Rachel Morgan 471 Test 3

High Risk Pregnancy

High Risk Pregnancy

Life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to the pregnancy

High risk status last

Through puerperium - 6 wks after birth

Three leading causes to maternal mortality

Gestational hypertension, pulmonary embolism, and hemorrhage

High risk socioeconomic factors in pregnancy

Age (younger than 20 older than 35)

Lack of prenatal care

Low education attainment

Unmarried status

Non-caucasian

Socio-demographic

Biophysical

Originates within the mother or fetus (gym, gHTN)

Psychosocial

Maternal behaviors or lifestyles that have a negative effect on mother or fetus (drug use, mental illness)

Sociodemographic

Arise from the mother and her family (poverty, lack of prenatal care/support)

Environmental

Hazards in workplace or general environment (plant work, hospital, radiation exposure)

Biophysical assessment

Daily fetal movement counts

Ultrasound

Biophysical Profile

MRI

Biochemical assessment

Amniocentesis

Chorionic Villus Sampling

Percutaneous Umbilical Blood Sampling

Alpha Fetoprotein

Electronic Fetal Monitoring Test

Non Stress Test (NST)

Contraction Stress Test (CST)

Daily Fetal Movement Count

Performed after 28 weeks

Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation

Danger (DFMC)

3 or less kicks in one hours or no movement for 12 hours (fetal alarm signals)

2 hours method (DFMC)

Count 2 or 3 times a day after meals for 2 hours until 10 kicks are perceived

Juice? Snacks?

12 hour method (DFMC)

Count all movements in 12 hours until 10 movements are perceived

1 hour method (DFMC)

3 kicks in one hour

Ultrasonography types

Abdominal

Transvaginal

Indications for ultrasonography use

Fetal heart activity and overall well being

Gestational Age

Fetal growth and anatomy

Placental position and function

Adjunct to other invasive tests

Doppler blood flow analysis

Amniotic fluid volume

Biophysical profile

Variables of BPP

Fetal breathing movement

Gross body movement

Fetal tone

Reactive FHR

Amniotic fluid index

Fetal breathing movements

Practice breathes, consistently for 30 seconds

Gross body movement

Movement in utero

Fetal tone

Fetus maintaining flexed position

Amniotic fluid volume index

>2cm pocket

Normal BPP

Functional CNS (no hypoxia)

• Accurate indicator of impending fetal death

Magnetic resonance imaging (MRI)

Look at tissue in multiple planes

Can evaluate (detailed fetal structures, placenta, quantity of amniotic fluid, maternal structures)

Fetal nuchal translucency

11-14 wks.

Ultrasound scan to measure fluid in the nape of fetal neck

Used as marker for genetic disorders and downs

Amniocentesis

Done after 14 weeks

Obtains amniotic fluid

Indications for amniocentesis

Genetic testing

Fetal maturity (L/S ratio)

Fetal hemolytic disease

Meconium

Chorionic villus sampling (CVS)

Earlier dx, rapid results

Performed b/w 10-13 weeks gestation

Removal of small tissue (fetal portion of placenta)

Percutaneous umbilical blood sampling (PUBS)

Direct access to the fetal circulation during 2nd and 3rd trimester

Most widely used method for transfusion (d/t fetal anemia)

Insertion of needle directly into fetal umbilical vessel under ultrasound guidance to remove blood from cord

PUBS complications

Fetal injury, cord laceration, PROM, infection

Maternal serum alpha-fetoprotein (MSAFP)

Done b/w 15-20 weeks

Maternal serum levels used as screening tool

High: NTD’s, anencephaly, gastroschisis, omphalocele

Low: Trisomy 21

False positive/negatives

Gestational age not always accurate

What is MSAFP

It is a protein released by fetus, crosses into maternal blood stream

Maternity 21 and quad screen

Exact DNA makeup of fetus

Coomb’s test

Test for Rh incompatibility

Detects other antibodies that may place fetus at risk for incompatibility with maternal antigens

Nonstress test (NST)

Performed after 28 weeks

20 minutes

Vibroacoustic can be used to stimulate fetus

Exceptions - hypoxia, acidosis, drugs, fetal sleep, some congenital anomalies

Basis of NST

Normal fetus will produce characteristic heart rate patterns in response to fetal movement (85% gross fetal movements assoc. with accelerations in FHR)

Non-Reactive Stress Test v. Reactive Stress Test

Reactive: 2 or more in a 20 min period

Non-reactive: fetal hypoxia, drugs, sleep cycle

Contraction stress test

Identify that fetus is stable at rest but showed evidence of compromise after stress

Nipple stimulation

Oxytocin stimulation

CI: placental previa, classical incision, baby not stable at rest

Negative CST

Good

No decels

Positive CST

Bad

Late decels with 50% or more of contractions

Equivocal/suspicious CST

Intermittent late or variable decels (less than 50% of ctxs)

Decels w tachysystole

Unsatisfactory CST

Fewer than 3 ctx in a 10-minute period

Hypertension definition

Systolic BP >140

Diastolic BP >90

Proteinuria - 1+ on dipstick or 300mg/24hrs

Hypertension classifications

Gestational HTN

Preeclampsia

Eclampsia

Chronic HTN

Gestational HTN

140/90 × 2 readings 4 hours apart without s/s

Onset after 29 wks. gestation w/o proteinuria

Termed chronic if not reversed by 12 wks. PP

Benign, good outcomes

Preeclampsia

HTN w/ proteinuria or s/s

Unique to pregnancy

s/s develop after 20 wks. and disappear after placenta delivery

Cause unknown, begins at conception but s/s not seen until later

Placental abnormalities

Early

Poor, shallow implantation in uterine lining > narrow vessels w/ atherosclerosis > poor perfusion

Preeclampsia clinical manifestations

Poor perfusion causes an inflammatory response > endothelial damage, vasospasms, clotting cascade

Vasospasms results in 40-60% reduction in perfusion to placenta, kidneys, liver, and brain

Characterized by increasing BP, proteinuria, and hemoconcentration

S/s of preeclampsia

Abd. pain

Increased AST and ALT

Decreased Platelets

Proteinuria

Decreased UO

Edema

Increased BP

Severe HA, changes in vision, NV, SOB

Risk factors preeclampsia

Hx of preeclampsia, HTN dx

Cure for preeclampsia

Delivery of placenta

Preeclampsia with severe features

BP >160/110 ×2 readings, 4 hrs apart

Visual disturbances

SOB/pulmonary edema

Epigastric pain/ increases LFTs

Abnormal renal studies/serum Cr >1.1

Platelets <100,000

HELLP syndrome

Variant of preeclampsia

Plt < 100,000

PT, PTT, and bleeding times usually normal

Most often seen in older Caucasian, nulliparous women

Eclampsia

Presence of a seizure

Chronic HTN

Present prior to pregnancy

dx <20 wks. gestation

Persists longer than 6-12 weeks PP

Assoc. w/ increased risk of abruption, superimposed preeclampsia, increased perinatal mortality

Fetal effects: IUGR or SGA babies

Chronic HTN w/ superimposed preeclampsia

Chronic HTN develops into preeclampsia or eclampsia

Occurs in 25% chronic HTN pts.

Chronic HTN with new onset of proteinuria o features of preeclampsia

Severe complications to both mother and fetus

Assessment of pts. with HTN disorders

BP checks

Observe for edema

DTR

Clonus (clonic beats)

BPP

Labs: CBC, clotting studies, urine for pr, liver enzymes, chemistry to check kidney function, P/C ration

24-hour urine

UO

Labetalol

Beta blockers

Manage hypertension

Assess apical pulse before administering

Nifedipine (procardia)

Calcium channel blocker used to treat high blood pressure

Methyldopa

Centrally acting alpha-2 adrenergic agonist

Low dose aspirin

81 mg per day

Inhibiting the production of certain substances in the body that cause blood clotting

Magnesium sulfate

Administered intravenously to prevent seizures and control blood pressure in women with severe preeclampsia or eclampsia

Works by relaxing blood vessels and reducing the risk of convulsions

Management of fetus - HTN mother

NSTs, BPPs, EFM, Celestone, Neuro Magnesium

Unproven HTN tx

Vit C and E, reduce salt, exercise, bedrest

Mag level

4-8g/dL

S/s mag toxicity

Decreased resp, decreased reflexes, slurred speech, sleepy, decreased LOC

What do you do? Stop it

Antidote for mag sulfate

Calcium gluconate

Mag effects on baby

Decreased resp, decreased muscle tone

PP effects of mag

PP hemorrhage risk

Miscarriage (Spontaneous abortion)

Pregnancy ending from natural causes

(<20 wks or 500g)

10-20% of pregnancies

80% chromosomal abnormalities

Hormones used to determine normality of pregnancy

Estrogen and progesterone

Threatened miscarriage

Bleeding and cramping

Bedrest, progesterone injections, management of s/s

Complete miscarriage

Return to homeostasis

Completely passed all tissues

Transfusion, Rhogam, emotional support

Missed miscarriage

Prostaglandins, D&C

Everything normal, no heartbeat

Incompetent cervix

Passive, painless, recurring losses at progressively shorter durations

Def: recurrent premature dilation of the cervix

Causes of incompetent cervix

Previous cervical laceration during childbirth

Excessive cervical dilation for curettage or biopsy

Patient’s mother treated with DES

Management of incompetent cervix

Conservative - bed rest, tocolytics, hydration

Cerclage b/w 10 and 14 wks

Dx of incompetent cervix

U/S, pt. hx

Ectopic pregnancy

Implantation occurs outside of uterus

95% occur within fallopian tubes

Leading cause of maternal mortality in the 1st trimester

S/s of ectopic pregnancy

Abd. pain, bleeding, shoulder pain, shock

Dx of ectopic pregnancy

Lab values

Tx of ectopic pregnancy

Surgical or medicinal

• Salpingostomy (removal of embryo)

  • Salpingectomy (removal of tube)

Hydatidiform mole

Molar pregnancy

Gestational trophoblastic disease (GTN) which means it arises from the placental trophoblast (outer lining of placenta)

Considered malignancy, but most curable gynecologic malignancy (mortality rate is 0%)

Complete hydatidiform mole

Fertilization of an egg with no nucleus (ovular defect)

Partial hydatidiform mole

Fertilization of a normal egg by two sperm

Dx of hydatidiform mole

Ultrasound and B-hCG levels (Increased)

Tx of hydatidiform mole

D&C with Pitocin after, birth control 6-12 months, follow up 1x year - ensure normal hCG levels

Placenta previa

Placenta implants in lower uterine segment over of near cervical os

Total, partial, marginal, low-lying

Painless vaginal bleeding, 20% bleeding with contractions

Risks of placenta previa

Previous c/s, smoker, close pregnancies

Dx placental previa

Ultrasound

always considered potential emergency

Vasa Previa

Fetal vessels covering cervical os

Velamentous insertion of the cord

Fetal vessels attach into the membrane - risk is vessel rupture

Placental abruption

Detachment of part or all of the placenta from its implantation site

70-80% have vaginal bleeding and pain

Delivery if term and bleeding is mod-severe

Tx placental abruption

C-section

Risk factors of placental abruption

Smokers, cocaine, gHTN

Diabetes in pregnancy

More cortisol and growing baby

Tested 24-28 weeks

Primary goal: euglycemia through a combination of diet, insulin and exercise

Poor glycemic control in the beginning = miscarriage, in the end = macrosomia

Hyperemesis

Vomiting in pregnancy excessive enough to cause weight loss of at least 5% if prepregnancy weight

Begins in 1st 10 weeks

Cause unknown (poss. relaxed GI tract r/t estrogen, progesterone, and hCG, possibly psych)

Hyperemesis more common in -

Nulliparas

Female fetus

BMI < 18.5 or >25

Migraines

Twins

Molar pregnancies

Tx hyperemisis

IV fluids, TPN, Vit B6 plus Doxylamine (Diclegis), ginger, diet

No Zofran in 1st trimester