Complicated Pregnancies Part 2 Flashcards
What is chronic hypertension?
BP 140/90 or high
PRIOR to pregnancy or before 20th week of gestation
What is gestational hypertension?
BP 140/90 or higher
AFTER 20 weeks, no proteinuria (40% will progress to pre eclampsia)
What is the early problem of preeclampsia? (How does it start?)
Defect of trophoblastic invasion due to exaggerated maternal immune response = small placenta, more fibrous blood vessels, intermittent blood flow to placenta
What is the later problems of preeclampsia?
Growing fetus places demand on placenta as a struggles with an adequate blood flow= hypoxia
Hypoxia triggers and immune response
Immune response leads to the generalized inflammation and endothelial vasospasms and capillary injury
Science and symptoms of pre-eclampsia begin
When do we give low dose aspirin
Should be initiated between 12 weeks and 28 weeks of gestation and continued daily until delivery
What type of patient would get ASA regarding prevention of preeclampsia?
History of preeclampsia
Renal disease
Auto immune disease
Type I or type II diabetes
Chronic hypertension
First pregnancy
Maternal age of 35 years or older
BMI > 30
What are some maternal complications of preeclampsia?
Seriously impacts cardiovascular system, kidneys, liver, lungs, placenta function
What are fetal complications of preeclampsia?
Small for gestational age (SGA)
Fetal hypoxia
Fetal death related to placenta abruption
Prematurity related to pre term labour
Define mild preeclampsia
BP> 140/90 on at least 2 occasions 6 hours apart
Proteinuria 1+ to 2+
What are worsening signs of preeclampsia?
Increase in generalized edema and/or NV
Worsening HA and/or blurred vision
Epigastric/shoulder or RUQ pain
Decreased UO
Hyperreflexia
Disorientation/confusion
How to diagnose severe preeclampsia?
BP> 160/110 on two occasions at least 6 hours apart while the woman is on bedrest
PLUS
Proteinuria > 5g/L in 24 hours: Two 3+ urine dip stick readings at least 4 hours apart
PLUS
one or more of the following:
Headache or visual disturbance
Pulmonary edema, or cyanosis
Epigastric or RUQ pain
Elevated liver enzymes (ALT,AST)
Elevated creatine
Thrombocytopenia (<100,000)
What does HELLP syndrome stand for?
H- Hemolysis (decreased H&h)
EL- Elevated Liver enzymes
LP- Low Platelets (thrombocytopenia)
What is HELLP syndrome?
A complication of severe preeclampsia
How do you care for severe preeclampsia
Bed rest, reduce stimuli
Magnesium sulfate IV for seizures prophylaxis
Bethamethasone IM <34 weeks for fetal lung maturity
Deliver at 34 weeks or sooner for maternal or fetal indications
What is the “cure” for preeclampsia
Delivery! Induction of labour at 37 weeks if mild, sooner if severe
C section
Magnesium sulfate for seizure prevention for severe PIH
What is eclampsia
Woman has a seizure
What does PROM stand for?
Premature rupture of membranes
What is PROM
Spontaneous rupture of membranes at/after 37 weeks, but prior to labor
What is pre term PROM
PPROM is PROM less than 37 weeks
What is maternal risk and fetal risk of PROM
Maternal — infection
Fetal — complications of prematurity and neonatal infection
How to tell if patient is ruptured?
Fluid check with nitrazine paper
Sterile speculum exam for pooling and collection of swabs for
-fern test
Ultrasound
What is the amnisure test?
99% accurate in diagnosing ruptured membranes
Detects a protein present in amniotic fluid
Takes 2-10 mins
What is fetal fibronectin (fFN)
This sticky glue (glycoprotein) where the maternal and fetal areas touch.
If we see it then it’s a direct biochemical predictor for preterm birth
Why is fetal fibronectin an excellent negative predictor of pre term labour?
Negative results mean a 96% chance of NOT delivering in the next two weeks.
What does it mean when the fetal fibronectin test is positive?
That doesn’t mean she’s going to deliver right away.
Only 30-40% will deliver within the next 2 weeks
Define enfacement?
The gradual thinning, shortening and drawing up of the cervix measured in percentages from 0 to 100%
How do you diagnose PTL?
Contractions every 5 minutes for 20 mins… or.. 8 contractions in 60 mins
AND
Documented cervical change like 80% effaced… or… cervical dilation > 1 cm
How do you manage PTL
Goal: stop or slow labour
Bed rest/hydration
Betamethasone
Tocolytics
-mag sulfate for fetal neuro
protection for 2 days
-procardia after the 2 days
What is hyperemesis
Excessive vomiting during pregnancy, in which NV are so severe, that they affect maternal hydration and nutritional status
How do you diagnose hyperemesis?
Unmanageable vomiting in the first half of pregnancy
Dehydration
Ketonuria
Weight loss of 5% pre-pregnancy weight
How do you manage hyperemesis?
Control vomiting
Correct dehydration
Restore electrolyte balance
Nutrition maintenance
Small meals/ simple carbohydrates
What happens if mom is Rh - and fetus is Rh +
Some fetal Rh+ blood enter the mother’s blood
First time exposure causes development of maternal immunoglobulin M (IgM).
What happens the second time an Rh - mom has a fetus that is Rh+
Rapid production of maternal IgG which is small enough to cross the placenta
Fetus is attacked by these antibodies causing hemolysis of fetal RBC = fetal anemia
What is erythroblastosis fetalis
Presence of nucleated RBCs related to fetal response to the anemia
What is the biophysical profile?
Represents an assessment of five fetal bio physical variables:
Fetal breathing
Fetal movements
Fetal tone
Amniotic fluid volume
Reactive FHR
How do we test the biophysical profile?
Feel breathing, fetal movements, fetal tone, amniotic fluid volume are all determined by ultrasounds
Reactive fetal heart rate is assessed by the non stress test (NST) which is just an external fetal monitor
How is the biophysical profile scored?
Each normal finding is a score of 2
Each abnormal finding is scored 0
Total scores of 8-10 (with normal amniotic fluid) are considered normal
What is a poor scoring on the BPP?
A score of 6 is questionable.
A score of 4 indicates that delivery should be imminent
If amniotic fluid is 0 or BPP is 0 or 2, then delivery should be considered regardless of other points
What is a non stress test (NST)
The NST is the most common test performed, and consists of using an electronic fetal monitor to obtain a tracing of the fetal heart rate, and observing the accelerations of the FHR with movement
What does the acceleration of FHR indicate?
It indicates an intact central and autonomic nervous system that is not being affected by intrauterine hypoxia
Why do we perform an NST?
The primary goal of the test is to measure the heart rate of the fetus in response to its own movements
After 30-32 weeks the NST is a non invasive good indicator of current fetal well being, but it is not a good predictor of future outcomes
How can we tell if a reactive NST is good?
At least 2 FHR accelerations of at least 15 bpm above the baseline lasting at least 15 seconds within 20 mins
What is amniocentesis
Insertion of a needle through the maternal abdomen into the uterine cavity to obtain an amniotic fluid sample
What is the point of patient counseling regarding fetal testing?
Make sure the client understands why testing is needed
Risk to mother/fetus versus benefits of information
What type of information may be obtained? And what we will do with this info
