Week 6: Gestational Conditions and Labor and Birth Complications

What causes 31.6% of maternal deaths during delivery hospitalization?

Hypertensive Disorder

Hypertensive Disorder Classifications

-Chronic HTN

-Gestational HTN
-Preeclampsia, eclampsia

What should all pregnant black individuals be considered for to prevent preeclampsia?

Aspirin

Mild Chronic HTN Blood Pressure

Greater than/Equal to 140/90

Mild Chronic HTN Defintion

-HTN diagnosed/present before pregnancy or before 20 of gestation

-HTN diagnosed for the 1st time during pregnancy that does not resolve in the postpartum period (> 12 weeks)

Maternal Risks of Chronic HTN in Pregnancy

-Death

-Stroke

-Pulmonary edema

-Renal insufficiency

-Cardiomyopathy

-Preeclampsia

-Placental abruption

-Cesarean Section

-PPH

-Gestational Diabetes

Fetal and Neonatal Risks of Chronic HTN in Pregnancy

-Stillbirth or perinatal death

-IUGR

-Preterm birth

-Congenital anomalies

Chronic HTN Care Management

-Counsel on weight loss, diet, and lifestyle changes

-Initiate low-dose aspirin after 12 weeks

-Frequent prenatal visits

-BP monitoring

-Medications (Labetalol and nifedipine)

When should medication be initiated in chronic HTN?

If BP is greater than 140/90 mm Hg

Gestational HTN

-Systolic BP 140 mmHg or more or a diastolic BP of 90 mmHg or both

-On two occasions at least 4 hours apart after 20 weeks

-In a women with a previously normal BP

-Without proteinuria

-Severe features develop after 20 weeks

-BP return to normal in PP period

Preeclampsia Definition

-Systolic BP of 140 mmHg or more or diastolic BP of 90 mmHg

-On two occasions at least 40 hours apart after 20 weeks in a women with a previously normal BP

-With proteinuria

Is preeclampsia or gestational HTN accompanied with proteinuria?

Preeclampsia

What plays a key role in preeclampsia?

The placenta

High Risk Factors for Preeclampsia

-Hx of preeclampsia

-Multifetal gestation

-Chronic HTN

-Type 1 or 2 DM

-Renal disease

-Autoimmune disease (SLE)

Moderate Risk Factors for Preeclampsia

-Nulliparity

-Obesity

-Family hx of preeclampsia

-Age 35 years or older

-Sociodemographic characteristics

-Personal history factors

Preeclampsia Vascular Changes

Intense vasospasm

Preeclampsia Hematologic Changes

Thrombocytopenia results from increased platelet activation, aggregation, and consumption

Preeclampsia Renal Changes

Contraction of the intravascular space secondary to vasospasm leads to worsening renal sodium and water retention

Preeclampsia Hepatic Changes

Elevated liver enzymes

Preeclampsia Urinalysis Lab Test

Check for proteinuria and creatinine

Preeclampsia CBC Lab Test

Check hemolysis and platelet count

Preeclampsia Comprehensive Metabolic Panel

Chemistry (BUN, Creatinine): Renal Function

Preeclampsia AST ALT Lab Test

Liver enzymes

Preeclampsia PT PTT, Fibrinogen Lab Test

Check for coagulopathy

Preeclampsia Uric Acid Lab Test

Marker of maternal renal injury

What happens to the spiral uterine arteries in preeclampsia?

Remain thick walled and decreases blood flow to placenta

Preeclampsia Maternal Risks

-CNS (hyperreflexia, HA, blurred vision, dizziness, epigastric pain, and eclamptic seizure)

-Increased intraocular pressure

-Acute tubular pressure

-Thrombocytopenia

Preeclampsia Fetal-neonatal Risks

-Placental insufficiency (IUGR)
-Premature birth

-Placental abruption

-Over-sedation d/t medications

Severe Preeclampsia Blood Pressure

160/110 mmHg or higher on 2 occasions at least 4 hours apart

Severe Preeclampsia Urine Protein

>/= 2.0g/24 hours

>/= 3+ dipstick

Severe Preeclampsia Oliguria

</= 500 mL/24 hours

Severe Preeclampsia S/S

-CNS disturbances

-Epigastric pain

-Pulmonary edema or cyanosis

-Impaired Liver Function (Elevated ALT/AST)

-Thrombocytopenia

HELLP Syndrome

-Hemolysis

-Elevated Liver enzymes

-Low Platelet count

What is HELLP syndrome associated with?

Severe preeclampsia

Can HELLP syndrome occur in the absence of HTN or proteinuria?

Yes

When can HELLP syndrome occur?

Anytime between 20 weeks gestation through postpartum (usually 3rd trimester)

What increases with HELLP syndrome?

Maternal morbidity and mortality

Eclampsia

-The convulsive manifestation of hypertensive disorders of pregnancy and is among the more severe manifestations of the disease

-New onset tonic clonic, focal or multifocal seizures in the absence or other causative conditions (epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, or drug use)

Home Care of Gestational HTN and Mild Preeclampsia

B/P greater than/equal to 140/90 mmHg

Proteinuria < 1 g/24 hours; 2+ dipstick

Monitor BP, weight, urine for protein daily

Frequent office visits and fetal monitoring exams

Hospitalized Care of Severe Preeclampsia

-Daily fetal monitoring

-Bedrest

-Anti-convulsants (Mg sulfate)

-Corticosteroids

-Antihypertensives

-Fluid/electrolyte imbalance

-Childbirth

Magnesium Sulfate Action

-CNS depressant

-Decreases acetylcholine release

-Blocks neuromuscular transmission

-Smooth muscle relaxant

Magnesium Sulfate Dosage

4-6 grams loading dose over 20-30 minutes

-then 1-2 grams/hour

Magnesium Sulfate Therapeutic Range

-Every 6 to 8 hours

-4 to 8 mg/dl

Magnesium Sulfate Maternal S/E

-Lethargy and weakness

-Warmth and flushing

-N/V

-HA

-Slurred speech

-Blurred vision

-Decreased respirations

-Palpations or decreased myocardial contractility

-Pulmonary edema

-Uterine atony

Magnesium Sulfate Fetus/Neonate S/E

Readily crosses placenta

-Respiratory depression

-Lethargy

-Poor eating

When should magnesium sulfate be stopped?

-Resp. rate less than 12/minute

-Diminished or absent patellar tendon reflex

-Urine output < 30 ml/hr

-Chest pain

Magnesium Sulfate Antidote

Calcium Gluconate

-1 g IV over 3 minutes for resp/cardiac arrest

What differentiates chronic HTN from gestational HTN?

-Gestational HTN is HTN that begins after 20 weeks gestation

-Chronic is before 20 weeks or still present after 12 weeks postpartum

What differentiates gestational HTN from preeclampsia?

There is proteinuria with preeclampsia or presence of severe features

Preterm Labor Definition

Labor that occurs between 20 0/7 weeks and 36 6/7 weeks

Preterm Labor Maternal Risks

-Initial cause (hemorrhage, infection)

-Side effects for medications

-Bed rest (psychological and physiological)

Preterm Labor Fetal-neonatal Risks

Increased morbidity and mortality

Preterm Labor Symptoms

-Abdominal pain

-Back pain

-Pelvic pain

-Menstrual-like cramps

-Vaginal bleeding

-Increased vaginal discharge

-Pelvic pressure

What is the criteria for a diagnosis of preterm labor in gestations of 20-37 weeks?

Documented uterine contractions (4 in 20 minutes, 8 in 60 minutes)

Must be accompanied by 1 or more

-Cervical changed

-Cervical effacement of 0% or more

-Cervical dilation for 2 cm or more

Cervical Length (Via transvaginal U/S)

Predictor of the risk of premature delivery

What does a shorter cervix predict?

Higher risk of preterm labor

Why is assessing cervical length via transvaginal U/S beneficial?

-More reliable than digital exams

Cervical effacement changes often predate dilation

What is fetal fibronectin?

A glycoprotein that is an adhesive “glue” produced by fetal membranes and binds the membranes and placenta to the decidua

When is fetal fibronectin not normally detected?

20 to 34 weeks

What does fetal fibronectin predict?

Risk of preterm delivery when measured

How is preterm labor managed?

-Medications to delay birth 24-48 hours

-Tocolytics

Common Tocolytics

-Magnesium sulfate (MgSO4)

-Ca++ channel blockers

-Prostaglandin synthetase inhibitors

MgSO4 for Preterm Labor: MOA

Ca++ antagonist

-Tocolytics effect by directly affecting myocetrial contractility

-CNS depressant

MgSO4 for Preterm Labor: Dose

4 to 6 g IV bolus followed by 1-4g/hr

MgSO4 for Preterm Labor Side Effects (Maternal)

-Drowsiness

-Flushing

-N/V

-Blurry vision

-Depressed reflexes

-Respiratory depression

-Cardiac arrest

MgSO4 for Preterm Labor Side Effects (Fetal)

Hypotonia and lethargy that persists for 1-2 days

Prostaglandin Synthetase Inhibitors (NSAIDS) MOA

Depresses synthesis of PGs by inhibiting the cyclooxyrgenase (COX) enzyme pathway

Prostaglandin Synthetase Inhibitors (NSAIDS) Dose

Loading dose=100 mg

then 50 mg every 6 hours x 48 hours

Prostaglandin Synthetase Inhibitors (NSAIDS) Maternal Effects

-HA
-Dizziness

-Depression

Prostaglandin Synthetase Inhibitors (NSAIDS) Fetal Effects

-Ductus arteriosus constriction

-Oligohydraminos (not > 32 wks)

Ca++ Channel Blockers MOA

Inhibits the influx of Ca ions through cell membranes thereby decreasing smooth muscles contractility

Ca++ Channel Blockers Dose

10-20 mg every 3 to 6 hours until rare contractions

-then 30 to 60 mg every 8 to 12 hours x 48 hours

What medications promote fetal lung maturity?

Antenatal Glucocorticoids

What do Antenatal Glucocorticoids decrease the incidence of?

-Respiratory distress syndrome

-Necrotizing enterocolitis

-Death in neonates

When should you not attempt to stop labor?

-Fetal demise

-Lethal fetal anomaly

-Acute non-reassuring fetal status

-Severe preeclampsia/eclampsia

-Maternal bleeding with hemodynamic instability

-Chorioamnionitis

-Preterm premature rupture of membranes

-Maternal contraindications totocolysis

Premature Rupture of Membranes (PROM)

Spontaneous rupture of membranes before the onset of labor

-After 36 completed weeks

Preterm Premature Rupture of Membranes (PPROM)

ROM before 37 weeks gestation

-Complicates 3% of pregnancies

-Associated with 30-40% preterm births

Risk Factors for PPROM

-Previous preterm birth

-Previous PPROM

-Cervicitis

-UTI

-Amniocentesis

-Placenta previa

-Hydramnios

-Loop electrosurgical excision procedure (LEEP)

-Multiple pregnancy

-Maternal genital tract anomalies

-Smoking, substance abuse

-Fetal anomalies

PPROM Maternal Risks

-Chorioamnionitis (Intra-amniotic bacterial infection and inflammation of the membranes prior to birth

-Endometritis (postnatal infection of endometrium)

PPROM Fetal-neonatal Risks

-Prematurity and related complications

-Infection

Assessment of PPROM

-Question woman about time of initial fluid loss

-Note color, consistency, amount, and odor

-Nitrazine paper

-Fern testing

-Ultrasound

Management of PPROM

-Conservative if no infection and < 37 weeks

-Amniocentesis

-Hospitalization

-Bed rest

-Frequent vitals and labs

-Consider Antibiotics if unknown or +GBBS

PPROM Fetal-Neonatal Risks

-Respiratory distress syndrome

-Necrotizing enterocolitis

-Intraventricular hemorrhage

-Infection

-Hypoxia

-Behavior/learning difficulties

Dystocia

Lack of progress in labor for any reason

Dysfunctional Labor

-Long, difficult or abnormal labor

-Ineffective uterine contractions or bearing down effects

-Fetal causes

-Alterations in the pelvic structure

Cephalopelvic Disproportion (CPD)

Disproportion between size of fetus and size of maternal pelvis due to:

-Macrosomia

-Pelvic shape/size

What is often the problem instead of cephalopelvic disproportion?

Fetal Positions

Malposition

Persistent Occiput Posterior (OP) Positon

Malpresentation

Breech

External Cephalic Version

Procedure to used to change fetal presentation by external manipulation of maternal abdomen

-Changes breech or shoulder presentation to vertex

What criteria is needed for external cephalic version?

-Singleton

-Not engaged

-Adequate amniotic fluid

-Reactive NST

-36 to 37 weeks gestation

When is external cephalic version contraindicated?

-Placental insufficiency (IUGR, FHR issues)
-Uterine anomalies

-Fetal anomalies

-3rd trimester bleeding

-C/S indicated anyways

-Previous C/S

-Oligohydramnios

-Nuchal Cord

External Version Procedure

-Performed in a birthing center

-NPO for 8 hours prior

-Tocolytic to relax uterus

-Epidural or spinal analgesia

-Prior and continuous monitoring of mother and fetus

Induction of Labor

-Stimulating uterine contractions before spontaneous onset of labor (chemical or mechanical)

-Therapeutic option when benefits outweigh risks

Induction Defintion

Stimulate uterine contractions before spontaneous onset of labor

-with or without ruptured membranes

Labor Augmentation

Artificial stimulation of uterine contractions

Indications for Induction of Labor

-Maternal conditions

-Preeclampsia, eclampsia

-PROM

-Chorioamnionitis

-Fetal demise

-Post-term pregnancy

-Fetal compromise

-Risk of rapid labor

-Mild abrupt placentae

-Non-reassuring FHR

-Psychosocial

When is IOL contraindicated?

-Placenta previa

-Transverse/breech

-Umbilical cord prolapse

-Previous classical cesarean

-Active herpes infection

-Previous myomectomy

What is an elective IOL?

Performed without medical or obstetrical indication

-most common reason inductions are performed

Adverse Outcomes of Elective IOL

-Increased C/S rates

-Increased NICU admissions

-Longer hospital stays

-Increased costs