High Risk PregnancyHigh Risk Pregnancy

A pregnancy with increased risk of a A pregnancy with increased risk of a poor outcome for mother and/or baby poor outcome for mother and/or baby

because of social, demographic, because of social, demographic, medical, or obstetric risk factors in the medical, or obstetric risk factors in the

mother.mother.

Pregnancy at RiskPregnancy at Risk

Pre-Gestational Problems Pre-Gestational Problems

Risk FactorsRisk Factors

• Age: Age: adolescence or >35adolescence or >35

• Blood type: Blood type: Rh negative / ABO incompatibilityRh negative / ABO incompatibility

• Socioeconomic statusSocioeconomic status• Psychologic well being:Psychologic well being:

addicted/abused/compromised ability to think or use coping addicted/abused/compromised ability to think or use coping mechanismsmechanisms

• Parity and previous pregnancy historyParity and previous pregnancy history

• Pre-existing medical disordersPre-existing medical disorders

Adolescent Pregnancy RisksAdolescent Pregnancy Risks

• Preterm birthPreterm birth

• Low-birth weightLow-birth weight

• CPDCPD

• Poor nutritionPoor nutrition

• Poor prenatal carePoor prenatal care

• PIH and pre-eclampsiaPIH and pre-eclampsia

• STD’sSTD’s

• Cigarette and drug Cigarette and drug useuse

• Interruption of Interruption of developmental taskdevelopmental task

• Prolonged dependence Prolonged dependence on govt.on govt.

• Dec. chance for stable Dec. chance for stable relationshiprelationship

• Higher rates of abuse Higher rates of abuse or neglector neglect

• Higher rates of Higher rates of behavioral problems in behavioral problems in childrenchildren

Advanced Maternal Age Advanced Maternal Age RisksRisks

• Higher incidence of congenital Higher incidence of congenital anomaliesanomalies

• Increased possibility of complicationsIncreased possibility of complications

• Increased incidence of preexisting Increased incidence of preexisting medical conditionsmedical conditions

Preexisting Medical Conditions Preexisting Medical Conditions Which Affect PregnancyWhich Affect Pregnancy

• Substance AbuseSubstance Abuse

• Diabetes MellitusDiabetes Mellitus

• AnemiaAnemia

• Cardiac DisordersCardiac Disorders

• Chronic HypertensionChronic Hypertension

• InfectionsInfections

• MiscellaneousMiscellaneous

Substance AbuseSubstance Abuse

• Includes legal and illegal substancesIncludes legal and illegal substances

• Legal implications involvedLegal implications involved

• Impairment of mother-infant bondingImpairment of mother-infant bonding

AlcoholAlcohol

• Almost 19% of pregnant women Almost 19% of pregnant women consume alcoholconsume alcohol

• Fetal alcohol syndrome-Fetal alcohol syndrome-IUGR, CNS IUGR, CNS impairment, facial features, SGA, developmental impairment, facial features, SGA, developmental delaysdelays

• WithdrawalWithdrawal• Fetal hypoxia and dec. fetal nutrient Fetal hypoxia and dec. fetal nutrient

absorptionabsorption• Breastfeeding not contraindicatedBreastfeeding not contraindicated

CocaineCocaine

• Approx. 1 in 10 pregnant women are Approx. 1 in 10 pregnant women are believed to use cocainebelieved to use cocaine

• Uterine contractionsUterine contractions• Placental abruptionPlacental abruption• Preterm labor and deliveryPreterm labor and delivery• Spontaneous AB and stillbirthSpontaneous AB and stillbirth• IUGRIUGR• Infant tremors, tachycardia, HTNInfant tremors, tachycardia, HTN• Poor feedersPoor feeders• Breastfeeding contraindicatedBreastfeeding contraindicated

MarijuanaMarijuana

• Little researchLittle research

• No strong evidence of teratogenic No strong evidence of teratogenic effects to fetuseffects to fetus

• Difficult to evaluateDifficult to evaluate

Heroin and MethadoneHeroin and Methadone

• HeroinHeroin1.1. Poor nutritionPoor nutrition

2.2. Anemia Anemia

3.3. Pre-eclampsiaPre-eclampsia

4.4. STD’sSTD’s

5.5. IUGRIUGR

6.6. Meconium aspiration Meconium aspiration and hypoxiaand hypoxia

7.7. Overdose and Overdose and withdrawalwithdrawal

• MethadoneMethadone1.1. Used for tx of opioid Used for tx of opioid

addictionaddiction

2.2. Pre-eclampsiaPre-eclampsia

3.3. Placental problemsPlacental problems

4.4. Abnormal fetal Abnormal fetal presentationpresentation

5.5. SGASGA

6.6. Withdrawal for Withdrawal for newbornnewborn

7.7. Benefits vs. risksBenefits vs. risks

NicotineNicotine

• Increased incidence of preeclampsiaIncreased incidence of preeclampsia

• Low birth weightLow birth weight

• Polycythemia of the newbornPolycythemia of the newborn

• Increased risk for SIDSIncreased risk for SIDS

AssessmentAssessment

• OngoingOngoing

• Weight gainWeight gain

• Nutrition Nutrition

• Fetal monitoringFetal monitoring

• Screening for STD’sScreening for STD’s

• Maternal-infant bondingMaternal-infant bonding

Teaching and Nursing Teaching and Nursing ImplicationsImplications

• Preparation for withdrawalPreparation for withdrawal

• Prepare environmentPrepare environment

• Treat familyTreat family

• Prepare for “addicted” babyPrepare for “addicted” baby

• Nonjudgmental approachNonjudgmental approach

• Pain medsPain meds

Diabetes MellitusDiabetes Mellitus

• Inadequate production or utilization Inadequate production or utilization of insulinof insulin

• System of checks and balancesSystem of checks and balances

• Usually diagnosed between 24-30 Usually diagnosed between 24-30 weeksweeks

• If abnormal 1 hour glucose, then 3 If abnormal 1 hour glucose, then 3 hour glucose is donehour glucose is done

Maternal EffectsMaternal Effects

• EarlyEarly1.1. Hormones stimulate insulin production and glycogen storageHormones stimulate insulin production and glycogen storage

• LateLate1.1. Increased resistance to insulin and diminished effectivenessIncreased resistance to insulin and diminished effectiveness

• Requirements change with pregnancyRequirements change with pregnancy

• Poor wound healingPoor wound healing

• PIH and preeclampsia more commonPIH and preeclampsia more common

• KetoacidosisKetoacidosis

Fetal EffectsFetal Effects

• Hydramnios Hydramnios

• Increased risk for infectionIncreased risk for infection

• RDS five times more common in full term RDS five times more common in full term neonatesneonates

• Macrosomia or IUGRMacrosomia or IUGR

• Shoulder dystociaShoulder dystocia

• HyperbilirubinemiaHyperbilirubinemia

• Increased incidence of congenital Increased incidence of congenital anomaliesanomalies

• HypoglycemiaHypoglycemia

AssessmentAssessment

• Treatment should begin 3-6 months Treatment should begin 3-6 months before pregnancybefore pregnancy

• Strict control of plasma glucose levels Strict control of plasma glucose levels (Glycosylated HgB)(Glycosylated HgB)

• VasculopathyVasculopathy

• NeuropathyNeuropathy

• Nephropathy Nephropathy

• Retinopathy Retinopathy

Teaching and TreatmentsTeaching and Treatments

• Referrals when necessaryReferrals when necessary

• Activity and exerciseActivity and exercise

• CBG monitoringCBG monitoring

• Dietary control/snacksDietary control/snacks

• Insulin therapyInsulin therapy

• Vaginal delivery usually OKVaginal delivery usually OK

• Breast feeding encouragedBreast feeding encouraged

AnemiaAnemia

• HgB less than 10 g/dLHgB less than 10 g/dL• Risk factorsRisk factors

1.1. Previous close pregnanciesPrevious close pregnancies2.2. Twin gestation, excessive vaginal bleedingTwin gestation, excessive vaginal bleeding3.3. Hx of poor nutritional statusHx of poor nutritional status

• Increased risk for spontaneous AB, Increased risk for spontaneous AB, premature birth, SGApremature birth, SGA

• Limits OLimits O22 available for fetal exchange available for fetal exchange• Fatigue Fatigue • Exercise intoleranceExercise intolerance

Types and TreatmentsTypes and Treatments

• Fe DeficiencyFe Deficiency

• Folic Acid DeficiencyFolic Acid Deficiency

• Sickle Cell AnemiaSickle Cell Anemia

Teaching and Nursing Teaching and Nursing ImplicationsImplications

• MedicationsMedications

• FoodsFoods

• MonitoringMonitoring

• ReassuranceReassurance

HIV/AIDSHIV/AIDS

• Pregnancy is not believed to accelerate Pregnancy is not believed to accelerate the progression of the diseasethe progression of the disease

• Transmission to fetus occurs via the Transmission to fetus occurs via the placenta at birth and through breast milkplacenta at birth and through breast milk

• Risk of transmission is about 25%, but Risk of transmission is about 25%, but significantly lower when the mother significantly lower when the mother receives ZDV, and even lower with receives ZDV, and even lower with scheduled Cesareanscheduled Cesarean

Teaching and Nursing Teaching and Nursing ImplicationsImplications

• Nutrition and rest are vitalNutrition and rest are vital

• Meticulous skin care Meticulous skin care

• Breastfeeding contraindicatedBreastfeeding contraindicated

• Legal aspectsLegal aspects

• Med administrationMed administration

• Support Support

• Nonjudgmental careNonjudgmental care

TORCHTORCH

• ToxyplasmosisToxyplasmosis

• Other Other

• RubellaRubella

• CytomegalovirusCytomegalovirus

• Herpes genitalisHerpes genitalis

Heart DiseaseHeart Disease

• Rheumatic heart disease-scarring Rheumatic heart disease-scarring and stenosisand stenosis

• Congenital heart disease-seeing Congenital heart disease-seeing more with technologymore with technology

• Mitral valve prolapse-usually benignMitral valve prolapse-usually benign

• Coronary artery disease (CAD)-Coronary artery disease (CAD)-increasing with late childbearingincreasing with late childbearing

Normal Cardiac ChangesNormal Cardiac Changes

• C.O.C.O.

• Plasma volumePlasma volume

• Rise in SVRise in SV

• Vascular ResistanceVascular Resistance

• Expanding Blood VolumeExpanding Blood Volume

• Lower Extremity EdemaLower Extremity Edema

Signs and Symptoms of CHFSigns and Symptoms of CHF

• Cough Cough

• Progressive dyspnea with exertionProgressive dyspnea with exertion

• Dyspnea Dyspnea

• Pitting or generalized edemaPitting or generalized edema

• Palpitations Palpitations

• Progressive fatigue or syncope with Progressive fatigue or syncope with exertionexertion

Intrapartal TherapyIntrapartal Therapy

• Dependent on class levelDependent on class level

• Antibiotics Antibiotics

• Look at benefits vs. risksLook at benefits vs. risks

• May deliver vaginally if Class I or IIMay deliver vaginally if Class I or II

• Epidural recommendedEpidural recommended

• Close monitoring of stress of laborClose monitoring of stress of labor

• Possible use of low forcepsPossible use of low forceps

NutritionNutrition

• Protein and FeProtein and Fe

• NASNAS

• Limit caffeineLimit caffeine

• Limit Vitamin K if on HeparinLimit Vitamin K if on Heparin

• Avoid excessive weight gainAvoid excessive weight gain

Other Medical ConditionsOther Medical Conditions

• Rheumatoid Rheumatoid arthritisarthritis

• Epilepsy Epilepsy

• Hepatitis BHepatitis B

• Hyperthyroidism/ Hyperthyroidism/ HypothyroidismHypothyroidism

• Mental retardationMental retardation

• Maternal PKUMaternal PKU

• Multiple sclerosisMultiple sclerosis

• LupusLupus

• TBTB

Rh SensitizaionRh Sensitizaion

• Occurs when Rh negative mom carries an Occurs when Rh negative mom carries an Rh positive fetusRh positive fetus

• Does not affect 1Does not affect 1stst pregnancy, but affects pregnancy, but affects fetus of subsequent onesfetus of subsequent ones

• Can be avoided by Rh negative mom Can be avoided by Rh negative mom receiving RhoGAM at 28 weeks gestation, receiving RhoGAM at 28 weeks gestation, in event of bleeding episode or trauma in event of bleeding episode or trauma during pregnancy, and within 72 hours during pregnancy, and within 72 hours after pregnancyafter pregnancy

Indirect Coombs’Indirect Coombs’

• Measures # of antibodies in maternal Measures # of antibodies in maternal blood against RBC’s in the serumblood against RBC’s in the serum

• Screening portion of type and screenScreening portion of type and screen

• Neative titers/negative Coombs’—Neative titers/negative Coombs’—fetus without riskfetus without risk

• Type and screen should be done at Type and screen should be done at beginning of pregnancy and upon beginning of pregnancy and upon entering the hospitalentering the hospital

Implications for Rh IncompatibilityImplications for Rh Incompatibility

• Teach mom implications for future Teach mom implications for future pregnanciespregnancies

• During pregnancies:During pregnancies:1.1. Percutaneous umbilical samplePercutaneous umbilical sample

2.2. If baby Hct below 25% may give intrauterine blood If baby Hct below 25% may give intrauterine blood transfusiontransfusion

3.3. If fetus is severely sensitized may require birth at 32-If fetus is severely sensitized may require birth at 32-34 weeks34 weeks

May result in hydrops fetalisMay result in hydrops fetalis

Other Gestational RisksOther Gestational Risks

• Pregnant woman Pregnant woman requiring surgeryrequiring surgery

• TraumaTrauma

• Battered WomanBattered Woman

• Perinatal InfectionPerinatal Infection

• ToxoplasmosisToxoplasmosis

• RubellaRubella

• CytomegalovirusCytomegalovirus

• Herpes Simplex Herpes Simplex VirusVirus

Group B StrepGroup B Strep

• Bacteria that lives in vagina of some Bacteria that lives in vagina of some womenwomen

• Screening done at 34-36 weeksScreening done at 34-36 weeks

• If positive, intrapartum antibiotics If positive, intrapartum antibiotics are indicatedare indicated

• No risk to mother, risk for invasive No risk to mother, risk for invasive group B strep to new borngroup B strep to new born