Antepartum Complications
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Transcript Antepartum Complications
Rosemary Schiller 610 5196813
St. Mary’s 1st Floor,
Office Hours Tue 11:30-1:30
http://www39.homepage.vill
anova.edu/rosemary.schille
r/
Antepartum Complications
High-Risk Pregnancy
What is a High Risk
Pregnancy
Increased probability of poor maternal or
fetal outcome due to one or more of the
following factors:
medical
reproductive
psychosocial
Medical Risk Factors
Preexisting Medical Conditions
e. g. diabetes, anemia, heart disease, herpes
genetic factors
lifestyle factors
Obstetric/Reproductive
Past pregnancy conditions
previous preterm labor and delivery
previous cesarean sections
previous pregnancy induced hypertension
grand multiparity
Psychosocial factors
access to prenatal care
social support systems
adaptation to pregnancy
client compliance
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?
Changes in Healthcare contributing to better
pregnancy outcomes:
Improved control for diabetics
Better heart disease detection and prevention
Improved anesthesia
Availability of blood products/antibiotics
New technologies
ultrasound
prenatal diagnosis
Risk assessment tools
Risk Assessment
Many risk assessment tools
ACOG Antepartum Record
Assessment tools are only as good as the person
eliciting the information is at getting a
comprehensive holistic history
Most risk assessment tools do a better job of
predicting risk in multiparas than in primiparas
Diagnostic Tests
Ultrasound
Examination of the
fetus
Prenatal Diagnosis
Amniocentesis, Chorionic villus sampling
Maternal Alpha-fetoprotein
Ultrasound scanning, basic and targeted
Doppler flow studies
Percutaneous umbilical blood sampling
Stress and nonstress tests
Biophysical profile
Fetal Movement
Chorionic
villus sampling
Amniocentesis
BIOPHYSICAL PROFILE
(30 minute observation period)
1.
2.
3.
4.
5.
REACTIVE NST
FETAL BREATHING MOVEMENT
FETAL BODY MOVEMENT
FETAL TONE
AMNIOTIC FLUID VOLUME
SCORE
2 POINTS=NORMAL
0 POINTS=ABNORMAL
results:8-10 maximal score
0-4 severe fetal compromise
delivery indicated
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
Spontaneous Abortion
Threatened Abortion
Inevitable Abortion
Complete Abortion
Missed Abortion
Recurrent Abortion
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
Pregnancy outside the uterus
fallopian tubes
abdomen
rare:coincidence of ectopic and uterine
preg.
associated with
PID
previous ectopic
tubal surgery
IUD (?)
Ectopic Pregnancy
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
weight loss
dehydration
ketonuria
high urine specific gravity
ETIOLOGY
UNKNOWN
possible causes:
hormonal (HCG, estradiol, thyroxine)
incidence in multiple gestations
Management
hospitalization if severe
IV fluids
Intake and Output (strict)
NPO for 24-48 hrs.
Antiemetics
Phenothiazines (phenergan, compazine)
Parenteral Nutrition
Psychotherapeutic Measures
Second and third trimester
disorders
Second and Third
Trimester Bleeding
Placenta Previa
Implantation of the placenta in the lower
uterine segment
Abruptio Placenta
Separation of some or all of the placenta
from the uterine wall
Placenta Previa
Incidence=1:200
deliveries
Classification
marginal, partial or
total
Placenta Previa
Placenta Previa
Complete placenta
previa following
cesarean
hysterectomy
Risk Factors
Increasing maternal age
Multiparity
Prior uterine scar
Associated with breech and transverse
presentations
Symptoms
Painless bright red bleeding (p 20 wks)
Recurrent and heavier as preg progresses
Management
Double set up examination
Ultrasound diagnosis
CS If >37 wks or fetal maturity
documented unless marginal
<37 wks--expectant management
Expectant management
Bedrest
no digital or speculum exams (no tampons)
frequent NSTs and fetal monitoring
MgSO4 for preterm labor
betamethasone if delivery anticipated
Immediate delivery if vaginal bleeding
includes fetal blood (KOH test)
Placental Abruption
Incidence--10% of all
deliveries
Types
partial
complete
occult
(concealed,retroplacental)
Risk factors
prior history of
abruption
maternal hypertension
smoking or cocaine
use
maternal age
multiparity
trauma
Placental abruption
Abruptio placenta
Retroplacental clot
following removal of a
placenta which had
completely abrupted
Symptoms
Pain and hypotension (disproportionate to bleeding)
Increased uterine tone
Tetanic contractions
Fetal distress
Management
Expectant management if mild
Immediate delivery if shock and fetal
distress (usually CS)
Treatment of shock
Treatment 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)
RISK FACTORS
FIRST PREGNANCY
MULTIPLE GESTATION
POLYHYDRAMNIOS
HYDATIDIFORM MOLE
MALNUTRITION
FAMILY HISTORY
VASCULAR DISEASE
PREECLAMPSIA AND
ECLAMPSIA
PREECLAMPSIA
defined as:
Hypertension or PIH
Proteinuria
Edema (wt gain)
MILD PREECLAMPSIA
HYPERTENSION (140/90)
PROTEINURIA>300mg/24 hrs
MILD EDEMA,signaled by wt gain
(>2 lb/week or >6 lb/month)
URINE OUTPUT>500ml/24hrs
SEVERE PREECLAMPSIA
Any of the following symptoms:
BP>160/110 (2X, 6hrs apart, bedrest)
Proteinuria.5g/24 hours (3+ or 4+ dipstick)
Massive edema
Oliguria <400ml/24 hrs
IUGR in fetus
Systemic symptoms
Systemic symptoms
Pulmonary edema
headaches
visual changes
RUQ pain
Liver Enzymes
Thrombocytopenia
Eclampsia
Occurrence of a seizure that is not
attributable to other causes.
Assessment
History
Physical
Lab studies
History
Document risk factors and any symptoms
reported by client
Physical
Look for edema (esp. hands and face)
BP changes
Retinal changes
hyperreflexia
clonus
RUQ tenderness
Lab studies
Blood--CBC, lytes, BUN, Creat., uric acid
Liver function studies
Coagulation studies
24hr Urine
HELLP syndrome
Hemolysis
elevated Liver function tests
Low Platelet count
Complications
Eclamptic seizures
HELLP syndrome
Hepatic rupture
DIC
pulmonary edema
renal failure
placental abruption
cerebral hemorrhage
fetal demise
PIH or mild preeclampsia
Home bed rest
BP monitoring
wt and urine checks
NST’s early
US for IUGR
Hospital management
bedrest with BRP
IV
daily weight
fetal movement count
monitor reflexes
daily NST
weekly US for AFV and IUGR
monitor symptoms continuously
Treatment
Delivery is the Tx of choice
Betamethasone for fetal maturity
antihypertensive therapy
anticonvulsive therapy (MgSO4)
MgSO4 Therapy
Loading dose IV 4-6 g/20min
continued at 2 g/hr
check for adverse effects
respiratory depression
diminished reflexes are expected
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
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)
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
POLYHYDRAMNIOS
Excessive amniotic fluid
idiopathic (60%)
maternal (20%)
diabetes
Rh incompatibility (fetal hydrops)
fetal (20%)
neural tube defect
GI obstruction
cardiac
dwarfism
Oligohydramnios
Too little amniotic fluid
placental insufficiency
cardiac failure
fetal demise
fetal renal disease
Preterm Labor
Onset of contractions between 20-37 wks.
With cervical dilitation
difficult to discern in early stages from
“false labor”
Etiology
Maternal factors
infections
uterine anomalies
cervical incompetence
overdistended uterus
premature rupture of the membranes
Fetal factors
congenital anomalies
intrauterine death
Management
Ultrasound for fetal wt/gest. age/position
Monitor for FHT and contractions
Nitrozine test
Cath for UA and Culture
Tocolysis
Tocolysis
Pharmacological inhibition of uterine
activity
Terbutaline (Brethine) IV, then po
maintenance
MgSO4 (sometimes used)
Ineffective if labor is well established or cervix
dilated to 4cm or more
Steroids given to accelerate fetal lung
maturity (betamethasone or
dexamethasone 12.5 mg. IM q 24 hrs for
48 hours
Diabetes in Pregnancy
Gestational Diabetes Mellitus (GDM)
Complications--Infant:
RDS (5x normal risk)
Macrosomia and associated birth trauma
Neonatal hypoglycemia
Risk of congenital anomalies with 1st
trimester hypoglycemia
Intrauterine fetal demise
Complications to Mother
Preeclampsia
polyhydramnios
infection
postpartum bleeding
cesarean section
birth canal trauma from macrosomic
infant
Treatment
Careful control of diabetes
Dietary management
exercise
accucheck QID ac and hs
maintain fasting levels at <105mg/dl
through diet or insulin
check for ketonuria
Monitoring fetal wellbeing
Early US for accurate gestational dating
US if macrosomia is suspected
amniocentesis for fetal lung maturity
antepartum NST weekly p. 34 wks
Mom should have GTT at 6 weeks pp
Habits Misc
Alcohol
Tobacco
Crack cocaine or other illicit drugs
Medications
Exposure to infections
Alcohol
Midtrimester abortion
mental retardation
behavior and learning disorders
Abstinence is best
Treatment for chronic abuse
Tobacco
Low birth weight
premature labor
spontaneous abortions
stillbirth
birth defects
respiratory infections and otits in children
of smoking parents
Cocaine and other drugs
Perinatal addiction
preterm labor
placental abruption
cognitive and psychological difficulties
Abstinence an treatment necessary
Medications
Category A--safe (vitamins)
Category B--no animal effects (penicillin)
Category C--no studies available
Category D--evidence of risk but benefits
outweigh the risks
Category X--risks outweigh benefits