Chapter 20
High-Risk Pregnancy: A Woman
with a Preexisting or a Newly
Acquired Illness
INTRODUCTION
• A high-risk pregnancy is one in which a
concurrent disorder, pregnancy-related
complication, or external factor jeopardizes
the health of the mother, the fetus, or both.
• Both the mother & the fetus can be at risk
for complications because either the
pregnancy can complicate the disease, or the
disease can complicate the pregnancy.
INTRODUCTION
• When women with a preexisting disease
become pregnant, a thorough history and
physical examination must be obtained at
the first prenatal visit to establish a baseline
of information on the condition.
• Documentation of any medication being
taken for a secondary condition is also
necessary to protect against adverse drug
interactions and the possibility of teratogenic
action on the fetus.
INTRODUCTION
• Teaching is an important nursing intervention
because a woman with a preexisting illness
must make modifications in her usual
therapy to adjust to pregnancy.
• Pregnancy often stimulates women to learn
more about their primary disease as well.
INTRODUCTION
• Nursing care focuses on:
– Preventing such disorders from affecting
the health of the fetus.
– Helping a woman regain her health as
quickly as possible.
– Helping a woman learn more about her
chronic illness so she can continue to
safeguard her health during her childrearing years.
Identifying the High-Risk Pregnancy
High-risk pregnancy
 A concurrent disorder, pregnancy-related
complication, or external factor
jeopardizes the health of the mother,
fetus or both
Cardiac Disease
Cardiovascular disease in pregnancy is
responsible for 5% of maternal deaths
during pregnancy.
The danger of pregnancy in a woman with
cardiac disease occurs primarily because of
the increase in circulatory volume.
The most dangerous time is in wks. 28 – 32,
just after the blood volume peaks.
 a diffuse inflammatory disease characterized by
a delayed response to an infection by Group A
beta-hemolytic streptococci (GAS) in the
tonsillopharyngeal area
classified as a collagen-vascular disease or
connective tissue disease
organs involved:
- Heart
- Joints
- Central nervous system
Incidence in developing countries :100 per
100,000 people.
ETIOLOGY AND RISK FACTORS:
•Familial predisposition
•Age (most common age is between 6
and 15 years)
•Poor hygiene
•Crowding (low incidence of RF in
spacious housing with no crowding)
•Poverty
Most serious complication is:
RHEUMATIC HEART DISEASE
PATHOPHYSIOLOGY
Untreated sore throat infection by GABS
2-6 weeks after: leads to rheumatic fever
Binds to Receptors on the heart, other tissues,
and joints
Trigger an autoimmune response
RHEUMATIC FEVER : fever weakness,
malaise, weight loss, anorexia
Diffuse, proliferative, & exudative inflammatory
lesions develop in the connective tissues,
joints, skin, brain cells, heart
Major Manifestations:
1. Subcutaneous nodules
2. Migratory polyarthritis
3. Erythema marginatum
4. Chorea
5. carditis
Carditis
Most destructive consequence
Inflammation of the 3 layers of the heart
Present in at least 50% of clients with RF
(most specific manifestation)
Characterized by:
-Heart murmur
-Pericarditis with a rub
-Cardiomegaly
-Heart failure
Carditis
10% develop RHD
Endocardial inflammation
Swelling of valve leaflets
Bacterial vegetations leads to platelet
and fibrin clumps
Shortening of valves: Valve stenosis /
regurgitation
Valvular damage
Inflammation penetrates the:
1. Myocardium
* Aschoff bodies – minute
nodules surrounded by
areas of necrosis in the
myocardium
2. Pericardium
Cardiomegaly
Heart failure
Cardiac Disease
Woman with L-sided heart failure
 Mitral valve stenosis & mitral insufficiency
is a heart condition
which consists of mitral
valve thickening which
becomes rigid, it cannot
be fully opened.
Cardiac Disease
Woman with L-sided heart failure
 Aortic coarctation
Cardiac Disease
Left-sided heart failure
 The inability of the MV to push blood
forward causes:
1) Back pressure on the pulmonary circulation
causing it to be distended
2) Systemic Bp decreases due to lowered
cardiac output
3) Pulmonary hypertension
Cardiac Disease
Left-sided heart failure
3) Pulmonary hypertension
• Pressure in pulmonary artery reaches 25
mmHg(normal pressure at rest: 8-20 mmHg),
fluid begins to pass from pulmonary capillary
membranes into the interstitial spaces
surrounding the alveoli and then into the alveoli
(pulmonary edema)
Cardiac Disease
Left-sided heart failure
4) Pulmonary edema
• Dyspnea
5) Pulmonary capillaries rupture
• Productive cough with blood-speckled sputum
Cardiac Disease
Left-sided heart failure
 Because of limited O2 exchange, women
with pulmonary hypertension are at
extremely high risk for:
• Spontaneous miscarriage
• Preterm labor
• Maternal death
Cardiac Disease
Left-sided heart failure S/Sx:
1) Increased RR
2) Increased fatigue, weakness & dizziness
due to lack of O2
Cardiac Disease
Left-sided heart failure S/Sx:
3) Systemic decrease in Bp
• causes increased HR, peripheral
vasoconstriction
− Decreased blood supply to placenta
• Retention of Na and water occurs
PATHOPHYSIOLOGY OF LHF
MV stenosis, aortic coarctation
Back pressure of blood in the Left Side of heart
And become distended
decreased systemic Bp
pulmonary increased Bp
Increased heart rate,
Peripheral vasoconstriction
retention of sodium & water
(stimulation of renin-angiotensin
Fluid shift from pulmonary
capillary membrane to
interstitial spaces
surrounding the alveoli
system)
PATHOPHYSIOLOGY OF LHF
Pulmonary edema
Capillaries rupture
dyspnea
decreased O2 exchg.
& decreased O2 sat.
Productive cough
With blood-speckled
Sputum (hemoptysis)
spontaneous miscarriage,
preterm labor, maternal death
CLASSES, OR STAGES, OF HEART FAILURE
• Heart failure is classified by how severe it is. These four
classes of heart failure have been defined by the New
York Heart Association.
• Class I (No Symptoms): You can keep up your physical
activities as usual.
• Class II (Mild): Your physical activity is slightly limited.
You are comfortable when sitting or resting, but ordinary
activity causes fatigue, palpitations (feeling that your
heart is pounding or racing) or shortness of breath.
CLASSES, OR STAGES, OF HEART FAILURE
• Class III (Moderate): Your physical activity becomes
more limited. You are comfortable when sitting or
resting, but activity causes fatigue, palpitations or
shortness of breath.
• Class IV (Severe): You experience shortness of breath
with any physical activity and when sitting or resting, you
may feel fatigue, cough, shortness of breath and chest
pain.
Cardiac Disease
Left-sided heart failure Med. Mgt.:
1) If MV stenosis is present, thrombus
formation can occur from non circulating
blood.
•
•
Adm. Anticoagulant
•
Heparin (does not cross the placenta) for early
pregnancy
•
Warfarin (Coumadin) can be used after 12 wk.
but returned to heparin during the last month of
pregnancy
Balloon valve angioplasty
Cardiac Disease
Left-sided heart failure Med. Mgt.:
2) If coarctation of the aorta is present…
• Dissection of the aorta
• May be prescribed with:
•
Antihypertensive
•
Diuretics to reduce blood volume
•
Beta-blockers to improve ventricular filling
Cardiac Disease
Left-sided heart failure
 If complications result in impaired blood flow
to the uterus, the following events can
occur:
1) Poor placental perfusion
2) IU growth restriction
3) Fetal mortality
 Woman needs serial U/S and non-stress
tests done after wks. 30 – 32.
Cardiac Disease
Right-side heart failure
 Common causes:
1) Pulmonary valve stenosis
2) Atrial & ventricular septal defects
3) Eisenmenger syndrome
−R to L atrial or ventricular septal defect with
pulmonary stenosis.
 Occurs when:
1) Output of the RV is less than the blood volume
received by the RA from the vena cava
EISENMENGER SYNDROME
EISENMENGER SYNDROME
Cardiac Disease
Right-side heart failure
2) Back-pressure results in:
• congestion of the systemic venous
circulation
• Decreased cardiac output to the lungs
3) Bp decreases in the aorta bec. Less blood is
reaching it.
4) High pressure in the vena cava from backpressure of blood.
Cardiac Disease
Right-side heart failure
5) Jugular venous distention
6) Increased portal circulation
• Liver & spleen become distended
−Can cause extreme dyspnea and pain in
pregnant woman
7) Distention of abdominal vessels can lead to
exudate of fluid from the vessels into the
peritoneal cavity (ascites).
Cardiac Disease
Right-side heart failure Med. Mgt.:
1) Those with uncorrected anomaly of this type
(Eisenmenger syndrome) may be advised not to
get pregnant.
•
If they do, expect to be hospitalized for the
last part of pregnancy.
•
O2 adm. And frequent arterial blood gas
assessments to ensure fetal growth.
Cardiac Disease
Right-side heart failure Med. Mgt.:
•
During labor, may need a pulmonary artery
catheter inserted to monitor pulmonary
pressure.
•
Close monitoring after epidural anesthesia to
minimize the risk of hypotension.
Cardiac Disease
Assessment
 Level of exercise
Reports exhaustion in relation to daily
activities
 Cough or edema
 Baseline vital signs
 Liver size
 ECG
Cardiac Disease
Fetal assessment
Promote rest
Need 2 rest periods/day
Lie on left lateral recumbent position
Promote healthy nutrition
Must not gain so much weight that her
heart & circulatory system become
overburdened.
Cardiac Disease
Fetal assessment
 Promote healthy nutrition
Prenatal vitamins
Iron supplements
Anemia should be prevented.
Limit sodium intake
Cardiac Disease
Fetal assessment
 Educate regarding medication
 Educate regarding avoidance of infection
Cardiac Disease
Nursing interventions during labor and
birth
 Monitor fetal heart tones and uterine
contractions
 Vital signs
Postpartum nursing interventions
 Assess for heart failure
 Assess baby
A WOMAN WITH CARDIAC DISEASE
LEFT-SIDED HEART FAILURE
RIGHT-SIDED HEART FAILURE
Main Problem : Failure of the mitral
valve/Dysfunctional mitral valve that
the left ventricle cannot push the
volume of the blood forward that is
received by the LA from the pulmonary
circulation.
Main Problem: The output of the RV is less than the blood
volume received by the RA from the vena
cava.
Causes
Causes
: Mitral Stenosis, Mitral Insufficiency,
Aortic Coarctation
Clinical
Manifestations : - Pulmonary hypertension
- Pulmonary edema
- productive cough of blood-speckled
sputum
- increase RR (tachypnea)
- Increase fatigue, weakness, dizziness
- Edema (generalized)
- Orthopnea
- Paroxysmal nocturnal dyspnea
- thrombus formation
Complications : Spontaneous miscarriage, Preterm
Labor, Maternal Death, Poor Placental
Perfusion, Intrauterine Growth
restriction, Fetal death
: Congenital heart defects (pulmonary valve
stenosis), Atrial or Ventricular Septal
defect
Clinical
Manifestations: - Decrease aortic blood pressure
- Distended jugular vein
- Distended Liver, Spleen
- Extreme dyspnea
- Pain
- Ascites
- Peripheral edema
HYPEREMESIS GRAVIDARUM
Hematologic Disorders
Anemia
 True anemia
•Hemoglobin <11 g/dl (hematocrit
<33%) in the 1st or 3rd trimester of
pregnancy
•Hemoglobin <10.5 g/dl (hematocrit
<32%) in the 2nd trimester
Hematologic Disorders
Anemia
 Iron-deficiency anemia
•Causes:
1. Diet low in iron
2. Heavy menstrual periods
3. Unwise weight-reduction program
Hematologic Disorders
Anemia
•Causes:
4. Women who were pregnant in <2 yrs.
before the current pregnancy
5. Low socio-economic levels who have not
had iron-rich diets.
Hematologic Disorders
Anemia
•Is associated with:
1. Low birth weight & preterm birth
2. Extreme fatigue & poor exercise tolerance
Hematologic Disorders
Anemia
 Iron-deficiency anemia Med. Mgt.:
1. Women should take prenatal vitamins
containing an iron supplement of 60 mg
during pregnancy.
2. Eat a diet high in iron and vitamins.
3. Will be prescribed with 120 – 200 mg
elemental iron (ferrous sulfate or ferrous
gluconate)
Hematologic Disorders
Anemia
 Folic acid-deficiency anemia
Folic acid (folacin), one of the B
vitamins, is necessary for:
1. the normal formation of RBC in the mother
2. Prevention of neural tube defects in the
fetus
Hematologic Disorders
Anemia
 Folic acid-deficiency anemia
 It occurs most often in:
1. multiple pregnancies because of the
increased fetal demand
2. Women with secondary hemolytic illness in
which there is rapid destruction and
production of new RBC.
Hematologic Disorders
Anemia
 Folic acid-deficiency anemia
 It occurs most often in:
3. Women who are taking hydantoin, an
anticonvulsant agent that interferes with
folate absorption
4. Women who have been taking oral
contraceptives
Hematologic Disorders
Anemia
 Folic acid-deficiency anemia
 It occurs most often in:
5. Women who have had gastric bypass for
morbid obesity
 The anemia that develops is called
megaloblastic anemia (enlarged RBC)
Hematologic Disorders
Anemia
 Folic acid-deficiency anemia Med. Mgt.:
1. Women expecting to become pregnant
• Supplement of 400 ug folic acid daily
• Eat folacin-rich foods
2. During pregnancy
• Folic acid req is 600 ug/day
Diabetes Mellitus
Is an endocrine disorder in which the
pancreas cannot produce adequate
insulin to regulate body glucose level.
Normal blood glucose level
 80 – 120 mg/dl
Diabetes Mellitus
Pathophysiology and clinical
manifestation
Diabetes during pregnancy
Gestational diabetes
Diabetes Mellitus
Classification of diabetes mellitus
Assessment
Monitoring Education
 Exercise
 Insulin
 Insulin pump therapy
 Blood glucose monitoring
Nursing Process:
Care of a High-Risk Woman
Assessment
 Thorough understanding of the signs &
symptoms of illnesses in addition to an
understanding of the course of a normal
pregnancy.
 Assessment techniques include:
1) Baseline V/S
Nursing Process:
Care of a High-Risk Woman
Assessment
 Assessment techniques include:
2) Extent of edema
3) Level of exhaustion
 Teach a woman to assess her own
health in relation to objective
parameters.
Nursing Process:
Care of a High-Risk Woman
Nursing diagnosis
 Examples of possible Nsg. Dx:
 Ineffective tissue perfusion (cardiopulmonary)
r/t poor heart function 2° MVP during
pregnancy
 Pain r/t pyelonephritis 2° pressure on ureters
 Social isolation r/t prescribed bed rest during
pregnancy 2° to concurrent illness
Nursing Process:
Care of a High-Risk Woman
Nursing diagnosis
 Examples of possible Nsg. Dx:
 Ineffective role performance r/t increasing
level of daily restrictions 2° to chronic illness
and pregnancy.
 Knowledge deficit r/t normal changes of
pregnancy vs illness complications
 Fear regarding pregnancy outcome r/t chronic
illness
Nursing Process:
Care of a High-Risk Woman
Nursing diagnosis
 Examples of possible Nsg. Dx:
 Health-seeking behaviors r/t the effects of
illness on pregnancy
 Situational low esteem r/t illness during
pregnancy
Nursing Process:
Care of a High-Risk Woman
Outcome identification and planning
 Expected outcomes established are
realistic in light of a woman’s pregnancy
and the restrictions placed on her by her
health.
 Make plans with a woman who has a preexisting medical condition based on the
pattern of her life before the pregnancy.
Nursing Process:
Care of a High-Risk Woman
Outcome identification and planning
 Planning for a woman with a new illness
may be difficult because of the shock of
the diagnosis.
 Give the woman the available
alternatives.
 Allowing a woman to choose among the
alternatives helps her to participate in her
own care and maintain self-esteem.
Nursing Process:
Care of a High-Risk Woman
Implementation
 For pregnant woman with chronic illness
 Focus on teaching her new or additional
measures to maintain health because of the
pregnancy.
 For women who developed a new illness
 provide an opportunity to talk about the
event after her initial care is complete to
identify concerns.
Nursing Process:
Care of a High-Risk Woman
Outcome evaluation
 If the expected outcome is not being met,
new assessment, analysis & planning
need to be done.
 Make evaluation ongoing to ensure
whether interventions are successful.
Nursing Process:
Care of a High-Risk Woman
Outcome evaluation
 Examples of outcomes:
 Client states she rests for 2 hrs morning and
afternoon; dependent edema remains at 1+ or
less at next prenatal visit.
 Family members state they are all
participating in an exercise program since
mother developed gestational diabetes.
Nursing Process:
Care of a High-Risk Woman
Outcome evaluation
 Examples of outcomes:
 Client reports no burning on urination or flank
pain at next prenatal visit.
 Client states she understands the importance
of taking daily thyroid medicine for total
length of pregnancy.