Complications of Pregnancy

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

2. 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.

3. 4 Categories approved by the NIH and Nat’l High Blood Pressure Education Program(NHBPEP) • Chronic Hypertension–HTN that was either present before conception or detected before the 20th week of gestation & did not resolve in the early postpartum. • 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 20th 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/mm3) &  liver enzymes

4. 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.

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

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

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

8. Proteinuria • The “Gold Standard” is a 24hr urine specimen with excretion of >300mg of protein in 24 hrs. • This correlates with a dipstick of 1+(30mg/dL) or greater if specific gravity is < 1.030 OR 2+ if the specific gravity is higher.

9. Edema criterion— • weight gain of • > 1.5kg/month (3.3lb.) in the second trimester • or > 0 .5kg/week(1.1 lb) in the third trimester. • Puffiness of face and hands rather than dependent edema manifested as swollen ankles and feet • Pitting edema of lower extremities while on bedrest

10. Predisposing Factors • 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

11. Changes in Normal Pregnancy •  Cardiac output by 50% •  Blood volume by 1500ml •  Peripheral vascular resistance •  BP •  Renin •  GFR •  ECF • Aldosterone effects blocked

12. Changes in Preeclampsia (pg382; 10th 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)

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

14. Treatment • 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.

15. 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 > 6g/day), moderate  protein to replenish what is spilled by kidneys

16. Hospital care of mild preeclampsia (Cont’d) • Assessment of fetal well-being • DFMC, BPP, NST, Amniocentesis • Assessment of maternal well-being • BP assessed qid or q4hr • Daily wt, and assessment of worsening edema • Assessment of HA, visual changes, epigastric pain, hyperreflexia • 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)

17. Severe Preeclampsia • Signs and symptoms • BP of 180/110 or higher on 2 occasions at least 6 hr apart while on bedrest • Proteinuria  5g/L in 24 hr or 3+ or > on 2 random urine samples 4 hrs apart • Oliguria: urine output <500ml/24hr • 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

18. 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

19. Medications used in treatment • Magnesium Sulfate: a 4-6 gm bolus is given IV over 20 minutes, then a continuous infusion of 2gm/hr is generally advocated. • If 40 grams are added to 1000mls of LR, at what rate would you set the IV pump to administer 4gm in 20 minutes? • If you are to continue to infuse at 2gm/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. 572 Davidson 10th ed. for more info

20. 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 2nd 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

21. Other anti-convulsants: • Phenytoin and Diazepam have not been found to be as effective as MgSO4, so seldom used

22. Eclampsia—occurs in 1 in 1600 pregnancies • 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

23. Safety precautions • Quiet environment—no phone calls, TV, lights, pulled shades, etc. • Padded side rails in bed • O2 ready and available • Suction ready and available • Emergency tray available with • Diazepam 10 mg given IV push not > 30mg • or Phenytoin 10mg/kg IV push • Monitor FHR for bradycardia

24. Refer to Nursing Care Planpp. 389-391 Davidson et al, 10th ed. • Note importance of careful monitoring of mother and fetus throughout hospitalization with severe pre-eclampsia • Prevention of complications is key to healthy management

25. HELLP Syndrome • Hemolysis • Elevated Liver Enzymes • Low Platelets (< 100,000/mm3) • 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.

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

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

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

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

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

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

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

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

34. Management of Pre-gestational Diabetes • Hgn A1c • Good control = 2.5% to 5.9 % • Fair Control = 6% - 8% • Poor Control = > 8% • Diet VERY CAREFULLY BALANCED • Should be followed by Registered Dietician • Exercise • Not vigorous, Best time is after meals

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

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

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

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

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

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

41. Gestational Diabetes Management • GOAL Keep blood sugars within levels for Pre-gestational 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

42. Gestational Diabetes Management • Delivery • Frequent NST/BPP in last 2 months of pregnancy • Deliver by 40 weeks • Excellent resource link from theNational Diabetes Education Program with handouts in various languages and lots of resources. • Another great resource with tables from Merck Manual

43. Perinatal Infections • 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) • If Positive –Treat in Labor • Penicillin: 5 million Units IV x 1; 2.5 million units every 4 hours • Ampicillin: 2 GMs IV x1; 1 GM every 4 hours • Clindamycin 900mg IV q 8 hr OR Erythromycin 500mg IV q 6hr till delivery if allergic to Penicillin.

44. Perinatal Infections • 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

45. Other Perinatal infections • Syphyllis • Gonorrhea • Chlamydia • TORCH p.394-400; 10th ed. • Toxoplasmosis • Rubella • Cytomegalovirus • Herpes, Human B19 Parvovirus

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

47. Hemorrhagic Complications • Types of Abortions (know the differences) • Threatened • Imminent • Incomplete • Missed • Habitual

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

49. Gestational Trophoblastic Dz

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