Diagnosis - Physiological-Psychological Changes in Pregnancy PDF

 Objectives At the end of this lecture every student should be able to: 1- Identify the signs and symptoms of pregnancy. 2- Explain physiological changes occurring in different body systems during pregnancy. 3 - Identify physiological changes that cause discomfort to the mother....

 Objectives At the end of this lecture every student should be able to: 1- Identify the signs and symptoms of pregnancy. 2- Explain physiological changes occurring in different body systems during pregnancy. 3 - Identify physiological changes that cause discomfort to the mother. 4 - Define the terms that describe the specific changes in the pregnant woman due to hormonal influences. Terminology * Gravida - number of pregnancies * Para - number of pregnancies carried to viability and delivered * Primigravida - pregnant for first time * Multigravida - pregnant more than once * Viability - able to survive outside the womb (24+ weeks gestation) * Nulliparous - never carried a pregnancy to viability * Multiparous - has had two or more deliveries that were carried to viability  Diagnosis of Pregnancy Pregnancy may be diagnosed by the presence of certain signs and symptoms (Presumptive signs ) are subjective and recorded under the history of present illness. Probable and positive signs of pregnancy are objective and recorded as physical assessment findings  6 Hegar,s signs Hegar,s signs 7  Urine pregnancy test Reacts with human chorionic gonadotropin (hCG) Performed on first voided urine sample of the day; positive results possible before the first day of a missed menstrual period. Serum pregnancy test Useful in monitoring expected pattern of progression of hCG; detects hCG as early as 9 days post-conception Ultrasound Confirms presence of gestational sac, fetal pole, and fetal cardiac activity Validates location of pregnancy (intrauterine versus ectopic) 8  Sure signs of pregnancy 1. Hearing of fetal heart rate 2. Feeling of fetal movement 3. Feeling of fetal parts by examiner 4. Ultrasonography to visualize fetal parts ,fetal movement, fetal heart movement 5. X- ray to detect fetal skeleton 9 Physiological Changes in Pregnancy *Pregnancy brings both psychological and physical changes to the woman. *Physiologic changes occur gradually but eventually affect all organ systems of a woman’s body. *Psychological changes occur in response to physiologic alterations. *Pregnancy represents wellness not illness.  Physiological Changes in Pregnancy Nurses must understand the normal anatomical and physiological changes in pregnancy to recognize any deviation from normal. In addition to physical changes, there are also psychological changes that occur with pregnancy. Physiological Changes of Pregnancy Local changes - confined to the reproductive organs. Systemic changes - affecting the entire body. Both subjective (symptoms) and objective (signs) findings are used to diagnose and mark the progress of the pregnancy. Physiological Changes of Pregnancy Reproductive System Changes: Uterine changes: Increase in size, length, depth, width, weight, wall thickness and volume. Length-from 7.5 to 35 cm. Depth-increases from 2.5 to 22 cm. Width-expands from 4 to 24 cm. Weight-increases from 50 to 1,000 g. Uterine wall thickens from 1 cm to 2 cm by the end of pregnancy, the wall thins so it is supple and 0.5 cm thick. Physiologic Changes of Pregnancy *Uterine growth is due to formation of a few new muscle fibers and stretching of existing muscle fibers (2 to 7 times longer). *Week 12 the fetus is palpated just above the symphysis pubis. *Week 20 or 22 the fetus is at the umbilicus. *Week 36 should touch the xiphoid process which causes some Obstructed Breathing. Physiologic Changes of Pregnancy Lightening - 2 weeks before term (week 38) the fetal head settles into the pelvis to prepare for birth and the uterus returns to the height it was at on the 36 week. This permits better lung expansion and easier breathing. This is predictable in 1st birth but not others. Uterine growth is a presumptive sign of pregnancy. Physiologic Changes of Pregnancy As the uterus increases in size it: pushes the intestines to the side elevates the diaphragm and liver puts pressure on the bladder Uterine blood flow increases: before pregnancy - 15 to 20 mL/ min. by the end of pregnancy - 500 to 750 mL/min. with 75% going to the placenta. Uterine bleeding can be a major blood loss. Uterus is anteflexed, larger and softer. Physiologic Changes of Pregnancy Hegar’s sign - softening of the lower uterine segment. The wall can not be felt or it feels as thin as tissue paper with bimanual exam. Ballottement - on bimanual exam, tapping of lower segment the fetus is felt to bounced or rise in the amniotic fluid up against the to top examining hand (week 16 to 20). Braxton Hicks contractions - painless, irrgular contractions. practice contractions. Week 12 until term. Waves of hardness or tightening across the abdomen. Physiologic Changes of Pregnancy They serve as warm-up exercise and increase placental perfusion. False labor, the do not cause cervical dilation. Amenorrhea - absence of menstruation due to suppression of The follicle-stimulating hormone( FSH). Cervical changes: Cervix more vascular and edematous. Increased fluid between the cells causes Physiologic Changes of Pregnancy the cervix to soften and increased vascularity causes it to darken from pale pink to a violet hue. A mucus fills the cervical canal. Operculum - mucous plug - seals out bacteria during pregnancy and to protect the fetus and fetal membranes from infection.  The mucus plug is expelled at the end of the pregnancy. When the mucus is blood-tinged, it is referred to as a "bloody show." Goodell’s sign - softening of the cervix. – Nonpregnant cervix is like the nose. – Pregnant is like earlobe. Physiologic Changes of Pregnancy Just before labor the cervix becomes soft like butter and is “ripe” for birth. Vaginal changes: vaginal epithelium become hypertrophic and enriched with glycogen under high estrogen level which results in white vaginal discharge throughout pregnancy. The pH become acidic (3.5-6) to prevent multiplication of pathogenic organisms. Chadwick’s sign - vaginal walls are deep violet color due to increased circulation. Physiologic Changes of Pregnancy Ovarian changes: ovulation stops. Corpus luteum increases in size until week 16 and then the placenta has taken over as provider of progesterone and estrogen. Physiological Changes of Pregnancy Changes in the breasts: result of estrogen and progesterone production. (1st change) feeling of fullness and tenderness. Size increases due to hyperplasia of mammary alveoli and fat deposits. Aerola darkens and diameter increases to 3.5 cm to 5 or 7.5 cm (1 1/2 to 3 inches) blue veins become prominent. Montgomery’s tubercles-sebaceous glands  Montgomerys tubercles Increase size , vascularity Physiological Changes of Pregnancy of the areola enlarge and become protuberant. secretions keep the nipple supple and help prevent cracking and drying during lactation week 16 colostrum-a thin, watery, high protein fluid can be expelled from the breast Systemic Changes: CHANGES OF THE SKIN DURING PREGNANCY Alterations in hormonal balance and mechanical stretching are responsible for several changes in the skin. Systemic Changes CHANGES OF THE SKIN DURING PREGNANCY Linea nigra This is a dark line that runs from the umbilicus to the symphysis pubis and may extend as high as the sternum. It is a hormone- induced pigmentation. After delivery, the line begins to fade, though it may not ever completely disappear. Chloasma Systemic Changes chlosama (mask of pregnancy) - This is the brownish hyper pigmentation of the skin over the face and forehead. It begins about the 16th week of pregnancy and gradually increases, and then it usually fades after delivery. Vascular spiders - small fiery-red branching spots on thighs, increases estrogen. Palmar erythema - redness and itching. Increased sweat gland activity. Scalp hair growth increases.  Striae Gravidarum (Stretch Marks). It reflects a separation within underlying connective tissue of the skin. This occurs over areas of maximal stretch-- the abdomen, thighs, and breasts. It will usually fade after delivery although they never completely disappear. Systemic Changes Respiratory System The respiratory rate rises to 18 to 20 to compensate for increased maternal oxygen consumption, which is needed for demands of the uterus, the placenta, and the fetus.. Polyuria - increased urination due to plasma bicarbonate excreted by the kidneys. Systemic Changes congestion of nasopharynx - increased estrogen levels Temperature: increased for 16 weeks due to secretion of progesterone from the corpus luteum, returns to normal once the placenta takes over. mother may feel warmer or experience "hot flashes Systemic Changes Cardiovascular System: Changes are extreme and significant to the health of the fetus. Blood volume increases by 30 to 50 % blood loss at birth-300 to 500 mL cesarean birth-800 to 1,000 mL increase blood volume peaks at week 28 to 32 Systemic Changes anemia - concentration of hemoglobin and erythrocytes decline. Iron needs fetus requires 350 to 400 mg to grow. Mother has an increase in RBC needing an additional 400 mg of iron. Prenatal vitamins and foods supply needs. Heart cardiac output increases by 25 to 50 % heart rate increases by 10 beats/ min. heart is shifted more transverse Systemic Changes 3rd trimester blood flow to lower extremities is impaired due to pressure on veins and arteries. leads to edema and varicosities. Blood pressure: does not normally rise may decrease in 2nd trimester Systemic Changes Supine hypotension syndrome: when woman lies supine the weight of the uterus presses on the vena cava obstructing blood return to the heart. risk fetal hypoxia lightheadedness, faintness and palpitations. rest on left side. Supine Hypotension Syndrome Systemic Changes Gastrointestinal system Uterus displaces the stomach and intestines toward the back and sides of the abdomen. Pressure slows peristalsis and the emptying time of the stomach. Leads to heartburn, and constipation. Nausea and vomiting in early morning when hCG and progesterone begin to rise. Systemic Changes May be a systemic reaction to increases estrogen or decreased glucose levels. Subsides after 3 months Generalized itching due to reabsorption of bilirubin into the mother’s blood stream due to decreased emptying of bile from the GB. Systemic Changes Urinary System Effects of estrogen and progesterone activity. Compression of the bladder and ureters. Increased blood volume Fluid retention: total body water increases to 7.5 L increase sodium reabsorption Systemic Changes Potassium remains adequate. Water retention increases blood volume to serve as a source of nutrients to the fetus. Renal Function: Kidneys change size. Urinary output increases by 60 to 80 %. Renal plasma flow increase. Creatinine clearance tests for renal function. Systemic Changes Ureter and Bladder Function ureters increase in diameter due to increased progesterone. bladder capacity increases to 1,500 mL pressure on the urethra may lead to poor bladder emptying and infections. May lead to kidney infection. Systemic Changes Skeletal System Calcium and phosphorus increase for fetal skeleton. Softening of pelvic ligaments and joints. Relaxin (ovarian hormone) and placental progesterone. Separation of symphysis pubis-3 to 4 mm. Stand straighter and taller - lordosis Center of gravity is changed. CHANGES IN BODY WEIGHT DURING PREGNANCY Normal weight gain is about 12-13kg during pregnancy weight gain 2.5 kg by the end of the first trimester(1st-20week). weight gain 10kg by the rest of the pregnancy(20-40week) i.e 0.5kg/week.  Components of increased weight: Fetus (3.5 kgm), placenta (0.5 kgm), uterine growth (0.5 kgm), amniotic fluid (1 kgm ), breast growth (0.5 kgm), blood volume(l.5 kgm), protein retention (2 kgm) and water retention (2kgm) Systemic Changes Endocrine System Almost all aspects of the endocrine system increase. Placenta is an endocrine organ Produces estrogen, progesterone, hCG, human placental lactogen,relaxin, prostaglandins. Pituitary Gland there is a halt to FSH and LH due to high estrogen and progesterone levels. Systemic Changes Increase in production of growth hormone and melanocyte-stimulating hormone. Late in pregnancy it produces oxytocin and prolactin. Thyroid and Parathyroid Glands Parathyroid Gland. This gland increases in size slightly. It meets the increased requirements for calcium needed for fetal growth.iodine and thyroxine are elevated. Posterior Pituitary. Near the end of term, the posterior pituitary will begin to secrete oxytocin that was produced in the hypothalamus and stored there. It will serve to initiate labor. Anterior Pituitary. At birth, the anterior pituitary will begin to secrete prolactin. This stimulates the production of breast milk.  Placenta. The placenta acts as a temporary endocrine gland during pregnancy. It produces large amounts of estrogen and progesterone by 12 to 16 weeks of pregnancy. It serves to maintain the growth of the uterus, helps to control uterine activity, and is responsible for many of the maternal changes in the body 55 Hormone Functions Estrogen 1. Increase uterine muscle mass 2. Increase blood flow to uterus 3. Prepare breasts for lactation Progesterone 1. Relax venous walls 2. Inhibit uterine contractions Human chorionic gonadotropin Stimulate estrogen/progesterone production Human placental lactogen 1. Maturation of breast ducts/ alveoli 2. Stimulate lactation Prolactin 1. Insulin antagonist 2. Allow adequate glucose for fetal demand