Pregest Risk

8/3/2019 Pregest Risk

http://slidepdf.com/reader/full/pregest-risk 1/65

PRE-GESTATIONAL

CONDITIONS

MRS. CATHERINE V. STA.MONICA



Pregnancy stresses your heart and

circulatory system.

During pregnancy, your blood

volume increases by 30 to 50

percent to nourish your growing

baby.

The amount of blood your heart

pumps each minute also increases

by 30 to 50 percent.Your heart rate increases as well.

These changes cause your heart to

work harder.



Risks depend on the nature and severity of the underlyingheart condition

Heart rhythm issues. Minor abnormalities in heart rhythm

are common during pregnancy. Heart valve issues. If you have an artificial heart valve or

your heart or valves are scarred or malformed, you mightface an increased risk of complications during pregnancy.Mechanical artificial heart valves also pose serious risks

during pregnancy due to the need to adjust use of bloodthinners and the potential for life-threatening clotting(thrombosis) of heart valves.

Congestive heart failure. As blood volume increases,congestive heart failure can get worse.

Congenital heart defect. If you were born with a heartproblem, your baby has a greater risk of developing sometype of heart defect, too. You may also be at risk of premature delivery.



EARLY DETECTION

Blood pressure monitoring

Urinalysis

C

BC

Echocardiogram, a test that

uses sound waves to produce

images of the heart

Electrocardiogram, a test that

records the heart's electrical

activity



Congenital Heart Defects

Most commonly seen in pregnant women include:

Atrial septal defect

Patent ductus arteriosus

Coarctation of aorta

Tetralogy of fallot

impact of pregnancy depends on the specific defect.-if the heart has been surgically repaired & noevidence of heart disease remains, the woman may

undertake pregnancy with confidence.-woman withCHD who experience cyanosis should be counseled toavoid pregnancy because the risk to mother & fetus ishigh.





Rheumatic Heart Disease

Results from an infection (caused by the

bacteria,streptococci) known as rheumatic

fever, which starts with a sore throat & leads

to the scarring of one or more heart valves.

The injured valves are unable to open & close

normally, resulting in obstruction to the

flow of blood.

Is it possible to become pregnant?



Laboratory tests for detecting RHD:

1. Throat cultures- for group A streptococcus usually arenegative by the time symptoms of rheumatic fever or RHDappear. Isolate the organism before the initiationof antibiotic therapy to help confirm a diagnosis of streptococcal pharyngitis & to allow typing of theorganism if it is isolated successfully.

2. Rapid Antigen- this test allows rapid detection of group Astreptococcal antigen & allows the diagnosis of streptococcal pharyngitis & the initiation of antibiotictherapy while the patient is still in the physicians office.



3. Anti-streptococcal Antibodies

-this is useful for confirming previous

group A streptococcal infection. Antibody titer

should be checked @ 2-week intervals in

order to detect a rising titer.



General measures to be followed once you becomepregnant:

Make sure to keep your follow-up appointments withyour obstetrician throughout your pregnancy.

Plan regular follow-up visits with your cardiologist.

Carefully follow all the recommendations of thecardiologist.

The diet should be nutritious & fluid & sodium intakeshould be restricted.

Take adequate rest.

Watch your weight.

Avoid alcohol.

Stop smoking.



PRE-GESTATIONAL DIABETES

MELLITUS



Diabetes Mellitus

An endocrine disorder of

carbohydrate metabolism, results

from inadequate production or

use of insulin.

Insulin- produced by B cells of

Islets of Langerhans in the

pancreas, lowers blood glucoselevels by enabling glucose to

move from the blood into muscle

& adipose tissue cells



METABOLIC CHANGES DURING PREGNANCY

Caloric requirement for a pregnant womanis 300 kcal higher than the non-pregnantwomans basal needs

Placental hormones affect glucose and lipidmetabolism to ensure that fetus has ample

supply of nutrients Lipid metabolism:

± Increased lipolysis (preferential use of fat forfuel, in order to preserve glucose andprotein)

Glucose metabolism: ± Decreased insulin sensitivity

± Increased insulin resistance



Increased insulin resistance Due to hormones secreted by the

placenta that are diabetogenic:

Growth hormone Human placental lactogen

Progesterone

Corticotropin releasing hormonE

Transient maternal hyperglycemia occurs aftermeals because of increased insulin resistance

Baseline hypoglycemia

Proliferation of pancreatic beta cells (insulin-secreting cells) leads to increased insulin secretion

Insulin levels are higher than in pregnant than

nonpregnant women in fasting and postprandial states

Hypoglycemia between meals and at night becauseof continuous fetal draw

Blood glucose levels are 10-20% lower



Ist half of pregnancy: Increased

insulin production and increased

response to insulin

2nd half of pregnancy: Increased

insulin resistance and increased

glucose tolerance; mother may need2-3 times the insulin dosage

Fetus uses glucose from maternal

stores = increased disruption inmaternal carbohydrate metabolism

Increased maternal lipolysis and ketone

production



MANAGEMENT OF PRE-GESTATIONAL

DM

All women screened at 24-28 weeks

Strict glycemic control

Oral agents are not recommended ;

after 1st trimester, glyburide may be

used

Lispro or Humalog insulin titrated to

caloric intake

Delivery at or around week 39; based

on BPP



RISKS TO BABY AND MOTHER

Macrosomia

Hypoglycemia

Polycythemia and hyperbilirubinemia

Congenital anomalies

IUGRRespiratory Distress Syndrome

Hydramnios

Ketoacidosis

Retinopathies

Vaginitis, UTIs



Three main types of Diabetes:

1.Type I diabetes

- results from the bodys failure to produceinsulin, & presently requires the person toinject insulin.

2.Type II diabetes

- results from insulin resistance, acondition in which cells fail to use insulinproperly, sometimes combined witan absolute insulin deficiency.

3.Gestational diabetes- is when pregnant women, who havenever had diabetes before, have a highblood glucose level during pregnancy.



Diabetes on pregnancy outcome

The pregnancy of a woman

who has diabetes carries a

higher risk of complications,

especially perinatal mortality& congenital anomalies.

Tight metabolic control reducesthe risk.



Management Antepartal

Prenatal care- using a team approach to

ensure an optimally healthy mother &newborn.

- woman needs clear explanations &

teaching to gain her cooperation inensuring a good outcome.

- the nurse-educator plays a major role inthis counseling.- the woman with

pregestational diabetes needs tounderstand what changes she can expectduring pregnancy.



a. Dietary regulation

- the pregnant woman with diabetes needsto increase her caloric intake by300 kcal/day.- on the first trimester she needs about 35kcal/day of ideal body weight.Approximately 40% to 50% of the caloriescame from complex, highfiber carbohydrates,20% from protein, &30% to 40% from fats.

- the food is divided into 3 meals & 3 snacks.Bedtime snack is the most important &

should include both protein & complexcarbohydrates to prevent nightimehypoglycemia.



b. Glucose monitoring

- is essential to determine the need for

insulin & to assess glucose control.

c. Insulin Administration- Many women

with gestational diabetes need insulin

to maintain normal glucose levels.Human insulin should be used because

it is the least likely to cause an allergic

reaction.- given either in multipleinjections or by continuous

subcutaneous infusion.

Oral hypoglycemics- not rarely used



Intrapartal

a. Timing of birth- most pregnant women with

diabetes, regardless of the type are allowed to goto term, with spontaneous labor.

Some clinicians opt to induce labor in a woman at

term to avoid problems related to an agingplacenta.

Cesarean birth maybe indicated if signs of fetaldistress exist.



b. Labor management- maternal glucose levels aremeasured hourly to determine insulin need.

Primary goal is to prevent neonatal hypoglycemia.

Often given two IV lines are used, one witH a50%dextrose solution & one with a saline solution.

The saline solution is for piggybacking insulin or if abolus is needed.

IV insulin is discontinued @ the end of the third stageof labor.



Post partal Management

First 24 hours postpartum, women wit pre-existingdiabetes typically require very little insulin.

They are usually managed with a sliding scalespecifying dosage based on blood glucose levels.

Antihyperglycemics are contraindicated duringbreastfeeding.

The woman should be reassessed 6 weeks postpartum

to determine whether her glucose levels are normal. If the levels are normal, she should be reassessed at aminimum of 3 year intervals



Rh INCOMPATIBILITY



Rh incompatibility results from an antigen-

antibody reaction (alloimmunization).

The fetus develops anemia, jaundice, cardiac

failure (hydrops fetalis) and neurological

damage (kernicterus).







Early Diagnosis Pregnancy f or Rh incompatibility

Hx previous blood transfusions

Blood group and Rh status of pregnant woman Rh antibody titer for Rh negative woman at the firstpregnancy visit and repeat at 32-38 weeks of pregnancy

Normal titer is 0Minimal ratio 1:8

Chorionic villus sampling in early pregnancy. Amniocentesis and amniotic fluid

spectrophotometry for biliribin Regular ultrasound from 14-18 weeks onwards look for fetal ascites and subcutaneous edema (hydropsfetalis)



Prevention f or Rh incompatibility

Screening for the blood group of all

pregnant women. Arrange for further investigations if thewoman is Rh negative. Anti D (RhoD or RhoGAM) injection 300µg

IM for the mother at 28 weeks of gestation. Anti D (RhoD or RhoGAM) injection 300µgIM for the mother within 72 hours of anabortion, delivery of Rh positive baby or after

procedures like amniocentesis or chorionicvillus sampling.



ANEMIA



A low level of

hemoglobin (less than

10 gm/dl) duringpregnancy. Hemoglobin

carries oxygen to body

tissues via the red bloodcells

Anemia in pregnancy is

very common and is

present in almost 8o%

of pregnant women.



CAUSES

Poor intake of iron in diet

Folic acid deficiency

Loss of blood from bleeding hemorrhoids orgastrointestinal bleeding.

Even if iron and folic acid intake are sufficient,a pregnant woman may become anemicbecause pregnancy alters the digestiveprocess.

Also the unborn child consumes some of theiron or folic acid normally available to themother's body.



RISK FACTORS

Twin or multiple pregnancy

Poor nutrition, especially multiple vitamin

deficiencies

Smoking, which reduces absorption of

important nutrients

Excess alcohol consumption, leading to poor

nutrition

Any disorder that reduces absorption of

nutrient



DIAGNOSIS

The blood tests determines the red blood cell

count, hemoglobin level ,iron and folic acid

levels in the blood.



SIGNS AND SYMPTOMS

Comm

on Sympt

oms:

Tiredness, weakness or fainting.

Paleness

Breathlessness

Occasional Symptoms:

Headache

Nausea

Inflamed, sore tongue

Palpitations or an abnormal awareness of theheartbeat

Forgetfulness

Jaundice (rare)

Abdominal pain (rare)



MEDICATIONS

Medications:

Iron deficiency anemia is treated with iron tablets, preferably as

ferrous sulphate 300 mg, to be taken no more than twice daily. Thisis because the side effects of iron tablets (stomach upset andconstipation) are increased if more than 2 tablets are taken.

About 20% of pregnant women fail to ingest or absorb adequateamount of iron and may need to be treated with intra-muscular ironinjections. Iron dextran is given every alternate day, in divided

doses, for a total of about 1000 mg. over a period of 3 weeks. Iron, folic acid and other supplements may be prescribed. For

better absorption, take iron supplements 1 hour before eating, orbetween meals. Iron will turn bowel movements black, and oftencauses constipation.

It is advisable that most pregnant women should be given

supplemental iron (ferrous sulphate 300 to 600mg per day). Eventhough the hemoglobin is normal at the beginning of pregnancy.This preventive measure prevents depletion of iron reserves andanemia that may occur in case of bleeding or with futurepregnancy.

Folic acid deficiency anemia is treated with folate tablets.



PREVENTION

Eat foods rich in iron, such as liver, beef,

whole-grain breads and cereals, eggs anddried fruit.

Eat foods high in folic acid, such as wheatgerm, beans, peanut butter, oatmeal,mushrooms, collards, broccoli, beef liver andasparagus.

Eat foods high in vitamin C, such as citrus

fruits and fresh, raw vegetables. Vitamin Cmakes iron absorption more efficient.

Take prenatal vitamin and mineralsupplements, especially folic acid



Activity:

No restrictions, except rest often until anemia

disappears.

Diet:

Eat well and take prescribed supplements

Increase fiber and fluid intake to prevent

constipation



POSSIBLE COMPLICATIONS

Premature labor

Dangerous anemia from normal blood loss

during labor, requiring blood transfusions

Increased susceptibility to infection after

childbirth



SUBSTANCE ABUSE



Substance Abuse

Occurs when a person experiences difficulties

with work, family, social relations, & health as

a result of alcohol or drug use.

Drugs that are commonly misused includes:-

tobacco, alcohol, cocaine, marijuana,

amphetamines,barbiturates, hallucinogens,

club drugs, heroin andnarcotics.



Substances commonly abused during pregnancy

1. Alcohol- is a central nervous system depressant& a potent teratogen.

The incidence of alcohol abuse is highest among

women ages 20 to 40 years although alcoholismis also seen in teenagers.

Chronic abuse of alcohol can undermine maternal

health by causing malnutrition, bone marrowsuppression, increased incidence of infections,& liver disease.



Alcohol dependence-result is that a woman mayhavewithdrawal seizures in the intrapartal period

as early as 12 to 48 hours after se stops drinking.

Delirium tremens may occur in the postpartalperiod& the newborn may suffer a withdrawal

syndrome.

Care includes sedation to decrease irritability&tremors, seizure precautions, IV fluid therapyfor hydration & preparation foran addicted newborn.



The effect of alcohol on the fetus may result in

a group of signs known as fetal alcohol

syndrome (FAS).

2. Cocaine & crack =Nearly 3% of pregnant

women use illicit drugs such as cocaine,marijuana, ecstasy, other amphetamines

&heroin.

Cocaine use during pregnancy tends to affectbetween1% & 5% of newborns



Cocaine- acts as the nerve terminals to prevent

there uptake of dopamine & norepinephrine,

which in turn results in vasoconstriction,tachycardia, & hypertension.T his can be taken by

IV injection or by snorting the powdered form.

Crack- a form of freebase cocaine that is made

up of baking soda, water, and cocaine mixed into

a paste and microwaved to form a rock, can be

smoked. Smoking crack leads to a quicker, moreintense high because the drug is absorbed

through the large surface area of the lungs.



Major adverse maternal effects of cocaine use

includes:

Hallucinations

Pulmonary edema

Cerebral hemorrhage

Respiratory failure

Heart problems



Women who use cocaine have an increasedincidence of spontaneous abortion, abruptio

placentae, pretermbirth, and stillbirth.

Cocaine crosses into breastmilk and maycauses ymptoms in the breastfeeding infant,including extreme irritability, vomiting,diarrhea, dilated pupils, and apnea.

Thus, women who continue to use cocaineafte rchildbirth should avoid breastfeeding.



3. Marijuana - is the most widely used illicit

drugs among women, both pregnant and non

pregnant. More than 25% womenof reproductive age admit to current or past

marijuana use. Marijuana use is associated

with impaired coordination, memory, andcritical thinking ability.

As a result, the pregnant women or new

mother who uses marijuana may be at risk

if she tries to perform tasks that

require complex mental activities.



4. MDMA (Ecstasy)

Methylenedioxymethamphetamine (MDMA),

better known as Ecstasy, is the most

commonly used of a group of drugs referred

to as club drugs, so called because they have

become popular among adolescents andyoung adults who frequent dance clubs and

raves.

Is taken by mouth usually as a tablet. Itproduces euphoria and feelings of empathy

for others.



5.Heroin - is an illicit CNS depressant narcotic that altersperception and produces euphoria. It is anaddictive drug that is generally administered IV.

Pregnancy in women who use heroin is consideredhighrisk because of the increased incidence in thesewomen of poor nutrition, iron deficiency anemia, andpreeclampsia.

The fetus of a heroin-addicted woman is at increasedrisk for IUGR, meconium aspiration, and hypoxia.

The newborn frequently show signs of heroin addictionsuch as restlessness; shrill, high-pitched cry; irritability;fist sucking, vomiting, and seizures.



6.Methadone- is the most commonly usedtherapy for women dependent on opioids such asheroin.

Blocks withdrawal symptoms and reduces oreliminates the craving for narcotics.

Crosses the placenta and has been associatedwith preeclampsia, placental problems, andabnormal fetal presentation.

Prenatal exposure to methadone may result inreduced head circumference and lower birthweight.



Management

A team approach to the care of the pregnantwoman with substance abuse problems ensuresthe management necessary to provide safelabor and birth for the woman and her child.

The management of drug addiction may includehospitalization if necessary to start detoxification.

Urine screening is also done regularly throughoutthe pregnancy if the woman has a known orsuspected substance abuse problem. This testinghelps to identify the type and amount of drugbeing abused.



Little is yet known about the effects of MDMA

on pregnancy. However, the timing of ecstasy

used by the pregnant woman during fetalbrain development may be critical issue.

Infants exposed to ecstasy in uteromay experience some of the same risks as

infants exposed to other amphetamines

during pregnancy, including the possibility of withdrawal like symptoms such as drowsiness,

jitteriness, and breathing problems.



IV. HIV/AIDS

Human immunodeficiency virus infection is

one of todays major health concerns.

It leads to a progressive disease that

ultimately results in acquiredimmunodeficiency syndrome (AIDS). Women

account for about 18% of cases in the U.S.



Pathophysiology

HIV-1 enters the body through:Blood Blood Products Or other body fluids suchas semen, vaginal fluid and breastmilk

It affects T-cells, thereby decreasing the bodyssimmune responses.

This makes the affected person susceptible toopportunistic infections such as Pneumocystiscarinii



Once infected with the virus, the individualdevelops antibodies that can be detected withthe enzyme-linked immunosorbent assay

(ELISA) & confirmed with the Western Blot test.

Can be detected within 6 mos after exposure.

Asymptomatic lasting from a few mos to as longas 17years.

Diagnosis of AIDS is made when a person isHIV positive & has one of several specificopportunistic infections.



Maternal Risks

Many women who are HIV positive choose to avoid pregnancybecause of the risk of infecting the fetus &the possibility of dying beforethe child is raised.

Women who become pregnant should be advised that pregnancy isnot believed to accelerate the progression of HIV/AIDS, that the use of antiretroviral (ARV)therapy during pregnancy significantly reduces the riskof transmitting the HIV-1 to the fetus, and that most medications usedtreat HIV can be taken during the pregnancy.

Fetal-Neonatal Risks

HIV/AIDS may develop in infants whose mothers are seropositive,usually due to perinatal transmission. Perinatal transmissionoccurs transplacentally, at birth when the infant is exposed to maternalblood and vaginal secretions, via breastmilk.

anagemen



g

Combination of ARV therapy suppresses viralreplication, helps preserve immune function,

and reduces the development of resistance.

Usually consists of two nucleoside analogues

reverse transcriptase inhibitors and a proteaseinhibitor

Zidovudine (ZDV) is perhaps the best known of

the nucleoside analogues



Pregnant women who are currently on ARVtherapy should continue their provider-

recommended regimen and should receiveregular, careful monitoring for pregnancycomplications and possible toxicities.

Because the fetus is most susceptible toteratogenic effects during the first 10 weeks of pregnancy, and the risks of ARV therapy is not

well known, women in 1

st

trimester mightelect to delay therapy until after 12weeksgestation.



To reduce the risk of perinatal transmission, all

pregnant women with HIV infection should be

offered the three-part ZDV prophylaxisregimen beginning after the first trimester.

This regimen includes:1.Oral ZDV daily

2.Intravenous ZDV during labor until birth

3.Oral ZDV for the infant starting 8 to 12 hoursafterbirth and continuing for 6 weeks.



At each prenatal visit, asymptomatic, HIV infectedwomen are monitored for early signs of

complications, such as weight loss in the secondor third trimester or fever.

Each trimester the woman should have a visual

examination and examination of the retina todetect such complications as toxoplasmosis.

In addition to routine prenatal testing, the

woman who is HIV positive should be assessedregularly for serologic changes indicating thatHIV/Aids is progressing



A pregnancy complicated by HIV infection,even if asymptomatic, is considered high risk,

and the fetus is monitored closely. Women who are HIV positive are at increased

risk for complications such as intrapartal orpostpartal hemorrhage, postpartal infection,

poor wound healing and infections of thegenitourinary tract.

Thus, they need careful monitoring andappropriate therapy as indicated.

HIV positive woman should be cautionedagainstbreast feeding her infant



Documents

Pregest Risk