Chapter 20 Pregnancy complication from a pre-existing or newly acquired illness
Mar 26, 2015
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