NCM lec

• High-Risk Pregnancy


  Pregnancy that taxes the circulatory system and requires close monitoring
• Cardiovascular disorders and pregnancy

  • Woman should visit pregnancy care provider for preconception care
  • Pregnancy increases blood volume and cardiac output by 30-50% by midpregnancy

  
• Left-Sided Heart Failure


  • Occurs in conditions like mitral stenosis, mitral insufficiency, and aortic coarctation
  • Leads to lower cardiac output and pulmonary hypertension
  • Causes pulmonary edema, shortness of breath, cough with blood-speckled sputum, increased respiratory rate, orthopnea, paroxysmal nocturnal dyspnea

  
• Management of Left-Sided Heart Failure

  • Anticoagulants to prevent thrombus formation
  • Antihypertensives to decrease strain on aorta and lower blood pressure
  • Diuretics
  • Beta-blockers to improve ventricular filling

  
• Right-Sided Heart Failure


  • Can be caused by unrepaired pulmonary valve stenosis
  • Leads to jugular venous distention, increased portal circulation, liver and spleen distention, peripheral edema

  
• Management of Right-Sided Heart Failure

  • Woman may be advised not to become pregnant
  • If they plan to get pregnant, expect to be hospitalized for at least some days during last part of pregnancy
  • Need extremely close monitoring after epidural anesthesia to minimize risk of hypotension

  
• Assessment of a Woman with Cardiac Disease

  1. Thorough health history to document prepregnancy cardiac status

  2. Document exercise performance level

  3. Ask about cough or edema

  4. Assess baseline vital signs and jugular vein status

  5. If right-sided heart failure, assess liver size at prenatal visits

  6. ECG or echocardiogram may be done periodically

  
• Fetal Assessment


  • Infants of women with severe heart disease tend to have low birth weights or be small for gestational age
  • This can result in preterm labor, exposing newborn to hazards of immaturity and low birth weight
• Woman with Artificial Valve Prosthesis

  • Usually placed on low-molecular-weight heparin instead of warfarin
  • Observe for signs of petechiae and premature placental separation
• Woman with Chronic Hypertensive Vascular Disease

  • Places woman and fetus at high risk due to poor perfusion
  • Management includes beta-blockers and calcium channel blockers to reduce blood pressure
• Woman with Venous Thromboembolic Disease


  • Increases during pregnancy due to blood stasis and hypercoagulability
  • Diagnosed by history and Doppler ultrasound
  • Treated with bed rest, IV then subcutaneous heparin
  • Risk can be reduced by avoiding constrictive stockings, prolonged standing
  • Signs of pulmonary embolism (chest pain, dyspnea, hemoptysis, tachycardia) are an emergency

  
• Anemia and Pregnancy


  True anemia is hemoglobin <11 g/dL in 1st/3rd trimester or <10.5 g/dL in 2nd trimester

  
• Iron-Deficiency Anemia


  • Most common anemia of pregnancy
  • Confirmed by low serum iron, high iron-binding capacity
  • Causes microcytic, hypochromic anemia with fatigue and pica
  • Treated with 27 mg iron in prenatal vitamins, high-iron diet, 120-200 mg elemental iron supplements
• Folic Acid-Deficiency Anemia


  • Occurs in multiple pregnancies, with anticonvulsants, after oral contraceptives
  • Causes megaloblastic anemia that may contribute to miscarriage or placental abruption
  • Treated with 400 ug folic acid daily and folacin-rich foods
• Sickle-Cell Anemia


  • Recessively inherited hemolytic anemia with sickle-shaped red blood cells
  • Causes vessel blockage, hemolysis, and severe anemia
  • All African American women should be screened at first prenatal visit
  • Hemoglobin 6-8 mg/100 mL normally, 5-6 mg/100 mL in crisis
  • More susceptible to bacteriuria, need folic acid, no routine iron, require hydration, oxygen, pain relief, antibiotics, hydroxyurea, and periodic transfusions

  
• Diabetes mellitus is an endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose levels

  
• Indirect bilirubin


  Increase in
• Bacteriuria


  More susceptible to
• Monitor a woman's nutritional intake (folic acid)
• Should not take a routine iron supplement
• Drink at least 8 glasses of water daily
• Assess lower extremities for varicosities
• A woman with sickle-cell anemia

  • Three primary needs: pain relief, adequate hydration, and oxygenation
• Therapeutic management for a woman with sickle-cell anemia

  1. Pain: Acetaminophen or morphine

  2. Hydration: IV replacement; electrolyte replacement for acidosis

  3. Oxygen via NC

  4. Antibiotic for an infection

  5. Hydroxyurea, an antineoplastic agent that has the potential to increase the strength and oxygenation capacity of sickled cells

  6. Periodic exchange or blood transfusions throughout pregnancy
• Diabetes mellitus


  An endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose levels
• Risk factors for diabetes mellitus in pregnancy

  • Obesity
  • Age over 25 years
  • History of large babies (10 lb or more)
  • History of unexplained fetal or perinatal loss
  • History of congenital anomalies in previous pregnancies
  • History of polycystic ovary syndrome
  • Family history of diabetes (one close relative or two distant ones)
  • Member of a population with a high risk for diabetes (Native American, Hispanic, Asian)

  
• Because diabetes is such a serious complication in pregnancy, all women should be screened during pregnancy for gestational diabetes

  
• Gestational diabetes diagnosis


  • Fasting plasma glucose greater than or equal to 126 mg/dl
  • Nonfasting plasma glucose greater than or equal to 200 mg/dl
  • Needs to be confirmed using a 100-g oral glucose challenge test
• Therapeutic management for a woman with diabetes before pregnancy

  1. Meet with physician to determine best insulin program to control hyperglycemia, esp 1st tri

  2. Measurement of glycosylated hemoglobin (upper normal level of HbA1c is 6)

  3. Urine culture per trimester

  
• Nutrition regimen during pregnancy for a woman with diabetes

  • 1,800- to 2,400-calorie diet (or one calculated at 30 kcal/ kg of ideal weight), divided into three meals and three snacks to try and keep carbohydrate evenly distributed during the day so the glucose level remains constant
  • 20% of dietary calories should be from protein, 40% to 50% from carbohydrate, up to 30% from fat
• Reduce amount of saturated fats and cholesterol and an increased amount of dietary fiber
• Extremely vulnerable to hypoglycemia at night, make her final snack of the day one of protein and a complex carbohydrate (e.g., an egg and whole grain toast, hummus and whole grain crackers)
• Later in pregnancy, she must maintain good control of glucose levels and keep her weight gain to a suitable amount (approximately 25 to 30 lb)
• Urge women, however, not to reduce their intake to below 1,800 calories during pregnancy
• Therapeutic management for a woman with gestational diabetes

  1. Started on insulin therapy if diet alone is unsuccessful in regulating glucose values

  2. Combination of short-acting (regular) insulin and intermediate action insulin, 2/3 in AM, 1/3 in PM

  3. Intermediate to short-acting insulin ratio is 2:1 given 30min before breakfast

  4. Just before dinner a ratio of 1:1

  5. Caution women to eat almost immediately after injecting these short-acting insulins to prevent hypoglycemia before mealtimes

  6. Oral hypoglycemia agents are not used for regulation during pregnancy
• Insulin adjustment


  Keep fasting blood glucose level below 95 to 100 mg/dl and a 2-hour postprandial level below 120 mg/dl
• Blood glucose monitoring for a woman with diabetes


  1. All women need to do blood glucose monitoring to determine whether hyperglycemia or hypoglycemia exists

  2. If hypoglycemia is present, drink fluid with some form of sustained carbohydrate such as a glass of milk and some crackers

  3. If hyperglycemia is present, assess urine for ketones

  4. Hypoglycemia is most common in the second and third months, before insulin resistance peaks; hyperglycemia is most common in the sixth month, when insulin resistance is becoming most pronounced

  
• Timing of birth for a woman with diabetes

  1. Vaginal birth is preferred if possible, may be induced by rupture of the membranes or an oxytocin infusion after measures to induce cervical

  2. Labor contractions and fetal heart sounds need to be consciously monitored during labor to ensure early detection of placental dysfunction

  3. Glucose level is regulated during labor by an intravenous infusion of short-acting or regular insulin with frequent blood glucose assays to prevent hypoglycemia in the mother or rebound hypoglycemia in the newborn

  4. If a woman will be given an epidural anesthetic, Ringer's lactate or 0.9% saline is infused instead of IV glucose solution

  
• Postpartum adjustments for a woman with diabetes

  1. With insulin resistance gone, often she needs no insulin during the immediate postpartum period

  2. One- or 2-hour postprandial blood glucose determinations help to regulate how much insulin she needs during this adjustment period

  3. A woman with gestational diabetes usually demonstrates normal glucose values by 24 hours after birth

  4. If hydramnios was present during pregnancy, she is at risk of hemorrhage from poor uterine contraction

  5. Women with diabetes may breastfeed because insulin is one of the few substances that does not pass into breast milk from the bloodstream

  6. Because a woman who has had gestational diabetes is at risk for developing type 2 diabetes later in life, she should have glucose testing done during health maintenance visits throughout life
• Rh incompatibility


  Occurs when an Rh-negative mother (one negative for a D antigen or one with a dd genotype) carries a fetus with an Rh-positive blood type (DD or Dd genotype)