Antepartum problems

Question 1

gestational diabetes

Answer 1

any degree of glucose inteolerance with onset or recognition during pregnancy; identified during 2nd or 3rd trimester

Question 2

diabetes goal

Answer 2

optimal outcome is strict maternal glucose control before conception and throughout the pregnancy

Question 3

Insulin 1st tri

Answer 3

less insulin needed; risk hypoglycemia

Question 4

insulin 2nd tri

Answer 4

gradually increase; need about back to baseline

Question 5

insuline 3 tri

Answer 5

insulin dose above baseline (2-4x)

Question 6

hormones that cause insuline resistance

Answer 6

HPL, prolactin, estrogen, progesterone, cortisol, insulinase

Question 7

non-diabetics

Answer 7

pancrease compensates for insulin resistance

Question 8

maternal complications with preexisting diabetes

Answer 8

miscarriage- 1st trimester
macrosomnia
hydramnios
ketoacidosis
hyperglycemia
hypoglycemia
preeclampsia
infection

Question 9

fetal and neonatal risk preexisting diabetes

Answer 9

sudden and unexplained still birth
congenital malformations
birth injuries

Question 10

prenatal evaluation

Answer 10

Laboratory test (pregestational): renal function, thyroid function, glycosylated hemoglobin A (HgbA1C)
Urine testing for UTI, glucose, protein at PN visits
Monitoring blood glucose levels & logging
Maintain FBS 65-105; 2 hr PP <120
Determination of birth date and mode of birth
Complications requiring hospitalization
Fetal surveillance/consider effects on fetus:
Additional ultrasound evaluations; measurement of MSAFP; echo; DFMC @ 28 wks; NST @ 32 wks
↑glucose in mom→fetal insulin production (structure similar to growth hormone)

Question 11

preexisting dm- action

Answer 11

nutrition counseling, insulin (3rd tri especially), diet and exercise

Question 12

GDM risk

Answer 12

fam hx
obesity
HTN
glucosuria
maternal age >25
more than 1/2 without risk factors

Question 13

maternal GDM risk

Answer 13

preeclampsia
cesarean birth
dev type 2 DM later

Question 14

neonatal GDM risk

Answer 14

macrosomia
birht injuries
electrolyte imbalance
hypoglycemia

Question 15

OGTT

Answer 15

routine screening between 24 and 28 weeks

Question 16

Intrapartume care GDM

Answer 16

monitor closely
complications: dehydration, hypo/hyperglycemia
may require a cesarean birth

Question 17

Postpartum care GDM

Answer 17

Insulin requirements decrease substantially (as little as 1/2 to ⅓ the pregnancy dose): the placenta was the major source of insulin resistance
Newborn: glucose source gone after delivery🡪hypoglycemia within 1 hour
Risk for preeclampsia/eclampsia, hemorrhage (overdistention &/or overstimulation-oxytocin), infection
Encourage breastfeeding (antidiabetogenic effect on child & decreased risk of childhood obesity if breastfed for at least 6 mos)
Contraception

Question 18

HTN types

Answer 18

chronic essential
gestational
preeclampsia

Question 19

chronic HTN

Answer 19

Present before the pregnancy or diagnosed before week 20 of gestation or persists beyond the PP period

Question 20

gestational HTN

Answer 20

SBP >140/90 on 2 occasions at least 4 hours apart, with previously normal blood pressure, after the 20th week of pregnancy
Resolves PP but may take 6-12 months

Question 21

Preeclampsia→eclampsia

Answer 21

Pregnancy-specific condition
Hypertension with proteinuria develops after 20 weeks of gestation in previously normotensive client; may develop PP
A vasospastic systemic disorder categorized as mild or severe
Decreased placental perfusion & hypoxia
Eclampsia: onset of seizure activity or coma in client with PreE with no history of seizure pathology

Question 22

Chronic hypertension with superimposed preeclampsia

Answer 22

Women with chronic hypertension may acquire preeclampsia or eclampsia

Question 23

PreE pathophysicology

Answer 23

Progresses along a continuum from mild to severe
Caused by disruptions in placental perfusion
Placental ischemia stimulates release of a substance toxic to endothelial cells
Poor tissue perfusion in all organ systems; increased peripheral resistance & BP
Reduced kidney perfusion

Question 24

PreE etiology

Answer 24

Signs and symptoms develop only during pregnancy and disappear after birth
Associated high-risk factors: history of preE, multifetal pregnancy, chronic hypertension, diabetes, renal disease, autoimmune disease
Associated moderate risk factors: family history, obesity, maternal age 35 & older, Black race, low SES, more than 10-year pregnancy interval

Question 25

Identify and Prevent PreE

Answer 25

Assess:
Edema
Deep tendon reflexes
Clonus
RUQ/epigastric pain
Headaches (frontal)
Visual disturbance

Question 26

diagnostic Cue

Answer 26

proteinuria (>0.3)

Question 27

PreE effects on fetus

Answer 27

fetal growth restriction
decreased amniotic fluid volume
abnormal fetal oxygenation
LBW
preterm birht

Question 28

preE sever features

Answer 28

BP 160/110 X 2, at least 4h apart or higher
Massive proteinuria
Platelet count <100,000
Abnormal liver function
Progressive renal insufficiency
Pulmonary edema
Cerebral/visual disturbance

Question 29

HELLP syndrome

Answer 29

Laboratory diagnostic variant of severe preeclampsia
involves hepatic dysfunction, characterized by:
Hemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP)
Usually develops in antepartum period
Malaise
Influenza-like symptoms
Epigastric/RUQ abdominal pain
Symptoms worsen at night, better during daytime
Can progress rapidly

Question 30

HELLP increase risk for

Answer 30

pulmonary edema
renal failure
liver hemorrhage or failure
disseminated intravascular coagulation
placental abruption
acute respiratory distress syndrome
sepsis
stroke
fetal and maternal death

Question 31

actions for gestational HTN and PreE without sever features

Answer 31

Maternal and fetal assessment: BP, urine, labs, S&S, DFMC, NST, fetal growth, amniotic fluid volume
Activity modification
See Patient Teaching

Question 32

Preeclampsia with severe features

Answer 32

Greater risk for pregnancy complications→hospitalize
Magnesium sulfate to prevent eclampsia (Box 12.3) (MED SHEET)
Monitor BP, reflexes, urine output, cerebral status, presence of epigastric pain, tenderness, labor or vaginal bleeding
Low stim environment/seizure precautions
Antihypertensive therapy, if necessary (labetalol, nifedipine)
Maternal eval: serial BP, symptom assessment, lab evaluation
Fetal monitoring: ultrasound (fetal growth, fluid volume), NST/BPP
Corticosteroids (betamethasone/dexamethasone) for fetal lung development up to 34 wks; deliver at 34 wks or greater

Question 33

PreE with seve features actions

Answer 33

Intrapartum care
Early identification of abnormal FHR & prevention of maternal complications
Assess for signs of placental abruption (vaginal bleeding, tense tender uterus, uterine tachysystole)
Assess CNS, CV, pulmonary, hepatic, renal
Seizure precautions
Future health care
Increased risk for severe preeclampsia with future pregnancy, development of chronic hypertension and CV disease later in life–educate on lifestyle changes

Question 34

Eclampsi

Answer 34

Prevention! – Prenatal care for assessment and early interventions
Usually preceded by premonitory S&S: persistent headache, blurred vision, severe epigastric or RUQ pain, altered mental status
Immediate care: ensure patent airway and patient safety
How would you respond to a patient having a seizure???

Question 35

associated with chronic HTN

Answer 35

placental abruption
superimposed preeclampsia
increase perinatal mortality
fetal effect
- growth restriction
- preterm birth

Question 36

Anithypertensive meds

Answer 36

labatalol- safe for breastfeeding