Transcript OB High Risk II - Dr. NurseAna's Nursing Reviews

OB High Risk II
Ana H. Corona, MSN, FNP-C
Nursing Instructor
February 2008
eMedicine2007, Nursing 353 Maternal Risk Factors 2005;
Congenital Varicella Syndrome
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Results from maternal infection during pregnancy
Period of risk may extend through first 20 weeks of
pregnancy
Atrophy of extremity with skin scarring, low birth
weight, eye and neurologic abnormalities
Risk appears to be small (< 2%)
Groups at Increased Risk of
Complications of Varicella
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Healthy adults
Immunocompromised persons
Newborns of mothers with rash onset
within 5 days before to 48 hours after
delivery
Pathogens of Special Importance
During Pregnancy
Toxoplasma gondii
– Cats (litter boxes) are carriers
– Undercooked meats
 Listeria monocytogenes
– Found in high-protein foods served raw (milk or fish)
or without reheating (deli meats, hot dogs, seafood
salads). Several outbreaks have been caused by soft
cheeses made with raw milk.
 Pregnant women are 20 times more likely than
other healthy adults to be infected
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Risky Food Preferences Consumed
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– Store-bought Mexican-style soft cheese (queso fresco or
blanco, Panela)
– Cold deli or lunch meats, served without reheating
– Fresh squeezed juice, unpasteurized
– Cold hot dogs, served without reheating
– Homemade Mexican-style soft cheese (queso fresco or
blanco, Panela)
– Raw fish, ceviche
– Raw (unpasteurized) milk
– Alfalfa or other raw sprouts
– Ground meat not fully cooked
– Raw cookie dough containing eggs
– Eggs with runny yolks
High Risk Pregnancy
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Examples include:
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GDM
Previous loss
AMA
HTN
Abnormalities with the neonate
Antepartum Testing
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FKCs BID
UTZ
 FHR
 Gestation age
 Abnormalities
 IUGR
 Placental location and quality
 AFI
 Position
 BPP
 Doppler flow
 Fetal growth
Ultrasound
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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 growth and
well-being, AFI
Doppler flow analysis via ultrsound
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Study blood blow in the fetus and placenta
Done on high risk mothers:
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IUGR
HTN
DM
Multiple gestation
AFI (amniotic fluid index)
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Polyhydramnios – too much amniotic fluid
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AFI of more than 24 cm
Oligohydramnios – too little amniotic fluid
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AFI less than 7 cm
Studies show that oral hydration, by having the
women drink 2 liters of water, increases the AFI by
30%.
BPP (Biophysical Profile)
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Includes 5 components:
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Fetal breathing movements
Gross body movements
Fetal tone
AFI
NST - reactive
Amniocentesis
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Used with direct ultrasound
Less than 1% result in complications
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Complications include:
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Fetal death, miscarriage
Maternal hemorrhage
Infection to fetus
Preterm labor
Leakage of amniotic fluid
Meconium
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Visual inspection of amniotic fluid
Meconium is defined as thin and thick and
particulate
Associated with fetal stress: hypoxia,
umbilical cord compression
CVS (chorionic villi Sampling)
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Done between 9 -12 weeks
Genetic studies
Removal of small amount of tissue from the
fetal portion of the placenta
Complications: vaginal spotting, miscarriage,
ROM, chorioamnionitis
If done prior to 10 weeks, increased risk of
limb anomalies
AFP (alpha-fetoprotein)
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Genetic test
Done with mothers blood
16-20 weeks gestation
Mandated by state of California
EFM (electronic fetal monitoring)
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Third trimester goal is to continue to observe
the fetus within the intrauterine environment
Goal: dx uteroplacental insufficiency
NST vs. CST
NST (non-stress test)
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90% of gross fetal body movements are
associated 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 affected by
maternal medications, glucose etc.
NST
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To be reactive must meet criteria
Must be at least 20 minutes in length
Must have 2 or more accelerations that meet the ’15
X 15’ criteria
Must have a normal baseline
Must have LTV
To stimulate a fetus that is not meeting criteria:
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Change positions of the mother – LS, RS
Increase fluids
Acoustic stimulator
CST (Contraction stress testing)
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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
Endocrine and Metabolic Disorders
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#1 Diabetes Mellitus
Disorders of the thyroid
Hyperemesis
Diabetes
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Hyperglycemia
May be due to inadequate insulin action or
due to impaired insulin secretion
Type 1 – insulin deficiency
Type 2 – insulin resistance
GDM – glucose intolerance during pregnancy
DM
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10th week fetus produces it own insulin
Insulin does not cross the placental barrier
Glucose levels in the fetus and directly
proportional to the mother
2nd and 3rd trimesters – decreased tolerance
to glucose, increased insulin resistance,
increased hepatic function of glucose
Diabetic Neuropathy
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Increased risks for:
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Preeclampsia
IUGR
PTL
Fetal distress
IUFD
Neonatal death
DM
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Poor glycemic control is associated with
increased risks of miscarriage at time of
conception
Poor glycemic control in later part of
pregnancy is assoc. with fetal macrosomia
and polyhydramnios
Polyhyraminos
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May compress on the vena cava and aorta
causing hypotension, PROM, PP
hemorrhage, maternal dyspnea
Macrosomia
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Disproportionate increase in shoulder and
trunk size
4000-4500gms or greater
Fetus will have excess stores of glycogen
Increased risks of
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Shoulder dystocia
C/S
Assisted deliveries
IUGR
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Compromised uteroplacental insufficiency
02 available to the fetus is decreased
RDS
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Increased RDS due to high glucose levels
Delays pulmonary maturity
Neonatal Hypoglycemia
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Usually 30-60 minutes after birth
Due to high glucose levels during pregnancy
and rapid use of glucose after birth
Related to mothers level of glucose control
Neonates normal glucose level: 40-65mg/dl
Premature infants: 20-60mg/dl
DM laboratory
HBA1c
 1 hour PP
 FBS
Monitoring Glucose Levels
 FBS
 1 hour PP
 HS
 5 checks / day
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DM Diet
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Sweet success diet
Well balanced diet
6 small meals / day
Have snack at HS
Never skip meals
Avoid simple sugars
Insulin
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Regular/Lispro and NPH
2/3 dose in am and 1/3 dose in pm
Fetal Surveillance
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NSTs done around 26 weeks, weekly
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At 32 weeks done biweekly with NST/BPP
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Infections are increased:
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Candidiasis
UTIs
PP infections
Increased risk of IUFD after 36 weeks
Increased congenital anomalies
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Cardiac defects
CNS defects
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Spina bifida
anencephaly
Skeletal defects
Cardiovascular Disorders in Pregnancy
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The heart must compensate for the increased
workload
If the cardiac changes are not well tolerated
than cardiac failure can develop
1% of pregnancies are complicated by heart
disease
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Cardiac output is increased
Peak of the increase 20-24 weeks gestation
Cardiac problems should be managed with
cardiologist
Mortality with pulmonary hypertension and
pregnancy is more than 50%
Diet: low sodium
Nursing Care
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Avoiding anemia
Avoid strenuous activity
Monitor for: cardiac failure and pulmonary
congestion
Nursing Care during labor
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Side lying position
Prophylactic antibiotic
Epidural
Attempt vaginal delivery
If anticoagulant therapy is needed:
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Heparin
Lovenox
Anemia
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Most common iron deficiency
Hgb falls below 12 (most labs)
Typically seen in the end of 2nd trimester
Iron supplementation
Folic Acid Deficiency Anemia
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Increases risk of NTD, cleft lip
Recommended dose 400 mcg/day
Supplemented in cereal and many other
foods
Sickle Cell Anemia
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Abnormal hemoglobin SS types in the blood
People have recurrent attacks of fever and
pain in the abdomen and extremities
Caused from tissue hypoxia, edema
African-Americans
Sickle Cell Trait:
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Typically asymptomatic
Sickling of the RBCs but with a normal RBC
life span
Thalassemia
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Common anemia
Insufficient amount of Hgb is produced to fill
the RBCs
Mediterranean region
Genetic disorder
May be associated with LBW babies and
increased fetal death
Asthma
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Common with FH
1-4% of pregnant women have Asthma
Possible adverse events associated with
asthma:
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LBW
Perinatal mortality
Preeclampsia
Complicated labor
Hyperemesis
Asthma Continue
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Goal is to relieve the attack, prevent the
asthma attack, and maintain 02
Should be managed with OB and ENT
May require tx: albuterol, steroids, O2
Epilepsy
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Seizure disorder
May result from developmental abnormalities
or injury
20% have an increase in seizure activity
during pregnancy
Risks: more seizures, risk of vaginal
bleeding, abruptio placentae, fetus may
experience seizures
Epilepsy continue
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Use of antiepeleptic meds during pregnancy
has been linked to risks for the fetus
Smallest therapeutic dose to be given
Daily folic acid supplementation
Managed with OB and neurologist
Cholelithiasis
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More often in women
Pregnancy makes women more vulnerable
Surgery often delayed until after delivery
TORCH
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Toxoplasmosis – protozoan infection, neonatal
effects – jaundice, hydrocephalus, microcephaly
Other- Heb A or B, Group B, Varicella, HIV
Rubella (German measles) – if contracted in 1st
Trimester fetus may have congenital deformities
CMV- transmitted person to person, may cause CNS
damage to fetus
Herpes Simplex (HSV 2) – if initial infection occurs
in pregnancy, higher incidence of perinatal loss.
Fetus may pick up virus if present in the vagina
during labor
SMOKING
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Risks of any amount of smoking include:
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SAB
SGA
Bleeding
IUFD
Prematurity
SIDS
ALCOHOL
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Many women reluctant to tell health care
provider
Risks:
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LBW
Mental retardation
Learning and physical deficits
With FAS – severe facial deformities
ALCOHOL
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Risks to mother:
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HTN
Anemia
Nutritional deficits
Pancreatitis
Cirrhosis
Alcoholic hepatitis
MARIJUANA
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Crosses the placenta and causes increased
carbon monoxide levels in mother’s blood
May cause fetal abnormalities
COCAINE
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In the US, 10-15% of all pregnant women use
cocaine
Problems associated with use: polydrug use,
poor health, poor nutrition, STIs, infections,
HIV
Poverty big issue
COCAINE DURING PREGNANCY
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Maternal effects:
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Cardiovascular stress
Tachycardia
HTN
Dysrhythmias
MI
Liver damage
Sz
Pulmonary disease
Death
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Fetal Complications:
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Abruptio placentae
PTL
Precipitous labor
Risks for abdominal
pregnancy
Fetal complications after
delivery
OPIATES IN PREGNANCY
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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
Methamphetamines
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CNS stimulant
Most common use n the 18-30 yr old range
Neonatal complications include:
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IUGR
PRL/PTB
Hyperemesis Gravidarum
Management:
 Intake and output
 IV fluids
 Monitor urine for ketones
 NPO until vomiting stops
 BRAT diet after
 Monitor for premature labor, Hemorrhage,
jaundice metabolic acidosis
Multifetal Pregnancy
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Monozygotic: from one fertilized ovum that
divides creating identical twins
Dizogotic: from two separate ova fertilized at
the same time
Genetic makeup and sex of each fetus can
vary
Complications: maternal anemia,
spontaneous abortion, PIH, hydraminos
Hydatidiform Mole
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Gestational trophoblastic disease
Cause is unknown
Higher risk with clomid (fertility drug)
Egg is fertilized with nuclei lost or not active
Nucleus of sperm duplicates causing fluid filled
vesicles like a bunch of grapes
Uterus becomes larger than normal for gestational
age
No amniotic fluid present
Nausea/vomiting believed to be from elevates HCG
in blood
Some have bleeding into uterine cavity and
experience vaginal bleeding.
Hydatidiform Mole
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May pass vesicles around 16 weeks
Tests: ultrasound, amniography, HCG, CBC
for anemia
D & C for evacuation of the mole
Prevent pregnancy for 1 year
Question
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1. A client asks the nurse to again explain
the purpose of the amniocentesis test. The
nurse responds that one purpose of this test
is to indicate the:
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Accurate age of the fetus
Presence of certain congenital anomalies
Biparietal diameter of the skull
Hormone content of the amniotic fluid
Mainly the presence of Down’s syndrome
Question
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2. The nurse explains to a new mother that
the condition of SGA is caused by:
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Placental insufficiency
Maternal obesity
Primipara
Genetic predisposition
Question
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3. A pregnant client with diabetes is controlled by
insulin. When she asks the nurse what will happen
to her insulin requirements during pregnancy, the
correct response is:
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A. “Because your case is so mild, you are likely not to
need much insulin during your pregnancy”
B. “It’s likely that as the pregnancy progresses you will
need increased insulin”
C. “Every case is individual so there is really no way to
know”
D. “If you follow the diet closely and don’t gain too much
weight, your insulin needs should stay the same”
Question
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4. The nurse in the newborn nursery
understands that assessing a newborn with a
diabetic mother, initially the insulin level
would be:
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B.
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Higher than in normal infants
Lower than in normal infants
The same as in normal infants
Varied from baby to baby
Question
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5. A client is admitted to L&D, at 38 weeks
gestation. She is there for evaluation because she
is experiencing polyhydramnios. The nurse
understands that this diagnosis means that:
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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