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Maternal/Child > Lecture 6.1 - At Risk Pregnancies 1 > Flashcards

Lecture 6.1 - At Risk Pregnancies 1 Flashcards

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1
Q

What is a high risk pregnancy?

A

A situation where the life, health, and welfare of the mother and/or developing fetus are at risk due to
medical, social, or environmental factors

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2
Q

What antepartum testing is done in the first two trimesters?

A

Chromosomal tests + prenatal screening

Biochemical diagnosis
–> Offered if prenatal screen is positive or pt is older than 40

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3
Q

What antepartum tests are done in the third trimester?

A

Fetal Well-Being
–> Determine if fetus is thriving in uterine environment
–> Informs decision about the timing of birth

Indicated when increased risk of maternal or fetal morbidity/mortality

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4
Q

What things are assessed in a FWB assessment?

A

Fetal movement counting –> Electronic monitoring –>
Ultrasound

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5
Q

Fetal movement counting should include how much activity?

A

At least 6 movements in 2 hours

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6
Q

What can ultrasound be used to assess in the third trimester?

A

Biophysical profile
Amniotic fluid volume
Doppler blood flow analysis

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7
Q

What kind of electronic fetal monitoring is done in a FWB assessment?

A

Non-stress test
Contraction-stress test or oxytocin challenge test

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8
Q

What is a non-stress test?

A

Monitoring fetal HR/contracting with monitor at any point before labour
–> Assessing dyad while not in labour

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9
Q

What is a normal NST for a pregnancy over 32 weeks gestation?

A
  1. 2 or more accelerations of >15 bpm x 15 second over 40 minutes
  2. Baseline 110-160
  3. Moderate variability (6-25)
  4. No decelerations (or less than 30 seconds)
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10
Q

What is an atypical NST for a pregnancy over 32 weeks gestation?

A
  1. Less than 2 accelerations of >15 bpm x 15 second over 40-80 minutes
  2. Absent or minimal variability
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11
Q

What is an abnormal NST that requires urgent action for a pregnancy over 32 weeks gestation?

A
  1. Less than 2 accelerations of >15 bpm x 15 second over more than 80 minutes
  2. Erratic baseline, HR outside of 100-160 for 30 minutes
  3. Late decelerations or variable decelerations > 60 seconds
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12
Q

What is a consideration for fetal monitoring before 32 weeks GA?

A

Good accelerations can be 10bpmX10seconds instead of 15x15

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13
Q

What is contraction stress test or oxytocin challenge test?

A

Observe FHR response to 3 one minute contractions over 10 minutes
–> Induced by IV oxytocin/nipple stimulation

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14
Q

What is a negative and positive contraction stress test?

A

Negative
–> Normal baseline, no late decels

Positive
–> Late decels with half or more of contractions

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15
Q

What are some contraindications to a contraction stress test?

A

Preterm labour
Placenta previa
Multiple gestation
Previous classic uterine incision

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16
Q

What is assessed in an ultrasound of assessing biophysical profile (BPP)? What is it scored out of?

A

Physical exam
Amniotic fluid volume
Fetal breathing, tone, movement

May include NST

BATMaN - Breathing, Amniotic fluid, tone, movement & NST

Scored out of 10

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17
Q

What is a normal BPP?

A

1+ fetal breathing movement last 30+ seconds

At least 3 trunk or limb movements in 30 minutes

Extensions with flexion return

Pocket of free fluid 2x2 cm

Normal NST

All worth 2 points

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18
Q

What if there is a BPP score of less than 6?

A

We have to jailbreak baby asap
–> Suspect chronic asphyxia

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19
Q

What if there is a BPP score of 6 with normal fluid?

A

Repeat testing in 24 hours

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20
Q

What to do if there is a BPP score of 6 with abnormal fluid?

A

Deliver term bb d/t risk of chronic asphyxia

If < 34 weeks, intense surveillance to determine risks of preterm birth/remaining in utero

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21
Q

Oligohydramnios indicates what?

A

Fetal renal issues, intrauterine growth restriction, premature rupture

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22
Q

Polyhydramnios is associated with what?

A

GI blockage/abnormality, multiple fetuses, fetal hydrops

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23
Q

An antepartum doppler blood flow analysis assesses what?

A

Blood flow in:
–> Maternal uterine arteries (Predicts growth restrictions)
–> Fetal umbilical + middle cerebral arteries (predict fetal anemia)

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24
Q

What are the levels of maternal/NB services ontario?

A

Level 1
–> Term, low risk
–> C/S births not always available

Level 2
–> Moderate risk, uncomplicated twins
a) >34 weeks & 1800 g
b) >32 weeks & 1500 g
c) >30 week & 1200 g

Level 3
–> Onsite adult ICU/timely access to surgical intervention
A) no on site surgery but timely access
B) on-site surgical services at all times

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25
Childbearers with obesity are at increased risk of what preconception, gestational, and postpartum complications?
Preconception: Infertility, Spontaneous abortions, Recurrent pregnancy loss During pregnancy: GDM, HTN/preeclampsia Intrapartum: Macrosomia, altered uterine contractility, challenges to implement interventions like FHR, epidural, intubation Postpartum: PPH, breastfeeding issues, venous thromboembolism, infection
26
What pre-conception care is needed for those with obesity? What percent weight loss is recommended? Should weight loss drugs me used? How long after bariatric surgery should a person wait to become pregnant, ideally? What screenings should be prioritized?
Ideally, obtain weight in normal range before pregnancy --> Better outcomes with 5-10% weight loss Discontinue weight loss drug therapy, wait 24 months after bariatric surgery to become pregnant, smoking cessation. Screen for DMII, HTN, CDV disease .4 mg/day folic acid starting 3 months prior to conceptions
27
What antenatal care is needed for those with obesity? What wait gain is recommended in in the first trimester and by term? What screenings should be prioritized? How do we manage to increased with for pre-eclampsia in this population?
Recommend GA weight gain of 11-20 lbs with minimal weight gain during 1st trimester. --> Regular exercise and nutritional counseling. Careful screening for GDM, HTN If risk for pre-eclampsia - low dose aspirin before 16 weeks GA
28
When is an induction performed for someone with a BMI > 40
39 weeks --> Minimizes c/s and stillbirths
29
What intrapartum care considerations must be made for someone with obesity?
EFM in labour when BMI is greater than 35 Maximize pulmonary functions/minimize O2 consumption --> Pulse oximetry, good pain control Avoid general anesthesia is c/s in pts with obesity Population at risk of passenger factors like macrosomia and shoulder dystocia, as well as altered uterine contractility
30
What postpartum care considerations must be made for someone with obesity?
Consider LC Early mobilization following vaginal delivery and C/S - may need PT Teaching: Inspect incision, incision care, s/s infections
31
Neonates of childbearers with obesity are at increased risk of...
Stillbirth Neural tube, ventral wall anomalies Macrosomia Shoulder dystocia Meconium aspiration Interventions & NICU admission
32
What is the most common medical disorder of pregnancy?
Anemia
33
How does the body compensate for decreased oxygen carrying capacity of RBCs?
Increased Cardiac output
34
What is the most common type of anemia?
IDA
35
What is considered IDA?
Serum ferritin < 12 mcg/L deficient with Hb < 110 g/L
36
Why should all pregnant people be screened for IDA?
25% of pregnant individuals have it
37
What is the iron recommendation for pregnant people?
Iron intake 27 mg/day --> Consider additional supplementation if vegetarian
38
What lab values are considered anemia?
Hb - < 110 Hct -
39
What maternal factors make pregnant individuals more susceptible to complications d/t IDA?
Further depletion of stores Less capacity to tolerate blood loss during pregnancy
40
What are some risks for the NB when the pregnant individual has IDA?
Preterm birth low birth weight
41
How is postpartum IDA treated?
30 mg/day prenatal vitamin or 60-120 mg/day iron supplement *Can be given IM if PO causes N/V
42
What are folic acid and folate?
Both forms of B9 --> Folate - naturally occurring --> Folic acid - synthetic
43
folate deficiency can result in what for the NB?
Neural tube defects, cleft palate or lip
44
When would the need for folate in pregnancy extend beyond .4 mg/daily?
Multiple pregnancies close together Multiple fetuses
45
In pregnancy those with Sickle Cell Anemia are at increased risk of what?
Pain crises IUGR Pre-Eclampsia Infections
46
How can sickle cell crises be treated in pregnancy?
Analgesia, oxygen, hydration --> Monitoring fetal growth Prophylactic low dose aspirin Treat infections with antibiotics
47
How does sickle cell anemia result in hemolytic anemia and pain crises?
RBCs sickle and break down --> Hemolysis Sickling causes vascular occlusion --> Ischemia --> pain crisis
48
What is thalassemia? What are the two kinds and how do they impact pregnancy?
Hereditary disease resulting in abnormal synthesis of hemoglobin --> Minor - usually uncomplicated persistent anemia, often not a problem during pregnancy --> Major - shorter lifespan, infertility + major health concerns if pregnant
49
Bleeding during early pregnancy can indicate what?
Miscarriage Ectopic pregnancy Hydatidiform mole
50
Bleeding during late pregnancy can indicate what?
Placenta previa Placenta abruption
51
How much cardiac output flows through the placenta?
15%
52
80% of spontaneous abortions occur when?
Before 12 weeks d/t chromosomal abnormalities
53
What are considered late spontaneous miscarriages?
12-20 weeks
54
What is considered a spontaneous abortion?
A pregnancy that ends without medical or surgical intervention prior to 20 weeks of gestation or less than 500g fetal weight
55
What are the four types of spontaneous abortion?
Threatened Inevitable Incomplete Complete
56
What what is a threatened spontaneous abortion? --> Consider bleeding, dilation, cramping How is it treated?
Slight spotting with mild cramping --> No dilation, no passage of tissue Bed rest, US to assess fetus
57
What what is an inevitable spontaneous abortion? --> Consider bleeding, pain, and dilation How is it treated?
Moderate bleeding, mild to severe cramping --> Cervical dilation, no passage of tissue Bed rest if no pain, fever, or bleeding --> D&C if this changes or there is ROM
58
What is an incomplete spontaneous abortion? --> Consider bleeding, pain, dilation How is it managed?
Heavy, profuse bleeding, severe cramping with passage of tissue and dilation of cervix. May require D&C to ensure no tissue remains in uterus
59
What what is a complete spontaneous abortion? --> Consider bleeding, pain, and dilation How is it managed?
Slight bleeding at this point, with mild cramping. Tissue has been passed and cervix is not dilated. Further intervention may not be necessary, ensure to retained tissue.
60
What assessments and interventions are necessary for a miscarriage? Consider psychosocial, physical, medications, and labs.
Pregnancy history, emotional status --> Teaching, psychosocial support, emotional support, expectant management VS, pain, quantity and nature of bleeding --> Pain management + misoprostol --> May need D&C Labs: B-hCG, Hb, WBC
61
What is an ectopic pregnancy? What are the S/S?
Occurs when fertilized egg implants outside of uterus --> Life threatening hemorrhage S/S: vaginal bleeding, dull progressive pain that is often one sided
62
What are risk factors for ectopic pregnancy?
Previous EP, PID, endometriosis, previous pelvic surgery Advanced maternal age, smoking
63
How is ectopic pregnancy treated?
Surgery + methotrexate
64
What is a molar pregnancy?
A complete molar pregnancy is when a sperm fertilizes empty ovum - no true placenta or viable fetus Abnormal growth of placental tissue --> Benign growth into "grape-like cluster"
65
What are risk factors for molar pregnancy?
Advanced maternal age Previous Hx Deficiencies in folic acid
66
What are the S/S of a molar pregnancy?
Vaginal bleeding or spitting (dark brown to bright red) Passage of molar tissue Enlarged uterus for GA N&V, hyperemesis gravidarum (very high hCG)
67
How is a molar pregnancy treated?
Surgical removal in D&C --> Monitor hCG levels to ensure completely removed
68
What is placenta previa?
When the placenta partially or completely covers to cervix
69
What is a low-lying placenta? What is normal placenta location?
Normal - 2+ cm away from cervix Low - within 2 cm of cervical os
70
What are some risk factors for placenta previa?
Uterine/endometrial scarring --> Prev PP, CS, D&C, multiparity, assisted reproductive technology Impeded endometrial vascularization --> HTN, smoking, cocaine, higher altitude Increased placental mass --> Multiple gestation, male fetuses (size)
71
What are S/S of placenta previa?
Painless bright red blood w/o tenderness after 20 weeks --> Before onset of labour Suspect previa in all cases of bleeding after 20 weeks!! --> R/O w US
72
Can vital signs be a reliable indicator of bleeding in pregnancy?
No. A pregnant person can lose up to 40% of blood volume before showing signs of shock --> VS might be misleadingly normal
73
How does the fetus respond to placental previa?
FHR often normal until maternal shock d/t excessive blood loss
74
What will an abdominal exam look like in placenta previa?
Soft, relaxed, non-tender Fundal height greater than expected for GA
75
When is placenta previa diagnosed?
Provisional diagnosis can be made in second trimester - confirmational dx required at 32-36 weeks.
76
What transvaginal US findings indicate placental previa?
Edges of placenta greater than 1 cm or venous lakes of maternal blood at placental margin
77
What are fetal risks d/t placenta previa?
Preterm birth, IUGR d/t chronically compromised exchange
78
What are the three placenta accreta disorders?
Acretta - invades endometrium, does not detach Increta - invates myometrium Percreta - uterine serosa / other organs
79
What is velamentous cord insertion?
Absence of Warton's jelly - cord embedded in membranes --> higher risk of compression Increased risk with accreta disorders
80
What is vasa previa?
Velamentous cord insertion where the blood vessels overlay the cervix --> Compression with delivery
81
How is placenta previa managed?
Pelvic rest w continuation of other regular activity Antenatal corticosteroids - accelerate maturation of lungs if risk of birth is within 7 days WinRho after every bleeding event
82
How is a fetus with placenta previa delivered?
C/S --> 36 weeks with risk factors --> 37 weeks without risk factors
83
How is a baby with low lying placenta delivered?
TOL if edge is at least a cm away from cervical os C/S if less than 1 cm --> 37 weeks with risk factors --> 38 weeks with no risks
84
What is placenta abruption?
Premature detachment of part or all of the placenta --> after 20 weeks and before birth
85
What are the three types of placental abruptions?
Partial with external/apparent hemorrhage Partial with concealed hemorrhage Complete - often presents without bleedings d/t membranes preventing flow of blood
86
What are the classes of placental abruption? How much blood or pain is seen with each?
Class 1: Mild --> Minimal dark bleeding (less than 500 ml) --> Absent or mild pain Class 2: Moderate --> Moderate dark red bleeding (1000-1500 ml) --> Moderate to severe pain Class 3: Severe --> Severe, dark bleeding (>1500 mg) --> Agonizing, intermittent pain --> Board like uterus
87
What are the differences in presentation from placenta previa to placenta abruption?
Abruption --> Dark red (older blood) --> Often painful to some degree --> Rigidity, often with increased fundal height Previa --> Frank red (newer blood) --> Often painless --> Soft uterine tone
88
What percent of placental abruption have concealed bleeding?
20% are concealed
89
What are some maternal complications of placental abruption?
Hypovolemia + DIC + renal failure + thrombocytopenia Sensitization to Rh neg pts
90
What are the fetal risks for placenta abruption?
Related to severity and GA --> IUGR --> Oligohydramnios --> Preterm birth --> Hypoxemia NB at higher risk of neuro defects, CP, SIDS
91
How is placental abruption diagnosed?
Expect when there is sudden, intense uterine pain with or without bleeding --> Increased fundal height might be present --> Coagulopathy --> US to r/o previa --> FHR pattern abnormalities
92
Is a trial vaginal birth possible with placental abruption?
Yes, if mother is hemodynamically stable and there is no fetal distress
93
What are the priorities of care with placental abruption?
Restore blood loss and deliver infant.
94
What are the different kinds of level 2 birthing units in Ontario?
Level 2 --> Moderate risk, uncomplicated twins a) >34 weeks & 1800 g b) >32 weeks & 1500 g c) >30 week & 1200 g
95
What are the different kinds of level 3 birthing units in Ontario?
Level 3 --> Onsite adult ICU/timely access to surgical intervention A) no on site surgery but timely access B) on-site surgical services at all times
96
Low dose aspirin is given to pregnant patient with obesity at what point? Why?
Before 16 weeks GA if there is a risk of preeclampsia
97
How long after bariatric surgery should someone wait to become pregnant?
24 months
98
EFM is indicated during labour for patients with what BMI?
BMI 35 or greater
99
How often are third trimester serial US and FWB checks recommended for patients with obesity?
At 28, 32, and 36 weeks. Then weekly.
100
When should you suspect placental previa?
All cases of vaginal bleeding after 20 weeks --> Until ruled out by ultrasound
101
Placental previa carries which complications for fetal presentation?
Increased risk of malpresentation --> Transverse or breech
102
What kind of examination should not be done on a person with placenta previa?
No rectal or vaginal exams - pelvic rest
103
What medications are given is there is a risk of preterm labour in the next 7 days?
Corticosteroids - fetal lung development

Maternal/Child (14 decks)

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