Late Pregnancy Complications Flashcards
Late Pregnancy Complications examples ?
Preterm Labor
Premature Rupture of
Membranes
Amniotic Fluid Issues
Oligohydramnios
Polyhydramnios
Post-term Pregnancy
RH Alloimmunization & Blood
Group Incompatibilities
Stillbirth
Preterm Labor: Labor occurring after __ weeks and before __weeks gestation
20
37
Preterm Labor: Contractions are ?
regular and frequent
Preterm Labor: Cervical effacement ( thinning) or dilation is _______.
present
Preterm Labor: Preterm birth occurs in___ of US pregnancies
12%
1 cause of neonatal M&M ?
Preterm birth
Preterm Labor: Many causes of preterm labor, but 50% are __________.
idiopathic
Preterm Labor RF: Obstetric Complications ?
In previous or current pregnancy
- Placental abnormality
- Amniotic fluid ↓ or ↑
- Maternal age
- Socioeconomic status
Preterm Labor RF: Medical Complications ?
Pulm, heart or kidney disease
Smoking, alcohol use
Anemia, malnutrition, infection
Preterm Labor RF: Surgical Complications ?
Hx of intra-abdominal procedure, cervical conization (LEEP)?, c-section
Preterm Labor RF: Genital Tract Anomalies ?
Bicornuate or septate uterus
Cervical incompetence
Preterm Labor prevention ?
Not much prevention can be done but prolong as much as possible
For women with a history of prior preterm birth, some evidence that vaginal suppositories or IM injections of progesterone help reduce risk by 30%
Preterm Labor signs and sxs. ?
Uterine contractions
Dilation and effacement of cx
+/- bloody mucous vaginal discharge, mucus plug
Preterm Labor evaluation ?
Calculate gestational age –by FDLMP or sono estimation
Fetal monitoring
-2 belts around abd.
Tocodynamometry – confirm contractions
PE – check for cervical dilation, ROM, fundal tenderness ( sing of infection - endometritis) , vaginal bleeding, fever
Preterm Labor labs ?
CBC with diff
U/A with C&S
US
- Fetal weight estimation
- Presenting part – abnormal presentation more common
- Placenta location
- -make sure it is not over the oss
Amniocentesis – for fetal lung maturity, if indicated
Speculum exam – cervical culture, wet mount, GBS culture, check any vaginal fluid for amniotic fluid (nitrazine test
- *blue means amniotic fluid in the vag - rupture of membranes and a sign hat we cant prolong the pregnancy and evacuation is needed!
- *
about 100% survival rate of a preterm birth ?
> 34 weeks
1750-2000g
~100% survival
about 60% survival rate of a preterm birth ?
24-25 weeks
500-750 g
60% survival
Fetal Lung Maturity Testing done before ?
Elective deliveries
Fetal Lung Maturity Testing by ?
Fluorescence polarization
Lecithin/sphingomyelin ration (L/S ratio)
Phosphatidylglycerol (PG)
*Fluorescence polarization ?
polarized light in amniotic fluid measured by TDx-FLM analyzer
Moderate cost
Simple to run
Most widely used test
Lecithin/sphingomyelin ration (L/S ratio) ?
Large lab variation
Not the test of choice any longer
Phosphatidylglycerol ?
part of surfactant
Expensive
Maternal cases in which preterm labor should NOT be suppressed - DELIVER IT!
Severe HTN, eclampsia
Pulmonary or cardiac disease
Cervical dilation >4 cms
Maternal hemorrhage
Fetal cases in which preterm labor should NOT be suppressed - DELIVER IT!
Fetal death or lethal anomaly
Fetal distress
decelerations on fetal monitoring
Chorioamnionitis
Fetal weight < 2500g - viable - get it out!
Erythroblastosis fetalis
Severe IUGR
Preterm Labor: If no contraindication to suppress labor: ___________ management
versus
__________________.
Expectant
Intervention to induce
Expectant Management: If ________ weeks or fetal weight _____ – generally not viable
20-23
<550g
Expectant Management: Once _______ weeks, nearly same survival rate as __ weeks
NO steroids needed
34-37
37
Suppression of Preterm Labor- 24-34 weeks examples ?
Bedrest- controversial
Corticosteroids
ABS
Tocolytics
Corticosteroids for labor supression ?
for fetal lung maturation
Peak effect at 48 hours, lasts 7 days
2nd course of IM injections if still pregnant after two weeks
ABS for labor supression ?
Does not delay birth but for prevention of GBS
Tocolytics for labor supression ?
If cervix <5 cms
Short term goal is 48 hours, so steroids can reach peak effect
Long term goal is to get to 34-36 weeks
Many agents, each with contraindications and SE’s
Tocolytics examples ?
**Magnesium sulfate
Beta-mimetic adrenergics (Sub cut) - Terbutaline
Calcium channel blockers - Nifedipine
Prostaglandin synthase inhibitors (indomethacin)
Mutliple agents – better effect, but ↑ SE’s
**Magnesium sulfate ?
Reduces uterine contractility
Better tolerated, watch for resp and card depression
Plus, neuroprotective - reduces risk of cerebral palsy
** calcium glutinate is the antidote to mag sulfate - if fetus becomes under distress **
Terbutaline ?
Beta-mimetic adrenergics
Relaxes uterus, but CV side effects
Used only initially until other therapy started
- *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby
- *
Nifedipine ?
CCB
Reduces uterine contractility
Oral admin, less side effects
- *T and N used in triage in early labor but ideally it is mag sulfate to stop the contractions nd it is better tolerated and had neuroprotective effects on the baby
- *
indomethacin ?
Prostaglandin synthase inhibitors
Serious fetal effects
Tocolytics – when to stop ?
Adverse maternal or fetal response
Cervix reaches 5 cms dilation
Intrauterine infection
esp. if membranes has ruptured
Placental abruption (separation)
PROm can occur when and what is it ?
Can occur at any point in pregnancy
Rupture before onset of labor
Preterm PROM – ?
fetus is preterm
Prolonged PROM – ?
term fetus, but delay of contractions by >24 hours
- *risk for infections , open bag with bacterial being able to ascend into the U
- *
Is PROM common ?
Common – 10% of all pregnancies, usually at term
PROM RF ?
Decidual hemorrhage
Hx of spontaneous preterm birth
Intrauterine bacterial infection
Amniocentesis
Cervical insufficiency
Multiple gestation
PROM prevention ?
for women with hx of preterm birth, weekly progesterone (vaginally or IM) may help
PROM signs and sxs. ?
Sudden gush of fluid or continued leaking
Possible flecks of vernix (white cheesy stuff on the baby) or meconium in the fluid
Reduced uterine size
Increased prominence of fetus
PROM PE ?
STERILE SPECULUM
Pooling of amniotic fluid in posterior fornix
Nitrazine test - paper turns blue (alkaline)
Ferning – air-dried slide
PROM PE inspect cervix exams ?
Sterile speculum
Dilation and effacement
Cord prolapse
Observe for leakage of amniotic fluid with valsalva
If enough fluid
Send for tests of fetal lung maturity and infection
NO digital cervical ?
PROM - Labs ?
CBC with diff
U/A with C&S
US – fetal size and amniotic fluid index (Biophysical Profile)
PROM - Treatment depends on ?
gestational age
presence or absence of chorioamnionitis
**meconium staining in the right - deliver it - baby is turing blue
PROM and Chorioamnionitis pathology and S&S ?
Infection, usually due to bacteria ascending from vagina
ecoli, GBS, bacteriodes
Fever
Maternal leukocytosis
Uterine tenderness
Tachycardia
Foul-smelling amniotic fluid
PROM and Chorioamnionitis In all cases ?
Safer for fetus to be delivered than to stay in utero.
Delivery ASAP, regardless of gestational age
PROM in Term Pregnancy Without Chorioamnionitis (infection) What management is better ?
Expectant vs Active Management – active is preferred
PROM in Term Pregnancy Without Chorioamnionitis (infection) Tx. ?
Induce labor
Reduces amount of time between PROM and delivery
Reduces risk of chorioamnionitis
PROM -Preterm Pregnancy Without Chorioamnionitis Tx if 34 weeks ?
induce labor
PROM -Preterm Pregnancy Without Chorioamnionitis Tx. if 22-24 weeks ?
terminate pregnancy or expectant management
PROM -Preterm Pregnancy Without Chorioamnionitis Tx. 24-34 weeks /
Amniotic sample to check lung maturity
Antibiotics – prolong delivery after PROM and ↓ infection
Corticosteroids – before 32 weeks and IF no infection.
Magnesium sulfate – neuroprotective
** NO tocolytics, or for 48 hours only, to allow for steroids and ATB’s**
Amniotic Fluid Issues is measured by ?
amniotic fluid index (AFI) on ultrasound
Measure fluid pockets, correlate with gestational age
**measure 4 pockets of A fluid to see if it is to much or to little **
Amniotic Fluid Issues: Oligohydramnios inhibits ?
NL fetal movement
Amniotic Fluid Issues: Oligohydramnios can lead to ?
fetal deformation. umbilical cord compression, death
Amniotic Fluid Issues: Oligohydramnios can be caused by ?
fetal renal dz, post-term status, maternal disorder, PROM or idiopathic
Amniotic Fluid Issues: Oligohydramnios results in fetal death when ?
In 1st and 2nd trimester
not enough A fluid to support it
Amniotic Fluid Issues: Oligohydramnios what helps evaluate the fetus ?
Saline infusion
Amniotic Fluid Issues: Oligohydramnios Tx. ?
No long term treatment available
Trying maternal hydration and desmopressin (DDAVP
Amniotic Fluid Issues: Polyhydramnios caused by ?
decreased fetal swallowing or increased fetal urination
Amniotic Fluid Issues MC etiologies ?
Fetal malformations/genetic disorders
Maternal DM, multiple gestation, fetal anemia
Amniotic Fluid Issues Tx. ?
Dependent on age, degree
Amnioreduction - remove fluid
Indomethacin, plus steroids
- Not given after 34 weeks as may cause premature closure of ductus arteriosus
Postterm Pregnancy patho ?
+42 weeks from FDLMP
Postterm Pregnancy risks of what ?
dysmaturity from impaired nutritional supply
Weight loss, ↓subcut tissue, parchment-like skin
Postterm Pregnancy maternal risks ?
large fetal size (CPD)
- *CEPHALOPELVIC DISPROPORTION
- *
Postterm Pregnancy fetal risks ?
birthing injury, aging placenta
Postterm Pregnancy: Oligohydramnios risk ?
cord compression
Postterm Pregnancy offer induction at ?
41 weeks
If declined, careful fetal monitoring
Rh Alloimmunization 1 ?
Fetus gets half of genes from mom, half from dad
So, fetus may have RBC antigens different from mom
If enough fetal cells cross into maternal blood, can provoke an antibody response
If maternal antibodies cross the placenta, they can destroy fetal erythrocytes – hemolytic anemia ( in the next baby)
Fetus response – erythroblastosis fetalis (fetal hydrops). Death can result
Rh group causes the majority of cases
-Mom is Rh-negative, fetus is Rh-positive
Rh Alloimmunization 2 ?
Rh-negative mothers need prophylaxis to prevent sensitization
Screen pregnant woman at first prenatal visit
-ABO and Rh(D), also known as (Rh-negative)
Administer RhIgG (RhoGAM) -Prenatally, IM to mom at 28 weeks and again within 72 hours of delivery if infant is Rh-positive
Other times to administer RhoGAM ?
Abortion
Amniocentesis, Chorionic
Villus Sampling
Antepartum bleeding
Any time fetal blood mixes with maternal blood
Stillbirth definition ?
Intrauterine fetal death at or beyond 20 weeks
<1% of pregnancies
50% of cases – difficult to identify cause
Stillbirth RF ?
similar to risks for infertility and abortion
Stillbirth is determined by ?
absence of cardiac activity on US
Stillbirth sxs. ?
pain, bleeding or asymptomatic
Stillbirth evaluation ?
Thrombophilia
Maternal toxicology
Testing for diabetes
Placental pathology
Karyotyping (best done through amniotic fluid)
Stillbirth Tx. ?
Induction of labor
D&E – intact delivery up to
26-28 weeks with cervical dilation
Stillbirth prognosis ?
If no etiology found, risk for repeat stillbirth is 1-2%
