Assessment of High Risk Pregnancy (Unit 1)

Pregnancy Chapter Assessment

Assessment of Risk Factors

Importance

Identifying risk factors is crucial for nurses to assess if a mother is at high risk for complications during pregnancy, enabling timely interventions and supportive care.

Potential Indicators

  • Existing Health Conditions: Conditions like hypertension, diabetes, autoimmune disorders, and heart disease can significantly impact pregnancy outcomes and require careful monitoring and management.

  • Prior Pregnancy Complications: History of issues such as gestational diabetes, preterm labor, miscarriage, or severe pregnancy-related hypertension can indicate a higher risk in future pregnancies.

  • Lifestyle Factors: Use of substances such as tobacco, alcohol, or illicit drugs can adversely affect fetal development and overall pregnancy health. Nutritional status and obesity are also key considerations.

  • Maternal Age: Both young adolescents and women aged 35 years or older face different kinds of risks during pregnancy, such as increased chances for chromosomal abnormalities, preterm birth, or complications during labor.

Biophysical Assessment

Daily Fetal Movement Count (DFMC)

  • Purpose: To evaluate the condition of the fetus and detect any potential issues early on.

  • Methods: Women may be instructed to count movements once a day for 60 minutes or to monitor movements 2 to 3 times daily, aiming for 10 distinct movements within a 2-hour period to ensure the fetus's well-being.

  • its movements may be reduced temporarily if the women is taking meds that depress the CNS, drinking alcohol, or smoking a cig.

  • obesity decreases perception of fetal movements.

Ultrasonography

  • Reasons for Use: This imaging technique is essential for visualizing fetal structures, monitoring fetal growth, assessing pregnancy progress, and diagnosing potential anatomical or developmental anomalies.

  • Types of Ultrasound: Includes transabdominal and transvaginal methods, each serving different needs based on gestational age and clinical question.

Magnetic Resonance Imaging (MRI)

  • Uses: Utilized primarily to examine intricate fetal structures, assess placental position and density, evaluate the amount of amniotic fluid, and observe maternal anatomy when necessary. MRI can provide detailed images that aid in detecting anomalies like brain abnormalities or placental issues.

  • Oligohydramnios is a decreased fluid includes a fundal height that is small for gestational age

  • polyhydramnios is the increased amniotic fluid

  • Amniotic fluid (AFI)

  • Biophysical profile Is a noninvasive dynamic assessment of the fetus that is based on acute and chronic markers of fetal disease


Biochemical Assessment

Amniocentesis

  • Performed usually at or after 15 weeks gestation to obtain amniotic fluid which contains fetal cells

  • Rationale: Primarily performed to assess fetal health and genetic makeup through amniotic fluid analysis.

  • When to Perform: Typically indicated if there are previous indications of fetal issues, abnormal ultrasound findings, or when earlier screenings suggest further investigation is necessary, prenatal diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity and diagnosis of fetal hemolytic disease

  • Nursing Responsibilities: It is essential to monitor for complications post-procedure, including symptoms such as bleeding, infection, or rupture of membranes.

Chorionic Villus Sampling (CVS) or placental biopsy

  • Timing: Recommended at 10 to 13 weeks of gestation for early diagnosis of genetic conditions.

  • Process: involves the removal of tissue from the placenta, necessitating careful technique to avoid complications.

  • chorionic villi originates in zygote , the tissue reflects the genetic makeup of the fetus.

  • Rh-negative women should receive Rh0D immunoglobulin after CVS to prevent red cell alloimmunization.

Percutaneous Umbilical Blood Sampling (PUBS)

  • can also be called cordocentesis

  • Method: This technique provides direct access to the fetal circulation via an umbilical vessel under ultrasound guidance, allowing for immediate blood testing of the fetus.

  • Current Use: Though it gives invaluable insights into fetal health, many centers are increasingly opting for placental biopsies instead due to risks involved.

Maternal Assays

  • Alpha-fetoprotein (AFP): Used as a screening tool for neural tube defects and abdominal wall defects.

  • Multiple marker Screens Help detect chromosomal abnormalities, particularly trisomy 21. These screenings often combine multiple biomarkers to improve detection rates.

  • Coombs’ Test: Essential for screening Rh incompatibility and other antibody incompatibilities, which can pose risks for fetal development.

  • Cell-free DNA Screening: The newest method in non-invasive prenatal genetic diagnosis, assessing fetal Rh status, gender, and certain genetic disorders with minimal risk to the mother or fetus.

Antepartal Assessment Using Electronic Fetal Monitoring

Nonstress Test (NST)

  • Purpose: This test determines if the intrauterine environment is supportive of the fetus, evaluating fetal heart rate patterns in response to its movements.

  • Procedure: Continuous monitoring of fetal heart rate and activity is performed, usually over a 10 to 15 minute period.

  • Vibroacoustic stimulation (fetal acoustic stimulation test) often used to change the fetal state from quiet to active sleep if the initial NST results is non reactive

  • Reactive test 2 acceleration in 20 minutes period each lasting at least 15 seconds and peaking at least 15 beats/min above the baseline. (Before 32 weeks of gestation an acceleration is defined as a rise of at least 10 beats/min lasting at least 10 sec from onset to offset

  • Nonreactive test does not demonstrate at least 2 qualifying acceleration within a 20 min window

Contraction Stress Test (CST)

  • Or oxytocin challenge test it purpose was to identify the jeopardized fetus that stable at rest but showed evidence of compromise after stress

  • Types:

    • Nipple-stimulated Contraction Test: Women are instructed to stimulate their nipples to cause contractions.

    • Oxytocin-stimulated Contraction Test: Involves administering oxytocin to induce contractions actively.

  • Benefits: The CST provides an earlier warning of potential fetal compromise than NST by evaluating fetal response during contractions, which may indicate distress.

Physiological Considerations in High-Risk Pregnancy

  • Monitoring: Continuous assessment throughout pregnancy is essential, with close attention given to maternal and fetal well-being.

  • Emotional Health: High-risk pregnancies may lead mothers to experience increased stress, low self-esteem, or frustration, which can negatively affect maternal-fetal bonding. Mental health support may be necessary to help manage these feelings effectively.

  • Nursing Role: Nurses play an integral role in offering support, education, and encouragement to mothers, facilitating a supportive environment that fosters both physical and emotional health.

  • Interpretation of the contraction stress test

  • Negative at least 3 uterine contractions in a 10 minutes period with no late or significant variable deceleration ( usually resume routine weekly testing schedule)

  • Positive late deceleration occur with 50% or more of contractions even if there are fewer than 3 contractions in 10 min ( usually warrants hospital admission for further evaluation and or delivery)

Clinical Consideration

Amniotic Fluid Volume

  • Oligohydramnios: Defined as having less than 300 mL of amniotic fluid, associated with renal, cardiac, gastrointestinal, or neurologic anomalies in the fetus. Monitoring changes in fluid levels can aid in preventing serious complications.