Presumptive Signs of Pregnancy

• During pregnancy, routine prenatal care should involve reviewing obstetric and medical histories, as well as the results of physical exams and labs
• Travel, work, dental care, exercise, sex, and immunizations are all aspects integral to health guidance to be reviewed during prenatal care
• Vaccines, nutrition, genetic screening, monitoring both during and after pregnancy, medication safety and labs are important discussion points
• This means it's subjective as it depends on the patient, and are signs of pregnancy

Presumptive Signs of Pregnancy

• Presumptive signs, means "Physiologic changes that indicate to her that she is pregnant.”
• Absent menstruation is a potential sign of pregnancy
• Breast changes such as tenderness and enlargement could indicate pregnancy
• Elevated basal body temperature can signal probability of pregnancy
• There is increased salivation
• Vaginal color changes
• Fatigue sets in
• Nausea and vomiting
• Elevated urinary frequency with bladder irritability
• The skin also changes with hyperpigmentation and melasma ("pregnancy mask")
• Fetal movement is another indicator

Probable Signs of Pregnancy

• Enlargement of the abdomen/uterus
• Palpation of fetal outline
• Uterine Changes
  • Hegar's sings: Softening of the lower part of the uterus around the 6-12 week period
  • McDonald's sign: Flexion of uterine body and cervix
  • Piskacek's sign: Irregularity of uterine shape due to implantation
• Cervical Changes
  • Goodell's Sign: Softenign of the cervix at 5-6 weeks
  • Chadwick's Sign: Bluish purple coloration of vagina and cervix at 6-8 weeks

Positive Signs of Pregnancy

• Ultrasound verifies the presence of an embryo or fetus
  • A gestational sac is present at 5-6 weeks via TVUS
• Detection of fetal movement
• Cardiac activity

Common Discomforts of Pregnancy

• There is increased joint relaxation due to hormonal changes of progesterone and relaxin

• Creates difficulty with ambulation and low back pain

• The enlarging uterus causes increased lordosis and changes the center of gravity

• Other common symptoms such palmar erythema

• Skin changes such as chloasma, linea nigra, darkened areola and external genitalia, striae, and angiomas

• Delayed gastric emptying occurs

• The enlarging uterus displaces stomach and intestines

• Dyspnea occurs due to increased estrogen and progesterone, uterus growing, and iron deficiency

• Edema is common with decreased blood return and increased circulatory

• Nosebleeds are expected, but exclude sinusitis

• Heartburn occurs, so avoid spicy foods and sleep in semi-fowlers

• Constipation occurs so utilize small meals with protein and liquids versus solids

• Leg cramps occur due to lower calcium levels

• There are also hormonal and BP changes leading to mood and diet changes

• Round ligament pain occurs in the 2nd semester; treat with warm compress

• Varicosities occur due to gravity and genetics; wear compression stockings

• There is often fatigue or urinary frequency

• If dysuria occurs, consider UTI, but breast changes occur as well

• In a patients first visit: Complete an initial OB visit 6–8 weeks after the first missed period, return for a q4-week visits up to 28 weeks, q2-weeks until 36, then once a week in the absence of other symptoms

• There should be a travel discussion, work discussion, dental appointment discussion, exercise, or any specific vaccines to consider

• Screening testing should be routine, considering options that are safe.

Genetic Screening Key Points

• There should be a clinical indication to genetic studies, which are: family history, patient history, ethnic origin, test indication
• Consider what to tell patients and be prepared, offering without bias and using resources to make proper choice
• Autosomal Trisomymies should be considered for risk, especially Trisomy 21,13, and 18
• Structural sex chromosome abnormalities such as Turner syndrome

Aneuploidy Screenings -

• Performed above or below normal
• There are both single screenings and additional screenings with steps

First Trimester Combined Screening

• Measured between 11-13 weeks to confirm nuchal translucency, B-CGA and protein levels in the plasma

Second Trimester Serum Integrated or Quadruble

• Measured between 15-22 weeks, with estriol and inhibin hormone levels

Cell-Free DNA

• Done after 10 weeks to determine Rhesus, any defects, sex and genetic risk

• Be aware of anatomy with high or low body fat, especially on ultrasounds

• Can screen fetal anatomies during ultrasounds (best after 18 weeks), but these are not diagnositc

• Can offer genetic amniocentesis as an adjunct which are offered based on patient needs and timing and is done after 15 weeks

• One can also perform chorionic villi samples, transcervical or transabodominal

Cardiovascular Changes in Pregnancy

• Cardiac output increases 30-50% starting as early as Week 6, cardiac and stroke volume increases while BP drops, as well as resting maternal heart rate. The position of the patient impacts the results
• Respiratory processes are altered and are designed to be acidemic
• Tidal volume increases, while total capacity decreases
• The nasopharynx becomes edematous

Endocrine Changes in Pregnancy

All hormones increase to support the growing fetus:

• Thyroid issues may mimic pregnancy
• Free thyroid should remain normal

Skeletal Changes during Pregnancy

• Maternal calcium is high, with pregnancy having high bone turnover
• Joints soften
• Visual acuity and eyes may be impacted

Determining Pregnancy Length

• Naegle's rule determines pregnancy length (add 7 days to LMP, subtract 3 months)
• Visits include one during 6 weeks, then monthly to week 28, biweekly till week 36, and then weekly until birth
• Vaccination administration must be discussed with a pregnancy

Vaccinating During Pregnancy

• The main considerations are whooping cough, rubella and varicella, for which one needs to determine Rho/D status for immunization if required

Complications During Trimesters

• During the First Trimester: Nausea/vomiting, fatigue, urinary frequency, tenderness, nasal issues
• During the Second and Third Trimesters: Heartburn, bowel changes, edema, leg cramping, heart problems

Ultrasound Basics

During ultrasound:

• Use gain/focus, adjust the power, orient the insonication as required, and select best diagnostic modalities

Ultrasound Timeframes:

• First Trimester:Confirm and find any abnormalities, such as CRL, uterine size
• Second/Third Trimester: Inspect cardiac and placental placement

Ultrasound Orientation:

• Know the presentation, amniotic flow, placentation at 2cm, visualize and get what is required

First Trimester Sonographic Protocol

• Intrauterine determination, examine ovaries and dimensions of gestational sac and embryo
• Measure yolk and heartbeat

Anatomic Survey by Sonography

• Examine the extremities, brain ventricles, nuchal area, cerebellum, placenta and more

Other Sonographic Factors

• Can be related to the face, amniotic fluiq, cord, and what are they
• The test should be done in three trimesters and be detailed for what one should assess.

Placental Makeup

The placenta

• Has two layers of surfaces of the chorion and basal plate - it has a smooth texture and attaches with the unbillical cord
• The two surfaces are divided to create branching trees made in capillary dimension
• Is initiated with the blastocyst

Placental Issues

Villi can have abnormalities:

• It functions through transport hormones and endocrinology
• There is diffusion of fluids and protein, with the creation of steriods and proteins for support

Pregnancy Risks

• There is fetal malnutrition, low blood, vaso constrictions, and abruption
• In addition, there are chromosomal issues such as down syndromre, Edwards sundrome and such
• There are single chromosomes with alterations that may occur
• There are also risks such as twin translocation with blood diffusion and increased flow

First Semester Screenings

The trimester screenings should be:

• First trimester measurements (NT and proteins)
• Followed by high and low indication measures after such are presented from such screening

ACOG testing reccomendations

• ACOG reccomends ACOG be 28 weeks for negative Rho d to get prophylactic D immunoglobulin
• Anti-D immunoglobulin in other areas

Common Prenatal Testing:

• Ultrasounds: measure everything
• Amnios: measure placenta (15 days) and chorionic (first trimester

Screening of Diseases

• Screen for hemoglobinopathies with family history

Testing for Couples

• Ask couples about ancestry/ ethnicity to assess certain common traits

First line Recommendations (Chapter 6)

For nutritional changes, the best steps may be vitamin tracking (D, C & A ) for heart and weight

• Then there B6, and other such options to consider

Complications

• May be related to pre-eclampsia
• Monitor BP, and blood pressure changes
• Use Tums and other such methods to prevent and limit pain to an extent

Pregnancy Needs

Consider that the body must supply protein, calcium, iron, vitamin D during pregnancy

• In addition to any other dietary needs
• Limit caffeine

1st Trimester

• Confirm pregnancy
• Assess vaginal fluid, pelvic tenderness
• Use blood for STDS / CBC
• Check thyroid

High Order Risks

High order risks may warrant:

• First trimester ultrasound, as opposed to waiting for the 15-21 week anatomy scan
• Genetic testing to decide the pregnancy outlook from 15 to 21 weeks

Prenatal

• In every follow-up: evaluate the height, inspect cardiac areas, inspect movement

Maternal/ Fetal testing

• These can determine what is going on
• There is fetal well being scale that can inform
• In addition a non stress test can alert concerns
• All must be done by certain measures depending on circumstances and high level
• Doppler ultrasound
• There is biophysical profile that will show whether they need to change things

Testing on Abdominal Area

• Test for structural items and measure the umbilical flow/function
• Ultrasound, C V scan.
• Also take a sample culture to ensure the presence of a fetus.