Lecture 6.1 - At Risk Pregnancies 1 Flashcards
What is a high risk pregnancy?
A situation where the life, health, and welfare of the mother and/or developing fetus are at risk due to
medical, social, or environmental factors
What antepartum testing is done in the first two trimesters?
Chromosomal tests + prenatal screening
Biochemical diagnosis
–> Offered if prenatal screen is positive or pt is older than 40
What antepartum tests are done in the third trimester?
Fetal Well-Being
–> Determine if fetus is thriving in uterine environment
–> Informs decision about the timing of birth
Indicated when increased risk of maternal or fetal morbidity/mortality
What things are assessed in a FWB assessment?
Fetal movement counting –> Electronic monitoring –>
Ultrasound
Fetal movement counting should include how much activity?
At least 6 movements in 2 hours
What can ultrasound be used to assess in the third trimester?
Biophysical profile
Amniotic fluid volume
Doppler blood flow analysis
What kind of electronic fetal monitoring is done in a FWB assessment?
Non-stress test
Contraction-stress test or oxytocin challenge test
What is a non-stress test?
Monitoring fetal HR/contracting with monitor at any point before labour
–> Assessing dyad while not in labour
What is a normal NST for a pregnancy over 32 weeks gestation?
- 2 or more accelerations of >15 bpm x 15 second over 40 minutes
- Baseline 110-160
- Moderate variability (6-25)
- No decelerations (or less than 30 seconds)
What is an atypical NST for a pregnancy over 32 weeks gestation?
- Less than 2 accelerations of >15 bpm x 15 second over 40-80 minutes
- Absent or minimal variability
What is an abnormal NST that requires urgent action for a pregnancy over 32 weeks gestation?
- Less than 2 accelerations of >15 bpm x 15 second over more than 80 minutes
- Erratic baseline, HR outside of 100-160 for 30 minutes
- Late decelerations or variable decelerations > 60 seconds
What is a consideration for fetal monitoring before 32 weeks GA?
Good accelerations can be 10bpmX10seconds instead of 15x15
What is contraction stress test or oxytocin challenge test?
Observe FHR response to 3 one minute contractions over 10 minutes
–> Induced by IV oxytocin/nipple stimulation
What is a negative and positive contraction stress test?
Negative
–> Normal baseline, no late decels
Positive
–> Late decels with half or more of contractions
What are some contraindications to a contraction stress test?
Preterm labour
Placenta previa
Multiple gestation
Previous classic uterine incision
What is assessed in an ultrasound of assessing biophysical profile (BPP)? What is it scored out of?
Physical exam
Amniotic fluid volume
Fetal breathing, tone, movement
May include NST
BATMaN - Breathing, Amniotic fluid, tone, movement & NST
Scored out of 10
What is a normal BPP?
1+ fetal breathing movement last 30+ seconds
At least 3 trunk or limb movements in 30 minutes
Extensions with flexion return
Pocket of free fluid 2x2 cm
Normal NST
All worth 2 points
What if there is a BPP score of less than 6?
We have to jailbreak baby asap
–> Suspect chronic asphyxia
What is there is a BPP score of 6 with normal fluid?
Repeat testing in 24 hours
What to do if there is a BPP score of 6 with abnormal fluid?
Deliver term bb d/t risk of chronic asphyxia
If < 34 weeks, intense surveillance to determine risks of preterm birth/remaining in utero
Oligohydramnios indicates what?
Fetal renal issues, intrauterine growth restriction, premature rupture
Polyhydramnios is associated with what?
GI blockage/abnormality, multiple fetuses, fetal hydrops
An antepartum doppler blood flow analysis assesses what?
Blood flow in:
–> Maternal uterine arteries (Predicts growth restrictions)
–> Fetal umbilical + middle cerebral arteries (predict fetal anemia)
What are the levels of maternal/NB services ontario?
Level 1
–> Term, low risk
–> C/S births not always available
Level 2
–> Moderate risk, uncomplicated twins
a) >34 weeks & 1800 g
b) >32 weeks & 1500 g
c) >30 week & 1200 g
Level 3
–> Onsite adult ICU/timely access to surgical intervention
A) no on site surgery but timely access
B) on-site surgical services at all times
Childbearers with obesity are at increased risk of what preconception, gestational, gestational, and postpartum compliactions?
Preconception: Infertility, Spontaneous abortions,
Recurrent pregnancy loss
During pregnancy: GDM, HTN/preeclampsia
Intrapartum: Macrosomia, altered uterine contractility, challenges to implement interventions like FHR, epidural, intubation
Postpartum: PPH, breastfeeding issues, venous thromboembolism, infection
What pre-conception care is needed for those with obesity?
What percent weight loss is recommended?
Should weight loss drugs me used?
How long after bariatric surgery should a person wait to become pregnant, ideally?
What screenings should be prioritized?
Ideally, obtain weight in normal range before pregnancy
–> Better outcomes with 5-10% weight loss
Discontinue weight loss drug therapy, wait 24 months after bariatric surgery to become pregnant, smoking cessation.
Screen for DMII, HTN, CDV disease
.4 mg/day folic acid stating 3 months prior to conceptions
What antenatal care is needed for those with obesity?
What wait gain is recommended in in the first trimester and by term?
What screenings should be prioritized?
How do we manage to increased with for pre-eclampsia in this population?
Recommend GA weight gain of 11-20 lbs with minimal weight gain during 1st trimester.
–> Regular exercise and nutritional counseling.
Careful screening for GDM, HTN
If risk for pre-eclampsia - low dose aspirin before 16 weeks GA
When is an induction performed for someone with a BMI > 40
39 weeks
–> Minimizes c/s and stillbirths
What intrapartum care considerations must be made for someone with obesity?
EFM in labour when BMI is greater than 35
Maximize pulmonary functions/minimize O2 consumption
–> Pulse oximetry, good pain control
Avoid general anesthesia is c/s in pts with obesity
Population at risk of passenger factors like macrosomia and shoulder dystocia, as well as altered uterine contractility
What postpartum care considerations must be made for someone with obesity?
Consider LC
Early mobilization following vaginal delivery and C/S - may need PT
Teaching: Inspect incision, incision care, s/s infections
Neonates of childbearers with obesity are at increased risk of…
Stillbirth
Neural tube, ventral wall anomalies
Macrosomia
Shoulder dystocia
Meconium aspiration
Interventions & NICU admission
What is the most common medical disorder of pregnancy?
Anemia
How does the body compensate for decreased oxygen carrying capacity of RBCs?
Increased Cardiac output
What is the most common type of anemia?
IDA
What is considered IDA?
Serum ferritin < 12 mcg/L deficient with Hb < 110 g/L
Why should all pregnant people be screened for IDA?
25% of pregnant individuals have it
What the iron recommendation for pregnant people?
Iron intake 27 mg/day
–> Consider additional supplementation if vegetarian
What lab values are considered anemia during pregnancy?
Hb - < 110
Hct - </= 0.32
Hct of .32 can be normal d/t physiological anemia of pregnancy, but Hb should not decrease below 110.
What maternal factors make pregnant individuals more susceptible to complication d/t IDA?
Further depletion of stores
Less capacity to tolerate blood loss during pregnancy
What are some risks for the NB when the pregnant individual has IDA?
Preterm birth
low birth weight
How is postpartum IDA treated?
30 mg/day prenatal vitamin or 60-120 mg/day iron supplement
*Can be given IM if PO causes N/V
What are folic acid and folate?
Both forms of B9
–> Folate - naturally occurring
–> Folic acid - synthetic
folate deficiency can result in what for the NB?
Neural tube defects, cleft palate or lip
When would the need for folate in pregnancy extend beyond .4 mg/daily?
Multiple pregnancies close together
Multiple fetuses
In pregnancy those with Sickle Cell Anemia are at increased risk of what?
Pain crises
IUGR
Pre-Eclampsia
Infections
How can sickle cell crises be treated in pregnancy?
Analgesia, oxygen, hydration
–> Monitoring fetal growth
Prophylactic low dose aspirin
Treat infections with antibiotics
How does sickle cell anemia result in hemolytic anemia and pain crises?
RBCs sickle and break down –> Hemolysis
Sickling causes vascular occlusion –> Ischemia –> pain crisis
What are thalassemia? What are the two kinds and how do they impact pregnancy?
Hereditary disease resulting in abnormal synthesis of hemoglobin
–> Minor - usually uncomplicated persistent anemia, often not a problem during pregnancy
–> Major - shorter lifespan, infertility + major health concerns if pregnant
Bleeding during early pregnancy can indicate what?
Miscarriage
Ectopic pregnancy
Hydatidiform mole
Bleeding during late pregnancy can indicate what?
Placenta previa
Placenta abruption
How much cardiac output flows through the placenta?
15%
80% of spontaneous abortions occur when?
Before 12 weeks d/t chromosomal abnormalities
What are considered late spontaneous miscarriages?
12-20 weeks
What is considered a spontaneous abortion?
A pregnancy that ends without medical or surgical intervention prior to 20 weeks of gestation or less than 500g fetal weight
What are the four types of spontaneous abortion?
Threatened
Inevitable
Incomplete
Complete
What what is a threatened spontaneous abortion?
–> Consider bleeding, dilation, cramping
How is it treated?
Slight spotting with mild cramping
–> No dilation, no passage of tissue
Bed rest, US to assess fetus
What what is an inevitable spontaneous abortion?
–> Consider bleeding, pain, and dilation
How is it treated?
Moderate bleeding, mild to severe cramping
–> Cervical dilation, no passage of tissue
Bed rest is no pain, fever, or bleeding
–> D&C if this changes or there is ROM
What what is an incomplete spontaneous abortion?
–> Consider bleeding, pain, dilation
How is it managed?
Heavy, profuse bleeding, severe cramping with passage of tissue and dilation of cervix.
May require D&C to ensure no tissue remains in uterus
What what is a complete spontaneous abortion?
–> Consider bleeding, pain, and dilation
How is it managed?
Slight bleeding at this point, with mild cramping.
Tissue has been passed and cervix is not dilated.
Further intervention may not be necessary, ensure to retained tissue.
What assessments and interventions are necessary for a miscarriage?
Consider psychosocial, physical, medications, and labs.
Pregnancy history, emotional status –> Teaching, psychosocial support, emotional support, expectant management
VS, pain, quantity and nature of bleeding
–> Pain management + misoprostol
–> May need D&C
Labs: B-hCG, Hb, WBC
What is an ectopic pregnancy? What are the S/S?
Occurs when fertilized egg implants outside of uterus
–> Life threatening hemorrhage
S/S: vaginal bleeding, dull progressive pain that is often one sided
What are risk factors for ectopic pregnancy?
Previous EP, PID, endometriosis, previous pelvic surgery
Advanced maternal age, smoking
How is ectopic pregnancy treated?
Surgery + methotrexate
What is a molar pregnancy?
A complete molar pregnancy is when a sperm fertilizes empty ovum - no true placenta or viable fetus
Abnormal growth of placental tissue
–> Benign growth into “grape-like cluster”
What are risk factors for molar pregnancy?
Advanced maternal age
Previous Hx
Deficiencies in folic acid
What are the S/S of a molar pregnancy?
Vaginal bleeding or spitting (dark brown to bright red)
Passage of molar tissue
Enlarged uterus for GA
N&V, hyperemesis gravidarum (very high hCG)
How is a molar pregnancy treated?
Surgical removal in D&C
–> Monitor hCG levels to ensure completely removed
What is placenta previa?
When the placenta partially or completely covers to cervix
What is a low-lying placenta? What is normal placenta location?
Normal - 2+ cm away from cervix
Low - within 2 cm of cervical os
What are some risk factors for placenta previa?
Uterine/endometrial scarring
–> Prev PP, CS, D&C, multiparity, assisted reproductive technology
Impeded endometrial vascularization
–> HTN, smoking, cocaine, higher altitude
Increased placental mass
–> Multiple gestation, male fetuses (size)
What are S/S of placenta previa?
Painless bright red blood w/o tenderness after 20 weeks
–> Before onset of labour
Suspect previa in all cases of bleeding after 20 weeks!!
–> R/O w US
Can vital signs be a reliable indicator or bleeding in pregnancy?
No. A pregnant person can lose up to 40% of blood volume before showing signs of shock
–> VS might be misleadingly normal
How does the fetus respond to placental previa?
FHR often normal until maternal shock d/t excessive blood loss
What will an abdominal exam look like in placenta previa?
Soft, relaxed, non-tender
Fundal height greater than expected for GA
How is placenta previa diagnosed?
Provisional diagnosis can be made in second trimester - confirmations dx required at 32-36 weeks.
What transvaginal US findings indicate placental previa?
Edges of placenta greater than 1 cm or venous lakes of maternal blood at placental margin
What are fetal risks d/t placenta previa?
Preterm birth, IUGR d/t chronically compromised exchange
What are the three placenta accreta disorders?
Acretta - invades endometrium, does not detach
Increta - invates myometrium
Percreta - uterine serosa / other organs
What is velamentous cord insertion?
Absence of Warton’s jelly - cord embedded in membranes
–> higher risk of compression
Increased risk with accreta disorders
What is vasa previa?
Velamentous cord insertion where the blood vessels overlay the cervix
–> Compression with delivery
How is placenta previa managed?
Pelvic rest w continuation of other regular activity
Antenatal corticosteroids - accelerate maturation of lungs if risk of birth is within 7 days
WinRho after every bleeding event
How is a fetus with placenta previa delivered?
C/S
–> 36 weeks with risk factors
–> 37 weeks without risk factors
How is a baby with low lying placenta delivered?
TOL if edge is at least a cm away from cervical os
C/S if less than 1 cm
–> 37 weeks with risk factors
–> 38 weeks with no risks
What is placenta abruption?
Premature detachment of part or all of the placenta
–> after 20 weeks and before birth
What are the three types of placental abruptions?
Partial with external/apparent hemorrhage
Partial with concealed hemorrhage
Complete - often presents without bleedings d/t membranes preventing flow of blood
What are the classes of placental abruption?
How much blood or pain is seen with each?
Class 1: Mild
–> Minimal dark bleeding (less than 500 ml)
–> Absent or mild pain
Class 2: Moderate
–> Moderate dark red bleeding (1000-1500 ml)
–> Moderate to severe pain
Class 3: Severe
–> Severe, dark bleeding (>1500 mg)
–> Agonizing, intermittent pain
–> Board like uterus
What are the differences in presentation from placenta previa to placenta abruption?
Abruption
–> Dark red (older blood)
–> Often painful to some degree
–> Rigidity, often with increased fundal height
Previa
–> Frank red (newer blood)
–> Often painless
–> Soft uterine tone
What percent of placental abruption have concealed bleeding?
20% are concealed
What are some maternal complications of placental abruption?
Hypovolemia + DIC + renal failure + thrombocytopenia
Sensitization to Rh neg pts
What are the fetal risks for placenta abruption?
Related to severity and GA
–> IUGR
–> Oligohydramnios
–> Preterm birth
–> Hypoxemia
NB at higher risk of neuro defects, CP, SIDS
How is placental abruption diagnosed?
Expect when there is sudden, intense uterine pain with or without bleeding
–> Increased fundal height might be present
–> Coagulopathy
–> US to r/o previa
–> FHR pattern abnormalities
Is a trial vaginal birth possible with placental abruption?
Yes, if mother is hemodynamically stable and there is no fetal distress
What are the priorities of care with placental abruption?
Restore blood loss and deliver infant.
What are the different kinds of level 2 birthing units in Ontario?
Level 2
–> Moderate risk, uncomplicated twins
a) >34 weeks & 1800 g
b) >32 weeks & 1500 g
c) >30 week & 1200 g
What are the different kinds of level 3 birthing units in Ontario?
Level 3
–> Onsite adult ICU/timely access to surgical intervention
A) no on site surgery but timely access
B) on-site surgical services at all times
Low dose aspirin is given to pregnant patient with obesity at what point? Why?
Before 16 weeks GA if there is a risk of preeclampsia
How long after bariatric surgery should someone wait to become pregnant?
24 months
EFM is indicated during labour for patients with what BMI?
BMI 35 or greater
How often are third trimester serial US and FWB checks recommended for patients with obesity?
At 28, 32, and 36 weeks. Then weekly.
When should you suspect placental previa?
All cases of vaginal bleeding after 20 weeks
–> Until ruled out by ultrasound
Placental previa carries which complications for fetal presentation?
Increased risk of malpresentation
–> Transverse or breech
What kind of examination should not be done on a person with placenta previa?
No rectal or vaginal exams - pelvic rest
What medications are given is there is a risk of preterm labour in the next 7 days?
Corticosteroids - fetal lung development
