Glucose Metabolism in Pregnancy

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Chapter 20
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Glucose Metabolism in Pregnancy

• Metabolically all pregnant woman live in a state
  of accelerated starvation.
• Until 24 weeks estrogen and progesterone increase
  tissue response to insulin
• HPL produced by enlarging placenta is anti-
  insulin
• Promotes lipolysis, decreases glucose uptake and
  glucogenesis

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Pathophysiology

• Diabetes Mellitus-carbohydrates cannot be
  utilized due to insulin deficiency
• Glucose unable to enter cells- cells are
  starving- blood glucose high
• Cells use fat and protein for energy
• Byproduct is ketones

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Diabetes in Pregnancy

• Insulin requirements fluctuate
• Insulin requirements during first trimester are
  low due to N/V
• Insulin needs rise as pregnancy progresses
• Need to balance glucose and insulin during labor
• At risk for ketoacidosis and vascular disease

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Maternal Risks

• Hydramnios- excessive urination by fetus
• Preeclampsia- due to vascular damage
• Ketoacidosis- caused by metabolism of fatty
  acids, decreased gastric motility and HPL

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Fetal Risks

• Hyperglycemia if untreated fetus at risk for
  demise
• Increase risk for fetal anomalies
• Macrosomia- increase glucose leads to increase
  utilization by fetus
• IUGR- poor placental perfusion
• RDS- fetal insulin inhibits surfactant production
• Polycythemia- inability of glycosylated hgb in
  mothers blood to release oxygen, cause
  hyperbilirubinemia

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Screening

• Done at 24-28 weeks
• 25 years or older
• Obese
• Family history
• Black, Hispanic, Native American, Asian
• Abnormal glucose tolerance test
• Poor obstetrical outcome

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Testing

• Give 50gms of glucose, blood drawn 1 hr later
• If exceeds 105 need three hour
• Draw blood q hr for 3 hrs
• HgbA1C- measures glucose control over 6-8 wk
  period.
• Greater than 7.5 have 44 chance of adverse
  outcome, less than 7.5 have 7 risk

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Management

• Use team approach to facilitate teaching
• Teach nutrition, three meals three snacks.
• Enroll family
• Teach glucose monitoring and self injection
• Oral meds never used, causes hypoglycemia
• Need AFP_at_16-20 wks, anomalies scan _at_ 18 wks, 28
  wks SD, BPP, FKC 28 wks, 32-36 wks biweekly NST

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Intrapartal Management

• Timing of birth- LGA, SGA, and FLM
• During labor need frequent assessment of glucose
• May need insulin drip

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Postpartum Care

• Insulin need fall after deliver of placenta
• If Type I need less insulin
• Type II glucose control returns
• Need follow up _at_ 6 weeks
• Encourage parental attachment
• Encourage breastfeeding
• Teach contraception

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Nursing Care

• Visits twice/month first two trimesters, once
  week for third
• Exercise program
• Glucose control
• Have milk and hard candy available
• Enroll family

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Heart Disease

• Pregnancy causes increase cardiac output, volume
  and heart rate
• Most heart conditions are congenital and
  asymptomatic
• Problems with mitral(stenosis and prolapse) valve
  most common
• Peripartum cardiomyopathy-dysfunction of left
  ventricle S/S are similar to CHF

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Classifications of Heart Disease

• Based upon ability to perform activities of daily
  living
• Class I-asymptomatic. No limitations
• Class II-slight limitations, asymptomatic at rest
• Class III-moderate limitations. Symptomatic
  during ADLs
• Class IV-Discomfort with physical activities.
  Symptoms while at rest

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Cardiac Disease

• Class I-II few complications during gestation and
  labor
• Class III-IV at risk for heart failure, usually
  need invasive cardiac monitoring and assisted
  delivery
• May need ABX and anticoagulant tx.

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Nursing Assessment

• Pulse, BP, assess for tachypnea, tachycardia
• Fatigue and activity level
• Cough, edema, weight gain palpitations
• Diet high in protein and iron, restrict sodium
• Encourage rest, avoid infections
• Seen every 2 weeks until 20 weeks, then q week
• Blood volume reaches max. _at_ 28-30 weeks

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Labor

• Maintain L lat, 02, ABX, pain management
• Provide calm atmosphere
• Continuous fetal monitoring
• Keep client aware of progress and need for close
  monitoring

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Postpartum Care

• First 48 hours critical
• Fluid shifts from extravascular to blood stream
• Keep lat, head up, monitor V/S frequently
• Give stool softeners to avoid straining
• Gradual activity
• Evaluate meds for breastfeeding

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Chronic Hypertension

• Occurs before 20 weeks
• At risk for preeclampsia
• Rest L lat
• Self monitor BP
• Limit salt
• Continue to take antihypertensive meds

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Asthma

• Alteration in oxygenation harmful to fetus
• Avoid triggers
• Treat aggressively
• Teach s/s of exacerbation
• Use pulse oximeter-Assess fetus
• Pain management during labor

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TB

• Resurgence of disease
• Populations at risk
• Screen for symptoms- cough, night sweats,
  hemotysis
• Administer PPD
• Teach medication regime

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Anemia

• Difficult to meet iron requirements with diet
  alone
• Assess nutritional status
• Nursing- take with food for GI upset
• Risk to fetus- PT delivery, LBW
• Mother- hemorrhage, infection

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Thalasemia- Sickle Cell

• Thalasemia-hgb molecule defective- anemia
• Evaluate labs
• Sickle cell- r/t hgb- cause capillaries and
  vessels to clog
• S/S- anemia, pain
• Nursing- hydration, pain management

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TORCH

• Toxoplasmosis raw meat, feces of cat
• Identify woman at risk
• Test serologically
• Rubella- risk in first trimester
• Do not give attenuated virus to pregnant woman

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TORCH

• CMV - transmitted to fetus by asymptomatic mother
• CMV in urine
• HSV-2, transmission occurs after ROM, or during
  delivery
• Active lesions deliver by C/S

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Hepatitis B

• More risk than HIV
• Blood, sexual contact, substance abuse
• S/S- Anorexia, N/V, jaundice
• Risk to newborn- PT, LBW, chronic carrier.
• If positive give HBV immunoglobulin
• Tx newborn within 12 hours

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Varicella- Parvo

• Chicken pox- shingles
• Fetus can be infected in utero
• Avoid maternal exposure
• Parvo-Greatest risk of before 20 weeks
• Nursing- good hand washing and clean objects

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GBS

• Found in vagina and rectum
• Culture for colonization between 35-37 wks
• Treat during labor
• Assess newborn for S/S of infection

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Teenage Pregnancy

• Most unintended
• Low SES
• Higher incidence among minorities
• Lack knowledge about contraception
• More likely to come from abusive home
• Assess for abuse and incest

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Physiological, Psychological, and Sociological
Risks

• Physiological- minimal risk if seek PNC
• If no PNC at risk for PIH, LBW, CPD, PTL
• Nursing-assess developmental level
• Sociological- dependency, lack of education,
  financial consequences, dysfunctional
  relationships
• Risk for children

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Nursing Care

• Assess family and social support
• Assess adolescents knowledge
• Assist with problem solving while promoting
  responsibility
• Assess diet, BP, STDs, substance abuse
• Promote self care
• Prenatal education
• PP teach contraception

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HIV

• More woman with HIV, especially of color
• Enters through body fluids and breastmilk
• Effects T-cells, inhibits immune response
• AIDS dx based on opportunistic infections and
  T-cell count
• Risk of transmission lessened with antiviral meds
• Newborns can have titer for up to 15 months

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HIV

• CDC guidelines recommend taking Zidovudine
• Assess for STD and opportunistic infections
• Evaluate weight loss, fevers, serology
• NST _at_ 32 weeks, bpp, utz, NO AMNIO
• C/S lessens risk of vertical transmission
• PP-_at_ risk for infection, delayed wound healing,
  pp hemorrhage

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Nursing Care

• Counseling
• Teach S/S of progression of disease
• Always practice universal precautions
• Facilitate use of social services
• Recommendation is for scheduled C/S

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Substance Abuse in Pregnancy

• Commonly used drugs
• Frequently missed dx
• HCP fail to ask client about SA
• Often hide SA or seek PNC late
• During PNC may be receptive to nursing
  interventions

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Alcohol

• CNS depressant- leading cause of preventable
  retardation.
• FAS physical and mental abnormalities
• Avoid alcohol during organogenesis
• Nursing observe for S/S of DT
• Need sedation and supportive care
• Breast feeding dependent on degree of addiction

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Cocaine and Crack

• Causesvasoconstriction, tachycardia,
  hypertension
• Metabolites present from 4-7 days
• Higher incidence of abruption, stillbirth, PT and
  AB
• Hard to detect abuse
• Should not breastfeed

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Heroin and Methadone

• Methadone is tx for opioid addiction
• Heroin lifestyle associated with poor nutrition,
  crime, STD
• Both associated with in utero problems
• Withdrawal for newborn more severe with methadone

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Nursing Care

• Unsafe to go Cold Turkey
• Be alert to subtle clues that suggest addiction
• Matter of fact and non-judgmental approach
• Focus is general health, nutrition, infections,
  other body systems and returning for PNC

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Nursing Plan and Implementation

• Establish trusting relationship, refer to TX
  programs
• May have low thresh hold to pain with
  associated labor, consider epidural
• Prepare for depressed, SGA, premature and
  addicted newborn