High Risk Prenatal Client

High risk pregnancy

- When life or wellbeing of woman or fetus has significantly increased risk of harm, damage, injury, or disability (morbidity) or loss of life or death (mortality)
by disorder coincidental w/ or unique to pregnancy
RISK FACTORS
A. DEMOGRAPHIC FACTOR
I. Age
- 20-30 optimal age for bearing
- below 16 / 35 up
II. Weight
- overweight
- underweight
III. Height
- Less than 5ft (high risk because of pelvic shape)
B. SOCIO-ECONOMIC FACTOR
1. Inadequate finances
2. Overcrowding
3. Poor standards of housing
4. Poor hygiene
5. Unplanned and prepared pregnancy esp. among adolescent
6. Poverty and low educational status
C. OBSTETRIC HISTORY
1. History of infertility or multiple gestation
2. Grandmultiparity
3. Previous abortion or ectopic pregnancy
4. Previous loses : fetal death, stillbirth, neonatal or perinatal death
5. Previous operative OB, CS, and midforceps delivery
6. Previous uterine or cervical abnormality
7. Previous abnormal labor : Premature labor or postmature labor, prolonged labor
8. Previous high-risk infant : low birth wt (LBW), macrosomic (LGA) w/ neurologic deficit, birth injury or malformation
9. Previous hydatidiform mole (H-mole)
D. CURRENT OB STATUS
1. Late or No prenatal care
2. Maternal anemia
3. Rh sensitization
4. Antepartal bleeding, placenta previa and abruption placenta
5. Pregnancy-induced hypertension
6. Multiple gestation
7. Premature or post-mature labor
8. Polyhydramios
9. PROM
10. Fetus inappropriately large or small; abnormality in tests for fetal well being; abnormality in presentation
E. MATERNAL HISTORY STATUS
1. Cardiac or pulmonary disease
2. Metabolic disease : DM, thyroid disease
3. Endocrine disorder : pituitary, adrenal
4. Chronic renal disease : repeated UTI, bacteriuria
5. Chronic hypertension
6. Venereal and other infectious disease
7. Major congenital anomalies of reproductive tract
8. Hemoglobinopathies : sickle cell anemia, thalassemia
9. Seizure disorder
10. Malignancy
11. Major emotional distress, mental retardation

F. HABITS/HABITUATION
1. Smoking
2. Regular alcohol intake
3. Drug abuse/use

DIAGNOSTIC TESTS in high risk-pregnancy

1. ULTRASONOGRAPHY/UTZ/ULTRASOUND
- A non-invasive diagnosis procedure utilizing a high-frequency sound waves to detect intrabody structures.
Purposes:
1. In an early pregnancy : to confirm pregnancy
2. To detect :
fetuss
- viability, growth

-FHT

- number (multiple pregnancy)

- AOG

- position, presentation
- abnormalities
3. Detects placental location or placental abnormality
4. An important aid in high-risk procedures like amniocentesis
Preparation:
1. Advices mother to drink 1 quarter of water 2 hrs before procedure.
2.Instruct not to void (Ultrasound)
In amniocentesis w/ ultrasound to offer visualization, the mother should void to prevent injuring the distended bladder w/ needle insertion.
3. Transmission gel is spread over maternal abdomen
4. Psychological support is given to the mother/father
-confinement is not needed
-no need for dye and there is no x-ray radiation
-takes about 30 min. to accomplish
2. NON-STRESS TEST (NST)
- Observation of FHR related to movement
- Test of fetal well-being
Preparation:
1. Position semi-fowlers or left lateral
2. Check BP
3. Explain :
- Procedure takes : 30-60 min.
- Mother needs to activate mark button w/ each fetal movement
- Does not need hospitalization ambulatory basis
4. Requires external electronic monitoring of FHT w/ ultrasound transducer and tocodynamometer to trace fetal activity and or uterine activity
Interpretation:
1. Normal : Reactive
- Increased FHR (acceleration)
- 15 bpm above baseline
- lasting 15 sec or more in a 10-20 min period w/ fetal movement
2. Abnormal : Non reactive
-No FHR acceleration w/ fetal movement
Implication of Results:
1. Normal : High risk pregnancy continues
2. Abnormal : Mother needs another test, may be BPP
3. OXYTOCIN CHALLENGE TEST (OCT) OR CONTRACTION STRESS TEST (CST)
Purposes :
1. Observation of response of the fetus to individual uterine contractions

2. A test of feto-placental wellbeing

Preparation:
1. Semi-fowlers or left lateral
2. BP is checked priorly and every 15 min. during test
3. Explain
-Procedure takes 1-3 hr to finish
-Mother receives Oxytocin of increasing dosage
-Soluset to the mainline and Aimed to cause 3 uterine contractions in 10 min.
-May be done on outpatient basis
4. Require external electronic FHT monitoring w/ ultrasound transducer and tocodynamometer to detect uterine activity
Interpretation:
1. Normal : Negative
-No late deceleration of FHR w/ each of 3 contractions during a 10 min. interval
2. Abnormal : Positive
- w/ late decelerations of FHR w/ 3 contractions in 10 min.
Implication of Results:
1. Normal: Pregnancy continues, normal result of OCT may require weekly tests
2. Abnormal result: may indicate a need to terminate pregnancy
4. NIPPLE STIMULATION CONTRACTION TEST
Purposes:
1. Determine feto-placental function/well-being
2. Breasts are stimulated w/ rolling of nipples or warm-towel applicaition
3. The baseline data are obtained through monitoring as in OCT procedure
4. Interpretation: as in OCT : the absence of late decelerations in 3 contractions in 10 min is the desired result
5. BIOPHYSICAL PROFILE (BPP)
- a scoring combining ultrasound assessment of :
1. Fetal breathing
2. Fetal movement
3. Fetal muscle tone
4. Reactivity of heart rate
5. Amniotic fluid volume
Scores:
8-10 : Normal, low risk for chronic asphyxia
4-6 : Suspected chronic asphyxia
0-2 : Strong suspicion of chronic asphyxia
6. AMNIOCENTESIS
- Entering the amniotic sac to aspirate amniotic fluid for a variety of diagnostic exams to detect fetal wellbeing
Major risks:
1. Trauma : fetus, placenta, umbilical cord
2. Infection
3. Abortion
4. Preterm labor
Preparation:
1. Secure an informed consent
2. Prepare for ultrasound : to locate placenta and to provide visualization to a blind procedure
-ultrasound in amniocentesis : client needs to void
-pelvic ultrasound only: clients should not void
3. Increase oral fluids: Take 1 quarts water 2 hrs before
4. Prepare needle , gauge : 20-22 , 3 -6
5. Prepare for administration of local anesthesia of abdomen
6. Provide psychological support
-Amt. of amniotic fluid to be aspirated up to 30ml at 15 to 18 weeks gestation

Implications:
1. Decreased L/S ratio
2. Fetal blood false high levels of AFP

Aftercare:
1. Monitor 30-60 min
2. Observe for side effects such as :
-vaginal discharge
-increase uterine/fetal activity
- fever and chills
Analysis of amniotic fluid
1. TO determine fetal lung maturity
L/S ratio: 2:1 means mature lungs
2. Determination of AOG
-Creatinine levels : 2.0 mg 36 wks AOG

more than 2.0 mg greater than 36 wks

-Nile blue stain (lipid cells) when 20 % of cells are stained w/ orange means fetal weight is at least 2500 g
3. Alpha-fetoprotein levels :
High levels : presence of neural defects such as :
-aspina bifida
-tracheoesophageal atresia
4. Genetic disorder
5. Rh incompatibility : Increased levels of bilirubin identified isoimmunization; evaluated for intrauterine transfusion or deliver
6. Inborn errors metabolism : biochemical analysis of fetal cell enzymes
*Rh- rhesus
7. Fetal distress: passage of meconium in cephalic presentation (not significant in breech presentation)
8. Sex-linked disorders : sex chromosome determination
7. X-RAY LATERAL PELVIMETRY
-Indications for radiography to determine pelvic size and shape
- suspected cephalopelvic disproportion
-history of injury/disease of pelvis and spine
-previous difficult delivery
- cases of maternal deformity or limp
8. SERIAL ESTRIOL DETERMINATION
-Measures feto-placental wellbeing
-specimens: serum/ 24 hr urine
Results:
1. Normal : gradual increase in serial estriol w/c is 12-50 mg/day at term
2. Abnormal : sudden drop of less than 50% of level means fetal distress
3. Persistent low levels means fetal wellbeing is compromised
9. CHORIONIC VILLI SAMPLING (CVS)
- Earliest test possible on fetal cells
- Sample obtained by slender catheter passed through cervix to implantation site
10. PUBS
- Used in 2nd and 3rd tri.
-Uses ultrasound to locate umbilical cord
-Cord blood aspirated and tested

IDENTIFYING A HIGH RISK PREGNANCY

High risk pregnancy
- One in w/c a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, fetus, or both.
CARDIOVASCULAR DISORDERS
1. Valve damage Caused by rheumatic fever or Kawasaki disease
2. Congenital anomalies e.g., Atrial septal defect or uncorrected coarctation of the aorta
3. Aortic dilatation Caused by Marfans syndrome
4. Coronary artery disease and varicosities As the number of women delaying their first pregnancy until later in life
Blood volume and cardiac output increase during pregnancy
1. Functional heart murmurs Because of increased blood flow past valves
2. Heart palpitations also normal
Valvular and aortic artery constrictions
- Women who had Kawasaki disease as a child may have this and it can lead to true valve dysfunction and organic murmurs
1. The danger of pregnancy in a woman w/ cardiac disease is primarily because of Increase in circulatory volume
2. The most dangerous time for a woman is in weeks 28-32 just after the blood volume peaks
3. A womans heart may become so overwhelmed by the increase in blood volume toward the end of pregnancy that her cardiac output falls to the point that vital
organs including the placenta are no longer perfused adequately. Then , neither oxygen nor nutritional requirements of her cells or those of the fetus can be met.
4. There are 4 categories of heart disease

CARDIAC DISEASE
- Caused by inability to cope w/ added volume and increase cardiac output that occurs during pregnancy.
Class I- Uncompromised
- No symptoms of insufficiency
- No limits on physical activity

Class II Slightly compromised

- Slight limitation of activity
- Dyspnea, fatigue, palpitation, chest pain or angina pain
- W/ ordinary activity
*Recommendation (I & II)
- Sleep for 10 hrs
- Rest 30 min. every after meal
*Good prognosis for vaginal delivery
Class III- Markedly compromised
- Considerable limitation of activity
- Less than normal activity procedures
- Excessive symptoms of fatigue, palpitations, chest pain, dyspnea, comfortable only at rest
*Recommendation
- Early hospitalization for 7-8 mos. of pregnancy

Class IV- Severely compromised

- Inability to perform any physical activity
- Symptoms of insufficiency present at rest
*Recommendation
- Therapeutic abortion

*Poor prognosis for vaginal delivery; no lithotomy and valsalva maneuver w/c can trigger cardiac arrest ; no rectal suppository w/c can trigger valsalva maneuver

CONGENITAL ANOMALIES
- Atrial septal disease
- Ventricular septal defect
- Occur from congenital or rheumatic heart disease
- Pulmonary stenosis
- Coarction of Aorta
1. RHEUMATIC HEART DISEASE (rheumatic endocarditis)
- Endocarditis w/ scar tissue formation on the mitral, aortic, tricuspid valves w/ resulting stenosis or insufficiency
- Patient w/ mitral valve prolapsed may require prophylactic therapy during labor
Pathophysio :
valve stenosis Decrease blood flow , work on the heart chambers increase regurgitation occurs through incomplete closed valve , workload on heart increases
Assessment
1. Tachycardia
2. Dyspnea
3. Diastolic murmur
4. Crackles at lung bases
5. Hemoptysis
6. Orthopnea
Management
1. Activity limitation
2. Close medical supervision
3. Rest
4. Limited sodium intake
5. Prophylactic antibiotics
6. Serial ultrasound, non stress test, and BPP
Nursing intervention
1. Assess maternal V/S and cardiopulmonary status
2. Monitor weight gain
3. Prescribed medication
4. Frequent prenatal visit
5. Report danger signs and symptoms
6. Assess nutritional pattern
7. Frequent rest
8. Report any signs and symptoms of infection
9. Advise rest in lateral recumbent position
10. Anticipate use of epidural anesthesia labor
11. Close observation for changes during labor
12. Monitor V/S
13. W/ severe heart failure used anticoagulant and cardiac glycoside therapy
14. Encourage ambulation
15. Administer of a prophylactic antibiotic
16. Instruct to avoid high altitude, smoking area, crowded areas, drinking alcohol, and food w/ caffeine and smoking is prohibited
Remember
*should avoid
- infection
- excessive weight
- edema
- anemia

2. DIABETES MELLITUS
- Metabolic disorder characterized by hyperglycemia resulting from lack of insulin
- Endocrine disorder of carbohydrate, proteins and fat metabolism
Gestational DM (GDM)
Pregestational DM (PGDM) prior to pregnancy

Classification:
1. Type I (IDDM) Insulin dependent DM
2. Type II (NIDDM) Non insulin dependent DM
Factors :
1. Hereditary
2. Environment
3. Lifestyle
Susceptible for type I:
1. Production of autoantibodies against beta cells of pancreas
2. Restriction of beta cells
3. Decline or lack of insulin
4. Hyperglycemia
5. Lipolysis
6. Protein catabolism
Assessment:
1. Hyperglycemia
2. Glycosuria
3. Polyuria
4. Polydipsia
5. Weight loss
6. Increased incidence of candidal infections
7. Hydramnios
8. S/S of macrovascular and microvascular changes
9. Peripheral vascular disease
10, Retinopathy
11. Nephropathy
12. Neuropathy
Diagnostic test
1. Screening w/ an oral glucose challenge test
2. 100 g glucose load used at 24-28 wks gestation
Management
1. Blood glucose monitoring
2. Target glucose level of FBS
3. Diet, exercise and insulin administration
Type 1
1. Monitoring of glucose level
2. Evaluation of glycosylated hgb (HbA1c) level every 3-4 mos.
Interventions
1. Monitor patient status throughout the pregnancy
2. Review result of fingerstick blood glucose monitoring
3. Follow up lab results
4. Encourage consistent exercise program
5. Diabetic care management
6. Assist w/ preparation for labor
7. Assess possible complications and effects
Mother:
1. Has 30% to 40% chance of developing DM in 1-25 yrs.
2. Dystocia because of large infant
3. Increased risk for postpartum hemorrhage due to over distention of uterus
4. Polyhydramnios
5. Gestational hypertension
6. Maternal mortality
7. Retinopathy and nephropathy
8. Preterm delivery
9. UTI

10. Candidiasis , Moniliasis

11. Spontaneous abortion
Infant:
1. Sacral agenesis
2. Congenital anomalies
3. Macrosomia
4. Prematurity
5. Hypoglycemia and Hypocalcemia
6. Birth injury
7. Respiratory distress
8. Intrauterine fetal growth retardation
9. Fetal death
3. SUBSTANCE ABUSE
- Misuse or overuse of substance including alcohol, prescription, OTC, and illicit drugs
I. Caffeine
- Coffee, tea, cola, chocolate, cold remedies, analgesics
Maternal effects:
1. CNS and cardiac function stimulation
2. Vasoconstriction
3. Mild dieresis results
Fetal effect:
1. Placental barrier is crossed
II. Tobacco
- Decrease in O2 carrying capacity of hemoglobin
- Carbon monoxide crosses the placenta
- Nicotine causes decrease in uterine perfusion and vasoconstriction
- Cadmium interferes w/ placental transfer and zinc
Maternal effects:
1. Decrease in placental perfusion
2. Anemia
3. PROM
4. Preterm labor
5. Spontaneous abortion
Fetal effects:
1. Prematurity
2. LBW
3. Fetal demise
4. Developmental delays
5. Incidence of SIDS
6. Pneumonia
III. Alcohol
- Interferes w/ nutrient absorption
- Neuronal differentiation
- Facilitate free radical damage
- Induces premature death of cells that develop into facial bone and cartilage
Maternal effects:
1. Spontaneous abortion
Fetal effects:
1. Fetal demise
2. IUGR
3. Fetal alcohol syndrome (facial and cranial)
4. Fetal alcohol effects

IV. Narcotics
- heroin, methadone, morphine
Maternal effects:
1. Spontaneous abortion
2. ROM
3. Preterm labor
4. Increase incidence of STD
5. HIV exposure
6. Hepatitis
7. Malnutrition
Fetal effects
1. IUGR
2. Perinatal asphyxia
3. Intellectual impairment
3. Neonatal abstinence syndrome
4. Neonatal infections
5. Neonatal death (SIDS, child abuse and neglect)
V. Cocaine
- cracked
- Causes decrease in blood flow to the heart
- Platelet aggregation
- Brain (seizures)
- Intestines
- Uterus
-Increase in fetal neurotransmitter causes teratogenic effects

Maternal effects:
1. Hyperarousal state
2. Generalized vasoconstriction
3. HPN
4. Spontaneous abortion
5. Abruptio placenta
6. Preterm labor
7. Cardiovascular complications
8. Seizure
9. STD
Fetal effects:
1. Stillbirth
2. Poor feeding reflexes
3. N/V
4. Diarrhea
5. Decrease in intellectual development
6. Prune-belly syndrome resulting from absence of abdominal muscle
VI. Amphetamine
- speed in ice
- When processed in crystals to smoke methampethetamines ecstasy
Maternal effects:
1. Malnutrition
2. Tachycardia
3. Withdrawal symptoms
Fetal effects:
1. Increase in risk for Cardiac anomalies
2. Cleft palate
3. IUGR
4. Withdrawal syndrome
5. Fetal death

VII. Marijuana
- pot , grass
- Delta-9-tetrahydrocannabiral crosses placenta
- Takes 30 days to be excreted
- Increase in carbon monoxide 5x more than tobacco
- Detrimental when used during 1st tri. where fetal organs are being formed
Maternal effects:
1. High incidence of anemia
2. Inadequate weight gain
Fetal effects:
1. IUGR
2. Neonatal tremors
3. Sensitivity to light

Assessment:
1. Malnutrition
2. STD
3. poor self image