high risk pregnancy

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HIGH RISK PREGNANCY

Is one in w/c the mother or fetus has a significant increased chance of harm,

damage, injury, or disability (morbidity), and loss of life or death (mortality)

HIGH-RISK PREGNANCY A. DEMOGRAHPIC

FACTORS 1. Age 2. Weight 3. Height B. SOCIOECONOMIC

STATUS 1.inadequate

finances 2. overcrowding, poor

standard of housing, poor hygiene 2

3. Nutritional deprivation4. Severe social problem5. Unplanned and

unprepared pregnancy,specially among adolescents

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Adolescent Pregnancy: Contributing Factors Peer pressure Self-esteem Lack of role

models Gain attention Media Poverty Rite of passage

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Implications of Adolescent Pregnancy

Socioeconomic:

•reliance on welfare

•cycle repeats itself

Maternal health:

•CPD

•PIH

•anemia

•nut deficits

mortality

Fetal Health:

•LBW

•prematurity

•resp complications

•cp

•cognitive deficits

•death

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Adolescent Pregnancy: Assessment

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

C. OBSTETRIC HISTORY

1.Hx of infrtility or multiple gestation2. Grand multiparity3. prev. abortion or ectopic preg.4. Prev losses5. prev. operative OB,uterine or

cervical abnormalities6.prev. abnormal labor

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7. prev. high-risk infant8. prev. hydatidiform mole.

D. CURRENT OB STATUS1. Late or no prenatal; care2. Maternal anemia3. Rh sensitization4.Antepartal bleeding5.preg. Induce hypertension

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6.Multiple gestation7. pre-term- post term labor8.Polyhydramnios9. PROM10. Fetus inappropriately large or

small,abnormality in test fetal well being; abnormality in presentation

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E. MATERNAL MED.Hx/status

1. Cardiac or pulmonary dx2. Metabolic ds.3. Endocrine disoder4. Chronic renal ds.5.Chronic hypertension6.Veneral and other infectious ds.7.Major congenital disorder or rep.tract

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8. Hemoglobinopathies9.Seizure disorder10.Malignancy11. Major emotional dis, mental

retardation

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Diagnostic test in high-risk preg./prenatal det. Of fetal well being

1. Ultrasound-is a diagnostic technique which uses high-frequency soundwaves to create an image of the internal organs. A screening ultrasound is sometimes done during the course of a pregnancy to monitor normal fetal growth and verify the due date.

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PURPOSESIn the first trimester: to establish the dates of a

pregnancy to determine the number of fetuses

and identify placental structures to diagnose an ectopic pregnancy

or miscarriage to examine the uterus and other

pelvic anatomy to detect fetal abnormalities

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Mid-trimester: (sometimes called the 18 to 20 week scan)

to confirm pregnancy dates to determine the number of fetuses

and examine the placental structures to assist in prenatal tests such as an

amniocentesis to examine the fetal anatomy for

presence of abnormalities to check the amount of amniotic fluid to examine blood flow patterns

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to observe fetal behavior and activity

to examine the placenta to measure the length of the cervix to monitor fetal growth

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Third trimester: to monitor fetal growth to check the amount of amniotic fluid as part of other testing such as the

biophysical profile to determine the position of a fetus to assess the placenta

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NON – STRESS TEST Tocodynamometer records fetal movements and

Doppler ultrasound measures fetal heart rate to assess fetal well-being after 28 weeks.

Nonstress test is basically performed to evaluate on how the baby is doing inside. How often you need the test will depend on your doctor; it can be every week or more often till the baby is born.

• The test result is considered to be normal or reactive if baby's heart beats faster on two separate occasions during the 20 minute span.

• If baby is resting the result will most likely be non-reactive. However if results persist to be non-reactive even after one hour, it doesn't necessarily mean something is wrong with the baby.

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• Results may also be non-reactive due to baby's age; babies below week 32 have not hit the required maturity for reactivity. • The test time may be extended or the mother may have to go for more comprehensive tests like biophysical profile• If your doctor is absolutely sure that baby is not thriving inside, the labor may be induced

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Preparationa. position- semi-fowler’s or left lateral

position slightly turn to the leftb. BP is check firstc. Explain >procedure takes 30 to 60 mins

long >mother needs to activate”mark

botton”w/ each fetal movement > does not need

hospitalization/ambulatory basis20

Who needs the nonstress test..• Women with preexisting medical conditions such as

diabetes• Women with pregnancy-induced medical conditions such

as hypertension• Baby is less active than normal• Baby is small for its age• Amniotic fluid is either too much or too little

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• Women who have previously lost their babies in the second half of their pregnancies

• Women with pregnancies continuing after week 40 to basically check on the well- being of baby

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INTERPRETATION

A. Normal:Reactive- increased FHT (acceleration) greater than 16 bpm /secor more in 10 to 20 min. period w/ fetal movement

B. Abnormal: Non reactive- No FHR ACCELERATION WITH FETAL MOVEMENT

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INTERPRETATION

A. Normal : high –risk pregnancy continue

b. Abnormal result: mother needs another test, maybe biophysical profile

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OXYTOCIN CHALLENGE TEST(OTC) OR CONTRACTION STRESS TEST (CST)

CST is based on the observation that during contractions, blood flow to the placenta lessens temporarily. An evaluation is done on how the fetus handles this stress. (utero-placental well being)

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Interpretation:

a. normal: negative – No late decelerations of FHR w/ each of 3 contractions during a 10 minute interval

b. Abnormal: positive – with late decelerations of FHR with 3 contractions in 10 minutes.

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E. BIOPHYSICAL PROFILE

A scoring combining ultrasound assessment of: a. Fetal breathing

b. Fetal movement c. Fetal tone d. Reactivity of the heart rate e. Amniotic fluid volume BPP could

be used to predict fetal well-being in high-risk pregnancy

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Purpose

The purpose of the BPP is to assess fetal well-being. It is a tool used near or at term by clinicians to assess the potential risk of fetal compromise or demise due to fetal hypoxia or acidosis. Intervention such as maternal hospitalization, or delivery may follow a BPP score of four or below

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Biophysical variable Normal ( score =2) Abnormal (score= 0)

Fetal breathing movement

Gross fetal movement

Fetal tone

Reactive fetal heart rate

Greater than or = to 1 episode of 30 sec. or more of fetal breathing movement in 30 min3 or more discreet movements of the body or any limb in 30 minutes

Absence of 30 secs. Or longer of fb movement in 30 min

2 or lesser discreet movement of body or a limb in full extension or absent fetal movementEither slow extension with return to partial flexion or movement of limb in full extension or absent fetal movement

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EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

Surveillance of fetal well-being is based on 5 categories:

• Non-stress test (NST)• Amniotic fluid index• Fetal breathing movements• Fetal tone• Reactive heart rate

Note: each category carries a score of 2 and the summative number interpreted by the physician. A score of 8-10 is reassuring.

BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

AMNIOCENTESISAMNIOCENTESIS

AMNIOCENTESISAMNIOCENTESIS

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

AMNIOCENTESISAMNIOCENTESIS

Used to determine fetal maturity and detect certain birth defects such as DOWN SYNDROME, SPINAL BIFIDA, HEMOLYTIC DISEASE OF THE

NEWBORN, SEX AND CHROMOSOMAL ABNORMALITIES.

Used to determine fetal maturity and detect certain birth defects such as DOWN SYNDROME, SPINAL BIFIDA, HEMOLYTIC DISEASE OF THE

NEWBORN, SEX AND CHROMOSOMAL ABNORMALITIES.

Amniotic fluid is aspirated by a needle which is inserted through the abdominal wall and uterine walls.

Amniotic fluid is aspirated by a needle which is inserted through the abdominal wall and uterine walls.

Done at 16 weeks to assess L/S ratio and detect genetic disorder.Possible after week 14.

Done at 16 weeks to assess L/S ratio and detect genetic disorder.Possible after week 14.

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

AMNIOCENTESISAMNIOCENTESISPREPARATION:PREPARATION:

Prior to procedure, the patient’s bladder should be emptied.Ultrasound used prior to procedure to guide needle to prevent fetal and placental trauma.TEST RESULTS: within 2-4 weeks

COMPLICATIONS:COMPLICATIONS:COMPLICATIONS:COMPLICATIONS:

Premature labor, infection, Rh isoimmunizationMonitor fetus and uterine contractions after procedure. Teach client to report decreased fetal movement or increased abdominal discomfort.

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

ALPHA – FETOPROTEIN SCREENINGALPHA – FETOPROTEIN SCREENING

•Maternal serum screens for open neural tube defects. Alpha-fetoprotein is a glycoprotein produced by fetal yolk sac, GIT and liver.

•Test is done between 16-18 weeks gestation.

•High levels indicate neural tube defects and anencephaly and spinal bifida; also associated with congenital nephrosis, esophageal atresia, fetal demise.

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

• Uses amniotic fluid to ascertain fetal lung maturity through measurements of presence and amounts of lung surfactants Lecithin and Spingomyelin.

• At 35-36 weeks, ratio is 2:1 indicative of mature levels.

• May be done in laboratory or by “SHAKE” tests.

LECITHIN/SPINGOMYELIN RATIOLECITHIN/SPINGOMYELIN RATIO

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

• In conjunction with the L/S ratio, contributes to increased reliability of fetal lung maturity esp. in diabetics.

• Value equal or greater than 3% is needed.

• May be done in laboratory or by “SHAKE” tests.

EVALUATION OF PHOSPHATIDYL GLYCEROL (PG)EVALUATION OF PHOSPHATIDYL GLYCEROL (PG)

EVALUATION OF FETAL WELL-BEING

CREATININE LEVELCREATININE LEVELEstimates fetal renal maturity and function.

More than 2.0 mg indicates fetal age greater than 36 weeks.

DETERMINATION OF SEX-CHROMATINDETERMINATION OF SEX-CHROMATINDetects sex-linked disorders.( Hemophilia, Duchenne’s Muscular

Dystrophy, Color Blindness)

BILIRUBIN LEVELBILIRUBIN LEVELHigh in pregnancy then drops after 36 weeks’ gestation.

Increase in bilirubin needs evaluation for Rh incompatibility.

EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING

• Assess placental functioning.

INTERPRETATION OF RESULTS:INTERPRETATION OF RESULTS:

• Sudden drop = fetal hypoxia• Continuous drop = fetal compromise.

20% of cells stained orange indicates fetal weight at least 2500 gms.

URINARY/ SERUM ESTRIOL URINARY/ SERUM ESTRIOL

LIPID CELLS (NILE BLUE STAIN)LIPID CELLS (NILE BLUE STAIN)

EVALUATION OF FETAL WELL-BEING

• Involves inserting a needle into the fetal umbilical cord and aspirating blood for analysis.

• The procedure is guided by U/S and is used to screen karyotypes (chromosomes), examine antibodies for teratogenic viruses and provide assess for fetal blood transfusions..

PERCUTANEOUS UMBILICAL BLOOD SAMPLING

PERCUTANEOUS PERCUTANEOUS UMBILICAL CORD UMBILICAL CORD SAMPLINGSAMPLING

COMPLICATION OF PREGNANCY Pre-gestational conditions: Pregnancy induced hypertension (PIH)

is a condition of high blood pressure (HYPERTENSION) during pregnancy. Your blood pressure goes up, you retain water (EDEMA), and protein(PROTEINURIA) is found in your urine. It is also called toxemia or preeclampsia. The exact cause of PIH is unknown.

7-10%bof all preg. Major causes of MCn mortality 42

ETIOLOGIC FACTORS: A first-time mom Women whose sisters and mothers had

PIH Women carrying multiple babies; teenage

mothers; and women older than age 40 Women who had high blood pressure or

kidney disease prior to pregnancy,polyhydramnios, chronic hypertension and renal disease

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SIGN AND SYMPTOMS: headaches, blurred vision inability to tolerate bright light fatigue nausea/vomiting urinating small amounts pain in the upper right abdomen shortness of breath and tendency to bruise easily

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2 types of PIH

1. Preeclampsia (mild and severe)2. Eclampsia

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SIGN MILD PREECLAMPSIA SEVERE PREECLAMPSIA

Hypertension 40 /90 or symmHg or more above theBaseline; diastolic rise 15mm Hg or moresystolic inc. of 30

160/110 or systolic increase at or above the 160 or morethan 50 mmHg over the baseline; diastolic rise greater than 110 mmHg or more on 2 readings taken 6 hours apart after bed rest

Proteinuria 1+ or 1g/day 3+ to4+ or 5g/day

Edema Generalized, confined to face (periorbital) and fingers

Generalized, severe facial puffiness, severe swelling of face

Weekly wt. gain-greater than 1lb/week

Excessive wt gain- 5 lbs/week or moreEpig. Pain due to edema of liver capsuleCerebral disturbances• severe frontal headache• inc, irritability• blurring of vision• hyper reflexia

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SIGN MILD PREECLAMPSIA SEVERE PREECLAMPSIA

• severe dizziness• halo vision, blind spots• persistent vomiting•Disorientation

Oliguria Absent output above 500 ml in 24 hours

Present; output 400ml or less in 24 hours

IUGR (intra-uterine growth retardation )

absent Present

Others HypoproteinemiaHemoconcentrationHypernatremia

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TABLE 15–3 Deep Tendon Reflex Rating Scale

FIGURE 15–4 To elicit clonus, with the knee flexed and the leg supported, sharply dorsiflex the foot, hold it momentarily, and then release it. Normally

the foot returns to its usual position of plantar flexion. Clonus is present if the foot “jerks” or taps against the examiner’s hand. If so, the number of taps or

beats of clonus is recorded.

B. DIABETES MELLITUS

A chronic, metabolic disorder characterized by a deficiency in insulin production by islets of Langerhans resulting in improper metabolic interaction of carbohydrates, fats. Protein and insulin

GDM] is usually diagnosed around 24

to 28 weeks of pregnancy.50

SIGN AND SYMPTOMS 1.Hyperglycemia 2.glucosuria 3. Polyuria 4. Polydipsia 5. weight loss 6. Ketoacidosis

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RISK FACTOR A. Family history B. Rapid hormonal change in pregnancy C. tumor/ infection of the pancreas D. Obesity E. Stress

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Complication of dm in mother Preeclampsia Urinary tract infections Future diabetes Dystocia Maternal mortality Diabetic retinophaty Diabetic nephropathy

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Fetus/ infant Excess growth. Extra glucose will

cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.

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Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Severe episodes of this problem may provoke seizures in the baby. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal

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Respiratory distress syndrome. If your baby is delivered early, respiratory distress syndrome — a condition that makes breathing difficult — is possible. Babies born to women with gestational diabetes have more breathing problems than do those born to women without the problem, even at the same gestational age. Babies who have respiratory distress syndrome might need help breathing until their lungs become stronger. 56

Jaundice. This yellowish discoloration of the skin and the whites of the eyes may occur if a baby's liver isn't mature enough to break down a substance called bilirubin, which normally forms when the body recycles old or damaged red blood cells. Although jaundice usually isn't a cause for concern, careful monitoring is important.

Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.

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Developmental problems. If you have gestational diabetes, your child may have an increased risk of problems with motor skill development, such as walking, jumping, or other activities that require balance and coordination. An increased risk of attention problems or hyperactivity disorders also is a concern.

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CARDIAC DISEASE This involves a variety of heart

conditions both congenital and acquired that complicate pregnancy.

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TYPES OF SPONTANEOUS ABORTIONS

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Spontaneous Abortion Management

Threatened

Inevitable

Notify MD/MW Check fetus by U/S Bedrest, no sexual activity

for 2 weeks after bleeding stops

No false reassurance Check by U/S for complete

vs. incomplete Analgesics for D&C RhoGAM

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Spontaneous Ab Mgmt, cont.

Incomplete

Missed

Hospitalization Before 14 wks – D&C + IV

Pitocin After 14 wks – Pitocin or

Prostaglandins Wait 3 to 5 wks for spont Ab

(93%) Monitor for DIC

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Post Abortion Education Bldg, cramping X 1-2 wks vaginal rest X 1 wk temp BID f/u in 2 wks

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SITES OF ECTOPIC PREGNANCY

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S & S Ectopic Pregnancy Missed Period Abdominal Pain Vaginal Spotting Rupture ↓ hCG levels No gestational sac on U/S

Severe lower abd pain

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Surgical Management of Ectopic Pregnancy

Med Mgmt of Ectopic PG MTX

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S & S Hydatiform Mole Vaginal bleeding

anemia uterus size,

cramps No FHT’s N/V Early PIH

Therap. Mgmt: vacuum aspiration & curettage

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Spontaneous Abortion Matching – Choose all that apply.1. 1. Initial symptom is

vaginal bleeding2. 2. Membranes rupture and

cervix dilates3. 3. Some, not all, products

of conception are expelled.4. 4. Treatment includes D&C5. 5. All products of

conception passed6. 6. All unsensitized Rh neg

women should receive RhoGAM

7. 7. May be treated with bedrest

8. 8. Retained dead fetus9. 9. May be complicated by

DIC10. 10. Pregnancy may continue

A. Threatened abortionB. Inevitable abortionC. Incomplete

abortionD. Complete abortionE. Missed abortion

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Medical Mgmt of Placenta Previa

Mom stable,

fetus immature

•Bedrest

•no sex act

•report bldg

Fetus > 36 wks

•Amnio to lung maturity

•delivery

S&S hypovol in mom

•delivery

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S&S Abruptio Placentae

•Vag bldg (unless concealed)

•abd pain

U-act

•hemorrhage•boardlike abd

•late decels

•s&s shock

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Med Mgmt of Placental Abruption

Mom stable,

fetus immature

bedrest

tocolytics

bleeding,

fetal distress

Emergency CS

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DIC

Placental Bleeding

Thromboplastin release

Clot formation (systemic response)

clotting factors (fibrinogen, plts, PTT, FDP)

inability to form clots

profuse bleeding

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The Pathological Processes of Pre-eclampsia

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S&S Pre-eclampsia Rapid wt gain edema of hands & face proteinuria hyperreflexic DTR’s H/A, visual disturbances epigastric pain

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Treatment of Pre-eclampsia

Bedrest protein diet document fetal

activity weekly NST

Bedrest, stimuli Meds

Apresoline for severe HTN

MgSO4 (anticonvulsant & antihypertensive)

Delivery

Mild: diastolic < 100, trace to 1+ proteinuria, no H/A

Severe: diastolic > 110, 3+ proteinuria, U/O, H/A, visual disturbances

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S&S Eclampsia/HELLP Syndrome

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

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

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Treatment of Eclampsia/HELLP Syndrome

Bedrest Meds

MgSO4 Valium or Phenobarb (if Mg not effective,

not within 2 hr of delivery) Hydralazine (for severe ↑ B/P) steroids to fetal lung maturity

Delivery

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Assessment: Hypertensive Disorders of Pregnancy

Prenatal: wt, B/P, U/A, H/A, visual disturbances

Hospitalized Ct: daily wt hourly u/o, dipstick urine Q4H VS, FHR LOC, DTR’s, H/A clonus

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Risk Control Strategies for Hypertensive Disorders of Pregnancy Sz precautions monitor for s/s Mg toxicity(RR<12, absent

DTR’s, sweating, flushing, confusion, B/P) Ca gluconate @ BS Mg levels IV MgSO4 (should be “Y” connected to

another primary bag) D/C MgSO4 for RR < 12 or absent

DTR’s renal function (30 mL/hr)

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Incompetent CervixS&S

•advanced cervical dilation

•low abd pressure

•bloody show

•urinary frequency

Treatment

•cerclage

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Premature Labor/Rupture of Membranes

S&S contractions cramps backache diarrhea vag d/c ROM

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

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Nursing Care for PTL/PROM Assessment

Thorough hx bleeding ROM BPP (for PROM)

Teaching Infection Control FMC

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Postterm Pregnancy S&S

Wt loss uterine size Meconium in AF

Risks fetal mortality cord compression mec asp LGA shoulder

dystocia CS episiotomy/laceration depression

Treatment fetal surveillance

NST, CST, BPP Q wk

mom monitors mvmt

Induction Pitocin (10-20U/L)

@ 1-2 mU/min every 20-60 min

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Disorders of Amniotic Fluid Polyhydramnios

S&S uterine dist dyspnea edema of lower

extr Treatment

therapeutic amniocentesis

Oligohydramnios Risks

cord compression musculoskeletal

deformities pulmonary

hypoplasia Treatment

amnioinfusion

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Risks of Multifetal Gestation

PIH GDM PPH Anemia UTI PTL Placenta previa CS

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(Fetal) S&S Rh Incompatibility Hyperbilirubinemia

jaundice Kernicterus (severe neuro d.o. r/t

bili) anemia hepatosplenomegaly Hydrops fetalis

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Sequence of Assessments for Rh Sensitization

Blood Test for Type & Rh Factor

Rh-negative Rh-positive

No further testingIndirect Coombs

Give RhoGAM

Repeat frequently Titer increasing

amniocentesis ( bilirubin)Titer not increasing

continue to monitor No change

retest prn

Elevated

retest, U/S

intrauterine transfusion or early delivery

+-

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Management of Rh Incompatibility

Prevention RhoGAM at 28

weeks (unsensitized women only)

Postpartum direct Coomb’s RhoGAM to mom if

baby is Rh+ (within 72 hrs of birth)

Prenatal

•per algorithm

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Hyperemesis Gravidarum S&S

U/O wt loss ketonuria dry muc

membranes poor skin turgor

Treatment IVF, TPN antiemetics advance diet as

tol

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Glucose Tolerance Test

11 GTT GTT (24 - 28 wks)

drink 50g glucose,

if 1 BS > 140

33 GTT GTT•hi carb diet X 2 days, then NPO after MN

•FBS, then drink 100g glucose,

1, 2, 3 BS

Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results:

1 > 190, 2 > 165, 3 > 145

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Effects of Pre-Existing DM

Maternal risk of:

PIH Cystitis DKA Spont Ab

Fetal risk of:

NTD’s Cardiac defects Macrosomia or IUGR Polycythemia hyperbilirubinemi

a

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Treatment of Pre-existing DM Team approach Monitor glycosylated Hgb A Diet: 50% carb, 20% prot, 30% fat Insulin TID Hourly glucoses during labor NST’s weekly (starting at 28-30 wks) Amnio ( lung maturity)

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Effects of Gestational Diabetes Maternal Effects

UTI hydramnios PROM/preterm

labor shoulder dystocia epis/lac CS HTN

Fetal Effects macrosomia hypoglycemia at

birth RDS

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Treatment of Gestational Diabetes

30 to 35 cal/kg/day (3 meals, 2 snacks)

Insulin FBS, post-prandial BS’ Q week NST, BPP Q week glycosylated Hgb A Amnio ( lung maturity)

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Diabetes: Patient Education

Glucose monitoring insulin administration

type, onset, peak, duration, times, sites, injection technique

diet s/s hypoglycemia

tremors, pallor, cold/clammy skin give milk & crackers or glucagon inj

s/s hyperglycemia fatigue, flushed skin, thirst, dry mouth, check glu, call MD for insulin order

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PPCM: Manifestations

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

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PPCM: Energy Management Epidural Activity restriction Minimize anxiety

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PPCM: Cardiac Care Meds Sidelying, HOB ↑ Monitor VS, FHR, heart pressures

(Swan-Ganz) Strict I/O Assess lungs

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PPCM: Patient Education Avoid excessive wt gain/edema

Diet: 2200 cal, protein, NAS rest/avoid exertion avoid exposure to environmental

extremes emotional stress

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Sickle Cell Disease Maternal Effects

pain jaundice Pyelonephritis PIH/preeclampsia leg ulcers CHF

Fetal Effects IUGR/SGA skeletal changes

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Systemic Lupus Erythematosis

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

Fetal effects IUGR preterm delivery

Treatment

•PO or IV Steroids

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AIDS Maternal Effects

vag candidiasis PID genital herpes HPV PCP

Fetal Effects Asymptomatic at birth Candidal diaper rash thrush diarrhea recurrent bacterial

infections FTT dev delay

Treatment:

ZDV (zidovudine) during PG, L&D

ZDV to neonate for 6 wks

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Which of the following socioeconomic factors contributes to the high incidence of adolescent pregnancy in the US?

A. lack of adequate birth control

B. poverty

C. lack of information on safe sex

D. availability of public assistance for unmarried mothers

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Which genetic screening test for chromosomal abnormalities provides an older expectant couple with information within the first trimester?

A. Chorionic villus sampling (CVS)

B. Amniocentesis

C. Genetic karyotyping

D. Ultrasonography

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When caring for a woman with mild preeclampsia, the nurse would be concerned with which finding?

a. +4 proteinuria

b. +2 dependent edema in ankles

c. Blood pressure 156/100

d. +2 DTR’s, absent clonus

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

a. Prepare a solution of 20 g MgSO4 in 100cc D5W

b. Monitor maternal VS, FHR and uterine contractions every hour

c. Expect the maintenance dose to be approximately 4g/hr

d. Discontinue the infusion and report a respiratory rate of < 12 breaths/minute

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

a. Exhibits a decrease in both systolic and diastolic blood pressure

b. Experiences no seizures

c. States that she feels more relaxed and calm

d. Urinates more frequently, resulting in a decrease in pathologic edema

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

a. Anticipate that the woman will be sent home and placed on bedrest with instructions to avoid stress or orgasm

b. Prepare the woman for a dilatation and curettage

c. Notify a grief counselor to assist the woman with the imminent loss of her fetus

d. Tell the woman that the doctor most likely will perform a cerclage to help maintain the pregnancy

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CASE STUDY I

A G3P2 woman, at 38 wks gestation, arrives at the obstetric unit with c/o painless vaginal bleeding.

1. What is the nursing priority at this time?

2. What assessments are necessary?

3. What is the most likely etiology of the bleeding?

4. What is the expected treatment for Anne?

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CASE STUDY II

A G1P0 woman, at 35 wks gestation, is visiting the midwife for a routine prenatal visit. On assessment, the nurse finds that she has gained 8 lbs in the past month.

1. What is the significance (if any) of this weight gain?

2. What other assessments should the nurse make at this time?

3. What is the required treatment for this client?

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CASE STUDY IIIA 22 y.o. G1P0 who has a history of IDDM X 6 yrs and whose LMP was 12 wks ago arrives at the prenatal clinic.

1. How will this client’s diabetes be affected by her pregnancy?

2. What changes will she most likely have to make to adjust to her pregnancy?

3. What routine assessments will be made at each prenatal visit?

4. What tests will be required as the pregnancy progresses?

5. What fetal effects occur with pre-existing diabetes?

6. How will L&D be altered by pre-existing diabetes?

7. What possible newborn complications could occur with pre-existing diabetes?

8. What nursing care will the infant require?

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MATH PROBLEM

For induction, Pitocin is ordered – 10 Units in 500 mL to start at 2 mU/min and increase by 1 mU/min every 20 minutes until effective contractions are achieved.

At what rate will the nurse start the IV? By how much will the rate be increased every 20 minutes?

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THE END