1
Pregnancy at Risk
Lecture 9
I.
Disorders Causing Bleeding in Early Pregnancy
A.
hemorrhage during pregnancy
1.
emergent situation-complicates 1 in 5 pregnancies
B.
2.
during the first half-usually result of SAB, ectopic, molar
or incompetent cx
3.
during the second half-usually placenta previa,
placenta abruptio
4.
risk for maternal exsanguination with 8-10 minutes
r/t uterine blood flow is 650 ml/min (15% of CO)
spontaneous abortion
1.
pregnancy that ends before 20 weeks
2.
or fetal weight less than 500 gms
3.
incidence-10-15% of all pregnancies
4.
early-occurring prior to 12 weeks
a.
50% causation from chromosomal abnormalities
b.
80% occur within the first 12 weeks
c.
other causes
-endocrine imbalance (IDDM)
-immunological factors (antiphospholipid
antibodies)
-infections (chlamydia, bacteruria)
-systemic disorders (lupus)
-genetic factors
5.
late-12-20 weeks
a.
usually r/t maternal causes
-AMA
-parity
-chronic infections
-premature dilation of cx
-reproductive tract anomalies
-chronic diseases
-inadequate nutrition
-recreational drug use/abuse
2
C.
6.
types
a.
threatened-spotting, closed cervix, cramping
b.
inevitable-open cervix, mod-heavy bleeding,
mod-severe cramping
c.
incomplete-some POC retained
d.
complete-all POC removed
e.
missed-death in utero without obvious S & S
diagnosed by U/S
f.
recurrent-3 or more
7.
clinical manifestations
a.
increasingly severe as gest. age increases
b.
before 6 weeks-increased flow like heavy
menses
c.
6-12 weeks-moderate discomfort, blood loss
d.
12 weeks-severe pain
8.
assessment
a.
check PN history and hCG level
b.
U/S
c.
CBC
d.
blood type and Rh factor
e.
assess for infection
9.
plan of care
a.
rest and supportive care
b.
D&C
c.
D&E
d.
may need prostaglandins, IV, or pitocin for
fetal demise
10.
teaching
a.
report heavy or bright red bleeding
b.
some scant dark discharge 1-2 weeks post
c.
no vaginal insertions until bleeding stops
d.
take entire course of abx if prescribed
e.
grief counseling if needed
f.
refer to support group
induced abortion
1.
elective-by request
2.
therapeutic-for maternal/fetal health or disease
3.
primarily done in 1st trimester
3
D.
4.
assessment
a.
informed consent
b.
options explored
c.
discuss conflicts/fears
5.
procedure
a.
laminaria then vacuum aspiration (D & E )
b.
may use PG gel to ripen cx
c.
need to monitor temp. and bleeding
d.
may use RU486 (Mifepristone)
e.
may use methotrexate IM with vaginal
misoprostol
6.
complications
a.
infection
b.
retained POC
c.
clots
d.
bleeding
Ectopic pregnancy
1.
fertilized ovum outside the uterus
2.
accounts for 2% of all pregnancies
3.
95% occur in the fallopian tubes
a.
1% ovary
b.
3% abdominal cavity
c.
1% cervix
4.
responsible for 10% of all maternal mortality &
leading cause of infertility
5.
assessment
a.
bleeding
b.
dull, colicky pain
c.
tenderness
d.
referred shoulder pain r/t diaphragmatic
irritation
e.
shock if ruptured
f.
Cullen’s sign-ecchymotic blueness around the
umbilicus indicating hematoperitoneum
6.
diagnosis
a.
clinical picture sounds like other infections or
diseases
b.
need to r/o appendicitis, SAB, etc.
c.
√ beta hCG, CBC, and U/S
d.
progesterone ≥25ng/mL=intrauterine
4
progesterone <5ng/mL=dead fetus/ectopic
E.
7.
procedure
a.
unruptured-methotrexate to dissolve residual
tissue
b.
salpingostomy
c.
ruptured-laparotomy with salpingectomy
8.
plan
a.
b.
c.
d.
e.
f.
g.
teaching concerning possible procedures
monitor labs-CBC, hCG, blood type, Rh
administration of IV fluids/blood transfusion
frequent vital signs
administration of Rhogam PRN
post-op teaching
support groups/grief counseling
Gestational trophoblastic disease
1.
hydatidiform mole, invasive mole, and choriocarcinoma
2.
incidence: 1:1200, slightly higher in Asians
3.
types of hydatidiform moles:
a.
complete-fertilized egg whose nucleus is lost
(egg has no genetic material-sperm grows on its own)
-intrauterine contents resemble bunch of white
grapes-grow and enlarge uterus
-no fetus, placenta, membranes, or fluid
-avascular vesicles
-associated with choriocarcinoma
b.
partial-2 sperm fertilized normal ovum, results
in ambiguous parts, congenital anomalies
-karyotype of 69 xxy, 69 xxx, or 69 xy
-fetus with multiple anomolies
4.
etiology unknown
5.
risk factors: clomid, teens, women over 40, h/o molar preg,
h/o miscarriages
6.
manifestations
a.
early part of pregnancy uncomplicated
b.
dark brown vaginal discharge or bright red
c.
higher than expected fundal height (50%)
d.
associated with anemia, hyperemesis
gravidarum, abdominal cramps
e.
PIH-9-12 weeks
f.
16 weeks-passage of vesicles
5
7.
labs/tests
a.
serial hCG
b.
U/S
8.
plan
a.
b.
c.
9.
II.
suction curettage of tissue
induction with pitocin/prostaglandins NOT
recommended r/t increase risk of embolization
of trophoblastic tissue
Rhogam if needed
nursing plan
a.
care for grief/loss
b.
therapeutic communication
c.
return for serial hCG protocol for 1 year &
baseline chest x-ray to detect lung metastasis
d.
monitor hCG and increasing fundal height for
possible choriocarcinoma-chemo/methotrexate
Disorders Causing Bleeding in Later Pregnancy
A.
Placenta previa
1.
implantation of placenta in lower uterine segment
near or over internal cervical os
2.
types
a.
total-os totally covered when cervix dilated
b.
partial-incomplete
c.
marginal-edge extends to os but may increase
during dilation
d.
low-lying-implanted in lower uterine segmentdoesn’t reach os
3.
incidence: 0.5% of all births
4.
associated risk factors
a.
previous placenta previa (12X risk)
b.
previous C/S
c.
induced abortion
d.
multifetal
e.
closely spaced pregnancies
f.
AMA
g.
ethnic-African-American, Asians
h.
smoking
i.
cocaine
6
B.
5.
manifestations
a.
70% painless bleeding
b.
20% uterine activity
6.
diagnosis
a.
transabdominal ultrasound
b.
requires C/S
c.
ck NST, BPP, fetal lung maturity
d.
bed rest PRN
e.
observation for FHR, vaginal bleeding, VS
7.
plan
a.
b.
c.
d.
e.
f.
g.
h.
if term and in labor with bleeding-C/S
if before 36-37 weeks-rest/observation
NST, fetal monitoring
monitor bleeding and vital signs
monitor CBC
give Betamethasone
no vaginal exams
do C/S later if stable
Abruptio placenta
1.
premature separation of placenta, detachment of part
or all of placenta from implantation site after 20 weeks
gestation
2.
significant perinatal mortality for both fetus/mother
3.
risk factors
a.
HTN
b.
cocaine
c.
blunt trauma-battering, MVA
d.
smoking
e.
malnutrition
f.
risk of recurrence significant
4.
classification
a.
Grade 1-mild separation-10-20%
b.
Grade 2-moderate-20-50%
c.
Grade 3-severe->50%
5.
clinical
a.
significant uterine tenderness/pain
b.
vaginal bleeding
c.
contractions
d.
may have no bleeding
e.
hypovolemic shock
f.
coagulopathy
7
g.
h.
i.
j.
6.
diagnosis-U/S
7.
plan
a.
b.
c.
d.
8.
III.
couvelaire uterus-R/T blood trapped between
placenta and uterine wall→hysterectomy
DIC-disseminated intravascular coagulation
complications-hemorrhage, shock, infection
perinatal mortality-hypoxia in utero, PTL, SGA,
neurological deficits
depends on gestation age, status, and mom
VS, fetal monitoring, I & O, IV fluids, blood admin.
betamethasone if applicable
usually requires C/S-may have problems with
uncontrollable bleeding
nursing care
a.
large bore IV’s
b.
foley catheter
c.
watch for decrease in urinary output
d.
blood administration PRN
e.
monitor FHR
f.
monitor for pain
g.
monitor CBC, fibrinogen, PT, PTT
h.
therapeutic communication for anxiety, grief
Hyperemesis Gravidarum
A.
Risk factors
1.
less than 20 yrs old, obesity, multifetal, molar
2.
B.
etiology-obscure, multifactorial-may be associated with
transient hyperthyroidism or elevated levels of estrogen
Priority nursing care
1.
plan
a.
admit, place IV, keep NPO
b.
diet-advance as tolerated
c.
medications: according to need
-Zofran-ondansetron HCl
-Reglan-metoclopramide
-Benadryl-diphenhydramine
-Inapsine-droperidol
-corticosteroids
d.
psych consult PRN
2.
nursing care
a.
therapeutic communication
b.
I&O
8
c.
d.
e.
f.
g.
h.
IV.
daily weight
rest
diet as tolerated
small, frequent meals
decrease fats and protein if not tolerated
monitor IV site
Hypertensive disorders of pregnancy
A.
Background
1.
HTN is the most common medical complication of
pregnancy-1-5%
B.
2.
preeclampsia complicates 2-7% of all pregnancies
-14% in twin pregnancies
3.
women with chronic HTN or renal disease=25% risk for
preeclampsia
4.
rate has risen since early 1990’s
5.
2nd only to emboli as cause of maternal mortality
6.
predisposes mother for eclampsia, DIC, abruptio,
hepatic failure, ARDS, cerebral hemorrhage
7.
maternal and perinatal morbidity and mortality are
highest when eclampsia is seen early in gestation
(before week 28), moms over the age of 35,
multigravidas, and chronic HTN or renal disease
8.
fetus at risk from abruptio placentae, PTL, IUGR, and
acute hypoxia
Risk factors
1.
chronic renal disease
2.
chronic hypertension
3.
family h/o PIH
4.
multifetal gestation
5.
primigravida
6.
maternal age <19 yrs, >35 yrs
7.
diabetes
9
C.
8.
Rh incompatibility
9.
obesity
Classification/assessment
1.
2 basic types-chronic HTN and pregnancy-induced
a.
CHTN-predates the pregnancy or HTN that
continues beyond 42 weeks postpartum
b.
PIH/GHTN-onset of HTN generally after the 20th week
may occur independently or simultaneously
2.
preeclampsia
a.
pregnant specific
b.
HTN after week 20
c.
multisystem vasopastic disease-HTN with
Proteinuria (1-2+)
d.
characterized mild or severe
e.
↑ BP is first warning sign-↑140/90
f.
pathologic edema in face, hands, or abdomen
or weight gain >2 kg/week
g.
urine and BP checks need 2 + results to be
classified preeclampsia
3.
severe preeclampsia
a.
BP ↑ 160/110
b.
> 3+ or 4+ on dipstick: 5g≥ 24 hr urine collection
c.
oliguria-<400-500 ml/dy
d.
visual disturbances/headaches/altered LOC
e.
hepatic involvement
f.
↓ platelets-thrombocytopenia
g.
pulmonary/cardiac involvement
h.
development of HELLP syndrome
i.
severe fetal growth retardation
4.
eclampsia
a.
onset of seizure activity in the woman diagnosed
with PIH with no neurologic pathology
b.
may be initial sign patient has PIH
5.
HELLP-hemolysis, elevated liver enzymes, low PLT
a.
variant of severe preeclampsia
b.
appears in 2-12% of women with severe
preeclampsia
c.
maternal mortality-as high as 24%
d.
seen more frequently in older women, Caucasians,
and multiparous women
10
e.
f.
g.
h.
D.
65% will have c/o epigastric/RUQ pain
50% will have N & V
can be normotensive and without proteinuria
thought to be caused by arterial vasospasms,
endothelial damage, and platelet aggregation
6.
chronic HTN
a.
HTN before pregnancy or diagnosed before
week 20
b.
also considered chronic if HTN lasts longer than
6 weeks PP
c.
considered mild if diastolic remains below 110
d.
drug of choice: Aldomet (methyldopa)
7.
chronic HTN with superimposed preeclampsia
a.
BP with ↑ systolic 30 mm Hg, diastolic 15 mm Hg
b.
with proteinuria and generalized edema
8.
transient HTN
a.
development of HTN during pregnancy or
in the first 24 hours post partum
b.
no other S & S of preeclampsia
Pathophysiology/etiology
↑ BP→vasospams
↓
↓ placental perfusion
↓
endothelial cell activation
↓
↓
↓
vasoconstriction
activation of intravascular
coagulation
fluid
cascade
redistribution
↓
decreased organ perfusion
1.
mild preeclampsia→severe preeclampsia→HELLP→
or eclampsia
2.
reflects alterations in normal adaptations of pregnancy
a.
increase blood plasma volume
b.
vasodilation
c.
decreased systemic vascular resistance
d.
elevated cardiac output
e.
decreased colloid osmotic pressure
3.
main pathogenic factor is not ↑ BP but poor perfusion
as a result of vasospasm
11
E.
HELLP syndrome
1.
is a laboratory, not clinical, diagnosis
a.
platelets < 100,000/mm3
b.
↑ liver enzymes
-AST-aspartate aminotransferase ↑
-ALT-alanine aminotransferase ↑
c.
some evidence of hemolysis
-elevated bili level & burr cells on smear
d.
unlike DIC, coagulation panel normal
2.
F.
complications reported with HELLP include:
a.
renal failure
b.
pulmonary edema
c.
ruptured liver hematoma
d.
DIC
e.
abruptio placentae
Nursing process
1.
recognized risk factors
2.
history
a.
headache
b.
epigastric pain
c.
visual disturbances
3.
assess BP, wt., edema, proteinuria, and DTR’s
a.
edema on a scale of 0-+4
b.
DTR-patella and bicep, √ for clonus
4.
fetal assessment
5.
uterine tonicity
6.
vaginal exam
7.
lab tests
a.
CBC
b.
clotting factors
c.
liver enzymes
d.
chem panel: uric acid, creatinine, BUN, RBS
e.
type and screen
f.
urinalysis or 24 hr proteinuria
12
8.
G.
nursing diagnoses
a.
anxiety
b.
altered tissue perfusion
c.
knowledge deficit
d.
risk for impaired gas exchange
e.
risk for ↓ CO
f.
risk of injury to fetus or mother
g.
ineffective coping R/T powerlessness
Pharmacology and related nursing interventions
1.
mild PIH
a.
rest at home, on L side when possible
b.
teach mom to assess BP, dip urine, fetal
kick count
c.
possible frequent NST’s
d.
may want to encourage low Na diet
2.
severe PIH or HELLP
a.
immediate birth or conservative management
b.
labs as directed
c.
wt., foley, strict I & O, vag. exam, abd. palpation
d.
EFM
e.
bed rest, quiet, dark room, no visitors
f.
padded side rails
g.
suction equipment at bedside
h.
toxemia box in room-resuscitation meds
i.
continue to monitor during the intra to postpartum
3.
pharmacology
a.
magnesium sulfate
-helps prevent or treat convulsions
-interferes with acetylcholine at synapses
-↓ neuromuscular and CNS irritability
-↓ cardiac conduction
-increases blood flow in uterus to protect the
fetus
-increases prostracylins to prevent uterine
vasoconstriction
-secondary infusion
loading dose-4-6 gms over 20-30 min
maintenance-1-3 gms/hr
-mag level in 4-6 hrs (therapeutic level 4-8 mg/dl)
-frequently ck RR, UO, DTR’s
-have calcium gluconate at bedside (antidote)
-toxicity-nausea, flushing, ↓ reflexes, slurred
speech, and muscle weakness
-may be given IM for transport yet absorption
13
rate isn’t controlled, IM is more painful
-diuresis within 24 hours is an + prognostic sign
-if eclampsia develops-2-6 gms MgSO4 IV push
over 3-5 minutes
b.
c.
d.
amobarbital sodium-sedative
-250 mg slow push over 3-5 min
diazepam-occasionally used
-may cause phlebitis, venous thrombosis
-if given too rapidly-apnea, cardiac death
antihypertensives
-IV hydralazine (Apresoline)
-labetalol HCl, methyldopa, or nifedipine
V.
Maternal-fetal blood incompatibilities
(See High Risk Neonates)
VI.
Diabetes mellitus
A.
Classifications
1.
Type 1: pancreatic cell destruction-insulin deficient
prone to ketoacidosis (acidosis R/T excessive ketones)
B.
2.
Type 2: insulin resistant, relative insulin deficiency
most prevalent form of DM, etiology unknown
a.
develops gradually, may miss S & S
(polydipsia, polyuria, polyphagia)
b.
increase risk if obese or fat around abdomen
c.
age, sedentary lifestyle, HTN, previous GDM
d.
runs in families
3.
Pregestational: Type 1 or 2 that exists before preg.
4.
Gestational: any degree of glucose intolerance with
onset or recognition during pregnancy
a.
may or may not be insulin dependent
b.
should be reclassified 6 weeks PP
Pathophysiology
1.
Group of metabolic diseases characterized by
hyperglycemia R/T defects in insulin secretion, action,
or both
2.
Beta cells→insulin→moves glucose into adipose and
muscle cells to be used for energy
3.
↓ or ineffective insulin→hyperglycemia→
hypersosmolarity→↑ intracellular fluid into the vascular
system→ ↑ blood volume→ excess UO with glycouria
14
C.
4.
cells burns proteins/fats for energy=ketoacidosis
5.
weight loss from breakdown of fat and muscle tissues
6.
complications: retinopathy, nephropathy, neuropathy,
and premature atherosclerosis
7.
metabolic factors:
a.
1st trimester-↑ estrogen/progesterone=↑ insulin
production=↑ peripheral glucose utilization
b.
↑ tissue glycogen stores=↓ hepatic glucose
production (this can affect insulin needs)
c.
2nd & 3rd trimesters-↑ levels of hPL, estrogen,
progesterone, prolactin, cortisol, and insulinase
= ↑ insulin resistance (they are insulin antagonists)
(antagonists-counteract the action of another)
(synergists-enhances the action of another)
d.
maternal insulin requirements may double or
quadruple by 36 weeks of pregnancy
(leaves abundant supply of glucose for fetus)
Risk factors
1.
best predictor of pregnancy outcome=degree of
maternal control of glucose levels
2.
↓ glycemic control in early pregnancy=SAB
3.
↓ glycemic control late in pregnancy =
a.
↑ macrosomic fetus = ↑ risk birth trauma
b.
↑ risk for C/S
c.
↑ for PIH or preeclampsia
d.
↑ risk for polyhydramnios→overdistention of uterus
which can lead to PTL or PROM
e.
infections
f.
ketoacidosis (DKA)→fatty acids move from fat to
circulation→oxidized→ketone bodies into
circulation→↑ blood glucose and ketones=osmotic
diuresis=↓ fluids/electrolytes,
volume depletion, cellular dehydration=
maternal and fetal death
4.
fetal risks
a.
stillborn-etiology unk, ?chronic hypoxia
b.
congenital anomalies (6-10% chance)
-cardiac most common
c.
macrosomia/birth traumas
d.
IUGR R/T vascular disease
15
e.
f.
D.
RDS
hypocalcemia, hypoglycemia, hypomagnesemia,
hyperbilirubinemia, and polycythemia
Nursing Process
1.
Lab work
a.
euglycemia=65-130 mg/dl
b.
assessment of glycosylated hemoglobin A1c
-helps assess level of hemoglobin saturated
with glucose caused by hyperglycemia
-good control 7%
->10 % = ↑ risk for fetal anomalies (20-25%)
c.
urine screen for UTI, proteinuria, creatinine
clearance
d.
thyroid function screening
2.
Educate to test glucose at home-dietary changes
3.
Dietary management based on blood sugar tests
-1st trimester-2200 kcal/dy
-2nd and 3rd trimester-2500 kcal/dy
-40-45% CHO, 12-20% protein, 35-40% fats
-need bedtime snack to maintain BS level thru night
4.
Exercise after meals to prevent drop in BS
5.
Insulin therapy
a.
1st trimester, insulin dosage may decrease
b.
oral agents may be viable solution
-Glyburide (sulfonylurea) ↑ insulin secretion
-doesn’t cross the placenta
c.
2nd and 3rd trimesters→↑ insulin resistance = ↑
insulin dosage
d.
Some insulin can cross the placenta
e.
various regimens followed
f.
insulin pump may be used during pregnancy
g.
see California Diabetes and Pregnancy Program
-CDAPP
-Sweet Success
6.
Fetal surveillance to monitor well-being
a.
NST’s, BPP’s, U/S, kick counts
b.
MSAFP
c.
Fetal echocardiogram (18-22 weeks)
7.
Urine testing at home
a.
test first morning urine
b.
recheck if meal missed, ill, or BS > 200mg/dl
16
c.
d.
E.
spilling small amounts of ketones ok
spilling large amounts of ketones-CALL MD
8.
Intrapartum
a.
follow hospital’s P & P
b.
watch for dehydration, hypo/hyperglycemia
c.
mainline usually D5LR with insulin on secondary
infusion
d.
sched C/S in morning-hold AM insulin, NPO
9.
Postpartum
a.
insulin needs drop dramatically with removal of
placenta
b.
several days before CHO homeostasis
c.
complications
-preeclampsia
-eclampsia
-hemorrhage
-infection
d.
breastfeeding encouraged
-helps use up CHO in milk production
-risk for hypoglycemia
-risk for mastitis
-may reduce infants risk for DM
-may need to recalculate insulin dose
e.
discuss contraceptive methods
-barrier method safest
-OC’s have risk of thromboembolic/vascular
complications
-use of IUD risks infection
-tubal ligation if completed family
Gestational Diabetes
1.
7% of all pregnancies/90% of diabetic pregnancies
2.
less common in Caucasians
3.
risk factors
a.
obese
b.
over age 30
c.
family history
d.
h/o macrosomic infant
e.
unexplained stillbirth
f.
miscarriage
g.
having an infant with congenital anomalies
17
4.
VII.
screening
a.
1 hour glucola-50 gram oral glucose load
-considered + if >140 mg/dl
b.
3-hour glucose tolerance test
-fasting glucose
-drink a 100 gm loading dose
-ck serum and urine every hour
-+GDM if 2 or more of the results are elevated
fasting = 95
1 hour = 180
2 hour = 155
3 hour = 140
Preexisting cardiac disease
A.
Overview
1.
CV changes that occur normally with pregnancy can
affect women with cardiac disease
a.
↑ intravascular volume
b.
↓ systemic vascular resistance
c.
change in CO
d.
change in intravascular volume postpartum
B.
2.
cardiac disease complicates 1% of all pregnancies
a.
leading cause of non-OB maternal mortality
b.
4th ranking cause of maternal death
3.
some of the more common cardiac diseases
a.
mitral stenosis
b.
mitral valve prolapse
-use Inderal if symptomatic, ie: chest pain
-use abx if having regurgitation
c.
congenital heart defects, i.e. septal defect
d.
periparum cardiomyopathy
-dysfunction of the L ventricle
-seen in last month of preg or 1st 5 months PP
-mortality rate of 25-50 %
-tx-treat the symptoms
Classifications
1.
Class I: Asymptomatic at normal levels of activity
mortality = 1%
a.
corrected Tetralogy of Fallot
b.
pulmonic/tricuspid disease
c.
mitral stenosis (class I, II)
d.
septal defects
2.
Class II: Symptomatic with increased activity
mortality = 5-15%
18
a.
b.
c.
d.
e.
f.
C.
mitral stenosis with atrial fibrillation
artificial heart valves
mitral stenosis (class III, IV)
uncorrected Tetralogy of Fallot
aortic coarctation (uncomplicated)
aortic stenosis
3.
Class III: Symptomatic with ordinary activity
mortality = 25-50%
a.
aortic coarctation (complicated)
b.
myocardial infarction
c.
Marfan’s syndrome
d.
true cardiomyopathy
e.
pulmonary HTN
4.
Class IV: Symptomatic at rest
Nursing Process
1.
medical care is multidisciplinary
2.
educated R/T S & S of cardiac decompensation
a.
subjective
-increasing fatigue
-difficulty breathing
-frequent cough
-palpitations
-swelling of face, feet, legs, fingers
b.
objective
-irregular, weak, rapid pulse, over 100
-progressive, generalized edema
-crackles at base of lungs
-orthopnea
-tachypnea, over 25
-moist, frequent cough
-increasing fatigue
-cyanosis of lips and nail beds
3.
identify areas that may lead to stress
4.
identity coping mechanisms
5.
support groups
6.
consultation with dietician
19
7.
watch for S & S of thromboembolism
a.
redness
b.
swelling
c.
tenderness
e.
pain
8.
avoid constipation and straining for BM
9.
report any S & S of infection
10.
keep all PN appts.
11.
may be put on prophylactic abx
12.
labs/studies
a.
CBC, chem panel
b.
ECG
c.
chest x-rays
d.
EFM
13.
medications
a.
heparin for anticoagulation-doesn’t cross
placenta
b.
coumadin-contradindicated-teratogenic
c.
abx-↓ risk of bacterial endocarditis
d.
diuretics to treat CHF
e.
digitalis for arrhythmias and heart failure
14.
intrapartum
a.
side lying or semi-fowlers
b.
O2 via mask
c.
diuretics to ↓ fluid retention
d.
prophylactic abx
e.
encourage pain meds to decrease stress-Epid.
f.
monitor FHR and maternal
g.
may use vacuum to shorten 2nd stage
h.
no ritodrine/terbutaline for tocolysis
-may cause myocardial ischemia
i.
no methergine
15.
postpartum
a.
1st 24-48 hours most important for hemodynamic
stability
b.
bed rest, asst. with ADL’s as needed
c.
prevent constipation
d.
breastfeeding may be contraindicated in higher
classifications of disease
20
VIII.
Anemias-Table 15-1, pg. 304
A.
Iron deficiency anemia
1.
most common
a.
< 11 g/dl in 1st ∆
b.
< 10.5 g/dl in 2nd ∆
c.
< 11 g/dl in 3rd ∆
B.
C.
2.
iron for fetus comes from maternal serum
3.
oral iron supplements-30-60mg/dy
a.
clinical-325 mg ferrous sulfate tablets
b.
metabolized better with Vit. C
4.
risk to fetus
a.
LBW
b.
preterm
c.
↑ perinatal mortality-maternal Hbg < 6g/dl
Folic acid deficiency anemia→megaloblastic anemia
1.
increases risk for neural tube defect, cleft lip/palate
2.
recommended daily intake 400 microgram/day
3.
“enriched foods” have additional folic acid
Sickle cell anemia-recessive autosomal disease
1.
abnormal hemoglobin in the blood
2.
recessive, hereditary, familial hemolytic
a.
African-Americans (10% have trait)
b.
Mediterranean ancestry
3.
crisis: fever, pain in abdomen, extremities
a.
attacks R/T vascular occlusion, tissue hypoxia,
edema, RBC destruction, and organ failure
b.
associated with jaundice, normochromic
anemia, reticulocytosis, + sickle cell test,
and demonstrated abnormal hemoglobin
4.
maternal/fetal risks
a.
pyelonephritis
b.
bone infection
c.
heart disease
d.
PIH
e.
fetal loss due to impaired oxygen supply
21
5.
tx:
a.
b.
c.
d.
folic acid-1mg/day
abx as needed
O2 and IV’s
SCD’s postpartum
IX.
Maternal infections
Pages 342-346
KNOW: Type of organism, S/S, tx, and implications for pregnancy
and fetus…such as:
T-toxoplasmosis-retinochoroiditis, convulsions, microcephaly
O-others-Hepatitis, HIV, syphilis-infection, SAB,
R-rubella-DM, hearing loss, glaucoma, encephalitis
C-cytomegalovirus-90% of survivors have neurological problems
H-herpes simplex-hyper/hypothermia, jaundice, seizures
X.
Psychosocial problems during pregnancy
A.
Preexisting psychiatric illness-effect on pregnancy
1.
women with bipolar disorder, schizophrenia, or
chronic depression may be on psychotropic meds
that can cross the placenta or be found in breast
milk
B.
C.
2.
need to weigh the benefits of therapy to risks to mom
and fetus
3.
fetal risks to medications
a.
congenital anomalies
b.
tremors
c.
hypertonicity
d.
weakness
e.
poor sucking
Abuse/Battering -pp. 102-106, 341
1.
may increase with enlargement of abdomen
2.
must be reported
3.
hook up pt. with social services/women’s shelters
Substance abuse-pg. 303
1.
barriers to tx
a.
little understanding how drug effects fetus or
pregnancy
b.
delay seeking PN care
c.
stigma, shame, guilt
22
d.
conceal abuse
2.
legal considerations
a.
risk to unborn may = criminal charges to mom
b.
may be arrested, jailed, housed in psychiatric
hospital for rest of the pregnancy
c.
baby may be give to child protective services
3.
risks
a.
b.
c.
d.
e.
f.
g.
4.
SAB, preterm birth, IUGR, neonatal addiction,
neonatal neurobehavioral handicaps, AIDS,
fetal and maternal death
alcohol-FAS
cocaine-a. placenta, PTL, SGA, microencephaly
heroin-PTL, PROM, IUGR, convulsions
speed-PTL, IUGR, ↓ head circumference, altered sleep
patterns
smoking-SIDS, LBW, pediatric allergies, respiratory
dysfunction
caffeine-IUGR, LBW
case management
a.
find out about pt.’s environment, past drug use,
current drug use, and support systems
b.
drug testing-blood and urine
-alcohol can go undetected in urine
c.
can test neonate’s hair or meconium to analyze
past drug usage
d.
screen for h/o physical abuse or psychosocial
problems
e.
determine need for women’s health services,
social services, and education for family
f.
support groups, i.e. AA
g.
alcohol withdrawal tx
-benzodiazepines (psychotropic-sedative)
-nutritional follow-up
-psychotherapy
h.
methadone (synthetic opioid) controversial
-impaired blood flow to placenta
-detrimental fetal effects
-stronger withdrawal symptoms for neonate
compared to heroin
01/16