Pre-term Labor Flashcards
Preterm labor
infant who born before 37 weeks gestation is consider preterm birth
34-36 =late preterm
<34= early preterm
preterm labor risk factors
history
previous preterm birth pregnant women born preterm short cervical length ( less than 25mm between 24-28 week) prior cervical surgery uterine surgery
preterm labor risk factors
maternal factors
smoking low maternal body weight (BMI 40 years stress substance abuse (cocaine crack heroin) low socioeconomic status
preterm labor risk factors
current pregnancy
cervical insufficiency/short cervix multiple gestation hydramnios (polyhydramnios) pyelonephritis severe maternal illness intrauterine infection imminent fetal jeopardy (isoimmuniztion with hydrops, fetal growth restriction with evidence of compromise)
preterm labor risk factors (associate factors)
asymptomatic bacteria lower uterine infection genital tract infections periodontal disease vaginal bleeding
preterm labor risk factors ( preventable iatrogenic)
failure to accurately determine gestational age
elective induction of labor
ill-timed cesarean birth
signs & symptoms of preterm labor
pelvic pressure lower back pain abdominal tightness or "cramps" contractions more than 6 per hour fetus dropping low into pelvis before 36 weeks increased vaginal discharge vaginal bleeding diarrhea.
Diagnose preterm labor
regular uterine contractions accompanied by a change in cervical dilation, effacement, or both or initial presentation with regular contractions and cervical dilation of at least 2cm
Cervical length
associated with preterm labor
short cervix
sonographic cervical length of 10-20mm (or less than 25mm) measured at 18 to 24 weeks’ gestation
women with very short cervix less than 15mm prior to 24 weeks gestation regardless of other risk factors need immediate medical consultation for consideration of cerclage placement. ***
Transvaginal Ultrasound
Gold Standard for cervical length measurement
fetal fibronectin
glycoprotiein that acts as an adhesive between the fetal membranes and the maternal decidua.
fetal fibronectin present in cervicovaginal secretions before 20 weeks gestation & after 37 weeks gestation.
not recommend to use as screening tool
what effect fetal fibronectin
sexual activity within 96 hours
vaginal bleeding
collect before digital examination
Sterile Speculum Examination
examine the cervix to see if it open (dilating or thinning (effacing)
find out how far the baby has moved down the birth canal (station)
check for fluid leaking from your vagina
Progesterone therapy
anti-inflammatory effect & increase progesterone in maternal tissue (decrease progesterone = labor)
use for women with hx of preterm & start at 16-36 weeks.
for asymptomatic women w/o prior preterm birth incidentally identified less than or equal to 20mm before 24 weeks of gestation.
progesteron does not reduce the incidence of preterm birth in women with twin or triplet
magnesium sulfate
for neuroprotection reduce occurence of cerebral palsy
given before 32 week
corticosteroids
accelerate fetal organ maturation
given between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery w/in 7 days.
regardless of membrane status
Premature rupture of membrane
membrane rupture before labor and before 37 weeks of gestation
premature rupture of membrane etiology
intraamniotic infection history of preterm PROM short cervical length second & third trimester bleeding low body mass index low socioeconomic status cigarette smoking illicit drug use
complications/risk for PROM
respiratory distress sepsis intraventricular hemorrhage necrotizing enterocolitis neurodevelopmental impairment early gestational age at membrane rupture increase risk of white matter
diagnosis of PROM
visualization of amniotic fluid passing from cervical canal and pooling in the vagina;
a basic pH test of vaginal fluid
arborization (ferning) of dried vaginal fluid
normal vaginal secretion VS amniotic fluid
vaginal secretion 4.5-6.0
amniotic fluid 7.1-7.3
management of PROM
electronic fetal monitoring
uterine activity monitoring
determine gestational age
nonreassuring fetal status & clinical chorioamnionitis are indications for delivery.
vaginal bleeding should raise concern for abruption placentae
antibiotic for PROM
for preterm ROM less than 24 week
combination of erythromycin and ampicillin or amoxicillin is recommended.
corticosteroid for preterm labor
24-34 weeks
magnesium sulfate for PROM
before 32 weeks
tocolytic for PROM
not recommend
Gestational Diabetes Mellitus
glucose intolerance with onset or first recognition during pregnancy.
associated risk for GDM
obstetric morbidity
fetal macrosomia
perinatal death.
risk factors for GDM
age over 25 or 30 years old BMI over 25 or 27 Ethnic origin: non Caucasian women DMI or II or GDM in first degree relative Previous hx of GDM
sign & symptoms of GDM
fasting sugar >105 mg/dL or postprandial (2hours) >120mg/dL glycosuria loss of energy size larger than appropriate for dates polyuria polydipsia
DX / screening for GDM
50 gram 1 hour glucose challenge w/o previous fasting >130 mg/dL or 140mg/dL , then 3 hours glucose test if >200mg DX GDM 3 hours GTT @ 24-28 week fasting >95mg 1hr >180mg 2hr >155mg 3hr> 140mg
management diet for GDM
diet: Folate, six small meal, complex carb 35-40 of diet, fat 30% or less, 1800-2400kcal/day
* underwt: 40kcal/kg/day
* average wt: 30kcal/kg/day
* overweight 24kcal/kg/day
* obese: 12-15kcal/kg/day
oral hypoglycemic
more convenient, reduce risk of hypoglycemic compared to insulin
glyburide
use after organegenesis (3rd - 8th weeks)
metformin
first line oral medication
insulin therapy
when more than 20% of the 2 hours postprandial glucose values exceed 120mg/dL
glucose monitoring
twice weekly start at 32 weeks
perform daily fetal movement counts
antenatal surveillance
ultrasound fro EFW & growth discrepancies
NST
BPP
Labor & Delivery –> 40 week induction
indication for induction
4o weeks positive non-reassure FHT on insulin therapy fetal macrosomia poor/marginal control
Midwife scope of practice for GDM
midwives may provide prenatal care to women with GDM or controlled type 2 DM in collaboration with a physician, appropriate subspecialist & nutritional support personnel
management of type 1 or GDM that is require insulin is generally REFERRED
Iron Deficiency Anemia
microcytic hypochromic plasma iron level low high iron binding capacity LOW SERUM FERRITIN (diagnosis) increased level of free erythrocyte protoporphym
Iron deficiency Anemia risk factor.
tobacco use hx closed spaced pregnancies blood loss heavy menses chronic illness malabsorption syndrome (nookworms, bariatric surgery) living in high altitudes malignancy African descent mediterrance descent asian descent
signs & symptoms IDA
fatigue dizziness headache sore tongue PICA dyspnea palpitation/ tachycardia antacid & calcium supplement reduce iron absorption in the gut.
lab values for iron deficiency anemia
MCV <11g/dL RDW increased serum ferritin decreased total binding capacity increased. stool for occult blood
management of iron deficiency anemia
FeSO4 325mg PO TID (has 60mg of Elemental iron per tablet)
prevention: Elemental iron 30mg PO qday –get from prenatal vitamin
take iron with vitamin C for best absorption
take at HS
avoid caffeine & black teas
***GI symptoms for 10-20% who take iron supplements
IDA associated with
low birth weight
preterm birth
low iron store in offspring
increased susceptibility to infection
hemoglobin level
12-13
IDA 9-12
severe IDA 6-7
mean corpuscular volume (MCV)
80-100
IDA <80
RBC morphology IDA
hypochromic
microcytic
serum ferritin
10-150ng/mL
IDA <10
total iron binding capacity (TIBC)
216-400
IDA 350-400
severe IDA >410
Folate Deficiency Anemia
cause by alcoholism liver disease myelodyplasia aplastic anemia hypothyroidism increased reticulocyte count MCV >100fL
neural tube defect
neural tube closes between 4-6 weeks after LMP
women should start supplement in preconception period if possible and at the first prenatal visit if not already taking a prenatal supplement
treatment for Folate deficiency
4mg of folic acid per day starting 1 month before conception and through the first 4 months of pregnancy.
who is at risk for Folate deficiency
previous pregnancy complicated by NTD
women who take anticonvulsant medication
type I or type 2 DM
family hx of NTD
lab values for Folate deficiency
MCV >100 macrocytic
increased RDW
hypersegmented neutrophils
Fetus Low birth Weight & Neutral Tube Defect
Sickle Cells Disease
autosomal recessive inheritance pattern sickle cell associated with hemolytic anemia and multiorgan dysfunction secondary to microvascular destruction by RBC agglutination
women with SS accumulate iron & become Iron overload despite having microcytic anemia
Sickle Cell Trait
asymptomatic increased risk for UTI Iron deficiency and need iron supplement (when not accumulated) predominantly in African Descent (prevelance in
Sickle cell pathophysiology
hemoglobin in RBC are carrier of oxygen from lungs to vital organ and transfer CO2 to lungs
instead of HbA, sickle cell is HbS
sickle cell cause blockage in blood vessel impairing blood flow to organs and limbs resulting episode of chronic acute pain or vaso-occlusive crisis, severe bacteriuria infection & necrosis
concerns about Sickle Cells
increase sickle cell crisis spontaneous abortion PTL preeclampsia fetal growth restriction prematurity low birth weight still birth.
screening & diagnosis for SCD
all women 8-10 weeks full blood count Hb electrophoresis father screen too -d/t the risk of fetus affected pneumonoccocal vaccines swine flue streptococcus pneumonia heamophilus influenza are common in SCD
Mediation for SCD
frequent blood transfusions (<6g/dL is the lower limit for blood transfusion)
iron chelations agent to reduce subsequent iron overload
iron supplement only given by venous blood sample
Folate deficiency d/t growing fetus. 5mg daily
low dose aspirin taken from 12 week of pregnancy is recommended
pain management
morphine and diamorphine are preferred opioid used for crisis pain pethidine is not recommended. oxygenation oral fluids IV if vomiting/diarrhea or severe pain
induction of labor for SCD
at 40 weeks
vaginal delivery is best mode of delivery for SCD
syntocinon is preferred
Thalassemia
Southeast Asian or Mediterranean descent
normal iron indices
low MCV
partner testing and genetic counseling if beta or alpha thalassemia trait is identified
Thalassemia associated with what risk during pregnancy
Diabetes
cardiovascular disease
alpha thalassemia
non immune fetal hydrops
intrauterine fetal death
beta thalassemia
uncomplicated pregnancies but increase risks for oligohydramnios and fetal growth restriction
G6PD deficiency
inadvertent use of medications such as nitrofurantoin (Macrobid, Macrodantin) and sulfa derivatives (including Bactrim)
which cause hemolysis
neonatal hemolysis from inherited G6PD deficiency can lead to severe jaundice and kernicterus
Therefore at time of birth neonatal provider should be aware of maternal or parental family hx consistent with G6PD deficiency.
Fetal Growth Restriction (FGR)
EFW below 10th percentile for gestational age
what is associated with FGR
constitutional small stillbirth chromosome abnomalities genetic gene mutation inborn errors of metabolism intrauterine infections multiple gestation chronic malnutrition substance abuse previous history of fetal growth stress depression expose to certain meds (Depakene) obesity abnormal placental attachment to the uterus reduced perfusion secondary to maternal vascular disease
FGR surveillance
no increase or slower than expected increases in fundal height
poor or no maternal weight gain
development of risk factors such as hypertension
obtain USN
consult with physician
polyhydramnios (hydramnios)
excessive amount of amniotic fluid
Amniotic Fluid Index (AFI) of 24 cm or more
or maximum deepest vertical pocket that is 8cm or more.
causes of polydramnios
multiple gestation especially monozygotic twins pre-gestational DM GDM infections isoimmunization fetal-maternal hemorrhage fetal chromosomal abnomalities. GI tract tracheoesophageal fistual and CNS anomalies including anencephaly and meningomyelocele
polyhydramnios findings
when uterine enlargment maternal abdominal girth
fundal height are larger than expected for the fetus’s gestational age.
difficult to auscultate fetal heart tones and palpate fetal outline & fetal parts
unstable lie- and change in lie may be detected during Leopold maneuvers.
s/x polyhydramnios
dyspnea lower extremity and vulvar edema pressure pains in the back abdomen and thigh heartburn or nausea vomiting
complications of polyhydramnios
preterm labor secondary to uterine distention premature rupture of membranes, malpresentation of fetus cord prolapse abruptio placenta dysfunctional labor postpartum hemorrhage. GDM alloimmunization
oligohydramnios
abnormally low volume of amniotic fluid.
amniotic fluid volume in the third trimester of less than 5cm pocket in a singleton pregnancy or less than 2cm pocket in a twin pregnancy is considered oligohydramnios.
complications of olygohydramnios
genitourinary abnormalities sucha s malformed or absent kidneys, premature rupture of membranes, uteroplacental perfusion abnormality and posterm pregnancy
amniotic fluids function
required for normal chest expansion and fetal breathing
oligohydramnios develops between 24 and 34 weeks is associated with major fetal anomalies, fetal growth restriction, and preterm birth.
s/sx oligohydramnios
molding of the uterus around the fetus.
fetus easily outlined
fetus that is not ballottable
fetus that is lagging fundal height
surveillance of oligohydramnios
increase hydration
frequent surveillance of fetal well being that includes fetal movement counts, nonstress tests
BPP and possilby color ultrasound to determine the Doppler indices in the umbilical vessels will be initiated.
multiple gestation
two or more fetus
major fetal risk is preterm birth and fetal growth restriction.
major risk factor for multiple gestation
preterm birth fetal growth restriction fetal anomales early pregnancy loss stillbirth FGR placenta previa preterm labor & birth GDM preeclampsia malpresentation dysfunctional labor
sign & symptoms of multiple gestation
large for dates uterine size, fundal height, abdominal girth, associated with rapid uterine growth during the second trimester
severe nausea & vomiting (high hCG levels)
history of recent use of ovulation inducing drugs (Clomid) or menotropins (Pergonal)
Abdominal palpation of three or more large parts or multiple small parts
Auscultation of more than one clearly distinct fetal heart tone (different by more than 10 beats per minutes and separate from the maternal pulse)
survellaine for multiple gestation
more frequent prenatal visit
serial ultrasound to monitor growth
earlier changes in home and work responsibilities
ultrasound perform every 3-4 weeks from 20weeks until term
extra nutrition
management
limit activity
increase rest
use condom- prostaglandins in semen can cause uterine irritability or may extend to complete pelvic rest including avoidance of orgams,.
fetal demise
before 20 weeks is miscarriage
after 20 weeks stillbirth or fetal death
s/sx fetal demise
loss of fetal movement
inability to detect fetal heart tones
management
induction
expectant
complication of fetal demise
DIC - fetus is retained in utero for more than 4-5 weeks
d/t slow release of tissue factor from fetal tissue
coagulation studies consisting of thrombobin, partial thrombin fibrinogen and platelets may be performed to screened for DIC prior induction and at intervals in expectant management continues beyond a week or two.
