1. Nursing 353 Maternal Risk Factors Fetal Assessment February 3 rd, 2005

2. High Risk Pregnancy The life or health of the mother or fetus is jeopardized The life or health of the mother or fetus is jeopardized Examples include: Examples include: –GDM –Previous loss –AMA –HTN –Abnormalities with the neonate

3. Perinatal Mortality Overall maternal deaths are small Overall maternal deaths are small Many deaths a preventable Many deaths a preventable Education and prenatal care are very Education and prenatal care are veryimportant

4. Antepartum Testing FKCs BID FKCs BID UTZ UTZ –FHR –Gestation age –Abnormalities –IUGR –Placental location and quality –AFI –Position –BPP –Doppler flow –Fetal growth

5. Ultrasound Can be done abdominally or transvaginally Can be done abdominally or transvaginally 1 st trimester done to detect viability, calculate EDC 1 st trimester done to detect viability, calculate EDC 2 nd trimester done to detect anomalies, calculate EDC 2 nd trimester done to detect anomalies, calculate EDC 3 rd trimester done to do BPP, fetal growth and well-being, AFI 3 rd trimester done to do BPP, fetal growth and well-being, AFI

6. Doppler Flow Analysis via UTZ Study blood blow in the fetus and placenta Study blood blow in the fetus and placenta Done on high risk mothers: Done on high risk mothers: –IUGR –HTN –DM –Multiple gestation

7. AFI Polyhydramnios – too much amniotic fluid Polyhydramnios – too much amniotic fluid Oligohydramnios – too little amniotic fluid Oligohydramnios – too little amniotic fluid

8. Biophysical Profile Includes 5 components: Includes 5 components: –Fetal breathing movements –Gross body movements –Fetal tone –AFI –NST - reactive

9. Amniocentesis Used with direct ultrasound Used with direct ultrasound Less than 1% result in complications Less than 1% result in complications –Complications include:  Fetal death, miscarriage  Maternal hemorrhage  Infection to fetus  Preterm labor  Leakage of amniotic fluid

10. Meconium Visual inspection of amniotic fluid Visual inspection of amniotic fluid Meconium is defined as thin and thick and particulate Meconium is defined as thin and thick and particulate Associated with fetal stress: hypoxia, umbilical cord compression Associated with fetal stress: hypoxia, umbilical cord compression

11. CVS Done between 9 -12 weeks Done between 9 -12 weeks Genetic studies Genetic studies Removal of small amount of tissue from the fetal portion of the placenta Removal of small amount of tissue from the fetal portion of the placenta Complications: vaginal spotting, miscarriage, ROM, chorioamnionitis Complications: vaginal spotting, miscarriage, ROM, chorioamnionitis If done prior to 10 weeks, increased risk of limb anomalies If done prior to 10 weeks, increased risk of limb anomalies

12. AFP Genetic test Genetic test Done with mothers blood Done with mothers blood 16-20 weeks gestation 16-20 weeks gestation Mandated by state of California Mandated by state of California

13. EFM Third trimester goal is to continue to observe the fetus within the intrauterine environment Third trimester goal is to continue to observe the fetus within the intrauterine environment Goal: dx uteroplacental insufficiency Goal: dx uteroplacental insufficiency NST vs. CST NST vs. CST

14. NST 90% of gross fetal body movements are associated with accelerations of the FHR 90% of gross fetal body movements are associated with accelerations of the FHR Can be performed outpatient Can be performed outpatient Not as sensitive Not as sensitive User friendly but must interpret strip User friendly but must interpret strip Fetus may be in a sleep state or affected by maternal medications, glucose etc. Fetus may be in a sleep state or affected by maternal medications, glucose etc.

16. NST To be reactive must meet criteria To be reactive must meet criteria Must be at least 20 minutes in length Must be at least 20 minutes in length Must have 2 or more accelerations that meet the ’15 X 15’ criteria Must have 2 or more accelerations that meet the ’15 X 15’ criteria Must have a normal baseline Must have a normal baseline Must have LTV Must have LTV

17. NST To stimulate a fetus that is not meeting criteria: To stimulate a fetus that is not meeting criteria: –Change positions of the mother – LS, RS –Increase fluids –Acoustic stimulator

18. CST Done in the inpatient setting only! Done in the inpatient setting only! Has contraindications Has contraindications May be expensive if meds/IV needed May be expensive if meds/IV needed Monitored for 10 minutes first Monitored for 10 minutes first Then may use nipple stimulation or oxytocin stimulation Then may use nipple stimulation or oxytocin stimulation No late decelerations than negative CST No late decelerations than negative CST

19. CST

21. Endocrine and Metabolic Disorders #1 Diabetes Mellitus #1 Diabetes Mellitus Disorders of the thyroid Disorders of the thyroid Hyperemesis Hyperemesis

22. Diabetes Hyperglycemia Hyperglycemia May be due to inadequate insulin action or due to impaired insulin secretion May be due to inadequate insulin action or due to impaired insulin secretion Type 1 – insulin deficiency Type 1 – insulin deficiency Type 2 – insulin resistance Type 2 – insulin resistance GDM – glucose intolerance during pregnancy GDM – glucose intolerance during pregnancy

23. DM 10 th week fetus produces it own insulin 10 th week fetus produces it own insulin Insulin does not cross the placental barrier Insulin does not cross the placental barrier Glucose levels in the fetus and directly proportional to the mother Glucose levels in the fetus and directly proportional to the mother 2 nd and 3 rd trimesters – decreased tolerance to glucose, increased insulin resistance, increased hepatic function of glucose 2 nd and 3 rd trimesters – decreased tolerance to glucose, increased insulin resistance, increased hepatic function of glucose

24. Diabetic Nephropathy Increased risks for: Increased risks for: –Preeclampsia –IUGR –PTL –Fetal distress –IUFD –Neonatal death

25. DM Poor glycemic control is associated with increased risks of miscarriage at time of conception Poor glycemic control is associated with increased risks of miscarriage at time of conception Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios

26. Polyhydramnios May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

27. Macrosomia Disproportionate increase in shoulder and trunk size Disproportionate increase in shoulder and trunk size 4000-4500gms or greater 4000-4500gms or greater Fetus will have excess stores of glycogen Fetus will have excess stores of glycogen Increased risks of Increased risks of –Shoulder dystocia –C/S –Assisted deliveries

28. IUGR Compromised uteroplacental insufficiency Compromised uteroplacental insufficiency 02 available to the fetus is decreased 02 available to the fetus is decreased

29. RDS Increased RDS due to high glucose levels Increased RDS due to high glucose levels Delays pulmonary maturity Delays pulmonary maturity

30. Neonatal Hypoglycemia Usually 30-60 minutes after birth Usually 30-60 minutes after birth Due to high glucose levels during pregnancy and rapid use of glucose after birth Due to high glucose levels during pregnancy and rapid use of glucose after birth Related to mothers level of glucose control Related to mothers level of glucose control

31. Labs with DM HBA1c HBA1c 1 hour PP 1 hour PP FBS FBS

32. Diet Sweet success diet Sweet success diet Well balanced diet Well balanced diet 6 small meals / day 6 small meals / day Have snack at HS Have snack at HS Never skip meals Never skip meals Avoid simple sugars Avoid simple sugars

33. Insulin Regular/Lispro and NPH Regular/Lispro and NPH 2/3 dose in am and 1/3 dose in pm 2/3 dose in am and 1/3 dose in pm

34. Monitoring Glucose Levels FBS FBS 1 hour PP 1 hour PP HS HS 5 checks / day 5 checks / day

35. Fetal Surveillance NSTs done around 26 weeks, weekly NSTs done around 26 weeks, weekly At 32 weeks done biweekly with NST/BPP At 32 weeks done biweekly with NST/BPP

36. Infections and DM Infections are increased: Infections are increased: –Candidiasis –UTIs –PP infections

37. DM Increased risk of IUFD after 36 weeks Increased risk of IUFD after 36 weeks Increased congenital anomalies Increased congenital anomalies –Cardiac defects –CNS defects  Spina bifida  anencephaly –Skeletal defects

38. DM and labor Continuous fetal monitoring Continuous fetal monitoring Blood glucose levels in tight control Blood glucose levels in tight control Be prepared for CPD Be prepared for CPD

39. GDM Women with GDM at risk of developing DM later on in life Women with GDM at risk of developing DM later on in life NSTs around 28 weeks NSTs around 28 weeks

40. Hyperthyroidism Typically caused by Grave’s disease Typically caused by Grave’s disease S/S: S/S: –Fatigue –Heat intolerance –Warm skin –Diaphoresis –Weight loss

41. Should be treated in pregnancy Should be treated in pregnancy Tx with PTU Tx with PTU Beta blockers Beta blockers May lead to thyroid storm if untreated May lead to thyroid storm if untreated

42. Hypothyroidism Usually caused by Hashimoto’s Usually caused by Hashimoto’s S/S: S/S: –Weight gain –Cold intolerance –Fatigue –Hair loss –Constipation –Dry skin

43. Tx with thyroid hormones such as synthroid or levothyroxine Tx with thyroid hormones such as synthroid or levothyroxine Maintain TSH wnl Maintain TSH wnl Checked periodically throughout the pregnancy Checked periodically throughout the pregnancy

44. Cardiovascular Disorders The heart must compensate for the increased workload The heart must compensate for the increased workload If the cardiac changes are not well tolerated than cardiac failure can develop If the cardiac changes are not well tolerated than cardiac failure can develop 1% of pregnancies are complicated by heart disease 1% of pregnancies are complicated by heart disease

45. NY Heart Association Classes Class I Class I Class II Class II Class III Class III Class IV Class IV

46. Cardiac output is increased Cardiac output is increased Peak of the increase 20-24 weeks gestation Peak of the increase 20-24 weeks gestation Cardiac problems should be managed with cardiologist Cardiac problems should be managed with cardiologist Mortality with pulmonary hypertension and pregnancy is more than 50% Mortality with pulmonary hypertension and pregnancy is more than 50% Diet: low sodium Diet: low sodium

47. Nursing Care Avoiding anemia Avoiding anemia Avoid strenuous activity Avoid strenuous activity Monitor for: cardiac failure and pulmonary congestion Monitor for: cardiac failure and pulmonary congestion

48. During Labor Side lying position Side lying position Prophylactic antibiotic Prophylactic antibiotic Epidural Epidural Attempt vaginal delivery Attempt vaginal delivery If anticoagulant therapy is needed: If anticoagulant therapy is needed: –Heparin –Lovenox

49. MVP Common and usually benign Common and usually benign May experience syncope, palpitations and dyspnea May experience syncope, palpitations and dyspnea Prophylactic antibiotics given before invasive procedure or birth Prophylactic antibiotics given before invasive procedure or birth

50. Anemia Most common iron deficiency Most common iron deficiency Hgb falls below 12 (most labs) Hgb falls below 12 (most labs) Typically seen in the end of 2 nd trimester Typically seen in the end of 2 nd trimester Iron supplementation Iron supplementation

51. Folic Acid Deficiency Anemia Increases risk of NTD, cleft lip Increases risk of NTD, cleft lip Recommended dose 400 mcg/day Recommended dose 400 mcg/day Supplemented in cereal and many other foods Supplemented in cereal and many other foods

52. Sickle Cell Anemia Abnormal hemoglobin SS types in the blood Abnormal hemoglobin SS types in the blood People have recurrent attacks of fever and pain in the abdomen and extremities People have recurrent attacks of fever and pain in the abdomen and extremities Caused from tissue hypoxia, edema Caused from tissue hypoxia, edema African-Americans African-Americans

53. Sickle Cell Trait Typically asymptomatic Typically asymptomatic Sickling of the RBCs but with a normal RBC life span Sickling of the RBCs but with a normal RBC life span

54. Thalassemia Common anemia Common anemia Insufficient amount of Hgb is produced to fill the RBCs Insufficient amount of Hgb is produced to fill the RBCs Mediterranean region Mediterranean region Genetic disorder Genetic disorder May be associated with LBW babies and increased fetal death May be associated with LBW babies and increased fetal death

55. Asthma Common with FH Common with FH 1-4% of pregnant women have Asthma 1-4% of pregnant women have Asthma Possible adverse events associated with asthma: Possible adverse events associated with asthma: –LBW –Perinatal mortality –Preeclampsia –Complicated labor –Hyperemesis

56. Asthma Continued Goal is to relieve the attack, prevent the asthma attack, and maintain 02 Goal is to relieve the attack, prevent the asthma attack, and maintain 02 Should be managed with OB and ENT Should be managed with OB and ENT May require tx: albuterol, steroids, O2 May require tx: albuterol, steroids, O2

57. Epilepsy Seizure disorder Seizure disorder May result from developmental abnormalities or injury May result from developmental abnormalities or injury 20% have an increase in seizure activity during pregnancy 20% have an increase in seizure activity during pregnancy Risks: more seizures, risk of vaginal bleeding, abruptio placentae, fetus may experience seizures Risks: more seizures, risk of vaginal bleeding, abruptio placentae, fetus may experience seizures

58. Epilepsy Continued Use of antiepeleptic meds during pregnancy has been linked to risks for the fetus Use of antiepeleptic meds during pregnancy has been linked to risks for the fetus Smallest therapeutic dose to be given Smallest therapeutic dose to be given Daily folic acid supplementation Daily folic acid supplementation Managed with OB and neurologist Managed with OB and neurologist

59. RA Chronic arthritis Chronic arthritis Pain upon movement and swelling in joint spaces Pain upon movement and swelling in joint spaces More often in women More often in women 2/3 of women with RA find the severity of symptoms decrease during pregnancy 2/3 of women with RA find the severity of symptoms decrease during pregnancy Typically give baby ASA Typically give baby ASA

60. SLE Inflammatory disease, autoimmune antibody production Inflammatory disease, autoimmune antibody production Advised to wait until in remission for 6 months to become pregnant Advised to wait until in remission for 6 months to become pregnant 15-60% of women will develop exacerbation of SLE during pregnancy or postpartum 15-60% of women will develop exacerbation of SLE during pregnancy or postpartum Tx: ASA and steroids Tx: ASA and steroids

61. Cholelithiasis More often in women More often in women Pregnancy makes women more vulnerable Pregnancy makes women more vulnerable Surgery often delayed until after delivery Surgery often delayed until after delivery

62. Appendicitis Dx may take more time to find Dx may take more time to find Sxs: abdominal pain, nausea, vomiting, loss of appetite Sxs: abdominal pain, nausea, vomiting, loss of appetite Increases incidence of PTL or SAB Increases incidence of PTL or SAB

63. Maternal Infections

64. TORCH Toxoplasmosis – protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly Toxoplasmosis – protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly Other- Heb A or B, Group B, Varicella, HIV Other- Heb A or B, Group B, Varicella, HIV Rubella (German measles) – if contracted in 1 st Trimester fetus may have congenital deformities Rubella (German measles) – if contracted in 1 st Trimester fetus may have congenital deformities

65. TORCH CMV- transmitted person to person, may cause CNS damage to fetus CMV- transmitted person to person, may cause CNS damage to fetus Herpes Simplex (HSV 2) – if initial infection occurs in pregnancy, higher incidence of perinatal loss. Fetus may pick up virus if present in the vagina during labor Herpes Simplex (HSV 2) – if initial infection occurs in pregnancy, higher incidence of perinatal loss. Fetus may pick up virus if present in the vagina during labor

66. Mental Health Disorders

67. Anxiety Disorders Most common mental disorders Most common mental disorders Include: phobias, panic disorders, OCD, PTSD Include: phobias, panic disorders, OCD, PTSD Tx: relaxation techniques, breathing exercises, imagery Tx: relaxation techniques, breathing exercises, imagery

68. Depression in Pregnancy 6% of women develop depression for the 1 st time during pregnancy 6% of women develop depression for the 1 st time during pregnancy Tx: counseling and tx with SSRIs Tx: counseling and tx with SSRIs Wellbutrin only med named as Category B Wellbutrin only med named as Category B Many women opt to DC meds during pregnancy Many women opt to DC meds during pregnancy

69. Substance Abuse in Pregnancy

70. Substance Abuse Damaging effects well documented in research to fetus Damaging effects well documented in research to fetus Any use of ETOH or illicit drugs during pregnancy is considered abuse Any use of ETOH or illicit drugs during pregnancy is considered abuse 31% of women had used one or more substances during pregnancy (as compared to 62% during prepregnancy) 31% of women had used one or more substances during pregnancy (as compared to 62% during prepregnancy)

71. Smoking Risks of any amount of smoking include: Risks of any amount of smoking include: –SAB –SGA –Bleeding –IUFD –Prematurity –SIDS

72. Alcohol Many women reluctant to tell health care provider Many women reluctant to tell health care provider Risks: Risks: –LBW –Mental retardation –Learning and physical deficits –With FAS – severe facial deformities

73. Alcohol during Pregnancy Risks to mother: Risks to mother: –HTN –Anemia –Nutritional deficits –Pancreatitis –Cirrhosis –Alcoholic hepatitis

74. Marijuana Crosses the placenta and causes increased carbon monoxide levels in mother’s blood Crosses the placenta and causes increased carbon monoxide levels in mother’s blood May cause fetal abnormalities May cause fetal abnormalities

75. Cocaine In the US, 10-15% of all pregnant women use cocaine In the US, 10-15% of all pregnant women use cocaine Problems associated with use: polydrug use, poor health, poor nutrition, STIs, infections, HIV Problems associated with use: polydrug use, poor health, poor nutrition, STIs, infections, HIV Poverty big issue Poverty big issue

76. Cocaine in Pregnancy Maternal effects: Maternal effects: –Cardiovascular stress –Tachycardia –HTN –Dysrhythmias –MI –Liver damage –Sz –Pulmonary disease –Death Fetal Complications: Fetal Complications: –Abruptio placentae –PTL –Precipitous labor –Risks for abdominal pregnancy –Fetal complications after delivery

77. Opiates in Pregnancy Drugs include: heroin, Demerol, morphine, codeine, methadone Drugs include: heroin, Demerol, morphine, codeine, methadone Methadone is used to treat addiction to other opiates Methadone is used to treat addiction to other opiates Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL Tx: Methadone and psychotherapy Tx: Methadone and psychotherapy Goal: prevent withdrawal symptoms Goal: prevent withdrawal symptoms

78. Methamphetamine CNS stimulant CNS stimulant Most common use n the 18-30 yr old range Most common use n the 18-30 yr old range Neonatal complications include: Neonatal complications include: –IUGR –PRL/PTB

79. Postpartum Psychologic Complications

80. Baby Blues Usually within 4 weeks of childbirth Usually within 4 weeks of childbirth Many experience this Many experience this

81. PPD Intense sadness, crying all the time, mood swings, fears, anger, anxiety, irritability Intense sadness, crying all the time, mood swings, fears, anger, anxiety, irritability Incidence of PPD at 8 weeks – 12% and 8% at 12 weeks Incidence of PPD at 8 weeks – 12% and 8% at 12 weeks Many women feel guilty Many women feel guilty May need tx but usually resolves on own May need tx but usually resolves on own

82. Postpartum Psychosis Delusions, hurting self or the infant, emotional lability, insomnia, suspiciousness, confusion, obsessive concerns regarding the baby Delusions, hurting self or the infant, emotional lability, insomnia, suspiciousness, confusion, obsessive concerns regarding the baby 1-2/1000 births 1-2/1000 births 35-60% recurrence with each subsequent birth 35-60% recurrence with each subsequent birth Usually symptoms appear within 8 weeks of birth Usually symptoms appear within 8 weeks of birth

83. Medical Management Supportive family Supportive family Intense psychotherapy Intense psychotherapy Emergency Emergency Tx: SSRIs Tx: SSRIs SSRIs contraindicated while breastfeeding SSRIs contraindicated while breastfeeding

84. 1. A client asks the nurse to again explain the purpose of the amniocentesis test. The nurse responds that one purpose of this test is to indicate the: 1. A client asks the nurse to again explain the purpose of the amniocentesis test. The nurse responds that one purpose of this test is to indicate the: –A. Accurate age of the fetus –B. Presence of certain congenital anomalies –C. Biparietal diameter of the skull –D. Hormone content of the amniotic fluid –E. Mainly the presence of Down’s syndrome

85. 2. The nurse explains to a new mother that the condition of SGA is caused by: 2. The nurse explains to a new mother that the condition of SGA is caused by: –A. Placental insufficiency –B. Maternal obesity –C. Primipara –D. Genetic predisposition

86. 3. A pregnant client with diabetes is controlled by insulin. When she asks the nurse what will happen to her insulin requirements during pregnancy, the correct response is: 3. A pregnant client with diabetes is controlled by insulin. When she asks the nurse what will happen to her insulin requirements during pregnancy, the correct response is: –A. “Because your case is so mild, you are likely not to need much insulin during your pregnancy” –B. “It’s likely that as the pregnancy progresses you will need increased insulin” –C. “Every case is individual so there is really no way to know” –D. “If you follow the diet closely and don’t gain too much weight, your insulin needs should stay the same”

87. 4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be: 4. The nurse in the newborn nursery understands that assessing a newborn with a diabetic mother, initially the insulin level would be: –A. Higher than in normal infants –B. Lower than in normal infants –C. The same as in normal infants –D. Varied from baby to baby

88. 5. A client is admitted to L&D, at 38 weeks gestation. She is there for evaluation because she is experiencing polyhydramnios. The nurse understands that this diagnosis means that: 5. A client is admitted to L&D, at 38 weeks gestation. She is there for evaluation because she is experiencing polyhydramnios. The nurse understands that this diagnosis means that: –A. There is the normal amount of amniotic fluid, thinner in volume –B. A less-than-normal amount of amniotic fluid is present –C. An excessive amount of amniotic fluid is present –D. A leak is causing the fluid to accumulate outside the amniotic sac