Antepartum problems Flashcards
gestational diabetes
any degree of glucose inteolerance with onset or recognition during pregnancy; identified during 2nd or 3rd trimester
diabetes goal
optimal outcome is strict maternal glucose control before conception and throughout the pregnancy
Insulin 1st tri
less insulin needed; risk hypoglycemia
insulin 2nd tri
gradually increase; need about back to baseline
insuline 3 tri
insulin dose above baseline (2-4x)
hormones that cause insuline resistance
HPL, prolactin, estrogen, progesterone, cortisol, insulinase
non-diabetics
pancrease compensates for insulin resistance
maternal complications with preexisting diabetes
miscarriage- 1st trimester
macrosomnia
hydramnios
ketoacidosis
hyperglycemia
hypoglycemia
preeclampsia
infection
fetal and neonatal risk preexisting diabetes
sudden and unexplained still birth
congenital malformations
birth injuries
prenatal evaluation
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)
preexisting dm- action
nutrition counseling, insulin (3rd tri especially), diet and exercise
GDM risk
fam hx
obesity
HTN
glucosuria
maternal age >25
more than 1/2 without risk factors
maternal GDM risk
preeclampsia
cesarean birth
dev type 2 DM later
neonatal GDM risk
macrosomia
birht injuries
electrolyte imbalance
hypoglycemia
OGTT
routine screening between 24 and 28 weeks
Intrapartume care GDM
monitor closely
complications: dehydration, hypo/hyperglycemia
may require a cesarean birth
Postpartum care GDM
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
HTN types
chronic essential
gestational
preeclampsia
chronic HTN
Present before the pregnancy or diagnosed before week 20 of gestation or persists beyond the PP period
gestational HTN
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
Preeclampsia→eclampsia
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
Chronic hypertension with superimposed preeclampsia
Women with chronic hypertension may acquire preeclampsia or eclampsia
PreE pathophysicology
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
PreE etiology
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
Identify and Prevent PreE
Assess:
Edema
Deep tendon reflexes
Clonus
RUQ/epigastric pain
Headaches (frontal)
Visual disturbance
diagnostic Cue
proteinuria (>0.3)
PreE effects on fetus
fetal growth restriction
decreased amniotic fluid volume
abnormal fetal oxygenation
LBW
preterm birht
preE sever features
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
HELLP syndrome
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
HELLP increase risk for
pulmonary edema
renal failure
liver hemorrhage or failure
disseminated intravascular coagulation
placental abruption
acute respiratory distress syndrome
sepsis
stroke
fetal and maternal death
actions for gestational HTN and PreE without sever features
Maternal and fetal assessment: BP, urine, labs, S&S, DFMC, NST, fetal growth, amniotic fluid volume
Activity modification
See Patient Teaching
Preeclampsia with severe features
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
PreE with seve features actions
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
Eclampsi
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???
associated with chronic HTN
placental abruption
superimposed preeclampsia
increase perinatal mortality
fetal effect
- growth restriction
- preterm birth
Anithypertensive meds
labatalol- safe for breastfeeding
