Class 3: Complicated Pregnancy Flashcards
when can pregnancy complications occur? who can they impact?
- any time throughout pregnancy
- can be a concern for the fetus, pregnant person, or both
what is important to prevent complications in pregnancy
- identification of risks, with appropriate and timely interventions
decisions about management of pregnancy complications involve…
- a balance between gains in fetal maturity and maternal/fetal consequences of continuing w the pregnancy
what are some major causes of maternal death (6)
- infection
- hemorrhage
- hypertensive disorders
- complications from the birth
- unsafe abortion
- pulmonary and amniotic embolism
what factors are strongly related to maternal death (3)
- age (<20, >35)
- lack of prenatal care
- low education level
what are leading causes of newborn morbidity and mortality (2)
- preterm
- multiple birth rates
what are other causes of newborn death (4)
- low birth weight
- resp distress syndrome
- sudden infant death
- effects of maternal complications
infant death rate is high if mother is…
- of lower socioeconomic status
what are the metabolic functions of the placenta (4)
- respiration (diffusion of O2 and CO2) = fetal gas exchange
- nutrition
- excretion
- storage
placental function is dependent on… what does this mean?
- maternal blood pressure supplying circulation
- therefore, interference with circulation to the placenta = placenta cannot supply the fetus
what cause interference w circulation to the placenta? (4)
- vasoconstriction/vasospasm
- hyperstimulation of the uterus (contractions)
- decreased maternal blood pressure
- decreased cardiac output
what can cause vasoconstriction/vasospasm, and therefore interfere w circulation to the placenta? (3)
- HTN
- cocaine use
- diabetes
what can cause decreased maternal blood pressure? (2)
- maternal compression of the vena cava = supine hypotension
- hypotensive episode – epidural admin
what can cause decreases cardiac output (2)
- infection
- antepartum hemorrhage
decreased circulation to the uterus/placenta may lead to what 2 categories of outcomes?
- fetal outcomes
- neonatal outcomes
what fetal outcomes might decreased circulation to the uterus/placenta lead to? (4)
- intrauterine growth reduction (IUGR)
- fetal hypoxia
- metabolic acidosis
- still birth (fetal death)
what neonatal outcomes might decreased circulation to the uterus/placenta lead to? (5)
- small for gestational age/low birth weight
- metabolic acidosis
- seizures (d/t low oxygen)
- cerebral palsy
- neonatal mortality
describe the connection between placental function and gestational age
- placental function decreases as the placenta ages (postdates concerns)
what is the purpose of antepartum testing
- detection of fetal compromise, primarily in the 3rd trimester
why/when is beta hCG assessed in antepartum testing (3)
- routine prenatal care
- confirmation of pregnancy
- vaginal bleeding <20 weeks
why is CBC assessed with antepartum testing (6)
- routine prenatal care
- present to triage w complains of fatigue/feeling unwell
- signs/symptoms of infection
- prenatal bleeding
- history of anemia
- HTN disorders of pregnancy (decreased plts associated w adverse maternal outcomes, RBC, HELLP)
When (1) and why (3) is amniocentesis done as an assessment in antepartum testing
- diagnostic test (performed after 14 weeks gestation)
- to diagnose fetal chromosomal abnormalities
- determining fetal lung maturity
- fetal hemolytic disease
why might liver function tests (AST, ALT) and renal function (serum creatinine and uric acid) be completed in antepartum testing?
- HTN disorders of pregnancy (increase associated w adverse maternal outcome)
why might INR/aPTT be assessed in antepartum testing
- HTN disorders of pregnancy –> can be increased when DIC is present
why might blood type, Rh, and antibody screen be assessed in antepartum testing (4)
- routine prenatal care
- present w vaginal bleeding, abdominal trauma, S&S of placental abruption
- severe anemia
- previous history of PPH
why might a UA be assessed in antepartum testing? (5)
- routine prenatal care –> 1st prenatal visit and prn (screen for asymptomatic bacteruria)
- HTN disorders of pregnancy (proteinuria)
- diabetes
- suspicious of infection
- hyperemesis gravidarium
When (1) and why (1) might MSU and C&S be assessed in antepartum testing
- routine prenatal care
- suspicion of infection
why might a US be used in antepartum testing? (10)
- routine prenatal care 2nd trimester (placental placement, fetal anatomy, fetal growth, gestational age, # of fetuses)
- confirm viability
- prenatal bleeding (detect placenta previa or placental abruption)
- decreased fetal movement (assessment fetal wellbeing, BPP)
- assess fetal size (macrosomia, IUGR)
- determine fetal position (breech, cephalic)
- assess amniotic fluid volume
- doppler flow studies
- detect placental maturity
why might OGTT 50gm test be done in antepartum testing (2)
- routine prenatal care to screen for GDM
- can be performed at any time prior to 24 weeks in pregnancy if risk for GDM
when might GBS vaginal/perianal swab be done in antepartum testing (2)
- routine prenatal care, normally around 35-37 weeks gestation
- if pt presents w suspicion of labour/rupture of membranes and swab not yet completed (i.e if less than <35 weeks)
why is gestational age from 1st day of late menstrual period (LMP) / EDD by assessed in antepartum testing?
- at each prenatal encounter to determine gestational age at presentation
when is obstetrical history & GTPAL assessed w antepartum testing (2)
- at initial prenatal visit
- reviewed at each prenatal encounter
why (2) and when (2) is social history assessed w antepartum testing
- at initial prenatal visit
- screened at each prenatal encounter
- IPV – placental abruption?
- substance use (i.e cocaine) – placental abrutpion?
what is included in HTN disorders of pregnancy focused assessment? (5)
- headache
- visual disturbances (seeing stars, blurriness)
- RUQ/epigastric pain
- deep tendon reflexes
- clonus
why is a speculum exam completed w antepartum testing (2)
- c/o vaginal discharhe/ordour –> rupture of membranes? infection (chorioamnioitis)?
- vaginal bleeding –> placental previa? placental abruption?
why is a pelvic exam done with antepartum testing (3)
- labour?
- assess labour progress
- cervical assessment for induction of labour
When (1) and why (2) are VS and pain assessment done w antepartum testing
- routinely at all prenatal and pregnancy encounters, throughout labour and postpartum
- blood pressure to screen for HTN disorders, for targets and effectiveness of antiHTN drugs
- temp to screen for infection
When and why is fundal height assessed w antepartum testing? (2)
- routine prenatal care –> indicates fetal growth, should correlate w gestational age (at 18 week onward)
- fundal height outside expected parameters can indicate anomalies (ex. multifetal gestation, IUGR, oligo or polyhydramnios)
why is a nitrazine test/Ferning test done with antepartum testing?
- confirmation/rule out rupture of membranes
when (2) is FHR assessed w antepartum testing? Why is FHR important to assess?
- routinely at all prenatal and triage visits
- intrapartum care
- normal rate and rhythm are an indication of fetal wellbeing
when (3) is fetal movement assessed w antepartum testing? Why is it important?
- routine prenatal care
- all pregnant people should be aware of their regular daily fetal movements from week 26 onward
- daily “kick count” advised for pregnancies w additional risk factors, performed daily starting at 26 weeks
- indicates fetal wellbeing
Nonstress testing (NST) is considered in pregnant persons w risk factors for adverse perinatal outcomes: (6)
- decreased fetal movements
- HTN disorders of pregnancy
- diabetes
- previous history of stillbirth
- prenatal bleeding
- postdates
a biophysical profile (BPP) is recommended in pregnant persons with risk factors for adverse potential outcomes, where expertise exists: (6)
- decreased fetal movement
- HTN disorders of pregnancy
- diabetes
- previous hisotry of stillbirth
- prenatal bleeding
- postdates
umbilical artery doppler (doppler flow analysis) is indicated for assessment of the fetal placental circulation in pregnant persons when placental insufficiency is suspected. such as: (4)
- postdates
- HTN disorders of pregnancy
- decreased fetal mvmt
- IUGR
what are some common maternal and fetal indications for antepartum testing (11)
- diabetes
- HTN disorders of pregnancy
- renal disease
- cholestasis of pregnancy, class 2
- multiple gestation
- oligohydramnios
- preterm premature rupture of membranes
- post date or post-term gestation
- previous stillbirth
- fetal growth restriction (IUGR)
- decreased fetal movement
what impact can diabetes have on the amt of amniotic fluid? size of fetus?
- polyhydramnios
- intrauterine growth restriction ( maternal)
what impact do HTN disorders of pregnancy have on amt of amniotic fluid? fetal growth?
- oligohydramnios
- intrauterine growth restriction (maternal)
HTN disorders of pregnancy are risk factors for (2)
- oligohydramnios
- intrauterine growth restriction (maternal)
what impact do renal diseases have on fetal growth
- intrauterine growth restriction (maternal)
what impact does post-term gestation have on amt of amniotic fluid
- oligohydramnios
what impact might IUGR have on amt of amniotic fluid
- oligohydramnios
what is the goal of 3rd trimester testing for fetal wellbeing? (2)
- determine if the intrauterine enviro is supportive to fetus
- supports the determination of the timing of childbirth especially for those at risk for uteroplacental insufficiency
what are risks for uteroplacental insuff? (3)
- HTN disorders of pregnancy
- postdates
- diabetes
decreased placental function results in.. (2)
- inadequate nutrient delivery to the fetus –> IUGR
- compromised resp function –> fetal hypoxia
what is included in 3rd trimester assessment (4)
- fetal movement counting (kick counts)
- antepartum assessment using electronic fetal monitoring
- biophysical profile (BPP)
- doppler blood flow analysis
what are examples of antepartum assessments using electrical fetal monitoring (3)
- nonstress test (NST)
- contraction stress test (CST)
- fetal responses to hypoxia and asphyxia (variability)
what is a NST? why is it used?
- assesses fetal movement associated w FHR accelerations
- reasoning: the normal fetus produces characteristic FHR patterns in response to movement –> in a health fetus w intact CNS = gross fetal body movements = FHR accelerations
describe the evidence r/t NST
- poor evidence that its use decreases perinatal morbidity and mortality
describe the procedure for NST (4)
- empty bladder
- seated or semi-fowlers position w slight left tilt
- 20 min
- assess FHR/uterine activity/fetal movements
in NST, assess FHR for: (4)
- baseline –> 110-160 beats/min
- variability –> 6-25 beats/min, <5bpm for <40 min
- decelerations –> none or occassional variable (<30 sec)
- accelerations –> 2 accelerations w acme of >15 bpm, lasting 15 sec < 40 min of testing (>40 min = concern)
what should be done if the NST test is normal and there are no risk factors?
- daily fetal movement counting
what should be done if the NST is normal and there are risk factors or suspicion of IUGR or oligohydramnios? (2)
- US for either biophysical profile or amniotic fluid volume assessment within 24 hrs
- AND daily fetal movement counting
what should be done if the NST is atypical/abnormal
- further testing –> ex. biophysical profile, amniotic fluid vol
what is a CST
- evaluates the response of the fetus to induced contractions and designed to identify poor placental function
what are 2 ways a CST is performed
- nipple-stimulated contraction test
- oxytocin-stimulated contracxtion test
what does a positive CSt result mean
- signs of decreased placental fnxn
what risks are associated w CST (2)
- hyperstimulation
- labour/birth
d/t the risks associated w CST, when should a CST test never be done
- if we aren’t okay with them potentially going to birth
what is a desirable result with CST
- 3 contractions, lasting 1 min each, within a 10 min period
what does a BPP measure (4)
test completed by fetal assessment team that is performed over 30 min using ultrasound to measure:
- fetal breathing movements
- fetal movements
- fetal tone
- amniotic fluid volume (AFV)
what impact does low placental perfusion have on AFV
- low placental perfusion = low AFV
what should the fetal tone of the fetus be?
- well flexed, not flaccid
describe the scoring of BPP
each component provides a score of
- 0 = absent
- 2 = present
- scored out of 8, or out of 10 if NST included
the presence of normal fetal biophysical activities indicate:
- that the CNS is functional
what is an amniotic fluid index (AMI)? what is considered normal?
- an estimate of the amniotic fluid volume in a pregnant uterus
- normal = 10-25 cm
what is polyhydramnios?
- condition characterized by excessive accumulation of amniotic fluid in the uterus during pregnancy
what indicates polyhydramnios? (3)
- AFI > 25 cm
- US: single deepest pocket >8 cm
- fundal height will be large for dates
what potential fetal complication can polyhydramnios lead to?
- umbilical cord prolapse with rupture of membranes = UC between head and cervix = compression of cord = impaired gas exchange = emergency
what potential maternal complications can polyhydramnios lead to?
- increased pressure of the uterus = dyspnea and edema of lower extremities
what is oligohydramnios
- a medical condition in pregnancy characterized by a deficiency of amniotic fluid
what indicates oligohydramnios? (4)
- AFI < 5cm
- US: single deepest pocket <2 cm
- fundal height may be small for dates
- may see prominent fetal parts
what can cause oligohydramnios (2)
- uteroplacental insufficiency (ex. preeclampsia)
- renal
oligohydramnios should query/need to rule out…
- rupture of membranes
what potential fetal complications can oligohydramnios lead to? (5)
- cord compression (no cushion to protect from)
- fetal anomalies
- IUGR
- adverse fetal outcomes/distress in labour
- underdevelopment of the fetal lungs
what does doppler blood flow analysis show
- systolic/diastolic flow ratios and resistance to estimate blood flow in various arteries
umbilical artery doppler is indicated when?? What are 3 examples of when placental insufficiency is suspected?
- to assess placental circulation when placental insufficiency is suspected (not routine)
ex. with preeclampsia, post dates, suspected IUGR
Reduced, absent, or reservsed umbilical artery end-diastolic flow is an indication for? (2)
- enhanced fetal surveillance or delivery
- delivery may be delayed in order to gain fetal maturity and admin glucocorticoids to the pregnant person to improve fetal lung maturity
what is included in management of pregnancy complications and assessments (2)
- birth may be indicated
- continued fetal/maternal monitoring
what is included in continued fetal/maternal monitoring (2)? where could it take place?
- fetal movement counts
- could include regular NST, BPP assessments
- location: at home (antenatal homecare program), admission to hospital antepartum unit)
