Chapter 26: Concurrent Disorders During Pregnancy Flashcards
First diagnosis during pregnancy
Gestational diabetes**
Women with any risk factors should be screened for
Type 2 or GDM at FIRST prenatal visit
During the second half of pregnancy, what hormones can create resistance to insulin in maternal cells?
Progesterone
Estrogen
Human Placental Lactogen
The increase resistance in maternal cells to insulin allows
An abundant supply of glucose to be available for fetus.
Increased resistance to insulin in maternal cells may have a
Diabetogenic effect -> mom will have episodes of Hyperglycemia and insufficient insulin
White Classification: A-1
Diet controlled
White Classification: A-2
Diet and insulin controlled
Risk factors for gestational diabetes
o Overweight (BMI 25> to 25.9) or obesity (>30 or morbidly obese >40)
o Maternal age older than 25 years
o Previous birth outcome assoc. w/ GDM (neonatal macrosomia, maternal HTN, infant w/ unexplained congenital abnormalies, previous fetal death).
o Gestational diabetes in previous pregnancy
o History of abnormal glucose tolerance
o History of DM in a close (1st degree) relative
o Member of high-risk ethnic group (African American, Hispani or latino, American indian, Asian American, pacific islander)
Screening for gestational diabetes
- Everyone gets it during first visit.
- Either by identification of history/risk factors consistent for type 2 DM or GDM or by blood glucose testing.
What tests are used for screening of gestational diabetes?
- Basic glucose challenge screening test (GCT)
- Oral glucose tolerance test
What women get the basic glucose challenge screening test?
Low risk women
Basic Glucose Challenge Screening Test is administered when?
Between 24-28 weeks of gestation, both in low/high risk antepartum patients.
What women get oral glucose tolerance test?
- May be used as initial test if woman is high risk for GDM.
- Mainly used for diagnosis following abnormal GCT levels.
Basic Glucose Challenge Screening Test Procedure
o Fasting NOT necessary for GCT, not required to follow pretest dietary instructions
o Ingests 50 g of oral glucose solution **
o Blood sample taken 1 hour later**
Basic Glucose Challenge Screening Test: 140 mg/dL or greater
3 hour oral glucose tolerance test**
Basic Glucose Challenge Screening Test: 130-135 mg/dL
Identify more women at risk
Oral Glucose Tolerance Test
Gold standard for diagnosis. More complex.**
Oral Glucose Tolerance Test Procedure
o Must be fasting from midnight to the day of the test.
o After fasting plasma glucose is determined, woman ingests 100 g of oral glucose solution
o Plasma glucose levels determine at 1, 2, and 3 hours. **
GDM is diagnosis if fasting blood glucose level is abnormal or if two or more of following values occur on the OGTT
- Fasting, greater than 95 mg/dL
- 1 hour, greater than 180 mg/dL
- 2 hours, greater than 155 mg/dL
- 3 hours, greater than 140 mg/dL
2 or more that are abdnormal = diagnosis
When is the placenta completed?
Placenta not completed until 12 weeks.
GDM risk factors are similar to those existing in preexisting diabetes, except that GDM is
- NOT associated with increased risk for maternal ketoacidosis or spontaneous abortion.
- Usually not associated with increase in major congenital malformations.
Maternal Hyperglycemia during 3rd trimester increases the risk for
Neonatal morbidity and mortality
Gestational Diabetes Mellitus: Maternal Risks
o Preeclampsia
o UTIs
o Hydramnios (fetal diuresis cause)
o Labor dystocia
o C/S
o Uterine atony w/ hemorrhage after birth
o Birth injury to maternal tissues (hematoma, lacerations)
Gestational Diabetes Mellitus: Fetal Neonatal Risks
- Fetal Growth: Marcosomia**
- Decreased placental perfusion
- SGA or IUGR
- Oligohydramnios
What causes macrosomia in the fetus with a mother who has gestational diabetes mellitus?
- Fetus produces insulin by 10th week of gestation, maternal insulin does not cross.
- Overproduction of insulin which acts as a growth hormone when glucose is ↑.
Gestational Diabetes: Neonatal Risk Factors
- Hypoglycemia**
- Hypocalcemia
- Hyperbilirubinemia
- Respiratory distress syndrome**
What causes hypoglycemia in the newborn with a mother with gestational diabetes?
- Fetal insulin production accelerated during pregnancy to metabolize excessive glucose received from mother.
- When maternal glucose supply is abruptly withdrawn at birth, level of neonatal insulin exceeds available glucose, hypoglycemia develops rapidly
What causes hypocalcemia in newborns with mothers with gestational diabetes?
- During last half of pregnancy, large amounts of calcium are transported across placenta from mother to fetus.
- At birth, this is stopped, leading to dramatic decrease in total/ionized calcium.
- <7 mg/dL , first 3 days of life.**
What causes hyperbilirubinemia in the newborn with a mother with gestational diabetes?
- Fetus experiencing recurrent hypoxia compensate by producing additional erythrocytes (polycythemia) to carry oxygen supplied by mother.
- After birth, excess erythrocytes are broken down, releases large amt of bilirubin into neonate’s circulation.
- Poor glycemic control further reduces infant’s ability to metabolize/excrete excess bilirubin.
What causes respiratory distress syndrome in the newborn with a mother with gestational diabetes?
Fetal hyperinsulinemia retards cortisol production, necessary for surfactant needed to keep newborn’s alveoli open after birth = ↑ risk for resp. distress syndrome.
Primary goal for gestational diabetes mellitus in pregnancy
Maintaining normal blood glucose levels
Gestational Diabetes Mellitus Teaching
o Eliminate simple sugars in diabetic diet ADA.
o Recommend 30 kcal/kg/day and if obese then 25kcal/kg/day
o Limits carbs to 30 g during pregnancy for breakfast = ↑ levels of cortisol and growth hormones that period.
o Calories divided among three meals and at least 3 snacks.
o Do graduate physical exercise program.
Nursing Care for Gestational Diabetes Mellitus in Pregnancy
- Blood glucose levels evaluated
- Administer insulin, perform regular fetal surveillance.
- Increase effective communication.
- Provide opportunities for control.
- Providing normal pregnancy care.
How are blood glucose levels evaluated?
Common method is measuring fasting blood glucose level (no food for previous 4 hours) and postprandial blood glucose level (2 hours after each meal)
When is insulin started for GDM?
Insulin started if fasting is 95+ and/or postprandial values 120+
Maternal Testing in mothers with GDM
o Baseline renal function w/ 24-hour urine collection for protein excretion and creatinine clearance.
o UTI random urine sample
o Dipstick on urine (detect ketones, protein, glucose)
o Thyroid function tests → preexisting DM
o Glycosylated hemoglobin or hemoglobin A1c
Glycosylated Hemoglobin or hemoglobin A1C
- Accurate measurement during preceding 2-3 months**
- Not affected by recent intake or restriction of food.
Fetal testing in babies with mothers with GDM
o “Kick counts” o Ultrasonography for fetal growth and amniotic fluid volume o Biophysical profile o Non stress test o Contraction stress test o Amniocentesis for fetal lung maturity
When is testing done to identify fetal compromise in babies with mothers with GDM?
Testing to identify fetal compromise begins 28 weeks of gestation if woman has poor glycemic control or by 34 weeks of gestation in lower-risk women with GDM.
What are the major maternal risks of DM on pregnancy?
- HTN
- Preeclampsia
- Ketoacidosis
- UTI
- Labor dystocia, C/S, uterine atony with hemorrhage after birth
- Birth injury to maternal tissues (hematoma, laceration)
What are the major fetal and neonatal risks of DM on pregnancy?
- Congenital Anomalies
- Perinatal Death
- Macrosomia (>4000g)
- IUFGR
- Preterm labor, PROM, preterm birth
- Birth injury
- Hypoglycemia
- Polycythemia
- Hyperbilirubinemia
- Hypocalcemia
- Respiratory distress syndrome
What increases the risk for UTI in pregnant women with DM?
Increased bacterial growth in nutrient rich urine.
What increases the risk for uterine atony in pregnant women with DM?
Hydramnios secondary to fetal osmotic diuresis d/t hyperglycemia -> uterus to be overstretched.
What increases the risk for perinatal death in a fetus/newborn whose mother has DM?
Poor placental perfusion because of maternal vascular impairment, primarily in type 1 DM.
What increases the risk for macrosomia in a fetus/newborn whose mother has DM?
Fetal hyperglycemia stimulates production of insulin to metabolize carbs, excess nutrients transported to fetus.
Anemia
Decline in circulating RBC mass reduces capacity to carry oxygen to the vital organs of the mother or the fetus.
A woman is considered anemic if
Hemoglobin is <10.5 or 11 g/dL**
Signs and symptoms of anemia include
o Fatigue
o Pale skin
o PICA → sign of anemia, not eating food = problems with weight (loss)
o IN FETUS: If Hgb 6→ reduced variability, late decels (uteroplacental insufficiency), will NOT tolerate labor. Chronic lack of oxygenation.
Implications of anemia on infant
Significant maternal anemia is associated with preterm birth and low birth weight.
Common Types of Anemia include
- Iron Deficiency
2. Folic Acid Deficiency
Iron Requirement
1000 mg
Sources of iron include
- Meat
- Fish
- Chicken
- Liver
- Green leafy vegetables
Signs and symptoms of Iron Deficiency Anemia in mother
o Pallor, fatigue, lethargy, headache
o Inflammation of lips and tongue**
o PICA
o Labs show RBCs that are microcytic and hypochromic
o Plasma iron and serum ferritin levels are low, total iron binding capacity is higher than normal.
What women are more likely to be anemic during pregnancy?
Women who have multifetal pregnancies or bleeding complications are more likely to be anemic during pregnancy.
Affect of iron deficiency anemia on fetus
- Will receive adequate stores at a cost to their mother.
- If severe, fetus may have reduced RBC volume, Hgb, and iron stores.
-Profound maternal anemia = reduced fetal oxygen supply
Folic Acid
-Functions as a coenzyme in synthesis of deoxyribonucleic acid (DNA), essential for cell duplication and fetal and placental growth.
Essential nutrient for RBCs.
Folic Acid Deficiency
- Large immature erythrocytes (megaloblasts)
- Often present with iron deficiency anemia
Signs and symptoms in mother with folic acid deficiency anemia
-Reduction in rate of DNA synthesis and mitotic activity of individual cells, resulting in presence of megaloblasts.
What are nonfood factors that contribute to folic acid deficiency?
- Hemolytic anemia’s
- Increased RBC turnover anemia
- Multifetal gestation
- Anticonvulsants
- Malabsorptions
Effect of folic acid deficiency anemia on baby
- Increased risk for spontaneous abortion
- Abruptio placentae
- Fetal anomalies
- Possible neural tube defect**
Iron Deficiency Anemia: Treatment
• Ferrous sulfate 325 mg 1-3x per day is commonly prescribed.
Iron Deficiency Anemia: Treatment Instructions
- Women experience less GI discomfort if iron supplementation is take w/ meals, although absorption is less.
- Take with 500 mg Vitamin C which may enhance absorption.
- Take stool softener!!!!!!!!!
What should women avoid during iron deficiency anemia treatment?
Avoid milk, cheese, calcium products and caffeine
How long is iron deficiency anemia treatment continued for?
Therapy continued for about 6 months after anemia has been corrected.
Folic Acid Deficiency Anemia: Treatment
- Recommend to take 400 mcg (0.4 mg) of folic acid daily and increase to 600 when pregnant.
- 4 mg of folic acid for 1 month BEFORE and DURING 1st trimester of pregnancy.
Why should you increase folic acid in diet?
- RDA for it doubles during pregnancy, must take supplements
* Diabetics more prone to neural tube defects. ↑ folic acid to prevent this.
What foods are high in folic acid?
Fortified greens: black beans lentils, peanuts, fresh dark green leafy vegetables.
During treatment, the nurse should monitor what in the fetus?
BPP and NST
GBS infection
15-40% colonized of pregnant women**
-Leading cause of life-threatening perinatal infection in US.
GBS infection occurs when
Gram + bacterium colonizes in the rectum, vagina, cervix, urethra** of pregnant woman as well as in non-pregnant woman.
GBS Infection: Presentation
Presents as asymptomatic, symptomatic maternal infections can occur
- UTI w/ GBS
- Chorioamnionitis
- Metritis
- Most women respond quickly to antimicrobial therapy.
GBS Infection: Fetal-newborn complications
- Sepsis, pneumonia and meningitis are primary infections in early onset GBS disease (Respiratory, low temperature, mottled blue)
- Permanent neurological consequences likely in infants who survive meninges infections.
When does early onset newborn GBS disease occur?
First week after birth, 48 hours
What is the treatment for GBS infection?
- PCN is the first line agent for antibiotic treatment of infected women during birth.**
- Cephazolin is alternate for patient with non-life threatening PCN allergy.
- Clinamycin is used for woman with high risk for anaphylaxis **
Optimal identification of GBS carrier status is obtained by
Vaginal and rectal culture between 35-37 weeks of gestation.
What are factors that can indicate GBS-positive at delivery?
- Woman who have had previous infant w/ GBS or a GBS in their urine in any trimester.
- Delivery at or before 37 weeks
- Has ruptured membranes >18 hours
- Has a temperature of 100.4 F (38 C) or higher
If a patient is positive for GBS, tell the patient
That she will be treated with IV antibiotics during labor.
Herpes II (HSV)
- Genital herpes one of the most common STD in the HSV group.
- Most infections of genital herpes is type 2.
Herpes II (HSV) Characteristics
o Occurs as a direct contact of the skin or mucous membranes with an active lesion.
o Lesions form at site of contact and begin as a group of painful papules that progress rapidly to become vesicles, shallow ulcers, pustules, and crusts.
o Infected person sheds virus until lesions are healed.
Is breast feeding okay in women with herpes II?
OK if no lesions are on breasts
Herpes II (HSV) virus migrates along
- Sensory nerves to reside in sensory ganglion, disease enters latent phase**
- Reactive later as recurrent infection.
Maternal symptoms of herpes II
-Many will have no signs and symptoms and shed virus unknowingly.
Treatment for Herpes II
- Antiviral chemotherapy (Acyclovir) is prescribe to reduce symptoms and shorten duration of lesions.
- Given during LATE pregnancy to a woman w/ recurrent outbreak to reduce possibility of her having active lesions at time of birth.
Ventrical Transmission of Herpes II
From mother to infant. Occurs either:
1. After rupture of membranes -> virus ascends from active lesions**
OR
2. During birth, when the fetus comes in contact w/ infectious genital secretions or when fetal skin is punctured such as w/ FSE.**
Fetal effect of herpes II
- Complications are rare.
- If primary infection occurs during pregnancy, rates of spontaneous abortions, IUGR and preterm labor increases.
Neonatal effect of herpes II
- Skin lesions or systemic (disseminated) and appear within the first week, disease progresses rapidly.
- 50% risk of death
Is vaginal birth allowed if mother has herpes II?
- Allowed if there are no genital lesions at time of labor.
- If there are genital lesions, C/S is done.
- Same goes for FSE.
- Risk for sepsis**
What should you observe in the fetus with a mother that has herpes II?
Signs of infections: temperature instability, lethargy, poor sucking, jaundice, seizures, herpetic lesions.
Treatment for neonates infected with herpes II
Acytoclovir is also prescribed for neonatal infection
HIV - Perinatal exposure
Infected person with virus that fails the immune system and develops opportunistic infections or malignancies that ultimately are fatal.
Time from infection of HIV to development of AIDS is approximately how long?
Approximately 11 years with current antiretroviral therapy.
What can confirm the diagnosis of AIDS?
-CD4 T lymphocyte total count of <200 cells/mm
What infant tests are done to diagnose HIV?
PCR for viral DNA and viral culture in addition to standard antibody tests.
Infant HIV tests can
Remain positive for up to 18 months after birth because of passive maternal antibodies.
What are maternal symptoms of HIV?
1) Flulike symptoms may develop and last a few weeks. Antibodies to HIV (seroconversion) generally appear within few months. HIV +
2 ) Middle or asymptomatic period of minor or no clinical problems follows. Low level viral replication and CD4 cell loss. HIV +
3) Transitional period of symptomatic disease follows (AIDS regardless of CD4 count)
4 ) a late or crisis period of symptomatic disease follows, which consist of opportunistic infections lasting months or years. (AIDS)
Treatment for HIV during pregnancy
- Zidovudine is the primary drug.
- It is the most effective to reduce vertical transmission from mother to infant. **
Things to consider during treatment of HIV
- If mother has had any antiretroviral therapy during pregnancy, including ZDV, and when it began
- If mother had any prenatal care and when she started
- Fetal gestation age
- If membranes have ruptured, how long they have been ruptured.
In mothers with HIV, it is recommended that
They have a c/s at 38 weeks prior to labor.**
Perinatal Transmission of HIV
Infant infection can occur during pregnancy, during L&D, or after birth if infant is breastfed**
Fetal/neonatal effects of HIV
o Infected newborn is typically asymptomatic at birth, but S&S may become obvious during first year of life.
o Enlargement of liver and spleen
o Lymphadenopathy
o Failure to thrive
o Persistent thrush
o Extensive seborrheic dermatitis (Cradle cap)**
o Often have bacterial infections: meningitis, pneumonia, osteomyelitis, septic arthritis, septicema
