HIGH RISK ANTEPARTUM NURSING CARE

1. HIGH RISK ANTEPARTUM NURSING CARE Developed by D. Ann Currie, R.N., M.S.N.

2. Identifying the clients at risk • Begins prior to pregnancy for those women with disease processes or conditions such as Cardiac disease, Diabetes Mellitus, Systemic Lupus Erythematosus, etc. • It may also will begin with the first prenatal visit and will continue throughout the pregnancy, into the intrapartum , and postpartum periods. • Many factors may influence the Outcome of a Pregnancy. • The nurse should be able to assess and identify those factors that place the the Antepartum Client at risk.

3. Risk Factors which effect a Pregnancy • Age-under 17 or over 30-35 • Lower Socioenomic • Race-Afro-American or Hispanic • Nutritional Status • Environmental Factors • Pregestational Conditions • Substance Abuse • Infections-STI’s, TORCH, and other • No Prenatal Care • See text for complete list

4. Hypertensive Disorders in Pregnancy • Pregnancy –induced Hypertension disorders: • Preeclampsia • Eclampsia • HELLP syndrome • Pregnancy-induced hypertension( Gestational Hypertension • Chronic Hypertension

5. PREECLAMPSIA • A hypertension condition which may occur in pregnancy starting in the third trimester of pregnancy, and/or the intrapartum, and/or postpartum periods. • The clinical manifestations include: • Hypertension- B/P over 140/90 • Proteinuria • ? Edema( if client has generalized edema with other clinical manifestations • Others …. Depending on severity • Types- mild, moderate, and severe

6. Preeclampsia • Risk Factors: • Nulliparity • Maternal age-teens under 19 or over 30 • Race-Afro-American and Hispanics • Lower Socioeconomic status • Family history of preeclampsia • Chronic hypertension • Diabetes mellitus • Systemic Lupus Erythematosus • Multigestation • Gestational Trophoblastic disease • Fetal hydrops

7. PREECLAMPSIA-Pathophysiology

8. Vasospasm seen in Preeclampsia

9. PREECLAMPSIA • Complications of Preeclampsia • Hypertensive Crisis • Pulmonary edema • Renal Failure • HELLP • DIC • Eclampsia • Cerebral Vascular Accident • Blindness • Hepatic Failure • Hepatic Rupture • Abruptio placenta • Uteroplacental insuffiency • IUGR • Preterm delivery • Fetal Death • Maternal Death-3th • leading cause of maternal mortality in USA

10. PREECLAMPSIA • Mild Preeclampsia: • Hypertension over 140-/90 –MAP-over 105 • Proteinuria( over 1+)0.3grams/liter in a 24 hour urine collection • Weight gain(2-2.5 pounds/week) • ?edema • Other

11. PREECLAMPSIA • Moderate Preeclampsia: • B/P-160/100 • Proteinuria-+3 • Edema facial and finger • Visual Problems

12. PREECLAMPSIA • Severe Preeclampsia:: • B/P – Over 180/110 ,MAP- • Proteinuria- 3+to4+ or more than 500grams in a 24 hour specimen. • Oliguria-less 400-500ml/day or less than 30 ml/hour • Sudden large weight gain • Generalize edema-facial, lung may have crackles • Central nervous system irritability: • Headaches • Hyperreflexia-DTR’s greater than +3-+4 with clonus • Visual disturbances-scotomata or burred vision

13. PREECLAMPSIA • Cont-Severe Preeclampsia • Hepatic involvement- upper right quadrant pain or epigastric pain. • Pulmonary edema • others

14. PREECLAMPSIA • Nursing Assessment guidelines for the client with preeclampsia: • Obtain a thorough history • Past medical history-check risk factors • Past Obstetrical history • Current pregnancy history • Assessment of the various systems • Cardiovascular assessment: • Vital signs and B/P frequency will depend of severe of preeclampsia • Ausculate heart sounds and lung sounds • Assess for edema-generalized pitting and pulmonary edema • Daily weight-A.M. same scale • Check capillary refill

15. PREECLAMPSIA • CONT. -Nsg. Assessment • Respiratory Assessment: • Assess respiratory rate, quality, and pattern • Ausculate lung sounds • Assess skin color. • Monitor oxygenation with pulse oximetry if indicated • Renal Assessment: • Assess Strict Urinary Output- frequency will depend on severity of preeclampsia maybe as often as every hour. • Assess for Protienuria-dipstick • Maintain 24 hour urine collect • Monitor laboratory valves-Electrolytes, BUN, Creatine, Serum protein, Uric acid

16. PREECLAMPSIA • Cont. Nsg. Assessment- • Hematologic- • Monitor Laboratory Studies • CBC-RBC, PLT, Hg, and Hct • Coagulation profile-fibrogen, fibrin split products, coagulation factors, PT ,and PTT • Monitor client for bleeding-in urine, bruises, etc. • Central Nervous System Assessment • Assess DTR’s • Assess level of consciousness • Pain- headaches • Visual changes • Assess for clinical manifestation of ICP-H/A, N/V, etc. • Change in behavior

17. PREECLAMPSIA • Liver Assessment • Assess for pain-epigastric or upper right quadrant pain • Monitor Liver Functions: • LDH • SGOT • SGPT • Alkaline phosphate • Bilirubin • Assess Skin Color • Fetal Assessment • Fetal movement • NST • Biophysical Profile

18. PREECLAMPSIA • Uterine Assessment • Monitor for uterine contractions • Assess for Uterine bleeding-Placental abruption. • Assess for clinical manifestations of uteroplacental insufficiency- AFI under 5cm or Decrease FM

19. PREECLAMPSIA • Nursing Diagnoses: • Alt.Tissue Perfusion-Cerebral, Uterine, Renal , etc relate to Vasospasms • Risk for Injury • Fluid Volume Deficient

20. PREECLAMPSIA • Nursing Care for the client who has Preeclampsia: depends on the severity of the disorder. • Mild Preeclampsia: • Bedrest at home-BRP- Bed exercises • Frequent rest periods or naps • Diet high in protein-70grams-100grams • and no added salt/ no salty foods-2-4grams of sodium • Daily Weights- A.M. • Assessment of B/P , dipstick urine for protein. • Fetal movement counts • Teach client/family signs to report to health care provider that may indicate complications • Client will frequent visits will the doctor-discuss the importance of these visits • Provide support for client’s/family’s concerns and fears.

21. PREECLAMPSIA • Moderate Preeclampsia: • The client with moderate and severe Preeclampsia will be admitted to the hospital.

22. PREECLAMPSIA • SEVERE PREECLAMPSIA: • Bed rest • Decrease CNS stimulation: • A quiet calm environment: • Lights low • Limit visitors • Prepare Room/equipment for emergencies : • Pad side rails • Oxygen and suction setups • IV equipment that can handle several kind of medications or lines • Dinomap and pulse oximeter • Fetal Monitor for continuous monitoring • Foley catheter • Preeclampsia tray: • Emergency equipment and drugs including : • Calcium gluconate • Valium

23. PRECLAMPSIA • SEVERE PREECLAMPSIA: • Complete initial and continuous assessment( see guideline for assessment) • Diet – maybe high in protein or NPO • Vital signs- B/P, HR, RR, and FHR every 15 minutes • Intake and output every hour-strict • Deep tendon reflexes every 15 minutes • Daily Weights • Position client in lateral position • Monitor IV infusions • Monitor laboratory tests

24. PREECLAMPSIA • SEVERE PREECLAMPSIA: Medications • Magnesium Sulfate-Antidote-Calcium gluconate • Hypertensive agents: • Methyldopa-Aldomet • Hydralazine- Apresoline • Labetalol-Normodyne • Nifedipine-Procardiac xl • Nitroprusside sodium-Nitropride • Glucorticosteriods-solu-medrol • Diazepam-Valium and/ or Phenytoin- Dilantin • Diuretics- Lasix-only with CHF or pulmonary edema

25. ELCAMPSIA • ECLAMPSIA is the development of: • Convulsions(seizures) Tonic-Clonic seizures • Coma • in the client who has clinical manifestations of preeclampsia. • It can occur in the antepartum, intrapartum, or postpartum periods. • Nursing Care: • Seizure care- refer to med-surg. text • Monitor fetal status and prepare for delivery • Prevent complications • Administer Medications

26. HELLP Syndrome • HELLP Syndrome is a multisystem condition, a severe form of preeclampsia in which the client may present with a variety of clinical manifestations. • Exhibits common laboratory markers: • H: Hemolysis.-Low RBC, present of burr cells • EL: Elevated Liver enzymes .- All liver functions will be high • LP: Low Platelets.-PLT.-less than 100,000 • The progression from severe preeclampsia to the development of multiple organ involvement and damage leads to HELLP.

27. HELLP SYNDROME • The client may complain of malaise, epigastric or upper right quadrant pain, nausea and vomiting, or vague symptoms ( not feeling well). She may be pale or jaundice. • Nursing Care- • Assessments and management of care is the same as severe preeclampsia. • Monitor laboratory values: • CBC • Liver Function Tests • Coagulation Studies • Type and Crossmatch • Possible Blood Transfusions and /or Platelet

28. HELLP SYNDROME • Cont. NSG. Care: • Prepare for delivery • Notify Charge nurse ,Anesthesia staff, and INC • Client will go to a Intensive Care Unit • Clint will have a Central line placed. • Medical or surgerical physicians maybe called in. • Equipment maybe needed from the surgery unit.

29. CHRONIC HYPERTENSION • Pregestational Hypertension • Maintain B/P within normal limits • Observe for complications • Medications: • The pregnant client should not take ACE Inhibitors or Beta Blockers for antihypertension agents. • Also Diuretics are usually not given except with the client will CHF • Monitor Fetal Well Being • Assist client to use non- pharmacological methods to help to control blood pressure.

30. Hemorrhagic Conditions in Pregnancy • ECTOPIC PREGNANCY • GESTATIONAL TROPHOBLASTIC DISORDER • ABORTIONS • PLACENTA PREVIA • ABRUPTIO PLACENTA

31. ECTOPIC PREGNANCY • ECTOPIC PREGNANCY is one in which the fertilized ovum implants in a location other than the endometrial cavity of the uterus. • The Fallopian Tube is the most common site. • The risk of an ectopic pregnancy increases with STI’s and with increase age(35-45) • Ectopic pregnancy is a significant cause of first trimester maternal deaths.

32. ECTOPIC PREGNANCY LOCATIONS

33. ECTOPIC PREGNANCY • Clinical manifestations: • Mild vaginal bleeding • Abdominal pain • Palpable mass • Signs of blood loss • Ultrasound will confirm an extrauterine pregnancy • Management of the ectopic pregnancy: • Surgerical involves laparoscopy or laparotomy for salingectomy with the partial or complete removal of the fallopian tube or removal of the ectopic pregnancy from other sites. –Prep for surgery

34. Ectopic Pregnancy • Alternate method to surgery is administer of Methotrexate • Only if the fetus is under 2.5-3.5 cm. • Single dose • Follow-up with ultrasounds and beta-hCG • Start IV as soon possible- be prepare to give blood • Provide emotional support to the client • If client is Rh-negative administer RhoGam • Monitor client for hemorrhage and infection • Discharge Instructions : • Teach client to report signs of infection and/or blood loss to the health provider • Anemic clients should take iron supplements • Importance of follow up care.

35. Gestational Trophoblastic Disease • GESTATIONAL TROPHOBLASTIC DISEASE is also know as Hydatidiform Mole or Molar pregnancy. • It is an abnormal growth of the trophoblasitc tissue including the placenta and chorion. • Risk Factors: • Clients of Southeast Asia- Japanese or Taiwan descent • Mothers over 40 • Possibly Vitamin A deficiency • Previous GTD. • Complications: • Hemorrhage • Infection • Choriocarcinoma • DIC

36. GESTATIONAL TROPHOBLASTIC DISEASE

37. Gestational Trophoblastic Disease • Clinical Manifestations: • Vaginal Bleeding- red to prune color • Severe nausea and vomiting • Uterine size greater than dates • Passing on grape-like vesicles • No fetal parts palpated and no FHR heard • Abnormal labs : • Very high hCG levels • Very low MSAFP • Possible low Rbc, Hct, and Hg

38. Gestational Trophoblastic Disease • Clinical Manifestations: • Preeclampsia prior than 20 weeks • Ultrasound will have characteristic “snow storm” pattern with no fetus • Nursing Care for client who has GTD: • Monitor Vital Signs • Insert IV catheter and maintain IV infusion • Prepare the client for surgery-suction uterine evacuation of mole. • Administer RhoGam is client is Rh-negative. • Administer chemotherapy as order- Methotrexate

39. Gestational Trophoblastic Disease • Cont. NSG. Care: • Teach client: • About the disease process, and treatment • The need for follow up care for a year • Weekly hCG testing at first, than every 3monthsfor a year • No pregnancies for at least one year and the use of contraception • Signs of problems to report to the health care provider • About the Medications being used • Acknowledge and support the need to grieve the loss of the pregnancy

40. Abortions • An ABORTION is the termination of a pregnancy prior to 20 weeks. In Texas a fetus must have two of the three criteria’s; be under 20 weeks, or under 500 grams, or under 14 inches, to be considered an abortion. • Types of Abortions: • Spontaneous- lay term is Miscarriage • Elective or Therapic-surgically or medically induce termination of the pregnancy.

41. Spontaneous Abortions • TYPES of SPONTANEOUS ABORTIONS: • Threatened Abortion • Inevitable Abortion • Incomplete Abortion • Complete Abortion • Missed Abortion • Reoccurring Abortions (Habitual Abortion) • Septic Abortion • Risk Factors: vary

42. Threatened Abortion

43. Incomplete Abortion

44. Imminent Abortion

46. Spontaneous Abortions • Clinical manifestations: • May vary • Vaginal bleeding • Cramping • May have cervical dilation • May pass tissue and/or clots • Dull backache • Regression of signs of pregnancy • Falling hCG levels • No fetal heart tone • Smaller uterine size • Signs of infection in infection is present

47. Spontaneous Abortions • Nursing Care: • Depends on the type of spontaneous abortion • Bedrest and no sexual activity if threaten abortion • Save any tissue pass • Prepare for surgery: dilatation and curettage(D&C) • Assess client • Insert IV catheter and maintain IV infusion • Obtain lab specimens and sent to lab: • CBC • Type and Rh- Type and cross match • Serum beta-hCG • Possible coagulation studies • Prepare for ultrasound • Administer RhoGam if client is Rh-negative • Provide emotional support remember this a loss • Refer to pregnancy –loss or grief support groups

48. FETAL LOSS • If client spontaneous loses baby 0r it is an intrauterine death and if the client/family would like to view and/or visit with baby, Provide the opportunity in a private area • Allow the client to name the baby • Take pictures • Give something for the client to take home • Clean the baby with soft cloth or cotton • Never give a cold baby…Wrap in warm blankets • Allow family to visit • Provide the opportunity for religion beliefs

50. Elective Abortions/Therapeutic Abortions • Elective Abortion is the intentional termination of pregnancy before 20-24weeks. • Therapeutic Abortion is the termination of the pregnancy for medical reasons. • The termination of the pregnancy is done by surgery – Dilatation and Curettage (D&C) or with medications called abortifacts • The nurse should be aware of the state’s specific regulations governing abortions. • Abortions have many ethical issues. The nurse should know beliefs concerning this issue.