High-Risk Pregnancy

Risk Factors

Biophysical- Genes, nutrition, medical/obstetric issues

Psychosocial- Substance use

Sociodemographic- low income, age, ethnicity, marital status, low access

Environmental- diet, stress, diseases, chemicals

High Risk Pregnancy Antepartum Testing Goals

• Identify fetuses at risk for injury due to poor oxygenation

• Prevent permanent injury/death

• Identify appropriately oxygenates fetuses to avoid interventions

Antepartum Testing: Fetal Monitoring

Fetal Monitoring typically begins by 32-34 wks

Indications for Antepartum testing:

• Diabetes
• Chronic hypertension
• Preeclampsia (with or without severe features)
• Suspected or confirmed fetal growth restriction
• Multiple gestations
• Oligohydramnios
• Preterm premature rupture of membranes (PPROM)
• Late-term or post-term gestation
• Previous stillbirth
• Decreased fetal movement
• Systemic lupus

Fetal Biophysical Assessment

•Daily fetal movement count
• Perform kick counts 2-3 times a day. Report <3
per hour or lack of movement for 12 hours
•Ultrasonography
•MRI

Assessment of Fetal Well-Being

• Ultrasound (abdominal,
transvaginal, and Doppler)
• High-frequency sound waves
used to visualize fetus and
maternal structures (fetal heart
rate (FHR), pelvic anatomy)
• Allows for early diagnosis of
complications, permits earlier
interventions, and decreases
neonatal and maternal
morbidity and mortality

External Fetal Monitor (EFM)

• Non-Stress test- Quickly & easily performed in outpatient setting

• Contraction stress test- Nipple/Oxytocin stimulation

Biophysical Profile (BPP)

• Ultrasound used to visualize the physical and physiological characteristics of
the fetus and responses to stimuli
• Score 8 to 10 is normal and low risk of chronic fetal asphyxia;
• Score 6 or less is abnormal, suspect chronic fetal asphyxia

Biophysical Profile (BPP) Combines

FHR monitoring (non-stress test) and fetal ultrasound
• FHR
• Fetal breathing movements
• Gross body movements
• Fetal tone
• Qualitative amniotic fluid volume

Ectopic Pregnancy: Tubal Pregnancy Tx & Goal

• Implantation of the pregnancy outside of the uterus
What are the treatment options?
• Medical management
• Surgical management
What is our goal?
• Prevent hemorrhage

Ectopic Pregnancy: Risk factors

• STIs (PID)
• Tubal infections and damage
• Contraceptive devices
• Scarring from previous surgeries

Ectopic Pregnancy: Symptoms

• Unilateral pain
• Delayed menses
• Vaginal spotting/bleeding
• Referred shoulder pain
• Symptoms of hemorrhage

Hyperemesis Gravidarum

• Persistent N/V beyond 16th week of pregnancy
• Weight loss, electrolyte imbalance, nutritional deficiencies, and
ketonuria

Hyperemesis Gravidarum Risk Factors

Young maternal age, nulliparity, BMI less than 18.5 or greater
than 25, low socioeconomic status, carrying a female fetus,
multifetal gestation, maternal family history

Hyperemesis Gravidarum Tx & Complications

• Reducing nausea and vomiting. Maintaining nutrition and fluid
balance. Providing emotional support
• Prematurity, Small for gestational age, Low birth weight

DM Maternal Risks

Preeclampsia, Hydramnios, Infections (UTI,
vaginal infections), Ketoacidosis, Macrosomia, Shoulder Dystocia

DM Fetal & Neonatal Risks

• Fetal risks: Congenital malformation, Variations in fetal size (macrosomia), Stillborn
• Neonatal Risks: Hypoglycemia, Hypocalcemia, Hyperbilirubinemia, Respiratory
distress syndrome

Gestational diabetes is

Diagnosed 2nd half of pregnancy. Maternal insulin resistance
increases as much as 3-fold due to hormonal effects of pregnancy. GDM results
when the pancreas can’t keep up with the demands of insulin need

Gestational DM Risk Factors

Overweight or obesity (BMI > 25)
Maternal age
Gestational diabetes in previous pregnancy
History of abnormal glucose tolerance level
History of diabetes in a close relative
Hypertension
Ethnicity

Gestational Diabetes Dx

• Glucose screening test
• Between 24 to 28 weeks
gestation
• Glucose tolerance test
• High-risk women
• If GCT results are elevated

Gestational Diabetes Management

• Glucose control
• Diet
• Exercise
• Glucose level
monitoring
• Pharmacological
therapy
• Fetal surveillance

Hypoglycemia

• Shakiness (tremors)
• Sweating
• Pallor; cold, clammy skin
• Disorientation, irritability
• Headache
• Hunger
• Blurred vision

Hyperglycemia

• Fatigue
• Flushed, dry skin
• Dry mouth, excessive
thirst
• Frequent urination
• Rapid, deep respirations;
odor of acetone on the
breath (fruity breath)
• Drowsiness, headache
• N/V
• Abdominal pain

Placenta Previa Classification

Implantation of the placenta in the lower uterine segment
• Complete
• Marginal
• Low lying placenta

Placenta Previa S/S

• Painless, bright red vaginal bleeding
• Abdomen soft, relaxed, and non-tender
• Fundal height greater than expected
• Malpresentation of fetus

Placenta Previa Dx & Complications

Dx: • Patient history
• Transvaginal US
Complications:
• Hemorrhage
• Abnormal placental detachment

RhoGAM and Rh Incompatibility

• Mother’s blood type is checked
on initial antepartum visit to
assess blood type and Rh
antibody status
• Rh incompatibility: Rh- mom
with Rh+ infant →
isoimmunization can occur

RhoGAM

• 1st dose at 28 wk
• 2nd dose within 72 hrs of delivery