Exam 2 Flashcards
(163 cards)
1
Q
Three Cycles related to Pregnancy
A
Endometrial Cycle—thickening of the endometrium for pregnancy; shed 2 weeks after ovulation if no pregnancy
Hypothalamic-Pituitary Cycle—pituitary sends signals to the ovaries to develop and mature eggs
Ovarian Cycle—ovarian follicles are stimulated to mature and release an egg; implantation of fetus 7-10 days after ovulation
2
Q
3 phases of ovarian cycle
A
Follicular: begins with the onset of menses; 1st day of menstrual cycle
Ovulatory: begins when estrogen levels peak and ends with release of oocyte (egg)
Luteal: begins on day of LH surge-Lasts approx. ~ 14 days (If pregnancy occurs, releases progesterone and estrogen until placenta matures; if no pregnancy; corpus luteum degenerates and progesterone decreases
3
Q
Menstrual Cycle
Length
Duration
Total blood loss
Regularity impacted by (3)
A
Length: 24-36 days (average is 28; but varies cycle to cycle)
Duration: 3-6 days (average 5 days)
Total Blood loss: 20-80 mL (average 50 mL)
Regularity impacted by stress, exercise, nutrition
4
Q
Prostaglandins
Action
Effects (7)
A
Action: oxygenated fatty acids; hormones
Effects
- Ovulation (ovum trapped if prostaglandin does not increase w/ LH surge)
- Fertility
- Changes in cervix and cervical mucus
- Tubal and uterine motility
- Sloughing of endometrium (menstruation)
- Onset of abortion (spontaneous and induced)
- Onset of labor (term and preterm)
5
Q
Three ovulation indicators
A
- Basal body temperature: drops 1 day (< 37 C) prior to ovulation then rises 1 degree at ovulation for 10 -12 days
- Spinnbarkeit: Change in cervical mucus (abundant, watery, clear, more alkaline, ferns under microscope)
- Mittleschmerz- localized abdominal pain that coincides with ovulation
6
Q
Most cost-effective genetic test
A
Obtaining a family history going back 3 generations on both maternal and paternal sides
(most other genetic tests are not done unless risk factors)
7
Q
Risk factors for miscarriages (9)
A
- chromosomal abnormalities (25% of first trimester losses)
- Prior pregnancy loss
- Advanced maternal age (> 35 yrs)
- Endocrine abnormalities (DM, luteal phase defects)
- Drug use or environmental toxins
- Autoimmune disorders (SLE)
- Infections
- Uterine or cervical abnormalities
- black woman
8
Q
How to obtain karyotype of fetus? (4)
A
- amniocentesis (cells from amniotic fluid)- risk for miscarriage
- cells from fetal blood
- cells from fetal skin
- CVS-Chorionic Villi sampling (sample from placenta b/w 9-11 weeks)
9
Q
Autosomal Recessive Disorders
5 disorders
A
- Sickle Cell Anemia- abnormal hgb molecule reducing oxygen carrying capacity; present among AA and Mediterranean
- Tay Sachs Disease- hexosaminidase deficiency affecting lipid storage usually dead by 2 yrs; among Ashkenazi Jews and French Canadians in Quebec
- Cystic Fibrosis- exocrine glands produce excessive viscous secretions leading to respiratory and digestive problems; among Caucasians
- Phenylketonuria (PKU)- phenylalanine hydroxylase deficiency so limit phenylalanine (amino acid) in diet; among Northern Europeans
- Thalassemia
10
Q
Autosomal Dominant Disorders
2 disorders
A
- xeroderma pigmentation
- huntington’s disease ( uncontrollable muscle contractions b/w 30-50 yrs then loss of memory and personality)
11
Q
Autosomal Recessive vs Autosomal Dominant
A
Autosomal Dominant-If one parent carries the gene, 50% chance of child being affected.
Autosomal Recessive Inheritance - both parents must be carriers and both pass on abnormal gene to child for trait, disorder, or disease to be present (1 in 4 chance each pregnancy)
12
Q
Risk factors for chromosomal abnormalities (6)
A
- maternal age > 35 yrs by due date (esp trisomy 21)
- paternal age 50 or older
- History of miscarriage or stillbirth
- Diabetes in mom (not fam hx)
- Family history of birth defects/genetic diseases (Huntington’s, Down Syndrome, Muscular dystrophy, hemophilia, cystic fibrosis, intellectual disability)
- Family history of hypercholesterolemia and PKU
13
Q
4 Tips for coping with prenatally diagnosed genetic disorder
A
- Provide ongoing info on genetic disorder (including appropriate websites)
- Refer couple to support group for parents w/ children w/ same genetic disorder
- Encourage open communication b/w couple about feelings and concerns
- Let couple know that it is normal for them to grieve over the loss of their “dream child”
14
Q
Sex-linked abnormalities
Disorders (4)
A
Turner syndrome (short stature, risk for cardiac defect, failure of ovaries to develop) in Females=45, X.
Klinefelter Syndrome (infertility) in Males= 47, XXY
X-Linked- hemophilia (Lack of factor VIII impairs chemical clotting)
X-linked- Duchenne’s-muscular dystrophy (replace muscle tissue w/ adipose or scar tissue so progressive loss of muscle function; fatal by 20 yrs)
15
Q
3 Conditions for Fertilization
A
Ovulation occurs -> mature ovum enters a patent fallopian tube (fimbriae of fallopian tube capture ovum and cilia propel ovum to uterus)
Sperm cells are deposited in vagina & travel to fallopian tube surviving 48 hrs (max 5 days)
One sperm cell must penetrate ovum usually in outer third of fallopian tube (ampulla) within 24 hours of ovulation.
16
Q
Pre-embryonic fetal development
Zygote (3)
Morula (3)
A
Zygote
- secretes BhCG to signal pregnancy
- has 46 chromosome
- single fertilized oocyte
Morula
- develops by day 3
- 16-cell sphere
- outer cells secrete fluid creating blastocyst
17
Q
Pre-embryonic fetal development
Blastocyst (4)
A
Blastocyst
- develops by day 5
- fetus develops from inner cell mass (embryoblast)
- placenta and membranes develop from outer layer (trophoblast)
- trophoblast becomes chorion and secretes enzymes for implantation around 6-10 days
18
Q
Embryonic Period (3)
A
- Week 3 through 8 of pregnancy
- Period of organogenesis - highest risk of structural damage by teratogens (chemicals, drugs, viruses, fever)
- rapid hyperplasia of fetal cells
19
Q
Pregnancy Lengths
Total Pregnancy
Conception
1st trimester
2nd trimester
3rd trimester
A
Total Pregnancy: 40 weeks, 280 days
Conception: 2 weeks after 1st day of menstrual cycle
1st trimester: 1st day of LMP through 13 weeks
2nd trimester: Week 14 through 26
3rd trimester: Week 27 through 40+
20
Q
Teratogenic Effects: 3-8 weeks (9)
A
- Neural tube defects (anencephaly, spina bifida) at 4 wks due to inadequate folic acid
- Limb defects
- Intellectual disability
- Cleft lip, cleft palate
- Deafness
- Microphthalmia (small eyes), cataracts, glaucoma
- Enamel hypoplasia, staining
- Masculinization of female genitalia
- Heart Defects (Truncus arteriosus, VSD, ASD (heart problems)
21
Q
Teratogenic Effects: 9 weeks to delivery (3)
A
- Functional defects (IUGR or reduced organ size)
- Minor anomalies( ears, eyes, teeth, palate, external genitalia)
- CNS (vulnerable throughout pregnancy
22
Q
Fetal Alcohol Syndrome characteristics (4)
A
- low birth weight
- microcephaly and mental retardation
- unusual facial features due to midfacial hypoplasia
- cardiac defects.
23
Q
Teratogens (10)
A
- Tobacco (IUGR, preterm, SIDS, nicotine = vasoconstrictor so decreased perfusion)
- Heroin, methadone (IUGR, prematurity, Neonatal abstinence syndrome)
- cocaine (increases maternal BP, IUGR, placental abruption, prematurity; organ defects)
- alcohol (> 1 drink/day– fetal alcohol syndrome)
- ionizing radiation (>10 rads)
- radioiodine
- Tetracycline
- carbamazepine (NTDs)
- ACE inhibitors (renal tubular dysplasia, IUGR)
- warfarin (spontaneous abortion, hemorrhage)
24
Q
Infections and Fetal Anomalies (11)
A
- Toxoplasmosis (protozoan)- fetal demise, blindness, mental retardation
- Cytomegalovirus- hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss
- Syphilis (RPR)- skin, bone, or teeth defects; fetal demise
- Varicella- hypoplasia of hands and feet, blindness or cataracts, mental retardation
- Zika - microcephaly, blindness, hearing defects
- HSV
- Influenza
- HIV
- Chlamydia
- HPV
- Rubella
25
Prenatal Screening: Fetal Anomalies
Offered to?
Types (2)
Results for quad (2)
- offered to all expectant women
Types
- Multiple Marker Screen (Triple, Quad or Penta Screen)– during 2nd trimester for Trisomy 21, Trisomy 18, NTD
- Cell free DNA (cfDNA) blood test for gender, trisomy 21 and 18 but not NTD
Results (quad screen)
- Alpha-Fetoprotein (AFP) is high = increased risk for NTDs
- Low AFP levels = increased risk for Trisomy 21 (Down Syndrome)
26
Prenatal Diagnostics: Fetal Anomalies
Offered to? (2)
Types (3)
- offered to high risk OR positive screening
Types
- Chorionic Villi Sampling (CVS) at 11-13 weeks
- Amniocentesis at 14-16 weeks (results in 2 weeks)
- Percutaneous Umbilical Cord Sampling (PUBS)- assess for fetal anemia, isoimmunization; diagnosis genetic disorders
27
Pre-embryonic: Germ layers
Mesoderm (5)
Mesoderm
- bones (4th week)
- muscles (4th week)
- kidneys (5th week)
- hematologic system (bone marrow, blood, lymphatic tissue)
- Heart (4th week beats; forms in 3rd week
28
Pre-embryonic: Germ layers
Ectoderm (4)
Ectoderm
- CNS
- Integumentary (skin, hair, nails, sweat, oral mucosa)
- optic
- otic
29
Pre-embryonic: Germ layers
Endoderm (3)
Endoderm
- GI (liver, pancreas, esophagus, stomach)
- Respiratory
- Thyroid
30
Membranes: Amniotic fluid
Function (6)
Function
- maintain body temp
- barrier for infection
- musculoskeletal development (freedom for movement and symmetrical growth via prevention of membrane tangling)
- fetal lung development (swallow fluid)
- electrolyte balance (urinates around 11 wks)
- cushion
31
Membranes: Amniotic fluid
Structure (4)
Structure
- Volume is important to fetal well-being (700-1000 mL)
- contains mostly water plus urine (urea), lanugo hair, epithelial cells
- usually clear (brown/yellow if meconium)
- maintained by amniotic membrane then fetal kidneys
32
Membranes: Amniotic fluid
Problems (2)
Problems
- Oligohydramnios (< 500 ml) cause reduced fetal lung development, renal problems
- Polyhydramnios (>1500-2000 ml) cause chromosomal, GI, cardiac, and NTDs
33
Fetal Period (3)
- 9 weeks to end of pregnancy
- refinement of structure and function
- viability (ability to live outside uterus, 22-25 weeks based on CNS and lung maturity)
34
Membranes: Umbilical cord
Function
Composition (2)
Problems (3)
Function: Supplies the embryo with maternal nutrients and oxygen
Composition
- Wharton's jelly (CT cushions vessels from compression)
-2 arteries (carry deoxygenated blood from embryo to placenta), 1 vein (carry oxygenated blood from placenta to embryo- larger than 2 arteries)
Problems
- thin cord
- short cord
- cord w/ one artery and one vein (risk for cardiac or vascular anomaly)
35
Membranes: Placenta
Composition (3)
Problems (2)
Composition
- Chorionic villus (contains fetal blood vessels and imbeds in decidua basalis)
- intervillous space (contains maternal blood)
- Cell layer (prevents mixing of maternal and fetal blood)
Problems
- small placenta (poorly nourished and oxygenated child)
- teratogens can cross placenta (C, D, X drugs, live vaccines, viruses (rubella, cytomegalovirus)
36
Membranes: Placenta
Function (2)
Expected appearance
Function
- metabolic (exchange of gases, nutrients, wastes, and antibodies b/w fetus and maternal)
- endocrine gland (hCG, hCS, progesterone, estrogen, hPL, Growth hormone, Cortiotropin-releasing hormone)-- insulin antagonists starting at week 6 or 7
Expected appearance
- maternal side dull, fetal side shiny
37
Membranes
Yolk Sac
Endometrium (2)
Yolk sac
- Becomes primitive digestive system
Endometrium
- Decidua parietalis (lines uterine cavity)
- Decidua basalis (maternal part of placenta; divided in cotyledons/lobes; hemorrhage here usually for miscarriage)
38
Hormones in Pregnancy: Follicle Stimulating Hormone (FSH)
Functions (5)
Secreted from the anterior pituitary
Stimulates growth of the ovarian follicles
stimulates the follicles to secrete estrogen.
Stimulates sperm production
Decreases in pregnancy (Amenorrhea)
39
Hormones in Pregnancy: Estrogen
Functions (6)
- Secreted from the follicle cells,
- promotes the maturation of the ovum
- Stimulates enlargement of breasts and uterus.
- Decreases maternal use of insulin.
- Increases vascularity
- responsible for hyperpigmentation
40
Hormones in Pregnancy: Luteinizing Hormone (LH)
Functions (2)
Secreted from the pituitary gland
Stimulates testosterone production
41
Hormones in Pregnancy: Progesterone
Functions (2)
- Facilitates implantation by thickening and making endometrium more vascular
- decreases uterine contractility to maintain pregnancy by relaxing smooth muscles
42
Hormones in Pregnancy: Human Chorionic Gonadotropin (hCG)
Functions (3)
- produced by fertilized ovum and chorionic villi
- Stimulates corpus luteum so it will secrete estrogen and progesterone until placenta takes over
- Pregnancy tests detect this hormone in 1st trimester
43
Hormones in Pregnancy: Prolactin
Function
Prepares breast for lactation
44
Hormones in Pregnancy: Oxytocin
Functions (2)
- Stimulates uterine contractions
- stimulates milk ejection from breasts (milk let-down or ejection reflex)
45
Hormones in Pregnancy: Human placental lactogen (hPL) and human chorionic somatomammotropin (hCS)
Functions (2)
* insulin antagonist (promotes fetal growth by regulating glucose)
* stimulates breast development in preparation for lactation.
46
Fetal Developmental Milestones: 9 weeks (2)
- urine in amniotic fluid
- male/female anatomy (9-12 weeks)
47
Fetal Developmental Milestones: 12 weeks (5)
- Placenta complete
- organ systems complete
- thumb sucking
- somersaults
- heart tone heard on doppler
48
Fetal Developmental Milestones: 16 weeks (3)
- meconium in bowel
- sucking motions
- skin transparent
49
Fetal Developmental Milestones: 20 weeks (6)
- hearing develops
- quickening
- vernix caseosa and lanugo covers body
- sleep/wake cycles
- insulin produced
- brown fat develops
50
Fetal Developmental Milestones: 24 weeks (4)
- rapid brain growth
- hiccups
- vernix caseosa = thick
- Lecithin (L) present (lungs begin producing surfactant)
51
Fetal Developmental Milestones: 28 weeks (5)
- Lungs allow gas exchange)
- hair on head
- eyes open and close
- senses develop (taste buds, process sounds)
- subQ fat develops
52
Fetal Developmental Milestones: 32 weeks (3)
- bones fully developed
- increased subQ fat
- Lecithin/sphingomyelin (L/S) ratio (1.2:1) - enough surfactant to increase survival
53
Fetal Developmental Milestones: 36 weeks (3)
- decreased amniotic fluid
- Lanugo disappears
- Lecithin/sphingomyelin (L/S) ratio > 2:1 (lungs mature)
54
Fetal Developmental Milestones: 40+ weeks (2)
- considered full term at 38 weeks
- Hepatic (enough iron for 5 months post birth)
55
Fetal Circulatory System
Functions
- ductus venosus (2)
- foramen ovale (2)
- ductus arteriosus (3)
Ductus venosus
- Connects umbilical vein to inferior vena cava
- Allows most of oxygenated blood to enter right atrium
Foramen ovale
- may not fully close till 3 months of age
- Opening b/w right and left atria which shunts oxygenated blood right-to-left
Ductus arteriosus
-lungs do not function for gas exchange; ductus arteriosus (b/w aorta and pulmonary artery) used to bypass lungs
- Majority of oxygenated blood shunted from left atria to aorta; small amount to lungs
- Constricts after delivery due to higher blood oxygen levels and prostaglandins
56
What do the following mean:
Mono-di
mono-mono
di-di
Mono-di: share placenta but own amniotic sac for monozygotic twins
Mono-mono: share placenta and amniotic sac for monozygotic twins
di-di: own placenta and own amniotic sac for fraternal twins twins
57
Presumptive Signs of Pregnancy (7)
- any subjective symptoms reported by patient
- Amenorrhea
- Nausea/vomiting (weeks 2-12)
- Breast changes (sore, enlarged) - wks 2-3
- Fatigue (1st trimester)
- Increased Urinary frequency (pressure of enlarged uterus)
- Quickening (sensation of fetal movement around 18-20 wks)
58
Probable signs of Pregnancy (7)
- Chadwick’s sign (bluish-purple cervix) - 6-8 wks
- Goodell’s sign (cervix softens w/ leukorrhea) - 8 weeks
- Hegar’s sign (softened lower uterine segment) - 6 weeks
- Uterine growth
- Skin hyperpigmentation (chloasma, linea nigra)
- Ballottement (tap of examiner finger causes fetus to bounce in amniotic fluid) - 16-18 wks
- Positive pregnancy test (hCG blood, urine or home test) - detects anywhere from 1 week before missed period to 4 weeks gestation
59
Positive signs of Pregnancy (3)
- Auscultation of fetal heart (normal: 110-160 bpm) - 10-12 wks
- Observation and palpation of fetal movement by provider - 20 wks
- Sonographic visualization (cardiac movement or gestational sac) - 4-8 wks
60
Determining Pregnancy Due Date
Naegele's rule (2)
- 1st day of LMP + 7 days - 3 months = EDD
- inaccurate if irregular cycles or cycles > 28 days
61
Determining Pregnancy Due Date
Ultrasound (2)
- measure crown-rump length (< 14 weeks)
- measure Biparietal diameter, Head circumference, Femur length, Abdominal circumference (> 14 weeks)
62
Determining Pregnancy Due Date
Fundal height (4)
- in cm = gestational age starting at 10-12 weeks
- zero tape on symphysis pubis and top on fundus
- empty bladder prior to measurement
- unreliable in obese, IUGR, multi-gestation
63
Ultrasound: When indicated? (7)
- used when unclear hx of LMP or irregular cycles
- Pelvic pain or vaginal bleeding in first trimester
- Hx of repeated pregnancy loss or ectopic pregnancy
- Discrepancy b/w actual size and expected size of pregnancy based on history
- screen for aneuploidy (enlarged nuchal translucency i.e fluid filled space on dorsal of neck))
- Fetal biometric measurements (gestational age measurements, growth, activity, amnionicity, number)
- identify placental placement
64
Ultrasound: Transabdominal
Notes (3)
- Pt in supine position
- Full bladder necessary in first half of pregnancy
- Transmission gel and transducer placed on abdomen to create image
65
Ultrasound: Transvaginal
Notes (5)
- done in 1st trimester or if abdominal inconclusive b-c more accurate
- Pt in lithotomy position
- HCP uses sterile probe or transducer in vagina
- Assess for latex allergies
- Inform pt. they will feel pressure but not pain
66
Adaptations in Pregnancy: Endocrine (4)
- Thyroid (hyperplasia and increased vascularity) - causes heat intolerance and fatigue
- Decreased Glucose due to high BMR from fetal activity
- Increased insulin and pancreatic activity due to fetal depletion of glucose
- Increased cortisol (which increases risk of hyperglycemia if maternal resistance to insulin)
67
GTPAL
Gravida: total # of times woman has been pregnant (INCLUDES CURRENT PREGNANCY and no regard to # of fetus)
Term: # of births after 20 weeks’ gestation whether live or stillbirths ( twins= 1 delivery)
Preterm: number of Preterm deliveries (b/w 20 weeks & 1 day to 36 weeks & 6 days)
Abortion: number of Abortions (either spontaneous/miscarriage or induced) before 20 weeks’ gestation
Living: number of children currently Living (not including adopted or step children)
68
Adaptations in Pregnancy: Skin (7)
- striae (thighs, breast, buttocks, abdomen--usually darkish gray)
- chloasma (mask of pregnancy, brownish pigmentation on face)
- linea nigra (dark line on abdomen)
- acne (due to increased estrogen, progesterone, sebaceous glands secretions)
- Angiomas (spider nevi)
- Palmar erythema (pinkish-red mottling over palms of hands; red fingers)
- Vasomotor instability (hot flashes, flushing, alt hot and cold, increased perspiration)
69
Adaptations in Pregnancy: Breast (3)
- tenderness
- enlarged and darkened areola
- colostrum @ 16 weeks
70
Benefits of left lateral recumbent position (4)
* Maximize cardiac output, renal plasma volume, and urine output.
* Stabilize fluid and electrolyte balance.
* Minimize dependent edema.
* Maintain optimal blood pressure.
71
Adaptations in Pregnancy: Cardiac (10)
- heart shifts up and to the left
- systolic murmur and S3
- 45% increase in blood volume
- anemia (physiologic b-c hemodilution of high volume more than polycythemia AND iron-deficiency from fetal demand)
- high WBC (no infection)
- decreased systemic vascular resistance
- increased circulation (10-20 bpm increase)
- supine hypotension ( enlarged uterus compresses inferior vena cava so reduced blood flow to right atrium; decreased CO, BP, GFR, and urine output
- varicose veins and venous stasis (incl. hemorrhoids
- hypercoagulability (increased fibrin and decreased inhibition of coagulation)- low platelets
72
Adaptations in Pregnancy: Respiratory (4)
- increased nasal congestion and epistaxis
- upward displacement of diaphragm (dyspnea, decreased capacity)
- increased oxygen needs ( high RR, increased inspiratory capacity and decreased expiratory volume)
- slight hyperventilation (light respiratory alkalosis)
73
Adaptations in Pregnancy: Renal (4)
- increased UTI risk due to dripping
- delayed emptying times (urinary stasis b-c poor tone)
- Hyperemia (increased renal blood flow b-c increased CO and blood volume)-- decreased in 3rd trimester
- glycosuria and proteinuria (b-c exceeds tubal reabsorption threshold)
74
Adaptations in Pregnancy: Gastrointestinal (8)
- NV due to HcG (better by 16 weeks)
- lost of esophageal tone (heartburn)
- delayed emptying (normal may be BM q3days)
- displaced intestines (bloating, flatulence, cramping, pelvic heaviness, constipation)
- gingivitis/bleeding gums r/t vascular congestion
- change in taste and smell ( Pica, aversions)
- gallstones and cholestasis (b-c bile stasis and elevated LDL, Pruritis is sign)
- profuse salivation (ptyalism)
75
Adaptations in Pregnancy: Musculoskeletal (5)
- round ligament spasm
- waddle gait (softens ligaments; increases joint mobility)
- lordosis (lumbar curvature to compensate for change in center of gravity)
- widening and increased mobility of pubis
- diastasis recti (separation of rectus abdominis muscles in midline; benign in 3rd trimester)—weakened muscles
76
Adaptations in Pregnancy: Uterus (3)
- Cervical mucus plug (protective barrier b/w uterus and vagina via hypertrophy of cervical glands) -- opens during labor
- Braxton-Hick’s contractions (2nd trimester; intermittent and painless; irregular pattern)
- changes from elastic and muscular to thin in pregnancy
77
Adaptations in Pregnancy: Vagina (3)
- Increased acidity to prevent bacteria (allows Candida albicans)
- Relaxation and softening of wall and perineal body to stretch
- Leukorrhea: increased discharge in response to estrogen-induced hypertrophy of glands and increased vascularity
78
Discomforts in Pregnancy: Nausea and Vomiting
Tips (3)
- level blood sugar before getting out of bed (eat crackers)
- scopolamine patch
- biggest concern = dehydration (hyperemesis gravidarum)
79
Discomforts in Pregnancy: Headaches
Tips (4)
- Tylenol
- hydration
- tap of caffeine
- normal discomfort in 1st trimester; concern in 3rd trimester due to possible hypertension and preeclampsia)
80
Discomforts in Pregnancy: Indigestion/heartburn
Tips (3)
- antacids (tums)
- stay upright postprandial
- eat smaller meals
81
Discomforts in Pregnancy: Frequent urination
Tips (5)
- urinate as soon as the urge comes (b-c UTI from stasis possible and can lead to preterm pregnancy or pylonephritis)
- encourage wearing pads for dripples
- do kegel exercises (prevent prolapse as well)
- do not limit fluids
- Prevent UTI (wipe front to back, cotton underwear, voiding after intercourse, and not douching)
82
Discomforts in Pregnancy: Backache
Tips (4)
- wear good supportive bra b-c heavy breast can impair posture
- maternity belt and clothes to support uterus esp in multigravida or multi-gestation
- use pillow b/w legs
- Tylenol
83
Discomforts in Pregnancy: Constipation
Tips (6)
- hydration
- increased fiber
- avoid straining
- understand BM q3day (may be impaction if > 5 days)
- never use enema during pregnancy
- stool softeners are okay but risk for rebound constipation
84
Prenatal Care: Frequency of visits (4)
- monthly until 28 weeks
- Biweekly until 36 weeks
- Weekly until delivery/ 40 weeks
- twice a week over 40 weeks
85
Initial Prenatal Visit: Assessment (6)
- 1st day of LMP and degree of certainty about the date (Regularity, frequency, and length of menstrual cycles
- hx of current pregnancy (knowledge of conception date, Recent use or cessation of contraception, Signs and symptoms of pregnancy)
- psychosocial concerns (intended or unintended?, woman’s response to being pregnant, familial and partner support)
- Obstetrical history (GTPAL, Type of birth experiences, complications and neonatal outcomes)
- Physical and pelvic exams (bimanual)
- Fetal Heart rate w/ ultrasound doppler around 10-12 wks.
86
Initial Prenatal Visit: Labs (7)
- ABO and Rh (RhoGAM @26-28 wks if Rh-)
- Hct/Hgb (detect anemia, give iron if low)
- serological (varicella, rubella, syphilis, gonorrhea, chlamydia, HIV)
- Urine culture and protein ( UTI)
- HepB (Hep B vaccine at birth)
- HPV (pap q3 yrs even if pregnant till 30 then q5 yrs)
- TB skin test (if high risk)
87
First Trimester: Warning Signs (6)
- Vaginal bleeding (postcoital spotting is normal)
- Urinary symptoms (dysuria, frequency, urgency)- (UTIs need antibiotic)
- Abdominal cramping or pain( threatened abortion, UTI, or appendicitis)
- Absence of fetal heart tone (missed abortion)
- Fever or chills (infection)
- Prolonged NV (hyperemesis gravidarum, risk of dehydration)
88
2nd and 3rd Trimester: Assessments (8)
- BP decreases slightly at end of 2nd trimester
- Urine dipstick for glucose, albumin, ketone (mild proteinuria and glucosuria normal)
- Fetal- quickening (confirms EDD), FHR, kick count
- Leopold’s maneuvers (palpation of abdomen) to identify fetus in utero
- Ultrasound (to confirm EDD
- Fundal height measurement (equal weeks of gestation)
- Edema (slight in lower body is normal, abnormal if upper body esp. face)
- discuss psychosocial (fetal attachment, sexual activity, familial support, body image)
89
Second Trimester: Labs (3)
- Glucola (1-hr @ 24-28 weeks, earlier if obese; not done if pregestational diabetic)
- ABO and Rh (RhoGAM @26-28 wks if Rh-)
- Hct/Hgb (detect anemia, give iron if low) @ 29-32 weeks
90
2nd and 3rd Trimester: Warning Signs (5)
- Absence of fetal movements once felt ((fetal hypoxia or death))
- s/s of preeclampsia (swelling in face; new onset heartburn (liver involvement), severe headache, visual changes)
- Rhythmic intermittent Abdominal or pelvic pain ( PTL, UTI, pyelonephritis, or appendicitis)
- Vaginal bleeding (possible infection, friable cervix due to pregnancy changes, placenta previa, abruptio placenta, or PTL)
- Leaking of amniotic fluid (PROM)
91
Assessments: Fetal Kick Count
Procedure
Reassuring (2)
Procedure: pt. palpates abdomen and tracks fetal movement (kicks, flutters, swishes, rolls) daily for 1-2 hrs while at home
Reassuring:
- at least 10 movements in 2 hrs
- at least 4 movements in 1 hr.
92
Third Trimester: Labs (3)
- GBS vaginal and rectal swab at 35-37 wks (intrapartal antibiotics if positive)
- repeat STI (gonorrhea, chlamydia, syphilis, HIV, Hep B)
- do glucola, H&H if not done in 2nd
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Pregnancy Education: Safety (6)
- avoid chemicals (hair dyes) in first trimester
- avoid piercings and tattoos
- avoid contact w/ cat feces (no cleaning or changing litter box- toxoplasmosis risk)
- cook all EGGS, MEATS,FISH thoroughly
- do not eat food left out for > 2hrs
- rinse all rare fruits and veggies
94
Pregnancy: Foods to avoid (7)
- sushi or smoked seafood)
- cold deli meats and hot dogs (must be heated) (listeriosis risk)
- unpasteurized products (brie, camembert, feta cheeses; juices, dairy)
- limit caffeine to 200 mg (includes coffee, tea, soft drinks, cocoa butter)
- rare beef or lamb (toxoplasmosis risk)
- Certain fish (king mackerel, orange roughie, marlin, shark, swordfish, tilefish) due to high mercury
- Raw sprouts of any kind
95
Pregnancy Education: Travel (3)
- okay up until 36 weeks if low-risk
- travel w/ prenatal records for safety
- extended travel puts you at risk for blood clots (stay hydrated, take baby aspirin, wear antiembolism stockings)
96
Pregnancy Education: Dentition (3)
- good oral care (increased gingivitis risk)
- x-rays are okay
- get two dental screenings
97
Pregnancy Education: Exercise (3)
- recommended 30 minutes each day
- swimming and brisk walking are good
- Not recommended (things that can fall or easy loss of hydration): horse riding, hot yoga, sauna, hot tubs
98
Psychosocial Adaptation in Pregnancy
Changes in Trimesters (2)
Changes with trimester
- Ambivalence in 1st trimester (Concern if ambivalence in 3rd trimester)
- nesting behavior in 3rd trimester
99
Psychosocial Adaptation in Pregnancy
Factors that influence maternal adaptation (9)
- parity (multiparity have more info but may grieve special bond w/ first child)
- maternal age (adolescence and older have difficult time)
- sexual orientation (social stigma, heteronormativity of care, legal implications for gender miniorites)
- single parenting (legal and financial concerns)
- hx of abuse (pregnancy can trigger or worsen IPV)
- multigestational
- military deployment (higher mental health disorders)
- cultural and SES factors
- planned vs unplanned
100
Maternal Adaptation in Pregnancy
Significant tasks (4)
- Ensure safe passage of child and self (knowledge and care-seeking)
- Ensure social acceptance of child by significant others
- Attaching or binding in to the child (maternal-fetal attachment)
- Giving oneself to demands of motherhood (willingness and efforts to make personal sacrifices for child)
101
Maternal Adaptation in Pregnancy
Dimensions of Maternal Role Development (6)
- Acceptance of pregnancy
- Identification with motherhood role
- Relationship to her mother (Ideal is positive and relates to daughter as adult vs child)
- Reordering partner relationships ( sexual activity, impact of pregnancy on relationship, partner support) - open communication is key
- Preparation for labor (via classes, reading, fantasizing, dreaming)
- fears about labor (self-esteem, helplessness, loss of control over body and emotions))
102
Paternal Adaptation in Pregnancy
Effects of Pregnancy on Partner (2)
- Partners have fears, questions, concerns esp anxiety and worry
- Couvade syndrome/sympathetic pregnancy: pregnancy-like symptoms similar to pregnant pt such as minor weight gain, altered hormone levels, morning nausea, disturbed
103
Paternal Adaptation in Pregnancy
Announcement phase (3)
Announcement Phase (as news of pregnancy is revealed)
- Lasts from hours to weeks
- Internal conflict if partner feels different from societal expectations (Often men feel ambivalence in early pregnancy and postpartum)
- Main task: accept biological fact of pregnancy and accept expectant father role
104
Paternal Adaptation in Pregnancy
Moratorium Phase (3)
Moratorium Phase
- Often put conscious thought of pregnancy aside
- Problems: Conflict when woman communicates about pregnancy to partner, Fear of hurting fetus during intercourse, Feeling of rivalry with fetus
- Main task: accept pregnancy including pt’s emotional state, reality of fetus usually in 2nd trimester when changes in pt body, fetal movements
105
Paternal Adaptation in Pregnancy
Focusing phase (3)
Focusing Phase (last trimester)
- Actively involved in pregnancy and relationship with child
- See self as father
- Main task: negotiate w/ patient the role they will play in labor and prepare for parenthood
106
Sibling Adaptation to Pregnancy
Under 2
2-4 yrs
4-5 yrs
school-age
adolescence
- Under 2, usually unaware and do not understand explanations about new arrival
- 2-4 yrs, sensitive to environmental disruptions esp parental behavior and changes in home (may regress or show jealousy) -- prep 2 months in advance
- 4-5 yrs, interested in fetal development unless interferes w/ maternal ability to lift and play w/ them
- School age (6-12), usually enthusiastic and interested in details of pregnancy and birth
- Adolescent, May be uncomfortable w/ evidence of parent’s sexuality OR indifferent OR offer support and help like an adult
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Nutritional Needs for Pregnancy
Calories
Needs (2)
Cravings
Caloric requirements
- 300 extra calories
Needs
- Vitamins (folic acid)
- Hydration (8 to 10 glasses)
Cravings
- Pica: nonnutritive cravings (clay, dirt, starch)—can be toxic or lead to malnutrition
108
Suggested Weight Gain during Pregnancy based on Pre-pregnancy BMI
Underweight (<18.5)
Normal (18.5-24.9)
Overweight (25-25.9)
Obese (>30)
Underweight: 28-40 lb
Normal: 25-35 (37-54 for twins)
Overweight: 15-25 (31-50 for twins)
Obese (>30): 11-20 (25-42 for twins)
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Difference b/w the following
Miscarriage
Spontaneous abortion
Early Pregnancy loss
Miscarriage: loss of intrauterine pregnancy before 20 weeks/viability
Spontaneous abortion: Nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus w/o fetal heart activity within the first 12 6⁄7 weeks of gestation
Early Pregnancy loss: Spontaneous pregnancy demise before 10 weeks of gestational age
110
Miscarriage: Assessment Findings
S/s (2)
Confirmation (2)
S/s
- Uterine bleeding and cramping
- infection (fever, uterine tenderness, foul smell)
Confirmation: Ultrasound (if had previous ultrasound, now is bleeding and has an empty uterus) or serial HCG
111
Miscarriage: Medical Management (3)
- surgical evacuation
- mistoprostol (prostaglandin) - 800 microgram to remove products
- Rhogam (50 micrograms) if Rh- and unsensitized (given 72 hrs after diagnosis)
112
Miscarriage: Patient Education (5)
- report heavy bleeding (if soak 2 pads in 1 hr for 2 hrs) esp if mistoprostol used
- prevent miscarriage w/ vaginal micronized progesterone in women w/ hx of early pregnancy bleeding and miscarriage
- diet high in iron and protein to replace blood loss
- Pelvic rest (Nothing per vagina i.e. no tampons, douching, sexual intercourse
- Pericare (hygiene, prevent hemorrhage and infection)
113
Risks of recurrent miscarriages (2)
- obstetric complications in future pregnancies
- predictor of CVD and VTE
114
Swanson's Theory of Caring (r/t miscarriages)
5 concepts
- Knowing (assess needs, what did the loss mean to them)
- Being with (listen, be present, accepting their emotions/feelings)
- Doing for (performing interventions the patient and/or partner can't do for themselves)
- Enabling (gives options for care, guides, educates, empowers the couple; encourage to name baby and use baby name)
- Maintaining hope (instills believe in their ability to cope and move through)
115
Miscarriage: Psychosocial Education (5)
- Educate parents about what to expect (What the baby might look like)
- Encourage them to hold the baby.
- Ask them what they want (Funeral, burial, chaplain, pastor, priest)
- Encourage memory making with the family (Take photos, footprints, use a special gown for the baby, provide blankets and bereavement boxes as the hospital provides)
- Allow as much time with the baby as they want.
116
Maternal risks of Hypertension/Preeclampsia (6)
- Renal Failure
- Coagulopathy (DIC, thrombocytopenia)
- Cardiac (higher risk for heart disease, CHF, Pulmonary edema)
- hepatic Failure (HELLP)
- Placental abruption
- CNS (Stroke, cerebral edema, hemorrhage)
117
Fetal risks of Hypertension/Preeclampsia (6)
- Uteroplacental Insufficiency (placenta abruption, hypoxia, asphyxia)
- intolerance of labor (Premature Birth)
- IUGR
- metabolic and Cardiovascular diseases (DM, obesity, metabolic syndrome)
- oligohydramnios
- stillbirth
118
Define the following:
Gestational Hypertension
Preeclampsia
Eclampsia (2)
Gestational hypertension
- Onset of hypertension without proteinuria after week 20 of pregnancy and returns to normal 12 weeks postpartum
Preeclampsia (Pregnancy-specific syndrome)
- new onset hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman
Eclampsia
- Onset of seizure activity or coma in a woman with preeclampsia
- can occur during pregnancy or postpartum
119
Define the following:
Chronic hypertension (2)
Chronic hypertension w/ superimposed preeclampsia (2)
Chronic hypertension
- Hypertension present before pregnancy or diagnosed before week 20 of gestation
- Persist longer than 12 weeks postpartum
Chronic hypertension with superimposed preeclampsia
- Chronic hypertension with new onset proteinuria
- Significant worsening of hypertension or proteinuria
120
Chronic Hypertension: Patient Education (4)
-severity of HTN and organ damage assessed at initial visit to determine risk for complications
- limit sodium to 2.4 g per day
- use methyldopa (Aldomet) OR labetalol, hydralazine, nifedipine-- safe for breastfeeding
- increase # of prenatal visits
121
4 Causes of Preeclampsia
- Abnormal Placental implantation with abnormal trophoblasts invasion of uterine vessels at 8-10 wks gestation (higher systemic resistance) - (early onset before 34 wks gestation)
- Immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues ((late onset after 34 wks gestation)
- Maternal maladaptation to cardiovascular changes or inflammatory changes of pregnancy
- Genetic factors incl. inherited predisposing genes and epigenetic influences
122
6 Signs and Symptoms of Preeclampsia
- HTN > 140/90 on 2 occasions (4-6 hrs apart)
- Proteinuria = 2+ or 3+ dip on 2 occasions (6hrs apart) OR > 300 mg in 24 hrs
- Dependent or pitting edema (esp on face, hands, feet)
- CNS (Blurred vision, Scotoma (blindspot), headache, irritability)
- Hepatic signs (RUQ pain, jaundice, elevated enzymes)
- muscle changes (Hyperreflexia (DTR 3+ or 4+, clonus), seizures, coma)
123
Risk factors for preeclampsia (8)
- Nulliparity
- Age >35 years
- Pregnancy with assisted reproductive technology
- Family hx or personal hx of preeclampsia; poor outcome in pregnancy
- Interpregnancy interval >7 years
- Woman herself born small for gestational age
- obesity (> 30 prepregnancy)
- multifetal gestation
124
7 Medical Conditions which increase risk for Preeclampsia
- Renal disease
- Type 1 DM or GDM
- Antiphospholipid antibody syndrome
- Factor V Leiden mutation
- Autoimmune (SLE)
- chronic HTN
- thrombophilia
125
General Patho of Preeclampsia
- poor perfusion to placenta secondary to vasospasm, increased peripheral resistance, and increased endothelial cell permeability leading to poor tissue perfusion
126
Preeclampsia: Consequences of Vasospasm (7)
- hypertension
- uteroplacental spasm (IUGR)
- glomerular damage (oliguria, increased plasma, uric acid, creatinine, calcium; decreased GFR)
- cortical brain spasm ( headaches, hyperreflexia, seizures)
- retinal arteriolar spasm (blurred vision, scotoma, double vision, photophobia)
- hyperlipidemia
- liver ischemia (elevated liver enzymes, NV, epigastric pain (microvascular fat deposits), RUQ pain (hemorrhage necrosis))
127
Preeclampsia: Consequences of Intravascular coagulation (3)
- hemolysis of RBCs
- platelet adhesion (thrombocytopenia, Disseminated intravascular coagulation)
- increased factor VIII antigen
128
Preeclampsia: Consequences of Increased permeability/capillary leakage (4)
- proteinuria
- generalized edema
- pulmonary edema (dyspnea; left ventricular failure b-c high vascular resistance)
- hemoconcentration (high hct)
129
9 Signs of Severe Preeclampsia
- oliguria
- platelets < 100,000 (thombocytopenia)
- BP > 160/110 (4-6 hrs apart x 2)
- Proteinuria (> 3+ dip or > 500 mg 24 hr)
- Creatinine > 1.1 or doubled in absence of renal disease
- Elevated liver enzymes (2x normal)
- New onset cerebral or visual disturbances (headaches, blurred vision, scotoma (blind spot), hyperreflexia), photophobia
- Persistent epigastric pain (RUQ pain) due to subcapsular hematoma in liver from hemorrhagic necrosis
- Pulmonary edema (r/t volume overload from high vascular resistance)---s/s: SOB, chest tightness, cough O2 < 95%, increased RR or HR, apprehension, anxiety, restlessness
130
Severe Preeclampsia: medical management
Goal
Notes (5)
Goal: control BP and prevent seizures
- corticosteroids (fetal lung maturity) if preterm
- magnesium sulfate
- benzos (if magnesium sulfate contraindicated)
- antihypertensives
- Induced birth indicated at >34 weeks if unstable or with severe features to prevent poor outcomes (hospitalization if < 34 weeks)
131
Preeclampsia: Antihypertensives
Tips (4)
* Given within 30-60 minutes for severe hypertension
* No need for cardiac monitoring if IV or immediate release
* Monitor BP q5-15 mins
* Give q20 min PRN
132
Severe Preeclampsia: Nursing management (6)
- Continuous EFM ( intrauterine resuscitation of fetus (IV fluid, O2, lateral position))
- Seizure precautions (side-lying)
- Limit stimulation (Quiet environment, dim lighting, relaxation techniques)
- Strict I & O and daily weights (fluid < 2 L/24 hr)
- check DTRs (brachial if regional anesthesia used)
- check BP at level of heart (not left lateral b-c gives false low)
133
Biophysical Profile
5 components
Normal value
Abnormal Value
Components: nonstress test (NST), fetal movement, fetal breathing, fetal tone, and amniotic fluid index (AFI))
Normal: 8 (w/ NST) to 10 (w/ reactive NST)
Abnormal: <4 = fetal compromise
134
Umbilical artery Doppler velocimetry
Purpose (2)
Normal value
Abnormal Values (2)
Purpose:
- Shows fetal compromise (IUGR) or placental dysfunction prior to clinical signs
- measure hemodynamic changes in fetal and placental circulation
Normal: Systolic/Diastolic ratio declines w/ pregnancy due to decreased placental resistance
Abnormal
- increased S/D ratio in IUGR due to arthrosis of placenta vessels increasing resistance in preeclampsia
- absent or reversed-end diastolic flow through arteries (deoxygenated blood should be in arteries and carry to placenta, veins carry oxygenated blood)
135
Preeclampsia: medical management
Mild (5)
- low dose prophylaxis aspirin
- Activity restriction
- Frequent office visits (weekly)
- BP monitoring
- Antenatal testing (BPP, NST, kick counts, serial ultrasounds)
136
Magnesium sulfate
Use
Action
Loading dose
Continuous dose
Therapeutic level
Antidote
Use: CNS depressant/muscle relaxant to prevent seizures
Action: Promotes cerebral vasodilation and reduce ischemia caused by vasospasm
Loading dose: 4-6 grams in 100 ml over 15-20 minutes
Continuous piggyback infusion: 1-2 g/hr in 100 ml
Therapeutic level: 4.8-9.6 mg/dl (4-7 mEq/L)
Antidote: calcium gluconate
137
Magnesium sulfate
Maternal Side effects (8)
- Hot flashes and sweating
- burning at IV site
- N&V
- dry mouth
- drowsiness, lethargy
- blurred vision
- SOB
- transient hypotension
138
Magnesium sulfate
Fetal Side effects (4)
- decreased variability
- respiratory depression
- hypotonia
- decreased suck reflex
139
Magnesium sulfate
Nursing Care (5)
- monitor CNS (DTRS, clonus) q 1 hr
- may need oxytocin stimulation for contractions
- give 24 hr after delivery (discontinue within 48 hrs)
- Verify dose / second nurse
- Labs: Serum magnesium levels q 4-6 hours
140
Magnesium sulfate
Signs of Magnesium Toxicity (7)
- hypocalcemia (muscle weakness)
- RR < 12/min
- absent DTRs
- Mg level > 8mEq/dl
- Urine output < 30/hr
- slurred speech
- dysrhythmias and circulatory collapse
141
Magnesium sulfate
Contraindications (3)
- renal failure
- myasthenia gravis
- pulmonary edema
142
HELLP Syndrome
3 parts
Hemolysis (RBC destruction via constricted vessels)- total bilirubin > 0.2, abnormal peripheral smear
Elevated Liver Enzymes (Decreased blood flow and Damage to the liver)- AST > 70, RUQ pain, NV, malaise
Low platelets (<100,000)- Platelets aggregate at the site of damaged endothelial vessels (platelet consumption and thrombocytopenia)-- easy bleeding, bruising
143
HELLP Syndrome
Onset
Risks (3)
Treatment (2)
Onset: any time including postpartum
Risks: placental abruption (PTL, death), renal failure, liver hematoma
Treatment
- Delivery but may worsen in first 48 hrs postpartum
- platelet replacement
144
Hydralazine (Apresoline)
Side Effect
Contraindication
* Side effect: maternal hypotension
* Contraindication: mitral valve disease
145
Labetalol Hydrochloride (Normodyne)
Side Effect
Contraindications (3)
Side Effect: neonatal bradycardia
Contraindication: HF, heart disease, asthma
146
Nifedipine (Procardia)
Side Effects (2)
maternal tachycardia and overshoot hypotension
147
Corticosteroids (betamethasone, dexamethasone)
Use
Action
Dosage (2)
Maternal Side Effects (2)
Fetal Side effect
Action: Stimulates fetal lung maturity
Indication: Prevent/reduce the severity of neonatal respiratory distress syndrome b/w 24-34 weeks gestation
Dosage and Route:
Betamethasone – 12mg IM, 2 doses 24 hrs apart
Dexamethasone – 6mg IM, 4 doses 12 hours apart
Side effects:
Maternal – increase in WBCs, hyperglycemia (lasts 72 hrs)
Fetal – decrease in fetal breathing and body movements (lasts 72 hrs)
148
Eclampsia: care during seizure(4)
* Stay with patient
* Call for help and notify HCP
* Safety (lower bed, turn on side, suction PRN to prevent aspiration; keep side rails up and padded)
* Record time, length, and type of seizure activity
149
Eclampsia: care after seizure (4)
* Delivery after maternal hemodynamic stabilization
* Monitor maternal and fetal vitals
* Give meds (magnesium, antihypertensive)
* Give oxygen 10L/min via mask
150
Eclampsia
Fetal Risks (3)
Maternal risks (4)
Fetal
- Recurrent and prolonged FHR decelerations
- Fetal tachycardia (bradycardia during seizure r/t hypoxia)
- reduced variability
Maternal
- hypoxia
- trauma
- aspiration pneumonia
- neurologic damage (impaired memory and cognition)
151
Diabetes in Pregnancy: Contributors to Insulin Resistance (6)
- Increased maternal adiposity
- Insulin desensitizing hormones from placenta ((Progesterone, growth hormone, Corticotropin releasing hormone, human placental lactogen, insulinase secretion, human chorionic somatomammotropin (HCS)) shift energy source to ketones and fatty acids
- increased calories
- decreased exercise
- Glucose is the primary fuel for the fetus
- Insulin needs increase during the first trimester
152
Define the following:
Pregestational Diabetes
Gestational Diabetes
Pregestational diabetes: glucose levels above normal but below cutoff for overt diabetes in nonpregnant women
Gestational Diabetes: glucose intolerance not present before pregnancy due to insulin resistance in pregnancy
153
Preconception care: women w/ pre-existing diabetes (3)
- Establish glycemic control before conception (Poor glycemic control at conception and in the early weeks increases risk for miscarriage and fetal anomalies)
- Diagnose any vascular complications (kidney, heart, thyroid function, ophthalmic tests)
- May need 3-4x prepregnancy level of insulin
154
Gestational Diabetes Mellitus: Maternal Risks (9)
- polyhydramnios ( >2000ml = risks for abruption, PROM and preterm labor, anomalies)
- infection, inflammation, leukocyte function (UTI, monilial vaginitis)
- placental abruption
- Postpartum hemorrhage and anemia
- C-section, assisted delivery
- type 2 DM, GDM in future
- Metabolic disturbances (hyperemesis, NV)
- Exacerbation of chronic conditions (DKA (2nd semester), HTN, preeclampsia)
- Oligohydramnios (decreased placental perfusion)
155
Diabetes Mellitus: Fetal risk (5)
- macrosomia (> 4-4.5 kg b-c high glucose= high insulin = high growth)
- congenital defects (during organogenesis mainly for pregestational)
- IUFD (intrauterine fetal death) ( r/t hyperglycemia, infection)-- stillbirth
- IUGR (due to vascular issues)
- asphyxiation
156
Diabetes Mellitus: Neonatal risks (7)
- hypoglycemia (few hrs)
- hypocalcemia/ hypomagnesemia
- hyperbilirubinemia (r/t polycythemia and increased erythropoietin; RBC breakdown)
- Respiratory Distress Syndrome (RDS) and transient tachypnea of newborn (TTN)
- cardiomyopathy
- shoulder dystocia, birth trauma
- chronic conditions later in life (Type 2 DM, obesity)
157
Gestational Diabetes
Risk Factors (5)
- Metabolic syndrome (central obesity, dyslipidemia, hyperglycemia, hypertension)
- Hx of fetal macrosomia, GDM
- Physical inactivity
- PCOS
- Family hx of diabetes
158
GDM: Blood sugar goals
Fasting
1-hr postprandial
2-hr postprandial
HgbA1C
Fasting <95mg/dl
1 hr PP < 140
2 hr PP < 120mg/dl
HgbA1C < 6%
159
GDM: Management (6)
- diet preferred (2000-2500 cals/day; minimum 1800)
- Nutritional breakdown (40% carbs, 20% protein, 30-40% fat)
- moderate exercise (3/ week for 20 min)
- Self-monitoring (SMBG 4-8 times a day before and after meals
- Medication Therapy: Insulin (if necessary) or Oral agents (Glyburide, metformin)
- Fetal surveillance (detect compromise early to prevent IUFD-- NST around 28-32 weeks)
160
GDM: When to call provider (4)
- Glucose > 200 mg/dL
- Moderate ketones in urine
- Decreased fetal movement
- Persistent nausea and vomiting
161
GDM: Intrapartal care (4)
- Evaluate fetal lung maturity via checking amniotic fluid for phosphatidylglycerol (averts RDS in < 38 wks gestation)
- glucose-maintained b/w 70-110 in labor (IV insulin given; glucose checked q1-2 hrs and ketones q4h)
- If corticosteroid given to prevent preterm delivery, increase insulin
- cesarean needed if fetus > 4.5 kg
162
GDM Screening
Who? (2)
Two-steps
- all pregnant at 24-28 weeks (high risk also at first prenatal visit)
Steps
- Initial: 50-g oral glucose load (positive if > 135-140 mg/dl (fasting not necessary))
- If positive, do 3-hour oral glucose tolerance test (OGTT) with a 100gm oral glucose load: (fasting required)
163
GDM: 3 hr Glucose tolerance test
Procedure
Criteria for Positive (4)
Procedure
- 3-hr glucose tolerance test after 8-12 hrs of fasting w/ 100 g glucose
- Plasma glucose drawn at fasting, 1, 2, 3 hrs
Criteria
If 2 or more levels high
GDM diagnosis made
* Fasting > 95
* 1 hr > 180
* 2 hr > 155
* 3 hr > 140
