Infertility And Gestational Diabetes Flashcards
Reproductive structures that produce and release female gametes and sex hormones like estrogen and progesterone
Ovaries
Tiny, sac-like structures that each hold a single primary oocyte
Ovarian follicles
The process of egg production
Oogenesis
Hormones involved in the reproductive cycle
GnRH (released by hypothalamus), FSH & LH (released by anterior pituitary)
Male gonads responsible for making sperm and the androgen hormone testosterone
Testicles
Why are the testicles outside of the body?
For proper spermatogenesis (sperm are very sensitive to temperature)
An inability to conceive after one year of regular, unprotected sexual intercourse
Primary infertility
Inability to conceive after carrying a child to viability (at least 20 weeks)
Secondary infertility
Why is a comprehensive history and physical necessary when assessing for infertility?
Because ANY disruption in the process of conception may cause infertility
The nurse should refer for evaluation after _____ of failure to conceive
1 year
The nurse should refer for evaluation after _____ of failure to conceive for HIGH RISK patients
6 months
Maternal age >___ poses a risk for infertility
35
Genetic conditions that may cause a higher risk of infertility
Turner or Down Syndrome
Examples of fertility-lowering diseases
Endometriosis, Polycystic Ovarian Disease
What are the 6 essential components of female fertility?
Favorable cervical mucus, clear passage between cervix and tubes, patent tubes with normal motility, ovulation and release of ova, no obstruction between ovary and tubes, endometrial preparation
Lack of ovulation
Anovulation
Syndrome by which no oocytes are retrieved from the mature follicle after ovulation induction in IVF cycles
Empty follicle syndrome
Syndrome resulting from trauma to the endometrium in which curettage scar tissue bonds together and decreases the volume of the uterine cavity
Asherman’s syndrome
Female CNS/Endocrine factors that can contribute to infertility
Excessive weight loss, thyroid dysfunction, stress, inadequate estrogen/progesterone levels
What are the 4 essential components of male fertility?
Normal semen analysis, unobstructed genital tract, normal genital tract excretions, ejaculate deposited at the cervix
What is often the FIRST diagnostic test for male infertility because it is least invasive?
Semen analysis
How does obesity contribute to male infertility?
Inhibits adequate vaginal penetration
Oligospermia is classified as <___ mil/mL
20
Infections that affect sperm production and maturation factors
Gonorrhea, Chlamydia, Orchitis
Diseases that affect sperm production and maturation factors
Mumps infection after puberty
Examples of trauma that affect sperm production and maturation factors
Vasectomy, riding mountain bikes
Environmental factors that affect sperm production and maturation
Radiation, smoking, alcohol, drug use, malnutrition, stress, constrictive underclothing
Factors that can alter the shape or motility of sperm
Infections (prostatitis, chlamydia), polyspermia, asthenospermia
Loss or reduction of sperm motility
Asthenospermia
Ejaculation into the bladder
Retrograde ejaculation
Initial infertility assessment factors
Ovarian function, cervical mucus, sperm adequacy, tubal patency, pelvic organ condition
Female infertility assessment
Age (35+), history (medical, surgical, obstetric, gynecologic, sexual), occupation/environment risk, nutrition status, substance use
Male infertility assessment
History (medical, surgical, sexual), substance use, occupation/environment risk
Tests/procedures that determine when/if a female is ovulating
Basal body temp. Charts, urine ovulation predictor, endometrial biopsy, transvaginal ultrasound
Patient education for measuring basal body temperature
Take temp each morning before rising
Basal body temperature BEFORE ovulation
Temp drop 0.2 F 24-36 hours before ovulation
Basal body temperature AFTER ovulation
Temp rises 0.5-1.0 F 24-72 hours after ovulation due to progesterone released by the corpus luteum
Urine ovulation predictor identifies
LH surge prior to ovulation
Procedure that checks the endometrial response to hormonal cycle to ensure proper prep for implantation
Endometrial biopsy
What female hormones are analyzed for the diagnosis of infertility?
Prolactin, progesterone, estrogen, FSH, LH, thyroid
Female infertility diagnostic procedure that uses radiopaque dye to visualize fallopian tube patency and flushes debris or adhesions
Hysterosalpingography (HSG)
Nursing consideration for HSG
Assess for iodine/seafood allergy
Radiographic procedure that examines internal structures of the uterus
Hysteroscopy
Female infertility diagnostic for patients with endometriosis consisting of gas insufflation to visual internal organs and remove endometrial deposits while the patient is under general anesthesia
Laparoscopy
Infertility diagnostic in which patients have sex at a particular time followed by analysis of mucus and sperm interaction
Postcoital test
Semen analysis examines
Number, morphology, and motility
Semen analysis sample should be obtained after ___ days of abstinence and ___ separate analysis should be done
3; 2
Infertility diagnostic that assesses for antisperm antibodies and enzymatic defect (which prevents sperm from penetrating ova)
Sperm Penetration Assay (SPA) or Hamster Test
Male infertility diagnostic that visualizes testes transrectally to assess ejaculatory ducts, seminal vesicles, and vas deferens
Ultrasonography
Testicular biopsy checks for
Endocrine issues, blockage, or non-production
Male infertility diagnostic consisting of an X-ray of veins after administration of dye and assesses blood flow to scrotum
Venography
Postcoital mucus examination timing
Before ovulation, 8-12 hours after intercourse
Cervical mucus characteristics before ovulation
Raw egg white
Cervical mucus characteristics after ovulation
Thick, cloudy, pasty
Infertility treatment modalities education
Change in lifestyle (drugs, diabetes control), sexual techniques, timing of sexual intercourse
Infertility medications teaching
Must be taken on a regular schedule
Medication that induces ovulation by stimulating GnRH, LH, and FSH
Clomiphene citrate (Clomid)
Patient education for Clomid
Take for 5 consecutive days, starting with lowest dose
Medication that stimulates follicular development and blocks conversion to estrogen, therefore stimulating FSH and GnRH
Letrozole (Femara)
Patient education for Femara
Take for 5 consecutive days
Clomid and Femara work by
Increasing ovulation
Medication that supports ovulation by managing hyperinsulinemia in patients with PCOS
Metformin
Too much insulin may prevent
Ovulation
Assisted Reproductive Technology that places prepared sperm at cervical OS or in uterus
Intrauterine Insemination (IUI)
Therapeutic donor insemination may be useful for
Chromosomal concerns
Individual that is inseminated with semen and carries fetus until birth
Surrogate mother
Assisted reproductive technology in which eggs are collected and fertilized in laboratory with sperm, then embryo is transferred into uterus
In Vitro Fertilization
Assisted reproductive technology involving fertilization in the fallopian tube
In vivo fertilization
Two types of In Vivo Fertilization
Gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT)
ART Laparoscopic procedure in which oocytes are retrieved and immediately combine with sperm, then immediately transferred into fallopian tubes
GIFT
ART laparoscopic procedure that combines IVF and GIFT in which zygote is transferred to fallopian tube for transport to the uterus
ZIFT
Infertility complementary and alternative therapies
Acupuncture, herbal treatments, chiropractic care
Cons of IVF
Ethical/moral issues, expensive! (One cycle can range from 12-20K)
A group of conditions characterized by a high level of blood glucose (blood sugar)
Diabetes
Diabetes resulting from destruction of beta cells in the pancreas by the immune system causing reduced insulin production
Type I
Characteristics of type I diabetes
Early and sudden onset, typically occurring before age 20
Type I diabetes management
Insulin Injections (this type of diabetes is “insulin dependent”)
Diabetes in which the pancreas produces enough insulin, but cells become unresponsive/resistant to insulin
Type II
Type II diabetes risk factors
Obesity, inactivity, unhealthy diet
Characteristics of Type II diabetes
Gradual onset, typical occurring in adulthood after age 30
Management for type II diabetes
Weight loss, low-carb diet
Insulin deficiency caused by insulin resistance due to placental hormones that typically resolves after birth of the baby
Gestational diabetes
Hormone produced by the beta cells of the pancreas necessary for glucose intake by target cells
Insulin
Gestational diabetes risk factors
Family hx, obesity, previous unexplained stillbirth, prior infant weight >9 lbs, prior fetal anomalies, age >25, any ethnic group
As pregnancy progresses, Human Placental Lactogen (HPL) and progesterone cause
Decreased gastric motility, reduced insulin receptor sensitivity, and increased insulin resistance
As pregnancy progresses, tolerance to glucose __________
Decreases
As pregnancy progresses, hepatic glucose production _________
Increases
As pregnancy progresses, insulin secretions _________ to compensate, and insulin production __________ by the 3rd trimester
Increase; doubles
Why does insulin production and secretion increase during pregnancy?
To ensure that glucose is going to the baby for fuel
As a result of large amount of circulating glucose diverting to the fetus, the mother will
More quickly dip into glucose stores for fuel
Behaviors of normal pregnancy
Mild fasting hypoglycemia, progressive insulin resistance, hyperinsulinemia, mild postprandial (after eating) hyperglycemia
Why does a pregnant women experience mild fasting hypoglycemia?
Due to the overproduction/elevation of insulin which will drop blood sugar
Significance of mild postprandial hyperglycemia in pregnancy
Mild postprandial hyperglycemia increases the amount of time of elevated maternal glucose level and increases the flux of maternal nutrients to the fetus
During the first trimester of pregnancy, the need for insulin is _________
Decreased
During the first trimester of pregnancy, estrogen and progesterone levels _________
Increase
Function of increased levels of estrogen and progesterone during the first trimester of pregnancy
Stimulate increased insulin secretion, enhance peripheral glucose utilization and transport to fetus, decrease fasting blood glucose
Hormones that decrease blood glucose during the first trimester of pregnancy
Cortisol and HPL
Decreased food intake during the first trimester of pregnancy results in increased risk of __________
Hypoglycemia
During the second and third trimester, insulin need is __________
Increased
During the second and third trimester, pregnancy hormones antagonize insulin’s effectiveness at cellular level which can result in a(n) _________ release of glucose from storage
Increased
Placental enzyme that accelerates the breakdown of insulin which results in decreased insulin effectiveness and decreased peripheral uptake of glucose during the second and third trimesters of pregnancy
Insulinase
Why do insulin requirements often decrease dramatically during labor and delivery?
Decreased food intake (decreased need for insulin), increased metabolism and workload for labor (labor is considered a workout which eliminates the need for insulin)
Postpartum behaviors
Significant decrease in hormones (HPL, progesterone, estrogen), increased insulin sensitivity (after separation of placenta), further decreased insulin requirements with breastfeeding
Influence of pregnancy on diabetes and insulin requirements
Insulin requirements change throughout pregnancy and may double or quadruple by the end of pregnancy
Influence of pregnancy on diabetes: complications
Increased risk of HTN, nephropathy, retinopathy, hypoglycemia, ketoacidosis, and progression of vascular disease
Maternal risks of diabetes on pregnancy outcome
Hydramnios, increased risk for preeclampsia/eclampsia, ketoacidosis, dystopia (fetopelvic disproportion), worsening retinopathy, urinary/vaginal infection (r/t glycosuria)
Fetal-neonatal risks of diabetes on pregnancy outcome
Congenital anomalies, Intrauterine Growth Restriction (IUGR) with vascular disease present, LGA/macrosomia (>9 lbs), respiratory distress syndrome (RDS), polycythemia/hyperbilirubinemia, hypoglycemia
How does maternal diabetes influence RDS in fetus/neonate?
High levels of fetal insulin inhibit an enzyme needed for surfactant production
How does maternal diabetes influence neonatal polycythemia/hyperbilirubinemia?
Due to diminished glycosylated hemoglobin to carry oxygen
How does maternal diabetes influence neonatal hypoglycemia?
After maternal blood glucose is cut off, high levels of insulin activity deplete glucose levels leaving newborn at risk
Maternal antepartum diabetes medical management goals
Maintain physiologic equilibrium between insulin availability and glucose utilization; optimal health for both mother and newborn
Maternal antepartum diabetes dietary regulation
Balanced diet lower in carbs
Maternal antepartum glucose monitoring
3-4x a day
What is recommended for diabetic women who are trying to conceive?
Preconception counseling (diabetes should be very well managed prior to pregnancy to prevent complications!!)
Maternal antepartum insulin administration
Intermediate or short acting, or oral hypoglycemics such as metformin
Medication that prevents the development of preeclampsia
Aspirin 81 mg PO daily starting second trimester
Fetal antepartum medical management at 8-10 weeks
Crown-rump length for dating
Fetal antepartum medical management at 16-18 weeks
Maternal serum alpha fetoprotein
Fetal antepartum medical management at 18-20 weeks
Anatomy scan
Fetal antepartum medical management at 20-22 weeks
Fetal echocardiogram
Fetal antepartum medical management at 24 weeks
US for growth restriction every 4 weeks
Fetal antepartum medical management at 32 weeks
Twice weekly NSTs (or earlier if complications)
What do Non-Stress Tests (NSTs) assess?
Fetal oxygenation and well-being
Reassuring NST
2 accelerations in 20 minutes
Fetal antepartum medical management at 37-39 weeks
Consider induction if complications
Fetal antepartum medical management at 39 weeks
Delivery
Gestational diabetes HgbA1c levels
> /= 6.5%
Oral Glucose Tolerance Test (OGTT) screening for gestational diabetes
Done between 24-28 wks, 100 g oral glucose load, 1 hour screening, if 1 hour failed (BS</= 130) then proceed to 3 hour
If ___ or more values are abnormal following a 3 hour OGTT, then gestational diabetes is diagnosed
2
Fasting OGTT normal BG results
95 mg/dL
1 hr OGTT normal BG results
180 mg/dL
2 hour OGTT normal BG results
155 mg/dL
3 hour OGTT normal BG results
140 mg/dL
Goal fasting BG level
<95
Goal 1 hour postprandial BG level
<130-140
Goal 2 hour postprandial BG
<120
Goal BG during active labor
<110
Normal A1c level
4.5-6.0%
A1c level ___ 8.5% poses a 3-4% risk congenital anomaly
<
A1c ___ 8.5% poses a 22.4% risk of congenital anomaly
>
Maintaining maternal euglycemia intrapartum
BG q1-2 hours during active labor, IV insulin
Goal of diabetes medical management intrapartum
Prevention of neonatal hypoglycemia
OGTT should be repeated ___-___ weeks postpartum
4-12
Recommended contraception postpartum
Progesterone only or hormone free
Prevention of fetal hypoglycemia
Frequent feedings (breastfeeding or formula)
What weight classifies a LGA/macrosomic neonate?
> 4500 g, characterized by excessive body fat and organomegaly
Excessive growth (LGA/macrosomia) is due to
High levels of maternal glucose
Small for gestational age (SGA) is due to
Perfusion issues from diabetes related to vascular disease
Increased newborn glucose can cause
Hypovolemia (or decreased body water)
Newborn hypoglycemia
BG < 40 mg/dL
S/S of newborn hypoglycemia present within ___-___ hours of delivery
1-2
Newborn hypoglycemia treatment
IV or oral glucose, or feeding
S/S of newborn hypoglycemia
Poor feeding and/or vomiting, apnea, hypothermia, jitteriness, grunting, irritability, bluish/pale skin color, lethargy, tremors/seizures
Decreased maternal serum magnesium levels at term, caused by increased urinary excretion of calcium, causes secondary __________ in the newborn
Hypoparathyroidism (low calcium)
Newborn hypocalcemia is characterized by
Tremors
T/F: newborn hypocalcemia rarely requires treatment
True
Newborn hyperbilirubinemia develops between ___-___ hours post-delivery
48-72
Causes of newborn hyperbilirubinemia
Decreased extracellular volume causing increased Hct and increased breakdown of RBCs, hepatic immaturity impairing bilirubin conjugation, birth trauma/hematoma
Causes of birth trauma
Macrosomia, shoulder dystocia
Shoulder dystocia can result in
Broken clavicle and nerve damage
Birth trauma increases the risk for
Newborn jaundice
Newborn polycythemia pathophysiology
Fetal hyperglycemia and hyperinsulinemia = increased O2 consumption; glycosylated hemoglobin binds to O2, decreased amount of O2 available to fetus which stimulates production of erythropoietin and RBCs. Increased RBCs increases Hct which increased risk for hyperbilirubinemia
RDS occurs particularly in
Infants of poorly controlled diabetic mothers
RDS pathophysiology
Fetal lungs are less mature than expected for gestational age due to insulin antagonizing synthesis of lectin, and decreased phospholipid phosphatidylglycerol levels
Protein needed for lung maturation and surfactant production
Lectin
Lipid needed for surfactant stabilization
Phospholipid phosphatidylglycerol
RDS nursing consideration
Test for lung maturity prior to delivery if before 39 weeks
Congenital heart defects related to diabetes
Transposition of the great vessels, ventricular septal defect, patent ductus arteriosus
Congenital heart defect resulting in a hole in the heart
Ventricular septal defect
Congenital heart defect resulting in an opening between the 2 major blood vessels leading from the heart
Patent ductus arteriosus
Congenital birth defects related to diabetes
Small left colon syndrome, renal anomalies, neural tube defects, sacral agenesis
Congenital birth defect specific to diabetes in which there is partial or complete absence of the sacrum and lower lumbar spine
Sacral agenesis
Prevention of congenital birth defects related to diabetes
TIGHT glycemic control!!
