High Risk Pregnancies

High Risk Pregnancies

 

A high risk pregnancy is one in which the life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to pregnancy.

 

Risk assessment:

Biophysical -factors that originate within the mother or fetus and affect the development or functioning of either one or both.

Examples: genetic disorders, nutritional and general health status, and medical or obstetric-related emergencies

Psychosocial -maternal behaviors and adverse lifestyles that have a negative effect on the health of the mother or fetus.

Ex: emotional distress and disturbed interpersonal relationships, inadequate social support, unsafe cultural practices, substance use, abuse

Sociodemographic -arise from the mother and her family. These risks may place the mother and fetus at risk.

Ex: lack of prenatal care, age, low income, marital status, ethnicity.

Environmental– hazards in the workplace and the woman’s general environment. May include environmental chemicals (ie: pesticides, lead, and mercury), radiation, and pollutants.

 

Risk factors are interrelated and cumulative in their effects.

 

Morning Sickness Hyperemesis Gravidarum
Begins at 4-6 weeks gestation- peaks at 8-12 weeks Begins during the first 10 weeks gestation
Confined to first trimester (ends at 16-20 weeks) Continues throughout pregnancy
More common when HCG is higher (ie: multiples) Excessive- causes a weight loss of at least 5% of prepregnancy weight.–> significant weight loss
Normal- may be histamine response or psychological. Accompanied by dehydration, electrolyte imbalance, ketosis, and acetonuria
Able to keep down small meals and clear liquids Unable to keep down anything, even clear liquids
  Decreased BP, increased pulse rate, poor skin turgor
Tx: Small meals, crackers before arising, etc Tx: IV therapy for correction of fluid and electrolyte imbalance, NPO status until dehydration has resolved and for at least 48 hours after vomiting has stopped

– Meds may be needed for uncontrolled n/v

  If not resolved, TPN may be used as last resort.

 

First Trimester Bleeding

Miscarriage– a pregnancy that ends before 20 weeks of gestation.

– 20 weeks is considered the point of viability- or when the fetus is able to survive in an extrauterine environment.

– A fetal weight of <500g may also be used to define miscarriage.

Spontaneous Abortions/Miscarriages

(1) Threatened– include spotting of blood but with the cervical os closed. Mild uterine cramping may be present.

(2) Inevitable– involves a heavy amount of bleeding with an open cervical os. Tissue may be present with the bleeding. May involve rupture of membranes and cervical dilation. Passage of the products of conception may occur.

(3) Incomplete– Involves expulsion of the fetus with retention of the placenta.

(4) Complete– all fetal tissue is passed, the cervix is closed and there may be slight bleeding.

(5) Missed– a pregnancy in which  the fetus has died but the products of conception are retained in utero for several weeks.

 

Causes:

– Early miscarriage (under 12 weeks)- causes include endocrine imbalance, immunologic factors, systemic disorders (ie: lupus), and genetic factors.

-A late miscarriage/abortion (12-20 weeks) usually results from maternal causes, such as advancing maternal age and parity, chronic infections, premature dilation of the cervix and other anomalies of the reproductive tract, chronic debilitating diseases, poor nutrition, and recreational drug use.

 

Diganosis: Assess pain, bleeding, LMP (to determine gestational age), pain (type, location, duration, precipitating and palliative factors), vital signs, previous pregnancies (incl. losses), emotional status

– HCG levels: low levels of HCG are characteristic of miscarriage (HCG should double q48 hr in normal preg).

            – Draw 2 levels 48 hours apart- levels should double.

– Ultrasound

 

Treatment: Threatened- bed rest and supportive care.

Others- treat hemorrhage and infection. (IV, blood type and crossmatch, H&H, u/s

– Dilation and Curetage (D&C)- surgical procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents.  Used to tx inevitable and incomplete miscarriages.

 

Ectopic Pregnancy- the fertilized ovum is implanted outside the uterine cavity.

– leading pregnancy-related cause of 1st trimester maternal deaths and is responsible for 9% of all maternal deaths.

– Implants within 1st week, as it grows, baby can rupture tube and cause fullness.

 

S/S: abnormal vaginal bleeding, adnexal fullness and pain are classic sx. Abdominal pain is usually the primary presenting sx at approx 5-6 weeks of gestataion.

– Infection (gonorrhea, chlaymia, std’s) can cause ectopic preg..

– If impants on intestines, will very rarely grow to term

– The tenderness can progress from a dull pain to a colicky pain when the tube stretches, to sharp stabbing pain.

– pain may be unilateral, bilateral, or diffuse over the abdomen.

– If ectopic pregnancy ruptures, pain increases.

– Referred shoulder pain if internal bleeding.

– Ecchymotic blueness around the umbilicus (Cullen’s sign) indicating hematoperitoneum.

– other presenting sx include dizziness, fainting, and pregnancy sx

DES Daughter- have reproductive issues d/t mother taking med for preterm labor.

 

Treatment:

– Vaginal exam should be performed only once, and then great caution.

– Removal of the ectopic preg. is possible when the pregnancy is <2cm in length.

            – Methotrexate (chemo drug) can be given to attack rapidly growing cells.  

– Advanced ectopic preg, requires laparotomy

– Both tubes are often affected, so future fertility is often an issue.

 

Gestational Trophoblastic Disease (Hydatidiform Mole)

  • Persistent trophblastic tissue presumed to be malignant.
  • Women at higher risk for mole formation:  Teens, over 40, from far east or tropics.
  • Mole looks like a bunch of white grapes.
    • Fluid-filled vesicles grow rapidly, causing uterus to be larger than expected for the duration of the pregnancy.
  • Bleeding into uterine cavity and vaginal bleeding occur.
  • Anemia from blood loss, hyperemesis gravidarum, abdominal cramps caused by uterine distension common.
  • Diagnosis made by HCG levels (100’s-1000x normal) and ultrasound (snowstorm pattern)
  • Treatment: dilation and evacuation
    • Then weekly HCG levels are drawn until normal- then monthly for 1 year.
    • Need to avoid pregnancies for this 1-year because of close monitoring of HCG levels.
    • Need birth control counseling.
    • Termination of pregnancy.
    • Most cases benign- but can be cancer.
    • If cancerous, highly metastatic to brain and lungs
    • Can cause PIH in 1st trimester

 

Incompetent Cervix

  • Passive and painless dilation without labor or contractions
  • Occurs late 2nd or early 3rd trimester.

Risk Factors:

  • Previous cervical trauma, threatened abortions, biopsy, congenital problem (DES Daughter).

Diagnosis:

  • Ultrasound- short cervix and effacement of internal os (Cervical funneling)

Treatment:

  • Bedrest, hydration, progesterone, antiinflammatories, antibiotics
  • Cerclage– ‘purse string’ closure of the cervix
  • Prophylactic cerclage- closure at 11-15 weeks-> pelvic rest, no heavy lifting, no prolonged (>90min) standing.
  • Needs to be taught- if contractions start- need to come to hospital immediately to have cerclage removed (risk for cervical tearing).
  • Risk for self-esteem, grieving
  • Risk for preterm labor r/t procedure, hemorrhage, fever

 

Anemia

  • Hemoglobin = 11 or less (normal non-preg 37-47%, pregnant = >33%)
  • Have s/s if Hgb <6-7
  • Results in decrease of O2 carrying capacity of the blood- heart tries to compensate by increasing the cardiac output.
  • Anemia that occurs with any other complication (ie: preeclampsia) may result in CHF
  • Increased risk of puerperal complications.
  • Iron deficiency anemia= most common

Treatment:

  • Ask about PICA
  • Women who eat balanced diet are encouraged to take multivitamin with iron.
  • Increase iron dosage (60-120 mg/day)
  • Watch GI side effects
  • Vitamin C helps with iron absorption.

 

Folate Deficiency

  • Poor diet and increased alcohol intake may contribute
  • Malabsorption may play a part in development of anemia
  • S/S: Pallor, fatigue, lethargy
  • More common in multiple gestation
  • Recommended intake during pregnancy= 400 mcg
  • Should consume legumes, green/leafy vegetables.

 

Sickle Cell

  • Stress of pregnancy can active it- causing sickle cell crisis
  • Risk for UTI’s, iron deficiency, and hematuria.
  • Fetal complications= SGA, IUGR, Skeletal changes

 

Thalassemia

  • Hemoglobin problem- premature RBC death
  • 2 types: Major and minor
    • Minor= trait- minor persistent anemia during pregnancy but RBC’s normal or elevated
    • Major= disease

 

 

 

Thromboembolic Disease

  • SVT’s and DVT’s
  • Deep Vein Thrombosis= more prevalent in pregnancy
  • s/s: unilateral leg pain, calf tenderness, swelling
  • Fibrogenin increases-> blood is hyperclottable
  • Venous stasis- hard for blood to come up body
  • Tx: Heparin-> doesn’t cross placenta.
    • Can use subq heparin at home
    • No oral contraceptives- increases risk of DVT’s
    • Okay to breastfeed- avoid cracked nipples
  • SVT= more common in postpartum
  • s/s: warmth, tenderness, enlarged hardened vein over site.

 

Substance Abuse

  • Marijuana and cocaine most commonly used
  • Cocaine= causes severe muscle contractions, abruption of placenta
  • Methadone (heroin)= every effort is made to get mom on methodone. More controlled source
  • Alcohol= no safe limit- fetal alcohol syndrome-

–          mental, physical and behavioral effects.

 

Cardiac Disease

Risk greatest in 2nd trimester and immediately after delivery

All extra circulating volume that was in placenta, etc has to go back into mom’s circulation= massive overload

Degree of disability divided into classes:

            Class I: asymptomatic- without limitation of physical activity

            Class II: Symptomatic- with slight limitation of activity

            Class III: Symptomatic with marked limitation of activity (ie: can’t go up 2 stairs without getting winded)

            Class IV: Symptoms at rest (Can’t sit in chair without getting winded)

Classes I and II = will do close monitoring during pregnancy

Classes III and IV= Major difficulties in pregnancy- should be in specialized hospital.

            Usually admitted at approx. 20 weeks on telemetry floor

Tx: Rest, avoid infections, low salt diet, avoid anemia, O2, avoid constipation, monitor for thrombophlebitis, decrease stress

            Avoid beta blockers (inderal)- can interfere with uterine perfusion.

2 Responses to High Risk Pregnancies

  1. Amber says:

    This was really helpful, thanks for sharing.

  2. Karen says:

    So informative and to the point

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