Maternal Complications

what does pre-gestational diabetes include?

T1DM & T2DM diagnosed prior to pregnancy

what is gestational diabetes (GDM)?

a carbohydrate intolerance

- only occurs during pregnancy

what causes GDM?

hormones:

- produced by the placenta which can lead to insulin resistance

- increase in production as the placental size increases, resulting in metabolism difficulties later in pregnancy, but not early on

what can GDM lead to risks of?

- macrosomnia

- birth injuries

- neonatal hypoglycemia, hypocalcemia, & hyperalbuminemia

- preeclampsia

- polyhydramnios

- fetal hepatomegaly &/or cardiomegaly

risk factors for GDM:

- hispanic or native american

- older age

- obesity

- family hx

- previous macrosomic infant

- previous stillborn infant

how can obese women reduce their risk of GDM?

pre-pregnancy weight loss

women at high risk for GDM (those w/ hx of previous GDM or who are obese), can be tested in the first trimester w/ ________.

A1C

- this will detect preexisting, but previously undiagnosed T2DM

what is the most common approach for screening for GDM?

2 step approach

1. 1 hr glucose loading/challenge test (GLT or GCT) on all pregnant women 24-28 wks gestation

2. if they test positive on the above (>/= 140), then do: 3 hr OGTT

is fasting required for the 1 hr GLT?

no

1 multiple choice option

is fasting required for the 3 hr OGTT?

yes

1 multiple choice option

what is considered a positive (+) result on the 1 hr GLT?

>/= 140

how is GDM diagnosed?

positive OGTT (2/4 values are high)

why is it less common to skip the 1 hr GLT & go straight to the 2 hr OGTT?

bc the patient must be fasting, & 1/3 values must be elevated for diagnosis

what are usually done at every prenatal visit to screen for GDM throughout pregnancy?

urine dipsticks for glucose & protein

how is GDM treated?

- diet

- monitor glucose levels 4x/day

- failure of diet control = insulin (but occasionally an oral agent)

- US near 37 wks to estimate fetal weight if macrosomnia will be a risk factor

diet controlled patients w/ GDM usually have..

normal delivery management

medication controlled patients w/ GDM usually are..

induced at 39 wks or earlier

when is elective c-section recommended in GDM?

when the fetal weight is 4500 g or more (macrosomnia)

why should vaginal deliveries for those w/ GDM be performed by experienced OBs?

bc there is an increased risk for shoulder dystocia

what is the follow-up for patients w/ GDM?

higher risk of developing GDM in future pregnancies & T2DM

- fasting blood sugars should be done at postpartum visit & every 1-3 yrs thereafter

children born from mothers w/ GDM have an increased risk of:

obesity & T2DM

are the potential complications in pregnancy greater for patients w/ pre-gestational DM or GDM?

pre-gestational DM

pregestational DM affects the fetus from time of conception, while GDM..

does not affect the fetus until about the end of the 2nd trimester

congenital anomalies that result from hyperglycemia occur w/i the _______________ of pregnancy, making preconception glycemic control essential

1st 8 wks

- other complications, such as: stillbirth, may occur later in pregnancy

what effects can pregestational diabetes have on the fetus?

increased risk of:

- congenital malformations

- growth abnormalities

- spontaneous abortion

- IUFD

control of __________________ levels greatly affects fetal outcome

maternal glucose

what effects can pregestational diabetes have on the mother?

increased risk of:

- infection

- preeclampsia

- eclampsia

- polyhydramnios

- postpartum hemorrhage

- diabetic emergencies

- end organ involvement

patients w/ HgbA1C of _____________ usually have good outcomes

< 6.0 - 6.5%

what are the blood glucose goals in pregnancy?

- fasting: < 90

- post prandial: < 120 - 140

type 2 diabetics who are on oral agents prior to pregnancy will usually be changed to _________

insulin

what does USPSTF recommend that all pregnant women w/ T1DM, T2DM or chronic HTN take to help prevent preeclampsia?

daily 81 mg aspirin

- starting at 12 wks gestation

all pts w/ GDM or pregestational DM will receive..

weekly fetal monitoring

- usually starting at 32 weeks

w/ pregestational diabetes if there are no apparent complications, delivery may be induced at _____________ gestation

37-39 wks

- complications may indicate an earlier delivery

blood pressure during pregnancy is usually ___________.

decreased

1 multiple choice option

hypertensive disorders are a leading cause of..

premature delivery

- bc the only tx is delivery (no matter gestational age)

hypertension in pregnancy increases the mother's risk of:

- cardiac failure

- stroke

- seizure

- liver complications & renal failure

hypertension in pregnancy increases the baby's risk of:

- IUGR

- placental abruption

- death due to poor placental transfer of oxygen

chronic/pre-existing HTN:

HTN occurring before conception or before 20 wks of gestation

gestational hypertension (GH):

BP that is >140/90

- first detected after 20 wks gestation

- does NOT include proteinuria or other sx of preeclampsia

- may progress to preeclampsia

preeclampsia

BP that is >140/90

- first detected after 20 wks gestation

- does include either proteinuria or one of the following features of end organ dysfunction:

*low platelet count

*high SCr/renal insufficiency

*high liver enzymes/RUQ pain

*new onset HA

*visual sx

*pulmonary edema

eclampsia

occurrence of grand mal seizures in the preeclamptic patient

preeclampsia superimposed on chronic hypertension

occurs when a patient w/ chronic HTN develops new onset proteinuria or other sx of preeclampsia

HELLP syndrome

subcategory of preeclampsia

- pt presents w/:

*Hemolysis

*Elevated Liver enzymes

*Low Platelets

- may develop before, during, or after delivery

acute fatty liver of pregnancy (AFLP)

rare progression towards liver failure

- often associated w/ preeclampsia

what is the BP goal for a woman w/ chronic HTN but w/o preeclampsia during pregnancy?

<150/100

- or to avoid severe HTN (>160/110)

which antihypertensive meds are used during pregnancy?

- methyldopa

- labetalol

- nifedipine (sustained release)

can patients who took diuretics to control their BP prior to pregnancy continue them during pregnancy?

yes

1 multiple choice option

can patients who took ACE-Is or ARBs to control their BP prior to pregnancy continue them during pregnancy?

no, need to be changed to avoid kidney failure in fetus

1 multiple choice option

for gestational hypertension, medications are usually not indicated unless approaching severe levels ____________________________.

>150/100 - 160/110

patients w/ gestational HTN should be followed closely, (1-2x weekly), as preeclampsia is likely to develop.

remember, urine protein dipstick can have false negatives.

what can be used instead?

spot urine albumin-to-creatinine ratio

- or repeat dipstick in 24 hrs

w/ gestational HTN, the baby should be evaluated weekly from ________ gestation, w/ non-stress test or biophysical profile

32 wks

w/ gestational HTN, delivery should be induced by ______________ gestation, unless HTN becomes severe (>160/110), then goal is ______________ gestation

37-38 wks ; 34-36 wks

what is the classic triad of sx w/ preeclampsia?

- HTN

- proteinuria

- nondependent edema (face/hands)

*however, edema & proteinuria are not actually required for diagnosis

what causes preeclampsia?

exact cause is unknown, but believed to be a result of generalized arteriolar constriction

- can be triggered by a variety of different factors involving poor placental perfusion

preeclampsia always develops after ________ gestation, usually in the 3rd trimester near term

20 wks

what should preeclampsia type sx that occur before 20 wks gestation make you suspicious of?

hydatidiform mole/trophoblastic disease

what are the risk factors for developing preeclampsia?

- chronic HTN

- multiple gestation

- autoimmune disease

- chronic renal disease

- previous preeclampsia

- pregestational DM

- age < 20 or > 35

- nulliparity

- abnormal placenta

- new paternity

- black race

- prepregnancy BMI >25

- cohabitation less than 1 yr

- mother in law had preeclampsia

what can reduce risk of preeclampsia?

exercise

- 140 min/wk of moderate exercise

do calcium supplements reduce risk of preeclampsia?

only in women w/ low calcium intake

- ex: in a patient who cannot eat dairy

how is preeclampsia designated?

- w/ severe features

- w/o severe features

preeclampsia w/o severe features

new-onset HTN (>/= 140/90 on 2 separate occasions) w/ >/= 2+ proteinuria

- but no additional sx

preeclampsia w/ severe features

new onset HTN (>/= 140/90 on 2 occasions or >160/110 on 1 occasion) w/ one or more of the following:

- elevated serum creatinine (w/ possible oliguria)

- elevated AST or ALT, or persistent, intense, RUQ or epigastric pain (including hepatic dysfunction)

- new onset HA, visual sx (w/ possible altered consciousness or retinal hemorrhages [including cerebral complication], does not respond to acetaminophen)

- thrombocytopenia

- pulmonary edema

what is the ultimate treatment for preeclampsia?

delivery

- so if the pregnancy is at term (37 wks), labor should be induced

how is preeclampsia w/o severe features managed?

outpatient or inpatient

- determine if severe sx are present or not (CBC, CMP, possibly urine albumin to creatinine ratio if dipstick was negative)

- restricted activity (resting lowers BP, pt on left side increases blood flow to essential organs)

- weekly to twice weekly prenatal visits from time of diagnosis (NST, CBC, CMP done weekly; however, WHO says that these do not need to be repeated unless change in s/s from previous visit)

- US q 3 wks or monthly

- antihypertensives & dietary restrictions are NOT generally used

- any progression of s/s indicates a consultation w/ an OB or hospital admission

- delivery should be induced by 37 wks gestation

when are antihypertensives considered for tx of preeclampsia?

only when severe features develop

- used if BP >160/110 to prevent stroke, but will not change preeclampsia

how is preeclampsia w/ severe features managed?

delivery, even when gestation is preterm

- admit immediately

- IV Mg2+ sulfate for seizure prophylaxis

- hydralazine or labetalol to stabilize BP

- vaginal delivery recommended, except when seizure or BP do not respond to medication

what is eclampsia?

lifethreatening, grand mal seizures in preeclamptic patient

- before, during or after delivery

- hospitalize

- control BP w/ hydralazine or labetalol

- Mg sulfate to prevent future seizures

- once patient has stabilized, initiate delivery

infections that can be particularly difficult for pregnant women include:

- pyelonephritis

- influenza

- chorioamnionitis

why is influenza comparatively more dangerous for pregnant women than non-pregnant women?

bc pregnant women have decreased lung capacity & changes to their cell-mediated (t-lymphocytes) immunity

- more likely to develop pneumonia, sepsis or acute respiratory distress

what is chorioamnionitis?

infection of the amniotic fluid & the amniotic sac

- leads to complications for the baby & mother, but more so the mother

- leads to postpartum uterine atony w/ potential for hemorrhage

- also increases maternal risk of septic shock

___ of pregnancies have UTIs, & hospitalization is common

20%

why does the initial prenatal appointment always include a full urine dipstick & urine culture?

to detect asymptomatic bacteriuria (ASB)

- which allows for treatment, & reduces risk of developing pyelonephritis

________________ occurs in pregnancy due to hormonal influence on smooth muscles, & incomplete emptying of the bladder, along w/ other physiologic changes

urinary stasis

during pregnancy, cell-mediated immunity also is weaker & cannot respond to ________ as efficiently, which causes the majority of these infections

E. coli

____________ includes dysuria & urinary urgency/frequency

cystitis

how can both ASB & cystitis be treated in all trimesters of pregnancy?

amoxicillin or cephalexin

- nitrofurantoin & Bactrim can also be used, but carry some cautions in 3rd trimester

- repeat culture in 2 wks, & retreat w/ alternate med if positive

if the infection extends to the kidneys, it's called _______________

pyelonephritis

s/s of pyelonephritis:

- urgency/frequency

- fever

- chills

- flank pain

- N/V

- labs: changes on dipstick, as well as WBC casts on urine microscopic exam & elevated WBC on CBC

why is pyelonephritis particularly serious in pregnancy?

risk of sepsis

- leading to acute respiratory distress syndrome which is often fatal

tx for pregnant women w/ pyelonephritis:

- hospitalize

- IV fluids

- IV abx

- followed by: 10 to 14 day oral abx (which is then followed by daily prophylactic abx for the remainder of pregnancy)

what is cervical insufficiency?

painless dilation of the cervical os before term w/o labor (mild cramping may or may not occur)

- usually in 2nd trimester & often results in miscarriage or preterm delivery

- dx: may or may not be noted on US or pt may present w/ bleeding, discharge or ruptured membranes

- tx: according to individual presentation

risk factors for cervical insufficiency:

- cervical surgery

- cervical lacerations w/ previous delviery

- congenital abnormality of cervix

*many pts have no risk factors

tx options for cervical insufficiency:

- strict bed rest & betamethasone

- close cervix w/ sutures, called cerclage (this can be emergent or preventatively in subsequent pregnancies)

- progesterone therapy at a later date