Transcript Conditions That Complicate Pregnancy

PREGNANCY AT RISK: CONDITIONS
THAT COMPLICATE PREGNANCY
CHAPTER 16
OBJECTIVES
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1. Compare and contrast the pathophysiology of the three major classifications of diabetes
in the pregnant woman.
2. Explain treatment goals for the pregnant woman with diabetes.
3. Differentiate between the care of the pregnant woman with pregestational diabetes and
one with gestational diabetes.
4. Describe typical nursing concerns for the pregnant woman with diabetes.
5. Explain the goals of treatment and nursing care for the pregnant woman with heart
disease.
6. Differentiate between pregnancy concerns for the woman with iron-deficiency anemia
and one with sickle cell anemia.
7. List treatment considerations for the pregnant woman with asthma.
8. Detail the risk to pregnancy from epilepsy and its treatment.
9. Describe the impact on pregnancy from the TORCH infections.
10. Differentiate between common sexually transmitted infections according to cause,
treatment, and impact on pregnancy.
11. Outline treatment for the pregnant woman with human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS).
12. Describe nursing considerations for the pregnant woman with a sexually transmitted
infection.
13. Describe nursing concerns and treatment for the pregnant woman who is the victim of
intimate partner violence.
14. Delineate special concerns associated with adolescent pregnancy.
15. Describe the impact of delayed childbearing on pregnancy.
PREGNANCY AT RISK: CONDITIONS THAT COMPLICATE
PREGNANCY
 More
women are entering pregnancy with
chronic medical conditions
 You will assist the registered nurse (RN) to
provide care for the pregnant woman at risk
 Maternal–fetal medicine (focus on prenatal
period)
PREGNANCY COMPLICATED BY MEDICAL
CONDITIONS
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Risk factors for the pregnant woman
Chronic medical conditions
 Acute infections
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Several ways in which pregnancy and medical conditions
are interrelated
Normal physiologic changes of pregnancy sometimes alleviate
and at other times intensify the symptoms of illness
 Medical conditions can affect the progress and outcome of
pregnancy
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DIABETES MELLITUS
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A chronic disease in which glucose metabolism is
impaired by lack of insulin in the body or by
ineffective insulin utilization
Poorly controlled, can adversely affect pregnancy
outcomes
 Challenging to manage in pregnancy
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Complicates approximately 3% to 10% of
pregnancies
 Specialists should be involved in the care of the
pregnant woman with DM
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DIABETES MELLITUS (CONT.)
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Classification of Diabetes Mellitus
 Pregestational
Diabetes Mellitus (DM)
Type 1 DM
Higher incidence of spontaneous
abortion (miscarriage)
The diabetic woman is more likely to
experience a cesarean birth
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DIABETES MELLITUS (CONT.)
 Pregestational
Diabetes Mellitus
(DM) (cont.)
Fetus at high risk for congenital
anomalies and/or stillbirth
Mother at higher risk for
‒ Hypertensive disorders
‒ Polyhydramnios (excess levels
of amniotic fluid)
‒ Preterm delivery
‒ Shoulder dystocia in the infant
DIABETES MELLITUS (CONT.)
 Gestational
DM
 Increased risk for developing type 2 DM
after pregnancy (30-50% GDM within 5-20 yrs)
 Underlying pathophysiology of GDM is
insulin resistance
 Diabetogenic effect of pregnancy (page 355)
 Greatest risk for the fetus is macrosomia
 Screen for GDM at approximately 24–28
weeks’ gestation
DIABETES MELLITUS (CONT.)
 Treatment
Prepregnant care (prior to pregnancy),
consult w/MD prior, euglycemia,
multivitamin w/folic acid (1mg)
 Monitoring glycemic control (HbA1C)
 Maintaining glycemic control
Insulin therapy
Oral hypoglycemic agents (glyburide &
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metformin-does not cross placenta)
Diet therapy
Exercise
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DIABETES MELLITUS (CONT.)
 Treatment
(cont.)
 Fetal surveillance (sonogram)- first
trimester determines gestational age and
fetal viability and @ 18-20 wks. a more
detailed-close look at structural defects
 Determining timing of delivery-optimum
time and method for the delivery, DM delay
in fetal lung maturation, may need a
amniocentesis (3rd trimester)-too long can
lead to shoulder dystocia or fetal demise
TREATMENT OVERVIEW FOR DM/GDM
DIABETES MELLITUS (CONT.)
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Nursing process for the pregnant woman with DM
 Assessment
 Selected nursing diagnoses (page 357)
 Outcome identification and planning
 Implementation
 Monitoring management of therapeutic regimen
 Monitoring for and preventing infection
 Monitoring fetal status
 Estimating fetal weight
 Evaluation: goals and expected outcomes
QUESTION
Gestational diabetes is a form of diabetes mellitus that occurs during
pregnancy. It is caused by insulin resistance. What is the result of
gestational DM in a normal pregnancy?
a. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals
b. Blood glucose levels are higher than normal (mild
hyperglycemia) when fasting
c. Blood glucose levels are lower than normal (mild
hypoglycemia) after meals
d. Insulin levels are decreased (hypoinsulinemia) after
meals.
ANSWER
a. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals
Rationale: The result in a normal pregnancy is threefold:
1. Blood glucose levels are lower than normal (mild
hypoglycemia) when fasting
2. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals
3. Insulin levels are increased (hyperinsulinemia) after
meals
CARDIOVASCULAR DISEASE
 Clinical
manifestations and diagnosis
 Signs and symptoms vary depending on the
underlying cause of heart disease
 Earliest warning sign of cardiac
decompensation is persistent rales in the bases
of the lungs
 Treatment
 Activity levels
 Stress management
 Diet and medications
 Management during labor and the postpartum
period
CARDIOVASCULAR DISEASE (CONT.)
 Nursing
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care
Excellent nursing assessment and
reporting of abnormal findings is critical
Most important nursing action is to monitor
for and teach the woman to recognize signs
of cardiac decompensation
Especially important for the pregnant
woman with heart disease to protect herself
from infection
Precautions to avoid clot formation
CARDIOVASCULAR DISEASE (CONT.)
 Nursing
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care (cont.)
Advise the woman to get adequate rest and to
avoid strenuous physical activity
Inquire about illicit drug use and cigarette
smoking
Assist the woman with tests for fetal wellbeing
Monitor the woman particularly closely during
labor-increases demand on the heart
Do not encourage active maternal pushing
during the second stage of labor
Post-partum period: immediately report fever,
increased bleeding, and any signs of
decompensation
ANEMIA
 Iron-deficiency
anemia
 Clinical manifestations and diagnosis
Common signs and symptoms of irondeficiency anemia in the pregnant woman
are tachycardia, tachypnea, dyspnea, pale
skin, low blood pressure, heart murmur,
headache, fatigue, weakness, and dizziness.
Pica (ingestion of nonfood substances such as
clay and laundry starch) and pagophagia
(frequent chewing or sucking on of ice) are
both associated with severe iron-deficiency
anemia.
Hemoglobin levels less than 10 g/dL define
anemia during pregnancy
 Treatment-diet rich in iron and folate
ANEMIA (CONT.)
 Sickle-cell
anemia
 Clinical manifestations and diagnosis
Woman rarely experiences symptoms
At risk for a sickle cell crisis at any
time during the pregnancy
May experience recurrent bouts of
pain in the joints, bones, chest, and
abdomen
 Treatment-hydration, avoid infection,
adequate rest, balance diet
ANEMIA (CONT.)
 Nursing
care
 Iron-deficiency anemia
Counseling
‒ Vitamin C enhances and folate
‒ Iron supplements predispose to
constipation
 Sickle-cell anemia
Support and teaching
Adequate fluid intake and rest are important
QUESTION
A pregnant woman with cardiovascular disease can
usually continue to take her cardiac medications
during pregnancy. What medication cannot be
continued during pregnancy?
a. Digoxin
b. Heparin
c. Hydrochlorothiazide
d. Coumadin
ANSWER
d. Coumadin
Rationale: The woman usually can continue to take her
cardiac medications during pregnancy, with the exception
of warfarin (Coumadin), angiotensin-converting enzyme
(ACE) inhibitors, and angiotensin II receptor blockers.
Warfarin crosses the placenta and increases the risk of
congenital anomalies.
ASTHMA
Clinical manifestations and diagnosis
 Treatment
 Management of acute exacerbation
 Labor and birth management
 Nursing care
 Teaching is a major role
 Smoking cessation and control of the environment
 Goal: prevention of acute episodes, control of
symptoms, maintenance normal pulmonary
function, avoidance of emergency department visits
and hospitalizations (serve to maximize the health
of the woman and fetus)
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EPILEPSY
Clinical manifestations
 Treatment
 Current recommendations are for the woman to
remain on the drug that most effectively controls her
seizures
 Difficult to maintain therapeutic drug level
 AEDs major cause of fetal defects (cleft lip & palate,
cardiac, urinary and neural tube defects)
 Blunt trauma is major risk
 Status epilepticus–emergency complication
 Nursing care
 Teach importance of carefully following her treatment
regimen
 Teach importance of eating a diet high in folic acid and
of taking folic acid supplementation
 Provide emotional support during prenatal testing for
fetal anomalies
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INFECTIOUS DISEASES
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TORCH-Box 16-6, pg. 367
 Toxoplasmosis-rarely produces symptoms in the woman,
harmful if fetus contracts parasite between 10-24 wks.
(chorioretinitis, intracranial calcification, hydrocephalus in
the newborn)
treatment-medications
 Other infections:
 Hepatitis B-90% infants who acquire HBV become
chronic carriers (high risk for developing cirrhosis & liver
CA)
treatment-immunoglobulin & vaccine
 Syphilis-up to 40% result in miscarriage without
treatment, infant born with blindness, deafness,
Hutchinson’s triad
 Varicella Herpes zoster
 Rubella-congenital rubella-no cure, treatments are
supportive
 Cytomegalorivus-silent menace
 Herpes simplex virus-neonatal herpes is rare
INFECTIOUS DISEASES (CONT.)
 Prevention
is the focus of interventions
because many of the TORCH infections do
not have effective treatment regimens
 Routine screenings for hepatitis B, syphilis,
and rubella
 TORCH screen
 Latent (“old”) infection-rare that the fetus
will acquire a latent infection
INFECTIOUS DISEASES (CONT.)
 Sexually transmitted infections
 Many STIs are reportable diseases tracked
by the CDC
 Chlamydia
Most common STI in the United States
Untreated chlamydia increases the risk of
contracting HIV/AIDS
 Gonorrhea
Second most reported
Transmitted during sexual contact
Resistance to antibiotics
Can leave the woman infertile or
susceptible to ectopic pregnancy because of
scarring in the reproductive tract
Ophthalmia neonatorum
INFECTIOUS DISEASES (CONT.)
Human papillomavirus
Most common viral STI in the United
States
Has a tendency to increase in size during
pregnancy
Neonatal HPV infection can result in lifethreatening laryngeal papillomas
 Trichomoniasis
Associated with adverse pregnancy
outcomes (PROM, preterm delivery, low
birth weight)
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INFECTIOUS DISEASES (CONT.)
 Sexually
transmitted infections
(cont.)
 HIV/AIDS
Very important for the practitioner to
know the pregnant woman’s HIV
status
Clinical manifestations-pg. 373, box
16-7
INFECTIOUS DISEASES (CONT.)
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HIV/AIDS (cont.)
Treatment
‒ Two main goals of treatment for the
pregnant woman infected with HIV
 Prevent progression of the disease in
the woman
 Prevent perinatal transmission of the
virus to the fetus
INFECTIOUS DISEASES (CONT.)
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HIV/AIDS (cont.)
Nursing care
‒ Assure confidentiality
‒ If the woman is HIV-positive, ensure
that she understands the risk to her
sexual partners
‒ Explain the risks of perinatal
transmission of HIV and the benefits of
therapy
‒ Explore her understanding of the
treatment regimen
INFECTIOUS DISEASES (CONT.)
 Nursing
process for the pregnant
woman with an STI
 Assessment
 Selected nursing diagnosis
 Outcome identification and planning
INFECTIOUS DISEASES (CONT.)
 Nursing
process for the pregnant woman
with an STI (cont.)
 Implementation
Controlling risks of STIs
Maintaining immune status and protection
from additional infections
Ensuring knowledge of STIs and treatment
regimen
Enhancing self-esteem
Reducing anxiety
 Evaluation: goals and expected outcomes
QUESTION
TORCH is an acronym for a special group of infections that
can be acquired during pregnancy and transmitted
through the placenta to the fetus. Why is TORCH so
important during pregnancy?
a. Macrocephaly can occur
b. Can cause post-mature delivery
c. It is teratogenic
d. Can cause hepatospleno-growth retardation
ANSWER
c. It is teratogenic
Rationale: Each infection is teratogenic, and the
effects are different, depending upon when the
infection occurs during pregnancy.
PREGNANCY COMPLICATED BY INTIMATE PARTNER
VIOLENCE
 Clinical
manifestations and diagnosis
 Cycle of violence
 Warning signs
 Treatment
 Routine screening of all women is the key to
assisting those who are ready to report abuse
and receive help
 Interventions for the victim of IPV are directed
toward safety assessment and planning
PREGNANCY COMPLICATED BY INTIMATE PARTNER
VIOLENCE
 Nursing
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care
Assist the RN to assess for abuse
Determining whether a woman should leave
an abusive relationship must be made
exclusively by the woman
Always document the woman’s responses to
questions about IPV
Be careful to respond with supportive
statements
Document your assessment objectively
Be knowledgeable about local resources
PREGNANCY COMPLICATED BY AGE-RELATED
CONCERNS
 Adolescent
pregnancy
 Clinical manifestations
Many pregnant teens seek late prenatal care
May be fearful of disclosing her pregnancy
 Treatment
The best treatment for teenage pregnancy is
prevention
Advocacy for the pregnant adolescent
Help the teen to develop an adequate support
network
PREGNANCY COMPLICATED BY AGE-RELATED
CONCERNS
 Adolescent
pregnancy (cont.)
 Nursing care
Caring for developmental needs
‒ Pregnancy does not change the
developmental tasks, although it may
complicate the issues
Caring for physical needs
‒ Adequate nutrition is essential
Caring for emotional and psychological needs
‒ Be knowledgeable about community
resources for the pregnant teen
PREGNANCY COMPLICATED BY AGE-RELATED
CONCERNS (CONT.)
 Pregnancy in later life
 Clinical manifestations
 Treatment: preconception visit, increased risk
of chromosomal abnormalities
 Nursing care
Approach the older pregnant woman with an
open mind
May feel they have “too much” medical
information and feel overwhelmed
Do not want the constant reminders of
increased risks…
QUESTION
Tell whether the following statement is true or false.
Intimate partner violence (IPV) is a reality in our society. It
is important to assess every pregnant woman for IPV
because pregnancy is a very vulnerable time for a woman
in a relationship where IPV is a component.
ANSWER
True
Rationale: Pregnancy is a vulnerable time for a
woman. IPV may begin or escalate during
pregnancy, particularly if the pregnancy is
unplanned. Researchers estimate that 4% to 8%
of all pregnant women experience abuse during
the pregnancy.