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Chapter 26 Concurrent Disorders During Pregnancy
Terms in this set (59)
Preexisting, or type 1, diabetes mellitus
a complex disorder of carbohydrate metabolism caused primarily by a partial or complete lack of insulin secretion by the beta cells of the pancreas.
classic symptoms of diabetes mellitus
increase thirst (polydipsia)
gestational diabetes mellitus
-is one in which any degree of glucose intolerance has its onset or first recognition during pregnancy.
-Two subgroups are GDM A1 (diet control) and GDM A2 (insulin control with diet).
-from the end of 20 weeks of gestation until birth
• Type 1
Insulin dependence. Onset in childhood or young adulthood. Involves autoimmune destruction of pancreatic beta cells. Prone to ketosis
Increase risk for Congenital Anomalies
• Type 2:
May be diet controlled or require insulin related to increasing insulin resistance. Usual onset after age 40 years. Associated with obesity that often occurs in young adults or children. Ketosis less likely to occur than in type 1 diabetes mellitus.
🌟Women who have GDM in pregnancy
have a 35% to 60% likelihood of developing diabetes in the next 10 to 20 years
-Preeclampsia-Type 1-HTN-spilling of protein
-Urinary tract infections are more common
- shoulder dystocia
development of ketoacidosis is a threat to women who require insulin to properly control their diabetes. Ketoacidosis is often precipitated by infection or missed insulin doses, particularly in the woman with type 1 diabetes.
(excess volume of amniotic fluid), which may result from fetal hyperglycemia and consequent fetal diuresis, and premature rupture of membranes, which may be caused by overdistention of the uterus by hydramnios or a large fetus. Over urination of the fetus
(delayed or difficult birth of fetal shoulders after the head is born), and injury to the birth canal are more likely if the fetus is large.
First 20 weeks of pregnancy---body is producing more demands
During the first trimester
hypoglycemia, hyperglycemia, and ketosis, may lead to an increased incidence of spontaneous abortion or major fetal malformations.
7% of pregnancies
result in gestational diabetes
Increased rates of gestational diabetes in
African Americans 14%
90 to 95%
of the total population are type two diabetics
Gestational diabetes is responsible for two major complications in the fetus
-Large fetal size-- larger than 4000g at term
-results when elevated levels of blood glucose stimulate excessive production of fetal insulin, which acts as a powerful growth hormone.
Body producing insulin to keep up with the mother
Gestational Diabetes Mellitus
• Overweight (body mass index [BMI] 25 to 25.9 kg/m2), obese (BMI 30 to 39.9 kg/m2), or morbidly obese (BMI ≥40 kg/m2)
• 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)
• GDM in previous pregnancy
• History of abnormal glucose tolerance
• History of diabetes in a close (first-degree) relative
• Member of a high-risk ethnic group (Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry)
prenatal screening test is the glucose challenge test (GCT)
administered between 24 and 28 weeks.
Women with a fasting glucose level
greater than 126 mg/dL or a nonfasting level of more than 200 mg/dL meet the criteria for GDM, and no added testing is needed
Glucose Challenge Test
-Fasting is not necessary for a GCT
-The woman should ingest 50 g of oral glucose solution; 1 hour later a blood sample is taken. If the blood glucose concentration is 140 mg/dL or greater, a 3-hour oral glucose tolerance test (OGTT) is recommended. Some practitioners use a lower cutoff of 130 or 135 mg/dL to identify more women at risk
Oral Glucose Tolerance Test (gold standard for diagnosing diabetes) NOT TO EAT OR DRINK AFTER MIDNIGHT
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
The woman should take 15 g of carbohydrate if she can swallow. Retest after 15 minutes. If the level is less than 70 mg/dL, repeat carbohydrate intake and retest every 15 minutes until the blood glucose level returns to normal
Examples of foods containing 15 g of carbohydrate include:
•Three glucose tablets, depending on their carbohydrate content; oral glucose gel
•4 to 6 ounces fruit juice or regular soft drink
•Six saltine crackers
•1 tablespoon of syrup or honey
Signs and Symptoms of Maternal Hypoglycemia
• Shakiness (tremors)
• Pallor; cold, clammy skin
• Disorientation, irritability
• Blurred vision
Signs and Symptoms of Maternal Hyperglycemia
• Flushed, hot skin
• Dry mouth, excessive thirst
• Frequent urination
• Rapid, deep respirations; odor of acetone on the breath
• Drowsiness, headache
• Depressed reflexes
Expand blood volume approx. 500ml
Be careful not to overload with fluid in IV
Signs and Symptoms of Congestive Heart Failure
• Cough (frequent, productive, hemoptysis)
• Progressive dyspnea with exertion
• Pitting edema of legs and feet or generalized edema of face, hands, or sacral area
• Heart palpitations
• Progressive fatigue or syncope with exertion
• Moist rales in lower lobes, indicating pulmonary edema
Rheumatic Heart Disease
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. As a result, pressure in the left atrium, the pulmonary veins, and pulmonary capillaries is chronically elevated. This elevation may lead to pulmonary hypertension, pulmonary edema, or congestive heart failure.
🌟🌟The FIRST warnings of heart failure include PERSISTANT RAILS at the base of the lungs, dyspnea on exertion, cough, and hemoptysis. Progressive edema and tachycardia are additional signs of heart failure.
Congenital heart defects
-Needs to be managed. Very high risk to become pregnant.
-The risk to the fetus varies with severity of disease in the mother.
-The risk for a congenital heart defect in the fetus is also higher and varies with the number of affected relatives
Atrial septal defect (ASD)
Pregnancy is well tolerated by women with no complications.
No problems with the baby.
ventricular septal defects (VSDs)
-usually detected and corrected before children reach childbearing age.
Tetralogy of Fallot
Very dangerous for the mother and the baby
Mitral Valve Prolapse
-The leaflets of the mitral valve prolapse into the left atrium during ventricular contraction in mitral valve prolapse (MVP).
-Most women with MVP are asymptomatic
🌟🌟-physicians administer prophylactic antibiotics before and during labor and delivery.
woman is usually considered anemic
hemoglobin is lower than 11 g/dL in the first and third trimesters or lower than 10.5 g/dL in the second trimester
Signs and symptoms of iron deficiency anemia
pallor, fatigue, lethargy, and headache
Therapeutic Management of anemia
-Ferrous sulfate, 325 mg, one to three times per day is a common supplement.
-Many women experience less gastrointestinal discomfort if iron is taken with meals.
-Taking iron with 500 mg of vitamin C may enhance the iron absorption.
Folic Acid Deficiency (Megaloblastic) Anemia
associated with an increased risk for spontaneous abortion, abruptio placentae, and fetal anomalies, especially neural tube defects such as spina bifida or anencephaly.
-400 mcg (0.4 mg)/day, is recommended for all women of childbearing age
-600 mcg (0.6 mg) is recommended when pregnancy is confirmed.
Sickle Cell Disease
-The primary goal is to prevent sickle cell crisis during pregnancy. -Baby can die if there is a crisis
-High risk for infection
Signs of sickle cell crisis
The most common indications are pain in the abdomen, chest, vertebrae, joints, or extremities; pallor; and signs of cardiac failure.
Fertility is very low
No therapy or treatment
Watch for infection
Systemic lupus erythematosus
is a chronic, inflammatory autoimmune disease that can affect any organ or system in the body.
High Risk, increase in abortion, fetal death, exacerbation of the disease
Systemic lupus erythematosus symptoms
joint pain, photosensitivity, thrombocytopenia, and a "butterfly" rash on the face that is easily confused with normal pigmentation changes of pregnancy. Fatigue is a common symptom.
-Thyroid-stimulating hormone should be tested before or in early pregnancy and hypothyroidism corrected within the first trimester
-low dose aspirin
No effective therapy is currently available for the treatment of congenital infection.
Women who are immune do not become infected, so it is critical to determine the immune status of all women of childbearing age. A rubella titer of 1:8 or greater provides evidence of immunity. Women who are not immune should be vaccinated before they become pregnant, and they should be advised not to become pregnant for 4 weeks after vaccination because the live-virus vaccine poses a possible risk to the fetus.
-Nonimmune women are usually vaccinated during the postpartum period so that they will be immune before becoming pregnant again
VZIG should be administered within 96 hours to provide passive (temporary) immunity to pregnant women who have been exposed and are susceptible. A nonimmune postpartum woman should receive her first immunization before discharge and her second one 4 weeks postpartum. Pregnancy should be avoided for 1 month after each dose
-high mortality rate and most survivors are not normal.
-Risk for transmission via amniotic fluid or contact
-C Section Delivery
-also called fifth disease
-is characterized by a distinctive "lacelike" rash. The rash starts on the face with a "slapped-cheeks" appearance, followed by a generalized maculopapular rash.
-Other symptoms include fever, malaise, and joint pain.
-The risk to the fetus is greatest when the mother is infected in the first 20 weeks of pregnancy although that risk is about 10%, and loss risk after 20 weeks is less than 1%.
-no specific treatment
The infant is tested 1 to 3 months after completing the HBV immunization schedule to identify presence of chronic infection. Breastfeeding is considered safe as long as the newborn has been vaccinated
-Breastfeeding is not recommended because of possible viral transmission in the milk.
-Zidovudine therapy for the infant should begin 6 to 12 hours after birth.
-Infection is transmitted through organisms in raw or undercooked meat, through contact with infected cat feces, or across the placental barrier to the fetus if the expectant mother acquires the infection during pregnancy.
-Baby Brain Development
Group B Streptococcus Infection
Dormant...Swab by rectum, vagina
Optimal identification of the GBS carrier status is obtained by vaginal-rectal culture between 35 and 37 weeks of gestation. Penicillin is the first-line agent for antibiotic treatment of the infected woman during birth if she is not allergic.
Symptomatic individuals with TB
have general malaise, fatigue, loss of appetite, weight loss, and fever.
Signs of congenital TB
include failure to thrive, lethargy, respiratory distress, fever, and enlargement of the spleen, liver, and lymph nodes.
Drug management for the woman with latent TB
would be isoniazid and pyridoxine during pregnancy and postpartum
With TB for the infant
-Breastfeeding is not contraindicated.
-The infant should be skin tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 to 4 months.
-Isoniazid is usually continued for at least 9 months.
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