High Risk Preg-Pre-existing(Unit 1) (1)

High Risk Perinatal Care Overview

Pre-existing Conditions

  • Significance of Pregnancy and Chronic Illness: For some women, pregnancy can pose considerable risk as it overlaps with chronic illnesses.

  • Maternal and Fetal Needs: Unique needs arise from both the chronic condition and usual pregnancy-related concerns must be addressed.

Metabolic Disorders

Diabetes Mellitus

  • Commonality: Most prevalent endocrine disorder in pregnancy.

  • Risk Classification: Pregnancy with diabetes is classified as high risk.

  • Management Approach: A multidisciplinary approach is essential for successful management.

  • Key Focus: Maintaining strict maternal glucose control is crucial for optimal outcomes.

  • Pathogenesis: Defined as a group of metabolic diseases marked by hyperglycemia due to defects in insulin secretion or action.

    • Causes include:

      • Impaired insulin secretion

      • Inadequate action of insulin in target tissues

Classification of Diabetes

  • Types:

    • Type 1 diabetes

    • Type 2 diabetes

    • Gestational diabetes mellitus (GDM): Any degree of glucose intolerance recognized during pregnancy.

Pregestational Diabetes Mellitus

  • Characteristics: Affects women with pre-existing diabetes, typically insulin-dependent.

  • Associated Complications: Complications may include vascular disease, retinopathy, or nephropathy. Type 2 is more common.

  • preconception counseling

    • women with pregestational diabetes are counseled before the time of conception to plan the optimal time for pregnancy, establish glycemic control before conception, and diagnose any vascular complications.

    • Counseling should include a discussion of microvascular and macrovascular complications that carry significant risk for maternal morbidity and mortality during pregnancy, such as CAD and renal insufficiency.

    • Contraction is important to talk about because it helps the couple in planning effectively for pregnancy.

    • They should be encouraged to use reliable contraptions until glycemic control is optimal.

Complications of Pregestational Diabetes

Maternal Risks

  • Complications May Include:

    • Macrosomia (large baby): defined as a birth weight of more than 4000 to 4500 g or greater than 90%.

      • They tend to have a disproportionate increase in shoulder, trunk, and chest size. The risk for shoulder dystocia is greater in these babies.

    • Hydramnios (excess amniotic fluid): usually defined as an amniotic fluid index (AFI) greater than 24 cm, frequently develops during the 3rd trimester or pregnancy in women with diabetes.

    • Ketoacidosis occurs most often during the 2nd and 3rd trimesters, when the diabetogenic effects of pregnancy is greatest. when maternal metabolism is stressed by illness or infection, an increased risk for DKA.

    • Hyperglycemia-

    • Hypoglycemia-

Fetal and Neonatal Risks

  • Risks to the fetus include:

    • Sudden, unexplained stillbirth—a constant finding in women with stillbirth is poor glycemic control.

      • hyperglycemia, congenital abnormalities, placental insufficiency or fetal growth restriction, macrosomia or polyhydramnios, or obstructed labor.

    • Congenital malformations affecting various systems: hyperglycemia during the 1st trimester of pregnancy is related to birth defects in infants.

      • Cardiovascular system

      • Central nervous system

      • Skeletal system

    • Other issues lead to significant neonatal morbidity.

    • A1c levels are usually lower in pregnant women

Care Management

Antepartum Care

  • Evaluation Components:

    • Interview and physical examination

    • Laboratory tests for baseline renal function

    • Monitoring glycosylated hemoglobin A.

    • More frequent monitoring is required for these patients.

Care strategies include:

  • Diet and Exercise: Essential for managing blood sugar levels.

  • Insulin Therapy

    • In the 1st trimester, the insulin dose should be reduced by 10% to 25% to avoid hypoglycemia.

    • 2nd trimester and 3rd trimester, because of insulin resistance, the dose must be increased significantly to maintain target glucose levels. Insulin requirements peak at 36 weeks of gestation and then drop significantly after that time. Sliding scale

    • Delivery the BG is checked hourly

  • Blood Glucose Monitoring

    • target levels of BG during pregnancy are lower.

  • Fetal Surveillance

    • the goals of fetal surveillance include monitoring fetal well-being and detecting any signs of distress, which can help guide management decisions throughout the pregnancy.

Intrapartum and Postpartum Care

  • Intrapartum Care: Close monitoring during labor; consideration for cesarean delivery if complications arise.

    • Women with pregestational diabetes must be monitored closely to prevent complications related to dehydration hypoglycemia, and hyperglycemia.

  • Postpartum Care: Insulin needs typically decrease significantly; encouraging breastfeeding is beneficial for mother and child.


Gestational Diabetes Mellitus (GDM)

  • Risks and Management: Maternal-fetal risks associated with GDM and the need for a comprehensive care plan throughout the antepartum and postpartum phases.

    • As with pregestational diabetes, infants born to women with GDM are at risk for macrosomia and associated risks for birth trauma and electrolyte imbalances, including neonatal hypoglycemia.

  • Screening Procedures: Details on oral glucose tolerance tests (OGTT) for diagnosis.

    • Both the ADA and ACOG recommended that women with high-risk factors for type 2 diabetes be tested for preexisting diabetes at their initial prenatal visit, one of the methods used to diagnose diabetes in the nonpregnant.

  • GDM is usually diagnosed during the 2nd and 3rd trimesters of pregnancy.

  • Insulin therapy- metformin and glyburide are both used for blood glucose control in women in GDM.

  • fetal surveillance-

  • intrapartum

    • During the labor and birth process, blood glucose is monitored hourly to maintain levels at 80 to 110 mg/dl.

    • Infusing a rapid-acting insulin IV may be necessary during labor to maintain the desired blood glucose levels.

  • postpartum care

    • Kids born to women with GDM are at risk for future health-related complications because they may develop obesity and type 2 diabetes later in life.

    • recommended assessing all women who had GDM for carbohydrate intolerance with a 75-g, 2-hour OGTT or fasting plasma glucose level at 4 to 12 weeks postpartum.

    • Women with a history of GDM should engage in lifestyle modification, including weight reduction and increased physical activity, which can significantly decrease their risk for developing type 2 diabetes in the future.

    • Encourage breastfeeding

    • Contraception no birth control with a lot of hormones

Maternal Phenylketonuria (PKU)

  • Definition: A metabolic disorder leading to the accumulation of phenylalanine (PAH), which harms brain development.

    • toxic accumulation of phenylalanine in blood interferes with brian development and function

  • Prevention Focus: Identify women with this disorder early, especially before conception. Breastfeeding contraindicated.

Cardiovascular Disorders During Pregnancy

  • Changes in Cardiovascular Function:

    • Increased intravascular volume and changes in systemic vascular resistance.

    • Increased cardiac output during labor; notable changes occur postpartum.

    • Higher incidence of miscarriage, preterm labor, growth restriction, and congenital heart issues in offspring.

    • preterm labor and birth are more prevalent

    • Intrauterine growth restriction is the more common

    • incidence of congenital heart lesions increased in children of mothers with congenital heart diseases.

Classification of Cardiovascular Disease

  • Class 1: asymptomatic without limitation of physical activity

  • class 2: symptomatic with slight limitation of activity

  • class 3: symptomatic with marked limitation of activity

  • class 4: symptomatic with inability to carry on any physical activity without discomfort.

    • Assessment was taken at 3 and again at 7-8 months gestation due to the potential progression of the condition.

Heart Transplantation and Pregnancy

  • Pregnancy after Heart Transplant: A growing number of heart transplant recipients are successfully seeing pregnancies. Pre-conception assessment is crucial.

  • signs and symptoms of cardiac decompensation

    • subjective symtoms

      • increasing fatigue or difficulty breathing, or both, with her usual activities

      • feeling of smothering

      • frequent cough

      • palpitations; feeling that her heart is “racing”

      • generalized edema: swelling of face, feet, legs, fingers

    • objective signs

      • irregular, weak, rapid pulse (>100 beats/min)

      • progressive, generalized edema

      • crackles at the base of the lungs after 2 inspirations and exhalations that don’t clear after coughing

      • orthopnea; increasing dyspnea

      • rapid respiration (> 25 breaths/min)

      • moist, frequent cough

      • cyanosis of the lips and nail bed

    • bed rest

    • nutrition counseling

      • pregnant women need a diet with iron and folic acid supplementation, high protein levels, and adequate calories to gain weight

      • iron supplements can cause constipation so stool softeners and an increase in fluids and fiber are recommended

    • cardiac meds

      • anticoagulant therapy prescribed for: recurrent venous thrombosis, pulmonary embolus, RHD, prosthetics valves, or cyanotic congenital heart defects

      • teaching about self-admin of heparin or low-molecular-weight heparin

      • women taking warfarin ( coumadin) require specific nutritional teaching about avoiding foods high in vitamin K.

Additional Medical Disorders in Pregnancy

Pulmonary Disorders

  • Cystic Fibrosis: complications arise from chronic hypoxia and frequent infections impacting maternal and infant health.

    • with severe disease, pregnancy is often complicated by chronic hypoxia and frequent pulmonary infections

    • exocrine glands produce excessive viscous secretions

    • problems with the respiratory and digestive system

Substance Abuse

Overview

  • Definition: Continued use of substances despite related problems across various life areas.

  • Treatment Barriers: Fear of custody loss, and criminal prosecution leads to treatment reluctance; under 10% of pregnant women receive treatment.

Care Management Strategies**

  • Contraindications: Breastfeeding is not recommended for mothers using harmful substances (e.g., amphetamines, alcohol).

  • Care Difficulties: Substance abusers present unique challenges during intrapartum and postpartum care.

Management Prior to Discharge

  • Assessment: Ensuring home safety and support systems are in place before infant discharge. Possible referral to child protective services if infant well-being is compromised.