HIGH RISK PREGNANCY
1
Adolescent Pregnancy:
Contributing Factors
Peer pressure
Self-esteem
Lack of role models
Gain attention
Media
Poverty
Rite of passage
2
Implications of Adolescent Pregnancy
Socioeconomic:
•reliance on welfare Fetal Health:
•cycle repeats itself •LBW
Maternal health: •prematurity
•CPD •resp complications
•PIH •cp
•anemia •cognitive deficits
•nut deficits •death
mortality 3
Adolescent Pregnancy: Assessment
Risks
fundal height
# of sexual partners
knowledge of infant care/needs
family unit/support system
baseline VS/weight
4
IMPLICATIONS OF DELAYED PREGNANCY
Pre-existing conditions
Preterm labor SGA/LBW
IUGR
PIH Abruption
C-section
Uterine fibroids PP hemorrhage
Chromosomal abnormalities
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DELAYED PREGNANCY:
ASSESSMENT
Pre-existing conditions
Fundal height
Anxiety
Psychosocial issues
(career vs baby)
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TYPES OF SPONTANEOUS ABORTIONS
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Spontaneous Abortion Management
Threatened Notify MD/MW
Check fetus by U/S
Bedrest, no sexual activity
for 2 weeks after bleeding stops
No false reassurance
Check by U/S for complete vs.
Inevitable incomplete
Analgesics for D&C
RhoGAM
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Spontaneous Ab Mgmt, cont.
Incomplete Hospitalization
Before 14 wks – D&C + IV
Pitocin
After 14 wks – Pitocin or
Prostaglandins
Wait 3 to 5 wks for spont Ab
Missed
(93%)
Monitor for DIC
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Post Abortion Education
Bldg, cramping X 1-2 wks
vaginal rest X 1 wk
temp BID
f/u in 2 wks
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SITES OF ECTOPIC PREGNANCY
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S & S Ectopic Pregnancy
Missed Period
Abdominal Pain
Vaginal Spotting
Rupture Severe lower abd pain
↓ hCG levels
No gestational sac on U/S
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Surgical Management of
Ectopic Pregnancy
Med Mgmt of Ectopic PG MTX
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S & S Hydatiform Mole
Vaginal bleeding
anemia
uterus size,
cramps
No FHT’s
N/V
Early PIH
Therap. Mgmt: vacuum aspiration & curettage
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Spontaneous Abortion Matching –
Choose all that apply.
1. Initial symptom is vaginal
1.
bleeding
A. Threatened abortion
2. 2. Membranes rupture and B. Inevitable abortion
cervix dilates
3. 3. Some, not all, products of C. Incomplete abortion
conception are expelled.
4. 4. Treatment includes D&C D. Complete abortion
5. All products of conception
5.
passed E. Missed abortion
6. 6. All unsensitized Rh neg
women should receive
RhoGAM
7. 7. May be treated with
bedrest
8. 8. Retained dead fetus
9. 9. May be complicated by DIC
10. 10. Pregnancy may continue
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Medical Mgmt of Placenta Previa
Mom stable, Fetus > 36 wks S&S hypovol
in mom
fetus immature
•Bedrest •Amnio to •delivery
•no sex act lung maturity
•report bldg delivery
•
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S&S Abruptio Placentae
Vag bldg
•
(unless concealed)
abd pain
•
U-act
hemorrhage
•
boardlike
•
abd
•late decels
•s&s shock
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Med Mgmt of Placental Abruption
Mom stable,
bleeding,
fetus immature
fetal distress
bedrest
tocolytics Emergency CS
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DIC
Placental Bleeding
Thromboplastin release
Clot formation (systemic response)
clotting factors (fibrinogen, plts, PTT, FDP)
inability to form clots
profuse bleeding 19
Hemorrhagic Conditions:
Abruption & DIC
ASSESSMENT
•Bleeding
• Pain
• VS/FHR
• U-Activity
• OB Hx
• Fundal Ht
• Lab Data (H/H, coags)
• Emotional response
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The Pathological Processes of Pre-eclampsia
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S&S Pre-eclampsia
Rapid wt gain
edema of hands & face
proteinuria
hyperreflexic DTR’s
H/A, visual disturbances
epigastric pain
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Treatment of Pre-eclampsia
Mild: diastolic < Severe: diastolic > 110,
100, trace to 1+ 3+ proteinuria, U/O,
proteinuria, no H/A H/A, visual disturbances
Bedrest Bedrest, stimuli
protein diet Meds
document fetal Apresoline for severe
activity HTN
MgSO4 (anticonvulsant &
weekly NST antihypertensive)
Delivery
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S&S Eclampsia/HELLP Syndrome
Eclampsia HELLP Syndrome
facial twitching RUQ pain
tonic-clonic sz n/v
pulmonary edema edema
circ/renal failure H/H, plts
liver enzymes
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Treatment of Eclampsia/HELLP Syndrome
Bedrest
Meds
MgSO4
Valium or Phenobarb (if Mg not effective, not
within 2 hr of delivery)
Hydralazine (for severe ↑ B/P)
steroids to fetal lung maturity
Delivery
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Assessment: Hypertensive
Disorders of Pregnancy
Prenatal:
wt, B/P, U/A, H/A, visual disturbances
Hospitalized Ct:
daily wt
hourly u/o, dipstick urine Q4H
VS, FHR
LOC, DTR’s, H/A
clonus
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Risk Control Strategies for
Hypertensive Disorders of Pregnancy
Sz precautions
monitor for s/s Mg toxicity(RR<12, absent
DTR’s, sweating, flushing, confusion, B/P)
Ca gluconate @ BS
Mg levels
IV MgSO4 (should be “Y” connected to
another primary bag)
D/C MgSO4 for RR < 12 or absent DTR’s
renal function (30 mL/hr)
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Incompetent Cervix
S&S
•advanced cervical dilation
•low abd pressure
•bloody show
•urinary frequency
Treatment
•cerclage
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Premature Labor/Rupture of Membranes
S&S Treatment
contractions Tocolytics
cramps IV hydration
backache bedrest
diarrhea steroids, if needed
vag d/c abx, if needed
ROM
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Nursing Care for PTL/PROM
Assessment Teaching
Thorough hx Infection Control
bleeding FMC
ROM
BPP (for PROM)
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Postterm Pregnancy
S&S Treatment
Wt loss
uterine size
fetal surveillance
Meconium in AF NST, CST, BPP Q wk
mom monitors mvmt
Risks Induction
fetal mortality Pitocin (10-20U/L) @
cord compression 1-2 mU/min every 20-
mec asp 60 min
LGA shoulder dystocia
CS
episiotomy/laceration
depression
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Disorders of Amniotic Fluid
Polyhydramnios Oligohydramnios
S&S Risks
uterine dist cord compression
dyspnea musculoskeletal
edema of lower extr deformities
Treatment
pulmonary hypoplasia
therapeutic
Treatment
amniocentesis amnioinfusion
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Risks of Multifetal Gestation
PIH
GDM
PPH
Anemia
UTI
PTL
Placenta previa
CS
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(Fetal) S&S Rh Incompatibility
Hyperbilirubinemia
jaundice
Kernicterus (severe neuro d.o. r/t bili)
anemia
hepatosplenomegaly
Hydrops fetalis
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Sequence of Assessments for Rh Sensitization
Blood Test for Type & Rh Factor
Rh-positive
Rh-negative
No further testing
Indirect Coombs
- +
Repeat frequently Titer increasing
Give
RhoGAM Titer not increasing
amniocentesis ( bilirubin)
Elevated
continue to monitor No change
retest, U/S
retest prn
intrauterine transfusion or
early delivery 35
Management of Rh Incompatibility
Prenatal
•per algorithm
Prevention Postpartum
RhoGAM at 28 weeks direct Coomb’s
(unsensitized women RhoGAM to mom if
only) baby is Rh+ (within
72 hrs of birth)
36
Hyperemesis Gravidarum
S&S Treatment
U/O IVF, TPN
wt loss antiemetics
ketonuria advance diet as tol
dry muc membranes
poor skin turgor
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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 38
Effects of Pre-Existing DM
Maternal Fetal
risk of: risk of:
PIH NTD’s
Cystitis Cardiac defects
DKA Macrosomia or
Spont Ab IUGR
Polycythemia
hyperbilirubinemia
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Treatment of Pre-existing DM
Team approach
Monitor glycosylated Hgb A
Diet: 50% carb, 20% prot, 30% fat
Insulin TID
Hourly glucoses during labor
NST’s weekly (starting at 28-30 wks)
Amnio ( lung maturity)
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Effects of Gestational Diabetes
Maternal Effects Fetal Effects
hydramnios macrosomia
PROM/preterm labor hypoglycemia at
shoulder dystocia birth
epis/lac RDS
41
Treatment of Gestational
Diabetes
30 to 35 cal/kg/day (3 meals, 2 snacks)
Insulin
FBS, post-prandial BS’ Q week
NST, BPP Q week
glycosylated Hgb A
Amnio ( lung maturity)
42
Diabetes: Patient Education
Glucose monitoring
insulin administration
type, onset, peak, duration, times, sites, injection
technique
diet
s/s hypoglycemia
tremors, pallor, cold/clammy skin
give milk & crackers or glucagon inj
s/s hyperglycemia
fatigue, flushed skin, thirst, dry mouth,
check glu, call MD for insulin order
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PPCM: Manifestations
dyspnea
edema, wt gain
chest pain
palpitations
jug vein distention
enlarged heart
spont ab,
44
PPCM: Energy Management
Epidural
Activity restriction
Minimize anxiety
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AIDS
Maternal Effects Fetal Effects
vag candidiasis
Asymptomatic at birth
PID
Candidal diaper rash
genital herpes
thrush
HPV
diarrhea
PCP
recurrent bacterial
infections
FTT
dev delay
Treatment:
ZDV (zidovudine) during PG, L&D
ZDV to neonate for 6 wks
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Which of the following socioeconomic factors
contributes to the high incidence of
adolescent pregnancy in the US?
A. lack of adequate birth control
B. poverty
C. lack of information on safe sex
D. availability of public assistance for
unmarried mothers
47
Which genetic screening test for
chromosomal abnormalities provides an
older expectant couple with information
within the first trimester?
A. Chorionic villus sampling (CVS)
B. Amniocentesis
C. Genetic karyotyping
D. Ultrasonography
48
When caring for a woman with mild
preeclampsia, the nurse would be concerned
with which finding?
a. +4 proteinuria
b. +2 dependent edema in ankles
c. Blood pressure 156/100
d. +2 DTR’s, absent clonus
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The nurse is preparing to infuse
magnesium sulfate to treat preeclampsia.
In implementing this order the nurse
understands the need to:
a. Prepare a solution of 20 g MgSO4 in
100cc D5W
b. Monitor maternal VS, FHR and uterine
contractions every hour
c. Expect the maintenance dose to be
approximately 4g/hr
d. Discontinue the infusion and report a
respiratory rate of < 12 breaths/minute
50
The primary expected outcome for care
associated with the administration of
MgSO4 would be met if the woman:
a. Exhibits a decrease in both systolic and
diastolic blood pressure
b. Experiences no seizures
c. States that she feels more relaxed and
calm
d. Urinates more frequently, resulting in a
decrease in pathologic edema
51
A primigravida at 10 weeks gestation reports
slight vaginal spotting without passage of tissue
and mild uterine cramping. When examined, no
cervical dilation is noted. The nurse caring for this
woman should:
a. Anticipate that the woman will be sent
home and placed on bedrest with
instructions to avoid stress or orgasm
b. Prepare the woman for a dilatation and
curettage
c. Notify a grief counselor to assist the
woman with the imminent loss of her
fetus
d. Tell the woman that the doctor most
likely will perform a cerclage to help
maintain the pregnancy 52
CASE STUDY I
A G3P2 woman, at 38 wks gestation, arrives at
the obstetric unit with c/o painless vaginal
bleeding.
1. What is the nursing priority at this time?
2. What assessments are necessary?
3. What is the most likely etiology of the
bleeding?
4. What is the expected treatment for
Anne?
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CASE STUDY II
A G1P0 woman, at 35 wks gestation, is
visiting the midwife for a routine prenatal
visit. On assessment, the nurse finds that
she has gained 8 lbs in the past month.
1. What is the significance (if any) of this
weight gain?
2. What other assessments should the
nurse make at this time?
3. What is the required treatment for
this client?
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CASE STUDY III
A 22 y.o. G1P0 who has a history of IDDM X 6 yrs and whose LMP
was 12 wks ago arrives at the prenatal clinic.
1. How will this client’s diabetes be affected by her
pregnancy?
2. What changes will she most likely have to make to adjust
to her pregnancy?
3. What routine assessments will be made at each prenatal
visit?
4. What tests will be required as the pregnancy
progresses?
5. What fetal effects occur with pre-existing diabetes?
6. How will L&D be altered by pre-existing diabetes?
7. What possible newborn complications could occur with
pre-existing diabetes?
8. What nursing care will the infant require?
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MATH PROBLEM
For induction, Pitocin is ordered – 10
Units in 500 mL to start at 2 mU/min
and increase by 1 mU/min every 20
minutes until effective contractions are
achieved.
At what rate will the nurse start the IV?
By how much will the rate be increased
every 20 minutes?
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THE END
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