Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.
-
Upload
clinton-lawson -
Category
Documents
-
view
217 -
download
2
Transcript of Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.
![Page 1: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/1.jpg)
Management of Pregnancy at Risk Chapter 19 & 20
Mary L. Dunlap MSN, APRNFall 2015
![Page 2: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/2.jpg)
High-Risk Pregnancy
• Jeopardy to mother, fetus, or both• Condition due to pregnancy or result
of condition present before pregnancy• Higher morbidity and mortality• Risk assessment with first Antepartal
visit and each subsequent visit • Risk factors (see Box 19-1 p.605)
![Page 3: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/3.jpg)
Conditions Complicating Pregnancy
• Perinatal Loss• Bleeding• Hyperemesis gravidarum• Gestational hypertension• HELLP syndrome• Gestational diabetes
![Page 4: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/4.jpg)
Perinatal Loss
• Death of a fetus or newborn no matter when it occurs is devastating to the mother and family
• Nurses need to understand their own personal feelings so they can provide support and compassionate care
• What to say- I understand , I am here to listen, Does your baby have a name
![Page 6: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/6.jpg)
![Page 7: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/7.jpg)
![Page 8: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/8.jpg)
Causes of Bleeding
• Spontaneous abortion
• Ectopic pregnancy
• GTD/Hydatiform mole
• Cervical insufficiency
• Placenta Previa• Abruptio
placenta
![Page 9: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/9.jpg)
Spontaneous Abortion
• Termination of pregnancy before viability prior to 20wks less than 500g
• Presentation-Vaginal bleeding and cramping
• Management-Bed rest, serial hCG’s & H&H, Dilation and curettage may be necessary to remove products of conception, RhoGam if mother RH -
![Page 10: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/10.jpg)
Causes
• Congenital abnormalities• Incompetent cervix• Anomaly of the uterine cavity• Hypothyroidism• Diabetes mellitus • Drug use• Infection
![Page 11: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/11.jpg)
Categories of Abortions
• Complete–all products of conception expelled
• Incomplete–a portion of the products of conception retained in the uterus
• Threatened–bleeding and cramping
![Page 12: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/12.jpg)
Categories of Abortions
• Missed– nonviable embryo retained in uterus for at least 6 weeks
• Habitual–three or more successive abortions
• Inevitable–cannot be stopped• Table 19-1 pg. 607
![Page 13: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/13.jpg)
Spontaneous Abortion
Nursing care• Assess bleeding and signs of shock• Assess pain level• Assess for infection• Provide emotional support
![Page 14: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/14.jpg)
Ectopic Pregnancy
• Fertilized ovum implanted outside the uterine cavity usually due to an obstruction of the fallopian tube
• 95%- 99% occur in the fallopian tube• Possible implantation sites Fig 19-1
pg 531
![Page 15: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/15.jpg)
![Page 16: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/16.jpg)
Contributing Factors
• Previous ectopic• STD’s• Endometriosis• Tubal or pelvic
surgery
• Uterine fibroids• IUD• Progesterone
only BC pills (slows ovum transport)
![Page 17: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/17.jpg)
Ectopic Pregnancy
Manifestations• Missed menses • Vaginal bleeding & pelvic pain 6-8
wks after missed menses• Diagnosis: Lab test & Ultrasound
![Page 18: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/18.jpg)
Ectopic Pregnancy
Management• Administer Methotrexate, • Surgical-Salpingectomy• Nursing Care: Monitor for shock,
prepare for surgery & provide emotional support
![Page 19: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/19.jpg)
Gestational Trophoblastic Disease (GTD)
• GTD is a disease characterized by an abnormal placental development resulting in the production of fluid filled grape like clusters and vast proliferation of Trophoblastic tissues
• Diagnosis- trans vaginal U.S. showing vesicular molar pattern (grape clusters) high hCG levels
![Page 20: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/20.jpg)
![Page 21: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/21.jpg)
GTD
• Complete (or classic): mole results from fertilization of egg with lost or inactivated nucleus and is associated with Choriocarcinoma
• Partial mole: result of two sperm fertilizing a normal ovum
• Cause unknown
![Page 22: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/22.jpg)
GTD
Clinical manifestations• Bleeding grape like tissue• Sever Hyperemesis• Uterine size larger than dates• Extremely high hCG levels • Early development preeclampsia
![Page 23: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/23.jpg)
GTD
Management• Immediate evacuation of uterine
content by Dilatation & suction curettage
• Tissue evaluate for Choriocarcinoma• Follow up for one year
![Page 24: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/24.jpg)
Nursing Assessment• Assess for expulsion of grapelike vesicles• Sever morning sickness due to the high hCG
levels• Unable to detect heart rate after 10-12 wks.• Early development of preeclampsia
(prior to 24 wks.)
GTD
![Page 25: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/25.jpg)
Cervical Insufficiency
• Premature cervical dilatation due to a weak structurally defective cervix that spontaneously dilates in the absence of contractions in the 2nd trimester
• 18–22 wks. Usual time for development
• Repetitive second trimester losses
![Page 26: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/26.jpg)
Possible causes• Trauma to the cervix• Structure of cervix- less collagen and
more smooth muscle
Cervical Insufficiency
![Page 27: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/27.jpg)
Cervical Insufficiency
Management• Bed rest• Pelvic rest• Avoid heavy lifting• Cervical cerclage placed 2nd trimester
if no infection present fig 19.3 pg.615
![Page 28: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/28.jpg)
Cervical Insufficiency
Nursing Assessment Monitor for:• Preterm labor• Backache• Increase vaginal discharge• Rupture of membranes• Contractions
![Page 29: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/29.jpg)
Placenta Previa
• Occurs when the placenta implants near or over internal cervical os
• Classification based on degree internal cervical os is covered by placenta
![Page 30: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/30.jpg)
Placenta Previa
• Complete Placenta Previa • Partial Placental Previa• Marginal Previa• Low-lying
![Page 31: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/31.jpg)
Previa classifications
![Page 32: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/32.jpg)
Placenta Previa
Symptoms• Painless vaginal bleeding that occurs
during the last two months of pregnancy
![Page 33: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/33.jpg)
Placenta Previa
Therapeutic Management• Based on bleeding, location of Previa
and fetal development• “Wait and see” approach if fetus stable
and no active bleeding may go home on bed rest
• Bleeding present admitted to hospital monitoring bleeding, FHR, and avoid vaginal exams.
![Page 34: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/34.jpg)
Placenta Previa
Nursing Management• Monitor vaginal bleeding• Monitor for fetal distress• Provide emotional support• Education• Nursing care plan 19.1 pg. 618 & 619
![Page 35: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/35.jpg)
Abruptio Placenta
• Premature separation of placenta form the uterine wall after 20 weeks of gestation leading to compromised fetal blood supply.
• Significant cause of 3rd trimester bleeding
![Page 36: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/36.jpg)
Abruptio Placenta
Clinical manifestations: • Knife like pain• Port wine vaginal bleeding• Prolonged contraction• Ridged abdomen• Uterine tenderness• Decrease FHR
![Page 37: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/37.jpg)
Abruptio Placenta
Classification systems grades 1,2,3• Grade 1 (mild) less than 500 mL• Grade 2 (moderate) 1000-1500mL• Grade 3 (severe) greater than 1500
![Page 38: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/38.jpg)
Classifications of Abruptio Placenta
![Page 39: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/39.jpg)
Diagnostic Testing
• CBC• Fibrinogen levels• PT/PTT• Type and Cross match• Kleihauer-Betke test• NST• Biophysical Profile
![Page 40: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/40.jpg)
Abruptio Placenta
Management Goal• Assess, control and restore blood loss• Positive out come for mother and Baby• Prevent coagulation disorder
Box 19.2 pg. 621
![Page 41: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/41.jpg)
Abruptio Placenta
Nursing Management• O2 therapy• Monitor FHR tracing• Monitor fundal height• Bed rest- left lateral position• Monitor V.S. for shock• Monitor for DIC• Emotional support
![Page 42: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/42.jpg)
Hyperemesis
• “Morning sickness” normal nausea and vomiting experienced by 80% of pregnant women .
• Symptoms are mild and usually resolve at the end of the first trimester
• Management Teaching Guidelines 19.1 pg. 627
![Page 43: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/43.jpg)
Hyperemesis Gravidarum
• Excessive vomiting accompanied by dehydration, electrolyte imbalance, ketosis, acetonuria and weight loss
• Continues past the 20th wks.• Experiences N&V for the first time after
9 wks.• These mothers require hospitalization
![Page 44: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/44.jpg)
Hyperemesis Gravidarum
• Possible causes: etiology unknown could be due to high hormone levels, low blood glucose levels, Vit B complex and protein deficiency, metabolic stress, depression, elevated thyroid hormone levels
• Collaborative care: GI consult to r/o GI problems , Psychiatric consult , Dietary consult
![Page 45: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/45.jpg)
Hyperemesis Gravidarum
Diagnostic Test• Liver enzymes • CBC• Urine• BUN • Urine specific gravity• Electrolytes • US
![Page 46: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/46.jpg)
Hyperemesis Gravidarum
Management• NPO for 24-36 hr.• IV therapy• Medications-Reglan, Phenergan,
Zofran, Compazine, B6 (19-2 pg.625)• Comfort• Emotional support• Teaching Guidelines 19.1
![Page 47: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/47.jpg)
Hypertension Classification
Chronic Hypertension
Gestational Hypertension
PreeclampsiaEclampsia
Help Syndrome
![Page 48: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/48.jpg)
Assessing Blood Pressure
• Never place patient in Left Lateral Tilt position will give a false lower B/P
• Setting or semi-Fowler’s position• Make sure patient is comfortable• Use the appropriately sized cuff• Cuff needs to be at the level of the right
atrium (mid-sternum• If ≥149/90 recheck in 15 min.
![Page 49: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/49.jpg)
Hypertension Classification
• Chronic hypertension, appears before the pregnancy or the 20th week and is persistence after 12 wks. PP
• Oral antihypertensive are used (avoid ACEs & ARBs due to teratogenic side effects)
![Page 50: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/50.jpg)
Antihypertensive Therapy
• Prevent CVA and maintain placental perfusion
• Apresoline- can cause rebound tachycardia
• Labetalol – beta blocker due not use with asthmatic patients
• Aldomet• Procardia
![Page 51: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/51.jpg)
Hypertensive Emergency
ACOG Guidelines
Acute onset lasting 15 minutes or longer• SBP ≥ 160 mm Hg
or• DBP ≥ 110 mm Hg• Loss of cerebral vasculature auto
regulation• Treat with Hydralazine & Labetalol
![Page 52: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/52.jpg)
Hypertension Classification
• Gestational hypertension- Onset without proteinuria after 20th week of pregnancy and returns to normal by 12 wks. Postpartum
• Mild- SBP 140-159 DBP 90-109• Severe- SBP ≥ 160 DBP ≥ 110
![Page 53: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/53.jpg)
Risk to Fetus
• Progression to preeclampsia• Mild: outcome comparable to no
hypertension• Severe: significant outcome similar to
patient with severe preeclampsia
![Page 54: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/54.jpg)
Management of Mild Gestational Hypertension
• Educate patient about s/s of preeclampsia and when to call provider
• Patient assess daily for signs of preeclampsia and decrease fetal movement
• B/P evaluated twice at week, one being done by provider along with assessing for proteinuria, liver enzymes and platelets
![Page 55: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/55.jpg)
Management of Severe Gestational Hypertension
• Admit to hospital for stabilization• Lower B/P to < 160/110: IV Hydralazine
or labetalol • Monitor B/P and s/s of preeclampsia• Administer oral antihypertensive to
control B/P• Delivery based on fetal status and
gestational age
![Page 56: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/56.jpg)
Hypertension Classification
• Preeclampsia- Hypertension develops after 20 weeks of gestation in previously normotensive woman and proteinuria
• Proteinuria ≥ 300 mg/24hr urine collection
• Protein/creatinine ratio ≥ 0.3 mg/dl
![Page 57: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/57.jpg)
Preeclampsia
• Pathophysiology not understood feel it is a disease of the placenta due to Trophoblastic tissue
• Multisystem disorder• Signs and symptoms develop only
during pregnancy and disappear after birth
• Classifications- Mild, Sever, Eclampsia
Chart 19.2 pg. 629
![Page 58: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/58.jpg)
Preeclampsia Pathophysiology
Decreased placental perfusion
Placental production of a toxic substance endothelin
Vasospasms
Increased Thromboxane
Fluid shift intravascular to
intracellular
Endothelial cell damage
Intravascular
coagulation
![Page 59: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/59.jpg)
Clinical Manifestations
• Classic Triad hypertension, proteinuria, and edema
• New belief edema does not have to be present
• Proteinuria can also be absent if hypertension present along with signs of multisystem involvement
![Page 60: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/60.jpg)
Clinical Manifestations
Headache
Visual Changes
Epigastric Pain
CNS
Irritability
![Page 61: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/61.jpg)
Assessment
• B/P• Edema• Output• Deep tendon reflexes (DTRs)• Clonus • Laboratory tests
![Page 62: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/62.jpg)
Mild Preeclampsia
• B/P greater than 140/90 after 20weeks• Edema- mild facial or hands• Weight gain• Urine protein - 300mg in 24hrs • 1+ to 2+ protein dip stick• Reflexes- normal
![Page 63: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/63.jpg)
Management
• Conservative treatment- bed rest at home, balanced diet and instructed to call provider if any signs of sever preeclampsia develop
• Weekly assessment by provider• Teaching Guidelines 19.2 pg. 632
![Page 64: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/64.jpg)
Sever Preeclampsia • B/P >160/110• Protein 500 mg/24hrs• Urine protein > 3+ • Oliguria- less than 400mL/24hrs• Hyperreflexic• Pulmonary edema• Blurred Visual • Headaches• Epigastric pain
![Page 65: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/65.jpg)
Management
• Hospital care/Seizure precautions• Magnesium sulfate• Blood pressure• Pulmonary edema • Monitor -V.S., DTR’s, Clonus, edema,
urinary output every hour• Continuous FHR monitoring
![Page 66: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/66.jpg)
Magnesium Therapy
• Administration must be verified by a second nurse
• Insert Foley catheter• Monitor V S, Urinary output, reflexes,
and protein level hourly • Monitor patient for toxicity
![Page 67: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/67.jpg)
Magnesium Toxicity
• Absent DTRs (use brachials for pt. with epidural)
• Respirations < 12/min• Urine output < 30 mL/hr.• ↓LOC• Discontinue Magnesium Sulfate and notify
physician• Administer 1 gram 10% calcium gluconate IVP
over 5 min. for respiratory arrest
![Page 68: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/68.jpg)
Hypertension Classification
• Eclampsia- preeclampsia with seizure state
![Page 69: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/69.jpg)
Eclampsia
Symptoms of Sever preeclampsia plus • Marked proteinuria • Seizures/Coma• Hyper reflexive• Possible HELLP syndrome
![Page 70: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/70.jpg)
Eclampsia• Stabilize• Continuous FHR• Seizure precautions• Initiate Magsulfate therapy• Evaluate lab results for HELLP
syndrome• Prepare for delivery
![Page 71: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/71.jpg)
HELLP Syndrome
Hepatic Dysfunction characterized by•Hemolysis of red blood cells(H)•Elevated liver enzymes (EL)•Low platelets (LP)
![Page 72: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/72.jpg)
HELLP Syndrome
Increase risk for:• Placental abruption• Acute renal failure• Subcapsular hepatic hematoma• Hepatic rupture• Fetal and maternal death • DIC
![Page 73: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/73.jpg)
HELLP Syndrome
Management• Transfusion of FF plasma or platelets
to reverse thrombocytopenia (count below 100,000)
• Deliver
![Page 74: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/74.jpg)
Disseminated Intravascular Coagulopathy (DIC)
• Loss of balance between clot-forming thrombin and clot-lysing activity of plasmin
• Box 19.2 pg. 621
![Page 75: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/75.jpg)
DIC
Symptoms• Widespread external/internal bleeding• Lab results
Decrease fibrinogen/platelets
Prolonged PT/PTT
Positive D-dimer test
![Page 76: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/76.jpg)
Stages Of Clotting Process
Time of Stage Stage Factors Involved Test
I Platelets initiate clotting
Platelets
Takes 3-5 min. II Thromboplastin generated
PTT
Takes 8-16 min. III Prothrombin converted to
Thrombin
PT
Almost instantly IV Fibrinogen converted to fibrin
Fibrin Levels
![Page 77: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/77.jpg)
DIC
Management • Administer fluids to restore volume
until blood is available• Monitor VS and output• Administer blood and needed blood
components
![Page 78: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/78.jpg)
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
![Page 79: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/79.jpg)
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)
![Page 80: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/80.jpg)
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
![Page 81: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/81.jpg)
Pregestational Diabetes Mellitus
• Maternal & Fetal risksTable 20-2 pg. 651
![Page 82: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/82.jpg)
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
![Page 83: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/83.jpg)
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
![Page 84: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/84.jpg)
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
![Page 85: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/85.jpg)
Gestational Screening• ACOG prenatal risk assessment• Screening
When Diagnosis Test Cutoff for Diagnosis
First Prenatal visit
High RiskPatient
FastingHbA1C
Random
60-90 mg/dL<7%
200 mg/dL
24-28 weeks GDM Fasting1hr GTT
3hr GTT
92mg/dL140mg/dL
1hr <180mg/dL2hr <153mg/dL3hr < 140mg/dL
![Page 86: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/86.jpg)
GDM
• Incidence GDM 2-15%• GDM-A1 able to maintain glycemic
control with diet/exercise• GDM-A2 require medication to
maintain glycemic control
![Page 87: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/87.jpg)
GDM
• Management• Diet• Exercise• Monitor blood glucose levels• Pharmacologic therapy• Maternal & fetal Surveillance
![Page 88: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/88.jpg)
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
![Page 89: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/89.jpg)
![Page 90: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/90.jpg)
Pregnancy at Risk
• Blood incompatibility• Polyhydramnios & Oligohydramnios• Multiple gestation• Premature rupture of membranes• Preterm labor
![Page 91: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/91.jpg)
Blood Incompatibility
Blood type incompatibility• ABO incompatibility: type O mothers
& fetuses with type A or B blood (less severe than Rh incompatibility)
![Page 92: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/92.jpg)
Blood Incompatibility
Rh incompatibility• Exposure of Rh-negative mother to Rh-
positive fetal blood causes sensitization and antibody production
• Risk increases with each subsequent pregnancy and fetus with Rh-positive blood
![Page 93: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/93.jpg)
Blood Incompatibility
• Nursing assessment: maternal blood type and Rh status
• Antibody screen (indirect Coombs)• Nursing management: RhoGAM at 28
weeks
![Page 94: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/94.jpg)
Hydramnios
• Also known as polyhydramnios, too much fluid ( greater than 2000ml)
• Occurs 32-36 weeks• Causes: maternal diabetes, Neural
tube defect, multiple gestation
![Page 95: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/95.jpg)
Hydramnios
Medical Management• Monitor fluid levels• Remove excess amniotic fluid• Administer Indomethacin- decreases
fetal urinary output
![Page 96: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/96.jpg)
Hydramnios
Nursing Management• Monitor for abdominal pain, dyspnea,
uterine contractions and edema of the lower extremities
• Due to the over extension of the uterus educate the patient about the signs and symptoms of preterm labor
![Page 97: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/97.jpg)
Oligohydramnios
• Decrease in amniotic fluid ( less than 500cc) between 32-36 weeks
• Fetus at risk for perinatal morbidity & mortality
• Risk Factors
![Page 98: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/98.jpg)
Oligohydramnios
Nursing Management• Monitor fetal well being• Educate mother about positions that will
encourage the best blood flow to the fetus
• Assist with amnio infusion
![Page 99: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/99.jpg)
Multiple Gestation
• More than one fetus being born to a pregnant women
• The number of multiple gestations have increased due to the use of fertility drugs
• These women are at higher risk for complications
![Page 100: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/100.jpg)
Multiple Gestation
• Monozygotic( Identical)- single fertilized ovum that splits. There is one placenta and chorion and two bags of amniotic fluid
• Dizygotic (Fraternal)- two eggs /sperm
There are two placentas, chorions and bags of amniotic fluid
![Page 101: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/101.jpg)
Multiple Gestation
![Page 102: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/102.jpg)
Multiple Gestation
Medical Management• Serial ultrasounds to assess fetal
growth and development• NST’s and Biophysical profiles to
assess fetal well being• Close monitoring during labor• Operative delivery (common)
![Page 103: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/103.jpg)
Multiple Gestation
Nursing Management• Monitor lab results for anemia• Educate the patient about the need for
adequate nutrition, rest periods, signs and symptoms of preterm labor
![Page 104: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/104.jpg)
Multiple Gestation
Nursing management:• Labor management with perinatal
team on standby• Postpartum assessment for possible
hemorrhage
![Page 105: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/105.jpg)
Premature Rupture of Membranes
• PROM rupture of membranes prior to the onset of labor and is beyond 37 weeks gestation
• PPROM is the preterm premature rupture of membranes prior to the onset of labor prior to the 37th week gestation
![Page 106: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/106.jpg)
Premature Rupture of Membranes
Assessment• Determine if ruptured- Positive Nitrazine
and fern pattern• Transvaginal ultrasound• Vaginal & Cervical culture • Review Box 19.3 pg. 642
Key assessment with PROM
![Page 107: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/107.jpg)
Premature Rupture of Membranes
Management • PROM deliver patient• PPROM if no signs of labor in 48hrs may
discharged to home. • Goal prevent infection, monitor for signs
of labor and promote fetal lung maturity• Review teaching guidelines 19.3 pg 644
![Page 108: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/108.jpg)
Premature Rupture of Membranes
Nursing Management• Focus on preventing infection and
identifying contractions• Monitor V.S.• Monitor fetal heart rate for tachycardia
or variable decelerations• Provide emotional support
![Page 109: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/109.jpg)
Preterm Labor
• Regular uterine contractions with cervical change between 20 to 37 weeks gestation.
• Most common complication• Cause is not always known• Usually due to infection or over
distended uterus
![Page 110: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/110.jpg)
Preterm Labor
Signs of labor• Lighting- fetus dropped into pelvic
cavity• Bloody show• Rupture of membranes
![Page 111: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/111.jpg)
Preterm Labor
Management Goal• Inhibit or reduce contraction strength
and frequency• Optimize fetal status by prolonging
pregnancy• ACOG 2009 recommendations
![Page 112: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/112.jpg)
Preterm Labor
• Fetal Fibronectin • Monitor contraction pattern• Tocolytic therapy Drug guide 21.1 pg. 720
• IV fluids• Betamethasone• Amniocentesis
![Page 113: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/113.jpg)
Preterm Labor
Nursing Management • Educate patient about preterm labor• Preterm labor prevention • Importance of fetal lung maturity• Review Teaching guidelines 21.1 pg.
724
![Page 114: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/114.jpg)
![Page 115: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/115.jpg)
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
![Page 116: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/116.jpg)
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
![Page 117: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/117.jpg)
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
![Page 118: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/118.jpg)
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
![Page 119: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/119.jpg)
Care Management
Minimizing heart stress
Weekly Evaluations
Lab and diagnostic
Education signs & symptoms decompensation
Bed rest
Treated Infections promptly
Proper Nutrition
Counseling
Medications
![Page 120: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/120.jpg)
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
![Page 121: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/121.jpg)
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
![Page 122: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/122.jpg)
![Page 123: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/123.jpg)
TORCH Infections
• Toxoplasmosis• Other infections• Rubella virus• Cytomegalovirus• Herpes simplex viruses
![Page 124: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/124.jpg)
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
![Page 125: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/125.jpg)
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
![Page 126: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/126.jpg)
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
![Page 127: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/127.jpg)
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
![Page 128: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/128.jpg)
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
![Page 129: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/129.jpg)
Women Who Are HIV Positive
Nursing management• History and physical• Pretest and posttest counseling• Testing for STI’s• Education • Support
![Page 130: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/130.jpg)
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
![Page 131: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/131.jpg)
Women Who Are HIV Positive
Labor, Birth, and Postpartum• Elective cesarean birth • Compliance with antiretroviral therapy• Family planning methods
![Page 132: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/132.jpg)
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
![Page 133: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/133.jpg)
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
![Page 134: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/134.jpg)
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
![Page 135: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/135.jpg)
Vulnerable Populations
• Adolescents• Pregnant woman over age 35• Women who abuse substances
![Page 136: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/136.jpg)
Pregnant Adolescent
• Adolescence 11-19 yr. old • Vacillate between being children and young
adults• Developmental Tasks• Box 20.3 Factors contributing to pregnancy
![Page 137: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/137.jpg)
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
![Page 138: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/138.jpg)
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
![Page 139: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/139.jpg)
Woman Over Age 35
Nursing assessment• Preconception counseling; • Laboratory and diagnostic testing for
baseline; amniocentesis; quadruple blood test screen
![Page 140: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/140.jpg)
Woman Over Age 35
Nursing management• Promotion of healthy pregnancy• Education • Regular prenatal care• Dietary teaching• Fetal surveillance
![Page 141: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/141.jpg)
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
![Page 142: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/142.jpg)
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
![Page 143: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/143.jpg)
Pregnancy and Substance Abuse
Nursing assessment • History and physical • Screening questions Box 20-5 pg. 698• Urine toxicology
![Page 144: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/144.jpg)
Pregnancy and Substance Abuse
Nursing management • Refer for intervention and counseling• Nonjudgmental approach • State protection agency notified of positive
newborn drug screen• Education
![Page 145: Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015.](https://reader038.fdocuments.in/reader038/viewer/2022103123/56649d8e5503460f94a77afb/html5/thumbnails/145.jpg)
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