Wk 13 Antepartum Safety

Question 1

Define - alpha-fetoprotein (AFP)

Answer 1

plasma protein produced by the fetus

Question 2

Define - amniocentesis

Answer 2

trans abdominal puncture of the amniotic sac to obtain a sample of amniotic fluid that contains fetal cells and biochemical substance for laboratory exam

Question 3

Define - biophysical profile

Answer 3

method of evaluating fetal status during the antipartum period based on five fetal variables: fetal heart rate variability, fetal breathing movements, gross body movements, muscle tone and amniotic fluid volume
**combines fetal heart rate monitoring (nonstress test) and fetal ultrasound

Question 4

Define - chorionic villus sampling

Answer 4

transcervical or transabdominal sampling of chorionic villi for analysis of fetal cells

Question 5

Define - contraction stress test

Answer 5

method for evaluating fetal status during the antepartum period by observing the response of the fetal heart to intermittent stress of induced uterine contractions

Question 6

Define - lecithin/sphingomyelin ratio

Answer 6

ratio of two phospholipids in amniotic fluid that is used to estimate fetal lung maturity

Question 7

Define - cordocentesis

Answer 7

known as percutaneous umbilical blood sampling

Question 8

Define - ultrasonography

Answer 8

It uses sound waves to show a picture of your baby in the uterus

Question 9

Assessment for risk factors

DEMOGRAPHIC FACTORS

Answer 9

Younger than 16 yrs or over 35 yrs old
Low socioeconomic status/need public assistance
Nonwhite
Multiparity

Question 10

Assessment for risk factors

SOCIAL-PERSONAL FACTORS

Answer 10

Low prepregnancy weight
Obesity
Under 5' in height
Smoking
Use of alcohol/drugs
Intimate partner violence

Question 11

Assessment for risk factors

OBSTETRIC FACTORS

Answer 11

Previous infant over 4000g (8lb, 13oz)
Previous preterm birth
Previous fetal or neonatal death
Rh sensitization

Question 12

Assessment for risk factors

EXISTING MEDICAL CONDITION

Answer 12

Diabetes mellitus
Hypothyroidism
Hyperthyroidism
Cardiac disease
Renal disease
Concurrent infections

Question 13

Assessment for risk factors

RACIAL AND ETHNIC MINORITIES

Answer 13

Experience a disproportionate burden of disease, disability, premature death
Infant mortality rates are highest among Native American, Alaska Native and Puerto Rican women
*Minority women in poverty have higher rates of chronic diseases: heart, cancer, hepatitis, AIDS, mental health issues

Question 14

Assessment for risk factors

UNDERLYING HEALTH CONDITIONS LEAD TO:

Answer 14

High risk for poor obstetric outcomes; self and infant
High rates of preterm labor
Gestational hypertension
Intrauterine growth restrictions

Question 15

Assessment for risk factors
ADOLESCENT GIRLS (AGES 15-19)

Answer 15

70% report sevual activity by 19
Risky behavior: eating disorders, depression, sexual activity
77% of teen pregnancies are unintended
Unprotected sex
Sexually transmitted infections rates are higher among adolescent and young adults (HPV, Chlamydia, Gonorrhea)
Misinformed about STI’s and AIDS

Question 16

Assessment for risk factors

INCARCERATED WOMEN

Answer 16

Many report a history of sexual/physical abuse
Lack of support family
Have difficulty providing emotional stability, secure housing, health promotion role model

Question 17

Assessment for risk factors

LIFESTYLE CHOICES INCLUDE

Answer 17

Risky sexual relationships
Illicit drugs
Smoking
Risk for STI, HIV, AIDS
Complicated pregnancies

Question 18

Intimate Partner Violence

Answer 18

Includes: physical, sexual, emotional, social and economic abuse
1 in 6 women are victims
4%-8% to as many as 20% are abused during pregnancy
Women do not disclose violence

Question 19

Intimate partner violence

PHYSICAL AND EMOTIONAL

Answer 19

Physical:
Occurs with mental abuse, threats, coercion
Threats, hitting, rape, weapons, even death
Emotional:
Causes shame, loss of self respect, powerlessness
The abuser blames the victim for the abuse
Social abuse; isolating from friends/family

Question 20

Intimate partner violence

THREE PHASES

Answer 20

1. Tension building phase
2. Battering incident: slaps, punches, kicking, burns and mutilation
3. Honeymoon or calm phase: partner displays kind loving behavior and leas for forgiveness.

Question 21

Cardiac disease

Answer 21

Mitral valve prolapse:
1% or woman, usually benign
Valve leaflets prolapse into the left atrium during systole
Allows back flow
Most asymptomatic:
May have chest pain, anxiety, palpitations, dyspnea, risk for endocarditis
Signs:
Auscultate late systolic murmur and midsystolic click
Pregnancy usually well tolerated:
Antibiotic prophylaxis

Question 22

Infections GBS

Answer 22

Group B Strep
Bacteria colonizes in rectum, vagina, cervix, urethra of women
Was the most common cause of neonatal sepsis and meningitis in US
Decreased of 70% with screening and admin penicillin
GBS infection in the neonate occurs in first weeks of life, usually first 24 hours

Question 23

Infections GBS

Risks

Answer 23

Risk factors for early onset include:
low birth weight
preterm birth
ruptured of membranes >24 hours
maternal fever
previous GBS infant
maternal GBS bacterium and multiple gestation

Question 24

Infections GBS

Late onset of GBS

Answer 24

1 week to 3 months (24 day average)
85% develop meningitis
50% of survivors develop neurological damage

Question 25

Infections GBS | Therapeutic management

Answer 25

Vaginal-rectal culture between 35-37 weeks gestation Penicillin G during labor for positive mother (no allergy) Penicillin and an aminoglycoside for neonate with confirmed or possible GBS (ampicillin, cefaxolin, clindamycin or erythromycin are alternative) 48 hour obs of infant if mother did not receive intrapartum prophylaxis

Question 26

Tobacco use

Answer 26

12% of women causes vasoconstriction decreases oxygen to fetus decrease maternal appetite; decreased nutrition

Question 27

Tobacco use | effects of smoking during pregnancy

Answer 27

``` Spontaneous abortion Abruptio placentae Placenta previa Premature rupture of membranes perinatal mortality ```

Question 28

Tobacco use | effects on infant

Answer 28

30% higher chance of prematurity low birth weight and length 3x higher risk of sudden infant death syndrome increased risk of learning disabilities

Question 29

Tobacco use | Nurse's role

Answer 29

Teaching: smoking cessation risks of smoking benefits of quitting

Question 30

Alcohol use stats

Answer 30

1 in 12 women drink alcohol during pregnancy 1 in 30 women drink 5 or more drinks Excessive amounts recirculated until fetal liver can break it down Teratogen CNS effects that is identified years later

Question 31

Alcohol use | fetal alcohol spectrum disorder

Answer 31

Fetal alcohol syndrome: group of severe physical, behavioral and mental abnormalities Partial fetal alcohol syndrome Alcohol related neurodevelopmental disorder: leading cause of cognitive impairment. Effects on brain are permanent

Question 32

Alcohol use | birth defects

Answer 32

``` small head low nasal bridge small eye openings short nose thin upper lip underdeveloped jaw smooth philtrum flat midface epicanthal folds ```

Question 33

Substance abuse | Marijuana

Answer 33

Most common illicit drug in US Tetrahydrocannabinal (THC) accumulates in the fetus Cocaine and alcohol often used with Marijuana Increases carbon monoxide in mother's blood and reduces oxygen to fetus Effects to infant: neurobehavioral problems, tremors and sleep disturbances

Question 34

Substance abuse | Cocaine

Answer 34

- blocks re-uptake of norephinephrine and dopamine | - produces euphoria, sexual excitement, increased alertness, hyper-arousal

Question 35

Substance abuse | Cocaine, physical effects

Answer 35

``` Less likely to seek prenatal care Poor nutrition Increased risk of STI Cardiovascular stimulation Vasoconstriction ```

Question 36

Substance abuse | Cocaine, maternal, fetal, neonate effects

Answer 36

-Abruptio placentae from vasospams-placental ishemia, reflex vasodilation and disruption of placental vaculature -severe hypertension, pulmonary edema, fetal hypoxia, meconium staining, still birth Neonate: CNS irritability, lethargy, poor response to interaction

Question 37

Substance abuse | Opioids

Answer 37

Morphine, heroin, methadone, hydromorphone, propoxyphen, oxycodone Herioin produces severe physical dependence CNS depressant Dependence is discontinuing drug causes withdrawal symptoms (abstinence syndrome)

Question 38

Substance abuse | Opioids, maternal effects

Answer 38

poor appetite, poor absorption of nutrients STI, hepatitis, HIV exposure from needle sharing spontaneous abortion Cardiac disease Thrombosis

Question 39

Substance abuse | Opioids, fetal effects

Answer 39

hypoxia (deprived of adequate oxygen supply at the tissue level) risk for meconium aspiration fetal growth restriction preterm labor, premature rupture of membranes, fetal distress, still birth

Question 40

Substance abuse | Opioids, neonatal effects

Answer 40

``` abstinence syndrome neurological and GI system signs low birth weight increase incidence of SID's child neglect and abuse ```

Question 41

Substance abuse | Management

Answer 41

Methadone replacement to prevent withdrawal in pregnancy | Buprenorphine can be used in stead of methadone: less severe neonatal withdrawal

Question 42

Substand abuse | Neonatal Abstinence Syndrome (NAS)

Answer 42

neonates demonstraes signs of drug withdrawal agitation, diarrhea, tremors, hypertonic muscle contraction, inconsolable crying, poor duck and swallow *newborns must withdraw from methadone after birth

Question 43

Genetic disorders

Answer 43

First trimester screening: Ultrasound test for fetal nuchal translucency (FNT) (fluid under the skin behind the fetal neck in the first-trimester) Pregnancy associated plasma protein-A (PAPP-A) Human chorionic gonadotropin (hCG)

Question 44

Screening tests | Maternal Assays

Answer 44

Maternal Assays - alpha fetoprotein - screening for nuerotube disorders and open ab wall defects - 80-85% detected early - recommended for all pregnant women - AFP (Alpha fetoprotein) is produced by the fetal liver and is detectable at 14-34 weeks

Question 45

Screening tests | Maternal serum quad test

Answer 45

Quad screen test is a maternal blood screning that looks for four specific substance: AFT, hCG, Estroil, Inhibin-A performed 16-18 weeks, all should be offered test Recommended for: family history of birth defets 35 years or older used harmful mediation or drugs during pregnancy diabetes and use insulin viral infection exposed to high level of radiation

Question 46

Amniocentesis | how, when, why?

Answer 46

``` ultrasound guided to obtain amniotic fluid contain fetal cells after week 15-20 weeks diagnosis of genetic disorders congenital anomalies, neurotube pulmonary maturity fetal hemolytic disease ```

Question 47

Amniocentesis | Maternal complications

Answer 47

hemorrhage, fetomaternal hemorrhage with Rh isoimmunixation (RhoGAM if neg), infection, labor, abruptio placentae, inadvertent damage to intestines, bladder and amniotic fluid embolism **mom report if having contractions, vag bleeding, leaking of fluid, fever

Question 48

Amniocentesis | Fetus complications

Answer 48

Death, hemorrhage, infection (amnionitis), direct injury from needle, miscarriage, preterm labor, leakage of fluid.

Question 49

Chorionic villus sampling

Answer 49

Removal of small tissue specimen from the fetal portion of the placenta Transcervically Transabdominally

Question 50

Chorionic villus sampling advantages disadvantage complications

Answer 50

``` Advantages: earlier diagnosis: fetal chromosomal, metabolic or DNA dx. Rapid results Disadvantage: risk to the fetus Complications: vag spotting/bleeding miscarriage rupture of membranes Chorioamnionitis (infection) **Rh negative should receive immune globulin to avoid isoimmunization from fetomaternal hemorrhage (mixing of Rh neg and Rh pos ```

Question 51

PUD or Cordocentesis

Answer 51

PUD- Percutaneous umbilical blood sampling fetal circulation during 2nd and 3rd trimester fetal blood sampling transfusion in severally anemic fetus

Question 52

PUD or Cordocentesis | testing for?

Answer 52

inherited blood disorders Karyotyping of malformed fetus (detect chromosomal abnormalities) detection of fetal infection acid base status with IUGR (interutern growth restrictions assess/treat isoimmunization and thrombocytopnia

Question 53

PUD or Cordocentesis | complications

Answer 53

``` leaking fo blood cord laceration thromboembolism preterm labor premature rupture of membranes infection ```

Question 54

PUD or Cordocentesis | nursing role

Answer 54

FHR monitoring for 1 hour | repeat ultrasound in 1 hour to ensure no bleeding or hematoma

Question 55

Biophysical profile

Answer 55

Noninvasive dynamic assessment, physical exam, vital signs assessment of acute/chronic markers of disesae fetus response to central hypoxia (acidosis) by alteration of movement, muscle tone, breathing, HR Accurate indicator of impending fetal death **combines fetal heart rate monitoring (nonstress test) and fetal ultrasound

Question 56

Biophysical profile scoring

Answer 56

An abnormal score and oligohydramninos (small amount of amniotic fluid) indicate labor should be induced 8-10 is reassuring <4 is nonreassuring (labor should be induced)

Question 57

Nonstress test

Answer 57

most widely applied technique - noninvasive - takes 20-30 min - in healthy fetus with an intact CNS, 90% of gross fetal body movements are associated with FHR accelerations * **2 fetal heart increases within 20 sec period. 15bpm above baseline within 15 seconds

Question 58

Nonstress test, movement responses may be blunted by?

Answer 58

``` hypoxia acidosis drugs (analgesics, barbiturates, B-blockers) fetal sleep congenital anomalies ```

Question 59

Nonstress test disadvantages

Answer 59

high rate of false positive results for nonreactivity as a result of fetal sleep cycles, chronic tobacco smoking, medications, fetal immaturity

Question 60

Nonstress test reactive and nonreactive tracings

Answer 60

Reactive: 2 or more fetal heart increases of 15bpm above baseline within 15 seconds over a 20 min period normal baseline rate moderate variability Nonreactive: test does not meet criteria in 40 minutes

Question 61

Contraction stress test

Answer 61

To identify the jeopardized fetus that is stable at rest but evidence of compromise after stress - uterine contractions decrease uterine blood flow and placental perfusion - time consuming and expensive - invasive procedure if oxytocin stimulation is required - contraindicated in those at risk fo preterm labor, previous C-section, placenta previa

Question 62

Contraction stess test

Answer 62

- Nipple stimulated contraction test- massaging nipples release of oxytocin. with adequate contractions, stop stimulus - Oxytocin stimulated- IV at low dose until 3 contractions within 10 min * Negative: no late deceleration observed with contractions (want negative) * Positive: repetitive lat decelerations

Question 63

TORCH stands for?

Answer 63

``` Toxoplasmosis Other Rubella infection Cytomegalovirus infection Herpes simplex virus ```

Question 64

TORCH "T"

Answer 64

Toxoplasmosis -carried in cats that hunt infected birds/mice, excreted in feces -hand to mouth infection, ingesting raw meat from cattle/sheep grazing on contaminated fields, unwashed/unpeeled fruits/vegetables ->70% infants are asymptomatic -perinatal mortality/morbidity (10-15% die) -85% severe psychomotor problems or cognitive impairment by age 2-4 -50% visual problems by 1 Treatment: pyrimethamine and oral sulfadiazine and folic acid to prevent anemia

Question 65

TORCH "O"

Answer 65

``` Gonorrhea Hepatitis B Syphilis Varicella-zoster virus Parvovirus B19 HIV ```

Question 66

TORCH "R"

Answer 66

Rubella infection aka German or 3 day measles Risk: vaccination failures, lack of compliance, immigration of unimmunized Postpartum: Rubella titer and IgM and IgG HI antibody titer <1:8 with little/no immunity HI antibody titer >1:10-1:20 successfully imunized or had disease IgM (recent infection) IgG (prior infection/vaccination) interpretation

Question 67

TORCH "R" Rubella vaccine: postpartum

Answer 67

Live attenuatd virus, not communicable, can breastfeed Virus shed in urine/body fluids DO NOT GIVE if mother/person in household is immune compromised Made of duck eggs Avoid pregnancy for 1 month Infant born with rubella may culture positive for up to 18 months after birth Should be isolated until pharyngeal/urine are free of virus

Question 68

TORCH "C"

Answer 68

Cytomegalovirus infection -can lead to miscarriage, still birth, congenital illness -asymptomatic at birth but may sensorineural hearing impairment/learning disabilities later 10% may have IUGR and microcephaly Rash, jaundice, hepatosplenomegaly

Question 69

TORCH "H"

Answer 69

Herpes simplex virus -transplacental infection -contamination during passage through infected birth canal -transmission from infected personnel/family -organ involvement: liver, adrenal glands, lungs -skin vesicles in 33% sepsis symptoms in 1st or 2nd week of life -25% death from CNS involvement, respiratory distress, pnemonititis, shock, bleeding

Question 70

TORCH "H" treatment

Answer 70

``` Herpes Simplex Virus standard precautions inspect eyes, oral, skin for lesions blood, urine and CSF cultured circumcision delayed breastfeed ok if no lesions prophylactic eye ointment for 5 days parenteral acyclovir for neonatal herpes ```