Risk factors in Complex Pregnancy - Research Paper Example

Complex Pregnancy: Case Analysis Introduction This paper provides a case analysis of a complicated pregnancy that ends in preterm labor and delivery respectively; Kylie, the woman in the case experiences preterm labor in her present sixth IVF pregnancy. This paper will identify and discuss three risk factors in Kylie’s history that predispose her to preterm labor and delivery; thereafter, this paper will offer an analysis and discussion of the treatment and management required when caring for a preterm neonate like James in the neonatal nursery, with rationales. In the end, this paper will explain the specific postnatal cares and management that the midwife would provide to Kylie following delivery and during her stay on the postnatal ward. Risk factors for preterm labor and delivery in Kylie’s history Perceived psychosocial stress as well as the overall psychological wellbeing of a woman during pregnancy has been attributed to preterm delivery and intrauterine growth retardation (Dolatian, Mirabzadeh, Forouzan, Sajjadi, Majd et al, 2013). Empirical evidence supports the conclusion that preterm delivery is predicated by lack of social support, which increases the risk for psychosocial stress (Ghosh, Wilhelm, Dunkel-schetter, Lombardi, & Ritz, 2010); from the case study, Kylie is described as a 40 year old G6PO with her 6th IVF pregnancy who presents alone to the birth unit of the local tertiary hospital. The fact that Kylie has had 6 IVF pregnancies and presents alone to the local tertiary hospital suggests that she could be living alone, unmarried or unsupported, and without adequate social support from family or friends. Upon further enquiry, Kylie discloses experiencing anxiety and depression related to her recent separation from her husband of ten years; Kylie is referred to the Obstetric social worker and psychologist for support since it was evident that her depression and anxiety was related to her lack of social support. Research indicates that preterm delivery is common in women of lower social class, unmarried, or unsupported mothers (Mannem, & Chava, 2011); lack of social support greatly predisposes such women to psychosocial stress. The presence of a spouse and social cycles greatly reduce the risk for psychosocial stress for pregnant women because they are able to share their fears and frustrations thereby alleviating the risk of worry and anxiety that may trigger preterm labor and delivery (Mirabzadeh, Dolatian, Forouzan, Sajjadi, Majd et al, 2013). In that respect, the lack of social support that greatly predisposes Kylie to psychosocial stress is highly predictive of preterm labor and delivery that she experiences in her 6th IVF pregnancy. Medical complications such as previous preterm deliveries, recurrent vaginal bleeding during early pregnancy, as well as heart disease has also been attributable to cases of preterm labor and delivery in women. Previous preterm deliveries have mostly been associated with preterm labor and delivery; precisely, 2-4 previous miscarriages, or stillbirths are highly indicative of the risk for preterm labor and delivery (Goldenberg, Culhane, Iams & Romero, 2008). From the case study, it is clear that Kylie has a complex obstetric history as predicated by her previous five pregnancies that all resulted in late miscarriages between 10-16 weeks of gestation. Furthermore, after her third miscarriage, Kylie had a laparoscopy and surgery to divide a small uterine septum; it is also narrated that Kylie had a cervical sature inserted at 8 weeks gestation in her last pregnancy. Furthermore, Kylie had been taking daily doses of Aspirin and Fragmin for clinically confirmed obstetric lupus that was diagnosed after she lost her third pregnancy. Lupus pregnancies like Kylie’s often always end up in miscarriages, which make them high-risk pregnancies; whereas active lupus often cause miscarriages in the first trimester, later trimester pregnancies are attributable to lupus anticoagulant antibodies. These antibodies interrupt the normal functioning of blood vessels and may also lead to narrowing of the vessels thereby triggering high blood pressure; furthermore, lupus women are more likely to retain body fluid that may rupture the placenta triggering a miscarriage or preterm delivery. All the miscarriages and complications that characterize Kylie’s complex obstetric history greatly predispose her to preterm labor and delivery, as suggested by empirical evidence linking previous pregnancy complications to the high risk of preterm labor and delivery. Urinary tract infections (UTIs) have been attributed to preterm labor and delivery since they may cause a reaction in a mother’s body eventually irritating the uterus and making contractions more likely to start. Infections, particularly chorioamnionitis, often lead to preterm labor since when unwanted organisms slip through the cervical mucus plug into the uterus they inevitably trigger an inflammatory response not only in the placenta, but also in the fetal membranes as well as in the maternal decidua (Rours, Krijger, Ott, Willemse, Groot, et al, 2011). Consequently, the cytokines that are released following such inflammatory reactions eventually stimulate the flow of prostaglandin production that lead to the ripening of the cervical and uterine contractions, thereby causing preterm labor and delivery. From the case study, it is reported that Kylie experienced a urinary tract infection at 28 weeks gestation, which led to her admission to the antenatal ward where she was treated and managed for an episode of premature labor. In that respect, the urinary tract infection may have triggered the false biological alarms that accentuated the ripening of the cervical and uterine contractions, thereby leading to the preterm labor and delivery that she later experienced. Treatment and management of a premature neonate The present prevalence of diagnoses of thromboembolic events in preterm neonates has been attributed to the widespread use of umbilical catheters and central venous catheters (Van Elteren, Pas, Kollen, Walther & Lopriore, 2010); low-molecular-weight heparin (LMWH) is highly recommended for a vast majority of clinical indications of thromboembolic events in premature neonates. For instance, deep venous thrombosis, cerebral sino-venous thrombosis as well as renal vein thrombosis are often treated with LMWH; nonetheless, there is limited data on the efficacy of LMWH treatment in neonates, especially in extremely low birth weight category. Methadone is increasingly used in neonatal intensive care units not only as an analgesic, but also as an agent that contributes to the weaning of patients from prenatal exposure to opioids like morphine and fentanyl (George, Kitzmiller, Ewald, O’Donell & Becter et al, 2012). The pediatric population highly regards methadone as a superior form of anesthetic, unlike other anesthetics, thus great care must be taken to avoid methadone toxicity in infants due to an overdose. Preterm neonates like James are also at an increased risk of Hypoglycemia, which is a common complication associated with preterm births; the immaturity of the neonate’s fasting system coupled with insufficiency of energetic stores as well as hyper-insulinism have been associated with the prevalence of recurrent hypoglycemia in premature infants. Severe and prolonged exposure of preterm neonates to hypoglycemia may lead to neurologic sequelae since the brain relies on glucose for it to function normally; in that respect, identification of risk factors for hypoglycemia helps to improve the hypoglycemia prophylaxis of the preterm, thereby aiding in the prevention of future risks for abnormalities in the central nervous system. The inactivated form of protein C serves as a safe therapeutic option in preterm neonates since their susceptibility to bleeding coupled with lower plasma levels of protein C13 implies that they cannot be treated with activated vitamin C, which inevitably increases the risk for bleeding (De Carolis, Polimeni, Papacci, Laceranza & Romagnoli, 2008). The vacuum-assisted closure (VAC) is recommended as an effective way of managing and facilitating closure of large and complex wounds in preterm infants with their extraordinarily soft tissue defects (Mortellaro, Peter, Fike & Islam, 2011). The care for large and chronic wounds in neonatal and pediatric patients is a highly delicate matter since they could potentially degenerate to life-threatening wounds; in that respect, the VAC therapy uses negative pressure to treat acute chronic wounds in premature neonates (Choi, Mcbride & Kimble, 2011). In this therapy, the negative pressure applied to the wound reduces edema while enhancing the local circulation of blood besides removing extracellular fluid to create an optimal moist environment that facilitates healing respectively. Presently, perforated necrotizing enterocolitis (NEC) in low-birth weight neonates is a predominant surgical issue in neonatal intensive care units (NICU) (Ibáñez, Couselo, Marijuán, Vila, & García-sala, 2012; Choo, Papandria, Zhang, Camp, Salazar, et al, 2011). The local surgical option of local peritoneal drainage has greatly improved neonatal care outcomes; nevertheless, local drainage of the peritoneal cavity is often advocated for as definitive treatment for perforated NEC, especially in neonates that are so weak to undergo surgery. Postnatal care and management in the postnatal ward The immediate postpartum period following delivery has been confirmed to be a very crucial transition period for women since they are normally predisposed to numerous vulnerabilities that often endanger the health of both the mother and the infant (Barros, Bhutta, Batra, Hansen, Victora et al, 2010); Malin, Susan, Kristian & Eskild 2010). Postnatal care is very significant for mothers, particularly after preterm delivery since it helps alleviate the risk of maternal and infant morbidity and mortality. In the post natal care ward, healthcare professionals are able to evaluate the mothers to determine any post-delivery complications and to offer prompt treatment (Titaley, Hunter, Heywood, & Dibley, 2010). The high risk of maternal problems and fatalities in the first days following delivery necessitates the provision of speedy and early post-delivery mediations with the aim of not only influencing but totally altering the maternal and child mortality incidences globally (Barros, Bhutta, Batra, Hansen, Victora et al, 2010). Vaginal soreness as a result of episiotomy or vaginal tear in the course of delivery is a common issue for many mothers after successful vaginal delivery; similarly, vaginal discharge, urination problems as well as contractions are inevitable in the days following delivery. The postnatal midwife should provide essential advise to the mothers in their care on how to deal with these issues and most importantly, on how to maintain proper hygiene to avoid infection of the mother; the midwifes may also provide other appropriate help such as medications, particularly antibiotics, to promote quick recovery of the mother. Mothers in the postnatal period must also eat right and whenever they are hungry as opposed to maybe when they are available since proper nutrition is crucial for the quick recovery of the mother after delivery. The postnatal care midwife should provide advice on proper dietary options for the mothers; for instance, mothers must maintain a proper diet by avoiding high-fat snacks, eating low-fat foods that have all the essential nutritional values while drinking plenty of fruits. A preterm delivery is often accompanied by heavy psychological distress as well as depression for the mother, which have been attributed to the inevitable separation of the mother from the baby, the infant’s ailing status, uncertainties regarding possible outcomes and socioeconomic worries (Kukreja, Datta, Bhakhri, Singh, & Khan, 2012). Postnatal psychological distress and depression is highly prevalent among mothers following preterm delivery in comparison with mothers giving birth at full term due to the high incidence of immediate stressful factors (Miniati, Callari, Calugi, Rucci, Savino, et al, 2014). Nearly 10-15% of postpartum women suffer postpartum depression (Haga, Ulleberg, Slinning, Kraft, Steen, et al, 2012). Psychological distress and depression in women in postnatal care may persist even after the stressful circumstances have been resolved successfully (Moel, Buttner, Ohara, Stuart, & Gorman, 2010); post-partum depression does not only undermine family dynamics, but may also undermine health of the infant and the mother significantly, thereby contributing to maternal and infant morbidity (Furuta, Sandall, Cooper, & Bick, 2014). Evidently, postnatal psychological distress and depression is often ignored or underestimated among many mothers following preterm delivery; in that respect, mothers must undergo thorough screening for symptoms of psychological distress and depression after pre-term delivery. In our case study, Kylie must be screened thoroughly for features of psychological distress and depression in her early postnatal days at the post natal ward; early detection and timely management of the condition eventually promotes outcomes of interventions thereby promoting the health and wellbeing of both the mother and the infant. Numerous psychological as well as pharmacological interventions have been advanced for treating postnatal depression in developed nations; for instance, 12 sessions of interpersonal therapy given to women after preterm delivery could potentially improve moods of the women (Carter, Grigoriadis, & Ross, 2010). In the post natal care ward, the midwife must ensure mothers receive optimum maternal care while meeting all the emotional needs of the mothers; precisely, healthcare professionals must constantly find out how mothers are coping psychologically (McLellan & Laidlaw, 2013). In that respect, Kylie could benefit greatly from sessions of interpersonal therapy to help her overcome the heightened risk of postnatal psychological distress and depression that is high in women after a preterm delivery. Furthermore, given that postpartum distress is highly associated with maternal exhaustion (Kurth, Spichiger, Stutz, Biedermann, Hösli & Kennedy, 2010), women receiving care in the postnatal ward like Kylie must be treated to adequate bed-rest to facilitate the recuperation process, consequently alleviating the risk for postpartum distress. Adequate rest can be facilitated through routine postnatal care activities that attend to all the needs of mothers in the postnatal ward, to prevent tiredness or fatigue as well as severe sleep deprivation that mothers often suffer in the process of providing infant care. Summary From the analysis of Kylie’s case, three risk factors that predisposed her to preterm labor and delivery were identified; firstly, Kylie’s preterm labor and delivery is attributable to psychosocial stress. The case reveals that Kylie did not have adequate social support during her pregnancy because she had been separated from her husband of nearly ten years, which predisposed her to psychosocial stress. The second risk factor that highly predisposed Kylie to preterm labor and delivery was her previous preterm deliveries; the case also shows that she had experienced five late pregnancy loses before, which could have put her at risk of preterm labor and delivery in her present pregnancy. Equally, Kylie’s preterm labor and delivery can be attributable to the urinary tract infection that she experienced at 28 weeks gestation, which led to her admission to the antenatal ward where she was treated and managed for an episode of premature labor. Preterm neonates like James require specialized treatment and management in the neonatal intensive care unit to survive since they are delicate and vulnerable in many ways. For instance, thromboembolic events in preterm neonates are managed through low-molecular-weight heparin (LMWH) while methadone is used in neonatal intensive care units both as an analgesic and as medication for neonatal opiate withdrawal syndrome. Mothers like Kylie, require essential postpartum care and services such as psychological support in the postnatal care ward, to cope effectively with the postpartum distress and depression following preterm delivery. References Barros, F. C., Bhutta, Z. A., Batra, M., Hansen, T. N., Victora, C. G., & Rubens, C. E. 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