Week 3.docx

High-Risk Pregnancy lecture: - Women usually referred to Ob provider usually around 10-12 weeks - Goal as a FNP is to ensure that our patients are in a state that is safe for pregnancy so that when they do get pregnant patients are healthy and will help prevent complications Risk Fact...

High-Risk Pregnancy lecture: - Women usually referred to Ob provider usually around 10-12 weeks - Goal as a FNP is to ensure that our patients are in a state that is safe for pregnancy so that when they do get pregnant patients are healthy and will help prevent complications Risk Factors for Maternal Outcomes: Preexisting Health Conditions - These place increased risk of pregnancy complications as well as complications/progression of the disease - Common maternal conditions affecting pregnancy: anemia, cancer, diabetes, GI disorders, heart disease, hypertension, infectious diseases, kidney disease, obesity, thyroid disorders **Pregnancy and Diabetes:** - Rising rates in diabetes prevalence - Important to remember that the early pregnancy period (0 to 8 weeks) is where most of the organogenesis happens - Diabetes is strongly associated with risk of pregnancy complications - Physiologic changes in pregnancy alter carbohydrate metabolism- remember that some hormones in pregnancy can cause insulin resistance; for a pregnant diabetic patient this just means that it will require more to ensure that their blood sugar is controlled - **Gestational Diabetes Diagnosis:** screening occurs between 24-28 weeks gestation with the glucose tolerance test A1C may not be as accurate during pregnancy due to increase in red blood cells (may make a1C look low when it may actually be high) standard of care for pregnancy: screening for gestational diabetes with oral glucose challenge (start with 50-gram test- looking to see if your body can create enough insulin to control the rush of sugar) one step approach vs two step approach why is this important during pregnancy? Sugar will cross the placenta and this will cause the baby to store fat (high insulin = high fat stores) With gestational diabetes there is a lower risk for fetal malformations because it is past the first trimester - Pre-gestational Diabetes in Pregnancy: (before pregnancy) miscarriage/stillbirth congenital anomalies intrauterine growth restriction/macrosomia oligohydramnios/polyhydramnios worsening of diabetic complications - Gestational Diabetes in Pregnancy develops at 24-28 weeks increased risk for developing diabetes macrosomia polyhydramnios stillbirth - Fetal Macrosomia: these are large babies that will be in the NICU because they do not know how to regulate their insulin and blood sugars yet these babies are at higher risk for childhood obesity - Diabetes and Pregnancy: Preconception Care ask women about plans for pregnancy during routine primary and gynecologic care prescription of prenatal vitamins (at least 400 mg of folic acid and 150 ug of potassium iodide) review risks of diabetes including attainment of glycemic goals and medication profile taking prenatal vitamins 3 months prior to conception improves birth outcomes Text Description automatically generated Pregnancy Care with Diabetes: - **Aspirin for all pregnant women who are at risk for developing pre-eclampsia later in pregnancy**- First trimester - Fetal anatomy ultrasound - Serial growth - Fetal assessment - Timing of delivery Postpartum: - Encourage breastfeeding - Contraceptive counseling **Pregnancy Surveillance:** - Well controlled glucose levels and no vascular disease want to deliver at 39 +0 to 39 +6 weeks - **Uncontrolled hyperglycemia or vascular disease: deliver at 36 and 0 to 38 and 6 weeks** - **Scheduled C-section birth to avoid birth trauma is typically offered at 39 and 0 weeks to patients with gestational diabetes and an estimated fetal weight \>4500 grams** **Blood Glucose Goals for Pregnant Women:** - The control is much tighter for pregnant women and their blood sugar - **Fasting blood sugar should be less than 95** - One-hour after eating less than 140 - Two-hours after eating less than 120 - Average 100 - Middle of the night greater than 60 **Diet and Exercise**: - Exercise 150 min/week unless contraindicated - Caloric composition: need 40-50% from complex high-fiber carbs; 20% from protein; 30-40% from primarily unsaturated fats - Daily distribution - The goal is to prevent maternal hyperglycemia, ketosis, promote optimal weight gain and provide nutrients for baby **Treating Diabetes in Pregnancy:** - **[Insulin is first line]** - Oral hypoglycemics: metformin (maybe glyburide) **Postpartum Care:** - Breastfeeding is strongly encouraged - Contraception planning - Screen for diabetes 6 weeks after delivery **Hypertensive Disorders of Pregnancy:** - Hypertensive disorders are one of the leading causes of maternal morbidity - Chronic HTN is HTN present from 0 wks to 20 wks or present before pregnancy - **HTN from 20 wks-40 wks: gestational HTN**, Preeclampsia, Eclampsia, Superimposed preeclampsia **Role of the primary care provider in HTN in pregnancy:** - Preconception care - **Nifedipine and Labetalol** (best for pregnancy); avoid ACE and ARBs - Threshold of **140/90 mmHg** or more - Evaluate end organ dysfunction - Rule out secondary hypertension\* - These patients usually deliver around 37 weeks **Baseline evaluation for Chronic HTN in Pregnancy:** - Complete blood count - Complete metabolic panel - Urine protein: spot protein/creatinine ratio, 24 hr urine - EKG/Echocardiogram **The Role of Aspirin:** - USPTF guidelines on low dose aspirin for prevention of preeclampsia - Impaired uteroplacental blood flow: fetal growth restriction, oligohydramnios, placental abruption, preterm birth, stillbirth - **162 mg daily between 12-28 weeks gestation** **Preterm Birth:** - Delivery occurring \>20 weeks gestation and before 37 weeks - Early is less than 34 weeks - Late is greater than 34 wk 0 days -- 36 week 7 days (better prognosis) - Etiology: uterine contractions with cervical dilation, preterm premature rupture of membranes, cervical insufficiency, medically indicated - The earlier the baby is born, the higher the risk of morbidity and mortality **Prevention of Preterm Birth:** - Need to assess risk through a thorough OB/GYN history, discuss modifiable risk factors, - Can give 200 mg progesterone vaginal - Endo-vaginal ultrasound [**short cervix \ - Decrease environmental stimuli: low light, quiet environment, minimize unnecessary stimulation, swaddle - Frequent diaper changes - Pacifier - Feed on demand - Rooming-in, skin-to-skin contact, and breastfeed if there are no contraindications **pharmacologic care: [1^st^ line is morphine or methadone]**, **2^nd^ line: clonidine** **(preferred bc of HTN)** or phenobarbital Discharge: with close follow up within 48 hrs if off meds and stable for 24-48 hrs **Follow-Up of Substance Exposed Infants:** - Referral to early intervention services - Referral to home-visitation programs - Referral to early head start **Treatment of Substance Use:** - Behavioral counseling - Reduce/discontinue use and start appropriate treatment - Identify comorbid conditions - Use multidisciplinary approach - Address social determinants of health - Individualize prenatal care **Treatment of Opioid Use Disorder in Pregnancy:** - Should not withdraw or treat with abstinence b/c there is a high risk for relapse and negative fetal and maternal consequences - **[Treat with methadone or buprenorphine]** - **If on naltrexone:** not studied in pregnancy, discontinue if relapse risk is low, switch to methadone or buprenorphine - **If on buprenorphine/naloxone (Suboxone),** some experts recommend switching to buprenorphine monotherapy, but recent data shows no difference in neonatal or maternal outcomes Benefits of Opioid Agonist Therapy: - Maternal benefits- 70% reduction in overdose related deaths, decrease in risk of HIV, HBV, HCV - Fetal benefits- reduces fluctuations in maternal opioid levels; reducing fetal stress, decrease in preterm delivery Methadone vs. Buprenorphine: - Methadone is better for women that failed treatment in the past **Breastfeeding and NOWs:** - 30% decrease in the development of NOWS - 50% decrease in neonatal hospital stay - Improved mother-infant bonding - **Moms on methadone or buprenorphine should be encouraged as both methadone and buprenorphine are compatible with breastfeeding** **Breastfeeding and Alcohol:** - One drink a day or more can cause decreased milk production - Abstaining from drinking is the safest option - Alcohol level in breastmilk is the same as the alcohol level in mother's bloodstream; levels are highest 30-60 minutes after drinking - "pumping and dumping" can help with mother's comfort but has no effect on level of alcohol in breast milk **Breastfeeding and Smoking:** - Recommended to stop smoking - But if unable to quit, it is recommended to keep breastfeeding - Smoke away from infant - Smoker should wash hands and change clothes prior to holding baby - Nicotine levels are reduced to half 2 hrs after smoking Breastfeeding and marijuana: - Limited data, current recc is to abstain - THC does pass into breastmilk and has been shown to have negative effects on the developing brain Breastfeeding and Meth: - AAP advises against breastfeeding if mother is using meth - Wait 48 hrs after recreational use Breastfeeding and Cocaine: - Advised against breastfeeding if mother is using cocaine - Wait 24-36 hrs following recreational use