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Pregnancy at Risk: Pregestational Problems Chapter 14.

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Presentation on theme: "Pregnancy at Risk: Pregestational Problems Chapter 14."— Presentation transcript:

1 Pregnancy at Risk: Pregestational Problems Chapter 14

2 Substance Abuse in Pregnancy Commonly used drugs Frequently missed dx HCP fail to ask client about SA Often hide SA or seek PNC late During PNC may be receptive to nursing interventions

3 Alcohol CNS depressant- leading cause of preventable retardation. FAS physical and mental abnormalities Avoid alcohol during organogenesis Nursing observe for S/S of DT Need sedation and supportive care Breast feeding dependent on degree of addiction

4 Cocaine and Crack Causes:vasoconstriction, tachycardia, hypertension Metabolites present from 4-7 days Higher incidence of abruption, stillbirth, PT and AB Hard to detect abuse Should not breastfeed

5 Heroin and Methadone Methadone is tx for opioid addiction Heroin lifestyle associated with poor nutrition, crime, STD Both associated with in utero problems Withdrawal for newborn more severe with methadone

6 Nursing Care Unsafe to go “Cold Turkey” Be alert to subtle clues that suggest addiction Matter of fact and non-judgmental approach Focus is general health, nutrition, infections, other body systems and returning for PNC

7 Nursing Plan and Implementation Establish trusting relationship, refer to TX programs May have low thresh hold to pain with associated labor, consider epidural Prepare for depressed, SGA, premature and addicted newborn

8 Diabetes Mellitus Endocrine disorder of carbohydrate metabolism Insulin produced in pancreas by B- cells in Islets of Langerhorn facilitates glucose utilization of cells Populations at risk

9 Glucose Metabolism in Pregnancy Metabolically all pregnant woman live in a state of accelerated starvation. Until 24 weeks estrogen and progesterone increase tissue response to insulin HPL produced by enlarging placenta is anti- insulin Promotes lipolysis, decreases glucose uptake and glucogenesis

10 Pathophysiology Diabetes Mellitus-carbohydrates cannot be utilized due to insulin deficiency Glucose unable to enter cells- cells are starving- blood glucose high Cells use fat and protein for energy Byproduct is ketones

11 Cardinal Signs of DM Polyuria- due to decrease reabsorption of renule tubules Polydipsia- dehydration due to polyuria Polyphasia- starvation due to cells inability to use glucose Weight loss- due to use of fat and muscle for energy

12 Classification of DM Type I-insulin deficiency. Immunological destruction of B-cells, usual onset is childhood, often brittle Type II- adult onset, glucose intolerance Exhaustion of cells, obesity, can control with diet Gestational- glucose intolerance identified during pregnancy,

13 Diabetes in Pregnancy Insulin requirements fluctuate Insulin requirements during first trimester are low due to N/V Insulin needs rise as pregnancy progresses Need to balance glucose and insulin during labor At risk for ketoacidosis and vascular disease

14 Maternal Risks Hydramnios- excessive urination by fetus Preeclampsia- due to vascular damage Ketoacidosis- caused by metabolism of fatty acids, decreased gastric motility and HPL

15 Fetal Risks Hyperglycemia if untreated fetus at risk for demise Increase risk for fetal anomalies Macrosomia- increase glucose leads to increase utilization by fetus IUGR- poor placental perfusion RDS- fetal insulin inhibits surfactant production Polycythemia- inability of glycosylated hgb in mothers blood to release oxygen, cause hyperbilirubinemia

16 Screening Done at 24-28 weeks 25 years or older Obese Family history Black, Hispanic, Native American, Asian Abnormal glucose tolerance test Poor obstetrical outcome

17 Testing Give 50gms of glucose, blood drawn 1 hr later If exceeds 130 need three hour Draw blood q hr for 3 hrs HgbA1C- measures glucose control over 6-8 wk period. Greater than 7.5% have 44% chance of adverse outcome, less than 7.5% have 7% risk

18 Management Use team approach to facilitate teaching Teach nutrition, three meals three snacks. Enroll family Teach glucose monitoring and self injection Oral meds never used, causes hypoglycemia Need AFP@16-20 wks, anomalies scan @ 18 wks, 28 wks S=D, BPP, FKC 28 wks, 32-36 wks biweekly NST

19 Intrapartal Management Timing of birth- LGA, SGA, and FLM During labor need frequent assessment of glucose May need insulin drip

20 Postpartum Care Insulin need fall after deliver of placenta If Type I need less insulin Type II glucose control returns Need follow up @ 6 weeks Encourage parental attachment Encourage breastfeeding Teach contraception

21 Nursing Care Visits twice/month first two trimesters, once week for third Exercise program Glucose control between 70 and 120 Have milk and hard candy available Enroll family

22 HIV More woman with HIV, especially of color Enters through body fluids and breastmilk Effects T-cells, inhibits immune response AIDS dx based on opportunistic infections and T- cell count Risk of transmission lessened with antiviral meds Newborns can have titer for up to 15 months

23 HIV CDC guidelines recommend taking Zidovudine Assess for STD and opportunistic infections Evaluate weight loss, fevers, serology NST @ 32 weeks, bpp, utz, NO AMNIO C/S lessens risk of vertical transmission PP-@ risk for infection, delayed wound healing, pp hemorrhage

24 Nursing Care Counseling Teach S/S of progression of disease Always practice universal precautions Facilitate use of social services

25 Heart Disease Pregnancy causes increase cardiac output, volume and heart rate Most heart conditions are congenital and asymptomatic Problems with mitral(stenosis and prolapse) valve most common Peripartum cardiomyopathy-dysfunction of left ventricle S/S are similar to CHF

26 Classifications of Heart Disease Based upon ability to perform activities of daily living Class I-asymptomatic. No limitations Class II-slight limitations, asymptomatic at rest Class III-moderate limitations. Symptomatic during ADLs Class IV-Discomfort with physical activities. Symptoms while at rest

27 Cardiac Disease Class I-II few complications during gestation and labor Class III-IV at risk for heart failure, usually need invasive cardiac monitoring and assisted delivery May need ABX and anticoagulant tx.

28 Nursing Assessment Pulse, BP, assess for tachypnea, tachycardia Fatigue and activity level Cough, edema, weight gain palpitations Diet high in protein and iron, restrict sodium Encourage rest, avoid infections Seen every 2 weeks until 20 weeks, then q week Blood volume reaches max. @ 28-30 weeks

29 Labor Maintain L lat, 02, ABX, pain management Provide calm atmosphere Continuous fetal monitoring Keep client aware of progress and need for close monitoring

30 Postpartum Care First 48 hours critical Fluid shifts from extravascular to blood stream Keep lat, head up, monitor V/S frequently Give stool softeners to avoid straining Gradual activity Evaluate meds for breastfeeding

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