NUR306 EXAM 3

pre-gestational risk

pre-existing conditions that can affect a woman during pregnancy

gestational risk

current conditions that can affect a woman during pregnancy

how to tell if a pregnancy is high risk

1. will it harm the mother?
2. is it harming the fetus?
3. will it result in a high risk infant?

pregnancy outcomes depend on...

1. the effect of the problem on the physiology of pregnancy and fetal development
2. the severity of the problem
3. the ability to manage the mother's disease and its effect on the pregnancy while protecting the well being of mother and fetus

conditions that affect pregnancy outcomes

systemic lupus erythematosus (SLE)
HIV
hep B
positive GBS
anemia
STIs

HIV risk

if untreated, 25% risk of transmission to her newborn
if treated with antiretroviral therapy, 2% risk of transmission to her newborn if she delivers by c-section at 38 weeks and avoids breastfeeding

hep B risk

infants must receive hep B vaccination within 12 hours of birth, at 1 yr., and 15 mo.

positive GBS risk

if untreated, infant is at risk for respiratory distress, pneumonia, meningitis, sepsis
treat with IV penicillin until delivery

iron deficiency anemia risk

Hgb < 11g/dL
maternal risks include risk for infection, fatigue, higher chance of preeclampsia, postpartum hemorrhage
fetal risks include SGA, prematurity, stillbirth, neonatal death
treat with 60-120 mg iron/day

folic acid deficiency anemia risks

maternal risks include N & V, anorexia, low Hgb levels
fetal risks include neural tube defects
treat with 1 mg folic acid supplement

chlamydia risk

treat mom
repeat culture in 3 weeks
infant at risk for chlamydial eye infection
treat with erythromycin eye ointment at birth

syphilis (VDRL or RPR) risk

test in 1st trimester if mother is symptomatic or has preterm labor
fetal risks include abortion, stillbirth, or infected infant
treat with benzathine penicillin IM

candidiasis risk

infant at risk for thrush

trichomonas risk

fetal risks include PROM, preterm birth, low birth weight

bacterial vaginosis risk

maternal risks include endometritis postpartum
fetal risks include preterm labor, PRO, intra-amniotic infection

steps taken against prenatal care complications

1. identify
2. treat
3. prevent

nursing goals of prenatal care

promoting the physical well being of the woman and fetus
preventing or controlling further complications
providing information and emotional support to the woman and her family

substance use disorder

continued substance craving and use despite significant life disruption and/or physical risk
alcohol, cocaine, marijuana, ecstasy, heroin
assess with drug and alcohol screening
can cross into breast milk and affect newborn

cocaine use risk

maternal risks include seizure, cardiopulmonary compromise, death
fetal risks include decreased O2, spontaneous abortion, intrauterine growth restriction, prematurity, low birth weight, stillbirth, withdrawals (feeding difficulties, lasting neurological problems)

etoh use risk

maternal risks include bone marrow suppression, increased incidence of infections, liver disease
fetal risks include fetal alcohol spectrum disorders, microcephaly, mental retardation, intrauterine growth restriction, potential teratogenic effects

teratogenic effects

results related to substance abuse that can cause defects to a developing fetus

substance use disorder treatment

referrals for treatment & social services
team approach for cessation
possible hospitalization for withdrawal/detox

substance use disorder labor and birth issues

local or regional anesthesia decreases risk of respiratory depression for fetus
respiratory depression, SGA, prematurity, withdrawal symptoms
DCFS/CPS home visits after discharge

withdrawal symptoms in infants

tremors, excessive high-pitched crying, sleep problems, hyperactive reflexes, tight muscle tone, seizures

pathology of diabetes mellitus

endocrine disorder of carbohydrate metabolism resulting from decreased production or utilization of insulin
high sugar spills UA and draws H2O from cells, preventing reabsorption in the kidneys

cardinal signs and symptoms of diabetes mellitus

polyuria, polydipsia, weight loss, polyphagia, glucosuria

diabetes in the 1st trimester

decreased insulin need, low levels of human placental lactogen acts as an insulin antagonist
fetal needs are minimal, woman may have N & V and consume less food
insulin requirements rise late in the first trimester, then double or quadruple by end of pregnancy

diabetes in the 2nd and 3rd trimester, labor, and birth

increased need for insulin to sustain the supply of glucose for growing fetus
possible increased insulin needs in labor
when placenta is delivered, there is a decreased insulin requirement

gestational diabetes

glucose intolerance of variable severity with onset or first recognition during pregnancy
occurs in 6-7% of pregnancies

causes of gestational diabetes

unidentified pre-existing disease
effect of pregnancy on a compensated metabolic abnormality
direct consequence of altered metabolism from changing hormonal levels

gestational diabetes hydramnios

causes increased fetal fluid from fetal polyuria r/t fetal hyperglycemia

gestational diabetes ketoacidosis

in the blood from increased fatty acid production
higher glucose levels after eating from low gastrointestinal motility

risks of gestational diabetes

dystocia-fetopelvic disproportion due to macrosomia (LGA)
increased susceptibility to infection such as monilial vaginitis & UTIs

fetal risks of gestational diabetes

perinatal mortality due to severe maternal ketoacidosis
congenital heart, CNS, and skeletal anomalies
LGA due to high levels of insulin
macrosomia due to elevated maternal glucose resulting in excessive growth and fatty deposits
intrauterine growth restriction
hypoglycemia
respiratory distress syndrome due to increased fetal insulin levels that inhibit fetal enzymes necessary for surfactant growth
polycythemia
hyperbilirubinemia due to elevated RBC, causing increased bilirubin, causing immature fetal liver growth that cannot metabolize increased bilirubin
hypocalcemia indicated by tetany, irritability

risk factors for gestational diabetes

non-caucasian
prior history of DM or LGA birth
marked obesity (BMI > 30)
diagnosis of PCOS
hypertension
glycosuria
family history of type 2 DM

what do you look for in a urinalysis when assessing for gestational diabetes?

glucose and ketones

what do you look for in a Ha1c screening when assessing for gestational diabetes?

equal to or greater than 6.5%

what do you look for in a fasting plasma glucose tolerance test when assessing for gestational diabetes?

equal to or greater than 126

low risk gestational diabetes screening test 1 step approach

2 hour oral glucose tolerance test (75 g)
-if positive, blood glucose will be > 92 when fasting, > 180 after 1 hour, > 153 after 2 hours

low risk gestational diabetes screening 2 step approach

3 hour oral glucose tolerance test (100 g)
-if positive, blood glucose will be > 95 when fasting, > 180 after 1 hour, > 155 after 2 hours, > 140 after 3 hours
GDM diagnosed if > 2 levels are met or exceeded

gestational diabetes treatment goals

maintain a physiologic equilibrium of insulin availability and glucose utilization
work with OB, endocrinologist, diabetes nurse educator, perinatal nurse, dietician, social worker

signs and symptoms of hyperglycemia

polyuria, polydipsia, polyphagia
fatigue, nausea, rapid breathing, acetone breath, ketones/glucose in urine

signs and symptoms of hypoglycemia

sweating, disorientation, shakiness, pallor, irritability, hunger, blurred vision

how is gestational diabetes controlled

diet and exercise
glucose monitoring, insulin therapy, oral hypoglycemic meds (Glyburide, Metformin)

a gravid client at 27 weeks' gestation, has been diagnosed with gestational diabetes. which of the following therapies will most likely be ordered for this client?

diet control and exercise

fetal assessment with maternal gestational diabetes

quad screen 16-20 wks. for NTD's
fetal activity monitoring and weekly non-stress tests at 28 wks.
amniocentesis at 37-39 wks. if poor glycemic control

fetal assessment is looking at...

FHR acceleration through non-stress test, fetal breathing, fetal movements, fetal muscle tone, amniotic fluid volume
scores each variable 0-2 points

fetal assessment often performed in women with...

decreased fetal movement, a non reactive non-stress test, intrauterine growth restriction, preterm labor, gestational diabetes, hypertension, post-term pregnancy, PROM

spontaneous abortion (miscarriage)

termination of pregnancy at any time before 20 weeks
occurs in 15-20% of pregnancies

signs and symptoms of spontaneous abortion

pelvic cramping, backache, vaginal bleeding

spontaneous abortion treatment

bedrest, abstinence, CBC, blood transfusion, uterine evacuation, RhoGAM if indicated

ectopic pregnancy

implantation of fertilized egg outside the uterine cavity (in ovary, fallopian tube, cervix)

ectopic pregnancy risk factors

association w/ IUD, high levels of progesterone, anomalies of the fallopian tube, smoking, > 35 yo.

ectopic pregnancy treatment

if fallopian tube rupture- salpingectomy
if no fallopian tube rupture- Methotrexate, monitor hCG on day 4 and 7 for decrease
salpingostomy

gestational trophoblastic disease (GTD)

abnormal proliferation of trophoblastic tissue
non-viable pregnancy
cause unknown

hydatidiform mole

empty ovum with many trophoblastic cells that are swollen and grape like

risk of molar pregnancy

association with choriocarcinoma, which is a rapidly metastasizing malignancy

signs and symptoms of gestational trophoblastic disease

vaginal bleeding, passing of hydropic vesicles, rapid uterine growth and increased fundal heights, inability to auscultate FHTs, hyperemesis gravidarum, preeclampsia, high hCH, low Hct and Hgb, low MSAFP

gestational trophoblastic disease treatment

evacuation of the molar pregnancy & curettage of the uterus to fully remove all placental fragments

complications of gestational trophoblastic disease

anemia, hyperthyroid, infection, ovarian cysts, disseminated intravascular coagulation (clotting disorder)

placenta previa

improper implantation of the placenta in the lower uterine segment (over/near cervical os)

abruptio placentae

premature separation of the placenta from the uterine wall

cervical insufficiency (incompetent cervix)

premature passive dilation of the cervix that is painless with no contractions
causes prolapse and ballooning of membranes into vagina

signs and symptoms of cervical insufficiency

bloody show or increased pelvic pressure

risk factors for cervical insufficiency

multiples, repetitive 2nd trimester losses, previous preterm birth, short labor, elective abortion, cervical manipulation

cervical insufficiency treatment

uncomplicated/emergent cervical cerclage
goal is to prevent preterm birth
cerclage removed at 37 weeks

cervical cerclage

a strong stitch inserted into and around the cervix in early pregnancy

hyperemesis gravidarum

excessive vomiting during pregnancy
indicated problems with nutrition and hydration, fluid and electrolyte imbalances, acidosis, and weight loss

nursing care goals for hyperemesis gravidarum

control vomiting with antiemetics (vitamin b6, diclegis, zofran, phenergan, reglan)
correct dehydration
restore electrolyte balance
maintain adequate nutrition
in severe cases, TPN necessary

nursing care for PROM

determine duration of PROM
assess gestational age (before or after 37 weeks)
observe for sx of infection
assess fetal status
assess childbirth preparation and coping
provide comfort measures
provide education

preterm labor

labor between 20-37 weeks gestation

symptoms of preterm labor

abdominal, black, and pelvic pain
menstrual like cramps
vaginal bleeding
increased discharge
pelvic pressure
urinary frequency
diarrhea

risk factors for preterm labor

maternal infection
multiple gestation
known cervical incompetence
vaginal bleeding
precious preterm labor
fetal abnormality
smoking/substance use
age extremes

management of preterm labor

labor suppression if indicated
preterm labor allowed if there are maternal/fetal complications
assess for fetal fibronectin

fetal fibronectin

protein from fetal cells found in vaginal mucous and is indicative of preterm labor

labor suppression

tocolytics (inhibit uterine contractions)
-beta mimetics
-mag sulfate
-prostaglandin inhibitors
-calcium blockers
betamethasone

nursing care during labor suppression

EFM, toco monitoring, bedrest, input/output

hypertension

due to preeclampsia & eclampsia, chronic hypertension, gestational hypertension

what is the most common complication during pregnancy?

hypertension

risk factors for preeclampsia

primigravida, age extremes, multiple gestation, family history, obesity, PCOS, new partner

classic dyad of preeclampsia

hypertension
proteinuria (edema)

signs and symptoms of preeclampsia

hypertension
-mild is > 140/90
-severe is > 180/110
proteinuria
weight gain
2nd tri > 3.3 lbs./month
2rd tri > 1.1 lbs./week

scoring deep tendon reflexes

4+ hyperactive
3+ brisker than average
2+ average response
1+ diminished response
0 no response

indicative of mild preeclampsia

BP > 140/90
proteinuria 1-2+
urinary protein 300 mg in 24 hrs.

indicative of severe preeclampsia

BP > 160/110
proteinuria 3+ in random urine
proteinuria > 5 g/L in 24 hrs.
massive edema
oliguria 500 mL in 24 hrs.
visual changes, irritability, clonus

eclampsia

seizure activity or coma associated with pregnancy in the absence of neurologic pathology

etiology of eclampsia

exact cause is unknown

cure for eclampsia

birth of baby

lab work relating to eclampsia

high Hgb, uric acid, BUN and creatinine, LDH, AST, ALT
decreased platelet count
prolonged PT and PTT

management of eclampsia

bedrest at home
keep BP < 150/100, proteinuria < 3+, plts >120,000, fetal wellbeing
bedrest in hospital if severe
delivery if term or severely preeclamptic

magnesium sulfate is given if...

severe preeclampsia occurs, to decrease seizures

magnesium sulfate administration

4-6 g bolus over 15-20 minutes
followed by 2 g/hr IV infusion

side effects of magnesium sulfate

flushing, feeling of warmth, headache, blurred vision, lethargy

nursing care of magnesium sulfate administration

monitor VS, DTR's, clonus, strict I & O, monitor fetal well being

magnesium sulfate toxicity occurs at...

4-8 mg/dL

magnesium sulfate antagonist

calcium gluconate
administer 1 g over 3 min.

signs and symptoms of magnesium sulfate toxicity

respirations < 12, diminished DTR's, severe hypotension, oliguria, decreased LOC

betamethasone administration for preeclampsia/eclampsia

given IM to mother
stimulates fetal lung maturity
can be repeated if pregnancy is prolonged

antihypertensive administration for preeclampsia/eclampsia

given to prevent stroke
give if BP is sustained > 160/105/-110
Labetalol and Hydrazaline

HELLP syndrome

Hemolysis
Elevated Liver enzymes
Low Platelets
appears in 10-20% of severe preeclampsia