Final notes Flashcards
Effects of Diabetes on Pregnancy in EARLY PREGNANCY
- Insulin release in response to serum glucose levels accelerates. As a result, significant hypoglycemia may occur, particularly in women who experience the nausea, vomiting, and anorexia that often arise during the first weeks of pregnancy.
- The availability of glucose and insulin, favors the development and storage of fat during the first half of pregnancy. Accumulation of fat prepares the mother for the rise in energy use by the growing fetus during the second half of pregnancy.
Effects of Diabetes on Pregnancy in LATE PREGNANCY
- During the second half of pregnancy, when fetal growth accelerates, levels of placental hormones rise sharply. These hormones, particularly estrogen, progesterone, and human placental lactogen (hPL), create resistance to insulin in maternal cells. which allows an abundant supply of glucose to be available for the fetus. They also have a diabetogenic effect in that they may leave the woman with insufficient insulin and episodes of hyperglycemia.
Effects of Diabetes on Pregnancy in during Birth
- Type
- Maintenance of normal maternal glucose levels is essential during birth to reduce neonatal hypoglycemia.
- Women with diabetes usually maintain their glucose testing and continue administration of doses of insulin the day before scheduled induction or cesarean birth.
- Day prior to c-section or induction - Women with an insulin pump continue using their pump through the night. After admission with nothing by mouth (NPO) after the prescribed time, their glucose level is checked and continuous infusion of insulin and glucose is started based on hourly glucose levels.
Effects of Diabetes on Pregnancy in the Postpartum Period
- The need for additional insulin falls during the postpartum period.
- Breastfeeding is encouraged not only for the newborn’s benefit but also because the added calorie intake by the mother helps lower the amount of insulin needed in women with types 1 and 2 diabetes mellitus.
- The woman with gestational diabetes mellitus (GDM) usually needs no insulin after birth but the greater risk for later development of type 2 diabetes should be emphasized with teaching before discharge.
Maternal Effects of Pre-Existing Diabetes TYPE 1
- Increased risk for hypertension, urinary tract infections, and ketosis.
Increased Maternal risks due to Diabetes Mellitus on Pregnancy
- Hypertension; preeclampsia Hypertension
- Urinary tract infections - Increased bacterial growth in nutrient-rich urine
- Ketoacidosis (risk for mother and fetus) - Uncontrolled hyperglycemia or infection; most common in women with type 1 diabetes
- Labor dystocia; cesarean birth; uterine atony with hemorrhage after birth - Hydramnios secondary to fetal osmotic diuresis caused by hyperglycemia; uterus is overstretched
- Birth injury to maternal tissues (hematoma, lacerations) - Fetal macrosomia causing difficult birth
- First trimester may have an abnormal environment such as hypoglycemia, hyperglycemia, ketosis
- This can cause an increased risk of SAB/s, fetal malformations and a two to three fold increase risk of developing - Ployhydraminos
Fetal and neonatal adverse effects of Diabetes Mellitus in Pregnancy
- Congenital anomalies
- Perinatal death
- Macrosomia (>4000 g)
- IUGR
- Preterm labor
- Overdistention of uterus caused by hydramnios
- Birth injury Large fetal size
- Fetal growth (increased or decreased)
- Hypoglycemia
- Polycythemia
- Hyperbilirubinemia
- Hypocalcemia
- Respiratory distress syndrome
Therapeutic Management of Diabetes
- Preconception Care - Control the disease
- Diet
- Self monitoring - Check/log blood glucose levels multiple times a day
- ** Blood Glucose Monitoring.
- Blood glucose levels should be evaluated to determine whether levels are normal. A common method is measurement of fasting blood glucose level (no food for the previous 4 hours) and postprandial blood glucose level (2 hours after each meal).
- If fasting capillary blood glucose levels repeatedly exceed 95 mg/ dL or postprandial values exceed 120 mg/dL, insulin therapy is started. Additional tests for glucose levels may be performed, as needed.
- Insulin therapy
Laboratory test for a pregnant woman with Diabetes
- In addition to routine prenatal laboratory examinations
- baseline renal function should be assessed with a 24-hour urine collection for total protein excretion and creatinine clearance.
- Assess for urinary tract infections, which are common in women with diabetes.
- Urine also should be checked by using a dipstick for the presence of glucose, ketones, and protein.
- Glycemic control should be evaluated on the basis of the level of glycosylated hemoglobin or hemoglobin A1c (HbA1c). With prolonged hyperglycemia, a percentage of hemoglobin will remain saturated with glucose for the life of the red blood cell (RBC). The glycosylated hemoglobin assay is an accurate measurement of the average glucose concentrations during the preceding 2 to 3 months.
The goals of therapeutic management for a pregnant woman with diabetes are to
(1) maintain normal blood glucose levels
(2) facilitate the birth of a healthy baby, and
(3) avoid accelerated impairment of blood vessels and other major organs. To achieve this outcome, an intensive, team approach to care is required.
Maternal adverse effects of gestational diabetes
- increased urinary tract infections
- hydramnios
- premature rupture of membranes
- the development of preeclampsia.
Risk Factors for Gestational Diabetes Mellitus
- Overweight (body mass index [BMI] ≥25 to 25.9) or obesity (BMI ≥30 or morbidly obese (BMI ≥ 40 or higher)
- Maternal age older than 25 years
- Previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension, infant with unexplained congenital anomalies, previous fetal death)
- Gestational diabetes in previous pregnancy
- History of abnormal glucose tolerance
- History of diabetes in a close (first-degree) relative
- Member of a high-risk ethnic group (African-American, Hispanic or Latino, American Indian, Asian American, or Pacific Islanders) Women with any of these factors should be screened for type 2 or gestational diabetes at the first prenatal visit (ACOG,
Screening for Gestational Diabetes Mellitus
Glucose Challenge Test.
- A GCT is administered between 24 and 28 weeks of gestation, often to both low- and high-risk antepartum patients.
- . Fasting is not necessary for a GCT, and the woman is not required to follow any pretest dietary instructions.
- STEPS: The woman should ingest 50 g of oral glucose solution. A blood sample is taken 1 hour later. If the blood
glucose concentration is 140 mg/dL or greater, a 3-hour oral glucose tolerance test is recommended.
Oral Glucose Challenge Test.
- An oral glucose tolerance test (OGTT) may be used as the initial test if a woman is at high risk for GDM, but the test
is more likely to be used for diagnosis following abnormally high GCT results
- OGTT is the gold standard for diagnosing diabetes, but it is a more complex test.
- The woman must fast from midnight on the day of the test. After a fasting plasma glucose level is determined, the
woman should ingest 100 g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3
hours.
* GDM is the diagnosis if the fasting blood glucose level is abnormal or if two or more of the 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
Signs and symptoms of maternal HYPOglycemia include:
- Shakiness (tremors)
- Sweating
- Pallor; cold, clammy skin
- Disorientation; irritability
- Headache
- Hunger
- Blurred vision Teach family members how
Signs and symptoms of maternal hyperglycemia include the following:
- Fatigue
- Flushed, hot skin
- Dry mouth; excessive thirst
- Frequent urination
- Rapid, deep respirations; odor of acetone on the breath
- Drowsiness; headache
- Depressed reflexes
Managing HYPOglycemia
- Treat hypoglycemia at once to prevent damage to the fetal brain, which is dependent on glucose.
- Woman experiencing hypoglycemia should ingest 15 g of carbohydrate if she can swallow food.
Examples of foods that supply this are 3 glucose tablets or glucose gel, 1 2 cup of fruit juice or SAFETY - Teach family members how to inject glucagon in the event that the woman cannot swallow or retain food.
- Notify the physician at once.
- IV glucose will be administered if she is hospitalized.
*****If untreated, hypoglycemia can progress to convulsions and death. To prevent hypoglycemia, instruct the woman to have meals at a fixed time each day and to plan snacks at 10 am, 3 pm, and bedtime. Suggest that she always carry glucose tablets or gel or some crackers with her.
Managing HYPERglycemia
- Because infection is the most common cause of hyperglycemia, pregnant women must be instructed to notify the physician whenever they have an infection of any type.
- Untreated hyperglycemia can lead to ketoacidosis, coma, and maternal and fetal death.
- notify the physician at once so that treatment can be initiated.
- Hospitalization often is necessary to monitor blood glucose levels, for IV insulin administration to normalize glucose levels, and for treatment of any underlying infection.
Congenital Heart Diseae
Atrial Septal Defect - Pulmonary hypertension occasionally develops in uncorrected atrial septal defects because the additional blood that moves to the right side of the heart is transported to the lungs through the pulmonary artery
Ventricular Septal Defect - Bacterial endocarditis is common with unrepaired defects, and antibacterial prophylaxis is recommended
Patent Ductus Arteriosus. - The patent ductus arteriosus tends to become infected, so antibiotic prophylaxis before labor is recommended
Mitral Valve Prolapse. Mitral valve prolapse is one of the most common cardiac conditions among the general population. In mitral valve prolapse, the leaflets of the mitral valve prolapse into the left atrium during ventricular contraction.Some physicians consider mitral valve prolapse to be a significant risk factor for bacterial endocarditis and administer prophylactic antibiotics before and during labor and delivery. Beta-blockers such as atenolol
Rheumatic Heart Disease
Rheumatic heart disease is a complication that sometimes follows streptococcal pharyngitis (“strep throat”). Even one bout of rheumatic fever may cause scarring of the heart valves, resulting in stenosis (narrowing) of the openings between the chambers of the heart.
- The mitral valve is the most common site of stenosis. Mitral stenosis obstructs free flow of blood from the left atrium to the left ventricle. The left atrium becomes dilated, and as a result, pressure in the left atrium, pulmonary veins, and pulmonary capillaries is chronically elevated. This elevation may lead to pulmonary hypertension, pulmonary edema, or CHF.
- The first warnings of heart failure include persistent rales at the base of the lungs, dyspnea on exertion, cough, and hemoptysis. Progressive edema and tachycardia are additional signs of heart failure.
Signs and Symptoms of Heart Disease
- Dyspnea,
- Syncope (fainting) with exertion
- Hemoptysis (coughing up of blood)
- Paroxysmal nocturnal dyspnea
- Chest pain with exertion.
-
** Additional signs that confirm the diagnosis are
(1) cyanosis;
(2) clubbing;
(3) diastolic, presystolic, or continuous heart murmur;
(4) cardiac enlargement;
(5) a loud, harsh systolic murmur associated with a thrill; and
(6) serious dysrhythmias
Therapeutic Management for Class I or II Heart Disease
- Limit physical activity. the woman should remain free of symptoms of cardiac stress such as dyspnea, chest pain, and tachycardia.
- Avoid excessive weight gain. Excessive weight increases demands on the heart. A diet adequate in protein, calories, and sodium is necessary. A low-sodium diet may be advised to avoid CHF.
- Prevent anemia. Anemia decreases the oxygen-carrying capacity of the blood and results in a compensatory increase in heart rate that a diseased heart may be unable to tolerate. Most anemia is prevented by administration of iron and folic acid.
- Prevent infection. Immunizations for influenza, pertussis, and pneumonia are available. Prevention may include administration of prophylactic antibiotics.
- Undergo careful assessment for the development of CHF, pulmonary edema, and cardiac dysrhythmias. Characteristics of heart failure may include persistent basilar rales, often accompanied by a cough during the night as the woman tries to sleep, sudden inability to carry out usual activities, dyspnea, cough, hemoptysis, increasing edema, and tachycardia.
Therapeutic Management for Class III or IV Heart Disease
The PRIMARY goal of management is to prevent cardiac decompensation and development of CHF.
- Also, every effort is made to protect the fetus from hypoxia and IUGR, which can occur if placental perfusion is inadequate.
- In addition to the precautions listed for classes I and II heart disease, the woman may require bed rest, especially during the last trimester, because she has little reserve to tolerate rising metabolic demands.
- Reduced activity increases the maternal risk for thrombus formation and will require prophylaxis such as elastic compression stockings or a serial or boot compression device.
- Prophylactic anticoagulation may be needed.
Drug therapy for Heart Disease in Pregnant women
Anticoagulants. During pregnancy, clotting factors normally increase and thrombolytic activity decreases. These changes predispose the pregnant woman to thrombus formation.
- Warfarin (Coumadin) is associated with fetal malformations and should be restricted throughout pregnancy. * *** Postpartum anticoagulation is continued with warfarin - Subcutaneous heparin, which does not cross the placental barrier, is an effective alternative anticoagulant for most. * ******Heparin is withheld during labor & resumed 6 hs after vaginal birth and 18 - 24 hrs after cesarean - Enoxaparin (Lovenox), a LMWH, may be used instead of standard heparin because it requires less-frequent monitoring for bleeding complications. * **** Enoxaparin and heparin are not interchangeable. Both are given subcutaneously, but only heparin may be given intravenously.
Antidysrhythmics
- In addition to controlling the dysrhythmias, beta-blockers and calcium channel blockers may be used to control
maternal hypertension.
- Digoxin, adenosine, and calcium channel blockers appear to be safe.
Drug therapy for Heart Disease in Pregnant women
Anticoagulants. During pregnancy, clotting factors normally increase and thrombolytic activity decreases. These changes predispose the pregnant woman to thrombus formation.
- Warfarin (Coumadin) is associated with fetal malformations and should be restricted throughout pregnancy.
** Postpartum anticoagulation is continued with warfarin
- Subcutaneous heparin, which does not cross the placental barrier, is an effective alternative anticoagulant for most.
**Heparin is withheld during labor & resumed 6 hs after vaginal birth and 18 - 24 hrs after cesarean
- Enoxaparin (Lovenox), a LMWH, may be used instead of standard heparin because it requires less-frequent monitoring for
Bleeding complications.
** Enoxaparin and heparin are not interchangeable. Both are given subcutaneously, but only heparin may be given intravenously.
Antidysrhythmics
- Digoxin, adenosine, and calcium channel blockers appear to be safe.
- Beta-blockers have been associated with neonatal respiratory depression, sustained bradycardia, and
hypoglycemia when administered late in pregnancy or just before delivery but may be needed in selected cases.
- The beta-blockers atenolol and metoprolol may be preferred because they do not cause the uterine stimulation
that other drugs of this class may cause
Antiinfectives.
- A woman with an increased risk for bacterial endocarditis may receive prophylactic antibiotics such as amoxicillin,
penicillin, ampicillin, and gentamicin at delivery.
- Ceftriaxone or vancomycin also may be given for acute endocarditis.
Diuretics - Drugs for heart failure
- Carefully monitor electrolytes and water balance to avoid adverse effects on mother and fetus
- IUGR has been associated with furosemide, and neonatal jaundice, thrombocytopenia, anemia, and hypoglycemia
have been associated with thiazide diuretics