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Hematologic Disorders and Pregnancy

  • Involve blood formation or coagulation disorders.

1. Anemia and Pregnancy

  • Pseudoanemia:

    • Blood volume expands during pregnancy faster than red cell count increases.

    • This is a normal condition in early pregnancy.

  • True Anemia:

    • Hemoglobin (Hgb) concentration less than 11 g/dL (Hematocrit <33%) during the first and third trimesters.

    • Hgb concentration less than 10.5 g/dL (Hematocrit <32%) during the second trimester.

2. Iron-Deficiency Anemia

  • Most common anemia in pregnancy.

  • Causes:

    • Diet low in iron (linked to low socioeconomic status).

    • Heavy menstrual flow.

    • Unwise weight-reducing programs.

    • Getting pregnant less than 2 years before the current pregnancy.

    • Pica.

  • Iron Absorption and Transport:

    • Iron is absorbed from the duodenum into the bloodstream after ingestion.

    • In the bloodstream, it binds for transport to the liver, spleen, and bone marrow.

    • At these sites, it is incorporated into hemoglobin or stored as ferritin.

Signs and Symptoms:

  • Extreme fatigue and poor exercise tolerance.

    • Reason: Inability to transport oxygen effectively.

  • Associated with low birth weight and preterm birth.

    • Reason: Body recognizes increased nutrient needs; some women develop pica.

Medication:

  • Ferrous Sulfate

    • Anti-anemic medication.

Management for Anemia and Iron-Deficiency Anemia:

  1. Prenatal Vitamins:

    • Prescribed prenatal vitamins containing 27 mg of iron as prophylactic therapy.

  2. Diet:

    • Advise women to eat a diet high in iron and vitamins.

    • Examples: green leafy vegetables, meat, and legumes.

  3. Iron Supplementation:

    • Ferrous Sulfate or Ferrous Gluconate: 120-200 mg elemental iron per day.

  4. Enhancing Iron Absorption:

    • Advise women to take iron with orange juice or a vitamin C supplement.

    • Reason: Iron is absorbed in an acidic environment.

  • New red blood cells should begin to increase, or the reticulocyte count should rise from 0.5\% and 1.5\% to 3\% and 4\% by two weeks.

  • Possible Effects:

    1. Constipation: high fiber diet, increase fluid intake to 6-8 glasses per day.

    2. Gastric irritation: take oral tablet with a full stomach.

    3. Turning stools black in color: advise women that this is normal.

  • Intravenous Iron:

    • Prescribed if iron deficiency is severe and the woman has difficulty taking oral tablets.

  • Taking Iron With Milk:

    • Do not take iron supplements with milk because it can interfere with iron absorption.

3. Folic Acid-Deficiency Anemia

  • Folic acid (folate or folacin) is a B vitamin necessary for the normal formation of red blood cells.

  • Helps prevent neural tube and abdominal wall defects in the fetus.

  • B9.

  • Common among:

    1. Multiple pregnancies (increased fetal demand).

    2. Women with secondary hemolytic illness (rapid destruction and production of new red blood cells).

    3. Women taking hydantoin (an anticonvulsant agent that interferes with folate absorption).

    4. Women with poor gastric absorption.

  • Megaloblastic Anemia:

    • Enlarged red blood cells; a type of anemia that develops.

    • The mean corpuscular volume will be elevated, in contrast to the lowered level seen with iron-deficiency anemia.

Management:

  • All women expecting to become pregnant should take 400 ug of folic acid daily, plus eat folate-rich foods.

    • Examples: green leafy vegetables, oranges, dried beans.

4. Sickle-Cell Anemia

  • Recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of hemoglobin.

  • With the disease, the majority of RBCs are irregularly or sickle-shaped, so they cannot carry as much hemoglobin as normally shaped RBCs can.

  • When oxygen tension becomes reduced (e.g., at high altitudes) or blood becomes more viscid than usual (e.g., dehydration), the cells clump together because of their irregular shape, resulting in vessel blockage with reduced blood flow to the organs.

  • The cells will hemolyze (be destroyed), reducing the number available and causing severe anemia.

  • Races Usually Affected:

    • Blacks often have the sickle-cell trait or carry a recessive gene for S hemoglobin but are asymptomatic.

  • Effects on Pregnancy:

    • Blockage to the placental circulation can directly compromise the fetus, causing low birth weight and possibly fetal death.

  • Assessment:

    1. Screening at the first prenatal visit: hemoglobin analysis.

      • Women with the condition - hemoglobin: 6-8 mg/100 ml

    2. Urinalysis: due to vascular stasis, women are prone to bacteriuria.

    3. Monitor a woman's nutritional intake to ensure sufficient folic acid consumption.

    4. Ensure women drink at least 8 glasses of fluid daily to prevent dehydration.

    5. Assess lower extremities for varicosities, which can lead to red cell destruction.

    6. Monitor fetal health by ultrasound examination at 16-24 weeks to assess intrauterine fetal growth.

Therapeutic Management:

  1. Periodic Exchange or Blood Transfusions:

    • Replace sickled cells with non-sickled cells.

    • Serves the secondary purpose of removing a quantity of the increased bilirubin resulting from the breakdown of RBCs and restoring the hemoglobin level.

  2. Crisis Management:

    • Control pain, administer oxygen, and increase the fluid volume of the circulatory system to lower viscosity.

  3. If with Infection:

    • Hospitalization.

  4. Delivery Considerations:

    • If the fetus is mature, the time and method of delivery are considered.

    • Keep the woman well hydrated during labor and delivery.

    • Epidural anesthesia is the method of choice.

  • During the postpartal period:

    • Early ambulation and wearing pressure stockings or IPC boots can help reduce the risk of thromboembolism from stasis in lower extremities.

  • Parents are generally interested in determining the condition of the infant.

    • The condition is recessively inherited; if one parent has the disease and the other is free, the chance the child will inherit the disease is zero.

    • If the woman has the disease and her partner has the trait, the chance the child will inherit the disease is 50%.

    • If both parents have the disease, all their children will also have the disease.

    • There's no iron supplementation as part of the management of Sickle Cell Anemia.

5. Thalassemia

  • A group of autosomal recessively inherited blood disorders that lead to poor hemoglobin formation and severe anemia.

  • An inherited blood disorder that causes your body to have less hemoglobin than normal. Hemoglobin enables red blood cells to carry oxygen.

    • Most common in Mediterranean, African, and Asian populations.

    • Symptoms first appear in childhood.

  • Treatment:

    • Combating anemia through folic acid supplementation and sometimes, blood transfusion to infuse hemoglobin-rich RBC.

    • Women with the condition usually do not take iron supplementation during pregnancy because they could receive an iron overload because iron is infused with blood transfusions.

Coagulation Disorders and Pregnancy

  • Most coagulation disorders are sex-linked or occur only in males and so have little effect on pregnancies

1. Von Willebrand Disease

  • A coagulation disorder inherited as an autosomal dominant trait and occurs in women.

  • Women have normal platelet counts, but bleeding time is prolonged.

  • Levels of factor VIII-related antigen (VIII-R) and factor VIII coagulation activity (VIII-C) are both reduced.

  • Since childhood, women with the disorder might have menorrhagia or frequent episodes of epistaxis.

  • Cannot diagnose immediately if not severe until the woman gets pregnant and experiences a spontaneous miscarriage or postpartum hemorrhage.

Management:

  • Replacement of the missing factors by blood transfusion of cryoprecipitate or fresh frozen plasma before labor to prevent excessive bleeding with birth.

2. Hemophilia B (Christmas Disease)

  • Factor IX deficiency, is a sex-linked disorder.

  • Occurs only in males.

  • Females are carriers and may have a reduced level of factor IX (only 33% of normal) that results to hemorrhage with labor or a spontaneous miscarriage.

  • Carriers of the disorder should be identified before pregnancy.

Management:

  • Restoration of factor IX by infusion of factor IX concentrate or fresh frozen plasma.

  • Maternal serum analysis can be used to detect whether a fetus has a coagulation disorder during pregnancy.

3. Idiopathic Thrombocytopenic Purpura (ITP)

  • A decreased number of platelets is not inherited

  • Can occur anytime in life and can occur during pregnancy

  • Cause is unknown

  • Symptoms usually occur shortly after a viral invasion such as an upper respiratory tract infection.

  • It is assumed to be an autoimmune reaction (an antiplatelet antibody that destroys platelets is apparently released).

  • Laboratory analysis reveals a marked thrombocytopenia—platelet count is as low as 20,000/mm^3 from a usual count of 150,000/mm^3

  • If an inadequate number of platelets, the woman is prone to frequent nosebleeds, and minute petechiae or large ecchymosis appear on her body.

Renal and Urinary Disorders and Pregnancy

1. Urinary Tract Infection

  • Caused by Escherichia coli from an ascending infection.

  • Can also be a descending infection; can begin in the kidneys from the filtration of organisms present from other body infections.

  • If caused by Streptococcus B indicates the woman has an extensive infection.

  • Assessment: Based on signs and symptoms

    • Pain on urination

    • In case of Pyelonephritis: woman develops pain in the lumbar region usually on the right side that radiates downward.

      • The area is tendered upon palpation.

      • Nausea and vomiting

      • Malaise

      • Frequency of Urination

      • Temperature 103-104 degrees F

  • A growing body of evidence suggests that it is the degree of re Insufficiency, rather thin the diagnosis itself that determines the course and outcomes of pregnancy in these patients

Diagnosis:

  • Urine culture reveals over 100,000 organisms per milliliter of urine.

Therapeutic Management:

  • Clean-catch urine

  • Culture and Sensitivity (C & S) to determine what antibiotic needs to be prescribed.

  • Examples: Amoxicillin, Ampicillin, and Cephalosporins—safe antibiotics during pregnancy.

  • Sulfonamides can be used early in pregnancy but not near term because they interfere with protein binding of bilirubin, which can lead to hyperbilirubinemia in the newborn.

  • Tetracyclines are contraindicated in pregnancy; can cause retardation of bone growth and staining of the fetal teeth.

Precautionary Measures:

  • Voiding frequently, at least every two hours

  • Wiping from front to back after bowel movement

  • Wearing cotton, nonsynthetic fiber underwear

  • Voiding immediately after sexual intercourse

  • Drinking an increased amount of fluid to flush out the infection from the urinary tract, up to 3-4L/24H

Other Measures:

  • Knee-chest position for 15 minutes morning and evening—the weight of the uterus is shifted forward, releasing the pressure on the uterus and allowing urine to drain more freely

  • If with Pyelonephritis

    • Hospitalized for 24H-48H then placed on home care and treated with IV antibiotics.

    • After birth—IVP (intravenous pyelogram or ultrasound) is scheduled to help detect any urinary tract abnormality that might be present.

    • After this episode, maintained on a drug such as Oral Nitrofurantoin (Macrodanti) for the remainder of the pregnancy

  • Acidifying the urine by the use of Ascorbic Acid (Vit. C), which is often recommended in non-pregnant women

    • Not recommended during pregnancy because the newborn can develop scurvy in the immediate neonatal period.

2. Chronic Renal Disease

  • Before, women with this chronic renal disease did not reach childbearing age or were advised not to have children because of their automatic high-risk status during pregnancy

  • Today, with conscientious prenatal care, women with this condition who have had renal transplants can expect to have healthy pregnancies and healthy children

  • Chronic kidney disease (CKD) means your kidneys are damaged and can't filter blood the way they should. The disease is called "chronic" because the damage to your kidneys happens slowly over a long period of time. This damage can cause wastes to build up in your body

    • GFR (90/17] =" for 23 months

Causes:

  • Hypertension

  • Diabetes

Complications:

  • Electrolyte abnormalities

  • Toxin buildup

Arising Problems:

  • Pregnancy increases the workload of the kidneys because they must excrete waste products not only for the woman but also for the fetus for 40 weeks.

  • Can cause severe anemia on women because their diseased kidneys do not produce erythropoietin, a glycoprotein necessary for red cell formation, and so they may develop a severe anemia.

  • The glomerular filtration rate normally increases during pregnancy; the woman is able to clear waste products from her body for both herself and the fetus with such efficiency that her serum creatinine is slightly below normal during pregnancy.

  • Average glomerular filtration rate by age:

    • Ages 20 to 29: 116

    • Ages 30 to 39: 107

    • Ages 40 to 49: 99

    • Ages 50 to 59: 93

    • Ages 60 to 69: 85

    • Ages 70 and older: 75

  • Normal creatinine level - 0.7 mg per 100 ml of blood

    • During pregnancy - 0.5 mg per 100 ml of blood.

    • If more than 2.0 mg/dL, advise the woman not to get pregnant because it can lead to kidney failure.

  • There is a possibility of glucose and protein in the urine during pregnancy because of increased glomerular permeability.

Treatment:

  • Corticosteroid (prednisone) infant may be hyperglycemic at birth because of the suppression of insulin activity by corticosteroid

  • Dialysis to aid kidney function.

Respiratory Disorders and Pregnancy

1. Influenza

  • Caused by a virus identified as type A, B, or C.

  • Associated with preterm labor and spontaneous miscarriage.

Signs and Symptoms:

  • Increased temperature

  • Sore throat

Treatment:

  • Antipyretic (Acetaminophen/Tylenol) to control fever

  • Oseltamivir (Tamiflu)

  • Women may be immunized against influenza with the influenza virus

2. Pneumonia

  • Bacterial or viral infection of lung tissue by pathogens such as Streptococcus pneumoniae, Hemophilus influenzae, and Mycoplasma pneumoniae

  • Pneumonia is an infection that inflames your lungs' air sacs (alveoli). The air sacs may fill up with fluid or pus, causing symptoms such as a cough, fever, chills, and trouble breathing

    • After the invasion, an acute inflammatory response occurs in the lung alveoli causing an exudate of RBC, fibrin, and polymorphonuclear leukocytes to flood into the alveoli

    • This process has a helpful effect of confining the bacteria or virus within the segments of the lobes of the lungs, but it has a less helpful effect of filling alveoli with fluid, blocking off breathing space.

    • If the collection of fluid becomes extreme, it can limit the oxygen available not only for the woman but also for the fetus.

    • Associated with preterm labor due to oxygen deficit

Treatment:

  • Antibiotic and oxygen administration

3. Asthma

  • A long-term disease of the lungs. It causes your airways to get inflamed and narrow, and it makes it hard to breathe

  • Marked by reversible airflow obstruction, airway hyperactivity, and airway inflammation.

  • Triggered by an irritant such as an inhaled allergen (pollen, dust, or cigarette smoke)

    • With inhalation of these allergens, there is a release of bioactive mediators such as histamine and leukotrienes from an immunoglobulin interaction.

    • This results in constriction of the bronchial smooth muscle

    • Has the potential to reduce oxygen supply in the fetus

    • Is improved during pregnancy because of high levels of corticosteroid

Signs and Symptoms:

  • Marked mucosal inflammation and swelling.

  • Production of thick bronchial secretions

  • Difficulty with air exchange

  • High-pitched whistling sound (bronchial wheezing)

  • If ineffective, inhaled glucocorticoid such as Beclomethasone (Beclovent/Vancerinase) or fluticasone (Flovent), an oral corticosteroid such as prednisone, or a mast cell stabilizer such as Intal may be added to the regimen

4. Tuberculosis

  • Caused by Mycobacterium Tuberculosis an acid-fast bacillus

Assessment:

  • PPD test (purified protein derivative) Mantoux Test

  • Follow-up CXR with (+) reactions; the abdomen should be covered

  • Sputum culture

Signs and Symptoms:

  • Chronic Cough

  • Weight Loss

  • Hemoptysis

  • Night Sweats

  • Low-grade fever

  • Chronic fatigue

Treatment:

  • Isoniazid (INH)—result in peripheral neuritis in women if she doesn't take Pyridoxine (Vit B12)

  • Ethambutol Hydrochloride (Myambutol)

    • No teratogenic effect

    • EMB is the main cause of optic nerve involvement: atrophy and loss of green color recognition.

    • To detect, test women with the Snellen test.

    • If symptoms continue, discontinue the drug.

  • Take Calcium to ensure tuberculosis pockets are not broken down

  • Wait for 1–2 years after infection becomes inactive before attempting to conceive because recent inactive tuberculosis can become active during pregnancy.

  • Although tuberculosis can be spread by the placenta to the fetus, it is usually spread to the infant after birth

  • If with a history of tuberculosis, 3 negative sputum cultures before she holds or cares for her infant

  • If negative, no need to isolate the infant to the mother

  • If active TB is in the home, the infant is discharged on prophylactic INH to prevent infection, with follow-up skin testing at 3-month intervals.

  • If the infant is to be placed on INH, a mother taking INH should not breastfeed, or it might be toxic to the infant.

Rheumatic Disorders and Pregnancy

1. Systemic Lupus Eryrhematosus (SLE)

  • SLE is an autoimmune disease in which the immune system attacks its own tissues

  • Is a multisystem chronic disease of the connective tissue that can occur in women of childbearing age.

  • Widespread degeneration of connective tissue (heart, kidneys, blood vessels, spleen, skin, and retroperitoneal tissue) occurs with the onset of the illness

Signs and Symptoms:

  • Marked skin change: a characteristic erythematous butterfly-shaped rash on the face.

  • Kidneys: fibrin deposits plugging and blocking the glomeruli and leading to necrosis and scarring

  • Blood vessels: thickening of collagen tissue cause vessel obstruction.

  • Life-threatening to the woman if blood flow to vital organs is obstructed and also to the fetus

  • Women with SLE have antiphospholipid antibodies, which increase the tendency for thrombi to form

Treatment:

  • Corticosteroid

  • NSAID

  • Heparin

  • Salicylates

  • To decrease symptoms

  • The naturally increased circulation of corticosteroid during pregnancy may lessen symptoms in some women

Complications:

  • Acute nephritis with glomerular destruction

  • Increased BP

  • Develop hematuria and decreased urine output

  • PIH (pregnancy-induced hypertension) - no hematuria

Diagnosis:

  • Frequent creatinine assessments to assess kidney function

Gastrointestinal Disorders and Pregnancy

1. Appendicitis

  • Inflammation of the appendix

  • Its incidence is high in young adults, so occurs as frequently as 1 in 1500 to 2000 pregnancies

Assessment:

  • Begins with a few hours of nausea

  • After 1-2H-generalized abdominal discomfort

  • Vomiting

  • Typical sharp, peristaltic, lower right quadrant pain

  • If overstretched ligament pain morning sickness pain is diffuse or sharp

  • Non-pregnant woman the sharp localized pain appears at McBurney's point (a point halfway between the umbilicus and the iliac crest on the lower right abdomen

  • Pregnant woman the appendix is often displaced so far up in the abdomen that it resembles the pain of gallbladder disease

  • CBC leukocytosis normal for nonpregnant women to have elevated WBC

  • Increased temperature

  • Ketones in the urine

Diagnosis:

  • Ultrasound

Management:

  • Advise the woman not to take any food, liquid, or laxative increased peristalsis tends to cause an inflamed appendix to rupture.

  • If 36 weeks pregnant: C/S and removed the appendix

  • If early pregnancy: laparoscopy

  • If the appendix ruptured before surgery: risk for both mother and fetus

Complications:

  • Peritonitis

  • Appendix rupture

  • Infertility

2. Cholecystitis and Cholelithiasis

  • Cholecystitis: gallbladder inflammation

  • Cholelithiasis: gallbladder formation; gallstones are formed from cholesterol

  • Predisposing Factors

    • Age

    • Obesity

    • Multiparity

    • High-fat diet

Signs and Symptoms:

  • Constant aching and pressure in the right epigastrium

  • Jaundice

Diagnosis:

  • Ultrasound

Management:

  • Intake but not free fat diet during pregnancy because of the importance of linoleic acid for fetal growth

  • If acute episode IVF to provide fluid and nutrients and analgesics for pain

  • Surgical removal of gallstone laparoscopic technique

3. Hepatitis

  • Liver disease that may occur from invasion of A, B, C, D, and E viruses.

Hepatitis A:

  • Fecal-oral contact (children in day care settings)

  • Fecally contaminated H_20 or shellfish after an incubation period of 2-3 weeks.

  • Women may be given prophylactic gamma globulin to prevent the disease and exposure.

  • Not known to be transmitted to the fetus.

Hepatitis B and C:

  • Exposure to contaminated blood or blood products

  • Can be spread by contact with contaminated semen or vaginal secretions

  • Considered an STD

  • Incubation period : 6 weeks to 6 months (Hepatitis B)

  • Can lead to liver cirrhosis

  • Hepatitis C may demonstrate symptoms for 12 months

Treatment:

  • Immunoglobulin for prophylaxis

Assessment (all forms of Hepatitis):

  • Nausea and vomiting

  • The liver may feel tender to palpation

  • Urine is light-colored from lack of bilirubin

  • Jaundice (late symptom)

  • Physical examination: hepatomegaly (enlargement of the liver)

  • Bilirubin level increased

  • Specific antibodies against the virus can be detected in the blood serum

Management:

  • Bed rest

  • Increased caloric diet

  • Standard precaution

After Birth:

  • The infant should be washed well to remove any maternal blood and hepatitis B immune globulin (HBlg), and immunization against Hepatitis B should be administered

Complications:

  • Lead to spontaneous miscarriage or preterm labor

  • Later in pregnancy, the mother contracts Hepatitis B, the greater the risk the infant will be affected or develop Hepatitis B

Neurologic Disorders and Pregnancy

1. Myasthenia Gravis

  • An autoimmune disorder characterized by the presence of IgG antibody against acetylcholine receptors in striated muscle

  • Myasthenia gravis (MG) is a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle

  • Causes failure of the striated muscles to contract, particularly of the oropharyngeal, facial, and extraocular groups

  • Occurs usually at 20-30 years old.

Treatment/Management:

  1. Medications

    • Anticholinesterase drugs (DOC) such as pyridostigmine (Mestinon) or neostigmine (Prostigmin) and corticosteroid such as prednisone
      They may be continued during pregnancy as the fetus will experience no effects from them

    • Atropine is a lifesaving antidote for neostigmine if an overdose should occur

  2. Plasmapheresis: removal and replacement of plasma/to remove immune complexes from the bloodstream.

  • Smooth muscle is not affected by the disease; labor should occur without complications

  • Magnesium Sulfate to halt preterm labor or to treat hypertension of pregnancy should be avoided because it can diminish the acetylcholine effect and increase symptoms

  • An infant born to a woman with the disease may show symptoms at birth because of the transfer of antibodies

2. Multiple Sclerosis.

  • Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system

  • Nerve fibers become demyelinated and therefore lose functions

Signs and Symptoms:

  • Fatigue

  • Numbness

  • Blurred vision

Treatment and Management:

  1. Medication:

    • ACTH (adrenocorticotropic hormone) or corticosteroid to strengthen nerve conduction, and both can be administered safely during pregnancy.

    • Immunosuppressants such as cyclosporine (Sandimmune), azathioprine (Imuran), and cyclophosphamide (Cytoxan), which are usually prescribed, should be used with caution during pregnancy

  2. Plasmapheresis

  • It is a medical procedure where a device or machine separates the cellular components and plasma from the whole blood

  • The plasma is then discarded and replaced with a colloid fluid, combined back with the cellular components, and returned to the same patient

Musculoskeletal Disorders and Pregnancy

1. Scoliosis

  • Lateral curvature of the spine

  • Most common among girls between 12 and 14 years of age

  • If not corrected at this time, the curvature progresses until it can interfere with respiration and heart action because of chest compression

  • If a woman's spine is extremely curved, epidural anesthesia may be difficult to administer for pain management in labor

Management:

  1. Preventive Measures:

    • Girls can wear a body brace during their adolescent years to maintain an erect posture

  2. Surgical Management:

    • Stainless steel rods are implanted on both sides of the vertebrae to strengthen and straighten the spine

    • Rods do not interfere with pregnancy

Side Effects:

  • Women may have more than usual back pain from increased tension on back muscles

  • If a woman's pelvis is distorted, a cesarean birth may be scheduled to ensure a safe birth.

  • If vaginal birth, the same management is applied

  • Cephalopelvic disproportion can be recognized during the first stage of labor

Endocrine Disorders and Pregnancy

1. Hypothyroidism

  • Underproduction of thyroid hormone is a rare condition in late adolescents and especially rare in pregnancy because women with symptoms of untreated hypothyroidism are often anovulatory and unable to conceive

  • The thyroid gland produces hormones that regulate the body's metabolic rate, controlling heart, muscle and digestive function, brain development and bone maintenance

    • Women who conceive have difficulty increasing thyroid function to a necessary pregnancy level, which can lead to spontaneous miscarriage

Signs and Symptoms:

  • Fatigue easily

  • Tend to be obese

  • Skin is dry (myxedema)

  • Have little tolerance to cold

  • Hyperemesis gravidarum

Management and Treatment:

  1. Medication: levothyroxine (Synthroid) to supplement lack of thyroid hormone.

    • advise woman who is taking this medication and planning to conceive to consult her doctor to certain her dose will be high enough to maintain a pregnancy

    • Rule: The dose of the medication will need to be increased as much as 20\% to 30\% for the duration of pregnancy to stimulate the increase that would normally occur in pregnancy

    • Caution: take the medication at a different time from any medication containing iron, calcium, or any soy product by about 4 Hours to be certain there is not a problem with the absorption of the drug

  • After pregnancy, medication should be tapered back to the prepregnancy level for both her health and so she can breastfeed safely

2. Hyperthyroidism

  • Overproduction of thyroid hormone

Signs and Symptoms:

  • Rapid heart rate

  • Exophthalmia-protruding eyeballs

  • Heat intolerance

  • Heart palpitations

  • Weight loss

  • Graves disease- (overactive thyroid) seen mostly in pregnancy than in hypothyroidism

    • If undiagnosed, women may develop heart failure due to her heart already stressed, cannot manage the increasing blood volume that occurs during pregnancy

    • More prone to have gestational diabetes, fetal growth restriction, and preterm labor

Diagnosis:

  • Using nuclear medicine imaging study involving radioactive uptake of 131I subtype.

    • Should not be used during pregnancy because the fetal thyroid would also incorporate this drug, resulting in destruction of the fetal thyroid

Treatment:

  • Thioamides (methimazole) or propylthiouracil (PTUI) reduce thyroid activity

    • Cross the placenta and can lead to congenital hypothyroidism and enlarged thyroid gland(goiter) in the fetus.

    • Women should be regulated on the lowest possible dose and advice to keep a record of doses taken so as not to forget or unintentionally duplicate a dose

Methimazole-drug of choice for pregnant women.

  • If hyperthyroidism is not regulated during pregnancy, an infant may be born with symptoms of hyperthyroidism because of the excess stimulation he or she receives in utero

Signs and Symptoms Among Newborn:

  • Jittery with tachypnea and tachycardia

Diagnosis for Fetus:

  • An assay of fetal cord blood will reveal the level of thyroxine (T4) and thyroid-stimulating hormone and the need for therapy in the infant

  • Women who are taking minimal doses of antithyroid drugs may breastfeed; if large doses, do not breastfeed because they are excreted in breast milk.

  • If women desire other children, surgical treatment can be suggested to reduce the functioning of the maternal thyroid gland

3. Diabetes Mellitus

  • An endocrine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose level

  • A. Type 1 Diabtetes Mellitus: a disorder that involves an absolute or relatively deficiency of insulin.

    • Results from immunologic damage to islet cells in susceptible individuals

    • If one child in the family has diabetes, sibling will also develop the illness.

Disease Process:

  • The pancreas produces plenty of insulin (the hormone responsible for "unlocking" cells so that glucose can enter them and provide energy), but a condition known as insulin resistance prevents them from using it effectively. When insulin doesn't work properly, blood glucose or blood sugar builds up in the bloodstream and gestational diabetes is the result

  • From HYPERGLYCEMIA:

    • If kidneys detect this, it will excrete excess glucose into the urine

      • Glycosuria

      • Polyuria

      • Polydipsia

      • Polyphagia

    • The body still needs a source of energy; it will break down protein and fat

      • Weight loss and ketone bodies (the acid end product of fat breakdown)

Effects:

  • High serum cholesterol and ketoacidosis

  • Potassium and phosphate, attempting to serve as buffers, pass from the body cells into the bloodstream

Assessment Among Children:

  • Increased thirst

  • Increased urination

  • Dehydration that can also cause constipation

Among Pregnant Women:

  • Increased thirst

  • Increased appetite

  • Unusual fatigue

  • Frequent Urination

Assessment Through Laboratory Studies:

  1. Random plasma glucose level greater than 200mg/dL

    • Normal range: 70 to 110 mg/dL fasting: 90 to 180 mg/dL not fasting

  2. Glucose Screening test: between 24 to 48 weeks; may be repeated at 32 weeks if obese or over age 40

    • After the oral 50g glucose load is ingested, a venous blood sample is taken for glucose determination 60 minutes after

    • If the result is more than 140mg/dL, the patient is scheduled for a 100g 3-H fasting glucose tolerance test

    • If two of the four blood samples collected are abnormal or the fasting value is above 95mg/dL, a diagnosis of diabetes can be made

  • Fetal monitoring after Diagnosis of GD

    • NonStress Test or periodic ultrasound around 32 weeks to check for the bay's well being
      Also called the biophysical profile

    • The test measures the baby's fetal heart rate, both at rest and during movement, by attaching a monitor to the mother's abdomen. Monitoring is done for 20 to 30 minutes, noting any fetal distress.

      • If the baby is getting too big, insulin will be started

Maternal Effects:

  • Hypoglycemia during the first trimester

  • Hyperglycemia during the third trimester

  • Frequent infection

  • Moniliasis

  • Polyhydramnios

  • Dystocia