Complications of Pregnancy PreEclampsiaEclampsia Diabetes in Pregnancy Perinatal

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

n 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.

4 Categories approved by the NIH and Nat’l High Blood Pressure Education Program(NHBPEP) n Chronic Hypertension– HTN that was either present before conception or detected before the 20 th week of gestation & did not resolve in the early postpartum. n Chronic Hypertension with superimposed preeclampsia—the disorder most often associated with severe maternal & fetal complications. It is seen in women who ¨ Were hypertensive before the 20 th 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 (<100, 000 cells/mm 3) & liver enzymes

n 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.

n Pre-eclampsia—This is a pregnancy-specific, multi-system syndrome. ¨ Diagnosis is determined by presence of HTN, occurring after the 20 th 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.

We will use Preeclampsia in place of PIH n Definition— BP (generally defined as 140/90 OR an in systolic of 30 and diastolic of 15) occurring after 20 th 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.

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

Proteinuria The “Gold Standard” is a 24 hr urine specimen with excretion of >300 mg of protein in 24 hrs. n This correlates with a dipstick of 1+(30 mg/d. L) or greater if specific gravity is < 1. 030 OR 2+ if the specific gravity is higher. n

Edema criterion— n weight gain of ¨> 1. 5 kg/month (3. 3 lb. ) in the second trimester ¨ or > 0. 5 kg/week(1. 1 lb) in the third trimester. Puffiness of face and hands rather than dependent edema manifested as swollen ankles and feet n Pitting edema of lower extremities while on bedrest n

Predisposing Factors n n n n Nulliparas Multigestational pregnancies Hx of previous pregnancy with preeclampsia Maternal age <19 or >40 African American ethnicity Family Hx of preeclampsia Presence of pre-existing disease: chronic HTN, renal disease, diabetes mellitus

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

Changes in Preeclampsia (p 461 Davidson 9 n th 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) ¨

Mild Preeclampsia n Signs & Symptoms ¨ BP > 140/90 ¨ Periorbital edema ¨ 1+ to 2+ proteinuria by dipstick ¨ Mild edema of face & hands ¨ Platelet count > 120, 000

Treatment n Home care of mild preeclampsia ¨ Monitor daily wt for gain ¨ Monitor BP daily ¨ Monitor urine for protein daily (dipstick) ¨ Remote NST’s 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.

n Hospital care of mild preeclampsia ¨ Bedrest, left lateral recumbent position to renal perfusion which promotes diuresis and lowers BP ¨ Diet—well balanced, nutritious, moderate sodium (not > 6 g/day), moderate protein to replenish what is spilled by kidneys

Hospital care of mild preeclampsia (Cont’d) ¨ Assessment of fetal well-being n DFMC, BPP, NST, Amniocentesis ¨ Assessment of maternal well-being n BP assessed qid or q 4 hr n Daily wt, and assessment of worsening edema n Assessment of HA, visual changes, epigastric pain, hyperreflexia n 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)

Severe Preeclampsia n Signs and symptoms ¨ BP of 180/110 or higher on 2 occasions at least 6 hr apart while on bedrest ¨ Proteinuria 5 g/L in 24 hr or 3+ or > on 2 random urine samples 4 hrs apart ¨ Oliguria: urine output <500 ml/24 hr ¨ Cerebral or visual disturbances—HA, scotomata or blurred vision ¨ Pulmonary edema or cyanosis ¨ Epigastric or RUQ pain ¨ Impaired liver function ( AST, APT) ¨ Thrombocytopenia ¨ IUGR ¨ Hyperreflexia, irritability, emotional tension, N&V

n Treatment of Severe Preeclampsia ¨ Absolute bedrest ¨ Quiet environment to reduce stimuli ¨ High protein, moderate sodium diet ¨ Anticonvulsants—Magnesium Sulfate is drug of choice because of its CNS depressant action ¨ Corticosteroids—betamethasone or dexamethasone is given to mother to promote lung development in fetus ¨ Fluid & electrolyte replacement– need to keep balance ¨ Antihypertensives—if diastolic > 105 -110

Medications used in treatment n Magnesium Sulfate: a 4 -6 gm bolus is given IV over 20 minutes, then a continuous infusion of 2 gm/hr is generally advocated. ¨ If 40 grams are added to 1000 mls of LR, at what rate would you set the IV pump to administer 4 gm in 20 minutes? ¨ If you are to continue to infuse at 2 gm/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. 468 Davidson 9 th ed. for more info

n Anti-hypertensives: given for sustained sys BP> 160 -180 and dias BP> 105 -110 ¨ NO DIURETICS should ever be Rx’d 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 2 nd line drug after Methyldopa for tx of chronic hypertension, but still the drug of choice in hypertensive crisis. ¨ Labetalol—is an adrenergic-receptor blocking agent given orally or IV more frequently these days. ¨ Nifedipine—given orally or IV ¨ ACE inhibitors are contraindicated in pregnancy

n Other anti-convulsants: ¨ Phenytoin and Diazepam have not been found to be as effective as Mg. SO 4, so seldom used

Eclampsia— occurs in 1600 pregnancies n Symptoms of impending seizure: ¨ Hyperreflexia— 4+ ¨ Scotomata—dark spots or flashing lights ¨ Blurred vision ¨ Epigastric pain ¨ Vomiting ¨ Persistent Headache generally frontal ¨ Neurologic hyperactivity ¨ Pulmonary edema ¨ Cyanosis

n Safety precautions ¨ Quiet environment—no phone calls, TV, lights, pulled shades, etc. ¨ Padded side rails in bed ¨ O 2 ready and available ¨ Suction ready and available ¨ Emergency tray available with Diazepam 10 mg given IV push not > 30 mg n or Phenytoin 10 mg/kg IV push n ¨ Monitor FHR for bradycardia

Refer to Nursing Care Plan pp. 471 -473 Davidson et al, 9 th ed. Note importance of careful monitoring of mother and fetus throughout hospitalization with severe pre-eclampsia n Prevention of complications is key to healthy management n

HELLP Syndrome Hemolysis n Elevated Liver Enzymes n Low Platelets (< 100, 000/mm 3) n ¨ 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.

Diabetes In Pregnancy Did it exist BEFORE Pregnancy? n Pregestational Diabetes Mellitus ¨ Type 1 ¨ Type 2 ¨ 1/2000 pregnancies n Gestational Diabetes ¨ Any degree of glucose intolerance with the onset or first recognition occurring during pregnancy ¨ 2 -5% of all pregnancies n n 90% of all cases of diabetes in pregnancy 25% of these women will develop Type 2 diabetes later in life

Normal CHO Metabolism in PG Goal of changes is to provide adequate glucose to fetus for growth n Maternal glucose crosses the placenta n Maternal insulin does NOT n KEY CONCEPT TO UNDERSTAND n

CHO Metabolism— 1 st Trimester in E & P stimulate Beta cells of Pancreas to Insulin production n = use of glucose in serum glucose levels (FBS ) n in tissue glycogen stores n in liver glycogen production n = Pregestational Diabetics Hypoglycemia n

CHO Metabolism-2 nd & 3 rd Trimester Pregnancy is a “diabetogenic” state n Hormones levels lead to tolerance to glucose n insulin resistance n ¨ HPL-Human n Insulin antagonist—Won’t let insulin work ¨ Placental n Placental Lactogen Insulinases Breakdown insulin at placental site

Net Result = Changes in Insulin Needs for Mother during Pregnancy n 1 st trimester = ¨ need for insulin production, N&V, transfer to fetus food intake, 2 nd Trimester = Gradual n 3 rd Trimester = 2 -4 times higher need for insulin by 36 week, then levels off til labor n After delivery = ; glucose/insulin balance OK by 7 -10 days n

Risks to Mother n Pregestational Diab. ¨ If poor control very early in PG Miscarriage ¨ Macrosomic baby C/S ¨ Pre-eclampsia ¨ PTL ¨ Infections (UTI’s, Vag) ¨ Polyhydramnios ¨ Ketoacidosis / Hypogylecemia n Gestational-Onset ¨ 2 X likely to have preeclampsia ¨ Macrosomic baby C/S

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

Management of Pre-gestational Diabetes n Pre-conceptual Counseling ¨ Establish glycemic control BEFORE PG ¨ Understand the VERY close monitoring Blood glucose levels 4 -8 times a day. n Frequent MD visits n ¨ If Type 2—Some oral hypoglycemic agents are teratogenic Insulin SQ during pregnancy

Management of Pre-gestational Diabetes n Hgn A 1 c ¨ Good control = 2. 5% to 5. 9 % ¨ Fair Control = 6% - 8% ¨ Poor Control = > 8% n Diet VERY CAREFULLY BALANCED ¨ Should n be followed by Registered Dietician Exercise ¨ Not vigorous, Best time is after meals

Management of Pre-gestational Diabetes-Insulin n Multiple daily injections needed ¨ Mixed of longer-acting and rapid-acting in AM and PM Humulin or Novolin, NOT pork or beef insulins n Humalog, if newly diagnosed n

Management of Pre-gestational Diabetes-Insulin n GOAL—keep blood sugar in narrow margin ¨ Fasting = 60 -90 mg/dl ¨ 2 -hour postprandial = 90 -120 mg/dl

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

Gestational Diabetes-Screening n Low-risk ¨< 25 y/o ¨ No family Hx ¨ Normal BMI ¨ Not in High-Risk group ¨ No Hx of Abnormal GTT n Hi-Risk ¨ Hx of gestational Diabetes ¨ Overweight/Obese BMI ¨ High-risk group n n African-American Native-American Latina Pacific-Islander

Gestational Diabetes-Screening n First pre-natal visit ¨ 50 gm glucose load -> draw serum 1 hour later Negative < 140 mg/dl n Positive > 140 mg/dl n n Screen again 24 -28 weeks gestation

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

Gestational Diabetes Management n n n GOAL Keep blood sugars within levels for Pregestational diabetes Diet—Main course of treatment; 3 meals and 3 snacks Exercise Insulin— 20% 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

Gestational Diabetes Management n 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. n Another great resource with tables from Merck Manual n

Perinatal Infections n 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) n If Positive –Treat in Labor Penicillin: 5 million Units IV x 1; 2. 5 million units every 4 hours ¨ Ampicillin: 2 GMs IV x 1; 1 GM every 4 hours ¨ Clindamycin 900 mg IV q 8 hr OR Erythromycin 500 mg IV q 6 hr till delivery if allergic to Penicillin. ¨

Perinatal Infections n If GBS status unknown—Prophylactic trx is indicated if: ¨ Previous infant with GBS ¨ GBS bacturia during this pregnancy ¨ PTL ¨ Temp in labor > 100. 4 F ¨ Membranes ruptured > 18 hours

Other Perinatal infections Syphyllis n Gonorrhea n Chlamydia n TORCH p. 486 -492 9 th ed. n ¨ Toxoplasmosis ¨ Rubella ¨ Cytomegalovirus ¨ Herpes, Human B 19 Parvovirus

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

Hemorrhagic Complications n Types of Abortions (know the differences) ¨ Threatened ¨ Imminent ¨ Incomplete ¨ Missed ¨ Habitual

Other Hemorrhagic Complications n Ectopic Pregnancy ¨ Egg n implants outside of uterus ¨ Lots of pain and internal bleeding –manifested by sx of shock—lifethreatening ¨ Surgical intervention needed ¨ Link with photos Hydatidiform Mole ¨ No fetus, Fluid filled vesicles ¨ N&V, No FHT’s, 2 nd trimester bleeding— Prune-juice ¨ D&C ¨ Not get pregnant for 1 year ¨ Choriocarcinoma, if HCG elevated

Gestational Trophoblastic Dz

Other Hemorrhagic Complications n Incompetent Cervix ¨ Cerclage— Mc. Donald’s or Shirodkar procedure n 10 -14 weeks gestation n NO Intercourse, Prolonged standing, heavy lifting n On bedrest as much as possible n Teach signs of Preterm Labor n Take tocolytics as ordered n Home uterine monitoring ¨ Remove suture at 37 weeks vaginal ¨ Leave suture in C/Sec

Shirodkar Procedure for Incompetent Cervix

Other Complication of Pregnancy Hyperemesis Gravidarum n n 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 doesn’t respond to small, frequent meals, then needs hospitalization: NPO, IV fluids with KCl to prevent hypokalemia, B-vitamin replacement (B 1 and B 6 especially) ¨ If still unable to eat, may need TPN temporarily

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