NURS 482 Exam 2 - High Risk Pregnancies

diabetes mellitus

- both pregestational and gestational diabetes

- Most common endocrine disorder associated with pregnancy

- Occurs in 6-7% of pregnant individuals

- 90% of cases are gestational diabetes (GDM)

- This is considered a high-risk pregnancy

- Care is generally the same as for diabetic patients who are not pregnant

gestational diabetes mellitus (GDM)

any degree of glucose intolerance with onset or recognition during pregnancy

maternal metabolic changes during pregnancy

- 1st trimester: increased endogenous insulin lowers BG levels (and decreased insulin requirements)

- 2nd and 3rd trimester: insulin resistance leading to increasing insulin requirements - peaks at 36 weeks)

- Postpartum: return to normal BG within 7-10 days

fetal metabolic changes during pregnancy

- Glucose (but not insulin) crosses placenta

- Fetal pancreas produces insulin at 10 weeks

Preconception counseling and care for those with pre-existing diabetes

- Reduces perinatal mortality, congenital anomalies

- Helps protect mother's health

- Plan optimal time for pregnancy

- Establish glycemic control

- Diagnose vascular complications

- May include contraceptive use

complications for those with pregestational diabetes

- Preeclampsia

- Miscarriage

- Preterm birth

- Infections

- Polyhydramnios

- C/S or operative vaginal birth

- Shoulder dystocia

- Postpartum hemorrhage

- Postpartum depression

polyhydramnios

excessive amniotic fluid

Effects of pre-gestational diabetes on the fetus or neonate

- Congenital anomalies - Cardiac, CNS, skeletal

- Stillbirth (IUFD)

- Macrosomia or small baby

- Birth injury

- Respiratory distress syndrome

- Hypoglycemia

- Hyperbilirubinemia

pregestational diabetes blood glucose goals during pregnancy

- fasting = 60-95

- 1 hour postprandial = 140 or less

- 2 hours postprandial = 120 or less

Pregestational diabetes during pregnancy

- Insulin need drops first trimester, then insulin resistance could begin as early as week 14-16

- Sleep, diet, insulin, BG testing, exercise on consistent daily schedule

- Some clients will be diet-controlled, some with use of oral medication, but almost all clients will need insulin for blood sugar control during pregnancy

- Pregnancy may accelerate the progress of vascular complications

pregestational diabetes - during labor

- BG every hour: goal is 90-100

- IV: continuous insulin infusion (Saline or LR) until BG < 70, then switch to dextrose

- Continuous fetal monitoring

- Alert for shoulder dystocia

- Peds/NICU present for birth

- Newborn glucose monitoring

- Skin to skin!

- Breastfeed early!

pregestational diabetes - postpartum

- May need IV insulin until eating regular diet

Insulin needs will be close to pre-pregnancy levels, lower if breastfeeding (recommended)

- Monitor for pre-eclampsia, hemorrhage, infection

gestational diabetes

- When diabetes develops during the pregnancy

- Diagnosis typically occurs during the 2nd half of pregnancy

- Pancreas, stressed by adaptation of pregnancy, falls behind on insulin production

- Increasing prevalence due to rising mean maternal age and weight

GDM maternal risks

- Cesarean or operative birth (17-25%)

- Increased risk of future type 2 DM (up to 70%)

- Increased risk of preeclampsia (9.8-18%)

- Increased risk of postpartum depression

GDM fetal/neonatal risks

- Macrosomia

- Birth trauma

- Hypoglycemia

screening for gestational diabetes

- Initial prenatal visit

- Screening by history, risk factors, blood glucose

- Universal screening at 24-28 weeks

GDM diagnostic criteria

- Screening: positive 1 hr - OGTT > or 130

- Diagnostic: 3 hr. OGTT (done if 1 hr OGTT > or 130):

- Fasting = > or 95

- 1 hr = > or 180

- 2 hr = > or 155

- 3 hr = > or 140

- Positive for GDM if 2 results at or above levels

- Oral glucose tolerance test 50 g of sugar

risk factors for GDM

- Age > 25 yr

- Obesity

- Family history of type II diabetes

- Polycystic ovarian syndrome (PCOS)

- Previous pregnancy history:

- Macrosomia > 4500 g

- Polyhydramnios

- Unexplained stillbirth

- Miscarriage

- Infant with congenital anomalies

management of GDM

- Diet and exercise

- Blood glucose monitoring; urine testing

- Possible pharmacologic therapy: oral (glyburide, metformin)

- About 25% need insulin

- Fetal surveillance: U/S, monitor growth; Non-Stress Test (NST) start at 32 weeks if on insulin

Intrapartal/PP Management of GDM

- Blood glucose goal: 80-110

- Avoid dextrose IV

- May need rapid-acting insulin IV

- Postpartum:

- Encourage breastfeeding

- Follow-up glucose levels

- Assess for PPD

summary of GDM

- Normal pregnancy insulin requirements go down 1st trimester and increase in 2nd and 3rd trimesters

- Pregestational DM can cause fetal anomalies, IUGR or macrosomia

- May require tight control with insulin and possibly require iV insulin in labor

- Gestational DM occurs after 20 weeks

- May not need insulin

- Screen at 24 weeks

- Macrosomia common

- During labor, no IV dextrose unless BG < 70 = Risk for pre-eclampsia, infection, birth injury

- NEWBORNS AT RISK! = Keep them warm

preconception health

- The health of an individual before and between pregnancies

- Impacts life-long well-being

- Focus on managing health risks, chronic conditions, and genetic factors for individuals of reproductive age (15-49)

- Access to trusted healthcare providers

why preconception health matters

- Reduces maternal and infant mortality

- Prevents complications such as low birth weight and birth defects

- Addresses modifiable health risks

- Every person, every time: ensuring healthcare at every visit

social determinants of health and preconception

- Access to healthcare

- Mental health and stress levels

- Nutrition and healthy weight

- Tobacco and substance use

- Chronic conditions and prevention

pregnant-capable individuals

- In the US, 50.8% of the population are individuals capable of pregnancy

- Have specialized biological and psychosocial attributes that necessitate specialized care

- However, our country is made up of many areas in which reproductive/maternal health care is minimal or non-existent (Maternity Care Deserts)

north carolina report card

The March of Dimes report gives NC a D+ rating

policy and advocacy

Critical to ensuring access to care!

parental leave policies

- Parental leave policies are important for the health and well-being of families

- They provide new parents with the time off they need to care for their newborns and bond with their children, which can have long-lasting benefits for both parents and children

- Advocate for adequate leave policies

advocacy for perinatal and child health

- Advocating for perinatal and child health is essential to ensure access to quality healthcare and resources for healthy pregnancies and families

- This includes advocating for increased funding and supporting policies that promote healthy pregnancies and families

racial and ethnic bias in maternity care

- Unequal care and its impact on maternal and newborn outcomes

- Implicit Bias = healthcare providers may unconsciously hold negative stereotypes about certain racial and ethnic groups, which can affect the care provided

- This can lead to things like: underestimation of pain levels in black and brown women & dismissal of reported symptoms or concerns

risk assessment (bias)

- Many black and brown women are classified as "high-risk" due to racial bias and then placed on obstetrical pathways of care that lead to over-pathologization or medicalization of their pregnancy, labor, or birth

- This can lead to:

- Increased or unnecessary interventions

- Reduced access to midwifery care

- Misinterpretation of social determinants of health as innate physiological differences

What contributes to socioeconomic bias?

- Educational bias

- Body size bias

- Language and cultural bias

- Age-related bias

call to action

- Advocate for policy changes on a local and national level

- Serve rural communities

- Seek continuing education and other learning opportunities to provide culturally safe and unbiased care

hyperemesis gravidarum

- Severe nausea and vomiting of pregnancy

- Weight loss, dehydration, electrolyte imbalance, nutritional deficiencies, ketonuria

- Incidence: 0.5% of live births

- Usually occurs in first 20 weeks

hyperemesis gravidarum risk factors

- Nulliparity

- Overweight

- History of migraines

- Hx of psychiatric problems

- Thyroid disorder

- Diabetes

- Self or family history of hyperemesis

- Fetus with chromosomal abnormality (e.g. trisomy 21)

- Multifetal gestation

- Gestational trophoblastic disease

- Female fetus

hyperemesis etiology

- Uncertain

- High levels of hCG or hyperthyroidism

- Gastric reflux, dysrhythmias, reduced motility

- Psychosocial factors: ambivalence, stress

hyperemesis maternal complications

- Metabolic acidosis

- Jaundice

- Esophageal rupture

- Vitamin K deficiencies; Wernicke's encephalopathy

hyperemesis fetal complications

- IUGR

- LBW

- Preterm delivery

taking a good history (hyperemesis)

- Nausea and vomiting, other GI symptoms

- Precipitating factors

- Nonpharmacologic and pharmacologic interventions

- Pre-pregnancy weight; gain or loss

- Self or family hx of hyperemesis

hyperemesis assessment

- Vital signs

- Weight

- Dehydration

labs for hyperemesis

- electrolytes

- CBC

- liver enzymes

- bilirubin

- thyroid

- urine for ketones & sp. gravity

management of hyperemesis

- NPO initially until vomiting stops

- Slowly introduce liquids and bland foods

- IV fluids

- Medications

medications for hyperemesis

- B6 + sleep aid

- Antinausea

- Corticosteroids: if not responding to other meds - Risk of facial clefting if used in first trimester

- In severe cases = Enteral or parenteral nutrition

non-pharmacologic management of hyperemesis

- Hypnosis

- Supportive psychotherapy

- Acupressure - Stimulate median nerve

additional nursing actions for hyperemesis

- I & O; amount and character of emesis

- Good oral hygiene

- Quiet environment avoid strong odors

- Psychological support for patient and family

patient education for hyperemesis

- Small, frequent meals; q 2-3 hours

- Low fat, high protein

- No greasy foods

- Herbal tea: ginger, chamomile, raspberry leaf

- Ginger ale (warm with sugar)

- Salty and sweet approach

preterm labor and birth

- Contraction causing cervical change between 20 and 36 6/7 weeks gestation

- March of Dimes is the leading organization for pregnancy and baby health with focus on Preterm Labor (PTL) and Preterm Birth (PTB)

March of Dimes Preterm Birth Report Card

- United States has a D+ rating, 10.4% of all births are premature

- US has one of the highest rates for PTD of industrialized countries in the world

- NC has a D+ rating

- NC ranks 32 out of 52 (all states including DC and Puerto Rico

- The preterm birth rate in the US has worsened for a fourth year, from 9.63% in 2015 to 10.4% in 2024

- Premature birth and its complications are the largest contributor to infant death in this country and globally

preterm birth (PTB)

Birth between 20 and 36 6/7 weeks

NC racial disparities (PTB)

- In NC, the preterm birth rate among black women is 48% higher that the rate among all other women

- This disparity is related to structural racism and implicit bias

cost to healthcare systems (PTB)

- Longer hospital stays = higher costs

- Normal newborn = 2 days

- Premature infant = 24.2 days

- Premature babies often face serious and long-term health problems

- Ethical decisions regarding treatment

preterm labor risk factors

- History of prior preterm births - most significant!

PPROM

- Infection (Group B Strep, STIs, bacterial vaginitis, UTI)

- Age < 17 or > 34 years

- Short cervix or cervical "insufficiency"

- Uterine variations or complications (e.g. fibroids)

- Multiple miscarriages

- Multiple gestation

- Smoking, cocaine, and other substance abuse

- Socioeconomic factors, work/stress, access to care

- Underweight - low BMI

RN's role (PTL)

- Identifying clients at risk for PT birth

- Helping clients modify risk factors (smoking, STIs, etc.)

- Educating clients to identify symptoms of PTL

PTL - nursing care and assessment

- Screen for risk factors

- Patient education: teach signs and symptoms to report

signs and symptoms of PTL

- 6 contractions/hr or more

- Cramps: menstrual-like

- Discharge

- Pushing down pressure

- Low, dull backache

diagnosis of preterm labor

- Nursing contribution - history taking, observation

- Cervical changes - early effacement, dilation, consistency

- Diagnostic tests - fetal fibronectin (FFN), cervical length

Fetal Fibronectin (FFN)

- Biochemical Marker for Risk Assessment

- The test checks for FFN (glycoprotein "glue") in vaginal secretions

- FFN is a glycoprotein (protein with sugar) that acts as an adhesive, keeping the baby's sac attached to the uterus

- Presence is normal after 35 weeks

- Presence is abnormal between 22-35 weeks

- A negative result often means low risk for the next two weeks, while a positive result indicates increased risk, though not definitive

negative FFN result

Has positive predictive value (highly and reliably predicts 99%) that patients will not give birth in the next two weeks

positive FFN result

- Low predictive value: does not reliably predict going into labor

- BUT requires action:

- Do ultrasound for cervix length

- Consider steroids for fetal lung development

- Consider meds to stop contractions

- Plan for potential need for intensive care nursery (ICN)

cervical length

- Determined by transvaginal ultrasound

- Cervix less than 3 cm increases likelihood of preterm birth

- The shorter the cervix, the higher risk of PTB

Preterm Premature Rupture of Membranes (PPROM)

- Rupture of membranes before 37 weeks

- Serious complication is chorioamnionitis (bacterial infection)

PPROM diagnosis

- Nitrazine paper (alkalinity)

- Ferning (fern pattern microscope) - more specific

PPROM intervention

- Assess for infection, PTL, and fetal well-being

- Administer meds if ordered

- Active v/s expectant management

PPROM causes

- Infection in the uterus

- STIs/UTIs

- Smoking

- Cervical conization or LEEP procedure = cone biopsy of cervix to remove precancerous cells

- Short cervix

- Overdistended uterus

- Low BMI/nutrition deficiencies/low socioeconomic status

preterm labor interventions

- prevention is #1

- treatment

- tocolytic therapy

- steroids for fetal lung maturity

PTL prevention

- 17 P (alpha-hydroxyprogesterone) = weekly injection to prevent recurrent preterm birth

- Early recognition and diagnosis

- Lifestyle modifications

PTL treatment

Cerclage for cervical problems = sews the cervix shut to prevent preterm birth (recurrent/weakened cervix)

PTL - tocolytic therapy

- Terbutaline/Brethine

- Nifedipine/Procardia

- Indomethacin/Indocin

steroids for fetal lung maturity

Betamethasone - 12 mg (IM) x 2 doses, 24 hours apart

magnesium sulfate in PTL

- We used to use magnesium sulfate as a tocolytic therapy

- Today we administer magnesium sulfate as a tool for fetal neuroprotection

- Protecting against brain injury from hypoxia, inflammation, and excitotoxicity

- 4-6 gm loading dose followed by 1-2 gm/hour continuous

- Considered for threatened delivery between 24-32 weeks, some guidelines extend through 34 weeks

- Maternal side effects: flushing nausea, respiratory issues

nursing support during PTL and PTB

- Emotional support & sensitivity

- Education

- Advocacy

- Breast pumping

- Promote bonding

- Refer for additional resources

early pregnancy bleeding (within first 20 weeks)

- Spontaneous abortion (miscarriage)

- Hydatiform molar (molar pregnancy)

Spontaneous Abortion

- A pregnancy that ends due to "natural causes" before 20 weeks gestation

- Often due to a "non-viable fetus"

- Also referred to as a miscarriage

- Incidence: 10-15% of all pregnancies

- 80% of these occur early (<12 weeks gestation)

- When after 12 weeks GA, considered a "late miscarriage"

- 25% of losses result from chromosomal abnormalities

- Other causes: endocrine imbalance (diabetes), immunologic (antiphospholipid antibodies) & systemic disorders (lupus) & genetic factors

second trimester loss

- A late miscarriage occurs at 12-20 weeks

- (after 20 weeks = pre-term birth)

risk factors for a second trimester loss

- Poor outcomes in a previous pregnancy

- Extremes of maternal age - Older people

- Severe dietary deficiencies - Eating disorders

- Regular or heavy alcohol use

- Morbid obesity

- Excessive caffeine intake

threatened miscarriage

- spotting & mild cramping, the cervix is closed

- Showing signs but not starting to dilate cervix yet

Inevitable miscarriage

moderate to heavy bleeding & mild to severe cramping. The cervix dilates

incomplete miscarriage

retained placenta. Results in heavy bleeding & severe cramping

complete miscarriage

after all fetal tissue is expelled. The cervix is closed. Results in slight bleeding & mild cramping

missed miscarriage

- the fetus dies in utero but is not expelled

- DNC/DNE

recurrent miscarriage

loss of three or more pregnancies <20 weeks

septic miscarriage

- (uncommon)

- slight to heavy vaginal bleeding that is usually malodorous, fever & abdominal tenderness

assessment (miscarriage)

- Pregnancy history, last menstrual period

- Vital signs

- Type & location of pain

- Quantity & nature of bleeding

- Emotional status

- Labs: B-hCG & CBC: Pregnancy hormone → levels can be high/low depending on the week of pregnancy → look at trends

- Management depends on the classification of the miscarriage and the signs and symptoms

miscarriage medical and nursing interventions

- Threatened AB - bed rest (50% remain pregnant)

- Most miscarriages will end with spontaneously passing the POC - "Products of conception"

- Some will need a dilation and curettage (D&C) procedure

- Recurrent - if due to weakness of cervical tissue, can be corrected surgically by cerclage placement: In cervix → stitch that strengthens cervix (doesn't dilate too quickly)

- Administer RhoGam if RH- : If potential for mixing blood

- Provide and refer for support as needed

spontaneous abortion review

- Spontaneous AB = loss of pregnancy < 20 weeks due to natural causes

- Early = < 12 weeks, 25% of losses result from chromosomal abnormalities

- Late = 12-20 weeks

- Diagnosed by history, S&S, labs, cervical exam and transvaginal ultrasound

- Care management depends on the classification of the AB and S&S

ectopic pregnancy

- Fertilized ovum is implanted outside the uterine cavity

- Once it implants, you can't move it = non-viable

- 90% are in a uterine (fallopian) tube

- Incidence: 1-2% = accounts for 6% of all pregnancy-related deaths

ectopic pregnancy etiology

- The uterine tubes have fimbriated (fringed) ends that pull the ovum into the tube at ovulation

- The ovum is usually fertilized in the mid/outer section of the tube, then travels to the uterus to implant

- With an ectopic pregnancy, the ovum does not travel to the uterus often due to a blockage in the tube

ectopic pregnancy risk factors

- Tubal surgery

- Infection and/or damage

- Sexually transmitted diseases

- IUD

- Assisted reproductive technologies

sites of implantation of ectopic pregnancies

- Fimbrial

- Amupullar

- Isthmic

- Tuboovarian

- Interstitial

- Ovarian

- Abdominal

- Cervical

unruptured ectopic pregnancy

- Occurs around 6-8 weeks after LMP

- Abdominal pain which begins as dull lower quadrant pain (on one side) then changes to a sharp pain as the tube stretches

- Believes experiencing a delayed period (1-2 weeks) or lighter than usual

- Abnormal vaginal bleeding (mild/moderate, dark red or brown)

ruptured ectopic pregnancy

- Occurs between 6-12 weeks of gestation

- Pain increases and may be generalized, one-sided or in the deep lower quadrant

- Referred shoulder pain as blood enters the peritoneal cavity

- Signs of shock (low BP, increased HR, confusion, decreased LOC, clammy skin, etc.)

diagnostic tests for ectopic pregnancy

- Transvaginal ultrasound

- hCG & progesterone level

- CBC

care for unruptured ectopic pregnancy

- < 4 cm in size & no cardiac activity - IV methotrexate = (chemo-type drug that stops growth of cells)

- Antimetabolite, antineoplastic agent

- Stops the growth of actively dividing cells (embryonic, fetal and early placental cells)

- Helps to maintain tubal patency and fertility

care for ruptured ectopic pregnancy

- Surgical repair or removal of uterine tube

- Might have to remove the tube that ruptured

- Administer RhoGAM for Rh- clients

I- ncrease risk for infertility and recurrent ectopic pregnancy

hydatiform mole

- Also known as molar pregnancy

- A slow-growing tumor that develops from trophoblastic cells in the uterus (never becomes a fetus)

symptoms of hydatiform mole

- vaginal bleeding (dark clumps), N/V, "grape-like cysts", pelvic pressure or pain

- If not found early, s/sx include a rapidly growing uterus, no fetal heart tones or fetal movement

complications of hydatiform mole

may become malignant and spread to other tissues or organs

treatment of hydatiform mole

D&C and possible chemotherapy for persistent gestational trophoblastic neoplasia (GTN)

late pregnancy bleeding (after 20 weeks)

- placenta previa

- abruptio placentae

placenta previa

- The placenta implants in the lower uterine segment near or over the cervical os

- Could cover cervix - DO NOT WANT

- Occurs in 1/200 pregnancies