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Chapter 11
High Risk Perinatal Care:
Pre-existing Conditions
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Pre-existing Conditions
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For some women pregnancy represents
significant risk because it is superimposed on a
chronic illness
Unique maternal and fetal needs caused by
these conditions must be met in addition to the
usual pregnancy-related feelings, needs, and
concerns
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Pre-existing Conditions (Cont.)
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Metabolic disorders
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Diabetes mellitus
Thyroid disorders
Cardiovascular disorders
Respiratory, gastrointestinal, integumentary, and
central nervous system disorders
Autoimmune disorders
Substance abuse
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Metabolic Disorders
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Diabetes mellitus
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The most common endocrine disorder associated
with pregnancy
Pregnancy complicated by diabetes considered high
risk
Diabetes can be successfully managed with a
multidisciplinary approach
Key to an optimal outcome is strict maternal glucose
control
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Metabolic Disorders (Cont.)
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Pathogenesis
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Group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin
secretion, insulin action, or both
Diabetes may be caused by either or both:
• Impaired insulin secretion
• Inadequate insulin action in target tissues
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Metabolic Disorders (Cont.)
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Classification of diabetes
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type 1 diabetes
type 2 diabetes
Other specific types (caused by infection or druginduced)
Gestational diabetes mellitus (GDM) is any degree of
glucose intolerance with onset or recognition during
pregnancy
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Metabolic Disorders (Cont.)
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Metabolic changes associated with pregnancy
Pregestational diabetes mellitus
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Occurs in women who have pre-existing disease
 Complicated by vascular disease, retinopathy, or
nephropathy
 Type 2 is not common
 Almost all of these patients are insulin-dependent
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Metabolic Disorders (Cont.)
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Pregestational diabetes mellitus
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Preconception counseling
Maternal risks and complications
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Macrosomia
Hydramnios
Ketoacidosis
Hyperglycemia
Hypoglycemia
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Metabolic Disorders (Cont.)
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Pregestational diabetes mellitus
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Fetal and neonatal risks
• Sudden and unexplained stillbirth
• Congenital malformations
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Cardiovascular system
Central nervous system
Skeletal system
• Other problems that cause significant neonatal morbidity
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Care Management
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Antepartum evaluation
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Interview
Physical examination
Laboratory tests
• Baseline renal function
• Glycosylated hemoglobin A
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Patient needs much more frequent monitoring
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Care Management (Cont.)
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Antepartum care
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Diet and exercise
 Insulin therapy
 Monitoring blood glucose levels
 Urine testing
 Determination of birth date and mode of birth
 Complications requiring hospitalization
 Fetal surveillance
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Care Management
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Intrapartum care
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Monitor patient closely
Complications
May require a cesarean birth
Postpartum care
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Insulin requirements decrease substantially
Encourage breastfeeding
Contraception
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Care Management (Cont.)
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Gestational diabetes mellitus
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Maternal-fetal risks
Screening for gestational diabetes mellitus
• Antepartum care
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Diet and exercise
Monitoring blood glucose levels
Insulin therapy
Fetal surveillance
• Intrapartum and postpartum care
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Metabolic Disorders
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Thyroid disorders
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Hyperthyroidism
• Graves’ disease 90% to 95% of cases
• Rare in pregnancy
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Hypothyroidism
• If untreated at risk for infertility and miscarriage
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Metabolic Disorders (Cont.)
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Maternal phenylketonuria
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Recognized cause of mental retardation caused by
deficiency in enzyme phenylalanine hydrolase
Toxic accumulation of phenylalanine in blood
interferes with brain development and function
Key to prevention is identification of women with
disorder in their reproductive years
Should be advised against breastfeeding
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Cardiovascular Disorders
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Major cardiovascular changes during pregnancy
that affect women with cardiac disease are:
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Increased intravascular volume
Decreased systemic vascular resistance
Cardiac output changes during labor and birth
Intravascular volume changes that occur just after
childbirth
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Cardiovascular Disorders (Cont.)
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Cardiovascular disease classification
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Class I
Class II
Class III
Class IV
Determined at 3 months and again at 7 or 8 months
of gestation as progression may occur
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Cardiovascular Disorders (Cont.)
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Increased incidence of miscarriage
Preterm labor and birth more prevalent
Intrauterine growth restriction is more common
Incidence of congenital heart lesions increased
in children of mothers with congenital heart
disease
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Selected Cardiovascular Disorders
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Congenital cardiac disease
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Atrial septal defect
Ventricular septal defect
Coarctation of the aorta
Tetralogy of Fallot
Acquired cardiac disease
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Mitral valve prolapse
Mitral valve stenosis
Aortic stenosis
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Selected Cardiovascular Disorders
(Cont.)
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Ischemic heart disease
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Myocardial infarction
Other cardiac diseases and conditions
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Persistent pulmonary hypertension
Peripartum cardiomyopathy
Infective endocarditis
Eisenmenger syndrome
Marfan syndrome
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Cardiovascular Disorders (Cont.)
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Heart transplantation
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Increasing numbers of heart recipients are
successfully completing pregnancies
Before conception woman must be assessed for
quality of ventricular function and potential rejection of
transplant
Conception should be postponed for 1 year after
transplant
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Care Management
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Antepartum assessment
Plan of care and implementation
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Therapy focused on minimizing stress on heart
Signs and symptoms of cardiac decompensation
Bed rest
Nutrition counseling
Cardiac medications as needed
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Care Management (Cont.)
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Plan of care and implementation
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Anticoagulant therapy
• Heparin: large-molecule drug does not cross placenta
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Intrapartum care
• Care focuses on promoting cardiac function
• Prophylactic antibiotics
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Postpartum care
• Monitoring for cardiac decompensation
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Other Medical Disorders in Pregnancy
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Anemia
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Iron deficiency anemia
Folic acid deficiency anemia
Sickle cell hemoglobinopathy
Thalassemia
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Other Medical Disorders in Pregnancy
(Cont.)
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Pulmonary disorders
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Asthma
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Exacerbations and remissions
Hyperactive airways
Effective pregnancies unpredictable
At increased risk for postpartum hemorrhage
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Other Medical Disorders in Pregnancy
(Cont.)
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Pulmonary disorders
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Cystic fibrosis
• Infants of mothers with cystic fibrosis will be carriers of gene
• With severe disease, pregnancy is often complicated by
chronic hypoxia and frequent pulmonary infections
• Exocrine glands produce excessive viscous secretions
• Problems with respiratory and digestive systems
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Other Medical Disorders in Pregnancy
(Cont.)
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Integumentary disorders induced by pregnancy
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Melasma (chloasma)
Vascular “spiders”
Palmar erythema
Striae gravidarum
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Other Medical Disorders in Pregnancy
(Cont.)
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Skin problems aggravated by pregnancy
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Acne vulgaris (in the first trimester)
Neurofibromatosis (von Recklinghausen disease)
Pruritic urticarial papules and plaques
Intrahepatic cholestasis
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Neurologic Disorders
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Epilepsy
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Failure to take medications is common factor
• Should receive preconceptual counseling
• At risk of congenital anomalies if mother is taking
anticonvulsants
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Multiple sclerosis
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Bed rest and steroids used to treat acute
exacerbations
Bell palsy
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Acute facial paralysis
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Autoimmune Disorders
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Systemic lupus erythematosus
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Autoimmune antibody production affects skin, joints,
kidneys, lungs, central nervous system, liver, and
other body organs
Immunosuppressive medications not recommended
during pregnancy
Efforts are aimed at reducing the risk of infection
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Autoimmune Disorders (Cont.)
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Myasthenia gravis (MG)
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Autoimmune motor (muscle) endplate disorder
Muscle weakness in the eyes, face, neck, limbs, and
respiratory muscles
Women with MG usually tolerate labor well
May require forceps or vacuum delivery
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Substance Abuse
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The continued use of substances despite related
problems in physical, social, or interpersonal
areas
Dual diagnosis
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Substance abuse plus another psychiatric disorder
Damaging effects on the fetus are well
documented
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Substance Abuse (Cont.)
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Barriers to treatment
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Women fear losing custody of child and criminal
prosecution
Less than 10% of pregnant women receive treatment
Substance-abuse treatment programs do not address
issues affecting pregnant women
Long waiting lists and lack of health insurance
present further barriers to treatment
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Substance Abuse (Cont.)
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Care management
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Drug testing during pregnancy
Screening for substance abuse
Initial care
Methadone maintenance program
Follow-up care
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Substance Abuse (Cont.)
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Care management
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Breastfeeding definitely contraindicated in women
who continue to use amphetamines, alcohol, cocaine,
heroin, or marijuana
Substance abusers difficult to care for particularly
during intrapartum and postpartum periods
Substance abuse is an illness; women deserve to be
treated with patience, kindness, consistency, and
firmness
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Substance Abuse (Cont.)
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Care management
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Before discharge
• Home situation must be assessed for safe environment
• Someone available to meet infant’s needs
if mother is unable
• Family members or friends should become actively involved
with mother before discharge
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If infant’s well-being is questionable, case will be
referred to child protective services agency
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Question
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During a prenatal visit, the nurse is explaining dietary
management to a woman with pregestational diabetes.
The nurse evaluates that teaching has been effective
when the woman states:
“I will need to eat 600 more calories per day since I am
pregnant.”
“I can continue with the same diet as before pregnancy
as long as it is well balanced.”
“Diet and insulin needs change during pregnancy.”
“I will plan my diet based on results of urine glucose
testing.”
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