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OB | Pregnancy Endocrine Complications
Description
Diabetes Mellitus in Pregnancy Diabetes during pregnancy includes pregestational types (Type 1 and Type 2) and Gestational Diabetes Mellitus (GDM). GDM affects 5-9% of all pregnancies and is characterized by increased insulin resistance and beta cell dysfunction that typically develop in the second or third trimester due to pregnancy hormones like human placental lactogen (hPL). Key risk factors for GDM include a BMI > 25-30, polycystic ovary syndrome (PCOS), family history of diabetes, previous GDM, and previously delivering a large for gestational age (LGA) infant over 9 pounds.
Clients may present with polyuria, polydipsia, polyphagia, and fatigue. Diagnostic screening typically involves a 1-hour glucose tolerance test (GTT); if blood glucose exceeds 140 mg/dL, a 3-hour GTT is required. Diagnosis is confirmed if two of the four 3-hour values are elevated (fasting >95 mg/dL, 1-hour >180 mg/dL, 2-hour >155 mg/dL, 3-hour >140 mg/dL). Maternal complications include an increased risk of pre-eclampsia, polyhydramnios, and infections, while fetal risks involve macrosomia, shoulder dystocia, birth trauma, and postnatal hypoglycemia. Treatment begins with diet (40% carbohydrates, 20% protein, 40% fat) and exercise, escalating to insulin or glyburide if glucose levels remain abnormal. Both pregestational and gestational diabetes carry significant psychosocial impacts, often causing anxiety, depression, and stress over finances and frequent medical visits.
Hyperemesis Gravidarum (HG) Affecting up to 3% of pregnant clients, HG causes persistent, severe nausea and vomiting that can lead to significant dehydration and may require hospitalization. Etiological factors include elevated hCG (such as in molar or multiple gestations), progesterone, estradiol, and H. pylori infections. Clinical presentation includes signs of dehydration like dry mouth, dark urine, rapid heart rate, dizziness, and confusion. Severity can be tracked using the Pregnancy Unique Quantification of Emesis (PUQE) score. Lab tests are used to monitor for electrolyte imbalances, checking expected ranges for potassium, sodium, calcium, and glucose. Treatments range from non-pharmacological trigger avoidance and ginger, to Vitamin B6, antihistamines, antiemetics, IV fluids, and total parenteral nutrition (TPN).
Thyroid Disorders Hypothyroidism affects 3-5% of pregnancies and is primarily caused by Hashimoto's disease, an autoimmune condition. Symptoms like fatigue, constipation, weight gain, feeling cold, and bradycardia are common but may be overlooked as general pregnancy symptoms. Maternal risks are severe, including pregnancy loss, preeclampsia, placental abruption, and postpartum hemorrhage, alongside fetal neurological development issues. Treatment involves the thyroid replacement levothyroxine, and clients must avoid taking prenatal vitamins within 4 hours of their dose.
Hyperthyroidism is rarer, usually autoimmune-driven (such as Graves' disease with elevated TSI), and is diagnosed by decreased TSH and elevated T4 levels. Symptoms include flushing, sweating, anxiety, hand tremors, and a racing heart. Treatment utilizes antithyroid medications: Propylthiouracil (PTU) is given until the 16th week of pregnancy, after which clients are transitioned to Methimazole