1. Canadian Maternity, Newborn, and Women’s Health Nursing Chapter 13:
High-Risk Pregnancy

2. Pregnancy Risk Assessment
Psychosocial
Economic
Nutrition-related
Family-related considerations

3. Health Complications in Pregnancy
Asthma
Labour: assess vital signs; shortness of breath, increased respiratory rate, inspiratory and expiratory effort, oxygen saturation
Asthma medicine; avoid Demerol or morphine
Aim for adequate respiratory function; ability to cope with labour and birth; verbalize understanding of and fetal well-being; consistency of care

4. Health Complications in Pregnancy (cont.)
Cystic fibrosis
Observe for signs of malabsorption; monitor maternal weight and pancreatic enzymes, fluid and electrolyte balance; assess results of laboratory testing; adequate oxygenation
Oral supplements, pulse oximetry, oxygen if required; breastfeeding permitted once sodium content has been determined

5. Health Complications in Pregnancy (cont.)
Cardiovascular disease
Types
Class I: angina during strenuous or prolonged activity
Class II: angina during vigorous activity
Class III: symptoms with daily activities
Class IV: symptomatic when resting

6. Health Complications in Pregnancy (cont.)
Cardiovascular disease (cont.)
Mitral stenosis
Mitral valve prolapse
Peripartum cardiomyopathy
Atrial septal defects

7. Health Complications in Pregnancy (cont.)
Cardiovascular disease (cont.)
Collaborative management: pregnancy
Physical examination, chest x-ray, ECG, blood gas analysis, echocardiogram
Activity restriction, rest, iron supplementation; monitoring of mother and fetus
Aim for adequate ventilation, tissue perfusion, hydration

8. Health Complications in Pregnancy (cont.)
Cardiovascular disease (cont.)
Collaborative management: labour and birth
Vital signs; fatigue, difficulty breathing or shortness of breath, palpitations, swollen feet
Reduce cardiac workload; goal is vaginal birth after 36 weeks’ gestation; hemodynamic monitoring, urine output, fetal monitoring

9. Health Complications in Pregnancy (cont.)
Anemia
Iron-deficiency anemia
Assess hemoglobin, hematocrit, serum ferritin, free erythrocyte protoporphyrin
Dietary review; prenatal vitamins, adequate iron; financial discussion regarding affordable diet

10. Health Complications in Pregnancy (cont.)
Anemia (cont.)
Sickle cell anemia
Health history, blood count, reticulocyte count, blood urea nitrogen, glucose, direct bilirubin, urinalysis
Folic acid supplementation
Sickle cell crisis: acute episode of vascular occlusion

11. Health Complications in Pregnancy (cont.)
Autoimmune diseases
Systemic lupus erythematosus
Frequent prenatal visits; monitor renal function, blood pressure, fetal health
Corticosteroid therapy
Labour: blood pressure, edema, proteinuria, urine output, cardiac monitoring, lung sounds, blood counts, fetal monitoring
May need cesarean delivery
This slide is overwhelming. Too much information. Need to use bullets and have a skeleton for reference not every word on the slide.

12. Health Complications in Pregnancy (cont.)
Autoimmune diseases (cont.)
Antiphospholipid syndrome
Recurrent spontaneous abortions, unexplained pregnancy loss in second or third trimester, venous thrombosis, arterial thrombosis, stroke, SLE, autoimmune thrombocytopenia, prolonged clotting assay
Treatment: prednisone with low-dose aspirin; low-molecular-weight heparin

13. Health Complications in Pregnancy (cont.)
Infections
HIV: test during pregnancy for early diagnosis and treatment of newborn
Teach risks and benefits of care; determine level of knowledge about disease; plan for the newborn
Assess emotional state and ability to cope
Goal is to reduce maternal viral load before delivery; might have cesarean birth

14. Health Complications in Pregnancy (cont.)
Infections (cont.)
HIV (cont.)
Therapy: start antiretroviral drug during pregnancy; give intravenously during labour and birth
Test for HIV in newborn; ongoing medical treatment will be an extension of the care started during pregnancy

15. Health Complications in Pregnancy (cont.)
Infections (cont.)
Sexually transmitted infections (STIs)
Prenatal care: inquire about sexual activity, previous STIs, risk factors
Physical examination
Screening, treatment, and follow-up throughout pregnancy
Group B test done at 36 weeks gestation. Again this slide is too much information. Need to breakdone into bullets. So it is easy to read.

16. Health Complications in Pregnancy (cont.)
Infections (cont.)
Group B streptococcus
Prenatal: swab at 35 to 37 weeks; if positive, need antibiotics at least 4 hours before birth
Rubella
Screen for rubella immunity at first prenatal visit; if no immunity, counsel to avoid contact with children who have not been immunized
Group B test done at 36 weeks gestation. Again this slide is too much information. Need to breakdone into bullets. So it is easy to read.

17. Question
A client develops a rash on her face, and rubella is suspected. Which transmission-based precautions would the nurse use when caring for this client?
Contact precautions
Droplet precautions
Airborne precautions

18. Answer b) Droplet precautions
Transmission of rubella is by droplet. Symptoms of rubella infection include a rash that may or may not be itchy that begins on the face and progresses to the trunk.

19. Health Complications in Pregnancy (cont.)
Infections (cont.)
Toxoplasmosis: thorough cooking of meat; avoid cat feces; use gloves when gardening; treat with spiramycin
Cytomegalovirus: avoid contact with children in daycare or health care settings; encourage frequent hand washing
Parvovirus: transmission by inhaled particles, hand-to-mouth contact, contaminated blood

20. Health Complications in Pregnancy (cont.)
Renal and urinary problems
UTIs and pyelonephritis
Recognize difference between UTI and normal pregnancy changes
Pyelonephritis: costovertebral angle tenderness, high fever, chills, myalgia, nausea, vomiting
Antibiotics and antimicrobial agents
Hygiene: wipe from front to back after urination and intercourse; extra fluid intake; cotton underwear

21. Health Complications in Pregnancy (cont.)
Renal and urinary problems (cont.)
Acute renal failure
Sudden decrease in renal function
Thorough health history and physical examination; vital signs; blood count, electrolytes, coagulation profile
Fetal monitoring

22. Health Complications in Pregnancy (cont.)
Diabetes mellitus
May be pre-existing or gestational
Potential nursing diagnosis
Anxiety
Deficient knowledge
Risk for ineffective health maintenance
Imbalanced nutrition
Ineffective coping

23. Health Complications in Pregnancy (cont.)
Diabetes mellitus (cont.)
Review or teach blood glucose self-monitoring
Promote diet management
Encourage activity and exercise
Administer insulin
Monitor the fetus
Provide care during labour and birth

24. Psychosocial Disorders and Problems
Depression
Changes in mood, sleep patterns, appetite, weight; feelings of helplessness
Counselling, medications
Bipolar disorder
Cyclic patterns of depression and mania
Medications may be teratogenic

25. Psychosocial Disorders and Problems (cont.)
Intimate-partner violence
May begin or increase during pregnancy
Screen for suggestive indicators
Nonthreatening, nonjudgemental approach
SOS: Screen, Offer options, Safety

26. Psychosocial Disorders and Problems (cont.)
Intimate-partner violence (cont.)
Potential nursing diagnoses:
Fear
Anxiety
Chronic pain
Deficient knowledge
Pain
Impaired parenting

27. Psychosocial Disorders and Problems (cont.)
Intimate-partner violence (cont.)
Emergency safety plan; treat with respect and dignity; one-to-one nursing care
Provide encouragement and support; information about community resources and shelters; ensure safety and well-being of mother and fetus

28. Psychosocial Disorders and Problems (cont.)
Substance use
Tobacco, alcohol, marijuana, cocaine, alcohol, opioids
Methadone treatment in perinatal period
Eating disorders
Anorexia, bulimia

29. Obesity and Pregnancy Obesity
Increased risk of hypertension, vascular disease, diabetes, cesarean birth
Increased risk for fetal anomalies

30. Gestational Complications
Hyperemesis gravidarum
Severe nausea and vomiting
Many theories regarding etiology
Assess history, weight; complete blood count, electrolytes, liver enzymes, thyroid and bilirubin levels, urine for ketones and protein
Monitor intake and output; nutritional counselling

31. Gestational Complications (cont.)
Hypertensive problems
Diastolic higher than 90 mm Hg
Pre-existing hypertension
Gestational hypertension
With comorbid conditions (diabetes, renal disease)
With preeclampsia (after 20 weeks, with proteinuria)

32. Collaborative Care: The Pregnant Client With Hypertension
Monitor blood pressure, urine output, protein in urine, neurologic signs, renal function, edema, headaches, blood counts, liver function tests
Fetal assessment: movement counts, nonstress tests, biophysical profile, Doppler studies
Potential nursing diagnoses: anxiety, ineffective health maintenance, pain, risk for compromised family coping, social isolation
Risk for seizures
Pharmacologic treatments

33. HELLP Syndrome Hemolysis, elevated liver enzymes, low platelet count
Epigastric pain, nausea and vomiting
Hemolytic anemia, hepatic dysfunction
Critically ill

34. HELLP Syndrome (cont.)
Management depends on gestational age, maternal health, fetal status
Ongoing monitoring of reflexes, intake and output, BP, fetal heart rate
Antihypertensive therapy
Magnesium sulfate to prevent seizures

35. Question
A pregnant client is showing severe signs of gestational hypertension. What would the nurse expect when testing the client’s reflexes?
Hyperreflexia
Normal reflexes
Absence of reflexes

36. Answer a) Hyperreflexia
Neurological signs are very important to monitor when caring for a client with gestational hypertension. A client may present with brisk reflexes or hyperreflexia.

37. Preterm Premature Rupture of Membranes
Premature rupture of membranes (PROM)
Preterm premature rupture of membranes (pPROM): before 37 weeks
Risk factors: nutritional deficiencies, substance use, multifetal pregnancy, infections, trauma
Risk for chorioamnionitis, preterm birth, intrauterine death, amniotic band syndrome

38. Collaborative Care: Preterm Premature Rupture of Membranes
Potential nursing diagnoses: constipation, anxiety, fatigue; risk for infection, maternal/fetal injury, deficient fluid volume;
Maternal vital signs, fetal heart rate, abdominal palpation, inspection of perineal area, Nitrazine and fern tests
Bed rest; assess for fever, chills, change in amniotic fluid; uterine contractions and fetal heart rate; assess amniotic fluid for lecithin/sphingomyelin ratio

39. Cervical Insufficiency/Incompetence
Cervical insufficiency (painless cervical dilation) can progress to pPROM and preterm birth
Risk factors: history of excessive cervical dilation for curettage or biopsy; previous cervical lacerations during childbirth; cervical or uterine anomalies
Cerclage: suturing early in second trimester helps prevent cervical relaxation and dilation

40. Disseminated Intravascular Coagulopathy
Complex coagulation disorder
Complete blood count, prothrombin time, activated partial prothrombin time, fibrinogen, fibrin degradation products, d-dimer
Monitor vital signs, oxygen saturation, blood pressure, pulse; replace blood volume; blood products, coagulation components; cardiovascular and respiratory support

41. Placental Alterations
Placenta previa
Placenta implants in lower uterine segment
Risk factors: previous cesarean, previous placenta previa, uterine anomalies
Complications: coagulopathy, postpartum hemorrhage
Anticipate cesarean birth; blood administration

42. Placental Alterations (cont.)
Invasive placenta
Placenta implants into myometrium; doesn’t separate after birth
Complications: hemorrhage
Anticipate cesarean birth; blood administration
Circumvallate placenta

43. Question
A pregnant client has an ultrasound indicating the placenta extends up to the internal os but is not covering it. As the client’s nurse, you would classify this as which type of placenta previa?
Type I
Type II
Type III
Type IV

44. Answer
b) Type II
As her nurse, you should classify the condition as Type II placenta previa. Type II placenta previa is marginal implantation and includes the lower edge of the placenta extending to but not covering the internal os.

45. Placental Alterations (cont.)
Placental abruption: placenta separates from uterus; bleeding may be visible or concealed
Risk factors: hypertension; cocaine, alcohol, tobacco use; abdominal trauma
Vaginal bleeding, pain in abdomen or back, uterine tenderness and rigidity
Goal is stabilization; delivery method depends on risk for hemorrhage and risk for fetus

46. Collaborative Care: The Pregnant Adolescent
Assess teen’s social support system
Potential nursing diagnoses: fatigue, deficient knowledge, situational low self-esteem; risk for ineffective health maintenance, imbalanced nutrition, delayed growth and development

47. Collaborative Care: The Pregnant Adolescent (cont.)
Provide information about options
Educate about procedures, processes, risks, benefits; refer to community nursing, social services for psychosocial support
Collaborate with health care providers to determine care plan

48. Multiple Pregnancy Increased potential for abnormalities, prematurity
Assess by ultrasound: gestation, fetal growth, amniotic fluid volume
Nutritional considerations; activity may need to be restricted

49. Multiple Pregnancy (cont.)
Potential nursing diagnoses: anxiety, fear, constipation, imbalanced nutrition, ineffective health maintenance, deficient knowledge, compromised family coping
Teach symptoms of preterm labour; prepare for emotional, financial, practical stresses
Movement counts, Doppler studies, biophysical profiles, NST

50. Perinatal Loss Early pregnancy loss
Ectopic pregnancy: implantation outside the uterus
Gestational trophoblastic disease: proliferation and degeneration of trophoblastic villi
Late pregnancy loss
Stillbirth: fetal death at >20 weeks, >500 g

51. Collaborative Care: Pregnancy Loss
Potential nursing diagnoses: chronic sorrow, social isolation, interrupted family processes; risk for dysfunctional grieving
Provide privacy, pain relief, supportive care; acknowledge pain and grief
After delivery: see and hold baby, save mementos
Support groups