1. Endocrine and Metabolic Disorders
Chapter 29
Endocrine and Metabolic Disorders
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. 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.

3. 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.

4. Learning Objectives (Cont.)
Discuss care management for the woman with phenylketonuria during the perinatal period.
Examine the effects of maternal phenylketonuria on pregnancy outcome.

5. 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.

6. 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

7. 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)

8. 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

9. Diabetes Mellitus Introduction (Cont.)

10. 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

11. 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

12. Care Management: Pregestational Diabetes Mellitus (Cont.)
Intrapartum
Monitoring for dehydration
Blood glucose levels carefully monitored
Continuous EFM
Intravenous infusion
Possible cesarean birth for macrosomia

13. Care Management: Pregestational Diabetes Mellitus (Cont.)
Postpartum
First 24 hours, insulin requirements drop substantially
Risk of hemorrhage due to uterine distention

14. 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

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

16. GDM Care Management (Cont.)

17. GDM Care Management (Cont.)

18. 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

19. 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

20. Hyperemesis Gravidarum (Cont.)
Etiology
Clinical manifestations
Management
Assessment
Assess severity
Weight, V/S, presence of ketonuria
Psychosocial assessment: role of anxiety

21. 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

22. 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 beats/minute
Primary treatment during pregnancy is drug therapy.

23. 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., T4 [Synthroid])

24. 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 phenylalanine- restricted 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. Question Women with hyperemesis gravidarum:
Are a majority, because 80% of all pregnant women suffer from it at some time
Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance
Need IV fluid and nutrition for most of their pregnancy
Often inspire similar, milder symptoms in their male partners and mothers
ANS: B
Feedback
A Incorrect: Although 80% of pregnant women experience nausea and vomiting, less than 0.5% proceed to this severe level.
B Correct: Treatment for several days sets things right in most cases.
C Incorrect: IV administration may be used at first to restore fluid levels, but it is seldom needed for very long.
D Incorrect: Women suffering from this condition want sympathy because some authorities believe that difficult relationships with mothers or partners may be the cause.