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High Risk Pregnancy

High Risk Pregnancy. A pregnancy with increased risk of a poor outcome for mother and/or baby because of social, demographic, medical, or obstetric risk factors in the mother. Pregnancy at Risk. Pre-Gestational Problems. Risk Factors. Age: adolescence or >35

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High Risk Pregnancy

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  1. High Risk Pregnancy A pregnancy with increased risk of a poor outcome for mother and/or baby because of social, demographic, medical, or obstetric risk factors in the mother.

  2. Pregnancy at Risk Pre-Gestational Problems

  3. Risk Factors • Age: adolescence or >35 • Blood type: Rh negative / ABO incompatibility • Socioeconomic status • Psychologic well being: addicted/abused/compromised ability to think or use coping mechanisms • Parity and previous pregnancy history • Pre-existing medical disorders

  4. Preterm birth Low-birth weight CPD Poor nutrition Poor prenatal care PIH and pre-eclampsia STD’s Cigarette and drug use Interruption of developmental task Prolonged dependence on govt. Dec. chance for stable relationship Higher rates of abuse or neglect Higher rates of behavioral problems in children Adolescent Pregnancy Risks

  5. Advanced Maternal Age Risks • Higher incidence of congenital anomalies • Increased possibility of complications • Increased incidence of preexisting medical conditions

  6. Preexisting Medical Conditions Which Affect Pregnancy • Substance Abuse • Diabetes Mellitus • Anemia • Cardiac Disorders • Chronic Hypertension • Infections • Miscellaneous

  7. Substance Abuse • Includes legal and illegal substances • Legal implications involved • Impairment of mother-infant bonding

  8. Alcohol • Almost 19% of pregnant women consume alcohol • Fetal alcohol syndrome-IUGR, CNS impairment, facial features, SGA, developmental delays • Withdrawal • Fetal hypoxia and dec. fetal nutrient absorption • Breastfeeding not contraindicated

  9. Cocaine • Approx. 1 in 10 pregnant women are believed to use cocaine • Uterine contractions • Placental abruption • Preterm labor and delivery • Spontaneous AB and stillbirth • IUGR • Infant tremors, tachycardia, HTN • Poor feeders • Breastfeeding contraindicated

  10. Marijuana • Little research • No strong evidence of teratogenic effects to fetus • Difficult to evaluate

  11. Heroin Poor nutrition Anemia Pre-eclampsia STD’s IUGR Meconium aspiration and hypoxia Overdose and withdrawal Methadone Used for tx of opioid addiction Pre-eclampsia Placental problems Abnormal fetal presentation SGA Withdrawal for newborn Benefits vs. risks Heroin and Methadone

  12. Nicotine • Increased incidence of preeclampsia • Low birth weight • Polycythemia of the newborn • Increased risk for SIDS

  13. Assessment • Ongoing • Weight gain • Nutrition • Fetal monitoring • Screening for STD’s • Maternal-infant bonding

  14. Teaching and Nursing Implications • Preparation for withdrawal • Prepare environment • Treat family • Prepare for “addicted” baby • Nonjudgmental approach • Pain meds

  15. Diabetes Mellitus • Inadequate production or utilization of insulin • System of checks and balances • Usually diagnosed between 24-30 weeks • If abnormal 1 hour glucose, then 3 hour glucose is done

  16. Maternal Effects • Early • Hormones stimulate insulin production and glycogen storage • Late • Increased resistance to insulin and diminished effectiveness • Requirements change with pregnancy • Poor wound healing • PIH and preeclampsia more common • Ketoacidosis

  17. Fetal Effects • Hydramnios • Increased risk for infection • RDS five times more common in full term neonates • Macrosomia or IUGR • Shoulder dystocia • Hyperbilirubinemia • Increased incidence of congenital anomalies • Hypoglycemia

  18. Assessment • Treatment should begin 3-6 months before pregnancy • Strict control of plasma glucose levels (Glycosylated HgB) • Vasculopathy • Neuropathy • Nephropathy • Retinopathy

  19. Teaching and Treatments • Referrals when necessary • Activity and exercise • CBG monitoring • Dietary control/snacks • Insulin therapy • Vaginal delivery usually OK • Breast feeding encouraged

  20. Anemia • HgB less than 10 g/dL • Risk factors • Previous close pregnancies • Twin gestation, excessive vaginal bleeding • Hx of poor nutritional status • Increased risk for spontaneous AB, premature birth, SGA • Limits O2 available for fetal exchange • Fatigue • Exercise intolerance

  21. Types and Treatments • Fe Deficiency • Folic Acid Deficiency • Sickle Cell Anemia

  22. Teaching and Nursing Implications • Medications • Foods • Monitoring • Reassurance

  23. HIV/AIDS • Pregnancy is not believed to accelerate the progression of the disease • Transmission to fetus occurs via the placenta at birth and through breast milk • Risk of transmission is about 25%, but significantly lower when the mother receives ZDV, and even lower with scheduled Cesarean

  24. Teaching and Nursing Implications • Nutrition and rest are vital • Meticulous skin care • Breastfeeding contraindicated • Legal aspects • Med administration • Support • Nonjudgmental care

  25. TORCH • Toxyplasmosis • Other • Rubella • Cytomegalovirus • Herpes genitalis

  26. Heart Disease • Rheumatic heart disease-scarring and stenosis • Congenital heart disease-seeing more with technology • Mitral valve prolapse-usually benign • Coronary artery disease (CAD)-increasing with late childbearing

  27. Normal Cardiac Changes • C.O. • Plasma volume • Rise in SV • Vascular Resistance • Expanding Blood Volume • Lower Extremity Edema

  28. Signs and Symptoms of CHF • Cough • Progressive dyspnea with exertion • Dyspnea • Pitting or generalized edema • Palpitations • Progressive fatigue or syncope with exertion

  29. Intrapartal Therapy • Dependent on class level • Antibiotics • Look at benefits vs. risks • May deliver vaginally if Class I or II • Epidural recommended • Close monitoring of stress of labor • Possible use of low forceps

  30. Nutrition • Protein and Fe • NAS • Limit caffeine • Limit Vitamin K if on Heparin • Avoid excessive weight gain

  31. Rheumatoid arthritis Epilepsy Hepatitis B Hyperthyroidism/ Hypothyroidism Mental retardation Maternal PKU Multiple sclerosis Lupus TB Other Medical Conditions

  32. Rh Sensitizaion • Occurs when Rh negative mom carries an Rh positive fetus • Does not affect 1st pregnancy, but affects fetus of subsequent ones • Can be avoided by Rh negative mom receiving RhoGAM at 28 weeks gestation, in event of bleeding episode or trauma during pregnancy, and within 72 hours after pregnancy

  33. Indirect Coombs’ • Measures # of antibodies in maternal blood against RBC’s in the serum • Screening portion of type and screen • Neative titers/negative Coombs’—fetus without risk • Type and screen should be done at beginning of pregnancy and upon entering the hospital

  34. Implications for Rh Incompatibility • Teach mom implications for future pregnancies • During pregnancies: • Percutaneous umbilical sample • If baby Hct below 25% may give intrauterine blood transfusion • If fetus is severely sensitized may require birth at 32-34 weeks May result in hydrops fetalis

  35. Pregnant woman requiring surgery Trauma Battered Woman Perinatal Infection Toxoplasmosis Rubella Cytomegalovirus Herpes Simplex Virus Other Gestational Risks

  36. Group B Strep • Bacteria that lives in vagina of some women • Screening done at 34-36 weeks • If positive, intrapartum antibiotics are indicated • No risk to mother, risk for invasive group B strep to new born

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