Management of Pregnancy at Risk

Chapter 19 & 20

Mary L. Dunlap MSN, APRN

Fall 2015
 High-Risk Pregnancy

• Jeopardy to mother, fetus, or both

• Condition due to pregnancy or result
of condition present before pregnancy
• Higher morbidity and mortality
• Risk assessment with first Antepartal
visit and each subsequent visit
• Risk factors (see Box 19-1 p.605)
 Conditions Complicating
Pregnancy
• Perinatal Loss
• Bleeding
• Hyperemesis gravidarum
• Gestational hypertension
• HELLP syndrome
• Gestational diabetes
 Perinatal Loss

• Death of a fetus or newborn no matter

when it occurs is devastating to the mother
and family
• Nurses need to understand their own
personal feelings so they can provide
support and compassionate care
• What to say- I understand , I am here to
listen, Does your baby have a name
 Fetal Demise

• Fetal Demise True Story

 Causes of Bleeding

• Spontaneous • Cervical
abortion insufficiency
• Ectopic • Placenta Previa
pregnancy • Abruptio
• GTD/Hydatiform placenta
mole
 Spontaneous Abortion
• Termination of pregnancy before
viability prior to 20wks less than 500g
• Presentation-Vaginal bleeding and
cramping
• Management-Bed rest, serial hCG’s &
H&H, Dilation and curettage may be
necessary to remove products of
conception, RhoGam if mother RH -
 Causes

• Congenital abnormalities
• Incompetent cervix
• Anomaly of the uterine cavity
• Hypothyroidism
• Diabetes mellitus
• Drug use
• Infection
 Categories of Abortions

• Complete–all products of conception

expelled
• Incomplete–a portion of the products of
conception retained in the uterus
• Threatened–bleeding and cramping
 Categories of Abortions

• Missed– nonviable embryo retained in

uterus for at least 6 weeks
• Habitual–three or more successive
abortions
• Inevitable–cannot be stopped
• Table 19-1 pg. 607
 Spontaneous Abortion

Nursing care
• Assess bleeding and signs of shock
• Assess pain level
• Assess for infection
• Provide emotional support
 Ectopic Pregnancy

• Fertilized ovum implanted outside the

uterine cavity usually due to an
obstruction of the fallopian tube
• 95%- 99% occur in the fallopian tube
• Possible implantation sites Fig 19-1
pg 531
 Contributing Factors

• Previous ectopic • Uterine fibroids

• STD’s • IUD
• Endometriosis • Progesterone
• Tubal or pelvic only BC pills
surgery (slows ovum
transport)
 Ectopic Pregnancy

Manifestations
• Missed menses
• Vaginal bleeding & pelvic pain 6-8
wks after missed menses
• Diagnosis: Lab test & Ultrasound
 Ectopic Pregnancy

Management
• Administer Methotrexate,
• Surgical-Salpingectomy
• Nursing Care: Monitor for shock,
prepare for surgery & provide
emotional support
Gestational Trophoblastic Disease
(GTD)
• GTD is a disease characterized by an
abnormal placental development
resulting in the production of fluid filled
grape like clusters and vast
proliferation of Trophoblastic tissues
• Diagnosis- trans vaginal U.S. showing
vesicular molar pattern (grape clusters)
high hCG levels
 GTD

• Complete (or classic): mole results

from fertilization of egg with lost or
inactivated nucleus and is associated
with Choriocarcinoma
• Partial mole: result of two sperm
fertilizing a normal ovum
• Cause unknown
 GTD

Clinical manifestations
• Bleeding grape like tissue
• Sever Hyperemesis
• Uterine size larger than dates
• Extremely high hCG levels
• Early development preeclampsia
 GTD

Management
• Immediate evacuation of uterine
content by Dilatation & suction
curettage
• Tissue evaluate for Choriocarcinoma
• Follow up for one year
 GTD
Nursing Assessment
• Assess for expulsion of grapelike vesicles
• Sever morning sickness due to the high hCG
levels
• Unable to detect heart rate after 10-12 wks.
• Early development of preeclampsia
(prior to 24 wks.)
 Cervical Insufficiency
• Premature cervical dilatation due to a
weak structurally defective cervix that
spontaneously dilates in the absence
of contractions in the 2nd trimester
• 18–22 wks. Usual time for
development
• Repetitive second trimester losses
 Cervical Insufficiency

Possible causes
• Trauma to the cervix
• Structure of cervix- less collagen and
more smooth muscle
 Cervical Insufficiency
Management
• Bed rest
• Pelvic rest
• Avoid heavy lifting
• Cervical cerclage placed 2nd trimester
if no infection present fig 19.3 pg.615
 Cervical Insufficiency

Nursing Assessment Monitor for:

• Preterm labor
• Backache
• Increase vaginal discharge
• Rupture of membranes
• Contractions
 Placenta Previa

• Occurs when the placenta implants

near or over internal cervical os
• Classification based on degree internal
cervical os is covered by placenta
 Placenta Previa

• Complete Placenta Previa

• Partial Placental Previa
• Marginal Previa
• Low-lying
Previa classifications
 Placenta Previa
Symptoms
• Painless vaginal bleeding that occurs
during the last two months of
pregnancy
 Placenta Previa
Therapeutic Management
• Based on bleeding, location of Previa
and fetal development
• “Wait and see” approach if fetus stable
and no active bleeding may go home on
bed rest
• Bleeding present admitted to hospital
monitoring bleeding, FHR, and avoid
vaginal exams.
 Placenta Previa

Nursing Management
• Monitor vaginal bleeding
• Monitor for fetal distress
• Provide emotional support
• Education
• Nursing care plan 19.1 pg. 618 & 619
 Abruptio Placenta

• Premature separation of placenta

form the uterine wall after 20 weeks of
gestation leading to compromised fetal
blood supply.
• Significant cause of 3rd trimester
bleeding
 Abruptio Placenta

Clinical manifestations:
• Knife like pain
• Port wine vaginal bleeding
• Prolonged contraction
• Ridged abdomen
• Uterine tenderness
• Decrease FHR
 Abruptio Placenta

Classification systems grades 1,2,3

• Grade 1 (mild) less than 500 mL
• Grade 2 (moderate) 1000-1500mL
• Grade 3 (severe) greater than 1500
Classifications of Abruptio
Placenta
 Diagnostic Testing

• CBC
• Fibrinogen levels
• PT/PTT
• Type and Cross match
• Kleihauer-Betke test
• NST
• Biophysical Profile
 Abruptio Placenta
Management Goal
• Assess, control and restore blood loss
• Positive out come for mother and Baby
• Prevent coagulation disorder
Box 19.2 pg. 621
 Abruptio Placenta
Nursing Management
• O2 therapy
• Monitor FHR tracing
• Monitor fundal height
• Bed rest- left lateral position
• Monitor V.S. for shock
• Monitor for DIC
• Emotional support
 Hyperemesis

• “Morning sickness” normal nausea

and vomiting experienced by 80% of
pregnant women .
• Symptoms are mild and usually
resolve at the end of the first trimester
• Management Teaching Guidelines
19.1 pg. 627
 Hyperemesis Gravidarum

• Excessive vomiting accompanied by

dehydration, electrolyte imbalance,
ketosis, acetonuria and weight loss
• Continues past the 20th wks.
• Experiences N&V for the first time after
9 wks.
• These mothers require hospitalization
 Hyperemesis Gravidarum
• Possible causes: etiology unknown
could be due to high hormone levels,
low blood glucose levels, Vit B
complex and protein deficiency,
metabolic stress, depression, elevated
thyroid hormone levels
• Collaborative care: GI consult to r/o
GI problems , Psychiatric consult ,
Dietary consult
 Hyperemesis Gravidarum
Diagnostic Test
• Liver enzymes
• CBC
• Urine
• BUN
• Urine specific gravity
• Electrolytes
• US
 Hyperemesis Gravidarum
Management
• NPO for 24-36 hr.
• IV therapy
• Medications-Reglan, Phenergan,
Zofran, Compazine, B6 (19-2 pg.625)
• Comfort
• Emotional support
• Teaching Guidelines 19.1
Hypertension Classification
Chronic
Hypertension

Help Gestational
Syndrome Hypertension

Eclampsia Preeclampsia
 Assessing Blood Pressure
• Never place patient in Left Lateral Tilt
position will give a false lower B/P
• Setting or semi-Fowler’s position
• Make sure patient is comfortable
• Use the appropriately sized cuff
• Cuff needs to be at the level of the right
atrium (mid-sternum
• If ≥149/90 recheck in 15 min.
 Hypertension Classification

• Chronic hypertension, appears before

the pregnancy or the 20th week and is
persistence after 12 wks. PP
• Oral antihypertensive are used (avoid
ACEs & ARBs due to teratogenic side
effects)
 Antihypertensive Therapy

• Prevent CVA and maintain placental

perfusion
• Apresoline- can cause rebound
tachycardia
• Labetalol – beta blocker due not use with
asthmatic patients
• Aldomet
• Procardia
 Hypertensive Emergency
ACOG Guidelines
Acute onset lasting 15 minutes or longer
• SBP ≥ 160 mm Hg
or
• DBP ≥ 110 mm Hg
• Loss of cerebral vasculature auto
regulation
• Treat with Hydralazine & Labetalol
 Hypertension Classification

• Gestational hypertension- Onset

without proteinuria after 20th week of
pregnancy and returns to normal by 12
wks. Postpartum
• Mild- SBP 140-159 DBP 90-109
• Severe- SBP ≥ 160 DBP ≥ 110
 Risk to Fetus

• Progression to preeclampsia
• Mild: outcome comparable to no
hypertension
• Severe: significant outcome similar to
patient with severe preeclampsia
 Management of Mild Gestational
Hypertension
• Educate patient about s/s of
preeclampsia and when to call provider
• Patient assess daily for signs of
preeclampsia and decrease fetal
movement
• B/P evaluated twice at week, one being
done by provider along with assessing
for proteinuria, liver enzymes and
platelets
 Management of Severe
Gestational Hypertension
• Admit to hospital for stabilization
• Lower B/P to < 160/110: IV Hydralazine
or labetalol
• Monitor B/P and s/s of preeclampsia
• Administer oral antihypertensive to
control B/P
• Delivery based on fetal status and
gestational age
 Hypertension Classification

• Preeclampsia- Hypertension develops

after 20 weeks of gestation in
previously normotensive woman and
proteinuria
• Proteinuria ≥ 300 mg/24hr urine
collection
• Protein/creatinine ratio ≥ 0.3 mg/dl
 Preeclampsia
• Pathophysiology not understood feel it
is a disease of the placenta due to
Trophoblastic tissue
• Multisystem disorder
• Signs and symptoms develop only
during pregnancy and disappear after
birth
• Classifications- Mild, Sever, Eclampsia
Chart 19.2 pg. 629
Preeclampsia Pathophysiology

Decreased placental perfusion

Placental production of a toxic substance endothelin

Endothelial cell
Vasospasms
damage

Fluid shift
Increased Intravascular
intravascular to
Thromboxane coagulation
intracellular
 Clinical Manifestations

• Classic Triad hypertension, proteinuria,

and edema
• New belief edema does not have to be
present
• Proteinuria can also be absent if
hypertension present along with signs of
multisystem involvement
Clinical Manifestations

Headache

Epigastric
Pain

Visual CNS
Changes Irritability
 Assessment
• B/P
• Edema
• Output
• Deep tendon reflexes (DTRs)
• Clonus
• Laboratory tests
 Mild Preeclampsia
• B/P greater than 140/90 after 20weeks
• Edema- mild facial or hands
• Weight gain
• Urine protein - 300mg in 24hrs
• 1+ to 2+ protein dip stick
• Reflexes- normal
 Management

• Conservative treatment- bed rest at

home, balanced diet and instructed to
call provider if any signs of sever
preeclampsia develop
• Weekly assessment by provider
• Teaching Guidelines 19.2 pg. 632
 Sever Preeclampsia
• B/P >160/110
• Protein 500 mg/24hrs
• Urine protein > 3+
• Oliguria- less than 400mL/24hrs
• Hyperreflexic
• Pulmonary edema
• Blurred Visual
• Headaches
• Epigastric pain
 Management

• Hospital care/Seizure precautions

• Magnesium sulfate
• Blood pressure
• Pulmonary edema
• Monitor -V.S., DTR’s, Clonus, edema,
urinary output every hour
• Continuous FHR monitoring
 Magnesium Therapy

• Administration must be verified by a

second nurse
• Insert Foley catheter
• Monitor V S, Urinary output, reflexes,
and protein level hourly
• Monitor patient for toxicity
 Magnesium Toxicity
• Absent DTRs (use brachials for pt. with
epidural)
• Respirations < 12/min
• Urine output < 30 mL/hr.
• ↓LOC
• Discontinue Magnesium Sulfate and notify
physician
• Administer 1 gram 10% calcium gluconate IVP
over 5 min. for respiratory arrest
 Hypertension Classification

• Eclampsia- preeclampsia with seizure

state
 Eclampsia

Symptoms of Sever preeclampsia plus

• Marked proteinuria
• Seizures/Coma
• Hyper reflexive
• Possible HELLP syndrome
 Eclampsia
• Stabilize
• Continuous FHR
• Seizure precautions
• Initiate Magsulfate therapy
• Evaluate lab results for HELLP
syndrome
• Prepare for delivery
 HELLP Syndrome

Hepatic Dysfunction characterized by

• Hemolysis of red blood cells(H)
• Elevated liver enzymes (EL)
• Low platelets (LP)
 HELLP Syndrome
Increase risk for:
• Placental abruption
• Acute renal failure
• Subcapsular hepatic hematoma
• Hepatic rupture
• Fetal and maternal death
• DIC
 HELLP Syndrome

Management
• Transfusion of FF plasma or platelets
to reverse thrombocytopenia (count
below 100,000)
• Deliver
 Disseminated Intravascular
Coagulopathy (DIC)

• Loss of balance between clot-forming

thrombin and clot-lysing activity of
plasmin
• Box 19.2 pg. 621
 DIC

Symptoms
• Widespread external/internal bleeding
• Lab results
Decrease fibrinogen/platelets
Prolonged PT/PTT
Positive D-dimer test
 Stages Of Clotting Process
Time of Stage Stage Factors Involved Test
I Platelets initiate Platelets
clotting
Takes 3-5 min. II Thromboplastin PTT
generated
Takes 8-16 min. III Prothrombin PT
converted to
Thrombin
Almost instantly IV Fibrinogen Fibrin Levels
converted to fibrin
 DIC

Management
• Administer fluids to restore volume
until blood is available
• Monitor VS and output
• Administer blood and needed blood
components
 Diabetes Mellitus

• Diabetes mellitus is the most common

endocrine disorder associated with
pregnancy
• Before discovery of insulin in 1922, it
was uncommon for a woman with
diabetes to give birth to a healthy baby
• Pregnancy complicated by diabetes is
considered high risk
 Diabetes Mellitus

• Metabolic disease characterized by

hyperglycemia due to defects in insulin
secretion, insulin action, or both.
• Type 1
• Type 2
• Gestational diabetes mellitus (GDM)
 Pregestational Diabetes Mellitus

Goal
• Preconception counseling and early
pregnancy glycemic control during
organogenesis to reduce the risks of
birth defects
• Fetal Basis of Adult Disease Theory
Pregestational Diabetes Mellitus

• Maternal & Fetal risks

Table 20-2 pg. 651
 Pregestational Diabetes Mellitus
and Pregnancy
Plan of care
• Diet and exercise
• Insulin therapy
• Monitoring blood glucose levels
• Fetal surveillance
• Determination of birth date and
mode of birth
 Diabetes Mellitus- Gestational
(GDM)
• Impairment in CHO metabolism during
pregnancy due to placental hormones
• Placental hormones cause insulin
resistance
• Beta Cells are unable to produce the
required amount of insulin
• Develops during the second trimester
Insulin Needs during Pregnancy
• First trimester: reduced
• Second trimester: starts to increases
• Third trimester: peaks to provide more
nutrients for the fetus
• Delivery: Maternal insulin needs drop
to prepregnancy
• Breastfeeding mother: lower insulin
needs
 Gestational Screening
• ACOG prenatal risk assessment
• Screening
When Diagnosis Test Cutoff for
Diagnosis

First High Risk Fasting 60-90 mg/dL

Prenatal visit Patient HbA1C <7%
Random 200 mg/dL

24-28 weeks GDM Fasting 92mg/dL

1hr GTT 140mg/dL

3hr GTT 1hr <180mg/dL

2hr <153mg/dL
3hr < 140mg/dL
 GDM

• Incidence GDM 2-15%

• GDM-A1 able to maintain glycemic
control with diet/exercise
• GDM-A2 require medication to
maintain glycemic control
 GDM

• Management
• Diet
• Exercise
• Monitor blood glucose levels
• Pharmacologic therapy
• Maternal & fetal Surveillance
 GDM
Nursing Management
• Educate patient about blood glucose
monitoring, optimal glucose control and
fetal well being assessments
• Dietary changes
• Exercise
• Medications
• Teaching Guidelines 20.1 pg. 659
 Pregnancy at Risk

• Blood incompatibility
• Polyhydramnios & Oligohydramnios
• Multiple gestation
• Premature rupture of membranes
• Preterm labor
 Blood Incompatibility

Blood type incompatibility

• ABO incompatibility: type O mothers
& fetuses with type A or B blood (less
severe than Rh incompatibility)
 Blood Incompatibility

Rh incompatibility
• Exposure of Rh-negative mother to Rh-
positive fetal blood causes sensitization
and antibody production
• Risk increases with each subsequent
pregnancy and fetus with Rh-positive
blood
 Blood Incompatibility

• Nursing assessment: maternal blood type

and Rh status
• Antibody screen (indirect Coombs)
• Nursing management: RhoGAM at 28
weeks
 Hydramnios

• Also known as polyhydramnios, too

much fluid ( greater than 2000ml)
• Occurs 32-36 weeks
• Causes: maternal diabetes, Neural
tube defect, multiple gestation
 Hydramnios

Medical Management
• Monitor fluid levels
• Remove excess amniotic fluid
• Administer Indomethacin- decreases
fetal urinary output
 Hydramnios

Nursing Management
• Monitor for abdominal pain, dyspnea,
uterine contractions and edema of the
lower extremities
• Due to the over extension of the
uterus educate the patient about the
signs and symptoms of preterm labor
 Oligohydramnios

• Decrease in amniotic fluid ( less than

500cc) between 32-36 weeks
• Fetus at risk for perinatal morbidity &
mortality
• Risk Factors
 Oligohydramnios

Nursing Management
• Monitor fetal well being
• Educate mother about positions that will
encourage the best blood flow to the
fetus
• Assist with amnio infusion
 Multiple Gestation

• More than one fetus being born to a

pregnant women
• The number of multiple gestations
have increased due to the use of
fertility drugs
• These women are at higher risk for
complications
 Multiple Gestation

• Monozygotic( Identical)- single fertilized

ovum that splits. There is one placenta
and chorion and two bags of amniotic
fluid
• Dizygotic (Fraternal)- two eggs /sperm
There are two placentas, chorions and
bags of amniotic fluid
Multiple Gestation
 Multiple Gestation

Medical Management
• Serial ultrasounds to assess fetal
growth and development
• NST’s and Biophysical profiles to
assess fetal well being
• Close monitoring during labor
• Operative delivery (common)
 Multiple Gestation

Nursing Management
• Monitor lab results for anemia
• Educate the patient about the need for
adequate nutrition, rest periods, signs
and symptoms of preterm labor
 Multiple Gestation

Nursing management:
• Labor management with perinatal
team on standby
• Postpartum assessment for possible
hemorrhage
Premature Rupture of Membranes

• PROM rupture of membranes prior to

the onset of labor and is beyond 37
weeks gestation
• PPROM is the preterm premature
rupture of membranes prior to the
onset of labor prior to the 37th week
gestation
 Premature Rupture of Membranes

Assessment
• Determine if ruptured- Positive Nitrazine
and fern pattern
• Transvaginal ultrasound
• Vaginal & Cervical culture
• Review Box 19.3 pg. 642
Key assessment with PROM
Premature Rupture of Membranes

Management
• PROM deliver patient
• PPROM if no signs of labor in 48hrs may
discharged to home.
• Goal prevent infection, monitor for signs
of labor and promote fetal lung maturity
• Review teaching guidelines 19.3 pg 644
Premature Rupture of Membranes
Nursing Management
• Focus on preventing infection and
identifying contractions
• Monitor V.S.
• Monitor fetal heart rate for tachycardia
or variable decelerations
• Provide emotional support
 Preterm Labor

• Regular uterine contractions with

cervical change between 20 to 37
weeks gestation.
• Most common complication
• Cause is not always known
• Usually due to infection or over
distended uterus
 Preterm Labor

Signs of labor
• Lighting- fetus dropped into pelvic
cavity
• Bloody show
• Rupture of membranes
 Preterm Labor

Management Goal
• Inhibit or reduce contraction strength
and frequency
• Optimize fetal status by prolonging
pregnancy
• ACOG 2009 recommendations
 Preterm Labor

• Fetal Fibronectin
• Monitor contraction pattern
• Tocolytic therapy Drug guide 21.1 pg. 720
• IV fluids
• Betamethasone
• Amniocentesis
 Preterm Labor

Nursing Management
• Educate patient about preterm labor
• Preterm labor prevention
• Importance of fetal lung maturity
• Review Teaching guidelines 21.1 pg.
724
 Cardiovascular Disorders

• Preconception counseling crucial

• Woman with cardiac disease must be
assessed and diagnosed as soon as
possible
• Degree of disability important in
treatment and prognosis
• Heart Conditions Table 20.3 pg.661 &
662
 Cardiovascular Disorders

Heart transplantation
• Increasing numbers of heart
recipients are successfully completing
pregnancies
• Vaginal birth is desired, but transplant
recipients have an increased rate of
cesarean births
 Cardiovascular Disorders

• Functional classification based on past &

present disability & physical signs
• Class I &II can go through a pregnancy
without major complications
• Class III bedrest during pregnancy
• Class IV should avoid pregnancy
• Box 20.1 pg. 663 Mortality risk
 Cardiovascular Disorders

• Decompensating is the hearts inability to

maintain adequate circulation→ impaired
tissue perfusion in the mother & fetus
• Most vulnerable from 28-32 weeks and
48hrs postpartum
• S&S
 Care Management

Minimizing heart Bed rest

stress Treated Infections
Weekly Evaluations promptly
Lab and diagnostic Proper Nutrition
Education signs & Counseling
symptoms Medications
decompensation
 Infections in Pregnancy
Sexually transmitted infections
• Chlamydia
• Human papillomavirus
• Gonorrhea
• Herpes simplex virus type 2
• Syphilis
• Human immunodeficiency virus (HIV)
Review Table 20.4 pg. 677
 Infections in Pregnancy

TORCH infection
• Capable of crossing placenta and
adversely affecting developing fetus
• Produce influenza-like symptoms in
mother
• Exposure during first 12 wks. can
cause fetal anomalies
 TORCH Infections

• Toxoplasmosis
• Other infections
• Rubella virus
• Cytomegalovirus
• Herpes simplex viruses
 Toxoplasmosis

• Transferred by hand to mouth after

having contact with cat feces or
undercooked meat.
• Prevention is the key
• Teaching Guidelines 20.5 pg. 683
 Hepatitis B Virus

• CDC recommends all pregnant

women be tested for hepatitis B
surface antigen regardless of previous
HBV vaccine or screening
• Infants born from positive mothers
need to receive single-antigen HBV
vaccine & hepatitis B immunoglobulin
within 12 hrs. of birth
 Hepatitis B Virus
Nursing assessment
• History focused on behavior that puts
her at risk.
• Prenatal testing
• Can breast feed
• No need for surgical delivery
• Teaching Guidelines 20.4 pg.680
 Group Beta Strep
(GBS)
• Causes neonatal sepsis
• CDC guideline- vaginal and rectal
culture 35-37 weeks gestation
• Mother given antibiotics in labor if
positive, positive with previous
pregnancy, ROM greater than 18 hrs,
Hx of preterm delivery
 Women Who Are HIV Positive
• HIV is a retrovirus that is transmitted by
blood and body fluids
• It is a threat to the mother, fetus, and
newborn
• To date 20 million women are HIV positive
• 2.5 million children and most acquired HIV
via mother to child transmission
 Women Who Are HIV Positive

Nursing management
• History and physical
• Pretest and posttest counseling
• Testing for STI’s
• Education
• Support
 Women Who Are HIV Positive

Therapeutic management
• Oral antiretroviral drugs twice daily 14
weeks until birth
• IV administration during labor
• Oral syrup for newborn in 1st 6 weeks of
life
 Women Who Are HIV Positive

Labor, Birth, and Postpartum

• Elective cesarean birth
• Compliance with antiretroviral therapy
• Family planning methods
 Rubella

• Rubella, German measles, spread by

droplet or direct content with
contaminated object.
• Risk of transmission via the placenta
is greater with early exposure
• Pt. screened at 1st prenatal visit
• Avoid exposure to any with Rubella
 Cytomegalovirus
• Serious fetal injury occurs when mother
develops infection in 1st trimester or
early 2nd trimester
• Transmission sexual contact, blood
transfusions, kissing, and contact with
children in daycare centers.
• No therapy to prevent or treat CMV
infection
• Stress good hygiene
 Herpes Simplex Virus
(HSV)
• HSV-1 and HSV-2 cause oral lesions
(fever blisters) and genital lesions
• Transmission occurs by direct contact
of the skin or mucous membranes with
an active lesion.
• CDC recommends vaginal birth if no
lesions are present. If active lesions
present pt. should have cesarean birth
 Vulnerable Populations

• Adolescents
• Pregnant woman over age 35
• Women who abuse substances
 Pregnant Adolescent

• Adolescence 11-19 yr. old

• Vacillate between being children and young
adults
• Developmental Tasks
• Box 20.3 Factors contributing to pregnancy
 Pregnant Adolescent
Nursing assessment
• Vision of self in future
• Role models
• Emotional support
• Level of education
• Financial/community resource
• Anger/conflict resolution skills
• Knowledge of health and nutrition for
self and child
 Pregnant Adolescent
Nursing management
• Support
• Future planning (return to school; career
or job counseling); options for
pregnancy
• Frequent evaluation of physical and
emotional well-being
• Stress management; self-care
• Teaching Topics Box 20-6 pg. 691
 Woman Over Age 35

Nursing assessment
• Preconception counseling;
• Laboratory and diagnostic testing for
baseline; amniocentesis; quadruple
blood test screen
 Woman Over Age 35

Nursing management
• Promotion of healthy pregnancy
• Education
• Regular prenatal care
• Dietary teaching
• Fetal surveillance
Pregnancy and Substance Abuse

• Women with substance abuse

commonly abuse several substances
• Social attitudes prohibit some women
from seeking help and admitting they
have a problem.
• They will seek prenatal care late in the
pregnancy
Pregnancy and Substance Abuse
Impact on pregnancy
• Preterm labor
• Abortion
• Low birth wt. infant
• CNS and fetal anomalies
• Long term developmental issues
• Effect of common substances
Table 20-6 pg. 694
Pregnancy and Substance Abuse

Nursing assessment
• History and physical
• Screening questions Box 20-5 pg. 698
• Urine toxicology
Pregnancy and Substance Abuse

Nursing management
• Refer for intervention and counseling
• Nonjudgmental approach
• State protection agency notified of positive
newborn drug screen
• Education
 Alcohol Abuse

• Alcohol is a teratogen and is toxic to

human development
• Fetal alcohol spectrum disorder (FSDA)
• Cognitive and behavioral problems
associated with FASD Box 20.4 pg. 695
• Facial characteristics Figure 20.8 pg 695