ch. 29 endocrine metabolic Flashcards
pregnancy is
a naturally state of endocrine disruption, characterized by complex alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis
pregnancy exerts a “diabetogenic” effect on the maternal metabolic status
- decreased tolerance to glucose
- increased insulin resistance
- decreased hepatic glycogen stores
- increased hepatic production of glucose
at birth, expulsion of the placenta prompts
- abrupt drop in levels of circulating placental hormones, cortisol, and insulinase
- maternal tissues quickly regain their pre-pregnancy sensitivity to insulin
diabetes mellitus
worldwide growth at rapid rate
- complicates 6-7% of pregnancies
- pregnancy: high risk
diabetes mellitus pathogenesis
- group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
- body compensates for its inability to convert glucose into energy by burning muscle and fats
- over time, diabetes causes significant changes in the microvascular and macrovascular circulations
4 classifications of DM
1) type 1 DM: 5-10% all DM
- abrupt onset at young age
- ABSOLUTE INSULIN DEFICIENCY
2) type 2 DM: 90-95% all DM
- insulin resistance & relative insulin deficiency; cause unknown
- body makes insulin but not enough, have to supplement insulin
3) pregestational diabetes mellitus
- label given to type 1 or 2 diabetes that existed prior to pregnancy
4) gestational diabetes mellitus (GDM)
- after 20 wks gestation
pregestational DM
1) preconception counseling:
- DM, diet program
2) maternal risks/complications:
- macrosomia, with increases risks of birth complications
- hydramnios (polyhydramnios)
- infections
- ketoacidosis: DKA
- hypoglycemia/hyperglycemia
3) fetal/neonatal risks/complications:
- perinatal mortality rate is 3x higher for woman with diabetes than for women who do not have this disease
- IUFD (stillbirth)
- congenital malformations
- hypoglycemia at birth
TIP:
- dm produces more congenital anomalies
- fetal death x3 for DM woman than normal
pregestational DM: interprofessional care mgmt
1) assessment:
- complete physical examination & thorough evaluation of her health status
- routine prenantal lab tests & glycosylated hemoglobin A1c level
2) antepartum care:
- more frequent monitoring in pregnancy
- primary goal: achieving and maintaining constant euglycemia
- diet
- exercise
- insulin therpy
- self monitoring of blood glucose (SMBG)
- urine testing
- complications requiring hospitalization
- fetal surveillance
- determination of birth date and mode
pregestational DM: interprofessional care mgmt (intrapartum/postpartum)
1) intrapartum:
- monitoring for dehydration, hypoglycemia, and hyperglycemia
- blood glucose levels carefully monitored
- continuous EFM
- IV infusion
- possible c-section birth for macrosomia
2) postpartum:
- first 24H, insulin requirements drop substantially
- risk of hemorrhage due to uterine distention (macrosomia)
- women with diabetes are encouraged to breastfeed
- contraceptive methods education
gestational diabetes mellitus complicates about ___% of all pregnancies in US
9.2
risk factors for GDM
- family hx. of diabetes
- previous pregnancy that resulted in an unexplained stillbirth or the birth of a malformed or macrosomic fetus
- obesity, HTN, glycosuria, and maternal age older than 25 years
- more than half of women with GDM have none of these risk factors (paternal)
diagnosed during the 2/3 trimester of pregnancy
screening for GDM
1) early pregnancy screening:
- women with strong risk factors that should be screened earlier in pregnancy, before 24-28 weeks
Screen: 24-28 weeks
2) two step screening method: recommended by ACOG
- 1 hour, 50g oral glucose, glucose value of 130-140 mg/dL or higher = positive SCREEN
- 3 hour, 100g oral glucose (OGTT): DIAGNOSED with GDM if two or more values are met or exceeded
3) alternative one step screening method recommended by international association of diabetes and pregnancy study groups (IADPSG): 75g OGTT
GDM maternal risks
- preeclampsia (9.8% well controlled, 18% not well controlled)
- c-section delivery (17-25%)
- development of type 2 diabetes later in life (up to 70%)
GDM fetal risks
- macrosomia and associated risks for birth trauma (with vaginal birth)
- electrolyte imbalances including neonatal hypoglycemia and hyperinsulinemia
GDM: interprofressional care mgmt (antepartum care)
- goal: strict BG control
- dietary modification
- exercise
- self monitoring of BG
- pharmacologic theory
- fetal surveillance: women who require insulin or oral hypoglycemia agents for BG control may have twice weekly NSTs beginning at 32 weeks of gestation (NST: women on monitor to look for accels, reactive good, nonreactive bad)
GDM: interprofessional care mgmt (intrapartum/postpartum)
1) intrapartum:
- BG levels monitored Q1-2H
- maintain levels at 80-110 mg/dL
- infusion of insulin, if needed
2) postpartum:
- most return to normal glucose levels after birth
- for the rest, there is high risk for recurrent GDM in future pregnancies
- ACOG recommends assessing all women who had GDM for carbohydrate intolerance with a 75g, 2 hr OGTT or a fasting plasma glucose level at 6-12 weeks postpartum
- then lifelong, repeat screening at least every 3 years
hyperemesis gravidarum
- N/V complicate 50-80% of all pregnancies
- begins: 4-10 weeks gestation
- resolved: 20 weeks gestation
what: excessive, prolonged vomiting accompanied by:
- weight loss
- electrolyte imbalance
- nutritional deficiencies
- ketonuria
hyperemesis gravidarum: begins, RF, clinical manifestations
1) begins 1st trimester, 10% have symptoms throughout pregnancy
2) risk factors:
- younger maternal age
- nulliparity
- BMI less than 18.5 or greater than 25
- low socioeconomic status
- women with asthma
- migraines
- preexisting diabetes
- psychiatric illness
- hyperthyroid disorders
- GI disorders
- previous pregnancy complicated by hyperemesis gravidarum
3) clinical manifestations:
- significant weight loss, dehydration
- dry mucous membranes
- decreased BP
- increased pulse rate
- poor skin turgor
hyperemesis gravidarum: interprofessional care mgmt, interventions
1) assessment:
- severity, frequency, duration of episodes
- determination of ketonuria (urine dip stick)
- psychosocial assessment: role of anxiety (risk factor)
2) interventions:
- initial care: IV therapy for correction of fluid and electrolyte imbalances (LR 125), meds, enternal/parenteral nutrition as. a last resort (PICC)
- f/u care
hyperthyroidism pregnancy
- rare in pregnancy: complicating between 0.4-1.7% of births
- 90-95% cases in pregnancy are caused by Graves’ disease (overproduction of thyroid)
1) clinical manifestations:
- heat intolerance, diaphoresis, fatigue, anxiety, emotional lability, and tachycardia
- may include weight loss, goiter, and pulse rate greater than 100 bpm
2) primary treatment: drug therapy
hypothyroidism pregnancy
- severe hypothyroidism is associated with infertility and increased risk of miscarriage
- complicates between 0.2%-1.2% of pregnancies
- babies LOWER IQ if NOT treated
1) sx:
- weight gain
- lethargy
- decrease in exercise capacity
- cold intolerance
2) NI
- education
- medication regimen: levothyroxine (e.g. T4 - synthroid)
