HIGH-RISK

PREGNANCIES
By: Viamarie B. Bulagao, RN, CNN, MN
 ▪Is any pregnancy wherein
maternal and fetal life is
High-Risk
endangered by a disorder co-
Pregnancies existing with or unique to the
pregnancy.
 1. Biophysical
2. Behavioral
CATEGORIES:
3. Psychological Status
4. Socio-demographic
 ▪Genetic
Biophysical ▪Medical
▪Obstetric
 ▪Nutritional Status
▪Substance Abuse
Behavioral ▪Dental Hygiene
▪Abuse and Violence
 ▪Failure to seek prenatal
Psychological care
Status ▪Extreme Stress
 ▪Maternal Age ▪Racial and
▪Parity Ethnic Origin
▪Marital Status ▪Occupational
Socio- Hazards –
▪Residence
demographic Prolonged
▪Ethnicity Shifts, Extreme
▪Income Heat, Exposure
to Radiation
 ▪Identify risk factors and
Role of the estimate the potential effect
Nurse of the pregnancy outcome.
 1. Normal Delivery and other complications
r/t pregnancy occurring in the course of

Causes of labor, delivery, and puerperium.

2. Hypertension complicating pregnancy,
Maternal childbirth and puerperium

Mortality 3. Postpartum Hemorrhage

4. Pregnancy with abortive outcome
5. Hemorrhage r/t pregnancy
 Antepartum
Complications
 1.Hemorrhagic
2.Hypertensive Disorders
Antepartum 3.Gestational Diabetes Mellitus
Complications 4.Heart Disease
5.Multiple Pregnancies
6.Substance Abuse in Pregnancy
 General Management:
▪ CBR
▪ Avoid coitus
▪ Approximation or assess for bleeding:
▪ Counting of pads
Hemorrhagic ▪ Saturation: fully saturated, 30-40 cc
▪ Weight: 1mg = 1ml = 1cc
Disorders ▪ Assess for complications: hypovolemic shock
▪ Save discharges for histopathology: to
determine if product of conception has been
expelled
▪ Prepare the mother for sonography or UTZ: to
determine the integrity of the sac
 1. First Trimester Bleeding
Hemorrhagic 2. Second Trimester Bleeding
Disorders
3. Third Trimester Bleeding
 First Trimester Bleeding
DIFFERENT CONDITIONS:
1. Abortion 2. Fetal 3. Ectopic
Spontaneous Induced Demise Pregnancy
a. Threatened a. Therapeutic a. Antenatal
Abortion a. Unruptured
b. Inevitable Demise
c. Complete b. Illegal b. Intrapartum
b. Ruptured
d. Incomplete Abortion Demise
e. Missed
f. Habitual
Abortions
 TYPES OF SPONTANEOUS ABORTION
Threatened Inevitable Complete Incomplete Missed Habitual
✓Uterine ✓Uterine ✓All ✓Not All ✓All ✓3 or more
Contraction Contraction products of products of products of consecutive
✓Vaginal ✓Vaginal conception conception conception pregnancies
Bleeding Bleeding are expelled are expelled are retained resulted in
Description
✓Closed ✓Open ✓Ok Uterus ✓Not ok ✓Not ok abortion w/c
Cervix Cervix ✓ok Cervix Uterus & Uterus, is usually r/t
Cervix Cervix & incompetent
Fetus cervix
Ultrasound of Blood Test Blood Test Blood Test Ultrasound Ultrasound
Diagnostic viable Blood Test Shocks
Test pregnancy Co-morbidity
Psychogenic
• CBR • D&C • Supportiv • D & C • D&C • McDonald
• No Sex • Rhogam e Care • Rhogam • Antibiotic Operation
Manage- • Progestero • Emotional Therapy • Shirodkar
ment ne Meds Support • Rhogam Procedure
• Instruct
WOF
 TYPES OF INDUCED ABORTION
THERAPEUTIC ILLEGAL
• Ensures the life of the mother • Unwarranted termination of
especially if there are pregnancy
bioethical issues involved. • The mother’s and fetal life is
• It has a two-fold effect which not at stake.
opts for the choice of lesser • Not permitted by the laws in
evil. the Philippines.
• No.
 ▪ It is the termination of pregnancy after the age
of viability
ANTENATAL DEMISE – occurs before labor
INTRAPARTUM DEMISE – occurs after onset
of labor
FETAL
RISK FACTORS:
DEMISE ▪ Mostly Idiopathic ▪ Maternal Trauma
▪ Antiphospolipid ▪ Severe maternal
Antibody Syndrome isoimmunization
(APAS) ▪ Fetal aneuploidy
▪ Maternal Diabetes ▪ Fetal Infection
 UNRUPTURED ECTOPIC PREGNANCY
▪ Missed Period
▪ Abdominal Pain w/in 3-5 weeks of amenorrhea
▪ Scanty, dark brown vaginal bleeding
▪ Vague Discomfort
ECTOPIC RUPTURED ECTOPIC PREGNANCY
PREGNANCIES ▪ Sudden, sharp, knifelike, unilateral severe pain
▪ Shoulder pain (pos. intraperitoneal bleeding
that extends to diaphragm and phrenic nerve)
▪ (+) Cullen Sign or the bluish-tinged umbilicus
▪ Syncope
 ECTOPIC PREGNANCIES
RISK FACTORS FOR ECTOPIC PREGNANCY
LESSER GREATER GREATEST
• Previous pelvic or • Previous genital • Previous ectopic
abdominal infection pregnancy
surgery • Infertility • Previous tubal
• Cigarette Smoking • Multiple sexual surgery or
• Vaginal douching partners sterilization
• Age of first • Diethylstilbestrol
intercourse <18 exposure in utero
years • Documented tubal
scarring
• Use of IUD
SECOND Hydatidiform Mole (H-Mole)
TRIMESTER or
BLEEDING Gestational Trophoblastic
Disease
 H- MOLE
“Bunch of Grapes”

Gestational Anomaly of the Placenta

It is a neoplasm

Swelling of chorionic villi and lost nucleus of the fertilized egg

Sperm’s nucleus duplicates, producing a diploid number 46XX

Grows and enlarges the uterus rapidly

 ASSESSMENT
Vesicles passed thru Hypertension Hyperthyroidism
EARLY SIGNS

Late Signs

Serious Late Complication

vagina before 20th week Pulmonary
Hyperemesis Snowstorm on Embolus
gravidarum Sonogram
↑Fundic HGT Anemia
˟FHT Abdominal
Vaginal Bleeding Cramping
Metastasis
↑HCG Levels
Preeclampsia @ 12 weeks
Third Trimester Bleeding
– Placental Anomalies
 Third Trimester Bleeding
DIFFERENT CONDITIONS:

Placenta Previa Abruptio Placenta Placental Anomalies

a. Placenta
a. Low Implantation a. Partial Abruption
Succenturiata

b. Partial Abruption with b. Placenta Bipartia &

b. Partial Placenta Previa
Hemorrhage Tripartia
c. Complete Abruption
c. Velamentous
c. Total Placenta Previa with Concealed
Insertion of the Cord
Hemorrhage
PLACENTA PREVIA
• FRANK BRIGHT RED, PAINLESS VAGINAL
ASSESS- • BLEEDING
Engagement (Usually has not occurred)
MENT • Fetal Distress
• Presentation of placenta
DIAGNOSTIC • Ultrasound
TEST • Blood tests
• NO SEX, NO IE, NO ENEMA
• CBR S BRP
NURSING • Prepare to induce labor if cervix is ripe or
dilated
INTERVEN- • Administer IV Fluids
TIONS • Put mother on NPO in case of delivery via CS
• Prepare for double set-up
• Secure Consent
 • Preeclampsia and hypertensive disorders
• Illicit drug use
• Accidents
ABRUPTIO PLACENTA Predisposing • History of placental abruption
Factors • High Multiparity
• Increase maternal age
• Cigarette Smoking
• DARK RED, PAINFUL VAGINAL BLEEDING
• Concealed hemorrhage- rigid board like abdomen
Assessment • Couvelaire Uterus
• Severe Abdominal Pain
• Drop in Coagulation factor
Complication • Disseminated Intravascular Coagulopathy (DIC)

Medical • Emergency CS
• Vaginal Delivery
Management • Conservative in-hospital observation
• Infuse IV Fluids as ordered
• Blood Typing and cross matching for blood transfusion
Nursing • Monitor FHT (Fetus) and Monitor VS for shock (Maternal)
• Insert Foley Catheter
Interventions • Measure blood loss; STRICT I&O
• Report S&Sx of DIC
 Maximum of 15

FILM ABOUT minutes per group

Total of 7 groups:
1.
SUBSTANCE 2.
3.
Caffeine
Tobacco
Alcohol

ABUSE IN 4.
5.
Narcotics
Cocaine

PREGNANCY 6.
7.
Amphetamines
Marijuana
 GROUP GRADE
Content 40%
Creativity 25%
RUBRICS FOR Cinematography 20%
JUDGING Audience Impact 5%
TOTAL: 100%
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Deadline: October 9, 2022 (Sunday)
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 ▪Incidence
Hypertensive ▪Definitions
Disorders During
Pregnancy ▪Etiology/pathophysiology
▪Role of Nutrition
 ▪ Second leading cause of maternal
mortality in US
▪ 15% of maternal deaths (eclampsia:
disseminated intravascular
coagulation, cerebral hemorrhgae,
Incidence hepatic failure, acute renal failure)
▪ Hypertensive disorders occur in 6 to
8% of pregnancies
▪ Contribute to neonatal morbidity and
mortality
 High Risk Women
• Under age 20 or over 40
• Poor nutritional status
• Smoking
• Overweight
• Other health problems such as renal disease, endocrine
disorders (diabetes), autoimmune diseases (lupus)
• Multiple gestation
• Some fetal anomalies
• History of preeclampsia
• Risk 10% with mild preeclampsia late in pregnancy
• Risk 40% with severe preeclampsia started early in
pregnancy
 ▪Primigravida
▪Genetic disease factors
Risk Also
Associated with: ▪Familial predisposition
▪family history of
hypertension
 ▪ Known hypertension before pregnancy or
rise in blood pressure to > 140/90 mm Hg
before 20 weeks

Chronic ▪ Hypertension that is diagnosed for the

Hypertension first time during pregnancy and that does
not resolve postpartum is also classified as
chronic hypertension.
▪ ~ 25% risk of superimposed preeclampsia
Risks to Women with Chronic Hypertension
▪ 22% developed preeclampsia; of those:
▪ 48% had SGA baby
▪ 51% delivered before 37 weeks

▪ Risk of preeclampsia higher with:

• High BMI
• Smoking
• Black ethnic origin
 Hypertension detected for the
first time in pregnancy with
systolic BP 140 or greater &
diastolic BP 90 or greater; no
Gestational proteinuria
Hypertension
▪ 25-40% of women with gestational
hypertension advance to
preeclampsia
 ▪ Proteinuria is defined as the urinary
excretion of 0.3 g protein or greater in a
24-hour specimen.
▪ This will usually correlate with 30
mg/dL (“1+ dipstick”) or greater in a
random urine determination with no
evidence of urinary tract infection.
Proteinuria ▪ Because of the discrepancy between
random protein determinations and 24-
hour urine protein in preeclampsia it is
recommended that the diagnosis be
based on a 24-hour urine if at all possible
 Pre-eclampsia
The presence of hypertension accompanied by
proteinuria in pregnancy, usually after 20 weeks

▪ Symptoms may include renal failure &

HELLP syndrome (hemolysis, elevated
liver enzymes, low platelets)
▪ 4% of women with preeclampsia advance
to eclampsia
▪ Treatment: close monitoring & delivery
before mother’s health is at excess risk.
 Pre-elampsia Severity
Less Severe More Severe
Presentation ≥Gestational week 34 ≥Gestational week 35
Diastolic BP <100 mm Hg >110 mm Hg
Headache Absent Present
Visual disturbances Absent Present
Abdominal pain Absent Present
Oliguria Absent Present
Creatinine (GFR) Normal Elevated (decreasing)
LDH and AST proteinuria Normal mild to moderate Elevated nephrotic range (>3 g/24 h)b

Nonreassuring fetal testingc Absent Present

 ▪ Occurrence in a woman with
preeclampsia, of seizures that can
Eclampsia not be attributed to other causes
 Pathophysiology
▪ Appears to be strongly related to placenta
▪ When placenta is delivered begins to abate
▪ Initiating Scenario- Stage 1:
▪ Abnormal placental implementation & failed
remodeling of maternal spiral arteries
▪ Reduced blood flow to placenta & reduced
placental perfusion
Normal
Pregnancy:
vascular
luminal
diameter
increased 4
fold & vessel
wall modified
by loss of
smooth muscle
so becomes
flaccid
Figure 1. Two-stage model of the pathophysiology of preeclampsia. The model
indicates preeclampsia as occurring in 2 stages. The initiating abnormality (stage
1) is failed vascular remodeling of the vessels that supply the placental bed. This
is linked to the maternal syndrome of preeclampsia (stage 2).

© 2005 American Heart Association, Inc. Published by American Heart Association. 2

 ▪ Reduced placental blood flow leads to
▪ Oxidative stress
▪ Production of cytokines, antiangiogenic factors, other
products…
Stage 2 ▪ Abnormal function of maternal vascular
endothelium:
▪ Liver
▪ Kidney
▪ Brain
▪ Other organs
▪ Additional Characteristics:
▪ alterations in immune response at the maternal interface
▪ increase in inflammatory cytokines in placenta and
maternal circulation, “natural killer” cells, and neutrophil
activation
Emerging Understandings

▪ Early preeclampsia: appears to be more

related to the evolution of an extremely
altered cardiovascular response probably
triggered by a placental disorder.
▪ Late preeclampsia: seems to be more
linked to maternal constitutional factors.
▪ Predisposing cardiovascular or metabolic risks
 • Decreased blood volume
• Decreased placental blood
flow may occur 3-4 weeks
Fetal Impacts before increased BP
• Hypoxia
• Decreased nutrient delivery
Maternal fetal/placental interactions in preeclampsia. The development of the maternal
syndrome of preeclampsia (stage 2) requires that reduced placental perfusion interact with
maternal factors. These constitutional factors are the maternal characteristics that increase
the risk of cardiovascular disease in later life. They are modified by the physiological changes
of pregnancy.

© 2005 American Heart Association, Inc. Published by American Heart Association. 2

Long Term Outcomes Associated
with Hypertensive Disorders in
Pregnancy
 Women with
Preeclampsia are
at Higher Risk of
CVD later in Life

Morgana L. Mongraw-Chaffin, Piera M. Cirillo, Barbara A. Cohn. Preeclampsia and Cardiovascular

Disease Death Prospective Evidence From the Child Health and Development Study Cohort.
Hypertension. 2010;56:166-171
 Geelhoed, J. J. M. et al. Preeclampsia and Gestational Hypertension Are
Associated With Childhood Blood Pressure Independently of Family
Adiposity Measures Circulation.2010;122:1192-1199

Copyright ©2010 American Heart Association

 ▪ Stage 1 – very little known about
the impact of nutrition early in
placental development
State of ▪ Stage 2 – many nutrition studies
Nutritional attempting to intervene on
Science maternal responses
• Smooth muscle contraction
• Prostaglandin synthesis
 ▪ “Regular physical activity, particularly
when performed during the year before
Physical Activity pregnancy and during early pregnancy,
to Prevent is associated with a reduced risk of
Preeclampsia? preeclampsia.”
▪ Any regular activity – 35% reduction of risk
▪ Vigorous activities – 54% reduction of risk
 • Na: Pregnant women with
proteinuric hypertension have
lower plasma volume Na. restriction
is associated with accelerated
volume depletion – not
recommended
• Energy and Protein intake:
Other Nutrition increases not found to be useful
Related Factors • Weight reduction or limited gain
in pregnancy: not found to be
useful
• Garlic & Chinese Herbs: - no good
quality studies
Pregnant Women with Chronic Hypertension:
▪ Take prenatal vitamin mineral supplement
▪ Follow a diet that meets Dietary Guidelines
▪ Moderate physical activity
▪ Follow recommended weight gain patterns for BMI
 ▪ No real dietary treatment
Women ▪ Recommended levels of energy, protein,
Diagnosed with sodium

Preeclampsia ▪ Physical activity restrictions as medically

recommended
 ▪ At higher risk for CVD and subsequent hypertension in
pregnancy:
Postpartum ▪ Follow healthy lifestyle
Women who Had ▪ Specifically –
Preeclampsia ▪ Plenty of fruits & vegetables
While Pregnant ▪ Adequate calcium status
▪ Healthy weight
Gestational diabetes
mellitus (GDM)
 ▪ Gestational diabetes mellitus (GDM) is
defined as any degree of glucose
intolerance with onset or first
recognition during pregnancy. The
definition applies whether insulin or
only diet modification is used for
Definition treatment and whether or not the
condition persists after pregnancy. It
does not exclude the possibility that
unrecognized glucose intolerance may
have antedated or begun
concomitantly with the pregnancy.
 ▪ 7% of all pregnancies are
complicated by GDM in US
▪ more than 200,000 cases annually in
US
Prevalence ▪ prevalence may range from 1 to
14% of all pregnancies, depending
on the population studied and the
diagnostic tests employed.
 ▪ Higher risk of:
▪ neural tube defects
▪ birth trauma
▪ hypocalcemia
Infant Concerns ▪ hypomagnesemia
in GDM ▪ hyperbilirubinemia
▪ prematurity syndromes
▪ subsequent childhood and adolescent
obesity and risk of diabetes
 ▪ Macrosomia in infant due to high
glucose levels from mother and
fetal insulin response leading to
increased fat deposition, associated
Infant Concerns, with complications at delivery.

cont. ▪ Hypoglycemia of infant following

delivery due to high fetal insulin
levels at delivery and sudden
withdrawal of maternal glucose
transfer
 ▪Higher risk of:
▪ hypertension
Maternal ▪ preeclampsia
Concerns ▪ urinary tract infections
▪ cesarean section
▪ future diabetes
 ▪ Assess risk at first visit
▪ If high risk (marked obesity, personal
history of GDM, glycosuria, or a strong
family history of diabetes) GTT ASAP
Diagnosis ▪ Women of average risk should have
testing undertaken at 24–28 weeks of
gestation
▪ Low-risk status requires no glucose
testing
 ▪ Age <25 years
▪ Weight normal before pregnancy
▪ Member of an ethnic group with a
low prevalence of GDM
▪ No known diabetes in first-degree
relatives
Low Risk Criteria
▪ No history of abnormal glucose
tolerance
▪ No history of poor obstetric
outcome
 ▪ A fasting plasma glucose level >126
mg/dl (7.0 mmol/l) or a casual
plasma glucose >200 mg/dl (11.1
Non GTT dx mmol/l) meets the threshold for the
diagnosis of diabetes, if confirmed
on a subsequent day, and precludes
the need for any glucose challenge
 ▪ Perform a diagnostic oral
glucose tolerance test (OGTT)
without prior plasma or serum
One-step glucose screening
Approach ▪ May be cost-effective in high-
risk patients or populations
(e.g., some Native-American
groups).
 ▪ Initial screening by measuring the
plasma or serum glucose
concentration 1 h after a 100-g oral
Two-step glucose load
approach ▪ Diagnostic OGTT on that subset of
women exceeding the glucose
threshold value on the GCT
Table 1— Diagnosis of GDM with a 100-g oral glucose load

mg/dl mmol/l

Fasting 95 5.3
1-h 180 10.0
2-h 155 8.6
3-h 140 7.8

Two or more of the venous plasma concentrations must be met or exceeded

for a positive diagnosis. The test should be done in the morning after an
overnight fast of between 8 and 14 h and after at least 3 days of unrestricted
diet ( 150 g carbohydrate per day) and unlimited physical activity. The
subject should remain seated and should not smoke throughout the test.
 ▪ Treatment started before 30 weeks
reduces likelihood of serious neonatal
morbidity
▪ Individualize MNT
▪ Daily self monitoring of blood glucose
(SMBG)
Nutritional ▪ Insulin when needed (20% needed)

Therapy in ▪ Goals:
GDM ▪ prevent perinatal morbidity and mortality by
normalizing the level of glycemia
▪ prevent ketosis
▪ provide adequate energy and nutrients for
maternal and fetal health
▪ dependent on maternal body composition
 ▪ Daily self-monitoring of blood
glucose (SMBG)
▪ Urine glucose monitoring is not
useful in GDM. Urine ketone
Monitoring monitoring may be useful in
detecting insufficient caloric or
carbohydrate intake in women
treated with calorie restriction.
 ▪ Blood pressure and urine protein
monitoring to detect hypertensive
disorders.
▪ Increased surveillance for pregnancies at
Monitoring risk for fetal demise is appropriate
▪ Assessment for asymmetric fetal growth
by ultrasonography to assess need for
insulin
 ▪ All women with GDM should receive
nutritional counseling, by a registered
dietitian when possible
▪ For obese women (BMI >30 kg/m2), a 30–
33% calorie restriction (to 25 kcal/kg actual
Nutrition weight per day) has been shown to reduce
hyperglycemia and plasma triglycerides with
Management no increase in ketonuria
▪ Restriction of carbohydrates to 35–40% of
calories has been shown to decrease
maternal glucose levels and improve
maternal and fetal outcomes
 Insulin
▪ Insulin therapy is recommended when MNT fails to
maintain self-monitored glucose at the following levels:
▪ Fasting whole blood glucose 95 mg/dl (5.3 mmol/l)
▪ Fasting plasma glucose 105 mg/dl (5.8 mmol/l)
▪ 1-h postprandial whole blood glucose 140 mg/dl (7.8 mmol/l)
▪ 1-h postprandial plasma glucose 155 mg/dl (8.6 mmol/l)
▪ 2-h postprandial whole blood glucose 120 mg/dl (6.7 mmol/l)
▪ 2-h postprandial plasma glucose 130 mg/dl (7.2 mmol/l)
▪ Oral agents (not recommended in 2004), in 2007:
▪ Glyburide (glibenclamide): studies indicate may be useful
adjunct to MNT/PA; may be less successful with obese patients
▪ Metformin: crosses placenta, insufficient evidence that
prevents GDM
▪ Acarbose: safety not fully evaluated
 ▪ 4 trials, 114 women with GDM
Exercise for ▪ Trials conducted in third trimester for about 6 weeks;
Diabetic Pregnant exercising three times a week for 20-45 minutes
▪ “There is insufficient evidence to recommend, or advise
Women: against diabetic pregnancy women to enroll in exercise
programs…..further trials needed.”
Cochrane, 2009
 Follow-up Care
▪ Reclassification of maternal glycemic status should be performed
at least 6 weeks after delivery
▪ If glucose levels are normal post-partum, reassessment of glycemia should
be undertaken at a minimum of 3-year intervals
▪ Avoid medications that worsen insulin resistance (e.g., glucocorticoids,
nicotinic acid)
▪ Seek medical attention if develop symptoms suggestive of hyperglycemia.
▪ Increased risk of congenital anomalies in subsequent pregnancies
▪ Use family planning to assure optimal glycemic regulation from the start of
any subsequent pregnancy
 ▪ Majority will eventually develop
diabetes-
▪ 35-60 percent within 10 years
▪ risk continues at least 1-2 decades
after GDM pregnancy

Long Term ▪ “There is substantial research

evidence that lifestyle change and
use of metformin or
thazolidinediones can prevent or
delay the progression of IGT to type
2 diabetes after GDM.”
Thank you!