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Question #
- A pregnant woman with an asthma exacerbation tells the nurse she stopped taking her medication because she didn’t want it to affect her baby. What is the best response by the nurse? o A. “You are right to stop taking any medications while you are pregnant.” o B. “You should still take your asthma medication while you are pregnant to help control your asthma.” o C. “You should only take your asthma medications when you have an exacerbation.” o D. “You probably won’t need your medication because asthma always improves with pregnancy.” - B- Asthma treatment goals during pregnancy are to optimize control and limit exacerbations. Asthma improves during pregnancy in some woman and gets worse with others. The patient should continue taking medications as ordered during her pregnancy, regardless if she experiences an exacerbation. Epilepsy - About 1% to 2% of people have epilepsy - Children of mothers with epilepsy are at increased risk for developing a seizure disorder. - While most pregnancies are uneventful, complications due to epilepsy include preeclampsia, preterm labor, and fetal death. - Increased risk of congenital anomalies in women who take antiseizure medications during their pregnancy. - Nurses should teach patients to take antiseizure medications despite risks to fetus and to avoid individual seizure triggers. - Women on antiseizure medications should 4 mg folic acid daily, beginning 3
months before conception.
- Infants of mothers who take antiseizure medications are at increased risk for bleeding.
- First trimester assessments: o Hemoglobin A1c o Women with diabetes will have an evaluation of baseline kindey function with a 24-hour urine collection o She may also have a screening of her thyroid, heart, and eyes during the first trimester - Second and third trimester assessments: o Vasculopathy may be evidenced by fetal growth restriction o Antepartum testing for fetal well-being usually begins between 32- and 34- weeks’ gestation and may include: ▪ Nonstress test ▪ Biophysical profiles ▪ Contraction stress tests
- Delivery considerations o Vaginal delivery is not contraindicated, although some providers recommend a cesarean section for fetal macrosomia diagnosed by ultrasound o Labor often induced between 39 and 40 weeks. - Care Considerations o Diet, exercise, and medications are important care components that should be closely monitored. Question # - Which of the following recommendations should the nurse make to the patient with diabetes who is interested in becoming pregnant? o A. “Achieving excellent glycemic control now will help ensure positive pregnancy outcomes.” o B. “Because of your diabetes, you will not be able to deliver vaginally.” o C. “Pregnancy risks for diabetic mothers are caused by macrocosmic infants.” o D. “You will need to make sure to have good control of your blood sugars as soon as you find out you are pregnant.” - A- Excellent glycemic control before pregnancy improves maternal and fetal outcomes. A woman may need a cesarean birth, but vaginal deliveries are not contraindicated due to diabetes alone. Pregnancy risks for diabetic mothers include spontaneous abortion, fetal anomalies, and stillbirth in addition to risks caused by macrosomia. Multiple Sclerosis - MS is a chronic immune-modulated demyelinating disease of the central nervous system that often includes relapses and remissions. - Pregnancy is often a time of disease remission, while postpartum is a significant time for relapse. - In pregnancy, MS may slightly increase the risk for a cesarean birth and a decrease in neonatal birth weight. - Some medications for MS are teratogenic and contraindicated. Others have limited information available.
- Medical management of cardiac disease in pregnancy depends on the disease type, severity, and complications and often involves collaborations between several disciplines, including obstetrics, cardiology, and neonatology. - Signs and symptoms of cardiac decompensation include: o Signs ▪ Generalized edema that is progressive ▪ Frequent moist cough ▪ Cyanosis ▪ Tachypnea (25 or more respirations per min) ▪ Crackles in the lungs that do not clear with coughing ▪ Rapid, weak, irregular pulse ( 100 bpm or higher) o Symptoms ▪ Feeling of being smothered ▪ Palpitations ▪ Generalized edema ▪ Increased fatigue ▪ Difficulty catching breath ▪ Cough Chronic Hypertension - Maternal hypertension is associated with higher rate of poor pregnancy outcomes including intrauterine growth restriction, stillbirth, preeclampsia, and stroke. - Defined as blood pressure greater than 140/90 mm Hg that predates the pregnancy or appears before the 20 th^ week of pregnancy. - Mild to moderate hypertension is a systolic blood pressure between 140- and 159-mm Hg and/or a diastolic between 90- and 109-mm Hg. - Severe hypertension is a systolic blood pressure greater than 160 mm Hg and diastolic blood pressure greater than 110 mm Hg. - NSAIDS such as ibuprofen should be used cautiously for these patients postpartum as they are associated with increase blood pressure readings. - There is no clear benefit to treating women with mild to moderate hypertension during
pregnancy.
- Women with severe hypertension should be treated - The goal for women with severe hypertension is to maintain a systolic blood pressure of 140 to 150 mm Hg and a diastolic of 90 to 100 mm Hg (may. Be lower if she has evidence of organ damage) - Preferred antihypertensives in pregnancy include labetalol, methyldopa, and nifedipine - Women with chronic hypertension should be carefully monitored for preeclampsia and HELLP syndrome. Obesity - Approximately 35% of women between the ages of 20 and 39 are classified as obese. - Fat has endocrine function and can have a detrimental effect on inflammatory pathways, vasculature, and metabolism.
o History of eating disorder o Abnormally low BMI o Lack of weight gain over two prenatal visits o Electrolyte abnormalities o Problems with tooth enamel from vomiting (bulimia nervosa only) o Hyperemesis gravidarum Iron Deficiency anemia
- About 16-29% of women will become anemic during pregnancy - Severe anemia is associated with nonreasoning fetal heart rate, prematurity, fetal loss, and maternal death - Physiologic anemia Is an expected finding during pregnancy. A normal hemoglobin level below 10.5 g/dL is considered diagnostic in pregnancy
- Supplementing with iron improves maternal hemoglobin and hematocrit levels - Supplemental iron can cause pruritus, rash, and gastrointestinal symptoms. - Nurses should inform patients that iron is best absorbed if taken on an empty stomach but this may lead to gastrointestinal distress. Intimate Partner Violence - An estimated 7% to 20% of pregnancies are complicated by physical abuse. - Many women experience psychologic and sexual abuse during pregnancy, which often goes underreported. - Approximately 5% of women report their partners tried to get them pregnant when they did not want to be. - Women should be screened for IPV during prenatal visits, hospitalizations, and during postpartum appointments. - Asking about IPV can be intimidating; using a standardized screening tool can help with questioning. - Nurses should question patients about IPV when they are alone with the patient. Substance Abuse - About 15.4% of pregnant women smoke, 9.4% drink alcohol, and 5.4% use illegal drugs. - Women with substance abuse may not seek prenatal care because they feel ashamed or they are worried about the involvement of social services. - Complications from substance abuse include: o Infants exposed to opioids and opioid replacement drugs are at a high risk for neonatal abstinence syndrome. o Alcohol is a teratogen that can cause fetal alcohol syndrome. There is no known safe amount of alcohol that can be consumed in pregnancy. o Smoking can cause preterm birth, intrauterine growth restriction, and stillbirth. - All women should be screened for substance abuse during pregnancy - Counseling about the negative impact of substance abuse in pregnancy followed by a referral for treatment should be included in care - Stopping consumption of alcohol or drugs at any point during pregnancy can improve outcomes
Depression
- Major depression is not treated in pregnancy in up to half of women diagnosed because of cost, stigma, fear of harming the fetus, and a lack of clinical expertise in providers. - Untreated depression can lead to substance abuse, poor adherence to care, less prenatal care, and suicide risk. - Usually treated with selective serotonin reuptake inhibitors (SSRIs). - SRIs do not have any known teratogenic effects but may lead to lower Apgar scores. - Antidepressants are not contraindicated in breastfeeding. - Stigma is common to all mental illness, and a woman may feel shame and an unwillingness to discuss the problem. Anxiety - Generalized anxiety disorder (GAD) affects as many as 12% of people in the United States.
- People with GAD report fatigue, tension, irritability, and a pervasive sense of apprehension. - GAD can be assessed with a seven-item scale (GAD-7). - Treatment includes antidepressants (particularly SSRIs), counseling, and, occasionally, benzodiazepines. o Benzodiazepines may cause withdrawal in the neonate and a higher risk of fetal loss and preterm birth. - Nurses can empower patients with realistic education about therapies and self-care measures such as mindfulness, exercise, and good nutrition. Question #3- t or f - Often preconception care involves assessing and treating preexisting conditions and can have a positive impact on pregnancy outcomes. - True- evaluating the extent of preexisting conditions and controlling them as much as possible can improve the likelihood of conceiving, the health of the mother, and neonatal outcomes. (For example, diabetic women have better health outcomes when blood sugar is well controlled prior to pregnancy.) Chapter 20- conditions occurring during pregnancy Review- Fetal Surveillance - Non-stress test (NST) and contraction stress test (CST) o Presence of contractions determines the test type ▪ NST - Monitor FHR for 20 minutes - Results: reactive or nonreactive o Reactive= normal FHR, 2 accelerations in 20 minutes o Non-reactive= absence of 2 accelerations in 20 minutes ▪ CST
- Monitor FHR reaction to contractions (at least 3 in 10 min)
Conditions: First Trimester
- Multiple Pregnancy- multizygotic o Approximately 3% of births are twins o Multizygotic: 2 or more eggs are fertilized at the same time ▪ EX: 2 eggs fertilized= dizygotic or fraternal twin - 70% of multiple pregnancies ▪ Risk factors of multizygotic pregnancy - Artificial reproductive technology (ART) - Ethnicity (particularly African descent) - Family history - Advanced maternal age (Increase FSH can cause release of > egg as menopause approaches) ▪ Each fetus has a separate amnion and chorion ( Placentas may grow together) o Amnion and Chorion: ▪ Amnion : thin, tough sac of membrane that covers the embryo – protective, filled with amniotic fluid – inner membrane ▪ Chorion : outer membrane that surrounds the amnion – - support platform for fetus and amnion - provides nutrient exchange from mother to fetus + foundation for embryonic development - chorionic villi – barrier between maternal & fetal blood o Monozygotic ▪ All fetuses came from the same ovum – identical twins/triplets/etc. ▪ Time of ovum split determines # of amnions, chorions, placentas ▪ Random / spontaneous event ▪ Not associated with a genetically inherited trait or ethnic group ▪ ~3/1,000 twin pregnancies o Typical discomforts of pregnancy amplified in multiple pregnancy o Maternal/fetal risks in multiple pregnancy include:
▪ gestational diabetes ▪ hypertensive d/o, including preeclampsia ▪ pulmonary embolism ▪ preterm birth (50%) ▪ perinatal mortality (3x more for twins, 4x more for triplets) ▪ placenta previa ▪ fetal anomalies ▪ cord entanglement ▪ twin-to-twin transfusion syndrome (50% higher mortality rate) o Assessment o Interventions
- Hyperemesis Gravidarum
o Up to 20% of women report vaginal bleeding in early pregnancy ▪ Implantation bleeding – usually around 6-11 days after fertilization, bright red or dark brown, lasting ~1 day ▪ Other women: spotting due to infection, sex, increased blood flow to cervix – usually brief & painless o For some, vaginal bleeding may indicate a miscarriage, ectopic pregnancy, or gestational trophoblastic disease o A miscarriage (AKA spontaneous abortion) occurs before 20 weeks’ gestation o All bleeding should be carefully evaluated!! o Miscarriage ▪ Usually occurs ~5-8 weeks gestation ▪ Likely due to chromosomal abnormalities
▪ Risk factors:
- Advanced parental age
- Drug/alcohol use
- Poor maternal nutrition
- Use of teratogenic meds - Certain maternal health conditions (e.g. diabetes, lupus, uterine abnormalities) ▪ Nursing Assessment ▪ Interventions ▪ o Client Education ▪ Report all episodes of ▪ Heavy bleeding ▪ Fever ▪ Foul-smelling discharge ▪ Abdominal tenderness o Referral for counseling &/or support resources - Ectopic Pregnancy o A pregnancy that occurs outside the uterus, often occurs in the fallopian tube. o Ectopic pregnancies are considered life-threatening and must be ended urgently. o Signs of an ectopic pregnancy: ▪ Severe pelvic pain that may be unilateral (may refer to one shoulder)
