HIGH RISK PREGNANCY

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HIGH RISK PREGNANCY

• By
• Susan Sienkiewicz

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Adolescent Pregnancy Contributing Factors

• Peer pressure
• ? Self-esteem
• Lack of role models
• Gain attention
• Media
• Poverty
• Rite of passage

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Implications of Adolescent Pregnancy

• Socioeconomic
• reliance on welfare
• cycle repeats itself

• Fetal Health
• LBW
• prematurity
• resp complications
• cp
• cognitive deficits
• death

• Maternal health
• CPD
• PIH
• anemia
• nut deficits
• ? mortality

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Adolescent Pregnancy Assessment

• Risks
• fundal height
• of sexual partners
• knowledge of infant care/needs
• family unit/support system
• baseline VS/weight

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IMPLICATIONS OF DELAYED PREGNANCY

• Pre-existing conditions
• Preterm labor SGA/LBW
• IUGR
• PIH Abruption
• C-section
• Uterine fibroids PP hemorrhage
• Chromosomal abnormalities

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DELAYED PREGNANCY ASSESSMENT

• Pre-existing conditions
• Fundal height
• Anxiety
• Psychosocial issues
• (career vs baby)

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TYPES OF SPONTANEOUS ABORTIONS
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Spontaneous Abortion Management

• Threatened
• Inevitable

• Notify MD/MW
• Check fetus by U/S
• Bedrest, no sexual activity
• for 2 weeks after bleeding stops
• No false reassurance
• Check by U/S for complete vs. incomplete
• Analgesics for DC
• RhoGAM

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Spontaneous Ab Mgmt, cont.

• Hospitalization
• Before 14 wks DC IV Pitocin
• After 14 wks Pitocin or Prostaglandins
• Wait 3 to 5 wks for spont Ab (93)
• Monitor for DIC

• Incomplete
• Missed

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Post Abortion Education

• Bldg, cramping X 1-2 wks
• vaginal rest X 1 wk
• ? temp BID
• f/u in 2 wks

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SITES OF ECTOPIC PREGNANCY
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S S Ectopic Pregnancy

• Missed Period
• Abdominal Pain
• Vaginal Spotting
• Rupture
• ? ?hCG levels
• No gestational sac on U/S

Severe lower abd pain
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Surgical Management of Ectopic Pregnancy
Med Mgmt of Ectopic PG
MTX
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S S Hydatiform Mole

• Vaginal bleeding? anemia
• ? uterus size, cramps
• No FHTs
• ? N/V
• Early PIH

Therap. Mgmt vacuum aspiration curettage
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Spontaneous Abortion Matching Choose all that
apply.

• 1. Initial symptom is vaginal bleeding
• 2. Membranes rupture and cervix dilates
• 3. Some, not all, products of conception are
  expelled.
• 4. Treatment includes DC
• 5. All products of conception passed
• 6. All unsensitized Rh neg women should receive
  RhoGAM
• 7. May be treated with bedrest
• 8. Retained dead fetus
• 9. May be complicated by DIC
• 10. Pregnancy may continue

• A. Threatened abortion
• B. Inevitable abortion
• C. Incomplete abortion
• D. Complete abortion
• E. Missed abortion

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Medical Mgmt of Placenta Previa
SS hypovol in mom
Mom stable, fetus immature
Fetus gt 36 wks

• Bedrest
• no sex act
• report bldg

• Amnio to ? lung maturity
• delivery

• delivery

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SS Abruptio Placentae

• Vag bldg (unless concealed)
• abd pain
• ? U-act
• hemorrhage
• boardlike abd
• late decels
• ss shock

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Med Mgmt of Placental Abruption
Mom stable, fetus immature
? bleeding, fetal distress
bedrest tocolytics
Emergency CS
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DIC
Placental Bleeding ? Thromboplastin
release ? Clot formation (systemic response) ? ?
clotting factors (?fibrinogen, ? plts, ? PTT, ?
FDP) ? inability to form clots ? profuse bleeding
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Hemorrhagic Conditions Abruption DIC
ASSESSMENT

• Bleeding
• Pain
• VS/FHR
• U-Activity
• OB Hx
• Fundal Ht
• Lab Data (H/H, coags)
• Emotional response

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The Pathological Processes of Pre-eclampsia
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SS Pre-eclampsia

• Rapid wt gain
• edema of hands face
• proteinuria
• hyperreflexic DTRs
• H/A, visual disturbances
• epigastric pain

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Treatment of Pre-eclampsia
Mild diastolic lt 100, trace to 1 proteinuria,
no H/A
Severe diastolic gt 110, 3 proteinuria, ? U/O,
H/A, visual disturbances

• Bedrest
• ?protein diet
• document fetal activity
• weekly NST

• Bedrest, ? stimuli
• Meds
• Apresoline for severe HTN
• MgSO4 (anticonvulsant antihypertensive)
• Delivery

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SS Eclampsia/HELLP Syndrome

• Eclampsia
• facial twitching
• tonic-clonic sz
• pulmonary edema
• circ/renal failure

• HELLP Syndrome
• RUQ pain
• n/v
• edema
• ? H/H, ? plts
• ? liver enzymes

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Treatment of Eclampsia/HELLP Syndrome

• Bedrest
• Meds
• MgSO4
• Valium or Phenobarb (if Mg not effective, not
  within 2 hr of delivery)
• Hydralazine (for severe ? B/P)
• steroids to ? fetal lung maturity
• Delivery

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Assessment Hypertensive Disorders of Pregnancy

• Prenatal
• wt, B/P, U/A, H/A, visual disturbances
• Hospitalized Ct
• daily wt
• hourly u/o, dipstick urine Q4H
• VS, FHR
• ? LOC, DTRs, H/A
• ? clonus

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Risk Control Strategies for Hypertensive
Disorders of Pregnancy

• Sz precautions
• monitor for s/s Mg toxicity(RRlt12, absent DTRs,
  sweating, flushing, confusion, ? B/P)
• Ca gluconate _at_ BS
• ? Mg levels
• IV MgSO4 (should be Y connected to another
  primary bag)
• D/C MgSO4 for RR lt 12 or absent DTRs
• ? renal function (30 mL/hr)

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Incompetent Cervix

• SS
• advanced cervical dilation
• low abd pressure
• bloody show
• urinary frequency

• Treatment
• cerclage

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Premature Labor/Rupture of Membranes

• SS
• contractions
• cramps
• backache
• diarrhea
• vag d/c
• ROM

• Treatment
• Tocolytics
• IV hydration
• bedrest
• steroids, if needed
• abx, if needed

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Nursing Care for PTL/PROM

• Assessment
• Thorough hx
• ? bleeding
• ? ROM
• BPP (for PROM)

• Teaching
• Infection Control
• FMC

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Postterm Pregnancy

• SS
• Wt loss
• ? uterine size
• Meconium in AF
• Risks
• ? fetal mortality
• cord compression
• mec asp
• LGA ? shoulder dystocia ? CS
• episiotomy/laceration
• depression

• Treatment
• fetal surveillance
• NST, CST, BPP Q wk
• mom monitors mvmt
• Induction
• Pitocin (10-20U/L) _at_ 1-2 mU/min every 20-60 min

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Disorders of Amniotic Fluid

• Polyhydramnios
• SS
• uterine dist
• dyspnea
• edema of lower extr
• Treatment
• therapeutic amniocentesis

• Oligohydramnios
• Risks
• cord compression
• musculoskeletal deformities
• pulmonary hypoplasia
• Treatment
• amnioinfusion

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Risks of Multifetal Gestation

• PIH
• GDM
• PPH
• Anemia
• UTI
• PTL
• Placenta previa
• CS

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(Fetal) SS Rh Incompatibility

• Hyperbilirubinemia
• jaundice
• Kernicterus (severe neuro d.o. r/t ? bili)
• anemia
• hepatosplenomegaly
• Hydrops fetalis

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Sequence of Assessments for Rh Sensitization
Blood Test for Type Rh Factor
Rh-positive
Rh-negative
No further testing
Indirect Coombs
-

Repeat frequently
Titer increasing ? amniocentesis (? bilirubin)
Give RhoGAM
Titer not increasing ? continue to monitor
Elevated ? retest, U/S ? intrauterine transfusion
or early delivery
No change ? retest prn
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Management of Rh Incompatibility

• Prenatal
• per algorithm

• Postpartum
• ? direct Coombs
• RhoGAM to mom if baby is Rh (within 72 hrs of
  birth)

• Prevention
• RhoGAM at 28 weeks (unsensitized women only)

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Hyperemesis Gravidarum

• SS
• ? U/O
• wt loss
• ketonuria
• dry muc membranes
• poor skin turgor

• Treatment
• IVF, TPN
• antiemetics
• advance diet as tol

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Glucose Tolerance Test
1? GTT (24 - 28 wks) drink 50g glucose, if 1? BS
gt 140

• 3? GTT
• hi carb diet X 2 days, then NPO after MN
• FBS, then drink 100g glucose,
• ? 1?, 2?, 3? BS

Gestational Diabetes is diagnosed with FBS gt 105
or with 2 of the following BS results 1? gt
190, 2? gt 165, 3? gt 145
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Effects of Pre-Existing DM

• Maternal
• ? risk of
• PIH
• Cystitis
• DKA
• Spont Ab

• Fetal
• ? risk of
• NTDs
• Cardiac defects
• Macrosomia or
• IUGR
• Polycythemia
• hyperbilirubinemia

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Treatment of Pre-existing DM

• Team approach
• Monitor glycosylated Hgb A
• Diet 50 carb, 20 prot, 30 fat
• Insulin TID
• Hourly glucoses during labor
• NSTs weekly (starting at 28-30 wks)
• Amnio (? lung maturity)

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Effects of Gestational Diabetes

• Maternal Effects
• UTI
• hydramnios
• PROM/preterm labor
• shoulder dystocia
• epis/lac
• CS
• HTN

• Fetal Effects
• macrosomia
• hypoglycemia at birth
• RDS

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Treatment of Gestational Diabetes

• 30 to 35 cal/kg/day (3 meals, 2 snacks)
• Insulin
• ? FBS, post-prandial BS Q week
• NST, BPP Q week
• glycosylated Hgb A
• Amnio (? lung maturity)

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Diabetes Patient Education

• Glucose monitoring
• insulin administration
• type, onset, peak, duration, times, sites,
  injection technique
• diet
• s/s hypoglycemia
• tremors, pallor, cold/clammy skin
• give milk crackers or glucagon inj
• s/s hyperglycemia
• fatigue, flushed skin, thirst, dry mouth,
• check glu, call MD for insulin order

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PPCM Manifestations

• dyspnea
• edema, wt gain
• chest pain
• palpitations
• jug vein distention
• enlarged heart
• ? spont ab, PTL

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PPCM Energy Management

• Epidural
• Activity restriction
• Minimize anxiety

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PPCM Cardiac Care

• Meds
• Sidelying, HOB ?
• Monitor VS, FHR, heart pressures (Swan-Ganz)
• Strict I/O
• Assess lungs

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PPCM Patient Education

• Avoid excessive wt gain/edema
• Diet 2200 cal, ? protein, NAS
• rest/avoid exertion
• avoid exposure to environmental extremes
• ? emotional stress

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Sickle Cell Disease

• Maternal Effects
• pain
• jaundice
• Pyelonephritis
• PIH/preeclampsia
• leg ulcers
• CHF

• Fetal Effects
• IUGR/SGA
• skeletal changes

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Systemic Lupus Erythematosis

• Maternal effects
• fatigue
• muscle/joint pain
• wt loss
• rash
• proteinuria
• PIH/preeclampsia/HELLP
• PG loss

• Fetal effects
• IUGR
• preterm delivery

• Treatment
• PO or IV Steroids

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AIDS

• Fetal Effects
• Asymptomatic at birth
• Candidal diaper rash
• thrush
• diarrhea
• recurrent bacterial infections
• FTT
• dev delay

• Maternal Effects
• vag candidiasis
• PID
• genital herpes
• HPV
• PCP

Treatment ZDV (zidovudine) during PG, LD ZDV to
neonate for 6 wks
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Which of the following socioeconomic factors
contributes to the high incidence of adolescent
pregnancy in the US?
A. lack of adequate birth control B. poverty C.
lack of information on safe sex D. availability
of public assistance for unmarried mothers
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Which genetic screening test for chromosomal
abnormalities provides an older expectant couple
with information within the first trimester?
A. Chorionic villus sampling (CVS) B. Amniocentesi
s C. Genetic karyotyping D. Ultrasonography
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When caring for a woman with mild preeclampsia,
the nurse would be concerned with which finding?

• 4 proteinuria
• 2 dependent edema in ankles
• Blood pressure 156/100
• 2 DTRs, absent clonus

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The nurse is preparing to infuse magnesium
sulfate to treat preeclampsia. In implementing
this order the nurse understands the need to

• Prepare a solution of 20 g MgSO4 in 100cc D5W
• Monitor maternal VS, FHR and uterine contractions
  every hour
• Expect the maintenance dose to be approximately
  4g/hr
• Discontinue the infusion and report a respiratory
  rate of lt 12 breaths/minute

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The primary expected outcome for care associated
with the administration of MgSO4 would be met if
the woman

• Exhibits a decrease in both systolic and
  diastolic blood pressure
• Experiences no seizures
• States that she feels more relaxed and calm
• Urinates more frequently, resulting in a decrease
  in pathologic edema

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A primigravida at 10 weeks gestation reports
slight vaginal spotting without passage of tissue
and mild uterine cramping. When examined, no
cervical dilation is noted. The nurse caring for
this woman should

• Anticipate that the woman will be sent home and
  placed on bedrest with instructions to avoid
  stress or orgasm
• Prepare the woman for a dilatation and curettage
• Notify a grief counselor to assist the woman with
  the imminent loss of her fetus
• Tell the woman that the doctor most likely will
  perform a cerclage to help maintain the pregnancy

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CASE STUDY I
A G3P2 woman, at 38 wks gestation, arrives at the
obstetric unit with c/o painless vaginal
bleeding. 1. What is the nursing priority at this
time? 2. What assessments are necessary? 3. What
is the most likely etiology of the
bleeding? 4. What is the expected treatment for
Anne?
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CASE STUDY II
A G1P0 woman, at 35 wks gestation, is visiting
the midwife for a routine prenatal visit. On
assessment, the nurse finds that she has gained 8
lbs in the past month. 1. What is the
significance (if any) of this weight
gain? 2. What other assessments should the
nurse make at this time? 3. What is the
required treatment for this client?
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CASE STUDY III
A 22 y.o. G1P0 who has a history of IDDM X 6 yrs
and whose LMP was 12 wks ago arrives at the
prenatal clinic. 1. How will this clients
diabetes be affected by her pregnancy? 2. What
changes will she most likely have to make to
adjust to her pregnancy? 3. What routine
assessments will be made at each prenatal
visit? 4. What tests will be required as the
pregnancy progresses? 5. What fetal effects
occur with pre-existing diabetes? 6. How will LD
be altered by pre-existing diabetes? 7. What
possible newborn complications could occur with
pre-existing diabetes? 8. What nursing care will
the infant require?
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MATH PROBLEM

• For induction, Pitocin is ordered 10 Units in
  500 mL to start at 2 mU/min and increase by 1
  mU/min every 20 minutes until effective
  contractions are achieved.
• At what rate will the nurse start the IV? By how
  much will the rate be increased every 20 minutes?

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THE END