Nursing 353 Maternal Risk Factors Fetal Assessment

February 3rd, 2005

High Risk Pregnancy

The life or health of the mother or fetus is jeopardized Examples include:

GDM Previous loss AMA HTN Abnormalities with the neonate

Perinatal Mortality
Overall maternal deaths are small Many deaths a preventable Education and prenatal care are very important

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 UTZ

Study blood blow in the fetus and placenta Done on high risk mothers:

IUGR HTN DM Multiple gestation

AFI

Polyhydramnios too much amniotic fluid Oligohydramnios too little amniotic fluid

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
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
Genetic test Done with mothers blood 16-20 weeks gestation Mandated by state of California

EFM
Third trimester goal is to continue to observe the fetus within the intrauterine environment Goal: dx uteroplacental insufficiency NST vs. CST

NST
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

NST

To stimulate a fetus that is not meeting criteria:

Change positions of the mother LS, RS Increase fluids Acoustic stimulator

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

CST

Endocrine and Metabolic Disorders

#1 Diabetes Mellitus Disorders of the thyroid Hyperemesis

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

Diabetic Nephropathy

Increased risks for:

Preeclampsia IUGR PTL Fetal distress IUFD Neonatal death

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

Polyhydramnios

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

IUGR
Compromised uteroplacental insufficiency 02 available to the fetus is decreased

RDS
Increased RDS due to high glucose levels Delays pulmonary maturity

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

Labs with DM
HBA1c 1 hour PP FBS

Diet
Sweet success diet Well balanced diet 6 small meals / day Have snack at HS Never skip meals Avoid simple sugars

Insulin
Regular/Lispro and NPH 2/3 dose in am and 1/3 dose in pm

Monitoring Glucose Levels

FBS 1 hour PP HS 5 checks / day

Fetal Surveillance

NSTs done around 26 weeks, weekly At 32 weeks done biweekly with NST/BPP

Infections and DM

Infections are increased:

Candidiasis UTIs PP infections

DM
Increased risk of IUFD after 36 weeks Increased congenital anomalies

Cardiac defects CNS defects

Spina bifida anencephaly

Skeletal defects

DM and labor
Continuous fetal monitoring Blood glucose levels in tight control Be prepared for CPD

GDM
Women with GDM at risk of developing DM later on in life NSTs around 28 weeks

Hyperthyroidism
Typically caused by Graves disease S/S:

Fatigue Heat intolerance Warm skin Diaphoresis Weight loss

Should be treated in pregnancy Tx with PTU Beta blockers May lead to thyroid storm if untreated

Hypothyroidism
Usually caused by Hashimotos S/S:

Weight gain Cold intolerance Fatigue Hair loss Constipation Dry skin

Tx with thyroid hormones such as synthroid or levothyroxine Maintain TSH wnl Checked periodically throughout the pregnancy

Cardiovascular Disorders
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

NY Heart Association Classes

Class Class Class Class

I II III IV

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

During Labor
Side lying position Prophylactic antibiotic Epidural Attempt vaginal delivery If anticoagulant therapy is needed:

Heparin Lovenox

MVP
Common and usually benign May experience syncope, palpitations and dyspnea Prophylactic antibiotics given before invasive procedure or birth

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 Continued
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 Continued
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

RA
Chronic arthritis Pain upon movement and swelling in joint spaces More often in women 2/3 of women with RA find the severity of symptoms decrease during pregnancy Typically give baby ASA

SLE
Inflammatory disease, autoimmune antibody production Advised to wait until in remission for 6 months to become pregnant 15-60% of women will develop exacerbation of SLE during pregnancy or postpartum Tx: ASA and steroids

Cholelithiasis
More often in women Pregnancy makes women more vulnerable Surgery often delayed until after delivery

Appendicitis
Dx may take more time to find Sxs: abdominal pain, nausea, vomiting, loss of appetite Increases incidence of PTL or SAB

Maternal Infections

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

TORCH
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

Mental Health Disorders

Anxiety Disorders
Most common mental disorders Include: phobias, panic disorders, OCD, PTSD Tx: relaxation techniques, breathing exercises, imagery

Depression in Pregnancy
6% of women develop depression for the 1st time during pregnancy Tx: counseling and tx with SSRIs Wellbutrin only med named as Category B Many women opt to DC meds during pregnancy

Substance Abuse in Pregnancy

Substance Abuse
Damaging effects well documented in research to fetus Any use of ETOH or illicit drugs during pregnancy is considered abuse 31% of women had used one or more substances during pregnancy (as compared to 62% during prepregnancy)

Smoking

Risks of any amount of smoking include:

SAB SGA Bleeding IUFD Prematurity SIDS

Alcohol
Many women reluctant to tell health care provider Risks:

LBW Mental retardation Learning and physical deficits With FAS severe facial deformities

Alcohol during Pregnancy

Risks to mother:
HTN Anemia Nutritional deficits Pancreatitis Cirrhosis Alcoholic hepatitis

Marijuana
Crosses the placenta and causes increased carbon monoxide levels in mothers 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 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

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

Methamphetamine
CNS stimulant Most common use n the 18-30 yr old range Neonatal complications include:

IUGR PRL/PTB

Postpartum Psychologic Complications

Baby Blues
Usually within 4 weeks of childbirth Many experience this

PPD
Intense sadness, crying all the time, mood swings, 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

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 subsequent birth Usually symptoms appear within 8 weeks of birth

Medical Management
Supportive family Intense psychotherapy Emergency Tx: SSRIs SSRIs contraindicated while breastfeeding

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. B. C. D. E. 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 Downs syndrome

2. The nurse explains to a new mother that the condition of SGA is caused by:
A. B. C. D. Placental insufficiency Maternal obesity Primipara Genetic predisposition

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. Its 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 dont gain too much weight, your insulin needs should stay the same

4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be:
A. B. C. D. Higher than in normal infants Lower than in normal infants The same as in normal infants Varied from baby to baby

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