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Ch. 13
Preexisting Conditions for Preg at Risk
| Question | Answer |
|---|---|
| What is considered a key to optimal pregnancy outcome? | strict maternal glucose control before conception and thru preg |
| what is DM | hyperglycemia resulting in deficient insulin secretion/action/both |
| Where is insulin produced | B-cells in islets of Langerhans of pancreas |
| what does insulin do | reg blood glucose lvls by allowing glucose to enter adipose/muscle cells. It's used for energy. Stimulates protein synthesis. Stores free fatty acids |
| what is meant by hyperglycemia causes hyperosmolarity of the blood? | intracellular fluid moves into vascular system, resulting in cellular dehydration and expanded blood volume, |
| polyuria and glycosuria and polydipsia are all effects of what | the kidneys trying to excrete lg vol of urine to reg excess blood volume and excrete unused glucose. Excess thirst ensues |
| how does the body compensate for not converting glucose into energy, since it's trapped in blood? | Body burn proteins(muscle) and fats. End products: ketones and fatty acids forming ketoacidosis and acetonuria. Wt loss leads to polyphagia(excessive amts of food) |
| Which organ systems are affected most by DM? What complicatings ensue? | eyes, nerves, kidneys, heart atheroscloerosis, retinopathy, nephropathy, neuropathy |
| What are 4 groups of Diabetes | Type 1:absolute insulin deficient 2:insulin resistance (obese/HTN/genetics) Diabetes caused by inf/drugs Gestational diabetes mellitus(GDM)/White |
| When does fetus start secreting insulin | by 10th week. Glucose passes placenta, insulin does not, so glucose lvls proportional to mom's. |
| which hormones increase B cells to produce insulin? | estrogen/progesterone |
| What happens to insulin dependent women during 1st trimester? | prone to hypoglycemia b/c insulin need decr bc of incr prod by pancreas/decr food intake bc N/V, glucose xfer to fetus |
| What happens during 2nd trimester w/ women with DM | insulin resistance bc of all hormones, insulin antagonists. This acts as glucose sparing mechanism so fetus gets enuf glucose. |
| Third trimester insulin does what | requirement incr til 36 wk |
| Day of delivery does what to insulin/glucose | maternal insulin req drop. Breast feeding maintains lower insulin req(25%) |
| what are glucose levels for preconception for women w/ DM | before meals: 80-110 2 hours after meals: <155 |
| When assessing risks for pregnant women with DM, what will the nurse look for? | 1 blood glucose control- poor/good 2 time since dx of DM 3 presence of vascular disease |
| Poor glucose control leads to macrosomia, which is | excessive growth, wt>4000-4500g (50%) more shoulder dystocia and C-sections |
| Which hypertensive disorders are common in pregestational diabetes? What other complications to women are common? | preeclampsia/eclampsia. ...Preterm labor/birth, hydramnios, PROM, postpartum hemorrhage, infections |
| Which vaginal infections is most common in pregnant women with diabetes | monilial vaginitis, UTIs, |
| Which tocolytic drug can contribute to DKA | turbutaline (Brethine) |
| what is euglycemia | normal blood glucose lvl: 60-120 for preg woman w/ diabetes |
| what r some fetus complications related to diabetes | still births, congenital anomalies, CNS defects, cardiac, caudal regression |
| A test for glycosylated Hgb provides what? | measure of glycemic control over time, 8-12 wks. Measure Hgb A and want lvl of 5-6% = glucose 90-120. |
| what is included in physical exam for pregestational diabetes | electrocardiogram to get baseline, retinopathy eval, BP to asses risk for preeclampsia, wt gain, fundal ht(abnormal incr) |
| what are routine lab tests for pregestational diabetes | glycosylated hgb, 24hr urine(protein and creatine), urinalysis/culture(UTI), urine(ketones), thyroid |
| what lifestyle changes must woman make to ensure euglycemia | go to bed, get up, excercise, take insulin same time ea day, wear id bracelet, daily bath for good perineal/foot care, |
| what r s/s of hypoglycemia | nervousness, HA, shaking, irritability, personality change, hunger, blurred vision, sweaty skin, tingling of mouth. Not below 60 |
| what should hypoglycemic eat if glucose below 60 | 1/2c unsweetened fruit juice, 1/2c reg soda, 5-6 Lifesavers, 1T honey, 1c milk, 2-3 glucose tabs. Notify MD if rest 15, eat, rest 15 min and still <60 |
| what is ideal caloric amt for 1st tri? 2nd/3rd? | 1st: 2200 cal 2nd/3rd: 2500 |
| what is good option to prevent hypoglycemia and starvation ketosis during night? | 25g carb snack w/ some protein |
| what is ratio of carbs/fats/proteins to meet metabolic needs of fetus/woman | 40-50% carbs, 250g min, complex 20% protein 30-40% fats Wt gain = 12kg during preg (26.4lbs) |
| What kind of insulin is Lispro (Humalog) | rapid-acting w/in 25min, peaks at 30min - 1 1/2 hr. Lasts 4-5hrs. Convenient. |
| what kind of insulin is Humulin/Novolog | biosynthetic human insulin, less antibody formations. For new onset |
| A ratio of what | 2:1 long to short acting 2/3 b4 breakfast 1/3 b4 dinner |
| what are steps to adm insulin | insert air to long, air to shot, withdraw short, withdraw long |
| Table for insulin adm during preg | lispro(rapid): onset(15m), Peak(2-3h), Dur(3-4h) Reg(short): 30m, 3-4h, 6-8h Int: 2-4h, 4-12h, 12-24h Long: 3-4h, 14-24h, 24-36h |
| what are acceptable fasting levels during preg | 60-90 hypo <60 hyper >200 |
| During intrapartum, pregestational women usually get what solution? | IV lactated Ringers or 5% Dextrose, glucose taken q hr to stay at 70-90 to prevent hyperglycemia in mom and hypo in neonate |
| With c-section, when should it be scheduled with pregestational preg | early morn to facilitate glycemic control. |
| Does insulin incr or decr in postpartum and why | decr bc insulin resistance came from placenta, and levels need to reach 200 b4 insulin is given |
| what are possible postpartum complications | preeclampsia, eclampsia, hemorrhage, infection(endometritis) |
| breast feeding diabetic mothers are more risk for | mastitis and yeast inf |
| what is important teaching for family planning to diabetic woman | reliable birth control, barrier methods being best |
| What % of GDM will have DM | 50% in 5-10yrs of those dx early and obese, >30, fam hx of type 2, hx of infants wt >9lb, hydramnios, unexplained stillbirth/miscarriage/infant w/ anomalies |
| when is dx of GDM usually made? | Second 1/2 of preg, dev after wk 20 |
| GDM places neonate at what risks | hypo-glycemia/calcemia, hyperbilirubemia, thrombocytopenia, polycythemia, respiratory distress syndrome |
| who r low risk for GDM | normal wt, <25, no fam hx, not ethnic |
| When should high risk women be screened for GDM | first prenatal vist and 24-28 wks |
| what are target blood glucose lvls in preg? Target for GDM? | 60-120 GDM: Fasting: less than 105 1hr after meals: <155 2hr after meals: <130 Intrapartum: <110 |
| s/s of hyperthyroidism | fatigue, heat intolerance, wawrm skin, diaphoresis, tachy, wide PP, unplanned wt loss, loose nails(onycholysis), pulse>100 and not decr wtih Valsava |
| what are complications of untreated hyperthyroidism during preg | LBW, IUGR, stillbirth, preeclampsia, placental abruption, CHF, inf |
| Tx for hyperthyroidism | PTU(propylthiouracil) drug, cross placenta and can induce fetal hypothyroidism/goiter SE: agranulocytosis: fever, malaise, gingivitis, sore throat, thyroid storm(fever,tachy,vomiting,hypotension,stupor,CHF) adn tx: IV fluids/O2/PTU |
| Most hypothyroidism in preg is rare bc this condition can cause what? | sterility tx: synthroid (L-thyroxine) and don't take with iron |
| what is phenylketonuria | deficiency in phenylalanine hydrolase and impairs abilit to metabolize amino acid phenylalanine in protein foods. Leads to retardation cause builds in brain. Newborns tested after birth. Tx: strict diet low phenyl foods |
| what are major cardiac changes in preg that would affect cardiac diseased pt | incr intravascular vol, decr systemic vascular resistance, bc heart disease is #1 nonobstetric maternal killer |
| what conditions put women at higher mortality during preg in cardiac disease | aortic coarctation, myocardial infarction, Marfan syndrome wtih aortic involvement, pulmonary HTN |
| During birth, what is nsg mgmt goal for woman with cardiac disease | HR<110, prevent hypotension and maternal tachy, open glottis pushing |
| what is peripartum cardiomyopathy | PPCM: CHF dev in last mo of preg or w/in 5mos post Af Am, twin pregs, preeclampsia Tx: diuretics, anticoagulants, digoxin. (ACE inhibitors only post bc terattogenic) |
| Rheumatic Heart Disease(RHD) leads to damaged what? | heart valves(mitral), chorda tendineae. This mitral valve stenosis obstructs flow from atrium to ventricles |
| RHD can lead to what in preg? | ventricular failure, pulmonary edema, death Tx: limit activity, Na, diuretics, beta blockers, bed rest |
| what is mitral valve prolapse(MVP) | common, valve prolapses into lft atrium allowing backflow of blood. Hear: Midsystolic click/late systolic murmur tx: asymptomatic, none |
| what is Eisenmenger's Syndrome | right to left or bidirectional shunting at mitral/ventricular lvl and has high mortality rate in preg |
| what are Atrial/Ventricular Septal defects? | ASD: abnormal opening in atria left to right shunting. With incr plasma vol, may have rt-sided heart failure |
| what is Tetralogy of Fallot? | abnormals caused by maldev of truncus arteriosus and lead to right to left shunt. Tx: good prognosis, but untx can lead to infant death |
| what is Marfan Syndrome? | genetic disorder of weakness in connective tissue, result is joint deformities, ocular lens dislocation, weak aortic wall/root |
| How long should wait to get preg after transplant>? | 1yr to avoid rejection episodes |
| when is stress greatest on preg woman with heart disease | 28-32 weeks as hemodynamic changes reach max |
| when is best time for cardiac surgery? | 2nd trimester |
| If defibrillation is needed for preg woman where should the paddles be placed? | one rib interspace higher than normal bc displaced uterus |
| What are things to remember in CPR on preg woman | Not supine(lateral), if not breathing, give 2 slow breaths Rescue breathing w/o chest compressions: 10-12 breaths/min If no pulse: chest compressions 100/min at depth of 1 1/2 - 2in. Recheck pulse after 4 cycles. C-section if no pulse after 5 min. |
| Nomral H/H values in anemia preg woman? | Hct: <32% Hgb: <11 Restless Leg Syndrome common with anemia |
| Ferritin lvls of 10-15 confirm dx of what? | iron deficiency anemia |
| Folic acid deficiency causes? | neural tube defects, cleft lip, cleft palate. During preg, normal intake = 400mcg/day |
| Sickle cell anemia presents with fever and pain where? | abd and extremeties |
| Cooley anemia is what | insufficient globin to fill RBCs, leading RBC death and to bone deficiencies bc of marrow expansion. hereditary, mediterranean |
| what is most common pulmonary disease in preg | asthma and peaks bn 29-36wks |
| what is goal of therapy for asthma | prevent hypoxic episodes 1. relieve bronchospasms(dilators) 2 limit irritant stimuli 3. devr pulmonary response to allergen exposure(dustmites,pollen, dander) 4. limit inflammatory response in airway(antiinflam agents) Drug: Meperidine |
| cystic fibrosis women have higher incidence of | GDM, preterm births, IUGR, neonate deaths |
| what is cholelithiasis? cholecystitis? | choleithiasis: gallstones in gallbladder, more in preg. cholecystitis: inflammation of gallbladder diet: reduce fats to 40-50g/day, limit protein to 10-20%, more carbs, avoid fried foods |
| Accutane should be avoided in preg bc? | high teratogenicity |
| what is most common causes of pruritis in preg | polymorphic eruption of preg/pruritic urticarial papules adn plaques of preg(PUPPP) |
| what is most common neurological disorder with preg | epilepsy |
| anticonvulsants can counteract what with preg | contraceptives can be ineffective, teratogencity, infants can have hemorrhagic disorder bc vit K def. |
| what is MS | demyelinzation of spinal cord and CNS and can be viral disorder. Age 20-40 most common onset |
| what is most common autoimmune disorder in women of childbearing age | systemic lupus erythematosus (SLE)- multisystem inflammatory disease that affects skin, joints, kidneys, lungs, CNS, liver, other organs. Af Am s/s: pericarditis(initial s/s), fatigue, fever, skin rashes, wt loss, arthralgias |
| preg women with lupus should worry about | infection, family planning bc should wait til remission to get preg again |
| what is myasthenia gravis(MG)? | autoimmune muscle end-plate disorder affects motor fx. Muscle weakness in eyes/face/tongue/neck/limbs/resp muscles |
| what is absolutely contraindicated during labor of women with MG? | Mg sulfate bc interferes wtih neuromuscular transmission Tx: acetylcholinesterase inhibitors, immunosuppresive meds, corticosteroid therapy, |
| what might be used during delivery of women with MG | forceps/vacuum assist bc of muscle weakness |
| what factors incr risk of perinatal HIV transmission | prev hx of child w/ HIV, preterm birth, decr mom CD4 count, high mom viral load, firstborn twin, chorioamniontis, intrapartum blood exposure, no AZT tx during ante and intra of preg |
| HIV positive should be vaccinated against | hepB, pneumococcal, influenza, avoid varicella TB test and pap test performed |
| during birth, what should be done to avoid fetus contact wtih blood or secretions of mom wtih HIV | C-section, leave membranes in tact, avoid fetal scalp electrode/forceps/vacuum/episiotomy, bath infant asap, |
| Smoking during preg can cause? | bleeding, miscarriage, stillbirth, prematurity, placenta previa, placental abruption, LBW, SIDS |
| Women addicted to heroine are allowed what | methadone maintenance along wtih behavioral counseling |
Created by:
palmerag
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