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Complications of Pregnancy

Complications of Pregnancy . Pre-Eclampsia/Eclampsia Diabetes in Pregnancy Perinatal Infections Abortion & Others. ACOG (American Academy of Obstetricians and Gynecologists) created a task force of experts in the management of hypertension in pregnancy Reviewed available data

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Complications of Pregnancy

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  1. Complications of Pregnancy Pre-Eclampsia/Eclampsia Diabetes in Pregnancy Perinatal Infections Abortion & Others

  2. ACOG (American Academy of Obstetricians and Gynecologists) created a task force of experts in the management of hypertension in pregnancy • Reviewed available data • Published evidence based recommendations http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy

  3. 4 Categories Used By The Task Force • Chronic Hypertension (of any cause) • Chronic Hypertension with superimposed preeclampsia • Gestational Hypertension • Preeclampsia/Eclampsia

  4. Chronic Hypertension High blood pressure known to predate conception or detected BEFORE 20 weeks gestation

  5. Chronic Hypertension with Superimposed Preeclampsia (Maternal prognosis is worse than either condition alone) • HTN with proteinuria that develops after the 20th week OR • HTN and proteinuria before the 20th week WITH (At least one): • Sudden increase in BP • Sudden manifestation of other s/s ( i.e. increase in liver enzymes to abnormal levels) • Platelets below 100,000/microliter • Additional symptoms like RUQ pain & Severe headache • Pulmonary congestion or edema • Renal insufficiency • Sudden and sustained increase in protein excretion

  6. Gestational Hypertension • Transient— BP that occurs without proteinuria late in pregnancy or in the early pp period, but returns to normal by 12 weeks pp. • Chronic— BP that occurs without proteinuria late in pregnancy or in the early pp period, but remains  after 12 wks pp.

  7. Pre-eclampsia/Eclampsia (Pregnancy-specific, multi-system syndrome) • Hypertension that develops after the 20th week gestation AND • Proteinuria OR • Thrombocytopenia • Renal insufficiency • Impaired liver function • Pulmonary edema • Cerebral or visual symptoms

  8. Blood Pressure • > or = 140 systolic OR > or = to 90 diastolic on two occasions AT LEAST 4 hours apart in a woman with previously normal BP • > or = 160 systolic OR > or = 110 diastolic can be confirmed within a short interval to facilitate timely treatment. • Increase occurs AFTER the 20th week gestation

  9. Proteinuria • > or = 300 mg per 24 hour urine collection (GOLD STANDARD) OR • Protein/creatinine ratio > or = to 0.3 mg/dL • Dipstick reading of 1+ (used only if other quantitative methods are not available)

  10. Trombocytopenia • Platelet count less than 100,000/microliter Renal Insufficiency • Protein/creatinine ratio > or = to 0.3 mg/dL Impaired liver function • Elevated blood concentrations > 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease Pulmonary Edema Cerebral or Visual Symptoms

  11. Eclampsia The Presence of new-onset grand mal seizure in a woman with preeclampsia • Cannot be attributed to any other cause

  12. Predisposing Factors to Preeclampsia • Primiparity • Previous preeclamptic pregnancy • Chronic hypertension or chronic renal disease • History of thrombophilia • Multigestational pregnancies • In vitro fertilization • Family Hx of preeclampsia • Type I DM or Type II DM • Obesity • Systemic lupus erythematosus • Maternal age <19 or >40

  13. Changes in Normal Pregnancy •  Cardiac output by 50% •  Blood volume by 1500ml •  Peripheral vascular resistance •  BP •  Renin •  GFR •  ECF • Aldosterone effects blocked

  14. Changes in Preeclampsia (pg382; 10th ed) • Generalized Vasospasm  • Hypertension •  Intravascular volume   placental perfusion  IUGR of fetus, fetal distress •  renal perfusion   GFR  urine output (oliguria) •  BUN & Creatinine & uric acid •  proteinuria   serum albumin •  Extravascular fluid (edema)  Pulmonary, retinal, & cerebral edema  • Dyspnea, scotomata, CNS irritability/ hyperreflexia, HA, N& V, convulsions •  Hepatic perfusion   Liver function tests, epigastric pain (RUQ)

  15. Preeclampsia without severe features • Signs & Symptoms • BP > 140/90 • Proteinuria (Mild)

  16. Treatment of Preeclampsia w/o Severe Features • Daily kick counts • Ultrasound for fetal growth q 3 weeks • Amniotic fluid assessment at least 1/week • NST twice a week (non-reactive = BPP) • Monitor daily wt for gain • Monitor BP daily • Lab tests: CBC, liver enzyme & serum creatinine level at least once a week. • Regular diet w/ no salt restrictions • Instructed to go to hospital w/worsening sx

  17. Hospital care of mild preeclampsia • Bedrest, left lateral recumbent position to  renal perfusion which promotes diuresis and lowers BP • Diet—well balanced, nutritious, moderate  protein to replenish what is spilled by kidneys

  18. Hospital care of mild preeclampsia (Cont’d) • Assessment of fetal well-being • DFMC, BPP, NST, Amniocentesis • Assessment of maternal well-being • BP assessed qid or q4hr • Daily wt, and assessment of worsening edema • Assessment of HA, visual changes, epigastric pain, hyperreflexia • Lab tests: daily urine dipstick for protein, 24 hr protein, CBC w/ platelet count q 2 days, serum creatinine, uric acic, & liver function tests (AST, ALT, LDH, Bili)

  19. Severe Preeclampsia • Signs and symptoms • BP of 160/110 or higher on 2 occasions at least 4 hr apart while on bedrest • Proteinuria  5g/L in 24 hr or 3+ or > on 2 random urine samples 4 hrs apart • Oliguria: urine output <500ml/24hr • Cerebral or visual disturbances—HA, scotomata or blurred vision • Pulmonary edema or cyanosis • Epigastric or RUQ pain • Impaired liver function ( AST, APT) • Thrombocytopenia

  20. Treatment of Severe Preeclampsia • Absolute bedrest • Quiet environment to reduce stimuli • Delivery > 34 weeks gestation

  21. Management of Severe Preeclampsia <34 weeks

  22. Medications used in treatmentSeizure Prophylaxis • Magnesium Sulfate: a 4-6 gm bolus is given IV over 20 minutes, then a continuous infusion of 2gm/hr is generally advocated. • CNS depressant • Needs to be maintained at a therapeutic level as determined by each laboratory • Excessive levels lead to respiratory paralysis and cardiac arrest • Calcium gluconate given to reverse

  23. Case Study A 35 year old G1P0 patient is admitted to L&D with severe preeclampsia. Her most recent blood pressure readings have been 172/108 & 176/112. She complains of seeing spots and a severe headache. You have received orders for a 4gm IV bolus of Magnesium over 20 minutes followed by a 2gm/hr maintenance dose. • If 40 grams are added to 1000mls of LR, at what rate would you set the IV pump to administer 4gm in 20 minutes? • What amount would you put in the VTBI on the pump? • If you are to continue to infuse at 2gm/hr, at what rate would you set the pump? • What side effects can you educate your patient on? • What are the nursing implications? • What should you have available in case of Mag Sulfate toxicity? See p. 572 Davidson 10th ed. for more info

  24. Medications used in treatmentAnti-hypertensivesGiven for sustained BP’s >160/110 • First Line for Acute Hypertension • Labetalol: 20 mg IV over 2 min, can give q10 min if needed (max 300mg) – avoid with asthma or CHF • Hydralazine: 5mg IV over 1-2 min, can give q20 min if needed (max 30mg) • Expectant management • Oral Labetalol, Nifedipine, or Methyldopa • NO diuretics or ACE inhibitors

  25. Eclampsia—occurs in 1 in 1600 pregnancies • Symptoms of impending seizure: • Persistent occipital or frontal headaches • Blurred vision • Photophobia • Epigastric or right upper quadrant pain • Altered mental status • Hyperreflexia— 4+ • Scotomata—dark spots or flashing lights • Vomiting • Neurologic hyperactivity • Pulmonary edema • Cyanosis

  26. Safety precautions • Quiet environment—no phone calls, TV, lights, pulled shades, etc. • Padded side rails in bed • O2 ready and available • Suction ready and available

  27. Refer to Nursing Care Planpp. 389-391 Davidson et al, 10th ed. • Note importance of careful monitoring of mother and fetus throughout hospitalization with severe pre-eclampsia • Prevention of complications is key to healthy management

  28. HELLP Syndrome • Hemolysis • Elevated Liver Enzymes • Low Platelets (< 100,000/mm3) • Sometimes associated with severe preeclampsia • Sx: N & V, malaise, flu-like sx, or epigastric pain with or without HTN • Persons presenting with these sx should have CBC with platelets and liver enzymes drawn • These pts should be managed at tertiary care centers • Corticosteroids: while usually given to foster fetal maturity, they have been found to stabilize platelet counts and hepatic enzymes and LDH levels. Dexamethasone is often chosen for HELLP syndrome.

  29. Pregestational Diabetes Mellitus Type 1 Type 2 1/2000 pregnancies Gestational Diabetes Any degree of glucose intolerance with the onset or first recognition occurring during pregnancy 2-5% of all pregnancies 90% of all cases of diabetes in pregnancy 25% of these women will develop Type 2 diabetes later in life Diabetes In PregnancyDid it exist BEFORE Pregnancy?

  30. Normal CHO Metabolism in PG • Goal of changes is to provide adequate glucose to fetus for growth • Maternal glucose crosses the placenta • Maternal insulin does NOT • KEY CONCEPT TO UNDERSTAND

  31. CHO Metabolism—1st Trimester •  in E & P stimulate Beta cells of Pancreas to  Insulin production • =  use of glucose  in serum glucose levels (FBS ) •  in tissue glycogen stores • in liver glycogen production • = Pregestational Diabetics  Hypoglycemia

  32. CHO Metabolism-2nd & 3rd Trimester • Pregnancy is a “diabetogenic” state • Hormones levels lead to tolerance to glucose •  insulin resistance • HPL-Human Placental Lactogen • Insulin antagonist—Won’t let insulin work • Placental Insulinases • Breakdown insulin at placental site

  33. Net Result = Changes in Insulin Needs for Mother during Pregnancy • 1st trimester = need for insulin •  insulin production, N&V, food intake,  transfer to fetus • 2nd Trimester = Gradual  • 3rd Trimester = 2-4 times higher need for insulin by 36 week, then levels off til labor • After delivery = ; glucose/insulin balance OK by 7-10 days

  34. Pregestational Diab. If poor control very early in PG Miscarriage Macrosomic babyC/S Pre-eclampsia PTL Infections (UTI’s, Vag) Polyhydramnios Ketoacidosis / Hypogylecemia Gestational-Onset 2X likely to have pre-eclampsia Macrosomic baby  C/S Risks to Mother

  35. Pregestational Congenital Defects Heart, Skeletal, CNS Same as Gestational Gestational MacrosomiaBirth Trauma Hypoglycemia RDS Hypocalcemia Hyperbilirubinemia Thrombocytopenia Polycythemia Risks to Baby

  36. Management of Pre-gestational Diabetes • Pre-conceptual Counseling • Establish glycemic control BEFORE PG • Understand the VERY close monitoring • Blood glucose levels 4-8 times a day. • Frequent MD visits • If Type 2—Some oral hypoglycemic agents are teratogenic Insulin SQ during pregnancy

  37. Management of Pre-gestational Diabetes • Hgn A1c • Good control = 2.5% to 5.9 % • Fair Control = 6% - 8% • Poor Control = > 8% • Diet VERY CAREFULLY BALANCED • Should be followed by Registered Dietician • Exercise • Not vigorous, Best time is after meals

  38. Management of Pre-gestational Diabetes-Insulin • Multiple daily injections needed • Mixed of longer-acting and rapid-acting in AM and PM • Humulin or Novolin, NOT pork or beef insulins • Humalog, if newly diagnosed

  39. Management of Pre-gestational Diabetes-Insulin • GOAL—keep blood sugar in narrow margin • Fasting = 60-90 mg/dl • 2-hour postprandial = 90-120 mg/dl

  40. Management of Pre-gestational Diabetes-Delivery • Careful determination of ACTUAL due date • Amniocentesis Fetal lung maturity • Induce 39-40 wks-NO LATER THAN 40 WKS • If estimated fetal weight > 4000-4500 Gms  C/S • In L&D- Watch maternal glucose levels every 2 hours

  41. Low-risk < 25 y/o No family Hx Normal BMI Not in High-Risk group No Hx of Abnormal GTT Hi-Risk Hx of gestational Diabetes Overweight/Obese BMI High-risk group African-American Native-American Latina Pacific-Islander Gestational Diabetes-Screening

  42. Gestational Diabetes-Screening • First pre-natal visit • 50 gm glucose load -> draw serum 1 hour later • Negative < 140 mg/dl • Positive > 140 mg/dl • Screen again 24-28 weeks gestation

  43. Gestational Diabetes-Screening • If positive do 3-hour GTT (100g of glucose) • Positive for GDM = 2 or more levels are met or exceeded • Fasting < 95 mg/dl • 1-hr < 180 mg/dl • 2-hr < 155 mg/dl • 3-hr < 140 mg/dl

  44. Gestational Diabetes Management • GOAL Keep blood sugars within levels for Pre-gestational diabetes • Diet—Main course of treatment; 3 meals and 3 snacks • Exercise • Insulin—20% will need insulin during PG; safest • Glyburide (oral hypoglycemic agent) is being used with caution but not yet approved by ACOG • Blood glucose monitoring • Frequently done in MD office or at home

  45. Gestational Diabetes Management • Delivery • Frequent NST/BPP in last 2 months of pregnancy • Deliver by 40 weeks • Excellent resource link from theNational Diabetes Education Program with handouts in various languages and lots of resources. • Another great resource with tables from Merck Manual

  46. Perinatal Infections • Group-B Hemolytic Streptococcus • Major cause of perinatal infections • Found in Vagina and Urine • Increase fetal mortality and morbidity • Screen 35-37 wks (CDC Recommendations) • If Positive –Treat in Labor • Penicillin: 5 million Units IV x 1; 2.5-3 million units every 4 hours • Ampicillin: 2 GMs IV x1; 1 GM every 4 hours • Clindamycin 900mg IV q 8 hr OR Erythromycin 500mg IV q 6hr till delivery if allergic to Penicillin.

  47. Perinatal Infections • If GBS status unknown—Prophylactic trx is indicated if: • Previous infant with GBS • GBS bacturia during this pregnancy • PTL • Temp in labor > 100.4 F • Membranes ruptured > 18 hours

  48. Other Perinatal infections • Syphyllis • Gonorrhea • Chlamydia • TORCH p.394-400; 10th ed. • Toxoplasmosis • Rubella • Cytomegalovirus • Herpes, Human B19 Parvovirus

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