Nursing 353 Pregnancy Risk Factors by pptfiles

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									Nursing 353 Maternal Risk Factors Fetal Assessment
February 3rd, 2005

High Risk Pregnancy
The life or health of the mother or fetus is jeopardized  Examples include:
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– GDM – Previous loss – AMA – HTN – Abnormalities with the neonate

Perinatal Mortality
Overall maternal deaths are small  Many deaths a preventable  Education and prenatal care are very important
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Antepartum Testing
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FKCs BID UTZ
– – – – – – – – – – FHR Gestation age Abnormalities IUGR Placental location and quality AFI Position BPP Doppler flow Fetal growth

Ultrasound
Can be done abdominally or transvaginally  1st trimester done to detect viability, calculate EDC  2nd trimester done to detect anomalies, calculate EDC  3rd trimester done to do BPP, fetal growth and well-being, AFI
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Doppler Flow Analysis via UTZ
Study blood blow in the fetus and placenta  Done on high risk mothers:
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– IUGR – HTN – DM – Multiple gestation

AFI
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Polyhydramnios – too much amniotic fluid Oligohydramnios – too little amniotic fluid

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Biophysical Profile
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Includes 5 components:
– Fetal breathing movements – Gross body movements – Fetal tone – AFI – NST - reactive

Amniocentesis
Used with direct ultrasound  Less than 1% result in complications
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– Complications include:
 Fetal death, miscarriage  Maternal hemorrhage  Infection to fetus  Preterm labor  Leakage of amniotic fluid

Meconium
Visual inspection of amniotic fluid  Meconium is defined as thin and thick and particulate  Associated with fetal stress: hypoxia, umbilical cord compression
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CVS
Done between 9 -12 weeks  Genetic studies  Removal of small amount of tissue from the fetal portion of the placenta  Complications: vaginal spotting, miscarriage, ROM, chorioamnionitis  If done prior to 10 weeks, increased risk of limb anomalies
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AFP
Genetic test  Done with mothers blood  16-20 weeks gestation  Mandated by state of California
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EFM
Third trimester goal is to continue to observe the fetus within the intrauterine environment  Goal: dx uteroplacental insufficiency  NST vs. CST
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NST
90% of gross fetal body movements are associated with accelerations of the FHR  Can be performed outpatient  Not as sensitive  User friendly but must interpret strip  Fetus may be in a sleep state or affected by maternal medications, glucose etc.
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NST
To be reactive must meet criteria  Must be at least 20 minutes in length  Must have 2 or more accelerations that meet the ’15 X 15’ criteria  Must have a normal baseline  Must have LTV
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NST
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To stimulate a fetus that is not meeting criteria:
– Change positions of the mother – LS, RS – Increase fluids – Acoustic stimulator

CST
Done in the inpatient setting only!  Has contraindications  May be expensive if meds/IV needed  Monitored for 10 minutes first  Then may use nipple stimulation or oxytocin stimulation  No late decelerations than negative CST
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CST

Endocrine and Metabolic Disorders
#1 Diabetes Mellitus  Disorders of the thyroid  Hyperemesis


Diabetes
Hyperglycemia  May be due to inadequate insulin action or due to impaired insulin secretion  Type 1 – insulin deficiency  Type 2 – insulin resistance  GDM – glucose intolerance during pregnancy


DM
10th week fetus produces it own insulin  Insulin does not cross the placental barrier  Glucose levels in the fetus and directly proportional to the mother  2nd and 3rd trimesters – decreased tolerance to glucose, increased insulin resistance, increased hepatic function of glucose


Diabetic Nephropathy
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Increased risks for:
– Preeclampsia – IUGR – PTL – Fetal distress – IUFD – Neonatal death

DM
Poor glycemic control is associated with increased risks of miscarriage at time of conception  Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios


Polyhydramnios
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May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

Macrosomia
Disproportionate increase in shoulder and trunk size  4000-4500gms or greater  Fetus will have excess stores of glycogen  Increased risks of
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– Shoulder dystocia – C/S – Assisted deliveries

IUGR
Compromised uteroplacental insufficiency  02 available to the fetus is decreased
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RDS
Increased RDS due to high glucose levels  Delays pulmonary maturity
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Neonatal Hypoglycemia
Usually 30-60 minutes after birth  Due to high glucose levels during pregnancy and rapid use of glucose after birth  Related to mothers level of glucose control


Labs with DM
HBA1c  1 hour PP  FBS
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Diet
Sweet success diet  Well balanced diet  6 small meals / day  Have snack at HS  Never skip meals  Avoid simple sugars


Insulin
Regular/Lispro and NPH  2/3 dose in am and 1/3 dose in pm
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Monitoring Glucose Levels
FBS  1 hour PP  HS  5 checks / day
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Fetal Surveillance
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NSTs done around 26 weeks, weekly At 32 weeks done biweekly with NST/BPP



Infections and DM
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Infections are increased:
– Candidiasis – UTIs – PP infections

DM
Increased risk of IUFD after 36 weeks  Increased congenital anomalies


– Cardiac defects – CNS defects
 Spina bifida  anencephaly

– Skeletal defects

DM and labor
Continuous fetal monitoring  Blood glucose levels in tight control  Be prepared for CPD


GDM
Women with GDM at risk of developing DM later on in life  NSTs around 28 weeks


Hyperthyroidism
Typically caused by Grave’s disease  S/S:


– Fatigue – Heat intolerance – Warm skin – Diaphoresis – Weight loss

Should be treated in pregnancy  Tx with PTU  Beta blockers  May lead to thyroid storm if untreated


Hypothyroidism
Usually caused by Hashimoto’s  S/S:


– Weight gain – Cold intolerance – Fatigue – Hair loss – Constipation – Dry skin

Tx with thyroid hormones such as synthroid or levothyroxine  Maintain TSH wnl  Checked periodically throughout the pregnancy


Cardiovascular Disorders
The heart must compensate for the increased workload  If the cardiac changes are not well tolerated than cardiac failure can develop  1% of pregnancies are complicated by heart disease


NY Heart Association Classes
Class  Class  Class  Class


I II III IV

Cardiac output is increased  Peak of the increase 20-24 weeks gestation  Cardiac problems should be managed with cardiologist  Mortality with pulmonary hypertension and pregnancy is more than 50%  Diet: low sodium


Nursing Care
Avoiding anemia  Avoid strenuous activity  Monitor for: cardiac failure and pulmonary congestion


During Labor
Side lying position  Prophylactic antibiotic  Epidural  Attempt vaginal delivery  If anticoagulant therapy is needed:


– Heparin – Lovenox

MVP
Common and usually benign  May experience syncope, palpitations and dyspnea  Prophylactic antibiotics given before invasive procedure or birth


Anemia
Most common iron deficiency  Hgb falls below 12 (most labs)  Typically seen in the end of 2nd trimester  Iron supplementation


Folic Acid Deficiency Anemia
Increases risk of NTD, cleft lip  Recommended dose 400 mcg/day  Supplemented in cereal and many other foods


Sickle Cell Anemia
Abnormal hemoglobin SS types in the blood  People have recurrent attacks of fever and pain in the abdomen and extremities  Caused from tissue hypoxia, edema  African-Americans


Sickle Cell Trait
Typically asymptomatic  Sickling of the RBCs but with a normal RBC life span


Thalassemia
Common anemia  Insufficient amount of Hgb is produced to fill the RBCs  Mediterranean region  Genetic disorder  May be associated with LBW babies and increased fetal death


Asthma
Common with FH  1-4% of pregnant women have Asthma  Possible adverse events associated with asthma:


– LBW – Perinatal mortality – Preeclampsia – Complicated labor – Hyperemesis

Asthma Continued
Goal is to relieve the attack, prevent the asthma attack, and maintain 02  Should be managed with OB and ENT  May require tx: albuterol, steroids, O2
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Epilepsy
Seizure disorder  May result from developmental abnormalities or injury  20% have an increase in seizure activity during pregnancy  Risks: more seizures, risk of vaginal bleeding, abruptio placentae, fetus may experience seizures


Epilepsy Continued
Use of antiepeleptic meds during pregnancy has been linked to risks for the fetus  Smallest therapeutic dose to be given  Daily folic acid supplementation  Managed with OB and neurologist


RA
Chronic arthritis  Pain upon movement and swelling in joint spaces  More often in women  2/3 of women with RA find the severity of symptoms decrease during pregnancy  Typically give baby ASA


SLE
Inflammatory disease, autoimmune antibody production  Advised to wait until in remission for 6 months to become pregnant  15-60% of women will develop exacerbation of SLE during pregnancy or postpartum  Tx: ASA and steroids
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Cholelithiasis
More often in women  Pregnancy makes women more vulnerable  Surgery often delayed until after delivery


Appendicitis
Dx may take more time to find  Sxs: abdominal pain, nausea, vomiting, loss of appetite  Increases incidence of PTL or SAB
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Maternal Infections

TORCH
Toxoplasmosis – protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly  Other- Heb A or B, Group B, Varicella, HIV  Rubella (German measles) – if contracted in 1st Trimester fetus may have congenital deformities


TORCH
CMV- transmitted person to person, may cause CNS damage to fetus  Herpes Simplex (HSV 2) – if initial infection occurs in pregnancy, higher incidence of perinatal loss. Fetus may pick up virus if present in the vagina during labor


Mental Health Disorders

Anxiety Disorders
Most common mental disorders  Include: phobias, panic disorders, OCD, PTSD  Tx: relaxation techniques, breathing exercises, imagery


Depression in Pregnancy
6% of women develop depression for the 1st time during pregnancy  Tx: counseling and tx with SSRIs  Wellbutrin only med named as Category B  Many women opt to DC meds during pregnancy


Substance Abuse in Pregnancy

Substance Abuse
Damaging effects well documented in research to fetus  Any use of ETOH or illicit drugs during pregnancy is considered abuse  31% of women had used one or more substances during pregnancy (as compared to 62% during prepregnancy)


Smoking


Risks of any amount of smoking include:
– SAB – SGA – Bleeding – IUFD – Prematurity – SIDS

Alcohol
Many women reluctant to tell health care provider  Risks:


– LBW – Mental retardation – Learning and physical deficits – With FAS – severe facial deformities

Alcohol during Pregnancy


Risks to mother:
– HTN – Anemia – Nutritional deficits – Pancreatitis – Cirrhosis – Alcoholic hepatitis

Marijuana
Crosses the placenta and causes increased carbon monoxide levels in mother’s blood  May cause fetal abnormalities


Cocaine
In the US, 10-15% of all pregnant women use cocaine  Problems associated with use: polydrug use, poor health, poor nutrition, STIs, infections, HIV  Poverty big issue


Cocaine in Pregnancy


Maternal effects:
– – – – – – – – – Cardiovascular stress Tachycardia HTN Dysrhythmias MI Liver damage Sz Pulmonary disease Death



Fetal Complications:
– – – – Abruptio placentae PTL Precipitous labor Risks for abdominal pregnancy – Fetal complications after delivery

Opiates in Pregnancy
Drugs include: heroin, Demerol, morphine, codeine, methadone  Methadone is used to treat addiction to other opiates  Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL  Tx: Methadone and psychotherapy  Goal: prevent withdrawal symptoms


Methamphetamine
CNS stimulant  Most common use n the 18-30 yr old range  Neonatal complications include:


– IUGR – PRL/PTB

Postpartum Psychologic Complications

Baby Blues
Usually within 4 weeks of childbirth  Many experience this


PPD
Intense sadness, crying all the time, mood swings, fears, anger, anxiety, irritability  Incidence of PPD at 8 weeks – 12% and 8% at 12 weeks  Many women feel guilty  May need tx but usually resolves on own


Postpartum Psychosis
Delusions, hurting self or the infant, emotional lability, insomnia, suspiciousness, confusion, obsessive concerns regarding the baby  1-2/1000 births  35-60% recurrence with each subsequent birth  Usually symptoms appear within 8 weeks of birth


Medical Management
Supportive family  Intense psychotherapy  Emergency  Tx: SSRIs  SSRIs contraindicated while breastfeeding




1. A client asks the nurse to again explain the purpose of the amniocentesis test. The nurse responds that one purpose of this test is to indicate the:
– A. – B. – C. – D. – E. Accurate age of the fetus Presence of certain congenital anomalies Biparietal diameter of the skull Hormone content of the amniotic fluid Mainly the presence of Down’s syndrome



2. The nurse explains to a new mother that the condition of SGA is caused by:
– A. – B. – C. – D. Placental insufficiency Maternal obesity Primipara Genetic predisposition



3. A pregnant client with diabetes is controlled by insulin. When she asks the nurse what will happen to her insulin requirements during pregnancy, the correct response is:
– A. “Because your case is so mild, you are likely not to need much insulin during your pregnancy” – B. “It’s likely that as the pregnancy progresses you will need increased insulin” – C. “Every case is individual so there is really no way to know” – D. “If you follow the diet closely and don’t gain too much weight, your insulin needs should stay the same”



4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be:
– A. – B. – C. – D. Higher than in normal infants Lower than in normal infants The same as in normal infants Varied from baby to baby



5. A client is admitted to L&D, at 38 weeks gestation. She is there for evaluation because she is experiencing polyhydramnios. The nurse understands that this diagnosis means that:
– A. There is the normal amount of amniotic fluid, thinner in volume – B. A less-than-normal amount of amniotic fluid is present – C. An excessive amount of amniotic fluid is present – D. A leak is causing the fluid to accumulate outside the amniotic sac


								
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