Chapter 26Key Points Print26-2Elsevier items and derived items 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc.McKinney: Maternal-Child Nursing, 4th EditionChapter 26: Concurrent Disorders During PregnancyKey Points - PrintDuring early pregnancy, insulin release increases in response to serum glucose levels, and significant maternal hypoglycemia may occur. In an uncomplicated pregnancy, the availability of glucose and insulin favors the development and storage of fat.During the second half of pregnancy, fetal growth accelerates, and placental hormone levels rise sharply. These hormonesparticularly estrogen, progesterone, and human placental lactogencreate resistance to insulin in maternal cells to provide an abundant supply of glucose for the fetus.Diabetes is classified as type 1 (insulin deficient) or type 2 (insulin resistant) based on whether the person needs insulin to prevent ketoacidosis. A third type, gestational diabetes mellitus, is diabetes that begins during pregnancy. Gestational diabetes mellitus is divided into A1 (diet controlled) and A2 (diet and insulin controlled).Pregnant women with preexisting diabetes are at risk for preeclampsia, ketosis, and urinary tract infections.The fetus of a woman with preexisting diabetes may have major congenital malformations, including neural tube defects, caudal regression syndrome (malformation that results when the sacrum, lumbar spine, and legs fail to develop), and cardiac defects.The infant of a mother with preexisting diabetes has an increased risk of hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome.Because gestational diabetes develops after the first trimester, it is not usually associated with an increase in the incidence of major congenital abnormalities. However, poorly controlled gestational diabetes during the third trimester is associated with fetal macrosomia and neonatal hypoglycemia.Therapeutic management of gestational diabetes consists of diet, exercise, glucose level monitoring, and fetal surveillance. The normal heart adapts to pregnancy. In a woman with underlying heart disease, the adaptations can impose an additional burden on an already compromised heart, causing cardiac decompensation and congestive heart failure.The primary goal of managing class III and class IV heart disease is to prevent cardiac decompensation and congestive heart failure.Intrapartum management of heart disease focuses on preventing fluid overload, which can cause a sharp rise in cardiac effort.Anemias often seen in pregnant women include iron deficiency anemia, folic acid deficiency anemia, the anemia associated with sickle cell disease, and thalassemia.Iron deficiency causes 75% of anemias in pregnancy. Although prenatal vitamins containing iron are part of routine care, routine supplemental iron therapy, rather than therapy for anemia, is controversial.Folic acid supplementation of 400 mcg (0.4 mg)/day is recommended for all women of childbearing age, and 600 mcg (0.6 mg)/day is recommended when pregnancy is confirmed. Folate deficiency is associated with an increased risk of spontaneous abortion; abruptio placentae; and fetal anomalies, especially neural tube defects, such as spina bifida or anencephaly.Most treatment of sickle cell anemia during pregnancy is directed toward avoiding sickle cell crisis. The goal of nursing management is to help the pregnant woman maintain a healthy status and avoid hospitalization.Women with beta-thalassemia minor often have mild hypochromic and microcytic anemia.During the first trimester, systemic lupus erythematosus carries a risk of miscarriage and fetal death. Preeclampsia may be early and severe. Other risks include later pregnancy loss and premature birth because of hypertension, renal complications, and preterm rupture of membranes.Complications of antiphospholipid syndrome include fetal loss, early-onset preeclampsia, intrauterine growth restriction, and preterm birth. Untreated maternal hypothyroidism during pregnancy can adversely affect the childs mental development.Pregnancy may affect the frequency and management of seizures, and seizures may affect the course of pregnancy. Anticonvulsant drug levels often decrease in pregnant women. Viral infections that are mild or asymptomatic in the mother can have serious effects on the fetus. Maternal infections with the greatest risk of harming the fetus or neonate include cytomegalovirus, rubella, varicella-zoster virus, herpes simplex, hepatitis B, and human immunodeficiency virus.Perinatal transmission of human immunodeficiency virus has fallen with routine prenatal testing for most women and antiviral therapy.Nonviral infections that may affect the fetus or newborn include toxoplasmosis, group B streptococcus infection, and tuberculosis.