Ch 26, Assessment of high risk pregnancy Flashcards
The risk factors for a pregnancy are assessed by breaking them down into 4 separate categories. What are these categories?
-Biophysical
-Psychosocial
-Sociodemographic
-Environmental
In risk factor assessment, what does the category of “Biological” risk factors mean?
Factors that originate in the pregnant woman or fetus and affect development/functioning of the woman or baby
What are some examples of biological risk factors?
-Diabetes Mellitus (leads to Polyhydramnios)
-Maternal Hypertension (Leads to Oligohydramnios)
-IRGR (Fetal infection, Teratogenic exposure, HTN)
-AMA (chromosome abnormalities)
-
What are “Psychosocial” risks that affect pregnancy?
-Emotional distress
-Hx of depression
-d\Disturbed relationships
-Intimate partner violence
-Substance abuse
-No social support
What are some “Sociodemographic” risks for pregnancy?
-Lack of prenatal care
-Low income
-Single marital status
-Ethnic minorities
What are “Environmental” risk factors that affect pregnancy?
“Workplace hazards and toxic home environment”
-Chemicals (mercury)
-Anesthetic gases
-Radiation
-Asbestos
When does Antepartum testing typically begin?
Between 32-34 weeks of gestation, and continues regularly until birth
What are some common Maternal and Fetal indications for Antepartum testing?
-Diabetes
-HTN
-Preeclampsia
-Lupus
-Renal Disease
-Cyanotic Heart Disease
-Oligohydramnios
What is a DFMC and what is it used for?
DFMC stands for Daily Fetal Movement Count
DFMC, also called the “kick” count, is used to monitor a baby in a pregnancy with conditions that may affect fetal oxygenation (DM, HTN, etc.)
DFMC, also called the “(____)” count, is used to monitor a (____) in a pregnancy with conditions that may affect fetal (___________) (DM, HTN, etc.)
DFMC, also called the “(kick)” count, is used to monitor a (fetus) in a pregnancy with conditions that may affect fetal (oxygenation) (DM, HTN, etc.)
Decreased fetal activity is noted in response to what?
Hypoxemia
Several different protocols are used for counting DFMC. One method is to count (____) a day for long?
Several different protocols are used for counting DFMC. One method is to count (once) a day for 60 minutes
Another method for DFMC is for women to count ALL fetal activity in a (__) hour period each day until (__) movements are counted
Another method for DFMC is for women to count ALL fetal activity in a (12) hour period each day until (10) movements are counted
The 12-10 method
When is the fetal alarm signal sounded?
No fetal movements are recorded in 12 hours. EMERGENCY!!!!!!!!!!!!
When a woman reports decreased fetal activity, what test is usually preformed?
A non-stress test
It is important to know that fetal movement cannot be recorded during the fetal (____-____)) and movements may be reduced if the mother it taking (_______) that depress the (___)
It is important to know that fetal movement cannot be recorded during the fetal (sleep-cycle)) and movements may be reduced if the mother it taking (medications) that depress the (CNS)
What is considered the most valuable diagnostic tool in obstetrics?
The Ultrasound
Ultrasonography can be used to detect fetal genetic disorders and physical anomalies. What is the technique known as NT, and what does stand for?
NT stands for Nuchal Translucency, and an NT screening uses ultrasound measurements of fluid in the nape of the neck between 10 and 14 weeks to ID fetal abnormalities
NT stands for (_____ ___________), and an NT screening uses ultrasound measurements of (____) in the (____) of the neck between (__) and (__) weeks to ID fetal abnormalities
NT stands for (Nuchal Translucency), and an NT screening uses ultrasound measurements of (fluid) in the (nape) of the neck between (10) and (12) weeks to ID fetal abnormalities
In an NT test, a fluid collection greater than (___) is considered abnormal
In an NT test, a fluid collection greater than (3mm) is considered abnormal
An elevated NT level indicates an increased risk for isolated anomalies, such as what 3 things?
-Congenital heart defects
-Abdominal wall defects
-Diaphragmatic hernia
When combined with abnormal maternal (____) marker levels, increased NT levels indicate the possibility of (__________) abnormalities, such as (________) 13, 18, and 21
When combined with abnormal maternal (serum) marker levels, increased NT levels indicate the possibility of (chromosomal) abnormalities, such as (trisomies) 13, 18, and 21
An ultrasound is also valuable in DX relating to the location of the placenta. After 16 weeks of gestation, where should the edge of the placenta be in relation to the cervix to be considered normal?
The edge of the placenta needs to be AT LEAST 2cm from the cervix to be normal.
If the placental edge is LESS THAN 2cm from the cervix, it is considered previa. What is previa?
What should be done?
Previa is a low-lying placenta
Repeat ultrasound scans as the pregnancy progresses until it moves away from the cervical os. 90% of Previas resolve by the 3rd trimester
Why do 90% of Previas resolve by the 3rd trimester?
Because the placenta grows towards the fundus, where the blood supply is way better than the lower uterine segment
PUBS (Percutaneous Umbilical Blood Sampling) and CVS (Chorionic Villus Sampling) are two adjunct methods of DX used with an ultrasound to do what?
PUBS identifies the umbilical cord
(Percutaneous Umbilical Blood Sampling)
CVS identifies the Chorion Frondosum
(Chorionic Villus Sampling)
AFV and FBM’s are abbreviations that mean what in fetal well-being assessments?
AFV is Amniotic Fluid Volume
FBM is Fetal Breathing Movements
Which fetal assessment tool is used to analyze systolic/diastolic flow ratios and resistance to estimate blood flow to certain arteries?
Doppler Blood Flow Analysis
What are the 3 most studies vessels in the Doppler Blood Flow Analysis?
(2 fetal, 1 mother)
-Fetal umbilical arteries
-Middle cerebral arteries
-Maternal uterine arteries
Significantly increased peak systolic velocity in the (______) (______) artery predict moderate to severe fetal (____). Abnormal (______) (______) artery levels predict IUGR
Significantly increased peak systolic velocity in the (middle) (cerebral) artery predict moderate to severe fetal (anemia). Abnormal (maternal) (abdominal) artery levels predict IUGR
Determine which of these subjective measurements are examples of the AFV issues:
Oligohydramnios or Polyhydramnios
-Fundal height that is small for gestational age and easily palpable
-Fundal height that is large for gestational age and cannot be easily palpated (ballotable)
-Fundal height that is small for gestational age and easily palpable is indicative of Oligohydramnios
Fundal height that is large for gestational age and cannot be easily palpated (ballotable) is indicative of polyhydramnios
What are the FV differences and amniotic vertical pocket cm differences between Oligohydramnios and Polyhydramnios?
Oligohydramnios is an AFV of <300 and an amniotic pocket circumference of less than 2cm
Polyhydramnios is an AFV of 2L and an amniotic pocket circumference of greater than 8cm
An AFI (Amniotic Fluid Index) of what indicates Oligohydramnios?
An AFI of what indicates Polyhydramnios?
AFI of less than <5cm Indicates Oligo
AFI of greater than >25cm indicates Poly
Prelabor ruptures and IUGR is associated with which AFV issue?
GI/CNS issues, twin-to-twin transfusion syndrome and infections are associated with which AFV issue?
Prelabor ruptures and IUGR are associated with Oligo
GI/CNS issues, twin-to-twin transfusion syndrome, and infections are associated with Poly
The BPP can be considered a physical examination of the fetus. What is BPP?
Biophysical Profile
Why can BPP be considered a reliable, physical examination of the fetus’s well-being, while an AFV test only demonstrates placental function over the pregnancy?
The BPP takes into account FHT’s, FBM’s, Fetal tone, movement and FHR determined by a non-stress test. This put together determines CNS status
What is a desired BPP score?
8 or 10, like a good APGAR
When is the BPP test used?
Frequently in the late second trimester and early 3rd trimester
What is a drawback of a BPP test?
If the fetus is in a quiet sleep state, it can take a long time to get results
What is the nurses role in an Ultrasound and BPP?
To provide counseling and education about the procedure
What is three and four-dimensional ultrasonography?
Is it covered by insurance?
Three and Four-Dimensional ultrasonography is when an ultrasound image is made like a professional photograph, capturing a 3-d image of a fetus
It is not covered by insurance
Why is 3-d ultrasonography discouraged by AIUM and ACOG? (2 reasons)
Exposing the fetus to high-frequency sound waves without a clear medical reason should be avoided.
It’s also casual and performed without a trained medical professional and can give false reassurance that the pregnancy is fine.
An MRI is an excellent way to view a fetus, because unlike a CT scan, (_____) (________) is not used to visualize vascular structures.
An MRI is an excellent way to view a fetus, because unlike a CT scan, (ionizing) (radiation) is not used to visualize vascular structures.
In an MRI, you can evaluate fetal (_______) and overall (_____), the (_______), the (_______) of Amniotic fluid, Maternal; structures like the (_____) and (_____), and the biochemical status of tissues and organs.
In an MRI, you can evaluate fetal (structure) and overall (growth), the (placenta), the (quantity) of Amniotic fluid, Maternal structures like the (uterus) and (cervix), and the biochemical status of tissues and organs.
What fetal and maternal anomalies can be detected in an MRI?
Metabolic, soft-tissue, and functional
During an MRI, what position should a pregnant woman be put into?
Supine with one hip elevated
During an MRI, a fetus may move and obscure details. What is the only way to deal with this issue?
What should that method of resolution be reserved for?
Sedate the woman to resolve the issue
Only use a sedative is the visualization of fetus detail is critical
An MRI has what effect on the fetus?
Little to no effect on the fetus
Biochemical assessments involve Procedures used to obtain needed specimens. What are these 4 procedures? amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, and maternal sampling
-Amniocentesis
-Percutaneous Umbilical Blood Sampling
(PUBS)
-Chorionic Villus Sampling
(CVS)
-Maternal sampling
An implication of biochemical assessment is that, based on test results, woman may consider having what?
An induced Abortion
A Coombs test is a Biochemical assessment tool used for the testing of what?
A Coombs test checks for antibodies that attack your red blood cells; RH antibody test for mothers
When is an Amniocentesis performed and what is this test for?
An Amniocentesis is performed usually at or after 15 weeks’ gestation (NOT BEFORE) and is for collecting amniotic fluid for testing fetal cells.
How is an Amniocentesis conducted?
A needle is inserted abdominally into the uterus and amniotic fluid is absorbed into a syringe
What test is commonly used to check for fetal lung maturity?
An LBC test is commonly used to test for fetal lung maturity
When performed in the 1st trimester, a CVS is better known as a what?
A Placental biopsy
When can a Chorionic Villus Sampling (CVS) be performed?
between 10 and 13 weeks’ gestation
PUBS is also called what?
PUBS is also called Cordocentesis
What is the purpose of PUBS?
PUBS is used for fetal blood sampling and transfusions
PUBS has recently been replaced with the newer, faster, and easier method of collecting fetal blood samples by using what method?
A Placental biopsy, aka CVS
What is the procedure for a PUBS?
PUBS involves inserting a needle directly into the umbilical cord (under ultrasound guidance)
PUBS is most often used when fetal blood is needed in determining a (_______)
PUBS is most often used when fetal blood is needed in determining a (mutation)
What are the 2 most common complications of PUBS?
Bleeding from the umbilical cord puncture and fetal-maternal bleeding
What are 3 other things that a PUBS can test for in a fetus?
-Anemia
-Infection
-Thrombocytopenia
Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for (___)’s during pregnancy.
Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for (NTD)’s during pregnancy.
Through the use of Maternal serum alpha-fetoprotein’s (MSAFP) approximately (__)% to (__)% of open (___)’s and almost ALL cases of (___________) can be found early
Through the use of Maternal serum alpha-fetoprotein’s (MSAFP) approximately (85)% to (90)% of open (NTD)’s and almost ALL cases of (anencephaly) can be found early
MSAFP screening occurs during what gestational weeks?
15-20 weeks, with 16-18 being best
What should be done if there are elevated AFP levels?
Ultrasound
Screening to detect fetal chromosomal abnormalities like down syndrome occurs during what trimester and gestational age?
1st trimester, 11-14 weeks gestation
The 1st trimester screening for chromosomal abnormalities (Down Syndrome) involves measuring what 3 biochemical markers?
PAPP-A (Pregnancy Associated Plasma Protein-A)
-HCG
-ADAM 12
cfDNA, aka cell-free DNA, is the newest screening test for Aneuploidy. What is Aneuploidy?
Aneuploidy is having one or more extra chromosomes in the 23 pairs each individual normally possesses
If women test positive in a cfDNA test, what tests are they referred to for further analysis?
An Amniocentesis or CVS to confirm the findings
Common aneuploids are (_______) 13, 18, and 21, each of which results in an extra (____________)
Common aneuploids are (trisomies) 13, 18, and 21, each of which results in an extra (chromosome)
The accuracy of a cfDNA test relies on the proportion of what?
What is the proportional value?
When is it best to perform this test?
Relies on the proportion of fetal DNA to mother DNA in the maternal plasma.
It needs to be at least 4% of the mothers plasma DNA to be accurate.
Best to test by 11 to 13 weeks, when the proportion is at 10% of the maternal DNA
Many Fetal Care Centers have a (____) who coordinates with the family to navigate appointments
Many Fetal Care Centers have a (nurse) who coordinates with the family to navigate appointments
Fetal Care Centers give access to support services such as (_______) counseling, social work, (_______) services, a palliative care team, and (_____) consultation because of the complex emotional stressors they face
Fetal Care Centers give access to support services such as (genetic) counseling, social work, (chaplain) services, a palliative care team, and (ethics) consultation because of the complex emotional stressors they face
The goal of third trimester testing is to determine what?
Whether the intrauterine environment continues to support the fetus
What is the most widely applied technique for antepartum evaluation of the fetus?
The Nonstress test
What medications and chronic condition can adversely affect the NST?
Meds: Opioids and Propranolol
Chronic condition: Smoking
What is the basis for the NST?
The fetus produces normal FHR (Fetal Heart Rate) patterns in response to fetal movement, uterine contractions, or stimulation.
Most fetuses who do not produce results from a NST are NOT compromised, they usually are just what?
In a quiet sleep state
What is one way a physician may try to stimulate the fetus during an NST?
Having the mother drink orange juice to spike her blood sugar
During a NST, what tools are used to monitor the fetus?
-A Doppler transductor monitors the FHR
-A Toco detects uterine contractions and fetal movements
If 40 minutes have passed over the course of a NST, and there is still no reactive fetal activity, what should be done?
A CST or a BPP test should be performed
If normal methods during a NST don’t work, what is an adjunct test used to stimulate the fetus during an NST?
A VAS test
Vibroacoustic stimulation (VAS), also called FAST (Fetal Acoustic Stimulation Test) is another method of testing for the what?
VAS/FAST tests for the FHR
What does a VAS test do to stimulate the fetus?
A VAS test uses a combo of sound and vibrations to stimulate the fetus.
How long is a fetus monitored for a baseline before a VAS test is given?
10 to 20 minutes to establish a baseline
CST stands for what?
Contraction Stress Test
CST is an (_______) procedure if (_____) stimulation is required and more (____) consuming than an NST.
CST is an (invasive) procedure if (oxytocin) stimulation is required and more (time) consuming than an NST.
The two methods of CST are the (______)-stimulated contraction test, and the more commonly used (_______)-stimulated contraction test
The two methods of CST are the (nipple)-stimulated contraction test, and the more commonly used (oxytocin)-stimulated contraction test
What does the labeling of “high-risk” pregnancy to a woman’s psyche?
It can lead to an increase in a patient’s sense of vulnerability
Labeling a pregnancy as “high-risk” can bring about several psychological conditions upon a mother, such as?
-Anxiety
-Low self-esteem
-Guilt
-Frustration
-Inability to function
In many settings, a nurse must perform what 3 pregnancy assessment tests?
-Nonstress Tests (NST’s)
-Contraction Stress Tests (CST’s)
-Biophysical Profiles (BPP’s)
Receiving a negative CST suggests what?
Fetal well-being
