CHAPTER

11

High Risk Perinatal Care:

Preexisting Conditions

KEY POINTS
Diabetes mellitus, currently the most common endocrine disorder associated with pregnancy, occurs in approximately 4% to
14% of pregnant women. The perinatal mortality rate for wellmanaged diabetic pregnancies, excluding major congenital
malformations, is approximately the same as for any other
pregnancy.
The current diabetes classification system includes four groups:
type 1 diabetes, type 2 diabetes, other specific types (e.g., diabetes
caused by genetic defects in beta cell function or insulin action,
disease or injury of the pancreas, or drug-induced diabetes), and
gestational diabetes mellitus (GDM).
Dr. Priscilla White developed a classification system. Whites
system was based on the following: age at diagnosis; duration of
illness; and presence of end-organ involvement, especially eye
and kidney. Her classification system is still used frequently to
assess both maternal and fetal risk. Women in classes A through
C generally have positive pregnancy outcomes as long as their
blood glucose levels are well controlled. However, women in
classes D through T usually have poorer pregnancy outcomes
because they have already developed the vascular damage that
often accompanies long-standing diabetes.
Careful monitoring of blood glucose levels, insulin, or oral hypoglycemic medication administration when necessary and dietary
counseling are used to create a normal intrauterine environment
for fetal growth and development in the pregnancy complicated
by pregestational diabetes or GDM.
Poor maternal glycemic control before conception and during
pregnancy may be responsible for fetal congenital malformations
and maternal complications such as miscarriage, infection, and
dystocia (difficult labor) caused by macrosomia.
Preconception counseling is recommended for all women of
reproductive age who have diabetes because it is associated with
less perinatal mortality and fewer congenital anomalies.
Maternal insulin requirements increase as the pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol.
In the immediate postpartum period insulin requirements
decrease substantially because the major source of insulin resistance, the placenta, has been removed. Women may require only
one third to one half of their last pregnancy insulin doses on the
first postpartum day, provided they are eating a full diet.

Although most women are screened for GDM between 24 and

28 weeks of gestation, those with strong risk factors should be
screened earlier in pregnancy. Women with morbid obesity, a
strong family history of diabetes, a history of GDM in a previous
pregnancy, or a history of giving birth to a macrosomic stillborn
infant or an infant weighing more than 4500g are candidates for
early screening.
Thyroid dysfunction during pregnancy requires close monitoring of thyroid hormone levels to regulate therapy and prevent
fetal insult.
Hyperthyroidism in pregnancy is rare. Clinical manifestations of
hyperthyroidism include heat intolerance, diaphoresis, fatigue,
anxiety, emotional lability, and tachycardia. Many of these symptoms also occur with pregnancy; thus the disorder can be difficult to diagnose.
Hypothyroidism occurs in two to three pregnancies per 1000.
Because severe hypothyroidism is often associated with infertility
and an increased risk of miscarriage, it is not often seen during
pregnancy.
Education of the pregnant woman with thyroid dysfunction is
essential to promote compliance with the plan of treatment.
Important points for the nurse to discuss with the woman and
her family include the following: the disorder and its potential
effect on her, her family, and her fetus; the medication regimen
and possible side effects; the need for continuing medical supervision; and the importance of compliance.
High levels of phenylalanine in the maternal bloodstream cross
the placenta and are teratogenic to the fetus. Damage can
be prevented or minimized by dietary restriction of
phenylalanine.
The stress of the normal maternal adaptations to pregnancy on
a heart the functions of which are already taxed may cause
cardiac decompensation.
Currently cardiomyopathy and congenital heart disease are the
major causes of cardiac disease in pregnant women.
Common congenital heart defects are ASD, VSD, coarctation of
the aorta, and tetralogy of Fallot. Acquired cardiac diseases
include mitral value prolapse, mitral stenosis, and aortic
stenosis.
Anemia is a common medical disorder of pregnancy that affects
at least 20% of pregnant women.

All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

CHAPTER 11 High Risk Perinatal Care: Preexisting Conditions

Women with sickle cell trait usually do well in pregnancy.
However, they are at increased risk for preeclampsia, intrauterine
fetal death, preterm birth and low-birth-weight infants, and
postpartum endometritis. They are also at increased risk for
UTIs and may be deficient in iron.
Asthma may be the most common potentially serious medical
condition to complicate pregnancy. The prevalence and morbidity rates are increasing, although the asthma-related mortality
has dropped in recent years.
Cystic fibrosis is a common autosomal recessive genetic disorder
in which the exocrine glands produce excessive viscous secretions, which cause problems with both respiratory and digestive
functions.
The pregnant woman with a neurologic disorder must deal with
potential teratogenic effects of prescribed medications, changes
of mobility during pregnancy, and impaired ability to care for
the baby. The nurse should be aware of all medications the
woman is taking and the associated potential for producing congenital anomalies.

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A pregnant woman with epilepsy should take only one anticonvulsant medication, at the lowest dose level that is effective at
keeping her seizure free if at all possible.
Many autoimmune disorders (e.g., SLE and MG) are often diagnosed in women during their reproductive years; therefore they
may occur during pregnancy.
Women with SLE are advised to wait until they have been in
remission for at least 6 months before they attempt to become
pregnant.
Alcohol and other drugs easily pass from a mother to her baby
through the placenta. Smoking during pregnancy has serious
health risks, including bleeding complications, miscarriage, stillbirth, prematurity, low birth weight, and sudden unexplained
infant death. Congenital anomalies have occurred in infants of
mothers who have taken drugs.
Support from a variety of sources, including family and friends,
health care providers, and the recovery community, is needed
to help perinatal substance abusers achieve and maintain
sobriety.

All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.