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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?

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 Risk factors
prior history of abruption maternal hypertension smoking or cocaine use maternal age multiparity trauma

Types
partial complete occult
(concealed,retroplacental)

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 NSTs 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