Pregnancy at Risk: Pregestational Problems Chapter 14.

Pregnancy at Risk:Pregestational Problems

Chapter 14

Substance Abuse in Pregnancy

• Commonly used drugs

• Frequently missed dx

• HCP fail to ask client about SA

• Often hide SA or seek PNC late

• During PNC may be receptive to nursing interventions

Alcohol

• CNS depressant- leading cause of preventable retardation.

• FAS physical and mental abnormalities

• Avoid alcohol during organogenesis

• Nursing observe for S/S of DT

• Need sedation and supportive care

• Breast feeding dependent on degree of addiction

Cocaine and Crack

• Causes:vasoconstriction, tachycardia, hypertension

• Metabolites present from 4-7 days

• Higher incidence of abruption, stillbirth, PT and AB

• Hard to detect abuse

• Should not breastfeed

Heroin and Methadone

• Methadone is tx for opioid addiction

• Heroin lifestyle associated with poor nutrition, crime, STD

• Both associated with in utero problems

• Withdrawal for newborn more severe with methadone

Nursing Care

• Unsafe to go “Cold Turkey”

• Be alert to subtle clues that suggest addiction

• Matter of fact and non-judgmental approach

• Focus is general health, nutrition, infections, other body systems and returning for PNC

Nursing Plan and Implementation

• Establish trusting relationship, refer to TX programs

• May have low thresh hold to pain with associated labor, consider epidural

• Prepare for depressed, SGA, premature and addicted newborn

Diabetes Mellitus

• Endocrine disorder of carbohydrate metabolism

• Insulin produced in pancreas by B- cells in Islets of Langerhorn facilitates glucose utilization of cells

• Populations at risk

Glucose Metabolism in Pregnancy

• Metabolically all pregnant woman live in a state of accelerated starvation.

• Until 24 weeks estrogen and progesterone increase tissue response to insulin

• HPL produced by enlarging placenta is anti- insulin

• Promotes lipolysis, decreases glucose uptake and glucogenesis

Pathophysiology

• Diabetes Mellitus-carbohydrates cannot be utilized due to insulin deficiency

• Glucose unable to enter cells- cells are starving- blood glucose high

• Cells use fat and protein for energy

• Byproduct is ketones

Cardinal Signs of DM

• Polyuria- due to decrease reabsorption of renule tubules

• Polydipsia- dehydration due to polyuria

• Polyphasia- starvation due to cells inability to use glucose

• Weight loss- due to use of fat and muscle for energy

Classification of DM

• Type I-insulin deficiency.• Immunological destruction of B-cells, usual

onset is childhood, often brittle• Type II- adult onset, glucose intolerance• Exhaustion of cells, obesity, can control

with diet• Gestational- glucose intolerance identified

during pregnancy,

Diabetes in Pregnancy

• Insulin requirements fluctuate• Insulin requirements during first trimester are

low due to N/V• Insulin needs rise as pregnancy progresses• Need to balance glucose and insulin during

labor• At risk for ketoacidosis and vascular disease

Maternal Risks

• Hydramnios- excessive urination by fetus

• Preeclampsia- due to vascular damage

• Ketoacidosis- caused by metabolism of fatty acids, decreased gastric motility and HPL

Fetal Risks

• Hyperglycemia if untreated fetus at risk for demise

• Increase risk for fetal anomalies• Macrosomia- increase glucose leads to increase

utilization by fetus• IUGR- poor placental perfusion• RDS- fetal insulin inhibits surfactant production• Polycythemia- inability of glycosylated hgb in

mothers blood to release oxygen, cause hyperbilirubinemia

Screening

• Done at 24-28 weeks

• 25 years or older

• Obese

• Family history

• Black, Hispanic, Native American, Asian

• Abnormal glucose tolerance test

• Poor obstetrical outcome

Testing

• Give 50gms of glucose, blood drawn 1 hr later• If exceeds 130 need three hour• Draw blood q hr for 3 hrs• HgbA1C- measures glucose control over 6-8 wk

period.• Greater than 7.5% have 44% chance of adverse

outcome, less than 7.5% have 7% risk

Management

• Use team approach to facilitate teaching• Teach nutrition, three meals three snacks.• Enroll family• Teach glucose monitoring and self injection• Oral meds never used, causes hypoglycemia• Need AFP@16-20 wks, anomalies scan @

18 wks, 28 wks S=D, BPP, FKC 28 wks, 32-36 wks biweekly NST

Intrapartal Management

• Timing of birth- LGA, SGA, and FLM

• During labor need frequent assessment of glucose

• May need insulin drip

Postpartum Care

• Insulin need fall after deliver of placenta

• If Type I need less insulin

• Type II glucose control returns

• Need follow up @ 6 weeks

• Encourage parental attachment

• Encourage breastfeeding

• Teach contraception

Nursing Care

• Visits twice/month first two trimesters, once week for third

• Exercise program

• Glucose control between 70 and 120

• Have milk and hard candy available

• Enroll family

HIV

• More woman with HIV, especially of color• Enters through body fluids and breastmilk• Effects T-cells, inhibits immune response• AIDS dx based on opportunistic infections and T-

cell count• Risk of transmission lessened with antiviral meds• Newborns can have titer for up to 15 months

HIV

• CDC guidelines recommend taking Zidovudine

• Assess for STD and opportunistic infections• Evaluate weight loss, fevers, serology• NST @ 32 weeks, bpp, utz, NO AMNIO• C/S lessens risk of vertical transmission• PP-@ risk for infection, delayed wound

healing, pp hemorrhage

Nursing Care

• Counseling

• Teach S/S of progression of disease

• Always practice universal precautions

• Facilitate use of social services

Heart Disease

• Pregnancy causes increase cardiac output, volume and heart rate

• Most heart conditions are congenital and asymptomatic

• Problems with mitral(stenosis and prolapse) valve most common

• Peripartum cardiomyopathy-dysfunction of left ventricle S/S are similar to CHF

Classifications of Heart Disease

• Based upon ability to perform activities of daily living

• Class I-asymptomatic. No limitations• Class II-slight limitations, asymptomatic at rest• Class III-moderate limitations. Symptomatic

during ADLs• Class IV-Discomfort with physical activities.

Symptoms while at rest

Cardiac Disease

• Class I-II few complications during gestation and labor

• Class III-IV at risk for heart failure, usually need invasive cardiac monitoring and assisted delivery

• May need ABX and anticoagulant tx.

Nursing Assessment

• Pulse, BP, assess for tachypnea, tachycardia• Fatigue and activity level• Cough, edema, weight gain palpitations• Diet high in protein and iron, restrict sodium• Encourage rest, avoid infections• Seen every 2 weeks until 20 weeks, then q week

• Blood volume reaches max. @ 28-30 weeks

Labor

• Maintain L lat, 02, ABX, pain management

• Provide calm atmosphere

• Continuous fetal monitoring

• Keep client aware of progress and need for close monitoring

Postpartum Care

• First 48 hours critical

• Fluid shifts from extravascular to blood stream

• Keep lat, head up, monitor V/S frequently

• Give stool softeners to avoid straining

• Gradual activity

• Evaluate meds for breastfeeding