Pregnancy Complications Chapters 19-20 PDF

Chapter 19 Pregnancy Complications Conditions Associated with Early Bleeding During Pregnancy **spontaneous abortion, fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency. Conditions associated with late bleeding include placenta previa, placental abruption,...

Chapter 19 Pregnancy Complications Conditions Associated with Early Bleeding During Pregnancy **spontaneous abortion, fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency. Conditions associated with late bleeding include placenta previa, placental abruption, and placenta accreta,** Spontaneous Abortion the loss of an early pregnancy from natural causes, usually before week 20 of gestation. The most common cause for first-trimester miscarriage is fetal genetic abnormalities, usually unrelated to the mother. maternal disease is more likely the cause in the second trimester. Women experiencing a first-trimester miscarriage at home without a (D&C) to require frequent monitoring of hCG levels to validate that all the conceptus tissues have been expelled. Women going through a second-trimester miscarriage are admitted to the hospital to have an augmented labor and delivery. When a pregnant woman reports vaginal bleeding she must be seen as soon as possible. Ask about the color of the vaginal bleeding (bright red is significant) and the amount, the frequency with which she is changing her peripads, and the passage of any clots or tissue. Instruct her to save any tissue or clots passed and bring them with her to the health care facility. When she gets to facility assess her vital signs and observe the amount, color, and characteristics of the bleeding. Ask her to rate her current pain level, using an appropriate pain assessment tool. Also evaluate the amount and intensity of the woman's abdominal cramping or contractions and assess the woman's level of understanding about what is happening to her. expect to administer RhoGAM within 72 hours after the abortion is complete if she is Rh negative. Types of Spontaneous Abortion Threatened abortion: Vaginal bleeding (often slight) early in a pregnancy, No cervical dilation or change in cervical consistency, Mild abdominal cramping ,Closed cervical os, No passage of fetal tissue Diagnosis: Vaginal ultrasound to confirm if sac is empty, Declining maternal serum hCG and progesterone levels to provide additional information about viability of pregnancy Therapeutic management: Conservative supportive treatment Possible reduction in activity in conjunction with nutritious diet and adequate hydration Inevitable abortion: Vaginal bleeding (greater than that associated with threatened abortion), Rupture of membranes, Cervical dilation, Strong abdominal cramping, Possible passage of products of conception Diagnosis: Ultrasound and hCG levels to indicate pregnancy loss Therapeutic management: Vacuum curettage if products of conception are not passed to reduce risk of excessive bleeding and infection, Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed) Incomplete abortion (passage of some of the products of conception): Intense abdominal cramping ,Heavy vaginal bleeding, Cervical dilation Diagnosis: Ultrasound confirmation that products of conception still in uterus Therapeutic management: Client stabilization Evacuation of uterus via D&C or prostaglandin analog Complete abortion (passage of all products of conception) History of vaginal bleeding and abdominal pain, Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding Diagnosis: Ultrasound demonstrating an empty uterus Therapeutic management: No medical or surgical intervention necessary Follow-up appointment to discuss family planning Missed abortion (nonviable embryo retained in utero for at least 6 weeks) Absent uterine contractions, Irregular spotting Possible progression to inevitable abortion Diagnosis: Ultrasound to identify products of conception in uterus Evacuation of uterus Therapeutic management: (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention Recurrent abortion History of three or more consecutive spontaneous abortions, Not carrying the pregnancy to viability or term Diagnosis: Validation via client's history No diagnostic ultrasound findings Therapeutic management; Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems) Cervical cerclage in second trimester if incompetent cervix is the cause Spontaneous Abortion: Nursing Management Explaining some of the causes of spontaneous abortions can help the woman understand what is happening and may allay her fears and guilt that she did something to cause the pregnancy loss. Many women experience an acute sense of loss and go through a grieving process with a spontaneous abortion. Providing sensitive listening, counseling, and anticipatory guidance to the woman and her family will allow them to verbalize their feelings and ask questions about future pregnancies. Encourage friends and family to be supportive but give the family space and time to work through their loss. Referral to a community support group for parents who have experienced a loss can be helpful during this grief process Ectopic Pregnancy A ruptured ectopic pregnancy is a medical emergency; therefore, prediction of any tubal rupture before its occurrence is extremely important. It is a potentially life-threatening condition and involves pregnancy loss most cases are the result of tubal scarring secondary to pelvic inflammatory disease (PID). Organisms such as Neisseria gonorrhea and Chlamydia trachomatis preferentially attack the fallopian tubes, producing silent infections. Other associated risk factors include previous tubal surgery, infertility, PID, previous pregnancy loss (induced or spontaneous), use of an intrauterine contraceptive system, previous ectopic pregnancy, uterine fibroids, sterilization, smoking (which alters tubal motility), history of multiple sexual partners, use of progestin-only oral contraceptives, douching, and exposure to diethylstilbestrol (DES) in non-ruptured ectopic pregnancies, laparoscopic surgery or intramuscular (IM) methotrexate administration are safe and effective treatments. The diagnosis of ectopic pregnancy can be challenging because many women are asymptomatic before tubal rupture. Symptoms of ectopic pregnancy are abdominal pain, amenorrhea, and vaginal bleeding. Physical exam findings include a tender abdomen, painful vaginal exam, cervical motion tenderness, and a possible adnexal mass. a transvaginal ultrasound is used to visualize the misplaced pregnancy With early diagnosis, most women with ectopic pregnancy could be treated with methotrexate, but patient must be hemodynamically stable. a single-dose IM injection of methotrexate (Rheumatrex, Trexall) is given with outpatient follow-up. Methotrexate is ordered based on the client's body surface area. A decreasing beta-hCG level is highly predictive of treatment success With a ruptured ectopic pregnancy, surgery is necessary as a result of possible uncontrolled hemorrhage. the woman's beta-hCG level is monitored until it is undetectable to ensure that any residual trophoblastic tissue that forms the placenta is gone. Symptoms usually begin at about the 7th or 8th week of gestation. A missed menstrual period, adnexal fullness, spotting, and tenderness may indicate an unruptured tubal pregnancy. As the tube stretches, the pain increases. Pain may be unilateral, bilateral, or diffuse over the abdomen With rupture symptoms may worsen and include severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity; feelings of faintness; referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation; hypotension; marked abdominal tenderness with distention; and hypovolemic shock Gestational Trophoblastic Disease all trophoblastic lesions produce hCG, which serves as a clinical marker for the presence of persistent or progressive trophoblastic disease. These cells would normally develop into the placenta during pregnancy. Gestational tissue is present, but the pregnancy is not viable. A complete mole contains no fetal tissue and develops from an "empty egg," which is fertilized by a normal sperm. It is not viable and dies. No circulation is established, and no embryonic tissue is found and its associated with the development of choriocarcinoma. Patient will present with Brownish vaginal bleeding/spotting, Expulsion of grape-like vesicles, anemia, excessively enlarged uterus, preeclampsia, and hyperemesis. Can become choriocarcinoma, but highly responsive to chemo. The first symptoms of choriocarcinoma is shortness of breath, indicative of metastasis to the lungs because the lung is the most common site of metastases. The partial mole has a triploid karyotype (69 chromosomes) because two sperm cells have fertilized the ovum. Rarely transform into choriocarcinoma. Patient presents with the clinical features of a missed or incomplete abortion, including Brownish vaginal bleeding/spotting, Expulsion of grape-like vesicles, and a small- or normal-sized-for-date uterus. Treatment consists of immediate evacuation of the uterine contents. D&C is used. Serial levels of hCG are used to detect residual trophoblastic tissue for 1 year. Strong recommendation to avoid pregnancy for 1 year because the pregnancy can interfere with the monitoring of hCG levels and get chest x ray every 6 months. hCG levels are chcked every week until undetectable for three consecutive weeks; then serial hCG levels monthly for 1 year Placenta Previa occurs during the last two trimesters of pregnancy. It is initiated by implantation of the embryo in the lower uterus, perhaps due to uterine endometrial scarring or damage in the upper segment, which may incite placental growth in the unscarred lower uterine segment. the cervical os may become covered by the developing placenta. Placental vascularization is defective, allowing the placenta to attach directly to the myometrium (accreta), deeply attach to the myometrium (increta), or infiltrate the myometrium (percreta). If the mother and fetus are both stable, therapeutic management may involve expectant ("wait-and-see" or watchful waiting) care. This care can be carried out at home (bed rest) or on a prenatal unit in the health care facility. painless, bright red vaginal bleeding occurring during the second or third trimester. The initial bleeding is usually not profuse and it ceases spontaneously, only to recur again. The first episode of bleeding occurs at 27 to 32 weeks' gestation Do pad count, avoid vaginal exams, and monitor FHR, fetus may be in the breech or transverse lie with no presentation Placental Abruption early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage. Abruption occurs when the maternal vessels tear away from the placenta and bleeding occurs between the uterine lining and the maternal side of the placenta. As the blood accumulates, it pushes the uterine wall and placenta apart. If the abruption continues, loss of placental function results in fetal hypoxia and possibly fetal death. Most of the cases originate from maternal hypertension and preeclampsia. Blood is dark, constant uterine tenderness and uterus is firm/rigid, baby can be I any fetal presentation- it has nothing to do with he abruption \*\*Grade 0: Clinically unrecognized before birth, diagnosis is made retrospectively after birth Mild \*\*(grade 1): No sign of vaginal bleeding or minimal bleeding (less than 500 mL), marginal separation (10% to 20%), tender uterus, no coagulopathy, no signs of shock, no fetal distress Moderate \*\*(grade 2): No sign of bleeding or moderate bleeding (1,000 to 1,500 mL), moderate separation (20% to 50%), continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia, evidence of fetal distress Severe \*\*(grade 3): Absent to moderate bleeding (more than 1,500 mL), severe separation (more than 50%), profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal blood pressure, significant maternal tachycardia and the development of DIC Emergency measures include starting two large-bore IV lines with normal saline or lactated Ringer's solution to combat hypovolemia, obtaining blood specimens for evaluating hemodynamic status values and for typing and cross-matching, and frequently monitoring fetal and maternal well-being. cesarean birth is done immediately if fetal distress is evident. If the fetus is not in distress, close monitoring continues with birth planned at the earliest signs of fetal distress. Laboratory studies that assist in the diagnosis of DIC include: Decreased fibrinogen and platelets, Prolonged PT and aPTT, Positive D-dimer tests and fibrin (split) degradation products (objective evidence of the simultaneous formation of thrombin and plasmin) !!!! Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock!!!! place mother on strict bed rest and in a left lateral position to prevent pressure on the vena cava. This position provides uninterrupted perfusion to the fetus. Expect to administer oxygen therapy via nasal cannula to ensure adequate tissue perfusion. Assess fundal height for changes. An increase in size would indicate bleeding. Monitor the amount and characteristics of any vaginal bleeding as frequently as every 15 to 30 minutes **symptoms of DIC = bleeding gums, tachycardia, oozing from the IV insertion site, and petechiae- administer blood products as ordered if DIC occurs.!!!!** Hyperemesis Gravidarum severe form of nausea and vomiting of pregnancy associated with significant costs and psychosocial impacts. results in dehydration, weight loss, electrolyte imbalance, and the need for hospitalization, decreased placental blood flow, decreased maternal blood flow, and acidosis. The peak incidence is at 8 to 12 weeks of pregnancy, and symptoms usually resolve by week 20. In hyperemesis gravidarum, the hCG levels are often higher and extend beyond the first trimester. Usually dietary/lifestyle changes are the FIRST LINE of treatment. If this fails then HOSPITALIZATION is necessary. The first choice for fluid replacement is generally normal saline and Oral food and fluids are withheld for the first 24 to 36 hours to allow the gastrointestinal tract to rest. Diclegis is a first-line therapy that may be sufficient in controlling symptoms. In addition, vitamin B6 (pyridoxine) and doxylamine should be given. If the client does not improve after several days of bed rest, "gut rest," IV fluids, and antiemetics, total parenteral nutrition or feeding through a percutaneous endoscopic gastrostomy tube is instituted to prevent malnutrition. Monitor the rate of infusion to prevent overload \*\*\*\*\*\*\*\*\*\*Avoid noxious stimuli, such as strong flavors, perfumes, or strong odors like frying bacon, that might trigger nausea and vomiting. Avoid tight waistbands to minimize pressure on abdomen. Eat small, frequent meals throughout the day. Separate fluids from solids by consuming fluids in between meals. Avoid lying down or reclining for at least 2 hours after eating. Eat when you are hungry, regardless of normal mealtimes. Drink herbal teas containing peppermint or ginger. Eat foods that settle the stomach, such as dry crackers, toast, or soda. Hypertensive Disorders of Pregnancy (All hypertensive disorders including HELLP, including signs and symptoms, management, nursing assessment, and nursing management) \*\*Chronic hypertension: Hypertension that exists prior to pregnancy or that develops before 20 weeks' gestation with blood pressure readings greater than 140/90 mm Hg \*\*Gestational hypertension: A new-onset blood pressure elevation (140/90 mm Hg) identified after 20 weeks' gestation without proteinuria; blood pressure returns to normal by 12 weeks' postpartum \*\*Preeclampsia/eclampsia and HELLP: Most common hypertensive disorder of pregnancy, which develops with proteinuria after 20 weeks' gestation; a multisystem disease process, which is accompanied by at least one of the following: proteinuria, elevated creatinine, liver involvement, epigastric or abdominal pain, neurologic complications, hematologic complications, and uteroplacental dysfunction; eclampsia occurs when seizure activity develops \*\*Chronic hypertension with superimposed preeclampsia: develops after 20 weeks' gestation and occurs in approximately 25% of pregnant women with increased maternal and fetal morbidity rates Chronic hypertension is defined as blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. mild/moderate 140 to 159 systolic and diastolic 90 to 109 or severe higher than 160 systolic or diastolic higher than 110. Mild to moderate hypertension does not require antihypertensive therapy during pregnancy gestational hypertension is nonproteinuric hypertension of pregnancy, in which the pathophysiologic disturbances of the preeclampsia syndrome do not develop before giving birth. Gestational hypertension is a temporary diagnosis for hypertensive pregnant women who do not meet the criteria for preeclampsia. characterized by BP (higher than 140/90 mm Hg) on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. Preeclampsia can be described as new-onset hypertension accompanied by proteinuria and/or maternal organ dysfunction that targets the cardiovascular, hepatic, renal, and central nervous systems (CNS). Preeclampsia can present with severe features, or it may not. Mild preeclampsia management: Bed rest, daily BP monitoring, and fetal movement counts Hospitalization; IV magnesium sulfate during labor, nutritional diet with no sodium restriction, drink six to eight 8-oz glasses of water daily Severe preeclampsia management: Hospitalization; oxytocin and magnesium sulfate; preparation for birth, may develop suddenly or within days and bring with it high blood pressure of more than 160/110. complete bed rest in the left lateral lying position. Ensure that the room is dark and quiet to reduce stimulation. Give sedatives as ordered to encourage quiet bed rest Eclampsia management: Seizure management, magnesium sulfate, antihypertensive agents; birth once seizures controlled !!!!!The absolute BP of 140/90 should be obtained on two occasions 4 to 6 hours apart to be diagnostic of preeclampsia. Proteinuria is defined as 300 mg or more of urinary protein per 24 hours or more than 1+ protein by chemical reagent strip or dipstick of at least two random urine samples collected at least 4 to 6 hours apart with no evidence of urinary tract infection (UTI)!!! Nursing management of the woman with preeclampsia focuses on close monitoring of blood pressure and ongoing assessment for evidence of disease progression. Throughout the client's pregnancy, fetal surveillance is essential. At every prenatal visit, assess the fetal heart rate with a Doppler device. Also check a clean-catch urine specimen for protein using a dipstick. if levels are 1 to 2+ or greater, a 24-hour urine collection is completed After birth of the newborn, continue to monitor the client for signs and symptoms of preeclampsia/eclampsia for at least 48 hours. Expect to continue to administer magnesium sulfate infusion for 24 hours to prevent seizure activity, and monitor serum magnesium levels for toxicity. **HELLP Syndrome: hemolysis, elevated liver enzymes, and low platelet count.** characterized by abnormal vascular tone, vasospasm, and coagulation defects. Can cause complications such as cerebral hemorrhage, retinal detachment, hematoma/liver rupture, DIC, placental abruption, eclampsia, acute renal failure, pulmonary edema, and maternal death can happen. It can present prior to the presence of an elevated blood pressure. Is a severe form of preeclampsia involving hemolysis, thrombocytopenia, and liver dysfunction. occur during the later stages of pregnancy and sometimes after childbirth. Misdiagnosis and delayed recognition of HELLP syndrome are common due to vague and varying presentation. It is unique, as it is a laboratory value-specific diagnosis. Hyperbilirubinemia and jaundice result from liver impairment. Low platelets result from vascular damage, the result of vasospasm, and platelets aggregate at sites of damage, resulting in thrombocytopenia in multiple sites. After this syndrome is diagnosed and the woman's condition is stable, birth of the infant is indicated. Nursing assessment of the woman with HELLP is similar to that for the woman with preeclampsia with severe features. should be transferred to a tertiary care center once she has been assessed and stabilized. Hydramnios too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks. associated with maternal diabetes mellitus and fetal anomalies of development such as upper gastrointestinal obstruction or atresia, neural tube defects, and anterior abdominal wall defects, together with impaired swallowing in fetuses with chromosomal anomalies, such as trisomies 13 and 18 and anencephaly. low 5-minute Apgar scores and increased neonatal birth weight is often seen with these babies. associated with poorer fetal outcomes because of the increased incidence of preterm births, fetal malpresentation, and cord prolapse. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Assess for complaints of discomfort in abdomen, such as being severely stretched and tight. Also note any reports of uterine contractions, which may result from overstretching of the uterus. Assess for shortness of breath resulting from pressure on her diaphragm and inspect her lower extremities for edema, which results from increased pressure on the vena cava. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present. An ultrasound is usually done to measure the pockets of amniotic fluid to estimate the total volume Can cause overdistension and may lead to preterm labor and prolabor rupture of membranes Oligohydramnios decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks' gestation that is associated with poor pregnancy outcomes. may result from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac. Reduction in amniotic fluid reduces the ability of the fetus to move freely without risk of cord compression, which increases the risk for fetal death and intrapartum hypoxia. can be managed on an outpatient basis with serial ultrasounds and fetal surveillance through nonstress testing and biophysical profiles. As long as fetal well-being is demonstrated with frequent testing, no intervention is necessary. If fetal well-being is compromised, however, birth may be planned along with amnioinfusion Leaking in conjunction with a uterus that is small for expected dates of gestation also suggests oligohydramnios. However, the woman may not present with any symptoms. Typically, the reduced volume of amniotic fluid is identified on ultrasound. Premature Rupture of Membranes rupture of membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation. Perinatal risks associated with PPROM may stem from immaturity, including respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus, and necrotizing enterocolitis. Under no circumstances is an unsterile digital cervical examination done until the woman enters active labor to minimize infection exposure. If the fetal lungs are mature, induction of labor is initiated. PROM is not a lone indicator for surgical birth. If the fetal lungs are immature, expectant management is carried out with adequate hydration, reduced physical activity, pelvic rest, and close observation for possible infection, such as with frequent monitoring of vital signs and laboratory test results (e.g., white blood cell count). Corticosteroids may be given to enhance fetal lung maturity if lungs are immature Discharge home (PPROM) if no labor within 48hours Chapter 20 Diabetes Mellitus -- Focus on Gestational Diabetes (Patho, management, assessment, nursing management) pregestational diabetes (alteration in carbohydrate metabolism identified before conception), which includes women with type 1 or type 2 disease, and gestational diabetes, which develops during pregnancy. Early screening, ideally before 13 weeks' gestation, is important to identify pregestational diabetes. If glucose levels are abnormal in the first half of pregnancy, the woman would be diagnosed with pregestational diabetes, not gestational diabetes. prenatal visits occur more frequently (every 2 weeks up to 28 weeks and then twice a week until birth), providing the nurse with numerous opportunities for ongoing assessment, education, and counseling. Nutrient requirements and recommendations for weight gain for the pregnant woman with diabetes are the same as those for the pregnant nondiabetic woman. PATHO: the existence of pancreatic beta cell dysfunction prior to pregnancy and the unmasking of this problem by the development of insulin resistance during pregnancy, which requires enhanced insulin production to maintain normal blood glucose ranges. Normal pregnancy is characterized by increasing peripheral resistance to insulin and a compensatory increase in insulin secretion. Therefore, pregnancy might be viewed as a stress test for the glucose homeostasis mechanisms. Human placental lactogen (hPL), progesterone, cortisol, prolactin, and growth hormone (somatotropin) increase in direct correlation with the growth of placental tissue, rising throughout the last 20 weeks of pregnancy and causing insulin resistance. Subsequently, insulin secretion increases to overcome the resistance of these two hormones. In the pregnant woman without diabetes, the pancreas can respond to the demands for increased insulin production to maintain normal glucose levels throughout the pregnancy If the initial risk assessment is high, rescreening should take place between 24 and 28 weeks. Typically, a one-step screening protocol for gestation diabetes is based on a 75-g, 2-hour glucose tolerance test. If the result is abnormal, a 3-hour glucose tolerance test is done. - Fasting blood glucose level: Less than 95 mg/dL - At 1 hour: Less than 140 mg/dL - At 2 hours: Less than 120 mg/dL - At 3 hours: Less than 95 mg/dL A diagnosis of gestational diabetes can be made only after an abnormal result is obtained on the glucose tolerance test. One or more abnormal values confirm a diagnosis of gestational diabetes. Achieving good metabolic control during the period prior to conception is essential to reducing congenital malformations. The primary goals of care are to maintain glycemic control and minimize the risks of the disease on the fetus. Key aspects of treatment include nutritional management, exercise, insulin regimens, and close maternal and fetal surveillance The goals of preconception care are to: integrate the woman into the management of her diabetes. achieve the lowest glycosylated hemoglobin A1c test results without excessive hypoglycemia. ensure effective contraception until stable glycemia is achieved. identify and evaluate long-term diabetic complications such as retinopathy, nephropathy, neuropathy, cardiovascular disease (CVD), and hypertension. Excellent control of blood glucose as evidenced by normal fasting blood glucose levels and a glycosylated hemoglobin (HbA1c) level is crucial to achieve the best pregnancy outcome. A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. Preconception counseling is important in reducing the risk of congenital malformation. The most common malformations associated with diabetes occur in the renal, cardiac, skeletal, and central nervous systems. Since these defects occur by the eighth week of gestation, preconception counseling is critical. The rate of congenital anomalies in women with pregestational diabetes can be reduced if excellent glycemic control is achieved at the time of conception. Lifestyle modification, nutritional changes, and encouragement of physical activities form the primary mode of therapy for diabetes during pregnancy. Therapeutic management for the woman with gestational diabetes mellitus focuses on tight glucose control. A moderately low-carbohydrate diet with a carbohydrate content of 40% of the calories results in good glycemic control for most. Insulin is calculated based on the woman's weight. Combining intermediate- and short-acting insulin yields the best result for most women. Two insulin doses are given daily with two thirds of the total insulin in the morning to cover energy needs of the active day and one third at night. Generally, insulin doses are reduced in the first trimester to prevent hypoglycemia resulting from increased insulin sensitivity as well as from nausea and vomiting. Short-acting insulins such as lispro (Humalog) and aspart (NovoLog), which do not cross the placenta, may help reduce postprandial hyperglycemia, episodes of hypoglycemia between meals. Target fasting glucose values of 60 to 90 mg/dL and 1-hour postprandial values lower than 140 mg/dL are necessary to provide good glycemic control and good pregnancy outcomes. If the glycemic target is not reached, the use of metformin with lifestyle interventions appears to be a safe alternative to insulin. It remains an option as a second-line treatment in women who refuse insulin or who are unable to administer insulin safely. For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL throughout labor to reduce the likelihood of neonatal hypoglycemia. Maternal surveillance may include: - Urine check for protein (may indicate the need for further evaluation for preeclampsia) and for nitrates and leukocyte esterase (may indicate a urinary tract infection) - Urine check for ketones (may indicate the need for evaluation of eating habits) - Kidney function evaluation every trimester for creatinine clearance and protein levels - Eye examination in the first trimester to evaluate the retina for vascular changes HbA1c every 4 to 6 weeks to monitor glucose trends recommend the following: Avoid weight loss and dieting during pregnancy. Ensure that food intake is adequate to prevent ketone formation and promote weight gain. Be physically active daily. Eat three meals a day plus three snacks to promote glycemic control: 40% of calories from good-quality complex carbohydrates 35% of calories from protein sources 25% of calories from unsaturated fats Small frequent feedings throughout the day are recommended. Bedtime snacks are recommended for all women. Include protein and fat at each meal. Also encourage the woman to participate in an exercise program that includes at least three sessions which last at least 30 minutes daily. Exercise may lessen the need for insulin or dosage adjustments. Monitor blood glucose levels every 1 to 2 hours or more frequently if necessary. Keep a syringe with 50% dextrose solution at the bedside to treat profound hypoglycemia. After birth, monitor blood glucose levels every 2 to 4 hours for the first 48 hours to determine the woman's insulin need, and continue IV fluid administration as ordered. Encourage breast-feeding to assist in maintaining good glucose control. - Perform blood glucose self-monitoring as directed, usually before each meal and at bedtime - Drink eight to 10 8-oz glasses of water each day to prevent bladder infections and maintain hydration - Wear proper, well-fitted footwear when walking to prevent injury - Consider breast-feeding your infant to lower your blood glucose levels. - Avoid simple sugars (cake, candy, cookies), which raise blood glucose levels - Wash your hands frequently to prevent infections - Wear a diabetic identification bracelet at all times Asthma Maternal asthma is associated with an increased risk of infant death, preeclampsia, IUGR, preterm birth, and low birth weight. When a pregnant woman has trouble breathing, her fetus also has trouble getting the oxygen it needs for adequate growth and development. Severe persistent asthma has been linked to the development of maternal hypertension, low birth weight, preterm birth, preeclampsia, placenta previa, uterine hemorrhage, and oligohydramnios. A woman whose asthma is poorly controlled during pregnancy is at increased risk of preterm birth, low birth weight, and stillbirth. The ultimate goal of asthma therapy is to prevent hypoxic episodes to preserve continuous fetal oxygenation; improved maternal and perinatal outcomes are achieved with optimal control of asthma. For exercise-triggered asthma, the use of a bronchodilator 5 to 60 minutes before exercise. Allergy injections may benefit those with allergies and asthma, called allergic asthma. Also called immunotherapy. Laboratory studies usually include a complete blood count with differential (to assess the degree of nonspecific inflammation and identify anemia) and pulmonary function tests (to assess the severity of an attack and to provide a baseline to evaluate the client's response to treatment). Women should be observed using their inhalers and correct use reinforced. Nurses should instruct and strongly urge women to remain on asthma medications during pregnancy. During labor, monitor the client's oxygenation saturation by pulse oximetry and provide pain management through epidural analgesia to reduce stress, which may trigger an acute attack. Continuously monitor the fetus for distress during labor and assess fetal heart rate patterns for hypoxia. Assess the newborn for signs and symptoms of hypoxia. TB The newborn is at risk of postnatally acquired TB if the mother still has active TB at the time of birth. Therefore, prenatal diagnosis and effective treatment of the mother are essential. DO NOT GIVE STREPTOMYCIN- ototoxic to fetus Pregnant women should start treatment as soon as TB is suspected. The woman with active TB should be treated with isoniazid (INH) (300 mg/day) combined with rifampin (600 mg/day) for 9 months. In addition, pyridoxine (vitamin B6) (50 mg/day) should be given to prevent the peripheral neuropathy that is associated with INH treatment. Women who are being treated with antituberculosis drugs may breast-feed. risk factors such as immunocompromised status, recent immigration status, homelessness or overcrowded living conditions, and injectable drug use. Women emigrating from developing countries such as Latin America, Asia, the Indian subcontinent, Eastern Europe, Russia, China, Mexico, Haiti, and Africa. avoiding crowded living conditions, avoiding sick people, maintaining adequate hydration, eating a nutritious, well-balanced diet, keeping all prenatal appointments to evaluate fetal growth and well-being, and getting plenty of fresh air outside. Breast-feeding is not contraindicated during the time the mother is on the medication regimen and should in fact be encouraged. If the mother is untreated for TB at the time of childbirth, she should not breast-feed or be in direct contact with the newborn until at least 2 weeks after starting antitubercular medications. Untreated mothers can be encouraged to pump their milk to feed their newborns until they can breast-feed directly Management of the newborn of a mother with TB involves preventing transmission by teaching the parents not to cough, sneeze, or talk directly into the newborn's face. **At prenatal visits, be alert for clinical manifestations of TB, including fatigue, fever or night sweats, nonproductive cough, weakness, slow weight loss, anemia, hemoptysis, fatigue, and anorexia** Iron Deficiency Anemia Iron-deficiency anemia mainly reflects poor nutrition, principally attributed to poor economic status. The risks of hemorrhage (impaired platelet function) and infection during and after birth also are increased. Clinical symptoms include fatigue, diminished quality of life, impaired cognitive function, increased risk for thromboembolic events, diabetes, headache, hypertension, placental abruption, restless legs syndrome, and pica.eating behaviors. The goals of treatment for iron-deficiency anemia in pregnancy are to eliminate symptoms, correct the deficiency, and replenish iron stores. ide effects of iron supplementation are nausea, abdominal pain, constipation, and black stool. Attempting to meet maternal iron requirements solely through diet in the face of diminished iron stores is difficult. Laboratory tests usually reveal low Hgb (less than 11 g/dL), low Hct (less than 35%), low serum iron (less than 30 mcg/dL), microcytic and hypochromic cells, and low serum ferritin (less than 100 mg/dL). Recommend foods high in iron, such as dried fruits, whole grains, green leafy vegetables, lean meats, peanut butter, and iron-fortified cereals Infections (All infections mentioned on your PowerPoint) **Cytomegalovirus**: a member of the herpesvirus family, which includes herpes simplex virus (HSV) types 1 and 2, varicella zoster virus, and Epstein--Barr virus. It is typically asymptomatic in most individuals. CMV is the most common congenital and perinatal viral infection in the world. It is a leading cause of hearing loss and intellectual disability. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in daycare centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breast-feeding. The virus can be found in virtually all body fluids. may result in abortion, stillbirth, low birth weight, IUGR, microcephaly, deafness, blindness, intellectual disability, jaundice, or congenital or neonatal infection. If it occurs during pregnancy, the first or primary infection is the most dangerous to the fetus. here are three time periods during which mother-to-child transmission can occur: in utero, during birth, and after birth. However, permanent disability only occurs in association with in utero infection. More severe disabilities are usually associated with maternal infection during the first trimester. - Wash hands frequently with soap and water and wear gloves, especially after diaper changes, feeding, wiping nose or drool, and handling children's toys. - Do not share cups, plates, utensils, food, or toothbrushes. - Do not share towels or washcloths. - Do not put a child's pacifier in your mouth. - Clean toys, countertops, and other surfaces that come in contact with children's urine or saliva. - Practice safe sex, including limiting sexual partners and using condoms consistently. **Rubella:** spread by droplets or through direct contact with a contaminated object. The risk of a pregnant woman transmitting this virus through the placenta to her fetus increases with earlier exposure to the virus. symptoms in the newborn, include congenital cataracts, glaucoma, cardiac defects, microcephaly, and hearing and intellectual disabilities. Hearing impairment is the most common manifestation. **Herpes Simplex Virus:** Infection occurs by direct contact of the skin or mucous membranes with an active lesion through such activities as kissing, sexual contact, or routine skin-to-skin contact. A primary infection lasts approximately 3 weeks and manifests with multiple genital lesions that begin as vesicles and develop into ulcerative lesions. The greatest risk of transmission occurs when the mother develops a primary infection near term and it is not recognized. Most neonatal infections are acquired at or around the time of birth through either ascending infection after ruptured membranes or contact with the virus at the time of birth. if the woman has active herpetic lesions within 6 weeks of term, a cesarean birth is preferred. All invasive procedures that might cause a break in the infant's skin should be avoided, such as artificial rupture of membranes, fetal scalp electrode, or forceps and vacuum extraction. transmission can result in severe neurologic impairment or death, treatment of the mother with an antiviral agent such as acyclovir (Zovirax) must be started as soon as the culture comes back positive. **Hepatitis B Virus**: associated with an increased risk of preterm birth, fetal distress during labor, meconium peritonitis, low birth weight, and neonatal death. The fetus is at particular risk during birth because of the possible contact with contaminated blood at this time. The CDC recommends that all pregnant women should be tested for hepatitis B surface antigen (HBsAg) regardless of previous HBV vaccine or screening Review the woman's history for factors placing her at high risk: History of STIs Household contacts with HBV-infected persons, Employment as a health care provider, Abuse of IV drugs, Prostitution, Foreign born, Multiple sexual partners, Chinese, Southeast Asian, or African heritage, Sexual partners who are HBV-infected **If a woman tests positive for HBV, expect to administer HBV immune globulin** The newborn will also receive HBV vaccine within 12 hours of birth. The second and third doses of the vaccine are given at 1 and 6 months of age **Varicella Zoster Virus:** the virus that causes both varicella (chickenpox) and herpes zoster (shingles). Pregnant women are at risk for developing varicella when they come in close contact with children who have active infections. there is a higher incidence during winter and spring months. can be transmitted to the fetus through the placenta, leading to congenital varicella syndrome if the mother is infected during the first half of pregnancy via an ascending infection during birth or by direct contact with infectious lesions, leading to infection after birth. The varicella vaccine is contraindicated for pregnant women. characterized by low birth weight, skin lesions in a dermatomal distribution, spontaneous abortion, chorioretinitis, cataracts, pneumonia, fetal growth restriction, delayed milestones, cutaneous scarring, limb hypoplasia, microcephaly, ocular abnormalities, intellectual disability, and early death. some pregnant women are at risk for developing varicella pneumonia, which may put them at risk of life-threatening ventilatory compromise and death. Risk of varicella pneumonia appears to increase during pregnancy **Parvovirus B19:** (FIFTH DISEASE) majority of women have no adverse pregnancy outcomes. Those who do may experience spontaneous abortion and severe fetal anemia. Transmitted by respiratory secretions of hand-to-mouth contact. Most infected persons are asymptomatic. a common, self-limiting, benign childhood virus that causes erythema infectiosum. Fetal infection may be associated with a normal outcome, but fetal death may also occur without ultrasound evidence of infectious sequelae The risk to the fetus is greatest when the woman is exposed and infected within the first 20 weeks' gestation. In addition to hydrops, other fetal effects of parvovirus include spontaneous abortion, congenital anomalies (central nervous system, craniofacial, and eye), and long-term effects such as hepatic insufficiency, myocarditis, and learning disabilities If mother is nonimmune to parvo, then referral to a perinatologist is recommended, and counseling regarding the risks of fetal transmission, fetal loss, and hydrops is necessary. Teachers, daycare workers, and women living with school-age children are at highest risk for being seropositive for parvovirus B19. the characteristic rash starts on the face with a "slapped-cheeks" appearance and is followed by a generalized maculopapular rash. Fever, arthralgia, and generalized malaise are usually present in the mother. Prepare the mother for antibody testing **Group B Streptococcus:** most common cause of sepsis and meningitis in newborns and is a frequent cause of newborn pneumonia. Newborns with early-onset (within a week after birth) GBS infections may have pneumonia or sepsis, while late-onset (after the first week) infections often manifest in meningitis. GBS colonization in the mother is thought to cause chorioamnionitis, endometritis, and postpartum wound infection. all pregnant women should be screened for GBS at 35 to 37 weeks' gestation and treated. Penicillin G is the treatment of choice for GBS infection because of its narrow spectrum. The drug is usually administered IV at least 4 hours before birth so that it can reach adequate levels in the serum and amniotic fluid to reduce the risk of newborn colonization. risk factors for perinatal transmission of GBS, including previous colonization with GBS, low socioeconomic status, African American race, age younger than 20 years, positive colonization at 35 to 37 weeks' gestation, GBS in urine sample, previous birth of GBS-positive newborn, preterm birth, and use of invasive obstetric procedures. Many women with GBS infection are asymptomatic, but they may have urinary tract infections, uterine infections, and chorioamnionitis. **Toxoplasmosis:** It is transferred by hand to mouth after touching cat feces while changing the cat litter box or through gardening in contaminated soil. Consuming undercooked infected meat, such as pork, lamb, or venison drinking contaminated water, and eating unwashed fruits and vegetables can also transmit this organism. fetus who contracts congenital toxoplasmosis typically has a low birth weight, enlarged liver and spleen, visual problems, cerebral palsy, hearing loss, seizures, chorioretinitis, jaundice, IUGR, hydrocephalus, microcephaly, neurologic damage, and anemia. \*Cook all meat to an internal temperature of 160°F (71°C) throughout \*Clean cutting boards, work surfaces, and utensils with hot, soapy water after contact with raw meat or unwashed fruits and vegetables. \*Peel or thoroughly wash all raw fruits and vegetables before eating them. \* Wash hands thoroughly with warm water and soap after handling raw meat. \* Avoid feeding the cat raw or undercooked meats. \*Wash hands with soap and water after handling fruits and vegetables. \*Avoid emptying or cleaning the cat's litter box. Have someone else do it daily. \*Keep outdoor sandboxes covered to prevent cat feces contamination. \*Keep the cat indoors to prevent it from hunting and eating birds or rodents. \*Avoid uncooked eggs and unpasteurized milk. \* Wear gardening gloves when in contact with outdoor soil. \*Avoid contact with children's sandboxes, because cats can use them as litter boxes. **HIV**: Black and Latina make up most of theinfected. transmitted by blood and body fluids. risk factors to assess for include women who exchange sex for money or drugs or have sex partners who do; a woman whose past or present sex partners were HIV-infected; high maternal viral load; chorioamnionitis; prolonged rupture of membranes; vaginal birth; breast-feeding; and having had a blood transfusion between 1978 and 1985. risk for preterm delivery, fetal growth restriction, premature rupture of membranes, intrapartal or postpartum hemorrhage, postpartum infection, poor wound healing, and genitourinary tract infections. the fetus and newborn also are at risk for prematurity, IUGR, low birth weight, and infection. Prompt treatment with antiretroviral medications for the infant with an HIV infection may slow the progression of the disease. women who are HIV-positive should avoid breast-feeding to prevent HIV transmission to the newborn. The goal of therapy is to reduce the viral load as much as possible, which reduces the risk of transmission to the fetus. avoiding the use of an episiotomy, fetal scalp electrodes, and fetal scalp sampling, will reduce the newborn's exposure to body fluids. question the woman about any flu-like symptoms such as a low-grade fever, fatigue, sore throat, night sweats, diarrhea, cough, skin lesions, or muscle pain. determine if she has lost weight recently. Assess for signs and symptoms of STIs, such as vulvovaginal candidiasis, bacterial vaginosis, HSV, chancroid, CMV, or chlamydia. Current evidence suggests that cesarean birth performed before the onset of labor and before the rupture of membranes significantly reduces the rate of perinatal transmission Pregnant Adolescent adolescent pregnancy contributes to a loss of self-esteem, societal discrimination, a destruction of life projects, and the prolonging of poverty. Adolescent pregnancy also places the client at high risk for obstetric complications such as preterm labor and births; low-birth-weight infants; STIs; poor maternal weight gain; preeclampsia; iron-deficiency anemia; poor eating habits and inadequate nutrition; and postpartum depression Pregnant Woman with Substance Abuse substance abuse (cigarettes, alcohol, or illicit drugs) can contribute to low birth weight, fetal growth restriction, preterm births, newborn addiction, and sepsis **Alcohol**: Spontaneous abortion, inadequate weight gain, IUGR, FASD (the leading cause of intellectual disability) **Caffeine:** Vasoconstriction and mild diuresis in mother; fetal stimulation, but teratogenic effects not documented via research. Don't drink no more than 200 mg/day **Nicotine**: Vasoconstriction, reduced uteroplacental blood flow, decreased birth weight, abortion, prematurity, placental abruption, fetal demise **Cocaine**: Vasoconstriction, gestational hypertension, placental abruption, abortion, central nervous system defects, IUGR **Marijuana**: Anemia, inadequate weight gain, "amotivational syndrome," hyperactive startle reflex, newborn tremors, prematurity, IUGR **Opiates and Narcotics**: Maternal and fetal withdrawal, placental abruption, preterm labor, premature rupture of membranes, perinatal asphyxia, newborn sepsis and death, intellectual impairment, malnutrition **Sedatives**: Central nervous system depression, newborn withdrawal, maternal seizures in labor, neonatal abstinence syndrome, delayed lung maturity Factors associated with substance abuse during a pregnancy may include low self-esteem, inadequate support systems, low self-expectations, high levels of anxiety, socioeconomic barriers, involvement in abusive relationships, chaotic familial and social systems, and a history of psychiatric illness or depression. Marijuana in NB= altered responses to visual stimuli, increased tremulousness, and a high-pitched cry, which might indicate insults against the central nervous system Caffeine in NB= growth restriction, reduced birth weight, preterm birth, and stillbirth Sedatives in NB= may be physically dependent on the drugs themselves and are more prone to respiratory problems, feeding difficulties, seizures, hyperactivity, disturbed sleep patterns, sweating, irritability, and fever Opioids in NB= irritability, hypertonicity, jitteriness, fever, excessive and often high-pitched cry, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures Cocaine use produces vasoconstriction, dilates pupils, and increases body temperature, tachycardia, and hypertension in both the mother and the fetus