Diabetes and Pregnancy

Diabetes

• Includes explanations of type 1, type 2, and gestational diabetes
• Discusses potential detection methods for diabetes
• Possible affects on pregnancy is explained
• Considers potential effects of pregnancy on diabetes
• Looks at developing an antenatal care plan for women with diabetes, including risk factors

Types of diabets

• Type 1: No insulin produced
• Type 2: insulin resistance + decreased insulin production and/or immature insulin production
• Gestational: Carbohydrate intolerance results in variable severity hyperglycemia during pregnancy
• Constant battle between fetus needing growth and storage and mum needing to store for birth & lactation
• Risk factors (offer 2h 75g OGTT at 24-28 weeks): Family history of DM, macrosomic baby (>4.5kg), obesity (BMI >30), South Asian/Caribbean/Middle Eastern ethnicity, previous GDM, persistent glycosuria, PCOS, previous stillbirth

Symptoms

• GDM is often asymptomatic, but may include headaches, blurred vision, thirst, shakiness/unsteadiness, nausea (when hungry), frequent urination, tiredness, recurrent infections

Effects of Pregnancy on Diabetes

• Rapid insulin increases are needed between 28 and 32 weeks of gestation

Managing Diabetes During Pregnancy

• Type 1 diabetes: increase insulin dosage as pregnancy progresses
• Type 2 diabetes: add insulin to oral therapy (metformin)
• Nausea/vomiting makes glycaemic control difficult
• Frequent hypoglycaemia is more common
• Altered hypoglycaemia symptoms may not always be recognised
• Possible Deterioration of pre-existing neuropathy may occur
• Possible Deterioration of pre-existing diabetic nephropathy may occur (reduced creatinine clearance and proteinuria, hypertension)
• Deterioration of pre-existing diabetic retinopathy or first appearance in pregnancy is a risk
• Increased risk of diabetic ketoacidosis occurs (rare but dangerous)

Effects on the Mother from Pre-existing Diabetes or GDM

• Increased risk of miscarriage
• 3-4x increase of pre-eclampsia, especially if hypertension or renal disease are present
• Increased risk of infections such as vaginal candidiasis can be present
• Increased IOL and intrapartum interventions are often required
• Obstructed labour may be linked to macrosomia, early IOL
• Caesarean section rate increases to 65% (early IOL)
• Psychosocial issues can develop
• Birth choices may be needed

Effects on the Fetus or Neonate

• Cardiac and Neural Tube Defects (sacral agenesis) is possible
• Renal abnormalities
• Polyhydramnios has associated risk
• Stillbirth risks increase
• Birth Trauma
• Shoulder Dystocia may occur
• Perinatal mortality caused by macrosomia is possible
• Pre-term delivery may be needed early
• Neonatal hypoglycaemia can result from fetal hyperinsulinemia
• Polycythaemia and Jaundice may be a problem
• Hyaline membrane disease or Respiratory Distress Syndrome (RDS) can result
• Risk of early separation from mother (NICU)
• Reduced breastfeeding rate occurs
• Risk of diabetes and obesity later in life increases
• Macrosomia - birthweight over 4.5kg or >90th centile
• Macrosomia is often associated with polyhydramnios
• Risks include premature SROM, cord prolapse, shoulder dystocia and birth trauma

Effects of Hyperglycemia

• IUD is possible
• Hypoglycaemia increase
• Insulin =anabolic, growth-promoting hormone
• Babies may be fat, and plethoric (flushed),
• All organs, especially the liver may be enlarged (hepatomegaly)
• Effects are greater if maternal glucose control is poor
• Increased incidence when maternal blood glucose >7.2 mmol/l

Antenatal Care Plan

• Added specialist diabetic clinic surveillance/pathway should be added
• Dietician should provide lifestyle advice
• Regular blood sugar monitoring is vital
• Therapy via diet is important
• Fetal surveillance (4 week growth scans- cardiac scans)
• Routine fetal monitoring prior to 38 weeks is not necessary unless otherwise indicated
• Colostrum harvesting + antenatal classes should occur
• Discussion about mode of delivery and infant feeding
• Monitor for signs or symptoms of pregnancy complications (pre-eclampsia, UTI, other infections, IUGR or macrosomia)

Target Glucose Levels

• Fasting: <5.3 mmol/L
• 1 hour after meals: <7.8 mmol/L
• 2 hours after meals: <6.4 mmol/L
• If on insulin or glibenclamide, maintain plasma glucose level above 4 mmol/Litre.

Intrapartum Care Plan

• Diabetes is not contraindication for women to attempt vaginal birth after previous C/S
• If ultrasound indicates macrosomic fetus, advise the women about risks and benefits of vaginal birth, induction and C/S
• Advanced neonatal resuscitation skills and equipment available on site (24hrs/day)
• Consultant to be in charge (inform diabetic team)
• IV access, bloods, antibiotics (instrumental delivery or C/S) are needed
• EFM should be maintained
• Shoulder dystocia should be expected
• Paediatric support for delivery needed
• Maintenance of blood glucose control during labour:
  • Maintain women with diabetes with levels from between 4 -7mmol/l every hour during labour
  • IV dextrose and insulin infusions should be used from onset of labour for those women with type 1

Continued Intrapartum Guidelines

• Use IV dextrose and insulin infusions for women with diabetes if capillary plasma glucose is not maintained between 4-7mmol/l
• Antacids may be required
• Review anaesthesia options
• Normal labour observations required
• Reduced rate of insulin IVI after 3rd stage
• Return to pre-pregnancy insulin dosage in puerperium
• Tightly controlled blood glucose less vital in puerperium

Postnatal Care

• Women with insulin-treated pre-existing diabetes should reduce insulin immediately after birth and monitor blood glucose
• Discuss risk of hypoglycaemia for women with insulin-treated pre-existing diabetes
• Women with GDM discontinue blood glucose-lowering therapy
• Lifestyle advice should occur (weight control, diet, exercise)
• Fasting plasma glucose test at 6-13 weeks to exclude diabetes should occur
• If not done by 13 weeks, HbA1c test occurs later
• Do not routinely offer a 75g 2-hour OGTT
• Contraception methods should be implemented
• Annual HbA1c test for women with gestational diabetes
• Primary care's role is follow up, contraception, lifestyle, preconception guidelines
• 50% women with GDM will develop Type 2 DM within 10 years
• How might a midwife anticipate and recognise the development of this condition in pregnancy? Answer involves risk factors for gestational diabetes + antenatal care to optimise mother/baby outcome

Cardiac Disorders: Cardiovascular Changes in Pregnancy

• Oxygen consumption increases by up to 20% to oxygenate baby
• Plasma volume increases by up to 50% to prepare the body to bleed
• Red blood cells increase by up to 30%
• Resistance lowers in systemic circulation due to progesterone
• Compensatory response: Increased cardiac output, 10-20bpm increased heart rate, and increased stroke volume
• By 8 weeks, cardiac output has increased by 20%, with peak increase of 40% around 20-28 weeks
• At term, the heart is physiologically dilated, myocardial contractility increases
• Blood pressure falls in the 2nd trimester, then reaches or exceeds pre-pregnancy levels by term
• Central venous pressure unchanged
• Colloid oncotic pressure falls by 10-15%, increasing likelihood of pulmonary oedema, and odema in limbs
• Possible ECG changes: Ectopic beats, inverted T wave, sinus tachycardia, ejection systolic murmur

Generic Principles for Cardiac Patients During Labour

• During the first stage of labour, cardiac output increased 15% due to catecholamines
• During the second stage of labour, cardiac output increased 50% (holding breath when pushing)
• Following delivery, cardiac output increases 60-80% due to relief of the inferior vena cava; compression and contraction of the uterus (autotransfusion of blood back into the circulation)
• Pulmonary oedema risks increase
• Returns to normal by 2 weeks postpartum
• Give ABs prophylactically to prevent endocarditis
• Aim for SVD unless indication for C/S like severe HD
• Consider labour:
• Careful positioning to avoid aortocaval compression
• Epidural anaesthesia to mitigate BP fluctuation and pain, consider a slow epidural
• Limiting the 2nd stage as there is Valsalva contraindicated
• Use Invasive monitoring (as necessary)
• Use Active management of third stage
• Strict fluid balance must be maintained
• Medication plan to be followed
• Avoid ergometrine
• Avoid Carboprost (Hemabate)
• Use use oxytocin (vasodilatory to coronary arteries) which can decrease BP

Post-Birth Management

• Senior obstetrician and cardiology review; early cardio follow up
• Monitor status for 48hrs; T, P, RR, BP, fluid balance + blood loss
• Detect infection early + antibiotics for two weeks
• Examine baby for CHD and spacing advice
• PN support groups will be needed

Specific Cardiac Conditions

• Eisenmenger's syndrome (shunt in heart from left to right), mixing of oxygenated and deoxygenated blood
• R-to-L shunting increases during pregnancy due to Systemic Vascular Resistance falls - Fallot's Tetralogy –Four defects with this condition

1. Hole in the wall: Two sides of the heart
2. Narrowing (stenosis): Main artery to the lungs
3. Abnormal thickening: Right ventricle
4. Abnormality in the position: Main artery - Coarctation of the aorta
5. Congenital heart defect
6. Constriction of the aorta = hypertension - Rheumatic fever

• Autoimmune disease (contracted in childhood) occurring from a throat infection. Antibodies that are created to fight the infection end up causing tissue damage to heart valves - Mitral Stenosis
• Narrowing that impedes the pressure from L atrium to L ventricle, leading to pulmonary congestion (oedema) - Aortic stenosis
• Causes increase in SV, which may lead to failure of the left ventricle - Marfan's syndrome
• Increases risk of risk of rupture -Puerperal cardiomyopathy
• The heart muscle is weakened

Recognition

• Fatigue, breathlessness and difficulty breathing
• Progressive limitation: physical activity due to breathlessness
• Chest pain; exercise
• Fainting
• High risk only: primary pulmonary HT, Eisenmenger, Coarctation of aorta, Marfan

Pre-eclampsia

• New hypertension which occurs after 20 weeks with proteinuria
• If severe, can damage organ and aetiology includes four factors:
  • Genetic predisposition, immunological, placental development/implantation cardiovascular link Risk factors include:
• Maternal family history of PET.
• Previous personal history of PET.
• Chinese, Vietnamese, American Indians/Alaska Natives, Non-Hispanic black ethnic background.
• Teenage & multiple pregnancies
• Over 40s + high interval between pregnancies
• BMI >35kg/m2 at 1st visit

How to recognise?

• Frontal headache which does not subside
• Visual + reflective problems and pains
• Severe pain just below ribs in the upper right quadrant

Blood tests?

• AKI with elevated transaminases
• Thrombocytopenia
• Dysfunction such as fetal growth restrictions
• Abnormal umbilical artery + Doppler waveforms
• Sudden swelling and vomiting
• Proteinuria = endothelial damage
• Aim for < 30mg/mmol

Cardio Assessment

• Fetal breathing; movements, muscle tone; liquor check & CTG/ MHR
• Fluid + renal check and levels
• Respiratory distress presence

Pre-eclamptic signs?

• High blood pressure
• Any clinical concerns for wellbeing
• BP is to be checked every 48 hours with a close liver, bloods, and renal assessment
• Higher hypertension will allow more aggressive and regular blood checks but if
  falls below then assess as hypertension cases and give antihypertensive medications if needed.

How to treat:

• The goal is to maintain material diastolic BP.
• Involves alpha & beta blockers, channel blockers e.t.c.
• Labetalol is NICEs 1st response
• Fast action IV:Hydralazine

When to give anticonvulsants

• Severe hypertension
• If fits of eclampsia have occurred
• With one or more of the following nausea, visual troubles, epligastic pains
• Use catheter and magnesium sulphate in required instances
  • Recurrent fits should be treated with a dose of intravenous 2-4g every 5-15

What not to do

• Do not be alternative with magnesium
• Caution as both meds can cause the condition to deeply intensify.
• Measure and consider epidural

Continue hypertensives but follow the

• Diastolic BP levels
• Closely check fluid limit+ balance and give psychological support if needed.
  • After delivery, reduce and watch those said signs
  • Medicate if normal tests persist

Sepsis

• Prevalent childbirth organisms + pathophysiology
• What are the red flags
• Sepsis 6 : rationale for implementing

What organism :

• The most likely is identified in lancefield, streptococcus coli
• Common in both (especially in chorioamnionitis)
• Colifrom infections

What is SIRS

• Used to identify patients with sepsis
• New confusion, tachycardia, unusual or hight temperatures and bad ventiation for the the loss due to BP

Quick SOFA

• Systemic BP , 100
• Respiratory rate more than 22
• Alteration of mental state: Pathophysiology
  • Reduce blood flow/ pressure and clots
  • Red flag: pathway for sepsis six
  • Responds not,
  • Systolic lower 90
• Needs extra O2

Important care

• Take arterial samples
• Commencing every hr for extra care
• IV’s if possible/ neccessary
• Blood culture
• Harmful complications can lead from over or under use
• Low Hb can means less oxygen and higher needs
• Reduced output and can’m give good flow.
• Inflammatory infections, tissue damage, reduced endothelium & co.
• This is why the patient may be at major risk because of previous reactions

Three steps

• There needs to injuries/ inflammatory steps to heal the point quickly

Symptoms of UTI

• Dysuria
• Frequency and urgency
• Haematuria and nocturia
• Pain and offensive smell

Managing the UTI

• If there are high levels of copies then known infections are likely
• Systemic levels: admission
• Mild: antibiotics for around 7 days, if there are reactions with sepsis admission is vital.
• Collect patients mental or health to refer
• The relevant medical background e.t.c

Common Asthma problems

• The main respiratory is undiagnosed more than treated.
• Attacks can be very easy severe with acute reactions and remissions
• Pathophysiology
• Exposure to known triggers will inflame fast.
• Narrow Airways , and a release in production of mucus

pregnancy and changes?

• Enhanced efficiency is required to fuel the right volume
• Increase metabolic, diaphragm rises as oxygen. Capillary rises and expands if needed.
• Small alkalosis can be an sign
• Labor pains intensify the consumption and can lead to the death of oxygen

Important facts with pregnancy and asthma

• Usually can peak around 29-36 mostly peaking those levels
• Asthma can improve with steroids ,but can have big effects as a result.
• Uncontrolled asthma can mean many mortalities for all.

Steps midwives should take:

• Encourage for all,
• Document and assessment checks
• Inpatints may not have ready access

After delivery

• Monitor all conditions,
• Deliver well being and keep adequate
• Check breathing, support and provide the highest standards of medications

HG- Hyperemesis Gravidarum

• Theories and possible reasons
• Severe side effects of mother and baby
• Medical plan and general midwifery care that will ensue
  • 1/2 percent affect and have severe affect with time.

Types of cases

• Mild to unresponsive to the line of medication
• Rehydration is needed
• Additional risk factors
• Gastric, hormones, mental and health related ones.
• Physical complications and risks are a high trigger as result
• Many deficiencies if all conditions occur, alongside many long term and serious medical affects if untreated

Pregnancy related

• Death is at major risk because
• The risk is long term as the mother as the lack of health will always be a side affect.
• Genetic and low social are long lasting results, with a low rate success due it being a trigger from within that could happen many times.

General

• Check the stomach well
• If the symptoms proceed , look to have further examinations
• Look at long time risks and be very wary of the results and how they could drastically affect the situation.

Anaemia

• Lack of Iron related
• Leads to blood lacking and low amounts when high is highly needed. This can come with more blood lose as result. The factors will need addressing e.t.c chronic illnesses and many mal-absorption

What this leads to :

• Low fetal and physical with no protein store being kept
• Can effect the heart and make it enlarge or have issues
• Is very common and easy to occur when lacking the care and protein. A good and well check will reduce risk to high level, whilst there many steps and methods that will provide all results for the client

Sickle cell details

• Will have severe affect/ damage with oxygen
• Lack of clotting or not enough platelets.
• Involves all the organs and tissues
• All vessels need blood and oxygen, all clots needs to be destroyed.
• The more we know/ look to know/ investigate now will allow great protection
• Many tests and all support will allow great and the highest level of protection