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 well-being 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 placentaSpontaneous 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. Recurrent/Habitual: Occurs consecutively in 3 or more pregnancies Septic: Infection is present. Malodorous discharge.

NANDAs Acute pain r/t abdominal cramping secondary to threatened abortion Anticipatory grieving r/t expected loss of unborn childNote: 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 possible fetal loss. Assess familys response to situation

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 Rh- immune 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)

Hydatidiform mole (molar pregnancy) is a disease in which: Abnormal developments of the placenta occurs resulting in hydropic vesicles (fluid-filled, grapelike cluster) Trophoblastic tissue proliferates 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

NANDAs Fear r/t possible development of choriocarcinoma Anticipatory grieving r/t loss of the pregnancy

Procedures: Ultrasound Suction curettage to aspirate & evacuate the mole Follow up hCG for 1 year (^hCG may indicate choriocarcinoma) Chemotherapy if choriocarcinoma (Methotrexate)

Nursing Interventions: Monitor for s/s of trophoblastic disease: rapid uterine growth, vaginal bleeding accompanied by discharge, excessive 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

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 hemorrhageMarginal: placenta separates at its edges, the blood passes between the fetal membranes & the uterine wall, blood escapes vaginallyCentral: placenta separates centrally, blood trapped between placenta & uterine wall. Concealed bleedingComplete: Total separation of placenta. Massive vaginal bleeding

S/S: sudden onset of intense localized uterine pain, vaginal bleeding, board-like abdomen that is tender, fetal distressMaternal Implications: intrapartum hemorrhage, DIC, hypofibrinogenemia (coagulation factors decreased), fatal hemorrhagic shock, renal failure, vascular spasm, intravascular clottingFetal-Neonatal Implications: sequelae of prematurity, hypoxia, anemia, brain damage, fetal demise

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 Monitor I & O & urine Specific Gravity Measure abdominal girth as ordered Review & evaluate diagnostic tests Hgb, Hct, coagulation status Neonatal resuscitation as ordered Provide information & emotional support

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 coveredPartial internal os is partially coveredMarginal edge of os is coveredLow-lying placenta implanted in lower segment in proximity to os Major complications: maternal hemorrhage, fetal prematurity, death

S/S: painless, bright-red vaginal bleeding

NANDAs Fluid volume deficit Anxiety Impaired gas exchange

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 Ringers solution) 2 U of crossmatched blood available for transfusion Provide information & emotional support Verify familys ability to cope with anxiety of unknown outcome

INCOMPETENT CERVIX P. 343

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

Surgical Procedures: Shirodkar procedure (cerclage) or a modification of it by McDonald: reinforces the weakened cervix by encircling it at the level of the internal os w/ suture material. Purse-string suture placed in cervix. Once suture is placed, a cesarean birth may be planned (to prevent repeating procedure in future pregnancies) or the suture may be cut at term & vaginal birth permitted

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 Uterine contractions, ROM, infection Educate client to refrain from sex, heavy lifting & prolonged standing Administer tocolytics prophylactically to inhibit uterine contractions

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

NANDAS Imbalanced nutrition < body requirements Fear

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

PREMATURE RUPTURE OF MEMBRANES (PROM) P.345

PROM Spontaneous rupture of the membranes prior to the onset of labor PPROM (Preterm premature rupture of membranes: is the rupture of membranes occurring after 20 wks but before 37 wks of gestationInfection 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 DONT DO Digital vaginal examination - increases risk of infection

Interventions: Start antibiotic therapy immediately if maternal signs of infection are evident On admission to nursery, newborn is assessed for sepsis & placed on antibiotics 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 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 moreFetal-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 (B-adrenergic 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

BP begins to rise after 20 weeks of gestation Decreased level of vasodilators & increase level of vasoconstrictors Preeclampsia is the most common hypertensive disorder in pregnancy. It is defined as gestational hypertension with a BP of 140/90 (mild) or 160/110 (severe) or higher on 2 occasions at least 6 hrs apart accompanied by proteinuria (5g in a 24 hr urine collection) & edema. Dipstick urine protein 31-41 in 2 random samples obtained 4 hrs apart. It most often occurs in the last 10 wks of gestation, during labor, or in the first 48 hrs after childbirth. Most common in women < 17 yrs or > 35. Eclampsia is the most severe form of preeclampsia, characterized by generalized seizures or coma. May occur antepartum, intrapartum or postpartum

Maternal Risks: Hyperreflexia, headache, seizures, renal failure, abruption placentae, DIC, ruptured liver, PE, HELLP syndromeFetal-Neonatal Risks: Small for gestational age, premature, Hypermagnesemia (Mg Sulfate administration to mother), increased morbidity & mortality

Assessment: BP every 1-4 hrs, Temperature every 4 hrs, pulse & respirations Fetal heart rate Urinary output: 700 mL or greater in 24 hrs, or at least 30 mL/hr Urine protein: 3+ or 4+ indicates loss of 5g or more of protein in 24 hrs Urine specific gravity hourly Weight: weigh the woman daily at the same time, she should be wearing the same robe or gown & slippers Pulmonary edema: observe for coughing, auscultate lungs for moist respirations Deep tendon reflexes & clonus: for signs of hyperreflexia Placental separation: for vaginal bleeding & uterine rigidity Headache Visual disturbances: blurring or any changes Epigastric pain Laboratory blood tests Level of consciousness, emotional response & level of understanding Assess for Mg sulfate toxicity: if suspected, immediately discontinue infusion & administer calcium gluconate

Management: Home care of Mild preeclampsia: Woman monitors her BP, weight, urine protein daily. Remote NSTs performed daily or biweekly. Advise to report any changes. Hospital care of mild preeclampsia: Bed rest primarily on left side to decrease pressure on vena cava, moderate-high protein diet.Tests to evaluate fetus status: Fetal movement record Nonstress test Ultrasonography every 3-4 wks for serial determination of growth Biophysical profile Serum Creatinine Amniocentesis to determine fetal lung maturity Severe preeclampsia: Birth may be treatment of choice for both mother & fetus, even if fetus is immature. Other include: bed rest, diet (high protein, moderate Na+), anticonvulsants (Mg Sulfate treatment of choice), F & E replacement, corticosteroids, antihypertensives Eclampsia: An eclamptic seizure requires immediate, effective treatment. Bolus of 4-6 g Mg Sulfate is given IV over 5 min. Sedatives (Diazepam), Dilantin (for prevention), Diuretics (Lasix) for pulmonary edema, Digitalis (for circulatory failure). I & O monitored hourly. Woman is observed for signs of labor & vaginal bleeding & abdominal rigidity which may indicate abruption placentae. While she is comatose, she is positioned on her left side / the side rails up. Intrapartal Management: Labor inducement with IV oxytocin if evidence of fetal maturity & cervical readiness. Assessment for signs of worsening preeclampsia. Analgesics may be used for discomfort or epidural block. O2 is administered.Postpartal Management: Woman with preeclampsia usually improves rapidly after giving birth, although seizures can still occur during first 48 hrs postpartum. If hypertension is severe, woman may continue to receive antihypertensives or Mg sulfate.

Extra interventions: Explain medical therapy & its purpose & offer honest information Maintain quiet, low-stimulus environment Avoid unlimited phone calls Keep woman on left side as much as possible Explain to family the reason of the seizures

HELLP SYNDROME P. 352

H hemolysis (anemia & jaundice)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)

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

Management: BP measurements Platelet transfusions if