OB Exam 3 Chapter 20 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations

diabetes type 1

Absolute insulin deficiency. Associated with beta cell destruction (autoimmune)

diabetes type 2

-Insulin resistance or deficiency. Progressive loss of beta cell insulin secretion.

-Associated with obesity and sedentary lifestyle.

-Most common type of diabetes.

-Often diagnosed after age 30 though is now being diagnosed in children.

gestational diabetes

-Glucose intolerance with onset during pregnancy. Usually diagnosed during the second or third trimester of pregnancy

-NOT clearly overt prior to pregnancy...May become a diabetic later in life

Stress increases insulin requirement and pregnancy is stressful

:)

N/V lowers insulin requirements (1st trimester needs typically decrease) but second and third may increase her insulin need

:)

Review of the pathophysiology of Diabetes Mellitus (Type I)

Pancreas

Glycosuria

Insulin

Polydipsia

Ketosis

Polyuria

Glucose

Polyphagia

DM

-A chronic disease

-Person affected has a relative lack of insulin OR absence of the hormone necessary for glucose metabolism

-1/7 of all Americans are diabetic (ADA)

Gestational Diabetes Mellitus (GDM):

-Glucose intolerance of variable severity

-Onset or first recognition during the second or third trimester of pregnancy (ADA, 2018)

-GDM occurs in up to 10% of pregnancies in the U.S. (Ricci, 2021, p. 688).

** Often, women with GDM eventually progress to Type II DM.

Effects of Pregnancy on Women with Type I Diabetes Mellitus

Ability to control diabetes?

Insulin needs by trimester (1<2,3)

Effect of placental hormone(s)(hPL providing insulin resistance to feed baby, requiring >insulin needs)

Insulin needs after delivery (lower d/t loss of hPL)

Risk of glycosuria

Progression of vascular disease

Nephropathy and retinopathy

pregestational diabetes

-Carbohydrate (CHO) metabolism alterations existing prior to pregnancy

-Includes women with Type 1 or Type 2 Diabetes

description of gestational diabetes

-"Glucose intolerance with onset during pregnancy."

-Usually diagnosed in the second or third trimester

-NOT clearly overt prior to pregnancy

**no need to check A1C

Pre-Gestational Diabetes

-*Assess ALL pregnant women for risk factors at first prenatal visit*

-Note presence of Type 1 or Type 2 Diabetes (pre-gestational diagnosis)

High Risk Factors noted with any of the following

•Fasting blood glucose level: > 126 mg/dL

•HbA1c: > 7%

•Random (non-fasting) blood glucose: > 200 mg/dL

goal of pre-gestational diabetes

-Achieve good metabolic control pre-conception to reduce fetal and maternal risks during pregnancy

-First prenatal visit: HbA1c testing. Goal = < 7%

management of pre-gestational diabetes during pregnancy

-Insulin to maintain glycemic control

-Exercise (per HCP recommendation)

-Diet (nutritional management)

-Fetal surveillance (monitoring...U/S, NST, fetal kick counts)

risk factors for gestational diabetes

-History: Family history, Gestational diabetes in previous pregnancy

-Status of previous infant(s): Congenital anomalies, Fetal demise, Previous large baby (> 9 lbs.) macrosomia, Multiples

-Age: 35 or older

-Pregnancy Symptoms: Glycosuria, 3 polys + fatigue

-Health status Obesity: PCOS, HTN (prior to or during pregnancy)

-Ethnicity: Hispanic, Native American, Pacific Islander, African American

screening for gestational diabetes

-step 1: screening!!! (step 2 is diagnostic)

-24 - 28 weeks' gestation

-Screening Test: 1-hour, 50 g. GTT/OGTT (Glucose Tolerance Test/Oral Glucose Tolerance Test)

gestational diabetes procedure 2 step approach

-Non-fasting (low-carb)

-Measure blood glucose levels prior to administering the glucose

-Administer a 50 g oral glucose load

-Measure blood glucose levels 1 hour later

-Goal: blood glucose < 140 mg/dL

results of gestational diabetes screening

-Positive screening test = > 140 mg/dL

-If results from Step 1 are abnormal (screening results), patients move to

-then Step 2 (diagnostic procedure).

step 2 gestational diabetes: diagnostic procedure

-Fast for 8 hours prior to this test

-Draw fasting blood glucose prior to administering the glucose

-Administer 100 g oral glucose

step 2 gestational diabetes: diagnostic criteria

-IF 2 or more of the below values are met or exceeded a diagnosis of GDM

(Gestational Diabetes Mellitus) is made

-If one is elevated, it doesn't mean she has DM we just need to monitor her more closely but if 2 or more are elevated then she has DM

** One elevated value from the list below ..... Recommended increased surveillance in pregnancy

diagnostic values for gestational diabetes

-Fasting blood glucose of > 95 mg/dL

-Blood glucose at 1 hour = > 180

-Blood glucose at 2-hours = > 155

-Blood glucose at 3 hours = > 140

tx recommendations for gestational diabetes

Gestational Diabetes: Manifests for first time during pregnancy

First treatment: Diet control

Second treatment: Insulin (does not cross the placenta)

Third treatment: Oral hypoglycemic, last choice due to risk to baby

management of gestational diabetes

-Nutritional management: Preferred...Implement pharmacotherapy if unable to manage with nutrition, Maintain fasting blood glucose < 92 mg/dL, Maintain postprandial glucose < 180 mg/dL at 1-hour, Maintain postprandial glucose < 153 mg/dL at 2-hours

-Exercise: Per HCP recommendation

-Insulin (if indicated): Does not cross the placenta, and Usually combine intermediate and short-acting

oral hypoglycemic if indicated

-Metformin: Crosses the placenta, Less risk of hypoglycemic episodes than with Glyburide

-Glyburide: Crosses the placenta and is Associated with more negative outcomes

(macrosomia, birth injury)

fetal surveillance for gestational DM

Monitoring (U/S, NST, Fetal kick counts)

maternal risks with diabetes in pregnancy

-Hydramnios: Fetal diuresis (hyperglycemia) and polyuria

-Gestational Hypertension with risk for Preeclampsia/eclampsia; bc diabetes affects the vascular system

-Ketoacidosis: Uncontrolled hyperglycemia

-Preterm Labor (PTL): Potential Premature ROM (uterine overdistention... macrosomia, hydramnios)

-Stillbirth: Risk with poor glucose control/ketoacidosis

-Hypoglycemia: Especially first trimester (glucose diverted to baby, NVP)

-Difficult labor/Possible C-Section: Macrosomic infant

-Post Partal Hemorrhage (PPH): Over-distended uterus (macrosomia, hydramnios)

Infection Risk: UTI's (glycosuria)

Yeast Infections (hyperglycemia --- changes in normal flora)

Congenital anomalies (major cause of death) r/t maternal DM

-Related to hyperglycemia in 1st trimester

-Heart

-CNS (NTDs): *sacral agenesis* (malformation of sacral are)

-Skeletal

-GI

fetal risks with DM

-Cord prolapse: Related to polyhydramnios & abnormal fetal position

-LGA/Macrosomia: Fetal hyperglycemia and hyperinsulinemia

-Birth trauma (shoulder dystocia/other): Macrosomia

-Respiratory Distress Syndrome (RDS): Poor surfactant production (hyperinsulinemia inhibits production of phospholipids of which surfactant is made)

-Neonatal hypoglycemia: Related to hyperinsulinemia

-Preterm birth:Related to polyhydramnios, poor placental perfusion

more risks to the fetus from DM

-Polycythemia: Related to increased RBC's due to fetal hypoxia

-Neonatal Hyperbilirubinemia: Related to excessive breakdown of RBC's (hypoxia)

and immature liver

-Perinatal death: Poor placental perfusion/hypoxia

-Childhood outcomes: Potential for obesity and CHO intolerance

IUGR from DM

**Intrauterine growth restriction (IUGR): Related to maternal vascular involvement and decreased placental perfusion

-More often associated with long-term diabetes (type 1) (>20 yrs bc her vascular system has had time to be affected)

Monitoring Fetal Well-Being in Pregnancy

Ultrasound: all trimesters, monitor growth

Quadruple Screen (maternal blood test): 2nd trimester, monitor for NTD's

Fetal Activity Monitoring: Primarily 3rd trimester

Non-stress test (NST): Primarily 3rd trimester

Biophysical Profile (BPP):Primarily 3rd trimester, indicated for NR-NST.

intrapartum care priorities

Term delivery (goal)

Vaginal birth (goal/preferred if possible)

Good control of maternal glucose levels during labor to prevent neonatal hypoglycemia

Insulin needs often decrease during labor

IV access available

Dextrose and Insulin available

postpartum care priorities

Insulin needs decrease (placenta, hormones)

Breastfeeding encouraged

Contraception (barrier methods preferred)

Health Promotion/Patient Teaching with DM

-Keep prenatal appointments

-Glucose self-monitoring as directed

-Daily fetal activity monitoring (kick counts)

-Drink 8-10 8-oz glasses of water daily (help prevent UTI/maintain hydration)

-Planned exercise program (after meals)

-Wear diabetic ID

-Consider breast-feeding (lower glucose levels)

-No smoking (fetal and vascular damage)

-Insulin administration/storage/travel

-C-Section (may be needed)

s/s hypoglycemia (develop rapidly)

-sweating, tremors, clammy, hunger, irritability, HA, blurred vision

-Treat with glucose boosters --- hard candy, glucose tablets, milk and crackers

s/s of hyperglycemia (develop slowly)

thirst, tired, flushed, frequent urination, increased RR, drowsy (Treat - notify HCP)

Promoting Optimal Maternal Glucose Control

-No dieting/Adequate dietary intake: goal = no ketone formation, adequate weight gain

-3 meals/day and 3 snacks/day: Include protein and fat at each meal

-40% of calories from complex carbs

-35% of calories from protein

-25% of calories from unsaturated fats

-Bedtime snack (recommended for ALL pregnant women)

-Daily physical activity

cardiovascular disease

Leading cause of death for women in the U.S.

obstetric emergencies r/t heart disease

Severe bleeding, amniotic fluid embolism, etc., cause most deaths at delivery.

Maternal mortality first week after delivery (most common causes):

Severe bleeding

High blood pressure (pre-e)

Infection

cardiomyopathy

-Leading cause of death 1 week to 1 year

after delivery (after the first week post delivery)

-Excess fluid on the heart is problematic for those with heart issues

Reason for concern in pregnancy r/t CV disease

-Uterine blood flow increases by at least 1 L per minute

-Result is increased blood:

RBC's: 25% increase

Plasma volume: 50% expansion

Clotting factors and platelets (increased)

increased workload on the heart

Increased cardiac output (30 - 50%)

Increased stroke volume (20 -30%)

Increased blood volume (30 -50%)

Increased heart rate (10 -20 bpm/30% increase)

Other related cardiovascular effects in pregnancy:

-B/P is decreased: effects of progesterone

-Hypercoagulability in pregnancy: potential increased risk of clots

recommendations for CV effects in pregnancy

Risk assessment PRIOR to pregnancy in women who have congenital or acquired heart disease

Focus of care for women with cardiac disease who become pregnant:

-Teaching signs and symptoms of cardiac compromise

-Dietary and lifestyle changes to promote the best pregnancy outcomes

-Increased frequency of prenatal visits

(every 2 weeks until last month of pregnancy then every week until delivery)

Class I and Class II cardiac disease:

Usually tolerate pregnancy without major complications (more mild)

class 3 heart disease

Frequent visits with cardiac care team throughout the pregnancy (more severe)

class IV heart disease

Degree of limitation experienced during physical activity as related to breathing (normal/degrees of shortness of breath) and/or chest pain

Woman's ability to function during pregnancy is often more important than the actual diagnosis of the cardiac condition

just bc she is class IV, if she isn't symptomatic it might be ok

Congenital defects: general info

-Improved surgical techniques now allows those affected to reach childbearing age

-If surgically repaired and no evidence of disease exists, pregnancy is uncomplicated

-Those with chronic cyanosis have increased pregnancy risks

pregnancy risks with congenital defects

Intrauterine growth restriction (IUGR)/Fetal growth restriction(FGR)

Preterm labor/birth

Pre-eclampsia

post partal risks with congenital defects

Hemorrhage (PPH)

Infection

Rheumatic heart disease

Incidence has decreased due to earlier treatment of strep throat infections

Scars valves

Risk for respiratory (dyspnea, orthopnea, pulmonary edema) and CHF effects

MVP (mitral valve prolapse)

-Usually tolerate pregnancy well

-Least symptomatic one with pregnancy (MVP)

Peripartum cardiomyopathy

-Leading cause of death 1 week to 1 year post delivery

-Affects left ventricle

-Symptoms similar to CHF

-Tends to recur

-Subsequent pregnancies not recommended

-Time frame of occurrence = last month of pregnancy, first 5 months after delivery

Marfan syndrome

-- autosomal dominant disorder

-- affects connective tissue

-- pregnancy not usually recommended

**Concerned about rupture of the aorta

Know the risk factors (4 main ones) linked to CVD-related maternal mortality

1. Race/ethnicity: higher risk of death in non-Hispanic black women

2. Age: over age 40

3. HTN/pre-eclampsia: especially during pregnancy

4. Obesity

monitoring with cardiac disease

-V.S. and weight. Note changes

-Edema

-Fetal well being/activity. Teach fetal kick counts and NST

-S/S of PTL and teach mom

-S/S of cardiac decompensation and teach mom

s/s cardiac decompensation

* Most vulnerable from 28 - 32 weeks gestation AND first 48 hours postpartum*

* Accurate maternal assessment is vital. Mom's hemodynamic status determines fetal well-being*

respiratory decompensation s/s

SOB on exertion/dyspnea

Tachypnea

Moist, frequent cough

cardiovascular decompensation s/s

-Irregular heartbeat, heart racing, palpitations

-Chest pain with effort or emotion

-Jugular vein engorgement

-Cyanotic lips/nail beds

-Swelling of face/hands/feet

-Syncope with exertion

-Increasing fatigue

nurses role with cardiac decompensation (teaching and s/s)

-Accurate assessment with each prenatal visit

-Teach: More frequent prenatal visits (usually every 2 weeks until last month then weekly

-S/S to report: Cardiac decompensation, pre-term labor

-Activity level as tolerated/frequent rest

-Importance of nutrition (especially iron, protein and fiber/prevent straining

-Lower sodium intake if indicated

Medications that may be implemented for CV disease

-Diuretics

-Digitalis

-Anti-arrhythmics

-Beta and calcium channel blockers

-Anticoagulants (Heparin) NOT Warfarin (Coumadin)

**Note: Heparin DOES NOT cross the placenta.

Coumadin is associated with birth defects, IUGR, spontaneous abortion, stillbirth (crosses placenta)

Labor and Birth prep with cardiovascular disease

-- Possibly give 02, monitor V.S., monitor fetus, semi-fowlers or lateral positions

-- epidural

-- vaginal if tolerated

**We don't sign her up for a C/S just bc she has a heart problem unless absolutely necessary

postpartum prep for CV disease

Monitor fluids and vital signs

Possible longer stay

Semi-fowlers or lateral position

Physiologic anemia as well which is normal but if Hgb <10.5 then iron deficiency

:)

anemia

"A reduction in RBC volume"

anemia measured by

Hematocrit (Hct)

A decrease in the concentration of hemoglobin (Hgb) in the peripheral blood

A sign of an underlying problem

result of anemia

Decreased O2-carrying capacity of the blood

Can affect vital organs of mom and fetus

anemia in pregnancy

Hgb < 11 g/dL in 1st and 3rd trimesters

Hgb , 10.5 g/dL or less in 2nd trimester

Physiologic Anemia of Pregnancy

-Related to increased blood plasma volume in comparison to red blood cells.

-Results in a decrease in Hgb and Hct in pregnancy

-Considered normal (is NOT true anemia)

-Does NOT result in reduced oxygen-carrying capacity

Iron Deficiency Anemia

-"Iron deficiency is the most common pathologic cause of anemia in pregnancy."

-Affects ¼ of all pregnancies

-Maternal anemia in early pregnancy negatively impacts fetal neurologic development

-Greatest need is in 2nd half of pregnancy: baby is gaining most of its weight during this time

causes of iron deficiency anemia in pregnancy

Iron deficient diet

GI issues affecting iron absorption

Short interval between pregnancies

maternal risks from iron deficiency

Preterm delivery

Infection

Fatigue

Pre-eclampsia

Post partal hemorrhage (PPH)

Post partum depression

fetal-neonatal risks from iron deficiency

-LBW (low birth weight)

-Prematurity

-Stillbirth/Neonatal death

-Intellectual disability/poor mental and psychomotor performance

-Cardiovascular strain

**Baby suffers neurologically without enough iron in pregnancy

Goals of treatment for iron-deficiency anemia in pregnancy:

Eliminate symptoms

Correct the deficiency

Replenish iron stores

Recommendations for all pregnant women:

-Ferrous sulfate or Ferrous gluconate

-Ferrous sulfate: 325 mg = 65 mg elemental iron (1-3x/day)

-Ferrous gluconate: 240 mg = 27 mg/day

-Ascorbic acid: 500 mg to enhance iron absorption

-Inhibit absorption: Milk, caffeine, antacids and Ca++ supplements inhibit iron absorption

Difficult to meet maternal iron requirements through diet alone

:)

Side effects of iron supplementation:

GI upset (nausea, abdominal pain)

Constipation

Black stools

dietary sources of iron

-meats (red) iron and whole wheat fortified cereals/breads

-dried fruits

-leafy green veggies

-legumes

-peanut butter

Folic Acid Deficiency Anemia facts

-Folic acid deficiency is the most common cause of megaloblastic anemia

-Folic Acid is necessary for DNA and RNA synthesis

-A deficiency of folic acid in pregnancy is linked to NTD's (neural tube defects)

-Folic acid supplementation daily for 3 months prior to and 3 months after conception reduces the risk of first occurrence NTD's.

Recommendations for Prevention of Folic Acid Deficiency Anemia (all women of childbearing age)

-0.6 mg/day (600 mcg) folate total recommended intake in pregnancy (diet + supplement in PNV)

-Daily supplement needed, not enough in diet

*Daily intake of the above recommended amount of folic acid has been shown to reduce the risk of NTD's by two thirds*

:)

Thalassemia

-Autosomal recessive

-Management depends on severity

-Regular evaluation of cardiac function by cardiologist (prevent fluid overload)

-Monitor hemoglobin and iron (ferritin) levels (avoid iron overload)

sickle cell

-Autosomal recessive (considered a chronic disease in adults)

-More common in those of African American descent (also Middle Eastern and Southeast Asian descent)

-Moderate to severe anemia (RBC's have shorter than normal life span)

-Greater risk for negative pregnancy outcomes

-Early, continuous prenatal care is recommended

-Fetal well being tests in pregnancy (kick counts, NST, BPP, others)

-Labor = rest, pain management, O2, fluids.

-Post partum = anti-embolic stockings

**Pregnancy is a stressor and she is at risk for sickle cell crisis

depression

Often is undiagnosed and untreated

May result in preterm birth, SGA, LBW

dipolar disorder

Depressive phase (symptoms of depression)

Manic phase (risk-taking behaviors)

anxiety disorders

Wide range of symptoms depending on the disorder

Anxiety can result in physical symptoms (chest pain, SOB, fear, terror, etc.

schizophrenia

Most disabling of the psychological disorders

Difficult to treat in pregnancy, meds. can be teratogenic

Increased rise of preterm birth, LBW, SGA, placental abnormalities and antenatal hemorrhage

Nurse's Role in caring for women with psychologic disorders

-Good history

-Consistent care providers (establish trust/rapport)

-Use therapeutic communication

-Attentiveness to behavioral cues, verbal and non-verbals

-Acknowledge fears

-Assist with coping

-Non-judgmental approach

-Promote calm, supportive, confident care

Common Viral Infections affecting Pregnancy

Cytomegalovirus

Rubella

Herpes simplex

Hepatitis B

Varicella

Parvovirus B19

COVID 19

Common Non-viral Infections affecting Pregnancy

Toxoplasmosis (Ricci, p. 722)

Group B Streptococcus (GBS)

TORCH

T: Toxoplasmosis

O: "Other infections"

R: Rubella

C: Cytomegalovirus

H: Herpes Simplex Virus (HSV)

concern with infections

Infection may cross the placenta and be teratogenic to the baby

toxoplasmosis

-A protozoal (parasite) infection

-Primary host: Cats (shed the virus in their feces)

-Other sources: See below

-Method of transmission: Hand to mouth (handling cat feces .. Directly or indirectly)

sources of toxoplasmosis

-Raw or undercooked meat (especially pork, lamb or venison)

-Unpasteurized milk

-Raw eggs

-Cat feces/infected cat

-Contaminated water

-Unwashed fruits and vegetables

**Education to moms is so important!!

Effects if toxoplasmosis contracted first time during pregnancy:

Woman may remain asymptomatic

Risk of PTL (preterm labor) and stillbirth

fetal risks of toxoplasmosis

-Exposure via placental transfer

-Earlier exposure during the pregnancy = more severe outcomes

-Affects vision, hearing, growth, neurologic status