High Risk Pregnancy

Question 1

High Risk Pregnancy Risk Factors

Answer 1

Age, Race, Poverty, Marital Status
Drug Use, Alcohol, Smoking
High BP, Overweight, Infection, Nutrition

Question 2

Non Stress Test

Answer 2

NST
On a monitor, mother pushes a button when the baby moves- the heart rate should increase
Reactive = a positive result
Non- Reactive = a negative result

Question 3

Contraction Stress Test

Answer 3

CST
Start Pitocin- look at HR response to contractions
Negative = no late or significant variable decels
Positive = Late decals with >50% of contractions
Equivocal = Suspicious, intermittent late decals or significant variable decels

Question 4

Biophysical Profile

Answer 4

BPP
0 = present, 2 = not present
1. NST
2. Fetal breathing movements on ultrasound
3. Fetal Movement
4. Fetal Tone
5. Amniotic fluid index- looking for pockets

Question 5

BPP Scoring

Answer 5

8-10 = Normal
6 = Equivocal
< 4 = DELIVER NOW

Question 6

Hypertensive Disorders

Answer 6

Gestational HTN - High BP - NO Protein
Pre-eclampsia - High BP - + Protein
Eclampsia - Seizures
Chronic HTN - High BP pre-pregnancy

Question 7

Maternal HTN Complications

Answer 7

Placental abruption, ARDS, Stroke, Cerebral Hemorrhage, Hepatic or Renal Failure, DIC, Pulmonary Edema
Cerebral edema- swelling in the eyes
Edema- Strict I/O’s

Question 8

Fetal HTN Complication

Answer 8

Related to placental insufficiency

IUGR, Prematurity, Hypoxia

Question 9

Mild Pre-eclampsia

Answer 9

BP > 140/90
>1+ Proteinuria
>300 mg Protein in 24hr urine
Output = Input

Question 10

Severe Pre-eclampsia

Answer 10

BP > 160/110
>3+ Proteinuria
Output <400-500 ml in 24hr urine

Question 11

Pre-eclampsia Risk Factors

Answer 11

First pregnancy or new partner
< 19 or > 40
Obesity 
History
Multifetal pregnancy or mole
Poor outcome in previous pregnancy 

Don’t know the exact cause

Question 12

HELLP Syndrome

Answer 12

Severe pre-eclampsia involving liver dysfunction

H: Hemolysis
EL: Elevated liver enzymes
LP: Low platelet count

Question 13

Diagnosis of HELLP

Answer 13

Increased risk of adverse outcomes including:

Pulmonary edema, acute renal failure, DIC, liver hemorrhage or failure, ARDS, sepsis or stroke

Question 14

Assessment of Pre-eclampsia

Answer 14

BP
Edema
DTR’s and clonus

Question 15

Severe Pre- eclampsia Treatment

Answer 15

Dark quiet room
Seizure precautions: bedrest and side rails up, emergency drugs, O2, and suction
Magnesium Sulfate
Limit intake - 125 ml/hr

Question 16

Magnesium Sulfate

Answer 16

2-4 gram bolus over 20 minutes
FEEL AWFUL- N/V, HA, red
DO NOT leave your patient!
Calms CNS- reflexes are minimal if taken for a long time

Question 17

Magnesium Sulfate Toxicity

Answer 17

Order blood levels
4-7 = Therapeutic
8 or 9 + = STOP NOW!!
TOO much = breathing stops, pp hemorrhage
Calcium glucanate or calcium chloride reverse this!

Question 18

Miscarriage Causes

Answer 18

10-15% of all pregnancies, mostly before 12 weeks

Chromosomal abnormalities, endocrine imbalances, hypothyroidism, varicella, parvovirus, IDDM with high glucose levels, immunologic factors, systemic disorders, genetic.

Question 19

Ectopic Pregnancy

Answer 19

9% of all maternal deaths

Fertilized ovum implanted outside the uterine cavity

Question 20

Ectopic Pregnancy Classic Symptoms

Answer 20

Abdominal pain
Delayed menses- when was their last one??
Abnormal vaginal bleeding
Rupture!! Referred shoulder pain
Signs of shock: fainting, dizziness, not necessarily vaginal bleeding
HIGH SUSPICION

Question 21

Ectopic Pregnancy Treatment

Answer 21

Methotrexate- safe, effective, low cost

Surgery- Salpingotomy if not ruptured, Salpingectomy if ruptured

Question 22

Hydatiform Mole

Answer 22

Benign proliferation growth of the placental trophoblast
No viable fetus
Contraception for up to a year
High risk for cancer and another molar pregnancy
Treatment: Remove with D&C

Question 23

Placenta Previa

Answer 23

Completely or partially covering the cervix or enough to the cervix to cause bleeding with dilation
1 in 200

Question 24

Placenta Previa Risk Factors

Answer 24

Previous c section with a scar
>35 years old
Multipartiy
History of curettage
Smoking

Question 25

Placenta Previa Symptoms

Answer 25

PAINLESS bright red bleeding- 2nd and 3rd trimester Non-tender uterus with normal tone Fetal mal-presentation Hemorrhage- complication Preterm birth, stillbirth, fetal anemia, IUGR

Question 26

Placenta Previa Treatment

Answer 26

At or beyond 36 weeks - c section More than 2cm from cervical os, asymptomatic = labor safely PP HEMORRHAGE CAN OCCUR

Question 27

Placental Abruption

Answer 27

Detachment of all or part of a normally implanted placenta before the baby is born 1 in 75- 1 in 226

Question 28

Placental Abruption Risk Factors

Answer 28

Smoking HTN Drug Use

Question 29

Placental Abruption Symptoms

Answer 29

Dark red blood 70-80%, 10-20% hidden Abdominal pain- intense Board like placenta More likely twins

Question 30

Placental Abruption Complications

Answer 30

Can lead to DIC! Low platelets, prolonged PT and PTT, d-dimer test. More then 50% abruption- fetal death likely IUGR, Preterm birth, SIDS, CP, Neuro decifits

Question 31

Placental Abruption Management

Answer 31

< 34 weeks and stable mother and fetus- monitor closely, assessments of fetal well being, corticosteriods to accelerate lung development *Will try to keep the baby in-utero as long as possible Term gestation or moderate bleeding- IMMEDIATE DELIVERY Large bore IV, labs, VS, catheter, vaginal birth preferred

Question 32

Diabetes Mellitus

Answer 32

Most common endocrine disorder with pregnancy 4-14% of pregnant women High risk pregnancy Can be managed!

Question 33

Diabetes Mellitus Classifications

Answer 33

Type 1- lack of insulin Type 2- insuline resistance Gestational Diabetes- any degree of glucose intolerance with onset of pregnancy

Question 34

Fetal Risks with DM

Answer 34

``` Death Congenital malformations Hyperglycemia 1st trimester Severe hypoglycemic 1/2 hr after birth Big baby- macrosomia Brachial plexus palsy, facial nerve injury, humerus or clavicle fracture, cephalahematoma ```

Question 35

Fetal Movement Counts

Answer 35

Counts begin at 28 weeks- 10 movements within 24 hours, 2 accelerations in 20 minutes Acceleration is up 15beats in 15 sec NST, CST, BPP around 34 weeks

Question 36

Intrapartum Diabetes

Answer 36

Hourly blood sugars D5W IV Fluid Maintain at 140 or less

Question 37

Postpartum Diabetes

Answer 37

Rapidly decreases after birth | May only require 1/3 to 1/2 as much insulin

Question 38

Gestational Diabetes Risk Factors

Answer 38

``` > 25 yrs Previous infant Previous IUFD, GDM Strong family history of GDM or Type 2 Obesity Fasting blood glucose > 140 ```

Question 39

Gestational Diabetes

Answer 39

``` Test at 26 weeks Insulin demands as much as 3-4 times No increase risk in birth defects Controlled with diet and exercise Up to 20% need insulin, return to normal after birth Higher risk for GDM in future AND Type 2 Children born are at risk for obesity ```

Question 40

Anemia

Answer 40

Iron deficiency is most common Fetus receives enough- but takes from mom Easily treated with iron supplements- hard to adhere to Supplement side effects: constipated, dark stool, nausea

Question 41

Asthma

Answer 41

4-8% of pregnant women have asthma 1/3 improve, 1/3 stay the same, 1/3 get worse Associated with placental insufficiency, IUGR, preterm birth

Question 42

Asthma Treatments

Answer 42

``` Maintain O2 Prevent Hypoxic episodes Avoid triggers and inhaled steroids Epidural are recommended Avoid morphine ```

Question 43

UTI's

Answer 43

``` Most common complication Screen women! Associated with preterm birth and LBW Follow up is important! Safe antibiotics- take more often, harder adherence ```

Question 44

TORCH

Answer 44

``` Toxoplasmosis- cat liter Other- Hep a & b Rubella- blindness Cytomegalovirus- herpes family Herpes- Type 1 or 2, outbreak can transmit to a baby` ```

Question 45

Surgery during Pregnancy

Answer 45

Monitor the fetus!!

Question 46

Trauma during Pregnancy

Answer 46

MVA, falls, blunt trauma, abuse Observe for at least 4 to 6 hours MAKE SURE HEART RATE IS OKAY!