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Flashcards in 8. High Risk Pregnancy Deck (93):
1

Three biggest risk factors for maternal mortality

PIH
PPH
PE

2

Hypertensive disorders of pregnancy (3)

o Pregnancy-Induced HTN (PIH)
o Pre-Eclampsia
o Eclampsia

3

PHI: Def

HTN in pregnancy with onset after 20 weeks gestation

4

Chronic HTN in pregnancy

• Onset before 20 weeks
• Continuing past PP period (42 days)

5

HTN: Def (#s)

+ 140/90

6

Pre-eclampsia: Def

PIH with proteinuria

7

DIagnosis of PIH

Proteinuria on two separate tests at least 6 hours parat

8

Can pre-eclampsia occur postpartum?

Yes, up to 48 hours

9

Pre-eclampsia "triad" of symptoms symptoms (3)

• HTN
• Proteinuria
• Edema

10

Pre-eclampsia 2ndary symptoms (4)

• Headaches
• Visual changes
• Epigastric pain
• Sudden excessive weight gain

11

Why would a pre-eclampsia patient experience headache and visual changes?

Vasoconstriction → Increased pressure

12

Why would a pre-eclampsia patient experience epigastric pain?

Decreased perfusion to the liver → Elevated liver enzymes

13

Diagnosis of mild preeclampsia
• 2 Diagnostic criteria
• 2 characteristics patient would have

o BP 140/90
o 2+ to 3+ protein

o Moderate puffiness
o Deep tendon relfexes are WNL

14

Diagnosis of severe preeclampsia
• 2 diagnostic criteria
• 4 other characteristics patient would have

o BP 160/110
o 3+ to 4+ protein

o Generalized edema and noticeable puffiness
o Hyperreflexive
o Symptomatic
o Oliguria

15

Management of mild preeclampsia

o Rest in LLP Periodically
o High protein and high calorie diet
o Fetal movement counting

16

Management of severe preeclampsia

o Hospital and bed rest
o Decreased environmental stimulation
o Is and Os
o Fetal assessment (NST/BPP)
o Magnesium sulfate

17

Eclampsia (def)

Pre-eclampsia with convulsions

18

Treatment of eclampsia

Magnesium sulfate therapy

(BIRTH IS THE ONLY CURE)

19

Mechanism of Magnesium sulfate in eclampsia

Blocks neuromuscular transmission, causes vasodilation

20

Loading dose of magnesium sulfate for eclampsia

IV piggyback 4-6 grams over 15-30 minutes

21

MAintenance dose of magnesium sulfate for eclampsia

2g/h

22

Safe magnesium serum levels

4-7 or 8

23

Signs and symptoms of magnseium toxicity (5)

• Decreased respiratory rate
• Decreased urine output (oliguria)
• Feeling of warmth, nausea
• Muscle weakness, decreased reflexes
• Slurred speech

24

Risk factors for eclampsia (10)

• Chronic renal disease
• Chronic HTN
• Diabetes
• Obesity

• Primigravity
• Twin gestation

• Family hx of PIH
• History of Preeclampsia in past pregnancies

• Maternal age < 19 or > 40 years old

• Rh Incompatibility


25

HELLP Syndrome (def)

Life threatening occurrence that compromises 10% of people with PIH. Acronym for lab results.

26

What does HELLP stand for

• H - Hemolysis
• E - Elevated
• L – Liver Enzymes
• L - Low
• P – Platelets

27

Platelet levels with HELLP

Typically below 100,000 (normal ~ 150,000 – 400,000); coagulants are all normal. Abnormal Clotting factor.

28

Causes of early pregnancy bleeding: (5)

o Spontaneous abortion
o Molar pregnancy
o Incompetent cervix
o Ectopic Pregnancy
o Implantation spotting

29

Spontaneous abortion
- Definition
- Criteria for "early"
- Criteria for "late"

• Def: Pregnancy that ends before 20 weeks
• Early: Prior to 12 weeks
• Late: 12-20 weeks

30

• _____% of clinically recognized pregnancies end in abortion
• ___% of this is related to
____________

• 10-20%
• 50% related to chromosomal abnormalities

31

Complete abortion: def

Fetus and all of the products of conception have been expelled from the uterus

32

Incomplete abortion (def)

Loss of pregnancy; some but not all of the products of conception have been expelled from the uterus

33

Threatened abortion: Def

Possible loss of pregnancy with early signs and symptoms.

34

Four characteristics of a threatened abortion

• Cervix beginning to dilate
• Cramping
• Bleeding
• No POC has passed

35

Inevitable abortion: Def

Threatened loss of pregnancy that cannot be prevented or stopped.

36

Four characteristics of an inevitable abortion

• Cramping
• Bleeding
• Os is opened
• Usually ROM

37

Missed abortion: Def

Loss of pregnancy where the POC remain in the uterus.
• Your body missed the cue to get rid of it.

38

Risk factors for spontaneous abortion: 7

• Endocrine Imbalance
• Infection
• Maternal structural problems
• Immunological factors
• Systemic disorders
• Drug use
• Inadequate nutrition

39

What is a molar pregnancy?

When a hydatidiform mole forms instead of a fetus.

40

Choriocarcinoma (def)

When a molar pregnancy becomes cancerous

41

Gestational Trophoblastic Disease (def)

Problem with trophoblast cells early on. Instead of helping embryo attach, trophoblastic cells give rise to a tumor.

42

Molar pregnancy: Complete v. Parital

• Complete: Contains no genetic material
• Partial: Nonviable fetus

43

Signs and Symptoms of a molar pregnancy (5)

• Vaginal bleeding
• Severe nausea and vomiting
• Uterus is large for dates
• No fetal heart tones or activity
• hCG levels high and rising rapidly

44

Treatment for molar pregnancy (4)

• Bereavement counseling
• Remove the fetus
• hCG monitoring
• Continued monitoring, no pregnancy for 1 year

45

What should happen to hCG levels after molar pregnancy is removed?

• Declines
• Should be undetectable by 3 weeks

46

Incompetent Cervix (def)

Passive and painless dilation of the cervix in the 2nd trimester

47

Risk factors for incompetent cervix (4)

• Hx of previous cervical lacerations during childbirth
• Excessive cervical dilation
• Congenitally short cervix
• Cervical uterine abnormalities

48

Ectopic pregnancy: Def

Fertilized ovum is implanted outside of the cervix

49

Where do most ectopic pregnancies occur?

95% are implanted in the AMPULE (the outer 3rd)

50

Causes of late pregnancy bleeding (3)

o Placenta previa
o Placenta abruption
o Gestational Diabetes

51

Placenta previa (def)

Placenta partially or completely covers the internal cervical os

52

What is the difference in what the woman feels with a placenta previa versus a placenta abruption

Placenta previa is painless,
Placenta abrupta is painful

53

Management of placenta previa (5)

• Bed rest
• NPV
• Evaluate fetal well-being
• NEVER do a vaginal exam
• C-Section

54

Risk factors for placenta previa: History (4)

• Previous previa
• Previous C-Section
• Hx of Elective TOP (Termination of Pregnancy)
• Closely spaced pregnancies

55

Risk factors for placenta previa: Current Pregnancy (5)

• Multiple gestation
• Closely spaced pregnancies
• Advanced medical age
• Smoking -- Vasoconstrictor
• Cocaine use -- Vasoconstrictor

56

Placenta abruption (def)

Premature separation of the placenta from the uterine wall

57

SxS of placental abruption
- 2 Classic symptoms
- 2 other symptoms

“Classic” S&S:
o Uterine-tenderness
o Board-like abdomen

• Vaginal bleeding may be concealed
• Abdominal pain w/ctx greater than expected; may be localized



58

What does a "board-like abdomen" indicate?

Indicates internal hemorrhage

59

Risk factors for placental abruption (5)

• PIH
• Cocaine use
• Trauma (Blunt force)
• Smoking
• Poor nutrition

60

Gestational diabetes: Def

Physiologic glucose intolerance in pregnancy

61

Gestational diabetes: Epidemiology

Occurs in 4% of all pregnancies

62

Gestational diabetes: Prognosis

50% will develop glucose intolerance later in life

63

Glucose testing in pregnant women: Screening

Glucose Challenge Test (GCT)
o 24-28 weeks

64

Glucose testing in pregnant women: Diagnostic

Glucose Tolerence Test (GTT)
o Follow-up to evaluated GCT

65

Gestational Diabetes Risk Factors: History (4)

• Family history of IDDM: Maternal (esp insulin dependent)
• Previous baby weighing >4000g
• Previous unexplained stillbirth
• Spontaneous abortion

66

Gestational Diabetes Risk Factors: Current (5)

• Maternal age >30
• Obesity
• Congenital anomalies
• Sxs of diabetes
• Recurrent glucosuria noted on dipstick

67

Diagnosing Gestational Diabetes (2)

• GCT value of >200
OR
• 2 abnormal values on GTT

68

Abnormal values on GTT (4)
• Fasting
• 1 hr
• 2 hr
• 3 hr

FASTING >/= 105 mg/dL
1 hour >/= 190mg/dL
2 hour >/= 165mg/dL
3 hour >/= 145mg/dL

69

Big picture: What should you worry about with maternal glucose?

Stable vs Volitle

70

Dietary treatment for gestational diabetes (6)

• Standard diabetic diet
• Small, frequent meals
• High fiber meals
• High fiber foods
• Lower fat intake
• Avoid sugar, concentrated sweets

71

Lab goals for glucose control (3)

• Fasting levels <120mg/dL
• Goal: 60mg/dL and 100 mg/dL

72

"Size less than dates": Causes (3)

• Intrauterine Growth Restriction (IUGR)
• Small for gestational age
• Oligohydraminos

73

What causes IUGR? (2)

• Pathological process
• Decreased oxygen and nutritional availability to fetus

74

IUGR: Symmetrical (2 char)

• Represents chronic / long-term insult
• Small in all parameters including head development

75

IUGR: Assymetrical (3 char)

• Late occurring / short-term deprivation
• “Head-sparing”
• Typical small body, large head

76

What is the difference between an "IUGR" diagnosis and a "Small for gestational age" diagnosis?

• UGR is pathological
• SGA is non-pathological

77

Oligohydraminos: Def

Abnormally small amount of amniotic fluid

Amniotic fluid index <5

78

Normal amniotic fluid index

5-20cc

79

Oligohydraminos is associated with _____

Marked perinatal mortality

80

Factors that coincide with oligohydraminos (4)

o Congenital anomilies
o IUGR
o Early rupture of membranes
o Post-maturity

81

Management of oligohydraminos (5)

o Bedrest
o Hydration
o Encourage good nutrition
o Assess fetal well-being: FMC, AFV, BPP
o Induction and delivery if severe and fetus is mature

82

"Size Greater than Dates" Causes (6)

• Macrosomia
• Large for gestational age (LGA)
• Multifetal preganancy
• Fibroid uterus
• Polyhydraminos
• Post-term pregnancy

83

Polyhydraminos: Def

Excessive amount of amniotic fluid

(Amniotic fluid index >20cc)

84

Polyhydraminos: Characteristics (2)

• Difficulty auscultating fetal heart tones and palpating fetus
• Unstable fetal lie

85

What do you have to rule out with polyhydraminos?

GDM and ABO/Rh Disease

86

Risk factors for polyhydraminos (4)

o Multiples
o Uncontrolled GDM
o Fetal Malformations
o Chromosomal Abnormalities

87

Complications of polyhydraminos (6)

o Fetal malpresentation
o Placental abruption
o Uterine dysfunction during labor
o PP Hemorrhage
o Cord prolapse
o Preterm labor

88

Post-term pregnancy: Def

Pregnancy that extends beyond the 42nd week gestation

89

Clinical manifestations of post-term pregnancy (4)

o Maternal weight loss
o Decreased uterine size
o Meconium in the fluid
o Advanced bone maturation of the fetal skeleton with a hard skull

90

Maternal risks involved with post-term pregnancy (5)

o Dysfunctional labor
o Perineal trauma
o PPH
o Infection
o Interventions (forceps, vacuum, c-section) are more likely to be necessary

91

Fetal risks involved with post-term pregnancy (4)

o Macrosoma
o Birth trauma
o Distress
o Hypoxia / asphyxia

92

Management of post-term pregnancy (3)

o Testing: BPP, NST, FMC
o Cervical assessment for ripeness
o Induction

93

Normal platelet levels

normal ~ 150,000 – 400,000