High Risk Pregnancy

NURSING CARE FOR WOMEN W/ COMPLICATIONS DURING PREGNANCY High-risk pregnancy -One in which the health of the mother/fetus is in Jeopardy -increased risk of morbidity/mortality before/after delivery -leading cause of death and disability among women (515,000 women/yr) -women: 30-endure injuries; infection and disabilities -early and consistent assessment for risk factors during prenatal visits Ways for identification clients at risks 1. Assessment of risk factors a. Physiological b. Psychological C. Social Risk Assessment Tool -Hobel, 1973 -risk factors are assigned a score corresponding to the degree of risk -A score 19 or more indicates a high risk that should receive more than routine prenatal care OB Hx Risk Factor • Previous still birth 10 • Previous neonatal death 10 • Previous premature infant 10 • Post term.42 weeks 10 • Fetal blood transfusion for hemolytic disease 10 • Repeated miscarriages 5 • Previous infant >10lbs 5 • Six/more completed pregnancy 5 • Hx of eclampsia 5 • Previous cesarean section 1 • Hx of preeclampsia 1 • Hx of preeclampsia 1 • Hx of fetus w/ anomalies 1/0 Medical Hx Risk factor • Abnormal PAP Test 10 • Chronic HPT 10 • Heart disease NYHA class II-IV (symptomatic) 10 • Insulin dependent diabetes (>A2) 10

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Moderate to severe renal disease Previous endocrine ablation 10 Sickle cell disease 5 Epilepsy 5 Heart disease NYHA class I (no symptoms) 5 Hx of TB/PPD >10mm 5 Positive serology (for syphilis) 5 Pulmonary disease 5 Thyroid disease 5

Family Hx • DM 1 Physical risk factors • Incompetence cervix 10 • Uterine malformalities 10 • Maternal weight <100lbs or >200 lbs 5 • Maternal age 35 and over 15 and under 5 • Small pelvis 5 Current pregnancy risk factors • Abnormal fetal position 10 • Moderate to severe preeclamsia 10 • Multiple pregnancy 10 • Placenta abruption 10 • polylydromnios/oligohydromnios 10 • excessive use of drugs/alcohol 5 • gestational diabetes (A1) 5 • kidney infection 5 • mild preeclampsia 5 • Rh sensitization only 5 • Severe anemia <9g/dl hemoglobin 5 • Severe flu syndrome/viral disease 5 • Vaginal spotting 5 • Bladder infection 1 • Emotional problem 1 • Mild anemia 9g/dl hemoglobin 1 • Moderate alcohol use 1 • Smoking > = 1 pack/day Fetal diagnostic tests -birth defects -diagnostic/screening test Diagnostic vs. screening Diagnostic – whether a fetus has a particular condition w/ certainty but may provide limited information about the other types of birth defects

Screening- not accurate, help to identify patient at risk who light benefit from diagnostic test Fetal well-being -fetus movements are directly r/t infant’s sleep-wake cycle vary from mother -typical active fetal period lasts 40 min and peaks between 9PM and 10 PM in response to maternal hypoglycemia Ultrasound -non-invasive procedure;uses intermittent ultrasonic waves transmitted by an alternating current to a transducer applied to abdomen -ultrasonic waves: defect off tissues w/in abdomen, showing structures of varying densities -requires full bladder (1-2 qts of water) Transvaginal Ultrasound -detect shortened cervical length/funelling (predict preterm labor) -uses a probe inserted into vagina -done early is pregnancy (fetal age, suspected etopic pregnancy) Transabdominal Ultrasound -transducer -often scanned with full bladder (water every 15 mins. 90mins before examination) Nursing Responsibility (UT2) -inform patient about the procedure -provide comfort and privacy *empty bladder (transvaginal UT2) -dorsal recumbent *full bladder (transabdominal UTV) -supine *position *drape Alpha-Fetoprotein Testing (AFP) -maternal alpha-fetoprotein test -determine level of fetal protein in women's serum/sample of amniotic fluid -16-22 weeks of pregnancy High levels of AFP -a neural tube defect spinabifidy (open supine) anecephaly (incomplete division of skull and brain) -defects with esophagus -gastroschisix (baby's failure)

Low levels of AFP -abnormal chromosomal or gestational trophoblastic disease -Trisomy 21 (Down syndrome) -Trisomy 18 (Edward's syndrome) Chorionic Villi Sampling (CVS) -obtain a small part of developing placenta to analyze fetal cells -10-12 weeks -results = 24-48 hours -can't determine spina bifida/anecephaly -identify chromosome (abnormal) -newborn: limb reduction defects -Rh (D) immune globulin given to Rhnegative woman -↑ rate spontaneous abortion than amniocentesis Amniocentesis -insertion of thin needle through abdominal and uterine walls (sample on amniotic fluid); invasive -15-17 weeks -early: 11-14 weeks of some disorder Usage (Amniocentesis) -identify chromosome abnormalities, biochemical disorders and level of AFP -spontaneous abortion -identify severity of maternal fetal blood incompatibility and assess fetal lung maturity -Rh (D) immune globulin given to Rhnegative woman Nursing Responsibilities (Amniocentesis) -obtain informed consent -provide comfort and privacy full bladder, position, drape -aseptic technique (hand wash, gloves) Non-stress Test (NST) -response of FHR to fetal movement -monitor FHR Usage of (NST) -identify fetal compromise (poor placenta function) -reassess placenta is functioning well and oxygenated, intact CNS *Non-reactive at risk = not good *1 fetal movement = +45FHR -30-32 weeks

*Reactive= 2 accelerations of FHR with fetal movements of 15 beats/min, lasting 15 sec or more for 20 min *2-15 beats-15sec-20min Contraction Test (CT) -evaluating respiratory function of placenta -identify risk for intrauterine asphyxia by observing response of FHR to stress contraction Negative- shows 3 contractions good quality lasting 40 or more secs in 10 min without evidence of late decelerations -fetus can handle the hypoxic stress of uterine contractions Positive – shows repetitive persistent late deceleration with more than 50% of contractions -hypoxic stress cause showing FHR Equivocal – non persistent late decelerations or with hyper stimulation (2 min frequency of duration longer than 90) Percutaneous Umbilical Blood Sampling (PUBS) -anemic fetus (maternal fetal blood incompatibility, placenta previa, abrupt placentae) -blood sample from placental vessel Lecithin to Sphingomyelin (l/S) ratio -respiratory complications in adapting extrauterine life 34-38 weeks -lung mature → ↑ lecithin ↓ Sphingomyelin -2:1 (normal value) Phosphatidyl glycerol (+) - baby will not suffer respiratory distress syndrome on delivery Biophysical Profile (BPP) 1. FHR and reactivity (NST) [reactive 2] 2. Fetal Breathing Movement [breathing/60sec – 2] 3. Fetal Body Movement [3 movements of arms, legs, body – 2] 4. Fetal Tone [ return of flexion – 2] 5. Volume of amniotic fluid [>1cm – 2]

-identify reduced fetal oxygenation in conditions associated with poor placental functioning -↑FHR → deprivation of oxygen -fetal hypoxia increases, FHR changes, cessation -amniotic fluid is reduced when placental function is poor of fbrem, gross body movement, loss of FT A-mniocentesis L-/S ratio O-xytocin Test N- on-stress Test E-steriol level PREGNANCY AT RISK:PREGESTAITIONAL PROBLEMS Sexually Transmitted Disease (STD) -15-24y/o -↑ STD group: Sexually active youth -Pregnant: miscarriage, premature delivery Risk factors: 1. lower socio-economic status 2. lower education level 3. sexual activity with multiple partners 4. unsafe sexual intercourse Etiologic Agent: Candida Albicaus (fungus) Candidiasis – thick yellow vaginal disharge − extreme pruritus (yeasty or no odor) Med management: 1. application of an over-the-counter anti-fungal cream (Monistat) for 7 days 2. oral flucanozole (anti fungal) Trichomoniasis – irritation, itching Etiologic agent: Trichomonas vagindlis Signs and symptoms – profuse greenishyellow discharge with foul odor Effects – preterm labor, premature rapture of membranes, post cesarean infection Med management: 1. metronidazole ( anti fungal) Nursing management: 1. Verbalize feelings Bacterial Vaginosis Etiologic agent – Gardenella Vaginalis Signs and symptoms – gray discharge, fishy odor/musty

-pruritus Effects: 1. pelvic inflammatory disease 2. posthysterectomy vaginal cuff cellulitis 3. endometritis 4. amniotic fluid infection 5. preterm delivery/labor 6. PROM 7. spontaneous abortion Med management: 1. topical – Metronidazole (Flagyl) 0.75% vaginal gel Clyndamycin 2% cream 2. Oral – Metronidazole 500% mg (2x) - Clyndamycin 300mg (2x) Chlamydia Etiologic agent – chlamydia vaginalis -ectopic pregnancy, preterm PROM, premature delivery -heavy gray-white discharge -cervicitis, urethritis, vaginalis, pelvic inflammatory disease (clinical manifestations) -60-70% risk → infected birth canal Effects – conjunctivitis, pneumonia Med management 1. tetracydin and deoxycycline 2. amoxicillin – pregnant 3. aztromycin (1g) -pregnant Syphilis Etiologic agent – treponema pallidum Signs and symptoms: • primary stage – small, hard-based sore • secondary stage – skin rashes, loss of patches of hair, malaise, fever • latent stage – asymptomatic • tertiary stage – gumma formation (rubbery mass of tissue) Effects: 1. spontaneous abortion 2. still born infant 3. premature labor 4. congenital syphilis (enlarged liver, spleen, skin lesions, rashes, pneumonia, hepa) Med management: 1. benzathine penicillinG (pregnant)

2. procaine penicillin, IM, 750mg for 10 days 3. erythromycin 500mg, 4x//day for 14 days (allergy to penG) 4. azithromycin 500mg, daily for 10 days (allergy to penG) Jarisch-Herxcheimer reaction -caused due to sudden destruction of spirochetes;last for 24 hours Signs and symptoms – fever, tachycardia, muscle aches Gonorrhea etiologic agent – neissoria gonorrhoeae Signs and symptoms – yellow-green vaginal discharge effects to fetus/pregnancy: 1. severe eye infection → blindness 2. endocervitis 3. PROM Med management 1. oral cefixime (Suprax) 400mg, once 2. ceftriaxone (rocephin) 125-250mg, IM, once Side effects: nausea, vomiting HIV/AIDS -4th leading cause of death among women 25-44 y/o -leading cause of death and disease world wide, main risk factor: unsafe sex Stages of HIV infection: 1. initial invasion – flulike symptoms 2. serocoversion- converts from having no HIV antibodies -happens 6weeks-1year after exposure 3. asymptomatic period -weight loss, fatigue (3-11yrs) 4. symptomatic period – oppurtunistic infection occur oral and vaginal candidiasis, Kaposi sarcoma... Dx procedure: a. ELISA(screening test) enzyme-linked immunoabsorbent assay antibody detection test b. western blot analysis – confirmatory test Dx:risk for infection r/t dysfunction immune system Nursing management:

1. aseptic technique 2. administration of med as prescribed 3. provide health care education on: -breastfeeding -protected sexual activity Nursing management for STD 1. assessment Hx taking (multiply partners, unprotected sex) 2. Dx = knowledge deficit 3. intervention: -discuss causes of STD:multiply partners -teach about proper hygiene:perineal and hand washing -sensitivity, confidentiality -counseling before and after testing allay fears -provide accurate information -provide referral to needed medical and psychological services Cardiovascular Diseases -total blood volume: at least 30% -iron requirement: 800mg -cardiac output by 25%-50%, increase heart rate NYHA Class I – no discomfort (dyspnea, palpitation, anginal pain) on ordinary act Class II – discomfort on ordinary act Class III- discomfort on less than ordinary act Class IV- dyspnea at rest. Patient is decompensated

-ascites (leak of fluid to peritoneal act) -peripheral edema Effect to fetus: 1. low birth weight 2. abortion 3. intrauterine growth retardation 4. still birth 5. premature labor Med management: 1. Digoxin – to slow ventricular response and to increase myocardial contractility 2. diuretics -for acute and chronic heart failure 3. beta-adrenergic blockers (propandol) – arrhythmia associated with ischemic heart disease 4. amonophylline – relives bronchospasm 5. heparin- with artificial valves or artrial fibrillation Surgical management: 1. therapeutic abortion -Class II and IV 2. cardiac surgery – alternative to the therapeutic abortion -closed cardiac surgery is preferred Nursing management: 1. monitor fetal well being (9PM-10AM) 2. promote rest 3. promote healthy nutrition – low sodium diet 4. instruct about avoiding infection

Effects to mother: Left-sided H.F. -edema -Prod cough of blood-speckled sputum -orthopnea -increase RR -fatigue -dizziness -weakness -paroxysmal nocturnal dyspnea

Right-sided H.F. -jugular vein distension -hepatomegaly -extreme dyspnea -pain

-there you go. Aralin niyo yan! :)) ©BSN-2H notes