Antepartum Complications

4 Categories of High Risk Pregnancy

• Biophysical

• Psychosocial

• Sociodemographic

• Environmental

Biophysical examples?

• genetics

• nutrition

• medical/OB disorders

Psychosocial examples?

• caffeine

• mental health

• alcohol/drug use

• smoking

Sociodemographic examples?

• age

• party

• marital status

• residence

• income

• ethnicity

Environmental examples?

• infections

• pollution

• stress

• chemicals/air quality

See box 7-1 in textbook, and table 6-1

..

Screenings are done on pregnant women to…

* identify those at risk for injury

Diagnostics are done to…

• Help identify a disease or provide information to diagnose

• Usually in high risk pregnancies

Abnormal screening leads to…

* diagnostic testing
* the obstetrician/midwife selects the tests based on effectiveness and individual client

Nurses main role with screening/diagnostic tests?

Education and Counseling

Screening and Diagnostic testing: Maternal?

• Alpha-fetoprotein (AFP)

• Multiple Marker Screening

Alpha-fetoprotein?

a glycoprotein produced in the fetal GI tract and liver

Alpha-fetoprotein uses…

maternal serum

Alpha-fetoprotein is only a…

screening; need amniocentesis to diagnose

Normal AFP?

16-18

Low AFP is a risk for…

down syndrome or hydatidiform mole

High AFP is a risk for…

neural tube defects

Multiple Marker screen is done at?

15-16 weeks

Serum Biochemical Markers?

• AFP

• hCG

• estriol

Markers could show risk for?

• trisomy 21 and 18

• neural tube defects

Diagnostic testing of Fetus?

• Amniocentesis

• Chorionic Villus Sampling

• Cordocentesis

Amniocentesis?

removal of amniotic fluid

done after 14th week

Amniocentesis requires…

ultrasonography (ultrasound)

Amniocentesis looks for…

• genetic disorders

• fetal lung maturity

  • lamellar bodies count

• intrauterine infection

Nursing responsibilities with Amniocentesis?

• monitor for supine hypotension (lying on back)

• obtain NST after procedure

• know maternal blood type; if Rh -, administer RhoGAM

==Cordocentesis (Percutaneous umbilical cord sampling)== can be done after week…

18

Cordocentesis is most often done to…

test for anemia in fetus

Screenings done for Fetus?

• Daily Fetal Movement Count – “kick count”

• Contraction Stress Test (CST)

• Ultrasound

• Biophysical Profile

Fetal kick counts are taught to…

• EVERY pregnant woman

• easiest and most non-invasive screening

FKCs are recorded after…

28 weeks

With FKCs, we want -- movements -- hours

* 10 movements in 2 hours
* helpful to eat or drink something or lie on side

If decreased fetal kick counts, mom will come in for?

Non-stress test (NST)

NST?

• looks at fetal heart rate patterns in response to fetal movement, contractions, or stimulation

• Reactive vs. Nonreactive

We want what kind of NST?

==Reactive== - want an increase in HR of 15 bpm lasting 15 seconds (accelerations) in 20 min

Nonreactive NST?

NO accelerations in 40 min

\*can try feeding mom

If mom fails NST, then we perform…

a Contraction Stress Test or Biophysical Profile

Contraction Stress Test?

Evaluation of FHR in response to contractions

• Get mom hooked up to oxygen to help promote contractions

• Nipple stimulation can also cause contractions

*Need 3 contractions in a 10 min period

Contraction Stress Test: Positive vs. Negative?

Negative (GOOD):

• no late decelerations

Postive (BAD):

• repetitive late decelerations

NST and CST are specifically used for?

==women with uteroplacental insufficiency==

ex. diabetes and HTN

An ultrasound is useful in any…

trimester

• multiples?

• anatomy scan?

• growing properly in utero?

Anatomy scan of fetus is done around…

18 weeks

Ultrasound can help assess for -- and diagnose --

too much or too little fluid volume

fetal disorders

**Oligohydramnios**

too little fluid volume

Oligohydramnios can cause…

• renal agenesis

  • a complete absence of one or both kidneys

• IUGR

  • intrauterine growth restriction

**Polyhydramnios?**

too much fluid volume

Polyhydramnios can cause…

• neural tube defects

• obstruction of GI tract

• fetal hydrops

  • a condition in which large amounts of fluid build up in a baby's tissues and organs, causing extensive swelling (edema)

  • hydrops fetalis r/t Rh incompatibility

Biophysical profile is often used in the…

late 2nd trimester and 3rd trimester

BP is done to…

assess fetal well being

BP variables?

• fetal breathing movements

• gross body movements

• fetal tone

• reactive FHR (NST)

• qualitative amniotic fluid volume

BP is based on?

Acute and Chronic markers

Acute Markers reflect?

current CNS status =

• fetal HR

• fetal movements

• fetal tone

• fetal breathing

Chronic Markers reflect?

amniotic fluid volume ---demonstrates adequacy of placental function over longer period of time

If fetus is in quiet sleep, BP…

can take longer to complete

BP normal score?

BP equivocal score?

BP abnormal score?

• 8-10: CNS is functional and fetus is not in hypoxia

• 6

• <4

Hyperemesis is…

N/V with…

• weight loss

• electrolyte imbalance

  • hyponatremia and hypokalemia

• nutritional deficiencies

• ketonuria

Hyperemesis usually occurs in…

1st trimester

Hyperemesis may be associated with…

• high levels of estrogen and hCG (Human chorionic gonadotropin)

• psychological component

Hyperemesis interventions?

• IV therapy - fluid and electrolyte replacement

• Gut rest -- NPO

Once acute vomiting has stopped with Hyperemesis…

•Small frequent meals

•Bland food but what sounds good

•Ginger tea/ginger ale

•Compassionate, calm, and sympathetic care

Bleeding should always be followed up by…

Calling the provider

Early pregnancy bleeding?

• Miscarriage

• Ectopic pregnancy

• Hydatidiform mole

Miscarriage patients will usually end up in…

ER -- could be lots of bleeding

Ectopic pregnancy, fertilized ovum implants…

outside of uterine cavity (mostly in fallopian tube)

What will bring patients into ER with an ectopic pregnancy?

PAIN

\*want to catch them before rupture

Hydatidiform mole, you will see

the uterus grow abnormally fast

Late pregnancy bleeding?

• Placenta previa

• Placenta abruption

Complete and Partial previa will always be a…

C-section and will be delivered early b/c we don’t want hemorrhage

Placenta previa bleeding characteristics?

• always see bleeding

• blood is bright red

• could be a small amount to hemorrhage

Placenta previa is a -- bleed

painless

Placenta previa characteristics of the uterus?

• Usually soft, relaxed, non-tender

• Contractions may or may not be present

In placenta previa, FHR and Moms VS will be normal unless…

we have bleeding

Labs to monitor for placenta previa?

• Hgb

• Hct

• coag studies

• platelet count

Greatest risk to fetus in placenta previa is…

preterm birth

With a placenta previa, we do not want anything going in…

the vagina -- will hit uterus first and could cause rupture

\*No vaginal or rectal exams for moms with placenta previa\*

\++

Biggest risk factor for placenta previa?

Multiple C-sections

Placenta abruption means…

placenta has come away from uterine wall

With placenta abruption you will either see -- bleeding or -- bleeding

dark red vaginal; concealed

Placenta abruption presents with -- pain

severe

Most common risk factor for placenta abruption?

Other risk factors as well?

Most common: maternal HTN

Others:

• cocaine use

• smoking

• blunt abdominal trauma (vehicle accident)

• preeclampsia

With placenta abruption, what will we see with contractions and abdomen?

• no relaxation between contractions

• tetanic, persistant contractions

• abdomen is board-like (hard)

With placenta abruption, what will we see with FHR?

• late decelerations

• decreasing variability and rate

• potential stillbirth

With both Placenta Previa and Placenta Abruption, if mom is

Corticosteroids - Betamethasone most common

If a 36-weeks pregnant woman presents with vaginal bleeding, which of the following could the nurse use to help decide if the bleeding was from a placenta previa or an abruption? (select all that apply)

\
A.  Is your bleeding bright red or dark red?

B.  Are you having any pain?

C.  Are you having any headaches or visual changes?

D.   Does your abdomen feel soft/nontender or like a   constant contraction?

A, B, D

Pre-gestational diabetics?

people who have DM before getting pregnant - type I and type II diabetics

With Pre-gestational diabetics, we want them to have a stable BS at least…

3 months before getting pregnant

**When** can things go wrong for pre-gestational diabetics? and **what** can happen?

• first trimester is a sensitive time where things can go wrong

• if pregnant woman is not controlling her BS then she is at increased risk for miscarriages or congenital anomalies

Gestational diabetics?

people who become diabetics while in pregnancy

All pregnant woman are screened for diabetes between…

24-28 weeks - fail screening they become GDM

What begins happening in the second trimester of pregnancy?

* Rising hormones in second trimester start acting as insulin antagonists (resistance) - most of population can handle this and don’t become diabetics because body can still meet insulin needs

Why would some pregnant women fail their DM screening?

Some peoples body’s cannot handle the increased insulin resistance and their body’s will not meet the insulin needs thus glucose begins getting higher and higher and then they become gestational diabetics

Prior to diabetic woman becoming pregnant, we want their A1C to be less than -- for at least -- months

7%; 2

How often are Pre Gestational Diabetics Monitored during each trimester?

• 1st and 2nd: q1-2 weeks

• 3rd: 1-2x a week

Pre-gestational and Gestational diabetic moms should keep a daily detailed record of…

• BS

• ketones

• diet

• exercise

• insulin

Pre-gestational diabetic moms are at increased risk for…

• -- abortion

• --

• -- labor

• -- (excessive amniotic fluid)

• difficult birth d/t --

• --

• --

• --

• spontaneous

• preeclampsia

• pre-term labor

• polyhydramnios

• macrosomia (shoulder dystocia)

• c-section or assisted brith

• infections

• ketoacidosis

Fetal complications d/t pre-gestational diabetes?

• birth injuries d/t larger size (>4,000-4,500 grams)

  • shoulder dystocia

• mortality rate is 3x higher

  • Delayed lung maturity d/t delayed surfactant production r/t excess maternal blood glucose levels.

  • Still birth

  • RDS and TTN

  • Extreme prematurity

• 1st trimester hyperglycemia affects organs and organ systems

  • main cause of diabetes-related congenital birth defects (CNS and cardiovascular)

• hypoglycemia at birth d/t

  • abrupt loss of maternal glucose

  • newborn pancreas still producing higher insulin

Antepartum goals for gestational diabetes?

• strict BG control

• diet

  • carbs should be 50% of caloric intake

• self monitoring of BG

  • Upon rising in a.m.

  • 1-2 hrs after breakfast

  • Before and after lunch; before dinner

  • Bedtime

• most will require insulin

How often should Gestational Diabetics check their glucose and what range should they aim for?

• BG should be checked q2-4hrs

• 70-110

Big difference between Pre-gestational diabetics vs. Gestational diabetics risk factor?

Spontaneous abortion -- mom has already made it past the 20 week mark since we don’t find out that she has diabetes until 24-28 weeks

How do insulin needs increase throughout pregnancy?

They increase during the second and third trimesters