High Risk Pregnancy
Card Set Information
High Risk Pregnancy
lccc nursing ob highrisk pregnancy
For Siegmunds Exam 3
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
Excessive alcohol consumption
Intimate Partner violence
High or low BMI
Age <16 or >35 (AMA)
What Preexisting Medical Disorders are Prenatal High-Risk Factors?
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)
Rh or ABO sensitization
What are some prenatal high risk factors during a current pregnancy?
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
What are the possible complications for GDM and Pregestational diabetes?
-hypoglycemia after birth
-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
What are the risks for the newborn with a mother with GDM or pregestational diabetes?
-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
-development of nongestational dm
How is pregestational diabetes treated?
Medical nutritional therapy & exercise
Preconception care with goal of HbA1C <7%
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?
-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
: therapeutic or elective
: 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?
: cervix is closed with slight bleeding
: cervix dilated with cramps and moderate to severe bleeding
: products are completely passed
: heavy bleeding with severe cramps and some tissue passed
: slight bleeding with cramps and cervix closed. products remain inside and fetus dies
: 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 corrective surgery
Previous ectopic pregnancy
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
-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
: BP >140/90 after 20 wks with proteinuria
: HTN before 20 wks and persisting after 6wks PP
: 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
family hst of preeclampsia
preexisting HTN or renal disease
What are the clinical differences between mild and severe preeclampsia?
-Trace to +1 Proteinuria
-Proteinuria 2+ or greater
What is the HELLP syndrome? What risks are involved?
Elevated Liver enzymes
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
: 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
-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?
-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
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)
What is the nursing care for eclampsia?
During a Seizure:
-remain with the woman
-call for help
-notify the health provider
-turn onto side
-have suction available
-tongue blade still recommended but not used
After a Seizure:
-assess maternal and fetal status
-02 @10L via mask
-Ensure IV access with large bore
-Admin Mag Sulf
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
-Low birth weight
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
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
Describe the Herpes Simplex Virus and its treatment
Fetal neonatal risks include mortality of 50-60%, sepsis, and neurological complications
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
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
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
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
Progesterone supplementation for women with history of spontaneous PTL
Contradinications for treatment include
-need to end the pregnancy is higher than keeping the pregnancy
-severe maternal disease
-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
: terbulatine is good for emergencies, but the effects on the cardiac system limit its use
: 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
: Nifedipine cannot be used with mag sulf or it will drop the bp too low
Prostaglandin synthesis inhib
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
Cocaine, methamphetamines use
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?
-hypoxic damage to organs
-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
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
-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
-US for location of placenta
-c-birth unless low lying
What is the nursing care for placenta previa?
Monitor blood loss, pain, uterine contractility
Monitor maternal vital signs
Complete laboratory evaluation
Admin IV Fluid, betamethasone
Describe the difference in clinical manifestations between placenta previa and placenta abruption
bright Red blood
No Pain unless in labor
Uterus is soft
Fetus is often breech
-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