High-Risk Perinatal Care: Preexisting Conditions PPT

Why can pregnancy be high-risk in women with preexisting conditions?

What are preexisting conditions in pregnancy?

Chronic illness is superimposed on pregnancy → unique maternal + fetal needs in addition to usual pregnancy needs.

Chronic illnesses that exist before pregnancy and increase maternal and fetal risks. They require meeting unique needs alongside normal pregnancy needs.

What are common preexisting conditions seen in pregnancy?

• Metabolic disorders (diabetes, thyroid disorders)

• Cardiovascular disorders

• Respiratory, gastrointestinal, and integumentary disorders

• Central nervous system disorders

• Autoimmune disorders

• Substance abuse

What is the most common endocrine disorder associated with pregnancy?

Diabetes mellitus.

What key factor determines positive outcomes for pregnant clients with diabetes?

Strict maternal glucose control with multidisciplinary care and consistent blood glucose monitoring.

What characterizes diabetes mellitus?

Hyperglycemia due to defects in insulin secretion, insulin action, or both

What causes diabetes mellitus?

• Impaired insulin secretion from beta cell dysfunction

• Decreased cellular sensitivity to insulin (insulin resistance)

What are the major classifications of diabetes?

• Type 1 diabetes (absolute insulin deficiency)

• Type 2 diabetes (insulin resistance)

• Gestational diabetes mellitus (onset during pregnancy)

• Other specific types (infection or drug-induced)

What defines gestational diabetes mellitus (GDM)?

Any degree of glucose intolerance with onset or first recognition during pregnancy in a person who was not previously diabetic.

How does gestational diabetes differ from pregestational diabetes?

• Gestational: develops during pregnancy and usually resolves postpartum

• Pregestational: preexisting type 1 or type 2 diabetes before conception

What are the risks of gestational diabetes for the mother and fetus?

• Mother: higher risk for type 2 diabetes later in life

• Fetus: increased risk for macrosomia, hypoglycemia, and birth trauma

What are the major metabolic changes during pregnancy for diabetic patients?

• First trimester: ↓ insulin needs due to increased insulin sensitivity and pancreatic function

• Second trimester: ↑ insulin needs as placental hormones act as insulin antagonists

• Third trimester: insulin needs may double or quadruple, then level off at 36 weeks

• During labor: insulin needs drop sharply

• Postpartum: insulin needs decrease dramatically, especially with breastfeeding

What maternal complications are associated with diabetes in pregnancy?

• Preeclampsia and eclampsia

• Hemorrhage (from hydramnios or macrosomia)

• Infection (especially endometritis)

What fetal and neonatal risks are associated with diabetes in pregnancy?

• Congenital malformations

• Macrosomia

• Perinatal mortality

• Respiratory distress syndrome

• Intrauterine fetal demise

• Neonatal hypoglycemia

What preconception counseling is important for diabetic women?

• Optimize blood glucose control before conception

• Evaluate for complications (retinopathy, nephropathy)

• Review medications for safety

• Educate about insulin and diet adjustments during pregnancy

What are key nursing assessments for diabetic pregnancies?

• Obtain detailed health history and physical exam

• Evaluate renal function and hemoglobin A1C

• Monitor for protein, ketones, and glucose in urine

• Review blood glucose monitoring practices

What are antepartum nursing interventions for diabetes?

• Balanced diet and exercise

• Insulin or oral medication as ordered

• Frequent glucose checks

• Monitor fetal growth and well-being

What are intrapartum considerations for diabetic mothers?

• Close monitoring of glucose levels during labor

• May require insulin infusion

• Prepare for potential cesarean birth if macrosomia or hypertension present

What are postpartum considerations for diabetic mothers?

• Insulin requirements drop sharply after delivery

• Encourage breastfeeding (reduces insulin needs)

• Monitor for infection and hemorrhage

• Assess contraception choices due to thromboembolic risk

What are contraceptive considerations for women with diabetes?

• Non-smoking, no vascular disease: low-dose combined oral contraceptives may be used

• Vascular disease: progestin-only contraceptives preferred to reduce cardiovascular risk

What are the differences in risk between pregestational and gestational diabetes?

• Pregestational diabetes: higher risk for maternal and fetal complications

• Gestational diabetes: fewer risks but still at risk for preeclampsia, cesarean birth, and future diabetes

What are the two-step method thresholds for diagnosing gestational diabetes?

Step 1: 50 g 1-hour glucose screen

• Normal: <130–140 mg/dL

• If ≥130–140 mg/dL → proceed to step 2
  Step 2: 100 g 3-hour OGTT

• Gestational diabetes diagnosed if two or more of the following are met or exceeded:

  • Fasting: ≥95–105 mg/dL

  • 1 hour: ≥180–190 mg/dL

  • 2 hour: ≥155–165 mg/dL

  • 3 hour: ≥140–145 mg/dL

What are the one-step method thresholds for diagnosing gestational diabetes?

75 g 2-hour OGTT — gestational diabetes diagnosed if any value is met or exceeded:

• Fasting: ≥92 mg/dL

• 1 hour: ≥180 mg/dL

• 2 hour: ≥153 mg/dL

What is antepartum management of gestational diabetes?

• Monitor blood glucose levels regularly

• Follow appropriate diet and exercise plan

• Administer insulin or medications as prescribed

• Monitor fetal growth with ultrasounds

What is intrapartum management of gestational diabetes?

• Continuous glucose monitoring during labor

• May require insulin infusion

• Avoid IV fluids containing dextrose

What is postpartum management of gestational diabetes?

• Most women return to normal glucose levels

• Reassess at 6–12 weeks postpartum

• Educate on risk for type 2 diabetes and importance of follow-up

Which thyroid condition is most relevant in pregnancy?

Hyperthyroidism — it is rare but more common than hypothyroidism in pregnancy.

What is the primary cause of hyperthyroidism in pregnancy?

Graves’ disease (accounts for 90–95% of cases).

What are symptoms of hyperthyroidism in pregnancy?

• Weight loss (unusual in normal pregnancy)

• Heart rate >100 bpm

• Goiter

• Heat intolerance

• Diaphoresis

• Fatigue

• Anxiety and emotional lability

• Tachycardia

How can hyperthyroidism be differentiated from normal pregnancy changes?

• Weight loss

• Goiter

• Pulse rate >100 bpm are not normal findings in pregnancy.

What lab findings confirm hyperthyroidism?

• Elevated T3 and T4 levels

• Suppressed TSH

What complications can occur if hyperthyroidism is untreated during pregnancy?

• Miscarriage

• Preterm birth

• Preeclampsia

• Heart failure

• Fetal goiter or thyroid dysfunction

What are nursing interventions for pregnant patients with hyperthyroidism?

• Monitor thyroid labs (T3, T4, TSH)

• Educate on proper use of thyroid medications

• Provide nutritional counseling

• Monitor for cardiac and metabolic complications

Why is hypothyroidism rarely discussed in pregnancy?

It is extremely rare and almost non-existent in pregnancy, though it is covered in the textbook.

What is maternal phenylketonuria (PKU)?

A genetic metabolic disorder caused by deficiency of the enzyme phenylalanine hydroxylase, leading to toxic accumulation of phenylalanine in the blood.

What are the risks of PKU during pregnancy?

• Interference with brain development

• Intellectual disability in the fetus

• Potential congenital anomalies

How is PKU managed in pregnancy?

• Identify women with PKU before conception

• Maintain a low-phenylalanine diet

• It means avoiding high-protein foods such as meat, fish, eggs, cheese, milk, nuts, and beans, and using special low-protein products or medical formulas instead.

Examples of allowed foods:

• Fruits and most vegetables

• Certain low-protein breads, pastas, and cereals

• Specialized “PKU formula” drinks that provide safe protein substitutes

• Avoid breastfeeding (to prevent passing phenylalanine to the infant)

Why is pregnancy especially risky for women with cardiovascular disorders?

Pregnancy increases intravascular volume, cardiac output, and oxygen demand, which may strain an already compromised heart.

What normal cardiovascular changes in pregnancy affect women with heart disease?

• Increased intravascular volume

• Decreased systemic vascular resistance

• Increased cardiac output

• Postpartum fluid shifts

What can occur if cardiac changes are not tolerated during pregnancy?

Cardiac failure or decompensation can occur during pregnancy, labor, or postpartum.

What percentage of pregnancies are complicated by cardiovascular disease?

About 1–4%.

What is the main cause of cardiac decompensation during pregnancy?

Fever.

How is cardiovascular disease classified in pregnancy?

• Class I: Asymptomatic, no activity limitation

• Class II: Symptoms with slight activity limitation

• Class III: Symptoms with marked activity limitation

• Class IV: Symptoms at rest or with any activity

What pregnancy outcomes are more common in women with cardiovascular disease?

• Miscarriage

• Preterm labor and birth

• Intrauterine growth restriction (IUGR)

• Congenital heart lesions in infants

What are common congenital cardiac disorders relevant in pregnancy?

• Atrial septal defect (ASD)

• Ventricular septal defect (VSD)

• Patent ductus arteriosus (PDA)

• Coarctation of the aorta

• Tetralogy of Fallot

What is an atrial septal defect (ASD)?

An abnormal opening between the atria causing a left-to-right shunt; often asymptomatic.

What risks are associated with ASD in pregnancy?

Right-sided heart failure, arrhythmias, and blood clots due to increased plasma volume.

What is a ventricular septal defect (VSD)?

An opening between the right and left ventricles causing left-to-right shunting.

What complications can occur with large VSDs during pregnancy?

Arrhythmias, heart failure, and pulmonary hypertension.

What is patent ductus arteriosus (PDA)?

Persistence of the ductus arteriosus, creating a left-to-right shunt.

What are possible complications of PDA?

Endocarditis and pulmonary emboli.

What is coarctation of the aorta?

Narrowing of the aorta near the ductus arteriosus, leading to hypertension in the upper extremities and hypotension in the lower extremities.

What is tetralogy of Fallot?

A cyanotic heart defect consisting of:

• Ventricular septal defect (VSD)

• Pulmonary stenosis

• Overriding aorta

• Right ventricular hypertrophy

What are risks for women with unrepaired Tetralogy of Fallot?

• Hypoxemia

• Poor prognosis

• Potential for right-to-left shunting during pregnancy.

What is mitral valve prolapse?

Prolapse of mitral valve leaflets into the left atrium during systole, allowing blood backflow.

What symptoms may occur with mitral valve prolapse?

Chest pain, palpitations, syncope, anxiety, and dyspnea on exertion.

What is mitral stenosis?

Narrowing of the mitral valve opening, usually due to rheumatic heart disease.

How is mitral stenosis managed in pregnancy?

• Reduced activity and sodium intake

• Diuretics

• Regular cardiac assessments and echocardiograms

What is aortic stenosis?

Narrowing of the aortic valve, leading to obstruction of blood flow from the left ventricle.

What are general care interventions for cardiovascular disease in pregnancy (antepartum, intrapartum, postpartum)?

• Antepartum: Reduce cardiac stress, monitor for decompensation, low-sodium diet, beta blockers or diuretics as needed.

• Intrapartum: Continuous cardiac monitoring, assess ABGs, minimize anxiety.

• Postpartum: Watch for decompensation, provide stool softeners, support infant care, and discuss contraception.

What types of anemia can occur during pregnancy?

• Iron deficiency anemia

• Folic acid deficiency anemia

• Sickle cell hemoglobinopathy

• Thalassemia

What pulmonary disorders may complicate pregnancy?

• Asthma

• Cystic fibrosis

What integumentary (skin) conditions may occur during pregnancy?

• Melasma

• Vascular spiders

• Palmar erythema

• Striae gravidarum

• Pruritus gravidarum

• Polymorphic eruption of pregnancy

• Intrahepatic cholestasis of pregnancy

What does polymorphic eruption of pregnancy look like?

Papules and lesions that typically appear on the abdomen and may extend to the thighs.

Why might epilepsy worsen during pregnancy?

Women often stop taking anticonvulsants once pregnant, increasing seizure frequency.

What is the risk of anticonvulsant medications in pregnancy?

They may cause congenital anomalies, but abrupt discontinuation increases seizure risk.

How is multiple sclerosis managed in pregnancy?

Bed rest and corticosteroids during acute exacerbations.

What autoimmune neurologic disorder causes muscle weakness during pregnancy?

Myasthenia gravis

What are nursing considerations for pregnant women with myasthenia gravis?

• Muscle weakness may affect eyes, face, limbs, and respiration

• Labor is usually tolerated but may need assisted delivery (forceps/vacuum)

What is systemic lupus erythematosus (SLE)?

An autoimmune disease causing inflammation of the skin, joints, kidneys, lungs, and CNS.

What are nursing interventions for lupus in pregnancy?

• Monitor closely for infection

• Minimize stress and fatigue

• Prevent disease flare-ups

What is a dual diagnosis in substance abuse?

The presence of substance abuse along with a psychiatric disorder.

What are potential effects of substance use during pregnancy?

• Preterm labor

• Fetal growth restriction

• Miscarriage or stillbirth

• Neonatal withdrawal

• Fetal alcohol syndrome

Why might pregnant women avoid seeking help for substance abuse?

• Fear of losing custody

• Fear of legal prosecution

• Social stigma

• Lack of understanding about fetal effects

• Limited treatment access

What are barriers to substance abuse treatment for pregnant women?

• Long waiting lists

• Lack of insurance

• Few pregnancy-focused programs

When should screening for substance use occur?

At the first prenatal visit (includes prescription and herbal substances).

What diagnostic methods may be used to detect substance use?

Urine, meconium, or hair toxicology screening.

What infections are common among pregnant women who use substances?

HIV, hepatitis, syphilis, and other STIs.

What are nursing interventions for substance abuse during pregnancy?

• Educate about drug effects

• Provide nonjudgmental care

• Encourage treatment participation

• Monitor for withdrawal and pain

• Support maternal–infant bonding

What should follow-up care include for women with substance abuse?

• Assess home safety

• Involve social services

• Support systems and home visits

• Report to CPS if infant safety is in question