DQ Reply 12 634

Question 1

Gestational Diabetes Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Why did you select these tests or tools as being appropriate to this scenario? Support your summary and recommended plan with a minimum of two peer-reviewed references in addition to the course materials.

Question 2

Imagine a patient comes into your office with your selected condition or disorder. What elements in the patient history and physical exam would indicate the patient has the selected condition or disorder? Select two differential diagnoses that could be applied to this patient. How did you arrive at the two differential diagnoses? Include history and physical examination findings that would support each of the two alternative diagnoses.

DQ-1

Iron deficiency anemia (IDA) is the most prevalent nutrition-related deficiency in developing countries and the developed world, affecting approximately 52 percent of pregnant women. The physiologic demand for iron is high in pregnancy with an estimated 1000–1200 mg of iron needed. The need varies across gestation with lower need in the first trimester (0.8 mg/day) and is much higher in the third trimester (3.0–7.5 mg/day), which is when IDA generally develops. Some of the total iron needs may be met by maternal iron stores in iron-replete women, and approximately 300 mg of this total iron is recycled and again available to the mother as her RBC volume contracts postpartum (Api,Breyman, Çetiner, Demir, & Ecder, 2015).

The causes of IDA during pregnancy are multifactorial and include a history of iron deficiency anemia before pregnancy, micronutrient deficiencies of iron and folate, as seen with a vegetarian diet, and socio-economical status. Close interval between pregnancies, substance use, especially alcohol or tobacco, and chronic infections like TB and HIV are also all contributing factors (Abu-Ouf & Jan, 2015).

Typical features of iron deficiency anemia are caused by lowered oxygen delivery to the tissues and include pallor, fatigue, apathy, fainting, and breathlessness. Additional features include headaches, palpitation, hair loss, and tinnitus. With more severe degrees of anemia, cardiac failure may develop. It also correlates with negative perinatal outcomes including premature labor, intrauterine growth retardation, low birth weight, birth asphyxia, and neonatal anemia (Api et al., 2015).

Laboratory findings for IDA during pregnancy include a serum ferritin concentration ess than 30 μg/L together with a hemoglobin (Hb) concentration less than 11 g/dL during the 1st trimester, less than 10.5 g/dL during the 2nd trimester, and 11 g/dL or less during the 3rd trimester. A peripheral blood smear will show microcytic and hypochromic erythropoiesis, which are low values for mean corpuscular volume and mean corpuscular hemoglobin concentration. If ferritin and hemoglobin indicate IDA, anemia treatment should be initiated. Hb should be measured in each trimester because the probability of an increase in the need for iron and development of iron deficiency is possible, even if the baseline value is normal. Moreover, the Hb concentration during delivery is important because a low maternal Hb can result in fetal problems, including mortality(Api et al., 2015).

  A healthy varied diet should be routinely supplemented by prophylactic doses of iron to prevent the depletion of iron stores. The total iron intake during pregnancy should not be less than 1000 mg. Oral iron preparations can be used throughout pregnancy, whereas IV iron therapy is recommended as the first option in the presence of severe anemia and risk factors, and in emergency situations (Abu-Ouf, & Jan, 2015).

 

Abu-Ouf, N. M., & Jan, M. M. (2015). The impact of maternal iron deficiency and iron deficiency anemia on child's health. Saudi medical journal, 36(2), 146–149. https://doi.org/10.15537/smj.2015.2.10289

 Api, O., Breyman, C., Çetiner, M., Demir, C., & Ecder, T. (2015). Diagnosis and treatment of iron deficiency anemia during pregnancy and the postpartum period: Iron deficiency anemia working group consensus report. Turkish journal of obstetrics and gynecology, 12(3), 173–181. https://doi.org/10.4274/tjod.01700

DQ-2

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting during pregnancy occurring initially in the first trimester. Clinical manifestation of symptoms dehydration, nutritional deficiencies, electrolyte imbalances, ketosis, as well as a weight loss greater than 5% of the pre-pregnancy weight according to O’Donnell, McParlin, Robson, Beyer, Moloney, Bryant, …, & Vale, (2016, p.1). Pregnancy-unique quantification of emesis and nausea (PUQE) score is a screening form evaluating the severity of nausea, vomiting, and retching during a 12-hour duration. A score of 13 indicates severe symptoms researched by Koren et al, (2002) as cited in (O’Donnell, 2016, p.2). Diagnostic laboratory tests include BMP, urinalysis, urine culture, renal function, thyroid, and a hemoglobin and hematocrit discussed by Rose & Vicknair, (2018, p.1).

The diagnosis of HG is based on the clinical presentation and exclusion of other differential diagnoses. In a meta-analysis study from the United Kingdom there is a strong correlation between women diagnosed with HG and the occurrence of gestational transient thyrotoxicosis. This was researched by Goodwin, Poursharif, & Korst et al., (2008) as cited in (O’Donnell, 2016, p.2).

References

Goodwin TM, Poursharif B, Korst LM, MacGibbon KW, Romero R, Fejzo MS. Secular trends in the treatment of hyperemesis gravidarum. Am J Perinatol 2008;25:141–7. 10.1055/s-2008-1040344. [PubMed] [CrossRef] [Reference list]

Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynecol 2002;186:S228–31. 10.1067/mob.2002.123054. [PubMed] [CrossRef] [Reference list]

O’Donnell, A., McParlin, C., Robson, S. C., Beyer, F., Moloney, E., Bryant, A., ... Vale, L. (October 2016). Treatment for hyperemesis gravidarum and nausea and vomiting in pregnancy: A systematic review and economic assessment. NIHR Journals Library, 20.74(), 1-7. https://doi.org/10.3310/hta20740

Rose, G. M., & Vicknair, B. C. (July 3, 2018). Hyperemesis gravidarum. CareOnPoint, 1-4. Retrieved from http://app.careonpoint.com/Search.aspx

DQ-3

Preterm labor is defined as regular uterine contractions and cervical dilation prior to the 37th week of gestation (Talati, Hackney & Mesiano, 2017). Preterm labor with intact membranes is the number one cause of Spontaneous preterm birth (Talati, Hackney & Mesiano, 2017). Currently, preterm labor and birth is a large healthcare and socioeconomic problem that affects 10-15% of overall pregnancies and 70-80% of perinatal mortality and morbidity (Talati, Hackney & Mesiano, 2017).

The pathophysiology of preterm labor is thought to be an interruption of the effects of progesterone on the uterus and that this interruption can come from a variety of sources (Talati, Hackney & Mesiano, 2017).  For example, a decrease in the hormonal production levels of progesterone would lead to a lower overall serum level and effect on the uterus, infections like frequent UTIs can cause an interruption between the action of progesterone on the uterus, and the subsequent inflammation can cause an interruption of progesterone's uterus (Talati, Hackney & Mesiano, 2017). 

The decreasing efficacy of progesterone regardless of the source has a major impact on the rest of the body (Talati, Hackney & Mesiano, 2017).  Once progesterone levels fall low enough, estrogens become the dominant steroid and promote labor by increasing responsiveness of myometrial cells to labor agents such as oxytocin and prostaglandin (Talati, Hackney & Mesiano, 2017). This increase in responsiveness creates gap junctions that allow the myometrial cells to increase in contractions and coordination (Talati, Hackney & Mesiano, 2017). 

Patient presentation is usually with complaints of abdominal cramping that is regular and diffuse and lower abdominal pressure (Suman & Leuther, 2020). These patients usually present in the ER as they are already worried about preterm labor, some patients present in their OBGYN depending on the availability of appointments the same day that the symptoms begin (Suman & Leuther, 2020). However, OBGYNs usually recommend visiting the ER if they present with regular rhythmic lower abdominal cramping (Suman & Leuther, 2020). 

Treatment is dependent on the patient's health history, comorbidities, fetal health, and gestational age (Suman & Leuther, 2020). If the mother is greater than 34 weeks, she is admitted and fetal health is assessed (Suman & Leuther, 2020). If the mother and fetus appear in good health, with a non-reactive fetal stress test, and complications of pregnancy have been excluded, she can be sent home with recommendations to follow up in 1-2 weeks with their OBGYN (Suman & Leuther, 2020). If the mother is less than 34 weeks and presents with preterm labor, she is hospitalized and tocolytic drugs for up to 48 hours are used to inhibit labor (Suman & Leuther, 2020). During this time fetal stress tests, lab-work, and fetal ultrasounds are obtained to rule out any possible complications of pregnancy (Suman & Leuther, 2020).  

References:

Talati, A. N., Hackney, D. N., & Mesiano, S. (2017). Pathophysiology of preterm labor with intact membranes. Seminars in Perinatology, 41(7), 420–426. https://doi-org.lopes.idm.oclc.org/10.1053/j.semperi.2017.07.013

Suman V, & Luther, E.E. (2020). Preterm Labor. StatPearls. StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK536939/