A. Description

1. Pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change.

2. Maternal glucose crosses the placenta, but insulin does not.

3. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions.

4. The newborn of a diabetic mother may be large in size, but has functions related to gestational age rather than size.

5. The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and congenital anomalies.

During the first trimester, maternal insulin needs decrease. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client’s insulin dose. After placental delivery, placental hormone levels abruptly decrease and insulin requirements decrease.

1. Gestational diabetes occurs in pregnancy (during the second or third trimester) in clients not previously diagnosed as diabetic and occurs when the pancreas cannot respond to the demand for more insulin.

2. Pregnant women should be screened for gestational diabetes between 24 and 28 weeks of gestation.

3. A 3-hour oral glucose tolerance test is performed to confirm gestational diabetes mellitus.

4. Gestational diabetes frequently can be treated by diet alone; however, some clients may need insulin.

5. Most women with gestational diabetes return to a euglycemic state after birth; however, these individuals have an increased risk of developing diabetes mellitus in their lifetimes.

C. Predisposing conditions to gestational diabetes

1. Older than 35 years

2. Obesity

3. Multiple gestation

4. Family history of diabetes mellitus

5. Large for gestational age fetus

D. Assessment

1. Excessive thirst

2. Hunger

3. Weight loss

4. Frequent urination

5. Blurred vision

6. Recurrent urinary tract infections and vaginal yeast infections

7. Glycosuria and ketonuria

8. Signs of gestational hypertension

9. Polyhydramnios

10. Large for gestational age fetus

E. Interventions

1. Employ diet, medications (if diet cannot control blood glucose levels), exercise, and blood glucose determinations to maintain blood glucose levels between 65 mg/dL (3.7 mmol/L) and 130 mg/dL (7.4 mmol/L) as prescribed.

2. Observe for signs of hyperglycemia, glycosuria and ketonuria, and hypoglycemia.

3. Monitor weight.

4. Increase calorie intake as prescribed, with adequate insulin therapy so that glucose moves into the cells.

5. Assess for signs of maternal complications such as preeclampsia (hypertension and proteinuria).

6. Monitor for signs of infection.

7. Instruct the client to report burning and pain on urination, vaginal discharge or itching, or any other signs of infection to the health care provider (HCP).

8. Assess fetal status and monitor for signs of fetal compromise.

Gestational diabetes mellitus

Interventions during labor

1. Monitor fetal status continuously for signs of distress and, if noted, prepare the client for immediate cesarean section.

2. Carefully regulate insulin and provide glucose intravenously as prescribed because labor depletes glycogen.

Gestational diabetes mellitus

Interventions during the postpartum period

1. Observe the mother closely for a hypoglycemic reaction because a precipitous decline in insulin requirements normally occurs (the mother may not require insulin for the first 24 hours).

2. Reregulate insulin needs as prescribed after the first day, according to blood glucose testing.

3. Assess dietary needs, based on blood glucose testing and insulin requirements.

4. Monitor for signs of infection or postpartum hemorrhage.

A. Description: A pregnant client with cardiac disease may be unable physiologically to cope with the added plasma volume and increased cardiac output that occur during pregnancy; blood volume peaks at weeks 32 to 34 and then declines slightly to week 40.

C. Assessment

1. Signs and symptoms of cardiac decompensation

a. Cough and respiratory congestion

b. Dyspnea and fatigue

c. Palpitations and tachycardia

d. Peripheral edema

e. Chest pain

2. Signs of respiratory infection

3. Signs of heart failure and pulmonary edema

D. Interventions

1. Monitor vital signs, fetal heart rate, and condition of the fetus.

2. Limit physical activities, and stress the need for sufficient rest.

3. Monitor for signs of cardiac stress and decompensation, such as cough, fatigue, dyspnea, chest pain, and tachycardia; also monitor for signs of heart failure and pulmonary edema.

4. Encourage adequate nutrition to prevent anemia, which would worsen the cardiac status; in addition, a low-sodium diet may be prescribed to prevent fluid retention and heart failure.

5. Avoid excessive weight gain.

6. During labor, prepare to do the following:

a. Monitor vital signs frequently.

b. Place the client on a cardiac monitor and on an external fetal monitor.

c. Maintain bed rest, with the client lying on her side with her head and shoulders elevated.

d. Administer oxygen as prescribed.

e. Manage pain early in labor.

f. Use controlled pushing efforts to decrease cardiac stress.

Excessive weight gain places stress on the heart. In addition, obesity places the client at increased risk for complications during pregnancy.

Group I (Mortality Rate, 1%)

▪ Corrected tetralogy of Fallot

▪ Pulmonic or tricuspid disease

▪ Mitral stenosis (classes I and II)

▪ Patent ductus arteriosus

▪ Ventricular septal defect

▪ Atrial septal defect

▪ Porcine valve

Group II (Mortality Rate, 5% to 15%)

▪ Mitral stenosis with atrial fibrillation

▪ Artificial heart valves

▪ Mitral stenosis (classes III and IV)

▪ Uncorrected tetralogy

▪ Aortic coarctation (uncomplicated)

▪ Aortic stenosis

Group III (Mortality Rate, 25% to 50%)

▪ Aortic coarctation (complicated)

▪ Myocardial infarction

▪ Marfan syndrome

▪ True cardiomyopathy

▪ Pulmonary hypertension

A. Description

1. The risks of prematurity, low birth weight, and neonatal death increase if the mother has hepatitis B infection.

2. Hepatitis is transmitted through blood, saliva, vaginal secretions, semen, and breast milk and across the placental barrier.

B. Interventions

1. Minimize the risk for intrapartum ascending infections (limit the number of vaginal examinations).

2. Remove maternal blood from the neonate immediately after birth.

3. Suction the fluids from the neonate immediately after birth.

4. Bathe the neonate before any invasive procedures.

5. Clean and dry the face and eyes of the neonate before instilling eye prophylaxis.

6. Infection of the neonate can be prevented by the administration of hepatitis B immune globulin and hepatitis B vaccine soon after birth.

7. Discourage the mother from kissing the neonate until the neonate has received the vaccine.

8. Inform the mother that the hepatitis B vaccine will be administered to the neonate and that a second dose should be administered at 1 month after birth and a third dose at 6 months after birth.

Support breast-feeding after neonatal treatment for hepatitis B; breastfeeding is not contraindicated if the neonate has been vaccinated.