Module 6 Unit B Flashcards
What is the pattern of fundle height measurement associated with size less than dates?
Serial fundal height measurements help to determine- concernings is measurement of 3 cm less than dates in women with certain pregnancy dating.
Slow increase or no increase in fundal height
Slow or no increase in maternal weight gain
What is the difference between small for gestational age and fetal growth restriction?
SGA= born at term below the 10th percentile for gestational age, weight relative to gest age
FGR=
Asymmetric - estimated weight is below the 10th percentile but the head circumference is larger than the 10th percentile
Most common type
Typically later in pregnancy, after 30 weeks
Symmetric - both the head and body weight are measuring less than 10th percentile together.
Newer terms will put FGR at <5 percentile for growth.
What is the difference between symmetric and asymmetric fetal growth restriction?
Asymmetric - estimated weight is below the 10th percentile but the head circumference is larger than the 10th percentile
Most common type
Typically later in pregnancy, after 30 weeks
Symmetric - both the head and body weight are measuring less than 10th percentile together.
What are potential causes of symmetric fetal growth restriction?
Chromosomal or congenital anomalies
Infections, such as CMV and rubella
Exposure to other teratogens, such as smoking, alcohol, cocaine, narcotics,
Exposure to antiseizure medications such as phenytoin or valproate
When does symmetric fetal growth restriction typically occur?
During the period of hyperplasia, making it is less amenable to improvement by prenatal interventions.
What are potential causes aymmetric fetal growth restriction?
Asymmetric FGR is usually the result of uteroplacental insufficiency, which causes chronic fetal hypoxemia and malnutrition in utero, with onset most common in the third trimester.
When does asymmetric fetal growth restriction typically occur ?
Most common in the third trimester.
In this case, the insult occurs during the phase of hypertrophy, causing the fetal cell to be smaller in size but normal in number.
What are risk factors for SGA and FGR?
Maternal prepregnancy conditions Hypertensive disorders Diabetes Renal disease Collagen vascular disease Autoimmune disorders Thrombophilias Some hemoglobinopathies Severe anemia Prepregnancy BMI <20 or ≥30 Use of assisted reproductive technologies
Present pregnancy conditions
Multiple gestation
Hypertensive disorders
Inadequate weight gain, particularly if associated with
low protein intake
Placental abnormalities (circumvallate placenta,
placenta accreta, single umbilical artery, partial
placental infarction, hemangioma, placental abruption,
and placenta previa)
Relative hypoglycemia or a “flat response” on a 3‐hour
glucose tolerance test, reflecting reduced glucose
supply to the placenta
Unexplained abnormal serum genetic screening
Prior maternity and family history
Prior history of FGR infant
Family or personal history of infant with chromosomal abnormalities, congenital malformations, or genetic syndromes
Maternal teratogenic exposures Smoking Moderate alcohol use Substance use Environmental exposures
Maternal exposure to infection (especially during the first trimester) CMV Rubella Toxoplasmosis Herpes simplex Syphilis
What is the clinical presentation for SGA and FGR?
The clinical hallmark of FGR is a fundal height measurement of 3 cm less than dates in women with certain pregnancy dating.
Experienced clinicians sometimes detect a fetal weight smaller than expected for gestational age through palpation.
These physical findings have a low sensitivity in detecting FGR, but they are often the trigger to initiate further testing.
How can the nurse midwife diagnose SGA and FGR?
Experienced clinicians sometimes detect a fetal weight smaller than expected for gestational age through palpation.
Diagnosis of FGR is made by consecutive ultrasound measurements performed at least 3 weeks apart
What are the potential fetal and neonatal implications of SGA and FGR?
Increased perinatal and neonatal morbidity and mortality, Developmental delays and disabilities
Cerebral palsy
Some adult‐onset diseases
What are the antenatal management options for SGA and FGR fetuses?
Once FGR is diagnosed, targeted ultrasounds are performed to evaluate fetal anatomy and AFV.
This will assist in determining if fetal anomalies or signs of aneuploidy are the cause of the FGR, in conjunction with genetic counseling and testing.
Serial fetal growth ultrasounds are commonly performed at 3–4 week intervals to assess the fetal growth curve
Measurements of the biparietal diameter (BPD), head circumference (HC)/abdominal circumference (AC) ratio, fetal weight, and AFV should be included.
The fetal AC provides the best single measurement to screen for poor growth.
Serial arterial Doppler flow studies of the umbilical artery are performed weekly or biweekly to assess for the presence of fetal acidemia.
Serial NSTs performed every 3–7 days, depending on the fetal risk status, also provide evidence of fetal acid–base status.
The BPP or modified BPP provides a highly sensitive reflection of chronic hypoxia and is an important component of fetal assessment.
An estimate of AFV by itself is poorly correlated with fetal acidemia; however, a declining AFI in the presence of FGR is an indicator of worsening uteroplacental function and warrants a complete BPP, umbilical artery Doppler flow studies, and/or a period of prolonged monitoring.
Daily maternal evaluation of fetal movement is an appropriate adjunct to antepartum fetal surveillance.
The decision to continue expectant management with close monitoring or to schedule an immediate induction is one that is determined in collaboration with or after referral to a physician colleague, depending on the practice model and setting.
What is the midwifery intrapartum management for SGA and FGR fetuses?
Continuous electronic fetal monitoring, umbilical core my umbilical cord blood analysis, watch for fetal intolerance of labor
What is the midwifery management meant for SGA and FGR fetuses?
Collaborative unless preterm < 34-week delivery is indicated or need for cesarean
How can FGR be prevented?
Eliminate exposure to substances, medications, infections.
Regular and early prenatal care, healthy diet, steady weight gain.
What is the clinical definition of oliogohydramnios?
Oligohydramnios= abnormally low volume of amniotic fluid, typically <5cm in singleton preg
Oligohydramnios is diagnosed by ultrasound and defined by varying parameters, such as an amniotic fluid volume (AFV) of ≤200–500 mL, a deepest vertical pocket (DVP) of ≤2 cm, or an amniotic fluid index (AFI) of ≤5 cm.
What is the clinical presentation of oliogohydramnios?
Fetus easily palpated in abdominal exam, fetus not ballotable, lagging fundal height
What are risk factors for oliogohydramnios?
Early- Fetal anomalies, such as renal agenesis, dysplasia, or obstructive disorders, where there is either a lack of urine production or the inability to pass urine.
Preterm prelabor rupture of membranes (PPROM), midpregnancy oligohydramnios,
In the third trimester, oligohydramnios is more commonly associated with either uteroplacental insufficiency or post‐term pregnancy.
Congenital anomalies (renal agenesis, viral diseases, FGR, uteroplacental insufficiency, PPROM , and post-term pregnancy, substance abuse)
How is oliogohydramnios diagnosed?
- Accurate pregnancy dating and serial assessment of fundal height are essential to detecting oligohydramnios.
- Leopold maneuvers reveal an easily palpated fetus when amniotic fluid is low.
- If the woman’s fundal height is measuring smaller than expected by dates, a screening ultrasound should be obtained, if not previously performed, to confirm the expected date of birth (EDB) and evaluate fluid volume.
The status of the amniotic sac should be evaluated by history and physical exam as indicated.
If screening ultrasound for dating has been performed and EDB is confirmed, a targeted ultrasound should be scheduled to obtain an anatomy scan and AFV.
What are the potential fetal and neonatal implications of oliogohydramnios?
Cerebral palsy
adult-onset CV disease
increased risk of meconium‐stained amniotic fluid (MSAF)
fetal intolerance of labor
neonatal intensive care unit (NICU) admissions
poor neonatal outcomes.
Meconium aspiration syndrome, with its risk of chemical pneumonitis and neonatal death, is one of the more serious sequelae associated with MSAF in the presence of oligohydramnios.
What level of midwifery management is indicated in patients with oliogohydramnios?
Collaborative unless preterm < 34-week delivery is indicated or need for cesarean
How accurate is ultrasound measurement in determining fetal weight for the SGA fetus?
US gives an estimate of weight off of measurements r/t typical gestational age for that measurement.
In SGA, EFW can be off by 25% when EFW is <1800g, but typically is off by about 20%
When US EFW suggests a small fetus <10th percentile, it may deviate from actual birth weight
As much as 20% in 95% of cases
5% of cases deviation >20%
<1800g (4 lb) EFW inaccurate as much as 25%
Differentiate chorionicity of placentation with twins.-
Dichorionic/Diamniotic= two embryos, two amnions and two chorions, separate or fused placentas
Monochorionic/Diamniotic= one chorion, two amnion
Monochorionic/Monoamniotic= one chorion and one amnion
Monozygotic twins come from 1 egg and 1 sperm, they are identical
Dizygotic twins come from two eggs and two sperm cells
Chorionic refers to placenta while amniotic refers to bag of waters.
Monozygotic twins may be mono or dichorionic.
Dizygotic twins are always dichorionic and therefore diamniotic, may have a fused placenta
What are the risks of multiple gestation to the birthing person?
GDM preeclampsia acute fatty liver disease PUPPS rash DVT/PE ICP dysfunctional labor
What are the risks of multiple gestation to the fetus?
Preterm labor/preterm birth
low birth weight
congenital malformations
CP
stillbirth
TRAP syndrome (Tumor necrosis factor
receptor-associated periodic syndrome (TRAPS)
is arare multisystem genetic
disordercharacterized by unexplained periodic
episodes or attacks of fever associated with
additional symptoms including muscle pain
(myalgia), abdominal pain, headaches and
skin rashes.
TTTS (in monochorionic twins)
FGR
malpresentation
What antepartum counseling/teaching should the nurse midwife give to a patient with a multi fetal gestation?
Nutritional counseling
P & P p. 544
What is amniofusion?
During Eminem fusion, sterile eye synthetic fluids such as lactated Ringer solution or normal saline is instilled into the uterine cavity transvagically transvagically via intra uterine catheter to replace or expand amniotic fluid volume.
Amniofusion is recognized as an effective way to reduce fetal risks associated with chord compression, particularly when seen in association with oliogohydramnios.
When is amnio fusion indicated?
Amniofusion is recognized as an effective way to reduce fetal risks associated with chord compression, particularly when seen in association with oliogohydramnios.
Indications- treatment of variable or prolonged decels - only recommended indication
Prophylaxis for oligohydramnios, attempt to dilute or wash out thick meconium-stained fluid
When is ambiel infusion contraindicated?
Contraindications- known or suspected infection or IAF since this goes through an IUPC, polyhydramnios, multiple gestation, cat 3 FHT, abruption, non-cephalic presentation
How is amnio infusion performed?
Procedure- IUPC catheter can infuse warmed saline, normal is 500-800ml bolus followed by 3ml/hr
What are the potential complications of amnio infusion?
Potential complications- infection risk increases with use of IUPC, fetal intolerance, uterine overdistension, uterine hypertonus, uterine rupture, placental abruption
What is extra ovular replacement?
Placement of a IUPC outside the amniotic membranes without.
