxi Lualba".
Risk Factors:
- Primigravida.      - Family history of Preeclampsia or Eclampsia.
- Obesity - Diabetes mellitus. - Multiple gestations.
- Preexisting hypertensive vascular, autoimmune or renal disease.
- Extremes of maternal age (younger than 20 or older than 35 years).
- Hydatiform mole.           - Rh incompatibility
The incidence:
- PIH develops in the last 10 weeks of gestation, during labor or in the
    first 12-48 hours after delivery.
- It occurs in 5% of all pregnancies.



                                  138
- Adolescents, younger primiparas and low income women have 10%-
  30% risk.
- Women who have had PIH or those who have chronic hypertension
  have a chance of 25%-35%.
- In those who develop Preeclampsia, 5% go on to develop Eclampsia.
- Fetal death with Preeclampsia is about 10% and with Eclampsia 20%.



                                Preeclampsia
Preeclampsia is a pregnancy-specific systemic syndrome clinically
defined as an increase in blood pressure (140/90) after 20 weeks’
gestation accompanied by proteinuria.
Syndrome of pregnancy-induced hypertension accompanied by
proteinuria, edema and frequently other organ system disturbances.
                            Mild Preeclampsia
Is characterized by:
1. Hypertension: a rise of 30 mmHg systolic and 15 mmHg diastolic,
    blood pressure : 140/90 mmHg.
2. Proteinuria: of +2 or 1 g/L.
3. Edema: generalized, facial, hands and fingers reflecting weight gain of
    over than 0,7 kg/week.
Assessment:
- It is essential of prenatal assessment of all women is to establish a
    baseline blood pressure.
- In each prenatal visit, blood pressure and other signs of hypertension
    are assessed.
- Assessment includes urine testing for proteinuria.
- Weighting on the same scale.
- Assessing for edema, headache, epigastric pain…
- Assessment of fetal movement, non stress test and U/S.
Management:
- Initial management consists of rest and observation if patient is not a
    candidate for delivery. Bed rest maximizes uteroplacental flow.
- Delivery should be accomplished by 38th week or sooner if the fetus is
    mature.
Nursing intervention:
1. Diet: increase protein diet with moderate sodium intake.
2. Rest and activity: resting on the left lateral recumbent position is
    beneficial by increasing renal blood flow, glomerular filtration rate
    and placental perfusion. Complete bed rest may not be necessary,
    reduced activity is beneficial.



                                   139
3. Medical supervision: office visits are scheduled every 2 weeks or less
   depending on the symptoms for assessment of signs of Preeclampsia.
4. Danger signs: mothers are instructed to report any sudden change in
   their condition such as generalized edema, headache, fever, muscle
   tremors or seizures and sudden increase of body weight.




                                   140
109
                           Severe Preeclampsia
Criteria for severe Preeclamosia:
- Blood pressure: consistently > (160 mmHg systolic) or > (110 mmHg
   diastolic).
- New onset of proteinuria > (2 g in 24 hours urine collection) or > (3 g
   in a randomly collected specimen).
- Oliguris: (less than 400 ml/ 24 hours) or increasing serum creatinine
   levels.
- Edema: generalized, weight gain of 0,9 kg over a period of one week
   or less.
- Platelet count: less than 100,000; hemolytic anemia and increase in
   lactic acid dehydrogenase (LDH) and direct bilirubin levels.
- Headache, visual disturbances or other cerebral signs.
- Epigastric or right upper quadrant pain.
- Cardiac decompensation, pulmonary edema or cyanosis.
- Fetal growth retardation: due to reduction of intervillous perfusion.
Note: { HELLP variant (syndrome)}.
- Hemolysis (H): due to hypofibrogenemia.
- Elevated liver enzymes (EL).
- Low Platelet Count (LP).
Assessment:
1. Hospitalization is necessary.
2. The goal of care is to prevent seizures, lowering blood pressure,
   establishing an adequate renal function and to continue the pregnancy
   until fetal maturity.
3. If the pregnancy is at the 34th week or more, labor is induced or
   cesarean birth is performed.
4. Serial examinations recommended for Preeclamptic hospitalized
   patients include:
 Mother:
- Blood pressure: four times daily.
- Assessment for proteinuria, edema, weight, hyperreflexia, headache,
   visual disturbance, epigastric pain (daily).
- Hematocrit, platelet count (every 2 days).
- Serum uric acid and creatinine levels, 24 hours urine for total protein
   and creatinine clearance (twice weekly).
- Liver function test (weekly).
- Urinary output (at each voiding or by catheterization, should be more
   than 700 ml/24 hours or 30 ml/hr).




                                   89
 Fetus:
- Fetal movement (daily).
- Fetal heart rate (every 4 hours or continuously).
- Placental separation (hourly in case of severe Preeclampsia).
- Ultrasound for fetal growth (every 2 weeks).
- Non stress test (twice weekly).
Note:
Recommendation is to hospitalize patients from time of diagnosis to
delivery. Frequency of evaluations can be increased or decreased,
depending on severity of disease.
Management:
The goal of therapy is to reduce the risk of cerebral vascular accident,
while maintaining uteroplacental perfusion. A decrease in the diastolic
pressure to less than 90 mm Hg in the patient with severe hypertension
will decrease placental blood flow, often with a decrease in the fetal heart
rate (FHR). Management is directed at reducing the diastolic blood
pressure to a value of less than 110 mm Hg, but greater than 95 to 100
mm Hg.
1. Delivery is always the appropriate maternal therapy.
2. Fetal risk must be balanced against maternal risk.
- Consider conservative management between 25-30 weeks.
- Delivery indicated for severe Preeclampsia, IUGR or fetal distress.
3. Treating Hypertension:
- Treat for greater than 160/110 mmHg.
- Goal is to lower diastolic to 95 to 110 mmHg.
- Drug therapy: Hydralazine, aldomine, nefidipine.
- Carefully monitor urinary output.
4. Preventing Convulsions:
- Drug of choice is Magnesium Sulfate.
- Treat all Preeclamptic patients during labor and 24 hours postpartum.
- Dosing.
 4 g I.V. load then 2-3 g/ hour.
 Keep serum magnesium 4-8 mg/dl.
 IM doses more painful.
 10 g load IM, then 5 g IM every 4 hours.
- Toxicity:
 Loss of patellar reflex.
 Respiratory depression, respiratory rate is less than 12 breath/min.
 Defective cardiac conduction.
 Treatment of toxicity: Calcium Gluconate 10% (1 g I.V. over 3 min).




                                     90
Prognosis:
Typically resolves following delivery. Discharge is usually safe with
blood pressure less than 160/100 mmHg. Oral contraceptive
Acceptable, but wait until blood pressure normalizes.
Recurrence Rates:
- Mild disease in primigravida : rare.
- Severe Preeclampsia: 30%-50%.
- Superimposed Preeclampsia: 70%.
Nursing Care:
1. Maternal and fetal compromise related to edema, proteinuria,
   hypertension.
The goal: to minimize the effects of edema, proteinuria and hypertension.
- Control amount of stimulation, place in quiet private room with
   dimmed lighting, no phone or visitors.
- Maintain absolute bed rest with side rails up, disturb only for essential
   procedures.
- Have the woman select the people she wishes to stay with her.
- Explain rational for care.
- Monitor: level of consciousness, headache, irritability and epigastric
   pain…
2. Potential for injury related to effects of Magnesium Sulfate.
3. Potential injury to mother and fetus related to undetected
   hemoconcentration, clotting disturbances (DIC), hepatic problems.
- Send blood specimen for measurement of HCT, PLT and SGOT daily.
- Check results against normal values and report variations
   immediately.
4. Potential injury to fetus related to alteration in tissue perfusion of
   placenta.
- Prevent supine hypotension.
- Woman is placed on her left side.
5. Alteration in patterns of urinary elimination related to hypertension,
   proteinuria and edema.
- Check urinary output every hour.
- Report urinary output of less than 100 ml/4 hours.
- Check input every 8 hours.
- Check urine for protein every 8 hours.
- Send blood specimen to laboratory for measurement of creatinine and
   check results against normal values and report deviations immediately.




                                    91
6. Alteration in respiratory function related to edema and hypertension.
- Check for pulmonary edema, respiratory rate.
7. Ineffective individual and family coping related to stress of
    experiencing a major complication of pregnancy.
- Assess restlessness, anxiety, response to support person and response
    to labor contraction.
- Keep woman informed of progress.
8. Alteration in normal physiologic process related to type of delivery.
- Monitor woman for signs of progress in labor and for complications
    such as prolapsed cord.
- Prepare for precipitous labor, have delivery pack available in room.
- Prepare for elective delivery if ordered.
Evaluation:
- Symptoms improve.                - FHR remains stable
- Woman doesn't develop complications.
- Respiratory functions within normal limits.
- Urinary elimination pattern remains within normal limit.
- Labor progresses normally.
Possible Complications of Preeclampsia:
 Eclampsia.
 Abruptio placenta.
 Pulmonary edema.
 Congestive heart failure.
 Cerebral edema.
 Retinal detachment.
 Renal damage.




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