Chapter 29 ENDOCRINE AND METABOLIC DISORDERS Copyright 2016

Learning Objectives Differentiate the types of diabetes mellitus and their respective risk factors in pregnancy. Compare insulin requirements during pregnancy, postpartum, and with lactation. Identify maternal and fetal risks or complications associated with diabetes in pregnancy. Develop a plan of care for the pregnant woman with pregestational or gestational diabetes. Copyright © 2016 by Elsevier Inc. All rights reserved. 2

Learning Objectives (Cont. ) Explain the effects of hyperemesis gravidarum on maternal and fetal well-being. Discuss management of the woman with hyperemesis gravidarum. Explain the effects of thyroid disorders on pregnancy. Compare the management of a pregnant woman with hyperthyroidism with one who has hypothyroidism. Copyright © 2016 by Elsevier Inc. All rights reserved. 3

Learning Objectives (Cont. ) Discuss care management for the woman with phenylketonuria during the perinatal period. Examine the effects of maternal phenylketonuria on pregnancy outcome. Copyright © 2016 by Elsevier Inc. All rights reserved. 4

Endocrine and Metabolic Disorders Pregnancy can be complicated by these disorders, including the following: ◦ Diabetes mellitus ◦ Hyperemesis gravidarum ◦ Hyper- and hypothyroidism ◦ Phenylketonuria The primary objective of nursing care is to achieve optimal outcomes for both the pregnant woman and the fetus. Copyright © 2016 by Elsevier Inc. All rights reserved. 5

Diabetes Mellitus Introduction Diabetes mellitus (DM) ◦ Affects 4% to 14% of pregnant women ◦ Pregnancy complicated by diabetes is considered high risk ◦ Pathogenesis ◦ Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both ◦ Body compensates for its inability to convert glucose into energy by burning muscle and fats ◦ Key to an optimal outcome is strict glycemic control Copyright © 2016 by Elsevier Inc. All rights reserved. 6

Diabetes Mellitus Introduction (Cont. ) Classification ◦ Type 1 diabetes ◦ Absolute insulin deficiency ◦ Type 2 diabetes ◦ Relative insulin deficiency ◦ Gestational diabetes mellitus (GDM) ◦ Pregestational diabetes mellitus ◦ Label given to type 1 or 2 diabetes that existed prior to pregnancy ◦ White’s classification system ◦ New ADA system (distinguishes with or without vascular complications) Copyright © 2016 by Elsevier Inc. All rights reserved. 7

Diabetes Mellitus Introduction (Cont. ) Metabolic changes associated with pregnancy ◦ Normal pregnancy is characterized by alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis ◦ Glucose is the primary fuel for the fetus ◦ Glucose crosses the placenta, insulin does not ◦ Insulin needs increase during the first trimester ◦ Diabetogenic effect in second and third trimesters Copyright © 2016 by Elsevier Inc. All rights reserved. 8

Diabetes Mellitus Introduction (Cont. ) Copyright © 2016 by Elsevier Inc. All rights reserved.

Pregestational Diabetes Mellitus Pregestational diabetes mellitus ◦ About 10% of pregnancies have preexisting DM ◦ Preconceptional counseling ◦ Maternal risks and complications ◦ Hydramnios/polyhydramnios ◦ Ketoacidosis ◦ Hypoglycemia/hyperglycemia ◦ Fetal and neonatal risks and complications ◦ IUFD ◦ Congenital malformations ◦ Hypoglycemia at birth Copyright © 2016 by Elsevier Inc. All rights reserved. 10

Care Management: Pregestational Diabetes Mellitus Antepartum ◦ Diet ◦ Exercise ◦ Insulin therapy ◦ Monitoring blood glucose levels ◦ Urine testing ◦ Complications requiring hospitalization ◦ Fetal surveillance ◦ Determination of birth date and mode Copyright © 2016 by Elsevier Inc. All rights reserved. 11

Care Management: Pregestational Diabetes Mellitus (Cont. ) Intrapartum ◦ Monitoring for dehydration ◦ Blood glucose levels carefully monitored ◦ Continuous EFM ◦ Intravenous infusion ◦ Possible cesarean birth for macrosomia Copyright © 2016 by Elsevier Inc. All rights reserved. 12

Care Management: Pregestational Diabetes Mellitus (Cont. ) Postpartum ◦First 24 hours, insulin requirements drop substantially ◦Risk of hemorrhage due to uterine distention Copyright © 2016 by Elsevier Inc. All rights reserved. 13

Gestational Diabetes Mellitus (GDM) Complicates 3% to 9% of all pregnancies Fetal risks ◦ Women who are obese prior to conception and develop GDM are at an increased risk of giving birth to infants with central nervous system (CNS) defects Screening for gestational diabetes Copyright © 2016 by Elsevier Inc. All rights reserved. 14

GDM Care Management Antepartum ◦Diet ◦Exercise ◦Self-monitoring of blood glucose ◦Pharmacologic therapy ◦Fetal surveillance

GDM Care Management (Cont. ) Copyright © 2016 by Elsevier Inc. All rights reserved.

GDM Care Management (Cont. ) Intrapartum ◦ Blood glucose monitored hourly in labor ◦ Infusion of regular insulin Postpartum ◦ Will return to normal glucose levels after birth ◦ Likely to recur in future pregnancies Copyright © 2016 by Elsevier Inc. All rights reserved. 18

Hyperemesis Gravidarum Normal nausea and vomiting complicates 50% to 80% of all pregnancies, typically beginning at 4 to 10 weeks of gestation, usually resolving by 20 weeks of gestation Hyperemesis gravidarum is excessive, prolonged vomiting accompanied by the following: ◦ Weight loss ◦ Electrolyte imbalance ◦ Nutritional deficiencies ◦ Ketonuria Copyright © 2016 by Elsevier Inc. All rights reserved. 19

Hyperemesis Gravidarum (Cont. ) Etiology Clinical manifestations Management ◦ Assess severity ◦ Weight, V/S, presence of ketonuria ◦ Psychosocial assessment: role of anxiety Copyright © 2016 by Elsevier Inc. All rights reserved. 20

Hyperemesis Gravidarum (Cont. ) Initial care ◦ Intravenous (IV) therapy for correction of fluid and electrolyte imbalances ◦ Medications ◦ Enteral or parenteral nutrition as a last resort Nursing interventions Follow-up care Copyright © 2016 by Elsevier Inc. All rights reserved. 21

Thyroid Disorders Hyperthyroidism ◦ Rare in pregnancy ◦ 90% to 95% cases in pregnancy are caused by Graves’ disease ◦ Clinical manifestations ◦ Heat intolerance, diaphoresis, fatigue, anxiety, emotional lability, and tachycardia ◦ May include weight loss, goiter, and a pulse rate greater than 100 beats/minute ◦ Primary treatment during pregnancy is drug therapy. Copyright © 2016 by Elsevier Inc. All rights reserved. 22

Thyroid Disorders (Cont. ) Hypothyroidism (Cont. ) ◦ Severe hypothyroidism is often associated with infertility and an increased risk of miscarriage. ◦ Occurs in 2 to 3 in 1000 pregnancies ◦ Symptoms: weight gain, lethargy, decrease in exercise capacity, and cold intolerance ◦ Nursing care ◦ Education ◦ Medication regimen: levothyroxine (e. g. , T 4 [Synthroid]) Copyright © 2016 by Elsevier Inc. All rights reserved. 23

Maternal Phenylketonuria Inborn error of metabolism caused by an autosomal recessive trait that creates a deficiency in the enzyme phenylalanine hydrolase, which impairs the body’s ability to metabolize foods with protein If unrecognized, can cause cognitive impairment Prompt diagnosis and therapy with a phenylalaninerestricted diet significantly decreases the incidence of cognitive impairment. Women with PKU should be advised against breastfeeding because their milk contains a high concentration of phenylalanine. Copyright © 2016 by Elsevier Inc. All rights reserved. 24

Maternal Phenylketonuria (Cont. ) Prevention ◦ Identification of women in reproductive years who have disorder ◦ Screening at the first prenatal visit Infants born to women with this disorder are either homozygous or heterozygous for the trait. Copyright © 2016 by Elsevier Inc. All rights reserved. 25

Key Points In pregnant women with pregestational diabetes, lack of glycemic control before conception and in the first trimester of pregnancy may be responsible for fetal congenital malformations. For pregnant women who have diabetes and are insulin dependent, insulin requirements increase as the pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol. After birth, levels decrease dramatically; breastfeeding affects insulin needs. Poor glycemic control before and during pregnancy in women who have diabetes can lead to maternal complications such as miscarriage, infection, and dystocia (difficult labor) caused by fetal macrosomia. Copyright © 2016 by Elsevier Inc. All rights reserved. 26

Key Points (Cont. ) Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in the pregnancy complicated by diabetes mellitus. Because GDM is asymptomatic in most cases, all women who are not known to have pregestational diabetes undergo routine screening by history, clinical risk factors, or laboratory assessment of blood glucose levels during pregnancy. Two different methods for diagnosing GDM are currently used. Copyright © 2016 by Elsevier Inc. All rights reserved. 27

Key Points (Cont. ) The woman with hyperemesis gravidarum may have significant weight loss and dehydration. Management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting. Thyroid dysfunction, hyperthyroidism, or hypothyroidism during pregnancy requires close monitoring of thyroid hormone levels to regulate therapy and prevent fetal insult. High levels of phenylalanine in the maternal bloodstream cross the placenta and are teratogenic to the developing fetus. Damage can be prevented or minimized by dietary restriction of phenylalanine before and during pregnancy. Copyright © 2016 by Elsevier Inc. All rights reserved. 28

Question Women with hyperemesis gravidarum: a. Are a majority, because 80% of all pregnant women suffer from it at some time b. Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance c. Need IV fluid and nutrition for most of their pregnancy d. Often inspire similar, milder symptoms in their male partners and mothers Copyright © 2016 by Elsevier Inc. All rights reserved. 29