Chapter 20: Nursing Care of a Family Experiencing a Pregnancy Complication

By: Yzobelle Redondo

Identifying a High-Risk Pregnancy

 High Risk Pregnancy

- one in which a concurrent disorder, pregnancy related complication, or external factor
jeopardizes the health of the woman, the fetus or both
- it rarely refers to one causative factor

 Hyperglycemia
- increased serum glucose levels

Cardiovascular Disorders
- Valve Damage is the most common
Cause of Valve Damage: Rheumatic Fever; Kawasaki Dse
- Primary Cause of Danger in women w/CVD: increase in circulatory volume

Classification of CVD:
I.
 Uncompromised
 No discomfort with ordinary physical activity
 No symptoms of cardiac insufficiency
 No anginal pain

II.
 Slightly compromised
 Increased fatigue on ordinary activities
 Palpitation
 Dyspnea
 Angina

III.
 Markedly compromised
 Increased fatigue on ordinary activity
 Palpitation
 Dyspnea
 Angina

IV.
 Severely compromised
 Unable to carry out activities w/o discomfort
 Cardiac Insuffiency even when at rest
 Angina
Remember:
- Class I and II: can have a normal pregnancy & birth
- Class III: can complete pregnancy w/ complete bed rest
- Class IV: poor candidates for pregnancy bc they are in cardiac failure even at rest and not
pregnant

1. Left-Sided Heart Failure

Cause: Level of the Mitral Valve

s/sx:

 Fatigue
 Weakness
 Dizziness
 Dyspnea
 productive cough with blood-speckled sputum

Rationale: Pulmonary capillaries rupture under pressure, causing small amounts of blood to leak
into the alveoli

Pathognomonic Sign: Dyspnea

DOC: Heparin (anti-coagulant)

Nursing Intervention: Orthopneic Position

LHF occurs in conditions such as:

 Mitral Stenosis
 Mitral Insufficiency
 Aortic Coarctation
- Left side of the heart cannot move blood forward
- Inability to push blood forward  Backflow in the pulmonary circulation  Decreased
systemic BP  Pulmonary Hypertension
- Pressure on the pulmonary vein reaches 25 mmHg  leaking of fluid to interstital space
surrounding the alveoli  alveoli itself  pulmonary edema

 Orthopnea
– difficulty in breathing while in supine position
 Paroxysmal Nocturnal Dyspnea
- suddenly waking up at night with SOB
- Rationale: the heart works effectively at rest
 Balloon Valve Angioplasty
- Loosening of mitral adhesion
- Can be done while woman is pregnant
  Sodium Warfarin
- Teratogenic
- Anticoagulant drug
- Can be used after week 12 AOG
- 30 to 32 weeks AOG, serial ultrasound and nonstress test can be performed

2. Right-Sided Heart Failure

Cause: Eisenmenger Syndrome
s/sx:
 Jugular Vein Distention
 Congestion of systemic Circulation
 Distended liver & spleen
 Ascites
 Peripheral edema
 Dyspnea
 Angina
Nursing Intervention: Epidural Anesthesia

Complications of RHF:

 Pulmonary Valve Stenosis

 Ventral Septal Defects
 RV Output > RA Output
 Backflow to the RA  Systemic Circulation Congestion  Decreased cardiac output to the lungs 
Decreased BP in the aorta  Increased BP in the vena cava

3. Peripartal Heart Disease

Cause: idiopathic; probably caused by the effect of pregnancy in the circulatory system ; from
previously undetected heart dse
s/sx:
 SOB
 Angina
 Edema
 Cardiomegaly
DOC:
1. Low Molecular Weight Heparin: decrease the risk for thromboembolism
2. Immunosuppressive Therapy: improves experienced symptoms

Facts:

- Common in African American multiparas

 - Persistence of cardiomegaly in post partal period: do not attempt further pregnancies for the
condition can recur
- Oral contraceptives are contraindicated

 Peripartal Cardiomyopathy

- rare condition that originate in pregnant women with no previous hx of heart dse

Assessment of Women with CVD

1. Thorough Health Hx
2. Ask to always report coughing
Rationale: productive cough is indicative of pulmonary edema
3. Normal Edema During Pregnancy: feet & ankles
Abnormal Edema During Pregnancy: feet, ankles, face etc.
4. Assess for the level of exercise
5. Consider edema as PIH: after week 20 AOG
6. s/sx for edema of PIH:
 Irregular Pulse
 Rapid / Difficult respirations
 Angina on exertion

Nursing Interventions for Clients with CVD

1. Promote Rest
- Position: Left Lateral Recumbent Position
- 2 rest periods/day

2. Promote Healthy Nutrition

- Vitamin intake
- Sodium: necessary for maintaining fluid volume and balance

3. Educate regarding Medications

- Safe Drugs to Reduce Hypertension:
 ACE Inhibitors
 Beta Blockers
 Penicillin: antibiotic for heart dse; prophylaxis for rheumatic fever
 Nitroglycerin: DOC for angina

4. Educate regarding Avoidance of Infection

 5. Be prepared for emergency actions

Nursing Interventions for Labor and Birth

1. Monitor FHR and uterine contractions

2. Monitor HR, RR, BP
- >100bpm: ineffective pumping of the heart
3. Assume side-lying position: prevents supine hypotension
4. Semi-Fowler’s Position/Orthopneic Position: intervention for pulmonary edema
5. Fatigue: indicative of heart decompensation
6. O2 Administration: intervention for women with heart dse
7. Anesthetic Epidural: intervention for women with heart dse
8. Swanz Ganz Catheter: monitors heart fxn

4. Artificial Valve Protheses

Potential Problem: Use of oral anti coagulants

Nursing Intervention: Observe a woman taking anticoagulant for petechiae & signs of premature
separation of the placenta

Example:

1. Sodium Warfarin (Coumadin), increase the risk of congenital anomalies

2. Low-molecular weight heparin, take this before pregnancy to reduce the risk of congenital
anomalies

5. Chronic Hypertensive Vascular Disease

- associated with arteriosclerosis and renal dse

- management includes prescription of:

1. Beta-Blockers

2. ACE Inhibitors

DOC: Methyldopa (Aldomet)

6. Venous Thromboembolic Disease

Cause: stasis of blood + vessel damage + hypercoagulation

s/sx: Pain and redness in the calf of the leg

 DOC:

Nursing Intervention:

 Avoid the use of constrictive knee-high stockings

 Do not sit with cross legs
 Avoid standing in one position for a long period of time
 Bed rest and IV Heparin for 24-48 hrs.
 Subcutaneous Heparin for 12-24 hrs. (after the bed rest and IV Heparin)
Route Possible: only on the arms and thighs, NOT the abdomen
 Avoid taking additional injections once labor begins
Rationale: to help reduce the possibility of haemorrhage at birth

Dx:

1. Woman’s Hx
2. Doppler Ultrasonography

 Embolism – clot that moves to other parts of the body

 Pulmonary Embolism – clot lodging in the pulmonary artery, blocking circulation to the lungs

Signs of Pulmonary Embolism:

1. Chest Pain
2. Sudden Onset of Dyspnea
3. Cough with hemoptysis
4. Tachycardia/ missed beats
5. Severe dizziness/ fainting from low BP

Hematologic Disorders

1. Anemia
 Iron Deficiency Anemia
- most common anemia of pregnancy
- Hemoglobin Level: below 12 mg/Dl, suspect iron deficiency anemia
- Characteristic of IDA: microcytic & hypochromic
Rationale: when an inadequate supply of iron is ingested, it is unavailable for incorporation
in RBCs

- Mildly associated with low birth weight and preterm birth

s/sx:

 Extreme Fatigue
 Poor exercise tolerance
Rationale: Cannot transport O2 effectively

Nursing Interventions:
  Take prenatal vitamins w/ iron supplement of 60 mg as prophylaxis
 Eat a diet high in iron & vitamins (green leafy vegetables, meat, legumes, fruits)
 Take prescribed therapeutic level of medication of ferrous sulfate of 120/200mg
elemental iron/day
 Take Vit C/orange juice or any acid medium for maximum absorption of iron

Facts:

- Women who got pregnant in less than 2 yrs before the current pregnancy: iron stores are
apt to be low
- Iron Ingestion  Absorbed in duodenum  Bound to transferrin  transported to liver,
spleen & bone marrow  incorporated into haemoglobin, stored as ferritin (at these sites)
- Ferrous Sulfate turns stools black

Prophylaxis:

 60 mg elemental iron during pregnancy

 high iron diet (green leafy veggies, legumes, meat fruit)

2. Iron-Deficiency Anemia
Cause:
 Multiple pregnancies: increased fetal demand
 Women w/ 2ndary haemolytic dse: repid destruction & production of RBCs
 Women taking hydantoin (anti-convulsant): interferes w/ folate absorption

Nursing Intervention:

 Women expecting to be pregnant: 400 µg daily

 Pregnant women: 600 µg daily

Facts:

 Folic Acid: necessary for the normal formation of RBCs and preventing neural tube defects
 Folic Acid Deficiency Anemia: most apparent in the 2nd Trimester
 FADA: contributory factor to early miscarriage & premature separation of the placenta
 Folic Acid aka Folacin
 Megaloblastic Anemia
- enlarged red blood cells
- the kind of anemia that develops with folic acid deficiency

3. Sickle Cell Anemia

- Recessively inherited haemolytic anemia caused by abnormal amino acid in the beta chain
of haemoglobin

Facts:

- If a person is homozygous, sickle cell dse will result

- Many of the RBCs are irregularly shaped, and cannot carry much haemoglobin
- High altitude + dehydration: causes cells to clump bc of their irregular shape, and can block
blood vessels = reduced O2 supply to organs

- Does not appear to influence the course of pregnancy, prematuriry, miscarriage, or perinatal
mortality rate (but high risk ang mga w/ homozygous dse)

- High risk of developing asymptomatic bacteruria and pyelonephritis

Assessment:

- Hemoglobin Level of Sickle Cell Anima (+): 6-8 mg/100mL

- Detect bacteruria through clean catch urine sampling while woman is asymptomatic

- Check for varicosities in the lower extremities during prenatal visit

Nursing Intervention:

- Fluid administered is hypotonic

- Epidural anesthesia: poses a risk for hypoxia

-Postpartal period: early ambulation & wearing pressure stockings can reduce the risk of
thromboembolism