Ante Partum Complications

8/12/2019 Ante Partum Complications

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Rosemary Schiller 610 519-

6813

St. Marys 1st Floor,

Office Hours Tue 11:30-1:30

http://www39.homepage.vill

anova.edu/rosemary.schiller/


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Antepartum Complications

High-Risk Pregnancy


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What is a High Risk

Pregnancy

Increased probability of poor maternal orfetal outcome due to one or more of the

following factors:medical

reproductive

psychosocial


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Medical Risk Factors

Preexisting Medical Conditions

e. g. diabetes, anemia, heart disease, herpes

genetic factorslifestyle factors


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Obstetric/Reproductive

Past pregnancy conditions

previous preterm labor and delivery

previous cesarean sectionsprevious pregnancy induced hypertension

grand multiparity


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Psychosocial factors

access to prenatal care

social support systems

adaptation to pregnancy

client compliance


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Maternal Mortality Rates

In 1935 582 mothers died for every 100,000

live births, while today, the maternal

mortality rate has been reduced to7.8/100,000

What factors have contributed to thisdeclining maternal mortality rate?


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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


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Risk Assessment

Many risk assessment tools

ACOG Antepartum Record

Assessment tools are only as good as the personeliciting the information is at getting acomprehensive holistic history

Most risk assessment tools do a better job of

predicting risk in multiparas than in primiparas


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Diagnostic Tests

UltrasoundExamination of thefetus


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Chorionicvillus sampling


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Amniocentesis


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BIOPHYSICAL PROFILE(30 minute observation period)

1. REACTIVE NST

2. FETAL BREATHING MOVEMENT

3. FETAL BODY MOVEMENT

4. FETAL TONE

5. AMNIOTIC FLUID VOLUME


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SCORE

2 POINTS=NORMAL

0 POINTS=ABNORMAL

results:8-10 maximal score

0-4 severe fetal compromise

delivery indicated


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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

immaturitysleep

maternalsedation


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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


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2. FETAL BREATHING

MOVEMENT

Breathing period at least 60

seconds


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2.FETAL BODY

MOVEMENT

>3 discrete movements of

limbs/trunk


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4. FETAL TONE

Upper and lower limbs

usually flexed with head orchest

>1 episode of extension

with return to flexion


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5. AMNIOTIC FLUID VOLUME

Largest pocket> 1 cm in

vertical diameter withoutcontaining loops of cord


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COMMON COMPLICATIONS

EARLY PREGNANCY


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EARLY ANTEPARTUM

HEMMORAGE

Vaginal bleeding


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Incidence

15% to 25% clinically

recognizedMaybe as high as 50%


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Spontaneous Abortion

The naturally occurring

termination of pregnancybefore viability


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Spontaneous Abortion

Threatened Abortion

Inevitable Abortion

Complete Abortion

Missed Abortion

Recurrent Abortion


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Threatened Abortion:

Uterine bleeding in early pregnancy,

with or without cramping.


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Inevitable Abortion:

Symptoms of threatened abortion plus the physical

finding of dilatation of the internal os of the cervix.


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Incomplete Abortion:

Passage of a portion of the products of

conception from the uterus.


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Complete Abortion:

Passage of all of the products of

conception from the uterus.


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Missed Abortion:

Retention of the conceptus in the uterus for a

clinically appreciable time after death of the

embryo or fetus.


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Habitual Abortion:

The usual criterion is three or more consecutive

abortions.


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Complications of Abortion

Hemorrhage

Infection

Clotting Disorders


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HEMMORHAGE

More common with late abortions.

Continued heavy bleeding indicates

retained tissue (incomplete abortion).


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INFECTION

(septic abortion) seen most commonly

with criminally-induced abortionbut

may ensue in spontaneous ortherapeutic abortion.

Septic shock may occur in severe instances.


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CLOTTING DISORDERS

If a missed abortion is retained beyond one

month,thromboplastin maternal circulationmay result in a clotting disorder (DIC).

This risk is greater in late abortion.


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ECTOPIC PREGNANCY

Pregnancy outside the uterus

fallopian tubes

abdomenrare:coincidence of ectopic and uterine

preg.

associated with

PID

previous ectopic

tubal surgery

IUD (?)


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Ectopic Pregnancy

hydatiform mole


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hydatiform mole

trophoblastic proliferationof chorionic villi

uterus large for dates (50%)

severe eclampsia prior to 24 weeks1st trimester bleeding

abnormal elevation of beta-hCG

passing grapelike vesicles per vagina


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HYPEREMESIS

GRAVIDARUM

Excessive and debilitating emesis

resulting in symptoms ofweight loss

dehydration

ketonuriahigh urine specific gravity


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ETIOLOGYUNKNOWN

possible causes:hormonal (HCG, estradiol, thyroxine)

incidence in multiple gestations


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Management

hospitalization if severe

IV fluids

Intake and Output (strict)NPO for 24-48 hrs.

Antiemetics

Phenothiazines (phenergan, compazine)

Parenteral Nutrition

Psychotherapeutic Measures


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Second and third trimester

disorders

Second and Third


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Second and Third

Trimester Bleeding

Placenta Previa

Implantation of the placenta in the lower

uterine segmentAbruptio Placenta

Separation of some or all of the placenta

from the uterine wall


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Placenta Previa

Incidence=1:200deliveries

Classificationmarginal, partial or

total


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Placenta Previa


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Placenta Previa

Complete placentaprevia followingcesarean

hysterectomy


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Risk Factors

Increasing maternal age

Multiparity

Prior uterine scarAssociated with breech and transverse

presentations


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Symptoms

Painless bright red bleeding (p 20 wks)

Recurrent and heavier as preg progresses


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Management

Double set up examination

Ultrasound diagnosis

CS If >37 wks or fetal maturitydocumented unless marginal


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Expectant management

Bedrest

no digital or speculum exams (no tampons)

frequent NSTs and fetal monitoringMgSO4for preterm labor

betamethasone if delivery anticipated

Immediate delivery if vaginal bleedingincludes fetal blood (KOH test)


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Placental Abruption

Incidence--10% of alldeliveries

Types

partial

completeoccult

(concealed,retroplacental)

Risk factors

prior history ofabruption

maternal hypertension

smoking or cocaineuse

maternal age

multiparity

trauma

Pl t l b ti


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Placental abruption


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Abruptio placenta

Retroplacental clotfollowing removal of aplacenta which had

completely abrupted


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Symptoms

Pain and hypotension (disproportionate to bleeding)

Increased uterine tone

Tetanic contractionsFetal distress


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Management

Expectant management if mild

Immediate delivery if shock and fetal

distress (usually CS)Treatment of shock

Treatment of coagulopathy (DIC)


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multiple gestation

Incidence is increasing

twins in 1:85; triplets in 1:85x85; etcuterus large for dates

may have elevated hCG, hPL, and aFP

at risk for: IUGR, Prematurity


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PREGNANCY INDUCED

HYPERTENSION (PIH)

diastolic BP>90mmHg (or 15 over baseline)

systolic BP>140mmHg(or 30 over baseline)


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RISK FACTORSFIRST PREGNANCY

MULTIPLE GESTATION

POLYHYDRAMNIOS

HYDATIDIFORM MOLE

MALNUTRITION

FAMILY HISTORY

VASCULAR DISEASE


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PREECLAMPSIA AND

ECLAMPSIA


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PREECLAMPSIAdefined as:

Hypertension or PIH

Proteinuria

Edema (wt gain)


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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


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SEVERE PREECLAMPSIAAny of the following symptoms:BP>160/110 (2X, 6hrs apart, bedrest)

Proteinuria.5g/24 hours (3+ or 4+ dipstick)Massive edema

Oliguria


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Systemic symptoms

Pulmonary edema

headaches

visual changesRUQ pain

Liver Enzymes

Thrombocytopenia


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Eclampsia

Occurrence of a seizure that is not

attributable to other causes.


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Assessment

History

Physical

Lab studies


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History

Document risk factors and any symptoms

reported by client


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Physical

Look for edema (esp. hands and face)

BP changes

Retinal changeshyperreflexia

clonus

RUQ tenderness


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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


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Complications

Eclamptic seizures

HELLP syndrome

Hepatic ruptureDIC

pulmonary edema

renal failure

placental abruption

cerebral hemorrhagefetal demise


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PIH or mild preeclampsia

Home bed rest

BP monitoring

wt and urine checksNSTs early

US for IUGR


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Hospital management

bedrest with BRP

IV

daily weightfetal movement count

monitor reflexes

daily NST

weekly US for AFV and IUGR

monitor symptoms continuously


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Treatment

Delivery is the Tx of choice

Betamethasone for fetal maturity

antihypertensive therapyanticonvulsive therapy (MgSO4)


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MgSO4Therapy

Loading dose IV 4-6 g/20min

continued at 2 g/hr

check for adverse effectsrespiratory depression

diminished reflexes are expected

intrauterine growth


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retardation (IUGR)

definition: < 10th percentile for gestational ageusually not detectable before 32-34 weeks

(maximal fetal growth)

incidence: 3-7% of all deliveries12-47% 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


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IUGR EtiologiesPRIMARY FETAL CAUSES (20 )decreased intrinsic growth(symmetrical IUGR)

congenital heart disease

genitourinary anomalies

CNS anomalieschromsomal abnormalities (trisomy 13, 18,21)

viral infection (rubella, CMV)

IUGR: Etiology


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UTEROPLACENTAL INSUFFICIENCY (80 )maternal causesdeficient supply of nutrients:

smoking

malnutritionmultiple gestationsplacental causesextensive placental infarctions

chronic partial separation

placenta previa


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POLYHYDRAMNIOS

Excessive amniotic fluid

idiopathic (60%)

maternal (20%)diabetes

Rh incompatibility (fetal hydrops)

fetal (20%)

neural tube defect

GI obstruction

cardiac

dwarfism


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Oligohydramnios

Too little amniotic fluid

placental insufficiency

cardiac failurefetal demise

fetal renal disease


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Preterm Labor

Onset of contractions between 20-37 wks.

With cervical dilitation

difficult to discern in early stages fromfalse labor


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Etiology

Maternal factorsinfections

uterine anomalies

cervical incompetence

overdistended uterus

premature rupture of the membranes


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Fetal factors

congenital anomalies

intrauterine death


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Management

Ultrasound for fetal wt/gest. age/position

Monitor for FHT and contractions

Nitrozine testCath for UA and Culture

Tocolysis


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Tocolysis

Pharmacological inhibition of uterineactivity

Terbutaline (Brethine) IV, then pomaintenance

MgSO4(sometimes used)

Ineffective if labor is well established or cervix

dilated to 4cm or more


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Steroids given to accelerate fetal lungmaturity (betamethasone or

dexamethasone 12.5 mg. IM q 24 hrs for48 hours


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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


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Complications to Mother

Preeclampsia

polyhydramnios

infectionpostpartum bleeding

cesarean section

birth canal trauma from macrosomicinfant

Treatment


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Careful control of diabetes

Dietary management

exercise

accucheck QID ac and hsmaintain fasting levels at


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Monitoring fetal wellbeing

Early US for accurate gestational dating

US if macrosomia is suspected

amniocentesis for fetal lung maturityantepartum NST weekly p. 34 wks

Mom should have GTT at 6 weeks pp


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Habits Misc

Alcohol

Tobacco

Crack cocaine or other illicit drugsMedications

Exposure to infections


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Alcohol

Midtrimester abortion

mental retardation

behavior and learning disorders

Abstinence is best

Treatment for chronic abuse


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Tobacco

Low birth weight

premature labor

spontaneous abortionsstillbirth

birth defects

respiratory infections and otits in childrenof smoking parents


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Cocaine and other drugs

Perinatal addiction

preterm labor

placental abruptioncognitive and psychological difficulties

Abstinence an treatment necessary


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Medications

Category A--safe (vitamins)

Category B--no animal effects (penicillin)

Category C--no studies availableCategory D--evidence of risk but benefits

outweigh the risks

Category X--risks outweigh benefits

Documents

Ante Partum Complications