Maternal Health care-clinical

High risk pregnancy:

Gestational diabetes mellitus and gestational hypertension

: Students

Rashed Al-shawabkeh

Rahaf faza'a

Mohammed Al-najjar

Gestational hypertension
The Outline:

1. Prevalence of preeclampsia in Jordan

2. Definition of hypertension in pregnancy
3. classification of hypertension in pregnancy
4. Pathophysiology of gestational hypertension
5. Signs and symptoms for gestational hypertension
6. risk factor
7. physical findings
8. Maternal and infant-neonatal risk
9. Precaution of gestational hypertension
10. Reference

Hypertension in pregnancy
A recent study in 2018 shows that the overall incidence rate of preeclampsia among
Jordanian pregnant women was 1.3%. The risk of preeclampsia was 2.3 times higher
in first pregnancies than that in second or more pregnancies. The rates of low birth
weight (LBW) delivery (32.5% vs. 8.3%), and prematurity (30.8% vs. 7%), and the
neonatal mortality rate (81 vs. 12 per 1000 live births) were significantly higher
among women with preeclampsia.

Definition

Mean increase blood pressure during pregnancy and is one of the most
common problems during pregnancy.

There are 4 classification of Hypertension in pregnancy :

1. Preeclampsia: is increase in blood pressure after the 20 week of pregnancy.

Preeclampsia includes signs of damage to some of organs, such as liver or
kidney. The signs may include protein in the urine and very high blood
pressure. Preeclampsia can be serious for both you and your baby. Can occur
in antepartum, intrapartum, or postpartum period.

Eclampsia: is preeclampsia with seizures

2. chronic hypertension: is high blood pressure that started before the 20 week
of pregnancy or diagnosed for the first time during pregnancy without the
typical resolution in the postpartum period.
3. Chronic Hypertension with Superimposed Preeclampsia: Means the
pregnant women with chronic hypertension develops preeclampsia or
eclampsia
4. gestational hypertension: also referred to as Pregnancy-Induced
Hypertension (PIH) is high blood pressure that you develop while you are
pregnant. It starts after you are 20 weeks pregnant. It is not found protein in
the urine. Elevated BP is a systolic BP of 140 mm Hg more or a diastolic BP
of 90 mm Hg or more, or both, on two separate readings 4 hours apart.Some
women with gestational hypertension do go on to develop preeclampsia.If
preeclampsia does not develop and blood pressure returns to normal by 12
 weeks’ postpartum, the diagnosis of gestational hypertension may be assigned.
If the blood pressure elevation persists after 12 weeks postpartum, the woman
is diagnosed with chronic hypertension.

Pathophysiology

The Pathophysiology of gestational hypertension is unknown, suggested mechanisms

include:

failure of maternal uterine spiral arteries to undergo remodeling in the first trimester,
release of factors affecting maternal vascular endothelial function, systemic
vasospasm, leukocyte activation, coagulation system activation, alteration in
cytokines lead to increase in blood pressure during pregnancy.

Signs and symptoms for gestational hypertension

● edema, especially of hands and face

● Visual changes, including photopsia (seeing flashing lights), scotomata (blind
spot or spots), photophobia (intolerance to light)
● headache
● eclampsia
● epigastric or right upper quadrant abdominal pain
● nausea and vomiting
● dyspnea, activity intolerance, chest pain, orthopnea.

Risk factors:

Risk factors for preeclampsia and eclampsia:

● nulliparity or pregnancy with a new partner

● pre-existing medical conditions, such as chronic hypertension, diabetes,
collagen vascular disease, renal disease, or thrombophilia
● multiple gestation
● history of previous pregnancy with preeclampsia, especially with onset < 34
weeks gestation
● high body mass index
● maternal age over 40 years.

risk factors for chronic hypertension:

● family history
● obesity
● Black race (in this population, hypertension is more common, tends to occur at
a younger age, is more severe, and is more likely to involve damage to target
organs)
● diabetes mellitus.

Physical findings
 ● Elevated BP
● Proteinuria
● Edema
● Sudden weight gain (more than 4 lb [1.8 kg] in 1 week)
● Hyperreflexia
● Clonus
● Altered mental status
● Seizure (generalized tonic-clonic)

**If seizure occurred before arrival at the hospital, patient may be in a postictal state
with confusion, fatigue or exhaustion, and difficulty following conversation; she may
also have had urinary incontinence, trauma to the tongue or inside of the mouth, or
other trauma related to seizure activity

● Tachypnea
● Anxiety
● Wheezes
● Crackles

Maternal risk

● Progression to preeclampsia and eclampsia

● Pulmonary edema
● Hypertensive crisis
● Seizures
● Stroke
● Retinal detachment
● Abruptio placentae
● Thrombocytopenia
● HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which
happens when a woman with preeclampsia or eclampsia has damage to the
liver and blood cells. It is rare, but very serious.
● Disseminated intravascular coagulation (DIC)
● Subcapsular hematoma
● Periportal necrosis
● Acute renal failure
● Preterm labor/delivery
● Intrauterine growth restriction (IUGR)
● Preterm birth, both spontaneous and due to maternal/fetal indications Fetal
intolerance to labor
● Intrauterine fetal demise
● Increased risk for cardiovascular and metabolic disease in later life
● Increased risk for cardiovascular disease and obesity in offspring.

Fetal-neonatal risk

Gestational hypertension is a most cause of placental insufficiency and premature

birth. Infants of women with hypertension during pregnancy tend to be small for
gestational age (SGA) because of intrauterine growth restriction.
The cause is related specifically to maternal vasospasm and hypovolemia, which
result in fetal hypoxia and malnutrition. Placental abruption secondary to
hypertension may result in fetal hypoxia or even death. In addition, the newborn may
be premature because the treatment for the maternal condition may require early
childbirth.

At birth, the newborn may be overstated because of medications administered to the

woman. The newborn may also have hypermagnesemia caused by treatment of the
woman with large doses of magnesium sulfate.

Precaution of gestational hypertension

● Use salt as needed for taste

● Drink at least 8 glasses of water a day
● Increase the amount of protein you take in, and decrease the number of fried
foods and junk food you eat.
● Get enough rest.
● Exercise regularly.
● Elevate your feet several times during the day.
● Avoid drinking alcohol.
● Avoid beverages containing caffeine.

Reference

1. https://www.tandfonline.com/doi/abs/10.1080/14767058.2017.1297411
2. https://advisor.lww.com/lna/turnaway.do
3. Davidson, M, London. M, Ladewig, P (2017). Olds' Maternal-‐Newborn
Nursing & Women's Health across the Lifespan, 9th ED (international
edition), Prentice Hall

GESTATIONAL DIABETES

The Outline:

1. Prevalence of gestational diabetes in Jordan

2. Definition of gestational diabetes

3. Pathophysiology of gestational diabetes

4. Causes of gestational diabetes

5. Signs and symptoms for gestational diabetes

6. risk factors

7. Maternal and fetal-neonatal risk

8. Precaution of gestational diabetes

9. Reference

GESTATIONAL DIABETES MELLITUS

A recent study in 2018 shows that the overall prevalence 13.5% of the woman with
gestational diabetes. Found that the risk for GDM increased significantly with an
increase of maternal age, increase of the gravidity.

The prevalence of GDM seems quite high in Jordan, which is a trend observed in the
majority of countries worldwide, as mothers are getting older with the rising
incidence of obesity and other risk factors. Given that women with diabetes are
unaware of their condition, all pregnant women should be offered OGTT and
encouraged to do it at the proper time.

Definition

is defined as carbohydrate intolerance lead to high blood sugar levels during

pregnancy. The blood sugar levels were normal before got pregnant.

Pathophysiology of Diabetes Mellitus

One main aspect of the underlying pathology is insulin resistance, where the body’s
cells fail to respond to the hormone insulin in the usual way. The placental secretion
of human placental lactogen (hPL) and prolactin (from the decidua), as well as
elevated levels of cortisol (an adrenal hormone) and glycogen, cause increased
maternal peripheral resistance to insulin.

In the presence of insulin resistance, this uptake of blood glucose is prevented and
the blood sugar level remains high. The body then compensates by producing more
insulin to overcome the resistance and in gestational diabetes, the insulin production
can be up to 1.5 or 2 times that seen in a normal pregnancy.

Causes

1. unidentified preexistent disease

2. the unmasking of a compensated metabolic abnormality by the added stress of

pregnancy

3. a direct consequence of the altered maternal metabolism stemming from

changing hormonal levels.
Symptoms of Gestational Diabetes

● Feeling more thirsty with dry mouth

● Feeling more hungry and eating more

● Frequent urination

● Recurrent infections including thrush or yeast infection

● Weakness

● Blurred vision

Risk factors

● overweight before she got pregnant

● African-American, Asian, Hispanic, or Native American

● Have high blood sugar levels, but not high enough to be diabetes

● family history of diabetes

● Have had gestational diabetes before

● Have high blood pressure or other medical complications

● Have given birth to a large baby before (greater than 9 pounds)

● Have given birth to a baby that was stillborn or had certain birth defects

● Are older than 25

Maternal Risks

1- Hydramnios, or an elevated in the volume of amniotic fluid as a result of excessive

fetal urination because of fetal hyperglycemia.

2- ketoacidosis, because hyperglycemia due to insufficient amounts of insulin can

lead to increase in ketone bodies in the blood.

3- difficult labor (dystocia), caused by fetopelvic disproportion if fetal macrosomia

exists.

4- increased risk for recurrent monilial vaginitis and urinary tract infections because
of increased glycosuria, which contributes to a favorable environment for bacterial
growth.

5- pyelonephritis -if untreated asymptomatic bacteriuria- a serious kidney infection.

6- Diabetes in a future pregnancy

7-Diabetes later in life

** To prevent future diabetes or gestational diabetes, get tested for diabetes 6 to 12

weeks after give birth and every 1 to 3 years after.

Fetal-Neonatal Risks

*congenital anomalies as a result of severe maternal ketoacidosis that cause fetal

enzyme systems cease functioning in an acidic environment.

The anomalies often involve :

● the heart anomalies : Septal defects, coarctation of the aorta

● central nervous system (CNS): hydrocephalus, meningomyelocele, and

anencephaly.

● skeletal system: sacral agenesis, the sacrum and lumbar spine fail to develop
and the lower extremities develop incompletely.

● macrosomia: excessive growth

● Respiratory distress syndrome

● Polycythemia

● Hyperbilirubinemia is a result of the inability of immature liver enzymes to

metabolize the increased bilirubin resulting from the polycythemia.

● Hypocalcemia, characterized by signs of irritability or even tetany, may occur.

Precaution of gestational diabetes

● Eat healthy, low-sugar diet

● Lose excess weight before you get pregnant

● Exercise throughout pregnancy

● Get appropriate prenatal care

Reference

1- https://www.researchgate.net/publication/324581901_Prevalence_of_gestation
al_diabetes_and_contributing_factors_among_pregnant_Jordanian_women_att
ending_Jordan_University_Hospital
2- Davidson, M, London. M, Ladewig, P (2017). Olds' Maternal-‐Newborn
Nursing & Women's Health across the Lifespan, 9th ED (international
edition), Prentice Hall
 -

Purpose: To provide pregnant women with information necessary for high risk pregnancy
Goal: The mother will be able to know about high risk pregnancy
objectives Content Method of Time recourses Method name
outline instruction allotted( of
in min.) evaluation
Following a 40-minute
teaching session, the well
be able to:
1- Repeat signs and Sign and
symptoms of symptoms of Discussion 3 min Written Post-test Rahaf
gestational gestational handout
hypertension(cognitive) hypertension

2- To know risk factors of Risk factor Discussio

gestational n 3 min Written Post-test Rahaf
hypertension(cognitive) handout

3- To know maternal and Maternal and

fetal risks(cognitive) fetal – Discussion 8min Written Post-test Rahaf
neonatal risks handout

4- Alter her cognitive

about her nutrition by
increase the amount of Precaution of
protein take in, gestational Discussion 5 min Written Post-test Rahaf
decrease the number hypertension handout
of fried foods and junk
food you eat and
decrease salt in diet
(feeling)

5- Repeat sign and Sign and Post-test

symptoms of symptoms of Discussion 4min Written Mohammed
gestational diabetes gestational handout
(cognitive) diabetes and
images

6- To know risk factor of Risk factor Discussion 4min

gestational Written Post-test Mohammed
diabetes(cognitive) handout

7- To know maternal and Maternal and

fetal risks(cognitive) fatal- neonatal Discussion 8min
risls Videos Post-test
8- To design schedule of and Rashed
diet to prevent Precaution of images
diabetes during gestational
pregnancy diabetes Discussion 5min Written
(psychomotor) handout Post-test
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images

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Video
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