Lecture 6.2 - At Risk Pregnancy 2 Flashcards

1
Q

How might substance use in pregnancy result in lack of prenatal care? What are the results of this?

A

Perhaps d/t lack of access, psychosocial factors
–> Serious fetal conditions might be missed (including teratogenic effects of substances)

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2
Q

What is the relationship between substance use and unplanned pregnancies?

A

Substance use increases incidence of unplanned pregnancy

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3
Q

What are the four most common substances used in pregnancy?

A

Tobacco
Alcohol
Cannabis
Opioids

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4
Q

What are the recommended safe limits for alcohol consumption?

A

1-2 drinks/week

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5
Q

Who is as increased risk of alcohol consumption during pregnancy?

A

Those who binge drink pre-pregnancy

Cigarette smoking

Adverse childhood experiences

Unplanned pregnancy

Irregular prenatal care
–> information deficit, lack of access to education

Partner use

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6
Q

Why can folic acid supplementation reduce the risks of poor outcomes of alcohol consumption during pregnancy?

A

Prevention of neural tube defects

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7
Q

What harm reduction interventions are to prevent drinking during pregnancy or to help those who do?

A

Harm reduction strategies
–> Awareness raising activities
–> Routine conversations with childbearing age females about birth control if consuming alcohol
–> Non-judgmental support to maintain safety of dyad

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8
Q

What T-ACE score is positive?

A

2+
–> Indicates need for additional support

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9
Q

What are some features Fetal Alcohol Spectrum Disorder (FASD)?

A

Memory problems, poor judgement, cognitive processing problems, struggling with abstract concepts. Literal thinking.

Poor social skills, impulsive, disorganized. Inconsistent performance.

Developmental delay, delayed motor skills coordination

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10
Q

What are some ways support children and families with fetal alcohol spectrum disorder?

A

Nurture strengths in stable environment

Teaching child to respond to anger in non-violent ways

Provide educational accommodations or IEPs

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11
Q

Is use of opioids in pregnancy increasing?

A

Yes, as much as it has increased in the general population

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12
Q

Who is screened for opioids and other elicit substances in pregnancy?

A

Everyone is routinely screened with consent - Best practice recommendation, not a law
–> Every person who uses opioids should be offered comprehensive care including OB care, addiction care, community services, and counselling.

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13
Q

What is the recommended treatment for opioid dependence during pregnant?

A

Opioid Agonist Therapy (AOT)
–> Methadone/Buprenorphine

Long acting therapy decreases cravings & withdrawal.

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14
Q

What opioid agonist therapy has better neonatal effects?

A

Buprenorphine
–> Less symptoms of neonatal abstinence syndrome

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15
Q

What are the benefits of using a synthetic long-acting opioid during pregnancy for those with dependencies?

A

Increases GA, birth weight, and decreased infant mortality. Improves nutritional status and facilitates earlier access to prenatal care.

Stabilizes parent - preventing cycle of intoxication/withdrawal and decreased risk of overdose

Reduces harm - decreased risk of blood born infections (HIV, HepC)

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16
Q

What are some dosing considerations in the 3rd trimester for those using synthetic long-acting opioids?

A

There might need to be an increased dose in the 3rd trimester d/t increased metabolism

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17
Q

What might be noted in fetal heart surveillance for someone taking opioid agonist therapy?

A

Bradycardia, decreased variability, less accelerations and fetal activity

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18
Q

What are some barriers to treatment for opioid dependence in pregnancy?

A

Stigma, guilt, shame, lack of resources or awareness of available programs

Lack of awareness of adverse effects of substance us on fetus

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19
Q

What is a Finnegan score?

A

A Finnegan Neonatal Abstinence Score allows use to quantify the severity of the NAS and determine a plan of care

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20
Q

Why would serial ultrasounds be ordered during pregnancy in a patient with opioid dependence?

A

To confirm GA
–> Person may have amenorrhea d/t substance of or not the the date of LMP

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21
Q

What repeat testing should be done on a patient who is pregnant with opioid dependent?

A

Serial US for FWB and determining GA

Consider risk of STBBIs

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22
Q

How to manage labour pain in someone with opioid dependence? With what drug through which route?

A

PCEA is best relief - given early in labour to ensure efficacy

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23
Q

What drugs should be avoided as pain relief options for those is labour with opioid dependence?

A

Avoid agonist-antagonists systemically
–> Increased risk of withdrawal symptoms

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24
Q

What kind of community referrals might be made prior to discharge of a parent with opioid dependence?

A

Continued substance use treatment

Social support

Postpartum doula –> Community doula access to decrease barriers to care

Public health nurse home visit

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25
Q

How can we facilitate parent-infant attachment?

A

Skin-to-Skin

Cluster

Rooming together

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26
Q

Can those receiving opioid antagonist therapy breastfeed?

A

Yes, it is encouraged because benefits outweigh risks

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27
Q

Is there a legal requirement in Canada to drug test parents?

A

No, testing for parents and neonate depends on provincial/hospital agencies

Informed consent must be obtained.

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28
Q

Who is screened for HIV when pregnant? When?

A

Everyone!
–> In first trimester

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29
Q

What is the ultimate goal of care for pregnant individuals with HIV? How is this achieved?

A

Decrease risk of transmission to fetus
–> ART for everyone regardless of CD4s, promote adherence
–> Test for opportunistic infections including STIs
–> Decrease NB exposure to blood and secretions

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30
Q

When is a vaginal delivery an option for those with HIV?

A

Indicated in person is on ART and viral load is < 1000 copies/ml

If not, C/S.

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31
Q

What medication is given those with HIV during labour

A

IV zidovudine
–> Antiretroviral that prevents transmission

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32
Q

What should be avoided during delivery in parents with HIV?

A

Avoid anything that can damage fetal skin
–> Scalp probe, pH blood sampling, forceps, vacuum
–> Literature unclear, but avoid artificial ROM

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33
Q

What specialized care is provided to
the infant after delivery if parent is HIV+?

A

Immediately clean infant (remove body fluids)

Treat with Zidovudine within 6 hours, then Q6 for 6 weeks

Test for HIV at birth, 4 weeks, 3-4 months, and 18 months

Breastfeeding discouraged in countries where safe alternatives exist

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34
Q

When should the infant be treated with Zidovudine when parent is HIV+?

A

within 6 hours of life

Then q6 for 6 weeks

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35
Q

When should a neonate of a parent who is HIV+ be tested for it?

A

At birth, 4 weeks, 3-4 months, 18 months.

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36
Q

What is classified as GDM?

A

Elevated BGL that are first recognized during pregnancy

37
Q

What are some long-term risks of GDM?

A

Higher risk of developing DMII later in life

38
Q

Pregnant people with GDM have an increased risk of developing what adverse outcomes during labour?

A

Pre-eclampsia
Shoulder dystocia
Needing C/s and episiotomy

39
Q

What are some adverse affects of NBs of parents with GDM?

A

LGA (macrosomia)
Hypoglycemia
IUGR (poor perfusion)
IU fetal death

40
Q

GDM does not carry an increased risk of congenital anomalies. Why?

A

Because GDM usually only develops in the second trimester
–> After gross anatomy has already formed

41
Q

What are some risk factors for GDM?

A

> 35 yrs
Corticosteroid use
Obesity
PCOS or Acanthosis Nigricans
Pregestational diabetes or family Hx
Hx of giving birth to baby >4 kg

42
Q

What are the two types of screening for GDM?

A

Two step (preferred)
–> 50 mg non-fasting then test 1hr later
–> If 7.8-11 after t-test then 75g fasting. Then test at 1 and 2 hours after drinking.

One step –> involves only 75g fasting-challenge with 1-2 hour checks.

43
Q

When should pregnant people be screened for GDM?

A

Screening in 1st trimester for hyperglycemia in those with risk factors

+

Between 24-28 weeks for everyone, including those with risk factors

44
Q

What is the aim of treatment of GDM? What are appropriate BGL ranges?

A

Meticulous BGL control

Fasting: 3.8-5.2
1 hr post meal: 5.5-7.7
2 hr post meal: 5.0-6.6

45
Q

What teaching is necessary for pts with GDM?

A

Explanation of GDM and possible complications

Diet, exercise, monitoring

Medications
–> Glyburide, metformin
–> Insulin if needed

46
Q

What fetal surveillance is performed with GDM?

A

Serial ultrasounds every 3-4 weeks starting at 28 weeks to monitor:
–> Growth
–> Amniotic fluid volume

Weekly NSTs starting at 36 weeks

Additional assessments might be needed depending on BGL control and risk factors.

47
Q

Why is amniotic fluid level monitored closely with GDM?

A

If fetal BGL is high it will result in polyurea –> Polyhydramnios

48
Q

When should labour be induced with GDM? Why?

A

38-40 weeks
–> Concern with placental efficacy

49
Q

What is the ideal BGL for someone with GDM during labour? Why?

A

Less than 8 mmol/L (checked qh)
–> Linked to less severe NB hypoglycemia

50
Q

At what point would a fetal weight be indication for c/s?

A

> 4.5 kg
–> Concern for dystocia/laceration

51
Q

When is NB BGL tested in GDM?

A

2 hours of life (After first feed)
Then 3-6 hours (before feeds)

This protocol lasts 12 hours.

52
Q

Why is breastfeeding especially beneficial following GDM?

A

Decreased risk of DMII for both parent and child

53
Q

How does pregnancy change management or symptoms of pre-existing DM?

A

Change in symptoms of hypoglycemia, may need to switch from PO meds to add insulin

54
Q

Hyperglycemia is more likely to be teratogenic in which kind of DM?

A

Pre-existing
–> Because sugar instability is more likely to be present in 1st trimester

55
Q

What percent of pregnant people experience N&V vs hyperemesis gravidarum?

A

50-90% experience N/V

0.3-3% experience HG

56
Q

At what point does hyperemesis gravidarum start and improve? What might cause it?

A

Starts between 4-8 weeks and improves by week 16
–> R/t hCG + estrogen, also associated with transient hyperthyroidism

57
Q

Excessive vomiting can lead to what complications for a pregnant (or any) person?

A

Weight loss + Dehydration

Nutritional deficiencies, Electrolyte imbalances
–>Vit k, anemia
Ketonuria

58
Q

What hormones cause hyperemesis gravidarum?

A

Estrogen, hCG
Also associated with transient hyperthyroidism of pregnancy

59
Q

What are some factors that can lead to an increased risk of hyperemesis gravidarum?

A

Younger age
Nulliparity
BMI outside of 18.5-25
Low socioeconomic status
Family Hx

Female fetus or multiple gestation, gestational trophoblastic disease

60
Q

What medication is used to treat N&V in pregnancy?

A

Diclectin
–> Antihistamine (doxylamine) + B6

Not always effective for HG
–> May need Zofran, metoclopramide

61
Q

What are priorities of care with HG?

A

Supportive care: VS, treat N&V, I/O

Offer antiemetics, prescribed medication, clear fluids and high protein/carb, low fat meals as tolerated.
BRAT Diet - Bananas, Rice, Applesauce, Toast

Promote rest

62
Q

What are some poor maternal outcomes of hypertensive disorders of pregnancy?

A

Acute renal failure
Pulmonary edema
HELLP
Cerebral edema/eclampsia
Hepatic rupture
Placental abruption

63
Q

Which HDP complications cause the most maternal deaths?

A

Hepatic rupture + Placental abruption

64
Q

What are some fetal outcomes of HDP?

A

IUGR + Acute hypoxia
Preterm birth
Placental abruption
Congenital malformations

65
Q

What is considered pre-existing hypertension in pregnancy?

A

Diagnosed before 20 weeks.

66
Q

What is considered gestational hypertension?

A

Diagnosed after 20 weeks of pregnancy

67
Q

Can pre-eclampsia occur with pre-existing or gestational HTN?

A

Can occur independently or super-imposed with either of the two

68
Q

What is the diagnostic criteria for HDP?

A

sBP >140
dBP > 90

Or > 135/85 in a community environment

At least two readings, at least 15 minutes apart

69
Q

What is considered severe HTN?

A

sBP > 160
sBP > 110

70
Q

What is pre-eclampsia?

A

Multisystem, vasospastic disease process of reduced organ perfusion. Characterized by:

HTN + Proteinuria
OR
One or more adverse conditions

71
Q

What is the only cure for pre-eclampsia?

A

Removing the placenta

72
Q

What increases risk of pre-eclampsia?

A

Prior Hx
Obesity, HTN, DM, CKD, lupus

Hx of placental abruption, stillbirth, IUGR

Maternal age > 40 or multifetal pregnancy, use of assisted reproductive technology

73
Q

How do we test for proteinuria?

A

Dipstick of 2+

or

Lab testing of random urine specimens: 0.03 g/l in al least two specimens

74
Q

What is eclampsia?

A

Characterized by seizures from the profound cerebral effects of pre-eclampsia

75
Q

What is HELLP syndrome?

A

H - Hemolysis
EL - Elevated Liver enzymes
LP - Low platelets

May occur to women who do not have HTN or proteinuria

76
Q

What symptoms are indicative of HELLP?

A

RUQ pain, N&V
–> Often confused with gastritis, flu, gallbladder issue

77
Q

What factors lead to decreased maternal perfusion with pre-eclampsia?

A

Decreased intravascular volume in vessels surrounding placenta
–> Placenta is ischemic, gets upset, and releases vasoactive substances which cause endothelial injury + capillary leaking –> edema

Increased vasoconstriction
–> HTN caused by increased sensitivity to vasoactive substances and arterial vasospasm

78
Q

How can we prevent pre-eclampsia in those at increased risk?

A

Low dose ASA before 16 weeks and continued until 36 weeks
–> 81-162 mg

140 minutes of moderate intensity exercise

79
Q

When should people with pre-eclampsia be hospitalized?

A

When there are adverse maternal effects

80
Q

What medications are given to those with pre-eclampsia?

A

Monotherapy with labetalol, methyldopa, nifedipine
–> Or second line hydralazine

IV Magnesium
–> Increases seizure threshold
–> Keep Calcium gluconate available

81
Q

Is bedrest recommended with pre-eclampsia?

A

No. Increased risk of DVT outweighs benefits

82
Q

What is the antidote to magnesium sulfate?

A

calcium gluconate

83
Q

What should we test regularly in a person with preeclampsia or who is being administered Mg sulfate?

A

DTRs
–> preeclampsia - hyperreflexia
–> MgSO4 - hyporeflexia

84
Q

When should we expedite the birth in preeclampsia?

A

Uncontrolled HTN > 12 hours despite 3 antihypertensives

Eclampsia, stroke, TIA

Pulmonary edema

Compromised renal function

Abruption or maternal/child compromise

Concerns on EFM

85
Q

What position can be helpful during pre-eclampsia?

A

L-lateral recumbent

86
Q

What to do during a seizure?

A

Airway, left lateral, pillow under shoulder or back to keep head to side

Call for help

Bedrails up, pillows padding

Observe time of onset, duration

87
Q

What can be a sign that preeclampsia is improving following delivery? How often should we check VS?

A

Diuresis
–> Most women are clinically stable by 48 hours. VS Q4 for 48 hours to monitor

BP usually returns to normal by 4-6 weeks postpartum.

88
Q

What medication would we not use to increase uterine contractions in those with HTN?

A

Methergine
–> Increases BP

89
Q

Morbidity and mortality following eclampsia are higher in what situations?

A

When the eclampsia is seen before 28 weeks
Maternal age > 30
Multigravida
HTN/renal disease
No prenatal care