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Nursing 353Maternal Risk Factors

Fetal AssessmentFebruary 3rd, 2005

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High Risk Pregnancy

The life or health of the mother or fetus isjeopardized

Examples include:

GDM

Previous loss

AMA

HTN

Abnormalities with the neonate

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Perinatal Mortality

Overall maternal deaths are small

Many deaths a preventable

Education and prenatal care are veryimportant

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Antepartum Testing

FKCs BID

UTZ FHR

Gestation age

Abnormalities IUGR

Placental location and quality

AFI

Position

BPP

Doppler flow

Fetal growth

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Ultrasound

Can be done abdominally or transvaginally

1st trimester done to detect viability,calculate EDC

2nd trimester done to detect anomalies,calculate EDC

3rd

trimester done to do BPP, fetal growthand well-being, AFI

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Doppler Flow Analysis via UTZ

Study blood blow in the fetus and placenta

Done on high risk mothers:

IUGR HTN

DM

Multiple gestation

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AFI

Polyhydramnios too much amniotic fluid

Oligohydramnios too little amniotic fluid

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Biophysical Profile

Includes 5 components:

Fetal breathing movements

Gross body movements

Fetal tone

AFI

NST - reactive

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Amniocentesis

Used with direct ultrasound

Less than 1% result in complications

Complications include: Fetal death, miscarriage

Maternal hemorrhage

Infection to fetus

Preterm labor Leakage of amniotic fluid

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Meconium

Visual inspection of amniotic fluid

Meconium is defined as thin and thick andparticulate

Associated with fetal stress: hypoxia,umbilical cord compression

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CVS

Done between 9 -12 weeks

Genetic studies

Removal of small amount of tissue fromthe fetal portion of the placenta

Complications: vaginal spotting,

miscarriage, ROM, chorioamnionitis If done prior to 10 weeks, increased risk

of limb anomalies

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AFP

Genetic test

Done with mothers blood

16-20 weeks gestation Mandated by state of California

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EFM

Third trimester goal is to continue toobserve the fetus within the intrauterineenvironment

Goal: dx uteroplacental insufficiency

NST vs. CST

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NST

90% of gross fetal body movements areassociated with accelerations of the FHR

Can be performed outpatient

Not as sensitive

User friendly but must interpret strip

Fetus may be in a sleep state or affectedby maternal medications, glucose etc.

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NST

To be reactive must meet criteria

Must be at least 20 minutes in length

Must have 2 or more accelerations thatmeet the 15 X 15 criteria

Must have a normal baseline

Must have LTV

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NST

To stimulate a fetus that is not meetingcriteria:

Change positions of the mother LS, RS

Increase fluids

Acoustic stimulator

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CST

Done in the inpatient setting only!

Has contraindications

May be expensive if meds/IV needed Monitored for 10 minutes first

Then may use nipple stimulation or

oxytocin stimulation No late decelerations than negative CST

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CST

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Endocrine and Metabolic Disorders

#1 Diabetes Mellitus

Disorders of the thyroid

Hyperemesis

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Diabetes

Hyperglycemia

May be due to inadequate insulin action ordue to impaired insulin secretion

Type 1 insulin deficiency

Type 2 insulin resistance

GDM glucose intolerance duringpregnancy

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DM

10th week fetus produces it own insulin

Insulin does not cross the placental barrier

Glucose levels in the fetus and directlyproportional to the mother

2nd and 3rd trimesters decreased

tolerance to glucose, increased insulinresistance, increased hepatic function ofglucose

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Diabetic Nephropathy

Increased risks for:

Preeclampsia

IUGR

PTL

Fetal distress

IUFD

Neonatal death

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DM

Poor glycemic control is associated withincreased risks of miscarriage at time ofconception

Poor glycemic control in later part ofpregnancy is assoc. with fetal macrosomiaand polyhydramnios

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Polyhydramnios

May compress on the vena cava and aortacausing hypotension, PROM, PPhemorrhage, maternal dyspnea

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Macrosomia

Disproportionate increase in shoulder andtrunk size

4000-4500gms or greater

Fetus will have excess stores of glycogen

Increased risks of

Shoulder dystocia C/S

Assisted deliveries

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IUGR

Compromised uteroplacental insufficiency

02 available to the fetus is decreased

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RDS

Increased RDS due to high glucose levels

Delays pulmonary maturity

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Neonatal Hypoglycemia

Usually 30-60 minutes after birth

Due to high glucose levels duringpregnancy and rapid use of glucose afterbirth

Related to mothers level of glucose control

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Labs with DM

HBA1c

1 hour PP

FBS

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Diet

Sweet success diet

Well balanced diet

6 small meals / day Have snack at HS

Never skip meals

Avoid simple sugars

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Insulin

Regular/Lispro and NPH

2/3 dose in am and 1/3 dose in pm

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Monitoring Glucose Levels

FBS

1 hour PP

HS 5 checks / day

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Fetal Surveillance

NSTs done around 26 weeks, weekly

At 32 weeks done biweekly with NST/BPP

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Infections and DM

Infections are increased:

Candidiasis

UTIs

PP infections

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DM

Increased risk of IUFD after 36 weeks

Increased congenital anomalies

Cardiac defects

CNS defects

Spina bifida

anencephaly

Skeletal defects

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DM and labor

Continuous fetal monitoring

Blood glucose levels in tight control

Be prepared for CPD

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GDM

Women with GDM at risk of developingDM later on in life

NSTs around 28 weeks

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Hyperthyroidism

Typically caused by Graves disease

S/S:

Fatigue

Heat intolerance

Warm skin

Diaphoresis

Weight loss

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Should be treated in pregnancy

Tx with PTU

Beta blockers

May lead to thyroid storm if untreated

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Hypothyroidism

Usually caused by Hashimotos

S/S:

Weight gain

Cold intolerance

Fatigue

Hair loss

Constipation

Dry skin

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Cardiovascular Disorders

The heart must compensate for theincreased workload

If the cardiac changes are not welltolerated than cardiac failure can develop

1% of pregnancies are complicated byheart disease

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NY Heart Association Classes

Class I

Class II

Class III Class IV

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Cardiac output is increased

Peak of the increase 20-24 weeksgestation

Cardiac problems should be managed withcardiologist

Mortality with pulmonary hypertension andpregnancy is more than 50%

Diet: low sodium

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Nursing Care

Avoiding anemia

Avoid strenuous activity

Monitor for: cardiac failure and pulmonarycongestion

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During Labor

Side lying position

Prophylactic antibiotic

EpiduralAttempt vaginal delivery

If anticoagulant therapy is needed:

Heparin Lovenox

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MVP

Common and usually benign

May experience syncope, palpitations anddyspnea

Prophylactic antibiotics given beforeinvasive procedure or birth

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Anemia

Most common iron deficiency

Hgb falls below 12 (most labs)

Typically seen in the end of 2nd trimester

Iron supplementation

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Folic Acid Deficiency Anemia

Increases risk of NTD, cleft lip

Recommended dose 400 mcg/day

Supplemented in cereal and many otherfoods

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Sickle Cell Anemia

Abnormal hemoglobin SS types in theblood

People have recurrent attacks of fever and

pain in the abdomen and extremities

Caused from tissue hypoxia, edema

African-Americans

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Thalassemia

Common anemia

Insufficient amount of Hgb is produced tofill the RBCs

Mediterranean region

Genetic disorder

May be associated with LBW babies andincreased fetal death

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Asthma

Common with FH

1-4% of pregnant women have Asthma

Possible adverse events associated with

asthma: LBW

Perinatal mortality

Preeclampsia Complicated labor

Hyperemesis

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Asthma Continued

Goal is to relieve the attack, prevent theasthma attack, and maintain 02

Should be managed with OB and ENT

May require tx: albuterol, steroids, O2

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Epilepsy

Seizure disorder

May result from developmentalabnormalities or injury

20% have an increase in seizure activityduring pregnancy

Risks: more seizures, risk of vaginalbleeding, abruptio placentae, fetus mayexperience seizures

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Epilepsy Continued

Use of antiepeleptic meds duringpregnancy has been linked to risks for thefetus

Smallest therapeutic dose to be given

Daily folic acid supplementation

Managed with OB and neurologist

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RA

Chronic arthritis

Pain upon movement and swelling in jointspaces

More often in women

2/3 of women with RA find the severity ofsymptoms decrease during pregnancy

Typically give baby ASA

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SLE

Inflammatory disease, autoimmuneantibody production

Advised to wait until in remission for 6

months to become pregnant

15-60% of women will developexacerbation of SLE during pregnancy or

postpartum

Tx: ASA and steroids

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Cholelithiasis

More often in women

Pregnancy makes women more vulnerable

Surgery often delayed until after delivery

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Appendicitis

Dx may take more time to find

Sxs: abdominal pain, nausea, vomiting,loss of appetite

Increases incidence of PTL or SAB

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TORCH

Toxoplasmosis protozoan infection,neonatal effects jaundice,hydrocephalus, microcephaly

Other- Heb A or B, Group B, Varicella, HIV

Rubella (German measles) if contractedin 1st Trimester fetus may have congenital

deformities

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TORCH

CMV- transmitted person to person, maycause CNS damage to fetus

Herpes Simplex (HSV 2) if initial

infection occurs in pregnancy, higherincidence of perinatal loss. Fetus maypick up virus if present in the vagina

during labor

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Mental Health Disorders

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Anxiety Disorders

Most common mental disorders

Include: phobias, panic disorders, OCD,PTSD

Tx: relaxation techniques, breathingexercises, imagery

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Depression in Pregnancy

6% of women develop depression for the1st time during pregnancy

Tx: counseling and tx with SSRIs

Wellbutrin only med named as Category B

Many women opt to DC meds duringpregnancy

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Substance Abuse in

Pregnancy

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Smoking

Risks of any amount of smoking include:

SAB

SGA

Bleeding

IUFD

Prematurity

SIDS

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Alcohol

Many women reluctant to tell health careprovider

Risks:

LBW

Mental retardation

Learning and physical deficits

With FAS severe facial deformities

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Alcohol during Pregnancy

Risks to mother:

HTN

Anemia

Nutritional deficits

Pancreatitis

Cirrhosis

Alcoholic hepatitis

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Marijuana

Crosses the placenta and causes increasedcarbon monoxide levels in mothers blood

May cause fetal abnormalities

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Cocaine

In the US, 10-15% of all pregnant womenuse cocaine

Problems associated with use: polydrug

use, poor health, poor nutrition, STIs,infections, HIV

Poverty big issue

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Cocaine in Pregnancy

Maternal effects: Cardiovascular stress

Tachycardia

HTN Dysrhythmias

MI

Liver damage

Sz Pulmonary disease

Death

Fetal Complications:Abruptio placentae

PTL

Precipitous labor Risks for abdominal

pregnancy

Fetal complications

after delivery

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Opiates in Pregnancy

Drugs include: heroin, Demerol, morphine,codeine, methadone

Methadone is used to treat addiction to

other opiates Possible effects on pregnancy and heroin

use are: Preeclampsia, PROM, infections,PTL

Tx: Methadone and psychotherapy

Goal: prevent withdrawal symptoms

h h

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Methamphetamine

CNS stimulant

Most common use n the 18-30 yr oldrange

Neonatal complications include:

IUGR

PRL/PTB

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Postpartum Psychologic

Complications

B b Bl

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Baby Blues

Usually within 4 weeks of childbirth

Many experience this

PPD

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PPD

Intense sadness, crying all the time, moodswings, fears, anger, anxiety, irritability

Incidence of PPD at 8 weeks 12% and

8% at 12 weeks

Many women feel guilty

May need tx but usually resolves on own

P t t P h i

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Postpartum Psychosis

Delusions, hurting self or the infant,emotional lability, insomnia,suspiciousness, confusion, obsessive

concerns regarding the baby 1-2/1000 births

35-60% recurrence with each subsequentbirth

Usually symptoms appear within 8 weeksof birth

M di l M t

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Medical Management

Supportive family

Intense psychotherapy

Emergency

Tx: SSRIs

SSRIs contraindicated while breastfeeding

1 A client asks the nurse to again explain

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1. A client asks the nurse to again explainthe purpose of the amniocentesis test.

The nurse responds that one purpose ofthis test is to indicate the:

A. Accurate age of the fetus

B. Presence of certain congenital anomalies C. Biparietal diameter of the skull

D. Hormone content of the amniotic fluid

E. Mainly the presence of Downs syndrome

2. The nurse explains to a new mother

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that the condition of SGA is caused by:

A. Placental insufficiency

B. Maternal obesity

C. Primipara

D. Genetic predisposition

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4. The nurse in the newborn nursery

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4. The nurse in the newborn nurseryunderstands that assessing a newborn

with a diabetic mother, initially the insulinlevel would be:

A. Higher than in normal infants

B. Lower than in normal infants

C. The same as in normal infants

D. Varied from baby to baby

5. A client is admitted to L&D, at 38

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5. A client is admitted to L&D, at 38weeks gestation. She is there forevaluation because she is experiencingpolyhydramnios. The nurse understandsthat this diagnosis means that:A. There is the normal amount of amniotic

fluid, thinner in volume B. A less-than-normal amount of amniotic

fluid is present

C. An excessive amount of amniotic fluid is

present D. A leak is causing the fluid to accumulate

outside the amniotic sac