OB pt 3

high risk pregnancy

• Jeopardy to mother, fetus, or birth

• Condition due to pregnancy or result of condition present before pregnancy

• Higher morbidity and mortality

• Risk assessment with 1st antepartal visit ongoing

High risk pregnancy risk factors

• Diabetes

• Cardiac and respiratory disorders

• anemia

• specific infections

Gestational diabetes

• Diagnosis with GTT (glucose tolerance test) in pregnancy

• Maternal hyperglycemia= fetal hyperinsulinemia

  • Insulin is a growth factor

    1. Macrosomia

    2. Decreased surfactant

GD risk factors

• Obesity

• Family hx

• Advancing age over 25

• Past hx

• Hx stillbirth or large baby

• Hx abnormal GTT

GD diagnosis

• Urine testing

• HbA1C??

• Screening with 1 hour Glucose tolerance test (GTT)

  • Random- non scheduled

  • 24-28 weeks

  • 50g oral glucose load (glucola), <140

• Diagnostic with 3 hour GTT

  • 100g load

  • Fasting (<92) 

  • 1 hr, 2 hr, 3 hr blood tesing

    • 1 hour: <180

    • 2 hour <153

    • 3 hour: <140

GD TX

• Diet

  • Nutritional consult

• Meds

  • Oral

    • is an option bur most as good as insulin

    • Glyburide

    • Metformin

  • Insulin

  • Post Prandial BG of <120

    • Short acting

    • Insulin pump

    • Will have insulin pump intrapartum

    • Postpartum will have 2hr PP BG with insulin or nothing

GD complications

• Mom

  • HTN

  • Postpartum hemorrhage

  • C/S birth

• Fetus

  • Polyhydramnios

  • Congenital disorders

  • Macrosomia

  • Asphyxia/Stillbirth

• Neonate

  • Prematurity

  • RDS

  • Hypoglycemia

cardiac and acquired HD

• Pathophysiology

  • Hemodynamic changes/increased cardiac workload overstressing woman’s cardiovascular system

• Therapeutic management

  • Risk assessment, prenatal counseling, increased prenatal visits, Perinatologist

• Nursing assessment

  • Vital signs, heart sounds, weight, fetal activity, lifestyle

  • Assess for cardiac decompensation

  • Intrapartum: delivery in side-lying position, FHR, ABG, no Terb!

  • Postpartum: 24-48 they are still not stable, side lying, HOB

congenital, Acquired, and ischemic HD

• Congenital Heart Disease

  • Septal defects

  • CoArc

  • TOF 

• Acquired Heart Disease

  • Mitral valve prolapse

  • Mitral valve stenosis

  • Aortic stenosis

• Ischemic Heart Disease

  • Myocardial infarction

Anemia

1. Iron deficiency

   • Usually due to inadequate dietary intake

   • Therapeutic management: eliminate symptoms, correct deficiency, replenish iron stores

   • Nursing assessment

     • Fatigue, weakness, malaise, anorexia, susceptibility to infection (frequent colds), pale mucous membranes, tachycardia, pallor

     • Abnormal lab results

       • Low hemoglobin, low hematocrit, low serum ferritin <12

   • Compliance with drug therapy: prenatal vitamin and iron supplement

   • Dietary instruction and counseling

specific infections

TORCH

T toxoplasmosis

O other

R rubella

C

H herpes 1

Toxoplasmosis

Protozoa the infects warm blooded animals – causing toxoplasmosis

• Cats are hosts/reservoirs, found cat feces, litter boxes, gardens

• Human transmission:

  • Ingestion of undercooked eggs, red meats containing protozoa cysts/oocytes

  • Hand to mouth transmission with infected hand

• Complications: embryonic damage, or congenital transmission: LBW, liver damage

• Prevention is key

  • Nutrition education

  • Pet cat: other people change little box or gloves

Rubella

• German measles

• Worse effects in first 12 weeks of pregnancy

• Congenital rubella:

  • Cataracts

  • Glaucoma

  • Hearing loss

  • Cardiac defects

  • Neuro effects

• Prevention:

  • Screening

  • Education

  • Vaccination – PP

Hepatitis B virus

• Transmission through blood and bodily fluids

• 100 times more infectious than HIV ( can live outside body for >week)

• Congenital HBV worse in 3^rd trimester

• 40% of infants of moms with HBV will have Chronic HBV by 6 months of age

• Screening for all moms

• HBV+ moms

• Infant will get HBV vaccine AND HBIG within 12 hours

• Breastfeeding??

Parvovirus 19

• Very common viral infection of children (AKA Fifth’s disease)

  • Erythema “slapped face” appearance

• Most people have been exposed then immune

• Greatest risk to fetus within 20 weeks

• Complications to fetus:

  • Hydrops

  • IUFD

  • Cardiac anomalies

• Prevention:

  • School, preschool, daycare workers- education!

Herpes simplex

• HSV-1, HSV-2: both can cause genital infections

• HSV-1 now main cause of genital infections

• Greatest risk of transmission is new active infection near time of birth

  • Ascending infections after ROM

  • Direct contact during birth

  • SAB, IUGR, Neuro damage, Congenital HSV, fetal death

• Method of birth

  • Absence of active infection= vaginal birth

  • Avoid all procedures (AROM, FSE, instrument delivery)

  • Active infection: C/S

• Prevention

  • Prophylaxis at 36 weeks with antiviral

  • Effect on fetus depends on timing of infection

Group B strep

• Naturally found in GI tract in 50% of women

• 25% pregnant women have GBS in the rectal/vaginal area

• Most common cause of meningitis/sepsis in newborn

• Tested at 36 weeks via vaginal/rectal swab or from urine

• Fetal risk also with previous pregnancy with + GBS

• +GBS moms will get prophylaxis with PCN intrapartum

  • Every 4 hours until delivery (at least 1 dose 4 hours before birth)

  • Clindamycin or Cephalosporin if allergic to PCN

• Unknown GBS moms- infants to be closely monitored

Spontaneous abortion

• Loss before 20 weeks: spontaneous/induced

• Cause unknown and highly variable

  • First trimester commonly due to fetal genetic abnormalities

    • 20% of pregnant women have vaginal bleeding in 1st trim, ½ of these are having a spontaneous abortion

  • Second trimester is more likely related to maternal conditions

    • Cervical insufficiency

    • Uterine anomalies

    • Diabetes

    • Cocaine

    • HTN

    • TORCH

Spontaneous abortion risk factors

• Up to 50% of all fertilized eggs die and are lost (aborted)

• Usually before women know they are pregnant

• Usually happens between week 7-12

• Higher risks with:

• AMA (>35)

• Diabetes or Thyroid issues

• Hx of 3 or more spontaneous abortions

Spontaneous abortion assessment

• Pt will report bleeding, cramping, products of conception

• Vaginal bleeding

  • Color: bright red is significant

  • Amount: 1 pad/hr is significant

  • Clots/tissue: Save them!

• Vital signs, pain level

• Intensity of cramping/contractions

• Client’s understanding/emotional needs

• Proper history and assessment will let us know what type of AB

Spontaneous abortion types

• Threatened

  • Slight bleeding, no dilation, cervical change or loss of fetal tissue

  • Confirm viability of fetus with u/s

  • Supportive treatment: rest, nutrition, hydration

• Incomplete

  • some products passed, D/C

• Complete-

  • all products passed, f/u with MD office, HCG levels

• Missed

  • nonviable embryo retained, D/C or induction

Spontaneous abortion nursing management

• Continued monitoring:

  • vaginal bleeding, pad count, passage of products of conception

  • pain level

  • preparation for procedures

  • medications

    • Misoprostol (Cytotec)

    • Mifepristone(RU-486) – prostaglandin to stimulate contractions/sloughing

• Support: physical and emotional; stress that woman is not the cause of the loss; verbalization of feelings, grief support, referral to community support group

Ectopic pregnancy

• AKA- “tubal pregnancy”

• Ovum implantation other than the endometrium of uterus  (see Figure 19.1)

• Most common cause of maternal death in 1st trimester!

• Obstruction to or slowing passage of ovum through tube to uterus

• Causes:

  • Tubal damage/scarring from PID

  • Altered tubal motility, chromosomal abnormalities

  • Douching??

ectopic pregnancy management

• Therapeutic management

  • Hallmark sign: abdominal pain with spotting within 6 to 8 weeks after missed menses

  • HCG test, U/S

  • Medical: to remove tube or just POC to preserve and no scarring

  • Surgery if ruptured or implantation other than adnexa

  • Rh immunoglobulin if woman Rh negative

• Medication:

  • Methotrexate – chemo drug

  • IM, single dose, 90% success

  • Folic acid antagonist- inhibits cell division

  • Pt must be hemodynamically stable

• Preparation for treatment

  • Analgesics for pain

  • Medications for medical treatment

  • Teaching about signs and symptoms of rupture

  • Surgery

• Emotional support

• Education

cervical insufficiency

• Premature dilatation of cervix

• Causes:

  • Lacerations from previous births

  • Cervical procedures

  • Congenital issues

• Nursing assessment

  • Pink-tinged vaginal discharge or pelvic pressure

  • Cervical shortening via transvaginal ultrasound

• Therapeutic management

  • Bed rest, pelvic rest, avoidance of heavy lifting

  • Cervical cerclage

  • 16 weeks,  removed at 37

Preeclampsia

• Patho

  1. Most common HTN in pregnancy

     1. HTN with proteinuria after 20 wks

     2. Mild or severe

  2. Vasopasm and hypoperfusion -> decreased placental perfusion-> vasoconstriction, activation of coagulation cascade, fluid redistribution -> degreased organ perfusion

  3. Only cure is delivery

preeclampsia risks

• Extreme age >40, <19

• Nulliparity

• Sperm!

  • AA

• Preexisting HTN, renal dx, Diabetes

• Multifetal pregnancy

• History

  • Previous Hx

  • Family Hx

  • FOB Family Hx

• BMI >29

 

preeclampsia symptoms

• BP

  1. Mild: >140/90 after 20wks

  2. Severe: >160/110

• Proteinuria

  1. Mild: 300mg/ 24 he >1+ protein DS

  2. Severe: 500mg/ 24hr > 3+ protien DS

• Hyperreflexia (severe) 4+ DTR eith or without clonus

• Mild: Hand/facial edema, wt gain

• Severe: HA, blurred vision, pulmonary edema, thrombocytopenia, epigastric pain HELLP

preeclampsia nursing management

• Labs:

  • CBC, BUN, AST/ALT, UA

• Nursing management

  • Quiet environment, sedatives, seizure precautions

  • Antihypertensives

  • DTR testing

  • Assessing for magnesium toxicity and labor

  • Seizure management for eclampsia

  • Preparation for birth

• Mild preeclampsia management (no renal/hepatic/coagulation issues)

  • Home: Bed rest, daily BP monitoring, and fetal kick counts

  • Hospitalization

  • Hypertensive medication/MgSO4

• Severe preeclampsia management

  • Hospitalization

  • oxytocin and magnesium sulfate

  • preparation for birth

preeclampsia TX

• Magnesium Sulfate (MGSO4)

  • Treatment at least 24 hr after delivery  or longer

  • increased CNS irritability

  • SE:

    • flushed, warm, “gorked”

  • Toxic SSX:

    • No DTRs, resp dispression, increased lethargy

  • 4 gm bolus  then 2gm/hr maintenance 

  • have a calcium antidote to prevent OD

• Antihypertensives

  • Hydralizine

  • Labetalol

  • Nifedipine

  • Aldomet

Eclampsia

• Patho

  • Preeclamspia with seizures

• Risks

• Symptoms

  • BP

  • PROTEINURIA

  • SEIZURE/COMA

  • Hyperreflexia

  • HA, blurred vision, general edema, thrombocytopenia, epigastric pain HELLP, cerebral hemorrhage

• Nursing management

  • Eclampsia management

  • Preventable if preeclampsia is caught early

  • Seizure management, MgSO4, HTN meds; birth (c/s) once seizures controlled

HELLP

• Hemolysis: RBC, plt, #Bilirubin

  • Destruction d/t traveling through constricted vessels

• Eevated Liver enzymes

  • Vasospasms $blood flow in liver = tissue damage

• Low Platelets

  • Plts collect at site of all endothelial damage= all used up = DIC

• Occurs in 3rd trimester or w/in 48hrs postpartum

• High risk for renal failure, DIC, abruption, liver failure, stroke

• Nursing assessment: similar to that for severe preeclampsia; laboratory test results

  • Nursing management

• same as for severe preeclampsia

• Blood products to correct hemolysis

PROM

• SROM before labor women beyond 37 wks gestation ( at term)

  • Risk factors

    1. Weakened membranes

    2. Inflammation, UTI

    3. Contractions

    4. increased intrauterine pressure

  • SS

    • BP

      • Mild: >140/90 after 20 wks

      • severe: >160/110

    • Proteinuria

      • mild: 300mg/ 24 hr > 1+ protein DS

      • severe: > 500mg/24 hr > 3+ protein DS

    • Hyperreflexia (only severe)

    • HA

    • Blurred vision

    • pulmonary edema

    • thrombocytopenia

    • epigastric pain

    • HELLP

PROM management

1. Management

   • Identification of uterine contractions

   • Infection prevention

     • Chorioamniotis- infection of amniotic cavity

       • GBS, Ecoli, BV ( long labor, PROM, Multiple vag exams)

       • Maternal tachy, fever, uterine tenderness, foul odor!

       • Antibiotic therapy (3) intra/pp

• Mild preeclampsia management (no renal/hepatic/coagulation issues)

• Home: Bed rest, daily BP monitoring, and fetal kick counts

• Hospitalization

• Hypertensive medication/MgSO4

• Severe preeclampsia management

• Hospitalization

• oxytocin and magnesium sulfate

• preparation for birth

• C/S- dystocia or Fetal distress

• TX

  • dependent on gestational age

    • no unsterile digital cervical exams until woman is in active labor

    • expectant management if fetal lungs immature

PPROM

water broke before labor in preterm mom, (preterm) women less than 37 weeks’ gestation

SS

• BP: >160/110

• Marked Proteinuria

• Proteinuria

• seizure/Coma

• Hyperreflexia

• HA

• Blurred vision

• general edema

• cerebral hemorrhage

• renal failure

• thrombocytopenia

• epigastric pain

• HELLP

Management

• Preventable if preeclampsia is caught early

• Seizure management, MgSO4, HTN meds; birth (c/s) once seizures controlled

overall goal for a pregnant client with CAD

• Goal is to keep them stable

• For congenital and acquired heart disease risk assessment, screening for conditions during prenatal care

• To reduce cardiac workload have them turned to lt side, monitor ABGs and FHR, don’t give terbutaline

plan of care for a client and newborn with HIV.

• GA has high numbers of HIV- similar to 3rd world country

• Today, if a woman takes HIV medicine daily as prescribed throughout pregnancy, labor, and delivery and gives HIV medicine to her baby for 4-6 weeks after delivery, the risk of transmitting HIV to the baby can be as low as 1% or less. 35% if no treatment

• NO BREASTFEEDING

Prenatally all women are given the choice of screening

• Complications:

  • Pregnancy: preterm, IUGR, PROM, infection, poor wound healing

  • Newborn: transmission (2% increase in transmission every hour after ROM)

• Therapeutic management: oral antiretroviral drugs BID from 14 weeks until birth; IV administration during labor; oral syrup for newborn for first 6 weeks of life; decision for birthing method

• Birthing method: depends on viral load (viral shedding)

  • >1000- C/S

  • <1000- may attempt vaginal delivery

• Nursing management: history and assessment; HIV antibody testing;

  • Intrapartum: medication, prevention of invasive procedures (episiotomy)

  • PP: bath infant immediately- before meds

nurses role in care of pregnant teen

• 11% of births are in girls 15-19

• 1 in 4 teen mothers have another baby within 2 years

• Realistic role models; emotional support

• Nursing management:

  • Assessing knowledge of health and nutrition for self and child

  • Challenges of parenting role/future planning

  • EDUCATION!

  • Care coordination/social services

risk factors and outcomes of a pregnant client over the age of 35.

1. risks

   1. gestational diabetes

   2. preeclampsia

   3. labor dystocia

   4. C-section delivery

   5. preterm birth

   6. postpartum hemorrhage

   7. low birth weight of the baby

   8. severe issues with the baby

   9. indicating a stay in the NICU

   10. obesity

2. Outcomes

   1. higher risk for APGARs below 7 after 5 minutes

   2. asphyxia at birth, congenital malformations

   3. being LGA

   4. aspiration of meconium,

   5. jaundice

   6. transient tachypnea

   7. brachial plexus injury

   8. seizures

   9. sepsis

   10. intrauterine death.

substance abuse during pregnancy

• True stats of substance abuse in pregnancy unknown

• Maybe 7% of all pregnancies (illicit, smoking, alcohol

• 5% use illicit drugs

• Types:

  • Cocaine – preterm labor, abruption

  • Heroin

  • Marijuana

  • Methadone- treat as an opioid (for morphine/heroine addiction)

  • Tobacco- IUGR, LBW

  • Alcohol - FAS

• Effects on fetus: growth restrictions, increased risk of SIDS

• Worse in 1st trimester – neuro development issues

Alcohol

• 30% of pregnant women continue to drink alcohol

• Fetus gets same alcohol concentration

• Fetal Alcohol Spectrum Disorder

  • Structural birth defect anomalies

  • Behavioral/neurocognitive disorders

  • 1 in 100 infants/ yr

substance abuse nursing management

• Nursing assessment: urine toxicology (mom and baby)

• Nursing management

  • Nonjudgmental approach

  • State protection agency investigation for positive newborn drug screen

• Neonatal Abstinence Syndrome

  • WITHDRAWAL (symptoms)

  • Nursing interventions

metabolic changes in pregnancy

• Normal pregnancy:

  • 1st half: increased E+P, insulin, response to insulin = hypoglycemia

  • 2nd half: increased human placental lactogen, cortisol, glycogen, insulin resistance

  • Fetus removes glucose from maternal blood, but not insulin

  • Mom uses fat liposis for energy (watch for ketones)

    • = hyperglycemia- protection for fetus to have enough glucose

• Altered insulin requirements

  • 1st half: insulin needs may decrease

  • 2nd half: insulin needs may double or more

  • After delivery- may abruptly decrease insulin needs

  • Breastfeeding may also decrease insulin needs

  • 7-10 days after breastfeeding/or no breastfeeding will return to normal insulin needs.