Management of Pregnancy at Risk

NURSING
MANAGEMENT
OF PREGNANCY
AT RISK
LEARNING OBJECTIVES
• Identify at least two conditions present before
pregnancy that can have a negative effect on a
pregnancy
• Explain how a condition present before

pregnancy can affect the woman
physiologically and psychologically when she
becomes pregnant.
TOPICS
• Diabetes Mellitus
• Cardiovascular Disorders
- Congenital and Acquired Heart Disease
- Chronic Hypertension
DIABETES MELLITUS
• Chronic disease characterized by a relative
lack of insulin or absence of the hormone,
which is necessary for glucose metabolism.
Diabetes commonly is classified based on
disease etiology (ADA, 2007a)
• Type 1 diabetes: absolute insulin deficiency
(due to an autoimmune process); usually
appears before the age of 30 years;
• Type 2 diabetes: insulin resistance or deficiency

(related to obesity, sedentary lifestyle);
diagnosed primarily in adults older than 30
years of age but is now being seen in children;
• Impaired fasting glucose and impaired
glucose tolerance: characterized by
hyperglycemia at a level lower than what
qualifies as a diagnosis of diabetes (fasting
blood glucose level between 100 and 125
mg/dL; blood glucose level between 140 and
199 mg/dL after a 2-hour glucose tolerance
test, respectively) ; symptoms of diabetes are
absent
• Gestational diabetes mellitus: glucose
intolerance with its onset during pregnancy or
first detected in pregnancy
Diabetes in Pregnancy is categorized into two
(2) :
• Pre Existing Diabetes – Type 1 or Type 2

• Gestational Diabetes
Therapeutic Management
• Integrate the woman into the management of her diabetes
• Achieve the lowest glycosylated hemoglobin A1C test

results without excessive hypoglycemia
glycosylated hemoglobin (HbA1C) level (a measurement of

the average glucose levels over the past 100 to 120 days), is
crucial to achieve the best pregnancy outcome
• less than 7% indicates good control

• more than 8% indicates poor control and warrants
intervention
• Ensure effective contraception until stable
glycemia is achieved
• Identify and evaluate long-term diabetic
complications such as retinopathy,
nephropathy, neuropathy, cardiovascular
disease, and hypertension (ADA, 2007b)
Laboratory and Diagnostic Finding
• Typically, screening is based on a 50-g 1-hour
glucose challenge test, usually performed
between week 24 and 28 of gestation.
• A 50-g oral glucose load is given, without regard

to the timing or content of the last meal. Blood
glucose is measured 1 hour later; a level above
140 mg/dL is abnormal. If the result is abnormal,
a 3-hour glucose tolerance test is done.
• Fasting blood glucose level: less than 105 mg/dL
• At 1 hour: less than 190 mg/dL

• At 2 hours: less than 165 mg/dL
• At 3 hours: less than 145 mg/dL
• A diagnosis of gestational diabetes can be made

only after an abnormal result is obtained on the
glucose tolerance test. Two or more abnormal
values co,nfirm a diagnosis of gestational
diabetes
Maternal Surveillance
• Urine check for protein (may indicate the need
for further evaluation for preeclampsia) and for
nitrates and leukocyte esterase (may indicate a
urinary tract infection)
• Urine check for ketones (may indicate the

need for evaluation of eating habits)
Maternal Surveillance
• Kidney function evaluation every trimester for
creatinine clearance and protein levels
• Eye examination in the first trimester to

evaluate the retina for vascular changes
• HbA1c every 4 to 6 weeks to monitor glucose

trends
Nursing Management
• Promoting Optimal Glucose Control
1. Review the mother’s blood glucose levels,

including any laboratory tests and self-
monitoring results.
2. If the woman is receiving insulin therapy, assist

with any changes needed if glucose levels are
not controlled.
3. Obtain a urine specimen and check for glucose,
protein, and ketones
4. Discuss dietary measures related to blood

glucose control.
- Avoid weight loss and dieting during pregnancy.
- Ensure that food intake is adequate to prevent
ketone formation and promote weight gain.
• Eat three meals a day plus three snacks to
promote glycemic control.
–40% of calories from good-quality
complex carbohydrates
–35% of calories from protein sources
–25% of calories from unsaturated fat
Cardiovascular Disorders
• Congenital and Acquired Heart Disease
- involves structural defects that are present
at birth but may not be discovered at that
- Women with certain congenital conditions

should avoid pregnancy
- Acquired heart disease is typically rheumatic
in origin
Tetralogy of Fallot
Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Mitral Valve Prolapse
• Mitral Valve Stenosis
• Aortic Stenosis
• Peripartum cardiomyopathy
• Myocardial Infarction
Functional Classification System of Heart
Disease
• Class I: asymptomatic with no limitation of
physical activity
• Class II: symptomatic (dyspnea, chest pain)
with increased activity
• Class III: symptomatic (fatigue, palpitations)
with normal activity
• Class IV: symptomatic at rest or with any
physical activity
Nursing Assessment
• Encourage the woman to continue taking her
cardiac medications as prescribed
• Discuss the need to conserve energy
• Encourage the client to eat nutritious foods
and consume a high-fiber diet to prevent
straining and constipation.
• Assist the woman in preparing for diagnostic
tests to evaluate fetal well-being
• Instruct the woman in how to monitor fetal
activity and movements.
• Explain the signs and symptoms of these
complications and review the sign and
symptoms of cardiac decompensation
Cardiac Decompensation
a combination of symptoms and signs that
indicate that the heart by reason of its
abnormal condition no longer is able to
maintain an efficient circulation.
• Chronic Hypertension - exists when the
woman has high blood pressure before
pregnancy or before the 20th week of
gestation, or when hypertension persists
for more than 12 weeks postpartum.
Classification of Blood Pressure
• Normal: systolic less than 120 mmHg, diastolic
less than 80 mmHg
• Prehypertension: systolic 120 to 139 mmHg,
diastolic 80 to 89 mmHg
• Mild hypertension: systolic 140 to 159 mmHg,
diastolic 90 to 99 mmHg
• Severe hypertension: systolic 160 mm Hg or
higher, diastolic 100 mm Hg or higher
• Methyldopa (Aldomet) is commonly
prescribed because of its safety record during
pregnancy.
• This slow-acting antihypertensive agent helps

to improve uterine perfusion.
Nursing Management
• Instruct client to have Dietary Approaches to
Stop Hypertension (DASH) diet, which contains
an adequate intake of potassium, magnesium,
and calcium. Sodium is usually limited to 2.4 g
• Suggest aerobic exercise, although the woman

should cease it once the pregnancy is
confirmed.
Nursing Management
• Encourage smoking cessation and avoidance of
alcohol.
• Assist the woman in scheduling appointments for

antepartum visits every 2 weeks until 28 weeks’
gestation and then weekly.
• Prepare the woman for frequent fetal

assessments.
Nursing Management
• Stress the importance of daily periods of rest
(1 hour) in the left lateral recumbent position
to maximize placental perfusion.
• Encourage women with chronic hypertension

to use home blood pressure monitoring
device.

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NURSING

• Explain how a condition present before

• Type 2 diabetes: insulin resistance or deficiency

• Pre Existing Diabetes – Type 1 or Type 2

• Achieve the lowest glycosylated hemoglobin A1C test

glycosylated hemoglobin (HbA1C) level (a measurement of

• less than 7% indicates good control

• A 50-g oral glucose load is given, without regard

• At 1 hour: less than 190 mg/dL

• A diagnosis of gestational diabetes can be made

• Urine check for ketones (may indicate the

• Eye examination in the first trimester to

• HbA1c every 4 to 6 weeks to monitor glucose

1. Review the mother’s blood glucose levels,

2. If the woman is receiving insulin therapy, assist

4. Discuss dietary measures related to blood

- Women with certain congenital conditions

• This slow-acting antihypertensive agent helps

• Suggest aerobic exercise, although the woman

• Assist the woman in scheduling appointments for

• Prepare the woman for frequent fetal

• Encourage women with chronic hypertension

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