Lecture 6.2 - At Risk Pregnancy 2 Flashcards
How might substance use in pregnancy result in lack of prenatal care? What are the results of this?
Perhaps d/t lack of access, psychosocial factors
–> Serious fetal conditions might be missed (including teratogenic effects of substances)
What is the relationship between substance use and unplanned pregnancies?
Substance use increases incidence of unplanned pregnancy
What are the four most common substances used in pregnancy?
Tobacco
Alcohol
Cannabis
Opioids
What are the recommended safe limits for alcohol consumption?
1-2 drinks/week
Who is at increased risk of alcohol consumption during pregnancy?
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
Why can folic acid supplementation reduce the risks of poor outcomes of alcohol consumption during pregnancy?
Prevention of neural tube defects
What harm reduction interventions are to prevent drinking during pregnancy or to help those who do?
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
What T-ACE score is positive?
2+
–> Indicates need for additional support
What are some features Fetal Alcohol Spectrum Disorder (FASD)?
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
What are some ways support children and families with fetal alcohol spectrum disorder?
Nurture strengths in stable environment
Teaching child to respond to anger in non-violent ways
Provide educational accommodations or IEPs
Is use of opioids in pregnancy increasing?
Yes, as much as it has increased in the general population
Who is screened for opioids and other elicit substances in pregnancy?
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.
What is the recommended treatment for opioid dependence during pregnant?
Opioid Agonist Therapy (AOT)
–> Methadone/Buprenorphine
Long acting therapy decreases cravings & withdrawal.
What opioid agonist therapy has better neonatal effects?
Buprenorphine
–> Less symptoms of neonatal abstinence syndrome
What are the benefits of using a synthetic long-acting opioid during pregnancy for those with dependencies?
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)
What are some dosing considerations in the 3rd trimester for those using synthetic long-acting opioids?
There might need to be an increased dose in the 3rd trimester d/t increased metabolism
What might be noted in fetal heart surveillance for someone taking opioid agonist therapy?
Bradycardia, decreased variability, less accelerations and fetal activity
What are some barriers to treatment for opioid dependence in pregnancy?
Stigma, guilt, shame, lack of resources or awareness of available programs
Lack of awareness of adverse effects of substance us on fetus
What is a Finnegan score?
A Finnegan Neonatal Abstinence Score allows use to quantify the severity of the NAS and determine a plan of care
Why would serial ultrasounds be ordered during pregnancy in a patient with opioid dependence?
To confirm GA
–> Person may have amenorrhea d/t substance of or not the the date of LMP
What repeat testing should be done on a patient who is pregnant with opioid dependence?
Serial US for FWB and determining GA
Consider risk of STBBIs
How to manage labour pain in someone with opioid dependence? With what drug through which route?
PCEA is best relief - given early in labour to ensure efficacy
What drugs should be avoided as pain relief options for those in labour with opioid dependence?
Avoid agonist-antagonists systemically
–> Increased risk of withdrawal symptoms
What kind of community referrals might be made prior to discharge of a parent with opioid dependence?
Continued substance use treatment
Social support
Postpartum doula –> Community doula access to decrease barriers to care
Public health nurse home visit
How can we facilitate parent-infant attachment?
Skin-to-Skin
Cluster
Rooming together
Can those receiving opioid antagonist therapy breastfeed?
Yes, it is encouraged because benefits outweigh risks
Is there a legal requirement in Canada to drug test parents?
No, testing for parents and neonate depends on provincial/hospital agencies
Informed consent must be obtained.
Who is screened for HIV when pregnant? When?
Everyone!
–> In first trimester
What is the ultimate goal of care for pregnant individuals with HIV? How is this achieved?
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
When is a vaginal delivery an option for those with HIV?
Indicated in person is on ART and viral load is < 1000 copies/ml
If not, C/S.
What medication is given those with HIV during labour
IV zidovudine
–> Antiretroviral that prevents transmission
What should be avoided during delivery in parents with HIV?
Avoid anything that can damage fetal skin
–> Scalp probe, pH blood sampling, forceps, vacuum
–> Literature unclear, but avoid artificial ROM
What specialized care is provided to
the infant after delivery if parent is HIV+?
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
When should the infant be treated with Zidovudine when parent is HIV+?
within 6 hours of life
Then q6 for 6 weeks
When should a neonate of a parent who is HIV+ be tested for it?
At birth, 4 weeks, 3-4 months, 18 months.
What is classified as GDM?
Elevated BGL that are first recognized during pregnancy
What are some long-term risks of GDM?
Higher risk of developing DMII later in life
Pregnant people with GDM have an increased risk of developing what adverse outcomes during labour?
Pre-eclampsia
Shoulder dystocia
Needing C/s and episiotomy
What are some adverse affects of NBs of parents with GDM?
LGA (macrosomia)
Hypoglycemia
IUGR (poor perfusion)
IU fetal death
GDM does not carry an increased risk of congenital anomalies. Why?
Because GDM usually only develops in the second trimester
–> After gross anatomy has already formed
What are some risk factors for GDM?
> 35 yrs
Corticosteroid use
Obesity
PCOS or Acanthosis Nigricans
Pregestational diabetes or family Hx
Hx of giving birth to baby >4 kg
What are the two types of screening for GDM?
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.
When should pregnant people be screened for GDM?
Screening in 1st trimester for hyperglycemia in those with risk factors
+
Between 24-28 weeks for everyone, including those with risk factors
What is the aim of treatment of GDM? What are appropriate BGL ranges?
Meticulous BGL control
Fasting: 3.8-5.2
1 hr post meal: 5.5-7.7
2 hr post meal: 5.0-6.6
What teaching is necessary for pts with GDM?
Explanation of GDM and possible complications
Diet, exercise, monitoring
Medications
–> Glyburide, metformin
–> Insulin if needed
What fetal surveillance is performed with GDM?
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.
Why is amniotic fluid level monitored closely with GDM?
If fetal BGL is high it will result in polyurea –> Polyhydramnios
When should labour be induced with GDM? Why?
38-40 weeks
–> Concern with placental efficacy
What is the ideal BGL for someone with GDM during labour? Why?
Less than 8 mmol/L (checked qh)
–> Linked to less severe NB hypoglycemia
At what point would a fetal weight be indication for c/s?
> 4.5 kg
–> Concern for dystocia/laceration
When is NB BGL tested in GDM?
2 hours of life (After first feed)
Then 3-6 hours (before feeds)
This protocol lasts 12 hours.
Why is breastfeeding especially beneficial following GDM?
Decreased risk of DMII for both parent and child
How does pregnancy change management or symptoms of pre-existing DM?
Change in symptoms of hypoglycemia, may need to switch from PO meds to add insulin
Hyperglycemia is more likely to be teratogenic in which kind of DM?
Pre-existing
–> Because sugar instability is more likely to be present in 1st trimester
What percent of pregnant people experience N&V vs hyperemesis gravidarum?
50-90% experience N/V
0.3-3% experience HG
At what point does hyperemesis gravidarum start and improve? What might cause it?
Starts between 4-8 weeks and improves by week 16
–> R/t hCG + estrogen, also associated with transient hyperthyroidism
Excessive vomiting can lead to what complications for a pregnant (or any) person?
Weight loss + Dehydration
Nutritional deficiencies, Electrolyte imbalances
–>Vit k, anemia
Ketonuria
What hormones cause hyperemesis gravidarum?
Estrogen, hCG
Also associated with transient hyperthyroidism of pregnancy
What are some factors that can lead to an increased risk of hyperemesis gravidarum?
Younger age
Nulliparity
BMI outside of 18.5-25
Low socioeconomic status
Family Hx
Female fetus or multiple gestation, gestational trophoblastic disease
What medication is used to treat N&V in pregnancy?
Diclectin
–> Antihistamine (doxylamine) + B6
Not always effective for HG
–> May need Zofran, metoclopramide
What are priorities of care with HG?
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
What are some poor maternal outcomes of hypertensive disorders of pregnancy?
Acute renal failure
Pulmonary edema
HELLP
Cerebral edema/eclampsia
Hepatic rupture
Placental abruption
Which HDP complications cause the most maternal deaths?
Hepatic rupture + Placental abruption
What are some fetal outcomes of HDP?
IUGR + Acute hypoxia
Preterm birth
Placental abruption
Congenital malformations
What is considered pre-existing hypertension in pregnancy?
Diagnosed before 20 weeks.
What is considered gestational hypertension?
Diagnosed after 20 weeks of pregnancy
Can pre-eclampsia occur with pre-existing or gestational HTN?
Can occur independently or super-imposed with either of the two
What is the diagnostic criteria for HDP?
sBP >140
dBP > 90
Or > 135/85 in a community environment
At least two readings, at least 15 minutes apart
What is considered severe HTN?
sBP > 160
sBP > 110
What is pre-eclampsia?
Multisystem, vasospastic disease process of reduced organ perfusion. Characterized by:
HTN + Proteinuria
OR
One or more adverse conditions
What is the only cure for pre-eclampsia?
Removing the placenta
What increases risk of pre-eclampsia?
Prior Hx
Obesity, HTN, DM, CKD, lupus
Hx of placental abruption, stillbirth, IUGR
Maternal age > 40 or multifetal pregnancy, use of assisted reproductive technology
How do we test for proteinuria?
Dipstick of 2+
or
Lab testing of random urine specimens: 0.03 g/l in al least two specimens
What is eclampsia?
Characterized by seizures from the profound cerebral effects of pre-eclampsia
What is HELLP syndrome?
H - Hemolysis
EL - Elevated Liver enzymes
LP - Low platelets
May occur to women who do not have HTN or proteinuria
What symptoms are indicative of HELLP?
RUQ pain, N&V
–> Often confused with gastritis, flu, gallbladder issue
What factors lead to decreased maternal perfusion with pre-eclampsia?
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
How can we prevent pre-eclampsia in those at increased risk?
Low dose ASA before 16 weeks and continued until 36 weeks
–> 81-162 mg
140 minutes of moderate intensity exercise
When should people with pre-eclampsia be hospitalized?
When there are adverse maternal effects
What medications are given to those with pre-eclampsia?
Monotherapy with labetalol, methyldopa, nifedipine
–> Or second line hydralazine
IV Magnesium
–> Increases seizure threshold
–> Keep Calcium gluconate available
Is bedrest recommended with pre-eclampsia?
No. Increased risk of DVT outweighs benefits
What is the antidote to magnesium sulfate?
calcium gluconate
What should we test regularly in a person with preeclampsia or who is being administered Mg sulfate?
DTRs
–> preeclampsia - hyperreflexia
–> MgSO4 - hyporeflexia
When should we expedite the birth in preeclampsia?
Uncontrolled HTN > 12 hours despite 3 antihypertensives
Eclampsia, stroke, TIA
Pulmonary edema
Compromised renal function
Abruption or maternal/child compromise
Concerns on EFM
What position can be helpful during pre-eclampsia?
L-lateral recumbent
What to do during a seizure?
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
What can be a sign that preeclampsia is improving following delivery? How often should we check VS?
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.
What medication would we not use to increase uterine contractions in those with HTN?
Methergine
–> Increases BP
Morbidity and mortality following eclampsia are higher in what situations?
When the eclampsia is seen before 28 weeks
Maternal age > 30
Multigravida
HTN/renal disease
No prenatal care
