Complications of Pregnancy: Endocrine Disorders Practice Flashcards

Anatomy and Physiology of Endocrine and Metabolic Disorders in Pregnancy

Placental Development and Hormonal Changes: * Hormonal fluctuations occur throughout the gestational period, starting from Week $0$ through Week $40$ . * The placenta plays a critical role in metabolic regulation and hormone secretion affecting insulin resistance and thyroid function.

Pregestational Diabetes Mellitus (PGDM)

Pathophysiology: * Type 1 Diabetes Mellitus (DM): An autoimmune disorder characterized by the destruction of beta cells leading to decreased or absent insulin production. * Type 2 Diabetes Mellitus (DM): Characterized by insulin resistance where the body's cells do not respond effectively to insulin. * Pregnancy Impact: Human placental lactogen ( $hPL$ ) is a primary hormone produced during pregnancy that acts as an insulin antagonist, increasing insulin resistance to ensure nutrient availability for the fetus.
Etiology and Risk Factors: * Type 1 DM: Influenced by genetic factors and environmental triggers. * Type 2 DM: Influenced by genetic predisposition and lifestyle factors (e.g., diet, activity level).
Epidemiology: * Type 1 DM: Affects approximately $1.7 \times 10^6$ adults in the U.S. and $5.7\%$ of the world’s population. * The lowest prevalence is found in Asian populations. * Diagnosis typically peaks in early adolescence. * Found in $0.3\%$ of pregnancies; carries the highest risk for maternal and fetal morbidity and mortality. * Type 2 DM: Increasing frequency in pregnancies, now affecting $1\%$ to $2\%$ of all pregnancies.
Client-Centered Care and Psychosocial Impact: * Psychosocial Factors: Anxiety and depression are common due to increased surveillance. * Implications: Frequent lab work and additional office visits can increase stress and impact employment and finances. * Clinical Considerations/Risks: * Congenital malformations. * Preterm birth. * Large for gestational age ( $LGA$ ) measurement. * Birth injury. * Hypoglycemia in the neonate. * Long-term risk of obesity for the offspring. * Health Promotion and Education: * Emphasis on early treatment and prevention. * Education topics: Nutrition, Exercise, Medication adherence, Office visit compliance, and Glucose monitoring.
Clinical Presentation: * Presentations are similar to non-pregnant diabetics. * Classic triad: Polyphagia (excessive hunger), polydipsia (excessive thirst), and polyuria (excessive urination). * Additional symptoms: Slow wound healing, dry skin, visual disturbances, and fatigue.
Lab Testing, Diagnostics, and Glucose Goals: * Hemoglobin A1C: Monitored every $2$ months; the goal is less than $6\%$ . * Fetal Surveillance: Ultrasound, Non-stress Test ( $NST$ ), Biophysical Profile ( $BPP$ ), and neural tube screening. * Timing of Delivery: Induction of labor is typically planned after $39$ weeks. * Target Glucose Levels (ACOG, 2018c): * Fasting blood glucose: Less than $95\,mg/dL$ . * $1$ -hour postprandial glucose: Less than $140\,mg/dL$ . * $2$ -hour postprandial glucose: Less than $120\,mg/dL$ .
Treatments and Therapies: * Type 1 DM: Insulin dosage requirements typically decrease in the first trimester but increase significantly in the second and third trimesters. Rapid-acting insulin may be added to the regimen. * Type 2 DM: Clients may continue their pre-pregnancy insulin regimen. Oral hypoglycemics (such as glyburide) or insulin therapy may be utilized. * Care Coordination: Involves the primary provider, perinatologist, endocrinologist, and diabetic educator/nutritionist.

Gestational Diabetes Mellitus (GDM)

Pathophysiology and Etiology: * Characterized by increased insulin resistance, usually developing in the second or third trimester. * Etiology involves pregnancy hormones affecting insulin sensitivity and beta cell dysfunction. * Clients with GDM are more likely to develop Type 2 DM later in life.
Risk Factors: * $BMI > 25$ . * History of GDM or family history of diabetes. * History of $A1C$ between $5.7\%$ and $6.4\%$ . * Previous $LGA$ infant weighing above $4.08\,kg$ ( $9\,lbs$ ).
Psychosocial Impact and Maternal Considerations: * Feelings of guilt, shame, anxiety, and depression. * Strain from increased antenatal testing, provider visits, and diagnostic costs. * Increased risk for other pregnancy complications such as preeclampsia and preterm birth.
Clinical Presentation: * Increased thirst and urination. * Fatigue and nausea. * Symptoms can be difficult to discern from normal pregnancy changes without diagnostic testing.
Health Promotion and Screening: * Clients at high risk receive a glucose tolerance test prior to $24$ weeks. * 1-Hour Glucose Tolerance Test (GTT): * Performed on all clients. * No fasting required. * A result greater than $140\,mg/dL$ requires a follow-up $3$ -hour screening. * 3-Hour Glucose Tolerance Test (GTT): * Diagnosis is confirmed if $2$ of the $4$ glucose levels are out of range. * Desired Values (Mayo Clinic, 2022d): * Fasting: Less than $95\,mg/dL$ . * $1$ -hour postprandial: Less than $180\,mg/dL$ . * $2$ -hour postprandial: Less than $155\,mg/dL$ . * $3$ -hour postprandial: Less than $140\,mg/dL$ .
Treatments and Interventions: * Nutritional Counseling: Dietary breakdown comprising $40\%$ carbohydrates, $20\%$ protein, and $40\%$ fat, with high fiber intake. Food diaries are used for monitoring. * Exercise: Encouraged as part of management. * Pharmacological Therapy: Long-acting and fast-acting insulin may be used.

Hyperemesis Gravidarum (HG)

Pathophysiology and Etiology: * Linked to hormonal changes, specifically elevated human chorionic gonadotropin ( $hCG$ ) and progesterone. * Elevated $hCG$ is often seen in molar pregnancies or multiple gestations, leading to increased estradiol. * Associated with Genetic predisposition, Helicobacter pylori (H. pylori) infection, and ptyalism (excessive salivation).
Epidemiology and Risk Factors: * Most clients experience some nausea, but HG affects up to $3\%$ of pregnancies and may require hospitalization. * Risk factors include being a nulliparous client or having a previous history of HG.
Clinical Presentation: * Persistent nausea and vomiting. * Signs of Dehydration: Dry mouth, lips, and eyes; dizziness; fatigue; dark or strong-smelling urine; headaches; infrequent urination; rapid heart rate; and confusion.
Psychosocial Impact: * Confusion, anger, depression, and Post-Traumatic Stress Disorder (PTSD). * Delayed seeking of medical assistance and social isolation due to severe nausea.
Lab Testing and Diagnostics: * Complete blood count (CBC), Metabolic panel, and H. pylori screening. * Reference Values for Comparison: * Potassium: $3.5 \text{ to } 5\,mEq/L$ . * Sodium: $136 \text{ to } 145\,mEq/L$ . * Calcium: $9 \text{ to } 10.5\,mg/dL$ . * Glucose: $74 \text{ to } 106\,mg/dL$ .
Standardized Scoring Systems: * Pregnancy Unique: Quantification of Emesis (PUQE) Score: * Evaluates manifestations in the past $12$ hours. * Duration of nausea: $0$ (1 pt), $\le 1\,hr$ (2 pts), $2 \text{ to } 3\,hrs$ (3 pts), $4 \text{ to } 6\,hrs$ (4 pts), $> 6\,hrs$ (5 pts). * Vomiting episodes: $0$ (1 pt), $1 \text{ to } 2$ (2 pts), $3 \text{ to } 4$ (3 pts), $5 \text{ to } 6$ (4 pts), $7+$ (5 pts). * Dry heave episodes: $0$ (1 pt), $1 \text{ to } 2$ (2 pts), $3 \text{ to } 4$ (3 pts), $5 \text{ to } 6$ (4 pts), $7+$ (5 pts). * Hyperemesis Level Prediction (HELP) Score: A comprehensive 11-point assessment tool covering nausea levels, vomiting frequency, urination patterns, medication tolerance, inability to work, coping/mood, food/fluid retention, and weight loss.
Treatments and Interventions: * Pharmacological: Antihistamines, Vitamin $B_6$ , antiemetics, IV fluids, and Total Parenteral Nutrition ( $TPN$ ) in severe cases. * Non-pharmacological: Avoiding triggers, ginger, and pressure points. * Goals: Symptom management and maintaining homeostasis for the client and fetus.

Hypothyroidism in Pregnancy

Types: * Subclinical Hypothyroidism: Increase in serum $TSH$ but normal $T_4$ levels; often asymptomatic. * Overt Hypothyroidism: Characterized by elevated $TSH$ and low $T_4$ .
Pathophysiology and Etiology: * Increased demand on the thyroid after implantation; the thyroid increases in size and $T_4$ secretion rises due to rising $hCG$ . * Estrogen increases the binding effect of thyroid hormones. * Causes: Hashimoto’s disease (autoimmune), thyroiditis, congenital factors, or surgical/pharmacological interventions.
Epidemiology and Risk Factors: * Affects $3\%$ to $5\%$ of all pregnancies (mostly subclinical). * Risk factors: Female gender, African American ethnicity, surgical history, history of autoimmune disorders, age, high $BMI$ , and multiparity. * Associated with iron-deficient diets and low socioeconomic status.
Clinical Presentation (Overt): * Fatigue, constipation, confusion, weight gain, amenorrhea, bradycardia, peripheral edema, and feeling cold. Symptoms may be overlooked as normal pregnancy changes.
Maternal and Fetal Considerations: * Increased risk for: Pregnancy loss, gestational diabetes, preeclampsia, placental abruption, preterm labor, and postpartum hemorrhage. * Impacts on fetus: Impaired neurological development, placental dysfunction, and goiter development.
Lab Testing and Reference Ranges: * $TSH$ : $0.35 \text{ to } 4.9\,mIU/L$ . * $T_4$ : $0.6 \text{ to } 1.8\,ng/dL$ .
Treatments and Therapies: * Thyroid Replacement: Levothyroxine (dosage titration is dependent on diagnosis timing). * Intervention Teaching: Avoid taking prenatal vitamins for at least $4$ hours after the levothyroxine dose; regular $TSH$ monitoring is required.

Hyperthyroidism in Pregnancy

Types, Pathophysiology, and Etiology: * Types: Subclinical and Overt. * Pathophysiology: Decreased serum $TSH$ and elevated serum $T_4$ . * Etiology: Autoimmune factors are most common, specifically Graves’ disease (elevated thyroid-stimulating immunoglobulin, or $TSI$ ). Also caused by thyroiditis or goiter.
Epidemiology and Risk Factors: * Rarer than hypothyroidism; most prevalent in females aged $30 \text{ to } 50$ . * Risk factors: Family history, autoimmune disorders, iodine intake (or lack thereof), smoking, adrenal insufficiency, and pernicious anemia.
Clinical Presentation: * Flushing, sweating, anxiety, changes in bowel habits, sleep difficulty, tremors, and a racing heart.
Testing and Monitoring: * $TSH$ , $T_4$ , thyroid ultrasound, and serum $TSI$ . * Serial lab work and growth indicators via ultrasound are required.
Treatments: * Antithyroid medications: Propylthiouracil ( $PTU$ ) is used until the $16$ th week; Methimazole is used after the $16$ th week. * Goal: Maintain $T_4$ levels in the high-expected range.

The Nursing Process in Endocrine Disorders

Clinical Judgment Functions: * Recognize Cues: Perform assessment and history-taking (e.g., checking for polyuria, dehydration, or thyroid symptoms). * Analyze Cues: Interpret data and lab values ( $GTT$ , $TSH$ , $T_4$ , Electrolytes). * Prioritize Hypothesis: Determine the most urgent needs (e.g., ketoacidosis risk vs. nutritional education). * Generate Solutions: Develop a plan including medication, diet, and monitoring. * Take Action: Implement interventions such as administering insulin, IV fluids, or anti-thyroid meds and providing client education. * Evaluate Outcomes: Determine the effectiveness of the care plan through follow-up labs and symptom assessment.

Questions & Discussion

Risk Factors: What modifiable risk factors can the nurse encourage in a pregnant client with Type 1 DM? Type 2 DM?
Insulin Therapy: Discuss the plan of care the nurse should anticipate for the pregestational diabetic client. What client teaching will be needed regarding insulin therapy?
Nursing Care Comparison: How will nursing care for the gestational diabetic client differ from the care of a pregestational diabetic client?
Hypothyroidism Causes: Discuss the potential causes of hypothyroidism in pregnancy.
Treatment and Prevention: Discuss the important education the nurse should provide regarding treatment and prevention of complications related to hypothyroidism.
Comparison: What are the differences in causes of hypo versus hyperthyroidism?