Module 2: Pregnancy II Flashcards
ovulation
mature egg released from ovary
moves down fallopian tube
fertilization
Fimbriae: little fingers that draw egg into fallopian tube
Implants into endometrium
Implants on day 8-9 post-fertilization
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.
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%
hormones causing GDM
Human placental lactogen
- Sends more glucose to the baby
- Main culprit
Progesterone
Cortisol
Growth hormone
Prolactin
normal glucose metabolism during pregnancy
Mild fasting hypoglycemia
Postprandial hyperglycemia
Higher blood sugars after eating
Hyperinsulinemia
abnormal glucose metabolism in GDM
More insulin resistant
Impaired release of insulin
maternal complications of GDM
Pre-eclampsia
C-section
Postpartum hemorrhage
3rd and 4th degree laceration
Development of type 2 DM later in life
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
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
shoulder dystocia
Head comes out, shoulders stuck in pelvis
Can get nerve injury
Broken clavicle
Lowered oxygen to brain
fetal long-term complications of GDM
Increased risk as child/adult of:
Diabetes
Obesity
Hypertension
Metabolic syndrome
Learning disabilities and autism
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
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)
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
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
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
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
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
