High-Risk Pregnancy Factors

High-Risk Pregnancy Factors

• A high-risk pregnancy poses a greater risk to either the mother or the fetus.

Risk Factors - Mothers

• Maternal age <= 18 increases pregnancy risk
• Multiples (twins, triplets, etc.) increases pregnancy risk
• Lack of prenatal care increases pregnancy risk
• Substance abuse increases pregnancy risk
• Maternal obstetrical/gynecological history increases pregnancy risk
• Medical history (cardiac issues, hypertension, diabetes) increases pregnancy risk
• Lifestyle choices impact pregnancy risk
• AMA (Advanced Maternal Age): increases risk for preexisting conditions.
• AMA (Advanced Maternal Age) increases the risk for preeclampsia due to preexisting conditions

Existing Health Conditions and Pregnancy Risk

• Hypertension and diabetes increase pregnancy risk
• PCOS (Polycystic Ovary Syndrome) increases pregnancy risk
• Obesity increases pregnancy risk
• Zika virus increases pregnancy risk
• Autoimmune disorders increase pregnancy risk
• Nutrition impacts pregnancy risk
• Substance abuse increases pregnancy risk

Additional Factors

• Genetic factors contribute to pregnancy risk
• Environmental factors contribute to pregnancy risk
• Sociodemographic factors like low income, age, and parity (number of previous pregnancies) increase pregnancy risk

Substance Abuse Effects

Alcohol

• Leads to abnormalities in brain and neuron development
  • LBW (Low Birth Weight) is a potential outcome
  • Prematurity is a potential outcome
  • Fetal alcohol syndrome is a potential outcome
• Major cause of mental retardation

Cocaine

• Can cause cardiac events and maternal death.
• Can cause abruption and premature rupture of membranes (PROM).
• Fetal effects come directly from the drug.
  • Vasoconstriction and neuroexcitation.

Opioids

• Withdrawal symptoms in the neonate.
• Symptoms referred to as Neonatal Abstinence Syndrome (NAS).

Smoking / Tobacco

• Decreases fertility
• Increases the risk of miscarriage
• Can cause placenta previa
• Can cause IUGR (Intrauterine Growth Restriction)
• Long-term cognitive function and increased risk of brain damage

Preterm Infants

• Infants born before term labor

  • The following points discuss the differences between pre-term and term infants

• Preterm infants have a larger proportion of water compared to term infants

• Preterm infants have less subcutaneous fat, which affects their ability to maintain body temperature.

• Preterm infants have poorly calcified bones

• Preterm infants have incomplete nerve and muscle development.

• Suck reflexes may be weak; typically appear around 32-34 weeks, affecting feeding ability.

• Preterm infants have limited ability for digestion, absorption, and renal function

• Preterm infants have an immature liver causing lack of developed metabolic enzyme systems and inadequate iron stores

• Tiny preterm babies require special feeding, often through tube feedings.

• Supplements may be required to increase calories.

Multi Gestation

• Refers to pregnancies involving more than one fetus.

Placenta Types

• Monochorionic: one chorion, at risk for TTTS (twin to twin transfusion syndrome)

• Dichorionic: two chorions

• Monozygotic twins come from one zygote that divides in the first few weeks.

  • Monozygotic twins are identical and of the same gender.
  • Can be dichorionic/diamniotic, monochorionic/diamniotic, or monochorionic/monoamniotic.
    • Monoamniotic pregnancies carry a high risk of cord entanglement.

• Dizygotic twins come from two eggs fertilized at the same time; fraternal twins can be same or different gender.

  • Always dichorionic/diamniotic.

• Increased rates of perinatal mortality and neurological injury in monochorionic, diamniotic twins compared with dichorionic pairs

• Monozygotic twins have morbidity and mortality rates 3 to 10 times higher than for dizygotic twins for sharing amniotic sacs and placental resources.

High-Risk Maternal Complications

• Occurs when the following are present: HTN/Pre-E, GDM, Hemorrhage, Abruptions, Previa C/S, PTL, Cord Prolapse

• Twin pregnancy is associated with higher rates of almost every potential complication of pregnancy

• Hypertensive disorders, preeclampsia, tend to develop earlier, are more severe, and are related to enlarged placenta.

• Hypertensive conditions associated with multifetal gestations are proportional to the total fetal number, risk increases with each additional fetus.

• Gestational diabetes due to physiological changes required for supporting multiple fetuses.

• Antepartum hemorrhage, abruptio placenta, placenta previa

• Anemia related to dilutional anemia

• Peripartum cardiomyopathy, pulmonary edema, pulmonary embolism

• Intrahepatic cholestasis

• Acute fatty liver

• Cesarean birth

• PTL (Preterm Labor)

High Risk Fetal Complications, Mortality

• LBW (low birth weight) / TTTS (Twin-to-Twin Transfusion Syndrome)

• Increased fetal morbidity and mortality due to sharing uterine space and placental circulation

• Increased perinatal mortality is more likely, threefold higher than in singleton pregnancy

• Increase of Low Birth Weight, 20% higher than singleton

• Monochorionic twins have shared fetoplacental circulation, which puts them at risk for specific serious pregnancy complications, such as TTTS, twin anemia-polycythemia sequence.

• Increase of intrauterine growth restriction (IUGR) is a potential complication

• Twin-to-twin transfusion is caused by an imbalance in blood flow

• Fivefold increased risk of stillbirth

• Sevenfold increased risk of neonatal death, primarily due to complications of premature birth in multiple gestation pregnancies.

• Preterm delivery is six times more likely, playing a large role in the increased perinatal mortality and short-term, long-term morbidity in these infants

• Higher rates of fetal growth restriction and congenital anomalies are possible

• Monochorionic twins are at risk for complications unique to these pregnancies, such as discordant growth, twin to twin transfusion syndrome (TTTS), which can be lethal or associated with serious morbidity

Hyperemesis Gravidarum

• Caused by rising serum levels of pregnancy-related hormones: chorionic gonadotropin (hCG), progesterone, and estrogen
• Dehydration requires medical management, including: IVF, anti-nausea meds, gut rest, vitamin B6, dextrose, and correcting ketosis
• Most patients also have hyponatremia, hypokalemia, and low serum urea level
• Ptyalism is a typical symptom
• Typically peaks at 9 weeks of gestation and subsides by approximately 20 weeks

Symptoms

• Vomiting that may be prolonged, frequent, and/or severe
• Weight loss
• Signs and symptoms of dehydration include:
  • Lightheadedness, dizziness, faintness, tachycardia, or inability to keep food or fluids down for more than 12 hours
  • Dry mucous membranes
  • Poor skin turgor
  • Malaise
  • Low blood pressure
• Acetonuria
• Ketosis

Intrahepatic Cholestasis of Pregnancy (ICP)

• Reversible liver disease and also known as obstetric cholestasis and is the most common pregnancy-specific liver disease.
• A reversible type of hormonally influenced cholestasis, frequently develops in late pregnancy in individuals who are genetically predisposed.
• Characterized by generalized itching, often with pruritus of the palms of the hands and soles of the feet with no other skin manifestations
• Most often presents in the late second or early third trimester of pregnancy and affects approximately 1% of pregnancies in the United States

Treatment and Risks

• Antihistamines are usually ineffective at relieving severe pruritus in women with ICP.
• Risk of IUFD, PTD, and meconium
• The risk of complications for the fetus is associated with the serum level of maternal serum bile acids, and women with more severe cholestasis are at greater risk

Medication

• Ursodeoxycholic acid (UDCA) is the most effective medication for managing elevated bile acid levels.

Diabetes

Type 1

• Insulin deficient and managed with insulin
• Results from autoimmunity of beta cells of the pancreas, causing absolute insulin deficiency
• Diagnosed earlier in life and comprises about 5% to 10% of diabetic patients

Type 2

• Insulin resistance and diagnosed later in life
• Characterized by insulin resistance and inadequate insulin production
• The most prevalent form of diabetes, making up about 90% to 95% of diabetics
• Linked to increased rates of obesity and sedentary lifestyle
• Prevalence is rising, including in younger populations and women of childbearing age.

Pregestational diabetes

• Categorized as either type 1 or type 2 diabetes.
• Diagnosis blood glucose levels are above the normal range but below the cutoff for overt or clinical diabetes in the nonpregnant woman
• Commonly presents with women with polycystic ovarian syndrome.
• These pregnancies have a fivefold increase in the incidence of major fetal anomalies of the heart and central nervous system

Gestational Diabetes

• (GDM) is glucose intolerance that does not present before pregnancy.

• Two main contributors to insulin resistance are:

  • Increased maternal adiposity
  • Insulin desensitizing hormones produced by the placenta

Placental Antagonists to Insulin

• hPL
• Progesterone
• hCG (Human Chorionic Gonadotropin)
• Insulin demand increases with the development of pregnancy and is a normal physiological process
• Pregnant women who have continued hyperglycemia are diagnosed with gestational diabetes
• Factors that causes insulin resistance:
  • alterations in growth hormone and cortisol secretion (insulin antagonists), human placental lactogen secretion (produced by the placenta)
  • Placental lactogen effects: affects fatty acids and glucose metabolism, promotes lipolysis, and decreases glucose uptake -Insulinase secretion (produced by the placenta, insulin metabolism and facilitates metabolism of insulin)

Diagnosing Gestational Diabetes

• Between 24-28 weeks
• 1st: non-fasting glucose test (“failed” if > 95 or higher)
• If that is not enough, then...
• 2nd: 3-hour fasting (“failed” if > 140 or higher)

Risks Factors for Developing GDM or Gestational Diabetes

• Age: 2-2-4-9 (34, 93-96)
• Family history of diabetes: 2-3-3-5 (24,95)
• BMI: 1.1-5.4 (4, 95, 97, 98)
  • Overweight: 2.8 (34, 95, 97, 98)
  • Obesity: 5.6 (34, 95, 97, 98)
• Multiparity: 1.4 (34)
• History of previous gestational diabetes: 8.4-21.1 (34,95)
• Polycystic ovarian syndrome: 2.0-2.9 (34, 99-101)
• Hypothyroidism: 1.9 (102)
• Pregnancy-induced hypertension: 3.2 (34)
• History of stillbirth: 2.3-2.4 (34,95)
• History of preterm delivery: 1.9-3.0
• History of congenital malformation: 3.2 (25)
• History of macrosomia: 2.5-4.4 (34,95)
• Physical activity: 0.7-0.9 (103)
• Passive smoking: 1.5 (104)

Maternal and Fetal Risks

• Pre-E is potential, as well as c/s due to diabetes later, hypoglycemia and DKA

  • Hypoglycemia and DKA are risks
  • Preeclampsia risk Cesarean birth risk

• Development of non gestational diabetes after delivery is a risk Hypertensive disorders are a possible risk

• Women with GDM who require a cesarean section may be at higher risk for delayed wound healing, infection, and post-operative mortality

• Fetal Risks- Macrosomia, IUGR, hypoglycemia, RDS, ↑bilirubin, shoulder dystocia

• Newborns born to GDM are similar to the risks as newborns born to pregestational diabetic women (except without the risk of congenital anomalies)

• Macrosomia, refers to a weight greater than the 90th percentile for gestational age and sex or a birth weight of 4,000 g to 4,500 g

  • Macrosomia places the fetus at risk for birth injuries, including brachial plexus injury.
  • There is an increased likelihood of IUGR During the first few hours post birth, hypoglycemia risk is high. Other risks may be, hyperbilirubinemia, shoulder dystocia, respiratory distress syndrome, need for assisted delivery with either a vacuum or forceps, and birth trauma

• Magnesium of fetal-neonatal complications are proportional to the severity of maternal hyperglycemia. Stillbirth related to diabetes is often due to hyperglycemia The next points cover controlling diabetes.

Controlling Diabetes

• Glycemic control is crucial (euglycemia), check sugars, manage diet, EXERCISE
• 1st Trimester (1-13)= Increased insulin sensitivity → Hypoglycemia risk
• 2nd Trimester(14-26) = Rising insulin resistance → Screen for GDM
• 3rd Trimester(27-40) = Peak insulin resistance → Hyperglycemia risk

Hypertension in Pregnancy

• Diagnosed when systolic pressure measures 140 mm Hg or greater or diastolic pressure of 90 mm Hg or greater.
  • Affects 12-22% of pregnant women.
  • Second leading cause of maternal death, and a significant contributor to neonatal morbidity and mortality.
• Hypertension is diagnosed when either value is elevated in pregnancy
  • Elevation of both systolic and diastolic pressures is not required for a diagnosis, just one. 1st Trimester = Slight BP decrease due to vasodilation 2nd Trimester = Lowest BP (~mid-pregnancy) 3rd Trimester = Gradual return to baseline; watch for hypertension!

Chronic Hypertension

• Refers to when someone has hypertension before pregnancy

• Women with hypertension before pregnancy who later develop preeclampsia signs are considered to have chronic hypertension with superimposed preeclampsia. Systolic BP needs to measure 140mmHg or greater, or 90 mm Hg or greater diastolic before conception

• Defined as hypertension present and observable before pregnancy or diagnosed <20 weeks' gestation

  • Predates conception or detected <20 weeks of gestation. Persists beyond 12 weeks postpartum.

Preeclampsia - eclampsia

• Refers to chronic hypertension with superimposed preeclampsia with the following scenarios:

1. Women with hypertension only in early gestation who develop proteinuria after 20 weeks of gestation.
2. Women with chronic hypertension who develop new-onset or increased proteinuria and manifest other signs and symptoms such as an increase in liver enzymes or creatinine = may present with thrombocytopenia may present with symptoms of right upper quadrant pain and headaches, blurred vision, or scotoma, and may develop pulmonary edema or congestion.

Gestational Hypertension

• (hypertension with an onset of pregnancy without the symptoms of preeclampsia)

  • Systolic BP of 140 mm Hg or greater or diastolic pressure of 90 mm Hg or greater for the first time after 20 weeks, without other signs and systemic finding of preeclampsia

• Generally, gestational hypertension is the onset hypertension after the 20th week of gestation, in a previously normotensive woman. If hypertension is first diagnosed during pregnancy, does not progress into preeclampsia, and is normotensive by 12 weeks postpartum

• In 25% of cases, gestational hypertension progresses to preeclampsia; therefore, increased maternal-fetal surveillance is required Hypertensive, multisystem disorder. Qualifying blood pressures PLUS another organ involvement Occurs AFTER the 20th week of pregnancy

Preeclampsia

• Multisystem hypertensive disease that is unique to pregnancy
• Hypertension is accompanied by proteinuria after the 20th week of gestation

Preeclampsia with Severe Features: Preeclampsia plus at least one of the following:

• SBP of 160 mm Hg or greater or DBP of 110 mm Hg or greater.
• Serum creatinine greater than 1.1 mg/dL or doubling of serum creatinine in the absence of renal disease
• Platelets lower than 100,000/μL
• Elevated serum liver enzymes to twice normal
• New-onset cerebral or visual disturbances
• Persistent epigastric pain

More

• The term “mild” preeclampsia is discouraged for clinical classification, and the recommended terminology: -"Preeclampsia without severe features." -"preeclampsia with severe features" (severe)

Maternal Risk for Preeclampsia:

• Cerebral edema, hemorrhage, or stroke Disseminated intravascular coagulation (DIC) Pulmonary edema Congestive heart failure

• Maternal sequelae resulting from organ damage results in: damage include renal failure, HELLP syndrome, thrombocytopenia, and disseminated intravascular coagulation, pulmonary edema, eclampsia(seizures), and hepatic failure

• Abruptio placenta will likely occur

• Women with a history of preeclampsia have a 1.5 to 2 times higher risk of developing heat disease.

Treatment

Medical Management Includes:

• Magnesium sulfate, a CNS depressant, reduces seizure activity to the woman and fetus.
• The antidote for magnesium toxicity is calcium gluconate
• Magnesium sulfate indicated for women with severe features of preeclampsia; It will result in cerebral vasodilation to reduce seizures
• Magnesium sulfate also slows neuromuscular conduction, depresses the vasomotor center, and decreases CNS irritability
• Antihypertensive medications are used to control blood pressure (Labetal, Hydralazine, Nifedipine)
• Induced birth is indicated for women at less than 34 weeks' gestation- if unstable
• Planned early delivery after 34 weeks' gestation. is better for disorders
• Consists of serial ultrasonography determine fetal growth, weekly antepartum testing, close monitoring of blood pressure, and weekly laboratory tests

Nursing Actions

• How to assess a Pre-E pt!: Blood pressure, labs (H/H, platelets, pain, lungs, and urine for protein testing), fetal death
• Hypoperfusion to fetus causes hypoxia, oligohydramnios, IUGR. Preeclampsia exposes the fetus to an adverse intrauterine environment and results in chronic hypoxia and stillbirth
• Prevent asphyxia and stillbirth via fetal surveillance
• Examine parameters affected by hypoxia: nonstress test (NST), fetal movement, fetal breathing, fetal tone, and amniotic fluid index (AFI)
• A normal BPP, Biophysical profile score is 8 to 10 with a reactive NST; a score of 4 or less needs medical intervention
• Oligohydramnios: increase risk of perinatal mortality Because amniotic fluid is mostly made up of fetal urine, low fluid is a renal issue/lack of perfusion

Eclampsia

• Eclampsia is seizure activity in the presence of preeclampsia.
• Convulsive manifestation of the hypertensive disorders of pregnancy and most severe manifestations of the disease.
• May be triggered by cerebral vasospasm, hemorrhage, ischemia, or edema
• Warning signs: severe headache/epigastric pain, n/v, hyper reflexes with clonus, restlessness Lower HOB, side rails up/padded, turn head, keep airway safe, MgSO4 is needed during seizure Assess airway, FHT

HELLP

• Caused from severe Pre-E. Consists of H(emolysis), EL(evated liver) enzymes, LP(Low platelets) Clinical presentation is hemolysis, elevated liver enzymes, and low platelet count Thesyndrome is one of the more severe forms of preeclampsia, associated with increased rates of maternal morbidity and mortality A variant change in lab values that occur complication of severe: Hemolysis: cell disruption from constricted vessels. Elevated: Result blood and liver. Low: Platelet aggregation.

Symptoms

• Nausea- vomiting, malaise, epigastric

Placenta Abnormalies

• Plancenta Previa:* the plancecta attaches to the lower segment of the the uterus, or the cervical oss- endometrial.
• scaring.
• previa. Previous:
• cs birth. Previous:
• curutage. abortion : Mulpti parity.
• short .
• Maternal Risk:*

Painless red bleeeding, in a relaxed. vagina Fetal: should have,cs. decrease blood must avoid.

• Cord prolase:* happens with mal prsentation

ABRUPTION

placenta separates delivery.

• at least 20 weeks.
• hemorrhage to placenta, forms destruction. Rupture into seperation. increases abrubtion- risk.
• prior csecttion,
• Maternal*: Risks- hemorage
• Fetal Death is rare* Perinanal- asphixa still birth.

Tender abdomen pain: -concelead Bleeding

DIC- Death distressed- baby.

• acrata:* seperation or uterinan- wall
• high hyterectomy

increta:

• to into wall

Percrea:

• adherence to organs pelvic - adhesion

Other Topics

Spantaneous ellective Abortion or before 20/7

• E topic Peg. implantation.
• life- Threat As pregnancy- Can surgery

Rusk factors:

PELUC Disease'

Molar P.

abnormal- trphplahsis- growth non viable

• gest. Trophoblast.
• non molar.

PELVIC sensation pain High thyroid

ABO incombatibiy

o- with.

• AB AB red

• in red - breakdown.

• jaundice d HOD.

Less severe rch.

PREMATEN-

• antibody

New born Direct or red

TH: rh rh -

Mother not

• with birth Amniotisis

If rh type.

Senthszed by-

28 shot

• give rh.

3; -

• treat

S H

• GBS* if posituve - make baby iill. Infection. low
• Antiboitics 4 days before delivery.

POllyhydramios

high over 2L

-oligo

too little 500

Vital Signs

Pulse:

• 110-160 beats/min

Pressue- 750.

6- tempera - 3;.

• 66 high min. symptons abdono

BW

2;. 579.

Gest Age

• Posture.
• skun.
• genatalia.

HEAD variaitons

Molding. Capet

Hemaloma to blood w-within suture. with in suture.

Reds.

• Air Way Brealthing.

A. -

normal.

- call the provider.

Strior excess cynaion.

• Distress,

• stable high hr-

• glucose-

537 C

• 63
• cysnsi

Abstinence

1-2 with .k-

1-13 High for pre-e!