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Chapter 20
Pregnancy complication from a preexisting or newly acquired illness
Identifying the High-Risk Pregnancy
High-risk pregnancy
A concurrent disorder, pregnancy-related
complication, or external factor jeopardizes
the health of the mother, fetus or both
Table 20.1 Factors that categorize a
pregnancy as High Risk:
Psychological
Social
Physical
Congenital and Acquired Heart
Disease
• Congenital usually due to structural defects at birth Number is
diminishing
• Acquired primarily rheumatic in origin
• Functional classification system to predict pregnancy outcomes
(Table 20.1)
– Class I: asymptomatic; no limitation of physical activity:
experience normal birth
– Class II: symptomatic (dyspnea, chest pain) with increased
activity: experience normal birth
– Class III: symptomatic (fatigue, palpitation) with normal
activity: complete pregnancy with maintenance of bedrest
– Class IV: symptomatic at rest or with any physical activity:
poor candidates advised to avoid pregnancy
Congenital and Acquired
Heart Disease (cont’d)
• Pathophysiology
– Hemodynamic changes overstressing woman’s cardiovascular
system
• Therapeutic management
– Risk assessment, prenatal counseling, increased frequency of
prenatal visits
• Nursing assessment
– Vital signs, heart sounds, weight, fetal activity, lifestyle
– Signs and symptoms of cardiac decompensation
Cardiac Disease
Left-sided heart failure
Orthopnea
Paroxysmal nocturnal dyspnea
Cardiac Disease
Right-side heart failure
Distended liver and spleen
Ascites
Peripheral edema
Cardiac Disease
Peripartal heart disease
Originates late in pregnancy
Previously undetected heart disease
Shortness of breath, chest pain, edema
Cardiomegaly
Congenital and Acquired
Cardiac Disease (cont’d)
• Nursing Management
– Stabilization of hemodynamic status
– Risk reduction measures: education, counseling, support
– Cardiac medications if prescribed
– Energy conservation; nutrition
– Fetal activity monitoring
– Signs and symptoms of cardiac decompensation
– Monitoring during labor
Cardiac Disease
Assessment
Level of exercise
Cough or edema
Baseline vital signs
Liver size
ECG
Cardiac Disease
Fetal assessment
Promote rest
Promote healthy nutrition
Educate regarding medication
Educate regarding infection
Cardiac Disease
 Nursing interventions during labor and birth
 Anesthesia
 Monitor fetal heart tones and uterine contractions
 Vital signs
 Postpartum nursing interventions
 Assess for heart failure
 Assess baby
Cardiac Disease (cont’d)
• Artificial valve prosthesis: Heparin LMW
• Chronic hypertension vascular disease: see
next slide
• Venous thromboembolic disease: DVT
– Heparin: PTT
– Antiphospholipid Antibodies
– Chief Danger is PE
Chronic Hypertension
• Hypertension before pregnancy or before 20th week of gestation
or persistence >12 weeks postpartum
• Therapeutic management: preconception counseling, lifestyle
changes, antihypertensive agents for severe hypertension; fetal
movement monitoring; serial ultrasounds
• Nursing assessment
• Nursing management: lifestyle changes (DASH diet); frequent
antepartal visits; monitoring for abruptio placentae,
preeclampsia; daily rest periods; home BP monitoring; close
monitoring during labor and birth and postpartum follow-up
Hematologic Disorders
• Pseudo Anemia
Iron Deficiency Anemia
• Usually due to inadequate dietary intake
• Therapeutic management: eliminate symptoms, correct
deficiency, replenish iron stores
• Nursing assessment
– Fatigue, weakness, malaise, anorexia, susceptibility to
infection (frequent colds), pale mucous membranes,
tachycardia, pallor
– Abnormal lab results
• Low hemoglobin, low hematocrit, low serum iron,
microcytic and hypochromic cells, and low serum ferritin
Iron Deficiency Anemia
(cont’d)
• Nursing management
– Compliance with drug therapy: prenatal vitamin and
iron supplement
– Dietary instruction and counseling
– Education for drug therapy
Folic Acid Deficiency
• B vitamin
• Megaloblastic anemia
• Multiple pregnancies, hydantoin, OCP, gastric
bypass
• 400-800mcg folic acid
Sickle Cell Anemia
• Defect in hemoglobin molecule (hemoglobin S)
• Therapeutic management: dependent on status; supportive
therapy; blood transfusions for severe anemia, analgesics for
pain, antibiotics for infection
• Nursing assessment: signs and symptoms; evidence of crisis
• Nursing management
– Support, education, follow-up
– Labor: rest; pain management ; oxygen and IV fluids; close FHR
monitoring
– Postpartum: antiembolism stockings; family planning options
Thalassemia
• Two forms: alpha (minor); beta (major)
– Women with minor form: little effect on pregnancy except
for mild persistent anemia
– Women with major form: usually no pregnancy due to
lifelong, severe hemolysis, anemia, and premature death
• Management dependent on severity of disease
• Supportive care and expectant management
Malaria
• Infection causes RBC to stick to surface of
capillaries causing obstruction.
• International travel
• Antimalaria drugs: Chloroquine
Other Genetic or Auto-Immune
Hematologic Disorders
Coagulation disorders
Von Willebrand disease: history
menorrhagia/epistaxis
Hemophilia B: Female Carriers SAB
Idiopathic thrombocytopenia purpura:
decreased platelets after viral invasion
Autoimmune
Renal and Urinary Disorders
Urinary tract infection: Bladder
Pyelonephritis: Urinary stasis/stricture
of ureter
Usually R side (intestines on left pushes
uterus to R)
Assessment
Therapeutic management
Chronic renal disease
Kidney transplant
Chronic Renal Disease
• Difficult to interpret kidney function
• Develop severe anemia: diseased kidneys do
not produce erythropoietin
• Safe administration in pregnancy
Respiratory Disorders
Acute nasopharyngitis
Influenza
Pneumonia
Severe acute respiratory syndrome
Asthma
Asthma
• Pathophysiology
– Effect of normal physiologic changes of pregnancy on
respiratory system
– May improve due to high circulating levels corticosteroids
• Therapeutic management
– Drug therapy (budesonide, albuterol, salmeterol)
– Taper albuteral close to term
• Nursing assessment
– Asthma triggers; lung auscultation
• Nursing management
– Client education
– Oxygen saturation monitoring during labor
Tuberculosis
• Therapeutic management
– Medications: combination of isoniazid, rifampin,
ethambutol
• Nursing assessment
– PPD at first prenatal visit in high risk areas
– Risk factors; signs and symptoms of TB
– Screening
• Nursing management
– Compliance with drug therapy
– Education; health promotion activities and Calcium
– Transmission prevention
Respiratory Disorders
COPD
Cystic Fibrosis
Modifications for pregnancy
Modifications for postpartal period
Rheumatic Disorders
Juvenile rheumatoid arthritis
Systemic lupus erythematosus
Gastrointestinal Disorders
Appendicitis
Gastroesophageal reflux disease or
hiatal hernia
Cholecystitis and cholelithiasis
Pancreatitis
Hepatitis
Inflammatory bowel disease
Neurologic Disorders
Seizures
Myasthenia gravis
Multiple sclerosis
Musculoskeletal Disorders
Scoliosis
Girls 12-14 years of age
If uncorrected, causes deformity
Unable to wear brace during last half of
pregnancy
Potential for cephalopelvic disproportion
Endocrine Disorders
Thyroid dysfunction
Hypothyroidism
Hyperthyroidism
Diabetes Mellitus
• Typical classification
– Type 1
– Type 2
– Impaired fasting glucose and impaired glucose tolerance
– Gestational diabetes
• Classification during pregnancy
– Pregestational diabetes
– Gestational
Diabetes Mellitus (cont’d)
• Pathophysiology and pregnancy
– Fetal demands
– Role of placental hormones
– Changes in insulin resistance
– Effects on mother
– Effects on fetus
•
Diabetes
Mellitus
(cont’d)
Assessment
– Health history; physical examination; risk factors
– Screening at first prenatal visit; additional screening at 24 to
28 weeks for women considered at risk O’Sullivan Test
– Maternal surveillance: urine for protein, ketones, nitrates, and
leukocyte esterase; evaluation of renal function/trimester;
eye exam in 1st trimester; HbA1c q 4-6 weeks <7%
– Fetal surveillance: ultrasound; alpha-fetoprotein levels;
biophysical profile; nonstress testing; amniocentesis
Diabetes Mellitus (cont’d)
• Therapeutic management
– Preconception counseling
– Blood glucose level control (HbA1C <7%)
– FBG < 100 and 2hour PPL < 120
– Glycemic control: Humulin
– Insulin Pump
– Nutritional management: 30Kcal per kg of ideal weight (1800
to 2400 calories) divided into 3 meals and 3 snacks
– Hypoglycemic agents
– Close maternal and fetal surveillance
– Management during labor and birth
– Eye Exams
Diabetes Mellitus (cont’d)
• Education
– Exercise
– Insulin
– Insulin-pump therapy
– Blood glucose monitoring
Other
• Cancer
• Mental illness