OB - Exam 3

During the 2nd and 3rd trimesters, pregnancy exerts a ________ effect on the maternal metabolic status

"Diabetogenic" Because of the major hormonal changes, *decreased tolerance to glucose, increased insulin resistance, decreased hepatic glycogen stores, & increased hepatic production of glucose occur*. Rising levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, & insulinase *INCREASE insulin resistance through their actions as insulin antagonists* *Insulin resistance is a glucose-sparing mechanism that ensures an abundant amount of glucose for the fetus* Maternal insulin requirements gradually increase from 18-24 weeks to about 36 weeks Insulin requirements double or quadruple by end of pregnancy

In women with pregestational diabetes, the goals of fetal surveillance are to:

*Detect fetal compromise as early as possible & prevent IUFD or unnecessary preterm birth* 1. ultrasounds to monitor fetal growth and size 2. *maternal serum alpha-fetoprotein performed between 15-20 weeks bc fetus is at increased risk for neural tube defects* (spina bifida, anencephaly, or microcephaly) and then *ultrasound at 18-20 weeks to check* 3. *ultrasound measurement of fetal nuchal translucency (NT)* with maternal serum screening late in first trimester (11-14 weeks) has been *found to increase detection of heart defects* and other anomalies 4. *fetal echo between 20-22 weeks* to detect cardiac anomalies 5. *doppler studies of umbilical artery* if mom has vascular disease to detect placental compromise 6. *daily fetal movement counts beginning at 28 weeks* 7. NST to evaluate fetal well-being -*Usually start at 32 weeks then twice weekly* -If nonreactive, BPP or contraction stress test -*Testing earlier (28-32 weeks) if woman has vascular disease or poor glucose control*

Management of placenta previa is based on:

*Gestational age, amount of bleeding, fetal conditions* 1. Active Management: -If a patient is *> 37 weeks' gestation, in labor, or bleeding persistently then deliver by C/S* -C-Section is *always performed in the presence of complete previa* regardless of status -*Vaginal birth may be an option for those with a partial or marginal previa with minimal bleeding* 2. Deliver regardless of gestational age if: -Heavy bleeding -Fetal distress 3. Following delivery -Monitor for postpartum hemorrhage: fundal portion of the uterus exerts the strongest contractions therefore would control bleeding in a normally implanted placenta. -The lower portion of the uterus does not exert as much contraction force therefore *leaving a patient prone to postpartum hemorrhage due to possible retained placental fragments* following delivery

Insulin acts as a growth hormone, causing the fetus to produce excess stores of:

*Glycogen, protein, and adipose tissue and leading to increased fetal size, or macrosomia* Birth injuries are more common in infants born to moms with diabetes compared to moms who do not, and macrosomic fetuses have the highest risk for this complication

Hyperglycemia occurs as a result of increased:

*Hepatic glucose production & decreased peripheral glucose use* Stress hormones released > fatty acid mobilized into circulation > ketone bodies released into peripheral circulation > buffering system unable to compensate > metabolic acidosis develops > osmotic diuresis with fluid loss *MEDICAL EMERGENCY NEEDING PROMPT TREATMENT*

Post-loss follow up

*Important times for follow up are: 1 week, 3 weeks- 4 months, due date * Initial session 4-6 weeks after loss: 1. Flag chart so that personnel that interact with patient are aware there has been a loss 2. Minimize time in waiting room, instruct front desk staff to take family back to room immediately 3. Designate a RN in the practice as the resource for information on local resources for families experiencing loss 4. Follow up with phone call or note to patient—above nurse should coordinate follow up. 5. *HIGHER risk for postpartum depression* 6. Assessment of the grieving process 7. Additional genetic services, if indicated 8. Review preliminary autopsy data -Of the parents who suffer a perinatal loss, at least 80% become pregnant again within 18 months -*Anxiety and depression are common maternal responses during subsequent pregnancies after a loss*. -During subsequent pregnancies, it's *important for previous loss to be acknowledged and for the mother to have the opportunity to contact the health care team as often as needed*.

Premature preterm rupture of membranes (PPROM) occurs when a patients amniotic sac ruptures when?

*Prior to 37 weeks gestation* 1. The cause of PPROM is unknown, however *infection is thought to be a major contributor* 2. *Chorioamnionitis is a major complication of PPROM* -Chorioamnionitis is an infection of the chorion and amnion: it can be life-threatening for both fetus and mother 3. Other risk factors associated with PPROM -*Cord prolapse* -*Cord compression* -*Placental abruption* 4. Treatment -*Antenatal glucocorticoids if no sign of infection* -*Prophylactic antibiotics to prevent infections* - unknown effectiveness

DIC is often triggered by:

*Release of large amounts of thromboplastin* 1. *placental abruption (most common cause of DIC)* 2. retained dead fetal syndrome 3. anaphylactoid syndrome 4. Severe preeclampsia 5. HELLP syndrome 6. Gram-negative sepsis 7. Amniotic fluid embolism (usually not able to be determined until autopsy) 8. Hemorrhagic shock 9. Transfusion reaction

Pregestational diabetes

*Woman already has type 1 or type 2 diabetes at the time she becomes pregnant* -almost all women with this are *insulin dependent during pregnancy* -normal hormonal adaptations of pregnancy affect glycemic control and pregnancy *may accelerate progress of vascular complications* -*first trimester: insulin may have to be reduced to prevent hypoglycemia* -*NV and cravings typically result in dietary fluctuations* that influence maternal glucose levels and *may necessitate reduction in insulin dose as well* -*Then insulin requirements steadily increase so insulin dose adjusted to prevent hyperglycemia* -Insulin resistance begins as early as 14- 16 weeks and continues to rise until stabilizes during last few weeks of pregnancy

Common causes of iatrogenic/indicated preterm birth

*intentionally delivered due to maternal or fetal health reasons:* 1. Preeclampsia/Eclampsia 2. OB disorders or risk factors in the current or a previous pregnancy 3. Previous C/S via a classic uterine incision 4. Placental disorders 5. Medical disorders 6. Seizures 7. Thromboembolism 8. Maternal HIV or active herpes infection 9. Obesity 10. Advanced maternal age 11. Fetal disorders 12. Chronic (IUGR) or acute (abnormal NST or BPP) fetal compromise 13. Excessive or inadequate amount of amniotic fluid (oligo/polyhydramnios​) 14. Congenital fetal abnormalities

HTN disorders in pregnancy

-Common -Medical complications (5-10%) of pregnancy. -Major cause of: 1. Perinatal Mortality & Morbidity -Uteroplacental Insufficiency -Premature Birth 2. Maternal Mortality & Morbidity -Renal Failure -Coagulopathy -Cardiac or Liver Failure -Placental abruption -Seizure -Stroke

How is perinatal loss different?

-Suddenness and unexpected nature of loss -The way infant death is socially defined in our culture -Loss of dreams and future with the child -In some situations, anticipatory grief is experienced. Two major types: 1. death of fetus or newborn 2. birth of less than perfect child

5 nursing interventions for preterm labor

1. *Bedrest in side-lying position* -*promotes uteroplacental perfusion* 2. Hydration -*Dehydration can contribute to uterine contractions*; therefore, *hydration may be the first intervention used* to suppress contractions. -CAUTION should be used when hydrating a patient currently being treated with tocolytics *due to the increased risk of pulmonary edema* (magnesium sulfate and the beta-adrenergic agonists) -Total PO and IV fluid intake should be kept between *1500-2400ml/24 hours* -Monitor respiratory status & breath sounds, accurate I&O, daily weights 3. Tocolytics to suppress uterine activity 4. Antenatal glucocorticosteroids -*promote fetal lung maturity & reduce complications of prematurity such as necrotizing enterocolitis and cerebral hemorrhage* 5. Antibiotic therapy -*if beta strep status is unknown, prophylactic treatment with antibiotics is used to prevent neonatal sepsis* in event of delivery

Immediate care of a patient experiencing eclampsia

1. *Call for help & stay with patient* *Ensure airway* 2. Turn onto side: Done first to avoid aspiration and supine hypotension 3. Suction: AFTER seizure activity stops to clear food and fluid from the airway 4. *O2 via face mask @ 10L/min* 5. IV Magnesium Sulfate: if no IV, place one with a large bore needle 6. Monitor fetus: *Transient fetal bradycardia and decreased FHR variability are common* 7. Uterine & Cervical Assessment during a seizure: -membranes may have ruptured -cervix may have dilated -birth may be imminent 8. Following a seizure, a decision must be made regarding delivery. May try to postpone delivery until antenatal glucocorticoids can be given and benefit received 9. Document: Time, duration, and any urinary or fecal incontinence

Discharge teaching for the woman after early miscarriage

1. *Clean the perineum* after each voiding or bowel movement & change perineal pads often 2. Shower *(avoid tub baths) for 2 weeks* 3. *Avoid tampon use, douching, & vaginal intercourse for 2 weeks* 4. Notify your physician if an *elevated temperature or a foul-smelling vaginal discharge* develops 5. Eat foods high in iron & protein to promote tissue repair & RBC replacement 6. Seek assistance from support groups 7. Allow yourself (and your partner) to *grieve the loss before becoming pregnant again*

Pregestational diabetes - postpartum interventions

1. *First 24 hours: insulin requirements DECREASE* a lot bc major source of insulin resistance (the placenta) has been removed 2. *Type 1 diabetic patient may require 1/3 - 1/4th of the prenatal insulin dose the first postpartum day. Some will require no insulin for 24 - 72 hours* 3. C section usually on IV dextrose and insulin until egular diet is resumed; subq dose of insulin one hour before discontinuing IV insulin 4. Blood glucose frequently assessed and insulin dose adjusted 5. Insulin-dependent diabetic woman needs to realize importance of eating on time even if the baby needs feeding or other pressing demands exists 6. Type 2 often require no insulin and can be managed by diet of oral hypoglycemic agents 7. Possible PP complications: preeclampsia, eclampsia, hemorrhage, infection (increased risk for endometritis)

Incomplete miscarriage

1. *Heavy, profuse* bleeding 2. *Severe* uterine cramping 3. *Passage of tissue* 4. Cervical dilation *WITH tissue in cervix* 5. Management: -*May or may not require additional cervical dilation before curettage* -Suction curettage may be performed -*D&C, D&E, or induction of labor depending on gestational age*

Inevitable miscarriage

1. *Moderate* bleeding 2. *Mild to severe* uterine cramping 3. *NO passage* of tissue 4. Cervical dilation 5. Management: -Bed rest if no pain, bleeding, or infection -*If ROM, pain, bleeding, or infection is present then prompt termination of pregnancy* is accomplished usually by *dilation and curettage (D&C)* -can also be terminated by *dilation & evacuation (D&E) or induction of labor depending on gestational age*

Placenta previa is typically characterized by:

1. *Painless bright red vaginal bleeding* -bleeding is associated with the *disruption of placental blood vessels that occurs with stretching & thinning* of the lower uterine segment 2. Vital signs may be normal, even with heavy blood loss (pregnant woman can lose up to 40% of her blood volume without showing signs of shock) 3. FHR is normal unless major detachment of placenta occurs 4. *Uterus is soft, non-tender, with normal tone* 5. *Presenting part of fetus remains high* bc placenta occupies the lower uterine segment; fundal height is greater than expected 6. Bc of the abnormally located placenta, *fetal malpresentation is common*

Risk factors for spontaneous preterm labor

1. *Previous history of preterm labor and birth* 2. Nonwhite race - *black & hispanics have a higher incidence of preterm birth* 3. *Genital tract colonization & infection* 4. Multifetal gestation 5. Second-trimester bleeding 6. Low prepregnancy weight 7. Poverty, lack of education, living in a disadvantaged neighborhood, state, or region, & lack of access to prenatal care are also risk factors 8. Risk also appears to be genetically related - women whose sisters gave birth prematurely are also more likely to do so

Preeclampsia risk factors

1. *Primip in age extremes (< 19/> 40 yo)* 2. *First pregnancy/new partner* 3. *Pt/family hx of preeclampsia* 4. ↑ trophoblastic tissue -Twins or more -Hydatidiform mole 5. Poor outcome pregnancy -Intrauterine growth restriction (IUGR) -Placental abruption -Fetal death 6. Periodontal disease 7. Obesity 8. Preexisting medical or genetic conditions -Chronic HTN, Renal Dx, Type 1 DM, Collagen Dx 9. Thrombophilias -Antiphospholipid antibody syndrome -Protein C, protein S, antithrombin deficiency -Factor V Leiden mutation

Complete miscarriage

1. *Slight* bleeding 2. *Mild* uterine cramping 3. *Passage of tissue* 4. NO cervical dilation; *cervix has already closed after tissue passage* 5. Management: -*No further interventions* may be needed *if uterine contractions are adequate to prevent hemorrhage and no infection* is present. -*Suction curettage* may be performed to *ensure no retained fetal or maternal tissue* -*Monitor for bleeding*

Threatened miscarriage

1. *Slight* bleeding, *spotting* 2. *Mild* uterine cramps 3. NO passage of tissue 4. NO cervical dilation 5. Management: -*Bed rest often ordered* but has not been proven to be effective in preventing progression to actual miscarriage -*Sedation* -*Repetitive transvaginal ultrasounds and assessment of hCG and progesterone levels* may be done to *determine if the fetus is still alive and in the uterus* -Further treatment depends on whether progression to actual miscarriage occurs

Indomethacin (Indocin) 5 nursing considerations

1. *Used ONLY if gestational age is less than 32 weeks.* 2. *Only administer for 48 hours* 3. Do no use if presence of renal/hepatic disease, active PUD, poorly controlled HTN, asthma, or coagulation disorders 4. *Administer with food* to decrease GI distress 5. Monitor for *signs of postpartum hemorrhage*

GDM - intrapartum interventions

1. *monitor blood glucose to keep at 80-110* 2. avoiding dextrose will usually keep levels at right place 3. c section if preeclampsia or macrosomia

GDM - postpartum interventions

1. *most return to normal levels after birth* 2. some will develop type 2 DM 3. *monitor glucose 6-12 weeks PP and every 3 years* 4. encourage lifestyle changes 5. oral contraception is fine with these 6. if overweight or HTN or high lipid levels, use contraceptive w/o potential for causing cardiovascular side effects (IUD is good option)

Causes of preterm birth

1. 25% of preterm births are classified as "iatrogenic" -fetus was *intentionally delivered prematurely due to maternal or fetal health reasons* 2. 25% of preterm births are a result of PPROM 3. *50% are "idiopathic" which means it occurs spontaneously and may be preventable* 4. At least 50% of all women who deliver prematurely have no identifiable cause or risk factor

Screening for GDM - 1 step method

1. 75- g OGTT 2. Between 24-28 weeks 3. Requires *fasting blood glucose levels drawn before giving glucose load then drawn 1 and 2 hours later* 4. *If one value is exceeded = positive* -*fasting: 92 mg/dl* -*1 hr: 180 mg/dl* -*2 hr: 153 mg/dl*

6 warning signs of magnesium toxicity

1. Absent DTR 2. Respiratory Depression 3. Blurred Vision 4. Slurred Speech 5. Severe Muscle Weakness 6. Cardiac Arrest

Hydralazine (Apresoline)

1. Arteriolar vasodilator 2. Targets *peripheral arterioles to decrease muscle tone, decrease peripheral resistance*; hypothalamus and medullary vasomotor center for minor decrease in sympathetic tone 3. Maternal effects: *H/A, flushing, palpitations, tachycardia, some decrease in uteroplacental flow, increase in HR and cardiac output* 4. Fetal effects: *tachycardia, late decels and bradycardia if maternal diastolic pressure <90*

Bedrest - nursing interventions

1. Assess for adverse effects of bedrest & initiate/administer appropriate interventions 2. Psychological support for both patient and support system with referral to appropriate resources -referrals to chaplain, nutritionist, social worker -refer to support groups 3. Assist the patient in planning activities to aid in self-care and decrease boredom (journaling, scrapbook, passive exercise, knitting etc.) 4. Nurses caring for patients that have been on prolonged bedrest should be aware that the *adverse effects can carry over into the postpartum period.* -*have a longer recovery time* due to the decreased endurance and muscle wasting -*at a higher risk for postpartum depression* and other psychological issues like feelings of guilt for not being able to carry their baby to term. *All of which can effect infant bonding.*

Antihypertensive agents 4 nursing actions

1. Assess for effects of medication; alert woman to expected effects of medication 2. *Assess BP frequently because a quick drop can lead to shock and perhaps placental abruption* 3. If multiple doses, *wait 20 minutes after the first dose is given to administer an additional dose* to allow time to assess the effects of the initial dose 4. Maintain bed rest in *lateral position with side rails up*

Magnesium sulfate 8 nursing considerations

1. Assess woman and fetus to obtain baseline before beginning therapy and then before and after each incremental change 2. *Drug almost always given IV* 3. Monitor serum Mag levels, *therapeutic range between 4- 7.5 mEq/L or 5.8 mg/dl* 4. Be prepared to *D/C if intolerable adverse effects* occur *(respiratory rate <12, pulmonary edema, ABSENT DTRs, chest pain, severe hypotension, altered LOC, urine output less than 25-30 mL/hr., serum levels of 10 or higher)* 5. Strict I&O 6. Total IV intake should be *limited to 125 mL/ hr.* 7. *Calcium gluconate*/calcium chloride readily available *to reverse mag toxicity* 8. *Should NOT be given if woman has a hx with myasthenia gravis*

DIC 8 nursing interventions

1. Assessment for signs of bleeding 2. Signs of complications 3. Protect from injury 4. *Administer blood products* 5. Monitor VS, urinary output 6. Patient remains in *side-lying position* 7. *O2 with face mask @ 8 - 10 L/min* 8. Support to woman and family

Ectopic pregnancy management

1. B-hCG level & progesterone level -*if lower than expected, have patient return in 2 days for a follow up* 2. Transvaginal ultrasound to confirm intrauterine or tubal pregnancy 3. Assess for signs of rupture -*vertigo, shoulder pain, hypotension, & tachycardia* Treatment: 4. *Removal by salpingostomy is possible before rupture* with residual tissue *dissolved by methotrexate* 5. *Methotrexate can be used to treat an ectopic pregnancy if it is not ruptured and < 4cm* -done on an outpatient basis with single injection 6. Patient has follow up *beta-hCG levels drawn until titers decrease* 7. Patient education while waiting for beta-hCG levels return to normal includes: -*Vaginal rest* -*Avoid sun exposure* -*Avoid alcohol and vitamins containing folic acid*

Severe preeclampsia

1. BP *> 160/110* -4-6 hours apart x2 2. MAP: >105 3. Proteinuria *> 3+ dipstick* 4. 24 hours *urine protein > 500 mg* 5. Irritability 6. Visual changes 7. Headache 8. Maybe: impaired liver function, pulmonary edema, epigastric pain, thrombocytopenia

Pregestational diabetes - postpartum contraception

1. Barriers and IUD safe 2. *Oral meds controversial bc possible increased risk of thromboembolic and vascular complications and effect on carb metabolism* 3. Long acting implants debated 4. Patches and vaginal ring (fine unless obese then high failure rates) 5. Since pregnancy puts at risk for vascular changes and risks get worse with age, sterilization recommended if done with family, who has poor metabolic control, or who has significant vascular problems 6. Vasectomy safer than woman sterilization

What laboratory tests would be expected for a pregnant woman with pregestational diabetes?

1. Baseline renal function with 24hr urine protein and creatinine clearance 2. Urinalysis & culture to assess for presence of UTI (common in diabetic pregnancy) 3. Urine glucose and ketones 4. Thyroid function (risk of coexisting thyroid disease) 5. *Glycosylated hemoglobin A1c - Provides measurement of glycemic control over time* -with prolonged hyperglycemia some of the hemoglobin remains saturated with glucose for the life of the RBC - *Good diabetic control 2.5% to 5.9%* - *Fair control 6% to 8%* - *Poor control >8%* 6. Review of patient's self-monitoring results (should be reviewed at every prenatal visit)

Self-management treatment for hypoglycemia

1. Be familiar with S/S 2. Check blood glucose with symptoms 3. If BG <70: -Eat 2-4 glucose tablets/gel (8-16 g carbs) -½ cup (4 oz.) unsweetened orange juice or soda *(regular soda, not diet)* -5 or 6 hard candies/lifesavers -1 cup (8 oz.) skim milk 4. Rest 15 minutes and recheck BG 5. If BG still <70, eat 2-4 additional glucose tabs 6. If BG >70, eat a meal to stabilize the sugar level 7. Recheck in 15 minutes. If BG is still <70, notify HCP immediately 8. If nausea r/t hypoglycemia prevents ingestion of carb, inject 0.15 mg glucagon IM. This will elevate the BG enough to allow eating

A pt with DIC is at risk for ischemia to major organs due to:

1. Blood loss 2. Loss of intracellular volume 3. Activation of intrinsic clotting factors 4. Hypotension

Why are mothers with diabetes encouraged to breastfeed?

1. Breastfeeding has an antidiabetogenic effect for the baby 2. Breastfed infants of women with diabetes are also *less likely to become obese* -important bc a child born to a mom with DM2 has a 70% chance of also developing DM2 later in life

Nifedipine (procardia)

1. Calcium channel blocker 2. Targets arterioles: to reduce systemic vascular resistance by relaxation of arterial smooth muscle 3. Maternal effects -*H/A, flushing; may interfere with labor* 4. Fetal effects -Minimal 5. *Avoid concurrent use with magnesium sulfate* because skeletal muscle blockage can result 6. *Do not administer sublingually*

In rare instances there is abnormal adherence of the placenta to the myometrium. Why does this occur?

1. Cause is unknown; thought to be due to *implantation into an area of defective endometrium* 2. Placenta cannot be removed in the usual manner -If attempted, can cause laceration or perforation of the uterine wall -Places the woman *at risk for postpartum hemorrhage and infection* 3. Extensive involvement *may require a hysterectomy and the infusion of blood components*

Nursing interventions for hypoglycemia

1. Check BG level when symptoms 1st appear 2. If BG less than 70, eat 2-4 glucose tablets or gel (8-16 g carb) immediately 3. Recheck BG level in 15 min. If glucose level is still less than 70, eat 2-4 additional glucose tabs. 4. Recheck BG in 15 min. If still less than 70, notify HCP immediately 5. *If woman is unconscious, administer 50% dextrose IV push, 5-10% dextrose in water IV drip, or 1 mg glucagon IM* 6. Obtain blood & urine specimens for lab testing

Molar pregnancy - 2 types

1. Complete mole -Results from *fertilization of an egg with an inactivated or lost nucleus* -*The mole resembles a bunch of white grapes* -Contains *no fetus, placenta, amniotic membranes, or fluid.* -Maternal blood has *no placenta to receive it*; therefore, *hemorrhage into the uterine cavity and vaginal bleeding occur* 2. Partial mole -*One apparently normal ovum is fertilized by two or more sperms* -Often have *embryonic or fetal parts and an amniotic sac* -*Congenital anomalies* are usually present -*Less risk of persistent GTD* than a complete mole -If GTD does occur, it is *usually not a choriocarcinoma*

DIC treatment involves:

1. Correction of the underlying cause (removal of the dead fetus, treatment of existing infection or of preeclampsia or eclampsia, or removal of an abrupted placenta) 2. Volume expansion 3. *Rapid replacement of blood products and clotting factors* 4. Optimization of O2 & perfusion 5. Achievement of normal body temperature 6. Continued reassessment of labs -*priority labs = hct & hgb* 7. Vitamin K 8. Recombinant activated factor VII

9 adverse effects of bedrest

1. Decreased muscle tone 2. Weight loss 3. Calcium loss 4. Glucose intolerance 5. Constipation 6. Thrombophlebitis 7. Fatigue 8. Depression 9. Anxiety

What should be obtained in the initial interview of a pregnant woman with pregestational diabetes?

1. Detailed history of disease: onset, duration, management, degree of control 2. The woman and her partner's understanding of the disease and management with teaching -needs identified and followed up on at every subsequent visit 3. Emotional response to pregnancy (concerns and fears should be addressed) 4. Assessment of support system 5. Socioeconomic factors

Antepartum interventions for pregestational diabetes

1. During 1st-2nd trimester, routine prenatal visits every 1-2 weeks 2. During 3rd trimester, 1-2 times per week 3. *Blood glucose levels should be in range of 60-99 before meals and 100-129 when measured 1 hour after meal; after 2 hours, should be no higher than 120* 4. Need to get up and go to bed, eat, exercise, and take insulin *at same time each day* 5. Daily bath that includes thorough perineal and foot care is important 6. Avoid tight clothing 7. Shoes should fit properly 8. Avoid extreme temps

Preeclampsia maternal complications

1. Eclampsia 2. Pulmonary edema 3. Stroke 4. Hepatic failure 5. ARDS 6. DIC 7. Placental abruption 8. Cerebral hemorrhage 9. Acute renal failure -*Complications most commonly occur in 2nd trimester* -Majority of deaths result from complications of *hepatic rupture, placental abruption, or eclampsia*

Mild preeclampsia

1. Elevated BP often 1st sign of preeclampsia - *>140/90 @ 4-6 hrs apart x 2* -MAP >105 2. *Proteinuria > 1+ dipstick* -dipstick measurement on *2 random samples at least 6 hrs apart* with no sign of UTI 3. 24 hr urine *protein > 300 mg* 4. *> 25-30 ml/hr urine output* 5. No epigastric pain 6. No visual changes 7. Maybe a headache or irritability

Self-management - what to do if symptoms of preterm labor occur

1. Empty your bladder 2. Drink 2-3 glasses of water or juice 3. Lie down on your side for 1 hour 4. Palpate for contractions 5. If symptoms continue, call your HCP or go to the birthing facility 6. If symptoms go away, resume light activity, but not what you were doing when the symptoms began 7. If symptoms return, call your HCP or go to the birth faciltiy 8. If any of the following symptoms occur, call your HCP or go to the birth facility immediately: -*uterine contractions every 10 min or less for 1 hour or more* -*vaginal bleeding* -*smelly vaginal discharge* -*fluid leaking from the vagina*

Nursing care for the woman receiving tocolytic therapy (9)

1. Explain the purpose and side effects of the tocolytic medications to the woman and family 2. *Position the woman on her side to enhance placental perfusion and reduce pressure on the cervix* 3. Monitor maternal vital signs including lung sounds and respiratory effort, FHR and pattern, and labor status 4. Assess the mother and fetus for signs of adverse reactions related to the tocolytic medications being administered 5. Determine maternal fluid balance by measuring the daily weight and intake and output. 6. *Limit fluid intake to 2500 to 3000 mL/ day, especially if beta adrenergic agonist or magnesium sulfate is being administered* 7. Provide psychosocial support and opportunities for the woman and family to express feelings and concerns 8. Offer comfort measures as needed 9. Encourage diversional activities and relaxation techniques

With placental abruption, deliver if:

1. Fetus is term 2. Moderate to severe bleeding 3. Maternal or fetal jeopardy -Deliver by c-section -Start large bore IV (16 gauge) -Frequent monitoring of maternal vital signs *(increased HR & decreased BP = signs of shock)* -Foley catheter placement to monitor urinary output *(monitor shock and organ perfusion)* -Continuous fetal monitoring is mandatory -Serial laboratory studies: H&H and clotting studies -*Blood and fluid replacement with the goal of maintaining urinary output at 30ml/hr & Hct at 30% or more* -Fresh frozen plasma or cryoprecipitate may be given to maintain fibrinogen level at a minimum of 100-150mg/dl -Cryoprecipitate: derived from whole blood - consists of fibrinogen, factor VIII, von Willebrand factor, factor XIII, and fibronectin

Preeclampsia postpartum

1. Frequent VS, I&Os, DTRs, & LOC 2. *Magnesium sulfate is administered 12-24 hours post delivery to prevent the development of eclampsia* 3. Uterine tone & lochia -Magnesium sulfate can interfere with the uterus clamping down thus causing a *boggy uterus and heavy lochia flow, placing the woman at risk for postpartum hemorrhage* -*Oxytocin should be administered to treat the boggy uterus and control bleeding* -*Methergine and Ergotrate are contraindicated* because they cause an increase in BP 4. Family support & bonding -encourage breastfeeding. Breastfeeding is the best form of nutrition for premature infant. *Magnesium sulfate is NOT a contraindication for breast feeding* 5. Preeclampsia *S/S typically resolve ≤ 48 hrs* 6. Caution: *NSAIDs ↑ BP* 7. Teach when to call HCP 8. *BP monitoring for 72 hrs & recheck (7-10 days)* -*BP should be monitored every 4 hours for 48 hours* 9. Assess for HA, visual disturbances, epigastric pain, diuresis, & decreased edema

During normal pregnancy, adjustments in maternal ______________, ________________, & _______________ occur

1. Glucose metabolism, insulin production, and metabolic homeostasis. *Adjustments in maternal metabolism allow for adequate nutrition for both mother and fetus.* 2. *Glucose, the primary fuel for the fetus*, is transported across the placenta through the process of carrier-mediated facilitated diffusion *(glucose levels in fetus are directly proportional to mom glucose levels)* 3. *Although glucose crosses the placenta, insulin does NOT.* 4. 10th week of pregnancy infant secretes their own insulin at levels adequate to use the glucose from mom (significant for the management of IDM) 5. *As maternal glucose levels rise → so do fetal glucose levels resulting in increased fetal insulin production.*

Common laboratory changes in preeclampsia

1. Hgb (12-16)/hct (37-47%): may increase 2. Platelets (150,000-400,000): decreases; <100,000 3. PT (12-14 sec), PTT (60-70 sec): unchanged 4. Fibrinogen (200-400): increases; 300-600 5. FSPs (normal = absent): absent or present 6. BUN (10-20): increases 7. Creatinine (0.5-1.1): increases; >1.1 8. Creatinine clearance (80-125): increases; 130-180 9. LDH (45-90): increases 10. AST (4-20): elevated 11. ALT (3-21): elevated 12. Uric acid (2-6.6): increases; >5.9 13. Bilirubin (0.1-1): unchanged or increased

HELLP syndrome lab values

1. Hgb, hct decreases 2. Platelets <100,000 3. PT, PTT unchanged 4. Fibrinogen decreases 5. FSPs present 6. BUN increases 7. Creatinine increases 8. LDH increases (>600) 9. AST increases (>70) 10. ALT increases 11. Creatinine clearance decreases 12. Burr cells present 13. Uric acid >10 14. Bilirubin increases (>1.2)

Preeclampsia assessment

1. History & S/S -1st Prenatal Visit: thorough history to identify risk factors for the development of preeclampsia -Assess for S/S of preeclampsia at each subsequent prenatal visit 2. Vitals: BP measured in a standardized manner 3. Breath sounds are auscultated to assess for crackles, which may indicate pulmonary edema. *Pulmonary edema is associated with severe preeclampsia* 4. Edema: assess for distribution, degree, & pitting -*NO LONGER A DIAGNOSTIC MEASURE*; occurs in too many normal pregnancies -pathological edema: generalized fluid accumulation of face, hands, or abdomen that does not respond to 12 hours of bedrest -*Diuretics are only used in preeclampsia when there is evidence of CHF or pulmonary edema* -Daily weights: *weight gain of >2 kg (4.4 lbs) in 1 week* 5. DTRs -Assess biceps & patellar reflexes as well as ankle clonus (hyperactive reflexes) -Negative clonus: No rhythmic oscillations (negative beats of clonus) -Positive clonus: Presence of rhythmic oscillations (positive # of beats of clonus) -*Hyperreflexia is a sign of CNS irritability (sign of impending eclampsia)* -*Absence of reflexes when a patient is being treated with magnesium sulfate is a sign of toxicity* 6. Fetal status 7. Uterine tonicity 8. Laboratory results

Placental abruption assessment

1. History and physical -Gravidity and parity -EDC -Bleeding: quantity, precipitating event, associated pain present 80% of the time 2. Uterine and fetal assessment -abdominal *pain and uterine tenderness* are usually present -*Boardlike abdomen to palpation* -*Contractions present with uterine tetany* (incomplete relaxation) -*Fetal distress* may or may not be present depending on the amount of placental separation 3. Laboratory Studies -Clotting studies *(due to many women demonstrating coagulopathy or excessive bleeding with uterine abruption)* -Fibrinogen, platelet count, prothrombin time, partial thromboplastin time, fibrin split products 4. Ultrasound performed to rule out placenta previa -Not always diagnostic for placenta abruption

PPROM 13 risk factors

1. History of prior preterm birth, especially if associated with preterm PROM 2. History of cervical cerclage 3. Urinary or genital tract infection 4. Short cervical length in the 2nd trimester 5. Preterm labor in the current pregnancy 6. Uterine overdistention 7. 2nd & 3rd trimester bleeding 8. Pulmonary disease 9. Connective tissue disorders 10. Low socioeconomic status 11. Low BMI 12. Nutritional deficiences 13. Smoking

Management of severe preeclampsia

1. Hospital bedrest -*Management of severe preeclampsia is best achieved in a tertiary care center* 2. Maternal monitoring -Baseline labs and frequent laboratory monitoring *observing for an increase in liver enzymes, decrease in platelets, changes in coagulation studies and electrolytes*. Assess for HELLP and DIC -Daily weights, I&O, foley catheter placement to assess for renal function 3. Close fetal surveillance is warranted; *observing for signs of uteroplacental insufficiency* through daily NST, biophysical profile, umbilical artery doppler flow studies 4. May require an ICU setting and/or hemodynamic monitoring -Invasive monitoring should be considered for women with severe cardiac disease and/or renal failure, and in some instances pulmonary edema 5. Environment should be *quiet and non-stimulating due to CNS irritability* 6. Seizure precautions -*emergency medications and equipment close by and readily available (suction and oxygen)* 7. Safety precautions 8. Pharmacological interventions 9. Delivery -If immediate delivery is indicated then *c-section would most likely be the delivery mode of choice*, especially if the cervix is unfavorable. A *prolonged labor could increase risk of maternal morbidity*

Placenta previa etiology

1. Hx of previous cesarean birth 2. Advanced maternal age 3. Multiple gestation 4. Hx of prior suction curettage 5. Smoking 6. Occurs more frequently in women carrying male fetuses (placental sizes are larger in pregnancies with males) 7. Hx of placenta previa

4 antihypertensive agents

1. Hydralazine (Apresoline) 2. Labetalol Hydrochloride (Normodyne) 3. Methyldopa (Aldomet) 4. Nifedipine (Procardia)

Pregestational diabetes - intrapartum interventions

1. IV hydration: *Lactated Ringers with 5% Dextrose or Lactated Ringers* 2. Insulin administration: *Continuous infusion or intermittent injection based on blood glucose monitoring. Only regular insulin is used during the intrapartum period* 3. Blood glucose monitoring: monitored hourly with adjustments made in fluids and insulin to *maintain a capillary blood glucose level between 80-120 mg/dl* 4. Continuous fetal monitoring for fetal tolerance to labor 5. Monitoring of labor progression: Possibility of failure to progress 6. During second stage the nurse should be alert to the *possibility of shoulder dystocia* 7. *If scheduled C/S, scheduled first thing in the am.* -Pt. NPO prior to surgery. -MD may have patient hold am insulin -*Epidural anesthesia recommended because hypoglycemia can be detected earlier if the woman is awake.*

Antenatal glucocorticoids

1. Indications -To prevent or *reduce the severity of neonatal respiratory distress syndrome* by *accelerating lung maturity in fetuses between 24 and 34 weeks of gestation* -also less likely to experience *intraventricular hemorrhage, necrotizing enterocolitis, or neonatal death* 2. Dosage & route -Betamethasone: 12 mg intramuscular for 2 doses 24 hours apart -Dexamethasone: 6 mg IM for 4 doses 12 hours apart 3. Effects -Maternal: *Transient (lasting 72 hours) increase in WBCs & hyperglycemia* -Fetal: *Transient (lasting 72 hours) decrease in fetal breathing and body movements* 4. Nursing considerations -Give deep IM in ventral gluteal or vastus lateralis muscle -*MUST BE GIVEN IM* -Injection is painful -Med should NOT affect maternal BP -*Assess blood glucose levels*. Women with DM whose blood sugars have previously been well controlled *may require increased insulin doses for several days* -*fetus is at risk for hypoglycemia*

Screening for GDM - 2 step method

1. Initial 50-g oral glucose load: positive if plasma level 130-140 mg/dl or greater (fasting not necessary) 2. If positive, follow with a 3 hour glucose tolerance test (OGTT) with a 100 g oral glucose load (fasting required) 3. Pt should be on an *unrestricted diet 3 days prior* to 3 hour GTT. *12 hours prior to the exam the patient should maintain NPO and avoid caffeine and smoking* 4. If *2 or more values are met or exceeded*, woman is diagnosed with GDM -*fasting: 95 mg/dl or greater* -*1 hour: 180 mg/dl or greater* -*2 hour: 155 mg/dl or greater* -*3 hour: 140 mg/dl or greater*

Perinatal loss - what parents appreciate

1. Involvement in decision making 2. Being treated like parents 3. Time to grieve - not being rushed 4. Positive memories/mementos 5. Sense of empathy and being cared for 6. Time with supportive family & friends 7. Continuity in care of caregivers 8. Unlimited time with infant 9. Seeing, holding, touching the baby 10. Direct communication

Preterm labor prevention interventions

1. Lifestyle modifications -The nurse caring for a woman with preterm labor should help her identify activities that precipitate the symptoms of preterm labor and then assist the woman in lifestyle modifications to avoid these activities. 2. Bedrest -*used to decrease pressure on the cervix and to promote blood flow to the uterus* -prescribed in & out of hospital -commonly used, but no evidence to support its effectiveness 3. Home uterine activity monitoring -ordered by the physician to aid in the detection of contractions

Phase of intense grief

1. Loneliness, emptiness, yearning 2. Guilt 3. Anger, resentment, bitterness, irritability 4. Fear and anxiety 5. Disorganization 6. Difficulty with cognitive processing 7. Sadness and depression 8. Physical symptoms Nursing considerations: -difficulty processing: explain & repeat information. -Hard for them to follow even simple instructions sometimes. -Don't take the anger personally. -Guilt very common: reassure them they did nothing to cause this loss.

Eclampsia - after care

1. Maternal and infant stabilization, timing and method of delivery may be necessary 2. *Regional anesthesia is avoided for eclamptic women with coagulopathy or platelet count less than 50,000*

Magnesium sulfate nursing care

1. Maternal monitoring: *hr 1-3 monitor every 15-30 min; hr 4-7 monitor every hour* 2. Continuous fetal monitoring 3. Blood pressure per hospital protocol. *Report SBP > 160mm Hg and DBP > 110mm Hg* 4. Pulse 5. Respirations: *Report < 12/min* 6. Monitor for pulmonary edema 7. DTRs: *Report loss of DTRs or increased DTRs* 8. LOC 9. I&O -Restrict hourly intake 100-125cc/hr -Urinary output (indwelling cath): If renal dysfunction (low urinary output), at risk for Magnesium toxicity (level >8mg/dl) -Report urinary output < 25-30ml/hr 10. *Headache, visual disturbances, epigastric or right quadrant pain* 11. Labor progression 12. Laboratory values: Report any abnormal values

Perinatal loss

1. Miscarriage -any in utero death *prior to 20 weeks of gestation* 2. Ectopic pregnancy 3. Stillborn -5-12% per 1000 live births in US -occurs at *20 weeks or later* 4. Neonatal loss 5. Loss of "healthy child"- delivery of preterm infant or baby with anomalies

Bleeding in early pregnancy

1. Miscarriage (spontaneous abortion) 2. Ectopic pregnancy 3. Molar pregnancy

Miscarriage - nursing responsibilities

1. Monitor bleeding & vital signs 2. Administer medications as ordered: -*10 to 20 Units of oxytocin in 1000ml of fluids to prevent hemorrhage* -*Ergot products to control bleeding (methergine)* -Antibiotics as indicated -Analgesics for cramping -Transfusion if shock or anemia 3. *Administer Rhogam within 72 hours if Rh negative & no isoimmunization* 4. Psychological support & referral to support group -Includes patient and family -Explanations are provided regarding the nature of the miscarriage, expected procedures, possible future implications for pregnancy

Management of mild preeclampsia

1. Monitoring of BP: report elevations 2. Home Bedrest -*if proteinuria <.3 gm on a 24 hr urine specimen, without subjective complaints, & home situation & support system conducive* 3. Daily weights: report abnormal weight gain 4. Fetal surveillance -Home: *fetal kick counts daily* and if available home NST 1-2 times weekly -Hospital: NSTs; biophysical profiles as indicated -*Ultrasound for fetal growth at diagnosis and every 3 weeks* 5. Monitor urine protein: *dip urine daily & report any increase in value* 6. Educate on warning signs 7. Healthy diet & adequate hydration 8. Emotional support

Pregestational diabetes - antepartum diet

1. Must be educated to incorporate changes of pregnancy into diet 2. Diet individualized to allow for increased fetal and metabolic requirements 3. Dietary goals: *to provide weight gain consistent with normal pregnancy, prevent ketoacidosis, and minimize wide fluctuation of blood glucose levels* 4. *2200-2500 cal ADA divided among 3 meals and 2 or 3 snacks* -Large bedtime snack of at least 25 g of complex carb with some protein or fat is recommended to help prevent hypogylcemia and starvation ketosis during night 5. Woman must follow a *consistent eating schedule* - meals should be eaten on time and never skipped 6. Going more than 4 hours w/o food intake increases risk for episodes of hypoglycemia

Missed miscarriage

1. No bleeding 2. No uterine cramping 3. No passage of tissue 4. No cervical dilation 5. Management: -*If spontaneous evacuation of the uterus does not occur within 1 month, pregnancy is terminated by method appropriate* to duration of pregnancy -*Blood clotting factors are monitored* until uterus is empty -*DIC & incoagulability of blood with uncontrolled hemorrhage may develop in cases of fetal death after the 12th week, if products of conception are retained for longer than 5 weeks* -may be treated with *D&C or misoprostol (cytotec) given orally or vaginally*

Hyperglycemia (DKA) nursing interventions

1. Notify HCP immediately 2. Administer insulin in accordance with BG levels 3. Give IV fluids such as NS solution or 1/2 NS solution; potassium when urinary output is adequate; bicarb for pH <7 4. Monitor lab testing of blood & urine

PPROM expectant management

1. Observe for infection: *fever, abdominal tenderness, vaginal discharge with foul odor or change in color, elevated WBC's* 2. Frequent biophysical profiles to monitor fetal status and amniotic fluid volume 3. Frequent nonstress tests: this can be done with home monitoring if patient is discharged 4. Instructions on signs and symptoms that warrant immediate medical attention (Infection, decreased fetal movement, signs of labor, vaginal bleeding) 5. Instructions on self-care: -Ways to decrease risk of infection: *no tub baths, nothing in vagina, proper hygiene after BM, frequent pad changes, monitoring of temperature* -*Fetal kick counts* (movement chart, keeps track of baby's well-being) 6. *Delivery if Chorioamnionitis* -*ACOG recommends delivery at 34 weeks if PPROM*

Placenta previa assessment

1. Obtain History & Physical -Gravidity and Parity -Estimated date of confinement (EDC) -General status -Bleeding: quantity, precipitating event, associated pain 2. Uterine & Fetal Assessment -*Assess for fetal distress (uteroplacental insufficiency)* 3. Laboratory Studies -CBC, type & screen, coagulation profile, possible type & cross match 4. Ultrasound -Transabdominal -Transvaginal used if placenta location not clearly seen with transabdominal 5. *NO VAGINAL EXAMS* -*Nurses are not to perform vaginal exams in the presence of vaginal bleeding* -Usually *not done by physician if <34 weeks* and then done by sterile speculum -If the physician feels that a vaginal exam is necessary then it should be done under a *DOUBLE SET UP* -Double Set Up is when the *woman is placed in an OR set up for a cesarean birth because profound hemorrhage may occur* and the medical team must be prepared for an emergency C-section

Induction for demise

1. Pain relief 2. Plan of care: what is different from previous deliveries, i.e. monitoring of contractions only 3. Keep them informed of labor progress 4. *Explain what to expect based on gestational age, i.e. size of baby, may have shorter pushing stage, etc* 5. Most patients do well when *informed about possible appearance of baby, ie: peeling skin, bruising, etc.*

Perinatal loss in the office

1. Parents have a urgent need for information and to receive attention during the initial phase of shock. 2. Value sympathetic staff and feeling cared for 3. Freedom of choice to see the USG monitor 4. Support from care givers is an important factor regarding how well parents handle the acute situation and later move on 5. If not an urgent need to be admitted to hospital, *most patients appreciate being given a choice* 6. If office is located within the delivery hospital, *inquire if hospital chaplains or social workers are available* to patients prior to hospital admission If expectant mother has come alone to office, *offer to call a family member/friend so she is not alone*. In recognition that the family is in the shock phase, they may need instructions repeated and written down as well. Continuity in HCPs is valued by the expectant mother.

Nursing actions - memory making

1. Photographs, foot prints, armband, lock of hair 2. Naming of baby 3. Involve family in rituals and memory making 4. Offer the family the option of bathing and dressing infant 5. Each delivery hospital will have bereavement supplies - donated smoked gowns, blankets, hats, educational materials 6. Offer baptism/blessing - Hospital Chaplain usually immediately available. They can also assist in calling in a rabbi or priest

Adherent retained placenta - 3 degrees of attachment

1. Placenta Accreta- *Slight penetration* of myometrium by placenta trophoblast 2. Placenta Increta- *Deep penetration* of myometrium by placenta 3. Placenta Percreta - *Perforation* of uterus by placenta

Bleeding in late pregnancy

1. Placenta previa 2. Placenta abruption 3. Adherent Retained Placenta

Effects of preeclampsia

1. Placental -*uteroplacental spasm results in IUGR, decreased amniotic fluid volume, abnormal fetal oxygenation, low birth weight, & preterm birth* 2. Renal -reduced kidney perfusion decreases GFR & can lead to degenerative glomerular changes & oliguria -*protein (primarily albumin) is lost in the urine* -uric acid clearance is decreased; serum uric acid levels increase -sodium & water are retained 3. Hepatic -*decreased liver perfusion can lead to impaired function & elevated liver enzymes* -if hepatic edema & subcapsular hemorrhage develop, woman may complain of *epigastric pain* 4. Neurological -cerebral edema & hemorrhage and increased CNS irritability *(HA, hyperreflexia, positive ankle clonus, & seizures)* -arteriolar vasospasms and decreased blood flow to the retina can lead to *visual disturbances* (scotoma & blurred/double vision)

DIC - laboratory coagulation screening test results

1. Platelets—decreased 2. Fibrinogen—decreased 3. Factor V (proaccelerin)—decreased 4. Factor VII (antihemolytic factor)—decreased 5. Prothrombin time—prolonged 6. Activated partial thromboplastin time—prolonged

Gestational age classification

1. Preterm or premature: *born before completion of 37 weeks of gestation, regardless of birth weight* 2. Late preterm: 34-36 6/7 weeks 3. Early term: 37-38 6/7 weeks 4. Full term: 39-40 6/7 weeks 5. Late term: 41-41 6/7 weeks 6. Postterm: 42 weeks & beyond 7. Postmature: born after completion of week 42 of gestation & showing the effects of progressive placental insufficiency

Preterm labor is generally diagnosed clinically as:

1. Regular contractions along with a change in cervical effacement, dilation, or both OR 2. Presentation with regular uterine contractions and cervical dilation of at least 2cm (because of their small size, preterm fetuses can be delivered through a partially dilated cervix)

Pregestational diabetes - antepartum exercise

1. Regular exercise may be contraindicated in women with diabetes who also have uncontrolled HTN, advanced retinopathy, or severe autonomic or peripheral neuropathy 2. Exercise monitored by PCP 3. Best type: aerobic exercise with resistance training for at least 30 min most days of week 4. Other exercises: non-weight bearing activities 5. Best time: after meals, when blood glucose level is rising 6. Monitor blood glucose and should be with someone else in case something happens 7. *Avoid if: have positive urine ketones or blood glucose greater than 250 mg/ dl bc hyperglycemia and ketosis can worsen with physical activity* 8. Uterine contractions may occur; *stop immediately if felt, drink 2-3 glasses of water, lie down on side for hour; if continues, call doctor*

Some activities associated with symptoms of preterm labor are:

1. Sexual activity *(not contraindicated in pregnancy unless symptoms of preterm labor occur)* 2. Riding or standing for long periods of time 3. Lifting and carrying heavy loads such as small children or laundry 4. Strenuous physical work 5. Infrequent rest periods

Miscarriage diagnosis is based on:

1. Signs & symptoms present 2. Laboratory findings 3. Ultrasound 4. *The further in gestation, typically more bleeding & pain* -miscarriage that occurs between weeks 6 & 12 of pregnancy causes moderate discomfort & blood loss -*after week 12, miscarriage is typified by severe pain, similar to that of labor, because the fetus must be expelled*

DIC possible examination findings

1. Spontaneous bleeding from gums, nose 2. Oozing, excessive bleeding from venipuncture site, intravenous access site, or site of insertion of urinary catheter 3. Petechiae (e.g., on the arm where BP cuff was placed) 4. Other signs of bruising 5. Hematuria 6. GI bleeding 7. Tachycardia 8. Diaphoresis

Gestational diabetes patho

1. The stomach converts food to glucose & glucose enters the mother's bloodstream. Mother's pancreas produces sufficient insulin, but the insulin is resistant. Glucose can't get into body's cells causing high glucose levels in bloodstream 2. High glucose levels in the mother's blood enter the baby through the placenta. The baby's pancreas makes more insulin to handle the excess glucose 3. Gestational diabetes affects the mother in late pregnancy, after the baby's body is fully formed, but while the baby is still growing 4. Since the baby is getting more energy than it needs to grow, the extra energy is stored as fat causing the baby to weigh much more than normal 5. Gestational diabetes can causes problems for the mom & baby during delivery. The baby may need to be delivered by c-section & may have breathing problems. As adults they may develop diabetes or obesity

What should be included in the physical exam of a pregnant woman with pregestational diabetes?

1. Thorough physical assessment 2. Baseline EKG 3. Evaluation for *retinopathy (changes in kidneys) (microvascular changes)* 4. Blood pressure - *should be followed closely during pregnancy to observe for preeclampsia* 5. Weight gain 6. *Fundal height - hydramnios*

5 types of miscarriage

1. Threatened 2. Inevitable 3. Incomplete 4. Complete 5. Missed

Why should a diabetic woman obtain preconception counseling?

1. To plan the optimal time for pregnancy 2. Establish euglycemia control before conception 3. Diagnose vascular complications 4. Associated with decreased infant mortality & decrease in congenital anomalies 5. *HbA1c < 7 is goal for those with DM*

3 types of placenta previa

1. Total/complete: internal os is *completely covered* by the placenta 2. Partial: *incomplete covering* of the internal os 3. Marginal: *only an edge of the placenta extends to the internal os* but *may extend onto the os during dilation* of the cervix

GDM - antepartum interventions

1. Treatment as soon as diagnosed 2. Educate a lot since this is new 3. Diet: -*Mainstay of treatment is diet modification* -Placed on standard diet for diabetes -30 kcal/ kg/ day unless obese then 25 -Carb intake restricted to about 50% of caloric intake -Meet with dietician 4. Exercise: moderate exercise if overweight to improve blood sugar control and facilitate weight loss 5. Self-monitoring blood glucose: on rising, 1 or 2 hours after breakfast, before and after lunch, before dinner, at bedtime 6. Pharm therapy: -¼ require insulin during pregnancy to maintain satisfactory levels, despite diet change -If fasting plasma continually more than 95, 1 hour postmeal more than 140, 2 hour postmeal more than 120 -Try oral meds before injections -*Glyburide most commonly used; only small amounts cross to placenta* -Take 30 min- 1 hour before meals -*Metformin crosses placenta more but doesn't appear teratogenic* 7. Fetal surveillance: -if levels well controlled, low risk for IUFD so antepartum fetal testing not done routinely unless also have HTN, hx of stillbirth, or suspected macrosomia -begin fetal testing at 40 weeks

Molar pregnancy treatment

1. Usually *spontaneous delivery* - if not, suction curettage -*induction with oxytocic agents or prostaglandin = not recommended* bc of increased risk of embolization of trophoblastic tissue 2. *Administer Rhogam if patient is Rh negative* 3. Educate on follow up management -serial beta-hCG levels are drawn watching for increased levels; *increasing levels & enlarging uterus may indicate choriocarcinoma* -*pregnancy should be avoided for 1 year*; any contraceptive measure is appropriate *EXCEPT for an IUD* -oral contraceptives preferred bc they are highly effective

Signs & symptoms of preterm labor

1. Uterine activity -Uterine contractions *occurring more frequently than every 10 minutes persisting for 1 hour or more.* -Uterine contractions may be painful or painless 2. Discomfort -Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea -Dull, intermittent low back pain (below the waist) -Painful, menstrual-like cramps -Suprapubic pain or pressure -Pelvic pressure or heaviness; feeling that "baby is pushing down" -Urinary frequency 3. Vaginal discharge -Change in character or amount of usual discharge: thicker (mucoid) or thinner (watery), bloody, brown or colorless, increased amount, color -Rupture of amniotic membranes

Preeclampsia fetal complications

1. Uteroplacental insufficiency -*causes hypoxia/acidosis & placental abruption* 2. IUGR 3. Premature birth 4. Intrauterine fetal death (IUFD)

Molar pregnancy clinical manifestations

1. Vaginal bleeding -*May be dark brown to bright red - scant to heavy* (resembles prune juice) 2. Excessive nausea & vomiting *(hyperemesis gravidarum)* 3. Anemia from blood loss 4. Abdominal cramps caused by uterine distention are common 5. Excessively enlarged uterus or smaller than expected 6. *Preeclampsia* occurs in 70% of women with large hydatidiform moles & occurs earlier than usual -*if diagnosed before 24 weeks, hydatidiform should be suspected & ruled out* 7. hyperthyroidism

Nursing care immediately after cervical cerclage placement

1. Woman will likely be on bedrest for at least a few days -also will probably be advised to *avoid sexual intercourse until after a post-op check* -after, decisions about physical activity & lifestyle changes are *individualized based on the status of the woman's cervix* 2. Woman must understand the need for close observation & supervision for the remainder of pregnancy -*home uterine contraction monitoring* 3. Preterm labor precautions & instructions on when to return to the hospital: *strong contractions less than 5 min apart, PPROM, severe perineal pressure, & an urge to push* 4. *Stich removal for vaginal delivery* -active labor with dilation, ROM < infection, term pregnancy (37 wks) 5. *If c-section then the stitch can be left in place*

Methyldopa (aldomet)

1. a2-receptor agonist 2. Targets postganglionic nerve endings: interferes with chemical neurotransmission to reduce peripheral vascular resistance; *causes CNS sedation* 3. Maternal effects -*Sleepiness, postural hypotension, constipation; rare, drug induced fever and positive coomb's test* 4. Fetal effects -*After 4 months of maternal therapy, positive coomb's test result in infant*

Labetalol Hydrochloride (Normodyne)

1. alpha & beta blocker 2. Targets peripheral arterioles 3. Maternal effects -Minimal: flushing, tremulousness, orthostatic hypotension; *minimal changes in pulse rate 4. *Fetal effects minimal*, if any 5. *Less likely to cause excessive hypotension and tachycardia; less rebound hypotension than hydralazine* 6. *DO NOT use in women with asthma or HF* 7. *Do NOT exceed 80 mg in a single dose*

2 predictive diagnostic measures for preterm labor

1. fFN 2. endocervical length *more powerful when used together in predicting spontaneous preterm birth*

Self-monitoring of blood glucose

1. fingersticks recommended for site 2. *routinely assessed before meals; 1-2 hours after meals; at bedtime; in middle of night* if nighttime insulin is being adjusted 3. if NVD, monitor more frequently 4. acceptable pregnancy levels: -fasting: 60-99 -peak (1 hour) postmeal: 100-129 -2 hour postmeal: < 120 5. Report recurrent episodes of hypoglycemia (less than 70) and hyperglycemia (more than 200) 6. *Hypoglycemia treated with 15 g of carb if mild; if severe need IV* 7. *Hyperglycemia less likely but rapidly progresses to DKA and associated with increased risk of fetal death*

Anticipatory grief may be experienced when the following occurs:

1. in threatened miscarriage 2. when there is a diagnosis of a fetal condition incompatible with life 3. as a result of selective pregnancy termination 4. when a newborn is born prematurely or becomes critically ill 5. voluntary termination

An infant's weight is classified as:

1. low birth weight if they are born weighing *less than 2500 grams (about 5.5 pounds)* 2. very low birth weight if they weigh *less than 1500 grams (about 3.3 pounds).* 3. extremely low birth weight (ELBW) if they weigh *less than 1000 grams (2.2 pounds).*

Pregestational diabetes - determination of birth date & mode of birth

1. optimal time for birth is 39-40 weeks as long as good metabolic control maintained and parameters of antepartum fetal surveillance remain within normal limits 2. reasons to proceed with birth: poor metabolic control, coexisting HTN, nonreassuring FHR 3. many plan for elective labor induction between 38-40 weeks 4. to confirm fetal lung maturity, amniocentesis if birth before 38 weeks 5. c section when fetal weight expected to be over 4500 g

The fetal pancreas begins to secrete insulin at ________ to _______ weeks of gestation

10 to 14 weeks The fetus responds to maternal hyperglycemia by secreting large amounts of insulin (hyperinsulinemia)

The major goal of caring for a laboring pt with preeclampsia is: (select all that apply) 1). Rapid delivery 2). Maintain uteroplacental perfusion 3). Prevent seizures 4). Prevent IUGR

2). Maintain uteroplacental perfusion 3). Prevent seizures

Preterm birth is any birth that occurs between:

20-36 6/7 weeks of gestation

Insulin requirements normally peak at ______ weeks of gestation and drop significantly after that

36

Placental abruption - expectant management

< 36 weeks gestation with mild abruption: 1. *Hospital Bedrest* 2. Observe for Bleeding and Labor 3. Close Fetal Surveillance (BPP & NST) 4. *Antenatal Glucocorticoids* 5. *Rhogam* if Rh negative mother 6. Emotional Support

With HELLP syndrome, RBCs are damaged as they pass through narrowed blood vessels & become hemolyzed, resulting in:

A *decreased RBC & platelet count*, as well as *hyperbilirubinemia.* Endothelial damage & fibrin deposits in the liver lead to *impaired liver function* & can cause hemorrhagic necrosis. *Liver enzymes are elevated when hepatic tissue is damaged*

Risk factors for GDM

A family history of diabetes and previous pregnancy that resulted in unexplained stillbirth or birth of malformed or macrosomic fetus Other risk factors include obesity, HTN, glycosuria, & maternal age older than 25 years However, more than half of all women diagnosed with GDM do not have these risk factors

Hydatidiform mole (molar pregnancy) is what type of disease?

A gestational trophoblastic disease (GTD) 1. GTD is a group of pregnancy-related *trophoblastic proliferative disorders WITHOUT a viable fetus that are caused by abnormal fertilization* 2. Women are at *higher risk if they have been treated with Clomid* (infertility drug) 3. Etiology is unknown, *may be r/t an ovular defect or nutritional deficiency* 4. Women who had a prior molar pregnancy & those who are in their *early teens or older than 40* are also at risk

A client with an incompetent cervix with a previous pregnancy had a cerclage procedure done at 18 wks in the current pregnancy. The client calls the clinic at 37 wks gestation bc of irregular contractions occurring every 5-7 minutes. Which response by the nurse is most appropriate? A. "go to the hospital to have the cerclage removed so your cervix isn't injured & to allow the birth to progress" B. "wait & come in when contractions are closer & harder" C. "you sound like you are worried about this baby. It must be frightening for you"

A. "go to the hospital to have the cerclage removed so your cervix isn't injured & to allow the birth to progress"

A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication. (Select all that apply.) A. Acute fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension

A. Acute fetal distress C. Vaginal bleeding D. Cervical dilation greater than 6 cm

A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone (Celestone) B. Indomethacin (Indocin) C. Nifedipine (Adalat) D. Methylergonovine (Methergine)

A. Betamethasone (Celestone)

A woman with a adherent retained placenta is at risk for: (select all that apply) A. Hemorrhage B. Hysterectomy C. Perforation of the uterine wall D. Preterm labor E. PP infection

A. Hemorrhage B. Hysterectomy C. Perforation of the uterine wall E. PP infection

If gestational diabetes is left untreated in the mother, what are potential outcomes for the baby? (Select all that apply.) A. High Birth Weight B. Respiratory Distress Syndrome (RDS) C. Hypoglycemia D. Shoulder Dystocia

A. High Birth Weight - caused by mothers increased sugar level that triggers the fetus' pancreas to produce more insulin, causing the baby to grow larger than normal B. Respiratory Distress Syndrome (RDS) - caused from underdeveloped lungs which occurs if baby is born preterm; high blood sugar levels in the newborn can impede lung development thus contributing to breathing problems C. Hypoglycemia - due to high insulin production D. Shoulder Dystocia - due to large baby

A nurse is providing care for a client who is diagnosed with a marginal abruptio placenta. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) A. Maternal hypertension B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

A. Maternal hypertension B. Blunt abdominal trauma C. Cocaine use E. Cigarette smoking

A nurse is caring for a client at 14 weeks gestation who has hyperemesis gravidarum. The nurse is aware that which of the following are risk factors for the client? (Select all that apply.) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Migrane headache E. Oligohydramnios

A. Obesity B. Multifetal pregnancy D. Migrane headache

A nurse is reviewing the physician's orders for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's order should the nurse question? A. Perform a vaginal examination every shift B. Monitor maternal vital signs every 4 hours C. Monitor fetal heart rate (FHR) continuously D. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours

A. Perform a vaginal examination every shift

A client, 34 weeks pregnant, arrives at the ER with SEVERE abdominal pain, uterine tenderness and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decels. The client most likely has which of the following? A. Placental Abruption B. Placenta Previa C. Molar pregnancy D. Ectopic pregnancy

A. Placental Abruption

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations fewer than 12/min. B. Urinary output less than 30 mL/hr. C. Hyperreflexic deep-tendon reflexes. D. Decreased level of consciousness. E. Flushing and sweating

A. Respirations fewer than 12/min. B. Urinary output less than 30 mL/hr. D. Decreased level of consciousness.

The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the clients pulse to be 144. The nurse's priority action should be to A. withhold the medication B. Decrease the dose by half C. Administer the medication D. Wait 15 minutes, then recheck the rate

A. withhold the medication not administered if HR > 130

Ketoacidosis

Accumulation of ketones in the blood *resulting from hyperglycemia* & leading to metabolic acidosis Occurs most often during the *2nd & 3rd trimesters, when the diabetogenic effect of pregnancy is greatest*

Who needs to be educated early in their pregnancy on signs & symptoms of preterm labor & what to do if they occur?

All women, not just those who have identifiable risk factors.

Perinatal loss - active listening

Allow them to tell their story 1. Start with a sincere acknowledgement of the loss 2. Ask if they would like to tell you what happened 3. Allow for silence - don't rush them 4. Assess whether touch should be used as a therapeutic technique

A client's admitting medical diagnosis is third-trimester bleeding: rule out placenta previa. Each time the nurse enters the client's room, the woman asks: "Please tell me, do you think the baby will be all right?" Which of the following is an best nursing diagnosis for this client? A. Hopelessness related to possible fetal loss. B. Anxiety related to unidentified diagnosis. C. Situational low self-esteem related to blood loss. D. Potential for altered parenting related to inexperience.

B. Anxiety related to unidentified diagnosis.

A mother is newly diagnosed with gestational diabetes. The nurse anticipates the doctor to first suggest: A. Insulin Therapy B. Diet & Exercise C. Oral Hypoglycemic Agents D. Delivery of baby

B. Diet and exercise Start out with the least invasive measure

A nurse is caring for a client who is receiving nifedipine (Procardia) for prevention of preterm labor. The nurse should monitor the client for which of the following clinical manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence

B. Dizziness

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

B. Ectopic pregnancy

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a clinical manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase (ALT) 20 IU/L D. Serum glucose 114 mg/dL

B. Urine ketones present

The nurse is reviewing a food log from a mother with gestational diabetes. Which of these foods would the nurse tell the mother to avoid? A. Liver B. White Rice C. Eggs D. Kiwi

B. White Rice -*Avoid foods white in color: bread, pasta, crackers, bagels, rolls, rice, tortillas* Liver & Eggs are high in Protein Fresh fruits are okay with gestational diabetes in moderation

A client at 33 weeks gestation and leaking amniotic fluid is placed on EFM. The monitor indicates uterine irritability and contractions occurring every 4-6 min. The doctor orders terbutaline. Which of the following teaching statements is appropriate for this client? A. This medicine will make you breathe better B. You may feel fluttering or tight sensation in your chest C. This will dry your mouth and make you thirsty D. You'll need to replace potassium lost by this drug

B. You may feel fluttering or tight sensation in your chest Tachycardia is a SE of terbutaline

Chronic hypertension with superimposed preeclampsia

BP increases *> 30 mmHg systolic or > 15 mmHg diastolic from baseline with onset of significant proteinuria* 1. Hypertension before 20 weeks: new onset proteinuria (> 5g protein in 24 hour urine) 2. Hypertension before 20 weeks AND proteinuria = an exacerbation of hypertension plus one of the following: thrombocytopenia, or increase in hepatocellular enzymes (liver enzymes)

When should women be screened for GDM?

Between 24-28 weeks of gestation -those with strong risk factors should be screened earlier in pregnancy; if results are normal, they should be rescreened at 24-28 weeks

Common birth injuries associated with diabetic pregnancies include:

Brachial plexus palsy, facial nerve injury, humerus or clavicle fracture, and cephalhematoma Most of the injuries are associated with difficult vaginal birth & shoulder dystocia *Hypoglycemia at birth is also a risk for infants born to mothers with diabetes*

Oral glucose tolerance test for gestational diabetes is usually done during: A. 12 to 14 weeks of pregnancy B. 32 to 36 weeks of pregnancy C. 24 to 28 weeks of pregnancy

C. 24 to 28 weeks of pregnancy

A client in preterm labor (32 weeks) who is dilated to 5cm has been given magnesium sulfate and the contractions have stopped. If the labor can be delayed for the next 2 days, which of the following medications does the nurse expect that will be prescribed? A. Fentanyl (Sublimaze) B. Sufentanil (Sufenta) C. Betamethasone (Celestone) D. Butorphanol tartrate (Stadol)

C. Betamethasone (Celestone)

Which of the following laboratory test must be monitored for pregnant patients receiving dexamethasone? A. RBC count B. Serum calcium C. Blood sugar D. Uric acid

C. Blood sugar *Blood glucose levels may INCREASE while taking steroids*

Which drug would the nurse choose to utilize as an antagonist for magnesium sulfate? A. Oxytocin B. Terbutaline C. Calcium Gluconate D. Narcan

C. Calcium Gluconate

Oral glucose tolerance test is a gestational diabetes test that measures: A. How insulin is processed in the mother's body B. Baby's glucose levels C. How a mother's body processes sugar D. Hormone levels in the placenta

C. How a mother's body processes sugar In the oral glucose tolerance test, glucose is administered to the mother, and blood sugar levels are measured at regular intervals. This test is done after overnight fasting. It measures how the body processes the sugar administered orally.

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

C. Hydatidiform mole

A pregnant client is receiving magnesium sulfate therapy for the control of preterm labor. A nurse discovers that the client is encountering toxicity from the medication in which of the following assessment? A. Urine output of 25 ml/hr B. The presence of deep tendon reflex C. Respirations of 10 breaths per minute

C. Respirations of 10 breaths per minute

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

C. Respiratory depression

The nurse is preparing to administer methotrexate to a client. This hazardous drug is most often used for which obstetric complication? A. Complete hydratidiform mole B. Missed Abortion C. Unruptured ectopic pregnancy D. Placental Abruption

C. Unruptured ectopic pregnancy

Insulin requirements in breastfeeding women may be half of prepregnancy levels because of the:

Carbs used in human milk production 1. Bc glucose levels are lower than normal, *BF women are at increased risk for hypoglycemia, especially in the early PP period & after BF sessions*, particularly after late night nursing 2. BF mothers with diabetes may be at increased risk for mastitis & yeast infections of the breast 3. *The insulin dose, which is DECREASED during lactation, must be recalculated at weaning*

Hypoglycemia (insulin shock) - causes, onset, & symptoms

Causes: excess insulin, insufficient food (delayed or missed meals), excessive exercise or work, indigestion, diarrhea, vomiting Onset: rapid (regular insulin), gradual (modified insulin or oral hypoglycemic agents) Symptoms: irritability, hunger, sweating, nervousness, personality change, weakness, fatigue, blurred/double vision, HA, pallor/clammy skin, shallow respirations, rapid pulse -urine negative for sugar & acetone -BG less than 70

Hyperglycemia (DKA) - causes, onset, & symptoms

Causes: insufficient insulin, excess or wrong kind of food, infection, injuries, illness, emotional stress, insufficient exercise Onset: slow (hours-days) Symptoms: thirst, N/V, abdominal pain, constipation, drowsiness, dim vision, increased urination, HA, flushed/dry skin, rapid breathing, weak/rapid pulse, acetone (fruity) breath order -urine positive for sugar & acetone -BG >200

_________________ is defined as *passive and painless dilation* of the cervix leading to recurrent preterm births

Cervical insufficiency/incompetent cervix 1. Cervical cerclage (cervical stitch) is a *prophylactic measure to prevent preterm delivery*. Usually *placed between 10 and 14 weeks when a patient has a history of previous losses* as a result of passive, painless dilation. 2. Can also be *placed before 25 weeks if found to have a shortened or dilated cervix* 3. *Rarely used after 25 weeks* gestation *due to the risk of infection and PPROM.* -In this case, tocolytics + bedrest = best treatment option 4. Most common procedure is the McDonald cerclage used to constrict the internal os of the cervix

Changes in ______________ occur BEFORE uterine activity, so cervical measurement can identify women in whom the labor process has begun

Cervical length -however, because *preterm cervical shortening occurs over a period of weeks,* neither digital nor ultrasound cervical examination is very sensitive at predicting imminent preterm birth -women whose cervical length is *greater than 30 mm are UNLIKELY to give birth prematurely* even if they have symptoms of preterm labor *(<30 mm in a singleton pregnancy = predicts some instances of preterm labor)*

_________________ is defined as elevated blood pressure *prior to pregnancy or is diagnosed prior to 20 weeks* gestation

Chronic hypertension -HTN initially diagnosed during pregnancy that *persists longer than 12 weeks postpartum is also classified as chronic HTN*

In addition to hyperglycemia, other causes of stillbirth include:

Congenital abnormalities, placental insufficiency or fetal growth restriction, macrosomia or polyhydramnios, or obstructed labor (intrapartum stillbirth)

Major causes of perinatal mortality associated with maternal diabetes are:

Congenital malformations, respiratory distress syndrome, & extreme prematurity IUFD (sometimes called stillbirth) remains a major concern; *poor glycemic control is the most consistent finding in women who had a stillbirth*

Many women report feeling the baby "balling up". They should be educated that this could be:

Contractions & warrants closer attention

A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin (Indocin) C. Nifedipine (Procardia) D. Betamethasone (Celestone)

D. Betamethasone (Celestone)

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine (Adalat) B. Pyridoxine (vitamin B6) C. Ferrous sulfate D. Calcium gluconate

D. Calcium gluconate

Which of the following foods/drinks would NOT be appropriate to give a mother experiencing hypoglycemia? A.1/2 cup of Orange juice B. 5 hard Lifesavers C. 1 cup of skim milk D. ½ cup of Diet Coke

D. Diet Coke We would want to give this mother regular soda and not diet.

A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heart beat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? A. Cervical cerclage. B. Amniocentesis. C. Nonstress testing. D. Dilation and curettage

D. Dilation and curettage

A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following should be included in the teaching? A. Use a condom with sexual intercourse. B. Avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts.

D. Keep a daily record of fetal kick counts.

A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following is an expected finding? A. No alteration in menses. B. Transvaginal ultrasound indicating a fetus in the uterus. C. Serum progesterone greater than the expected reference range. D. Report of severe shoulder pain.

D. Report of severe shoulder pain.

A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion/miscarriage. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? A. Luteinizing hormone level. B. Endometrial biopsy. C. Hysterosalpinogram. D. Serum progesterone level

D. Serum progesterone level

Placenta previa - home care

Decided on case-by-case basis; woman's condition *should be stable, and she should have experienced no vaginal bleeding for at least 48 hours* before discharge 1. Can she be compliant with bedrest at home 2. Will she always have someone with her incase she starts bleeding 3. How far does she live from the hospital 4. Would she have to care for other children 5. Transportation to physician office and hospital 6. Is there a phone in the house to call an ambulance

In preeclampsia, vascular remodeling does NOT occur or only PARTIALLY develops, resulting in:

Decreased placental perfusion & hypoxia *(vessels of uterus are too thick & can't handle increased blood volume)*

Hyperglycemia during the 1st trimester of pregnancy, when organs and organ systems are forming, is the main cause of:

Diabetes-associated birth defects Anomalies commonly seen in infants born to women with diabetes affect primarily the *CV system & the CNS*

When the maternal metabolism is stressed by illness or infection, the woman is at increased risk for:

Diabetic ketoacidosis -DKA can also be caused by poor compliance with treatment or use of beta-mimetic drugs such as *terbutaline (Brethine) for tocolysis to treat preterm labor or corticosteroids for fetal lung maturation* -*May occur with blood glucose levels barely exceeding 200* (in nonpregnant it would be 300 or more)

________________ is a pathological form of clotting

Disseminated intravascular coagulation (DIC) 1. diffuse & consumes large amounts of clotting factors, causing *widespread external bleeding, internal bleeding, or both & clotting* 2. *NEVER a primary diagnosis*. Instead it results from some event that triggered the clotting cascade

GDM is usually diagnosed when?

During the 2nd half of pregnancy -As nutrient demands rise, maternal nutrient ingestion induces greater and more sustained levels of blood glucose -Maternal insulin resistance is also increasing so maternal insulin demands rise greatly -Most pregnant women are capable of increasing insulin production to compensate for insulin resistance and maintain euglycemia but when pancreas is unable to produce sufficient insulin or insulin is not used effectively, GDM can result

Etiology of early & late miscarriage

Early 1. The majority - *80% of miscarriages - are early pregnancy losses, occurring before 12 weeks* 2. *Result from chromosomal abnormalities* 3. Other possible causes include endocrine disorders, autoimmune disorders, STDs, immunologic factors (antiphospholipid antibodies), systemic disorders, genetic factors -*infection is NOT a common cause of early miscarriage* -however, there's an *increased risk for spontaneous abortion with varicella infection in the 1st trimester* Late 1. Sometimes called a *2nd trimester loss, occurs between 12-20 weeks of gestation* 2. Risk factors include *advanced maternal age and parity, chronic infections, premature dilation, anomalies of the reproductive tract*

_________________ is the *onset of seizure activity or coma* in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity.

Eclampsia -onset after 20 weeks of gestation -although eclamptic seizures can occur before, during, or after birth, *approximately 50% of cases occur during the antepartum period*

_______________ is a pregnancy that occurs outside of the uterus.

Ectopic pregnancy 1. Fallopian tube is the most common site of occurrence 2. *Leading cause of infertility* 3. Contributing factors: *tubal sterilization, STDs, pelvic inflammatory disease* 4. Clinical manifestations: -Abdominal pain that *may refer to the shoulder if a rupture of the ectopic pregnancy occurs* -*Dark red or brown vaginal bleeding*: 50-80% of patients -*An ecchymotic blueness around the umbilicus (Cullen sign)* indicating blood in the abdominal cavity, may develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy

Insulin, produced by the beta cells in the islets of Langerhans in the pancreas, regulates blood glucose levels by:

Enabling glucose to enter adipose and muscle cells, where it is used for energy. *When insulin is insufficient or ineffective in promoting glucose uptake by the muscle and adipose cells, glucose accumulates in the bloodstream*, and hyperglycemia results.

During the first trimester of pregnancy (1-13 weeks) the pregnant woman's metabolic status is significantly influenced by the rising levels of:

Estrogen & progesterone These hormones *stimulate the beta cells in the pancreas to increase insulin production, which promotes increased peripheral use of glucose and decreased blood glucose*, with fasting levels being reduced by 10% At the same time, an *increase in tissue glycogen stores & a decrease in hepatic glucose production occur*, which further encourage lower fasting glucose levels As a result of these normal metabolic changes of pregnancy, *women with insulin-dependent diabetes are prone to hypoglycemia during the first trimester* -NV & decreased food intake contribute to hypoglycemia

Achieving and maintaining constant ___________ is the primary goal of medical therapy for GDM

Euglycemia (normal blood glucose level; normoglycemia) fasting: <95 preprandial: 65-95 1 hr postprandial: <130-140 2 hr postprandial: <120 2-4 am: 60-120

Plan of care for expectant management of placenta previa

Expectant management is *implemented if <36 weeks of gestation, woman is not in labor, & bleeding is either mild or has stopped* 1. Bedrest 2. Pad count 3. Fetal surveillance - BPP & NST 4. Laboratory studies for H&H and changes in coagulation studies 5. IV access 6. *Administration of antenatal glucocorticoids if less than 34 weeks of gestation* 7. *NO VAGINAL EXAMS* 8. Possible transfer to tertiary center 9. Emotional support for patient & family

High blood sugar level in the mother does not affect the fetus' sugar level. True or false?

False. They do affect the fetus' sugar level As maternal glucose levels rise → so do fetal glucose levels resulting in increased fetal insulin production.

_________ is a glycoprotein "glue" found in plasma & produced during fetal life & is a diagnostic test for preterm labor

Fetal fibronectin (fFN) -*normally* appears in cervical & vaginal secretions *early in pregnancy & then again in late pregnancy* -test is performed by collecting fluid from the woman's vagina using a swab during a speculum exam -*presence of fFN during the late 2nd & early 3rd trimesters of pregnancy may be r/t placental inflammation*, which is thought to be one cause of spontaneous preterm labor *(not normally found between 24-34 weeks)* -*presence of fFN alone is NOT very sensitive as a predictor of preterm birth* -often the test is *used to predict who will NOT go into preterm labor, because preterm labor is very unlikely to occur with a negative result* -negative result indicates a <95% chance of delivering prematurely

White's classification of diabetes in pregnancy

GDM Class A: *Any degree of glucose intolerance with the onset or first recognition during pregnancy* -Mom and baby have same reactions: Big Mom → Big Baby Class A - C generally have good pregnancy outcomes. Class D - T *usually have poorer pregnancy outcomes because of pre-existing vascular change*

Placental ischemia causes endothelial cell dysfunction by stimulating the release of a toxic substance to endothelial cells. This dysfunction causes:

Generalized vasospasm, which results in poor tissue perfusion in all organ systems, increased peripheral resistance & BP, increased endothelial cell permeability, leading to intravascular protein loss and ultimately to less plasma volume

_________________ is the onset of hypertension WITHOUT proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.

Gestational HTN 1. defined as systolic BP greater than 140 or a diastolic BP greater than 90. *Only one pressure (either systolic or diastolic) needs to be elevated to meet the definition of HTN* 2. the HTN should be recorded on *two occasions at least 4 hours* apart after 20 weeks of gestation in a woman with a previously normal BP. 3. *Does NOT persist longer than 12 weeks postpartum* & usually *resolves during the first postpartum week*

Management of HELLP syndrome

Gestational age <32 weeks: 1. Administer a corticosteroid 2. Manage the patient based on the clinical response during period of observation 3. Patients conditions worsen -Delivery 4. Patient is stable -Monitor the patient in a tertiary care facility Gestational age 32-34 weeks 1. Administer a corticosteroid 2. Is the patient eligible for conservative management? -If no, deliver -if yes, counsel the pt about the potential benefit of continuing the pregnancy for 2 more weeks to allow more time for fetal lung maturity -Transfer the patient to a tertiary care facility that has neonatal intensive care unit 3. Patient's condition worsens -Delivery 4. Patient is stable -Monitor the pt. in a tertiary care facility *Gestational age >34 weeks = Deliver*

_________________ is a long-acting insulin lasting approximately 24 hours and is not approved for use in pregnancy but appears to be safe

Glargine (Lantus) -No peak since slowly released -when administered with rapid or short-acting insulin, *unpredictable spikes in insulin levels & resulting hypoglycemia appear to occur less often*

Classification of placental abruption

Grade 1: small amount of vaginal bleeding and some uterine contractions, no signs of fetal distress or low blood pressure in the mother. Grade 2: mild to moderate amount of bleeding, uterine contractions, the *FHR may show signs of distress.* Grade 3: moderate to severe bleeding or concealed (hidden) bleeding, *uterine contractions that do not relax (called tetany), abdominal pain, low blood pressure, fetal death*

________________ is a laboratory diagnosis for a variant of *severe preeclampsia* that *involves hepatic dysfunction*

HELLP syndrome Characterized by: H - *hemolysis* (*↑ Bilirubin level or presence of Burr cells* on peripheral smear) EL - *elevated liver enzymes* (*↑ AST, ALT*) LP - *low platelet count* (*↓ Platelets <100,000/mm³*)

Women with preexisting diabetes are at risk for several obstetric and medical complications, including:

HTN, preeclampsia, c section, preterm birth, & maternal mortality

Gestational diabetes (GDM) is more likely to occur among:

Hispanic, African American, Native American, Asian, Pacific Islander women than Caucasions -likely to recur in future pregnancies -risk for development of overt diabetes later in life is also increased

____________________ frequently develops during the 3rd trimester of pregnancy in women with diabetes.

Hydramnios (*poly*hydramnios) -*amniotic fluid level >2000 ml* -*caused by an increased glucose concentration* in amniotic fluid resulting from maternal & fetal hyperglycemia which *induces fetal polyuria*

When vomiting during pregnancy becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, the disorder is termed:

Hyperemesis gravidarum Risk factors: hyperthyroid disorders, prepregnancy psych diagnosis, previous pregnancy complicated by hyperemesis gravidarum, molar pregnancy, multiple gestation with a male & female fetus, diabetes, & GI disorders. Women carrying a female fetus are more at risk CM: weight loss, dehydration, dry mucous membranes, decreased BP, increased HR, & poor skin turgor Most important lab test is determination of ketonuria Tx: IV therapy for correction of fluid & electrolyte imbalances

The risk of________________, a less than normal amount of glucose in the blood, is also increased during pregnancy

Hypoglycemia -*early in pregnancy, when hepatic production of glucose is diminished & peripheral use of glucose is enhanced, hypoglycemia occurs frequently, often during sleep* -women with a prepregnancy history of severe hypoglycemia are at increased risk for severe hypoglycemia during gestation -*hypoglycemic episodes do NOT appear to have significant damaging effects on fetal well-being*

The first step in preventing preterm labor & birth is:

Identifying who is at-risk. This is done by obtaining a complete history and physical starting at the first prenatal visit.

During the 2nd and 3rd trimesters, because of insulin resistance, the insulin dose must be:

Increased significantly to maintain target glucose levels

In the 1st trimester, from weeks 3 to 7 of gestation, insulin requirements are:

Increased, followed by a decrease between weeks 7 and 15 of gestation

___________________, a NSAID, has been shown to suppress preterm labor by blocking the production of prostaglandins.

Indomethacin (Indocin) 1. Prostaglandin synthetase inhibitors 2. Relaxes uterine smooth muscle by inhibiting prostaglandins 3. Dosage & route: *50 mg PO then 25-50 mg every 6 hours for 48 hours* 4. Adverse effects -Maternal (common): NV, heartburn -less common, but more serious: *GI bleeding, prolonged bleeding time, thrombocytopenia* -Fetal: *Constriction of ductus arteriosus, oligohydramnios (caused by reduced fetal urine production), neonatal pulmonary hypertension*

____________ is the only factor KNOWN to be associated with preterm labor

Infection -cervical, bacterial, or urinary tract infection

Complications of pregestational diabetes requiring hospitalization

Infection, which can lead to hyperglycemia & DKA, is an indication for hospitalization, regardless of gestational age Hospitalization during the 3rd trimester for close maternal & fetal observation may be indicated for women whose diabetes is poorly controlled Women with diabetes are more likely to have preexisting HTN or develop preeclampsia, which may necessitate hospitalization

__________________ are more common & more serious in pregnant women with diabetes than in those without the disease

Infections -*disorders of carb metabolism alter the normal resistance of the body to infection* -the inflammatory response, leukocyte function, & vaginal pH are all affected -vaginal infections (monilial vaginitis) are more common -UTIs are also more prevalent -*women who are insulin dependent are more likely to have postpartum infection*

Infection in pregnant women with diabetes is serious because it causes increased ________________ and may result in ___________________

Insulin resistance; ketoacidosis

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in:

Insulin secretion, insulin action, or both

Ketoacidosis occurring at any time during pregnancy can lead to:

Intrauterine fetal death

Low birth weight does not necessarily mean a preterm birth has occurred. An infant can be born with a low birth weight at term. This is called:

Intrauterine growth restriction (IUGR) & occurs when there has been *complications of pregnancy that interferes with uteroplacental perfusion*

_________________ and __________________ are commonly prescribed rapid-acting insulins with a shorter duration of action than regular insulin and are preferred for use during pregnancy

Lispro (Humalog) and aspart (Novolog) -Advantages: *convenient bc injected immediately before meals, produce less hyperglycemia after meals, cause fewer hypoglycemic episodes* in some people -*Effects only last 3-5 hours* so most clients also require longer-acting insulin

____________ placenta is the term used when the placenta is implanted in the lower uterine segment *but does NOT reach the os*

Low-lying

Poor glycemic control later in pregnancy increases the rate of fetal _______________

Macrosomia (birth weight more than 4000-4500 g or greater than 90th percentile) -Tend to have *disproportionate increase in shoulder, trunk, & chest size* -Risk for *shoulder dystocia is high* -Women with diabetes face an *increased likelihood of c section because of failure of fetal descent or labor progress or of operative vaginal birth* (birth involving use of episiotomy, forceps or vacuum)

______________ is the most commonly used tocolytic agent because maternal and fetal or neonatal adverse reactions are less common than with the beta-adrenergic agonists.

Magnesium sulfate 1. CNS depressant 2. relaxes smooth muscles, including uterus 3. Dosage & Route: -*IV* -*loading dose 4-6 gms/30 min* -*maintenance dose 1-4 gms/hr*

________________ is the drug of choice for preventing and treating seizure activity (eclampsia).

Magnesium sulfate Indications: 1. Severe preeclampsia 2. HELLP syndrome 3. Eclampsia prevention/treatment Administer: 1. IVPB 2. Loading dose: 4-6 grams (over 15-30 min) 3. Maintenance dose: 1 to 2 g/hr (40 g in 1000 ml of LR; 1 g= 25 ml) and administered by an infusion pump at 2-3 g/hr -*this dose should maintain a therapeutic serum magnesium level of 4-7 mEq/L*

Contraindications to Tocolytics

Maternal 1. Severe Preeclampsia 2. Ecclampsia 3. Bleeding with hemodynamic instability 4. Contraindications to specific medications Fetal 1. Intrauterine fetal demise 2. Lethal fetal anomaly 3. Non-reassuring fetal status 4. Chorioamnionitis (inflammation of membranes) 5. PPROM

Complications of placental abruption

Maternal complications are associated with the abruption or its treatment: 1. hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia 2. DIC 3. Infection 4. Renal failure and pituitary necrosis may result from ischemia 5. Rh sensitization -Fetal mortality occurs as a result of fetal hypoxia, preterm birth -increased risk of neurological defects

Magnesium sulfate adverse effects

Maternal: -hot flashes, NV, HA, lethargy, dyspnea, *hypocalcemia*, blurred vision, transient hypotension Fetal: -decreased breathing movement, reduced FHR variability, nonreactive NST, *respiratory depression*, hypotonia, lethargy

Poor glycemic control around time of conception and in early weeks is associated with:

Miscarriage & preeclampsia Metabolic control is instrumental in decreasing the risk of congenital abnormalities & miscarriages

______________, a calcium channel blocker, is a tocolytic agent that can suppress contractions. It works by preventing calcium from entering smooth muscle cells, thus reducing uterine contractions.

Nifedapine (Procardia) 1. Dosage & route: *Initial 10-20 mg PO, then q 3-6 hours until contractions are rare* 2. Adverse effects -Maternal (most effects are mild): hypotension, *HA*, flushing, dizziness, nausea -fetal: hypotension (questionable) 3. Contraindications: -*Should NOT be given concurrently with magnesium sulfate* because skeletal muscle blockade can result -*Should NOT be given simultaneously or immediately after terbutaline* because of effects on heart rate and blood pressure.

GDM - fetal risks

No increase in defects if GDM is developed after first trimester since organ formation is complete Still at risk for macrosomia and birth trauma and electrolyte imbalances including neonatal hypoglycemia

Magnesium sulfate nursing responsibilities & patient safety

Nursing responsibilities: 1. Educate patient and family on use and side effects 2. *Assist patient into side lying position* Patient safety: 1. Seizure Precautions 2. Discontinue infusion if toxicity is suspected (to prevent respiratory/cardiac arrest) 3. Have Calcium Gluconate and intubation equipment close by 4. *Siderails ↑ x 4* 5. Call button within reach 6. Delivery pack accessible 7. Maintain *quiet environment with lights dimmed* 8. Therapeutic Magnesium Sulfate level - 4 to 7 mg/dl 9. *NEVER Abbreviate Magnesium Sulfate as MgSO4*

Who should be included in preconception counseling & why?

Partner should be included 1. Assess their understanding of the effects of pregnancy on diabetes mellitus and potential complications 2. Educate on the need for a multidisciplinary approach (perinatologist, nutritionist, ophthamologist) 3. Discuss financial implications related to frequent maternal & fetal surveillance (cost of missed work, possible bedrest) 4. Review contraception to plan ideal time for pregnancy (need for strict metabolic control) 5. Educate on the possible need of changing medication prior to pregnancy -*oral hypoglycemic agents are contraindicated during pregnancy, however, glyburide is being used experimentally. Metformin also being used*. -*need to be taking folic acid 0.4mg/ day (4mg a day if previous birth with a neural tube defect [NTD])* to decrease the risk of NTD.

In _______________ the placenta is implanted in the lower uterine segment

Placenta previa -the placenta *completely or partially covers the cervix* or is close enough to the cervix *to cause bleeding when the cervix dilates or the lower uterine segment effaces* -If placenta previa occurs early in pregnancy, there is a *chance that as the uterus grows the placenta will migrate up* thus resolving the placenta previa. -*The placenta NEVER migrates down*

Premature separation of the placenta from site of implantation is called:

Placental abruption Etiology: 1. *Maternal hypertension (most prominent)* 2. Cocaine -causes vascular disruption in the placental bed 3. Trauma: MVA, domestic abuse 4. Smoking & poor nutrition 5. Multiple gestation

The complications most frequently associated with hydramnios are:

Placental abruption, uterine dysfunction, & postpartum hemorrhage PPROM as a result of hydramnios leading to premature labor

At birth, expulsion of placenta prompts an abrupt drop in levels of circulating:

Placental hormones, cortisol, and insulinase Maternal tissues quickly regain prepregnancy sensitivity to insulin *Nonbreastfeeding: insulin-carb balance usually returns in 7-10 days* *Lactation uses maternal glucose* so breastfeeding mom's *insulin requirements remain LOWER DURING LACTATION* (prepregnancy requirement reestablished after weaning)

DIC is an overactivation of the clotting cascade and the fibrinolytic system, resulting in depletion of:

Platelets and clotting factors, which causes the formation of fibrin clots -*blood cells are destroyed as they pass through these fibrin choked vessels* -thus, *DIC results in clotting, bleeding, & ischemia*

What effect does poor metabolic control have on lactogenesis?

Poor metabolic control may DELAY lactogenesis & contribute to decreased milk production

The main pathogenic factor of preeclampsia is not an increase in BP but:

Poor perfusion as a result of vasospasm and reduced plasma volume

__________________ is a pregnancy-specific condition that occurs after 20 weeks of gestation or early postpartum and is determined by *hypertension and proteinuria in a woman who previously had neither condition*.

Preeclampsia -ranges from mild to severe & then may progress into HELLP syndrome or eclampsia -*occurs prior to 20 weeks in the case of trophoblastic disease (hydatidiform mole)*

Because magnesium sulfate depresses the function of the CNS, it is essential that the nurse frequently assesses the woman's:

Respiratory status, DTR, & LOC to identify signs that the serum level of magnesium sulfate is reaching toxic levels

An extremely important point to understand is that women with HELLP syndrome may not have:

Signs or symptoms of severe features of preeclampsia. -although most women have HTN, BP may be only mildly elevated in 15-50% of cases -proteinuria may be absent -as a result, *women with HELLP syndrome are often misdiagnosed*

Because using a calcium channel blocker can result in orthostatic hypotension & dizziness, it's essential to instruct women to:

Slowly change position from supine to upright and then sit until any dizziness disappears before standing. It is important to maintain adequate fluid balance to reduce the drop in BP that can occur with the drug-related vasodilation

Any pregnancy that ends prior to 20 weeks gestation is defined as:

Spontaneous abortion -Fetal weight less than 500 grams may also be used to classify as spontaneous abortion

______________ is the most commonly administered beta2-adrenergic agonist. It relaxes smooth muscles, inhibiting uterine activity by stimulating beta2-receptors

Terbutaline (Brethine) 1. Dosage & route: *subcutaneous injection of 0.25 mg every 4 hours* 2. Has many maternal & fetal adverse reactions, including *beta1-stimulated cardiopulmonary (tachycardia) effects & beta2-stimulated metabolic (hyperglycemia) effects* -maternal: *tachycardia*, palpitations, tremors, dizziness, nervousness, HA, nasal congestion, NV, *hypokalemia, hyperglycemia, hypotension* -fetal: *Mild tachycardia, fetal hyperglycemia, & neonatal hypoglycemia* 3. Contraindications: -*HR greater than 130 bpm* -Heart dx -Severe preeclampsia/eclampsia -Gestational diabetes -Hyperthyroidism

Prolapse of the umbilical cord occurs when:

The cord lies below the presenting part of the fetus Cord prolapse may be occult (hidden, rather than visible) at any time during labor whether or not the membranes are ruptured Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina & holding the presenting part off the umbilical cord The woman may also be assisted into a position such as modified sims, Trendelenburg, or knee-chest position, in which gravity keeps the pressure of presenting part off the cord

Many times women confuse the signs of preterm labor with:

The usual discomforts of pregnancy. They need to be educated that if any symptoms occur *it is best to be evaluated and sent back home than to let them continue unchecked* and therefore arrive to labor and delivery too late for successful intervention.

Normally in pregnancy the spiral arteries in the uterus widen to:

Thinner, saclike vessels with much larger diameters. This change *increases the capacity of the vessels, allowing them to handle the increased blood volume* (40%) during pregnancy

______________ are medications used to arrest labor.

Tocolytics -*No medication is approved for use as a tocolytic in the US.* -No medication has been shown to reduce the rate of preterm birth -The rationale for giving these meds is to *delay birth long enough (at least 48 hours) to allow time for maternal transport and for corticosteroids to reach maximum benefit* to reduce neonatal morbidity & mortality -Most common: Magnesium Sulfate, Terbutaline (Brethine), Nifedapine (Procardia), Indomethacin (Indocin)

A molar pregnancy is diagnosed by:

Transvaginal ultrasound & serum hCG 1. Transvaginal ultrasound is the most accurate tool -A characteristic *pattern of multiple diffuse intrauterine masses*, often called snowstorm pattern, is *seen in place of, or along with, an embryo or a fetus* 2. hCG levels are *persistently high or rising beyond 10-12 weeks of gestation*, the time they would begin to decline in a normal pregnancy

DM classification

Type 1: caused by *pancreatic islet beta cell destruction and prone to ketoacidosis* -usually *abrupt onset at young age and absolute insulin deficiency* Type 2: *insulin resistance and usually relative insulin deficiency* -risk factors: obese, aging, sedentary lifestyle, family history and genetics, puberty, HTN, prior gestational diabetes GDM: diabetes *diagnosed during pregnancy* that is clearly not overt (preexisting) diabetes

Glycosuria (excess sugar in urine) puts a diabetic expectant women at a higher risk for:

UTI

Spontaneous preterm labor is caused by multiple pathologic processes that eventually result in:

Uterine contractions, cervical changes, & rupture of membranes -*preventable* 1. Placental implantation bleeding (1st or 2nd trimester) 3. *Maternal & fetal stress (#1 major cause of preterm labor)* 4. Uterine overdistention 5. Allergic reaction 6. Decrease in progesterone level

Classic symptoms of placental abruption include:

Vaginal bleeding, abdominal pain, and uterine tenderness and contractions

What to say & what not to say to bereaved parents

What to say: "I'm sad for you" "how are you doing with all of this?" "this must be hard for you" 'What can I do for you?" "I'm sorry" "I'm here, and I want to listen" What not to say: "God had a purpose for her" "Be thankful you have another child" "The living must go on" "I know how you feel" "It's God's will" "You have to keep on going on for her sake" 'We'll see you back here next year, and you'll be happier" "Now you have an angel in heaven" "This happened for the best" "Better for this to happen now, before you knew the baby" "There was something wrong with this baby anyway"

Infant morbidity and mortality rates associated with diabetic pregnancy are significantly reduced how?

With strict control of maternal glucose levels before and during pregnancy

A woman who's 36 weeks pregnant comes into the labor & delivery unit with mild contractions. Which of the following complications should the nurse watch out for when the client informs her that she has placenta previa? a. sudden rupture of membranes b. vaginal bleeding c. emesis d. fever

b. vaginal bleeding

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? a. Painless vaginal bleeding b. Abdominal cramping c. Throbbing pain in the upper quadrant d. Sudden, stabbing pain in the lower quadrant

d. Sudden, stabbing pain in the lower quadrant