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Nursing Management of the Pregnancy at Risk Chapter 20

Nursing Management of the Pregnancy at Risk Chapter 20. Mary L. Dunlap MSN, APRN Fall 2014. Diabetes Mellitus. Diabetes mellitus is the most common endocrine disorder associated with pregnancy

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Nursing Management of the Pregnancy at Risk Chapter 20

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  1. Nursing Management of the Pregnancy at RiskChapter 20 Mary L. Dunlap MSN, APRN Fall 2014

  2. Diabetes Mellitus • Diabetes mellitus is the most common endocrine disorder associated with pregnancy • Before discovery of insulin in 1922, it was uncommon for a woman with diabetes to give birth to a healthy baby • Pregnancy complicated by diabetes is considered high risk

  3. Diabetes Mellitus • Metabolic disease characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both. • Type 1 • Type 2 • Gestational diabetes mellitus (GDM)

  4. Pregestational Diabetes Mellitus Goal • Preconception counseling and early pregnancy glycemic control during organogenesis to reduce the risks of birth defects • Fetal Basis of Adult Disease Theory

  5. Pregestational Diabetes Mellitus • Maternal & Fetal risks Table 20-2 pg. 651

  6. Pregestational Diabetes Mellitusand Pregnancy Plan of care • Diet and exercise • Insulin therapy • Monitoring blood glucose levels • Fetal surveillance • Determination of birth date and mode of birth

  7. Gestational Screening • ACOG prenatal risk assessment • Screening

  8. Diabetes Mellitus- Gestational(GDM) • Impairment in CHO metabolism during pregnancy due to placental hormones • Placental hormones cause insulin resistance • Beta Cells are unable to produce the required amount of insulin • Develops during the second trimester

  9. Insulin Needs during Pregnancy • First trimester: reduced • Second trimester: starts to increases • Third trimester: peaks to provide more nutrients for the fetus • Delivery: Maternal insulin needs drop to prepregnancy • Breastfeeding mother: lower insulin needs

  10. GDM • Incidence GDM 2-15% • GDM-A1 able to maintain glycemic control with diet/exercise • GDM-A2 require medication to maintain glycemic control

  11. GDM • Management • Diet • Exercise • Monitor blood glucose levels • Pharmacologic therapy • Maternal & fetal Surveillance

  12. GDM Nursing Management • Educate patient about blood glucose monitoring, optimal glucose control and fetal well being assessments • Dietary changes • Exercise • Medications • Teaching Guidelines 20.1 pg. 659

  13. Cardiovascular Disorders • Preconception counseling crucial • Woman with cardiac disease must be assessed and diagnosed as soon as possible • Degree of disability important in treatment and prognosis • Heart Conditions Table 20.3 pg.661 & 662

  14. Cardiovascular Disorders Heart transplantation • Increasing numbers of heart recipients are successfully completing pregnancies • Vaginal birth is desired, but transplant recipients have an increased rate of cesarean births

  15. Cardiovascular Disorders • Functional classification based on past & present disability & physical signs • Class I &II can go through a pregnancy without major complications • Class III bedrest during pregnancy • Class IV should avoid pregnancy • Box 20.1 pg. 663 Mortality risk

  16. Cardiovascular Disorders • Decompensating is the hearts inability to maintain adequate circulation→ impaired tissue perfusion in the mother & fetus • Most vulnerable from 28-32 weeks and 48hrs postpartum • S&S

  17. Care Management Minimizing heart stress Weekly Evaluations Lab and diagnostic Education signs & symptoms decompensation Bed rest Treated Infections promptly Proper Nutrition Counseling Medications

  18. Infections in Pregnancy Sexually transmitted infections • Chlamydia • Human papillomavirus • Gonorrhea • Herpes simplex virus type 2 • Syphilis • Human immunodeficiency virus (HIV) Review Table 20.4 pg. 677

  19. Infections in Pregnancy TORCH infection • Capable of crossing placenta and adversely affecting developing fetus • Produce influenza-like symptoms in mother • Exposure during first 12 wks. can cause fetal anomalies

  20. TORCH Infections • Toxoplasmosis • Other infections • Rubella virus • Cytomegalovirus • Herpes simplex viruses

  21. Toxoplasmosis • Transferred by hand to mouth after having contact with cat feces or undercooked meat. • Prevention is the key • Teaching Guidelines 20.5 pg. 683

  22. Hepatitis B Virus • CDC recommends all pregnant women be tested for hepatitis B surface antigen regardless of previous HBV vaccine or screening • Infants born from positive mothers need to receive single-antigen HBV vaccine & hepatitis B immunoglobulin within 12 hrs. of birth

  23. Hepatitis B Virus Nursing assessment • History focused on behavior that puts her at risk. • Prenatal testing • Can breast feed • No need for surgical delivery • Teaching Guidelines 20.4 pg.680

  24. Group Beta Strep(GBS) • Causes neonatal sepsis • CDC guideline- vaginal and rectal culture 35-37 weeks gestation • Mother given antibiotics in labor if positive, positive with previous pregnancy, ROM greater than 18 hrs, Hx of preterm delivery

  25. Women Who Are HIV Positive • HIV is a retrovirus that is transmitted by blood and body fluids • It is a threat to the mother, fetus, and newborn • To date 20 million women are HIV positive • 2.5 million children and most acquired HIV via mother to child transmission

  26. Women Who Are HIV Positive Nursing management • History and physical • Pretest and posttest counseling • Testing for STI’s • Education • Support

  27. Women Who Are HIV Positive Therapeutic management • Oral antiretroviral drugs twice daily 14 weeks until birth • IV administration during labor • Oral syrup for newborn in 1st 6 weeks of life

  28. Women Who Are HIV Positive Labor, Birth, and Postpartum • Elective cesarean birth • Compliance with antiretroviral therapy • Family planning methods

  29. Rubella • Rubella, German measles, spread by droplet or direct content with contaminated object. • Risk of transmission via the placenta is greater with early exposure • Pt. screened at 1st prenatal visit • Avoid exposure to any with Rubella

  30. Cytomegalovirus • Serious fetal injury occurs when mother develops infection in 1st trimester or early 2nd trimester • Transmission sexual contact, blood transfusions, kissing, and contact with children in daycare centers. • No therapy to prevent or treat CMV infection • Stress good hygiene

  31. Herpes Simplex Virus(HSV) • HSV-1 and HSV-2 cause oral lesions (fever blisters) and genital lesions • Transmission occurs by direct contact of the skin or mucous membranes with an active lesion. • CDC recommends vaginal birth if no lesions are present. If active lesions present pt. should have cesarean birth

  32. Vulnerable Populations • Adolescents • Pregnant woman over age 35 • Women who abuse substances

  33. Pregnant Adolescent • Adolescence 11-19 yr. old • Vacillate between being children and young adults • Developmental Tasks • Box 20.3 Factors contributing to pregnancy

  34. Pregnant Adolescent Nursing assessment • Vision of self in future • Role models • Emotional support • Level of education • Financial/community resource • Anger/conflict resolution skills • Knowledge of health and nutrition for self and child

  35. Pregnant Adolescent Nursing management • Support • Future planning (return to school; career or job counseling); options for pregnancy • Frequent evaluation of physical and emotional well-being • Stress management; self-care • Teaching Topics Box 20-6 pg. 691

  36. Woman Over Age 35 Nursing assessment • Preconception counseling; • Laboratory and diagnostic testing for baseline; amniocentesis; quadruple blood test screen

  37. Woman Over Age 35 Nursing management • Promotion of healthy pregnancy • Education • Regular prenatal care • Dietary teaching • Fetal surveillance

  38. Pregnancy and Substance Abuse • Women with substance abuse commonly abuse several substances • Social attitudes prohibit some women from seeking help and admitting they have a problem. • They will seek prenatal care late in the pregnancy

  39. Pregnancy and Substance Abuse Impact on pregnancy • Preterm labor • Abortion • Low birth wt. infant • CNS and fetal anomalies • Long term developmental issues • Effect of common substances Table 20-6 pg. 694

  40. Pregnancy and Substance Abuse Nursing assessment • History and physical • Screening questions Box 20-5 pg. 698 • Urine toxicology

  41. Pregnancy and Substance Abuse Nursing management • Refer for intervention and counseling • Nonjudgmental approach • State protection agency notified of positive newborn drug screen • Education

  42. Alcohol Abuse • Alcohol is a teratogen and is toxic to human development • Fetal alcohol spectrum disorder (FSDA) • Cognitive and behavioral problems associated with FASD Box 20.4 pg. 695 • Facial characteristics Figure 20.8 pg 695

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