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Management of Pregnancy at Risk Chapter 19

Management of Pregnancy at Risk Chapter 19. Mary L. Dunlap MSN, APRN Fall 2014. High-Risk Pregnancy. Jeopardy to mother, fetus, or both Condition due to pregnancy or result of condition present before pregnancy Higher morbidity and mortality

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Management of Pregnancy at Risk Chapter 19

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  1. Management of Pregnancy at Risk Chapter 19 Mary L. Dunlap MSN, APRN Fall 2014

  2. High-Risk Pregnancy • Jeopardy to mother, fetus, or both • Condition due to pregnancy or result of condition present before pregnancy • Higher morbidity and mortality • Risk assessment with first Antepartal visit and each subsequent visit • Risk factors (see Box 19-1 p.605)

  3. Conditions Complicating Pregnancy • Perinatal Loss • Bleeding • Hyperemesis gravidarum • Gestational hypertension • HELLP syndrome • Gestational diabetes

  4. Pregnancy at Risk • Blood incompatibility • Polyhydramnios & Oligohydramnios • Multiple gestation • Premature rupture of membranes • Preterm labor

  5. Perinatal Loss • Death of a fetus or newborn no matter when it occurs is devastating to the mother and family • Nurses need to understand their own personal feelings so they can provide support and compassionate care • What to say- I understand , I am here to listen, Does your baby have a name

  6. Causes of Bleeding • Spontaneous abortion • Ectopic pregnancy • GTD/Hydatiform mole • Cervical insufficiency • Placenta Previa • Abruptio placenta

  7. Spontaneous Abortion • Termination of pregnancy before viability prior to 20wks less than 500g • Presentation-Vaginal bleeding and cramping • Management-Bed rest, serial hCG’s & H&H, Dilation and curettage may be necessary to remove products of conception, RhoGam if mother RH -

  8. Causes • Congenital abnormalities • Incompetent cervix • Anomaly of the uterine cavity • Hypothyroidism • Diabetes mellitus • Drug use • Infection

  9. Categories of Abortions • Complete–all products of conception expelled • Incomplete–a portion of the products of conception retained in the uterus • Threatened–bleeding and cramping

  10. Categories of Abortions • Missed– nonviable embryo retained in uterus for at least 6 weeks • Habitual–three or more successive abortions • Inevitable–cannot be stopped • Table 19-1 pg. 607

  11. Spontaneous Abortion Nursing care • Assess bleeding and signs of shock • Assess pain level • Assess for infection • Provide emotional support

  12. Ectopic Pregnancy • Fertilized ovum implanted outside the uterine cavity usually due to an obstruction of the fallopian tube • 95%- 99% occur in the fallopian tube • Possible implantation sites Fig 19-1 pg 531

  13. Contributing Factors • Previous ectopic • STD’s • Endometriosis • Tubal or pelvic surgery • Uterine fibroids • IUD • Progesterone only BC pills (slows ovum transport)

  14. Ectopic Pregnancy Manifestations • Missed menses • Vaginal bleeding & pelvic pain 6-8 wks after missed menses • Diagnosis: Lab test & Ultrasound

  15. Ectopic Pregnancy Management • Administer Methotrexate, • Surgical-Salpingectomy • Nursing Care: Monitor for shock, prepare for surgery & provide emotional support

  16. Gestational Trophoblastic Disease(GTD) • GTD is a disease characterized by an abnormal placental development resulting in the production of fluid filled grape like clusters and vast proliferation of Trophoblastic tissues • Diagnosis- trans vaginal U.S. showing vesicular molar pattern (grape clusters) high hCG levels

  17. GTD • Complete (or classic): mole results from fertilization of egg with lost or inactivated nucleus and is associated with Choriocarcinoma • Partial mole: result of two sperm fertilizing a normal ovum • Cause unknown

  18. GTD Clinical manifestations • Bleeding grape like tissue • Sever Hyperemesis • Uterine size larger than dates • Extremely high hCG levels • Early development preeclampsia

  19. GTD Management • Immediate evacuation of uterine content by Dilatation & suction curettage • Tissue evaluate for Choriocarcinoma • Follow up for one year

  20. GTD Nursing Assessment • Assess for expulsion of grapelike vesicles • Sever morning sickness due to the high hCG levels • Unable to detect heart rate after 10-12 wks. • Early development of preeclampsia (prior to 24 wks.)

  21. Cervical Insufficiency • Premature cervical dilatation due to aweak structurally defective cervix that spontaneously dilates in the absence of contractions in the 2nd trimester • 18–22 wks. Usual time for development • Repetitive second trimester losses

  22. Cervical Insufficiency Possible causes • Trauma to the cervix • Structure of cervix- less collagen and more smooth muscle

  23. Cervical Insufficiency Management • Bed rest • Pelvic rest • Avoid heavy lifting • Cervical cerclage placed 2nd trimester if no infection present fig 19.3 pg.615

  24. Cervical Insufficiency Nursing Assessment Monitor for: • Preterm labor • Backache • Increase vaginal discharge • Rupture of membranes • Contractions

  25. Placenta Previa • Occurs when the placenta implants near or over internal cervical os • Classification based on degree internal cervical os is covered by placenta

  26. Placenta Previa • Complete Placenta Previa • Partial Placental Previa • Marginal Previa • Low-lying

  27. Previa classifications

  28. Placenta Previa Symptoms • Painless vaginal bleeding that occurs during the last two months of pregnancy

  29. Placenta Previa Therapeutic Management • Based on bleeding, location of Previa and fetal development • “Wait and see” approach if fetus stable and no active bleeding may go home on bed rest • Bleeding present admitted to hospital monitoring bleeding, FHR, and avoid vaginal exams.

  30. Placenta Previa Nursing Management • Monitor vaginal bleeding • Monitor for fetal distress • Provide emotional support • Education • Nursing care plan 19.1 pg. 618 & 619

  31. Abruptio Placenta • Premature separation of placenta form the uterine wall after 20 weeks of gestation leading to compromised fetal blood supply. • Significant cause of 3rd trimester bleeding

  32. Abruptio Placenta Clinical manifestations: • Knife like pain • Port wine vaginal bleeding • Prolonged contraction • Ridged abdomen • Uterine tenderness • Decrease FHR

  33. Abruptio Placenta Classification systems grades 1,2,3 • Grade 1 (mild) less than 500 mL • Grade 2 (moderate) 1000-1500mL • Grade 3 (severe) greater than 1500

  34. Classifications of Abruptio Placenta

  35. Diagnostic Testing • CBC • Fibrinogen levels • PT/PTT • Type and Cross match • Kleihauer-Betke test • NST • Biophysical Profile

  36. Abruptio Placenta Management Goal • Assess, control and restore blood loss • Positive out come for mother and Baby • Prevent coagulation disorder Box 19.2 pg. 621

  37. Abruptio Placenta Nursing Management • O2 therapy • Monitor FHR tracing • Monitor fundal height • Bed rest- left lateral position • Monitor V.S. for shock • Monitor for DIC • Emotional support

  38. Hyperemesis • “Morning sickness” normal nausea and vomiting experienced by 80% of pregnant women . • Symptoms are mild and usually resolve at the end of the first trimester • Management Teaching Guidelines 19.1 pg. 627

  39. Hyperemesis Gravidarum • Excessive vomiting accompanied by dehydration, electrolyte imbalance, ketosis, acetonuria and weight loss • Continues past the 20th wks. • Experiences N&V for the first time after 9 wks. • These mothers require hospitalization

  40. Hyperemesis Gravidarum • Possible causes: etiology unknown could be due to high hormone levels, low blood glucose levels, Vit B complex and protein deficiency, metabolic stress, depression, elevated thyroid hormone levels • Collaborative care: GI consult to r/o GI problems , Psychiatric consult , Dietary consult

  41. Hyperemesis Gravidarum Diagnostic Test • Liver enzymes • CBC • Urine • BUN • Urine specific gravity • Electrolytes • US

  42. Hyperemesis Gravidarum Management • NPO for 24-36 hr. • IV therapy • Medications-Reglan, Phenergan, Zofran, Compazine, B6 (19-2 pg.625) • Comfort • Emotional support • Teaching Guidelines 19.1

  43. Hypertension Classification

  44. Assessing Blood Pressure • Never place patient in Left Lateral Tilt position will give a false lower B/P • Setting or semi-Fowler’s position • Make sure patient is comfortable • Use the appropriately sized cuff • Cuff needs to be at the level of the right atrium (mid-sternum • If ≥149/90 recheck in 15 min.

  45. Hypertension Classification • Chronic hypertension, appears before the pregnancy or the 20th week and is persistence after 12 wks. PP • Oral antihypertensive are used (avoid ACEs & ARBs due to teratogenic side effects)

  46. Antihypertensive Therapy • Prevent CVA and maintain placental perfusion • Apresoline- can cause rebound tachycardia • Labetalol – beta blocker due not use with asthmatic patients • Aldomet • Procardia

  47. Hypertensive Emergency ACOG Guidelines Acute onset lasting 15 minutes or longer • SBP ≥ 160 mm Hg or • DBP ≥ 110 mm Hg • Loss of cerebral vasculature auto regulation • Treat with Hydralazine & Labetalol

  48. Hypertension Classification • Gestational hypertension- Onset without proteinuria after 20th week of pregnancy and returns to normal by 12 wks. Postpartum • Mild- SBP 140-159 DBP 90-109 • Severe- SBP ≥ 160 DBP ≥ 110

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