Unit 5 Flashcards
Biophysical Risk Factors of a Complicated Pregnancy
- Factors that originate within the mother or fetus and affect the development or functioning of either one or both.
- Medical problems for mom/her general health
Genetic issue with the fetus - Not enough or too much weight gain during pregnancy
- Complications in pregnancy: preeclmapsia, gestational hypertesnion, diabetes
Psychosocial Risk Factors of a Complicated Pregnancy
- Consist of maternal behaviors and adverse life events that have a negative effect on the health of the mother or fetus.
- Smoking, drugs, alcohol
- Extreme stress
Sociodemographic Risk Factors of a Complicated Pregnancy
- Arise from the context in which the mother and family live.
- Low income
- Low socioeconomic status
- Lack of social support
- Ethnicity
- Age (young and old)
Environmental Risk Factors of a Complicated Pregnancy
- Hazards in the workplace and the woman’s general environment
- Secondhand smoke
- Being exposed to radiation or chemicals
- Infections in the environment (herpes, rubella, varicella)
Polyhydramnios Risk Factors
Poorly Controlled Diabetic Mother
Certain Congenital Anomalies
- GI anomaly such as esophageal atresia ( baby can’t swallow the fluid so it builds up)
- CNS congenital anomalies in baby (meningocele)
(Fetomaternal hemorrhage)
(Genetic disorders)
(Twin-to-twin transfusion syndrome)
Oligohydramnios Risk Factors
What is it a sign of?
- Renal anomalies in baby
- Maternal hypertension
- (Maternal dehydration/hypovolemia)
- Prolonged pregnancy
- Severely growth restricted fetus (IUGR)
- (Prelabor rupture of membranes)
- (Uteroplacental insufficiency)
Besides renal anomalies, it is a sign of placental insufficiency
Why we see it in prolonged pregnancy: placenta is wearing out
Chromosome abnormalities
Risk Factors
- Older maternal age
- Abnormal screening test (maternal serum AFP, quad screen, nuchal translucency)
- Ultrasound Findings (e.g., fetal structural anomalies, IUGR, amniotic fluid volume abnormalities)
- Mother that had a previous baby with a chromosomal abnormality
- (Parental chromosomal rearrangements)
Intrauterine growth restriction (IUGR) – Maternal causes
- Diabetes with vascular involvement: Retinopathy, neuropathy
- Hypertensive disorders
- Thrombophilia: Issues with clotting; Can develop thrombi in placental circulation that affect perfusion
- Cyanotic heart disease: Perfusion issues
- Chronic Renal Disease
- Collagen Vascular Disease (SLE): Lupus
- Smoking, alcohol, illicit drug use: Especially illicit drugs that are vasoconstrictors
- Poor weight gain
- Multifetal gestation
- Living at a high altitude
- ALL: Potential for placental insufficiency
Intrauterine growth restriction - Fetoplacental causes
What classifies it?
- Chromosomal abnormalities
- Congenital malformations
- Intrauterine infection
- Torch: herpes, varicella, etc
- Genetic syndromes (Trisomy 13, 18, 21)
- Usually less than 3rd percentile
- Abnormal placental development
Common Maternal and Fetal Indications for Antepartum Testing
- Chronic hypertension
- Preeclampsia (with or without severe features)
- Suspected or confirmed fetal growth restriction (IUGR)
- Multiple gestation
- Oligohydramnios
- Preterm prelabor rupture of membranes
- Late term or postterm gestation
- Previous stillbirth
- Decreased fetal movement
- Systemic lupus erythematosus
- Renal disease
- Cholestasis of pregnancy
Antepartum Testing is usually done at…
Electronic Fetal Monitoring (EFM) Indications
Nonstress test (NST)
Usually begins by 32-34 weeks of pregnancy
EFM
- Used to determine whether the intrauterine environment continues to be supportive of the fetus
NST
- Basis of the test is that the normal fetus will produce characteristic heart rate patterns in response to fetal movement
- Expect to see accelerations with fetal movement
- Performed one or two times a week
- On monitor for 20 min minimum
Non-Stress Test Interpretation
Reactive:
Nonreactive:
What to do if nonreactive:
Reactive:
- Two accelerations in a 20 minute period
- Less than 32 weeks: 2 10X10 in a 20 min period
- 32 weeks or greater: 2 15x15 in a 20 min period
Nonreactive:
- Test that does not have 2 accelerations in 20 minutes
- ALWAYS Requires further testing
- Infants go through sleep cycles, so this doesn’t necessarily mean there’s a problem
If Nonreactive:
- We can extend the test to 40 seconds
- Follow-up: BPP can be done
- Get mom to eat or drink to wake the baby up
- If found in a doctor’s office, mom could be sent to the hospital
Antepartum Testing: EFM
Contraction Stress Test
What is the purpose?
What is done?
- Also called the oxytocin challenge test (OCT)
- Identifies the jeopardized fetus that was stable at rest but shows compromise with stress
- Provides an EARLIER warning of fetal compromise than the NST with fewer false positive results
- An abnormal CST means there is an issue whereas with NSTs an abnormal result does not necessarily mean there’s a problem
Nipple stimulated contraction test: - Have patient massage one nipple for 2 minutes, rest for 5 minutes
- Stimulation of nipples causes release of oxytocin
- Cycle is repeated until adequate uterine activity is met
- We want 3 contractions in a 10 minute window
Oxytocin stimulated contraction stress test - IV Pitocin is given to stimulate uterine contractions (very low)
- Rate is increased until 3 uterine contractions occur in a 10 minute window
Contraction stress test (CST): Interpretation
Negative test: at least 3 contractions occur in a 10-minute window with no late decels (healthy fetus)
- Desirable outcome
Positive test: late decelerations occur with 50% or more of contractions
- Bad outcome, baby is compromised in some way
- Associated with IUFD (stillbirth)
Equivocal/Suspicious test: Decelerations occur with less than 50% of contractions
- Hard to tell if baby is okay or not
Unsatisfactory test : Fewer than 3 contractions in a 10-minute period or unable to maintain continuous fetal monitoring
Daily fetal movement count (DFMC)
Protocol
- Best indicator of fetal well-being, non-invasive, free, doesn’t require Dr. appointment
- Also called kick counts
- Count 2-3 times daily (after meals, before bedtime) for 2 hours or until 10 FM are felt
- Very low number of movements and/or a downward trend is concerning!
- No movement in 12 hours should be immediately investigated
- A count of fewer than 3 fetal movements within 1 hour warrants further evaluation (NST, CST, BPP)
- Obese women are usually not able to feel fetal movements as well
Ultrasonography
Abdominal vs. Transvaginal
Abdominal
- Used more in 2nd and 3rd trimester
- Client needs to have a FULL bladder; helps to push the uterus up, makes picture clearer
Transvaginal
- Sonographer inserts a lubricated probe vaginally
- Used earlier in pregnancy (1st trimester) usually first used to detect a pregnancy
- Client needs to have an EMPTY bladder; if full, it would be uncomfortable
- Useful in obese women (adipose tissue makes abdominal more difficult)
Ultrasonography
1st trimester uses vs. 2nd and 3rd trimester uses
1st Trimester Uses
- Confirm pregnancy and viability; determine gestational age
- Rule out ectopic pregnancy
- Assess for fetal cardiac activity
- How many babies? How many gestational sacs?
- Pregnancy dating
- Determine cause of vaginal bleeding
- Visualization during chorionic villus sampling
- Detect maternal abnormalities such as bicornuate uterus, ovarian cysts, fibroids
2nd and 3rd Trimester Uses
- Confirm gestational age and viability
- Looking at anatomy
- Looking for congenital anomalies
- Looking at baby’s growth (look for IUGR, macrosomia) and position
- If risk factors present, mom may do serial growth ultrasounds
- Look at placenta, look at its location (previa, abruption)
- Look at amniotic fluid level (polyhydramnios or oligohydramnios)
- Assess for preterm labor
- Visualization during amioncentesis, BPP
- Doppler flow studies
Ultrasonography: Indications
Fetal heart activity
Gestational age
Fetal growth
Fetal anatomy
Ultrasonography: Indications
Fetal genetic disorders and physical anomalies
Nuchal translucency:
What findings are associated with Down Syndrome?
Nuchal translucency:
- Can only be measured at 11-14 weeks
- Between 11-14 weeks, we can measure fluid collection at the nape of the neck
- When nuchal translucency is abnormally thick, it is associated with genetic and cardiac problems
Down Syndrome:
- Short femurs and absent nasal bone are associated with Down Syndrome
Ultrasonography: Indications
Placental position and function
Low lying placenta/ placenta previa
- Look at how close tip of placenta is to cervix; it is important that it not be too close to the cervix (bleeding issues)
Grading of placental aging
- Calcification of placenta would indicate aging
Ultrasonography: Indications
Adjunct to other invasive tests to do what?
- Completed with other tests such as amniocentesis to locate the fetus, placenta, and pocket of amniotic fluid
- Chorionic Villus Sampling and Amniocentesis are diagnostic tests US can be done with
Ultrasonography: Indications
Fetal well-being
Amniotic fluid volume:
BPP:
What is being tested?
- Amniotic fluid index (AFI) gold standard for what is measured
Biophysical profile (BPP) - Evaluates 5 markers: amniotic fluid volume, fetal breathing movements, fetal movement, fetal tone, and the reactivity on a 20 minute tracing (NST)
- 4 are US findings + NST
- Amniotic fluid tells us about placental function (usually seen in chronic issue)
- Acute issues: could still see normal fluids
- Fetal breathing movements, movements, tone, and reactivity reflects current CNS status of baby; warns of injury
- Score is out of 10 points
- If all 5 markers are present: 10/10
10: Normal; low risk for chronic asphyxia
8: Normal; low risk for chronic asphyxia
6: Suspect chronic asphyxia
4: Suspect chronic asphyxia
0-2: Strongly suspect chronic asphyxia
Amniocentesis
When is it done?
Procedure
Possible Complications + Nursing Indications
- Can be done any time after 15 weeks (need to wait for adequate amount of fluid)
- Obtains a sample of amniotic fluid
- A needle is inserted abdominally into the uterus and amniotic fluid is withdrawn with ultrasound guidance
- Amniotic fluid has fetal DNA (skin cells, urine); karyotype is done
Possible Complications
Maternal - Labor, Fetomaternal Hemorrhage (mom and baby’s blood mixes) With Possible Rh Isoimmunization, Leakage of Amniotic Fluid
- Give Rhogam to Rh- mom that gets amniocentesis!!!
Fetal - Death, Direct Injury, Hemorrhage
- Assess fetal heart tones after an amniocentesis!!!
Amniocentesis
Indications
Genetic concerns
- Fetal karyotype
Structural anomalies
- Neural tube defect (AFP is screening test for this)
- Abdominal wall defect (omphalocele)
Fetal lung maturity
- For the baby that needs to be delivered early if mom has issues
- Can be assessed by:
- Presence of PG in amniotic fluid
- Determining the Lecithin/ Sphingomyelin (L/S) ratio in the amniotic fluid
- Lamellar body count (LBC)
Amniotic fluid culture/gram stain
- Suspected chorioamnionitis
Chorionic Villus Sampling (CVS)
When can it be done?
Procedure
Nursing Indications
- Performed between 10-13 weeks
- Removal of small specimen of placenta: Sample of chorionic villus
- Reflects the genetic makeup of the fetus: Fetal karyotype
- Can be completed through the abdomen or the cervix
- Give Rhogam to Rh- mother
Maternal Morbidity and Mortality related to hypertensive disorders
- Placental abruption
- Cerebral hemorrhage/stroke
- Hepatic or renal dysfunction
- Disseminated Intravascular Coagulation (DIC)
- Cardiac failure
- Pulmonary edema
- Seizures
- Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide
Gestational Hypertension
What is it?
Diagnosis
When does it appear?
- Onset of hypertension without proteinuria or other systemic findings after 20 weeks gestation
- Systolic BP >140 OR diastolic BP >90 (doesn’t have to be both) on 2 separate occasions, more than 4 hours apart
- Greater than 140/90: mild
- Greater than 160/110: severe
- Doesn’t appear till 3rd trimester (after 26-28 weeks)
- The cure is delivery. It will not go away till after the baby is delivered.
- Potential to get worse and develop into preeclampsia
Preeclampsia
Definition/Diagnosis
Hypertension AND proteinuria OR other systemic symptoms develop after 20 weeks gestation in a woman who previously had neither condition
Can also develop in the postpartum period, but majority occur during pregnancy
Systemic involvement findings:
- Platelets: Low platelets <100,000
- Liver function: Altered, liver enzymes (AST and ALT) increase
- Kidneys: Renal insufficiency, rising creatinine (0.5-1.2 mg/dL is normal)
- Lungs: Pulmonary edema
- Brain/CNS: New onset headaches and visual disturbances (spots, flashing lights)
Risk Factors for Preeclampsia
- Primigravidity or new partner in this pregnancy (new father)
- Extremes of maternal age (young or old)
- Multiple gestation (increases a lot of potential complications in pregnancy)
- Obesity (more likely to have gestational hypertension and preeclampsia)
- Personal or family history of preeclampsia
- Certain pre-existing medical conditions (e.g., Diabetes)
Preeclampsia Pathophysiology
- Could be immunologic reaction to fetal tissue or inflammatory reaction to the cardiac changes in pregnancy
- In pregnancy, vascular remodeling widens spiral arteries in the uterus and allows for more blood flow
- In preeclampsia, vascular remodeling does not happen to the same extent; not as much blood flowing to the uterus leading to placental ischemia
- Placental ischemia causes release of toxins that cause endothelial damage and generalized vasospasm (vasoconstriction) all over the body
- Generalized arterial vasospasm (vasoconstriction) results in poor perfusion to all organs, increased PVR (peripheral vascular resistance) and BP, and increased endothelial cell permeability “leaky capillaries”
- Increased endothelial cell permeability results in intravascular fluid loss and decreased plasma volume -> edema and third spacing
Preeclampsia
Vasospasm and decreased organ perfusion leads to:
Intravascular coagulation leads to:
Increased permeability and capillary leakage leads to:
Vasospasm and Decreased Organ Perfusion:
- Hypertension
- Uteroplacental spasm: IUGR
- Cortical brain spasm: HA, hyperreflexia, seizure activity
- Retinal arteriolar spasm: Blurred vision, scotoma (blind spots)
- Hyperlipidemia
- Liver ischemia: Elevated liver enzymes, N/V, epigastric pain, RUQ pain
Intravascular Coagulation:
- Hemolysis of RBCs
- Platelet adhesion: Low platelet count, DIC
- Increased factor VIII antigen
Increased Permeability and Capillary Leakage
- Proteinuria
- Generalized edema
- Pulmonary edema: Dyspnea
- Hemoconcentration: Increased hematocrit
What is HELLP syndrome?
Signs/Symptoms?
Laboratory diagnosis for a severe variant of preeclampsia that involves hepatic dysfunction: not a separate illness
- Hemolysis (H)
- Elevated liver enzymes (EL)
- Low platelets (LP)
Presenting Symptoms
- Malaise
- Headache
- Epigastric, RUQ pain “heartburn”
- N/V
Identifying and preventing preeclampsia
Health assessment
- Accurate measurement of BP (manual = gold standard)
- Edema: distribution, degree and pitting (2mm = 1+, 4mm = 2+, 6mm = 3+, 8mm = 4+)
- Deep Tendon Reflexes: +2 is normal
- Clonus: when foot is put in dorsiflexion, it “beats” down to plantar flexion = 4+ hyperreflexia
- Association of hyperactive reflexes with seizure activity (Irritated CNS)
- Proteinuria: 24 hour urine: > 300 mg protein present
- Weight Gain : >2 kg weight gain in a week warrants further investigation
Signs and Symptoms
Mild Preeclampsia
BP ≥ 140/90
≥ 1+ protein on dipstick
≥300 mg protein in 24 hrs
Possible headache, mild and intermittent (can go away with Tylenol)
Can be treated at home
Signs and Symptoms
Severe Preeclampsia
BP ≥ 160/110
Massive proteinuria
- ≥3+ protein on dipstick
- ≥5 g protein in 24 hr urine
Decreased UOP, may see rising Creatinine
Persistent headache, more severe (do not go away)
Visual disturbances
RUQ/ epigastric pain (liver involvement)
Shortness of breath (pulmonary edema)
N/V (liver involvement)
Planning for delivery
Laboratory value changes: Preeclampsia vs. HELLP
Preeclampsia:
- H/H: normal
- Platelets: unchanged or <100,000
- BUN/Creatinine: Normal or elevated
- AST/ALT: Normal or elevated
HELLP
- H/H: low
- Platelets: <100,000
- Critically elevated ALT/AST
