High Risk Prenatal Care

High Risk Prenatal Care

Gestational Conditions

  • Disorders that did not exist before pregnancy include:
      - Gestational Hypertension
      - Preeclampsia/eclampsia
      - Hyperemesis gravidarum
      - Hemorrhagic complications
      - Surgery during pregnancy
      - Trauma
      - Urinary tract infections

  • The occurrence of these conditions places both the woman and the fetus at risk.

Hypertension in Pregnancy

Overview

  • Hypertensive disorders are the most common medical complication in pregnancy.

  • They pose a high risk of maternal and fetal morbidity and mortality.

Classification of Hypertension

  • Chronic Hypertension:
      - Diagnosed before 20 weeks of gestation.

  • Gestational Hypertension:
      - Onset occurs without proteinuria after 20 weeks of gestation.
      - There is an increased risk of developing preeclampsia.

  • Chronic Hypertension with Preeclampsia:
      - This type includes women who have chronic hypertension and develop preeclampsia.

Risks Associated with Hypertension in Pregnancy

  • Risks include:
      - Placental abruption
      - Superimposed preeclampsia
      - Increased perinatal mortality
      - Fetal effects such as:
        - Growth restriction
        - Preterm birth

Safe Prescriptions for Management

  • Medications that can be prescribed safely include:
      - Labetalol
      - Hydralazine
      - Aldomet (Methyldopa)

  • These antihypertensives are considered safe during breastfeeding.

Preeclampsia

Definition and Onset

  • Preeclampsia is characterized by hypertension occurring after 20 weeks of gestation in women who were previously normotensive.

  • It causes decreased placental perfusion and affects various organ systems.

Risk Factors

  • High-risk factors for developing preeclampsia include:
      - Family history of preeclampsia
      - Multiple fetal pregnancies
      - Being of African-American descent
      - Obesity
      - Maternal age younger than 19 or older than 40
      - Pre-existing medical or genetic conditions.

Pathophysiology

  • Preeclampsia causes inadequate vascular remodeling leading to:
      - Decreased placental perfusion and hypoxia
      - Endothelial cell dysfunction
      - Increased peripheral resistance and vasospasm
      - Increased endothelial cell permeability leading to decreased tissue perfusion.

Mild vs. Severe Symptoms

  • Mild symptoms:
      - Blood pressure (BP) ≥ 140/90
      - Urine dipstick protein ≥ 1+
      - Decreased placental perfusion

  • Severe symptoms:
      - BP ≥ 160/110
      - Urine dipstick protein ≥ 3+
      - Persistent or severe headache
      - Blurred vision or photophobia
      - Epigastric pain
      - Intrauterine growth restriction of the fetus

Care Management

  • Assess & identify risk factors or personal history of preeclampsia.

  • Physical examination should assess for:
      - Edema (hands, face)
      - Deep tendon reflexes (≥ +3)
      - Clonus (≥ 3 beats)

  • Laboratory tests should include:
      - Proteinuria, CBC, and renal & liver function tests.

Management of Severe Preeclampsia

  • The management includes:
      - Preventing seizures and controlling blood pressure.
      - Administering loading dose/maintenance therapy.
      - Monitoring vital signs including respiratory rate, consciousness level, deep tendon reflexes, intake/output, and serum magnesium (< 9 mg/dL).
      - Use of Magnesium sulfate or Calcium gluconate.
      - Risk factors to manage include:
        - Eclampsia and immediate care with seizure precautions.
      - Postpartum care includes delivery as a "cure" and monitoring for excess diuresis of fluids & hypertension risk later in life.

HELLP Syndrome

  • HELLP syndrome is a variant of severe preeclampsia diagnosed by laboratory tests showing:
      - Hemolysis,
      - Elevated Liver enzymes,
      - Low platelets.

Risks Associated with HELLP Syndrome

  • Increases the risk for:
      - Pulmonary edema
      - Renal failure
      - Liver hemorrhage or failure
      - Disseminated intravascular coagulation (DIC)
      - Placental abruption
      - Acute respiratory distress syndrome
      - Sepsis, stroke, and fetal and maternal death.

Hyperemesis Gravidarum

Definition

  • Defined as excessive vomiting accompanied by:
      - Ketosis
      - Dehydration
      - Electrolyte imbalance
      - Acetonuria

Etiology

  • The etiology remains unknown.

Clinical Manifestations

  • Symptoms include:
      - Dehydration
      - Electrolyte imbalance
      - Weight loss

Care Management

  • Initial care includes:
      - Intravenous (IV) rehydration
      - Control of vomiting

  • Follow-up care is essential to monitor recovery.

Early Pregnancy Bleeding

Spontaneous Abortion (Miscarriage)

  • Incidence and etiology vary based on type of miscarriage occurring within the first 20 weeks of gestation.

  • Clinical manifestations differ based on the type of miscarriage experienced.

  • Management will depend on the type and may include support for psychosocial aspects of care and necessary follow-up.

Types of Spontaneous Abortion

  • Include:
      - Threatened
      - Inevitable
      - Complete
      - Partial
      - Missed

Surgical Management: Cervical Insufficiency

Cerclage

  • A surgical procedure that involves placement of a circumferential tape around the uterine isthmus at 11-13 weeks gestation.

Medical Management

  • Conservative management may include:
      - Bed rest
      - Tocolytics
      - Progesterone
      - Anti-inflammatory drugs
      - Antibiotics
      - Hydration

  • If the cervix opens, the pregnancy cannot be saved.

Ectopic Pregnancy

Definition

  • Ectopic pregnancy is defined as the implantation of a fertilized ovum outside the uterus, most commonly in the fallopian tube (95% of cases).

  • Other sites may include:
      - Ovary
      - Abdominal cavity
      - Cervix

Clinical Manifestations

  • Symptoms include:
      - Abdominal pain, possibly referred shoulder pain.
      - Delayed menses or abnormal vaginal bleeding.
      - Weakness, dizziness, hypotension (indicative of hypovolemia).

Management

  • Medical and surgical management options include:
      - Methotrexate for medical management.
      - Surgical options include:
        - Salpingectomy (removal of all or part of the tube)
        - Salpingostomy (removal of products of conception and repair of the fallopian tube).

Preterm Labor (PTL)

Diagnosis Criteria

  • Diagnosis is based on three factors:
      - Gestation between 20-36 weeks
      - Uterine activity (contractions)
      - Progressive cervical changes (dilation and effacement)

Risk Factors

  • Include:
      - History of preterm labor (the primary risk factor)
      - Multiple gestation
      - Gestational diabetes
      - Advanced maternal age
      - Obesity
      - Second-trimester bleeding
      - African-American race
      - Low pre-pregnancy weight
      - Urogenital tract infections.

Signs of Preterm Labor

  • Include:
      - Contractions every 10 minutes or less for one hour or more (six or more in an hour)
      - Lower abdominal menstrual-like cramps
      - Dull, intermittent low back pain
      - Suprapubic pain or pressure
      - Pelvic pressure or heaviness
      - Changes in cervical discharge (leukorrhea)
      - Rupture of amniotic membranes
      - Signs of urinary tract infection (UTI).

Treatment for Preterm Labor

  • Lifestyle modifications include reducing activity, avoiding heavy lifting, and not riding long distances.

  • Continue hydration.

  • Tocolytic medications that help relax the smooth muscle include:
      - Magnesium sulfate (used to decrease seizure risk)
      - Terbutaline (either oral or SC; monitor pulse rate, >120 beats/min holds due to potential cardiac issues)
      - Indomethacin (Indocin)
      - Nifedipine (Procardia).

Multiple Gestation

Definition

  • A pregnancy involving multiple fetuses (twins, triplets, etc.) is associated with increased complications including:
      - Increased blood volume requirement to support multiple fetuses, which causes cardiovascular stress.
      - Uterine over-distention leading to preterm labor and post-partum hemorrhage.
      - Complications related to the placement of the placenta, such as previa or abruption.
      - Malpresentation that may require surgical delivery.

  • Nutritional considerations are paramount during multiple gestation.

Bleeding in Late Pregnancy

Types

  • Bloody Show: Not frank bleeding; scant pink to bloody mucus plug.

  • Placenta Previa: Defined as abnormal positioning of the placenta obstructing the cervical opening.

  • Abruptio Placentae: Characterized by premature separation of the placenta from its implantation site.

Normal vs. Abnormal Placenta Positions

  • A low-lying placenta, partial or total placenta previa can lead to obstetric complications.

  • Risks in placenta previa may lead to excessive bleeding, requiring no vaginal examinations until evaluation is complete.

Management of Placenta Previa

  • The occurrence of prior C-section, suction curettage, or a large placenta increases risks.

  • Diagnostic methods include transabdominal ultrasound for observation and assessment.

  • Management may include antepartum observation, bed rest, and potential Cesarean delivery if conditions warrant.

Abruptio Placentae

Definition

  • Defined as the premature separation of the placenta from the implantation site after 20 weeks.

Clinical Significance

  • Symptoms include:
      - Painful vaginal bleeding
      - Abdominal pain that is possibly severe and causes a rigid, board-like abdomen
      - Uterine contractions characterized by hypertonus
      - May present with port wine-stained amniotic fluid.

Risk Factors

  • Risk factors responsible for abruptio placentae include:
      - Hypertension associated with the pregnancy
      - Abdominal trauma
      - Cigarette smoking
      - Alcohol and cocaine use
      - Blood clotting disorders
      - Diabetes and previous history of abruptions.

Manifestations and Management

  • Symptoms vary based on the severity of abruption, categorized as:
      - Mild (1): Dark red bleeding, hypovolemia with < 500 mL of blood loss, normal uterine tone.
      - Moderate (2): Moderate severity, with 1000-1500 mL blood loss and mild to moderate tenderness.
      - Complete/concealed (3): Greater than 1500 mL, with severe or prolonged shock and board-like uterine tone.

  • Management involves active vs. expectant care with observation, monitoring for hemorrhage, and preparing for delivery if needed.

Coagulation Dynamics in Pregnancy

Normal Clotting Mechanism

  • Homeostasis refers to the normal balance of opposing hemostatic and fibrinolytic systems.

  • Coagulation functions include:
      - Formation of insoluble fibrin and hemostatic platelet plug.
      - Each clotting factor activates the next through a cascading effect.

Bleeding Disorders - Hypocoagulation

  • Conditions related to decreased clotting factors include:
      - Thrombocytopenia, aplastic anemia, leukemia, and von Willebrand disease.

  • This may be further impacted by liver disorders and medications like anticoagulants and NSAIDs.

Clotting Disorder - Hypercoagulation

  • Hypercoagulation normal increases during pregnancy may lead to risks such as:
      - Venous thrombosis
      - Miscarriage
      - Intrauterine growth restriction due to thrombophilia (e.g., Factor V Leiden).

Disseminated Intravascular Coagulation (DIC)

  • DIC is a pathological secondary disorder causing widespread bleeding and unrelated clot formation.

  • Triggered by significant conditions including:
      - Severe preeclampsia
      - HELLP syndrome
      - Hemorrhage, shock, hypoxia, and sepsis.

  • Clinical presentations include petechiae, purpura, and bleeding from mucous membranes.

Management of DIC

  • Requires treatment aimed at replacing blood and clotting factors lost.

  • Supportment of vital functions and addressing the underlying cause are critical to managing the condition.

Urinary Tract Infection (UTI)

Risks in Pregnancy

  • Increased risk of premature labor and ascending infections.

  • Asymptomatic Bacteriuria: Presence of bacteria without symptoms.

  • Cystitis: Characterized by symptoms like dysuria, frequency, urgency, most common during the second trimester.

  • Pyelonephritis: A serious complication that can lead to hospitalization.

Surgical Emergencies During Pregnancy

Common Conditions

  • Appendicitis: Associated with hormonal effects on smooth muscle and external pressure from the uterus.

  • Laparoscopic cholecystectomy may be necessary for cholelithiasis and cholecystitis.

Maternal Physiologic Characteristics

  • Requires adapted strategies for resuscitation, fluid therapy, positioning, and intervention assessments due to physiological changes during pregnancy such as elevated hormone levels and decreased tolerance to hypoxia.

Trauma Care during Pregnancy

Fetal Physiologic Characteristics

  • Fetal monitoring can function as an internal indicator of maternal well-being.

  • Types of trauma include:
      - Blunt abdominal trauma
      - Penetrating abdominal trauma
      - Thoracic trauma.

Management

  • Important steps include immediate stabilization, a primary survey involving CPR, secondary survey, and fetal monitoring.

  • In cases of significant hemorrhage, ultrasound may be used to assess fetal-maternal hemorrhage.

  • Consider perimortem cesarean delivery if necessary.

High Risk Prenatal Care - Diabetes

Common Pre-existing Conditions

  • Include metabolic disorders such as:
      - Diabetes mellitus (most significant issue).
      - Thyroid disorders.
      - Cardiovascular disorders.
      - Various disorders affecting the respiratory, gastrointestinal, and central nervous systems.
      - Autoimmune disorders and substance abuse history.

Diabetes Mellitus in Pregnancy

  • It poses significant risks and requires multidisciplinary management for optimal maternal glucose control to ensure the best outcomes.

  • Distinction between pre-gestational and gestational diabetes, each presenting different challenges related to impaired insulin action and secretion.

Insulin Needs during Pregnancy

  • Affected by the trimester:
      - 1st Trimester: Insulin needs decreased.
      - 2nd Trimester: Insulin needs begin to increase.
      - 3rd Trimester: Needs may increase 2-4 times, stabilizing after 36 weeks.
      - At birth: Insulin needs decrease significantly.
      - During breastfeeding: Insulin requirements may be up to 25% lower.
      - Post-weaning returns to pre-pregnancy levels.

Maternal Risks with Pregestational Diabetes

  • Risks include:
      - Comorbidities such as hypertension and vascular disease
      - Risks of early pregnancy loss or preterm labor
      - Macrosomia leading to cesarean delivery
      - Polyhydramnios, hyperglycemia, and ketoacidosis
      - More frequent and serious infections
      - Postpartum hemorrhage risks.

Fetal and Neonatal Risks

  • Fetal impacts may include:
      - Sudden or unexplained stillbirth
      - Congenital malformations affecting:
        - Cardiovascular system
        - Central nervous system
        - Skeletal structure
      - Increased chances of macrosomia, prematurity, and respiratory distress.

Care Management for Pregestational Diabetes

  • Should include comprehensive antepartum evaluations that encompass interviews, physical examinations, and laboratory tests:
      - Baseline renal function assessments
      - Glycosylated hemoglobin A1C and frequent monitoring of blood glucose levels.

Antepartum Care

Management Strategies

  • Include:
      - Dietary and exercise modifications in coordination with insulin therapy.
      - Close monitoring of blood glucose levels and urine testing.
      - Organizational coordination of determining the anticipated birth date and method of delivery.
      - Hospitalization in cases of complications.
      - Close monitoring of fetal health status.

Gestational Diabetes Mellitus

  • Antepartum Care Management includes:
      - Primary focus on diet and exercise.
      - Insulin is introduced if diet is ineffective in controlling glucose levels.
      - Monitoring for blood glucose levels and ensuring fetal health monitoring.
      - Gestational diabetes increases the risk of developing type 2 diabetes later in life.

Screening Methods

  • 1-hour Glucose Challenge Test: Conducted at 24-28 weeks; results >130-140 mg/dL warrant a diagnostic 3-hour Oral Glucose Tolerance Test (OGTT).

  • Risk Factors for Gestational Diabetes:
      - Obesity
      - Family history
      - Age >35 years
      - Presence of comorbidities
      - History of prior infants weighing >9 lbs at birth.

Diagnostic Tests for Gestational Diabetes

  • 1-hr (50 g) Oral Glucose Tolerance Test (OGTT):
      - Negative if results <130-140 mg/dL; routine prenatal care continues.
      - Positive if ≥130-140 mg/dL; need to follow up with a 3-hr (100 g) OGTT.

  • 3-hr OGTT Criteria: Positive for GDM if two or more values are met or exceeded:
      - Fasting: ≥ 95 mg/dL
      - 1-hr: ≥ 180 mg/dL
      - 2-hr: ≥ 155 mg/dL
      - 3-hr: ≥ 140 mg/dL.

Care During Delivery

  • Intrapartum care requires close monitoring and responding to complications, which may lead to a cesarean birth.

  • Postpartum care should feature significant reductions in insulin requirements, careful monitoring of mother and neonate for hypoglycemia, encouragement of breastfeeding, and contraception advice post-delivery.