Clinical Manifestations:Severe nausea and vomiting Severe dehydration-fluid lossElectrolyte imbalance:

Hypokalemia Hyponatremia

Ketosis- Ketones in the urine (Ketonuria)Metabolic acidosisWeight lossBleeding gums

Complications:Metabolic acidosisStarvation/malnutritionAcid-base imbalanceMaternal deathFetal problems (CNS malformation, IUGR)Termination of pregnancy

NURSING CARE: IV therapy with replacement of electrolytes and

possible TPN.Maintain NPO status for 24-48 hour vomiting has

stoppedFacilitate the client’s environment- quiet , stress

free, and odor free Assess and Monitor:

VS, I&O, Daily wt. Nutritional status, Emotional support. Laboratory studies: CBC, UA, Serum chemistries, and

liver function studiesAdminister antiemetics- Relgan , Zofran,

Nursing Care:After vomiting has stopped diet progresses

slowly : Clear liquids Bland diet – cold foods first, small servings, without fluid Regular diet

Teach client about the disease process, procedures and treatments, diet, medications, and follow up care

Provide emotional supportMonitor Fetus if ordered.

Diabetes Mellitus Cardiac disease or conditions Hypothyroidism Hyperthyroidism Anemia’s Rh sensitization Systemic Lupus erythematosus Anticardiolipin Antibody Syndrome Myasthenia gravis Renal Disease Epilepsy Asthma

DIABETES MELLITUS is an endocrine order in which major effect is on carbohydrate metabolism and is the results from an inadequate product of insulin or insulin resistance

Classification of DM:Pregestational:

Type I Type II

Gestational: Type III (GDM)

White’s Classifications of diabetes in pregnancy

Pregestational Diabetes: It is best if the client have her diabetes mellitus

under control before getting pregnant. Blood sugars in normal ranges

Preconceptual care and guidanceType I:

Insulin therapy will vary Complications:

KetoacidosisFetal problems-IUGR

Type II: Possible oral agent will be change or change to Insulin Fetal problems

Gestational Diabetes Mellitus is the result of the pancreas is unable to meet the increase demands for insulin production during pregnancy and/or insulin resistance from various hormones during pregnancy: Increase cortisol level Placenta hormones-Human Placenta lactogen (hPL),

insulinase GDM starting in the last half of the pregnancy

around 28-32 weeks) Client may show Clinical Manifestations of DM and

problems with immune system-Freq. UTI’s and can

It is diagnosis by : Elevated blood glucose levels GTT-1 hour or 3hour

Review clinical manifestations of:Diabetes mellitusHypoglycemiaHyperglycemiaDiabetes Ketoacidosis (DKA)Normal Adult Blood Glucose Levels

Risk factors for GDM(Class A) :PregnancyObesityPrevious large infants,previous unexplained stillborn

Complications: Varies with the degree of extent of disease process of

DM Preeclampsia Polyhydraminos Abortion Fetal Anomalies‘- Cardiac and Neurolical defects Stillbirth Neonatal Problems:

Macrosomia Hypoglycemia Hyperbilirubinemia Delayed lung maturity? RDS

NURSING CARE:Facilitate maintaining blood glucose levels within

normal levels: Teach or review:

ADA diet Assessing Blood glucose Exercise Medications:

NO Oral Hypoglycemic Agents ( except for those that do not cross the placenta)

InsulinMonitor fetal well being- FMC and other

Calories- 30-35 kcal/IBW(Kg) in first trimester and 35-36 Kcal/IBW(Kg) per day.

3-4 small meals and 3-4 snack per day Bedtime snack important with at least

25grams of carbohydrates At least 250 Grams of carbohydrates per

day. Carbohydrates- 50-60% of calories Protein-12-20% of calories Fats-limited to under 30grams according

to ADA & AHA

Nursing Care:Monitor client for development of complicationsPrepare for possible preterm delivery or cesarean

section. Intrapartum care will depend on the extent of the

disease process and blood glucose levels- IV Insulin therapy maybe used.

Maintain postpartum blood glucose levels ( blood glucose levels will drop in this period because of hormonal influences of pregnancy decrease and stop-about 3-4days after delivery.)

Careful observation of the neonate whose mother has DM.

CARDIAC DISEASE and pregnancy :Because of the hemodynamic changes that occur

in pregnancy the client who has a cardiac disorder will have problems and complications.

Outcomes will depend on the degree of cardiac compromise. See NYHA Classifications of heart disease.

Clients who have a history of Rheumatic fever may have undiagnosed cardiac effects, and may need further evaluation.

Client will never to be seen by Cardiologist and Perinatalogist

NSG. DX- Decrease cardiac output, Fluid volume excess, Activity intolerance, Risk for infection, Anxiety.

Classification Functional Capacity

Asymptomatic will normal levels of activity-No physical limitations

Slightly compromisedSymptomatic with greater

than ordinary physical activity

Marked compromised Symptomatic with ordinary

activity Severely compromised Symptomatic at bed rest

I

II

III

IV

Complications:Decreased cardiac output and altered blood flowDecreased maternal and fetal perfusionCongestive heart failurePreterm deliveryDeath

NURSING CARE: Teach client to maintain healthy life style:

Adequate nutrition for pregnancy Take Prenatal vitamins and iron to prevent anemia Avoid excessive weight gain Stress management Exercise such as walking No over exertion and frequent rest periods Monitor for signs of infection Go to all appointments with her physicians Monitor fetal well being with FMC Report signs of cardiac decompensation ( heart

failure)to health care providers

Assess and monitor for signs of cardiac decompensation.

Medication therapy:Prenatal vitamins and iron Stool softenersProphylactic Antibiotics with any invasive

procedures and before deliveryCardiac glycosides (digitalis)Antidysrhythmia agents Furosemide (Lasix) – only with CHFHeparin if anticoagulant therapy is needed No warfarin (Coumadin)

Nursing Care: Head of bed elevated Labor:

Avoid excessive stress Epidural anesthesia is preferred No prolonged pushing in labor- forceps or vacuum

extraction may be used Postpartum:

Continue prenatal vitamins and iron Frequent rest periods No staining with BM’s Monitor closely during this period for cardiac

decompensation

Iron Deficiency Anemia ( Microcyctic) Folic Acid Deficiency Anemia (Macrocyctic) Sickle Cell Anemia ETC. Any problem with low RBC’s will effect

oxygenation to maternal and fetal tissues

Iron Deficiency Anemia is a result of a decrease intake of iron. It can range from mild to severe. The decrease of RBC’s can effect the transportation of oxygen to the maternal organs and to the fetus.

All pregnant women need to increase their intake of iron during pregnancy through diet or supplements

Foods high in Iron.

SICKLE CELL DISORDER is a heterozygous form of hemoglobin S (HbAS) that is common in people from the Mediterrian area and Africa. It is an Autosomal Recessive Disorder.

Sickle Cell Anemia(SCA) is the most common inherited anemia complicating pregnancy.

SCA Crisis because of the stress of the pregnancy.

Clinical manifestations of SCA Crisis: Hemolytic anemia Pain in joints , back, abdomen, extremities Blood clots Infections Infarction to organs

Precipitated factors for SCA Crisis :HypoxiaAcidosisDehydrationStressColdInfection

Complications of SCA CRISIS:Vaso-occlusion CrisisPainPulmonary emboliFolic anemia Fetal problems:

IUGR Stillborn Hypoxia

NURSING CARE:Asses and monitor client for clinical

manifestations of SCA Crisis and complications

Provide the client a warm environment, and hydration ,possible blood transfusions

Be prepared to start IV, give O2, analgesia.Medications:

Folic Acid Heparin- not warfarin Analgesia-NO ASA and Demerol