High Risk PregnancyThe Women With a Preexisting Condition or Newly Acquired Illness
When a woman enters pregnancy with a chronic condition both she and the fetus are at risk for complications.
Focus on:
Close observation of maternal and fetal well being.
Education of the woman and her family.
Actions to minimize complications.
Cardiovascular disease, diabetes.
Outcomes and goals are realistic.
Educate and support.
Identifying the High Risk Pregnancy
Concurrent disorder, pregnancy related complication, or external factor jeopardizes the health of the mother, fetus or both.
May develop a complication later in pregnancy or as a result of pregnancy.
Circumstances – poverty, coping….
Factors for high risk, social, psychological and physical.
Minimal, moderate and extensive.
Many factors-look at pt holistically.
STD and Pregnancy
Effects on pregnancy, fetus,or newborn.
Can be prevented, tx. based on causative organism and education.
Candidiasis:
Fungus candida
Thick discharge, cream cheese, pruritus, red, irritated.
Increased estrogen level, antibiotics, diabetes, HIV
Dx. by vaginal secretion on wet slide
Tx. Monistat for 7 days or Diflucan x 1
Trichomoniasis:
Single cell protozoan
Yellow-gray, frothy, odorous vag.discharge
KOH wet slide
Tx. Flagyl (not 1st trimester) or clotrimazole topical
Associated with preterm labor, premature ROM and postcesarean infection.
Bacterial Vaginosis:
Common Gardnerella vaginalis organism
Gray, fishy odor, pruritus
Tx. Topically. Flagyl (not 1st trimester)
Chlamydia:
Common, screened at 1 and 3rd trimester.
Gram negative intracellular parasite
Heavy gray white discharge.
Culture for chlamydia and gonorrhea
Tx. Zithromax or amoxicillin to both woman and partner.
Syphilis:
Systemic disease caused by spirochete Treponema pallidum.
Chancre on vulva or vagina.
Screened-VDRL, ART, FTA-ABS, RPR
Tx. Penicillin G IM single dose.
Herpes Simplex Virus Type 2:
Transmitted across placenta. Cesarean birth.
Dx.- by appearance, Pap smear, ELISA
Tx. Zovirax
Gonorrhea:
Gram negative coccus, Neisseria gonorrhoeae.
Yellow-green discharge or no symptoms.
Culture and tx. partner.
Tx. Suprax IM single dose.
Blindness in newborn.
Papillomavirus Infection HPV:
Fibrous tissue overgrowth on vulva, cauliflower like lesion.
Tx. Trichloroacetic acid (TCA) or bichloracetic acid (BCA) applied to lesion weekly. Lg. Lesion removed by laser therapy, cryocautery or knife.
Cesarean birth if canal is obstructed.
Risk- cervical cancer.
Group B Streptococcal Infection:
Higher incidence. Screen at 35 to 38 wks.
Ampicillin.
Hepatitis B or C:
HIV:
AIDS is fatal to mother and child.
Caused by retrovirus that infects and disables T Lymphocytes.
Vertical transmission across the placenta to fetus at birth or breast milk.
CD4 cell count determines how many T4 cells are present and functioning.
Mild flu symptoms, no routine screening.
Test – ELISA antibody reaction, Western blot analysis is required.
Infants will develop AIDS in 1 year.
Tx. ZVD Zidovudine 100 mg 5 times a day beginning 14th week of pregnancy and newborn receives the drug for 6 weeks.
Goal is to maintain CD4 count > 500 cells/MM and viral load at < 5000 copies/ minute.
May require numerous other medications for other complications.
Avoid fetal exposure, amniocentesis….
Educate and support.
Hematologic Disorders
Anemia
Blood volume expands during pregnancy, slightly ahead of red cell count. Pseudoanemia early in pregnancy.
Iron Deficiency Anemia:
Most common, microcytic(sm. RBC) hypochromic. H&H- 33% and 10mg/dL
Low birth wt., preterm birth.
Prenatal vitamins with 60 mg iron supplement. If anemic – 120 to 180 mg.
Ferrous sulfate or gluconate. (OJ)
Diet high in iron and roughage.
IM or IV iron dextran if noncompliant.
Folic Acid Deficiency Anemia:
Folacin-B Vitamin for formation of RBC in mother and preventing neural tube defects.
Megaloblastic. MCV elevated.
Seen 2nd trimester, slow to develop.
Miscarriage or premature separation of placenta.
Before pregnancy take 400ug folic acid qd.
Prenatal vitamins have 600ug
Sickle Cell Anemia:
Recessively inherited hemolytic anemia.
Cause-abnormal amino acid in the beta chain of hemoglobin. (replaces amino acid valine)
1 in10 African Americans has trait and 1 in 400 have the disease.
Blockage to the placental circulation to the fetus = low birth wt. or death.
Screened frequently, susceptible to bacteriuria, diet, fluids, pooling of blood in lower extremities, US at 16 to 24 weeks.
In crisis-exchange transfusion, O2, pain control, fluids (0.45 saline), no iron supplement.
Give folic acid supplement
Symptoms appear at 3 to 6 months.
Coagulation Disorder:
Most are sex linked or occur in males.
Von Willebrand disease
Bleeding time prolonged
Replacement of factor VIII by infusion of cryprecipitate or fresh-frozen plasma before labor to prevent excessive bleeding.
Hemophilia B (Christmas disease, factor IX deficiency) is sex linked disorder in males.
Women carrier, infusion before labor factor IX.
Umbilical blood sample to detect hemophilia before internal monitor is attached.
Idiopathic Thrombocytopenic Purpura:
Decreased number of platelets.
Petechiae, ecchymoses, nose bleeds.
Platelet count as low as 20,000/mm
Lasts 1 to 3 months
Transfusion, oral prednisone.
Renal And Urinary Disorders
Woman is excreting waste products for herself and fetus.
UTI:
Urine stasis can progress to pyelonephritis.
Preterm labor, premature ROM, fetal loss.
Escherichia coli R/O strep
Frequency and pain on urination.
Pyelonephritis-pain in lumbar region rt. side radiates downward, nausea and vomiting, malaise, tenderness, temp,
Culture C&S
Amoxicillin, ampicillin and cephalosporin.
Chronic Renal Disease:
Increases workload of the kidney.
Take prednisone maintenance
Glomerular filtration rate increased during pregnancy.
Proteinuria, B/P, creatinine levels
May require dialysis(need IM progesterone)
Risk to both mother and fetus
Give time to bond, support.
Range from mild-cold to severe-TB
Rising uterus compresses the diaphragm, reduces size of thoracic cavity.
Acute Nasopharyngitis:
Common cold- more severe due to estrogen causing nasal congestion.
Avoid meds unless ordered by doctor.
Influenza:
Virus types A,B,C
High fever, aching, sore, raw throat.
Tylenol, TamiFlu
Preterm labor, miscarriage
May be immunized (killed virus).
Pneumonia:
Bacterial or viral invasion of lung tissue.
Fluid in lungs can limit O2 available to fetus.
Antibiotic, O2
Preterm labor
Asthma:
Reversible airflow obstruction, airway hyperreactivity, and airway inflammation.
Triggered by irritant, inhaled allergen.
Bronchial narrowing > wheezing, decreased O2 supply to fetus.
May improve due to high levels of circulating corticosteroids during pregnancy.
Beta-adrenergic agonists-terbutaline, albuterol, beclovent, vancenase, flovent
prednisone, Intal, Singulair, Accolate (B)
Tuberculosis:
Mycobacterium tuberculosis, acid fast bacillus
Macrophages and T lympocytes surround the bacillus and confine it.
Mantoux (PPD) test. If positive do chest X Ray.
SS-chronic cough, wt. loss, hemoptysis, night sweats, low-grade fever, chronic fatigue.
Isoniazid (INH) and ethambutol hydrochloride (Myambutol) may be given during pregnancy.
Need Vitamin B, calcium,
Recent inactivated TB can become active during pregnancy.
Spread by placenta and at birth.
Active TB in home – infant is on INH and skin test in 3 month intervals.
No breast feeding in both on INH.
Cystic Fibrosis:
Recessively inherited disease, dysfunction of exocrine glands. (chromosome 7)
Thick mucous secretions in pancreas and lungs. Also cervix, semen=infertility.
Chorionic villi sampling or amniocentesis.
Pancrease and bronchodilator or antibiotic.
Chest physiotherapy daily to reduce secretion build up.
Iron, serum glucose levels. Fatigue.
Rheumatic Disorders
Juvenile Rheumatoid Arthritis:
Disease of connective tissue with joint inflammation and contracture.(autoimmune)
Synovial membrane destruction.
May improve due to increased circulating corticosteroids during pregnancy.
NSAIDS – prolonged pregnancy decrease 2 wks. before term.
Salicylate interferes with prostaglandin synthesis.
Systemic Lupus Erythematosus:
Multisystem chronic disease of connective tissue. (age 20 to 40).
Butterfly shaped rash on face.
Corticosteroid, NSAIDs, heparin, salicylates.
Acute nephritis may occur. B/P
IV hydrocortisone during labor.
Infant may have lupud rash, anemia, low platelet count, congenital heart block.
Gastrointestinal Disorders
Normal- nausea, heartburn, constipation.
Acute abdominal pain and protracted vomiting are causes for concern.
Appendicitis:
McBurney’s point. May be displaced far up in abdomen.
Sonogram
If 36 weeks may do cesarean birth.
If not , may do laparoscopy.
If ruptures, infected material is free in the peritoneum and can spread to fallopian tube to the fetus.
Adhesions may develop, infertility risk.
Gastroesophageal Reflux or Hiatal Hernia:
Uterus pushes stomach up against the esophagus.
SS-heartburn, gastric regurgitation, dysphagia, wt. loss, hematemesis.
Dx. endoscopy or US
Antacid, ranitidine, elevate HOB.
Cholecystitis and cholelithiasis:
Gallbladder inflammation and gallstone formation.
Usually > age 40, obesity, multiparity, ingestion of high fat diet.
SS-constant pain and pressure in rt. epigastrium, jaundice.
Low fat intake, sonogram, laparoscope in needed.
Hepatitis:
Liver disease from invasion of A,B,C,D,or E virus.
Tender liver, urine dark yellow, stools light color, jaundice, bilirubin level is elevated.
Liver enzymes, Hep profile.
Bedrest, high calorie diet.
After birth wash baby, hepatitis B immune globulin and immunization against hepatitis B given. Do not breast feed.
Inflammatory Bowel Disease:
Crohn’s disease-inflammation of terminal colon and ulcerative colitis – inflammation of distal colon.
Age 12 to 30 autoimmune process.
Shallow ulcers, diarrhea, wt. loss, occult blood in stool, nausea and vomiting.
TPN to rest GI tract, Azulfidine.
Neurologic Disorders
Seizure Disorder:
Causes unknown or head trauma or meningitis.
Continue taking medications (teratogenic), may need to increase dosage.
Dilantin, Trimethadione, Valproic acid, Tegretol, Zarontin.
Myasthenia Gravis:
Autoimmune disorder-presence of IgG antibody against acetylcholine receptors in striated muscles.(fail to contract)
Tx. Anticolinesterase drugs-Mestinon, prostigmin, prednisone, plasmapheresis.
Infant may have disease symptoms at birth due to transfer of antibodies.
Multiple Sclerosis:
Age 20 to 40
Nerve fibers become demyelinated and lose function.
ACTH or corticosteroid- Sandimmune, Imuran, Cytoxan
Fatigue, UTI.
Scoliosis:
Lateral curvature of spine.
Age 12 to 14
Pelvic distortion may need cesarean birth.
Cardiovascular Disorders
1% of all pregnancies.
Pregnancy taxes the circulatory system.
Blood volume and cardiac output increase 30% within the first 28 weeks.
Most dangerous time is weeks 28 to 32.
Cardiovascular Disorders
Classification of heart disease.
Left Sided Heart Failure:
Mitral stenosis, mitral insufficiency, aortic coarctation.
Serum albumin decreases in pregnancy normally. Can lead to pulmonary edema.
Productive cough, blood speckled sputum, orthopnea, sudden SOB at night, fatigue, weakness, dizziness.
Tx. Antihypertensives, diuretics, beta blockers, low sodium diet, US, nonstress test at 30 to 32 weeks, heparin.
Right Sided Heart Failure:
Pulmonary valve stenosis, atrial and ventricular septal defects (Eisenmenger syndrome)
Hospitalized during pregnancy, O2, arterial blood gases.
Ascites, edema, enlarged liver.
Peripartal Heart Disease:
Rare-occurs in African American multiparas with hypertension.
SS-MI
Reduce activity, diuretic, digitalis, low dose heparin, immunosuppressive therapy.
No more pregnancies.
Assessment is continuous, educate patient.
ECG, chest X-Ray, echocardiogram
Fetal Assessment
Cardiac failure affects fetal growth. Low birth weight, preterm labor.
Promote rest-left lateral recumbent position, 2 rest periods/ day, good nights sleep.
Promote healthy nutrition-prenatal vitamins with iron, sodium restricted diet.
Educate regarding medication-may need to be increased,
Educate regarding avoidance of infection- call doctor if URI or UTI.
Nursing in L&D
Should not push with contractions, use low forceps or vacuum extraction, side lying, may need semi-Fowlers.
Postpartal
Most critical time, blood volume increased by 20% to 40% with in 5 minutes due to delivery of the placenta.
May need anticoagulant, digoxin, walk, antiembolic stockings, antibiotic, oxytocin (increases B/P), stool softener, help at home.
Artificial Valve Prosthesis:
Heparin therapy does not cross the placenta.
Monitor for signs of premature separation of the placenta during pregnancy and labor.
Chronic Hypertensive Vascular Disease:
Associated with arteriosclerosis or renal disease.
Poor placental perfusion risks.
Venous Thromboembolic Disease:
Due to stasis of blood in lower extremities from uterine pressure and hypercoagulability.
DVT leads to PE
SS-chest pain, sudden onset of dyspnea, cough with hemoptysis, tachycardia or missed beats, severe dizziness or fainting from low B/P
Doppler studies, bedrest, IV heparin for 24 hours then SQ heparin every 12 to 24 hours for duration of pregnancy in arms and thighs, PTT.
No oral contraceptives.
Endocrine Disorders
Serious because enzymes or hormones control so many specific body functions.
Thyroid Dysfunction:
Thyroid enlarges during normal pregnancy due to increased vascularity.
Hypothyroidism:
Unable to conceive, spontaneous miscarriage
Synthroid needs to be increased during pregnancy.
Hyperthyroidism:
SS-rapid heart rate, exophthalmos, heat intolerance, nervousness, heart palpitations, weight loss.
If undiagnosed the woman may have heart failure, hypertension, fetal growth restrictions, and preterm labor.
Tx. Meds are teratogens, PTU, Tapazole.
Lowest possible dose, infant may be born hyperthyroidism, jittery, tachypnea, tachycardia.
Diabetes Mellitus:
Pancreas can not produce adequate insulin to regulate glucose levels.
20 to 50 per 1000 pregnancies.
Control is difficult during pregnancy.
Glomerular filtration increases (glycosura), rate of insulin secretion is increased, fasting blood sugar is lowered.
Fetus uses glucose may lead to hypoglycemia for the mother between meals.
Amniotic fluid increases by 25%
Infants are large, subcutaneous fat deposits.
At birth neonates are prone to hypoglycemia, RDS, hypocalcemia and hyperbilirubinemia. Congenital anomaly.
Gestational Diabetes:
Midpoint of pregnancy when resistance becomes most noticeable. Symptoms fade after pregnancy.
Factors- obesity, age over 25, hx. of lg baby
Hx of unexplained fetal or perinatal loss
Hx of congenital anomalies in previous pregnancies
Family history of diabetes
Member of a population with high risk
Assessment:
Screened prenatally, 24 and 28 weeks.
GTT
Glycosylated hemoglobin HbA
Eye exam.
Table 14.3 and 14.4 p 359
Education regarding nutrition
1800 to 2200 caloric diet (3 meals 3 snacks)
Reduce saturated fats and cholesterol and fiber
If overweight; intake 1800 calories
Weight gain of 25 to 30 lbs
Education regarding exercise
Muscles increase their uptake of glucose, lasts 12 hours after exercise.
30 minutes of walking every day.
Management:
More frequent prenatal visits
Insulin specific for each woman
Regular and intermediate type, 2/3 in am and 1/3 in evening.
No oral hypoglycemia agents-cross the placenta and are teratogenic.
Keep FBS below 95 to 100 mg/dL and 2 hour 2 hour postprandial level < 120mg/dl
Insulin Pump:
Continuous rate of 1 unit/hour, bolus before meals or snacks
Clean site daily and change site q 24 to 48 hours.
Glucose monitoring fasting and 1 hour after meals.
Blood Glucose Monitoring:
Test for Placental Function and Fetal Well Being.
Serum alphafetoprotein level at wk 15-17
US at 18-20 wks.
Creatinine clearance test each trimester.
Nonstress test
Timing for Birth:
Cesarean birth at 37 weeks was the old standard
Vaginal birth is preferred now. IV regular insulin, blood glucose every hour.
Postpartal Adjustment:
1 to 2 hour postprandial blood glucose
Returns to normal in 24 hours after birth.
May breast feed because insulin does not pass into breast milk.
May develop type 2 diabetes later in life.
Cancer:
Cervical, breast,ovarian, thyroid, leukemia, melanoma, lymphomas.
1st trimester decisions about Tx.(teratogens)
Chemo in 2nd and 3rd trimester no risk.
Surgery to remove tumor
Does not metastasize to fetus.
Mental Illness
Depression most common.
Stress makes it more difficult to cope.
Lithium is a teratogen.
Cared for by a psychiatrist.
Trauma:
Injury by force. Auto accidents, homicide, and suicide.
Last trimester due to clumsiness, fainting, hyperventilation.
A woman’s body will maintain her own homeostasis at the expense of the fetus.
Abdominal pain is difficult to localize because organs are pushed aside.
Psychosocial Considerations:
Apprehensive and frightened.
Worries about tx., feels guilty, increased stress.
They do not process information well-review later also.
Assess and support patient. (Table 14.5)
Health history, has she felt the baby move, circumstances, degree of injury in proportion to the history.
Management:
Immediate care to stabilize and continuing care once emergency has passed.
CPR
Ephedrine to restore B/P, Dopamine
Laceration:
Pressure to stop bleeding, suture, Xylocaine
Puncture Wounds:
Tetanus immunization within 10 yrs.
Degree of violence.
Fistulogram
Surgical repair, may need cesarean birth to avoid strain on repair.
Animal Bites:
Usually dog, check rabies immunizations
Wound is washed and treated.
Blunt Abdominal Trauma:
Auto accidents
Underlying tissue becomes edematous, broken vessels ooze, form hematoma at sight.
Peritoneal lavage, US
Dislodgement of placenta or preterm labor.
Palpate uterus and monitor fetal heart.
Sonogram, pelvic exam, kleihauer-Betke test for presence of fetal blood cells in maternal bloodstream. (Rh neg)
Magnesium sulfate to halt preterm labor.
Gunshot Wound:
Intended, innocent, suicide.
Point of entry and exit (intestines are high in abdomen)
Cleanse, debrided and ampicillin.
Report to police.
Poisoning:
Accident, foods, suicide.
Poison control center, Syrup of ipecac, activated charcoal.
Choking:
Heimlich maneuver is difficult, successive chest thrusts instead.
Orthopedic Injuries:
Poor balance late in pregnancy.
May result in wrist injury due to the attempt to break her fall.
Ice, X-Ray, monitor preterm labor.
Previous injuries, laxness of body cartilage.
Burns:
Thermal injury and carbon monoxide gases can lead to fetal hypoxia (crosses the placenta).
Prostaglandins are produced and possibly causing preterm labor. Body tissue heals quickly during pregnancy.
Post Mortem Cesarean Birth
If fetus is past 24 weeks and fewer than 20 minutes have passed. (5 min. preferred)
No consent needed.
Intimate Partner Abuse:
20 to 25%
Woman is unable to resist sexual advances, having a child will change the partner, someone to love her.
Another mouth to feed, clothe.
Fear of reporting of abuse, may not come in, no money, no labs due to cost, diet the partner wants, anxious if running late in the office, covers up bruises, anxious to hear the fetal heart beat due to recent trauma.
Sonogram
Educate and support.