Chapter 11

DM in Pregnancy: Foundational Concepts

• Gestational diabetes mellitus (GDM):

  • Carbohydrate intolerance or DM first identified during the 2nd or 3rd trimester

    • — that is not clearly preexisting overt DM

• Placental transfer:

  • Maternal glucose crosses the placenta

    • fetal glucose levels reflect maternal levels

  • maternal insulin does not cross the placenta

• 1st trimester:

  • Increased maternal insulin production and peripheral glucose use

    • lower fasting glucose

    • increase hypoglycemia risk

  • insulin doses may need reduction

• 2nd and 3rd trimesters:

  • increases insulin resistance:

    • Placental hormones

    • cortisol

    • insulinase

  • need for Insulin rises from ~18–24 weeks through ~36 weeks

    • may double, or quadruple

• After birth:

  • Placental delivery removes a major source of insulin resistance

    • produces abrupt decline in insulin requirements

• Lactation:

  • Milk production uses maternal glucose

  • breastfeeding can lower insulin needs by as much as 25% below prepregnancy requirements

    • can increase hypoglycemia risk

      
      

Pregestational DM: Assessment and Laboratory Testing

• Preconception planning:

  • Optimize glycemic control before conception

  • review medication safety

  • identify vascular or end-organ complications

  • discuss pregnancy risks

  • use reliable contraception until control is adequate

• Initial assessment:

  • Complete health Hx and physical examination

  • assess complications including retinopathy, nephropathy, neuropathy, vasculopathy, and cardiac disease.

• Baseline laboratory studies:

  • Obtain routine renal assessment

    • may include 24-hour urine protein and creatinine clearance

• Thyroid evaluation:

  • Thyroid-function testing may be indicated

    • thyroid disease can coexist with DM

• Hemoglobin A1c:

  • Measures recent glycemic control

  • red-blood-cell turnover increases during pregnancy

  • A1c measures past 2–6 weeks

• A1c and fetal risk:

  • hemoglobin A1c below 6.5% early in pregnancy is associated with lowest congenital-anomaly rates

  • iron-deficiency anemia can falsely increase A1c

Pregestational DM: Maternal risks

• Early pregnancy:

  • Poor glycemic control around conception increases miscarriage and congenital-anomaly risk

  • first-trimester hypoglycemia is common

• Later pregnancy:

  • HTN

  • preeclampsia

  • DKA

  • infection

  • worsening kidney or vascular disease

  • preterm birth

  • operative delivery

  • maternal mortality

• DKA:

  • A medical emergency involving:

    • insulin deficiency

    • hyperglycemia

    • ketone production

    • dehydration

    • electrolyte loss

    • metabolic acidosis

  • can cause maternal deterioration or fetal death

• Hypoglycemia:

  • May occur when:

    • sleep

    • delayed meals

Pregestational DM: Fetal and neonatal risks

• Congenital anomalies:

  • Poor early glucose control increases risk

    • neural-tube defects

    • congenital cardiac defects

• Macrosomia:

  • Excessive fetal growth

    • often with disproportionately large shoulders, trunk, and chest

  • increases:

    • shoulder dystocia

    • birth trauma

    • cesarean-birth risk

• Other risks:

  • Growth restriction when maternal vascular disease is present

  • stillbirth

  • prematurity

  • neonatal hypoglycemia

  • metabolic abnormalities

Pregestational DM: Antepartum Management

• Frequent prenatal visits:

  • High-risk status requires:

    • more frequent maternal assessment

    • individualized glucose review

    • coordinated obstetric and DM care

• Nutrition counseling:

  • coordinate carb intake w/ meds and activity

• Home monitoring:

  • Self-monitor blood glucose as prescribed

  • carry:

    • rapid carbohydrate

    • DM identification

• Medication adjustment:

  • Insulin requirements change by trimester

  • doses and regimens must be adjusted, to maintain:

    • maternal euglycemia

    • reduce fetal exposure to hyperglycemia.

• Exercise

• Fetal surveillance:

  • Use serial ultrasound to assess:

    • growth

    • estimated weight

    • amniotic fluid

    • anomalies

  • teach daily fetal movement counting beginning around 28 weeks

• Detailed fetal evaluation:

  • Maternal serum alpha-fetoprotein is assessed

  • 15–20 weeks

    • ideally 16–18 weeks

  • detailed anatomy ultrasound is performed

    • 18–20 weeks

• Fetal echocardiography:

  • May be performed at 20–22 weeks

    • congenital cardiac anomalies are more common

      • particularly when early glycemic control was poor

• Nonstress testing:

  • Generally begins by 32 weeks

  • performed at least twice weekly

  • start earlier when vascular disease, poor control, or suspected growth restriction is present

    • 28–32 weeks

• Birth planning:

  • glycemic control and fetal surveillance are reassuring?

    • birth around 39 weeks may be planned

  • earlier birth may be required for poor control, hypertension, or nonreassuring testing

Pregestational Diabetes: Intrapartum and Postpartum Care - Labor and birth

• Close monitoring:

  • Assess glucose approximately hourly and adjust fluids and insulin to maintain a target of approximately 90–110 mg/dL.

• Intravenous therapy:

  • Use IV fluids as indicated; dextrose may be added when glucose falls or active labor begins, and short-acting insulin may be infused when glucose exceeds the desired range.

• Maternal-fetal surveillance:

  • Prevent dehydration, hypo- or hyperglycemia, and ketoacidosis; use continuous fetal monitoring and upright or side-lying positioning.

• Birth complications:

  • Monitor for labor arrest, cephalopelvic disproportion, macrosomia, and shoulder dystocia.

Pregestational Diabetes: Intrapartum and Postpartum Care - Planned cesarean birth

• Scheduling:

  • Schedule early in the morning when possible

    • to simplify glucose management

• Insulin and intake:

  • usual insulin dose is taken night before surgery

    • morning insulin is withheld on the day of surgery

      • NPO order

• Anesthesia:

  • Regional anesthesia allows pts to remain awake

    • facilitating earlier recognition of hypoglycemia

Pregestational DM: Intrapartum and Postpartum Care - Postpartum care

• Insulin needs:

  • Decrease immediately after placental delivery

  • Once oral intake resumes:

    • insulin may be restarted at the prepregnancy dose

      • or ~ 1/2 to 1/3 of pregnancy dose

• Monitoring:

  • Check glucose closely

    • carb balance stabilizes

    • adjust medications to food intake/breastfeeding

• Postpartum complications:

  • Monitor for:

    • preeclampsia/eclampsia

    • hemorrhage

    • infection

      • endometritis (uterus lining inflammation)

• Breastfeeding:

  • Encourage breastfeeding

  • provide lactation support

  • Check glucose before feeds

    • below 100 mg/dL?

      • 15 g carbs w/o additional insulin

Gestational DM: Prevalence, Risk Factors, and Complications

• Mechanism:

  • Pregnancy-related insulin resistance increases during the 2nd and 3rd trimesters

  • develops when pancreas cannot produce enough insulin

    • or insulin is not used effectively

• Risk factors:

  • Family Hx of DM

  • previous unexplained stillbirth

  • malformed fetus

  • macrosomic infant

  • obesity

  • HTN

  • glycosuria

  • age older than 25

  • previous GDM

• Screening implication:

  • More than ½ of pts diagnosed with GDM lack classic risk factors

    • risk-factor Hx alone is insufficient

• Maternal risks:

  • Preeclampsia

  • increased cesarean-birth likelihood

  • recurrent GDM

  • future T2DM

• Fetal and neonatal risks:

  • Macrosomia

  • shoulder dystocia and birth injury

  • neonatal hypoglycemia

    • other metabolic abnormalities

• Congenital-malformation distinction:

  • GDM developing after 1st trimester is not associated with the same increase in birth defects as preexisting poorly controlled DM

    • because major organ formation has already occurred

Gestational DM - Screening and Diagnosis

• Early assessment:

  • At 1st prenatal visit, evaluate:

    • Hx

    • clinical risk factors

    • labs

  • pts at higher risk may be tested early for previously unrecognized DM

• Routine timing:

  • pts w/o previously diagnosed DM are usually screened at 24–28 weeks of gestation

Gestational Diabetes Screening and Diagnosis - Two-step method

• Step 1:

  • Give 50-g oral glucose load w/o fasting

  • measure plasma glucose 1 hour later

    • ~ 130–140 mg/dL or greater is a positive screen

• Step 2:

  • After a positive screen:

    • perform fasting 3hr, 100-g oral glucose tolerance test

      • with fasting

      • 1hr, 2hr, 3hr measurements

• Dx:

  • GDM is diagnosed when at least 2 values meet or exceed selected diagnostic thresholds

• Preparation:

  • Before the diagnostic test:

    • overnight fast

    • unrestricted cab-containing diet beforehand

    • avoidance of caffeine and smoking

Gestational Diabetes Screening and Diagnosis - One-step method

• Procedure:

  • fasting 2hr

    • 75-g oral glucose tolerance test is performed between 24 and 28 weeks

• Dx: One value meeting or exceeding relevant threshold establishes GDM

• Comparison:

  • two-step method as recommended by ACOG

    • one-step method identifies more pts

      • — but increases testing and associated care

Gestational Diabetes Management - Antepartum management

• Diet:

  • Use individualized nutrition plan

  • distribute carb intake to control glucose

    • — while supporting maternal and fetal nutritional needs

• Exercise:

  • For appropriate pts:

    • ~30min of moderate aerobic activity at least 5 days weekly

      • or at least 150 minutes per week

• Self-monitoring:

  • Often monitor x4 daily:

    • fasting/before breakfast and after each meal

• Glucose thresholds for medication:

  • Consider pharmacologic treatment when:

    • fasting values remain above 95 mg/dL

    • 1-hour postmeal values above 140 mg/d

    • 2-hour postmeal values above 120 mg/dL

• Preferred medication:

  • Insulin

    • preferred when diet and exercise do not maintain target glucose levels

• Oral medications:

  • Metformin and glyburide are discussed as alternatives in selected situations

    • both cross the placenta

      • use for GDM lacks FDA approval

• Fetal monitoring:

  • Individualize growth surveillance and antepartum testing

Gestational Diabetes Management - Intrapartum management

• Labor care:

  • to reduce neonatal hypoglycemia:

    • Monitor glucose hourly

    • aim for ~80–110 mg/dL

• Treatment:

  • Avoid unnecessary dextrose-containing IV fluids

  • IV rapid-acting insulin may be required if glucose cannot otherwise be controlled

• Mode of birth:

  • GDM alone is not an indication for cesarean birth

  • cesarean may be necessary for:

    • macrosomia

    • preeclampsia

Gestational Diabetes Management - Postpartum management

• Immediate course:

  • Glucose often returns to normal after delivery

    • impaired glucose metabolism, or previously unrecognized DM, may persist

• Postpartum testing:

  • Perform a fasting plasma glucose test or 75-g

  • 2hr oral glucose tolerance test 4–12 weeks after birth

• Long-term screening:

  • If postpartum results are normal, repeat DM screening at least every 3 years throughout life

• Future risk reduction:

  • Encourage counseling about recurrent GDM and future T2DM

Thyroid Disorders During Pregnancy - Hyperthyroidism

• Common cause:

  • Most cases result from Graves disease

• Findings:

  • Heat intolerance

  • diaphoresis

  • anxiety

  • fatigue

  • tachycardia

  • weight loss

  • goiter

  • labs typically shows elevated T3/T4 and markedly suppressed TSH

• Maternal and fetal risks:

  • Miscarriage

  • preterm birth

  • severe preeclampsia

  • heart failure

  • fetal or neonatal thyroid dysfunction

• Medication management:

  • Propylthiouracil is recommended in the 1 trimester

  • after 1st trimester

    • pts requiring treatment are switched to methimazole

      • — bc differing fetal and maternal medication risks

• Safety:

  • Use the lowest effective dose

  • monitor thyroid tests

  • Radioactive iodine must not be used during pregnancy

    • → can destroy fetal thyroid

• Thyroid storm:

  • potentially life-threatening complication, involving:

    • fever

    • marked tachycardia

    • restlessness

    • vomiting,

    • AMS

  • requires urgent treatment

• Breastfeeding:

  • May be possible with appropriately limited doses and timing of antithyroid medication after feeding

Thyroid Disorders During Pregnancy - Hypothyroidism

• Common cause:

  • Often autoimmune thyroid destruction

    • Hashimoto thyroiditis

• Findings:

  • Fatigue

  • weight gain

  • cold intolerance

  • constipation

  • dry skin

  • hair loss

  • elevated TSH

    • with or without low T4

• Pregnancy risks:

  • Miscarriage

  • preeclampsia

  • placental abruption

  • preterm birth

  • stillbirth

    • low birth weight

• Treatment:

  • Levothyroxine replacement

  • repeat lab monitoring

  • dose adjustment as pregnancy progresses

  • treatment commonly continues postpartum

    • is compatible with breastfeeding

• Medication teaching:

  • Take levothyroxine at least 4hrs apart from iron supplements

    • — bc iron decreases absorption

Thyroid Disorders During Pregnancy - Nursing and nutrition management

• Nutrition counseling:

  • Ensure adequate pregnancy nutrition and individualized dietary support

    • hyperthyroidism causes poor weight gain

    • hypothyroidism reduces appetite and energy

Maternal Phenylalanine Hydroxylase Deficiency / PKU

• Definition:

  • formerly called phenylketonuria

  • An autosomal recessive metabolic disorder

  • inadequate phenylalanine hydroxylase activity prevents normal metabolism of phenylalanine

• Mechanism:

  • Phenylalanine accumulates to toxic levels

    • can interfere with fetal brain development and other organ formation

• Fetal risks:

  • Intellectual disability

  • microcephaly

  • seizures

  • impaired growth

  • congenital cardiac anomalies

• Dietary management:

  • Begin a phenylalanine-restricted diet before conception

  • continue throughout pregnancy with specialist and nutrition support

• Target levels:

  • maternal phenylalanine below 6 mg/dL for at least 3 months before conception

  • 2–6 mg/dL during pregnancy

• Breastfeeding:

  • Safe when infant does not also have phenylalanine hydroxylase deficiency

    • infant is affected?

      • breastfeeding requires specialist guidance

Cardiovascular Changes and Functional Classification

• Normal pregnancy changes:

  • Increased intravascular volume

  • reduced systemic vascular resistance

  • increased cardiac output

  • labor-related hemodynamic stress

  • major fluid shifts immediately after birth

    • increases cardiac workload

• Cardiac output:

  • increase of 30%–45%

    • substantial change early in pregnancy

    • peak strain during midpregnancy

• Cardiac decompensation:

  • heart cannot maintain adequate cardiac output

  • pregnancy, labor, infection, anemia, and postpartum fluid shifts can precipitate deterioration

Cardiovascular Changes and Functional Classification - New York Heart Association functional classes

• Class I:

  • No Sx

  • no limitation of physical activity

• Class II:

  • Sx

  • slight limitation of activity

• Class III:

  • Sx

  • marked limitation of activity

• Class IV:

  • Sx

  • inability to perform physical activity without discomfort

• Clinical use:

  • Functional status can worsen as pregnancy increases cardiac workload

  • reassess during pregnancy rather than assuming the initial class remains unchanged

Categories of Maternal Cardiac Disease - Congenital cardiac disease

• Septal defects:

  • Atrial and ventricular septal defects create abnormal openings between cardiac chambers

  • Small uncomplicated defects may be tolerated

  • larger defects increase:

    • arrhythmia

    • heart-failure

    • pulmonary-HTN

    • embolism risk

• Patent ductus arteriosus:

  • A persistent fetal connection may contribute to shunting, infection, or pulmonary issues

• Coarctation of the aorta:

  • Localized aortic narrowing may produce:

    • upper-extremity HTN

    • heart failure

    • aortic complications

  • corrected disease generally carries less risk

• Tetralogy of Fallot:

  • A cyanotic congenital condition, involving:

    • ventricular septal defect

    • pulmonary stenosis

    • overriding aorta

    • right-ventricular hypertrophy

  • uncorrected disease increases:

    • hypoxemia

    • pregnancy risk

Categories of Maternal Cardiac Disease - Acquired cardiac disease

• Mitral valve prolapse:

  • Often benign and well tolerated

  • Sx

    • palpitations

    • dyspnea

    • chest discomfort

• Mitral stenosis:

  • Often follows rheumatic heart disease

  • Narrowing obstructs left-heart blood flow

    • can cause:

      • pulmonary edema

      • AFib

      • embolism

      • heart failure

• Valve replacement:

  • Mechanical or bioprosthetic valves require individualized surveillance

  • mechanical valves generally require:

    • anticoagulation

      • balancing thrombosis against maternal and fetal bleeding risks.

Categories of Maternal Cardiac Disease - Ischemic and other cardiac disorders

• Ischemic heart disease:

  • Reduced coronary blood supply

  • previous MI increases maternal risk

    • requires coordinated specialist assessment

• Pulmonary hypertension and Eisenmenger syndrome:

  • Markedly increase maternal morbidity and mortality

  • may make pregnancy especially dangerous

• Peripartum cardiomyopathy:

  • Heart failure developing near the end of pregnancy or during the postpartum months

  • monitor for:

    • dyspnea

    • fatigue

    • edema

    • worsening cardiac function

• Other concerns:

  • Arrhythmias

  • Marfan syndrome or aortic disease

  • endocarditis

  • severe ventricular dysfunction

Categories of Maternal Cardiac Disease - Heart transplantation

• Pregnancy considerations:

  • Assess:

    • transplanted-heart function

    • potential rejection

    • HTN

    • medication exposure

    • need for ongoing specialist monitoring

• Care approach:

  • coordinated obstetric

  • cardiology

  • transplant care

  • evaluate:

    • ventricular function

    • maternal-fetal status

Cardiac Disease: Antepartum Management

• Primary goal:

  • Minimize cardiac workload

  • maintaining adequate maternal O2, circulation, and fetal perfusion

• Frequent monitoring:

  • functional status

  • vitals

  • activity tolerance

  • edema

  • lung sounds

  • infection

  • anemia

  • nutrition

  • Sx of decompensation

• Reduce contributing stressors:

  • Treat fever or infection promptly

  • address:

    • HTN

    • anemia

    • hyperthyroidism

    • obesity

    • emotional stress

• Medication management:

  • Continue or adjust cardiac medications as appropriate

  • pregnancy-related plasma-volume expansion and renal clearance may alter therapeutic levels

• Anticoagulants:

  • May be needed for:

    • prosthetic valves

    • recurrent thrombosis

    • pulmonary embolism

    • rheumatic heart disease

    • cyanotic defects

  • teach prescribed self-administration and bleeding precautions

• Rest and activity:

  • Individualize activity restriction and rest according to functional class and Sx

• Nutrition:

  • Provide adequate calories, protein, iron, folate, and fluid/fiber

  • consider sodium or fluid restrictions when prescribed

  • prevent constipation or straining

• Fetal assessment:

  • Monitor growth, placental function, and fetal well-being

  • congenital maternal heart disease can increase concern for fetal cardiac defects and may warrant targeted evaluation

• Warning signs:

  • Report:

    • worsening dyspnea

    • persistent moist cough

    • palpitations

    • generalized edema

    • distended neck vein

    • crackles

    • cyanosis

    • rapid pulse

Cardiac Disease: Intrapartum and Postpartum Management - Intrapartum care

• Primary goal:

  • Promote cardiac function

  • minimize pain, anxiety, oxygen demand, and hemodynamic stress

• Monitoring:

  • Assess maternal BP, pulse, O2, respiratory findings, cardiac rhythm, fluid balance

  • use continuous FHR monitoring when indicated

• Positioning:

  • Use side-lying or elevated-head positioning

  • avoid prolonged supine positioning

  • use a wedge if supine positioning is necessary

• Pain relief:

  • Epidural analgesia can reduce stress and oxygen consumption

  • monitor carefully for hypotension

• Open-glottis pushing:

  • Encourage pushing without prolonged breath-holding

  • avoid the Valsalva maneuver

    • → it interferes with cardiac filling

      • can overload the heart

• Shorten the second stage when needed:

  • Episiotomy and vacuum- or forceps-assisted birth

    • may reduce prolonged pushing and cardiac workload

• Birth route:

  • Vaginal birth is usually preferred

  • cesarean is not routinely indicated solely for cardiac disease

    • → can involve greater blood loss and fluid shifts

• Antibiotic prophylaxis:

  • Routine prophylaxis for all cardiac pts is not recommended

    • may be used for selected highest-risk pts

      • including some with cyanotic disease or prosthetic valves

• Avoid ergot derivatives:

  • Do not use methylergonovine or related ergot products

    • → they increase BP

    • oxytocin is commonly used to prevent postpartum hemorrhage

Cardiac Disease: Intrapartum and Postpartum Management - Postpartum care

• Most critical period:

  • 1st 24–48 hours after birth are especially hazardous

    • rapid fluid shifts and increased venous return can overload a compromised heart

• Assessment:

  • Monitor:

    • vitals

    • O2

    • heart and lung sounds

    • edema

    • bleeding

    • urinary output

    • pain

    • signs of heart failure

    • signs of cardiac decompensation

• Ongoing risk:

  • Extravascular fluid continues

  • returning to circulation during the first 2 postpartum weeks

  • pts w/o earlier Sx can deteriorate after birth

• Supportive care:

  • Balance rest, activity, nutrition, medication needs, infant care, breastfeeding goals, family support, and discharge planning.

• Family planning:

  • Provide individualized contraceptive counseling

    • → another pregnancy may pose substantial maternal risk

Anemia and Hematologic Disorders

• Clinical importance:

  • Anemia reduces O2-carrying capacity

  • can worsen fatigue, cardiac workload, pregnancy outcomes

Anemia and Hematologic Disorders - Iron-deficiency anemia

• Assessment:

  • Evaluate hemoglobin, hematocrit, and serum ferritin

  • low ferritin with low hemoglobin supports iron deficiency

• Findings and risks:

• Pallor, fatigue, and reduced iron store

• severe disease is associated with preterm birth and low birth weight

• Management:

  • Increase dietary iron and administer oral iron supplements

  • IV or intramuscular iron or blood transfusion may be needed in selected severe cases

Anemia and Hematologic Disorders - Folate-deficiency anemia

• Mechanism:

  • Increased pregnancy requirements or inadequate intake can produce megaloblastic anemia

    • often during the 3d trimester.

• Findings and treatment:

  • Fatigue, pallor, glossitis, and rough skin

  • treat with folic acid supplementation and nutritional counseling

Anemia and Hematologic Disorders - Sickle cell disease and other hemoglobinopathies

• Sickle cell disease:

  • Abnormal hemoglobin promotes red-blood-cell sickling and vaso-occlusive pain crises, especially with dehydration, hypoxia, or acidosis.

• Pregnancy risks:

  • Miscarriage, preeclampsia, infection, preterm birth, growth restriction, and stillbirth.

• Management:

  • Provide genetic counseling, hydration, oxygen and analgesia during crises, folic acid, prompt infection treatment, and fetal-growth surveillance.

• Iron safety:

  • Do not automatically give iron to pts with sickle cell disease or thalassemia unless iron deficiency is established

    • → iron overload can occur

Pulmonary Disorders: Cystic Fibrosis

• Definition:

  • An autosomal recessive disorder affecting pulmonary function and other organs

  • frequently causing thick secretions, recurrent infection, pancreatic insufficiency, and nutritional problems

• Pregnancy considerations:

  • Outcome is generally better when prepregnancy lung function and nutritional status are good

  • severe disease increases hypoxemia, infection, DM, growth restriction, and uteroplacental insufficiency

• Interprofessional management:

  • Coordinate obstetric, pulmonary, nutrition, respiratory-therapy, and pharmacy care

• Nutrition:

  • Monitor weight gain and nutritional markers

  • provide pancreatic enzymes, adequate calories, and assessment of fat-soluble vitamin status

• Respiratory care:

  • Use pulmonary-function monitoring, airway clearance, chest physiotherapy, and early treatment of infection.

• Diabetes screening:

  • Screen early because cystic-fibrosis-related diabetes can complicate pregnancy.

• Fetal surveillance:

  • Monitor growth and amniotic fluid

  • NSTs or biophysical profiles may begin around 32 weeks

• Breastfeeding:

  • May be possible with adequate maternal nutrition, caloric intake, hydration, and individualized clinical support

Pregnancy-Related Itching and Skin Disorders - Pruritus gravidarum

• Definition:

  • Generalized itching without a rash, often concentrated on the abdomen and related to skin stretching or striae.

• Associated factors:

  • Multiple gestation, fertility treatment, diabetes, and nulliparity.

• Clinical significance:

  • Not associated with poor perinatal outcomes.

• Treatment:

  • Skin lubricants, topical antipruritics, oral antihistamines, and other comfort measures

Pregnancy-Related Itching and Skin Disorders - Polymorphic eruption of pregnancy / PUPPP

• Terminology:

  • Polymorphic eruption of pregnancy

  • also called pruritic urticarial papules and plaques of pregnancy (PUPPP)

• Typical presentation:

  • Intensely itchy papules and plaques

    • beginning on abdomen during the mid-to-late 3rd trimester

  • often in 1sr pregnancy

  • eruption may spread to the arms, thighs, back, or buttocks

• Associated factors:

  • Multiple gestation

  • increased maternal weight gain

  • HTN

  • induction of labor

• Maternal-fetal significance:

  • Although itching may be severe

  • condition is not associated with poor maternal or fetal outcomes

• Treatment:

  • Topical antipruritics

  • topical corticosteroids

  • oral antihistamines

  • severe Sx may require oral prednisone

• Expected course:

  • Usually resolves before birth or w/n several weeks postpartum

  • usually does not recur in later pregnancies

Pregnancy-Related Itching and Skin Disorders - Intrahepatic cholestasis of pregnancy

• Definition:

  • A pregnancy-related liver disorder characterized by generalized itching

  • often worst on the palms and soles and at night

    • without primary skin lesions

• Laboratory findings:

  • Elevated serum bile acids and liver-function tests

  • jaundice, dark urine, and light-colored stools may occur

• Why it matters:

  • cholestasis increases fetal risks

    • asphyxial events

    • meconium complications

    • preterm birth

    • stillbirth

• Treatment:

  • Ursodeoxycholic acid

  • follow-up bile-acid and liver testing

  • antihistamines or comfort measures

  • fetal surveillance with NST and/or biophysical profile

• Birth planning:

  • fetal testing remains reassuring?

    • birth at 37 weeks should be considered

• Maternal bleeding risk:

  • Vitamin K deficiency can increase postpartum hemorrhage risk

  • some providers administer oral vitamin K

Neurologic Disorders: Multiple Sclerosis and Bell Palsy - Multiple sclerosis

• Definition:

  • A CNS demyelinating disorder characterized by exacerbations and remissions

• Symptoms:

  • Weakness, numbness or paresthesias, visual changes, impaired coordination, and possible bladder dysfunction

• Pregnancy course:

  • Remission during pregnancy is common

  • relapse is more likely postpartum

  • Pregnancy generally does not worsen the long-term disease course

• Management:

  • Assess gait and fall risk

  • treat severe relapse with corticosteroids or other prescribed therapy

• Disease-modifying medications:

  • Most experts described in the chapter recommend stopping disease-modifying therapy before conception because pregnancy safety data are limited

• Birth and breastfeeding:

  • Epidural analgesia is not shown to worsen the disease

  • cesarean is usually unnecessary for MS alone

  • breastfeeding decisions should consider relapse risk and medication exposure

Substance Use Disorder: Definition, Risks, and Dual Diagnosis

• Definition:

  • A chronic, relapsing, progressive disorder involving ongoing substance use and resulting physical, social, interpersonal, or behavioral problems.

• Dual diagnosis:

  • Substance use disorder occurring with another psychiatric or mental-health disorder; coexisting conditions increase treatment complexity and barriers.

• Warning signs:

  • Late or absent prenatal care, missed visits, poor treatment adherence, poor nutrition, family conflict, legal involvement, or unstable living conditions.

• Direct fetal effects:

  • Depending on exposure and gestational timing, substances can cause miscarriage, congenital abnormalities, central-nervous-system injury, impaired growth, or fetal death.

• Indirect fetal effects:

  • Poor maternal nutrition, placental insufficiency, reduced prenatal care, violence, infection, or untreated mental illness can further compromise fetal well-being.

Substance Use Disorder: Definition, Risks, and Dual Diagnosis - Examples of substance-specific risks

• Tobacco:

  • Associated with ectopic pregnancy, placenta previa, placental abruption, preterm membrane rupture, orofacial clefts, growth restriction, low birth weight, and increased perinatal mortality.

• Alcohol:

  • No amount is described as safe during pregnancy

  • exposure can cause fetal alcohol syndrome and other developmental or pregnancy complications.

• Opioids:

  • Associated with maternal dependence and withdrawal, fetal growth concerns, preterm birth, and neonatal abstinence syndrome.

• Cocaine:

  • Vasoconstriction is associated with growth restriction, hypertension, placental abruption, and other serious pregnancy complications.

• Methamphetamines:

  • Associated with low birth weight, microcephaly, preterm birth, placental abruption, and fetal brain or cardiac abnormalities.

• Marijuana:

  • fetal and child effects remain concerning and data are incomplete