High Risk Antepartum
Chapter 36 ( pp. 925-938)
1. What are the definitions of preterm labor and preterm birth?
Preterm labor-cervical changes and uterine contractions occurring between 20 and 37
weeks of pregnancy.
Preterm-birth- any birth that occurs before the completion of 37 weeks of preg. A
pregnancy ending before 20 wks gestation is termed a miscarriage.
2. Why isn’t a neonate’s birth weight a good indication of his/her gestational age? Birth
wt at the time of birth describes only wt at time of birth. Low birth wt babies can be, but
are not necessarily, preterm; LBW can be caused by conditions other than preterm birth,
such as intrauterine growth restriction.
3. Memorize the information in Boxes 36-1 and 36-2 (just kidding!). Take a look at it
though to see if anything on the list doesn’t make sense. If so, post it in WebCt or bring it
up in class next week.
4. What are some signs (including. biochemical markers) and symptoms (box 36-3) of
preterm labor?
Uterine activity:
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Uterine contractions occurring Q 10 min or more frequently and persisting for 1
hour or more
Uterine contractions may be painful or painless
Discomfort:
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Lower abd cramping similar to gas pains; may be accompanied by diarrhea
Dull, intermittent low back pain (below the wasit)
Painful, menstral like cramps
Suprapubic pain or pressure
Pelvic pressure or heaviness; feeling that baby is pushing down
Urinary frequency
Vaginal discharge:
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Change in character or increase in amount of usual discharge: thicker (mucoid) or
thinner (watery), bloody, brown, or colorless, increased amount, odor
ROM
Biochemical markers
Fetal fibronectins- glycoproteins found in plasma and produced during fetal life. They
appear in the cervical canal in early pregnancy and late preg. Their appearance between
wks 24 and 34 predicts labor
Salivary estriol- form of estrogen produced by the fetus that is present in plasma at 9
weeks gestation. Levels have been shown to increase before preterm birth
Endocervical length-studies suggest a shortened cervix precedes preterm labor and can be
determined by US
5. What is antenatal glucocorticoids (Betamethasone) used for? Medication given to
accelerate fetal lung maturity.
6. If a woman calls with symptoms of preterm labor, what would you want to ask her?
7. What are the pluses to bedrest and HUAM in preterm labor? (Trick question!) there is
no efficacy of bedrest in reducing preterm birth rates. Research evidence indicates that
HUAM is a form of care unlikely to be beneficial in preventing preterm birth.
8. What are tocolytic agents? What are some of the classifications of drugs that are used?
Check out the medication guide starting on page 933. There’s our old buddy MgSO4!
Drugs that suppress uterine activity. The best reason to use tocolytics is that they afford
the opportunity to begin administering antenatal corticosteroids to accelerate fetal lung
maturity and reduce the severity of sequelae in infants born preterm.
Mag sulfate is the most common because maternal and fetal/neonatal adverse reactions
are less common than the beta adrenergic agonists. Ritodrine and terbutaline are beta
adrenergic agonists that work by relaxing uterine smooth muscle. Calcium channel
blockers and prostaglandin synthetase inhibitors are also used.
9. What’s the major complication that can occur with PPROM? Membranes rupture
before 37 wks gestation. This occurs in up to 25% of all cases of preterm labor. Infection
often precedes PPROM, but the etiology remains unknown. Infection is a serious side
effect of PPROM that makes a major complication of pregnancy. Chorioamniotis is an
intraamniotic infection of the chorion and amnion that is potentially life threatening for
the fetus and the woman.
Even in the absence of infection, PPROM can precipitate cord prolapse, or cause
oligohydraminos. Leading to cord compression, potentially life threatening complications
for the fetus
Chapter 32
1. Review what the differences are between Type 1 and Type 2 (pregestational diabetes)
and gestational diabetes.
2. What are the effects of estrogen and progesterone on insulin levels and why do these
change occur?
3. What happens to insulin requirements in the first, second and third trimester of
pregnancy and then in breast feeding women? What’s all this stuff about insulin
sensitivity and insulin resistance?
4. Why do women with diabetes need to be in “tight control” when they conceive and
during the embryonic development?
5. What potential complications of diabetes is a woman at risk for during pregnancy?
6. What are the potential complications for fetuses/newborns of diabetic women?
7. What’s a hemoglobin A1c?
8. What dietary changes would you want a pregnant diabetic women to make?
9. What effect does exercise have on diabetes in pregnancy?
10. What effect does pregnancy have on diabetes? What would you want to counsel a
type 1 pregestational diabetic woman about related to insulin dosing during pregnancy?
11. What are the target glucose levels during pregnancy?
12. How do we monitor a fetus of a diabetic mother?
13. In a diabetic woman what two things must be carefully controlled for in labor?
14. What three conditions are diabetic women at increased risk for during the postpartum
period?
15. What are some potential problems for infants of diabetic mothers? This is actually a
review question!
16. Some people think of gestational diabetes mellitus (GDM) as being a self-limiting
disease. Why is that not a true statement?
17. How do we screen for diabetes in pregnancy? Who do we screen? Why do we screen?
18. What is done once a woman is diagnosed with IDM?
19. A pregnant woman with GDM keeps her blood sugars within the normal range with
lifestyle changes alone. Is she at increase risk for complications during her pregnancy?
20. How is hyperemesis gravidarum different than nausea and vomiting in pregnancy?
21. What are some of the suspected etiologies?
22. In general what are the goals of treatment for hyperemesis gravidarum?
23. What are some signs of Graves’ Disease? What are some symptoms of Graves’
Disease?
24. What is the usually cause of hypothyroidism? What are some signs? What are some
symptoms?
25. What is PKU?
Chapter 33
1. How do you do the Heimlich Maneuver on a pregnant woman?
Stand behind the woman and place your arms under her armpits to encircle her chest.
Press backward with quick thrusts until the foreign body is expelled. If the woman
becomes unresponsive, follow the steps for victims who become unresponsive, but use
chest thrusts chest thrust instead of abd thrusts.
Clearing the airway in a woman in the second or third trimester of preg also requires
modifications
2. What is the most common cause of anemia in pregnancy? What is the second most
common cause of anemia? Anemia results in reduction of the oxygen-carrying capacity
of the blood and the heart tries to compensate by increasing the cardiac output. This effort
increases the workload of the heart and stresses ventricular function. Therefore anemia
that occurs with any other complication (e.g preeclampsia) may result in CHF.
Anemia is primarily caused by iron deficiency. Second-folic acid
3. Why do we care if a pregnant woman is anemic? When a woman has anemia during
preg, the loss of blood at birth, even if minimal, is not well tolerated. She is at an
increased risk for requiring blood transfusions. Women with anemia have higher
incidence of puerpal complications, such as infection, than preg women with normal
hematologic values.
4. What are some risks for a pregnant women with sickle cell? What are some risks for
her fetus?
Woman with the sickle cell trait usually do well in pregnancy, although they are at
increased risk for UTI’s and may be deficient in iron. If the woman has sickle cell
anemia, the anemia that occurs in normal pregnancies may aggravate the condition abd
bring on more crises. Women are prone to pyelonephritis, bone abnormalities, strokes,
cardiomyopathy, CHF and preeclampsia.
Fetal risks-preterm birth and IUGR
5. What vitamin and what mineral do we supplement women who have sickle cell disease
with during pregnancy? Folic acid and iron?
6. What pregnancy complications are women with asthma more likely to develop?
Hyperemesis graidarum, preterm birth, preeclampsia, gestational diabetes, IUGR, and
neonatal mortality. The more severe the asthma, the more likely that risks will occur for
the woman and the fetus.
7. What are some good things (prevention!) to talk to a pregnant women about related to
her asthma?
Avoid and eliminate environmental triggers (dust mites, animal dander, pollen, wood
smoke), drug therapy (bronchodilators and anti-inflammatory agents), and client
education. Rest infections should be treated, and mist of steam inhalation used to aid
expectoration of mucus. Acute episodes may require B-agonists such as albuterol,
steroids, amniphylline, and O2. almost all asthma meds are considered safe in pregnancy.
Asthma attacks can occur in labor; thus meds for asthma are continued in labor and PP.
during PP women with asthma are at increased risk for hemorrhage. If excessive bleeding
occurs, oxytocin is the recommended drug.
The other stuff in this chapter is interesting, but really beyond the scope of this class.