ELO C: Nursing Care of Women with Complications During Pregnancy

High-Risk Pregnancy Causes

• Pregnancy itself can lead to complications such as hemorrhage, hyperemesis gravidarum, hypertensive disorders, and blood incompatibilities.
• Maternal medical conditions or injury can complicate pregnancy, including diabetes mellitus, cardiac disease, anemias, and immunologic issues.
• Environmental hazards, like exposure to workplace chemicals, can affect both the mother and fetus.
• Maternal behaviors and lifestyles, like smoking, drug use, and eating disorders, can negatively impact the mother and fetus.
• Early and consistent prenatal assessment is crucial for positive outcomes for both mother and fetus.

Signs of Pregnancy Complications

• Vaginal bleeding
• Sudden gush of fluid from the vagina
• Abdominal pain
• Abnormal "kick count"
• Persistent vomiting
• Epigastric pain
• Edema of the face and hands
• Severe, persistent headache
• Blurred vision or dizziness
• Chills with fever greater than 100.4°F
• Painful urination or reduced urine output

Prenatal Tests

• Ultrasound Examination: Uses high-frequency sound waves to visualize structures within the body, including the fetus.
  • Abdominal ultrasound requires a full bladder and is used during early pregnancy.
  • Transvaginal ultrasound requires an empty bladder and is used to determine cervix length.
  • Targeted ultrasound detects specific fetal anomalies.
  • Doppler scan detects fetal heart activity at 6-10 weeks.
  • 3D and 4D imaging provides clear detail.
• Uses of Ultrasound in Pregnancy:
  • Confirmation of pregnancy
  • Identify site of implantation
  • Verify fetal viability or death
  • Identify multifetal pregnancy
  • Diagnose fetal structural abnormalities
  • Determine gestational age
  • Guide invasive procedures like chorionic villus sampling, amniocentesis, and percutaneous umbilical blood sampling
  • Identify markers like nuchal translucence
  • Locate placenta, amniotic fluid, fetal movements, and determine estimated delivery date
• Amniotic Fluid Volume: Measured by ultrasound to assess amniotic fluid pockets in all four quadrants around the mother's umbilicus, producing an Amniotic Fluid Index (AFI).
  • Normal AFI: 5-19 cm
  • Oligohydramnios (insufficient amniotic fluid): Less than 5 cm, associated with growth restriction and fetal distress during labor due to cord compression.
  • Polyhydramnios (excess amniotic fluid): Greater than 30 cm, associated with neural tube defects, gastrointestinal obstruction, and fetal hydrops.
• Estimation of Gestational Age: Ultrasound is more accurate than LNMP before 22 weeks.
  • Crown-rump length at 7-14 weeks indicates fetal age.
  • Biparietal diameter and femur length after 12 weeks provide accurate estimation of fetal age.
• MRI: Noninvasive radiological view of fetal structures, including the placenta.
  • Used when there is a high suspicion of an anomaly.
• Kick Count: Maternal assessment of fetal movement.
  • Woman counts fetal movements while lying on her left side, 1 hour after a meal.
  • Less than 3 kicks in 30 minutes or less than 10 kicks in 3 hours require evaluation.
  • Daily fetal movement record is kept to monitor fetal health.
• Doppler Ultrasound Blood Flow Assessment: Uses ultrasound to study blood flow through fetal vessels.
  • Detects speed and direction of blood flow.
  • Assesses adequacy of blood flow through the placenta and umbilical cord vessels in women with potential blood flow impairment.
• Alpha-Fetoprotein Testing (AFP): Determines AFP levels in maternal serum or amniotic fluid.
  • High levels are associated with open defects such as spina bifida, anencephaly, and gastroschisis.
  • Low levels are associated with chromosome abnormalities or gestational trophoblastic disease.
• Chorionic Villus Sampling: Obtains a small part of the developing placenta to analyze fetal cells at 10-12 weeks gestation.
  • Identifies chromosomal abnormalities or other genetic defects.
  • Higher risk of spontaneous abortion compared to amniocentesis.
• Cell-free DNA: Test of the mother's blood to identify chromosomal anomalies.
• Amniocentesis: Obtaining a sample of amniotic fluid through the abdominal and uterine walls.
  • Early pregnancy: Identifies chromosome abnormalities, biochemical disorders, and AFP levels.
  • Late pregnancy: Identifies the severity of maternal-fetal blood incompatibility and assesses fetal lung maturity.
• Non-Stress Test (NST): Evaluates fetal heart rate (FHR) for accelerations of at least 15 beats per minute lasting 15 seconds in a 20-minute period.
  • Identifies fetal compromise in conditions associated with poor placental function.
• Vibroacoustic Stimulation Test: Similar to NST, but uses an artificial larynx device to stimulate the fetus with sound.
  • Clarifies the results of a questionable NST.
  • Used during labor to clarify questionable FHR patterns.
• Contraction Stress Test (CST): Evaluates FHR response to mild uterine contractions.
  • Contractions are induced by nipple stimulation or intravenous oxytocin.
  • May be done if NST results are non-reassuring or questionable.
• Biophysical Profile (BPP): Consists of five fetal assessments: FHR and reactivity, fetal breathing movements, fetal body movements, fetal tone, and amniotic fluid volume.
  • Identifies reduced fetal oxygenation with greater precision than NST.
• Percutaneous Umbilical Blood Sampling: Obtains a fetal blood sample from a placental vessel or umbilical cord to monitor fetal heart health.
  • Identifies fetal conditions that can only be diagnosed with a blood sample, including fetal anemia.
  • May be used for fetal blood transfusions.
• Tests of Fetal Lung Maturity: Use amniotic fluid to determine substances that indicate fetal lungs are mature enough for extrauterine life.
  • Evaluates whether the fetus is likely to have respiratory complications in adapting to extrauterine life.
  • Determines whether fetal lungs are mature enough for elective C-section or labor induction.

Hyperemesis Gravidarum (HG)

• Excessive nausea and vomiting that significantly interferes with food intake and fluid balance.
• Can lead to fetal growth restriction and low birth weight.
• Dehydration impairs placental perfusion, reducing oxygen and nutrient delivery to the fetus.
• Signs and Symptoms:
  • Persistent nausea and vomiting
  • Significant weight loss
  • Dehydration
  • Electrolyte and acid-base imbalances
  • Ketonuria
• Treatment:
  • Rule out other causes for excessive nausea.
  • Correct dehydration and imbalances with oral or intravenous fluids.
  • Antiemetic drugs: Diclegis, Clonidine transdermal patch, Ondansetron.
  • Hospitalization may be necessary for severe cases.
• Nursing Care:
  • Focuses on patient teaching as most care occurs at home.
  • Avoid food odors and triggers for nausea.
  • Monitor intake and output, daily weights, and record emesis amounts.
  • Administer small frequent meals and fluids.
  • Sit upright after meals to reduce reflux.

Bleeding Disorders in Pregnancy

• Common bleeding disorders include abortion, ectopic pregnancy, and hydatidiform mole.
• Maternal blood loss decreases oxygen-carrying capacity, resulting in fetal hypoxia.
• Spontaneous Abortion: Unintentional termination of pregnancy before 20 weeks, with subgroups:
  • Threatened Abortion: Cramping and light spotting with a closed cervix, no tissue passed.
    • Treatment: Ultrasound, bedrest, avoid coitus.
  • Inevitable Abortion: Increased bleeding and cramping with a dilated cervix.
    • Treatment: Bedrest, awaiting natural evacuation of uterus.
  • Incomplete Abortion: Bleeding, cramping, and dilation of cervix with passage of tissue.
    • Treatment: Emptying of remaining tissue with dilation and evacuation (D&E) or vacuum extraction.
  • Other Subgroups:
    • Complete Abortion: Passage of all products of conception with a closed cervix.
    • Missed Abortion: Fetus has died but remains in the uterus.
    • Septic Abortion: Infection of the reproductive tract, may include fever, chills, and foul vaginal discharge.
• Ectopic Pregnancy: Implantation of the fertilized egg outside the uterus.
• Hydatidiform Mole: Abnormal growth of tissue in the uterus that resembles grape-like clusters.

Complete Abortion

• All products of conception are expelled from the uterus.
• The cervix closes, and bleeding stops.
• Treatment involves monitoring the patient and providing emotional support.
• RhoGAM may be administered if indicated.

Missed Abortion

• The fetus dies in utero, but it is not expelled.
• Uterine growth stops, and sepsis can occur.
• If the fetus is not expelled, the uterus is evacuated by dilation and evacuation (D&E).

Recurrent Abortion

• Two or more consecutive spontaneous abortions occur.
• Common causes include incompetent cervix or inadequate progesterone levels to maintain pregnancy.
• Treatment involves investigating potential causes, such as genetic, immunological, anatomical, endocrine, or infectious factors.
• An incompetent cervix can be sutured closed to prevent it from opening as the fetus grows.
• Patients are closely monitored for early signs of labor at term to prevent uterine rupture.

Induced Abortion

• The intentional termination of pregnancy before the age of viability.

Therapeutic Abortion

• Intentional termination of pregnancy to preserve the health of the mother.
• Treatment involves D&E performed under sterile conditions.
• Supportive counseling is essential.

Elective Abortion

• Intentional termination of pregnancy for reasons other than the health of the mother, such as fetal anomaly.
• Treatment may involve D&E, mini-suction, hypertonic saline, or vacuum curettage to remove the products of conception.
• The mother is at risk for hemorrhage and infection.
• Counseling is advised even if the mother chooses to abort.

Nursing Care Following Abortion

Physical Care

• Document the amount and character of bleeding, saving any tissue or clots for evaluation by a pathologist.
• A pad count and estimation of saturation can accurately document blood loss.
• Teach women with threatened abortions to report increased bleeding or tissue passage.
• Monitor for hypovolemic shock in hospitalized women by assessing bleeding and vital signs.
• Maintain NPO status if active bleeding to prevent aspiration if anesthesia is required for dilation and evacuation.
• Monitor lab values for hemoglobin and hematocrit.
• After vacuum aspiration or curettage, observe vaginal bleeding and vital signs every 15 minutes for one hour and every 30 minutes until discharge.
• Monitor temperature every 4 hours for infection.

Discharge Instructions

• Report increased bleeding and avoid tampons to prevent infection.
• Take temperature every 8 hours for 3 days; report temperatures over 100.4 degrees Fahrenheit, foul odor, or brownish vaginal discharge.
• Take oral iron supplements if prescribed.
• Resume sexual activity as recommended by the healthcare provider, usually after bleeding has stopped.
• Return for a checkup and contraception information at the recommended time.
• Pregnancy can occur before the first menstrual period returns after an abortion procedure.

Emotional Care

• Society may underestimate the emotional distress of a spontaneous abortion, even if the pregnancy was unplanned or unsuspected.
• Listen to the woman and acknowledge the normal stages of grief, evaluating if it is progressing normally or if dysfunctional grieving is present.
• Provide presence, empathy, and open communication, encouraging the family to express feelings about the loss.
• Spiritual support of the family's choice and community support groups can help families work through grief.
• Reinforce explanations given by the healthcare provider because grieving individuals may not hear or understand them initially.

Ectopic Pregnancy

• Occurs when a fertilized ovum implants outside the uterus.
• 95% of ectopic pregnancies occur in the fallopian tube due to obstructions or abnormalities.
• Scarring from previous pelvic infections, fallopian tube deformities, or impaired tubal motility can contribute.
• The zygote will not survive long in the fallopian tube due to inadequate blood supply and size.
• The zygote may die and be reabsorbed, or the tube may rupture causing abdominal bleeding, leading to a surgical emergency.

Manifestations

• Missed menstrual period.
• Lower abdominal pain, sometimes with light vaginal bleeding.
• Sudden, severe lower abdominal pain, vaginal bleeding, and signs of hypovolemic shock if the tube ruptures.
• Shoulder pain is a symptom that often accompanies bleeding into the abdominal cavity.

Treatment

• Sensitive pregnancy test for hCG to confirm pregnancy.
• Transvaginal ultrasound to determine if the embryo is growing in the uterine cavity.
• Culdocentesis (puncture of the upper posterior vaginal wall) may be performed to identify blood in the pelvis, suggesting tubal rupture.
• Laparoscopic examination to view the damaged tube.
• Medical management focuses on controlling bleeding.
• The course of action depends on the gestational age and the extent of tubal damage:
  • No action if the body is resorbing the pregnancy.
  • Medical therapy with methotrexate (if the tube is not ruptured) inhibits cell division in the embryo, allowing it to be reabsorbed.
  • Surgery to remove the products of conception from the tube, if the damage is minimal. More extensive damage may require removal of the entire tube, and occasionally, the uterus.

Nursing Care for Post-Operative Ectopic Pregnancy

• Measure vital signs to identify hypovolemic shock and infection.
• Assess vaginal bleeding. Most blood is internal, so report increasing pain, particularly shoulder pain, to the healthcare provider.
• Assess lung and bowel sounds.
• Administer intravenous fluids and blood replacements if necessary.
• Administer antibiotics as ordered.
• Provide pain medication.
• Resume oral intake gradually, starting with ice chips, then clear liquids, and advance as bowel sounds return.
• Insert a Foley catheter as ordered to monitor fluid balance.
• Encourage progressive ambulation.
• Provide emotional support to the woman and family as they may grieve similar to that accompanying a spontaneous abortion.

Hydatidiform Mole (Gestational Trophoblastic Disease)

• Characterized by abnormal growth of chorionic villi (fringelike structures of the placenta) into grape-like vesicles.
• May be complete (no fetus) or partial (only part of the placenta has vesicles).
• May cause hemorrhage, clotting abnormalities, hypertension, and potentially cancer.

Manifestations

• Bleeding, from spotting to profuse hemorrhage, often brown in color with cramping.
• Rapid uterine growth greater than expected for gestational age.
• Failure to detect fetal heart activity.
• Signs of hyperemesis gravidarum.
• Unusually early development of gestational hypertension.
• Higher than expected hCG levels.
• Ultrasound shows a "snowstorm" pattern but no developing fetus.

Treatment

• Transvaginal ultrasound confirms the diagnosis.
• The uterus is evacuated by vacuum aspiration or dilation and evacuation.
• Serial hCG levels are monitored until undetectable and followed for one year. Persistent or increasing levels suggest remaining vesicles or malignant changes. Delay conceiving until follow-up care is complete because a new pregnancy can interfere with hCG testing.
• RhoGAM is prescribed for Rh-negative women.

Nursing Care for Hydatidiform Mole

• Monitor for bleeding and shock.
• If the woman experiences hyperemesis gravidarum or preeclampsia, incorporate nursing care for those complications.
• Provide emotional care for grieving.
• Emphasize follow-up exams and the proper use of contraceptives to delay pregnancy until follow-up care is complete.

Placenta Previa

• Occurs when the placenta develops in the lower part of the uterus, rather than the upper part, covering the cervix.
• Three degrees of placenta previa:
  • Marginal: Placenta reaches within 2-3 centimeters of the cervical opening.
  • Partial: Placenta partially covers the cervical opening.
  • Total: Placenta completely covers the cervical opening.
• A low-lying placenta is implanted near the cervix but does not cover the opening. It may not be accompanied by bleeding.

Manifestations

• Painless, bright red vaginal bleeding.
• Risk of hemorrhage increases as the woman nears term due to cervical dilation and effacement which disrupts placental attachment.
• Abnormal fetal presentation due to placental occupation of the lower uterus.
• Fetal anemia or hypovolemic shock due to fetal blood loss.
• Fetal hypoxia due to reduced oxygen and nutrient transfer from a disrupted placental surface.
• Increased risk of maternal infection and postpartum hemorrhage.

Treatment

• The goal is to maintain pregnancy until fetal lung maturity to reduce the risk of respiratory distress.
• Delivery is performed if bleeding jeopardizes the mother or fetus, regardless of gestational age.
• The mother should lie on her side or with a pillow under one hip to prevent supine hypotension.
• Cesarean section is performed for extensive bleeding or near-term gestation in partial or total cases.
• Low-lying or marginal cases may be delivered vaginally unless bleeding is excessive.

Nursing Care for Placenta Previa

• Continuous fetal heart monitoring and assessment of contraction character are essential.
• Document and report vaginal blood loss and signs of shock.
• Take vital signs every 15 minutes if actively bleeding and administer oxygen to increase fetal oxygen delivery.
• Vaginal exams should be avoided as they can precipitate bleeding; they may be performed with preparations for vaginal and cesarean delivery in place.
• Provide supportive care as parents may experience fear for their child.

Abruptio Placentae

• The premature separation of the normally implanted placenta.
• Predisposing factors include:
  • Hypertension.
  • Cocaine use.
  • Cigarette smoking.
  • Poor nutrition.
  • Abdominal trauma.
  • Previous abruptio placentae.
  • Folate deficiency.

Manifestations

• Bleeding accompanied by abdominal or low back pain, which distinguishes abruptio placentae from placenta previa.
• Bleeding may be partial or total, marginal (edge separation) or central (middle separation), visible or concealed behind a partially attached placenta.
• Uterus is tender and firm due to blood leaking into its muscle fibers.
• Frequent, cramp-like uterine contractions (uterine irritability) occur.
• Fetal problems may or may not occur depending on the extent of placental disruption.
• Disseminated Intravascular Coagulation (DIC) is a complication that consumes clotting factors, leading to bleeding from other sites.
• Postpartum hemorrhage may occur because the injured uterine muscle does not contract effectively.
• Infection is more likely due to damaged tissue susceptibility.

Treatment

• Immediate cesarean delivery is the treatment of choice to reduce the risk of maternal shock, clotting disorders, and fetal death.
• Clotting factor replacement may be needed to address DIC.

Nursing Care for Abruptio Placentae

• Prepare for cesarean section and closely monitor vital signs, intake, output, fetal heart, and contractions.
• Report signs of shock and bleeding from unexpected sites immediately.
• Rapid uterine enlargement suggests blood accumulation within the uterus. Observe for pain and uterine rigidity or tenderness.
• Administer oxygen by mask.
• Document blood loss, verify blood typing and crossmatch orders, and monitor coagulation studies.
• Prepare for newborn resuscitation, as fetal death may occur before delivery. Support the grieving family.
• Postpartum nursing care is similar to that for placenta previa.

Gestational Hypertension

• Risk factors:
  • First pregnancy.
  • Obesity.
  • Family history of preeclampsia.
  • Age greater than 35 years or less than 19 years.
  • Multifetal pregnancy.
  • Chronic hypertension.
  • Chronic renal disease.
  • Diabetes mellitus.
  • Autoimmune disease.
  • Pregnancy interval longer than 10 years.

Hypertensive Disorders of Pregnancy

Chronic Hypertension

• Blood pressure greater than 140/90 mmHg before 20 weeks gestation.
• Usually persists beyond 12 weeks postpartum.
• New onset proteinuria, sudden increases in blood pressure, or kidney involvement in pregnant patients with chronic hypertension are indicative of preeclampsia.

Gestational Hypertension (GH)

• Hypertension develops during pregnancy in previously normotensive women.
• Blood pressure greater than 140/90 mmHg after 20 weeks of pregnancy.
• Usually resolves 6-12 weeks postpartum.
• Does not involve proteinuria.
• Despite increased blood volume and cardiac output, many women do not experience hypertension due to resistance to vasoconstricting factors.
• Hormonal changes reduce resistance to blood flow.
• Edema may occur, but it is not essential for diagnosis.

Preeclampsia

• Increased blood pressure and proteinuria developing after 20 weeks gestation in a previously normotensive woman.
• Mild preeclampsia:
  • Systolic blood pressure greater than 140 mmHg, but less than 160 mmHg.
  • Diastolic blood pressure greater than 90 mmHg, but less than 110 mmHg.
  • These values should be assessed on multiple visits, at least one week apart.
• Severe preeclampsia:
  • Sustained systolic blood pressure of 160 mmHg and diastolic blood pressure of 110 mmHg or greater.
  • Proteinuria of 1+ or greater on two separate urine specimens.
  • Excess weight gain of more than 4 pounds in one week during the second and third trimester.

Preeclampsia

• Preeclampsia can occur during pregnancy and is characterized by hypertension and proteinuria.
• Edema is not always present.
• Risk factors for preeclampsia include:
  • First pregnancy
  • African American race
  • Obesity
  • Family history of preeclampsia
  • Diabetes
  • Gestational trophoblastic disease
  • Age under 19 or over 35
• Vasospasm reduces blood flow to the mother's organs and placenta, leading to symptoms such as:
  • Hypertension
  • Proteinuria: confirms preeclampsia
  • Edema: severe when pitting edema is present
• Other manifestations of preeclampsia include:
  • Central nervous system: Severe headache and hyperactive deep tendon reflexes
  • Eyes: Blurred or double vision, "spots before the eyes"
  • Urinary tract: Decreased urine production and worsening hypertension
  • Respiratory system: Pulmonary edema
  • GI & Liver: Epigastric pain, nausea, elevated liver enzymes
  • Blood clotting: HELLP syndrome

HELLP Syndrome

• HELLP Syndrome is a variant of preeclampsia characterized by:
  • Hemolysis: Erythrocytes break down due to hypertension
  • Elevated Liver enzymes: Obstructed hepatic blood flow
  • Low Platelets: Platelets gather at damaged blood vessels, reducing circulation
• HELLP syndrome is more common in women with preeclampsia but can occur without hypertension and proteinuria.
• Treatment is the same as for preeclampsia.

Eclampsia

• Eclampsia is preeclampsia with seizures.
• Seizures can cause:
  • Cerebral hemorrhage
  • Abruptio placentae
  • Fetal compromise
  • Maternal and fetal death

Preeclampsia with Superimposed Chronic Hypertension

• Chronic hypertension with new proteinuria, thrombocytopenia, and increased liver enzymes.

Fetal Effects of Preeclampsia

• Reduced maternal blood flow and nutrition through the placenta decreases fetal oxygen.
• Fetal hypoxia may result in meconium passage and fetal distress.
• Intrauterine growth restriction (IUGR) is possible, leading to a long, thin baby with peeling skin.
• Fetal death can occur.

Preeclampsia Treatment

• Focuses on prevention, early detection, and maintaining blood flow to the mother and placenta.
• Prevention:
  • Correcting risk factors
  • Early and regular prenatal care
• Management depends on severity:
  • Mild preeclampsia can be managed at home with monitoring and rest.
  • Severe preeclampsia requires hospitalization.
• Nursing care:
  • Activity restriction: Conserve blood flow to vital organs and the placenta
  • Maternal assessment of fetal activity
  • Blood pressure monitoring 2-4 times daily
  • Daily weight measurement
  • Urine protein check with a dipstick
  • Discontinue smoking and alcohol use
  • Balanced diet with sufficient protein
  • Teach signs and symptoms of problems

Drug Therapy for Preeclampsia

• Magnesium sulfate:
  • Anticonvulsant
  • May reduce hypertension and inhibit uterine contractions
  • Therapeutic level: 4-8 mg/dL
  • Antidote: Calcium gluconate
• Antihypertensive medications to reduce blood pressure:
  • Hydralazine
  • Labetalol
  • Nifedipine

Nursing Care for Preeclampsia

• Promoting prenatal care
• Helping to cope with therapy
  • Importance of reduced activity and rest
  • Positioning on the left side
• Caring for the acutely ill woman:
  • Quiet, low-light environment
  • Bed rest on the left side
  • Padded side rails
  • Avoid stimulation
  • Limit visitors
  • Suction equipment available
  • Steroids may be given to aid fetal lung maturity
• If a seizure occurs:
  • Turn the mother on her side
  • Protect the woman from injury
  • Place an oral airway
  • Oxygen by face mask
  • Reorient the woman
  • Continuous fetal monitoring
• Providing postpartum care:
  • Monitor for pulmonary edema, renal failure, and convulsions.
  • Close monitoring for 48 hours after delivery.
  • Labetalol is the preferred antihypertensive for breastfeeding mothers.

Rh Incompatibility

• Rh-negative is a recessive trait.
  • Erythrocytes have no antigens.
  • Cannot receive Rh-positive blood because Rh-positive blood has antigens.
• Rh-positive is a dominant trait.
  • Erythrocytes have antigens.
  • Can receive Rh-negative blood without complications.
• Incompatibility occurs between an Rh-negative mother and an Rh-positive fetus.
• The mother develops antibodies against Rh-positive antigens, which can damage subsequent Rh-positive fetuses.
• Prevention with RhoGAM:
  • Given after delivery of an Rh-positive infant.
  • Administered at 28 weeks of pregnancy.
  • Given after spontaneous/therapeutic abortion, amniocentesis, and bleeding during pregnancy.

ABO Incompatibility

• Most commonly seen between a mother with O blood type and an A or B group infant.
• The mother develops antibodies against A or B antigens.
• Generally less severe than Rh incompatibility.
• Anemia and jaundice may be present.

Early Pregnancy Loss

• Educational information for patients and families:
  • Explanation of diagnostic tests and procedures.
  • Discussion of stages of grief.
  • Open communication techniques.

Diabetes Mellitus during Pregnancy

• Classification:
  • Type 1: Exists before pregnancy, insulin deficiency.
  • Type 2: Exists before pregnancy, insulin resistance.
  • Pregestational diabetes mellitus: Type 1 or Type 2 diabetes present before pregnancy.
  • Gestational Diabetes Mellitus (GDM): Glucose intolerance diagnosed during pregnancy.
• Pathophysiology:
  • Pancreas does not produce enough insulin.
  • Glucose accumulates in the blood (hyperglycemia).
  • Increased thirst (polydipsia).
  • Dehydration, polyuria (increased urination), and glycosuria (glucose in urine).
  • Body metabolizes proteins and fat, leading to ketoacidosis.
  • Weight loss despite eating large amounts of food (polyphagia).
• Effect of pregnancy on glucose metabolism:
  • Pregnancy alters metabolism to provide glucose for the fetus.
  • Placental hormones increase insulin resistance and speed up insulin breakdown.
  • Increased insulin secretion required to maintain normal carbohydrate metabolism.
  • Hyperglycemia can occur.
  • Hypoglycemia can occur between meals and during the night.
  • Increased tissue resistance to maternal insulin action in the second and third trimesters.
  • Risk of fetal organ damage from hyperglycemia.
  • Newborn at risk for hypoglycemia after birth due to change in insulin environment.

Maternal Effects of Preexisting Diabetes Mellitus

• Pregnancy with pre-existing diabetes can increase the risk of spontaneous abortions, congenital malformations, gestational hypertension, preterm labor, and premature rupture of membranes.
• Vaginal infections like UTIs are more common due to the presence of glucose in urine, providing a nutrient-rich medium for bacterial growth.
• Moms are at higher risk for developing ketoacidosis.
• Fetal macrosomia (weight over 4,000g) can lead to difficult labor, shoulder dystocia and injury to the birth canal.

Fetal and Neonatal Effects of Preexisting Diabetes Mellitus

• Congenital malformations: Most common include neural tube defects, caudal regression syndrome, and cardiac defects.
• Fetal macrosomia: Elevated blood glucose stimulates fetal insulin production, which acts as a growth hormone.
• Intrauterine growth restriction: A possible consequence of poor maternal control.
• Birth injury: Possible consequence of fetal macrosomia.
• Delayed lung maturation: Decreased surfactant production due to a lack of cortisol production.
• Neonatal hypoglycemia: Maternal glucose is abruptly withdrawn at birth, leading to insulin exceeding available glucose.
• Neonatal hypocalcemia: Maternal calcium supply is abruptly stopped, resulting in a decrease in total and ionized calcium.
• Neonatal polycythemia: Caused by hypoxia.
• Neonatal hyperbilirubinemia and jaundice: Fetal hypoxia leads to increased erythrocyte production, which are broken down at birth, releasing bilirubin.
• Perinatal death: Increased risk is associated with pre-existing diabetes.

Risk Factors for Gestational Diabetes Mellitus (GDM)

• Maternal obesity greater than 198 lbs.
• Large infant weight.
• Maternal age older than 25 years.
• Previous unexplained stillbirth or infant with congenital abnormalities.
• History of GDM in a previous pregnancy.
• Fasting glucose more than 126 mg/dL or postmeal glucose more than 200 mg/dL.

Treatment of Gestational Diabetes Mellitus (GDM)

• Identification: Glucose Tolerance Test (GTT) is routinely performed at 24-28 weeks of gestation, or earlier if risk factors exist.
• Diet modifications: Balanced food intake divided into meals and snacks to maintain stable blood glucose levels.
• Blood glucose monitoring: Multiple times a day as directed and HgbA1C every 3 months, lower numbers indicate better glucose control.
• Monitoring of ketones: Urine ketones should be checked to identify the need for more carbohydrates. Ketouria with hyperglycemia requires prompt evaluation for diabetic ketoacidosis.
• Insulin administration: Oral hypoglycemic agents like Glyburide and Metformin can be used, but may need to be supplemented with injectable insulin. Dosage changes throughout pregnancy are common.
• Exercise: Levels should be prescribed by a healthcare professional and closely monitored. Exercise after meals is preferred to prevent hypoglycemia.
• Fetal Assessment: Ultrasound can identify IUGR, macrosomia, polyhydramnios, and oligohydramnios. Non-stress test, contraction stress test, and biophysical profile can identify placental function issues.
• Care during labor: Dextrose IV plus regular insulin may be given. Glucose levels are monitored hourly, and insulin is adjusted on a sliding scale.
• Care of the neonate: Monitoring for hypoglycemia, respiratory distress, birth injuries, and other complications from GDM.

Nursing Care for Women with Preexisting Diabetes Mellitus

• Teaching self-care: Educate on how diabetes management changes during pregnancy, monitoring blood glucose levels, signs of hypoglycemia and hyperglycemia, insulin administration, diet, exercise, etc.
• Providing emotional support: Help expectant mothers express anxieties and fears. Emphasize that close monitoring is temporary.
• Encouraging breastfeeding: Exclusive breastfeeding has lower risk of developing diabetes later in life.

Postpartum Contraception

• Barrier methods or IUDs are preferred.
• Oral contraceptives increase blood clot and cardiac problems, which can be elevated in women with GDM.

Heart Disease During Pregnancy

• A small percentage of pregnant women are affected.
• Pathophysiology: Physiological strain on the heart due to increased heart rate, blood volume, and cardiac output.
• Manifestations: Increased clotting factors predispose women to thrombosis. Congestive heart failure with symptoms such as orthopnea, persistent cough, moist lung sounds, difficulty breathing on exertion, palpitations, fatigue or fainting on exertion, and severe pitting edema.
• Treatment: Under the care of a cardiologist and obstetrician. Frequent antepartum visits, weight management, preventing anemia, and limiting physical activity.
• Drug therapy: Heparin to prevent clot formation, beta-adrenergic blocking drugs for hypertension and dysrhythmias, diuretics, digitalis, and antiarrhythmic medications under careful supervision.

Nursing Care for Women with Heart Disease During Pregnancy

• Educate on changes in regime.
• Monitor laboratory testing for heparin therapy.
• Educate on signs of excessive anticoagulants.
• Teach signs of congestive heart failure.
• Identify ways to obtain rest and avoid exertion in extreme temperatures.
• Help plan diets that provide needed calories without excessive weight gain.
• Discuss stressors and help reduce them.
• Monitor for signs of dyspnea, tachycardia, tachypnea, and abnormal breath sounds.
• Report postpartum bradycardia for evaluation.

Anemia During Pregnancy

• Anemia reduces the blood's ability to carry oxygen to cells. Hemoglobin levels below 10.5 g/dL (second trimester) and 11 g/dL (first and third trimesters) indicate anemia.
• Manifestations: Fatigue, decreased energy, pale skin and mucous membranes, shortness of breath, pounding heart, and rapid pulse.
• Nutritional anemias: Iron deficiency and folic acid deficiency.

Iron Deficiency Anemia

• Pregnant women require additional iron for increased blood volume, transfer to the fetus, and blood loss during birth.
• Cells are small (microcytic) and pale (hypochromic).
• Iron supplements are commonly used.
• High iron foods: Meats, chicken, fish, liver, legumes, green leafy vegetables, whole or enriched grains, nuts, blackstrap molasses, tofu, eggs, dried fruit.
• High Vitamin C foods: Citrus fruits and juices, strawberries, cantaloupe, cabbage, green and red peppers, tomatoes, potatoes, green leafy vegetables.
• Treatment: Oral elemental iron for 3 months after anemia is corrected.

Folic Acid Deficiency Anemia

• Often coexisting with iron deficiency.
• Large, immature RBCs (megablastic anemia).
• Prevention: Folic acid is crucial for fetal growth and development. Daily supplementation (400-800 mcg) is recommended for all women of childbearing age.
• Treatment: Supplementation because diet alone is insufficient.

Genetic Anemias

• Sickle cell disease and thalassemia.

Sickle Cell Disease

• Hemoglobin becomes distorted into a sickle shape during episodes of hypoxia or acidosis.
• Autosomal recessive trait.
• Pregnancy may cause a sickle cell crisis.
• Risk to the fetus includes occlusion of vessels supplying the placenta, leading to preterm birth, growth restriction, and fetal death.
• Treatment: Frequent evaluation of fetal growth, placental function, and anemia management during prenatal care.
• Nursing care: Oxygen and fluids during labor to prevent crisis. Genetic counseling. Prevent dehydration and activities that cause hypoxia.

Thalassemia

• Genetic trait causing an abnormality in the alpha or beta chain of hemoglobin.
• Beta chain variety is more prevalent in the United States.
• Beta-thalassemia minor: Usually mild anemia and rarely affects the fetus.
• Beta-thalassemia major (Cooley’s anemia): Inheriting one abnormal gene from each parent.
• Iron supplementation can cause overload in women with beta-thalassemia.
• Nursing care: Avoid infection exposure, report symptoms promptly.

Viral Infections

• Viral infections often have no effective therapy during pregnancy and can be dangerous for both the mother and fetus.
• Immunizations can help prevent some viral infections during pregnancy.

Cytomegalovirus (CMV)

• CMV is a herpes infection that is sexually transmitted.
• CMV is often asymptomatic in the mother; however, a symptomatic mother may be given immunoglobulin during pregnancy.
• Infected infants can face several serious problems:
  • Intellectual impairment
  • Seizures
  • Blindness
  • Deafness
  • Dental abnormalities
  • Petechiae
• CMV treatment:
  • Primary prevention: Hand washing.
  • Therapeutic pregnancy termination if CMV is discovered early in pregnancy.
  • Antiviral medications (Ganciclovir or valganciclovir) can help with improving the developmental outcome in newborns.

Rubella

• Mild viral disease with a low fever and rash.
• Rubella can be destructive to the developing fetus.
• Effects of rubella on the embryo/fetus:
  • Microcephaly (small head size)
  • Intellectual impairment
  • Congenital cataracts
  • Deafness
  • Cardiac defects
  • IUGR
• Treatment and nursing care:
  • Immunization against rubella infections; even after immunization, some women are still susceptible.
  • If a woman is immunized, she should not become pregnant for at least one month.
  • Nurses should check postpartum women’s charts for rubella immunity and notify the health care provider if the woman is not immune.

Herpesvirus

• Herpes 1 is more likely to cause fever blisters or cold sores.
• Herpes 2 is more likely to cause genital herpes.
• After the initial infection, the virus becomes dormant in the nerves and may be reactivated later as a recurrent infection.
• Initial infection during the first half of pregnancy may cause spontaneous abortion.
• Infants can be infected with herpes in one of two ways:
  • The virus ascends into the uterus after the membranes rupture.
  • The infant has direct contact with infectious lesions during vaginal delivery.
• Neonatal herpes can be localized or widely disseminated.
• Disseminated neonatal herpes has a high mortality rate, and survivors may have neurologic complications.
• Treatment and nursing care:
  • Avoid contact with lesions to prevent neonatal herpes infection. If lesions are active when the membranes rupture or labor begins, a cesarean delivery may be required.
  • Cesarean delivery is not necessary if there are no active genital lesions.
  • Breastfeeding is safe if there are no lesions on the breasts.
  • Antiviral medication (acyclovir) may be given orally during pregnancy to reduce the occurrence of active lesions at the time of birth. Infected infants may receive acyclovir and be closely monitored.

Hepatitis B

• Transmitted through blood, saliva, vaginal secretions, semen, and breast milk; can cross the placental barrier.
• Can be asymptomatic or cause acute illness with chronic low-grade fever, anorexia, nausea, and vomiting. Some individuals become chronic carriers.
• The fetus may be infected transplacentally or by contact at birth with blood and vaginal secretions.
• The infant may become a chronic carrier and a continuous source of infection.
• High-risk individuals for Hepatitis B:
  • Intravenous drug users.
  • Individuals with multiple sex partners.
  • People with repeated infections with sexually transmitted infections.
  • Health care workers with occupational exposure to blood products and needle sticks.
  • Hemodialysis patients.
  • Recipients of multiple blood transfusions or other blood products.
  • Household contact with a hepatitis carrier or hemodialysis patient.
  • Individuals arriving from countries where there is a higher incidence of the disease.

Hepatitis B Treatment and Nursing Care

• All women should be screened for hepatitis B during prenatal care; screening should be repeated during the third trimester for women in high-risk groups.
• Infants born to women who are positive for hepatitis B should receive a single dose of hepatitis B immune globulin (for temporary immunity right after birth) followed by hepatitis B vaccine (for long-term protection).
• Routine hepatitis vaccination is given at birth, 1-2 months, and 6-18 months for all infants.
• Delay injections until after the first bath so that blood and secretions are removed to avoid introducing them under the skin.

Sexually Transmitted Infections

Human Immunodeficiency Virus (HIV)

• HIV is the causative organism of acquired immunodeficiency syndrome.
• The virus cripples the immune system, making the person susceptible to infections that eventually result in death.
• Transmission of HIV:
  • Unprotected sexual contact with an infected person.
  • Sharing a needle with an infected person.
  • Mucous membrane exposure to infected body fluids.
  • Perinatal exposure:
    • Transplacentally.
    • Through contact with infected maternal secretions at birth.
    • Through breast milk.
• There is a 20-40% chance of transmission of the virus to her fetus perinatally.
• Infants born to an HIV+ woman will be HIV+ at birth because maternal antibodies to the virus pass through the placenta to the infant. Infants who are truly infected can be identified after 3-6 months.

Nursing Care for HIV

• Counseling should be provided to all women concerning behaviors that place them at risk for contracting HIV.
• HIV testing is recommended for all prenatal patients.
• Education that transmission of HIV to the newborn can be reduced with appropriate drug therapy.
• Pregnant women with AIDS are more susceptible to infections, and the fetus may develop an opportunistic infection after birth.
• Breastfeeding is contraindicated for mothers who are HIV+.
• Zidovudine (ZDV) starts 6-12 hours after birth and is continued for 6 weeks to prevent transmission of the virus from mother to infant.
• Assist the mother to cope with the anxiety that is almost certain to occur about whether the neonate is infected.
• Social Services can help the family with the care of the child at home.

Nonviral Infections

Toxoplasmosis

• Caused by toxoplasma gondii, a parasite that may be acquired by contact with cat feces or raw meat and transmitted through the placenta.
• The woman is usually asymptomatic or has mild symptoms.
• Fetal effects:
  • Low birth weight.
  • Enlarged liver and spleen.
  • Jaundice.
  • Anemia.
  • Inflammation of eye structures.
  • Neurologic damage.

Toxoplasmosis Treatment and Nursing Care

• Treatment of the mother reduces the risk of congenital infections.
• Pyrimethamine and sulfadiazine are used after the first trimester.
• Leucovorin after 18 weeks gestation.
• Infants are treated with pyrimethamine, sulfadiazine, and leucovorin for 1 year, which may reduce the severity of the congenital effects of the disease.
• Cook all meat thoroughly.
• Wash hands and all kitchen surfaces after handling raw meat.
• Avoid touching the mucous membranes of the eyes or mouth while handling raw meat.
• Avoid uncooked eggs and unpasteurized milk.
• Wash fresh fruits and vegetables well.
• Avoid material contaminated with care feces, such as litter boxes, sandboxes, and garden soil.

Group B Streptococcus Infection (GBS)

• Leading cause of perinatal infections that result in a high neonatal mortality rate.
• The organism can be found in the woman’s rectum, vagina, cervix, throat, or skin.
• Colonized women are asymptomatic, but the infant may be infected through contact at birth with vaginal secretions.
• Risk is greater if the woman has a long labor or premature rupture of membranes.
• GBS is a significant cause of maternal postpartum infection, especially after a cesarean birth.
• Diagnosis of GBS is confirmed by vaginal or rectal culture.
• Manifestations include an elevated temperature within 12 hours after delivery, tachycardia, and abdominal distention.
• GBS can be fatal for the infant.
• An infant may have either early-onset (before 7 days) or late-onset (after 7 days) GBS infection.

GBS Prevention and Treatment

• Rectal and lower vaginal cultures are routinely taken at 35-37 weeks gestation.
• All positive cultures require antibiotic treatment during pregnancy, labor, and the newborn is treated with antibiotics at birth.
• High-risk factors such as previous history of GBS infection, or fever greater than 100F during labor necessitates antibiotic treatment to prevent GBS infection.

Tuberculosis

• Pregnant women are routinely screened.
• If positive, the woman should have a CXR with an abdominal lead apron shield, and sputum cultures that are positive for the bacterium confirm diagnosis.
• Presents with fatigue, weakness, loss of appetite and weight, fever, and night sweats.
• The newborn may acquire the disease by contact with an untreated mother after birth.

Tuberculosis Treatment and Nursing Care

• Public health department is notified of positive cultures and chest x-ray results.
• The TB+ mother and infant are to be kept in different rooms after discharge, and the discharge plans must be approved before discharge.
• Pregnant women with active TB are treated with:
  • Isoniazid (INH) and rifampin for 9 months.
  • Pyridoxine (Vit B6) to reduce the risk of peripheral neuritis.
  • Ethambutol (EMB) may be prescribed for drug-resistant TB.
• Infants may receive preventive therapy with isoniazid for 3 months after birth.
• Patient education should cover how the organism is transmitted and the importance of continuing antitubercular drugs consistently for the full course of therapy. Incompletely treated TB is a significant cause of multi-drug resistant organisms.
• Modern antitubercular drugs usually render the sputum culture negative within 2 weeks.

Urinary Tract Infections

• The urinary tract is usually self-cleaning because of the acidic nature of urine that inhibits the growth of bacteria and flushes them out of the body with each voiding. Pregnancy alters this action as pressure on urinary structures keeps the bladder from emptying completely, and the ureters dilate and lose motility under the relaxing effect of progesterone. Urine that is retained in the bladder becomes more alkaline, providing a favorable environment for the growth of bacteria.
• Asymptomatic infection may eventually cause cystitis if left untreated and can cause pyelonephritis.
• Cystitis manifestations:
  • Burning with urination.
  • Increased frequency and urgency of urination.
  • Normal or slightly elevated temperature.
• Pyelonephritis is a particularly serious infection in pregnancy and manifests as:
  • High fever is dangerous to the fetus because it increases fetal metabolism, which increases fetal oxygen needs to levels that the mother cannot readily supply.
  • Chills.
  • Flank pain or tenderness.
  • Nausea and vomiting.
  • Can lead to maternal hypertension due to damage to the kidney, chronic renal disease, and premature labor.

UTI Treatment

• UTI treated with oral antibiotics for 7 days.
• Asymptomatic UTI treated with oral antibiotics for 10 days.
• Pyelonephritis treated with multiple antibiotics, initially IV.
• Cystitis treated with oral antibiotics for 7 days.

UTI Nursing Care

• Teach the importance of wiping from front to back after urination or a bowel movement; also when doing perineal care or applying or removing peripads.
• Adequate fluid intake promotes frequent voiding. At least 8 glasses of liquid per day and exclude caffeine-containing beverages.
• Cranberry juice will increase the acidity of the urine.
• Sexual intercourse mildly irritates the bladders and urethra. Urinating before and after intercourse reduces this irritation.
• Use a water-soluble lubricant to reduce periurethral irritation.
• Teach signs and symptoms of cystitis and pyelonephritis so that they can seek treatment early.

Test your knowledge on essential practices and potential hazards during pregnancy. This quiz covers topics such as maternal lifestyle behaviors, conditions affecting pregnancy, and important medical procedures. Answer questions about monitoring fetal health and recognizing warning signs for a healthy pregnancy.