ch 12 - gestational conditions

gestational condition

a disorder that did not exist before pregnancy and develops or is recognized during pregnancy.

gestational diabetes mellitus (gdm)

impaired glucose tolerance with first onset or recognition during pregnancy.

gdm - fasting/premeal glucose

the instructor material gives about 60 to 99 mg/dl fasting and an acceptable premeal range of 65 to 95 mg/dl.

gdm - 1 hour postmeal glucose

less than 140 mg/dl.

gdm - 2 hour postmeal glucose

less than 120 mg/dl.

gdm - sleeping glucose

should not be less than 70 mg/dl in the instructor material.

gdm - fetal/neonatal risks

macrosomia, birth trauma, electrolyte imbalance, neonatal hypoglycemia, and complications associated with polyhydramnios.

gdm - maternal concerns

ketoacidosis, hypoglycemia, hyperglycemia, infection, polyhydramnios, and hypertensive complications.

gdm - hypoglycemia causes

too much insulin, skipped or late meals, or increased exercise.

gdm - hyperglycemia significance

can cause excessive fetal growth or macrosomia.

gestational hypertension

hypertension after 20 weeks without proteinuria in the instructor material.

gestational hypertension - blood pressure threshold

140/90 mm hg or higher on two occasions at least 4 hours apart.

preeclampsia

pregnancy-specific hypertensive disorder after 20 weeks with proteinuria and systemic findings in the instructor framework.

eclampsia

preeclampsia with seizure activity or coma.

chronic hypertension

hypertension present before pregnancy or diagnosed before 20 weeks and persisting beyond pregnancy.

preeclampsia - risk factors

first pregnancy, multifetal gestation, previous preeclampsia, chronic hypertension, diabetes, thrombophilia, sle, bmi over 30, age 35 or older, kidney disease, and obstructive sleep apnea.

preeclampsia - pathophysiology

poor placental perfusion and endothelial dysfunction lead to generalized vasospasm, hypertension, tissue edema, and reduced organ perfusion.

preeclampsia - kidney effects

reduced renal perfusion, oliguria, proteinuria, and increased creatinine/uric acid.

preeclampsia - neurologic effects

severe headache, hyperreflexia, clonus, visual changes, scotoma, seizures, and possible intracranial complications.

preeclampsia - liver effects

elevated liver enzymes, epigastric or right upper quadrant pain, nausea, and vomiting.

preeclampsia - hematologic effects

thrombocytopenia, hemolysis, hellp syndrome, and possible dic.

preeclampsia - fetal effects

decreased placental perfusion, iugr, hypoxia, and placental abruption risk.

preeclampsia - subjective findings

severe continuous headache, nausea, blurred vision, flashes/spots, epigastric pain, and right upper quadrant pain.

preeclampsia - objective findings

hypertension, proteinuria, facial/hand/abdominal edema, pitting edema, vomiting, oliguria, hyperreflexia, dyspnea, diminished breath sounds, seizures, and jaundice.

preeclampsia - laboratory findings

elevated ldh/ast, increased creatinine, increased uric acid, thrombocytopenia, hyperbilirubinemia, and hemoglobin changes.

hellp syndrome

hemolysis, elevated liver enzymes, and low platelets.

hellp - complications

pulmonary edema, acute renal failure, dic, placental abruption, liver hemorrhage/failure, ards, sepsis, and stroke.

deep tendon reflexes in preeclampsia

assessed for hyperreflexia because increased reflexes can indicate increased seizure risk.

clonus

repetitive beats after sudden dorsiflexion of the foot; positive clonus suggests increased neuromuscular irritability and seizure risk.

eclampsia - immediate priorities

control seizures, protect the client, correct hypoxia/acidosis, control severe hypertension, assess neurologic status, and deliver after maternal stabilization.

magnesium sulfate

anticonvulsant used to prevent or treat seizures in severe preeclampsia and eclampsia.

magnesium sulfate - monitoring

blood pressure, pulse, respirations, dtrs, level of consciousness, urine output, headache, visual symptoms, epigastric pain, contractions, fetal heart rate, and fetal activity.

magnesium sulfate - urine output goal

maintain at least 25 ml/hr in the instructor material.

magnesium toxicity

excess magnesium causing neuromuscular, respiratory, and cardiac depression.

magnesium toxicity - signs

absent patellar dtrs, urine output less than 30 ml/hr, respirations less than 12/min, decreased level of consciousness, and cardiac dysrhythmias.

magnesium toxicity - first action

immediately discontinue the magnesium sulfate infusion.

magnesium sulfate antidote

calcium gluconate.

calcium gluconate - instructor dose

1 g iv over 3 minutes.

magnesium sulfate - expected bolus effects

flushing, warmth, sedation, diaphoresis, and burning at the iv site can occur.

hyperemesis gravidarum

severe persistent vomiting causing weight loss, dehydration, electrolyte imbalance, nutritional deficiency, and ketonuria.

hyperemesis gravidarum - findings

significant weight loss, dehydration, dry mucous membranes, decreased blood pressure, increased pulse, poor skin turgor, inability to retain fluids, electrolyte abnormalities, and ketonuria.

hyperemesis gravidarum - important lab

ketonuria is emphasized by perry as an important initial laboratory finding.

hyperemesis gravidarum - initial care

iv fluids and electrolyte correction when oral intake cannot be retained, plus medications and nutritional support as prescribed.

hyperemesis gravidarum - diet teaching

once vomiting improves, use small frequent fluids and bland foods and gradually advance intake.

miscarriage

pregnancy loss from natural causes before fetal viability, commonly before 20 weeks.

cervical insufficiency

inability of the cervix to remain closed during pregnancy, contributing to painless dilation and second-trimester loss or preterm birth.

ectopic pregnancy

implantation of a fertilized ovum outside the uterine cavity, usually in a fallopian tube.

ectopic pregnancy - risk factors

stis, assisted reproduction, tubal surgery, and other factors that damage or compromise the fallopian tubes.

ectopic pregnancy - expected findings

one-sided stabbing lower abdominal pain or tenderness with scant dark red or brown spotting.

ruptured ectopic pregnancy

can cause severe internal hemorrhage with dizziness, faintness, hypotension, tachycardia, pallor, and shock.

ectopic pregnancy - diagnostics

serum progesterone and hcg plus transvaginal ultrasound.

ectopic pregnancy - methotrexate

medical treatment option for selected unruptured ectopic pregnancies.

methotrexate teaching

avoid alcohol, avoid folic-acid vitamins, and protect from sun/photosensitivity according to the instructor material.

hydatidiform mole

gestational trophoblastic disorder involving abnormal placental/trophoblastic tissue growth.

molar pregnancy - findings

vaginal bleeding, uterus often larger than expected, excessive nausea/vomiting, abdominal cramping, high hcg, and possible passage of vesicles.

molar pregnancy - unusual clue

preeclampsia occurring unusually early can suggest molar pregnancy.

molar pregnancy - follow-up

serial hcg monitoring is required because persistent gestational trophoblastic disease can occur.

placenta previa

placenta implanted in the lower uterine segment near or over the cervical os.

placenta previa - classic finding

painless bright-red vaginal bleeding in the second or third trimester.

placenta previa - uterus

typically soft and nontender.

placenta previa - fetal position

breech, oblique, or transverse lie is more common; presenting part may remain high.

placenta previa - diagnosis

ultrasound; the instructor calls transvaginal ultrasound the gold standard.

placenta previa - vaginal exam

do not perform a digital vaginal examination because it can trigger severe hemorrhage.

placental abruption

premature partial or complete separation of the placenta from the uterine wall after 20 weeks.

placental abruption - risk factors

maternal hypertension, blunt trauma, cocaine use, previous abruption, cigarette smoking, prom, and multifetal pregnancy.

placental abruption - classic findings

sudden painful dark-red bleeding, uterine tenderness, hypertonicity, frequent contractions, rigid or board-like abdomen, fetal distress, and shock.

concealed placental abruption

blood is trapped behind the placenta, so visible vaginal bleeding may underestimate total blood loss.

placental abruption - fundal height

may increase with concealed hemorrhage.

placental abruption - diagnosis

primarily clinical; a negative ultrasound does not rule it out.

placental abruption - nursing priorities

assess uterine tone and tenderness, monitor fetal heart rate and maternal vital signs, track urine output, support circulation with iv fluids/blood as prescribed, provide oxygen, and prepare for urgent birth when indicated.

placenta previa vs abruption - bleeding

previa: bright red; abruption: dark red or concealed.

placenta previa vs abruption - pain

previa: painless; abruption: painful.

placenta previa vs abruption - uterus

previa: soft/nontender; abruption: tender, hypertonic, rigid or board-like.

placenta previa vs abruption - shock

previa shock usually reflects visible blood loss; abruption shock can be more severe than visible bleeding suggests because hemorrhage may be concealed.