Module 2: Pregnancy II Flashcards by Melissa D'Alessio

ovulation

mature egg released from ovary
moves down fallopian tube

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fertilization

Fimbriae: little fingers that draw egg into fallopian tube
Implants into endometrium
Implants on day 8-9 post-fertilization

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what is gestational diabetes mellitus (GDM)?

GDM: hyperglycemia

Glucose intolerance of variable severity with onset or first recognized in pregnancy

Hormone levels of progesterone, cortisol, hPL, prolactin, and growth hormone are increased. This decreases insulin sensitivity and allows adequate glucose transmission to fetus. There will be no compensatory increase in insulin secretion which leads to hyperglycemia.

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how common is GDM?

Affects 7% of all pregnancies
Depending on population, can be as high as 14%
New york state: 6.5%
NYC: 11.5%

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hormones causing GDM

Human placental lactogen
- Sends more glucose to the baby
- Main culprit
Progesterone
Cortisol
Growth hormone
Prolactin

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normal glucose metabolism during pregnancy

Mild fasting hypoglycemia
Postprandial hyperglycemia
Higher blood sugars after eating
Hyperinsulinemia

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abnormal glucose metabolism in GDM

More insulin resistant
Impaired release of insulin

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maternal complications of GDM

Pre-eclampsia
C-section
Postpartum hemorrhage
3rd and 4th degree laceration
Development of type 2 DM later in life

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pre-eclampsia

10% of pregnancies
Blood pressure goes up
Protein in urine
Can cause stillbirth, seizures, kidney failure
Only cure is to deliver the baby → problem comes from placenta
Most typical during end of pregnancy, but can be premature and problematic
Can develop almost overnight

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fetal short-term complications of GDM

Large baby/macrosomia (>9 pounds)
Shoulder dystocia/birth injury
Stillbirth
Respiratory distress syndrome
Cardiomyopathy
Hypoglycemia
Electrolyte abnormalities
Polycythemia/hyperbilirubinemia

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shoulder dystocia

Head comes out, shoulders stuck in pelvis
Can get nerve injury
Broken clavicle
Lowered oxygen to brain

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fetal long-term complications of GDM

Increased risk as child/adult of:
Diabetes
Obesity
Hypertension
Metabolic syndrome
Learning disabilities and autism

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screening for GDM

Tested 24-28 weeks
1 hour glucose challenge test (50g glucose load)
If score >135, perform 3 hr glucose tolerance test (100g glucose load)
If score >200, no need for 3 hr test
2 out of 4 values need to be elevated for diagnosis of GDM
Carpenter/Coustan criteria

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treatment for GDM (non-pharmacologic)

About 2000 kcal/day diet
Complex carbohydrates 40%
Protein 20%
Unsaturated fat 40%
Exercise 20-30 minutes per day
Once giving birth, you no longer have GDM (insulin treatment can be immediately stopped)

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treatment for GDM (pharmalogic)

Metformin
- Crosses the placenta
- Side effects: nausea, vomiting, diarrhea, abdominal, cramping, bloating
- 10-46% need insulin
Insulin
- Doesn’t cross the placenta
- Gold standard

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future risks of GDM

Recurrence risk if ~40% in future pregnancies
Increased risk for type 1 DM, type 2 DM, metabolic syndrome, and cardiovascular disease
30% will have impaired glucose tolerance in the early postpartum period
10x higher risk of developing type 2 DM in the future
2x higher risk for future cardiovascular disease

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obesity increases risks for (fertility related)

Women with obesity have higher risk for infertility
- If they have polycystic ovarian syndrome, the loss of just 5-10% of body weight will restore ovulation in 55-100% within six months
Obesity increases risk for miscarriage
Obesity increases risk for birth defects (e.g. spina bifida)
Obesity increases risk for stillbirth
Underweight (BMI <18) also have higher risk of infertility and preterm labor
- Prevents ovulation

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pre-conception weight loss counseling

Try to achieve normal BMI (<25) prior to pregnancy
Losing any weight can be helpful
Small nutritional changes
Increasing activity levels

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weight gain in pregnancy

Necessary to provide nutrients to developing fetus
Nutrient stores for breastfeeding
Too little or too much weight gain can result in complications

if obese pregnant women gain less than recommendation,

reduced risk of preeclampsia

IOM weight guidelines, twins

Adequate weight gain is especially important in twins because growing small or premature birth is more common

underweight pregnant women have higher risk of

preterm birth
ensure is recommended as a supplement

Increased Gestational Weight Gain (even if starting pregnancy at a normal weight) leads to increased risk for

Increased risk for:
Pre-eclampsia
Gestational diabetes
Large baby (macrosomia)
C-section
Delayed lactation
Postpartum obesity

major pregnancy hormones

human chorionic somatotropin
human placental lactogen
leptin

human chorionic somatotropin

Increases insulin resistance Promotes fat breakdown for energy

human placental lactogen

Increases availability of glucose and amino acids Implicated in gestational diabetes

leptin

Regulates appetite and lipid metabolism Regulates weight gain and utilization of fat stores

undernutrition reduces

uterine blood flow

placenta development

Develops from embryonic tissue (before fetus) Larger than the fetus Uses 30-40% of glucose delivered by maternal circulation

placenta functions

Hormone and enzyme production Nutrient and gas exchange Removal of waste products Barrier to some harmful compounds

things passed mother to fetus

Water electrolytes, urea, FFAs, steroids, vitamins, glucose, amino acids, calcium, iron, iodine, globulins, phospholipids, lipoproteins

things passed fetus to mother

Carbon dioxide, water, urea, hormones, cytokines

the fetus is NOT a parasite

Nutrients are first used for maternal needs, then for placenta, and last for fetal needs The fetus is harmed more than the mother by poor maternal nutrition

What changes in kidney function occur during pregnancy and what are some consequences of these changes?

Increased glomerular filtration rate (50-60%) If on medications processed by the kidneys, dosage must increase Increased sodium conservation Increased risk for urinary tract infections Increased frequency of urination Progesterone stimulates bladder to contract more often

cardiovascular changes during pregnancy

Blood volume increases by 20% Increase in heart rate by 16% Increase stroke volume by increasing the cardiac output and heart rate Decrease in blood pressure Around 8 weeks is lowest blood pressure Heart enlarges (cardiomegaly) If you become pregnant and have history of heart problems, they will likely worsen (Pregnancy puts a lot of pressure on the heart)

Why shouldn’t women lay on their backs after 20 weeks (like Beyoncé when performing last year)? What happens to blood volume during pregnancy and why?

Aortocaval compression syndrome After 20 weeks, pregnant people must sleep on their side Inferior vena cava is compressed by the uterus → decreased blood supply to the heart → low blood pressure

Why are pregnant women often short of breath?

Increased amount of air inhaled and exhaled Increased oxygen consumption Increased respiratory rate “Dyspnea of pregnancy”

musculoskeletal changes are caused by which hormone

relaxin

musculoskeletal changes during pregnancy

Exaggerated lordosis of the lower back, forward flexion of the neck, and downward movement of the shoulders compensate for the enlarged uterus and change in center of gravity - This is why pregnant women are at high risk of injury or falling Joint laxity in the ligaments of the lumbar spine Widening and increased mobility of the sacroiliac joints and pubic symphysis

What is the role of progesterone in the GI tract during pregnancy and what symptoms are associated with these effects?

Increased gastric and intestinal transit time Heartburn Constipation Nausea and vomiting

skin changes caused by estrogen

Estrogen → darkening of skin Linea nigra → line from pubic symphysis to zyphoid process (middle of chest) Darker axilla (armpits)/groin/areola vascular spiders All temporary!

melasma

mask of pregnancy Up to 75% of pregnant people Darker cheeks/forehead/upper lip/noise Often goes away, but sometimes lasts for years

nevi enlarge

moles get bigger

palmar erythema

red palms

varicosities

veins are larger and filled with blood (legs and vulva)

hair changes during pregnancy

Hirsutism: increased hair on face, trunk, extremities Scalp hair: thicker/denser due to slowing of the normal progression of hairs from anagen (the “growing” stage) to telogen (the “resting” stage) so more hairs are in the anagen phase Postpartum: 1-5 months postpartum hair loss (telogen effluvium) is common and scalp hair becomes thin