High-Risk Pregnancy: A Woman With a
Pre-existing or a Newly Acquired Illness
A HIGH-RISK PREGNANCY
− Concurrent disorder, pregnancy-related
complication, or External factor jeopardizes the health
of the mother, the fetus, or both.
− Both the mother & the fetus can be at risk for
Complications because either the pregnancy can
complicate the disease, or the disease can complicate
the pregnancy.
− A thorough history and physical examination must
be obtained at the first prenatal visit to establish a
baseline of information on the condition.
− Documentation of any medication being taken for
a secondary condition is also necessary to protect
against adverse drug interactions and the possibility of
teratogenic action on the fetus.
− Teaching is an important nursing intervention
because a woman with a preexisting illness must make
modifications in her usual therapy to adjust to
pregnancy.
− Pregnancy often stimulates women to learn more
about their primary disease as well.
NURSING CARE FOCUSES ON
 Preventing such disorders from affecting the
health of the fetus.
 Helping a woman regain her health as quickly as
possible.
 Helping a woman learn more about her chronic
illness so she can continue to safeguard her
health during her childrearing years.
NURSING PROCESS:
CARE OF A HIGH-RISK WOMAN
A. Assessment
✓ Understanding of the course of a normal pregnancy.
✓ Signs & symptoms of illnesses
✓ Assessment techniques include:
▪ Baseline V/S
▪ Extent of edema
✓ Level of exhaustion
✓ Woman to assess her own health in relation to
Objective parameters.
B. Nursing diagnosis
✓ Examples of possible Nsg. Dx:
▪ Ineffective tissue perfusion (cardiopulmonary) r/t
poor heart function 2° MVP during pregnancy
▪ Social isolation r/t prescribed bed rest during
pregnancy 2° to concurrent illness
▪ Ineffective role performance r/t increasing level of
daily restrictions 2° to chronic illness and
pregnancy.
▪ Knowledge deficit r/t normal changes of
pregnancy vs illness complications
▪ Fear regarding pregnancy outcome r/t chronic
illness
▪ Health-seeking behaviors r/t the effects of illness
on pregnancy
▪ Situational low esteem r/t illness during
pregnancy
C. Outcome identification and planning
✓ Expected outcomes established are realistic in light
of a woman’s pregnancy and the health restrictions.
✓ Give the woman the available alternatives.
✓ Allow a woman to choose among the alternatives.
D. Implementation
✓ For pregnant woman with chronic illness
▪ Focus on teaching her new or additional
measures to maintain health.
✓ For women who developed a new illness
▪ Provide an opportunity to talk about the event
after her initial care is complete to identify
concerns.
E. Outcome Evaluation
✓ If the expected outcome is not met, reassessment,
analysis & planning need to be done.
✓ Make evaluation ongoing to ensure whether
interventions are successful.
✓ Examples of outcomes:
▪ Client states she rests for 2 hrs morning and
afternoon; dependent edema remains at 1+ or
less at next prenatal visit.
▪ Family members state they are all participating
in an exercise program since mother developed
gestational diabetes.
▪ Client reports no burning on urination or flank
pain at next prenatal visit.
▪ Client states she understands the importance of
taking daily thyroid medicine for total length of
pregnancy.
IDENTIFYING A HIGH-RISK PREGNANCY
The cardiovascular disorders that most commonly
cause difficulty during pregnancy are:
A. Valve damage concerns caused by rheumatic
fever or Kawasaki disease.
B. Congenital anomalies such as atrial septal
defect or uncorrected coarctation of the aorta
(Gordon, Jimenez Fernandez, Daniels, et al.,
2014)
HIGH-RISK PREGNANCY: CARDIOVASCULAR SYSTEM
✓ Cardiovascular disease complicates only 1% of
Pregnancies but accounts for 5% of maternal deaths.
✓ Blood volume and cardiac output increase up to
50%% during pregnancy (peaks at 28 to 32 weeks)
which places stress on a compromised heart.
CARDIAC DISEASE
A. WOMAN WITH L-SIDED HEART FAILURE
✓ Mitral valve stenosis & mitral insufficiency
✓ Mitral valve thickening which becomes rigid, it cannot
be fully opened.
✓ Aortic coarctation
✓ The inability of the MV to push blood forward causes:
▪ Back pressure on the pulmonary circulation
causing it to be distended
▪ Systemic Bp decreases
▪ Pulmonary hypertension – pressure in
pulmonary vein reaches 25 mmHg, fluid begins
to pass from pulmonary capillary membranes
 into the interstitial spaces surrounding the alveoli
and then into the alveoli (pulmonary edema)
▪ Pulmonary edema
▪ Pulmonary capillaries rupture
✓ Because of limited O2 exchange, women with
pulmonary hypertension are at extremely high risk for:
▪ Spontaneous miscarriage
▪ Preterm labor
▪ Maternal death
✓ If complications result in impaired blood flow to the
uterus, the following events can occur:
▪ Poor placental perfusion
▪ IU growth restriction
▪ Fetal mortality
✓ Woman needs serial U/S and non-stress tests done
after wks. 30 – 32.
SIGNS AND SYMPTOMS OF LEFT-SIDED HEART FAILURE
1. Increased RR
2. Increased fatigue, weakness & dizziness
3. Systemic decrease in Bp
MEDICAL MANAGEMENT FOR LEFT-SIDED HEART FAILURE
1. If MV stenosis is present, thrombus formation can
occur from non-circulating blood.
✓ Adm. Anticoagulant
▪ Heparin (does not cross the placenta) for early
pregnancy
▪ Warfarin (Coumadin) can be used after 12 wk. but
returned to heparin during the last month of pregnancy.
✓ Balloon valve angioplasty
2. If coarctation of the aorta is present
✓ Dissection of the aorta
✓ May be prescribed with:
▪ Antihypertensive
▪ Diuretics to reduce blood volume
▪ Beta-blockers to improve ventricular filling
B. RIGHT-SIDED HEART FAILURE
✓ Common causes:
▪ Pulmonary valve stenosis
▪ Atrial & ventricular septal defects
▪ Eisenmenger syndrome
• R to L atrial or ventricular septal defect with
pulmonary stenosis.
✓ Occurs when:
▪ Output of the RV is less than the blood volume
received by the RA from the vena cava.
▪ Back-pressure results in:
• Congestion of the systemic venous circulation
• Decreased cardiac output to the lungs
▪ Bp decreases in the aorta
▪ High pressure in the vena cava
▪ Jugular venous distention
▪ Increased portal circulation
• Liver & spleen become distended
▪ Distention of abdominal vessels can lead to exudate
of fluid from the vessels into the peritoneal cavity
(ascites).
MEDICAL MANAGEMENT FOR RIGHT-SIDED HEART FAILURE
1. Those with uncorrected anomaly of this type
(Eisenmenger syndrome) may be advised not
to get pregnant.
C. A WOMAN WITH PERIPARTUM HEART DISEASE
✓ Peripartal Cardiomyopathy
▪ can originate in pregnancy in women with no
previous history of heart disease (Desplantie,
Tremblay-Gravel, Avram, et al., 2015).
▪ Cause: unknown
▪ may occur because of the stress of the pregnancy
on the circulatory system.
▪ The mortality rate = 50%.
✓ Signs & Symptoms
▪ shortness of breath
▪ chest pain
▪ nondependent edema
▪ Her heart increases in size (i.e., cardiomegaly).
✓ For therapy
▪ she must sharply reduce her physical activity
▪ Diuretic
▪ an arrhythmia agent, and digitalis therapy to
maintain heart function.
▪ Low–molecular-weight heparin may be
administered.
▪ Immunosuppressive therapy (Corticosteroids)
✓ If the cardiomegaly persists past the postpartum
period.
▪ it is generally suggested a woman not to attempt
any further pregnancies because the condition
tends to recur or worsen in additional pregnancies.
▪ oral contraceptives are contraindicated because
of the danger of thromboembolism that these can
create.
CLASSIFCATION OF HEART DISEASE
− To predict a pregnancy outcome, heart disease is
divided into four categories based on criteria
established by the New York Heart Association.
ASSESSMENTS FOR CARDIAC DISEASE
A. Assessment
✓ A thorough health history to document Prepregnancy
cardiac status.
✓ Woman’s level of exercise performance.
✓ Ask if she normally has a cough or edema
✓ Ask if she normally has a cough or edema
▪ Coughing could be a sign of pulmonary edema.
▪ The usual innocent edema of pregnancy must
be distinguished from the beginning of edema
from heart failure (serious).
✓ Baseline vital signs
▪ Irregular pulse, rapid or difficult respirations,
and perhaps chest pain on exertion will probably
also be present.
▪ Record a baseline blood pressure, pulse rate,
and respiratory rate in either a sitting or lying
position at the first prenatal visit, throughout
pregnancy.
▪ At future health visits, always obtain these in
the same position for the most accurate
comparison.
▪ Making comparison assessments for nail bed
filling (should be <5 seconds) and jugular venous
distention can also be helpful throughout
pregnancy.
✓ Liver size
▪ If a woman’s heart disease involves rightsided
heart failure, assess liver size at prenatal visits.
✓ ECG
▪ An electrocardiogram (ECG) or an
echocardiogram may be done at periodic points
in pregnancy.
▪ ECG merely measures cardiac electrical
discharge and so cannot harm her fetus in any
way.
▪ Echocardiography uses ultrasound and,
likewise, will not harm her fetus.
B. Fetal assessment
✓ At the point that maternal blood pressure becomes
insufficient to provide an adequate supply of blood and
nutrients to the placenta, fetal health can be
compromised.
✓ This can result in preterm labor
✓ If the placenta is not filling well, a fetus may not
respond well to labor (evidenced by late
deceleration patterns on a fetal heart monitor).
✓ Cesarean birth may be necessary (an increased
risk for both the mother and fetus).
NURSING DIAGNOSIS
c AND RELATED
INTERVENTIONS
A. Nursing diagnosis
✓ Deficient knowledge regarding steps to take to
reduce the effects of maternal cardiovascular disease
on the pregnancy and fetus.
B. Outcome Evaluation
✓ Patient identifies danger signs such as angina pain
and steps to take when they occur;
✓ Maternal blood pressure is maintained above 100/60
mmHg and fetal heart rate at 110 to 160 beats/min.
✓ Be certain that goals and outcomes established with
a woman with heart disease are realistic.
▪ Not all women with heart disease, for example,
will be able to complete a pregnancy successfully;
▪ However, there are positive actions a woman with
heart disease can take to reduce or eliminate
complications during pregnancy, such as
increasing periods of rest to strengthen heart
action.
C. Related interventions
✓ Promote Rest.
▪ As a rule, women with cardiac disease need two
rest periods a day (fully resting, not getting up
frequently) and a full night’s sleep (not tossing and
turning) to obtain adequate rest.
▪ Women should plan activities so they stop
exercising before the point when cardiac output
becomes insufficient to meet systemic body
demands causing peripheral and
uterine/placental constriction.
▪ Some women, for example, may need to
discontinue employment early in pregnanc rather
than work until the end.
▪ A prescription to allow “normally heavy
housework may mean nothing more strenuous
than dusting to some women.
▪ To others, it may mean washing windows, turning
mattresses, and shoveling snow.
✓ Promote healthy nutrition
▪ She must not gain so much weight that her heart
and circulatory system become overburdened.
▪ Be certain she is remembering to take her
prenatal vitamins.
▪ Prevent Anemia
▪ Sodium-restricted diet may be continued during
pregnancy; but not severely restricted.
✓ Educate Regarding Medication
▪ Women taking cardiac medication, such as
digoxin, before pregnancy may need to increase
their maintenance dose because of their
expanded blood volume during pregnancy.
▪ Digoxin – can be administered to the
woman to slow the fetal heart if fetal
tachycardia is present.
▪ Antihypertensive and arrhythmia
agents such as adenosine, β-blockers,
and calcium channel blockers to reduce
hypertension
▪ Nitroglycerin, a compound often
prescribed for angina (a category C drug),
is also considered safe (Karch, 2015).
▪ A woman who was taking penicillin
prophylactically because she had rheumatic fever
as a child (which is often taken for 10 years after
the occurrence of rheumatic fever, or at least until
age 18 years) should continue to take this drug
during pregnancy because penicillin is not known
to be a teratogenic (a category B drug).
▪ Close to the anticipated day of birth, some
primary care providers prescribe an additional
course of ampicillin, amoxicillin (Amoxil), or
clindamycin (Cleocin) to prevent streptococci
bacteria from invading the denuded placental site
on the uterus.
✓ Educate Regarding Avoidance of Infection.
▪ A systemic infection can increase her cardiac
output as her metabolism increases.
▪ Caution women with heart disease to avoid
visiting or being visited by people with infections
 and to alert healthcare personnel at the first
indication of an upper respiratory tract infection or B. A woman may need a program of decreased activity
urinary tract infection (UTI) C. Anticoagulant and digoxin therapy until her
▪ Antibiotic therapy can begin early in the course circulation stabilizes.
of the infection. D. Antiembolic stockings or intermittent pneumatic
▪ Monthly screening for bacteriuria with a clean- compression (IPC) boots may be prescribed to
catch urine test at prenatal visits should help increase venous return from the legs.
detect UTIs. E. Prophylactic antibiotics should be started
immediately after birth to discourage subacute
NURSING INTERVENTIONS bacterial endocarditis caused by the introduction of
DURING LABOR AND BIRTH microorganisms through the placental site.
F. Stool softener can be prescribed to prevent straining
A. Frequently assess a woman’s blood pressure,
with bowel movements.
pulse, and respirations
G. Oxytocin (Pitocin), should be used with caution
B. Monitor fetal heart rate to assess fetal well-being.
because they tend to increase blood pressure, which
C. Monitor uterine contractions during labor for women
necessitates increased heart action.
with heart disease to be certain their circulatory system
H. Kegel exercises are acceptable for perineal
is not failing and the placenta is filling adequately.
strengthening immediately
D. Advise a woman to assume a side-lying position
I. Postpartum exercises to improve abdominal tone
during labor to reduce the possibility of supine
until her primary care provider approves them.
hypotension syndrome.
J. Assess baby
E. May need oxygen administered during labor
because of the need for extra oxygen due to the ✓ Acrocyanosis is normal in newborns, so the
exertion of labor; woman does not interpret her baby’s peripheral
F. Continuous hemodynamic monitoring such as by a cyanosis as cardiac inadequacy.
Swan-Ganz catheter to monitor heart function may be
prescribed.
G. Many women with heart disease should not push
with contractions, as pushing requires more effort than
they should expend.
✓ That makes epidural anesthesia the anesthetic
of choice for women with heart disease.
H. Because of the lack of pushing, low forceps or a
vacuum extractor may be used for birth.

NURSING INTERVENTIONS
DURING POSTPARTUM

A. Assess for heart failure.

✓ The period immediately after birth is a critical
time for a woman with heart disease.
✓ After birth, the increase in pressure takes place
within 5 minutes, so the heart must make a rapid
and major adjustment (Easterling & Stout, 2012).