Endocrine Disorders

1. Diabetes a. Pregnancy drastically alters insulin requirements for mom b. May accelerate vascular problems renal and retinopathy c. Depends on the type: 2. Hyperthyroidism 3. Hypothyroidism

1. Gestational Diabetes
Dx in 2nd of pregnancy When the pancreas is unable to produce sufficient insulin or insulin isnt used effectively Insulin blocked by hormones produced by the placenta o Have a contra-insulin effect:: begins @ 20-24 weeks (when they do GTT) The larger the placenta the more hormones produced and the greater the resistance becomes Pancreas cant keep up with demands for insulin, therefore mom gets gestational After birth & delivery of placenta- mom has significant in insulin requirements because she no longer has the contra insulin effect from placental hormones

Placental Hormones: Cortisol, Estrogen, human placental lactogen

Risk Factors
Obesity- (although non obese can experience it too) we need to monitor closely for this + Family hx Previous large infant, Previous stillbirth Polyhydraminos- volume of amniotic fluid may be tied to fetal polyuria, polydipsia-

Maternal Risks
Premature labor 2x Pregnancy Induced Hypertension Fetal Macrosomia Risk (Big baby syndrome) o Perineal Lacerations o Episiotomy o Cesarean Birth o Shoulder Dystocia o Birth Trauma

Infant Risks
RDS-Respiratory distress syndrome increased fetal insulin inhibits some enzymes necessary for surfactant production Glucose saturated blood cant release adequate O2 Compensate by RBC production
innability of immature liver enzymes to metabolize (bili is from polycythemia)

Polycythemia

Hyperbilinrubinemia-

Risk of developing Glucose Intolerance later 50 % develop Diabetes within 5-10 years
Large Baby- Takes In extra glucose hyperinsulin effect= big baby

As the RBCs break down you get the icterus/jaundice

Hypoglycemia :: BEWARE hypoglycemia in baby after cord cut Thrombocytopenia Hypocalcemia

Diagnostic Criteria 3 hr GTT Diagnostic Fasting: 1 hour3 hour-

105 190 165 145

Normal Fasting:
1 hour: 2 hour: 3 hour

80 120 105 90

2 hour-

Gestational Diabetes:: Nursing Interventions

GOAL: Tight Glucose Control to risks of gestational diabetes ANTEPARTUM TX begins ASAP with DX Educate women and family Stress importance of tight glucose control Teach GDM usually disappears after pregnancy DIETARY MODIFICATION = mainstay of treatment

INTRAPARTUM Glucose levels monitored every 1-2 hours to maintain levels < 110 (this range with risk of hypoglycemia in neonate) Women who have been on insulin to control glucose, can receive IV of regular insulin during labor NO BOLUS to women with GDM NOTE: C-Section not required but may be necessary in case of Fetal Macrosomia or Preeclampsia

POSTPARTUM Most women return to normal post childbirth, however will recur in future pregnancies Carbohydrate intolerance initiated 6-12 wks postpartum or post breastfeeding should repeat at regular intervals throught womans life Obesity major risk factor for later development of diabetes Encourage women to make lifestyle changes including weight loss and exercise to reduce this risk Regular health care for children is important because they are often at risk for developing obesity and DM in childhood or adolescence

Congenital Anomalies in infants of women with GDM approaches that of the general population because it usually develops after week 20 (the critical period of organogenesis)

Congenital Defects
Occur 3-4 times more often with diabetes Heart- septal, coarctations of aorta, transposition of great arteries CNS- hydrocephaliz, anacephaly, myelomeningecyl SkeletalSacral Agenesis/Caudal Regression Syndrome o Unique to diabetic moms o Sacrum and spine fail to develop o Lower extremities develop incompletely To prevent congenital defects Tight glycaemic control and preconception counseling is extremely important

Nursing Education for Women with Gestational Diabetes Increase caloric intake by 300 day
o Complex Carbs 50-60% o Protein 20% o Fats 20-25% o Three meals o Three snacks

o Bedtime snack
Bedtime snack important to prevent starvation response due to decrease blood sugar that results in use of fat and muscle stores and increase ketones.

o Self monitor BS with coverage PRN o Fetal evaluation

Hyperthyroidism
1-2 of every 1000 pregnancies Symptoms between 4-8 wks

Hypothyroidism
Rare because most women with this disorder are infertile Lethargy Weakness Anorexia Weight gain Cold intolerance Mental impairment Headache

Distinguishing Signs from Normal Pregnancy

Unplanned weight loss Onycholysis (loose nails) Pulse > 100 bpm - doesnt with valsalva maneurver

Signs and Symptoms SEVERE Nausea & Vomiting Nervousness, Hyperactivity, Weakness, Fatigue, Weight loss Poor weight gain, Diarrhea, Tachycardia, SOB, Perspiration, Tremors Heat intolerance Fertility issues Possible transplacental to fetus Connection to HYPEREMESIS
Treat with propythiouracil

A serious, but uncommon complication of undiagnosed or partially treated hyperthyroid ism is thyroid storm, which may occur in response to stress such as infection, birth, or surgery. Symptoms of this emergency disorder include 1. Fever & hypothermia 2. Restlessness & Hypertension 3. Fever and Restlessness 4. Bradycardia and Hypertension Fever, restlessness, tachycardia, vomiting, hypotension and stupor are symptoms of a thyroid storm.

Cardiovascular Disorders Intravascular Volume systemic vascular resistance CO changes occurring during pregnancy, labor and birth Intravascular volume changes that occur just after childbirth Strain is present during pregnancy and continues for a few weeks after birth When cardiovascular changes are not well tolerated, cardiac failure can develop Cardiac Decomensation: Inability of the heart to maintain a sufficient CO Occurs with Myocardial disease Valvular disease Congenital heart defects