Pregnancy at Risk - Preexisting Conditions Jennifer L. Kelly PhD, RN, CNM Preexisting Conditions For some women pregnancy represents significant risk because it is superimposed on preexisting illness Unique maternal and fetal needs caused by these conditions must be met in addition to the usual pregnancy-related feelings, needs, and concerns Metabolic disorders Diabetes mellitus Thyroid disorders Cardiovascular disorders Respiratory, gastrointestinal, integumentary, and Autoimmune disorders Substance abuse Human immunodeficiency virus (HIV) Metabolic Disorders Diabetes mellitus Despite advances in care, the woman whose pregnancy is complicated by diabetes may still have poor outcomes Pregnancy complicated by diabetes considered high risk Diabetes can be successfully managed with a multidisciplinary approach Pathogenesis 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 Classification of diabetes Type 1 diabetes Type 2 diabetes Other specific types (caused by infection or drug-induced) Gestational diabetes mellitus is any degree of glucose intolerance with onset or recognition during pregnancy Metabolic changes associated with pregnancy Pregestational diabetes mellitus Preconception counseling Maternal risks and complications Ketoacidosis Hypoglycemia Pregestational diabetes mellitus Fetal and neonatal risks Sudden and unexplained stillbirth Congenital anomalies Central nervous system Cardiac defects Skeletal defects Other problems that cause significant neonatal morbidity Nursing Care Management Assessment Interview Physical examination Laboratory tests Plan of care and implementation Antepartum Diet and exercise Insulin therapy Monitoring blood glucose levels Fetal surveillance Complications requiring hospitalization Determination of birth date and mode of birth Family planning and contraception Gestational diabetes mellitus Maternal-fetal risks Screening for gestational diabetes mellitus Antepartum care Diet and exercise Monitoring blood glucose levels Insulin therapy Fetal surveillance Intrapartum and postpartum care Metabolic Disorders Thyroid disorders Hyperthyroidism Graves’ disease 90% to 95% of cases Hypothyroidism Nursing care Maternal phenylketonuria Recognized cause of mental retardation caused by deficiency in enzyme phenylalanine hydrolase Toxic accumulation of phenylalanine in blood interferes with brain development Key to prevention is identification of women with disorder in their reproductive years Cardiovascular Disorders Major cardiovascular changes during pregnancy that affect women with cardiac disease are: Increased intravascular volume Decreased systemic vascular resistance Cardiac output changes during labor and birth Intravascular volume changes that occur just after childbirth Cardiovascular disease classification 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 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 Peripartum cardiomyopathy Rheumatic heart disease Mitral and aortic valve stenosis Mitral valve prolapse Infective endocarditis Eisenmenger’s syndrome Atrial and ventricular septal defects Tetralogy of Fallot Marfan syndrome Heart transplantation 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 Vaginal birth is desired, but transplant recipients have an increased rate of cesarean births Conception should be postponed for 1 year after transplant Neonate may exhibit immunosuppressive effects during first week of life Breastfeeding not advised for infants of mothers taking cyclosporine Nursing Care Management Assessment Plan of care and implementation Therapy focused on minimizing stress on heart Signs and symptoms of cardiac decompensation Bed rest Nutrition counseling Cardiac medications as needed Anticoagulant therapy Heparin: large-molecule drug does not cross placenta Heart surgery during pregnancy Intrapartum care Postpartum care Cardiopulmonary Resuscitation of the Pregnant Woman Cardiopulmonary resuscitation of pregnant woman For cardiac arrest, standard resuscitative efforts with few modifications implemented If defibrillation needed, paddles must be placed one rib interspace higher than usual Fetus should be monitored during the cardiac arrest Anemia Iron deficiency anemia Folic acid deficiency anemia Sickle cell hemoglobinopathy Thalassemia Pulmonary Disorders Asthma Therapy objectives Relieve the bronchospasm Limit irritant stimuli Decrease the pulmonary response to allergen exposure Limit the inflammatory response in the airways 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 Gastrointestinal Disorders Cholelithiasis (gallstones) Cholecystitis (inflammation of the gallbladder) Inflammatory bowel disease Integumentary Disorders Dermatologic disorders induced by pregnancy include: Melasma (chloasma) Vascular “spiders” Palmar erythema Striae gravidarum Skin problems aggravated by pregnancy Acne vulgaris (in the first trimester) Erythema multiforme Herpetiform dermatitis (fever blisters and genital herpes) Granuloma inguinale (Donovan bodies) Condylomata acuminata (genital warts) Neurofibromatosis (von Recklinghausen’s disease) Pemphigus Neurologic Disorders Epilepsy Failure to take medications is common factor Message that drugs are harmful to the fetus Risks to the infant have been exaggerated Multiple sclerosis Bed rest and steroids used to treat acute exacerbations Bell’s palsy Autoimmune Disorders Systemic lupus erythematosus 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 Myasthenia gravis (MG) 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 HIV and AIDS Preconception counseling Pregnancy risks Pregnancy does not accelerate the condition 100 to 200 infants are infected each year Mother to child transmission Minority races and ethnicities at increased risk Obstetric complications Nursing care management HIV-infected women should be treated with highly active antiretroviral therapy (HAART) during pregnancy Should be tested for other sexually transmitted infections and hepatitis Opportunistic infections should be treated with medications specific for that infection Every effort should be made to decrease neonate’s exposure to blood and secretions Immediately after birth infants should be wiped free of all body fluids and then bathed All staff working with mother or infant must adhere strictly to infection control techniques Observe Standard Precautions for blood and other body fluids Substance Abuse Alcohol and other drugs easily pass from mother to baby through the placenta Smoking during pregnancy has serious health risks, including: Bleeding complications Miscarriage Stillbirth Prematurity Placenta previa Placental abruption Low birth weight Sudden infant death syndrome Barriers to treatment Women fear losing custody of child and criminal prosecution Substance-abuse treatment programs do not address issues affecting pregnant women Long waiting lists and lack of health insurance present further barriers to treatment Legal considerations Women who abuse substances may face criminal charges Nurses who encourage prenatal care, counseling, and treatment are of greater benefit to mother and child than prosecution Nursing care management Women often deny or greatly underreport usage of drugs or alcohol consumption Crucial for nurse to display nonjudgmental and matter-of-fact attitude to gain woman’s trust and elicit reasonably accurate estimate Michigan alcohol screening test CAGE T-ACE and TWEAK specifically for alcohol use during pregnancy Realistic goal may be to decrease substance use Consequences of drug use should be clearly communicated, and abstinence recommended Women more receptive to making lifestyle changes during pregnancy than at any other time Women for Sobriety Methadone treatment for pregnant women Cocaine use during pregnancy has increased dramatically 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 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 If infant’s well-being is questionable, case will be referred to child protective services agency Key Points Careful monitoring of blood glucose levels, insulin administration, and dietary counseling used to create normal intrauterine environment for fetal growth and development in pregnancy complicated by diabetes mellitus Poor maternal glycemic control may be responsible for fetal congenital malformations and maternal complications such as miscarriage, infection, preeclampsia, and dystocia caused by macrosomia Maternal insulin requirements increase as pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol Thyroid dysfunction during pregnancy requires close monitoring of thyroid hormone levels to regulate therapy and prevent fetal insult High levels of phenylalanine in maternal bloodstream cross placenta and are teratogenic to the fetus Damage can be prevented or minimized by dietary restriction of phenylalanine The stress of the normal maternal adaptations to pregnancy on a heart whose functions are already taxed may cause cardiac decompensation For cardiac arrest in pregnant woman, the standard advanced cardiac life support guidelines should be implemented without modification Anemia affects 20% of pregnant women Women in reproductive years show predilection for autoimmune disorders (e.g., systemic lupus erythematosus and myasthenia gravis) and may occur during pregnancy Perinatal administration of HAART is recommended to decrease transmission of HIV from mother to fetus Support, including family and friends, health care providers, and recovery community, is necessary to help perinatal substance abusers achieve and maintain sobriety Apply It! Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: Frequent episodes of maternal hypoglycemia. Congenital anomalies in the fetus. Polyhydramnios. Hyperemesis gravidarum. When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which are: A regular heart rate and hypertension. An increased urinary output, tachycardia, and dry cough. Shortness of breath, bradycardia, and hypertension. Dyspnea; crackles; and an irregular, weak pulse.