High Risk Pregnancy

Front 1

What aspects are considered when assessing if a woman is at risk for High risk pregnancy?

Back 1

-Biophysical
-Psychosocial
-Socio-demographic
-Environmental

Front 2

What groups of women are susceptible to high risk pregnancies? LIst them

Back 2

1. ages < 20 and > 35
2. lack pre-natal care
3. Low educational attainment
4. unmarried status
5. african american
6. If mom or sister had HTN related to pregnancy

Front 3

WHat are the 3 major causes of maternal death worldwide?

Back 3

1. PIH/Pre-eclampsia
2. Pulmonary Edema (PE)
3. PPH

Front 4

What indicators would tell if a pregnant woman has CHRONIC hypertension?

Back 4

-SBP ≥ 140 mmHG or DSP ≥ 90 mmHg
**That was known to exist prior to pregnancy and/or is present BEFORE 20 weeks gestation

Front 5

What is the latest that a diagnosis for chronic HTN can occur?

Back 5

After the PP period (6weeks) when the mom's HTN does not return to normal levels

Front 6

What is the definition of gestational HTN?

Back 6

HTN in pregnancy with onset AFTER 20 weeks of gestation

Front 7

WHat are the 2 indicators for gestational HTN?

Back 7

SBP ≥ 140 and DBP ≥ 90 OR a change from baseline of S ↑ > 30 or D ↑ > 15.

-No significant proteinuria

Front 8

Which HTN disorder is accompanied by proteinuria urine dip of ≥ 1?

Back 8

Pre- eclampsia

Front 9

What are the "triad" symptoms of pre-ecplampsia?

Back 9

-HTN
-Proteinuria
-Edema**

**in hands and feet when she is lying down. Does not respond to bed rest

Front 10

When can pre-eclampia occur?

Back 10

Up to 48 hours pp

Front 11

How much weight gain may be seen with pre-eclampsia?

Back 11

2Kg in 1 week or 4.4 lbs

Front 12

What are the SxS of pre-eclampsia?

Back 12

1. Headaches (vasoconstrict)
2. Visual changes
3. Epigastric pain (hepatic involvement)
4. Elevated BP
5. Sudden excessive weight gain
6. Hand and face edema
7. Proteinuria

Front 13

Describe Mild Preeclampsia.

Back 13

SBP ≥ 140 but ≤ 160
- DBP ≥ 90 but ≤ 110
- +1 protein
- moderate puffiness
- DTRs WNL

Front 14

What are the signs of Severe Preeclampsia?

Back 14

- SBP ≥ 160 (2 readings 6 hours apart)
- DBP ≥ 110
- +3 or > protein
- Generalized edema and noticeable puffiness
- Hyperreflexive
- Oliguria (lack of urine)

Front 15

How do you manage mild preeclampsia?

Back 15

-The pt can be at home
-Bed rest in LLP periodocially
- Monitor BP at least 2x a day
- Daily urine dips and weight measurements
-FMC (want 6/hour)

Front 16

How is severe preeclampsia managed?

Back 16

- Hospital bed rest!
- Decrease environmental stimulation
- Sz precautions
- Monitor Is and Os
- Fetal Assessment (NST/BPP)
- MgSO4

Front 17

What is the drug of choice for preeclampsia?

Back 17

MgSO4

Front 18

If there is any evidence of multi-system involvement with preeclampsia, what must be done?

Back 18

The baby must be delivered even if at 34 weeks!

Front 19

What is the only cure to preeclampsia?

Back 19

Birth

Front 20

What was the antidote to MgSO4?

Back 20

Calcium gluconate

Front 21

What is the most important goal of preeclampsia?

Back 21

The prevention or control of seizures

Front 22

What is the initial dose of MgSO4? How is it administered?

Back 22

4-6 grams in 100 to 250 cc over 15-30 mins IVPB

Front 23

What is the maintenance dose of MgSO4?

Back 23

40g/1000 of LR via pump at 2g/hour

-Must always be on a pump

Front 24

What is the therapeutic level of MgSO4?

Back 24

4-7

Front 25

What are the SxS of MgSO4 toxicity?

Back 25

-Depressed RR
-CNS depression
-lowered DTR's
-Oliguria

Front 26

What does HELLP Syndrome stand for? What is it?

Back 26

H- hemolysis
E- Elevated
L- liver enzymes
L- Low
P- Platelets

-Life threatening occurrence that complicates about 10% of preeclamptic women

Front 27

What is the treatment of HELLP syndrome?

Back 27

Birth! Must do a C-section

Front 28

What is the platelet level in hellp syndrome? What is the coag level?

Back 28

Plts < 100,000

Coags are normal
-abnormal clotting factor

Front 29

What are the risk factors for HELLP Syndrome?

Back 29

-Chronic renal disease
-Chronic HTN
-Family h/o PIH
- Primigravidity
-Maternal age > 40
- Diabetes
-Obesity
-Twin (+) gestation

Front 30

What is Eclampsia?

Back 30

Preeclampsia with Seizures

Front 31

When a person has elevated liver enzymes, what test will be high? What is it usually caused by?>

Back 31

AST
A- alcohol
S- statins
T- Tylenol overdose

Front 32

What are the complications that can cause vaginal bleeding in pregnancy?

Back 32

- Spontaneous abortion
- Molar pregnancy
- Incompetent cervix
- Ectopic pregnancy
- implantation spotting

Front 33

What is an SAB?

Back 33

Spontaneous abortion that ends before 20 weeks

Front 34

What is an early SAB? Late?

Back 34

Before 12 weeks gestation.

After 12 weeks and before 20

Front 35

Define a complete SAB?

Back 35

All products of conception are expelled.

- Cervix is closed

Front 36

What type of SAB occurs when some, but not all products of conception are expelled from uterus?

WHat are the SxS?

Back 36

Incomplete

-bleeding, severe cramping, cervix is open!

Front 37

What is a threatened SAB?

Back 37

Have bleeding but poc are not expelled?

-Body is giving a signal to rest or an SAB will occur

Front 38

If abortion cannot be stopped because of ROM and dilation, what type of SAB is occurring?

Back 38

Inevitable SAB

Front 39

Describe a Missed SAB. What must be done? What can be a sign?

Back 39

The fetus dies, but the products are retained. Placenta atrophy and cervix is closed

-Must go in and get the products
-Uterine height may cease to grow

Front 40

WHat are recurrent SABs?

Back 40

3 or more consecutive pregnancies end in SAB

Front 41

How many clinically recognized pregnancies end in SAB?

Back 41

10-15%

Front 42

What % of SAB are due to chromosomal abnormalities?

Back 42

50%

Front 43

WHen do the majority of SABs occur?

Back 43

75% occur between weeks 8-13

Front 44

What are the risk factors for a SAB?

Back 44

-Endocrine imbalance
- infection
- maternal structural problems
- immunological factors
- systemic disorders
- drug use
- inadequate nutrition

Front 45

Define an incompetent/ insufficient cervix.

Back 45

Passive and painless dilation of the cervix in the 2nd trimester

Front 46

WHat are the risk factors for an incompetent cervix?

Back 46

- H/O previous cervical lacerations during childbirth
- Excessive cervical dilation
- Congenitally short cervix
- Cervical uterine abnormalities

Front 47

How do you treat an incompetent cervix?

Back 47

Cerclage

Front 48

What is a cerclage? When is it done? what instructions must be given to mom?

Back 48

A running stitch around the cervix to pull it closed.
-can be done 10-15 weeks for prophylaxis, but usually done 2nd trimester not after 25 weeks
-Must not have sex! no tampons and no long term standing

Front 49

What % of woman will deliver a viable baby is their cerclage is left in place?

Back 49

80-90%

Front 50

Where does fertilzation usually occur?

Back 50

in the ampula (95%)

Front 51

WHat is an ectopic pregnancy?

Back 51

When fertilization occurs outside of the uterine cavity

Front 52

What must occur if an ectopic pregnancy is found>

Back 52

Must be removed!! Not viable

Front 53

What are the SxS of ectopic pregnancy?

Back 53

From women:
-pregnancy
-vaginal bleeding

Clinical findings!!
-Low or slowly rising HCG levels
-Adnexal tenderness and fullness on exam
-Referred pain in the shoulder

Front 54

If a woman has pain in her shoulder, low HCG levels and adnexal tenderness, what might she have?

Back 54

ectopic pregnancy

Front 55

What is a molar pregnancy?

Back 55

AKA gestational trophoblastic disease or hydatidiform mole

-abnormal growth of trophoblastic cells taht attach the fertilized ovum to the uterine wall

-fill the uterus with vesicles that resemble cluster of grapes

Front 56

Is a molar pregnancy viable?

Back 56

No

Front 57

What is thought to cause a molar pregnancy?

Back 57

Unknown
-some correlation with clomid (fertility drug)

Front 58

what is a partial molar pregnancy?

Back 58

-fetal tissue or membranes are present
-chromosomes contribution is present
-nonviable fetus

Front 59

What are the SxS of molar pregnancy?

Back 59

-Vaginal bleeding
-ELEVATED HCG levels
-Severe nausea and vomiting
-uterus is large for date
-No fetal heart tones or activity
-HcG levels high and rising

Front 60

How do you manage a molar pregnancy?

Back 60

-Immediate vacuum evacuation after diagnosis
-Identify tissue for cancer
-Take weekly measurements of HcG
-Must monitor up to 1 year and No pregnancy for 1 year

Front 61

When should HCG levels be undetectable following the removal of a molar pregnancy?

Back 61

3 weeks

Front 62

What are 2 possible causes of late pregnancy bleeding?

Back 62

1. Placenta previa
2. Placental abruption

Front 63

What is placenta previa?

Back 63

Placenta partially or completely covers the internal os
-related to a postion, is painless

Front 64

What is a placental abruption?

Back 64

premature separation of the placenta from the uterine wall

-Painful

Front 65

In what cases of placenta previa must a C/S be performed?

Back 65

Complete and Partial

Front 66

What are the risk factors for placenta previa?

Back 66

-Previous previa
-Previous C/S
- Elective TOP
- Multiple gestation
- closely spaced pregnancies
- Advanced maternal age
- smoking (placenta grows bigger to get more O2)
- cocaine use

Front 67

How is a placenta previa managed?

Back 67

-Bed rest
-NPV
-Evaluate fetal well-being
-never do a vaginal exam!
-C/S

Front 68

What are the SxS of placental abruption?

Back 68

-May or my not have bleeding
-abdominal pain for ctx greater than expected and may be localized

-Uterine tenderness
-BOARD-LIKE abdomen

Front 69

What are the risk factors for abruption?

Back 69

1. PIH
2. Cocaine USE
3. Trauma (a kick)
4. Smoking
5. Poor nutrition

Front 70

What is gestational diabetes? How often does it occur?

Back 70

Physiological glucose intolerance during pregnancy

4% of all pregnancies

Front 71

What are women with GDM more at risk for later in life?

Back 71

50% will develop diabetes later in life

Front 72

What are the risk factors for GDM?

Back 72

1. Maternal age >30
2. Obesity
3. Family history of IDDM
4. Previous baby weighing > 4000g
5. polyhydraminos
6. previous unexplained stillbirth
7. SAB
8. congential anomalies
9. SxS of diabetes
10. Recurrent glucosuria noted on D stick

Front 73

What is the glucose challenge Test?

Back 73

SCREENING test done between 24-28 weeks.

-Do not have to fast for this test
-levels between 130-140 will go on to do GTT
-if GCT is > 200 it is used to tell if you have GDM

Front 74

What is the Glucose Tolerance TEst?

Back 74

Test to see how your body responds to glucose

-First take a fasting reading
-Then drink sugary drink and test again right away, at 1 hour, 2 hours, 3 hours etc. It should go down

Front 75

What are the # values to know for diagnosing GDM?

Back 75

GCT > 200 or

-2 abnormal values on GTT

-Fasting ≥ 95-105
-1 hour ≥ 180-190
-2 hours ≥ 155-165
-3 hours ≥ 135-145

Front 76

What is the treatment for GDM?

Back 76

Glucose control!

-Want fasting levels to stay ≤ 105
-2 hour post prandial should be ≤ 120

Diet and exercise

Front 77

What are some of the dietary guidelines for GDM?

Back 77

1. Standard diabetic diet
2. small frequent meals
3. high fiber foods
4. lower fat intake
5. avoid sugar and concentrated sweets

Front 78

What are some causes for baby size < dates (S<D)?

Back 78

1. Intrauterine growth restriction
2. Small for gestational age (benign)
3. Oligohydramnios

Front 79

What is Symmetric IUGR?

Back 79

-Represents chronic/long term

-Small in all parameters including head development

Front 80

What is asymmetric IUGR?

Back 80

-Late occurring/short-term deprivation

-Head sparing

-Typically small body, but with a large head

Front 81

What are the risk factors for IUGR?

Back 81

1. Poor nutrition and poor maternal weight gain
2. maternal vascular disease
3. pre-eclampsia
4. Multiples
5. smoking
6.genetic disease
7. drug/ alcohol abuse
8. anemia

Front 82

Is being SGA pathological?

Back 82

No

Front 83

What is oligohydramnios?

Back 83

Abnormally small amount of amniotic fluid
< 5cm

Front 84

What is the normal range for the AFI?

Back 84

5-20

Front 85

What is oligohydramnios associated with?

Back 85

Marked perinatal mortality

Front 86

What are the factors associated with Oligohydramnios?

Back 86

-Congenital anomalies
-IUGR
-Early rupture of membranes
-Post-maturity

Front 87

How do you manage oligohydramnios?

Back 87

-Bed rest
-hydration
-encourage nutrition
-assess fetal well-being
-induction and delivery if severe and fetus is mature

Front 88

What is the normal range for amniotic fluid volume?

Back 88

800-1200cc

Front 89

What are some disorders associated with Size greater than dates (S>D)

Back 89

-Macrosomia
- LGA
- Mutlifetal pregnancy
- fibroid uterus
- polyhydramnios

Front 90

What is fluid volume is considered polyhydramnios?

Back 90

> 2000 cc

Front 91

What AFI is associated with polyhydramnios?

Back 91

AFI > 20cm

Front 92

What difficulties in assessment can occur due to polyhydramnios?

Back 92

-Difficulty auscultating the heart sounds
-difficulty palpating fetus

Front 93

what Can occur with fetal positioning with polyhydramnios?

Back 93

Unstable fetal lie, baby can move and get stuck in a malpresentation

Front 94

What must be ruled out when diagnosing polyhydramnios?

Back 94

GDM and ABO/Rh disease

Front 95

What are some risk factors for polyhydramnios?

Back 95

1. multiples
2. uncontrolled GDM
3. Fetal malformations
4. chromosomal abnormalities

Front 96

List the complications involved with polyhydramnios.

Back 96

1. Fetal malpresentation
2. Placental abruption
3. uterine dysfunction during labor
4. PP hemmorhage
5. Cord prolapse
6. Preterm labor

Front 97

What is post-term pregnancy?

Back 97

Extends beyond the 42nd week of gestation.

-no known cause

Front 98

If a woman has a post term labor in first pregnancy, how likely is she to have it again in her second or third?

Back 98

30-40% more likely

Front 99

If a woman experiences weight loss, decreased uterine size, meconium in the fluid and advanced bone maturation of the fetal head, what may she have?

Back 99

She may be in POST TERM Pregnancy

Front 100

List the maternal risks of post term pregnancy/

Back 100

-dysfunctional labor
-perineal trauma
-PPH
-Infection
-Interventions (forceps/suction)
-Emotional distress

Front 101

What are the fetal risks associated with post term pregnancy?

Back 101

-Macrosomia
-Birth trauma
-distress
-hypoxia/asphyxia

Front 102

How do you best manage post term pregnancy?

Back 102

-BPP, NST, FMC
-cervical assessment for ripeness
- induction!