Chapter 11
High Risk Perinatal Care:
Preexisting Conditions
Copyright © 2018 by Elsevier Inc. All rights reserved.
Preexisting Conditions


For some women pregnancy represents
significant risk because it is superimposed on a
chronic illness
Unique maternal and fetal needs caused by
these conditions must be met in addition to the
usual pregnancy-related feelings, needs, and
concerns
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2
Preexisting Conditions (Cont.)
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Metabolic disorders
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Diabetes mellitus
Thyroid disorders
Cardiovascular disorders
Respiratory, gastrointestinal, integumentary, and
central nervous system disorders
Autoimmune disorders
Substance abuse
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3
Metabolic Disorders

Diabetes mellitus

The most common endocrine disorder associated
with pregnancy
 Pregnancy complicated by diabetes considered high
risk
 Diabetes can be successfully managed with a
multidisciplinary approach
 Key to an optimal outcome is strict maternal glucose
control
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4
Metabolic Disorders (Cont.)

Pathogenesis
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Group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin
secretion, insulin action, or both
Diabetes may be caused by either or both:
• Impaired insulin secretion
• Inadequate insulin action in target tissues
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5
Metabolic Disorders (Cont.)
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Classification of diabetes
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type 1 diabetes
type 2 diabetes
Other specific types (caused by infection or druginduced)
Gestational diabetes mellitus (GDM) is any degree of
glucose intolerance with onset or recognition during
pregnancy
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6
Metabolic Disorders (Cont.)
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Metabolic changes associated with pregnancy
Pregestational diabetes mellitus
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Occurs in women who have preexisting disease
Complicated by vascular disease, retinopathy, or
nephropathy
Almost all of these patients are insulin-dependent
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8
Metabolic Disorders (Cont.)

Pregestational diabetes mellitus
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
Preconception counseling
Maternal risks and complications
•
•
•
•
•
Macrosomia
Hydramnios
Ketoacidosis
Hyperglycemia
Hypoglycemia
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9
Metabolic Disorders (Cont.)
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Fetal and neonatal risks and complications
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Perinatal mortality risk increased
Congenital malformations
Respiratory distress syndrome (RDS)
Prematurity
IUFD (intrauterine fetal demise)
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10
Care Management

Assessment and nursing diagnosis
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Interview
Physical examination
• Assess acute and chronic complications of diabetes

Laboratory tests
• Baseline renal function
• UA and culture
• Glycosylated hemoglobin A

Patient needs much more frequent monitoring
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11
Care Management (Cont.)
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
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Review self-monitoring
Assess for falsification of results
Apply nursing diagnoses
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12
Care Management (Cont.)
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Antepartum care
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Diet and exercise
Insulin therapy
Self-monitoring blood glucose levels
Urine testing
Complications requiring hospitalization
Fetal surveillance
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13
Care Management (Cont.)
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Intrapartum care
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Monitor patient closely
Complications
May require a cesarean birth
After birth care

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Insulin requirements decrease substantially
Encourage breastfeeding
Contraception
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14
Gestational Diabetes Mellitus

Gestational diabetes mellitus
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
Fetal risks
Care management

Screening for gestational diabetes mellitus
• Early pregnancy screening
• Screening at 24 to 28 weeks
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15
Gestational Diabetes Mellitus
(Cont.)

Interventions

Antepartum
•
•
•
•
•
Diet
Exercise
Monitoring blood glucose
Pharmacologic therapy
Fetal surveillance
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16
Gestational Diabetes Mellitus
(Cont.)
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Interventions
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Intrapartum
• Glucose monitoring hourly
• Insulin infusion
• Avoid dextrose solutions
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After birth
•
•
•
•
Most return to normal
High risk for future GDM in pregnancy
Increased risk of type 2 diabetes
Reassess at 6-12 weeks
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18
Thyroid Disorders
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Hyperthyroidism
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Graves’ disease in 90% to 95% of cases
Rare in pregnancy
Symptoms similar to those of pregnancy
Watch for:
• Weight loss
• HR over 100
• Goiter

Increased risk of pregnancy complications
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19
Thyroid Disorders (Cont.)

Hypothyroidism
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
If untreated, at risk for infertility and miscarriage
Watch for:
•
•
•
•


Weight gain
Lethargy
Decrease in exercise capacity
Cold intolerance
Thyroid hormone supplements
Monitor thyroid studies
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20
Metabolic Disorders (Cont.)

Maternal phenylketonuria

Recognized cause of intellectual disability caused by
deficiency in enzyme phenylalanine hydrolase
 Toxic accumulation of phenylalanine in blood
interferes with brain development and function
 Key to prevention is identification of women with
disorder in their reproductive years
 Should be advised against breastfeeding
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21
Cardiovascular Disorders

Major cardiovascular changes during pregnancy
that affect women with cardiac disease are:

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
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Increased intravascular volume
Decreased systemic vascular resistance
Cardiac output changes during labor and birth
Intravascular volume changes that occur just after
childbirth
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Cardiovascular Disorders (Cont.)
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Cardiovascular disease classification
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Class I
Class II
Class III
Class IV
Determined at 3 months and again at 7 or 8 months
of gestation as progression may occur
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Cardiovascular Disorders (Cont.)
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Increased incidence of miscarriage
Preterm labor and birth more prevalent
Intrauterine growth restriction is more common
Incidence of congenital heart lesions increased
in children of mothers with congenital heart
disease
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Selected Cardiovascular Disorders
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Congenital cardiac disease
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Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Coarctation of the aorta
Tetralogy of Fallot
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Cardiac Conditions (Cont.)

Acquired cardiac disease
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Mitral valve prolapse
Mitral valve stenosis
Aortic stenosis
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Selected Cardiovascular Disorders
(Cont.)
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Ischemic heart disease
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Myocardial infarction
Other cardiac diseases and conditions
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Primary pulmonary hypertension
Peripartum cardiomyopathy
Infective endocarditis
Eisenmenger syndrome
Marfan syndrome
Valve replacement
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27
Selected Cardiovascular Disorders
(Cont.)

Heart transplantation
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

Increasing numbers of heart recipients are
successfully completing pregnancies
Before conception woman must be assessed for
quality of ventricular function and potential rejection of
transplant
Conception should be postponed for 1 year after
transplant
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28
Care Management
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Assessment and nursing diagnosis
Interventions
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Antepartum
•
•
•
•
•
•
Therapy focused on minimizing stress on heart
Signs and symptoms of cardiac decompensation
Bed rest
Nutrition counseling
Cardiac medications as needed
Heart surgery
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Care Management (Cont.)

Interventions
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Intrapartum
•
•
•
•
•
•
Routine assessments
Assessments for cardiac decompensation
ABGs
ECG monitoring
Promote cardiac function
Minimize anxiety
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30
Care Management (Cont.)

Interventions

After birth
•
•
•
•
•
•
•
Monitor for cardiac decompensation
ABG monitoring
Monitor for chest pain
Activity as tolerated
Stool softeners
Assess for additional care assistance with infant
Contraceptive counseling
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31
Other Medical Disorders
in Pregnancy

Anemia
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Iron deficiency anemia
Folic acid deficiency anemia
Sickle cell hemoglobinopathy
Thalassemia
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32
Other Medical Disorders
in Pregnancy (Cont.)

Pulmonary disorders

Asthma
•
•
•
•
Exacerbations and remissions
Hyperactive airways
Effective pregnancies unpredictable
At increased risk for after birth hemorrhage
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33
Other Medical Disorders
in Pregnancy (Cont.)

Pulmonary disorders (Cont.)

Cystic fibrosis
• Infants of mothers with cystic fibrosis will be carriers of gene
• With severe disease, pregnancy is often complicated by
chronic hypoxia and frequent pulmonary infections
• Exocrine glands produce excessive viscous secretions
• Problems with respiratory and digestive systems
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34
Other Medical Disorders in
Pregnancy (Cont.)

Integumentary disorders induced by pregnancy

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
Melasma (chloasma)
Vascular “spiders”
Palmar erythema
Striae gravidarum
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35
Other Medical Disorders in
Pregnancy (Cont.)

Integumentary disorders



Pruritus gravidarum
Pruritic urticarial papules and plaques of pregnancy
Intrahepatic cholestasis of pregnancy
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36
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37
Neurologic Disorders

Epilepsy

Failure to take medications is common factor
• Should receive preconceptual counseling
• At risk of congenital anomalies if mother is taking
anticonvulsants

Multiple sclerosis


Bed rest and steroids used to treat acute
exacerbations
Bell’s palsy

Acute facial paralysis
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38
Autoimmune Disorders

Systemic lupus erythematosus



Autoimmune antibody production affects skin, joints,
kidneys, lungs, central nervous system, liver, and
other body organs
Immunosuppressive medications not recommended
during pregnancy
Efforts are aimed at reducing the risk of infection
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39
Autoimmune Disorders (Cont.)

Myasthenia gravis (MG)
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Autoimmune motor (muscle) endplate disorder
Muscle weakness in the eyes, face, neck, limbs, and
respiratory muscles
Women with MG usually tolerate labor well
May require forceps or vacuum delivery
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40
Substance Abuse


The continued use of substances despite related
problems in physical, social, or interpersonal
areas
Dual diagnosis


Substance abuse plus another psychiatric disorder
Damaging effects on the fetus are well
documented
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41
Substance Abuse (Cont.)
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Barriers to treatment
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Women fear losing custody of child and criminal
prosecution
Less than 10% of pregnant women receive treatment
Substance abuse treatment programs do not address
issues affecting pregnant women
Long waiting lists and lack of health insurance
present further barriers to treatment
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42
Substance Abuse (Cont.)

Legal considerations

Some states consider in utero exposure to be abuse
or neglect
 Health care practitioner possibly required to report
positive results
 Legal mandating may impact provider-patient
relationship
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43
Substance Abuse (Cont.)
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Screening
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First prenatal visit
Past and present use
Include prescription and herbal substances
Nonjudgmental approach
4Ps Plus tool
Toxicology testing
• Urine
• Meconium
• hair
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44
Substance Abuse (Cont.)

Assessment


Additional assessment related to conditions more
likely in women with substance abuse issues
Infections
•
•
•
•

HIV
Hepatitis
Syphilis
Common STIs
Ultrasounds
• Gestational age
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45
Substance Abuse (Cont.)

Interventions

Medical management
•
•
•
•
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Education
Consequences of drug use
Monitoring
Treatment programs
Nursing interventions
• Low threshold for pain requires additional approaches to
management
• Decreased involvement with infant requires advice and
education
• Considerations for breastfeeding related to infant exposure
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46
Substance Abuse (Cont.)

Follow-up care

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Assess safety of home environment
Social services involved
Availability of friends/family support systems
Home care visits
If infant’s well-being is questionable, case will be
referred to child protective services agency
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47