Psychosocial factors zaccess to prenatal care zsocial support systems zadaptation to pregnancy zclient compliance
Maternal Mortality Rates In 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?
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
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
Diagnostic Tests zUltrasound Examination of the fetus
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
zChorionic villus sampling
BIOPHYSICAL PROFILE (30 minute observation period) z1. REACTIVE NST z2. FETAL BREATHING MOVEMENT z3. FETAL BODY MOVEMENT z4. FETAL TONE z5. AMNIOTIC FLUID VOLUME
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
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
2. FETAL BREATHING MOVEMENT Breathing period at least 60 seconds
2.FETAL BODY MOVEMENT >3 discrete movements of limbs/trunk
4. FETAL TONE Upper and lower limbs usually flexed with head or chest >1 episode of extension with return to flexion
5. AMNIOTIC FLUID VOLUME Largest pocket> 1 cm in vertical diameter without containing loops of cord
COMMON COMPLICATIONS EARLY PREGNANCY
EARLY ANTEPARTUM HEMMORAGE Vaginal bleeding <20 weeks of gestation
Incidence 15% to 25% clinically recognized Maybe as high as 50%
Spontaneous Abortion The naturally occurring termination of pregnancy before viability
Threatened Abortion: Uterine bleeding in early pregnancy, with or without cramping.
Inevitable Abortion : Symptoms of threatened abortion plus the physical finding of dilatation of the internal os of the cervix.
Incomplete Abortion: Passage of a portion of the products of conception from the uterus.
Complete Abortion : Passage of all of the products of conception from the uterus.
Missed Abortion: Retention of the conceptus in the uterus for a clinically appreciable time after death of the embryo or fetus.
Habitual Abortion: The usual criterion is three or more consecutive abortions.
Complications of Abortion Hemorrhage Infection Clotting Disorders
HEMMORHAGE More common with late abortions. Continued heavy bleeding indicates retained tissue (incomplete abortion).
INFECTION (septic abortion) seen most commonly with criminally-induced abortionbut may ensue in spontaneous or therapeutic abortion. Septic shock may occur in severe instances.
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.
ECTOPIC PREGNANCY zPregnancy outside the uterus yfallopian tubes yabdomen yrare:coincidence of ectopic and uterine preg. associated with PID previous ectopic tubal surgery IUD (?)
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
HYPEREMESIS GRAVIDARUM Excessive and debilitating emesis resulting in symptoms of zweight loss zdehydration zketonuria zhigh urine specific gravity
ETIOLOGY UNKNOWN possible causes: zhormonal (HCG, estradiol, thyroxine) incidence in multiple gestations
Management zhospitalization if severe zIV fluids zIntake and Output (strict) zNPO for hrs. zAntiemetics zPhenothiazines (phenergan, compazine) zParenteral Nutrition zPsychotherapeutic Measures
Second and third trimester disorders
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
Placenta Previa zIncidence=1:200 deliveries zClassification ymarginal, partial or total
zComplete placenta previa following cesarean hysterectomy
Risk Factors zIncreasing maternal age zMultiparity zPrior uterine scar zAssociated with breech and transverse presentations
Symptoms zPainless bright red bleeding (p 20 wks) zRecurrent and heavier as preg progresses
Management zDouble set up examination zUltrasound diagnosis zCS If >37 wks or fetal maturity documented unless marginal z<37 wks--expectant management
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)
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
Abruptio placenta zRetroplacental clot following removal of a placenta which had completely abrupted
Symptoms zPain and hypotension (disproportionate to bleeding) zIncreased uterine tone zTetanic contractions zFetal distress
Management zExpectant management if mild zImmediate delivery if shock and fetal distress (usually CS) zTreatment of shock zTreatment of coagulopathy (DIC)
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
PREGNANCY INDUCED HYPERTENSION (PIH) diastolic BP>90mmHg (or 15 over baseline) systolic BP>140mmHg(or 30 over baseline)
PREECLAMPSIA defined as: zHypertension or PIH zProteinuria zEdema (wt gain)
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
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
PIH or mild preeclampsia zHome bed rest zBP monitoring zwt and urine checks zNST’s early zUS for IUGR
Hospital management zbedrest with BRP zIV zdaily weight zfetal movement count zmonitor reflexes zdaily NST zweekly US for AFV and IUGR zmonitor symptoms continuously
Treatment zDelivery is the Tx of choice zBetamethasone for fetal maturity zantihypertensive therapy zanticonvulsive therapy (MgSO 4 )
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
intrauterine growth retardation (IUGR) definition: < 10th percentile for gestational age usually not detectable before 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
Preterm Labor Onset of contractions between wks. With cervical dilitation difficult to discern in early stages from “false labor”
Etiology zMaternal factors xinfections xuterine anomalies xcervical incompetence xoverdistended uterus xpremature rupture of the membranes
zFetal factors ycongenital anomalies yintrauterine death
Management zUltrasound for fetal wt/gest. age/position zMonitor for FHT and contractions zNitrozine test zCath for UA and Culture zTocolysis
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
zSteroids given to accelerate fetal lung maturity (betamethasone or dexamethasone 12.5 mg. IM q 24 hrs for 48 hours
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
Complications to Mother zPreeclampsia zpolyhydramnios zinfection zpostpartum bleeding zcesarean section zbirth canal trauma from macrosomic infant
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
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
Habits Misc zAlcohol zTobacco zCrack cocaine or other illicit drugs zMedications zExposure to infections
Alcohol zMidtrimester abortion zmental retardation zbehavior and learning disorders Abstinence is best Treatment for chronic abuse
Tobacco zLow birth weight zpremature labor zspontaneous abortions zstillbirth zbirth defects zrespiratory infections and otits in children of smoking parents
Cocaine and other drugs zPerinatal addiction zpreterm labor zplacental abruption zcognitive and psychological difficulties Abstinence an treatment necessary
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