High Risk Pregnancy-7 Flashcards
Common risk factors for high risk pregnancy
● Existing health conditions
● A history of prior pregnancy complications
● Complications that arise during pregnancy, such as gestational diabetes or preeclampsia
● Being overweight or obese
● Carrying more than one fetus
Being ≤ 18
● Advanced maternal age
General nursing actions for complication
● Provide time for the woman and family to express their concerns and feelings
● Provide information repeatedly with patient and significant other(s) to facilitate a realistic appraisal of events.
● Facilitate referrals related to the condition
● Encourage the woman and her family to participate in decision making
● have flexible guidelines for the family to minimize separation.
● Be a skilled communicator
● Be a witness to events
Preterm labor (PTL)
regular contractions of the uterus resulting in changes in the cervix before 37 weeks of gestation.
Preterm birth (PTB)
birth between 20 °/7 weeks of gestation and 36 % weeks of gestation.
Spontaneous preterm labor and birth- what and why
unintentional, unplanned delivery before the 37th week of pregnancy.
A history of delivering preterm
infection or inflammation or unknown cause
Medically indicated preterm birth
health care provider recommends preterm delivery in the existence of a serious medical condition such as preeclampsia.
Non-medically indicated (elective) preterm delivery
inducing labor or having a cesarean delivery in the absence of a medical reason to do so, even though this practice is not recommended.
Late preterm infant
34 and 37 weeks of gestation
Very preterm infant
before 32 completed weeks of gestation
Viability
at 25 and rarely, fewer completed weeks gestation
Periviability
before the third trimester of pregnancy
Long term potential issues from preterm babies
cerebral palsy, hearing and vision impairment, and chronic lung disease.
four major factors leading to preterm labor
excessive uterine stretch or distension, decidual hemorrhage, intrauterine infection, and maternal or fetal stress.
Other factors leading to preterm labor
● Uteroplacental vascular insufficiency exaggerated ●inflammatory response ● hormonal factors ●cervical insufficiency ● genetic predisposition ●Excessive uterine stretch or distention ●Decidual activation
3 most common risk factors for preterm birth
● Prior preterm birth
● Multiple gestation
● Uterine/cervical abnormalities, diethylstilbestrol (DES) exposure
Other risk factors
● Fetal anomalies
● History of second trimester loss, incompetent cervix or cervical insufficiency
● IVF pregnancy
● Hydramnios or oligohydramnios
● Infection, especially genitourinary infections and periodontal disease
● Premature rupture of membranes
● Short pregnancy interval
● Pregnancy associated problems such as hypertension, diabetes, and vaginal bleeding
● Chronic health problems such as hypertension, diabetes, or clotting disorders
● Inadequate nutrition, low BMI, low pre-pregnancy weight, or poor weight gain
● Age younger than 17 or older than 35 years old
● Late or no prenatal care
● Obesity, high BMI, or excessive weight gain
● Working long hours, long periods of standing
● Ancestry and ethnicity
● Maternal unmarried status
● Preterm birth is more likely in the presence of intimate partner violence (IPV), mental health issues, substance abuse
● Lack of social support
● Smoking, alcohol, and illicit drug use
● Lower education and socioeconomic status, poverty
Preterm birth screening
● Transvaginal cervical ultrasonography
● Fetal fibronectin
S/S preterm birth
● Change in type of vaginal discharge (watery, mucus, or bloody)
● Increase in amount of discharge
● Pelvic or lower abdominal pressure
● Constant low, dull backache
● Mild abdominal cramps, with or without diarrhea
● Regular or frequent contractions or uterine tightening, often painless
● Possible ruptured membranes
Tocolytic drugs
medications used to suppress uterine contractions in preterm labor.
Antibiotics use in preterm labor
preterm premature rupture of membranes and group B streptococci carrier status
Progesterone supplementation
useful to prevent preterm birth for women with a history of spontaneous preterm birth
Neonatal neuroprophylaxis with intravenous magnesium sulfate
reduce microcapillary brain hemorrhage in premature birth of the neonate.
Corticosteroid therapy with antenatal steroids
accelerate fetal lung maturity
24 weeks and 34 weeks of gestation who are at risk of delivery within 7 days
Will raise blood sugar
Premature rupture of membranes (PROM)
rupture of membranes before the onset of labor
preterm PROM.
Membrane rupture before labor and before 37 weeks of gestation
Risk factors for preterm PROM
● Previous preterm PROM or preterm delivery
● Bleeding during pregnancy
● Short cervical length
● Hydramnios
● Multiple gestation (up to 15% in twins, up to 20% in triplets)
● Sexually transmitted infections (STIs)
● Low body mass index
● Low socioeconomic status
● Cigarette smoking and illicit drug use
pre PROM mom risks
● Maternal infection (i.e., chorioamnionitis, endometritis)
● Abruptio placenta and retained placenta
● Increased rates of cesarean birth
pre PROM baby risks
● Fetal or neonatal sepsis
● Fetal deformities before 26w
● Preterm delivery and complications of prematurity
● Hypoxia or asphyxia
Nursing actions pre PROM
● Assess FHR and uterine contractions
● Assess for signs of infection
● Monitor for labor and for fetal compromise.
● Provide antenatal testing including non-stress tests (NSTs) and biophysical profiles (BPPs)
Cervical insufficiency
inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester
Cervical insufficiency risks mom
● Repeated second trimester or early third trimester births
● Reported complications of cerclage include rupture of membranes, chorioamnionitis, cervical lacerations, and suture displacement
Cervical insufficiency risks baby
● Preterm birth and consequences of prematurity
S/S Cervical insufficiency
usually are asymptomatic, some may report nonspecific symptoms, such as backache, uterine contractions, vaginal spotting, pelvic pressure, or mucoid vaginal discharge.
Indications for Cervical Cerclage (singleton pregnancies)
● History of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or abruptio placentae
● Prior cerclage due to painless cervical dilation in the second trimester
● Painless cervical dilation in the second trimester
● Current singleton pregnancy, prior spontaneous preterm birth at less than 34 weeks of gestation, and short cervical length (less than 25 mm) before 24 weeks of gestation
Postoperative Nursing Actions cerclage
● Monitor for uterine activity with palpation.
● Monitor for vaginal bleeding and leaking of fluid/rupture of membranes.
● Monitor for infection
●Patient teaching
Transvaginal McDonald cerclage remova
36 to 37 weeks of gestation
Multiple gestation
more than one fetus. They result from either the fertilization of one zygote that subsequently divides (monozygotic) or the fertilization of multiple ova.
Risks of multiple gestation mom
● Hypertensive disorders and preeclampsia
● Gestational diabetes
● Antepartum hemorrhage, abruptio placenta, placenta previa
● Anemia related to dilutional anemia
● Peripartum cardiomyopathy, pulmonary edema, and pulmonary embolism
● Intrahepatic cholestasis
● Acute fatty liver
● Cesarean birth
Risks of multiple gestation baby
● Increase in fetal morbidity and mortality
● Increase of low birth weight neonates
● Increase of intrauterine growth restriction (IUGR) and discordant growth
● Monochorionic twins have a shared fetoplacental circulation- specific serious pregnancy complications
● Increase of congenital, chromosomal, and genetic defects, in particular structural defects, with monozygotic twins.
Hyperemesis gravidarum
vomiting during pregnancy that is so severe it leads to dehydration, electrolyte and acid-base imbalance, starvation ketosis, and weight loss.
Hyperemesis gravidarum medical management
● Treatment of nausea and vomiting of pregnancy with vitamin B6 or vitamin B6 plus doxylamine
● Intravenous hydration
● Laboratory studies to monitor kidney and liver function
● Correction of ketosis and vitamin deficiency
● Medication may be needed in refractory cases of nausea and vomiting
Hyperemesis gravidarum- nursing actions
● Assess factors that contribute to nausea and vomiting.
● Reduce or eliminate factors that contribute ●ginger ●antiemetics as ordered ●early treatment ●emotional support ●comfort measures ●IV and meds as ordered ●daily weight ●monitor I/Os ●labs ●NPO until vomiting controlled ●prenatal vitamins with snack at night ●minimize fluid intake with meals ●complementary therapies
Intrahepatic cholestasis of pregnancy (ICP)
most common pregnancy-specific liver disease. It is a reversible type of hormonally influenced cholestasis and frequently develops in late pregnancy in individuals who are genetically predisposed.
causes pruritus of hands and feet
Type 1 diabetes
autoimmunity of beta cells of the pancreas resulting in absolute insulin deficiency and is managed with insulin.
Type 2 diabetes
insulin resistance and inadequate insulin production.
Pregestational diabetes
categorized as either type 1 or type 2 diabetes.
Gestational diabetes mellitus (GDM)
glucose intolerance that does not present prior to pregnancy.
Pregestational diabetes
blood glucose (BG) levels that are found to be above the normal range but below the cutoff for diagnosing overt or clinical diabetes in the nonpregnant woman
Gestational diabetes mellitus (GDM)
characterized by elevated blood sugar levels that do not meet criteria for clinical diabetes diagnosis. GDM is defined by ACOG as a carbohydrate intolerance leading to hyperglycemia that is first discovered in pregnancy.
Hypertension
systolic pressure 140 mm Hg or greater or diastolic pressure 90 mm Hg or greater.
Preeclampsia
multisystem hypertensive disease unique to pregnancy, with hypertension accompanied by proteinuria after the 20th week of gestation.
Eclampsia
onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia.
Gestational hypertension
Systolic BP ≥ 140/90 for the first time after 20 weeks, without other signs and systemic finding of preeclampsia.
Chronic hypertension
Hypertension (BP ≥ 140/90) before conception. High blood pressure known to predate conception or detected before 20 weeks of gestation
Preeclampsia s/s
BP over 160/110 visual problems pulmonary edema, shortness of breath abnormal liver function test abnormal kidney test low platelet count (<100,000) liver abnormalities HELLP syndrome
Risk Factors Preeclampsia
● Nulliparity
● Age younger than 20 or older than 35 years
● Obesity
● Multiple gestation
● Family history of preeclampsia
● Chronic hypertension, kidney disease, lupus, or diabetes prior to pregnancy
● Previous preeclampsia or eclampsia
● Gestational diabetes
Meds for preeclampsia and eclampsia
Magnesium sulfate
Antihypertensive medications
Anticonvulsant medications
Potential side effects of magnesium sulfate
Maternal: Nausea Flushing Diaphoresis Blurred vision Lethargy Hypocalcemia Depressed reflexes Respiratory depression-arrest Cardiac dysrhythmias Decreased platelet aggregation Circulatory collapse
Fetal/neonatal: Fetal heart rate decreased variability Respiratory depression Hypotonia Decreased suck reflex Signs and symptoms of magnesium toxicity
preeclampsia risks mom
● Cerebral edema/hemorrhage/stroke
● Disseminated intravascular coagulation (DIC)
● Pulmonary edema
● Congestive heart failure
● Maternal sequelae resulting from organ damage
● Abruptio placenta
●risk for heart failure later in life
preeclampsia risks baby
● Fetal/neonatal morbidity and mortality are consequences of intrauterine growth restriction (IUGR), prematurity, and placental abruption.
● Fetal intolerance to labor because of decrease placental perfusion
● Stillbirth
Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period
- maternal stabilization before delivery treatment within 30-60 min
- Intravenous (IV) labetalol and hydralazine
Immediate release oral nifedipine also may be considered as a first-line therapy, particularly when IV access is not available.
Biophysical profile
used to screen for acute or chronic fetal hypoxia by examining five fetal parameters most affected by hypoxia.
nonstress test, fetal movement, fetal breathing, fetal tone, and amniotic fluid index
Warning signs of potential eclampsia include:
● Severe persistent headaches
● Epigastric pain
● Nausea and vomiting
● Hyperreflexia with clonus
● Restlessness
eclampsia cause
● Cerebral vasospasm
● Cerebral hemorrhage
● Cerebral ischemia
● Cerebral edema
HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets)
the variant changes in laboratory values that can occur as a complication of severe preeclampsia.
Eclampsia Nursing Interventions
● Call for assistance and notify primary physician.
● Designate team leader, checklist reader/recorder, and primary RN.
● Ensure side rails are up and padded.
● Protect airway and improve oxygenation; administer supplemental oxygen (100% non-rebreather face mask); ensure suction and bag-mask ventilation are available; maternal pulse oximetry.
● Place in lateral decubitis position.
● Monitor and record description, characteristics, and duration of seizure activity, if present.
● Continuous fetal monitoring
● Establish and maintain IV access; draw preeclampsia labs.
● Administer magnesium sulfate.
● Administer antihypertensive therapy.
● Develop delivery plan, if appropriate.
● Update and communicate with patient, family, and obstetric team.
placenta previa
occurs when the placenta attaches to the lower uterine segment of the uterus, near or over the internal cervical os instead of in the body or fundus of the uterus
Risk Factors for Placenta Previa
● Endometrial scarring
● Previous placenta previa
● Prior cesarean birth
● Abortion involving suction curettage
● Multiparity or short pregnancy interval
● Impeded endometrial vascularization
● Advanced maternal age (>35 years)
● Diabetes or hypertension
● Cigarette smoking
● Uterine anomalies/fibroids/endometritis
● Increased placental mass
● Large placenta
● Multiple gestation
Placenta Previa s/s
● painless vaginal bleeding in the third trimester. ● Hemodynamic changes ● Fetal heart rate changes ● Ultrasound confirms placental location ●fear/anxiety
Placental abruption (abruptio placentae)
bleeding at the decidual-placental interface that causes partial or complete placental detachment prior to delivery of the fetus.
Placental abruption (abruptio placentae) risks
● Previous abruption increases risk up to 15%
● Hypertensive disorders, prior cesarean section, maternal age, multiple gestation, preterm premature rupture of membranes, uterine anomalies/fibroids
● Abdominal trauma
● Cocaine, methamphetamine use, and/or cigarette smoking
● Thrombophilia
Placental abruption (abruptio placentae) s/s
● Vaginal bleeding is present in up to 80% of women with abruption.
●changes in fetal heart rhythm
Placenta accreta
general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall.
Placenta accreta s/s
● The mainstay of antenatal diagnosis is obstetric ultrasonography.
Maternal assessment findings at delivery include:
● Hypovolemic shock
● Hypotension
● Oliguria
● Thready pulse
● Shallow/irregular respirations
● Pallor
● Cold, clammy skin
● Anxiety
Abortion
spontaneous or elective termination of pregnancy before 20 weeks’ gestation.
Abortion risk
● Increased parity
● Increased maternal and paternal age
● Endocrine abnormalities such as diabetes or luteal phase defects
● Drug use or environmental toxins
● Immunological factors such as autoimmune diseases
● Infections
● Systemic disorders
● Genetic factors
● Uterine or cervical abnormalities
ectopic pregnancy (EP)
when a fertilized egg grows outside the uterus as a result of the blastocyst implanting somewhere other than the endometrial lining of the uterus
ectopic pregnancy (EP) risks
● Pelvic inflammatory disease
● Previous ectopic pregnancy
● Infertility
● Pelvic or abdominal surgery
● Endometriosis
● Sexually transmitted diseases
● Prior tubal surgery (such as tubal sterilization)
● Cigarette smoking
● Exposure to the drug diethylstilbestrol (DES) during her mother’s pregnancy
● Increased age
ectopic pregnancy (EP) s/s
● Pelvic or abdominal pain
● Light or heavy bleeding
● Abdominal or pelvic pain
● Blood from the ruptured tube can build up under the diaphragm, causing shoulder pain.
● Weakness, dizziness, or fainting caused by blood loss
● Vital signs become unstable
gestational trophoblastic disease
group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception
gestational trophoblastic disease risk
● Maternal age younger than 20 or older than 35 years
● Previous molar pregnancy
gestational trophoblastic disease s/s
● Pelvic pain or sensation of pressure
● Anemia
● Hyperemesis gravidarum
● Hyperthyroidism (secondary to the homology between the beta-subunits of hCG and thyroid-stimulating hormone (TSH), which causes hCG to have weak TSH-like activity)
● Preeclampsia early in pregnancy
● Amenorrhea
● Nausea and vomiting
● Abnormal uterine bleeding ranges from spotting to profuse hemorrhage
● Enlarged uterus
● Abdominal cramping and expulsion of vesicles
Human immunodeficiency virus (HIV)
chronic illness caused by the retrovirus of the lentivirus family that has an affinity for the T-lymphocytes, macrophages, and monocytes.
HIV Risks to Fetus and Newborn
● Risk of transmission is 20% to 25% without the use of antiretroviral drugs but can be as low as 2% with appropriate antepartal drug treatment.
● Preterm delivery
● Preterm PROM
● IUGR
STI risks mom
● STIs can cause pelvic inflammatory disease (Table 7–4).
● Pelvic inflammatory disease (PID) can lead to infertility, chronic hepatitis, and cervical and other cancers.
● STIs during pregnancy can lead to PTL, PROM, and uterine infection.
STI risk baby
● STIs can pass to the fetus by crossing the placenta; some can be transmitted to the baby during delivery as the baby passes through the birth canal
● Harmful effects to babies include preterm birth, low birth weight, neonatal sepsis, and neurological damage.
TORCH
Toxoplasmosis, Other (hepatitis B), Rubella, and Cytomegalovirus and Herpes simplex virus
Cytomegalovirus (CMV)
common cause of congenital infection
Group B Streptococcus (GBS)
colonizes the female genital tract and rectum
Group B Streptococcus (GBS) causes what
UTI, pyelonephritis, chorioamnionitis, preterm labor, vaginal discharge, postpartum endometritis, post cesarean section wound infection, and in rare instances endocarditis
Group B Streptococcus (GBS) treatment
● Common cause of sepsis, meningitis, and pneumonia
● Positive test for GBS in current pregnancy or previous pregnancy. CDC recommends routine cultures of vagina and rectum between 35 and 37 weeks’ gestation.
most common cause of maternal death by trauma
abdominal injury
head injury
predominant causes of reported trauma during pregnancy
Motor vehicle accidents and domestic violence/intimate partner violence
Percentage of blood to placental bed
15%
what can happen after blunt trauma to the abdomen:
● Placental abruption
● Uterine rupture
Complications to mom with cardiac disease
● Pulmonary hypertension
● Pulmonary edema
● Congestive heart failure
● Maternal or fetal death
anemia during pregnancy- why
expansion of plasma volume without normal expansion of maternal hemoglobin mass.
anemia risk factors
● History of poor nutritional status or eating disorder
● Close spacing of pregnancies
● Multiple gestation
● Excessive bleeding
● Adolescence
Anemia risks mom/baby
Risks for the Woman
● Fatigue
● Reduced tolerance to activity
Risks for the Newborn
● Preterm birth
● Intrauterine growth restriction
Asthma
chronic syndrome characterized by varying levels of airway obstruction, bronchial hyperresponsiveness, and bronchial edema.
Asthma risks baby
● Hypoxia to the fetus is a major complication.
● Preterm birth
● Low birth weight
● Fetal-growth restriction
asthma risks mom
● Uncontrolled asthma increases the risk of preeclampsia, hypertension, and hyperemesis gravidarum.
Chronic kidney disease in pregnancy management
careful blood pressure monitoring, renal function testing, and 24-hour urine protein collections.
Cholelithiasis
presence of gallstones in the gallbladder.
why is Cholelithiasis common in pregnancy?
increased estrogen levels cause cholesterol supersaturation and increased gallstone formation.
Acute fatty liver of pregnancy (AFLP)
rare disorder characterized by the onset of abdominal pain and jaundice, typically occurring after week 34 of gestation.
Venous thromboembolism (VTE)
a blood clot that starts in a vein.
Thromboembolism
blood clot that can potentially block blood flow and damage the organs
deep vein thrombosis (DVT)
a clot in a deep vein, usually in the leg, but sometimes in the arm or other veins.
Pulmonary embolism (PE)
occurs when a DVT clot breaks free from a vein wall, travels to the lungs, and blocks some or all the blood supply.
DVT s/s
dependent edema, abrupt unilateral leg pain, erythema, low-grade fever, and positive Homan’s sign (i.e., pain with dorsiflexion of foot).
PE s/s
shortness of breath, tachypnea, tachycardia, dyspnea, pleural chest pain, fever, and anxiety.
Obesity risks mom
● Preeclampsia
● Deep vein thrombosis
● Urinary tract infections
● Gestational diabetes
● Preterm birth
● Cesarean delivery
● Operative and post-operative complications
Obesity risks baby
● Congenital anomalies, including cardiac and neural tube defects
● Growth abnormalities and facial clefting
● Macrosomia
● Miscarriage
● Stillbirth
Hyperthyroidism
greater risk of preterm delivery, severe preeclampsia, and heart failure with an increase in medically indicated preterm deliveries, low birth weight infants, and possible fetal loss.
Hypothyroidism
inadequate thyroid hormone production and is associated with elevated TSH levels and decreased FT4 levels.
Systemic lupus erythematosus
heterogenous autoimmune disease characterized by immune system abnormalities, including overactive B lymphocytes.
Systemic lupus erythematosus s/s
● Malaise
● Fever
● Weight loss
● Arthritis
● Rash
● Pleuro-pericarditis
● Photosensitivity
● Anemia
● Cognitive dysfunction
Substance use risks mom
● Preterm labor
● PPROM
● Poor weight gain and nutritional status
● Placental abnormalities
substance use risks baby
● Fetal effects may include CNS abnormalities and intrauterine growth restriction, small for gestational age, low birth weight, prematurity, and stillbirth
● Neonatal withdrawal syndrome
● Sudden infant death syndrome (SIDS)
