Care of Complex Patients

NURS546

What are some general physiological changes that happen in pregnancy?

Hormonal changes, increased immunologic tolerance, decreased systemic vascular resistance, 50% increase in GFR, 40% increase in blood volume, 40% increase in cardiac output, and increase in oxygen consumption

What happens when you remove the corpus luteum from pregnancy?

The pregnancy will be terminated because of no progesterone source.

What happens hormonally in pregnancy?

Estradiol: uterine muscle and uterine artery diameter increases. Increase in basal cells at squamo-columar junction (can affect a pap smear, best to get one PP)

Progesterone: decreases GI motility, lax ligaments

How long does the corpus luteum produce progesterone?

7 weeks, then the placenta takes over

What happens to the gastrointestinal system during pregnancy?

Decreased esophageal peristalsis (increase in heartburn), slower emptying time, and relaxation of cardiac sphincter

Increased Gastrin production: decreased stomach pH, increase in stomach volume, decreased Motilin levels (stimulates smooth muscle)

What can mitigate the risk of regurgitation and aspiration in pregnancy?

Vegan diet

What happens to the liver in pregnancy?

Serum albumin decreases d/t hemodilution and decreased synthesis in the liver.

Increase liver enzyme production: alkaline phosphate d/t placental production, fibrinogen (50%: increased risk for thromboembolism), cholesterol, triglycerides, and phospholipids.

Increased bile acids

If a pregnant patients fibrinogen is less than 300, what is the next step?

Investigate for coagulopathy

What happens to the pancreas in pregnancy?

Increase in beta cells, maternal fastin with accelerated starvation, peripheral resistance to insulin (80%), placenta produces hpL (reduces the effectiveness of insulin)

What happens to insulin resistance as pregnancy progresses?

Increases

How does the fetus get glucose from the parent and how do they use it?

Through simple diffusion and facilitates. Maternal insulin is not needed for use of glucose as fuel

What are kisspeptins?

Neuropeptides produced by the placenta from the KISS-1 gene. A decreased level is noted in GDM, FGR, and in those at high risk for SAB.

Why are pregnant patients advised to lay in lateral recumbent rather than supine late in pregnancy?

Compression of the vena cava

What is glycosuria and how does it happen?

Glucose in the urine (can lead to infection) and it could happen from an increase in GFR→ impaired tubular reabsorption.

What happens to the bladder in pregnancy?

It is displaced upward, flattened, vascularity increases and muscle tone decreases. Increase in urinary frequency

How would a pregnant person’s labs look compared to pre-pregnancy?

Increased: HR, CO, Pao2, PAo2, WBC, Factors I,VII, VIII, IX, X, Fib, d-Dimer, ESR, alk phos, aldosterone, cortisol (serum, free), insulin and lipids

Decreased: SVR, BP, PVR, FRC, PaCO2, HCO3, Hgb/Hct, Protein S, Factors XI, XIII, Cr, BUN, Uric acid, fasting blood glucose

What happens to the thyroid in pregnancy?

Decrease in organic iodine levels by 50%, increase in renal filtration of iodine

What must happen if a person is taking a supplement for thyroid dysfunction?

Increase supplement to (220: Varney’s) 250 mcg/day

What do thyroid hormones, T₃ and T_{4, do?}

Increased metabolism, growth and development, and increased catecholamine effect

How does the fetal thyroid develop?

<10wk: no iodine, 11-12wks: produces iodothyronines and T₄, 12-14wks: concentrate iodine, 12 wks: thyroid-pituitary axis exists

All thyroid hormones but which one cross the placenta?

TSH

What are some foods with high iodine content and some with low?

High: Cod, Haddock, milk/yogurt, iodized salt, eggs, cheese, nuts, shrimp and bread

Low: Sea salt, himalayan salt, dairy alternatives, vegetables, and fruit

PNV are in the middle

What happens if a pregnant parent has high thyroid peroxidase antibodies?

Increased risk of fetal loss, miscarriage, perinatal mortality, and large for gestational age infants

What happens in maternal hyperthyroidism?

.2% of pregnancies; increased prematurity, IUGR, preeclampsia, still birth, neonatal morbidity and mortality; Graves: remission in pregnancy, worse postpartum

What is the treatment for hyperthyroidism?

PTU (propylthiouracil), methimazole, check free T₄ levels every 4 weeks, evaluate at 30 wka for d/c, surgery if medicine fails

What is a thyroid storm?

Acute, rare and life-threatening. Complication of hyperthyroidism (1-2%). Preceipitated by infection, labor, CS, not taking medication. Symptoms: Pre-e, hyperthermia, tachycardia, perspiration, high output failure. Maternal mortality: 25%

What happens in neonatal thyrotoxicosis?

Happens to 1% of babies born to mothers with graves. Suspect with FHR > 160bpm, neonatal mortality: 16%

What are signs and symptoms of fetal and neonatal hyperthyroidism?

Fetus: Goiter/thyromegaly, growth restriction, accelerated bone maturation, heart failure, hydrops, tachycardia, IUFD

Neonate: SGA at birth, hyperexcitability, diarrhea, failure to thrive, vomiting, heart failure and cardiac arrythmias, systemis and pulmonary hypertension, jaundice, thrombocytopenia, small anterior fontanelle

What are signs and symptoms of fetal and neonatal hypothyroidism?

Fetus: Goiter & maybe hyperextension of neck, polyhydramnios, delayed bone maturation.

Neonate: Dull look, puffy facial features, thickened tongue, poor feeding, constipation, short stature and/or failure to grow, poor muscle tone. Developmental retardation

What does maternal hypothyroidism look like?

Elevated TSH, low fT₄ and fT₃, hashimoto’s: most common cause.

Sx: fatigue, constipation, cold intolerance, muscle cramps and weight gain, edema, dry skin, hair loss, +/- goiter

What are some fetal outcomes of maternal hypothyroidism?

Increased spontaneous abortion, pre-e, abruption, low birth weight, still born, and lower intelligence

What is the treatment for hypothyroidism?

Synthroid 1-2 mcg/kg daily. Measure TSH to adjust dose every 4 weeks. Anticipate a 25

What is subclinical hypothyroidism?

Elevated TSH and normal fT₄. Unlikely to progress

What are the two phases of postpartum thyroiditis?

Phase 1: New abnormal TSH and free T₄, destruction-induced thyrotoxicosis, small painless nodule, lasts a few months

Phase 2: overt hypothyroidism, occurring between 4 and 8 months postpartum, sx of hypothyroidism are more common and prominent, treat for 6-12 mo, 1/3 will have permanent hypothyroidism

How long should women with thyroid cancer wait to conceive after an RAI treatment?

6 months

If a pregnant patient has epilepsy and her last seizure was >2 years ago, do we treat in pregnancy?

No medications needed

If we are treating epilepsy in pregnancy, how do we go about this?

Monotherapy; freq does not change; no valproate

What are the risks of seizures in pregnancy?

Preeclampsia, poor fetal growth/stillbirth, 4-6% babies with malformations, premature labor

What can happen to a patient with epilepsy in labor and/or postpartum?

Tonic-clonic seizures

What are the newer drugs that are used for treatment of epilepsy?

Lamotrigine, Levetriacetam (fewer seizures compared to lamotrigine), and topiramate

What can happen to the fetus if a pregnant patient is taking too much phenytoin?

Hypoplasia of the nail and distal phalanges, microcephaly, growth deficiency, developmental delays, mental retardation, dysmorphic craniofacial features

What are some things that can happen to the fetus if the pregnant patient is taking too much valproate (depakote)?

Poor neurodevelopmental outcomes, increased risk of autism

What should pregnant patients who are taking phenytoin also take during the pregnancy?

4mg/day of folic acid, adjust medication level

What is important to remember about carbamazepine?

7-fold increase in spida bifida

What happens to the medication efficacy of lamotrigine (lamictal) in pregnancy?

2-3 fold increase in clearance, drug levels must be checked to ensure their optimal

What do we need to know about caring for pregnant patients who are on levetiracetam (keppra)?

Significant dose increase in 2nd trimester, close level monitoring

What supplements should pregnant patients with epilepsy take?

Folate 1mg/day, Vitamin D supplementation (PNV), Oral Vitamin K 10mg/day in 3rd trimester

What should we do if a pregnant patient with epilepsy has a seizure?

Immediate hospitalization, patent airway, adequate oxygen, IV diazepam or lorazepam, phenytoin

How do we treat epileptic patients in labor?

Follow OB indications and continue anticonvulsant drugs

Are patients taking epileptic medications okay to breastfeed?

Yes

How do we treat an epileptic seizure in labor?

Lorazepam

What is asthma and how is it classified?

Chronic inflammatory disorder. Classified by mild intermittent, mild persistent, moderate persistent, and severe persistent

What is the sx frequency, nighttime awakening, interference with normal activity and FEV₁/Peak flow for asthma in pregnancy?

Intermittent (well controlled): 2 days/week or less; twice per month or less; none; more than 80%

Mild persistent (not well controlled): More than 2 days per week, but not daily; more than twice per month; minor limitation; more than 80%

Moderate persistent (not well controlled): daily symptoms; more than once per week; some limitation; 60-80%

Severe persistent (very poorly controlled): throughout the day; four times per week or more; extremely limited; less than 60%

What are some risks for severe asthma in pregnancy?

Miscarriage, preeclampsia, intrauterine fetal death, fetal growth restrictions, and preterm birth → gestational diabetes, C/S, PE, admission to ICU

How can our pregnant patients with asthma prevent pregnancy complications?

Hydrate, early and aggressive treatment of URI, vaccination, acoid excessive exercise, hyperventilation, allergens

What medication could a pregnant patient need while in labor?

Stress dose steroids

Why does blood flow increase in pregnancy?

Uterus and fetal metabolic needs, kidneys and other organs