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COMPLICATIONS OF PREGNANCY Jeanie Ward Risk Factors Age – under 17 over 35 Gravida and Parity Socioeconomic status Psychological well-being Predisposing chronic illness – diabetes, heart conditions, renal, etc. Pregnancy related conditions – hyperemesis gravidarum, PIH, etc. High Risk Pregnancy Goals of Care Provide with optimum care for the mother and the fetus Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings Abortions Termination of pregnancy at any time before the fetus has reached viability Either: spontaneous – occurring naturally induced – artificial Question 1 What would cause a woman to abort a pregnancy ? • Chromosomal abnormalities - Faulty germ plasm -imperfect ova or sperm, genetic make-up (chromosomal disorders), congenital abnormalities • Faulty implantation • Decrease in the production of progesterone • Drugs or radiation • Maternal causes -- infections, endocrine disorders, malnutrition, hypertension, cervix disorder Nursing Assessment The nurse collects the following data from Mrs. X.: Gravida 1, Para 0 14 weeks gestation Had bright red vaginal bleeding Experiencing abdominal pain What is the appropriate action now? Threatened Abortion • Signs and Symptoms – vaginal bleeding, spotting – Mild cramps, backache – Cervix remains CLOSED • Treatment and Nursing Care – – – – Bed rest, sedation, Avoid stress and intercourse Progesterone therapy A period of “watchful waiting” • The more blood loss, the more likely the woman is to progress from threatened to inevitable abortion. • A = True • B = False Inevitable Abortion • Signs and Symptoms – Loss is certain – Bleeding is more profuse – Painful uterine contractions – Cervix DILATES • Treatment and Nursing Care – Assess all bleeding. Save all pads. (May need to weigh the pads) – Use the bedpan to assess all products expelled – Treated by evacuation of the uterus usually be a D & C or suction • Provide Psychological Support Complete Abortion • All products of conception are expelled • No treatment is needed, but may do a D & C With speculum inserted into the vagina, first the os of cervix is dilated and then the curette device is used to empty the contents of the uterus. Incomplete Abortion • Parts of the products of conception are expelled, with placenta and membranes retained • Treated with a D & C or suction evacuation • Provide support to the family A woman who is 12 weeks gestation comes to the ER complaining of vaginal bleeding. What is the Appropriate action(s) of the nurse? (select all that apply) a. b. c. d. e. f. Save all clots or material passed Perform a vaginal exam to assess dilation Prep her for a D&C Assess vital signs Assess quickening Prep for ultrasound Missed Abortion • • • • Fetus dies, but is retained in the uterus. Symptoms of pregnancy disappear Maceration occurs Treatment: – D&C; Hysterotomy Question? • What are two main complications related to a missed abortion? • 1. • 2. Recurrent / Habitual Abortion • Abortion occurs consecutively in _____ or more pregnancies • Usually due to an Incompetent Cervical Os • Occurs most often about 18-20 weeks gestation. Habitual Abortion • Treatment – Cerclage procedure -- pursestring suture placed around the internal os to hold the cervix in a normal state Nursing Care • Bedrest in a slight trendlenburg position to decrease the pressure on the new sutures • Teach: – Assess for leakage of fluid, bleeding – Assess for contractions – Assess fetal movement and report decrease movement (if old enough) – Assess temperature for elevations Delivery options: • When time for delivery there are several options: – physician will clip suture and allow patient to go into labor on her own – induce labor – cesarean delivery Key Concepts to Remember!! • If a woman is Rh-, RhoGam is given within 72 hours • Provide emotional support. Feelings of shock or disbelief are normal • Encourage to talk about their feelings. It begins the grief process Bleeding Disorders Ectopic Pregnancy • Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus ovary (5) Cervical Question 2 Etiology / Contributing Factors • • • • • Salpingitis Pelvic Inflammatory Disease, PID Endometriosis Tubal atony or spasms Imperfect genetic development Question 3 Assessment Ectopic Pregnancy • Early: • Missed menstruation followed by vaginal bleeding (scant to profuse) • Unilateral pelvic pain, sharp abdominal pain • Referred shoulder pain • Cul-de-sac mass • Acute: • Shock • Cullen’s sign -- bluish discoloration around umbilicus • Nausea, Vomiting • Faintness Diagnostic Tests Ectopic Pregnancy • Diagnosis: • Ultrasound • Culdocentesis • Laparoscopy Treatment Options / Nursing Care • Combat shock / stabilize cardiovascular • Draw blood for type and cross match • Give blood replacements • IV’s. • Laparotomy • Psychological support • Linear salpingostomy • Methotrexate – used prior to rupture Question 4 Gestational Trophoblastic Disease Hydatiform Molar Pregnancy Etiology A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI As cells degenerate, they become filled with fluid and appear as fluid filled grapesize vessicles. Question 5 Assessment: • Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) • Enlargement of the uterus out of proportion to the duration of the pregnancy • Vaginal discharge of grape-like vesicles • May display signs of pre-eclampsia early • Hyperemesis gravidarium • No Fetal heart tone or Quickening • Abnormally elevated levels of HCG Question 6 Interventions and Follow-Up • Empty the Uterus by D & C or Hysterotomy • Prior to evacuation the following lab tests are done to develop a baseline: – Chest x-rays – Blood chemistry tests – Serum β-hCG Question 7 Hydatiform Molar Pregnancy • Extensive Follow-Up for One Year • • • • • Assess for the development of choriocarcinoma Blood tests for levels of HCG frequently Chest X-rays Placed on oral contraceptives If the levels rise, then chemotherapy started usually Methotrexate Question 8 Critical Thinking Exercise • A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her. • How should the nurse respond? Placenta Previa • Low implantation of the placenta in the uterus • Etiology • Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors • Three Major Types: • Low or Marginal • Partial • Complete Question 9 Abruptio Placenta Premature separation of the placenta from the implantation site in the uterus Etiology: Chronic Hypertension Sudden decompression of an over-distended uterus Trauma Injudicious use of Pitocin Smoking / Caffeine / Cocaine Vascular problems Placenta Previa • PAINLESS vaginal bleeding • Bright red bleeding • First episode of bleeding is slight then becomes profuse • Signs of blood loss comparable to extent of bleeding • Uterus soft, non-tender • Fetal parts palpable; FHT’s countable • Blood clotting defect absent Abruptio Placenta Bleeding accompanied Abruptio by PAIN Dark red bleeding First episode of bleeding usually profuse Signs of blood loss out of proportion to visible amount Uterus board-like, painful Fetal parts non-palpable, FHT’s non-countable Blood clotting defect (DIC) likely Signs of Concealed Hemorrhage Increase in fundal height Hard, board-like abdomen High uterine baseline tone on electronic fetal monitoring Persistent abdominal pain Systemic signs of hemorrhage Question 9-C Interventions and Nursing Care Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to deliver vaginally Cesarean delivery for All other types of previa Treatment and Nursing Care Abruptio Placenta Deliver by cesarean delivery immediately Combat shock – blood replacement / fluid replacement Blood work – assessment of DIC Critical Thinking Mrs. A. , G3 P2, 38 weeks gestation is admitted to L & D with bleeding. What is the priority nursing intervention at this time? A. Assess the fundal height for a decrease B. Place a hand on the abdomen to assess if hard, board-like, tetanic C. Place a clean pad under the patient to assess the amount of bleeding D. Prepare for an emergency cesarean delivery Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time. Question 10 Etiology Defect in the Clotting Cascade • An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin Thrombin (powerful anticoagulant) is produced Fibrinogen fibrin which enhances platelet aggregation Widespread fibrin and platelet deposition in capillaries and arterioles Resulting in Thrombosis (multiple small clots) Excessive clotting activates the fibrinolytic system Lysis of the new formed clots create fibrin split products These products have anticoagulant properties and inhibit normal blood clotting A stable clot cannot be formed at injury sites Hemorrhage occurs Ischemia of organs follows from vascular occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and can result in death Disseminated Intravascular Coagulation (DIC) Precipating Factors: Abruptio placenta PIH Sepsis Retained fetus (fetal demise) Fetal placenta fragments Assessment Signs and Symptoms Spontaneous bleeding -- from gums and Epistasis, and injection and IV sites, incisions Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis Tachycardia, diaphoresis, restlessness, hypotension Hematuria, oliguria, occult blood in stool Question 10-C Mental changes if brain affected. Diagnostic Tests Lab work reveals: PT – Prothrombin time is prolonged PTT – Partial Thromboplastin Time increased D-Dimer – increased Product that results from fibrin degradation. More specific marker of the degree of fibrinolysis Platelets -- decreased Fibrin Split Products – increase An increase in both FSP and D-Dimer are indicative of DIC DIC Interventions and Nursing Care Remove Cause Evaluate vital signs Replace blood and blood products Fluid replacement May give Heparin Question 10-D: E Which signs and symptoms would support the diagnosis of DIC? a. Sudden onset of chest pain and frothy sputum b. Foul smelling, concentrated urine c. Oozing blood from the IV catheter site d. A reddened inflamed central line catheter site Try This! • C.M., 42y/o, comes into the Clinic complaining of: – vaginal bleeding and abdominal pain that is completely unlike her usual monthly cramping. She describes her pain as “very sharp” and an “11” on a scale of 0 to 10. – Her vital signs are T 98.8, P 102, R 24, and BP 102/64. She indicates that her blood pressure is “usually 130/90.” – She is unable to recall the date of her last menstrual period. Additionally, she has almost soaked an entire pad in the last hour. C.M. is very anxious and says, “I’ve never had any real female problems before, except for the little cramping I get on the first day of my period. She admits sheepishly to having gonorrhea five years ago. How about this one? • J.J. is a 40 y/o GiPo who is 22 weeks’ gestation, although her fundal height is consistent with 26 weeks’ gestation. She indicates that throughout the pregnancy she had periodic spotting that resembles prune juice. J.J. states: “I knew pregnancy would be difficult at my age in spite of what my grandmother says, but I am vomiting so much that my weight is down to 102 pounds. My pressure is up a little but I guess that’s because of my age too.” J.J.’s records indicate that her weight at the initial prenatal visit was 110 pounds. Her vital signs are T 98.6, P 86, R 20, and BP 142/90, but fetal heart tones and movement are not detected. She states, “It gets harder and harder to keep working in our restaurant.” HYPEREMESIS GRAVIDARIUM **Pernicious vomiting during Pregnancy Question 11 Hyperemesis Gravidarium Etiology Increased levels of HCG Assessment Persistent nausea and vomiting Weight loss from 5 - 20 pounds May become severely dehydrated with oliguria increased specific gravity, ketones in the urine, and dry skin Depletion of essential electrolytes Metabolic alkalosis -- Metabolic acidosis Starvation Nursing Care / Interventions Hyperemesis Gravidarium Control vomiting Maintain adequate nutrition and electrolyte balance Allow patient to eat whatever she wants If unable to eat – Total Parenteral Nutrition Combat emotional component – provide emotional support. Mouth care Weigh daily Check urine for output, ketones Question 12 & 13 PREGNANCY INDUCED HYPERTENSION A hypertensive disease of pregnancy. Known as pre-eclampsia and eclampsia. Pre-eclampsia = hypertension, edema proteinuria, Eclampsia = other signs plus convulsions It develops between the 20th and 24th week of gestation and disappears after the tenth day postpartum Question 14 PRIMIGRAVIDA UNDER 17 AND OVER 35 MULTIPLE PREGNANCY HYDATIFORM MOLE PREDISPOSING FACTORS FAMILY HISTORY VASCULAR DISEASE Diabetes, renal LOWER SOCIOECONOMIC STATUS Severe malnutrition, decrease Protein intake Inadequate or late prenatal care Question 15 PATHOLOGICAL CHANGES PIH is due to: GENERALIZED ARTERIOLAR CYCLIC VASOSPASMS (decrease in diameter of blood vessel) INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW ( in blood pressure) Endothelial CELL DAMAGE Intravascular Fluid Redistribution Decreased Organ Perfusion Question 16 Multi-system failure Disease Clinical Manifestation HYPERTENSION Earliest and The Most Dependable Indicator of PIH Hypertension B/P = 140 / 90 if have no baseline. 1. 30 mm. Hg. systolic increase or a 15 mm. Hg. diastolic increase (two occasions four to six hours apart) 2. Increase in MAP > 20 mm.Hg over baseline or >105 mm. Hg. with no baseline Positive Roll Over Test Rationale for HYPERTENSION The blood pressure rises due to: ARTERIOLAR VASOSPASMS AND VASOCONSTRICTION causing (Narrowing of the blood vessels) an increase in peripheral resistance fluid forced out of vessels HEMOCONCENTRATION Increased blood viscosity = Increased hematocrit Key Point to Remember ! HEMOCONCENTRATION develops because: Vessels became narrowed forcing fluid to shift Fluid leaves the intracellular spaces and moves to extracellular spaces Now the blood viscosity is increased (Hemocrit is increased) **Very difficult to circulate thick blood Test Yourself ! Which of these readings indicates hypertension in the patient whose blood pressure normally is 100 / 60 and MAP of 77? a. 120 / 76; b. 110 / 70; c. 130 / 80; d. 125 / 70; MAP 96 MAP 83 MAP 98 MAP 88 Proteinuria With Renal vasospasms, narrowing of glomular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate (damage to glomeruli) PROTEINURIA Spilling of 1+ of protein is significant to begin treatment Oliguria and tubular necrosis may precipitate acute renal failure Significant Lab Work Changes in Serum Chemistry • Decreased urine creatinine clearance (80-130 mL/ min) • Increased BUN (12-30 mg./dl.) • Increased serum creatinine (0.5 - 1.5 mg./dl) • Increased serum uric acid (3.5 - 6 mg./dl.) Question 18 Weight Gain and Edema • Clinical Manifestation: – Edema may appear rapidly – Begins in lower extremities and moves upward – Pitting edema and facial edema are late signs – Weight gain is directly related to accumulation of fluid WEIGHT GAIN AND EDEMA Rationale: • Decreased blood flow to the kidneys causes a loss of plasma proteins and albumin • This leads to a decreased colloid osmotic pressure. • A in COP allows fluid to shift from from intravascular to extravascular. • Now there is an accumulation of fluid in the tissues. • Increased angiotensin and aldostersone triggers retention of sodium and water. The Nurse Must Know The difference between dependent edema and generalized edema is important. The patient with PIH has generalized edema because fluid is in all tissues. Placenta With Vasospasms and Vasoconstriction of the the vessels in the placenta. Decreased Placental Perfusion and Placental Aging Positive OCT / __________Decelerations With Prolonged decreased Placental Perfusion: Fetal Growth is retarded - IUGR, SGA Condition is Worsening • Oliguria – 100ml./4 hrs or less than 30 cc. / hour • Edema moves upward and becomes generalized (face, periorbital, sacral) • Excessive weight gain – greater than 2 pounds per week Central Nervous System Changes • Cerebral edema -- forcing of fluids to extracellular – Headaches -- severe, continuous – Hyperreflexia – Level of Consciousness changes – changes in affect – Convulsions / seizures Visual Changes Retinal Edema and spasms leads to: • Blurred vision • Double vision • Retinal detachment • Scotoma (areas of absent or depressed vision) • Nausea and Vomiting • Epigastric pain –often sign of impending coma Pre-Eclampsia Mild B/P Protein Edema Weight 140/90 1+ 2+ 1+, lower legs <1 lb. / week Reflexes 1+ 2+ brisk Retina 0 GI, Hepatic 0 CNS 0 Fetus 0 Severe 160/110 3+ 4+ 3+ 4+ >2lb. / week 3+ 4+ (Hyperreflexia) Clonus present Blurred vision, Scotoma Retinal detachment N & V, Epigastric pain, changes in liver enzymes Headache, LOC changes Premature aging of placenta IUGR; late decelerations Question 17 Interventions and Nursing Care • Home Management – Decrease activities and promote bed rest • Sedative drugs • Lie in left lateral position • Remain quiet and calm – restrict visitors and phone calls – Dietary modifications • increase protein intake to 70 - 80 g/day • maintain sodium intake • Caffeine avoidance – Weigh daily at the same time – Keep record of fetal movement - kick counts Question 19 – Check urine for Protein Hospitalization • If symptoms do not get better then the patient needs to be hospitalized in order to further evaluate her condition. • Common lab studies: – CBC, platelets; type and cross match – Renal blood studies -- BUN, creatitine, uric acid – Liver studies -- AST, LDH, Bilirubin – DIC profile -- platelets, fibrinogen, FSP, D-Dimer Hospital Management Nursing Care Goal 1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant Question 19 Decrease CNS Irritability Provide for a Quiet Environment and Rest 1. MONITOR EXTERNAL STIMULI Explain plans and provide Emotional Support Administer Medications 1. Anticonvulsant -- Magnesium Sulfate 2. Sedative -- Diazepam (Valium) 3. Apresoline (hydralazine) Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available Magnesium Sulfate ACTION CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter release ROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours • Prior to administration: – Insert a foley catheter with urimeter for assessment of hourly output Magnesium Sulfate NURSING IMPLICATIONS 1. Monitor respirations > 14-16; < 12 is critical 2. Assess reflexes for hyporeflexia -- D/C for hyporeflexia 3. Measure Urinary Output >100cc in 4 hrs. 4. Measure Magnesium levels – normal is 1.5-2.5 mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl; Cardiac arrest is > 15 mg/dl. • Have Calcium Gluconate available as antagonist Test Yourself ! A Woman taking Magnesium Sulfate has a respiratory rate of 10. In addition to discontinuing the medication, the nurse should: a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids Nursing Care: Hospital Management 1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant Control Blood Pressure • Check B / P frequently. • Give Antihypertensive Drugs – – – – Hydralzine ( apresoline) Labetalol Aldomet Procardia • Check Hemocrit •Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. •WHY? Nursing Care: Hospital Management 1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant Promote Diuresis **Don’t give Diuretic, masks the symptoms of PIH • Bed rest in left or right lateral position • Check hourly output -- foley cath with urimeter • Dipstick for Protein • Weigh daily -- same time, same scale Nursing Care: Hospital Management 1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant Monitor Fetal Well-Being FETAL MONITORING-- assessing for late decelerations. NST -- Non-stress test OCT --oxytocin challenge test If all else fails ---- Deliver the baby Key Point to Remember ! SEVERE COMPLICATIONS OF PIH: PLACENTAL SEPARATION - ABRUPTIO PLACENTA; DIC PULMONARY EDEMA RENAL FAILURE CARDIOVASCULAR ACCIDENT IUGR; FETAL DEATH HELLP SYNDROME HELLP Syndrome • A multisystem condition that is a form of severe preeclampsia eclampsia • H = hemolysis of RBC • EL = elevated liver enzymes • LP = low platelets <100,000mm (thrombocytopenia) Question 20 Etiology of HELLP Hemolysis occurs from destruction of RBC’s Release of bilirubin Elevated liver enzymes occur from blood flow that is obstructed in the liver due to fibrin deposits Vascular vasoconstriction endothelial damage platelet aggregation at the sites of damage low platelets. HELLP Syndrome Assessment: 1. 2. 3. 4. 5. Right upper quadrant pain and tenderness Nausea and vomiting Edema Flu like symptoms Lab work reveals – a. anemia – low Hemoglobin b. thrombocytopenia – low platelets. < 100,000. c. elevated liver enzymes: -AST asparatate aminotransferase (formerly SGOT) exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L. - LDH – when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L/ HELLP • Intervention: • 1. Bedrest – any trauma or increase in intraabdominal pressure could lead to rupture of the liver capsule hematoma. • 2. Volume expanders • 3. Antithrombic medications Diabetes in Pregnancy Diabetes creates special problems which affect pregnancy in a variety of ways. Successful delivery requires work of the entire health care team Endocrine Changes During Pregnancy There is an increase in activity of maternal pancreatic islets which result in increase production of insulin. Counterbalanced by: a. Placenta’s production of Human Chorionic Somatomammotropin (HCS) b. Increased levels of progesterone and estrogen-antagonistic to insulin c. Human placenta lactogen – reduces effectiveness of circulating insulin d. Placenta enzyme-- insulinase Effects of Diabetes on the Pregnancy MATERNAL Increase incidence of INFECTION Fourfold greater incidence of Preeclampsia Increase incidence of Polyhydramnios Dystocia – large babies Rapid Aging of Placenta Fetus Effects • Glucose, the primary fuel used by the fetus, is transported across the placenta through diffusion. • This means that the glucose levels in the fetus are directly proportional to maternal levels. FETAL COMPLICATIONS Increase morbidity Increase Congenital Anomalies neural tube defect (AFP) Cardiac anomalies Spontaneous Abortions Large for Gestation Baby, LGA Increase risk of RDS Effects of Pregnancy on the Diabetic Insulin Requirements are Altered First Trimester--may drop slightly Second Trimester-- Rise in the requirements Third Trimester-- double to quadruple by the end of pregnancy Fluctuations harder to control; more prone to DKA Possible acceleration of vascular diseases Key Point to Remember! If the insulin requirements do not rise as pregnancy progresses that is an indication that the placenta is not functioning well. Test Yourself? Mrs. R.’s is 31 weeks gestation and her insulin requirements have dropped. What additional test could be performed to assess fetal well-being? a. L/S ratio b. Estriol levels c. Oxytocin Challenge Test Goals of Care • Normalize and maintain maternal blood glucose levels at near normal levels • Delivery of healthy baby • Avoid acceleration of diabetic condition Blood Glucose Monitoring • Measurement of Glycosylated hemoglobin A1c • Self-monitoring – keep records • Goal is to keep the levels in the range of 60 -120 mg/dl Diet Therapy – dietary management must be based on BLOOD GLUCOSE LEVELS – Pre-pregnant diet usually will not work – Diet should provide the calories and nutrients needed for maternal and fetal health – Need ~2200- 2500 calories / day – Divide among three meals and three snacks – A large bedtime snack of ~25 g of CHO with some protein is recommended Insulin Regulation Goal – maintaining optimal blood glucose levels – Usually 2/3 of daily dose is with intermediateacting insulin (NPH) combined with a shortacting insulin Lispro (Humulin or Novolin) Insulin Onset Peak Duration Lispro (rapid acting) Within 15 min 2-3 hr 3-4 hr Regular (short acting) 30 min 3-4 hr 6-8 hr Intermediate acting 2-4 hr 4-12 hr 12-24 hr Long acting 3-4 hr 14-24 hr 24-36 hr – Many women using insulin pumps to maintain control IV. EXERCISE – A consistent and structured exercise program is O.K. V. MONITOR FETAL WELL-BEING – The objective is to deliver the infant as near to term as possible and prevent unnecessary prematurity NST Ultrasound L / S ratio Hypoglycemia • • • • • • • Shakiness ( tremors) Sweating Pallor, cold, clammy skin Disorientation, irritability Headache Hunger Blurred vision Treatment Fruit juice or soft drink Glucose tablets Honey or syrup candy Hyperglycemia • • • • • • • Fatigue Flushed hot skin Dry mouth, excessive thirst Frequent urination Rapid deep respirations Drowsiness Depressed reflexes Treatment Usually requires hospitalization and intravenous administration of insulin GESTATIONAL DIABETES Diabetes diagnosed during pregnancy, but unidentifable in non-pregnant woman Intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after delivery Glucose tolerance test: 1 hr oral GTT – if elevated, do 3 hour GTT Gestational diabetes if: Fasting – 95 mg / dl 1 hour - 180 mg/ dl 2 hour - 155 mg/ dl 3 hour – 140mg/dl •Treatment Diabetes: for the patient with Gestational • Treatment - controlled mainly by diet • Less than 20% are treated with insulin • No use of oral hypoglycemics Cardiac Response in All Pregnancies Every Pregnancy affects the cardiovascular system Increase in Cardiac Output 30% - 50% Expanded Plasma Volume Increase in Blood (Intravascular) Volume A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications Effects of Heart Disease on Pregnancy Growth Retarded Fetus Spontaneous Abortion Premature Labor and Delivery Effects of Pregnancy on Heart Disease The Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure). The effect may be varied depending upon the classification of the disease Classification of Heart Disease Class 1 Uncompromised No alteration in activity No anginal pain, no symptoms with activity Class 2 Slight limitation of physical activity Dyspnea, fatigue, palpitations on ordinary exertion comfortable at rest Class 3 Marked limitation of physical activity Excessive fatigue and dyspnea on minimal exertion Anginal pain with less than ordinary exertion Class 4 Symptoms of cardiac insufficiency even at rest Inability to perform any activity without discomfort Anginal pain Maternal and fetal risks are high Nursing Care - Antepartum Decrease Stress – Teach the importance of REST! – watch weight – assess for infections - stay away from crowds – assess for anemia – assess home responsibilities Teach signs of cardiac decompenstion Key Point to Remember Signs of Congestive Heart Failure Cough (frequent, productive, hemoptysis) Dyspnea, Shortness of breath, orthopnea Palpitations of the heart Generalized edema, pitting edema of legs and feet Moist rales in lower lobes, indicating pulmonary edema Teach about diet high in iron, protein low in sodium and calories ( fat ) Watch weight gain Teach how to take their medicine – – – – Supplemental iron Heparin, not coumarin – monitor lab work Diuretics – very careful monitoring Antiarrhythmics –Digoxin, quinidine, procainamide. *Beta-blockers are associated with fetal defects. Reinforce physicians care Key point to remember ! Never eat foods high in Vitamin K while on an anticoagulant! ( raw green leafy vegetables) Nursing Care: Intrapartum Labor in an upright or side lying position Restrict fluids On O2 per mask throughout labor and cardiac monitoring. Sedation / epidural given early Report fetal distress or cardiac failure Stage 2 - gentle pushing, high forceps delivery Nursing Care Postpartum The immediate post delivery period is the MOST significant and dangerous for the mom with cardiac problems Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion Cardiac output increases, blood volume increases Strain on the heart! Watch for cardiac failure Test Yourself ! • Mrs. B. has mitral valve prolapse. During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time? a. Class I b. Class II c. Class III d. Class IV Urinary Tract Infection Most common infection complicating Pregnancy Etiology Pressure on ureters and bladder causing Stasis with compression of ureters Reflux Hormonal effects cause decrease tone of bladder Assessment Dysuria, frequency, urgency lower abdominal pain; costal vertebral pain fever Interventions Monthly cultures Oral Sulfonamides; Amoxicillin, Ampicillin, Cephalosporins, NO tetracyclines Increase fluid intake to 3 – 4 liters / day Complication Premature labor T O R C H A Infections T = Toxoplasmosis O = Other Syphilis, Gonorrhea, Chlamydial,Hepatitis A or B R = Rubella C = Cytomegalovirus H = Herpes A = Aids Toxoplasmosis Etiology Protozoan infection. Raw meat and cat litter Maternal and Fetal Effects Mom - flu-like symptoms, lymphadenopathy Fetus – stillborn, premature birth, microcephaly; mental retardation Interventions / Nursing Care Instruct to cook meat thoroughly * Avoid changing cat litter * Advise to wear gloves when working in the garden, sand boxes Treatment: Sulfa drugs * Syphilis • Etiology • Spirochete – Treponema Pallium • Maternal and Fetal Effects – May pass across the placenta to fetus causing spontaneous abortion. Major cause of late, second trimester abortions – Infant born with congenital anomalies Syphilis • Intervention: • 1. Penicillin – if newly diagnosed • 2. Advise to return for prenatal visits monthly to assess for reinfection. • 3. Advise that if treated early, fetus may not be infected Gonorrhea Etiology – Neisseria Gonorrhoeae Maternal and Fetal Effects: May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infant Mom will experience dysuria, frequency, urgency Major cause Pelvic Inflammatory Disease which leads to infertility. Treated with Treat partner!! Rocephin Spectinomycin Chlamydia Three times more common than gonorrhea. Etiology - Chlamydia trachomatis Maternal and Fetal Effects Mom – pelvic inflammatory disease, dysuria, abortions, pre-term labor Fetus -- Stillbirth, Chylamydial pneumonia Interventions Erythromycin, doxycycline, zithromax Advise treatment of both partners is very important Hepatitis A or B • Highly contagious when transmitted by direct contact with blood or body fluids • Maternal and Fetal Effects: • All moms should be tested for Hep B during pregnancy • Mom will have abdominal pain, jaundice, fever, rash • Fetus may be born with low birth weight and liver changes • May be infected through placenta, at time of birth, or breast milk • Intervention: • Recommend Hepatitis B vaccination to both mother and baby after delivery. Rubella Etiology Spread by droplet infection or through direct contact with articles contaminated with nasopharyngeal secretions. Crosses placenta Maternal and Fetal Effects Mom– fever, general malaise, rash Most serious problem is to the fetus--causes many congenital anomalies (cataracts, heart defects) Intervention Determine immune status of mother. If titer is low, vaccine given in early postpartum period CYTOMEGALOVIRUS Etiology -- Member of the Herpes virus • Crosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milk Effects on Mom and Fetus • Mom – no symptoms, not know until after birth of the baby Fetus -- Severe brain damage; Eye damage • Intervention No drug available at this time Teach mom should not breast feed baby Isolate baby after birth Herpes Simplex Type 2 Maternal and Fetal Effects Painful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeks Culture lesions to detect if Herpes, No cure If mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth *Virus is lethal to fetus if inoculated at birth Intervention: Zivorax AIDS • Etiology: Human Immunodeficiency Virus, HIV • Transmission of HIV to the fetus occurs through: – The placenta; birth canal – Through breast milk **The virus must enter the baby’s bloodstream to produce infection. Maternal and Fetal Effects: – Mom - brief febrile illness after exposure to with symptoms of fatigue and lymphadenopathy – Fetus has a 2-5% chance of being infected. No symptoms until about 1 year of age Diagnosis: • ELISA test – identifies antibodies specific to HIV. If positive = person has been exposed and formed antibodies • Western Blot – used to confirm seropositivity when ELISA is positive. • Viral load - measures HIV RNA in plasma. It is used to predict severity – lower the load the longer survival. • CD4 cell count – markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system. Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count. Nursing Care: • **Provide Emotional Support • **Teach measures to promote wellness AZT oral during pregnancy IV during labor liquid to newborn for 6 weeks. • **Provide information about resources Fetal Demise / Intrauterine Fetal Death DEFINITION: Death of a fetus after the age of viability Assessment: 1. First indication is usually NO fetal movement 2. NO fetal heart tones Confirmed by ultrasound 3. Decrease in the signs and symptoms of pregnancy Treatment: • Deliver the fetus • How??? Substance Abuse • Drugs that commonly misused are: – – – – – – – Tobacco Alcohol Cocaine Marijuana Amphetamines, barbiturates , hallucinogens Heroin Others • Effects – vary depending on the drug, time exposed, etc. Substance Abuse • Patient Teaching – Very dangerous to use any drugs during the first 8 weeks of gestation – Drugs that cross the placenta may cause possible problems in the infant: • mental retardation • Microcephaly • FAS • IUGR • Congenital heart defects Treatment and Nursing Care • Team approach – establish a relationship of trust and support • Hospitalization to start detoxification • Patient teaching The End