High Risk Pregnancy
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What is the definition of a high risk pregnancy?
One in which the life of health of the mother or fetus is jeopardized by a disorder or condition coincidental with or unique to pregnancy
What social-personal aspects are Prenatal high-risk factors?
- Low income level
- Low educational level
- Poor diet
- Excessive alcohol consumption
- Intimate Partner violence
- High or low BMI
- Age <16 or >35 (AMA)
- Substance Abuse
What Preexisting Medical Disorders are Prenatal High-Risk Factors?
- Diabetes Mellitus
- Cardiovascular disease such as cardiac (due to increased blood volume), hypertension (poor perfusion to placenta), and Thromboembolic Disease (due to increase of fibrinogen during pregnancy)
- Anemia (Decreased iron means not enough 02 to baby)
- Thyroid Disorder (baby increases metabolism)
- Renal disease (Decreased perfusion)
What aspects of a previous Pregnancy are prenatal High Risks?
- habitual/recurrent abortion (3+x)
- cesarean section
- Rh or ABO sensitization
What are some prenatal high risk factors during a current pregnancy?
- Grandmultiparity >5
- Twin Gestation
- Metabolic problem
- Endocrine problem
- Blood Incompatibilities
- Trauma/Substance Abuse
- Prelabor complications
- Placental Abnormalities
How does pregnancy effect glucose metabolism?
- Insulin resistance increased by insulin antagonists growth hormone and cortisol secretion (produced due to estrogen, progesterone, and placental hormones)
- Human Placental Lactogen (hPL) affects fatty acids & glucose metabolism, promotes lipolysis, decreases glucose uptake
- Insulinase secretion by placenta which facilitates metabolism of insulin
How does pregnancy influence existing diabetes?
- Physiologic changes of pregnancy alter insulin requirements
- Accelerates progress of vascular disease
- More difficult to control in pregnancy
- Primary concern is control of blood glucose levels
- Higher risk of complications
What maternal risk factors increase the chance for gestational DM?
- History of macrosomia (>8lb baby)
- Strong family history of DM
- 50% of women diagnosed with GDM have no risk factors
What is the screening for GDM?
- Done at 24-28 wks gestation
- Non-fasting 1 hr (50gram) glucose tolerance: 130-140 mg/dL is positive and will need a follow up 3hr GTT
- 3 hr (100G) GTT: if levels are elevated 2x, GDM
- Elevated levels:
- -fasting >95 mg/dL
- -1 hr >180 mg/dL
- -2 hr >155 mg/dL
- -3 hr >140 mg/dL
What are the possible complications for GDM and Pregestational diabetes?
- -hypoglycemia after birth
- -shoulder dystocia
- -congenital defects r/t maternal hyperglycemia during organogenesis
- -Macrosomia r/t fetal hyperinsulinemia
- -Hypocalcemia and hypomagnesium
- -IUGR r/t poor perfusion
- -Asphyxia r/t fetal hyperglycemia
- -RDS r/t delayed delayed lung maturity
- -Birth injury r/t macrosomia
- -Still birth
- -Sacral agenesis
What are the risks for the newborn with a mother with GDM or pregestational diabetes?
- -HTN disorders/preeclampsia
- -Preterm labor
- -Spontaneous abortion
- -polyhydramnios (r/t fetal anomalies, fetal hyperglycemia)
- -Oligohydramnios (r/t placental profusion)
- -Exacerbation of chronic diabetes related conditions
- -Infection r/t hyperglycemia
- -Induction of labor
- -Cesarean birth
- -development of nongestational dm
How is pregestational diabetes treated?
- Medical nutritional therapy & exercise
- Preconception care with goal of HbA1C <7%
- Multidisciplinary approach
- Insulin needs of Type 1 will increase over the pregnancy
- Timing of the delivery to decrease the chance of macrosomia, birth trauma, and decreased placental perfusion
How is GDM treated?
- Medical nutritional therapy and exercise
- 40% may need insulin
- Oral hypoglycemia medication (metformin or glyburide)
- Cesarean birth recommended for infants >4500grams (macrosomia)
- Monitor for type 2 dm after birth
What is Hyperemesis Gravidarum and what are the s/s??
- Disabling nausea & vomiting that leads to dehydration, electrolyte & acid base imbalance, starvation ketosis, and weight loss
- The cause is unclear, but the theory is that H.pylori or ambivalence towards the pregnancy can contribute
- S/S include prolong, severe, and frequent vomiting, weight loss, acetonuria, ketosis, and s/s of dehydration
How is Hyperemesis gravidarum treated?
- First line medications are B6 and B6/doxylamine combination
- IV hydration with possible electrolytes and vitamins added
- Antienemics such as Antihistamine H1 receptor blockers, phenothiazines, benzamides
- Hospitalization may be necessary
- TPN if other interventions do not allow for nutrition long term
- Emotional support is very important!!
What could cause bleeding during pregnancy?
- -sexual relations
- -cervical or vaginal lesions
- -implantations of the pregnancy
- -threatened or impending abortion
- ***All bleeding must be assessed because it is never normal during a pregnancy
What are the different types of abortion?
- Defined as the termination of pregnancy before fetus reaches 20 wks or 500 grams
- Induced: therapeutic or elective
- Spontaneous (miscarriage): early (up to 12 wks r/t chromosomal abnormalities or placental insufficiency) or late (12-20 wks gestation)
What are the different types of spontaneous abortion?
- Threatened: cervix is closed with slight bleeding
- Inevitable: cervix dilated with cramps and moderate to severe bleeding
- Complete: products are completely passed
- Incomplete: heavy bleeding with severe cramps and some tissue passed
- Missed: slight bleeding with cramps and cervix closed. products remain inside and fetus dies
- Habitual/Recurrent: any spontaneous abortion occurring 3x or more
What nursing care should be done for a woman/family suffering from a spontaneous abortion?
- Assess amount an appearance of any vaginal bleeding
- Monitor woman's vital signs and degree of discomfort
- Use discretion if looking for FHT as this is controversial
- Assess the need for Rhogam
- Assess response and coping of the woman and her family
- Disposition of products of conception by following policies and supporting the family in their decision
What is an ectopic pregnancy and what are the s/s?
- Pregnancy with implantation outside of the uterus, 95% in the fallopian tube
- Other sites include the ovary, cervix, and abdomen
- S/S Before Rupture: pelvic & abdominal pain, abnormal bleeding, vital signs stable
- S/S after rupture: severe lower abdominal or pelvic pain, vertigo/syncope, vital signs indicate hypovolemia, pain in the neck or the shoulder
What are the risk factors for an ectopic pregnancy?
- Tubal damage
- Tubal corrective surgery
- Tubal sterilization
- Previous ectopic pregnancy
- Assisted reproduction
- Abdominal adhesions
What treatment is done for an ectopic pregnancy?
- Must first differentiate from other disorders thru careful assessment of menstrual history, ultrasound, and early diagnosis to prevent rupture
- Methotrexte terminates pregnancies by stopping rapid cell production
- Surgery to preserve the fallopian tube
What is gestational trophoblastic disease and what are the s/s?
- Molar or Nonmolar
- Results from a positive pregnancy
- There is a proliferation of the placenta with early embryo death causing tumor formation which appears as grape like clusters
- The pregnancy is always nonviable
- -rapid uterine growth
- -severe n/v
- -early preeclampsia
- -high hcg levels
- -red or brown vaginal bleeding
- -passage from vagina of grapelike clusters
- -absence of fht
- -looks like snow globe on US
What is the treatment for Gestational Trophoblastic disease?
- Suction evacuation and curettage of uterus early to decrease complications
- Rhogam if mom is Rh-
- Careful follow up for 6mo as its a high risk for choriocarcinoma
- Serial hcgs to detect cancer
- If hcgs rise, methotrexate only or combo therapy
What are the four types of HTN during pregnancy?
- Gestational Hypertension (GH):BP >140/90 after 20wks with BP returning to normal after 6 wks. No Proteinuria
- Preeclampsia: BP >140/90 after 20 wks with proteinuria
- Chronic HTN: HTN before 20 wks and persisting after 6wks PP
- Preeclampsia: with superimposed chronic hypertension
What is preeclampsia? When does it progress to eclampsia?
- A HTN, multisystem disorder or pregnancy
- A syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation
- Affects both the mother and the fetus
- Increase in BP after 20wks with proteinuria
- Onset of s/s might not occur until after birth
- Pathology is unclear, but the key features involve the uterine spiral arteries
What are the risk factors for preeclampsia?
- Age <19 or >35 y/o
- Multiple gestation
- family hst of preeclampsia
- preexisting HTN or renal disease
What are the clinical differences between mild and severe preeclampsia?
- -Systolic 140-160
- -Diastolic <100
- -Trace to +1 Proteinuria
- -Systolic >160
- -Diastolic 110+
- -Proteinuria 2+ or greater
What is the HELLP syndrome? What risks are involved?
- Elevated Liver enzymes
- Low Platelets
- HIGH RISK FOR DIC
- Risk for woman: abruption, renal failure, liver hematoma and possible rupture, death
- Risk for fetus: preterm birth, death
- **The only treatment is immediate delivery (avoid spinal and epidural anesthesia due to low platelets)
Describe Eclampsia and the warning signs
- ONSET OF SEIZURES
- May be triggered by: cerebral vasospasm, cerebral hemorrhage, cerebral ischemia, cerebral edema
- Warning signs: severe and persistent headache, epigastric pain, n/v, hyperreflexia/clonus, restlessness
What is the treatment for preeclampsia?
- Outpatient treatment for mild preeclampsia:
- -frequent office visits
- -activity restriction
- -antenatal testing (frequent NST and kick counts)
- Hospitalization for severe preeclampsia:
- -first line drugs
- ---Hydralazine (apresoline) is a vasodilator causes rapid BP drop, risking perfusion to uterus
- ---Methyldopa (aldomet) has a slow onset of several days
- ---Labetalol is a beta blocker
- -second line drugs
- ---Nifedapine is a calcium channel blocker
What is the treatment for Eclampsia?
- The main goal is to stop seizures thru CNS depression (keep seizure precautions on board to prevent harm and aspiration)
- MAGNESIUM SULFATE reduces seizures by depressing CNS
- Calcium gluconate is the antidote
- Monitor for depressed dtr for toxicity or hypertonia as a sign of impending seizure
- Monitor resp status
- *birth is the only cure, but this can also occur PP
What are the risks to both the mother and the baby concerning preeclampsia and eclampsia?
- -cerebral edema/hermorrhage/stroke
- -Pulmonary edema
- hepatic failture
- -renal failure
- -abruptio palcenta
- -Low Birth Weight
- -fetal Intolerance to labor r/t decreased placental perfusion
What is the nursing care for preeclampsia?
- Accurate assessments to monitor for worsening of the disease
- BP assessed while in sitting position as side lying gives false BP
- Admin Medications
- Assess for CNS changes like HA, visual changes, or clonus of dtr
- Assess lung sounds for s/s of pulmonary edema
- Assess for proteinuria (24 hr urine is gold standard)
- Daily weights for edema
- Assess for epigastric pain (liver)
- Quiet Environment
- Emotional Support
- Patient Education
- Fetal Assessment: NST
What is the nursing care for eclampsia?
- During a Seizure:
- -remain with the woman
- -call for help
- -notify the health provider
- -maintain airway
- -turn onto side
- -have suction available
- -tongue blade still recommended but not used
- After a Seizure:
- -assess maternal and fetal status
- -assess airway
- -02 @10L via mask
- -Ensure IV access with large bore
- -Admin Mag Sulf
- -Quiet Environment
- -Schedule delivery
What is the difference between a fetal infection early in the pregnancy and later in the pregnancy?
- During the embryonic period there is greater chance of miscarriage or anomalies
- Infection later in the pregnancy can lead to growth restriction and neurologic disturbances
What is a Group B Streptococcus infection, how is it dx, and how is it tx?
- Can occur in the either the urogenital system or the lower gastrointestinal tract
- Leading cause of neotnatal sepsis and mortality
- Mom has no symptoms as this is normal flora
- Screen done on vag secretions at 35-37 wks
- Antibiotic treatment (penicillin or ampicillin) give as prophylaxis at onset of labor (ideally 2 bags prior to birth)
- If GBS is found in urine, it is treated during pregnancy
- If GBS status is unknown at labor or if not enough antbx are instilled, fetal cbc is taken at birth and the baby is monitored
How can HIV transmission from mother to fetus be decreased?
- HIV can be transmitted through the placenta, through breast milk, and during labor and delivery
- Rate of transmission can be decreased through maternal prophylactic antiretroviral therapy, an elective c-birth prior to rupture of membranes, and the avoidance of BF
How can an STI impact a fetus during pregnancy?
- STI can pass to fetus during pregnancy
- STI can pass to infant during birth
- -Preterm birth
- -Low birth weight
- -Neonatal sepsis
- -Neurological damage
What are the TORCH infections?
- Other (hep B)
Describe toxoplasmosis and its treatment
- Caused by the protozoan Toxoplasma gondrii
- Can be transmitted thru the domestic cats feces and is innocuous in the healthy adult
- Pregnant women should avoid cleaning the litter box, gardening without gloves, and eating raw meat
- High risk of abortion and severe damage in first trimester, although transmission rates are lower in the first trimester
- Treatment after the first trimester includes suldadiazone and pymethamine
Describe Hep B and its treatment
- Infants have a 90% chance of becoming chronically infected
- Admin hep B immunoglobin within 12 hrs from birth if exposed
- Admin first Hep B vaccine within 24 hrs from birth for all infants
Describe Rubella and its treatment
- A mild illness in children and adults, but poses high fetal-neonatal risks
- The first trimester has the greatest risk for deafness,eye defects, CNS anomalies, and severe cardiac malformations
- Mental retardation
- Congenital rubella syndrome
Describe Cytomegalovirus and its treatment
- Belongs to herpes simplex virus (HSV) group
- No treatment for maternal cytomegalovirus (MCV)
- Low birth weight for fetus
- hearing impairment
- CNS abnormalities
Describe the Herpes Simplex Virus and its treatment
- Fetal neonatal risks include mortality of 50-60%, sepsis, and neurological complications
- No Cure
- Acyclovir to suppress outbreak (mom)
- C-birth recommended to avoid infant exposure
What is Rh incompatibility and how is it treated?
- Maternal and fetal blood should not mix, but there may be leaks if there is damage to the placenta
- If mother is Rh- and baby is Rh+,mother can be sensitized to produce antibodies to the fetal RBCs
- These antibodies pass through the placenta and harm the baby
- Rhogam is given at 28 weeks and then within 72 hrs of delivery
- Rhogam also given for abdom trauma, amniocentesis, or abortion
- No treatment after sensitization occurs
What is ABO Incompatibility and how is it treated?
- Most common incompatibility of blood type
- Mother O while baby is A or B
- Maternal serum antibodies cross the placenta leading to hemolysis of fetal RBCs
- Not treated antepartally
- Affects neonates with mild anemia and hyperbilirubinemia
What are some common forms of trauma during pregnancy?
- MVA are the most common cause of blunt force injury
- Penetrating injury is most commonly r/t gunshot wounds
- Fetal outcome is dependent on the injury and maternal physiological response
- Blunt trauma to abdomen can cause placental abruption and uterine rupture
- Maternal conditions takes precedence over fetal condition for maternal compromise and resuscitation, which in turn effects the fetal outome
What are some s/s of intimate partner violence?
- Repeated non-specific complaints
- Overuse of the health care system
- Hesitancy embarrassment, or evasiveness in relating history of injury
- Time lag between injury and presentation of care
- Untreated serious injuries
- Overly solicitous partner
- Breasts and abdomen are targets f assault during pregnancy
- Presence of bruises at various stages of healing
What questions should you ask? What are the ABCDES of patient care?
- 1.Within the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone?
- 2. Since you have been pregnant have you been hit, slapped, kicked, or otherwise physically hurt by someone?
- 3.Within the last year, has anyone forced you to have sexual activities?
- Alone (she is not alone)
- Belief (you believe her)
- Confidentiality (explain mandatory reporting)
- Safety (most dangerous when she tries to leave)
What are some common forms of substance abuse during pregnancy? What is the risk for mother and for fetus?
- Tobacco (SGA, abruption)
- Alcohol (fetal alcohol system)
- Illicit drugs (preterm, abruption, previa, meconium staining)
- Risks for women: preterm labor, premature preterm rupture, poor weight gain and nutritional status, placental abnormalities, previa, abruption
- Risks for fetus/newborn: stillbirth, low birth weight, preterm birth, IUGR, neonatal withdrawal syndrome, SIDs
What is Ewings screening tool for substance abuse during pregnancy? What other medical assessments can be done?
- Ewings 4 Ps:
- -Pregnancy- have you ever used drugs or alcohol during this pregnancy?
- Past- have you had a problem with drugs or alcohol in the past?
- Partner- dos our partner have a problem with drugs or alcohol?
- Parents- do you consider one of your parents to have a problem with drugs or alcohol
- -screen all pregnant women
- -refer to multispeciality clinics
- -refer to drug treatment program
- -screen for IPV
- -conduct frequent urine toxicity tests
- -ultrasounds to rule out congential anomolies
- -Antepartal testing
What is an insufficient or incompetent cervix and what is the treatment?
- Painless cervical dilation without contractions
- Medical treatment includes cervical ultrasound for funneling, cervical cultures for infections and antibiotics
- Surgical treatment is a cerclage
- 12-16 wks prophylactically if hist of unexplained recurrent painless cervical dilation and miscarriage
- Up to 24 weeks if cervical dilation withno uterine contractions
- This will not stop labor and the cerclage must be removed if labor or infection occurs
- ABSOLUTELY NO INTERCOURSE
What is PROM?
Premature rupture of membranes (spontaneous) before labor onset (labor to be induced)
What are the maternal and fetal risks for PROM?
- Prematuraity of the neonate
- neonatal sepsis
How is PROM diagnosed and treated?
- Nitrazine testing of fluide
- Sterile speculum exam for pooling
- Microscopic examination of ferning on slide
- Treated by balancing therisk of prematurity with the risk of infection
- Prolong pregnancy as long as possible unless close to term
- Corticosteroids (2 doses of betamathasone 24hrs apart is ideal) to decrease risk of RDS and increase lung function
- Prophylactic antibiotics
- Tocolytic use is controversial but appears to improve outcomes in an attempt to get a 48hr window for betamethasone
What are the warning signs of Preterm labor?
- Decreased count kicks
- Increased in number of contractions (regular contractions)
- Low backache, cramping, pelvic pressure
- Increased vaginal discharge
- Fever higher than 100.4
- Something doesn't feel right
What is preterm labor, who is at risk, and how is it detected?
- PTL occurs between 20-38 completed weeks of pregnancy
- Regular uterine contractions with ROM and/or cervical changes
- Risks include a previous PTL, although 50% have no risks
- Detected with US for funneling (if thickness 30 mm, PTL excluded. If <20mm, strong predictor of PTL)
- Testing for Fetal Fibronectin
How is Preterm Labor treated?
- Best rest is not effective and risks DVTs
- Tocolytic medications
- IV hydration
- Progesterone supplementation for women with history of spontaneous PTL
- Contradinications for treatment include
- -need to end the pregnancy is higher than keeping the pregnancy
- -active hemorrhage
- -severe maternal disease
- -fetal compromise
- -fetal death
- -ROM prior to 24 wks
What are tocolytics and which ones are used for PTL?
- Tocolytics attempt to stop labor
- may delay labor for 2-7 days with the hope of creating enough time for betamethasone and GBS treatment
- Beta-adrenergic Agonists: terbulatine is good for emergencies, but the effects on the cardiac system limit its use
- magnesium Sulfate: watch for resp depression and decreased DTR. POssible neuroprotective effects to reduce incidence of cerebral palsy
- Therapeutic range for mag sul is 5-8 mg/dL
- CCB: Nifedipine cannot be used with mag sulf or it will drop the bp too low
- Prostaglandin synthesis inhib: Indomethacin
What is Hydramnios/Polyhydramnios?
- Chronic or acute
- Amount of fluid >1500-2000mL
- increased incidence of chromosomal, GI, cardiac, and neural tube disorders
- Risk of prolapsed cord
- Diagnosed by ultrasound and fundal height measurements
What is Oligohydramnios?
- Less than a normal of amniotic fluid
- <500ml at eterm, or a 50% reduction
- Associated with prematurity, IUGR secondary to placental insufficiency, fetal renal malformation
- Effects the first part of pregnancy by fetal skin and skeletal abnormalities r/t impaired movement
- During labor and birth it is a risk for cord compression (variable decels)
What is abruptio Placentae and what are the risk factors?
- Premature separation of the placenta from the uterine wall
- Previous abruption
- abdominal trauma
- Cocaine, methamphetamines use
- Uterine anomalies
What are the different types and classifications of Abruptio Placentae?
- -Marginal- edges detach with mild bleeding
- -central- concealed hemorrhage
- -Mild- marginal with bleeding Grade 1
- -Moderate- central with bleeding grade 2
- -Severe-complete with grade 3 bleeding
What are the maternal and fetal risks for Abruptio placentae?
- Maternal risks:
- -hemorrhagic shock
- -hypoxic damage to organs
- -postpartum hemorrhage
- Fetal-neonatal risks:
- -complications from preterm birth
- -hypoxia, neurological injury
What is the Clinical therapy for abruptio placentae?
- Evaluate for s/s of DIC with fibrinogen lebels, platelet counts, and PT and PTT
- Maintain cardiovascular status of mom with IV support
- Continue EFM
- Kleihauer Betke test indicates presence of fetal RBCs in moms blood after damage to placenta
- Rh Neg women need to have Rhogam
- Vaginal birth can be achieved with a mild separation if monitored very closely
- Moderate and severe abruptions need c-birth after hypofibrinogenemia is treated
What is placenta previa and what are the risk factors?
- Placenta is improperly implanted into the lower uterus when it should be on the posterior fundus
- Villi are torn from the uterine wall when the cervix dilates and the placenta may block the cervical opening
- Risk factors:
- -previous previa
- -previous c-birth
- -DM, HTN
- -uterine anomalies
- -large placenta/multiple gestation
What are the classifications of Placenta previa and what assessment findings can you expect?
- Total placenta previa- covers cervical opening and requires c-birth
- Partial Placental Previa- partially covers cervical opening and requires c-birth
- Marginal Placenta Previa- edge near cervix but may be able to delivery
- Low lying Placenta- attached to side of uterine wall and does not cover cervical opening. May be able to deliver vaginally
- -painless, red vaginal bleeding
- -fetal malposition
- -US for location of placenta
- -c-birth unless low lying
What is the nursing care for placenta previa?
- Monitor blood loss, pain, uterine contractility
- Evaluate FHR/FHT
- Monitor maternal vital signs
- Complete laboratory evaluation
- Admin IV Fluid, betamethasone
- Rhogam avail
Describe the difference in clinical manifestations between placenta previa and placenta abruption
- Quiet onset
- bright Red blood
- No Pain unless in labor
- Uterus is soft
- Fetus is often breech
- -Abrupt onset
- -Dark red blood if present
- -Severe and steady pain
- -Firm, board-like uterus
- -Fetus is in the vertex position
Describe hypovolemia in the pregnant or laboring woman
- A life threatening condition requiring whole blood
- Emergency c-birth with living fetus
- vaginal birth is preferable if fetus is stillborn
- IV Fluids, central venous pressure monitoring
- Monitor I/O and labs
- Code Crimson is an interdisciplinary approach that can be called in advance if a problem is expected or suspected
What is placenta accreta?
Placenta has implanted past the endometrium and into the myometrium (uterine muscle). placenta can even implant past the uterus into the abdominal cavity
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