High-Risk Pregnancy: Chapter 2

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Care of At-Risk/High Risk and Sick Mother - Chapter 2

• Lesson 1 focuses on identifying clients at risk during pregnancy.

Learning Outcomes

• Defining high-risk pregnancy
• Defining at-risk individual
• Defining risk factors in pregnancy
• Explaining factors that contribute to pregnancies at risk.

Warm-Up Activity

• Try and list down five factors that may put pregnancy at risk and explain, discuss with classmates

Jeopardy of Pregnancies

• All pregnancies and deliveries are potentially at risk
• Certain pregnancies place the mother, fetus, or neonate at increased jeopardy.
• Approximately 20–30% of pregnancies fall into high-risk categories.

Definition of Terms

• Risk pregnancy is a pre-existing or developing condition threatening the pregnancy and the delivery of a healthy term infant.
• Risk factors are circumstances/characteristics increasing the risk of developing a morbid process.
• At-risk individual exhibits an increased likelihood of disease or complications.

High-Risk Pregnancy Defined

• This describes situations where the mother, fetus, or both are at higher risk for pregnancy or delivery problems.
• This is defined as a pregnancy complicated by factors that adversely affect the pregnancy outcome (maternal or perinatal).

Factors That May Put Pregnancy At Risk

• Personal-social factors.
• Socio-economic factors.
• Behavioral factors.
• Occupational factors.
• Health care delivery.

Risks of Pregnancy Due to Maternal Age

• Maternal age is a risk factor, below 16 and above 35 years of age
• Pregnant teens develop high blood pressure and anemia, and are prone to preterm labor and delivery
• Older first-time mothers generally experience normal pregnancies
• Research indicates older women face higher risks compared to younger women.

Physical Risks with Pregnancy below 16 Years Old

• Rapid growth during adolescence affecting physical health
• Rapid fetal growth putting a strain on a young mother's body

Psychosocial Risks with Pregnancy below 16 Years Old

• Lack of motivation impacting prenatal care
• Denial of pregnancy leading to delayed medical attention
• Ignorance about proper nutrition and healthy habits
• Rebellion against authority affecting adherence to medical advice
• Pride interfering with seeking help and support
• Failure to complete education thus limiting opportunities
• Dependence on others for support due to limited financial literacy
• Failure to establish a stable family life affecting child's well-being
• High rate of marital failure contributing to emotional stress
• High incidence of repeated out-of-wedlock pregnancies risking future pregnancies

Risks with Advanced Pregnancy Over 35 Years

• Increased overall risk during pregnancy
• Increased incidence of placenta previa, chromosomal abnormalities, abruptio placentae, uterine inertia, hypertension, toxemia, and low birth weight babies

Birth Interval as Risk Factor

• Short intervals between pregnancies are associated with higher risk for preterm birth
• Short intervals between pregnancies are associated with infants considered small for their gestational age.

Weight As Risk Factor

• Women who are considered very thin, BMI less than 19.8 or who weigh less than 100lbs pre-pregnancy are more likely to have underweight babies.
• Overweight women, BMI 25 to 29.9 or obese, BMI >30 are more likely to have large babies making delivery difficult

Height As Risk Factor

• Shorter mothers have shorter pregnancies, may deliver smaller babies face higher risk for preterm birth.
• Mother's height influences the risk for preterm birth.
• Maternal height, is determined by genetic factors, fetal environment, and influences pregnancy length and prematurity frequency.

Parity as Risk Factor

• First pregnancies have the highest risk
• Death risk is at its lowest during second, third and fourth pregnancies
• Fifth pregnancies have marked increased risk particularly with expecting mothers over 40 years of age

Poor Diet and Nutritional Deficiencies

• These increase the risk for iron deficiency anemia and Preeclampsia which can lead to fetal malnutrition, and prematurity.
• There is decreased resistance to disease, and low birthweights
• Lack of Folate can lead to defects in the neural tube

Socio Economic Indicators that present Risk

• Low income levels that can lead to Malnutrition, strenuous job conditions that affect time for rest, poor financial status that affects access prenatal care, and poor parental occupation lead to risk in birth
• Low level of education that may affect ability to understand and use health information

Behavioral Factors

• These are highlighted through compliance from expecting mothers

Smoking

• Puts the fetus at risk for preterm birth, certain birth defects, and sudden infant death syndrome "SIDS"
• Doubles or even triples the risk of still birth after 20 weeks pregnancy
• Effects in the infant may include changes to their immune system
• Second hand smoke puts mother and fetus at risk for health problems

Drugs

• Smoking marijuana while pregnant harms the fetus/affects infant health
• Exposure doubles the risk of still birth
• Smoking marijuana could interfere with normal brain development- leading to long term problems

Use of Alcohol

• Increases the risk for a baby having "FADS" which may include a variety of symptoms from mild to severe. It ranges from intellectual/developmental disabilities, behavior issues or abnormal features like heart, bone or hearing problems
• There is higher risk of a miscarriage and still birth for women who also drink
• There is no safe ammount of alcohol that can be consumed while pregnant
• Infants can sustain long term development problems even with small low levels of exposure to prental alcohol

Intake of Caffenine

• Moderate intake of about 200mg per day, does not seem to contribute to miscarrige/preterm birth
• Concerns over a potential relationship between caffeine exposure/spontaneous miscarriage. As caffine crosses placenta/maternal catecholamine levels increase

Occupational Factors

• Exposure to heavy metals such as lead, air pollutants and particulate matters, bisphenol A, phthalate compounds, and environmental tobacco smoke "ETS"

Unhealthy Health Care Delivery

• Health risks influenced by social/political trends
• The characteristics and management of hospitals affect risks
• If staff and the system lead to premature or delayed discharge there may be risk to baby and expecting mother

Activity

• To reflect on the learning from this lesson, watch the video and connect with the message

Wrap Up

• Quality Family planning and gynecology at centers provides a unique opportunity to maximize maternal health
• As a health professional, learn how you can help assess clients who are at risk during pregnancy, so that they may have a better outcome

Pre-Gestational Conditions - Lesson 2

• Describing illnesses like cardiovascular disease, diabetes mellitus, or renal/blood disorders causing pregnancy complications.
• Analyzing how nursing care stays family-centered with pre-existing/acquired illnesses during pregnancy.
• Assessing illness due to pregnancy-related changes or pregnancy effects. Additionally, formulate nursing diagnoses related to the effect of a pre-existing/newly acquired illness on pregnancy, identify expected outcomes to contribute to a safe outcome when illness occurs and make a nursing care plan

Learning Outcomes

• Formulating nursing diagnoses related to the effect of a pre-existing or newly acquired illness on pregnancy
• Identifying expected outcomes that will contribute to a safe pregnancy outcome when illness occurs with pregnancy
• Formulating a plan to supply proper medical care for a woman when there is an illness

Learning Outcomes

• Implementing proper care for a woman when an illness leads with complications
• Evaluating expected outcomes to achieve effectiveness in care

Listed Pre-Gestational Conditions

• Cardiac Disease
• Diabetes Mellitus
• RH Sensitization
• Anemia
• Thryoid Disorder

Gestational Diabetes Mellitus

• A variety of concepts apply

Diabetes Mellitus

• Hereditary endocrine disorder, resulting from inadequate insulin production that leads to high glucose absorption and results in hyperglycemia

Types of Diabetes Mellitus

Type 1 Type 2 Gestational Diabetes Mellitus

Classifications of Diabetes Mellitis; Type 1

• This form of diabetes is diagnosed in childhood as well as arising from immunologic destruction of pancreas cells, that ends in insulin being needed for the rest of their life
• a state characterized by the destruction of the beta cells in the pancreas that usually leads to absolute insulin deficiency.

Classifications of Diabetes: Type 2 and Gestational

Type 2
   Adult onset glucose.
   Patients are frequently overweight and are frequently managed through weight controlled diets
   Is a result from insulin resistance rather than complete damage
        usually arises because of insulin resistance combined with a relative deficiency in the production of insulin

Gestational
      Is a form of abnormal glucose metabolism occuring when pregnant
      There may be an increased risk of type 2 later on in life
      For the majority it subsides post pardum, however glucose intolerance can occur in later patient outcomes

Type A-1 Gestational Diabetes - diet controlled

• This means that the abnormal oral glucose tolerance test results in normal plasma glucose levels while fasting/then testing after a total of 2 hours later
• Diet affects the body's abilities to properly manage glucose

Type A-2 Gestational Diabetes - diet and insulin controlled

• Where the body has abnormal oral glucose test results combined with abnormal plasma levels while there are no adjustments with fasting or total glucose levels
• This level of diabetes has to be treated with insulin or some kind of other medication

Risk Factors for Gestational Diabetes Mellitus

• A variety of concepts apply like High BMI, genetics, gestational obseity low HDL etc.
• A gestational age of 25 years of age or more
• Having a history of delivering big babies or other fetal abnormalities

Effect of Gestational Diabetes on Pregnancy

• May impair insulin absorption and disrupt carbohydrate metabolosim, which will increase the need for insulin at a rate that advances the pregancy's progress
• There is a form of rapid starvation that happens that leads to rapid activation of lypolysis in the short term
• There is greater risk of a Ketoacidisis infection
• This accelerates the effect of vascular changes

Pathophysiology

• Gestational Diabetes in primarily categorized by an increased state of hyperinsulinemia and the process of insulin resistance
• The following occurs trimester by trimester

What Pathophysiology Happens in Each Trimester

(Occurs from first, too early 2nd trimester) Due to elevated levels of estrogen comes extra insulin (This is from late 2nd to early 3rd) the bodies natural insulin resistance increases due to a range of hormones - including placental lactogen, progesterone, prolactin, cortisol and adiponectin. The following steps all occur in a chain of the bodies natural response

• Human Placental lactogen "HPL" is increased by enlarging placenta which causes a range of reactions including changing metabolism and promoting lipolysis to increase fatty acids/decreasing gluecose levels

Gestational Complications

Normally there is a Contra Insulin effect, were the hormones from the placenta start the chain of reactions.

Here are some Pathophysiologic Chain Reactions

• The following occur from partial of complete lack of insuling leading to glucose accumulation, leading to increased thirst, kidneys increasing the need to remove more urine and cellular starvation
• From glucose increasing cellular activity one can fall back into a chain reaction of kidneys attempting to excrete large amounts of fluid, leading to more cellular starvation, leading back to higher weight loss and creating a large appetite

Signs and Symptoms of Gestational Diabetes Mellitus

Hyperglycemia. - Pancreas is unable to regulate a certain level of insulin Glycosuria - the body goes beyond a typical renal threshold Polyruia - A greater amount of glucose attracts fluid increase in thirst and the body removes fluid Weight Loss - the body cannot regulate glucose it therefore uses protien as its energy source Ketoacidoisis - Body is unable to excrete this hormone correctly

Common Traits of Gestational Diabetes

Polyphagia Polydipsia Polyruia

Problems Due To Gestational Diabetes

Increases serious risk at birth and can double Higher chance of a cesarean delivering The higher rate of infants having NICU admissions can quadrouple

Fetal Effect to Mother With Diabetes Mellitus

Greater risk of higher tendency for preeclampsia and UTI's
Higher change of having dystocia with a baby that weights more
Higher risk  postpardum to overextension

Other aspects also include, material mortality and diabetic nephropathy

Breakdown for a Fetal State and Complications

During Stage 1, there may be abnormalities in the heart and related areas More complications occur during delivery Asphyxia And Post RDS, Jaundice, hypoxia

• Important to Check Hemoglobin if expecting the need to deliver in case complications could arise

Diagram to Chart the Effects

Following an increase in a mothers glucose in the blood, they release it to the fetus who then increases output. The mother has to release a stress hormone to stop her own body from breaking down protein, and then creates lipolysis which then can cause stress and a whole other set of chain reactions related to giving birth.

Implications

High glucose causes stress which results in an anaerobic metabolism where oxygen intake is reduced which causes cell death.

Additional Note

An enlarged heart, extra or lower amounts of HCG and insulin and some birth weights can be affected.

Prenatal Management

Suspect DM, those with a history of family medical medical history Those that are obese or have had large fetus, and have a history of congenital anomaly

Who needs Testing? Those with

• 1st antenatal contact, 2-28 weeks for the pregnant, at lease 4 weeks between each test, and even to those who have come late

Glucose and Tolerance Tests

There tests can vary from a low to high weight, it may depend on the local doctor or physician . If those levels are elevated it is said you may have a glucose tolerance Depending on what and were one is may have varying levels in glucose Goal, we plan make sure we are having sugar levels of 90mg for those fasting if your not doing that we plan for it to be 120 milligrams

The following tests are done for pregnant woman that are with diabetes

-The first test can detect any hyperglycaemia
-After testing an Ultra sound may come to check on all relevant things baby is going through, this occurs around weeks 18-20 and is checked on during 28-38 to evaluate 
What to look for...
 Normal test results
  Alpha P 
  Ultrasound test

• If everything goes well than you evaluate every two weeks

Care during this time also includes

-Check the mother if she has any infections -The mother should also check for social or political trends And always make sure to consult to with health care These include but or not limited to ... social trends, or changes to the hospital

Prenatal Management: Diet

Diet requirements of all clients
 Caloric intake
  Should be between 1-800- 2400 a day while dividing this into at lease 3 meals a day while

Make sure CHO levels are properly distributed Make sure that 20% of calories come from CHON and 50% from CHO as for fats make sure its only comes from 30%

Always remind to stick to food that are nutrition conscience while not gaining or loosing weight that that could endanger or effect the size of the baby

Other notes related to nutrition Reduce fatty diet Reduce Cholestrol Make sure there is enough fiber in diet You should also recommend to avoid fasting

Nutrition should include

• Those that have protein, and all minerals including all fluids

Management:Exercise

aside from the food we can implement other concepts such as

Cardivascular - Which improves glucose levels at a normal rate and you implement those on a regular bases.

But be cautious that when some type of exercize is being preformed always have a sugar or carbs for sudden drops

Prenatal Management: Insulin Therapy

• Insulin requirements in the body increase at this point It is also crucial that the patient doesn't use Hypoglycemic products like tolbat or diam because its teratogenic And you will affect both their cells as well

Best Practice

A balanced set of fast acting and intermixed can fix humilin but its allergic rates must be low. If all goes to plan give 2/3, and dinner Then you just watch the levels of sugar so everything flows

How To manage all those levels

The fasting and pre meal may also help understand and create reference points if anything goes wrong or may have to be checked .

The Following can be done

-Check and look for everything, if something is wrong check hemoglobin
-You need to tell the client her body so you have an understand of the symptoms if this or that
 Then make a assessment depending on these situations but don't jump into conclusion

• This step happens very early, you check everything like what her state may be,
• Important, you cant check her if or not she is on a normal weight

You can look if she can have this in the first pregnancy, but look for infection and test on what she needs.

Post Partum Treatment

This to manage and make well

Those with GDM has an easier way

A great set to to implement is GTT, after 6 weeks after (All the test are normally performed on the 3 day. Look at values if she has a high glucose because its not normal The main sign to spot those with diabetes Mellitus The first thing is to check that they can breath You treat those with hydro what has that to due with to tell if theres any issues with the diagphram and or how it will go with lung functions

You have those tell the if is they want to use b. Norplant " which is great

In a Case or situation what to do

Always see if she is being told about all symptoms if pregnancy is moving beyond some expectations

In short..

This can be done be the end point with 40 weeks of service

It is a must to recommend induction for the proper
This can also effect many and different parts of the woman with a child

• Important to check weight And is its not to high.

Cardiac Disease

These can fall to 4 classes on which will tell in the outcomes of pregnancy: Class 1 is at no pain and comfort with regular activity Class 2 Is very light the person will have a difficultly in normal activity Class 3 has greater level and can be more difficult, where its very hard for the person to do any work And those that are class 4 cannot function alone

• Important check and look for what one might have

How to class a cardiac related complication

Congenital: This include parts of the heart or valves relating those structures that might have bad or good levels of blood or heart function. You Can tell is a great sign that these traits and genetics or there history can follow threw

Rheumatic those area or the body those test the lungs all tell us about the status if the patients This can cause cardio or a loss of heart function where we may not achieve the levels for organs in the body..

If you are pregnant with diseases of the heart and how it can come along

If the cardiac levels are low than it is safe to assume the

How can you make sure things happen so that everything will have great results for baby and everyone?

• The best plan is for it stop coming. And the
• The best to be made will have better outcome

Make sure those you come alway side may not get all that you might know during this time to understand that she will get better.

• To keep note that a heavy increase could bring lots of pain.

So to make sure some areas have the best check so we check....

Look for

The head, and the veins It can affect and cause pain that is in the arm or leg

• These concepts can also mimic certain changes.

So what do to next

You tell the symptoms there is a more accurate way is make sure things are right on there side

We can go and make sure that you are doing it

Nurse Help

"It important to to remember with all that there a void to infection, and that all the points listed before are as clear as we will expect things on your body"

Another thing

That there can be a risk after 

This include
a problem the with heart as a main source, all because the person decided to quit

• This is can happen before because to much can cause alot and can take a toll

With those traits that you come accross you will have better points, this is so you can have this in order to better understand those that you should listen too

With there is much that the patient must understand to have a better life when it

RH Sensitization

Most are  formed of a blood vessel is mixed by accident
 And then it starts its way threw
These are bad and are bad news,

If so more will comes and this comes to cause.

The most important things that can happen comes from RH neg

Those will have the blood  

If you then have blood then 50 % of children  can also have the same

And if that becomes reality and all children will follow with that line

If so that the fetus

Those things are bad and that the body will see the as bad agents So for a check you will.

Those can have and and have

 That a can be with everything

These can cause some pain just make sure everything

• These might lead to a increase so that is bad

"Always remember to find the people that do, the way you must tell them"

All this process and action are know as the following

We will now go to something new so now... (A new term)
Is it

Test 3
 Those that make all those list can see then go up to

What happens then?

When that is on side, be sure to not to let it down. It cant get a bit bad in those 8

There for it to all go well

• That your
• All that this, will always help
• Then
• and those that say that is will work all will get better

Management 🔑

• Suspension of breastfeeding to prevent high progestrone (up to 24 hours)
• Destruction of RBC
• Phototherapy
• This can also allow RBC's and has well, a vessel to help

Final Notes

We want to say to manage the risks it can take a major hurt down To check asphyxia to

Last But not Least

    Always look for or expect . For we never can to to much on out baby's that we carry in our arms. To. Ever show if of how they truly will shine

• Disclaimer*
• A disclaimer applies in the summary due to word variety constraints, consult with medical source to see whats changed over time

The following may add and effect

In short always remember the 3 key thing and tell then to never look away,

Always have 130 as what comes to that is that what's needs to be always given

Anemia

Most may be a genetic transfer and most may come and not work And more or less you see 25 and what happens

What this implies is there will be 6 and its not a issue but something must be know If there is damage or those signs happen it will be what is asked ""There area is and that all there is can will show "" So all will be well

So we see the problems coming to. Play

• It needs to be 0 or we must check. All those who can be effected. 8% you ask and to never is what happens

Anemia In the System

Can't let it get above 11 Or fall below with a high level 10

A better way

All these can happen if this goes out of hand, do your best. Is for things to not be ok

With that check or what ever

• There will always be some hurt with the child if one.

If what is listed or followed all these may still hurt so. Plan This may not be perfect so look to the best there can to the help

To help find a better way we list

    You need to have water
   We try and tell to all that might need our help

• If all fall and you see one, do what must be to all and ask why with is in your hearts

"Please have a better read or find a good health care for what this cant find