High-Risk Pregnancy

High-Risk Pregnancy
Assessment of Fetal Well-being - Maternal assessment of fetal activity

* Vigorous fetal activity provides reassurance of fetal well-being

* Marked decrease in activity or cessation of fetal movement indicates possible fetal compromise or death * Beginning at 28 weeks * Mother instructed to count fetal movements at same time each day

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* Fewer than 10 movements in a 3-hour period or significantly less than normal, mother should contact health care provider * Any perception of decreased movement for a 24-hour period should indicate further testing * Movements vary with fetal sleep-wake cycles

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Procedures - Ultrasound * Most common methods of scanning are transabdominal and transvaginal

* Transabdominal
- Transducer moved across womans abdomen - Mineral oil or transducer gel is used to enhance the picture

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Provide opportunity for questions Explain the procedure Tell woman to drink at least 1 to 1.5 quarts of fluids prior to test and arrive with a full bladder

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* Uses of Ultrasound - Early confirmation of pregnancy - Observation of fetal heart beat and fetal breathing movements - Identification of > 1 embryo/fetus - Measurement of biparietal diameter of head or femur length to assess growth patterns - Clinical estimation of birth weight - Detection of fetal anomalies

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-

- Examination for nuchal translucency Down syndrome - Fetal echocardiography - Length of fetal nasal bone (Down) - Identification of amniotic fluid volume - Location of placenta - Placental grading - Detection of fetal death

- Fetal presentation and position

- Accompanying procedures (amniocentesis)

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- Nuchal Translucency Testing * Used to detect trisomies 13, 18 & 21

* Scans clear area in back of neck where excess fluid accumulates with certain genetic disorders * Nuchal translucency measurements of > 3 mm are at risk
* Detects 70-80% Down syndromes

* 5% false positives when combined with serum alpha feto-protein

* Option is then amniocentesis

High-Risk Pregnancy
* Doppler Blood Flow Studies - Umbilical velocimetry Non-invasive ultrasound test Measures maternal and fetal blood flow and changes that occur to assess placental function Doppler directed at umbilical artery Result is a picture that looks like a series of waves

High-Risk Pregnancy
Highest point is systolic reading Lowest point is diastolic reading Interpretation = S/D ratio Decrease in placental perfusion indicated by a high S/D ratio (vessel narrowing Normal = < 2.6 by 26 weeks and < 3 by term

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* Non-Stress Test - Most widely applied technique for fetal evaluation during pregnancy - Based on fact that normal fetus will produce characteristic heart rate changes in response to its own movement

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- In normal fetus with intact CNS, 90% of gross fetal movements are associated with accelerations of the FHR - External fetal monitor (tocotransducer and doppler) - If evidence of fetal movement not visible on strip, woman is asked to depress a button when baby moves - marks the strip

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- If fetus seems to be in a sleep cycle, acoustic stimulation is used to rouse the fetus - Reactive = > 2 accelerations of 15 bpm lasting for 15 seconds over a 20 minute period, normal baseline rate and long-term variability amplitude of > 10 bpm - Non-reactive = notify care provider and prepare for contraction stress test

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Reactive Non-Stress Test

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Non-Reactive Non-Stress Test

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Biophysical Profile - Combines ultrasonography and FHR monitoring - Assesses both acute and chronic markers of non-reassuring fetal status - Fetal breathing movements, fetal movements, fetal tone, fetal heart rate patterns (NST) and amniotic fluid volume * Fetal breathing movements = > 1 episodes in 30 minutes, each lasting > 30 seconds

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- Gross body movements = > 3 discrete body/limb movements in 30 minutes - Fetal tone = > 1 episodes of active extension with a return to flexion of limbs/trunk or opening and closing of hand - Reactive fetal heart rate (NST)

- > 1 pocket of amniotic fluid measuring > 1cm

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* Contraction Stress Test (CST)

- Uterine contractions decrease uterine blood flow and placental perfusion

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- Uterine contractions can be stimulated by IV oxytocin or by self nipple stimulation by the woman (causes oxytocin release from the posterior pituitary)

- Many practitioners are substituting the Biophysical Profile for a CST

- The compromised fetus becomes hypoxic and a decreased FHR results - What type of FHR decelerations would this produce on the monitor tracing?

High-Risk Pregnancy
Positive Contraction Stress Test

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Amniotic Fluid Analysis - Quadruple screen * Gives information about possible Down syndrome and neural tube defects - High levels of alpha feto-protein can indicate neural tube defects and low levels can indicate Down syndrome

- Evaluation of fetal maturity

* L/S (lecithin-sphingomyelin) ratio - 2:1 = lung maturity (surfactant)

High-Risk Pregnancy

* Phosphatidyglycerol (PG) - Another phospholipid in surfactant * Lamellar body counts (LBC) - Over 50,000 predictive of lung maturity

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* Woman must come to amniocentesis with an empty bladder

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Pre-Gestational Risks - Substance Abuse

* Definition = continued use of substances despite related problems in physical, social or interpersonal areas * ANY use of alcohol or illicit substances in pregnancy is considered abuse

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- Risks * Low birthweight, preterm birth, miscarriage, stillbirth, bleeding complications, sudden infant death syndrome (SIDS), birth defects

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- Alcohol * A potent teratogen

* Abuse is highest among women 20-40 years of age

* Use during pregnancy significantly lower than when non-pregnant * Birth defects can occur before woman knows she is pregnant * Fetal Alcohol Spectrum Disorders - Characteristic physical and mental abnormalities

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* Also undermines maternal health from malnutrition, infections and liver disease

* Implications for nurses caring for these women in labor, sedation and fluid therapy
- Cocaine and Crack * Cause vasoconstriction, tachycardia and hypertension * Increased incidence of spontaneous abortion, abruptio placentae, preterm birth and stillbirth

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* Fetal effects include intrauterine growth restriction (IUGR), small head circumference, cerebral infarctions, altered brain development, congenital malformations, shorter body length, increased incidence of SIDS and neurobehavioral disturbances - Marijuana * Most widely used illicit drug among pregnant women

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* No strong evidence of teratogenic influences on the fetus * Some infants may show withdrawal symptoms - Ecstasy (MDMA) * Third most widely used illicit drug in US * Little known about teratogenic effects - Heroin * Women who use high-risk because of poor nutrition, pre-eclampsia

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* Heroin withdrawal is contraindicated during pregnancy because of jeopardy to fetus (may die) * Women put on Methadone program * Newborn shows signs of heroin or methadone addiction and withdrawal that may last days to weeks

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Many pregnant substance users are

unaware of the effects of the abuse on the pregnancy/baby Many do not come in for prenatal care until very late, if at all Women may be open to making lifestyle changes during pregnancy more than any other time

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* Nursing Assessment - Many substance abusers register late for prenatal care, if at all - Screen all women for substance abuse

* Be alert for clues

- Known substance abusers

* * * *

Nutritional disorders Risk for infection Ineffective health maintenance Fetal injury

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- Nursing Interventions

* Establish relationship of respect, trust and support

* Provide information about relationship between substance use and existing health problems as well as implications for unborn child

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Diabetes Mellitus (Pre-gestational)
- Perinatal mortality for well-managed diabetic pregnancies is approximately the same as for normal pregnancies - The key to optimal outcome is strict glucose regulation before pregnancy as well as throughout the gestational period

- Etiologic classification of Diabetes by White

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- Carbohydrate metabolism in pregnancy * In early pregnancy, insulin production stimulated by estrogen and progesterone * In second and third trimesters, placental production of human placental lactogen causes an insulin resistance and decreased glucose tolerance * Delicate system of checks and balances between glucose production and use is stressed by the growing fetus

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- Influence of Pregnancy on Diabetes * Diabetes in pregnancy may be difficult to control because insulin requirements are changeable
* During first trimester, need for insulin

decreases because human placental lactogen (HPL) levels are low, fetal needs are small and women may not eat much

* Nausea and vomiting may cause dietary fluctuations and increased hypoglycemic episodes

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* Insulin requirements begin to rise in the 2nd trimester as glucose use and storage by the woman and fetus increase * Insulin requirements may double or quadruple by the end of pregnancy due to high levels of HPL * Increased levels of insulin may be needed to balance IV glucose

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* Abrupt decrease in insulin requirement occurs after delivery of the placenta
* Decreased renal threshold for glucose usually shows some glycosuria * Ketoacidosis may occur at lower serum levels of glucose in a pregnant woman

* Accompanying vascular disease may progress during pregnancy

* Hypertension may occur, contributing to vascular changes * Nephropathy and retinopathy may develop

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- Impact on pregnancy outcome * Tight glucose control (FBS < 95 mg/dL and 2-hour pp < 120 mg/dL) reduces risks of complications * Some types of oral hypoglycemic agents may have teratogenic effects and must be discontinued prior to conception

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- Maternal Risks & Complications * Maternal morbidity and mortality has improved considerably but the pregnant woman with diabetes remains at risk for the development of complications

- Miscarriage, if glycemic control is poor at conception

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- Pregnancy-induced hypertension/preeclampsia - Polyhydramnios - Infections - Ketoacidosis (2nd and 3rd trimesters) - Retinopathy

- Monilial (yeast) vaginal infections

- Urinary tract infections

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- Fetal-Neonatal Risks * 5-10% risk of congenital anomalies

* Large-for-gestational-age infants (macrosomic)

- Fetus makes insulin in proportion to the amount of glucose coming from the mother - Insulin acts as a growth hormone in the fetus

High-Risk Pregnancy
- Once maternal glucose supply is cut off when umbilical cord is cut, infant rapidly goes into hypoglycemia - Lungs of infants of diabetic mothers are often less mature than other infants due to the effects of insulin on the production of surfactant

* Can go into respiratory distress syndrome (RDS), polycythemia and hyperbilirubinemia

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Clinical Management * Preconceptional Period - Ideally, women are counseled before conception so that glucose control can be maximized and before any of the vascular complications of diabetes have occurred

- Estimated that only < 20% of women in US receive preconceptional counseling

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* Pregnancy

- All women, regardless of risk, are screened with a 1-hour screen at 24-28 weeks of pregnancy
- Women with risk factors are screened earlier * obesity, family history of diabetes, macrosomic infant, stillborn, hypertension or glycosuria

High-Risk Pregnancy
* If 1-hour screen above 130-140 mg/dL, a 3-hour glucose tolerance test is done Fasting 1-hour 2-hour 3-hour 95 mg/dL 180 mg/dL 155 mg/dL 140 mg/dL

* If 2 or more levels are elevated, gestational diabetes is diagnosed * Measurements of HbA1c show control for past 4-6 weeks - Greater than 10% = associated with fetal anomaly rates of 20-25%

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- Dietary regulation * 1st trimester 30 kcal/kg ideal wt.

* 2nd & 3rd trimesters 35 kcal/kg ideal wt.

* 40-45% from complex carbohydrates * 12-20% from protein * 35-40% from fats * Divided among 3 meals and 3 snacks

- Bedtime snack is most important and should include both protein and complex carbohydrates

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- Glucose monitoring * Self-monitoring of glucose levels is done by woman at home * Levels should be maintained at: - Fasting < 95 mg/dL - 2-hour postprandial < 120 mg//dL * Careful client education is essential so that woman understands correct technique

High-Risk Pregnancy
* Insulin Therapy - Adequate insulin is primary factor for maintaining euglycemia duringpregnancy - Frequent adjustments of insulin dosage due to dramatic changes in insulin requirements during pregnancy

High-Risk Pregnancy
- Use human insulin less likely to cause allergic reaction

- Commonly use multiple (4) injections

- Lispro vs. Regular insulin - Lispro before each meal - NPH or Lente before breakfast and at bedtime

* Although most oral hypoglycemics have teratogenic effects, glyburide does not cross the placenta and is now being used

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Hospitalization

May be needed to regulate insulin and stabilize glucose levels Infection can lead to hyperglycemia and is also an indication for admission May be necessary during the 3rd trimester for closer maternal and fetal observation

High-Risk Pregnancy
- Monitoring of fetal status * Maternal evaluation of fetal activity begun at 28 weeks * Biophysical profiles * Non-stress testing weekly at 28 weeks and twice weekly at 32 weeks - Determination of Birth Date

* Most pregnancies allowed to progress to 38-40 weeks as long as good glucose control and fetal surveillance shows normal limits

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- Many practitioners elect to deliver these pregnancies around 38 weeks, depending on fetal lung maturity based on amniotic fluid sampling (amniocentesis)

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Labor & Delivery - Prevent dehydration, hypoglycemia, hyperglycemia - IV with lactated 5% glucose solution with a saline solution for piggy-backing insulin - Monitor blood glucose levels hourly and adjust fluids and insulin accordingly - Continuous FHR monitoring

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Postpartum - Insulin requirements decrease substantially with expulsion of the placenta - Possibility of hemorrhage or infection increased - Breastfeeding is encouraged but women may be at increased risk of hypoglycemia

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- Expected Outcomes of Care * Client will discuss her condition and its possible impact on pregnancy, labor and postpartum period * Client will participate in developing a health care regimen to meet her needs * Client avoids hyper- or hypo-glycemia

* Client will give birth to a healthy infant at term

* Client is able to care for her newborn

High-Risk Pregnancy
Anemia

Most common medical disorder of pregnancy (20% of pregnant women) When O2 carrying capacity is decreased, cardiac output increases as compensatory mechanism Anemia in presence of another complication can lead to congestive heart failure Hemodilution that occurs with the increase in plasma volume can lead to Hcts as low as 34%

High-Risk Pregnancy Pregnant woman is considered anemic

if her Hgb is < 11 g/dL in 1st trimester, <10.5 mg/dL in 2nd trimester <11 g/dL in 3rd trimester If a woman is anemic during pregnancy, blood loss at delivery may not be well tolerated Women with anemia also at higher risk for puerperal complications (i.e., infection) Must distinguish among various types of anemia to treat them

High-Risk Pregnancy
Iron-Deficiency Anemia

90% of anemias in pregnancy are of this type Iron for fetus comes from maternal serum so many women will end their pregnancies iron-deficient Diet, alone, cannot replace iron losses in pregnancy Oral iron supplements (FeSO4 , 30-60 mg./day)

High-Risk Pregnancy

Intake of Vitamin C enhances iron absorption

Some women have gastrointestinal side effects (nausea, vomiting, constipation)

Not uncommon to have a folate deficiency, even in well-nourished women Common in multiple pregnancies

Folate Deficiency Anemia

High-Risk Pregnancy

Folate deficiency before and during the first few weeks of pregnancy is associated with neural tube defects in fetus Recommended intake is 400 micrograms/day

Differentiation of iron-deficiency from folic acid-deficiency is done by the red blood cell indices (MCH, MCV, MCHC) - Iron-deficiency is microcytic (low MCV) and hyperchromic (high MCHC) - Folic acid-deficiency is macrocytic (high MCV) and hypochromic (low MCHC)

High-Risk Pregnancy
Sickle Cell Hemoglobinopathy

Almost 10% of African-Americans have sickle cell trait; fewer than 1% have sickle cell anemia Trait = SA Hgb
S A

Disease = SS Hgb
S S

S
A

SS

SA AA

S
A

SS SA

SS SA

SA

High-Risk Pregnancy
Women with sickle cell trait usually do
well in pregnancy - At increased risk for urinary tract infections - May show borderline anemia

Women with sickle cell disease - Frequently need additional folic acid (1 mg/day) - Oxygen and Iv fluids during labor

High-Risk Pregnancy
- May have increase in sickle crises * Prone to pyelonephritis, leg ulcers, strokes, cardiomyopathy, CHF and pre-eclampsia * Treated with oxygen, rehydration, antibiotics and analgesics - Fetal complications include IUGR,, SGA, skeletal changes

High-Risk Pregnancy
Human Immunodeficiency Virus and AIDS - Women are fastest growing population of persons with HIV and AIDS in the US and 80% of cases result from high-risk heterosexual contact * 19% of cases from IV drug use - Women of color are disproportionately affected (82% of women with AIDS are African-American or Latina)

High-Risk Pregnancy
- Pregnancy is not encouraged in HIV+ women but many women with HIV do get pregnant - HIV has significant impact on the pregnancy, infant feeding method and babys health status - Fetal-Neonatal Risks * Placental transmission may result in the fetus developing HIV/AIDs * Also when fetus is in contact with maternal blood and vaginal secretions at birth or via breast milk

High-Risk Pregnancy
* In US, rate of transmission has dropped to 2% because of universal HIV counseling and use of retroviral prophylaxis, routine use of cesarean birth and avoidance of breast feeding * following birth, infants may have a + antibody titer - Reflects passive transfer of maternal antibodies and not HIV infection * CDC guidelines state that HIV screening as early as possible in pregnancy should be done for all women

High-Risk Pregnancy
- With the understanding that a woman can opt out * ACOG recommends repeat screening of high-risk women in 3rd trimester * Antiretroviral prophylaxis * Wide array of options exist - Highly active antiretroviral therapy (HAART) * Minimum of 3 antiretroviral agents

High-Risk Pregnancy
* Includes: - Zudovudine (AZT) - Didanosine or lamivudine - Nevirapine or indinar, ritonavir or saquinavir

* Treatment delayed if possible until after 1st trimester

- Hiv-positive women should also be treated for other common infections and conditions (TB, toxoplasmosis, cytomegalovirus, cervical dysplasia)

High-Risk Pregnancy
- Also monitored for changes in serologic status and early signs of complications

- If complication occurs, fetus monitored closely with weekly NSTs starting at 32 weeks and serial ultrasounds to monitor fetal growth
- AZT (ZDV) given IV during labor - Scheduled cesarean delivery at 38 weeks - Nursing care involves assisting woman and family to cope with this disease, guilt, blame and other family stresses

High-Risk Pregnancy
- Women are monitored at each prenatal visit for signs of complications (opportunistic infections, pneumonia) - Also for serologic evidence of progression of the disease - Weekly non-stress testing of the fetus begun at 32 weeks * CDC Guidelines for pregnant women with HIV infection all providers must

High-Risk Pregnancy

Cardiovascular Disorders - Normal pregnancy causes changes put a physiologic strain on the heart - While the normal heart can compensate, the diseased heart cannot

- If cardiovascular changes are not well tolerated, cardiac failure can develop during pregnancy, labor or the postpartum period
- Half of all heart disease in pregnancy are congenital heart lesions

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- Complicates about 1% of pregnancies but is most common cause of maternal death, overall

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- Impact of heart disease for women with congenital lesions depends on the type of defect * If defect was repaired, antibiotic prophylaxis during labor is recommended

- Rheumatic heart disease

* Risk of developing congestive failure related to the scarred valve(s)

- Mitral valve prolapse

* Usually no risk but a few women are symptomatic

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- Peripartum Cardiomyopathy * Last month of pregnancy or first 5 months of postpartum * Dysfunction of left ventricle * Maternal mortality 25%-50% - cause unknown * Clinical findings are those of CHF (left ventricular failure)

High-Risk Pregnancy
* Signs of congestive failure

- Cough with or without hemoptysis

- Progressive dyspnea on exertion - Edema progressive, generalized - Heart murmurs - Palpitations - Rales - Weight gain

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* Medical management includes digoxin, siuretics, vasodilators, anticoagulants, sodium restriction and strict bed rest * Subsequent pregnancy strongly discouraged - Clinical Therapy * Early diagnosis and ongoing management * Early diagnosis and treatment of anemia and infections

High-Risk Pregnancy
* Expected Outcomes - Client will verbalize understanding of the disorder, management and probable outcome - Client will describe her role in management, including when and how to take medication, adjust diet, and prepare for and participate in treatment - Client is able to cope with emotional reactions to the pregnancy and infant at risk

High-Risk Pregnancy

Client will adapt to physiologic stressors of pregnancy, labor and birth Client will identify and utilize appropriate support systems Client is able to carry fetus to the point of viability or term

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* Nursing Management

- Maintain balance between cardiac workload and cardiac reserve

- Priority of actions based on severity of disease - Dietary = diet high in iron, protein and nutrients and adequate calories to ensure normal weight gain but low in sodium

High-Risk Pregnancy
- Woman seen every 2 weeks during first half of pregnancy and weekly after that Labor and Delivery - Evokes much apprehension in clients with cardiac disorders - Focus is on the promotion of cardiac function

High-Risk Pregnancy
- Nursing comfort measures and childbirth preparation techniques used

- Minimize anxiety
- Elevate womans head and shoulders and support body parts with pillows - Side-lying position to facilitate hemodynamics

- Epidural anesthesia is used (but hypotension must be avoided)

High-Risk Pregnancy
- May require anticoagulants and antibiotic prophylaxis - Vaginal birth is recommended if no obstetric problems

- Avoid Valsalva maneuver

- No stirrups - Mask O2 - Episiotomy and forceps to decrease cardiac work

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Postpartum Period - First 24-48 hours postpartum are hemodynamically the most difficult for the woman - Head of bed is elevated and woman encouraged to lie on side - Bedrest may be ordered - Progressive ambulation as tolerated - Stool softeners

High-Risk Pregnancy
* Signs of Congestive Heart Failure - Cough with or without hemoptysis - Progressive dyspnea on exertion

- Progressive, generalized edema

- Heart murmurse on auscultation

- Palpitations
- Rales in lung bases on auscultation - Weight gain from fluid retention

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Gestational Problems

- Bleeding disorders
* Spontaneous abortion = expulsion of the fetus prior to viability (20 weeks or weight less than 500 gm) * Also called miscarriage - Nursing measures with client who is bleeding: * Monitor BP and P frequently * Observe client for signs of shock

High-Risk Pregnancy
* Count and weigh sanitary pads to assess amount of bleeding over time; save tissue or clots expelled * If pregnancy> 12 weeks, listen for fetal heart tones with Doppler * Prepare for IV therapy * Prepare equipment for an examination and have O2 available

* Collect and organize all data, including medical record information and lab data * Notify members of health care team

High-Risk Pregnancy
* Obtain order for type and crossmatch for blood if bleeding is significant

* Assess coping mechanisms of woman and family members - Miscarriage

* 10% - 15% of all pregnancies but maternal age influences this * Majority occur prior to 8 weeks and are related to chromosomal abnormalities

High-Risk Pregnancy
- Classification of miscarriage * Threatened abortion

- Vaginal spotting, closed cervical os, may have cramping

* Inevitable abortion (Inevitable) - Vaginal bleeding with a dilated cervix and maybe rupture of membranes * Incomplete abortion - Passage of fetus but not placenta

- Cervix is dilated with tissue present

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* Complete abortion - All fetal tissue is passed; cervix is closed * Missed abortion

- Fetus has died but products of conception have not been expelled; cervix is not dilated

High-Risk Pregnancy
* Recurrent abortion (habitual) - Occurs consecutively in 3 or more pregnancies * Septic abortion - Infection is present

* Late miscarriages
- Between 12 and 20 weeks - Maternal causes (advanced age, chronic infections, premature dilatation of cervix, anomalies of reproductive tract

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Threatened Imminent Incomplete

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- Clinical Therapy * Speculum exam and ultrasound are performed * IV therapy and possible transfusions

* D & C or suction curettage to remove remainder of tissue * RhoGAM given if client is Rh-negative and not sensitized

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Ectopic Pregnancy - Fertilized ovum implanted outside of uterine cavity - 95% occur in the fallopian tube (ampulla) - Other sites include abdominal cavity, ovary and cervix

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- Reported incidence is rising due to: * Improved diagnostic techniques (vaginal ultrasound) * Endometriosis * Increased incidence of sexuallytransmitted infections * Increased number of tubal sterilizations and their reversal * Use of intrauterine devices * Exposure to DES in utero

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- Clinical manifestations

* Missed period

* Adnexal (area around ovaries and tubes) fullness and tenderness

* Pain (sudden, sharp; may have referred shoulder pain from peritoneal irritation)

* Abnormal vaginal bleeding (dark red or brown)

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* Woman may show signs of shock - Vaginal ultrasound is performed - hCG levels drawn low in ectopic - Treatment is medical or surgical

* If hCG levels high and ectopic unruptured, Methotrexate is given IM (folic acid antagonist) - If hCG lvels low, surgery
* Type of surgery depends on desire for future pregnancies

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Gestational Trophoblastic Disease (Hydatidiform Mole/Molar Pregnancy)

- Results from fertilization of an egg with as lost or inactivated nucleus

- Pathologic proliferation of trophoblastic cells - Resembles a bunch of white grapes - Fluid-filled vesicles grow fast so uterus is larger than expected for gestational age

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- Maternal blood has no placenta to receive it so hemorrhage into uterine cavity and vaginal bleeding (bright red or dark brown) result - High hCG levels after when they usually drop (70-100 days) - Excessive nausea and vomiting (high levels of hCG) - Pre-eclampsia at 9 12 weeks - 20% progress to choriocarcinoma of the uterus

High-Risk Pregnancy
- Most moles abort spontaneously but

suction curettage may be necessary

- RhoGam is administered if woman is Rh- Long follow-up with serial hCGs, pelvic exams and ultrasounds to watch for choriocarcinoma of the uterus - Pregnancy postponed and contraceptive use (usually oral contraceptives) is very important for one year

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Recurrent Premature Dilatation of the Cervix (Incompetent Cervix)

- Passive and painless dilatation of the cervix during the 2nd trimester
- Risk factors * Frequent D & C * Repeated abortions (2nd trimester) * Ingestion of DES (diethylstilbesterol) by clients mother during pregnancy

High-Risk Pregnancy
* History of previous cervical lacerations during childbirth

- Treatment
* Cervical cerclage (Shirodkar procedure) * Band of nonabsorbable fabric (Mersilene) placed around the cervix beneath the mucosa to constrict the internal os

High-Risk Pregnancy
- Placed prophylactically 10-14 weeks of pregnancy - Woman told to refrain from intercourse, standing more than 90 minutes at a time and heavy lifting - Followed by ultrasound to detect cervical shortening and funneling

- Removed at 37weeks or left in place and C/S performed

- Must be repeated with each pregnancy

High-Risk Pregnancy
- Procedure not without risk * Premature rupture of membranes * Preterm labor * Chorioamnionitis

- May also be placed on oral tocolytics

- Rarely performed after 25 weeks when bedrest and tocolytic therapy can be used

High-Risk Pregnancy

Hyperemesis Gravidarum

- Nausea and vomiting occur in 70% of pregnancies but are usually confined to first trimester - Excessive nausea/vomiting that results in weight loss of at least 5% of pre-pregnant weight accompanied by dehydration, electrolyte imbalance, ketosis and acetonuria - May be a multi-fetal pregnancy or hydatidiform mole

High-Risk Pregnancy
- May lead to a low birth weight infant - Can become so severe as to cause hypovolemia, hypotension, tachycardia, increased hematocrit and BUN and decreased urine output

- Etiology can include several things but none is confirmed as entirely explanatory
- Treatment consists of IV therapy for correction of fluid and electrolyte imbalance

High-Risk Pregnancy
- Followed by antiemetic medications - Followed by small, frequent feedings

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Hypertension in Pregnancy
- Hypertension is the most common medica condition of pregnancy (incidence 1% 5%) - Classification (NIH, 2000) * Chronic hypertension * Preeclampsia-eclampsia (Pregnancyinduced hypertension PIH) * Chronic Hypertension with superimposed preeclampsia or eclampsia - Gestational hypertension (transient)

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Preeclampsia - Multisystem, vasospastic disease process - Characterized by hemoconcentration, hypertension and proteinuria - Classified as Mild or Severe - Risk factors: Obesity, Rh incompatibility, twins, first pregnancy, family history, age < 19 or > 40, diabetes, chronic hypertension, chronic renal disease

High-Risk Pregnancy
Preeclampsia, Pathophysiology
Vasospasm BP
Kidney Perfusion

Activation of Endothelial System

Placental Perfusion

Vasoconstriction Intravascular Fluid Redistribution Viscosity of blood

Activation of Coagulation Cascade

High-Risk Pregnancy
- Prostacyclin-Thromboxane (prostaglandins) ratio changes * Prostacyclin is potent vasodilator * Thromboxane is vasoconstrictor and platelet aggregator

- Partially produced by placenta (reason why preeclampsia is reversed by delivery of the placenta) - Decreased nitric oxide production (also a vasodilator)
- All lead to decreased placental perfusion

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Continuum of Pre-eclampsia

Mild BP 140/90

Severe BP 160-110 > 4+ proteinuria Generalized edema

HELLP Syndrome Hemolysis Elevated Liver Enzymes Low Platelets

Eclampsia Seizures or coma

1+ - 2+ proteinuria
Dependent edema

Normal reflexes
Normal urine output

> 3+ reflexes
Reduced urine output

High-Risk Pregnancy
Severe Preeclampsia and HELLP Syndrome - Hemolysis, Elevated Liver Enzymes, Lowered Platelets - Care focuses on stabilization of the woman and preparation for delivery - Woman is admitted to a tertiary care center

- Assessments: CNS, cardiovascular system, renal system, pulmonary system and hematologic system

High-Risk Pregnancy
Medical Management - Assessment of risk factors - Early detection - Early and continuous prenatal care

- Fetal surveillance
Nursing Assessment

- History (what??)
- Nutritional assessment - Weight (why??)

High-Risk Pregnancy
Goals of Medical Management and Care - Ensure maternal safety - Deliver a normal newborn as close to term as possible Mild Preeclampsia and Home Care - Allows time for fetal growth and maturity

- Close monitoring of fetus

* Ultrasound for fetal growth every 3 weeks

High-Risk Pregnancy
* NST or BPP twice weekly

* Daily fetal movement counting by mother

Instructions for Self-Care

- Take your blood pressure on the same arm, resting it at heart level on a table - Report any increase in blood pressure immediately

High-Risk Pregnancy
- Weigh yourself each day, using the same scale and wearing the same clothes after voiding, before breakfast and report any gain > 1 lb./week

- Dipstix your clean catch urine and report any proteinuria 2+

High-Risk Pregnancy
- Count your babys movements every day and report anything < 3-4 per hour - Keep a log of your daily records for your home health nurse Bedrest - Benefits have not been proven - Left lateral recumbent position (why left??)

High-Risk Pregnancy
- Left side decreases blood pressure and promotes diuresis - Bedrest becoming controversial because of excessive diuresis, weight loss and muscle atrophy as well as psychological stress

- How would you help a woman on bedrest during her pregnancy?

High-Risk Pregnancy
Nursing Care - Place patient in quiet, dark area near nurses station; limit visitors - Blood pressure, pulse and respirations (every hour)

- Urine specimen for protein 24-hour)

- Edema (where) - Deep tendon reflexes (DTRs) - Clonus - Weight

High-Risk Pregnancy

High-Risk Pregnancy
- Urinary output (will have foley in) - Urine specific gravity (why?)

- Pulmonary edema (moist respirations)

- Laboratory tests * * * * * CBC BUN, creatinine, uric acid Clotting studies Liver enzymes Electrolyte levels

- Danger signs: headache, visual disturbances, epigastric pain, change in level of consciousness

High-Risk Pregnancy
- Fetal assessments (continuous monitoring, NST, BPP)

- Medical Management
- Antihypertensive (if diastolic >100110) - Corticosteroids if preterm delivery seems a possibility * Mature fetal lungs by increasing the production of surfactant

High-Risk Pregnancy
- Magnesium Sulfate (MgSO4)

- Goal is prevention of seizures

- Administered as a secondary infusion to primary IV - Loading dose followed by a maintenance dose - Interferes with release of acetylcholine at synapses, neuromuscular irritability, depresses cardiac conduction and CNS irritability

High-Risk Pregnancy
- If renal or respiratory function decrease, MgSO4 must be discontinued - Signs of toxicity: decreased urinary output, loss of patellar reflexes, respiratory depression, decreased level of consciousness - Must have antidote (Calcium Gluconate) at the bedside

High-Risk Pregnancy
Eclampsia
- Convulsion - Preceded by hypertension and tonic contraction of all body muscles - Half begin prior to labor and half during labor - Tonic-clonic convulsions - Respirations cease and begin again with long, stertorous inhalations - Hypotension and coma follow

High-Risk Pregnancy
- Disorientation and amnesia in immediate recovery period - Can result in trauma to the woman as well as aspiration

- Marked insult to the fetus (baby and mother not receiving O2 during convulsions)
- What would you do first?

High-Risk Pregnancy
- Requires immediate, effective treatment * Bolus of 4-6 G magnesium sulfate * Antihypertensive agents * Woman may be cared for in an intensive care unit

Care of Woman at Risk for Rh-Sensitization (Isoimmunization)

- When the Rh antigen is present on the red blood cells of a person, that person is said to be Rh-positive - The person without the antigen is Rhnegative

High-Risk Pregnancy
- If an Rh-negative person is exposed to Rhpositive blood, this person forms antibodies against the Rh-positive blood * This causes agglutination and hemolysis of the Rh-positive cells - Although fetal and maternal bloods theoretically do not mix, in some cases, there are leaks and fetal blood cells pass into the maternal system

High-Risk Pregnancy
* If the mother is Rh-negative and the baby is Rh-positive, the mother will form antibodies that will destroy the babys red blood cells - Rh negative mother has an Rhpositive fetus because the fetus has inherited dominant Rh positive gene from father

High-Risk Pregnancy
- Father can be heterozygous (+ -) or homozygous (+ +) positive

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High-Risk Pregnancy
- Screening during pregnancy * Determine maternal ABO and Rh factor blood type at first prenatal visit * If Rh-negative, review past history for possible sensitization (abortion, miscarriage, blood transfusions, etc.) * Perform indirect Coombs test to determine presence of antibodies against the Rh-positive factor at 28 weeks * If it is negative, administer RhoGAM to the woman

High-Risk Pregnancy
* If it is positive, the baby is followed closely to see if it needs to be delivered or given exchange transfusions - Postpartum * A direct Coombs test is done on the cord blood of the baby * If it is negative, mother is given RhoGAM within 72 hours of delivery

High-Risk Pregnancy ** Discussion of ABO incompatibilty and infections during pregnancy will be reserved for our discussion on the high-risk newborn **

High-Risk Pregnancy
Infections Acquired in Pregnancy - Sexually-transmitted infections - Responsible for significant morbidity and mortality for mother and baby

TORCH Infections (viral) - Toxoplasmosis - Other (hepatitis) - Rubella - Cytomegalovirus - Herpes

High-Risk Pregnancy
- Herpes Simplex

* Plan Cesarean delivery if active lesions present - Group B Beta Hemolytic Streptococcus
* Give penicillin G, 5 million units followed by 2.5 million units IV during labor - See Handout on Blackboard