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ch 11 High risk perinatal care: Preexisting conditions
Preexisting and Gestational Conditions
Terms in this set (59)
Most common endocrine disorder associated with pregnancy. Goal is to restrict maternal glucose control before contraception and throughout gestational period.
Key is to control maternal glucose levels
Women with gestational diabetes should be retested 6-12 weeks after pregnancy ends.
Target Levels of Glucose During Pregnancy
Lower than nonpregnant values
1-hr postmeal: 130-140
Fetal Risks with Diabetes
NTD, cardiac anomalies (esp when moms have poorly controlled glucose - check A1c)
Occurs in women with pre-existing disease.
Insulin dose must be significantly increased during the 2nd and 3rd trimesters. Plateaus after 35 weeks gestation.
Humulin typically used.
Type II is not common
Risks and Complications from Pregestational DM
Birthweight greater than 4000g
Caused by poor glycemic control
Shoulder dystocia can result - increased likelihood for C-sections
Develops during the 3rd trimester in moms with DM
Increases risk for abruption placentae, uterine dysfunction, and postpartum hemorrhage
Accumulation of ketones in the blood resulting from hyperglycemia and leading to metabolic acidosis.
Prompt treatment needed to prevent maternal coma or death. Can also lead to fetal death (10% Stillborn)
Due to increased hepatic glucose
Occurs due to stress factors or infection/illness
Occurs frequently in early pregnancy.
Mild-to-moderate hypoglycemic episodes do not seem to affect fetus
Fetal Risks from Pregestational DM
Morbidity and mortality rates are reduced with controlled maternal glucose
Increased incidence of stillbirth - thought to be caused by fetal acidosis in third trimester
Congenital malformations r/t to severity and duration of diabetes.
DM Fetal Risks: First Trimester
Hyperglycemia leads to birth defects.
Primarily affects cardiovascular system, CNS, and skeletal system
DM: Antepartum Evaluation
Complete physical exam is performed. Patient needs more frequent monitoring
Assess the effects of diabetes, including retinopathy, nephropathy, peripheral vascular, and cardiac involvement.
Tests: Baseline renal function assessed with a 24-hour urine collection. Glycosylated hemoglobin A1 to measure glycemic control
DM: Antepartum Care
Maintaining tight glucose control means mom must follow consistent daily schedule.
Diet: goal is to provide weight gain consistent with a normal pregnancy, prevent ketoacidosis, and minimize wide fluctuations of blood glucose levels. Woman should not go more than 4 hours without food. Large bedtime snack is recommended.
Exercise: Should be prescribed by PCP. Aerobic exercise with resistance training is best; decreases insulin at the cellular level.
Insulin Therapy: Type 1 diabetics will need multiple daily injections; type 2 will need to begin administering them. Humulin the most common type used.
Monitoring Blood Glucose: Moms are more likely to develop hypoglycemia.
Urine Testing: Testing for glucose not beneficial during pregnancy due to lowered renal threshold for glucose; test for ketones and protein in the urine.
Determination of birthdate: Optimal birthdate is between 38.5 and 40 weeks as long as good metabolic control is maintained. Birth can occur earlier due to poor metabolic control, HTN disorders, fetal macrosomia, or fetal growth restriction. About 50-80% of moms have C-sections.
Complications Requiring Hospitalization: Regulation of insulin therapy and stabilization of glucose levels. Infection. Preeclampsia/HTN.
Fetal Surveillance: Follow-up ultrasounds performed every 4-6 weeks to monitor fetal growth and estimate weight. Fetal echocardiography performed between 20-22 weeks to check for cardiac anomalies.
Pregestational DM: Intrapartum Care
Monitor for complications r/t dehydration, hypoglycemia, and hyperglycemia.
IV line inserted for maintenance fluid. Once active labor begins or glucose falls below 70, infusion changed to 5% dextrose. Hyperglycemia can cause hypoglycemia in neonate.
C-sections should be scheduled early in the morning to facilitate glycemic control. No morning insulin given day of. surgery.
Pregestational DM: Postpartum Care
Insulin requirements decrease substantially because placenta is gone.
Several days may be required for reestablish carbohydrate homeostasis.
Woman must be reminded to eat on time. Breastfeeding is encouraged because it has an antidiabetogenic effect for the baby.
Should discuss risks and benefits of contraceptive methods with mother and partner before discharge. Barrier methods recommended as well as IUD. OC are controversial due to risk for thomboembolytic complications and effect on carbohydrate metabolism.
Accounts for 90% of all diabetic pregnancies. Usually diagnosed during the second trimester
More likely to occur in Hispanic, Native American, Asian, and AA women. Likely to recur in future pregnancies.
Risk factors: family history of diabetes, previous pregnancy with unexplained stillbirth, malformed or macrosomic fetus, obesity, HTN, glycosuria, maternal age greater than 25
Gestational GM: Maternal-Fetal Risks
No increase in birth defects have been found in women who develop GDM after first trimester. Due to the fact that critical period of organ formation has already passed.
Screening for GDM
All pregnant women not known to have pregestational diabetes should be screened for GDM.
Oral glucose tolerance test is performed.
Typically, 2-step test is performed.
GDM: Antepartum Care
Diet and exercise: Woman receives standard diabetic diet. Regular exercise can decrease need for insulin in overweight women.
Monitoring blood glucose: Women should monitors blood glucose daily.
Insulin therapy: 25% of women with GDM require insulin. Initially managed with diet and exercise. Glyburide is the oral agent most frequently prescribed.
Fetal surveillance: Women will well-controlled glucose are at low risk for IUFD. Antepartum testing is therefore not performed unless there is HTN, history of stillbirth, or suspected macrosomia. Women can continue pregnancy until 40 weeks gestation but fetal growth should be monitored.
GDM: Intrapartum Care
Monitored hourly to maintain levels of 80-120 mg/dL. IV fluids with dextrose should be avoided.
GDM: Postpartum Care
Most women with GDM return to normal glucose levels after childbirth. 35-75% chance GDM will recur in next pregnancy. Women also have increased chance of developing type 2 diabetes.
Screening Process for GDM
1-hour oral glucose tolerance test (OGTT).
If negative (less than 130-140 mg/dL), routine prenatal care is implemented.
If positive (greater than 130-140 mg/dL), 3 hours OGTT is implemented. Results can be negative or positive.
Rare in pregnancy.
Treatment is to inactivate the thyroid.
At risk for infertility and miscarriage, rare in pregnancy.
Recognized cause of mental retardation caused by deficiency in enzyme phenylalanine hydrolase.
If mother has PKU, they are advised against breastfeeding and special formula is used.
During pregnancy there is an increase intravascular volume, decreased systemic vascular resistance.
Increased risk of miscarriage, preterm labor and birth more prevalent, and intrauterine growth restriction is more common.
Congenital Cardiac Diseases
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Coarctation of the aorta
Tetralogy of the heart
With ASD and VSD - monitor for S&S of CHF, arrhythmia, pulmonary HTN, and emboli.
With Coarctation and Tetralogy, prophylactic antibiotics are given.
Acquired Cardiac Diseases
Mitral valve prolapse
Mitral valve stenosis
Aortic stenosis (more dangerous for Mom)
Myocardial infarction (MI) is rare but usually older moms (>33).
If MI occurs during pregnancy, the baby becomes severely hypoxic.
Other Cardiac Conditions
Peripartum Cardiomyopathy (PCM)
Eisenmenger and Marfan Syndromes - close monitoring, and planned C-section
Heart Transplantation - lower risk, mom on immunosuppressant regimen, conception should be postponed for at least 1 year
Plan of Care for pregnant woman with cardiac disorder
minimize stress on heart, monitor for S&S of cardiac decompensation, bed rest, nutrition counseling, adjusted cardiac meds, limit sodium in diet
Anticoagulant therapy - Heparin - Large molecule drug does not cross the placenta
Intrapartum - Prophylactic antibiotics and focus on promoting cardiac function; reduce pressure on superior vena cava
Postpartum - focus on monitoring for cardiac decompensation
Reduces oxygen-carrying capacity of the blood. Heart tries to compensate by increasing output. Can lead to CHF.
Hematocrit for pregnant women may be as low as 33%.
If a woman has blood loss during birth and is anemic, it is not well-tolerated.
Iron Deficiency Anemia
Most common form of anemia. Levels below 12 mcg/L reflect anemia.
Association with preterm and low birthweight infants.
Iron given IV or IM.
Folic Acid Deficiency Anemia
Women who have hemoglobinopathies, take anticonvulsant meds, are pregnant with multiples, or have frequent pregnancies are at risk for deficiency.
Most common cause of megaloblastic anemia. Not a significant cause of perinatal morbidity.
Sickle Cell Hemoglobinopathy
Women with sickle cell trait have increased risk for preeclampsia, intrauterine fetal death, preterm birth, and low-birthweight infants, and UTI. Baby is also at risk for adverse effects from narcotics.
Women require genetic counseling prior to pregnancy. Women with sickle cell are at high risk for poor pregnancy outcomes, including miscarriage, IUGR, and stillbirth. Risk for preeclampsia and infection.
Should labor in side-lying position.
Uncommon anemia in which insufficient amount of hemoglobin is produced to fill RBCs.
Chronic inflammatory disorder involving tracheobronchial airways. Characterized by exacerbations and remissions.
Effect of pregnancy on asthma is unpredictable. Associated with preeclampsia, low birth weight or IUGR, preterm birth, and perinatal mortality.
Women with moderate to severe asthma require antepartum fetal testing by 32 weeks. During postpartum period, women are at increased risk for hemorrhage.
Hemabate cannot be given in hemorrhage due to risk of bronchospasm.
Medication given after delivery.
Moms advised to not breastfeed.
Genetic testing is done for the baby
Delivery can be either vaginal or c-section
anticonvulsants increase incidence for congenital anomolies; preconception counseling
Multiple Sclerosis (MS)
Mom is placed on bed rest and given steroids to treat acute exacerbation
acute facial paralysis; steroid therapy
Systemic Lupus Erythematosus
focus on reducing risk of infection; babies are usually IUGR
May require forceps or vacuum or possibly a c-section delivery
Integumentary Disorders in Pregnancy
Skin Problems Aggravated by Pregnancy
Acne vulgaris (in 1st trimester)
Pruritic urticarial papules and plaques (PUPPP) - typically occurs in primigravidas with multiple gestation; goal is to treat symptoms
Intrahepatic cholestasis - liver disorder characterized by pruritus; begins in third trimesters; affects palms and soles of feet and is worse at night. No skin lesions. Poor fetal outcomes are associated
Continued use of substances despite related problems in the physical, social, or interpersonal areas.
Includes dual diagnosis - substance abuse plus another psychiatric disorder
Alcohol and other drugs pass through placenta, causing bleeding complications, miscarriage, stillbirth, prematurity, low birth weight, and SIDS
Barriers to Substance Abuse Treatment
Women fear losing custody of child and criminal persecution
Less than 10% of pregnant women receive treatment
Substance-abuse treatment programs do not address issues affecting pregnant women
Long waiting lists and lack of health insurance present further barriers to treatment
Screening for Substance Abuse
Questions for alcohol and drug abuse should be included in the overall assessment at the first prenatal visit.
Screening with the 4Ps Plus: Parents, Partner, Past, Pregnancy
Asking about substance use before pregnancy is a good indicator.
Substance Abuse: Initial Care
Begins with education about the specific drug effects on pregnancy, fetus, and newborn
Antabuse is teratogenic - should not be used for pregnant women.
Methadone can be used for women who are dependent on heroine or other narcotics.
Substance Abuse: Follow-Up Care
Before a known substance abuser is discharge with her baby, the home situation must be assessed to determine that it is safe
Breastfeeding contraindicated in women who continue to use amphetamines, alcohol, cocaine, heroin, or marijuana.
Sign of cocaine abuse is a quick, fast, hard labor.
Development of HTN after week 20 of pregnancy in previously normotensive woman without proteinuria.
Development of HTN and proteinuria in previously normotensive woman after 20 weeks of gestation or in early postpartum period
Severe CNS irritability; check deep tendon reflexes
Development of convulsions or coma not attributable to other causes in preeclamptic women.
Eclamptic seizures can occur before, during, or after birth.
Elevated Liver enzymes
Low Platelet count
More in Caucasian women
Consequence of severe preeclampsia
Preeclampsia Risk Factors
First child with a new partner
Preexisting medical condition
Preeclampsia in a prior pregnancy
Pregestational Diabetes (DM type 1)
When the placenta attaches, new vasculature forms but in preeclampsia this isn't formed correctly and causes vasospasm, increased peripheral resistance, and increased endothelial cell permeability leading to decreased tissue perfusion
Poor perfusion resulting from vasospasm which diminishes diameter of blood vessels which impedes blood flow to all organs and increases BP which causes significant decreases in placental, kidney, liver, and brain function
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