Assessment of High Risk Pregnancy Chapter 26 Assessment of High Risk Pregnancy Copyright © 2016 by Elsevier Inc. All rights reserved.

Learning Objectives Explore biophysical, psychosocial, sociodemographic, and environmental influences on high-risk pregnancy. Examine risk factors identified through history, physical examination, and diagnostic techniques. Differentiate among screening and diagnostic techniques, including when they are used in pregnancy and for what purposes.

Learning Objectives (Cont.) Discuss psychologic considerations for the woman and her family experiencing a high-risk pregnancy. Develop a teaching plan to explain screening and diagnostic techniques and implications of findings to women and their families.

Assessment of Risk Factors A comprehensive approach to high risk pregnancy is used now. The factors associated with high risk childbearing are grouped into broad categories based on threats to health and pregnancy outcomes.

Assessment of Risk Factors (Cont.) Biophysical Originates with the mother or the fetus May affect development and functioning of both Genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses

Assessment of Risk Factors (Cont.) Psychosocial Maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus May include emotional distress and disturbed interpersonal relationships Inadequate social support Unsafe cultural practices

Assessment of Risk Factors (Cont.) Sociodemographic Arise from mother and her family Lack of prenatal care, low income, marital status, and ethnicity Environmental Hazards in workplace and woman’s general environment May include chemicals, anesthetic gases, and radiation

Antepartum Testing: Biophysical Assessment Daily fetal movement count (DFMC) Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation Also called kick counts Several different protocols are used for counting A count of fewer than three kicks in 1 hour warrants further evaluation by a nonstress test (NST). Fetal alarm signal

Antepartum Testing: Biophysical Assessment (Cont.)

Antepartum Testing: Biophysical Assessment (Cont.) Ultrasonography Levels of ultrasonography Abdominal Transvaginal Indications for use Fetal heart activity Gestational age Fetal growth Fetal anatomy

Antepartum Testing: Biophysical Assessment (Cont.) Ultrasonography (Cont.) Indications for use Fetal genetic disorders and physical anomalies Placental position and function Adjunct to other invasive tests Fetal well-being Doppler blood flow analysis Amniotic fluid volume Biophysical profile (BPP) Modified biophysical profile

Antepartum Testing: Biophysical Assessment (Cont.)

Antepartum Testing: Biophysical Assessment (Cont.) Ultrasonography (Cont.) Nursing role Nonmedical ultrasounds 3-D and 4-D increasingly popular with pregnant women and their families American Institute of Ultrasound in Medicine (AIUM) and the American College of Obstetricians and Gynecologists (ACOG) have published statements that strongly discourage this practice Exposure of the fetus to high-frequency sound waves without a clear medical indication Performed by people who are not qualified health care professionals

Antepartum Testing: Biophysical Assessment (Cont.)

Antepartum Testing: Biophysical Assessment (Cont.) Magnetic resonance imaging (MRI) Noninvasive radiologic technique Examiner can evaluate the following: Fetal structure, overall growth Placenta Quantity of amniotic fluid Maternal structures Biochemical status of tissues and organs Soft-tissue, metabolic, or functional anomalies

Antepartum Testing: Biochemical Assessment (Cont.) Biochemical assessment involves biologic examination and chemical determinations Procedures used to obtain the needed specimens include amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, and maternal sampling Amniocentesis: obtains amniotic fluid Potential complications Indications for use Genetic concerns Fetal maturity Fetal hemolytic disease

Antepartum Testing: Biochemical Assessment (Cont.)

Antepartum Testing: Biochemical Assessment (Cont.) Chorionic villus sampling (CVS) Technique for genetic studies Earlier diagnosis, rapid results Performed between 10 and 13 weeks of gestation Involves removal of small tissue specimen from fetal portion of placenta Transcervically or transabdominally

Antepartum Testing: Biochemical Assessment (Cont.)

Antepartum Testing: Biochemical Assessment (Cont.) Percutaneous umbilical blood sampling (PUBS) (also called cordocentesis) Direct access to the fetal circulation during the second and third trimesters Most widely used method for fetal blood sampling and transfusion Insertion of needle directly into fetal umbilical vessel under ultrasound guidance

Antepartum Testing: Biochemical Assessment (Cont.)

Antepartum Testing: Biochemical Assessment (Cont.) Maternal assays Maternal serum alpha-fetoprotein (MSAFP) Maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy Screening recommended for all pregnant women Triple- and quad-screening to detect autosomal trisomies

Antepartum Testing: Biochemical Assessment (Cont.) Maternal assays (Cont.) Multiple marker screens Coombs’ test Screening tool for Rh incompatibility Detects other antibodies that may place fetus at risk for incompatibility with maternal antigens

Antepartum Testing: Biochemical Assessment (Cont.) Maternal assays (Cont.) Cell-free DNA screening in maternal blood Noninvasive prenatal genetic testing Provides definitive diagnosis noninvasively for fetal Rh status, fetal gender, and certain paternally transmitted single gene disorders Performed as early as 10 weeks of gestation Results are usually available in about 10 business days

Fetal Care Centers Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as support services for families with a fetal anomaly diagnosis. Access to support services such as genetic counseling, social work, chaplain services, a palliative care team, and ethics consultation because of the complex emotional stressors they face

Antepartum Assessment Using Electronic Fetal Monitoring Indications Does the intrauterine environment continue to support the fetus? Nonstress test Procedure Interpretation: reactive or nonreactive Vibroacoustic stimulation Contraction stress test Nipple-stimulated contraction test Oxytocin-stimulated contraction test Interpretation

Non-Stress Test (NST) Non-stress test (NST)-is the most widely applied technique for antepartum evaluation of the fetus Basis for the NST is that the normal fetus will produce characteristic heart rate (HR) patterns in response to fetal movement FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements

Vibroacoustic Stimulation (fetal acoustic stimulation Another method of testing antepartum FHR response and is sometimes used in conjunction with the NST Test takes approximately 15 minutes to complete, with the fetus monitored for 5 to 10 minutes before stimulation to obtain a baseline FHR Fetal baseline pattern is nonreactive, the sound source is then activated for 3 seconds Monitoring continues for 5 more minutes

Contraction Stress Test (CST) provides an earlier warning of fetal compromise than the NST with fewer false-positive results Monitored electronically with the fetal ultrasound transducer and uterine tocodynamometer Tracing is observed 10 to 20 minutes for baseline rate, long-term variability, and the possible occurrence of spontaneous contractions Two methods of CST

Nipple-Stimulating Contraction Test Woman applies warm moist washcloths to both breast for several minutes Woman massages one nipple for 10 minutes Massaging the nipples causes a release of oxytocin from the posterior pituitary Woman massages the nipple for 2 minutes, rest for 5 minutes, and repeats the cycle as necessary to achieve adequate uterine activity

Oxytocin-Stimulated Contraction Test Exogenous oxytocin also can be used to stimulate uterine contractions Given IV 30 units of Pitocin in 500 ml fluid Method of oxytocin infusion is to begin at 0.5 mU/min double the dose every 20 minutes Until three uterine contractions of lasting 40 to 60 seconds are observed within a 10-minute period

Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

Psychologic Considerations Related to High-Risk Pregnancy Label of high risk often increases the patient’s sense of vulnerability May exhibit anxiety, low self-esteem, guilt, frustration, and inability to function May affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy

Nursing Role in Antepartal Assessment for Risk Provide education Anticipatory planning Counseling for family adaptation Support person In many settings nurses perform the following: NSTs CSTs BPPs

Key Points A high-risk pregnancy is one in which the life or well- being of the mother or infant is jeopardized by a biophysical or psychosocial disorder coincidental with or unique to pregnancy. Biophysical, sociodemographic, psychosocial, and environmental factors place the pregnancy and fetus or neonate at risk.

Key Points (Cont.) Biophysical assessment techniques include DFMCs, ultrasonography, and MRI. Biochemical monitoring techniques include amniocentesis, PUBS, CVS, MSAFP, multiple marker screens, and cell-free DNA screening in maternal blood.

Key Points (Cont.) Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as care coordination and other support services for families with a fetal anomaly diagnosis. Reactive NSTs and negative CSTs suggest fetal well-being.

Key Points (Cont.) Most assessment tests have some degree of risk for the mother and fetus and usually cause some anxiety for the woman and her family. The nurse’s roles in assessment and management of the high-risk pregnancy are primarily those of educator and support person.

Question A prenatal screening technique called nuchal translucency (NT) uses ultrasound measurement of fluid at the nape of the neck between 14 and 16 weeks to identify possible fetal abnormalities. An elevated NT of greater than 3 mm indicates an increased risk of which of the following? Trisomy 13 Fetal cardiac disease Trisomy 18 Trisomy 21 ANS: B Feedback A Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 13. B Correct: An elevated NT alone indicates an increased risk for fetal cardiac disease. C Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 18. D Incorrect: When combined with low maternal serum marker levels, elevated NT indicates a possible increased risk of certain chromosomal abnormalities in the fetus, including trisomy 21.