Childbearing Exam 3 SG

Genetics

  • Homozygous Gene: genes carrying similar traits (DD, dd)
  • Heterozygous Gene: genes carrying dissimilar traits (Dd)
  • Patterns of Inheritance (Mendelian)
    • Autosomal Dominant: Doesn’t skip gen, 50% chance of expressing it.
      • Ex: Huntington’s
    • Autosomal Recessive: Skips a gen, 25% chance of expressing it. Both parents must be carrier
      • Sickle Cell, Cystic Fibrosis
    • X-linked Dominant: Doesn’t skip gen. If father has it, all daughters have it. If mother has, children are carriers.
      • Vit D Res Ricketts
    • X-linked Recessive: More common in mother → son d/t x-linked
      • Ex: colorblindness, muscular dystrophy
  • Non-Mendelian Inheritance
    • Multifactoral: d/t genetics + environment
    • Monosomy: one allele missing
    • Trisomy: one extra chromosome → trisomy 21 = DS

Fetal Surveillance

  • Fetal Movements: “Kick Counts”
    • Count for 1 hr after a meal. If < 3 in 1 hr or no movement in 12 hrs = BAD
    • Done after 24 wks, but regularly after 28 wks
  • US:
    • 1st Trimester (12 wks): determine fetal #, size, EDD, abnormalities, GA
    • 2nd: determines viability, GA, growth, abnormalities, placenta location, amniotic fluid volume
    • If done abdominal, better in later pregnancy. If done transvaginal, better early in pregnancy.
  • Doppler Blood Flow Analysis: blood flow through fetus + placenta
    • S/D ratio should be 3 or less at 30 wks. Higher value = placental insufficiency.
    • Used in pts w/ HTN, diabetes, IUGR, preterm
  • MRI: not very helpful d/t fetus needs to stay very still
  • Multiple Marker Screen: screens for DS and NTD by using MSFAP
    • Low, high hCG = DS, High MSFAP = NTD
    • Done at 16-18 wks
  • Nuchal Translucency: screen for DS by measuring amniotic fluid behind neck
    • > 3mm at 11-14 wks = abnormal
  • Cell-Free DNA Screening: fetal blood separated from maternal blood to screen for DS, trisomy 13 + 18.
  • CVS: taking part of placenta (10-13 wks)
    • Risks: SAB, bleeding, PROM, cramping, fever (>100.4)
    • Give Rhogham!
  • Amniocentesis: taking sample of amniotic fluid (14 wks)
    • Risks: bleeding, cramping, decreased fetal movement, fever (>100.4)
    • Give Rhogham!
  • Percutaneous Umbilical Sampling: blood taken from umbilical vessel to test blood disorders, karyotyping or anemia
    • 1-4cc removed
    • Give Rhogham!
  • Biophysical Profile: Tests for fetal well-being
    • GRAFF → Gross body movement, Reactive HR, Amniotic fluid volume, Fetal breathing, fetal tone
    • 8-10 normal, 4-6 further eval, 0-2 IMMEDIATE DELIVERY
  • Non-stress Test: tests fetal response to movement
    • Normal Reactive: accels 2x in 20 mins
    • Abnormal: no accels in 40 mins
    • If >32 wks (15 bts/15 secs), if <32 wks (10 bts/10 secs)
  • Vibroacoustic Stimulation: tests fetal response to sound waves if NST is non-reactive
    • Done AFTER 32 wks
    • 3 secs, up to 3 times qmin. No reaction can also mean bby is asleep.
  • Contraction Stress Test: tests fetal response to contractions
    • Done on pts who are high risk (IUGR, HTN, DM, Preterm)
    • Spontaneous contraction → CST, Oxytocin contraction → OCT (challenge test)
    • Need 3 CONTRACTION LASTING 40 SECS in 10 MINS
      • Normal: no decels
      • Abnormal: “positive”, Late decels → give O2, change position

Intrapartum Complications

  • Preterm Labor
    • Risk Factors: INFECTION, HIGH PARITY (> 6), Hx OF PRETERM, PROM, uterine anomalies, obesity, poor nutrition, bacterial vaginosis (gray discharge, look for clue cells), twins
    • s/s: cramping, low back pain, vaginal discharge, fetal fibronectin (FFN) → if positive, then risk for preterm delivery
    • Fetal Risk: low birth weight, resp distress, hypoxia
    • Tx: Tocolytics (slow down labor/relax smooth muscles), Steroids (HELP LUNGS MATURE)
      • Terbutaline: tocolytic given subq
        • ADR: TACHYCARDIA, hypotension, CP, pulmonary edema
        • Interventions: measure HR and lung sounds before + after (if pulse >120, no more doses)
        • Antidote: propranolol
      • Magnesium Sulfate: tocolytic given IV
        • Side effects: headache, flushing, fatigue
        • Toxicity: resp depression + decreased deep tendon reflexes
          • Asses resp, asses DTR, monitor vitals
        • Therapeutic Level: 4-7.5 mEq/L
        • Antidote: calcium gluconate
      • Nifedipine: antihypertensive, PO, improves contractility
        • DO NOT GIVE w/ MgSO4 or Terbutaline
      • Beta/Dexamethasone: given IM at 24-34 wks to increase L/S ratio (2:1)
        • 1 dose q24 hrs. Considered “ beta complete” 24 hrs after 2nd dose.
        • VERY PAINFUL
  • PROM: ROM at least 1hr before labor
    • PPROM: ROM <37 wks
    • Diagnostics: fluid pooling, ferning, pos nitrazine
    • Care: Monitor for infection (fetal tachycardia, fever, odor, tender abdomen), give antibiotics, monitor for labor, + fetal well-being, NO VAG EXAMS
  • Precipitous Birth: < 3 hrs from contraction to birth
    • Maternal Risk: Uterine rupture, hemorrhage, perineal tears
    • Fetal Risk: decreased O2 (d/t no recovery period btwn contractions), bruising, bleeding
    • Tx: TERBUTALINE (if tachysystole), turn pt L side lying
  • Dystocia: long, dysfunctional labor
    • Multifetal Pregnancy Dystocia: risk for PROM, pre-term delivery, and c/s in mother. Risk for IUGR and entanglement in fetus.
      • Vag delivery can only be done if one twin is vertex and larger than the other, OR if they are >32 wks + 2000g
    • Breech Presentation Dystocia
      • External version: manually turn bb around from outside. DONE at 37 wks, EXTREMELY PAINFUL.
      • Use tocolytic, US, and monitor FHR
      • NEED RHOGHAM
  • Induction: kick-START labor
    • Bishop Score: Want score above 9 to start labor. Score <6 needs cervical ripening
    • Cervical Ripening
      • Chemical: prostaglandin (Misoprostol/Cytotec), max 6 doses
      • Mechanical: balloon pump inserted in cervix to mimic dilation
      • AROM + Pitocin
  • Contraindications: Herpes infection, vertical uterine incision, placenta previa, malpresentation, cephalic pelvic disproportion (fetal head wont fit)
  • Forceps Assisted Birth
    • Indications: maternal exhaustion, fetal distress, fetus at 2+ station
    • Risks: fetal skull/neck injury, bruising, laceration, hematoma
    • Epidural recommended
  • Vacuum Assisted Birth: same indications as forceps
    • Risks: scalp injury, hematoma (less traumatic)
    • Monitoring: FHR, jaundice, anemia, hyperbilirubinemia. NO MORE than 3 pop-offs → immediate OR
  • C/s
    • Indications: mother is a repeat c/s, fetal distress
    • Complications: bleeding, infection, injuries, resp depression (from anesthesia)
      • Risk of uterine rupture if she tries to deliver vaginally after c/s. MD and OR MUST BE AVAILABLE in case of c/s.
    • Interventions
      • Preop: NPO for 6hrs, IV patency, FHR, Bicitra (neutralizes stomach acid)
      • Postop: monitor v/s, uterine atony, blood loss
  • Post-Term Preg: birth >42wks
    • Risks: Large fetus, Postmaturity Syndrome (less amniotic fluid, resp distress, hypoglycemia d/t placental insufficiency), Meconium Aspiration Syndrome (neonate inhales meconium in utero) → pneumonia risk
    • Tx:
      • Non-stress test/contraction stress test to see if ready for induction
      • Amnioinfusion (insert amniotic fluid to make more space)
  • OB Emergencies
    • Shoulder Dystocia: unable to pass shoulders
      • Interventions: McRoberts Maneuver (push legs all the way back to chest), Suprapubic Pressure (stand above pt, push down in a rocking motion), Gaskin Maneuver (hands and knees position)
        • MONITOR how long head has been delivered
    • Umbilical Cord Prolapse: cord comes out first and is being compressed
      • IMMEDIATELY shout for help → help pt to hands and knees → put on glove and maintain pressure off the cord (don’t remove until provider arrives) → C/s
        • Mother may feel pulsating in vagina
    • Uterine Rupture: uterus ruptures and is now in abdominal cavity
      • Risk factors: Hx of c/s, multip, anatomical defect, twins
      • Tx: Immediate c/s
      • Uterine window: uterine wall is so thin that it is see through
    • Amniotic Fluid Embolism: aka Anaphylactoid Syndrome
      • Risk Factors: eclampsia, precipitous birth
      • s/s: pulmonary edema, SOB, coughing, LOC changes, hypotension, frothy bloody sputum, possible DIC
      • FIRST ACTION: give O2 and call for help

High BP Pregnancy

  • Gestational HTN: 2 high BP readings after 20 wks
  • Preeclampsia: high BP reading after 20wks + other symptom
    • Risk Factors: Hx chronic HTN, high parity, smoking, diabetes, race
    • Mild: BP 140/90, elevated protein, mild headache, edema to hands + face
    • Severe: BP 160/110, elevated protein + creatinine, persistent headache, general edema, visual changes, epigastric pain
      • HELLP: Hemolysis, Elevated Liver enzymes, Low PLTs
    • Risks: SGA, preterm, fetal demise, hypoxia, maternal acute kidney injury
    • Tx
      • Monitor fetus: NST, BPP, kick counts
      • MgSO4: prevents seizures, therapeutic range 4-7.5 (REFER TO EARLIER)
      • Antihypertensive: hydralazine, labetolol
      • Bed rest, L side lying
      • Induction: 34wks for severe, 37 wks for mild
  • Eclampsia: seizures w/ preeclampsia and no Hx of seizures
    • Tx: induction → vaginal delivery if >30 wks and competent cervix, c/s if <30 and incompetent cervix
    • MgSO4 + seizure precautions
  • Chronic HTN: high BP before 20 wks, persists >12wks PP
    • Tx: antihypertensives, low sodium
  • Chronic HTN w/ Superimposed Preeclampsia: high BP + preeclampsia s/s before 20 wks AND low PLTs, elevated protein, elevated LFTs

Hemorrhagic Complications

  • Early Bleeding
    • SAB: pregnancy that ends before 20wks, or <500g
      • Early = <12 wks, Late = 12-20 wks
      • GIVE RHOGHAM FOR ALL if MOTHER IS Rh (-)
      • Threatened: light bleeding + cramping, no tissue passage or dilation
      • Inevitable: moderate bleeding + cramping, tissue passage and dilation
      • Incomplete: heavy bleeding + cramping, retained passage, dilated
      • Complete: light bleeding + cramping, ALL tissue passed, CLOSED cervix
      • Missed: fetal death (no expulsion), light bleeding, decreased size of preg
        • May need uterine evac, risk for DIC
      • Septic: pain, odorous/cloudy blood, monitor fetal status and for septic shock
        • More common in incomplete and missed AB
    • Incompetent Cervix: painless dilation during 2nd trimester
      • D/t: Hx of cervical laceration, uterine or cervical anomalies, being a DES daughter
      • s/s: leaking fluid, fetal parts in vagina, bulging water membrane
      • Prophylactic Cerclage: stitching cervix to keep it closed before term. Done in 1st trimester.
    • Ectopic Pregnancy: implantation of fertilized ovum outside of uterus
      • Risk Factors: Hx ectopic pregnancy, progesterone IUDs, smoking, uterine masses
      • s/s: adenexal pain (near ovaries), referred shoulder pain, shock (d/t rupture + bleeding)
      • Tx: transvaginal US (if hCG not btwn 1500 - 1800 = ectopic) progesterone level <5 = ectopic, surgical removal, methotrexate (IM injection, prevents cell growth)
    • Hydatidiform Mole: abnormal fertilization of ovum
      • Complete Mole: sperm duplicates itself in ovum → NO FETAL PARTS, FHR, OR FM, size >GA, grape-like vesicles
      • Partial Mole: 2 sperm fertilize ovum → Some fetal parts
      • General s/s: abnormally high hCG, preeclampsia, snowstorm US
      • Tx: D+C, pregnancy contraindicated for 1yr, NEED RHOGHAM
  • Late Bleeding
    • Placenta Previa: placenta is the presenting part, implanted lower
      • Risk factors: multip, AMA, multi-fetal pregnancy
      • s/s: painless BLEEDING, high fetal placement
      • Tx: expectant mngmt, NO VAG EXAMS
      • Pt ed: no sex, nothing up vag, go to ER if bleeding
    • Placental Abruption: placenta detaches early
      • Risk Factors: HTN, AMA, Hx of abruption, short umbilical cord
      • s/s: Triad (external/occult bleed, toned uterus, fetal distress), PAIN, decreased FM
      • RISK FOR DIC so monitor coag status
      • Tx: <36 wks → expectant mngmt, Term → DELIVERY
    • Cord Insertion
      • Vasa Previa: cord is inserted into the membrane of placenta, not the tissue
      • Battledore: cord inserts on the side, NOT THE MIDDLE.
  • DIC: triggered by PLACENTA ABRUPTION (most common), amniotic fluid embolism, severe preeclampsia/HELLP syndrome, sepsis
  • Substance Use:
    • Tx: group care, more visits, meds to reduce use of substances,
    • Considerations: what pain meds pts can be given during birth, neonatal withdrawal, breastfeeding concerns, 51-a filing (state will investigate situation)

Preexisting Conditions (Know what to do for this pt during preg/labor)

  • Class A1 diabetes = diet controlled; Class A2 diabetes = insulin controlled
  • Early preg = less insulin (d/t early preg s/s), Later preg = more insulin
    • Pregestational Diabetes: Goal is HgbA1C <6 before preg
      • Risks: macrosomia → PPH, preeclampsia, gestational HTN, hypoglycemia (<65), hyperglycemia (>200)
        • Routine Screening: eye exam, kidney exam, HgbA1C checks
        • Care: limit carbs, ketonuria monitoring, meals before breastfeeding, fetal monitoring
          • Glucose: normal is 65 -120 (may need insulin drip during labor). >140 = DO GTT test (also a routine test)
          • Exercise: 15-30 mins (increases insulin sensitivity) so measure glucose before + after
    • Gestational Diabetes: risks and care same as pregestational. Only difference is that glucose levels will return to normal w/in 24 hrs postpartum.
      • Do 2hr-GTT 6wks postpartum
  • Hyperemesis Gravidarum: prolonged vomiting (in btwn meals) with weight loss (>5%), dehydration, and electrolyte imbalance.
    • Tx: antiemetics, antihistamines (reduce vomit center activity), steroids, small frequent meals, eat before getting up, bland foods → Risk for LBW baby
  • Hypothyroidism:
    • Risks: miscarriage, stillbirth, LBW, preeclampsia,
    • Tx: Levothyroxine + Iron (GIVE AT DIFFERENT TIMES, iron blocks absorption of other med)
  • Hyperthyroidism: same as hypo
    • Tx: PTU, Methimazole, fluids, O2, Iodine
    • Thyroid Storm: hyperthermia, tachycardia, altered LOC (agitated, restless), vomiting, HTN
  • Maternal Phenylketonuria: inability to breakdown phenylalanine d/t enzyme deficiency
    • Fetal Risks: LBW, seizures, microcephaly, neuro delays
    • Tx: low protein diet, normal Phenylalanine level (<6mg/dL; measure weekly), Breastfeeding (held off until parents tested and then supplemented w/ phenylalinine),
  • CV Disorders:
    • Risks: HF, preterm birth, IUGR, death
    • Tx: antihypertensives, stool softener, side-lying position, HOB elevated, ASSISTED DELIVERY, NO METHERGINE OR TERBUTALINE, Monitor decompensation: d/t fluid shift → lung sounds, edema, HR, SOB
  • Iron Deficiency Anemia: take iron supplement, iron-rich foods, stool softener
  • Sickle Cell Anemia: IV FLUIDS (to dilute blood), opioids, O2
  • Asthma: MOST COMMON resp issue. Tx → ALBUTEROL, monitor FHR, give epidural (to reduce O2 consumption), risk for PPH (use Pitocin)
  • CF: Monitor FHR, LUNG FUNCTION + INFECTION. Give Epidural.
  • Skin Disorders:
    • Priritus Gravidarum: limited to abdomen, use antihistamine/anti-itch cream
    • PUPPP: use antihistamine, anti-itch, + steroid
    • Inhtrahepatic Cholestasis: itching of hands and feet d/t elevated serum bile → med is Ursodiol
  • Epilepsy: Care → anticonvulsants, seizure precautions, folic acid supplements
  • MS: remission during pregnancy! Care → Vitamin D, Epidural use, may have gait difficulties post-partum
  • Bell Palsy: s/s → unilateral facial weakness, difficulty closing eye, pain around ear
    • Care: preventing eye injury, facial muscle massage
  • Lupus: Care → steroids, LIMIT PREGNANCIES, follow-up w/ rheumatologist
  • Myasthenia Gravis: Care → steroids, assisted vag delivery (d/t muscle weakness)
    • Cant use MgSO4 d/t mag toxicity → USE KEPPRA
  • HIV:
    • Transmission: if high maternal load, prolonged ROM, chorioamnionitis
    • Care: DELIVER VIA C/S BEFORE ROM, monitor for infection, Treat other STDs, newborn bath ASAP, nothing up vagina, no breastfeeding, Use Zidovudine (antiretroviral)
  • UTIs: ANTIBIOITCS → s/s: dyuria, pain, urinary frequency/urgency, CVA tenderness, fever, chills
  • Surgery: should be delayed, but if emergent → best done in 2nd trimester
    • Appendicitis: often confused w/ early preg symptoms. Care = appendectomy + antibiotics
  • Trauma: from MVA, partner, GSW, stab, falls
    • Risk: miscarriage, preterm labor, PROM, hemorrhage, uterine rupture
    • Assess + stabilize mother FIRST (bleeding, contractions)
    • Code Order: call code → uterine displacement → CPR (if non responsive for 4-5min) → assess FHR → c/s