OB High risk conditions in the Antepartum Period

Hemodynamic changes of pregnancy increase the workload of the heart; cardiac output increases 30-50% by mid-pregnancy

A compromised heart may not be able to adapt to the added requirements of pregnancy

• Class I: No limitation of activity
• Class II: Slight limitation of activity
• Class III: Considerable limitation of activity
• Class IV: Symptoms present even at rest

• Edema
• Anemia
• Hypertension
• Murmers/Palpitation
• Diaphoresis
• Chest pain
•       Rest vs Exertion
• Cough --> best indicator heart is in trouble!!!
• Pallor
• Syncope
• SOB
• Stress/Anxiety
• Family Obligations
• Support Systems

• Progressive generalized edema
• Crackles at the bases of lungs
• Pulse irregularity

Congestive heart failure (CHF)

EKG and FHR monitoring

Oxygen by mask; pulse oximetry

Pain management to reduce stress/decrease HR

No intense pushing to prevent a vagal response

No stirrups. Why?

Forceps/vacuum usually required

C/S only in OB emergency

Avoid fluid overload

No ergot meds such as methergine as it increases blood pressure

Prevent endocarditis

Cardiac monitoring X 48 hours

IV fluid bolus --> 1-2 L

YES

Anticoagulants

Heparin.

Heparin doesn't cross the placenta

Antibiotics

ischemic cardiac disease and myocardial infarction

Cultural background affects the amount of support

Role expectations

• Pregnancy created resistance to insulin in maternal cells
• Why? --> to ensure fetus has enough glucose for growth and development
• If pancreas cannot produce enough insulin to compensate, then maternal hyperglycemia or gestational diabetes occurs

Glucose crosses placenta to fetus

High levels of maternal glucose stimulate fetal insulin production

@ Birth, glucose supply from mom ends suddenly.. but baby is still producing high levels of own insulin

High levels of fetal insulin and low levels of glucose CAN cause hypoglycemia in the neonate at birth

• Family history of diabetes mellitus
• Glucosuria on two successive occasions
• Obesity (>200 lbs)
• Multiparity
• Hypertension

• AT risk --> 1st visit
• All women --> 24-28 wks

Urine screen for sugar and ketosis at every prenatal visit

Urine screen is not as reliable as blood

Patient drinks 50 g oral glucose (glucola)

Blood glucose level drawn one hour later

Fasting not required

If result is >140 mg/dL this constitutes positive screen

Pt. then must have a 3-Hour Glucose Tolerance Test

Administered following a 3-day high carb diet and an 8-hour overnight fast

A baseline fasting blood glucose level drawn

Patient drinks 100 g oral glucose

Blood glucose levels then drawn at 1,2, and 3 hours

If two or more values are elevated, the patient is diagnosed with gestational diabetes

Fasting --> 95 mg/dL or higher

1 hours --> 180 mg/dL or higher

2 hours --> 155 mg/dL or higher

3 hours --> 140 mg/dL or higher

60-90 mg/dL

prevent hypoglycemia later for infant

Infection

Spontaneous abortion

Preterm or early labor

Macrosomia/newborn shoulder dystocia

Neonatal hypoglycemia

Fetal congential abnormalities

C-Section, forceps, vaccum assisted delivery

Most oral hypoglycemics are teratogenic in nature

Insulin does not cross the placenta --> will prescribe if needed

In most cases, diet and exercise will control gestational diabetes

Large for Gestational Age

• Over 9lbs
• >4000 g

Small for gestational age

• Less than 5 lbs
• <2500 g

• LGA
• SGA
• Infant of Diabetic Mom
• Symptomatic
• Preemies

Insulin need is reduced because of increased insulin production by pancreas

Insulin need increases as placental hormones such as hPL act as insulin antagonists, decreasing insulin’s effectiveness

Changing insulin needs during pregnancy

Insulin needs may double or even quadruple but usually level off at 36 weeks gestation

Insulin requirements drastically decrease

Mothers use glucose for breastfeeding; maintain lower insulin requirements

Insulin needs of non-breastfeeding mothers return to pre-pregnancy levels in 7-10 days

• Weaning of breastfeeding infant causes mother’s insulin needs to return to
• pre-pregnancy levels

Accu-checks: usually 3 performed in the immediate transitional period

Why? Performed to rule out hypoglycemia in the neonate

Normal level: 40-80 mg/dL

• If <40 mg/dL; infant is fed immediately. If rechecked and still <40, IV glucose initiated
• with a doctor’s order

Older moms

Occurs more commonly among hispanic, Native american, Asian, and African American populations

developing diabetes mellitus

Pregnancy-induced hypertension

Hypertension in pregnancy with proteinuria or edema or both

Convulsion in a person with preeclampsia

Severe PIH involving

• Hemolysis
• Elevated liver enzymes
• Low Platlets

1) Hypertension

2) Proteinuria

3) Generalized edema

Note: New evidence/literature suggests that edema should no longer be considered a cardinal symptom of preeclampsia since edema is so common in the pregnant patient

Factors affecting the peripheral resistance that do not allow normal vasodialation

Thomboxane: powerful vasoconstrictor that stimulates platelet affregation

Prostacyclin: Powerful vasodialator & inhibitor of platelet aggregation

• When there is an imbalance:
•        Progressive vasoconstriction --> thomboxane
•        Leads to hypertension, reduced circulation
•        to placenta and cardiovascular system

• B/P >140/90
• Protien
•      Trace to 2+ or 300 mg/24 hrs
• Mild edema
• Mild hypertension

• B/P > 160/110
• Protien
•      3-4+ or > 500mg/24 hrs

• HAVisual changes
• Increased liver enzymes
• Oliguria
• Decreased uteroplacental perfusion

Cerebral Edema, cerebral vasospasm

Retinal ateriolar spasm

Hepatic congestion

Generalized vasoconstriction

Hepatic congestion

Glomerular damage

Cortical brain spasms; cerebral edema

Cortical brain spasms; cerebral edema

Assesses for hyperreflexia at the ankle joint

• Examiner sharply dorsiflexes the foot, maintains the position for a moment and then
• releases the foot

Normal response (negative clonus) is elicited when no rhythmic jerks are felt

Abnormal response (positive clonus) is the rhythmic oscillations of one or more “beats”

Charted as 1, 2, or 3 beats of clonus

3 beats of clonus can suggest impending seizure

• Reflexes are graded on a scale of 0 to
• 4+ as follows:

4+  Hyperactive; very brisk, jerky, or clonic response; abnormal

3+  Brisker than average

2+  Average response; normal

1+  Diminished response; low normal

0  No response; no movement

Seizures (grand mal) or coma

• Complications:
•       Fetus not being perfused
•    
•       Increased risk of maternal death related to
•                Pulmonary embolism
•                Organ failure
•                Cardiac failure
•                Cerebral Hemorrhage

• H & H
• Liver enzymes --> liver damage??
• Platelets --> going into HELLP?
• DIC profile, clotting studies
• Chemistry panel including: BUN, creatinine, uric acid

Maintenance therapy for HTN

usually 100-200 mg PO BID

IV bolus for acute episodes of HTN

5-10 mg IV bolus Q 5 min X 3

Loading dose of 4-6 grams IV given over 20-30 min

Followed by 1-2 grams IV maintenance dose

• Critical drip --> always on a pump!!
• Never leave the room during the bolus!!!

4-7 mEq/L    or      5-8   mg/dL

• Preeclmpsia gets worse
• Urinary output decreases, proteinuria
• CNS remains overstimulated
• Increases risk of seizure
•        Clonus present
•        Brisk DTRs
•        N/V
•        HA, visual problems
•        Epigastric pain

• Patient becomes toxic
• Urinary output decreases
• Causes severe CNS depression
• Increases risk of respirator/cardiac arrest
•       DTRs absent
•       RR <12
•       Clonus absent
•       Somulence

Increase in urinary output

Calcium gluconate

1 gram IV (10mL of 10% solution)

ROA --> 2-3 min (can stop the heart)

Some agencies dictate that only docs can administer

• Frequent vital signs, especially B/P
• Assess edema and chart as 1+, 2+, 3+, 4+
• Record daily weight
• Encourage a high-protein diet
• Position client on left side
• Test urine for protein every 8 hours
• Measure and record urine intake/output
• Assess deep tendon reflexes/clonus Q 1-4 hrs as deemed necessary
• Insert Foley as ordered
• Implement seizure precautions
• Assemble oral airway, suction, and O2 @ bedside
• Administer anticonvulsant, magnesium sulfate as per orders; continue 24-48 hours after delivery (thomboxane still in body, kidneys still not working as well.. takes a while!)
• Assess fetal status by FHM
• Ensure bed rest or restricted activity
• Decrease environmental stimuli
• If situation becomes critical, prepare for C-Section
• Educate the client and family members

O2 by mask 8-10L

Halt seizures

5-10 mg/IV

• Administer slowly. Dose may be repeated Q 5-10 min (up to 30 mg/hr)
• Observe for resp depression or hypotension in mother and resp depression and hypotonia in infant at birth

• Hemolysis
• Elevated Liver enzymes
• Low Platelets <100,000

• Secondary Symptoms:
•        Jaundice
•        GI bleeding
•        Bleeding gums
•        Epigastric pain --> hepatic congestion

Report any increase in B/P, proteinuria, weight gain, decreased fetal movement

Rest/activity: bed rest may be necessary

Diet and fluid recommendations are much the same as for the healthy pregnant woman

Avoid alcohol and limit caffeine intake --> stimulant and vasoconstrict

Age extremes are most at risk

Native American and African American women have the highest occurrence rates

Asian and Pacific Islander women have the lowest rates

• Some cultural groups view pregnancy as a normal/healthy state; prenatal care is
• minimal. PIH may go undetected

Nausea/vomiting affects 70% of all pregnancies (morning sickness)

Usually occurs in 1st trimester; benign

• If vomiting is excessive resulting in dehydration, electrolyte imbalance or
• ketosis, hyperemesis gravidarum results

Remember: baby is getting everything it needs from the placenta (stores nutrients!!)

• Less than 20 years of age
• Obese
• Nonsmokers

• NPO --> 24-48 hours (give the gut a rest)
• IV therapy to hydrate and correct elect imbalances
• Nutritional Supplements
• Diet as tolerated

• Persistent, uncontrollable vomiting --> esp smells
• Decreased urinary output --> not drinking
• Rapid pulse --> from dehydration
• Low-grade fever --> push fluids!
• Weight loss --> vomiting
• Electrolyte imbalances

• Sedatives
• Antiemetics --> zofran, phenergan, compazine
• Correction of fluid and electrolyte imbalances
• Vit B6 and ginger very effective

• Eat small amounts Q 2-3 hours
• Eat low-protein food
• Avoid greasy or fried foods
• Sit upright after meals to reduce reflux
• Snack before going to bed
• Eat dry crackers before rising
• Get out of bed slowly and avoid sudden movements Avoid brushing teeth immediately after eating

Low Lying/Marginal -->  Placenta implanted near margin of internal os

Partial --> Placenta partially covers the internal os

Complete --> Placenta completely covers/obstructs the os

• Increased maternal age
• Multiple gestation
• History of placenta previa
• Uterine scarring
• Uterine tumors
• Closely-spaced pregnancies

Painless, bright red vaginal bleeding

Progressively more severe bleeding as delivery nears

Decreasing urinary output

Anxiety and fear

• Assess amount and character of bleeding
• Monitor vital signs
• Monitor urinary output
• Monitor fetal heart rate and fetal activity
• Avoid digital vaginal exams as this may cause a placental abruption
• Instruct client to avoid enemas, douching, sexual intercourse
• Monitor for continued bleeding/onset of labor
• Administer intravenous fluid replacement
• Administer steroids (betamethasone/dexamethasone) if delivery unavoidable

• Hemorrhage
• Fetal distress/demise related to hypoxia in utero
• Intrauterine growth restriction
• Cesarean delivery
• Preterm birth
• Blood transfusion reactions

• O2 at 8-10L via mask
• Frequent vital signs
• Measure blood loss frequently
• Prepare for C-Section
• Continuous electronic fetal monitoring
• CBC, type/match, clotting studies
• #16 gauge IV x 2 with LR or NS

Premature separation (prior to birth) of the placenta from the uterine wall

1) Apparent

2) Concealed/Occult

• History of previous abruption
• Hypertension/PIH
• Sudden uterine decompression such as AROM
• Short umbilical cord
• Drug use during pregnancy especially cocaine
• Smoking
• Folic acid deficiency
• Abdominal trauma

• Dark red vaginal bleeding
• Uterine rigidity; “boardlike” abdomen
• Sudden onset of intense abdominal pain
• Uterine contractions
• Fetal distress

• Assess amount and character of  bleeding; degree of abdominal rigidity; degree of pain
• Assess fetal activity and heart tones
• Measure fundal height if concealed bleeding is suspected
• Monitor for shock
• Provide emotional support
• Prepare for possible C-section
• Administer blood transfusions if ordered

• Anemia
• Hemorrhage
• Shock
• DIC
• Organ Ischemia
• Hysterectomy
• Death

• Fetal Hypoxia
• Prematurity
• Small for gestational age
• Neurologic deficits

• Glucose
• Oral hypoglycemics
• Coumadin
• TORCH infections

• Heparin
• Insulin