Pregnancy and Birth Sourcebook, Third Edition * breathing problems.

If you have gestational diabetes, your health care team may recommend some extra tests to check on your baby, such as: * an ultrasound exam, to see how your baby is growing; and * "kick counts" to check your baby's activity (the time between the baby's movements) or special "stress" tests.

Working closely with your health care team will help you give birth to a healthy baby.

Both you and your baby are at increased risk for type 2 diabetes for the rest of your lives.

How will gestational diabetes affect me?

Often, women with gestational diabetes have no symptoms. However, gestational diabetes may: * increase your risk of high blood pressure during pregnancy; and * increase your risk of a large baby and the need for cesarean section at delivery.

The good news is your gestational diabetes will probably go away after your baby is born. However, you will be more likely to get type 2 diabetes later in your life. You may also get gestational diabetes again if you get pregnant again.

Some women wonder whether breastfeeding is OK after they have had gestational diabetes. Breastfeeding is recommended for most babies, including those whose mothers had gestational diabetes.

Gestational diabetes is serious, even if you have no symptoms.

Taking care of yourself helps keep your baby healthy.

How is gestational diabetes treated?

Treating gestational diabetes means taking steps to keep your blood glucose levels in a target range. You will learn how to control your blood glucose using: * a meal plan; * physical activity; and * insulin (if needed).

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Gestational Diabetes Meal plan: You will talk with a diet.i.tian or a diabetes educator who will design a meal plan to help you choose foods that are healthy for you and your baby. Using a meal plan will help keep your blood glucose in your target range. The plan will provide guidelines on which foods to eat, how much to eat, and when to eat. Choices, amounts, and timing are all important in keeping your blood glucose levels in your target range. You will talk with a diet.i.tian or a diabetes educator who will design a meal plan to help you choose foods that are healthy for you and your baby. Using a meal plan will help keep your blood glucose in your target range. The plan will provide guidelines on which foods to eat, how much to eat, and when to eat. Choices, amounts, and timing are all important in keeping your blood glucose levels in your target range.

You may be advised to: * limit sweets; * eat three small meals and one to three snacks every day; * be careful about when and how much carbohydrate-rich food you eat-your meal plan will tell you when to eat carbohydrates and how much to eat at each meal and snack; and * include fiber in your meals in the form of fruits, vegetables, and whole-grain crackers, cereals, and bread.

Physical activity: Physical activity, such as walking and swimming, can help you reach your blood glucose targets. Talk with your health care team about the type of activity that is best for you. If you are already active, tell your health care team what you do. Physical activity, such as walking and swimming, can help you reach your blood glucose targets. Talk with your health care team about the type of activity that is best for you. If you are already active, tell your health care team what you do.

Insulin: Some women with gestational diabetes need insulin, in addition to a meal plan and physical activity, to reach their blood glucose targets. If necessary, your health care team will show you how to give yourself insulin. Insulin is not harmful for your baby. It cannot move from your bloodstream to the baby's. Some women with gestational diabetes need insulin, in addition to a meal plan and physical activity, to reach their blood glucose targets. If necessary, your health care team will show you how to give yourself insulin. Insulin is not harmful for your baby. It cannot move from your bloodstream to the baby's.

How will I know whether my blood glucose levels are on target?

Your health care team may ask you to use a small device called a blood glucose meter to check your levels on your own. You will learn: * how to use the meter; * how to p.r.i.c.k your finger to obtain a drop of blood; * what your target range is; and * when to check your blood glucose.

You may be asked to check your blood glucose: * when you wake up; 379.

Pregnancy and Birth Sourcebook, Third Edition * just before meals; * 1 or 2 hours after breakfast; * 1 or 2 hours after lunch; and * 1 or 2 hours after dinner.

Table 45.2 shows blood glucose targets for most women with gestational diabetes. Talk with your health care team about whether these targets are right for you.

Table 45.2. Blood Glucose Targets for Most Women with Gestational Diabetes Blood Glucose Targets for Most Women with Gestational Diabetes On awakening not above 95 1 hour after a meal not above 140 2 hours after a meal not above 120 Each time you check your blood glucose, write down the results in a record book. Take the book with you when you visit your health care team. If your results are often out of range, your health care team will suggest ways you can reach your targets.

Will I need to do other tests on my own?

Your health care team may teach you how to test for ketones in your morning urine or in your blood. High levels of ketones are a sign that your body is using your body fat for energy instead of the food you eat. Using fat for energy is not recommended during pregnancy.

Ketones may be harmful for your baby.

If your ketone levels are high, your health care providers may suggest that you change the type or amount of food you eat. Or you may need to change your meal times or snack times.

After I have my baby, how can I find out whether my diabe- tes is gone?

You will probably have a blood glucose test 6 to 12 weeks after your baby is born to see whether you still have diabetes. For most women, gestational diabetes goes away after pregnancy. You are, however, at risk of having gestational diabetes during future pregnancies or getting type 2 diabetes later.

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Chapter 46.

Gestational Hypertension What is high blood pressure?

Blood pressure is the amount of force exerted by the blood against the walls of the arteries. A person's blood pressure is considered high when the readings are greater than 140 mm Hg systolic (the top number in the blood pressure reading) or 90 mm Hg diastolic (the bottom number). In general, high blood pressure, or hypertension, contributes to the development of coronary heart disease, stroke, heart failure, and kidney disease.

What are the effects of high blood pressure in pregnancy?

Although many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both the mother and the fetus. Women with pre-existing, or chronic, high blood pressure are more likely to have certain complications during pregnancy than those with normal blood pressure.

However, some women develop high blood pressure while they are pregnant (often called gestational hypertension).

The effects of high blood pressure range from mild to severe. High blood pressure can harm the mother's kidneys and other organs, and From "High Blood Pressure in Pregnancy," by the National Heart, Lung and Blood Inst.i.tute (NHLBI, www.nhlbi.nih.gov), part of the National Inst.i.tutes of Health. The date of this doc.u.ment is unknown. Reviewed by David A. Cooke, MD, FACP, April 12, 2009 381.

Pregnancy and Birth Sourcebook, Third Edition it can cause low birth weight and early delivery. In the most serious cases, the mother develops preeclampsia-or "toxemia of pregnancy"- which can threaten the lives of both the mother and the fetus.

What is preeclampsia?

Preeclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the condition is known as eclampsia-the second leading cause of maternal death in the United States. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth.

There is no proven way to prevent preeclampsia. Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. The only way to "cure" preeclampsia is to deliver the baby.

How common are high blood pressure and preeclampsia in pregnancy?

High blood pressure problems occur in 6 percent to 8 percent of all pregnancies in the United States, about 70 percent of which are first-time pregnancies. In 1998, more than 146,320 cases of preeclampsia alone were diagnosed.

Although the proportion of pregnancies with gestational hypertension and eclampsia has remained about the same in the United States over the past decade, the rate of preeclampsia has increased by nearly one-third. This increase is due in part to a rise in the numbers of older mothers and of multiple births, where preeclampsia occurs more frequently. For example, in 1998 birth rates among women ages 30 to 44 and the number of births to women ages 45 and older were at the highest levels in three decades, according to the National Center for Health Statistics.

Furthermore, between 1980 and 1998, rates of twin births increased about 50 percent overall and 1,000 percent among women ages 45 to 49; rates of triplet and other higher-order multiple births jumped more than 400 percent overall, and 1,000 percent among women in their 40s.

Who is more likely to develop preeclampsia?

* Women with chronic hypertension (high blood pressure before becoming pregnant) 382.

Gestational Hypertension * Women who developed high blood pressure or preeclampsia during a previous pregnancy, especially if these conditions occurred early in the pregnancy * Women who are obese prior to pregnancy * Pregnant women under the age of 20 or over the age of 40 * Women who are pregnant with more than one baby * Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma How is preeclampsia detected?

Unfortunately, there is no single test to predict or diagnose preeclampsia. Key signs are increased blood pressure and protein in the urine (proteinuria). Other symptoms that seem to occur with preeclampsia include persistent headaches, blurred vision or sensitivity to light, and abdominal pain.

All of these sensations can be caused by other disorders; they can also occur in healthy pregnancies. Regular visits with your doctor help him or her to track your blood pressure and level of protein in your urine, to order and a.n.a.lyze blood tests that detect signs of preeclampsia, and to monitor fetal development more closely.

How can women with high blood pressure prevent prob- lems during pregnancy?

If you are thinking about having a baby and you have high blood pressure, talk first to your doctor or nurse. Taking steps to control your blood pressure before and during pregnancy-and getting regular prenatal care-go a long way toward ensuring your well-being and your baby's health.

Before becoming pregnant: * Be sure your blood pressure is under control. Lifestyle changes such as limiting your salt intake, partic.i.p.ating in regular physical activity, and losing weight if you are overweight can be helpful.

* Discuss with your doctor how hypertension might affect you and your baby during pregnancy, and what you can do to prevent or lessen problems.

* If you take medicines for your blood pressure, ask your doctor whether you should change the amount you take or stop taking 383 Pregnancy and Birth Sourcebook, Third Edition them during pregnancy. Experts currently recommend avoiding angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (AII) receptor antagonists during pregnancy; other blood pressure medications may be OK for you to use. Do not, however, stop or change your medicines unless your doctor tells you to do so.

While you are pregnant: * Obtain regular prenatal medical care.

* Avoid alcohol and tobacco.

* Talk to your doctor about any over-the-counter medications you are taking or are thinking about taking.

Does hypertension or preeclampsia during pregnancy cause long-term heart and blood vessel problems?

The effects of high blood pressure during pregnancy vary depending on the disorder and other factors. According to the National High Blood Pressure Education Program (NHBPEP), preeclampsia does not in general increase a woman's risk for developing chronic hypertension or other heart-related problems. The NHBPEP also reports that in women with normal blood pressure who develop preeclampsia after the 20th week of their first pregnancy, short-term complications- including increased blood pressure-usually go away within about 6 weeks after delivery.

Some women, however, may be more likely to develop high blood pressure or other heart disease later in life. More research is needed to determine the long-term health effects of hypertensive disorders in pregnancy and to develop better methods for identifying, diagnosing, and treating women at risk for these conditions.

Even though high blood pressure and related disorders during pregnancy can be serious, most women with high blood pressure and those who develop preeclampsia have successful pregnancies. Obtaining early and regular prenatal care is the most important thing you can do for you and your baby.

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Chapter 47.

Hyperemesis Gravidarum (Severe Nausea and Vomiting) Overview Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. If severe and/or inadequately treated, it is typically a.s.sociated with: * loss of greater than 5% of pre-pregnancy body weight (usually over 10%); * dehydration and production of ketones; * nutritional deficiencies; * metabolic imbalances; * difficulty with daily activities.

HG usually extends beyond the first trimester and may resolve by 21 weeks; however, it can last the entire pregnancy in less than half of these women. Complications of vomiting (e.g. gastric ulcers, esoph-ageal bleeding, malnutrition, etc.) may also contribute to and worsen ongoing nausea.

"Understanding Hyperemesis," 2006 Hyperemesis Education & Research Foundation. All Rights Reserved. For additional information, visit the HER Foundation website at www.helpher.org.

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Pregnancy and Birth Sourcebook, Third Edition There are numerous theories regarding the etiology of hyperemesis gravidarum. Unfortunately, HG is not fully understood and conclusive research on its potential cause is rare. New theories and findings emerge every year, substantiating that it is a complex physiological disease likely caused by multiple factors.

Diagnosis is usually made by measuring weight loss, checking for ketones, and a.s.sessing the overall condition of the mother. If she meets the standard criteria and is having difficulty performing her daily activities, medications and/or other treatments are typically offered.

Treating HG is very challenging and early intervention is critical.

HG is a multifaceted disease that should be approached with a broad view of possible etiologies and complications. When treating mothers with HG, preventing and correcting nutritional deficiencies is a high priority to promote a healthy outcome for mother and child.

Most studies examining the risks and outcomes for a pregnant woman with nausea and vomiting in pregnancy find no detrimental effects long-term for milder cases. Those with more severe symptoms that lead to complications, severe weight loss, and/or prolonged nausea and vomiting are at greatest risk of adverse outcomes for both mother and child.

The risk increases if medical intervention is inadequate or delayed.

The list of potential complications due to repeated vomiting or severe nausea is extensive, all of which may worsen symptoms. Common complications from nausea and vomiting include debilitating fatigue, gastric irritation, ketosis, and malnutrition. Aggressive care early in pregnancy is very important to prevent these and more life-threatening complications such as central pontine myelinolysis or Wernicke's encephalopathy. After pregnancy and in preparation of future ones, it is important to address any resulting physical and psychological complications.

Hyperemesis gravidarum impacts societies, families, and individuals. Recent, conservative estimations suggest HG costs nearly $200 million annually just for inpatient hospitalization. Considering many women are treated outside the hospital to save costs, the actual cost is likely many times greater. Beyond financial impact, many family relationships dissolve and future family plans are almost always limited. Women often lose their employment because of HG, and women are frequently undertreated and left feeling stigmatized by a disease erroneously presumed to be psychological.

Treatment Hyperemesis is no doubt a physiological disease. Treating it as anything else is not therapeutic and can be detrimental to the mother 386 Hyperemesis Gravidarum (Severe Nausea and Vomiting) and her unborn child. Early, aggressive therapy can often result in fewer complications and reduce overall medical costs. Medications, bed rest, IV (intravenous) fluids, and nutritional therapy are typically the most effective therapies for HG. HG may last throughout pregnancy in varying severity. As each woman is different, it is most critical that therapies target a mother's symptoms and response to treatment.

Women left untreated may terminate a wanted pregnancy to end the misery. Often secondary psychosocial challenges such as depression and anxiety result and complicate management. Depression is a natural consequence of being confined to home or bed, and unable to perform even simple daily activities, much less care for one's family.

Further, the accompanying anxiety often results from the thought of vomiting and retching relentlessly for hours, as well as feeling severely nauseous in between. Many women fear dying and feel guilty that they may cause the death of their unborn child if they don't force feed themselves, despite the inevitable vomiting that will follow. Treating the complex physiological changes that cause such severe symptoms can be very challenging.

Further, each woman will respond differently to treatments since the cause is multifactorial, so a single medication cannot be prescribed. It is becoming clear that proactive intervention with a treatment plan, can decrease both severity and duration, not to mention prevent many complications for many women. The challenge is finding the treatment that works for each woman.

The general good care of women with severe hyperemesis extends beyond the use of steroid therapy. Thiamine replacement, possibly with other water-soluble vitamins is required if vomiting has been prolonged in order to avoid Wernicke's encephalopathy. Deficiency can arise after lack of food intake for several weeks. Thiamine is an essential co-factor for critical enzymes of carbohydrate metabolism and it is important that it is replaced before carbohydrate is given. However, once thiamine has been replaced, provision of calories as IV 10% Dex-trose (which provides 400 kcal/L) hastens recovery. Significant heartburn is frequently caused by the regurgitated gastric acid and this requires treatment with ranitidine. Finally, mobilization must be gradual as physical movement exacerbates the underlying nausea.

Discharge is not wise as soon as IV fluids are no longer necessary, as this may be a.s.sociated with loss of control precipitated by the journey home. Full and sympathetic explanation of the condition and likely prognosis is also part of routine management. [Al-Ozairi MBChB MRCP, E., Waugh MBBS MRCOG, J. J. S. , & Taylor MD FRCP, R. (2009).

Termination is not the treatment of choice for severe hyperemesis 387 Pregnancy and Birth Sourcebook, Third Edition gravidarum: Successful management using prednisolone. Obstetric Obstetric Medicine. Medicine. 2, 3437.] 2, 3437.]

The HER Foundation Survey found bed rest and IV hydration to be two of the most beneficial treatments for HG. This does not mean these alone are adequate, rather these are nearly universally beneficial in women with HG. IV fluids can be given at home in some countries at very low cost and minimal risk. Fluids can also include much-needed vitamins. Insurance coverage often includes home IV care which allows the mother to have continuous fluids instead of cycling from hydration to vomiting and dehydration. This cycle worsens HG and delays recovery. Many women state they feel so much better after their trip to the emergency room for IV fluids, only to begin vomiting and have to return a few days later for more fluids. Home IV fluids can prevent this.

A regular IV can be left in for up to a week, provided it does not infil-trate or become infected. Many doctors are not aware of the concept of stopping the dehydration cycle to avoid exacerbation of HG. Any mother producing ketones or exhibiting signs of dehydration should receive IV fluids, preferably with IV vitamins. Vitamins are critical in mothers vomiting more than a few weeks to prevent life-altering complications.

* Medications: Medications: Antiemetic (anti-vomiting) medications are the most common and typically most effective treatments for HG. Antiemetic (anti-vomiting) medications are the most common and typically most effective treatments for HG.

The risks are often outweighed by the benefits.

* Allergy treatments: Allergy treatments: Sometimes HG symptoms can be managed with allergy management procedures. Sometimes HG symptoms can be managed with allergy management procedures.

* Complementary and alternative medicine (CAM): Complementary and alternative medicine (CAM): CAM CAM is sometimes effective in easing nausea and vomiting in milder cases of HG, however, it most often is used in conjunction with allopathic medicine (traditional medical care).

* Nutritional therapies: Nutritional therapies: Research shows that nausea and vomiting for more than a few weeks causes significant deficiency of important nutrients, which can worsen nausea and vomiting. If not replaced, a woman is at risk for more complications and a prolonged recovery. These can be replaced via an intravenous (IV) line or directly into the gastrointestinal (stomach/intestines) system. Research shows that nausea and vomiting for more than a few weeks causes significant deficiency of important nutrients, which can worsen nausea and vomiting. If not replaced, a woman is at risk for more complications and a prolonged recovery. These can be replaced via an intravenous (IV) line or directly into the gastrointestinal (stomach/intestines) system.

* Behavioral therapy: Behavioral therapy: This therapy uses stimulus control and imaging procedures and is sometimes used in mild cases with positive effects. This therapy uses stimulus control and imaging procedures and is sometimes used in mild cases with positive effects.

* Bed rest: Bed rest: Prolonged bed rest can produce negative effects like atrophy and a delayed recovery time after delivery. The best 388 Prolonged bed rest can produce negative effects like atrophy and a delayed recovery time after delivery. The best 388 Hyperemesis Gravidarum (Severe Nausea and Vomiting) strategy is to do all you can to get effective care and stay as mobile as possible. Physical therapy may be beneficial.

* Sensory deprivation therapy (SDT): Sensory deprivation therapy (SDT): This is essentially placing a woman in a room without any interaction or stimulation of any kind. She is denied any visitors such as her family for days or weeks. This is cruel and ineffective for true cases of HG. Isola-tion and secondary depression only worsen HG and increase the stress on a woman. It should not be used. However, since odors, noise, and light may worsen her symptoms, it is helpful to minimize as much as she requests. This is essentially placing a woman in a room without any interaction or stimulation of any kind. She is denied any visitors such as her family for days or weeks. This is cruel and ineffective for true cases of HG. Isola-tion and secondary depression only worsen HG and increase the stress on a woman. It should not be used. However, since odors, noise, and light may worsen her symptoms, it is helpful to minimize as much as she requests.

* Psychotherapy: Psychotherapy: This treatment may be effective for secondary complications such as depression and anxiety, if used in conjunction with antiemetic medications and hydration. It should never be used as a primary modality for cases of HG. It is helpful to some women to manage feelings related to HG, or with normal adjustments related to pregnancy and motherhood. Further, it is often very helpful postpartum to manage PPD [postpartum depression] and PTSD [posttraumatic stress disorder]. Since HG This treatment may be effective for secondary complications such as depression and anxiety, if used in conjunction with antiemetic medications and hydration. It should never be used as a primary modality for cases of HG. It is helpful to some women to manage feelings related to HG, or with normal adjustments related to pregnancy and motherhood. Further, it is often very helpful postpartum to manage PPD [postpartum depression] and PTSD [posttraumatic stress disorder]. Since HG is not a psychological disorder, this therapy must follow symptom management.

* Therapeutic abortion: Therapeutic abortion: Abortion in most cases of HG is avoidable with aggressive use of the available treatment options. Abortion in most cases of HG is avoidable with aggressive use of the available treatment options.

Women who choose abortion do so most often because of ineffective or inadequate treatment. Women left untreated sometimes become so metabolically imbalanced, abortion is chosen to save the life of the mother. However, it should be considered only a last resort. The long term consequences cannot be overlooked or underestimated.