OB High Risk II

Ana H. Corona, MSN, FNP-CNursing InstructorFebruary 2008eMedicine2007, Nursing 353 Maternal Risk Factors 2005;

Congenital Varicella Syndrome Results from maternal infection during pregnancy Period of risk may extend through first 20 weeks

of pregnancy Atrophy of extremity with skin scarring, low birth

weight, eye and neurologic abnormalities Risk appears to be small (< 2%)

Groups at Increased Risk of Complications of Varicella

Healthy adults Immunocompromised persons Newborns of mothers with rash onset

within 5 days before to 48 hours after delivery

Pathogens of Special ImportanceDuring Pregnancy Toxoplasma gondii– Cats (litter boxes) are carriers– Undercooked meats Listeria monocytogenes– Found in high-protein foods served raw (milk or fish)

or without reheating (deli meats, hot dogs, seafood salads). Several outbreaks have been caused by soft cheeses made with raw milk.

Pregnant women are 20 times more likely thanother healthy adults to be infected

Risky Food Preferences Consumed – Store-bought Mexican-style soft cheese (queso fresco or blanco, Panela) – Cold deli or lunch meats, served without reheating – Fresh squeezed juice, unpasteurized – Cold hot dogs, served without reheating – Homemade Mexican-style soft cheese (queso fresco or blanco, Panela) – Raw fish, ceviche – Raw (unpasteurized) milk – Alfalfa or other raw sprouts – Ground meat not fully cooked – Raw cookie dough containing eggs – Eggs with runny yolks

High Risk Pregnancy

Examples include: GDM Previous loss AMA HTN Abnormalities with the neonate

Antepartum Testing

FKCs BID UTZ

FHR Gestation age Abnormalities IUGR Placental location and quality AFI Position BPP Doppler flow Fetal growth

Ultrasound

Can be done abdominally or transvaginally 1st trimester done to detect viability, calculate

EDC 2nd trimester done to detect anomalies,

calculate EDC 3rd trimester done to do BPP, fetal growth and

well-being, AFI

Doppler flow analysis via ultrsound Study blood blow in the fetus and placenta Done on high risk mothers:

IUGR HTN DM Multiple gestation

AFI (amniotic fluid index)

Polyhydramnios – too much amniotic fluid AFI of more than 24 cm

Oligohydramnios – too little amniotic fluid AFI less than 7 cm Studies show that oral hydration, by having the

women drink 2 liters of water, increases the AFI by 30%.

BPP (Biophysical Profile)

Includes 5 components: Fetal breathing movements Gross body movements Fetal tone AFI NST - reactive

Amniocentesis

Used with direct ultrasound Less than 1% result in complications

Complications include: Fetal death, miscarriage Maternal hemorrhage Infection to fetus Preterm labor Leakage of amniotic fluid

Meconium

Visual inspection of amniotic fluid Meconium is defined as thin and thick and

particulate Associated with fetal stress: hypoxia,

umbilical cord compression

CVS (chorionic villi Sampling) Done between 9 -12 weeks Genetic studies Removal of small amount of tissue from the

fetal portion of the placenta Complications: vaginal spotting, miscarriage,

ROM, chorioamnionitis If done prior to 10 weeks, increased risk of

limb anomalies

AFP (alpha-fetoprotein)

Genetic test Done with mothers blood 16-20 weeks gestation Mandated by state of California

EFM (electronic fetal monitoring) Third trimester goal is to continue to observe

the fetus within the intrauterine environment Goal: dx uteroplacental insufficiency NST vs. CST

NST (non-stress test)

90% of gross fetal body movements are associated with accelerations of the FHR

Can be performed outpatient Not as sensitive User friendly but must interpret strip Fetus may be in a sleep state or affected by

maternal medications, glucose etc.

NST

To be reactive must meet criteria Must be at least 20 minutes in length Must have 2 or more accelerations that meet the ’15

X 15’ criteria Must have a normal baseline Must have LTV To stimulate a fetus that is not meeting criteria:

Change positions of the mother – LS, RS Increase fluids Acoustic stimulator

CST (Contraction stress testing) Done in the inpatient setting only! Has contraindications May be expensive if meds/IV needed Monitored for 10 minutes first Then may use nipple stimulation or oxytocin

stimulation No late decelerations than negative CST

Endocrine and Metabolic Disorders #1 Diabetes Mellitus Disorders of the thyroid Hyperemesis

Diabetes

Hyperglycemia May be due to inadequate insulin action or

due to impaired insulin secretion Type 1 – insulin deficiency Type 2 – insulin resistance GDM – glucose intolerance during pregnancy

DM

10th week fetus produces it own insulin Insulin does not cross the placental barrier Glucose levels in the fetus and directly

proportional to the mother 2nd and 3rd trimesters – decreased tolerance

to glucose, increased insulin resistance, increased hepatic function of glucose

Diabetic Neuropathy

Increased risks for: Preeclampsia IUGR PTL Fetal distress IUFD Neonatal death

DM

Poor glycemic control is associated with increased risks of miscarriage at time of conception

Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios

Polyhyraminos

May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

Macrosomia

Disproportionate increase in shoulder and trunk size

4000-4500gms or greater Fetus will have excess stores of glycogen Increased risks of

Shoulder dystocia C/S Assisted deliveries

IUGR

Compromised uteroplacental insufficiency 02 available to the fetus is decreased

RDS

Increased RDS due to high glucose levels Delays pulmonary maturity

Neonatal Hypoglycemia

Usually 30-60 minutes after birth Due to high glucose levels during pregnancy

and rapid use of glucose after birth Related to mothers level of glucose control Neonates normal glucose level: 40-65mg/dl Premature infants: 20-60mg/dl

DM laboratory

HBA1c 1 hour PP FBS

Monitoring Glucose Levels FBS 1 hour PP HS 5 checks / day

DM Diet

Sweet success diet Well balanced diet 6 small meals / day Have snack at HS Never skip meals Avoid simple sugars

Insulin

Regular/Lispro and NPH 2/3 dose in am and 1/3 dose in pm

Fetal Surveillance

NSTs done around 26 weeks, weekly

At 32 weeks done biweekly with NST/BPP

Infections are increased: Candidiasis UTIs PP infections

Increased risk of IUFD after 36 weeks Increased congenital anomalies

Cardiac defects CNS defects

Spina bifida anencephaly

Skeletal defects

Cardiovascular Disorders in Pregnancy The heart must compensate for the increased

workload If the cardiac changes are not well tolerated

than cardiac failure can develop 1% of pregnancies are complicated by heart

disease

Cardiac output is increased Peak of the increase 20-24 weeks gestation Cardiac problems should be managed with

cardiologist Mortality with pulmonary hypertension and

pregnancy is more than 50% Diet: low sodium

Nursing Care

Avoiding anemia Avoid strenuous activity Monitor for: cardiac failure and pulmonary

congestion

Nursing Care during labor

Side lying position Prophylactic antibiotic Epidural Attempt vaginal delivery If anticoagulant therapy is needed:

Heparin Lovenox

Anemia

Most common iron deficiency Hgb falls below 12 (most labs) Typically seen in the end of 2nd trimester Iron supplementation

Folic Acid Deficiency Anemia

Increases risk of NTD, cleft lip Recommended dose 400 mcg/day Supplemented in cereal and many other

foods

Sickle Cell Anemia

Abnormal hemoglobin SS types in the blood People have recurrent attacks of fever and

pain in the abdomen and extremities Caused from tissue hypoxia, edema African-Americans

Sickle Cell Trait: Typically asymptomatic Sickling of the RBCs but with a normal RBC

life span

Thalassemia

Common anemia Insufficient amount of Hgb is produced to fill

the RBCs Mediterranean region Genetic disorder May be associated with LBW babies and

increased fetal death

Asthma

Common with FH 1-4% of pregnant women have Asthma Possible adverse events associated with

asthma: LBW Perinatal mortality Preeclampsia Complicated labor Hyperemesis

Asthma Continue

Goal is to relieve the attack, prevent the asthma attack, and maintain 02

Should be managed with OB and ENT May require tx: albuterol, steroids, O2

Epilepsy

Seizure disorder May result from developmental abnormalities

or injury 20% have an increase in seizure activity

during pregnancy Risks: more seizures, risk of vaginal

bleeding, abruptio placentae, fetus may experience seizures

Epilepsy continue

Use of antiepeleptic meds during pregnancy has been linked to risks for the fetus

Smallest therapeutic dose to be given Daily folic acid supplementation Managed with OB and neurologist

Cholelithiasis

More often in women Pregnancy makes women more vulnerable Surgery often delayed until after delivery

TORCH

Toxoplasmosis – protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly

Other- Heb A or B, Group B, Varicella, HIV Rubella (German measles) – if contracted in 1st

Trimester fetus may have congenital deformities CMV- transmitted person to person, may cause

CNS damage to fetus Herpes Simplex (HSV 2) – if initial infection occurs

in pregnancy, higher incidence of perinatal loss. Fetus may pick up virus if present in the vagina during labor

SMOKING

Risks of any amount of smoking include: SAB SGA Bleeding IUFD Prematurity SIDS

ALCOHOL

Many women reluctant to tell health care provider

Risks: LBW Mental retardation Learning and physical deficits With FAS – severe facial deformities

ALCOHOL

Risks to mother: HTN Anemia Nutritional deficits Pancreatitis Cirrhosis Alcoholic hepatitis

MARIJUANA

Crosses the placenta and causes increased carbon monoxide levels in mother’s blood

May cause fetal abnormalities

COCAINE

In the US, 10-15% of all pregnant women use cocaine

Problems associated with use: polydrug use, poor health, poor nutrition, STIs, infections, HIV

Poverty big issue

COCAINE DURING PREGNANCY Maternal effects:

Cardiovascular stress Tachycardia HTN Dysrhythmias MI Liver damage Sz Pulmonary disease Death

Fetal Complications: Abruptio placentae PTL Precipitous labor Risks for abdominal

pregnancy Fetal complications after

delivery

OPIATES IN PREGNANCY

Drugs include: heroin, Demerol, morphine, codeine, methadone

Methadone is used to treat addiction to other opiates

Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL

Tx: Methadone and psychotherapy Goal: prevent withdrawal symptoms

Methamphetamines

CNS stimulant Most common use n the 18-30 yr old range Neonatal complications include:

IUGR PRL/PTB

Hyperemesis Gravidarum

Management: Intake and output IV fluids Monitor urine for ketones NPO until vomiting stops BRAT diet after Monitor for premature labor, Hemorrhage,

jaundice metabolic acidosis

Multifetal Pregnancy

Monozygotic: from one fertilized ovum that divides creating identical twins

Dizogotic: from two separate ova fertilized at the same time

Genetic makeup and sex of each fetus can vary

Complications: maternal anemia, spontaneous abortion, PIH, hydraminos

Hydatidiform Mole Gestational trophoblastic disease Cause is unknown Higher risk with clomid (fertility drug) Egg is fertilized with nuclei lost or not active Nucleus of sperm duplicates causing fluid filled

vesicles like a bunch of grapes Uterus becomes larger than normal for gestational

age No amniotic fluid present Nausea/vomiting believed to be from elevates HCG

in blood Some have bleeding into uterine cavity and

experience vaginal bleeding.

Hydatidiform Mole

May pass vesicles around 16 weeks Tests: ultrasound, amniography, HCG, CBC

for anemia D & C for evacuation of the mole Prevent pregnancy for 1 year

Question

1. A client asks the nurse to again explain the purpose of the amniocentesis test. The nurse responds that one purpose of this test is to indicate the: A. Accurate age of the fetus B. Presence of certain congenital anomalies C. Biparietal diameter of the skull D. Hormone content of the amniotic fluid E. Mainly the presence of Down’s syndrome

Question

2. The nurse explains to a new mother that the condition of SGA is caused by: A. Placental insufficiency B. Maternal obesity C. Primipara D. Genetic predisposition

Question

3. A pregnant client with diabetes is controlled by insulin. When she asks the nurse what will happen to her insulin requirements during pregnancy, the correct response is: A. “Because your case is so mild, you are likely not to

need much insulin during your pregnancy” B. “It’s likely that as the pregnancy progresses you will

need increased insulin” C. “Every case is individual so there is really no way to

know” D. “If you follow the diet closely and don’t gain too much

weight, your insulin needs should stay the same”

Question

4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be: A. Higher than in normal infants B. Lower than in normal infants C. The same as in normal infants D. Varied from baby to baby

Question

5. A client is admitted to L&D, at 38 weeks gestation. She is there for evaluation because she is experiencing polyhydramnios. The nurse understands that this diagnosis means that: A. There is the normal amount of amniotic fluid, thinner in

volume B. A less-than-normal amount of amniotic fluid is present C. An excessive amount of amniotic fluid is present D. A leak is causing the fluid to accumulate outside the

amniotic sac