Pregnancy at Risk: Pregestational Onset

1. Pregnancy at Risk: Pregestational Onset

2. Alcohol Use in Pregnancy • Maternal effects: • Malnutrition • Bone-marrow suppression • Increased incidence of infections • Liver disease • Neonatal effects: • Fetal alcohol spectrum disorders (FASD)

5. Cocaine Use in Pregnancy: Maternal Effects • Seizures and hallucinations • Pulmonary edema • Respiratory failure • Cardiac problems • Spontaneous first trimester abortion, abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth

6. Cocaine Use in Pregnancy: Fetal Effects • Decreased birth weight and head circumference • Feeding difficulties • Neonatal effects from breast milk: • Extreme irritability • Vomiting and diarrhea • Dilated pupils and apnea

7. Heroin Use in Pregnancy • Maternal effects: • Poor nutrition and iron-deficiency anemia • Preeclampsia-eclampsia • Breech position • Abnormal placental implantation • Abruptio placentae • Preterm labor

8. Heroin Use in Pregnancy (cont’d) • Maternal effects: • Premature rupture of the membranes (PROM) • Meconium staining • Higher incidence of STIs and HIV • Fetal effects: • IUGR • Withdrawal symptoms after birth

9. Substance Use in Pregnancy: Maternal Effects • Marijuana: difficult to evaluate, no known teratogenic effects • PCP - maternal overdose or a psychotic response • MDMA (Ecstasy) - long-term impaired memory and learning

10. Pathology of Diabetes Mellitus (DM) • Endocrine disorder of carbohydrate metabolism • Results from inadequate production or utilization of insulin • Cellular and extracellular dehydration • Breakdown of fats and proteins for energy

11. Gestational Diabetes (GDM) • Carbohydrate intolerance of variable severity • Causes: • An unidentified preexistent disease • The effect of pregnancy on a compensated metabolic abnormality • A consequence of altered metabolism from changing hormonal levels

13. Effect of Pregnancy on Carbohydrate Metabolism • Early pregnancy: • Increased insulin production and tissue sensitivity • Second half of pregnancy: • Increased peripheral resistance to insulin

14. Maternal Risks with DM • Hydramnios • Preeclampsia-eclampsia • Ketoacidosis • Dystocia • Increased susceptibility to infections

15. Fetal and Neonatal Risks with DM Perinatal mortality Congenital anomalies Macrosomia IUGR RDS Polycythemia

16. Fetal and Neonatal Risks with DM (cont’d) • Hyperbilirubinemia • Hypocalcemia

17. Screening for DM in Pregnancy • Assess risk at first visit: • Low risk - screen at 24 to 28 weeks • High risk - screen as early as feasible

18. Risk Factors • Age over 40 • Family history of diabetes in a first-degree relative • Prior macrosomic, malformed, or stillborn infant • Obesity • Hypertension • Glucosuria

19. Screening Tests • One-hour glucose tolerance test: • Level greater than 130-140 mg/dl requires further testing • 3-hour glucose tolerance test: • GDM diagnosed if 2 levels are exceeded

20. Treatment Goals • Maintain a physiologic equilibrium of insulin availability and glucose utilization • Ensure an optimally healthy mother and newborn • Treatment: • Diet therapy and exercise • Glucose monitoring • Insulin therapy

21. Fetal Assessment • AFP • Fetal activity monitoring • NST • Biophysical profile • Ultrasound

22. Nursing Management • Assessment of glucose • Nutrition counseling • Education about the disease process and management • Education about glucose monitoring and insulin administration • Assessment of the fetus • Support

23. Iron-deficiency Anemia • Maternal complications: • Susceptible to infection • May tire easily • Increased chance of preeclampsia and postpartal hemorrhage • Tolerates poorly even minimal blood loss during birth

24. Iron-deficiency Anemia (cont’d) • Fetal complications: • Low birth weight • Prematurity • Stillbirth • Neonatal death

25. Iron Deficiency Anemia (cont’d) • Prevention and treatment: • Prevention - at least 27 mg of iron daily • Treatment - 60-120 mg of iron daily

26. Folate Deficiency • Maternal complications: • Nausea, vomiting, and anorexia • Fetal complications: • Neural tube defects • Prevention - 4 mg folic acid daily • Treatment - 1 mg folic acid daily plus iron supplements

27. Folate Deficiency • Maternal complications: • Nausea, vomiting, and anorexia • Fetal complications: • Neural tube defects • Prevention - 4 mg folic acid daily • Treatment - 1 mg folic acid daily plus iron supplements

28. Sickle Cell Anemia • Maternal complications: • Vaso-occlusive crisis • Infections • Congestive heart failure • Renal failure

29. Sickle Cell Anemia (cont’d) • Fetal complications include fetal death, prematurity, and IUGR. • Treatment: • Folic acid • Prompt treatment of infections • Prompt treatment of vaso-occlusive crisis

30. HIV in Pregnancy • Asymptomatic women - pregnancy has no effect • Symptomatic with low CD4 count - pregnancy accelerates the disease • Zidovudine (ZDV) therapy diminishes risk of transmission to fetus • Transmitted through breast milk • Half of all neonatal infections occurs during labor and birth

31. HIV in Pregnancy: Maternal Risks • Intrapartal or postpartal hemorrhage • Postpartal infection • Poor wound healing • Infections of the genitourinary tract

32. HIV Effects on Fetus • Infants will often have a positive antibody titer • Infected infants are usually asymptomatic but are likely to be: • Premature • Low birth weight • Small for gestational age (SGA)

33. Treatment DuringPregnancy • Counsel about implications of diagnosis on pregnancy: • Antiretroviral therapy • Fetal testing • Cesarean birth

34. Cardiac Disorders in Pregnancy • Congenital heart disease • Marfan syndrome • Peripartum cardiomyopathy • Eisenmenger syndrome • Mitral valve prolapse

35. Less Common Medical Conditions in Pregnancy • Rheumatoid arthritis • Epilepsy • Hepatitis B • Hyperthyroidism • Hypothyroidism • Maternal phenylketonuria

36. Less Common Medical Conditions in Pregnancy (cont’d) • Multiple sclerosis • Systemic lupus erythematosus • Tuberculosis

37. Pregnancy at Risk: Gestational Onset

38. Spontaneous Abortion • Threatened abortion • Imminent abortion • Incomplete abortion • Complete abortion

39. Types of spontaneous abortion. A Threatened The cervix is not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs.

40. B Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased.

41. C Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.

42. Spontaneous Abortion (cont’d) • Missed abortion • Recurrent pregnancy loss • Septic abortion

43. Spontaneous Abortion: Treatment • Bed rest • Abstinence from coitus • D&C or suction evacuation • Rh immune globulin

44. Spontaneous Abortion: Nursing Care • Assess the amount and appearance of any vaginal bleeding • Monitor the woman’s vital signs and degree of discomfort • Assess need for Rh immune globulin. • Assess fetal heart rate • Assess the responses and coping of the woman and her family

45. Ectopic Pregnancy: Risk Factors • Tubal damage • Previous pelvic or tubal surgery • Endometriosis • Previous ectopic pregnancy • Presence of an IUD • High levels of progesterone

46. Ectopic Pregnancy: Risk Factors (cont’d) • Congenital anomalies of the tube • Use of ovulation-inducing drugs • Primary infertility • Smoking • Advanced maternal age

47. Ectopic Pregnancy: Treatment • Methotrexate • Surgery

48. Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy

49. Ectopic Pregnancy: Nursing Care • Assess the appearance and amount of vaginal bleeding • Monitors vital signs • Assess the woman’s emotional status and coping abilities • Evaluate the couple’s informational needs. • Provide post-operative care

50. Gestational Trophoblastic Disease: Symptoms • Vaginal bleeding • Anemia • Passing of hydropic vesicles • Uterine enlargement greater than expected for gestational age • Absence of fetal heart sounds • Elevated hCG