High Risk Pregnancy
Cord Prolapse
- Membranes must be ruptured - Part of cord drops through the opening of the cervix - Part of Baby's body pushes on cord Intervention: Must hold presenting part of infant off of cord until baby is delivered by C-Section
Glucose Tolerance Test
- 50g of oral glucose - Blood sample one hour later - >130mg, further testing using 3 hour test - Newer recommendations for 75g OGTT but has not been readily adopted
Risk Factors for PTL
- African-American race (double the risk) - Maternal Age extremes (< 16, or > 40) - Low socioeconomic status - Alcohol, Smoking or Drug Use - History of previous Preterm Birth (triple the risk) - Multiple Gestations - Short cervical length Infections (UTI, STI, - Bacterial Vaginosis) Stress
HIV and Conception
- An HIV positive woman with an HIV negative partner can become pregnant without endangering her partner by using artificial insemination. - Provides total protection for the man, but does nothing to reduce the risk of HIV transmission to the baby. - If the man has HIV then the only effective way to prevent transmission is sperm washing. - Involves separating sperm cells from seminal fluid, and then testing these for HIV before artificial insemination or in vitro fertilization.
Management of Eclampsia
- Assessment - Maintain Airway - Prevent Injury - Magnesium Sulfate - Dilantin or other anti- convulsant - Prepare for birth
Eclampsia
- BP of 160/110 mmHg - Marked proteinuria - SEIZURES - Hyperreflexia - Other symptoms may include: severe headache, generalized edema, epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP
Management of Severe Preeclampsia
- Bed Rest (dark and quiet room to decrease stimulation) - Diet - Anticonvulsants (Magnesium Sulfate) - Corticosteroids (Betamethasone) - Fluid and Electrolyte Replacement - Antihypertensive
Placenta Previa Management
- Bed rest until 37 weeks - No vaginal exams - Monitoring blood loss - Monitor fetal heart tones - Bethamethasone (for fetal lung development) - IV Fluids and monitor mom's vitals - Pelvic rest including no intercourse
Management of PTL
- Bedrest - Tocolytic Therapy (to delay birth) - Corticosteroids: Betamethazone (to prevent or reduce respiratory distress not he infant in case of delivery)
Nursing Considerations for Patient on Mag Sulfate
- Blood Pressure - Magnesium Levels (every 6-8 hours) - Respirations - Reflexes - Urinary output - Fetus - Calcium Gluconate at bedside (reversal agent for Magnesium toxicity) - After birth, the neonate should be monitored and observed for magnesium toxicity for 24-48 hours
Cause of Placental Abruption
- Cig smoking - Increased maternal age - Alcohol - Cocaine - Short umbilical cord - Multiparity - Trauma - HTN (most common cause)
Management of Diabetes in Pregnancy
- Dietary Regulation - Home Glucose Monitoring - Insulin Administration - Evaluation of fetal status
Biophysical Risk Factors
- Genetic Conditions - Chromosomal abnormalities - Multiple pregnancies - Inherited disorders - Large fetal size - Preterm labor and birth - Cardiovascular disease - Placental abnormalities - Infection - Diabetes - Nutritional Status - Post-term Pregnancy
Rhogam
- Given to Rh(-) woman (given twice; once at half way through pregnancy and one after delivery) - Given @ 28 weeks gestation - Given within 72 hours after birth After: Abortion, chorionic villus sampling, ectopic pregnancy, amniocentesis - Given IV or IM Indication: to prevent Rh (-) woman from developing Rh antibodies
Other Infections
- Hep B - Syphilis (congenital syphilis) - Herpes Zoster, the virus that causes chickenpox
Hyperemesis Gravidarium
- Hyperemesis so severe that it affects hydration and nutritional value - Cause is unknown Frequent in: adolescents, multiple gestation, women with mother or sister with history, or history in previous pregnancy Diagnosis criteria: history of intractable vomiting first half of pregnancy, dehydration, ketonuria, weight loss of 5% pre-pregnancy weight
Medication for Newborn of HIV+ Mother
- If an HIV positive woman is taking AZT then it will probably be recommended that her baby is given AZT (usually as a syrup) for: - the first six weeks of its life - starting 8-12 hours after birth
Signs and Symptoms that Preeclampsia is Worsening
- Increasing edema - Worsening headache - Epigastric Pain - Visual Disturbances - Decreasing Urinary Output - Nausea/vomiting - Bleeding Gums - Disorientation - Generalized complaints of not feeling well - Hyperactive Reflexes
Environmental Risk Factors
- Infections - Radiation - Pesticides - Illicit Rugs
Preterm Labor
- Labor that occurs between 20 and 37 completed weeks of pregnancy - #1 cause of neonatal morbidity - 1 in 10 babies born prematurely Infant may experience long-term health problems - Estimated cost in the U.S.: 30 billion annually spent on maternal and infant care related to prematurity
Signs of Fetal Withdrawl
- Listless - Poor muscle reflexes - Poor feeding - High pitched cry - Jitteriness/tremors - Restless - Inability to be consoled when crying
Prenatal Loss
- Loss of fetus from time of conception until time of delivery - Spontaneous abortion/ miscarriage - Stillbirth - Ectopic Pregnancy - Death shortly after birth
Cytomegalovirus
- Most common viral cause of intrauterine infection 7 per 1000 births - Found in urine, saliva, cervical mucus, semen and breast milk - Able to be transmitted by asymptomatic women across the placenta or by cervical route during birth - No effective therapy CMV Risks: Mental impairment Hearing loss Learning disabilities Fetal death Hydrocephaly Cerebral Palsy No Damage at all
Sociodemographic Factors
- Poverty - lack of prenatal care - Age younger that 15 or older than 35 - Marital Status - Accessibility to Healthcare - Ethnicity
Management of Abortion
- Psychological Support - Reflective Listening - Pain Relief - Nursing Management
Nursing Management of the Pregnant Teen
- Quality Care - Assess Teen's family and social support - Listening more and talking less to develop a trusting relationship with the teen - Self-Esteem - Decision Making Skills (teach them and help sort through things)
Psychosocial Risk Factors
- Smoking - Caffeine - Alcohol and Substance Abuse - Inadequate support system - Maternal Obesity - Situational Crisis - History of Violence - Emotional Distress - Unsafe cultural practices
Signs and Symptoms of PTL
- Spontaneous rupture of membranes (SROM) - Abdominal Pain - Low, Dull Back Pain - Pelvic Pain - Menstrual-like cramps - Vaginal Bleeding - Increased Vaginal discharge - Urinary Frequency - Diarrhea - Pelvic Pressure
Classifications of Abortion
- Threatened - Imminent/ Inevitable - Complete - Incomplete - Missed - Recurrent Pregnancy Loss - Septic
Postmortem Care after a Perinatal Loss
- place appropriate signage on the outside of the room so everyone in the hospital is aware of the loss - give the parents the opportunity to spend time with their baby - bathe and swaddle baby - support parents wishes regarding photography
Cocaine
1 in 10 pregnant women use May cause: HTN, hallucinations, respiratory failure, spontaneous abortions, abruptio placenta, preterm birth, stillbirth, - The newborn usually weighs less at birth and smaller head circumference - Also irritable, jittery, tremors, high-pitched cry, and excessive suck
HELLP Lab Work
1. Anemia - low Hemoglobin 2. Thrombocytopenia - low platelets. <100,000. 3. Elevated liver enzymes: -AST aspartate aminotransferase exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L. - LDH - when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum. > 90 u/L
Criteria for Diagnosis of PTL
1. Cervical Dilation and Effacement plus 2. 4 uterine contractions in 20 mins or 8 uterine contractions in 1 hour
Classifications of Placenta Abruption
1. Marginal: blood passes between the fetal membranes and the uterine wall and escapes vaginally (may or may not become more severe) 2. Central: placenta separates centrally and blood is trapped between the placenta and the uterine wall (concealed bleeding) 3. Complete: massive vaginal bleeding (almost total separation)
Antepartum Bleeding
1. Placenta Previa 2. Abruptio Placenta
Classifications for HTN Disorders
1. Preexisting condition (Chronic Hypertension) 2. Hypertension that presents during pregnancy (Gestational Hypertension or Pregnancy Induced Hypertension) 3. Preeclampsia (most common hypertensive disorder in pregnancy) 4. Eclampsia (onset of seizures) 5. Chronic Hypertension with superimposed preeclampsia 1, 2 and 3 can be further described as mild or severe
Infections: How do infections enter the uterus?
1. Through the placenta 2. Ascend from the vagina into the uterus through the cervix
Classifications of Placenta Previa
1. Total: Internal opening is completely covered by the placenta 2. Partial: Internal opening is partially covered by placenta 3. Marginal: Edge of placenta is at the margin of the internal opening 4. Low- lying Placenta: placenta is implanted in the lower segment but does not reach the opening
Marijuana
15% of pregnant women use Newborn -tremors -prolonged startles -irritability
Group Beta Strep
A bacterial infection found in the lower GI or urogenital tract - Transmit GBS in utero or during childbirth - Leading infectious cause of neonatal sepsis and mortality today - 10% to 30% of pregnant women are carriers - Colonization Intrapartum prophylaxis (anyone who test positive for GBS receives antibiotics while in labor or prior to C-section) -Penicillin G 5 million units IV initial -followed by: Penicillin G 2.5 million units every 4 hours -Ampicillin 2g initial then 1g
HIV Transmission to the Baby
An HIV positive woman can transmit the virus to her baby during: pregnancy labor and delivery breastfeeding If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.
Important test for the HIV Pregnant Patient
CD4 test - determines how much HIV has weakened the immune system A high CD4 count denotes a strong immune system. Viral load test- determines how much HIV is in the blood. A pregnant HIV positive woman with a low viral load is less likely to have an HIV positive baby than a woman with a high viral load.
Classes of Placenta Abruptions
Class O: asymptomatic Class I: mild; most common Class II: moderate; mom and fetus show distress Class III: severe; maternal shock and fetal death likely
Cardiovascular Disease in Pregnancy
Congenital Heart Defects; Rheumatic Heart Disease; Peripartum Cardiomyopathy; Mitral Valve Prolapse Heart Disease: Pregnant women with heart disease do remain at risk for other complications including: heart failure arrhythmia stroke - Women with congenital heart disease now comprise the majority of pregnant women with heart disease. - The next largest group includes women with rheumatic heart disease. Management: define the diagnosis and sequelae, assess functional status, genetic counseling when relevant, although new recommendations do not require prophylaxis, assess need for endocarditis prophylaxis during labor and delivery Care for Patients with Heart Disease: - Anticipate vaginal delivery in almost all cases, unless there are obstetrical contraindications - Early epidural anesthesia - Modify labor and delivery to reduce cardiac work - oxygen, side lying, forceps - Postpartum monitoring, sometimes in a coronary or intensive care unit setting
Multiple Gestations
Dizygotic (from two ovum) hereditary -Same or different genders Monozygotic (from one ovum) 1. Dichorionic-diamniotic (own chorion, amnion, placenta) 2. Monochorionich-monamniotic (twins lie in same amniotic sac) Risks: - Spontaneous Abortion - HTN - Hydramnios - PROM - Incompetent Cervix - IUGR - PP hemorrhage - Abnormal Presentations - If share sac-increase chance of cord entrapment, twin-to twin transfusion, fetal demise
Education to Teen of Pregnancy
Education is the primary responsibility of the nurse caring for the pregnant teen - Nutrition, Exercise, Labor, Newborn Care - Family planning/contraception - Health Screening - Support - Parenting Behavior - Father Involvement
3 Hour Glucose Tolerance Test (GTT)
Fasting >95mg/dl 1hr >180mg/dl 2hr >155mg/dl 3hr > 140mg/dl if above these #s signs point to gestational diabetes
Alcohol
Fetal Alcohol Spectrum Disorder (FASD) Alcohol is a teratogen (toxic to human development) Defects related to alcohol occur as early as 3-8 weeks gestation.
Clinical Therapy Hyperemesis Gravidarium
GOALS 1. Control Vomiting 2. Correct Dehydration 3. Restore Electrolyte Balance 4. Maintain Adequate Nutrition Initial treatment home care: start small with avoidance of environmental triggers, small frequent meals, anti-emetics - If no improvement hospitalization may be necessary
Tocolytic Therapy
Goal of Tocolytic Therapy: Arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy Procardia (Nifedipine) Indomethacin (Indocin) Atosiban (Tractocile, Antocin) Magnesium Sulfate Big risk for serious side effects with mom
HELLP
H: Hemolysis EL: Elevated Liver Enzymes LP: Low platelet count variant of preeclampsia and eclampsia - increased risk of cerebral hemorrhage, retinal detachment, hematoma/ liver rupture, acute renal failure, disseminated intravascular coagulation (DIC), placenta abruption, and maternal death Symptoms include: Nausea, Vomiting, flulike symptoms, epigastric pain - Misdiagnosis common (gastroenteritis, hepatitis, gallbladder disease, etc.) - Perinatal morbidity and mortality high
Zidovudine (also known as AZT or ZDV)
Has been shown to be particularly useful for preventing HIV from being passed from a mother to her child. AZT or combination therapy is usually taken two or three times daily, starting after the first trimester sometime between 14 to 34 weeks of pregnancy, as well as being taken during labor.
Corticosteroids: Betamethasone (Celestone)
Help prevent or reduce the frequency and severity of respiratory distress syndrome and intraventricular hemorrhage in the premature infant - Stimulate surfactant production in the unborn baby - Administered 2 doses IM 24 hours apart - Effects seen as soon as 48 hours after initial administration Nursing Implications: Monitor maternal lung sounds and signs of infection
Gestational Trophoblastic Disease
Hydatidiform Mole (Molar Pregnancy) Condition in which a proliferation of trophoblastic cells (outermost layer of embryonic cells) results in the formation of a placenta characterized by hydropic (fluid-filled) grapelike clusters. Signs and Symptoms: - Dark brown vaginal bleeding - Anemia - Hydrophic Vesicles - Abnormal Uterine Enlargement - Absence of FHT - Marked hCG elevation - Hyperemesis Gravidarum Interventions: surgery, Rhogam, Methotrxate (because of possible development of choriocarcinoma), no new pregnancies for a year
Gestational HTN (PIH)
Hypertension that begins after the 20th week of pregnancy - BP of 140/90 or greater without Proteinuria - Must have an elevated BP on 2 occasions, six hours apart - Usually resolves by 12 weeks postpartum
Herpes Simplex Virus
If patient is in labor and has an outbreak or indications of impending outbreak C-Section is warranted Antiviral Therapy recommended after 36 weeks - acyclovir Newborn Infection Symptoms: Fever Jaundice Seizures Poor Feeding Vesicular Skin Lesions
Opiates and Narcotics
Includes Heroin, morphine, codeine, oxycodone, and methadone - CNS Depressant May cause: poor nutrition, PIH, abnormal implantation of placenta, abruptio placenta, PROM, preterm labor Fetus is at risk for preterm birth, IUGR, withdrawal symptoms after delivery, irritability, high-pitched cry, vomiting and seizures - Neonatal Abstinence Syndrome
Stillbirth
Loss of a fetus after the 20th week of pregnancy 1 out of 160 pregnancies Can happen right up until time of delivery Causes: placental abruption, pre-eclampsia, growth restriction and resulting hypoxia, infections, chromosomal disorders, umbilical cord torsion, nuchal cord, trauma Risk factors: advanced maternal age, smoking, drug use, malnutrition, lack of prenatal care, women of African-American ethnicity
Maternal/ Fetal Complications in Teen Pregnancy
Maternal: -delay in seeking prenatal care - poor nutrition - PIH - Bleeding Disorders - STD's - Withdrawl - Psychological Reactions Fetal: - Genetic, teratogenic effects - Spontaneous Abortion - IUGR - Prematurity - Withdrawal - Abuse and Neglect
Indirect Coombs Test
Measures # of Rh+ antibodies in maternal blood (indirect antiglobulin test) Screens pregnant women for antibodies that may cause hemolytic disease in the newborn Negative - fetus at no risk Positive - Fetus at risk
Management of Gestational Diabetes
Medications - Oral Hypoglycemics- Glyburide - Insulin Glucose monitoring NST- non-stress test Education Diet Exercise
Preeclampsia
Multisystem, vasopressive disorder that targets the cardiac, hepatic, renal and central nervous system (BV aren't formed properly in placenta so blood flow isn't right) Pathophysiology - Vasospasm which results in elevated BP reducing the blood flow to the brain, liver, kidneys, placenta, and lungs. - Decrease liver perfusion presents as epigastric pain and increased liver enzymes - Decreased brain perfusion leads to headaches, visual disturbances, and hyperactive deep tendon reflexes (DTRs) - Decreased kidney perfusion leads to decreased urine output - Proteinuria of 300mg or greater in a 24-hour urine specimen
Direct Coombs Test
On infant to detect antibody coated Rh+ blood cells (Direct antiglobulin test) A positive result indicates an immune mechanism is attacking the baby's own RBC's Rh incompatibility
Diabetes in Pregnancy
Pregestational affects insulin requirements, possible acceleration of vascular disease Effects of Diabetes on Mother: - Hydramnios (execs fluid) - Dystocia (difficult birth because of large baby) - Infections - PIH - Retinopathy Effects of Diabetes on Baby: - LGA- hyperinsulinism (as a response to mother) acts as a growth hormone - IUGR- poorly controlled insulin dependent mothers - Congenital Anomalies - Hypoglycemia (after birth) - Hyperbilirubinemia (Jaundice)
Rubella (German Measles)
Pregnant woman cannot be vaccinated Clinical signs in infants include congenital cataracts, congenital heart defects, deafness, mental impairment, cerebral palsy
Rh Sensitivity
Rh (-) woman carries a Rh (+) fetus in the next Rh- positive pregnancy, maternal antibodies attack fetal red blood cells Rh Antibodies enter Fetal Circulation - Hemolysis - Generalized Edema - CHF - Jaundice
TORCH
T- Toxoplasmosis O- Other infections R- Rubella C- Cytomegalovirus H- Herpes simplex virus- 2
Teen Pregnancy
Teen moms may not be prepared physically, emotionally, psychologically, or economically for parenthood Infants of Teen Moms: - Higher Rate of Low Birth Weight Infants - Higher Rate of Infant Mortality - Increased Rate of - - Sudden Infant Death - Premature Deliveries (less than 37 weeks) - More likely to become hospitalized during their childhood - More likely have children with medical and developmental delays
Toxoplamosis
Toxoplasma gondii - Eating raw or poorly cooked meat - Unpasteurized goat's milk - Feces of infected cats
Vaginal Delivery vs C-Section
Vaginal delivery is the first choice if woman has taken ARV drugs and has a low viral load C/S delivery is first choice for high viral load
Causes of Spontaneous Abortion
Week 4-8: chromosomal abnormalities Week 4-10: insufficient or excessive hormones Week 4-12: maternal infections Weeks 12-19: usually caused by a maternal factor such as cervical insufficiency or maternal disease
High Risk Pregnancy
a condition exists that jeopardizes the health of the mother, her fetus, or both condition may result from pregnancy or may be present before the woman became pregnant - 1 in 4 pregnancies is considered high risk
Gestational Diabetes
a form of diabetes of variable severity with onset or first recognition during pregnancy; MOM DOESN'T HAVE PREEXISTING
Chronic HTN
blood pressure of 140/ 90 mm Hg before pregnancy or before 20 weeks gestation - 25% of women with chronic hypertension develop preeclampsia during pregnancy Management: if BP exceeds 160/ 100 drug treatment is recommended
Cure for Preeclampsia and Eclampsia
delivery of the placenta
Ectopic Pregnancy
implantation of a fertilized ovum in a site other than the endometrial lining of the uterus; (fallopian tubes, ovary, peritoneal cavity, cervix) Risk Factors: tubal obstruction/ damage, delayed tubal transport, congenital anomalies, altered hormonal status, smoking, AMA Interventions: Methotrexate, Surgery (salpingostomy, salpingectomy), Rhogam
HTN in Pregnancy
most commonly encountered medical condition in pregnant women - result sin frequent hospital admissions, maternal mortality, preterm births, and infant mortality HTN Disorders Include: Gestational HTN, Preeclampsia, Eclampsia, HELLP
Substance Use in Pregnancy
most frequently missed diagnosis in maternity care Most commonly used substances: - Alcohol - Non-medical pain relievers - Marijuana - Phencyclidine (PCP) - MDMA (ecstasy) - Heroin
Spontaneous Abortion
naturally occurring abortion prior to 20 weeks Risk factors: - AMA (advanced maternal age) - Drug use - Weakened Cervix - Placenta abnormalities - Chronic maternal disease
Management of Mild Preeclampsia
no signs of renal or hepatic dysfunction - Bed Rest (lateral recumbent position) - Diet - Monitor Fetal Status - Frequent evaluation of CBC, liver enzymes, platelet levels, and clotting factors - Monitor protein in urine
Incompetent Cervix
painless dilation of the cervix without labor or uterine contractions Contributing Factors: 1. Congenital Factors 2. Acquired 3. Biochemical Factors Interventions: - close observation with ultrasound for the cervical thinning - Ceclage - Tocolytics - Broad spectrum Antibiotics
Placenta Previa
the placenta is improperly implanted in the lower uterine segment; attaches close to opening (cervix) - placenta may cover the cervical opening; usually diagnosed by ultrasound early Classical Presentation: painless, bright red bleeding
Abruptio Placenta (Placental Abruption)
the premature separation of a normally implanted placenta from the uterine wall Classic Symptoms: sudden pain, blood can be visible or concealed, may have fetal distress and uterus may be firm or rigid - concealed bleeding vs. visible bleeding