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240 Cards in this Set

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  • Back
What is the false positive rate for 1st and 2nd trimester screen?
5%
What does the ultrascreen test for? When is it offered?
For fetal chromosomal abnormalities (trisomies)
-FIRST trimester screen
-Looks for
1. Maternal serum- blood test
2. Free B-hCG and plasma protein A
3. Higher B-hCG levels and lower levels of PAPP-A
**Does NOT tell you about neural tube defects**
Why do you look at nuchal translucency? When will this test be done?
If 4.5-5.5 mm then 50% chance of Down's
-Looking for trisomies in 1st semester screen
-Optimal time is 11 weeks, can stretch to 10-13.6 wks
-Thickness is accumulation of lymph fluid at fetal neck
Why do you do an early US?
At 7-8 wks to verify pregnancy, estimate getational age with crown/rump length, detect variations from normal, look for fetal echocardiograms
What does the second trimester screening look for?
-Detection of fetal chromosomal abnormalities and neural tube defects
-15-21 weeks
-This is Quad screen and looks for maternal serum alpha feto protein (MSAFP) used to detect fetal neural tube defects. Elevation correlates with defects and this is done 15-18 weeks gestation
What are the types of neural tube defects?
encephalocele, myelmeningocele, anencephaly and spina bifida
When and why might you do an amniocentesis? What is the risk?
15-18 weeks- karyotyping. Risk are injury to placenta, cord, fetus, pregnancy loss about 1/200. Risk decreased wtih use of US guidance
**What are the 4 maternal serum markers of the Quad screen?**
1. MSAFP
2. Estriol
3. hCG
4. inhibin-A
80% decetion of trisomy and NTD, 5% false positive rate
What levels of MSAFP are associated with NTD? with Down Syndrome?
Higher with NTD
Lower with Down's
What does integrated screening mean?
Results of first semester ultra screen with second trimester quad screen that has highest detection rate. However results are not shared until 2nd semester
With which prenatal invasive procedure would the possibility of finding chromosomal mosaicism be highest?
chocionic villi sampling (transabdominal to where the cord and placenta meet)
Can you do DNA testing for neural tube defects?
NO! Cannot know about this until screen in 2nd trimester or US at 20 weeks
What is the etiology of most birth defects?
unknown (65%)
15-20% thought to be genetic, 8-10% from environmental factors or maternal disease
Is hydrocephalus a chromosomal disorder?
No
US dating in first trimester is accurate plus or minus how many days? 2nd trimester? 3rd?
5-7 days in 1st, 2nd is up to 2 weeks off, 3rd up to 3 weeks off
What environmental factors might contribute to abnormalities?
viruses (might contribute heavily to first trimester losses), radiation, drugs
What is a monosomy? Give an example
absence of a chromosome
ex: XO turner syndrome
What is a trisomy?
presence of an extra chromosome
13= patau
19= Edward's
21= down
What does the ultrascreen test for?
**Trisomy 13, 18, 21**
What causes Down Syndrome?
1. Trisomy
2. Translocation
3. Mosaicism- may be milder, translocation happens later
What is mosaicism?
accident at cell division during mitosis
Give an example of an autosomal dominant disease
Achondroplasia
Give examples of autosomal recessive diseases
Cystic fibrosis, phenylketonuria, Tay-Sachs, oculocutaneous albinism, infantile polycystic kidney, sickle cell anemia
What is PKu?
don't have enzyme to break down phenylalanine
Give some examples of X-linked recessive diseases
Color blindness, hemophilia A and B, Duchenne's muscular dystrophy, glucose-6-phosphate dehydrogenase deficiency
What is mutlifactorial inheritance? Give some examples.
-Secondary to the interaction of environment and genetic factors
-Incidence of recurrence in blood relatives is 2-5%
-ex: congenital heart disease, club foot, neural tube defects, pyloric stenosis, cleft lip/palate, congeniatal hip dysplasia
What is genetic counseling?
Process that opens the lines of communication between the health-care provider and the patient for the purpose of disseminating accurate and reliable information, thereby allowing the patient and her partner to make fundamental decisionas about conception, abortion, antenatal procedures, and tests.
What are the risks of delivery after 35 years?
incrased risk of trisomy 21, recurrence is about 1%
What might you see in a down syndrome fetus on US?
-reduced fetal femur length
-nuchal skin fold thickness greater than 5 mm
-look between 15-20 weeks gestation
What are the most common birth defects?
**neural tube defects**
How do you test for NT defects?
**MSAFP at 15-19 weeks, up to 22 weeks**
-must be corrected for maternal age, race, and the presence of DM
-universal screening may detect up to 20% of the cases of trisomies in women younger than 35 years at delivery
What impacts NT defect incidence?
geographic location, seasonal influence, use of anticonvulsants
What is the recurrence risk for NT defects?
if one child- 4-5%
if 2 children 10%
will be asked to take 4 mg folic acid instead of 1 mg
What is alpha-feto protein (AFP)?
-enzyme found in maternal blood and amniotic fluid. Elevated in the presence of neural anomalies, most GI anomalies, fetal death, twins, wrong estimation of dates, and maternal liver problems
What do amniotic fluid assays look at?
-alpha-fetoprotein
-acetylcholinesterase
-may identify an additional 5% of small NTD's undetectable by current high resolution imaging techniques
What does the triple screen look at?
-Alpha feto protein
-HCG
-estriol

might ID 60% in low risk pop
What does the triple screen look at?
-Alpha feto protein
-HCG
-Estriol
-Inhibin A and B
In a triple screen, what levels would indicate Down's syndrome?
positive would be low serum estriol, low AFP, elevated levels of HCG
If a woman has a child with NT defect, how much folic acid should she take with this pregnancy?
4 mg
take it at least 4 wks prior to conception through 1st trimester
What might decrease the absorption of folic acid?
birth control pills and smoking
Inborn errors in what might be incompatible with life?
metabolism, many of these are autosomal recessive or X-linked. Look at enzyme activity assay of cultured amniotic fluid cells or of placental villi
Give examples of invasive testing
-Chrionic villi sampling
-Amniocentesis
-Cordocentesis
-Genetic amnio
-Rh immunoglobulin
When could you do an early amnio?
12-14 weeks, need about 150cc of fluid to do
What are the risks of CVS? when can it be done?
could cause limb deformity of miscariage
-**do from 10-12 and 6 weeks** if prior to 10 weeks the risk of limb deformity goes up
What is fluorescence in situ hybridization (FISH) used for?
-On amniotic fluid provides rapid prenatal dx
-rapid aneuploidy detection- used as an adjunct in cases of increased risk for a fetal trisomy
-option to terminate may be offered earlier than the traditional time frame of 2-3 wks
What is PUBS?
cordocentesis
-fine-needle aspiration of fetal blood under US guidance, after 18-20 weeks
-analysis of lymphocytes, fetal karyotype
-risk of fetal loss is 1.15%
What would you consider if a woman has n/v before 4-5 weeks (instead of the 6-7 weeks we might expect)?
multiples or molar pregnancy
What can a limited US look at?
This is when the US is done by a nonsonographer
-estimate gestation age in 1st trimester
-antepartum vaginal bleeding
-determiniation of fetal number
-fetal presentation
-evaluation of fetal well being
-cardiac activity
-measure ovarian follicles
What can be seen/done at different points in the first trimester with US?
-gestational sac at 4.5-5 wks
-secondary yolk sac at 5-12
-embryo fetus at 5.5-6
-Meaure crown rump length 6-11
-biparietal diameter (BPD) starting at 12 weeks
What are first trimester biochemical markers for aneuploidy?
-beta hCG
-pregnancy associated plasma protein A (PAPP-A) done with ultrascreen
-this combo is thought to detect about 82% of Downs
What does the first trimester Ultrascreen include?
US and 2 blood tests
When do you measure for fetal nuchal translucency?
at 10-14 weeks, screen positive result if the NT was above 99%
When does hydrocephaly usually develop?
rare if develops before 3rd trimester
How accurate are fetal weight estimates at 36-37 weeks? how do you do it?
within 10-15%
look at biparietal diameter, femur length, and abdominal circumference
What is the earliest you can detect fetal cardiac activity?
7-8 weeks. If 8 weeks with a heartbeat the chance of miscarriage is decreased
When would a comprehensive US be ordered?
when a fetal anatomic anomal or deviation from normal is noted on basic US, target the specific anatomic location and performed by a sonologist
ex: to follow a low lying placents
What portion of fetus fall into IUGR? what causes it?
for those in less than 10th percentile
-way to track fetus that doesn't meet landmarks
-caused by intrinsic (genetic) and extrinsic, or both
How do you screen for IUGR?
50% not dx until delivery
-serial funday height measurements from 20 weeks
-single measurement at 32-34 weeks is about 70-85% sensitive and 96% specific for detecting IUGR
-if suspect then send for US
What percent of pregnancies are small for gestational age (SGA)?
4-7%, this increases mortality
How much does genetics and in utero env impact birth weight?
-genetics= 40%
-in utero environment= 60%
mother's weight gain will greatly influence (?40%?)
clinical estimates of weight will be how accurate?
at best, 80% of cases within 450 gms (1lb). if less than 2270 grams then less accurate
When does fetal growth rate peak?
singleon- 34 weeks
twins- 28-32 weeks (they catch up by 1 yr)
What influences survival in utero?
-number of cells
-differentiated properly
-adequate nutrients
-oxygen
-uteroplacental unit
-intervilla space
**What is early-onset IUGR?*
-problem with cell division, organ size or fucntion
-baby will have very small and symmetric appearance
-irreversible diminution of organ size and possibly functions
-20% of all IUGR
-as early as 2nd trimester or early 3rd
What is early-onset IUGR associated with?
-Hereditary factors
-Immunologic abnormalities
-chronic maternal disease
-fetal infection
-multiple pregnancy
-lupus
**What is delayed onset IUGR?**
-growth is more dependent on cellular hypertrophy vs. hyperplasia
-more reversible b/c not so many genetic factors
-decreased cell size
-**80% of IUGR
** Primary cause is uteroplacental insufficiency impacted by diseases that have not been controlled
**will be asymmetric in appearance, decrease in abdominal circumference but preservation of head and femur growth
Can you always determine the cause of IUGR?
**Definite cause of IUGR cannot be Id'd in 50% of all cases, must be suspected at every visit**
**What are the causative factors for early vs delayed IUGR?**
-with symmetric early- constituttional, chromosomal, infection, multiples, maternal chronic disease
-asymmetric delayed- smoking, drugs, alcohol, nutritional deficiencies, maternal disease
**What is the most common maternal factor in IUGR?** others?
HTN
others include cyanotic heart disease, hemoglobinopathies and coagulopathies
What are fetal causes of IUGR?
congenital infections such as rubella, cytomegalovirus. very few bacterial infections
-start to make milestones about 7-8 months
What part of the fetus is NOT affected by IUGR?
**fetal cerebellum, can tell unaltered on US**
Restoration of normal size with adequate nutrition is primarily associated with?
delayed onset IUGR
When are fundal height measurements helpful?
15/20-36 weeks
What is oligohydramnios?
decrease in urine production and excretion, excessive loss of fluid
look up numbers!!
How do you assess amniotic fluid volume?
1. maximum vertical pocket depth (MVP) want greater than 2 cm
2. Amniotic fluid index (AFI)- measure from four quadrants. usually > 5 cm
When does AF start to decrease/
after 40 weeks?
How sill stress impact AF?
redistribution of blood flow during hypoxic stress will decrease UOP
What is the risk with oligohydramnios?
in second trimester mortality is 80-90%
fetal anomalies increase
What is polyhydramnios?
AF index greater than 24 cm, MVP greater than 8 cm
1 cm of fluid is how many cc?
50
What are the risks associated with polyhydramnios?
high perinatal risk
-multiple anomalies
-if acute, prognosis for survival is poor
What is mild polyhydramnios associated with?
diabetes, erythrobastosis, idiopathic
What might be done for polyhydramnios?
-serial amniotic fluid reduction by amniocentesis
-indomethacin
What are the fetal essentials?
adrenal, brain, heart
When woul you expect a rise in hormones in the pp nonlactating woman? Menses?
about 3 weeks
6-8 weeks
will be hypoestrogen with shiny smooth vagina until estrogen returns
wen would a BF mom expect menses?
2-18 months
What is involution? When does it happen?
The return of the uterus to prepregnant state, about 6 weeks
When do after birth pains normally end?
48-72 hours
worse with each delivery
oxytocin that is released from posterior pituitary and prolactin from anterior pituitary
give ibuprofen (better than narcotics but those are beeter for lacerations
What would you expect if after birth pain continues?
**INFECTION** infection=pain
What if the woman is bleeding a lot
**retained placental fragment= blood**
What is endometritis? *What is the most common causative organism?*
-Infection
-**commonly caused by strep**
more susceptible if lots of exams, longer time between rupture and delivery, internal monitoring, trauma
-obese are at greater risk
-outside of abdomen will be v. tender to touch
What is the most common causative organism of mastitis?
staph
-
What might you consider other than placental fragments if continue to bleed bright red blood?
chlamydia
How will lochia progress?
-Rubra- bright red 0-3/5 days
-serosa 3-10 days
Alba 10-21 days
Might continue until 5th week
REsume intercourse when lochia ends
Sloughing of superficial layer where placenta has been
When will the cervical os close postpartum?
as much as it ever will at 3-6 weeks
When will episiotomy heal?
6 weeks or longer
when will the rectus abdominus muscles close?
6 weeks to 2-4 months
What initiates milk production?
prolactin from anterior pituitary
What causes milk letdown?
oxytocin from posterior pituitary
How long does collostrum last?
3-5 days
What is in collostrum?
antibodies, protein, immunoglobulins, minerals
what should be included in PP visit?
-review charts first
-check immune status
-general health
-relationship with partner
-pp blues
-VS
-weight
-urine
-breast exam
-thyroid
-back and extremities
-abdominal exam
pelvic
What are common problems in postpartum?
-infection
-endometritis
-mastitis
-mammary adenitis
--PP bleeding
What is preterm labor?
-Labor after 20 weeks and before 37 weeks
-Uterine contractions (4 per 20 min or every 10 min for at elast 30 min) and cervical dilation over 1 cm (progressive) and at least 80% effaced
What might increase PTL?
Stress, diet, working, multiples
What is late preterm birth?
34-36 weeks
How significant is preterm birth?
-12% in US, has risen
-Account for 85% of perinatal morbidity and mortality
What are the 3 types of preterm birth?
1. Medically inidcated for maternal or fetal reasons
2. Preterm premature rupture of membranes (25%)
3. Idiopathic/ spontaneous- 50%
What is the cause of preterm birth?
often unknown!!
What are some risk factors for PTL?
Infection/inflammation, abruption, placenta previa, anemia, fetal anomalies, short interpregnancy interval, maternal weight, thrombophilias, **HISTORY OF PTL**, uterine or cervical anomalies, repeated 2nd trimester abortions, incompetent cervix, multiple gestation, polyhydramnios, overdistended uterus, late or no prenatal care, smoking, drugs and alcohol, poor nutrition, strenuous job, fatigue, maternal age extremes, ethnicity, low SES, domestic abuse
What infection is specifically linked to PRL?
**BActerial vaginosis** consider screening for this
What is the most predictive risk factor for preterm labor?
**History of previous preterm labor and birth**
What is the pathophysiology of preterm labor?
Unknown, but do know these links
1. Inflammatory or infectious response, cytokine response- such as chorioamnitis (80%!). Treating does not help
2. maternal or fetal stress-production of corticotrophin releasing hormone
What are some other pathophys explanations for preterm labor?
-abruption or decidual hemorrhage- this disrutps uterine tone --> initiation of clotting cascade and thrombin induced protease production --> uterine irritation and contractions
-mechanical stretch- with multiples of polyH
What are some symptoms of PTL?
persisent, low dull backache, vaginal spotting, pelvic pressure, abdominal tightening/cramping, increased vaginal discharge, uterine contractions, feels like "baby is balling up"
-Often subtle and intermittens! might be present for 2 weeks
How do you dx PTL?
-S&S
-contractions and cervical change
-digital cervical exam
-US cervical length
-fetal fironectin
-bishop score- if >6 risk is increased
What is normal cervical length?
10-50 mm
What cervical length indicates an increased risk for PTL?
<25 mm between 16-24 weeks
What cervical length indicates that delivery is not likely in the next week?
>15-30mm, high negative predictive value
What is fetal fibronectin? What will it tell you?
-a glycoprotein (biomarker) produced by the chorion, found at the junction of the chorion and decidua
-not found after 20 wks unless a disruption between chorion and decidua occurs
-very predictive of PTL
How do you collect fetal fibronectin?
-with speculum in place, insert dacron swab into fornix and leave for 10s, place in tube with buffer and send to lab
What might cause a false positive fetal fibronectin test?
-Vag exam in last 24 hrs
-cervical dilation >3cm
ROM
Cerclage in place
-vaginal bleeding or placental previa
-sexual intercourse within past 24 hours
Other than meds, what are some treatments for PTL?
-rest
-fluids
-sedation
-get urine sample, vag cultures
-smoking cessation
What do you need to evaluate in PTL?
-health and reproductive history
-prenatal course
-determination of fetal gestational age, LMP, USG, fundal ht
-S&S of PTL- onset, duration, severity, activities and relief measures
When do you start treatment for PTL?
When there is documented uterine contractions with cervical change
What is the late cutoff for treating PTL?
34 weeks, b/c baby will most likely be fine and risks to mother are no longer worth it
What are the contraindications to treating PTL?
-fetal demise
-NR fetal status
-maternal hemodynamic instability
-intraamniotic infection
-advanced cervical dilation
What are the treatment goals for PTL?
-delay delivery to get maximum benefit from glucocorticoids
-time to transport mom
-prolong pregnancy to treat an underlying cause
what are the indications for tocolytic therapy?
diagnosed PTL, gestation beyond 23/23 weeks but less than 34, live fetus
Name some tocolytic agents
-beta mimetic adrenergic agents- terbutaline
-Magnesium sulfate
-Indomethacin
-Nifedipine= procardia
**How does terbutaline work? What is the number one side effect?**
-**Acts on smooth muscle, acts on them all**
-Acts directly on beta receptors to relax the uterus and uterine vessels
-Promotes binding of intracellular Ca
-Inhibits actin and myocin chain
**Number one complication is tachycardia**
Other SE include hypoTN, hyperglycemia (consider this before giveing to diabetic), pulmonary edema. Fetal complications are rare
How is terbutaline given? What is the dose?
-po2.5-5 mg po 2-4 times per day
-SubQ .25-.5 mg every 2-4 hrs for 12 hours
-can go home on this and might prolong delivery for 2 wks
When should a woman NOT take her terbutaline?
if HR > 120 bpm
How does magnesium sulfate work?
-inhibits the re-uptake of acetylcholine at nerve synapse
-CNS depressant, blocks neuromuscular transmission
What is the big risk with mag?
**PULMONARY EDEMA**
**INFANT MORTALITY** b/c crosses placenta --> respiratory depression
What are the maternal and infant complications of mag sulfate?
flushing, thirst, pulmonary edema, toxicity, infant mortality, respiratory depression in newborn
What might you see in mag toxicity?
absence of DTRs (9-12 mg/dl), resp depression (12-18 mg/dl), cardiac arrhythmias, cardiac arrest (24-30 mg/dl), decreased UOP
What is the therapeutic level for mag?
5-8 mg/dl
What is the dosing for mag sulfate?
initial 4-6g IV bolus followed by maintenance rate of 1-3
**What is the antidote for mag sulfate?**
**CALCIUM GLUCONATE**
Can you use a calcium channel blocker with magnesium sulfate?
**NO! This will lead to cardiovascular collapse**
What calcium channel blocker is used for PTL? What are some complications?
Nifedipine (procardia)
inhibits smooth muscle contractions
-hypoTN, tachycardia, palpitations, facial flushing, HA, peripheral edema
What prostaglandin antagonist is used for PTL? What is the main complication?
Indomethacin (indocin)
-prostaglandins are part of labor cascade
**Main complications are for the fetus** risk increases after 32 weeks
-should not take for more than 72 hrs or must be watched for fetal affects
What is the indocin dosing?
50 mg pr followed by 25 mg po every 6 hours for 72 hrs. If give for greater than 72 hrs do fetal echo weekly, twice weely US for AFI
What are fetal complications of indocin?
decreased UOP, oligohydramnios, premature closure of ductus arteriosus
= fetal circulation and renal system
NOTE also increases risk for PP hemmorhage b/c platelets are less sticky
what does 17p progesterone do?
usally weekly Im injections
-decreases conduction of contractions, increases threshold for stimulation, decreases spontaneous activity, prevents formation of gap junctions, decreases number or oxytocin receptors
What are the 17P recommendations?
not widely available, use only with women with previous PTD prior to 37 weeks
What do corticosteroids do?
accelerate fetal lung maturity
why might you give a PTL pt antibiotics?
prohylaxis for group B strep
What is the best way to improve fetal outcomes?
early detection of preterm labor
What are the three interventions that have been proven to reduce perinatal morbidity and mortality?
-Transport of woman to facility with NICU
-Administration of glucocorticoids
-Treatment with ab for GBS
What are late preterm babies at risk for?
-this is brith from 34-37 weeks, on the rise and majority of NICU
-from 34-40 weeks there are major changes in rain size and development- cerebellum grows, white matter increases
-increased risk for cardiovascular disease, diabetes and cancer
-increase in ADHD
-twice as likely to die of SIDS
What is the long term significance of preterm birth?
developmental disabilities, vision impairment, CP
hat is premature rupture of membranes?
rupture of fetal membranes with release of amniotic fluid more than 1 hr before the onset of labor- 50% will go into labor in 24 hrs
What is preterm PROM?
PROM before 37 wks
What is prolonged PROM?
Prolonged if more than 24 hrs
PPROM is responsible for what percent of preterm births?
1/3
What is the primary risk factor for PROM?
previous hx
What are some possible mechanisms for PPROM?
choriodecidual infection, collagen degradation, dcreased membrane collagen content, localized membrane defects, membrane stretch, programed amniotic cell stretch
What could lead to pulmonary hypoplasia?
Baby practices breathing in utero. If not enough fluid then can't pracice as well and the lungs don't develop as they should
What are some PPROM risks?
Neonatal- immaturity, infection, cord accident, pulmonary hypoplasia
Maternal- amnionitis, abruption, c/s, death
How is PPROM dx?
clinical suspicion, pt hx, testing
-have pt cough to see if visualize fluid coming out into fornix
what does nitrazine tell you?
test pH to see if alkaline, paper will turn bluie in the presence of amniotic fluid. could also be blood, semen or vaginitis
How will amniotic fluid crystallize?
fern leaf pattern that can't be viewed under microscope
What should you do for PPROM?
tocolytics to give time or corticosteroids to work
-antibiotics improve neonatal outcome
-monitor with NST twice weekly, BPP daily if AFI< 5cm or twice weekly if greater
NOTE that fetus can become septic before maternal symptoms
What is the preterm fetus more susceptible to?
hypoxic insult, declines more quickly so it is CRITICAL to ID and intervene with NR FHT patterns
What is chronic HTN?
-prior to conception or before 20 weeks gestation
-might know if still HTN in postpartum
-at risk for pre-eclampsia (25%) so watch for new onset proteinuria or sudden and uncontrollable HTN
How might you dx chronic HTN in pregnancy?
retinal changes on exam
cardiac enlargement
decreased renal function
med disorders known to lead to HTN
multip with previous HTN in pregnancy
What is gestational HTN?
-detected 1st in pregnancy after 20 weeks
-no proteinuria
What are the hallmarks of pre-eclampsia?
-HTN (over 140/90)
-proteinuria
-no longer must have edema
what level is considered proteinuria?
>0.3 g protein/L of 24 hr urine GOLD STANDARD
>0.1 g protein/L (2+ urine dipstick) on 2 random urine samples that are at least 4 hrs apart
NOTE that this will be affected by urine concentration
What might interfere with an accurate proteinuria?
pH< 8
discharge, blood, AF, bacteria might lead to false pos
What kind of edema are you assessing for with pre-eclampsia?
nondependent of face, hands, abdomen that is not responsive to 12 hrs bed rest. Or rapid wt gain of more than 2 lbs in 1 week
What are some other signs of pre-eclampsia?
HA, visual changes, oliguria, hyper-reflexia, n/v, epigastric pain
What are the clinical manifestations of severe preeclampsia? If have one of these, considered severe
-BP> 160-180/110
-Proteinuria > 5 g/24 hr
-elevated creatinine
-eclampsia
-pulmonary edema
-oliguria
-microangiopathic hemolysis
-thrombocytopenia (<100,000)
-hepatocellular dysfunction
-IUGR or oligo
-symptoms of end-organ involvement
What is the pathophysiology of pre-eclampsia?
-Random vasoconstriction in vasculature
-Damages endothelial lining of blood vessel
-Blood is inhibited past the constiction --> hypoxia and ischemia
-Damage --> permeability that looks like a soaker hose --> leakage into 3rd space
-body tries to form platelet plugs and fibrin clots (maybe DIC)
What happens to the kidneys in pre-eclampsia?
-decreased renal perfusion
-endothelial damage
-proteinuria
Why are most pre-eclampsia pts hypovolemic?
fluid is leaking into vasculature, so volume inside vessels is depleted. this leads to decreased renal perfusion
What is the majority of protein loss due to?
endothelial damage
How you manage oliguria depends on the cause. Give examples of management for differing hemodynamic profiles
1. low PCWP, hyperdynamic LV, moderate increase SVR --> volume
2. VAsoconstriction- Normal or increase PCWP, normal LV function, normal SVR --> delivery
3. BP is high and blood can't get out of the heart- Marked increase PCWP, decreased LV function, marked increase SVR --> volume restriction and afterload reduction
How can you tell the pt can't hold fluid in the vessel?
colloid osmotic pressure and low serum albumin
What are the 2 types of pulmonary edema?
1. Cardiogenic- fluid volume overload(increased hydrostatic pressure), elevated SVR, might stretch the L ventricle and cause dysfunction
2. Noncardiogenic- pulmonary capillary permeability, volume depletion. Lasix will make it worse
NOTE: pre-eclampsia + pulmonary edema = critical!
What are the clinical manifestations of pulmonary edema?
CHEST PAIN
SOB, tachypnea, cough, decreased O2, abnormal ABGs, breath sounds
How mgiht pre-eclampsia impact the liver? the cerebral hemispheres?
1. Liver- ischemia from vasoconstriction, swelling, rupture, Will see elevated liver enzymes
2. Cerebral edema, ischemia, hyperreflexia (degree does not tell you severity), seizures, coma, hemorhage
How might pre-eclampsia impact the CV system?
dysrythmia and MI from vasoconstriction
What is HELLP syndrome?
a complication of pre-eclampsia
Hemolysis
Elevated Liver Enzymes
Low Platelets
rule out with labs
What are some symptoms of HELLP/
epigastric pain, n/v, malaise, jaundice, HA, vision changes, bleeding
What labs would you do for HELLP?
hemolysis, hepatic, hemoglobin, hematocrit, RBC volume to see if hemoconcentrated, BUN, creatinine, DIC with d dimer (VERY predictive of DIC), bleeding times
what eclampsia?
Pre-eclampsia + seizures. Must rule out other reasons for seizure
What symptoms might precede eclampsia?
HA, hyper-reflexia, proteinuria, edema, clonus, visual signs, epigastric pain
How do pre and eclampsia effect the fetus?
-abruptio placentae (cal lead to DIC and fetal death)
-IUGR
-prematurity
-placental infarction
-acute hypoxia
-death
What are some risk factors for pre-eclampsia?
**Preeclampsia in previous preg with same FOB and diabetes**
nulliparity, family hx, obesity, multiples, poor outcome in previous preg, chronic HTN, renal disease, thrombophilias
What is the recurrence risk?
preeclampsia 43%
HELLP 19-27%, if less than 32 weeks then 61%
Counsel pt about this!
How do you prevent preeclampsia?
At present, there is no proven method
what is the cure for preeclampsia?
delivery
What do you do for preeclampsia at 40 weeks? 37-40? less than 37?
at 40-deliver
37-40 deliver or cervical ripening and deliver
under 37- expectant management
What are some criteria for expectant management?
BP not too high, proteinuria <500/day, platelet >125,000, normal liver enzymes, Cr <1.32, no IUGR, no oligo, no signs that pt is getting worse
What does expectant management include?
rest, position, hydration, teaching, lots of contact with HCP
Woman must evaluate BP, reflexes, edema, HA, etc. Platelet counts every 2-4 days, NST, AFI
How do you check for fetal lung maturity?
amniocentesis
what HTN meds might be used?
"go low and go slow"
hydralazine, labetalol, nifedipine (only right before delivery or in pp),
What should you avoid in pregnancy?
ACE INHIBITORS --> bad stuff and renal failure
What is the standard treatment of chronic HTN in pregnancy?
methyldopa
what BP is needed to organ perfusion?
**if < 90 may inhibit organ perfusion**
What does mag sulfate do in terms of seizures?
prevent vs control is controversial
-4-6 g IV loading dose then 1-2 g/hr (or 2-3 of eclampsia)
-if recurrent seizure give another bolus of 2-4 gm
When do you sedate a mother?
not recommended, may mask sympotms and increase risk
when would you give diuretics?
for cardiogenic pulmonary edema only
Do you ahve to have HTN to have HELLP?
NO!
Who does expectant management help?
improves perinatal outcome in a select group of women with severe preeclampsia before 32 weeks gestation
What is the rate of induction? Augmentation?
20.5%, 17.5%
2/3 for non-medical issues
Who is most likely to have an induction?
caucasian, well educated, insured, married, prenatal care, no medical or OB complications
-higher in community hospitals
What are indications for induction?
When benefits of an expeditious delivery outweigh the risks of continuing pregnancy
When is an induction medically necessary?
placental abruptions, preeclampsia, chorioamnionitis, PROM, IUFD, post term, maternal medical condictions, fetal compromise, logistical reasons, psychosocial
What must be established prior to induction?
gestational age and fetal lung maturity
When is an induction and labor contraindicated?
If mom or baby could not take it- then do c/s
-look at EFM
-is there evidence of decreased placental function? IUGR? oligo?
What are maternal and fetal contraindications for labor?
placenta previa, classical uterine incision, extensive myomectomy, pelvis sructural anomalies, active HSV, invasive cervical carcinomas, hypertonic uterine activity, NR fetal status
What do you have to evaluate and document in regards to fetal presentation?
station of presenting part, above pelvic inlet? estimated fetal weight, flexed or extended neck, US, leopolds
What factors should be considered in induction?
cervical ripeness, fetal lung maturity, fetal ability to tolerate labor, uterine sensitivity to method of induction, maternal condition, gestational age, fetal size and presentation
What is bishop's pelvic scoring?
clinical evaluation of cervix that predicts the likelihood of vaginal delivery by looking at position, dilation, effacement, station and consistency
-will be higher as cervix gets ready for labor- especially imp in primip
How does fetal fibronectin help in induction of labor?
an indicator that the cervix is ready, so want it to be present to increase induction success. Expensive
With an elective induction, what should the pt be counseled about?
indication for induction, agents, methods, aplternative approaches, possibility of failure, c/s possibility
DOCUMENT!!
What is the risk of c/s to primips with induction?
Twice the risk of c/s with spontaneous labor
What are the risks of induction?
Increased risk of complications related to tachysystole, abnormal FHR patterns, cesarean birth for abnormal FHR patterns, failure to progress in labor
When should cervcial ripening be considered?
when there is a low bishop's score prior to induction
What is cervical ripening?
softening and effacement, rearrangement of collagen, elastin and smooth muscle cells, dilation (caused by degradation of collagen by proeolytic enzymes
How do mechanical agents of cervical ripening work?
expansion, promotes production of prostaglandin (might cause contractions), changes the collagen matrix of the cervix. Include catheter and dilators
How does a foley catheter help with cervical ripening?
-inserted into endocervix, inflated with 30-50 ml saline, left 24 hrs or until expulsion
-no complications reported
-potential infection risk, might be painful
-same efficacy as E2 gel
What are laminaria tents?
For mechanical cervical ripening, placed into cervical os, extract water from cervical tissues, expand
wWhat is stripping of the membranes?
to help with induction- digitally separation membranes
**must know where placenta is and that it is not low lying**
could be done outpatient, normal to spot
-risks for infectsion, unplanned ROM, disruption of previa, precipitous labor and birth
What chemical agents are used in cervical ripening?
Prostaglandins (PGE2, prepidil, cervidl)
Cytotec
Oxytocin
What is cytotec?
for cervical ripening
ACOGG supports usage
Be careful, is she ruptured, dilated, having contractions
What are some adverse effects of prostaglandin cervical ripening?
cramping, contractions, n/v/d, backache, fever/chills, hot flashes, muscular pain
When should you be cautious with prostaglandin use?
**Asthmatic!**
HTN, renal, liver, cardiac disease, seizure do, dm
How long after prostaglandin administration is it safe to give oxytocin?
*4 hours*
What is the definition of induction?
the stimulation of uterine contractions prior to the onset of spontaneous labor resulting in the delivery of the fetus
What is the definition of augmentation?
artificial stimulation of labor which bgan spontaneously, but which has progressed abnormally (lack of progress, failure of fetal descent)
What is an amniotomy?
For induction/augmentation
release arachonic acid, formation of prostaglandins, fetal head puts oforce on cervix
How does oxytocin work in induction/augmentation?
-increases contractions by increasing intracellular calcium. start with 0.5-2 mu/min increase 1-2 mu/min q30-60 minutes
NOTE this is a high alert medication! meaning it is likely to cause harm
What are the goals of induction?
uterine contractions q 2-3 min of 40-90 second duration. Moderate-firm intensity, with relaxed resting tone
What is active management of labor?
early amniotomy, hourly cervical examiniation, oxytocin administration for dilation of <1 cm/hr, expect 12 hrs from admission to delivery, nurse patient 1:1,
What is tachysystole?
excessive tension on uterine muscle, increased risk for uterine rupture, cervical laceration and UPI
Uterine hyperstimulation, >5 UCs in 10 mins averaged over 30 mins and look at FHR decels