High Risk Pregnancy Flashcards
High Risk Pregnancy Risk Factors
Age, Race, Poverty, Marital Status
Drug Use, Alcohol, Smoking
High BP, Overweight, Infection, Nutrition
Non Stress Test
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
Contraction Stress Test
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
Biophysical Profile
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
BPP Scoring
8-10 = Normal
6 = Equivocal
< 4 = DELIVER NOW
Hypertensive Disorders
Gestational HTN - High BP - NO Protein
Pre-eclampsia - High BP - + Protein
Eclampsia - Seizures
Chronic HTN - High BP pre-pregnancy
Maternal HTN Complications
Placental abruption, ARDS, Stroke, Cerebral Hemorrhage, Hepatic or Renal Failure, DIC, Pulmonary Edema
Cerebral edema- swelling in the eyes
Edema- Strict I/O’s
Fetal HTN Complication
Related to placental insufficiency
IUGR, Prematurity, Hypoxia
Mild Pre-eclampsia
BP > 140/90
>1+ Proteinuria
>300 mg Protein in 24hr urine
Output = Input
Severe Pre-eclampsia
BP > 160/110
>3+ Proteinuria
Output <400-500 ml in 24hr urine
Pre-eclampsia Risk Factors
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
HELLP Syndrome
Severe pre-eclampsia involving liver dysfunction
H: Hemolysis
EL: Elevated liver enzymes
LP: Low platelet count
Diagnosis of HELLP
Increased risk of adverse outcomes including:
Pulmonary edema, acute renal failure, DIC, liver hemorrhage or failure, ARDS, sepsis or stroke
Assessment of Pre-eclampsia
BP
Edema
DTR’s and clonus
Severe Pre- eclampsia Treatment
Dark quiet room
Seizure precautions: bedrest and side rails up, emergency drugs, O2, and suction
Magnesium Sulfate
Limit intake - 125 ml/hr
Magnesium Sulfate
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
Magnesium Sulfate Toxicity
Order blood levels
4-7 = Therapeutic
8 or 9 + = STOP NOW!!
TOO much = breathing stops, pp hemorrhage
Calcium glucanate or calcium chloride reverse this!
Miscarriage Causes
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.
Ectopic Pregnancy
9% of all maternal deaths
Fertilized ovum implanted outside the uterine cavity
Ectopic Pregnancy Classic Symptoms
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
Ectopic Pregnancy Treatment
Methotrexate- safe, effective, low cost
Surgery- Salpingotomy if not ruptured, Salpingectomy if ruptured
Hydatiform Mole
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
Placenta Previa
Completely or partially covering the cervix or enough to the cervix to cause bleeding with dilation
1 in 200
Placenta Previa Risk Factors
Previous c section with a scar >35 years old Multipartiy History of curettage Smoking
Placenta Previa Symptoms
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
Placenta Previa Treatment
At or beyond 36 weeks - c section
More than 2cm from cervical os, asymptomatic = labor safely
PP HEMORRHAGE CAN OCCUR
Placental Abruption
Detachment of all or part of a normally implanted placenta before the baby is born
1 in 75- 1 in 226
Placental Abruption Risk Factors
Smoking
HTN
Drug Use
Placental Abruption Symptoms
Dark red blood 70-80%, 10-20% hidden
Abdominal pain- intense
Board like placenta
More likely twins
Placental Abruption Complications
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
Placental Abruption Management
< 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
Diabetes Mellitus
Most common endocrine disorder with pregnancy
4-14% of pregnant women
High risk pregnancy
Can be managed!
Diabetes Mellitus Classifications
Type 1- lack of insulin
Type 2- insuline resistance
Gestational Diabetes- any degree of glucose intolerance with onset of pregnancy
Fetal Risks with DM
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
Fetal Movement Counts
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
Intrapartum Diabetes
Hourly blood sugars
D5W IV Fluid
Maintain at 140 or less
Postpartum Diabetes
Rapidly decreases after birth
May only require 1/3 to 1/2 as much insulin
Gestational Diabetes Risk Factors
> 25 yrs Previous infant Previous IUFD, GDM Strong family history of GDM or Type 2 Obesity Fasting blood glucose > 140
Gestational Diabetes
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
Anemia
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
Asthma
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
Asthma Treatments
Maintain O2 Prevent Hypoxic episodes Avoid triggers and inhaled steroids Epidural are recommended Avoid morphine
UTI’s
Most common complication Screen women! Associated with preterm birth and LBW Follow up is important! Safe antibiotics- take more often, harder adherence
TORCH
Toxoplasmosis- cat liter Other- Hep a & b Rubella- blindness Cytomegalovirus- herpes family Herpes- Type 1 or 2, outbreak can transmit to a baby`
Surgery during Pregnancy
Monitor the fetus!!
Trauma during Pregnancy
MVA, falls, blunt trauma, abuse
Observe for at least 4 to 6 hours
MAKE SURE HEART RATE IS OKAY!
