High Risk Pregnancy Pt. 1

What is the definition of high risk pregnancy?

a condition exists that jeopardizes health of mom, fetus, or both; may result from pregnancy or be present before pregnancy

What biophysical factors place women at risk for a high risk pregnancy?

genetic conditions, chromosomal abnormalities, multi pregnancies, inherited disorders, lg fetal sz, preterm labor & birth, CV disease, placental abnormalities, infec, diabetes, nutrtion status, post term preg

What environmental factors place women at risk for a high risk pregnancy?

infec, radiation, pesticides, illicit drugs

What psychosocial factors place women at risk for a high risk pregnancy?

smoking, caffeine, alcohol & subs abuse, inadequate support, maternal obesity, situ crisis, hx of violence, emotional distress, unsafe cultural practicessuch as domestic violence, low socioeconomic status, and mental health disorders.

What sociodemographic factors place women at risk for a high risk pregnancy?

poverty, prenatal carre lack, younger than 15 or older than 35, marital status, accessibility to healthcare, ethnicity

What is placental previa?

placenta improperly planted in lwr uterine segment; may cover cervical os

What is the classical presentation of placenta previa?

painless w/bright red bleeding

What is total placenta previa?

placenta completely covers internal os

What is partial placenta previa?

placenta partially covers internal os

What is marginal placenta previa?

edge of placenta at margin of internal os

What is low-lying placenta previa?

placenta implanted in lwr segment but doesn’t reach os

How is placenta previa managed?

bed rest until 37 weeks; no vaginal exams; monitor blood loss; monitor fetal heart tones; Betamethasone (fetal lung development); IV fluids; monitor V/S; pelvic rest including no intercourse; C-section if not resolved

what is abruptio placenta/placental abruption?

premature separation of normally implanted placenta from uterine wall

What are the classical Sx of placental 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?

smoking; incr maternal age; alcohol; cocaine; short umbilical cord; multiparity; trauma; HTN (most common cause)

What is marginal placental abruption?

blood passes b/t the fetal membranes and uterine wall and escapes vaginally (may or may not become more severe)

What is central placental abruption?

placenta separates centrally and blood is trapped b/t placenta and uterine wall (concealed bleeding)

What is complete placental abruption?

massive vaginal bleeding (almost total separation)

What is the class 0 classification of placental abruption?

asymptomatic

What is class I of placental abruption?

mild; most common

What is class II of placental abruption?

moderate; mom and fetus show distress

What is class III of placental abruption?

severe; maternal shock and fetal death likely

What are predisposing factors for postpartum hemorrhage?

uterine atony; lacerations; retained placental fragments; over distended bladder

What are the nursing interventions of postpartum hemorrhage?

uterine massage; freq voiding; assess H&H; meds (oxytocin, cytotec, methergine, hemabate); assess urinary output; encourage rest, foods high in Fe; safety (rise slow to minimize orthostatic hypotension & seated while holding NB)

What is prenatal loss?

loss of fetus from time of conception until time of delivery; spontaneous abortion/miscarriage; stillbirth; ectopic pregnancy; death shortly after birth

What is spontaneous abortion?

naturally occuring abortion prior to 20 weeks

What are the risk factors of spontaneous abortion?

advanced maternal age; drug use; weakened cervix; placental abnormalities; chronic maternal disease

What are the week 4-8 causes of spontaneous abortion?

chromosomal abnormalities

What are the week 4-10 causes of spontaneous abortion?

insufficient or excessive hormones

What are the week 4-12 causes of spontaneous abortion?

maternal infections

What are the week 12-19 causes of spontaneous abortion?

usu caused by maternal factor such as cervical insufficiency or maternal disease

What are the different classifications of spontaneous abortion?

threatened; imminent/inevitable; complete; incomplete; missed; recurrent pregnancy loss; septic

What is the postmortem care after a perinatal loss?

appropriate signage on outside of room; parents opportunity to spend time with baby; bathe/swaddle baby; support parents’ wished regarding photography; allow visitation in accordance w/parents wishes; assist in keepsake collection

What is stillbirth?

loss of fetus after 20th week of pregnancy; 1 of 160 pregnancies; can happen right up until time of delivery

What are the causes of stillbirth?

placental abruption; pre-eclampsia; growth restriction and resulting hypoxia; infections; chromosomal disorders; umbilical cord torsion; nuchal cord; trauma

What are the risk factors of stillbirth?

advanced maternal age; smoking; drug use; malnutrition; lack of prenatal care; women of af-amer ethnicity

What is ectopic pregnancy?

implantation of fertilized ovum in site other than endometrial lining of uterus; egg can implant in fallopian tube, ovary, peritoneal cavity, or cervix

What are the risk factors for ectopic pregnancy?

tubal obstruction/damage; delayed tubal transport; congenital anomalies; altered hormonal status; smoking; advanced maternal age

What are the interventions of ectopic pregnancy?

methotrexate; surgery (salpingostomy or salpingectomy); Rhogam

What is an incompetent cervix?

painless dilation of cervix w/o labor or contractions

What are the contributing factors to cervical insufficiency?

congenital factors; acquired; biochemical factors

What are the interventions for incompetent cervix?

close observation w/ultrasound for cervical thinning; cerclage; tocolytics; broad spectrum abx

What is gestational trophoblastic disease?

proliferation of trophoblastic cells (outermost layer of embryonic cells) results in formation of placenta characterized by hydropic (fluid-filled) grapelike clusters; hydatidiform Mole (molar pregnancy)

What are the S/Sx of gestational trophoblastic disease?

dark brown vaginal bleeding (prune juice); anemia; hydrophic vesicles; abnormal uterine enlgment; absence of FHTs; marked hCG elevation; hyperemesis gravidarum

What are the interventions for gestational trophoblastic pregnancy?

surgery; Rhogam; methotrexate (b/c of possible development of choriocarcinoma); no new pregnancies for a yr

What is preterm labor?

labor that occurs b/t 20-37 completed weeks of pregnancy; #1 cause of neonatal morbidity; 1 in 10 babies born prematurely; infant may experience long-term health probs

What are the risk factors for preterm labor?

Af-amer race (dbl risk); maternal age extremes (<16, or >40); low socioeconomic status; alcohol, smoking, or drug use; hx of prev preterm birth (triple risk); multiple gestations; short cervical length; infections (UTI, STI, bacterial vaginosis); stress;

What are the S/Sx of preterm labor?

SROM, ABD pain, low/dull back pain, pelvic pain, menstrual-like cramps, vaginal bleeding, incr vaginal discharge, urinary freq, diarrhea, pelvic pressure

What are the critieria for diagnosis for preterm labor?

cervical dilation & effacement + 4 uterine contractions in 20min or
8 uterine contractions in 1hr

How is preterm labor managed?

bedrest; tocolytic therapy (to delay birth); corticosteroids (to prevent or reduce resp distress on infant in case of delivery)

What is the goal of tocolytic therapy?

arrest labor and delay birth long enough to initiate prophylactic cortico therapy

Why are tocolytic drugs called “off label”?

may be effective for slowing down labor but haven’t been tested by FDA for this purpose

What medications are used for tocolytic therapy?

procardia (nifedipine); indomethacin (indocin); atosiban (tractocile, antocin); magnesium sulfate

What is magnesium sulfate and why is it used for tocolytic therapy?

calcium antagonist and CNS depressant; prevents seizures; lowers BP; relaxes smooth musc of uterus thru calcium displacement; crosses placenta; excreted by kidneys

What are the common side effects of magnesium sulfate?

HA, visual disturbance, lethargy, N/V

What are the side effects of magnesium toxicity?

absence of reflexes, resp depression, oliguria, confusion, cardica arrest
use w/caution in women w/renal insufficiency and myasthenia gravis

What are the nursing considerations of pt on mag sulfate?

BP, mag lvls Q6-8H; respirations; reflexes; UO; fetus; calcium gluconate at bedside (reversal agent); after birth neonate monitored/observed for mag toxicity for 24-48hrs

What corticosteroid is used in tocolytic therapy?

betamethasone (celestone)

Why is betamethasone used in tocolytic therapy?

helps prevent or reduce freq and severity of resp distress syndrome and intraventricular hemorrhage in premature infant; stimulate surfactant production in unborn baby

What is the dose of betamethasone and how soon are the effects seen?

2 doses IM 24hrs apart; effects seen as soon as 48hrs after initial admin

What are the nursing implications of betamethasone?

monitor maternal lung sounds and signs of infec

What is the most common medical condition in pregnant women?

HTN

What hypertension disorders are seen in pregnancy?

gestational HTN (pregnancy induced HTN, PIH); preeclampsia; eclampsia; HELLP

What is the most common hypertensive disorder in pregnancy?

preeclampsia

What classifications for hypertensive disorders in pregnancy can be further described as mild or severe?

preexisting condition (chronic HTN)
HTN that presents during pregnancy (gestational HTN or pregnancy induced HTN)
preeclampsia

What are the other classifications for hypertensive disorders?

eclampsia (onset of seizures)
chronic HTN w/superimposed preeclampsia

What are the parameters for chronic HTN during pregnancy?

BP of 140/90 before pregnancy or before 20 weeks gestation
25% of women w/chronic HTN develop preeclampsia during pregnancy

What is the mgmt of chronic HTN?

BP exceeds 160/100 tx is recommended

What are the parameters of gestational HTN (aka pregnancy induced HTN (PIH))?

HTN begins after 20th week; BP of 140/90 or grtr w/o proteinuria; must have elevated BP on 2 occasions, 6hrs apart; usu resolves by 12 weeks postpartum

What is preeclampsia?

multisystem, vasopressive d/o that targets cardiac, hepatic, renal and CNS; includes HTN, proteinuria, and organ damage

What is the pathophysiology of preeclampsia?

vasospasm l/t elev BP reducing blood flow to brain, liver, kidneys, placenta, and lungs
decr liver perfusion presents epigastric pain & incr liver enzymes
decr brain perfusion l/t HA, visual disturbances, & hyperactive deep tendon reflexes (DTRs)
decr kidney perfusion l/t decr urine output
proteinuria of 300mg or grtr in 24hr urine specimen

What is the mgmt for mild preeclampsia?

bed rest (lateral recumbent position); diet; monitor fetal status; freq eval of CBC, liver enzymes, PLT lvls, clotting factors; monitor protein in urine

What is the mgmt for severe preeclampsia?

bed rest (dark/quiet room to decr stimulation); diet; anticonvulsants (mag sulfate); corticos (betamethasone); F&E replacment; antihypertensive

What are the s/sx that preeclampsia is worsening?

incr edema; worsening HA; epigastric pain; visual disturbances; decr UO; N/V; bleeding gums; disorientation; generalized complaints of not feeling well; hyperactive reflexes

Describe eclampsia.

BP of 160/110; marked proteinuria; seizures; hyperreflexia; severe HA; generalized edema; epigastric pain; visual disturbances; cerebral hemorrhage; renal fail; HELLP

Describe the mgmt of eclampsia

assessment, maintain airway, prevent injury, mag sulfate, dilantin or otr anticonvulsant, prepare for birth

What is the cure for preeclampsia and eclampsia?

delivery of placenta

What does HELLP stand for?

H: hemolysis
EL: elev liver enzymes
LP: low PLT count

What is HELLP?

variant of preeclampsia and eclampsia w/incr risk of cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal fail, disseminated intravascular coagulation (DIC), placental abruption, and maternal death

What are the symptoms of HELLP?

N/V, flulike symptoms, epigastric pain

What happens when a pt is diagnosed w/HELLP?

have to give birth regardless of gestational age; perinatal morbidity and mortality high

What does lab work reveal when diagnosed with HELLP?

anemia; thrombocytopenia (<100,000); elev liver enzymes (incr AST and LDH)

Explain Rh sensitivity.

Rh- woman and man conceive Rh+ baby; cells from Rh+ fetus enter mom’s bloodstream; mom becomes sensitized (antibodies form to fight Rh+ blood cells); in next Rh+ pregnancy, maternal antibodies attack fetal RBCs

What happens when Rh antibodies enter fetal circulation?

hemolysis, generalized edema, CHF, jaundice

What is the 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 NB (neg = fetus at no risk; positive = fetus at risk)

What is the direct Coombs test?

on infant to detect antibody coated Rh+ blood cells (direct antiglobulin test); positive result indicates immune mechanism is attacking baby’s own RBCs; Rh incompatibility

What is Rhogam?

given to Rh- woman at 28 wks gestation & w/in 72hrs after birth
also after abortion, chorionic villus sampling, ectopic pregnancy, amniocentesis

What routes are used for Rhogam?

IV or IM

What is the indication for Rhogam?

to prevent Rh- woman from developing Rh antibodies

What is cold prolapse?

ruptured membranes; part of cord drops thru opening of cervix; part of baby’s body pushes on cord

What is the intervention for cord prolapse?

must hold presenting part of infant off cord until baby is delivered by C-section

What is hyperemesis gravidarium?

hyperemesis so severe that it affects hydration and nutritional value; cause unknown

When is hyperemesis gravidarium frequently seen?

adolescents, multiple gestation, women w/mom or sister w/hx; hx in previous pregnancy

What are the diagnosis criteria for hyperemesis gravidarium?

hx of intractable vomiting first half of pregnancy, dehydration, ketonuria, weight loss of 5% pre-pregnancy weight

What are the therapy goals for hyperemesis?

control vomiting; correct dehydration; restore lyte balance; maintain adequate nutrition

What is the initial home tx for hyperemesis?

start small w/avoidance of environmental triggers, small freq meals, anti-emetics; hospitalization may be req if no improvement

What are the pregestational affects of diabetes in pregnancy?

changes in insulin req; possible acceleration of vascular disease

What are the effects of diabetes on pregnant mom?

hydramnios, dystocia, infections, PIH, retinopathy

What are the effects of diabetes on baby?

LGA - hyperinsulinism (as response to mom) acts as growth hormone
IUGR - poorly controlled insulin dependent moms
congenital anomalies
hypoglycemia (after birth)
hyperbilirubinemia

How does the fetus grow larger than normal with mom that has diabetes?

mom’s blood brings extra glucose to fetus; fetus makes more insulin to handle extra glucose; extra glucose stored as fat and fetus becomes lgr than normal