C.

THIRD TRIMESTER BLEEDING

1. PLACENTA PREVIA – low implantation of the placenta

TYPES:

1. Low-lying – implantation of the placenta in the lower rather than in the upper portion of the uterus.
2. Marginal – placental edge approaches that or the cervical os
3. Partial – implantation that occludes a portion of the cervical os
4. Complete (totalis) – placenta that totally obstructs the cervical os

NORMAL PLACENTA

TOTAL PLACENTAL PREVIA

PARTIAL PLACENTA PREVIA

LOW-LYING PLACENTA PREVIA

PREDISPOSING FACTORS:

 Multiparity – single most imp. Factor

 Advanced maternal age – over 35 y/o
 Multiple pregnancies
 Uterine tumor
 Scarring from previous cs
 Decreased vascularity of upper uterine segment
= past uterine D & C
SIGNS AND SYMPTOMS:

 Painless, bright red vaginal bleeding during the 3rd trimester

 Abdomen soft, non-tender
 Ultrasound reveals placenta previa

NURSING MANAGEMENT:

1. Monitor vital signs and bleeding (weigh unused perineal pad, then weigh perineal pad soaked in blood, then subtract. The
difference is the amount of blood loss.)
2. Provide strict bed rest to minimize the risk to a fetus (CBR without BRPs)
3. Observe for further bleeding episodes. (prepare for BT) (hgb and Hct)
4. avoid vaginal examinations (NO IE). if ie is indicated, it should be done in a DOUBLE SET-UP environment. (meaning: the
Dr is prepared for a vaginal exam and for cesarean birth in case the examination precipitates profuse bleeding) wherein the
patient has already signed a consent form, pre-op meds have been given, abdominal prep has been done so that if the placenta
is accidentally detached because of manipulations, cs can be done immediately.
5. Assess fetal lung maturity
6. Observe strict aseptic technique
7. Observe PP hemorrhage
8. Provide emotional support during the grieving process.
NOTE: classical cesarian section (the uterus is incised in the vertical segment) is done in case of severe bleeding

COMPLICATION OF PLACENTA PREVIA

 Hemorrhage
 Infection
 Prematurity

NOTE: BLEEDING WITH PLACENTA PREVIA OCCURS WHEN THE LOWER UTERINE SEGMENT BEGINS TO
DIFFERENTIATE FROM THE UPPER SEGMENT LATE IN PREGNANCY (APPROXIMATELY WEEK 30 because of
uterine contractions) & THE CERVIX BEGINS TO DILATE. THE BLEEDING PLACES THE MOTHER AT RISK FOR
HEMORRHAGE. BECAUSE THE PLACENTA IS LOOSENED, THE FETAL OXYGEN MAY BE COMPROMISED”

IMMEDIATE CARE MEASURES:

= To ensure an adequate blood supply to the mother and fetus, place the woman on bed rest in a left side lying position. (LLP)

2. ABRUPTIO PLACENTA - abrupt separation of an otherwise normally implanted placenta after 20 weeks AOG before the fetus is
born. it occurs when there is bleeding & formation of a hematoma on the maternal side of the placenta.

TYPES:

1. Marginal (overt) - separation begins at the edges of the placenta allowing blood to escape from the uterus. bleeding is
external.
2. Central (covert or occult) – placenta separates at the center resulting in blood being trapped behind the placenta. bleeding
then is internal and not obvious.
TYPES OF ABRUPTION

 Mild abruptio - Develops gradually and produces mild to moderate bleeding

 Moderate abruptio - 50% placental separation abruptly produces continuous abdominal pain
 Severe abruptio - 70% abruptio, causes agonizing unremitting uterine pain

CAUSES:

1. MATERNAL HYPERTENSION (CHRONIC OR PREGNANCY-INDUCED)

2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – > 6 PREGNANCIES
4. HX of TRAUMA TO THE UTERUS
5. CIGARETTE SMOKING
6. COCAINE OR METHAMPHETAMINE HCL ABUSE

SIGNS AND SYMPTOMS:

1. sharp pain in the fundal area as the placenta separates

2. vaginal bleeding

3. rapid uterine contractions, often coming on right after another

4. uterine irritability w/ frequent low-intensity contractions

5. hard, rigid, firm, board-like abdomen caused by an accumulation of blood behind the placenta with fetal parts hard to palpate.

6. abnormal uterine tenderness that may be localized at the site of the abruption

7. signs of hypovolemic shock & fetal distress / fetal death as the placenta separates.

8. non-reassuring FHR patterns

MANAGEMENT:

1. when placenta abruptio is suspected or diagnosed, hospitalization is a must.

2. bedrest or side-lying position for optimum placental perfusion.
3. monitor vital signs, FHT, and amount of blood loss – give mask o2 if fetal distress is present.
4. delivery:
o VAGINAL DELIVERY – if there is no sign of fetal distress, bleeding is minimal & vital signs are stable.
o CESARIAN DELIVERY – if bleeding is severe, fetal distress is present & fetus cannot be delivered immediately
with a vaginal method.

COMPLICATIONS:
 1. COUVELAIRE UTERUS OR UTERINE APOPLEXY – infiltration of blood into the uterine musculature resulting in the
uterus becoming hard & copper colored.
2. HEMORRHAGE & SHOCK – treated by blood transfusion
3. DIC – managed by fibrinogen & cryoprecipitate

ABRUPTIO PLACENTA PLACENTA PREVIA

Hx Associated with PIH No association
Bleeding A single attack of bleeding Repeated warning hemorrhages
Pain tenderness Non-tender
Abdominal pain The patient is usually in labor, FHT Normal uterine tone, not in labor FHT
absent woody uterus present
Vaginal exam Placenta not palpable in the os Palpable placenta in the os
management delivery expectant

PREMATURE LABOR: (PTL) - Is labor that occurs after 20 weeks and before 38 weeks gestation characterized by regular uterine
contraction & result in cervical dilatation & effacement. It is the greatest cause of neonatal mortality & morbidity.

RISK FACTORS:

MATERNAL FACTORS:

1. Maternal Infection (leading cause)

2. Premature Rupture of Membranes (PROM)

3. Bleeding, incompetent cervix, uterine abnormalities

4. History of premature labor & Abortion

5. Overdistention of the uterus – caused by multiple pregnancies, hydramnios

6. trauma, no prenatal care, extremes of age, smoking, extreme emotional stress

FETAL FACTORS:
  Multiple pregnancies
 infections
 polyhydramnios

PLACENTAL FACTORS:

 Placental separation
 placental

COMPLICATIONS:

 Prematurity
 Fetal death
 SGA, IUGR
 Increase perinatal morbidity
 Mortality

SIGNS AND SYMPTOMS:

 Persistent, dull, low backache,

 Dx is made when there are regular uterine contractions occurring 5-8 minutes apart accompanied by:

 Progressive cervical changes

 Cervical dilatation of more than 2 cm

 Cervical effacement of 80% or more

 Duration of at least 30 secs

 10 mins apart

 Menstrual like cramping

 Watery or bloody vaginal discharge

MANAGEMENT: hospitalization > prevent premature delivery

1. Prevention – regular prenatal check-ups

2. If a fetus is less than 32-34 weeks, and still premature to be delivered, labor must be arrested:
 Bedrest on LLP (LR) to promote blood flow to the placenta
 Hydration – IV fluids oral
 Tocolytics – medications to stop uterine contractions (relaxes smooth muscles)
 Ritodrine Hcl (YUTOPAR)
 Terbutaline – (BRETHINE) (check pulse rate because it can cause tachycardia)
 MgSO4

CONTRAINDICATIONS TO ARRESTING PREMATURE LABOR:

1. Advanced pregnancy
2. Ruptured bag of waters
3. Maternal diseases like bleeding complication, PIH, heart diseases
4. Fetal distress
5. Presence of fetal problems like Rh isoimmunization
 6. Administration of GLUCOCORTICOID (CORTICOSTEROID) like BETAMETHASONE (CELESTONE) to accelerate
fetal lung maturity by stimulating the production of surfactant & prevents respiratory distress & hyaline membrane disease
(most common problem of the premature neonate).
DISCHARGES: Once contractions have stopped, & maternal and fetal conditions have stabilized, the client is discharged

HYPERTENSIVE DISORDERS IN PREGNANCY:

GESTATIONAL HYPERTENSION - hypertension that develops during pregnancy or during the first 24 hours after delivery which is not
accompanied by edema, proteinuria & convulsions & disappears within 10 days after delivery

CHRONIC HYPERTENSION - the presence of hypertension before pregnancy or hypertension that develop before 20 weeks gestation
in the absence of h-mole & persist beyond the postpartum period.

PREGNANCY-INDUCED HYPERTENSION (TOXEMIA) - hypertension that develops after the 20th week of gestation to a previously
normotensive woman.

RISK FACTORS:

1. SAID TO BE A DISEASE OF PRIMIPARAS – higher incidence in primiparas below 17 & above 35 years.
2. LOW SOCIOECONOMIC STATUS (LOW PROTEIN INTAKE)
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER, H-MOLE, DIABETES MELLITUS, MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE
4. HEREDITARY – hx of preeclampsia in mothers or sisters
5. Previous hx of preeclampsia

CAUSES:

1. THE EXACT CAUSE IS UNKNOWN = The primary cause of these & other s/Sx is damage to the endothelium ( cells that line the
blood vessels), resulting in vasospasm throughout the body
2. PROTEIN & CALCIUM DEFICIENCY THEORY
3. UTERINE ISCHEMIA
4. GENETIC PREDISPOSITION

TRIAD SX:

I. HYPERTENSION
2. EDEMA (INCREASE IN WEIGHT)
3. PROTEINURIA
= 2nd leading cause of maternal death
= chief causes of maternal death due to PIH:
- cerebral hemorrhage
- cardiac failure with pulmonary edema
- renal, hepatic or resp. failure
- obstetric hemorrhage assoc. with abruptio placenta
WARNING SIGNS:

 Rapid weight gain, 4-5 lbs in a single week

 Sudden swelling
 Swelling of face & hands
 Swelling of ankles or feet that does not go away after 12 hours rest
 A rise in BP
 Protein in the urine
  Severe headaches
 Blurry vision
 Seeing spots in the eyes ( scotoma)
 Severe pain over the stomach, under the ribs
 Decrease in the amount of urine

Signs and symptoms Mild pre-eclampsia Severe pre-eclampsia

Blood pressure 140/90; systolic elevation of 30 mm/Hg, 160/110
diastolic elevation of 15 mm/Hg
Proteinuria +1 to +2 300mg/L 24-hour urine +3 to +4 in clean catch urine or 5 g/24-
collection hour urine collection
Edema Digital edema (+1 +2) dependent edema Pitting edema (+3 +4) generalized edema
(anasarca)
Weight gain 3lbs/week More rapid weight gain
Urinary output Not less than 500 ml/24 hours Less than 500ml/24 hours; oliguria
Headache Occasional headache Severe headache
Reflexes Normal to +1 +2 Hyperreflexia, +3 +4
Visual disturbance Absent Photophobia, blurring spots before the
eyes
Epigastric pain (liver involvement) absent RUQ pain (aura to convulsion)

> With hpn, the cardiac system can be overwhelmed bec the heart is forced to pump against rising peripheral resistance. This
reduces the blood supply to organs, most markedly the kidney, pancreas, liver, brain, and placenta. Poor placental perfusion may
reduce the fetal nutrient & O2 supply. Ischemia in the pancreas may result in epigastric pain & an elevated amylase-creatinine ratio.
Spasm of the arteries in the retina leads to vision changes. If retinal hemorrhage ooccurs blindness could occur.

EDEMA:

(+1) – physiologic type in pregnancy, there is slight edema in the lower extremities ( due to pressure & posture)
(+2) – marked edema of lower extremities (pathologic)
(+3) – edema found on the face & fingers.
(+4) – generalized edema (anasarca)
 Non-pitting edema – if there is swelling or puffiness at some points in the body and a palpating finger is
depressed but the swelling cannot be indented with finger pressure

 Pitting edema – if the tissue can be indented slightly,1+ pitting edema; moderate indentation 2+; deep
indentation is 3+ & indentation is so deep it remains after removal of the finger is 4+ pitting edema

SEIZURE PRECAUTIONS:

1. side rails up
2. pad the side rails
3. put bed at lowest position.
4. room should be dim, quiet, & away from areas of activity. (avoid bright lights such as flashlights)
5. restrict visitors to allow patient to rest.
6. have emergency equipment available: - suction apparatus, o2

MEDICATIONS:
1. HYDRALAZINE – (APRESOLINE)
 - ANTIHYPERTENSIVE (PERIPHERAL VASODILATOR) USED TO DECREASE Hpn
Dosage – 5-10 mg/IV - administer slowly to avoid sudden fall in BP
- Maintain diastolic pressure at 90 mm/Hg to ensure adequate placental filling
2. MAGNESIUM SULFATE (MgSO4)
- DRUG OF CHOICE TO TREAT & PREVENT CONVULSIONS, also a muscle relaxant
- Classified as CATHARTIC – reduces edema by causing a shift in fluid from extracellular spaces into the intestine
- Loading dose is 4-6g. Maintenance dose is 1-2g/h IV
- Therapeutic dose 4-7 g
- Infuse loading dose slowly over 15-30 min.
- Always administer as a piggyback infusion
- Serum Mg level should remain below 7.5 mEq/L
ACTION OF MgSO4 = decreases neuromuscular irritability and blocks the release of acetylcholine at the neuromuscular
junction; depresses vasomotor center; depresses central nervous system (CNS) irritability

CHECK THE FOLLOWING FIRST BEFORE ADMINISTERING MgSO4:

1. deep tendon reflex present - +2 (normal)

2. RR should be at least 12 bpm
3. urine output should be at least 30 ml/hr
4. Women should be able to answer questions asked of her
NOTE: if MgSO4 toxicity develops as shown by the disappearance of the DTR, RR depression to less than 12 bpm & give
the antidote calcium gluconate & notify the physician.

- 1g/IV ( 10 ml of a 10% sol)

- have prepared at bedside when administering MgSO4

NOTE: If MgSO4 is given postpartum, monitor for uterine atony as it can cause uterine relaxation.

NURSE ALERT!! A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of
cardiac activity (EKG) through the administration of calcium gluconate is an essential part of a care

Repeat doses should not be given & physician should be notified if any of the following signs of Mg toxicity exist:
 Patellar knee jerk absent (test brachial reflexes if epidural anesthesia is present)
 Respirations less than 12/min
 Urine output less than 30 ml/hr
 Signs of fetal distress
 Elevated serum Mg levels (more than 8 mg/dl)

Symptoms of MgSO4 overdose:

 Disappearance of the DTR
 Decreased urine output
 Depressed respirations
 Reduced consciousness
Patellar reflex score:
 0 – no response, hypoactive, abnormal
 1+ - somewhat diminished response but not abnormal
 2+ Average response
  3+ Brisker than average but not abnormal
 4+ Hyperactive, very brisk, abnormal

Ankle clonus –a continuous motion of the foot (should be minimal)

 Dorsiflex the woman’s foot 3x in succession. As you take your hand away, observe the foot. If no further motion
is present, no ankle clonus is present If the foot continues to move involuntarily, clonus is present:
 Mild (2 movements)
 Moderate (2-5 movements)
 Severe (over 6 movements)

Diazepam (Valium)
 Halt seizures
 5-10 mg/IV
 Administer slowly
 The dose may be repeated every 5-10 mins (up to 30 mg/hr)
 Observe for respiratory depression or hypotension in the mother & respiratory depression & hypotonia in an
infant at birth.
PHARMACOLOGICAL MANAGEMENT OF PREGNANCY-INDUCED HYPERTENSION
Medication Side effects Nursing considerations
Magnesium sulfate Flushing, sweating CNS depressant, anticonvulsant
Symptoms of toxicity: Monitor BP, P, Rand , FHR at least every 15 min;
A sudden drop in BP, MgSO4 levels and DTR prior to administration,
respirations <12/min, mental status frequently; have resuscitation
urinary output <25-30 ml/hr,
equipment and calcium gluconate/ chloride
decreased/absent DTRs,
(antidote) in room
toxic serum levels
Hydralazine (Apresoline) Tachycardia, palpitations Vasodilator
Headache Maintain diastolic BP
Nausea and vomiting 90-100 mm Hg for adequate uteroplacental
Orthostatic hypotension flow;
monitor FHT and neonatal status
Diazepam (Valium) Risk of neonatal depression if Sedative, anticonvulsant
given within 24 h of delivery Monitor FHT and neonatal status
Methyldopa May mask symptoms of Used for chronic HTN
(Aldomet) preeclampsia; Monitor maternal, fetal, and neonatal vital signs
risk of maternal orthostatic Monitor maternal mental status
hypotension and decreased
pulse and BP in neonate for 2-
3d
Hemolytic anemia
Propranolol Decreased heart rate, Take apical rate before giving
(Inderal) depression, hypoglycemia Monitor BP, EKG

MANAGEMENT:
A. AMBULATORY MANAGEMENT
1. home management is allowed only if:
a. bp is 140/90 or below
 b. there is no proteinuria
c. there is no fetal growth retardation
d. the patient is not a young primipara.
2. bed rest- the woman should be on bed rest for most part of the day & free from physical & emotional stress.
3. the woman should consult the clinic as often as necessary.
4. diet should be high in protein & carbohydrates with moderate sodium restriction.
5. hospitalization is necessary if the condition worsens.
6. provide detailed instructions about warning signs:
a. epigastric pain –aura to convulsion
b. visual disturbances
c. severe continuous headache
d. nausea & vomiting

B. HOSPITAL MANAGEMENT
1. BP GOES ABOVE 140/90 mm Hg
2. BED REST IS ONE OF THE MOST IMPORTANT PRINCIPLES OF CARE.
a. rest in left lateral position to promote blood supply to the placenta & the fetus.

SIGNS AND SYMPTOMS OF ECLAMPSIA:

1. all the signs & symptoms of preeclampsia
2. convulsion followed by coma is the main difference of eclampsia & preeclampsia
3. oliguria

RESPONSIBILITIES DURING A CONVULSION

1. always monitor the patient for impending signs of convulsion: epigastric pain, severe headache, nausea &
vomiting.
2. the main responsibilities of a nurse during a convulsion are: maintenance of the patent airway & protection of
the patient from injury.
3. turn the patient to her side to allow drainage of saliva & prevent aspiration.
4. never leave an eclamptic patient alone
5. do not restrict movement during a convulsion as this could result in fractures.
6. watch for signs of abruptio placenta: vaginal bleeding, abdominal pain, decreased fetal activity.
7. take vital signs & FHT after a convulsion.
8. do not give anything by mouth unless the woman is fully awake after a convulsion
 THE ONLY KNOWN CURE OF PIH IS DELIVERY OF THE BABY.
 as soon as the baby is stable, the baby is delivered.
 the preferred method of delivery is vaginal.
 if labor induction is unsuccessful & fetal distress is so severe that the fetus needs to be delivered, cesarian section is
performed.
POSTPARTUM CARE:
1. the danger of convulsion exists until 24 hours after delivery. mgso4 therapy is continued until the immediate 24
hours postpartum.
2. ergot products are contraindicated because they are hypertensives.
 3. two years should elapse before another pregnancy is attempted to decrease the likelihood that PIH will recur on
the subsequent pregnancy.
NURSE ALERTS!!! = The risk of preeclampsia is increased for multigravida women if they have a new partner (father of
the baby different than the previous children) due to new genetic makeup of the fetus.

HELLP SYNDROME
 H – hemolysis
 EL – elevated liver enzymes
 LP – low platelets
 Severe case of PIH
 Cause is unknown
 Occurs in both primis and multis
SIGNS AND SYMPTOMS:
 nausea, epigastric pain, general malaise, right upper quadrant tenderness

LABORATORY RESULTS:
 hemolysis of RBC (fragmented on a peripheral blood smear is seen in the abnormal morphology of the cells),
thrombocytopenia ( platelet count below 100,000/mm3) r/t vasospasm & platelet adhesions & elevated liver
enzymes (ALT) alanine amino transferase ( AST) serum aspartate aminotransferase – associated with a
decreased blood flow to the liver as a result of fibrin thrombi.

MANAGEMENTS:

 TRANSFUSION OF FRESH FROZEN PLASMA

CX: liver hematoma, hyponatremia, renal failure, hypoglycemia.

METHOD OF DELIVERY PREFERRED:

 vaginal or CS

NOTE: Maternal bleeding may occur at birth because of poor clotting ability. Epidural anesthesia may not be possible
because of the low platelet count and the high possibility of bleeding at the epidural site

GESTATIONAL DIABETES MELLITUS - DM is a hereditary endocrine disorder due to inadequate or lack of insulin
production that results in impaired glucose absorption & metabolism.
- women appear to develop an insulin resistance as pregnancy progresses (insulin does not seem normally effective
during pregnancy) a phenomenon that is probably caused by the presence of the hormone Human Placental
Lactogen (HPL)

SIGNS AND SYMPTOMS:

1. Hyperglycemia - pancreas does not produce enough insulin, thus glucose is unable to enter the cells &
accumulates in the bloodstream resulting in hyperglycemia

2. Glycosuria –when blood glucose levels go beyond the renal threshold for sugar, glucose spills on the urine.

3. Polyuria – glucose attracts water so that when it is excreted in the kidney, it brings along with it large amounts
of water resulting in the woman excreting large amounts of urine, a condition called, POLYURIA.

4. Polydipsia – the excretion of large amounts of fluid from the body leads to dehydration. Excessive thirst or
polydipsia is an important symptom of dehydration.
EFFECTS OF DIABETES:

MOTHER:

1. Increased tendency to pre-eclampsia & eclampsia, UTI, & candidiasis

2. Increased risk for postpartum hemorrhage d/t overdistention of the uterus.
3. Maternal mortality
4. Preterm delivery

INFANT:

1. Macrosomia
2. Hydramnios
3. Prematurity
4. Hypoglycemia (lowered serum glucose levels)
5. Predisposition to diabetes mellitus later in life as the disease is hereditary
6. Birth injury

COMPLICATIONS:

1. Macrosomia – Infants of women with poorly controlled diabetes tend to be large ( more than 10 lbs.) because
glucose can cross the placental barrier, it acts as a growth stimulant. The increased glucose adds subcutaneous
fat deposits. All the nutrients that the fetus receives comes directly from the mother’s blood.

2. Birth Injury – may occur due to the baby’s large size and difficulty being born. (may cause CPD which may
necessitate being born by CS)

3. HYPOGLYCEMIA – refers to low blood sugar in the baby immediately after delivery. This problem occurs if the
mother’s blood sugar levels have been consistently high, causing the fetus to have a high level of insulin in its
circulation. After delivery, the baby continues to have a high insulin level, but no longer has the high level of
sugar from its mother, resulting in the newborn’s blood sugar level becoming very low. The baby’s blood sugar
level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously
 4. Respiratory distress (difficulty breathing) – too much insulin or too much glucose in a baby’s system may delay
lung maturation and cause respiratory difficulties in babies. This is more likely if they are born before 37 weeks
of pregnancy.

PRENATAL MANAGEMENT:

1. Diagnosis; Suspect DM in a woman

a. With a family history of DM

b. With a history of unexplained repeated abortions and stillbirth
c. With glycosuria
d. Who are obese?
e. Who have history of giving birth to large infants, over 10 lbs. and infants with congenital anomaly?

2. Screening tests
 Universal screening- 50-gram oral glucose tolerance test (OGTT) between 24-28 weeks gestation regardless of
the time of the day and meals are taken for all pregnant women. If the plasma value is more than 140 mg/dl
after one hour, 100-gram three-hour oral glucose tolerance test is performed to confirm if the woman is
having hyperglycemia.
1. DIET
a. Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,800 to 2,400 cal/day) but
not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50%
from carbohydrates, 30% from fats.
b. Weight gain should be about 24-25 lbs. Too much weight gain can lead to large infants and cephalopelvic
disproportion.
c. The goal is to maintain a fasting blood sugar level of 80 mg/dl and postprandial blood sugar level of 110mg/dl
2. Exercise
a. A liberal cardiovascular-conditioning exercise and diet therapy is the management for Gestational Diabetes
Mellitus
b. Exercise lowers blood glucose levels and decreases the need for insulin.
c. The exercise regimen should be individualized, performed regularly and under supervision.
d. Advise woman to eat complex carbohydrates before exercising to prevent hypoglycemia.

Remember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin:

 Short acting or regular insulin – after 2-3 hours of injection

 Intermediate or Lente insulin – after 6-8 hours of injection

 Long-acting or ultralente – after 16 – 18 hours of injection

 The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision

 Give a hypoglycemic person a glass of orange juice.

INSULIN THERAPY

• Insulin requirements increase during pregnancy

• Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are
teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia.
• Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of
choice during pregnancy because it is the least allergenic
 • 2/3 in the morning, 1/3 at dinner administered subcutaneously ½ hour before meals.
• Insulin requirement is decreased on the first trimester due to nausea & vomiting and highest during the third
trimester.

DELIVERY
1. Delivery is affected when the fetus is mature enough after 38 weeks gestation, but not too large so as to cause
cephalopelvic disproportion. Thus, early hospitalization and labor induction is performed to deliver the baby
before it becomes too large to pass the birth canal

2. If the cervix is not yet ripe, the baby is macrocosmic and fetal distress occurs, CS is performed

3. Regular insulin is given on the day of delivery not long-acting insulin because insulin requirement drops
immediately after delivery. The woman may not require insulin during the first 24 hours postpartum and her
insulin requirements usually fluctuates during the next few days.

CONTRACEPTION

A. IUD and combined oral contraceptives are contraindicated

> Progesterone interferes with insulin activity therefore increases blood glucose levels.

> Estrogen increases lipid & cholesterol levels & risk for increased blood coagulation

B. Norplant (subcutaneous progestin implant system) or Depo -provera may be good choices & safely used by
diabetic women

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

 Disorder of blood clotting
= Fibrinogen levels fall below effective limits
 Symptoms
= Bruising or bleeding
= massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may
result in tissue damage from multiple thrombil), which in turn stimulate fibrolytic activity, resulting in decreased
platelet and fibrinogen level and
= signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis,
hematuria, etc.)
 Monitor PT, PTT, and Hct, protect from injury; no IM injection; early anticoagulant therapy is controversial.

CLASSIFICATION OF CARDIAC DISEASE

CLASS I (Shows no signs of cardiac insufficiency) = no limitation of activity

CLASS II (Ordinary physical activity may result in = slight limitation of activity
 discomfort and signs of cardiac insufficiency)
CLASS III (Less than ordinary activity results in excessive = marked limitation of activity
feeling of fatigue, dyspnea)
CLASS IV (Signs of cardiac insufficiency may be = severe limitation; symptoms present even at rest
experienced even at rest; physical activity increases)
NOTE: Class I and II usually do well in pregnancy

NEW YORK HEART ASSOCIATION

 CLASS I
o Ordinary physical activity does not cause dyspnea, chest pain and undue fatigue
o No pulmonary congestion
o Asymptomatic
o No limitation of ADL’s
 CLASS II
o Slight limitation of ADL’s
o No symptoms at rest but symptoms with increased activity
o Basilar crackles and S3 murmur mat be detected.
 CLASS III
o Markedly limitation on ADL’s
o Comfortable at rest but symptoms present in less than ordinary activity
 CLASS IV
o Symptoms are present even at rest
NURSE ALERT:
“Remember a pregnant woman with heart disease should avoid infection, excessive weight gain, edema and anemia
because these conditions increase the workload of the heart.”

MANAGEMENT CARE:
1. Promotion of rest (class I & class II)
o 8 hours of sleep during the night and have frequent rest periods during the day.
o Light work is allowed but no heavy work, no stair climbing, no exhaustion.
2. Diet
o High in iron, protein, minerals and vitamins
3. Avoid high attitudes, smoking areas, unpressurized planes & overcrowded areas. cigarette smoking & alcoholic
beverages are strictly prohibited.
4. Prevention of infection
o Avoid person with active infections (colds, cough)
o Early treatment of infections
5. Provide instructions on danger signs of heart failure:
o Cough with crackles is usually the first sign of impending heart failure.
o Increase dyspnea, tachycardia, rales, edema

MEDICATIONS
 Iron supplementation to prevent anemia
 Digitalis to strengthen myocardial contraction and slow down heart rate
  Nitroglycerine to relieve chest pain
 Antibiotics to prevent and treat infection
 Diuretics may be prescribed in case of heart failure

INTRAPARTAL CARE:
1. Early hospitalization – woman is hospitalized before labor begins to promote rest, for closer supervision and
prevent infection
2. Woman labor’s in semi-fowler’s position or left lateral recumbent position. No lithotomy positions
3. Vital signs - vital signs are monitored continuously. tachycardia and respiratory rate more than 24 are signs of
impending cardiac decompensation. during the first stage, monitor vital signs every 15 minutes and more
frequently during the second stage
4. Epidural anesthesia- is instituted for painless and push less delivery. forceps is used to shorten the second stage.
pushing is contraindicated
5. Women with heart disease are poor candidate for cs due to increased risk for hemorrhage, *infection and
thromboembolism

POSTPARTUM CARE
1. The most dangerous period is the immediate postpartum because of the sudden increase in circulatory blood
volume.
2. monitor vital signs
3. Promote rest- restrict visitors to allow patient to rest, the woman stays in the hospital longer, until cardiac
status has stabilized.
4. early but gradual ambulation to prevent thrombophlebitis.
5. Medications
o antibiotics
o stool softeners to prevent straining at stool caused by constipation. sedatives may be ordered to promote
rest.