OB exam 1- Comps of Antepartum Flashcards
GDM pathophys
in 1st trimester there is a decreased need for insulin b/c hormones enhance insulin production & tissue response to insulin then late in the 1st, there is an increased need for insulin b/c hormones act like insulin antagonists
where does the fetus get insulin from
because glucose crosses the fetal membrane, the fetus produces its own insulin based on the glucose in mother’s blood
by the end of pregnancy, how much does insulin need increase
double or triple
maternal risks of GDM
-polyhydramnios d/t increased fetal urine
-preeclampsia / eclampsia
-ketoacidosis (main reason for still birth)
-dystocia (difficult birth)
-increased susceptibility to infections (UTI, yeast, ret)
fetal / neonatal risks w/ DM
-perinatal mortality
-congenital anomalies
-macrosomia
-growth restriction
-res distress
-polycythemia
-hypoglycemia after birth
-hyperbilirubinemia
when is a women screened for GDM
low risk: 24 to 28 wks
high risk: as early as possible
1hr glucose tolerance test
women comes into office and drinks a 50g glucose drink within 10-15 mins and then 1 hr later draw blood to test glucose, if >140 then further testing is needed
pt does not need to be fasting before
3hr glucose tolerance test
if 1hr is failed then women are recommended to eat a high carb diet for several days and then fast before coming into the office for a blood draw -> after the draw pt will drink a 100g glucose drink within 10-15 mins -> after finishing blood will be drawn 1hr later, 2hrs later and 3hrs later
if 2 out of the 4 levels are elevated they will get diagnosed w/ GDM
3hr GTT failing glucose marks
fasting >/95
1hr >180
2hr > 155
3hr >140
treatment goals for GDM
-diet therapy and exercise
-glucose monitoring
-insulin therapy
glucose goals for GDM
fasting <95
2hr post meals <120
to help provent macrosomia
nursing mgt of a GDM pt
-assessment of glucose
-nutrition counseling (consult RD)
-ed about the disease & mgt
-ed about how to monitor glucose & administer insulin (+overdoses risk)
-assess the fetus w/ ultrasounds every 4 wks, daily fetal movement counts and NST
-give support
when would we delivery a baby before 39 wks
complications
baby is too large
mom’s blood sugars are not staying within range
how often should you assess glucose during labor
every hour bc the stress of labor can impact glucose levels
continue to check after delivery
GDM mgt postpartum
-assess glucose and recognize maternal insulin requirements drop significantly
-encourage breastfeeding
-follow up at 6wks to check levels, if still high then dx of type 2
iron deficiency anemia
d/t inadequate iron intake, pt will feel tired and wont handle bleeding well (dx at lower then 11)
tx: iron supplement during pregnancy
sickle cell anemia
-recessive autosomal disease
-decreased O2 present d/c sickling
tx: prevent crisis by treating w/ IV fluids, 02 abx, folic acid and analgesics
folic acid deficiency anemia
-RBC fail to divide in the absence of folic acid putting the baby at high fetal risk of neural tube defects like SB
tx: women of childbearing age should take 400mcg of folic acid daily then during pregnancy take 1mg folate daily
what is the ideal nursing goal for substance abuse
prevention
what needs to be screened for in all pregnancies
HIV bc mother could have it without knowing
what is an important part of care for a substance abuse pt
-educating on the affects on herself as well as the baby
-establishing a trusting, non judgmental relationship
if a mother finds out she has HIV while pregnant, what is the next step
give mother antiretrovirals to reduce risk of transmission to baby (mother to baby is a vertical transmission)
what should be avoided as much as possible if a person has HIV
invasion procedures
a women with high risk is screened for HIV initially after finding out she was pregnant and the screen came back negative, what should you expect to be ordered later in pregnancy
during the 3rd trimester, re test for HIV
what is our recommendation for feeding to a HIV + mother
formula feed baby bc breastmilk can contain HIV if only option, then breastfeed, usually seen in 3rd world countries
congenital heart disease
pt born with it and it causes decreased cardiac reserve needed for extra work of pregnancy
peripartum cardiomyopathy
left ventricular dysfunction that may occur during last month of pregnancy through 5 month PP
sx: edema, cough, chest pain, fatigue
Eisenmenger syndrome
left to right shunting leading to pulmonary HTN
mitral valve prolapse
M value prolapses into the left atrium
standard changes during pregnancy
increased cardiac output
increased heart rate
increased blood volume
cardiac disease assessment during pregnancy
-monitor cardiac functional capacity
-VS
-signs of decomp
-factors that increase stress on heart
always cough, dyspnea, edema, murmur, palpitations, rales & wt gain
what are factors that increase stress on the heart
anemia, infection, lack of support, home & career demands
rest requirements for cardio pts
-restricted activities
-8 to 10 hr of sleep
-rests periods
-avoid sources of infection
if a pt has a cardiac disorder, how frequently should they visit their HCP
every 2 weeks during the first half of pregnancy and then every week during the 2nd half
diet for cardiac pts
high iron, high protein, low sodium, adequate calories
cardiac pt pushing parameters
shorter, moderate pushes with periods of relaxation between pushes
epidurals are recommended to help decrease cardiac output and oxygen demands
how often do you check VS postpartum for a cardiac pt
every 4 hours
what position do we encourage for cardiac pts
side lying or semi fowlers
postpartum of a cardiac pt, what medication do you expect to see ordered
stool softeners to prevent bearing down
threatened abortion
cervix is closed, placenta is attached and pt is experiencing bleeding and cramps
imminent abortion
cervix is dilated, the placenta is separated and the patient is bleeding
incomplete abortion
baby has been delivered by placenta is still inside the uterus + bleeding
nursing care during a miscarriage
-assess the amount and appearance of any vaginal bleeding
-monitor the women’s vital signs and degree of discomfort
-assess need for Rh immune globulin
-assess the response and coping of the women & her family
recurrent miscarriage
defined by 3 or more consecutive losses or >/2 if advanced maternal age
follow up testing for pt with recurrent miscarriage
-genetic testing of both parents
-anti phospholipid antibody syndrome
-thyroid disease screen
ectopic pregnancy
occurs when a fertilized egg is implant some other place other than the uterus’s endometrium
what might a pt with an ectopic pregnancy complain of
sharp, one sided pain, syncope or referred pain to their should or lower abdomen (possible bleeding)
what medication is given for an ectopic pregnancy
methotrexate IM that can be administered outpatient
methotrexate medication teaching
avoid sun exposure, report severe pain and heavy bleeding
ectopic pregnancy hospital based care
-if surgery is required then IV, preop & postop care
-assess for signs of shock
-administer analgesics
in a healthy pregnancy, what are hCG trends
should double every 2-3 days and if it doesn’t it is concerned low and concerning
gestational trophoblastic disease (molar disease)
proliferation of trophoblastic (outer layer of the embryonic cells)
hydatiform mole
either have a complete mole (ovum containing non genetic material is fertilized by normal sperm) or partial mole (normal ovum is fertilized by two sperm or sperm that has not divided)
if you have a complete mole, what are you at increased risk for
a chorionic carcinoma
what does a molar pregnancy cause
abnormal placenta development that lead to fluid filled grape like clusters
hydatiform mole
-dark brown vaginal bleeding & possible anemia
-hydropic “grape like” vesicles
-uterine enlargement
-absence of FHT
-elevated levels for hCG for dates
-very low serum levels of MSAFP
hydatiform mole sx
-hyperemesis gravidarum
-preeclampsia
hydatiform mole tx
-D&C
-possible hysterectomy d/t choriocarinoma in 20% of women
-follow up b/c increased risk for PE (watch for tachy & restlessness)
hyperemesis gravidarum
excessive vomiting during pregnancy that impact hydration and nutrition, cause unknown but syndrome is connected to nutritional deficits
hyperemesis gravidarum dx
problematic vomiting in 1st trimest, dehydration, ketouria, and wt loss of 5% of pre pregnancy wt
what supplement do pts w/ hyperemesis gravidarum need
thiamin (B1) to reduce risk of wernicke’s encephalopathy
hyperemesis gravidarum nursing interventions
-assess
-maintain fluids + ~TPN
-encourage balanced diet as tolerated
-provided relaxed low stim environment
-antiemetics
how does Rh alloimmunization occur
when you have an Rh negative mother and an Rh+ fetus and the mother is exposed to the babies blood
exposure can cause mother to to create antibodies against her baby
what happens if a mother create antibodies against the baby’s fetal blood
there will be a breakdown of fetal blood cells causing a rapid production of erythroblasts by the fetus that can then lead to hyperbilirubinemia
first baby is usually ok but it can hurt future offsprings
what happens if treatment for alloimmunization is not giving
-anemia resulting from the destruction of fetal RBCs which can cause fetal edema/hydrops fetalis
-CHF
-icterus gravis (jaundice)
-kernicterus leading to neurological damage
-erythroblastosis fetalis
hydrops fetalis
swelling around the fetal tissue and organs
lethal in 50% of cases
antepartum mgt for Rh determination
antibody screening (indirect combs test) @ first prenatal visit and 28 wks gestation to determine compatibility of mother and fetal blood
what is the next step if indirect combs comes back as incompatible but the mother has no antibodies produced
administer 300 mcg of Rhogam
prophylactic at 28wks if screen was negative
what other times is rhogam prophylactic
-after spontaneous or induced abortion (bc we do not know baby’s blood type)
-ectopic pregnancy
-after invasive procedures during pregnancy
-after maternal trauma
what is the next step if indirect combs comes back as incompatible and the mother has antibodies produced (aka mother is sensitized)
monitor the baby and complete NST, serial ultrasounds, amniotic fluid analysis (to see if we can delivery the baby early) and a doppler study (looking for signs of severe anemia or fetal hydrops)
if severe anemia or fetal hydrops is detected while monitoring of a sensitized women, what do you do
you may need to give the fetus an intrauterine blood transfusion or have a preterm delivery
what is a direct combs test
if mom has a negative blood type and baby is born with a positive blood type then you can test the cord blood and blood antibodies
if negative then the mothers and baby’s blood has not mixed
if the baby has a negative antibody screen, what is our care within the first 72 hrs of life
give rhogam bc one dose can prevent sensitization up to 30ml of Rh positive blood
if the baby has a positive antibody screen (direct combs), what is our care within the first 72 hrs of life
do not give rhogam and monitor infant for hemolytic disease
kleihauer Betke test
determines how much Rh positive blood is present in maternal circulation and determines the amount of rhogam needed
ABO incompatibility
occurs when mom is type O and infant is either type A, B, or AB causing the mom to create antibodies which can lead to hemolysis of fetal red blood cells & hyperbilirubinemia (jaundice)
severe anemia does not generally occur
