Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations (OB)

When do baby’s organs (brain, heart, kidneys, and lungs) start forming?

What can high blood sugar do during this stage?

The baby’s organs can start forming during the first 8 weeks of pregnancy

High BG can increase the chance of birth defects during this early stage (such as defects of the brain, heart, or spine)

How does pregnancy affect the heart?

What are pregnant pts with underlying cardiac disorders at risk for?

It causes an increase in blood volume, HR, and CO

Pregnant pts do not tolerate these changes well and are at risk for developing arrhythmias, pulmonary edema, and congestive heart failure

During pregnancy, how much is O2 consumed?

What happens from the uterus elevating the diaphragm?

There is an increase O2 consumption by 20%

The uterus elevates the diaphragm , which can cause limited mobility and functional capacity that cause complications, such as increased susceptibility to infections, and limited mobility

What does anemia do during pregnancy?

• It reduces the amount of oxygen available to the developing fetus, potentially leading to complications such as low birth weight, premature delivery, and impaired fetal growth

• The mother struggles to supply enough oxygen for both herself and her baby when her RBC count is low. Untreated anemia can also increase the mother’s risk of complications during labor and postpartum recovery

What are autoimmune disease?

When can disease flare ups occur?

• Autoimmune diseases happen when your body’s antibodies, which normally fight off infections, get confused and start attacking healthy tissue by mistake.

• Disease flare ups can occur due to hormonal changes and the body’s altered immune response can lead to increased symptoms

What complications can occur from autoimmune disease + pregnancy?

Potential complications of autoimmune disease and pregnancy are preterm birth, low birthweight, or preeclampsia depending on the specific condition

What are localized autoimmune diseases?

Localized disorders target specific organs such as the thyroid gland in Hashimoto thyroiditis and Graves disease

What are systemic autoimmune diseases?

Systemic disorders affect multiple organs. For example, in systemic lupus erythematosus (SLE), the immune system can target the lungs, hearts, joints, kidneys, brain, and RBC

What is cytomegalovirus?

• A common virus that belongs to the herpesvirus family. It is often harmless and remains dormant in the body after the initial infection

• This infection can be passed from mom to the fetus and is a significant risk to the fetus

• It is the most common cause of birth defects in the US

What is cytomegalovirus? (cont.)

• If a mom is infected for the first time during pregnancy, there’s about a 40% chance that the virus will be passed to the fetus

• While many infants may not show symptoms at birth, some can develop severe complications. Potential complications for the infant include possible hearing loss, vision problems, and developmental delays

When does rubella cause the most damage during pregnancy?

What risks could occur?

Infection with rubella virus causes the most severe damage during early in pregnancy, especially in the 1st 12 weeks (1st trimester)

If infected with the rubella virus while pregnant there is a risk for a miscarriage, stillbirth, or serious birth defects

How should the rubella vaccine be given?

Timing of the rubella vaccine is important because it is a live attenuated virus which means it contains a weakened form of the virus. It is given after delivery to non-immune moms to avoid any potential risk to the fetus of future pregnancies.

Rubella virus infection is a leading cause of vaccine preventable birth defects

How does Herpes simplex virus affect pregnancy?

HSV-1 (oral herpes/cold sores)and HSV-2 (genital herpes) can impact pregnancy in many ways, depending on whether the mother has a history of genital herpes or if she acquires it during pregnancy

With a preexisting infection of genital herpes, the risk is higher for transmission if there is an outbreak during the time of delivery. If there is a preexisting infection with no active lesions, the risk of transmission is significantly lower

How can HSV be transmitted?

What is neonatal herpes?

• Can be transmitted through skin to skin contact so if there is an active lesion on her breast, breastfeeding should be avoided until the lesion has healed

  • If there are no lesions on the other breast, breastfeeding can occur on that one

• The virus is not present in breastmilk itself so breastfeeding from a mother without lesions poses minimal risk. Same precautions apply for Type 1 or 2 with active lesions

Neonatal herpes is a serious condition that can affect a newborn’s brain, eyes, and other organs

What is hepatitis B virus?

How can it be spread?

• A serious liver infection caused by the hepatitis B virus that is easily preventable by a vaccine

• Pregnant patients with HBV can spread the infection to their babies during labor and delivery. The CDC recommends that all babies receive the hepatitis B vaccine at birth, regardless of mother’s HBV status

What can cause chronic hepatitis B virus during pregnancy? What does chronic HBV do during pregnancy?

How high of a chance do babies have of developing chronic HBV?

• Many complications such as placental abruption, preterm birth, gestational diabetes and fetal growth restriction have been associated with chronic HBV during pregnancy. Chronic HBV in pregnancy increases the risk of progression to cirrhosis.

• When babies become infected with HBV, they have a 90% chance of developing a lifelong, chronic infection

When can varicella cause a risk of complications during pregnancy?

When should women receive the varicella vaccine?

• Infection during the first or early second trimester could cause a risk of complications for the fetus, including congenital varicella syndrome, which can lead to birth defects.

• Women are generally advised to receive the varicella vaccine before becoming pregnant, so it’s important to be vaccinated well in advance

What is parvovirus B 19?

Fetal risk can result in what with parvovirus B 19?

• Virus that can cause fifth disease (face rash in children that is highly contagious). When pregnant, the virus can be passed to the fetus and lead to complications.

• Fetal risk can result in severe anemia in the fetus, which could lead to hydrops fetalis. (a serious condition that causes build up of fluid in a fetus). This condition could potentially result in stillbirth. The risk is highest during the first and second trimesters

What is group B streptococcus?

When is screening performed?

• GBS is type of bacteria that can be found in the intestines or the lower genital tract of some individuals. It is mostly harmless in adults, but cause risk during pregnancy

• Pregnant women are screened for GBS around the 35th to 37th week and a swab is taken from the vagina and rectum to check for the presence of the bacteria

What risk can occur if a pregnant women is positive for GBS?

What is given for positive GBS test?

• If a pregnant woman test positive for GBS, there is a risk of transmitting the bacteria to the baby during delivery. This can lead to serious conditions such as sepsis, pneumonia, or meningitis in newborns

• Prophylaxis antibiotics are given during labor for positive GBS test to reduce the risk of passing the bacteria to the baby. This is very important for women who have risk factors such as preterm labor or a history of GBS-positive pregnancies

What is toxoplasmosis?

How can the risk of toxoplasmosis be reduced?

A disease caused by a parasite and that enters mouth. If the parasite infects a pregnant woman, it can also affect the woman’s fetus

The risk for toxoplasmosis can be reduced by avoiding all potential sources of infection including:
1. Consumption of undercooked meat + raw eggs
2. Exposure to cat feces and cat liter + Insects (like flies) that have been in contact with cat feces

What is human immunodeficiency virus (HIV)?

How can someone with HIV have a healthy pregnancy?

• HIV is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases.

• A person with HIV can have a healthy pregnancy and give birth to an HIV- negative baby if they take antiretroviral therapy (ART) and have an undetectable viral load

When can HIV transmission occur during pregnancy?

What is the chance of untreated HIV being passed during pregnancy?

HIV transmission can occur during pregnancy:
1. Via placenta
2. During delivery
3. Breastfeeding

Untreated HIV in pregnancy has a 1 in 4 chance of passing
the virus to the baby

What careful management of newborn from HIV-positive mothers is done?

• Newborns typically receive antiretroviral medication 6 to 12 hours after birth (Oral (Zidovudine/Retrovir). This treatment can reduce the risk of transmission from the mother to the baby.

• Testing for HIV in newborns occurs 14 to 21 days after birth with follow up tests at 1-2 months and again from 4-6 months to confirm baby’s HIV status.

• In addition to ART therapy newborns may be given other medications to prevent opportunistic infections, such as pneumocystis pneumonia depending on the mother’s HIV treatment history.

• Breastfeeding is discouraged as the virus can be transmitted through breast milk

HIV can serve as a threat to who?

What therapeutic management is done for HIV?

What nursing management is done with HIV?

During pregnancy, HIV can serve as threat to self, fetus, + others

Therapeutic management: oral antiretroviral drugs twice daily from 14 weeks until birth; IV administration during labor; oral syrup for newborn in first 6 weeks of life; decision for birthing method made on an individual basis depending on factors of women’s health

Nursing assessment: history and physical examination; HIV antibody testing; testing for STIs

What comprehensive prenatal care is done for women with HIV?

Women infected with HIV should have comprehensive prenatal care, which starts with pretest and post-test counseling:

In pretest counseling, the client completes a risk assessment survey, and the nurse explains the meaning of positive versus negative test results, obtains informed consent for HIV testing, and educates the woman about how to prevent HIV infection by changing lifestyle behaviors if needed

Post-test counseling includes informing the client of the test results, reviewing the meaning of the results again, and reinforcing safer sex guidelines. All pretest and post-test counseling should be documented in the client’s chart

What education is done for HIV-positive pregnant women?

• Infection control issues at home

• Safer sex precautions

• Stages of the HIV disease process and treatment for each stage

• Symptoms of opportunistic infections

• Preventive drug therapies for the unborn infant

• Avoidance of breast-feeding

• Referrals to community support, counseling, and financial aid

• Client’s support system and potential caregiver

• Importance of continual prenatal care

• Need for a well-balanced diet

• Measures to reduce exposure to infections

What preparation for labor, birth, and postpartum are done for HIV-positive pregnant women?

• Current evidence suggests that cesarean birth performed before the onset of labor and before the rupture of membranes significantly reduces the rate of perinatal transmission

  • ACOG recommends HIV-positive women be offered elective cesarean birth to reduce the rate of transmission beyond that which may be achieved through ART. ACOG further suggests operative births be performed at 38 weeks’ gestation and amniocentesis be avoided to prevent contamination of the amniotic fluid with maternal blood

• Compliance w/ antiretroviral therapy

• Family planning:

  • It is clear that hormonal contraceptives are not protective against HIV infection and that dual protection with condoms should be the goal for women using hormonal contraception. Advise the woman that breast-feeding is not recommended. Instruct the woman who is HIV-positive in self-care measures, including the proper method for disposing of perineal pads to reduce the risk of exposing others to infected body fluids. Finally, teach her the signs and symptoms of infection in newborns and infants, encouraging her to report any to the health care provider

What is stage I of HIV?

• Acute infection

• Clinical picture:

  • Early stage with pervasive viral production

  • Flu-like symptoms 2–4 weeks after exposure

  • Signs and symptoms: weight loss, low-grade fever, fatigue, sore throat, night sweats, and myalgia

  • Ability to spread HIV is highest during this stage because large amounts of HIV are being produced in the body, and the CD4 count drops

What is stage II of HIV?

• Asymptomatic infection or clinical latency

• Clinical picture:

  • Viral replication continues within lymphatics, but slows down

  • Usually free of symptoms; lymphadenopathy

What is stage III of HIV?

• Persistent generalized lymphadenopathy

• Clinical picture:

  • Possibly remaining in this stage for years; AIDS develops in most within 7–10 years

  • Opportunistic infections occur

What is stage IV of HIV?

• End stage disease (AIDS)

• Clinical picture:

  • Severe immune deficiency; very vulnerable to infections

  • High viral load and low CD4 counts

  • Signs and symptoms: bacterial, viral, or fungal opportunistic infections, fever, wasting syndrome, fatigue, neoplasms, and cognitive changes

What is type 1 diabetes?

Type 2 diabetes?

Gestational diabetes?

• Type 1 diabetes: Absolute insulin deficiency due to autoimmune beta cell destruction.

• Type 2 diabetes: Insulin resistance or deficiency due to a progressive loss of beta cell insulin secretion frequently on the background of insulin resistance.

  • Related to obesity and sedentary lifestyle. It is the most common type of diabetes and is diagnosed more frequently in POC + older adults.

• Gestational diabetes mellitus: Glucose intolerance with its onset during pregnancy usually diagnosed in the second or third trimester of pregnancy that was not clearly overt prior to gestation

Difference b/t pregestational diabetes + gestational diabetes?

Pregestational diabetes (alteration in carbohydrate metabolism identified before conception), which includes women with type 1 or type 2 disease, and gestational diabetes, which develops during pregnancy

What therapeutic management is done for diabetes mellitus?

• Preconception counseling Out of control BS

• Blood glucose level control (HbA1c <7%)

• Glycemic control

• Nutritional management

• Hypoglycemic agents

• Close maternal and fetal surveillance

• Management during labor and birth

What assessment is done for diabetes mellitus?

• Health history; physical examination; risk factors

• Screening at first prenatal visit; additional screening at 24 to 28 weeks for women considered at risk

• Maternal surveillance: urine for protein, ketones, nitrates, and leukocyte esterase; evaluation of renal function/trimester; eye exam in first trimester; HbA1c q4–6 weeks

• Fetal surveillance: ultrasound; alpha-fetoprotein levels; biophysical profile; nonstress testing; amniocentesis

What nursing management is done for diabetes mellitus?

• Optimal glucose control
  o Blood glucose levels; medication therapy
  o Nutritional therapy

• Measures during labor and birth; postpartum

• Prevention of complications

• Client education and counseling

What is the patho of congenital and acquired heart disease?

What therapeutic management is done?

What nursing assessment is done?

• Pathophysiology:
  o Hemodynamic changes overstressing woman’s cardiovascular system

• Therapeutic management:
  o Risk assessment, prenatal counseling, increased frequency of prenatal visits

• Nursing assessment:
  o Vital signs, heart sounds, weight, fetal activity, lifestyle
  o Signs and symptoms of cardiac decompensation

How is congenital and acquired heart disease managed?

• Stabilization of hemodynamic status

• Risk reduction measures: education, counseling, support

• Cardiac medications if prescribed

• Energy conservation; nutrition

• Fetal activity monitoring

• Signs and symptoms of cardiac decompensation

• Monitoring during labor

What is chronic hypertension?

What therapeutic management is done for chronic hypertension?

• Hypertension before pregnancy or before 20th week of gestation or persistence >12 weeks postpartum

• Therapeutic management: preconception counseling, lifestyle changes, antihypertensive agents for severe hypertension; fetal movement monitoring; serial ultrasounds