Antepartum complications Flashcards
High-Risk Factors: Biophysical
Genetic Chromosome anomalies Trisomy 21 (DS), Trisomy 18, Trisomy 13 Multiple gestation Large fetal size ABO compatibility
Nutritional status
Inadequate nutrition for fetal growth
Medical or obstetric disorders
High-Risk Factors: Psychosocial
Smoking Low birth weight Caffeine High amount restricts uterine growth Alcohol Fetal alcohol disorders Narcotics Neonatal abstinence syndrome Psychologic
High-Risk Factors: Sociodemographic
Low income
Risk for inadequate nutrition, prenatal care or comorbidities
Lack of prenatal care
Financial barriers; lack of access to care
Age
Adolescents
Mature
Indications for High-Risk Testing (Box 10.3)
Diabetes Chronic Hypertension Preeclampsia Suspected or confirmed fetal growth restriction Multiple gestation Oligohydramnios amniotic fluid volume that is less than expected for gestational age Preterm premature rupture of membranes Late-term or post term gestation Previous stillbirth Decreased fetal movement Systemic lupus erythematosus Renal disease Cholestasis of pregnancy
Biophysical Assessment
Daily fetal movement count (DFMC)
Kick count
Once a day for 60 minutes or
2-3 times daily for 2 hours or until 10 movements counted or
All fetal movement in 12 hours or until 10 movements counted
No standard for number of movements
Fetal alarm signal
No movement for 12 hours or <3 movements in 1 hour=further evaluation
Biochemical Assessment
Amniocentesis
Needle aspirate of amniotic fluid
After 14 weeks of pregnancy
Indications
Prenatal diagnosis of genetic disorders or congenital abnormalities
Assess fetal lung maturity
Chorionic Villus Sampling
Needle aspirate of tissue specimen from fetal portion of placenta
Ideally between 10-13 weeks of gestation
Indications
Genetic studies
Percutaneous Umbilical Blood Sampling (PUBS)
Needle aspirate of blood from umbilical cord
Used for fetal blood samples or transfusion
Indications
Genetic studies
Fetal anemia, infection or thrombocytopenia
Maternal Assays
Alpha-Fetoprotein (AFP)
Screens for neural tube defects
Recommended for all pregnancies
Elevated protein level=ultrasound assessment
Multiple Marker Screens
Measurement of material biochemical markers
Screening for fetal chromosomal abnormalities
First semester screening for Trisomy 21
Second semester screening for Trisomy 21 and Trisomy 18
Indirect Coombs Test
Indirect screening of Rh incompatibility
Looks for antibodies in blood serum
Cell-Free (cfDNA) Screening
Measures the amount of cfDNA circulating in maternal blood
Screens for Trisomies 13, 18, and 21
Performed at 10-12 weeks of gestation
Electronic Fetal Monitoring
Nonstress Test (NST)
Fetal heartrate monitoring during fetal movement
Monitor for abnormal HR patterns
Usually completed weekly for 20-30 minutes
Vibroacoustic stimulation (VAS)
Performed in conjunction with NST
Fetus is stimulated (buzzed) to assess fetal heartrate during stimulation
Contraction Stress Test (CST)
Oxytocin used to induce contractions
Fetal heart rate is monitored to assess fetal response to stress of labor
HR slowing down is a sign of possible distress
(+) CST usually leads to hospitalization for monitoring until birth
Hypertension in Pregnancy
Gestational hypertension
HTN without proteinuria or preeclampsia after 20 weeks of pregnancy
SBP >140 or DBP >90
Preeclampsia
HTN and proteinuria after 20 weeks gestation.
Eclampsia
Onset of seizure activity or coma in pregnant person with preeclampsia with no history of seizures.
Chronic Hypertension
HTN present before pregnancy or persists beyond 12 weeks postpartum
Superimposed preeclampsia
Preeclampsia in addition to chronic hypertension
Preeclampsia Risk Factors
First pregnancy Multiple gestations Maternal age >35 HTN Diabetes Obesity Family history of preeclampsia
Preeclampsia Diagnostic Criteria (Table 12.2)
Hypertension >140/90 for preeclampsia >160/110 for severe preeclampsia Proteinuria Massive in severe preeclampsia Thrombocytopenia Platelets <100,000 Impaired liver function Elevated LFTs Elevated LFTs with RUQ pain in severe Renal insufficiency Elevated creatinine Progressively elevated creatinine in severe Pulmonary edema New onset in severe preeclampsia Cerebral or visual disturbances New onset in severe preeclampsia
HELLP Syndrome
Hepatic dysfunction characterized by Hemolysis Elevated Liver enzymes Low platelets Adverse outcomes Increased risk of maternal death Preterm delivery Pulmonary edema Acute renal failure Disseminated Intravascular Coagulation (DIC) Placental abruption Liver hemorrhage or failure Acute Respirator Distress Syndrome (ARDS) Sepsis Stroke
Preeclampsia
Accurate BP measurement Monitor trends over time Assess for pitting edema Assess for proteinuria 24-hour urine collection Assess deep tendon reflexes Hyper reflexivity is concerning Headache Epigastric pain (heartburn) RUQ abdominal pain Visual disturbances Scotoma (blind spot) Photophobia (bright light hurts eyes) Double vision
Interventions for Gestational HTN or Preeclampsia without Severe Features
Frequent maternal evaluations
Labs: Creatinine, platelets, LFTs, Hematocrit, proteinuria weekly
BP: Twice weekly
Frequent fetal evaluations Kick counts daily NST weekly Delivery at 37 weeks Normal diet Activity restrictions Monitoring for worsening of symptoms Abdominal pain, N/V Significant Headache or vision changes Uterine contractions Vaginal spotting Decreased fetal movement Decreased urine output
Interventions for Severe Gestational Hypertension and Preeclampsia with Severe Features
Frequent maternal assessments BP Urine output Neuro checks and DTRs Epigastric pain Contractions Vaginal bleeding Labs: Platelets, LFTs, Creatinine Frequent fetal assessments Continuous fetal heartrate and uterine contraction monitoring Ultrasound Expectant management for <34 weeks gestation Hospitalization Oral anti-hypertensives Corticosteroids Enhance fetal lung maturation Develops >34 weeks gestation Plan for delivery Complications=immediate delivery Eclampsia Uncontrolled, severe HTN Pulmonary edema Placental abruption DIC Fetal compromise or demise Gestation <24 weeks
Interventions for Severe Gestational Hypertension and Preeclampsia with Severe Features
Quiet environment Seizure precautions Antihypertensive medications Hydralazine, Labetalol, Nifedipine Magnesium Sulfate infusion Prevent and treats seizure activity Bolus then maintenance dose Monitor for toxicity Vital signs I&O DTRs Neuro assessments Continue Magnesium infusion x 24 hours Symptoms subside within 48 hours of delivery
Eclampsia
Persistent headache Blurred vision Photophobia Severe epigastric or RUQ pain Altered mental status Tonic-clonic convulsive seizures Maternal stabilization Padded side rails, protect airway during seizures Suction secretions Insert oral airway PRN Apply oxygen Start IV infusion of fluids and Magnesium IV lorazepam if additional seizures Fetal stabilization Monitor FHR
Miscarriage (Spontaneous Abortion)
25% from chromosomal abnormalities Endocrine imbalances Immunologic factors Systemic disorders Genetic factors Threatened Inevitable Incomplete Complete Missed Recurrent
Follow-up care
Discharge within a few hours after D&C
Stable VS, bleeding controlled, recovered from anesthesia
Rest, iron supplement for blood loss
Teaching
Cramping, type and amount of bleeding
Resume sexual activity when ready
Grief counseling or support groups for fetal loss
Ectopic Pregnancy
Symptoms Abdominal pain, delayed menses, abnormal vaginal bleeding (spotting) Rupture symptoms Referred shoulder pain One-sided, lower abdominal pain Cullen sign Hemorrhagic shock Diagnosis Symptoms (+) positive pregnancy test Transvaginal ultrasound
Ectopic Pregnancy
Methotrexate (Box 12.4) Hemodynamically stable Normal liver and kidney function Monitor for -hCG levels weekly until undetectable Removal of fallopian tube Removal of ectopic by opening tube Left to close on own
Hydatiform Mole (Molar Pregnancy)
Complete Placental tissue is abnormal, swollen Forms fluid-filled cysts Incomplete Normal and abnormal placental tissue May also form fetus—miscarried early in pregnancy Symptoms Dark brown to bright red vaginal bleeding in first trimester N/V Vaginal passage of grapelike cysts Pelvic pressure or pain
Molar Pregnancy
Transvaginal ultrasound Serum -hCG levels Suction curettage Hysterectomy Fetal loss counseling Frequent physical and pelvic exams Monitor -hCG levels
Placenta Previa
Complete placenta previa (picture A) Marginal placenta previa (picture B) Maternal age >35 History of caesarean birth or suction curettage Multiparity or male fetus Smoking or living at a high altitude
Placenta Previa symptoms
Painless bright red vaginal bleeding during the second or third trimester
Abdominal exam normal except Fundal height >than expected for gestational age
Fetal malpresentation common
Vital signs and FHR are usually normal
May present with decreased UO from low volume
Diagnostics
Transabdominal ultrasound
Transvaginal ultrasound
Coagulation panel
Placenta Previa Management
Expectant management (Hospitalization)
For fetus <36-37 weeks of gestation; normal growth; no other pregnancy complications
Monitor FHR and for contractions
Draw labs, IV access, bedrest
Administer corticosteroids for <34 weeks gestation
Administer tocolytic medications for contractions
Placenta previa complications
Maternal Complications Hemorrhage Blood transfusion reactions and anemia Hysterectomy Abnormal placental attachment Complications from cesarean delivery Thrombophlebitis and infection Perinatal complications Preterm birth Intrauterine growth restriction (IUGR)
Abruptio Placentae
Grade 1-3
Mild, moderate or severe separation
Physical and lab findings
Ultrasound findings
Risk Factors
Maternal hypertension (chronic or pregnancy induced)
Cocaine use or smoking
Blunt abdominal trauma
History of abruption or premature rupture of membranes
Multipara
Abruptio Placentae
Vary with degree of separation Vaginal bleeding Abdominal pain Uterine tenderness Contractions
Maternal Hemorrhage and hypovolemic shock Thrombocytopenia Renal failure and pituitary necrosis Fetal IUGR Preterm birth Hypoxemia Stillbirth Increased risk for SIDs
Managing Abruptio Placentae
Expectant
20-34 weeks gestation; stable mother and fetus
Monitoring for abruption and IUGR
Tests for fetal well-being
Corticosteroids to accelerate fetal lung maturity
Active
Term gestation; mother or fetus in jeopardy
Moderate to severe bleeding
Immediate birth (vaginal preferred)
IV, labs, vitals, fetal monitoring, foley
Disseminated Intravascular Coagulation (DIC)
Release of large amounts of thromboplastin
Placental abruption; retained dead fetus; amniotic fluid embolus
Widespread damage to vascular integrity
Preeclampsia; HELPP syndrome; sepsis
DIC Symptoms and Management
Spontaneous bleeding from gums; nose Oozing IV or puncture sites Petechiae; bruising Hematuria; GI bleeding Tachycardia; diaphoresis
Treat the cause
Supportive care
Volume expansion; blood products; clotting factors
Optimize oxygenation; normalize body temp
Monitor for renal failure
