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