• Anomaly that most causes this condition in
NCM109 LEC WEEK 1
Nursing Care of a Family Experiencing a
Pregnancy Complication from a Preexisting or
Newly Acquired Illness
1. CV Disorders and Pregnancy
2. Anemia and Pregnancy
3. Diabetes Mellitus
4. Isoimmunization (Rh Incompatibility)
5. HIV/AIDS
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
CV Disorders and Pregnancy
➢ Should visit her pregnancy care provider for
preconception care
➢ Pregnancy taxes the circulatory system of every
woman, even those without cardiac disease
➢ Blood volume and CO increase ~30% (& up to as
much as 50%) during pregnancy
➢ Half of this increase occurs by 8 WEEKS; it is
maximized by mid-pregnancy
LEFT-SIDED HEART FAILURE
• Occurs in conditions such as mitral stenosis,
mitral insufficiency, and aortic coarctation
• Lower CO and pulmonary HTN
• Pulmonary edema and SOB
• Productive cough with blood-speckled sputum
• Increased RR
• Orthopnea
• Paroxysmal nocturnal dyspnea
• High risk for
o Spontaneous miscarriage – when fetus
does not meet age of viability
o PTL – fetus has already reached age of
viability
o Maternal death
MANAGEMENT
❖ Anticoagulant – to prevent thrombus formation
(Low-molecular weight heparin)
❖ Antihypertensive – decrease strain in aorta →
lowers blood pressure
❖ Diuretics
❖ Beta-blockers – to improve ventricular filling
RIGHT-SIDED HEART FAILURE
• Can be caused by an unrepaired pulmonary
valve (unrepaired congenital heart defect)
• When the right ventricle is overwhelmed by the
amount of blood received by the right atrium
from the inferior and superior vena cava
women of reproductive age is the Eisenmenger
syndrome (structural malformations of heart)
• Jugular venous distention and increased portal
circulation
• Liver and spleen distention
• Peripheral edema
MANAGEMENT
❖ Advise patient not to become pregnant; but if
they really desire, it must be thoroughly
planned out; expect to be hospitalized during
the last part of pregnancy
❖ Close counseling and monitoring
❖ Counsel for prenatal checkup
❖ Need extremely close monitoring after epidural
anesthesia to minimize risk of hypotension
ASSESSMENT of a Woman with Cardiac Diseases
Begins with thorough health history to
document prepregnancy cardiac status
Document woman’s level of exercise
performance
Ask if she normally has cough or edema
Assess baseline vital signs and jugular vein
status
NOTE: for edema – distinguish physiologic from
pathologic; edema is normally present in legs or
lower extremities.
If right-sided heart failure – assess liver size at
prenatal visits
For additional cardiac status assessment:
o ECG / Echocardiogram periodically
o 12 Lead ECG periodically
FETAL ASSESSMENT
Infants of women with severe heart disease
tend to have low birth weights or be SGA
This can result in preterm labor, which exposes
the newborn to the hazards of immaturity as
well as low birth weight
Nursing Diagnosis
Deficient knowledge regarding steps to take to reduce
the effects of maternal cardiovascular disease on the
pregnancy and fetus
Nursing Interventions
➢ PROMOTE REST
o 2 rest periods/day (fully resting, not
getting up frequently) and a full night’s
sleep (not tossing and turning)
o Rest should be in the LEFT LATERAL
RECUMBENT position to prevent supine
hypotension syndrome and increased
heart effort
➢ HEALTHY NUTRITION
o Be certain she is remembering to take
her prenatal vitamins (IRON)
NCM 109 LECTURE WEEK 1 (OLI) 1
 o If a woman was following a sodium-
restricted diet before pregnancy, this
may be continued during pregnancy
o With normal BMI, expected weight gain
is 2.5 – 3.5 lb
➢ EDUCATE REGARDING MEDICATION
o If taking digoxin before pregnancy, may
need to increase their maintenance
dose
o Digoxin may also be given to slow the
fetal heart if fetal tachycardia is present
o Arrhythmia agents such as adenosine,
beta-blockers, and ACE inhibitors to
reduce hypertension are safe to use
during pregnancy and are also
frequently prescribed
o If taking penicillin as a child (for
rheumatic fever), should continue to
take this drug during pregnancy
➢ EDUCATE REGARDING AVOIDANCE OF
INFECTION
o Avoid visiting or being visited by people
with infections
o Alert HCP at the first indication of an
upper respiratory tract of UTI
o Monthly screening for bacteriuria with a
clean-catch urine test at prenatal visits
should help detect UTIs
o Infection can cause:
▪ PTL
▪ Spontaneous
miscarriage/abortion
Nursing Interventions during LABOR AND BIRTH
➢ Frequently assess MVS, FHR, and uterine
contractions
➢ Advise woman to assume a side-lying position
during labor to reduce possibility of supine
hypotension syndrome
➢ If woman has come pulmonary edema,
however, it may be necessary for her to elevate
her head and chest (semi-Fowler’s position) to
ease the work of breathing
➢ Determine fatigue
➢ Oxygen via NC
➢ Should not push with contractions, as pushing
requires more effort than they should expand,
making epidural anesthesia and anesthetic of
choice
Nursing Interventions POSTPARTUM
➢ The blood that supplied the placenta is released
into her general circulation, increasing her
blood volume by 20%-40%
➢ May need a program of decreased activity and
possibly anticoagulant and digoxin therapy until
her circulation stabilizes
➢ Anti-embolic stockings or intermittent
pneumatic compression (IPC) boots may be
prescribed to increase venous return from the
legs
➢ Prophylactic antibiotics should be started
immediately after birth to discourage subacute
bacterial endocarditis
➢ Stool softener can be prescribed to prevent
straining with bowel movements
➢ Oxytocin (Pitocin) should be used with caution
because they tend to increase BP, which
necessitates increased heart action (rebound
reaction)
o Methergine, mergot – increases BP
➢ As a rule, women with heart disease can
breastfeed without difficulty
ARTIFICIAL VALVE PROSTHESIS
• One potential problem involves the use of oral
anticoagulants women take to prevent the
formation of blood clots at the valve site
o Why? – some anticoagulants are
teratogenic (ex. coumadin)
o Low-molecular weight heparin – DRUG
OF CHOICE
• Usually placed on low-molecular weight heparin
therapy instead of usual warfarin
• Observe a woman who is taking an
anticoagulant for signs of PETECHIAE and
PREMATURE SEPARATION OF PLACENTA during
both pregnancy and labor
CHRONIC HYPERTENSIVE VASCULAR DISEASE
• Places both the woman and the fetus at high
risk because of poor heart, kidney, and/or
placental perfusion during the pregnancy
• Chronic HTN – BP 140/90 at <20 weeks AOG
• Gestational HTN – BP 140/90 at ≥20 weeks AOG
o If persists >12 weeks postpartum =
CHRONIC HTN
• Preeclampsia – HTN, proteinuria, edema
• Eclampsia – HTN, proteinuria, edema, seizure
MANAGEMENT
❖ Beta-blockers and Ca Channel blockers to
reduce blood pressure by peripheral dilation to
a safe level
❖ Labetalol (Trandate) and nifedipine (Procardia)
are typical drugs that may be prescribed
VENOUS THROMBOEMBOLIC DISEASE
• DVT triad
o Stasis + vessel damage +
hypercoagulation
• Increases during pregnancy because of a
combination of stasis of blood in the lower
extremities from uterine pressure and
hypercoagulability (the effect of elevated
estrogen)
• The likelihood of DVT leading to pulmonary
emboli is highest in women 30 years of age or
older
NCM 109 LECTURE WEEK 1 (OLI) 2
 • Pain and redness usually in the calf of a leg
diagnosed by a woman’s history and Doppler
ultrasound
• Will be treated with bed rest and IV heparin for
24-48h, then SC heparin she can self-inject
every 12-24h for the duration of the pregnancy
MANAGEMENT
❖ Can be reduced thru common sense measures
such as avoiding the use of constrictive knee-
high stockings, not sitting with legs crossed at
the knee, and avoiding standing in one position
for a long period
❖ Signs of pulmonary embolism need to be
recognized because it is an immediate
emergency
o Chest pain
o Sudden onset of dyspnea
o Cough with hemoptysis
o Tachycardia or missed beats
o Dizziness and fainting
ANEMIA AND PREGNANCY
True anemia is typically considered to be present when:
• Hemoglobin concentration is <11 g/dL
(hematocrit 33%) in the first or third trimester
of pregnancy or
• When the hemoglobin concentration is >10.5
g/dL (hematocrit 32%) in the second trimester
True Anemia level during pregnancy
1st trimester 2nd trimester 3rd trimester
<110 mg <105 mg <110 mg
<11 g/dL <10.5 g/dL <11 g/dL
IRON-DEFICIENCY ANEMIA
• Most common anemia of pregnancy
• From diet low in iron, heavy menses, unwise
weight loss program
• Confirmed by corresponding low serum iron
level (under 30 ug/dL) and an increased iron-
binding capacity (over 400 ug/dL)
MANAGEMENT
❖ Prenatal vitamins containing 27 mg of iron as
prophylactic therapy during pregnancy
❖ Diet high in iron and vitamins (ex. green leafy
veggies, meat, legumes)
❖ Will be prescribed therapeutic levels of
medication (120-200 mg elemental iron/day),
usually in the form of ferrous sulfate or ferrous
gluconate
❖ Take iron supplements with orange juice or a
vitamin C supplement, which supplies ascorbic
acid – iron is best absorbed in acidic
environment
❖ Some women report constipation or gastric
irritation when taking oral iron supplements
❖ Ferrous sulfate turns stools black
❖ For severe form, IV iron can be prescribed
FOLIC-ACID DEFICIENCY ANEMIA
• Folic acid during:
o 3 months before pregnancy and
o First 3 months – critical for
neurogenesis (to prevent neural tube
defect)
• Occurs most often in multiple pregnancies
because of the increased fetal demand
• Occurs in women who are taking hydantoin, an
anticonvulsant agent that interferes with folate
absorption
• In women who have been taking oral
contraceptives
• Megaloblastic anemia (enlarged red blood cells)
• Slow to progress, may take several weeks to
develop or may not be apparent until the 2nd
trimester of pregnancy
• Full blown, it may be a contributory factor in
early miscarriage or premature separation of
the placenta
MANAGEMENT
❖ Begin a supplement of 400 ug folic acid daily
❖ Eat folacin-rich foods (ex. green leafy veggies,
oranges, dried beans)
❖ Women who develop folic acid deficiency
anemia are prescribed even higher or
therapeutic levels of folic acid
SICKLE-CELL ANEMIA
• Recessively inherited hemolytic anemia caused
by an abnormal amino acid in the beta chain of
hemoglobin, sickling hemoglobin (HbS) results
• The majority of red blood cells are irregular or
sickle-shaped, so they cannot carry as much
hemoglobin
• When oxygen tension becomes reduced (ex. at
high altitudes) or blood becomes more viscid
than usual (ex. dehydration), the cells clump
together because of their irregular shape,
resulting in vessel blockage with reduced blood
flow to organs. The cells then will hemolyze,
thus reducing the number available and causing
severe anemia
• Other cause = acidosis
ASSESSMENT
All African American women who have not
been previously tested should be screened for
sickle-cell anemia at a 1st prenatal visit
May normally have a hemoglobin level of 6-8
mg/100 mL
In a sickle-cell crisis (5 or 6 mg/100 mL),
increase in indirect bilirubin
More susceptible to bacteriuria
Monitor a woman’s nutritional intake (folic acid)
Should not take a routine iron supplement
o Iron is not the problem
Drink at least 8 glasses of water daily
Assess lower extremities for any signs of
varicosities
NCM 109 LECTURE WEEK 1 (OLI) 3
THERAPEUTIC MANAGEMENT
❖ Three primary needs:
o Pain relief
o Adequate hydration!!! – to lower
viscosity
o Oxygenation
❖ PAIN: acetaminophen or morphine
❖ HYDRATION: IV replacement; electrolyte
replacement for acidosis
❖ OXYGEN: via NC
❖ Antibiotic for an infection
❖ Hydroxyurea, and antineoplastic agent that has
the potential to increase the strength and
oxygenation capacity of sickled cells
❖ Keep a woman in labor well hydrated and help
her resist strenuous exertion
❖ If an operative birth is necessary, epidural
anesthesia is the method of choice
❖ In the POSTPARTAL PERIOD
o Early ambulation and wearing pressure
stockings or IPC boots can help reduce
risk of thromboembolism from stasis in
lower extremities
❖ Electrophoresis of red blood cells obtained
from maternal serum or by amniocentesis
during pregnancy
DIABETES MELLITUS
• Endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate
body glucose levels
• Risk factors
o Obesity
o Age >25
o History of large babies (10 lb or more)
o History of unexplained fetal or perinatal
loss
o History of congenital anomalies in
previous pregnancies
o History or PCOS
o Family history of diabetes (one close
relative or two distant ones)
o Member of a population with a high risk
for diabetes (Native American,
Hispanic, Asian)
• Is a serious complication in pregnancy → all
women should be screened during pregnancy
for gestational diabetes (type III DM)
• Fasting plasma glucose (FBS) = ≥126 mg/dL
• Non-fasting plasma glucose (RBS) = ≥200 mg/dL
• Gestational DM (Type III)
o FBS
▪ >92 and <126
o RBS
▪ >140 mg/dL
• Needs to be confirmed using a 75 g oral glucose
challenge test
Oral Glucose Challenge Test Values
Test Type Pregnancy Glucose Level (mg/dL)
Fasting 95
1 hr. 180
2 hr. 155
3 hr. 140
• A woman with diabetes BEFORE pregnancy
should meet with her physician to determine
the best insulin program to control
hyperglycemia, esp. for 1st tri
• Measurement of glycosylated hemoglobin
(upper normal level of HbA1c is 6)
• Urine culture per trimester
MANAGEMENT (MNT)
❖ A 1,800-2,400-calorie diet (or one calculated at
30 kcal/kg of ideal weight), divided into three
meals and three snacks to try and keep
carbohydrate evenly distributed during the day
so the glucose level remains constant, is a
typical nutrition regimen during pregnancy
❖ 20% of dietary calories should be from protein
❖ 40-50% from carbohydrate
❖ Up to 30% from fat
❖ Reduce amount of saturated fats and
cholesterol and an increased amount of dietary
fiber
❖ Extremely vulnerable to hypoglycemia at night,
make her final snack of the day one of protein
and a complex carbohydrate
o Ex. an egg and whole grain toast,
hummus, and whole grain crackers
❖ Later in pregnancy, she must maintain good
control of glucose levels and keep her weight
gain to a suitable amount (~25-30 lb)
❖ Urge women, however, not to reduce their
intake to below 1,800 calories during pregnancy
THERAPEUTIC MANAGEMENT
❖ Women with GDM will be started on insulin
therapy if diet alone is unsuccessful in
regulating glucose values (insulin is gold
standard)
❖ Women with diabetes who is pregnant – less
insulin in 1st tri; increase insulin in later part
❖ The insulin will be a combination of:
o Short-acting (regular) insulin +
intermediate action insulin
o Dose is given 2/3 in AM, 1/3 in PM
❖ Intermediate to short-acting insulin ratio is 2:1
given 30 MINS BEFORE BREAKFAST
❖ Just before dinner, a ratio of 1:1
❖ Caution women to eat almost immediately
after injecting these short-acting insulins to
prevent hypoglycemia before mealtimes
❖ Oral hypoglycemia agents are not used for
regulation during pregnancy
NCM 109 LECTURE WEEK 1 (OLI) 4
Blood Glucose Monitoring
• All women with diabetes need to do blood
glucose monitoring to determine whether
hyperglycemia hypoglycemia exists
• If a woman discovers hypoglycemia is present,
she should drink fluid with some form of
sustained carbohydrate such as a glass of milk
and some crackers
• If a woman discovers an elevated blood glucose
level, she should assess her urine for ketones
• The most common time during pregnancy for
hypoglycemia to occur is the 2nd and 3rd
months, before insulin resistance peaks.
• For hyperglycemia, it is the 6th month, or the
time the insulin resistance is becoming most
pronounced
Timing of birth
• If possible, vaginal birth is preferred. Labor may
be induced (41 weeks AOG or earlier) by
rupture of membranes or an oxytocin infusion
after measures to induce cervical ripening
• Both labor contractions and fetal heart sounds
need to be consciously monitored during labor
to ensure early detection of placental
dysfunction
• Glucose level is regulated during labor by an IV
fusion of short-acting or regular insulin with
frequent blood glucose assays to prevent
hypoglycemia in the mother or rebound
hypoglycemia in the newborn
• If a woman will be given an epidural anesthetic,
Ringer’s lactate or 0.9% saline is infused instead
of IV glucose solution
Postpartum adjustments
• With insulin resistance GONE, often she needs
NO INSULIN during the immediate postpartum
period
• 1- or 2-hour postprandial blood glucose
determinations help to regulate how much
insulin she needs during this adjustment period
• A woman with gestational diabetes usually
demonstrates normal glucose values by 24 h
after birth
o Placental hormones cause high blood
glucose
• If hydramnios was present during pregnancy,
she is at risk of hemorrhage from poor uterine
contraction
o Hydramnios = too much fluid → larger
uterine → takes too long to contract →
prone to hemorrhage
• Women with diabetes may breastfeed because
insulin is one of the few substances that DOES
NOT PASS INTO BREAST MILK from bloodstream
• Because a woman who has had gestational
diabetes is at risk for developing type 2 DM
later in life, she should have glucose testing
done during health maintenance visits
throughout life
ISOIMMUNIZATION (Rh
INCOMPATIBILITY)
ASSESSMENT
All women with Rh-negative blood should have
an anti-D antibody titer done at 1st pregnancy
visit
If a woman’s anti-D antibody titer is elevated at
1st assessment (1:16 or greater), showing Rh
sensitization, the well-being of the fetus in this
potentially toxic environment will be monitored
every 2 weeks (or more often) by Doppler
velocity of the fetal middle cerebral artery
If the artery velocity remains high, a fetus is not
developing anemia and most likely is a Rh-
negative fetus
THERAPEUTIC MANAGEMENT
❖ RhIG (RhoGAM), a commercial preparation of
passive Rh (D) antibodies against the Rh factor,
is administered to women who are Rh negative
at 28 weeks of pregnancy, then in the first 72 h
after birth
❖ If Coombs’ negative,
o And baby is Rh+, the mother will
receive the injection
o If baby is Rh‒, the mother will not
receive the injection
❖ Blood transfusion can be performed on the
fetus in utero to restore fetal RBCs
❖ Injecting RBCs by amniocentesis technique
directly into a vessel in the fetal cord or
depositing them in the fetal abdomen where
they migrate into the fetal circulation
❖ Monitor urine contractions and FHT during the
procedure
❖ After birth, the infant may require therapy with
phototherapy lights to reduce the level of
bilirubin released from destroyed RBCs
❖ An exchange transfusion to remove hemolyzed
RBCs and replace them with healthy blood cells
HIV INFECTION
• Occurs more often in women who have bisexual
or multiple sexual partners or where women or
their partners use IV drugs
• If the disorder is first discovered during
pregnancy, pregnancy does not appear to
accelerate the progression of the disease
• Early symptoms are more subtle and often
difficult to differentiate from those of other
diseases or even from the symptoms of early
pregnancy such as
o Fatigue
o Anemia
o Diarrhea
o Weight loss
• Women who practice high-risk sexual behaviors
should be asked if they want to be screened
NCM 109 LECTURE WEEK 1 (OLI) 5
 • May also have contracted other STIs such as
syphilis, gonorrhea, chlamydia, and hepatitis B,
and so should be screened for these as well as
tuberculosis
• If a woman is found to be HIV+ during
pregnancy, need to address:
o Issues of safer sex practices
o Testing of sexual contacts
o Continuation or termination of
pregnancy
o Treatment during pregnancy

THERAPEUTIC MANAGEMENT

❖ Education about effective reproductive life

planning
❖ Oral zidovudine
❖ Pneumocystis pneumonia (PCP) – TMP-SMZ
(Bactrim, Gantanol)
❖ Kaposi sarcoma – chemotherapy
❖ Thrombocytopenia (lowered platelet count)
may be present as a part of HIV disease
pathology or as a response to zidovudine
therapy
❖ Women may need a platelet transfusion close
to birth to restore coagulation ability
❖ This may make a woman a poor candidate for
an epidural injection for anesthesia during labor
or for episiotomy for birth
❖ To reduce risk of mother-to-newborn
transmission, women are offered the option of
a cesarean birth
❖ Pregnant women with CD4 counts <200
cells/mm3 may be prescribed drugs to help
prevent opportunistic infections
o Acyclovir (Zovirax) – herpes simplex
o Clotrimazole troches (Mycelex) – oral
candidiasis
o Pyrimethamine (Daraprim) and
sulfadiazine – toxoplasmosis

NCM 109 LECTURE WEEK 1 (OLI) 6