Transcript HIGH RISK PREGNANCY

HIGH RISK
PREGNANCY
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HIGH RISK PREGNANCIES
A. Definition: pregnancy wherein maternal
and fetal life is endangered by a
disorder co-existing with or unique to
the pregnancy.
B. Categories:
1. Biophysical – genetic (ex. Trisomy
13), medical (HPN, CHF, asthma),
obstetric (dystocia).
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2. Behavioral
a. Nutritional Status
b. Substance Abuse
c. Dental hygiene
d. Abuse and violence
3. Psychological Status – failure to seek
prenatal care, extreme stress
4. Socio-demographic
a. Maternal age
b. Parity
c. Marital status
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d. Residence
e. Ethnicity
f. Income
g. Racial and ethnic origin
h. Occupational hazards
- Prolonged shifts
- Extreme heat
- Exposure to radiation
C. Role of the nurse: identify risk factors
and estimate the potential effect of
pregnancy outcome.
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d. Causes of Maternal Mortality:
1. Normal delivery and other
complications related to pregnancy
occurring in the course of labor,
delivery, and puerperium.
2. Hypertension complicating
pregnancy, childbirth and
puerperium
3. Post partum hemorrhage
4. Pregnancy with abortive outcome
5. Hemorrhage related to pregnancy
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ANTEPARTUM COMPLICATIONS
A. HEMORRHAGIC DISORDERS
 General Management
- Complete Bed Rest (CBR)
- Avoid sexual contact
- Approximation or assess for
bleeding:
* Counting of pads
* Saturation: fully saturated, 30-40 cc
* Weight: 1 gm = 1 cc
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* Assess for complications:
hypovolemic shock
* Save discharges for histopathology:
to determine if the product of
conception has been expelled.
* Prepare the mother for sonography
or UTZ: to determine the integrity of
the sac.
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1. 1st TRIMESTER BLEEDING
a. Abortions – termination of pregnancy
before the age of viability (<20
weeks).
 Types of Abortion:
 Spontaneous Abortion or Miscarriage
* Nature’s way of expelling a defective
fetus.
* Caused by chromosomal aberration,
blighted ovum and germ plasma defect.
* Maternal age of >35 years old
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 Types of Spontaneous Abortions:
a. Threatened – sonogram finding of a
viable pregnancy with vaginal
bleeding but no cervical dilatation.
Pregnancy is jeopardized by bleeding
and cramping but the cervix is closed.
1. Management: Observation. No
intervention is generally indicated or
effective but complete bed rest and
administration of progesterone may be
acceptable.
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2. Patient should report increased
bleeding, passage of tissue, or fever.
Passed tissue should be saved for
examination.
b. Inevitable – vaginal bleeding and uterine
cramping leading to cervical dilatation
but no products of conception has yet
passed.
1. Management: emergency suction
dilatation and curettage to prevent
further blood loss and anemia.
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2. Dimmunoglobulin (RhoGAM) is
administered to Rh-negative,
unsentisized patients to prevent
isoimmunization
C. Complete – all products of conception
are expelled. The uterus is well
contracted, and the cervical may be
closed or opened.
1. No need for dilatation and curettage
2. Supportive care
3. Emotional support
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d. Incomplete – vaginal bleeding and
uterine cramping leading to cervical
dilatation, with some but not all,
products of conception having been
passed.
1. Placenta and membranes retained .
2. Dilatation and curettage is done to
prevent further blood loss and
anemia.
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e. Missed – is diagnosed when products of
conception are retained after the fetus has
expired. If product is/are retained, a
severe coagulopathy with bleeding often
occurs, fetus dies:
1. Should be suspected when the
pregnant uterus fails to grow when
fetal heart tones disappear.
2. Amenorrhea may persist, or intermittent
vaginal bleeding, spotting or brown
discharge may be noted.
3. Ultrasound confirms the diagnosis.
4. Management: RhoGAM administration
to Rh-negative unsensitized patients.
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f. Habitual Abortions – three or more
consecutive pregnancies result in
abortion which is usually related to an
incompetent cervix.
 CHARACTERISTICS:
a. Abnormalities of the fetus; blighted
embryo.
b. Abnormalities of the reproductive tract.
c. Physical and emotional shocks
d. Endocrine problems
e. Infectious diseases
f. Maternal diseases
g. Psychogenic problems
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Management: Surgery of the cervix
a. McDonald Operation – temporary cerclage
of the incompetent cervical os.
1. Done at 2-3 months gestation
2. Suturing is done around the cervix in a
simple purse-string fashion to hold
growing fetus and is removed by 36
weeks gestations to allow the mother
to deliver via normal spontaneous
delivery.
b. Shirodkar Procedure
1. The suture is buried beneath the
cervical mucosa and is often left in
place.
2. Delivery via C-Section only.
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 Induced Abortion
 Therapeutic Abortion – ensures life of
mother especially if there are
bioethical issues. It has two-fold
effect which opts for the choice of
lesser evil.
 Illegal Abortion – unwarranted
termination of pregnancy which
does not put the life of the
mother nor the fetus’ life in
jeopardy and is not permitted by
law.
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Fetal Demise – termination of pregnancy
after the age of viability.
 Types:
* Antenatal demise – occurs before
labor
* Intrapartum demise – occurs after the
onset of labor.
 Risk Factors:
* Mostly idiopathic
* Antiphospholipid syndrome
* Maternal diabetes
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* Maternal trauma
* Severe maternal isoimmunization
* Fetal aneuploidy
* Fetal infection
A. Ectopic Pregnancy – is one in which the
fertilized ovum is implanted in any
tissue other than the uterine wall.
Most ectopic pregnancies occur in the
fallopian tube, but implantation can
also occur in the cervix, ovaries and
abdomen.
* Common site: ampulla or tubal
* Dangerous site: interstitial
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 Risk Factors for Ectopic Pregnancy
* Lesser Risk
- Previous pelvic or abdominal surgery
- Cigarette smoking
- vaginal douching
- age of 1st intercourse <18 years
* Greater Risk
- Previous genital infections.
- Infertility
- Multiple sexual partners
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* Greatest Risk
- Previous ectopic pregnancy
- Precious tubal surgery or sterilization
- Diethylstilbestrol exposure in utero
- Documented tubal scarring
- Use of intrauterine contraceptive
device.
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 Nursing Intervention
* Vital signs monitoring
* Administer IV fluids as ordered
* Monitor vaginal bleeding
* Monitor intake and output
* Culdocentesis – to determine hemo
peritoneum
* Non surgical Management:
Methotrexate.
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2. SECOND TRIMESTER BLEEDING
a. Hydatidiform Mole or Gestational
Trophoblastic Disease – “bunch of
grapes”
 Gestational anomaly of the placenta
consisting of a bunch of clear vesicles.
 Progressive degeneration of chronic villi
with unknown cause.
 Risk Factors: increased prevalence
geographically is most common in
Taiwan and the Phil. Other risk factors
are maternal age extremes and folate
deficiency.
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 Assessment:
 Early signs
- Most common symptom:
- Hyperemises gravidarum
- Most common sign: rapid increase in
fundic height, absence of fetal hart
tones.
- Vaginal bleeding
- Most common site of distant metastasis
is the lungs.
 Early in Pregnancy
- High level of HCG
- Preeclampsia at about 12 weeks
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 Late signs
- Hypertension before 20th week
- Vesicles look like a “snowstorm”
on sonogram.
- Anemia
- Abdominal cramping
 Serious Late Complications
- Hyperthyroidism
- Pulmonary embolus
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 Nursing Interventions:
* Prepare for D & C.
* Do not give oxytoxic drugs
* Teachings: Return for pelvic exams as
scheduled for 1 year to monitor HCG and
assess for enlarged uterus and rising
titer could be indicative of
choriocarcinoma.
* Avoid pregnancy for at least 1 year and
have regular exams.
* 12-18 months of regular monthly urine
exam
* Sex is allowed but advice the use of
condom
* No pills, it will alter the result of HCG.
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3. THIRD TRIMESTER BLEEDING
– Placental Anomalies
a. Placenta Previa – it occurs when the
placenta is improperly the cervical os.
 Total Placenta Previa – placenta
completely covers the internal cervical
os. This is the most dangerous
location because of its potential for
hemorrhage.
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 Assessment
* Outstanding Sign:
- Frank bright red, painless vaginal
bleeding
* Engagement
* Fetal distress
* Presentation
 Diagnostic Test: Ultrasound
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 Nursing Interventions:
* No sex, Intenal Exam or Enema –
these may lead to sudden fetal
blood loss.
* Bed rest
* Prepare to induce labor if cervix is
ripe or dilated.
* Administer IV fluids
* Put mother on NPO in case delivery
via C-section is necessary
* Prepare for double set-up (DR-OR)
* Secure consent
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b. Abruptio Placenta – is the premature
partial or complete separation of a
normally implanted placenta. It usually
occurs after the 20th week of gestation.
 Most common cause of late pregnancy
bleeding.
 Predisposing Factors
* Preeclampsia and hypertensive
disorders.
* Illicit drug use
* Accidents
* History of placental abruption
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* High multiparity
* Increasing maternal age
* Cigarette smoking
 Assessment
* Outstanding signs
- dark red, painful vaginal bleeding
- concealed hemorrhage – rigid board
like abdomen
* Couvelaire uterus – inability of the
uterus to contract due to concealed
bleeding.
* Severe abdominal pain
* Drop in coagulation factor.
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 Complication: Disseminated Intravascular
Coagulopathy (DIC)
 Medical Management:
* Emergency caesarian section if
maternal and fetal jeopardy is present.
* Vaginal delivery if bleeding is heavy but
controlled or pregnancy is greater than
36 weeks.
* Conservative in-hospital observation if
both mother and fetus is stable,
bleeding is minimal and contractions
are lessened.
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 Nursing Interventions:
* Infuse IV fluids as ordered.
* Blood Typing and cross matching
* Prepare for blood transfusion
* Monitor FHR
* Insert Foley catheter
* Measure blood loss; count perineal
pads.
* Report signs and symptoms of DIC
* Monitor vital signs for shock
* Strict I & O.
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c. Placenta Succenturiata – there is 1 or 2
lobes connected to the placenta by a
blood vessels.
d. Placenta Bipartita – the placenta divides
into 2 lobes.
e. Placenta Tripartita – placenta divides into
3 lobes.
f. Velamentous Insertion of the Cord – a
situation wherein the cord has divided
into small vessels before entering the
placenta.
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g. Vasa Previa – a situation wherein the
velamentous insertion of the cord has
implanted in the cervical os, which is
the same with Placental Previa.
 Rarely confirmed before delivery but may
be suspected when antenatal sonogram
with color-flow Doppler reveals a vessel
crossing the membranes over the
internal cervical os.
 Classic Triad: rupture of membranes and
painless vaginal bleeding followed by
fetal bradycardia.
 Management: immediate caesarian
delivery to avoid fetal hypovolemia
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B. HYPERTENSIVE DISORDERS
1. Pregnancy Induced Hypertension –
Hypertension after 20 weeks and solved
6 weeks postpartum. Formerly known
as “Toxemia” but later not proven as
authorities failed to find any toxins.
This usually occurs in 6-8% of
pregnancies.
a. Gestational Hypertension
 Sustained blood pressure elevation of
greater than or equal to 140/90 after 20
weeks of pregnancy.
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 Hypertension w/out edema and
proteinuria
 Unremarkable physical finding
 No damage of the fetus
 Nursing intervention: BP monitoring
and close observation to ensure that
the patient is not experiencing early
preeclampsia.
 The BP normalizes postpartum.
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b. Preeclampsia
 Sustained blood pressure elevation
after 20 weeks of gestation in the
absence of preexisting hypertension
 Predisposing Factors to preeclampsia
- Primipara – due to 1st exposure to
chronic villi.
- Multiple pregnancy – due increase
exposure to chorionic villi.
- Decreased mother’s socio-economic
status
- Low intake of CHON predisposes to
PIH
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- Hydatidiform mole
- Diabetes mellitus
- Age extremes
- Chronic hypertension
- Chronic renal disease
 Triad signs and synptoms: H-E-P/A
- Hypertension
- Edema
- Proteinuria or Albuminuria
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 Three Types of Pre-eclampsia
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Mild Preeclampsia
- Increase in weight because of
developing edema
- Characterized by inability to wear or
tightening of wedding ring
- BP is 140/90
- Proteinuria: +1-+2 or greater or equal to
300mg on a 24 hour urine collection
- Management:
a. Conservative in patient; no
antihypertensive medications or
magnesium sulfate are used
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b. Delivery: indicated after 36 weeks
gestation; Induction with oxytocin
is used and continuous infusion of
IV magnesium sulfate to prevent
eclamptic seizures.
- Complication: progression to severe
preeclampsia may occur.
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Severe Preeclampsia
- Characterized by visual disturbances,
persistent headache, epigastric pain
- Epigastric pain is an aura of impending
convulsion.
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- Oliguria
- Thrombocytopenia
- Elevated liver enzymes
- Cyanosis
- Pulmonary edema
- Sustained blood pressure elevation
greater or equal to 160/110
- Proteinuria: +3 to +4 or greater or equal
to 5 grams on a 24-hour urine collection
- Edema may or may not be seen
- Complication: progression from severe
preeclampsia to eclampsia may occur
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Eclampsia – presence of unexplained
grand mal seizures in a hypertensive,
proteinuric pregnant woman after 20
weeks gestation.
- Risk factors: same with mild and severe
preeclampsia. Having primary seizure
disorder does not predispose a patient
to eclampsia
- Etiology: severe diffuse cerebral
vasospasm resulting to decreased
cerebral perfusion and cerebral edema
- Presenting symptoms: those present in
pre-eclampsia plus unexplained tonicclonic seizures.
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- Treatment
a. Establish airway and protect
patient’s tongue
b. Magnesium Sulfate administration
c. STAT delivery of the fetus
d. Administration of IV hydralazine and
labetalol to lower diastolic BP
between 90 and 100 mmHg.
- Complications: intracerebral
hemorrhage and or death.
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c. HELLP Syndrome – occurs in 5-10% of
preeclamptic patients and is
characterized by:
* Hemolysis
* Elevated Liver Enzymes
* Low Platelet Count
 Occurs Twice as often in multigravidas
than in primigravidas
 Prompt delivery at any gestational age
is appropriate
 Complications: DIC, abruptio placenta,
fetal demise, ascites and hepatic
rupture.
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2. Transitional Hypertension – Hypertension
between 20-24 weeks of gestation
3. Chronic or Pre-existing Hypertension
- Hypertension before 20 weeks and not
solved 6 weeks postpartum
Nursing Care: P-E-A-C-E
a. Promote bedrest
 To decrease O2 demand
 It facilitates Sodium excretion
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b. Prevent Convulsions by nursing
measures.
 Seizure Precautions:
- Maintain a dimly lit room
- Quiet and calm environment
- Avoid jarring the bed
- Plan procedure to minimize patient
handling
 Place patient across the nurse’s station
for close monitoring.
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c. Prepare the following at bedside:
 Padded tongue depressor should be
given before seizure
 Do not restraint. Put up side rails prior
to seizure episode
 Side lying position after episode of
convulsion to facilitate drainage
excretion
 Open airways: oxygen administration
as ordered, suctioning as needed.
 Ensure safety and comfort.
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d. Ensure adequate protein intake
(1g/kg/day)
 To replace protein loss
 Sodium in moderation
e. Antihypertensive drug: Hydralazine
(Apresoline)
f. Convulsion prevention by Magnesium
Sulfate.
 CNS depressant or anti-convulsant
 Antidote: Calcium Gluconate.
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g. Evaluate physical parameters for
magnesium sulfate toxicity
(hypermagnesemia): B-U-R-P
 BP decrease
 Urine output decrease
 RR <12bpm.
 Patellar reflex absent – the first sign of
hypermagnesemia.
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B. GESTATIONAL DIABETES MELLITUS
- a disorder of carbohydrates, protein
and fat metabolism characterized by an
increase in fasting blood glucose and
abnormal glucose tolerance levels.
1. Risk Factors:
a. Maternal age older than 30 years.
b. Pregravid weight more than 90 kg.
c. Family history of diabetes
d. Race
e. Multiparity
f. Macrosomia
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2. In 3-6 % of pregnant women, there is a
tendency to develop gestational
diabetes as a result of placental
hormones, variations in insulin level
and an increase in free cortisol.
a. Abnormalities disappear after
pregnancy.
b. Maternal hyperglycemia is mild but
may gravely affect fetus.
c. Modification of diet is of utmost
concern though insulin therapy may be
started if diet doesn’t control
condition.
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3. Main problem: lack or absence of insulin
a. Insulin is produced in the pancreas.
It facilitates the transport of glucose
into the cell.
b. Glucose – cell enegizer
c. Maternal glucose crosses the
placenta but insulin does not.
Maternal glycemia therefore, results
to fetal hyperglycemia which leads to
fetal hyperinsulinism.
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