HIGH RISK OBSTETRICS

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HIGH RISK OBSTETRICS

• NUR 202
• Mary Starkey Wallace

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High Risk Obstetrics

• A pregnancy in which the life or health of the
  mother or fetus is jeopardized by a disorder
  coincidental with or unique to pregnancy

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High Risk Obstetrics

• High Risk status for the mother extends through
  the puerperium
• (6 weeks after childbirth)

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High Risk Obstetrics

• Postbirth maternal complications
• are usually resolved within one month of birth,
  but.
• Perinatal morbidity may continue for months or
  years

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High Risk Obstetrics

• Advances in management of disorders that affect
  pregnant women have resulted in a significant
  decrease in maternal mortality and morbidity rates

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High Risk Obstetrics

• In the United States maternal mortality and
  morbidity rates remained the same for several
  years
• In 1980-1998 the rate remained at
• 7- 8 per 100,000 pregnancies

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High Risk Obstetrics (cont)

• In 2000 rate increased to 9.8 but
• Increase attributed to change in reporting rather
  than an actual increase

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High Risk Obstetrics

• Poses a problem for modern medical and nursing
  care
• Emphasis on quality of life and wanted child
• Reduced family size and number of unwanted
  pregnancies

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High Risk Obstetrics

• Today emphasis on safe birth of normal infants
  who can reach their potential
• Birth of a neonate who does not meet cultural,
  societal, or family norms and expectations many
  times results from high risk pregnancy

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High Risk Obstetrics

• Three leading causes of maternal mortality have
  remained unchanged over last 50 years
• They are
• 1) pregnancy induced hypertension
• 2) pulmonary embolism
• 3) hemorrhage

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High Risk Obstetrics

• Factors strongly related to maternal death
• -age (younger than 20 and 35 or older)
• - lack of prenatal care
• -low educational attainment
• -unmarried status
• -nonwhite race

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High Risk Obstetrics

• Ongoing research needed to identify
• extent that
• -financial -sociocultural
• -behavioral -educational
• factors affect perinatal morbidity and mortality

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Induction of Labor

• Considered when ending the pregnancy
• -benefits woman or fetus
• -when labor and vaginal birth
• considered safe

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Contraindications to Induction

• Any Contraindications to labor and vaginal birth
  such as
• -placenta previa (hemorrhage during labor)
• -vasa previa (umbilical cord vessels
  branch over amniotic sac
• rather than inserting into placenta
• fetal hemorrhage possibility

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Contraindications to Induction(cont)

• -transverse fetal lie
• -umbilical cord prolapse (immediate delivery
  by cesarean indicated)
• -classic uterine incision
• -extensive surgery for fibroids

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Induction of Labor

• Prior to induction assessment must indicate
• -fetal maturity
• -cervical readiness

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Induction of Labor

• Fetal maturity best determined by
• -early ultrasounds
• -accurate menstrual dating
• -amniotic fluid studies
• (L S Ratio 21)

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Induction of Labor

• Cervical Readiness best evaluated by cervical
  exam
• Bishop scoring system evaluates cervical
  readiness for labor

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Bishop Scoring System

• Uses 5 factors to estimate cervical
• readiness for labor
• -dilation
• -effacement
• -fetal station
• -cervical consistency
• -cervical position

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Bishop Scoring System (cont)

• Each factor is assigned a score of 0, 1, 2, or 3
  according to specific criteria for each score
• The numbers are then totaled for the composite
  score
• Multipara usually has successful induction when
  score is 5 or higher
• Primipara usually has successful induction if
  score is 7 or higher

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Bishop System of Cervical Scoring

• Assessment score Dilation Effacement Fetal
  Consistency Position Position
• (cm) () station
• 0 0 0-30 -3 Firm Poster
• 1 1-2 40-50 -2 Medium Mid
• 2 3-4 60-70 -1 Soft Anter
• 3 5-6 80 1,2, -- --

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Bishop System of Cervical Scoring

• NOTE Add the score for each of the clinical
  assessments
• If the total score is greater than 8, the
  success of induction approaches that of
  spontaneous labor.

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Cervical Ripening

• Cervix has to be ripe or soft prior to induction
  to make it likely to dilate with forces of
  labor
• Cervical ripening is done most frequently the
  day before the morning of induction

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Cervical Ripening(cont)

• Consists of effacement and softening of the
  cervix
• May be used at or near term to enhance success of
  and reduce time needed for labor induction when
  continuing pregnancy is undesirable
• May hasten beginning of labor or shorten course
  of labor

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Cervical Ripening(cont)

• Prostaglandlin should be used cautiously
• in the presence of the following -asthma
• -glaucoma
• -ischemic heart disease
• -pulmonary disease
• -hepatic disease
• -renal disease

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Absolute Contraindications toCervical Ripening

• Placenta or vasa previa
• Transverse fetal lie
• Prolapsed umbilical cord
• Prior classic uterine incision or myomectomy that
  entered the uterine cavity
• Pelvic structural abnormality
• Active genital herpes infection
• Invasive cervical cancer

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Relative Contraindications to Cervical Ripening

• Abnormal fetal heart rate patterns
• Breech presentation
• Maternal heart disease
• Multifetal pregnancy
• Polyhydramnios
• Presenting part above the pelvic inlet
• Severe maternal hypertension

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Cervical Ripening(cont)

• Prostaglandin Agents used for cervical ripening
• -dinoprostone (Prepidil, Cervidil)
• -misoprostol (Cytotec)

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Cervical Ripening(cont)

• Dinoprostone (such as Cervidil or Prepidil Gel)
  can be inserted as a suppository into the vagina
  (intravaginally).
• It can also be given as a gel that is gently
  squirted into the opening of the cervix
  (intracervically

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Cervical Ripening(cont)

• Dinoprostone should be administered with the
  patient in or near a labor and delivery suite
• The patient is expected to remain recumbent for
  the first 30 minutes and should be monitored for
  a further 30 to 120 minutes
• When contractions occur, they usually appear
  within 60 minutes and peak within four hours

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Cervical Ripening(cont)

• The optimal interval for administering another
  dose has not been determined
• Six hours is commonly used
• The gel should be kept refrigerated and brought
  to room temperature immediately before use
• The manufacturer recommends that no more than
  three doses be administered per 24 hours

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Cervical Ripening(cont)

• Misoprostol (Cytotec) is a pill taken by mouth or
  placed in the vagina (using a smaller dose)
• It is a medication currently approved for
  treating ulcers
• Using it for cervical ripening is a widely
  accepted but unlabeled use of this medication

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Cervical Ripening(cont)

• (Misoprostol) Cytotec is an effective, safe and
  inexpensive agent for cervical ripening and labor
  induction
• Prepidil and Cervidil cost 150 and 175 per
  insert, respectively, whereas a 100-µg Cytotec
  tablet costs 0.60.

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Cervical Ripening(cont)

• Misoprostol is a synthetic analog of PGE1.
• When given orally it is rapidly absorbed by the
  gastrointestinal tract and undergoes
  de-esterification to its free acid
• This state is responsible for its clinical
  activity
• The total systemic bioavailability of vaginally
  administered misoprostol is three times greater
  than that of orally administered misoprostol

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Cervical Ripening(cont)

• Dose is one-quarter of 100 mcg (25 mcg) tablet
  vaginally
• A 100 mcg tablet not scored
• Hospital pharmacy should prepare the 25 mcg
• dose for greater accuracy

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Cervical Ripening(cont)

• Maternal outcomes such as the need for cesarean
  delivery because of FHR abnormalities, the arrest
  of labor or the need for tocolytic
  administration, are not significantly different
  between misoprostol and dinoprostone.

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Cervical RipeningMechanical

• MECHANICAL MODALITIES
• All mechanical modalities share a similar
  mechanism of actionnamely, some form of local
  pressure that stimulates the release of
  prostaglandins
• The risks associated with these methods include
  infection (endometritis and neonatal sepsis have
  been associated with natural osmotic dilators),
  bleeding, membrane rupture, and placental
  disruption.

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Cervical RipeningMechanical (cont)

• Hygroscopic dilators absorb endocervical and
  local tissue fluids, causing the device to expand
  within the endocervix and providing controlled
  mechanical pressure
• The products available include natural osmotic
  dilators (e.g., Laminaria) and synthetic osmotic
  dilators (e.g.,Lamicel)
• The main advantages of using hygroscopic dilators
• include outpatient placement and no
  FHR-monitoring
• requirements.

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Cervical RipeningMechanical (cont)

• Balloon devices provide mechanical pressure
  directly on the cervix as the balloon is filled
• A Foley catheter (26 Fr) or specifically designed
  balloon device can be used

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Cervical RipeningSurgical

• SURGICAL METHODS
• Stripping of the Membranes. Stripping of the
  membranes causes an increase in the activity of
  phospholipase A2 and prostaglandin F2 (PGF2) as
  well as causing mechanical
• dilation of the cervix, which releases
  prostaglandins.

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Stripping of Membranes

• Gloved finger inserted into internal os and
  rotating 360 degrees twice separating amniotic
  membranes lying against lower uterine segment
• Does not require monitoring or other assessments
  - Often done as outpatient service
• May not induce labor - if labor is initiated, it
  typically begins within 48 hours
• May cause bleeding

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Amniotomy

• A pelvic examination is performed to evaluate the
  cervix and
• station of the presenting part
• The fetal heart rate is recorded before and after
  the procedure.
• The presenting part should be well applied to the
  cervix

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Amniotomy (cont)

• A cervical hook is inserted through the cervical
  os by sliding it along the hand and fingers (hook
  side toward the hand)
• The membranes are scratched or hooked to effect
  rupture
• The nature of the amniotic fluid is recorded
  (clear, bloody, thick or thin, meconium)

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Amniotomy (cont)

• Amniotomy increases the production of, or causes
  a release of, prostaglandins locally
• Risks associated with this procedure include
  umbilical cord prolapse or compression, maternal
  or neonatal infection, FHR deceleration, bleeding
  from placenta previa
• or low-lying placenta, and possible fetal
  injury.

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Pitocin Infusion

• Usually effective at producing contractions - may
  cause hyperstimulation of the uterus
• Requires small, precise dosage (infusion pump)
• Maximum rate and dosing interval based on
  facility protocol, clinician order, individual
  situation, and maternal-fetal response

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Pitocin Infusion (cont)

• Palpating uterus essential, unless IUPC in place
• May initially decrease blood pressure

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Pitocin (cont)

• Oxytocin increases intracellular calcium levels,
  stimulating contractions in myometrial smooth
  muscle
• Oxytocin is the preferred pharmacologic agent
  for inducing labor when the cervix is ripe

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Pitocin Infusion (cont)

• Commonly used Guidelines for Oxytocin
  Administration from American College of
  Obstetricians and Gynecologists are as follows
• Dilute 10-20 Units in 1000 ml of balanced
  isotonic solution as piggyback per IV pump

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Pitocin Infusion (cont)

• After adequate contraction pattern established
• Cervix dilated to 5 to 6 cms
• Oxytocin may be reduced by increments similar for
  induction

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Pitocin Infusion (cont)

• Uterus more sensitive to Oxytocin as labor
  progresses
• Due to increased sensitivity Pitocin
  administration titrated to uterine and fetal
  response

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Labor Augmentation

• When labor augmented with Pitocin
• a lower total dose is usually needed to achieve
  an adequate contraction
• pattern

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Pregnancy Induced Hypertension(PIH)

• Classification
• Preeclampsia
• Eclampsia
• Gestational Hypertension
• Chronic Hypertension

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Pregnancy Induced Hypertension(PIH)

• Preeclampsia
• -Systolic blood pressure 140 mm Hg
• -Diastolic blood Pressure 90 mm Hg
• -Occurring after 20 weeks gestation
• -Accompanied by proteinuria
• 0.3 g in 24 hour specimen
• 1 with random dipstick

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Pregnancy Induced Hypertension(PIH)

• Formally edema considered classical sign
• Presently edema considered nonspecific
• Now know that edema occurs in many
• pregnancies not accompanied by
• hypertension

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Pregnancy Induced Hypertension(PIH)

• Eclampsia
• Preeclampsia progresses to true eclampsia when
  patient has seizure
• Seizure is generalized tonic-clonic and cannot
  be attributed to any other cause
• PIH may occur postpartum

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Pregnancy Induced Hypertension(PIH)

• Only known cure for preeclampsia
• or eclampsia is delivery of fetus

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Pregnancy Induced Hypertension(PIH)

• Gestational Hypertension
• -Blood Pressure elevation (140/90 mm Hg) after
  20 weeks gestation
• -No proteinuria
• May have trace on random dipstick
• without significance to this category

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Pregnancy Induced Hypertension(PIH)

• Chronic Hypertension
• Blood Pressure 140/90 mm Hg
• known before pregnancy

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Pregnancy Induced Hypertension(PIH)

• Textbook addresses
• -Preeclampsia superimposed on
• chronic hypertension
• -Proteinuria lt0.3 g in 24 hour specimen
• in woman with chronic hypertension

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Pregnancy Induced Hypertension(PIH)

• Preeclampsia superimposed on chronic hypertension
  (cont)
• -When proteinuria before 20 weeks gestation
  preeclampsia suspected if sudden increase from
  baseline
• -Sudden increase in previously well controlled
  blood pressure

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Pregnancy Induced Hypertension(PIH)

• Preeclampsia superimposed on chronic hypertension
  (cont)
• -platelets lt100,000/mm³
• -abnormal elevations of liver enzymes
• (AST or ALT)

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Risk Factors for PIH

• First pregnancy
• Young primigravida
• Older than 35 years
• African-American
• Positive family history
• Chronic hypertension
• Renal Disease

• Diabetes
• Multifetal Pregnancy
• Autoimmune
• Disorders
• Father previously
• fathered pregnancy in another female
  complicated by PIH

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Pathology of PIH

• Loss of normal vasodilation capability
• Increased levels of vasoconstrictors (partially
  produced by placenta)
• Decreased levels of vasodilators
• Concurrent vasospasm
• BP begins to rise after 20 weeks gestation

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Pathology of PIH(cont)

• Prostacyclin is potent vasodilator and inhibits
  platelet aggregation (clumping)
• More thromboxane A² than prostacyclin
• results in vasoconstriction
• Increase of potent vasoconstrictor and platelet
  aggregate thromboxane A² over prostacyclin

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Pathophysiology of Preeclampsia
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Clinical Manifestations

• Hyperreflexia and headache
• Seizures, renal failure and abruptio placentae
• Disseminated intravascular coagulation (DIC)
• Ruptured liver and pulmonary embolism

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Clinical Manifestations (cont)

• Altered mental function (headache, confusion) and
  hyperreflexia caused by altered cerebral
  perfusion 2º arterial vasospasms
• Visual disturbances (spots, blurred, double
  vision) indicate arterial spasms and edema in
  retina
• Decreased urinary output results from decreased
  renal perfusion

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Clinical Manifestations (cont)

• Decreased renal perfusion results in tissue
  necrosis with proteinuria
• Decreased perfusion to liver leads to
• hepatic edema and subcapsular hemorrhage with
  epigastric pain
• Decreased placental perfusion results in infarcts
  that increase risk for abruptio placentae and DIC

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Diagnostic Testing

• Remember
• Classic signs of Preeclampsia
• -hypertension first
• -proteinuria

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Measurement of Blood Pressure

• Blood Pressure Measurement should be
  uniform
• Woman seated, arm supported, cuff appropriate
  size for arm
• Diastolic Blood Pressure recorded at
• Korotkoff phase V (disappearance of
• sound)

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Measurement of Blood Pressure

• Hospitalization may be necessary for
• serial observations of blood pressure
• Serial checks differentiates true blood pressure
  elevation from those induced by anxiety

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Diagnosis

• Mild preeclampsia
• BP 140/90 mm Hg or higher
• 1 proteinuria may occur
• Liver enzymes may be elevated minimally
• Edema may be present

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Diagnosis

• Severe preeclampsia
• BP 160/110 mm Hg or higher
• measurements, 6 hours apart
• Proteinuria 5 g in 24 hour specimen
• (3 or higher on random dipstick
• Oliguria
• Visual Distrubances

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Diagnosis

• Vascular constriction and narrowing of small
  arteries when retina examined
• Elevated Liver Enzyme Studies (ALT and AST)
• Proteinuria with Clean Catch Urine Specimen

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Diagnosis

• Deep tendon reflexes very brisk
• (Hyperreflexia)
• Decreased platelets (Impaired coagulation)
• Increased hematocrit (fluid shift to interstitial
  spaces)

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Diagnosis

• Generalized edema often occurs and may be severe
• Fluid retention measured by rapid weight gain
• Facial edema may be subtle but is pathological
• Edema about lower extremities expected in healthy
  pregnancy

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ASSESSMENT OF PITTING EDEMA
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ASSESSMENT OF EDEMA

• Minimal edema of lower extremities 1
• Marked edema of lower extremities 2
• Edema of extremities, face, hands, and
• sacral area 3
• Generalized massive edema that indicates ascites
  (accumulation of fluid in peritoneal cavity) 4

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Diagnosis

• NOTE
• Pulmonary edema more common in women with massive
  edema from any cause (includes preeclampsia/eclamp
  sia)
• Edema may not be present in preeclampsia

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Nutritional Considerations

• Diet
• High-protein, moderate-sodium
• for severe preeclampsia
• Regular diet without salt or fluid restriction
  usually prescribed
• Diet appropriate for hypertension and
• diabetes prescribed for women who also have
  these disorders

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Nutritional Considerations

• High protein intake ( blood osmolarity, reduce
  movement of vascular fluid into interstitial
  space)
• Diet should be well balanced
• Do not eliminate sodium. Do avoid high salt
• Avoid alcohol and smoking
• Drink 8-10 (8 oz) glasses water/day
• Eat foods with roughage

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Treatment

• Initial evaluation of severity done in hospital
• May be managed at home if preeclampsia -mild
• -woman and fetus stable
• -woman can adhere to treatment plan
• -woman can return for frequent visits

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Home vs Hospital Care

• Home care of mild preeclampsia
• Client monitors her blood pressure
• Measures weight and tests urine protein daily
• Remote NSTs performed daily or bi-weekly
• Advised to report signs of worsening preeclampsia
• Hospital care of mild preeclampsia
• Bed rest and moderate to high protein diet
• Fetal evaluation

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Home Care

• Need to stop working
• Activity Restrictions
• Bed rest minimum of 1 ½ hours per day
• in a side-lying position

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Home Care

• Woman keeps record of fetal movements
• called kick count
• Woman should report decrease in fetal movements
  or no movement felt in 4
• hour period

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Home Care

• Blood pressure assessments 2-4 times per day
• Family and patient taught to assess blood
  pressure in same arm, same position, with
  appropriate size cuff
• Family taught to use electronic blood pressure
  equipment

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Home Care

• Daily weights at
• -same time
• -similar clothing
• -same scales

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Home Care

• Urine dipstick for protein daily
• First voided specimen
• Physician may request more frequent testing

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Home Care

• Sonography for fetal growth and quality of
  amniotic fluid or as part of biophysical profile
  
• If less than 34 weeks and delivery considered,
  amniocentesis done to evaluate pulmonary
  maturity (L/S Ratio)

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Hospital Care

• Severe Preclampsia
• Goals
• -prevent convulsions
• -maintain pregnancy until safe to deliver
  fetus

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Hospital Care

• Bedrest
• Quiet environment with reduced external stimuli
  (lights, noise, visitors)
• Reduced external stimuli to prevent convulsions
• Magnesium Sulfate administration IV as
• anticonvulsant
• Apresoline antihypertensive agent of choice

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Intrapartum Care

• Most seizures occur during labor and the
  postpartum period
• Monitor continuously for signs of seizures
• Maintain side lying position
• Narcotic analgesics or epidural analgesia used to
  control seizure precipitating pain

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Intrapartum Care

• Induction of labor by IV oxytocin if condition
  deteriorates
• Vaginal birth delivery method of choice
• Oxytocin to stimulate labor and magnesium sulfate
  to prevent convulsions
• Both administered IV as two secondary infusions

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Intrapartum Care

• Continuous electronic fetal monitoring
• identifies fetal heart rate patterns suggestive
  of fetal compromise
• Pediatrician, neonatologist, or neonatal nurse
• practitioner must be available to care for
  newborn

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MAGNESIUM SULFATE

• Loading Dose 4-6 Gms in 100 ml fluid IV
• over 15-20 minutes
• Maintenance dose 40 Gms in 1000 ml
• Ringers Lactate IV via infusion pump at
• 2 g per hour
• Maintain serum magnesium level of 4-8 mg/dl

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MAGNESIUM SULFATE

• Assess for MAGNESIUM TOXICITY
• Respirations lt 12/MIN
• Maternal Oximeter reading lt than 95
• Hyporeflexia or absent DTR (patella)
• Urinary Output 30 ml/hr
• Toxic serum level 8 mg/dL
• Fetal Distress or drop in fetal HR
• Significant drop in maternal pulse or BP

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MAGNESIUM TOXICITY

• ADMINISTER CALCIUM GLUCONATE OR CALCIUM CHLORIDE
  1g IV OVER
• THREE MINUTE INTERVAL OR AS ORDERED

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ASSESSING REFLEXES
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Deep Tendon Reflex Scale

• 0 Reflex absent
• 1 Reflex present, hypoactive
• 2 Normal Reflex
• 3 Brisker than average reflex
• 4 Hyperactive reflex
• clonus may also be present

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Assessing Reflexes

• Assessing Clonus
• -Flex lower extremity at knee over
• examiner's arm
• -Dorsiflex foot to stretch tendon
• -Hold flexion at knee
• -Rapid rhythmic tapping motions of the
  foot indicates clonus (hyperreflexia)

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To elicit clonus, with the knee flexed and the
leg supported, sharply dorsiflex the foot, hold
it momentarily, and then release it. Normally the
foot returns to its usual position of plantar
flexion. Clonus is present if the foot jerks or
taps against the examiners hand. If so, the
number of taps or beats of clonus is recorded.


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Assessment of Edema

• Characteristics Grade
• Minimal edema of lower extremities 1
• Marked edema of lower extremities. 2
• Edema of lower extremities, face, hands, and
• sacral area.. 3
• Generalized massive edema that includes
• ascites (accumulation of fluid in peritoneal
• cavity). 4

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Eclampsia

• Diuretic Furosemide (Lasix)
• (to treat pulmonary edema)
• Anticonvulsant Bolus of magnesium sulfate
• Inotropic Drug Digitalis (for circulatory
  failure)
• Strict monitoring of intake and output
• (Urinary output ?30ml/hr suspect renal failure)

105
Eclampsia

• Nursing care
• Monitor vital signs and auscultate lungs
• Evaluate fetal heart rate patterns
• Monitor urinary output and urine protein hourly
• Check specific gravity of the urine hourly
• Weigh the woman daily at the same time
• Assess deep tendon reflexes and clonus

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Eclampsia

• Stimulates uterine irritability
• Monitor closely for signs of labor
• Monitor closely for signs of Abruptio
• Placentae

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Interventions for Seizures

• Protecting the woman and fetus
• Remain with the woman
• During the tonic phase, turn the woman on her
  side
• Note the time and sequence of the convulsion

108
Interventions for Seizures (contd)

• After the seizure, insert an airway
• Suction the woman's mouth and nose
• Administer oxygen
• Observe fetal monitor patterns for signs of
  hypoxia

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Post Seizure Care

• Keep on side while unresponsive
• Raise padded siderails
• Deliver when vital signs stabilized
• Anticipate orders for chest x-ray and arterial
• blood gas analysis after initial stabilization
• (aspiration leading cause of maternal
  morbidity and mortality after seizure)

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Nursing Process

• Formulation of nursing diagnoses
• Set goals and outcome criteria
• Implement specific nursing interventions
• Interventions are aimed at meeting goals
• Evaluation of nursing interventions

111
Nursing Process

• Priority Nursing Diagnosis
• Deficient fluid volume
• Risk for injury
• Anxiety

112
Nursing Process

• Evaluation
• -client does not experience eclampsia or
  HELLP syndrome
• -client delivers a healthy mature infant
  without further complications

113
HELLP Syndrome

• Laboratory diagnostic variant of severe
  preeclampsia involves hepatic dysfunction,
  characterized by
• Hemolysis (H)
• Elevated liver enzymes (EL)
• Low platelets (LP)

114
HELLP Syndrome

• Platelet count must be less than 100,000/mm³
• Fibrin split products present
• A LABORATORY NOT CLINICAL DIAGNOSIS

115
HELLP Syndrome

• Although variant of severe preeclampsia
• hypertension may be absent
• May occur during postpartum period
• Risk for hemorrhage, pulmonary edema and hepatic
  rupture

116
HELLP Syndrome

• Hemolysis results from erythrocyte changes as
  they pass through damaged blood vessels
• Liver enzyme elevations results from decreased
  hepatic blood flow
• Low platelet levels results from platelets
  aggregating at sites of vascular damage

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HELLP Syndrome

• NOTE
• -Avoid traumatizing liver by abdominal
• palpation
• -Sudden ? in intraabdominal pressure
• potential for rupture of subcapsular hematoma
  resulting in internal bleeding and hypovolemic
  shock

118
HELLP SyndromeClinical Manifestaions

• Pain
• -upper right quadrant
• -lower chest
• -epigastric pain
• Tenderness over liver
• Nausea and vomiting
• Severe edema

119
HELLP Syndrome

• Diagnostic Testing and Medical Management same as
  that appropriate for preeclampsia or eclampsia
• Manage in facility with full intensive care
• Life-threatening condition

120
Cardiac Disease

• Hemodynamic changes of pregnancy increases the
  workload of the heart
• Cardiac output increases up to 50
• Plasma volume increases by 50

121
Cardiovascular Disease

• Cardiovascular changes of pregnancy
• Plasma volume increases gradually
• Plasma volume peeks at 50 greater than
  nonpregnant level between 28 and 32 weeks
  gestation

122
Cardiovascular Disease

• Cardiovascular changes of pregnancy
• ?Increase in erythrocytes also contributes to
• peek plasma volume
• ?Total erythrocyte count increases
• -by about 30 in women who receive iron
  -by only about 18 in women who
  do not

123
Cardiovascular Disease

• Cardiovascular changes of pregnancy
• Plasma volume increase (50) is greater than
  erythrocyte increase (30)
• Since plasma volume increase is greater than
• erythrocyte increase
• Hematocrit decreases slightly resulting in
• Physiologic Anemia of Pregnancy

124
Cardiovascular Disease

• Cardiovascular changes of pregnancy
• Blood flow increases to organ systems with
  increased workload (uterus and kidneys)
• ? Results in increased cardiac output in early
  pregnancy
• Cardiac Output remains elevated throughout
  pregnancy

125
Cardiovascular Disease

• Cardiovascular changes of pregnancy
• Enlarging uterus puts pressure on pelvic and
  femoral vessels
• -impedes return blood flow causing stasis of
  blood in lower extremities
• -stasis predisposes to postural hypotension
• -dependant edema
• -hemorrhoids (vulva, extremities, rectum)

126
Incidence Risk Factors for Cardiovascular
Disease

• ? Compromised heart
• -inadequate cardiac capacity
• -decreased reserves
• Compromised heart may not be
• able to adapt to added requirements
• of pregnancy
• ? Cardiac decompensation congestive heart
  failure (CHF) can result

127
Incidence Risk Factors for Cardiovascular
Disease

• Successful treatment
• - congenital cardiac anomalies
• - mitral stenosis (resulting from
• rheumatic heart disease)
• allows many females to reach childbearing age
  and bear children

128
Incidence Risk Factors for Cardiovascular
Disease

• (cont)
• Rheumatic heart disease not endemic to United
  States may be found in recent immigrants
• Hypertensive heart disease due to obesity
  increasing in childbearing population
• Cardiomyopathy due to disorder of muscle
  structure may have several causes

129
Incidence Risk Factors for Cardiovascular
Disease

• (Cont)
• CHF
• -may be 2º to underlying heart disease or
  damage
• -may occur 2º to treatment for other
  conditions

130
Cardiovascular Disease

• Maternal congenital heart defects that have been
  effectively treated seen more and more during
  pregnancy
• This population is reaching adulthood

131
Cardiovascular Disease

• There are decreasing numbers of pregnant women
  with heart damage from rheumatic fever
• Streptococcal infections now effectively treated

132
New York Heart Classification of Heart Disease

• Class I uncompromized no limitation on
  activity
• Class II slightly compromised ordinary
  activity causes fatigue
• Class III marked limitation of physical
  activity less than ordinary activity causes
  excessive fatigue

133
New York Heart Classification of Heart Disease
(cont)

• Class IV inability to perform any activity
  without discomfort
• symptoms of cardiac insufficiency
  even at rest
• Generally Classes I and II can tolerate pregnancy
  with close supervision
• Classes III and IV have great difficulty
• with pregnancy

134
Recognition of Heart Disease

• Early recognition important
• Specific signs and symptoms
• -dyspnea
• -paroxysmal nocturnal dyspnea
• -hemoptysis
• -syncope with exertion
• -chest pain with exertion

135
Recognition of Heart Disease

• Additional Signs that confirm diagnosis
• -heart murmur
• -loud harsh systolic murmur associated
  with a thrill
• -cardiac enlargement
• -serious dysrhythmias

136
Diagnosis

• Made from.
• -clinical signs and symptoms
• -physical exam
• Confirmed by
• -chest x-ray
• -EKF
• -echocardiogram

137
Congenital Heart Disease

• Left to right shunting
• -atrial and ventricular septal defects
• -patent ductus arteriosus
• Right to left shunting
• -cyanotic heart defect (tetralogy of Fallot)
• - patent ductus arteriosus (when pulmonary
  vascular resistance exceeds peripheral
  vascular resistance (pulmonary hypertension)

138
Congenital Heart Disease

• Anomalies with left-to-right shunt

139
Atrial Septal Defect

• Defect causes left-to-right shunt because
  pressure is higher in left side of heart than in
  right side of heart
• Pregnancy well tolerated with no complications
• Bacterial endocarditis rare
• Prophylactic antibiotics not required
• Not associated with heart failure

140
Ventricular Septal Defect

• Usually detected and corrected before females
  reach childbearing age
• Mostly asymptomatic
• Occasionally fatigue or symptoms of pulmonary
  congestion occur
• The smaller the defect the better pregnancy will
  be tolerated

141
Ventricular Septal Defect

• (cont)
• Bacterial Endocarditis common with unrepaired
  defect
• Antibacterial prophylaxis is used
• If heart failure or dsyrhythmias occur
• managed as in nonpregnant patient

142
Patent Ductus Arteriosus

• Communicating shunt between pulmonary artery and
  aorta
• Usually discovered and treated in early childhood
• If patent ductus small may be well tolerated
  during pregnancy unless complicated by pulmonary
  hypertension
• Bacterial endocarditis common treat with
  antibiotics

143
Congenital Heart Disease

• Anomalies with right-to-left shunt

144
Tetralogy of Fallot

• Primary cause of right-to-left shunting
• Combination of four defects
• -ventricular septal defect
• - pulmonary valve stenosis
• -right ventricupatlar hypertrophy
• -displacement of aorta (overrides part of
  right ventricle

145
Tetralogy of Fallot

• (cont)
• If untreated will have the following
  symptoms.(obvious symptoms of heart disease)
• -cyanosis
• -clubbing of the fingers
• -inability to tolerate activity
• If defect repaired and no reappearance of
  cyanosis, may do well with pregnancy

146
Eisenmenger Syndrome

• Cyanotic heart condition
• Develops when pulmonary resistance equals or
  exceeds systemic resistance
• to blood flow right-to-left shunt develops
• Several congenital defects may underlie
• equalization of pressures within ventricles
  (Large ventricle septal defect or large patent
  ductus arteriosus (PDA)

147
Eisenmenger Syndrome

• Operative correction of anomalies must be done as
  soon as possible to prevent Eisenmenger Syndrome
• If late surgery and woman survives
• there is 50 mortality risk
• After late surgery, mortality risk is usually
  from ventricular failure

148
Mitral Valve Prolapse (MVP)

• Common cardiac condition
• Associated with a variety of conditions
• Leaflets of mitral valve prolapse into left
  atrium during ventricular contraction
• Most with MVP are asymptomatic

149
Nutritional Considerations

• Well balanced diet for pregnancy to ensure
  adequate weight gain
• (avoid excessive weight gain)
• Prenatal vitamins and iron to prevent anemia
• Monitor for signs of infection

150
Medical Management for Class I and II heart
Disease

• Limit physical activity
• Prevent anemia
• Prevent infection
• Careful assessment to detect development
• of congestive heart failure, pulmonary edema
  or cardiac dysrhythmias

151
Medical Management for Class III and IV Heart
Disease

• Prevent development of congestive heart failure
• Protect fetus from hypoxia and intrauterine
  growth retardation (IUGR)
• Same measures as for Class I and II
• Bedrest especially during third trimester

152
Medical Management for Class III and IV Heart
Disease

• Decreased mobility leads to increased
• risk for thrombus
• -elastic compression stockings or
• -serial or boot dompression device
• -prophylactic anticoagulant therapy may be
  required

153
Medical Management

• Observe for complications from hemodynamic
  changes immediately
• after delivery
• -(congestive heart failure)

154
Pharmacologic Agents

• Anticoagulants
• Warfarin (Coumadin) is teratogenic
• and restricted during pregnancy
• Subcutaneous Heparin safe to use
• -monitor partial thromboplastin time
• -activated partial thromboplastin time
• -platelet count

155
Pharmacologic Agents

• Anticoagulants (cont)
• Enoxaparin (Lovenox) may be used rather than
  heparin
• Do not interchange Lovenox and heparin
• Lovenox also given subcutaneously
• Lovenox requires less-frequent monitoring

156
Pharmacologic Agents

• Antidysrhythmics
• Safe to use
• -Digoxin
• -Adenosine
• -Calcium Channel Blockers

157
Pharmacologic Agents

• Antidysrhythmics (cont)
• Beta blockers associated with
• -neonatal respiratory depression
• -sustained bradycardia
• -hypoglycemia
• if administered late in pregnancy or just
  prior to delivery

158
Pharmacologic Agents

• Antiinfectives
• For endocarditis chosen according to
• infecting microorganism
• Antiinfectives used
• -amoxicillin -ampicillin
• -penicillin -gentamycin

159
Pharmacologic Agents

• Drugs for Pregnancy Associated Heart Failure
• If congestive heart failure uncontrolled by
  restriction of activity and sodium intake
  diuretics used
• -furosemide
• -thiazide

160

Pharmacologic Agents

• Drugs for Pregnancy Associated Heart Failure
  (cont)
• -ACE inhibitors
• -angiotensin receptor blockers
• -digoxin

161
Nursing Process

• Nursing Diagnosis
• -Decreased cardiac Output
• -Excess fluid volume
• -Impaired gas exchange
• -Activity intolerance
• -Anxiety
• -Risk for Infection

162
Nursing Process

• Evaluation
• -Client experiences healthy pregnancy
• -Client avoids heart failure
• -Client gives birth to healthy infant

163
Pre-Term Labor

• Labor beginning after the 20th week of gestation
• But before the end of the 37th week of gestation

164
Pre-Term Labor

• No greater risk to the mom than regular labor
  unless complications ie, infection, hemorrhage
• Different with neonate
• May result in birth of neonate ill prepared for
  extrauterine life

165
Client Teaching about PretermLabor

• Should teach at first visit and reinforce at
  subsequent visits
• Contractions occurring q10 minutes or less with
  or without pain
• Low abdominal cramping with or without
• diarrhea
• Intermittent sensation of pelvic pressure,
  urinary frequency

166

• (cont)
• Low constant or intermittent backache
• Increased vaginal discharge, may be pink-tinged
• Leaking amniotic fluid

167
Immediate Actions for Preterm Labor

• Empty bladder
• Assume a side-lying position, left-lateral
• perferred
• Drink 3-4 eight ounce glasses of water
• Palpate abdomen, if contractions 10 minutes apart
  or closer, contact healthcare provider

168
Immediate Actions for Preterm Labor

• Rest for thirty minutes
• Slowly resume activity, if symptoms disappear
• Symptoms not subsided within 1 hour
• Call healthcare provicer

169
(No Transcript)
170
Preterm Labor and Birth

• Causes of preterm labor and birth
• Infections
• Pregnancy complications
• Sociodemographic factors
• Poverty, low educational level, lack of social
  support, smoking, little or no prenatal care,
  domestic violence, and stress

171
(No Transcript)
172
Care Management

• Assessment and nursing diagnoses
• Begins at time of entry to prenatal care
• Use known successful modalities for teaching
  about early recognition of preterm symptoms
• Teach what to do if symptoms occur
• Women may ignore symptoms
• Ignorance regarding significance
• Belief that symptoms are expected during pregnancy

173
Care Management

• Signs and symptoms of preterm labor
• Uterine activity
• Uterine contractions more frequent than every 10
  minutes persisting for 1 hour or more
• Discomfort
• Lower abdominal cramping similar to gas pains
  may be accompanied by diarrhea
• Dull, intermittent low back pain

174
Care Management

• Signs and symptoms of preterm labor
• Discomfortcontd
• Painful, menstrual-like cramps
• Suprapubic pain or pressure
• Pelvic pressure or heaviness
• Urinary frequency
• Vaginal discharge
• Change in discharge
• Rupture of amniotic membranes

175
Care Management

• Plan of care and interventions
• Prevention
• Educate woman about early symptoms of preterm
  labor
• Any symptoms of uterine contractions or cramping
  between 20 and 37 weeks of gestation that do not
  go away are not normal discomforts of pregnancy
  and require contacting primary health care
  provider

176
Care Management

• Early recognition and diagnosis
• Three major diagnostic criteria
• Gestational age between 20 and 37 weeks
• Contractions
• Progressive cervical change
• Effacement of 80
• Cervical dilation of 2 cm or greater

177
Care Management

• Lifestyle modifications
• Activities resulting in preterm labor symptoms
  should be curtailed
• Engaging in sexual activity
• Carrying heavy loads
• Standing more than 50 of the time
• Doing heavy housework or climbing stairs
• Performing hard physical work
• Being unable to stop and rest when tired

178
Care Management

• Bed rest
• Commonly used for prevention of preterm birth
• Not a benign intervention
• No evidence to support effectiveness in reducing
  preterm birth rates
• Home care
• Modify environment for conveniences
• Home uterine activity monitoring

179
Care Management

• Suppression of uterine activity
• Tocolytics
• Afford opportunity to begin administering
  antenatal glucocorticoids
• Accelerate fetal lung maturity
• Reduce severity of sequelae in preterm births

180
Care Management

• Promotion of fetal lung maturity
• Antenatal glucocortoids
• NIH recommends for all women at risk for preterm
• Not indicated when
• Cord prolapse
• Chorioamnionitis
• Abruptio placentae

181
Care Management

• Management of inevitable preterm birth
• Labor progressed to cervical dilation of 4 cm
  likely to lead to inevitable preterm birth
• Preterm births in tertiary care centers lead to
  better neonatal and maternal outcomes
• Women at risk should be transferred quickly to
  ensure best possible outcome
• First dose of antenatal glucocorticoids should be
  given before transfer

182
Premature Rupture of Membranes (PROM)

• Rupture of amniotic sac and leakage of amniotic
  fluid beginning at least 1 hour before onset of
  labor at any gestational age

183
Preterm Premature Rupture of Membranes (PPROM)

• Membranes rupture before 37 weeks of gestation
• Occurs in up to 25 of preterm labor cases
• Often preceded by infection
• Etiology unknown
• Diagnosed after woman complains of sudden gush or
  slow leak of vaginal fluid
• Care management home vs. hospital