Signs and Symptoms of Pregnancy

Signs & Symptoms of Pregnancy

• Presumptive signs are subjective and indicate a potential pregnancy through physiological changes in the body
• Amenorrhea is the absence of menstruation
• Breast changes encompass tenderness and enlargement
• Elevated basal body temperature (BBT) occurs
• Ptyalism involves excessive salivation
• Changes in vaginal mucosa color manifest
• Fatigue is experienced
• Nausea and vomiting occur
• Urinary frequency and bladder irritability increase
• Hyperpigmentation of skin, known as chloasma or melasma gravidarum results in a “pregnancy mask”
• Fetal movements, or quickening, are perceived by the woman
• Probable signs are objective, indicating maternal physiological and anatomical changes detected by an examiner
• Abdomen and uterus enlargement detected
• Fetal outline palpation
• Uterine changes such as Hegar's sign which signals corpus or isthmus softening of the lower uterine segment between 6-12 weeks
• McDonald's and Piskacek's signs are uterine inflexion and irregularity, respectively
• Cervical changes include softening with Goodell's sign in 5-6 weeks
• Chadwick's sign indicates bluish-purple coloration of vaginal mucosa and cervix at 6-8 weeks
• Endocrine testing through hCG detection either via urine (ELISA) or blood (B-serum radioimmunoassay) confirms pregnancy
• Positive signs directly indicate the presence of a fetus detectable and documentable by an examiner
• Ultrasound verification of an embryo or fetus through visualization and a gestational sac seen as early as 5-6 weeks with a TVUS
• Fetal movement felt by an experienced clinician
• Auscultation of fetal heart tones and cardiac activity via transvaginal US (4 weeks post-conception) and transabdominal US (6 weeks after)
  • Doppler can be used at 10-12 weeks, or a fetoscope at 17-19 weeks

Uterine Sizing

• At 12 weeks, the fundus is just above the pubic bone
• By 40 weeks (term), the fundus drops below the 38-week level as the presenting part descends into the pelvis

Common Discomforts of Pregnancy

• Backache is caused by increased joint relaxation from progesterone and relaxin production
• It leads to difficulty with ambulation and low back pain
• Enlarging uterus increases lordosis and changes the center of gravity
• Skin changes include palmar erythema, increased pigmentation (chloasma/melasma gravidarum, linea nigra, striae, darkening of areola), and angiomas
• Constipation is due to delayed gastric emptying and the enlarging uterus displacing the stomach/intestines
• Dyspnea is caused by increased estrogen/progesterone leading to hyperventilation, uterine growth putting pressure on the diaphragm, and iron deficiency anemia causing shortness of breath
• Edema results from decreased blood return and increased circulatory volume
• Epistaxis is caused by estrogen engorgement of nasal mucosa; allergies
• Vigorous nose blowing and nose picking worsen the condition and dry air
• Heartburn is due to hormonal/mechanical factors where the growing uterus displaces stomach above the esophagus
• Management via diet, frequent small meals, and avoiding lying down
• Antacids and H2-receptor inhibitors are the first-line pharmacological treatment
• PPIs can be used in moderate to severe GERD
• Hemorrhoids are a result of rectal pressure from growing uterus
• Insomnia can be caused by increased estrogen/progesterone levels, pressure on the diaphragm and it leads to difficulty getting comfortable
• Leg Cramps are caused by lower calcium levels, changes in blood circulation, muscle fatigue, and pressure on blood vessels and nerves
• Nausea and Vomiting result from the hCG hormone secreted by the placenta and BP (estrogen)
• Hormones can cause BP fluctuations and changes in carbohydrate metabolism and delayed gastric emptying
• Round Ligament Pain is most common in the 2nd trimester
• Uterine growth and stretching of ligaments are the main cause
• Acetaminophen, heat/warm baths, assuming hands-knees position, and pelvic tilt can help relieve pain
• Varicosities are due to genetics, progesterone effects, AMA, parity, and prolonged standing,
• Support stockings, rest with legs elevated, and avoiding prolonged standing will help
• Fatigue is usually the worst in the 1st and 3rd trimesters and is of unclear origin
• Urinary Frequency is most common in the 1st and 3rd trimesters
• It is triggered by increased dilation of kidneys/ureters and increased bladder tone, increasing the risk of stasis/ infection
• Increased renal plasma flow and GFR
• Must R/O UTI if accompanied by dysuria, hematuria, or hesitancy
• Breast Discomfort is due to the effect of estrogen and progesterone

Prenatal Care Visits

• 1st visit is for preconception or an initial OB visit 6-8 weeks after 1 missed menses

• Return visits:

• From the initial 28 weeks a visit every 4 weeks

• From 28 weeks to 36 weeks a visit every 2 weeks

• The following components determine each visit: urinalysis, GBS, labs

• Health Guidance in Pregnancy includes: travel, work, dental care, exercise, sex and immunizations

Important Topics

• Vaccines, nutrition, genetic screening, monitoring during pregnancy, and medication safety must be considered

Genetic History

• Personal and family history for heritable disorders, birth defects, mental retardation, or a psychiatric disorder has to be recorded
• Maternal and paternal age and ethnic origin, must be recorded
• Referral to a genetic counselor or clinical geneticist should be considered to determine if carrier screenings are indicate
• Genetic counseling should be offered to all patients
• Complete a thorough maternal, paternal, and family history to identify risk factors

Chromosome Abnormalities

• Autosomal trisomies:
• Trisomy 21 (Down's), Trisomy 13, and Trisomy 18 all occur during maternal meiosis and are associated with the maternal age effect
• Structural chromosome abnormalities such as translocations, deletions, and duplications happen
• Cri du chat, Williams, Prader-Willi, Angelman, Smith-Magenis all happen
• Sex chromosome abnormalities include Turner syndrome and Klinefelter syndrome

Screening for Aneuploidy

• Aneuploidy represents a condition where a person has one or a few chromosomes above or below the normal number
• Screening is not equivalent to definitive testing
• First Trimester Screen is performed between 11.0 and 13.6 weeks to take Nuchal translucency measurement and Serum free B-hCG (Pregnancy-associated plasma protein)
• Quadruple Screen is is performed between 15.0 and 22.6 weeks and US is not required
• hCG, AFP, dimeric inhibin A, and unconjugated estriol + maternal factors are looked at
• It assesses for age, weight, race, presence of diabetes, plurality or Provides
• Triple Screen includes hCG, AFP, and unconjugated estriol
• It is lower sensitivity for detection of Down Syndrome than quad screen and first trimester screening

Combined First & Second Trimester Screening

• Integrated Screening looks at both trimesters, NT measurements and analyte screenings Serum Integrated Screening:
• Stepwise & Contingent Screening Models assesses risk for high risk cell and low risk quad screens in 2nd trimester

Cell Free DNA Screening

• It is performed as early as 10 weeks of gestation and the test screens for aneuploidy and determines fetal sex
• It is important to use Ultrasound to assess measurement
• Use of US can be impacted by High maternal BMI or Multiple gestation

Prenatal Genetic Diagnosis

• Amniocentesis is usually performed after 15 weeks
• Chorionic Villus Sampling (CVS) is performed first trimester between 10-13 weeks and is performed Transcervical or transabdominal
• Fetal Blood Sampling US directs percutaneous umbilical blood sampling (PUBS)
• All pregnant women should be offered prenatal assessment for aneuploidy by screening or diagnostic testing
• Prenatal genetic testing cannot identify all abnormalities or problems in the fetus but genetic testing should be discussed as early as possible

Carrier Screening for Heritable Disorders

• CF (cystic fibrosis) and Hemoglobinopathies (Sickle cell and Thalassemia) can be done
• Ashkenazi Couples:
• Tay Sachs, Canavan disease, CF, or Familial dysautonomia if only ONE partner is Ashkenazi, screen that individual first

Cardiovascular

• Cardiac output increases 30-50% with peak at 16-28 weeks then returns to pre-pregnancy level after a few weeks
• HR and SV increases:
• BP drops during the 2nd trimester and returns to normal during the 3rd trimester
• Pregnancy increases frequency of functional murmurs accentuated heart sounds
• Premature atrial & ventricular beats COMMON
• Hematologic expansion increases blood volume by 40-50%
• Lowered Hgb occurs by dilution and WBC increases progressively during pregnancy
• PEAKS DURING LABOR, Iron requirements increase total of about 1g during pregnancy
• Platelets count decreases while platelet function increases
• Pregnancy hypercoagulability results in an increased thromboembolic disease
• Increased levels of most factor Decreases in: Fibrinolytic and Some natural inhibitors
• Urinary dilation of ureters and renal pelvic begins in the 2nd months
• GFR increase 30-50% and BUN decrease if position is upright
• Respiration increase in progesterone creates a volume
• Mucosa of the nasopharynx and oxygen increases to meet metabolic needs for Fetus Placenta Maternal organs
• Transfer of CO2 during pregnancy increases minute ventilation

Gastrointestinal

• Pressure from enlarging uterus causes constipation (can be because of elevated progesterone or intake during pregnancy)
• Decreased GI motility and gastric emptying can be causes
• Relaxation of lower esophageal sphincter, Diaphragmatic, production, gallbladder filling can be caused
• LFTs (liver function tests) normal or Alkaline phosphates during 3rd trimester can be caused Normal thyroid levels mirror thyroid functions-
• Produces Hormone stimulation for thyroid
• Increased resistance caused by Liver
• Fasting and hyperglycemia are some of the results
• Enlarges about about 1/3 during pregnancy
• Increased estrogens, progesterone cause pigment changes -Darking of Areolae skin
• Progressively increases lumbar
• Thickness is the cornea and a decreased is preassure

Prenatal Visits and Vaccines

• Typical pregnancy lasts 280 days or 40 weeks which starts with the first day of the last normal period (LMP) as day 1
• Naegele's rule states that gestational age equals to count back 3 calendar months then Add 1 year and 7 days to that date

Vaccines

• Vaccines before pregnancy are important to keep accurate vaccine recorded and UTD protects from preventable disease and Contraction.

• Getting vaccines will ensure less blood lost with MMR

• Vaccines to take are the following Pertussis and Flu caused by immune changes

What Are Standard Exams

• 1st Semester are Yolk, and Embryo/fetus are detected to document video or check activity before dissauding

Trimester to use to scan the abdomen and vaginal area

Tranvaginal are good in any cases for anomolies in women

Women's Health OB Ultrasound Procedures

• Confirmation of the presence may be shown to get Confirmation to get: Ectopic age and Gestrational size are important to see on a image
• Evaluation of cervical area and uterine masses Screening are important to avoid fetal anomilies and any changes

Screening for Genetic Issues

-Determining Risk blood is always checked or scan done to detect the risk

• AIUM, ACOG and ACR is recommended

Maternal blood tests

Checkup tests for:

• Cardiac Activity to heart before and after births so blood passes after the blood flow (location and internail) then Visualixe