lowdermilk and perry: maternity and women’s health care copyright © 2006 by mosby, inc. all...

Copyright © 2006 by Mosby, Inc. All rights reserved.Lowdermilk and Perry: Maternity and Women’s Health Care1 of 16

Endocrine and Metabolic Endocrine and Metabolic DisordersDisorders

Copyright © 2006 by Mosby, Inc. All rights reserved.

Chapter 32: Endocrine and Metabolic Disorders

Lowdermilk and Perry: Maternity and Women’s Health Care2 of 16

Endocrine and Metabolic DisordersEndocrine and Metabolic Disorders

Require careful management to promote Require careful management to promote maternal and fetal well-beingmaternal and fetal well-being

Diabetes mellitus is the most common Diabetes mellitus is the most common endocrine disorder associated with endocrine disorder associated with pregnancypregnancy




Diabetes Mellitus Diabetes Mellitus

Diabetes mellitusDiabetes mellitus■ HistoryHistory

Discovery of insulin in 1922 enabled healthy Discovery of insulin in 1922 enabled healthy birth of babybirth of baby● Pregnancy complicated by diabetes still Pregnancy complicated by diabetes still

considered high riskconsidered high risk




Diabetes Mellitus PathogenesisDiabetes Mellitus Pathogenesis Group of metabolic diseases characterized by hyperglycemia Group of metabolic diseases characterized by hyperglycemia

resulting from defects in insulin secretion, insulin action, or bothresulting from defects in insulin secretion, insulin action, or both

Insulin, produced by the beta cells in the islets of Langerhans in Insulin, produced by the beta cells in the islets of Langerhans in the pancreas, regulates blood glucose levels by enabling glucose the pancreas, regulates blood glucose levels by enabling glucose to enter adipose and muscle cells, where it is used for energy. to enter adipose and muscle cells, where it is used for energy.

When insulin is insufficient or ineffective in promoting glucose When insulin is insufficient or ineffective in promoting glucose uptake by the muscle and adipose cells, glucose accumulates in uptake by the muscle and adipose cells, glucose accumulates in the bloodstream, and the bloodstream, and hyperglycemiahyperglycemia results. results.

Hyperglycemia causes Hyperglycemia causes hyperosmolarityhyperosmolarity of the blood, which of the blood, which attracts intracellular fluid into the vascular system, resulting in attracts intracellular fluid into the vascular system, resulting in cellular dehydrationcellular dehydration and expanded blood volume. and expanded blood volume.

Consequently, the kidneys function to excrete large volumes of Consequently, the kidneys function to excrete large volumes of urine (urine (polyuriapolyuria) in an attempt to regulate excess vascular volume ) in an attempt to regulate excess vascular volume and to excrete the unusable glucose (and to excrete the unusable glucose (glycosuriaglycosuria). ).

Polyuria, along with cellular dehydration, causes excessive thirst Polyuria, along with cellular dehydration, causes excessive thirst ((polydipsiapolydipsia).).




Diabetes Mellitus Diabetes Mellitus The body compensates for its inability to convert carbohydrate The body compensates for its inability to convert carbohydrate

(glucose) into energy by burning proteins (muscle) and fats. (glucose) into energy by burning proteins (muscle) and fats. However, the end products of this metabolism are However, the end products of this metabolism are ketones and fatty ketones and fatty acidsacids, which, in excess quantities, produce , which, in excess quantities, produce ketoacidosis ketoacidosis andand acetonuriaacetonuria. Weight loss occurs as a result of the breakdown of fat . Weight loss occurs as a result of the breakdown of fat and muscle tissue. This tissue breakdown causes a state of and muscle tissue. This tissue breakdown causes a state of starvation that compels the individual to eat excessive amounts of starvation that compels the individual to eat excessive amounts of food (food (polyphagiapolyphagia).).

Over time, diabetes causes significant changes in both the Over time, diabetes causes significant changes in both the microvascularmicrovascular and and macrovascularmacrovascular circulations. These structural circulations. These structural changes affect a variety of organ systems, particularly the changes affect a variety of organ systems, particularly the heart, heart, eyes, kidneys, and nerveseyes, kidneys, and nerves. Complications resulting from diabetes . Complications resulting from diabetes include premature atherosclerosis, retinopathy, nephropathy, and include premature atherosclerosis, retinopathy, nephropathy, and neuropathy.neuropathy.

Diabetes may be caused by either impaired insulin secretion, when Diabetes may be caused by either impaired insulin secretion, when the beta cells of the pancreas are destroyed by an autoimmune the beta cells of the pancreas are destroyed by an autoimmune process, or by inadequate insulin action in target tissues at one or process, or by inadequate insulin action in target tissues at one or more points along the metabolic pathway. Both of these conditions more points along the metabolic pathway. Both of these conditions are commonly present in the same person, and it is unclear which, if are commonly present in the same person, and it is unclear which, if either, abnormality is the primary cause of the diseaseeither, abnormality is the primary cause of the disease




Diabetes Mellitus ClassificationDiabetes Mellitus Classification

■ Type 1 diabetesType 1 diabetes Absolute insulin deficiencyAbsolute insulin deficiency

■ Type 2 diabetesType 2 diabetes Relative insulin deficiencyRelative insulin deficiency

■ Pregestational diabetes mellitusPregestational diabetes mellitus■ Gestational diabetes mellitus (GDM)Gestational diabetes mellitus (GDM)




Diabetes Mellitus Diabetes Mellitus Metabolic changes associated with pregnancyMetabolic changes associated with pregnancy

■ Alterations in maternal glucose metabolism, insulin production, and metabolic Alterations in maternal glucose metabolism, insulin production, and metabolic homeostasishomeostasis

■ During normal pregnancy, adjustments in maternal metabolism allow for During normal pregnancy, adjustments in maternal metabolism allow for adequate nutrition for both the mother and the developing fetus. Glucose, the adequate nutrition for both the mother and the developing fetus. Glucose, the primary fuel used by the fetus, is transported across the placenta through the primary fuel used by the fetus, is transported across the placenta through the process of carrier-mediated facilitated diffusion. This means that the glucose process of carrier-mediated facilitated diffusion. This means that the glucose levels in the fetus are directly proportional to maternal levels. Although glucose levels in the fetus are directly proportional to maternal levels. Although glucose crosses the placenta, insulin does not. crosses the placenta, insulin does not.

■ Around the tenth week of gestation the fetus begins to secrete its own insulin at Around the tenth week of gestation the fetus begins to secrete its own insulin at levels adequate to use the glucose obtained from the mother. Thus, as maternal levels adequate to use the glucose obtained from the mother. Thus, as maternal glucose levels rise, fetal glucose levels are increased, resulting in increased fetal glucose levels rise, fetal glucose levels are increased, resulting in increased fetal insulin secretion.insulin secretion.

■ During the first trimester of pregnancy the pregnant woman's metabolic status is During the first trimester of pregnancy the pregnant woman's metabolic status is significantly influenced by the rising levels of estrogen and progesterone. These significantly influenced by the rising levels of estrogen and progesterone. These hormones stimulate the beta cells in the pancreas to increase insulin production, hormones stimulate the beta cells in the pancreas to increase insulin production, which promotes increased peripheral use of glucose and decreased blood glucose, which promotes increased peripheral use of glucose and decreased blood glucose, with fasting levels being reduced by approximately 10%with fasting levels being reduced by approximately 10%

■ There is a concomitant increase in tissue glycogen stores and a decrease in There is a concomitant increase in tissue glycogen stores and a decrease in hepatic glucose production, which further encourage lower fasting glucose levels. hepatic glucose production, which further encourage lower fasting glucose levels. As a result of these normal metabolic changes of pregnancy, women with insulin-As a result of these normal metabolic changes of pregnancy, women with insulin-dependent diabetes are prone to dependent diabetes are prone to hypoglycemia during the first trimesterhypoglycemia during the first trimester..




Diabetes Mellitus Diabetes Mellitus ■ During the second and third trimesters, pregnancy exerts a "diabetogenic" During the second and third trimesters, pregnancy exerts a "diabetogenic"

effect on the maternal metabolic status. Because of the major hormonal effect on the maternal metabolic status. Because of the major hormonal changes, there is decreased tolerance to glucose, increased insulin changes, there is decreased tolerance to glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Rising levels of human estrogen, progesterone, production of glucose. Rising levels of human estrogen, progesterone, chorionic somatomammotropin, prolactin, cortisol, and insulinase increase chorionic somatomammotropin, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements may double supply of glucose for the fetus. Maternal insulin requirements may double or quadruple by the end of the pregnancy, usually leveling off or declining or quadruple by the end of the pregnancy, usually leveling off or declining slightly after 36 weeksslightly after 36 weeks

■ At birth, expulsion of the placenta prompts an abrupt drop in levels of At birth, expulsion of the placenta prompts an abrupt drop in levels of circulating placental hormones, cortisol, and insulinasecirculating placental hormones, cortisol, and insulinase.. Maternal tissues Maternal tissues quickly regain their prepregnancy sensitivity to insulin. For the quickly regain their prepregnancy sensitivity to insulin. For the nonbreastfeeding mother the prepregnancy insulin-carbohydrate balance nonbreastfeeding mother the prepregnancy insulin-carbohydrate balance usually returns in approximately 7 to 10 daysusually returns in approximately 7 to 10 days..

■ Lactation uses maternal glucose; thus the breastfeeding mother's insulin Lactation uses maternal glucose; thus the breastfeeding mother's insulin requirements will remain low during lactation. On completion of weaning, requirements will remain low during lactation. On completion of weaning, the prepregnancy insulin requirement is reestablishedthe prepregnancy insulin requirement is reestablished




Diabetes MellitusDiabetes MellitusChanging insulin needs during pregnancyChanging insulin needs during pregnancy




Diabetes Mellitus Diabetes Mellitus Pregestational diabetes mellitusPregestational diabetes mellitus

■ Preconception counselingPreconception counseling■ Maternal risks and complicationsMaternal risks and complications

Pregnancy lossPregnancy loss Fetal macrosomiaFetal macrosomia Hypertensive disorders, renal dysfunctionHypertensive disorders, renal dysfunction Preterm labour, PROMPreterm labour, PROM HydramniosHydramnios InfectionInfection KetoacidosisKetoacidosis HypoglycemiaHypoglycemia

■ Fetal and neonatal risksFetal and neonatal risks Congenital anomalies (cardiac, central nervous system, skeletal Congenital anomalies (cardiac, central nervous system, skeletal

defects)defects) RDS, polycytemia, hyperbilirubinemiaRDS, polycytemia, hyperbilirubinemia




Diabetes Mellitus Diabetes Mellitus Physical examinationPhysical examination

ECGECG Evalution for retinpathyEvalution for retinpathy BPBP Weight gainWeight gain Fundal heightFundal height




Diabetes MellitusDiabetes MellitusLaboratory testsLaboratory tests

Baseline renal function (proteinuria, Baseline renal function (proteinuria, createnine clearance)createnine clearance)

Glucose-, ketonurea Glucose-, ketonurea Thyroid gland functionThyroid gland function Glycosylated hemoglobin A1c Glycosylated hemoglobin A1c

Adult/elderly without diabetes: 2.2% to 4.8%Adult/elderly without diabetes: 2.2% to 4.8% Good diabetic control: 2.5% to 5.9%Good diabetic control: 2.5% to 5.9% Fair diabetic control: 6% to 8%Fair diabetic control: 6% to 8% Poor diabetic control: greater than 8%Poor diabetic control: greater than 8%




Diabetes MellitusDiabetes MellitusAntepartum careAntepartum care

Routine visit Routine visit every 1-2 weeks at I and II trimevery 1-2 weeks at I and II trim 1-2 times each week at last trim1-2 times each week at last trim

HospitalizationHospitalization Insulin dose changesInsulin dose changes

Maintain constant euglycemiaMaintain constant euglycemia




Diabetes MellitusDiabetes MellitusAntepartum care. DietAntepartum care. Diet

Dietary management during diabetic pregnancy must be based on Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levelsblood (not urine) glucose levels

The dietary goal is to provide weight gain consistent with a normal The dietary goal is to provide weight gain consistent with a normal pregnancy, to prevent ketoacidosis, and to minimize widely fluctuating pregnancy, to prevent ketoacidosis, and to minimize widely fluctuating blood glucose levelsblood glucose levels

Energy needs are usually calculated on the basis of 30 to 35 calories Energy needs are usually calculated on the basis of 30 to 35 calories per kilogram of ideal body weight, with the average diet including 2200 per kilogram of ideal body weight, with the average diet including 2200 calories (first trimester) to 2500 calories (second and third trimesters). calories (first trimester) to 2500 calories (second and third trimesters). Total calories may be distributed among three meals and one evening Total calories may be distributed among three meals and one evening snack or, more commonly, three meals and at least two snacks. Meals snack or, more commonly, three meals and at least two snacks. Meals should be eaten on time and never skipped. Snacks must be carefully should be eaten on time and never skipped. Snacks must be carefully planned in accordance with in sulin therapy to avoid fluctuations in blood planned in accordance with in sulin therapy to avoid fluctuations in blood glucose levels. A large bedtime snack of at least 25 g of carbohydrate glucose levels. A large bedtime snack of at least 25 g of carbohydrate with some protein is recommended to help prevent hypoglycemia and with some protein is recommended to help prevent hypoglycemia and starvation ketosis during the nightstarvation ketosis during the night




Diabetes MellitusDiabetes MellitusAntepartum careAntepartum care ExerciseExercise

Although it has been shown that exercise enhances the use of glucose Although it has been shown that exercise enhances the use of glucose and decreases insulin need in women without diabetes, data are limited and decreases insulin need in women without diabetes, data are limited regarding exercise in women with pregestational diabetes. Any prescrip regarding exercise in women with pregestational diabetes. Any prescrip tion of exercise during diabetic pregnancy should be done by the tion of exercise during diabetic pregnancy should be done by the primary health care provider and should be closely monitored to primary health care provider and should be closely monitored to prevent complications, especially for women with vasculopathy. Women prevent complications, especially for women with vasculopathy. Women with vasculopathy typically depend completely on exogenous insulin with vasculopathy typically depend completely on exogenous insulin and are at greater risk for wide fluctuations in blood glucose levels and and are at greater risk for wide fluctuations in blood glucose levels and ketoacidosis, which can be made worse by exercise.ketoacidosis, which can be made worse by exercise.

Careful instructions are given to the woman. Exercise need not be Careful instructions are given to the woman. Exercise need not be vigorous to be beneficial: 15 to 30 minutes of walking four to six times a vigorous to be beneficial: 15 to 30 minutes of walking four to six times a week is satisfactory for most pregnant women. Other exercises that week is satisfactory for most pregnant women. Other exercises that may be recommended are non-weight-bearing activities such as arm ex may be recommended are non-weight-bearing activities such as arm ex ercises or use of a recumbent bicycle. The best time for exercise is ercises or use of a recumbent bicycle. The best time for exercise is after meals, when the blood glucose level is rising. To monitor the effect after meals, when the blood glucose level is rising. To monitor the effect of insulin on blood glucose levels, the woman can measure blood of insulin on blood glucose levels, the woman can measure blood glucose before, during, and after exercise.glucose before, during, and after exercise.




Diabetes MellitusDiabetes MellitusAntepartum careAntepartum care Insulin TherapyInsulin Therapy

Insulin requirements during pregnancy change Insulin requirements during pregnancy change dramatically as the pregnancy progresses, dramatically as the pregnancy progresses, necessitating frequent adjustments in insulin dosage. necessitating frequent adjustments in insulin dosage.

In the first trimester there is little or no change in In the first trimester there is little or no change in prepregnancy insulin requirements; however, insulin prepregnancy insulin requirements; however, insulin dosage may need to be decreased because of dosage may need to be decreased because of hypoglycemia. hypoglycemia.

During the second and third trimester, because of During the second and third trimester, because of insulin resistance, dosage must be increased to insulin resistance, dosage must be increased to maintain target glucose levels.maintain target glucose levels.





type 2 diabetes injections of insulin.type 2 diabetes injections of insulin. human insulin preparationshuman insulin preparations Most women with insulin-dependent diabetes are managed with Most women with insulin-dependent diabetes are managed with

two to three injections per day. Usually, two thirds of the daily two to three injections per day. Usually, two thirds of the daily insulin dose, with longer-acting (NPH) and short-acting (regular insulin dose, with longer-acting (NPH) and short-acting (regular or lispro) insulin combined in a 2:1 ratio, is given before or lispro) insulin combined in a 2:1 ratio, is given before breakfast. Sometimes, the remaining one third, again a breakfast. Sometimes, the remaining one third, again a combination of longer- and short-acting insulin, is administered combination of longer- and short-acting insulin, is administered in the evening before dinner. To reduce the risk of hypoglycemia in the evening before dinner. To reduce the risk of hypoglycemia during the night, separate injections often are administered, with during the night, separate injections often are administered, with short-acting insulin given before dinner, followed by longer-short-acting insulin given before dinner, followed by longer-acting insulin at bedtime.acting insulin at bedtime.

Another alternative insulin regimen that works well for some Another alternative insulin regimen that works well for some women is to administer short-acting insulin before each meal women is to administer short-acting insulin before each meal and longer- acting insulin at bedtimeand longer- acting insulin at bedtime





lthough subcutaneous insulin injections are most commonly used, lthough subcutaneous insulin injections are most commonly used, continuous insulin infusion systems may be used during pregnancy. continuous insulin infusion systems may be used during pregnancy. The insulin pump is designed to mimic more closely the function of the The insulin pump is designed to mimic more closely the function of the pancreas in secreting insulin (Fig. 3). This portable, battery-powered pancreas in secreting insulin (Fig. 3). This portable, battery-powered device infuses regular insulin at a set basal rate and has the capacity device infuses regular insulin at a set basal rate and has the capacity to deliver up to four different basal rates in 24 hours. The pump also to deliver up to four different basal rates in 24 hours. The pump also delivers bolus doses of insulin before meals to control postmeal blood delivers bolus doses of insulin before meals to control postmeal blood glucose levels. The infusion tubing from the insulin pump can be left in glucose levels. The infusion tubing from the insulin pump can be left in place for several weeks without local complications. Although the place for several weeks without local complications. Although the insulin pump is convenient and generally provides good glycemic insulin pump is convenient and generally provides good glycemic control, complications such as DKA, infection, or hypoglycemic coma control, complications such as DKA, infection, or hypoglycemic coma can still develop. Use of the insulin pump requires a knowledgeable, can still develop. Use of the insulin pump requires a knowledgeable, motivated pa tient; skilled health care providers; and 24-hour availability motivated pa tient; skilled health care providers; and 24-hour availability of emergency assistanceof emergency assistance




Fetal surveillanceFetal surveillance Diagnostic techniques for fetal surveillance are often Diagnostic techniques for fetal surveillance are often

performed to assess fetal growth and well-being. The performed to assess fetal growth and well-being. The goals of fetal surveillance are to detect fetal goals of fetal surveillance are to detect fetal compromise as early as possible and to prevent compromise as early as possible and to prevent intrauterine fetal death or unnecessary preterm birth.intrauterine fetal death or unnecessary preterm birth.

Early in pregnancy, efforts are made to determine the Early in pregnancy, efforts are made to determine the estimated date of birth. A baseline sonogram is done estimated date of birth. A baseline sonogram is done during the first trimester to assess gestational age. during the first trimester to assess gestational age. Follow-up ultrasound examinations are usually Follow-up ultrasound examinations are usually performed during the pregnancy (as often as every 4 performed during the pregnancy (as often as every 4 to 6 weeks) to monitor fetal growth; estimate fetal to 6 weeks) to monitor fetal growth; estimate fetal weight; and detect hydramnios, macrosomia, and weight; and detect hydramnios, macrosomia, and congenital anomalies.congenital anomalies.




Fetal surveillanceFetal surveillance Because diabetic pregnancies are at greater risk for neural tube defects (e.g., Because diabetic pregnancies are at greater risk for neural tube defects (e.g.,

spina bifida, anencephaly, microcephaly), measurement of maternal serum spina bifida, anencephaly, microcephaly), measurement of maternal serum alpha-fetoprotein is performed between 16 and 18 weeks of gestation. This is alpha-fetoprotein is performed between 16 and 18 weeks of gestation. This is often done in conjunction with a detailed ultrasound study to examine the fetus often done in conjunction with a detailed ultrasound study to examine the fetus for neural tube defects.for neural tube defects.

Fetal echocardiography may be performed between 18 and 22 weeks of Fetal echocardiography may be performed between 18 and 22 weeks of gestation to detect cardiac anomalies. Some practitioners repeat this fetal gestation to detect cardiac anomalies. Some practitioners repeat this fetal surveillance test at 34 weeks. Doppler studies of the umbilical artery may be surveillance test at 34 weeks. Doppler studies of the umbilical artery may be performed in women with vascular disease to detect pla-cental compromise.performed in women with vascular disease to detect pla-cental compromise.

The majority of fetal surveillance measures are concen trated in the third The majority of fetal surveillance measures are concen trated in the third trimester, when the risk of fetal com promise is greatest. Pregnant women should trimester, when the risk of fetal com promise is greatest. Pregnant women should be taught how to do daily fetal movement counts.be taught how to do daily fetal movement counts.

The nonstress test used to evaluate fetal well-being may be used weekly or The nonstress test used to evaluate fetal well-being may be used weekly or more often, typically beginning around 28 to 30 weeks of gestation. After 32 more often, typically beginning around 28 to 30 weeks of gestation. After 32 weeks, testing may be done twice weekly. For the woman with vascular disease, weeks, testing may be done twice weekly. For the woman with vascular disease, testing may begin earlier and continue more fre quently. In the presence of a testing may begin earlier and continue more fre quently. In the presence of a nonreactive nonstress test, a contraction stress test or fetal biophysical profile nonreactive nonstress test, a contraction stress test or fetal biophysical profile may be used to evaluate fetal well-being may be used to evaluate fetal well-being




Complications requiring Complications requiring HospitalizationHospitalization

Complete baseline cardiovascular, renal, Complete baseline cardiovascular, renal, ophtalmologic evaluations, balance diet and ophtalmologic evaluations, balance diet and insulin regimentinsulin regiment

InectionsInections Fail to maintain acceptable glucose levelFail to maintain acceptable glucose level Before labourBefore labour To confirm fetal lung maturity: lecithin/ To confirm fetal lung maturity: lecithin/

sphingomyelin ratio sphingomyelin ratio




Cesarean birthCesarean birth

Fetal distressFetal distress Estimate fetal weight is 4000-4500 kgEstimate fetal weight is 4000-4500 kg




Diabetes MellitusDiabetes MellitusIntrapartum careIntrapartum care

must be monitored closely to prevent complications related to must be monitored closely to prevent complications related to dehydration, hypoglycemia, and hyperglycemia. Most women dehydration, hypoglycemia, and hyperglycemia. Most women use large amounts of energy (calories) to accomplish the work use large amounts of energy (calories) to accomplish the work and manage the stress of labor and birth; however, this calorie and manage the stress of labor and birth; however, this calorie expenditure varies with the individual. Blood glucose levels and expenditure varies with the individual. Blood glucose levels and hydration must be carefully controlled during labor. An IV line is hydration must be carefully controlled during labor. An IV line is inserted for infusion of a maintenance fluid, such as lactated inserted for infusion of a maintenance fluid, such as lactated Ringer's solution or 5% dextrose in lactated Ringer's solution. Ringer's solution or 5% dextrose in lactated Ringer's solution. Insulin may be administered by continuous infusion or Insulin may be administered by continuous infusion or intermittent subcutaneous injection. Determinations of blood intermittent subcutaneous injection. Determinations of blood glucose levels are made every hour, and fluids and insulin are glucose levels are made every hour, and fluids and insulin are adjusted to maintain blood glucose levels between 60 and 100 adjusted to maintain blood glucose levels between 60 and 100 mg/dl. It is essential that these target glucose levels be mg/dl. It is essential that these target glucose levels be maintained because hyperglycemia during labor can precipitate maintained because hyperglycemia during labor can precipitate metabolic problems in the neonate, particularly hypoglycemia.metabolic problems in the neonate, particularly hypoglycemia.




Diabetes MellitusDiabetes MellitusIntrapartum careIntrapartum care

During labor, continuous fetal heart monitoring is necessary. The woman should During labor, continuous fetal heart monitoring is necessary. The woman should assume a side-lying position during bed rest in labor to prevent supine assume a side-lying position during bed rest in labor to prevent supine hypotension because of a large fetus or polyhydramnios. Labor is allowed to hypotension because of a large fetus or polyhydramnios. Labor is allowed to progress provided normal rates of cervical dilation, fetal descent, and fetal well-progress provided normal rates of cervical dilation, fetal descent, and fetal well-being are maintained. Failure to progress may indicate a macrosomic infant and being are maintained. Failure to progress may indicate a macrosomic infant and cephalopelvic disproportion, necessitating a cesarean birth. The woman is cephalopelvic disproportion, necessitating a cesarean birth. The woman is observed and treated during labor for diabetic complications such as observed and treated during labor for diabetic complications such as hyperglycemia, ketosis, ketoacidosis, and glycosuria. During second-stage hyperglycemia, ketosis, ketoacidosis, and glycosuria. During second-stage labor, shoulder dystocia may occur if delivery of a macrosomic infant is labor, shoulder dystocia may occur if delivery of a macrosomic infant is attempted. A neonatologist, pediatrician, or neonatal nurse practitioner may be attempted. A neonatologist, pediatrician, or neonatal nurse practitioner may be present at the birth to initiate assessment and neonatal care.present at the birth to initiate assessment and neonatal care.

If a cesarean birth is planned, it should be scheduled in the early morning to If a cesarean birth is planned, it should be scheduled in the early morning to facilitate glycemic control. The morning dose of insulin should be withheld and facilitate glycemic control. The morning dose of insulin should be withheld and the woman given nothing by mouth. Epidural anesthesia is recommended the woman given nothing by mouth. Epidural anesthesia is recommended because hypoglycemia can be detected earlier if the woman is awake. After because hypoglycemia can be detected earlier if the woman is awake. After surgery, glucose levels should be closely monitored, at least every 2 hours, and surgery, glucose levels should be closely monitored, at least every 2 hours, and an IV solution containing 5% dextrose is infusedan IV solution containing 5% dextrose is infused




Diabetes MellitusDiabetes MellitusPostpartum carePostpartum care

In the immediate postpartum period, insulin require ments In the immediate postpartum period, insulin require ments decrease substantially because the major source of insulin decrease substantially because the major source of insulin resistance, the placenta, has been removed. Women with type 1 resistance, the placenta, has been removed. Women with type 1 diabetes may require only one half to two thirds of the prenatal diabetes may require only one half to two thirds of the prenatal insulin dose on the first postpartum day, provided that they are insulin dose on the first postpartum day, provided that they are eating a full diet. It takes several days after birth to reestablish eating a full diet. It takes several days after birth to reestablish carbohydrate homeostasis (see Fig. 1, D and E). Blood glucose carbohydrate homeostasis (see Fig. 1, D and E). Blood glucose levels are monitored in the postpartum period, and insulin levels are monitored in the postpartum period, and insulin dosage is adjusted ac cordingly. Usually insulin is not given until dosage is adjusted ac cordingly. Usually insulin is not given until the blood glucose level is greater than 200 mg/dl. The woman the blood glucose level is greater than 200 mg/dl. The woman with insulin-dependent diabetes must realize the importance of with insulin-dependent diabetes must realize the importance of eating on time even if the baby needs feeding or other pressing eating on time even if the baby needs feeding or other pressing demands exist. Women with type 2 diabetes often require no demands exist. Women with type 2 diabetes often require no insulin in the postpartum period and are able to maintain insulin in the postpartum period and are able to maintain euglycemia through diet alone or with oral hypoglycemics.euglycemia through diet alone or with oral hypoglycemics.




Diabetes MellitusDiabetes MellitusPostpartum carePostpartum care

Possible postpartum complications include preeclampsia-eclampsia, Possible postpartum complications include preeclampsia-eclampsia, hemorrhage, and infection. Hemorrhage is a possibility if the mother's hemorrhage, and infection. Hemorrhage is a possibility if the mother's uterus was overdistended (hy-dramnios, macrosomic fetus) or uterus was overdistended (hy-dramnios, macrosomic fetus) or overstimulated (oxytocin induction). Postpartum infections such as overstimulated (oxytocin induction). Postpartum infections such as endometritis are more likely to occur in a woman with diabetes.endometritis are more likely to occur in a woman with diabetes.

Mothers are encouraged to breastfeed. In addition to the advantages of Mothers are encouraged to breastfeed. In addition to the advantages of maternal satisfaction and pleasure, breastfeeding has an maternal satisfaction and pleasure, breastfeeding has an antidiabetogenic effect. Insulin requirements may be half the antidiabetogenic effect. Insulin requirements may be half the prepregnancy levels because of the carbohydrate used in human milk prepregnancy levels because of the carbohydrate used in human milk production. Because glucose levels are lower, breastfeeding women production. Because glucose levels are lower, breastfeeding women are at increased risk for hypoglycemia, especially in the early are at increased risk for hypoglycemia, especially in the early postpartum period and after breastfeeding sessions. Breastfeeding postpartum period and after breastfeeding sessions. Breastfeeding mothers with diabetes may be at increased risk for mastitis and yeast mothers with diabetes may be at increased risk for mastitis and yeast infections of the breast. Insulin dosage, which is decreased during infections of the breast. Insulin dosage, which is decreased during lactation, must be recalculated at weaning (see Fig. 1, F).lactation, must be recalculated at weaning (see Fig. 1, F).




Gestational Diabetes MellitusGestational Diabetes Mellitus




Risk factors for GDM include Risk factors for GDM include maternal age over 30 years; maternal age over 30 years; obesity; obesity; family history of type 2 diabetes; family history of type 2 diabetes; and an obstetric history of an infant weighing more and an obstetric history of an infant weighing more

than 4000 g, than 4000 g, hydramnios, hydramnios, unexplained stillbirth, unexplained stillbirth, miscarriage, or an infant with congenital anomalies. miscarriage, or an infant with congenital anomalies. Women at high risk for GDM are often screened at Women at high risk for GDM are often screened at

their initial prenatal visit and then rescreened later in their initial prenatal visit and then rescreened later in pregnancy if the initial screen is negativepregnancy if the initial screen is negative




Maternal-Fetal RiskMaternal-Fetal Risk of developing hypertensive disorders compared with normal of developing hypertensive disorders compared with normal

pregnant women pregnant women fetal macrosomia, which can lead to increased rates of perineal fetal macrosomia, which can lead to increased rates of perineal

lacerations, episiotomy, and cesarean birth lacerations, episiotomy, and cesarean birth macrosomia with associated shoulder dystocia and birth trauma. macrosomia with associated shoulder dystocia and birth trauma. hypoglycemia, hypocalcemia, hyperbilirubinemia, hypoglycemia, hypocalcemia, hyperbilirubinemia,

thrombocytopenia, polycythemia, and respiratory distress thrombocytopenia, polycythemia, and respiratory distress syndrome syndrome

The overall incidence of congenital anomalies among in fants of The overall incidence of congenital anomalies among in fants of women with gestational diabetes approaches that of the general women with gestational diabetes approaches that of the general population because gestational diabetes usually develops after population because gestational diabetes usually develops after the twentieth week of pregnancy—after the critical period of the twentieth week of pregnancy—after the critical period of organogenesis (first trimester) has passed.organogenesis (first trimester) has passed.




Thyroid DisordersThyroid Disorders

HyperthyroidismHyperthyroidism■ 90% to 95% caused by Graves’ disease90% to 95% caused by Graves’ disease■ Clinical manifestationsClinical manifestations

Increased basal metabolism rateIncreased basal metabolism rate Increased sympathetic nervous system Increased sympathetic nervous system

activityactivity■ HypothyroidismHypothyroidism

Rare; women with condition are often Rare; women with condition are often infertileinfertile




HyperthyroidismHyperthyroidism

Complication: preeclampsia, hyperemesis Complication: preeclampsia, hyperemesis gravidarumgravidarum

Treatment: propylthiouracil (PTU), beta-Treatment: propylthiouracil (PTU), beta-adrenergic blockers, subtota thyroidectomyadrenergic blockers, subtota thyroidectomy




HypothyroidismHypothyroidism risk for preeclampsia, placental abruption, and risk for preeclampsia, placental abruption, and

stillbirth. Infants born to mothers with hypothyroidism stillbirth. Infants born to mothers with hypothyroidism may be of low birth weight, but for the most part they may be of low birth weight, but for the most part they are healthy and without evidence of thyroid are healthy and without evidence of thyroid dysfunction dysfunction

Treatment: Levothyroxine (e.g., L-thyroxine Treatment: Levothyroxine (e.g., L-thyroxine [Synthroid]). The usual beginning dosage is 0.10 to [Synthroid]). The usual beginning dosage is 0.10 to 0.15 mg per day, in a single daily dose. 0.15 mg per day, in a single daily dose.

The aim of drug therapy is to maintain the woman's The aim of drug therapy is to maintain the woman's TSH level within the normal range for pregnant TSH level within the normal range for pregnant women.women.




HypothyroidismHypothyroidism

The fetus depends on maternal thyroid The fetus depends on maternal thyroid hormones until 12 weeks of gestation, when hormones until 12 weeks of gestation, when fetal production begins. Thus maternal fetal production begins. Thus maternal hypothyroidism does not cause fetal hypothyroidism does not cause fetal hypothyroidism. However, maternal treatment hypothyroidism. However, maternal treatment of hypothyroidism may result in increased of hypothyroidism may result in increased fetal levels of thyroid hormones. Careful fetal levels of thyroid hormones. Careful monitoring of the neonate's thyroid status is monitoring of the neonate's thyroid status is im portant to detect any abnormalities.im portant to detect any abnormalities.




Maternal Phenylketonuria Maternal Phenylketonuria

Inborn error of metabolism caused by an Inborn error of metabolism caused by an autosomal recessive trait that creates a autosomal recessive trait that creates a deficiency in the enzyme phenylalanine deficiency in the enzyme phenylalanine hydrolasehydrolase

Recognized cause of mental retardationRecognized cause of mental retardation




Maternal PhenylketonuriaMaternal Phenylketonuria

MiscarridgeMiscarridge Mental retardationMental retardation MicrocephalyMicrocephaly Congenital heard disease Congenital heard disease Low birth weightLow birth weight




Maternal Phenylketonuria Maternal Phenylketonuria

PreventionPrevention■ Identification of women in reproductive years Identification of women in reproductive years

who have disorderwho have disorder Infants born to women with disorder either Infants born to women with disorder either

homozygous or heterozygous for traithomozygous or heterozygous for trait




Key Points Key Points

Lack of maternal glycemic control before Lack of maternal glycemic control before conception and in first trimester of pregnancy conception and in first trimester of pregnancy may be responsible for fetal congenital may be responsible for fetal congenital malformationsmalformations

Maternal insulin requirements increase as Maternal insulin requirements increase as pregnancy progresses and may quadruple by pregnancy progresses and may quadruple by term as a result of insulin resistance created term as a result of insulin resistance created by placental hormones, insulinase, and by placental hormones, insulinase, and cortisol cortisol





At birth, levels decrease dramatically; At birth, levels decrease dramatically; breastfeeding will affect insulin needsbreastfeeding will affect insulin needs

Poor glycemic control before and during Poor glycemic control before and during pregnancy can lead to maternal complications pregnancy can lead to maternal complications such as miscarriage, infection, and dystocia such as miscarriage, infection, and dystocia caused by fetal macrosomiacaused by fetal macrosomia





Careful glucose monitoring, insulin Careful glucose monitoring, insulin administration when necessary, and dietary administration when necessary, and dietary counseling are used to create a normal counseling are used to create a normal intrauterine environment for fetal growth and intrauterine environment for fetal growth and development in pregnancy complicated by development in pregnancy complicated by diabetes mellitusdiabetes mellitus

Because gestational diabetes mellitus is Because gestational diabetes mellitus is asymptomatic in most cases, many women asymptomatic in most cases, many women undergo routine screening during pregnancyundergo routine screening during pregnancy





Hyperemesis gravidarum is frequently Hyperemesis gravidarum is frequently managed at homemanaged at home■ Woman should receive IV fluids and Woman should receive IV fluids and

electrolytes and remain on NPO status until electrolytes and remain on NPO status until nausea and vomiting have stoppednausea and vomiting have stopped

■ Woman can then slowly advance her diet as Woman can then slowly advance her diet as toleratedtolerated





Thyroid dysfunction during pregnancy Thyroid dysfunction during pregnancy requires close monitoring of thyroid hormone requires close monitoring of thyroid hormone levels to regulate therapy and prevent fetal levels to regulate therapy and prevent fetal insultinsult

High levels of phenylketonuria (PKU) in High levels of phenylketonuria (PKU) in maternal bloodstream cross placenta and are maternal bloodstream cross placenta and are teratogenic to the developing fetus:teratogenic to the developing fetus:■ Prevented or minimized by dietary restriction Prevented or minimized by dietary restriction

of phenylalanine before and during pregnancyof phenylalanine before and during pregnancy

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