T3: Infections/Substance Abuse/Eclampsia/HELLP/Gest. Diabetes Flashcards
What does HELLP stand for?
H: Hemolysis
EL: Elevated liver enzymes
LP: Low platelets
If you don’t get HELLP with preeclampsia, increased risk for DIC?
DIC: disseminated intravascular coagulation = the proteins that control blood clotting become overactive. Leads to bleeding and blood clots.
What can we diagnose preeclampsia with?
After 20 weeks gestation:
Systolic BP of 140+
Diastolic BP of 90+
– OR –
an increase of 30 systolic or increase of 15 diastolic: 2 consecutive BPs, 6 hours apart
– AND –
Proteinuria (300 mg/24 hours) : due to the endothelial damage.
What percentage of the reproducing population is obese?
50% are obese.
Of these, they are 8.5 times more likely to develop GDM (gestational diabetes mellitus).
What diabetogenic effects can we expect to see naturally, in pregnancy?
- Mild fasting hypoglycemia
- Progressive insulin resistance
- Hyperinsulinemia: the amount of insulin in your blood is higher than what’s considered normal. Most often caused by insulin resistance and the pancreas responds by making more insulin.
- Mild postprandial hyperglyciemia: regarding the increased estrogen, increased progesterone, and trying to increase our glycogen stores for the developing fetus.
- An increase in estrogen and progesterone
- Increased glycogen storage can result in hypoglycemia.
What are the effects seen from the progressive increase of Human Placental Lactogen and Progesterone?
- Decrease in gastric mobility.
- Decrease in insulin receptor sensitivity.
- Increase in insulin resistance (Goal is to increase the available nutrients to the fetus)
This hormone is an insulin antagonist, its purpose is to increase the availability of nutrients to the fetus:
Human Placental Lactogen.
What happens to the hepatic glucose production during pregnancy?
It increases and continues to increase as the pregnancy progresses.
Does the insulin secretion go up or down as the pregnancy progresses?
Increases.
By the 3rd trimester, it has doubled.
Insulin needs decrease during the 1st trimester related to the mild hypoglycemia from the increased glycogen storage.
What is the percentage of women with GDM who develop Type II DM within 10 years of giving birth?
50%
90% of all diabetes while pregnant is gestational diabetes.
Who are at increased risk of developing GDM?
- The obese
- Those with a family Hx of DM
- Multiparity (aged pancreas?)
- Hydramnios
- AMA: Advanced Maternal Age, 35+
- Hx of fetal loss
- African, Hispanic, Native Am., and Asian are at higher risk.
S and S of GDM:
Polydipsia
Polyuria
Weight loss
How do we Dx GDM?
GTT at 24 wks.
This test at this time because the HPL hormone has not completely kicked in yet (which would affect the insulin resistance) and its far enough along where the estrogen and progesterone effects of early pregnancy have calmed down… this gives a better picture of how the mother’s pancreas is actually working.
Note: 2 elevated values needed to Dx GDM
Normal BG range for pregnant women?
70-110
What are the target goals for the fasting, 1 hour, and 3 hour glucose checks?
Fasting to be under 95 mg/dl
1 hour to be under 140 mg/dl
3 hour to be under 120 mg/dl
What is macrosomia?
Fetal macrosomia is when a newborn is born significantly larger than average.
There are some significant risks associated with GDM name 6:
- Preeclampsia: r/t endothelial damage caused by the sugar crystals in the blood.
- C-section
- Infection: r/t hyperglycemia. Most common and are red flags: UTI, yheast, group b strep.
- Thromboembolism: endothelial damage.
- Hydramnios: Causes preterm labor and possible post partum hemorrhage. From the polyuria of the fetus.
- Perinatal mortality. Risk decreases if glucose is kept under control.
GDM poses risks to the fetus, name 6:
- Neural tube defects
- Heart defects
- LGA: Large for Gestational Age
- IUGR: IntraUterine Growth Restriction. Due to lowered placental perfusion due to the endothelial damage from the sugar.
- Preterm birth: due to hydramnios stretching the uterus.
- Miscarriage: The excessive sugar has a taratogenic effect, ESP in the first trimester.
GDM poses risks to the neonate as well, name 5:
- Hypoglycemia: following birth the baby may need IV dextrose bc they are used to the maternal high levels of glucose, their pancreas is used to secreting large amounts of insulin.
- Polycythemia: An increased RBC production due to the compensation of the decreased placental perfusion. They will generally have a red “ruddy” face.
- Jaundice: Increased RBC broken down due to the polycythemia.
- Respiratory Distress Syndrome: Excessive insulin inhibits surfactant protection. Leading to an increased risk for immature lungs.
- Birth trauma: from macrosomia. Childhood obesity risk is also increased for these babies (all babies born from a diabetic mother).
Does insulin cross the placenta?
Does glucose?
Insulin does NOT cross.
Glucose DOES.
4 EVB strategies for managing GDM:
PREVENT
- Exercise started B4 20 weeks gestation decreases GDM risk by 50%. 60% if begun a year B4 conception.
- Carbohydrate control
SCREEN
- Random glucose test in the 1st trimester
- GTT at 24 weeks (“universal”).
HEALTH EDUCATION
* Weight gain guideline, diet edu, glucose monitor/management.
SELF MONITORING
- Empower them to take control of their own disease process and give them strategies to do it.
- Monitor glucose levels, goal is under 110.
4 more evidence based strategies for managing GDM: What specifics might you cover under physical activity, dietary changes, medication, and delivery plan?
PHYSICAL ACTIVITY
* 40 minutes a day has extreme effects on decreasing the morbidity and/or mortality outcomes.
DIETARY
- ADA (American Diabetes Association) guidelines, stay within them.
- A consult with a dietician - Key - helps them with real life, livable strategies.
MEDICATION
- Short-acting insulin (regular)
- Oral anti-hyperglycemic agents such as Metformin and Glyburide. These are category B for pregnancy.
DELIVERY GOAL
- Carry to term if they’ve controlled it.
- 38 weeks if LGA
Pre-pregnancy BMIs are the deciding factor regarding a healthy weight gain during pregnancy. What are the BMIs and their corresponding weight gain?
<18.5 = 28 to 40 pounds
18.5 - 24.9 = 25 to 35 pounds
25 - 29.9 = 15 to 25 pounds
> 30 = 11 to 20 pounds
Does insulin go up or down in early pregnancy?
Goes down.
What does insulin production do in late pregnancy?
Increase.
How many fetal kicks after 28 weeks should the mother feel?
10 kicks within a 2 hour window.
What are two ways to monitor the well-being of the fetus?
- Fetal monitoring: A no stress test
* Antenatal test: Ultrasound for fetal measurements and well-being.
How do we treat postprandial hyperglycemia?
With diet and exercise.
Postprandial means after a meal.
How do we treat fasting hyperglycemia?
This would require insulin therapy.
What does intrapartum mean and what sort of management should we be anticipating for GDM?
Intrapartum means occurring during labor or delivery.
- The insulin requirements go down during labor bc they’re being used up during the exercise of the labor.
- Glucose monitoring: either by capillary every 1 to 2 hours or every 1 to 5 MIN with continuous.
- Avoid using dextrose IV fluids unless it’s given with insulin IV
- Follow the insulin drip algorithm carefully to stay within the 70-110 range.
- Newborn risk: May need IV dextrose for hypoglycemic baby, also increased risk for admission into the nursery.
- Other Risks: Shoulder dystocia and C-section.
What will the insulin requirements be postpartum?
The insulin levels will continue to decrease and the insulin sensitivity will increase significantly after the expulsion of the placenta.
This is bc of the decrease of the hormonal antagonistic effects.
Why is a postpartum GTT performed and when is it done?
At 6 - 12 weeks postpartum the mother should take the GTT in order to help determine her risk for developing type II DM.
What is strongly encouraged to help stabilize BG levels PP?
Breastfeeding.
It helps mom AND baby.
It also reduces insulin requirements of the mother.
It decreases the risk for developing DM later for both the mother and the baby.
WATCH for mother develop hypoglycemia due to the increased caloric expenditure.
What are the common symptoms of hyperglycemia?
- Polyuria
- Polydipsia
- Blurred vision
- Fatigue
- HA - also for hypoglycemia though.
- Dry mouth (late sign)
- Rapid breathing (late sign)
- Confusion (late sign)
What are the common signs of hypoglycemia?
- Shakiness
- Dizziness
- Sweating
- Hunger
- Irritability or moodiness
- Anxiety or nervousness
- Headache - also in hyperglycemia
What kind of diet should the mother go on postpartum?
Regular diet… we will monitor and see how it goes.
Treat a carb with a protein.
Encourage mom to stick with the dietary changes she made during pregnancy to lower her risk of acquiring DM within the next 10 years (50% of GDM women do).
Document.
Postpartum risks for mom:
Hemorrhage
Preeclampsia is possible up to 6 weeks postpartum
Infection bc of hyperglycemia.
What does TORCHH stand for?
Toxoplasmosis Rubella Cytomegalovirus Herpes Simplex Human immunodeficiency Virus
Mother may show slight symptoms but grave to the fetus.
This is the most common infection in the world and is a PROTOZOAN transmitted via felines:
Toxoplasmosis.
Our immune systems usually keep it in check and we don’t even know.
Transferred through cat feces, under-cooked meat, or unpasteurized milk.
S and S of Toxoplasmosis:
Fetal outcome?
None. Maybe fatigue, muscle aches, fever, mild rash, splenomegaly, and enlarged lymph nodes.
SAB or fetal demise, preterm birth, severe eye infections, leading to blindness/seizures/coma/microcephaly/hydrocephalis/Mental retardation/neonatal death.
Sometimes asymptomatic at birth and may not see until school aged.
How is toxoplasmosis diagnosed and treated?
Dx with Blood test, followed by amnio, then serial ultrasounds.
Tx: specific antibiotics, but prevention is important.
TEACH moms that spores can be carried in the wind and don’t adhere to their cat’s fur… safe to handle the cat. But when changing the box, do it more often before the spores have a chance to germinate, still wear gloves and WASH HANDS.
