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N113 Risky Pregnancy

N113 - High Risk Pregnancy

Heart disease - prenatal Assess functional capacity-ADL's, factors that increase strain on heart-wt gain, infection, anxiety, Assess for CHF.
Heart disease - diet Increased need for iron & protein, decrease sodium
Heart disease - rest Very important - 8-10 hrs of sleep needed to preserve cardiac reserve - frequent rest periods are necessary
Heart disease - infection Upper respiratory infection can tax the heart and increase risk for endocarditis
Heart disease - blood volume Week 28-30 is when maximum blood volume is reached
Heart disease - during labor Decrease physical exertion & fatigue, frequent vitals. Pulse >100 or respirations >25 may indicate decompensation. Side lying & semi-fowlers ensure cardiac emptying & adequate O2. Prevent valsalva maneuver
Heart disease - postpartum Increased blood flow w/decreased intra-abdominal pressure can lead to CHF. Monitor carefully.
Diabetes - 1st 1/2 of pregnancy Increased estrogen & progesterone stimulate increased insulin production & increase response to insulin - can cause decrease in blood sugar levels. By 8th week fetus secretes insulin.
Diabetes - 2nd 1/2 of pregnancy Hormones (HPL & others) increase insulin resistance. Assures an abundant supply of glucose to the fetus. Fat is metabolized and can cause ketones in urine - normal. Too resistant = gestational diabetes
Detection & diagnosis of gestational diabetes Urine test on every visit for ketones & glucose.
1 hour glucose tolerance test Done at 24-28 weeks, results over 140 requires 3 hour GTT
Glycosylated Hgb (Hgb A1C) Reflects glucose control over 4-12 weeks.
Management of diabetes in pregnancy Must have excellent blood sugar control. Insulin administration only oral=glyburide, usually injectable insulin.
Diabetes & fetal status Placental concerns due to vascular changes. Serum AFP 16-18 wks due to risk of neural tube defects. Repeat non-stress tests. Daily evaluation of fetal activity beginning at 28 wks.
Diabetes & labor management Frequent glucose levels, difficult labor w/fetal macrosomia, increased risk for infection,
Diabetes & fetal/neonatal risks Macrosomia in neonate, hypoglycemia, IUGR, respiratory distress syndrome, polycythemia, hyperbilirubinemia,
Macrosomia High levels of fetal insulin stimulated by high glucose from mother leads to excessive growth. Can be decreased with tight glucose control. Infants over 10 lbs - suspect maternal diabetes
IUGR w/diabetes With advanced DM in mother, vascular changes decrease the efficiency of the placenta
Respiratory distress syndrome w/diabetes High levels of insulin inhibit fetal production of sufactant
Diabetes & postpartal period Maternal insulin needs decrease significantly w/regular & gestational diabetes. Breast feeding decreases insulin needs.
Pregnancy & diabetes Pregnancy will cause problems associated with diabetes to accelerate, such as vascular disease - renal & peripheral
Influence of DM on pregnancy Higher risk of complications, increased amniotic fluid, may lead to PROM & premature labor, fetal malformation & neural tube disorders, PIH
Pregnancy induced hypertension (PIH) Progressive disorder - Pre-eclampsia, HELLP syndrome, eclampsia. Some women become more sensitive to angiotension II leading to vasoconstriction.
PIH complications Decreased renal profusion leads to decreased urine output, increased serum creatinine, BUN & uric acid. NA retention increases extracellular volume & increases sensitivity to angiotension II.
PIH definition BP of 140/90 during 2nd half of pregnancy in previously normotensive women. Noted on 2 occasions at least 6 hours apart. Close observation if systolic of 30mm or 15 mm diastolic over baseline.
Mild preeclampsia definition All of the symptoms of PIH plus proteinuria & pathaologic edema.
Proteinuria > or = to 30 mg/dl on a dipstick or > or = 0.3 in 24/hr
Preeclampsia BP 160/110 or greater Proteinuria > or = to 5g/24 hrs or 2+ or 3+ Oliguria < or = to 400 ml/24hrs less than 20 ml/hr
HELLP syndrome Hemolyhsis, Elevated Liver enzymes, Low Platelets
HELLP syndrome treatment Only treatment is delivery of fetus.
HELLP Maternal risks Retinal detachment, increased deep tendon reflexes, clonus, seizures
HELLP & seizures If seizures occur = eclampsia. Baby must be delivered ASAP
HELLP Fetal risks Decreased placental perfusion, small for gestational age, prematurity, fetal mortality
HELLP syndrome treatment Bed rest-left lateral recumbent, moderate to high protein diet, restricted sodium, evaluation of fetal status
HELLP syndrome medications Magnesium sulfate to prevent seizures
Created by: jrb265