Maternal Risk Factors Fetal Assessment

1. Maternal Risk FactorsFetal Assessment

2. High Risk Pregnancy • The life or health of the mother or fetus is jeopardized • Examples include: • GDM • Previous loss • AMA • HTN • Abnormalities with the neonate

3. Perinatal Mortality • Overall maternal deaths are small • Many deaths a preventable • Education and prenatal care are very important

4. Antepartum Testing • FKCs BID • UTZ • FHR • Gestation age • Abnormalities • IUGR • Placental location and quality • AFI • Position • BPP • Doppler flow • Fetal growth

5. Ultrasound • Can be done abdominally or transvaginally • 1st trimester done to detect viability, calculate EDC • 2nd trimester done to detect anomalies, calculate EDC • 3rd trimester done to do BPP, fetal growth and well-being, AFI

6. Doppler Flow Analysis via UTZ • Study blood blow in the fetus and placenta • Done on high risk mothers: • IUGR • HTN • DM • Multiple gestation

7. AFI • Polyhydramnios – too much amniotic fluid • Oligohydramnios – too little amniotic fluid

8. Biophysical Profile • Includes 5 components: • Fetal breathing movements • Gross body movements • Fetal tone • AFI • NST - reactive

9. Amniocentesis • Used with direct ultrasound • Less than 1% result in complications • Complications include: • Fetal death, miscarriage • Maternal hemorrhage • Infection to fetus • Preterm labor • Leakage of amniotic fluid

10. Meconium • Visual inspection of amniotic fluid • Meconium is defined as thin and thick and particulate • Associated with fetal stress: hypoxia, umbilical cord compression

11. CVS • Done between 9 -12 weeks • Genetic studies • Removal of small amount of tissue from the fetal portion of the placenta • Complications: vaginal spotting, miscarriage, ROM, chorioamnionitis • If done prior to 10 weeks, increased risk of limb anomalies

12. AFP • Genetic test • Done with mothers blood • 16-20 weeks gestation • Mandated by state of California

13. EFM • Third trimester goal is to continue to observe the fetus within the intrauterine environment • Goal: dx uteroplacental insufficiency • NST vs. CST

14. NST • 90% of gross fetal body movements are associated with accelerations of the FHR • Can be performed outpatient • Not as sensitive • User friendly but must interpret strip • Fetus may be in a sleep state or affected by maternal medications, glucose etc.

16. NST • To be reactive must meet criteria • Must be at least 20 minutes in length • Must have 2 or more accelerations that meet the ’15 X 15’ criteria • Must have a normal baseline • Must have LTV

17. NST • To stimulate a fetus that is not meeting criteria: • Change positions of the mother – LS, RS • Increase fluids • Acoustic stimulator

18. CST • Done in the inpatient setting only! • Has contraindications • May be expensive if meds/IV needed • Monitored for 10 minutes first • Then may use nipple stimulation or oxytocin stimulation • No late decelerations than negative CST

19. CST

21. Endocrine and Metabolic Disorders • #1 Diabetes Mellitus • Disorders of the thyroid • Hyperemesis

22. Diabetes • Hyperglycemia • May be due to inadequate insulin action or due to impaired insulin secretion • Type 1 – insulin deficiency • Type 2 – insulin resistance • GDM – glucose intolerance during pregnancy

23. DM • 10th week fetus produces it own insulin • Insulin does not cross the placental barrier • Glucose levels in the fetus and directly proportional to the mother • 2nd and 3rd trimesters – decreased tolerance to glucose, increased insulin resistance, increased hepatic function of glucose

24. Diabetic Nephropathy • Increased risks for: • Preeclampsia • IUGR • PTL • Fetal distress • IUFD • Neonatal death

25. DM • Poor glycemic control is associated with increased risks of miscarriage at time of conception • Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios

26. Polyhydramnios • May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

27. Macrosomia • Disproportionate increase in shoulder and trunk size • 4000-4500gms or greater • Fetus will have excess stores of glycogen • Increased risks of • Shoulder dystocia • C/S • Assisted deliveries

28. IUGR • Compromised uteroplacental insufficiency • 02 available to the fetus is decreased

29. RDS • Increased RDS due to high glucose levels • Delays pulmonary maturity

30. Neonatal Hypoglycemia • Usually 30-60 minutes after birth • Due to high glucose levels during pregnancy and rapid use of glucose after birth • Related to mothers level of glucose control

31. Labs with DM • HBA1c • 1 hour PP • FBS

32. Diet • Sweet success diet • Well balanced diet • 6 small meals / day • Have snack at HS • Never skip meals • Avoid simple sugars

33. Insulin • Regular/Lispro and NPH • 2/3 dose in am and 1/3 dose in pm

34. Monitoring Glucose Levels • FBS • 1 hour PP • HS • 5 checks / day

35. Fetal Surveillance • NSTs done around 26 weeks, weekly • At 32 weeks done biweekly with NST/BPP

36. Infections and DM • Infections are increased: • Candidiasis • UTIs • PP infections

37. DM • Increased risk of IUFD after 36 weeks • Increased congenital anomalies • Cardiac defects • CNS defects • Spina bifida • anencephaly • Skeletal defects

38. DM and labor • Continuous fetal monitoring • Blood glucose levels in tight control • Be prepared for CPD

39. GDM • Women with GDM at risk of developing DM later on in life • NSTs around 28 weeks

40. Hyperthyroidism • Typically caused by Grave’s disease • S/S: • Fatigue • Heat intolerance • Warm skin • Diaphoresis • Weight loss

41. Should be treated in pregnancy • Tx with PTU • Beta blockers • May lead to thyroid storm if untreated

42. Hypothyroidism • Usually caused by Hashimoto’s • S/S: • Weight gain • Cold intolerance • Fatigue • Hair loss • Constipation • Dry skin

43. Tx with thyroid hormones such as synthroid or levothyroxine • Maintain TSH wnl • Checked periodically throughout the pregnancy

44. Cardiovascular Disorders • The heart must compensate for the increased workload • If the cardiac changes are not well tolerated than cardiac failure can develop • 1% of pregnancies are complicated by heart disease

45. NY Heart Association Classes • Class I • Class II • Class III • Class IV

46. Cardiac output is increased • Peak of the increase 20-24 weeks gestation • Cardiac problems should be managed with cardiologist • Mortality with pulmonary hypertension and pregnancy is more than 50% • Diet: low sodium

47. Nursing Care • Avoiding anemia • Avoid strenuous activity • Monitor for: cardiac failure and pulmonary congestion

48. During Labor • Side lying position • Prophylactic antibiotic • Epidural • Attempt vaginal delivery • If anticoagulant therapy is needed: • Heparin • Lovenox

49. MVP • Common and usually benign • May experience syncope, palpitations and dyspnea • Prophylactic antibiotics given before invasive procedure or birth

50. Anemia • Most common iron deficiency • Hgb falls below 12 (most labs) • Typically seen in the end of 2nd trimester • Iron supplementation