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Complications of Pregnancy Pre-Eclampsia/Eclampsia Diabetes in Pregnancy Perinatal Infections Abortion & Others ACOG (American Academy of Obstetricians and Gynecologists) created a task force of experts in the management of hypertension in pregnancy Reviewed available data Published evidence based recommendations http://www.acog.org/Resources-And-Publications/Task-Force-andWork-Group-Reports/Hypertension-in-Pregnancy 4 Categories Used By The Task Force Chronic Hypertension (of any cause) Chronic Hypertension with superimposed preeclampsia Gestational Hypertension Preeclampsia/Eclampsia Chronic Hypertension High blood pressure known to predate conception or detected BEFORE 20 weeks gestation Chronic Hypertension with Superimposed Preeclampsia (Maternal prognosis is worse than either condition alone) HTN with proteinuria that develops after the 20th week OR HTN and proteinuria before the 20th week WITH (At least one): Sudden increase in BP Sudden manifestation of other s/s ( i.e. increase in liver enzymes to abnormal levels) Platelets below 100,000/microliter Additional symptoms like RUQ pain & Severe headache Pulmonary congestion or edema Renal insufficiency Sudden and sustained increase in protein excretion Gestational Hypertension Transient— BP that occurs without proteinuria late in pregnancy or in the early pp period, but returns to normal by 12 weeks pp. Chronic— BP that occurs without proteinuria late in pregnancy or in the early pp period, but remains after 12 wks pp. Pre-eclampsia/Eclampsia (Pregnancy-specific, multi-system syndrome) Hypertension that develops after the 20th week gestation AND Proteinuria OR Thrombocytopenia Renal insufficiency Impaired liver function Pulmonary edema Cerebral or visual symptoms Blood Pressure > or = 140 systolic OR > or = to 90 diastolic on two occasions AT LEAST 4 hours apart in a woman with previously normal BP > or = 160 systolic OR > or = 110 diastolic can be confirmed within a short interval to facilitate timely treatment. Increase occurs AFTER the 20th week gestation Proteinuria > or = 300 mg per 24 hour urine collection (GOLD STANDARD) OR Protein/creatinine Dipstick ratio > or = to 0.3 mg/dL reading of 1+ (used only if other quantitative methods are not available) Trombocytopenia Platelet count less than 100,000/microliter Renal Insufficiency Protein/creatinine ratio > or = to 0.3 mg/dL Impaired liver function Elevated blood concentrations > 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease Pulmonary Edema Cerebral or Visual Symptoms Eclampsia The Presence of new-onset grand mal seizure in a woman with preeclampsia Cannot cause be attributed to any other Predisposing Factors to Preeclampsia Primiparity Previous preeclamptic pregnancy Chronic hypertension or chronic renal disease History of thrombophilia Multigestational pregnancies In vitro fertilization Family Hx of preeclampsia Type I DM or Type II DM Obesity Systemic lupus erythematosus Maternal age <19 or >40 Changes in Normal Pregnancy Cardiac output by 50% Blood volume by 1500ml Peripheral vascular resistance BP Renin GFR ECF Aldosterone effects blocked Changes in Preeclampsia (pg382; 10 th ed) Generalized Vasospasm Hypertension Intravascular volume placental perfusion IUGR of fetus, fetal distress renal perfusion GFR urine output (oliguria) BUN & Creatinine & uric acid proteinuria serum albumin Extravascular fluid (edema) Pulmonary, retinal, & cerebral edema Dyspnea, scotomata, CNS irritability/ hyperreflexia, HA, N& V, convulsions Hepatic perfusion Liver function tests, epigastric pain (RUQ) Preeclampsia without severe features Signs & Symptoms BP > 140/90 Proteinuria (Mild) Treatment of Preeclampsia w/o Severe Features Daily kick counts Ultrasound for fetal growth q 3 weeks Amniotic fluid assessment at least 1/week NST twice a week (non-reactive = BPP) Monitor daily wt for gain Monitor BP daily Lab tests: CBC, liver enzyme & serum creatinine level at least once a week. Regular diet w/ no salt restrictions Instructed to go to hospital w/worsening sx Hospital care of mild preeclampsia left lateral recumbent position to renal perfusion which promotes diuresis and lowers BP Bedrest, balanced, nutritious, moderate protein to replenish what is spilled by kidneys Diet—well Hospital care of mild preeclampsia (Cont’d) Assessment of fetal well-being DFMC, BPP, NST, Amniocentesis Assessment of maternal well-being BP assessed qid or q4hr Daily wt, and assessment of worsening edema Assessment of HA, visual changes, epigastric pain, hyperreflexia Lab tests: daily urine dipstick for protein, 24 hr protein, CBC w/ platelet count q 2 days, serum creatinine, uric acic, & liver function tests (AST, ALT, LDH, Bili) Severe Preeclampsia Signs and symptoms BP of 160/110 or higher on 2 occasions at least 4 hr apart while on bedrest Proteinuria 5g/L in 24 hr or 3+ or > on 2 random urine samples 4 hrs apart Oliguria: urine output <500ml/24hr Cerebral or visual disturbances—HA, scotomata or blurred vision Pulmonary edema or cyanosis Epigastric or RUQ pain Impaired liver function ( AST, APT) Thrombocytopenia Treatment of Severe Preeclampsia Absolute bedrest Quiet environment to reduce stimuli Delivery > 34 weeks gestation Management of Severe Preeclampsia <34 weeks Medications used in treatment Seizure Prophylaxis Magnesium Sulfate: a 4-6 gm bolus is given IV over 20 minutes, then a continuous infusion of 2gm/hr is generally advocated. CNS depressant Needs to be maintained at a therapeutic level as determined by each laboratory Excessive levels lead to respiratory paralysis and cardiac arrest Calcium gluconate given to reverse Case Study A 35 year old G1P0 patient is admitted to L&D with severe preeclampsia. Her most recent blood pressure readings have been 172/108 & 176/112. She complains of seeing spots and a severe headache. You have received orders for a 4gm IV bolus of Magnesium over 20 minutes followed by a 2gm/hr maintenance dose. If 40 grams are added to 1000mls of LR, at what rate would you set the IV pump to administer 4gm in 20 minutes? What amount would you put in the VTBI on the pump? If you are to continue to infuse at 2gm/hr, at what rate would you set the pump? What side effects can you educate your patient on? What are the nursing implications? What should you have available in case of Mag Sulfate toxicity? See p. 572 Davidson 10th ed. for more info Medications used in treatment Anti-hypertensives Given for sustained BP’s >160/110 First Line for Acute Hypertension Labetalol: 20 mg IV over 2 min, can give q10 min if needed (max 300mg) – avoid with asthma or CHF Hydralazine: 5mg IV over 1-2 min, can give q20 min if needed (max 30mg) Expectant management Oral Labetalol, Nifedipine, or Methyldopa NO diuretics or ACE inhibitors Eclampsia— occurs in 1 in 1600 pregnancies Symptoms of impending seizure: Persistent occipital or frontal headaches Blurred vision Photophobia Epigastric or right upper quadrant pain Altered mental status Hyperreflexia— 4+ Scotomata—dark spots or flashing lights Vomiting Neurologic hyperactivity Pulmonary edema Cyanosis Safety precautions Quiet environment—no phone calls, TV, lights, pulled shades, etc. Padded side rails in bed O2 ready and available Suction ready and available Refer to Nursing Care Plan pp. 389-391 Davidson et al, 10th ed. Note importance of careful monitoring of mother and fetus throughout hospitalization with severe pre-eclampsia Prevention of complications is key to healthy management HELLP Syndrome Hemolysis Elevated Liver Enzymes Low Platelets (< 100,000/mm3) Sometimes associated with severe preeclampsia Sx: N & V, malaise, flu-like sx, or epigastric pain with or without HTN Persons presenting with these sx should have CBC with platelets and liver enzymes drawn These pts should be managed at tertiary care centers Corticosteroids: while usually given to foster fetal maturity, they have been found to stabilize platelet counts and hepatic enzymes and LDH levels. Dexamethasone is often chosen for HELLP syndrome. Diabetes In Pregnancy Did it exist BEFORE Pregnancy? Pregestational Diabetes Mellitus Type 1 Type 2 1/2000 pregnancies Gestational Diabetes Any degree of glucose intolerance with the onset or first recognition occurring during pregnancy 2-5% of all pregnancies 90% of all cases of diabetes in pregnancy 25% of these women will develop Type 2 diabetes later in life Normal CHO Metabolism in PG Goal of changes is to provide adequate glucose to fetus for growth Maternal glucose crosses the placenta Maternal insulin does NOT KEY CONCEPT TO UNDERSTAND CHO Metabolism—1st Trimester in E & P stimulate Beta cells of Pancreas to Insulin production = use of glucose in serum glucose levels (FBS ) in tissue glycogen stores in liver glycogen production = Pregestational Diabetics Hypoglycemia CHO Metabolism-2nd & 3rd Trimester Pregnancy is a “diabetogenic” state Hormones levels lead to tolerance to glucose insulin resistance HPL-Human Insulin antagonist—Won’t let insulin work Placental Placental Lactogen Insulinases Breakdown insulin at placental site Net Result = Changes in Insulin Needs for Mother during Pregnancy need for insulin insulin production, N&V, transfer to fetus 1st trimester = food intake, 2nd Trimester = Gradual 3rd Trimester = 2-4 times higher need for insulin by 36 week, then levels off til labor After delivery = ; glucose/insulin balance OK by 7-10 days Risks to Mother Pregestational Diab. If poor control very early in PG Miscarriage Macrosomic babyC/S Pre-eclampsia PTL Infections (UTI’s, Vag) Polyhydramnios Ketoacidosis / Hypogylecemia Gestational-Onset 2X likely to have preeclampsia Macrosomic baby C/S Risks to Baby Pregestational Congenital Defects Heart, Skeletal, CNS Same as Gestational Gestational MacrosomiaBirth Trauma Hypoglycemia RDS Hypocalcemia Hyperbilirubinemia Thrombocytopenia Polycythemia Management of Pre-gestational Diabetes Pre-conceptual Counseling Establish glycemic control BEFORE PG Understand the VERY close monitoring Blood glucose levels 4-8 times a day. Frequent MD visits If Type 2—Some oral hypoglycemic agents are teratogenic Insulin SQ during pregnancy Management of Pre-gestational Diabetes Hgn A1c Good control = 2.5% to 5.9 % Fair Control = 6% - 8% Poor Control = > 8% Diet VERY CAREFULLY BALANCED Should be followed by Registered Dietician Exercise Not vigorous, Best time is after meals Management of Pre-gestational Diabetes-Insulin Multiple daily injections needed Mixed of longer-acting and rapid-acting in AM and PM Humulin or Novolin, NOT pork or beef insulins Humalog, if newly diagnosed Management of Pre-gestational Diabetes-Insulin GOAL—keep blood sugar in narrow margin Fasting = 60-90 mg/dl 2-hour postprandial = 90-120 mg/dl Management of Pre-gestational Diabetes-Delivery Careful determination of ACTUAL due date Amniocentesis Fetal lung maturity Induce 39-40 wks-NO LATER THAN 40 WKS If estimated fetal weight > 4000-4500 Gms C/S In L&D- Watch maternal glucose levels every 2 hours Gestational Diabetes-Screening Low-risk < 25 y/o No family Hx Normal BMI Not in High-Risk group No Hx of Abnormal GTT Hi-Risk Hx of gestational Diabetes Overweight/Obese BMI High-risk group African-American Native-American Latina Pacific-Islander Gestational Diabetes-Screening First pre-natal visit 50 gm glucose load -> draw serum 1 hour later Negative < 140 mg/dl Positive > 140 mg/dl Screen again 24-28 weeks gestation Gestational Diabetes-Screening If positive do 3-hour GTT (100g of glucose) Positive for GDM = 2 or more levels are met or exceeded Fasting 1-hr 2-hr 3-hr < 95 mg/dl < 180 mg/dl < 155 mg/dl < 140 mg/dl Gestational Diabetes Management GOAL Keep blood sugars within levels for Pregestational diabetes Diet—Main course of treatment; 3 meals and 3 snacks Exercise Insulin—20% will need insulin during PG; safest Glyburide (oral hypoglycemic agent) is being used with caution but not yet approved by ACOG Blood glucose monitoring Frequently done in MD office or at home Gestational Diabetes Management Delivery Frequent NST/BPP in last 2 months of pregnancy Deliver by 40 weeks Excellent resource link from the National Diabetes Education Program with handouts in various languages and lots of resources. Another great resource with tables from Merck Manual Perinatal Infections Group-B Hemolytic Streptococcus Major cause of perinatal infections Found in Vagina and Urine Increase fetal mortality and morbidity Screen 35-37 wks (CDC Recommendations) If Positive –Treat in Labor Penicillin: 5 million Units IV x 1; 2.5-3 million units every 4 hours Ampicillin: 2 GMs IV x1; 1 GM every 4 hours Clindamycin 900mg IV q 8 hr OR Erythromycin 500mg IV q 6hr till delivery if allergic to Penicillin. Perinatal Infections If GBS status unknown—Prophylactic trx is indicated if: Previous infant with GBS GBS bacturia during this pregnancy PTL Temp in labor > 100.4 F Membranes ruptured > 18 hours Other Perinatal infections Syphyllis Gonorrhea Chlamydia TORCH p.394-400; 10th ed. Toxoplasmosis Rubella Cytomegalovirus Herpes, Human B19 Parvovirus Hemorrhagic Complications Abortion = loss of pregnancy BEFORE 20 weeks gestation spontaneous (miscarriage) or induced 10% of all pregnancies end in a miscarriage Most in 1st Trimester Hemorrhagic Complications Types of Abortions (know the differences) Threatened Imminent Incomplete Missed Habitual Other Hemorrhagic Complications Ectopic Pregnancy Egg implants outside of uterus Lots of pain and internal bleeding –manifested by sx of shock—lifethreatening Surgical intervention needed Link with photos Hydatidiform Mole No fetus, Fluid filled vesicles N&V, No FHT’s, 2nd trimester bleeding— Prune-juice D&C Not get pregnant for 1 year Choriocarcinoma, if HCG elevated Gestational Trophoblastic Dz Other Pregnancy Complications Incompetent Cervix premature delivery Cerclage— McDonald’s or Shirodkar procedure 10-14 weeks gestation NO Intercourse, Prolonged standing, heavy lifting On bedrest as much as possible Teach signs of Preterm Labor Take tocolytics as ordered Home uterine monitoring suture at 37 weeks vaginal Leave suture in C/Sec Remove Shirodkar Procedure for Incompetent Cervix Other Complication of Pregnancy Hyperemesis Gravidarum Intractable Vomiting in Pregnancy 5% loss of body weight, dehydration, ketosis, metabolic alkalosis, Rule out Gestational Trophoblastic Dz by ultrasound Medical Management/Nursing Care If doesn’t respond to small, frequent meals, then needs hospitalization: NPO, IV fluids with KCl to prevent hypokalemia, B-vitamin replacement (B1 and B6 especially) If still unable to eat, may need TPN temporarily There you have it! Refer to other supplement for more detail on these complications