High-Risk Pregnancy Scenarios

• A high-risk pregnancy is jeopardizing the health of the woman and/or the fetus due to concurrent disorder, pregnancy-related complication, or external factor.

Nursing Process for High-Risk Pregnancies

• Assessment includes objective data (vital signs) and subjective data (edema level, exhaustion).
• Potential nursing diagnoses:
  • Impaired tissue perfusion, secondary to poor heart function from mitral valve prolapse
  • Pain, secondary to pyelonephritis from uterine pressure on ureters
  • Fear regarding pregnancy outcomes and related chronic illnesses
• Outcome identification and planning are based on the client’s pattern of life.

2020 National Health Goals for Pregnancy Complications Include

• Reduce fetal deaths from 6.2 to 5.6 per 1,000 live births.
• Reduce maternal deaths from 12.7 to 11.4 per 100,000 live births.
• Reduce maternal illness and complications during pregnancy from 31.1 to 28 per 100 births.

High-Risk Pregnancy: Cardiovascular System

• Cardiovascular disease complicates 1% of pregnancies but accounts for 5% of maternal deaths.
• Blood volume and cardiac output increase by up to 50% during pregnancy, peaking at 28-32 weeks.
• The New York Heart Association criteria are used to categorize heart disease severity.
• Damaged valves due to rheumatic fever/Kawasaki disease, and congenital anomalies like coarctation of the aorta/atrial septal defect are some of the most common complications.
• 28-32 weeks gestation is a dangerous time.
• Successfully completing a pregnancy depends on the type and the extent of the cardiovascular disease.

Cardiovascular Clinical Findings

• Left-sided heart failure occurs in conditions such as mitral stenosis, mitral insufficiency, and aortic coarctation.
  • Orthopnea (elevating chest and head during sleep) can occur due to pulmonary edema.
  • Paroxysmal nocturnal dyspnea (suddenly waking at night, short of breath) can occur.

Interventions

• Low-molecular-weight heparin can be given because it does not cross the placental barrier.

• Antidiuretics, antihypertensives and beta/blockers may be prescribed.

• Serial UTZ and NST will be scheduled to determine placental perfusion.

• Right-sided heart failure is caused by unrepaired congenital heart defects like pulmonary valve stenosis or Eisenmenger syndrome.

  • Causes distended liver and spleen, ascites, and peripheral edema.

• Patients with uncorrected RSHF should not get pregnant.

• Repeated ABG's may be needed to ensure fetal growth.

• A pulmonary artery catheter may be needed to monitor pulmonary pressure.

• Close monitoring may be needed after epidural anesthesia to minimize the risk for hypotension.

Classification of Heart Disease:

• Class 1: No discomfort or symptoms with ordinary physical activity.
• Class 2: Slight compromise, excessive fatigue, palpitation, dyspnea, or anginal pain with ordinary phsycial activity.
• Class 3: Markedly compromised, patient experiences excessive fatigue, palpitations and dyspnea, or anginal pain with less-than-ordinary activity.
• Class 4: Severely compromised, patient is unable to carry out any physical activity without experiencing discomfort, cardiac insufficiency or anginal pain.

High-Risk Pregnancy: Cardiovascular Issues:

• Valve damage with or without valve replacement, congenital anomalies, coronary artery disease, chronic hypertensive vascular disease, venous thromboembolic disease, and peripartum heart disesase are cardiovascular issues.

• Peripartal cardiomyopathy is rare and has an unknown cause, originating in pregnancy in those with no previous personal history of heart disease.

  • It has a 50% mortality rate.
  • It occurs in black multiparas with gestational hypertension.
  • Patients experiencing symptoms such as shortness of breath, chest pain, nondependent edema, and cardiomegaly may be given immunosuppressive therapy.
  • If it persists postpartum, the woman may be allowed to get pregnant.
  • No oral contraceptives should be taken because of the possibility of thromboembolism.
  • A patient may need a heart transplantation for another pregnancy.

Cardiovascular System Assessment Includes:

• Level of exercise, presence of cough/edema, comparison of baseline vital signs, liver size (right-sided heart failure involvement), ECG/echocardiogram, and fetal size (small for gestational age) & poor response to labor (FHR decelerations).

• Deficient knowledge of steps to take to reduce the effects of maternal cardiovascular disease on the pregnancy and fetus is a nursing diagnosis.

• Promote rest, healthy nutrition, educate regarding medication and educate regarding avoidance of infection are nursing interventions during the antepartal period.

Nursing intervention during the intrapartum period include:

• Positioning, providing epidural anesthesia, and assisting with vaginal delivery.
• Nursing interventions during the postpartum period include:
  • Assessing for heart failure, administering anticoagulant/digoxin therapy, and providing intermittent pneumatic compression boots.

Quality & Safety Education For Nurses(QSEN)

• Patient-centered care, teamwork & collaboration, evidence-based practice, quality improvement, safety, and informatics are key.

• Venous thromboembolic disease during pregnancy is related to stasis of blood in the lower extremities, uterine pressure, and hypercoagulability.

• Risk factors: DVT, being older than 30.

• Symptoms consist of chest pain, sudden onset of dyspnea, a cough with hemoptysis, tachycardia/missed beats, and dizziness/fainting.

Interventions

• Avoid constrictive knee-high stockings, sitting with legs crossed at the knee, standing in one position, Heparin may need to be prescribed.

• Pseudoanemia complicates 15%-25% from causes such as diet low in iron, heavy menstrual periods, and unwise weight-reducing programs.

• Interventions:

  • Antenatal Effects: Poor weight gain, Pre-term labour, Pre-eclampsia
  • INTRANATAL EFFECTS: Dysfunctional labour, Haemorrhage and Shock, Cardiac Failure
  • POST NATAL EFFECTS: Puerperal Sepsis, Sub - Involution, Embolism
  • FETAL EFFECTS: Risk of pre-maturity, IUGR, LBW, Poor apgar score, Depleted iron store in neonates and anaemia in infancy period, High prevalence of failure to thrive and poor intellectual development.

High-Risk Pregnancy: Endocrine System #1

• Diabetes mellitus, pathophysiology and clinical manifestations, classification and gestational diabetes are to be consisdered.
• Decreased glucose regulation and affecting the fetal size and infant hypoglycemia can result during pregnancy.

A Pregnant Patient with Malaria:

• Malaria is a protozoan infection transmitted by Anopheles mosquitoes with an incubation period of 12-14 days.
• Signs
  • Elevated liver enzymes
  • Fever
  • Malaise
  • Headache
  • Thrombocytopenia
  • Renal failure
• Treat or prevent by wearing clothing that covers most of the body, wearing insect repallant, sleeping witha night mesquito net, keeping windows closed, and delaying travel to endemic aeas.
  • Combination of anti-malarial drugs

Combination of anti-malarial drugs

o To reduce LBW and Pre-term birth. • Sulfadoxine/ Pyrimethamine-safe on third trimester • Chloroquine (DOC)-all trimesters • Teratogenic-Quinine, Atovaquone, Proguanil, Tetracyclines

A Pregnant Patient with UTI

• Progesterone dilates ureters so stasis of urine can occur, minimal glucose provides a medium for bacterial growth, and can be associaated qith preterm labor and PROM being caused by E.Coli.
• Treatable (safe)with -Amoxycillin -Ampicillins -Cephalosporins -Sulfonamides can be used early, can cause hyperbilirubinemia it not used near term -Tetracycline can cause bone growth retardation and teeth staining

A Pregnant Patient with COVID-19:

• Wash hands, cover mouth and nose when coughing, and maintain a distance of at least 1 meter from others.
• Symptoms include fever, cough, fatigue, diarrhea, and mylagia.
• Can cause severe respiratory and cardiovascular symptoms
• Pregancy can lead to suseptibility to complications, vaccine is allowed

Diabetes During Pregnancy:

• Screening and monitoring during pregnancy.
• Nursing Diagnosis: Inadequate knowledge related to therapeutic regimen necessary during pregnancy.
• Provide education regarding nutrition and exercise.
• Therapeutic management includes:
  • Assess Insulin needs and dosage adjustments.
  • Educate related to blood glucose monitoring.
  • Insulin pump therapy
  • Educate related to pump care and use.
  • Tests for placental function and fetal well-being.
  • Educate on fetal movement.
  • Post delivery management of blood glucose

High-Risk Pregnancy: Renal and Urinary System Assessment: Includes:

• Assess Elevated blood pressure, Flank pain, urin issues, and Serum creatinine levels.
• Interventions should be nutritional consults and monitoring fluid intake, Hygiene, voiding frequently after sex, and Cranberry juice intake.

Question and Answer

• Question 1: Which statement by a woman who is 8 weeks pregnant and has cardiac disease would you most likely follow up closely?
  • B. "I have gained 4 lb during the last week, but I'm not eating more than before.”
    • Rationale: a gain of 4 lbs in the first 8 weeks without edditional intacke can signal circulatory fluid and impeding heart failure.
• Question 2:What is the most accurate statement regarding exercise and nutrition during pregnancy for a woman with diabetes?
  • D. Ideally, dietary calorie intake should be approximately 20% from protein, 40% to 50% from carbohydrates, and up to 30% from fats.
    • Rationalle: Balance can allow for good glycemic control.
• Question 3: Which is the most accurate and reliable outcome measurement for evaluation an intervention?
• A. A fasting glucose level of 85mg/dl
• Rationalle: Is the only outcome measure.

This quiz focuses on nursing interventions and risk assessment in high-risk pregnancies. Questions cover topics such as preventing thromboembolism, managing cardiovascular issues, identifying complications like pulmonary embolism, and diabetic pregnancy care.