Perinatal Challenges Essay Example for Free

Perinatal Challenges Essay Perinatal challenges during pregnancy and birth are associated with different varieties of diseases and complications, such as gestational diabetes and shoulder dystocia during birth. According to Gullotta, Adams and Ramos (2006), perinatal period commences during the 22nd week of gestation or after 154 gestational days (p. 392). During this stage, perinatal environment is exposed to different bodily changes associated to the bodily responses of the mother towards pregnancy. According to Ben-Haroush, Yogev and Hod (2003), gestational diabetes often progresses during perinatal periods wherein metabolic absorption of carbohydrates becomes impaired possibly due to insufficiency in insulin production, metabolic impairments associated to receptor malformations, and release of anti-insulin hormones (e. g. human placental lactogen, etc. ). As supported by Callahan and Caughey (2006), progressive occurrence of gestational diabetes may result to different complications during child birth, such as macrosomia, shoulder dystocia and neonatal hypoglycemia (p. 1). Specifically, shoulder dystocia is one of the most common complications associated with gestational diabetes. This is usually identified in cases wherein the mother encounters difficulty of childbirth due to problematic passing of the infant’s anterior shoulder (Gullotta, Adams and Ramos, 2006 p. 392). Shoulder dystocia and gestational diabetes are linked problems during pregnancy. As supported by Queenan, Spong and Lockwood (2007), perinatal occurrence of diabetes usually ends up in problematic infant’s size proportion, which eventually displaces the infant’s body parts in inappropriate positions during childbirth resulting to the difficulty of delivery (p. 179). Gestational diabetes is regarded as a prominent mortality contributor especially during perinatal periods wherein the development of the child is greatly compromised due to the metabolic impairments of the mother. According to Zazworksky, Bolin and Gaubeca (2006), â€Å"perinatal mortality, consisting of both fetal and neonatal deaths, is probably directly related to metabolic derangement in diabetic pregnancies† (p. 192). Perinatal stage of pregnancy, as with other periods of pregnancy, largely depends on the occurring environment inside of the mother. If the maternal metabolic glucose absorption and insulin levels are compromised, the infant’s development is therefore at risked of developing different complications associated to such condition. According to Hod, Javanovic and Di Renzo et al. 2003), gestational diabetes occurring during perinatal period results to four-fold higher mortality rates compared to those non-diabetic pregnancies (p. 431). Pregnancy complications resulting from progressive perinatal diabetes are the most difficult scenarios to deal with. Macrosomic or those proportionately enlarged infants are main problem caused by gestational diabetes. As supported by Goroll, Mulley and Mulley, Jr. (2006), gestational diabetes and the incidence of macrosomic delivery trigger increased risk for serious traumatic childbirth and the need for extensive cesarean section (p. 81). Traumatic complication of macrosomia induced by gestational diabetes is shoulder dystocia, which greatly increases the likelihood of cesarean section and birth trauma for normal section (Hod, Javanovic and Di Renzo et al. , 2003 p. 431). In this study, the emphasis mainly involve (a) the perinatal challenges brought by gestational diabetes and (b) the complications of child birth resulted by shoulder dystocia as a complication of gestational diabetes. Discussion Formally, the perinatal period commences after 22 completed gestation weeks and ends a fter seven days of post-delivery. Perinatal challenges in pregnancy involve different bodily conditions that can be life-threatening to both mother and the infant. World Health Organization defines perinatal period as the â€Å"period of prenatal existence after viability of the fetus is reached, the duration of labor, and the early part of extra-uterine life† (cited in Siegel, Swanson and Shyrock, 2004 p. 354). According to DeCherney and Goodwin (2007), life threatening complications of pregnancy are usually greatest during the perinatal period than any other stages of pregnancy due to variety of mortality causes (p. 188-189). As supported by Herbert (2003), the last three months of fetal life in the womb are considered the most vital stage of pregnancy due to the heightened sensitivity of the baby to the environmental health inside the mother (p. 44). One of the most common challenges faced during this period of conception is the metabolic disorder exclusive during pregnancy – gestational diabetes. The metabolic disorder during pregnancy, gestational diabetes, is an exclusive condition associated to impaired glucose absorption brought by the insufficiency of systemic insulin levels of the body (Callahan and Caughey, 2006 p. 105). Physical challenges and threats brought by gestational diabetes during perinatal period undeniably life-threatening and vital to the survival of both mother and child. According to Queenan, Spong and Lockwood (2007), gestational diabetes is considered a warning sign of gestation-induced insulin resistance (p. 179). Gestational diabetes is usually detectable on the early or latter weeks of perinatal period, which is approximately 24 weeks of gestation (Dudek, 2006 p. 290). The incidence and prevalence of gestational diabetes during the perinatal periods are statistically more pronounced compared to other periods of conception. According to Porth (2005), gestational diabetes occurs up to 14% of all pregnancies depending on the population and diagnostic procedures utilized (p. 998). As claimed by the Australian Institute of Health and Welfare (2007), gestational diabetes occurs among the approximately 3% to 8% of females not previously diagnosed with diabetes. Added by the public organization Diabetes Australia (2004), incidences of gestational diabetes occurs more predominantly among (higher than 20%) aboriginal women compared to other ethnic diversities. Etiologies attributed to the increasing incidence of gestational diabetes are still unknown due to the unproven etiological propositions of gestational diabetes. However, different studies (Buchanan and Xiang, 2005; Langer, Yogev, and Most et al. , 2005; Rosenberg, Garbers and Chavkin et al. , 2003) have proposed their hypothetical explanation to the etiological nature of gestational diabetes itself. The first theory proposed by Buchanan and Xiang (2005) is associated with the genetic nature of the mother predisposing to her to gestational diabetes. As supported by Porth (2005), gestation diabetes is more prominent among mothers who have history of glucose intolerance or metabolic problems related to glucose absorption (p. 988). In the study of Buchanan and Xiang (2005), gestational diabetes is claimed to be the end-product of monogenic dysfunction of B-cells. Mutations in the mitochondrial DNA of beta cells trigger the autosomal mutations eventually causing beta cell dysfunction. Meanwhile, according to the study of Rosenberg, Garbers and Chavkin et al. (2003), gestational diabetes is triggered by lifestyle practices prior and during pregnancy. In the study, a total of 63. % of the total women in the heaviest group (weight: 300 lbs or 136 kg) have had incidence of gestational diabetes and other complications during pregnancy compared to the women whose weight range between 200 to 299 pounds (49. 8%). According to Callahan and Caughey (2006), another hypothetical explanation to the etiology of this condition is the release of placental hormone, specifically known as the human placental lactogen (a. k. a human chorionic somatomammotropin), which acts as an anti-insulin substances increasing the insulin resistance and generalized carbohydrate intolerance of the mother systemically (p. 05). Added by LeRoith, Taylor and Olefsky (2003), beta cells secretion of insulin is incapable of fully compensating the increasing bodily requisites of both infant and mother; hence, glucose intolerance results (p. 1295). If this glucose malabsorption continues, the mother’s body encounter severe rise of sugar levels inducing gestational diabetes, while the infant is considered at risk of experiencing hypoglycemia due to insufficient levels of insulin used for glucose absorption (Callahan and Caughey, 2006 p. 105). As supported by Porth (2006), gestational diabetes is more prominent during 24th up to 28th week of gestation, which is actually the perinatal period (p. 988). Compared to the normal pregnancy, mothers with gestational diabetes manifest decreased secretory activity, compromised insulin response per unit of glycemic stimulation and absence of insulin progressiveness (LeRoith, Taylor and Olefsky, 2003 p. 1295). Potential risks involved in gestational diabetes are the complications that may arise during perinatal periods. Continuous occurrence of gestational diabetes also predisposes potential problems during child delivery or the last seven days of perinatal period. According to Brown, Isaacs and Krinke et al. (2005), potential outcomes of gestational diabetes during perinatal period leads to the surge of insulin levels within the uterine environment, which eventually increases glucose reuptake of fetal cells converting them to triglycerides (p. 127). In such conditions, the infant develops dramatic fat deposits with increased body frame size and weight compared to the normal infant (4500 grams). As supported by Wehren and Marks (2004), the rise of blood glucose in the mother’s internal environment also increases the blood glucose levels circulating within the infant, which consequently places the child under the circumstance of neonatal hyperglycemia (p. 209). Aside from neonatal hyperglycemia, biochemical risks brought by gestational diabetes also include hypocalcemia, hyperbilirubinemia and polycythemia (Callahan and Caughey, 2006 p. 05). LeRoith, Taylor and Olefsky (2003) claim the frequency of acquiring gestational diabetes increases with progressive age and BMI conditions (p. 1295). Meanwhile, complications that may occur on the infant involve stillbirth risk, spontaneous abortion, macrosomia, neonatal hypo- and hyperglycemia, increased risk of developing insulin resistance and most commonly shoulder dystocia (Brown, Isaacs and Krinke et al. , 2005 p. 127). Treatment and diagnostic to the effects of gestational diabetes are crucial to the prevention and care of the pregnancy. Diagnostic procedures for gestational diabetes should be done at the end of the second trimester between 24 and 28 weeks of gestation (Callahan and Caughey, 2006 p. 105). Patients developing at least two associated risk factors should have their diagnostic screening at their first prenatal visit and during each subsequent trimester. Added by Joslin, Kahn and Weir et al. ), universal diagnostic procedure for gestational diabetes is also dependent on the series of identifiable factors, such as age of first pregnancy, body weight, history of abnormal glucose metabolism and racial or ethnic background, that place the mother in a series of more intensive tests (p. 1043). One example of these diagnostics involves a screening test consisting of 50g of glucose administration followed by glucose-plasma measurement one hour after the administration. If the results reveal 1-hour glucose level higher than 140 mg/dL, the implication is positive and the procedure called glucose tolerance testing is indeed necessary for the purpose of validation (Callahan and Caughey, 2006 p. 105). If the mother’s glucose level reveals positive result during the 1-hour glucose test, the individual is referred for 3-hour oral glucose tolerance test (GTT) in order to assess their carbohydrate metabolism levels (Hod, Jovanovic and Di Renzo et al. , 2003 p. 331). In this procedure, oral glucose of exactly 100 mg is given to the mother after the 8-hour fasting period preceded by a 3-day intensive carbohydrate diet. After the commencement of GTT, glucose is then measured three times every after an hour after the intake of dose. According to Hod, Jovanovic and Di Renzo et al. (2003), patients with plasma glucose of 126 mg/dl should have their blood glucose monitored for the next 24 to 38 weeks of pregnancy (p. 330). Added by Callahan and Caughey (2006), â€Å"if the fasting glucose or two or more of the postprandial values are elevated, a diagnosis of gestational diabetes is made† (p. 05). After the diagnosis, the mother is immediately placed under strict diabetic diet with 2200 calorie consumption a day including 200 to 220 g of carbohydrate serving per day (Zazworsky, Bolin and Gaubeca, 2006 p. 195). Diabetic diet is usually accompanied by recommended exercise in order to stimulate blood circulation. According to Callahan and Caughey ( 2006), if blood sugar values are already 25 to 30% elevated, insulin medications or oral hypoglycemic agents are usually administered (p. 106). With the continuous progression of gestational diabetes during the perinatal stage of pregnancy, another common perinatal challenge during childbirth is being predisposed shoulder dystocia. Maternal complications during continuous progression of gestational diabetes may also include increased risk of preeclampsia, pregnancy-induced hypertension, maternal obesity, and the increased risk of developing Type II diabetes mellitus and gestational diabetes for subsequent pregnancy (Brown, Isaacs and Krinke et al. 2005 p. 127). In fact, in the study of Langer, Yogev, and Most et al. (2005), pregnant mothers diagnosed with gestational diabetes (n=555) have experienced pregnancy and childbirth complications, specifically macrosomia and shoulder dystocia. The rates of complication are found higher (59%) among those untreated mothers, while a smaller number of complicated cases (18%) occurred among those treated pregnancies. Shoulder dystocia is considered as an obstetric emergency with a very unpredictable nature. Such complication can be identified once the fetal head has already been delivered. The midwife or attending physician might encounter difficulties in delivering the shoulders most commonly due to the impaction of the anterior shoulder behind the pubic symphysis (Callahan, Caughey and Heffner, 2004 p. 69). Despite of its unpredictable nature, shoulder dystocia has been associated to different pregnancy complications that are considered as its potential predisposing factors, such as macrosomia, gestational diabetes and maternal obesity. According to Simpson and Creehan (2007), gestational diabetes is the nearest related risk factor of shoulder dystocia due to the larger body frames and marked anthropometric differences in infants of diabetic mothers (p. 329). Despite the emergent and life-threatening character of shoulder dystocia, Reichman and Simon (2003), considers this as a rare obstetric complication with a varying incidence rate of 1% to 4% of cephalic spontaneous vaginal deliveries (p. 1043). As supported by Simpson and Creehan (2007), shoulder dystocia occurs more prominently among macrosomic infants with weights of 5,000 g with an incidence rate of 70% to 60%. In the retrospective study of Ouzounian and Gherman (2005), among the 267,228 vaginal births during the study period from January 1991 to June 2001, reported cases of shoulder dystocia are only 1,686 (n=0. 6% of the total 267,228 sample). Meanwhile, in the earlier studies conducted by Nasar, Usta and Khalil (2003), among the 189 recorded deliveries, there are only 13 cases complicated by shoulder dystocia. According to Reichman and Simon (2003), cases with complication of shoulder dystocia are usually diagnosed during the actual birth itself unless radiographic imagery reveal inappropriate fetal positioning while still inside the uterine environment (p. 1043). Despite the many efforts of predicting the incidence or occurrence of shoulder dystocia, modern obstetrics are only able to determine the potential risk factors associated to this birth complication. According to Callahan and Caughey (2006), majority of the identified risk factors of shoulder dystocia are related to gestational diabetes itself and the accompanied symptoms (e. g. maternal obesity, macrosomia, etc. ) of the metabolic impairment (p. 79). Other associated risk factors of shoulder dystocia are the number of previous pregnancy, history of shoulder dystocia, overweight status of the mother and during assisted vaginal deliveries (Grady, Howell and Grady et al. 2007 p. 221). Meanwhile, intrapartum labor induction and prolonged second-stage labor are also being proposed as potential risk factors of shoulder dystocia (Simpson and Creehan, 2007 p. 328). Nevertheless, these risk factors are also inaccurate basis for predicting shoulder dystocia; although, many reported cases of shoulder dystocia have manifested at least one of these reported risk components (Reichman and Simon, 2003 p. 1043).