OB/GYN Exam 1

Common Normal Pregnancy Discomforts/Interventions

Backache: -Minimize standing, increase rest, support belt; good shoes, pelvic tilt, acetaminophen. Constipation: -Increase fluid and high-fiber foods. Dyspnea: -Stand and stretch arms overhead; good posture; sleep with head elevated. Dependent edema: Elevate legs, avoid constrictive clothing, prolonged standing, lie on left side, support girdle. Epistaxis: -Nose bleeding, avoid vigorous blowing, nose picking, dry air. Heartburn: Eliminate spicy, high-acid foods; small frequent meals, sleep in semifowlers. -Antiacids O.K. in pregnancy. Hemorrhoids: Minimize constipation; sitz baths; ice packs; stool softeners; witch hazel. Insomnia: Warm baths, warm drinks, relaxation. Leg cramps: Heat, massage, stretching, calcium lactate and high potassium foods. Nausea and vomiting: Avoid spicy and fatty foods, eat small frequent meals, Phenergan, reglan. Varicosities: Support stockings. Elevate legs and avoid prolong standing. Fatigue: Rest, good nutrition exercise. Urinary frequency: Reduce fluids before bedtime Breast Discomfort: Wear well-fitting, supportive bra.

Early Pregnancy Bleeding

Bleeding during early pregnancy is alarming to the woman and of concern to health care providers. -The common bleeding disorders of early pregnancy include: -Miscarriage (spontaneous abortion) -Premature dilation of the cervix (incompetent cervix) -Ectopic pregnancy -Hydatidiform mole (molar pregnancy). Miscarriage (spontaneous abortion): A pregnancy that ends as a result of natural causes before 20 weeks of gestation or a fetus less than 500g. -Approximately 10% to 15% of pregnancies end in miscarriage. Types of miscarriages: Threatened: -Vaginal bleeding or spotting occur early in pregnancy. -No cervical changes; Cervix is closed. -Symptoms of threatened miscarriage include spotting of blood but with the cervical os closed. Mild uterine cramping may be present. Inevitable: -Termination of pregnancy cannot be prevented. -Cervical changes; Cervix is dilated; large amount of bleeding. -Product of conception not yet passed. -Severe pains, cramping, membranes ruptured. Inevitable and incomplete miscarriages involve a moderate to heavy amount of bleeding with an open cervical os. Tissue may be present with the bleeding. Mild to severe uterine cramping may be present. An inevitable miscarriage is often accompanied by rupture of membranes (ROM) and cervical dilation. Passage of the products of conception will occur. Incomplete: -Same as inevitable, but open cervix with partial expulsion of product of conception. -Vaginal bleeding, pain/cramps/contractions. -Cervical changes, and no FHR. An incomplete miscarriage involves the expulsion of the fetus with retention of the placenta. Complete: -Expulsion of all products of conception. -In a complete miscarriage, the cervix has already closed after all fetal tissue was expelled. Slight bleeding may occur and mild uterine cramping may be present, as well. Missed: -Brownish vaginal discharge; cervix is closed. -Fetus dies in uterus and is retained. -Missed miscarriage refers to a pregnancy in which the fetus has died, but the products of conception are retained in utero for up to several weeks. It may be diagnosed by ultrasonic examination after the uterus stops increasing in size or even decreases in size. There may be no bleeding or cramping, and the cervical os remains closed. Recurrent: Recurrent miscarriage is three or more spontaneous pregnancy losses before 20 weeks of gestation -Miscarriage care management Assessment and nursing diagnoses

Significance and Incidence

Common medical complication of pregnancy: -Hypertensive disorders are a major cause of perinatal morbidity and mortality worldwide due to the following: -Uteroplacental insufficiency -Premature birth -Of maternal deaths worldwide, 10% to 15% can be attributed to preeclampsia and eclampsia. -Preeclampsia accounts for more than 50,000 maternal deaths each year.

Cord insertion and placental variations

Cord insertion and placental variation: Vasa previa: Fetal vessels lie over the cervical os, and the vessels are implanted into the fetal membranes rather than into the placenta Velamentous insertion of the cord: The cord vessels begin to branch at the membranes and then course onto the placenta Succenturiate placenta: Placenta has divided into two or more separate lobes. Battledore (marginal) insertion of the cord: Increases the risk of fetal hemorrhage, especially after marginal separation of the placenta.

Variations in Prenatal Care

Cultural influences: -Many cultural variations are found in prenatal care -Cultural barriers to prenatal care: lack of money, lack of transportation, language barriers, modesty -Cultural prescriptions tell women what to do, and cultural proscriptions establish taboos. Emotional response: -Virtually all cultures emphasize the importance of maintaining a socially harmonious and agreeable environment for a pregnant woman. A lifestyle with minimal stress is important in ensuring a successful outcome for the mother and baby. Physical activity and rest: -Norms that regulate the physical activity of mothers during pregnancy vary tremendously. Many groups, including Native Americans and some Asian groups, encourage women to be active. Clothing -Modesty is an expectation of many cultures. Sexual activity -In most cultures sexual activity is not prohibited until the end of pregnancy. Diet -Nutritional information given by Western health care providers also may be a source of conflict for many cultural groups. Ex: Muslim and Jewish people require special preparation. Age differences: Normal developmental processes that occur in both very young and older mothers are interrupted by pregnancy and require a different type of adaptation to pregnancy than that of the woman of typical childbearing age. Adolescents -Less likely than older women to receive adequate prenatal care -Most of these young women are unmarried, and many are not ready for the emotional, psychosocial, and financial responsibilities of parenthood. -These young women also are more likely to smoke and less likely to gain adequate weight during pregnancy. As a result of these and other factors, babies born to adolescents are at greatly increased risk of LBW. Women older than 35 years Multiparous women: Multiparous women may have never used contraceptives because of personal choice or lack of knowledge concerning contraceptives. They also may be women who have used contraceptives successfully during the childbearing years, but as menopause approaches they may cease menstruating regularly or stop using contraceptives and consequently become pregnant. Primiparous women -Not uncommon anymore. -Reasons for delaying pregnancy include a desire to obtain advanced education, career priorities, and use of better contraceptive measures. Women who are infertile do not delay pregnancy deliberately but may become pregnant at a later age as a result of fertility studies and therapies. Multifetal pregnancy -When the pregnancy involves more than one fetus, the mother and fetuses are at an increased risk for adverse outcomes -Multifetal pregnancies are more likely to end in prematurity. -Spontaneous rupture of membranes before term is more common. -Congenital malformations twice as common in monozygotic twins as in singletons Counseling needs to be provided for -Risk of preterm labor -Modification of weight gain and nutritional intake -Selective reproduction -Lifestyle changes -Can place a strain on finances, space, workload, and the woman's and family's coping capabilities Perinatal Education -Goal is to help individuals and family members to make informed and safe decisions about pregnancy, birth, infant care, and early parenthood Classes for expectant parents: -Education programs consist of a menu of class series and activities from preconception through the early months of parenting. Prenatal Care Choices: -Physicians: Able to deliver babies with complicated births such as c sections etc. -Midwives -Certified nurse-midwives (CNMs) -Direct entry midwives or certified midwives (CMs) -Traditional or lay midwives -Doulas: Help the patients with breathing exercises and pushing, etc. -Birth plans Birth Setting Choices: -Hospital -Labor, delivery, recovery rooms (LDRs) -Labor, delivery, recovery, postpartum rooms (LDRPs) -Birth centers -Home birth -Remains a controversial topic in American health care Danger Signs During Pregnancy: -Gush of fluid from the vagina (rupture of amniotic fluid) prior to 37 weeks of gestation. -Vaginal bleeding (placental problems such as abruption or previa). -Abdominal pain (premature labor, abruptio placentae, or ectopic pregnancy). -Changes in fetal activity (decreased fetal movement may indicate fetal distress). -Persistent vomiting (hyperemesis gravidarum) -Severe headaches (gestational hypertension) -Elevated temperature (infection) -Dysuria (urinary tract infection) -Blurred vision (gestational hypertension) -Edema of face and hands (gestational hypertension) -Epigastric pain (gestational hypertension) -Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and headache (hyperglycemia) -Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness (hypoglycemia)

Preeclampsia Management

Cure is delivery Close monitoring of maternal B/Ps Non Stress Test (NST) MgSO4 to prevent seizures Lebetalol and hydralazine for acute management of high BP Mild vs Severe Preeclampsia Mild Preeclampsia: -Pregnancy is greater than 20 weeks -Blood pressure is greater than 140 systolic or 90 diastolic -0.3g of protein is collected in a 24-hour urine sample, or persistent 1+ protein measurement on urine dipstick -There are no other signs of problems with the mother or the baby Severe Preeclampsia: One of the following findings is also necessary for a diagnosis of severe preeclampsia: -Signs of central nervous system problems (severe headache, blurry vision, altered mental status) -Signs of liver problems (nausea and/or vomiting with abdominal pain) -At least twice the normal measurements of certain liver enzymes on blood test -Very high blood pressure ( greater than 160 systolic or 110 diastolic) -Thrombocytopenia (low platelet count) -Greater than 5g of protein in a 24-hour sample -Very low urine output (less than 500mL in 24 hours) -Signs of respiratory problems (pulmonary edema, bluish tint to the skin) -Severe fetal growth restriction -Stroke -Turn patient to the side -Do not use a tongue blade; may cause gagging -Slow IV push of 4mg of magnesium sulfate; prevents reoccurence -After a convulsion, administer O2 and auscultate lungs -Allow fetus to recover prior to rushing to delivery. MgSO4: -Magnesium sulfate interferes with the release of acetylcholine at the synapses, decreasing neuromuscular irritability, depressing cardiac conduction, and decreasing CNS irritability. 4-6 grams loading dose over 20 minutes. 2-3 grams per hours maintenance dose Antihypertensives may be needed to control severe BP.

Antepartum Testing

Daily fetal movement count (DFMC) -Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation. -Also called kick counts -Several different protocols are used for counting, reccomended to count fetal movements two or three times daily for 60 minutes at a time. -A count of fewer than three kicks in 1 hour warrants further evaluation by a nonstress test (NST) or a contraction stress test (CST) biophysical profile, or a combination of these. -Fetal alarm signal: fetal movements cease entirely for 12 hours. Ultrasonography: Levels of ultrasonography: -The standard examination is used most frequently and can be performed by ultrasonographers or other heath care professionals, including nurses, who have had special training. Used to primarily detect fetal viability, determine the presentation of the fetus, assess gestational age, locate the placenta, examine the fetal anatomic structures for malformations, and determine amniotic fluid volume (AFV). -Limited examinations are performed for specific indications such as identifying fetal presentation during labor or evaluating fetal heart rate (FHR) activity when it is not detected by other methods. -Specialized or targeted examinations are performed if a woman is suspected of carrying an anatomically or a physiologically abnormal fetus. Indications for this comprehensive examination include abnormal findings on clinical examination, especially with polyhydramnios or oligohydramnios, elevated alpha-fetoprotein (AFP) levels, and a history of offspring with anomalies that can be detected by ultrasound examination. Specialized ultrasonography is performed by highly trained and experienced personnel. Abdominal: -Abdominal ultrasonography is more useful after the first trimester, when the pregnant uterus becomes an abdominal organ. During the procedure the woman should have a full bladder to displace the uterus upward to provide a better image of the fetus. Transvaginal: -No need for a full bladder, handled well by most women. Allows pelvic anatomic features to be evaluated in greater detail and intrauterine pregnancy to be diagnosed earlier. Probe inserted into the vagina. Ideally used in the first trimester to detect ectopic pregnancies, monitor the developing embryo, help identify abnormalities, and help establish gestational age. -Both methods produce a three dimensional view from which a pictorial image is obtained. Indications for use: Ultrasonography provides earlier diagnoses, allowing therapy to be instituted sooner in the pregnancy, thereby decreasing the severity and duration of morbidity, both physical and emotional, for the family -Fetal heart activity: Fetal heart activity can be demonstrated as early as 6 to 7 weeks of gestation by real time echo scanners and at 10 to 12 weeks by Doppler mode. By 9 to 10 weeks, gestational trophoblastic disease can be diagnosed. Fetal death can be confirmed by lack of heart motion, the presence of fetal scalp edema, and maceration and overlap of the cranial bones. -Gestational age: Gestational dating by ultrasonography is indicated for conditions such as uncertain dates for the last normal menstrual period, recent discontinuation of oral contraceptives, a bleeding episode during the first trimester, uterine size that does not agree with dates, and other high risk conditions. Usually more accurate than LMP dating. -Fetal growth: Fetal growth is determined by both intrinsic growth potential and environmental factors. Conditions that require ultrasound assessment of fetal growth include poor maternal weight gain or pattern of weight gain, previous pregnancy with intrauterine growth restriction, chronic infections, ingestion of drugs, maternal diabetes mellitus, hypertension, multifetal pregnancy, and other medical or surgical complications. -Fetal anatomy: Anatomic structures that can be identified by ultrasonography (depending on the gestational age) include the following: head (including ventricles and blood vessels), neck, spine, heart, stomach, small bowel, liver, kidneys, bladder, and limbs. Ultrasonography permits the confirmation of normal anatomy, as well as the detection of major fetal malformations. Plans can be made to deliver the baby vaginally or via c section and in specific hospitals that are more equipped to handle the babies needs once the baby is born. -Fetal genetic disorders and physical anomalies: A prenatal screening technique called nuchal translucency (NT) screening uses ultrasound measurement of fluid in the nape of the fetal neck between 10 and 14 weeks of gestation to identify possible fetal abnormalities. Fluid collection greater than 3mm is considered abnormal. -Placental position and function: The pattern of uterine and placental growth and the fullness of the maternal bladder influence the apparent location of the placenta by ultrasonography. During the first trimester, differentiation between the endometrium and small placenta is difficult. By 14 to 16 weeks the placenta is clearly defined; but if it is seen to be low lying, its relationship to the internal cervical os can sometimes be dramatically altered by varying the fullness of the maternal bladder. -Another use for ultrasonography is grading of placental aging. -Adjunct to other invasive tests: The safety of amniocentesis is increased when the positions of the fetus, placenta, and pockets of amniotic fluid can be identified accurately. Ultrasound scanning has reduced risks previously associated with amniocentesis, such as fetomaternal hemorrhage from a pierced placenta. -Percutaneous umbilical blood sampling and chorionic villus sampling also are guided by ultrasonography to identify the cord and chorion frondosum accurately. Fetal well-being: Doppler blood flow analysis: -Ability to study blood flow noninvasively in the fetus and placenta with ultrasound. -A helpful adjunct in the management of pregnancies at risk because of hypertension, IUGR, diabetes mellitus, multiple fetuses, and preterm labor. Amniotic Fluid Index: The total AFV can be evaluated by a method in which the vertical depths (in centimeters) of the largest pocket of amniotic fluid in all four quadrants surrounding the maternal umbilicus are totaled, providing an amniotic fluid index (AFI). Normal AFI is 10cm or greater. Biophysical profile (BPP) Noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease. The BPP includes AFV, FBMs, fetal movements, and fetal tone determined by ultrasound and FHR reactivity determined by means of NST. The BPP may therefore be considered a physical examination of the fetus, including determination of vital signs. FHR reactivity, FBMs, fetal movement, and fetal tone reflect current central nervous system (CNS) status, whereas the AFV demonstrates the adequacy of placental function over a longer period. -Reliable predictor of fetal wellbeing. BPP of 8-10 is considered normal. Modified biophysical profile Magnetic resonance imaging (MRI): MRI provides excellent pictures of soft tissue. Unlike CT, ionizing radiation is not used. Therefore, vascular structures within the body can be visualized and evaluated without injecting an iodinated contrast medium, thus eliminating any known biological risk. Noninvasive MRI radiologic technique Examiner can evaluate the following: -Fetal structure, overall growth -Placenta -Quantity of amniotic fluid -Maternal structures -Biochemical status of tissues and organs -Soft-tissue, metabolic, or functional anomalies -Biochemical assessment involves biologic examination and chemical determinations. -Procedures used to obtain the needed specimens include amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, and maternal sampling explained below. -Amniocentesis: obtains amniotic fluid which contains fetal cells. Usually under direct ultrasonography to guide needle. - Amniocentesis is possible after week 14 of pregnancy, when the uterus becomes an abdominal organ, and sufficient amniotic fluid is available for testing. Potential complications: -Maternal: hemorrhage, fetomaternal hemorrhage with possible maternal Rh isoimmunization, infection, labor, placental abruption, inadvertent damage to the intestines or bladder, and anaphylactoid syndrome of pregnancy (amniotic fluid embolism) -Fetal: death, hemorrhage, infection (amnionitis), direct injury from the needle, miscarriage or preterm labor, and leakage of amniotic fluid Many of the complications have been minimized or eliminated by using ultrasonography to direct the procedure. -Indications for the procedure include: Prenatal diagnosis of genetic disorders or congenital anomalies (NTDs in particular), assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease. Genetic concerns: -Historically, prenatal assessment of genetic disorders was focused on women older than 35 years with a previous child with a chromosomal abnormality, or with a family history of chromosomal anomalies. -Fetal cells can be cultured for karyotyping. -Biochemical analysis of enzymes in amniotic fluid can detect inborn errors of metabolism. Fetal maturity: Late in pregnancy, accurate assessment of fetal lung maturity is possible. Fetal hemolytic disease: Another indication for amniocentesis is the identification and follow-up of fetal hemolytic disease in cases of isoimmunization. Chorionic villus sampling (CVS): -Indications for CVS are similar to those for amniocentesis, although CVS cannot be used for maternal serum marker screening because no fluid is obtained. CVS performed in the second trimester carries no greater risk of pregnancy loss than amniocentesis and is considered equal to amniocentesis in diagnostic accuracy. -Involves the removal of a small tissue specimen from the fetal portion of the placenta, this tissue reflects the genetic makeup of the fetus. -CVS procedures can be accomplished transcervically or transabdominally. -Technique for genetic studies -Earlier diagnosis, rapid results -Performed between 10 and 13 weeks of gestation. Maternal assays: Maternal serum alpha-fetoprotein (MSAFP): -Maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy -Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy -Screening recommended for all pregnant women Triple- and quad-screening to detect autosomal trisomies: -Used to detect autosomal trisomy 18 and 21. -The triple-marker screen, performed at 16 to 18 weeks of gestation, measures the levels of three maternal serum markers: MSAFP, unconjugated estriol, and hCG. -The quad-screen adds an additional marker, a placental hormone called inhibin A, to increase the accuracy of screening for Down syndrome in women less than 35 years of age. Multiple marker screens: -Screening to detect fetal chromosomal abnormalities, particularly Trisomy 21 (Down syndrome) is now available, beginning in the first trimester of pregnancy. -It includes measurement of two maternal biochemical markers, pregnancy associated placental protein (PAPP-A) and human chorionic gonadotropin (hCG) or the free beta-human chorionic gonadotropin (β-hCG) subunit, and evaluation of fetal NT, or a combination of both. Coombs' test: -The indirect Coombs test is a screening tool for Rh incompatibility. If the maternal titer for Rh antibodies is greater than 1:8, amniocentesis for determination of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia. -The Coombs test can also detect other antibodies that may place the fetus at risk for incompatibility with maternal antigens.

Diabetes Mellitus Introduction:

Diabetes mellitus (DM) Affects 4% to 14% of pregnant women Pregnancy complicated by diabetes is considered high risk Pathogenesis: -Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. -Body compensates for its inability to convert glucose into energy by burning muscle and fats -Key to an optimal outcome is strict glycemic control Classification Type 1 diabetes: -Absolute insulin deficiency -Type 1 diabetes includes cases that are caused primarily by pancreatic islet beta cell destruction and that are prone to ketoacidosis. People with type 1 diabetes usually have an abrupt onset of illness at a young age and an absolute insulin deficiency. Type 2 diabetes -Relative insulin deficiency -Type 2 diabetes is the most prevalent form of the disease and includes individuals who have insulin resistance and usually relative (rather than absolute) insulin deficiency. Gestational diabetes mellitus (GDM): -Is any degree of glucose intolerance with the onset or first recognition occurring during pregnancy. This definition is appropriate whether or not insulin is used for treatment or the diabetes persists after pregnancy. It does not exclude the possibility that the glucose intolerance preceded the pregnancy or that medication might be required for optimal glucose control. -Women experiencing gestational diabetes should be reclassified 6 weeks or more after the pregnancy ends. -Glucose intolerance that is first recognized during pregnancy. -Insulin available but pregnancy hormones decreases receptivity. -Human placental lactogen increases insulin resistance, allowing more glucose to be passed to the fetus. -Associated with increased macrosomia/Large for gestational age infant. -Shoulder dystocia. Pregestational diabetes mellitus: Pregestational diabetes mellitus is the label sometimes given to type 1 or type 2 diabetes that existed before pregnancy. Metabolic changes associated with pregnancy: -Normal pregnancy is characterized by alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis -Glucose is the primary fuel for the fetus -Glucose crosses the placenta, insulin does not -Insulin needs increase during the first trimester -Diabetogenic effect in second and third trimesters, this is because of the major hormonal changes, decreased tolerance to glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose occur. -Maternal insulin requirements gradually increase from approximately 18 to 24 weeks of gestation to approximately 36 weeks of gestation. -Once birth is given, the breastfeeding mothers insulin requirements drop significantly. An abrupt drop in placental hormones.

Assessment of Risk Factors

-A comprehensive approach to high risk pregnancy is used now. -The factors associated with high risk childbearing are grouped into broad categories based on threats to health and pregnancy outcomes. Biophysical -Originates with the mother or the fetus May affect development and functioning of both. -Nutritional status, adequate nutrition. -Genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses Psychosocial -Maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus -May include emotional distress and disturbed interpersonal relationships. -Inadequate social support -Unsafe cultural practices -Alcohol, smoking, caffeine, drugs. Sociodemographic: -Arise from mother and her family -Lack of prenatal care -Low income -Marital status -Ethnicity Environmental: -Hazards in workplace and woman's general environment. -May include chemicals, anesthetic gases, and radiation

Key Points

-A high-risk pregnancy is one in which the life or well-being of the mother or infant is jeopardized by a biophysical or psychosocial disorder coincidental with or unique to pregnancy. -Biophysical, sociodemographic, psychosocial, and environmental factors place the pregnancy and fetus or neonate at risk. -Biophysical assessment techniques include DFMCs, ultrasonography, and MRI. -Biochemical monitoring techniques include amniocentesis, PUBS, CVS, MSAFP, multiple marker screens, and cell-free DNA screening in maternal blood. -Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as care coordination and other support services for families with a fetal anomaly diagnosis. -Reactive NSTs and negative CSTs suggest fetal well-being. -Most assessment tests have some degree of risk for the mother and fetus and usually cause some anxiety for the woman and her family. -The nurse's roles in assessment and management of the high-risk pregnancy are primarily those of educator and support person.

Key Points

-A woman's nutritional status before, during, and after pregnancy contributes, to a significant degree, to her well-being and that of her developing fetus and newborn. -Many physiologic changes occurring during pregnancy influence the need for additional nutrients and the efficiency with which the body uses them. -Both the total maternal weight gain and the pattern of weight gain are important determinants of the outcome of pregnancy. -The appropriateness of the woman's prepregnancy weight for height (BMI) is a major determinant of her recommended weight gain during pregnancy. -Nutritional risk factors include adolescent pregnancy; abuse of nicotine, alcohol, or drugs; bizarre or faddish food habits; a low or high weight for height; and frequent pregnancies. -Iron supplementation is usually routinely recommended during pregnancy. Other supplements may be warranted when nutritional risk factors are present. -Food safety is important for pregnant women to prevent adverse maternal and fetal effects. -Women who are pregnant should consume seafood that is low in methylmercury. -The nurse and the pregnant woman are influenced by cultural and personal values and beliefs during nutrition counseling. -Pregnancy complications that can be nutrition-related include anemia, gestational hypertension, gestational diabetes, and IUGR. -Dietary modifications can be effective interventions for some of the common discomforts of pregnancy, including nausea and vomiting, constipation, and heartburn.

Future Healthcare

-BP and proteinuria subside when birth is given. -Women with preeclampsia with severe features have a significantly increased risk of developing preeclampsia in a future pregnancy. -These women have an increased risk of developing chronic hypertension and cardiovascular disease later in life. -For now, women should be educated about lifestyle changes (maintaining a healthy weight, increasing physical activity, and avoiding smoking) that may decrease the risk for developing future health problems.

Antepartal Hemorrhagic Disorders

-Bleeding in pregnancy jeopardizes maternal and fetal well-being. Maternal blood loss decreases oxygen-carrying capacity, which places the woman at increased risk for hypovolemia, anemia, infection, and preterm labor, and adversely affects oxygen delivery to the fetus. Fetal risks from maternal hemorrhage include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth. Hemorrhagic disorders in pregnancy are medical emergencies. Information is outlined below. -Maternal blood loss decreases oxygen-carrying capacity and increases risk for the following conditions: Hypovolemia Anemia Infection Preterm labor Impaired oxygen delivery to the fetus -Fetal risks from maternal hemorrhage Blood loss, anemia Hypoxemia Hypoxia Anoxia Preterm birth -Hemorrhagic disorders in pregnancy are medical emergencies. -The incidence and type of bleeding vary by trimester.

Key Points

-Blood loss during pregnancy should always be regarded as a warning sign until the cause is determined. -Some miscarriages occur for unknown reasons, but fetal or placental maldevelopment and maternal factors account for many others. -The type of miscarriage and signs and symptoms direct care management. -Cervical insufficiency may be treated with a cervical or abdominal cerclage; the woman is instructed on recognizing the warning signs of preterm labor, preterm premature rupture of membranes, and infection. -Ectopic pregnancy is a significant cause of maternal morbidity and mortality. -Hydatidiform mole is a gestational trophoblastic disease (GTD). GTD refers to a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization. -Placenta previa and placental abruption are differentiated by type of bleeding, uterine tonicity, and presence or absence of pain. -Management of late-pregnancy bleeding requires immediate evaluation; care is based on gestational age, amount of bleeding, and fetal condition. -DIC is a pathologic form of clotting that causes widespread bleeding and clotting. It is never a primary diagnosis but always results from some event that triggered the clotting cascade.

Fetal Care Centers

-Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as support services for families with a fetal anomaly diagnosis. -Access to support services such as genetic counseling, social work, chaplain services, a palliative care team, and ethics consultation because of the complex emotional stressors they face

Classification of Hypertensive Disorders

-Gestational hypertension Onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after 20 weeks of pregnancy Systolic BP >140, diastolic BP >90 -Preeclampsia Pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman. Vasospasm disease, increase in blood volume increases in bp, which leads to vasoconstriction of the blood vessels and leads to decreased placental perfusion and hypoxia. In the absence of proteinuria, preeclampsia may be defined as hypertension along with the following: -Thrombocytopenia -Impaired liver function -New development of renal insufficiency -Pulmonary edema -New-onset cerebral or visual disturbances Eclampsia -Onset of seizure activity or coma in a woman with already diagnosed with preeclampsia. -No history of preexisting pathology -50% of eclamptic women develop the condition while pregnant -Women can develop eclampsia in the immediate postpartum period -Eclamptic seizures can occur before, during, or after birth almost always in the first 48 hours post partum. Chronic hypertension -Hypertension present before pregnancy or diagnosed before week 20 of gestation -Severe chronic hypertension can have an increased risk of perinatal mortality. Chronic hypertension with superimposed preeclampsia: -Women with chronic hypertension may acquire preeclampsia or eclampsia -Can be difficult to diagnose

Key Points

-Hypertensive disorders during pregnancy are a leading cause of maternal and perinatal morbidity and mortality worldwide. -The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia. -Preeclampsia is a multisystem disease, and the pathologic changes are present long before clinical manifestations such as hypertension become evident. -HELLP syndrome, which is usually diagnosed during the third trimester, is a variant of preeclampsia, not a separate illness. -Magnesium sulfate, the anticonvulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, and renal function. -Women with preeclampsia (especially early-onset and preeclampsia with severe features) have an increased risk of developing chronic hypertension and cardiovascular disease later in life. -The intent of emergency interventions for eclampsia is to prevent self-injury, enhance oxygenation, reduce aspiration risk, and establish control with magnesium sulfate.

Postpartum Nutrition

-Lose the weight gained during pregnancy. -Appropriate weight loss goals: Nonlactating women—0.5 to 0.9 kg per week; Lactating women—1 kg per month. -Attain a healthy weight. -Weight loss and breastfeeding

Morbidity and Mortality

-Maternal complications associated with hypertensive disorders include placental abruption (abruptio placentae), acute respiratory distress syndrome, stroke, cerebral hemorrhage, hepatic or renal failure, disseminated intravascular coagulation (DIC), and pulmonary edema. -Most perinatal complications are related to placental insufficiency which causes intrauterine growth restriction (IUGR), prematurity associated with indicated preterm birth, hypoxia/acidosis, or placental abruption Morbidity: Renal failure Coagulopathy Cardiac or liver failure Placental abruption Seizures Stroke Mortality: Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide.

Key Components of Preconception and Prenatal Nutritional Care

-Nutrition assessment, including appropriate weight for height, dietary intake and habits, and preexisting issues that can affect nutritional status -Diagnosis of nutrition-related problems or risk factors such as diabetes and obesity -Interventions to promote appropriate weight gain, ingestion of a variety of foods, appropriate use of dietary supplements, and physical activity -Evaluation as an integral part of the nursing care provided to women during the preconception period and pregnancy, with referral to a nutritionist or dietitian as necessary

Nutritional Care and Teaching

-Programs for women with limited financial resources: WIC -Daily food guide and menu planning -Food safety -Medical nutrition therapy -Nutrition-related concerns during pregnancy: -Iron supplementation: The nutritional supplement most commonly needed during pregnancy is iron. Nutrition-related discomforts of pregnancy: -Nausea and vomiting -Hyperemesis gravidarum, or severe and persistent vomiting causing weight loss, dehydration, and electrolyte abnormalities, occurs in up to approximately 1% of pregnant women. -Constipation: Improved bowel function generally results from increasing the intake of fiber such as bran and whole-grain products, popcorn, and raw or lightly cooked vegetables in the diet, because fiber helps to create a bulky stool that stimulates intestinal peristalsis. -Heartburn (pyrosis): minimized by the consumption of small, frequent meals, rather than two or three larger meals daily. Vegetarian diets: -Consuming a variety of different plant proteins—grains, dried beans and peas, nuts, and seeds—on a daily basis can provide all of the essential amino acids. . B12 is found only in foods of animal origin Iron and zinc may not be as well absorbed from plant foods as they are from meats, and calcium intake can be low if milk products are avoided. Cultural influences: -Nurse should be aware of what constitutes a typical diet for each cultural or ethnic group.

Nutrient Needs During Lactation:

-Similar to those during pregnancy -Needs for energy, protein, vitamins, minerals are greater than nonpregnant needs -The recommended energy intake for the first 6 months PP is 330 kcal more than nonpregnant intake. -The AAP recommends that breastfeeding women who are well nourished should add 450 to 500 kcal/day to a balanced diet. -Adequate fluid intake -Avoid smoking, alcohol, and excessive caffeine

Key Points:

-The prenatal period is a preparatory one both physically, in terms of fetal growth and parental adaptations, and psychologically, in terms of anticipation of parenthood. -Pregnancy affects parent-child, sibling-child, and grandparent-child relationships. -Discomforts and changes of pregnancy can cause anxiety for the woman and her family and require sensitive attention and a plan for teaching self-management measures. -Education about safety during activity and exercise is essential, given maternal anatomic and physiologic responses to pregnancy. -Important components of the initial prenatal visit include detailed and carefully documented findings from the interview, a comprehensive physical examination, and selected laboratory tests. -Follow-up visits are shorter than the initial visit and are important for monitoring the health of the mother and fetus and providing anticipatory guidance as needed. -Even in normal pregnancy the nurse must remain alert to hazards such as supine hypotension, signs and symptoms of potential complications, and signs of family maladaptations. -Blood pressure is evaluated on the basis of absolute values and length of gestation and is interpreted in light of modifying factors. -Each pregnant woman needs to know how to recognize and report signs of potential complications such as preterm labor. -There is an increased incidence of physical, mental, and verbal abuse during pregnancy. -Culture, age, parity, and multifetal pregnancy can have a significant effect on the course and outcome of the pregnancy. -Nurses must ask pregnant women and their families about preferences, practices, and customs related to childbearing to provide culturally sensitive care. -Childbirth education teaches tuning in to the body's inner wisdom and coping strategies that enhance women's ability to cope effectively with labor and birth. -Perinatal education strives to promote healthier pregnancies and family lifestyles. -Nurses can help pregnant women and their families to make informed decisions about care providers, birth settings, and labor support.

Other Nutritional Issues During Pregnancy

Alcohol: -There is no safe amount or type of alcohol during pregnancy, and there is no time during pregnancy when alcohol consumption is without risk. -Caffeine Data unclear but general recommendation of no more than 200 mg of caffeine a day -Artificial sweeteners -Pica and food cravings: One problem with pica is that regular and heavy consumption of low-nutrient products may cause more nutritious foods to be displaced from the diet Adolescent pregnancy needs focus on improving: Many adolescent females have diets that provide less than the recommended intakes of key nutrients, including calcium and iron. Pregnant adolescents and their infants are at increased risk of complications during pregnancy and parturition. -Nutrition knowledge -Meal planning -Food preparation -Access to prenatal care -Nutritional interventions -Educational programs Physical activity during pregnancy: Factors to consider prior to exercise: -Dehydration -Calorie intake

Care Management

Assessment Obstetric and gynecologic effects on nutrition: -A history of preterm birth or birth of an LBW or small-for-gestational-age (SGA) infant may indicate inadequate dietary intake. Birth of a largefor- gestational-age (LGA) infant often indicates the existence of maternal diabetes mellitus. -Diet history: Ideally a nutritional assessment should be done before pregnancy. -Health history: Chronic maternal illnesses such as diabetes mellitus, renal disease, liver disease, cystic fibrosis or other malabsorptive disorders, seizure disorders and the use of anticonvulsant agents, hypertension, and PKU may affect a woman's nutritional status and dietary needs. -It is extremely important for nutritional care to be started and for the condition to be optimally controlled before conception. -Usual maternal diet: -The woman's usual food and beverage intake, the adequacy of her income and other resources to meet her nutritional needs, any dietary modifications, food allergies and intolerances, and all medications and nutrition supplements being taken, as well as pica practice and cultural dietary requirements, should be ascertained. -The presence and severity of nutrition related discomforts of pregnancy such as morning sickness, constipation, and pyrosis (heartburn) should be determined. -The quality of the diet improves with increasing socioeconomic status and educational level. Physical examination: -Anthropometric measurements provide short- and longterm information on a woman's nutritional status and are thus essential to the assessment. -BMI, physiologic changes of pregnancy may complicate the interpretation of physical findings Laboratory testing: -Hematocrit or hemoglobin measurement to screen for the presence of anemia, the only laboratory test that is necessary. -Anemia

Ectopic pregnancy

Ectopic pregnancy: The fertilized ovum is implanted outside the uterine cavity; also called "tubal pregnancies" Risk Factors: -Previous ectopic pregnancy -History of tubal surgery. -Pelvic inflammatory disease. -Infertility. -Past or current IUD use. -Uterine abnormalities Incidence and etiology: -Women are less likely to have a successful subsequent pregnancy after an ectopic pregnancy. -Ectopic pregnancy is also the leading cause of infertility. -Ectopic pregnancies are often called tubal pregnancies because approximately 95% are located in the uterine tube Clinical manifestations: -Typically s/s occur 6 to 8 weeks after the last normal menstrual period -The three most classic symptoms are the following: Abdominal pain Delayed menses Abnormal vaginal bleeding (spotting) Diagnosis Difficult differential diagnosis: -Numerous disorders share similar signs and symptoms. Every woman with abdominal pain, vaginal spotting or bleeding, and a positive pregnancy test should undergo screening for ectopic pregnancy. -Quantitative β-hCG levels -Transvaginal ultrasound examination -Progesterone level Tubal pregnancy management: Medical management: -Methotrexate to dissolve the tubual pregnancy. Surgical management: -One option is removal of the entire tube. (Salpingostomy/Salpingectomy) Follow-up care: -The woman and her family should be encouraged to share their feelings and concerns related to the loss. Future fertility should be discussed. A contraceptive method should be used for at least three menstrual cycles to allow time for the woman's body to heal.

Estimating the Date of Birth:

Estimated date of birth (EDB) Older terms -Estimated date of delivery (EDD) -Estimated date of confinement (EDC) Ultrasound -Standard procedure for determining the gestational age of the fetus Naegele's rule to calculate EDB -Assumes that the woman has a 28-day cycle and that fertilization occurs on the 14th day -After determining the first day of the LMP, subtract 3 calendar months, add 7 days

Preeclampsia

Etiology -A condition unique to human pregnancy -Common risk factors -Primigravidity in woman <19 or >40 years of age -First pregnancy with a new partner -History of preeclampsia -Pregnancy-onset snoring -The cause of preeclampsia is unknown. -Many theories Pathophysiology -Progressive disorder with placenta as the root cause -Begins to resolve after the placenta has been expelled -Spiral arteries in the uterus normally become larger and thicker to handle increased blood volume. This vascular remodeling does not occur or only partially develops in women with preeclampsia and decreased placental perfusion and hypoxia result. Placental ischemia is thought to cause endothelial cell dysfunction by stimulating the release of a substance that is toxic to endothelial cells. This anomaly causes generalized vasospasm, which results in poor tissue perfusion in all organ systems, increased peripheral resistance and BP, and increased endothelial cell permeability, leading to intravascular protein and fluid loss and ultimately to less plasma volume. -Placental ischemia → endothelial cell dysfunction by releasing toxic substances to endothelial cells. -Generalized vasospasm → poor tissue perfusion in all organ systems, leads to Increased peripheral resistance and blood pressure (BP) and increased endothelial cell permeability -Reduced kidney perfusion can lead to decreased GFR and degenerative glomerular changes including oliguria. -Plasma colloid osmotic pressure decreases as serum albumin levels decrease. -Decreased liver perfusion can lead to impaired liver function and elevated liver enzymes. -Neurologic complications include cerebral edema and hemorrhage and increased central nervous system (CNS) irritability Hepatic dysfunction characterized by: HELLP syndrome: Hemolysis Elevated Liver enzymes Low Platelet count. -Not a separate illness, just a variation of severe preeclampsia. -Laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction -Hemolysis (H) -Elevated liver enzymes (EL) -Low platelets (LP) below 100,000 -HELLP syndrome occurs in 0.5% to 0.9% of all pregnancies. -10% to 20% of women who have preeclampsia with severe features develop it. -Pathophysiologic changes are a result of arteriolar vasospasm, endothelial cell dysfunction with fibrin deposits, and adherence of platelets in blood vessels. -Red blood cells are damaged as they pass through narrowed blood vessels and become hemolyzed, resulting in a decreased red blood cell and platelet count, as well as hyperbilirubinemia. Endothelial damage and fibrin deposits in the liver lead to impaired liver function and can cause hemorrhagic necrosis. Liver enzymes are elevated when hepatic tissue is damaged. The clinical presentation is often nonspecific; most women with the disorder report the following: -History of malaise -Influenza-like symptoms -Epigastric or right upper quadrant abdominal pain -Nausea, vomiting, headaches. -Symptoms worsen at night and improve during the daytime.

Nursing Interventions: Education for Self-Management

Expected maternal and fetal changes -Nutrition -Personal hygiene: During pregnancy the sebaceous glands are highly active because of hormonal influences, and women often perspire freely. -Prevention of urinary tract infections: urinary tract infections (UTIs) are common but they may be asymptomatic because of changes that occur in the renal system. Kegel exercises: -Deliberate contraction and relaxation of the pubococcygeus muscle. The muscles of the pelvic floor encircle the vaginal outlet, and they need to be exercised because an exercised muscle can then stretch and contract readily at the time of birth. Preparation for breastfeeding: -Prepare to breastfeed aside from HIV or HEP positive may be risky. Dental health: -Nausea during pregnancy may lead to poor oral hygiene. Physical activity: -Physical activity promotes a feeling of well-being in the pregnant woman. It improves circulation, promotes relaxation and rest, and counteracts boredom, as it does in the nonpregnant woman. Posture and body mechanics: -As pregnancy progresses, the pregnant woman's center of gravity changes, pelvic joints soften and relax, and stress is placed on abdominal musculature. Poor posture and body mechanics contribute to the discomfort and potential for injury. To minimize these problems, women can learn good body posture and body mechanics -Rest and relaxation: The sidelying position is recommended because it promotes uterine perfusion and fetoplacental oxygenation by eliminating pressure on the ascending vena cava and descending aorta. Employment: -Employment of pregnant women usually has no adverse effects on pregnancy outcomes. Job discrimination that is based strictly on pregnancy is illegal. However, some job environments pose potential risk to the fetus. Clothing: -Loose clothing. -Tight bras and belts, stretch pants, garters, tight-top knee socks, panty girdles, and other constrictive clothing should be avoided because tight clothing over the perineum encourages vaginitis and miliaria Travel: Travel is not contraindicated in low risk pregnant women. However, women with high risk pregnancies are advised to avoid long-distance travel after fetal viability has been reached to avert possible economic and psychologic consequences of giving birth to a preterm infant far from home. -Travel to areas in which medical care is poor, water is untreated, or malaria is prevalent should be avoided if possible. Medications and herbal preparations: -The greatest danger of drug-caused developmental defects in the fetus extends from the time of fertilization through the first trimester, a time when the woman may not realize she is pregnant. Self-treatment must be discouraged. -A lot is still unknown of OTC and various drug effects on fetus. Immunizations: -Some individuals have raised concern over the safety of various immunization practices during pregnancy. Immunization with live or attenuated live viruses is contraindicated during pregnancy because of its potential teratogenicity but should be part of postpartum care. Alcohol, cigarette smoking, caffeine, drugs: -None should be used except for caffeine -Most studies of human pregnancy have revealed no association between caffeine consumption and birth defects or LBW. Some studies have documented an increased risk for miscarriage with caffeine intake greater than 200 mg/day. -Normal discomforts Recognizing potential complications: One of the most important responsibilities of care providers is to alert the pregnant woman to signs and symptoms that indicate a potential complication of pregnancy. The woman needs to know how and to whom to report such warning signs. -Recognizing preterm labor: Teaching each expectant mother to recognize preterm labor is necessary for early diagnosis and treatment. Preterm labor occurs after the twentieth week but before the thirty-seventh week if pregnancy and consists of uterine contractions that if untreated cause the cervix to open earlier than normal and result in preterm birth. Sexual counseling: -Nurses can initiate discussion about sexual adaptations that must be made during pregnancy, but they themselves need a sound knowledge base about the physical, social, and emotional responses to sex during pregnancy Using the history -The couple's sexual history provides a basis for counseling, but history taking also is an ongoing process. Countering misinformation: -Many myths and much of the misinformation related to sex and pregnancy are masked by seemingly unrelated issues. -Safety and comfort during sexual activity -Psychosocial support

Vitamins and Minerals

Fat soluble vitamins (A, D, E, K); stored in the liver, excess consumption may result in toxic effects. Because of the high potential for toxicity, pregnant women are advised to take fat-soluble vitamin supplements only as prescribed. -Vitamin E is needed for protection against oxidative stress -Adequate intake of vitamin A is needed so that sufficient amounts of the vitamin can be stored in the fetus; however, a well-chosen diet including adequate amounts of deep yellow and deep green vegetables and fruits such as leafy greens, broccoli, carrots, cantaloupe, and apricots provides sufficient amounts of carotenes that can be converted in the body to vitamin A. Congenital malformations have occurred in infants of mothers who took excessive amounts of preformed vitamin A (from supplements) during pregnancy, and thus supplements are not recommended routinely for pregnant women. -Vitamin D is needed for proper calcium absorption and metabolism. Daily intake of water soluble vitamins (B6, B12, C, folic acid, thiamine, riboflavin and niacin) Excesses are not stored but excreted Vitamin and mineral supplements must be used carefully to prevent excess intake and toxic effects

G.T.P.A.L. Five Digit System

G= Gravida T= Term P= Preterm A= Abortions L= Living Examples: Parity G1 Para 0000 G2 Para 0101 Pregnant twice, one before one now G2 Para 1001 Must differentiate between pre term and abortion. Above 20 weeks = pre term below 20 weeks = abortion

Gestational Diabetes Mellitus (GDM)

Gestational Diabetes Mellitus (GDM): -Complicates 3% to 9% of all pregnancies -Classic risk factors for GDM include maternal age older than 25 years, previous macrosomic infant, previous unexplained IUFD, previous pregnancy with GDM, strong immediate family history of type 2 diabetes or GDM, obesity (weight more than 90 kg), and fasting blood glucose greater than 140 mg/dl or random blood glucose greater than 200 mg/dl. Fetal Risks: -No increase in the incidence of birth defects has been found among infants of women who develop gestational diabetes after the first trimester because the critical period of organ formation has already passed by that time. -Women who were obese before conception (BMI more than 30 kg/m2) and developed gestational diabetes were at greater risk to give birth to infants with CNS defects. Screening for gestational diabetes: -All pregnant women not known to have pregestational diabetes should be screened for GDM by history, clinical risk factors, or laboratory screening of blood glucose levels. -Screening test (glucola screening) most often used consists of a 50-g oral glucose load followed by a plasma glucose measurement 1 hour later. A glucose value of 130 to 140 mg/dl is considered a positive screen and should be followed by a 3-hour (100-g) oral glucose tolerance test (OGTT). GDM Care Management: Antepartum: -When the diagnosis of gestational diabetes is made, treatment begins immediately. -The nurse and other health care providers should educate the woman and her family, providing detailed and comprehensive explanations to ensure understanding, participation, and adherence to the necessary interventions. -Potential complications should be discussed, and the need for maintenance of euglycemia throughout the remainder of the pregnancy reinforced. Diet: -Dietary modification is the mainstay of treatment for GDM. The woman with GDM is placed on a standard diabetic diet. Exercise: -Exercise decreased the need for insulin in overweight women with GDM. Self-monitoring of blood glucose: Blood glucose monitoring is necessary to determine whether euglycemia can be maintained by diet and exercise. Pharmacologic therapy: -Many women will require insulin during the pregnancy -In contrast to women with insulin-dependent diabetes, women with gestational diabetes are initially managed with diet and exercise alone. Fetal surveillance: -Women whose blood glucose levels are well controlled by diet are at low risk for fetal complications. -Women with hypertension, a prior IUFD, or suspected macrosomia or those who require insulin for blood glucose control may have twice-weekly nonstress testing beginning at 32 weeks of gestation. Gestational Diabetes Screening: ACOG guidelines: High risk: Screen at 1st prenatal visit 16-20weeks; if negative repeat at 24-28 weeks. At 24-28weeks, Oral 50g glucose load. A blood sample is drawn one hour later. If glucose is greater than 140, + result. If above test positive, then administer 3 hour 100g GTT. Intrapartum -Blood glucose monitored hourly in labor -Infusion of regular insulin -Cesarian birth procedure may be necessary in the presence of preeclampsia or macrosomia. Postpartum -Will return to normal glucose levels after birth -Recurrence risk for GDM in the next pregnancy is 35% to 75%. -In addition, women who have had GDM have a 35% to 60% risk for developing type 2 diabetes mellitus within the next twenty years. Maternal Effects: -Hypoglycemia -Diabetic ketoacidosis Fetal Effects: -Macrosomia. -Cardiac anomalies. -Respiratory distress syndrome, hyperglycemia. -Polycythemia and hyperbilirubinemia. -Hyperinsulinemia. -Fetal Demise.

Chapter 27 Hypertensive Disorder

Gestational hypertensive disorders develop during pregnancy, labor, or after birth. These disorders include gestational hypertension, preeclampsia, and eclampsia. Chronic hypertensive disorders precede pregnancy or develop before 20 weeks of gestation.

Gravida: Gravidity: Multigravida Nulligravida

Gravida: a woman who is pregnant Gravidity: pregnancy regardless of whether or not the fetus was viable. Number of overall pregnancies. Multigravida: a woman who has had two or more pregnancies Multipara: a woman who has completed two or more pregnancies to 20 or more weeks of gestation Nulligravida: a woman who has never been pregnant -par... = viable pregnancies -grav..= pregnancies

Hydatidiform mole (molar pregnancy)

Hydatidiform mole (molar pregnancy): -Type of gestational trophoblastic disease -Benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster -Gestational trophoblastic disease (GTD) is a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus. Incidence and etiology: Occurs in 1 in 1000 pregnancies in the United States Cause is unknown Types -Complete: The complete mole results from fertilization of an egg in which the nucleus has been lost or inactivated. There are no embryonic or fetal parts. -Partial: Often have embryonic or fetal parts and an amniotic sac Clinical manifestations: -Vaginal bleeding and discharge. -Anemia from blood loss, excessive nausea and vomiting (hyperemesis gravidarum), and abdominal cramps caused by uterine distension. Diagnosis: -Transvaginal ultrasound -Serum hCG levels Care management: -Suction curettage -Nursing interventions -The nurse provides the woman and her family with information about the disease process, the necessity for a long course of follow-up, and the possible consequences of the disease. The nurse also helps the woman and her family cope with the pregnancy loss and recognize that the pregnancy was not normal. Follow-up care Follow-up care includes frequent physical and pelvic examinations along with weekly measurements of the β-hCG level until the level decreases to normal and remains normal for 3 consecutive weeks.

Hyperemesis Gravidarum

Hyperemesis Gravidarum: -Normal nausea and vomiting complicates 50% to 80% of all pregnancies, typically beginning at 4 to 10 weeks of gestation, usually resolving by 20 weeks of gestation. -Pregnancies complicated by nausea and vomiting generally have a more favorable outcome than those without these symptoms Hyperemesis gravidarum is excessive, prolonged vomiting accompanied by the following: Weight loss Electrolyte imbalance Nutritional deficiencies Ketonuria -Fetal and neonatal complications include small-for-gestationalage fetuses, low birth weight, prematurity, and 5 minute Apgar scores less than 7. Etiology: -Hyperemesis gravidarum may be related to high levels of estrogen or hCG and may be associated with transient hyperthyroidism during pregnancy. -Gastric dysrhythmias, esophageal reflux, and reduced gastric motility may also contribute to the development of hyperemesis gravidarum. Clinical Manifestations: Weight loss Dehydration Decreased blood pressure Increased pulse rate Poor skin turgor Electrolyte imbalances Management: Assessment: -Assess Severity -The most important initial laboratory test to be obtained is a determination of ketonuria. -Other laboratory tests that may be ordered are a urinalysis, a complete blood cell count, electrolytes, liver enzymes, and bilirubin levels. -The assessment should include frequency, severity, and duration of episodes of nausea and vomiting. If the woman reports vomiting, then the assessment should also include the approximate amount and color of the vomitus. -Other symptoms such as diarrhea, indigestion, and abdominal pain or distention also are identified. The woman is asked to report any precipitating factors relating to the onset of her symptoms. Any pharmacologic or nonpharmacologic treatment measures used should be recorded. Prepregnancy weight and documented weight gain or loss during pregnancy is important to note. -Psychosocial assessment includes asking the woman about anxiety, fears, and concerns related to her own health and the effects on pregnancy outcome. Family members should be assessed both for anxiety and in regard to their role in providing support for the woman. Initial care: -Initially the woman who is unable to keep down clear liquids by mouth will require IV therapy for correction of fluid and electrolyte imbalances. -Medications may be used if nausea and vomiting are uncontrolled. -Enteral or parenteral nutrition as a last resort Nursing interventions: Interventions may include initiating and monitoring IV therapy, administering drugs and nutritional supplements, and monitoring the woman's response to interventions. -The nurse observes the woman for any signs of complications such as metabolic acidosis (secondary to starvation), jaundice, or hemorrhage and alerts the physician should these occur. -Monitoring includes assessment of the woman's nausea, retching without vomiting, and vomiting, given that these symptoms, although related, are separate. Intake and output, including the amount of emesis, should be accurately measured and recorded. -Oral hygiene while the woman is receiving nothing by mouth, and after episodes of vomiting, helps allay associated discomforts. -Assistance with positioning and providing a quiet, restful environment that is free from odors may increase the woman's comfort. Follow-up care: -Most women are able to take nourishment by mouth after several days of treatment. -Should be encouraged to eat small frequent meals. Contributing factors: Hormonal abnormalities- increased HCG and estrogen Hydatidiform mole. Multiple pregnancy emotional factors and irregular eating habit Vitamin B deficiency High stress level

Care Management:

Identifying and preventing preeclampsia: -No reliable test or screening tool has been developed -Low-dose aspirin (60 to 80 mg) may help certain high risk women -Potential biomarkers being investigated -Tyrosine kinase (sFLt) and serum placental growth factor -Abnormal uterine artery Doppler velocimetry in the first or second trimester of pregnancy Assessment and nursing diagnoses: -Accurate measurement of BP -Assessment of edema, although the presence of edema is no longer included in the definition of preeclampsia -Deep tendon reflexes (DTRs) -Assess for hyperactive reflexes (clonus) -Proteinuria: ideally determined by evaluation of a 24-hour urine collection Evaluate for signs and symptoms of severe preeclampsia: -Headaches -Epigastric pain -Right upper quadrant abdominal pain -Visual disturbances

Key Points:

In pregnant women with pregestational diabetes, lack of glycemic control before conception and in the first trimester of pregnancy may be responsible for fetal congenital malformations. For pregnant women who have diabetes and are insulin dependent, insulin requirements increase as the pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol. After birth, levels decrease dramatically; breastfeeding affects insulin needs. Poor glycemic control before and during pregnancy in women who have diabetes can lead to maternal complications such as miscarriage, infection, and dystocia (difficult labor) caused by fetal macrosomia. Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in the pregnancy complicated by diabetes mellitus. Because GDM is asymptomatic in most cases, all women who are not known to have pregestational diabetes undergo routine screening by history, clinical risk factors, or laboratory assessment of blood glucose levels during pregnancy. Two different methods for diagnosing GDM are currently used. The woman with hyperemesis gravidarum may have significant weight loss and dehydration. Management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting. Thyroid dysfunction, hyperthyroidism, or hypothyroidism during pregnancy requires close monitoring of thyroid hormone levels to regulate therapy and prevent fetal insult. -High levels of phenylalanine in the maternal bloodstream cross the placenta and are teratogenic to the developing fetus. Damage can be prevented or minimized by dietary restriction of phenylalanine before and during pregnancy.

Antepartum Assessment Using Electronic Fetal Monitoring

Indications: First- and second-trimester antepartal assessment is directed primarily at the diagnosis of fetal anomalies. The goal of third trimester testing is to determine whether the intrauterine environment continues to be supportive to the fetus. Nonstress test: The NST is the most widely applied technique for antepartum evaluation of the fetus. It is an ideal screening test and is the primary method of antepartum fetal assessment at most sites. -The basis for the NST is that the normal fetus will produce characteristic heart rate patterns in response to fetal movement. In the term fetus, accelerations are associated with movement more than 85% of the time. -The most common reason for the absence of FHR accelerations is the quiet fetal sleep state. However, medications such as narcotics, barbiturates, and beta-blockers, maternal smoking, and the presence of fetal malformations can also adversely affect the test -Disadvantages include the requirement for twice-weekly testing and a high false-positive rate. Procedure: The woman is seated in a reclining chair (or in semi-Fowler position) with a slight lateral tilt to optimize uterine perfusion and prevent supine hypotension. The FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements. The tracing is observed for signs of fetal activity and a concurrent acceleration of FHR. If evidence of fetal movement is not apparent on the tracing, the woman may be asked to depress a button on a handheld event marker connected to the monitor when she feels fetal movement. The movement is then noted on the tracing. Because almost all accelerations are accompanied by fetal movement, the movements need not be recorded for the test to be considered reactive. The test is usually completed within 20 to 30 minutes, but more time may be required if the fetus must be awakened from a sleep state. Interpretation: Results are either reactive or nonreactive. Vibroacoustic stimulation: -Vibroacoustic stimulation is often used to stimulate fetal activity if the initial NST result is nonreactive and thus hopefully shortens the time required to complete the test. Another method of testing antepartum FHR response. This test is generally performed in conjunction with the NST and uses a combination of sound and vibration to stimulate the fetus. -The desired result is a reactive NST. The accelerations produced may have a significant increase in duration Contraction stress test: It was devised as a graded stress test of the fetus, and its purpose was to identify the jeopardized fetus that was stable at rest but showed evidence of compromise after stress. Uterine contractions decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus, a deceleration in FHR will result. The CST provides an earlier warning of fetal compromise than the NST and with fewer false-positive results. However, in addition to the contraindications described earlier the CST is more time consuming and expensive than the NST. It is also an invasive procedure if oxytocin stimulation is required. Because of these disadvantages, the CST is used infrequently. Procedure: The woman is placed in semi-Fowler position or sits in a reclining chair with a slight lateral tilt to optimize uterine perfusion and avoid supine hypotension. She is monitored electronically with the fetal ultrasound transducer and uterine tocodynamometer. The tracing is observed for 10 to 20 minutes for baseline rate and variability and the possible occurrence of spontaneous contractions. The two methods of CST are the nipple-stimulated contraction test and the more commonly used oxytocin stimulated contraction test. Contraction test: Nipple-stimulated contraction test -Woman asked to massage the nipple, massaging the nipple causes a release of oxytocin from the posterior pituitary stimulating uterine contractions. Oxytocin-stimulated contraction test: Exogenous oxytocin also can be used to stimulate uterine contractions. An intravenous (IV) infusion is begun, and a dilute solution of oxytocin is administered. Interpretation: CST results are either negative, positive, equivocal, suspicious, or unsatisfactory. If no late decelerations are observed with the contractions, the findings are considered negative.

Care Management

Initial visit -Prenatal interview: Comprehensive health history emphasizing the current pregnancy, previous pregnancies, the family, a psychosocial profile, a physical assessment, diagnostic testing, and an overall risk assessment. -Reason for seeking care: Why has the pregnant woman come for a visit? -Current pregnancy: A review of symptoms she is experiencing and how she is coping with them helps establish a database to develop a plan of care. -Childbearing and female reproductive history: Data are gathered on the woman's age at menarche, menstrual history, and contraceptive history; the nature of any infertility or reproductive system conditions; a history of any STIs; a sexual history; and a detailed history of all her pregnancies, including the present pregnancy, and their outcomes. The date of the last Papanicolaou (Pap) test and the result are noted. -Health history: The health history includes those physical conditions or surgical procedures that may affect the pregnancy -Nutritional history The woman's nutritional history is an important component of the prenatal history because her nutritional status has a direct effect on the growth and development of the fetus. -History of drug and herbal preparation use: Woman past use of illegal and legal drugs. Many substances cross the placenta and affect the fetus. -Family history: Familial and genetic disorders. -Social, experiential, occupational history: Family's ethnic and cultural background and socioeconomic status -History or risk of intimate partner violence: Likelihood of abuse increases during pregnancy -Review of systems: Identify and describe preexisting or concurrent problems in any of the body systems Physical examination: -The physical examination begins with assessment of vital signs and height and weight -Supine hypotension: Must remain alert to signs of supine hypotension. Low blood pressure that occurs while the woman is lying on her back Laboratory tests: -Urine, cervical, and blood samples -Screening and diagnostic tests for infectious diseases and metabolic conditions -Urine tested for HCG to confirm pregnancy. -Urinalysis and urine culture, CBC, blood type and Rh factor. -Antibody screen and titer. -Hepatitis B surface antigen. -Syphilis screening(RPR or VDRL). -Rubella immune status -Chlamydia/gonorrhea screen(PRN) -Pap (PRN) -Offer/encourage HIV testing. -Other testing based on increased risk or history -Serology evidence of immunity: -Rubella titer greater than or equal to 1:9 -Varicella titer greater than or equal to 1:8 -Blood type, Rh factor, and presence of irregular antibodies determines the risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. -Indirect Coombs' test identifies clients sensitized to Rh-positive blood. -For patients who are Rh-negative and not sensitized, the indirect Coombs' test is repeated between 24 to 28 weeks of gestation. -Group B Streptococcus (GBS)Obtained at 35 to 37 weeks of gestation. Routine Lab tests: -One-hour glucose tolerance -Identifies hyperglycemia; done at initial visit for at-risk clients, and at 24 to 28 weeks of gestation for all pregnant women (> 140 mg/dL requires follow up). -Papanicolaou (PAP) test -Screening tool for cervical cancer, herpes -Simplex type 2, and/or human papillomavirus. -Vaginal/cervical culture -Detects streptococcus ß-hemolytic, bacterial vaginosis, or sexually transmitted infections (gonorrhea and chlamydia). Nursing assessments: -Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for clients who are Rh-negative. Recommended visit schedule ( Low-risk pregnancies): Initial prenatal visit within 6-8weeks after first missed menses Visit with provider between 10-12weeks. Return visits: At 28 weeks, every 4weeks 28-36weeks; every 2-3weeks 36 weeks to delivery; every week Increase in frequency post dates. Follow-up visits -Interview: Follow-up visits are less intensive than the initial prenatal visit. Asked less questions and simply how the pregnancy is going, any concerns or complaints. -Physical examination Fetal assessment: -Gestational age -Fetal heart tones -Health status -Fundal height: Measurement of the height of the uterus above the symphysis pubis) -Laboratory/other tests

Psychologic Considerations Related to High-Risk Pregnancy

Label of high risk often increases the patient's sense of vulnerability May exhibit anxiety, low self-esteem, guilt, frustration, and inability to function May affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy

Management of Miscarriage:

Management: Initial care Depends on the classification of the miscarriage and on signs and symptoms. Management of different types: Threatened Abortion: Pelvic rest and caution is recommended. Incomplete Abortion: Dilation and Curettage (removal of contents) by MD. Followed by Pitocin administration. Complete: Rests with administration of Pitocin. Missed: Immediate evacuation of uterus and antibiotic. Expectant management: If bleeding and infection do not occur, expectant management is a reasonable option. In approximately half of all threatened miscarriages managed in this way, the pregnancy continues. ^ SEE TABLE 27.1 PAGE 672 in PDF^ Medical management: misoprostol (Cytotec) Surgical management: Dilation and curettage (D&C) a surgical procedure in which the cervix is dilated and a suction curette is inserted to scrape the uterine walls and remove uterine contents. Follow-up care: -Teaching includes information about normal physical findings, such as cramping, type and amount of bleeding, resumption of sexual activity, and family planning. -Assess physical and emotional recovery. -Follow-up phone calls; support groups Cervical insufficiency: One cause of late miscarriage is recurrent premature dilation of the cervix (incompetent cervix) which has traditionally been defined as passive and painless dilation of the cervix during the second trimester. Etiology: -Passive and painless dilation of the cervix during the second trimester. -May be either acquired or congenital -Etiologic factors include a history of previous cervical trauma such as lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or ingestion of diethylstilbestrol (DES) by the woman's mother while pregnant with the woman. -History of Fetal loss@>14 weeks EGA. -History of cervical laceration, cervical conization with large amount of tissue removed. -History of overdistension of cervix with prolonged 2nd stage of labor. -Multiple 1st or 2nd trimester abortions. Diagnosis: -Short labors, recurring loss of the pregnancy at progressively earlier gestational ages, advanced cervical dilation at the time of first presentation for care, and a history of prior cervical surgery or trauma suggest reduced cervical competence -Ultrasound examination during pregnancy is used to diagnose this condition objectively. -A short cervix (less than 25 mm) is indicative of reduced cervical competence -Often the short cervix is accompanied by cervical funneling (beaking) or effacement of the internal cervical os. (Speculum/digital pelvic exams transvaginal U/S, cervical funneling) Care management: -Medical management consists of bed rest, pessaries, antibiotics, antiinflammatory drugs, and progesterone supplementation. -Surgical manage via placement of cerclage may be chosen instead. May be placed either prophylactically or as a therapeutic or rescue procedure after cervical change has been identified -Removed by 36 weeks of gestation Follow-up care -Bed rest for a few days following cerclage Watch for and report signs of preterm labor, rupture of membranes, and infection.

Maternal Phenylketonuria

Maternal Phenylketonuria: -Recognized cause of mental retardation. An inborn error of metabolism caused by an autosomal recessive trait that creates a deficiency in the enzyme phenylalanine hydrolase, which impairs the body's ability to metabolize foods with protein. Absence of this enzyme impairs the body's ability to metabolize the amino acid phenylalanine, found in all protein foods. Consequently, toxic accumulation of phenylalanine in the blood occurs, which interferes with brain development and function. -If unrecognized, can cause cognitive impairment -Prompt diagnosis and therapy with a phenylalanine-restricted diet significantly decreases the incidence of cognitive impairment. -Women with PKU should be advised against breastfeeding because their milk contains a high concentration of phenylalanine. Prevention -Identification of women in reproductive years who have disorder and dietary compliance for women who are diagnosed. -The dietary modification normally excludes all highprotein foods such as meat, milk, eggs, and nuts, as well as wheat products. Phenylalanine levels are monitored at least once and preferably twice a week throughout pregnancy. -Screening at the first prenatal visit -Infants born to women with this disorder are either homozygous or heterozygous for the trait.

Adaptations to Pregnancy

Maternal adaptation: Accepting the pregnancy: -The first step in adapting to the maternal role is accepting the idea of pregnancy and assimilating the pregnant state into the woman's way of life. -Identifying with the mother role: choosing between motherhood or a career, being married or single, being independent rather than interdependent, or being able to manage multiple roles. -Reordering personal relationships: Close relationships of the pregnant woman undergo change during pregnancy as she prepares emotionally for the new role of mother. -Establishing relationship with fetus: attachment process of the mother to the unborn child. Phase 1: She accepts the biologic fact of pregnancy Phase 2: She accepts the growing fetus as distinct from herself Phase 3: She prepares realistically for the birth and parenting of the child -Preparing for childbirth: prepare for birth by reading books, viewing films, attending parenting classes, and talking to other women. Paternal adaptation -Accepting the pregnancy -Couvade syndrome: Now some men experience pregnancy-like symptoms, such as nausea, weight gain, and other physical symptoms. -Developmental tasks experienced by the expectant father -Identifying with the father role: Each man brings to pregnancy attitudes that affect the way in which he adjusts to the pregnancy and parental role. -Reordering personal relationships -Establishing relationship with the fetus -Preparing for birth -Adaptation to parenthood for the nonpregnant partner: -Sibling adaptation: Sharing the spotlight with a new brother or sister may be the first major crisis for a child. -Depends on age and dependency needs -Grandparent adaptation, realization that they are getting old, preparation.

Intervention

Mild gestational hypertension and preeclampsia without severe features: -Goals of therapy are to ensure maternal safety and deliver a healthy newborn close to term. -Home care: Criteria for home health care include BP less than 150/100; proteinuria less than 500 mg per day; normal platelet count, liver enzymes, and creatinine levels; normal (reassuring) fetal status; and no signs or symptoms of severe preeclampsia -Maternal and fetal assessment: Maternal assessment includes measurement of hematocrit, platelet count, liver function tests, and a 24 hour urine protein assessment once each week. Activity restriction: -Complete or partial bed rest for the duration of the pregnancy is still frequently recommended Diet: Women with mild preeclampsia may have a regular diet with adequate protein (60 to 70 g), calcium (1200 mg), 400 mcg of folic acid, and adequate zinc and sodium (2 to 6 g). Women with severe gestational hypertension are at greater risk for pregnancy complications than are women with mild preeclampsia. Therefore, women with severe gestational hypertension should be managed as if they have severe preeclampsia. Severe gestational hypertension and preeclampsia with severe features: -Goals of care are to ensure maternal safety and formulate a plan for delivery. -Intrapartum care -Bed rest with siderails up -Darkened environment -Magnesium sulfate therapy -Antihypertensive medications Intrapartum Care: -Intrapartum nursing care is directed toward the early identification of FHR abnormalities and the prevention of maternal complications. Continuous FHR and uterine contraction monitoring are initiated and the woman should be assessed for signs of placental abruption such as hypertonic contractions or vaginal bleeding. Postpartum care -Vital signs, DTRs (deep tendon reflexes), level of consciousness -30% of cases of eclampsia and HELLP syndrome occur postpartum. -Unable to tolerate excessive blood loss -Signs that preeclampsia has resolved include diuresis and decreased edema Future health care: -Seven-fold risk of developing preeclampsia or eclampsia in a future pregnancy -Increased risk of adverse perinatal outcomes such as preterm labor and birth, fetal growth restriction, placental abruption, and fetal death. Eclampsia: Eclampsia is usually preceded by premonitory signs and symptoms, including persistent headache, blurred vision, severe epigastric or right upper quadrant abdominal pain, and altered mental status. However, convulsions can appear suddenly and without warning in a seemingly stable woman with only minimal BP elevations. Immediate care: -Ensuring a patent airway and client safety. -Call for help but do not leave the bedside. -Make certain that the side rails on the bed are raised; pad them with a folded blanket or pillow if possible. Lower head of the bed and turn woman to her side. -Premonitory signs: persistent headache and blurred vision -Epigastric or right upper quadrant pain -Altered mental status -Convulsions appearing without warning -Ensuring a patent airway and client safety -Maternal stabilization Chronic hypertension -Affects 4% to 5% of pregnant women -Ideally the management of chronic hypertension in pregnancy begins before conception. -Associated with increased incidence of the following: Abruptio placentae Superimposed preeclampsia Increased perinatal mortality IUGR Preterm birth Postpartum complications Pulmonary edema Renal failure Heart failure Encephalopathy

Nutrient Needs During Pregnancy:

Nutrient Needs During Pregnancy: -Healthy diet ensures adequate nutrients for developing fetus -First trimester is critical in terms of embryonic and fetal development so adequate nutrition is imperative. -Folic acid intake: 0.4 mg in fortified foods recommended. Neural tube defects can occur with poor intake of folic acid. -During the first trimester the synthesis of fetal tissues places relatively few demands on maternal nutrition; therefore, during the first trimester, when the embryo or fetus is very small, the needs are only slightly greater than those before pregnancy. In contrast, the last trimester is a period of noticeable fetal growth, when most of the fetal stores of energy and minerals are deposited. Therefore, as fetal growth progresses during the second and third trimesters, the pregnant woman's need for some nutrients increases greatly. -Desirable body weight reduces maternal and fetal risks -Dietary reference intakes (DRIs) - Recommendations for daily nutritional intake. -Energy needs are met by carbohydrate, fat, and protein in the diet. Protein is used to provide amino acids for the synthesis of new tissues. -Weight gain: The primary factor to consider in making a weight gain recommendation is the appropriateness of the pre pregnancy weight for the woman's height. -Severely underweight women are more likely to have preterm labor and to give birth to LBW infants. -Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction (IUGR). -Greater-than-expected weight gain during pregnancy may occur for many reasons, including multiple gestation, edema, gestational hypertension, and overeating. Pattern of weight gain: -During the first and second trimesters, growth takes place primarily in maternal tissues, and during the third trimester, growth occurs primarily in fetal tissues. -The recommended energy (kcal) intake corresponds to the recommended pattern of gain. Hazards of restricting adequate weight gain: -Obsession of thinness. -Pregnancy is not a time for a weight reduction diet in those who are obese and wish to loose weight. Even overweight or obese pregnant women need to gain at least enough weight to equal the weight of the products of conception. If they limit their energy intake to prevent weight gain, they also may excessively limit their intake of important nutrients Excessive weight gain: -Pregnancy is not an excuse for extreme dietary inattentiveness or over eating. Protein: -Increase in demands, growing uterus, growing fetus etc. -An adequate protein intake is essential to meet increasing demands in pregnancy. Fluids: -Essential during the exchange of nutrients and waste products across cell membranes, water is the main substance of cells, blood, lymph, amniotic fluid, and other vital body fluids. It also aids in maintaining body temperature. A good fluid intake promotes regular bowel function, which is sometimes a problem during pregnancy. Omega-3 fatty acids Minerals and vitamins: Iron: -Iron is needed to allow transfer of adequate iron to the fetus and to permit expansion of the maternal RBC mass. Physiologic anemia : The relative excess of plasma causes a modest decrease in the hemoglobin concentration and hematocrit. Calcium: -There is no increase in the DRI of calcium during pregnancy and lactation, in comparison to the recommendation for the nonpregnant woman Magnesium: -Adolescents are likely to be low in magnesium -Dairy products, nuts, whole grains, and green leafy vegetables are good sources of magnesium. Sodium: -During pregnancy the need for sodium increases slightly, primarily because the body water is expanding, sodium is essential for body water balance. Potassium: Diets including adequate intakes of potassium are associated with reduced risk of hypertension. Potassium has been identified as one of the nutrients most likely to be lacking in the diets of women of childbearing age. A diet including 8 to 10 servings of unprocessed fruits and vegetables daily, along with moderate amounts of low-fat meats and dairy products, has been effective in reducing sodium intake while providing adequate amounts of potassium Zinc: Zinc is a constituent of numerous enzymes involved in major metabolic pathways. Zinc deficiency is associated with malformations of the central nervous system in infants. Fluoride: -There is no evidence that prenatal fluoride supplementation reduces the child's likelihood of tooth decay during the preschool years. No increase in fluoride intake over the nonpregnant DRI is currently recommended during pregnancy. -Fat-soluble vitamins discouraged and only as prescribed because they can store in tissues and become toxic. -Water-soluble vitamins reccomended: Folate and folic acid Vitamin C, or ascorbic acid, plays an important role in tissue formation and enhances the absorption of iron. Vitamin B6, or pyroxidine is involved in protein metabolism. Vitamin B12 Multivitamin-multimineral supplements during pregnancy

Parity: Nullipara: Primipara: Multipara:

Parity: number of pregnancies in which fetus or fetuses have reached viability, not the number of fetuses born Nullipara: a woman who has not completed a pregnancy with a fetus or fetuses who have reached 20 weeks of gestation. Primipara: A woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation Multipara: A woman who has completed two or more pregnancies to 20 weeks of gestation or more

Placenta previa

Placenta previa: In placenta previa the placenta is implanted in the lower uterine segment such that it 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 efface. -Placenta is implanted in lower uterine segment near or over internal cervical os Risk Factors: -Advanced maternal age. -Multiparity. -Smoking, Cocaine use, -Prior occurrence of Placenta Previa. -Prior uterine surgery. -Fibroids and other uterine abnormalities. -Multiple gestations. -Marginal: The placenta is near to but does not cover any part of the internal os -Partial: The placenta implants near and partially covers the internal os -Total: The placenta completely covers the internal os -Degree to which the internal cervical os is covered by placenta used to classify three types: Complete placenta previa: -If placenta previa totally covers the internal cervical os. Marginal placenta previa: -The edge of the placenta is seen on transvaginal ultrasound to be 2.5 cm or closer to the internal cervical os. Low-lying placenta: -When the exact relationship of the placenta to the internal cervical os has not been determined or in the case of apparent placenta previa in the second trimester, the term low- lying placenta is used Incidence and etiology: 1 in 200 pregnancies Clinical manifestations -Painless bright red vaginal bleeding during second or third trimester. Maternal and fetal outcomes: -Major complication is hemorrhage -Another serious complication is development of an abnormal placental attachment. -Fetal death (caused by preterm birth) -Stillbirth, malpresentation, fetal anemia, intrauterine growth restriction (IUGR) Diagnosis: Transabdominal ultrasound examination Care management: Expectant management (observation and bed rest. Home care: She should be willing and able to comply with activity restrictions (bed rest with bathroom privileges and pelvic rest), have access to a telephone, close supervision by family or friends in the home, and constant access to transportation Active management: If the woman is at or beyond 36 weeks of gestation or bleeding is excessive or persistent, immediate cesarean birth is indicated.

Pregestational diabetes mellitus

Pregestational diabetes mellitus: About 10% of pregnancies have preexisting DM. -Type 2 is a more common diagnosis than type 1. -Almost all women with pregestational diabetes are insulin dependent during pregnancy. Preconceptional counseling: -Preconception counseling is recommended for all women of reproductive age who have diabetes because it is associated with less perinatal mortality and fewer congenital anomalies. -Ideally, women with pre gestational diabetes are counseled before conception, maintaining glycemic control and diagnosing any vascular complications. Maternal risks and complications: -Poor glycemic control around the time of conception and in the early weeks of pregnancy is associated with an increased incidence of miscarriage. -Macrosomia has been defined in several different ways, including a birth weight more than 4000 to 4500 g, a birth weight greater than the 90th percentile, and estimates of neonatal adipose tissue. Macrosomia occurs in approximately 40% of pregestational diabetic pregnancies and in up to 50% of pregnancies complicated by GDM. -In one study the rates of preeclampsia, preterm birth, cesarean birth, and maternal mortality were much higher in women with preexisting diabetes than in women who did not have this disease. -The rate of hypertensive disorders in all types of pregnancies complicated by diabetes is 15% to 30%. Chronic hypertension occurs in 10% to 20% of all pregnant women with diabetes, and in up to 40% of those women who have preexisting renal or retinal vascular disease. Hydramnios/polyhydramnios: -Hydramnios (polyhydramnios) frequently develops during the third trimester of pregnancy in women with diabetes. -A condition in which excess amniotic fluid accumulates during pregnancy. Ketoacidosis: -Accumulation of ketones in the blood resulting from hyperglycemia and leading to metabolic acidosis -DKA can also be caused by poor client compliance with treatment or the onset of previously undiagnosed diabetes. Hypoglycemia/hyperglycemia: -Decreased/Increased blood sugar levels. Fetal and neonatal risks and complications: Infant morbidity and mortality rates associated with diabetic pregnancy are significantly reduced with strict control of maternal glucose levels before and during pregnancy. IUFD: -Sometimes called stillbirth. -Approximately 2% to 5% of all fetal deaths occur in women whose pregnancies are complicated by preexisting diabetes. -Hyperglycemia, ketoacidosis, congenital anomalies, infections, and maternal obesity are thought to be reasons for fetal death. In the third trimester, fetal acidosis is the most likely cause of fetal death. Congenital malformations: -Most common cause of perinatal loss, accounts for 30% to 50% of all perinatal loss. -The incidence of congenital malformations is related to the severity and duration of the diabetes. Hyperglycemia during the first trimester of pregnancy, when organs and organ systems are forming, is the main cause of diabetes-associated birth defects. Anomalies commonly seen in infants affect primarily the cardiovascular system, the central nervous system (CNS), and the skeletal system. Hyperglycemia at birth: The fetus responds to maternal hyperglycemia by secreting large amounts of insulin (hyperinsulinism). 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. Macrosomia causes many birthing complications associated with difficult vaginal births. Hypoglycemia at birth: -Hypoglycemia at birth is also a risk for infants born to mothers with diabetes. Risk factors for Gestational Diabetes: -Previous history of GDM -Strong family history of GDM. -Previous infant weighing >4000g at delivery. -Marked Obesity. -Recurrent glycosuria. Care Management: Antepartum: -When a pregnant woman with diabetes initiates prenatal care, a thorough evaluation of her health status is completed including physical examination. -Effects of the diabetes are assessed, specifically retinopathy, nephropathy, peripheral and autonomic neuropathy, peripheral vascular, and cardiac. -The glycosylated hemoglobin A1c level may be measured to assess recent glycemic control. -Renal, thyroid function testing. -Because of high risk pregnancy status, the pregnant woman is monitored more carefully. -Euglycemia is a goal and the woman should be constantly monitoring her blood sugar. Achieved through a combination of diet, exercise and insulin treatment. -The woman with diabetes is at increased risk for infections. Diet: -The woman must be educated to incorporate changes into dietary planning. For the woman who has "controlled" her diabetes for several years the changes in her insulin and dietary needs mandated by pregnancy may be difficult. -Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levels. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy -The dietary goals are to provide weight gain consistent with a normal pregnancy, to prevent ketoacidosis, and to minimize wide fluctuation of blood glucose levels. -Complex carbohydrates that are high in fiber content are recommended because the starch and protein in such foods help regulate the blood glucose level by more sustained glucose release. -Large bedtime snacks recommended to prevent hypoglycemia during the night. Exercise: -Any prescription of exercise during pregnancy for women with diabetes should be given by the primary health care provider and should be monitored closely to prevent complications. -When exercise is prescribed by the health care provider as part of the treatment plan, specific instructions are given to the woman. Aerobic exercise with resistance training for at least 30 minutes most days of the week is the best type of exercise -Non-weight-bearing activities such as arm exercises or use of a recumbent bicycle -Best time for exercise is after meals. Insulin therapy: -Adequate insulin is the primary factor in the maintenance of euglycemia during pregnancy, thus ensuring proper glucose metabolism of the woman and fetus. -For the woman with type 1 pregestational diabetes who has typically been accustomed to one injection per day of intermediate- acting insulin, multiple daily injections of mixed insulin are a new experience. -The woman with type 2 diabetes previously treated with oral hypoglycemics is faced with the task of learning to self-administer injections of insulin. Monitoring blood glucose levels: -Blood glucose testing at home with a glucose reflectance meter is considered the standard of care for monitoring blood glucose levels during pregnancy. Drop of blood via finger prick allows you to know your blood glucose levels. -Pregnant women with diabetes are much more likely to develop hypoglycemia than hyperglycemia. -Hyperglycemia is less likely than hypoglycemia to occur, but it can rapidly progress to DKA, which is associated with an increased risk of fetal death. Urine testing: -Urine testing is not beneficial during pregnancy because of the lowered renal threshold for glucose, the degree of glycosuria does not accurately reflect the blood glucose level. -Urine testing for ketones, however, continues to have a place in diabetic management. Monitoring for urine ketones may detect inadequate caloric or carbohydrate intake or skipped meals or snacks. Complications requiring hospitalization: -Occasionally, hospitalization is necessary to regulate insulin therapy and stabilize glucose levels. Infection, which can lead to hyperglycemia and DKA, is an indication for hospitalization, regardless of gestational age. -Preexisting hypertension or development of preeclampsia may necessitate hospitalization. Fetal surveillance: -Diagnostic techniques for fetal surveillance are often performed to assess fetal growth and well-being. -The goals of fetal surveillance are to detect fetal compromise as early as possible and to prevent intrauterine fetal death or unnecessary preterm birth. Determination of birth date and mode: -The optimal time for birth is between 38.5 and 40 weeks of gestation, as long as good metabolic control is maintained and parameters of antepartum fetal surveillance remain within normal limits. -Reasons to proceed with birth before term include poor metabolic control, worsening hypertensive disorders, fetal macrosomia, or fetal growth restriction. -Although vaginal birth is expected for most women with pregestational diabetes, the cesarean rate for these women ranges from 50% to 80% -Cesarean birth should be considered when the estimated fetal weight is expected to be greater than 4500 g in an attempt to reduce the risk of shoulder dystocia. Intrapartum: During the intrapartum period the woman with pregestational diabetes must be monitored closely to prevent complications related to dehydration, hypoglycemia, and hyperglycemia. -During labor continuous fetal heart monitoring is necessary. The woman should assume an upright or side-lying position during bed rest in labor to prevent supine hypotension -Intravenous infusion of insulin -Possible and suggested cesarean birth for macrosomia to prevent shoulder dystocia, ideally in the early morning for glycemic control. Postpartum: -First 24 hours, insulin requirements drop substantially because the major source of insulin resistance, the placenta, has been removed. -Possible postpartum complications include preeclampsia or eclampsia, hemorrhage, and infection. -Risk of hemorrhage due to uterine over distention or over stimulation. -Mothers are encouraged to breastfeed. In addition to the advantages of maternal satisfaction and pleasure, breastfeeding has an antidiabetogenic effect for the children of women with diabetes and for women with gestational diabetes. Breastfeeding women are at increased risk for hypoglycemia.

Pregnancy Tests:

Pregnancy Tests: -Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy -Production begins as early as day of implantation. -Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses -Many pregnancy tests available. -Radioimmunoassay (RIA) pregnancy tests are accurate with low hCG levels and can confirm pregnancy before the first menstrual period. -Radioreceptor assay (RRA) is a serum test that measures the ability of a blood sample to inhibit the binding of radiolabeled hCG to receptors. The test is 90% to 95% accurate from 6 to 8 days after conception. -Enzyme-linked immunosorbent assay (ELISA) testing is the most popular method of testing for pregnancy. It requires minimal time and offers results in less than 5 minutes. A positive test result is indicated by a simple color-change reaction.

Endocrine and Metabolic Disorders:

Pregnancy can be complicated by these following metabolic or endocrine disorders: Diabetes mellitus Hyperemesis gravidarum Hyper- and hypothyroidism Phenylketonuria The primary objective of nursing care is to achieve optimal outcomes for both the pregnant woman and the fetus.

Premature separation of placenta

Premature separation of placenta (abruptio placentae, placental abruption) -Detachment of part or all of placenta from implantation site on the uterine wall after 20 weeks of gestation. -Occurs in 1 in 75 to 1 in 226 pregnancies -Maternal hypertension is a primary risk factor Risk Factors: Advanced maternal age. Smoking, Cocaine Use Trauma. Hypertension. Multiparity. Classification Systems: Grade 1: 10-20% detachment Grade 2: 20-50% detachment Grade 3: More than 50% detachment Clinical manifestations: -Separation may be partial, complete, or only involve margin of placenta. -Vaginal bleeding, abdominal pain, and uterine tenderness and contractions Boardlike abdomen; Couvelaire uterus Maternal and fetal outcomes: -The mother's prognosis depends on the extent of placental detachment, overall blood loss, degree of coagulopathy present and time between placental detachment and birth. Maternal complications are associated with the abruption or its treatment Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption. Renal failure and pituitary necrosis may result from ischemia. -Placental abruption is associated with a perinatal mortality rate of 20% to 30%. If more than 50% of the placenta is involved, fetal death is likely to occur. Other fetal and neonatal risks include IUGR and preterm birth. Risks for neurologic defects, cerebral palsy, and death from sudden infant death syndrome are also increased in newborns. Diagnosis: -Placental abruption is primarily a clinical diagnosis. Although ultrasound can be used to rule out placenta previa, it cannot detect all cases of abruption. -Physical examination usually reveals abdominal pain, uterine tenderness, and contractions. Management: Intervention: Maternal stabilization. Fetal evaluation. Cesarean birth. Expectant: Management depends on the severity of blood loss and fetal maturity and status. If the fetus is less than 34 weeks of gestation and both the woman and fetus are stable, expectant management can be implemented. The woman is monitored closely because the abruption may extend at any time. The fetus will be regularly assessed for evidence of appropriate growth, because there is risk for IUGR. In addition, assessments of fetal well-being (e.g., NST and BPP) are performed regularly. Active: Immediate birth is the management of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy

Definitions:

Prenatal period: A time of physical and psychologic preparation for birth and parenthood Duration of pregnancy: Gestation Spans 9 calendar months, 10 lunar months 40 weeks or 280 days Trimesters: -First: weeks 1-13 -Second: weeks 14-26 -Third: weeks 27-40

Signs of Pregnancy

Presumptive: The changes that are felt by the woman (e.g., amenorrhea, fatigue, breast changes) Probable: Those changes observed by an examiner (e.g., Hegar sign, ballottement, pregnancy tests) Positive: Those signs attributed only to the presence of the fetus (e.g., hearing fetal heart tones, visualizing the fetus, palpating fetal movements)

Preterm: Late Preterm: Early Term: Full Term: Late Term: Post Term:

Preterm: a pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation Late preterm: a pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days of gestation Early term: a pregnancy that has reached between 37 weeks 0 days and 38 weeks 6 days of gestation Full term: a pregnancy that has reached between 39 weeks 0 days and 40 weeks 6 days of gestation Late term: a pregnancy that has reached between 41 weeks 0 days and 41 weeks 6 days of gestation Post term: a pregnancy that has reached between 42 weeks 0 days and beyond of gestation

Nursing Role in AntepartalAssessment for Risk

Provide education Anticipatory planning Counseling for family adaptation Support person In many settings nurses perform the following: Non Stress Test (NST) Constraction Stress Test (CSTs) Biophysical profile (BPPs)

Adaptations to Pregnancy:

Reproductive system and breasts Uterus: -Changes in size, shape, and position -Changes in contractility -Uteroplacental blood flow -Cervical changes -Pregnancy may "show" after the 14th week Ballottement (between 16-18 weeks) -Fetus is floating within the amniotic fluid -Examiner palpates (taps lightly) on the vagina (can also be internal) - fetus rebounds against the examiner's finger Quickening (14-16 weeks) -Fluttering/ butterfly movements of the fetus "Feeling of life" inside the uterus Lightening: weeks 38 to 40 -The baby settles, or drops lower, into the mother's pelvis. Uterine softening may occur: Chadwick's sign: -Is visualized, it is the bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. -Hegar's sign: -Softening and compressibility of the uterine isthmus. - It is demonstrated as a softening in the consistency of the uterus, and the uterus and cervix seem to be two separate regions. Goodell's Sign: -It is a significant softening of the vaginal portion of the cervix from increased vascularization -Softening of the cervical tip. -Braxton Hick's contractions may be felt Known as false labor contractions Irregular Painless Facilitates uterine blood flow Vagina and vulva: -Leukorrhea: is a white or slightly gray mucoid discharge with a faint musty odor. Operculum: -The formation of the mucous plug. Cervical changes: -Goodell sign: softening of the cervical tip -Friability: tissue is easily damaged Uterine growth by gestational weeks Breasts: Montgomery tubercles: -Hypertrophy of the sebaceous (oil) glands embedded in the primary areolae. -May have a protective role in that they keep the nipples lubricated for breastfeeding Colostrum: -The creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples General body systems: Cardiovascular system: -Slight cardiac hypertrophy is probably secondary to the increased blood volume and cardiac output that occurs. -Blood pressure decreases. -Blood volume and composition: increases by approximately 30% to 45% -Cardiac output increases -Circulation and coagulation times. -Pregnancy is considered a hypercoagulable state -High chance of blood coagulation Supine Hypotensive Syndrome: -In the supine position, blood pressure may appear to be lower due to the weight and pressure of the gravid uterus on the venacava, which decreases venous blood flow to the heart. Signs and symptoms of supine hypotension: -Dizziness, lightheadedness, and pale, clammy skin. -Encourage the patient to engage in maternal positioning on the left-lateral side, semi-Fowler's position, or, if supine, with a wedge placed under one hip to alleviate pressure to the vena cava. *encourage patients to lie sideways during pregnancy because lying on the back can lead to supine hypotension as a result of compression of the inferior vena cava.* Respiratory system: Pulmonary function: Respiratory changes in pregnancy are related to the elevation of the diaphragm and to chest wall changes. Changes in the respiratory center result in a lowered threshold for carbon dioxide. Basal metabolism rate: The basal metabolic rate (BMR) increases during pregnancy. This is due to increased oxygen demands. BMR is the rate at which the body uses energy while at rest to keep vital functions going, such as breathing and keeping warm. Acid-base balance: -Pregnancy is a state of respiratory alkalosis -Maternal oxygen needs increase. -Diaphragm rises up: increase subcostal angle, chest circumference. -Increase nasal congestion/stuffiness. -Increase in tidal volume. -Increase in respiratory effort but pulmonary function not affected. -Disease of respiratory system may be exacerbated by pregnancy. Renal system Anatomic changes: -Changes in renal structure during pregnancy result from hormonal activity (estrogen and progesterone), pressure from an enlarging uterus, and an increase in blood volume. -Bladder irritability, nocturia, and urinary frequency and urgency (without dysuria) are commonly reported in early pregnancy. Near term. -Urinary frequency results initially from increased bladder sensitivity and later from compression of the bladder. Functional changes: -In normal pregnancy, renal function is altered considerably. Glomerular filtration rate (GFR) and renal plasma flow (RPF) increase early in pregnancy. Fluid and electrolyte balance: -Selective renal tubular reabsorption maintains sodium and water balance regardless of changes in dietary intake and losses through sweat, vomitus, or diarrhea. Integumentary system: Chloasma or mask of pregnancy: A blotchy, brownish hyperpigmentation of the skin over the cheeks, nose, and forehead, especially in dark-complexioned pregnant women. Linea nigra: -Pigmented line extending from the symphysis pubis to the top of the fundus in the midline; Striae gravidarum: Stretch marks Palmar erythema: -Pinkish-red, diffuse mottling or well-defined blotches are seen over the palmar surfaces of the hands Pruritus: -Itchiness Musculoskeletal system: -The gradually changing body and increasing weight of the pregnant woman cause noticeable alterations in her posture and the way she walks. -The great abdominal distention that gives the pelvis a forward tilt, decreased abdominal muscle tone, and increased weight bearing require a realignment of the spinal curvature late in pregnancy. -Neurologic system: -Carpal tunnel : The syndrome is characterized by paresthesia (abnormal sensation such as burning or tingling) and pain in the hand, radiating to the elbow. Edema involving the peripheral nerves. Gastrointestinal system: -Appetite fluctuate throughout the course of pregnancy, some may have nausea with or without vomiting. Mouth: -The gums become hyperemic, spongy, and swollen during pregnancy. They tend to bleed easily. Esophagus, stomach, and intestines: -Herniation of the upper portion of the stomach occurs in some. -Peptic ulcer formation or flare-up of existing peptic ulcers is uncommon during pregnancy. Iron is absorbed more readily in the small intestine. Increase in water absorption from the colon and may cause constipation. Gallbladder and liver: -The gallbladder is quite often distended because of its decreased muscle tone during pregnancy. Increased emptying time and thickening of bile caused by prolonged retention are typical changes. Abdominal discomfort: -Pelvic heaviness or pressure, round ligament tension, flatulence, distention and bowel cramping, and uterine contractions. -Pyrosis (heartburn) -Ptyalism (excessive salivation) -Appendicitis can be difficult to diagnose in pregnancy because the appendix is displaced upward and laterally Endocrine system: -Pituitary and placental hormones: During pregnancy, the elevated levels of estrogen and progesterone suppress secretion of FSH and LH by the anterior pituitary. -Oxytocin production -Progesterone produced to maintain pregnancy. -Hcs produced by the placenta Thyroid gland: -During pregnancy, gland activity and hormone production increase. Parathyroid gland: -Pregnancy induces a slight hyperparathyroidism, a reflection of increased fetal requirements for calcium and vitamin D Pancreas: -Increased insulin secretion to meet the glucose needs of the baby. -Adrenal glands change little during pregnancy. *increase of hormones overall during pregnancy*

Diagnosis of Pregnancy

Signs and symptoms: Many of the indicators of pregnancy are clinically useful in the diagnosis of pregnancy, and they are classified as presumptive, probable, or positive. Presumptive indicators: -Presumptive indicators of pregnancy include subjective symptoms and objective signs. Subjective symptoms are reported by the woman and include amenorrhea, nausea and vomiting (morning sickness), breast tenderness, urinary frequency, and fatigue. Quickening, the mother's first perception of fetal movement, is noted between weeks 16 and 20. -Presumptive signs are reported by the woman herself. -Amenorrhea, nausea and vomiting, breast tenderness, urinary frequency, fatigue -Quickening Probable indicators -Detected by examiner -Uterine enlargement -Braxton Hicks contractions -Placental souffle -Ballottement -Positive pregnancy test Positive indicators -Attributed to the fetus -Fetal heartbeat distinct from mother's -Fetal movement felt by someone other than mother -Visualization of the fetus

Key Points

The biochemical, physiologic, and anatomic adaptations that occur during pregnancy are profound and revert to the nonpregnant state after birth and lactation. Maternal adaptations are attributed to the hormones of pregnancy and to mechanical pressures arising from the enlarging uterus and other tissues. Adaptations to pregnancy protect the woman's normal physiologic functioning, meet the metabolic demands that pregnancy imposes, and provide for fetal developmental and growth needs. Accuracy of results of home pregnancy tests depends on following instructions correctly. Presumptive, probable, and positive signs of pregnancy aid in the diagnosis of pregnancy; only positive signs (identification of a fetal heart tone, verification of fetal movements, and visualization of the fetus) can establish the diagnosis of pregnancy. Physiologic anemia of pregnancy results from increase in plasma volume greater than the increase in red blood cells. During pregnancy maternal blood pressure remains the same or decreases slightly. Heart rate increases 10 to 15 beats/minute by 32 weeks of gestation and persists until term. Respiratory rate is unchanged during pregnancy, although tidal volume and minute ventilation increase by 30% to 50%. Pregnancy is a hypercoagulable state with increased risk for thrombotic disease. Dilation of renal pelves and ureters during pregnancy increases the risk of urinary tract infection. Balance and coordination are affected by changes in joints and in the woman's center of gravity as pregnancy progresses. Decreased muscle tone during pregnancy contributes to heartburn, reflux, and constipation. Endocrine changes are essential to maintaining pregnancy and promoting fetal growth.

Calculation of the expected date of delivery

Using Nageles Rule standard method for Determining the estimated date of delivery: The rule estimates the expected date of delivery (EDD) by adding a year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP). -Subtract 3 months from the first day of the last menstrual period -Add 7 days -EDD