Chapter 11 High Risk Perinatal Care: Pre-existing Conditions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of.

Chapter 11

High Risk Perinatal Care: Pre-existing Conditions

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

For some women pregnancy represents significant risk because it is superimposed on a chronic illness

Unique maternal and fetal needs caused by these conditions must be met in addition to the usual pregnancy-related feelings, needs, and concerns

Pre-existing Conditions

2All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Metabolic disorders Diabetes mellitus Thyroid disorders

Cardiovascular disorders Respiratory, gastrointestinal, integumentary, and

central nervous system disorders Autoimmune disorders Substance abuse

Pre-existing Conditions (Cont.)


Diabetes mellitus The most common endocrine disorder associated with

pregnancy Pregnancy complicated by diabetes considered high

risk Diabetes can be successfully managed with a

multidisciplinary approach Key to an optimal outcome is strict maternal glucose

control

Metabolic Disorders


Pathogenesis Group of metabolic diseases characterized by

hyperglycemia resulting from defects in insulin secretion, insulin action, or both

Diabetes may be caused by either or both:• Impaired insulin secretion • Inadequate insulin action in target tissues

Metabolic Disorders (Cont.)


Classification of diabetes type 1 diabetes type 2 diabetes Other specific types (caused by infection or drug-

induced) Gestational diabetes mellitus (GDM) is any degree of

glucose intolerance with onset or recognition during pregnancy



Metabolic changes associated with pregnancy Pregestational diabetes mellitus

Occurs in women who have pre-existing disease Complicated by vascular disease, retinopathy, or

nephropathy Type 2 is not common Almost all of these patients are insulin-dependent




Pregestational diabetes mellitus Preconception counseling Maternal risks and complications

• Macrosomia • Hydramnios• Ketoacidosis• Hyperglycemia• Hypoglycemia



Pregestational diabetes mellitus Fetal and neonatal risks

• Sudden and unexplained stillbirth • Congenital malformations

Cardiovascular system Central nervous system Skeletal system

• Other problems that cause significant neonatal morbidity



Antepartum evaluation Interview Physical examination Laboratory tests

• Baseline renal function• Glycosylated hemoglobin A

Patient needs much more frequent monitoring

Care Management



Antepartum care Diet and exercise Insulin therapy Monitoring blood glucose levels Urine testing Determination of birth date and mode of birth Complications requiring hospitalization Fetal surveillance

Care Management (Cont.)



Intrapartum care Monitor patient closely Complications May require a cesarean birth

Postpartum care Insulin requirements decrease substantially Encourage breastfeeding Contraception

Care Management


Gestational diabetes mellitus Maternal-fetal risks Screening for gestational diabetes mellitus

• Antepartum care Diet and exercise Monitoring blood glucose levels Insulin therapy Fetal surveillance

• Intrapartum and postpartum care




Thyroid disorders Hyperthyroidism

• Graves’ disease 90% to 95% of cases• Rare in pregnancy

Hypothyroidism• If untreated at risk for infertility and miscarriage

Metabolic Disorders


Maternal phenylketonuria Recognized cause of mental retardation caused by

deficiency in enzyme phenylalanine hydrolase Toxic accumulation of phenylalanine in blood

interferes with brain development and function Key to prevention is identification of women with

disorder in their reproductive years Should be advised against breastfeeding



Major cardiovascular changes during pregnancy that affect women with cardiac disease are: Increased intravascular volume Decreased systemic vascular resistance Cardiac output changes during labor and birth Intravascular volume changes that occur just after

childbirth

Cardiovascular Disorders


Cardiovascular disease classification Class I Class II Class III Class IV Determined at 3 months and again at 7 or 8 months

of gestation as progression may occur

Cardiovascular Disorders (Cont.)


Increased incidence of miscarriage Preterm labor and birth more prevalent Intrauterine growth restriction is more common Incidence of congenital heart lesions increased

in children of mothers with congenital heart disease



Congenital cardiac disease Atrial septal defect Ventricular septal defect Coarctation of the aorta Tetralogy of Fallot

Acquired cardiac disease Mitral valve prolapse Mitral valve stenosis Aortic stenosis

Selected Cardiovascular Disorders


Ischemic heart disease Myocardial infarction

Other cardiac diseases and conditions Persistent pulmonary hypertension Peripartum cardiomyopathy Infective endocarditis Eisenmenger syndrome Marfan syndrome

Selected Cardiovascular Disorders (Cont.)


Heart transplantation Increasing numbers of heart recipients are

successfully completing pregnancies Before conception woman must be assessed for

quality of ventricular function and potential rejection of transplant

Conception should be postponed for 1 year after transplant



Antepartum assessment Plan of care and implementation

Therapy focused on minimizing stress on heart Signs and symptoms of cardiac decompensation Bed rest Nutrition counseling Cardiac medications as needed

Care Management


Plan of care and implementation Anticoagulant therapy

• Heparin: large-molecule drug does not cross placenta

Intrapartum care• Care focuses on promoting cardiac function• Prophylactic antibiotics

Postpartum care• Monitoring for cardiac decompensation



Anemia Iron deficiency anemia Folic acid deficiency anemia Sickle cell hemoglobinopathy Thalassemia

Other Medical Disorders in Pregnancy


Pulmonary disorders Asthma

• Exacerbations and remissions• Hyperactive airways• Effective pregnancies unpredictable• At increased risk for postpartum hemorrhage

Other Medical Disorders in Pregnancy (Cont.)


Pulmonary disorders Cystic fibrosis

• Infants of mothers with cystic fibrosis will be carriers of gene• With severe disease, pregnancy is often complicated by

chronic hypoxia and frequent pulmonary infections• Exocrine glands produce excessive viscous secretions• Problems with respiratory and digestive systems



Integumentary disorders induced by pregnancy Melasma (chloasma) Vascular “spiders” Palmar erythema Striae gravidarum



Skin problems aggravated by pregnancy Acne vulgaris (in the first trimester) Neurofibromatosis (von Recklinghausen disease) Pruritic urticarial papules and plaques Intrahepatic cholestasis




Epilepsy Failure to take medications is common factor

• Should receive preconceptual counseling • At risk of congenital anomalies if mother is taking

anticonvulsants

Multiple sclerosis Bed rest and steroids used to treat acute

exacerbations Bell palsy

Acute facial paralysis

Neurologic Disorders


Systemic lupus erythematosus Autoimmune antibody production affects skin, joints,

kidneys, lungs, central nervous system, liver, and other body organs

Immunosuppressive medications not recommended during pregnancy

Efforts are aimed at reducing the risk of infection

Autoimmune Disorders


Myasthenia gravis (MG) Autoimmune motor (muscle) endplate disorder Muscle weakness in the eyes, face, neck, limbs, and

respiratory muscles Women with MG usually tolerate labor well May require forceps or vacuum delivery

Autoimmune Disorders (Cont.)


The continued use of substances despite related problems in physical, social, or interpersonal areas

Dual diagnosis Substance abuse plus another psychiatric disorder

Damaging effects on the fetus are well documented

Substance Abuse


Barriers to treatment Women fear losing custody of child and criminal

prosecution Less than 10% of pregnant women receive treatment Substance-abuse treatment programs do not address

issues affecting pregnant women Long waiting lists and lack of health insurance present

further barriers to treatment

Substance Abuse (Cont.)


Care management Drug testing during pregnancy Screening for substance abuse Initial care Methadone maintenance program Follow-up care



Care management Breastfeeding definitely contraindicated in women

who continue to use amphetamines, alcohol, cocaine, heroin, or marijuana

Substance abusers difficult to care for particularly during intrapartum and postpartum periods

Substance abuse is an illness; women deserve to be treated with patience, kindness, consistency, and firmness



Care management Before discharge

• Home situation must be assessed for safe environment• Someone available to meet infant’s needs

if mother is unable• Family members or friends should become actively involved

with mother before discharge

If infant’s well-being is questionable, case will be referred to child protective services agency



During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. The nurse evaluates that teaching has been effective when the woman states:

“I will need to eat 600 more calories per day since I am pregnant.”

“I can continue with the same diet as before pregnancy as long as it is well balanced.”

“Diet and insulin needs change during pregnancy.” “I will plan my diet based on results of urine glucose

testing.”

Question


Chapter 11 High Risk Perinatal Care: Pre-existing Conditions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of.

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