Pregnancy at Risk: Pregestational Problems

1. Pregnancy at Risk:Pregestational Problems Chapter 14

2. Substance Abuse in Pregnancy • Commonly used drugs • Frequently missed dx • HCP fail to ask client about SA • Often hide SA or seek PNC late • During PNC may be receptive to nursing interventions

3. Alcohol • CNS depressant- leading cause of preventable retardation. • FAS physical and mental abnormalities • Avoid alcohol during organogenesis • Nursing observe for S/S of DT • Need sedation and supportive care • Breast feeding dependent on degree of addiction

4. Cocaine and Crack • Causes:vasoconstriction, tachycardia, hypertension • Metabolites present from 4-7 days • Higher incidence of abruption, stillbirth, PT and AB • Hard to detect abuse • Should not breastfeed

5. Heroin and Methadone • Methadone is tx for opioid addiction • Heroin lifestyle associated with poor nutrition, crime, STD • Both associated with in utero problems • Withdrawal for newborn more severe with methadone

6. Nursing Care • Unsafe to go “Cold Turkey” • Be alert to subtle clues that suggest addiction • Matter of fact and non-judgmental approach • Focus is general health, nutrition, infections, other body systems and returning for PNC

7. Nursing Plan and Implementation • Establish trusting relationship, refer to TX programs • May have low thresh hold to pain with associated labor, consider epidural • Prepare for depressed, SGA, premature and addicted newborn

8. Diabetes Mellitus • Endocrine disorder of carbohydrate metabolism • Insulin produced in pancreas by B- cells in Islets of Langerhorn facilitates glucose utilization of cells • Populations at risk

9. Glucose Metabolism in Pregnancy • Metabolically all pregnant woman live in a state of accelerated starvation. • Until 24 weeks estrogen and progesterone increase tissue response to insulin • HPL produced by enlarging placenta is anti- insulin • Promotes lipolysis, decreases glucose uptake and glucogenesis

10. Pathophysiology • Diabetes Mellitus-carbohydrates cannot be utilized due to insulin deficiency • Glucose unable to enter cells- cells are starving- blood glucose high • Cells use fat and protein for energy • Byproduct is ketones

11. Cardinal Signs of DM • Polyuria- due to decrease reabsorption of renule tubules • Polydipsia- dehydration due to polyuria • Polyphasia- starvation due to cells inability to use glucose • Weight loss- due to use of fat and muscle for energy

12. Classification of DM • Type I-insulin deficiency. • Immunological destruction of B-cells, usual onset is childhood, often brittle • Type II- adult onset, glucose intolerance • Exhaustion of cells, obesity, can control with diet • Gestational- glucose intolerance identified during pregnancy,

13. Diabetes in Pregnancy • Insulin requirements fluctuate • Insulin requirements during first trimester are low due to N/V • Insulin needs rise as pregnancy progresses • Need to balance glucose and insulin during labor • At risk for ketoacidosis and vascular disease

14. Maternal Risks • Hydramnios- excessive urination by fetus • Preeclampsia- due to vascular damage • Ketoacidosis- caused by metabolism of fatty acids, decreased gastric motility and HPL

15. Fetal Risks • Hyperglycemia if untreated fetus at risk for demise • Increase risk for fetal anomalies • Macrosomia- increase glucose leads to increase utilization by fetus • IUGR- poor placental perfusion • RDS- fetal insulin inhibits surfactant production • Polycythemia- inability of glycosylated hgb in mothers blood to release oxygen, cause hyperbilirubinemia

16. Screening • Done at 24-28 weeks • 25 years or older • Obese • Family history • Black, Hispanic, Native American, Asian • Abnormal glucose tolerance test • Poor obstetrical outcome

17. Testing • Give 50gms of glucose, blood drawn 1 hr later • If exceeds 130 need three hour • Draw blood q hr for 3 hrs • HgbA1C- measures glucose control over 6-8 wk period. • Greater than 7.5% have 44% chance of adverse outcome, less than 7.5% have 7% risk

18. Management • Use team approach to facilitate teaching • Teach nutrition, three meals three snacks. • Enroll family • Teach glucose monitoring and self injection • Oral meds never used, causes hypoglycemia • Need AFP@16-20 wks, anomalies scan @ 18 wks, 28 wks S=D, BPP, FKC 28 wks, 32-36 wks biweekly NST

19. Intrapartal Management • Timing of birth- LGA, SGA, and FLM • During labor need frequent assessment of glucose • May need insulin drip

20. Postpartum Care • Insulin need fall after deliver of placenta • If Type I need less insulin • Type II glucose control returns • Need follow up @ 6 weeks • Encourage parental attachment • Encourage breastfeeding • Teach contraception

21. Nursing Care • Visits twice/month first two trimesters, once week for third • Exercise program • Glucose control between 70 and 120 • Have milk and hard candy available • Enroll family

22. HIV • More woman with HIV, especially of color • Enters through body fluids and breastmilk • Effects T-cells, inhibits immune response • AIDS dx based on opportunistic infections and T-cell count • Risk of transmission lessened with antiviral meds • Newborns can have titer for up to 15 months

23. HIV • CDC guidelines recommend taking Zidovudine • Assess for STD and opportunistic infections • Evaluate weight loss, fevers, serology • NST @ 32 weeks, bpp, utz, NO AMNIO • C/S lessens risk of vertical transmission • PP-@ risk for infection, delayed wound healing, pp hemorrhage

24. Nursing Care • Counseling • Teach S/S of progression of disease • Always practice universal precautions • Facilitate use of social services

25. Heart Disease • Pregnancy causes increase cardiac output, volume and heart rate • Most heart conditions are congenital and asymptomatic • Problems with mitral(stenosis and prolapse) valve most common • Peripartum cardiomyopathy-dysfunction of left ventricle S/S are similar to CHF

26. Classifications of Heart Disease • Based upon ability to perform activities of daily living • Class I-asymptomatic. No limitations • Class II-slight limitations, asymptomatic at rest • Class III-moderate limitations. Symptomatic during ADLs • Class IV-Discomfort with physical activities. Symptoms while at rest

27. Cardiac Disease • Class I-II few complications during gestation and labor • Class III-IV at risk for heart failure, usually need invasive cardiac monitoring and assisted delivery • May need ABX and anticoagulant tx.

28. Nursing Assessment • Pulse, BP, assess for tachypnea, tachycardia • Fatigue and activity level • Cough, edema, weight gain palpitations • Diet high in protein and iron, restrict sodium • Encourage rest, avoid infections • Seen every 2 weeks until 20 weeks, then q week • Blood volume reaches max. @ 28-30 weeks

29. Labor • Maintain L lat, 02, ABX, pain management • Provide calm atmosphere • Continuous fetal monitoring • Keep client aware of progress and need for close monitoring

30. Postpartum Care • First 48 hours critical • Fluid shifts from extravascular to blood stream • Keep lat, head up, monitor V/S frequently • Give stool softeners to avoid straining • Gradual activity • Evaluate meds for breastfeeding