2. Rosemary Schiller 610 519- 6813 St. Mary’s 1st Floor, Office Hours Tue 11:30-1:30 http://www39.homepage.vill anova.edu/rosemary.schille r/

5. Antepartum Complications zHigh-Risk Pregnancy

6. What is a High Risk Pregnancy zIncreased probability of poor maternal or fetal outcome due to one or more of the following factors: ymedical yreproductive ypsychosocial

7. Medical Risk Factors zPreexisting Medical Conditions ye. g. diabetes, anemia, heart disease, herpes ygenetic factors ylifestyle factors

8. Obstetric/Reproductive zPast pregnancy conditions yprevious preterm labor and delivery yprevious cesarean sections yprevious pregnancy induced hypertension ygrand multiparity

9. Psychosocial factors zaccess to prenatal care zsocial support systems zadaptation to pregnancy zclient compliance

10. Maternal Mortality Rates In 1935 582 mothers died for every 100,000 live births, while today, the maternal mortality rate has been reduced to 7.8/100,000 What factors have contributed to this declining maternal mortality rate?

11. Changes in Healthcare contributing to better pregnancy outcomes: zImproved control for diabetics zBetter heart disease detection and prevention zImproved anesthesia zAvailability of blood products/antibiotics zNew technologies yultrasound yprenatal diagnosis zRisk assessment tools

12. Risk Assessment zMany risk assessment tools yACOG Antepartum Record xAssessment tools are only as good as the person eliciting the information is at getting a comprehensive holistic history xMost risk assessment tools do a better job of predicting risk in multiparas than in primiparas

13. Diagnostic Tests zUltrasound Examination of the fetus

14. Prenatal Diagnosis zAmniocentesis, Chorionic villus sampling zMaternal Alpha-fetoprotein zUltrasound scanning, basic and targeted zDoppler flow studies zPercutaneous umbilical blood sampling zStress and nonstress tests zBiophysical profile zFetal Movement

15. zChorionic villus sampling

16. Amniocentesis

17. BIOPHYSICAL PROFILE (30 minute observation period) z1. REACTIVE NST z2. FETAL BREATHING MOVEMENT z3. FETAL BODY MOVEMENT z4. FETAL TONE z5. AMNIOTIC FLUID VOLUME

18. SCORE z2 POINTS=NORMAL z0 POINTS=ABNORMAL results:8-10 maximal score 0-4 severe fetal compromise delivery indicated

19. 1. NON STRESS TEST(NST) external monitoring for 20 minutes; poor specificity >4 fetal heart accelerations (>15 bpm over baseline for 15 seconds) following fetal movement in fetus >34 weeks no heart accelerations in immaturity sleep maternalsedation

20. contraction stress test CST (not used for biophysical profile) external monitoring after oxytocin or maternal breast stimulation > 3 uterine contraction in 10 minutes; 50% specificity

21. 2. FETAL BREATHING MOVEMENT Breathing period at least 60 seconds

22. 2.FETAL BODY MOVEMENT >3 discrete movements of limbs/trunk

23. 4. FETAL TONE Upper and lower limbs usually flexed with head or chest >1 episode of extension with return to flexion

24. 5. AMNIOTIC FLUID VOLUME Largest pocket> 1 cm in vertical diameter without containing loops of cord

25. COMMON COMPLICATIONS EARLY PREGNANCY

26. EARLY ANTEPARTUM HEMMORAGE Vaginal bleeding <20 weeks of gestation

27. Incidence 15% to 25% clinically recognized Maybe as high as 50%

28. Spontaneous Abortion The naturally occurring termination of pregnancy before viability

29. Spontaneous Abortion zThreatened Abortion zInevitable Abortion zComplete Abortion zMissed Abortion zRecurrent Abortion

30. Threatened Abortion: Uterine bleeding in early pregnancy, with or without cramping.

31. Inevitable Abortion : Symptoms of threatened abortion plus the physical finding of dilatation of the internal os of the cervix.

32. Incomplete Abortion: Passage of a portion of the products of conception from the uterus.

33. Complete Abortion : Passage of all of the products of conception from the uterus.

34. Missed Abortion: Retention of the conceptus in the uterus for a clinically appreciable time after death of the embryo or fetus.

35. Habitual Abortion: The usual criterion is three or more consecutive abortions.

36. Complications of Abortion Hemorrhage Infection Clotting Disorders

37. HEMMORHAGE More common with late abortions. Continued heavy bleeding indicates retained tissue (incomplete abortion).

38. INFECTION (septic abortion) seen most commonly with criminally-induced abortionbut may ensue in spontaneous or therapeutic abortion. Septic shock may occur in severe instances.

39. CLOTTING DISORDERS If a missed abortion is retained beyond one month,thromboplastin  maternal circulation may result in a clotting disorder (DIC). This risk is greater in late abortion.

40. ECTOPIC PREGNANCY zPregnancy outside the uterus yfallopian tubes yabdomen yrare:coincidence of ectopic and uterine preg. associated with PID previous ectopic tubal surgery IUD (?)

41. Ectopic Pregnancy

42. hydatiform mole trophoblastic proliferationof chorionic villi uterus large for dates (50%) severe eclampsia prior to 24 weeks 1st trimester bleeding abnormal elevation of beta-hCG passing grapelike vesicles per vagina

43. HYPEREMESIS GRAVIDARUM Excessive and debilitating emesis resulting in symptoms of zweight loss zdehydration zketonuria zhigh urine specific gravity

44. ETIOLOGY UNKNOWN possible causes: zhormonal (HCG, estradiol, thyroxine)  incidence in multiple gestations

45. Management zhospitalization if severe zIV fluids zIntake and Output (strict) zNPO for 24-48 hrs. zAntiemetics zPhenothiazines (phenergan, compazine) zParenteral Nutrition zPsychotherapeutic Measures

46. Second and third trimester disorders

47. Second and Third Trimester Bleeding zPlacenta Previa Implantation of the placenta in the lower uterine segment zAbruptio Placenta Separation of some or all of the placenta from the uterine wall

48. Placenta Previa zIncidence=1:200 deliveries zClassification ymarginal, partial or total

49. Placenta Previa

50. zComplete placenta previa following cesarean hysterectomy

51. Risk Factors zIncreasing maternal age zMultiparity zPrior uterine scar zAssociated with breech and transverse presentations

52. Symptoms zPainless bright red bleeding (p 20 wks) zRecurrent and heavier as preg progresses

53. Management zDouble set up examination zUltrasound diagnosis zCS If >37 wks or fetal maturity documented unless marginal z<37 wks--expectant management

54. Expectant management zBedrest zno digital or speculum exams (no tampons) zfrequent NSTs and fetal monitoring zMgSO 4 for preterm labor zbetamethasone if delivery anticipated zImmediate delivery if vaginal bleeding includes fetal blood (KOH test)

55. Placental Abruption zIncidence--10% of all deliveries zTypes ypartial ycomplete yoccult (concealed,retroplacental ) zRisk factors yprior history of abruption ymaternal hypertension ysmoking or cocaine use y  maternal age ymultiparity ytrauma

56. Placental abruption

57. Abruptio placenta zRetroplacental clot following removal of a placenta which had completely abrupted

58. Symptoms zPain and hypotension (disproportionate to bleeding) zIncreased uterine tone zTetanic contractions zFetal distress

59. Management zExpectant management if mild zImmediate delivery if shock and fetal distress (usually CS) zTreatment of shock zTreatment of coagulopathy (DIC)

60. multiple gestation Incidence is increasing twins in 1:85; triplets in 1:85x85; etc uterus large for dates may have elevated hCG, hPL, and aFP at risk for: IUGR, Prematurity

61. PREGNANCY INDUCED HYPERTENSION (PIH) diastolic BP>90mmHg (or 15 over baseline) systolic BP>140mmHg(or 30 over baseline)

62. RISK FACTORS zFIRST PREGNANCY zMULTIPLE GESTATION zPOLYHYDRAMNIOS zHYDATIDIFORM MOLE zMALNUTRITION zFAMILY HISTORY zVASCULAR DISEASE

63. PREECLAMPSIA AND ECLAMPSIA

64. PREECLAMPSIA defined as: zHypertension or PIH zProteinuria zEdema (wt gain)

65. MILD PREECLAMPSIA zHYPERTENSION (140/90) zPROTEINURIA>300mg/24 hrs zMILD EDEMA,signaled by wt gain (>2 lb/week or >6 lb/month) zURINE OUTPUT>500ml/24hrs

66. SEVERE PREECLAMPSIA Any of the following symptoms: zBP>160/110 (2X, 6hrs apart, bedrest) zProteinuria.5g/24 hours (3+ or 4+ dipstick) zMassive edema zOliguria <400ml/24 hrs zIUGR in fetus zSystemic symptoms

67. Systemic symptoms zPulmonary edema zheadaches zvisual changes zRUQ pain z  Liver Enzymes zThrombocytopenia

68. Eclampsia Occurrence of a seizure that is not attributable to other causes.

69. Assessment zHistory zPhysical zLab studies

70. History Document risk factors and any symptoms reported by client

71. Physical zLook for edema (esp. hands and face) zBP changes zRetinal changes zhyperreflexia zclonus zRUQ tenderness

72. Lab studies zBlood--CBC, lytes, BUN, Creat., uric acid zLiver function studies zCoagulation studies z 24hr Urine zHELLP syndrome yHemolysis yelevated Liver function tests yLow Platelet count

73. Complications zEclamptic seizures zHELLP syndrome zHepatic rupture zDIC zpulmonary edema zrenal failure zplacental abruption zcerebral hemorrhage zfetal demise

74. PIH or mild preeclampsia zHome bed rest zBP monitoring zwt and urine checks zNST’s early zUS for IUGR

75. Hospital management zbedrest with BRP zIV zdaily weight zfetal movement count zmonitor reflexes zdaily NST zweekly US for AFV and IUGR zmonitor symptoms continuously

76. Treatment zDelivery is the Tx of choice zBetamethasone for fetal maturity zantihypertensive therapy zanticonvulsive therapy (MgSO 4 )

77. MgSO 4 Therapy zLoading dose IV 4-6 g/20min zcontinued at 2 g/hr ycheck for adverse effects xrespiratory depression diminished reflexes are expected

78. intrauterine growth retardation (IUGR) definition: < 10th percentile for gestational age usually not detectable before 32-34 weeks (maximal fetal growth) incidence: 3-7% of all deliveries 12-47% of twin pregnancies complications: increased risk for perinatal asphysia, meconium aspiration, electrolyte imbalance from metabolic acidosis, polycythemia 6-8 fold increase for intrapartum and neonatal death

79. IUGR Etiologies PRIMARY FETAL CAUSES (20%) decreased intrinsic growth (symmetrical IUGR ) congenital heart disease genitourinary anomalies CNS anomalies chromsomal abnormalities (trisomy 13, 18,21) viral infection (rubella, CMV),,,

80. IUGR: Etiology UTEROPLACENTAL INSUFFICIENCY (80%) maternal causes deficient supply of nutrients: smoking malnutrition multiple gestations placental causes extensive placental infarctions chronic partial separation placenta previa

81. POLYHYDRAMNIOS zExcessive amniotic fluid yidiopathic (60%) ymaternal (20%) xdiabetes xRh incompatibility (fetal hydrops) yfetal (20%) xneural tube defect xGI obstruction xcardiac xdwarfism

82. Oligohydramnios zToo little amniotic fluid yplacental insufficiency ycardiac failure yfetal demise yfetal renal disease

83. Preterm Labor Onset of contractions between 20-37 wks. With cervical dilitation difficult to discern in early stages from “false labor”

84. Etiology zMaternal factors xinfections xuterine anomalies xcervical incompetence xoverdistended uterus xpremature rupture of the membranes

85. zFetal factors ycongenital anomalies yintrauterine death

86. Management zUltrasound for fetal wt/gest. age/position zMonitor for FHT and contractions zNitrozine test zCath for UA and Culture zTocolysis

87. Tocolysis zPharmacological inhibition of uterine activity yTerbutaline (Brethine) IV, then po maintenance yMgSO 4 (sometimes used) Ineffective if labor is well established or cervix dilated to 4cm or more

88. zSteroids given to accelerate fetal lung maturity (betamethasone or dexamethasone 12.5 mg. IM q 24 hrs for 48 hours

89. Diabetes in Pregnancy zGestational Diabetes Mellitus (GDM) Complications--Infant: zRDS (5x normal risk) zMacrosomia and associated birth trauma zNeonatal hypoglycemia zRisk of congenital anomalies with 1st trimester hypoglycemia zIntrauterine fetal demise

90. Complications to Mother zPreeclampsia zpolyhydramnios zinfection zpostpartum bleeding zcesarean section zbirth canal trauma from macrosomic infant

91. Treatment Careful control of diabetes zDietary management zexercise zaccucheck QID ac and hs zmaintain fasting levels at <105mg/dl through diet or insulin zcheck for ketonuria

92. Monitoring fetal wellbeing zEarly US for accurate gestational dating zUS if macrosomia is suspected zamniocentesis for fetal lung maturity zantepartum NST weekly p. 34 wks Mom should have GTT at 6 weeks pp

93. Habits Misc zAlcohol zTobacco zCrack cocaine or other illicit drugs zMedications zExposure to infections

94. Alcohol zMidtrimester abortion zmental retardation zbehavior and learning disorders Abstinence is best Treatment for chronic abuse

95. Tobacco zLow birth weight zpremature labor zspontaneous abortions zstillbirth zbirth defects zrespiratory infections and otits in children of smoking parents

96. Cocaine and other drugs zPerinatal addiction zpreterm labor zplacental abruption zcognitive and psychological difficulties Abstinence an treatment necessary

97. Medications zCategory A--safe (vitamins) zCategory B--no animal effects (penicillin) zCategory C--no studies available zCategory D--evidence of risk but benefits outweigh the risks zCategory X--risks outweigh benefits