Transcript HIGH RISK OBSTETRICS - Alabama Community College System

HIGH RISK
OBSTETRICS
NUR 202
Mary Starkey Wallace
High Risk Obstetrics
A pregnancy in which the life or health
of the mother or fetus is jeopardized
by a disorder coincidental with or
unique to pregnancy
High Risk Obstetrics

High Risk status for the mother
extends through the puerperium
(6 weeks after childbirth)
High Risk Obstetrics
Postbirth maternal complications
are usually resolved within one
month of birth, but…….
 Perinatal morbidity may continue for
months or years

High Risk Obstetrics

Advances in management of
disorders that affect pregnant women
have resulted in a significant
decrease in maternal mortality and
morbidity rates
High Risk Obstetrics


In the United States maternal mortality
and morbidity rates remained the same
for several years
In 1980-1998 the rate remained at
7- 8 per 100,000 pregnancies
High Risk Obstetrics (cont)
In 2000 rate increased to 9.8 but
 Increase attributed to change in
reporting rather than an actual
increase

High Risk Obstetrics
Poses a problem for modern medical
and nursing care
 Emphasis on quality of life and
wanted child
 Reduced family size and number of
unwanted pregnancies

High Risk Obstetrics
Today emphasis on safe birth of
normal infants who can reach their
potential
 Birth of a neonate who does not meet
cultural, societal, or family norms
and expectations many times results
from high risk pregnancy

High Risk Obstetrics
Three leading causes of maternal
mortality have remained unchanged
over last 50 years
 They are
1) pregnancy induced hypertension
2) pulmonary embolism
3) hemorrhage

High Risk Obstetrics

Factors strongly related to maternal death
-age (younger than 20 and 35 or
older)
- lack of prenatal care
-low educational attainment
-unmarried status
-nonwhite race
High Risk Obstetrics

Ongoing research needed to identify
extent that
-financial
-sociocultural
-behavioral
-educational
factors affect perinatal morbidity and
mortality
Induction of Labor

Considered when ending the
pregnancy
-benefits woman or fetus
-when labor and vaginal birth
considered safe
Contraindications to Induction

Any Contraindications to labor and
vaginal birth such as
-placenta previa (hemorrhage
during labor)
-vasa previa (umbilical cord
vessels branch over amniotic sac
rather than inserting into placenta;
fetal hemorrhage possibility
Contraindications to Induction
(cont)
-transverse fetal lie
-umbilical cord prolapse
(immediate delivery by cesarean
indicated)
-classic uterine incision
-extensive surgery for fibroids
Induction of Labor

Prior to induction assessment must
indicate
-fetal maturity
-cervical readiness
Induction of Labor

Fetal maturity best determined by
-early ultrasounds
-accurate menstrual dating
-amniotic fluid studies
(L S Ratio 2:1)
Induction of Labor
Cervical Readiness best evaluated by
cervical exam
 Bishop scoring system evaluates
cervical readiness for labor

Bishop Scoring
System
 Uses 5 factors to estimate cervical
readiness for labor
-dilation
-effacement
-fetal station
-cervical consistency
-cervical position
Bishop Scoring
System (cont)




Each factor is assigned a score of 0, 1, 2, or 3
according to specific criteria for each score
The numbers are then totaled for the composite
score
Multipara usually has successful induction
when score is 5 or higher
Primipara usually has successful induction if
score is 7 or higher
Bishop System of Cervical Scoring
Assessment score Dilation
Effacement Fetal
Consistency Position
Position
(cm)
0
1
2
3
0
1-2
3-4
5-6
(%)
station
0-30
40-50
60-70
≥80%
-3
-2
-1
+1,+2,
Firm
Poster
Medium Mid
Soft
Anter
---
Bishop System of Cervical Scoring


NOTE: Add the score for each of the clinical
assessments
If the total score is greater than 8, the success
of induction approaches that of spontaneous
labor.
Cervical Ripening


Cervix has to be ripe or soft prior to
induction to make it likely to dilate
with forces of labor
Cervical ripening is done most
frequently the day before the morning
of induction
Cervical Ripening
(cont)
• Consists of effacement and softening of the
cervix
• May be used at or near term to enhance
success of and reduce time needed for labor
induction when continuing pregnancy is
undesirable
• May hasten beginning of labor or shorten
course of labor
Cervical Ripening
(cont)

Prostaglandlin should be used cautiously
in the presence of the following
-asthma
-glaucoma
-ischemic heart disease
-pulmonary disease
-hepatic disease
-renal disease
Absolute Contraindications to
Cervical Ripening





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
Placenta or vasa previa
Transverse fetal lie
Prolapsed umbilical cord
Prior classic uterine incision or myomectomy that
entered the uterine cavity
Pelvic structural abnormality
Active genital herpes infection
Invasive cervical cancer
Relative Contraindications to
Cervical Ripening

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Abnormal fetal heart rate patterns
Breech presentation
Maternal heart disease
Multifetal pregnancy
Polyhydramnios
Presenting part above the pelvic inlet
Severe maternal hypertension
Cervical Ripening
(cont)

Prostaglandin Agents used for
cervical ripening…
-dinoprostone (Prepidil, Cervidil)
-misoprostol (Cytotec)
Cervical Ripening
(cont)


Dinoprostone (such as Cervidil or Prepidil
Gel) can be inserted as a suppository into the
vagina (intravaginally).
It can also be given as a gel that is gently
squirted into the opening of the cervix
(intracervically
Cervical Ripening
(cont)



Dinoprostone should be administered with the
patient in or near a labor and delivery suite
The patient is expected to remain recumbent
for the first 30 minutes and should be
monitored for a further 30 to 120 minutes
When contractions occur, they usually appear
within 60 minutes and peak within four hours
Cervical Ripening
(cont)




The optimal interval for administering another
dose has not been determined
Six hours is commonly used
The gel should be kept refrigerated and
brought to room temperature immediately
before use
The manufacturer recommends that no more
than three doses be administered per 24 hours
Cervical Ripening
(cont)



Misoprostol (Cytotec) is a pill taken by
mouth or placed in the vagina (using a smaller
dose)
It is a medication currently approved for
treating ulcers;
Using it for cervical ripening is a widely
accepted but unlabeled use of this medication
Cervical Ripening
(cont)


(Misoprostol) Cytotec is an effective, safe and
inexpensive agent for cervical ripening and
labor induction
Prepidil and Cervidil cost $150 and $175 per
insert, respectively, whereas a 100-µg Cytotec
tablet costs $0.60.
Cervical Ripening
(cont)




Misoprostol is a synthetic analog of PGE1.
When given orally it is rapidly absorbed by the
gastrointestinal tract and undergoes deesterification to its free acid
This state is responsible for its clinical activity
The total systemic bioavailability of vaginally
administered misoprostol is three times
greater than that of orally administered
misoprostol
Cervical Ripening
(cont)



Dose is one-quarter of 100 mcg (25 mcg)
tablet vaginally
A 100 mcg tablet not scored
Hospital pharmacy should prepare the 25 mcg
dose for greater accuracy
Cervical Ripening
(cont)

Maternal outcomes such as the need for
cesarean delivery because of FHR
abnormalities, the arrest of labor or the need
for tocolytic administration, are not
significantly different between misoprostol and
dinoprostone.
Cervical Ripening
Mechanical



MECHANICAL MODALITIES
All mechanical modalities share a similar mechanism
of action—namely, some form of local pressure that
stimulates the release of prostaglandins
The risks associated with these methods include
infection (endometritis and neonatal sepsis have been
associated with natural osmotic dilators), bleeding,
membrane rupture, and placental disruption.
Cervical Ripening
Mechanical (cont)



Hygroscopic dilators absorb endocervical and local
tissue fluids, causing the device to expand within the
endocervix and providing controlled mechanical
pressure
The products available include natural osmotic
dilators (e.g., Laminaria) and synthetic osmotic
dilators (e.g.,Lamicel)
The main advantages of using hygroscopic dilators
include outpatient placement and no FHR-monitoring
requirements.
Cervical Ripening
Mechanical (cont)


Balloon devices provide mechanical pressure
directly on the cervix as the balloon is filled
A Foley catheter (26 Fr) or specifically
designed balloon device can be used
Cervical Ripening
Surgical


SURGICAL METHODS
Stripping of the Membranes. Stripping of the
membranes causes an increase in the activity
of phospholipase A2 and prostaglandin F2
(PGF2) as well as causing mechanical
dilation of the cervix, which releases
prostaglandins.
Stripping of Membranes
• Gloved finger inserted into internal os and rotating
360 degrees twice separating amniotic membranes
lying against lower uterine segment
• Does not require monitoring or other assessments Often done as outpatient service
• May not induce labor - if labor is initiated, it typically
begins within 48 hours
• May cause bleeding
Amniotomy



A pelvic examination is performed to
evaluate the cervix and
station of the presenting part
The fetal heart rate is recorded before and
after the procedure.
The presenting part should be well
applied to the cervix
Amniotomy (cont)



A cervical hook is inserted through the
cervical os by sliding it along the hand
and fingers (hook side toward the hand)
The membranes are scratched or hooked
to effect rupture
The nature of the amniotic fluid is
recorded (clear, bloody, thick or thin,
meconium)
Amniotomy (cont)


Amniotomy increases the production of, or
causes a release of, prostaglandins locally
Risks associated with this procedure include
umbilical cord prolapse or compression,
maternal or neonatal infection, FHR
deceleration, bleeding from placenta previa
or low-lying placenta, and possible fetal injury.
Pitocin Infusion



Usually effective at producing contractions may cause hyperstimulation of the uterus
Requires small, precise dosage (infusion
pump)
Maximum rate and dosing interval based on
facility protocol, clinician order, individual
situation, and maternal-fetal response
Pitocin Infusion (cont)
Palpating uterus essential, unless
IUPC in place
 May initially decrease blood pressure

Pitocin (cont)
Oxytocin increases intracellular
calcium levels, stimulating
contractions in myometrial smooth
muscle
 Oxytocin is the preferred
pharmacologic agent for inducing
labor when the cervix is ripe

Pitocin Infusion (cont)


Commonly used Guidelines for Oxytocin
Administration from American College of
Obstetricians and Gynecologists are as
follows…
Dilute 10-20 Units in 1000 ml of
balanced isotonic solution as piggyback
per IV pump
Pitocin Infusion (cont)
After adequate contraction pattern
established
 Cervix dilated to 5 to 6 cms
 Oxytocin may be reduced by
increments similar for induction

Pitocin Infusion (cont)
Uterus more sensitive to Oxytocin as
labor progresses
 Due to increased sensitivity Pitocin
administration titrated to uterine and
fetal response

Labor Augmentation

When labor augmented with Pitocin
a lower total dose is usually needed
to achieve an adequate contraction
pattern
Pregnancy Induced Hypertension
(PIH)

Classification
 Preeclampsia
 Eclampsia
 Gestational Hypertension
 Chronic Hypertension
Pregnancy Induced Hypertension
(PIH)

Preeclampsia
-Systolic blood pressure ≤140 mm Hg
-Diastolic blood Pressure ≤90 mm Hg
-Occurring after 20 weeks gestation
-Accompanied by proteinuria
≤0.3 g in 24 hour specimen
≤1+ with random dipstick
Pregnancy Induced Hypertension
(PIH)



Formally edema considered classical sign
Presently edema considered nonspecific
Now know that edema occurs in many
pregnancies not accompanied by
hypertension
Pregnancy Induced Hypertension
(PIH)




Eclampsia
Preeclampsia progresses to true
eclampsia when patient has seizure
Seizure is generalized tonic-clonic and
cannot be attributed to any other cause
PIH may occur postpartum
Pregnancy Induced Hypertension
(PIH)

Only known cure for preeclampsia
or eclampsia is delivery of fetus
Pregnancy Induced Hypertension
(PIH)

Gestational Hypertension
-Blood Pressure elevation (≤140/90 mm
Hg) after 20 weeks gestation
-No proteinuria
May have trace on random dipstick
without significance to this category
Pregnancy Induced Hypertension
(PIH)

Chronic Hypertension
Blood Pressure ≤ 140/90 mm Hg
known before pregnancy
Pregnancy Induced Hypertension
(PIH)

Textbook addresses…
-Preeclampsia superimposed on
chronic hypertension
-Proteinuria <0.3 g in 24 hour specimen
in woman with chronic hypertension
Pregnancy Induced Hypertension
(PIH)
Preeclampsia superimposed on chronic
hypertension (cont)
-When proteinuria before 20 weeks
gestation preeclampsia suspected if
sudden increase from baseline
-Sudden increase in previously well
controlled blood pressure
Pregnancy Induced Hypertension
(PIH)
Preeclampsia superimposed on chronic
hypertension (cont)
-platelets <100,000/mm³
-abnormal elevations of liver enzymes
(AST or ALT)
Risk Factors for PIH

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First pregnancy
Young primigravida
Older than 35 years
African-American
Positive family
history
Chronic hypertension
Renal Disease

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
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Diabetes
Multifetal Pregnancy
Autoimmune
Disorders
Father previously
fathered pregnancy
in another female
complicated by PIH
Pathology of PIH
Loss of normal vasodilation capability
 Increased levels of vasoconstrictors
(partially produced by placenta)
 Decreased levels of vasodilators
 Concurrent vasospasm
 BP begins to rise after 20 weeks’
gestation

Pathology of PIH
(cont)



Prostacyclin is potent vasodilator and
inhibits platelet aggregation (clumping)
More thromboxane A² than prostacyclin
results in vasoconstriction
Increase of potent vasoconstrictor and
platelet aggregate thromboxane A² over
prostacyclin
Pathophysiology of Preeclampsia
Clinical Manifestations

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

Hyperreflexia and headache
Seizures, renal failure and abruptio
placentae
Disseminated intravascular coagulation
(DIC)
Ruptured liver and pulmonary embolism
Clinical Manifestations (cont)



Altered mental function (headache,
confusion) and hyperreflexia caused by
altered cerebral perfusion 2º arterial
vasospasms
Visual disturbances (spots, blurred, double
vision) indicate arterial spasms and edema
in retina
Decreased urinary output results from
decreased renal perfusion
Clinical Manifestations (cont)



Decreased renal perfusion results in
tissue necrosis with proteinuria
Decreased perfusion to liver leads to
hepatic edema and subcapsular
hemorrhage with epigastric pain
Decreased placental perfusion results in
infarcts that increase risk for abruptio
placentae and DIC
Diagnostic Testing

Remember

Classic signs of Preeclampsia
-hypertension first
-proteinuria
Measurement of Blood Pressure



Blood Pressure Measurement should be
uniform
Woman seated, arm supported, cuff
appropriate size for arm
Diastolic Blood Pressure recorded at
Korotkoff phase V (disappearance of
sound)
Measurement of Blood Pressure


Hospitalization may be necessary for
serial observations of blood pressure
Serial checks differentiates true blood
pressure elevation from those induced by
anxiety
Diagnosis

Mild preeclampsia
 BP 140/90 mm Hg or higher
 1+ proteinuria may occur
 Liver enzymes may be elevated
minimally
 Edema may be present
Diagnosis

Severe preeclampsia
 BP 160/110 mm Hg or higher
 measurements, 6 hours apart
 Proteinuria ≥5 g in 24 hour specimen
(3+ or higher on random dipstick
 Oliguria
 Visual Distrubances
Diagnosis



Vascular constriction and narrowing of
small arteries when retina examined
Elevated Liver Enzyme Studies (ALT and
AST)
Proteinuria with Clean Catch Urine
Specimen
Diagnosis



Deep tendon reflexes very brisk
(Hyperreflexia)
Decreased platelets (Impaired
coagulation)
Increased hematocrit (fluid shift to
interstitial spaces)
Diagnosis




Generalized edema often occurs and may
be severe
Fluid retention measured by rapid weight
gain
Facial edema may be subtle but is
pathological
Edema about lower extremities expected
in healthy pregnancy
ASSESSMENT OF PITTING
EDEMA
ASSESSMENT OF EDEMA

Minimal edema of lower extremities +1

Marked edema of lower extremities +2
Edema of extremities, face, hands, and
sacral area +3
Generalized massive edema that indicates
ascites (accumulation of fluid in peritoneal
cavity) +4


Diagnosis


NOTE
Pulmonary edema more common in
women with massive edema from any
cause (includes preeclampsia/eclampsia)
*Edema may not be present in
preeclampsia
Nutritional Considerations
Diet:
 High-protein, moderate-sodium
for severe preeclampsia
 Regular diet without salt or fluid
restriction usually prescribed
 Diet appropriate for hypertension and
diabetes prescribed for women who
also have these disorders

Nutritional Considerations



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High protein intake ( blood osmolarity, reduce
movement of vascular fluid into interstitial
space)
Diet should be well balanced
Do not eliminate sodium. Do avoid high salt
Avoid alcohol and smoking
Drink 8-10 (8 oz) glasses water/day
Eat foods with roughage
Treatment


Initial evaluation of severity done in
hospital
May be managed at home if preeclampsia
-mild
-woman and fetus stable
-woman can adhere to treatment plan
-woman can return for frequent visits
Home vs Hospital Care

Home care of mild preeclampsia

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Client monitors her blood pressure
Measures weight and tests urine protein daily
Remote NSTs performed daily or bi-weekly
Advised to report signs of worsening preeclampsia
Hospital care of mild preeclampsia

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Bed rest and moderate to high protein diet
Fetal evaluation
Home Care

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
Need to stop working
Activity Restrictions
Bed rest minimum of 1 ½ hours per day
in a side-lying position
Home Care


Woman keeps record of fetal movements
called “kick count”
Woman should report decrease in fetal
movements or no movement felt in 4
hour period
Home Care



Blood pressure assessments 2-4 times per
day
Family and patient taught to assess blood
pressure in same arm, same position, with
appropriate size cuff
Family taught to use electronic blood
pressure equipment
Home Care

Daily weights at
-same time
-similar clothing
-same scales
Home Care



Urine dipstick for protein daily
First voided specimen
Physician may request more frequent
testing
Home Care


Sonography for fetal growth and quality
of amniotic fluid or as part of
biophysical profile
If less than 34 weeks and delivery
considered, amniocentesis done to
evaluate pulmonary maturity (L/S
Ratio)
Hospital Care
Severe Preclampsia
Goals…
-prevent convulsions
-maintain pregnancy until safe to
deliver fetus
Hospital Care

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Bedrest
Quiet environment with reduced external
stimuli (lights, noise, visitors)
Reduced external stimuli to prevent
convulsions
Magnesium Sulfate administration IV as
anticonvulsant
Apresoline antihypertensive agent of choice
Intrapartum Care




Most seizures occur during labor and the
postpartum period
Monitor continuously for signs of
seizures
Maintain side lying position
Narcotic analgesics or epidural analgesia
used to control seizure precipitating pain
Intrapartum Care




Induction of labor by IV oxytocin if condition
deteriorates
Vaginal birth delivery method of choice
Oxytocin to stimulate labor and magnesium
sulfate to prevent convulsions
Both administered IV as two secondary
infusions
Intrapartum Care


Continuous electronic fetal monitoring
identifies fetal heart rate patterns suggestive of
fetal compromise
Pediatrician, neonatologist, or neonatal nurse
practitioner must be available to care for
newborn
MAGNESIUM SULFATE



Loading Dose 4-6 Gms in 100 ml fluid IV
over 15-20 minutes
Maintenance dose 40 Gms in 1000 ml
Ringers Lactate IV via infusion pump at
2 g per hour
Maintain serum magnesium level of 4-8 mg/dl
MAGNESIUM SULFATE

Assess for MAGNESIUM TOXICITY
Respirations < 12/MIN
Maternal Oximeter reading < than 95%
Hyporeflexia or absent DTR (patella)
Urinary Output ≥ 30 ml/hr
Toxic serum level ≥ 8 mg/dL
Fetal Distress or drop in fetal HR
Significant drop in maternal pulse or BP
MAGNESIUM TOXICITY

ADMINISTER CALCIUM
GLUCONATE OR CALCIUM
CHLORIDE 1g IV OVER
THREE MINUTE INTERVAL OR
AS ORDERED
ASSESSING REFLEXES
Deep Tendon Reflex Scale
0:
+1:
+2:
+3:
+4:
Reflex absent
Reflex present, hypoactive
Normal Reflex
Brisker than average reflex
Hyperactive reflex;
clonus may also be present
Assessing Reflexes
Assessing Clonus
-Flex lower extremity at knee over
examiner's arm
-Dorsiflex foot to stretch tendon
-Hold flexion at knee
-Rapid rhythmic tapping motions of the
foot indicates clonus (hyperreflexia)
To elicit clonus, with the knee flexed and the leg supported, sharply dorsiflex the foot,
hold it momentarily, and then release it. Normally the foot returns to its usual position
of plantar flexion. Clonus is present if the foot “jerks” or taps against the examiner’s
hand. If so, the number of taps or beats of clonus is recorded.
Assessment of Edema
Characteristics
Grade
Minimal edema of lower extremities…… +1
Marked edema of lower extremities……. +2
Edema of lower extremities, face, hands, and
sacral area…………………………….. +3
Generalized massive edema that includes
ascites (accumulation of fluid in peritoneal
cavity)…………………………………. +4

Eclampsia
Diuretic: Furosemide (Lasix)
(to treat pulmonary edema)
 Anticonvulsant: Bolus of magnesium
sulfate
 Inotropic Drug: Digitalis (for
circulatory failure)
 Strict monitoring of intake and output
(Urinary output ↓30ml/hr suspect
renal failure)

Eclampsia

Nursing care
 Monitor vital signs and auscultate lungs
 Evaluate fetal heart rate patterns
 Monitor urinary output and urine protein
hourly
 Check specific gravity of the urine hourly
 Weigh the woman daily at the same time
 Assess deep tendon reflexes and clonus
Eclampsia



Stimulates uterine irritability
Monitor closely for signs of labor
Monitor closely for signs of Abruptio
Placentae
Interventions for Seizures
Protecting the woman and fetus
 Remain with the woman
 During the tonic phase, turn the woman on her
side
 Note the time and sequence of the convulsion
Interventions for Seizures
(cont’d)




After the seizure, insert an airway
Suction the woman's mouth and nose
Administer oxygen
Observe fetal monitor patterns for signs of
hypoxia
Post Seizure Care




Keep on side while unresponsive
Raise padded siderails
Deliver when vital signs stabilized
Anticipate orders for chest x-ray and arterial
blood gas analysis after initial stabilization
(aspiration leading cause of maternal
morbidity and mortality after seizure)
Nursing Process
Formulation of nursing diagnoses
 Set goals and outcome criteria
 Implement specific nursing
interventions
 Interventions are aimed at meeting
goals
 Evaluation of nursing interventions

Nursing Process

Priority Nursing Diagnosis
Deficient fluid volume
Risk for injury
Anxiety
Nursing Process

Evaluation
-client does not experience eclampsia
or HELLP syndrome
-client delivers a healthy mature infant
without further complications
HELLP Syndrome

Laboratory diagnostic variant of severe
preeclampsia involves hepatic
dysfunction, characterized by:
 Hemolysis (H)
 Elevated liver enzymes (EL)
 Low platelets (LP)
HELLP Syndrome
Platelet count must be less than
100,000/mm³
 Fibrin split products present
 A LABORATORY NOT CLINICAL
DIAGNOSIS

HELLP Syndrome



Although variant of severe preeclampsia
hypertension may be absent
May occur during postpartum period
Risk for hemorrhage, pulmonary edema
and hepatic rupture
HELLP Syndrome



Hemolysis results from erythrocyte
changes as they pass through damaged
blood vessels
Liver enzyme elevations results from
decreased hepatic blood flow
Low platelet levels results from platelets
aggregating at sites of vascular
damage
HELLP Syndrome

NOTE
-Avoid traumatizing liver by abdominal
palpation
-Sudden ↑ in intraabdominal pressure
potential for rupture of subcapsular
hematoma resulting in internal bleeding
and hypovolemic shock
HELLP Syndrome
Clinical Manifestaions




Pain…
-upper right quadrant
-lower chest
-epigastric pain
Tenderness over liver
Nausea and vomiting
Severe edema
HELLP Syndrome



Diagnostic Testing and Medical
Management same as that appropriate for
preeclampsia or eclampsia
Manage in facility with full intensive care
Life-threatening condition
Cardiac Disease



Hemodynamic changes of pregnancy
increases the workload of the heart
Cardiac output increases up to 50%
Plasma volume increases by 50 %
Cardiovascular Disease
Cardiovascular changes of pregnancy
 Plasma volume increases gradually
 Plasma volume peeks at 50% greater than
nonpregnant level between 28 and 32
weeks gestation
Cardiovascular Disease
Cardiovascular changes of pregnancy
▪Increase in erythrocytes also contributes to
peek plasma volume
▪Total erythrocyte count increases
-by about 30% in women who receive iron
-by only about 18% in women who do not
Cardiovascular Disease
Cardiovascular changes of pregnancy
 Plasma volume increase (50%) is greater than
erythrocyte increase (30%)
 Since plasma volume increase is greater than
erythrocyte increase
 Hematocrit decreases slightly resulting in
 Physiologic Anemia of Pregnancy
Cardiovascular Disease
Cardiovascular changes of pregnancy
 Blood flow increases to organ systems with
increased workload (uterus and kidneys)
▪ Results in increased cardiac output in early
pregnancy
 Cardiac Output remains elevated throughout
pregnancy
Cardiovascular Disease
Cardiovascular changes of pregnancy
 Enlarging uterus puts pressure on pelvic and
femoral vessels
-impedes return blood flow causing stasis
of blood in lower extremities
-stasis predisposes to postural hypotension
-dependant edema
-hemorrhoids (vulva, extremities, rectum)
Incidence & Risk Factors for
Cardiovascular Disease
▪ Compromised heart
-inadequate cardiac capacity
-decreased reserves
 Compromised heart may not be
able to adapt to added requirements
of pregnancy
▪ Cardiac decompensation {congestive
heart failure (CHF)} can result
Incidence & Risk Factors for
Cardiovascular Disease

Successful treatment
- congenital cardiac anomalies
- mitral stenosis (resulting from
rheumatic heart disease)
allows many females to reach
childbearing age and bear children
Incidence & Risk Factors for
Cardiovascular Disease
(cont)
 Rheumatic heart disease not endemic to
United States; may be found in recent
immigrants
 Hypertensive heart disease due to obesity
increasing in childbearing population
 Cardiomyopathy due to disorder of
muscle structure may have several causes
Incidence & Risk Factors for
Cardiovascular Disease
(Cont)

CHF
-may be 2º to underlying heart disease or
damage
-may occur 2º to treatment for other
conditions
Cardiovascular Disease


Maternal congenital heart defects that
have been effectively treated seen more
and more during pregnancy
This population is reaching adulthood
Cardiovascular Disease


There are decreasing numbers of
pregnant women with heart damage from
rheumatic fever
Streptococcal infections now effectively
treated
New York Heart Classification of
Heart Disease



Class I: uncompromized; no limitation
on activity
Class II: slightly compromised; ordinary
activity causes fatigue
Class III: marked limitation of physical
activity; less than ordinary
activity causes excessive fatigue
New York Heart Classification of
Heart Disease (cont)



Class IV: inability to perform any
activity without discomfort;
symptoms of cardiac
insufficiency even at rest
Generally Classes I and II can tolerate
pregnancy with close supervision
Classes III and IV have great difficulty
with pregnancy
Recognition of Heart Disease


Early recognition important
Specific signs and symptoms
-dyspnea
-paroxysmal nocturnal dyspnea
-hemoptysis
-syncope with exertion
-chest pain with exertion
Recognition of Heart Disease

Additional Signs that confirm diagnosis
-heart murmur
-loud harsh systolic murmur
associated with a thrill
-cardiac enlargement
-serious dysrhythmias
Diagnosis
Made from….
-clinical signs and symptoms
-physical exam
 Confirmed by
-chest x-ray
-EKF
-echocardiogram

Congenital Heart Disease


Left to right shunting
-atrial and ventricular septal defects
-patent ductus arteriosus
Right to left shunting
-cyanotic heart defect (tetralogy of Fallot)
- patent ductus arteriosus (when pulmonary
vascular resistance exceeds peripheral vascular
resistance (pulmonary hypertension)
Congenital Heart Disease
Anomalies with left-to-right shunt
Atrial Septal Defect





Defect causes left-to-right shunt because
pressure is higher in left side of heart than in
right side of heart
Pregnancy well tolerated with no
complications
Bacterial endocarditis rare
Prophylactic antibiotics not required
Not associated with heart failure
Ventricular Septal Defect




Usually detected and corrected before
females reach childbearing age
Mostly asymptomatic
Occasionally fatigue or symptoms of
pulmonary congestion occur
The smaller the defect the better
pregnancy will be tolerated
Ventricular Septal Defect
(cont)
 Bacterial Endocarditis common with
unrepaired defect
 Antibacterial prophylaxis is used
 If heart failure or dsyrhythmias occur
managed as in nonpregnant patient
Patent Ductus Arteriosus




Communicating shunt between pulmonary
artery and aorta
Usually discovered and treated in early
childhood
If patent ductus small may be well tolerated
during pregnancy unless complicated by
pulmonary hypertension
Bacterial endocarditis common; treat with
antibiotics
Congenital Heart Disease
Anomalies with right-to-left shunt
Tetralogy of Fallot


Primary cause of right-to-left shunting
Combination of four defects
-ventricular septal defect
- pulmonary valve stenosis
-right ventricupatlar hypertrophy
-displacement of aorta (overrides part
of right ventricle
Tetralogy of Fallot
(cont)
 If untreated will have the following
symptoms….(obvious symptoms of heart
disease)
-cyanosis
-clubbing of the fingers
-inability to tolerate activity
 If defect repaired and no reappearance of
cyanosis, may do well with pregnancy
Eisenmenger Syndrome



Cyanotic heart condition
Develops when pulmonary resistance
equals or exceeds systemic resistance
to blood flow; right-to-left shunt develops
Several congenital defects may underlie
equalization of pressures within
ventricles (Large ventricle septal defect
or large patent ductus arteriosus (PDA)
Eisenmenger Syndrome



Operative correction of anomalies must
be done as soon as possible to prevent
Eisenmenger Syndrome
If late surgery and woman survives
there is 50% mortality risk
After late surgery, mortality risk is
usually from ventricular failure
Mitral Valve Prolapse (MVP)




Common cardiac condition
Associated with a variety of conditions
Leaflets of mitral valve prolapse into
left atrium during ventricular
contraction
Most with MVP are asymptomatic
Nutritional Considerations



Well balanced diet for pregnancy to
ensure adequate weight gain
(avoid excessive weight gain)
Prenatal vitamins and iron to prevent
anemia
Monitor for signs of infection
Medical Management for Class I
and II heart Disease




Limit physical activity
Prevent anemia
Prevent infection
Careful assessment to detect development
of congestive heart failure, pulmonary
edema or cardiac dysrhythmias
Medical Management for
Class III and IV Heart Disease




Prevent development of congestive heart
failure
Protect fetus from hypoxia and
intrauterine growth retardation
(IUGR)
Same measures as for Class I and II
Bedrest especially during third trimester
Medical Management for
Class III and IV Heart Disease

Decreased mobility leads to increased
risk for thrombus
-elastic compression stockings or
-serial or boot dompression device
-prophylactic anticoagulant therapy
may be required
Medical Management

Observe for complications from
hemodynamic changes immediately
after delivery
-(congestive heart failure)
Pharmacologic Agents

Anticoagulants
Warfarin (Coumadin) is teratogenic
and restricted during pregnancy
Subcutaneous Heparin safe to use
-monitor partial thromboplastin time
-activated partial thromboplastin time
-platelet count
Pharmacologic Agents
Anticoagulants (cont)
 Enoxaparin (Lovenox) may be used
rather than heparin
 Do not interchange Lovenox and heparin
 Lovenox also given subcutaneously
 Lovenox requires less-frequent
monitoring
Pharmacologic Agents
Antidysrhythmics
Safe to use
-Digoxin
-Adenosine
-Calcium Channel Blockers
Pharmacologic Agents
Antidysrhythmics (cont)
 Beta blockers associated with
-neonatal respiratory depression
-sustained bradycardia
-hypoglycemia
if administered late in pregnancy or just
prior to delivery
Pharmacologic Agents
Antiinfectives
 For endocarditis chosen according to
infecting microorganism
 Antiinfectives used
-amoxicillin -ampicillin
-penicillin
-gentamycin
Pharmacologic Agents

Drugs for Pregnancy Associated Heart
Failure
If congestive heart failure
uncontrolled by restriction of activity
and sodium intake diuretics used
-furosemide
-thiazide
Pharmacologic Agents

Drugs for Pregnancy Associated Heart
Failure (cont)
-ACE inhibitors
-angiotensin receptor blockers
-digoxin
Nursing Process

Nursing Diagnosis
-Decreased cardiac Output
-Excess fluid volume
-Impaired gas exchange
-Activity intolerance
-Anxiety
-Risk for Infection
Nursing Process

Evaluation
-Client experiences healthy pregnancy
-Client avoids heart failure
-Client gives birth to healthy infant
Pre-Term Labor


Labor beginning after the 20th week of
gestation
But before the end of the 37th week of
gestation
Pre-Term Labor



No greater risk to the mom than regular
labor unless complications ie, infection,
hemorrhage
Different with neonate
May result in birth of neonate ill prepared
for extrauterine life
Client Teaching about Preterm
Labor




Should teach at first visit and reinforce at
subsequent visits
Contractions occurring q10 minutes or
less with or without pain
Low abdominal cramping with or without
diarrhea
Intermittent sensation of pelvic pressure,
urinary frequency
(cont)
 Low constant or intermittent backache
 Increased vaginal discharge, may be
pink-tinged
 Leaking amniotic fluid
Immediate Actions for Preterm
Labor




Empty bladder
Assume a side-lying position, left-lateral
perferred
Drink 3-4 eight ounce glasses of water
Palpate abdomen, if contractions 10
minutes apart or closer, contact
healthcare provider
Immediate Actions for Preterm
Labor




Rest for thirty minutes
Slowly resume activity, if symptoms
disappear
Symptoms not subsided within 1 hour
Call healthcare provicer
Preterm Labor and Birth

Causes of preterm labor and birth



Infections
Pregnancy complications
Sociodemographic factors

Poverty, low educational level, lack of social support,
smoking, little or no prenatal care, domestic violence,
and stress
Care Management

Assessment and nursing diagnoses




Begins at time of entry to prenatal care
Use known successful modalities for teaching
about early recognition of preterm symptoms
Teach what to do if symptoms occur
Women may ignore symptoms


Ignorance regarding significance
Belief that symptoms are expected during pregnancy
Care Management

Signs and symptoms of preterm labor

Uterine activity


Uterine contractions more frequent than every 10
minutes persisting for 1 hour or more
Discomfort


Lower abdominal cramping similar to gas pains; may be
accompanied by diarrhea
Dull, intermittent low back pain
Care Management

Signs and symptoms of preterm labor

Discomfort—cont’d





Painful, menstrual-like cramps
Suprapubic pain or pressure
Pelvic pressure or heaviness
Urinary frequency
Vaginal discharge


Change in discharge
Rupture of amniotic membranes
Care Management

Plan of care and interventions

Prevention


Educate woman about early symptoms of preterm labor
Any symptoms of uterine contractions or cramping
between 20 and 37 weeks of gestation that do not go
away are not normal discomforts of pregnancy and
require contacting primary health care provider
Care Management

Early recognition and diagnosis

Three major diagnostic criteria



Gestational age between 20 and 37 weeks
Contractions
Progressive cervical change


Effacement of 80%
Cervical dilation of 2 cm or greater
Care Management

Lifestyle modifications

Activities resulting in preterm labor symptoms
should be curtailed






Engaging in sexual activity
Carrying heavy loads
Standing more than 50% of the time
Doing heavy housework or climbing stairs
Performing hard physical work
Being unable to stop and rest when tired
Care Management

Bed rest




Commonly used for prevention of preterm birth
Not a benign intervention
No evidence to support effectiveness in reducing
preterm birth rates
Home care


Modify environment for conveniences
Home uterine activity monitoring
Care Management

Suppression of uterine activity

Tocolytics

Afford opportunity to begin administering antenatal
glucocorticoids


Accelerate fetal lung maturity
Reduce severity of sequelae in preterm births
Care Management

Promotion of fetal lung maturity

Antenatal glucocortoids

NIH recommends for all women at risk for preterm

Not indicated when:
 Cord prolapse
 Chorioamnionitis
 Abruptio placentae
Care Management

Management of inevitable preterm birth




Labor progressed to cervical dilation of 4 cm likely
to lead to inevitable preterm birth
Preterm births in tertiary care centers lead to better
neonatal and maternal outcomes
Women at risk should be transferred quickly to
ensure best possible outcome
First dose of antenatal glucocorticoids should be
given before transfer
Premature Rupture of
Membranes (PROM)

Rupture of amniotic sac and leakage of amniotic
fluid beginning at least 1 hour before onset of
labor at any gestational age
Preterm Premature Rupture of
Membranes (PPROM)






Membranes rupture before 37 weeks of gestation
Occurs in up to 25% of preterm labor cases
Often preceded by infection
Etiology unknown
Diagnosed after woman complains of sudden gush
or slow leak of vaginal fluid
Care management: home vs. hospital