What is a High Risk Pregnancy?
A pregnancy with a concurrent disorder or complication.
The course of a normal pregnancy vs. the pregnancy with a pre-existing disease or condition
"Disease can complicate the pregnancy; pregnancy can complicate the disease"
What will nursing care for the high risk pregnancy include?
Care and support as with a "normal", uncomplicated pregnancy, as well as application of knowledge re: preexisting disease, pathophys, implications in preg., etc.
What is the primary objective of nursing care in the high risk pregnancy?
Guidance and support, "anticipatory" guidance" and anticipation of complications - surveillance of mother, fetus and newborn.
exists when there is deficiency of or resistance to insulin. It interferes with the body's ability to obtain nutrients for fuel & storage at the cellular level. Chronic hyperglycemia results in long-term damage to organs & vasculature. Incidence in pregnancy is increasing alarmingly ------ Despite advances in care, POOR OUTCOMES ARE NOT UNCOMMON IN DIABETIC PREGNANCY
In pregnancy, the mother's metabolism supports the growth & development of the fetus...directed toward supplying adequate nutrition for the fetus. What hormone supports this?
Human Placental Lactogen (HPL)
With a diabetic pregnancy, what actions are important as a part of the multidisciplinary team approach (nurse, obstetrician, endocrinologist, dietician, possibly neonatologist, pernatologist)?
-Strict dietary adherence
-Regular FSBS and labs
-Intensive fetal surveillance
What is the key to an optimal pregnancy in a diabetic mom?
Strict maternal glucose control, preconception through delivery
What can occur as early as the 8th week if a pregnant mom's diabetes is not strictly controlled?
Renal, cardiac, CNS, and skeletal deformities
In a diabetic mom, what can occur later in pregnancy, even at term, as a result of uncontrolled blood glucose?
Sudden fetal death
What are the pregnancy's effects on diabetes?
"Morning sickness" - N/V, decreased carbohydrate intake increases acidosis
HpL (human placental lactogen) decreases insulin response so need more insulin but pancreas can't keep up
Elevated metabolic rate
Lowered renal glucose threshold so spill more
Increased glucose in urine, saliva = ??
What things should be part of preconception/prenatal counseling for a diabetic woman?
- Involve mom in care, work with her early - "buy in" to compliance
-Achieve lowest glycosolated hemoglobin possible - HgA1C
-Delay pregnancy until euglycemic (within normal range) for 1-2 months
-ID long-term complications that may already exist (hypertension, retinopathy, cardiovascular, renal involvement, etc.) * Rationale: many fetal malformations a/w DM occur very early in pregnancy; if complications exist pre-pregnacy, they may be expected to worsen during pregancy *
What are the complications of diabetes on pregnancy?
* Preterm birth
* Childhood / Adult Obesity
* Type II diabetes later in life
>>>>>>BIGGEST scare is stillbirth (38-40 wks) with uncontrolled DM in the mom<<<<<<<<<<<<<<
Type 1 diabetes
Absolute insulin deficiency (due to an autoimmune process); usually appears before the age of 30 yrs; approx. 10% of those diagnosed have Type 1 diabetes
Type 2 diabetes
Insulin resistance or deficiencyc (r/t obesity, sedentary lifestyle); diagnosed primarily in adults older than 30 yrs of age but is now being seen in children; accounts for 90% of all diagnosed cases
Gestational diabetes mellitus
Glucose intolerance with its onset during pregnancy or first detected in pregnancy
Gestational Diabetes Risk Factors
Marked obesity before pregnancy
personal history of GDM
strong family history of DM
Common symptoms: polydipsia, polyuria, polyphagia, fatigue
Glucose tolerance testing
Screening done at 24-28 wks, one hour glucose challenge test
Blood glucose after one hour is > 140 mg/dL, test is positive
If positive, 3 hour glucose tolerance test is indicated. Positive for GDM if 2 or more levels are met or exceeded:
Fasting >90-95 mg/dL
1 hour >180
3 hour >140
Glycosylated hemoglobin - for all types of DM
A measurement of the average blood glucose level over the past 120 days
** HgA1C = <7% means good glycemic control; levels trending down for best management, closer to 6% (practice)
Therapeutic management with any type of DM focuses on...
TIGHT glucose control....
Keeping blood glucose <120 postprandial, 60-90 fasting
Nursing Care of the diabetic mother
Most is the same as with any diabetes patient: teaching regarding: diet, exercise, blood glucose testing and control.
Teaching: based on anticipatory guidance and prevention
Nutritional plan for diabetic mother?
Achieve/maintain euglycemia = <120
Provide adequate energy to gain weight & prevent ketosis
Make sure they are taking their prenatal vitamins
Nutrients for mother/fetus while maintaining tight control
Assess medical, social, food history
* 2000-2200 cal/day, consistent carbohydrates, 3 meals with 2-3 snacks *
Exercise plan for diabetic mother?
Consistent exercise plan burns extra glucose, greatly assists in control: Glycemic control, decreases insulin resistance, prevents excess weight gain
20-30 minute aerobic activity
Doesn't have to be vigorous or lengthy to make a difference
After meals, as glucose is rising, is best. Effects can last up to 14 hours (Walking after dinner) >>My notes say "better to exercise before bed" ???
Blood glucose monitoring - FSBS management
Teach technique, meter/strip suppliers, schedule AC, HS, some PP
******* IMPORTANT- IMMEDIATELY REPORT levels ,
<60 or >120 ********
Hypoglycemia treated with?
Oral intake of simple carbs - 10-20 gms:
1 T. honey
1 T. Karo syrup
4 oz. OJ
2 glucose tablets
4 oz. Coke (not diet!)
Important that diabetic mom & family are taught.....?
The S/S of hypoglycemia, hyperglycemia and interventions
S/S of Hypoglycemia AND treatment needed
Sweating, tremors, cold, clammy skin, headache, feeling hungry, blurred vision, disorientation, irritability
TREATMENT: Drink 8 oz. of milk and eat two crackers or glucose tablets. Carry "glucose boosters" (such as LifeSavers) to prevent hypoglycemia
S/S of Hyperglycemia AND treatment needed
Dry mouth, frequent urination, excessive thirst, rapid breathing, feeling tired, flushed, hot skin, headache, drowsiness
TREATMENT: Notify health care provider, since hospitalization may be needed
With diabetic mom, urine speciment is used...?
testing for ketones with first morning urine; plan for sick days
Medications for the diabetic mom? If GDM, diet alone may control, yet....
If GDM, diet alone may control, yet may need to be on insulin at some point. NO oral agents currently available for use during pregnancy.
ANTICIPATE! If preexisting diabetes, wil need to change to insulin from oral agents
Rapid acting and/or long acting insulin in the PM
Teaching self-injection...or even insulin pumps
Assessment and surveillance of the diabetic mom?
More frequent; both mother and fetus:
Review FSBS journal -look at it -should have readings 4-6xday
HgA!C every 2-3 months
BP, UA, NST, BPP, growth
Higher risk of PIH
Psychosocial support/stress management
EKG (looking for cardiac changes), retinal exams each trimester, 24 hour urine
Amniocentesis close to term - still frequently done
IMPORTANT: Need dental checkup every 6 mos!
Nursing Diagnoses regarding diabetes in pregnancy
1. Deficient knowledge r/t diabetic pregnancy, management, potential effects on pregnant woman and fetus
2. Anxiety.../fear.../powerless... r/t effects of diabetes, potential sequelae, threat to maternal and fetal well-being
(PRIORITY) 3. Risk for fetal injury r/t elevated maternal glucose levels...........uteroplacentral insufficiency... birth trauma
4. Risk for maternal injury r/t improper insulin administration...hypo/hyperglycemia....C-section, operative vaginal birth...postpartum infection
Management of diabetes in pregnancy
Insulin therapy - REMEMBER NO ORAL AGENTS (teratogenic!)
Will see increased requirements for insulin during the 2nd and 3rd trimesters as insulin resistance increases. Type 2 moms may need to learn to self-administer insulin
2-3 injections per day; or pump
Labor & Delivery considerations with diabetic mom
When to deliver? Early to avoid stillbirth?
PIH? Poor metabolic control? Macrosomia? IUGR? Risk of stillbirth?
Amniocentesis? L/H ratio 2:1 In diabetic pregnancies the fetal development of surfactant is delayed.....early deliveries may have respiratory distress.
Intrapartum care of the diabetic mom
Frequent FSBS - hourly
Continuous EFM - risk for uteroplacental insufficiency
Hydration; using D5W for glucose, or NS if quicker labor, with insulin, titrated drop to keep glucose level 60-100 mg/dL (titrated)
Observe for fetal descent, CPD ....45% of diabetic births are C-sections
Macrosomia is > 9.5 lbs!
Postpartum care for the diabetic mom?
(1) Insulin requirements immediately decrease
(2) The major source of insulin resistance is removed (the placenta!)
(3) Women with Type 1 may require obly 1/2 of usual dose on first day; Type 2 may no longer require insulin
(4) Observe for complications - INFECTION, hemorrhage
(5) Encourage to breast feed - antidiabetogenic process, lowers blood sugar as metabolism is changed
(6) Even if they weren't diabetic before, still might be hyperglycemia for a while
(7) Contraception/family planning! (so they can heal & recup for a while before next baby) Each pregnancy=significant risk!
Cardiac disease is
# 1 killer of women, kills more women than men, poorer prognosis than men. Cardiac disease in pregnancy accounts for 4% of women, 1/4 of maternal mortality.....congenital and acquired disease split evenly
How is the CV system taxed in a normal pregnancy?
* Blood volume increases 40-50% (1000-1500mL)
* Heart rate increases, CO increases 30% (how much pumped with each beat)
* Systemic vascular resistance decreases
* Blood pressure varies, murmurs can be heard
* Common symptoms of late pregnancy (palpitations, SOB w/ exertion, occasional chest pain) are also signs of cardiac disease
What are pregnancy effects on preexisting cardiac disease?
>Hemodynamic challenges prevent compensation (primarily increased circulatory volume)
>Increased risks for complications: CVA, heart failure, arrhythmias
>Mitral valve prolapse - most common cause of mitral valve regurgitation, most women tolerate pregnancy well
>Mitral valve stenosis - most common chronic rheumatic valvular lesion in pregnancy. Usually managed well medically (fixed cardiac output) but some develop right sided heart failure
What are cardiac disease effects on pregnancyf?
1. Can be contraindication to pregnancy; pre-conceptual counseling. With some grades of cardiac disease maternal mortality can rise to 50%!
2. Fetus also at risk of complications: PTL, LBW (<5 lbs), RDS, IVH (intraventricular hemorrhage), death, increased likelihood of fetal heart defects
Class I Heart Disease
No limitations on physical activity
Asymptomatic at normal levels of activity. Corrected tetralogy of Fallot, valve stenosis. Mortality rate 1%.
Class II Heart Disease
Slight limitation of physical activity
Symptomatic with ORDINARY ACTIVITY: causes excessive fatigue, palpitations, dyspnea, or angina
Mitral stenosis with atrial fib, artificial heart valve, aortic stenosis, uncorrected tetralogy of Fallot. Up to 15% mortality rate
Class III Heart Disease
Symptomatic with LESS THAN ORDINARY activity
Moderate to marked limitation in physical activity. During less than usual activity, experiences fatigue, palpitations, dyspnea, or angina.
Class III usually counseled not to get pregnant
Class IV Heart Disease
Symptomatic AT REST
Unable to carry out any physical activity without experiencing discomfort
Should NOT be pregnant. Dilated cardiomyopathy, primary pulmonary hypertension, aortic root dilation
Up to 50% mortality rate
Nursing Care of the Pregnant Cardiac Patient
Basic, practice guide is very similar to the diabetic patient:
lots of teaching
start with EKG, O2 saturation, etc.
What is the biggest concern with pregnant cardiac patient?
With congenital heart problems, valvular disease, if myocardial disease develops >> anticipate cardiac decompensation!!
Inability to maintain adequate circulation results in impaired tissue perfusion of the mother (and fetus)... AKA Heart failure
The danger in pregnacy occurs mainly bc of increased circulatory volume! (Up to 50% increase)
*Peak blood volume occurs at approx 24 wks of pregnacy..the heart may be so overwhelmed by increased volume that it just can't pumpt hard enough anymore..CO decreases to the point that vital organs are not perfused adequately
(In pregnancy this includes the uterus and placenta!)
How does left-sided heart failure occur?
When the left ventricle cannot move the volume of blood forward that is received by the left atrium from the pulmonary circulation
What will the patient exhibit with left-sided heart failure?
Wet crackly lung sounds
How often to check breath sounds in pregnant cardiac pt?
Assess the lungs every visit, every 30 minutes in labor, after delivery too!!
Pathophys of pulmonary edema
Muscular changes of the ventricle with hypertrophy....backflow increases pressure in the pulmonary veins, fluid passes from the pulmonary membrane into the interstitial spaces around the alveoli. Pregnancy doesn't require as big a change in pressure to see pulmonary edema!
Right-sided heart failure
occurs when the output of the right ventricle is less than the blood it receives from the right atrium. Back pressure causes congestion of systemic circulation and decreased CO to lungs
What will a patient with right-sided heart failure exhibit?
Portal circulation _______?? Engorged liver (look this up)
due to effects of pregnancy on the CV system - CHF
Postpartum recovery vs. heart transplant
Nursing management priorities in the pregnant cardiac patient
Document pre-pregnant status, limitations; weekly visits throughout pregnancy
More nsg mngmt priorities for preg. cardiac pt
Assessment: report any HTN, diaphoresis, pallor, syncope, fever, decreased capillary refill, jugular distention, EDEMA! (Pulmonary or body)
Question client about any changes in activity level, functional capability, factors increasing stress on heart
Stress the DANGER!! - SUDDEN inability to perform usual activities; sudden changes in activity level from what she was comfortable doing earlier...Visualize the change from class I to class II or III...See MD immediately
Nursing Diagnoses for the pregnant cardiac patient
** Activity intolerance r/t effects of pregnancy on heart disease
** Decreased cardiac output r/t increased circulatory volume secondary to pregnancy and cardiac disease
** Risk for ineffective management
** Risk for self-care deficit
Prenatal nursing interventions - teaching / anticipatory guidance
(1) 8-10 hrs sleep each night; 30 min nap after meals - how to manage
(2) Limit activities to functional classification
(3) Avoid heavy exertion - what about running the household?
(4) Bed rest if class III or IV
(5) ** Make absolutely certain patient/family know to seek medical care if SUDDEN INABILITY to perform activities she has been comfortable doing previously!!**
(6) Nutrition - balanced, hi-iron, protein, calories to gain weight
(7) Avoid constipation - fiber, fluid. No Val Salva maneuvers
Prenatal nursing interventions - teaching / anticipatory guidance.......CONTINUED
(8) Sodium - blood volume. Sodium attracts fluid, potassium...interferes with cardiac muscle action
(9) Meds - observe renal function - increased clearance of meds, adjust to maintain therapeutic levels
* anticoagulants - if needed, Heparin is used (does not cross placenta) - Coumadin/warfarin is teratogenic. Remember pic!
(10) Fetal surveillance - kick counts, NST, low back pain, pelvic pressure (PTL), ultrasounds for growth
(11) Always auscultate heart rate, sounds, any irregularities, weight gain, edema
(12) Changes in lifestyle, how she copes, support system, network analysis (neighbors, church family, bunco babes, work friends, family)
Intrapartal nursing interventions - the work of the heart increases during labor & delivery. Labor is an additional burden on the CV system, so that is when to especially watch for problems! See Graph!!
1. Vaginal birth is recommended; labor with HEAD ELEVATED (decreases cardiac congestion and workload on heart), side lying also important for uterine perfusion
2. Epidural anesthesia is recommended to minimize ValSalva maneuvers with stage II pushing... "Labor down" passively
3. Assess for DECOMPENSATION (acute CHF)
>> How assessed? Listen to lung/breath sounds!
>>Cough, crackles, HR >10; Resp >25
>> May need arterial pressure lines ("art line" or "Swan Ganz") to measure pressures inside heart, arteries....may need a CCU nurse to come to L&D or transport to high risk center
Postpartal interventions for preg. cardiac pt
Not out of the woods yet!
1. Assessing for cardiac compensation is critical! May be in CCU.
2. 24-48 hrs is most hemodynamically difficult>>>fluid shifts
3. Cardiac output increases rapidly as extravascular fluid is remobiliized into the vascular compartment...did she have edema/
4. It can take up to 6 weeks to stabilize the CV system
5. Elevated HOB, lie on side (uterus is still big, need renal perfusion)
6. Activity restrictions may be necessary - BR with BRP, ADL with assist
7. Progressive ambulation, checking VS and lungs before and after
8. Mom may need to direct OTHER family in care of the infant if she is restricted, SOB, etc....Focus on her needs and wishes about how who does what...
Pre-pregnancy or appearing before 20th wk of pregnancy or lasting longer than 12 wks postpartum. Seen in a growing percentage of young women (22%) varying with age, race, BMI. Complicates at least 5% of pregnancies, with 1 in 4 developing preeclampsia
1. Pre-conception counseling - lifestyle changes: diet, exercise, weight loss, smoking cessation. Modify these risk factors as well as caffeine, alcohol, sodium, NSAID use
2. Once pregnant, goal is to maintain normal BP w/o superimposed preeclampsia, normal fetal devt. HTN during pregnancy reduces uteroplacental perfusion. Pts are seen more frequently, assess BP, compliance w/ meds, fetal growth, amniotic fluid volume
3. Daily rest periods in left sidelying to increase placental perfusion; use home BP monitor & report elevation s. Positive feedback for compliance & attempts made to change lifestyle.
4. Preeclampsia can develop antenatal, intrapartal, or postpartally, superimposed on chronic HTN. Meds continue to be administered
Affecting 4% of pregnancies, asthma in pregnancy is common & potentially serious medical condition. Maternal asthma seen as RISK OF INFANT DEATH, IUGR, preterm birth & LBW, HTN/preeclampsia, placenta previa, hemorrhage & oligohydramnios. Very common & very serious
More on asthma in pregnancy....
A. The more severe the mother's asthma, the more severe the risk.
B. Reversible airway obstruction & bronchial hyper-responsiveness - inflammatory response of respiratory tract to various stimuli; reactive airway disease because there is BRONCHIAL CONSTRICTION in response to allergens, irritants & infections, temp. changes
Chronic Hypertension - Medications
Meds adjusted as many cannot be used in pregnancy.
***Aldomet (methyldopa) is safe in pregnancy & improves uterine perfusion...meds usu. reserved for severe HTN. Other safe ones include labetalol, atenolol, nifedipine, propranolol
Asthma in Pregnancy
Changes in anatomy with the enlarging uterus & increased progesterone create changes in lung capacity:
* metabolic rate increases
* O2 consumption increases
* diaphragmatic elevation
* decrease in functional lung residual capacity
If mom has trouble breathing...
the fetus has trouble getting oxygen.
Progressively worsening symptoms:
shortness of breath
These symptoms occur on a continuum ranging from mil persistent to severe life-threatening
How do you manage asthma in pregnancy?
Manage aggressively! Benefits outweigh risks.
** Goals are to prevent hospitalization, ER visits, lost days at work, disability
Medications for Asthma in pregnancy
PO or inhaled; usually include inhaled corticosteroid while pregnant, bronchodilators for long-term prevention and rescue:
Budesonide - Rhinocort, Pulmicort (not a rescue inhaler)
Albuterol - Proventil, Ventolin (recue inhaler)
Salmeterol - Serevent (long-term control)
What are some common asthma triggers?
Smoke and chemical irritants
Seasonal changes with pollen, molds & spores
Upper respiratory infections
Medications, such as aspirin & nonsteroidal anti-inflammatory
Emotional stress (Labor can be a trigger!)
Extra triggers in pregnancy - GERD - reflux increases risk for infection in pregnancy
Patient teaching for moms with asthma
*Pathophys (S/S of asthma progression, exacerbation)
*Importance & safety of meds to mom & fetus; correct use of MDI, adverse effects
*Warning signs to contact MD
*How to remove triggers
** IF YOUR RESCUE INHALER DOESN'T HELP AFTER 2 DOES, HEAD TO THE ER! **
Planning/Anticipatory guidance for asthma in pregnancy
WHEN IN LABOR....bring inhalers to L&D...
Pulse oximetry will be used
Epidural anesthesia is recommended b/c it will reduce oxygen consumption
Postpartum - increased risk for hemorrhage
When your asthma is not well controlled....
there is a significant increase in "attacks" during pregnancy!!!
30% no change in pregnancy
30-50% worsen, usually during weeks 24-36
What is the goal/outcome?
What factors should the nurse include in a teaching plan for a pregnant client with asthma?
See Teaching Guidelines 20.2 Box on p. 606
- Remove carpeting in house, esp. the BR, to reduce dust mites
-Use allergen-proof encasing on mattress, box spring & pilloes
-Wash all bedding in hot water
-Remove dust collectors in house, such as stuffed animals, books, knick-knacks
-Avoid pets in house to reduce exposure to pet dander
-Use a high-efficiency particulate air-filtering system in BR
-Do not smoke, and avoid places where you can be exposed to passive cigarette smoke form others
-Stay indoors & use A/C when pollen or mold count is high or air quality is poor
-Wear a covering over your nose and mouth when going outside in cold weather
-Avoid exposure to persons with colds, flu or viruses
Most common disorder of pregnancy. Oxygen-carrying capacity reduction causes cardiac compensation by increasing CO, cardiac workload, and taxing ventricular function. Sign of an underlying problem
What is criteria for anemia in pregnancy?
Less than 11 gm/dL hemoglobin
Less than 35% hematocrit (32-35% CDC)
Remember, blood volume increases by up to 50% in pregnancy, but...
total red blood cell expansion increases only 25% (because the red blood cells are diluted with the blood volume). This hemodilution can lead to PHYSIOLOGIC ANEMIA of prenancy, which is expected in the second trimester. This hemodilution phenomenon should not be confused with an iron deficiency nemia, in which the Hgb would be below 11 gm/100 mL and Hct below 35%
the most common type, PATHOLOGIC
*usually r/t inadequate dietary iron intake
*iron is actively transported across the placenta for fetal erythropoiesis causing maternal losses
What is the primary screening test to diagnose iron deficiency anemia?
Level of < 10-15 mcg/L is indicative of iron deficiency anemia
Pathophys of iron-deficiency anemia
Small red blood cells are microcytic, hypochromic b/c less hemoglobin than normal. Iron is unavailable for incorporation into RBCs.
What are goals in iron-deficiency anemia?
To eliminate symptoms, correct the deficiency and replenish iron stores.
Outcome: Hgb >12, FHR 120-180, taking iron supplements daily
Iron supplementation in pregnancy
Start early - 30 mg/day
Diet therapy alone is inadequate...may need 60-120 mg/day
Side effects of iron supplementation
TAKE WITH FOOD, acid/vitamin C
How to know if patient is compliant with iron supplements?
Iron stimulates erythropoiesis
Immature RBCs = reticulocytes (count will increase)
Dietary sources of iron
Meat (beef, chicken, pork, liver)
Green leafy vegetables
Legumes, dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortified breads and cereals (fortified is better than enriched)
Folic Acid Deficiency Anemia
One of the B vitamins, folic acid is necessary for RBC production in mom, PREVENTION OF NEURAL TUBE DEFECTS IN FETUS
Seen in up to 5% of pregnancies; occurs frequently in multiple gestation, with a hemolytic illness, women taking Dilantin or have been on OC.
Folic Acid Deficiency Anemia
is a megaloblastic anemia, with enlarged red blood cells, the opposite of iron deficiency anemia. May be a factor in early miscarriages or placental abruption.
Effects of folic acid deficiency anemia
Fetal effects occur in first weeks of gestation, primarily neural tube defects, so pre-conception correction and supplementation is essential
Folic acid requirements in pregnancy?
400 mcg prental, 600 micrograms during pregnancy.
Should be taking a prental vitamin, which supplies adequate folic acid, where general multivitamins do not have adequate amounts.
Dietary folic acid
folacin-rich foods (fortified cereal, green leafy, oranges, dried beans, broccoli, asparagus
Food preparation matters!
How does the nurse know whether client has folic acid or iron deficiency anemia?
Sickle Cell Hemoglobinopathy
Sickle cell trait 10%, with sickling of RBCs but they have a normal life span. Anemia in 1%, hemolytic anemia, abnormal hemoglobin
is a recessive trait, 1:10 have trait
RBCs cannot carry O2, O2 tension is decreased (a cell that is sickled cannot carry O2)
S/S of sickle cell anemia
Recurrent attacks (crises) of fever, pain in abdomen or extremities starting in childhood...caused by vascular occlusion (abnormal cell clumpin results in vessel blockage, tissue hypoxia, edema, hemolysis, severe anemia
Preconception for pts with sickle cell
genetic counseling; fetal loss is high. There is an expected increase in crises during pregnancy.....Dietary intake of folic acid supplements will help build RBC count. Daily fluid intake should increase.
Sickle cell anemia is made worse by
pregnancy. Impaired O2 supply, sickling, infarcts in placental circulation. Mom is prone to pyelonephritis, leg ulcers, CVA, CHF, cardiomyopathy, PIH
Interventions for sickle cell anemia
Ultrasounds to determine fetal growth/rule out IUGR; NST weekly.
Prophylactic transfusions decrease the sickle cells, increase hemoglobin
In sickle cell, C-section
not a good idea. Wnhy? In labor, hydration and O2 per MASK are common nursing interventions. TED hose postpartum
TORCH Syndrome Infections
Infection of the fetus occurs by any of a group of infections, mostly viral, which are transmitted through placenta from mother (Congenital infection). The severity & damage, along with severity, depends on the type of infection. Can be very damaging or fatal to fetus/neonate!
Other infections: (Hepatitis B, Syphilis, Varicella-Zoster, HIV, Parvo Virus, Group B Strep
A parasite; 50% transmission rate
* Undercooked meats, fresh foods/soil, kitchen practices, i.e. cutting boards, gloves for gardening
** KITTY LITTER! Cat feces common source **
* can build antibodies so if infected long ago, mom probably OK; flu-like, enlarged lymph glands
* may see no physical signs at birth, but will experience visual, hearing, learning disabilities. 15% mortality, 85% severe psychomotor/cognitive impairment by 2-4 y/o; 5-% visual by 1 y/o
Hepatitis B virus
Very common, can live outside body for a week.
* Blood, illicit drug use, sexual contact
* anorexia, abd. pain, N/V, fever, jaundice
* vertical infection (to fetus) 10% 1st trimester, 90% 3rd trimester. Increased risk of PTL, LBW, neonatal death. Likely to be chronic carrier, reservoir to public. Cirrhosis, liver cancer seen later
* 1st prenatal visit - hep B surface antigen (HbsAg) then again at 32-34 weeks
* Hep B immune globulin can be given in pregnancy, neonate at <12 hrs age.
>> Bathe early in hospital nursery
* 2-5% congenital acquisition rate. If syphilis in pregnancy is untreated, 50% will have neonatal syphilis symptoms at birth. If infected before 7 mos gestation, all fetuses will be affected. If later, pathologic changes are still evident: liver, spleen, kidneys, adrenals, bone periosteum and marrow, CNS disorders, teeth, cornea
* Infants edematous, anemic, enlarged liver & spleen...Or asymptomatic
Characteristic symptom: "SNUFFLES" clear, copious, serosanguineous mucous nasal discharge (babies typically are born with a snotty nose)
* After first wk if untreated, will see a copper-colored maculopapular rash, palms & soles, diaper area; later (yrs) neurosyphilis, deafness, gumma (gum and??), teeth deformities, keratitis of cornea
Same virus as chickenpox & shingles
* 7:10,000 pregnancies
* spontaneous abortion, LBW, chorioretinitis, cataracts, cutaneous scarring, skin lesions, along a dermatome, limb hypoplasia, microcephaly, ocular abnormalities, mental retardation, early death
* know immunity status pre-conception, know if work in areas of exposure
* risk of varicella pneumonia to mother, life-threatening compromise
* if mom contracts close to delivery, expect neonatal varicella and high mortality
3% - common, self-limiting benign childhood virus....erythema infectiosum (Fifth's disease). Majority of women have developed immunity.
* transplacental transmission, as with other viral infections
* fetal nonimmune fetal hydrops (hemolytic disease) secondary to edema, fetal loss, congenital anomalies (CNS, craniofacial, eyes), long term learning disabilities, myocarditis, liver
* Mom - rash on face "slapped cheeks", maculopapular rash, fever, arthralgia, malaise
* prevention is best strategy: handwashing, clean toys, stay away from day cares!?
Group B (beta) Streptococcus
Naturally occurring, common in adults.
* positive testing indicates carrier status; 25% carry GBS in rectum or vagina, thus the issue with the fetus at delivery; Sepsis or pneumonia are early onset crises in newborns, as is meningitis (late onset).
* antibiotic therapy for moms, so all pregnant women are screened at 35-37 weeks with vaginal or rectal cultures. If positive, the mom is treated with IV antiobiotics during labor/prior to delivery. Penicillin G drug of choice, given IVPB Q 4hr, hopefully receiving 2 doses at least an hour before delivery. If GBS status is unknown, they are treated as if positive.
* assess for s/s of infection: fever, UTI, chorioamnionitis, previous GBS, ROM >18 hrs, invasive obstetric procedures
Rubella (German measles) (3 day)
Droplet or direct contact
* early in pregnancy - 50% infection of fetus as well
* MMR has tremendously reduced rubella: titer drawn at 1st prenatal visit, >1:8 indicates immunity
* cannot be immunized while pregnant (live virus) but will be before hospital discharge postpartum
* high rate of fetal wastage; survivors have significant defects, deafness
Most common congenital and perinatal viral infection in the world! Up to 3% of all newborns....Acquired from sexual contact, blood transfusions, kissing, contact with children. In ALL body fluids.
* Results in abortion, stillbirth, LBW, IUGR, microcephaly, blindness, deafness, mental retardation
* if primary infection is during pregnancy, fetus has 50% chance of infection
* most women are asymptomatic; there is no therapy
* good handwashing, hygiene
* if preemie needs a transfusion, it must be with CMV-free blood
Herpes Simplex virus
Number of cases of newborn HSV infection rises annually.
* HSV-1 traditionally "fever blisters"
* HSV-2 traditionally genital herpes
* Now either can be either location... Once the virus enters the body, it never leaves!
* Significant mortality and morbidity to fetus/newborn; severe neurologic impairment. Danger is with direct contact to lesion/viral shedding. If active lesion at time of labor/delivery, C/Section is recommended
Nursing Diagnoses for Herpes Simplex Virus?
Risk of Injury, fetal
Risk for transmission of infection
Women are the fastest growing population. Virus attaches to a receptor (CD4) on the T4 helper T cells, the master immune cells. Once inside the T4, it destroys the cell. Without their functioning the entire immune system is weakened and suppressed.
How does the initial infection of HIV manifest?
With mononucleosis type sumptoms. The patient can be asymptomatic for months or even up to 10 years....all the while infectious
Should all pregnant women be screened for HIV?
Yes. Allows for early treatment, alerts providers so transmission minimized, allows for teaching
What is the risk of perinatal transmission with HIV?
25% with no antiretroviral therapy. Transmission occurs transplacentally, during delivery, and through breast milk. Of all pediatric AIDS cases, 90% were perinatal, breast feeding transmissions.
Antiretroviral therapy with HIV is with?
AZT (zidovudine - ZDV) very diligently can reduce the incidence of perinatal transmission to 8%. Combination therapies can reduce the incidence even further...almost eliminated in some studies. AZT inhibits viral RNA synthesis by inhibiting the enzyme DNA polymerase...prevents viral replication. Five doses daily! Q day!!
Intrapartal treatment for HIV ?
AZT continous infusion. Combination therapy if mom has not been on a treatment regimen, just diagnosed at admission, etc.
Delivery method with HIV infected mom?
Usually a C/Section is recommended to decrease likelihood of neonatal exposure to maternal blood; depends on viral load counts according to some studies. BathSye the babies early!
The most common neurological disorder accompanying pregnancy. Seizures may be more frequent or more severe in pregnancy depending on seizure status.
Pregnancy's effect on epilepsy?
Best predicted by pre-pregnancy seizure status.
* Women who have seizures at least monthly despite optimal AEDs can almost uniformly expect more seizures during pregnancy. Those who have not had a seizure in years will probably be OK.
* Hormones directly affect seizure threshold; Estrogens activate seizure foci; progestins dampen activity
increase hepatic estrogen metabolism and cause breakthrough bleeding and contraceptive failure - reason for unplanned pregnancy.
Fetus has enough reserve to withstand an isolated seizure, will be bradycardic during and for about 20 mins after a grand mal...however STATUS EPILEPTICUS is an immediate threat to both mom and fetus. May be a long term effect on intellectual performance in childhood
Medication therapy is critical in
epilepsy! Antiepileptic metabolism is altered differently during pregnancy for each drug. Volume of distribution increases for all; each one crosses the placenta. At term, maternal & cord blood levels are equal
Are AEDs (antiepileptic drugs) harmful in pregnancy?
All AEDs have some degree of teratogenicity. To maintain blood levels previously established for seizure control monthly blood levels are needed. Toxicity can occur postpartum if levels were increased during pregnancy.
*Teratogen potential is not fully known....a/w cleft lip & palate, neural tube defects, congenital heart, distal digital hypoplasia (small fingers)....SO....THE LOWEST DOSE possible to keep seizures at a minimum is what is needed. Balance risk & benefit...benefits will outweigh risks.
Nursing diagnoses for epilepsy in pregnancy?
Risk for injury, fetal
Risk for aspiration
Risk for deficient fluid volume r/t hemorrhage, fear, etc.
Nursing interventions for epilepsy?
Plan interventions in case of seizure:
Oxygen set up, suction ready, pad rails, etc.
Adolescent pregnancy rates
62 pregnancies/1000 adolescent girls (Arkansas is in the top 5!). US rate is 48/1000. Healthy People 2020 goal is 43/1000; there were 6000 births in 2006 to girls 10-14 y/o.
Most effective plan or approach is a "comprehensive sexuality education" program.
Not just "sex ed", but also sexuality, STD/HIV, abstinence/contraception, relationships
How does access to contraceptives affect the adolescent pregnancy rate?
Access to contraceptives as a part of a program also reduced birthrate.
Sexuality education details
Medically accurate info is given, opportunity for teens to develop and understand their values, assists teens to develop relationships and interpersonal skills, helps in exercising responsibility regarding sexual relationships, including abstinence, contraceptives, pressures to become sexually involved, and other sexual health measures
Examples: BART "Becoming a Responsible Teen", PYD "Positive Youth Development, Confident, Connectedness, Character, Competence
Adolescent Growth and Development
Adolescent pregnancy is not a new phenomenon, but does require special considerations. Historically, it was common for women/girls to marry at an early age (14) and to have a first baby during adolescence....and we saw maternal and neonatal deaths from seizures, hemorrhage, CPD, LBW, poor outcomes. Play that forward....adolescent female bodies are still adolescent (immature) bodies
Immaturity and Teen Pregnancy
See "Box 20.3" on page 616
A combination of factors contributes to the continuation of teen pregnancy.
1. Earlier age of menarche and unpredictable ovulation
2. Increased rate of sexual activity, peer pressure
3. Lack of knowledge, failure to use knowledge/ "invincibility"
4. Poverty, culture
5. Desire to have someone to love, parents don't "get them" but a baby will!
6. Drug use, truancy, low self-esteem
7. 2 year gap from male growth and development
Adolescents: Need to enhance self-concept
Have inadequate coping mechanisms
Need for immediate gratification
Immature search for attention/ideal love
Indulge in risk-taking, sexual acting-out
Lack of knowledge and experience
Belief in own invulnerability
Present, not future, thinking
Lack of concern for long-term consequences
Experience an increase in dysfunctional families, changed
Erikson Operational Thinking
how they "operate"
Center around self, get info from peers and environment.
Not necessarily interested / able to listen to parents' opinions or info
LIFE as they see it!
Developmental Tasks - Erikson
Sense of Identity
1. Establish sense of self-worth and own value system
2. Establish long-lasting relationships
3. Emancipate from parents
4. Choose a vocation
Focus on changing body, experience frequent mood changes, defining boundaries, trying out different roles, conflict with parents, limited abstract thought processes, egocentrical thinking, invincible, trieds out independent decision making
Tips for Teaching Adolescents to prevent pregancy
page 618, Box 20.4
Center around facilitating these developmental tasks and focus of adolescents. Assisting them to identify what is risky and why, plans and goals for future, what it will take to get there, protection from STDs, pregnancy, discuss sexuality, empower them, ask "what would it be like if..."
Prenatal Assessment - customized for teens
Consider a teen pregnancy to be a high-risk pregnancy, with nutritional deficiencies, starting later without any counseling or planning.
The adolescent girl is frightened, confused, looking for the nurse to assist her.
"Day in the Life of a Teen"
to learn more about the whole person. Series of questions that works through a typical day....non-threatening, elicits information without being judgmental or negative
Physical assessment and anticipatory guidance in adolescent pregnancy
should be customized for adolescent
Dietary concerns in adolescent pregnancy
- nutrition needs may not be met by typical teenager; eating habits.
- greater nutritional requirements exist due to rapid growth as body mass doubles
- minimum daily standards (MDR) cannot be set because of so many variations
- increased need for minerals, calcium, zinc, iron
Teens as High Risk Pregnancies
Complications are common
1. PIH - immature vascular system (puts them at risk for preeclampsia)
2. Anemia - iron deficiency anemia
3. Birth trauma - teen's body is not yet fully developed, postpartum hemorrhage is a risk
4. CPD - pelvis is not yet fully developed, yet fetus is normal sized
5. Postpartum Depression - immature thought processes, easily overwhelmed with changes and expectations
Nursing Diagnoses and Interventions with Adolescent Pregnancy
Altered Nutrition: less than body requirements r/t intake insufficient to meet metabolic needs of fetus and adolescent patient. INTERVENTIONS: assess current diet for nutritional content; tract wt gain & fetal growth; provide info, considering preferences and peer influences; include pt & support system
Nursing Diagnoses & Interventions with Adolescent Pregnancy (continued)
Risk for Injury, maternal or fetal, r/t inadequate prenatal care or screening. INTERVENTIONS: use therapeutic communications and confidentiality; provide info that will enhance establishment of a trusting relationship; discuss importantce of ongoing prenatal care & possible risks to pt & fetus; reinforce that ongoing assessment is crucial; discuss risks of alcohol, tobacco, illicit drugs, HIV/AIDS, STDs; screen for preeclampsia, anemia
Nursing Diagnoses & Interventions with Adolescent Pregnancy (continued)
Risk for social isolation r/t body image changes of pregnant adolescent. INTERVENTIONS: establish therapeutic relationship, listen objectively, non-judgmental; discuss changes in relationships to determine extent of isolation; provide resources and referrals; provide info regarding classes, support groups
Nursing Diagnoses & Interventions with Adolescent Pregnancy (continued)
Interrupted family processes r/t stress of adolescent pregnancy and parenting. INTERVENTIONS: assess patient's relationship with parents; involve baby's father as appropriate; assist with ways to adapt to changes of pregnancy; encourage continuation in school ***; schedule follow-up visits more frequently
Substance Abuse in Pregnancy
No longer unusual to see substance abuse in pregnancy.... ~10% and climbing
-- Drug free is way to be!...
1. Damaging effects of alcohol and drugs on pregnant women and their fetus are well documented
2. Alcohol and other drugs pass easily across the placenta
3. Smoking during pregnancy has serious health risks: bleeding, miscarriage, stillbirth, abruption, IUGR
4. Congenital anomalies occur
Legal implications of substance abuse in pregnancy
1. Drug screening requires consent ....which may be not refusing.
2. Garrett's Law - child abuse hotline, DHS
3. Being a patient advocate - any positive drug screen in a newborn requires investigation by the state protection agency
Barriers to treatment for substance abuse
2. Little understanding of effect of substances
3. Stigma, shame, guilt
4. Treatment centers lack OB understanding
Substance abuse impact on pregnancy
1. Increased risk of medical complications and outcomes
2. Fetal vulnerability to drug is much greater bc of ongoing development
3. Teratogen - environmental substance that can cause physical defects in the developing embryo/fetus
4. SEE TABLE 20.5, page 623... specific drug effects
* Nicotine - > vasoconstriction, reduced uteroplacental blood flow, abruption, demise, miscarriage, LBW
* Cocaine - > vasoconstriction, HTN, Abruption, IUGR, CNS DEFECTS!!
Fetal Alcohol Syndrome
Alcohol is a teratogen; "safe" amount in pregnancy is unknown....even a social, infrequent intake can have devastating effects. Fetal blood alcohol is the same level as mom's.
FAS - full range of birth defects: structural, behavioral, neurocognitive. Most common is mental retardation; craniofacial dysmorphia (fetal alcohol spectrum disorder). (small head circumference, small palpebric features, flat bridge of nose, smooth philtrum, thin upper lip). Children may struggle with academic, social, behavioral, emotion, cognitive areas.
Neonatal abstinence syndrome
Neonatal withdrawal from opioids
Irritability, hypertonicity, high-pitched cry, vomiting, diarrhea, respiratory distress, poor sleeping, diaphoresis, fever, poor feeding, tremors, seizures
Pregnant women with substance abuse problems....
1. ...commonly abuse several substances
2. ...are prohibited from admitting the problem and seeking treatment by society
3. ...are at risk for spontaneous abortion, abruption, PTL, IUGR/LWB, CNS and fetal anomalies, and long-term childhood developmental consequences
Nursing Assessment for Maternal Substance Abuse
1. Thorough history & physical assessment; screen all pregnant women for the possibility of substance abuse: ask about any drug use, r/t it can effect fetus, risks, advise against continuing.
2. Urine toxicology screen - determines recent drug use, heavy use
* Cocaine 24-48 hours in adult, 72-6 in infant
* Heroine 24 hours in adult, 24-48 in infant
* Marijuana 1 week to 1 month in adult, longer in infant
3. RAFFT screening
What is the RAFFT screening questionnaire?
Uses accepting terminology, can encourage the woman to answer honestly without fear:
R = Do you drink or take drugs to Relax, improve self-image, fit in?
A = Do you ever drink or take drugs while Alone?
F = Do you have any close Friends who drink or take drugs?
F = Does a close Family member have a problem with drugs or alcohol?
T = Have you ever gotten in Trouble from drinking or taking drugs?
Nursing Management for Maternal Substance Abuse
1. Focus on screening and prevention - identification of substances
2. Morbidity and mortality among passively addicted newborns
3. Support from varied sources
4. At risk for STDs, HIV
5. Chest Xray to look for lymphadenopathy, pulmonary edema, pneumonia, emboli
6. TB skin test
7. L&D, postpartum can see a very demanding patient, manipulation
8. Treat w/ patience, kindness, consisteny, and firmness
9. Must control pain
10. Facilitate bonding, identify strengths, positive reinforcement
11. Assessment of home environment - signal investigation
12. Breastfeeding is absolutely contraindicated in women who continue to abuse illicit drugs
13. Coping skills, support systems, vocational assistance