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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.

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Presentation on theme: "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."— Presentation transcript:

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

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

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

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

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

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

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

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

11 Heroin and Methadone Heroin Heroin 1.Poor nutrition 2.Anemia 3.Pre-eclampsia 4.STD’s 5.IUGR 6.Meconium aspiration and hypoxia 7.Overdose and withdrawal Methadone Methadone 1.Used for tx of opioid addiction 2.Pre-eclampsia 3.Placental problems 4.Abnormal fetal presentation 5.SGA 6.Withdrawal for newborn 7.Benefits vs. risks

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

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

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

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

16 Maternal Effects Early Early 1.Hormones stimulate insulin production and glycogen storage Late Late 1.Increased resistance to insulin and diminished effectiveness Requirements change with pregnancy Requirements change with pregnancy Poor wound healing Poor wound healing PIH and preeclampsia more common PIH and preeclampsia more common Ketoacidosis Ketoacidosis

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

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

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

20 Anemia HgB less than 10 g/dL HgB less than 10 g/dL Risk factors Risk factors 1.Previous close pregnancies 2.Twin gestation, excessive vaginal bleeding 3.Hx of poor nutritional status Increased risk for spontaneous AB, premature birth, SGA Increased risk for spontaneous AB, premature birth, SGA Limits O 2 available for fetal exchange Limits O 2 available for fetal exchange Fatigue Fatigue Exercise intolerance Exercise intolerance

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

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

23 HIV/AIDS Pregnancy is not believed to accelerate the progression of the disease Pregnancy is not believed to accelerate the progression of the disease Transmission to fetus occurs via the placenta at birth and through breast milk 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 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 Nutrition and rest are vital Meticulous skin care Meticulous skin care Breastfeeding contraindicated Breastfeeding contraindicated Legal aspects Legal aspects Med administration Med administration Support Support Nonjudgmental care Nonjudgmental care

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

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

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

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

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

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

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

32 Rh Sensitizaion Occurs when Rh negative mom carries an Rh positive fetus Occurs when Rh negative mom carries an Rh positive fetus Does not affect 1 st pregnancy, but affects fetus of subsequent ones Does not affect 1 st 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 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 Measures # of antibodies in maternal blood against RBC’s in the serum Screening portion of type and screen Screening portion of type and screen Neative titers/negative Coombs’—fetus without risk Neative titers/negative Coombs’—fetus without risk Type and screen should be done at beginning of pregnancy and upon entering the hospital 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 Teach mom implications for future pregnancies During pregnancies: During pregnancies: 1.Percutaneous umbilical sample 2.If baby Hct below 25% may give intrauterine blood transfusion 3.If fetus is severely sensitized may require birth at 32-34 weeks May result in hydrops fetalis

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

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


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