Summary
Various physiological changes occur during pregnancy. The daily need for protein, energy and various micronutrients is increasing. Malnutrition develops when these needs are not adequately met. Malnutrition is one of the important factors that threaten maternal and fetal health. Apart from this, many problems may arise that concern the Internal Medicine Specialist, especially hypertension and diabetes. Each of them should be questioned separately and solutions should be produced one by one for the problems that arise. In this article, internal problems that may arise during pregnancy and their solutions are presented.
Physiological Changes During Pregnancy
A number of physiological changes occur in the body during pregnancy. These are mainly hormonal, hematological, cardiovascular, metabolic, renal, gastrointestinal and musculoskeletal changes. Serum estrogen and progesterone levels increase throughout pregnancy. In this way, new menstrual cycles are prevented. Increased progesterone provides uterine relaxation. Increased prolactin causes hypertrophy of breast tissue. The increase in parathormone allows more calcium to be absorbed from the gastrointestinal tract. There is an increase in serum cortisol level. During pregnancy, blood volume increases by approximately 50% and is accompanied by relative anemia. Increase in erythrocyte volume, leukocytosis, increase in erythrocyte sedimentation rate, increase in plasma fibrinogen and factor VIII levels and the accompanying hypercoagulability are other hematological changes. During pregnancy, heart rate and cardiac output increase. In the first half of pregnancy, despite the increase in volume and flow rate due to vasodilation, there is a slight decrease in diastolic blood pressure, but later on, blood pressure returns to normal due to the increase in aldosterone effect. Increased blood pressure above normal can cause pre-eclampsia and eclampsia. Protein and fat storage increases during pregnancy. The increase in insulin resistance as well as the increase in serum cortisol levels are an attempt to protect the fetus from hypoglycemia, but this may lead to gestational diabetes. During pregnancy, the glomerular filtration rate increases by approximately 50% and returns to normal only within 20 weeks in the postpartum period. Thus, blood urea nitrogen and creatinine levels are low throughout pregnancy. self during pregnancy Nausea and vomiting may occur due to the increase in beta-HCG, especially in the first trimester. In late pregnancy, gastro-esophageal reflux disease may occur due to increased intra-abdominal pressure. As the body posture changes in the later stages of pregnancy, the back and abdominal muscles adapt to this (1).
Nutrition During Pregnancy
As metabolic needs increase during pregnancy, the daily requirement of various nutrients also increases. During pregnancy, daily energy needs increase by 300 kcal/day (80,000 kcal in total). This energy intake corresponds to an average maternal weight gain of 10-12 kg at term. The recommended daily energy increase of 300 kilocalories is 17% of the pre-pregnancy requirement. The requirement for vitamins and minerals increases by 20-100%. Therefore, the foods to be chosen should aim to meet these needs. During pregnancy, the daily protein need increases by 15 grams compared to before. Animal proteins come to the fore as protein sources, and it is known that chicken and fish meat are healthier than red meat. Omega-3 fatty acids contribute to the neural and visual development of the fetus. The most important sources of omega-3 fatty acids are soybeans and oily fish. It should be emphasized that they should meet their fat needs from non-hydrogenated vegetable oils, consume moderate amounts of fish products and turn to unprocessed natural foods. During pregnancy, the need for micronutrients as well as macronutrients increases. The need for calcium, iron, zinc, folate, vitamins D and E, ascorbic acid and B vitamins increases. Daily iron requirement is 5-6 mg more than normal (22-27 mg/day). Daily calcium requirement is 1000 mg, folate 400 μcg, zinc 15 mg, vitamin D 600 IU, vitamin E 15 mg, vitamin C 85 mg, vitamin A 770 μcg, thiamine 1.4 mg, riboflavin 1.4 mg, niacin 18 mg and pyridoxine 1.9 mg. (2,3).
Diseases That May Occur During Pregnancy
Apart from physiological changes, some pathological diseases may develop during pregnancy. The most important of these are gestational diabetes and hypertension. All diseases that occur during pregnancy risk the lives of the mother and the fetus if they are not treated effectively.
Hypertension
Hypertension is detected in 7-10% of all pregnancies. . Some of these are people who were diagnosed with hypertension before pregnancy. Gestational hypertension occurs after the 20th week. When hypertension is detected during pregnancy, blood pressure levels should first be determined, some modifications in the diet should be recommended without serious salt restriction, secondary organ damage should be investigated, and especially the presence of proteinuria should be investigated. Hypertension accompanied by proteinuria and edema (rapid development of edema in the lower extremities or edema development in other areas of the body) is considered pre-eclampsia, and all these findings accompanied by convulsion (epilepsy) is considered eclampsia. Treatment goals should be adjusted according to these data. During examination and treatment, fetal evaluation should be performed at regular intervals and the healthy development of the fetus should be monitored (4,5).
Risk factors for pre-eclampsia; mother being under 18 or over 35 years of age, previous history of pre-eclampsia, first pregnancy, family history of pre-eclampsia, obesity, presence of chronic hypertension, presence of secondary hypertension, history of pre-gestational diabetes, chronic kidney disease, systemic lupus erythematosus, The presence of thrombophilia, serotonin reuptake inhibitor use, multiple pregnancy, hydrops fetalis and gestational trophoblastic disease (5).
The blood pressure target in pregnant women with no organ damage or proteinuria is 140/90 mmHg. is. In the presence of these two conditions, the target is <140/90 mmHg. Above these values, bed rest, life modification and medication are required. In case of serious increases in blood pressure (>170/110 mmHg), treatment with hospitalization is recommended (4,5).
Antihypertensives that can be used during pregnancy are primarily methyldepa, labetalol and calcium channel blockers. Angiotensin converting enzyme inhibitors (ACEI) and Angiotensin 2 (AT2) receptor blockers are not used. However, in the presence of resistant hypertension, other antihypertensives other than ACEI and AT2 blockers can be used. In hypertensive crises, nitroprusside can be given in a controlled manner in a hospital setting. This treatment should be kept short-term, otherwise fetal thiocyanate poisoning may occur. In the presence of pre-eclampsia and eclampsia, magnesium sulfate can be given (6). If not treated appropriately, pre-eclampsia can risk the life of the mother and the fetus. Risks posed by pre-eclampsia; eclampsia, intracranial hemorrhage, pulmonary edema, acute renal failure, HELLP syndrome, disseminated intravascular coagulation, abruptio placentae, intrauterine growth restriction, premature birth and intrauterine death.
Gestational Diabetes
It is defined as diabetes that begins during pregnancy and usually ends with birth. Pre-existing insulin resistance that increases with pregnancy causes gestational diabetes (GDM). It is usually asymptomatic. Obesity, presence of insulin resistance before pregnancy, impaired glucose tolerance, maternal age ≥25, and history of diabetes in first-degree relatives are risk factors for the development of gestational diabetes. A screening test is performed with 50 g glucose between 24-28 weeks of pregnancy. This period should not be waited in risky patients. If blood sugar is >140 mg/dl at the end of the first hour, further testing is performed for diagnosis. The American Diabetes Association (ADA) still recommends 100 g on this issue. OGTT recommends 75 g, while the World Health Organization (WHO) recommends 75 g. It indicates performing an OGTT. With 100 g OGTT, at least two of the following: fasting blood sugar ≥95 mg/dl, 1st hour blood sugar ≥180 mg/dl, 2nd hour blood sugar ≥155 mg/dl, and 3rd hour blood sugar ≥140 mg/dl. If present, gestational diabetes is diagnosed. If one of these values is high, it is said that there is impaired glucose tolerance (7,8). According to the WHO evaluation, the diagnosis is made if fasting blood sugar is ≥126 mg/dl and 2-hour postprandial blood sugar is ≥200 with the 75-g OGTT (9). According to the most recently announced International Diabetes and Pregnancy Study Groups (IADPSG) criteria, 24-28. 75 g per week. With OGTT, diagnosis can be made if at least one of the following values: fasting blood sugar ≥92 mg/dl, 1st hour blood sugar ≥180 mg/dl, and 2nd hour blood sugar ≥153 mg/dl (10). Diagnosis cannot be made with HbA1c.
Insulin is administered in cases where diet and exercise program are not sufficient in the treatment. When calculating the calories of the daily diet, 30 kcal/kg/day is used for normal weight people, 25 kcal/kg/day for overweight people and 12 kcal/kg/day for obese people. Carbohydrate content in the diet is 40-45%, protein content is 1.1 It should be g/kg/day. It must contain omega-3 fatty acids, and folic acid, iron, calcium and vitamin D supplements should be made during follow-up. Saturated fat content should be kept low. Metformin is not preferred in medical treatment due to placental transfer. There are no sufficient data for acarbose and glinides. Insulin secretagogues are not used. Insulin therapy is currently recommended for the treatment of gestational diabetes. Mostly crystallized and NPH insulin is preferred. Short-acting analog insulins (aspart and lispro) can also be used. Long-acting analog insulins are not used (11,12). The initially selected dose should be 0.1-0.25 U/kg/day. NPH insulin or basal-bolus can be administered twice a day. In the follow-up, the target glycemia fasting glucose level should be <95 mg/dl and the 1st post prandial glucose level should be <140 mg/dl. A minimum of 30 minutes of exercise daily should be recommended. The condition improves in 1/3 cases after birth, and the findings continue in the remaining 2/3 individuals. Therefore, in the postpartum period 6-12. Carbohydrate metabolism should be examined with OGTT with 75 g glucose per week (8).
Heart Failure
During pregnancy, blood volume increases by approximately 50%, peak heart rate by 10-15/minute and cardiac output by 30-50%, and blood pressure decreases by 10%. During birth, cardiac output increases by an additional 50%. Heart failure develops in 1-4% of all pregnancies where it was not present before. The risk is much higher in pregnant women who have previously had cardiac problems. For example, according to the NYHA classification, the risk of mortality increases by 7% and the risk of morbidity increases by 30% in a pregnant woman with stage 3 and 4 heart failure. Risk factors for the development of heart failure during pregnancy: History of previous cardiac problems, previously known arrhythmia, NYHA stage 3 or 4 heart failure, heart valve disease and myocardial dysfunction due to any reason. The risk of heart failure is 4% when there is none of these risks, 27% if there is one, and 75% if there is more than one risk. Cardiac pathologies that pose a serious risk include severe pulmonary hypertension, cyanotic heart disease, Marfan syndrome with aortic valve involvement, severe aortic stenosis, aortic and/or mitral valve diseases causing moderate or severe left ventricular systolic dysfunction, accompanied by NYHA stage 3 or 4 heart failure. the one who does
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