Learning Objectives
By the end of this section, you will be able to:
- Explain the association between maternal age and pregnancy outcomes and obstetric management
- Explain the association between preexisting nutritional deficiencies and pregnancy outcomes and obstetric management
- Explain the association between special populations and pregnancy outcomes and obstetric management
- Explain the association between preexisting medical conditions and pregnancy outcomes and obstetric management
A high-risk pregnancy refers to a pregnancy that has an increased likelihood of maternal and fetal complications. Some of the factors that can contribute to a high-risk pregnancy include maternal age, preexisting medical conditions, poverty, and nutritional deficiencies. Specific social determinants of health can also contribute to a high-risk pregnancy, with disparities noted in outcomes for Black, American Indian, and Alaskan Native populations. Table 12.1 summarizes preconception factors that place a pregnancy at risk. These pregnancies require additional monitoring, interventions, and management to improve maternal, fetal, and newborn outcomes.
| Category | Factors |
|---|---|
| Physical and mental | Preexisting medical conditions (e.g., hypertension and diabetes), nutritional excess or deficits, mental health disorders, high-risk obstetric history |
| Lifestyle | Alcohol and/or substance use, lack of physical activity, unhealthy eating habits, lack of social support, high-risk behaviors |
| Social determinants of health | Age, socioeconomic status, homelessness, undocumented immigrant status, migrant work |
| Environmental | Work hazards, radiation exposure, poor living conditions, teratogen exposure, air pollutants |
The role of the nurse in caring for persons whose pregnancies are at risk is crucial, as the nurse is often the first point of contact for patients seeking antenatal care. Nurses provide education and support to patients while identifying potential risk factors and assisting the primary care provider.
Age
The age of the pregnant person plays an important role before, during, and after pregnancy. Age extremes at conception have been linked with increased risk factors during pregnancy, specifically pregnancies that occur in persons less than 20 years of age or in persons 35 years of age and older. While these age extremes provide discrete cutoffs, risk factors present on a continuum. For example, the risk of adverse outcomes decreases with every year of increase in the age of the adolescent (de la Calle et al., 2021). Conversely, the risk of adverse outcomes increases for every year after 35, termed advanced maternal age. Identification of the patient’s age during the initial assessment provides valuable information to help guide interventions during pregnancy.
Adolescence
The rate of pregnancy during adolescence varies by country but is generally predominant in low- or middle-income countries (World Health Organization [WHO], 2022). An adolescent pregnancy is one that occurs in persons between 10 and 19 years of age. Adverse maternal outcomes related to adolescent pregnancies include infection, hemorrhage, anemia, preeclampsia, and postpartum depression; neonatal adverse outcomes include prematurity, fetal growth restriction, stillbirth, and congenital anomalies (Maheshwari et al., 2022; Ursache et al., 2023). Pregnancy during adolescence is linked to poverty, unemployment, and social and psychologic problems (Govender et al., 2020). The incidence of late or no prenatal care is increased in adolescent pregnancy and may be associated with lack of knowledge about where to go for prenatal care (Hacker et al, 2021). Laws around parental consent provide an additional barrier for adolescents who become pregnant and seek access to health care. However, laws continue to evolve to allow persons under the age of 18 to consent to prenatal care. As of 2023, 33 states permit health-care providers to provide prenatal care to persons under the age of 18 without parental consent, although 14 states still allow health-care providers to notify parents that their child is receiving prenatal care (Guttmacher Institute, 2023).
The health-care team will evaluate the patient’s support system, psychologic status, and access to resources. Steps toward pregnancy prevention can minimize the risk of pregnancy. Nursing interventions at an individual level include education on contraceptives and prenatal care. The nurse can refer the patient to resources such as social support groups, counseling, and educational programs. Local programs such as Women, Infants, and Children (WIC) can provide additional support to adolescents, including prenatal nutrition classes, breast-feeding assistance, referrals for immunizations, employment assistance, and other social services.
Link to Learning
Women, Infants, and Children (WIC) is a federally funded program that offers local resources to women and their children of low-income status. Resources include breast-feeding support, nutrition counseling, health-care referrals, and other supplemental services. The U.S. Department of Agriculture (USDA) regulates the WIC program through planning, program development, funding, research, and monitoring.
Age 35 and Older
A pregnant person who will be 35 years or older on the estimated date of delivery is said to be of advanced maternal age. Advanced maternal age increases the pregnant person’s risk of ectopic pregnancy, multiple gestation, gestational diabetes, hypertensive disorders in pregnancy, cesarean delivery, and postpartum hemorrhage (Glick et al., 2021; Sheen et al., 2018). Fetal risks include spontaneous miscarriage, chromosomal abnormalities, congenital anomalies, prematurity, fetal growth restriction, and stillbirth (Glick et al., 2021). Preexisting medical conditions more common in this age group (such as hypertension, diabetes, and hypothyroidism) may also complicate pregnancy.
With the average age at first pregnancy increasing, the American College of Obstetricians and Gynecologists (ACOG) developed recommendations for health-care professionals providing obstetric care to patients of advanced maternal age (ACOG, 2022a). Recommendations include identifying patients and counseling them about risks to the pregnant person’s and fetus’s health, considering prescribing low-dose aspirin to reduce the risk of preeclampsia, using ultrasound to evaluate for multiple gestations and congenital anomalies, monitoring fetal growth, initiating close patient monitoring for stillbirth risk, and promoting vaginal delivery, if it is safe. Nurses play an important role in educating the pregnant person regarding lifestyle behaviors to decrease the incidence of complications.
Life-Stage Context
Risk Factors Related to Advanced Maternal Age
Patients of advanced maternal age carry additional risks of genetic abnormalities of the fetus and an increase in adverse outcomes for the pregnant person and the baby. Furthermore, differences exist between patients of advanced maternal age who are primiparous versus multiparous. Primiparous patients over 40 have an increased incidence of cesarean delivery, gestational hypertension, and preeclampsia when compared to multiparous patients. Fetal birth weight is lower when the pregnant person aged 40 or older is a primipara (Genc, 2021).
Nutritional Deficiencies and Excess
Nutritional imbalances place a pregnancy at risk because certain nutrients are necessary to ensure maternal health as well as fetal growth and development. As worldwide obesity rates rise, so do complications from obesity. The imbalance of nutrition that results from excessive food intake is called overnutrition. Obesity places the pregnant person at increased risk for preeclampsia, gestational diabetes, obstructive sleep apnea, cardiac dysfunction, stillbirth, and cesarean delivery (ACOG, 2021b). Risks to the fetus include congenital anomalies such as neural tube defects, congenital heart defects, limb or orofacial abnormalities, gastroschisis, and abnormal growth (ACOG, 2021b).
In contrast to nutritional excesses, inadequate weight gain before and during pregnancy can place the fetus at risk for undernutrition, which can negatively impact fetal health by causing brain defects, psychiatric disorders, vision and motor defects, and altered cognition (Cortés-Albornoz et al., 2021). Undernutrition occurs when there is inadequate intake of food and necessary nutrients. During routine prenatal visits, the health-care team can provide education on local services that provide access to food as needed. In the setting of inadequate weight gain, the team may also assess for other underlying medical conditions.
Optimizing nutrition prior to pregnancy can reduce risks associated with nutritional imbalances. Because pregnancy involves an increased demand for nutrients, it is imperative to correct nutritional deficits prior to conception. Of note, nutritional deficits still occur in cases of overnutrition. Health-care providers can counsel patients prior to conception to manage weight and improve nutritional status through dietary modifications, physical activity, and changes in behavior. Counseling should be specific to each patient and will vary based on age and weight prior to pregnancy.
Nurses should provide education on the intake of nutrients such as folic acid, iron, vitamin B12, calcium, vitamin D, iodine, and choline during pregnancy. Pregnant patients should take 400 mcg of folic acid per day starting at conception to decrease the risk of neural tube defects, prematurity, and low birth weight (U.S. Department of Agriculture [USDA], 2020).
Iron needs during pregnancy often vary by patient, and iron can be obtained through prenatal vitamins, animal products, or iron-fortified foods. Adequate iodine intake supports fetal neurodevelopment and can be found in seafood, eggs, dairy products, and iodized salt (USDA, 2020). Vitamin B12 is most commonly found in animal products, so patients with a vegan or vegetarian diet may require supplementation. On initial assessment, the health-care team can evaluate the patient’s dietary habits to evaluate for deficiencies in micronutrients. The nurse uses this information to assist the patient in identifying acceptable sources of needed nutrients to add to their daily intake.
Link to Learning
Through its website, Cleveland Clinic provides a general overview of high-risk pregnancy. The website summarizes information on the definition, diagnosis, signs and symptoms, prevention, management, and prognosis of high-risk pregnancy. It offers education on what it means to have a high-risk pregnancy and advises patients on when to seek care from a health-care provider.
Special Populations
Social determinants of health, such as income, education, support systems, and physical living and working conditions, play an important part in determining if a pregnancy is at risk. Populations with low socioeconomic status, undocumented immigrant status, homelessness, and misuse of substances, as well as those engaged in farm work, are affected by social determinants of health. Table 12.2 summarizes pregnancy risks related to special populations. Through identification of risk factors specific to these populations, the health-care provider can support maternal and fetal health by providing comprehensive care and monitoring of the pregnant person for complications. Nurses provide education on and support for overcoming barriers to optimum health throughout the pregnancy (Girardi et al., 2023).
| Special Population | Risks for Pregnancy | Effects on Fetus/Infant |
|---|---|---|
| Socioeconomic status (poverty) | Limited prenatal care Preeclampsia Gestational diabetes Malnutrition Increased maternal health problems Limited social support |
Preterm birth Miscarriage Decreased newborn care |
| Migrant farm work | Limited prenatal care Exposure to occupational hazards Poor living conditions Malnutrition Infection Limited education of prenatal care |
Preterm birth Low birth weight Birth defects Decreased newborn care |
| Undocumented immigrant status | Limited or delayed prenatal care Mental health disorders Increased maternal health problems Infection Lack of social support Chronic stress |
Preterm birth Low birth weight Decreased newborn care |
| Homelessness | Limited prenatal care Limited access to food Substance use or misuse Mental health disorders Exposure to environmental hazards Chronic stress Physical harm and violence |
Preterm birth Low birth weight Decreased newborn care |
| Substance use or misuse | Infections Increased maternal health problems Inadequate self-care Mental health disorder |
Fetal drug exposure Birth defects Low birth weight Intrauterine fetal death Neonatal withdrawal Neurodevelopmental impairment |
Socioeconomic Status (Poverty)
Socioeconomic status plays an important role in prenatal care. Limited resources related to low socioeconomic status can lead to increased maternal and fetal complications, often related to limited prenatal care. Patients from disadvantaged backgrounds often have limited access to health care, have poor nutrition, and live in stressful environmental conditions, all of which can increase the risk of adverse outcomes such as preterm delivery, preeclampsia, gestational diabetes, and miscarriage (Kim et al., 2018). Additionally, patients with a low socioeconomic status may be more likely to use tobacco, alcohol, or drugs, all of which can negatively impact fetal development. Limited access to food can impair maternal nutrition. Patients may also experience increased levels of stress and have inadequate support systems, which can lead to mental health and social support problems.
To support patients of low socioeconomic status, nurses can connect patients with local resources, provide education on prenatal care, offer emotional support, and refer for financial assistance. Health-care providers can advocate for patients by providing referrals, collaborating with social services, and encouraging patient self-advocacy.
Link to Learning
The nonprofit Hastings Center provides links to programs developed to increase access to care and are available to persons who are pregnant, postpartum persons, and infants.
Migrant Farm Work
Migrant farm workers may experience limited prenatal care because of frequent relocation, limited resources, low socioeconomic status, and language barriers. Cultural and religious beliefs may influence the willingness of patients to receive routine prenatal care, especially pregnant patients who request only female providers. Migrant farm workers experience challenging occupational conditions, such as extreme temperatures, heavy lifting, and exposure to chemicals. Pregnant farm workers are at increased risk of preterm birth and having low-birth-weight infants. Health-care providers should evaluate occupational hazards during initial assessment and provide education accordingly. Collaborating with a medical interpreter to translate during the prenatal visit will ensure the correct information is conveyed to the pregnant person and can promote a trusting relationship.
Undocumented Immigrant Status
The American College of Obstetricians and Gynecologists advocates for undocumented immigrants by recommending access to quality health care for all persons and by opposing policies and strict enforcement of immigration laws that prevent prenatal care to non-US citizens (ACOG, 2023). Illegal residents, or undocumented immigrants, face limited access to health care because of federal policies and disqualifications from health-care insurance. These challenges may explain the increased risks for maternal morbidity and mortality, preterm birth, and low infant birth weight in this population (Gieles et al., 2019). Increasing access to health-care coverage can promote prenatal health and reduce associated risk factors. In addition to providing culturally sensitive quality care, the nurse can connect patients to local resources and social support programs.
Homelessness
Homelessness and unstable housing place a pregnancy at risk and have been linked with mental health and substance use disorders (McGeough et al., 2020). Factors related to homelessness include inadequate prenatal care, unsafe living conditions, exposure to environmental hazards, increased stress, and limited access to food. These factors are associated with an increase in morbidity and mortality for both the pregnant person and the fetus.
Patients who are pregnant and experience homelessness may be at increased risk for physical harm and violence. Health-care providers may not be able to reduce the risk factors associated with homelessness but should instead focus on supporting the unique needs of the individual patient. Policy changes on a broader scale aimed at assisting with unemployment, supplying adequate housing, and reducing domestic violence can reduce the incidence of homelessness during pregnancy. Nurses can advocate for people experiencing homelessness by referring them to social services or WIC to help find prenatal classes where there is also access to prenatal vitamins and vouchers for more nutritious foods.
Substance Use
Health-care providers should ask about substance use prior to or during the first prenatal visits. Screening tools should inquire about the use of alcohol, tobacco, opioids, benzodiazepines, marijuana, and stimulants. By using validated screening tools such as the Parents, Partners, Past and Pregnancy (The 4P’s), NIDA Quick Screen, or Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) on all patients, the risk of stereotyping is reduced (ACOG, 2017b). Identification of substance use disorder during the first visit can not only reduce risks to maternal and fetal health but also provide additional maternal support. The risks to both the pregnancy and the fetus are summarized in Table 12.3. It is important for the health-care provider to establish a trusting relationship with the patient by using nonjudgmental and therapeutic communication. The health-care provider may then refer the patient to mental health resources or a local treatment facility as needed. When that referral is made, the nurse’s role is to provide the patient with more detailed education regarding what services are provided by the agency the pregnant person is being referred to.
Heavy alcohol intake during pregnancy has been associated with adverse fetal outcomes such as prematurity, low birth weight, and fetal alcohol spectrum disorders (Wilson et al., 2020). Alcohol is a known teratogen, and patients should be counseled to avoid it during pregnancy because no amount of alcohol intake has been proven safe. For patients who have trouble quitting alcohol, the nurse can provide information and referrals for assistance.
Smoking tobacco in pregnancy has been associated with fetal growth restriction, miscarriage, prematurity, placental abruption, stillbirth, tissue damage to the fetal lungs and brain, and neurodevelopmental disorders (Chen et al., 2023; Cohen et al., 2017; Nida, 2021). Providing patients with resources and education on smoking cessation during the preconception period or during pregnancy can reduce these risks for the pregnant person and fetus. Because there is a dose-response relationship between number of cigarettes and risk factors (Marufu et al., 2015), simply decreasing the number of cigarettes smoked per day can be beneficial.
| Substance | Risk to Pregnancy | Risk to Fetus/Infant |
|---|---|---|
| Alcohol | Miscarriage or stillbirth | Preterm birth Low birth weight Fetal alcohol spectrum disorders Developmental delay |
| Tobacco |
Miscarriage or stillbirth Placental abruption |
Fetal growth restriction Premature birth Tissue damage to fetal lung and brain Neurodevelopmental disorders |
| Opioids | Maternal mortality Stillbirth Poor nutrition Domestic violence Polysubstance use Exposure to bloodborne pathogens Inconsistent prenatal care |
Premature birth Neonatal abstinence syndrome (NAS) |
| Benzodiazepines | Withdrawal symptoms Physical dependence Drug interactions |
Neonatal abstinence syndrome (NAS) Hypotonia Hypothermia Lethargy Respiratory problems Feeding problems Birth defects Preterm birth Low birth weight |
| Marijuana | Mental health problems Respiratory problems related to smoking |
Neurodevelopmental impairment Low birth weight |
| Stimulants (cocaine, methamphetamines) | Placental abruption Intrauterine growth restriction |
Congenital anomalies Preterm birth |
Opioids may be prescribed, such as methadone and codeine, or nonprescribed, such as heroin. Opioid use during pregnancy increases the risk for maternal mortality, stillbirth, preterm birth, and neonatal abstinence syndrome (NAS) (Centers for Disease Control & Prevention [CDC], 2022a). Opioid use disorder can be linked with other comorbidities, including alcohol, benzodiazepine and stimulant use, poor nutrition, domestic violence, exposure to bloodborne pathogens, and inconsistent prenatal care (Wilson et al., 2020). Additional screening and testing may be indicated to evaluate for these comorbidities. Patients who become pregnant and use illicit drugs may be prescribed a safer alternative, such as methadone or buprenorphine, and referred to a treatment program to minimize withdrawal and prevent relapse (ACOG, 2017b). After birth, the infant will need to be monitored closely by a pediatric provider for signs of withdrawal.
Evidence is unclear about the adverse effects of benzodiazepine use (prescribed or not prescribed) during pregnancy, but it may be associated with increased signs of neonatal abstinence syndrome (Wilson et al., 2020). There are reports of hypotonia, hypothermia, lethargy, respiratory problems, and feeding difficulties associated with benzodiazepine use during pregnancy. The nurse should provide the patient with education about these potential effects (Wilson et al., 2020).
Because of the legalization of marijuana in some states, its use is on the rise and is quite controversial. Because of the concern for neurodevelopmental impairment and low birth weight, current recommendations discourage marijuana use prior to and during pregnancy (ACOG, 2017a; CDC, 2020).
Stimulants such as cocaine and methamphetamines cause vasoconstriction and can increase the risk for placental abruption, congenital anomalies, intrauterine growth restriction, and preterm birth (Wilson et al., 2020). The nurse should educate pregnant patients using stimulants about the adverse effects and encourage them to discontinue use immediately and participate in programs. Of note, stimulant use after pregnancy is a contraindication to breast-feeding.
Health-care providers can use screening tools to assess for substance misuse during pregnancy. The following screening tools are recommended, and their websites provide additional information on how these tools are used to screen for alcohol, tobacco, and drug use during pregnancy:
Medical Conditions
Patients with preexisting medical conditions often require a multidisciplinary approach to monitor maternal and fetal health before, during, and after pregnancy. A preexisting medical condition is one that is present prior to conception. High-risk pregnancies are often followed up by a maternal-fetal medicine specialist in addition to an obstetrician or midwife. Depending on the medical condition, additional specialties may be involved in patient care, including neonatology, nutrition, pharmacy, social work, case management, cardiology, nephrology, endocrinology, hematology, neurology, pulmonology, infectious disease, and others. The role of the nurse in this team is to educate the patient about why these additional specialties are needed, to encourage adherence to the overall care plan, and to support the patient in coordinating care.
Counseling during the preconception period can allow time for the patient to optimize health in preparation for pregnancy. Nurses should encourage patients to discuss medications with their health-care provider to determine possible teratogens that could have detrimental effects on fetal development. Health-care providers can promote contraception until the patient is ready to conceive. Pregnancy planning with effective management of medical conditions prior to conception can reduce adverse outcomes and increase the likelihood of a healthy pregnancy.
Hypertension
Hypertension that is present prior to pregnancy or before 20 weeks’ gestation or that persists 20 weeks following delivery is called chronic hypertension. It increases the risk of fetal growth restriction, stillbirth, preterm labor and delivery, fetal distress in labor, cesarean delivery, postpartum hemorrhage, gestational diabetes, and preeclampsia. During the preconception period, the health-care provider should evaluate for end-organ involvement and other comorbidities to maximize the health of both the pregnant person and the fetus (ACOG, 2019a). Nurses can provide education on lifestyle habits to increase the health of the pregnant person.
Management of chronic hypertension includes monitoring blood pressure (BP) regularly (as shown in Figure 12.2) and evaluating for adverse effects, such as preeclampsia, uteroplacental insufficiency, and fetal growth restriction. Antihypertensive therapy is recommended to maintain BP below 140/90 mm Hg, especially in the presence of other medical conditions, such as renal disease (ACOG, 2019a). First-line antihypertensive medications during pregnancy are nifedipine (Adalat) and labetalol (Trandate), while other hypertensive agents such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are contraindicated because of teratogenic effects (ACOG, 2019a). To reduce the risk of developing preeclampsia, daily low-dose aspirin should be prescribed between 12 and 28 weeks’ gestation and continued until delivery (ACOG, 2019a).
Surveillance of fetal well-being is conducted via ordered ultrasound (US) with Doppler, nonstress test (NST), and biophysical profile (BPP). For more about these tests, see Chapter 13 Prenatal Testing.
Diabetes Mellitus
The incidence of diabetes continues to rise in the United States, likely related to the rise in obesity. The two primary types of diabetes are type 1 and type 2. In type 1 diabetes, an autoimmune process that destroys the pancreatic beta cells that produce insulin, resulting in an insulin shortage. In type 2 diabetes, the beta cells do not secrete enough insulin in the setting of insulin resistance. Both types can affect patients of childbearing age.
During pregnancy, hormones fluctuate, resulting in alterations in insulin needs. During the first trimester, patients with preexisting diabetes are increasingly sensitive to insulin (Alexopoulos et al., 2019). Therefore, patients are at increased risk for hypoglycemia and may require lower doses of insulin. As the pregnancy progresses beyond 16 weeks’ gestation, insulin resistance progressively increases, and patients often require increased doses of insulin (Alexopoulos et al., 2019). Because of the increased risk for abnormal glucose levels throughout pregnancy, blood glucose may need to be more frequently monitored. Nurses should counsel patients on the fluctuations in insulin sensitivity and resistance during pregnancy and the importance of frequent glucose monitoring, as well as signs and symptoms of hypo- and hyperglycemia.
Diabetes, especially when glycemic control is not present prior to conception and throughout the pregnancy, is associated with an increased risk of maternal and fetal adverse outcomes, such as miscarriage, congenital anomalies, stillbirth, preeclampsia, fetal macrosomia, and neonatal hypoglycemia (American Diabetes Association [ADA], 2020). Table 12.4 contains a detailed list of maternal and fetal complications related to diabetes during pregnancy.
| Affected Person | Effects |
|---|---|
| Pregnant person | Preeclampsia Gestational hypertension Polyhydramnios Cesarean birth Hypoglycemia Diabetic ketoacidosis Postpartum hemorrhage Diabetic retinopathy Diabetic kidney disease Cardiac disease Neuropathy Early pregnancy loss Preterm delivery |
| Fetus | Neonatal hypoglycemia Large for gestational age/Macrosomia Fetal growth restriction Shoulder dystocia Respiratory distress syndrome Congenital malformations:
Hypocalcemia Stillbirth |
Testing for diabetes during the preconception period can minimize maternal and fetal complications. Testing includes a fasting glucose level or a hemoglobin A1c test. To minimize maternal-fetal risk, the target hemoglobin A1c should be less than 6.5 percent during the preconception period (ADA, 2020; Alexopoulos et al., 2019). Management of both types of diabetes during pregnancy involves insulin administration and requires an interdisciplinary approach. Patients with diabetes should be counseled on risks related to pregnancy and encouraged to closely monitor blood glucose levels during the preconception period. Elevated blood glucose levels during the first trimester have been linked with significant fetal abnormalities, such as congenital heart disease, anencephaly, microcephaly, renal anomalies, and caudal regression syndrome (ADA, 2020).
Pharmacology Connections
Insulin
Insulin is used in some patients who are pregnant and have diabetes. Insulin decreases high blood glucose levels that pose an increased risk for both the pregnant person and the fetus. Uncontrolled diabetes during pregnancy can lead to complications such as high blood pressure, premature birth, stillbirth, and birth defects.
- Generic Name: insulin
- Class/Action: classified as a hormone and antidiabetic agent
- Route/Dosage: Insulin is administered subcutaneously (SQ) with an insulin syringe but may also be administered intravenously (IV) in the form of a continuous drip in an acute care setting. Insulin dosage varies by individual patient, and doses are determined by an OB/GYN or maternal-fetal medicine specialist. Dosage adjustments may be necessary throughout pregnancy, as insulin requirements can change as the pregnancy progresses.
- Indication: for the management of hyperglycemia in patients with diabetes
- Mechanism of Action: Insulin is a hormone produced by the pancreas that helps regulate the amount of glucose in the blood. During pregnancy, the placenta produces hormones, such as estrogen, progesterone, cortisol, and lactogen, that can interfere with insulin's ability to lower blood glucose levels. Insulin therapy can help overcome this resistance and maintain blood glucose levels within a normal range.
- Contraindications: There are no absolute contraindications to insulin use; however, caution should be taken if allergy is a concern.
- Adverse Reactions: Hypoglycemia can be a serious adverse effect if glucose levels drop too low. Severe allergic reactions to insulin are rare but can occur. Symptoms of an allergic reaction may include rash, itching, swelling, dizziness, and difficulty in breathing.
- Side Effects: Common side effects of insulin use include injection site reactions such as pain, redness, and swelling. Other side effects may include hypoglycemia, weight gain, and fluid retention.
- Patient Education: Pregnant patients with diabetes who require insulin therapy should be educated on proper injection techniques, storage and mixing of insulins, blood glucose monitoring, and signs and symptoms of hypoglycemia and hyperglycemia. Patients should also be advised to follow a healthy diet, engage in regular physical activity, and attend all prenatal appointments.
(Skidmore-Roth, 2024)
Type 1
The likelihood of hypoglycemia increases during the first trimester of pregnancy for patients with type 1 diabetes due to increased insulin sensitivity related to hormonal changes as well as the nausea and vomiting that occur during this time. The nurse should encourage patients with diabetes and their families to closely assess and monitor for signs of hypoglycemia. Patient education should include the necessity for more frequent blood glucose monitoring. In the second trimester, insulin needs start to increase and increase at a faster pace in the third trimester. Patients with type 1 diabetes are also at an increased risk of diabetic ketoacidosis (DKA) during pregnancy, which is an obstetric emergency. The nurse should educate patients on prevention, when to call the provider, and the use of ketone strips (ADA, 2020). Signs and symptoms of hyperglycemia and DKA include dry mouth, polydipsia, polyuria, nausea, vomiting, abdominal pain, altered level of consciousness, weakness, deep breathing or tachypnea, fruity breath, tachycardia, dehydration, and ketonuria.
Type 2
Type 2 diabetes may be diagnosed during the first prenatal visit if a patient is at high risk, such as having obesity. Patients with type 2 diabetes have a higher risk of other comorbidities than those with type 1 diabetes and therefore may require additional monitoring and evaluation (ADA, 2020). Patients with type 2 diabetes will also need to frequently monitor blood glucose levels, and insulin doses may need to be increased during pregnancy to achieve euglycemia (ADA, 2020; ACOG, 2018a). Patients not taking any medication for diabetes prior to pregnancy may be able to achieve normoglycemia through lifestyle modifications, such as improved dietary habits and increased exercise. However, patients who take oral hypoglycemic medications will likely be transitioned to insulin during the first trimester. This is because oral diabetic medications, such as metformin, cross the placenta and have a decreased safety and efficacy profile (ACOG, 2018a; ADA, 2020).
Thyroid Disease
Evaluation and treatment of thyroid disease prior to pregnancy stabilizes maternal and fetal thyroid levels. Management during the preconception period should focus on achieving normal thyroid function levels, which may require adjusting medications and monitoring for side effects. Planning for pregnancy should prioritize stabilizing thyroid function prior to conception. Screening for thyroid disease during the first trimester is not universal but may be indicated if there is a history of thyroid disease in the patient or family, clinical signs or symptoms, or history of type 1 diabetes (ACOG, 2020a).
Hypothyroidism
The diagnosis for hypothyroidism is made when thyroid-stimulating hormone (TSH) levels are high (> 5 mIU/L) and thyroxine (free T4) levels are low (< 0.7 ng/dL). Clinical signs and symptoms include fatigue, weight gain, constipation, muscle cramps, cold intolerance, edema, hair loss, and dry skin. Adequate iodine intake is necessary for maternal and fetal thyroid health. Hashimoto thyroiditis, an autoimmune disorder, is a frequent cause of hypothyroidism during pregnancy (ACOG, 2020a). Hypothyroidism untreated during pregnancy increases the risk for low birth weight and impaired fetal neurodevelopment (Korevaar et al., 2017). Thyroid hormone replacement should be started prior to conception and will need be increased after conception due to increased demands related to pregnancy (Korevaar et al., 2017). Patients who are diagnosed with hypothyroidism after conception can be started on thyroid replacement medication at the full replacement dose (Korevaar et al., 2017). The nurse should counsel patients on the importance of adherence to medication regimens to promote stable thyroid levels.
Hyperthyroidism and Thyroxine (free T4)
In contrast to hypothyroidism, hyperthyroidism is diagnosed when thyroxine (free T4) levels are high (> 2 ng/dL) and thyroid-stimulating hormone (TSH) levels are low (< 0.5 mIU/L). Clinical signs and symptoms of hyperthyroidism include heat intolerance, weight loss, frequent stools, sweating, palpitations, insomnia, tachycardia, and hypertension. Hyperthyroidism left untreated can lead to miscarriage, stillbirth, fetal growth restriction, hypertension, and heart failure (Okosieme et al., 2018). Certain medications used to treat hyperthyroidism, such as methimazole (Tapazole), have teratogenic effects; and patients should be transitioned to a safer alternative, such as propylthiouracil (PTU), prior to pregnancy or during the first trimester (Morales et al., 2021).
Graves disease is the most common cause of hyperthyroidism in pregnancy (ACOG, 2020a). Radioiodine treatment or surgery may be warranted for the treatment of Graves disease prior to conception. Because maternal antibodies from Graves disease can cross the placenta and affect fetal thyroid levels, the pregnancy should be monitored closely for fetal effects (ACOG, 2020a). Newborns born to persons with Graves disease should be followed up by a pediatric provider to monitor for neonatal Graves disease. As with other preexisting conditions, the nurse provides education to and support of the pregnant person regarding extra prenatal appointments for fetal surveillance and additional laboratory tests.
Seizure Disorders
Patients who have seizures and their support persons should be counseled on risk factors of the pregnant person and the fetus related to seizure disorders during pregnancy and the possibility of increased seizure activity. Fetal exposure to antiepileptic medications has been associated with congenital malformations, fetal growth restriction, and impaired neurodevelopmental outcomes (Li & Meador, 2022). Seizure disorders also increase the likelihood of complications of pregnancy, such as maternal and fetal mortality, cesarean delivery, preeclampsia, postpartum hemorrhage, preterm delivery, and chorioamnionitis (MacDonald et al., 2015). Physiologic changes during pregnancy can impact the dose of antiepileptic medication needed to achieve therapeutic effect. Frequent drug monitoring ensures therapeutic levels and can minimize the risk of seizures. Nurses play a key role in encouraging the pregnant person to keep appointments with the health-care provider who is monitoring the seizure disorder.
Anemias
A level of red blood cells or hemoglobin that is too low to supply enough oxygen to the tissues of the body is called anemia. The number of red blood cells or amount of hemoglobin necessary for adequate oxygen delivery varies by age, sex assigned at birth, smoking status, geographic elevation of living conditions, and pregnancy.
Anemia affects populations worldwide in developed and developing countries (WHO, 2023a). During pregnancy, anemia has been linked with increased maternal and fetal morbidity and mortality, including postpartum hemorrhage, placental abruption, preterm birth, fetal growth restriction, and stillbirth (Shi et al., 2022). Current guidelines recommend screening for anemia during each trimester to minimize risks (ACOG, 2021a).
Nutritional Anemias
Dietary habits play an important role in preventing anemia. Diets deficient in iron, folate, and vitamin B12 can lead to anemia. For the prevention of iron deficiency anemia during pregnancy, current recommendations include taking a daily iron supplement to support maternal and fetal iron levels (National Academies of Sciences, Engineering, and Medicine, 2020). Patients can be encouraged to increase iron levels by consuming foods rich in iron, such as meats, beans or legumes, green leafy vegetables, iron-fortified cereals or whole grains, nuts, seeds, and dried fruits, shown in Figure 12.3. Caffeine intake through tea and coffee can inhibit iron absorption, so patients should be counseled to avoid caffeine around mealtimes. As with iron, folic acid can be supplemented through a prenatal vitamin to treat anemia related to folic acid deficiency. Daily requirements for folic acid increase during pregnancy, and folic acid intake can be increased by incorporating dark leafy vegetables, legumes, and animal proteins into a healthy diet.
Vitamin B12 deficiency is more common in patients with Crohn’s disease or in those who have a history of gastrectomy. Vitamin B12 deficiency may also be more common in vegan or vegetarian diets because vitamin B12 is primarily found in meat, fish, eggs, and dairy. Monthly intramuscular (IM) injections with vitamin B12 (cyanocobalamin, a synthetic form of vitamin B12) or oral supplements can treat B12 deficiency during pregnancy. The nurse can provide patient education at an individual or community level. Ensuring access to diverse food options promotes a well-balanced diet and adequate intake of protein, vitamin C, vitamin A, and iron to minimize anemia during pregnancy (Nana & Zema, 2018). Figure 12.4 shows foods rich in vitamin B12.
Cultural Context
Nutritional Deficiency Due to Cultural Food Beliefs
Cultural sensitivity is essential to establishing a trusting relationship with the patient and helping them understand their nutritional needs during pregnancy. A trusting relationship begins with respect for the patient’s cultural food beliefs and practices. The nurse can take the following steps while caring for the patient:
- Inquire about their beliefs, background, and practices related to food.
- Educate the patient on the importance of adequate nutrient intake and the risks associated with anemia.
- Identify food options that are culturally appropriate and nutrient dense.
- Consult a nutritionist or health-care provider who has experience with the patient’s cultural background.
- Identify barriers to accessing nutritional food options.
- Encourage the patient to interact with their family and support network to discuss ways to improve nutrition during pregnancy.
- Collaborate with an interdisciplinary team, including a social worker and interpreter, to maintain respect for the patient’s beliefs and practices.
- Advocate for the health of the patient and the fetus.
Sickle Cell Disease
Due to advances in medicine, the average lifespan of people with sickle cell disease (SCD) is increasing. As a result, patients with SCD are able to become pregnant and give birth to healthy newborns. With regular prenatal care, these patients can reduce maternal and fetal risks during pregnancy. Some complications of SCD during pregnancy include preeclampsia, preterm labor, miscarriage, and fetal growth restriction. Preconception counseling and pregnancy planning can reduce the risks of these complications. Patients with SCD or sickle cell trait may be counseled on the need for additional genetic testing, reproductive technology, or prenatal testing. Nurses can provide emotional and psychosocial support to aid parents with the decision-making process.
Physiologic changes of pregnancy can induce stress on various organs and lead to a sickle cell crisis, acute chest syndrome, or preeclampsia and eclampsia. Sickle cell crises can be reduced by maintaining adequate hydration and minimizing overexertion. Nurses can encourage patients to promptly visit their health-care provider when experiencing nausea and vomiting during the first trimester. Patients with SCD who may become pregnant should be counseled on the risks of pregnancy and the importance of prenatal care. Furthermore, patients taking medications with teratogenic effects, such as hydroxyurea (Droxia), angiotensin-converting enzyme (ACE) inhibitors, and iron chelators, should be instructed to discontinue these medications prior to pregnancy (Jain et al., 2019).
Thalassemia
Thalassemia is an inherited blood disorder in which the blood contains an inadequate amount of hemoglobin. Two types of polypeptide chains, alpha and beta, make up the hemoglobin molecule. Depending on which chain is mutated, a person develops alpha thalassemia. When this occurs, the amount of hemoglobin decreases, and anemia ensues.
Complications of pregnancy related to thalassemia include preterm birth, miscarriage, gestational hypertension, gestational diabetes, placental abruption, urinary tract infection, and renal and gallbladder stones (Petrakos et al., 2016). Patients with thalassemia should be monitored prior to and during pregnancy for cardiac problems, liver dysfunction, infection, and endocrine disorders. Because the most common cause of mortality in people with thalassemia is related to cardiac complications, it is important to closely monitor cardiac function. Liver dysfunction may also occur due to iron overload and chronic anemia. Because patients may have a history of frequent blood transfusions, testing for infections such as hepatitis B, hepatitis C, HIV, and cytomegalovirus may be indicated. Screening for endocrine disorders such as diabetes or hypothyroidism can further reduce pregnancy risk. Chelation therapy to decrease iron overload has been controversial during pregnancy and is generally reserved for severe cases in which maternal risk outweighs fetal risk (Petrakos et al., 2016). For patients with thalassemia, the risk of thrombosis increases with pregnancy, and patients should be educated on the prevention of blood clot formation and monitored closely for signs of blood clots. Nurses can educate the patient on the signs and symptoms of blood clots and the importance of undergoing testing and treatment as soon as possible.
Immune Thrombocytopenia
In the autoimmune disorder immune thrombocytopenia (ITP), platelets are destroyed, leading to low platelet levels. Diagnosis is usually made when there is isolated thrombocytopenia without other associated etiologies (ACOG, 2019b). First-line medications for treatment include corticosteroids and intravenous immunoglobulin (IVIG). Platelet transfusions may be indicated if the platelet count is less than 50 × 109/L near delivery or if there are signs of severe bleeding (ACOG, 2019b). Occasionally, newborns can develop thrombocytopenia from antibodies that cross the placenta, although this is not common.
Respiratory Disorders
Management of respiratory disorders prior to and during pregnancy focuses on establishing adequate oxygenation. Education on maternal and fetal risks related to pulmonary complications during pregnancy should be provided during the preconception period or the first prenatal visit. Respiratory disorders that can complicate pregnancy include cystic fibrosis, asthma, and tuberculosis.
Cystic Fibrosis
A genetic mutation in the transmembrane conductance regulator (CFTR) gene causes cystic fibrosis, a disorder in which thick mucus builds up in various organs of the body, such as the lungs, pancreas, and intestines. Patients with cystic fibrosis may experience pregnancy complications such as increased respiratory infections, impaired airway clearance, pancreatic insufficiency, and nutritional deficiencies. Pancreatic insufficiency affects both insulin production, resulting in diabetes, and production of digestive enzymes, resulting in malabsorption of some nutrients. The nurse can promote healthy habits by encouraging patients with cystic fibrosis to adhere to their current regimen related to medications, respiratory treatments, and dietary needs. Additional nursing interventions include assessment and monitoring, collaboration with a multidisciplinary team, medication administration, assistance with respiratory and nutritional support, and counseling and education. The other biological parent should be tested to see if they are a carrier of CF to determine the risk of the fetus inheriting the disease.
Asthma
Patients with asthma who become pregnant have an increased risk of asthma worsening in severity. Acute asthma exacerbations during pregnancy pose a risk for increased maternal and fetal morbidity and mortality. These risks can be decreased when asthma is well controlled. Exacerbations may be characterized by shortness of breath, wheezing, cough, and chest tightness. Albuterol (Ventolin), shown in Figure 12.5, is the primary treatment for acute exacerbations during pregnancy. Inhaled or systemic steroids may be indicated if symptoms worsen or persist. Systemic steroids should be prescribed judiciously due to the risk of congenital anomalies, preeclampsia, gestational diabetes, and prematurity (American Academy of Allergy, Asthma, and Immunology, 2023). Patients with asthma who become pregnant should be encouraged to identify and avoid exposure to triggers. The nurse should be prepared to teach patients about available medications and their side effects and remind them how to avoid triggers.
Tuberculosis
The bacterial illness tuberculosis (TB) is a global health problem that affects people of all ages. The bacterium Mycobacterium tuberculosis primarily impacts the lungs and can cause symptoms such as a chronic cough, hemoptysis, fever, night sweats, chills, fatigue, and chest pain; symptoms can range from mild to severe. People who live in close proximity with others, such as in overcrowded housing, homeless shelters, and prisons, are at an increased risk of exposure. A pregnant patient who has been exposed to TB should be promptly evaluated by their health-care provider. Screening can be done through a tuberculin skin or blood test, and if positive, a chest x-ray may be performed. The nurse can administer the tuberculin skin test and interpret the results 48 to 72 hours after administration, or the nurse may assist with collecting blood for the lab draw. Patients should be encouraged to adhere to the medication regimen, which can take several months, in order to eradicate the infection. Medications for active tuberculosis include isoniazid (Nydrazid), rifampin (Rifadin), and ethambutol (Etibi). All these drugs have an excellent safety record in pregnancy and are not associated with human fetal malformations. Monitoring for liver dysfunction, hepatitis, and medication interactions during treatment is generally recommended. A patient with tuberculosis should be placed in a negative pressure room on hospital admission to prevent the spread of infection. Untreated tuberculosis may increase the risk for low birth weight in the infant or, in rare cases, congenital tuberculosis (Leidecker & Dorman, 2016).
Cardiac Disease
Because pregnancy puts additional strain on the heart, patients with preexisting cardiac disease are at increased risk of cardiac complications. Preconception counseling should include the risk of further cardiac damage if the person becomes pregnant or whether the person’s current cardiac status can support a pregnancy. The need to change cardiac medications based on risks to the growth and development of the fetus is also included in preconception counseling. Cardiac conditions prior to pregnancy include congenital heart disease, valvular disease, coronary artery disease, and aortic diseases.
While congenital heart diseases range in severity, patients who become pregnant should be monitored primarily for arrhythmias and signs of heart failure. In cases of severe valvular disease, surgery may be indicated prior to conception. In patients with aortic diseases, the greatest risk during pregnancy includes aortic dissection or rupture, which can be fatal (Coleman, 2019; Kamel et al., 2016). Patients with coronary artery disease prior to pregnancy are at increased risk of acute cardiac events during pregnancy, such as myocardial infarction (Coleman, 2019). Monitoring during pregnancy may include routine cardiac assessment and imaging, such as echocardiogram and electrocardiogram. Patients should be counseled on the risk of cardiac dysfunction during pregnancy and the associated morbidity and mortality (Coleman, 2019). Classification of cardiac disease can assist the health-care team with evaluating risk. Table 12.5 summarizes the risks to the pregnant person and the fetus based on type and severity of cardiac disease (Meng et al., 2023). Management should involve a multidisciplinary approach, with cardiology playing an active role when indicated and delivery occurring at a facility with a high-risk pregnancy unit. Preexisting cardiac disease in the pregnant person increases the risk of fetal hypoxia and preterm birth.
| Class | Increased Fetal Risk |
|---|---|
| Class I | No increased risk of maternal mortality None or mild increased risk of morbidity |
| Class II | Small increased risk of maternal mortality Moderate increased risk of morbidity |
| Class III | Significant increased risk of maternal mortality Significant increased risk of severe morbidity |
| Class IV | Extremely high risk of maternal morbidity and mortality |
Renal Disease
Patients with chronic kidney disease (CKD) often experience decreased fertility. However, when pregnancy does occur, maternal complications include decreased kidney function, hypertensive disorders, miscarriage, and exacerbation of other medical conditions. Fetal complications include low birth weight, stillbirth, and prematurity. Because of these risks, pregnancy planning is crucial, and contraception should be encouraged until the patient is ready to conceive (Wiles et al., 2019). Preconception interventions include counseling patients on risks during pregnancy, adjusting medications to minimize fetal risk, obtaining a baseline health assessment with diagnostic tests, and managing other comorbidities. A multidisciplinary approach can incorporate nephrology to optimize renal function during pregnancy. Interventions during pregnancy may include close monitoring of lab tests and imaging, managing hypertension, preventing preeclampsia, optimizing nutrition, evaluating for gestational diabetes, and monitoring therapeutic drug levels when indicated. Fetal imaging can evaluate growth and assess for congenital anomalies.
Immune Disorders
Because autoimmune disorders are more common in persons assigned female at birth, they are often the most common preexisting condition relative to pregnancy (Merz et al., 2022). Autoimmune disorders range in severity and symptoms. Complications of autoimmune disease generally include miscarriage, stillbirth, fetal growth restriction, and prematurity (Merz et al., 2022). Patient education prior to pregnancy plays a pivotal role in risk factor reduction. Often this requires a multidisciplinary approach with increased involvement of multiple specialists for complex cases. As with other preexisting conditions, optimizing disease management prior to pregnancy is pivotal. Pregnancy planning should take into account the disease course and how medications impact conception and fetal development.
HIV
A patient who has human immunodeficiency virus (HIV) can give birth to a healthy infant who does not have HIV. While the virus can cross the placenta, viral suppression through antiretroviral therapy (ART) and adequate prenatal care can significantly reduce this risk. Counseling prior to conception and during pregnancy should focus on adhering to treatment regimens and minimizing risk factors. The nurse should teach the patient ways to reduce risks of HIV perinatal transmission, such as limiting alcohol, tobacco, and illicit drug use and avoiding unprotected intercourse. Patients who are planning to conceive can be educated on the increased risk of stillbirth, low birth weight, and preterm delivery.
The CDC currently recommends HIV screening for all patients who are pregnant (CDC, 2022c), but additional screening may be indicated for high-risk populations. Risk factors for acquiring HIV during pregnancy include multiple sex partners, IV drug use, and recent diagnosis of another sexually transmitted infection (Szlachta-McGinn et al., 2020). Management during pregnancy includes antiretroviral therapy (ART), scheduled cesarean delivery in the presence of high viral loads, and antiretroviral therapy for infants born to people who are HIV positive. Health-care providers and nurses can educate patients who are HIV positive that they can use formula or donor milk for newborn nutrition, or patients who have taken ART during pregnancy, delivery, and postpartum can breast-feed if they understand that their risk of transmission to the newborn through breast milk is less than 1 percent (CDC, 2023). Patients should continue ART while breast-feeding.
The HIV-positive patient should be monitored for opportunistic infections, such as oral thrush, during pregnancy as well as evaluated for other sexually transmitted infections. Tuberculosis testing should be performed because of the risk that a latent tuberculosis infection can become active. Serial lab monitoring should include CD4 counts, complete blood counts, renal and liver function tests, and viral loads.
Systemic Lupus Erythematosus
In the autoimmune disease systemic lupus erythematosus (SLE), the body’s immune system attacks healthy tissues in multiple organ systems. Ideally, SLE should be in a dormant state for 6 months prior to conception. An increase in SLE flares can occur during pregnancy. The antibodies most concerning during pregnancy are the Anti-Ro (SSA) and Anti-La (SSB) antibodies because they cross the placenta and can lead to neonatal heart block or neonatal lupus. Screening for these antibodies during pregnancy can help evaluate the risk of neonatal lupus. In pregnancy, SLE carries an increased risk of miscarriage, stillbirth, preeclampsia, and thrombosis. The presence of anti-phospholipid antibodies increases the risk of thrombotic events, so anticoagulation may be initiated. The more severe the course of the disease, the greater the risk to the pregnant person and fetus. Pregnancy planning helps to stabilize the disease and reduce the risks. Identification and management of associated complications, such as lupus nephritis, can lead to better outcomes.
Rheumatoid Arthritis
The systemic autoimmune disease rheumatoid arthritis (RA) is characterized primarily by joint inflammation, but it can impact other vital organs as well. Patients with RA are more likely to experience a cesarean delivery, develop preeclampsia, or deliver prematurely (Sim et al., 2023). Signs and symptoms of RA often improve in patients during pregnancy, beginning in the first trimester. Symptoms of RA during pregnancy include fatigue, joint pain, and swelling of the hands and feet. Health-care providers should review current medications to establish safe use during pregnancy. Certain medications, such as methotrexate (Trexall), are contraindicated during pregnancy. Patients should be counseled on the risk of adverse outcomes and the signs of RA to monitor during pregnancy.