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Complications%20of%20Pregnancy

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Complications of Pregnancy Pre-Eclampsia/Eclampsia Diabetes in Pregnancy Perinatal Infections Abortion & Others – PowerPoint PPT presentation

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Title: Complications%20of%20Pregnancy


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

2
  • NHBPEP advocates discarding the term
    pregnancy-induced hypertension because it does
    not differentiate between gestational
    hypertension, a relatively benign disorder, and
    the more serious preeclampsia.

3
4 Categories approved by the NIH and Natl High
Blood Pressure Education Program(NHBPEP)
  • Chronic Hypertension HTN that was either present
    before conception or detected before the 20th
    week of gestation did not resolve in the early
    postpartum.
  • Chronic Hypertension with superimposed
    preeclampsiathe disorder most often associated
    with severe maternal fetal complications. It is
    seen in women who
  • Were hypertensive before the 20th week gestation
    but have new onset proteinuria
  • Have both HTN and proteinuria before 20 weeks
    gestation
  • Have previously controlled HTN who have a sudden
    increase in BP
  • Exhibit thrombocytopenia (lt100,000 cells/mm3) ?
    liver enzymes

4
  • 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.

5
  • Pre-eclampsia-eclampsiaThis is a
    pregnancy-specific, multi-system syndrome.
  • Diagnosis is determined by presence of HTN,
    occurring after the 20th week gestation,
    accompanied by proteinuria.
  • Other sx that may occur with ? BP visual
    changes, headache, abdominal pain, or abnormal
    lab values.
  • ECLAMPSIA is the convulsive phase of
    preeclampsia, when the seizures cannot be
    attributed to other causes.

6
We will use Preeclampsia in place of PIH
  • Definition? BP (generally defined as 140/90 OR
    an ? in systolic of 30 and diastolic of 15)
    occurring after 20th week gestation accompanied
    by proteinuria. Edema is no longer used in the
    definition because it is so common in pregnancy,
    however, sudden wt gain does warrant close
    observation.

7
Increased BP after 20th wk gestation
  • 140/90 or higher if baseline pressures are
    unknown
  • ? of 30mm Hg systolic or 15mm Hg diastolic above
    baseline

8
Proteinuria
  • The Gold Standard is a 24hr urine specimen with
    excretion of gt300mg of protein in 24 hrs.
  • This correlates with a dipstick of 1(30mg/dL) or
    greater if specific gravity is lt 1.030 OR 2 if
    the specific gravity is higher.

9
Edema criterion
  • weight gain of
  • gt 1.5kg/month (3.3lb.) in the second trimester
  • or gt 0 .5kg/week(1.1 lb) in the third trimester.
  • Puffiness of face and hands rather than dependent
    edema manifested as swollen ankles and feet
  • Pitting edema of lower extremities while on
    bedrest

10
Predisposing Factors
  • Nulliparas
  • Multigestational pregnancies
  • Hx of previous pregnancy with preeclampsia
  • Maternal age lt19 or gt40
  • African American ethnicity
  • Family Hx of preeclampsia
  • Presence of pre-existing disease chronic HTN,
    renal disease,diabetes mellitus

11
Changes in Normal Pregnancy
  • ? Cardiac output by 50
  • ? Blood volume by 1500ml
  • ? Peripheral vascular resistance
  • ? BP
  • ? Renin
  • ? GFR
  • ? ECF
  • Aldosterone effects blocked

12
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)

13
Mild Preeclampsia
  • Signs Symptoms
  • BP gt 140/90
  • Periorbital edema
  • 1 to 2 proteinuria by dipstick
  • Mild edema of face hands
  • Platelet count gt 120,000

14
Treatment
  • Home care of mild preeclampsia
  • Monitor daily wt for gain
  • Monitor BP daily
  • Monitor urine for protein daily (dipstick)
  • Remote NSTs are performed
  • Daily Fetal Movement Counts
  • Lab tests BUN, Liver enzymes, 24-hr urine for
    protein, creatinine clearance
  • Encourage rest in Left Lateral position
  • Go to hospital with any worsening sx.

15
  • Hospital care of mild preeclampsia
  • Bedrest, left lateral recumbent position to ?
    renal perfusion which promotes diuresis and
    lowers BP
  • Dietwell balanced, nutritious, moderate sodium
    (not gt 6g/day), moderate ? protein to replenish
    what is spilled by kidneys

16
Hospital care of mild preeclampsia (Contd)
  • 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)

17
Severe Preeclampsia
  • Signs and symptoms
  • BP of 180/110 or higher on 2 occasions at least 6
    hr apart while on bedrest
  • Proteinuria ? 5g/L in 24 hr or 3 or gt on 2
    random urine samples 4 hrs apart
  • Oliguria urine output lt500ml/24hr
  • Cerebral or visual disturbancesHA, scotomata or
    blurred vision
  • Pulmonary edema or cyanosis
  • Epigastric or RUQ pain
  • Impaired liver function (? AST, APT)
  • Thrombocytopenia
  • IUGR
  • Hyperreflexia, irritability, emotional tension,
    NV

18
  • Treatment of Severe Preeclampsia
  • Absolute bedrest
  • Quiet environment to reduce stimuli
  • High protein, moderate sodium diet
  • AnticonvulsantsMagnesium Sulfate is drug of
    choice because of its CNS depressant action
  • Corticosteroidsbetamethasone or dexamethasone is
    given to mother to promote lung development in
    fetus
  • Fluid electrolyte replacement need to keep
    balance
  • Antihypertensivesif diastolic gt 105-110

19
Medications used in treatment
  • Magnesium Sulfate a 4-6 gm bolus is given IV
    over 20 minutes, then a continuous infusion of
    2gm/hr is generally advocated.
  • If 40 grams are added to 1000mls of LR, at what
    rate would you set the IV pump to administer 4gm
    in 20 minutes?
  • If you are to continue to infuse at 2gm/hr, at
    what rate would you set the pump?
  • Side effects
  • Nursing implications
  • What drug should you have on hand in case of Mag
    Sulfate toxicity?
  • See p. 572 Davidson 10th ed. for more info

20
  • Anti-hypertensives given for sustained sys BPgt
    160-180 and dias BPgt 105-110
  • NO DIURETICS should ever be Rxd in cases of
    preeclampsia
  • Methyldopa(Aldomet)central adrenergic inhibitor
    is drug of choice with no ill effects to mom or
    baby. Primarily for long-term use, NOT acute.
  • Hydralazine is now a 2nd line drug after
    Methyldopa for tx of chronic hypertension, but
    still the drug of choice in hypertensive crisis.
  • Labetalolis an adrenergic-receptor blocking
    agent given orally or IV more frequently these
    days.
  • Nifedipinegiven orally or IV
  • ACE inhibitors are contraindicated in pregnancy

21
  • Other anti-convulsants
  • Phenytoin and Diazepam have not been found to be
    as effective as MgSO4, so seldom used

22
Eclampsia occurs in 1 in 1600 pregnancies
  • Symptoms of impending seizure
  • Hyperreflexia 4
  • Scotomatadark spots or flashing lights
  • Blurred vision
  • Epigastric pain
  • Vomiting
  • Persistent Headache generally frontal
  • Neurologic hyperactivity
  • Pulmonary edema
  • Cyanosis

23
  • Safety precautions
  • Quiet environmentno phone calls, TV, lights,
    pulled shades, etc.
  • Padded side rails in bed
  • O2 ready and available
  • Suction ready and available
  • Emergency tray available with
  • Diazepam 10 mg given IV push not gt 30mg
  • or Phenytoin 10mg/kg IV push
  • Monitor FHR for bradycardia

24
Refer to Nursing Care Plan pp. 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

25
HELLP Syndrome
  • Hemolysis
  • Elevated Liver Enzymes
  • Low Platelets (lt 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.

26
Diabetes In Pregnancy Did it exist BEFORE
Pregnancy?
  • 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

27
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

28
CHO Metabolism1st 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

29
CHO Metabolism-2nd 3rd Trimester
  • Pregnancy is a diabetogenic state
  • Hormones levels lead to tolerance to
    glucose
  • ? insulin resistance
  • HPL-Human Placental Lactogen
  • Insulin antagonistWont let insulin work
  • Placental Insulinases
  • Breakdown insulin at placental site

30
Net Result Changes in Insulin Needs for Mother
during Pregnancy
  • 1st trimester need for insulin
  • ? insulin production, NV, 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

31
Risks to Mother
  • Pregestational Diab.
  • If poor control very early in PG? Miscarriage
  • Macrosomic baby?C/S
  • Pre-eclampsia
  • PTL
  • Infections (UTIs, Vag)
  • Polyhydramnios
  • Ketoacidosis / Hypogylecemia
  • Gestational-Onset
  • 2X likely to have pre-eclampsia
  • Macrosomic baby ? C/S

32
Risks to Baby
  • Pregestational
  • Congenital Defects
  • Heart, Skeletal, CNS
  • Same as Gestational
  • Gestational
  • Macrosomia?Birth Trauma
  • Hypoglycemia
  • RDS
  • Hypocalcemia
  • Hyperbilirubinemia
  • Thrombocytopenia
  • Polycythemia

33
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 2Some oral hypoglycemic agents are
    teratogenic? Insulin SQ during pregnancy

34
Management of Pre-gestational Diabetes
  • Hgn A1c
  • Good control 2.5 to 5.9
  • Fair Control 6 - 8
  • Poor Control gt 8
  • Diet VERY CAREFULLY BALANCED
  • Should be followed by Registered Dietician
  • Exercise
  • Not vigorous, Best time is after meals

35
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

36
Management of Pre-gestational Diabetes-Insulin
  • GOALkeep blood sugar in narrow margin
  • Fasting 60-90 mg/dl
  • 2-hour postprandial 90-120 mg/dl

37
Management of Pre-gestational Diabetes-Delivery
  • Careful determination of ACTUAL due date
  • Amniocentesis ?Fetal lung maturity
  • Induce 38-40 wks-NO LATER THAN 40 WKS
  • If estimated fetal weight gt 4000-4500 Gms ? C/S
  • In LD- Watch maternal glucose levels every 2
    hours

38
Gestational Diabetes-Screening
  • Low-risk
  • lt 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

39
Gestational Diabetes-Screening
  • First pre-natal visit
  • 50 gm glucose load -gt draw serum 1 hour later
  • Negative lt 140 mg/dl
  • Positive gt 140 mg/dl
  • Screen again 24-28 weeks gestation

40
Gestational Diabetes-Screening
  • If positive? do 3-hour GTT (100g of glucose)
  • Positive for GDM 2 or more levels are met or
    exceeded
  • Fasting lt 95 mg/dl
  • 1-hr lt 180 mg/dl
  • 2-hr lt 155 mg/dl
  • 3-hr lt 140 mg/dl

41
Gestational Diabetes Management
  • GOAL Keep blood sugars within levels for
    Pre-gestational diabetes
  • DietMain course of treatment 3 meals and 3
    snacks
  • Exercise
  • Insulin20 will need insulin during PG safest
  • Glyburide (oral hypyglycemic agent) is being used
    with caution but not yet approved by ACOG
  • Blood glucose monitoring
  • Frequently done in MD office or at home

42
Gestational Diabetes Management
  • Delivery
  • Frequent NST/BPP in last 2 months of pregnancy
  • Deliver by 40 weeks
  • Excellent resource link from the National
    Diabetes Education Program with handouts in
    various languages and lots of resources.
  • Another great resource with tables from Merck
    Manual

43
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 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.

44
Perinatal Infections
  • If GBS status unknownProphylactic trx is
    indicated if
  • Previous infant with GBS
  • GBS bacturia during this pregnancy
  • PTL
  • Temp in labor gt 100.4 F
  • Membranes ruptured gt 18 hours

45
Other Perinatal infections
  • Syphyllis
  • Gonorrhea
  • Chlamydia
  • TORCH p.394-400 10th ed.
  • Toxoplasmosis
  • Rubella
  • Cytomegalovirus
  • Herpes, Human B19 Parvovirus

46
Hemorrhagic Complications
  • Abortion loss of pregnancy BEFORE 20 weeks
    gestation
  • spontaneous (miscarriage) or induced
  • 10 of all pregnancies end in a miscarriage
  • Most in 1st Trimester

47
Hemorrhagic Complications
  • Types of Abortions (know the differences)
  • Threatened
  • Imminent
  • Incomplete
  • Missed
  • Habitual

48
Other Hemorrhagic Complications
  • Ectopic Pregnancy
  • Egg implants outside of uterus
  • Lots of pain and internal bleeding manifested by
    sx of shocklife-threatening
  • Surgical intervention needed
  • Link with photos
  • Hydatidiform Mole
  • No fetus, Fluid filled vesicles
  • NV, No FHTs, 2nd trimester bleedingPrune-juice
  • DC
  • Not get pregnant for 1 year
  • Choriocarcinoma, if HCG elevated

49
Gestational Trophoblastic Dz
50
Other Hemorrhagic Complications
  • Incompetent Cervix
  • Cerclage McDonalds or Shirodkar procedure
  • 10-14 weeks gestation
  • NO Intercourse, Prolonged standing, heavy lifting
  • On bedrest as much as possible
  • Teach signs of Preterm Labor
  • Take tocolytics as ordered
  • Home uterine monitoring
  • Remove suture at 37 weeks ? vaginal
  • Leave suture in ? C/Sec

51
Shirodkar Procedure for Incompetent Cervix
52
Other Complication of Pregnancy Hyperemesis
Gravidarum
  • Intractable Vomiting in Pregnancy
  • 5 loss of body weight, dehydration, ketosis,
    metabolic alkalosis,
  • Rule out Gestational Trophoblastic Dz by
    ultrasound
  • Medical Management/Nursing Care
  • If doesnt respond to small, frequent meals, then
    needs hospitalization NPO, IV fluids with KCl to
    prevent hypokalemia, B-vitamin replacement (B1
    and B6 especially)
  • If still unable to eat, may need TPN temporarily

53
There you have it! Refer to other supplement for
more detail on these complications
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