Gestational Conditions

Hyperemesis Gravidarum / Pernicious Vomiting

- the condition is associated with intrauterine growth restriction
Signs and Symptoms
• Severe nausea and vomiting
• Elevated hematocrit
• Reduce serum levels of sodium, potassium and chloride
• Polyneuritis
• Weight loss
• Urine positive for ketones
Nursing Implications:
• Women may need to be hospitalized for about 24 hours to document and monitor intake and
output, and blood chemistries and to restore hydration.
• All oral food and fluids are withheld for the first 24 hours.
• Intravenous fluids of 3,000 ml Ringer’s Lactate with added vitamin B1 may be administered to
increase hydration.
• An antiemetic, such as metoclopramide (Reglan, pregnancy class B), may be prescribed to
control vomiting.
• Intake and output is carefully measured, including the amount of vomitus.
• If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can
be started.

Pregnancy-Induced Hypertension
Description
 PIH, a systemic disorder affecting almost all organs, is a complication of pregnancy that places the

mother and fetus at high risk for problems.

 In PIH, the symptoms result from peripheral vascular spasm, but why this vascular spasm occurs is

difficult to establish.
 With PIH, there is a loss in the reduced responsiveness to blood pressure changes, resulting in

vasoconstriction and poor organ perfusion which leads to increased blood pressure.
 The vascular effects of vasospasm include vasoconstriction and dramatic increases in blood pressure.

 The kidney effects of vasospasm include decreased glomeruli filtration rate, increased permeability of

glomeruli membrane, increased serum blood urea nitrogen, uric acid creatine which leads to
decreased urine output and proteinuria.
 The interstitial effects include diffusion of fluid from the blood stream into interstitial tissue which

leads to edema.
 Blood supply to organs is reduced; this is followed by tissue hypoxia in the maternal vital organs

leading to poor placental perfusion, possibly reducing the fetal nutrient and oxygen supply.
Predisposing Factors:
 Primiparas younger than age 20 years or older than 40 years

 Women from a low socioeconomic background

 Women who have had five or more pregnancies

 Women of color

 Women with multiple pregnancy

 Women with underlying disease

 May be associated with poor calcium or magnesium intake

Classification with Signs and Symptoms

A. Gestational Hypertension
 Blood pressure of 140/90 mmHg

 No proteinuria

B. Mild Preeclampsia
 Blood pressure of 140/90 mmHg

 Proteinuria 1+ to 2+ on a random sample

 Weight gain more than 2 lb/week in the second trimester and 1 lb/week in the third trimester

 Mild edema in upper extremities or face

C. Severe Preeclampsia
 Blood pressure of 160/110 mmHg

 Proteinuria 3+ to 4+ on a random sample & 5 g on a 24-hour urine sample

 Oliguria (500ml or less in 24 hours)

 Cerebral or visual disturbances

 Pulmonary edema with shortness of breath

 Extensive peripheral edema

 Hepatic dysfunction

 Thrombocytopenia

 Epigastric pain, nausea and vomiting

 Marked hyperreflexia

D. Eclampsia
 Blood pressure greater than 160/110 mm Hg

 Tonic-clonic seizure

Management:
 Obtain a thorough antepartal history and physical examination

 Assess the client’s blood pressure

 Monitor the client’s weight gain

 Assess the client’s deep tendon reflexes

 Instruct the client to eat a high-protein, moderate sodium diet

 Encourage bed rest in the left lateral recumbent position

For Mild Preeclampsia

 Instruct the client regarding need for follow-up visits every 2 weeks; inform physician immediately if

symptoms worsen
For Severe Preeclampsia
 Anticipate the need for the client to be hospitalized

 Prepare for amniocentesis or induction of labor

 Place the client in a private room

 Darken the room

 Monitor the client’s blood pressure every 4 hours

 Obtain blood studies – CBC, platelet count, liver function test, BUN, creatinine and fibrin degradation

products to assess for renal and liver function and development of DIC
 Anticipate obtaining a type and cross match blood

 Insert and indwelling urinary catheter

 Obtain urine specimens for urinary proteins and specific gravity

 Monitor daily weights

 Assess fetal status every 4 hours

 Prepare the client for non-stress test or biophysical profile

 Administer oxygen as prescribed

 Institute safety measures

 Administer IV fluids

 Administer hydralazine (Apresoline) to reduce blood pressure

 Prepare to administer magnesium sulfate; before administering, check to make sure that urine output

is above 25 to 30 ml/hr, respirations are above 12/minute, the client can answer questions, ankle
clonus is minimal, and deep tendon reflexes are present.
 Monitor serum blood levels and maintain at 4 to 7 mg/100 ml.

 Keep a solution of 10 ml of 10% calcium gluconate at the bedside as antidote for magnesium sulfate

therapy.
For Eclampsia
 Monitor the client for signs of impending seizure

 Administer oxygen to protect the fetus

 Turn the client on left side

 Evaluate the fetus

 Administer magnesium sulfate or diazepam

 Monitor the client’s level of consciousness

 Assess for the possibility of abruptio placenta and uterine contractions

 Allow nothing by mouth (NPO)

Gestational Diabetes Mellitus/Diabetes Mellitus (DM) in Pregnancy
Description
 Is a preexisting condition that places the client at high risk during pregnancy.
 Is an endocrine disorder in which the pancreas is unable to produce adequate insulin to regulate
body glucose.
 Even a woman who has successful regulation of glucose-insulin metabolism before pregnancy is
apt to develop less than optimum control during pregnancy because of the changes occurring in
the glucose-insulin regulatory system as pregnancy progresses.
- Decreased renal threshold for sugar because of increased estrogen
- Glomerular filtration of glucose is increased
- Rate of insulin secretion is increased but the sensitivity of the body to insulin is decreased
- Insulin resistance develops
- Increased production of hormones, which affect carbohydrate and lipid metabolism, thus,
increasing concentration of glucose in the serum.
- Continued use of glucose by the fetus leads to hypoglycemia
 The primary problem is control of the balance between insulin and blood glucose to prevent
acidosis, a threat to the fetus.
 Approximately 2% to 3% of all women who do not begin a pregnancy with DM become diabetic
during pregnancy, usually at the midpoint of the pregnancy, when insulin resistance becomes
noticeable; this is called gestational diabetes.
 It places the mother and fetus at risk for problems, including fetal growth retardation; asphyxia;
abortion; stillbirth; maternal pregnancy-induced hypertension; infection; large-for-gestational-
age infants; delivery problems; infants prone to congenital anomalies, hypoglycemia, respiratory
distress syndrome, hypocalcemia, and hyperbilirubinemia; and hydramnios.
Risk Factors:
 Obesity  Family History of diabetes
 Age over 25 years  Member of a population with a high risk
 History of large babies (10 lb or more) for diabetes
 History of unexplained fetal loss
 History of unexplained perinatal loss
 History of congenital anomalies in
previous pregnancies
Signs and Symptoms
 Glycosuria
 Thirst
 Polyuria
 Possible monilial infection
 Ketonuria
 Dizziness (if hypoglycemic)
 Confusion (if hyperglycemic)
 Serum glucose greater than 140 mg/dl
with 1-hour glucose screening test
 Fasting serum glucose of 105 mg/dl or
greater with 3-hour glucose tolerance
test; 1-hour serum glucose level of 190
mg/dl or greater with 3-hour glucose
tolerance test; 2-hour serum glucose
level of 165 mg/dl or greater with 3-
hour glucose tolerance test; 3-hour
serum glucose level of 145 mg/dl or
greater with 3-hour glucose tolerance
test.
Oral Glucose Tolerance Test (Plasma Values)
TEST TYPE Pregnant mg/dl Glucose
Fasting 95
1H 180
2H 155
3H 140
Nursing Implications
 Prepare the client for glucose screening test at 24 to 28 weeks of pregnancy.
 Keep in mind that those women at high-risk for developing DM should be screened earlier in
pregnancy.
 Be aware that resistance to insulin during pregnancy requires the client to increase her insulin
dosage at about 24 weeks of pregnancy to prevent hyperglycemia.
 Warn the client that because of continued use of glucose by the fetus, she may experience
hypoglycemia between meals or overnight, especially common in the second and third
trimesters of pregnancy.
 Educate the client about necessary dietary changes, including the adherence to 1800- to 2,200-
calorie diet (or one calculated at 35 Kcal/kg of ideal weight) divided into 3 meals with 3 snacks;
urge the client to make her final snack of the day one of protein and complex carbohydrate to
prevent hypoglycemia at night.
 Instruct the client about an appropriate exercise program, including the effect of exercise on
insulin requirements.
 Reinforce instructions about insulin administration and blood glucose monitoring.
- If hypoglycemia is present, instruct the client to drink a glass of milk and eat some crackers.
- If hyperglycemia is present, instruct the client to check her urine for acetone and report the
findings to the health care professional.
 Assist with arranging diagnostic tests for evaluation of fetal well-being, such as serum alpha-
fetoprotein levels, ultrasonography, nonstress test, and biophysical profile.
 Keep in mind that following delivery, with insulin resistance gone, the client often needs no
insulin during the immediate postpartum period.

Urinary Tract Infection

 A urinary tract infection in a in a pregnant client occurs as a result of urinary stasis in ureters
that are dilated from the effect of progesterone.
 Glycosuria that occurs with pregnancy can contribute to the growth of organisms.
 The organisms most commonly responsible for urinary tract infections is Eschericia coli.
 An increase incidence of preterm labor, premature rupture of membranes, and fetal loss may be
associated with pyelonephritis.
Signs and Symptoms
 Pain in the lumbar area
 Nausea and vomiting
 Malaise
 Frequency in urination
 Fever
 Urine culture positive for over 100,000 organisms per ml of urine
Nursing Implications
 Obtain a clean-catch urine specimen for culture and sensitivity
 Instruct the client about ways to prevent UTI, such as voiding frequently, wiping from front to
back after bowel movements, wearing cotton not synthetic fiber underwear, and voiding after
intercourse.
 Encourage the client who has a UTI to increase her intake of fluids by giving her a specific
amount to drink every day, up to 3 to 4 L per hours.
 Teach the client how to promote urine drainage by assuming a knee-chest position for 15
minutes morning and evening to shift the weight of the uterus forward, freeing the ureter for
drainage.
 Know that sulfonamides are used early in pregnancy to treat UTI but should not be used near
term because they interfere with protein binding of bilirubin, which could lead to
hyperbilirubinemia in the neonate.
 Remember that tetracyclines are contraindicated in pregnancy because they cause retardation
of bone growth and staining of fetal teeth.