Pregnancy at Risk: Conditions That Complicate Pregnancy

Overview of At-Risk Pregnancies

• Historical Context: In the past, women with chronic medical conditions were often unable to become pregnant or give birth successfully.
• Modern Advancements: New treatments and medical advancements are now available to assist these women in achieving and maintaining pregnancy.
• Specialized Care: A Perinatologist is an obstetrician who specializes specifically in the care of at-risk pregnancies.
• Interrelation of Risks: Chronic medical conditions and pregnancy complications are significant risk factors that are often interrelated.     * Pregnancy can affect the course of an underlying disorder.     * Normal physiologic changes inherent to pregnancy can intensify the symptoms of a woman's illness.     * Medical conditions can impact the progress and eventual outcome of the pregnancy itself.     * Chronic medical conditions in the mother may adversely affect fetal development and health.

Diabetes Mellitus (DM) in Pregnancy

• Classification of Diabetes:     * Pregestational Diabetes: Includes Type 1 and Type 2 diabetes existing prior to pregnancy.         * Type 1: The pancreas does not produce insulin; the patient must receive exogenous insulin.         * Type 2: Characterized by insulin resistance; treatment varies.     * Gestational Diabetes Mellitus (GDM): Diabetes that occurs specifically during pregnancy, characterized by insulin resistance similar to Type 2.
• The Diabetogenic State of Pregnancy: Three normally occurring responses in pregnancy put a woman into this state:     1. Hypoglycemia: Low blood glucose levels, typically seen when fasting.     2. Hyperglycemia: High blood glucose levels, typically seen after meals.     3. Hyperinsulinemia: Increased insulin levels after meals.
• Risks Associated with Pregestational Diabetes:     * History of poor outcomes in previous pregnancies.     * Improvement of outcomes is dependent on strict control of blood glucose levels and consistent fetal surveillance.     * Poor Control Risks: Birth defects, stillbirth, hypertensive disorders, polyhydramnios (excessive amniotic fluid), preterm delivery, and macrosomia.
• Gestational Diabetes Mellitus (GDM) Specifics:     * Risk Factors: History of Large for Gestational Age (LGA) infants, previous GDM, previous unexplained fetal demise, maternal age $>35\text{ years}$, family history of Type 2 DM or GDM, obesity ($>200\,lb$), non-Caucasian ethnicity.     * Screening Thresholds: Fasting blood glucose $>140\,mg/dL$; random blood glucose $>200\,mg/dL$.     * Long-term Implications: Mothers have an increased risk of developing Type 2 diabetes $5$ to $20\text{ years}$ after delivery.
• Fetal Complications:     * Placental issues and abnormal fetal growth.     * Hypoglycemia immediately after birth.     * Birth trauma and delayed lung maturity issues.     * Increased health risks later in life and increased likelihood of cesarean delivery.     * Macrosomia Defined: A birth weight $>4,000\,g$ ($8.8\,lb$) or weight that is $\ge 90^{th}$ percentile for gestational age.

Treatment and Glycemic Control for Diabetes

• Prepregnancy Care:     * Consultation with a healthcare provider before conception.     * Hyperglycemia is particularly harmful during the first $8\text{ weeks}$ of growth.     * The goal is to achieve euglycemia (normal blood glucose) before pregnancy.     * Daily multivitamin supplements should be taken several months prior to conception.
• Monitoring: Use of fingerstick testing and HbA1C levels.
• Hypoglycemia Signs and Symptoms: Anxiety, shakiness, confusion, headache, tingling sensations around the mouth, hunger, sudden behavior changes, pale skin, cold and clammy skin, increased pulse, seizures, and unresponsiveness.
• Diabetic Ketoacidosis (DKA):     * Initial Symptoms: Polydipsia (excessive thirst), polyuria (excessive urination), polyphagia (excessive hunger).     * Progressive Signs: Glucose $>300\,mg/dL$, ketonuria, Kussmaul respirations, acetone (fruity) breath, sleepiness, language slurring, and decreased consciousness.     * Triggers: Too little insulin, too much food, infection, tocolytic therapy, corticosteroid use, or insulin pump failure.
• Management Strategies:     * Type 1 DM: Requires fetal surveillance, diet, exercise (with approval), and insulin therapy.     * GDM: Requires diet, exercise, and sometimes insulin.
• Fetal Surveillance Tools: Sonograms, maternal serum alpha-fetoprotein levels, HbA1C, fetal echocardiogram, nonstress test (NST), biophysical profile (BPP), and contraction stress test (CST).
• Delivery Timing: Determined via amniocentesis (to check lung maturity); labor may be induced if the cervix is favorable and lungs are mature.
• Multidisciplinary Team: Includes endocrinologists or perinatologists, RNs, certified diabetic educators, registered dietitians, social workers, and pastoral caregivers.
• Related Complications: Preeclampsia (symptoms: headache, visual disturbances, epigastric pain, generalized edema, urinary protein, elevated blood pressure).

Cardiovascular Disease in Pregnancy

• Overview: The leading cause of maternal deaths from 2014 to 2017.
• Common Conditions: Coronary heart disease, pulmonary hypertension, and congenital heart disease.
• Periods of Peak Risk: The end of the second trimester, during labor, and the early postpartum period.
• WHO Classification of Risk:     * Class I or II: Good prognosis for pregnancy.     * Class III or IV: Poor prognosis; requires extensive monitoring and treatment.
• Clinical Manifestations: Dyspnea (shortness of breath), orthopnea, nocturnal cough, dizziness, fainting, chest pain.
• Physical Exam Findings: Cyanosis, clubbing of fingers, neck vein distention, tachycardia, heart murmurs, and edema.
• Diagnostics: 12-lead ECG, echocardiogram, and Doppler studies.
• Medication Contraindications: Warfarin, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers are prohibited as they cross the placenta and increase the risk of congenital anomalies. Digoxin, Heparin, and Hydrochlorothiazide are typically considered safe to continue.
• Labor Management: Avoid the supine position; provide analgesia; monitor for hemorrhage; continuous cardiac and fetal monitoring.
• Nursing Care: Protect from infection, encourage proper positioning for rest, educate on the risks of smoking and illicit drugs, and perform fetal kick counts.

Anemia and Hematologic Disorders

• General Definition: Blood deficient in RBCs, hemoglobin, or total volume; usually a symptom of an underlying disorder.
• Causes: Blood loss, hemolysis, or decreased RBC production.
• Iron-Deficiency Anemia:     * The most common form; involves microcytic and hypochromic cells.     * Diagnostic Markers: Hemoglobin level $<11\,g/dL$; Hematocrit level $<33\%$.     * Signs: Tachycardia, tachypnea, dyspnea, pale skin, hypotension, heart murmur, headache, fatigue, and weakness.     * Associated Behaviors: Pica (eating non-food items) and pagophagia (compulsive ice eating).     * Treatment: Diet rich in iron and folate; supplements of iron, folate, and Vitamin C; possible iron injections.
• Sickle Cell Anemia:     * Genetic disorder involving abnormal hemoglobin; characterized by "crises."     * Maternal Risks: Decreased renal function, stroke, heart dysfunction, leg ulcers, and sepsis.     * Fetal Risks: Premature birth, Small for Gestational Age (SGA), and inheriting the disease.     * Crisis Management: IV fluids, medications, oxygen, and fetal heart monitoring.

Asthma and Epilepsy

• Asthma:     * Pre-pregnancy severity indicates pregnancy severity.     * One-third of women experience an attack in the second trimester.     * Attack Symptoms: Increased respiratory rate, SOB, expiratory wheeze, retractions, cough, and pulsus paradoxus.     * Status Asthmaticus: A severe attack non-responsive to treatment, leading to hypoxemia and respiratory failure.
• Epilepsy:     * Requires high-dose folic acid prior to and during pregnancy to prevent neural tube defects.     * Screening: High-resolution sonogram and maternal serum alpha-fetoprotein.     * Status Epilepticus: An emergency complication requiring immediate safety measures.     * Nursing Care: Diet high in folic acid; Vitamin K supplements; adequate sleep to maintain the seizure threshold.

Infectious Diseases and TORCH

• Key Terminology:     * Immunoprophylaxis: Prevention via active or passive immunity.     * Vertical Transmission: Mother-to-child transmission via pregnancy, childbirth, or breastfeeding.     * Suppressive Therapy: Management that suppresses but does not cure the virus.     * Viral Load: The amount of virus in the blood.
• The TORCH Acronym:     * T: Toxoplasmosis (caused by Toxoplasma gondii; transmitted via cat feces, raw meat).     * O: Other (Hepatitis B, Syphilis, Varicella, Herpes Zoster).     * R: Rubella (German Measles; can cause congenital anomalies; prevention is the only treatment).     * C: Cytomegalovirus (CMV; transmission via body fluids; can cause hearing loss and microcephaly).     * H: Herpes Simplex Virus (HSV; majority of neonatal cases occur during birth canal exposure; treated with acyclovir).
• General TORCH Characteristics: Teratogenic; can cross the placenta; effects depend on gestational age at exposure.
• Symptom Cluster: IUGR, microcephaly, hepatosplenomegaly, rash, CNS findings, jaundice, hearing defects, and chorioretinitis.
• Specific Infections:     * Hepatitis B: Screen for HBsAg; if positive, neonate needs HBIg and HBV vaccine within $12\text{ hours}$.     * Syphilis: Caused by Treponema pallidum; can cause "snuffles," hepatomegaly, and bone abnormalities in infants.     * Varicella: Highest risk in the second trimester (limb hypoplasia, cataracts).

Sexually Transmitted Infections (STIs) and HIV/AIDS

• Chlamydia: Most common STI in the U.S.; often asymptomatic; most frequent complication is Pelvic Inflammatory Disease (PID).
• Gonorrhea: Caused by Neisseria gonorrhoeae; untreated risks include PID and neonatal ophthalmia neonatorum.
• Human Papillomavirus (HPV): Most common viral STI; causes condylomata acuminata (warts) and cervical cancer.
• Trichomoniasis: Protozoan infection; causes foamy, yellow-green discharge and foul odor; treated with oral metronidazole.
• HIV/AIDS:     * Can transmit during pregnancy, childbirth, or breastfeeding.     * CDC recommends confidential testing for all.     * High-risk patients may face increased domestic violence or homelessness.     * The primary goal is the prevention of perinatal transmission.

Intimate Partner Violence (IPV)

• Dynamics: A goal of abusive behavior to maintain power and control.
• Cycle of Violence:     1. Tension-Building: Batterer is moody and critical; victim attempts to calm/avoid.     2. Explosion: Verbal attacks, physical hitting, choking, use of weapons, rape; victim protects self and children.     3. Honeymoon Phase: Batterer apologizes, brings presents, promises change; victim feels hopeful and resists intervention.
• Prevalence: Estimated $4\%$ to $8\%$ of pregnant women experience abuse.
• Risks: Antepartum hemorrhage, fetal growth restriction, fetal death, and preterm labor.
• Nursing Care: Always screen the woman alone; provide privacy; document objectively and take photos (with consent).

Age-Related Concerns

• Adolescent Pregnancy ($\le 19\text{ years}$):     * Higher risk for preeclampsia and Low Birth Weight (LBW).     * Often delayed prenatal care (third trimester).     * Needs: Nutritional guidance and increased emotional/psychological support; high risk for suicide.
• Pregnancy in Later Life ($>35\text{ years}$):     * Risk Factors: Multiple fetal pregnancies, chromosomal abnormalities (Trisomy 13, 18, 21), and placental abnormalities.     * Greater likelihood of pre-existing chronic conditions.

Questions & Discussion

• Question 1: What is the result of GDM in a normal pregnancy?     * Answer: Mild hyperglycemia after meals.     * Rationale: Normal pregnancy involves lower blood glucose (hypoglycemia) when fasting, higher blood glucose (hyperglycemia) after meals, and increased insulin levels (hyperinsulinemia) after meals.
• Question 2: Which cardiac medication cannot be continued during pregnancy?     * Answer: Warfarin.     * Rationale: It crosses the placenta and causes congenital anomalies.
• Question 3: What is a priority of nursing care for any potential pregnancy complication?     * Answer: Prevention of the complication.
• Question 4: Why is it important to assess for TORCH during pregnancy?     * Answer: They are teratogenic.
• Question 5: Is it true that pregnancy is a vulnerable time for IPV?     * Answer: True. IPV may begin or escalate during pregnancy, especially if unplanned.