Wk. 5 D Normal Diagnostic Laboratory Findings PDF

CU – 5 D NORMAL DIAGNOSTIC LABORATORY FINDINGS Juvy G. Reyes MAN, RN  MATERNAL NUTRITION AND FETAL HEALTH Objectives: 1. Describe the process of confirming and estimating the date of birth 2. Identify the typical nursing assessments, diagnosis, interventio...

CU – 5 D NORMAL DIAGNOSTIC LABORATORY FINDINGS Juvy G. Reyes MAN, RN  MATERNAL NUTRITION AND FETAL HEALTH Objectives: 1. Describe the process of confirming and estimating the date of birth 2. Identify the typical nursing assessments, diagnosis, interventions, and methods of evaluation in providing care for the pregnant woman 3.Identify areas of nursing care related to the normal diagnostic laboratory findings that could benefit from additional nursing research or application of evidence- based practice. Normal Diagnostic Laboratory Findings and Deviation during pregnancy  NORMAL DIAGNOSTIC LABORATORY FINDINGS AND DEVIATION DURING PREGNANCY Purpose: 1. Predict the outcomes of the pregnancy 2. Manage the remaining weeks of pregnancy 3. Plan for possible complications at birth 4. Decide whether to continue the pregnancy 5. Find conditions that may affect future pregnancy  Normal Diagnostic Laboratory Findings during Pregnancy A medical diagnosis of pregnancy serves to date when the birth will occur and also helps predict the existence of high-risk status. Pregnancy tests - are commercially available and can be performed by the trained personnel that are highly accurate and precise, if done with the correct technique NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY Pregnancy testing​ – relies on the detection of an antibody to the hormone human chorionic gonadotropin (hCG) or a subunit in the urine or serum Human Chorionic Gonadotropin- the first placental hormone produced and can be found shortly after implantation  SPECIMENS: 1. Urine – test to yield accurate results and it should be done 10 – 14 days after the missed menstrual period. This period guarantee level of hCG and prevents false negative results. a. Gravindex and Pregnosticon - are immunologic pregnancy test and approximately 95% accurate in diagnosing pregnancy and accurate in determining the absence of pregnancy  SPECIMENS: 1. Urine b. Radioimmunoassay​ – tests for the beta subunit of hCG and considered to be so accurate as to be diagnostic for pregnancy. PREPARATION FOR A PREGNANCY TEST 1. URINE TESTS - HCG a. Collect first voided urine using clean, dry bottle free of detergent or contamination b. Do not drink fluids from 8pm the night before to concentrate the urine c. Refrain from taking any drug 24 hrs. before the test  PREPARATION FOR A PREGNANCY TEST 1. URINE TESTS - HCG 4. Label the specimen with the woman’s name, date, and time of voiding. 5. Bring the specimen to the laboratory immediately 5. Refrigerate urine specimen-if more than one hour is pass before the specimen gets to the laboratory because room temperature is high enough to destroy HCG  NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 2. Blood –​ with sensitive assays hCG can be detected in maternal blood at 7 days after conception and are accurate close to 100% of the time​ NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 3. Progesterone Withdrawal test – a contraceptive pill is taken OD or TID (3xdays) If menstruation occurs within 10-15 days, the woman is not pregnant If corpus luteum produces enough hormones to neutralize the effect of withdrawn synthetic progesterone and no bleeding occurs, the woman is pregnant NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4. Ultrasound imaging​ – (Ultrasound scanning or Scanning) - involves exposing a part of the body to high frequency sound waves to produce pictures of the inside of the body The sound waves reflect best if the uterus can be held stable and it is helpful if the woman has a full bladder at the time of procedure NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4.Ultrasound imaging​ – (Ultrasound scanning or Scanning) It provides the physician, the ability to approach the developing fetus a separate patient with an identifiable set of reflexes reactions 7-11 wks. if the date of LMP is unknown, between 16-20 wks. Gestation to verify fetal structures and gender NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4. Ultrasound imaging​ – (Ultrasound scanning or Scanning) Purpose: a. Diagnose pregnancy as early as 6 wks. Gestation. b. Confirm the size, location of the placenta and amniotic fluid. c. Discover complications of pregnancy d. Establish if fetus is growing and no congenital anomalies. e. Predict maturity by measurement of biparietal diameter of the head​ NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY Types of Pelvic Ultrasound a. Abdominal or Transabdominal ​– the woman in supine position, the sonographer/radiologist applies the transducer on the lower abdomen  NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY Types of Pelvic Ultrasound b. Vaginal or transvaginal ​– the woman in lithotomy position, the sonographer/radiologist inserts into the vagina 2-3 inches of the vaginal transducer’s end with the protective cover and lubricating gel NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4. ULTRASONOGRAPHY Specific features of Sonogram: a. Biparietal diameter – used to predict fetal maturity: Measurement of fetal head - (8.5 cm. or greater) Weight. 2500 g (5.5 lb.)  NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4. ULTRASONOGRAPHY b. Doppler Umbilical Velocimetry ​– measures the velocity at which RBC in the uterine and fetal vessels travel to assess blood flow through the uterine blood vessels NORMAL DIAGNOSTIC LABORATORY FINDINGS DURING PREGNANCY 4. ULTRASONOGRAPHY b. Doppler Umbilical Velocimetry Determine the vascular resistance present in woman with Gestational diabetes or Hypertension and placental insufficiency Decreased Velocity – predictor of Uterine Growth Restriction ULTRASONOGRAPHY c. Placental grading for maturity – can be graded based on the amount of calcium deposits present in the based of the placenta (Ring-like structures) Grades: ▪ 0 – between 12 and 24 wks. ▪ 1 – 30 – 32 wks. ▪ 2 – 36 wks. ▪ 3 – 38 wks. – suggest fetus is mature  ULTRASONOGRAPHY c. Placental grading for maturity – can be graded based on the amount of calcium deposits present in the based of the placenta A calcified placenta occurs when small, round calcium deposits build up on the placenta, causing it to deteriorate gradually. The process occurs naturally as closer to the end of pregnancy. if placental calcification occurs before your 36th week, it could cause complications to the mother and her baby.  ULTRASONOGRAPHY c. Placental grading for maturity Complications: 1. Fetal growth restriction 2. Fetal distress in cases of preterm placental calcification. 3. Decreased blood flow in the placenta and compromise fetal circulation and growth 4. Preterm birth 5. Low birth weight  ULTRASONOGRAPHY c. Placental grading for maturity Complications 6. Low Apgar score 7. Postpartum hemorrhage 8. Placental abruption 9. Fetal distress 10. Stillbirth ULTRASONOGRAPHY c. Placental grading for maturity – can be graded based on the amount of calcium deposits present in the based of the placenta Grade 0 ▪ between 12 and 24 wks. gestation ▪ No calcification, no indentations ULTRASONOGRAPHY c. Placental grading for maturity Grade 1 ▪ 30 – 32 wks. gestation ▪ small diffuse calcifications ▪ randomly distributed in placenta ULTRASONOGRAPHY c. Placental grading for maturity – Grade 2 ▪ 36 wks. gestation ▪ dot dash calcifications along the basal plate ▪ larger indentations ULTRASONOGRAPHY c. Placental grading for maturity Grade 3 ▪ 38 wks. – suggest fetus is mature ▪ complete indentations of the chorionic plate ▪ hyper mature placenta associated with placental insufficiency 7. AMNIOTIC FLUID VOLUME (ULTRASOUND) The amount of amniotic fluid can estimate fetal health because a portion of the fluid is formed by fetal kidney output If a fetus is becoming so stressed in utero that circulatory and kidney function is failing urine output and the volume of amniotic fluid will decrease 7. AMNIOTIC FLUID VOLUME – THE AMOUNT OF AMNIOTIC FLUID PRESENT ESTIMATE FETAL HEALTH ▪ > 20 - 24 cm. – amount greater than indicates Hydramnios ▪ 12 -15 cm. average between 28 and 40 wks. ▪ < 5 - 6 cm – Oligohydramnios ▪ decrease in amniotic fluid volume puts the fetus at risk for compression of the umbilical cord 8. NUCHAL TRANSLUCENCY SCREENING a number of genetic disorders can be detected on sonogram during the 11 wks.-13 wks. of pregnancy children with a number of chromosomes anomalies have unusual pockets of fat or fluid deposits at the back of the fetal neck Assessment of Fetal Growth and Development  FETAL BIOPHYSICAL PROFILE NON INVASIVE FETAL TESTING a noninvasive method of assessing the general wellbeing of the fetus and fetal assessment used as early as 26-28 weeks for the surveillance of high-risk pregnancy requires the use of the electronic fetal monitor and the observation time takes about 30 mins  FETAL BIOPHYSICAL PROFILE NON INVASIVE FETAL TESTING combines five parameters into one assessment the fetal heart and breathing record measures short-term central nervous system function amniotic fluid volumes helps measures long-term adequacy of placental function FETAL BIOPHYSICAL PROFILE Five Parameters: 1. Fetal reactivity 2. Fetal breathing movements 3. Fetal body movements 4. Fetal tone 5. Amniotic fluid volume  FETAL BIOPHYSICAL PROFILE Indications: 1. Mother with Gestational Hypertension 2. Fetus appears to be small or not growing properly  FETAL BIOPHYSICAL PROFILE Indications: 3. Fetus is less active than normal (movement) 4. Too much or too little amniotic fluid  BIOPHYSICAL PROFILE SCORING Assessment Instrument Criteria for Score of 2 1. Fetal Breathing Sonogram At least one episode of 30 sec of sustained fetal breathing movements within 30 min of observation 2. Fetal Movement Sonogram At least 3 separate episodes of fetal limb or trunk movement within 30 mins. observation  BIOPHYSICAL PROFILE SCORING Assessment Instrument Criteria for Score of 2 3. Fetal Tone Sonogram The fetus must extend and flex the extremities at least once in 30 min 4. Amniotic fluid volume Sonogram A pocket of amniotic fluid measuring more than 2 cm in vertical diameter must be present  BIOPHYSICAL PROFILE SCORING Assessment Instrument Criteria for Score of 2 5. Fetal heart Nonstress test 2 or more accelerations of fetal reactivity heart rate of 15 beats/min, lasting 15 or more following fetal movements in a 20 min period Biophysical profiles may be done as often as daily during a high-risk pregnancy Results: 8 - 10 fetus is considered to be doing well 6 - is considered suspicious 4 - denotes a fetus probably in jeopardy  ESTIMATING FETAL WELL-BEING 1. Fetal Growth (Fundal Measurement) ▪ over the symphysis pubis – 12 wks. ▪ at the umbilicus – 20 wks. ▪ at the xyphoid process – 36 wks. ESTIMATING FETAL WELL-BEING 2. Mc Donald’s rule Formula: ▪ AOG in months – FH in cm. x 2/7 ▪ AOG in weeks – FH in cm. X 8/7  ASSESSING FETAL WELL-BEING 1. Fetal heart rate ▪ Fetal heart sounds a. 10 – 11 wks. – ultrasound b. 10 wks. – Doppler  ASSESSING FETAL WELL-BEING 2. Daily fetal Movement Count (Kicks Count) a. 18 – 20 wks. – quickening felt by the mother b. 28 – 38 wks. – 10 x / hr. peaks in intensity  ASSESSING FETAL WELL-BEING 3. Rhythm Strip testing – assessment of the fetal heart rate. ▪ Average FHR – 130 beats/ min. ▪ Average fetal moves – twice every 10 mins. – causes heart rate to increase 4. NONSTRESS TESTING – MEASURES THE RESPONSE OF THE FETAL HEART RATE TO FETAL MOVEMENT ▪ Fetal moves – HR increase 15 beats/ min. and remain elevated for 15 seconds ▪ If no increase in beats/minute on fetal movement – indicates poor oxygen perfusion of the fetus ▪ usually done for 20 minutes  NONSTRESS TESTING Test is Reactive (Healthy) if 2 acceleration of FHR (by 15 beats or more) lasting for 15 secs Nonreactive (fetal health may be affected) if no acceleration with the fetal movement If a 20 minute passes without any fetal movement, means the fetus is sleeping  NONSTRESS TESTING When the fetus has adequate oxygenation and intact CNS, there are acceleration of FHR with fetal movement 5. VIBROACOUSTIC STIMULATION – FOR ACOUSTIC (SOUND) STIMULATION ▪ Acoustic stimulator applied to the mother’s abdomen to produce sharp sound (80 db.), startling and waking the fetus. ▪ If spontaneous acceleration has not occurred within 5 mins, a 1-2 secs sound stimulation to the lower abdomen and can be repeated at the end of 10 mins  6. MAGNETIC RESONANCE IMAGING (MRI) can identify structural anomalies or soft tissue disorders most helpful in diagnosing complications a. Ectopic pregnancy , b. Trophoblastic disease  7. MATERNAL SERUM ALPHA- FETOPROTEIN SCREENING Alpha fetoprotein / Triple Screen Estriol is initially tested. If the result is abnormal, the woman is next referred for Ultrasound to confirm gestational age and to evaluate for neural tube defects and other structural abnormalities ↓ Estriol, ↑HCG and ↓ Alpha-fetoprotein – Trisomy 21 ↑ AFP – fetus has open spinal or abdominal defect 7. Maternal Serum Alpha- fetoprotein screening AFP is a substance produced by the fetal liver that can be found in both amniotic fluid and maternal serum between 15th and 20 wks. of pregnancy ▪ Level low – Chromosomal defect Trisomy 21 (Down’s syndrome) 7. MATERNAL SERUM ALPHA- FETOPROTEIN SCREENING ▪ Level High –begins to rise at 11 wks. and steadily increase until term gestation ▪ Fetus has an Open spinal (Neural tube defect) or abdominal defect, allow more AFP to enter the mother’s circulation  8. FETAL GENDER Ultrasound – determined at about 4 months Maternal serum analysis – as early as 7 wks. and could be helpful to a woman who has a X-carrying genetic disorder Male fetus – inherited the disease Female fetus – disease free  Lateral Pelvimetry – ​in suspected cephalopelvic disproportion (CPD) with a danger sign of absence of lightening in a primigravida in active labor Indications for lateral Pelvimetry 1. Suspected CPD 2. Previous difficult delivery 3. History of severe vitamin D and calcium deficiency n childhood 4. History of pelvic or spine injury 5. Cases of severe scoliosis  LABORATORY ASSESSMENT a. Urinalysis – tested for proteinuria, glycosuria, nitrates, pyuria b. Complete blood count c. Genetic screen (G6PD) Glucose6phosphate dehydrogenase) LABORATORY ASSESSMENT d. VDRL serologic test for syphilis e. Blood typing (Rh factor)  LABORATORY ASSESSMENT f. Maternal serum alpha- fetoprotein – done between 16-18 wks. of pregnancy g. Combs test – determination of whether Rh antibodies are present in an Rh (-) woman  LABORATORY ASSESSMENT h. HIV screening g. Serum antibody titers for rubella, hepatitis, varicella j. Tuberculosis Screening (Mantoux Test) INVASIVE FETAL TESTING 1. Chorionic Villi Sampling (CVS) Is a transcervical or transabdominal insertion of a needle into the fetal portion of the placenta CVS is performed at 8-12 weeks gestation under ultrasound guidance to ensure that the fetus is unharmed. 1. Chorionic Villi Sampling (CVS) Is a biopsy & analysis of chorionic villi for chromosomal analysis done at 8 to 10 wks. of pregnancy chorion cells are located by ultrasound Chorionic villi cells are examined to detect chromosome abnormalities such as Down syndrome and genetic disorders such as Cystic fibrosis 1. Chorionic Villi Sampling (CVS) A thin catheter is inserted vaginally or needle biopsy is inserted intravaginally or inserted abdominally, and a number of chorionic cells are removed for chromosome analysis (Genetic defect) Nursing Responsibilities: Instruct client to report bleeding, infection or leakage of fluid after procedure 1. Chorionic Villi Sampling (CVS) Reportable for signs and symptoms: a. Chills or fever (infection) b. Uterine contraction or vaginal bleeding (Threatened miscarriage)  2. AMNIOCENTESIS Amniocentesis - is the removal of fluid from the amniotic cavity by needle puncture. An ultrasound is performed first to determine the safe site where the needle can be inserted. Scheduled between the 14th and 16th wk.  2. AMNIOCENTESIS During the procedure, the fetus is continuously monitored by ultrasound to ensure its wellbeing. Complications: 1. Infection of the amniotic fluid 2. Puncture of the fetus.​  PURPOSES OF AMNIOTIC FLUID ANALYSIS 1. Detection of fetal abnormalities early in pregnancy 2. To determine fetal lung maturity 3. Lecithin/Sphingomyelin ratio 4. Lung Profile 5. Amniotic Fluid Bilirubin 6. Rh incompatibility 7. For detection of certain infections 8. Detection of fetal abnormalities early in pregnancy  AMNIOTIC FLUID CAN BE ANALYZED FOR: 1. AFP (Acetylcholinesterase) - a compound that rises to high levels if a neural tube anomaly is present Color Normal amniotic fluid - color of water, late in pregnancy, it may have a slightly yellow tinge Strong yellow – suggest a blood incompatibility (presence of bilirubin released from the breakdown of RBC)  AMNIOTIC FLUID CAN BE ANALYZED FOR: Color Green – suggest meconium staining a phenomenon associated with fetal distress 2. Fibronectin – is a glycoprotein plays a part in helping the placenta attach to the uterine decidua can be assess in woman cervical mucus in early pregnancy damage to fetal membranes from cervical dilatation releases fibronectin and preterm labor may be begin  AMNIOTIC FLUID CAN BE ANALYZED FOR: 3. Inborn error of metabolism – inherited diseases that can be detected by amniocentesis The body cannot breakdown and metabolized food due to defects of protein enzymes Detect the following diseases: Sickle cell disease, cystic fibrosis, muscular dystrophy, Tay-Sachs disease, amino acid disorder  AMNIOTIC FLUID CAN BE ANALYZED FOR: 4. Lecithin and sphingomyelin – are protein components of the lung enzyme surfactant that the alveoli begin to form at the 22nd-24 wks. of pregnancy can be determined by a shake test (if bubbles appear in amniotic fluid after shaking, the ration is mature L/S ratio of 2:1 is accepted as lung maturity  NURSING CARE DURING AMNIOCENTESIS 1. Assist client to empty her bladder before the procedure 2. Place in supine position and drape properly 3. Put rolled towel under right hip to tip body to the left and remove pressure of uterus on vena cava 4. Instruct not to take a deep breath and hold it while the needle is being inserted as it will shift the uterus and needle may hit placenta or fetus.  NURSING CARE DURING AMNIOCENTESIS 5. Inform the patient that it is not painful because anesthesia will be applied at the insertion site. She may experience pressure sensation during the insertionof the needle. 6. Monitor FHT before, during and in 30 minutes after the test. 7. Instruct patient to observe for: a. Infection b. Uterine or vaginal cramping  PERCUTANEOUS UMBILICAL BLOOD SAMPLING also called Cordocentesis or Funicentesis – is the aspiration of blood from umbilical vein for analysis a thin needle is inserted by amniocentesis technique into the uterus and is guided by ultrasound PUBS test reveals that the fetus is anemic, blood may be transfused into the cord  PERCUTANEOUS UMBILICAL BLOOD SAMPLING the blood obtained sample of blood is then removed for blood studies (CBC, direct Combs test, bloods gases and Karyotyping) Kleihauer-Betke test - is utilized to determine if there is fetal blood in maternal circulation, CONTRACTION STRESS TEST (CST)  CONTRACTION STRESS TEST (CST) Assess the ability of the fetus to withstand the stress of uterine contraction done during labor Contraction stress test is a means of evaluating the respiratory function of the placenta. Induced or Spontaneous contraction - decrease transport of O2 to the fetus.  CONTRACTION STRESS TEST (CST) A Healthy fetus - maintains a steady Heart rate. If Placental reserve is insufficient a. Fetal hypoxia b. Decrease FHR Testing is initiated when 3 contractions in every 10 minutes are attained. The test takes about 60-90 minutes to perform. PERIODIC CHANGES IN CONTRACTION STRESS TEST: Evaluating the respiratory function of the placenta a. Accelerations - a temporary normal increases in FHR caused by fetal movement or compression of the umbilical vein during contraction.  PERIODIC CHANGES IN CONTRACTION STRESS TEST: b. Early Decelerations - a periodic decreases in FHR resulting from pressure of the fetal head during contractions. ▪ Beginning when the contractions begins and ending when the contractions end ▪ Normal – late in labor  PERIODIC CHANGES IN CONTRACTION STRESS TEST c. Late Decelerations – there is a delayed deceleration until 30 to 40 secs. after the onset of a contraction and continue beyond the end of the contraction Uteroplacental insufficiency or ↓ blood flow through the intervillous spaces of the uterus during contraction  LATE DECELERATIONS Management: 1. Administer IVF 2. O2 as prescribed - If late decelerations persist prepare for possible prompt birth of the infant PERIODIC CHANGES IN CONTRACTION STRESS TEST (Nadir) - the lowest point of the deceleration occurs near the end of the contraction instead of at its peak occur with Hypertonia or with abnormal uterine tone caused by administration of oxytocin Management: 1. Stop or slow the administration of oxytocin 2. Change the position from supine to lateral to relieve pressure from the venacava d. Variable Decelerations Decelerations that occur at unpredictable times in relations to contractions - indicate compression of cord D. VARIABLE DECELERATIONS Decelerations that occur at unpredictable times in relations to contractions - indicate compression of cord a. Cord prolapsed- fetus is lying on the cord, occurs more frequently after rupture of membranes b. Oligohydramnios Position: Place the client in lateral position OLIGOHYDRAMNIOS Management: 1. Administer fluids and O2 as prescribed 2. If not relieved, Amnioinfusion may be prescribed Amnioinfusion – is the instillation of fluid into the amniotic cavity to treat severe deceleration.  INTERPRETATION OF RESULTS OF CONTRACTION STRESS TEST: 1. Positive There is persistent late decelerations with more than half the contractions; maybe associated with minimal or absent variability. A positive Contraction Stress Test means that the fetus is no longer receiving adequate oxygen and needs to be delivered.  INTERPRETATION OF RESULTS OF CONTRACTION STRESS TEST: 2. Negative: There is no late deceleration in a 10-minute period and this means that it is safe for the fetus to remain in utero for the next 7 days Prenatal testing maybe offered to women during pregnancy - to determine if the fetus has a possibility to be born with a genetic condition or birth defect. WK. 5 PRELIM