Nursing Care During High-Risk Pregnancy

1. Nursing Care During High-Risk Pregnancy

2. Complications of Pregnancy • A high-risk pregnancy is one in which the life or health of the mother or infant is jeopardized by a disorder coincidental with or unique to pregnancy. • Perinatologist • Risk Factors: • Genetic considerations • Medical & obstetrical d.o. • Nutrition • Teratogens: Smoking, Alcohol, Drugs, Caffeine • Environmental considerations • Age extremes • Lack of prenatal care • Multiple gestation

3. Complications of Pregnancy • Hyperemesis Gravidarum • Etiology • Vomiting during pregnancy that becomes excessive to cause electrolyte, metabolic, and nutritional imbalances • Exact cause unknown; possibly hormones (HCG) or psychogenic factors • Clinical Manifestations • Vomiting and retching that far exceed those seen with the usual morning sickness

4. Complications of Pregnancy • Hyperemesis Gravidarum (continued) • Assessment • Frequency, amount, and character of emesis • Fluid intake and output (I&O) • Skin turgor and mucous membranes • Psychosocial assessment • Fetal status • Daily weight

5. Complications of Pregnancy • Hyperemesis Gravidarum (continued) • Medical Management • Intravenous fluids • Solid intake is restricted until vomiting stops. • Bland solids such as toast and crackers are introduced slowly. • In severe cases, TPN may be required. • Small frequent meals • Liquids between meals

6. Complications of Pregnancy • Hyperemesis Gravidarum (continued) • Nursing Interventions and Patient Teaching • Oral hygiene • Emotional support • Patient teaching • Provide dietary consult. • Educate patient regarding condition. • Teach patient how to assist with her treatment. • Provide referrals for follow-up treatment.

7. Complications of Pregnancy • Multifetal Pregnancy • Etiology • Twins are classified as monozygotic (originate from one fertilized ovum) Maternal/identical. Or diazygotic Fraternal(two separate ova fertilized at the same time). • Pathophysiology • Maternal and fetal risks are increased during multiple pregnancy. • Because of over distention of the uterus, twins usually are delivered before term and may have extended hospital stays. • Most delivered by C-section

8. Figure 28-1 (From Hamilton, P.M. [1989]. Basic maternity nursing. [6th ed.]. St. Louis: Mosby.) Multiple pregnancies. A, Identical twins. B, Fraternal twins.

9. Complications of Pregnancy • Hydatidiform Mole (Molar Pregnancy) • A gestational trophoblastic disease • May be complete mole or partial mole • Etiology • Unknown, although an ovular defect possible • Women at higher risk are those who have undergone ovulation stimulation with clomiphene and those who are in their early teens or older than 40 years.

10. Complications of Pregnancy • Hydatidiform Mole (Molar Pregnancy) (continued) • Pathophysiology • Placental villi abnormally increase & develop vesicles. • The fluid-filled vesicles grow rapidly, causing the uterus to be larger than expected. • Usually there is no fetus, placenta, amniotic membranes, or fluid.

11. Complications of Pregnancy • Ectopic Pregnancy • Etiology • Implantation occurs somewhere other than within the uterus. • Most common site is within the fallopian tube; other possible sites are the abdominal cavity, ovary, ligaments, and cervix. • The progress of the fertilized ovum through the fallopian tube is slowed or obstructed.

12. Figure 28-2 (From Wong D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.) Sites of implantation of ectopic pregnancies in order of frequency of occurrence.

13. Complications of Pregnancy • Ectopic Pregnancy (continued) • Pathophysiology • Rupture of the fallopian tube and bleeding into the abdominal cavity • Clinical Manifestations • Slight vaginal bleeding • Signs of peritoneal irritation: sharp, localized, one-sided pain or pain referred to the shoulder • Abdomen may be rigid and tender.

14. Complications of Pregnancy • Ectopic Pregnancy (continued) • Medical Management • Rapid surgical treatment: salpingectomy or salpingostomy • Blood replacement • Methotrexate administration for unruptured ectopic pregnancy

15. Complications of Pregnancy • Spontaneous Abortion/Miscarriage • Etiology • Termination of pregnancy before the age of viability • May be caused by abnormal embryonic development, chromosomal defects, inheritable disorders, advancing maternal age and parity, chronic infections, chronic debilitating diseases, poor nutrition, and recreational drug use

16. Complications of Pregnancy • Spontaneous Abortion (continued) • Clinical Manifestations • Threatened: bleeding and cramping • Inevitable: bleeding increases and cervix dilates • Complete: all products of conception expelled • Incomplete: some, but not all, products of conception are expelled • Missed: fetus dies and growth ceases, but fetus remains in utero • Septic: malodorous bleeding, fever, and cramping • Habitual: spontaneously aborted in three or more consecutive pregnancies

17. Complications of Pregnancy • Spontaneous Abortion (continued) • Medical Management • IV fluids may be administered. • Replacement of blood loss • Dilation and curettage (D&C) • Dilation and evacuation (D&E) • Patient Teaching • Need for rest • Iron supplementation, if blood loss occurred • Psych support:HEAL program • Rhogam if RH neg

18. Complications of Pregnancy • Incompetent Cervix • Passive and painless dilation of the cervix during the first and second trimester • Treat with Prophylactic cerclage • Use suture material to constrict the internal os of the cervix • Placed @ 10-14 weeks gestation • Refrain from sexual intercourse, prolonged standing, or heavy lifting • If removed for delivery, must be replaced with subsequent pregnancies

19. Figure 28-4 (From Wong D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.) A, Cerclage correction, recurrent premature dilation of cervix. B, Cross section, closed internal os.

20. Bleeding Disorders • Placenta Previa • Etiology • Placenta implants in the lower uterine segment. • Described by the degree to which the placenta covers the internal cervical os. • Marginal • Partial • Total • Also Low implantation • Most important risk factor = previous cesarean birth

21. Figure 28-5 (From Wong D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.) Types of placenta previa. A, Complete (total). B, Incomplete (partial). C, Marginal (low lying).

22. Bleeding Disorders • Placenta Previa (continued) • Pathophysiology • In the last trimester of pregnancy, uterine size increases and the cervix begins to dilate and efface. • As the placenta separates from the cervix, sinuses at the site begin to bleed. • Clinical Manifestations • Painless, bright-red, vaginal bleeding occurs. • Bleeding may be intermittent or occurs in gushes.

23. Bleeding Disorders • Placenta Previa (continued) • Medical Management • Vaginal exam attempted only if ready for birth • Cesarean birth is usually the treatment of choice.

24. Bleeding Disorders • Abruptio Placentae • Etiology • This is premature separation of the normally implanted placenta from the uterine wall. • It generally occurs late in pregnancy, frequently during labor. • Cause is unknown. • Predisposing factors include trauma, chronic hypertension, and pregnancy-induced hypertension, drug use. • Blunt external abdominal trauma may also be a cause.

25. Bleeding Disorders • Abruptio Placentae (continued) • Pathophysiology • When the placenta separates from the uterine wall, bleeding occurs from the uterine sinuses. • The most common classification of placental abruption is according to type and severity. • Grade I, grade II, or grade III • Clinical Manifestations • Sudden, severe pain is accompanied by uterine rigidity.

26. Medical Complications of Pregnancy • Pregnancy-Induced Hypertension (PIH) • Etiology • A disease encountered during pregnancy or early in the puerperium • Classic S&S • HTN • Edema • Proteinuria • Includes preeclampsia and eclampsia • Increased risk for PIH if have multiple pregnancy, diabetes mellitus, or family history of PIH

27. Medical Complications of Pregnancy • Pregnancy-Induced Hypertension (continued) • Pathophysiology • Complex hormonal and vascular changes occur. • These lead to increased blood pressure, decreased placental perfusion, decreased renal perfusion, altered glomerular filtration rate, and fluid and electrolyte imbalance. • Clinical Manifestations • Edema, hypertension, and proteinuria

28. Medical (contd) • Pregnancy-Induced Hypertension (continued) • Assessment • Blood pressure • Weight • Edema: scale of 1+ to 4+ • Urine tested for albumin

29. Medical (contd) • Pregnancy-Induced Hypertension (continued) • Medical Management • May or may not need to be hospitalized • Bedrest; lateral recumbent position • Well-balanced diet with adequate protein • IV therapy for emergency situations • Magnesium sulfate to prevent seizures • Sedatives and antihypertensives

30. Medical (contd) • Pregnancy-Induced Hypertension (continued) • Nursing Interventions • Assess for headache, edema, and blurred vision. • Monitor I&O; indwelling catheter may be necessary. • Monitor fetal heart rate; fetal monitor may be needed. • Perform kick count • Monitor daily weight. • Enforce bedrest. • Provide emotional support. • DTR’s, Vitals, resp >12 • Mag levels: want between 4-7 mg/dl for therapeutic

31. Medical (contd) • Pregnancy-Induced Hypertension (continued) • Patient Teaching • Educate on danger signs of complications of pregnancy. • Stress the importance of regular medical supervision. • Encourage high-quality protein, vitamin, and mineral intake.

32. Complications Related to Existing Medical Conditions • Gestational Diabetes • Pathophysiology Gestational diabetes mellitus is characterized by an inability to produce sufficient insulin to maintain normal glucose levels during pregnancy. • Clinical Manifestations • Alteration in blood glucose levels; above 120 mg/dl significantly increases the risk of complications • Polyuria, polydipsia, and polyphagia

33. Complications Related to Existing Medical Conditions • Gestational Diabetes (continued) • Assessment • Urine testing should be done at all prenatal visits. • Presence of glucose indicates need for further testing. • Stress diet, activity, and medication compliance. • Assess for vascular system complications. • Diagnostic Tests • Blood glucose levels; glucose tolerance tests • Glycosylated hemoglobin • Tests to evaluate fetal well-being

34. Complications Related to Existing Medical Conditions • Diabetes Mellitus (continued) • Nursing Interventions • Assess the patient carefully at each visit. • Complete all blood glucose level evaluations. • Report any abnormalities to the physician. • Patient Teaching • Diet, medication, and health practices • Necessity of good control of the disease • Medications • Insulin – preferred drug; doesn’t cross placenta • Oral hypoglycemics – potential terratogenic effects • May consider Glyburide

35. Complications Related to the Cardiovascular System • Pregnancy increases demands on the cardiovascular system. • The normal, healthy heart is able to adapt to the increased demands. • Women who have preexisting cardiac disease face increased risk when cardiac function is challenged by pregnancy.

36. Complications Related to the Cardiovascular System • Etiology • Most common problems result from rheumatic heart disease, congenital heart defects, or mitral valve prolapse.

37. Complications Related to the Cardiovascular System • Pathophysiology • Increased blood volume, heart rate, and cardiac output overstress the cardiac muscle, valves, and vessels. • Symptoms of the underlying pathologic condition are exacerbated, resulting in cardiac decompensation, congestive heart failure, and other medical problems.

38. Concerns of drug therapy: • Oral anticoagulants • Beta blockers • Thiazide diuretics • ACE Inhibitors

39. Anemias during pregnancy: Iron deficiency anemia Folic acid deficiency anemia Sickle cell anemia Thalassemia

40. TORCH INFECTIONS • TOXOPLASMOSIS • OTHER • HEPATITIS A • HEPATITIS B • HIV/AIDS • GROUP B STREPTOCOCCUS • STD’S • UTI • RUBELLA • CYTOMEGALOVIRUS • HERPESVIRUS

41. Complications Related to Age • Adolescents • Growth and Development • Developmental tasks of adolescence must be accomplished before the child can become a mature adult. • Pregnancy interrupts work on identity formation and developmental tasks. • There several physiological concerns with the pregnant adolescent • Increased risk for PIH, cephalopelvic disproportion, abruptio plancentae, low birth weight, IUGR, anemia, infection, preterm delivery, and perinatal death

42. Complications Related to Age • Adolescents (continued) • Assessment • Encourage early and continued prenatal care. • Refer the adolescent for appropriate social support services. • Nursing Interventions • Labor and birth • Support of a knowledgeable coach is necessary. • Teach about relaxation, ambulation, side-lying, and comfort measures.

43. Complications Related to Age • Nursing Interventions • Postpartum Care • Explicit directions for self-care and infant care are required. • Assess new mother’s parenting abilities. • Postpartum contraception is a high priority. • Provide emotional support if contemplating adoption. • Adolescent Father • Needs support to discuss emotional responses • May have feelings of guilt, powerlessness, or bravado

44. Complications Related to Age • Older Pregnant Woman • Women who have their first child after they are 35 years old have an increased risk of maternal and fetal complications. • As women maintain better overall health and fitness, increased age appears to be less of an impediment to a normal pregnancy. • Psychosocial adjustment to parenthood at this time of life depends greatly on the individual and her particular situation.

45. Complications during labor: • Dysfunctional labor = abnormal labor • Dystocia = difficult labor • Hypertonic labor dysfunction: • Occurs during latent phase; frequent, poorly-coord., cramp-like contractions; painful & nonproductive • Treatment – mild sedation; uterine relaxant (tocolytic) • Provide comfort measures; promote rest & relaxation • Hypotonic labor dysfunction: • Weak, ineffective contractions; begin normally then diminish • Treatment – amniotomy, oxytocics, IVF • Provide emotional support; keep notified of progress; position Δ

46. Complications during labor: • Precipitate birth: completed in < 3 hrs.; may be no healthcare provider present • Premature Rupture of Membranes (PROM): spontaneous ROM @ term @ least 1 hr. before contractions begin • Preterm Premature ROM (PPROM): ROM before term with or without uterine contractions • Prolonged Pregnancy: lasts > 42 wks

47. Preterm Labor: • After 20 wks. & before 38 wks. Gestation • Main risks = problems of immaturity in newborn • Risk factors: • Age extremes • Chronic illness • Previous preterm labor • Previous pregnancy loss • Uterine or cervical abnormalities • Multifetal pregnancy • Chronic stress • Substance abuse

48. Preterm Labor: • Diagnosed based on cervical effacement & dilation of more than 2 cm. • Medical treatment = Uterine relaxants (tocolytic therapy) • Goal = stop uterine contractions & keep fetus in utero until lungs are mature enough to adapt to extrauterine life • DRUG OF CHOICE = MAGNESIUM SULFATE

49. Preterm Labor: • Initial measures to stop preterm labor: • Restrict activity • Hydration • Identify & treat any infections • Improving fetal lung maturity: • Give steroid injection to mother :Betamethasone • Thyroid releasing hormone • Give fetus surfactant after birth

50. Complications during labor Prolapsed Umbilical Cord: • Cord slips down into pelvis after ROM • Can be compressed between fetal head & woman’s pelvis - ↓ fetal blood supply • Treatment: • Displace fetus upward – trendelenburg, side-lying with hips elevated • Fetus may be held upward by hand • Oxygen • Tocolytic drugs • Deliver by quickest means – usually C-section