Term
Diabetes Mellitus
Classifications
1. Type 1 |
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Definition
Women with type 1 DM
@ greatest risk. |
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Term
Diabetes Mellitus
2. Type 2
3. Gestational |
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Definition
The key to a positive
outcome is excellent
glycemic control before
and during pregnancy . |
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Term
Pathophysiology – Type 1 DM
1. |
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Definition
1.Poor control results in hypoglycemia,
hyperglycemia, ketoacidosis and hyperlipidemia |
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Term
Pathophysiology – Type 1 DM
2 |
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Definition
2. Chronic hyperglycemic states scar basement
membranes leading to microangiopathy in eyes,
kidneys and skin. |
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Term
Pathophysiology – Type 1 DM
3. |
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Definition
3.Alterations in lipid metabolism result in
atherosclerotic plaque formations in larger
vessels. HTN and MI are common complications |
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Term
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Definition
< 20% of diabetic women participate in counseling
Partner needs to be involved and finances considered
Contraception choices require attention and teaching
Type 2 diabetic patients and gestational diabetics may
be able to safely take certain oral antihyperglycemics
or S.Q. insulin. |
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Term
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Definition
Poor control prior to and early in pregnancy
> rates of spontaneous abortion
Macrosomia (> 4000gm birth wt.) ~ 25% pregnancies.
HTN and preeclampsia rates increased
Hydramnios rates ten times greater
Infection rates higher (UTI and yeast) and result in
higher insulin resistance and ketoacidosis
Ketoacidosis r/t diabetogenic effects of pregnancy Retinopathy |
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Term
| Fetal and Neonatal Complications |
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Definition
Stillbirth, often after 36 weeks r/t maternal
complications
Congenital anomaly rates of 6-10% per
pregnancy with cardiac, CNS and skeletal most
common
Macrosomia leads to delivery complications
Increased risk for RDS
Neonatal hypoglycemia, electrolyte imbalances
hyperbilirubinemia and polycythemia |
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Term
Insulin Needs During Pregnancy
First trimester |
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Definition
1.Lower in 1st trimester
d/t increased
production by
pancreas & increased
peripheral insulin
sensitivity ergo,
hypoglycemia more
likely |
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Term
Insulin Needs During Pregnancy
2nd trimester |
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Definition
Increased need in 2nd
trimester d/t maternal
hormones acting as
insulin antagonists |
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Term
Insulin Needs During Pregnancy
3rd trimester |
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Definition
By 3rd trimester
dramatic increases occur.
At 36 weeks, levels off |
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Term
Insulin Needs During Pregnancy
After delivery |
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Definition
After delivery, maternal
needs significantly drop |
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Term
Insulin Needs During Pregnancy
Breast feeding moms |
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Definition
Breast feeding moms
need 25% - 50% less
insulin than when not pregnant |
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Term
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Definition
SBGM is the key
to control.
60-120 mg/dl
generally
acceptable range
Fasting < 95mg/dL
Daily urine
ketone checks
identify
ketoacidosis early
(Type 1).
Teaching requires
return demo with
pt. and ideally
one other |
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Term
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Definition
Screen low risk
pts. @ 24-28 weeks
using 1 hour 50
Gm glucose
tolerance test.
If glucose level
>130-140, a 3 hour
test is ordered |
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Term
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Definition
Values of > 6.5%
considered diagnostic
Fasting glucose > 126
confirms diagnosis |
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Term
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Definition
#1 Tight control may
require multiple
injections Q D or insulin
pump therapy
Usually 2/3 AM dose of
mixed regular and
longer acting, then 1/3
of mixed in PM.
Infusion pumps use
regular insulin and
require additional
teaching. |
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Term
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Definition
#2Lispro = Humalog
Insulin Aspart = NovoLog
are rapid acting
Regular = fast acting
Intermediate acting
Long acting
Nurses need to know
onset/peak/duration of
action for each |
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Term
Nursing Care
Assessment and History 1. |
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Definition
1. Age diagnosed
Glycemic control
Diet and activity
Insulin vs. noninsulin
dependence
Complications i.e.
HTN and renal
Prior illnesses and
pregnancies. |
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Term
Nursing Care
Assessment and History 2. |
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Definition
2. Assess mother for
knowledge base,
motivation to
control and
support systems
Symptoms
including weight
gain or loss
Labs:
urinalysis
urine C&S
Hgb A1C |
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Term
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Definition
Emotional well being
General hygiene
May require Q 1-2 week Pre-natal visits
Maintain diet of ~ 2200 Kcal/D 1ST Trimester
2500 Kcal/D 2ND and 3RD
ApproximateCalorie Breakdown:
Complex CHO 50%
Fats - 30%
Protein – 20%
PNV
Appropriate weight gain |
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Term
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Definition
Decreasing Stress: Needs strict daily routine
Diet = 3 meals, 3 snacks and never skip
Activity = With vasculopathy only mild exercise
Insulin = Appropriate dose that maximizes glucose
levels and reduces risk for hypoglycemia
Rest = Set sleep schedule with planned rest
SBGM = Keep level between 60-120mg/dl
depending on meals and time of day |
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Term
Teaching: Client will verbalize understanding of or
demonstrates ability to:1. |
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Definition
1.Recognize symptoms of hypo/hyperglycemia
Exercise requires close SBGM – (diary)
States diet menu plan – (diary)
Glucose < 60, immediately eat/drink 20 G of simple
CHO rest 15 min., recheck. If still low, repeat, may call provider. |
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Term
Teaching: Client will verbalize understanding of or
demonstrates ability to: 2. |
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Definition
2. Identify and reduce stressors in life
State insulin dose, frequency and technique
Describe effects of poor glycemic control on fetus
Keep all appointments!!!
State hygiene practices that promote wellness |
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Term
Nursing Diagnosis
Antepartal |
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Definition
Risk for Imbalanced Nutrition
Risk for fetal Injury r/t possible complications of
hypoglycemia and/or hyperglycemia
Knowledge Deficit
Anxiety
Intra-partum and post-partum have similar diagnoses |
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Term
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Definition
EDB established
Measure MSAFP between 16-18 weeks d/t
high rate of neural tube defects.
Fetal echocardiogram to detect cardiac
problems by 22 week
By 28 weeks NST weekly
In presence of non reactive NST, a contraction
test or BPP is ordered |
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Term
Other Considerations
1.Antepartum |
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Definition
1.Plan to induce
labor at ~38–39
weeks after
confirming lung
maturity.
C/S rates high
and delivery
methods
controversial |
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Term
Other Considerations
2.Intrapartum |
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Definition
2. Monitor closely
for hypo and
hyperglycemia
and dehydration
Monitor glucose
Q H and
maintain 60-100
glucose level |
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Term
Other Considerations
3.Postpartum |
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Definition
3. Placenta gone,
so too is vehicle
for insulin resist.
so decrease
dose!
Complications
include:
preeclampsia
hemorrhage and
infection |
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Term
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Definition
~ 7%* of all pregnancies
As many as 50% of GDM develop DM later
Often diagnosed in 2nd or 3rd trimester
Risk factors: Prior births >4500gm,
age > 30 , obesity, family history type 2 DM,
hydramnios and unexplained stillbirth
Screen high risk women much earlier
* Rates variable 4% - 18% (ADA) of pregnancies affected by GDM |
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Term
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Definition
One abnormal OGTT, treat conservatively
Confirmed GDM is first managed with diet & SBGM
ACOG recommends starting insulin or Glyburide if
fasting levels >105mg/dl &/or non-fasting > 120mg/dl
GDM less likely to require C/S
GDM typical in future pregnancies with earlier onset
Golden opportunity to teach!
Discuss modifiable risk factors/Evidenc |
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Term
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Definition
1.Most common medical disorder of
pregnancy affecting ~ 20% pts.
2. 90% r/t iron deficiency
3. Hgb < 11g/dl and Hct < 32%
4. Consideration for pts. with SCA
5. Differentiate physiologic anemia of
pregnancy and pathologic |
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Term
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Definition
Ferritin levels of <15mcg/L
confirm iron def.
Rx: 60-120 mg
elemental Fe/day
or parenteral form
Folic Acid 400 mcg and up to 1
mg/day or more
Encourage foods high in iron
and folic acid (foods listed as
folic acid enriched are good) |
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Term
Cardiac Disease
Normal changes during pregnancy |
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Definition
Heart pushed up & left as pregnancy progresses.
May appear enlarged on X-ray with no EKG changes
90% have systolic murmur by 20 wks.
Gallop is common with resolution after birth
HR increases to meet fetal demands.
CO increases and peaks at ~28 wks. from 4.5L/m to
6L/min. BP changes less dramatic |
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Term
Cardiovascular Disorders
Congenital |
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Definition
Related to birth
anomalies that
have been
treated/repaired. |
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Term
Cardiovascular Disorders
Acquired |
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Definition
Developing a disorder
after birth r/t Kawasaki
disease or Rheumatic
fever. |
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Term
Cardiovascular Disorders
Cardiomyopathy |
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Definition
(heart failure) of
pregnancy is serious.
30% of clients return to
normal VF six months
post delivery |
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Term
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Definition
Today may safely
deliver a healthy
baby versus 30
years ago patient
advised to avoid
pregnancy |
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Term
| Heart Disease Classification by Functional Capacity |
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Definition
I Have heart disease, but symptom free. No limits
II Have disease & experience dyspnea, angina or
palpitation with ordinary activity. Slight limits
III Comfortable at rest, but symptomatic with quiet
activity. Marked limitation of activity
IV Symptomatic at rest. Severe limitations |
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Term
Assessment Findings r/t Cardiac Function
Neuro |
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Definition
LOC, HA, vertigo, anxiety or pain
Respiratory: Rate, effort, dyspnea –on exertion or
progressive, adventitious sounds, cough,
hemoptysis |
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Term
Assessment Findings r/t Cardiac Function
Cardiac |
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Definition
Rate, rhythm, murmur, capillary refill,
pulses, Homan’s, temperature |
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Term
Assessment Findings r/t Cardiac Function
Integumentary |
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Definition
| Color, turgor, edema, weight gain |
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Term
Assessment Findings r/t Cardiac Function
GU |
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Definition
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Term
Assessment Findings r/t Cardiac Function
Goal |
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Definition
TREAT UNDERLYING PROBLEMS
THAT INCREASE WORK LOAD OF HEART, i.e.
anemia, infections, sodium or fluid overload and
emotional distress |
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Term
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Definition
Consequences of rheumatic fever include valve
damage, especially MV and AV.
Medications include vitamins, iron, prophylactic
PCN, if not allergic, to prevent further damage,
heparin if needed and dig and Lasix for CHF .
BE (bacterial endocarditis) prevention during labor
and in post partum period is recommended for
most patients |
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Term
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Definition
Floppy leaflets of MV cause blood to regurgitate
from LV to LA
3% of women, often asymptomatic
Tolerate pregnancy well.
May need beta blocker to control palpitations and
instruct to avoid caffeine
SBE precautions may not be needed |
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Term
| Peripartum Cardiomyopathy |
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Definition
Last month of pregnancy &/or in 1st 5 months post
Etiology unknown - associated with chronic HTN,
mitral stenosis, obesity and viral myocarditis.
Presents with anemia and infection
Rx: Antibiotics, dig, diuretics, vasodilators, heparin
NA restriction and strict bed rest.
Best to avoid another pregnancy as it may recur |
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Term
| Laboring & Post Partum Cardiac Patients |
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Definition
Assess functional capacity
Assess maternal wishes and make a plan
Epidural with/without forceps and/or vacuum
Assess for decompensation during/after delivery
Assess for fetal/maternal distress (C/S last resort)
Post partum: Assess for CHF, infection and clots |
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Term
| Other Gestational Conditions |
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Definition
Gestational Hypertension (GH)
Preeclampsia
Hyperemesis Gravidarium
Ectopic Pregnancy
Gestational Trophoblastic Disease (GTD) aka
Hydatidiform mole (Molar Pregnancy)
Bleeding Disorders of Pregnancy |
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Term
Classification of Hypertension (140/90)
1. |
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Definition
Chronic HTN:
Onset occurs before
pregnancy and
continues for at
least 42 days
postpartum or
longer |
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Term
Classification of Hypertension (140/90)
2. |
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Definition
Gestational HTN:
Pt. is hypertensive
after 20 weeks
gestation without
proteinuria. BP
returns to normal
range 3 months
after birth |
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Term
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Definition
GH is a leading cause of maternal mortality and
is a leading medical complication of pregnancy
GH contributes to fetal death and perinatal
mortality and morbidity
Incidence has increased since 1990 in all groups
Incidence by Race
Native American 46.5/1000
African-American 41.5/1000
Caucasian 38.1/1000
Hispanic 26.3/1000
Asian 20.8/1000 |
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Term
Antihypertensive Medications
2. |
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Definition
2.Nifedipine – Useful in
treating preterm labor also |
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Term
Antihypertensive Medications
1. |
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Definition
Labetalol – avoid if patient
has hx of asthma
Used when systolic
BP is >150-160 and
diastolic BP >100 |
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Term
Antihypertensive Medications
3. |
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Definition
Methyldopa – “Aldomet”
an old standard |
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Term
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Definition
HTN with proteinuria most commonly
occurring between 25-30 weeks and up to 48
hours after delivery. Edema is almost always
present.
Can be mild or severe |
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Term
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Definition
Familial
History of HTN, renal disease and DM
Higher rates in Native and African Americans
Poor nutrition, especially severe protein def.
Age < 20 and > 40 years
Obesity
Rh incompatibility |
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Term
Treatment of Preeclampsia
a) |
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Definition
Home care with close f/u if BP stable and
urine protein < 2 +
Teach self monitoring of BP, weight, urine
dipstick and fetal kick counts daily and
report abnormal findings to practitioner |
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Term
Treatment of Preeclampsia
b) |
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Definition
Healthy diet, avoid high salt & 8-10 cups
water/day
Coping with anxiety and bed rest
techniques
Identify support systems for family
Home Care – remote NST etc. i.e. Matria |
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Term
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Definition
Magnesium Sulfate IV piggyback
Position patient and inform her of drug effects.
Monitor VS, FHR and contractions continuously with
bolus, then Q 15-30 min until stable.
Hourly strict I&O, urine protein, DTR’s-clonus, &
condition
Continue infusing 24 hours postpartum
Report significant changes immediately.
Name @ least 3 significant changes
Remember comfort measures!
Focus of S&S of toxicity including loss of reflexes
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Term
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Definition
IV Labetalol or Apresoline also used. Critical to
monitor maternal response closely. If less severe,
PO Labetalol or Nifedipine may be ordered.
Caring for in the postpartum period is focused
on assessing BP Q 4 for 2 days, fundal checks
and observing lochia amount administering
oxytocin or prostaglandins if bleeding occurs
Observing and facilitating maternal bonding
Grief counseling if outcome is poor |
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Term
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Definition
Presence and increased
severity of symptoms
including VS &
neurovascular changes
Maternal anxiety
Fetal well-being CFM,
NST and/or BPP
Symptoms of placenta
abruption –
bleeding/fundal Ht.
and DIC |
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Term
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Definition
May need to induce labor using
PITOCIN or Miso while
maintaining Magnesium Sulfate
infusion
Failure to progress results in
emergency C/S
Boggy uterus a complication of
Mag, especially with C/S.
PP hemorrhage a big risk! |
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Term
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Definition
Seizure state following uncontrolled
hypertension. Severe HTN affects both
fetus and mother. May require
emergency C/S once patient is stable.
Birth is the cure for pre-eclampsia |
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Term
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Definition
H: HEMOLYSIS
E: ELEVATED
L: LIVER ENZYMES
L: LOW
P: PLATELET COUNT |
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Term
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Definition
Most common in older Caucasian multips who
may present with several days fatigue, abd pain
and often N/V
Symptoms of severe eclampsia
Lab, not clinical diagnosis as previously
described. BUN and creatinine also elevated |
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Term
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Definition
Mortality rates as
high as 24%
Increased risk for
Abruptio placenta
DIC
Cerebral
Hemorrhage
Liver failure
Acute renal failure |
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Term
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Definition
IUGR
Increased risk for
Fetal demise. Try to
delay delivery in
preterm infants
until L/S ratio = 2:1
or BMS is given to
mother |
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Term
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Definition
Interventions include seizure precautions,
educating mother and family about disorder
and treatment plan and associated risks
2. Maintain strict bed rest
3. Incorporate stress reducers in plan of care
4. Prepare for birth, recovery, discharge and
follow up with aim of extending pregnancy
as long as is feasible |
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Term
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Definition
Hypertension in pregnancy could
induce long-term metabolic and
vascular abnormalities that might
increase the overall risk of CVD
later in life. More research is
needed to study this hypothesis. |
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Term
Hyperemesis Gravidarum = HG
Part 1 |
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Definition
~70% of pregnant women experience some N/V in
1st trimester. Uncontrolled vomiting = HG
Less than 1% of pregnant women develop HG
Risk factors < 20 yrs., obese, multi-fetal or GTD |
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Term
| Hyperemesis Gravidarum = HG |
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Definition
Presents with > 5% pre-pregnancy weight loss,
dehydration, F&E imbalance, ketosis and ketonuria.
BP may be low and heart rate rapid
Exact cause unknown
Start management with thorough medical, social
and OB/GYN history and PE |
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Term
|
Definition
For sig. dehydration, hospitalize with IV fluids
Pyridoxine (B6) and Doxylamine first line agents
Metoclopramide and Ondansetron if above
ineffective
Diet: Low fat, mod-high protein, bland 5-6 smaller
meals
Chamomile tea, ginger ale may help.
Some women do well with PB on toast/crackers
Try to avoid corticosteroids – risky!
Worst case scenario is parenteral nutrition
Counseling and support. Prognosis good |
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Term
Ectopic Pregnancy
section 1 |
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Definition
Fertilized ovum
implants outside
uterine cavity
Risk Factors:
PID
Prior EP
Tubal surgery
IUD
Endometriosis
Assisted
Reproduction |
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Term
Ectopic Pregnancy
Section 2 |
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Definition
Symptoms
Missed period
Adenexal tenderness
Variable abdominal pain
Vaginal bleeding and or shock
Cullen’s sign (umbilical
bruising)
Labs & Diagnostic Tests
Low progesterone and hCG
levels Transvaginal
ultrasound |
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Term
| Ectopic Pregnancy-Management |
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Definition
Manage symptoms:
Pain, bleeding and emotional support
Medical treatment requires patient to be healthy with an
unruptured < 4 cm pregnancy and absence of FHR.
Methotrexate (MTX) drug of choice.
Surgery to spare the tube – Salpingostomy or
removal of tube – salpingectomy.
Check for Rh status of patient |
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Term
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Definition
Aka hydatidaform mole occurs with incomplete
fertilization of the ovum. Complete molar
pregnancies contain no fetus, placenta, amniotic
fluid etc. Incomplete molar pregnancy may contain
fetal parts
Result is grapelike clusters of fluid filled vesicles
which grow rapidly causing uterus to enlarge
Early stage complete molar pregnancy resembles
normal pregnancy, then bleeding starts, hCG levels
remain high and sonogram confirms |
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Term
|
Definition
Spontaneous abortion frequently occurs
Dilation and curettage D&C
Avoid inducing labor as embolytic events of
tissue may ensue
RhoGam if woman is Rh negative
Risk of choriocarcinoma is small but real so avoid
pregnancy for at least one year
Serial hCG testing
Provide emotional support to pt. and family |
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Term
| Cervical Insufficiency (Incompetent Cervix) |
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Definition
Painless dilatation of the cervix without contractions
that can lead to pregnancy loss in second trimester
Can be related to congenital factors (DES exposure)
or acquired factors like cervical trauma, inflammation
or surgical damage to name a few.
Assessing cervical length using ultrasound helpful.
For women with shorter cervixes, Cerclage has not
been shown to be effective in preventing preterm
birth. |
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Term
|
Definition
Cerclage placed at
~11-15 weeks
Continue Bedrest
Oral tocolytics if
needed
Monitoring
Hydration
Report to hospital if
contractions <5 min
apart, SROM, or
urge to push occurs |
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Term
|
Definition
no longer used for preterm
labor- d/t side effects, but can use it for 24-48 hours to
slow labor and administer BMS. Also pictured below is
Toco monitoring |
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Term
|
Definition
Up to 15% of pregnancies end in miscarriage
Miscarriage = spontaneous abortion < 20 wks
90% occur before 8 weeks and may be r/t fetal
anomalies, endocrine disturbances, infections
including Chlamydia and systemic disorders
5 types of miscarriage |
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Term
| Patient Care following Spontaneous abortion |
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Definition
Threatened = bed rest and support
Inevitable/incomplete = D&C with pre-post op care
Late miscarriages may require prostaglandins and
oxytocin to prevent hemorrhage
Shower for 2 weeks
Introduce nothing into vagina until bleeding stops
Diet high in protein and Fe and plenty of rest
Notify MD if foul smelling discharge, fever or fatigue
persists
Avoid becoming pregnant for at least 2 mos
Provide emotional support and spiritual care |
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Term
Expected Outcomes Following a Spontaneous
Abortion |
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Definition
Patient does not develop excessive bleeding or
infection
Verbalizes relief from pain
Identify and utilize support systems
Mother and family can discuss impact of loss on their
lives |
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