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PREGNANCY AT RISK: CONDITIONS THAT COMPLICATE PREGNANCY CHAPTER 16 OBJECTIVES 1. Compare and contrast the pathophysiology of the three major classifications of diabetes in the pregnant woman. 2. Explain treatment goals for the pregnant woman with diabetes. 3. Differentiate between the care of the pregnant woman with pregestational diabetes and one with gestational diabetes. 4. Describe typical nursing concerns for the pregnant woman with diabetes. 5. Explain the goals of treatment and nursing care for the pregnant woman with heart disease. 6. Differentiate between pregnancy concerns for the woman with iron-deficiency anemia and one with sickle cell anemia. 7. List treatment considerations for the pregnant woman with asthma. 8. Detail the risk to pregnancy from epilepsy and its treatment. 9. Describe the impact on pregnancy from the TORCH infections. 10. Differentiate between common sexually transmitted infections according to cause, treatment, and impact on pregnancy. 11. Outline treatment for the pregnant woman with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). 12. Describe nursing considerations for the pregnant woman with a sexually transmitted infection. 13. Describe nursing concerns and treatment for the pregnant woman who is the victim of intimate partner violence. 14. Delineate special concerns associated with adolescent pregnancy. 15. Describe the impact of delayed childbearing on pregnancy. PREGNANCY AT RISK: CONDITIONS THAT COMPLICATE PREGNANCY More women are entering pregnancy with chronic medical conditions You will assist the registered nurse (RN) to provide care for the pregnant woman at risk Maternal–fetal medicine (focus on prenatal period) PREGNANCY COMPLICATED BY MEDICAL CONDITIONS Risk factors for the pregnant woman Chronic medical conditions Acute infections Several ways in which pregnancy and medical conditions are interrelated Normal physiologic changes of pregnancy sometimes alleviate and at other times intensify the symptoms of illness Medical conditions can affect the progress and outcome of pregnancy DIABETES MELLITUS A chronic disease in which glucose metabolism is impaired by lack of insulin in the body or by ineffective insulin utilization Poorly controlled, can adversely affect pregnancy outcomes Challenging to manage in pregnancy Complicates approximately 3% to 10% of pregnancies Specialists should be involved in the care of the pregnant woman with DM DIABETES MELLITUS (CONT.) Classification of Diabetes Mellitus Pregestational Diabetes Mellitus (DM) Type 1 DM Higher incidence of spontaneous abortion (miscarriage) The diabetic woman is more likely to experience a cesarean birth DIABETES MELLITUS (CONT.) Pregestational Diabetes Mellitus (DM) (cont.) Fetus at high risk for congenital anomalies and/or stillbirth Mother at higher risk for ‒ Hypertensive disorders ‒ Polyhydramnios (excess levels of amniotic fluid) ‒ Preterm delivery ‒ Shoulder dystocia in the infant DIABETES MELLITUS (CONT.) Gestational DM Increased risk for developing type 2 DM after pregnancy (30-50% GDM within 5-20 yrs) Underlying pathophysiology of GDM is insulin resistance Diabetogenic effect of pregnancy (page 355) Greatest risk for the fetus is macrosomia Screen for GDM at approximately 24–28 weeks’ gestation DIABETES MELLITUS (CONT.) Treatment Prepregnant care (prior to pregnancy), consult w/MD prior, euglycemia, multivitamin w/folic acid (1mg) Monitoring glycemic control (HbA1C) Maintaining glycemic control Insulin therapy Oral hypoglycemic agents (glyburide & metformin-does not cross placenta) Diet therapy Exercise DIABETES MELLITUS (CONT.) Treatment (cont.) Fetal surveillance (sonogram)- first trimester determines gestational age and fetal viability and @ 18-20 wks. a more detailed-close look at structural defects Determining timing of delivery-optimum time and method for the delivery, DM delay in fetal lung maturation, may need a amniocentesis (3rd trimester)-too long can lead to shoulder dystocia or fetal demise TREATMENT OVERVIEW FOR DM/GDM DIABETES MELLITUS (CONT.) Nursing process for the pregnant woman with DM Assessment Selected nursing diagnoses (page 357) Outcome identification and planning Implementation Monitoring management of therapeutic regimen Monitoring for and preventing infection Monitoring fetal status Estimating fetal weight Evaluation: goals and expected outcomes QUESTION Gestational diabetes is a form of diabetes mellitus that occurs during pregnancy. It is caused by insulin resistance. What is the result of gestational DM in a normal pregnancy? a. Blood glucose levels are higher than normal (mild hyperglycemia) after meals b. Blood glucose levels are higher than normal (mild hyperglycemia) when fasting c. Blood glucose levels are lower than normal (mild hypoglycemia) after meals d. Insulin levels are decreased (hypoinsulinemia) after meals. ANSWER a. Blood glucose levels are higher than normal (mild hyperglycemia) after meals Rationale: The result in a normal pregnancy is threefold: 1. Blood glucose levels are lower than normal (mild hypoglycemia) when fasting 2. Blood glucose levels are higher than normal (mild hyperglycemia) after meals 3. Insulin levels are increased (hyperinsulinemia) after meals CARDIOVASCULAR DISEASE Clinical manifestations and diagnosis Signs and symptoms vary depending on the underlying cause of heart disease Earliest warning sign of cardiac decompensation is persistent rales in the bases of the lungs Treatment Activity levels Stress management Diet and medications Management during labor and the postpartum period CARDIOVASCULAR DISEASE (CONT.) Nursing care Excellent nursing assessment and reporting of abnormal findings is critical Most important nursing action is to monitor for and teach the woman to recognize signs of cardiac decompensation Especially important for the pregnant woman with heart disease to protect herself from infection Precautions to avoid clot formation CARDIOVASCULAR DISEASE (CONT.) Nursing care (cont.) Advise the woman to get adequate rest and to avoid strenuous physical activity Inquire about illicit drug use and cigarette smoking Assist the woman with tests for fetal wellbeing Monitor the woman particularly closely during labor-increases demand on the heart Do not encourage active maternal pushing during the second stage of labor Post-partum period: immediately report fever, increased bleeding, and any signs of decompensation ANEMIA Iron-deficiency anemia Clinical manifestations and diagnosis Common signs and symptoms of irondeficiency anemia in the pregnant woman are tachycardia, tachypnea, dyspnea, pale skin, low blood pressure, heart murmur, headache, fatigue, weakness, and dizziness. Pica (ingestion of nonfood substances such as clay and laundry starch) and pagophagia (frequent chewing or sucking on of ice) are both associated with severe iron-deficiency anemia. Hemoglobin levels less than 10 g/dL define anemia during pregnancy Treatment-diet rich in iron and folate ANEMIA (CONT.) Sickle-cell anemia Clinical manifestations and diagnosis Woman rarely experiences symptoms At risk for a sickle cell crisis at any time during the pregnancy May experience recurrent bouts of pain in the joints, bones, chest, and abdomen Treatment-hydration, avoid infection, adequate rest, balance diet ANEMIA (CONT.) Nursing care Iron-deficiency anemia Counseling ‒ Vitamin C enhances and folate ‒ Iron supplements predispose to constipation Sickle-cell anemia Support and teaching Adequate fluid intake and rest are important QUESTION A pregnant woman with cardiovascular disease can usually continue to take her cardiac medications during pregnancy. What medication cannot be continued during pregnancy? a. Digoxin b. Heparin c. Hydrochlorothiazide d. Coumadin ANSWER d. Coumadin Rationale: The woman usually can continue to take her cardiac medications during pregnancy, with the exception of warfarin (Coumadin), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers. Warfarin crosses the placenta and increases the risk of congenital anomalies. ASTHMA Clinical manifestations and diagnosis Treatment Management of acute exacerbation Labor and birth management Nursing care Teaching is a major role Smoking cessation and control of the environment Goal: prevention of acute episodes, control of symptoms, maintenance normal pulmonary function, avoidance of emergency department visits and hospitalizations (serve to maximize the health of the woman and fetus) EPILEPSY Clinical manifestations Treatment Current recommendations are for the woman to remain on the drug that most effectively controls her seizures Difficult to maintain therapeutic drug level AEDs major cause of fetal defects (cleft lip & palate, cardiac, urinary and neural tube defects) Blunt trauma is major risk Status epilepticus–emergency complication Nursing care Teach importance of carefully following her treatment regimen Teach importance of eating a diet high in folic acid and of taking folic acid supplementation Provide emotional support during prenatal testing for fetal anomalies INFECTIOUS DISEASES TORCH-Box 16-6, pg. 367 Toxoplasmosis-rarely produces symptoms in the woman, harmful if fetus contracts parasite between 10-24 wks. (chorioretinitis, intracranial calcification, hydrocephalus in the newborn) treatment-medications Other infections: Hepatitis B-90% infants who acquire HBV become chronic carriers (high risk for developing cirrhosis & liver CA) treatment-immunoglobulin & vaccine Syphilis-up to 40% result in miscarriage without treatment, infant born with blindness, deafness, Hutchinson’s triad Varicella Herpes zoster Rubella-congenital rubella-no cure, treatments are supportive Cytomegalorivus-silent menace Herpes simplex virus-neonatal herpes is rare INFECTIOUS DISEASES (CONT.) Prevention is the focus of interventions because many of the TORCH infections do not have effective treatment regimens Routine screenings for hepatitis B, syphilis, and rubella TORCH screen Latent (“old”) infection-rare that the fetus will acquire a latent infection INFECTIOUS DISEASES (CONT.) Sexually transmitted infections Many STIs are reportable diseases tracked by the CDC Chlamydia Most common STI in the United States Untreated chlamydia increases the risk of contracting HIV/AIDS Gonorrhea Second most reported Transmitted during sexual contact Resistance to antibiotics Can leave the woman infertile or susceptible to ectopic pregnancy because of scarring in the reproductive tract Ophthalmia neonatorum INFECTIOUS DISEASES (CONT.) Human papillomavirus Most common viral STI in the United States Has a tendency to increase in size during pregnancy Neonatal HPV infection can result in lifethreatening laryngeal papillomas Trichomoniasis Associated with adverse pregnancy outcomes (PROM, preterm delivery, low birth weight) INFECTIOUS DISEASES (CONT.) Sexually transmitted infections (cont.) HIV/AIDS Very important for the practitioner to know the pregnant woman’s HIV status Clinical manifestations-pg. 373, box 16-7 INFECTIOUS DISEASES (CONT.) HIV/AIDS (cont.) Treatment ‒ Two main goals of treatment for the pregnant woman infected with HIV Prevent progression of the disease in the woman Prevent perinatal transmission of the virus to the fetus INFECTIOUS DISEASES (CONT.) HIV/AIDS (cont.) Nursing care ‒ Assure confidentiality ‒ If the woman is HIV-positive, ensure that she understands the risk to her sexual partners ‒ Explain the risks of perinatal transmission of HIV and the benefits of therapy ‒ Explore her understanding of the treatment regimen INFECTIOUS DISEASES (CONT.) Nursing process for the pregnant woman with an STI Assessment Selected nursing diagnosis Outcome identification and planning INFECTIOUS DISEASES (CONT.) Nursing process for the pregnant woman with an STI (cont.) Implementation Controlling risks of STIs Maintaining immune status and protection from additional infections Ensuring knowledge of STIs and treatment regimen Enhancing self-esteem Reducing anxiety Evaluation: goals and expected outcomes QUESTION TORCH is an acronym for a special group of infections that can be acquired during pregnancy and transmitted through the placenta to the fetus. Why is TORCH so important during pregnancy? a. Macrocephaly can occur b. Can cause post-mature delivery c. It is teratogenic d. Can cause hepatospleno-growth retardation ANSWER c. It is teratogenic Rationale: Each infection is teratogenic, and the effects are different, depending upon when the infection occurs during pregnancy. PREGNANCY COMPLICATED BY INTIMATE PARTNER VIOLENCE Clinical manifestations and diagnosis Cycle of violence Warning signs Treatment Routine screening of all women is the key to assisting those who are ready to report abuse and receive help Interventions for the victim of IPV are directed toward safety assessment and planning PREGNANCY COMPLICATED BY INTIMATE PARTNER VIOLENCE Nursing care Assist the RN to assess for abuse Determining whether a woman should leave an abusive relationship must be made exclusively by the woman Always document the woman’s responses to questions about IPV Be careful to respond with supportive statements Document your assessment objectively Be knowledgeable about local resources PREGNANCY COMPLICATED BY AGE-RELATED CONCERNS Adolescent pregnancy Clinical manifestations Many pregnant teens seek late prenatal care May be fearful of disclosing her pregnancy Treatment The best treatment for teenage pregnancy is prevention Advocacy for the pregnant adolescent Help the teen to develop an adequate support network PREGNANCY COMPLICATED BY AGE-RELATED CONCERNS Adolescent pregnancy (cont.) Nursing care Caring for developmental needs ‒ Pregnancy does not change the developmental tasks, although it may complicate the issues Caring for physical needs ‒ Adequate nutrition is essential Caring for emotional and psychological needs ‒ Be knowledgeable about community resources for the pregnant teen PREGNANCY COMPLICATED BY AGE-RELATED CONCERNS (CONT.) Pregnancy in later life Clinical manifestations Treatment: preconception visit, increased risk of chromosomal abnormalities Nursing care Approach the older pregnant woman with an open mind May feel they have “too much” medical information and feel overwhelmed Do not want the constant reminders of increased risks… QUESTION Tell whether the following statement is true or false. Intimate partner violence (IPV) is a reality in our society. It is important to assess every pregnant woman for IPV because pregnancy is a very vulnerable time for a woman in a relationship where IPV is a component. ANSWER True Rationale: Pregnancy is a vulnerable time for a woman. IPV may begin or escalate during pregnancy, particularly if the pregnancy is unplanned. Researchers estimate that 4% to 8% of all pregnant women experience abuse during the pregnancy.