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High risk pregnancy
Condition/s which threaten maternal and/ or fetal health or interferes with normal fetal development, childbirth or transition to parenthood.
Biophysical, socio-demographic, psychosocial, environmental factors
Can become high risk at any point on the continuum.
high risk factors
- Preexisting factors that are affected by pregnancy and affect the pregnancy and its outcomes e.g. diabetes, cardiac disease
- Factors that are related to pregnancy only eg.) Gestational HTN
- Factors that have nothing to do with pregnancy e.g. trauma, but have potential to affect it
what are some effects of high risk pregnancy
-Physical effects on mother and/or baby
-Psychological effects
-Social effects
-Spiritual
-Effects on other family members
-May be financial effects
-Effects of long-term hospitalization
psychological effects of high risk pregnancy
-Increased stress \n -Uncertainty about outcomes \n -Disruption of family routines, role changes, child care issues, work disruption etc... \n -May have difficulty establishing relationship with fetus if outcome is questionable
goals of care for a high risk pregnancy
-Reduce the incidence of health problems affecting maternal/ fetal health and pregnancy outcomes by identifying the presence of risk factors and signs and symptoms of complications early.
-Treat ASAP \n -Minimize effects of complications on pregnancy outcome
-Monitor status of pregnancy \n -Emotional support
intimate partner violence / violence during pregnancy
high risk pregnancy
adolescent pregnancy
Statistics - rate generally decreasing in last few years
Can lead to physical, psychological, social & economic
problems for individuals and families
Social/economic problem for society
Individual differences
risks of adolescent pregnancy
- Can affect education & career options
- Many don’t seek antenatal and follow-up care
- Often have poor nutritional status; many smoke,
substance abuse
- Insufficient weight gain \n - increased Fe deficiency anemia \n - LBW; increased preterm birth \n -increased Risk of abuse to child especially if abandoned - increased Gestational Hypertension \n - Cephalopelvic Disproportion (CPD)
nursing care for adolescent pregnancy
Goals - assist girl in experiencing a physically safe and emotionally satisfying pregnancy, promote optimal health for mother and baby
Educate re: options. Provide support!! Treat with respect Don’t be judgmental
Need to assess developmental level
Encourage prenatal care and education
-supports/community resources
after age 35
After age 35, there's a higher risk of pregnancy-related complications that might lead to a C-section delivery. The risk of chromosomal conditions is higher. Babies born to older mothers have a higher risk of certain chromosomal conditions, such as Down syndrome. The risk of pregnancy loss is higher.
multiple pregnancy
-Ideal outcomes – to reach 36-37 weeks of gestation with all fetuses growing and developing normally \n
-Close monitoring (doppler studies, BPP, NST) useful in monitoring status of the pregnancy
-Increased Risk for cord entanglement, fetal compromise, and placental abruption. \n
-Method of childbirth depends on the position of the first fetus.
-Important to monitor subsequent fetus/es after the birth of the first, as well as maternal bleeding and vital signs
cardiovascular disorders during pregnancy
Normal changes during pregnancy impact woman with pre-existing cardiac disease.
Normal heart can compensate for increased workload
Diseased heart is hemodynamically challenged – if not
well tolerated, can lead to cardiac failure during
pregnancy, L&D, or postpartum period
Consider degree of disability rather than the type of
diagnosis when considering treatment and prognosis during pregnancy
autoimmune disorders
-Disrupt the function of the immune system
-Occur more frequently during reproductive
years \n -Can affect the course of pregnancy or are
detrimental to the fetus \n -Close monitoring before, during and after
pregnancy
what is the presence of gallstones in the bladder
cholelithiasis
cholelithiasis
-Presence of gallstones in the gallbladder.
-Hypothesis during pregnancy: Estrogen causes increased
cholesterol secretion of bile; Progesterone promotes decreased gallbladder motility .
-Increased hormone levels and pressure from uterus interfere with normal circulation and drainage of the gallbladder.
-Most gallstones asymptomatic; may have epigastric (right upper quadrant pain) that radiates to back or shoulders.
-May occur spontaneously, or after a high fat meal.
what is inflammation of the gallbladder
cholecystitis
cholecytitis
-Inflammation of the gallbladder \n -Causes: gallstone obstructs a cystic duct; pressure from
uterus interfere with normal circulation and drainage of the gallbladder. \n -Older pregnant women with several pregnancies and
history of previous attacks. \n -More severe epigastric pain than cholelithiasis.
-Nausea, vomiting and fever may also be present.
treatment for cholecystitis
-Antibiotics, analgesics, IV fluids, bowel rest, and N/G suctioning.
-Surgery should be postponed until the puerperium.
-Recurring may require immediate cholecystectomy – preferably during second trimester, but can be performed anytime during pregnancy.
Antepartal Hemorrhagic Disorders
In pregnancy, increases in plasma volume and RBC’s \n ✔meet metabolic demands of mother & fetus ✔protect against potentially deleterious impairment in venous return \n ✔safeguard the mother against the effects of blood loss at birth
• Maternal blood loss ↓ oxygen carrying capacity to tissues/organs / fetus.
• Any bleeding in pregnancy↑ risk of maternal and/ or fetal morbidity & mortality
bleeding in pregnancy
• Hemorrhage - major cause of death
• Bleeding in early pregnancy (Trimester 1): mostly spontaneous abortion
• Causes of late bleeding (Trimester 2 & 3):
– placenta previa
– abruptio placentae
– abnormal implantation and/or development of placenta
– trauma
what might be happening if someone is bleeding in early pregnancy (tri 1)
spontaneous abortion
what are some causes of bleeding in tri 2 and 3 during pregnancy
-placenta previa
-abruptio placentae
– abnormal implantation and/or development of placenta
– trauma
___________________ is a problem during pregnancy when the placenta completely or partially covers the opening of the uterus (cervix).
placenta previa
__________________ is defined as the premature separation of the placenta from the uterus.
abruptio placentae
a loss of pregnancy before 20 weeks is _________
abortion
types of abortion
-spontaneous
-voluntary (elective, therapeutic )
nursing care for induced/ elective / voluntary abortion
-Confirmation of pregnancy and gestation- bimanual exam/US
- Blood work \n -Pre-abortion counseling \n - Mostly dilatation and curettage and vacuum aspiration
- Nursing support during procedure \n - Recovery 4-5 hours then home \n - RhoGAM to woman who is Rh negative
client teaching for induced/ elective / voluntary abortion
Expect some cramping, bleeding like heavy period
Often- prophylactic antibiotics
NSAIDs for pain relief
Avoid douches, sex, tampons for about 2 wks
Next period- 4 to 6 wks
Contact Dr if temp increases, chills, abdominal pain, tenderness, excessive or
prolonged bleeding, foul smelling vaginal discharge
Info re birth control
Follow up with Dr.
spontaneous abortion (miscarriage)
Incidence- approximately 10-15% of pregnancies
Causes - genetic abnormalities, uterine or cervical problems,
infections, substance abuse, maternal medical conditions (e.g.
diabetes, hypothyroidism)
• Sub groups
- threatened
- inevitable \n - incomplete \n - complete \n - missed \n - recurrent (habitual)
nursing care for threatened abortion
THINK CONCEPTUALLY Bleeding/Infection/Pain
Assessment of pain & bleeding. May require IV
Blood work- Type, Rh, Hbg, Hct
Date of LMP
Obstetric history
Vital signs
Bed rest, nutritious diet, adequate hydration
Decreased Stress
Nosex
hCG levels
Ultrasound - confirmation
Emotional support -determine meaning of this
pregnancy for woman
threatened abortion
When the symptoms indicate a miscarriage is possible, the condition is called a "threatened abortion."
(This refers to a natural event that is not due to a medical or surgical abortion.)
following a spontaneous abortion
May require dilatation and curettage (D&C)
Follow up - phone calls
Referral as necessary
May have mood swings
Expect cramping
Monitor bleeding
Assess pain
Eat foods high in iron and protein
Refer to support groups
Avoid pregnancy for at least 2 months to allow recovery
Other advice - see induced abortion
methods of abortion
-Surgical and medical (meds) methods
-Suction curettage or vacuum aspiration
-Dilatation and Curettage
-Misoprostol (Prostaglandins)
-RU 486 (Mifepristone) - ”abortion pill” now available in Canada
-Mifepristone with misoprostol
second trimester abortions
-Dilatation and Evacuation (surgical) \n -Induction of labour with Misoprostal and Oxytocin (medical)
molar pregnancy.
gestational trophoblastic disease
Monitoring of hCG levels for 12 months
Risk of Choriocarcinoma
Avoidance of pregnancy for 12
months
ectopic pregnancy
Life-threatening condition
Products of conception implant anywhere other than the uterus
Incidence - 1.5% pregnancies
Sites- most in fallopian tubes, particularly in ampulla, Less common- abdominal cavity, ovary, cervix
Leading cause of infertility
cuases / risk factors of ectopic pregnancy
(blocked or narrowed fallopian tubes)
previous pelvic infection,
history of chlamydia infection,
previous appendicitis,
history of infertility
or cesarean birth,
age greater than 35,
smoking
management of ectopic pregnancy
Non surgical- methotrexate (unruptured) disrupts growth of developing embryo → cessation of pregnancy
Surgical - Removal by salping__ostomy__. Or If tube is ruptured→laparoscopic salping__ectomy__
ectopic pregnancy
Diagnosis :
– Rule out other conditions
– Ultrasound – transvaginal, abdominal, laparoscopy
to dx
– If previous positive pregnancy test, repeat hCG
levels over 48 hours
Treatment:
Drugs (unruptured)
Laparoscopic surgery
Supportive nursing care – gentle upon palpation, may
fear for safety and express concern for future fertility, psychological health with pregnancy termination
safety and express
clinical manifestations of ectopic pregnancy
-positive pregnancy
-vaginal bleeding
-abdominal pain
If rupture occurs → Increased pain from blood in perineum. Typically referred shoulder tip pain caused by internal bleeding irritating the diaphragm
Can lead to severe hemorrhage and shock
Cullen’s sign – ecchymotic blueness around umbilicus (ruptured ectopic pregnancy)
Bladder Pain \n Dizziness, pallor, and nausea
Placenta and Cord anomalies can also be a significant source of __________ in pregnancy.
bleeding
placenta previa
• Abnormal implantation of the placenta in the Lower uterine segment (LUS) , over or very close to the internal cervical os.
• Classified according to degree to which internal cervical os is covered by placenta:
⮚ Complete placenta previa
⮚ Partial Placenta previa \n ⮚ Marginal placenta previa
⮚ Low lying placenta
complete placenta previa
The placenta is completely covering your cervix, blocking your vagina.
partial placenta previa
The placenta partially covers your cervix.
__________ placenta previa is when The placenta is positioned at the edge of your cervix.
marginal
low lying placenta
out of these placenta previas:
⮚ Complete placenta previa
⮚ Partial Placenta previa \n ⮚ Marginal placenta previa
⮚ Low lying placenta
which 2 are not as risky
⮚ Marginal placenta previa
⮚ Low lying placenta
placenta previa manifestations
usually ==painless, vaginal bleeding, bright red. ==
With stretching and thinning of LUS, there is a disruption in placental blood vessels. Risk of bleeding ↑ as term approaches & effacement & dilatation occur. This disrupts the placental attachment. Uterus isn’t able to contract & stop blood flow. May have several bleeding episodes
▪ Uterus - soft and non tender
-vital signs may be normal because we have 40-45% extra blood during pregnancy.
-fetus may be in abnormal presentation
-blood clotting usually normal
-signs of fetal compromise (hypoxia) if maternal shock or extensive placental detachment
-fetal/neonatal anemia possibly
complications of placenta previa
• Preterm rupture of membranes
• Preterm labour and birth
• Anemia
• Uterine rupture
• Postpartum infection
• Postpartum hemorrhage
• Fetal death
what is B
Marginal placenta previa
placenta previa management
Management- depends on length of gestation and amount of bleeding:
Home care possibly if stable, no active bleeding and can get to hospital quickly. Otherwise - hospitalization
C/S for complete Placenta Previa
Delivery is necessary if bleeding is sufficient to jeopardize mother or
baby - C/S
If woman is less than 36 weeks and is not in labour, bleeding has
stopped – rest and close observation to allow time for fetus to
mature.
Monitor pads for amt of bleeding
Bed rest or bed rest with BRP if not
bleeding; limited activity
Vitals
Oxygen if required
Monitor fetus i.e., electronic fetal monitoring, NST, BPP
Assess blood loss, symptoms of shock, any contractions?
IV fluids
Have blood X matched
Corticosteroids if < 34/40
No PV exam
Psychosocial support
abruptio placentae
• Premature separation of a normally implanted placenta from the uterine wall
• Accounts for significant maternal & fetal morbidity and mortality
• Risk factors : -trauma, smoking, cocain use, multiple pregnancy, too much amnionitic fluid, diabeteies
abruptio placentae
• Various Degrees of placental abruption. May be a Partial abruption or Complete Abruption.
• It also occurs in various places of placental attachment. Therefore, there are several types:
• Marginal (partial: around edges) / Apparent
• Central / Concealed \n • Mixed or combined
clinical manifestations of placental abruption
Sudden, sharp, and severe onset of abdominal or back pain
Uterus- firm and board like
May be visible bleeding (dark red blood or port
wine stained amniotic fluid) or concealed
Vital signs
May have signs of shock (maternal
hypovolemia)
Uterine contractility
▪ Often impaired clotting
▪ *Fetal presentation - usually normal *
Fetal response depends on amount of
blood loss and extent of uteroplacental insufficiency. Often decreased variability or late/variable decels on FHR
complications of abruptio placentae
Complications - preterm birth, SGA baby, neuro damage to baby from hypoxia, DIC, PPH, infection
Management – depends on maternal and fetal status
Mother may need to be stabilized
If preterm, try to preserve pregnancy as long as possible. Steroids to accelerate fetal lung maturity if bleeding is stabilized or mild abruption
If condition deteriorates, cesearean birth.
nursing care for abruptio placentae
• Close monitoring of mother & fetus
Observe for shock, bleeding
Measure abdomen/ fundal
height- accumulation of blood Assess discomfort
Assess for contractions
Establish IV access and give IV
fluids
Catheter - intake & output
Monitor fetal status
Oxygen if fetal distress
May need corticosteroids
Psychosocial support
• Abruptio placentae and placenta previa are differentiated by:
type of bleeding :Bright red (periva); Dark red (abruption)
uterine tonicity: Soft non tender (pervia); Board like (abruption)
presence or absence of pain: Sharp sudden pain (abruption); Painless (Previa)
Abruptio placentae or placenta previa?
bright red bleeding
placenta previa
Abruptio placentae or placenta previa?
dark red bleeding
abruptio placenta
Abruptio placentae or placenta previa?
uterine atony: soft non tender
placenta previa
Abruptio placentae or placenta previa?
uterine atony: board like
abruptio placentae
Abruptio placentae or placenta previa?
sharpe sudden pain
abruptio placentea
Abruptio placentae or placenta previa?
painless
placenta previa
management of late pregnancy bleeding requires immediate evaluation
• Care based on: \n > Gestational age \n > Amount of bleeding
> Fetal condition
invasive placentas
placenta impants deeper than normal.
Invasive placenta is the term used to describe the condition when the whole or part of the placenta grows into the uterine wall and fails to detach from it during the delivery.
placenta has to be delivered (usually a c/s). hysterectomy if they can’t get placenta out.
• Three types of invasive placentas:
• Placenta Accreta \n • Placenta Increta \n • Placenta Percreta
placenta accreta
Slight penetration of myometrium
placenta increta
Deep penetration of myometrium
placenta percreta
Perforation of uterus
cord insertion anomalies
• Velamentous cord insertion (Vasa Previa) – fetal vessels running into or coming within close proximity to the internal cervical os
clotting disorders in pregnancy
• Disseminated Intravascular Coagulation (DIC)
-An over activation of the clotting cascade and the fibrinolytic system resulting in depletion of platelets and clotting factors
-Always a secondary diagnosis
-Often triggered by release of large amounts of thromboplastin:-abruptio placentae, retained demised fetus, amniotic fluid embolus, severe pre- eclampsia and sepsis also damage vasculature integrity
S&S of clotting disorders in pregnancy
• unusual spontaneous bleeding ie.) gums or nose \n • petechaie (especially after blood pressure cuff inflation)
• excessive bleeding from puncture sites ie.) IV,
venipuncture site \n • tachycardia and diaphoresis
management of clotting disorders in pregnancy
• correction of underlying cause \n • IV fluids to replace losses, \n • Packed RBC’s to maintain circulation and oxygen delivery
• Fresh frozen plasma to replace clotting factors \n • Administration of platelets
insulin is a growth hormone… so if the baby produces more insulin.. they get ?
big
pre-gestational diabetes
type 1 or 2 diabetes present prior to pregnancy
Normal pregnancy-diabetogenic state in latter part of second trimester and third trimester-need for glucose increased
.
Glucose transport to fetus facilitated by diffusion
Maternal insulin does not cross placenta
By 10 weeks, fetus secretes own _____ to use Mom’s _____
insuline.
glucose
Trimester 1
Maternal glucose levels drop below non pregnant values
Influence of estrogen & progesterone → increased insulin production → increased peripheral glucose utilization. Fetus also using more glucose so leads to decreasing maternal levels
Also possible N&V and appetite loss
Increased chance of hypoglycemia
Decreased need for insulin
trimester 2 & 3
Hormonal changes→decreased tolerance to glucose
Increased levels of human placental lactogen, estrogen, progesterone, cortisol, prolactin & insulinase→increase insulin resistance (glucose sparing mechanism ensuring abundant supply of glucose to fetus)
Placenta begins to manufacture insulinase
Results in increased need for insulin at beginning of Trimester 2 and increased
danger of hyperglycemia and ketoacidosis
normal glucose level for someone
4-7
complications of diabetes during L&D
Labour is a form of exercise and has a glucose lowering effect. In addition, laboring mother is often maintained on an NPO status, further complicating hypoglycemia. May be given IV therapy to maintain normoglycemic state.
No additional insulin is needed during labour; sufficient glucose should be infused to keep the woman from becoming ketotic from the prolonged period of starvation.
There is clear evidence that neonatal hypoglycemia is directly related to maternal hyperglycemia during labour
Birth Trauma from larger than average size newborn
Higher incidence of failure to progress, Cesarean delivery
diabetes during L&D:
birth trauma from larger than average newborn size
bigger baby.. more risk for tears, dystocia, c section, bigger baby = more risk for post partum hemorrhage
pre-gestational diabetes
Labour
Postpartum-abrupt drop in placental hormones, cortisol and
insulinase
Should be encouraged to breastfeed. Protective effect
Substantial decrease in insulin requirements
Takes 7-10 days to re-establish CHO homeostasis if not
breastfeeding
Lactation uses increased glucose so insulin requirements low until weaning
influence of pregnancy on pre-existing diabetes
May have drastic alteration in insulin requirements
Insulin requirements may double or quadruple by the end of
pregnancy
May be more difficult to control
May accelerate progress of vascular disease
most womens bodies can compensant for the extra needed insulin during pregnancy. some cant…. so then get ?
gestational diabetes (GDM)
Gestational Diabetes (GDM)
Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy
Incidence approximately 3-5% of pregnancies in non-aboriginal women, 8-18% in aboriginal women
Usually diagnosed after week 20 of gestation
Fetal nutrient demands increase in later T2 and T3
Maternal nutrient ingestion also increases→raises blood glucose. At the
same time, maternal insulin resistance increases. Insulin demands –> Increase 3-fold
Usually disappears after pregnancy but may develop diabetes later
Risk factors (obesity, bad eating habits, family hx)
Many are asymptomatic- detected by glucose testing 24-28 weeks
gestation
Treatment- diet mostly, possibly insulin
Need to teach about S & S of hypo and hyperglycemia
Dx of gestational diabetes
-50 GM Glucose Challenge test given at 24 – 28 weeks pregnancy 1 hr Post Glucose taken
-If < 7.8 mmol/L→Normal value \n
-7.8 – 11 mmol/L→retest with 75 gm Glucose challenge test with fasting PG, 1hrPG, 2hrPG. If
one of the three blood levels meets or exceeds \n (FPG > 5.3 mmol/L; 1hrPG > 10.6; 2 hrPG > 9 mmol/L)→ Gestational Diabetes
-> 11.1 mmol/L →Gestational Diabetes
management of pre-gestational / gestational diabetes
Preconception counselling
Nutrition
Urine testing
Fetal surveillance
Glucose checks
Insulin
Exercise
Lack of maternal glycemic control before conception and in T1 of pregnancy may be responsible for fetal congenital __________
malformations
key point - diabetes
Maternal insulin requirements increase as pregnancy progresses and may double to quadruple by term as a result of insulin resistance, created by placental hormones, insulinase, and cortisol
Key Points - diabetes
After birth levels decrease dramatically
Breastfeeding affects insulin needs
Poor glycemic control before and during pregnancy can lead to maternal complications such as miscarriage, infection and dystocia caused by fetal macrosomia
Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in pregnancy complicated by diabetes mellitus
Because GDM is asymptomatic mostly, routine screening during pregnancy is necessary
.
Infant of a mother with diabetes
▪Good glucose/A1C control prior to conception is essential
▪Appearance
-May be - at risk for injury at delivery \n -May be due to impaired uterine flow causing compromised placental functioning
an infant of a mother with diabetes will be at risk for ?
poor glucose control post birth
hypoglycemia
• Sustained state of hyperglycemia in pregnancy leads to hyperinsulinism.
• At birth, glucose supply is cut.
• Glucose depleted and leads to hypoglycemia in NB
infant of a mother with diabetes
▪At risk for developing respiratory distress & RDS (hyperinsulinemia in fetus alters surfactant production)
▪Increased risk of congenital abnormalities e.g., CHDs, spinal defects
▪Risk of hypoglycemia, hypocalcemia, hyperbilirubinemia, hypomagnesemia, polycythemia, cardiomyopathy
______________ is the most common medical complication in pregnancy
hypertension (High blood pressure)
pre-existing hypertension is hypertension present before pregnancy or diagnosed before week ___ of gestation
20
gestational hypertension
- Onset of hypertension @@after week 20 @@of pregnancy in a previously normotensive woman
\n - Systolic BP ≥140, diastolic BP ≥90
blood pressure of gestational hypertension
Systolic BP ≥140, diastolic BP ≥90
__________ is hypertension in pregnancy after week 20 + proteinuria ( high levels of protein in your urine)
preeclampsia
high levels of protein in urine indicate ________ damage
kidney