HIGH RISK PREGNANCY

• One in which a concurrent disorders, pregnancy related complication, or

external factor jeopardizes the health of a woman, the fetus or both
FACTORS THAT CONTRIBUTE TO HIGH RISK
PREGNANCY
Maternal age
Maternal parity
Maternal obstetric and gynecological history
Maternal medical history
Maternal lifestyle and occupation
Cultural background
Family history
MATERNAL AGE

• Age under 15 or over 35 when the baby is due

ADOLESCENTS- increased risk of low birth weight, preterm neonates,
anemia, labor dysfunction and cephalopelvic disproportion
Over 35- at risk for placenta previa, hydatidiform mole, vascular, neoplastic,
and degenerative diseases, fraternal twin, infants with genetic disorders such
as Down Syndrome
MATERNAL PARITY

Example- A multigravida who has had 5 or more pregnancies lasting at least 20

weeks is considered high risk; if the current pregnancy occurs within 3 months
of the last delivery
MATERNAL OBSTETRIC AND
GYNECOLOGICAL HISTORY

• 2 or more premature deliveries, or spontaneous abortion

• One or more stillbirths at term
• One or more neonates born with gross anomalies
• Pelvic anomaly or pelvic shaping
• Cervical incompetency
• Uterine incompetency, position or structural anomalies
• History of multiple pregnancy, placental anomalies, amniotic fluid
abnormalities, or poor weight gain
• History of gestational diabetes, gestational hypertension or infection
• History of delivering post term neonate
• History of dystocia, precipitous delivery, cephalopelvic disproportion,
hemorrhage during labor and deliver, or retained placenta
• Lack of previous prenatal care
• A pregnancy that occurs within 3 years of menarche indicates an increased
risk of maternal mortality and morbidity.
MATERNAL MEDICAL HISTORY

Example: abdominal trauma may lead to premature rupture of membranes

(PROM) or abruptio placenta, cardiac disease can adversely affect placental
perfusion, thus jeopardizing fetal nutrition
MATERNAL LIFESTYLE AND OCCUPATION

• Make the patient aware that what she consumes and what she’s exposed to
can seriously affect her pregnancy
Example: taking an OTC drug during pregnancy, cigarette smoking, exposure
to toxic substances such as lead, organic solvents, radiation and carbon
monoxide.
CULTURAL BACKGROUND

• Several genetic disorders are associated with specific cultures

Example: sickle cell anemia,
• Religious practices may also affect health during pregnancy
FAMILY HISTORY

• History of multiple pregnancies, congenital disease or deformities, mental

disability, father’s blood type
WHAT CAUSES CVD?- CONGENITAL
ANOMALIES

Atrial Septal Defect

Coarctation of the aorta that hasn’t been corrected
Valvular disease caused by rheumatic heart fever or Kawasaki disease
Older women- ischemic cardiac disease and myocardial infarction
Peripartal cardiomyopathy
ATRIAL SEPTAL DEFECT

• An atrial septal defect is a birth defect of the heart in which there is a hole

in the wall (septum) that divides the upper chambers (atria) of the heart.
• A hole can vary in size and may close on its own or may require surgery.
An atrial septal defect is one type of congenital heart defect
COARCTATION OF THE AORTA

• Coarctation of the aorta (CoA or CoAo), also called aortic narrowing, is a

congenital condition whereby the aorta is narrow, usually in the area where
the ductus arteriosus (ligamentum arteriosum after regression) inserts. ...
When a patient has a coarctation, the left ventricle has to work harder
RHEUMATIC HEART DISEASE

• Rheumatic heart disease is a condition in which permanent damage

to heart valves is caused by rheumatic fever. The heart valve is damaged
by a disease process that generally begins with a strep throat caused by
bacteria called Streptococcus, and may eventually cause rheumatic fever
VALVULAR DISEASE CAUSED BY KAWASAKI
DISEASE

• Inflammation can occur in the heart muscles (myocarditis).Kawasaki

disease can cause heart rhythm disorders (arrhythmia). Kawasaki
disease can cause heart valve disease (valvular heart disease)
ISCHEMIC CARDIAC DISEASE

• Ischemic means that an organ (e.g., the heart) is not getting enough blood
and oxygen. Ischemic heart disease, also
called coronary heart disease (CHD) or coronary artery disease, is the term
given to heart problems caused by narrowed heart (coronary) arteries that
supply blood to the heart muscle
MYOCARDIAL INFARCTION

• Myocardial infarction (MI), also known as a heart attack, occurs when

blood flow decreases or stops to a part of the heart, causing damage to the
heart muscle. The most common symptom is chest pain or discomfort which
may travel into the shoulder, arm, back, neck or jaw
PERIPARTUM CARDIOMYOPATHY

• Peripartum cardiomyopathy is a weakness of the heart muscle that by

definition begins sometime during the final month of pregnancy through
about five months after delivery, without any other known cause. Most
commonly, it occurs right after delivery. It is a rare condition that can carry
mild or severe symptoms
WHAT TO LOOK FOR: DEPENDING ON THE
TYPE AND SEVERITY

The most dangerous time for the pregnant woman and the fetus is between
weeks 28 to 32 gestation.
During this time, the blood volume peaks and the woman’s heart may be
unable to compensate adequately for the increase, as a result, cardiac
decompensation can occur, causing cardiac output to drop, possibly to such
an extent that the perfusion to vital organs, including the placenta is
significantly affected
LEFT SIDED HEART FAILURE

Mitral valve stenosis/disorder, mitral insufficiency, coarctation of the aorta

• Common signs and symptoms are those associated with pulmonary hypertension and pulmonary
edema:
 Decreased systemic blood pressure
 Productive cough with blood streak sputum
 Tachypnea, dyspnea on exertion progressing to dyspnea at rest
 Tachycardia
 Orthopnea
 Paroxysmal nocturnal dyspnea
 Ankle edema
 Thrombus formation for mitral stenosis secondary to failure of the blood
 High blood pressure
RIGHT SIDED HEART FAILURE

• Atrial and septal ventricular defect and pulmonary valve stenosis

- Occurs when the right ventricle is overwhelmed by the amount of blood
receive by the right atrium from the vena cava: can be caused by: unrepaired
congenital heart defect or by Eisenmenger syndrome
• With this, congestion of the systemic venous circulation and decreased
cardiac output to the lungs occurs.
SIGNS AND SYMPTOMS INCLUDE:

 Hypotension
 Jugular vein distension
 Liver and spleen enlargement
 Dyspnea and pain
ASSESSMENT OF A WOMAN WITH CARDIAC DISEASE
1. Level of exercise performance
2. Ask if she normally has a cough
3. Presence of edema
4. Record baseline blood pressure, pulse rate, respiratory rate on the first
prenatal visit
5. Assessment for nail bed filling
6. Jugular vein distension
7. For right sided, assess live size
TESTS

Electrocardiogram
Echocardiography
Fetal monitoring
Ultrasonography
HOW IT IS TREATED:

Medications
 With cardiac medications before pregnancy= medications are continued, dose may
be increased to aid in compensating for the increased blood volume associated in
pregnancy
 To deal with other drugs
- if digoxin (Lanoxin) is required before pregnancy, it can be continued during
pregnancy without risk
- Propranolol ( Inderal) – beta adrenergic blocker commonly used for cardiac
arrhythmias doesn’t appear to cause fetal abnormalities
 - same with nitroglycerine- for angina also appears to be safe
- heparin for venous thromboembolic disease
- warfarin for those who have valve replacement
Prophylactic
 For women with valvular or congenital cardiac disease, may begin
prophylactic antibiotic therapy
Bed rest
Balanced weight gain
Limited sodium intake
Prenatal vitamins
NURSING INTERVENTIONS DURING LABOR
AND BIRTH
• Assess maternal vital signs and cardiopulmonary status closely for changes: ask
about increased shortness of breath, palpitation, or edema, monitor FHR for
changes.
Rapidly increasing pulse rate
To those with pulmonary edema, semi fowlers position to ease the work of
breathing
Evaluate fatigue if heart or labor related
Epidural anesthesia- anesthetic of choice for women with heart disease- it will
decrease the sensation of pushing
POSTPARTUM INTERVENTIONS

Increase in blood volume during pregnancy is gradual, however after birth, the
increase in pressure takes place within 5 minutes which is rapid in adjustment
 Program of decreased activity to compensate for the rapid adjustment
 May need digoxin and anticoagulant therapy until circulation stabilizes
 Anti embolic stockings
 May be started
 Stool softener
 Exercise that will improve abdominal tone should be avoided
 Post partum check up
THINGS THAT NEED TO BE DONE /SUMMARY
OF NURSING INTERVENTIONS

Assess maternal V/S

Monitor weight gain
Reinforce use of prescribed medications
Anticipate needs for increased dosage of maintenance
Assess the mother’s nutritional pattern
Assess FH and ultrasound result
Encourage frequent rest periods
Advise to rest in the left lateral recumbent position
Monitor fetal heart rate
Encourage ambulation, as ordered, as soon as possible after delivery
Anticipate administration of antibiotic
A WOMAN WITH AN ARTFICIAL VALVE
PROSTHESIS

ONE POTENTIAL PROBLEM- the use of anticoagulant to prevent the

formation of blood clots at the valve site
 Coumadin ( sodium warfarin) - usual maintenance drug increases the risk for
congenital anomalies, it offers the best protection against thromboembolic
complications, but it freely crosses the placenta and is associated with
embryopathy, fetal loss and fetal cerebral hemorrhage
A WOMAN WITH A HYPERTENSIVE DISEASE

• Classification of Gestational Hypertension

1. Preeclampsia (toxemia) – is non-convulsive form, marked by the onset of
hypertension after 20 weeks gestation.
High blood pressure
Protein in the urine
Swelling in the legs, hands and feet
2. Eclampsia- convulsive form, occurs between 24 weeks gestation and the end
of the first postpartum week
HELLP SYNDROME ( hemolysis elevated liver enzymes and low platelet count
- Associated with sever preeclampsia
Treatment
 intensive care management
Drug therapy- magnesium sulfate
Transfusion of fresh frozen plasma or platelets to reverse thromnocytopenia
Delivery of the fetus
1. Mild preeclampsia- sudden weight gain of more than 1.4 kg/ week in the
second trimester or more than 0.5kg/week during the third trimester.
- History reveals high blood pressure readings (140 mm hg or more systolic or
an increase of 30 mm hg or more above the patient’s normal systolic
pressure, measured on 2 occasions, 5 hours apart
2. Severe preeclampsia- blood pressure readings increase to 160/110 mm Hg
or higher on 2 occasions, 6 hours apart during bed rest
- Ophthalmoscopic examination may reveal vascular spasm, papilledema
retinal edema or detachment and arteriovenous nicking or hemorrhage
3. Eclampsia- the onset of seizure signifies eclampsia
TREATMENT
Adequate nutrition, good prenatal care, control of preexisting hypertension during
pregnancy
CBR- left lateral recumbent position to enhance venous return
Administration of anti hypertensive drugs- methyldopa, hydralazine
Administration of magnesium sulfate to promote diuresis, reduce blood pressure and
prevent seizures if blood pressure fails to respond to bed rest and anti hypertensive
Caesarean delivery or labor induction with oxytocin
If the woman develops seizure
- Emergency treatment: immediate IV administration of magnesium sulfate and oxygen
therapy with electronic fetal monitoring
WHAT TO DO
 Monitor regularly for changes in BP, PR, RR, FHR, level of consciousness, deep tendon reflexes,
headache unrelieved by medications
 Monitor the extent of edema
 Patient receiving magnesium sulfate ( administer the loading dose over 15 to 30 minutes and then
maintain the infusion at a rate of 1 to 2 g/hour
 Asses fluid balance by measuring intake and output and check daily weight
 Provide quiet, darkened room, limit visitation until patient’s condition stabilizes and enforce CBR
 Provide emotional support
 Encourage to eat well balanced, high protein diet, high fiber food, limit high sodium foods, drink atleast
8 oz glasses of noncaffeinated beverages each day
 Instruct patients to report s/s of worsening gestational hypertension
Headache, vision disturbances, GI symptoms, worsening edema, noticeable decrease in
urine output
Prepare to administer betamethasone IM as indicated
EMERGENCY INTERVENTION FOR GESTATIONAL HYPERTENSION
Observe signs for fetal distress by closely monitoring the results of stress and nonstress test
Keep emergency resuscitative equipment and anticonvulsant drugs readily available incase
of seizure, cardiac or respiratory arrest
Maintain a patent airway and have oxygen readily available
Keep calcium gluconate readily available at the bedside
Prepare foe Emergency CS if indicated
Maintain seizure precautions to protect the patient from injury
FIRST AID IN CASE OF SEIZURE

Keep other people out of the way

Clear hard or sharp objects away from the person
Don’t try to hold her down or stop the movements
Place her on her side, to help keep her airway clear
Look at your watch at the start of the seizure , to time its length
Don’t put anything in her mouth.
ADMINISTERING MAGNESIUM SULFATE
SAFELY
 Always administer the drug as piggy back infusion
 Obtain a baseline serum magnesium level before initiating the therapy
 Keep in mind, for IV magnesium to be effective as anticonvulsant, serum
magnesium level should be between 5 and 8 mg/dl.
 Asses the patient’s patellar reflex, if the patient has received epidural
anesthesia, test the biceps or triceps reflex
 Assess for ankle clonus
A WOMAN WITH VENOUS
THROMBOEMBOLIC DISEASE

- Incidence increases during pregnancy due to combination of blood stasis in

the lower extremities from uterine pressure and hypercoagulability
Measure to reduce thrombus formation
1. Avoid constrictive knee high stockings
2. Avoid sitting with legs crossed at the knee
3. Avoid standing for a long period
S/S
Pain and redness in the calf of the leg
TREATMENT (avoid moving of thrombus and become pulmonary embolus)
Bed rest
IV heparin for 24 to 48 hours, afterwards SQ heparin
Signs of pulmonary embolism
- Chest pain
- Sudden onset of dyspnea
- Cough with hemoptysis
- Tachycardia or missed beats
- Dizziness and fainting
HEMATOLOGIC DISORDERS AND
PREGNANCY
Involves either blood formation or coagulation disorders

1. ANEMIA IN PREGNANCY
- Blood volume expands during pregnancy slightly ahead of the RBC count=
results to pseudo anemia in early pregnancy, this condition is normal
2. IRON DEFFICIENCY ANEMIA
- A disorder in which hemoglobin synthesis is deficient and the body’s
capacity to transport oxygen is impaired.
- Considered a microlytic hypochromic anemia
S/S
• Fatigue
• Listlessness
• Pallor and exercise intolerance
• Some may develop pica in response to the bodies need to increased nutrients
• Restless leg syndrome
SEVERE AND PROLONGED ANEMIA
• Dyspnea on exertion
• Inability to concentrate
• Susceptibility to infection
• Tachycardia
TREATMENT
• Iron supplement
• Eat a well balanced diet, to include food high in vitamins and iron
• Parenteral Iron
Total dose IV infusion of Iron Dextran in normal saline solution for 1 to 8
hours
NOTE: a test dose of 0.5 ml IV is given first to help minimize the risk for
allergic reaction
INTERVENTIONS
Instruct patient to use prenatal vitamins as prescribed
If patient is hospitalized administer oral iron with an acid
Monitor CBC and serum iron and ferritin levels regularly
If anemia is severe, expect to administer oxygen as ordered to help prevent
and reduce hypoxia
Administer iron supplements as needed
A WOMAN WITH FOLIC ACID ANEMIA
FOLATE- FOLACIN – ONE OF THE VITAMINS necessary for the red blood cells
formation, DNA synthesis, preventing neural tube and abdominal wall defects in the fetus
 Folic acid deficiency anemia is a common slowly progressive megaloblastic form of anemia
 CAUSES:
Occurs most often in multiple pregnancies due to increased fetal demand
Women with secondary hemolytic illness
Women who are taking drugs such as phenytoin
Women who has poor gastric absorption
Alcohol abuse
S/S
• History of severe, progressive fatigue
• With associated findings of shortness of breath, palpitations, diarrhea,
nausea, anorexia, headache, forgetfulness and irritability
• Weakness and lightheadedness
• Generalized pallor and jaundice
• Neurologic impairment is present only if the folic acid deficiency anemia is
assoc with vitamin B12 deficiency
TESTS: BLOOD STUDIES REVEAL

• Macrocytic RBCs
• Decreased reticulocyte count
• Increased mean corpuscular volume
• Abnormal platelet count
• Decreased serum folate levels below 4 mg/ml
TREATMENT

• Folic acid supplement orally or parenterally, 400 ug of folic acid daily

• Diet high in folic acid: green leafy vegetables, oranges, dried beans,
asparagus, beef liver, broccoli, mushrooms
INTERVENTIONS

• Urge women trying to get pregnant to take vitamin supplement or eat food
rich in folic acid
• Assist in planning a well balanced diet
• Encourage the woman to eat or drink a rich source of vit c
• Monitor CBC, platelet count serum folate level as ordered
• Assess maternal V/S and FHR as inidcated
CAUSES

• Homozygous inheritance of an autosomal recessive gene that produces a

defective hemoglobin molecule (hemoglobin S) caused by a structural change
in the gene that encodes the beta chain of hemoglobin
• Hemoglobin S causes the RBCs to become sickle shaped
• Sickle cell start to build up in the capillaries and smaller blood vessels,
making the blood more viscous
• Normal circulation is impaired, causing pain, tissue infarction and swelling
SIGNS AND SYMPTOMS

• Unusual swelling of the fingers and toes, chronic anemia, pallor, fatigue and
decreased appetite
TREATMENT
 Anti infectives ( such as low dose oral penicillin)
 Certain vaccines( such as polyvalent pneumococcal vaccine and Hemophilus
influenza vaccine)
 Analgesics