NEO: Antenatal assessment and high-risk delivery PPT (12/24)

Gravida

G#P#, or the number of pregnancies and number of children

Ex. G3P2 = lost a child

Antenatal

before birth

GA

weeks and days for gestational age

Ex. 37w2d

Full term, early term and pre term GAs

Full: 39w0d - 40w6d

Early: 37w0d - 38w6d

Pre: <37w

Late pre: 32 - 36w6d
Very pre: 28w - 31w6d
Extremely pre: <28w

Important maternal factors (5)

1. maternal age (<18 or >35 has increased risk)

2. past pregnancies

3. chronic condition (hypertension, CF, sickle cell, etc.)

4. infection (GBS+)

5. complications (mental health, where they live, etc.)

Diabetes mellitus cause and types (2)

persistent high blood sugar due to insulin issue:

1. pregestational: leads to fetal structural malformation (CVS MC)

2. gestational: increased risk of DKA, proliferative retinopathy and preeclampsia; adverse fetal outcomes (stillbirth, macrosomia), neonatal metabolic disorders and shoulder dystocia

Infectious disease importance + types (5)

Major contributors to morbidity and mortality as WHAT MOM GETS, BABY GETS!!!! Can also be sexual transmitted. Includes:

1. GBS+

2. HSV (MC sexually transmitted)

3. HBV (high risk of infection during fluid contact during delivery)

4. HIV

5. cytomegalovirus, rubella, toxoplasma gondii, listeria monocytogenes, mycobacterial species, syphilis

Toxic habits in pregnancies

1. Alcohol: fetal alcohol syndrome, causing IUGR, abnormalities, cognitive defects

2. Smoking: IUGR, low birth weight, PROM, placental abruption (detaches from uterine wall)

3. drugs: stimulants and opioids. stimulants cause low birth weight, PTL/PROM, and placental abuprtion; whereas, opioids cause NAS (floppy baby)

High-risk conditions: hypertensive disorders (4). How NOT to treat?

1. hypertension: complicates pregnancies with IUGR, placental abruption, preterm delivery, fetal demise

2. preeclampsia: low dose aspirin can decrease risk, managed up to 37wk.

3. eclampsia: preeclampsia w/ seizures, life threatening

4. HELLP: hemolysis, elevated liver enzymes, low platelets (high mortality of 25%)

Treatment that lowers BP negatively impacts profusion of fetus. Treat by DELIVERY!

Placental disorders: placental absorption

Complete or partial separation of placenta prior to delivery of fetus.

Fetal complications: hypoxia, acidosis, death
maternal complications: life threatening hemorrhage and coagulopathy

Placental disorders: placenta previa

partial or complete coverage of cervix/hole. Cannot remove baby normally so need a c-section.

Umbilical cord normal length + vessels

55cm, 3 vessels (2 arteries, 1 vein)

Abnormal umbilical cord types (4, 2Vs?)

1. Short = increased risk of abruption

2. Long = increased risk of nuchal, prolapse and knots

3. Velamentous = vessels crossover, unsupported by placenta or cord structure

4. Vasa previa = unprotected vessels near or on cervix, increased risk of rupture

PROM + PPROM, treatments for it

AKA water breaking! fetus w/i fluid-filled amniotic sac rupturing. Antibiotics are given to prolong period b/w rupture + labor.

PROM = premature rupture of membranes
PPROM = preterm premature rupture of membranes (<37wk, increasing risk of pulm. hypoplasia)

AFI. What happens with high AFI? low AVI?

AFI: amniotic fluid index

1. Oligohydraminos: AFI<5 = UNDERDEVELOPMENT.

   1. early GA = lung hypoplasia

   2. late GA = cord compression

2. polyhydraminios: AFI>25 caused by diabetes or infection. Over distends uterus and leads to PROM, PTL or cord prolapse, affecting swallowing.

antenatal assessment: US, amniocentesis, NST, BPP

US: evaluates multiples, fetal anatomy, growth, position, placenta and fluid volume.

amniocentesis: INVASIVE US determining lung maturity through chromosomal abnormalities in late gestation with Lecithin-to-sphingomyelin (L:S) ratio

NST: non-stress test, traces HR and uterine activity in a normal state for 20min, assessing its function. Accelerations = spont. fetal movement

BPP: biophysical profile, evaluating placental fxn and fetal well-being. 8 points for fetal breathing, tone, gross body movement and amniotic fluid volume (<4 is poor).

preterm birth GA and what it increases risks of (7)

GA <37wk, being the greatest cause of infant mortality. Increases risk of:

1. sepsis

2. RDS, BPD, ROP

3. intraventricular hemorrhage (IVH) and necrotizing enterocolitis (hole in gut escaping into abdominal cavity)

4. cerebral palsy

How to treat PTL? (3, what steroids and tocolytics?)

preterm labor (SHIT).

1. Steroids:

   1. betamethasone: 12mg IM Q24H x2,

   2. dexamethasone: 6mg IV Q12H x4 

2. Hydration

3. Tocolytics (delay labor to let steroids work)

   1. magnesium sulfate

   2. beta mimetic agents (terbutaline)

   3. indomethacin (prostaglandin inhibitor)

   4. nifedipine (calcium chanel blocker)

Magnesium fxn + indications (5)

Short-term vasodilator protecting + stabilizing CNS. prolonged exposure = floppy baby due to sedative effect.

Indications: HTN, pre-eclampsia, eclampsia, tocolysis, fetal neuroprotection for fetus <32wk GA

Post-term risks (6)

GA >40/42wk, causing an increased risk for:

1. MAS

2. placental insufficiency

3. stillbirth

4. large for gestational age (LGA)

5. shoulder dystocia

6. C-section or assisted vaginal delivery

Intrapartum monitoring: FHR tracing

Fetal heart rate tracing done either noninvasively or w/ electrodes, categorizing results based on accelerations + decelerations of HR, + contractions, showing fetal tolerance to labor.

I = normal
II = indeterminate, requires closer monitoring
III = in distress, requiring immediate attention

Modes of delivery

Most deliveries are VAGINAL, as natural squeeze helps get fluid out of body. Cesarean sections are 33%. Assisted vaginal delivery includes forceps and vacuum.

High-risk delivery

10% of all births requires some resuscitation, so its equipment should be readily available and properly functioning. Team should include: neonatologist, NNP, NICU RN, RT

2 key takeaways:

1. what mom gets, baby gets

2. ventilation is KEY for resuscitation to recruit airways.