Chapter 20

Pregnancy complication from a pre-existing or newly acquired illness

Identifying the High-Risk Pregnancy

High-risk pregnancyA concurrent disorder, pregnancy-related

complication, or external factor jeopardizes the health of the mother, fetus or both

Table 20.1 Factors that categorize a pregnancy as High Risk:PsychologicalSocialPhysical

Congenital and Acquired Heart Disease

• Congenital usually due to structural defects at birth Number is diminishing

• Acquired primarily rheumatic in origin

• Functional classification system to predict pregnancy outcomes (Table 20.1)– Class I: asymptomatic; no limitation of physical activity:

experience normal birth– Class II: symptomatic (dyspnea, chest pain) with increased

activity: experience normal birth– Class III: symptomatic (fatigue, palpitation) with normal

activity: complete pregnancy with maintenance of bedrest– Class IV: symptomatic at rest or with any physical activity:

poor candidates advised to avoid pregnancy

Congenital and Acquired Heart Disease (cont’d)

• Pathophysiology– Hemodynamic changes overstressing woman’s cardiovascular

system• Therapeutic management– Risk assessment, prenatal counseling, increased frequency of

prenatal visits• Nursing assessment– Vital signs, heart sounds, weight, fetal activity, lifestyle– Signs and symptoms of cardiac decompensation

Cardiac Disease

Left-sided heart failureOrthopneaParoxysmal nocturnal dyspnea

Cardiac Disease

Right-side heart failureDistended liver and spleenAscitesPeripheral edema

Cardiac DiseasePeripartal heart disease

Originates late in pregnancyPreviously undetected heart diseaseShortness of breath, chest pain, edemaCardiomegaly

Congenital and Acquired Cardiac Disease (cont’d)

• Nursing Management– Stabilization of hemodynamic status– Risk reduction measures: education, counseling, support– Cardiac medications if prescribed– Energy conservation; nutrition– Fetal activity monitoring– Signs and symptoms of cardiac decompensation– Monitoring during labor

Cardiac DiseaseAssessment

Level of exerciseCough or edemaBaseline vital signsLiver sizeECG

Cardiac DiseaseFetal assessment

Promote restPromote healthy nutritionEducate regarding medicationEducate regarding infection

Cardiac Disease

Nursing interventions during labor and birthAnesthesiaMonitor fetal heart tones and uterine contractionsVital signs

Postpartum nursing interventionsAssess for heart failureAssess baby

Cardiac Disease (cont’d)• Artificial valve prosthesis: Heparin LMW• Chronic hypertension vascular disease: see

next slide• Venous thromboembolic disease: DVT– Heparin: PTT– Antiphospholipid Antibodies– Chief Danger is PE

Chronic Hypertension• Hypertension before pregnancy or before 20th week of gestation

or persistence >12 weeks postpartum• Therapeutic management: preconception counseling, lifestyle

changes, antihypertensive agents for severe hypertension; fetal movement monitoring; serial ultrasounds

• Nursing assessment• Nursing management: lifestyle changes (DASH diet); frequent

antepartal visits; monitoring for abruptio placentae, preeclampsia; daily rest periods; home BP monitoring; close monitoring during labor and birth and postpartum follow-up

Hematologic Disorders• Pseudo Anemia

Iron Deficiency Anemia• Usually due to inadequate dietary intake• Therapeutic management: eliminate symptoms, correct

deficiency, replenish iron stores• Nursing assessment– Fatigue, weakness, malaise, anorexia, susceptibility to

infection (frequent colds), pale mucous membranes, tachycardia, pallor

– Abnormal lab results• Low hemoglobin, low hematocrit, low serum iron,

microcytic and hypochromic cells, and low serum ferritin

Iron Deficiency Anemia (cont’d)

• Nursing management– Compliance with drug therapy: prenatal vitamin and

iron supplement– Dietary instruction and counseling– Education for drug therapy

Folic Acid Deficiency• B vitamin• Megaloblastic anemia• Multiple pregnancies, hydantoin, OCP, gastric

bypass

• 400-800mcg folic acid

Sickle Cell Anemia• Defect in hemoglobin molecule (hemoglobin S)• Therapeutic management: dependent on status; supportive

therapy; blood transfusions for severe anemia, analgesics for pain, antibiotics for infection

• Nursing assessment: signs and symptoms; evidence of crisis• Nursing management– Support, education, follow-up– Labor: rest; pain management ; oxygen and IV fluids; close

FHR monitoring– Postpartum: antiembolism stockings; family planning options

Thalassemia• Two forms: alpha (minor); beta (major)– Women with minor form: little effect on pregnancy except

for mild persistent anemia– Women with major form: usually no pregnancy due to

lifelong, severe hemolysis, anemia, and premature death• Management dependent on severity of disease• Supportive care and expectant management

Malaria• Infection causes RBC to stick to surface of

capillaries causing obstruction.• International travel• Antimalaria drugs: Chloroquine

Other Genetic or Auto-Immune Hematologic Disorders

Coagulation disordersVon Willebrand disease: history

menorrhagia/epistaxisHemophilia B: Female Carriers SABIdiopathic thrombocytopenia purpura:

decreased platelets after viral invasion Autoimmune

Renal and Urinary DisordersUrinary tract infection: BladderPyelonephritis: Urinary stasis/stricture

of ureterUsually R side (intestines on left pushes

uterus to R)AssessmentTherapeutic management

Chronic renal diseaseKidney transplant

Chronic Renal Disease• Difficult to interpret kidney function• Develop severe anemia: diseased kidneys do

not produce erythropoietin• Safe administration in pregnancy

Respiratory DisordersAcute nasopharyngitisInfluenzaPneumoniaSevere acute respiratory syndromeAsthma

Asthma• Pathophysiology– Effect of normal physiologic changes of pregnancy on

respiratory system– May improve due to high circulating levels corticosteroids

• Therapeutic management– Drug therapy (budesonide, albuterol, salmeterol)– Taper albuteral close to term

• Nursing assessment– Asthma triggers; lung auscultation

• Nursing management– Client education – Oxygen saturation monitoring during labor

Tuberculosis• Therapeutic management– Medications: combination of isoniazid, rifampin,

ethambutol• Nursing assessment– PPD at first prenatal visit in high risk areas– Risk factors; signs and symptoms of TB– Screening

• Nursing management– Compliance with drug therapy – Education; health promotion activities and Calcium– Transmission prevention

Respiratory DisordersCOPDCystic Fibrosis

Modifications for pregnancyModifications for postpartal period

Rheumatic Disorders

Juvenile rheumatoid arthritisSystemic lupus erythematosus

Gastrointestinal DisordersAppendicitisGastroesophageal reflux disease or

hiatal herniaCholecystitis and cholelithiasisPancreatitisHepatitisInflammatory bowel disease

Neurologic Disorders

SeizuresMyasthenia gravisMultiple sclerosis

Musculoskeletal Disorders

ScoliosisGirls 12-14 years of ageIf uncorrected, causes deformityUnable to wear brace during last half of

pregnancyPotential for cephalopelvic disproportion

Endocrine Disorders

Thyroid dysfunctionHypothyroidismHyperthyroidism

Diabetes Mellitus• Typical classification– Type 1– Type 2– Impaired fasting glucose and impaired glucose tolerance– Gestational diabetes

• Classification during pregnancy– Pregestational diabetes– Gestational

Diabetes Mellitus (cont’d)

• Pathophysiology and pregnancy– Fetal demands– Role of placental hormones– Changes in insulin resistance – Effects on mother– Effects on fetus

Diabetes Mellitus (cont’d) • Assessment– Health history; physical examination; risk factors– Screening at first prenatal visit; additional screening at 24 to

28 weeks for women considered at risk O’Sullivan Test– Maternal surveillance: urine for protein, ketones, nitrates,

and leukocyte esterase; evaluation of renal function/trimester; eye exam in 1st trimester; HbA1c q 4-6 weeks <7%

– Fetal surveillance: ultrasound; alpha-fetoprotein levels; biophysical profile; nonstress testing; amniocentesis

Diabetes Mellitus (cont’d)

• Therapeutic management– Preconception counseling– Blood glucose level control (HbA1C <7%)– FBG < 100 and 2hour PPL < 120– Glycemic control: Humulin– Insulin Pump– Nutritional management: 30Kcal per kg of ideal weight (1800

to 2400 calories) divided into 3 meals and 3 snacks– Hypoglycemic agents– Close maternal and fetal surveillance– Management during labor and birth– Eye Exams

Diabetes Mellitus (cont’d)• Education– Exercise– Insulin– Insulin-pump therapy– Blood glucose monitoring

Other• Cancer• Mental illness