Concurrent Disorders During Pregnancy

Question 1

Diabetes Mellitus

Answer 1

Classifications of Diabetes Mellitus

Type I

Type II

Gestational (GDM)

• A₁GDM
• A₂GDM

Question 2

?

Are diet-controlled diabetics

May have oral medications they take to lower blood glucose

Do still produce insulin but not enough for what their body needs

In severe cases we can see a need for insulin

Answer 2

Type 2

Question 3

?

Are insulin-dependent diabetics

Are unable to produce insulin from their body; must get it from an exogenous source

Are very prone to ketosis, DKA

Answer 3

Type 1

Question 4

?

The onset of glucose intolerance is diagnosed during pregnancy

Initiates as gestational; could be type 2 but we won’t know exactly

These women will be followed postpartum as delivery of the placenta should cure the diabetes
> If this doesn’t, it’ll lead to the diagnosis of type 2 DM

Answer 4

Gestational (GDM)

Question 5

?

Insulin-controlled subtype but also with dietary management

Answer 5

A₂GDM

Question 6

?

Is the diet-controlled subtype

Answer 6

A₁GDM

Question 7

Effects on Pregnancy - Late Pregnancy (20 weeks gestation - birth)

Fetal growth accelerates, hormones sharply rise

Creates a ___

Insulin resistance in mom [glucose is not going into her cells efficiently] = oversupply of glucose for baby [is why we wait until 26 weeks gestation to test for DM]

High risk of ___ (in mother and baby)
> Remember that baby can produce insulin as well
> Baby is at risk of ___ at delivery

Answer 7

diabetogenic effect

hyperglycemia

hypoglycemia

Question 8

Effects on Pregnancy - Early Pregnancy (1-20 weeks gestation)

Maternal metabolic rates and energy needs change little

Increased insulin release in response to serum glucose levels

High risk of ___

Consider hyperemesis/fatigue that occur in early pregnancy

Answer 8

hypoglycemia

Question 9

Pre-Existing Diabetes Mellitus - Maternal Effects

* During pregnancy, ketoacidosis can develop at lower thresholds of hyperglycemia
> Higher risk of ketoacidosis, e.g. a blood glucose of 300 or less opposed to a previous 400 will lead to ketoacidosis in the woman

Answer 9

* Higher risk of preeclampsia; UTI’s; polyhydramnios (polyuria due to urine going into the amniotic fluid); PROM (see an overdistention of the uterus {from a larger baby} and polyhydramnios); the increased pressure from the overdistention increases risk that membranes could rupture prematurely); shoulder dystocia (due to fetal size); cesarean birth (due to larger baby); and postpartum hemorrhage

Question 10

Pre-Existing Diabetes Mellitus - Fetal Effects

* Dependent upon timing and severity of hypo- and hyperglycemia

* Increased risk of spontaneous abortion and fetal malformations (most common is neural tube [spina bifida, anencephaly] and cardiac defects)

* Fetal insulin production acts as a growth hormone which is why these babies are larger; macrosomic

Answer 10

* Risk of FGR/IUGR related to placental insufficiency
> Remember, diabetes can cause narrowing of the arteries and that can include the spiral arteries of the placenta

• So, the baby starts off with having those narrowed arteries which decreases the amount of O₂ coming in, CO₂ coming out, and amount of nutrients coming in

Question 11

Neonatal Effects (of infants born to pre-existing mothers with DM)

* Cardiomegaly
> Enlargement of the heart as insulin is a growth hormone
> Grows not only the body but internal organs as well

* Hypoglycemia

* Hypocalcemia

* Hyperbilirubinemia

Answer 11

* Respiratory Distress Syndrome

• Fetal lung maturation can be slower here than in a nondiabetic pregnancy
• If a diabetic mother arrives in preterm labor we want to prioritize the betamethasone or corticosteroid administration
• May take longer than 36 weeks for the diabetic mother
• Greater RDS risk due to hypoglycemia which can result in hypothermia; problems with thermoregulation

Question 12

Assessment

• Assess patient’s history of glycemic control, understanding, and ability to properly treat according to physician orders, including sliding scales
  > Type 1 tends to have better management than type 2
  > Type 2 have a higher glucose level, higher A1C and more trouble with glycemic control

Answer 12

• Physical examination, including obtaining baseline ECG [look at calcium], retinal assessment [complication is diabetic retinopathy], weight [consider that type 2 may be overweight or obese], and blood pressure
• Baseline laboratory tests, including midstream urine at each visit (at increased risk for UTI’s);
  > a UTI early in pregnancy can lead to spontaneous abortion; S/S present differently and you see a cystitis or pyelonephritis that can lead to preterm labor)
  baseline 24 hour urine (due to increased risk for preeclampsia); thyroid function test; and HbA1C

Question 13

• Fetal screenings for anomalies (neural tube defects [spina bifida, anencephaly]; abdominal wall defects [omphalacele]) including ultrasound and echocardiogram (assess for cardiomegaly during pregnancy and after delivery)

Answer 13

• Frequent surveillance with kick counts, biophysical profiles, and NSTs (keep in mind being at risk for placental insufficiency)

Question 14

Diabetic Diet During Pregnancy

Recommended caloric intake ___ kcal/kg/day

__-__% of calories from carbohydrates

__-__% calories from protein (the 2° source of energy)

Up to __% from [healthy] fats

* Distribute over 3 meals and 2 or more snacks

* Bedtime snack to contain complex carbohydrate and protein
> Bedtime snack as blood glucose levels can drop overnight; latter will help keep the carbohydrate stable and from bottoming out

Answer 14

30

40-45%

12-20%

40%

Question 15

Self-Monitoring Blood Glucose (SMG)

* Optimal frequency is not established for during pregnancy

* Study found postprandial levels most effective at predicting fetal macrosomia

* Perform at any time symptoms of hypo- or hyperglycemia arise

Answer 15

* Record results onto log and bring to each doctor’s visit (machines may self-document)

* Keeping a food log with a SMBG log can give the most insight (how does the A1C look?)

Question 16

Insulin

* Needs change throughout pregnancy
> First half needs are lower (fetal growth and development)
> End of 2nd half, 3rd trimester [fetus just growing] they’re increased; issues here are where we’ll see that macrosomic infant (insulin acts as a growth hormone)

* Needs typically drop in 1st trimester and increase markedly in 2nd and 3rd trimesters

Answer 16

* For type 1 diabetics, infusions of insulin, as well as a dextrose solution, are often needed in labor to maintain blood glucose levels between 80-110
> Consider if giving an epidural = cannot eat; normally clear liquids (ice chips, popsicles)

* Needs fall rapidly after delivery

* For type 2 diabetics more of a need to replete glucose

* Once the placenta is delivered, needs change significantly

Question 17

Gestational Diabetes Mellitus

Answer 17

Risk Factors

* Overweight, obese, or morbidly obese

* Maternal age over 25 years

* Previous birth outcome associated with GDM

* GDM in previous pregnancy

* History of abnormal glucose tolerance (maybe woman was told she is prediabetic at some point before)

* History of diabetes in a first-degree relative (i.e. mother/father/sister/brother)

* Member of a high-risk ethnic group

Question 18

Screening for Gestational Diabetes

Glucose Challenge Test (GCT) [done at ~26 weeks]

Fasting not necessary

Ingest ___ of oral glucose solution

Blood sample obtained 1 hour after completion

If glucose is ___ mg/dL or more, OGTT is recommended

Is a screening test

Answer 18

50g

140 mg/dL

Question 19

Oral Glucose Tolerance Test (OGTT)

Gold standard for diagnosis

Fasting screen less than __ mg/dL

Ingest ___ of oral glucose solution

1 hour screen less than ___ mg/dL

2 hour screen less than ___ mg/dL

3 hour screen less than ___ mg/dL

* If any 2 of these are abnormal, there is a diagnosis of GDM made

* If only 1 is abnormal, client is not

Answer 19

95 mg/dL (ensure that they did fast; if >95 = fail)

100g

180 mg/dL

155 mg/dL

140 mg/dL

Question 20

GDM: Management & Nursing Care

* Work with a registered dietician to create diet appropriate for woman

* Physician-guided exercise regimen

* SMBG based on regimen prescribed by physician

* Fetal surveillance in 2nd and 3rd trimesters (NST, BPP)

* Have open communication with the woman and her family

* Give a sense of control - let her be active in creating her plan of care

Question 21

Safety Alert: Identifying Hypo- and Hyperglycemia

Answer 21

Sx’s of Maternal Hyperglycemia

* Fatigue

* Flushed, hot skin

* Dry mouth; excessive thirst

* Frequent urination

* Rapid, deep respirations; acetone breath (with acidosis)

* Drowsiness, headache

! Depressed reflexes

Question 22

Sx’s of Maternal Hypoglycemia

* Tremors

* Diaphoresis

* Pallor; cold, clammy skin

* Disorientation; irritability

* Headache

* Hunger

* Blurred vision

Answer 22

Cardiac Disease

Question 23

?

* Note that this can develop from other cardiac diseases that are seen

Cough (frequent, productive, hemoptysis)

Progressive DOE

Orthopnea

Pitting edema of the legs and feet or generalized edema of the face, hands, or sacral area

Heart palpitations

Progressive fatigue or syncope with exertion

Moist rales in the lower lobes, indicating ?

Answer 23

Congestive Heart Failure (CHF)

pulmonary edema

Question 24

?

Uncommon in the US; may be seen in recent immigrants

Occurs following a streptococcal pharyngitis (i.e. strep throat)

Causing scarring, and thus narrowing, of heart valves; cannot dilate as needed

Can cause pulmonary hypertension, pulmonary edema, or CHF
> Coming from vena cava we see edema develop

Answer 24

Rheumatic Heart Disease

Question 25

Congenital Heart Disease \* Risk to fetus varies based on the severity of the disease in the mother \* Risk for congenital heart defects in the fetus varies on the number of relatives with the disorder

Question 26

Congenital Heart Disease - ? Left-to-right shunts: \_\_\_, \_\_\_, and \_\_\_

Answer 26

atrial septal defect (ASD) ventricular septal defect (VSD) patent ductus arteriosus (PDA)

Question 27

Congenital Heart Disease - ? Right-to-left shunts: \_\_\_, \_\_\_, \_\_\_

Answer 27

Tetralogy of Fallot Eisenmenger syndrome mitral valve prolapse

Question 28

Peripartum & Postpartum Cardiomyopathy (issue with the cardiac muscle) \* Rare condition associated with pregnancy after exclusion of other problems \* No underlying cardiac disease \* Symptoms of cardiac decompensation appear: dyspnea, edema, weakness, chest pain, and heart palpitations \* About 20% of women will have an abrupt downhill course, requiring cardiac transplant

Answer 28

\* 50% have a partial recovery, with long-term CHF \* Remaining 30% show recovery ! Recurs in future pregnancies

Question 29

Management Based on Classification of Heart Disease Class __ and __ Heart Disease \* Prevent cardiac decompensation & CHF \* Protect the fetus from hypoxia and fetal growth restriction \* May require bedrest, especially later in pregnancy \* Prevent thrombus formation

Answer 29

Class III & Class IV

Question 30

Class __ and __ Heart Disease \* Limit physical activity to reduce cardiac demand \* Be conscious of weight gain and sodium intake \* Prevention of anemia and infection

Answer 30

Class I & Class II

Question 31

Intrapartum Consideration & Management \* Labor creates a sharp rise in cardiac workload \* Be cautious with IV fluid administration to not create fluid overload ? _Cesarean_/_vaginal_ delivery is recommended over _vaginal_/_cesarean_ \* Forceps or vacuum-extractor may be used to reduce maternal pushing efforts \* After placental delivery, large fluid shift back into systemic circulation, posing increased risk, particularly with abrupt position changes

Answer 31

Vaginal; cesarean

Question 32

Hematologic & Immunologic Disorders During Pregnancy ? \* Responsible for 75% of anemias in pregnancy \* Maternal S/S include pallor, fatigue, lethargy, and headache \* \_\_, or a desire to consume nonfood substances such as clay and dirt, may be present \* __ (small), or __ (pale) red blood cells are seen \* Women with multifetal pregnancies or bleeding complications are more likely to experience ___ during pregnancy \* Management involves iron supplementation \* Promote good fluid intake and movement; good bowel movement

Answer 32

Iron Deficiency Anemia pica Microcytic; hypochromic anemia

Question 33

Folic Acid Deficiency \* Maternal needs for folic acid DOUBLE in pregnancy \* Primary cause of ___ during pregnancy \* Can be caused by hemolytic anemias and medications such as anticonvulsants \* Often presents WITH \_\_\_ \* Best diet sources of folic acid: kidney beans, lima beans, and dark green leafy vegetables

Answer 33

megaloblastic anemia iron deficiency anemias

Question 34

? Autosomal recessive genetic disorder that causes anemia Chronic anemia, susceptibility to infection, and periodic \_\_\_ Most common in those who have ancestors from Africa [people are tested to see if they have the trait; if both have the trait, can't get married], southern Europe, Middle Eastern countries, Central and South Americas, Saudi Arabia, and India \* Consider other conditions that cause pain due to a lack of O₂ to the tissues: MI, uterine contractions

Answer 34

Sickle Cell Disease sickle cell crisis

Question 35

Sickle Cell Crisis in Pregnancy [involves clumping of RBC's] \* Can cause infarctions in the joints and within major organs (the uterus is 1 of these) \* Has the potential to damage multiple organ systems \* Pregnancies tend to do well if crisis is avoided \* Fetal loss can occur if infarctions develop at the exchange surface of the placenta

Answer 35

\* Indications include pain in the abdomen, chest, vertebrae, joints, or extremities; pallor; and signs of cardiac failure

Question 36

? \* Chronic, _inflammatory_ autoimmune disease \* Pregnancy worsens ___ - best outcomes in patients with well-controlled ___ and no kidney involvement \* Associated with increased incidence of miscarriage and fetal death, premature birth, hypertension, renal complications, pPROM, and preeclampsia

Answer 36

Systemic Lupus Erythematosus (SLE)

Question 37

? Infrequent Transient photosensitive rash, thrombocytopenia, hepatitis, and hemolytic anemia

Answer 37

Neonatal Lupus Syndrome

Question 38

? \* Pregnancy can affect the frequency and the management of seizures \* Generalized seizures result in fetal hypoxia and acidosis \* The longer the woman has been seizure-free before pregnancy, the less likely she is to develop seizures during pregnancy \* _Teratogenic_ effects of anticonvulsant medications: \_\_\_

Answer 38

Epilepsy fetal hydantoin syndrome

Question 39

Infections During Pregnancy \* Cytomegalovirus (CMV) \* Rubella \* Varicella-Zoster Virus \* Herpesvirus Serotypes 1 and 2 (HSV 1 and 2) \* Parvovirus B19 \* Hepatitis B

Answer 39

\* Human Immunodeficiency Virus (HIV) \* Toxoplasmosis \* Group Beta Streptococcus Infection (GBS) \* Tuberculosis

Question 40

? Found in urine, saliva, blood, cervical mucus, semen, breast milk, and feces Most likely to transmit amongst young children and caregivers (consider 1. daycare workers and 2. pediatric nurses) Infection is often asymptomatic or produces minimal symptoms \_\_\_ infection is most harmful to the fetus 20-30% mortality rate for fetus/neonate \* Leading cause of ___ in children Other newborn problems include enlarged spleen and liver, CNS abnormalities, jaundice, chorioretinitis, and growth restriction

Answer 40

Cytomegalovirus (CMV) Primary (first) hearing loss

Question 41

? \* Symptoms include fever, general malaise, and maculopapular rash that begins on the face \* Transmitted via droplets or by direct contact with nasopharyngeal secretions \* Virus crosses the placental barrier and can infect the fetus

Answer 41

Rubella \* Is a live vaccine NOT to be given during pregnancy \* Do not get pregnant for 30 days after getting vaccinated \* Assess immunity status

Question 42

Rubella \* Common fetal complications if infected during 1st trimester: hearing loss, intellectual disabilities, cataracts, cardiac defects, growth restriction, microcephaly [a small head in relation to the body size] \* Infants born to mothers who had rubella during pregnancy can pass the virus to others for many months

Answer 42

**! Prevention is the only effective protection for the fetus**

Question 43

? \* A herpes virus transmitted by direct contact or via airborne transmission (N95 needed) \* Initial infection = chickenpox; reactivation = shingles \* Fetal risk of developing ? \> Clinical findings of ↑: limb hypoplasia, cutaneous scars, chorioretinitis, cataracts, microcephaly, and fetal growth restriction If developed by the mother within 2 weeks of birth, risk for ___ may develop

Answer 43

Varicella-Zoster Virus congenital varicella syndrome newborn varicella \* Varicella-zoster immune gloublin (VZIG)

Question 44

Herpesvirus Serotypes 1 and 2 (HSV 1 and 2) HSV ___ = genital HSV ___ = oral \* Diagnosed by serology and note that locations can intermingle \* Infection occurs as a result of direct contact of the skin or mucous membrane with an active lesion \* Vertical transmission occurs after ROM or during birth \* Highest risk if this is mother's primary HSV infection

Answer 44

2 1

Question 45

\* Neonatal herpes infection can develop with vaginal birth; an active outbreak is a reason for ___ delivery to bypass the vaginal canal \* Maternal-newborn separation is not necessary; educate mother on transmission and proper hygiene for prevention \* Antivirals are given during pregnancy to prevent outbreak: acyclovir, valacyclovir

Answer 45

cesarean

Question 46

? Causes erythema infectiosum, or \_\_\_ Symptoms include a "_slapped cheeks_" appearance on the face, followed by a generalized maculopapular rash \* Most common amongst young children \* Most infectious one week before the rash appears \* Greatest risk to fetus when maternal infection occurs before ___ weeks gestation (can lead to spontaneous abortion) \* Infection during pregnancy can cause fetal death, severe fetal anemia, hydrops, and heart failure

Answer 46

Parvovirus B19 *fifths disease* 20

Question 47

Hepatitis B (HepB) \* Transmitted through blood, saliva, vaginal secretions, semen, or breast milk and can cross the placenta \* Symptoms include vomiting, abdominal pain, jaundice, fever, rash, and painful joints \* Infection in pregnancy is associated with prematurity, low birth weight, and neonatal death and are at increased risk of active infection at birth

Answer 47

\* Goals to eliminate HepB within the US include: - universal newborn vaccination [Vitamin K, erythromycin ointment] - routine screening of all pregnant women - prophylaxis to infants born to infected mothers - routine vaccination to unvaccinated children and adults - vaccination of high-risk adults (such as healthcare workers) \* Infants born to positive mothers receive hepatitis B immune globulin (HBIG) and the HepB vaccine within 12 hours of birth \* **Cleanse newborn skin well before any injections or heel sticks**

Question 48

Human Immunodeficiency Virus (HIV) \* Perinatal transmission has fallen greatly with proper identification and treatment \* Symptoms include flu-like symptoms → asymptomatic → immune dysfunction → opportunist infections and cancers develop \* Antiretroviral therapy is administered throughout pregnancy to prevent transmission; though delayed start until 10-12 weeks [fetal development period] if safe

Answer 48

\* Infant begins Ziovudine (AZT) therapy within 6-12 hours after birth, up to 6 weeks after birth \* Infant HIV tests can remain positive up to 18 months after birth due to passive maternal antibodies \* Early signs of infection in the infant include enlargement of liver and spleen, lymphadenopathy, failure to thrive, persistent thrush, extensive seborrheic dermatitis

Question 49

? \* Transmitted via raw or undercooked meat, contact with infected cat feces, or across the placental barrier to the fetus if acquired during pregnancy \* Transmission to the fetus is highest during the third trimester, but more severe effects are noted when transmitted during the first trimester \* Advise pregnant women how to avoid infection

Answer 49

Toxoplasmosis

Question 50

? Leading cause of life-threatening perinatal infection in the United States Associated with preterm rupture of membranes and preterm birth Transmission to the newborn can result in the most serious infection, GBS septicemia, pneumonia, or meningitis Vaginal-rectal cultures performed between 35-37 weeks gestation

Answer 50

Group Beta Streptococcus Infection (GBS)

Question 51

\_\_\_ is the first line antibiotic; if allergic ampicillin, cefazolin, clindamycin, or erythromycin are possible alternatives If baby becomes infected results in GBS septicemia (GBS sepsis) Can lead to pneumonia and meningitis \* Is asymptomatic in mother

Answer 51

Penicillin

Question 52

? Transmitted via aerosolized droplets that are inhaled by a noninfected individual Symptoms include general malaise, fatigue, loss of appetite, weight loss, and fever Assess travel to high frequency areas of transmission

Answer 52

Tuberculosis

Question 53

Signs of congenital TB include failure to thrive, lethargy, respiratory distress, fever, and enlargement of the spleen, liver, and/or lymph nodes \* Multidrug therapy; respiratory isolation \> Negative pressure room; wear N95

Question 54

Medical Conditions Affecting Pregnancy

Answer 54

Appendicitis Inflammation of the appendix \* Most common non-gynecologic surgical emergency during pregnancy Difficult to diagnose during pregnancy Location of appendix altered by growing uterus (McBurney's point may have moved) Appendix should be removed to prevent rupture and consequent complications

Question 55

? Obstructive lung disease Dyspnea, cough, wheezing Varies in pregnancy Effective therapy results in good pregnancy outcomes Medications are well tolerated in pregnancy and appear safe for the fetus Remember labor/pushing is an activity that can trigger exacerbation ! Cannot administer ___ (\_\_\_) in cases of PPH

Answer 55

Asthma carboprost (hemabate)

Question 56

? _Overactive_, enlarged thyroid gland Normal changes of pregnancy can mimic \_\_\_ Ideally treatment is initiated before pregnancy, ___ is used during pregnancy Increased incidence of hypertension (including preeclampsia), PPH Thyroid Crisis

Answer 56

Hyperthyroidism hyperthyroidism Propylthiouracil

Question 57

? Inadequate thyroid secretion Elevated TSH and low T3, T4 Higher incidence of preeclampsia, abruptio placentae, low birth weight, and stillbirth Untreated can lead to neonatal goiter and congenital ___ and may or may not include neurological deficits Treatment = \_\_\_

Answer 57

Hypothyroidism hypothyroidism Levothyroxine (Synthroid)

Question 58

Maternal Phenylketonuria (PKU) \* Inherited single-gene recessive deficit \* Unable to metabolize phenylamine \* Goal is to be on a low phenylamine diet before conception and pregnancy

Answer 58

\* If not treated, fetus at risk for microcephaly, intellectual disabilities, heart defects, and IUGR

Question 59

Covid-19 & Pregnancy \* Increases risk of stillbirth \* Moms infected during the pregnancy do pass antibodies to the baby \* During hospitalization → intubation \* Partners unable to attend in person to the birth or office visits

Answer 59

\* Consider the psychological component; "long covid" \* We don't have all the data regarding vaccination in pregnancy \* We haven't seen infertility issues