family- high risk pregnancy (exam 1)

what is polyhydramnios? causes?

-too much amniotic fluid

-caused by uncontrolled DM/GDM and fetal abnormalities

what is oligohydramnios? causes?

-too little amniotic fluid

-caused by growth restrictions, tobacco, substance abuse, GI and cardiac issues, genetics and fetal infections

what can be assessed via ultrasounds

fetal heart beat, fetal wellbeing, gestational age, fetal growth, doppler blood flow, fetal anatomy, fetal genetic disorders/anomalies, placental location, amniotic fluid levels, adjunct to other tests

when are kick counts assessed

starts at 26-28 weeks

when should kick counts be assessed?

once per day usually after meals or before bed

how many kicks are considered normal?

10 kicks in 2 hours minimum

indications for antepartum testing?

conditions that impact fetal growth/placenta perfusion or maternal wellbeing

when should antepartum testing be started?

28 to 32 weeks

what is the goal of antepartum testing?

identify if the fetus is at risk and assess for fetal wellbeing

what is a non-stress test?

a 20 minute test involving monitoring the fetal heart rate using EFM

what is a reactive result?

-the desired reaction

-2 fetal HR accelerations with no decelerations with moderate variability

what is a non-reactive result?

-requires further testing

-no accelerations in 20 minutes

-can be a result of maternal hypoglycemia or the baby is asleep

what is a biophysical profile?

assesses fetal breathing, gross body movement, fetal tone and amniotic fluid index

-things are score 0 or 2

fetal breathing

mimics breathing in uterus- moving for 30 seconds with continuous rhythmic breathing

gross body movement

3 body or limb movements during the exam

fetal tone

flexed limbs, hands or spine movements- atleast one movement in the exam

amniotic fluid index

a pocket fluid is measured must be 1 cm across and 2 cm deep to score a 2

what are the 2 biochemical assessments

amniocentesis and chorionic villus sampling

what is an aminocentsis

-diagnostic test

-done at 15 weeks for genetic diagnosis/fetal hemolytic disease

-late pregnancy it can be done to assess fetal lung maturity

post procedure for aminocentesis?

s/s of infection, miscarriage (cramps and bleeding), access to emergency care

what is chorionic villus sampling?

-needle diagnostic-> into the placenta for chromosomal testing-> fetal abnormalities

-Done at 10-13 weeks

-Pre-/ post-procedure: education

-Care: ensure the baby is the right age for the test and emotional care

what are maternal assays?

screening tools for disease- all blood draws offered routinely

what are the 3 maternal assays?

alpha-fetoprotein, multiple marker screens, cell free DNA

what is alpha-fetoprotein

-Performed 15-20 weeks

- Indication: high AFP suggests open neural tube or abdominal defects

-Limitations: high false positive rate

what is multiple marker screens (AFP, HCG, estriol, inhibin A)?

-Performed: 11-14 weeks

-Indications: high screens suggest NTD defects or trisomy 21

-Limitations: 84% detection of Trisomy 21

what is cell free DNA?

-Performed: 10+ weeks

-Indications: can detect multiple chromosomal abnormalities

-Limitation: 99% detection of trisomy 21 but more expensive

what is the downside of maternal assays

increased BMI increases the chance of false results

what is EFM?

monitors fetal and maternal heart rate with contractions

what is a normal FHR?

110-160

what are variabilities?

fluctuations in the baseline and baby wellness

marked variabilities?

keep an eye on it, if it persistent assess it further

moderate variabilities?

most common and it a good sign

minimal variabilities?

could be because of the sleep cycle- monitor if it continues

absent variabilities?

dangerous requires immediate treatment- caused by fetal hypoxia, acidosis, renal issue

what are accelerations?

FHR increases at least 15 beats in 15 seconds-> associated with fetal wellbeing and fetal movement

what are early decelerations?

decrease on FHR with a contraction- nadir is at the peak of a contraction-> caused by head compression

what are variable decelerations?

V shaped decrease in FHR of >15 bpm lasting less than 30 sec- may occur with or without contraction-> caused by cord compression (baby turning, ruptured membrane, baby in birth canal)

what is late deceleration?

gradual decrease in FHR from baseline with a contraction with delayed timing of the nadir occurring after the peak of contraction-> placenta insufficiency

how does preexisting diabetes affect pregnancy

-Maternal hormones and beta cells-> glycogen stores and hepatic glucose production-> lowered glucose levels

-poor glycemic control in the first trimester causes birth defects and stillborns

maternal risks of preexisting DM

Hypoglycemia, increased infections, polyhydramnios, ketoacidosis, DKA threshold (200), increased PP hemorrhage, 3x maternal mortality

fetal risks of preexisting DM?

1. Macrosomnia, traumatic births, respiratory distress syndrome, premature birth

what should fasting BS be?

60 to <95

what should BS before meals be?

60-105

what is BS 1 hour after meals

<140

when is GDM assessed?

24-28 weeks

Postpartum management of GDM

-most BG normalizes after birth

-1/3 of GDM continue to have T2DM/70% lifelong risk for T2Dm

-6 weeks PP-> 2 hour GTT

antepartum management of DM?

-Diet and exercise effective

-Insulin is Rx of choice

intrapartum management of DM?

-Monitor BG hourly (80-110mg/dL)

-Sliding scale (SQ) or IV infusion

postpartum management of DM?

-Insulin requirements decrease immediately

-Insulin restarted at 1/3 or ½ of pre-pregnancy dose

preexisting hypothyroidism?

A-ssociated with infertility

-Increased risk of: miscarriage, preeclampsia, placenta abruption, preterm birth, low birth weight

-Med management: Levothyroxine, Synthroid (T4)

-Goal: maintain lower end of normal

preexisting hyperthyroidism?

-Rare, graves disease

-Labs: increase T3 and T4, decrease TSH

-Increased risk of miscarriages, preterm birth, infant born with goiter

-Med management: PTU (1st trimester), Methimazole (2nd/3rd)

-No radioactive iodine

when does anemia in pregnancy occur?

28 weeks

how is anemia in pregnancy diagnosed?

-Hgb <11-> treat with iron supplements

-Hct is 3x Hgb depending on cause

asthma in pregnancy?

-Affect on pregnancy is unpredictable

-Goal is to prevent exacerbations

-If poorly controlled: growth restrictions of fetus and preterm birth

-Tx: the same as before pregnancy

cystic fibrosis in pregnancy?

-Genetic counseling

-Patients are living longer with CF

-Risk: increased with maternal hypoxemia and frequent infections

-Comanaged with pulmonologist and OB

-Serial PFTs

-Antepartum testing

polymorphic eruptions in pregnancy

-Pruritus and rash on abdomen and thighs

-Third trimester

-Comfort measures (skin care with mild soap and Benadryl)

intrahepatic cholestasis of pregnancy?

-Pruritis> palms and soles at night

-Increased serum bile acids and LFTs

treatment of intrahepatic cholestasis of pregnancy?

-Ursodeoxycholic acid

-Antihistamines/oatmeal baths

-Deliver if >LFTS 37+ weeks

goal of epilepsy in pregnancy?

-Achieve seizure control prior to pregnancy

-Increased at risk birth defects

-Receive preconceptual counseling (delay pregnancy until better controlled)

management of epilepsy in pregnancy?

-Med management to decrease seizure activity

-4mg of folic acid

postpartum management of epilepsy?

-Sleep deprivation increases risk for seizures

-Support needed, nigh feeding

-Contraception

hypertension affects on the pregnancy body?

-Placenta: fetal growth restriction and placental abruption

- Kidneys: proteinuria, in creatinine and uric acid

-Lungs: pulmonary edema and SOB

-Brain: h/a, vision changes, hyperreflexia/clonus, seizures

- Liver: epigastric/RUQ pain and liver enzymes

-Platelets: low platelets, DIC, RBC lysis

prevention of hypertension in pregnancy?

-low dose aspirin (81mg)

-start at 12 weeks

assessment of hypertension?

- Accurate BP measurement

-Edema? Grade?

-DTRs/clonus

24 hour urine for protein

s/s of severe HTN

Severe headache, epigastric pain, SOB, RUQ pain, visual disturbances, facial swelling

s/s of eclampsia?

-persistent occipital or frontal headache

-blurred vision

-photophobia

-epigastric or RUQ pain

-altered mental statis

-eclampsia can occur with absent or minimal hypertension, no proteinuria and no edema

immediate care in eclampsia?

- seizure care

- patient safety

- rapid response

-maternal stabilization

goal of mag sulfate?

seizure precautions

side effects of mag sulfate?

lethargy, headache, n/v, flushing and sweating

toxicity for mag sulfate?

check mag levels. Monitor for changes in condition (decreased RR, patella reflexes, UOP, LOC), antidote is calcium gluconate

diagnosis of HELLP?

Hemolysis RBCs

Elevated liver enzymes

Low platelets

maternal outcomes with HELLP

-Pulmonary edema

-Acute renal failure

-Placenta abruption

- Liver failure

-DIC

-Acute respiratory distress

- Sepsis

- Stroke

s/s of ectopic pregnancy?

-delayed menses

- abdominal pain and/ or bleeding

- if ruptures-> shoulder pain

-faint/dizzy

-Cullen sign

diagnosis of ectopic pregnancy?

serum HCG and ultrasound

med management of ectopic pregnancy?

-Not a viable pregnancy

-Cannot be removed and implanted in the uterus

-If caught early it can be treated my methotrexate/mifepristone

-If large, rupture-> laparoscopy with salpingectomy

placenta previa?

- Low lying adjacent to or covering the cervix

-Painless bright red bleeding

- No cervical exam/pelvic rest

- 84% resolve-> if not-> C section

placental abruption?

-Premature separation of placenta

-Localized uterine pain, firm abdomen, tender to palpitation

-Bleeding may be concealed or heavy

- PPH protocol, HR for DIC

accreta placenta spectrum

-Placenta grows into uterine muscle (carrying depths)

-Increase risk associated with previous uterine surgeries

what is the leading cause of non-OB maternal deaths?

trauma

causes of trauma

Falls, burns, suicides, IPV, penetrating trauma

management of trauma?

-Based on cause and severity (and effect it has on mom and baby)

-Gestational age

immediate stabilization of mom

-Primary survey of mom (CABDs, IVF, ET intubation, blood transfusion, etc.)

-Apply a hip wedge

-Defibrillation: pads moved up 1 intercostal space

-Secondary survey of the fetus

-Postmortem cesarean?

-Left lateral uterine tilt