High Risk Pregnancy

NCM 104

Lyreyann C. Abella, RN
Nursing Care of Women with
Complications During
Pregnancy
High Risk Pregnancy…..Causes
Relate to the pregnancy itself
Occurs because the woman has a medical
condition
Results from environmental hazards
Arise from maternal behavior or
lifestyle
Assessment of Fetal Health

Nurses responsibility

◦ Preparing patient properly for test

◦ Explaining reason for test
◦ Clarifying and interpreting results in
collaboration with other HCPs
◦ Providing support to patient
US Images
4D US Images
AFI AMNIOTIC FLUID INDEX
Kick Count Assessment Tool

                                                                                                                                                                              
Doppler Ultrasound Blood Flow
Assessment
AFP ALPHA FETO PROTEIN
performed at about 15-20 weeks of pregnancy.

                                                             
Amniocentesis
NST non-stress test
is an objective recording of the fetal heart rate variation with
spontaneous movement..
Percutaneous Blood Sampling
 Danger Signs in Pregnancy

Sudden gush of fluid from vagina

Vaginal bleeding
Abdominal pain
Persistent vomiting
Epigastric pain
Swelling of face and hands
Severe, persistent headache
Danger Signs in Pregnancy
Blurred vision or dizziness
Chills with fever > 100.4 degrees
Painful urination or reduced urine
output
Pregnancy-Related Complications
Hyperemesis Gravidarum
◦ Manifestations
 Persisitent N/V
 Significant weight loss
 Dehydration: dry tongue and mucous membranes,
decreased turgor, scant concentrated urine, high
hematocrit
 Electrolyte and acid-base imbalance
 Unusual stress, emotional immaturity,
passivity, ambivalence
Pregnancy-Related Complications

◦ Treatment
 Correct electrolyte imbalances and
acid-base imbalances with oral or IV
fluids
 Antiemetic drugs
 Possibly parenteral nutrition
Pregnancy-Related Complications
◦ Nursing Care
 Focus is on teaching
 Avoid foods that trigger N/V
 Eat small, frequent meals
 Teach about intake and output
 Provide support to the mother
Bleeding Disorders of Early Pregnancy
Abortion
◦ Specific care depends on whether abortion induced or
spontaneous
◦ Treatment
 Cervical cerclage
 Suturing of cervix – to help maintain threatened
pregnancy
 Counseling
 Administration of oxytocin to help control blood loss
 Rhogam given if mother Rh negative
Cerclage
◦ Nursing Care for Abortion
 Physical care
 Document amount of bleeding
 Pad count
 Vital signs
 Instruct pt. To remain NPO if actively bleeding
 Instructions
 Report increased bleeding
 Monitor temp every 8 hours x 3 days
 Take iron supplement
 Resume sex as prescribed by HCP
 Appointment with HCP at assigned date and time
 Emotional Care for Abortion
 Acknowledge grief
 Provide for spiritual support
Ectopic Pregnancy
◦ Occurs when fertilized egg is implanted outside
uterine cavity
 95% in fallopian tube
◦ May result from
 Hormonal abnormalities
 Inflammation
 Infection
 Adhesions
 Congenital defects
 Endometriosis
 Use of intrauterine contraception – due to inflammation
 Failed tubal ligation
◦ Zygote cannot survive for long
 May die and be reabsorbed
 May rupture tube creating a surgical emergency
◦ Manifestations
 Lower abdominal pain
 Light vaginal bleeding
 If rupture occurs
 Sudden, severe abdominal pain, vaginal bleeding
and hypovolemic shock
 Referred shoulder pain
◦ Treatment for Ectopic Pregnancy
 Test for hCG
 Transvaginal US
 Laparoscopic exam
 Medical treatment
 No action if being reabsorbed
 Methotrexate (if tube not ruptured) – inhibits cell
division
 Surgery to remove pregnancy from tube or entire
tube if damage is severe
Surgical Management of Ectopic Pregnancy
◦ Nursing Care for Ectopic Pregnancy
 Vital signs
 Assessment of lung and bowel sounds
 IV fluids
 Blood replacement as necessary
 Antibiotics
 Pain management
 NPO
 Indwelling catheter
 Bed rest
 Emotional support
Hydatidiform Mole
◦ Molar pregnancy
 Occurs when the chorionic villi is abnormally increase
and form vesicles
 May be complete (no fetus) or partial (only part of
the placenta has vesicles)
 May cause
 Hemorrhage
 Clotting abnormalities
 Hypertension
 Later development of choriocarcinoma
◦ Chromosome abnormalities are common
◦ May occur in women at ages of extreme
reproductive life
◦ Manifestations
 Bleeding
 Rapid uterine growth
 Failure to detect FHR activity
 Signs of hyperemesis gravidarum
 Unusually early PIH
 Snowstorm pattern on US with no evidence of
fetus
Hydatidiform Mole
“Molar” Pregnancy
Treatment for Hydatidiform Mole

 Vacuum aspiration and D&C

 Level of hCG is tested until undetectable and
levels followed for at least 1 year
 Women advised to delay conception until
follow-up care complete
 Rhogam given if mother Rh negative
◦ Nursing Care for Hydatidiform Mole

 Observe for bleeding and shock

 Emotional support
 Education on reasons to delay pregnancy
 Contraception education
Placenta Previa

◦ Placenta develops in the lower part of

the uterus versus the upper part.

◦ There are 3 degrees of previa

 Marginal – reaches within 2-3 cm of

cervical opening
 Partial – placenta partially covers the
cervical opening
 Complete or Total – completely covers the
opening
◦ A low-lying placenta is near the cervix

 Not a true placenta previa

 May or may not be accompanied by bleeding
 May be discovered during a routine exam
◦ Manifestations of Placenta Previa

 Bright red, painless vaginal bleeding

 Risk of hemorrhage increases with nearing of
labor
 Fetus often in abnormal presentation
 Fetus may have anemia
 Mother may be more at risk postpartum for
infection and hemorrhage
 Vaginal organisms can easily reach placenta
site
 Lower portion of uterus has fewer muscles
resulting in weaker contractions
◦ Treatment

 Depends on length of gestation and amount

bleeding
 Goal is to maintain pregnancy as long as
safely possible
 Mother encouraged to lie on side or with
pelvic tilt to avoid supine hypotension
 Delivery by C-section if total or partial
 May deliver vaginally if low-lying or marginal
Nursing Care
◦ Observe for vaginal blood loss
◦ Observe for S/S of shock
◦ Vital signs q 15 minutes if actively bleeding
and oxygen administered
◦ NO VAGINAL EXAMS
◦ Continuous fetal monitoring
◦ Prepare for Cesarean if indicated
◦ Supportive Care
Abruptio Placentae

◦ Permanent separation of placenta from

implantation site
◦ Predisposing factors include
 Hypertension
 Cocaine or Alcohol Use
 Smoking
 Poor Nutrition
 Abdominal Trauma
 Prior History of Abruption Placentae
 Folate deficiency
◦ Manifestations of Abruptio Placentae

 Bleeding with abdominal or low back pain

 Bleeding may be concealed at first
 Dark red vaginal bleeding when blood leaks past
placenta
 Uterine tenderness and firm
 May have cramp-like contractions
 Fetus may or may not be in distress
 Fetus/Neonate may have anemia or
hypovolemic shock
◦ Disseminated Intravascular Coagulation
(DIC)

 May complicate abruptio placentae

 Large clot behind placenta consumes clotting
factors which leaves mother deficient
 Clot formation and destruction occurs at the
same time
 Mother may bleed from all orifices due to
depletion of clotting factors
 Postpartum hemorrhage may occur
 Infection likely due to damaged tissue being
susceptible to bacteria
◦ Treatment

 1st Choice – Immediate Cesarean

 Blood and clotting factor replacement if necessary
 After delivery problem quickly resolves

◦ Nursing Care

 Prepare for C-section

 Close, continuous monitoring of mother and baby
 Observe for S/S shock
 Prepare for compromised infant
 Prepare for grieving if infant dies
Premature Rupture of Membranes
Many risk factors

Maternal Sequelae: Abruption, amniotic

infection, post-partum infection of endometrium
Fetal sequelae: Respiratory distress, sepsis,
prolapsed cord
Diagnoses; nitrazine paper, microscopic test of
amniotic fluid
No digital examination!!!
Premature Rupture of Membranes
Signs and Symptoms
◦ contractions
◦ cramps
◦ backache
◦ diarrhea
◦ Vaginal discharge
◦ ROM
Premature Rupture of Membranes

Treatment
◦ Tocolytics
◦ IV hydration
◦ bedrest
◦ steroids, if needed
Nursing Interventions

Assess fetal well-being, gestational age

Administer antibiotics
< 37 weeks gestation, minimal options
> 34 weeks, assess lung maturity of fetus
Monitor for signs and prevent premature labor
Provide psychological support for mother and
family
Pre-term Labor
Onset of Labor from 20-37 weeks
Rarely due to a single cause
Common problem-11.6% of all births are
premature
Pre-term Labor
Multiple causes
◦ Maternal renal, CV, DM, PIH, placental
problems, trauma, PROM
Effects to fetus
◦ Maturational deficiencies- no body fat
◦ Respiratory Distress
◦ Poor glucose, heat regulation
Nursing Interventions/Care
Assessment
◦ Thorough hx
◦ check bleeding
◦ check ROM
◦ BP
Teaching
◦ Infection Control
◦ Report any leaking
Postterm Pregnancy
Signs and Symptoms
Wt loss Risks
 fetal mortalit
◦  uterine size cord compression
◦ Meconium in AF mec asp
LGA  shoulder
dystocia  CS
episiotomy/laceration
depression
Post-term Pregnancy

Treatment
fetal surveillance
 NST, q wk
 mom monitors fetal movement
Induction
 Pitocin (10-20U/L) @ 1-2 mU/min
every 20-60 min
Disorders of Amniotic Fluid
 Disorders of Amniotic Fluid
Polyhydramnios

Signs and Symptoms

uterine
distention
Dyspnea Treatment
edema of lower extr • Therapeutic
• amniocentesis
Disorders of Amniotic Fluid
Oligohydramnios

Risks
cord compression
musculoskeletal
deformities Treatment
pulmonary hypoplasia • amnioinfusion
 Hypertension During Pregnancy

Hypertension During Pregnancy

◦ High blood pressure in pregnancy (PIH)
◦ Preeclampsia
 PIH + proteinuria
◦ Eclampsia
 PIH + proteinuria + convulsions/seizures
◦ Toxemia – old terminology
◦ Cause unknown
◦ Birth only definitive cure
◦ Usually develops after 20th week, but
research has shown that it is determined at
implantation
◦ Vasospasm is main characteristic
◦ May increase risks of further complications
◦ Risk Factors for PIH

 1st pregnancy
 Obesity
 Family history of PIH
 >40 years or <19 years
 Multifetal pregnancy
 Chronic hypertension
 Chronic renal disease
 Diabetes mellitus
 Treated/Monitored with diet modification,
daily weights, activity restriction, BP monitoring,
fetal kick counts, frequent monitoring for
proteinuria
◦ Medication is started if BP exceeds
moderate range

Drugs of Choice
Methyldopa (Aldomet)
Labetalol
Nifedipine (Procardia)
◦ Manifestations of PIH

 Vasospasm impede blood flow to mother and placenta

resulting in:
 Hypertension
 Typically should not occur in pregnancy due to
hormonal changes which decrease resistance to blood
flow
 Edema
 Occurs when fluid leaves blood vessels and enters
tissues
 Proteinuria
 Develops as reduced blood flow damages kidneys
 Other Manifestations of Preeclampsia
 CNS – HA
 Eyes – Visual disturbances
 Urinary Tract – Decrease UO
 Respiratory – Pulmonary Edema
 GI and Liver – Epigastric pain and N/V,
elevated liver enzymes
 Blood – HELLP – hemolysis, elevated
liver enzymes, low platelets
Treatment of Pre-eclampsia
Mild: diastolic < 100, Severe: diastolic > 110, 3+
1+ proteinuria, no H/A proteinuria,  U/O, H/A, visual
disturbances
Bedrest Bedrest,  stimuli
protein Meds
diet
document fetal ◦ Apresoline for severe
HTN
activity ◦ MgSO4 (anticonvulsant
weekly NST & antihypertensive)
Delivery
 Eclampsia

 Woman has one or more generalized seizures

 Facial muscles twitch, then contraction of all
muscles
 Effects on Fetus
 Decreased oxygen availability which may
result in fetal hypoxia
 Meconium
 IUGR
 Fetal Death
◦ Treatment of PIH
 Prevention
 Management – as discussed previously
 Drug Therapy
 Magnesium Sulfate (anticonvulsant and
antihypertensive)
 Antihypertensive Drug Therapy if BP
> 160/100 mg Hg
◦ Nursing Care

 Assist to obtain PNC

 Help cope with therapy
 Provide care/Monitor
 Administer meds
 Postpartum Care
Blood Incompatibility
Rh and ABO Incompatibility

◦ Rh blood factor = Rh+

◦ No Rh blood factor in erythrocytes = Rh-
◦ Rh+ person can receive Rh- blood if all other
factors compatible because factor is not present
◦ Rh incompatibility only occurs if the mother is
Rh- and fetus is Rh+
◦ Rh- is autosomal recessive trait – both parents
must pass on this gene to the fetus
◦ Rh+ is dominate gene
◦ Rh+ person can inherit two Rh+ genes or one Rh+
and one Rh-
◦ Rh- mother does not have the factor and therefore
if her fetus does her body may respond with
antibody production as a defense mechanism
(isoimmunization)
 Typically occurs at delivery and would therefore
affect subsequent pregnancies
 Blood Incompatibility
◦ Manifestations
 If mother produces anti-Rh anitbodies no
outward manifestation
 Labs reveal increased antibody titers
 When maternal anti-Rh antibodies cross the
placenta fetal erythrocytes are destroyed
(erythroblastocis fetalis)
◦ Nursing Care
 Prevent antibody production
 Rhogam at 28 weeks and w/in 72 hours of
delivery
if mother Rh- and baby Rh+
 May also be given after amniocentesis as a
precaution
 Not effective if sensitization has already
occurred
 If antibody production occurs fetus is monitored
carefully
 Coomb’s test
 Amniocentesis
 Percutaneous umbilical sampling test
 Intrauterine transfusion if severely anemic
ABO INCOMPATIBILITY
More common than Rh incompatibility
Causes less severe problems
Mom’s blood is O, fetus blood is A, B, or
AB
 Naturally occurring anti-A and anti-B
antibodies transfer across placenta to
fetus.
 Baby may show weak positive Coombs
test result
 May result to hyperbilirubinemia that can
be treated with phototherapy.
·Rarely does this incompatibility lead to
the severe anemia of Rh incompatibility.
 First time infant will have the most issues
that other children.
Pregnancy Complicated by Medical
Conditions

Diabetes Mellitus

◦ Preexisting (Type I or Type II with

onset before pregnancy)
DIABETES MELLITUS
Diabetes mellitus that
occurs during
pregnancy(GDM)
Women who have
diabetes mellitus prior
to pregnancy are
referred to as
pregestational
diabetics (PGDM)
Pathophysiology of DM
 Pancreas produces insufficient insulin or cells
resist effect of insulin
 Cells cannot receive glucose
 Body metabolizes protein and fat for energy
 Ketones and acid accumulate
 Person loses weight
 Person experiences fatigue and lethargy
 Fluid moves to tissues to dilute excess
glucose leading to increased thirst resulting
in tissue dehydration and glycosuria
(glucose-bearing urine)
◦ Effect of Pregnancy on Glucose Metabolism
 Increased resistance of cells to insulin
 Increased speed of insulin breakdown

◦ Gestational Diabetes Mellitus

 Maternal Links to GDM
 Maternal Obesity (>198 lbs.)
 Previous macrosomic infant
 Maternal age > 25 years
 Previous unexplained stillbirth or infant with
congenital anomalies.
 Family history of DM
 Fasting glucose > 135 mg/dl or postmeal > 200 mg/dl
◦ Treatment of Diabetes During Pregnancy

 Identification
 Diet Modification
 Monitoring
 Ketone Monitoring
 PO antidiabetic agents
 Insulin
 Exercise
 Fetal monitoring
 May indicate early delivery
 Glucose Tolerance Test
1 GTT (24 - 28 wks) 3 GTT
drink 50g glucose, •hi carb diet X 2
if 1 BS > 140 days, then NPO after
MN
•FBS, then drink
100g glucose,
 1, 2, 3 BS
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the
following BS results:
1 > 190, 2 > 165, 3 > 145
◦ Nursing Care for Diabetes During
Pregnancy

 Self-care/Management
 Emotional Support
 Encourage Breastfeeding
Heart Disease

◦ Affects small percentage of pregnant women

◦ Manifestations
 Increased clotting causes predisposition to
thrombosis
 If cannot meet demand leads to CHF
 Priority of care is limiting demands on heart
throughout pregnancy, labor, delivery and
postpartum period
 Classification:
 Class I - no physical limitation
 Class II - slight limitation of physical activity
- Ordinary activity causes fatigue,
palpitation, dyspnea, or angina
 Class III - moderate to marked limitation of
physical activity; less than ordinary
activity causes fatigue
 Class IV -unable to carry on any activity
without experiencing discomfort

 Prognosis: Classes I & II – normal pregnancy & delivery

 Classes III & IV – poor candidates
◦ Nursing Care for Heart Disease

 Teach self-management to patient

 Teach S/S of CHF
 Diet modification
 Teach about eliminated stress
Anemia

◦ Hgb levels < 10.5-11.0 g/dl in pregnancy

◦ 4 types in pregnancy

 Iron-deficiency
 RBCs small and pale
 Prevention – iron supplements
 Treatment – elemental iron supplements
 Folic acid-deficiency

 Large, immature RBCs

 Iron-deficiency anemia may also be
present

 Prevention – folic acid supplement

 Treatment – 1mg/day supplement over
the amount of preventative supplement
Sickle cell disease

◦ Abnormal Hgb that causes erythrocytes to become

sickle-shaped during hypoxia or acidosis
◦ Autosommal recessive trait
◦ Approx 1/12 African Americans has the trait
◦ Pregnancy may cause crisis
◦ Risk to fetus – occlusion of vessels leading to
preterm birth, IUGR, fetal death
Thalasemia

Genetic trait that causes

abnormality in one of two
chains of Hgb ,alpha or beta
 Nursing Care for Anemias During
Pregnancy

 Nutrition education
 Education about changes in stool pattern
and characteristics
 avoid dehydration
Infections

◦ TORCH - Devastating infections for fetus

 T – toxoplasmosis
 O – other infections
 R – rubella
 C – cytomegalovirus
 H – herpes simplex virus
Viral Infections

◦ Cytomegalovirus – May be asymptomatic in

mother, but serious problem in infant

 Mental retardation
 Seizures
 Blindness
 Deafness
 Dental abnormalities
 Petechiae (blueberry muffin rash)
 No effective treatment, therapeutic abortion may
be offered if early in pregnancy
Rubella
mild virus with low fever and rash, but effects on
fetus can be devastating
 Microcephaly
 MR
 Congenital cataracts
 Deafness
 Cardiac defects
 IUGR
 Treatment – Immunization prior to pregnancy
Herpes virus – type 1 and type 2 – type 2
affects pregnancy

 Infection in infant can be localized or

widespread, may cause death or
neurological complications

 Treatment and Care – Avoid contact

with lesions, if active outbreak Cesarean
delivery
Hepatitis B

transmitted by blood and body fluids, can also

cross placenta

Treatment and Care – screen during

pregnancy, infants born to women who are
Hepatitis B+ should be given Hepatitis B
immune globulin (HbIG), followed by Hep B
vaccine
◦ HIV
 causative organism of AIDS, cripples immune system

Acquired one of three ways

 Sexual contact with infected person

 Parenteral or mucous membrane exposure to infected
body fluids
 Perinatal exposure (20% - 40% chance of infecting
infant)
 Transplacentally
 Contact with infected maternal secretions at birth
 Breastmilk
Nonviral Infections

Toxoplasmosis
 caused by Toxoplasma gondii, a parasite that may be
in cat feces in raw meat and transmitted through the
placenta
 Possible S/S in newborn
 Low birth weight
 Enlarged liver and spleen
 Jaundice
 Anemia
 Inflammation of eye structures
 Neurological damage
Treatment and Nursing Care

Cook all meats thoroughly

Wash hands after handling raw meat
Avoid litter boxes , soil and sand
boxes
Wash fresh fruits and veggies well
Group B streptococcus
– leading cause of perinatal infections. Organism found in
woman’s rectum, vagina, cervix, throat or skin. Woman
usually asymptomatic, but can be transmitted to baby at
delivery.

 Diagnosis
 + culture of woman’s vagina or rectum at 35-37 weeks
gestation

 Treatment
 Antibiotics to mother prior to delivery
 Antibiotic therapy to infant after delivery
TUBERCULOSIS
S/S
 fatigue
 weakness
 loss of appetite and weight
 Fever
 Night sweats
Treatment and Nursing Care

 Isoniazid and Rifampin to mother for 9 months

 Infant may have preventative therapy for 3 months
Sexually Transmitted Diseases
Prevention is by safe sex with protection of
condom

◦ Herpes
◦ HIV
◦ Syphilis
◦ Gonorrhea
◦ Chamydia
◦ Trichomoniasis
◦ Genital Warts
Urinary Tract Infections

◦ More common in pregnancy due to pressure

on urinary structures keeps bladder from
emptying completely and because ureters
dilate and lose motility under influence of
relaxing effects of progesterone and relaxin
◦ Cystitis – infection of bladder
 S/S
 Burning with urination
 Increased frequency and urgency
 May have slightly elevated temp
◦ Pyelonephritis – infection of kidney(s)
S/S
 High fever
 Chills
 Flank pian
 N/V

◦ Treatment for UTIs

 Antibiotic therapy

◦ Nursing Care
 Teach to wipe front to back
 Intake adequate fluid
 Urinate before and after intercourse
 Teach S/S
Substance Abuse
 the
use of illicit or recreational drugs during
pregnancy .

Treatment and Nursing Care

 Identify substance abused

 Educate on potential effects of drug
 Use nonjudgmental approach
alcohol

Alcohol, no safe level

 Displaces other nutritional food intake
 Fetus may show signs of:
 IUGR
 CNS dysfunction
 Craniofacial abnormalities (FAS)
·Cocaine

Causes vasoconstriction, elevated BP,

tachycardia
 May cause seizures
May cause spontaneous abortion, fetal
malformation, neural tube defects
 Newborn: irritability, hypertonicity, poor
feeding patterns, increased risk of SIDS
Opiates

 Produces analgesia, euphoria, respiratory

depression
 Newborns experience withdrawal within
24-72 hours after delivery
High-pitched cry, restlessness, poor
feeding seen in the newborn
Nursing care:
Provide quiet environment
 Wrap infant and hold snuggly
Observe for seizures
 Administer anticonvulsants, sedatives as
ordered
Trauma During Pregnancy
Manifestations of Battering
 May enter late to prenatal care
 May make up excuses

Treatment and Nursing Care

 Provide for privacy
 Be nonjudgmental
 Offer resources
 Assessment of maternal and fetal
well-being
Effects of a High-Risk Pregnancy
on the Family
Disruption of Roles
Financial Difficulties
Delayed Attachment
Loss of Expected Birth Experience
References
 Introduction to Maternity & Pediatric Nursing; Fourth Edition, 2003;
Gloria Leifer, Ma, RN; Associate Professor Obstetrics, Pediatrics, and
Trauma Nursing; Riverside Community
College; Riverside, California; Saunders
The END!!!