Pregnancy PDF

Pregnancy The Endocrine Placenta  Fertilized ovum when it enters the uterus and known as blastocyst  Specialized cells in the blastocyst secrete human chorionic gonadotropin (hCG)  Blastocyst implants into the wall of the uterus  Specialized layer of cells becomes th...

Pregnancy The Endocrine Placenta  Fertilized ovum when it enters the uterus and known as blastocyst  Specialized cells in the blastocyst secrete human chorionic gonadotropin (hCG)  Blastocyst implants into the wall of the uterus  Specialized layer of cells becomes the placenta and ultimately takes over hormonal regulation from the corpus luteum to maintain the pregnancy  Functions as an endocrine organ and secretes hormones that help growth of fetus and direct changes in the women’s body to prepare for birth and lactation  hCG  Progesterone  Estrogen Pregnancy Structure and Function Average length Trimester division Terminology of pregnancy 280 days from First: 12 weeks Primigravida to the first day of Second: 13 to primipara after the LMP 27 weeks delivery Equal to 40 Third: 28 weeks Multigravida is weeks, 10 lunar to delivery a woman who months, or 9 has previously calendar been pregnant months and becomes a multipara after delivery. GTPAL— gravida, term, preterm, abortion, living Changes During Pregnancy Presumptive Probable Positive Signs such as Signs detected Signs that amenorrhea, by the indicate direct breast examiner upon evidence of tenderness, inspection of the fetus, such fatigue, and the uterus but as FHTs or increased again may be positive urinary due to other cardiac activity frequency but causes than on ultrasound may be due to pregnancy other causes than pregnancy First Trimester (1 of 2)  Serum hCG becomes + and cessation of menses occurs  Estrogen, progesterone, and human placental lactogen (HPL) impact breast sensation and development  Increased likelihood of nausea and vomiting due to  hormonal changes, low blood sugar, gastric overloading, slowed peristalsis, uterine size increase, and/or emotional factors  Fatigue levels increase possibly due to decrease in metabolic rate early in pregnancy  Vascular changes in the uterus as a result of hormone production First Trimester (2 of 2)  Decrease in blood pressure due to decrease in systemic vascular resistance  Initial decrease in blood pressure due to decrease in systemic vascular resistance until mid-pregnancy  BP gradually returns to nonpregnant baseline by term  Embryonic period ends at 9 weeks and fetal period begins  FHTs can be heard by Doppler ultrasound between 9 and 12 weeks  Uterus may be enlarged above the symphysis at about 12 weeks Second Trimester (1 of 2)  After 12 to 16 weeks, nausea, vomiting, and urinary frequency improve in most individuals  Quickening: Perception of fetal movement between 18 and 20 weeks  Breast enlargement and colostrum may be expressed  Hormonal effects lead to darkening of body tissues:  Areola, nipples, and linea nigra  Striae gravidarum: May see “stretch marks” on breasts, abdomen, and areas of weight gain  Drop in blood pressure noticeable about 20 weeks and may cause orthostatic changes to occur Second Trimester (2 of 2)  Gastrointestinal changes as a result of displacement by growing uterus leading to:  Heartburn, constipation, and predisposition to gallstone formation  Transient changes in thyroid hormones (TSH) and plasma iodine levels:  As a result of increased hCG between 8 and 14 weeks  Increased cutaneous blood flow due to:  Decreased vascular resistance allowing for dissipation of heat  Gingivitis or epulis of pregnancy:  May occur as a result of hypertrophy and fragility of capillaries  FHTs are audible by fetoscope between 17 and 19 weeks  Fetal outline palpable through abdominal wall at 20 weeks Third Trimester (1 of 2)  Blood volume peaks in third trimester  Although erythrocyte mass increases, proportional increase in blood volume leads to hemodilution effect  Uterine enlargement causes:  The diaphragm to rise and the shape of the rib cage to widen at the base, leading to decreased lung expansion, which can result in SOB  Also displaces the heart up and to the left leading to increased CO, SV, and force of contraction  Pulse rate rises and functional systolic murmur (grade 2/6 or less) can be heard in >95% of pregnant patients (normal abnormal)  Dependent edema due to growing fetus as well as standing position  Increased likelihood for varicosities in legs, vulva, and rectal area Third Trimester (2 of 2)  Balance and positional changes:  Progressive lordosis noted to compensate for shifting center of balance  Positional changes due to weight of breasts (slumping shoulder and anterior neck flexion) may cause aching as well as numbness/tingling (carpal tunnel nerve compression).  Approximately 2 weeks prior to delivery, primigravida experiences engagement and lightening  Cervix begins to efface and dilate in preparation for labor  Mucous plug expelled at various times before or during labor  ACOG definition of term pregnancy:  Early term: from 37 0/7 weeks to 38 6/7 weeks  Should be avoided unless medically indicated  Full term: from 39 0/7 weeks to 40 6/7 weeks  Late term: from 41 0/7 weeks to 41 6/7 weeks Early Term Delivery  Avoided unless medically indicated due to increased risks of complications  Medical indications:  Placental/uterine issues  Fetal issues  Maternal issues  Obstetric issues Height of Fundus at Weeks of Gestation Determining Weeks of Gestation  Expected date of delivery (EDD) can be calculated from  280 days from the LMP  Calculated using Nägele's rule if menstrual period is regular  First day of LMP: add 7 days and subtract 3 months  Determined by pregnancy wheel  Estimated by physical examination  Estimated by hCG level  Ultrasound—most accurately (+/−2 days)   Associated risks of teen pregnancy compounded by socioeconomic, psychosocial and medical complications  Delay in seeking medical care and noncompliance plays a role during prenatal care  Delay in childbearing with advent of assisted fertility with more women older than 35 becoming pregnant  Risk for genetic deformities increases with age:  Genetic counseling, prenatal diagnosis and Developmental screening tests*  Invasive: Chorionic villi sampling (CVS), Competence amniocentesis or percutaneous umbilical blood sampling  Noninvasive*: US nuchal translucency with maternal serum levels of pregnancy- associated plasma protein-A and hCG, free cell DNA, fetal anatomy US  Complications due to comorbid conditions with “older moms”  Diabetes, obesity, & HTN can affect both mother and fetus Genetics and Environment (1 Risk offor3)  genetic disorders Potential for being a carrier of certain disease states (Tay Sachs or sickle cell, as examples)  Obesity epidemic impacts maternal and fetal outcomes  Racial disparities in obesity result in poor pregnancy outcomes  Gestational Diabetes (GDM) disproportionally impacts certain racial and ethnic groups  Highest prevalence Asian, non-Hispanic Black & Hispanic  Opioid epidemic and pregnancy  Associated with increased risk for stillborn birth and drug dependence in newborn  Screen for tobacco, alcohol, prescription pain meds, and/or street drugs  NAS: Neonatal abstinence syndrome Genetics and Environment (2 Transgender of 3) and Pregnancy  Marginalization of health care access  reproductive needs  Gender confirming medical care  Hormone therapy  Surgery  Combination of interventions  Counseling  Impact on fertility  Fertility preservation  Impact  May not be able to become pregnant  Chestfeeding Genetics and Environment (3 of 3)  Illicit Drugs and Pregnancy  Significant impact on fetus  Screening for drug/alcohol use  Legalization of drugs  Opioid epidemic and pregnancy  Associated with increased risk for stillborn birth and drug dependence in newborn  Screen for tobacco, alcohol, prescription pain meds, and/or street drugs  NAS: Neonatal abstinence syndrome  Increasing prevalence  Characteristics: poor feeding/jitteriness/high-pitched cry/irritability/diarrhea/unstable temperature & seizures Subjective Data  Menstrual history  Gynecologic history  Obstetric history  Current pregnancy  Medical history  Review of systems  Nutrition history  Environment/hazards Menstrual History  Ask about  LMP characteristics  Timing, premenstrual symptoms, length, amount of flow, cramping, number of days in cycle, pattern  Use Nägele's rule to calculate EDD  Use a pregnancy wheel to determine current week of gestation Gynecologic History  Ask patient whether she has had any of the following or specify:  Surgery r/t the cervical area  Abnormal Pap test or tested for HPV  History or exposure to genital herpes  History of STIs (sexually transmitted infections)  Tested for HIV—assess for risk factors  Sexual preference—sexual history  Mammogram or breast surgery Obstetric History  Ask about  GTPAL details  Complications r/t prior pregnancies  Previous pregnancies, labor, and delivery events  Cesarean as a mode of delivery/VBAC Current Pregnancy  Ask about  planned pregnancy and reaction to pregnancy  vaginal bleeding or abdominal pain general state of feeling—signs/symptoms of  pregnancy  edema  movement of fetus  plans for feeding infant: bottle or breast Medical History  Ask about  medications: Rx or OTC or herbal supplements  allergies to medications and/or foods and reactions  history/exposure to communicable diseases (rubella/chickenpox)  smoking/alcohol/drug history  exercise pattern  vitamin D levels checked Review of Systems  Ask about  Body weight prior to pregnancy: calculate BMI  Last dental appointment  HTN or kidney disease  Diabetes: type and treatment /prior pregnancy  UTIs  Depression/mental disorder/Tx  Safety in your environment and relationships  Abusive relationships/experiences Nutritional History  Ask the patient and/or advise the patient about  whether follows a special diet  vegetarian and type  relevant safety practices r/t food (avoiding mercury containing seafood and raw food products)  food intolerance  food craving  compliance with prenatal vitamins/folic acid/iron Environment/Hazards  Ask the patient and/or advise the patient about  occupation and physical work demands  exposure to chemicals, odors, radiation, or harmful substances  whether housing is adequate  seatbelt and car safety Additional History for Transgender Men  Obtain gender-confirming information  Hormone therapy/last dose  Surgical procedures  Planned pregnancy  Partner support  Family support  Plans for chestfeeding  Perinatal mental health Objective Data: Preparation  Preparation  Verbally prepare for exam  Empty bladder and obtain specimen as needed  Perform pelvic exam last  Drape for privacy and help maintain comfort level  Check BP while patient is seated to avoid positional compression  Place the patient in lithotomy position Objective Data: Equipment  Equipment  Stethoscope  BP cuff  Centimeter measuring tape  Doppler Fetal Heart Rate(FHR) monitor & gel  Reflex hammer  Urine specimen container and dipstick  Equipment needed for pelvic examination General Survey  Normal  Obtain vital signs & current weight  Observe normal state of nourishment: correlate with BMI (19-25) considered healthy  Note posture, grooming, and mood; assess mental state  Observe maturity and assess readiness level for health promotion  Abnormal  Monitor for signs of preeclampsia during course of pregnancy.  Undernourished or obese  First trimester weight loss of >5% may indicate hyperemesis gravidarum  Poor grooming or flat affect maybe signs of depression or relate to economic factors Skin  Normal  Note any scars and/or skin changes associated with pregnancy  Chloasma, linea nigra & striae  Inspect for PUPPP (Pruritic urticarial papules & plaques of pregnancy): most common pruritic skin rash of pregnancy  Abnormal  Bruises may suggest physical abuse  Facial edema (after 20 weeks) is significant finding suggesting preeclampsia  Track marks and/or nasal stuffiness or recurrent nose bleeds may suggest drug abuse  Some nasal congestion and nose bleeds may be normal due to increased blood volume  Note any suspicious nevi or lesion  Uncommon for nevi to change or become larger during pregnancy Mouth and Neck  Normal  Mouth  Mucous membranes dark pink and moist  Gum hypertrophy  Bleeding gums  Neck  Thyroid may be palpable and smooth during the normal pregnancy of an euthyroid patient  Abnormal  Mouth  Pale mucous membranes indicates anemia  Poor dental hygiene may lead to preterm birth  Neck  Solitary nodes indicate neoplasm  Multiple nodes usually indicate inflammation or a multinodular goiter  Significant diffuse enlargement occurs with thyroiditis Breasts  Normal  Enlarged and may be tender  Areolae and nipples darken  Mammary soufflé heard  Montgomery tubercles  Colostrum  Nipple presentation may vary.  Breast tissue feels nodular.  Teach BSE  Abnormal  Note any abnormal mass and refer for ultrasound Heart and Lungs  Normal  Heart  Late in pregnancy, you can palpate apical impulse left of the midclavicular line and up to the 4th intercostal space.  Functional soft blowing systolic murmur  Lung  Clear to auscultation  SOB is common in third trimester.  Abnormal  Heart  Note any abnormal murmur & refer  hemodynamic burden with cardiac disease  Valvular heart disease may require prophylactic antibiotics at delivery  Lung  Pregnant woman with asthma may have expiratory and inspiratory wheezes  Note any signs of respiratory infection: dyspnea, crackles, and congested cough   Normal  Peripheral vasculature  Legs may show diffuse, symmetric, bilateral pitting edema, especially in the 3rd trimester during exams late in day  Common varicose veins in 3rd trimester  Neurologic Peripheral  Check reflexes (biceps, patellar, and DTRs) using reflex hammer Vasculature  Abnormal  Normally 1+ to 2+ and  Peripheral vasculature  Assess for triad of preeclampsia: edema, Neurologic  proteinuria, and hypertension Edema and calf pain: DVT  Hot red streak: phlebitis  Neurologic  Brisk or >2+ and clonus in combination with elevated BP and cerebral edema in the preeclamptic patient Inspect and Palpate the Abdomen  Observe the shape and contours of the abdomen:  Note diastasis recti  Fundus  Should be palpable from 12 weeks’ gestation  Note fundal location by landmarks and fingerbreadths  After 20 weeks, fundal height should correlate with gestational age  Differences noted in fundal height may indicate problems with:  Gestational age assessment and/or perinatal complications  Lagging fundal height may indicate IUGR or transverse lie or oblique presentation of fetus  Fundal height greater than anticipated (< 4 cm) may indicate multiple gestation, excess amniotic fluid or uterine myoma  US warranted Leopold’s Maneuvers  In third trimester, perform Leopold’s maneuvers to determine fetal lie, presentation, attitude, position, variety, and engagement  Fetal lie: orientation of fetal spine to maternal spine— longitudinal, transverse, or oblique  Presentation: part of the fetus that is entering the pelvis first—vertex, head, or breech  Attitude: position of fetal parts in relationship to each other—flexed, military, or extended  Position: designates the location of a fetal part to the right or left of the maternal pelvis  Variety: location of the fetal back to the anterior, lateral, or posterior part of the maternal pelvis  Engagement: occurs when the widest diameter of the presenting part has descended into the pelvic outlet at the level of the ischial spines Leopold’s First Maneuver  This picture illustrates how to perform the first step of Leopold’s maneuver Leopold’s Second Maneuver  This picture illustrates how to perform the second step of Leopold’s maneuver Leopold’s Third Maneuver  This picture illustrates how to perform the third step of Leopold’s maneuver. It is also called Pawlik maneuver Leopold’s Fourth Maneuver  This picture illustrates how to perform the fourth step of Leopold’s maneuver and is done to determine engagement Auscultate FHTs  FHTs are a positive sign of pregnancy  Heard by Doppler ultrasound between 8 and 10 weeks of pregnancy  Auscultated best by locating the back of the fetus  Normal heart rate between 110 and 160 bpm  Spontaneous accelerations indicate fetal well-being  Differentiate FHTs between maternal heart rate and uterine soufflé  Difficulty in obtaining FHTs requires further investigation:  By 12 weeks, requires confirming fetal cardiac activity by US.  Below 110 or above 160 bpm Pelvic Examination: Genitalia  Genitalia  Use procedure for pelvic examination outlined in Chapter 27  Enlargement of labial minora is common in multiparous women  Labial varicosities may be present  Inspect perineal area for scarring, lesions, and hemorrhoids   Speculum  Observe for Chadwick’s sign  Note any vaginal discharge  Note appearance of cervical os  Bimanual  Note Hegar sign Pelvic  Chapter 27 provides detailed Examination: description—palpation of the uterus Speculum  Note Goodell’s sign  Assess adnexa to rule out the presence of a mass  Assess tone by asking patient to squeeze your fingers opportunity to teach Kegel exercises.   Blood pressure  Take BP after examination when she is the most relaxed in semi-Fowler’s or upright Blood  position During first routine prenatal visit, obtain panel Pressure,  lab tests pertinent to pregnancy Routine labs and radiologic imaging studies Routine   Prenatal panel testing Subsequently, obtain urine specimen at each Labs, and interval visit to check for abnormal components, such as proteinuria Radiologic  Standard of care in US is to have fetal anatomic survey at 18 to 20 weeks with cervical length measurement Imaging  Additional optional testing offered: quad screening and fetal nuchal translucency screening Studies  Antepartum fetal testing improves perinatal outcomes: fetal well-being testing, including but not limited to NST, CST, and biophysical profile Abnormal Findings: Preeclampsia  Classic symptoms  Hypertension, proteinuria, and edema  Combination of maternal and fetal factors:  Placenta implanted with abnormal trophoblastic invasion  Immunologic intolerance  Cardiovascular or inflammatory changes  Genetic factors  Monitor the patient closely for elevated BP changes and/or symptoms, such as headaches and visual changes  HELLP Syndrome (variant):  Hemolysis, elevated liver enzymes, and low platelets   Leading cause of death in pregnant people  Diagnosed when cumulative blood loss greater than 1,000mL or evidence of hypovolemia  Primary PPH within 24 hours of delivery/Secondary PPH 24 hours to 12 weeks after delivery Abnormal  Risk factors: Findings:  Nulliparity/multigravidity greater than 4 Postpartum   C/S Prolonged or precipitous labor Hemorrhage  Causes: (PPH)  Lack of uterine tone  Uterine trauma  Retained placenta  Clotting issues Abnormal Findings: Fetal Size Inconsistent with Dates  Size Small for Dates  Inaccuracy of Dates  Preterm Labor  Size Large for Dates  Hydatidiform Mole  Multiple Fetuses  Polyhydramnios  Oligohydramnios  Leiomyoma—Myoma or “Fibroids”  Fetal Macrosomia Abnormal Findings: Malpresentations  Malpresentations may be detected by  hands of experienced examiner  confirmed by fetal heart tone location  confirmed by ultrasound  Alternate delivery method may be warranted, based on malpresentation Summary Checklist: The Pregnant Woman (1 of 2)  Collect history  Determine EDD & current number of weeks of gestation  Instruct person to empty bladder and undress, saving urine specimen for dipstick testing/culture at first visit  Measure weight  Perform a physical examination starting with a general survey  Inspect skin for pigment changes/scars  Check oral mucous membranes Summary Checklist: The Pregnant Woman (2 of 2)  Palpate thyroid gland  Inspect breast changes & palpate for masses  Auscultate breath sounds, heart sounds, heart rate & note presence of any murmurs  Check lower extremities for edema, varicosities &reflexes  Abdomen: check fundal height, perform Leopold’s maneuvers & auscultate FHTs  Pelvic examination: note signs of pregnancy, condition of cervix & size/position of uterus  Measure BP  Obtain appropriate lab work