OB-High Risk Pregnancy

What is a High Risk Pregnancy?

A condition exists that jeopardizes the health of the mother, her fetus, or both

What are some Biophysical Factors that place women at risk?

• Genetic Conditions​

• Chromosomal abnormalities​

• Multiple pregnancies​

• Inherited disorders​

• Large fetal size​

• Preterm labor and birth​

• Cardiovascular disease​

• Placental abnormalities​

• Infection​

• Diabetes​

• Nutritional Status​

• Post-term Pregnancy

What are some Environmental Factors that place women at high risk?

• Infections​

• Radiation​

• Pesticides​

• Illicit rugs

What are some Psychosocial Factors that place women at high risk?

• Smoking​

• Caffeine​

• Alcohol and Substance Abuse​

• Inadequate support system​

• Maternal Obesity​

• Situational Crisis​

• History of Violence​

• Emotional Distress​

• Unsafe cultural practices

What are some Sociodemographic Factors that place women at high risk?

• Poverty​

• Lack of Prenatal Care​

• Age younger than 15 or older than 35​

• Marital Status​

• Accessibility to Healthcare​

• Ethnicity

What is Placenta Previa?

• The placenta is improperly implanted in the lower uterine segment.​

• Placenta may cover​ the cervical os

What is the classical presentation of Placenta Previa?

Painless, bright-red bleeding

Why is Placenta Previa dangerous?

Once dilation starts, the placenta tears off & oxygen is cut off from baby

What is Total Placenta Previa?

Internal os is completely covered by the placenta​

What is Partial Placenta Previa?

Internal os is partially covered by the placenta​

What is Marginal Placenta Previa?

Edge of placenta is at the margin of the internal os​

What is Low-lying placenta Previa?

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

How do you manage Placenta Previa?

• Bed rest until 37 weeks​

• No vaginal exams​

• Monitoring blood loss​

• Monitor fetal heart tones​

• Betamethasone (for fetal lung development)​

• IV fluids and monitor mom’s vitals​

• Pelvic rest including no intercourse​

• If it doesn’t resolve, C-Section will be required for safe delivery

What is Abruptio Placenta? (Placenta Abruption)

The premature separation of a normally implanted placenta from the uterine wall

What are the classic symptoms of a Placenta Abruption?

sudden pain, blood can be visible or concealed, may have fetal distress and uterus may be firm or rigid

What are the causes of Placental Abruption?

• CIGARETTE SMOKING​

• INCREASED MATERNAL AGE​

• ALCOHOL​

• COCAINE​

• SHORT UMBILICAL CORD​

• MULTIPARITY​

• TRAUMA​

• HYPERTENSION (most common cause)

What is Marginal Placenta Abruption?

blood passes between the fetal membranes and the uterine wall and escapes vaginally (may or may not become more severe)​

What is Central Placenta Abruption?

placenta separates centrally and blood is trapped between the placenta and the uterine wall (concealed bleeding)

What is Complete Placenta Abruption?

massive vaginal bleeding (almost total separation)

What are the classifications of Placenta Abruption?

• CLASS O – asymptomatic​

• CLASS I – mild; most common​

• CLASS II – moderate; mom and fetus ​show distress​

• CLASS III – severe; maternal shock and ​fetal death likely

What are some Predisposing Factors for Postpartum Hemorrhage?

• Uterine Atony​

• Lacerations​

• Retained Placental Fragments​​

• Over distended Bladder

What are some nursing interventions for postpartum Hemorrhage?

• Uterine massage​

• Frequent Voiding​

• Assess H&H

• Assess urinary output​

• Encourage Rest​

• Encourage foods high in iron​

• Safety​

  • Rise slowly to minimize orthostatic hypotension​

  • Seated while holding the newborn

What medications should you give for postpartum hemorrhaging?

• -Oxytocin (Pitocin)​

• -Cytotec​ (best used rectally)

• -Methergine​ (can raise BP)

• -Hemabate (can cause diarrhea)

What is Spontaneous Abortion?

Naturally occurring abortion prior to 20 weeks

What are the risk factors for a spontaneous abortion?

• AMA​ (advanced maternal age)

• Drug use​

• Weakened cervix​

• Placental abnormalities​

• Chronic maternal disease

What are the classifications of spontaneous abortion?

• Threatened​

• Imminent/Inevitable​

• Complete​

• Incomplete​

• Missed​

• Recurrent Pregnancy Loss​

• Septic

What are the signs of Threatened abortion?

• Possibility of a miscarriage

• Bleeding, cramping present

• Cervix closed

What are the signs of an Imminent/Inevitable abortion?

• Bleeding, cramping present

• Cervix dilated

• Membrane may rupture

What is a Complete abortion?

All products of conception are expelled from body

What is an Incomplete Abortion?

• Only parts of the product of conception are expelled from the body

• Placenta usually remains

• Dilation and Curettage are done (D&C)

What is a Missed abortion?

• Fetus died but not expelled

• Patient will become septic if fetus is not expelled

• Need to induce labor

What is a Recurrent Pregnancy loss?

A pregnancy loss three times or more

How do you manage Spontaneous Abortion?

• Psychological Support​

• Reflective Listening​

• Pain Relief​

• Nursing Management

How should the nurse help with postmortem care after a perinatal loss?

• Place appropriate signage on the outside of the room so everyone in the hospital is aware of the loss ​

• Give parents the opportunity to spend time with their baby​

• Bathe and swaddle baby ​

  • Allow parents to participate or do this independently as desired​

• Support parents’ wishes regarding photography (professional or otherwise)​

• Allow visitation in accordance with the wishes of the parents​

• Assist parents in the collection of keepsakes

What are stillbirths?

• Loss of a fetus after the 20th week of pregnancy​

• 1 out of 160 pregnancies​

• Can happen right up until time of delivery

What are the causes of stillbirths?

• placental abruption, pre-eclampsia

• growth restriction and resulting hypoxia

• infections, chromosomal disorders

• umbilical cord torsion, nuchal cord, trauma

What are the risk factors of having a stillbirth?

• advanced maternal age

• smoking, drug use, malnutrition

• lack of prenatal care

• women of African-American ethnicity​

What is an Ectopic Pregnancy?

• Implantation of a fertilized ovum in a site other than the endometrial lining of the uterus​

  • Egg can implant in the fallopian tube, ovary, peritoneal cavity, or cervix

What are the risk factors of Ectopic Pregnancies?

• Tubal obstruction/damage​

• Delayed tubal transport​

• Congenital anomalies​

• Altered hormonal status​

• Smoking​

• AMA (advanced maternal age)

What are some interventions for an Ectopic Pregnancy?

• Methotrexate​- Off label use. Can cause a miscarriage. Given until all parts are expelled

  ​

• Surgery:​

  • Salpingostomy​- an incision into a fallopian tube over the site of ectopic pregnancy and removal of the ectopic pregnancy to spare and retain patency of the fallopian tube for future fertility

  • Salpingectomy​- removal of one or both fallopian tubes

• Rhogam- Given to mom to prevent antibodies from attacking the fetus if there is incompatible Rh

What is an Incompetent Cervix?

Painless dilation​ of the cervix ​without labor or​ uterine contractions

What are the contributing factors for Cervical Insufficiency?

1. Congenital Factors​

2. Acquired​

3. Biochemical Factors

What interventions can be used for Cervical Insufficiency?

• Close observation with Ultrasound for cervical thinning​

• Cerclage​: surgical procedure that involves placing a stitch or band around the cervix to prevent it from opening too early during pregnancy

• Tocolytics​: medications used to stop or delay premature labor contractions

• Broad Spectrum Antibiotics​

What is Hydatidiform Mole (Molar Pregnancy)?

Condition in which a proliferation of trophoblastic cells (outermost layer of embryonic cells) results in the formation of a placenta characterized by hydropic (fluid-filled) grapelike clusters.

What are the s/s of Hydatidiform Mole or Molar Pregnancy?

• Dark Brown Vaginal Bleeding (like prune juice)​

• Anemia​

• Hydrophic Vesicles​

• Abnormal Uterine Enlargement​

• Absence of FHT’s​

• Marked hCG Elevation​

• Hyperemesis Gravidarum

What interventions are used to treat Molar Pregnancies?

• Surgery​

• Rhogam- if indicated​

• Methotrexate (b/c of possible development of choriocarcinoma)​

• No new pregnancies for 1 year

What is Preterm Labor (PTL)?

• Labor that occurs between 20 and 37 completed weeks of pregnancy​

• #1 cause of neonatal morbidity​

• 1 in 10 babies born prematurely​

• Infant may experience long-term health problems​

• Estimated cost in the U.S.: 30 billion annually spent on maternal and infant care related to prematurity​

What are the risk factors for Preterm labor?

• African-American race (double the risk)​

• Maternal Age extremes (< 16, or > 40)​

• Low socioeconomic status​

• Alcohol, Smoking or Drug Use​

• History of previous Preterm Birth (triple the risk)​

• Multiple Gestations​

• Short cervical length​

• Infections (UTI, STI, Bacterial Vaginosis)​

• Stress​

• Many More (see chart in textbook pg 812, Box: 21.2)​

What are the s/s of Preterm labor?

• Spontaneous rupture of membranes (SROM)​

• Abdominal Pain​

• Low, Dull Back Pain​

• Pelvic Pain​

• Menstrual-like cramps​

• Vaginal Bleeding​

• Increased Vaginal discharge​

• Urinary Frequency​

• Diarrhea​

• Pelvic Pressure

What criteria diagnoses Preterm labor?

1. Cervical Dilation and Effacement​

plus​

2. 4 uterine contractions in 20 minutes​

or ​

8 uterine contractions in 1 hour

How do you manage Preterm labor?

• Bedrest​

• Tocolytic Therapy ​(to delay birth)​

• Corticosteriods​ (to prevent or reduce ​respiratory distress on the​

infant in case of delivery)

What is Tocolytic Therapy?

using medications to inhibit uterine contractions and delay preterm labor, allowing more time for fetal development and potentially improving outcomes for the baby

What is the goal of Tocolytic Therapy?

• Arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy​

What medications are used in Tocolytic Therapy?

• Procardia (Nifedipine)​

• Indomethacin (Indocin)​

• Atosiban (Tractocile, Antocin)​

• Magnesium Sulfate

Why is Magnesium Sulfate used in Tocolytic Therapy?

• Decreases uterine contractions

• Calcium antagonist and CNS depressant​

• Prevents seizures; lowers blood pressure​

• Relaxes smooth muscle of the uterus through​ calcium displacement​

• Crosses the placenta​

• Excreted by the kidneys

What over the counter med should be stopped if taking Magnesium sulfate?

Folic acid vitamin

Affects absorption of Folic acid

What are the common side effects of Magnesium Sulfate?

Headache, visual disturbance, lethargy, nausea, and vomiting​

What are the signs of Magnesium Toxicity?

• Absence of reflexes, respiratory depression, oliguria, confusion, cardiac arrest ​

• Use with caution in women with renal insufficiency and Myasthenia Gravis​

What are some Nursing Considerations that should be monitored for in a patient on Magnesium Sulfate?

• Blood Pressure​

• Magnesium Levels (every 6-8 hours)​

• Respirations​

• Reflexes​

• Urinary output​

• Fetus​

• Calcium Gluconate at bedside (reversal agent for Magnesium toxicity)​

• After birth, the neonate should be monitored and observed for magnesium toxicity for 24-48 hours​

Why is Corticosteroids (Betamethasone (Celestone)) used in Preterm labor?

• Stimulate surfactant production in the unborn baby​

• Administered 2 doses IM 24 hours apart​

• Effects seen as soon as 48 hours after initial administration

• Help prevent or reduce the frequency and severity of respiratory distress syndrome and intraventricular hemorrhage in the premature infant​

What are the nursing implications for a mother receiving Betamethasone (Celestone)?

Monitor maternal lung sounds and signs of infection​

What is Hypertension in Pregnancy?

• Most commonly encountered medical condition in pregnant women (up to 15% of all pregnancies)​

• Results in frequent hospital admissions, maternal mortality, preterm births, and infant mortality​

What are the different Hypertension Disorders in pregnancy?

• Gestational Hypertension (pregnancy induced hypertension, PIH)​

• Preeclampsia​

• Eclampsia​

• HELLP

What are the classifications of Hypertensive Disorders in pregnancy?

• 1) Preexisting condition (Chronic Hypertension)​

• 2) Hypertension that presents during pregnancy (Gestational Hypertension or Pregnancy Induced Hypertension)​

• 3) Preeclampsia (most common hypertensive disorder in pregnancy)​

• 4) Eclampsia (onset of seizures)​

• 5) Chronic Hypertension with superimposed preeclampsia​

1, 2 and 3 can be further described as mild or severe​

What is Chronic Hypertension?

• Blood Pressure of 140/ 90 mm Hg before pregnancy or before 20 weeks gestation​

• 25% of women with chronic hypertension develop preeclampsia during pregnancy

• Does not have protein in the urine

How do you manage Chronic Hypertension?

If BP exceeds 160/100 drug treatment is recommended

What is Gestational Hypertension?

• Hypertension that begins after the 20th week of pregnancy​

• BP of 140/90 or greater without Proteinuria​

• Must have an elevated BP on 2 occasions, six hours apart​

• Usually resolves by 12 weeks postpartum

What is Preeclampsia?

• High BP and protein in urine

• Worldwide: 50,000 to 60,000 women die each year​

• Multisystem, vasopressive disorder that targets the cardiac, hepatic, renal and central nervous system

What is the Pathophysiology of Preeclamptia?

• Vasospasm which results in elevated BP reducing the blood flow to the brain, liver, kidneys, placenta, and lungs.​

• Decrease liver perfusion presents as epigastric pain and increased liver enzymes​

• Decreased brain perfusion leads to headaches, visual disturbances, and hyperactive deep tendon reflexes (DTRs)​

• Decreased kidney perfusion leads to decreased urine output​

• Proteinuria of 300mg or greater in a 24-hour urine specimen​

How do you manage mild Preeclampsia? (meaning no signs of renal or Hepatic dysfunction)

• Bed Rest (lateral recumbent position)​

• Diet​

• Monitor Fetal Status​

• Frequent evaluation of CBC, liver enzymes, platelet levels, and clotting factors​

• Monitor protein in urine

How do you manage Severe Preeclampsia?

• Bed Rest (dark and quiet room to decrease stimulation)​

• Diet​

• Anticonvulsants (Magnesium Sulfate)​

• Corticosteroids (Betamethasone)​

• Fluid and Electrolyte Replacement​

• Antihypertensive

What are the s/s that preeclampsia is worsening?

• Increasing edema​

• Worsening headache​

• Epigastric Pain​

• Visual Disturbances​

• Decreasing Urinary Output​

• Nausea/vomiting​

• Bleeding Gums​

• Disorientation​

• Generalized complaints of not feeling well​

• Hyperactive Reflexes​

What is Eclampsia?

• BP of 160/110 mm Hg​

• Marked Proteinuria​

• Seizures​

• Hyperreflexia​

• Other symptoms may include: severe headache, generalized edema, epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP

How do you manage Eclampsia?

• Assessment​

• Maintain Airway​

• Prevent Injury​

• Magnesium Sulfate​

• Dilantin or other anti-convulsant​

• Prepare for birth

What is the cure for Preeclampsia and Eclampsia?

DELIVERY of Placenta​

What does HELLP stand for?

• H: Hemolysis (breakdown of red blood cells)​

• EL: Elevated Liver Enzymes​

• LP: Low Platelet Count

What is HELLP?

• Variant of Preeclampsia and Eclampsia ​

​

What does HELLP put you at an increased risk for?

• Increased risk of cerebral hemorrhage, retinal detachment

• hematoma/liver rupture, acute renal failure

• disseminated intravascular coagulation (DIC), placental abruption

• maternal death​

What are the symptoms of HELLP?

Nausea, Vomiting, flulike symptoms, epigastric pain​

With HELLP only diagnosed with lab work, What would lab work reveal?

a. anemia – low Hemoglobin​

b.  thrombocytopenia – low platelets. <100,000. ​

c.  elevated liver enzymes:​

•    -AST aspartate aminotransferase ​exists within the liver cells and with ​damage to liver cells, the AST levels rise ​> 20 u/L. ​

•   - LDH – when cells of the liver are lysed, they ​spill into the bloodstream and there is ​an increase in serum. > 90 u/L​

How does a women become Rh Sensitivity?

• Rh-neg woman and Rh-positive man conceives

• Rh-neg woman w/ Rh-positive fetus

• Cells from Rh-positive fetus enter woman’s bloodstream

• Woman becomes sensitized- antibodies form to fight Rh-positive blood cells

• In next Rh-positive pregnancy, maternal antibodies attack fetal red blood cells

What happens when Rh Antibodies enter fetal circulation?

• *Hemolysis​

• *Generalized Edema​

• *CHF​

• *Jaundice

What is an 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​

• Positive – Fetus at risk​

What is a Direct Coombs Test?

• On infant to detect antibody coated Rh+ blood cells (Direct antiglobulin test)​

• A positive result indicates an immune mechanism is attacking the baby’s own RBC’s​

• Rh incompatibility

What is Rhogam?

• >Given to Rh(-) woman​​

• >Given @ 28 weeks gestation​

• >Given within 72 hours after birth​

• After: Abortion, chorionic villus ​sampling, ectopic pregnancy, ​amniocentesis​

• >Given IV or IM​ (hurts when given IM)

• Indication: to prevent Rh (-) woman from developing Rh antibodies

What is Cord Prolapse?

• Membranes must be ruptured​

• Part of cord drops through the opening of the cervix​

• Part of Baby’s body pushes on cord​

• Intervention: Must hold presenting part of infant off of cord until baby is delivered by C-Section

What is Hyperemesis Gravidarium?

• Hyperemesis so severe that it affects hydration and nutritional value​

• Cause is unknown​

Who most likely will experience Hyperemesis Gravidarium?

• adolescents, multiple gestation, women with mother or sister with history, or history in previous pregnancy​

• Diagnosis criteria: history of intractable vomiting first half of pregnancy, dehydration, ketonuria, weight loss of 5% pre-pregnancy weight​

What is the goal of clinical therapy for Hyperemesis Gravidarium?

1.) Control Vomiting​

2.) Correct Dehydration​

3.) Restore Electrolyte Balance​

4.) Maintain Adequate Nutrition

How do you treat Hyperemesis Gravidarium?

• --Initial treatment home care: start small with avoidance of environmental triggers, small frequent meals, anti-emetics​

• --If no improvement hospitalization may be necessary

What are the affects of Diabetes in Pregnancy?

• PREGESTATIONAL AFFECTS​

  • *CHANGES INSULIN REQUIREMENTS​

  • *POSSIBLE ACCELERATION OF​ VASCULAR DISEASE

What are the effects of Diabetes on mother?

• HYDRAMNIOS​ (excessive amniotic fluid)

• DYSTOCIA​ (baby head/mom hip disproportion)

• INFECTIONS​

• PIH​ (pregnancy-induced hypertension)

• RETINOPATHY

What are the Diabetes effects on baby?

• *LGA- hyperinsulinism (as a response to ​mother) acts as a growth hormone​

• *IUGR- poorly controlled insulin dependent mothers

• *CONGENITAL ANOMALIES​

• *HYPOGLYCEMIA (after birth)​

  • #1 concern

• *HYPERBILIRUBINEMIA

How do you manage Diabetes during pregnancy?

• Dietary Regulation​

• Home Glucose Monitoring​

• Insulin Administration​

• Evaluation of fetal status

What is Gestational Diabetes?

• ​A form of diabetes of variable severity with onset or first recognition during pregnancy

What is a Glucose Tolerance Test?

• 50 g of oral glucose​

• Blood sample one hour later​

• >130 mg, further testing using 3 hour test​

• Newer recommendations for 75 g OGTT but has not been readily adopted

How do you manage Gestational Diabetes?

• Medications​

  • Oral Hypoglycemics- Glyburide​

  • Insulin​

• Glucose monitoring​

• NST- non-stress test​

• Education​

• Diet ​

• Exercise

What are contributing factors to teen pregnancy?

• Peer Pressure​

• Poverty​

• Low educational achievement​

• Family dysfunction​

• Poor Self Esteem​

• Media​

• Substance Abuse​

• Physically, Emotionally ​or Sexually Abused​

• Lack of Contraceptive Use​

• Consequences of Behavior​

• Lack of Knowledge​

• Desire to become Pregnant​

• Adult Status​

• Incest​

• School Failure

What is the risk for infants of teen moms?

​

• Higher Rate of Low Birth Weight Infants​

• Higher Rate of Infant Mortality​

• Increased Rate of Sudden Infant Death​

• Premature Deliveries (less than 37 weeks)​

• More likely to become hospitalized ​during their childhood​

• More likely have children with​ medical and developmental delay

What are the increased risks for teen moms?

• Increased Rate of Anemia and High Blood Pressure during pregnancy​

• Increased Complications during delivery ​

• Higher Risk of STDs​

• Higher Risk of Smoking​

• Depression and Social Isolation​

• Increased Maternal Mortality during delivery​

• Not finishing High School​

• Life time of poverty