MCN High Risk Midterms

• High-risk pregnancy is one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of a woman, the fetus, or both
• Nursing care for a woman with pregnancy complications and pre-existing illnesses includes:

  • Close observation of maternal health and fetal well-being
  • Giving health education to the woman and her family on danger signs to watch during pregnancy
  • Actions to minimize complications whenever possible
• Labor and delivery generally occur without any problems, but serious problems can be anticipated and treated effectively. Regular check-up visits during pregnancy improve the chances of having a healthy baby and safe delivery
• Complications during pregnancy can result from conditions specifically linked to pregnancy and those that commonly arise in pregnant women. Complications affecting mother and fetus may arise at any stage of pregnancy: prenatal, labor, or postpartum
• Complications during pregnancy include:

  1. Hypertension

  2. Gestational Diabetes

  3. Infections

  4. Preeclampsia

  5. Preterm labor

  6. Miscarriage

  7. Stillbirth
• First trimester bleeding:

  • Refers to vaginal bleeding before 24 weeks of gestational age
  • Types of spontaneous miscarriage include threatened, imminent, missed, incomplete, and complete miscarriage
  • Causes of bleeding during pregnancy include abnormal fetal formation, teratogenic factors, chromosomal aberration, and more
• Surgically induced abortion procedures:

  1. Menstrual Extraction (Suction Evacuation)

  • Simplest type done in an ambulatory setting
  • Uterine lining is suctioned and removed by vacuum pressure

  2. Dilatation and Curettage

  • Used for less than 13 weeks AOG in an ambulatory setting
  • Complications include perforation and uterine infection
• Ectopic Pregnancy:

  • Implantation occurs outside the uterine cavity, commonly in the fallopian tube
  • Signs and symptoms include nausea, positive pregnancy test, and sharp abdominal pain
  • Complications of ectopic pregnancy include peritoneal irritation, shock, and septicemia
• Diagnosis and treatment of ectopic pregnancy:

  • Diagnosis is done through ultrasound
  • Treatment includes methotrexate or mifepristone before rupture, and emergency measures post-rupture
• Second and third trimester bleeding:

  • Causes include gestational trophoblastic disease (hydatidiform mole) characterized by abnormal proliferation of trophoblast cells
  • Symptoms include overgrowth of the uterus and bleeding from the vagina
• • "Empty ovum" fertilized
  • Partial Mole:
  • Some villi form normally
  • Syncytiotrophoblast layer of villi is swollen and misshapen
  • Macerated embryo of approximately 9 weeks gestation may be present
  • Fetal blood may be present
  • Has 69 chromosomes (triploid formation)
  • Rarely leads to choriocarcinoma
  • Assessment:
  • Uterus tends to expand faster than normal
  • Absent fetal heart sound
  • Positive pregnancy test (hCG produced by trophoblast cells)
  • Symptoms of PIH before 20 weeks gestation
• Hydatidiform Mole:

  • Also called Gestational trophoblastic disease
  • Abnormal proliferation and degeneration of trophoblastic villi
  • Cells degenerate and fill with fluid, appearing as clear fluid-filled, grape-sized vesicles
  • Embryo fails to develop beyond a primitive start
  • Associated with choriocarcinoma, a rapidly metastasizing malignancy
  • Incidence: 1 in every 1,500 pregnancies
  • Types:
  • Complete Mole:
  • All trophoblastic villi swell and become cystic
  • Embryo dies early at 1-2 mm in size
  • No fetal blood present
  • Karyotype normal, 46XX, 46 XY
• • Sonogram shows dense growth (typically snowflake pattern) but no fetal growth in the uterus
  • Vaginal spotting of dark-brown blood or fresh flow
  • Therapeutic Management:
  • Suction curettage to evacuate the mole
  • Baseline pelvic examination, chest X-ray, serum test for beta subunit of hCG after mole extraction
  • HCG monitoring every 2 weeks until normal, then every 4 weeks for 6-12 months
  • Oral contraceptive for 12 months
  • If HCG levels are negative after 6 months:
  • Free of malignancy
  • By 12 months, second pregnancy can be planned
• • Blood transfusion may be needed for severe anemia, chronic abruptio placenta, or placenta previa
  • Complications:
  • Hemorrhage, fetal distress/demise, intrauterine growth retardation, cesarean delivery, preterm birth
• Placenta Previa:

  • Occurs when placenta implants near or over the cervical os rather than in the uterine fundus
  • More common in multigravidas than in primigravidas
  • Risk Factors:
  • Uterine scarring, multiple gestation, history of placenta previa, closely-spaced pregnancies, uterine tumors, increased maternal age, endometritis, advanced maternal age, smoking
  • Signs and Symptoms:
  • Painless vaginal bleeding, lower uterine segment differentiation, cervix dilation, severe bleeding as delivery nears, decreasing urinary output, anxiety and fear, malpresentation or high presenting part
• • Diagnostic Tests and Labs:
  • Abdominal ultrasound, non-stress test if hospitalized, pelvic examination contraindicated
  • Therapeutic Nursing Management:
  • Assess amount and character of bleeding
  • Monitor vital signs, urinary output, fetal heart rate and activity
  • Avoid digital exams, enemas, douching, sexual intercourse
  • Provide bed rest if previa occurs before 36 weeks gestation
  • Monitor for continued bleeding and onset of labor
  • Administer IVF replacement
  • Pharmacology:
  • Betamethasone for preterm labor before 34 weeks gestation, to promote fetal lung maturity
• • Assess bleeding, abdominal rigidity, pain, fetal activity, fundal height if concealed bleeding
  • Monitor for shock, keep woman on lateral position, prepare for possible emergency cesarean delivery
  • Administer blood transfusion as ordered
  • Complications:
  • Severe compromised fetal wellbeing, fetal demise, maternal DIC, concealed central placental bleed, shock
• Abruptio Placenta:

  • Premature separation of part or entire placenta from uterine wall
  • Usually occurs in third trimester
  • Mild to severe abdominal pain and uterine rigidity differentiate from placenta previa
  • Abruption is a medical emergency with risk of maternal hemorrhage, fetal death, clotting defects
  • Suspected with sudden onset of intense uterine pain, hospitalization usually necessary
  • Pathophysiology:
  • Spontaneous rupture of blood vessels at placental bed
  • Treatment depends on severity of blood loss and fetal maturity
  • Risk Factors:
• • External uterine trauma, drug abuse, pregnancy-induced hypertension, previous abruption, folic acid deficiency, smoking, cocaine use, premature rupture of membranes, maternal hypertension, multifetal pregnancies, short umbilical cord
  • Diagnostic Tests and Labs:
  • Hemoglobin, hematocrit, ultrasound, blood type and crossmatch, coagulation profile, sonogram
  • Signs and Symptoms:
  • Dark red vaginal bleeding, uterine rigidity, severe abdominal pain, uterine contractions, fetal distress
  • Therapeutic Nursing Management:
• Preterm Labor:

  • Labor after 20th week but before 37th week of gestation
  • Contractions more frequent than every 10 minutes, lasting 30 seconds or longer
  • Associated with infection, frequently unknown cause
  • Risk Factors:
  • Cervical incompetence, preeclampsia/eclampsia, maternal injury, infection, UTI, chorioamnionitis, multiple gestation
  • Signs and Symptoms:
  • Contractions, infection, trauma, substance abuse, hypertension, cervicitis
  • Therapeutic Management:
  • Betamethasone for fetal lung maturity
  • Monitor for infection and shock
• Causes of preterm labor include:

  • Cervical incompetence
  • Preeclampsia/eclampsia
  • Maternal injury
  • Infection
  • UTI and chorioamnionitis (infection of the fetal membranes and fluid)
  • Multiple births
  • Placental disorders
• Assessment signs of preterm labor:

  • Uterine contractions (painful or painless)
  • Abdominal cramping (may be accompanied by diarrhea)
  • Low back pain
  • Pelvic pressure or heaviness
  • Change in the character and amount of usual discharge; may be thicker or thinner, bloody, brown or colorless and may be odorous
  • Rupture of amniotic membranes
• Interventions to halt labor:

  • Identify and treat infection
  • Restrict activity and ensure hydration
  • Maintain bed rest and a lateral position
  • Monitor fetal status
  • Administer fluids
  • Administer medications as prescribed (Tocolytics: nifedipine, indomethacin, magnesium sulfate, terbutaline sulfate)
• Prevention methods for preterm labor:

  • Minimize or stop smoking
  • Minimize or stop substance abuse/chemical dependency
  • Early and consistent prenatal care
  • Appropriate diet/weight gain
  • Minimize psychological stressors
  • Minimize/prevent exposure to infections
  • Learn to recognize signs and symptoms of preterm labor
• Therapeutic management for premature labor:

  • Attempt to arrest premature labor (tocolysis)
  • Medications used: Magnesium Sulfate, Beta adrenergic drugs (Terbutaline, Ritodrine), Nifedipine, Indomethacin, Betamethasone for fetal lung maturity
  • Nursing interventions: Keep client at rest, side-lying position, hydrate the patient, maintain continuous maternal/fetal monitoring
• Preterm rupture of membranes:

  • Rupture of fetal membranes with loss of amniotic fluid before 37 weeks
  • Associated with chorioamnionitis
  • Signs of chorioamnionitis: Fetal tachycardia, Maternal fever, Foul-smelling amniotic fluid, Uterine tenderness
  • Complications of chorioamnionitis: Sepsis, Death
  • Risks: Fetal infection, Sepsis, Perinatal mortality
  • Increase risks with every hour of ruptured membranes, every hour of labor, every vaginal examination
• Respiratory disorder in pregnancy:

  • Rising uterus compresses the diaphragm, reducing lung space
  • Asthma: airflow obstruction, airway hyperactivity, airway inflammation
  • Treatment options for asthma during pregnancy: Inhaled corticosteroids, Cromolyn Sodium, Beta-adrenergic agonists
  • Nursing diagnosis: Risk for ineffective breathing pattern related to respiratory changes during pregnancy
• Diabetes during pregnancy:

  • Changes in glucose-insulin regulatory system during pregnancy
  • Gestational diabetes risk factors: Obesity, Age over 25 years, History of large babies, Family history of diabetes
  • Classification of Diabetes Mellitus: Type 1, Type 2, Gestational Diabetes, Impaired Glucose Homeostasis
• Impaired glucose homeostasis is a state between "normal" and "diabetes" where the body is not using and/or secreting insulin properly
• Impaired fasting glucose is when fasting plasma glucose is at least 110 but under 126 mg/dl
• Impaired glucose tolerance is when the results of the oral glucose tolerance test are at least 140 but under 200 mg/dl in the 2-hour sample
• All women should be screened during pregnancy for gestational diabetes, usually done using a 50-g oral glucose challenge test at week 24-28 of pregnancy
• After the oral 50-g glucose load is ingested, a venous blood sample is taken for glucose determination 60 minutes later
• If the serum glucose at 1 hour is more than 140 mg/dL, the woman is scheduled for a 100-g 3-hour fasting glucose tolerance test
• An 1,800-2,200-calorie diet divided into three meals and three snacks is a usual regimen for a woman with diabetes during pregnancy
• Diet should include reduced saturated fats and cholesterol, increased dietary fiber, and specific percentages of protein, carbohydrates, and fats
• During pregnancy, a woman may develop pseudoanemia of early pregnancy, which is part of normal changes in the body
• True anemia in pregnancy can be pathologic or physiologic, depending on the cause
• Types of anemia in pregnancy include iron deficiency anemia, megaloblastic anemia or folic acid deficiency, and sickle cell anemia
• Iron deficiency anemia is characterized by low hemoglobin levels, small-sized RBCs, and low MCV and MCH