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OB High Risk II
Ana H. Corona, MSN, FNP-CNursing InstructorFebruary 2008eMedicine2007, Nursing 353 Maternal Risk Factors 2005;
Congenital Varicella Syndrome 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
Healthy adults Immunocompromised persons Newborns of mothers with rash onset
within 5 days before to 48 hours after delivery
Pathogens of Special ImportanceDuring 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 thanother healthy adults to be infected
Risky Food Preferences Consumed – 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
Antepartum Testing
FKCs BID UTZ
FHR Gestation age Abnormalities IUGR Placental location and quality AFI Position BPP Doppler flow Fetal growth
Ultrasound
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 Study blood blow in the fetus and placenta Done on high risk mothers:
IUGR HTN DM Multiple gestation
AFI (amniotic fluid index)
Polyhydramnios – too much amniotic fluid AFI of more than 24 cm
Oligohydramnios – too little amniotic fluid 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)
Includes 5 components: Fetal breathing movements Gross body movements Fetal tone AFI NST - reactive
Amniocentesis
Used with direct ultrasound Less than 1% result in complications
Complications include: Fetal death, miscarriage Maternal hemorrhage Infection to fetus Preterm labor Leakage of amniotic fluid
Meconium
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) 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)
Genetic test Done with mothers blood 16-20 weeks gestation Mandated by state of California
EFM (electronic fetal monitoring) 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)
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
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:
Change positions of the mother – LS, RS Increase fluids Acoustic stimulator
CST (Contraction stress testing) 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
Diabetes
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
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
DM
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
May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea
Macrosomia
Disproportionate increase in shoulder and trunk size
4000-4500gms or greater Fetus will have excess stores of glycogen Increased risks of
Shoulder dystocia C/S Assisted deliveries
Neonatal Hypoglycemia
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 Diet
Sweet success diet Well balanced diet 6 small meals / day Have snack at HS Never skip meals Avoid simple sugars
Infections are increased: Candidiasis UTIs PP infections
Increased risk of IUFD after 36 weeks Increased congenital anomalies
Cardiac defects CNS defects
Spina bifida anencephaly
Skeletal defects
Cardiovascular Disorders in Pregnancy 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
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
Avoiding anemia Avoid strenuous activity Monitor for: cardiac failure and pulmonary
congestion
Nursing Care during labor
Side lying position Prophylactic antibiotic Epidural Attempt vaginal delivery If anticoagulant therapy is needed:
Heparin Lovenox
Anemia
Most common iron deficiency Hgb falls below 12 (most labs) Typically seen in the end of 2nd trimester Iron supplementation
Folic Acid Deficiency Anemia
Increases risk of NTD, cleft lip Recommended dose 400 mcg/day Supplemented in cereal and many other
foods
Sickle Cell Anemia
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: Typically asymptomatic Sickling of the RBCs but with a normal RBC
life span
Thalassemia
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
Common with FH 1-4% of pregnant women have Asthma Possible adverse events associated with
asthma: LBW Perinatal mortality Preeclampsia Complicated labor Hyperemesis
Asthma Continue
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
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
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
More often in women Pregnancy makes women more vulnerable Surgery often delayed until after delivery
TORCH
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
ALCOHOL
Many women reluctant to tell health care provider
Risks: LBW Mental retardation Learning and physical deficits With FAS – severe facial deformities
MARIJUANA
Crosses the placenta and causes increased carbon monoxide levels in mother’s blood
May cause fetal abnormalities
COCAINE
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 Maternal effects:
Cardiovascular stress Tachycardia HTN Dysrhythmias MI Liver damage Sz Pulmonary disease Death
Fetal Complications: Abruptio placentae PTL Precipitous labor Risks for abdominal
pregnancy Fetal complications after
delivery
OPIATES IN PREGNANCY
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
CNS stimulant Most common use n the 18-30 yr old range Neonatal complications include:
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
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 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
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
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: A. Accurate age of the fetus B. Presence of certain congenital anomalies C. Biparietal diameter of the skull D. Hormone content of the amniotic fluid E. Mainly the presence of Down’s syndrome
Question
2. The nurse explains to a new mother that the condition of SGA is caused by: A. Placental insufficiency B. Maternal obesity C. Primipara D. Genetic predisposition
Question
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: 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
4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be: A. Higher than in normal infants B. Lower than in normal infants C. The same as in normal infants D. Varied from baby to baby
Question
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: 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
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