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HIGH RISK PREGNANCY

By Susan Sienkiewicz

Adolescent Pregnancy: Contributing Factors


Peer pressure Self-esteem Lack of role models Gain attention Media Poverty Rite of passage
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Implications of Adolescent Pregnancy


Socioeconomic:
reliance on welfare cycle repeats itself Fetal Health: LBW

Maternal health:
CPD PIH

prematurity
resp complications cp cognitive deficits death
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anemia
nut deficits mortality

Adolescent Pregnancy: Assessment


Risks fundal height # of sexual partners knowledge of infant care/needs family unit/support system baseline VS/weight

IMPLICATIONS OF DELAYED PREGNANCY Pre-existing conditions Preterm labor SGA/LBW IUGR PIH Abruption C-section Uterine fibroids PP hemorrhage Chromosomal abnormalities
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DELAYED PREGNANCY: ASSESSMENT


Pre-existing conditions Fundal height Anxiety Psychosocial issues (career vs baby)

TYPES OF SPONTANEOUS ABORTIONS

Spontaneous Abortion Management


Threatened

Notify MD/MW Check fetus by U/S Bedrest, no sexual activity


for 2 weeks after bleeding stops

Inevitable

No false reassurance Check by U/S for complete vs. incomplete Analgesics for D&C RhoGAM
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Spontaneous Ab Mgmt, cont.


Incomplete

Missed

Hospitalization Before 14 wks D&C + IV Pitocin After 14 wks Pitocin or Prostaglandins Wait 3 to 5 wks for spont Ab (93%) Monitor for DIC
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Post Abortion Education


Bldg, cramping X 1-2 wks vaginal rest X 1 wk temp BID f/u in 2 wks

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SITES OF ECTOPIC PREGNANCY

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S & S Ectopic Pregnancy


Missed Period Abdominal Pain Vaginal Spotting Rupture Severe lower abd pain hCG levels No gestational sac on U/S

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Surgical Management of Ectopic Pregnancy

Med Mgmt of Ectopic PG

MTX
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S & S Hydatiform Mole

Vaginal bleeding anemia uterus size, cramps No FHTs N/V Early PIH
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Therap. Mgmt: vacuum aspiration & curettage

Spontaneous Abortion Matching Choose all that apply.


1.

1.

2.

3.

4. 5.

6.

7. 8. 9. 10.

Initial symptom is vaginal bleeding 2. Membranes rupture and cervix dilates 3. Some, not all, products of conception are expelled. 4. Treatment includes D&C 5. All products of conception passed 6. All unsensitized Rh neg women should receive RhoGAM 7. May be treated with bedrest 8. Retained dead fetus 9. May be complicated by DIC 10. Pregnancy may continue

A. B. C. D. E.

Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion

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Medical Mgmt of Placenta Previa


S&S hypovol in mom

Mom stable, fetus immature

Fetus > 36 wks

Bedrest

no sex act
report bldg

Amnio to lung maturity


delivery

delivery

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S&S Abruptio Placentae


Vag bldg abd pain

(unless concealed)

U-act
hemorrhage
boardlike abd late decels s&s shock
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Med Mgmt of Placental Abruption

Mom stable, fetus immature

bleeding, fetal distress

bedrest tocolytics Emergency CS


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DIC
Placental Bleeding Thromboplastin release

Clot formation (systemic response)


clotting factors
(fibrinogen, plts, PTT, FDP)

inability to form clots profuse bleeding


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Hemorrhagic Conditions: Abruption & DIC


ASSESSMENT Bleeding
Pain VS/FHR U-Activity OB Hx

Fundal Ht
Lab Data (H/H, coags) Emotional response
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The Pathological Processes of Pre-eclampsia

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S&S Pre-eclampsia

Rapid wt gain edema of hands & face proteinuria hyperreflexic DTRs H/A, visual disturbances epigastric pain

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Treatment of Pre-eclampsia
Mild: diastolic <
Bedrest protein diet document fetal activity weekly NST
100, trace to 1+ proteinuria, no H/A

Severe: diastolic > 110, 3+ proteinuria, U/O, H/A, visual disturbances


Bedrest, stimuli Meds

Apresoline for severe HTN MgSO4 (anticonvulsant & antihypertensive)

Delivery
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S&S Eclampsia/HELLP Syndrome

Eclampsia

HELLP Syndrome

facial twitching tonic-clonic sz pulmonary edema circ/renal failure

RUQ pain n/v edema H/H, plts liver enzymes

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Treatment of Eclampsia/HELLP Syndrome

Bedrest Meds

MgSO4 Valium or Phenobarb (if Mg not effective, not


within 2 hr of delivery)

Hydralazine (for severe B/P) steroids to fetal lung maturity

Delivery
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Assessment: Hypertensive Disorders of Pregnancy

Prenatal:

wt, B/P, U/A, H/A, visual disturbances daily wt hourly u/o, dipstick urine Q4H VS, FHR LOC, DTRs, H/A clonus
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Hospitalized Ct:

Risk Control Strategies for Hypertensive Disorders of Pregnancy


Sz precautions monitor for s/s Mg toxicity(RR<12, absent


DTRs, sweating, flushing, confusion, B/P)

Ca gluconate @ BS Mg levels IV MgSO4 (should be Y connected to another primary bag) D/C MgSO4 for RR < 12 or absent DTRs renal function (30 mL/hr)
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Incompetent Cervix
S&S
advanced cervical dilation low abd pressure

bloody show
urinary frequency Treatment cerclage
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Premature Labor/Rupture of Membranes

S&S

contractions cramps backache diarrhea vag d/c ROM

Treatment

Tocolytics IV hydration bedrest steroids, if needed abx, if needed

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Nursing Care for PTL/PROM

Assessment

Teaching

Thorough hx bleeding ROM BPP (for PROM)

Infection Control FMC

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Postterm Pregnancy

S&S

Wt loss uterine size Meconium in AF

Treatment

fetal surveillance

NST, CST, BPP Q wk mom monitors mvmt Pitocin (10-20U/L) @ 1-2 mU/min every 2060 min

Risks

Induction

fetal mortality cord compression mec asp LGA shoulder dystocia CS episiotomy/laceration depression

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Disorders of Amniotic Fluid

Polyhydramnios

Oligohydramnios

S&S

Risks

uterine dist dyspnea edema of lower extr therapeutic amniocentesis

Treatment

cord compression musculoskeletal deformities pulmonary hypoplasia amnioinfusion

Treatment

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Risks of Multifetal Gestation


PIH GDM PPH Anemia UTI PTL Placenta previa CS


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(Fetal) S&S Rh Incompatibility

Hyperbilirubinemia

jaundice Kernicterus (severe neuro d.o. r/t bili)

anemia hepatosplenomegaly Hydrops fetalis

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Sequence of Assessments for Rh Sensitization


Blood Test for Type & Rh Factor Rh-negative Indirect Coombs Rh-positive No further testing

Give RhoGAM Titer not increasing continue to monitor

Repeat frequently

Titer increasing amniocentesis ( bilirubin)


Elevated retest, U/S intrauterine transfusion or early delivery 35

No change retest prn

Management of Rh Incompatibility
Prenatal per algorithm

Prevention

Postpartum

RhoGAM at 28 weeks (unsensitized women only)

direct Coombs RhoGAM to mom if baby is Rh+ (within 72 hrs of birth)

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Hyperemesis Gravidarum

S&S

Treatment

U/O wt loss ketonuria dry muc membranes poor skin turgor

IVF, TPN antiemetics advance diet as tol

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Glucose Tolerance Test


1 GTT (24 - 28 wks)
drink 50g glucose, if 1 BS > 140

3 GTT
hi carb diet X 2 days, then NPO after MN FBS, then drink 100g glucose,

1, 2, 3 BS
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results: 1 > 190, 2 > 165, 3 > 145
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Effects of Pre-Existing DM

Maternal

Fetal

risk of: PIH Cystitis DKA Spont Ab

risk of: NTDs Cardiac defects Macrosomia or IUGR Polycythemia hyperbilirubinemia


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Treatment of Pre-existing DM

Team approach Monitor glycosylated Hgb A Diet: 50% carb, 20% prot, 30% fat Insulin TID Hourly glucoses during labor NSTs weekly (starting at 28-30 wks)
Amnio ( lung maturity)
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Effects of Gestational Diabetes

Maternal Effects

Fetal Effects

UTI hydramnios PROM/preterm labor shoulder dystocia epis/lac CS HTN

macrosomia hypoglycemia at birth RDS

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Treatment of Gestational Diabetes

30 to 35 cal/kg/day (3 meals, 2 snacks) Insulin FBS, post-prandial BS Q week NST, BPP Q week glycosylated Hgb A Amnio ( lung maturity)
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Diabetes: Patient Education


Glucose monitoring insulin administration type, onset, peak, duration, times, sites, injection technique diet s/s hypoglycemia tremors, pallor, cold/clammy skin give milk & crackers or glucagon inj s/s hyperglycemia fatigue, flushed skin, thirst, dry mouth, check glu, call MD for insulin order
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PPCM: Manifestations

dyspnea edema, wt gain chest pain palpitations jug vein distention enlarged heart spont ab, PTL
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PPCM: Energy Management


Epidural Activity restriction Minimize anxiety

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PPCM: Cardiac Care


Meds Sidelying, HOB Monitor VS, FHR, heart pressures (Swan-Ganz) Strict I/O Assess lungs

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PPCM: Patient Education

Avoid excessive wt gain/edema

Diet: 2200 cal, protein, NAS

rest/avoid exertion avoid exposure to environmental extremes emotional stress

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Sickle Cell Disease

Maternal Effects

Fetal Effects

pain jaundice Pyelonephritis PIH/preeclampsia leg ulcers CHF

IUGR/SGA skeletal changes

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Systemic Lupus Erythematosis

Maternal effects

fatigue muscle/joint pain wt loss rash proteinuria PIH/preeclampsia/HELLP PG loss

Fetal effects

IUGR preterm delivery

Treatment PO or IV Steroids

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AIDS

Maternal Effects

Fetal Effects

vag candidiasis PID genital herpes HPV PCP

Treatment: ZDV (zidovudine) during PG, L&D ZDV to neonate for 6 wks

Asymptomatic at birth Candidal diaper rash thrush diarrhea recurrent bacterial infections FTT dev delay

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Which of the following socioeconomic factors contributes to the high incidence of adolescent pregnancy in the US?

A. B. C. D.

lack of adequate birth control poverty lack of information on safe sex availability of public assistance for unmarried mothers

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Which genetic screening test for chromosomal abnormalities provides an older expectant couple with information within the first trimester? A. B. C. D. Chorionic villus sampling (CVS) Amniocentesis Genetic karyotyping Ultrasonography

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When caring for a woman with mild preeclampsia, the nurse would be concerned with which finding?

a. +4 proteinuria b. +2 dependent edema in ankles

c. Blood pressure 156/100


d. +2 DTRs, absent clonus

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The nurse is preparing to infuse magnesium sulfate to treat preeclampsia. In implementing this order the nurse understands the need to: a. Prepare a solution of 20 g MgSO4 in 100cc D5W b. Monitor maternal VS, FHR and uterine contractions every hour c. Expect the maintenance dose to be approximately 4g/hr d. Discontinue the infusion and report a respiratory rate of < 12 breaths/minute
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The primary expected outcome for care associated with the administration of MgSO4 would be met if the woman:

a. Exhibits a decrease in both systolic and diastolic blood pressure b. Experiences no seizures c. States that she feels more relaxed and calm d. Urinates more frequently, resulting in a decrease in pathologic edema

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A primigravida at 10 weeks gestation reports slight vaginal spotting without passage of tissue and mild uterine cramping. When examined, no cervical dilation is noted. The nurse caring for this woman should:

a. Anticipate that the woman will be sent home and placed on bedrest with instructions to avoid stress or orgasm b. Prepare the woman for a dilatation and curettage c. Notify a grief counselor to assist the woman with the imminent loss of her fetus d. Tell the woman that the doctor most likely will perform a cerclage to help maintain the pregnancy

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CASE STUDY I
A G3P2 woman, at 38 wks gestation, arrives at the obstetric unit with c/o painless vaginal bleeding. 1. 2. 3. 4. What is the nursing priority at this time? What assessments are necessary? What is the most likely etiology of the bleeding? What is the expected treatment for Anne?
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CASE STUDY II
A G1P0 woman, at 35 wks gestation, is visiting the midwife for a routine prenatal visit. On assessment, the nurse finds that she has gained 8 lbs in the past month. 1. 2. 3. What is the significance (if any) of this weight gain? What other assessments should the nurse make at this time? What is the required treatment for this client?
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A 22 y.o. G1P0 who has a history of IDDM X 6 yrs and whose LMP was 12 wks ago arrives at the prenatal clinic.
1. 2. 3. 4. 5. How will this clients diabetes be affected by her pregnancy? What changes will she most likely have to make to adjust to her pregnancy? What routine assessments will be made at each prenatal visit? What tests will be required as the pregnancy progresses? What fetal effects occur with pre-existing diabetes?

CASE STUDY III

6.
7. 8.

How will L&D be altered by pre-existing diabetes?


What possible newborn complications could occur with pre-existing diabetes? What nursing care will the infant require?
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MATH PROBLEM
For induction, Pitocin is ordered 10 Units in 500 mL to start at 2 mU/min and increase by 1 mU/min every 20 minutes until effective contractions are achieved. At what rate will the nurse start the IV? By how much will the rate be increased every 20 minutes?
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THE END

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