High Risk pregnancy pt 2

Anemia

HgB <11 g/dl pregnant women : lower then normal d/t hemodilution

Affected by race, altitude, smoking, nutrition, and medications

causes during pregnancy:

• Insufficent Hgb production (decrease iron and folic acid intake)

• Hgb destruction (inherited disorders)

Important to test at first appointment

Maternal risk of anemia

May be asymptomatic

more susceptible to infection

tire easily

increase risk of preeclampsia and postpartum

healing may be delayed

poor toleration of even minimal blood loss

Fetal risks of anemia

low birth weight

prematurity

stillbirth/death

Prevention/treatment of anemia

First goal is prevention

• Iron-rich diet

• 27 mg supplement daily (most prenantal vitamins have this)

• education

  • may cause constipation: bowel regimen

Treatment

• 65 mg iron BID/ 325 mg ferrous sulfate

• large doses can cause Gi symptoms

• may give parenterally in severe cases

Patient self-monitoring

fetal kick counts

• fetus should kick at least 10x in 2 hrs during the final months of pregnancy)

Awareness of fetal routines

report vaginal bleeding, leakage of fluid, contractions ( 5 or more in one hour)

BP/glucose monitoring at home when indicated

educate about warning s/s, when to call the provider and seek care (reinforced at every visit)

Fetal growth assessment

U/S

• frequent growth (size and weight) measurements

Leopolds

amniotic fluid measurements

fetal growth restriction

<10th %

feto-placental or materal

macrosomia >400g

Umbilical artery dopplers

ordered for babies with abnormal fetal growth, high risk patient

abnormal values can indicate fetal risk

Non-stress test (NST)

Indicated for risk factors, post-dates, or any concerns about fetal well-being

decreased fetal movement

highly predictive of fetal well-being

Fetal activity marker utilized (by Mother)

• button she can push

Non-stress test (NST) reactive

What we want to see, reassuring baby is well oxygenated

2 or more fetal heart accelerations within a 20-minute period (may extend to 40 minutes)

FHR acceleration >15 beats/min above the baseline, lasting at least 15 seconds

Moderate variablity

Non-stress test (NST) nonreactive

Can’t definitvely say something is wrong, need more information

lacks sufficient FHR acceleration over a 40 minute period

Biophysical profile (BPP)

Non-invasive assessment of fetus based on acute and chronic markers of disease

Ultrasound and NST (often done following a non-reactive NST)

• Amniotic fluid volume

• fetal breathing movements

• fetal movements

• fetal tone

• FHR reactivity: non-stress test

• 10 possible points, anything less than 8 is concerning, less than 4 terminate

Amniotic fluid index (AFI)

Amniotic fluid volume determined by

• fetal swallowing

• fetal urine output

Oligohydramnios: AFI <5cm

Polyhydramnios: AFI > 25cm

Contraction stress test (CST)

Evaluated uteroplacental function

identifies intrauterine asphyxia

observes fetal heart rate response to contractions

Contraction stress test (CST) indications

IUGR

Diabetes

Postdates

Nonreactive NST

Abnormal biophysical profile

Contraction stress test (CST) results

must have 3 uterine contractions of at least 40 seconds duration in 10 minutes

FHR assessed in comparison to contractions

Contractions may be sponatenous or induced

• oxytocin administration

• nipple stimulation

Normal: negative

Abnormal: positive

Chronic Hypertension

defined as hypertension present prior to the start of the pregnancy or that develops during the first 20 weeks of the pregnancy

Gestational hypertension

onset at or after 20 weeks of pregnancy, without proteinuria

• fine during first part of pregnancy, then develops

2 readings of 140/90 or greater at least 4 hrs apart, in women normally normotensive

usually resolves within the first postpartum week

can progress to preeclamsia, so careful monitoring is necessary

Preeclampsia

onset at or after 20 weeks of pregnancy, with proteinuria or other severe systemic symptoms

high BP + proteinuria

2 readings of 140/90 at least 4 hrs apart, in women who were previously normotensive

progressive : can quickly move from mild to severe

Chronic hypertension considerations

Important to obtain BP reading during first trimester

2 readings of 140/90 or greater, at least 4 hrs apart

Ratings are increasing, especially among African American and other minority women

Maternal risk of chronic HTN

counseling on weight loss, diet and lifestyle modifications

limit dietary salts

initate low-dose aspirin after 12 weeks

frequent prenatal visits

increased fetal surveillance

blood pressure monitoring

Medications

Labetalol or nifedipine

Risk factors of Preeclampsia

High risk

• Previous pregnancy with preeclampsia

• mutlifetal gestation

• renal disease

• autoimmune disease

• diabetes mellitus

Moderate risk

• first pregnancy

• age 35 or olders

• BMI >30

• family history

• race

• low socio-econmoic status

Physiology of preeclampsia

progressive, widely believed that the placenta is the root cause

likely caused by disruption in plcaental perfusion and endothelial cell dysfunction

develops long before symptoms appear

lack of vascualr remodeling leads to decreased placental perfusion

placental ischemia causes release of substance toxic to endothelial cells

generalized vasospasm leads to poor tissue perfusion in all organ systems

Biggest organ affected by Preeclampsia

Placental dysfunction

• anti-angiogenic and inflammatory factors released into the maternal circulation

Systemic vasoconstriction

• leading to maternal hypertension

Fetal growth restriction

• impaired blood supply to the fetus can compromise fetal growth

Major organ damage

• impaired blood supply to major organs including the kidney, brain and heart

Symptoms of Preeclampsia

Headache

RUQ pain

• liver is the most vascular organ, causes discomfort because the liver is so swollen

Visual disturbances

• inflammation of the brain

Edema

• SPECIFICALLY HANDS/FACE….NOT NORMAL!

Hyperreflexia

• clonus, patellar reflex will have a huge response

diagnosis of Preeclampsia

BP 140/90 or greater, at least 4 hrs apart

and

Proteinuria >300 mg in 24 hr urine or protein/creatinine ratio >.3 or urine dip > 1+

or

• thrombocytopenia

• renal insufficency

• increased liver enzymes

• pulmonary edema

• cerebral or visual changes

Nurse should anticipate for Preeclampsia

Labwork

• CBC: platelets

• Liver enzymes

• Serum BUN and creatinine

• Serum uric acid

• 24 hr urine or P/C ratio or urine dip

Non stress test

if NST is. non-reactive, BPP

Preeclampsia treatment

no actual cure

mild forms can be treated at home with frequent BP monitoring, prenatal visits, and fetal assessment

severe preeclampsia or signs of fetal compromise necessitate inpatient care and/or delievery (consider cortiosteriods in case early delivery is indicted)

Magnesium Sulfate

not a cure for Preeclampsia but a treatment to prevent seizures d/t neurological irritability

IV bolus of 4-6g in 100ml over 20 minutes, followed by IV infusion of 2g/hr: continue for 24 hrs postpartum

Antidote: Calcium Gluconate 1g IV push over 3-5 minutes

Magnesium Sulfate monitoring

Respiratory rate

BP, HR

LOC

Fetal assessment

Deep tendon reflexes

Clonus

Hourly urine output

• use Foley catheter with urometer for accurate measurement

• kidneys are effected by preeclampsia, not putting out enough urine= mg sulfate isnt being properly excreted

Magnesium Sulfate toxicity

Decreased LOC

RR <12

Urine output <30ml an hr

Diminished and absent DTRS

slurred speech

feeling flushed or hot

chest pain

IMMEDIATELY

• discontinue magnesium sulfate drip

• administer calcium gluconate

• continue careful fetal monitoring

• notify provider

Eclampsia

the convulsive manifestation of the hypertensive disorders of pregnancy: among the more severe manifestations of the disease

defined by new-onset tonic-clonic, focal, or multifocal seizures in the absence of other causative conditions

HELLP Syndrome

Hemolysis, elevated liver enzymes, low platelets

Severe form of preeclampsia

can occur in absence of hypertension or proteinuria

can occur anytime between 20 weeks gestation through postpartum

Life threatening for patient and fetus

HELLP Syndrome s/s

Nausea, extreme fatigue, chest pain, RUQ pain, difficulty breathing, shoulder pain, malalise