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High-Risk Pregnancy

• A high-risk pregnancy involves conditions jeopardizing the health of the mother, fetus, or both.

Identification of High-Risk Client

Factors Categorizing Pregnancy as High Risk (Pre-pregnancy)

Psychological Factors

• History of drug dependence increases pregnancy risk
• History of intimate partner abuse can affect pregnancy outcomes
• History of mental illness can affect pregnancy outcomes
• History of poor coping mechanisms can denote pregnancy risk
• Being a survivor of childhood sexual abuse increases pregnancy risk
• Cognitive challenges can increase pregnancy risk

Social Factors

• Occupations involving handling toxic substances can increase pregnancy risk
• Environmental contaminants at home can affect pregnancy outcomes
• Lower economic level can affect access to care in pregnancy
• Poor access to transportation for care can increase pregnancy risk
• High altitude increases pregnancy risk
• A highly mobile lifestyle may affect pregnancy care
• Poor housing conditions can denote pregnancy risk
• Lack of social support increases pregnancy risk

Physical Factors

• Visual or hearing challenges can increase pregnancy risk

Additional Risk Factors

• Pelvic inadequacy due to misshape increases pregnancy risk
• Uterine incompetence or structural issues can cause pregnancy complications
• Secondary major illnesses can increase pregnancy risk
• Poor gynecologic or obstetric history increases pregnancy risk
• History of previous poor pregnancy outcomes increases pregnancy risk
• History of a child with congenital anomalies increases pregnancy risk
• Obesity can affect pregnancy outcomes
• Pelvic inflammatory disease increases pregnancy risk
• History of inherited disorder increases pregnancy risk
• Potential for blood incompatibility increases pregnancy risk
• Being younger than 18 or older than 35 increases pregnancy risk
• Cigarette smoking increases pregnancy risk
• Substance abuse increases pregnancy risk

Cardiovascular Disorders and Pregnancy

• Congenital heart anomalies are corrected in early infancy
• Cardiovascular disease can lead to serious complications for pregnancy
• It is responsible for 5% of maternal deaths during pregnancy
• Pregnancy danger in women with cardiac disease is primarily due to increased circulatory volume
• The weeks after peaks in blood volume are the most dangerous
• Women with artificial but well-functioning heart valves, pacemakers, or heart transplants can still have successful pregnancies

Classification of Heart Disease

Class I

• Uncompromised
• Ordinary physical activity causes no discomfort
• No symptoms of cardiac insufficiency and no anginal pain

Class II

• Slightly compromised
• Ordinary physical activity causes excessive fatigue, palpitation, dyspnea, or anginal pain

Class III

• Markedly compromised
• During less than ordinary activity, women experience excessive fatigue, palpitations, dyspnea, or anginal pain

Class IV

• Severely compromised
• Women are unable to carry out any physical activity without experiencing discomfort
• Even at rest, symptoms of cardiac insufficiency or anginal pain are present

Additional Notes

• Women with Class I or II heart disease can have normal pregnancies by maintaining special interventions like bed rest
• Women with Class III can complete pregnancies by maintaining special interventions like bed rest
• Women with Class IV heart disease are usually advised to avoid pregnancy

Cardiac Disease

The Ways It Can Affect Pregnancy

• Cardiac disease affects pregnancy differently based on whether the left or right side of the heart is involved

Normal Blood Circulation

• Unoxygenated blood empties from different parts of the body into the Superior and Inferior Vena Cava and goes into the Right Atrium
• From the Right Atrium, the Tricuspid Valve redirects into the Right Ventricle
• From the Right Ventricle it then flows through the Pulmonary Artery and into the lungs for Oxygenation
• Oxygenated blood from the Lungs flows into the Pulmonary Veins into the Left Atrium
• From the Left Atrium through the Mitral Valve into the Left Ventricle and through the aorta to different body parts

Left-Sided Heart Failure

• Left-sided heart failure occurs in conditions such as Mitral Stenosis, Mitral Insufficiency, and Aortic Coarctation.
• The left ventricle cannot move the large volume of blood from the pulmonary circulation forward, because it has been received by the left atrium
• Back pressure occurs, which becomes distended the left side of the heart causing systemic blood pressure decreases and pulmonary hypertension occurs
• Pulmonary Edema produces profound shortness of breath, interfering with oxygen-carbon dioxide exchange
• Pulmonary capillaries rupture causing blood to leak into the alveoli, which leads to a productive cough with blood-speckled sputum
• Because of the limited oxygen exchange, there is a high risk spontaneous miscarriage, preterm labor, or even maternal death for women with left-sided heart failure
• This condition can cause increased fatigue, weakness, and dizziness
• Placenta may not receive adequate blood because of decreased peripheral circulation
• As pulmonary edema becomes severe, a woman cannot sleep in any position except with her chest and head elevated
• This is termed Orthopnea, as elevating creates lung space for gas exchange by fluids settling to the bottom of her lungs and heart action is more effective
• With more effective heart action, interstitial fluid returns causing increased left-side failure and increased pulmonary edema, also known as Paroxysmal Nocturnal Dyspnea

Right-Sided Heart Failure

• It occurs when the right ventricle is overwhelmed by the amount of blood received by the right atrium from the vena cava
• It can be caused by an unprepared congenital heart defect such as pulmonary valve stenosis
• Congestion of the systemic venous circulation and decreased cardiac output to lungs result
• Blood pressure decreases and pressure is high in the vena cava from the back pressure of blood
• Jugular venous distention and increased portal circulation are evident
• The liver and spleen are distended
• Liver enlargement can cause dyspnea and pain
• Distended abdominal/lower extremity vessels can lead to exudate of fluid from into the peritoneal cavity/peripheral edema

Assessment of A Woman with Cardiac Disease

Nurses' Role

• They play a major role in caring for pregnant women with cardiovascular disease because the woman's health status, health education, and health promotion activities are essential

• Assessment begins with a health history to document pre-pregnancy cardiac status

• Document what level of exercise performance she has and ask if she normally has a cough or edema

• Documenting edema is important because distinguishing between normal pregnancy edema & heart failure edema is necessary

• Important differences between the two is while usual edema only involves feet and ankles, heart failure edema involves the whole body (systemic)

• Health teams must be certain to record a baseline blood pressure, pulse rate, and respiratory rate in either sitting or lying position at the first prenatal visit

• Always obtain the above in the same position for accurate comparison at future health visits

• Comparing nail bed filling and jugular venous distention can also be helpful throughout pregnancy

Venous Thromboembolic Disease

• The incidence of venous thromboembolic disease increases during pregnancy because of a combination of stasis of blood in the lower extremities
• Fetal head at birth puts pressure on veins damaging vein walls of lower extremity
• Increased pressure causes triad of effects setting up stage for thrombus formation in the lower extremities
• The likelihood of deep vein thrombosis (DVT) leading to embolism increases further in women over 30 due to age risk factor

Terms

• Hypercoagulability: the body's tendency to undergo thrombosis.
• Thromboembolism: blood clot that carries by the bloodstream that blocks another vessel.
• Stasis: Condition where blood is not reaching or circulating to all parts of the body properly.
• Heparin: Anticoagulant used to prevent blood clotting.

Reducing The Risk Of Thrombus

• Do not use constrictive knee-high stockings.
• Do not sit with legs are crossed at the knee
• Avoid standing in one position for a while

Clinical Manifestation

• Diagnosed through physical exam, Doppler Ultrasonography, or women noticing pain and redness (usually in calf of legs)
• Bed rest and Intravenous heparin treatment for 24-48 hours will keep thrombus from moving or becoming embolus
• After which Subcutaneous Heparin (self-injected every 12 to 14 hours) can continue for pregnancy
• Usually recommended lower abdomen be used but usually not due to pregnancy, administration sites are limited to arms and thighs

Pulmonary Embolism Signs

• Chest pain
• Sudden onset of dyspnea
• Cough with hemoptysis
• Tachycardia or missed beats
• Dizziness and fainting

Recognize Danger

• This needs to be recognized as it is an immediate emergency
• Any further injections should only be done once labor begins and should be cautioned
• Women are not candidates for routine episiotomy or epidural anesthesia for the same reason, unless it has been 4 hours since the last dose

Hematologic Disorders and Pregnancy

Anemia and Pregnancy

• Most women have pseudo anemia in early pregnancy because the blood volume expands before the red count cell does
• True anemia is typically considered present when a woman's hemoglobin concentration is less than 11g/dl (hematocrit <33%) in trimester 1 or 3
• Hemoglobin concentration is less than 10.5 g/d (hematocrit <32%) in trimester 2

Iron Deficiency Anemia

• This is the most common anemia during pregnancy
• Deficiency of iron stores may be caused by diet low in iron, heavy menstrual period, unwise weight-management programs, women who were pregnant less than 2 years before current pregnancy, or those from low socioeconomic levels
• Iron is made available to the body through absorption from the duodenum into the bloodstream and is incorporated into hemoglobin or stored as ferritin
• With an inadequate iron supply, microcytic (small red blood cell) and hypochromic (less hemoglobin than the average red cell) anemia occurs
• Women with iron deficiency anemia experience extreme fatigue and poor exercise tolerance because of not enough oxygen transport
• Is associated with low birth weights and preterm births

Signs

• Because the body needs better nutrients, some may want to develop pica (craving ice or starch)
• Use vitamins containing 27 mg of iron as therapy if pregnant
• Eat green leafy vegetables, meat, and legumes supplement
• Some women reports either constipation or gastric irritation when taking oral supplements.

Ways to Treat

• Ferrous turns stool back, so women should be cautioned.
• Intravenous can be prescribed if severity is to extreme or and the woman has difficulty.

Folic-Acid Deficiency Anemia

• Folic acid, or folacin- One of the B vitamins necessary for normal red blood cell formation- Prevents neural tube and wall defects
• Mostly occurs in pregnancies that are multiple pregnancies due to increased fetal demand
• Anemia- Enlarged red blood cells
• Slow deficiencies may take a week to develop
• A contributory factor in early miscarriage or separation

Recommend/Advice

• Use supplement of 400mg
• Try to become pregnant
• Folic-acid may be used
• Green leafy vegetables
• Oranges
• Dried beans

Sickell-Cell Anemia

Inherited Hemolytic Anemia

• Inherited recessive-Abnormality in bone marrow Abnormal amino acid in beta chain of hemoglobin -irregular or shaped red cells
• Cannot carry as much as normal cells

Causes and Contributing Factors

• High Altitude
• Viscid Viscosity
• Results in vessel blockage from irregular shapes
• Cells may hemolyze or reduce in the # of availability/ causes the severe anemia
• In almost 1-10 African Americans who have had sickle

Block

• Placental circulation
• Risk for low weight/ fetal dealth

Monitor

Monitor a Pregnant Women-6-8 Mg / 100 MI

• Sufficient for folic intake/ extra supplement, and what destroyed
• DO not take routine as cannot incorporate
• At least 8 glasses be for fluid intake and dehydration
• Assess prenatal visits for varicostities/ Lead to cell destruction.

Therapeutic Management

Prevention

• To Prevent Sickle Call crises: -Include Blood Transfusions Replace Sickling One
• Crises occur, such as Oxygen,Increasing fluid volume / low viscosity.

Patho-Physiology and Clinical Manifestations

• Controlling Imbalance between insulin and glucose level
• Hyperglycemia or hypoglycemia
• Infants are 5x more likely to have Gestational age or complications _ Glucose can't be used, use the stored glycogen to increase glucose level

High Levels

• Over 100MI The attempt to lower the
• Glycosuria Fluid volume or over hydration
• Affects - Type 1 diabetes, Autoimmune disorders
• Fail to produce, for the requirement

Type 2 Diabetes Gradual Loss/ Insulin Will Be present

• Tend to be (>10lb) Produces, the Growth Stimulent

Hyperglycemia

• Causes extra Fluid and increase fluid amounts

Diabetes

• Causes birth Problems High/ Increasing risks

High Indicence Of Regression/ Spontaneous

Higher At Risk

Distress Hypoglycemia Hypocalcemia Hyperbilirubinemia

1st Trimester

Keep Away and Lessens Malformation

Symptoms

• Main Symptoms of Diabetes
• Blood pressure
• Family - History
• Polycystic
• Polyhdria

Therapeutic Management

In Early Pregnancy

Use less Insulin, Because so Much Glucose From Cells

Later Pregnancy

• Increases Amounts
• Glycogen Levels Glycemic Levels

Administer: Oral Diabetes

Cannot Use For A Revaluation Of The Fetus

Bleeding Disorders During Pregnacy

Spontanous Miscarriage Is Commonly Aborted By:

More Than 20- 24 Weeks Or One Weight At Least 500

Before This Point A miscarried / Premature Both

• In This Point Before Week -16 Of Pregnancy Late

• Between 16-20 What Could Happen* Frequently Abnormal Fetal development Tratogeni, Cator Rejections of An Embryo To Immune Response

• Abnormalities

• Implantation in Adequacy Corpus Leuleum Fail To Produce

• Not Enough Ingenstaion on Alcohol Conception

• Ab. Fetal Growths Utis Premature Birth

• System Infestation

• Syphillis, All Kinds of Viruses, Infections And Sexually Diseases Such As Aids Alwayes Symptoms Spotting Blood In Virgin Blood All The Time