Week 10: High Risk Pregnancy Part 1

Hgb for anemia in prenancy

Risks of anemia pregnancy

Tire easily

Incr risk of preeclampsia & postpartum hemorrhage

Healing delayed

Poor toleration of minimal blood loss

Low birth weight, prematurity, stillbirth/death

Iron should be taken with

Vitamin C

Fetal kick counts

Fetus should kick at least 10x in 2 hrs during the final months of pregnancy

Fetal growth assessments

U/S

Leopold's

Amniotic Fluid Measurements

Fetal growth restricion

Umbilical artery dopplers

Ordered for high risk patients -- esp concern abt fetal growth

Non-Stress Test (NST)

Highly predictive of fetal well-being

Increased risk factors, post-dates, or any concerns about fetal well-being

Decreased fetal movement

Reactive non-stress test

2+ fetal accelerations in a 20 min periods -- want >15 beats above baseline, lasting at least 15 secs (or >10 beats for 10 secs before 32 weeks)

Fetal well-being

Non-reactive stress test

Lacks sufficient FHR accelerations over a 40 min period

Not reassuring of fetal well-being

Biophysical Profile (BPP)

Non-invasive assessment of fetus based on acute and chronic markers of disease

U/S and NST

- Amniotic fluid volume

- Fetal breathing movements

- Fetal tone

- FHR reactivity

10/10 is ideal

8/10 is okay

Amniotic Fluid Index

Determined by:

- Fetal swallowing

- Fetal urine output

Oligohydramnios

AFI < 5cm

too little amniotic fluid

Polyhydramnios

AFI >25cm

too much amniotic fluid

Increases risk for: PPROM, cord prolapse

Contraction Stress Test

Must have 3 contractions of at least 40 seconds duration in 10 mins

FHR assessed in comparison to contractions

Contractions may spontoons or induced -- through oxytocin or nipple stimulation

Negative contraction stress test

normal result!

no late or significant variable decels

Positive contraction stress test

abnormal result!

late decels following 50%+ contractions

Chronic HTN

Defined as HTN present prior to start of pregnancy or develops during first 20 weeks of pregnancy

Dx: 2 readings of 140/90 or greater, at least 4 hrs apart

13-40% go on to develop gestational HTN

Gestational HTN

Onset at or after 20 weeks of pregnancy WITHOUT proteinuria

Dx: 2 readings of 140/90 or greater, at least 4 hrs apart, who were previously normotensive

Preecampsia

Onset at or after 20 weeks of pregnancy WITH proteinuria (or another severe feature)

Dx: 2 readings of 140/90 or greater, at least 4 hrs apart, who were previously normotensive

Can also develop during postpartum period

Risks of chronic HTN

Death, stroke, stillbirth, fetal growth restriction, preterm, etc

Treatment of chronic HTN

Counseling

Initiate low-dose aspirin after 12 wks

Frequent prenatal visits

BP log

Treat if >140/90 w/ Labetalol of nifedipine

Risk factors of preeclampsia

Previous preeclampsia

Multifetal gestation

Renal disease

Autommune dx

DM

First pregnancy

35 y/o+

BMI>30

Family hx, race, low socioeconomci status

What does USPSTF recommend for pt's who are high risk for preeclampsia starting at 12 wks

Low dose (81mg) aspirin

Preeclampsia physiology

Progressive - likely caused by disruption in placental perfusion and endothelial cell dysfunction

Lack of vascular remodeling --> decr placental perfusion

Generalized vasospasm --> system poor organ tissue perfusion (why proteinuria is common)

Preeclampsia s/s

HA

RUQ pain

Visual disturbances ("it looks like a prism")

Edema (hands/face)

Hyperreflexia

HA med of choice in pregnancy

Acetaminophen

Preeclampsia diagnosis

BP 140/90 at least 4 hrs apart

Proteinuria or protein/creatinine ratio

OR

Thrombocytopenia

Renal insufficiency

Incr liver enzymrs

Pulmonary edema

Cerebral Visual Changes

When an NST is non-reactive...

Move onto Biophysical Profile

Treatment of preeclampsia

Delivery of baby

Magnesium Sulfate

Magnesium Sulfate

Given in preeclampsia to prevent seizures

Will IV bolus then go to a maintenance dose until 24 hrs postpartum

Assess: RR, HR, LOC, fetal HR, DTRs, Clonus, hourly urine output (use foley with urometer)

Antidote for Magnesium Sulfate

Calcium Gluconate

1g IV push over 3-5 minutes (SLOW TO PREVENT CARDIAC ARREST)

Magnesium Sulfate Toxicity

Decreased LOC

RR

Eclampsia

Convulsive manifestation of the HTN disorders of pregnancy

Can lead to maternal deathh

HELLP Syndrome

Hemolysis, Elevated Liver Enzymes, Low Platelets

Can occur in absence of HTN or proteinuria

S/s: Nausea, extreme fatigue, chest pain, RUQ pain, difficulty breathing, shoulder pain, malaise

Life-threatening for patient & fetus

2 severe syndromes that preeclampsia can progress into

HELLP syndrome & Eclampsia