Medical Conditions that Complicate Pregnancy

Pregestational Diabetes Maternal risks

ketoacidosis, polyhydramnios, hypo/hyperglycemia, GHTN, preeclampsia, infection, PPH, increased risk of maternal mortality

Pregestational Diabetes Fetal risks

macrosomia, hypoglycemia at birth, congenital anomalies, RDS, stillbirth, IURG

Diabetes have increased risk for

Congenital anomalies if not controlled prior to conception

Tx goals for diabetes during pregnancy

• normal glucose levels

• identify and tx diabetic associated complications

• routine screening

Routine screening for diabetes

HgbA1C, kidney function tests, eye exam, cardiovascular assessment, thyroid function tests

antepartum diabetic care period

• diet, exercise, insulin/blood glucose monitoring, urinalysis, frequent prenatal visits, fetal surveillance, determine delivery date/route 

  • Exercise: check BG before, during, and after exercise 

  • Insulin/Blood glucose monitoring: fasting/pre/postprandial, bedtime

  • 2x/week prenatal visits 

  • Fetal echo: 20-22 weeks, NST: 32 weeks, doppler blood flow, fetal growth 

    • Doppler blood flow: blood flow to and from placenta from mom

  • If baby >4500g: cesarean 

intrapartum care for diabetic pts

monitor fluid status, blood glucose monitoring, continuous fetal monitoring, possible cesarean delivery 

• Blood glucose monitoring 

  • Q1hr during active labor 

  • Pt usually NPO 

  • Insulin drip 

  • Before birth q2-4hrs 

• Possible caesarean delivery 

  • No AM insulin; Pt NPO

PP care for diabetic patients

glucose monitoring, monitor for postpartum complications, encourage breastfeeding

• Glucose monitoring: back to regular diet; may need increase insulin injection then day before 

• Monitor for PPH, Preeclampsia/Eclampsia 

• Patients may need to eat before breastfeeding!!!

Gestational diabetes occurs

usually between 24-48 weeks

Gestational diabetes Class A1

controlled

Gestational diabetes Class A2

requires treatment, if diet doesn’t control

Gestational diabetes risk factors

Personal hx of impaired glucose tolerance, A1C >5.7%, hx of gestational diabetes, family hx of diabetes, older MA >25, hx of macrosomia in prior pregnancy, hx of unexplained loss, hx of congenital anomalies, multiple gestation, latina, native american, AA, south or east asian, or pacific islander heritage

Gestational diabetes maternal risks

GHTN, preeclampsia, infections, complications due to macrosomia, polyhydramnios, Type 2 diabetes later in life, ketoacidosis

Gestational Diabetes fetal risks

hypoglycemia, macrosomia/LGA, stillbirth

Antepartum gestational care period

diet, exercise, blood glucose self monitoring, pharmacologic therapy, fetal surveillance 

• Diet: 15-35 kcals/day; nutritional counseling 

• Exercise: 15-20 mins; monitor BG before, during and after exercise 

• BG: fasting and postprandial 

• Pharmacologic: only done if levels are persistently elevated 

• Fetal surveillance: U/S 3-4x/week; NST 1-2x/week

Intrapartum gestational diabetes care

monitor BG, regular insulin infusion, possible cesarean delivery 

PP GDM care

levels will return to normal, medications discontinued, perform 2-hr GTT 6 weeks PP

Metabolic changes in early pregnancy diabetes

decreased insulin needs

Metabolic changes in late pregnancy diabetes

increased insulin needs

Placenta allows glucose

to come through

placenta allows insulin to come through as well?

NO

Breastfeeding pre/gestational diabetic women

insulin needs are lower, d/t glucose in breastmilk

Hyperemesis gravidarum

excessive, prolonged vomiting accompanied by other symptoms

Hyperemesis gravidarum symptoms

• weight loss

• electrolyte balance

• dehydration

• nutritional deficiencies

• ketonuria

Hyperemesis gravidarum risk facors

maternal age <20, nulliparity, BMI <18 or >25, gestational trophoblastic disease, hx of migraines, multiple gestation, female fetus, hx of hyperemesis

normal BMI

18-25

Hyperemesis gravidarum clinical manifestations

weight loss, dehydration, fluid and electrolyte imbalances, alkalosis, hypovolemia, hypotension, tachycardia, increased HCT, increased BUN, risk for altered cardiac function, starvation due to nutritional deficiencies 

Hyperemesis gravidarum fetal risks

decreased BW/SGA

Hyperemesis assessment

thorough assessment of N/V, dietary and elimination hx, GI symptoms, precipitating or relieving factors, PMH/PSH, psychosocial assessment

hyperemesis gravidarum physical exam

weight gain, VS, skin turgor, mucous membranes, condition of mouth, sweet odor to breath, abd palpiatations, bowel sounds, fetal growth

hyperemesis lab assessments

CBC, CMP, Magnesium, Urinalysis, Ketonuria 

hyperemesis nursing assessment initial

NPO education, intravenous fluid and electrolyte replacement, medications

hyperemesis meds

antiemetics, antihistamines, steroids

hyperemesis nursing assessment refractory

possible enteral or parenteral nutrition

hyperemesis nursing assessment follow up

diet education, when to call, emotional support

maternal phenylketonuria

autosomal recessive; inability to metabolize phenylalanine d/t enzyme deficiency; toxic accumulation

Maternal Phenylketonuria diet

low protein (no meat or fish, nuts, no aspartame)

Maternal Phenylketonuria pregnancy management

• Normalize phenylalanine levels (<6mg/dl) x3 months prior 

• Maintain 2-6mg/dL during pregnancy 

• Anatomy scan and fetal growth U/S 

• Fetal echo 

Maternal PKU PP

• PKU screening 

• Breastfeeding: if mom uncontrolled + father PKU status unknown, hold off breastfeeding

  • If PKU levels >6mg/dl= hold off breastfeeding

CV disorders maternal risks

maternal arrhythmias, heart failure, death, preterm birth 

CV disorders fetal risks

fetal growth restriction, fetal death

CV congenital diseases septal

atrial septal defect, v septal defect, patent ductus arteriosis

CV congenital diseases acyanotic

coarctation of aorta

CV congenital diseases cyanotic

tetralogy of fallot

acquired cardiac diseases

mitral prolapse, mitral stenosis (rheumatic heart disease), aortic stenosis 

ischemic heart disease

MI; frequent in 3rd trimester; multigravid >33

Cardiac conditions that should stay away from pregnancy

• Primary pulmonary HTN

• Marfan Syndrome

• Eisenmenger Syndrome

Primary Pulmonary Hypertension

not exchanging air at all→back up of heart; over 50% mortality rate if pregnant  

Marfan Syndrome

aortic weakening; mitral valve prolapse; up to 50% mortality rate

Eisenmenger Syndrome

right to left or bi shunting of blood; up to 50% mortality rate

Care and assessment of Pregnant CV client

cardiologist, maternal fetal medicine, perinatologist, RN, increased prenatal visit frequency

Antepartum care of CV pt

minimize stress, anemia prevention, monitor for infections, nutrition counseling: increase fluids, increase fiber, decrease NA, medications, fetal surveillance: fetal echo 20-22 weeks, education: edema, dyspnea + palpitations WARNING SIGNS; check daily weight

Intrapartum care of CV pt

routine labor assessments, decompensation assessments, maternal telemetry, continuous fetal monitoring, elevate head and shoulders, side lying position, epidural encouraged, forceps or vacuum delivery, antibiotics, no methergine/no terbutaline

PP care of CV pt

highest risk for decompensation 24-48 hrs PP, routine postpartum assessment + full physical assessment, HOB elevated, side lying encouraged, progressive activity, breastfeeding (but pt can opt out if they want), discharge planning + education

Anemia + hemorrhage can cause

reflex tachycardia

Epilepsy preconception counseling (maternal risks)

injury preeclampsia, preterm delivery, hemorrhage 

Epilepsy preconception counseling (fetal risks)

stillbirth, congenital anomalies, IUGR

Epilepsy preconception counseling care

ensure pregnancies are planned, folic acid, rule out preeclampsia by checking BP + proteinuria

antepartum epilepsy care

folic acid, medications, MSAFP/Fetal U/S, tx of seizures: anticonvulsants

intrapartum epilepsy care

anticonvulsants, seizure precautions, IV or rectal benzos during seizures

PP epilsepy care

breastfeeding, medication review

Multiple sclerosis antepartum care

no specific changes to routine OB care, remissions during pregnancy are common, screen for UTIs, Vit D, medications

Multiple sclerosis intrapartum care

epidural: safe to use, but if MS effects spinal cord then no, vag delivery

Multiple sclerosis PP care

breastfeeding (d/t medications, may be advised not to breastfeed), mobility

MS for pregnancy?

Yes pregnancy is okay

Bell Palsy clinical manifestations

unilateral facial weakness, difficulty closing eye, pain around ear

Bell Palsy management

prevention of corneal injury, facial muscle massage, caution eating, steroids

Bell Palsy Pt education

chewing on opposite side, oral care, finger sweep, drink with straw

Bell Palsy peaks

3rd semester + PP

SLE risks (maternal)

maternal: SLE exacerbation, miscarriage, preterm delivery, preelampsia

SLE risks (fetal)

stillbirth, IUGR

SLE

should be in remission x6 months before attempting pregnancy

antepartum SLE

steroids, close monitoring, fetal surveillance, planned delivery

intrapartum SLE

vaginal birth, stress dose steroids

PP SLE

encourage rest, limit number of pregnancies, close follow up with rheumatologist (1-3 months PP)

Myasthenia Gravis preconception counseling

avoid pregnnacy until symptoms improve

Myasthenia Gravis antepartum

steroids, acetylcholinesterase inhibitors

Myasthenia Gravis intrapartum

possible assisted vaginal delivery, regional anesthesia, medication caution (MgSO4 avoided; use Keppra or Calporate acid for preeclampsia)

neonatal Myasthenia Gravis s/sx

• Weak cry, resp difficulties, weak suck, weak moro, poor tone 

  • Resolves in 6 weeks, tx with acetylcholinesterase

HIV antepartum care

nutrition, optimize immune function, monitor for infections, test and treat STDs; pap smear if not up to date, medication, provide emotional support, refer as appropriate; no invasive procedures

HIV intrapartum and PP

no fetal scalp electrode, AROM, forceps, vacuum, Zidovudine, newborn bath, no breastfeeding: educate to mother during antepartum period

Cholelithiasis/Cholecystisis

• Increased incidence in pregnancy 

• Symptoms: epigastric pain, RUQ pain, N/V, fever 

• Medical management done before surgery 

• PP surgical intervention preferred

IBD

• Increased risk for preterm delivery, LBW, SGA

• Don't abruptly stop medication to avoid flare; folic acid 4mg; parenteral if severe

Urinary Tract Infections (REWATCH)

• Asymptomatic Bacteriuria: associated with preterm birth and LBW infants, antibiotics 

• Cystitis: assess for CVA tenderness; antibiotics 

• Pyelonephritis: leading cause of septic shock in pregnancy, outpatient vs inpatient management, antibiotics

Surgery best during

2nd trimester

Surgery indications during pregnancy

2nd trimester is BEST, NPO, fetal monitoring, lateral tilt, foley cath, VS monitoring, delay elective surgeries, displace the uterus

Appendicitis

most common non OB surgical emergenvies

appencititis clinical manifestations

• Often confused with pregnancy symptoms; general cramping, pain + increased WBC count 

• Symptoms: nausea, vomiting, increased WBC count, RLQ pain

Appendicitis management

appendectomy, antibiotics if rupture, monitor for preterm labor, antispasmodics, IV fluids, bowel rest, NG suctioning

Appendicitis pt education

should improve 48 hrs after therapy, surgery INCREASES risk of PTL

Trauma most common during

3rd trimester

Trauma maternal + fetal risks

• placental abruption, uterine rupture, preterm labor, PROM, hemorrhage, death

• miscarriage, fetal death

trauma blunt abd

MVA, IPV, falls

Trauma penetrating abd

gunshot, stab wounds

trauma thoracic

pneumothorax, hemothroax

trauma management

• STABILIZE MOTHER FIRST 

  • Assess mother: vag bleeding, uterine activity, abd pain/tenderness, loss of fluid 

  • Assess fetus: FHR, FM, gestational age

CPR modifications

uterine displacement, placement of pads (AED pad placed one rib higher d/t displacement of heart)

CPR perimorterm delivery

• If CPR not effective in 4-5 minutes 

• Fetus at or beyond viability 

• Cesarean delivery