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Nursing 353Maternal Risk Factors
Fetal AssessmentFebruary 3rd, 2005
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High Risk Pregnancy
The life or health of the mother or fetus isjeopardized
Examples include:
GDM
Previous loss
AMA
HTN
Abnormalities with the neonate
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Perinatal Mortality
Overall maternal deaths are small
Many deaths a preventable
Education and prenatal care are veryimportant
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Antepartum Testing
FKCs BID
UTZ FHR
Gestation age
Abnormalities IUGR
Placental location and quality
AFI
Position
BPP
Doppler flow
Fetal growth
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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 growthand well-being, AFI
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Doppler Flow Analysis via UTZ
Study blood blow in the fetus and placenta
Done on high risk mothers:
IUGR HTN
DM
Multiple gestation
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AFI
Polyhydramnios too much amniotic fluid
Oligohydramnios too little amniotic fluid
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Biophysical Profile
Includes 5 components:
Fetal breathing movements
Gross body movements
Fetal tone
AFI
NST - reactive
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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
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Meconium
Visual inspection of amniotic fluid
Meconium is defined as thin and thick andparticulate
Associated with fetal stress: hypoxia,umbilical cord compression
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CVS
Done between 9 -12 weeks
Genetic studies
Removal of small amount of tissue fromthe fetal portion of the placenta
Complications: vaginal spotting,
miscarriage, ROM, chorioamnionitis If done prior to 10 weeks, increased risk
of limb anomalies
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AFP
Genetic test
Done with mothers blood
16-20 weeks gestation Mandated by state of California
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EFM
Third trimester goal is to continue toobserve the fetus within the intrauterineenvironment
Goal: dx uteroplacental insufficiency
NST vs. CST
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NST
90% of gross fetal body movements areassociated 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 affectedby maternal medications, glucose etc.
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NST
To be reactive must meet criteria
Must be at least 20 minutes in length
Must have 2 or more accelerations thatmeet the 15 X 15 criteria
Must have a normal baseline
Must have LTV
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NST
To stimulate a fetus that is not meetingcriteria:
Change positions of the mother LS, RS
Increase fluids
Acoustic stimulator
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CST
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
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CST
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Endocrine and Metabolic Disorders
#1 Diabetes Mellitus
Disorders of the thyroid
Hyperemesis
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Diabetes
Hyperglycemia
May be due to inadequate insulin action ordue to impaired insulin secretion
Type 1 insulin deficiency
Type 2 insulin resistance
GDM glucose intolerance duringpregnancy
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DM
10th week fetus produces it own insulin
Insulin does not cross the placental barrier
Glucose levels in the fetus and directlyproportional to the mother
2nd and 3rd trimesters decreased
tolerance to glucose, increased insulinresistance, increased hepatic function ofglucose
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Diabetic Nephropathy
Increased risks for:
Preeclampsia
IUGR
PTL
Fetal distress
IUFD
Neonatal death
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DM
Poor glycemic control is associated withincreased risks of miscarriage at time ofconception
Poor glycemic control in later part ofpregnancy is assoc. with fetal macrosomiaand polyhydramnios
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Polyhydramnios
May compress on the vena cava and aortacausing hypotension, PROM, PPhemorrhage, maternal dyspnea
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Macrosomia
Disproportionate increase in shoulder andtrunk size
4000-4500gms or greater
Fetus will have excess stores of glycogen
Increased risks of
Shoulder dystocia C/S
Assisted deliveries
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IUGR
Compromised uteroplacental insufficiency
02 available to the fetus is decreased
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RDS
Increased RDS due to high glucose levels
Delays pulmonary maturity
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Neonatal Hypoglycemia
Usually 30-60 minutes after birth
Due to high glucose levels duringpregnancy and rapid use of glucose afterbirth
Related to mothers level of glucose control
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Labs with DM
HBA1c
1 hour PP
FBS
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Diet
Sweet success diet
Well balanced diet
6 small meals / day Have snack at HS
Never skip meals
Avoid simple sugars
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Insulin
Regular/Lispro and NPH
2/3 dose in am and 1/3 dose in pm
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Monitoring Glucose Levels
FBS
1 hour PP
HS 5 checks / day
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Fetal Surveillance
NSTs done around 26 weeks, weekly
At 32 weeks done biweekly with NST/BPP
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Infections and DM
Infections are increased:
Candidiasis
UTIs
PP infections
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DM
Increased risk of IUFD after 36 weeks
Increased congenital anomalies
Cardiac defects
CNS defects
Spina bifida
anencephaly
Skeletal defects
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DM and labor
Continuous fetal monitoring
Blood glucose levels in tight control
Be prepared for CPD
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GDM
Women with GDM at risk of developingDM later on in life
NSTs around 28 weeks
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Hyperthyroidism
Typically caused by Graves disease
S/S:
Fatigue
Heat intolerance
Warm skin
Diaphoresis
Weight loss
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Should be treated in pregnancy
Tx with PTU
Beta blockers
May lead to thyroid storm if untreated
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Hypothyroidism
Usually caused by Hashimotos
S/S:
Weight gain
Cold intolerance
Fatigue
Hair loss
Constipation
Dry skin
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Cardiovascular Disorders
The heart must compensate for theincreased workload
If the cardiac changes are not welltolerated than cardiac failure can develop
1% of pregnancies are complicated byheart disease
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NY Heart Association Classes
Class I
Class II
Class III Class IV
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Cardiac output is increased
Peak of the increase 20-24 weeksgestation
Cardiac problems should be managed withcardiologist
Mortality with pulmonary hypertension andpregnancy is more than 50%
Diet: low sodium
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Nursing Care
Avoiding anemia
Avoid strenuous activity
Monitor for: cardiac failure and pulmonarycongestion
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During Labor
Side lying position
Prophylactic antibiotic
EpiduralAttempt vaginal delivery
If anticoagulant therapy is needed:
Heparin Lovenox
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MVP
Common and usually benign
May experience syncope, palpitations anddyspnea
Prophylactic antibiotics given beforeinvasive procedure or birth
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Anemia
Most common iron deficiency
Hgb falls below 12 (most labs)
Typically seen in the end of 2nd trimester
Iron supplementation
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Folic Acid Deficiency Anemia
Increases risk of NTD, cleft lip
Recommended dose 400 mcg/day
Supplemented in cereal and many otherfoods
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Sickle Cell Anemia
Abnormal hemoglobin SS types in theblood
People have recurrent attacks of fever and
pain in the abdomen and extremities
Caused from tissue hypoxia, edema
African-Americans
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Thalassemia
Common anemia
Insufficient amount of Hgb is produced tofill the RBCs
Mediterranean region
Genetic disorder
May be associated with LBW babies andincreased fetal death
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Asthma
Common with FH
1-4% of pregnant women have Asthma
Possible adverse events associated with
asthma: LBW
Perinatal mortality
Preeclampsia Complicated labor
Hyperemesis
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Asthma Continued
Goal is to relieve the attack, prevent theasthma attack, and maintain 02
Should be managed with OB and ENT
May require tx: albuterol, steroids, O2
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Epilepsy
Seizure disorder
May result from developmentalabnormalities or injury
20% have an increase in seizure activityduring pregnancy
Risks: more seizures, risk of vaginalbleeding, abruptio placentae, fetus mayexperience seizures
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Epilepsy Continued
Use of antiepeleptic meds duringpregnancy has been linked to risks for thefetus
Smallest therapeutic dose to be given
Daily folic acid supplementation
Managed with OB and neurologist
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RA
Chronic arthritis
Pain upon movement and swelling in jointspaces
More often in women
2/3 of women with RA find the severity ofsymptoms decrease during pregnancy
Typically give baby ASA
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SLE
Inflammatory disease, autoimmuneantibody production
Advised to wait until in remission for 6
months to become pregnant
15-60% of women will developexacerbation of SLE during pregnancy or
postpartum
Tx: ASA and steroids
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Cholelithiasis
More often in women
Pregnancy makes women more vulnerable
Surgery often delayed until after delivery
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Appendicitis
Dx may take more time to find
Sxs: abdominal pain, nausea, vomiting,loss of appetite
Increases incidence of PTL or SAB
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TORCH
Toxoplasmosis protozoan infection,neonatal effects jaundice,hydrocephalus, microcephaly
Other- Heb A or B, Group B, Varicella, HIV
Rubella (German measles) if contractedin 1st Trimester fetus may have congenital
deformities
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TORCH
CMV- transmitted person to person, maycause CNS damage to fetus
Herpes Simplex (HSV 2) if initial
infection occurs in pregnancy, higherincidence of perinatal loss. Fetus maypick up virus if present in the vagina
during labor
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Mental Health Disorders
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Anxiety Disorders
Most common mental disorders
Include: phobias, panic disorders, OCD,PTSD
Tx: relaxation techniques, breathingexercises, imagery
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Depression in Pregnancy
6% of women develop depression for the1st time during pregnancy
Tx: counseling and tx with SSRIs
Wellbutrin only med named as Category B
Many women opt to DC meds duringpregnancy
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Substance Abuse in
Pregnancy
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Smoking
Risks of any amount of smoking include:
SAB
SGA
Bleeding
IUFD
Prematurity
SIDS
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Alcohol
Many women reluctant to tell health careprovider
Risks:
LBW
Mental retardation
Learning and physical deficits
With FAS severe facial deformities
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Alcohol during Pregnancy
Risks to mother:
HTN
Anemia
Nutritional deficits
Pancreatitis
Cirrhosis
Alcoholic hepatitis
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Marijuana
Crosses the placenta and causes increasedcarbon monoxide levels in mothers blood
May cause fetal abnormalities
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Cocaine
In the US, 10-15% of all pregnant womenuse cocaine
Problems associated with use: polydrug
use, poor health, poor nutrition, STIs,infections, HIV
Poverty big issue
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Cocaine in 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
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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
h h
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Methamphetamine
CNS stimulant
Most common use n the 18-30 yr oldrange
Neonatal complications include:
IUGR
PRL/PTB
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Postpartum Psychologic
Complications
B b Bl
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Baby Blues
Usually within 4 weeks of childbirth
Many experience this
PPD
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PPD
Intense sadness, crying all the time, moodswings, fears, anger, anxiety, irritability
Incidence of PPD at 8 weeks 12% and
8% at 12 weeks
Many women feel guilty
May need tx but usually resolves on own
P t t P h i
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Postpartum Psychosis
Delusions, hurting self or the infant,emotional lability, insomnia,suspiciousness, confusion, obsessive
concerns regarding the baby 1-2/1000 births
35-60% recurrence with each subsequentbirth
Usually symptoms appear within 8 weeksof birth
M di l M t
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Medical Management
Supportive family
Intense psychotherapy
Emergency
Tx: SSRIs
SSRIs contraindicated while breastfeeding
1 A client asks the nurse to again explain
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1. A client asks the nurse to again explainthe purpose of the amniocentesis test.
The nurse responds that one purpose ofthis 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 Downs syndrome
2. The nurse explains to a new mother
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that the condition of SGA is caused by:
A. Placental insufficiency
B. Maternal obesity
C. Primipara
D. Genetic predisposition
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4. The nurse in the newborn nursery
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4. The nurse in the newborn nurseryunderstands that assessing a newborn
with a diabetic mother, initially the insulinlevel 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
5. A client is admitted to L&D, at 38
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5. A client is admitted to L&D, at 38weeks gestation. She is there forevaluation because she is experiencingpolyhydramnios. The nurse understandsthat 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