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Maternal/Child > Lecture 6.2 - At Risk Pregnancy 2 > Flashcards

Lecture 6.2 - At Risk Pregnancy 2 Flashcards

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1
Q

How might substance use in pregnancy result in lack of prenatal care? What are the results of this?

A

Perhaps d/t lack of access, psychosocial factors
–> Serious fetal conditions might be missed (including teratogenic effects of substances)

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2
Q

What is the relationship between substance use and unplanned pregnancies?

A

Substance use increases incidence of unplanned pregnancy

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3
Q

What are the four most common substances used in pregnancy?

A

Tobacco
Alcohol
Cannabis
Opioids

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4
Q

What are the recommended safe limits for alcohol consumption?

A

1-2 drinks/week

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5
Q

Who is at increased risk of alcohol consumption during pregnancy?

A

Those who binge drink pre-pregnancy

Cigarette smoking

Adverse childhood experiences

Unplanned pregnancy

Irregular prenatal care
–> information deficit, lack of access to education

Partner use

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6
Q

Why can folic acid supplementation reduce the risks of poor outcomes of alcohol consumption during pregnancy?

A

Prevention of neural tube defects

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7
Q

What harm reduction interventions are to prevent drinking during pregnancy or to help those who do?

A

Harm reduction strategies
–> Awareness raising activities
–> Routine conversations with childbearing age females about birth control if consuming alcohol
–> Non-judgmental support to maintain safety of dyad

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8
Q

What T-ACE score is positive?

A

2+
–> Indicates need for additional support

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9
Q

What are some features Fetal Alcohol Spectrum Disorder (FASD)?

A

Memory problems, poor judgement, cognitive processing problems, struggling with abstract concepts. Literal thinking.

Poor social skills, impulsive, disorganized. Inconsistent performance.

Developmental delay, delayed motor skills coordination

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10
Q

What are some ways support children and families with fetal alcohol spectrum disorder?

A

Nurture strengths in stable environment

Teaching child to respond to anger in non-violent ways

Provide educational accommodations or IEPs

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11
Q

Is use of opioids in pregnancy increasing?

A

Yes, as much as it has increased in the general population

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12
Q

Who is screened for opioids and other elicit substances in pregnancy?

A

Everyone is routinely screened with consent - Best practice recommendation, not a law
–> Every person who uses opioids should be offered comprehensive care including OB care, addiction care, community services, and counselling.

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13
Q

What is the recommended treatment for opioid dependence during pregnant?

A

Opioid Agonist Therapy (AOT)
–> Methadone/Buprenorphine

Long acting therapy decreases cravings & withdrawal.

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14
Q

What opioid agonist therapy has better neonatal effects?

A

Buprenorphine
–> Less symptoms of neonatal abstinence syndrome

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15
Q

What are the benefits of using a synthetic long-acting opioid during pregnancy for those with dependencies?

A

Increases GA, birth weight, and decreased infant mortality. Improves nutritional status and facilitates earlier access to prenatal care.

Stabilizes parent - preventing cycle of intoxication/withdrawal and decreased risk of overdose

Reduces harm - decreased risk of blood born infections (HIV, HepC)

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16
Q

What are some dosing considerations in the 3rd trimester for those using synthetic long-acting opioids?

A

There might need to be an increased dose in the 3rd trimester d/t increased metabolism

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17
Q

What might be noted in fetal heart surveillance for someone taking opioid agonist therapy?

A

Bradycardia, decreased variability, less accelerations and fetal activity

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18
Q

What are some barriers to treatment for opioid dependence in pregnancy?

A

Stigma, guilt, shame, lack of resources or awareness of available programs

Lack of awareness of adverse effects of substance us on fetus

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19
Q

What is a Finnegan score?

A

A Finnegan Neonatal Abstinence Score allows use to quantify the severity of the NAS and determine a plan of care

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20
Q

Why would serial ultrasounds be ordered during pregnancy in a patient with opioid dependence?

A

To confirm GA
–> Person may have amenorrhea d/t substance of or not the the date of LMP

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21
Q

What repeat testing should be done on a patient who is pregnant with opioid dependence?

A

Serial US for FWB and determining GA

Consider risk of STBBIs

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22
Q

How to manage labour pain in someone with opioid dependence? With what drug through which route?

A

PCEA is best relief - given early in labour to ensure efficacy

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23
Q

What drugs should be avoided as pain relief options for those in labour with opioid dependence?

A

Avoid agonist-antagonists systemically
–> Increased risk of withdrawal symptoms

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24
Q

What kind of community referrals might be made prior to discharge of a parent with opioid dependence?

A

Continued substance use treatment

Social support

Postpartum doula –> Community doula access to decrease barriers to care

Public health nurse home visit

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25
How can we facilitate parent-infant attachment?
Skin-to-Skin Cluster Rooming together
26
Can those receiving opioid antagonist therapy breastfeed?
Yes, it is encouraged because benefits outweigh risks
27
Is there a legal requirement in Canada to drug test parents?
No, testing for parents and neonate depends on provincial/hospital agencies Informed consent must be obtained.
28
Who is screened for HIV when pregnant? When?
Everyone! --> In first trimester
29
What is the ultimate goal of care for pregnant individuals with HIV? How is this achieved?
Decrease risk of transmission to fetus --> ART for everyone regardless of CD4s, promote adherence --> Test for opportunistic infections including STIs --> Decrease NB exposure to blood and secretions
30
When is a vaginal delivery an option for those with HIV?
Indicated in person is on ART and viral load is < 1000 copies/ml If not, C/S.
31
What medication is given those with HIV during labour
IV zidovudine --> Antiretroviral that prevents transmission
32
What should be avoided during delivery in parents with HIV?
Avoid anything that can damage fetal skin --> Scalp probe, pH blood sampling, forceps, vacuum --> Literature unclear, but avoid artificial ROM
33
What specialized care is provided to the infant after delivery if parent is HIV+?
Immediately clean infant (remove body fluids) Treat with Zidovudine within 6 hours, then Q6 for 6 weeks Test for HIV at birth, 4 weeks, 3-4 months, and 18 months Breastfeeding discouraged in countries where safe alternatives exist
34
When should the infant be treated with Zidovudine when parent is HIV+?
within 6 hours of life Then q6 for 6 weeks
35
When should a neonate of a parent who is HIV+ be tested for it?
At birth, 4 weeks, 3-4 months, 18 months.
36
What is classified as GDM?
Elevated BGL that are first recognized during pregnancy
37
What are some long-term risks of GDM?
Higher risk of developing DMII later in life
38
Pregnant people with GDM have an increased risk of developing what adverse outcomes during labour?
Pre-eclampsia Shoulder dystocia Needing C/s and episiotomy
39
What are some adverse affects of NBs of parents with GDM?
LGA (macrosomia) Hypoglycemia IUGR (poor perfusion) IU fetal death
40
GDM does not carry an increased risk of congenital anomalies. Why?
Because GDM usually only develops in the second trimester --> After gross anatomy has already formed
41
What are some risk factors for GDM?
>35 yrs Corticosteroid use Obesity PCOS or Acanthosis Nigricans Pregestational diabetes or family Hx Hx of giving birth to baby >4 kg
42
What are the two types of screening for GDM?
Two step (preferred) --> 50 mg non-fasting then test 1hr later --> If 7.8-11 after t-test then 75g fasting. Then test at 1 and 2 hours after drinking. One step --> involves only 75g fasting-challenge with 1-2 hour checks.
43
When should pregnant people be screened for GDM?
Screening in 1st trimester for hyperglycemia in those with risk factors + Between 24-28 weeks for everyone, including those with risk factors
44
What is the aim of treatment of GDM? What are appropriate BGL ranges?
Meticulous BGL control Fasting: 3.8-5.2 1 hr post meal: 5.5-7.7 2 hr post meal: 5.0-6.6
45
What teaching is necessary for pts with GDM?
Explanation of GDM and possible complications Diet, exercise, monitoring Medications --> Glyburide, metformin --> Insulin if needed
46
What fetal surveillance is performed with GDM?
Serial ultrasounds every 3-4 weeks starting at 28 weeks to monitor: --> Growth --> Amniotic fluid volume Weekly NSTs starting at 36 weeks Additional assessments might be needed depending on BGL control and risk factors.
47
Why is amniotic fluid level monitored closely with GDM?
If fetal BGL is high it will result in polyurea --> Polyhydramnios
48
When should labour be induced with GDM? Why?
38-40 weeks --> Concern with placental efficacy
49
What is the ideal BGL for someone with GDM during labour? Why?
Less than 8 mmol/L (checked qh) --> Linked to less severe NB hypoglycemia
50
At what point would a fetal weight be indication for c/s?
>4.5 kg --> Concern for dystocia/laceration
51
When is NB BGL tested in GDM?
2 hours of life (After first feed) Then 3-6 hours (before feeds) This protocol lasts 12 hours.
52
Why is breastfeeding especially beneficial following GDM?
Decreased risk of DMII for both parent and child
53
How does pregnancy change management or symptoms of pre-existing DM?
Change in symptoms of hypoglycemia, may need to switch from PO meds to add insulin
54
Hyperglycemia is more likely to be teratogenic in which kind of DM?
Pre-existing --> Because sugar instability is more likely to be present in 1st trimester
55
What percent of pregnant people experience N&V vs hyperemesis gravidarum?
50-90% experience N/V 0.3-3% experience HG
56
At what point does hyperemesis gravidarum start and improve? What might cause it?
Starts between 4-8 weeks and improves by week 16 --> R/t hCG + estrogen, also associated with transient hyperthyroidism
57
Excessive vomiting can lead to what complications for a pregnant (or any) person?
Weight loss + Dehydration Nutritional deficiencies, Electrolyte imbalances -->Vit k, anemia Ketonuria
58
What hormones cause hyperemesis gravidarum?
Estrogen, hCG Also associated with transient hyperthyroidism of pregnancy
59
What are some factors that can lead to an increased risk of hyperemesis gravidarum?
Younger age Nulliparity BMI outside of 18.5-25 Low socioeconomic status Family Hx Female fetus or multiple gestation, gestational trophoblastic disease
60
What medication is used to treat N&V in pregnancy?
Diclectin --> Antihistamine (doxylamine) + B6 Not always effective for HG --> May need Zofran, metoclopramide
61
What are priorities of care with HG?
Supportive care: VS, treat N&V, I/O Offer antiemetics, prescribed medication, clear fluids and high protein/carb, low fat meals as tolerated. BRAT Diet - Bananas, Rice, Applesauce, Toast Promote rest
62
What are some poor maternal outcomes of hypertensive disorders of pregnancy?
Acute renal failure Pulmonary edema HELLP Cerebral edema/eclampsia Hepatic rupture Placental abruption
63
Which HDP complications cause the most maternal deaths?
Hepatic rupture + Placental abruption
64
What are some fetal outcomes of HDP?
IUGR + Acute hypoxia Preterm birth Placental abruption Congenital malformations
65
What is considered pre-existing hypertension in pregnancy?
Diagnosed before 20 weeks.
66
What is considered gestational hypertension?
Diagnosed after 20 weeks of pregnancy
67
Can pre-eclampsia occur with pre-existing or gestational HTN?
Can occur independently or super-imposed with either of the two
68
What is the diagnostic criteria for HDP?
sBP >140 dBP > 90 Or > 135/85 in a community environment At least two readings, at least 15 minutes apart
69
What is considered severe HTN?
sBP > 160 sBP > 110
70
What is pre-eclampsia?
Multisystem, vasospastic disease process of reduced organ perfusion. Characterized by: HTN + Proteinuria OR One or more adverse conditions
71
What is the only cure for pre-eclampsia?
Removing the placenta
72
What increases risk of pre-eclampsia?
Prior Hx Obesity, HTN, DM, CKD, lupus Hx of placental abruption, stillbirth, IUGR Maternal age > 40 or multifetal pregnancy, use of assisted reproductive technology
73
How do we test for proteinuria?
Dipstick of 2+ or Lab testing of random urine specimens: 0.03 g/l in al least two specimens
74
What is eclampsia?
Characterized by seizures from the profound cerebral effects of pre-eclampsia
75
What is HELLP syndrome?
H - Hemolysis EL - Elevated Liver enzymes LP - Low platelets May occur to women who do not have HTN or proteinuria
76
What symptoms are indicative of HELLP?
RUQ pain, N&V --> Often confused with gastritis, flu, gallbladder issue
77
What factors lead to decreased maternal perfusion with pre-eclampsia?
Decreased intravascular volume in vessels surrounding placenta --> Placenta is ischemic, gets upset, and releases vasoactive substances which cause endothelial injury + capillary leaking --> edema Increased vasoconstriction --> HTN caused by increased sensitivity to vasoactive substances and arterial vasospasm
78
How can we prevent pre-eclampsia in those at increased risk?
Low dose ASA before 16 weeks and continued until 36 weeks --> 81-162 mg 140 minutes of moderate intensity exercise
79
When should people with pre-eclampsia be hospitalized?
When there are adverse maternal effects
80
What medications are given to those with pre-eclampsia?
Monotherapy with labetalol, methyldopa, nifedipine --> Or second line hydralazine IV Magnesium --> Increases seizure threshold --> Keep Calcium gluconate available
81
Is bedrest recommended with pre-eclampsia?
No. Increased risk of DVT outweighs benefits
82
What is the antidote to magnesium sulfate?
calcium gluconate
83
What should we test regularly in a person with preeclampsia or who is being administered Mg sulfate?
DTRs --> preeclampsia - hyperreflexia --> MgSO4 - hyporeflexia
84
When should we expedite the birth in preeclampsia?
Uncontrolled HTN > 12 hours despite 3 antihypertensives Eclampsia, stroke, TIA Pulmonary edema Compromised renal function Abruption or maternal/child compromise Concerns on EFM
85
What position can be helpful during pre-eclampsia?
L-lateral recumbent
86
What to do during a seizure?
Airway, left lateral, pillow under shoulder or back to keep head to side Call for help Bedrails up, pillows padding Observe time of onset, duration
87
What can be a sign that preeclampsia is improving following delivery? How often should we check VS?
Diuresis --> Most women are clinically stable by 48 hours. VS Q4 for 48 hours to monitor BP usually returns to normal by 4-6 weeks postpartum.
88
What medication would we not use to increase uterine contractions in those with HTN?
Methergine --> Increases BP
89
Morbidity and mortality following eclampsia are higher in what situations?
When the eclampsia is seen before 28 weeks Maternal age > 30 Multigravida HTN/renal disease No prenatal care

Maternal/Child (14 decks)

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