Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015

Management of Pregnancy at Risk Chapter 19 & 20

Mary L. Dunlap MSN, APRNFall 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

http://www.youtube.com/watch?v=Fh2i9ODS17Y

Causes of Bleeding

• Spontaneous abortion

• Ectopic pregnancy

• GTD/Hydatiform mole

• Cervical insufficiency

• Placenta Previa• Abruptio

placenta

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• STD’s• Endometriosis• Tubal or pelvic

surgery

• Uterine fibroids• IUD• Progesterone

only BC pills (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

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.)

GTD

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

Possible causes• Trauma to the cervix• Structure of cervix- less collagen and

more smooth muscle



Management• Bed rest• Pelvic rest• Avoid heavy lifting• Cervical cerclage placed 2nd trimester

if no infection present fig 19.3 pg.615


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


• 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


Diagnostic Test• Liver enzymes • CBC• Urine• BUN • Urine specific gravity• Electrolytes • US


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

Gestational Hypertension

PreeclampsiaEclampsia

Help Syndrome

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.


• 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


• 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


• 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

Vasospasms

Increased Thromboxane

Fluid shift intravascular to

intracellular

Endothelial cell damage

Intravascular

coagulation

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

Visual Changes

Epigastric Pain

CNS

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


• 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 clotting

Platelets

Takes 3-5 min. II Thromboplastin generated

PTT

Takes 8-16 min. III Prothrombin converted to

Thrombin

PT

Almost instantly IV Fibrinogen converted to fibrin

Fibrin Levels

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 risksTable 20-2 pg. 651

Pregestational Diabetes Mellitusand 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 Prenatal visit

High RiskPatient

FastingHbA1C

Random

60-90 mg/dL<7%

200 mg/dL

24-28 weeks GDM Fasting1hr GTT

3hr GTT

92mg/dL140mg/dL

1hr <180mg/dL2hr <153mg/dL3hr < 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)


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


• 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


Assessment• Determine if ruptured- Positive Nitrazine

and fern pattern• Transvaginal ultrasound• Vaginal & Cervical culture • Review Box 19.3 pg. 642

Key assessment with PROM


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


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


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


• 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


• 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 stress

Weekly Evaluations

Lab and diagnostic

Education signs & symptoms decompensation

Bed rest

Treated Infections promptly

Proper Nutrition

Counseling

Medications

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


Nursing management• History and physical• Pretest and posttest counseling• Testing for STI’s• Education • Support


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


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


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


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


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

Documents

Management of Pregnancy at Risk Chapter 19 & 20 Mary L. Dunlap MSN, APRN Fall 2015