ANTE--PARTUM. Lecture 3. Medical Disorders, Substance Use &Infectious Diseases in Pregnancy Flashcards
Diabetes Defined. Diabetes in Pregnancy
Disease process marked by impaired production of, or impaired response to, insulin.
Disease process leads to hyperglycemia.
Chronic, untreated disease causes secondary effects in multiple body systems.
Diabetes Classifications
Type 1 Diabetes Mellitus:
Characteristics: Autoimmune condition where the body’s immune system attacks and destroys insulin-producing beta cells in the pancreas.
Onset: Typically occurs before the age of 30.
Mechanism: Results in insulin deficiency, requiring exogenous (external) insulin administration for blood sugar control.
Type 2 Diabetes Mellitus:
Characteristics: Associated with insulin resistance (cells not responding effectively to insulin) and often insulin deficiency over time.
Risk Factors: Obesity, sedentary lifestyle, genetics.
Onset: Can be seen across all age groups, but more common in older individuals.
Ethnic Variations: More prevalent in specific ethnic groups such as African Americans, Hispanic Americans, Native Americans, and Asian Americans.
Gestational Diabetes:
Characteristics: Occurs during pregnancy and is characterized by glucose intolerance.
Management: Gestational Diabetes Mellitus (GDM) can be managed through diet (GDMA1) or medications (GDMA2) when diet alone is insufficient.
Prevalence: Affects up to 10% of pregnancies in the United States.
Diabetes 2/2 Other Causes:
Causes: Diabetes can also be caused by factors other than the typical mechanisms of type 1 and type 2 diabetes. These include drug-induced diabetes (resulting from certain medications), diabetes caused by specific diseases or medical procedures.
Blood test levels used for the diagnosis of diabetes and prediabetes.
Diabetes:
A1C (percent): 6.5% or above
Fasting Plasma Glucose (mg/dL): 126 mg/dL or above
Oral Glucose Tolerance Test (2-hour value, mg/dL): 200 mg/dL or above
Prediabetes:
A1C (percent): 5.7% to 6.4%
Fasting Plasma Glucose (mg/dL): 100 mg/dL to 125 mg/dL
Oral Glucose Tolerance Test (2-hour value, mg/dL): 140 mg/dL to 199 mg/dL
Normal:
A1C (percent): About 5% (typically considered normal)
Fasting Plasma Glucose (mg/dL): 99 mg/dL or below
Oral Glucose Tolerance Test (2-hour value, mg/dL): 139 mg/dL or below
Diabetes in Pregnancy
Gestational Diabetes Mellitus (GDM):
GDM is a type of diabetes that develops during pregnancy and is characterized by elevated blood sugar levels. It usually occurs in the second or third trimester and is often managed through diet, exercise, and, in some cases, medications. GDM increases the risk of complications for both the mother and the baby during pregnancy.
Risks Associated with GDM:
Postpartum GDM Diagnosis:
Up to 10% of pregnant individuals who had GDM will continue to exhibit glucose intolerance and may be diagnosed with GDM even after giving birth.
Risk of Future Type 2 Diabetes:
Approximately 30-65% of individuals who experienced GDM during pregnancy have an increased risk of developing type 2 diabetes mellitus later in life, typically within 10-20 years after the pregnancy
GDM Risk Factors
Previous Pregnancy Affected by GDM: If a person had gestational diabetes in a previous pregnancy, their risk of developing GDM again in a subsequent pregnancy is increased.
History of Delivering a Large Baby (Infant >9 pounds): This can be an indicator of previous gestational diabetes and may increase the risk of GDM in future pregnancies.
Membership in an Ethnic Group with High Risk: Certain ethnic groups, such as African Americans, Hispanic Americans, Native Americans, and Asian Americans, have a higher risk of developing GDM.
Obesity: Being overweight or obese prior to pregnancy increases the risk of developing GDM.
Physical Inactivity: A sedentary lifestyle and lack of regular physical activity can contribute to the development of GDM.
Polycystic Ovary Syndrome (PCOS): PCOS is a condition characterized by hormonal imbalances and can increase the risk of GDM.
Hypercholesterolemia: High cholesterol levels may be associated with an increased risk of GDM. Insulin Resistance: Both hypercholesterolemia and GDM are associated with insulin resistance.
First-Degree Relative with Diabetes: Having a close family member (parent, sibling) with diabetes can increase the risk of developing GDM. Usually starts during pregnancy
Hypertension (High Blood Pressure): Having hypertension may contribute to an increased risk of GDM.
Diabetes Risk Assessment in pregnant women.
Nursing Care
Factors Associated with Lower Diabetes Risk:
No History of Glucose Intolerance: Individuals who have not previously shown signs of glucose intolerance have a lower risk of diabetes.
Younger than 25 Years Old: Younger age can be associated with a lower risk of developing diabetes.
Normal Body Weight: Maintaining a normal body weight and body mass index (BMI) is associated with a reduced risk of diabetes.
No Family History (First-Degree Relative) of Diabetes: The absence of a family history of diabetes, especially in first-degree relatives (parents, siblings), is generally associated with a lower risk.
No History of Poor Obstetric Outcomes: Not having a history of complications during pregnancy, such as gestational diabetes or delivering a large baby, may contribute to lower diabetes risk.
Not from an Ethnic/Racial Group with a High Prevalence of Diabetes: Certain ethnic and racial groups, as mentioned in the American Diabetes Association (ADA) guidelines, have a higher prevalence of diabetes. Not belonging to these groups may lower the risk.
GDM Sub-types
Class A-1 GDM (GDMA1 or A1GDM):
Characteristics:
Involves 2 abnormal values on an oral glucose tolerance test (OGTT).
Managed with diet control, meaning blood sugar levels are managed primarily through dietary adjustments and lifestyle modifications.
Fasting blood glucose levels are within the normal range.
Class A-2 GDM (GDMA2 or A2GDM):
Characteristics:
Managed with medication, indicating that medication is required to help control blood sugar levels.
No prior diagnosis of pregestational diabetes, meaning the diabetes developed during pregnancy and is not a preexisting condition.
Metabolic Changesin Pregnancy
Metabolism for Fetal Nutrition:
During pregnancy, the mother’s body shifts its metabolic processes to prioritize providing essential nutrients to the developing fetus. This ensures that the fetus receives the necessary nutrients for growth and development.
Increased Insulin Resistance:
Hormones such as estrogen, progesterone, human chorionic somatomammotropin (Hcs), cortisol, and human placental lactogen, which are released by the placenta, contribute to an increased resistance to insulin. Insulin resistance means that the body’s cells become less responsive to the effects of insulin, leading to elevated blood sugar levels.
Compensatory Insulin Production:
In response to the increased insulin resistance, the pancreas compensates by producing higher levels of insulin. This helps to regulate blood sugar levels and ensures that the mother’s body can still utilize glucose for energy despite the increased resistance.
Postpartum Return to Pre-Pregnant Metabolism:
After childbirth, the hormonal changes that contributed to insulin resistance start to normalize. As a result, the body’s insulin sensitivity improves, and the need for the heightened insulin production seen during pregnancy decreases. This gradual return to pre-pregnant metabolism allows the body to readjust its metabolic processes.
1st Trimester Metabolic Changesin Pregnancy
First Trimester Metabolic Changes:
Estrogen and Progesterone Effect on Beta Cells:
Hormones like estrogen and progesterone stimulate the insulin-producing beta cells in the pancreas to increase the production of insulin. This is important to meet the potential increased demand for insulin as the pregnancy progresses.
Increased Insulin Sensitivity:
During the first trimester, some individuals experience an increase in insulin sensitivity. This means that the body’s cells respond more effectively to the action of insulin, helping to regulate blood sugar levels.
Increased Glucose Metabolism and Decreased Blood Glucose:
The increased insulin production and improved insulin sensitivity lead to greater uptake and utilization of glucose by the cells. This results in lower blood glucose levels in the mother’s circulation.
Glycogen Stores and Glucose Production:
The body increases its storage of glycogen, a form of stored glucose, during the first trimester. At the same time, glucose production in the liver may decrease, contributing to the overall reduction in blood glucose levels.
Risk of Hypoglycemia in Pre-Gestational Diabetes:
In individuals with pre-gestational diabetes (diabetes that existed before pregnancy), the increased insulin sensitivity and enhanced insulin production can potentially lead to episodes of hypoglycemia (low blood sugar). This highlights the importance of careful monitoring, appropriate medication adjustment, and dietary management in pregnant individuals with diabetes.
2nd and 3rd Trimesters Metabolic Changesin Pregnancy
Second and Third Trimester Metabolic Changes:
Increased Insulin Resistance:
As pregnancy progresses, there is a natural increase in insulin resistance. This means that the body’s cells become less responsive to the effects of insulin. Insulin resistance ensures that an adequate supply of glucose is available for the fetus while maintaining appropriate glucose levels in the mother’s bloodstream.
Increased Hepatic Glucose Production: (Baby need more energy/food now that it’s bigger , more demand )
The liver increases its production of glucose during the later stages of pregnancy. This helps to maintain a steady supply of glucose to support the energy needs of the developing fetus.
Storage of Extra Glucose by Fetus: (baby thinking about when they are gonna leave the womb “provisiones”)
The extra glucose that is provided to the fetus is stored primarily as glycogen. Glycogen is a form of stored glucose, and the fetus stores it in its liver and muscles for future energy needs.
Maternal Nutrient Transfer:
The placenta plays a critical role in nutrient transfer from the mother to the fetus. Glucose, along with other nutrients, is transported across the placenta to support fetal growth and development.
Gestational Diabetes Screening
1st Trimester Screening for High-Risk Clients:
High-risk individuals, such as those with a history of gestational diabetes or other risk factors, may be screened for gestational diabetes during the first trimester. This early screening helps identify those who may need more intensive monitoring and care.
Inconsistent Practices:
Screening practices for gestational diabetes can vary based on healthcare provider preferences, guidelines, and patient risk factors. Some providers might conduct early screenings, while others may follow routine guidelines.
Routine Screening: 24-28 Weeks:
A common practice is to conduct routine screening for gestational diabetes between the 24th and 28th weeks of pregnancy. This is the time when insulin resistance typically increases, and the body’s ability to manage blood sugar levels may be challenged.
Glucose Challenge Test (GCT):
The glucose challenge test involves drinking a glucose solution and having blood sugar levels tested about an hour later. If the result is elevated, it might indicate the need for further testing.
Glucose Tolerance Test (GTT) if Indicated:
If the results of the glucose challenge test are abnormal, a more comprehensive test called the glucose tolerance test (GTT) might be recommended. The GTT involves fasting overnight and then drinking a more concentrated glucose solution, followed by multiple blood sugar measurements over a few hours.
ACOG Two-Step Approach:
The American College of Obstetricians and Gynecologists (ACOG) recommends a two-step approach to diagnosing gestational diabetes. This involves an initial glucose challenge test (GCT) followed by a glucose tolerance test (GTT) if the GCT results are above a certain threshold.
Testing:
Glucose Load vs. Glucose Tolerance
Oral Glucose Load Test (OGLT or GLT):
Administration of Glucose Solution: A 50g oral glucose solution (often referred to as Glucola) is administered to the individual orally.
1-Hour Blood Glucose Measurement: After consuming the glucose solution, a venous blood sample is drawn one hour later to measure the blood glucose level.
If the 1-hour venous blood glucose level is greater than 139 mg/dL, it may indicate elevated blood sugar, and the individual and the person is referred for further testing, such as the Oral Glucose Tolerance Test (OGTT aka GTT).
Some Labs Use 75g Load/2-Hour Blood Glucose: In some cases, a larger glucose load of 75g may be used, and blood glucose levels are measured at the 1-hour and 2-hour marks.
Oral Glucose Tolerance Test (OGTT or GTT):
Fasting Blood Glucose Measurement: The individual’s fasting venous blood glucose level is measured after an overnight fast.
Administration of Glucose Solution: A 100g oral glucose solution is administered orally.
Multiple Blood Glucose Measurements: Blood glucose levels are measured at various time intervals, including 1 hour, 2 hours, and 3 hours after consuming the glucose solution.
Testing:
Glucose Load vs. Glucose Tolerance cont’d
Oral Glucose Tolerance Test (OGTT) Normal Values:
Fasting Blood Glucose: Less than 95 mg/dL
One-Hour Blood Glucose: Less than 180 mg/dL
Two-Hour Blood Glucose: Less than 155 mg/dL
Three-Hour Blood Glucose: Less than 140 mg/dL
GDM Diagnosis Criteria:
If two or more of the blood glucose values obtained during the OGTT are elevated beyond the established normal values, it may lead to a diagnosis of gestational diabetes mellitus (GDM).
These values are used to determine whether an individual’s blood glucose levels fall within the normal range or if they have gestational diabetes. If two or more of the blood glucose measurements exceed the specified normal values, it suggests impaired glucose tolerance and an increased risk of complications for both the mother and the developing fetus.
Complications ofGDM: Pregnant Person
Complications of GDM for the Pregnant Person:
Polyhydramnios (Hydramnios):
Elevated blood sugar levels can lead to increased fetal diuresis (excess urine production), which may result in excessive amniotic fluid accumulation around the fetus. This condition is known as polyhydramnios or hydramnios.
Abnormal Blood Glucose:
Poorly controlled blood sugar levels in the mother can affect her own health, potentially leading to symptoms of hyperglycemia or hypoglycemia.
Pre-eclampsia and Hypertension (Gestational Hypertension - GHTN):
GDM can increase the risk of developing pre-eclampsia or gestational hypertension, both of which involve elevated blood pressure and potential complications for the mother’s health.
Ketoacidosis:
In severe cases of uncontrolled diabetes, diabetic ketoacidosis (DKA) can occur. This is a serious condition characterized by the body breaking down fats for energy, leading to the accumulation of acidic byproducts.
Cesarean Section (C-Section):
GDM increases the likelihood of needing a cesarean section due to concerns related to the size of the baby and other complications.
Instrument-Assisted Delivery:
Instrument-assisted deliveries, such as vacuum extraction or forceps, may be needed to assist in the delivery process if there are complications related to GDM.
Shoulder Dystocia:
Shoulder dystocia can occur during labor when the baby’s head passes through the birth canal, but the shoulders get stuck behind the mother’s pelvic bone. This can be more likely in larger babies, which can be a concern in GDM. Coz that extra sugar becomes fat and is stored in shoulders
Spontaneous Abortion (SAB):
Uncontrolled blood sugar levels can potentially increase the risk of pregnancy loss or spontaneous abortion.
Infections:
Women with GDM might have an increased risk of urinary tract infections (UTIs) and chronic monilial vaginitis (yeast infections). Coz they have + food
ASSESSING the Pregnant Woman With Diabetes Mellitus
Assessments for Pregnant Individuals with Diabetes Mellitus:
Dizziness (Hypoglycemia): (Neurons in the brain use mainly sugar to function. No glucose = energy and no energy= dizziness) Dizziness can be a symptom of hypoglycemia (low blood sugar), which is a potential concern in individuals with diabetes. Hypoglycemia during pregnancy requires prompt management to ensure the safety of both the mother and the baby.
Confusion (Hyperglycemia): Confusion can arise from high blood sugar levels (hyperglycemia). Monitoring blood sugar levels and managing hyperglycemia is crucial to prevent complications.
Thirst: Excessive thirst can be a sign of elevated blood sugar levels, leading to increased fluid intake.
Congenital Anomalies: Pregnant individuals with poorly controlled diabetes are at an increased risk of having a baby with congenital anomalies. Careful monitoring and management of blood sugar levels are essential to reduce this risk.
Macrosomia: Macrosomia refers to a larger-than-average baby at birth due to high blood sugar levels during pregnancy. This can lead to delivery complications and increase the risk of cesarean section.
Poor Fetal Heart Tone Variability: Elevated blood sugar levels can impact fetal tissue perfusion, leading to poor fetal heart tone variability and heart rate.
Glycosuria and Polyuria: Glycosuria (glucose in urine) and polyuria (increased urination) can be signs of poorly controlled blood sugar levels.
Hyperglycemia: Elevated blood sugar levels can have numerous negative effects on the mother’s and baby’s health, highlighting the importance of monitoring and management.
Increased Risk of Pregnancy-Induced Hypertension: Pregnant individuals with diabetes are at a higher risk of developing pregnancy-induced hypertension.
Hydramnios (Polyhydramnios): Excessive amniotic fluid accumulation around the fetus can result from elevated blood sugar levels.
Increased Risk of Monilial (Yeast) Infection: High blood sugar levels can create a favorable environment for the growth of yeast infections.
Complications ofGDM: Fetus/Neonate
Complications of GDM for the Fetus/Neonate:
Congenital Anomalies:
Hyperglycemia during the first trimester can increase the risk of neural tube defects (NDS), anencephaly, microcephaly, and cardiac anomalies in the developing fetus.
Macrosomia:
Elevated maternal blood sugar levels can lead to excessive fetal growth, resulting in macrosomia (large birth weight).
Preterm Birth:
GDM can increase the risk of preterm birth, where the baby is born before reaching full term.
Fetal Asphyxia:
Poorly controlled GDM can affect placental function and blood flow, potentially leading to fetal asphyxia (insufficient oxygen supply).
Intrauterine Growth Restriction (IUGR):
IUGR refers to a condition where the fetus fails to grow at a normal rate due to reduced nutrient supply.
Perinatal Death:
Severe cases of GDM can increase the risk of perinatal death (death around the time of birth).
Respiratory Distress Syndrome (RDS):
Babies born to mothers with GDM might be at a higher risk of developing respiratory distress syndrome, which involves difficulties in breathing due to immature lung development.
Polycythemia:
Elevated blood sugar levels can stimulate fetal red blood cell production, leading to polycythemia (high red blood cell count).
Hyperbilirubinemia:
High levels of bilirubin (a waste product) in the blood can result from GDM and lead to jaundice in the neonate.
Hypoglycemia:
Babies born to mothers with GDM may experience low blood sugar levels shortly after birth, as they are no longer exposed to the elevated glucose levels in the mother’s bloodstream.
Childhood Obesity/Carbohydrate Intolerance:
Children born to mothers with GDM might have an increased risk of developing obesity and carbohydrate intolerance later in life.
Screenings Throughout Pregnancy
Screenings Throughout Pregnancy:
Fundal Height Measurement:
Measuring the fundal height (the distance from the top of the uterus to the pubic bone) is a simple way to assess fetal growth and position.
Blood Tests for Genetic Screening:
Genetic screenings, such as prenatal genetic testing and carrier screening, are performed to assess the risk of certain genetic disorders in the fetus.
Ultrasound for Physical Anomalies:
Ultrasound imaging is used to visualize the fetus and assess its development. It can help identify physical anomalies and ensure normal growth.
Echocardiogram for Heart Anomalies:
An echocardiogram is a specialized ultrasound that focuses on the heart’s structure and function. It’s used to detect heart anomalies in the fetus.
Laboratory Tests:
Urine Analysis and Culture (U/A and Culture): Routine analysis of urine can help detect urinary tract infections and other issues.
Serum Glucose Test: Monitoring blood sugar levels helps identify and manage gestational diabetes.
Glycosylated Hemoglobin (A1c) Test: A1c provides information about average blood sugar levels over the past few months.
Electrolytes and Renal Function: Monitoring electrolytes and kidney function ensures the health of both the mother and the fetus.
Perinatal DiabetesNursing Care
Perinatal Diabetes Nursing Care: Pre-Gestational Counseling:
Complete Obstetric History (OB Hx):
Gathering a comprehensive obstetric history helps the healthcare provider understand the individual’s previous pregnancies, medical history, and any previous experiences with diabetes management during pregnancy.
Serum Lab Tests:
Hemoglobin A1c (HgA1c): A measure of average blood sugar levels over the past few months, indicating diabetes control.
Thyroid Function: Assessing thyroid health is important for overall pregnancy well-being.
Nephropathy and Retinopathy: These tests help assess kidney and eye health, which can be affected by diabetes.
Urine Screen (Point-of-Care):
Point-of-care urine screening helps identify any immediate concerns, such as urinary tract infections.
Education:
Dietary Modifications: Providing guidance on healthy eating and managing blood sugar levels through dietary choices.
Changes in Activity: Recommending appropriate levels of physical activity and exercise during pregnancy.
Blood Glucose Monitoring and Medication Administration: Educating individuals on how to monitor their blood sugar levels and administer medications as needed.
Home Blood Pressure (BP) Monitoring: Educating about the importance of monitoring blood pressure at home, especially for those with diabetes.
Referral to Dietitian/Nutritionist:
Referring individuals to a registered dietitian or nutritionist for personalized dietary guidance and support.
Patient Education:Nutrition
Follow Prescribed Diet Plan: This means adhering to the dietary recommendations provided by a healthcare professional, which could be tailored to the patient’s specific health condition, dietary restrictions, and goals.
Divide Daily Food Intake: Eating throughout the day in smaller, balanced portions helps maintain steady blood sugar levels and prevents overeating during main meals. This generally includes three main meals (breakfast, lunch, and dinner) along with 2 to 3 smaller snacks.
Eat Bedtime Snack to Prevent Hypoglycemia: For individuals who are at risk of low blood sugar levels (hypoglycemia) during the night, consuming a balanced snack before bedtime can help prevent this issue. The snack should include a mix of complex carbohydrates and a source of protein.
Avoid Refined Sugar Foods: Refined sugars are found in foods like sugary snacks, sodas, and desserts. These foods can cause rapid spikes and crashes in blood sugar levels and are generally low in nutritional value. Opting for natural sugars found in fruits and whole grains is a better choice.
Don’t Skip Meals or Snacks: Regular meals and snacks help maintain consistent energy levels and prevent extreme hunger, which can lead to overeating or poor food choices.
High Dietary Fiber Foods: Including high-fiber foods in the diet, such as whole grains, vegetables, fruits, legumes, and nuts, can aid in digestion, help regulate blood sugar levels, and promote a feeling of fullness.
Avoid Alcohol and Nicotine: Both alcohol and nicotine can have negative effects on health. Alcohol can impact blood sugar levels and interact with medications, while nicotine can affect overall health and appetite. Avoiding these substances is generally recommended.
Patient Education:Glycemic Index
Glycemic Index (GI): The glycemic index is a scale that measures how quickly and how much a carbohydrate-containing food raises blood glucose levels. Foods with a high GI are rapidly digested and cause a quick spike in blood sugar, while those with a low GI are digested more slowly, resulting in a slower and more gradual increase in blood sugar.
Low GI: Foods with a GI of 55 or less are considered low on the glycemic index. These foods have a slower impact on blood sugar levels, making them a better choice for maintaining stable glucose levels.
Medium GI: Foods with a GI between 56 and 69 fall into the medium range. They have a moderate effect on blood sugar levels.
High GI: Foods with a GI of 70 or above are considered high on the glycemic index. These foods cause a rapid spike in blood sugar levels and should be consumed in moderation, especially by individuals who need to manage their blood glucose levels.
Variables Affecting GI:
Cooking Time: The degree of cooking can affect the glycemic index of foods. Generally, more cooked or processed foods tend to have a higher GI compared to less processed ones.
Processing Level: Highly processed foods like white bread and sugary cereals usually have a higher GI due to the removal of fiber and other nutrients during processing.
Ripeness: The ripeness of fruits can influence their GI. Riper fruits tend to have a higher GI because the natural sugars are more readily available.
Glycemic index (GI) values
High GI Foods (70 and above):
Baguette (GI: 93)
White rice (GI: 92)
Doughnut (GI: 86)
Rice cake (GI: 85)
Potato (GI: 85)
Noodles (GI: 85)
Cola (GI: 65)
Corn (GI: 75)
Medium GI Foods (56 to 69):
Sponge cake (GI: 69)
Pineapple (GI: 66)
Whole wheat bread (GI: 64)
Burger buns (GI: 67)
Pasta (GI: 66)
Ice cream (GI: 63)
Cheese Pizza (GI: 60)
Pastry (GI: 59)
Low GI Foods (55 and under):
Instant noodles (GI: 73)
Popcorn (GI: 72)
Muffin (GI: 59)
Mangoes (GI: 60)
Banana (GI: 52)
F1 (GI: 16) [Note: Not sure what “F1” refers to here]
White corn (GI: 26)
Peanut (GI: 14)
Apple (GI: 46)
Sweet potato (GI: 48)
Tomato (GI: 30)
Green Tea (GI: 28)
Milk (GI: 25)
Brown Rice (GI: 50)
Patient Education:Target Blood Glucose in PG
Pre-Meal or Fasting:
Target Plasma Glucose: 60-99 mg/dL
Post-Meal 1 Hour:
Target Plasma Glucose: 100-129 mg/dL
Post-Meal 2 Hours:
Target Plasma Glucose: ≤120 mg/dL
Hypoglycemic Agents: Insulin. Insulin preferred med for GDMA2 (ACOG):
Insulin in GDM (Gestational Diabetes Mellitus):
Insulin is commonly considered the preferred medication for managing GDM when lifestyle modifications, such as dietary changes and exercise, are not sufficient to control blood glucose levels. GDM refers to diabetes that develops during pregnancy and affects how your body handles glucose (sugar). Managing blood glucose levels during pregnancy is crucial for both the health of the mother and the baby.
Weight-Based Dosing:
Insulin dosing for GDM, like for other types of diabetes, can be weight-based to ensure an appropriate and individualized dosage. Weight can play a role in how your body processes insulin and glucose.
Does Not Cross Placenta:
Insulin, being a protein hormone, does not cross the placental barrier. This means that when a pregnant person takes insulin to manage their blood glucose levels, the insulin itself doesn’t pass from the mother to the baby through the placenta.
Decreased in 1st Trimester:
During the first trimester of pregnancy, some pregnant individuals may experience decreased insulin needs. This can be attributed to hormonal changes and increased insulin sensitivity. However, as pregnancy progresses, insulin needs may increase due to factors like the growing placenta and hormonal changes.
Divided Dosing:
Insulin dosing in GDM might involve splitting the daily dose into multiple injections. This approach helps to maintain more stable blood glucose levels throughout the day.
Long-Acting or Intermediate-Acting:
Long-acting and intermediate-acting insulins are types of insulins that have a gradual and prolonged effect on blood glucose levels. They can provide coverage for an extended period, often up to 24 hours, which helps in managing fasting blood glucose levels.
Short-Acting (Rapid-Acting) Insulins:
Insulins like NovoLog (insulin aspart) and Humalog (insulin lispro) are rapid-acting insulins. They have a quicker onset and shorter duration of action, typically lasting around 3 to 6 hours. These insulins are used to control post-meal blood glucose spikes.
Hypoglycemic Agents: Oral Meds
Oral Hypoglycemic Agents as Second-Line Treatment: (not the first choice of treatment)
Oral medications for diabetes, including gestational diabetes, are considered when lifestyle modifications and insulin therapy are not sufficient in controlling blood glucose levels. They can offer an alternative to insulin injections, making it easier for some individuals to manage their condition.
Glyburide:
Promising Data: Glyburide is an oral sulfonylurea medication that has shown promise in managing GDM in some cases. It stimulates the pancreas to produce more insulin and helps lower blood glucose levels.
Dosage: Glyburide is typically prescribed at doses ranging from 2.5 mg to 20 mg per day, either once daily (QD) or divided into two doses (BID).
Placental Barrier: One of the advantages of using glyburide for GDM is that it does not readily cross the placenta, which means it has limited impact on the baby’s blood glucose levels.
Metformin:
Less Frequently Recommended: Metformin is an oral medication often used to manage type 2 diabetes. In the context of GDM, it’s considered less frequently recommended compared to insulin or glyburide.
Placental Crossing: Metformin does cross the placenta, and while it doesn’t appear to significantly increase the risk of birth defects, there are concerns about its potential effects on the developing fetus. This is why it might be considered second-line after other options.
Exercise during pregnancy
Amount of Exercise:
Aim for at least 30 minutes of moderate-intensity aerobic exercise on most days of the week. This translates to around 5 days a week.
Alternatively, you can accumulate a total of at least 150 minutes of moderate-intensity aerobic exercise throughout the week. This can be spread out across different days.
Post-Meal Walking:
Walking for about 10-15 minutes after a meal can help lower blood glucose levels. This is particularly beneficial for individuals with diabetes as it can assist in managing post-meal blood sugar spikes.
Type of Exercise:
The specific type of exercise should be discussed with a healthcare provider. Different exercises have varying effects on blood glucose levels, and the choice of exercise should align with an individual’s health status, preferences, and any potential limitations.
Fetal Assessments(Review!)
Kick Counts (Fetal Movement Counting): This is a simple way for pregnant individuals to monitor their baby’s activity level. The idea is to keep track of the baby’s movements and kicks over a specific period. A reduction in fetal movement can be a sign of potential issues and should prompt further evaluation.
Non-Stress Test (NST): A non-stress test is a commonly used antepartum test to assess the well-being of the fetus. It involves monitoring the baby’s heart rate in response to its own movements. An NST can help determine if the baby is receiving enough oxygen and if the placenta is functioning properly.
Biophysical Profile (BPP): The BPP combines several fetal assessments, including the NST, fetal movement, fetal tone, amniotic fluid volume, and sometimes, fetal breathing movements. It provides a comprehensive view of the baby’s well-being and helps healthcare providers make informed decisions regarding management.
Amniotic Fluid Index (AFI): The AFI measures the amount of amniotic fluid surrounding the baby in the womb. Amniotic fluid plays a vital role in cushioning and protecting the fetus. An abnormal AFI can indicate issues such as inadequate fetal growth or potential complications.
Contraction Stress Test (CST): The CST, also known as the “stress test,” evaluates the baby’s response to contractions. It is performed by inducing contractions either through nipple stimulation or intravenous medication. The goal is to determine how the baby’s heart rate responds to stress, which can provide insights into its oxygen supply.
Reactive non-stress test (NST) and a positive contraction stress test (CST)
Reactive Non-Stress Test (NST) Example:
In a reactive non-stress test (NST), the fetal heart rate (FHR) is monitored in response to fetal movements. A reactive result is considered reassuring as it indicates that the baby’s heart rate accelerates appropriately with fetal movements, which suggests a healthy nervous system and sufficient oxygen supply. Here’s an example:
Accelerations: Accelerations are temporary increases in the fetal heart rate. In this example, with each fetal movement (FM), the heart rate accelerates by 15 beats per minute and lasts for 15 seconds. These accelerations are a positive sign, indicating a reactive NST.
Positive Contraction Stress Test (CST) Example:
A positive contraction stress test (CST) is one where late decelerations in the fetal heart rate occur in response to contractions. Late decelerations suggest that the baby’s oxygen supply may be compromised during contractions, which could indicate potential fetal distress. Here’s an example:
Late Decelerations: Late decelerations are a drop in the fetal heart rate that occurs after the peak of a contraction. In this example, repetitive late decelerations occur with each contraction. Additionally, no accelerations of fetal heart rate are observed with three fetal movements.
Q: Which normal changes of pregnancy place a pregnant mother with cardiac issues at risk for more severe cardiac problems?
- Increased Cardiac Workload
- Decreased PVR
- Inc intravascular volume
- Hypercoagulability
- Decreased pulmonary resistance
This is why:
Increased Cardiac Workload: During pregnancy, there is an increase in the volume of blood pumped by the heart to meet the demands of the growing fetus. This increase in cardiac output can put additional strain on the heart, which can be problematic for pregnant mothers with pre-existing cardiac issues.
Decreased Pulmonary Resistance: Pregnancy is associated with a decrease in pulmonary vascular resistance (PVR), which facilitates increased blood flow to the lungs for oxygenation. While this change is normal during pregnancy, it can exacerbate existing cardiac problems by potentially leading to increased strain on the heart’s right side.
Increased Intravascular Volume: The pregnant body naturally expands its blood volume to support the growing fetus. However, this can be problematic for women with existing cardiac issues, as it can lead to further volume overload on the heart and contribute to complications like heart failure.
Hypercoagulability: Pregnancy leads to a state of hypercoagulability, which is an increased tendency for blood to clot. While this is a protective mechanism to prevent excessive bleeding during childbirth, it can be problematic for women with cardiac issues, as it increases the risk of blood clot formation within the already compromised circulatory system.
Cardiac Disease
&
Pregnancy
Cardiac Disease and Pregnancy: The information is highlighting the relationship between cardiac disease and pregnancy. Approximately 4% of pregnant individuals have pre-existing cardiac (heart) disease, which means they had heart conditions even before becoming pregnant. These heart conditions can either be congenital, meaning they are present since birth, or acquired, meaning they develop later in life.
Prevalence of Cardiac Disease in Pregnancy: The data indicates that about 4% of pregnant people have existing cardiac disease. This statistic is essential because having a pre-existing cardiac condition can impact the health and well-being of both the pregnant person and the developing fetus.
Maternal Mortality and Cardiac Disease: The information suggests that cardiac disease is a significant contributor to maternal mortality, which refers to the death of a pregnant person during pregnancy, childbirth, or within 42 days after the pregnancy ends. In this context, cardiac disease accounts for a range of 10-25% of maternal mortality cases. This highlights the seriousness of cardiac conditions during pregnancy and the importance of managing them effectively.
Risk Classes I-IV: The risk classes mentioned here represent a classification system that categorizes pregnant individuals based on the level of risk associated with their cardiac disease. The risk classes range from I to IV, with Class I being the lowest risk and Class IV being the highest risk. This classification helps healthcare providers determine the appropriate management and care for pregnant individuals with cardiac conditions, taking into account their heart’s functioning.
Congenital Heart Disease and Pregnancy: The information states that about half (1/2) of all cardiac diseases observed during pregnancy are related to congenital heart disease. This means that a significant portion of pregnant individuals with cardiac conditions have heart defects that were present since birth. Congenital heart disease refers to structural heart abnormalities that develop during fetal development and can affect how the heart functions.
Cardiac Disease and Pregnancy:Nursing Care
Early Diagnosis: Early identification of cardiac disease in pregnant individuals is crucial. It allows healthcare providers to implement appropriate interventions and management strategies promptly to ensure the health and safety of both the pregnant person and the developing fetus.
Assess Current Treatment and Implement a Plan: It’s essential to evaluate the pregnant person’s existing treatment plan for their cardiac condition. This includes reviewing any medications they are currently taking, as some medications might need to be adjusted or changed during pregnancy. Based on this assessment, healthcare providers can develop a customized care plan that considers both the cardiac condition and the pregnancy.
Nutrition Counseling: Proper nutrition is vital for the health of both the pregnant individual and the baby. Pregnant individuals with cardiac disease might have specific dietary needs and restrictions. Nutrition counseling helps ensure that they are getting the right nutrients to support their health and the development of the fetus.
Activity Level Consultation with MD: Physical activity recommendations can vary based on the severity of the cardiac condition. Consulting with a medical doctor is essential to determine the appropriate level of physical activity during pregnancy. Some individuals might need to limit strenuous activities to avoid putting excess strain on the heart.
Rest: Adequate rest is crucial for pregnant individuals with cardiac disease. Proper rest helps prevent excessive fatigue and stress on the heart. Healthcare providers might recommend specific positions for sleeping or resting to optimize comfort and cardiac function.
Fetal Surveillance: Regular monitoring of the fetus’s well-being is important. This can include regular prenatal check-ups, ultrasounds, and other fetal assessments to ensure that the baby is developing properly and isn’t experiencing any adverse effects from the maternal cardiac condition.
Monitor Weight Gain: Monitoring weight gain is a standard practice during pregnancy. For individuals with cardiac disease, maintaining a healthy weight gain is essential. Excessive weight gain can strain the heart, while insufficient weight gain can impact fetal growth. Healthcare providers will offer guidance on the appropriate weight gain range.
Cardiac Disease and Pregnancy:Nursing Care
Frequent and Thorough Assessments: Regular and comprehensive assessments are a cornerstone of nursing care for pregnant individuals with cardiac disease. These assessments should include monitoring vital signs, heart sounds, oxygen saturation levels, and any signs of distress or discomfort. Frequent assessments help in detecting any changes in the cardiac condition promptly, allowing for timely interventions.
Recognize Signs and Symptoms of Cardiac Decompensation: Nurses should be vigilant in identifying any signs of cardiac decompensation, which refers to a worsening of the heart’s ability to pump blood effectively. Signs might include shortness of breath, increased heart rate, sudden weight gain, swelling in the legs or ankles, and fatigue. Recognizing these symptoms early can help prevent severe complications.
During Labor: Anticipate Hemodynamic Monitoring: Labor and delivery can put additional stress on the heart. Anticipating and implementing hemodynamic monitoring, which involves assessing the heart’s performance and blood flow, is crucial. This monitoring helps healthcare providers understand how the heart is coping with the stress of labor and allows them to make informed decisions regarding interventions if needed.
Epidural and Assess for Fluid Overload: Epidural anesthesia is commonly used during labor to manage pain. However, individuals with cardiac disease might be more sensitive to changes in blood pressure and fluid balance. Nursing care includes closely monitoring blood pressure and fluid levels to prevent fluid overload, which can strain the heart.
Cardiac Disease and Pregnancy:Nursing Assessments
Cough: A persistent cough can be indicative of fluid accumulation in the lungs, a condition known as pulmonary edema. In individuals with cardiac disease, the heart’s pumping ability might be compromised, leading to fluid buildup in the lungs. Monitoring and assessing the nature and persistence of the cough can help in identifying potential cardiac complications.
Fatigue: Fatigue is a common symptom of cardiac disease, especially when the heart is unable to pump blood efficiently. Pregnant individuals with cardiac conditions might experience increased fatigue due to the added stress on the heart during pregnancy. Recognizing and addressing excessive fatigue is important for managing the cardiac condition.
Tachycardia: Tachycardia refers to an abnormally fast heart rate. In individuals with cardiac disease, the heart might struggle to maintain a normal heart rate due to its compromised function. Monitoring heart rate trends and identifying instances of tachycardia can provide insights into the heart’s performance.
Increased Respiratory Rate (RR): Increased respiratory rate can be a sign of inadequate oxygenation of the body’s tissues. It might indicate that the heart is not pumping enough oxygenated blood to meet the body’s demands. Assessing respiratory rate in conjunction with other symptoms can help determine the severity of the cardiac condition.
Poor Fetal Heart Rate (FHR) Variability from Poor Tissue Perfusion: Fetal heart rate variability refers to changes in the fetal heart rate over time and is a sign of a healthy fetal nervous system. Poor variability can be linked to poor tissue perfusion, where inadequate blood flow affects both maternal and fetal circulation. Monitoring fetal heart rate patterns can offer insights into the overall health of the fetus.
Decreased Amniotic Fluid from Intrauterine Growth Restriction (IUGR): Intrauterine growth restriction is a condition where the fetus is not growing at a normal rate. Decreased amniotic fluid levels can be associated with IUGR, which might occur due to poor blood flow and inadequate oxygen supply to the fetus. Monitoring amniotic fluid levels helps in detecting potential fetal growth issues.
Edema from Poor Venous Return: Edema, or swelling, can occur in the legs, ankles, and feet due to poor venous return—when blood has difficulty returning to the heart. Cardiac conditions can impair the heart’s ability to efficiently pump blood, leading to fluid retention and swelling. Assessing and addressing edema is important to manage venous insufficiency.
Rh Incompatability
Rh Factor and Coombs Test: The Rh factor, also known as the Rhesus factor, is a protein present on the surface of red blood cells. A Coombs test (or Direct Coombs test) is a blood test used to detect antibodies that may be coating red blood cells. It helps determine if there’s an immune response occurring in the blood.
Rh Positive (+) and Rh Negative (-): If a person’s red blood cells have the Rh factor present, they are Rh positive. If the Rh factor is not present, they are Rh negative. The presence or absence of the Rh factor is determined by genetics.
Rh-Negative Individuals and Rh Antigen Exposure: If an Rh-negative individual (a person without the Rh factor on their red blood cells) is exposed to Rh-positive blood, their immune system might recognize the Rh factor as foreign. This can trigger the production of antibodies against the Rh factor. This is particularly significant in pregnancies where the fetus has an Rh-positive blood type and the mother is Rh-negative.
Antibody Response and Rh Incompatibility: During pregnancy, if an Rh-negative mother is carrying an Rh-positive fetus, there’s a risk of Rh incompatibility. This occurs when a small amount of the fetus’s Rh-positive blood enters the mother’s bloodstream, usually during delivery or other events that cause bleeding during pregnancy. This exposure can lead to the mother’s immune system producing antibodies against the Rh factor. These antibodies can cross the placenta and affect the Rh-positive fetus’s red blood cells.
Hemolytic Disease of the Newborn (HDN): If Rh incompatibility is not managed, it can lead to a condition called hemolytic disease of the newborn (HDN), where the mother’s antibodies attack the fetus’s red blood cells, leading to anemia and other complications in the newborn.
RhoGAM function
Prevents Maternal Antibody Formation: RhoGAM is administered to Rh-negative pregnant individuals to prevent the formation of maternal antibodies against the Rh factor. This is crucial to avoid hemolytic disease of the newborn (HDN) in future pregnancies with Rh-positive fetuses.
Immunoglobulin/Blood Product: RhoGAM is made from immunoglobulins, which are antibodies present in the blood. It is derived from the plasma of individuals who have anti-D antibodies. The purpose of RhoGAM is to neutralize any Rh-positive fetal blood that might have entered the maternal bloodstream, preventing the mother’s immune system from reacting against it.
Possible Side Effects: Like any medication, RhoGAM can have side effects. These can include fever, headache, pain at the injection site, and a breakdown of red blood cells (hemolysis). However, serious side effects are rare.
Dose and Administration: RhoGAM is typically administered as an intramuscular (IM) injection. The standard dose is 300 micrograms (mcg) given at specific times during pregnancy and after events that might expose the mother to Rh-positive fetal blood, such as delivery or miscarriage.
Mechanism of Action: The exact mechanism by which RhoGAM prevents Rh antibody formation is not fully understood. However, it is believed that RhoGAM effectively “mops up” any Rh-positive fetal blood in the maternal circulation before the mother’s immune system has a chance to recognize and react to it.
Decreased Risk of Antibody Formation: RhoGAM has been highly effective in reducing the risk of Rh antibody formation. Without RhoGAM, the risk of antibody formation in Rh-negative pregnant individuals exposed to Rh-positive fetal blood is around 12%. With RhoGA
Q: If pregnant person has O+ blood and tests Coombs negative, do you need to give Rhogam?
Q: If pregnant person has O- blood and tests Coombs positive, do you need to give Rhogam?
If pregnant person has O+ blood and tests Coombs negative: No.
If pregnant person has O- blood and tests Coombs positive: Yes.
Iron Deficiency Anemia: Complications
Infection: Iron deficiency anemia can weaken the immune system, making the body more susceptible to infections. This is because immune cells require proper oxygen supply to function effectively, and anemia can compromise this supply.
Weakness and Fatigue: Anemia leads to reduced oxygen delivery to tissues, resulting in feelings of weakness, fatigue, and overall low energy levels.
Syncope: Syncope refers to fainting or loss of consciousness. Severe anemia can lead to reduced oxygen supply to the brain, which might trigger syncope.
Cardiac Failure: The heart has to work harder to compensate for the reduced oxygen-carrying capacity of the blood in individuals with anemia. Over time, this strain on the heart can potentially contribute to cardiac failure or exacerbate existing cardiac conditions.
Fetal Distress: In pregnant individuals with iron deficiency anemia, the fetus might experience distress due to reduced oxygen supply through the placenta. This can have implications for the baby’s well-being.
Low Birth Weight (LBW) and Intrauterine Growth Restriction (IUGR): Iron deficiency anemia during pregnancy can lead to poor oxygen delivery to the fetus, affecting its growth. This can result in low birth weight and intrauterine growth restriction, where the fetus doesn’t achieve its expected growth potential.
Pre-term Birth: Anemia during pregnancy has been associated with an increased risk of pre-term birth, which is the delivery of the baby before the completion of the full term of pregnancy. Pre-term birth can lead to a range of health complications for the baby.
