3318 High Risk Pregnancy

risk factors of high risk pregnancy

• biophysical: large fetal size, multiple pregnanceis, infection, DM, preterm labor/birth, placental abnormablities

• environmental factors: infections, radiation, pesticides, drugs

• psychosocial: caffeine, smoking, alcohol, situational crisis

• sociodemographic: poverty, lack of prenatal care, pubescent pregnancy, geriatric pregnancy,

placenta previa

placenta is implanted lower in the uterus and can cover the cervical oss

can be indication for c-section if placenta does not move itself up during pregnancy

PAINLESS BLEEDING

total placenta previa

cervical os is completely covered by the placenta

partial placenta previa

placenta is covering the cervical os partially

marginal placenta previa

placenta is right next to the cervical os

low lying placenta previa

placenta is implanted in the lower uterine segment but does not reach the os

placenta previa management

• bed rest until 37 weeks

• no vaginal exams BLEEDING RISK

• monitor FHT

• monitor blood loss

• betamethasone for fetal lung development

• IV fluids

• no intercourse

Placental Abruption

IMMATURE placenta detachment

PAINFUL, HIDDEN BLEEDING

may cause fetal distress, uterus firm or rigid

Causes of placental abruption

• cigarette smoking

• increased maternal age

• alcohol

• cocaine

• short umbilical cord

• HTN

marginal placental abruption

blood passes between fetal membranes and uterine wall and escapes, BLEEDING VISIBLE

central placental abruption

placenta abrupts centrally and blood is trapped between placenta and uterine wall, bleeding is concealed

complete placental abruption

massive vaginal bleeding, total separation

Class 0 Placental Abruption

asymptomatic

Class I Placental Abruption

mild symptoms, common

Class II Placental Abruption

moderate symptoms; maternal and fetal distress

Class III placental abruption

severe symptoms, maternal shock and fetal death likely

PPH risk factors

uterine atony

lacerations

retained placenta

distended bladder

PPH Intervention

• uterine massage

• bladder emptying

• asess H&H

• UTERINE CONTRACTION MEDICATIONS

  • cytotec

  • oxytocin (pitocin)

  • methergine

  • hemabate

• assess I&O

• encourage rest

prenatal loss

loss of a fetus from time of conception until time of delivery

spontaneous abortion/miscarriage

still birth

ectopic pregnancy

death shortly after birth

Week 4-8 Abortion

caused by chromosomal abnormality

weeks 4-10 abortion

caused byinsufficient or exceptive hormones

weeks 4-12

caused by maternal infections

weeks 12 -19 abortion

usually caused by a maternal factor such as cervical insufficiency or maternal disease

threatened abortion

unexplained cause, threathens to happen, bleeding cramping, resolves. cervix rmaines closed

imminent/inevitable abortion

increased bleeding/cramping, cervix dilates, membraned breaking, non preventable abortion

complete abortion

all products of conceptions expelled

incomplete abortion

not all parts of conception expelled, DNC required usually placenta is retained

missed abortion

fetus dies in utero and unexpelled. occurs usually within 16 wks no moving

recurrent pregnancy loss

2 or more miscarriage

septic abortion

infection causing loss of neonate, usually caused by Prolonged membrane rupture/systemic infection

nursing management of abortion

• psychological support

• reflective listening

• pain relief

• nursing management

postmortem care after perinatal loss

• place signs outside of door

• give parents the opportunity to spend time with their baby

• bathe and swaddle baby

• photography

• visitation with parents wishes

• assist parents with keepsakes

stillbirth

• loss of fetus after 20th week of pregnancy

• causes: placental abruption, preeclampsia, growth restriction = hypoxia, infections. chromosomal disorders, umbilical cord torsions

• risks: advanced maternal age, smoking, drugs, malnutrition, lack of prenatal care, A.A. women

ectopic pregnancy

implantation of a fertilized ovum in a site other than the endometrial lining of the uterus

risk factors of ectopic pregnancy

tubal obstruction/damage

delayed tubal transport

congenital anomalies

altered hormonal status

smoking

AMA

interventions of ectopic pregnancy

methotrexate: stops progression of ectopic pregnancy

surgery: salpnigectomy removal of fallopian tubes

rhogam: fetal cells can enter bloodstream during ectopic pregnancy so antibodies cannot

incompetent cervix

painless dilation of cervix without labor or uterine contractions

interventions for incompetent cervix

• observe closely for cervical effacement (thinning) on ultrasound

• cerclage: stitched cervix to prevent premature dilation

• tocolytics

• broad spectrum antibiotics

gestational trophoblastic disease

condition where trophoblastic cells (outermost layer of embryonic cells) results in placenta forming in hydropic (fluid-filled) grape like clusters. precancerous cells

AKA Hydatidiform Mole/Molar Pregnancy

signs symptoms of molar pregnancy

prune juice, dark brown vaginal bleeding

anemia

hydrophic vesicles

abnormal uterine enlargement

absence of FHT

marked hCG elevation

hyperemesis

interventions for molar pregnancy

surgical removal

rhogam

methotrexate d/t possible development of cancerous cells. expells all products of conception

no new pregnancies fpor one year, cancerous cells can return

preterm labor

labor from 20 weeks-27 weeks

risk factors for ptl

• AA race

• maternal age extremes

• low socioeconomic status

• infections

• 
  

signs and symptoms of PTL

symptoms include, all signs of labor

• SROM

• abdominal pain

• vaginal bleeding

criteria for PTL Diagnosis

• cervical dilation and effacement

• 4 contractions 20 mins/8 contractions 2 hr

mngmt of PTL

bed rest

tocolytic therapy to delay birth

corticosteroid: prevent/reduce respiratory distress on the infant in case of delivery

magnesium sulfate

calcium antagonist and CNS depresant

seizure prevention, lowers BP

relaces smooth muscles of uterus through calcium displacement

excreted by the kidneys

AE: HA, visual disturbance, lethargy, N/V

magnesium sulfate toxicity

absence of reflex

respiratory depression

oliguria

confusion

cardiac arrest

use in caution for women with renal insufficiency & myasthenia

nursing considerations for magnesium sulfate

• measure BP before admin

• collect magnesium levels q6-8h

• monitor RR

• assess reflexes

• monitor I&O

• assess FHT consistently

• calcium gluconate at bedside REVERSAL AGENT

• after birth, the neonate should be monitored and observed for magnesium toxicity 24-48h

corticosteriod: betamethasone (celestone)

• help prevent or reduce severity of fetal respiratory distress and intraventricular hemmorage in premature infant

• stimulate surfactant production in unborn baby

• administer 2 doses IM q24h

• effects seen usually 48hr after initial administration

monitor Maternal lung sounds and signs of infection

HTN in Pregnancy

Most common condition in pregnancy

results in frequent hospital admission, maternal mortality, preterm birth, infant mortality

HTN Disorders

• gestational HTN

• preeclampsia

• eclampsia

• HELLP

classifications for hypertensive disorder

1. preexisting htn

2. hypertension that presents during pregnancy (gestational hypertension or pregnancy induced HTN)

3. preeclampsia

4. eclampsia

5. chronic HTN

chronic HTN

BP of 140/90mmHg before 20 wks gestation

Gestational HTN

HTN before 20th wk of pregnancy

BP 140/90 or more proteinuria

must have an elevated BP on 2 occasions 6 hrs apart

usually resolves by 12 weeks PP

preeclampsia

multisystem vasopressive disorder that targets the cardiac, hepatic, renal and CNS

vasospasm = major organs gets less perfusion = decreased brain perfusion causig headache, visual disturbances, hyperactive deep tendon reflexes = decreased kidney perfusion, decreased urine output= proteinuria of 300mg in 24 hr collection

management of preeclampsia mild

no signs of renal or hepatic dysfunction

• encourage bed rest, lateral recumbent position

• diet

• monitor FHT

• evaluate CBC, liver enzyme, and clotting factors

• monitor proteinuria

management of severe preeclampsia

bed rest (dark and quiet room to decrease stimulation)

diet

anticonvulsant (magnesium sulfate)

corticosteroid (betamethasone)

fluid and electrolyte replacement

antihypertensive

signs of preeclampsia worsening

• increased edema

• worsening HA

• epigastric pain

• visual disturbances

• decreased UO

• N/V

• bleeding gums

• disorientation

• hyperactive reflexed

eclampsia

BP of 160/110

marked proteinuria

seizure

hyperreflexia

severe HA, generalized edema, epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP

management of eclampsia

• assessment

• maintain airway

• prevent injury

• magnesium sulfate

• dilantin or other anticonvulsant

• prepare for birth

cure for preeclampsia and eclampsia

delivery of placenta

HELLP abbreviation

hemolysis, elevated liver enzymes, low platelet count

What is HELLP

variant preeclampsia and eclampsia

increased risk of cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, disseminated intravascular coagulation, placental abruption, and maternal death

HELLP lab work

• anemia: low HGB

• thrombocytopenia: low platelets <100000

• elevated liver enzymes

Rh Antibodies Enter Fetal Circulation

hemolysis

generalized edema

CHF

Jaundice

Indirect Coombs Test

measures # of Rh antibodies in maternal blood (indirect antiglobulin test)

screens pregnant women for antibodies that may cause hemolytic disease in the newborn

Negative= fetus at no risk

Direct Coombs Tests

On infant to detect antibody coated Rh+ blood cells (direct antiglobulin test)

A positive result indicates an immune mechanism attacking infant RBC

Rh incompatibility

Rhogam

• given to Rh(-) women

• given 28wks gestation

• given within 72 hrs after birth: abortion, chorionic villus sampling, ectopic pregnancy, amniocentesis

• Given IV or IM

• precent Rh - women from developing Rh antibodies

cord prolapse

membranes must be ruptures

part of cord drops through the opening of the cervix

part of baby body pushes on cord

intervention: must hold presenting part of infant off of cord until baby is delivered by c/s

hyperemesis gravidarium

• hyperemesis so severe that it affects hydration and nutritional value

• unknown etiology

• frequent in adolescents, multiple gestation, women with mother or sister with hx, hx in previous pregnancy

• D/x criteria: hx of intractable vomiting first half og pregnancy, dehydration, ketonuria, weight loss of 5% pre-pregnancy weight

clinical therapy goals of hyperemesis gravidarium

1. control vomiting

2. correct dehydration

3. restore electrolyte balance

4. maintain adequate nutrition

initial treatment homecare: start small wiith avoidance of environment triggers, small frequent meals, antiemetics

pregnancy diabetes

pregestational affects, changes in insulin requirements, possible acceleration of vascular diseases

effects of diabetes on mother

• hydramnios

• dystocia

• infections

• PIH

• retinopathy

diabetes effects on baby

• LGA- hyperinsulinism (as a response to mother) acts as a growth hormones

• IUGR- poorly controlled insulin dependent mothers

• congenital anomalies

• hypoglycemia (after birth)

• hyperbilirubinemia (immature liver processing)

management of infant diabetes

• dietary regulation

• home glucose monitoring

• insulin administration

• evaluate fetal status

glucose tolerance test

• 50g of oral glucose

• blood sample 1 hr after consumption

• 130mg

• 
  

fasting BG

95mg/dL

1hr BG GTT

>= 180mg/dL

2hr BG GTT

>= 155mg/dL

3hr BG GTT

>= 140mg/dL

Management of BG GTT

• medications: oral hypoglycemics- glyburide insulin

• monitor BG

• NST Non-stress test

• Education

• Diet/exercise

Infants of Teen Moms

higher rate of low birth weight infants

higher rate of infant mortality

increased rate if sudden infant death

premature deliveries (less than 37 wks)

more likely to become hospitalized during their childhood

more likely have children with medical and developmental delays

consequences of maternal teen pregnancy

• increased rate of anemia and HTN in pregnancy

• increased complications during delivery

• higher risk of STIs

• higher risk of smoking

• depression and social isolation

• increased maternal mortality during delivery

• lifetime poverty

nursing management of pregnant teen

• provide quality care

• assess teen family and social support

• listening more and talking less to develop a trusting relationship with teen

• self esteem

• decision making skills

education of pregnant teen

• nutrition, exercise labor, newborn care

• family planning/contraception

• health screening

• support

• parenting behavior

• father involvement

most commonly abused substances

• alcohol

• nonmedical pain relievers

• marijuana

• phencyclidine (PCP_

• MDMA/esctasy

• heroin

maternal complications in substance abuse

• delay in seeking prenatal care

• poor nutrition

• PIH (pregancy induced hypertension)

• STDs

• bleeding disorders

• withdrawals

• psychological reactions

fetal/neonatal implication of drug abuse

genetic, teratogenic effects

spontaneous abortion

IUGR

Prematurity

withdrawal from drugs upon birth

abuse and neglect

signs of withdrawal in infants

• listless

• poor muscle refleces

• poor feeding

• high pitched cries

• jitteriness/tremors

• restless

• inability to be consoled when crying

fetal alcohol spectrum disorder

alcohol is teratogenic

defects r/t alcohol occur around 3-8 wks gestation

manifestations: small head, low nasal bridge, short nose, small eye opening, flat midface, thin upper lips, smooth philtrum

newborn implications on marijuana use

can cause tremors, prolonged startle, irritability

cocaine use in pregnancy

1 in 10 women

can cause HTN, hallucinations, respiratory failure, spontaneous abortions, placental abruption, preterm birth, stillbirth

the newborn usually weighs less at birth and smaller head circumference

also irritable, jittery, tremors, high-pitched cry, and excessive suck

opiates and narcotic use in pregnancy

use of heroin, morphine, codeine, oxxycodone, and methadone

CNS dependant

can cause poor nutrition, PIH, abnormal implantation of placenta, placental abruption, PROM, preterm labor

fetus is at risk for preterm birth, IUGR, withdrawal symptoms after delivery, irritability, high pitched cry, vomiting/ seizures= neonatal abstinence syndrome

TORCH

toxoplasmosis, other infections, rubella, cytimegalovirus, herpes simplex virus 2

Toxoplasmosis

toxoplasma gondii

caused by raw or poorly cooked meat

unpasturized goat milk

feces of infected cats

Rubella (german measles)

pregnant women cannot be vax

clinical signs in infants: congenital cataracts, congenital heart defects, deafness, mental impairment, cerebral palsy

cytomegalovirus

• most common casue of intrauterine infections

• found in urine, saliva, cervical mucus, semen, breast milk

• able to be transmitted by asymptomatic women across placenta

CMV risks

• mental impairment

• hearing loss

• learning disabilities

• fetal death

• hydrocephaly

• cerebral palsy

herpes simplex virus

indication for c/s

antiviral therapy recommended after 36 wks- acyclovir

newborn infection symptoms: fever, jaundice, seizures, poor feeding, vesicular skin lesions

group beta strep

a bacterial infection found in the lower GI or urogenital tract

intrapartum prophylaxis (anyone + for GBS receives antibiotics while in labor or prior to C/S)

• penicillin

• ampicillin

HIV transmission to the baby

an HIV positive woman can transmit the virus to her baby during pregnancy, Labor, breastfeeding