High-Risk Pregnancy: Identification and Care

Introduction to Midterms

• All pregnancies and deliveries carry potential risks.
• Pregnant women, fetuses, and neonates can experience increased jeopardy.
• Approximately 29% to 30% of pregnancies fall into this high-risk category.
• Improved obstetric outcomes require identification and extra care for high-risk mothers and infants.

High-Risk Pregnancy

• Defined by concurrent disorders, pregnancy-related complications, or external factors endangering the health of the woman and fetus.
• Per WHO (1973), risk factors are "ascertainable characteristics associated with an abnormal risk of developing or being adversely affected by a morbid process."
• Can be identified by:
• Previous recurrent miscarriages or preterm deliveries.
• Heart disease.
• Hypertension or pre-eclampsia.
• Diabetes.
• Severe anemia.
• Twins or triplets.
• Placental abruption.
• Threatened preterm labor.
• Hemolytic anemia.
• Thrombocytopenia or megaloblastic anemia.
• Bleeding disorders.
• Thalassemia.
• History of thrombosis or neurological disease.
• Malignancy.
• Antiphospholipid syndrome.
• Cervical incompetence.
• Fibroid uterus.
• Congenital malformations that can survive.

High-Risk Labor

• Considered to present in the following cases
• Preterm labor.
• Obstructed labor.
• Previous caesarean section.
• Shoulder dystocia.
• Rupture uterus.
• CPD (Cephalopelvic Disproportion).
• Retained placenta.
• Perineal tear.
• Prolonged labor.
• Inversion of uterus.

Assessment in High Risk Cases

• Aims to define the problem, diagnose, and develop specific treatment recommendations.

Screening in High Risk Cases

• Identifies apparently healthy individuals at increased disease/condition risk.
• Offers information, testing, and treatment to reduce risks/complications.

Screening High-Risk Cases

• Requires a comprehensive assessment at the initial antenatal examination, especially in the first trimester.
• Performed in various healthcare settings, including large institutions and peripheral health centers.
• Risk factors can emerge later and are detected at subsequent visits.
• Reassessment occurs near term and during labor for new risk factors.

Establishing a Baseline

• Important for identifying and assessing
• Initial screening history.
• Maternal age.
• Reproductive history.
• Pre-eclampsia, eclampsia.
• Anemia.
• Third-stage abnormality.
• Previous infant with Rh-isoimmunization or ABO incompatibility.
• Medical or surgical disorders.
• Psychiatric illness.
• Cardiac disease.
• Viral hepatitis.
• Previous operations like myomectomy.
• Prior perineal or vesicovaginal fistula repair.

Family History

• Important to assess
• Socio-economic status.
• Family history of diabetes and/or hypertension.
• Multiple pregnancy (maternal side)
• Congenital malformation.

Diagnostic Tests

• Establishes the presence or absence of disease, informing treatment decisions.
• Used for symptomatic or screen-positive individuals (confirmatory test).

Diagnostic Tests for High-Risk Pregnancy

• Noninvasive Diagnostic Tests
• Fetal Ultrasound
  • During pregnancy, uses reflected sound waves to create a picture of the fetus, placenta, and amniotic fluid.
  • Displayed on a TV screen (black and white or color); saved as sonogram or echogram.
  • Provides insights into the fetus' health.
  • The pictures are also called sonogram, echogram, or scan.
  • Fetal ultrasound camera can determine the health of the fetus.
  • Different information is gained at different points (trimesters) during a pregnancy.
  • The exam is typically done between weeks 18 to 20 weeks of pregnancy.
  • The timing of this ultrasound might be altered for reasons such as obesity or prior surgical incision at the scanning site, which could limit visualization of the fetus.
  • Most women get an ultrasound in their second trimester at 16 to 20 weeks of pregnancy.
  • Some also get a first-trimester ultrasound before 14 weeks of pregnancy.
  • 1st Trimester Ultrasound is done to:
    • Determine how pregnancy is progressing.
    • Find out if female is pregnant with more than 1 fetus
    • Estimate the age of the fetus (gestational age)
    • Estimate the risk of a chromosome defect, such as Down syndrome
    • Check for birth defects that affect the brain or spinal cord
• Sequence of Events in Early Pregnancy:
• 4-5 weeks: Small intrauterine fluid collection with rounded edges.
• 5.5 weeks: Yolk sac, an unequivocal sign of pregnancy.
• 6 weeks: Embryo appears adjacent to yolk sac.
• 7-8 weeks: Amnion.
• 2nd Trimester Ultrasound is done to:
• Estimates gestational age.
• Examines the fetus' size and position, along with the placenta and amniotic fluid.
• Determines the positioning of the fetus, umbilical cord, and placenta for procedures like amniocentesis or umbilical cord blood sampling.
• Detects major birth defects, like neural tube defects or heart problems.
• 3rd Trimester Ultrasound is done to:
• Confirms the fetus is alive and moving.
• Checks the size and position of the fetus, placenta, and amniotic fluid.

Additional Noninvasive Tests

• Cardiotocography (CTG)
• CTG is a technique for recording fetal heartbeat (cardio-) and uterine contractions (-toco-) during pregnancy, typically in the third trimester.
• The machine used to perform the monitoring is called a cardiotograph or an electronic fetal monitor (EFM).
• Non-Stress Test (NST)
• The non-stress test is used to check on a baby's health.
• During an NST, the baby's heart rate is monitored in relation to its movements.
• Typically recommended for women at increased risk of fetal death.
• Usually performed after week 26 of pregnancy.
• Certain results may necessitate further monitoring, testing, or specialized care.
• Contraction Stress Test (CST)
• Determines how well the fetus will cope with the contractions of childbirth.
• The aim is to induce contractions and check for heart rate abnormalities via cardiotocograph.

Invasive Diagnostic Tests

• Chorionic Villus Sampling
• Chorionic villi are small structures in the placenta that act like blood vessels.
• These structures contain cells from the developing fetus, and a CVS test removes a sample of these cells through a needle.
• CVS helps prenatally diagnose chromosomal or genetic disorders by testing the chorionic villus (placental tissue).
• CSV usually takes place at 10-12 weeks" gestation, earlier than amniocentesis or percutaneous umbilical cord sampling and It is a preferred technique before 15 weeks.
• Amniocentesis
• Can be done during pregnancy to look for birth defects and genetic problems in the developing baby by removing a small amount of fluid from the sac around the baby in the womb (uterus)
• Often done in a doctor's office or medical center and there is no need to stat in teh hospital
• Offered to women who are older when the baby is born, had a screening test result that shows there may be a birth defect or other problem and women with a family history of genetic disorders. The woman can chose genetic counseling before it happens.
• It allows to learn about other prenatal tests and to make an informed decision regarding options for prenatal diagnosis
• This test is a diagnostic test. It is 99% accurate for diagnosing Down Syndrome and is usually done between 14 and 20 weeks.
• It can diagnose different gene and chromosome problems to the baby for example Anencephaly, Down Syndrome, Rare metabolic disorders passed down from familes and other genetic abnormalities like trisomy 18.
• Embryoscopy
• Examination of the embryo (intact membranes) at 9-10 weeks' gestation.
• Introduces an endoscope into the exocoelomic space/cavity via transcervical or transabdominal routes
• Likely limited to early pregnancy management for recurrent genetic syndromes with recognizable external fetal abnormalities.
• The procedure-related risk of fetal loss is ~12%.
• Fetoscopy
• Examinations of the fetus in the amniotic fluid that take place after 11 weeks' gestation
• Transabdominally performed
• Percutaneous Umbilical Cord Blood Sampling
• Also called cordocentesis/PUBS.
• Diagnostic test examining fetal blood to detect abnormalities
• An advanced ultrasound determines the umbilical cord's insertion location into the placenta.
• The ultrasound is used to guide a needle to obtain a small sample of fetal blood
• Tests results avalible within 72 hours, and the procedure similar to amniocentesis but the objective is for blood not amniotic fluid.
• Usually done when information cannot be obtained and cordocentesis is performed after 17 weeks into pregnancy.
• Cordocentesis detects abnormalities and blood disorders like fetal hemolytic disease. and may also help detect Malformations of the fetus, Fetal infection and Rh-Isoimmunization.

Importance of Trained Personnel

• Utilizing trained community health workers and nurse-midwives in health centers is essential for primary care.

Screening in Urban and Rural Areas

• Screening is crucial in both urban and rural settings.
• Referrals to specialized centers is recommenced for high risk
• Having a precious pregnancy should be investigated before having another conception, to treat hypertension, diabetes, kidney disease, or thyroid disorders.
  • Treat Sexually transmitted diseases and repair cervical tears before becoming pregnant. Assess and address toxoplasma antibodies, and consider folic acid therapy Nursing Care of a Family Experiencing a Pregnancy Complication from Preexisting Illness

Pregnancy Changes

• Hyperdynamic, hypervolumic maternal circulation.
• Cardiac output increases by 50%, blood volume by 45% (peak at 32-34 weeks).

Cardiovascular System Considerations

• Cardiovascular disease complicates ~1% of pregnancies but is the cause in the 5% deaths in pregnancy.

Classification of Heart Disease

Divided into categories which help predict heart disese categorized by criteria established by the New York State Heart Association:

• Class I: Uncompromised. Ordinary physical activity causes no discomfort, symptoms, or anginal pain.
• Class II: Slightly compromised. Ordinary activity causes fatigue, dyspnea, or anginal pain.
• Class III: Markedly compromised. Less than ordinary activity results in excessive symptoms or anginal pain.
• Class IV: Severely compromised. Inability to carry out any physical activity without discomfort even at rest symptoms of cardiac insufficiency or anginal pain are present. Left-Sided Heart Failure Occurs in conditions such as mitral stenosis and aortic coarctation, where the left ventricle cannot move blood forward. The heart becomes overwhelmed and the mitral valve's inability to push blood causes back-pressure, leading to systemic blood pressure decreases and pulmonary hypertension. Severe pulmonary edema (orthopnea). Paroxysmal nocturnal dyspnea

Effects to pregnant woman Complications will result in impaired blood flow to the uterus, poor placental perfusion, intrauterine growth restriction, and fetal mortality and peripheral edema of fluid that moves from the systemic circulation into the lower extremity interstitial spaces Effects to Pregnant Woman with Uncorrected Anomaly: Women may need to avoid pregnancy, but if they become pregnant, they may be hospitalized until the late part of pregnancy

Therapy

Serial ultrasound and non-stress tests to monitor fetal health and Balloon valve to loosen mitral valve adhesions and give the proper treatment

High-Risk Pregnancy: Cardiovascular System Assessment Include determining the:

• Level of exercise, presence of cough or edema,
• Compare Vital signs with the Liver size and Fetal size as well as check the ECG/echocardiogram Nursing Intervention's to assist the cardiovascular in pregnant women include doing the Left lateral and proper supervision.

Other Complicated Situations in Pregnancy

Include those who wear A WOMAN WITH ARTIFICIAL VALVE PROSTHESIS in which one potential problem has to do with anticoagulant use and a woman with chronic, with high-blood pressure can do with their Fetal well-being. And proper management of venous thromboembolic .

Endocrine System Complications and Pregnancy

• The service of skilled health care people should provide the best care. A Woman with DIABETES MELLITUS Diabetic care include those who had type-1,type-2 or even gestational who have a high chance the glucose will have a negative affect the fetus and may have a chance at birth defect
• Decreased control of glucose regulation can have effects to fetal size and hypoglycemia.

Nursing intervention's to assist in diabetic care include knowing which medications you can't take while being pregnant while trying to provide education regarding nutrition.

Other Diagnostic Tests

Assessment with women who have hypothyroidism with little tolerance for cold's and treatment with levothyroxine also and who has hyperthyroidism. For other disorders such as a woman with lron-deficiency Anemia. in which 25 percent of pregnancies will be affected and may cause preterm birth. Prevent this by taking the dietary supplements and being vitamin healthy

This can occur in women with sickle-cell anemia can have serious results for those with inherited disorders such as a Uti.

Reproductive Disorder

For all disorders mentioned, it's necessary the woman's information and background to know the best decision for their health, even providing the family what options they have for everything and making them calm. With Abortions, if the woman is sure she is pregnant but it isn't successful, one thing you know will be there has to be something negative happening. An abortion has to be after 20 weeks of gestation. To diagnose the case for an abortion the cervix can be tested and the ultrasound might. In addition, for one that is to continue.

For those with cervical defects

Emphases the importance for those who to remove the damage done and protect the damage as well

Placenta Previa, Abruptio Placentae:

Disorders may need more help with ultrasounds and checkup's on the baby.

The Importance the Family Should Undergo

A woman must know that she might not be able to feel the fetus after what happens with her and they might have to make a choice and know where to be. Check-up's will still need to be done.

Preterm Labor:

Needs testing and ultrasounds because the fetus is too small for safety and it needs to have a stop put to it

Induced Labor:

Where a medical team has to get into the fetus to check for all health

Complications of Labor:

Has to get all help for all factors because everything could work better

Other Complications:

Are the amniotic embolism where labor sometimes begun during childbirth depending