High Risk Pregnancies Flashcards
Maternal condtions that signal a high risk pregnancy
Chronic HTN
Diabetes Mellitus
Obesity
Autoimmune conditions
Prior poor pregnancy outcomes
Preeclampsia/eclampsia
Post term pregnancy
RBC antigen sensitization
Renal disease
Seizure disorders
Vascular disease
Intrahepatic cholestasis Of pregnancy
Uterine malformations
Fetal conditions that signal a high risk pregnancy
Chromosome anomalies
Twin or greater pregnancies
Placenta previa, accreta and abruption
Antenatal testing and fetal surveillance
Purpose is to identify pregnancies at risk of hypoxic injury or death and to intervene before it gets to this point
This includes
- fetal kick counts (10 movements in 1 hr period 2x a day = golden zone)
- non stress test
- contraction stress test
- biophysical profile
- umbilical artery Doppler ultrasound
- estimation of fetal weight
- amniotic fetal assessment
Oligohydramnios
AFI (amniotic fluid index) < 5 cm and ADP <2cm
- all result in less than expected amnotic fluid
Rupture of membranes, placenta insufficiency, renal abnormalities are all possible etiologies
Treatment = amino infusion and treat underlying cause if determined
causes IUGR and potter sequence if not fixed (pulmonary hypoplasia, wrinkling of the skin, bilateral renal agenesis and PURs bilaterally, limb abnormalities)**
Polyhydramnios
AFI > 24 cm or SDP > 8cm
Causes are diabetes (most common), upper right GI abnormalities that impede swallowing or passing of fluid
- can be idiopathic
- rare but check for hemolysis of a newborn and TTTS*
Treatment = amino reduction to drain excess fluid and treat underlying cause
Non stress test
Measures the fetal heart rate patterns to determine overall health of the fetus
- measure all variables below and determines the “normals” of each variable
Observe
- baseline (normal = 110-160 bpm)
- variability (6-25 bpm from baseline is normal)
- accelerations ( 10 x 10 <32 weeks and 15 x 15 >32 weeks are normal benchmarks)
- decelerations
- (early (occurs at time of contractions) are associated with head compression and are good ,
- (variable (occurs at and not with time of contractions) are usually cord compression and can be pathological
- (late, are always delayed with timing of the contraction) are usually placental insufficiency and hypoxemia and is pathological and needs action)
- contractions
Contraction stress test
Similar to non stress except now adds oxytocin or nipple stimulation until 3 contractions occur in 10 minutes
Positive (abnormal) = late decelerations following > 50% of contractions
Negative (normal) = no late decelerations or varibale decelerations
Equivocal suspicious = intermittent late decelerations or significant variable decelerations
Equivocal tachysystolic = decelerations with contractions occurring more frequently every 2 minutes or lasting longer than 90 seconds
Unsatisfactory = fewer than 3 contractions in 10 minutes
Biophysical profile
Ultrasound of fetal well being assessment
10 points that include (each component is 2 points)
- non stress test (can be omitted)
- fetal movement
- fetal tone
- amniotic fluid assessment
- fetal breathing movements
if 10/10 or 8/8 = normal and risk of asphyxia in 1 week is near none
6/10 or 4/8 = equivocal and need to repeat in 24 hrs
- must have normal fluid level (if anhydramnios is present = -2 puts)
6/10-8/10 (4/8 or 6/8) = abnormal and risk of asphyxia in 1 week is 89/1000 births
(0-2-4)/10 = abnormal and risk of asphyxia in 1 week is 600/1000 (60%)
Umbilical artery Doppler ultrasound
Non invasive assessment of circulation and investigation of fetal hemodynamics
Most useful to assess pregnancies complicated by fetal growth restriction
Doppler waveforms need to be measured for
- presence
- direction
- profile
- volume
- impedance
Absent or reversed end diastolic flow velocity = placental insufficiency
Chronic HTN in pregnancy
Preexisting or HTN diagnosed before 20 weeks gestation
Management goals = get maternal BP < 150/100
- use BBs and CBB as needed as they are acceptable at this point (Labatalol and nifedipine as needed)
Preeclampsia
Mild:
- BP > 140/90 but < 160/110
- Proteinuria is < 300
- Patient is asymptomatic
- normal platlets and liver enzymes
Severe
- BP > 160/110
- proteinuria > 300
- patient is symptomatic
- thrombocytopenia or elevated liver enzymes ( if either of these two are present = automatic severe)
Management goals = monitor patient closely and try to maintain BP
- you will need to delivery early at 37-38 weeks for mild and severe = usually at diagnosis as long as they can
Also need to get labs for
- CBC, CMP and 24 hr urine protein every trimester
- 12 lead EKG
- multiple ultrasounds ever 4 weeks after 24 weeks
Magnesium sulfate OD in eclampsia
Loading dose should be 6-4 grams with 2 grams per hr ONLY for eclampsia
- prevents levels form getting above 5 mEq/Liter
5-10 mEq/L = EKG changes (prolonged PR and QT interval with widened QRS complexes)
10 mEq = areflexia
15 mEq/L = respiratory depression
> 25 = complete cardiovascular collapse
Pathophysiology assocaited with preeclampsia and eclampsia
Not 100% known but there are two potential thoughts
1) reduced placental perfusion possibly related to abnormal placental function.
- causes trophoblast invasion and inadequate remodeling of the uterine spinal arteries
2) maternal systemic manifestations with inflammatory metabolic and thrombotic responses which alter vascular function and result in multi-organ damage
Chronic maternal condtions that increases risk for preeclampsia and eclampsia
Chronic HTN
Diabetes mellitus (type 1 or 2)
Chronic kidney disease e
Auto-immune disease
Multiple gestation pregnancies
Chronic obesity
HELLP syndrome
Preeclampsia with hemolysis, elevated liver enzymes and low platelet counts
This immediately makes preeclampsia severe and requires immediate delivery once stable
Diagnosis of diabetes pregestationally
Any of the following lab values
- A1C > 6.5%
- fasting blood sugar > 126
- random blood sugar > 200
Complications of this include
- increased risk of miscarriage
- IUGR
- intrauterine fetal demise
- macrosomia > 4500gr
- malformations of NTDs congenital heart disease and the MSK system increases in risk 4-8x
Goal of treatment
- fasting glucose < 95
- 2 hr PP glucose < 120
- 1 hr PP glucose < 130/140
Type 1DM therapy for pregestational
Insulin therapy 1st line (split dose regimen NPH+ short acting)
Glucose needs to be monitored 4-5 times daily
Recommend caloric intake of 1800-2200 kcal/day divided into three meals and snacks
Frequent visits to OBGYN and evaluate for any infections and treat promptly if present
- if the patient is not responding to initial therapy = refer to endocrinology
always make sure to check kidneys, cardiac and ophthalmology exams since these three areas are hit the worst in diabetes
need to get lots of fetal echocardiogram to monitor heart defects as well as assess for NST 1x weekly and fetal growth every 3 weeks
Gestational diabetes
10% total and is diagnosed with
-1 hr GCT > 180 or 3 hr GTT > 130-140 or fasting > 95 (need two of these) in a previously non-diabetic patient who is pregnant (usually test at 24-28 weeks)
GDMA1 = gestational diabetes that is well controlled with lifestyle only modifications
- no increase in poor outcomes of birth
GDMA2 = needs medications and insulin to manage diabetes
- increased risk in poor outcomes of birth
- always use insulin first, then metformin and finally SU’s if needed
Complications in fetus (Usually NO cardiac anomalies (since the heart is finished development by now))
- macrosomia
- fetal asphyxia
- shoulder dystocia
- lacerations
Macrosomia
Weight is > 4500 grams in diabetics or > 5000 grams in non-diabetics
In diabetes, excess glucose is brought to the fetus from blood stream and results in hyper insulinemia. The glucose is stored as fat and causes macrosomia
- when the fetus is born = hypoglycemia can occur and cause issues
Risks of neonates born to mothers with diabetes are
- hyperviscosity
- hypocalcemia
- polycythemia
- respiratory distress
- hyperbilirubinemia
- hypoglycemia
GDM postpartum
Need to be screened 12 weeks out postpartum with a 2hr 75g OGTT test
- >80% will resolve after giving birth
however the chance of getting diabetes later in life = 33-50%
Autoimmune diseases in pregnancy
Most common are:
- SLE (usually worsen during pregnancy and often immediately post-partum as well. The presence of antiphosphlipid antibodies (weather from SLE or by itself) increases risks of perinatal mortality and fetal complications. Treatment for anti phospholipids = low dose ASA and heparin)
- RA (may present in pregnancy but if already present usually declines in severity)
- myasthenia gravis (20% chance of passing this on to fetus)
- ITP (worsens during pregnancy and have to monitor fetal platelets since this can be passed on as well)
- if fetal platlets are < 50,000 = likely to cause intracranial hemorrhages during brith**
**all are corticosteroids usually for treatment
Thyroid disease in pregnancy
Both extremes are associated with adverse outcomes
- also both can be passed on to **fetus
Universal screening is NOT recommended since it doesn’t change the outcomes**
Subclincial hyperthyroidism
- abnormally low TSH and normal free T4 levels
- as long as asymptomatic, does not need to be treated and is not associated with adverse pregnancy outcomes
Overt hyperthyroidism
- abnormally low TSH and high free T4 levels
- 95% chance this is Graves’ disease
- needs to be treated with PTU in 1st trimester/ whole pregnancy (can switch to methimazole in 2nd and 3rd trimester if needed)
- **goal is to get the serum free T4 in the upper 1/3 or normal range
Overt hypothyroidism
- abnormally high TSH and low free T4 levels
- 95% is hashimotos
- needs to be treated with levothyroxine titers (needs to check 8 weeks after any adjustment and every trimester even if the dosage is stable )
Subclincial hypothyroidism
- elevated TSH with normal free T4
- probably dont need to treat
Asthma in pregnancy
Goal = control asthma and prevent exacerbations
33% of asthmatics get better during pregnancy, don’t change and get worse (even split between the three)
Increases risk of
- perinatal mortality
- preeclampsia
- preterm brith
- low birth weight
need to monitor always and the preferred treatment = albuterol as the SABA and budesonide as the ICS choice
Types of asthma during pregnancy
Mild intermittent
- brief (<1hr) symptomatic exacerbations
- < 2 episodes a week and < 2 nocturnal symptoms a month
Mild persistent
- > 2 episodes a week and/or nocturnal symptoms > 2 months but is not daily exacerbations of <1 hr)
Moderate persistent
- daily exacerbations of < 1hr and nocturnal symptoms are present > 1 time a week
Severe persistent
- every thing is continuous and actually limit is daily living
- always need to give ICS if not already on
Urinary complications during pregnancy
Asymptomatic bacteriuria in 1st trimester is very common
- 10^5 colones (CFU)/ mL of urine
- this needs to be treated since it is associated with pyelonephritis, preterm birth and low birth weight!!
Cystitis, pyelonephritis and etc are all the same in pregnancy
need to test for specific organism
- almost always E. Coli, GBS or staph sap
Treatment options (non pyelonephritis):
- cephalexin (keflex)
- nitrofurantoin (macrobid)
Treatment options (pyelonephritis):
- aggressive IV hydration
- cephazolin (ancef) or ampicillin and gentamycin combo (if severe symptoms and grade is > 3)
- need to give prophylaxis for remainder of pregnancy since the risk of recurrence is super high
Vaginitis in pregnancy
3 main causes
1) Trichomoniasis
- pruritus, odor and dysuria
- treatment = metronidazole 2gram 1x P.O
- associated with PROM
2) bacterial vaginosis
- discharge + odor only
- treatment = metronidazole 500 mg P.O BID x 7days
- associated with chorioamnionits, endometritis
3) vaginal candidiasis
- discharge (white cheese like) and pruritis
- treatment = monistat OTC (topical miconazole)
Gonorrhea and chlamydia in pregnancy
Usually asymptomatic but gets postive for it in urine culture and NAAT
- if (+) for gonorrhea = treat both gonorrhea and chlamydia (may consider only gonorrhea treatment potentially)
- if (+) for chlamydia = treat for chlamydia ONLY
Treatments
- gonorrhea = ceftriaxone (rocephin) 250 mg IM x1
- chlamydia = azithromycin (Zithromax)1g PO x 1
Preterm and term definitions
Early preterm = 24 + 0 - 33 + 6
- 24 weeks is the earliest that it is physical possible for a fetus to exist outside the womb (still likely to die though but it is not impossible)
Late preterm = 34 + 0 - 36 + 6
Early term = 37 + 0 - 38 + 6
Full term = 39 + 0 - 40 + 6
Late term = 41 + 0 - 41 + 6
Post term > and equal to 42 +0
