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