Preexisting Conditions for Preg at Risk
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| What is considered a key to optimal pregnancy outcome? | strict maternal glucose control before conception and thru preg
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| what is DM | hyperglycemia resulting in deficient insulin secretion/action/both
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| Where is insulin produced | B-cells in islets of Langerhans of pancreas
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| 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
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| what is meant by hyperglycemia causes hyperosmolarity of the blood? | intracellular fluid moves into vascular system, resulting in cellular dehydration and expanded blood volume,
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| 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
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| 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)
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| Which organ systems are affected most by DM? What complicatings ensue? | eyes, nerves, kidneys, heart
atheroscloerosis, retinopathy, nephropathy, neuropathy
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| 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
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| When does fetus start secreting insulin | by 10th week. Glucose passes placenta, insulin does not, so glucose lvls proportional to mom's.
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| which hormones increase B cells to produce insulin? | estrogen/progesterone
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| 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
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| 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.
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| Third trimester insulin does what | requirement incr til 36 wk
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| Day of delivery does what to insulin/glucose | maternal insulin req drop. Breast feeding maintains lower insulin req(25%)
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| what are glucose levels for preconception for women w/ DM | before meals: 80-110
2 hours after meals: <155
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| 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
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| Poor glucose control leads to macrosomia, which is | excessive growth, wt>4000-4500g (50%)
more shoulder dystocia and C-sections
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| 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
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| Which vaginal infections is most common in pregnant women with diabetes | monilial vaginitis, UTIs,
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| Which tocolytic drug can contribute to DKA | turbutaline (Brethine)
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| what is euglycemia | normal blood glucose lvl: 60-120 for preg woman w/ diabetes
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| what r some fetus complications related to diabetes | still births, congenital anomalies, CNS defects, cardiac, caudal regression
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| 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.
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| 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)
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| what are routine lab tests for pregestational diabetes | glycosylated hgb, 24hr urine(protein and creatine), urinalysis/culture(UTI), urine(ketones), thyroid
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| 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,
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| what r s/s of hypoglycemia | nervousness, HA, shaking, irritability, personality change, hunger, blurred vision, sweaty skin, tingling of mouth.
Not below 60
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| 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
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| what is ideal caloric amt for 1st tri? 2nd/3rd? | 1st: 2200 cal
2nd/3rd: 2500
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| what is good option to prevent hypoglycemia and starvation ketosis during night? | 25g carb snack w/ some protein
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| 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)
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| What kind of insulin is Lispro (Humalog) | rapid-acting w/in 25min, peaks at 30min - 1 1/2 hr. Lasts 4-5hrs. Convenient.
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| what kind of insulin is Humulin/Novolog | biosynthetic human insulin, less antibody formations. For new onset
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| A ratio of what | 2:1 long to short acting
2/3 b4 breakfast
1/3 b4 dinner
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| what are steps to adm insulin | insert air to long, air to shot, withdraw short, withdraw long
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| 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
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| what are acceptable fasting levels during preg | 60-90
hypo <60
hyper >200
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| 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
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| With c-section, when should it be scheduled with pregestational preg | early morn to facilitate glycemic control.
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| 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
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| what are possible postpartum complications | preeclampsia, eclampsia, hemorrhage, infection(endometritis)
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| breast feeding diabetic mothers are more risk for | mastitis and yeast inf
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| what is important teaching for family planning to diabetic woman | reliable birth control, barrier methods being best
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| 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
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| when is dx of GDM usually made? | Second 1/2 of preg, dev after wk 20
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| GDM places neonate at what risks | hypo-glycemia/calcemia, hyperbilirubemia, thrombocytopenia, polycythemia, respiratory distress syndrome
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| who r low risk for GDM | normal wt, <25, no fam hx, not ethnic
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| When should high risk women be screened for GDM | first prenatal vist and 24-28 wks
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| 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
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| 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
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| what are complications of untreated hyperthyroidism during preg | LBW, IUGR, stillbirth, preeclampsia, placental abruption, CHF, inf
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| 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
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| Most hypothyroidism in preg is rare bc this condition can cause what? | sterility
tx: synthroid (L-thyroxine) and don't take with iron
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| 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
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| 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
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| what conditions put women at higher mortality during preg in cardiac disease | aortic coarctation, myocardial infarction, Marfan syndrome wtih aortic involvement, pulmonary HTN
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| During birth, what is nsg mgmt goal for woman with cardiac disease | HR<110, prevent hypotension and maternal tachy, open glottis pushing
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| 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)
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| Rheumatic Heart Disease(RHD) leads to damaged what? | heart valves(mitral), chorda tendineae. This mitral valve stenosis obstructs flow from atrium to ventricles
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| RHD can lead to what in preg? | ventricular failure, pulmonary edema, death
Tx: limit activity, Na, diuretics, beta blockers, bed rest
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| 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
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| what is Eisenmenger's Syndrome | right to left or bidirectional shunting at mitral/ventricular lvl and has high mortality rate in preg
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| 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
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| 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
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| what is Marfan Syndrome? | genetic disorder of weakness in connective tissue, result is joint deformities, ocular lens dislocation, weak aortic wall/root
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| How long should wait to get preg after transplant>? | 1yr to avoid rejection episodes
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| when is stress greatest on preg woman with heart disease | 28-32 weeks as hemodynamic changes reach max
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| when is best time for cardiac surgery? | 2nd trimester
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| If defibrillation is needed for preg woman where should the paddles be placed? | one rib interspace higher than normal bc displaced uterus
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| 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.
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| Nomral H/H values in anemia preg woman? | Hct: <32%
Hgb: <11
Restless Leg Syndrome common with anemia
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| Ferritin lvls of 10-15 confirm dx of what? | iron deficiency anemia
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| Folic acid deficiency causes? | neural tube defects, cleft lip, cleft palate.
During preg, normal intake = 400mcg/day
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| Sickle cell anemia presents with fever and pain where? | abd and extremeties
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| Cooley anemia is what | insufficient globin to fill RBCs, leading RBC death and to bone deficiencies bc of marrow expansion.
hereditary, mediterranean
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| what is most common pulmonary disease in preg | asthma and peaks bn 29-36wks
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| 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
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| cystic fibrosis women have higher incidence of | GDM, preterm births, IUGR, neonate deaths
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| 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
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| Accutane should be avoided in preg bc? | high teratogenicity
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| what is most common causes of pruritis in preg | polymorphic eruption of preg/pruritic urticarial papules adn plaques of preg(PUPPP)
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| what is most common neurological disorder with preg | epilepsy
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| anticonvulsants can counteract what with preg | contraceptives can be ineffective, teratogencity, infants can have hemorrhagic disorder bc vit K def.
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| what is MS | demyelinzation of spinal cord and CNS and can be viral disorder.
Age 20-40 most common onset
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| 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
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| preg women with lupus should worry about | infection, family planning bc should wait til remission to get preg again
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| what is myasthenia gravis(MG)? | autoimmune muscle end-plate disorder affects motor fx. Muscle weakness in eyes/face/tongue/neck/limbs/resp muscles
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| what is absolutely contraindicated during labor of women with MG? | Mg sulfate bc interferes wtih neuromuscular transmission
Tx: acetylcholinesterase inhibitors, immunosuppresive meds, corticosteroid therapy,
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| what might be used during delivery of women with MG | forceps/vacuum assist bc of muscle weakness
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| 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
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| HIV positive should be vaccinated against | hepB, pneumococcal, influenza, avoid varicella
TB test and pap test performed
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| 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,
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| Smoking during preg can cause? | bleeding, miscarriage, stillbirth, prematurity, placenta previa, placental abruption, LBW, SIDS
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| Women addicted to heroine are allowed what | methadone maintenance along wtih behavioral counseling
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