RISKS: Previous GDM Familial Hx of GDM, type 2 or type 1 diabetes

1. Gestational Diabetes Melitus RISKS: Previous GDM Familial Hx of GDM, type 2 or type 1 diabetes previous macrosomial infant unexplained stillbirth congenital anomalies advanced maternal age

3. Insulin needs of Type 1 diabetes May need decrease in beginning of 2nd trimester, but needs increase after

4. Complications for hyperglycemia To decrease complications, key is euglycemia – normal blood sugar Peoria is lower than book, frequent blood glucose checking & injections of Insullin Oral hypoglycemic agents are teratogenic & contraindicated during pregnancy If HbA1C is above 8 she probably is type 2 diabetic before PG – monitor closely after PG

5. Peak insullin resistance usually at 24 – 28 wks. (remember 1st unit) placental lactogen hormone Many more type 2 diabetics and on increase. Many are not diagnosed If develop GDM have a great % of developing diabetes (usually type 2) some time in your life. New research states the female child has in increase chance of developing GDM, both sexes have increased likelihood for type 2 diabetes Most screen at 24-28 weeks. Newer research says we should be screening earlier. Diabetes types 1 = insulin dependent 2 = diet & exercise or hypoglycemic agents 3 = GDM PRECONCEPTION COUNSELLING KEY – uglycemia for 3-6 mos before conception and throughout will decrease complications

6. Hyperemsis gravidarum (HEG): persistent uncontrollable vomining that begins before 20th wk can lead to loss of weight, dehydration, ketosis, acid-base & electrolyte (Na+ and K+ are lost) imbalance, Metabolic alkalosis may develop due to loss of hydrochloric acid. Increase risk: young age, first PG, problems with N&V in previous PG, a Hx of intolerance to oral contraceptives, Hx of gallbladder disease One theory is high levels of HCG – why many times N&V decrease after 12 wks but some with even low HCG levels develop HEC theory psychosomatic – no longer acceptable allergic theory – to fetus and placenta challenges mom immune system metabolic theory – Vit B6 deficiency but research is conflicting Tx: prevent complications, hydrate IV’s, vitamins meds – Phenergan, Benadryl, histamine-receptor antagonists such as Pepcid or Zantac, Zofran, Prilosec. reduce N&V find triggers – smells, try low-fat foods and easily digested carbohydrates, need salt to replace loss fluids K+ source fruits, vegetables, meat; magnesium=seeds, nuts, legumes & green veg

7. Thyroid problems: Hyperthyroid: many antithyroids such as Tapazole and PTU (preferred) are category D which may result in neonatal goiter or hypothyroidism Increased PIH, PP hemorrhage if not well controlled Hypothyroid: Thyroid replacement hormone Synthroid is category A crosses placenta only to a limited extent increased preeclampsia, abruptio placentae, low birth weight or stillborn infants, increase neonatal goiter and congenital hypothyroidism Cardiovascular problems: PG increase work load by heart are a high risk PG and need to be monitored carefully and often Rheumatic heart disease: stenosis of openings between chambers of heart due to scarring of the valves. Mitral valve is most common affected. Congenital heart disease: basically fall into left to right shunt category or right to left shunt. Study in cardiac Mitral Valve Prolapse: most common cardiac condition. Most of time a benign condition, some MD’s administer prophylactic antibiotics before &during labor (bacterial endocarditis)

8. Peripartum & postpartum cardiomyopathy = rare, no underlying cardiac conditions, but symptoms of cardiac decompensation appear during the last weeks of PG or from 2-20 wks PP. S&S = congestive heart failure (dyspnea, edema, weakness, chest pain, heart palpitations ) TX: digitalis, diuretics, sodium restrictions and prolonged bedrest Tendency to reoccur in later PG – PG are generally not advised Drug therapies: anticoagulants ; Heparin not Warfarin antiarrhythemics: digoxin & quinidine are generally thought of as safe B-blocker therapy only in late PG – fetal growth restriction anti-infectives: ampicillin and gentamicin diurtics: usually avoided Some with cardiac disease will need to have CS to avoid increase cardiac work during labor & vag delivery

9. Pulmonary disorders: asthma: inhaled corticosteriods are OK, encourage to breastfeed may decrease allergies & asthma in infant Anemia: iron-deficiency anemia: hemoglobin content mom: pica, inflammations of lips and tongue. Lab show RBC that are microcytic & hypochromic (pale) fetus: usually OK, but if mom severely anemic can reduce fetal RBC & hemoglobin Tx. Iron supplements (give with vit C) and what foods are high in iron folic acid deficiency or megaloblastic anemia: results in presence of large, immature erythrocytes (megaloblasts) mom: folic acid requirement doubles in PG. Dilatin, hemolytic anemias & malabsorption entities will contribute fetus: spontaneous abortion, abruptio placentae, and fetal anomalies, esp. neural tube defects TX. Supplements and foods liver, kidney beans, lima beans & fresh dark-green vegetables and now added to many cereals, breads, etc

10. Anemias continued: Sickle cell hemoglobinopathy: autosomal recessive genetic. Defect in hemoglobin causes RBC to become shaped like sickle or crescent. Low O2 – RBC cannot pass through small arteries and capillaries & tend to clump together & occulde the blood vessel. Mom: temporary cessation of bone marrow function, hemolytic crises with RBC destruction resulting in jaundice, severe pain, pyelonephritis, bone infection, heart disease fetus: prone to serious complications including prematurity & IUGR. Fetal death is common especially in those moms that have a sickle cell crises TX: S&S of sickle cell crises and treat Thalassemia: is a genetic disease that involves abnormal synthesis of a of B chains of hemoglobin. Leads to alterations in RBC membranes and decreased life span of RBC Mom: minor types often are mildly anemic – but have to be careful not to give large doses of iron because they absorb & store iron in the bodies excessively & must take a chelating agent to rid the excess Fetal: may inherit the problem due to genetics

11. Cholecytitis & cholelithiasis: increase during PG, but often absent or decrease after delivery Inflamatory bowel disease: may actually improve WHY? may vary from person to person Neurologic disorders: Epilepsy seizure: 0.3 to 0.6% of PG women affected. Effect on PG is variable & unpredictable higher incidence of stillbirth, preterm labor. teratogenic effects of anticonvulsant meds – fetal hydantoin syndrome includes craniofacial abnormalities, limb reduction defects, growth restriction, mental retardation, cardiac anomalies. TX preconception plan with neurologists very risky Bell’s palsey: thought to be caused by a virus, 3 X’s more common in PG 90% recover within weeks to months. TX. Steroids within the first few days., facial massage, cream.

12. Autoimmune disorders: Systemic Lupus Erythematosus (SLE): increased abortion and fetal death during the first trimester, the prognosis for live birth is as high as 90% if no active flare ups occur, 50% if hypertensive renal disease is present Fetus: congenital heart block which is permanent & will require a pacemaker Rheumatoid arthritis: marked improvement often during PG. (suppression of immune inflammatory response). Most relapse within 6 wks to 6 mos after delivery. In contrast to SLE, the risk of abortion does not increase. Multipe Scerosis: basically follows RH. Some women report an improvement of their MS while PG others will have more symptoms

13. Trauma in PG: as with any other trauma but now have fetus to worry about. FHM

15. TAB = therapeutic abortion EAB = elective abortion First trimester: D & C – dilation & curretage Second trimester: transabdominal intrauterine injection of hypertonic solution ofter sodium chloride D&C injection of urea solution after amniocentsis protaglandins – pitocin abdominal hysterotomy Complications RU 486 Morning after pill

17. Adolescent Pregnancy

19. Legal Tips - emancipated minor confidentiality parents of PG patient contraception retaining child custody adoption FOLLOW UP CARE IS VIP !!!!

22. Terbutaline or Brethine is the medication we see used the most If doesn’t work go to Magnesium Sulfate

23. Don’t worry about dosages

24. Effects on mother

25. Effects on mother

26. More effects on mom Tachyphylaxis: a phenomenon in which repeated administration of drug results in marked decrease within drug effectiveness

29. Used for stopping preterm labor & preeclampsia - eclampsia

30. Magnesium sulfate continued: Calcium gluconate must be at bedside or readily available counteracts effects of MgSo4

31. MgSo4 continued

32. Magnesium sulfate effects on fetus and neonate

33. Magnesium sulfate

35. Abnormal uterine types, cervical problems

37. May help with shoulder dystocia

38. Version

39. Prolapse of cord 1:200 May also be called Forelying

41. Nursing care when postpartum hemorrhage occurs Most causes: Uterine atony Lacerations Hematomas

42. Who is at a higher risk? Why?

43. Nursing care when postpartum hemorrhage occurs Most causes: Uterine atony Lacerations Hematomas

44. Uterine atony

45. Uterine message

48. Myometrium Decidua basalis Decidua spongiosa Amnion A = normal B = placenta accreta: placental tissue is adherent to myometruim C = placenta increta: placenta has penetrated into uterine muscle D = placenta percreta: placenta has penetrated through the uterine muscle rare 1: 7000 births

49. Uterine prolapse 1:15,00 May occur after placenta delivered or in PP period Etiology: bearing down, precipitous delivery, pulling on cord, fundal pressure, vigorous message of uterus, manual extraction of placenta S&S: pain, fear, blood loss, shock, infection, DIC TX: may need tocolytic to relax uterus, increase fluid, possible hysterectomy