Diabetes Mellitus and Pregnancy

• Coombs tests are for antibodies
• KB tests are for how much fetal blood has mixed with maternal blood

Diabetes Mellitus

• GDM is diagnosed during pregnancy, management includes diet, or insulin
• GDM diagnosis is done at 24 weeks via Glucose tolerance test
• Type 1 diabetes insulin adjustments needed throughout pregnancy, especially the second and third trimesters
• Type 2 diabetes management is done via oral meds and diet, though increased monitoring is required
• During labor, diabetic moms need glucose checks every hour

Diabetes Mellitus: Risks in Pregnancy

• Risk of LGA babies and IUGR
• Risk of infant hypoglycemia at birth
• Risk of UTIs
• Hydramnios requires increased monitoring of amniotic fluid
• Risk of ketonuria
• Risk of preeclampsia and potential low-dose aspirin
• Risk of retinopathies
• Risk of congenital abnormalities like sacral agenesis
• Risk of respiratory distress syndrome
• Risk of SAB can occur with poor glucose control
• Infants can become hypoglycemic after birth if the mother has hyperglycemia: high sugars cross the placenta, but insulin doesn't
• The fetus then produces its insulin, however, after the placenta is cut, the high levels of insulin do not get the sugars they need

Insulin and Pregnancy

• Insulin requirements decrease early in the first trimester because of human placental lactogen that is an insulin antagonist
• Insulin requirements then start increasing from this low point throughout the pregnancy
• Strict control of blood sugars and insulin is important
• Without diabetes diagnosis, the body adapts and there is no need to monitor glucose levels closely
• Estrogen and progesterone increase insulin production and tissue response to insulin
• Insulin needs decrease in first trimester
• During the second half hyperglycemia and hyperinsulinemia occur
• hPL and prolactin increase maternal peripheral resistance where glucose is shuttled to fetus causing accelerated starvation (ketonuria)
• Post partum: readjust insulin back to pre-pregnancy, and breastfeeding further decreases insulin requirements

Anemia: Assessment

• 1st prenatal visit:
  • Risk factors: previous DM, BMI, LGA in family, PCOS, HTN, non-caucasian,
  • HBA1C ≥ 6.5%
  • Fasting glucose ≥ 126
  • 2 hr PP glucose ≥ 200
  • Increased monitoring every 2 weeks, weekly during last trimester and nutrition consult

Anemia: Prenatal Visits

• Other Prenatal visits:
  • 24-28 weeks via Glucose tolerance test 1-2 hours fasting
  • HBA1C level checks
  • Glucose monitoring
  • Growth sonogram at 24, 28, 32, 36 weeks
  • NST/Amniotic fluid index at 32 weeks, 2x per week

Anemia: L&D and post partum

• Glucose via Ivls 1-2 hrs during active labor
• Insulin d/c at end of 3rd stage of labor
• Monitor for s/s post partum
• Provide pre-breastfeeding snacks
• Reassess 4-12 weeks post partum
• Iron deficient anemia is common, take iron with vit C, but milk and caffeine can impact absorption
• Folic acid deficiency happens more often in multiples, detected late in pregnancy
• Sickle cell disease needs increased folic acid and should be screening prenatally and in neonate with pain management.
• Thalassemia is an autosomal recessive disorder
• Hgb <11g/dL
• Risk factors: altitude, smoking, poor nutrition, medications
• Greatest need for iron in second half of pregnancy
• Stool softeners should be taken because iron can cause constipation

Anemia: Interventions

• Take iron with vit C, but taking with milk and caffeine can impact absorption
• Nutritional counseling
• Check h/h every 2 weeks
• s/s: fatigue, heart burn, headache, pallor, tachycardia, hgb less than 11

Substance Use

• Substance abuse has stigma, and often receive late prenatal care
• Alc
  • Is a Teratogen
  • Can lead to FAS
  • Can lead to Chronic abuse and malnutrition
• Marijuana
  • Can cause Low birth weight
• Cocaine/crack
  • Can cause Placental vasoconstriction
  • Can cause IUGR, SAB, abruption, preterm birth, still birth
  • Can cause SIDS, microcephaly, abnormalities
  • Can cause No breast feeding
• Opioid
  • Can cause Decreased RR
  • Can cause Abnormal placental implementation, abruption, PTL, PROM, meconium
  • Can cause IUGR, LBW, preterm birth, fetal distress
• Heroin
  • Can cause Preeclampsia, anemia, STIs
  • Can cause Preterm birth, IUGR

Psychological disorders

• Use therapeutic communication
• Share information
• Observe non-verbal cues
• Be aware of stages of labor and demeanor

Heart disease

• Check if congenital heart conditions were repaired
• Fine if repaired: tetralogy of fallot, atrial or ventricular septal defect, patent ductus arteriosus
• Pregnancy is contraindicated for: eisenmenger's syndrome, marfan syndrome , coarctation of the aorta, pulm htn, uncorrected coarctation of the aorta, aortic stenosis
• Pregnancy is tolerated well in mitral valve prolapse
• Peripartum cardiomyopathy – no previous hx: can cause Chest pain, heart palpitations, dyspnea, weakness, edema

Heart Disease: Risk classification

• Classification – CVD risk in pregnancy
  • Class I and II has no risk
  • Class III could be contraindicated
  • Class IV is contraindicated
• Assessments should be done during a critical period of 48 hrs pp with frequent monitoring
• Assessments are essential between 28 and 32 weeks
• In labor use Oxygen and diuretics
• Need Assisted delivery to reduce pushing
• Provide pain management

Asthma

• Do not use hemabate for asthma
• Increased difficulty breathing d/t compression of diagram
• Make sure well managed and that inhalers are available
• Always should be examined

Bleeding During Pregnancy

• Causes for Before 20 weeks
  • Gestational trophoblastic disease
  • Hydatidiform mole (molar pregnancy)
    • Completely empty egg, or partial – 69 chromosomes
    • Risk for choriocarcinoma
    • Symptoms: vaginal bleeding, anemia, uterus enlarges at a fast rate, nausea/vomiting, HTN before the 24th week, hyperemesis, high HCG, low AFP, absent fetal heart tones
    • Interventions: serum HCG weekly until negative, then normal until returns to baseline, baseline chest X ray and avoid pregnancy for 1 yr
• Abortion
  • Spontaneous abortion
    • Expulsion of the products of conception before viability (20 weeks or 500g)
    • Causes: chromosomal abnorms, low levels hcg, abnorm implantation, cervical insufficiency, teratogens, structural abnorms, endocrine imbalances, placental abnorms
  • Cervical insufficiency
    • Assessment: cervical length surveillance between 16 and 24 weeks, assessment for funneling of cervix
    • Cerclage: serial US of cervix and no sex until 34 weeks when cerclage is removed
  • Signs and symptoms include backache and ab tenderness, D/C or D/E after 16 weeks, Ultrasound, Prostaglandins for early ab before end of the first trimester and D/C dilation and curettage for late ab after first trimester but before 20 weeks
  • Interventions include: emptying the bladder, and if client is RH negative give rhogam w/in 72 hours and help client relax
  • Watch for vaso-vagal reaction and observe for signs of uterine perforation
  • May be give prophylactic antibiotics and Monitor VS
  • Discharge instructions: need to see provider if there is maternal fever, heavy blood, foul smelling vaginal discharge Small amount of discharge for 2 weeks is normal
• Pelvic rest is important for 2 weeks and antibiotics and support groups

Ectopic Pregnancy

• Definition: Implantation of fertilized egg anywhere outside of the uterus
• Not viable, must be removed or could be threatening to the life of the mother
• Etiology - iud, pelvic inflammatory disease, pelvic or tubal surgery, ovulation drugs, advanced maternal age
• s/s: positive pregnancy test, one sided lower abdominal pain , diffuse abdominal pain, fainting/dizziness, referred right shoulder pain
• Interventions: IV access, labs, US, emotional support, pelvic exam
• Treatment: remove via methotrexate IM or salpingostomy/salpingectomy

Trauma

• If mom is rh negative, give rhogam
• Assess for placental detachment, and mixing of fetal-maternal blood
• EFM, VS, KB test, hemoglobin F
• KB measures amount of fetal hemoglobin transferred to maternal bloodstream and diagnoses fetomaternal hemorrhage or risk for PTL.
• Low sensitivity, tends to overestimate volume of hemorrhage
• Hemoglobin F more reliable test for quantifying fetomaternal hemorrhage

Trauma After 20 Weeks

• Placenta Previa: placenta is low lying or covers the cervix and bleeding occurs in the third trimester d/t dilation of the cervix
• Placental abruption: placenta starts to separate before it is time, can either be complete or incomplete
• Factors that may contribute to abruption: Maternal HTN, PROM, Multifetal pregnancy, History of abruption, Blunt external abdominal trauma, Cocaine use
• Assessment includes dark red bleeding, port wine amniotic fluid, acute abdominal pain, sudden onset, hypotension, board like abdomen, increase in uterine size, contractions with hypertonicity, fetal distress
• Need to do h/h, clotting factors, KB test, coagulation factors
• Risk for DIC causes - fibrinogen and platelet decrease, PT and PTT prolonged with Clotting and anti clotting happening together
• Risk factors for clotting: Include fetal demise, severe preeclampsia, molar pregnancy, abruption hemorrhage, amniotic fluid embolism
• Assessment: bleeding, epistaxis, petechiae, ecchymosis, hypotension, tachycardia, oliguria
• Recommendation: CBC w/ dif, clotting factors, platelet transfusion, possible splenectomy
• Watch for less than 30 cc urine output per hour
• Up to date GTS is necessary

Labor

• Is Preterm labor
• Between 20 and 37 weeks of pregnancy: smoking/substance abuse, DM, multiple fetuses, Chorioamnitis, Preeclampsia, HTN, Hx PTL or ABS, Infections, Dehydration, Hydramnios, Younger than 17 or older than 35, Low SES, Domestic violence, Lack of prenatal care, placenta previa/abruption
• Assessment for PTL include ruptures of membranes, contractions, cervical dilations, persistent low back pain, pelvic pressure or cramping, GI cramping w/o diarrhea, vaginal discharge, urinary urgency/frequency
• Can do Fetal fibronectin (FFP) a vaginal swab to determine the PTB: vaginal swab between (22) 24-34 weeks which can predict if PTB in next 7 days, r/t inflammation of placenta, BPP, NST, Cervical cultures, Home uterine monitoring and Endocervical length measurement with US >30mm
• Interventions include Cerclage, Prevention (Hydration, Treatment of infection, screening, Cerclage), Activity restriction and Medications
• Medications include Terbutaline while betamethasone is given 2 doses 24 hours apart for the L:S ratio, Progesterone in hx a PTL, Nifedipine (CCB slows blood vessels)
• Mag sulfate Prolong preterm labor and Prophylactically while Idomethacin prevents prostaglandins

Nurse Role: Assessment

• Psychological support
• Monitor VS and bleeding amount
• Assess History such as ectopic pregnancy or thrombophlebitis
• Establish IV insertion, group type and screen, H/H
• Prepare for ultrasound and sterile vaginal exam if no plevia and assess rh status
• Assess fetal heart tones

Preeclampsia / hypertensive disorders

• May put them on magnesium
• Chronic is Htn before 20 weeks of pregnancy: > 140/90, no proteinuria
• Gestational is Htn that occurs after 20 wks, but 2 measurements >140/90 within 4-6 hours in one week. No protein uria and returns in 6 weeks after labour
• Preeclampsia-eclampsia
  • Mild: 1+ proteinuria (300 mg in 24 hr), May or may not have transient headaches or edema
  • Severe: 2+ proteinuria or more (500 mg in 24hr), BP 160/100 or greater, High creatinine or low platelets with Oliguria, Right upper quadrant epigastric pain, Visual disturbances, etc

Eclampsia

• Is Severe preeclampsia w/ onset of sz or coma.
• Is Preceded by HA, severe epigastric pain, hyperreflexia and hemo-concentrations
• Symptoms include: proteinuria and edema in hands and face causes injury to endothelial lining of blood vessels for an immune response
• HELLP syndrome coincides w/ severe preeclampsia: Hemolysis, Elevated Liver enzymes, Low Platelets due to possible DIC
• Nursing care is monitoring fluid and oxygen and reducing stimuli

Nursing Care: Preeclampsia

• Nursing care for mild preeclampsia includes: Frequent monitoring of VS and urine for protein while monitoring s/s like a headache that wont go away with pulse oxs, NST, BPP
• Nursing care for severe preeclampsia includes: Hourly VS, Maintain I/Os, Monitor urine output, Reflexes and lung sounds, epigrastic pain.
• Medications for mild preeclampsia include: Low dose aspirin after 12 weeks gestation, Methyldopa, Nifedipine
• Medications for severe preeclampsia include: Labetalol, magnesium sulfate lowers BP and neurodepressant
• Antidote: calcium gluconate (1g of 10% IV push over 3 mins) however avoid pregnancy, aspirin, ibuprofen

Birth related Procedures

• Amnioinfusion:
  • Amnioinfusion adds fluid via an IUPC into the amniotic sac to help when baby has decels or PPROM,
  • NS or LR may be used as warm fluid for oligohydramnios or fetal cord compression
• Amniotomy:
  • Amniotomy is an artificial rupture of membranes done sterally
  • Can help progress labor when fetus must be engaged or prevent cord prolapse: Sterilely push part off of cord after the T-berg or hands/knees

Extra Cephalic and Cervical Ripening

• Cut made either towards the anus or sagittally to help the baby's head fit
• Extra cephalic version (ECV): Use position changes with oil
• The team must be ready to use terbutaline including sono/NST

Cervical Ripening

• Can use a foley balloon, seaweed agents,
• Membrane striping - separating cervix from amniotic sac
• Chemical methods include misoprostol otherwise providers prefer Dinoprostone
• Why cervical ripening: induction of labor, Arrest of progress, chorioamnionitis
• BISHOP Score: To determine maternal readiness for labor by cervix with >8 for primiparous
• Score: dilation, effacement, station, consistency, position

Labor Augmentation

• Induction of labor: Can give oxytocics
• Augmented in women: with c section
• Use oxytocin and non pharma: caster oil

Assisted Birth

• Vacuum assisted birth: allowed to have 3 pop offs must be at +1

Cesarian

• Don't have more than 3
• Want to avoid pregnancy

Labor Risk

• Excess pressure, hypertonic contractions
• Risks: LGA, previous cesarean, multiples
• Assessment:
  • Pain, ripping sensation, increased tenderness, constant pressure
• Stat surgery/ Alert provider/ Patent IV/ IV fluids
• Preop nursing considerations (non obvious ones):Antacid
• Fetal can handle it & post partum hemorrhage

Dystocia and Post Partum Hemmhorage

• Dystocia - Difficult birth, typically caused by a large or awkwardly positioned fetus, by smallness of the maternal pelvis, or by failure of the uterus and cervix to contract and expand normally
• Ideal for C-section: Vaginal birth after cesarean (VBAC)
• Powers: Hypertonic Give terbutaline: Cardiac issue, preterm labor
• Procedure: amniotomy and manage with amniotomy pitocin or cord prolapse
• trial of labor for fetal can handle it & post partum hemorrhage: Trial of labor - start labor/augment, and see if fetus can handle it Is used for sitting or squatting position Blood loss after birth, early or late: Post partum hemorrhage – blood loss greater than 1000 for CS or 500 for vaginal

Hemmroage after Birth

• Early: Can be early Bright red uterus labor, uterus clamps properly
• Late: Late hemorrhage Retained baby or contracted Cause subinvolution, uterus may be hard to assess with Fundal,

Newborn Airway

• Prepare
• Warmer on
• Bulb suction ready
• Blankets warmed
• Assessment: APGAR
• Stimulate by drying

Vascular

• Venous thromboembolism thrombus infection
• Amniotic fluid embolus
• Position: LOCK Left lateral is best

Puerperal Infection

• Infection after birth
• Mastitis Milk is red burning
• Bladder UTI
• 3hrs or birth
• Don't break down
• Lightly pressure
• Stay calm