High Risk Pregnancy

MATERNAL RISK FACTORS

• adolescence

  • increased risk during teenage pregnancy for toxemias, anemia, prematurity, low birth weight, prolonged labour, high blood pressure (preeclampsia risk), STI, and postpartum complications

  • poverty, education and limited family resources lead to deteriorating mental health and lack of prenatal care

MENTAL HEALTH ILLNESS

• pt can be related to sbuse: physical, emotional, sexual and mental

• take note of any suspicious bruising and other injuries

SUBSTANCE ABUSE

• has several consequences for infant, passes easily though placenta and breast milk

• includes alcohol, smoking, use of OTC and illicit drugs

• marijuna and tobacco create greatest risk for stillborn

• their is no save amount of alcohol during pregnancy. the first trimester is the most violable period for fetal alcohol syndrome

PRE EXISTING HEALTH ISSUES

• cardiac disease, autoimmune, diabetes, renal disease

• obesity leads to hypertension during pregnancy

ADVANCED MATERNAL AGE

• referes to patients older than 35 years

• increased risk for gestational diabetes, hypertension, infertility, c section, fetal death and Down syndrome

• early screening to look for anomalies

HYPEREMESIS GRAVIDARUM

• no known ethology but suspected levels of high HCG and estrogen

• results in electrolyte imbalance and ketonuria, and vitamin b6 deficiency

• stress can bring on symptoms

• hypersensitivity and dysregulation of gastric rhythms

• peaks at 8-12 weeks usually resolves by 14wks

• causes decreased placental blood flow, maternal blood flow and acidosis - threats the health of mom and baby

• risks to mother include pregnancy loss, activity restiction and depression

HYPEREMESIS GRAVIDARUM RISK FACTORS

• young maternal age

• nulliparous

• low SES

• unplanned pregnancy

• high MBI

• smoking

• HG in previous pregnancy

HYPEREMESIS GRAVIDARUM TREATMENT

• clear fluids

• IV hydration

• TPN/NPO in severe cases

• electrolyte replacement

• medications

  • diclectin, gravel, mexeran, ondansetron

NURSING CARE FOR GRAVIADRUM

• psychosocial support

• ins and outs

• weights

• oral care

• quiet aroma free environment

• activity as tolerated

• fetal monitoring dependant on gestation

DIABETES IN PREGNANCY

• type one and 2

• requires adaptations to manage conditions

• INCREASED RISK OF

  • macrosomia

  • congenital anomalies

  • spontaneous abortion

GESTATIONAL DIABETIS

• carbohydrate intolerance of variable severity with onset or recognition during present pregnancy. After 20 weeks gestation.

  • beta cells of pancreas do not produce enough insulin, placenta produces high levels of hormones which impair action of insulin in cells, and raises blood sugars

• **pregnancy insulin resistance is main cause for increase in blood sugars, and hormones peak between 24 and 28 weeks.

RISK FACTORS FOR GB

• previous or fx history of gestational diabetes

• previous macrosomia of >4000g

• unexplained stillbirth

• previous neonatal hypoglucemia

• advanced maternal age

• obesity BMI over 30

• polyhydramnious

• hypertension

• at risk for ketoacidosis as the body cannot buffer acids as before pregnancy

• glucose crosses the placenta = increased fetal urine production = increased volume of amniotic fluid

SCREENING FOR GB

• recommended testing done at 24-28wks, >11.1 mmol confirms diagnosis

• screening completed by testing one hour plasma, glucose measurement following a 50g glucose load

• result between 7.8 to 11 is indication that mother has to take 75g 2 hours glucose test

• undergo a hemoglobin a1c to review control of sugars 3 months previous

  • additional testing serum creatinine and urinalysis for micro albumin

• intensive fetal monitoring done at the end of pregnancy 3rd trimester

  • includes fetal movement count ultrasound, NST, and doppler studies

  • used to reduce risk of trauma, and stillborn

GESTATIONAL DIABETIS PATHO

• 1st trimester:

  • raise in hormones stimulates insulin production and increase tissue response to insulin

  • insulin needs to decrease

• 2nd and 3rd trimester

• • human placental lactose causes increase resistance to insulin

• ethology of beta cell destruction unknown

• decrease glucose tolerance

• hyperglycemia

• insulin needs to increase two and 3 times

• frees up glucose for fetus

FETAL IMPLICATIONS

• maternal hyperglycaemia ➛ glucose crosses placenta = fetal hyperglycemia

  • leads to = macrosomia, congenital anomalies, intrauterine fetal demise

MANAGEMENT OF GDM IN ANTEPARTUM

• diet and exercise

• monitor of blood glucose

• require medication (25-50%)

• increase in fetal heart sounds

TREATMENT OF GDM

• self assess blood sugars 5-7x a day, post prandial and preprandial

• signs and symptoms of hypoglycemias

  • shakiness, sweating, clumsy or jerky movements, hunger, headaches, confusion

• nocturnal hypoglycaemia is increased risk, may need to take blood sugars at night

• evaluation q1hr during labour and birth - prevention of neonatal hypoglycemia

• If patient is on insulin during labour, as energy requirements increases, extra glucose is required. Goal is to keep insulin between 4-7

POTENTIAL NURSING DIAGNOSIS FOR GDM

• anxiety

• deficient knowledge

• ineffective health maintenance

• imbalanced nutrition

• ineffective coping

MANAGEMENT OF GDM IN LABOUR

• goal is to maintain blood glucose between 4 and 7 during labour

• continuous fetal heart survaliance

• blood glusose should be higher than 7 during labour

• insulin drip started with D5W infusion

HYPERTENSION IN PREGNANCY

• preexisting is before 20 wks

• gestational is after 20 wks

• **** PREECLAMSIA IS CLASSIFIED AS HYPERTENSION AFTER 20 WKS WITH PROTEINURIA (25%) MULTIORGAN INVOLVEMENT

Hypertensive disorders

• ethology not confirmed, risk increases with age over 40years

• risk increased with primaparas who are obese, overweight

• multipara are at risk if there is a new partner, preexisting hypertension, renal disease, diabetes or multiple gestation

PRE-ECLAMPSIA SYMPTOMS

• after 20 wks gestation

• PRE TRIAD - proteinuria, rising BP, edema

  • severe headaches

  • upper quadrant abd pain

  • naura, vomting

  • decreased urine output

  • thrombocytopenia

  • impaired liver function

  • shortness of breath

PRE ECLAMPSIA COMPLICATIONS

• fetal growth restriction

• pre term birth

• placental abduption

• HELLP syndrome

PRE ECLAMPSIA INTERVENTIONS

• medications:

  • antihypertensives (hydralazine, labetalol, nifedipine)- BP lowered

  • Corticosteriroids (dexamethasone or betamethasone) - increase surfactant in fetal lungs <34 weeks. Decrease fetal lung fluid, increase surfactant

  • MgSo4 (magnesium sulfate) - seizure prophylaxis

• assesments

  • neurological status - determine risk for seizures related to headaches

  • urinalysis - check for ptorien

  • blood work - K+, hematocrit, platelets, liver function

ECLAMPSIA

• symptoms

  • S - seizures

  • A - acute increase of BP, multi organ involvement

  • I - increased liver enzymes

  • B - blurred vision

  • H - hyperreflexia

  • A - agitation

• P - protienuria

• E - epigastric or RUQ pain

• L - loss of consciousness

• H - headaches or muscle pain

ECLAMPSIA COMPLICATIONS

• fetal growth restriction

• pre term birth

• placental abruption

  • ** preeclampsia/eclampsia will NOT resolve until baby is born

HELLP SYNDROME

• H - hemolysis

• E - elevated liver enzymes

• L - low platelet count

• L - liver enzymes

• P - platelet count

  • it can develop with or without pre existing hypertension, present with flu like symptoms, RUQ pain, weight gain and edema

  • ** is a severe complication of gestational hypertension, syndrome may not present with high BP

ASSESMENTS INTRAPARTUM

• perinatal assessment

  • BP readings, maintain low stimulation, assess for neurogenic symptoms, give magnesium and beta blockers

• fetal assessment

  • continuous fetal monitoring, decreased accelerations are expected if mom is receiving magnesium sulphate

  • fetal assessment

    • fetal movement count twice a day

    • non stress test done 2-3 x a wk

    • biophysical profile 1-2 x a wk

    • continuous fetal monitoring while mom is in labour

    • ultrasounds to assess amniotic fluid volume

    • doppler study to determine placental blood flow

INTRAHEPATIC CHOLESTASIS OF PREGNANCY

• is a pregnancy specific disorder

  • elevated serum bile acids, and pruitis developing ins second and third trimester

  • very increased risk for stillborn

• diagnosis

  • total bile acids over 10mmol

  • liver panel: AST and ALT elevated

  • differential diagnosis

• treatment

  • medications

  • delivery

• ursodexycholic acid is frontline treatment for icp. Analysis has shown that udca is superior at relieving maternal symptoms, and improving fetal outcomes.

  • delivery is needed

PLACENTAL ANOMALIES

• placenta previa

  • embryo implants in lower uterus that results in location of placenta over the cervical OS

• bleeding condition that occurs during the last 2 trimesters of pregnancy. Placenta implants over the cervical os

• serious complications arrise

  • hemmorage

  • abruption

  • preterm birth

  • emergency section

PLACENTA PREVIA NURSING IMPLICATIONS

• clue is to look for malpresentation or high presentation

• main symptoms is hemmoraging during last two trimesters - results in anemia, shock

• end result may be premature separation of placenta, pre term birth and emergency caesarean

• ** these patients cannot give birth vaginally

NURSING CARE PLACENTA PREVIA

• assesments

  • presentation

  • painless bleeding

  • home care teaching

• management

  • fetus not yet term

  • close monitoring

  • medications

  • ultrasound

• active management

  • fetus at term = safe delivery

• psychosocial assessment and support is very important for mom and supports

PLACENTAL ABRUPTION

• normally located placenta separates from uterus after 20wks gestation prior to birth

• result is hemmorage that results in fetal and maternal mortality

• can occur gradually as small parts of placenta detach, causing bleeding = clot formation = decreased maternal and fetal blood flow

  • classified as mild, moderate or severe

    • further classified as type of detachment of placenta (marginal or apparent, central or concealed, mixed or combined)

NURSING IMPLICATIONS PLACENTAL ABRUPTION

• be aware of abdominal pain or backache with uterine tenderness

• fetal heart sounds may be absent or abnormal

• if pt experiences shock and anemia out of proportion to blood loss

• result may be coagulopathy, the body’s ability to form blots is impaired

NURSING CARE PLACENTAL ABRUPTION

• assesments

  • Presentation - malpresentation or high presentation

  • bleeding - hemmorage during last two trimesters = shock, anemia

• active management

  • fluid volume replacement

PRE TERM LABOUR

• true labour that begins before 37 weeks gestation

• fetal implications include

  • intrauterine growth restriction, cerebral palsy, respiratory complications, blindness

• contributing factors include

  • premature rupture of membranes, multiple pregnancies, cervical insufficiency, maternal infection

RISK FACTORS FOR PRE TERM LABOUR

• adolescent pregnancy

• antepartum hemmorage

• polyhydramnous

• uterine anomaly

• alcohol and cocaine use

• anemia

• bacterial vaginosis

• chrioamnionitis

• diabetes

• hydramnios

• hypertension

• malnutrition

• multiple gestation

• placental problems

• urinary tract infections

common causes of indicated preterm birth

• pre existing or gestational diabetes

• chronic hypertension

• preeclampsia

• obstetrical disorders

• placental disorders

• seizures

• thromboembolism

• maternal hiv

• obesity

• advanced maternal age

• fetal disorders

• chronic intrauterine growth restriction

• abnormal stress test

• excessive or inadequate amount of amniotic fluid

• birth defects

Clinically indicated pre term birth

• pre eclampsia

• complicated insulin dependant diabetes

• abnormal fetal surveillance

• intrauterine growth restriction

• placenta abruption

• intrauterine fetal death

• chorioamnionitis

threatened pre term labour

• contraindications present between 20-37wks

• no cervical dilation

• interventions resolve contractions

  • rest

  • hydration

  • UTI, STI

  • tocolysis

Prevention of preterm labour

• primary prevention

  • smoking ceassation

  • stop maternal substance use

  • prenatal care

• secondary prevention

  • screening for and treating risk factors

  • bacterial vaginosis in woman with prior preterm birth

  • asymptomatic bacteriuria

prolonging pregnancy

• evidence for some efficacy

  • tocolytics

  • calcium Chanel blockers (nifedipine)

  • PG synthetase inhibitors (indomethacin)

  • nitroglycerin

• no evidence for efficacy

  • magnesium sulphate

  • bedrest

  • fluid bolus

  • sedation

  • home uterine monitoring

Contraindications to tocolysis

• any contraindication to continuing pregnancy

  • pre-eclampsia

  • chorioamnionitis

  • imminent delivery

  • abnormal fetal surveillance

  • significant antepartum hemmorage

Antenatal glucocorticoid theraphy

• cross placenta and induce enzymes that accelerate fetal pulmonary maturity

• full benefit 48hrs after dose

• given at gestation between viability and 34 wks

• betamethasone 12mg IM q24h x 2

• dexamethasone 6mg IV/IM q12 x 4

• contraindicated in gastric ulcers, TB and chorioamnionitis

MgSo4 for fetal neuroprotection

• considered when managing patients at risk for imminent delivery before 31wks 6 days gestation

• reduce risk of cerebral palsy and substantial motor dysfunction

• 4g IV over 30 mins - loading dose 1g/hr maintenance

Nursing care with Mgso4 admin

• monitor vital signs

• assess mom and fetus to obtain baseline vitals

• ensure calcium gluconate is available

• should not be given to moms with myasthenia graves

• adverse effects

  • hot flushes, sweating, burning at iv site, nausea, vomiting, dry mouth, drowsiness, blurred vision, diplopia, headaches, weakness, lethargy, dizziness, hypocalcemia, shortness of breath and transient hypotension

• fetal effects

  • decreased breathing movement, reduced FHR variability

COMPLICATIONS OF PREMATURITY

• short term

  • respiratory distress syndrome: common problem in premature babies. Need extra oxygen and help with breathing

  • intraventricular hemmorage: bleeding inside and around ventricles in brain. Ventricles are space that hold cerebrospinal fluid. Bleeding in brain can put pressure on nerve cells, damage them and if damage is severe to cells can lead to brain injury.

  • necrotising enterocolitis: happens when tissues in large intestine get inflamed. The inflammation damages and kills tissues in colon. Very common in sick and premature babies. The smaller the baby the higher risk for NEC.

• long term

  • CNS complications

  • Neuro developmental delay

  • bronchopulmonary dysplasia: chronic lung disease, results from damage to lungs caused by mechanical ventilation and long term oxygen use. Many infants can recover from BPD but some can suffer long term breathing difficulty.

RISK FACTORS PREMATURE RUPTURE OF MEMBRANES CNA PRETERM PREMATURE RUPTURE OF MEMBRANES

• premature rupture of membranes

  • birth of baby a few days after rupture

  • Caesarian birth

  • postpartum infection

  • compressed umbilical cord

  • infection of placental tissue

  • placental aruption

• preterm premature rupture of membranes (before 37wks gestation)

  • maternal and nutritional deficiencies

  • tobacco abuse

  • polyhydramnious

  • multiple gestations

  • antepartal trauma

  • chorioamnionitis, STI

  • intrauterine infection, chorioamnionitis is strongly associated with pPROM, and preterm birth at 21-24wks

  • fetal deformaties or fetal limb amputation )amniotic band syndrome)

ASSESMENTS RUPTURE OF MEMBRANES

• report of gush, pop or leaking (date and time)

• COAT (color, odour, amount, time)

• inspect perineal area for fluid, odour, endovervical mucous, bloody discharge

DIAGNOSTIC TESTS RUPTURE OF MEMBRANES

• nitrazine - ph of vaginal fluid (amniotic alkaline)

• Ferm tests - vaginal fluid on a slide (Fern pattern indicates amniotic fluid)

• fetal fibronectin - protein that glues amniotic sac. If connection is disrupted, fibronectin released into secretions near cervix. Connection can be disrupted by infection, inflammation, separation of placenta from wall of uterus, uterine contractions or shortening of cervix.

  • protein produced by fetal cells, found at interface of chorion and decidua. (between fetal sac and uterine lining)

• ultrasound - to check amniotic levels

NURSING CARE PROM/PPROM

• watch for infection fever, chills, tenderness, WBC test, changes in amniotic fluid

• antenatal corticosteriroids are ordered if pregnancy is less than 34 wks but viable at least 24wks

• tocolytics can be ordered

• adress psycho-social issues

  • anxiety, stress, good communication

CERVICAL INSUFFICIENCY

• occurs in 2nd trimester, defined as a structurally defective cervix, that spontaneously and painlessly dilates in absence of contractions

• progress to premature rupture of membranes, preterm birth

• thought to be linked to cervical damage from a congenital deformity, laceration or infection

DETECTION AND TREATMENT OF CERVICAL INSUFFICIENCY

• diagnosis

  • transvaginal ultrasound to examine cervix

  • pelvic exam to see if membranes are protruding through cervix

• detection

  • through history, has it happened before?

• treatment

  • cervical cerclage: cervix is stitched closed with sutures. Sutures will be removed last month of pregnancy during labour

INTRAUTERINE GROWTH RESTRICTION

• infants with signs of failure to thrive or hypoxia

• head and body are proportionally small

• results in increased risk for stillbirth, oligohydramnious, meconium aspiration, fetal distress/death

MECONIUM STAINING

• meconium aspiration causes a severe form of aspiration pneumonia

• before birth assess for:

  • assess fluid for presence of meconium after rupture of membranes

  • if fluid Is meconium stained, neonatal resuscitation is required

  • have someone perform endotracheal intubation at birth

• after birth

  • assess respirations, heart rate and muscle tone

  • suction babys mouth and nose if baby has

    • strong respiratory efforts

    • good muscle tone

    • heart rate >100beats/min

    • suction trachea using endotracheal tube connected to meconium aspiration device and suction to remove meconium before respirations occur.

  • perform assisted ventilation if

    • depressed respirations

    • decreased muscle tone

    • heart rate <100beats/min

AMNIOTIC FLUID IMBALANCES

• oligohydramnious

  • little amniotic fluid surrounding fetus and umbilical cord

  • diagnosed by ultrasound

  • caused by

    • renal genesis (potter syndrome)

    • preterm premature rupture of membranes

    • postdate pregnancy

    • uteroplacental insufficiency

    • hypertensive disorders in pregnancy

  • antepartum care

    • fetal wellness checks; kick counts and NST’s

    • serial ultrasounds to monitor amniotic fluid levels

  • intrapartum care

    • Continuous EFM, variable decelerations common

    • amnioinfusion can be done

• polyhydramnios

  • excess of amniotic fluid surrounding fetus and umbilical cord

    • diagnosed by ultrasound: see large symphysis - fundal height

  • caused by

    • diabetes, blood glucose beyond target

    • fetal congenital anomalies (twin to twin transfusion syndrome, GI obstruction)

    • increased risk of cord prolapse with ROM

  • antepartum care

    • receive normal care

  • intrapartum care

    • monitoring for SROM

    • if SROM immediate cervical exam to assess cord presentation

CHORIOAMNIONIIS

• organism that is part of vaginal flora ascent into amniotic cavity. Moms who have this infection can develop baceremia and can suffer from labour dystocia

• is characterized by an infection of the chorion and amniotic fluid. Foul smelling, maternal temp, fetal tachycardia

  • prevention of maternal and neonatal complications, treatment with broad spectrum antibiotics and with of the fetus is necessary

  • Ampicillin, gentamycin, or penicillin are used

• after section, antibiotic gives coverage for anaerobic organisms, such as clindamycin or metronidazoleshould be added

• increased use to antibiotic prophylaxis who are GBS positive demonstrated decreased incidence of chorioamnionitis

ISOIMMUNIZATION

• condition that occurs during pregnancy if woman is Rh- and baby has Rh+ blood

  • during delivery blood can intermingle

• maternal body recognizes baby’s Rh protein as foreign and can begin making antibodies against baby’s Rh proteins

  • if second child is Rh positive, maternal anti Rh antibodies will cross placenta and cause hemolytic disease in newborn

• antepartum is when pt should be tested for blood type

• postpartum is when WinRho immunization should be given 72hrs of delivery to non sensitized Rh negative women who delivered Rh positive infant

NURSING CARE FOR ISOIMMUNIZATION

• WinRho at 28wks

• earlier winRho if trauma or antepartum bleeding occur

• cord bood tested ‘if baby is Rh+ Kleihauer Betke drawn on mother baby unit