Week 3 - Pregnancy at Risk: Social and Physiological Factors

risk considerations of adolescent pregnancy

ages 10 to 19 years are at risk of eclampsia, infection, etc.

maternal mortality

perinatal complications (lead to maternal deaths)

early pregnancy / marriage causes dropout of school

impact of adolescent pregnancy

may interfere with developmental milestones

social isolation

fear of child services

stigma (actual & perceived)

need to be perceived as a "good mother"

adolescent friendly perinatal care includes...

being nonjudgemental

forming a connection

individualizing nursing care (be flexible and adaptable)

**treat everyone the same, be self-reflective

advanced maternal age and risks

pregnancy > 35 years

maternal death

miscarriage

stillbirth

low birth weight

perinatal mortality

down syndrome

women with disabilities and pregnancy

higher risk for social, economic, physical problems

-stigma / assumptions of care provides and family

-higher risk for social service involvement

-need for pre-planning, social support

IPV: who is at risk during pregnancy?

pre-pregnancy abuse

women under 25

SU by women or partner

single or lone parents

recently or abt to be separated

Indigenous women

women with disability

lesbian, bisexual, transgender

low SES

IPV and pregnancy is associated with...

preterm labour, prematurity, LBW, neonatal & infant/maternal mortality

maternal depression, SU

IPV screening tools: RADAR

Remember to ask abt IPV routinely

Ask directly abt violence (**interview in private)

Document findings r/t to violence in chart

Assess pt's safety

Review options with pt (referrals to shelters, support groups, legal advocates)

IPV screening tools: HITS

physically Hurt you

Insult or talk you down

Threaten you with harm

Scream or curse at you

**Likert scale: total score more than 10 suggests IPV

role of CHN and IPV

duty to report if there is a child under 16

show you believe and that there is help

do not judge; leaving takes time

reinforce that abuse is not her fault and apologies won't end abuse

reinforce their safety as top priority

offer referral, provide info, leave many resources

SU during pregnancy and risks

drugs can easily pass from mom to baby through placenta (eg. alcohol, cocaine, heroin, met)

bleeding complications, miscarriage, stillbirth

prematurity

low birth weight

sudden infant death syndrome

congenital anomalies

SU during pregnancy

-barriers to tx

-legal considerations

-guilt, fear, shame, fear of losing custody of child

-SU tx programs don't usually address issues impacting pregnant women

-long waiting lists, lack of women-only spaces

-non-judgemental and person-centred approach

-harm reduction model

-encourage prenatal care, counselling, tx

SU nursing care

assess for hx of violence, abuse, MH concerns, SDH

ensure confidentiality, non-judgemental, trauma-informed approach

harm reduction: supporting a pt's desire to stop using as well as assisting them in reducing risks

opioid agonist therapy (OAT) - methadone or buprenorphine tx recommended

education on use and side effects during pregnancy

postpartum follow up visits

early pregnancy bleeding

ANYTHING BEFORE 20 WKS = miscarriage/abortion

**miscarriage (spontaneous abortion): loss of pregnancy before 20 weeks gestation

early pregnancy bleeding: early vs late loss

early loss: before 12 weeks

-majority r/t **chromosomal abnormalities, teratogenic drugs, placental abnormalities, infections, etc.

late loss: 12-20 weeks

-advance maternal age, **premature dilation of cervix, chronic infection, use of recreational drugs

threatened abortion

threat that miscarriage could occur

slight bleeding, mild cramping, closed cx, no expulsion of products

bed rest, assess hCG and progesterone levels to determine if alive

inevitable abortion

miscarriage that cannot be prevented

mod bleeding, mild to severe cramping, open cx, no expulsion of products

bed rest if no bleeding or pain, rupture of mem/bleeding = uterus emptied via D&C

incomplete abortion

expulsion of products not fully out yet

heavy bleeding, severe cramping, closed cx, expulsion of products

may need dilation, suction curettage may be performed

complete abortion

all products are expelled

slight bleeding, mild cramping, closed cx

no further intervention if no hemorrhage or infection, suction curettage may be performed

missed abortion

death of a fetus or embryo within the uterus that is not naturally expelled after death

no bleeding or spotting, no cramping, closed cx, no expulsion of products

usually occurs before 1 month, monitor clotting factors and coagulation conditions, no fetal heartbeat on ultrasound

septic abortion

presence of infection

malodorous bleeding, cramping, cx open, expulsion

immediate termination, C&S, anitbiotics, treat spetic shock as needed

recurrent abortion

two or more consecutive spontaneous abortions

bleeding, cramping, cx open, expulsion

cerclage may be performed for premature cervical dilation

assessment & care: initial/general assessment for preg bleeding

VS, allergies, N/V, LOC

# of pregnancies, # of live births

last menstrual period / estimated DOB

pregnancy hx (previous & current)

pain (onset, quality, precipitating event, location)

bleeding or coagulation issues

emotional status and need for support

assessment & care: early pregnancy

confirmation of pregnancy w laboratory testing

bleeding (bright or dark, spotting or continuous)

pain (type, intensity, location, persistence)

vaginal discharge

assessment & care: late pregnancy

estimated DOB

bleeding (amt, pinky, menstrual-like, heavy)

pain (location, severity, intermittent, continuous)

vaginal discharge

amniotic membrane status

uterine activity, fetal HR and movement felt

management of incomplete abortion

-expectant management

-medical management

-surgical management

1. allows miscarriage to expel on its own

2. use of 2-drug combination - Mifepristone (for uterus prep) & Misoprostol (soften and dilate cx to aid in miscarriage)

2. dilation and curettage (D&C) - cx gently opened (dilation) and pregnancy removed with suction device (curettage)

discharge teaching after preg loss

*report any heavy, profuse, bright red bleeding

scant, dark discharge may persist for 1 to 2 weeks

avoid putting anything into vagina for 2 weeks or until bleeding has stopped

*take antibiotics as prescribed

*report temp elevated or foul-smelling discharge

eat foods high in iron and protein

encourage to speak with family, seek support from friends, groups, counselling

*postponed pregnancy for at least 2 months

ectopic pregnancy: manifestations, medical management

fertilized ovum implanted outside uterine cavity (most occur in fallopia tube on ampullar)

abd pain (one sided or lower quad), missed period, abnormal bleeding, referred shoulder pain

methotrexate - antimetabolite and folic acid antagonist; destroys rapidly dividing cells

teaching for methotrexate therapy

avoid intake of foods and vitamins containing folic acid

avoid eating "gas-forming" foods

avoid sun exposure

avoid sexual intercourse until β-hCG level is undetectable

contact HCP immediately if experiencing severe abd pain (impending or actual tubal rupture)

premature dilation of cervix

cervical insufficiency - dilation of cx w/o contractions or labour; painless

d/t structural weakness of cervix tissue (collagen disorder) or cervical trauam

nursing and interdisciplinary care for premature dilation of cervix

cervical cerclage

continuous close observation and supervision for rest of pregnancy

report signs of preterm labour, rupture of membranes, infection

ER if strong contractions, urge to push

late pregnancy bleeding: placenta previa

ANYTHING AFTER 20 WKS = preterm

placenta implanted in lower uterine segment near or over internal cervical os

3 types: low-lying, marginal, complete placenta previa

placenta previa: clinical presentation, diagnosis, complications

bright red bleeding, pain absent, uterine is normal, normal fetal HR

transabdominal or vaginal ultrasound

bleeding, preterm birth, IUGR

risk factors for placenta previa

smoking, cocaine use

multiparity

erythroblastosis

POC, low SES

infertility tx, prior uterine surgery

recurrent abortions

advancing age (> 35)

*multiple gestation (larger SA of placenta)

placenta previa nursing and interprofessional care

potential emergency d/t risk of massive blood loss

expectant management - reduce activity, close observation -when pt < 36 wks, not in labour, minimal bleeding

-no vaginal/rectal examinations, ultrasounds q2wks

-bleeding assessed thru amt of bleeding on pads (1g = 1ml)

-antepartum steroids (betamethasone) to promote fetal lung maturity

active management - C section

-when fetus is mature or pt w/ excessive bleeding; active labour

late pregnancy bleeding: placental abruption

ANYTHING AFTER 20 WKS = preterm

premature separation of placenta

3 grades of separation: 1 (mild), 2 (mod), 3 (severe)

*major cause of antepartum haemorrhage*

placental abruption: clinical presentation

vaginal bleeding, abdominal pain, uterine tenderness, contractions

risk factors for placental abruption

maternal HTN / preeclampsia

age, increasing parity, multiple gestations

polyhydramnios (excess amniotic fluid), chorioamnionitis

preterm PROM

trauma (assault or motor vehicle)

SU (eg. cocaine)

**hx of abruption

maternal and fetal complications of placental abruption

maternal

-hemorrhage, hypovolemic shock

-DIC

-infection

fetal

-IUGR, preterm birth, hypoxemia, stillbirth

-risks for neurological defects, death

placental abruption nursing and interprofessional care

expectant management - < 36 wks

-pt hospitalized

-fetal monitoring

-maternal VS for deterioration

-use corticosteroids to accelerate fetal lung maturity

-Rh -ve mom given Rho(D) immunoglobulin if baby Rh +ve

-emotional supports

DIC

disseminated intravascular coagulation

proteins controlling blood clotting becomes overactive, thus uses up all clotting factors = external & internal bleeding

DIC is often triggered by release of large amts of tissue thromboplastin (clotting factor) caused by

placental abruption (most common)

retained dead fetus syndrome

amniotic fluid embolus

pre-eclampsia, HELLP syndrome

gram-negative or gram-positive sepsis

stages of DIC

stage 1 - overactive clotting -> blood clots throughout blood vessel -> clots can reduce/block blood flow -> damages organs

stage 2 - overactive clotting uses platelets & clotting factors up that help blood to clot -> absence of platelets and clotting factors -> internal bleeding

physical examination of DIC

spontaneous bleeding from gums, nose

oozing, excessive bleeding from IV sites, foley entrance

petechiae (where BP cuff was)

bruising

hematuria

GI bleed

tachycardia, diaphoresis

coagulation screening test of DIC

platelets and fibrinogen decreased

clotting factors decreased

PT and PPT prolonged

d-dimer test increased

red blood smear - fragmented RBCs

DIC nursing and interprofessional care

correction of underlying cause (tx of infection, eclampsia; removal of placenta abruption)

**volume expansion, rapid replacement of blood products & clotting factors

vit K administration, recombinant activated factor VIIa, fibrinogen concentration

urinary output needs w in-dwelling catheter

keep pt warm w forced air warming system, warmed blankets, fluid warmers

severe vs chronic vs gestational HTN & pre-eclampsia/eclampsia

severe HTN: SBP > 160 mmHg and DBP > 110 mmHg

chronic HTN: prepregnancy HTN is present prior to 20 weeks of gestation

gestational HTN: develops after 20 weeks of gestation (absence of proteinuria)

pre-eclampsia/eclampsia: gestational HTN with proteinuria and/or other target organ involvement

pre-eclampsia & eclampsia

gestational or chronic HTN and new onset proteinuria

additional organ dysfunction may be present - acute kidney or liver dysfunction, neuro & hematological complications

pre-eclampsia (no convulsions), eclampsia (convulsions)

risk factors of pre-eclampsia & eclampsia

nulliparity, age > 40 yrs

family hx of pre-eclampsia

SGA pt

obesity/gestational DM

multifetal gestation

pre-eclampsia or poor outcome in previous pregnancy

pre-existing medical/genetic conditions

chronic HTN, renal disease, type 1 (insulin resistance) DM

pre-eclampsia etiology

poor perfusion from vasospasm => increased BP

smaller blood vessels impedes blood flow to all organs and increases BP

maternal complications of pre-eclampsia

multi organ failure

CNS - seizure, cerebral oedema, cerebral hemorrhage, stroke

kidney - renal failure, oliguria, hypo-proteinuria

lungs - pulmonary edema

liver - hepatic failure, hepatic rupture

hematological - DIC, HELLP

fetal complications of pre-eclampsia

preterm birth

still birth (IUFD)

fetal distress

uteroplacental insufficiency

placenta abruption → IUGR, hypoxic neurological

HELLP syndrome

severe pre-clampsia accompanied by...

-hemolysis (H)

-elevated liver enzymes (EL)

-low platelets (LP)

HTN and proteinuria, epigastric/RUQ pain, N/V, headache, malaise

HELLP syndrome associated with increased risk for...

placental abruption

renal failure

pulmonary edema

ruptured liver hematoma

DIC

pre-eclampsia & HELLP nursing care

BP assessment

deep tendon reflexes - bicep reflex, patellar reflex

fetal health surveillance (nonstress test [NST], contraction stress test [CST], biophysical profile [BPP], FHR ultrasonography, fetal movement counting)

activity restriction

pre-eclampsia pt teaching

report increase in BP (monitor)

dipstick test clean-catch urine sample to assess protein

decreased fetal movement (5 or less in 2 hours)

meds for pre-eclampsia & HELLP

control BP - hydralazine, labetalol, methyldopa, adalat

magnesium sulphate (antiseizure) - observe signs of toxicity (loss of reflexes, resp depression, oliguria, low LOC)

eclampsia/seizure precautions

quiet, non stimulating

lighting subdued

seizure precautions (have Mg sulphate available)

suction equipment tested and ready

O2 administration equipment tested and ready

call button within easy each

eclampsia nursing care

usually occurs after headache, blurred vision, photophobia, abd pain, altered mental status

immediate care = ensure patent airway, meds (Mg sulphate), assess fetal status

postpartum care = VS, I&O, reflexes, LOC

future = prenatal care assessment & early interventions

immediate care during seizure

keep airway patent → turn head to one side, place pillow under one shoulder/back if possible

call for assistance, do not leave bedside

padded side rails raised and safely locked

observe and record convulsion activity

after care for seizure

do not leave pt unattended until they are fully alert

observe for post convulsion coma, incontinence

use suction as needed

administer O2 & Mg sulphate/anticonvulsant med

insert in-dwelling urinary catheter and monitor hourly output

monitor BP, fetal and uterine status

expedite lab work as ordered to monitor kidney & liver function, coagulation system, med levels

provide hygiene and quiet environment

support pt and family; keep informed

be prepared to assist with birth as needed

gestational diabetes mellitus (GDM)

elevated glucose levels that are first recognized during pregnancy

increased risk of developing glucose intolerance later in life

increased incidence of adverse maternal and fetal outcomes

risk factors of GDM

> 35 yo

high-risk group (African, Arab, Asian, Latin-American, Indigenous, or South Asian)

using corticosteroid medication

pregestational diabetes

obesity

GDM in previous pregnancy

given birth to a baby that weighed more than 4 kg

a parent, brother, or sister with T2 diabetes

PCOS or acanthosis nigricans (darkened patches of skin) associated insulin resistance

screening for GDM

screen for pre-existing diabetes before 12 weeks gestation

universal screening between 24-28 weeks is recommended in Canada + Oral Glucose Tolerance Test

multiple risk factors -> should screen in 1st trimester

interventions

interventions for GDM

antepartum - good blood glucose control, diet, exercise, monitor BG, pharmacological therapy (insulin, glyburide, metformin), fetal surveillance

intrapartum - macrosomia, birth injuries d/t shoulder, newborn hypoglycemia

postpartum - women with GDM, test again 6-12 weeks postpartum

Rh incompatibility / alloimmunization

isoimmunization: when abt 0.1mL of Rh+ fetal blood mixes with maternal Rh-

RBCs from fetus invade mom circulation -> create Rh antibodies & anti-Rh agglutinin

first baby not affect, but for the ones after

cause severe hemolysis & anemia in fetus

Rh incompatibility / alloimmunization prevention

good hx of past pregnancies to assess for incompatibility potential

determine mom's blood type & Rh factor; routine Rh antibody screen

Rh [D] immune globulin (RhoGAM) is given (at 28 weeks of pregnancy & within 72 hours postpartum)

hyperemesis gravidarum

prolonged vomiting that causes severe dehydration, weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria

between 4 and 8 weeks of pregnancy, resolves by 20 weeks

require hospitalization - fetal complication (LBW, SGA, preterm), maternal (vit k deficiency, thiamine)

hyperemesis gravidarum nursing care

assessment (VS, signs of dehydration, deep stick test for ketones)

clear liquids, slowly introducing small, frequent, bland meals that are high in protein/carbs but low in fat

avoid odours, tastes, other activities that can trigger nausea (eg. stuffy room, visually stimulating lights, strong perfume, etc.)

calm, compassionate, sympathetic care

support for pt and family

initiating and monitoring IV therapy

hyperemesis gravidarum meds

pyridoxine (vit B6) ; B complex

diphenhydramine

metoclopramide - accelerates gastric emptying

antiemetic and meds to control heartburn or reflux (antacids, histamine blockers, PPIs)

ondansetron if above medication are not effective (last resort)

biochemical assessment during pregnancy

-Coombs' test

-amniocentesis

-chorionic villus sampling (CVS)

screening tool for Rh incompatibility

amniotic fluid for genetic testing - for genetic concerns, fetal maturity, fetal hemolytic disease

test chromosomal abnormalities and other genetic disorders - removal of small tissue specimen from fetal portion of placenta

amniocentesis has the potential for maternal and fetal complications, such as...

maternal complications

-leakage of amniotic fluid

-hemorrhage, fetomateral hemorrhage

-infection

-paternal Rh isoimmunization

-placental abruption

-damage to intestines or bladder

-amniotic fluid embolism

fetal complications

-death

-hemorrhage

-infection (amnionitis)

-injury from needle

3rd trimester assessment of fetal well-being

determine whether intrauterine environment continues to be supportive to fetus

determines timing of childbirth for pts at risk for uteroplacental insufficiency

-fetal movement counting

-nonstress test (NST)

-contraction stress test (CST)

-biophysical profile (BPP)

-ultrasound tests

non-stress test (NST)

measure fetal HR in response to movement of fetus (electronic fetal monitor)

HR of healthy fetus should increase when fetus moves

reactive (normal) - at least 2 FHR accelerations lasting at least 15 secs & rising at least 15 beats/minute above established baseline HR

nonreactive - lacks sufficient FHR accelerations over a 40 min period

biophysical profile (BPP) & indications

for women at increased risk of problems that could lead to complications or pregnancy loss

non-invasive test using ultrasound and fetal heart monitoring

low score on BPP might indicate further testing is needed; early or immediate delivery might be recommended

-pregnancy has gone past 40 weeks gestation

-multiple gestation pregnancy

-previous stillbirth

-polyhydramnios or oligohydramnios

-GDM

-preeclampsia or other hypertensive disorder in pregnancy

-IUGR

5 components of the biophysical profile

1. fetal breathing movements (1+ episodes of rhythmic fetal breathing movements of 30+ secs within 30 minutes)

2. fetal movement (3+ discrete body or limb movements within 30 minutes)

3. fetal tone (1+ episodes of extension of a fetal extremity with return to flexion, or opening or closing of a hand)

4. amniotic fluid volume (one pocket of amniotic fluid exceeding 2 cm considered evidence of adequate amt)

5. NST

**each component given a score of 2; high = normal, low = complications

contraction stress test (CST)

measure response of fetus (FHR) after uterus is stimulated to contract

ensure that during labour, fetus can handle contractions and get O2 needed from placenta

nipple- or oxytocin-stimulated contraction test

negative test: FHR does not show deceleration or late decelerations (GOOD)

positive test: FHR is showing decelerations and late decelerations (BAD)

amniotic fluid volume: oligohydramnios vs polyhydramnios

oligohydramnios (< 300 mL of amniotic fluid, associated with fetal renal abnormalitie)

polyhydramnios (> 2 L of amniotic fluid, associated with GI and other malformations)