Maternal Risks and Complications

Euglycemia is a normal blood glucose level, which is the goal.  Poor glycemic control around the time of conception and in the early weeks of pregnancy is associated with an increased incidence of miscarriage. Poor glycemic control later in pregnancy, particularly in women without vascular disease, increases the rate of fetal macrosomia. Macrosomia has been defined as a birthweight more than 4000 to 4500 g or greater than the 90th percentile. Infants born to women with diabetes tend to have a disproportionate increase in shoulder, trunk, and chest size. Women with diabetes face an increased likelihood of cesarean birth because of failure of fetal descent or labor progress or of operative vaginal birth (birth involving the use of episiotomy, forceps, or vacuum extractor). Women with preexisting diabetes are at risk for several obstetric and medical complications:

• Hypertension

• Preeclampsia

• Cesarean birth

• Preterm birth

• Maternal mortality

Risk of developing these complications increases with the duration and severity of the woman’s diabetes.

• Hydramnios (polyhydramnios) frequently develops during the third trimester of pregnancy in women with diabetes. Complications most frequently associated with hydramnios (defined as an amniotic fluid index [AFI] > 24 cm) are placental abruption, uterine dysfunction, and postpartum hemorrhage.

• Infections are more common, including vaginal infections such as urinary tract infections (UTIs).

• Ketoacidosis (accumulation of ketones in the blood resulting from hyperglycemia and leading to metabolic acidosis) occurs most often during the second and third trimesters, when the diabetogenic effect of pregnancy is greatest. DKA may occur with blood glucose levels barely exceeding 200 mg/dL, compared with 300 to 350 mg/dL in the nonpregnant state. During times of stress, such as infection or illness, stress hormones cause an increase in hepatic glucose production and decreased peripheral uptake of glucose, leading to hyperglycemia (a greater than normal amount of glucose in the blood). Ketoacidosis occurring at any time during pregnancy can lead to intrauterine fetal death.

• Risk for hypoglycemia (a less than normal amount of glucose in the blood) is increased during pregnancy. Early in pregnancy, when hepatic production of glucose is diminished and peripheral use of glucose is enhanced, hypoglycemia occurs frequently.

• Hyperglycemia creates an increased risk of:

  • • Miscarriage

    • Congenital malformations

    • Respiratory distress syndrome

    • Extreme prematurity

    • Hyperglycemia during the first trimester of pregnancy, when organs and organ systems are forming, is the main cause of diabetes-associated birth defects. Anomalies commonly seen in infants born to women with diabetes are the cardiovascular system and central nervous system (CNS).

Fetal Risks and Complications

• Fetal pancreas begins to secrete insulin at 10 to 14 weeks of gestation. Fetus responds to maternal hyperglycemia by secreting large amounts of insulin (hyperinsulinism). Insulin acts as a growth hormone, causing the fetus to produce excess stores of glycogen, protein, and adipose tissue and leading to increased fetal size, or macrosomia. Birth injuries are more common in infants born to mothers with diabetes compared with mothers who do not have diabetes, and macrosomic fetuses have the highest risk for this complication. Common birth injuries associated with diabetic pregnancies include:

  • • Brachial plexus palsy

    • Facial nerve injury

    • Humerus or clavicle fracture

    • Cephalhematoma

• Hypoglycemia for the infant at birth due to the hyperinsulinism

• Intrauterine Fetal Demise (IUFD - sometimes called stillbirth) remains a major concern. Poor glycemic control is the most consistent finding in women who had a stillbirth. In addition to hyperglycemia, other causes of stillbirth include:

  • • Congenital abnormalities

    • Placental insufficiency

    • Fetal growth restriction

    • Macrosomia

    • Polyhydramnios

    • Obstructed labor (intrapartum stillbirth)

Care Management

Routine prenatal laboratory tests are performed, and baseline renal function may be assessed with a 24-hour urine collection for total protein excretion and creatinine clearance. Urinalysis and culture are performed to assess for the presence of a UTI. Because of the risk for coexisting thyroid disease, thyroid function tests may also be performed (see later discussion of thyroid disorders). Glycosylated hemoglobin A1c level may be measured to assess recent glycemic control (“diabetic report card” or evaluation of past glycemic control). Hemoglobin A1c levels less than 6 to 6.5 in early pregnancy have been associated with the lowest rates of adverse fetal outcomes.

Client Problems

Problems often experienced by the woman with pregestational diabetes include the following:

• Need for health teaching related to...

  • • Diabetic pregnancy, management, and potential effects on pregnant woman and fetus

    • Insulin administration and its effects

    • Hypoglycemia and hyperglycemia

    • Diabetic diet

• Anxiety, grieving, decreased ability to cope, decreased adherence, decreased self-esteem related to...

  • • Stigma of being labeled “diabetic”

    • Effects of diabetes and its potential sequelae on the pregnant woman and the fetus

• Potential for injury to fetus related to...

  • • Disruption of oxygen transfer from environment to fetus

    • Birth trauma

• Potential for injury to mother related to...

  • • Improper insulin administration

    • Hypoglycemia and hyperglycemia

    • Cesarean or operative vaginal birth

    • Postpartum infection

Antepartum Care

During the first and second trimesters of pregnancy, routine prenatal care visits are scheduled every one to two weeks. In the last trimester women will likely be seen one or two times each week. Achieving and maintaining constant euglycemia is the primary goal of medical therapy. Blood glucose levels should be in the range of 60 to 105 mg/dL before meals and 140 mg/dL or less when measured one hour after a meal. Postmeal glucose levels at 2 hours should be no higher than 120 mg/dL. Euglycemia is achieved through a combination of diet, insulin, and exercise.

Diet

Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levels. Diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as:

• Prepregnancy weight

• Dietary habits

• Overall health

• Ethnic background

• Lifestyle

• Stage of pregnancy

• Knowledge of nutrition

• Insulin therapy

Exercise

Being active for 30 to 60 min/day is encouraged. Daily activity has been shown to:

• Increase insulin sensitivity, thus lowering blood glucose levels

• Increase utilization of glucose, especially after a meal

• Improve glucose control, perhaps eliminating the need for insulin therapy

• Reduce the risk for excessive weight gain

• Reduce the weight of the newborn by approximately 150

• Physical activity can be divided into 10- to 20-minute periods after each meal

Insulin Therapy

Adequate insulin is the primary factor in the maintenance of euglycemia during pregnancy. Insulin requirements during pregnancy change dramatically as the pregnancy progresses.

Self-Monitoring of Blood Glucose

• Blood glucose testing at home using a glucose meter is considered the standard of care for monitoring blood glucose levels during pregnancy.

• Urine testing for glucose is not beneficial during pregnancy.

Complications Requiring Hospitalization

Occasionally, hospitalization is necessary to regulate insulin therapy and stabilize glucose levels. Infection, which can lead to hyperglycemia and DKA, may be an indication for hospitalization. Hospitalization during the third trimester for close maternal and fetal observation may be indicated for women whose diabetes is poorly controlled. Women with diabetes are more likely than women who do not have diabetes to also have preexisting hypertension or develop preeclampsia, which may necessitate hospitalization.

Fetal Surveillance

Diagnostic techniques for fetal surveillance are often performed to assess fetal growth and well-being. Goals of fetal surveillance are to detect fetal compromise as early as possible and prevent IUFD or unnecessary preterm birth. Early in pregnancy the estimated date of birth is determined. Baseline ultrasound is obtained during the first trimester to assess gestational age. Follow-up ultrasound examinations are usually performed during the pregnancy (as often as every three to four weeks) to monitor:

• Fetal growth

• Estimate fetal weight

• Detect hydramnios

• Macrosomia

• Congenital anomalies

• Maternal serum α-fetoprotein is performed between 15 and 20 weeks of gestation

• Detailed ultrasound study to examine the fetus for neural tube defects and other anomalies should be performed between 18 and 20 weeks of gestation

Women with pregestational diabetes are also more likely to give birth to infants with congenital cardiac anomalies. Fetal echocardiography may be performed between 20 and 22 weeks of gestation to detect cardiac anomalies. Most fetal surveillance measures are concentrated in the third trimester, when the risk of fetal compromise is greatest. Goals of antepartum testing during the third trimester are to monitor fetal growth and ensure fetal well-being. Pregnant women should be taught how to make daily fetal movement counts, beginning at 28 weeks of gestation. A nonstress test (NST) is the preferred primary method to evaluate fetal well-being. It usually begins by 32 weeks of gestation and performed at least twice weekly. If the NST is nonreactive, a biophysical profile or contraction stress test will be performed. Testing often begins earlier, between 28 and 32 weeks of gestation, in women who have vascular disease, poor glucose control, or suspected fetal growth restriction.

Determination of Birth Date and Mode of Birth

Optimal time for birth is between 39 and 40 weeks of gestation, as long as good metabolic control is maintained and parameters of antepartum fetal surveillance remain within normal limits. Induction of labor at 39 weeks of gestation is often planned for women with well-controlled diabetes who do not have vascular disease. Reasons to proceed with birth before term are poor metabolic control, coexisting hypertension, and nonreassuring responses to fetal testing. To confirm fetal lung maturity, amniocentesis should be performed when birth will occur before 38 weeks of gestation. The cesarean rate for these women is high.

Intrapartum Care

Intrapartum care monitors dehydration, hypoglycemia, and hyperglycemia. IV line is inserted. Insulin is administered by continuous infusion, piggybacked into the main IV line. Only rapid- or short-acting insulin can be administered intravenously. Insulin may also be given intermittently by subcutaneous injection as needed to maintain glucose levels within the target range. Determinations of blood glucose levels are made every hour, and fluids and insulin are adjusted to maintain the blood glucose level between 90 and 110 mg/dL. Continuous fetal heart monitoring also occurs in this type of care.

Postpartum Care

During the first 24 hours postpartum, insulin requirements decrease substantially because the major source of insulin resistance, the placenta, has been removed. Possible postpartum complications include: preeclampsia or eclampsia, hemorrhage, or infections.

Causes of nausea and vomiting in pregnancy (NVP) :

• increasing levels of estrogen, progesterone, and human chorionic gonadotropin (hCG)

• gastric changes

• thyroid changes

When vomiting during pregnancy becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, the disorder is termed hyperemesis gravidarum.  Hyperemesis gravidarum usually begins during the first trimester and is classified as NVP that persists beyond the first trimester.  

Complications

Although rare, maternal complications of hyperemesis gravidarum:

• esophageal rupture

• pneumomediastinum

• deficiencies of vitamin K and thiamine

Infants born to women who had poor pregnancy weight gain because of hyperemesis may be small for gestational age, have a low birthweight, or be born prematurely.

Clinical Manifestations

A woman with hyperemesis gravidarum usually has:

• significant weight loss and dehydration

• dry mucous membranes

• decreased BP

• increased pulse rate

• poor skin turgor

• unable to keep down even clear liquids taken by mouth

• laboratory tests that reveal electrolyte imbalances

Assessment

Physical assessment should include:

• Frequency, severity, and duration of episodes of nausea and vomiting, including approximate amount and color of the vomitus

• Presence of diarrhea, indigestion, and abdominal pain or distention

• Precipitating and alleviating factors

• Any pharmacologic or nonpharmacologic treatment measures used

• Complete physical examination with special attention to measures of fluid and electrolyte balance, nutritional status, and gastric, liver, thyroid, heart, and lung function

• Prepregnancy weight and gain or loss during pregnancy

Care Management

It is very important for initial laboratory testing to be obtained for the determination of dehydration and ketonuria

Other laboratory tests that may be ordered:

• urinalysis

• complete blood cell count

• electrolytes

• liver enzymes

• bilirubin levels

• thyroid levels

• lab tests help to rule out underlying diseases:

  • gastroenteritis

  • pyelonephritis

  • pancreatitis

  • cholecystitis

  • peptic ulcer

  • hepatitis

  • hyperthyroidism

  • psychosocial assessment includes asking the woman about anxiety, fears, and concerns related to her own health and the effects on pregnancy outcome

Client Problems

Problems identified in women experiencing hyperemesis gravidarum include:

• Dehydration related to excessive vomiting as evidenced by fluid and electrolyte imbalance

• Inadequate weight gain, related to nausea and persistent vomiting as evidenced by weight decrease as compared with prepregnant weight

• Anxiety related to effects of hyperemesis on fetal well-being as evidenced by woman’s statements of concern

Interventions

Initially the woman who is unable to retain clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances.  Medications may be used if nausea and vomiting are uncontrolled including:

• pyridoxine (vitamin B6), either alone or in combination with doxylamine (Unisom)

• dopamine antagonists such as promethazine (Phenergan)

• chlorpromazine (Thorazine)

• prochlorperazine (Compazine)

• metoclopramide (Reglan) accelerates gastric emptying and corrects gastric dysrhythmias

• ondansetron (Zofran)

• droperidol (Inapsine)

• corticosteroids (methylprednisolone [Medrol] or hydrocortisone) may be prescribed for women who do not respond well to the medications previously discussed,

• antiemetic drugs, medications to control heartburn or reflux may also be prescribed

• antacids, histamine blockers, and proton pump inhibitors

In extreme cases of Hyperemesis, enteral or parenteral nutrition may be used

Nursing care of the woman with hyperemesis gravidarum:

• Implementing the medical plan of care 

  • initiating and monitoring IV therapy

  • administering drugs and nutritional supplements

  • monitoring the woman’s response to interventions

• Observe for any signs of complications such as:

  • metabolic acidosis (secondary to starvation)

  • Jaundice

  • hemorrhage and alerts the health care provider should these occur

  • monitoring includes:

    • assessing nausea, retching without vomiting (sometimes called dry heaves), and vomiting

    • intake and output

    • oral  hygiene

    • positioning and providing a quiet, restful environment that is free from odors may increase the woman’s comfort