High Risk Pregnancy: Endocrinology PDF

NCM 109- MODULE 1 LESSON 3 HIGH RISK PREGNANCY: PART IV PRE-EXISTING MEDICAL CONDITIONS HYPERTHYROIDISM ➔​ Hypermetabolism ENDOCRINE DISORDERS. ◆​ ssx: heat intolerance, tachycard...

NCM 109- MODULE 1 LESSON 3 HIGH RISK PREGNANCY: PART IV PRE-EXISTING MEDICAL CONDITIONS HYPERTHYROIDISM ➔​ Hypermetabolism ENDOCRINE DISORDERS. ◆​ ssx: heat intolerance, tachycardia, ➔​ An endocrine system disease usually involves exophthalmos, palpitation, weight loss the secretion of too much or not enough of a ➔​ Risk: heart failure, preterm labor, IUGR, hormone. gestational HTN, hyperemesis ➔​ HYPERSECRETION: too much hormone is ➔​ Treatment: Methimazole, PTU secreted ◆​ crosses placenta : congenital ➔​ HYPOSECRETION: not enough hormone is hypothyroidism, goiter secreted ◆​ keep lowest possible dose to keep a ➔​ Diabetes, thyroid disease: most common controlled thyroid level endocrine disease GESTATIONAL DIABETES MELLITUS. (1) GESTATIONAL DIABETES MELLITUS PATHOPHYSIOLOGY ➔​ Pathologic changes ➔​ Pregnancy ➔​ Defective insulin secretion ➔​ Release of placental hormone ➔​ Peripheral insulin resistance ◆​ (Insulinase, human placental lactogen, hGH) **develop less-than-optimal control during pregnancy, ➔​ Insulin resistance even having successful regulation of glucose and insulin ➔​ Hyperglycemia metabolism before pregnancy ◆​ Pregnancy per se: in the state of insulin **changes in the glucose-insulin regulatory system as resistance = hyperglycemia pregnancy progresses ➔​ Osmotic Diuresis ➔​ Glycosuria INCIDENCE ➔​ 2-3% becomes diabetic during pregnancy ↑ Glomerular filtration of glucose → ↓ Glomerular ➔​ 24-28 weeks AOG : peak of insulin resistance excretion threshold = slight glycosuria IMPLICATION ➔​ Resolves after birth/puerperium ↑ Rate of Insulin secretion → ↓ fasting blood sugar = ➔​ Risk: 50-60% developing DM type 2 develop insulin resistance as pregnancy progresses (2) THYROID DISEASES Placental insulinase → increased breakdown of degradation of insulin → resistance to insulin prevents NORMAL PREGNANCY the blood glucose from falling to dangerous limits, ➔​ hypertrophy of thyroid gland despite the increased (Human Placental Lactogen, ➔​ Thyromegaly estrogen, progesterone, hGH(somatotropin), HcG) HYPOTHYROIDISM Insulin secretion that occurs. It causes difficulty for a ➔​ Risk: anovulatory menstruation diabetic pregnant woman in that she must increase her ◆​ spontaneous abortion because pregnancy insulin dosage needs thyroid hormone to maintain → Beginning at about week 24 of pregnancy to pregnancy prevent hyperglycemia. ➔​ Treatment: Levothyroxine (Synthroid) → must guard against hypoglycemia and ◆​ dose of levothyroxine needs to be ketoacidosis increased by 25-30% for duration of pregnancy RISKS/DANGER OF DM DURING PREGNANCY IMPAIRED GLUCOSE ​ 1. macrosomia TOLERANCE/HOMEOSTASIS ​ 2. Polyhydramnios ➔​ Impaired fasting glucose ​ 3. labor: shoulder dystocia, CPD ◆​ A state when fasting plasma glucose is ​ 4. congenital anomaly at least 110 but under 126 ml/dl A1C – ​ 5. abortion, stillbirth 5.8-6.4% ​ 6. birth: newborn complication ➔​ Impaired glucose tolerance ​ ​ 1. hypoglycemia ◆​ A state when results of the oral glucose ​ ​ 2. respiratory distress of newborn tolerance test are at least 140 but under ​ ​ 3. hypocalcemia 200 mg/dl in the 2 hour sample ​ ​ 4. hyperbilirubinemia GESTATIONAL DIABETES MELLITUS. GESTATIONAL DIABETES MELLITUS. DIAGNOSTIC FINDINGS RISK FACTORS ➔​ Obesity BMI > 25 ORAL GLUCOSE TOLERANCE TEST (OGTT) ➔​ Age over 25 years ➔​ Screening during pregnancy ➔​ History of large babies (macrosomia, BW > 10 ➔​ 24-28 weeks AOG (routine) lbs) ➔​ Risk factor: First prenatal visit, 24-28th week ➔​ History of unexplained fetal or perinatal loss AOG ➔​ History of congenital anomalies in previous Procedure pregnancies ➔​ oral 50-g glucose loading PO ➔​ Family history of diabetes ( one close relative or ➔​ 60 minute later: venous blood drawn two distant one) ◆​ If the serum glucose at 1 hour is more ➔​ Member of a population with high risk for than 140 mhg/dL, diabetes (Asian, Hispanics, pacific islander) ➔​ 60 minute later: venous blood drawn – fasting glucose tolerance test **It is unknown whether gestational diabetes results ◆​ schedule for 100 g 3 hour OGTT from inadequate insulin response to carbohydrate or Results from excessive resistance to insulin: a combination of ➔​ two of four blood sample collected > 95 mg/dl both may occur. Test Type Pregnant Glucose Level GESTATIONAL DIABETES MELLITUS. (mg/dL) CLASSIFICATIONS Fasting 95 1 hour 180 TYPE 1 DM 2 hours 155 ➔​ Insulin-dependent diabetes mellitus 3 hours 140 ➔​ destruction of beta cells in the pancreas ➔​ absolute insulin deficiency GESTATIONAL DIABETES MELLITUS. MANAGEMENT TYPE 2 DM DIET ➔​ non-insulin dependent ➔​ Calorie: 1800-2400 (30 cl/kg of ideal BW) ➔​ insulin resistance ◆​ 40-50% CHO, 30-40% fats, 12-20% ➔​ relative insulin deficiency CHON ◆​ 2 meals, 3 snacks GESTATIONAL DM ➔​ Goals: keep CHO evenly distributed during the ➔​ abnormal glucose metabolism during pregnancy day ➔​ insulin resistance ◆​ Blood glucose level remain constant ◆​ Prevent hypoglycemia EXERCISE  ➔​ Eat snack with CHON and complex CHO prior ➔​ Risk for ineffective coping related to required before exercise change in lifestyle ➔​ Maintain a consistent exercise (low-moderate) ➔​ Risk for infection related to impaired healing program accompanying condition PHARMACOLOGIC ➔​ Deficient fluid volume deficit related to ➔​ Insulin polyuria accompanying disorder ◆​ Short-acting plus intermediate acting ➔​ Deficient knowledge related to difficult and ◆​ 2/3 before breakfast and 1/3 before complex health problem dinner ➔​ Health-seeking behaviors related to voiced need **Even calorie distribution: Maintains stable glucose to learn home glucose monitoring levels. **Reduced fats & cholesterol: Supports heart health. RESPIRATORY DISORDERS. **Increased fiber: Reduces post-meal glucose spikes and ➔​ range from mild (common cold) to severe lowers insulin needs. (pneumonia) to chronic (tuberculosis). Respiratory can worsen in pregnancy ➔​ Dm must be controlled prior to pregnancy ➔​ rising uterus ➔​ Risk : preterm labor, PIH, pregnancy loss, fetal ◆​ compresses the diaphragm demise, congenital anomaly, macrosomia ◆​ reduces thoracic cavity ➔​ Monitor A1c ◆​ reduces lung spaces ➔​ Ophthalmic examination ➔​ Risks ◆​ done once during pregnancy for a ◆​ Maternal” altered oxygen-CO2 woman with gestational diabetes and at exchange each trimester for women with known ◆​ Fetus: compromised uteroplacental diabetes ➔​ Urine culture ASTHMA. ◆​ done each trimester to detect ➔​ Exposure to allergen (irritants) IgE-mediated asymptomatic UTI ➔​ Release of biochemical mediators (histamine. ➔​ Timing for delivery Leukotriene) ◆​ 36-40th weeks AOG : most hazardous ◆​ constriction of bronchial smooth muscle time for fetus when fetus is drawing ​ Airway obstruction large stores of nutrients because of their ◆​ inflammation of bronchial wall increasing size ​ Airway inflammation (bronchial ◆​ vaginal birth: preferred if possible edema) ​ induce labor by oxytocin or ◆​ increase bronchial secretion rupturing of membrane after ​ Airway hyperreactivity cervical ripening ○​ WHEEZING ​ monitor FHR, progress of labor ➔​ Risk/dangers ​ assess for ssx uteroplacental ◆​ preterm labor: asthma reduces oxygen insufficiency supply to fetus ◆​ C-section: if CPD, shoulder dystocia, ◆​ IUGR - Intrauterine growth restriction fetal distress ➔​ inhaled corticosteroids Beclomethasone (Beclovent), Vancenase) and Budesonide GESTATIONAL DIABETES MELLITUS. (Pulmicort, Rhinocort) DIAGNOSIS ◆​ commonly used by women with ➔​ Risk for ineffective tissue perfusion related to persistent asthma and are the best choice reduced vascular flow for pregnant women and those who ➔​ Imbalanced nutrition less than body might become pregnant. requirements, related to inability to use glucose  ASTHMA. ANEMIA IN PREGNANCY. MANAGEMENT **During pregnancy: slight expansion in the blood ➔​ CORTICOSTEROIDS volume than the normal RBC count to cater the growing ◆​ anti-inflammatory effect fetus: PSEUDOANEMIA (Dilutional anemia) ◆​ promotes lung maturity → 30-50% blood volume increase ◆​ causes maternal hyperglycemia​ → 20-30% RBC increase ➔​ CROMOLYN SODIUM TRUE ANEMIA ◆​ mast cell stabilizer → Pathologic anemia: occurs when there is a disorder ◆​ symptom prevention in the production of erythrocytes or if there is excessive ➔​ BETA-ADRENERGIC AGONIST loss of erythrocytes due to bleeding or destruction. ◆​ Terbutaline → Physiologic anemia: occurs when there is decline in ◆​ prevents preterm labor production is due to hemodilution or when the plasma ◆​ S/E: hypokalemia volume expands more than the RBC ➔​ LEUKOTRIENE RECEPTOR ANTAGONIST ANEMIA IN PREGNANCY. ◆​ Montelukast IRON-DEFICIENCY ANEMIA ◆​ Symptom prevention ➔​ most common form during pregnancy ➔​ Etiology ASTHMA. ◆​ heavy menstrual periods NURSING DIAGNOSIS ◆​ poor nutritional intake ASTHMA DURING PREGNANCY ➔​ Characteristic: microcytic, hypochromic ➔​ Risk for ineffective breathing pattern related to ◆​ Small-sized RBC and reduced respiratory changes during pregnancy hemoglobin level than the average cell ◆​ RR: 16-20 cpm count ◆​ PO2: > 80 mmHg ◆​ LOW corpuscular volume and mean ◆​ PCO2: < 40 mmHg corpuscular hemoglobin ◆​ FHR: 120-160 bpm with good ➔​ Risk: low birthweight, premature delivery variability ➔​ Hemoglobin: < 11 mg/dl ➔​ Risk for uteroplacental insufficiency ➔​ Low serum iron level < 30 mcg/dl ➔​ Increased Iron-binding capacity > 400 mcg/dl ASTHMA. HEALTH EDUCATIONS MEGALOBLASTIC & FOLIC ACID DEFICIENCY Relieving Upper Respiratory Symptoms During ANEMIA Pregnancy ➔​ Nutritional ➔​ Use the following guidelines to help combat ➔​ hyperchromic, macrocytic anemia common cold symptoms during pregnancy: ◆​ High MCV is elevated compared to Iron ◆​ Be sure to get extra rest and sleep deficiency anemia ◆​ Eat a light diet high in vitamin C ➔​ Risks: NTD, abruptio placenta, abortion ◆​ If you experience any aches and pains, take acetaminophen every 4 hours →Definition ◆​ Apply a medicated vapor rub to your is defined as a disorder in the RBC production in chest which the red cells fail to divide and become enlarged. ◆​ Use a room humidifier , especially at night →Folic acid: important in synthesis of nucleic acid and ◆​ Use cold or warm compresses to relieve production of red blood cells. sinus Headaches ◆​ Ask MD Re: the use of over-the-counter →Treatment cough Drops, syrups or decongestants 1. Folic acid supplement 400 mcg daily : planning to become pregnant 2. Folic acid 800mcg – 1 mg = during pregnancy infection, and severe pain (due to veno- 3. dietary: green leafy vegetables, dried beans occlusive crisis ➔​ Observe and monitor hematologic laboratory results SICKLE CELL ANEMIA ➔​ Encourage the client to eat foods high in iron ➔​ Abnormal Hgb S, genetic (autosomal recessive) (organ meat, green leafy vegetable) and folic ➔​ Hemolytic anemia acids like green leafy vegetables, fish, meat, ➔​ Risks: veno-occlusive crisis poultry, eggs, and legumes. ➔​ Teach how to prepare food in order to minimize → caused primarily of the Hemoglobin S causing other the loss of iron and folic acid (steaming with red blood cells to sickle or follows a crescent shape small amount of water) causes inherited hemolytic anemia ➔​ Encourage to take foods high in Vitamin C → does not influence pregnancy itself, but for a woman ➔​ Manage possible side effects of medicationS with a sickle disease, pregnancy is considered a ➔​ Emphasize diet high in fiber and fluids to avoid complication. constipation (a side effect of iron intake) → threat: directed to the growth and well being of the ➔​ Emphasize also good hygiene to avoid urinary fetus because of clumping (due to increased tension to tract infection the cells) which in return causes some veno- occlusive ➔​ Also instruct the client to avoid people with crisis. infection, as they may be prone to acquire the infection, too. Blockage in Blood vessels ➔​ Teach the client to watch out for signs of → fetal compromise or death preterm labor ➔​ Observe and monitor the fetal well being SICKLE CELL ANEMIA ➔​ Allow the client to rest as much as possible and PATHOPHYSIOLOGY provide emotional support → irregularly shaped RBCs --- increased o2 tension (high altitude, dehydration) --- increases blood viscosity PREGNANT MOTHER WITH. --- blood clump together ---- blockage in the major CARDIOVASCULAR PROBLEM. organs --- vaso occlusive ➔​ Responsible for 5% maternal death during pregnancy →rapid hemolysis of RBC --- severe enemia ➔​ Causes: ◆​ valvular damage Dangers: preterm labor, IUGR, abortion, fetal demise ◆​ congenital anomalies ➔​ Complications: heart failure ➔​ Care of pregnant woman with Cardiovascular disease ◆​ Team/multidisciplinary approach: OB, Perinatology, Internist, OB nurse ◆​ Visit OB prior to pregnancy ◆​ Prenatal asap when suspecting pregnancy ◆​ Baseline 2D echocardiogram Complications ANEMIA IN PREGNANCY. →pregnancy taxes the circulatory system: blood NURSING CONSIDERATIONS volume and cardiac output increases by 30-50% ➔​ Assessment of nutritional intake and status →occurs as early as eth week AOG, maximized by ➔​ Assess for fatigue, pallor, sore tongue, anorexia, mid pregnancy nausea and vomiting, stomatitis, some signs of  → increase blood flow --- turbulent flow --- ◆​ PND murmur (function/innocent/transient) --- palpitation ➔​ Pulmonary hypertension → 28-32nd week AOG: most dangerous time after the increase in blood volume peaks LEFT SIDED HEART FAILURE. →heart may become overwhelmed by high blood ➔​ Pulmonary venous pressure increases to 25 volume --- decrease C.O. --- decreased perfusion to mmHg vital organ including placenta ➔​ Increases pulmonary capillary pressure (fluid →Frank-starling law shift) ➔​ Pulmonary edema PREGNANT MOTHER WITH. ◆​ interferes with O2-CO2 exchange CARDIOVASCULAR PROBLEM. ➔​ Pulmonary arteriole/capillary rupture DANGER: heart failure ➔​ Pulmonary edema (pink-frothy sputum) ➔​ Increase in circulatory volume ➔​ Overwhelms the heart towards the end of Risk of Pulmonary hypertension pregnancy ➔​ O2/CO2 exchange alteration ➔​ decrease CO to vital organ, placenta ➔​ uteroplacental insufficiency ➔​ decreased tissue perfusion ➔​ spontaneous abortion, preterm labor, maternal ➔​ decrease oxygen and nutrient delivery death NYHA heart failure classification LEFT SIDED HEART FAILURE. → predicts the outcome of pregnancy CLINICAL MANIFESTATIONS → degree of exertional dyspnea in relation to degree ➔​ Tachypnea → Easy fatigability → Weakness → of limitations Dizziness → Pulmonary congestion →SOB: failure symptoms: exertional dyspnea, orthopnea, PNDs, edema → Tachypnea: alveoli dysfunction, low oxygen Classification Description Complications Implications saturation → Increase fatigue, weakness, dizziness – decrease CO I No Expect normal pregnancy limitation → low O2 supply to brain II Slight Expect normal pregnancy limitation → Tachycardia, peripheral vasoconstriction – attempt to increase Systemic blood pressure III Moderate Complete pregnancy → Decrease CO to kidney limitation Bed rest strictly → low BP (hypotension) IV Severe Severe heart Advised to avoid → activates RAAS limitation failure pregnancy Decreased blood flow/supply to placenta (decrease peripheral circulation) PREGNANCY WITH LEFT SIDED FAILURE. ➔​ Causes mitral stenosis, mitral insufficiency, Pulmonary congestion COA ​ Orthopnea – head is elevated to breath, fluid ➔​ LV failure (pump failure) gravitate into base of the lungs ➔​ Backflow of blood into pulmonary circulation ​ PND – suddenly waking up at night for SOB ➔​ Normal Physiologic compensation: tachycardia ​ exertional dyspnea (pregnancy) ◆​ shortens diastole LEFT SIDED HEART FAILURE. ◆​ decrease Cardiac output MANAGEMENT ➔​ Decreased systemic venous pressure ➔​ Diuretics ➔​ Elevated pulmonary venous pressure ◆​ pulmonary congestion ➔​ Pulmonary congestion ➔​ Antihypertensive ◆​ Orthopnea: dyspnea on recumbent ➔​ Anticoagulant position  ◆​ Mitral stenosis – difficulty of blood to ​ - back pressure – systemic vascular congestion leave the LA --- blood stasis – ​ - decrease CO to lungs thrombus formation ​ - increased pressure in the vena cava ---- jugular ◆​ drug of choice, no teratogenic effect vein distention, increased portal congestion- ◆​ low molecular weight heparin (LMWH): hepatosplenomegaly drug of choice, does not cross placenta, ​ - peripheral edema no teratogenic effects Liver, spleen = distension, enlarged liver presses ◆​ Warfarin enlarged uterus ​ can be used after 12 weeks but Ascites – distention of abdominal vessels, transudate of should return to heparin during fluid to peritoneal cavity the last month Peripheral edema = fluid moved to systemic circulation ➔​ Fluid management in LE ➔​ Salt restriction **NO ACEi, beta blocker RIGHT SIDED HEART FAILURE. Nursing Diagnosis MANAGEMENT ​ Impaired blood flow to uterus/placenta, poor GOALS placental perfusion, IUGR, fetal demise, maternal death ➔​ treat systemic heart failure ➔​ treat irregular heartbeat RIGHT SIDED HEART FAILURE. TREATMENT CAUSES ➔​ Improve exercise tolerance ➔​ congenital heart disease (pulmonary valve ➔​ Improve strength of the heart stenosis, atrial/ventricular septal defect DIGOXIN UNCORRECTED ➔​ (+) inotropic, (-) chronotropic ➔​ not advised to get pregnant, if pregnancy occurs, DEFINITIVE TREATMENT needs monitoring and administration of O2, ➔​ Heart transplant bedrest ◆​ Right-sided > left sided HF PREGNANT WOMAN WITH VENOUS IF PREGNANCY OCCURS: THROMBOEMBOLISM (VTE’S) ➔​ needs close monitoring, Oxygen therapy and ​ - increases during pregnancy: Virchow’s triad bedrest (venous stasis, vessel injury, hypercoagulability) ​ ​ - stasis of blood in the lower extremities RIGHT SIDED HEART FAILURE. from uterine pressure ➔​ occurs when right ventricle is overwhelmed by ​ ​ - hypercoagulability (estrogenic effect) ​ ​ - increase pressure on lower extremity vein the amount of blood received by the right atrium wall (vascular injury) from vena cava. ​ - DVT --- pulmonary embolism ➔​ Decreased Right ventricular output Prevention ➔​ Back pressure builds up ​ 1. early ambulation ➔​ Increased pressure in the vena cava ​ 2. avoid: use constrictive knee-high stocking, ➔​ Systemic vascular congestion crossing the legs, standing in one leg when standing ◆​ JV distention, hepatosplenomegaly Assessment ◆​ Ascites ​ - pain/redness in the calf ◆​ Peripheral edema ​ - (+) Homans sign Etiology ​ - diagnostic: doppler ultrasound of the bilateral LE Treatment → unrepaired congenital heart disease: ​ - Bedrest during acute episode to prevent Pulmonary valve stenosis (Eisenmenger syndrome) ; dislodgement right-to-left atrial or VSD ​ - do not massage the area ​ - Heparin Right ventricular output – is less than the BV received ​ ​ - IV for 24-48 hrs. , then subcutaneously from RA from vena cava