spring 2012. risk factors age – under 17 over 35 gravida and parity socioeconomic status ...

Spring 2012

Risk Factors Age under 17 over 35 Gravida and Parity Socioeconomic status Psychological well-being Predisposing chronic illness diabetes, heart conditions, renal Pregnancy related conditions hyperemesis gravidarum, PIH

Goals of Care for High Risk Pregnancy Provide optimum care for the mother and the fetus Assist the client and her family to understand and cope through education

Abortions Termination of pregnancy at any time before the fetus has reached the age of viability Either: spontaneous occurring naturally induced artificial

Types of Abortions Threatened Imminent Complete Incomplete Missed Recurrent/Habitual

Question??? What are two main complications related to a missed abortion? 1. 2.

Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state

Key Concepts Related to Bleeding Disorders If a woman is Rh-, RhoGam is given within 72 hours of abortion Provide emotional support. Feelings of shock or disbelief are normal Encourage to talk about their feelings. It begins the grief process

Ectopic Pregnancy Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus (5) Cervical ovary

Assessment Ectopic Pregnancy Early: Missed menstruation followed by vaginal bleeding (scant to profuse) Unilateral pelvic pain, sharp abdominal pain Referred shoulder pain Cul-de-sac mass Acute: Shock blood loss poor indicator Cullens sign -- bluish discoloration around umbilicus Nausea, Vomiting Faintness

Treatment Options / Nursing Care Combat shock / stabilize cardiovascular Type and cross match Administer blood replacement IV access and fluids Laparotomy Psychological support Linear salpingostomy Methotrexate used prior to rupture. Destroys fast growing cells

Gestational Trophoblastic Disease Hydatiform Molar Pregnancy A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI As cells degenerate, they become filled with fluid and appear as fluid filled grape- size vessicles.

Assessment: Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) Possible anemia due to blood loss Enlargement of the uterus out of proportion to the duration of the pregnancy Vaginal discharge of grape-like vesicles May display signs of pre-eclampsia early Hyperemesis gravidarium No Fetal heart tone or Quickening Abnormally elevated level of HCG Question 6

Interventions and Follow-Up Empty the Uterus by D & C or Hysterotomy Extensive Follow-Up for One Year Assess for the development of choriocarcinoma Blood tests for levels of HCG frequently Chest X-rays Placed on oral contraceptives If the levels rise, then chemotherapy started usually Methotrexate

Critical Thinking Exercise A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesnt believe in birth control and does not intend to take the oral contraceptives that were prescribed for her. How should the nurse respond?

Placenta Previa Low implantation of the placenta in the uterus Etiology Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors Three Major Types: Low or Marginal Partial Complete Question 8

Interventions and Nursing Care Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to deliver vaginally Cesarean delivery for All other types of previa

Abruptio Placenta Premature separation of the placenta from the implantation site in the uterus Etiology: Chronic Maternal Hypertension Short umbilical cord Trauma History of previous delivery with separation Smoking / Caffeine / Cocaine Vascular problems such as with diabetes Multigravida status Defined as marginal, partial or complete

Treatment and Nursing Care Abruptio Placenta Cesarean delivery immediately Combat shock blood replacement / fluid replacement Blood work assessment for complication of DIC

Placenta Previa PAINLESS vaginal bleeding Bright red bleeding First episode of bleeding is slight then becomes profuse Signs of blood loss comparable to extent of bleeding Uterus soft, non-tender Fetal parts palpable; FHTs countable and uterus is not hypertonic Blood clotting defect absent Abruptio Placenta Bleeding accompanied by PAIN Bleeding accompanied by PAIN Dark red bleeding Dark red bleeding First episode of bleeding usually profuse First episode of bleeding usually profuse Signs of blood loss out of proportion to visible amount Signs of blood loss out of proportion to visible amount Uterus board-like, painful and low back pain Uterus board-like, painful and low back pain Fetal parts non-palpable, FHTs non-countable and high uterine resting tone (noted with IUPC) Fetal parts non-palpable, FHTs non-countable and high uterine resting tone (noted with IUPC) Blood clotting defect (DIC) likely Blood clotting defect (DIC) likely

Signs of Concealed Hemorrhage Increase in fundal height Hard, board-like abdomen High uterine baseline tone on electronic fetal monitoring Persistent abdominal pain and low back pain Systemic signs of hemorrhage

Critical Thinking Mrs. A., G3 P2, 38 weeks gestation is admitted to L & D with scant amount of dark red bleeding. What is the priority nursing intervention at this time? A. Assess the fundal height for a decrease B. Place a hand on the abdomen to assess if hard, board-like, tetanic C. Place a clean pad under the patient to assess the amount of bleeding D. Prepare for an emergency cesarean delivery

Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time.

Etiology Defect in the Clotting Cascade An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin into maternal bloodstream Thrombin (powerful anticoagulant) is produced Fibrinogen fibrin which enhances platelet aggregation and clot formation Widespread fibrin and platelet deposition in capillaries and arterioles

Resulting in Thrombosis (multiple small clots) Excessive clotting activates the fibrinolytic system Lysis of the new formed clots create fibrin split products These products have anticoagulant properties and inhibit normal blood clotting A stable clot cannot be formed at injury sites Hemorrhage occurs Ischemia of organs from vascular occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and can result in death

Assessment & Intervention Precipitating factors Abruption PIH/HELLP syndrome Sepsis Anaphylactoid Syndrome Labs to review PT, PTT, Platelets, D-Dimer, FSP Interventions Remove the cause Replace fluids (Blood or blood products) Meds

Assessment Persistent nausea and vomiting Weight loss from 5 - 20 pounds May become severely dehydrated with oliguria AEB increased specific gravity, and dry skin Depletion of essential electrolytes Metabolic alkalosis -- Metabolic acidosis Starvation

Nursing Care / Interventions Hyperemesis Gravidarium Control vomiting Maintain adequate nutrition and electrolyte balance Allow patient to eat whatever she wants If unable to eat Total Parenteral Nutrition Combat emotional component provide emotional support and outlet for sharing feelings Mouth care Weigh daily Check urine for output, ketones

Classification of HTN in Pregnancy Gestational HTN = Systolic BP > or equal to 140/90 after 20 weeks (replaces term of PIH), protein negative or trace Pre-eclampsia = BP > or equal to 140/90 after 20 weeks, proteinuria, edema considered nonspecific Eclampsia = other signs plus convulsions not attributable to other causes Chronic HTN = BP > or equal to 140/90 that was known to exist before pregnancy or does not resolve after 6 weeks after delivery

Predisposing Factors Primigravida Multiple gestation pregnancy Vascular Disease Age >35 Obesity

PATHOLOGICAL CHANGES PIH is due to: GENERALIZED ARTERIOLAR CYCLIC VASOSPASMS INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW ( in blood pressure) Endothelial CELL DAMAGE Intravascular Fluid Redistribution (decrease in diameter of blood vessel) Decreased Organ Perfusion Multi-system failure Disease

Rationale for HYPERTENSION The blood pressure rises due to: ARTERIOLAR VASOSPASMS AND VASOCONSTRICTION causing (Narrowing of the blood vessels) an increase in peripheral resistance fluid forced out of vessels HEMOCONCENTRATION Increased blood viscosity = Increased hematocrit

Key Point to Remember ! HEMOCONCENTRATION develops because: Vessels became narrowed forcing fluid to shift out of the vascular space Fluid leaves the intravascular space and moves to extravascular spaces Now the blood viscosity is increased (Hematocrit is increased) **Very difficult to circulate thick blood

Proteinuria With renal vasospasms, narrowing of glomerular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate PROTEINURIA Spilling of 1+ of protein is significant to begin treatment Oliguria and tubular necrosis may precipitate acute renal failure

Significant Lab Work Changes in Serum Chemistry Decreased urine creatinine clearance ( 80-130 mL/ min) Increased BUN (12-30 mg/dl.) Increased serum creatinine (0.5 - 1.5 mg/dl) Increased serum uric acid (3.5 - 6 mg/dl)

Weight Gain and Edema Clinical Manifestation: Edema may appear rapidly Begins in lower extremities and moves upward Pitting edema and facial edema are late signs Weight gain is directly related to accumulation of fluid

The difference between dependent edema and generalized edema is important. The patient with PIH has generalized edema because fluid is in all tissues. The Nurse Must Know

Placenta Due to Vasospasms and Vasoconstriction of the vessels in the placenta. Decreased Placental Perfusion and Placental Aging Fetal Growth is retarded - IUGR, SGA Positive CST / __________Decelerations With Prolonged decreased Placental Perfusion:

Oliguria 100ml/4 hrs or less than 30 cc. / hour Edema moves upward and becomes generalized (face, periorbital, sacral) Excessive weight gain greater than 2 pounds per week

Central Nervous System Changes Cerebral edema -- forcing of fluids to extracellular Headaches -- severe, continuous Hyper-reflexia LOC changes changes in affect Convulsions / seizures

Visual Changes Retinal Edema and spasms leads to: Blurred vision Double vision Retinal detachment Scotoma (areas of absent or depressed vision)

Nausea and Vomiting Epigastric pain often sign of impending coma

Pre-Eclampsia Mild Severe 140/90 Protien 1+ to 2+ Edema 1+ to lower legs < 1lb/ week Reflexes 1+ to 2+ 160/90 Protein 3+ to 4+ Edema 3+ to 4+ >2 lb/ week Reflexes 3+ to 4+ (hyperreflexia) Clonus present Blurred vision or Scotoma Retinal detachment N&V, Epigastric pain Elevated Liver enzymes Headache or change in LOC Premature aging of placenta, IUGR, & or late decelerations

Interventions and Nursing Care Home Management Decrease activities and promote bed rest Sedative drugs Lie in left lateral position Remain quiet and calm restrict visitors and phone calls Dietary modifications increase protein intake to 70 - 80 g/day maintain sodium intake Caffeine avoidance Weigh daily at the same time Keep record of fetal movement - kick counts Check urine for Protein

Hospitalization If symptoms do not get better then the patient needs to be hospitalized in order to further evaluate her condition. Common lab studies: CBC, platelets; type and cross match Renal blood studies -- BUN, creatinine, uric acid Liver studies -- AST, ALT, LDH, Bilirubin DIC profile -- platelets, fibrinogen, FSP, D-Dimer

Hospital Management Nursing Care Goal 1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant

Decrease CNS Irritability Provide for a Quiet Environment and Rest 1. MONITOR EXTERNAL STIMULI Explain plans and provide Emotional Support Administer Medications 1. Anticonvulsant -- Magnesium Sulfate 2. Sedative -- Diazepam (Valium) 3. Vasodilator-- Apresoline (hydralazine) Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available

Magnesium Sulfate ACTION CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter release ROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours Prior to administration: Insert a foley catheter with urimeter for assessment of hourly output

Magnesium Sulfate NURSING IMPLICATIONS 1. Monitor respirations > 14-16; < 12 is critical 2. Assess reflexes for hypo-reflexia -- D/C if hypo-refexia 3. Measure Urinary Output >100cc in 4 hrs. 4. Measure Magnesium levels normal is 1.5-2.5 mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl; Cardiac arrest is > 15 mg/dl. Have Calcium Gluconate available as antagonist

Test Yourself ! A Woman taking Magnesium Sulfate has a respiratory rate of 10. In addition to discontinuing the medication, the nurse should: a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids

Control Blood Pressure Check B / P frequently. Give Antihypertensive Drugs Hydralazine Labetalol Nifedipine Check Hematocrit Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90.Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. WHY?WHY?

Promote Diuresis ** Dont give Diuretic, masks the symptoms of PIH Bed rest in left or right lateral position Check hourly output -- foley catheter with urimeter Dipstick for Protein Weigh daily -- same time, same scale

Monitor Fetal Well-Being FETAL MONITORING-- assessing for late decelerations. NST -- Non-stress test CST contraction stress test BPP biophysical profile If all else fails ---- Deliver the baby!!

HELLP Syndrome A multisystem condition that is a form of severe preeclampsia - eclampsia H = hemolysis of RBC EL = elevated liver enzymes LP = low platelets

HELLP Syndrome Assessment: 1. Right upper quadrant pain and tenderness 2. Nausea and vomiting 3. Edema 4. Flu like symptoms 5. Lab work reveals a. anemia low Hemoglobin b. thrombocytopenia low platelets. < 100,000. c. elevated liver enzymes: - AST asparatate aminotransferase (formerly SGOT) exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L. - LDH when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L/

HELLP Intervention: 1. Bedrest any trauma or increase in intra- abdominal pressure could lead to rupture of the liver capsule hematoma. 2. Volume expanders 3. Antithrombic medications

Urinary Tract Infection Most common infection complicating Pregnancy Etiology Pressure on ureters and bladder causing Stasis with compression of ureters Reflux Hormonal effects cause decrease tone of bladder Assessment Dysuria, frequency, urgency lower abdominal pain; costal vertebral pain fever

T O R C H A Infections T = Toxoplasmosis O = Other Syphilis, Gonorrhea, Chlamydial,Hepatitis A or B R = Rubella C = Cytomegalovirus H = Herpes A = Aids

Toxoplasmosis Etiology Protozoan infection. Raw meat and cat litter Maternal and Fetal Effects Mom - flu-like symptoms, lymphadenopathy Fetus still, premature birth, microcephaly; mental retardation * Instruct to cook meat thoroughly * Avoid changing cat litter * Advise to wear gloves when working in the garden Treatment: Sulfa drugs

Syphilis Etiology Spirochete Treponema Pallium Maternal and Fetal Effects May pass across the placenta to fetus causing spontaneous abortion. Major cause of late, second trimester abortion Infant born with congenital anomalies

Syphilis Intervention: 1. Penicillin 2. Advise to return for prenatal visits monthly to assess for re-infection 3. Advise that if treated early, fetus may not be infected

Gonorrhea Etiology Neisseria Gonorrhoeae Maternal and Fetal Effects: May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infant Mom will experience dysuria, frequency, urgency Major cause Pelvic Inflammatory Disease which leads to infertility. Treated with Rocephin Spectinomycin Treat partner!!

Chlamydia Three times more common than gonorrhea. Etiology - Chlamydia trachomatis Maternal and Fetal Effects Mom pelvic inflammatory disease, dysuria, abortions, pre-term labor Fetus -- Stillbirth, Chylamydial pneumonia Interventions Erythromycin, doxycycline, zithromax Advise treatment of both partners is very important

Hepatitis A or B Highly contagious when transmitted by direct contact with blood or body fluids Maternal and Fetal Effects: All moms should be tested for Hep B during pregnancy Fetus may be born with low birth weight and liver changes May be infected through placenta, at time of birth, or breast milk Intervention: Recommend Hepatitis B vaccination to both mother and baby after delivery.

Rubella Etiology Spread by droplet infection or through direct contact with articles contaminated with nasopharyngeal secretions. Crosses placenta Maternal and Fetal Effects Mom fever, general malaise, rash Most serious problem is to the fetus--causes many congenital anomalies (cataracts, heart defects) Intervention Determine immune status of mother. If titer is low, vaccine given in early postpartum period

CYTOMEGALOVIRUS Etiology -- Member of the Herpes virus Crosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milk Effects on Mom and Fetus Mom no symptoms, not know until after birth of the baby Fetus -- Severe brain damage; Eye damage Intervention No drug available at this time Teach mom should not breast feed baby Isolate baby after birth

Herpes Simplex Type 2 Maternal and Fetal Effects Painful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeks Culture lesions to detect if Herpes, No cure If mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth *Virus is lethal to fetus if inoculated at birth Intervention: Zovirax

HIV/AIDS Etiology: Human Immunodeficiency Virus, HIV Transmission of HIV to the fetus occurs through: The placenta; birth canal Through breast milk **The virus must enter the babys bloodstream to produce infection.

Diagnosis: ELISA test identifies antibodies specific to HIV. If positive = person has been exposed and formed antibodies Western Blot used to confirm seropositivity when ELISA is positive. Viral load - measures HIV RNA in plasma. It is used to predict severity lower the load the longer survival. CD4 cell count markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system. Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count.

Nursing Care: **Provide Emotional Support **Teach measures to promote wellness AZT oral during pregnancy IV during labor liquid to newborn for 6 weeks. **Provide information about resources

Fetal Demise/ Intrauterine Fetal Death

Assessment: 1. First indication is usually NO fetal movement 2. NO fetal heart tones Confirmed by ultrasound 3. Decrease in the signs and symptoms of pregnancy

Diabetes in Pregnancy Diabetes creates special problems which affect pregnancy in a variety of ways. Successful delivery requires work of the entire health care team

Endocrine Changes During Pregnancy increase There is an increase in activity of maternal pancreatic islets which result in increase production of insulin. Counterbalanced by: a. Placentas production of Human Chorionic Somatomammotropin (HCS) b. Increased levels of progesterone and estrogen--antagonistic to insulin c. Human placenta lactogen reduces effectiveness of circulating insulin d. Placenta enzyme-- insulinase

Gestational Diabetes Diabetes diagnosed during pregnancy, but unidentifable in non-pregnant woman Known as Type III Diabetes - intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after delivery Glucose tolerance test: 1 hr oral GTT if elevated, do 3 hour GTT Gestational diabetes if: Fasting 95 mg / dl 1 hour - 180 mg/ dl 2 hour - 155 mg/ dl 3 hour 140mg/dl

Treatment Controlled mainly by diet May use insulin No use of oral hypoglycemics

Effects of Diabetes on the Pregnancy MATERNAL Increase incidence of INFECTION Fourfold greater incidence of Pre-eclampsia Increase incidence of Polyhydramnios Dystocia large babies Rapid Aging of Placenta FETAL increase morbidity Increase Congenital Anomalies neural tube defect (AFP) Cardiac anomalies Spontaneous Abortions Large for Gestation Baby, LGA Increase risk of RDS

Effects of Pregnancy on the Diabetic Insulin Requirements are Altered First Trimester--may drop slightly Second Trimester-- Rise in the requirements Third Trimester-- double to quadruple by the end of pregnancy Fluctuations harder to control; more prone to DKA Possible acceleration of vascular diseases

Interventions/ Nursing Care Diet Therapy Diet Therapy Insulin Regulation Insulin Regulation Blood Glucose Monitoring Blood Glucose Monitoring Exercise Exercise Monitor Fetal Well Being Monitor Fetal Well Being

Heart Disease in Pregnancy

Cardiac Response in All Pregnancies Increase in Cardiac Output 30% - 50% Expanded Plasma Volume Increase in Blood (Intravascular) Volume Every Pregnancy affects the cardiovascular system A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications

Effects of Heart Disease on Pregnancy Growth Restricted Fetus Spontaneous Abortion Premature Labor and Delivery

Effects of Pregnancy on A Diseased Heart The Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure). The effect may be varied depending upon the classification of the disease

Classification of Heart Disease Class 1 Uncompromised No alteration in activity No anginal pain, no symptoms with activity Class 2 Slight limitation of physical activity Dyspnea, fatigue, palpitations on ordinary exertion comfortable at rest

Class 3 Marked limitation of physical activity Excessive fatigue and dyspnea on minimal exertion Anginal pain with less than ordinary exertion Class 4 Symptoms of cardiac insufficiency even at rest Inability to perform any activity without discomfort Anginal pain Maternal and fetal risks are high

Nursing Care - Antepartum Decrease Stress teach the importance of REST! watch weight assess for infections - stay away from crowds assess for anemia assess home responsibilities Teach signs of cardiac decompensation

Assess for Signs of CHF Cough (frequent, productive, hemoptysis) Dyspnea, Shortness of breath, orthopnea Palpitations of the heart Generalized edema, pitting edema of legs and feet Moist rales in lower lobes, indicating pulmonary edema

Education Diet high in iron, protein low in sodium and calories ( fat ) Weight gain Medications Supplemental iron Heparin, not coumadin monitor lab work Diuretics very careful monitoring Antiarrhythmics Digoxin, quinidine, procainamide. *Beta-blockers are associated with fetal defects. Reinforce physicians care

Nursing Care: During Labor Labor in an upright or side lying position Restrict fluids On O 2 per mask throughout labor and cardiac monitoring. Sedation / epidural given early Report fetal distress or cardiac failure Stage 2 - gentle pushing, high forceps delivery

Nursing Care Postpartum The immediate post delivery period is the MOST significant and dangerous for the mom with cardiac problems because: Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion Cardiac output increases, blood volume increases Strain on the heart! Watch for cardiac failure

Test Yourself ! Mrs. B. has mitral valve prolapse. During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time? a. Class I b. Class II c. Class III d. Class IV

spring 2012. risk factors age – under 17 over 35 gravida and parity socioeconomic status ...

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