Complicated Pregnancies Part 1 Flashcards
What are the main pre gestational problems?
Diabetes
Anemias
Heart disease
HIV
What is the definition of pre-gestational problems?
Health conditions existing BEFORE pregnancy that affect maternal-fetal health outcomes
Why is pregnancy a diabetogenic state?
In all pregnancies, changes occur to ensure that glucose goes to the growing fetus
What are the three phenomenons that mimic diabetes during pregnancy?
Mild fasting hypoglycemia
Post prandial hyperglycemia
Hyperinsulinemia
What is hyperinsulinemia
First trimester:
Estrogen and progesterone cause higher amount of insulin to be secreted, causing:
- increase in maternal glycogen stores, causing:
- mild hypoglycemia
Why do we develop increased tissue resistance to insulin?
In the 2nd and 3rd trimesters, estrogen and progesterone are still present.. but now Human Placental Lactogen (HPL) shows up.. and creates maternal insulin resistance.
And at the same time, glycogen levels decrease = more glucose enters the maternal blood stream, causing elevated post prandial blood sugars
What is maternal insulin resistance
Insulin is still there/being produced, but the body isn’t using it correctly, so that glucose can go to the baby
What happens if you have any pre existing diabetes and become pregnant?
It will be made worse, and a patient with the potential for diabetes may develop gestational diabetes
What are the maternal risks with diabetes?
Hydramnios or polyhydramnios
—increase in amniotic fluid volume
— excessive fetal urination secondary to fetal hyperglycemia
Preeclampsia/ Eclampsia
Labor dystocia
— due to fetopelvic disproportion
Recurrent monilial vaginitis or UTIs
What are fetal risks with diabetes?
Macrosomic infant (big baby usually over 4000-5000 grams) if poor glucose control
— high levels of glucose crossing placenta
Respiratory distress syndrome (RDS)
— high levels of fetal insulin inhibit surfactant production
Severe congenital anomalies: often involving heart, CNS, and skeletal system (seen only with pre gestational diabetes)
What are some fetal surveillance for diabetics!?
Maternal serum alpha fetoprotein
Ultrasound
Fetal kick counts
Non stress test biweekly
Biophysical profile weekly at 32 weeks
Amniocentesis (if needed) to assess lung maturity
Define anemia
In adequate levels of hemoglobin in the blood
Less than 12 gm/dL in non pregnancy
Less than 11 in pregnancy
How do you prevent or treat anemia?
To prevent anemia in pregnancy, start 30 mg per day supplements at first prenatal visit - this amount is contained in most prenatal vitamins
If anemia is diagnosed, dosage should increase to 60 mg to 120 mg a day of iron. Add stool softener.
After one month, if anemia persists, further lab studies are indicated
How should we take iron supplementation?
Better absorption on empty stomach and if taken with vitamin C
- absorption is reduced by 40-50%
If taken with meals
Client may need to start on lower dose and build up tolerance
Teach that tarry stools and constipation will occur
Why do we need folic acid?
Folic acid is necessary for DNA and RNA synthesis, and cell duplication
What happens if there’s a lack of folic acid?
Immature RBCs fail to divide, become enlarged (megaloblastic) , and are fewer in number
How to prevent or treat folic acid deficiency
Prevention with daily dose of 0.4 mg folate
Treatment if diagnosed: 1 mg folate daily
Iron deficiency almost always coexist with folic acid deficiency, so add iron supplement too
What is the #1 cause of US pregnancy death?
Cardiovascular disease
What is the top four causes of maternal mortality
Hypertension
Hemorrhage
Infection
Heart disease
Danger signs with cardiac disease?
Cough- with or without hemoptysis
Dyspnea- progressive, upon exertion
Edema- progressive, including extremities, face, eyelids
Heart murmurs
Palpitations
What are the major causes for bleeding in pregnancy?
Spontaneous abortion (miscarriage)
Ectopic pregnancy
Gestational trophoblastic disease (molar pregnancy)
Abruptio placentae (premature detachment of the placenta off the wall of the uterus)
Placenta previa (abnormal implantation of the placenta either partially or completely in front of the cervix)
What is the greatest risk factor for spontaneous abortions?
Advanced maternal age (over 35)
Over 50% of miscarriages are due to what?
Over 50% are related to chromosomal abnormalities
What are some causes for miscarriages?
Teratogens, faulty implantation, placenta abnormalities, weakened cervix, previous history, maternal illness
What is the pathophysiology of a miscarriage?
Usually embryonic death occurs and hCG production ceases
Then estrogen and progesterone decreases.. the interline decidua is sloughed off
Uterus becomes irritable, contracts, and the fetus is expelled
What are the 5 types of miscarriages?
Threatened
Imminent/ inevitable
Incomplete
Complete
Missed
What is threatened miscarriages?
Unexplained bleeding, cramping, backache
Cervix closed
What is imminent/inevitable miscarriages?
Increase bleeding and cramping
Cervix dilates
What is incomplete miscarriages?
Part of the products of conception are retained
Cervix dilated
What is a complete miscarriage?
All products of conception expelled
What is a missed spontaneous abortion?
Fetus dies but not expelled
Cervix closed
What is an ectopic pregnancy?
Implantation of a fertilized ovum in a site other than the endometrial lining of the uterus
Where is the most common location for an ectopic pregnancy?
The ampulla of the fallopian tube
How does an ectopic pregnancy present itself?
First it will be normal signs and symptoms of pregnancy
But eventually.. the embryo outgrow the tubal space, and the tube ruptures:
Bleeding
One sided and lower abdominal pain
Fainting, dizziness
Referred right shoulder pain
How to evaluate an ectopic pregnancy?
Menstrual history
Pelvic exam to assess for masses or tenderness
Labs: quantitative beta HCG (increase more slowly than in a viable IUP)
How do you manage an ectopic pregnancy?
Methotrexate IM if stable, unruptured, 4cm or less, no cardiac motion
Other cases would need laparoscopic surgery
RhoGAM if RH negative
What is a molar pregnancy
Pathologic proliferation of trophoblastic cells (outer most layer of embryonic cells)—- instead of a baby it’s a hydropic (fluid filled) grape like clusters
Woman with GTD not only suffers the loss of pregnancy, but the remote, yet real possibility of developing choriocarcinoma
How does a molar pregnancy present itself?
Vaginal bleeding (generally dark brown… prune juice colour)
Anemia
Hydropic vessels passed
Uterine enlargement greater than expected
No fetal tones, yet presence of other symptoms of pregnancy
Elevated serum hCG
Very low levels of maternal serum alpha fetoprotein (MSAFP)
What is gestational diabetes (GDM)
The pancreas is unable to produce the amount of insulin required to overcome insulin resistance caused by the hormones… which means glucose levels rise abnormally and the patient becomes gestational diabetic
How do you screen for GDM?
Test between 24-28 weeks when human placental lactogen (Hpl) is really high
Non-fasting one hour glucose tolerance test and if it’s 140 or above, a fasting 3 hour glucose test is ordered
What does a GDM diagnosis mean for the mom?
It’s a higher maternal risk for C section, polyhydramnios, and ketoacidosis
What does a GDM diagnosis mean for the fetus?
Higher fetal neonatal risk for macrosomia, respiratory distress syndrome, hypoglycemia after birth, and hyperbilirubinemia
