Transcript Hyper / Hypo Disorders

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