Complexities of Pregnancy

what is Rhesus Incompatibility?

different blood types between mom and baby — mom and baby’s blood do not mix but come into contact in placental membrane

what is rhesus +

red blood cells have the rhesus antigen on them, body learn to recognize as part of your body

what rhesus -

red blood cells do not have antigen on them, when you come into contact with + your body thinks it needs to attack

what must be done when mom is rhesus +

nothing there is no problem if mom is rhesus +

if mom is rheus - and baby is rhesus + what happens?

Anytime baby’s blood gets into mothers' bloodstream she will create anti rhesus antibodies

what are sensitizing events?

how the baby’s blood gets into mom’s bloodstream

• Miscarriage > 12 weeks

• Abdominal trauma

• At birth

why does hemolysis in the newborn cause jaundice?

destroyed red blood cells release bilirubin — high bilirubin causes jaundice, which can damage the brain!

what is hemolytic disease of the newborn (HDN)?

Antibodies crossing across placenta into baby blood stream: hemolytic anemia or jaundice

how can the rhesus events be prevented?

Anti-D antibodies are given IM during sensitizing events, check rhesus status, and check baby

what is the benefit of anti-d antibodies IM?

Circulates around blood and destroys any of the baby blood or any blood cells in mom that contain antigen – no immune response = no sensitize

what should be assumed when checking rhesus status?

If negative, assume baby is + and give mom anti D injection

what is ABO incompatibility?

Mother will be blood group O and the baby will be blood group A OR B, can occur in first pregnancy

• more common, less severe → can trigger DIC

what is gestational diabetes mellitus?

Any degree of glucose intolerance with onset or first recognition during pregnancy

what is GDM associated with?

Associated with fetal macrosomia – increasing the risk of birth injury to mother and baby.

what are risk factors of GDM?

• Family history of diabetes in a first degree relative

• Body mass index ≥30kg/m2

• Maternal age ≥ 40years

• Previous unexplained perinatal death

• Current glycosuria

• Women on long term steroids

• Previous delivery of a baby weighing ≥ 4.5kg

• Polycystic ovary syndrome

• Polyhydramnios and/or macrosomia in existing pregnancy

what is a GDM diet?

Diet includes carbohydrates from fruit, vegetables, whole grains, legumes and low-fat milk are encouraged for good health

what is the benefit of physical activity in GDM?

helps control insulin levels

what is the recommended physical activity for GDM?

At least 150 minutes of exercise throughout their pregnancy (moderate and safe)

when should self-monitoring blood glucose be done for GDM?

SMBG should be performed 3-7 times a day

what is the target capillary blood glucose level pre-meal and pre-bed?

<5.0mmol/L

what is the target capillary blood glucose level 1 hr post-meal?

<7.0mmol/L

what is the ideal HBA1c for GDM?

As close to normal as possible, < 48 mmol/mol

what is intermediate acting insulin?

12-14 hours — insulated

what is long acting insulin?

no peak of action — lantus, levemir

• once a day ot twice daily injection

what is rapid acting analogues?

4-6 hours; lispro, aspart, and glulisine

what is metformin?

A biguanide and has a very low risk of maternal hypoglycemia — it is the first line treatment in type 2 diabetes (started after 20 weeks)

what is the antenatal care for GDM?

Self-monitor blood glucose levels and often have fasting post prandial testing done with the hospital's diabetes service

what is the fetal assessment done in GDM?

Fetal assessment scans are recommended at 32-34 weeks to assess fetal growth and wellbeing

what complications tend to happen more in GDM?

Macrosomia and shoulder dystocia occur more frequently

wha is essential during delivery for mom with GDM?

Intrapartum metabolic control is essential for both mother and fetus — blood glucose maintained bw 4-7mmol/L

what happens to mom with GDM postnatal?

once the placenta is delivered, maternal blood glucose and insulin levels return to normal — often 48 hours post delivery

does mom with GDM continue medication postnatal?

Insulin therapy and metformin should be discontinued immediately postpartum

what are neonates of mom with diabetes at risk for?

hypoglycemia, macrosomia, respiratory distress and hypocalcemia

when do the neonates blood glucose levels become normal?

Following delivery, neonatal blood glucose concentration falls quickly then rises and stabilizes by approximately 2-3 hours of birth

why is breastfeeding recommended immediately after birth for GDM?

breastmilk has protective effects against type 2 diabetes in the offspring in later life

what is the best way to prevent T2DM?

lifestyle interventions such as diet and physical activity, weight management is the best strategy

how does physical activity help with prevention of T2DM?

reduces insulin resistance

what is the focus of practice for obesity in pregnancy?

nutrition based approach

• encourage healthy balanced diet

• encourage appropriate caloric intake

• encourage supplements

would you advise and pregnant woman to lose weight if obese?

no, risk factor of nutrient deficiency to fetus

what is the US approach in obesity in pregnancy?

focuses more on weight tracking than nutrition focus, based on BMI categories

what medication is contraindicated during pregnancy?

GLP-1 medications — people trying to lose weight before pregnancy

why might people planning pregnancy use GLP-1 medications?

may be advised to lose weight before conception, but they must stop medication before trying to conceive

what is sickle cell anemia?

A genetic disease where red blood cells can take the shape of a crescent, or sickle and that change allows them to more easily be destroyed causing anemia

what causes sickle cell anemia?

caused by defective hemoglobin

what does sickle cell anemia cause?

chronic anemia and repeated vaso-occlusion

who can get sickle cell anemia?

• Autosomal recessive

• Sickle cell trait = carrier, usually asymptomatic

what are symptoms of sickle cell d/t hemolysis?

• Chronic anemia

• Jaundice

• Scleral icterus

• Gallstones

what are symptoms of sickle cell d/t vaso-occlusion?

• Severe pain crises

• Acute chest syndrome (respiratory distress & hypoxia)

• Stroke

• Bone pain, dactylitis, avascular necrosis

• Splenic infarction → functional asplenia

• Increased infection risk (especially encapsulated organisms)

what changes in pregnancy make complications of anemia more likely?

pregnancy naturally increases:

• Blood volume strain

• Oxygen demands

• Clotting tendency

• Infection risk

what are maternal complications that can happen from anemia?

• Increased maternal morbidity

• More vaso-occlusive pain crises

• Increased acute chest syndrome

• Increased stroke risk

• Increased infections

• Increased anemia

• Increased need for hospitalization

what fetal risks can happen from anemia?

• Miscarriage

• Fetal growth restriction

• Preterm birth

• Placental insufficiency

• Stillbirth

why do labor risks increase in anemia?

due to dehydration, pain, and hypoxia.exhaustion

what can dehydration, pain, and hypoxia trigger?

acute sickling crisis, acute chest syndrome, hypoxia, and severe pain flare

what dangerous loop does labor trigger for someone with sickle cell anemia?

pain → stress response → vasoconstriction → ↑ sickling → pain increases