OB - Nursing Mang.

of the Pregnancy at
Risk Ch. 20
Multiple Gestation
• Therapeutic management: serial ultrasounds, close monitoring during labor, operative
delivery (common)
• Nursing assessment: uterus larger than expected for EDB; ultrasound confirmation
• Nursing management: education and support antepartally; labor management with
perinatal team on standby; postpartum assessment for possible hemorrhage

Conditions Causing At-Risk Pregnancies

• Diabetes
• Cardiac and respiratory disorders
• Anemia
• Autoimmune disorders
• Specific infections

Vulnerable Populations
• Adolescents
• Pregnant women over age 35
• Obese pregnant women
• Women who are positive for the human immunodeficiency virus (HIV)
• Women who abuse substances

Diabetes Mellitus
Classifications
• Diabetes mellitus is a chronic disease characterized by a relative lack of insulin or
absence of the hormone that is necessary for glucose metabolism.

Typical classification

• Type 1 diabetes: absolute insulin deficiency (due to an autoimmune process); usually appears

before the age of 30 years; approximately 5% of those diagnosed have type 1 diabetes.
• Type 2 diabetes: insulin resistance or deficiency (related to obesity, sedentary lifestyle);
diagnosed primarily in adults older than 30 years of age but now being seen in children; the most
common type of diabetes. It is more common in African Americans, Latinos, Native Americans,
and Asian Americans/Pacific Islanders, as well as older adults.
• 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; newborns are at
risk for being large for gestational age (LGA).
• Gestational diabetes mellitus: glucose intolerance with its onset during pregnancy usually
around the 24th week or first detected in pregnancy. The prevalence of gestational diabetes has
been increasing in the United States and is as high as up to 10% in the United States.

Classification during pregnancy

• Pregestational diabetes: (alteration in carbohydrate metabolism identified before

conception), which includes women with type 1 or type 2 disease and gestational diabetes,
which develops during pregnancy.
• Gestational:  is associated with either neonatal complications such as macrosomia,
hypoglycemia, and birth trauma or maternal complications such as preeclampsia and
cesarean birth. 

Diabetes Mellitus: Pathophysiology and Pregnancy

• Fetal demands
– Pregnancy is accompanied by insulin resistance, mediated by placental secretion of
diabetogenic hormones.
– These and other metabolic changes that occur during pregnancy ensure that the fetus
has an ample supply of nutrients.
• Role of placental hormones
– Maternal metabolism is directed toward supplying adequate nutrition for the fetus.
– In pregnancy, placental hormones cause insulin resistance at a level that tends to
parallel the growth of the fetoplacental unit.
– As the placenta grows, more placental hormones are secreted.
– Human placental lactogen (hPL) and growth hormone (somatotropin) increase in
direct correlation with the growth of placental tissue, rising throughout the last 20
weeks of pregnancy and causing insulin resistance.
 – Subsequently, insulin secretion increases to overcome the resistance of these two
hormones.
– In the pregnant woman without diabetes, the pancreas can respond to the demands
for increased insulin production to maintain normal glucose levels throughout the
pregnancy.
– However, the woman with glucose intolerance or diabetes during pregnancy cannot
cope with changes in metabolism resulting from insufficient insulin to meet the
needs during gestation.
• Changes in insulin resistance
– Over the course of pregnancy, insulin resistance does change.
– It peaks in the last trimester to provide more nutrients to the fetus.
– The insulin resistance typically results in postprandial hyperglycemia, although some
women also have an elevated fasting blood glucose level.
– With this increased demand on the pancreas in late pregnancy, women with diabetes
or glucose intolerance cannot accommodate the increased insulin demand; glucose
levels rise as a result of insulin deficiency, leading to hyperglycemia.
– Subsequently, the mother and her fetus can experience major problems.
Effects on mother & Effects on fetus:

Diabetes Mellitus: Therapeutic Management

• Preconception counseling
 – Most common malformations associated with diabetes occur in the renal, cardiac,
skeletal, and central nervous systems. Since these defects occur by the eighth week of
gestation, preconception counseling is critical. The rate of congenital anomalies in
women with pregestational diabetes can be reduced if excellent glycemic control is
achieved at the time of conception.
• Blood glucose level control (HbA1C <7%)
– Excellent control of blood glucose, as evidenced by normal fasting blood glucose
levels and glycosylated hemoglobin (HbA1C) levels (a measurement of the
average glucose levels during the past 100 to 120 days), is crucial to achieve the best
pregnancy outcome. A glycosylated hemoglobin level of less than 7% indicates good
control; a value of more than 8% indicates poor control and warrants intervention. A
pregestational diabetic pregnant woman has up to a nine-fold increase in birth
defects, compared with the rate seen in nondiabetic pregnancies, if she does not have
glycemic control 
• Glycemic control:
– maintaining a fasting blood glucose level below 92 mg/dL, with 1-hour postprandial
levels below 180 mg/dL and 2-hour postprandial levels below 153 mg/dL. In
comparison, for pregnant women without diabetes, near-normal glucose values
include a fasting value of 60 to 90 mg/dL, a 1-hour postprandial value of 100 to 120
mg/dL, and a 2-hour postprandial value of 60 to 120 mg/dL. Such tight control has
been advocated because it is associated with a reduction in macrosomia. In addition,
maternal prepregnancy weight and weight gain during pregnancy appear to be
significant and independent risk factors for macrosomia in women with gestational
diabetes
• Nutritional management:
– Focuses on maintaining balanced glucose levels and providing enough energy and
nutrients for the pregnant woman, while avoiding ketosis, and minimizing the risk
of hypoglycemia in women treated with insulin. Nutrition therapy is the
cornerstone of therapy for women with gestational diabetes. Women should
receive ethically appropriate nutritional advice on how to change their dietary
habits from a dietitian. The diet counseling must be in keeping with their present
cultural dietary patterns and not radically different to become adopted and
followed. 
• Hypoglycemic agents:
– Glyburide (primary therapy for gestational diabetes) and metformin (Glucophage)
 safe, effective, and economical for the treatment of gestational diabetes.
Alternative to insulin therapy because they do not cross the placenta and therefore do
not cause fetal/neonatal hypoglycemia
– Insulin, however, still has an important role to play in gestational diabetes
• Close maternal and fetal surveillance: Frequent laboratory tests are done during pregnancy
• Management during labor and birth
– For the laboring woman with diabetes, intravenous saline or lactated Ringer’s is
given and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are
maintained below 110 mg/dL throughout labor to reduce the likelihood of neonatal
hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain
this level. If the woman was receiving insulin during her pregnancy, adjustments in
dosage may be necessary after birth since glucose diversion across the placenta to
supply the growing fetus is no longer present and insulin resistance is now removed.
– After giving birth, the overt glycemic abnormalities of gestational diabetes usually
resolve. 
Diabetes Mellitus: Assessment
• Health history; physical examination (classical triad of the symptoms of polydipsia,
polyphagia, and polyuria).
• Risk factors
– Previous infant with congenital anomaly (skeletal, renal, central nervous system,
cardiac)
– History of gestational diabetes or polyhydramnios in a previous pregnancy
– Family history of diabetes
– Medications: corticosteroids or antipsychotics
– Age 35 years or older
– Polycystic ovarian syndrome
– Multiple pregnancy (twins, triplets)
– Previous infant weighing more than 9 lb (4,000 g)
– Previous unexplained fetal demise or neonatal death
– Maternal obesity (body mass index [BMI] >30)
– Hypertension before pregnancy or in early pregnancy
– Hispanic, Native American, Pacific Islander, or African American ethnicity
– Recurrent monilia infections that do not respond to treatment
– Signs and symptoms of glucose intolerance (polyuria, polyphagia, polydipsia, fatigue)
– Presence of glycosuria or proteinuria 
• Screening at first prenatal visit; additional screening at 24 to 28 weeks for women
considered at risk
• Maternal surveillance: urine for protein, ketones, nitrates, and leukocyte esterase;
evaluation of renal function/trimester; eye exam in first trimester; HbA1c q4–6 weeks
• Fetal surveillance: ultrasound (provide information about fetal growth, activity, and
amniotic fluid volume and to validate gestational age); alpha-fetoprotein levels (detect
congenital anomalies); biophysical profile and nonstress testing (monitor fetal well-being);
amniocentesis (evaluate whether the fetal lung is mature enough for birth).

Diabetes Mellitus: Nursing Management

• Optimal glucose control
– Blood glucose levels; medication therapy
– Nutritional therapy
• Measures during labor and birth; postpartum
• Prevention of complications
• Client education and counseling

CONGENITAL & ACQUIRED HEART CONDITIONS

• Congenital Heart Conditions Affecting Pregnancy: Tetralogy of Fallot, Atrial septal
defect (ASD), Ventricular septal defect (VSD), Patent ductus arteriosus
• Acquired Heart Conditions Affecting Pregnancy: Mitral valve prolapse, Mitral valve
stenosis, Aortic stenosis, Peripartum cardiomyopathy, Myocardial infarction
Functional Classification System
 Class I: asymptomatic with no limitation of physical activity; no objective evidence of cardiac
disease. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or
chest pain.
 Class II: symptomatic (dyspnea, chest pain) with increased activity resulting in slight
limitation of physical activity. They are comfortable at rest. Ordinary physical activity results
in fatigue, palpitation, dyspnea, or anginal pain. Minimal CVD present.
 Class III: symptomatic (fatigue, palpitations) with normal activity resulting in marked
limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes
fatigue, palpitation, dyspnea, or anginal pain. Moderately severe CVD present.
 Class IV: symptomatic at rest or with any physical activity resulting in inability to carry on
any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome
may be present even at rest. If any physical activity is undertaken, discomfort is increased.
Severe CVD present.

Congenital and Acquired Heart Disease

• Pathophysiology
– Hemodynamic changes overstressing woman’s cardiovascular system. Increased
cardiac workload and greater myocardial oxygen demand during pregnancy place
the woman’s cardiovascular system at high risk for morbidity and mortality.
• Therapeutic management
– Risk assessment (consider the woman’s functional capacity, exercise tolerance,
degree of cyanosis, medication needs, and history of arrhythmias), prenatal
counseling  focuses on the impact of the hemodynamic changes of pregnancy,
the signs and symptoms of cardiac compromise, and dietary and lifestyle changes
needed. More frequent prenatal visits (every 2 weeks until the last month and then
 weekly) are usually needed to ensure the health and safety of the mother and
fetus.
• Nursing assessment
– Vital signs, heart sounds, weight, fetal activity, lifestyle
– Signs and symptoms of cardiac decompensation (the heart’s inability to maintain
adequate circulation).
– Shortness of breath on exertion, dyspnea
– Cyanosis of lips and nail beds
– Swelling of face, hands, and feet
– Jugular vein engorgement
– Rapid respirations
– Abnormal heartbeats, reports of heart racing or palpitations
– Chest pain with effort or emotion
– Syncope with exertion
– Increasing fatigue
– Moist, frequent cough

Congenital and Acquired Cardiac Disease: Nursing Management

• Stabilization of hemodynamic status
• Risk reduction measures: education, counseling, support
• Cardiac medications if prescribed
• Energy conservation; nutrition
• Fetal activity monitoring
• Signs and symptoms of cardiac decompensation
• Monitoring during labor

Chronic Hypertension
• Hypertension before pregnancy or before 20th week of gestation or persistence >12
weeks postpartum. most common complication is preeclampsia.
• Therapeutic management: preconception counseling, lifestyle changes, antihypertensive
agents for severe hypertension; fetal movement monitoring; serial ultrasounds
• Nursing management: lifestyle changes (DASH diet); frequent antepartal visits;
monitoring for abruptio placentae, preeclampsia; daily rest periods; home BP monitoring;
close monitoring during labor and birth and postpartum follow-up
– Normal: systolic less than 120 mm Hg, diastolic less than 80 mm Hg
– Prehypertension: systolic 120 to 139 mm Hg, diastolic 80 to 89 mm Hg
– Mild hypertension: systolic 140 to 159 mm Hg, diastolic 90 to 99 mm Hg
– Severe hypertension: systolic 160 mm Hg or higher, diastolic 100 mm Hg or higher

Asthma
• Asthma is an allergic-type inflammatory response of the respiratory tract to various stimuli
such as allergens (pollen and animal dander), irritants (cigarette smoke and chemicals),
stress, infections (colds or flu), and physical exertion. It is also known as reactive airway
disease because the bronchioles constrict in response to these stimuli. 
• Pathophysiology
– Effect of normal physiologic changes of pregnancy on respiratory system:
Although the respiratory rate does not change, hyperventilation increases at term
 by 48% due to high progesterone levels. Diaphragmatic elevation and a decrease
in functional lung residual capacity occur late in pregnancy, which may reduce
the woman’s ability to inspire deeply to take in more oxygen. Oxygen
consumption and the metabolic rate both increase, placing additional stress on the
woman’s respiratory system.
• Therapeutic management
– Drug therapy (budesonide, albuterol, salmeterol)
• Nursing assessment
– Asthma triggers: Smoke and chemical irritants, Air pollution, Dust mites, Animal
dander, Seasonal changes with pollen, molds, and spores, Upper respiratory
infections, Esophageal reflux, Medications, such as aspirin and nonsteroidal anti-
inflammatory drugs (NSAIDs), Exercise, Cold air, Emotional stress
– lung auscultation
• Nursing management
– Client education
– Oxygen saturation monitoring during labor
• Successful asthma management can reduce adverse perinatal outcomes: preeclampsia, preterm birth,
and low birth weight.

Tuberculosis
• TB  known as the great masquerader, and manifestation of the disease can be vague and
widespread. It is a disease that has been around for years but never seems to go away
completely. TB is curable and preventable. 
• A person becomes infected by inhaling the infectious organism Mycobacterium tuberculosis,
which is carried on droplet nuclei and spread by airborne transmission. The lung is the major
site of involvement, but the lymph glands, meninges, bones, joints, and kidneys can become
infected. Women can remain asymptomatic for long periods of time as the organism lies
dormant. Pregnant women with untreated TB are more likely to have an underweight infant,
an infant with a low Apgar score, and perinatal death. The newborn is at risk of postnatally
acquired TB if the mother still has active TB at the time of birth. Therefore, prenatal
diagnosis and effective treatment of the mother are essential.
• Therapeutic management
– Medications: combination of isoniazid, rifampin, ethambutol
– Streptomycin should be avoided in pregnancy because it is ototoxic to the fetus.
– Pregnant women should start treatment as soon as TB is suspected. The preferred
initial treatment regimen is INH, rifampin, and ethambutol daily for two months,
followed by INH and rifampin daily, or twice weekly for 7 months. Women taking
INH should also be taking pyridoxine (vitamin B6) supplementation.
• Nursing assessment
– Risk factors: immunocompromised status, recent immigration status, homelessness
or overcrowded living conditions, and injectable drug use. Women emigrating from
developing countries.
– Signs and symptoms of TB: fatigue, fever or night sweats, nonproductive cough,
weakness, slow weight loss, anemia, hemoptysis, fatigue, and anorexia.
– Screening: with purified protein derivative (PPD) administered by intradermal
injection. If the client has been exposed to TB, a reddened induration will appear
within 72 hours. If the test is positive, anticipate a follow-up chest x-ray with lead
shielding over the abdomen, as well as sputum cultures to confirm the diagnosis.
 • Nursing management
– Compliance with drug therapy
– Education; health promotion activities ( avoiding crowded living conditions,
avoiding sick people, maintaining adequate hydration, eating a nutritious, well-
balanced diet, keeping all prenatal appointments to evaluate fetal growth and well-
being, and getting plenty of fresh air outside).
– Transmission prevention
– Breast-feeding is not contraindicated during the time the mother is on the
medication regimen and should in fact be encouraged. If the mother is
untreated for TB at the time of childbirth, they should not breastfeed or be in
direct contact with their newborn until at least two weeks after starting anti-
tuberculin medications. Untreated mothers can be encouraged to pump their
milk to feed their newborns until they can breastfeed directly 
– preventing transmission by teaching the parents not to cough, sneeze, or talk
directly into the newborn’s face.

Iron-Deficiency Anemia
• Usually due to inadequate dietary intake
• Increased risk during pregnancy is due to increased maternal iron needs and demands from
the growing fetus, increased erythrocyte mass; and, in the third trimester, expanded
maternal blood volume.
• The clinical consequences of iron-deficiency anemia include preterm delivery, perinatal
mortality, and postpartum depression. Fetal and neonatal consequences include low birth
weight and poor mental and psychomotor performance.
• The risks of hemorrhage (impaired platelet function) and infection during and after birth
also are increased.
• Clinical symptoms of iron-deficiency anemia include fatigue, diminished quality of life,
impaired cognitive function, increased risk for thromboembolic events, headache, restless
legs syndrome, and pica (consuming nonfood substances) eating behaviors.
• Therapeutic management: eliminate symptoms, correct deficiency, replenish iron stores
• Nursing assessment
– Fatigue, weakness, malaise, anorexia, susceptibility to infection (frequent colds),
pale mucous membranes, tachycardia, pallor
– Abnormal lab results
– low Hgb (<11 g/dL), low Hct (<35%), low serum iron (<30 mcg/dL),
microcytic and hypochromic cells, and low serum ferritin (<100 mg/dL)
• Hemoglobin and hematocrit decrease normally during pregnancy in response to an increase in blood
plasma in comparison to red blood cells. This hemodilution can lead to physiologic anemia of
pregnancy, which does not indicate a decrease in oxygen-carrying capacity or true anemia.

Iron-Deficiency Anemia: Nursing Management

• Compliance with drug therapy: prenatal vitamin and iron supplement
• Dietary instruction and counseling
• Education for drug therapy
– Take your prenatal vitamin daily; if you miss a dose, take it as soon as you remember.
– For best absorption, take iron supplements between meals.
– Awareness of the side effects of iron supplementation
– Avoid taking iron supplements with coffee, tea, chocolate, and high-fiber foods.
 – Eat foods rich in iron, such as:
– Meats, green leafy vegetables, legumes, dried fruits, whole grains
– Peanut butter, bean dip, whole-wheat fortified breads and cereals
– For best iron absorption from foods, consume the food along with a food high in vitamin C.
– Increase your exercise, fluids, and high-fiber foods to reduce constipation.
– Plan frequent rest periods during the day.

Thalassemia
• Thalassemia is a group of hereditary anemic disorders in which synthesis of one or both
chains of hemoglobin molecules (alpha and beta) is defective. Inheritance is autosomal
recessive. A low Hgb and a microcytic, hypochromic anemia results.
• Two forms: alpha (minor); beta (major)
– Women with minor form: little effect on pregnancy except for mild persistent
anemia; the heterozygous form, results from the inheritance of one abnormal gene
from either parent, placing the offspring in a carrier trait state. These women have
little or no hematologic disease and are clinically asymptomatic (silent carrier
state).
– Women with major form: usually no pregnancy due to lifelong, severe hemolysis,
anemia, and premature death; Beta-thalassemia (major) is the form involving
inheritance of the gene from both parents. Beta-thalassemia major can be very
severe. 
• Management dependent on severity of disease: regular and periodic evaluation of cardiac
function by a cardiologist to prevent fluid overload; and frequent hemoglobin and ferritin
levels should be monitored to avoid iron overload.
• Supportive care and expectant management

Sickle Cell Anemia

• Sickle cell anemia is an autosomal recessive inherited condition that results from a defective
hemoglobin molecule (hemoglobin S). It is found most commonly in African Americans,
Southeast Asians, and Middle Eastern populations.
• Women with sickle cell disease can have more adverse maternal outcomes such as
preeclampsia, eclampsia, preterm labor, placental abruption, intrauterine growth restriction,
low birth weight, and maternal mortalities
• The gene offers protection against malaria but can be a cause of chronic pain and early death.
• Sickle cell anemia during pregnancy is associated with more severe anemia and frequent
vaso-occlusive crises, with increased maternal and perinatal morbidity and mortality.

Defect in hemoglobin molecule (hemoglobin S)

• Therapeutic management: dependent on status; supportive therapy; blood transfusions for
severe anemia, analgesics for pain, antibiotics for infection
• Nursing assessment: signs and symptoms; evidence of crisis; Ask the woman if she has
anorexia, dyspnea, or malaise.
– Inspect the color of the skin and mucous membranes, noting any pallor. Be alert
for indicators of sickle cell crisis, including severe abdominal pain, muscle
spasms, leg pains, joint pain, fever, stiff neck, nausea and vomiting, and seizures.
• Nursing management
– Support, education, follow-up
 – Labor: rest, pain management, oxygen and IV fluids, close FHR monitoring
– Postpartum: antiembolism stockings, family planning options

Women Who Are HIV Positive

• HIV  is a chronic infection caused by the retrovirus HIV, which infects T cells that causes
immunodeficiency. Once the CD4-positive cell count falls below a certain level, HIV infection
causes increased susceptibility to infections, cancers, and neurologic damage.
• Impact of pregnancy and HIV: threats to self, fetus, and newborn
– Risks: drug abuse, lack of access to prenatal care, poverty, poor nutrition, and high-
risk behaviors such as unsafe sex practices and multiple sex partners, women who
exchange sex for money or drugs or have sex partners who do; a woman whose past
or present sex partners were HIV infected; and women who had a blood transfusion
between 1978 and 1985. 
– HIV positive are at risk for preterm delivery, fetal growth restriction, premature
rupture of membranes, intrapartal or postpartum hemorrhage, postpartum infection,
poor wound healing, and genitourinary tract infections
– Perinatal transmission of HIV (from the mother to the fetus or child) also can occur.
– Women who are HIV positive should avoid breast-feeding to prevent HIV
transmission to the newborn.
– Fetus and newborn also are at risk for prematurity, IUGR, low birth weight, and
infection. Prompt treatment with antiretroviral medications for the infant with an
HIV infection may slow the progression of the disease.
• Therapeutic management: Drug therapy is the mainstay of treatment for pregnant women
infected with HIV. Oral antiretroviral drugs twice daily from 14 weeks until birth; IV
administration during labor; oral syrup for newborn in first 6 weeks of life; decision for
birthing method  cesarean birth may reduce the risk of HIV infection. 
• Nursing assessment: history and physical examination; HIV antibody testing; testing for
STIs
• Women who request an HIV test despite reporting no individual risk factors should be considered at
risk, since many are not likely to disclose their high-risk behaviors.

Women Who Are HIV Positive: Nursing Management

• Pretest and posttest counseling
• Education
• Support
– Preparation for labor, birth, and afterward
– Elective cesarean birth
– Compliance with antiretroviral therapy
– Family planning methods

Pregnant Adolescent: Nursing Assessment

• Adolescence lasts from the onset of puberty to the cessation of physical growth, roughly from
11 to 19 years of age.
• Vision of self in future
• Realistic role models; emotional support
• Level of child development education
• Financial and resource management; work and educational experience
• Anger and conflict resolution skills
 • Knowledge of health and nutrition for self and child
• Challenges of parenting role
• Community resources
TOPICS FOR TEACHING ADOLESCENTS TO PREVENT PREGNANCY
 High-risk behaviors that lead to pregnancy
 Involvement in programs such as Free Teens, Teen Advisors, or Postponing Sexual Involvement
 Planning and goal setting to visualize their futures in terms of career, college, travel, and education
 Choice of abstinence or taking a step back to become a “second-time virgin”
 Discussions about sexuality with a wiser adult—someone they respect can help put things in
perspective
 Protection against STIs and pregnancy if they choose to remain sexually active
 Critical observation and review of peers and friends to make sure they are creating the right
atmosphere for friendship
 Empowerment to make choices that will shape their life for years to come, including getting control of
their own lives now
 Appropriate use of recreational time, such as sports, drama, volunteer work, music, jobs, church
activities, and school clubs

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
• Education
Woman Over Age 35
• Nursing assessment
– Preconception counseling; lifestyle changes; beginning pregnancy in optimal state
of health
– Laboratory and diagnostic testing for baseline; amniocentesis; quadruple blood
test screen
• Nursing management
– Promotion of healthy pregnancy; education; early and regular prenatal care;
dietary teaching; continued surveillance

Pregnant Woman with Substance Abuse

• Perinatal drug abuse is the use of alcohol and other drugs by pregnant women. 
• Impact of pregnancy: fetal vulnerability; teratogenic effect; addiction consequences
• Effect of common substances
– Alcohol: FAS; FASD, Caffeine; nicotine, Cocaine, Marijuana, Opiates and
narcotics: neonatal abstinence syndrome, Sedatives, Methamphetamines
 • Nursing assessment: history and physical examination; urine toxicology
• Nursing management
– Nonjudgmental approach
– State protection agency investigation for positive newborn drug screen
– Counseling
– Education
• Characteristics of FASD include craniofacial dysmorphia (thin upper lip, small head
circumference, and small eyes), IUGR, microcephaly, and congenital anomalies such as limb
abnormalities and cardiac defects. 

Substance Abuse
• Pregnant women with substance abuse problems commonly abuse several substances,
making it difficult to ascribe a specific perinatal effect to any one substance. Societal
attitudes regarding pregnant women and substance abuse may prohibit them from
admitting the problem and seeking treatment.
• Substance abuse during pregnancy is associated with preterm labor, abortion, low birth
weight, central nervous system and fetal anomalies, and long-term childhood
developmental consequences.
Neonatal Abstinence Syndrome
• The most common harmful effect of heroin and other narcotics on newborns is
withdrawal, or neonatal abstinence syndrome
• This collection of symptoms may include irritability, hypertonicity, jitteriness, fever,
excessive and often high-pitched cry, vomiting, diarrhea, feeding disturbances,
respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness,
diaphoresis, fever, poor sucking, tremors, and seizures

KEY CONCEPTS
 Preconception counseling for the woman with diabetes is helpful in promoting blood glucose
control to prevent congenital anomalies.
 The classification system for diabetes is based on disease etiology and not pharmacology
management; the classification includes type 1 diabetes, type 2 diabetes, gestational diabetes,
and impaired fasting glucose and impaired glucose tolerance.
 A functional classification for heart disease during pregnancy is based on past and present
disability: class I, asymptomatic with no limitation of physical activity; class II, symptomatic
(dyspnea, chest pain) with increased activity; class III, symptomatic (fatigue, palpitation)
with normal activity; and class IV, symptomatic at rest or with any physical activity.
 Chronic hypertension exists when the woman has a blood pressure of 140/90 mm Hg or
higher before pregnancy or before the 20th week of gestation or when hypertension persists
for more than 12 weeks’ postpartum.
 Successful management of asthma in pregnancy involves elimination of environmental
triggers, drug therapy, and client education.
 Ideally, women with hematologic conditions are screened before conception and are made
aware of the risks to themselves and to a pregnancy.
 The prevalence of HIV/AIDS is increasing more rapidly among women than men: half of all
the HIV/AIDS cases worldwide now occur in women. There are only three recognized modes
of HIV transmission: unprotected sexual intercourse with an infected partner, contact with
infected blood or blood products, and perinatal transmission. Breast-feeding is a major
contributing factor in mother-to-child transmission of HIV.
 Cases of perinatal AIDS have decreased in the past several years in the United States,
primarily because of the use of zidovudine (ZDV) therapy in pregnant women with HIV. The
U.S. Preventive Services Task Force recommends that all pregnant women should be offered
HIV antibody testing regardless of their risk of infection, and that testing should be done
during the initial prenatal evaluation.
 The younger an adolescent is at the time of her first pregnancy, the more likely it is that she
will have another pregnancy during her teens. About 1 million teenagers between the ages of
15 and 19 become pregnant each year; about half give birth and keep their infants.
 The nurse’s role in caring for the pregnant adolescent is to assist her in identifying the
options for this pregnancy, including abortion, self-parenting of the child, temporary foster
care for the baby or herself, or placement for adoption.
 Pregnant women with substance abuse problems commonly abuse several substances,
making it difficult to ascribe a specific perinatal effect to any one substance. Societal attitudes
regarding pregnant women and substance abuse may prohibit them from admitting the
problem and seeking treatment.
 Substance abuse during pregnancy is associated with preterm labor, abortion, low birth
weight, central nervous system and fetal anomalies, and long-term childhood developmental
consequences.
 Fetal alcohol spectrum disorder is a lifelong yet completely preventable set of physical,
mental, and neurobehavioral birth defects; it is the leading cause of intellectual disability in
the United States.
 Nursing management for the woman with substance abuse focuses on screening and
preventing substance abuse to reduce the high incidence of obstetric and medical
complications as well as the morbidity and mortality among passively addicted newborns.