Pregnancy at Risk, Labor & Postpartum Complications – Review

Diabetes Mellitus in Pregnancy

• Classifications
• Type 1: autoimmune destruction of \beta-cells → insulin-dependent.
• Type 2: insulin resistance + relative insulin deficiency.
• Gestational Diabetes (GDM): glucose intolerance first diagnosed during pregnancy.

• Pathophysiology
• Placental hormones (hPL, progesterone, cortisol) ↑ maternal insulin resistance.
• Maternal hyperglycemia → placenta exposes fetus to high glucose → fetal hyperinsulinemia.

• Maternal Risks
• Polyhydramnios, pre-eclampsia, recurrent infections (UTI/yeast), DKA, ↑ C-section, postpartum hemorrhage (PPH).

• Fetal / Neonatal Risks
• Congenital anomalies (cardiac, neural-tube), macrosomia, shoulder dystocia, IUGR, RDS (↓ surfactant), hypoglycemia, polycythemia, hyperbilirubinemia, stillbirth.

• Glycemic Targets
• Fasting BG < 95\,\text{mg·dL}^{-1}
• 1-h post-prandial < 140\,\text{mg·dL}^{-1}
• 2-h post-prandial < 120\,\text{mg·dL}^{-1}

• Medications
• Insulin (first line; does NOT cross placenta). NPH ± Regular commonly combined; dose ↓ 1st tri, ↑ 2nd/3rd tri.
• Metformin or Glyburide if insulin impossible (metformin does cross placenta—monitor neonatal BG).
• Low-dose Aspirin for pre-eclampsia prophylaxis in very high-risk pts.

• Nursing Considerations / “KISS” mnemonic
• Keep BG in target (fasting < 95).
• Insulin timing with meals.
• Snack between meals.
• Self-monitor BG + fetal kick counts daily; report ↓ movement.
• Teach diet (Diabetes Plate Method), 20–30 min moderate exercise most days.
• Recognize & treat hypoglycemia (sweating, shakiness, hunger → juice/crackers) and hyperglycemia (dry mouth, rapid breathing → call HCP).

Car`    diac Conditions in Pregnancy

• Normal pregnancy ↑ blood volume & cardiac output → may unmask or worsen heart disease.

• Functional Classification
• Class I – Asymptomatic with ordinary activity.
• Class II – Symptoms with ordinary activity.
• Class III – Symptoms with < ordinary activity.
• Class IV – Symptoms at rest; pregnancy contraindicated.

• Example Lesions & Drugs
• Mitral stenosis/regurgitation → diuretics (furosemide – AM dosing, monitor K^+, daily weight), labetalol, LMWH.
• Aortic stenosis → close monitoring ± beta-blockers.
• Peripartum cardiomyopathy → furosemide, hydralazine, digoxin (same time daily, hold < 60 bpm, toxicity = halos, N/V).
• MVP → usually benign; beta-blockers if palpitations.

• Nursing Focus
• Frequent VS, auscultate for new murmurs / arrhythmias.
• Detect decompensation → “DANGER”: Dyspnea on exertion, Arrhythmia/palpitations, Night cough, Generalized edema, Easily fatigued, Rapid respirations.
• Side-lying rest, delegate tasks, high-fiber diet to avoid Valsalva.
• Avoid teratogens (warfarin). Monitor fetal growth & movement.

Asthma in Pregnancy

• Patho: airway inflammation → bronchoconstriction → ↑ risks (pre-eclampsia, IUGR, PTB).

• Safe Meds – “Breathe Air”
• Budesonide: inhaled corticosteroid (maintenance).
• Albuterol: short-acting \beta_{2} agonist (rescue). Avoid carboprost postpartum; avoid ergot derivatives.

• Nursing
• Lung sounds, RR, SpO_2, fetal heart.
• Trigger avoidance (smoke, pets), inhaler technique review.

Iron-Deficiency Anemia

• Dx: \text{Hgb}<11\,\text{g·dL}^{-1} (1st/3rd tri) or < 10.5\,\text{g·dL}^{-1} (2nd).

• S/S: fatigue, pallor, tachycardia, restless legs.

• Risks: pre-eclampsia, infection, PPH, LBW, impaired fetal neuro-development.

• Meds
• Ferrous sulfate (first-line): take on empty stomach if possible + vitamin C (OJ); avoid milk/tea; SE = N/V, metallic taste, black stools, constipation.
• Prenatal vitamin supplies 27\,\text{mg} elemental Fe.

• Nursing / “IRON” teaching
• Increase fluids/fiber to ↓ constipation.
• Rest stomach (empty) if tolerated.
• Orange juice ↑ absorption.
• No milk, tea, antacids near dose.
• Encourage iron-rich diet (meat, legumes, leafy greens); monitor Hgb/Hct.

Folic-Acid Deficiency Anemia

• Patho: inadequate folate → megaloblastic anemia + ↑ neural-tube-defect risk.

• Therapy
• Daily folic-acid supplement, morning with food.
• “FOLIC” foods: Fortified cereals, Orange juice, Leafy greens, Iron-rich beans, Corn/peas.

Hemoglobinopathies

• Sickle Cell Disease
• Abnormal Hgb S → sickling & vaso-occlusion.
• Pregnancy risks: crises, thromboembolism, IUGR, pre-eclampsia.
• Meds: folic acid, safe opioids for pain; NO routine iron.
• Care: “HOP” – Hydration, Oxygen prn, Pain control.

• Thalassemia Major
• Defective Hgb synthesis → chronic anemia.
• Needs transfusions; avoid iron unless ordered; monitor ferritin; multidisciplinary team.
• Memory aid: “NO IRON UNLESS ORDERED”.

Autoimmune & Musculoskeletal Disorders

• Systemic Lupus Erythematosus (SLE)
• Risks: flare, pre-eclampsia, PTB.
• Meds: hydroxychloroquine, cautious NSAIDs.
• Postpone conception until remission ≥ 6 mo; monitor proteinuria & infection.
• “LUPUS” monitoring: Labs, Use meds, Pregnancy in remission, Understand flare signs, Sun protection.

• Rheumatoid Arthritis (RA)
• Post-partum flare common.
• Stop methotrexate pre-conception; steroids/NSAIDs prn.
• “REST”: Relieve pain, Encourage exercise, Stop MTX, Take steroids AM w/ food.

• Multiple Sclerosis (MS)
• Fewer relapses in pregnancy; stop disease-modifying drugs before conception.
• “ENERGY”: Energy conservation, Neuro checks, Eat well, Rest, Gait safety, Yearly plan for flares.

• Fibromyalgia
• Chronic pain; meds: duloxetine, pregabalin (cross placenta—risk discussion).
• “CALM”: Coping strategies, Acetaminophen, Lifestyle balance, Movement.

Infections in Pregnancy

• TORCH mnemonic: Toxoplasmosis, Other (syphilis/varicella/parvo), Rubella, CMV, Herpes.

• Key Agents
• HIV → zidovudine during pregnancy & labor; infant prophylaxis; avoid scalp electrodes/AROM.
• HSV → acyclovir/valacyclovir from 36 wks; C-section if active lesions.
• GBS → Penicillin G IV in labor (cefazolin if allergy).
• Syphilis → benzathine pen G IM.
• Gonorrhea → ceftriaxone IM; newborn erythromycin eye ointment.
• Chlamydia → azithromycin orally; treat partner.
• Rubella → no Rx in pregnancy; vaccinate postpartum.
• Hep B → tenofovir if high viral load; neonate gets HBIG + vaccine.
• Varicella exposure → newborn Varizig.
• Avoid ergot alkaloids or carboprost in asthmatic pts.

Vulnerable Populations

• Pregnant Adolescents
• Risks: anemia, prematurity, poor prenatal care.
• Nursing: build trust; present info at developmental level; include support systems.

• Advanced Maternal Age (≥ 35 yrs)
• ↑ GDM, HTN, chromosomal anomalies.
• Early genetic screening (quad, amnio), lifestyle counseling.

• Substance Use
• Alcohol → FASD; Nicotine → LBW, SIDS; Opioids → NAS.
• SBIRT screening; non-judgmental; linkage to MAT programs.

• “MAP” mnemonic (adolescents & AMA)
• Monitor for GDM/HTN.
• Assess support.
• Provide tailored education.

Labor & Birth at Risk (Chapter 21)

Dystocia – Problems with 5 Ps

• Hypertonic Uterine Dysfunction (latent): frequent painful contractions, ↑ resting tone → ↓ placental perfusion.
• Hypotonic Uterine Dysfunction (active): weak/infrequent contractions; uterus easily indentable; arrest of progress.
• Precipitous Labor: total labor < 3 h → PPH, trauma, fetal distress.
• Management: hydration, rest, position changes, hands-and-knees, McRoberts + suprapubic pressure for shoulder dystocia; eval CPD/malpresentation → operative/C-S.
• 5 Ps mnemonic: “Please Pack Powerful Push Positions.”

Multiple Gestation

• ↑ uterine stretch → ↑ PTL, malpresentation, PPH.
• Monozygotic vs dizygotic membranes.
• Nursing: ↑ surveillance, neonatal team present, prepare for PPH.

Pelvic & Soft-Tissue Obstruction

• Pelvic shapes: Gynecoid (ideal) > Anthropoid > Android > Platypelloid.
• Bladder, fibroids can obstruct.

Maternal Stress / Anxiety

• Catecholamines ↓ uterine blood flow & contraction efficiency.
• Provide quiet, support person, relaxation.

Preterm Labor (< 37 wks)

• Dx: 4 ctx/20 min or 8 ctx/60 min + cervical change.
• Tocolytics – “It’s NIM”
• Nifedipine (watch BP).
• Indomethacin (< 32 wks; watch oligohydramnios/DA closure).
• Magnesium sulfate (monitor DTRs, RR ≥ 12, urine ≥ 30 mL·h^{-1}; antidote = calcium gluconate).
• Betamethasone 12\,\text{mg IM} ×2 doses 24 h apart for lung maturity; monitor maternal BG.

Post-term Pregnancy (> 42 wks)

• Aging placenta → calcifications, ↓ perfusion, macrosomia.
• NST/BPP; induction: prostaglandins (dinoprostone, misoprostol) or oxytocin; monitor meconium.

Intra-Uterine Fetal Demise (IUFD)

• Risk DIC; offer grief support, memory-making; monitor bleed.

Umbilical Cord Prolapse

• Knee-chest/Trendelenburg; gloved hand elevates part; O_2 10 L·min^{-1} face-mask; emergency C-S.

Placental Abruption

• Painful dark bleeding, rigid uterus, late decels.
• Large-bore IV, cross-match, continuous FHR, likely C-S.

Uterine Rupture

• Sudden pain, loss of station, fetal distress, shock.
• Emergency laparotomy, fluids, blood.

Amniotic Fluid Embolism

• Sudden dyspnea, hypotension, DIC.
• O_2, intubate, CPR, blood products.

Induction & Augmentation

• Bishop score to assess readiness.
• Amniotomy (risk infection, prolapse).
• Oxytocin titrated pump; stop for tachysystole (> 5 ctx/10 min or sustained > 90 s).

Amnio-infusion

• Warmed NS/LR via IUPC for variable decels; monitor output/FHR.

Operative Vaginal Birth

• Forceps/Vacuum for prolonged 2nd stage or distress; empty bladder; watch scalp, lacerations.

Cesarean & VBAC

• VBAC only with low-transverse scar; monitor rupture signs.
• C-S nursing: pre-op teaching, post-op fundus & lochia, incision care.

• Shoulder Dystocia “HELPERR”
• H Help, E Episiotomy eval, L Legs McRoberts, P Pressure suprapubic, E Enter (internal rotation), R Remove posterior arm, R Roll to hands-and-knees.

Postpartum Patient at Risk (Chapter 22)

Postpartum Hemorrhage (PPH)

• Definition: > 1000\,\text{mL} blood loss OR any loss with hypovolemia within 24 h (primary) or 24 h–12 wks (secondary).
• 4 Ts causes – Tone (atony), Tissue (retained), Trauma, Thrombin (coagulopathy).
• Management: fundal massage, empty bladder, IV fluids, blood products.
• Drugs – “O-M-C-M-T” (Only My Contractions Make Time)
• Oxytocin (first).
• Methylergonovine – IM; take BP first; avoid HTN.
• Carboprost – IM; avoid asthma; causes diarrhea.
• Misoprostol – rectal/oral; watch fever/shiver.
• Tranexamic Acid – IV within 3 h onset.

Sub-involution

• Uterus fails to return to pre-pregnancy size → prolonged lochia.
• Tx: oxytocics ± D&C.

Thrombo-embolic Disorders

• Venous stasis + hyper-coagulation → DVT/PE.
• DVT signs “RED HOT”: Redness, Edema, Discomfort, Hot, One-sided, Tender.
• Meds: heparin (monitor aPTT); warfarin postpartum (consistent vit K intake, monitor INR).
• Nursing: early ambulation, hydration, compression stockings.

Post-partum Infections

• Endometritis, wound infection, mastitis.
• S/S: temp > 38^{\circ}C after 24 h, foul lochia, uterine tenderness, incision REEDA changes, breast redness.
• Tx: broad antibiotics; continue breastfeeding with mastitis.

Post-partum Affective Disorders

• Baby Blues (< 2 wks, mild), PPD (> 2 wks, functional impairment), PP Psychosis (hallucinations, emergency).
• Mnemonic “B-D-P – Blues, Down, Panic”.
• SSRIs (sertraline) first-line; antipsychotics for psychosis.
• Universal screening; safety plan.

Key Routine Care

• VS, fundus, lochia, perineum, bladder, mood checks.
• Teach to report heavy bleeding, clots, foul odor, fever, leg pain, mood changes.
• Encourage hydration, balanced diet, early ambulation, rest. Continue iron as ordered (see “I RON”).

Consolidated Mnemonics Quick-View

• Diabetes mgmt – “KISS”.
• Cardiac decomp – “DANGER”.
• Asthma safe meds – “Breathe Air”.
• Iron teaching – “I RON”.
• Sickle cell crisis prevention – “HOP”.
• Lupus monitoring – “LUPUS”.
• RA care – “REST”.
• MS care – “ENERGY”.
• Fibromyalgia – “CALM”.
• Adolesc/AMA care – “MAP”.
• Pre-term labor tocolytics – “It’s NIM”.
• PPH drug order – “O-M-C-M-T”.
• PPH causes – “Too Tired To Think” (Tone, Tissue, Trauma, Thrombin).
• Shoulder dystocia – “HELPERR”.
• TORCH list – “The Other Risky Congenital Hazards”.
• Thrombosis signs – “RED HOT”.
• Post-partum mood – “B-D-P”.