Rosemary Schiller 610 519-6813 St. Mary’s 1st Floor, Office Hours Tue 11:30-1:30

1. Rosemary Schiller 610 519-6813St. Mary’s 1st Floor, Office Hours Tue 11:30-1:30 http://www39.homepage.villanova.edu/rosemary.schiller/

4. Antepartum Complications • High-Risk Pregnancy

5. 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

6. Medical Risk Factors • Preexisting Medical Conditions • e. g. diabetes, anemia, heart disease, herpes • genetic factors • lifestyle factors

7. Obstetric/Reproductive • Past pregnancy conditions • previous preterm labor and delivery • previous cesarean sections • previous pregnancy induced hypertension • grand multiparity

8. Psychosocial factors • access to prenatal care • social support systems • adaptation to pregnancy • client compliance

9. 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?

10. 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

11. 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

12. Diagnostic Tests • Ultrasound Examination of the fetus

13. 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

14. Chorionic villus sampling

15. Amniocentesis

16. BIOPHYSICAL PROFILE(30 minute observation period) • 1. REACTIVE NST • 2. FETAL BREATHING MOVEMENT • 3. FETAL BODY MOVEMENT • 4. FETAL TONE • 5. AMNIOTIC FLUID VOLUME

17. SCORE • 2 POINTS=NORMAL • 0 POINTS=ABNORMAL results:8-10 maximal score 0-4 severe fetal compromise delivery indicated

18. 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

19. 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

20. 2. FETAL BREATHING MOVEMENT Breathing period at least 60 seconds

21. 2.FETAL BODY MOVEMENT >3 discrete movements of limbs/trunk

22. 4. FETAL TONE Upper and lower limbs usually flexed with head or chest >1 episode of extension with return to flexion

23. 5. AMNIOTIC FLUID VOLUME Largest pocket> 1 cm in vertical diameter without containing loops of cord

24. COMMON COMPLICATIONS EARLY PREGNANCY

25. EARLY ANTEPARTUM HEMMORAGE Vaginal bleeding <20 weeks of gestation

26. Incidence 15% to 25% clinically recognized Maybe as high as 50%

27. Spontaneous Abortion The naturally occurring termination of pregnancy before viability

28. Spontaneous Abortion • Threatened Abortion • Inevitable Abortion • Complete Abortion • Missed Abortion • Recurrent Abortion

29. Threatened Abortion: Uterine bleeding in early pregnancy, with or without cramping.

30. Inevitable Abortion: Symptoms of threatened abortion plus the physical finding of dilatation of the internal os of the cervix.

31. Incomplete Abortion: Passage of a portion of the products of conception from the uterus.

32. Complete Abortion: Passage of all of the products of conception from the uterus.

33. Missed Abortion: Retention of the conceptus in the uterus for a clinically appreciable time after death of the embryo or fetus.

34. Habitual Abortion: The usual criterion is three or more consecutive abortions.

35. Complications of Abortion Hemorrhage Infection Clotting Disorders

36. HEMMORHAGE More common with late abortions. Continued heavy bleeding indicates retained tissue (incomplete abortion).

37. INFECTION (septic abortion) seen most commonly with criminally-induced abortionbut may ensue in spontaneous or therapeutic abortion. Septic shock may occur in severe instances.

38. 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.

39. ECTOPIC PREGNANCY • Pregnancy outside the uterus • fallopian tubes • abdomen • rare:coincidence of ectopic and uterine preg. associated with PID previous ectopic tubal surgery IUD (?)

40. Ectopic Pregnancy

41. 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

42. HYPEREMESIS GRAVIDARUM Excessive and debilitating emesis resulting in symptoms of weight loss dehydration ketonuria high urine specific gravity

43. ETIOLOGY UNKNOWN possible causes: hormonal (HCG, estradiol, thyroxine)  incidence in multiple gestations

44. Management hospitalization if severe IV fluids Intake and Output (strict) NPO for 24-48 hrs. Antiemetics Phenothiazines (phenergan, compazine) Parenteral Nutrition Psychotherapeutic Measures

45. Second and third trimester disorders

46. 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

47. Placenta Previa • Incidence=1:200 deliveries • Classification • marginal, partial or total

48. Placenta Previa

49. Placenta Previa • Complete placenta previa following cesarean hysterectomy

50. Risk Factors • Increasing maternal age • Multiparity • Prior uterine scar • Associated with breech and transverse presentations