Maternity week 3-1 Flashcards
Diabetes Defined
Disease process marked by impaired production of, or impaired response to, insulin.
Disease process leads to hyperglycemia.
Chronic, untreated disease causes secondary effects in multiple body systems.
pre-gestational diabetes
existed before pregnancy
Gestational Diabetes
Glucose intolerance/onset in pregnancy
GDMA1= diet-controlled; GDMA2 =medication controlled
Affects up to 10% of pregnancies in U.S.
Diabetes 2/2 Other causes:
Diabetes 2/2 Other causes: drug-induced, disease/procedure-induced
Diabetes in Pregnancy
Pregestational Diabetes vs. Gestational Diabetes Mellitus (GDM)
GDM dx confers risk of dx. of Type II DM Postpardum (this just means they had it before but didn’t know it. preg did not cause diabetes):
Up to 10% of pregnant people w/ GDM will receive GDM dx postpartum
30-65% of pregnant people w/ GDM will receive GDM dx 10-20 yrs later
GDM Risk Factors
Previous pregnancy affected by GDM
Hx of infant >9#
Member of ethnic group with high risk
Obesity
Physical inactivity
PCOS
Hypercholesteremia
1st deg relative w/ diabetes
HTN
Diabetes Risk Assessment:
Nursing Care
No history of glucose intolerance
Younger than 25 years old
Normal body weight
No family history (first-degree relative) of diabetes
No history of poor obstetric outcomes
Not from an ethnic/racial group with a high prevalence of diabetes
GDM Sub-types
CLASS A-1 (GDMA1 or A1GDM):
2 abnormal values on OGTT
Diet-controlled
Fasting blood glucose normal
CLASS A-2 (GDMA2 or A2GDM):
Medication controlled.
No dx of pre-gestational diabetes
Metabolic Changes in Pregnancy
1st trimester - more sensitive to insulin, in 2nd and 3rd, starts to drop.
“Diabetogenic” Effect of Pregnancy
Metabolism directed towards supplying adequate nutrition to the fetus
Increased resistance to insulin: estrogen, progesterone, human chorionic somatomam-motropin (Hcs), cortisol, human placental lactogen released by placenta
Compensatory increased production of insulin by the pancreas
Post Partum: Return to pre-pregnant metabolism
1st trimester
goes up = estrogen /progesterone stimulate beta cells to increase insulin production
Increased insulin sensitivity
Increased glucose metabolism/dec blood glucose
Increase in glycogen stores and decrease in glucose production
Pre-gestational DM= inc risk hypoglycemia
2nd and 3rd Trimesters
Increased insulin resistance
Increased hepatic production of glucose
How is extra glucose stored
by fetus?
Gestational Diabetes Screening
1st tri screening for high risk clients
Inconsistent practices
Routine screening: 24-28 weeks
GLT
GTT if indicated by abnormal GLT (ACOG: 2 step approach)
Testing:
Glucose Load vs. Glucose Tolerance
Oral Glucose Load Test (OGLT or GLT)
*Administer 50g oral glucose (Glucola) p.o.
*Draw1 hour venous blood glucose (bg) *Refer for GTT if bg >139 mg/dL
*Some labs do 75g load/2 hour bg
Oral Glucose Tolerance Test (OGTT or GTT)
*Draw fasting venous blood glucose
*Administer 100 g oral glucose p.o.
*Draw 1 hour, 2 hour, 3 hour bg
Testing:
Glucose Load vs. Glucose Tolerance cont’d
GTT normal values
*Fasting bg <95 mg/dL
*One hour bg <180 mg/dL
*Two hour bg <155 mg/dL
*Three hour bg <140 mg/dL
Two elevated bg=GDM dx
Complications of GDM: Pregnant Person
Polyhydramnios (hydramnios): hyperglycemia= inc fetal diuresis
Abnormal blood glucose
Pre-eclampsia/GHTN
Ketoacidosis
C-Section
Instrument assisted delivery (vac, forcep)
Shoulder dystocia
SAB
Infections: UTI, chronic monilial vaginitis
Complications of GDM: Fetus/Neonate
Congenital anomalies: hyperglycemia in 1st tri.:
NDS (neural tube defects, usually from folic acid)
Anencephaly/microcephaly
Cardiac anomolies
Macrosomia
Preterm birth
Fetal asphyxia
IUGR
Perinatal Death
RDS
Polycythemia
Hyperbilirubinemia
Hypoglycemia
Childhood Obesity/Carb Intolerance
Screenings Throughout Pregnancy
Fundal Height
Blood Tests for genetic screening
Ultrasound for physical anomalies
Echocardiogram for heart anomalies
Lab Tests: U/A and Culture, Serum Glucose, Glycosylated Hgb (A1c), Electrolytes and Renal Function
Perinatal Diabetes Nursing Care
Pre-gestational counseling for clients w/ DM
Complete OB hx
Serum lab tests: HgA1C thyroid function, nephropathy, and retinopathy
Urine screen (POC - point of care = at the bedside)
Teach: dietary modifications, changes in activity, blood glucose monitoring/med administration PRN, home BP monitoring
Refer to dietrician/nutritionist per provider order
Patient Education: Nutrition
Follow prescribed diet plan
Divide daily food intake: 3 meals, 2 -3 snacks
Eat bedtime snack to prevent hypoglycemia NOC
Avoid refined sugar foods
Don’t skip meals or snacks
High dietary fiber foods
Avoid alcohol and nicotine
Patient Education: Glycemic Index - don’t need to know this
Measures effects of food on bg (lower GI=lower BG):
Low:55 or less
Medium:56–69
High:70 or above
Variables that affect GI: cooking time, how processed, how ripe
Patient Education: Nutrition/Glycemic Load - don’t need to know this
(Grams of carbohydrate X Glycemic Index)/100 = Glycemic Load
Low GL: 10 or less
Medium GL: 11 to 19
High GL: 20 or higher
More precise than GI=effect on BG + how fast it enters blood stream
Patient Education: Target Blood Glucose in PG
Pre-meal or Fasting = 60-99
Post-meal 1 hr = 100 - 129
Post-meal 2 hr < or = 120
Hypoglycemic Agents: Insulin
Insulin preferred med for GDMA2 (ACOG):
Weight based dosing
Does not cross placenta
Decreased in 1st tri
Divided dosing
Long-acting or intermediate-acting: up to 24 hour effect
+
Short-acting:
Novolog/Humalog,“clear”: 3-6 hour effect
Hypoglycemic Agents: Oral Meds
2nd line
May be easier for clients to manage
Glyburide
Promising data
2.5 mg-20mg QD or BID
Does not cross placenta
Metformin: Less frequently recommended; ***crosses placenta
Exercise
How much?
30 min moderate-intensity aerobic exercise/5 days week
OR
150 minutes +/week.
Walking 10-15 post-meal lowers BG
Type of exercise should be discussed with HCP.
insulin = does it cross the placenta?Cardiac Disease
&
Pregnancy
NO
4% of pregnant people have pre-existing cardiac disease
Congenital or acquired (Ricci, Table 20.3, p 699-700)
Cardiac disease accounts for 10-25% of maternal mortality
Risk Classes I-IV: lowest to highest risk; based on level of functioning
Congenital heart disease=1/2 of all cardiac disease in pregnancy
risk class IV - cardiac disease
pregnancy not recommended - could lead to death
Cardiac Disease and Pregnancy: Nursing Care
Early Diagnosis
Assess current tx: make/implement plan
Nutrition counseling
Activity level: consult MD
Rest
Fetal surveillance
Monitor Weight Gain
Cardiac Disease and Pregnancy: Nursing Care
Frequent and thorough assessments
Recognize S&S of cardiac decompensation
During Labor anticipate hemodynamic monitoring, epidural and assess for fluid overload.
Cardiac Disease and Pregnancy: Nursing Assessments
Fatigue
Tachycardia
Increased RR
Poor FHT variability from poor tissue perfusion
Decreased amniotic fluid from IUGR
Edema from poor venous return
Rh Incompatability
Rh factor and Coombs (antibody) determined (1st visit)
Rh +, Rhesus antigen present
Rh -, Rhesus antigen is not present
Rh – exposed to Rh antigen=antibody response
if patient has Coombs positive test,
we can’t give rhogam bc the antibodies have already formed.
iron foods
peanut butter raisins***
cocaine
vasoconstriction, causing hemmorhage and Placental abruption and separation.
4 Ps for substance use disorder screening
Parents: Did either of your parents ever have a problem
with alcohol or drugs?
Partner: Does your partner have a problem with
alcohol or drugs?
Past: Have you ever had any beer or wine or liquor?
Pregnancy: In the month before you knew you were
pregnant, how many cigarettes did you smoke? In the
month before you knew you were pregnant, how much
beer, wine or liquor did you drink?
screening for alcohol/substances should be
ongoing
GBS - what trimester?
3rd
TORCH infections of pregnancy
Toxoplasmosis
Other (Syphylis)
Rubella
Cytomegalovirus
HSV
Reproductive Tract Infections in Pregnancy
Chlamydia * low birth weight
Gonorrhea *IUGR, preterm birth
Group B Strep *Preterm birth, sepsis
Herpes *Congenital infection
HPV *None known
Syphilis *IUGR, stillbirth,
congenital infection, preterm birth
Rubeola (Measles) in Pregnancy
SAB, PTL
Maternal encephalitis
Maternal pneumonia
Limited fetal effects (if no pregnancy loss
Rubella in Pregnancy (German Measles): Fetal Effects (Bella’s hearing)
Congenital cataracts
Glaucoma
Cardiac defects,
Microcephaly
Hearing and intellectual disabilities.
Hearing impairment is the most common manifestation
Cytomegalovirus (CMV) (mega liver)
Effects 60% of the population.
Fetus can be infected through placenta, more common with primary infection
Congenital effects > hepatosplenomegaly, jaundice, growth restriction, hearing loss, intellectual disability
Virus transmitted by sexual contact, saliva or urine, infected blood
Good hygiene to help prevent it
HIV - on test
1 in 9 women unaware HIV+
AIDS: 3rd leading cause of death in U.S. in ages 25-44
Routine screening at 1st PNC visit
Retrovirus: Standard tx is antiretroviral therapy independent of viral load
Perinatal transmission rate 1% if adequately tx’d/35% if not
Greatest risk of vertical transmission during labor/after ROM
Vertical transmission
Vertical transmission is where viruses can pass between mother and baby in utero
greatest risk of Vertical transmission is in the
intranatal period (this is during labor) and esp after the rupture of membranes
Hepatitis B
Universal testing for pregnant people
Hep B immunoglobulin within 12 hours of birth
Bathe NB
Hep B vaccine within 24 hours
Breastfeeding is not contraindicated unless bleeding nipples. any baby born to person with HIV or Hep B will get a bath.
Varicella
Congenital Varicella Syndrome when contracted early in pregnancy:
Low birth weight,
Skin lesions
SAB
chorioretinitis
Cataracts
Pneumonia
Fetal growth restriction
Delayed milestones
Cutaneous scarring
Limb hypoplasia, microcephaly
Ocular abnormalities
Intellectual disability and early death
Varicella
Varicella pneumonia (birthing person)
Newborns who contract it: 30% mortality rate
Offer PP vaccine if non-immune
