Week 4 - ppt

Nutrition for Childbearing (CHAPTER 8)

General Information

  • Nutrition significantly affects pregnancy outcomes.

  • Poor nutrition can lead to adverse effects on the baby.

  • Education on nutrition is critical during:

    • Preconception

    • Prenatal appointments

    • Antepartum appointments

Weight Gain during Pregnancy

  • Weight gain impacts fetal growth:

    • Insufficient weight gain can result in:

      • Low birth weight

      • Small for gestational age (SGA)

      • Preterm birth

      • Challenges in breastfeeding

      • Excessive weight gain can lead to:

      • Gestational hypertension (GHTN)

      • Preeclampsia (pre-e)

      • Gestational diabetes mellitus (GDM)

      • Prolonged labor

      • Cesarean section (C/S)

      • Macrosomia

      • Stillbirth

      • Congenital abnormalities

  • Nutrient intake is more critical than weight gain itself.

  • Recommendations based on Body Mass Index (BMI):

    • Important to consider multifetal pregnancies and teen pregnancies.

  • Pattern of weight gain:

    • 1.1 - 4.4 lbs during the first trimester.

    • Approximately 1 lb per week thereafter.

Breakdown of Weight Gain Sources

  • Breasts: 1-2 pounds

  • Baby: 6-8 pounds

  • Placenta: 1-2 pounds

  • Uterus: 1-2 pounds

  • Amniotic Fluid: 2-3 pounds

  • Blood: 3-4 pounds

  • Protein and fat storage: 8-10 pounds

  • Body fluids: 3-4 pounds

Pre-Pregnancy BMI Category

  • Body Mass Index (BMI) calculation: BMI = \frac{\text{Weight (kg)}}{\text{Height (m)}^2}

    • BMI < 18.5: Underweight

    • Recommended Total Weight Gain: 12.5-18.0 kg (28.0 - 40.0 lbs)

    • BMI 18.5 - 24.9: Normal Weight

    • Recommended Total Weight Gain: 11.5-16.0 kg (25.0 - 35.0 lbs)

    • BMI 25.0 - 29.9: Overweight

    • Recommended Total Weight Gain: 7.0-11.5 kg (15.0 - 25.0 lbs)

    • BMI ≥ 30: Obese

    • Recommended Total Weight Gain: 5.0-9.0 kg (11.0 - 20.0 lbs)

  • Total weight gain during pregnancy is typically 25-35 pounds.

Nutritional Recommendations

  • Increased caloric intake by:

    • 340-452 calories per day.

  • Focus on eating nutrient-dense foods.

  • Educate patients on hydration: Drink 8-10 cups of water per day.

Key Nutrients

Folic Acid

  • Also called folate.

  • Recommended intake:

    • 400 mcg per day for women of childbearing age.

    • Increase to 600-800 mcg during pregnancy (as recommended by the USPSTF).

  • Insufficient intake can lead to neural tube defects (NTDs).

  • History of NTDs necessitates an increased folic acid intake.

Iron

  • Recommended intake increases from 18 mg to 27 mg per day.

  • Essential for increased production of red blood cells (RBCs) and iron transfer to the fetus.

  • Fetal iron stores are low during the first several months after birth, so maternal transfer is crucial to prevent anemia.

  • Absorption of iron can be affected by other substances (calcium cancels out) (vitamin c improves absorption); may cause stomach issues, so it's recommended to take it in the evening.

Calcium

  • Important for fetal bone and teeth mineralization.

  • Small amounts of calcium are temporarily removed from the mother’s bones without causing damage.

  • Increased calcium intake is particularly necessary for teen mothers.

  • Calcium is best absorbed with vitamin D.

Influences on Nutrition

  • Factors affecting nutritional choices include:

    • Age

    • Nutritional knowledge

    • Exercise habits

    • Cultural beliefs regarding food (e.g., hot vs. cold food classifications)

    • Dietary practices such as vegetarianism and veganism

    • PICA (craving for non-food substances)

  • Strategies for educating patients about nutrition.

Nutrition after Birth

  • Increase caloric intake by 500 calories per day while breastfeeding.

  • Maintain a well-balanced diet.

  • Be cautious with dieting until milk supply is well established.

  • Consider the effects of alcohol (one serving of alcohol is totally fine), caffeine (200mg per day), and fluid intake (around 8 cups minimum).

Complications of Pregnancy (CHAPTER 10)

Hemorrhagic Conditions of Early Pregnancy

Spontaneous Abortion

  • Most common cause: Severe congenital abnormalities incompatible with life.

  • Types: Threatened, inevitable, incomplete, complete, missed, and recurrent abortion.

Diagnosis and Treatment

  • Diagnosis includes:

    • Blood testing

    • Ultrasound

    • Doppler studies.

  • Treatment options include:

    • Expectant management

    • Medical/surgical intervention.

  • Potential complications include:

    • Infection

    • Disseminated intravascular coagulation (DIC) - a serious condition where small blood clots form throughout the body's small blood vessels, leading to reduced blood flow to organs and resulting in organ dysfunction.

  • Nursing considerations:

    • Administration of RhoGAM

    • Patient education

    • Providing emotional support.

Ectopic Pregnancy

  • Defined as the implantation of a fertilized ovum outside the uterine cavity.

  • Common causes:

    • Pelvic infections

    • Inflammation

    • Surgical scarring

  • Risk factors include history of ectopic pregnancies, sexually transmitted infections (STIs), and assistive reproductive technology (ART).

Diagnosis and Treatment for Ectopic Pregnancy

  • Diagnosis through:

    • Blood testing,

    • Ultrasound.

  • Treatment involves:

    • Medical or surgical options.

  • Complications include:

    • Hemorrhage

    • Potential impact on future fertility.

  • Nursing considerations:

    • Administration of RhoGAM

    • Education

    • Emotional support.

Gestational Trophoblastic Disease (Hydatidiform Mole)

  • Defined as abnormal development of trophoblasts, leading to abnormal placenta formation.

  • May involve a fatal chromosomal defect if a fetus is present; can be partial or complete.

  • Very rare condition.

  • Risk factors include:

    • More common at extremes of reproductive age

    • History of molar pregnancy

    • Ethnic background (more prevalent in Asian, Hispanic, and Native American groups).

Diagnosis and Treatment for Gestational Trophoblastic Disease

  • Diagnosis through:

    • Blood testing

    • Ultrasound.

  • Treatment options include:

    • Surgical management

    • Medical management post-surgery.

  • Complications may involve:

    • Malignant changes

    • Bleeding.

  • Nursing considerations include:

    • Administration of RhoGAM

    • Patient education

    • Emotional support.

Hemorrhagic Conditions of Late Pregnancy

Placenta Previa

  • Defined as the implantation of the placenta in the lower uterus.

  • Classifications:

    • Total

    • Partial

    • Marginal.

  • Classic sign includes sudden onset of painless uterine bleeding in the latter half of pregnancy due to tearing of placental villi from the uterine wall as cervical dilation occurs.

Diagnosis and Treatment for Placenta Previa

  • Diagnosis is based on symptoms and ultrasound findings.

  • Treatment may involve:

    • Inpatient vs. home care,

    • Conservative management,

    • Cesarean birth (C/S).

  • Potential complications include:

    • Hemorrhage,

    • Premature birth,

    • Fetal death.

  • Nursing considerations:

    • Administration of RhoGAM and steroids,

    • Patient education (pelvic rest),

    • Fetal surveillance,

    • Emotional support.

Abruptio Placentae (Placental Abruption)

  • Characterized by the separation of a normally implanted placenta before the fetus is born.

  • Formation of a hematoma on the maternal side of the placenta, obstructing fetal vessels and potentially causing exsanguination of the mother and fetus.

  • Clinical manifestations include:

    • Abnormal bleeding

    • Abdominal tenderness

    • Uterine irritability

    • Low back pain

    • A board-like abdomen

    • Non-reassuring fetal heart rate patterns or fetal death

    • Signs of hypovolemic shock.

Diagnosis and Treatment for Abruptio Placentae

  • Diagnosis based on symptoms and clinical examination.

  • Treatment may involve:

    • Managing stable vs. unstable cases,

    • Conservative management,

    • Immediate delivery if necessary.

  • Complications can include:

    • Hemorrhage

    • Shock

    • DIC

    • Fetal hemorrhage

    • Premature birth and fetal death.

  • Nursing considerations include:

    • Administration of RhoGAM and steroids,

    • Maternal assessment and fetal surveillance,

    • Patient education

    • Emotional support.

Hypertensive Disorders of Pregnancy

  • Leading cause of maternal morbidity and mortality.

  • Defined as BP > 140/90 mmHg.

  • Types include:

    • Gestational Hypertension - hypertension onset after 20 weeks without proteinuria (working diagnosis).

    • Preeclampsia-eclampsia - hypertension with proteinuria.

      • eclampsia - when patient starts to seize

    • Chronic Hypertension with superimposed preeclampsia.

Preeclampsia

  • Affects 5-8% of pregnancies and can lead to multiple adverse outcomes.

  • Mechanism of action may involve generalized vasoconstriction and vasospasm leading to multi-organ failure.

    • Evidence suggests initiation may occur within the placenta in spiral arteries leading to diminished perfusion and inflammatory systemic response.

Pathophysiology of Preeclampsia

  • Decreased renal perfusion causes decrease in GFR, leading to glomerular damage and protein leakage across membranes, resulting in edema.

  • Reduced hepatic circulation can lead to hepatic edema and hemorrhage, indicated by elevated liver enzymes.

  • Vasoconstriction of cerebral vessels can lead to ruptured capillaries causing symptoms such as headaches and visual changes, along with hyperactive deep tendon reflexes.

  • Decreasing colloid oncotic pressure leads to pulmonary leakage and edema, while reduced placental circulation can result in infarctions and disruption (e.g., abruptio placenta, fetal outcomes including IUGR, persistent hypoxemia, and acidosis).

Severe Preeclampsia

  • Defined as BP > 160/110 on two occasions at least 4-6 hours apart.

  • Thrombocytopenia (platelets < 100,000).

  • Impaired liver function evidenced by elevated liver enzymes.

  • Progressive renal insufficiency.

  • May see pulmonary edema and disturbances in cerebral or visual functions.

  • Oliguria is common.

Magnesium Sulfate

  • Used primarily to prevent seizures due to its CNS depressant properties.

  • Not classified as an antihypertensive medication.

  • Mechanism of action involves relaxation of smooth muscle leading to reduced blood pressure.

  • Administered via IV infusion, typically starts with a bolus followed by maintenance dosing. 2 nurse verification for everything!!

  • Monitoring includes serum magnesium levels, vital signs, deep tendon reflexes, lung sounds, edema, visual changes, headaches, epigastric pain, input/output and fetal status, and safety measures for seizures.

  • CNS depression and respiratory depression = mag toxicity

  • mag toxicity —> calcium gluconate

Eclampsia

  • Associated with tonic-clonic seizures.

  • Expected transient effects on the fetus include:

    • Bradycardia

    • Loss of variability

    • Decelerations

  • Monitor closely for DIC and HELLP syndrome.

  • Half of seizures is high during labor and 48hrs after birth

Assessment of a Patient with Preeclampsia

  • Daily weights are critical for monitoring.

  • Routine vital signs typically checked every 4 hours.

  • Assess lung sounds

  • Evaluate for edema.

  • Maintain strict input/output (bedrest is common).

  • Perform reflex assessments and evaluate for clonus.

  • Ask about headaches, visual changes, or abdominal pain.

HELLP Syndrome

  • Stands for Hemolysis, Elevated Liver Enzymes, and Low Platelets.

  • Considered life-threatening.

  • Mechanism involves arteriolar vasospasm leading to damage to blood vessel linings, destruction of RBCs, and decreased blood flow to the liver, resulting in ischemia (elevated liver enzymes).

  • Endothelial damage fosters clot formation while consuming platelets, leading to DIC.

Incompatibility between Maternal & Fetal Blood

  • Occurs when Rh-negative mother carries Rh-positive fetus.

  • The problem arises for the fetus, not the mother.

  • Rh-positive individuals possess the antigen on red blood cells.

  • If Rh-positive blood enters an Rh-negative individual, their immune system may react, leading to antibody development that destroys Rh-positive RBCs, potentially resulting in spontaneous abortion (SAB) or extensive fetal-maternal hemorrhage.

  • Future pregnancies may be affected.

  • RhoGAM (Rh immunoglobulin) is administered to prevent the formation of antibodies.

Rh Factor Mechanism

  1. Rh+ father.

  2. Rh- mother carrying her first Rh+ fetus; fetal Rh antigens can enter the mother's bloodstream during delivery.

  3. In response, the mother produces anti-Rh antibodies.

  4. If she becomes pregnant again with another Rh+ fetus, the anti-Rh antibodies could cross the placenta and damage the fetal red blood cells.

Gestational Diabetes Mellitus

  • Diagnosed through the Glucose Challenge Test and Oral Glucose Tolerance Test.

  • Neonatal complications include:

    • Macrosomia (large baby)

    • Neonatal hypoglycemia.

    • respiratory distress syndrome - delayed maturation of alveolar epithelial cells

  • Management strategies include:

    • Diet modifications

    • Exercise

    • Blood glucose monitoring

    • Medication as needed.

Infections Impacting Pregnancy

  • Viral Infections:

    • Rubella

      • 10% adults not immune

      • greatest risk first 12 weeks, SAB or severe complications (deafness, cardiac, microcephaly, and developmental delays) in affected infants.

      • prevention

    • Herpes Simplex Virus (HSV)

      • 1- oral, 2- genital

      • lesions —> 40% transmission rate

      • prophylactic tx is acyclovir at

      • exam in labor

    • Hepatitis B

      • PTL or fetal hepatitis

      • Fetus: hep B immunoglobulins and vaccine

    • Human Immunodeficiency Virus (HIV)

      • PTL, preterm prelabor rupture of membranes, intrauterine growth restriction

      • meds- perinatal transmission <2%

      • c/s delivery

  • Non-Viral Infections:

    • Toxoplasmosis - protozoan in cat feces and raw meat

      • 40% w/infection will transmit

      • teaching cook meat, avoid unpasteurized milk, avoid cat feces

      • managed with meds

    • Group B Streptococcus infection - leading cause of life threatening perinatal infection in US

      • 20-25% of preg women colonized

      • Fetal: sepsis, pneumonia, meningitis

      • abx therapy - penicillin first line treatment given every 4 hrs for GBS infections, with alternatives such as ampicillin for patients with penicillin allergy.

      • monitor for 48hrs