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Premature separation of placenta; Ablatio placentae; Abruptio placentae; Placental abruption Definition
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Placenta abruptio is separation of the placenta (the organ that nourishes the fetus) from the site of uterine implantation before delivery of the fetus. Causes
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The exact cause of a placetal abruption may be difficult to determine. Direct causes are rare, but include: • • • Abnormally short umbilical cord Injury to the belly area (abdomen) from a fall or automobile accident Sudden loss in uterine volume (can occur with rapid loss of amniotic fluid or the delivery of a first twin)
Risk factors include: • • • • • • • • • Advanced maternal age Cigarette smoking Cocaine use Diabetes Drinking more than 14 alcoholic drinks per week during pregnancy High blood pressure during pregnancy -- About half of placental abruptions that lead to the baby's death are linked to high blood pressure History of placenta abruptio Increased uterine distention (as may occur with multiple pregnancies or abnormally large volume of amniotic fluid) Large number of prior deliveries
Placenta abruptio, including any amount of placental separation prior to delivery, occurs in about 1 out of 150 deliveries. The severe form, which results in fetal death, occurs only in about 1 out of 500 to 750 deliveries. Symptoms • • •
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Abdominal pain Back pain Vaginal bleeding
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Exams and Tests Tests may include: •
• • • • •
Complete blood count Fibrinogen level Partial thromboplastin time Pelvic exam Prothrombin time
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Treatment may fluids through a vein (IV) and blood transfusions. The mother will be carefully monitored for symptoms of shock and the unborn baby will be watched for signs of distress, which includes an abnormal heart rate. An emergency cesarean section may be necessary. If the fetus is very immature and there is only a small placenta rupture, the mother may be kept in the hospital for close observation and released after several days if the condition does not get worse If the fetus is developed (matured) enough, vaginal delivery may be chosen if there is minimal distress to the mother and child. Otherwise, a cesarean section may be the preferred choice. Outlook (Prognosis)
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The mother does not usually die from this condition. However, the following increase the risk for death in both the mother and baby: • • • • • Absence of labor Closed cervix Delayed diagnosis and treatment of placenta abruption Excessive blood loss resulting in shock Hidden (concealed) vaginal bleeding in pregnancy
Fetal distress appears early in the condition in about half of all cases. The infants who live have a 40-50% chance of complications, which range from mild to severe. Possible Complications
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Excessive loss of blood may lead to shock and possible death in the mother or baby. If bleeding occurs after the delivery and blood loss cannot be controlled by other means, a hysterectomy (removal of the uterus) may become necessary. When to Contact a Medical Professional
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Call your health care provider if you are in an auto accident, even if the accident is relatively minor. See your health care provider immediately, call your local emergency number (such as 911), or go to the emergency room if you are pregnant and have symptoms of this condition. Placenta abruptio can rapidly become an emergency condition that threatens the life of both the mother and baby. Prevention
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Avoid drinking, smoking, or using recreational drugs during pregnancy. Get early and continuous prenatal care. Early recognition and proper management of conditions in the mother such as diabetes and high blood pressure also decrease the risk of placenta abruptio. References
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Francois KE, Foley MR. Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics - Normal and Problem Pregnancies. 5th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2007:chap 18. Houry DE, Abbott JT. Acute complications of pregnancy. In: Marx J, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th ed. St Philadelphia, Pa: Mosby Elsevier; 2006:chap 177.
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Placental abruption Classification and external resources
DiseasesDB 40 MedlinePlus 000901 eMedicine med/6 emerg/12 D000037
Placental abruption (Also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40%
depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. The heart rate of the fetus can be associated with the severity.
• • • • • • •
1 Lasting effects 2 Symptoms 3 Pathophysiology 4 Risk factors 5 Intervention 6 References 7 External links
 Lasting effects
On the mother:
• • • •
A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract. 'APH weakens, for PPH to kill'. The mother may have problems with blood clotting for a few days. If the mother's blood does not clot (particularly during a caesarean section) and too many transfusions could put the mother into disseminated intravascular coagulation (DIC), the doctor may consider a hysterectomy. A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.
On the baby:
• • • •
If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery. It may die in utero, resulting in a Stillbirth. The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding. If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth. The newborn may have low blood pressure or a low blood count.
If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.
• • • •
contractions that don't stop pain in the uterus tenderness in the abdomen vaginal bleeding (sometimes)
Trauma, hypertension, or coagulopathy, contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death. Abruptions are classified according to severity in the following manner:
• • • •
Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.
 Risk factors
• • • • • •
Maternal hypertension is a factor in 44% of all abruptions. Maternal trauma, such as motor vehicle accidents, assaults, falls, or nosocomial Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk.
Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. some infections are also diagnosed as a cause
The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancyinduced hypertension.
Placental abruption is suspected when a pregnant woman has sudden localized uterine pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.
What is a miscarriage?
A miscarriage is the loss of a pregnancy during the first 20 weeks. It is usually your body's way of ending a pregnancy that has had a bad start. The loss of a pregnancy can be very hard to accept. You may wonder why it happened or blame yourself. But a miscarriage is no one’s fault, and you can't prevent it. Miscarriages are very common. About 1 in 4 pregnancies end in a miscarriage.1 It is also common for a woman to have a miscarriage before she even knows that she is pregnant.
What causes a miscarriage?
Most miscarriages happen because the fertilized egg in the uterus does not develop normally. A miscarriage is not caused by stress, exercise, or sex. In many cases, doctors don't know what caused the miscarriage. The risk of miscarriage is lower after the first 12 weeks of the pregnancy.
What are the common symptoms?
Common signs of a miscarriage include: • Bleeding from the vagina. The bleeding may be light or heavy, constant or off and on. It can sometimes be hard to know whether light bleeding is a sign of miscarriage. But if you have bleeding with pain, the chance of a miscarriage is higher. • • Pain in the belly, lower back, or pelvis. Tissue that passes from the vagina.
How is a miscarriage diagnosed?
Call your doctor if you think you are having a miscarriage. If your symptoms and a pelvic exam do not show whether you are having a miscarriage, your doctor can do tests to see if you are still pregnant.
How is it treated?
No treatment can stop a miscarriage. As long as you do not have heavy blood loss, a fever, weakness, or other signs of infection, you can let a miscarriage follow its own course. This can take several days. If you have Rh-negative blood, you will need a shot of Rhogam. This prevents problems in future pregnancies. If you have not had your blood type checked, you will need a blood test to find out if you are Rh-negative. Many miscarriages complete on their own, but sometimes treatment is needed. If you are having a miscarriage, work with your doctor to watch for and prevent problems. If the uterus does not clear quickly enough, you could lose too much blood or develop an infection. In this case, medicine or a procedure called a dilation and curettage (D&C) can more quickly clear tissue from the uterus. A miscarriage doesn't happen all at once. It usually takes place over several days, and symptoms vary. Here are some tips for dealing with a miscarriage:
Use pads instead of tampons. You will probably have vaginal bleeding for a week or so. It may be like or slightly heavier than a normal period. You may use tampons during your next period, which should start in 3 to 6 weeks.
Take acetaminophen (Tylenol) for cramps. Read and follow all instructions on the label. You may have cramps for several days after the miscarriage.
Eat a balanced diet that is high in iron and vitamin C. You may be low in iron because of blood loss. Foods rich in iron include red meat, shellfish, eggs, beans, and leafy green vegetables. Foods high in vitamin C include citrus fruits, tomatoes, and broccoli. Talk to your doctor about whether you need to take iron pills or a multivitamin.
Talk with family, friends, or a counselor if you are having trouble dealing with the loss of your pregnancy. If you feel very sad or depressed for longer than 2 weeks, talk to a counselor or your doctor.
Talk with your doctor about any future pregnancy plans. Most doctors suggest that you wait until you have had at least one normal period before you try to get pregnant again. If you don't want to get pregnant, ask your doctor about birth control options.
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Miscarriage Classification and external resources
ICD-10 ICD-9 MedlinePlus eMedicine MeSH
O03. 634 001488 topic list D000022
Miscarriage or spontaneous abortion is the natural or spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving, generally defined in humans at prior to 20 weeks of gestation. Miscarriage is the most common complication of early pregnancy. The medical term "spontaneous abortion" is used in reference to miscarriages because the medical term "abortion" refers to any terminated pregnancy, deliberately induced or spontaneous, although in common parlance it refers specifically to active termination of pregnancy.
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• • • • • • • • •
1 Terminology 2 Forms and types 3 Causes o 3.1 First trimester o 3.2 Second trimester o 3.3 General risk factors o 3.4 Correlations 4 Prevalence 5 Detection 6 Management 7 Pathology 8 Psychological aspects 9 ICD10 codes 10 See also 11 References 12 External links
Very early miscarriages - those which occur before the sixth week LMP (since the woman's Last Menstrual Period) are medically termed early pregnancy loss or chemical pregnancy. Miscarriages that occur after the sixth week LMP are medically termed clinical spontaneous abortion. In medical contexts, the word "abortion" refers to any process by which a pregnancy ends with the death and removal or expulsion of the fetus, regardless of whether it is spontaneous or intentionally induced. Many women who have had miscarriages, however, object to the term "abortion" in connection with their experience, as it is generally associated with induced abortions. In recent years there has been discussion in the medical community about avoiding the use of this term in favor of the less ambiguous term "miscarriage."
Labour resulting in live birth before the 37th week of pregnancy is termed "premature birth," even if the infant dies shortly afterward. The limit of viability at which 50% of fetus/infants survive longterm is around 24 weeks, with moderate or major neurological disability dropping to 50% only by 26 weeks. Although long-term survival has never been reported for infants born from pregnancy shorter than 21 weeks and 5 days, infants born as early as the 16th week of pregnancy may sometimes live for some minutes after birth. A fetus that dies while in the uterus after about the 20-24th week of pregnancy is termed a "stillbirth"; the precise gestational age definition varies by country. Premature births or stillbirths are not generally considered miscarriages, though usage of the terms and causes of these events may overlap.
 Forms and types
The clinical presentation of a threatened abortion describes any bleeding seen during pregnancy prior to viability, that has yet to be assessed further. At investigation it may be found that the fetus remains viable and the pregnancy continues without further problems. It has been suggested that bed rest improves the chances of the pregnancy continuing when a small subchorionic hematoma has been found on ultrasound scans. Alternatively the following terms are used to describe pregnancies that do not continue:
An empty sac is a condition where the gestational sac develops normally, while the embryonic part of the pregnancy is either absent or stops growing very early. Other terms for this condition are blighted ovum and anembryonic pregnancy. An inevitable abortion describes where the fetal heart beat is shown to have stopped and the cervix has already dilated open, but the fetus has yet to be expelled. This usually will progress to a complete abortion. A complete abortion is when all products of conception have been expelled. Products of conception may include the trophoblast, chorionic villi, gestational sac, yolk sac, and fetal pole (embryo); or later in pregnancy the fetus, umbilical cord, placenta, amniotic fluid, and amniotic membrane. An incomplete abortion occurs when tissue has been passed, but some remains in utero. A missed abortion is when the embryo or fetus has died, but a miscarriage has not yet occurred. It is also referred to as delayed miscarriage.
The following two terms consider wider complications or implications of a miscarriage:
A septic abortion occurs when the tissue from a missed or incomplete abortion becomes infected. The infection of the womb carries risk of spreading infection (septicaemia) and is a grave risk to the life of the woman. Recurrent pregnancy loss (RPL) or recurrent miscarriage (medically termed habitual abortion) is the occurrence of three consecutive miscarriages. If the proportion of pregnancies ending in miscarriage is 15%, then the probability of two consecutive miscarriages is 2.25% and the probability of three consecutive miscarriages is 0.34%. The occurrence of recurrent pregnancy loss is 1%.  A large majority (85%) of women who have had two miscarriages will conceive and carry normally afterwards.
Miscarriages can occur for many reasons, not all of which can be identified.
 First trimester
Most clinically apparent miscarriages (two thirds to three-quarters in various studies) occur during the first trimester. Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13 weeks. A pregnancy with a genetic problem has a 95% chance of ending in miscarriage. Most chromosomal problems happen by chance, have nothing to do with the parents, and are unlikely to recur. Genetic problems are more likely to occur with older parents; this may account for the higher miscarriage rates observed in older women. Another cause of early miscarriage may be progesterone deficiency. Women diagnosed with low progesterone levels in the second half of their menstrual cycle (luteal phase) may be prescribed progesterone supplements, to be taken for the first trimester of pregnancy. However, no study has shown that general first-trimester progesterone supplements reduce the risk of miscarriage, and even the identification of problems with the luteal phase as contributing to miscarriage has been questioned.
 Second trimester
Up to 15% of pregnancy losses in the second trimester may be due to uterine malformation, growths in the uterus (fibroids), or cervical problems. These conditions may also contribute to premature birth. One study found that 19% of second trimester losses were caused by problems with the umbilical cord. Problems with the placenta may also account for a significant number of later-term miscarriages.
 General risk factors
Pregnancies involving more than one fetus are at increased risk of miscarriage. Uncontrolled diabetes greatly increases the risk of miscarriage. Women with controlled diabetes are not at higher risk of miscarriage. Because diabetes may develop during pregnancy (gestational diabetes), an important part of prenatal care is to monitor for signs of the disease. Polycystic ovary syndrome is a risk factor for miscarriage, with 30-50% of pregnancies in women with PCOS being miscarried in the first trimester. Two studies have shown treatment with the drug metformin to significantly lower the rate of miscarriage in women with PCOS (the metformin-treated groups experienced approximately one-third the miscarriage rates of the control groups). However, a 2006 review of metformin treatment in pregnancy found insufficient evidence of safety and did not recommend routine treatment with the drug. High blood pressure and certain illnesses (such as rubella and chlamydia) increase the risk of miscarriage. Tobacco (cigarette) smokers have an increased risk of miscarriage. An increase in miscarriage is also associated with the father being a cigarette smoker. The husband study observed a 4% increased risk for husbands who smoke less than 20 cigarettes/day, and an 81% increased risk for husbands who smoke 20 or more cigarettes/day. Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder cases of hypothyroidism on miscarriage rates has not been established. Certain immune conditions such as autoimmune diseases greatly increase the risk of miscarriage. Cocaine use increases miscarriage rates. Physical trauma, exposure to environmental toxins, and use of an IUD during the time of conception have also been linked to increased risk of miscarriage.
Several factors have been correlated with higher miscarriage rates, but whether they cause miscarriages is debated. No causal mechanism may be known, the studies showing a correlation may have been retrospective (beginning the study after the miscarriages occurred, which can introduce bias) rather than prospective (beginning the study before the women became pregnant), or both. Nausea and vomiting of pregnancy (NVP, or morning sickness) are associated with a decreased risk of miscarriage. Several mechanisms have been proposed
for this relationship, but none are widely agreed on. Because NVP may alter a woman's food intake and other activities during pregnancy, it may be a confounding factor when investigating possible causes of miscarriage. One such factor is exercise. A study of over 92,000 pregnant women found that most types of exercise (with the exception of swimming) correlated with a higher risk of miscarriage prior to 18 weeks. Increasing time spent on exercise was associated with a greater risk of miscarriage: an approximately 10% increased risk was seen with up to 1.5 hours per week of exercise, and a 200% increased risk was seen with over 7 hours per week of exercise. High-impact exercise was especially associated with the increased risk. No relationship was found between exercise and miscarriage rates after the 18th week of pregnancy. The majority of miscarriages had already occurred at the time women were recruited for the study, and no information on nausea during pregnancy or exercise habits prior to pregnancy was collected. Caffeine consumption has also been correlated to miscarriage rates, at least at higher levels of intake. A 2007 study of over 1,000 pregnant women found that women who reported consuming 200 mg or more of caffeine per day experienced a 25% miscarriage rate, compared to 13% among women who reported no caffeine consumption. 200 mg of caffeine is present in 10 oz (300 mL) of coffee or 25 oz (740 mL) of tea. This study controlled for pregnancyassociated nausea and vomiting (NVP or morning sickness): the increased miscarriage rate for heavy caffeine users was seen regardless of how NVP affected the women. About half of the miscarriages had already occurred at the time women were recruited for the study. A second 2007 study of approximately 2,400 pregnant women found that caffeine intake up to 200 mg per day was not associated with increased miscarriage rates (the study did not include women who drank more than 200 mg per day past early pregnancy).
Determining the prevalence of miscarriage is difficult. Many miscarriages happen very early in the pregnancy, before a woman may know she is pregnant. Treatment of women with miscarriage at home means medical statistics on miscarriage miss many cases. Prospective studies using very sensitive early pregnancy tests have found that 25% of pregnancies are miscarried by the sixth week LMP (since the woman's Last Menstrual Period). Clinical miscarriages (those occurring after the sixth week LMP) occur in 8% of pregnancies. The risk of miscarriage decreases sharply after the 10th week LMP, i.e. when the fetal stage begins. The loss rate between 8.5 weeks LMP and birth is about two percent; loss is “virtually complete by the end of the embryonic period." The prevalence of miscarriage increases considerably with age of the parents. One study found that pregnancies from men younger than twenty-five years are
40% less likely to end in miscarriage than pregnancies from men 25-29 years. The same study found that pregnancies from men older than forty years are 60% more likely to end in miscarriage than the 25-29 year age group. Another study found that the increased risk of miscarriage in pregnancies from older men is mainly seen in the first trimester. Yet another study found an increased risk in women, by the age of forty-five, on the order of 800% (compared to the 20-24 age group in that study), 75% of pregnancies ended in miscarriage.
The most common symptom of a miscarriage is bleeding; bleeding during pregnancy may be referred to as a threatened abortion. Of women who seek clinical treatment for bleeding during pregnancy, about half will go on to have a miscarriage. Symptoms other than bleeding are not statistically related to miscarriage. Miscarriage may also be detected during an ultrasound exam, or through serial human chorionic gonadotropin (HCG) testing. Women pregnant from ART methods, and women with a history of miscarriage, may be monitored closely and so detect a miscarriage sooner than women without such monitoring. Several medical options exist for managing documented nonviable pregnancies that have not been expelled naturally.
Blood loss during early pregnancy is the most common symptom of both miscarriage and of ectopic pregnancy. Pain does not strongly correlate with miscarriage, but is a common symptom of ectopic pregnancy. In the case of concerning blood loss, pain, or both, transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with ultrasound, serial βHCG tests should be performed to rule out ectopic pregnancy, which is a life-threatening situation. If the bleeding is light, making an appointment to see one's doctor is recommended. If bleeding is heavy, there is considerable pain, or there is a fever, then emergency medical attention is recommended to be sought. No treatment is necessary for a diagnosis of complete abortion (as long as ectopic pregnancy is ruled out). In cases of an incomplete abortion, empty sac, or missed abortion there are three treatment options:
With no treatment (watchful waiting), most of these cases (65–80%) will pass naturally within two to six weeks. This path avoids the side effects and complications possible from medications and surgery.
Medical management usually consists of using misoprostol (a prostaglandin, brand name Cytotec) to encourage completion of the miscarriage. About 95% of cases treated with misoprostol will complete within a few days. Surgical treatment (most commonly vacuum aspiration, sometimes referred to as a D&C or D&E) is the fastest way to complete the miscarriage. It also shortens the duration and heaviness of bleeding, and is the best treatment for physical pain associated with the miscarriage. In cases of repeated miscarriage or later-term pregnancy loss, D&C is also the best way to obtain tissue samples for pathology examination.
When looking for gross or microscopic pathologic symptoms of miscarriage, one looks for the products of conception. Microscopically, these include villi, trophoblast, fetal parts, and background gestational changes in the endometrium. Genetic tests may also be performed to look for abnormal chromosome arrangements.
 Psychological aspects
Although a woman physically recovers from a miscarriage quickly, psychological recovery for parents in general can take a long time. People differ a lot in this regard: some are 'over it' after a few months, others take more than a year. Still others may feel relief or other less negative emotions. For those who do go through a process of grief, it is often as if the baby had been born but died. How short a time the fetus lived in the womb may not matter for the feeling of loss. From the moment pregnancy is discovered, the parents can start to bond with the unborn child. When the child turns out not to be viable, dreams, fantasies and plans for the future are disturbed roughly. Besides the feeling of loss, a lack of understanding by others is often important. People who have not experienced a miscarriage themselves may find it hard to empathize with what has occurred and how upsetting it may be. This may lead to unrealistic expectations of the parents' recovery. The pregnancy and miscarriage are hardly mentioned anymore in conversation, often because the subject is too painful. This can make the woman feel particularly isolated. Interaction with pregnant women and newborn children is often also painful for parents who have experienced miscarriage. Sometimes this makes interaction with friends, acquaintances and family very difficult.
 ICD10 codes
The exact etiology of this disorder is unknown, with several theories being advanced. Data have suggested that PIH may be the result of increased peripheral vascular resistance secondary to generalized vasospasm when the vessels are no longer refractory to the effects of pressor agents. New research proposes that elevated cardiac output and associated hyperdynamic vasodilation during the first trimester result in damage to the endothelium with compensatory vascular vasodilation. Regardless of the mechanisms, PIH is a chronic disease process, with a decrease in placental perfusion occurring before the late sign of hypertension is detected. (This plan of care is to be used in conjunction with the Trimesters and the High-Risk Pregnancy CPs.)
CLIENT ASSESSMENT DATA BASE Circulation
Persistent increase in BP over pregravid or first-trimester baseline readings after 20 wk of pregnancy (systolic elevation > 30 mm Hg, diastolic elevation > 15 mm Hg or a BP > 140/90 mm Hg on two consecutive readings assessed at least 6 hr apart). History of chronic hypertension. Jugular venous distension. Gallop rhythm may be present. Pulse may be decreased. May have spontaneous bruising, prolonged bleeding, or epistaxis (thrombocytopenia).
Oliguria/anuria may be present. Hematuria may be noted.
Nausea/vomiting. Weight gain of 2+ lb in 1 wk, 4 lb or more per month (depending on length of gestation). Malnourished (overweight or underweight by 20% or greater); poor protein/caloric intake. Edema may be present, ranging from mild to severe/generalized; and may involve facies, extremities, and organ systems (i.e., liver, brain). Glycosuria (diabetes mellitus).
Dizziness, frontal headaches. Decreased responsiveness/somnolence. Diplopia, blurred vision, or even loss of visual fields; scotomata (spots before eyes). Hyperreflexia; clonus. Convulsions—tonic, then tonic-clonic phases, followed by a period of loss of consciousness. Funduscopic examination may reveal edema or vascular spasm.
Epigastric pain (right upper quadrant [RUQ] region)
Respirations may be less than 14/min. Bibasilar crackles may be present. Dyspnea.
Rh incompatibility may be present.
Primigravida, multiple gestation, hydramnios, gestational trophoblastic disease (e.g.,: hydatidiform mole), hydrops fetalis (Rh antigen-antibody) Fetal movement may be diminished Signs of abruptio placentae may be present (e.g., uterine tetany, tenderness)
Adolescent (under age 15 yr) and older primigravida (age 35 yr or older) are at greatest risk Family history of pregnancy-induced hypertension (PIH)
Supine Pressor Test (“rollover test”): May be used to screen for clients at risk for PIH, 28–32 wk gestation, although accuracy is questionable; an increase of 20–30 mm Hg in
systolic pressure or 15–20 mm Hg in diastolic pressure indicates a positive test. Mean Arterial Pressure (MAP): 90 mm Hg at second trimester indicates PIH. Hematocrit (Hct): Elevated with fluid shifts, or decreased in HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). Hemoglobin (Hb): Low when hemolysis occurs (HELLP syndrome). Peripheral Smear: Distended blood cells or schistocytes in HELLP syndrome or intravascular hemolysis. Serum Platelet Counts: Less than 100,000/mm3 in disseminated intravascular coagulation (DIC) or in HELLP syndrome, because platelets adhere to collagen released from damaged blood vessels. Serum Creatinine Level: Elevated above 1.0 mg/dL and blood urea nitrogen (BUN): Greater than 10 mg/dL reflects severe renal involvement. AST, LDH, and Serum Bilirubin Levels (indirect particularly): Elevated in HELLP syndrome with liver involvement. Uric Acid Level: Greater than 5 mg/100 mL. Helpful in distinguishing preeclampsia from uncomplicated chronic hypertension. Prothrombin time (PT), Partial Thromboplastin Time (PTT), Clotting Time: Prolonged; fibronogen decreased, FSP and FDP positive when coagulopathy occurs (DIC). Urine-Specific Gravity: Elevated, reflecting fluid shifts/vascular dehydration. Proteinuria: By dipstick, may be 1+ to 2+ (moderate), 3+ to 4+ (severe), or greater than 500 mg/dL in 24 h. Creatinine Clearance: Decreased in preeclampsia (before serum BUN/Creatinine elevated). Urinary/Plasma Estriol Levels: Decline indicates reduced placental functioning. (Estroils are not as useful a predictor as biophysical profile [BPP] because of the lag time between fetal problem and test results.) Human Placental Lactogen Levels: Less than 4 mEq/ml suggests abnormal placental functioning (not frequently done n PIH screening). Ultrasonography: At 20–26 weeks’ gestation and repeated 6–10 wk later, establishes gestational age and detects IUGR. Tests of Amniotic Fluid (lecithin sphingomyelin [L/S] ratio, phosphalidylglycerol (PG), saturated phosphatidylcholine levels): Determine fetal lung maturity. Biophysical Profile (BPP) (amniotic fluid volume, fetal tone, fetal breathing movements [FMB], fetal movements, and fetal heart rate [FHR] reactivity)/Nonstress Test (NST): Determines fetal risk/well-being. CST: Assesses the response of the fetus to the stress of uterine contractions.
1. 2. 3. 4. Monitor maternal, fetal, and placental status. Prevent or reduce progressive fluid accumulation and other complications. Promote positive maternal/fetal outcome. Provide information to enhance self-care and therapeutic management.
(Inpatient care generally not required, unless fetal compromise or eclampsia develops, or when labor process begins.) If hospitalized: 1. Hemodynamically stable, free-of-seizure activity 2. Fetus active and in no distress 3. Condition, prognosis, therapeutic regimen understood 4. Participating in care with plan in place for home monitoring/management NURSING DIAGNOSIS: Fluid Volume deficit [isotonic] May Be Related To: Plasma protein loss, decreasing plasma colloid osmotic pressure, allowing fluid shifts out of the vascular compartment Possibly Evidenced By: Edema formation, sudden weight gain, hemoconcentration, nausea/ vomiting, epigastric pain, headaches, visual changes, decreased urine output DESIRED OUTCOMES/EVALUATION Verbalize understanding of need for close CRITERIA—CLIENT WILL: monitoring of weight, BP, urine protein, and edema. Participate in therapeutic regimen and monitoring, as indicated. Display Hct WNL and physiological edema with no signs of pitting.
Be free of signs of generalized edema (i.e., epigastric pain, cerebral symptoms, dyspnea, nausea/vomiting).
ACTIONS/INTERVENTIONS RATIONALE Independent
Weigh client routinely. Encourage client to Sudden, significant weight gain (e.g., more than monitor weight at home between visits. 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema. Distinguish between physiological and pathological The presence of pitting edema (mild, 1+ to 2+; severe, edema of pregnancy. Monitor location and 3+ to 4+) of face, hands, legs, sacral area, or abdodegree of pitting. minal wall, or edema that does not disappear after 12 hr of bedrest is significant. Note: Significant edema may actually be present in nonpre-eclamptic clients and absent in clients with mild or moderated PIH. Note signs of progressive or excessive edema Edema and intravascular fibrin deposition (in (i.e., epigastric/RUQ pain, cerebral symptoms, HELLP syndrome) within the encapsulated liver nausea, vomiting). Assess for possible eclampsia. are manifested by RUQ pain; dyspnea, indicating (Refer to ND: Injury, risk for maternal.) pulmonary involvement; cerebral edema, possibly leading to seizures; and nausea and vomiting, indicating GI edema. Note changes in Hct/Hb levels. Identifies degree of hemoconcentration caused by fluid shift. If Hct is less than 3 times Hb level, hemoconcentration exists. Reassess dietary intake of proteins and calories. Adequate nutrition reduces incidence of prenatal Provide information as needed. hypovolemia and hypoperfusion; inadequate protein/calories increases the risk of edema formation and PIH. Intake of 80–100 g of protein may be required daily to replace losses. Monitor intake and output. Note urine color, and Urine output is a sensitive indicator of circulatory measure specific gravity as indicated. blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Note: Administration of magnesium sulfate (MgSO4) may cause transient increase in output. Test clean, voided urine for protein each visit, or Aids in determining degree of severity/ daily/hourly as appropriate if hospitalized. progression of condition. A 2+ reading suggests Report readings of 2+, or greater. glomerular edema or spasm. Proteinuria affects fluid shifts from the vascular tree. Note: Urine contaminated by vaginal secretions may test positive for protein, or dilution may result in a false-negative result. In addition, PIH may be present without significant proteinuria. Assess lung sounds and respiratory rate/effort. Dyspnea and crackles may indicate pulmonary edema, which requires immediate treatment. Monitor BP and pulse. (Refer to ND: Cardiac Elevation in BP may occur in response to Output, decreased.) catecholamines, vasopressin, prostaglandins, and, as recent findings suggest, decreased levels of prostacyclin. Answer questions and review rationale for Diuretics further increase state of dehydration by avoiding use of diuretics to treat edema. decreasing intravascular volume and placental perfusion, and they may cause thrombocytopenia, hyperbilirubinemia, or alteration in carbohydrate metabolism in fetus/newborn. Note: May be useful in treating pulmonary edema.
Schedule prenatal visit every 1–2 wk if PIH is mild; Necessary to monitor changes more closely for the weekly if severe. well-being of the client and fetus. Review moderate sodium intake of up to 6 g/day. Some sodium intake is necessary because levels Instruct client to read food labels and avoid foods below 2–4 g/day result in greater dehydration in high in sodium (e.g., bacon, luncheon meats, some clients. However, excess sodium may hot dogs, canned soups, and potato chips). increase edema formation. Refer to dietitian as indicated. Nutritional consult may be beneficial in determining individual needs/dietary plan. Place client on strict regimen of bedrest; Lateral recumbent position decreases pressure encourage lateral position. onthe vena cava, increasing venous return and circulatory volume. This enhances placental and renal perfusion, reduces adrenal activity, and may lower BP as well as account for weight loss through diuresis of up to 4 lb in 24-hr period. Refer to home monitoring/day-care program, Some mildly hypertensive clients without as appropriate. proteinuria may be managed on an outpatient basis if adequate surveillance and support is provided and the client/family actively participates in the treatment regimen. Replace fluids either orally or parenterally Fluid replacement corrects hypovolemia, yet must via infusion pump, as indicated. be administered cautiously to prevent overload, especially if interstitial fluid is drawn back into circulation when activity is reduced. With renal involvement, fluid intake is restricted; i.e., if output is reduced (less than 700 ml/24 hr), total fluid intake is restricted to approximate output plus insensible loss. Use of infusion pump allows more accurate control delivery of IV fluids. When fluid deficit is severe and client is hospitalized: Insert indwelling catheter if kidney output is Allows more accurate monitoring of output/renal reduced or is less than 50 ml/hr. perfusion. Assist with insertion of lines and/or monitoring Provides a more accurate measurement of fluid of invasive hemodynamic parameters, such as volume. In normal pregnancy, plasma volume CVP and pulmonary artery wedge pressure increases by 30%–50%, yet this increase does not (PAWP). occur in the client with PIH. Monitor serum uric acid and creatinine levels, Elevated levels, especially of uric acid, indicate and BUN. impaired kidney function, worsening of maternal condition, and poor fetal outcome. Administer platelets as indicated. Clients with HELLP syndrome awaiting delivery of the fetus may benefit from transfusion of platelets when count is below 20,000. NURSING DIAGNOSIS: Cardiac Output, decreased May Be Related To: Hypovolemia/decreased venous return, increased systemic vascular resistance Possibly Evidenced By: Variations in blood pressure/hemodynamic readings, edema, shortness of breath, change in mental status DESIRED OUTCOMES/EVALUATION Remain normotensive throughout remainder of CRITERIA—CLIENT WILL: pregnancy. Report absence and/or decreased episodes of dyspnea. Alter activity level as condition warrants.
ACTIONS/INTERVENTIONS RATIONALE Independent
Monitor and graph BP and pulse. The client with PIH does not manifest the normal cardiovascular response to pregnancy (left ventricular hypertrophy, increase in plasma volume, vascular relaxation with decreased
peripheral resistance). Hypertension (the second manifestation of PIH after edema) occurs owing to increased sensitization to angiotensin II, which increases BP, promotes aldosterone release to increase sodium/water reabsorption from the renal tubules, and constricts blood vessels. Assess MAP at 22 weeks’ gestation. A pressure Pulmonary edema may occur, with changes in of 90 mm Hg is considered predictive of PIH. peripheral vascular resistance and decline in Assess for crackles, wheezes, and dyspnea; plasma colloid osmotic pressure. note respiratory rate/effort. Institute bedrest with client in lateral position. Increases venous return, cardiac output, and renal/placental perfusion.
Monitor invasive hemodynamic parameters. Provides accurate picture of vascular changes and fluid volume. Prolonged vascular constriction, increased hemoconcentration, and fluid shifts decrease cardiac output. Administer antihypertensive drug such as If BP does not respond to conservative measures, hydralazine (Apresoline) PO/IV, so that diastolic short-term medication may be necessary in readings are between 90 and 105 mm Hg. Begin conjunction with other therapies, e.g., fluid maintenance therapy as needed, e.g., methyldopa replacement and MgSO4. Antihypertensive drugs (Aldomet) or nifedipine (Procardia). act directly on arterioles to promote relaxation of cardiovascular smooth muscle and help increase blood supply to cerebrum, kidneys, uterus, and placenta. Hydralazine is the drug of choice because it does not produce effects on the fetus. Sodium nitroprusside is being used with some success to lower BP (especially in HELLP syndrome). Monitor BP and side effects of antihypertensive Side effects such as tachycardia, headache, nausea, drugs. Administer propranolol (Inderal), as and vomiting, and palpitations may be treated with appropriate. propranolol. Prepare for birth of fetus by cesarean delivery, If conservative treatment is ineffective and labor when severe PIH/eclamptic condition is induction is ruled out, then surgical procedure is stabilized, but vaginal delivery is not feasible. the only means of halting the hypertensive problems. NURSING DIAGNOSIS: Tissue Perfusion, altered: uteroplacental May Be Related To: Maternal hypovolemia, interruption of blood flow (progressive vasospasm of spiral arteries) Possibly Evidenced By: Intrauterine growth retardation, changes in fetal activity/heart rate, premature delivery, fetal demise DESIRED OUTCOMES/EVALUATION Demonstrate normal CNS reactivity on nonstress CRITERIA—FETUS WILL: test (NST); be free of late decelerations; have no decrease in FHR on contraction stresstest (NST); be free of late decelerations; have no decrease in FHR on contraction stress test/oxytocin challenge test (CST/OCT). Be full-term, AGA.
ACTIONS/INTERVENTIONS RATIONALE Independent
Provide information to client/couple regarding Reduced placental blood flow results in reduced home assessment/recording of daily fetal gas exchange and impaired nutritional functioning movements and when to seek immediate of the placenta. Potential outcomes of poor placental medical attention. perfusion include a malnourished, LBW infant, and prematurity associated with early delivery, abruptio placentae, and fetal death. Reduced fetal activity indicates fetal compromise (occurs before detectable alteration in FHR and indicates need for immediate evaluation/intervention. Identify factors affecting fetal activity. Cigarette smoking, medication/drug use, serum
glucose levels, environmental sounds, time of day, and sleep-wake cycle of the fetus can increase or decrease fetal movement. Review signs of abruptio placentae (i.e., vaginal Prompt recognition and intervention increases the bleeding, uterine tenderness, abdominal pain, likelihood of a positive outcome. and decreased fetal activity). Provide contact number for client to ask questions, Provides opportunity to address concerns/ report changes in daily fetal movements, and so forth. misconceptions and intervene in a timely manner, as indicated. Evaluate fetal growth; measure progressive fundal Decreased placental functioning may accompany growth at each office visit or periodically during PIH, resulting in IUGR. Chronic intrauterine stress home visits, as appropriate. and uteroplacental insufficiency decrease amount of fetal contribution to amniotic fluid pool. Note fetal response to medications such as MgSO4, Depressant effects of medication reduce fetal respiraphenobarbital, and diazepam. tory and cardiac function and fetal activity level, even though placental circulation may be adequate. Monitor FHR manually or electronically, as indicated. Helps evaluate fetal well-being. An elevated FHR may indicate a compensatory response to hypoxia, prematurity, or abruptio placentae.
Assess fetal response to BPP criteria or CST, as BPP helps evaluate fetus and fetal environment on maternal status indicates. (Refer to ND: Injury, five specific parameters to assess CNS function risk for maternal.) and fetal contribution to amniotic fluid volume. CST assesses placental functioning and reserves. Assist with assessment of fetal maturity and In the event of deteriorating maternal/fetal well-being using L/S ratio, presence of PG, condition, risks of delivering a preterm infant are estriol levels, FBM, and sequential sonography weighed against the risks of continuing the beginning at 20–26 weeks’ gestation. (Refer to pregnancy, using results from evaluative studies CP: The High-Risk Frequency; ND: Injury, risk of lung and kidney maturity, fetal growth, and for fetal.) placental functioning. IUGR is associated with reduced maternal volume and vascular changes. Assist with assessment of maternal plasma volume Identifies fetus at risk for IUGR or intrauterine at 24–26 weeks’ gestation using Evans’ blue dye fetal demise associated with reduced plasma when indicated. volume and reduced placental perfusion. Using ultrasonography, assist with assessment of Decreased placental function and size are placental size. associated with PIH. Administer corticosteroid (dexamethasone, Corticosteroids are thought to induce fetal pulmonary betamethasone) IM for at least 24–48 hr, but not maturity (surfactant production) and prevent respiramore than 7 days before delivery, when severe tory distress syndrome, at least in a fetus delivered PIH necessitates premature delivery between prematurely because of condition or inadequate 28 and 34 weeks’ gestation. placental functioning. Best results are obtained when fetus is less than 34 weeks’ gestation and delivery occurs within a week of corticosteroid administration. NURSING DIAGNOSIS: Injury, risk for maternal May Be Related To: Tissue edema/hypoxia, tonic-clonic convulsions, abnormal blood profile and/or clotting factors Possibly Evidenced By: [Not applicable: Presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Participate in treatment and/or environmental CRITERIA—CLIENT WILL: modifications to protect self and enhance safety.
DESIRED OUTCOMES/EVALUATION Be free of signs of cerebral ischemia (visual CRITERIA—CLIENT WILL (cont.): disturbances, headache, changes in mentation). Display normal levels of clotting factors and liver enzymes.
ACTIONS/INTERVENTIONS RATIONALE Independent
Assess for CNS involvement (i.e., headache, Cerebral edema and vasoconstriction can be irritability, visual disturbances or changes on evaluated in terms of symptoms, behaviors, or funduscopic examination). retinal changes. Stress importance of client promptly reporting Delayed treatment or progressive onset of symptoms signs/symptoms of CNS involvement. may result in tonic-clonic convulsions or eclampsia. Note changes in level of consciousness. In progressive PIH, vasoconstriction and vasospasms of cerebral blood vessels reduce oxygen consumption by 20% and result in cerebral ischemia. Assess for signs of impending eclampsia: Generalized edema/vasoconstriction, manifested hyperactivity of deep tendon reflexes (3+ to 4+), by severe CNS, kidney, liver, cardiovascular, and ankle clonus, decreased pulse and respirations, respiratory involvement, precede convulsive state. epigastric pain, and oliguria (less than 50 ml/hr). Institute measures to reduce likelihood of seizures; Reduces environmental factors that may stimulate i.e., keep room quiet and dimly lit, limit visitors, irritable cerebrum and cause a convulsive state. plan and coordinate care, and promote rest. Implement seizure precautions per protocol. If seizure does occur, reduces risk of injury. In the event of a seizure: Maintains airway by reducing risk of aspiration and Turn client on side; insert airway/bite block only preventing tongue from occluding airway. if mouth is relaxed; suction nasopharynx, as Maximizes oxygenation. Note: Be cautious with indicated; administer oxygen; remove restrictive use of airway/bite block, because attempts to insert clothing; do not restrict movement. Document when jaws are set may result in injury. motor involvement, duration of seizure, and postseizure behavior. Palpate for uterine tenderness or rigidity; These signs may indicate abruptio placentae, check for vaginal bleeding. Note history especially if there is a preexisting medical problem, of other medical problems. such as diabetes mellitus, or a renal or cardiac disorder causing vascular involvement. Monitor for signs and symptoms of labor Convulsions increase uterine irritability; labor may or uterine contractions. ensue. Assess fetal well-being, noting FHR. During seizure activity, fetal bradycardia may occur. Monitor for signs of DIC easy/spontaneous bruising, Abruptio placentae with release of thromboplastin prolonged bleeding, epistaxis, GI bleeding. predisposes client to DIC. (Refer to CP: Prenatal Hemorrhage.)
Hospitalize if CNS involvement is present. Prompt initiation of therapy helps to ensure safety and limit complications. Administer MgSO4 IM or IV using infusion pump. MgSO4 a CNS depressant, decreases acetylcholine release, blocks neuromuscular transmission, and prevents seizures. It has a transient effect of lowering BP and increasing urine output by altering vascular response to pressor substances. Although IV administration of MgSO4 is easier to regulate and reduces the risk of a toxic reaction, some facilities may still use the IM route if continuous surveillance is not possible and/or if appropriate infusion apparatus is not available. Note: Adding 1 ml of 2% lidocaine to the IM injection may reduce associated
discomfort. (Current research suggests the use of phenytoin infusion may be effective in the treatment of PIH without the adverse side effects, such as respiratory depression, and tocolytic effect on uterine smooth muscle, which can impede labor during intrapartal therapy.) Monitor BP before, during, and after MgSO4 A therapeutic level of MgSO4 is achieved with administration. Note serum magnesium levels in serum levels of 4.0–7.5 mEq/L or 6–8 mg/dL. conjunction with respiratory rate, patellar/deep Adverse/toxic reactions develop above 10–12 tendon reflex (DTRs), and urine output. mg/dL, with loss of DTRs occurring first, respiratory paralysis between 15–17 mg/dL, or heart block occurring at 30–35 mg/dL. Have calcium gluconate available. Administer Serves as antidote to counteract adverse/toxic 10 ml (1 g/10 ml) over 3 min as indicated. effects of MgSO4. Administer amobarbital (Amytal) or diazepem Depresses cerebral activity; has sedative effect (Valium), as indicated. when convulsions are not controlled by MgSO4. Not recommended as first-line therapy because sedative effect also extends to the fetus. Perform funduscopic examination daily. Helps to evaluate changes or severity of retinal involvement. Monitor test results of clotting time, PT, PTT, Such tests can indicate depletion of coagulation fibrinogen levels, and FPS/FDP. factors and fibrinolysis, which suggests DIC. Monitor sequential platelet count. Avoid Thrombocytopenia may occur because of platelet amniocentesis if platelet count is less than adherence to disrupted endothelium or reduced 50,000/mm3. If thrombocytopenia is present during prostacyclin levels (a potent inhibitor of platelet operative procedure, use general anesthesia. aggregation). Invasive procedures or anesthesia Transfuse with platelets, packed red blood cells, requiring needle puncture (such as spinal/ fresh frozen plasma, or whole blood, as indicated. epidural) could result in excessive bleeding. Rule out HELLP syndrome. Monitor liver enzymes and bilirubin; note hemolysis Elevated liver enzyme (AST, ALT) and bilirubin and presence of Burr cells on peripheral smear. levels, microangiopathic hemolytic anemia, and thrombocytopenia may indicate presence of HELLP syndrome, signifying a need for immediate cesarean delivery if condition of cervix is unfavorable for induction of labor. Prepare for cesarean birth if PIH is severe, When fetal oxygenation is severely reduced owing placental functioning is compromised, and cervix is to vasoconstriction within malfunctioning not ripe or is not responsive to induction. placenta, immediate delivery may be necessary to save the fetus. NURSING DIAGNOSIS: Nutrition: altered, risk for less than body requirements May Be Related To: Intake insufficient to meet metabolic demands and replace losses Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Verbalize understanding of individual dietary CRITERIA—CLIENT WILL: needs. DESIRED OUTCOMES/EVALUATION Demonstrate knowledge of proper diet as evidenced CRITERIA—CLIENT WILL (cont.): by developing a dietary plan within own financial resources. Display appropriate weight gain.
ACTIONS/INTERVENTIONS RATIONALE Independent
Assess client’s nutritional status, condition of Establishes guidelines for determining dietary hair and nails, and height and pregravid weight. needs and educating client. Malnutrition may be a contributing factor to the onset of PIH, specifically when client follows a low-protein diet, has
insufficient caloric intake, and is overweight or underweight by 20% or more before conception. Provide information about normal weight gain in The underweight client may need a diet higher in pregnancy, modifying it to meet client’s needs. calories; the obese client should avoid dieting because it places the fetus at risk for ketosis. Provide oral/written information about action and Daily intake of 80–100 g/day (1.5 g/kg) is uses of protein and its role in development of PIH. sufficient to replace proteins lost in urine and allow for normal serum oncotic pressure. Provide information about effect of bedrest and Reducing metabolic rate through bedrest and reduced activity on protein requirements. limited activity decreases protein needs.
Refer to dietitian, as indicated. Helpful in creating individual dietary plan incorporating specific needs/restrictions. NURSING DIAGNOSIS: Knowledge deficit [Learning Need] regarding condition, prognosis, self care and treatment needs May Be Related To: Lack of exposure/unfamiliarity with information resources, misinterpretation Possibly Evidenced By: Request for information, statement of misconceptions, inaccurate follow-through of instructions, development of preventable complications DESIRED OUTCOMES/EVALUATION Verbalize understanding of disease process and CRITERIA—CLIENT/COUPLE WILL: appropriate treatment plan. Identify signs/symptoms requiring medical evaluation. Perform necessary procedures correctly. Initiate lifestyle/behavior changes as indicated.
ACTIONS/INTERVENTIONS RATIONALE Independent
Assess client’s/couple’s knowledge of the Establishes data base and provides information disease process. Provide information about about areas in which learning is needed. Receiving pathophysiology of PIH, implications for information can promote understanding and mother and fetus; and the rationale for reduce fear, helping to facilitate the treatment plan interventions, procedures, and tests, as needed. for the client. Note: Current research in progress may provide additional treatment options, such as using low-dose (60 mg/day) aspirin to reduce thromboxane generation by platelets, limiting the severity/incidence of PIH. Provide information about signs/symptoms Helps ensure that client seeks timely treatment indicating worsening of condition, and instruct and may prevent worsening of preeclamptic state client when to notify healthcare provider. or additional complications. Keep client informed of health status, results of Fears and anxieties can be compounded when tests, and fetal well-being. client/couple does not have adequate information about the state of the disease process or its impact on client and fetus. Instruct client in how to monitor her own weight Gain of 3.3 lb or greater per month in second at home, and to notify healthcare provider if gain trimester or 1 lb or greater per week in third is in excess of 2 lb/wk, or 0.5 lb/day. trimester is suggestive of PIH. Assist family members in learning the procedure Encourages participation in treatment regimen, for home monitoring of BP, as indicated. allows prompt intervention as needed, and may provide reassurance that efforts are beneficial. Review techniques for stress management and Reinforces importance of client’s responsibility in diet restriction. treatment. Provide information about ensuring adequate Protein is necessary for intravascular and protein in diet for client with possible or extravascular fluid regulation. mild preeclampsia.
Review self-testing of urine for protein. Reinforce A test result of 2+ or greater is significant and rationale for and implications of testing. needs to be reported to healthcare provider. Urine specimen contaminated by vaginal discharge or RBCs may produce positive test result for protein.
III. DIAGNOSIS Ectopic Pregnancy. With ectopic pregnancy, fertilization occurs as usual in the distal third of the fallopian tube. Immediately after the union of ovum and spermatozoon, the zygote begins to divide and grow normally. Unfortunately, because an obstruction is present, such as an adhesion of the fallopian tube from a previews infection, congenital malformations, scars from tubal surgery, or a uterine tumor pressing on the proximal end of the tube, the zygote cannot travel the length of the tube. It lodges at the strictured site along the tube and implants there instead of in the uterus. There are seven sites where implantation occurs: ampullary, isthmic (most common is in the fallopian tube), fimbrial, cornual, abdominal, ovarian, and cervical. Approximately 2% of pregnancies are ectopic; ectopic pregnancy is the second most frequent cause of bleeding early in pregnancy. The incidence is increasing because of the increasing rate of pelvic inflammatory disease, which lead to tubal scarring. Ectopic pregnancy occurs more frequently in women who smoke compared to those who do not. There is some evidence that intrauterine devices ( IUD ) used for constipation may slow the transport of the zygote and lead to an increased incidence of tubal or ovarian implantation. The incidence also increases following in vitro fertilization. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic. This is because salpingitis that leaves scarring is usually bilateral. Congenital anomalies such as webbing may also be bilateral. Surprisingly, oral contraceptive may reduce the possibility of ectopic pregnancy. Causes of ectopic pregnancy include PID, tubal abnormalities, endometriosis, scarring, caused by previous tubal surgery, prior ectopic pregnancies. Tubal sterilization administration of hormones and the “morning after pill”. An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked it. Pelvic inflammatory disease (PID) is the most common of these infections. Endometriosis (when cells from the lining of the uterus detach and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress.
Some birth control methods can also increase your risk of ectopic pregnancy. If you get pregnant while using progesterone-only oral contraceptives, progesterone intrauterine devices (IUDs), or the morning-after pill, you're more likely to have an ectopic pregnancy. Manifestations. Signs and symptoms would include lower abdominal/pelvic pain, mild cramping on one side of the pelvis, amenorrhea, abnormal vaginal, bleeding (spotting), breast tenderness, nausea, low back pain. If rupture, and hemorrhaging occurs before treating the pregnancy, symptoms may worsen and include severe, sharp, and sudden pain in the lower abdominal area, feeling faint, or actually fainting and referred pain to the shoulder area. Diagnostic tests. Usually, a positive pregnancy test, hematocrit test may be normal or decreased, white blood count may be normal or increased, a culdocentesis may be performed to determine if free blood is present in the abdomen, an ultrasound illustrates an empty uterus, a D&C may be indicated to rule out a non-viable intra-uterine pregnancy. ASSESSMENT Subjective Data. The client describes amenorrhea, nausea, breast tenderness, and a dull ache on one side that has increasingly become more severe. When the tube ruptures, the client will describe a single excruciating pain in the abdomen and may also have referred shoulder pain. With the case of our patient, Rosenda, she verbalizes that she has had abdominal pain that has become very intense on the third day. Objective Data. Some vaginal bleeding may be apparent. Laboratory reports may show a low hemoglobin and hematocrit, a rising leukocyte level, and a slowly rising hCG level. The RBC count is low and sedimentation rate level elevated. The abdomen may be rigid and tender. Vital signs may indicate hypovolemic shock. The lowering trend of Rosenda’s blood pressure of 90/60 from the initial 100/70 reflects a significant amount of blood loss.
IV. MANAGEMENT Shock is the first symptom of nearly 20% of ectopic pregnancies if it has ruptured. Initial treatment is needed by keeping the womb warm, elevating her legs and administrating oxygen. Surgical laparotomy is performed to stop the immediate loss of blood and repair surrounding tissue damage as much as possible. In some cases, removal of the involved fallopian tube
(Salpingectomy) may be necessary. In the event that rupture has not occurred, methotrexate is administered. Ectopic pregnancies cannot continue to term, so the removal of the developing cells is necessary to save the life of the mother. The Therapeutic Management of Ectopic Pregnancy Although some ectopic pregnancies spontaneously resolve, requiring no treatment, it is difficult to predict when this will happen. Once an ectopic pregnancy ruptures, it is an emergency situation and the woman’s condition must be evaluated quickly. Keep in mind that the amount of blood evident is a poor estimate of the actual blood loss. Blood needs to be drawn immediately for hemoglobin level, typing and cross matching, and possibly HCG level for immediate pregnancy testing, if pregnancy has not been confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun. Blood also can be administered though this same line if necessary. The therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. A rough suture line on a fallopian may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube is done with microscopical technique. If a tube is removed, the woman is theoretically only 50% fertile, because every other months, when she ovulates from the ovary next to the removed tube, sperm cannot reach the ovum on that side. However, this is not a reliable contraceptive measures. Research in rabbits has shown that translocation of ova can occur-that is an ovum released from the right ovary can pass through the pelvic cavity to the opposite (left) fallopian tube and became fertilized and vice versa (Cunningham et al 2001) As with miscarriage, women with Rh-negative blood should receive Rh (D) immune globulin (RhIG) after an ectopic can be diagnosed by a routine sonogram before the tube has been ruptured, it can be treated medically by the oral administration of methotrexate followed by leucovorin. Methotrexate, folic acid antagonists chemotherapy agent, attacks and destroys fast-growing cells. Because trophoblast and zygote growth is rapid, the drug is drawn to the site of the ectopic pregnancy. Women are treated until a negative hcg titer is achieved. A hysterosalpingogram or sonogram is usually performed Therapeutic management of an unruptured ectopic pregnancy with intramuscular methotrexate is common and cost-effective. Two treatment protocols, the "single dose" and the "multidose," have been advocated and independently reported in the medical literature. This analysis systematically compares the success and prevalence of side effects of these two regimens.
Diagnosis in the unruptured state allows for a more conservative approach to patient management. Different conservative surgical and medical lines of management have been associated with increased chance of subsequent intrauterine pregnancy and decline in the incidence of repeat ectopic pregnancy. Laparoscopic salpingostomy has been the main definitive conservative surgical procedure of choice for unruptured ectopic pregnancy, although salpingectomy, salpingotomy and direct injection of cytotoxic agents are also modes of treatment. Laparoscopy was performed under general anesthesia. The abdominal cavity was examined thoroughly; separation of adhesions if present, removal blood clot and ectopic mass was detected. Unilateral salpingostomy, salpingectomy, salpingo-ophrectomy, partial ovarian resection, removal of the sac was done by mono and bipolar coagulation. Peritoneal cavity was irrigated thoroughly with Ringer’s lactate solution and proper hemostasis was established. Medical treatment includes use of methotrexate alone, or a combination of methotrexate and mifepristone. Medical treatment has been reported to be successful in 83% of cases when the mean duration of amenorrhoea was not more than 54 days, the mean serum beta human chorionic gonadotrophin level was not higher than 15, 127 miU/ml and the mean size of the ectopic mass was not larger than 23mm. In cases of persistent fetal cardiac activity after methotrexate treatment, complimentary potassium iodide injection into the pregnancy proved to be effective. Prevention. Forms of ectopic pregnancy other than tubal, are probably not preventable. However, tubal pregnancies may be prevented by avoiding those conditions that might cause scarring of the fallopian tubes. Such prevention may include avoiding risk factors for PID (e.g. multiple partners, intercourse without a condom, and contracting STD’s), early diagnosis and adequate treatment of STD’s, early diagnosis and adequate treatment of PID and salpingitis. Complications. Rupture, with resulting hemorrhage leading to shock and the risk of requiring a blood transfusion, or rarely death, is the most common complication. Also infertility occurs in 10-15% of women who experience an ectopic pregnancy.
V. NURSING CARE PLAN
Assessment Subjective cues: “tatlong araw ng sumasakit ang tiyan ko, ngayon masakit na talaga.” Diagnosis Acute pain related to tubal rupture and blood in the abdomen. Planning At the end of 2-hours nursing intervention, the patient will be relieved from severe pain. Intervention Assess the location, etiology and severity of pain. Rationale To know what is the cause of pain and determine what action will be done. To alleviate the pain. Evaluation After 2 hours of nursing intervention the client verbalize that there is no more pain or has at least become tolerable. Pain scale: 4 The patient be knowledgeable about the pain she feels. So the patient will increase self-esteem. To determine if the patient is in pain. To determine patient’s ability to control pain. To check any changes in the patients condition.
Administer analgesic as ordered and evaluate its effectiveness. Provide information about the cause of pain. Provide comfort measures.
Objective cues: BP: 90/60 mmHg Temp: 36.7 C PR: 88 bpm RR: 23 cpm >pain scale: 8 severe >pale skin >eye lack luster >guarding behavior
The patient can verbalize that the pain is subsided.
Observe nonverbal cues. Assess patient’s attitude toward pain and focus of control. Monitor vital signs usually altered in acute pain.
The patient can now verbalize that the pain is subsided.
Assessment Subjective Cues: “Expression sorrow on clients face.” Objective Cues: >patient withdraws from interaction with other people or shows sign of social isolation. Patient is changing mood. Patient doesn’t want companionship.
Diagnosis Anticipatory grieving related to the lost of pregnancy.
Planning Assist client to deal with the situation.
Intervention Use therapeutic communication skills of active listening, silence, acknowledgement Respect client’s desire/request not to talk. Ascertain response of family/SO(s) to client’s situation/concerns. Observe client’s body language and check out meaning with the client. Note emotional responses such as withdrawal, angry behavior, crying. Instruct in use of visualization and relaxation techniques.
Rationale To promote a free discussion of feelings and concerns.
Evaluation The patient is able to express her feelings with ease.
To know what is the family’s understanding of patient’s situation.
Patient can interact positively with other people.
To know how to deal with patient’s behavior. To lessen patient’s grieving.
Impaired tissue integrity related to rupture of the fallopian tube.
Client will regain tissue integrity of the fallopian tube or it will be
Identify client for surgery as ordered.
To ensure the procedure is appropriate to the problem.
Procedure successfully done.
BP: 90/60 Temp: 36.7 c PR: 88 bpm RR: 23 cpm >pain scale: 8 severe >guarding behavior >crying Pregnancy test (+) LMP: 4/19/07 AOG: 8 weeks Ultrasound Result Revealed: (+) Ampullary Pregnancy
Assessment Subjective Cues: “Natakot po ako baka maulit ang ganitong sitwasyon.”
Diagnosis Fear related to potential subsequent ectopic pregnancy.
Planning Assist client to deal with the fear.
Intervention Provide information as to what ectopic pregnancy is, what puts one at risk, and how to prevent it.
Rationale Gives the client a sense of control over the situation.
Evaluation Client verbalizes that she has less, or no more, fear of her next pregnancy being ectopic.
Objective Cues: >the patient continuously asks questions about ectopic pregnancy. >the patient’s facial grimace expresses fear.
Stay with the client or make arrangements to have someone else be there.
Sense of abandonment can exacerbate fear.
Client verbalizes confidence in having pregnancy in the future.
Reason for rising incidence
Adequate treatment for P.I.D. which in the past rendered women sterile IUCD use Increase in surgical procedures for tubal disease Improved diagnostic technique. 2 types of ectopic pregnancy Ruptured Unruptured Location (sites) of implantation Fallopian tube (96%). – – – – Ampullary region more common in (distal ⅔) Isthmus, Fimbriae, Interstitial(2%) Cervical, abdominal and ovarian 2% Heterotopic: combination of intrauterine and extrauterine gestation 1:30,000 (1:4000-15,000). Common in assisted reproduction (pregnancies) techniques 1:100. Bilateral ectopic( Incidence unknown). Broad ligament. (Which sides of the tube is very common= RT) Aetiology Unknown. Risk factors ( impair the migration of the fertilized ovum to the uterus or those that affect the tubal motility). P.I.D, contribute to 50% of all cases. Tubal endometriosis (rare). Tubal surgery (previous), tubo-tubal fistula . Intrauterine devices( IUCD). Transmigration (migration of the ovum). Previous Hx of ectopic pregnancy. Hx of Infertility. Intrauterine diethylstilbestrol exposure. Conception following IVF-ET. G.I.F.T. Z.I.F.T. Previous abdominal surgery Induction of ovulation following menopause gonadotrophins. Progestogen contraception. Induction of ovulation with menopausal gonadotrophin Natural course of ectopic gestation. Tubal abortion with the formation of haematocele. Rupture into the peritoneal cavity. Resorption. Rupture into the broad ligament. Abdominal pregnancy. Diagnosis. Symptoms Amenorrhoea (89%). May occur before the patient misses her period especially if it is in the isthmus). Pain (94%).Irritation of the peritoneum, distension of the gravid tube. Shoulder tip pain if blood tracks to the diaphragm and stimulates the phrenic nerve. Lower abdominal pain. Irregular vaginal bleeding (80%). (Effect of E2 withdrawal occurs after death of the ovum. Spotting. Decidua grows abundantly, it can be expelled as decidual cast). Signs. Evidence of blood loss – – – – Anaemia shock (Hypovolaemia) collapse (Hypotension) distension of the abdomen (shifting dullness) -Abdominal tenderness, guarding, rebound tenderness. Fluid thrill +ve Shifting dullness. VE: - Cx-al excitation tenderness. – Bleeding = brownish. – Fornices will be tender and bulging occasionally
Other methods for making diagnosis. Culdocentensis / cul-de-sacpuncture USS imaging especially transvaginal using vaginal probe. B Submit of hCG (RIA) (abnormal progression of BhCG level) = In normal pregnancy levels double every 2.4 days with a predictable slope of increase. Absence of this slope is abnormal (ectopic pregnancy). Laparoscopy Differential Diagnosis Chronic PID Acute PID Acute appendicitis Chronic appendicitis Spontaneous or induced abortion Threatening abortion Incomplete abortion Torsion of an ovarian cyst Rupture of an ovarian cyst. TREATMENT Surgical Medical SURGICAL I.V.Line. D/S. Use a wide-bore cannula Aspirate blood for grouping and cross-matching-1hr crossmatch.Uncrossmatched O negative blood Get to theatre as quickly as possible Inform anaesthetist Open and arrest the bleeding.TECHNIQUE. The scrub nurse can double as an assistant. Incision to make: Preferably midline vertical LAWSON TAIT of Birminghan who performed the first successful surgery for ectopic in 1880; MAKE AT ONCE AT THE SOURCE OF HAEMORRAGE,TIE IT ,THEN OTHER THINGS CAN BE DONE AT LEISURE. At surgery inspect both ovaries and Fallopian tubes – Partial salpingectomy – TotaL Salpingectomy – Salpigostomy AUTOTRANSFUSION.STEPS:duration of haemoperitoneum < 24hrs. Laparoscopy.RU486(MIFIPRISTONE) Iinjected to abortit from the fimbrial end. Steps in autotransfusion Place 8 layers of sterile gauze over a sterile measuring jar to filter clots,fat globules. Use kidney dish or gallipot to remove free unclotted blood from the peritoneal cavity. Tge filtered blood is transferred into citratd bottle(s). Transfuse back through blood giving set. 14 MEDICAL: Systemic methotrexate, Actinomycin D Local administration of KCL, methotrexate, mifipristone, prostanglandin E2 into the gestation. Closure of the abdomen -there is no need closing both visceral and parietal peritoneum. -use continuous O or no. 1 polyglycolic or nylon suture for the rectus sheet. -if not more than 2cm,the subcutaneous layer may be left. If it becomes necessary,interrupted O plain or 2/0 chromic catgut may be used. Drainage is not necessary unless in chronic ectopic pregnancy. 18 16 Postoperative Care -blood transfusion if necessary -i.v. fluid until bowel sound is present -analgesia (analgin or pentazocine) -broad spectrum antibiotics(ampicillin or ampiclox i.v.) -Commence orally as soon as the i.v. line is discontinued -Sit the patient out as soon the condition permits ,usually on the second day of the operation.
-discharge home on the 5th or 6th day -give 2 weeks appointment to the outpatient clinic, there after 4 weeks. Discharge Counselling Prognosis Family planning method Correct anaemia with ferrous sulphate Follow up visit.
Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy. Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied. No specific cause has been identified, but it is believed that the hormones produced during pregnancy increase a woman's resistance to insulin, resulting in impaired glucose tolerance. Babies born to mothers with gestational diabetes are at increased risk of problems typically such as being large for gestastional age (which may lead to delivery complications), low blood sugar, and jaundice. Gestational diabetes is a treatable condition and women who have adequate control of glucose levels can effectively decrease these risks. Women with gestational diabetes are at increased risk of developing type 2 diabetes mellitus after pregnancy, while their offspring are prone to developing childhood obesity, with type 2 diabetes later in life. Most patients are treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin.
Diabetes mellitus Types of Diabetes Diabetes mellitus type 1 Diabetes mellitus type 2 Gestational diabetes Pre-diabetes: Impaired fasting glycaemia Impaired glucose tolerance Disease Management Diabetes management: •Diabetic diet •Anti-diabetic drugs •Conventional insulinotherapy •Intensive insulinotherapy Other Concerns Cardiovascular disease Diabetic comas: •Diabetic hypoglycemia •Diabetic ketoacidosis •Nonketotic hyperosmolar Diabetic myonecrosis Diabetic nephropathy Diabetic neuropathy Diabetic retinopathy Diabetes and pregnancy Blood tests Blood sugar Fructosamine Glucose tolerance test Glycosylated hemoglobin
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1 Definition 2 Epidemiology 3 Pathophysiology 4 Risk factors and symptoms 5 Screening and diagnosis o 5.1 Screening pathways o 5.2 Non-challenge blood glucose tests o 5.3 Screening glucose challenge test
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5.4 Oral glucose tolerance test (OGTT) 5.5 Urinary glucose testing 6 Complications 7 Prognosis 8 Classification 9 Treatment 10 Controversy 11 See also 12 Footnotes
13 External links
Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy". This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether symptoms subside after pregnancy is also irrelevant to the diagnosis .
The frequency of gestational diabetes varies widely by study depending on the population studied and the study design. It occurs in between 5 and 10% of all pregnancies (between 1-14% in various studies).
Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor (1) on the cell membrane which in turn starts many protein activation cascades (2). These
include: translocation of Glut-4 transporter to the plasma membrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5) and fatty acid synthesis (6). The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor.. Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced in a normal pregnancy. Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which progresses thereafter to levels seen in non-pregnant patients with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance they cannot compensate with increased production in the β-cells of the pancreas. Placental hormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. Cortisol and progesterone are the main culprits, but human placental lactogen, prolactin and estradiol contribute too. It is unclear why some patients are unable to balance insulin needs and develop GDM, however a number of explanations have been given, similar to those in type 2 diabetes: autoimmunity, single gene mutations, obesity, and other mechanisms. Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), the fetus is exposed to higher glucose levels. This leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).
 Risk factors and symptoms
Classical risk factors for developing gestational diabetes are the following:
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a previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia a family history revealing a first degree relative with type 2 diabetes maternal age - a woman's risk factor increases as she gets older (especially for women over 35 years of age)
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ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from the Indian subcontinent) being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively. a previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g (8 lbs 12.8 oz)) previous poor obstetric history
In addition to this, statistics show a double risk of GDM in smokers. Polycystic ovarian syndrome is also a risk factor. Some studies have looked at more controversial potential risk factors, such as short stature. About 40-60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women. Typically women with gestational diabetes exhibit no symptoms (another reason for universal screening), but some women may demonstrate increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision.
 Screening and diagnosis
A number of screening and diagnostic tests have been used to look for high levels of glucose in plasma or serum in defined circumstances. One method is a stepwise approach where a suspicious result on a screening test is followed by diagnostic test. Alternatively, a more involved diagnostic test can be used directly at the first antenatal visit in high-risk patients (for example in those with polycystic ovarian syndrome or acanthosis nigricans). Tests for gestational diabetes Non-challenge blood glucose tests
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Fasting glucose test 2-hour postprandial (after a meal) glucose test Random glucose test
Screening glucose challenge test Oral glucose tolerance test (OGTT) Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. A blood glucose levels is determined when fasting, 2 hours after a meal, or simply at any random time. In contrast challenge tests involve drinking a glucose solution and
measuring glucose concentration therafter in the blood; in diabetes they tend to remain high. The glucose solution have a very sweet taste that some women find unpleasant; sometimes therefore artificial flavours are added. Some women may experience nausea during the test, and more so with higher glucose levels.
 Screening pathways
There are different opinions about optimal screening and diagnostic measures, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs. The most elaborate regime entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24-28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, women may be tested earlier. In the United States, most obstetricians prefer universal screening with a screening glucose tolerance test. In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test. The American Diabetes Association and the Society of Obstetricians and Gynecologists of Canada recommend routine screening unless the patient is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors) The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening. The U.S. Preventive Services Task Force found that there is insufficient evidence to recommend for or against routine screening.
 Non-challenge blood glucose tests
When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) after fasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required. These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates.
 Screening glucose challenge test
The screening glucose challenge test is performed between 24-28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). It involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later. If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will be detected. If this threshold for further testing is lowered to 130 mg/dl, 90% of
GDM cases will be detected, but there will also be more women who will be subjected to a consequent OGTT unnecessarily.
 Oral glucose tolerance test (OGTT)
Main article: oral glucose tolerance test The OGTT should be done in the morning after an overnight fast of between 8 and 14 hours. During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated during the test and should not smoke throughout the test. The test involves drinking a solution containing a certain amount of glucose, and drawing blood to measure glucose levels at the start and on set time intervals thereafter. The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes. The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:
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Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L) 1 hour blood glucose level ≥180 mg/dl (10 mmol/L) 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L) 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)
An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify less women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test. The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective cohort study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive.  Subsequent information led to alterations in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.
 Urinary glucose testing
Women with GDM may have high glucose levels in their urine (glucosuria). Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine dipstick testing has not been shown to cause underdiagnosis where universal screening is performed. Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%.
GDM poses a risk to mother and child. This risk is largely related to high blood glucose levels and its consequences. The risk increases with higher blood glucose levels. Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably. The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic) and small for gestational age. Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Macrosomia may affect 12% of normal women compared to 20% of patients with GDM. However, the evidence for each of these complications is not equally strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study for example, there was an increased risk for babies to be large but not small for gestational age. Research into complications for GDM is difficult because of the many confounding factors (such as obesity). Labelling a woman as having GDM may in itself increase the risk of having a caesarean section. Neonates are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia). GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis. Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations. A large case-control study found that gestational diabetes was linked with a limited group of birth defects, and that this association
was generally limited to women with a higher body mass index (≥ 25 kg/m²). It is difficult to make sure that this is not partially due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy. Because of conflicting studies, it is unclear at the moment whether women with GDM have a higher risk of preeclampsia. In the HAPO study, the risk of preeclampsia was between 13% and 37% higher, although not all possible confounding factors were corrected.
Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence. Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance). Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years. Depending on the population studied, the diagnostic criteria and the length of follow-up, the risk can vary enormously. The risk appears to be highest in the first 5 years, reaching a plateau thereafter. One of the longest studies followed a group of women from Boston, Massachusetts; half of them developed diabetes after 6 years, and more than 70% had diabetes after 28 years. In a retrospective study in Navajo women, the risk of diabetes after GDM was estimated to be 50 to 70% after 11 years. Another study found a risk of diabetes after GDM of more than 25% after 15 years. In populations with a low risk for type 2 diabetes, in lean subjects and in patients with auto-antibodies, there is a higher rate of women developing type 1 diabetes. Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life. This risk relates to increased maternal glucose values. It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome. There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed to confirm this finding.
The White classification, named after Priscilla White who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management. There are 2 subtypes of gestational diabetes (diabetes which began during pregnancy):
Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required
The second group of diabetes which existed prior to pregnancy is also split up into several subtypes.
The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease in cesarean section rates or perinatal mortality. These findings are still recent and controversial. Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes. Most women can manage their GDM with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy. Any diet needs to provide sufficient calories for pregnancy, typically 2,000 - 2,500 kcal with the exclusion of simple carbohydrates. The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more.
Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.
A kit with a glucose meter and diary used by a woman with gestational diabetes. Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low. Target ranges advised by the Australasian Diabetes in Pregnancy Society are as follows:
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fasting capillary blood glucose levels <5.5 mmol/L 1 hour postprandial capillary blood glucose levels <8.0 mmol/L 2 hour postprandial blood glucose levels <6.7 mmol/L
Regular blood samples can be used to determine HbA1c levels, which give an idea of glucose control over a longer time period. If monitoring reveals failing control of glucose levels with these measures, or if there is evidence of complications like excessive fetal growth, treatment with insulin might become necessary. The most common therapeutic regime involves premeal fast-acting insulin to blunt sharp glucose rises after meals. Care needs to be taken to avoid low blood sugar levels (hypoglycemia) due to excessive insulin injections. Insulin therapy can be normal or very thight; more injections can result in better control but requires more effort, and there is no consensus that it has large benefits. There is some evidence that certain oral glycemic agents might be safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes. However, few studies have been performed as of this time and this is not a generally accepted treatment. These agents may be used in research settings, or if the patient needs intervention but refuses insulin therapy, and is aware of the risks. Glyburide, a second generation sulfonylurea, has been shown to be an effective alternative to insulin therapy. In one study, 4% of women needed supplemental insulin to reach blood sugar targets. Metformin has shown promising results. Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels. A recent randomized controlled trial of metformin versus insulin showed that women preferred metformin tablets to insulin injections, and that metformin
is safe and equally effective as insulin. Severe neonatal hypoglycemia was less common in insulin-treated women, but preterm delivery was more common. Almost half of patients did not reach sufficient control with metformin alone and needed supplemental therapy with insulin; compared to those treated with insulin alone, they required less insulin, and they gained less weight. There remains a possibility of long-term complications from metformin therapy, although follow-up at the age of 18 months of children born to women with polycystic ovarian syndrome and treated with metformin revealed no developmental abnormalities. If diet, exercise, and oral medication are inadequate to control glucose levels, insulin therapy may become necessary. The development of macrosomia can be evaluated during pregnancy by using sonography. Women who use insulin, with a history of stillbirth, or with hypertension are managed like women with ouvert diabetes. Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child. A repeat OGTT should be carried out 2-4 months after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.
1.1 Reasons for the Development of Gestational Diabetes: The causes for the onset of gestational diabetes is still uncertain. Normally, 2 to 5 percent of women are affected by gestational diabetes. Pregnant women are more likely to develop gestational diabetes if they meet the following criteria: Have a family history of type-2 (adult-onset) diabetes. With an age of 25 and above. Have obesity.
Have previously given birth to a large baby or, with an abnormality. Previously had a stillbirth, late in pregnancy. Have a history of gestational diabetes in the past pregnancy. Though gestational diabetes usually does not cause any symptoms, increase in blood sugar levels, increased thirst and hunger, and frequent urination, are some of the symptoms,
which are also common late in the pregnancy. Thus, it is difficult to easily figure out the patient having gestational diabetes without going for a glucose tolerance test. Also, women are susceptible to gestational diabetes if they had the same in their past pregnancy. However, it should be noted that every pregnancy is different. Previous history of gestational diabetes does not necessarily result in its manifestation in subsequent pregnancy. Similarly, gestational diabetes may appear in subsequent pregnancies, but could not have shown up in the earlier pregnancy. Thus, during every pregnancy, mother should be tested for gestational diabetes, irrespective of their past medical history. 1.2 Effects of Gestational Diabetes: Since the changes in mother’s body that cause gestational diabetes normally occur only during pregnancy, most of the time, gestational diabetes disappears after the birth of the baby. After the baby is born, mother’s body goes back to normal function, and the condition of gestational diabetes goes away. Moreover, gestational diabetes is treatable, especially if it is found in early stages of pregnancy. If gestational diabetes is found in the early stage, necessary and adequate treatment can be given to safeguard both the mother and the child from its detrimental effects. If it is not detected in the early stages, then it can
cause several problems to the mother during delivery of the child, and to the child both during pregnancy and after the birth. In general, the effect of gestational diabetes can be classified into three groups based on whether it affects baby or mother, and at what stage, viz., 1. Effect of gestational diabetes on the foetus during pregnancy. 2. Effect of gestational diabetes on the baby after birth. 3. Effect of gestational diabetes on the mother. Detailed discussion is presented below. 1.2.1 Effect of Gestational Diabetes on the Foetus During Pregnancy: Due to increased blood glucose levels in mother’s blood, the baby grows larger. This
makes delivery of the baby injurious and difficult. In some cases, this condition leads to caesarean. If untreated, gestational diabetes can result in still birth babies. 1.2.2 Effect of Gestational Diabetes on the Baby after Birth: The offspring of gestational diabetes mother can face any one or, combination of the following problems: 1. In order to tolerate the increased blood glucose levels of mother, the pancreas of the baby secretes more amount of insulin while the foetus is growing. This condition continues even after birth, while higher blood glucose levels no longer
exists. Thus, after birth, the baby develops hypoglycaemia (low blood glucose level). This condition can be overcome by administering glucose through drip. 2. It is highly probable that the newborn baby will develop jaundice (yellowing of the skin and whites of the eyes). This condition fades away over a few weeks without the need for a medical treatment. 3. There is an increased risk for the baby to be born with congenital problems, such as a heart defect. At times, infants can be born with respiratory distress syndrome (RDS), in which the baby has breathing problems since the lungs have not matured as normal. But, this condition usually clears up with time. 4. The babies are more likely to be obese (overweight) as children or adults, which can lead to other health problems later in their life. 5. There is an increased risk for the child to develop type-2 diabetes (development of diabetes during adult stage). 6. There is also a slightly higher chance of stillbirth or death as a newborn. This can be avoided if the problem is detected earlier, and the glucose levels were well managed so as to avoid infant death. 1.2.3 Effect of Gestational Diabetes on Mother: Normally, gestational diabetes does not affect the mother. However, the mother who
developed gestational diabetes during first pregnancy is highly likely to develop the same
at the second pregnancy. They are also likely to develop type-2 diabetes. In some mothers, gestational diabetes leads to high blood pressure. It is also found to be associated with poly cystic ovary syndrome (PCOS; Bloomgarden, 2003), which leads to infertility. If mothers control their condition after detection of gestational diabetes, most of them have healthy pregnancies and healthy babies. If treatment is not taken, mothers with this condition could have very large babies. Since very large babies are difficult to deliver through natural delivery (delivery through the vagina), some mothers may need surgery to deliver their bigger babies. Surgery done towards this end can increase the mother's chances of getting an infection. Moreover, mothers who have their babies by surgery also take a longer time to recover. 1.3 Diagnosis for Gestational Diabetes: Normally it is difficult to detect gestational diabetes unless the doctor has a medical history of the patient, and ascertain that the patient is likely to develop it. Under this circumstance, the blood glucose level of pregnant mother is monitored regularly during the entire pregnancy period through urine test. If pregnant mother develops high blood glucose levels between 24 – 28 weeks of pregnancy, then she is said to have gestational diabetes. In order to confirm that the mother has gestational diabetes, glucose tolerance test is conducted. During this test, the pregnant mother is given a 100 g of glucose solution to drink after fasting for 8 hours. Then, blood samples are taken at regular intervals and glucose level is estimated. This is the only way to ascertain the condition of gestational diabetes in the pregnant mother.
1.4 Treatment for Gestational Diabetes The most important part of treatment is to control blood sugar levels. This can be
achieved by: 1. A carefully planned diet. 2. Regular exercise. 3. Taking proper medicines. 4. Monitoring the blood sugar at regular intervals. 5. Checking blood sugar after the birth. 1.4.1 Keeping Diet Under Control Keeping the diet under control is another important factor for the patients affected by gestational diabetes. Taking a balanced diet is important in order to keep the blood sugar at the optimum level. Normally the diet should consist of a variety of foods including plenty of starchy fillers such as bread, pasta, rice and potatoes, and at least five portions of fruit and vegetables each day. Moreover, it is important to limit consumption of sugary foods like cakes, biscuits and soft drinks. A diet that is low in fat, is also desirable. This can be achieved by avoiding full-fat dairy products such as butter and cream, and limiting fatty meat, pies, sausages and burgers. Grilling, steaming or, microwaving food, rather than frying or roasting means, less fat is added during cooking.
1.4.2 Regular Physical Exercise Apart from diet control and proper medication, gentle and regular exercise, such as walking, can help reduce blood sugar levels and promote the body condition of the mother. However, the doctor should be consulted before choosing proper body exercises. 1.4.3 Taking Proper Medicines Despite making the above lifestyle changes, a few women's blood sugar levels remain too high, and they may need daily injections of insulin. The extra insulin will not cross the placenta and will not affect the baby. Any woman who needs to take insulin will be taught how to take it by her doctor or nurse. Sometimes, it is possible to have too much insulin and this can cause low blood sugar (hypoglycaemia). Common symptoms of this are weakness, shaking, hunger and sweating. Thus, for people taking insulin, it is a good idea to keep a snack handy at all times in case low blood sugar develops.
1.4.4 Regular Monitoring of Blood Glucose Levels Normally, the blood glucose level should be tested once a week. For some women, frequent testing may be needed, and a good doctor should be consulted to keep the gestational diabetes under control. For those who need frequent testing, blood glucose level needs to be measured in the morning, before breakfast, and again two hours after breakfast. Sometimes, it may be necessary to test blood glucose levels in the midafternoon.
1.4.5 Checking Blood Sugar After the Birth of baby In almost every case, gestational diabetes disappears after the delivery of the baby. However, to be sure that the blood glucose levels have become normal, it is necessary to check the mother's blood sugar levels a few times after the birth. the onset of gestational diabetes in diverse groups of the people. causes for gestational diabetes are still not clearly known, the following factors are said to be important in inducing women with gestational diabetes: 1. Have a family history of type-2 (adult-onset) diabetes. 2. Age over 25 years. 3. Obesity. 4. Previously given birth to a large baby (macrosomia). 5. Previously given birth to a baby with congenital abnormality. 6. Previously had a stillbirth, late in pregnancy.
Thus, in this study all the patients were screened for the following critical parameters viz., Age. GRA/PARA. Responds positively to medication in reducing its detrimental effect both on the child and on the mother? Have drugs administered for gestational diabetes inflict any effect on the health of foetus and mother?
To what extend the foetus is affected by gestational diabetes? Whether women are more likely to develop gestational diabetes in the first pregnancy or, in the subsequent pregnancies? taken into account.
2.3.1 Glucose Tolerance Test for Gestational Diabetes: The patients’ urine was routinely tested for sugar throughout pregnancy. If high blood sugar was detected between 24 and 28 weeks of pregnancy, then they were supposed to have gestational diabetes.
However, a confirmation for gestational diabetes was ascertained only after a test for glucose tolerance was undertaken. This glucose tolerance test was carried out after eight hours without food – i.e., the patients were advised to come to the hospital in the morning without taking any food – including tea/coffee/milk or, other drinks. At the hospital the patient was given a solution of 100 g of glucose to drink, and then blood samples were taken at every half-an hour intervals and analysed to see how their body deals with the glucose, over time (O'Sullivan and Mahan, 1964). If higher glucose levels were detected during glucose tolerance test, then the patient was classified as having gestational diabetes.