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GESTATIONAL DIABETES MELLITUS (GDM) P.311  Any degree of glucose intolerance that has its onset or it is first diagnosed during pregnancy  Risk factors: Obesity, women w/ prior GDM, glycosuria, strong family history of DM, over 30 yrs  Symptoms may disappear a few weeks following delivery  50% of women develop DM within 5 yrs  Risks to the fetus: spontaneous abortion, infection, hydramnios, ketoacidosis, hypoglycemia, hyperglycemia (can cause macrosomia), hydramnios (can cause overdistention of uterus, premature rupture of membranes, preterm labor, hemorrhage), preeclampsia/eclampsia, polycythemia, hyperbilirubinemia, respiratory distress syndrome, neural tube effects (spina bifida)     NANDAs Altered nutrition < body requirements Risk for fetal/mother injury Risk for noncompliance w/ diabetic diet Risk for infection Treatment includes:  Restricting dietary intake of calories & carbohydrates  Educating pt on monitoring blood glucose & diet & exercise management  Educating pt on s/s of hypoglycemia & hyperglycemia w/ careful monitoring of fetus for macrosomia  3 meals & 3 snacks (one at bedtime)  Administering insulin to the client for glucose control as prescribed if needed  Client instruction on self-administration of insulin  Oral hypoglycemic are contraindicated due to possible teratogenic effects  Instruct pt to perform daily kick counts to assure fetal wellbeing  Keep 2 IV lines, one with 5% dextrose solution & one with a saline solution Notes:  Maternal insulin requirements decrease dramatically during labor  Calorie needs increase during lactation to 500-800 kcal above prepregnant requirements & insulin must be adjusted accordingly  Women should be reassessed 6 wks postpartum to determine whether her glucose levels are normal BLEEDING DISORDERS: SPONTANEOUS ABORTION (MISCARRIAGE) P.339  1st & 2nd trimesters major cause of bleeding: abortion  Abortion: expulsion of fetus prior to viability (before 20 weeks gestation, weight < 500g)> Can be spontaneous (often called miscarriage) or induced  1st half of pregnancy causes of bleeding: ectopic pregnancy & gestational trophoblastic disease  2nd half of pregnancy causes of bleeding: placenta previa & abruption placenta  Spontaneous abortions categories:  - Threatened: Unexplained bleeding, cramping & backache. Cervix closed. Bleeding may persist for days.  May be followed by partial or complete expulsion of embryo or fetus, placenta & membranes. “products of  conception”.  - Imminent/Inevitable: Bleeding & cramping increase.  Internal cervical os dilates. Membranes may rupture.  - Complete: All the products of conception are expelled. Cervix closed.  - Incomplete: Placenta is retained. Internal cervical os  dilated.  - Missed: Fetus dies is uterus but is not expelled. No bleeding or cramping occurs. Uterine growth ceases,  breast changes regress, & woman may report brown vaginal discharge. Cervix closed. Note: Spotting is relatively common during pregnancy & usually occurs following sexual intercourse or exercise because of trauma to the highly vascular cervix. However, women are advised to report any spotting or bleeding that occurs during pregnancy so that it can be evaluated Initial Assessment of bleeding: Monitor BP frequently Observe pt for behaviors indicative of shock (pallor, clammy skin, perspiration, dyspnea, restlessness) Count & weigh pads to assess amount of bleeding over a given time period; save clots/tissues expelled Assess fetal heart tones w/ Doppler if > 12 wks Prepare for IV therapy Have O2 available Collect & organize data, including antepartal history, onset of bleeding episode, laboratory studies Notify physician or nurse-midwife Obtain order to type & crossmatch for blood Assess coping mechanisms of the woman in crisis. She may feel quilty Give emotional support, explain clearly procedures, and communicate her status to family. Prepare woman for - Recurrent/Habitual: Occurs consecutively in 3 or more pregnancies - Septic: Infection is present. Malodorous discharge. possible fetal loss.  Assess family’s response to situation NANDAs  Acute pain r/t abdominal cramping secondary to threatened abortion  Anticipatory grieving r/t expected loss of unborn child       Nursing Interventions for bleeding/spontaneous abortion: Perform a pregnancy test Assist with an ultrasound Bed rest, abstinence from sex & sedation Administering analgesics is cramping is severe Administering antibiotics is septic abortion IV therapy or blood transfusions to replace fluids, & dilation & curettage (D&C) or suction evacuation (D&E) is performed to remove remainder of the products of conception.  If woman is Rh- & not sensitized, RhoGAM is given within 72 hrs  Give oxytocin (Pitocin) as prescribed to expulse products of conception ECTOPIC PREGNANCY P.340  Implantation of fertilized ovum in a site other than endometrial lining of the uterus  Occurs when the fertilized ovum is prevented or slowed in its passage through the tube & thus implants before it reaches the uterus, usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage  Risk factors: PID, contraceptive IUD, congenital anomalies of tube, endometriosis, previous tubal surgery  Initially symptoms of pregnancy  hCG present in blood & urine  Chorionic villi grow into the tube wall or implantation site  Rupture & bleeding into abdominal wall occurs  S/S: sharp unilateral pain, syncope, referred shoulder pain, lower abdominal pain, vaginal bleeding, adnexal tenderness. NANDAs  Acute pain  Anticipatory grieving        Nursing Interventions: Take VS, check skin color & urine output Determine level of pain Monitor for signs of shock Methotrexate injection IM to inhibit cell division & enlargement of the embryo. Prevents rupture of fallopian tube in order to preserve it if future pregnancy is desired Replacement of fluid loss & maintenance of electrolyte imbalances Provide pt education & psychological support Prepare client for surgery & postoperative nursing care Salpingostomy: via laparoscope. Incision made lengthwise & the products of conception are gently removed. Surgical incision is left open & allowed to close naturally. Possible before rupture. Salpingectomy (removal of the tube): via laparoscope. If the tube is ruptured or if future childbearing is not an issue. Note: Rh- women nonsensitized women are given Rhimmune globulin to prevent sensitization GESTATIONAL TROPHOBLASTIC DISEASE / HYDATIDIFORM MOLE P. 342  Pathologic proliferation of the trophoblastic cells  It includes hydatidiform mole, invasive mole (chorioadenmoma destruens) & choriocarcinoma (form of cancer) Procedures:  Ultrasound  Suction curettage to aspirate & evacuate the mole  Follow up hCG for 1 year (^hCG may indicate choriocarcinoma)  Chemotherapy if choriocarcinoma (Methotrexate) Hydatidiform mole (molar pregnancy) is a disease in which: - Abnormal developments of the placenta occurs resulting in Nursing Interventions: hydropic vesicles (fluid-filled, grapelike cluster)  Monitor for s/s of trophoblastic disease: rapid uterine growth, - Trophoblastic tissue proliferates vaginal bleeding accompanied by discharge, excessive  Molar pregnancies are classified in: - Complete: develops from an ovum containing no maternal genetic material, an “empty egg”, which is fertilized by a normal sperm - Partial: A normal ovum w/ 23 chromosomes is fertilized by two sperm or by a sperm that failed to undergo under the first meiotic division & therefore contains 46 chromosomes  S/S: vaginal bleeding, elevated serum hCG, anemia, no fetal heart tones & no fetal movement, gestational HTN before 24 wks, uterine enlargement        vomiting (hyperemesis gravidarum) due to excessive hCG levels, symptoms of pregnancy-induced hypertension (HTN, edema, proteinuria) Measurement of fundal height Check VS Type cross & match Administer oxytocin as ordered to keep uterus contracted & prevent hemorrhage Advise pt to avoid pregnancy for 1 year Give immune globulin (RhoGAM) to any Rh- woman Give emotional support, explain procedures NANDAs  Fear r/t possible development of choriocarcinoma  Anticipatory grieving r/t loss of the pregnancy ABRUPTIO PLACENTAE P. 513  Premature separation of a normally implanted placenta from the uterine wall  Considered catastrophic event because of the severity of the resulting hemorrhage Marginal: placenta separates at its edges, the blood passes between the fetal membranes & the uterine wall, blood escapes vaginally Central: placenta separates centrally, blood trapped between placenta & uterine wall. Concealed bleeding Complete: Total separation of placenta. Massive vaginal bleeding Management:  Place client on bed rest  Refrain from vaginal exams (may exacerbate bleeding)  Assess cardiovascular status of mother frequently - VS every 15 min, skin color & pulse quality hourly, measure CVP hourly as ordered  Monitor fetus & uterine activity electronically – resting tone& fetal status every 15 min  Develop a plan for the birth of the fetus (prepare for cesarean as needed) – if fetus is at term, vaginal delivery is preferred.  Monitor for signs of DIC  Maintain 2 large bore IV sites – fluids & blood products as ordered S/S: sudden onset of intense localized uterine pain, vaginal bleeding, board-like abdomen that is tender, fetal distress  Monitor I & O & urine Specific Gravity  Measure abdominal girth as ordered Maternal Implications: intrapartum hemorrhage, DIC, hypofibrinogenemia (coagulation factors decreased), fatal  Review & evaluate diagnostic tests – Hgb, Hct, coagulation status hemorrhagic shock, renal failure, vascular spasm,  Neonatal resuscitation as ordered intravascular clotting  Provide information & emotional support Fetal-Neonatal Implications: sequelae of prematurity, hypoxia, anemia, brain damage, fetal demise PLACENTA PREVIA P. 516  Placenta is abnormally implanted in the lower uterine segment rather than the upper portion of the uterus.  This implantation may be on a portion of the lower segment or over the internal cervical os Total – internal os completely covered Partial – internal os is partially covered Marginal – edge of os is covered Low-lying placenta – implanted in lower segment in proximity to os  Major complications: maternal hemorrhage, fetal prematurity, death S/S: painless, bright-red vaginal bleeding          Interventions: Bed rest with bathroom privileges as long as the woman is not bleeding NO VAGINAL EXAMINATIONS Monitor blood loss, pain, uterine contractility Evaluating FHR with an external fetal monitor Monitoring maternal vital signs every 5 min during active hemorrhage & every 15 min in the absence of hemorrhage Give O2 as ordered/needed Complete laboratory evaluation – Hgb, Hct, Rh factor, urinalysis Maintain large bore IV access for blood transfusion IV fluids (lactated Ringer’s solution) NANDAs  Fluid volume deficit  Anxiety  Impaired gas exchange  2 U of crossmatched blood available for transfusion  Provide information & emotional support  Verify family’s ability to cope with anxiety of unknown outcome INCOMPETENT CERVIX P. 343 Nursing Interventions:  Bed rest, hydration (to promote relaxed uterus & inhibit uterine contractions), antibiotics, anti-inflammatory, progesterone supplement  Monitor/Teach for premature labor & premature rupture of membranes& to notify healthcare provider  VS  Measure of s/s of incompetent cervix  Pelvic pressure  Assess vaginal discharge – pink stained bleeding Surgical Procedures:  Shirodkar procedure (cerclage) or a modification of it by  Uterine contractions, ROM, infection McDonald: reinforces the weakened cervix by encircling  Educate client to refrain from sex, heavy lifting & prolonged standing it at the level of the internal os w/ suture material. Purse Administer tocolytics prophylactically to inhibit uterine string suture placed in cervix. Once suture is placed, a contractions cesarean birth may be planned (to prevent repeating procedure in future pregnancies) or the suture may be cut at term & vaginal birth permitted  Premature dilatation of the cervix, usually in the 4th or 5th month  Associated w/ repeated 2nd trimester abortions  Causes: cervical trauma, infection, congenital cervical/uterine anomalies, ^uterine volume (as in multiple gestation)  Diagnosis: based on positive history of repeated painless/bloodless 2nd trimester abortions HYPEREMESIS GRAVIDARUM P. 344     Excessive nausea & vomiting during pregnancy Rare, cause unclear  ^ levels of hCG may play a role  Severe cases cause dehydration, F & E imbalances,  alkalosis, metabolic acidosis if untreated, severe K+ loss,  decreased urinary output, hypovolemia, hypotension,  tachycardia, ^ Hct & BUN, liver dysfunction (enzymes  elevated)  S/S: excessive vomiting for prolonged periods, dehydration, weight loss, decreased BP, increased pulse,   poor skin turgor  Interventions: NPO until dehydration corrected (48 hrs) IV fluids to correct dehydration & F & E imbalance (KCl) Administer antiemetics as prescribed Improve nutritional status: Vitamin B6 & B12 & TPN (if no improvement) Advance to clear liquids when vomiting stops Advance diet as tolerated with frequent, small meals, avoid greasy & highly seasoned foods, increase intake of K & Mg Stress-reduction techniques, relaxed environment Maintain oral hygiene Monitoring weight NANDAS  Imbalanced nutrition < body requirements  Fear PREMATURE RUPTURE OF MEMBRANES (PROM) P.345  PROM Spontaneous rupture of the membranes prior to the Interventions:  Start antibiotic therapy immediately if maternal signs of onset of labor  PPROM (Preterm premature rupture of membranes: is the infection are evident rupture of membranes occurring after 20 wks but before  On admission to nursery, newborn is assessed for sepsis & 37 wks of gestation placed on antibiotics         Infection is the major risk of PROM & PPROM for both the client & fetus because once the amniotic membranes have ruptured, micro-organisms can ascend from the vagina into the amniotic sac Associated with: infection, previous history of PROM, hydramnios, multiple pregnancy, UTI, amniocentesis, placenta previa, abruption placentae, trauma, incompetent cervix, bleeding during pregnancy, anomalies Risk for abruption placenta Maternal risk of infection ^ Fetal-Newborn risk: respiratory distress syndrome, fetal sepsis, malpresentation & prolapsed of umbilical cord Diagnosis Sterile speculum to detect amniotic fluid in vagina Nitrazine paper – turns blue Microscopic examination – Ferning Test DON’T DO Digital vaginal examination - increases risk of infection  Management of PROM in the absence of infection & gestation < 37 wks is usually conservative: hospitalization, bed rest, CBC, C-reactive protein & urinalysis, continuous electronic fetal monitoring, regular NST or biophysical profiles, VS every 4 hrs, regular laboratory evaluations, vaginal examination avoided, fetal lung maturity studies, administration of surfactant, administration of maternal corticosteroids Note: maternal corticosteroid administration to promote fetal lung maturity & prevent respiratory distress syndrome remains controversial  If patient discharged, give instructions: To continue bed rest w/bathroom privileges, monitor temperature & pulse every 4 hrs, keep fetal movement chart, have weekly NST, abstain from intercourse; & to call physician & return to hospital if she has fever/uterine tenderness or contractions/ increased leakage of fluids/decreased fetal movement/foul-smelling vaginal discharge PRETERM LABOR (PTL) P.347  Labor that occurs 20-37 wks gestation  Risk factors: UTI or vaginal infections, previous preterm birth, multifetal pregnancy, hydramnios (excessive amniotic fluid), age <17 or >35, low socioeconomic status, smoking, substance abuse, domestic violence, history of multiple miscarriages/abortions, DM, HTN, incompetent cervix, placenta previa, abruption placentae, uterine abnormalities, etc….. Indications of PTL:  Documented uterine contractions: 4 in 20 min or 8 in 1 hr  Documented cervical change: dilatation > 1cm  Cervical effacement of 80% or more Fetal-neonatal implications:  Morbidity & mortality (Respiratory distress syndrome)  Increased risk of trauma during birth  Maturational deficiencies Selfcare Measures to prevent PTL: rest 2-3 times a day on left side, drink water & juice fruit, avoid caffeine drinks, avoid lifting, contact healthcare provider if s/s of PTL, sexual activity may need to be modified/ avoided. Interventions:  Assessment of cervicovaginal fibronectin ( protein of amniotic fluid found in vaginal secretions when fetal membrane is lost)  Assessment of cervical length via ultrasound (if shorter than expected, positive signs of PTL)  Assess signs of vaginal infection  Obtain history of previous preterm birth  Assess laboratory studies (CBC, C-reactive protein, vaginal cultures, urine cultures)  Mother is asked to lie on her side to ^ profusion  IV infusion to promote maternal hydration  Tocolysis: medications used in an attempt to stop labor (Badrenergic agonists, Mg Sulfate, prostaglandin synthetase inhibitors, Ca channel blockers  Identify woman at risk  Assess progress of labor  Teach mother to recognize onset of labor (low backache, pressure in pelvis & cramping; increase/change/or blood vaginal discharge; regular uterine contractions with a frequency of every 10 min lasting 1 hr or longer, GI cramping sometimes w/ diarrhea, premature rupture of membranes) Management of a client who is in preterm labor includes focusing on stopping uterine contractions by restricting activity, ensuring hydration, identifying & treating an infection, administering tocolytic medications, & assuring fetal well-being by accelerating fetal lung maturity with glucocorticoids HYPERTENSION IN PREGNANCY, PREECLAMPSIA & ECLAMPSIA P. 352 Management:  BP begins to rise after 20 weeks of gestation  Decreased level of vasodilators & increase level of  Home care of Mild preeclampsia: Woman monitors her BP, vasoconstrictors weight, urine protein daily. Remote NSTs performed daily or  Preeclampsia is the most common hypertensive disorder biweekly. Advise to report any changes.  Hospital care of mild preeclampsia: Bed rest primarily on in pregnancy. It is defined as gestational hypertension with a BP of 140/90 (mild) or 160/110 (severe) or higher left side to decrease pressure on vena cava, moderate-high on 2 occasions at least 6 hrs apart accompanied by protein diet. proteinuria (5g in a 24 hr urine collection) & edema. Tests to evaluate fetus status: Dipstick urine protein 31-41 in 2 random samples Fetal movement record Nonstress test obtained 4 hrs apart. It most often occurs in the last 10 Ultrasonography every 3-4 wks for serial wks of gestation, during labor, or in the first 48 hrs after determination of growth childbirth. Most common in women < 17 yrs or > 35. Biophysical profile  Eclampsia is the most severe form of preeclampsia, Serum Creatinine characterized by generalized seizures or coma. May Amniocentesis to determine fetal lung maturity occur antepartum, intrapartum or postpartum  Severe preeclampsia: Birth may be treatment of choice for both mother & fetus, even if fetus is immature. Other Maternal Risks: Hyperreflexia, headache, seizures, renal include: bed rest, diet (high protein, moderate Na+), failure, abruption placentae, DIC, ruptured liver, PE, HELLP anticonvulsants (Mg Sulfate treatment of choice), F & E syndrome replacement, corticosteroids, antihypertensives Fetal-Neonatal Risks: Small for gestational age, premature,  Eclampsia: An eclamptic seizure requires immediate, Hypermagnesemia (Mg Sulfate administration to mother), effective treatment. Bolus of 4-6 g Mg Sulfate is given IV increased morbidity & mortality over 5 min. Sedatives (Diazepam), Dilantin (for prevention), Diuretics (Lasix) for pulmonary edema, Digitalis (for Assessment: circulatory failure). I & O monitored hourly. Woman is  BP every 1-4 hrs, Temperature every 4 hrs, pulse & observed for signs of labor & vaginal bleeding & abdominal respirations rigidity which may indicate abruption placentae. While she  Fetal heart rate is comatose, she is positioned on her left side / the side rails  Urinary output: 700 mL or greater in 24 hrs, or at least 30 up. mL/hr Intrapartal Management: Labor inducement with IV  Urine protein: 3+ or 4+ indicates loss of 5g or more of oxytocin if evidence of fetal maturity & cervical readiness. protein in 24 hrs Assessment for signs of worsening preeclampsia. Analgesics  Urine specific gravity hourly may be used for discomfort or epidural block. O2 is  Weight: weigh the woman daily at the same time, she administered. should be wearing the same robe or gown & slippers Postpartal Management: Woman with preeclampsia  Pulmonary edema: observe for coughing, auscultate lungs usually improves rapidly after giving birth, although seizures for moist respirations can still occur during first 48 hrs postpartum. If hypertension  Deep tendon reflexes & clonus: for signs of hyperreflexia is severe, woman may continue to receive antihypertensives  Placental separation: for vaginal bleeding & uterine rigidity or Mg sulfate.  Headache  Visual disturbances: blurring or any changes Extra interventions:  Epigastric pain  Explain medical therapy & its purpose & offer honest  Laboratory blood tests information  Level of consciousness, emotional response & level of  Maintain quiet, low-stimulus environment understanding  Avoid unlimited phone calls  Assess for Mg sulfate toxicity: if suspected, immediately  Keep woman on left side as much as possible discontinue infusion & administer calcium gluconate  Explain to family the reason of the seizures HELLP SYNDROME P. 352 H – hemolysis (anemia & jaundice) Management: EL – elevated liver enzymes (epigastric pain, nausea, vomiting, flu-like symptoms)) LP – low platelet count(thrombocytopenia, abnormal bleeding or clotting time, bleeding gums, petechiae, DIC)     BP measurements Platelet transfusions if <20,000/mm3. Assess fetus using NST & biophysical profile Observe for edema  Sometimes associated with severe preeclampsia  Variant of gestational hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction  Increased risk for: placenta abruption, acute renal failure, pulmonary edema, hepatic hematoma, ruptured liver, DIC, PE, fetal/maternal death Rh ALLOMMUNIZATION P. 361  Sensitization  Most often occurs when an Rh- woman carries an Rh+ fetus either to term or to termination by miscarriage or induced abortion  It can also occurs if an Rh- woman receives an Rh+ blood transfusion  RBCs from fetus invade the maternal circulation, thereby stimulating the production of Rh antibodies.  Because this transfer occurs at birth, first child is not affected  In subsequent pregnancies, however, Rh antibodies cross the placenta & enter the fetal circulation, causing severe hemolysis  Destruction of fetal RBCs cause anemia in the fetus Fetal-Neonatal risks: anemia, hemolytic syndrome (erhythroblastosis fetalis), fetal edema (hydrops fetalis), CHF, marked jaundice Screening for Rh Incompatibiliy & Sensitization:  Take a history of previous sensitization, abortions, blood transfusions, or children who developed jaundice or anemia during the newborn period  Identify Rh- woman by asking if she knows her blood type & Rh factor.  Ask if she had ever received Rh immune globulin, if she has any previous pregnancies & their outcomes, & if she knows her partner’s Rh factor  Identify other medical complications such as diabetes, infections or hypertension  Antibody screen (Indirect Coombs’ test done on the mother’s Note: Rh immune globulin (RhoGAM) administration blood to measure # of Rh+ antibodies & Direct Coomb’s prevents maternal sensitization. It provides passive test done on the infant’s blood to detect antibody-coated antibody protection against Rh antigens. This “tricks” the Rh+ RBCs) body, which does not then produce antibodies of its own.  Give injection of 300 mcg Rh immune globulin to pregnant An Rh- mother who has no antibody titer (indirect Coomb’s Rh- women who have no antibody titer, at 28wks test negative, nonsensitized) & has given birth to an Rh+ gestational age, to mothers whose baby’s father is Rh+, fetus (Direct Coomb’s test negative) is given an injection after each abortion & within 72 hrs postpartum, of Rh immune globulin within 72 hrs of childbirth so she amniocentesis & placenta previa, before invasive does not have time to produce antibodies to fetal cells that procedures that may cause bleeding entered her bloodstream when the placenta separated ABO INCOMPATIBILITY P.364 Management:  Type O mother incompatibility with a type A,B, or AB fetus  Anti-A & Anti-B antibodies occurs naturally because  Assess for potential for ABO incompatibility – type O mother & women are naturally exposed to the A & B antigens type A or B father  Following birth, assess newborn carefully for development of through the foods they eat & through exposure to infection. hyperbilirubinemia & treat it with phototherapy  Once they become pregnant, the maternal serum Anti-A & Anti-B antibodies cross the placenta & produce hemolysis of the fetal RBCs  Unlike Rh incompatibility, 1st infant is often involved  Antepartal treatment is never warranted