Nursing Management of Pregnancy at Risk PDF

NURSING MANAGEMENT OF PREGNANCY AT RISK Courtney Russell MSN, RN  LEARNING OBJECTIVES Discuss management of care for hyperemesis gravidarum Differentiate among causes of pregnancy bleeding. Discuss signs and symptoms, possible complic...

NURSING MANAGEMENT OF PREGNANCY AT RISK Courtney Russell MSN, RN  LEARNING OBJECTIVES Discuss management of care for hyperemesis gravidarum Differentiate among causes of pregnancy bleeding. Discuss signs and symptoms, possible complications, and management of miscarriage, ectopic pregnancy, cervical insufficiency, and hydatidiform mole. Compare and contrast placenta previa and placental abruption in relation to signs and symptoms, complications, and management. Differentiate assessment and management of gestational hypertension, preeclampsia, and chronic hypertension, and HELLP syndrome Assess for worsening condition in pre-eclampsia Discuss management of care for patient receiving Magnesium Sulfate Identify maternal and fetal risks or complications associated with diabetes in pregnancy Characterize normal versus abnormal findings for glucose tolerance tests Develop a plan of care for the pregnant woman with pregestational or gestational diabetes HYPEREMESIS GRAVIDARUM  HYPEREMESIS GRAVIDARUM Excessive N/V that is prolonged past 16 weeks Or is excessive, causes weight loss, dehydration, electrolyte imbalance, nutritional deficits, and ketonuria Risk Factors: o Maternal age < 30 years old o Personal or family hx of hyperemesis o Multifetal gestation – levels for HCG (especially with 2 babies or more) o Hyperthyroid disorder o Diabetes o Molar pregnancy  HYPEREMESIS GRAVIDARUM Assessment: o Excessive vomiting for prolonged period o Signs of dehydration/electrolyte imbalance o Weight loss o Increased HR, decreased BP o Tachycardia and hypotension o Poor skin turgor, dry mucous membranes o U/A: elevated specific gravity, ketonuria o Renal function: Low NA/K, Cl  HYPEREMESIS GRAVIDARUM Management: o Initial therapy is IV Lactated Ringers o Medications for N/V ▪ Pyridoxine (B6), Doxylamine (Unisom)----> Diclegis ▪ Promethazine- phenergan, Ondansetron - Zofran, Metoclopramide o ADT (next slide) o SEVERE cases may need enteral tube feedings or TPN o Hefty bolus of TPN  HYPEREMESIS GRAVIDARUM Recommended Diet: o Advance to clear liquids and bland foods once vomiting stops o Frequent, small meals o Bland foods then can advance as tolerated o Eat what sounds good and can tolerate DIABETES IN PREGNANCY  DIABETES MELLITUS Classification Type 1 Absolute insulin deficiency Have to get insulin injections Type 2 Relative insulin deficiency, resistance Some need insulin some don’t Gestational Diabetes Developed during pregnancy Pregestational Diabetes Women who has Type 1 or Type 2 DM prior to pregnancy  DIABETES MELLITUS (PREGESTATIONAL) 1st half of pregnancy (This is more for type 1) N/V Decreased need for insulin Placenta not fully developed/functioning (hPL not fully present) More at risk for hypoglycemia 2nd half of pregnancy Placenta fully developed and functional- hPL and other hormones leads to increased resistance to insulin which may lead to maternal hyperglycemia and hyperinsulinemia Will need MORE insulin to control hyperglycemia  MANAGEMENT PREGESTATIONAL DM Pre-conception counseling( we want them to be as healthy as possible before they are pregnant) Poor glycemic control around pregnancy increases risk for miscarriage and fetal anomalies Balance of diet, exercise, and monitoring (giving themselves insulin when needed and staying on schedule) More frequent prenatal visits- high risk 1st/2nd trimester Less insulin needed; more risk of hypoglycemia 2nd/3rd trimester More insulin needed due to metabolic changes; more risk of hyperglycemia  NURSING CARE & MANAGEMENT PREGESTATIONAL DIABETES MELLITUS Insulin: injections or pump Oral hypoglycemics: limited data regarding safety during pregnancy Monitor blood sugar frequently and administer insulin as needed Monitor fetal status: Screening for anomalies with first anatomical ultrasound around 20 weeks Daily kick counts ( start at 24 weeks) By 32 weeks: weekly/biweekly ultrasounds, NST, BPP  GDM-RISK FACTORS Obesity FH of DM Prior Hx of GDM Cardiovascular diseases (HTN) GDM SCREENING 24-28 WEEKS  NURSING ASSESSMENT Classic Symptoms 3 Ps Infections- UTIs, yeast infections Development of polyhydramnios(extra fluid in uterus); increased fundal height Screening can begin sooner if risks or symptoms/concerns exist Urine screening at every prenatal visit Glucose tolerance test  NURSING CARE & MANAGEMENT GESTATIONAL DIABETES Education- S/S of hypo/hyperglycemia Monitor fasting and postprandial glucose FBS or before meals 60-90 mg/dL 2 hrs after they eat ≤ 120 mg/dL Insulin may be needed Nutrition counseling- dietary modification to control excessive weight gain Balanced diet and exercise  PREGESTATIONAL & GESTATIONAL DIABETES MELLITUS Maternal Risks/Complications o Hypo/Hyperglycemia o Ketoacidosis (DKA) o Pre-eclampsia (vascular changes) o More likely with type 1 or type 2 o Gestational is less likely because there is less vascular change  PREGESTATIONAL & GESTATIONAL DIABETES MELLITUS Fetal & Neonatal Risks/Complications o Polyhydramnios o IUFD – intrauterine fetal death o Macrosomia (>4000g) o Hypoglycemia after birth – frequent heal sticks o RDS – respiratory distress syndrome o Insulin can cause an issue with surfactant  INTRAPARTUM CARE MANAGEMENT DIABETES MELLITUS Induction at 39-40 weeks Due to size of baby and don’t want more serious issues to develop Blood sugar checked on admission and as needed during labor typically q1- 2 hours with a goal of 90-110 They have less need for insulin because their metabolic rate is high, and they are in a stress state, so they are at a higher risk for hypoglycemia  POSTPARTUM CARE MANAGEMENT DIABETES MELLITUS Gestational- Will return to normal glucose levels after birth Likely to recur in future pregnancies 50% More likely to develop diabetes later in life Pregestational- Usually only require 50-60% most recent pregnancy insulin (because there is no more placenta and the HPL level has gone down) More at risk for hypoglycemia after birth Monitor blood sugars regularly CERVICAL INSUFFICIENCY  CERVICAL INSUFFICIENCY Passive and painless premature cervical dilation during the 2 nd or early 3rd trimester ( found by either contractions, transvaginal US or a cervical exam) Some women have a short cervix Can result in pregnancy loss/pre-term delivery Speculum or digital exam Transvaginal US Risks: hx of cervical trauma/surgery, hx of early pregnancy loss, short cervix Can be treated with bed rest, pelvic rest, avoidance of heavy lifting, progesterone supplementation, and cervical cerclage placement up to 28 weeks Once beyond there is nothing they can really do and they would just be in preterm labor  CERVICAL CERCLAGE Suture round the cervix to constrict the internal cervical os. Best results placed 12-14 weeks, removed around 37 weeks Inject lidocaine Purse strings If mother experiences Rupture Of Membranes or PTL you yes, it is make sure the cerclage is removed Education on signs of labor, infection, or ROM Bedrest? Not necessarily, if it is done early and if it is effective then yes it should be okay. Every pt is different Sexual Intercourse? As long as the cerclage is effective then yes, it is okay BLEEDING & LOSS OF PREGNANCY  EARLY PREGNANCY BLEEDING Miscarriage- (Spontaneous Abortion): a pregnancy loss result of natural causes before fetal viability (20 weeks or 500 Grams) What is priority Bleeding Hemmoragic shock Infection Psychological See table on ATI book for types of miscarriage and nursing care  EARLY PREGNANCY BLEEDING Assessment: Pregnancy hx, VS, pain assessment, quantity and nature of bleeding How many pads have you used Lab tests (HCG, CBC (H/H, WBC), clotting factors) Need baseline on WBC, RBC, Plts Care: May need a variety of interventions (IVF, blood products, D&C) Hemodiam Dilation and couratouge Scrape and suction dead fetus Any signs of infection Foul smelling discharge Rhogam if woman Rh- Follow-up care Emphasize rest Refrain from tub bath, sexual intercourse for 2 weeks Call for heavy bright red bleeding, foul smelling discharge, fever Take prescribed antibiotics ECTOPIC PREGNANCY Implantation of fertilized ovum outside of uterus- 90% are tubal pregnancies Risk Factors: STI’s IUD Hx of tubal/uterine surgeries Scar tissue  ECTOPIC PREGNANCY Clinical Manifestations: Typically, unilateral lower quadrant pain - sharp stabbing shooting pain Delayed Menses (1-2 weeks) Abnormal vaginal bleeding (spotting) May be a palpable unilateral mass Low HCG levels Rigid and tender abdomen (rupture) Trying to prevent fallopian tube rupture Referred shoulder pain if abdominal bleeding (rupture) S/S hemorrhage Pallor Hypotensive Tachycardic Diaphoretic Prolonged cap refill Decrease O2 stats Decreased level of consciousness  ECTOPIC PREGNANCY Management: Diagnose with HCG/Progesterone levels and transvaginal US & symptomology CBC, Blood type/Rh Early stages can be treated with methotrexate Stops the pregnancy from continuing to grow Methotrexate inhibits cells division and embryo enlargement Later stages: salpingostomy or salpingectomy Makes it harder to conceive At risk for hemorrhage and shock if ruptures: Monitor Hemoglobin/Hematocrit, WBC, IV fluids, blood replacement Lactated ringers Normal saline Rhogam for Rh- mothers prophylactic for any miscarriage  GESTATIONAL TROPHOBLASTIC DISEASE Hydatidiform mole/molar pregnancy most common type Degenerative anomaly that cause proliferative growth; becomes swollen, fluid-filled, appearance of grape like clusters Embryo fails to develop, structures associated with choriocarcinoma Risk for developing cancer Defect in the egg itself Occurrence & Cause 1 in 1,000 pregnancies in the US Cause is unknown but might be related to ovular defect or nutritional deficiency  GESTATIONAL TROPHOBLASTIC DISEASE Clinical Manifestations: Dark brown vaginal bleeding (prune juice), rapidly growing uterus, excessive N/V due to high hCG, anemia from blood loss Show very quickly look far along and they aren’t pregnant Diagnosis: Transvaginal ultrasound and persistently high hCG levels (will be way higher than they should be) Will have a positive pregnancy test Based off mom’s symptomology Care Management & Follow up Care Suction Curettage Rh- receive RhoGAM Grief support Monitor hCG levels closely- weekly for 3 weeks, monthly for up to 6-12 months. If the HCG levels continue to be elevated may require hysterectomy and chemotherapy due to choriocarcinoma Pregnancy discouraged for one year to recover and to make sure they are not developing cancer  PLACENTA PREVIA Placenta implanted in the lower urine segment near or over the internal cervical os Placental completely covers the cervical opening Placental partially covers the cervical opening This is not good because they eventually go into labor and once the cervix opens the placenta will start bleeding Incidence: 1in 200 pregnancies Classifications: Degree in which the internal cervical os is covered by placenta Complete placenta previa Partial placenta previa Marginal/Low-lying placenta  PLACENTA PREVIA Risk Factors: Previous C-Section Uterine scarring- curettage, endometritis Previous placenta previa AMA Multiparity (giving birth more than once) Smoking  PLACENTA PREVIA Clinical Manifestations: Painless (no tenderness, no cramping, no uterine contractions no nothing) bright red vaginal bleeding during 2nd and 3rd trimester Most are diagnosed on U/S before bleeding occurs Soft, relaxed non-tender uterus with normal tone Management: Will vary on type/symptoms Observation if less than 36/37 weeks U/S to locate placenta Avoid vaginal exams (Not number 1 go to)(do not go in blindly) Would do an ultrasound Monitor fetal status Limited activity Pelvic rest- nothing in the vagina, no sex (If not bleeding) If bleeding monitor H/H If delivery imminent Type and Screen; 2 units of cross matched PRBCs available  PLACENTA PREVIA Maternal & Fetal Outcomes: Major complication is hemorrhage Will deliver C-Section if: Full-term Excessive bleeding Active labor  ABRUPTIO PLACENTAE (PLACENTAL ABRUPTION) Premature separation from the uterus Detachment of part or all of placenta from implantation site after 20 weeks gestation; Leading cause of maternal death******** Can be concealed and still bleeding inside Risk Factors: Maternal HTN Pre-eclampsia Cocaine use (causes perfuse vasoconstriction) Cigarette smoking (causes perfuse vasoconstriction) Blunt external trauma; intimate partner violence Hx of abruption  PLACENTAL ABRUPTION Clinical Manifestations: Sudden onset of intense localized uterine pain Uterine rigidity (hard) and tenderness Dark red vaginal bleeding (not if concealed) Rapid S/S of maternal shock (hemorrhagic shock) and fetal distress (can lose baby within minutes) Management: Prepare for immediate delivery; most likely C-section Labs: H/H/CBC Coagulation factors, Cross and Type Match Identification of hemorrhagic shock and Tx Pallor Hypotension Tachycardia Diaphoretic Weak thready pulses TX: LR and NS Blood replacement Post-op monitor for signs of infection, shock, and DIC Can trigger body to go into DIC (BLEEDING AND CLOTTING ALL AT ONE TIME) HYPERTENSION DISORDERS IN PREGNANCY  HYPERTENSION IN PREGNANCY Hypertension disorders 5-10% of all pregnancies Major cause of perinatal morbidity and mortality Three most common types of hypertensive disorder in pregnancy: Chronic hypertension Gestational hypertension Preeclampsia  CHRONIC HYPERTENSION Hypertension present before pregnancy or diagnosed before 20 weeks gestations CHRONIC HTN MANAGEMENT Ideally management of chronic HTN begins before pregnancy Weight loss, nutritious diet, exercise, smoking and alcohol cessation Classified as either low risk or high risk based on many factors Women who are high risk are managed with antihypertensives and frequent assessments of maternal and fetal well being They will be on something to help their HTN GESTATIONAL HYPERTENSION Onset of hypertension (>140/90) without proteinuria/other findings after 20 weeks gestation SBP greater than 140 and/or diastolic >90 at least twice four hours apart in woman who previously had normal BP Resolves by 12 weeks postpartum  PREECLAMPSIA Development of hypertension and proteinuria (≥ 1+) after 20 weeks gestation in a previously normotensive woman ( BIG DADDY) Superimposed preeclampsia Can develop for the first time during the postpartum period ( the placenta is the problem) YOU CAN DEVELOP AFTER BIRTH BUT ITS RARE Severe Preeclampsia: BP ≥ 160/110 Proteinuria > 3+ Oliguria, GFR decreases, elevate creatinine >1.1 mg/dL Cerebral/visual disturbances (Headaches/Blurred vision, spotty vision) Hyperreflexia with possible ankle clonus (Beating motion) Extensive peripheral edema Hepatic dysfunction, elevated liver enzymes Epigastric and RUQ pain Thrombocytopenia (platelet levels will drop)  PREECLAMPSIA: RISK FACTORS First pregnancy > 40 years of age Personal or family Hx of preeclampsia Chronic hypertension Obesity Multifetal gestations Paternal hx of producing preeclamptic pregnancy  PREECLAMPSIA PATHOPHYSIOLOGY Progressive disorder ( starts at the very beginning and slowly gets worse until noticed in the late 2nd trimester early 3rd) with placenta as the root cause thus the disease begins to resolve after the placenta has been expelled Disruptions in placental perfusion and endothelial cell dysfunction occur early in pregnancy long before the s/s become evident (a lot going on behind the scenes)  PREECLAMPSIA PATHOPHYSIOLOGY Placental ischemia releases substances that are toxic to endothelial cell function in the vessels causing vasoconstriction (turns into an entire body problem) Vasoconstrictions results in decreased perfusion to organs including kidneys, liver, and eyes thus the symptoms associated with preeclampsia Endothelial injury increases vascular permeability causing fluid to leak out of vessels thus causing generalized edema of legs/feet, hands, and face. Can also cause pulmonary edema and cerebral edema Shortness of breath and cough Headaches and CNS irritability: hyperreflexia and seizures (trying to HAULT THIS)  PREECLAMPSIA PATHOPHYSIOLOGY Vasoconstriction and vasospasm leads to hypertension and reduction in blood flow: Kidneys- decreased GFR and proteinuria Liver- elevated liver enzymes, RUQ pain, epigastric pain Retina- blurred vision  ECLAMPSIA Onset of seizure activity or coma in a woman with severe preeclampsia who has no history of preexisting pathology (over stimulation in the brain) Usually preceded by headache, visual disturbances, and hyperreflexia  PREECLAMPSIA: ASSESSMENT Accurate and frequent measurement of BP Proteinuria Dipstick ≥ 1+ Ideally measured with 24 urine collection Assessment of generalized edema Hands Arms Face Legs Monitor for signs of severe preeclampsia: Assessment of DTR’s- hyperreflexia/clonus Headaches, blurred vision Oliguria RUQ pain/epigastric pain HELLP ( highly associated with liver prefusion and  HELLP SYNDROME Variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia. Laboratory diagnosis for a variant of preeclampsia that involves hepatic dysfunction characterized by: Hemolysis of RBCs: anemia and jaundice (bilirubin) Elevated Liver enzymes (ALT, AST) Low Platelets  INTERVENTIONS FOR PREECLAMPSIA AND GESTATIONAL HTN WITHOUT SEVERE FEATURES Goal is to ensure maternal safety and delivery of healthy newborn as close to term as possible Monitor BP regularly, fetal monitoring Frequent follow-up with provider Bedrest? Yes and Depends on the severity Education!!! SO IMPORTANT Nerological Headaches Epigastric pain S S S S s  INTERVENTIONS FOR GESTATIONAL HYPERTENSION AND PREECLAMPSIA WITH SEVERE FEATURES Preeclampsia management: Hospitalized care: dark, low stimulation, quiet environment Seizure precautions Mag Sulfate IV ( Antihypertensive meds Corticosteroids to enhance fetal lung maturity if needed Intrapartum Care: Assess LOC, VS, UO, daily weights Continuous FHR and uterine contraction monitoring Assess for sign of placental abruption (higher risk for this)  CONTROL OF HYPERTENSION Indicated when SBP exceeds 160 and/or DBP exceeds 110 Goal BP with antihypertensives(IV PUSH): 140-150/90-100 If left untreated concerns are HTN crisis, cerebral hemorrhage, placental abruption Hydralazine (Apresoline) – frequent Labetalol (Trandate) Nifedipine (Procardia)  MAGNESIUM SULFATE High alert medication CNS depressant- med of choice for preventing and treating seizure activity Administered IVPiggyBack or concurrently with IVF Initial loading dose is 4-6 gm over 20 -30 minutes Maintenance dose 1-2 gm per hour Has little effect on maternal BP  RR < 12/min MAG TOXICITY Absence of patellar DTR Decreased LOC Cardiac Dysrhythmia Urine output