Prenatal CarePrenatal Care

Lecture 5Lecture 5

SCREENING TESTSSCREENING TESTS 1. AFP 2. Triple Marker Test 3. Quad Test

Blood serum test

PProbabilityrobability of anomaly. of anomaly. If +, amniocentesis offered. If +, amniocentesis offered.

AFP screening: AFP screening: (alpha-fetoprotein) (alpha-fetoprotein) Screening Screening

11stst developed to detect developed to detect abnormalities in women abnormalities in women younger younger than age 35than age 35

AFP made by fetal liver and yolk AFP made by fetal liver and yolk sac. sac.

Secreted from fetal to maternal Secreted from fetal to maternal circulation AND to amniotic fluid circulation AND to amniotic fluid from kidney into amnion. from kidney into amnion.

Detects open neural tube Detects open neural tube defects, anencephaly, Down’s defects, anencephaly, Down’s syndrome. syndrome.

Abnormal concentrations may Abnormal concentrations may indicate serious fetal anomalies; indicate serious fetal anomalies; requires additional testing. requires additional testing.

Common Possible Indications Common Possible Indications :: High AFP= open neural tube defectsHigh AFP= open neural tube defects Low AFP = trisomies (Down’s Low AFP = trisomies (Down’s

syndrome).syndrome). 15 -18 wks of pregnancy.15 -18 wks of pregnancy.

Limitations areLimitations are:: 1) False + causes ^ anxiety/expense 1) False + causes ^ anxiety/expense

when F/U tests needed. when F/U tests needed. 2) Women who don’t seek prenatal 2) Women who don’t seek prenatal

care til > 18th wks miss opportunity care til > 18th wks miss opportunity for AFP screening. for AFP screening.

3) Results dependent on maternal 3) Results dependent on maternal weight: low maternal wt. > high weight: low maternal wt. > high AFP; high maternal wt. > low AFPAFP; high maternal wt. > low AFP

Triple Marker TestTriple Marker Test measures AFP, hCG, & measures AFP, hCG, &

unconjugated estriol. unconjugated estriol. developed after AFP. developed after AFP. higher rate of anomaly detection higher rate of anomaly detection

than AFP.than AFP. high false positive rate 7-9%high false positive rate 7-9% Common reason for false + is Common reason for false + is

misdated pregnancy. Negative misdated pregnancy. Negative result result notnot indicative of NO risk. indicative of NO risk. Indicates Indicates LOWLOW risk. risk.

Quad TestQuad Test

replacing Triple Test as replacing Triple Test as standard standard screening test screening test

Better at detecting more cases of Better at detecting more cases of Down syndrome, trisomy 18, 21, Down syndrome, trisomy 18, 21, & neural tube defects& neural tube defects

Decreased false positive rate. Decreased false positive rate. uses 4 serum assays (AFP, hCG, uses 4 serum assays (AFP, hCG,

unconjugated estriol, & dimeric unconjugated estriol, & dimeric inhibin A [DIA]) inhibin A [DIA])

DIA ^ with Down syndrome fetus.DIA ^ with Down syndrome fetus. Performed between 15 - 22 wks Performed between 15 - 22 wks

(16-18 wks. optimum). (16-18 wks. optimum).

CVS – Chorionic Villus SamplingCVS – Chorionic Villus Sampling

Allows early screening (1st trimester) @ Allows early screening (1st trimester) @ 10 wks.10 wks.

Cells from chorionic villi - same Cells from chorionic villi - same genetic makeup as fetus. Early genetic makeup as fetus. Early screening.screening.

Results in 48 hrs. - eliminates 2nd Results in 48 hrs. - eliminates 2nd trimester ABtrimester AB

risk of miscarriage - 1/100risk of miscarriage - 1/100 ultrasound guides trans-cervical ultrasound guides trans-cervical

catheter or trans-abdominal needle catheter or trans-abdominal needle into placenta. into placenta.

Chromosomal & DNA analysis done Chromosomal & DNA analysis done on fragments.on fragments.

Best @ 10-12 wks to avoid fetal Best @ 10-12 wks to avoid fetal harm.harm.

UltrasoundUltrasound – high frequency sound waves – high frequency sound waves converted converted

to 2 dimensional images. No X-ray hazard; to 2 dimensional images. No X-ray hazard; fetal structures seen. fetal structures seen.

1st trimester1st trimester : confirms pregnancy, viability : confirms pregnancy, viability (locates heartbeat), verify (locates heartbeat), verify dates/gestational age, size, detects twins, dates/gestational age, size, detects twins, r/o ectopic vs. intrauterine pregnancy r/o ectopic vs. intrauterine pregnancy [IUP]. IUD. Placenta previa.[IUP]. IUD. Placenta previa.

2nd & 3RD trimesters2nd & 3RD trimesters confirm location of placenta, confirm confirm location of placenta, confirm

gestational age, gestational age, determine fetal position, monitor fetal determine fetal position, monitor fetal

movements, movements, evaluate amniotic fluid, locate fetus prior to evaluate amniotic fluid, locate fetus prior to

& during& duringamnio/CVS.amnio/CVS.

External Fetal MonitoringExternal Fetal Monitoring

Detects uterine contractions & FHR - Detects uterine contractions & FHR - continuous or intermittent.continuous or intermittent.

External sensors: External sensors: Contractions - Contractions - tocotoco transducers transducers FHR - FHR - cardiocardio-transducers. -transducers. Maternal movements can cause loss of FHR Maternal movements can cause loss of FHR

pick up. pick up.

InternalInternal = more precise = more precise

Fetal scalp electrodeFetal scalp electrode – wire onto fetus – wire onto fetus scalp. scalp.

FHR recorded on graph paper. FHR recorded on graph paper. Normal FHR Normal FHR 110-160 bpm.110-160 bpm.

Intrauterine pressure catheter (IUPCIntrauterine pressure catheter (IUPC) = ) = probe probe

alongside fetus. Attached to pressure alongside fetus. Attached to pressure sensor; intensity of uterine contractions sensor; intensity of uterine contractions measured accurately. measured accurately.

Non-Stress Test: {Non-Stress Test: {EFM} toco & cardio EFM} toco & cardio

Records FHR, accels., decels., fetal Records FHR, accels., decels., fetal movement. One movement q 10-20 min. movement. One movement q 10-20 min.

Reactive NST = 2 FHR accels. > baseline Reactive NST = 2 FHR accels. > baseline by 15 bpm lasting longer than 15 sec. by 15 bpm lasting longer than 15 sec. within 20 min. within 20 min.

Daily fetal movement countDaily fetal movement count: uninvasive; : uninvasive; inexpensive; done @ home; 10 FM/30 min. inexpensive; done @ home; 10 FM/30 min. If not, eat snack, count again. Near due If not, eat snack, count again. Near due date more serious if low fetal movement. date more serious if low fetal movement. See MD if ↓ FM.See MD if ↓ FM.

Biophysical Profile (BPP) NST & ultrasound Biophysical Profile (BPP) NST & ultrasound to evaluate fetal well-being. to evaluate fetal well-being.

5 factors assessed: 5 factors assessed: 1] fetal muscle tone; 2] FM; 3] fetal 1] fetal muscle tone; 2] FM; 3] fetal

breathing movements; 4] Amniotic fluid breathing movements; 4] Amniotic fluid volume; 5] FHR reactivity. volume; 5] FHR reactivity.

Score of 2 on each; score 6 = equivocal. Score of 2 on each; score 6 = equivocal.

Score 8-10 = “reassuring”. Score 8-10 = “reassuring”. Amniotic Fluid Index = AFI = measures Amniotic Fluid Index = AFI = measures

fluid in 4 quadrants. > 5 “reassuring”; 5 fluid in 4 quadrants. > 5 “reassuring”; 5 or < is not. or < is not.

Assesses long term placental func. Assesses long term placental func.

AmniocentesisAmniocentesis: :

Removal of amniotic fluid from Removal of amniotic fluid from abdomen between 14 -16abdomen between 14 -16thth wk. New wk. New techniques 12 wks.techniques 12 wks.

11stst – 2 – 2nd nd trimester: R/O chromosomal trimester: R/O chromosomal abnormal abnormal

3rd trimester: fetal lung maturity - less 3rd trimester: fetal lung maturity - less than 37 wks than 37 wks

Fluid removed & analyzed. Fluid removed & analyzed.

Risk of miscarriage ~ 1/200. Assess for Risk of miscarriage ~ 1/200. Assess for labor.labor.

Rh (-) mother gets Rhogam.Rh (-) mother gets Rhogam.

Assess for contractions x 30 min.Assess for contractions x 30 min.

Amniotic fluid assessmentAmniotic fluid assessment: : Cytogenetic testing (karyotyping) - Cytogenetic testing (karyotyping) - chromosomal abnormalities. chromosomal abnormalities.

Fetal lung maturityFetal lung maturity: Lecithin & : Lecithin & sphingomyelin: lipoproteins keeps sphingomyelin: lipoproteins keeps alveoli open @ birth. L/S ratio 2:1 alveoli open @ birth. L/S ratio 2:1 adequate.adequate.

Steroids - ↑ rate of fetal lung Steroids - ↑ rate of fetal lung maturity [24-34 wks] for PTL. maturity [24-34 wks] for PTL. Betamethasone: 12 mg x 2 q 24 hr. Betamethasone: 12 mg x 2 q 24 hr. Dexamethasone: 6 mg q 6 hr x 4. IM Dexamethasone: 6 mg q 6 hr x 4. IM inj. inj.

Accelerates production of surfactant.Accelerates production of surfactant. Full-term baby's lungs already make Full-term baby's lungs already make

surfactantsurfactant Lubricates lining of air sacs & Lubricates lining of air sacs &

prevents sticking of membranes. prevents sticking of membranes. Good air exchange.Good air exchange.

Intrauterine surgery:Intrauterine surgery: Cesarean birth/cesarean Cesarean birth/cesarean section = C/Ssection = C/S. .

Birth by abdominal incision into uterusBirth by abdominal incision into uterus. .

Can be more complicated than vaginal Can be more complicated than vaginal birth. birth.

Considered one of safest surgeries Considered one of safest surgeries when compared to other when compared to other procedures. procedures.

Overall C/S rate: ~ 40%. [higher in Overall C/S rate: ~ 40%. [higher in NYS].NYS].

Major Indications for C/S:Major Indications for C/S: Active genital herpesActive genital herpes Overgrowth of genital wartsOvergrowth of genital warts CPD (cephalopelvic disproportion)CPD (cephalopelvic disproportion) Severe HTN (toxemia)Severe HTN (toxemia) Failure to progress Failure to progress Previous C/S w vertical incisionPrevious C/S w vertical incision Placenta previaPlacenta previa AbruptionAbruption Umbilical Cord ProlapseUmbilical Cord Prolapse Macrosomia Macrosomia Breech, Transverse fetal lieBreech, Transverse fetal lie Fetal Distress Fetal Distress

Prenatal TermsPrenatal TermsPerinatologyPerinatology: : high risk conditions of high risk conditions of

pregnant woman/fetus.pregnant woman/fetus.

NeonatologyNeonatology:: dx/tx of neonates. dx/tx of neonates. GestationGestation: weeks : weeks since 1st day of LMP.since 1st day of LMP. AbortionAbortion: < 20 wks. : < 20 wks. Preterm or premature laborPreterm or premature labor: > 20 wks; : > 20 wks;

< 37 wks.< 37 wks. Full-termFull-term: 37-41: 37-41 PostdatesPostdates: > 41 wks. : > 41 wks.

Prenatal Terms cont.Prenatal Terms cont.

AntepartumAntepartum: : between conception & between conception & onset of labor onset of labor

IntrapartumIntrapartum: : onset of true labor until onset of true labor until delivery of infant & placenta.delivery of infant & placenta.

PostpartumPostpartum: : delivery until woman’s delivery until woman’s body returns to pre-pregnant condition [6 body returns to pre-pregnant condition [6 wks.]wks.]

Prenatal Terms – Prenatal Terms – cont.cont.

GravidaGravida: Any pregnancy, regardless of : Any pregnancy, regardless of duration, includes present pregnancy.duration, includes present pregnancy.

ParaPara: birth > 20 weeks: birth > 20 weeks PrimigravidaPrimigravida: pregnant for 1: pregnant for 1stst time. time. PrimiPrimiparapara: birth to one child past age of : birth to one child past age of

viability.viability. MultigravidaMultigravida: 2nd or subsequent : 2nd or subsequent

pregnancy.pregnancy. Multipara (multipMultipara (multip): 2 or more deliveries ): 2 or more deliveries

>20 wks.>20 wks. Nulligravida: never been & currently not Nulligravida: never been & currently not

pregnant.pregnant. NulliparaNullipara: has not had delivery at more : has not had delivery at more

than 20 wks.than 20 wks. StillbornStillborn: fetal demise > 20 wks gestation.: fetal demise > 20 wks gestation.

Client ProfileClient Profile (client hx) (client hx)

1) Maternal age @ 1st prenatal visit.1) Maternal age @ 1st prenatal visit. Current pregnancy [1st , 2nd, 3rd] Current pregnancy [1st , 2nd, 3rd] LMP? cramping?, bleeding ? LMP? cramping?, bleeding ?

Planned?Planned?

2) OB Hx: past pregnancies, 2) OB Hx: past pregnancies, abortions, living children, types of abortions, living children, types of deliveries; complications; birth wts. deliveries; complications; birth wts. Blood type/Rh factor, childbirth Blood type/Rh factor, childbirth education classes.education classes.

Gravida Gravida = total pregnancies [= total pregnancies [include include current pregnancy]current pregnancy]

ParaPara: pregnancies > 20 weeks.: pregnancies > 20 weeks.

TPALTPAL - breakdown of Gravida/Para - breakdown of Gravida/Para

T = term infantsT = term infantsP = preterm infants (> 20 & < 37 P = preterm infants (> 20 & < 37 wks)wks)A = abortion (spontaneous or A = abortion (spontaneous or elective ≤ 20 wks.)elective ≤ 20 wks.)L = living children L = living children

3) Gynecologic Hx: age @ menarche, length of 3) Gynecologic Hx: age @ menarche, length of flow, flow,

length of cycle [# days bet periods] Fibroids? length of cycle [# days bet periods] Fibroids? Infertility? Infertility?

Tubal surgery? Previous C/S? Tubal surgery? Previous C/S?

4) Current medical history4) Current medical history

5) Past medical history5) Past medical history

6) Family medical history: pertinent hx; genetic 6) Family medical history: pertinent hx; genetic diseases?diseases?

7) Partner’s Hx: same7) Partner’s Hx: same

8) Personal: ETOH, tobacco, drugs, depression, 8) Personal: ETOH, tobacco, drugs, depression, anxiety, etc.anxiety, etc.

9) Medications [pt. taking now]9) Medications [pt. taking now]

10) Age10) Age

Multiple gestation Multiple gestation Twins - Twins - same as single fetus; may same as single fetus; may

attempt vaginal del; close attempt vaginal del; close monitoring near term.monitoring near term.

TripletsTriplets – close monitoring; – close monitoring; scheduled C/S.scheduled C/S.

Initial Physical Initial Physical AssessmentAssessment

1st prenatal visit - establish baseline data1st prenatal visit - establish baseline data helps develop health care planning helps develop health care planning

strategies. strategies. Time for Time for health teachinghealth teaching: wt. gain, : wt. gain,

nutrition, exercise, & potentially nutrition, exercise, & potentially detrimental habits: smoking, ETOH, etc. detrimental habits: smoking, ETOH, etc.

Do ROS; health history; & physical Do ROS; health history; & physical exam…exam…

Physical ExamPhysical Exam:: VS, UA/C&S, glucose, protein and weight [q VS, UA/C&S, glucose, protein and weight [q

visit]visit] Pap [1st visit & 28 wks.]Pap [1st visit & 28 wks.] CBC, SMA-7, Blood type/Rh, Coombs, titers, CBC, SMA-7, Blood type/Rh, Coombs, titers,

VDRL, HIV. Herpes simplex I & II, PPD.VDRL, HIV. Herpes simplex I & II, PPD.

+PPD+PPD Do chest x-ray.Do chest x-ray. + chest x-ray, INH [isoniazid] & vit.B6 x 9 + chest x-ray, INH [isoniazid] & vit.B6 x 9

mos. mos. Do F/U x-ray. Do F/U x-ray. Tx active TB right away. May breast feed Tx active TB right away. May breast feed

on TB therapy. Active TB in home, infant on on TB therapy. Active TB in home, infant on INH as prophalactic.INH as prophalactic.

Manual pelvic measurements: taken now Manual pelvic measurements: taken now or later [not done if already had vaginal or later [not done if already had vaginal delivery]delivery]

Skin –rashes, acneSkin –rashes, acne Head & neck – masses Head & neck – masses Vision, dentures, cavities, seizures, Vision, dentures, cavities, seizures,

headachesheadaches Breast exam: SBE [breast CA]Breast exam: SBE [breast CA] HTN, heart disease, blood transfusions.HTN, heart disease, blood transfusions. Gastrointestinal Gastrointestinal RespiratoryRespiratory

Pelvic exam: Pap; inspect for discharge & Pelvic exam: Pap; inspect for discharge & odor [monilia, BV] cx trich, GC, odor [monilia, BV] cx trich, GC, Chlamydia, herpes. Chlamydia, herpes.

Visual inspection of perineum -herpes & Visual inspection of perineum -herpes & condyloma. condyloma.

Cervical abnormality - tx in 2Cervical abnormality - tx in 2ndnd/3rd /3rd trimester.trimester.

Mental status – anxiety, depression, Mental status – anxiety, depression, psych. hxpsych. hx

Support Person: married, separated, FOB Support Person: married, separated, FOB involved? involved?

Ultrasound – viability of fetus; heartbeat? Ultrasound – viability of fetus; heartbeat? Prenatal visits are: q 4 wks. til 28 wks., q Prenatal visits are: q 4 wks. til 28 wks., q

2 wks. til 36, & q week til delivery. More 2 wks. til 36, & q week til delivery. More visits if high risk.visits if high risk.

DONE @ subsequent visits: DONE @ subsequent visits:

Triple screen. F/U with Amnio if +Triple screen. F/U with Amnio if + 50 gm. GCT @ 26-28 wks. [1h glucose].50 gm. GCT @ 26-28 wks. [1h glucose]. When is it done if pt. high risk? What When is it done if pt. high risk? What

makes a pt. high risk?makes a pt. high risk? If + GCT, do GTT.If + GCT, do GTT. RhRh-- moms - get Rhogam moms - get Rhogam

GBSGBS - normal vaginal flora. Can affect - normal vaginal flora. Can affect pregnancy outcomes.pregnancy outcomes.Risks: PT labor, UTI, chorioamnionitis, Risks: PT labor, UTI, chorioamnionitis, PP infections, perinatal PP infections, perinatal mortality/morbidity.mortality/morbidity.Do Do GBS cxGBS cx @ 36 wks. r/o GBS bacteria @ 36 wks. r/o GBS bacteria [vaginal/rectal][vaginal/rectal]+ GBS: tx in labor with multiple doses + GBS: tx in labor with multiple doses of antibiotics 4 hrs. before delivery. If of antibiotics 4 hrs. before delivery. If < 4 hrs, baby has CBC & bl. Cx < 4 hrs, baby has CBC & bl. Cx + Maternal temp, infant goes to + Maternal temp, infant goes to SPC/NICU.SPC/NICU.Untreated GBS: greatest cause of Untreated GBS: greatest cause of neonatal sepsis & meningitis.neonatal sepsis & meningitis.

Abdomen - measured q visit. Abdomen - measured q visit. Fundal height measurements start @ Fundal height measurements start @

10-12 wks. 10-12 wks. 10 – 12 wks: slightly above symphysis 10 – 12 wks: slightly above symphysis

pubispubis 16 wks: ½ bet symphysis & umbilicus16 wks: ½ bet symphysis & umbilicus 20-22 wks: @ umbilicus20-22 wks: @ umbilicus 28 wks: 3 FB above umbilicus28 wks: 3 FB above umbilicus 36 wks: below xiphoid process.36 wks: below xiphoid process. Measured in cm. [tape measure] every Measured in cm. [tape measure] every

visit.visit. Fetal heartbeats (110-160 beats/min.)Fetal heartbeats (110-160 beats/min.) Heard with doppler 10-12 wks.Heard with doppler 10-12 wks.

PRENATAL PERIODPRENATAL PERIOD

A. Signs & Symptoms of PregnancyA. Signs & Symptoms of Pregnancy PresumptivePresumptive- not definitive; other - not definitive; other

reasons for missed period reasons for missed period amenorrhea- missed period; + PT in 1-2 amenorrhea- missed period; + PT in 1-2

wks.wks. N & V [1st trimester]N & V [1st trimester] Urinary frequency d/t growing fetusUrinary frequency d/t growing fetus Tender breasts [1st sign of preg.]Tender breasts [1st sign of preg.] Fatigue [1st trimes]Fatigue [1st trimes] Quickening [ 20 wks.] movement felt by Quickening [ 20 wks.] movement felt by

mom. [gas?]mom. [gas?] Thinning & softening of fingernails [d/t Thinning & softening of fingernails [d/t

hormones]hormones]

Probable - SProbable - Suggests pregnancy. Not uggests pregnancy. Not 100%100%

Uterine enlargementUterine enlargement : growth of : growth of fetus. fetus.

Goodell’s signGoodell’s sign: cervix softens [6-12 : cervix softens [6-12 wks]wks]

Chadwick’s signChadwick’s sign: bluish color cervix, : bluish color cervix, vagina, vulva vagina, vulva [6-12 wks][6-12 wks]

Hegar’s signHegar’s sign: : softening lower uterine softening lower uterine segment [6-12 wks] segment [6-12 wks]

↑ ↑ skin pigmentation [chloasma; “mask of skin pigmentation [chloasma; “mask of pregnancy”] pregnancy”]

linea nigra: dark vertical line center of abd.; linea nigra: dark vertical line center of abd.; nipples, areola;nipples, areola;

striae gravidarum = stretch marksstriae gravidarum = stretch marks

Braxton Hick’sBraxton Hick’s contractions: contractions: periodic uterine tightening periodic uterine tightening

BBallottementallottement: fetus bounces off : fetus bounces off abd. wall with VE abd. wall with VE

PPositive Pregnancy resultsositive Pregnancy results: + : + HCG; urine/blood test; [possible HCG; urine/blood test; [possible ectopic - not viable]ectopic - not viable]

3. Positive 3. Positive [not attributed to other [not attributed to other conditions]conditions]

Fetal heartbeat [heard by examiner]Fetal heartbeat [heard by examiner]

Ultrasound [by 8 wks. complete fetus Ultrasound [by 8 wks. complete fetus seen]seen]

Fetal movement Fetal movement [felt by examiner & mom @ [felt by examiner & mom @ ~ 20 wks.]~ 20 wks.]

B. Physiologic Adaptations to B. Physiologic Adaptations to PregnancyPregnancy

1. Cardiovascular system1. Cardiovascular system Cardiac hypertrophy – heart enlarges ~ 1-2 cm.Cardiac hypertrophy – heart enlarges ~ 1-2 cm. Elevation of heart – assumes more transverse Elevation of heart – assumes more transverse

position in center of chest.position in center of chest. Progressive ↑ bl. vol. –gradual ↑ d/t placenta & fetal Progressive ↑ bl. vol. –gradual ↑ d/t placenta & fetal

circulation & for hemorrhage prevention @ del. – circulation & for hemorrhage prevention @ del. – 40% by 3rd trimes.40% by 3rd trimes.

Varying resting pulse rates - ↑ by 10 bpmVarying resting pulse rates - ↑ by 10 bpm

↑ ↑ femoral venous pressure – pt. supine - femoral venous pressure – pt. supine - wt. of growing uterus slows venous wt. of growing uterus slows venous return to heart from legs; lightheaded; return to heart from legs; lightheaded; ankle/leg edema; hypotension.ankle/leg edema; hypotension.

↑ ↑ fibrinogen levels – 50 % by end of fibrinogen levels – 50 % by end of preg.preg.

↑ ↑ levels of bl. coagulation factors levels of bl. coagulation factors ( vii,ix,x) ( vii,ix,x)

total ↑ RBC – accommodates fetal total ↑ RBC – accommodates fetal circulationcirculation

hematocrit drops [both d/t ↑ bl. vol.]hematocrit drops [both d/t ↑ bl. vol.] hemoglobin drops hemoglobin drops leukocyte prod. -↑ WBC to protect leukocyte prod. -↑ WBC to protect

against infection.against infection.

2. Gastrointestinal system2. Gastrointestinal system Swelling of gums: ^estrogen; ^ Swelling of gums: ^estrogen; ^

vascularity [bleeding of gums]vascularity [bleeding of gums] Lateral/posterior displacement of Lateral/posterior displacement of

intestines intestines Superior/lateral displacement of Superior/lateral displacement of

stomach stomach delayed intestinal motility: ^ delayed intestinal motility: ^

progesterone levels [GI progesterone levels [GI reflux/heartburn]reflux/heartburn]

Hemorrhoids: ^ pressure on rectal Hemorrhoids: ^ pressure on rectal veinsveins

Constipation: ↓ gastric motilityConstipation: ↓ gastric motility

GI cont.GI cont. Displacement of appendix – upward Displacement of appendix – upward

& outward position; appendicitis & outward position; appendicitis common non-obstetrical surgical common non-obstetrical surgical intervention of pregnancy.intervention of pregnancy.

↓ ↓ gallbladder emptying time – re-gallbladder emptying time – re-absorption of bilirubin into maternal absorption of bilirubin into maternal circ. > itchingcirc. > itching

^ gall stones – d/t ^ plasma ^ gall stones – d/t ^ plasma cholesterol levelscholesterol levels

3). Endocrine system3). Endocrine system Basal metabolic rate - ^ by 25% by term.Basal metabolic rate - ^ by 25% by term. Slight hyperplasia of thyroid ^ prod. of Slight hyperplasia of thyroid ^ prod. of

thyroxine causes ^ BMRthyroxine causes ^ BMR pituitary gland stops producing FSH & pituitary gland stops producing FSH &

LHLH posterior pit. produces oxytocin [uterine posterior pit. produces oxytocin [uterine

contx’s]contx’s] Increased prolactin, estrogen, Increased prolactin, estrogen,

progesterone, cortisol, HCS=[hPL] progesterone, cortisol, HCS=[hPL] produced by placenta - support placenta.produced by placenta - support placenta.

Insulin resistance –preg. hormones are Insulin resistance –preg. hormones are antagonistic. Excess glucose from mom antagonistic. Excess glucose from mom goes to fetus. goes to fetus.

Maternal fat stores used for energy for Maternal fat stores used for energy for mother.mother.

4. Respiratory system4. Respiratory system ↑ ↑ vascularization of respiratory tract vascularization of respiratory tract

[nasal stuffiness] - ^ estrogen[nasal stuffiness] - ^ estrogen Lungs pushed upward Lungs pushed upward Upward displacement of diaphragm [rises Upward displacement of diaphragm [rises

~ 4cm]~ 4cm] ↑ ↑ tidal volume [air inhaled & exhaled] tidal volume [air inhaled & exhaled] [ ↑ progesterone & ↑diaphragmatic [ ↑ progesterone & ↑diaphragmatic

excursion] progesterone causes smooth excursion] progesterone causes smooth muscle relaxation & vasodilation.muscle relaxation & vasodilation.

slight ^ RR – 2 breaths/min. slight ^ RR – 2 breaths/min.

5. 5. Metabolic systemMetabolic system

Pregnancy hyper-metabolic state - ^ Pregnancy hyper-metabolic state - ^ calories [300/day]calories [300/day]

Increase in H2O retention, serum Increase in H2O retention, serum lipids, iron, carbs & lipoproteins.lipids, iron, carbs & lipoproteins.

water level ^ 7.5L in average water level ^ 7.5L in average woman.woman.

Recommended Weight Gain: ~ 25-35 lbs. Recommended Weight Gain: ~ 25-35 lbs. (average weight & frame)(average weight & frame)* Each trimester = about 13 weeks so:* Each trimester = about 13 weeks so:1st trimester: 3 lbs. 1st trimester: 3 lbs. 2nd trimester: 12 – 13 lbs.2nd trimester: 12 – 13 lbs.3rd trimester: 12 – 13 lbs.3rd trimester: 12 – 13 lbs.

Weight gain distribution:Weight gain distribution: Fetus: 7.5 lbs.Fetus: 7.5 lbs. Placenta: 1.5 “Placenta: 1.5 “ Amniotic fluid: 2 “Amniotic fluid: 2 “ Uterus: 2.5 “Uterus: 2.5 “ Breasts: 3 lbs. [total]Breasts: 3 lbs. [total] Bl. Volume: 2-4 lbs.Bl. Volume: 2-4 lbs. Extravascular fluid/fat : 4-9 lbs. Extravascular fluid/fat : 4-9 lbs.

6. Integumentary system 6. Integumentary system

Pigmentary changes: ^ melanocytes, Pigmentary changes: ^ melanocytes, estrogen & progesteroneestrogen & progesterone

Hyperactive sebaceous/sweat glands [^ Hyperactive sebaceous/sweat glands [^ perspiration]perspiration]

Darkening of nipples, areola, cervix, vagina, Darkening of nipples, areola, cervix, vagina, & &

vulva vulva [8[8thth wk] wk]

Chloasma = melasma = mask of preg.Chloasma = melasma = mask of preg.

Linea nigra – vertical line along center of Linea nigra – vertical line along center of abd. abd.

7. 7. Genitourinary systemGenitourinary system

* Kidneys enlarge - meet demands of * Kidneys enlarge - meet demands of excretion excretion [mom/fetus][mom/fetus]

* Dilation of ureters/renal pelvis (kidneys)^ * Dilation of ureters/renal pelvis (kidneys)^ 25%; ^ estrogen25%; ^ estrogen

* ^ GFR (50%) d/t demands ^ * ^ GFR (50%) d/t demands ^ circulation/excretioncirculation/excretion

* ^ clearance of urea & creatinine so: ↓ BUN * ^ clearance of urea & creatinine so: ↓ BUN & creatinine & creatinine

* Glucosuria: ^ GFR, filtration of glucose ^.* Glucosuria: ^ GFR, filtration of glucose ^.* Glucose & protein can’t be reabsorbed fast * Glucose & protein can’t be reabsorbed fast

enough so some spills. + Protein more enough so some spills. + Protein more significant than glucose.significant than glucose.

* ↓ bladder tone [d/t progesterone] ^ urine * ↓ bladder tone [d/t progesterone] ^ urine * Na retention [maintains osmolarity d/t ^ * Na retention [maintains osmolarity d/t ^

fluid - K not retained]fluid - K not retained]

Genitourinary cont:Genitourinary cont:

i. ^ dimensions of uterus: i. ^ dimensions of uterus: Pre-pregnant Pre-pregnant PregnantPregnant 65 g. 1,200 g. (wt.)65 g. 1,200 g. (wt.)1.5 ml. 5,000 ml. (vol.)1.5 ml. 5,000 ml. (vol.)

j. ^ vascularity of cervical glands [to j. ^ vascularity of cervical glands [to prepare for labor]prepare for labor]

k. ^ vaginal secretions [leukorrhea] k. ^ vaginal secretions [leukorrhea] [Candida][Candida]

l. cessation of ovulation [pituitary] FSH & l. cessation of ovulation [pituitary] FSH & LH stopsLH stops

m. vagina thickens d/t ^ fat deposits & ^ m. vagina thickens d/t ^ fat deposits & ^ vascularityvascularity

C. Psychological AdaptationsC. Psychological Adaptations

Ambivalence – adjustment period; occurs Ambivalence – adjustment period; occurs even if plannedeven if planned; 20 wks aka ; 20 wks aka “quickening”. “quickening”.

Acceptance – dreaming about parenting Acceptance – dreaming about parenting role; man feels preg. symptoms role; man feels preg. symptoms -“couvade” syndrome.-“couvade” syndrome.

Introversion- concentrates on body Introversion- concentrates on body changes Extroversion – happy; everyone changes Extroversion – happy; everyone is paying attention is paying attention

Emotional lability – hormones changing; Emotional lability – hormones changing; crying then happy. Mood swings - crying then happy. Mood swings - normal.normal.

E. Gestational Age E. Gestational Age Assessment/Estimated date of Assessment/Estimated date of Confinement (EDD or EDC)Confinement (EDD or EDC)

Nagel’s Rule: 1st day of LMP, count back 3 Nagel’s Rule: 1st day of LMP, count back 3 mos, +7 days. Oct. 5 - 3mos. + 7 = July 12 mos, +7 days. Oct. 5 - 3mos. + 7 = July 12 = EDC.= EDC.

1st Trimester Measurement1st Trimester Measurement:: Crown to Crown to rump: most reliable. CRrump: most reliable. CR

22ndnd/3rd Trimester Measurements/3rd Trimester Measurements: : Fetal Biparietal diameter [side to side – Fetal Biparietal diameter [side to side –

most important]most important] Fetal Head Circumference, fetal abdominal Fetal Head Circumference, fetal abdominal

Circumference, Fetal Femur Length.Circumference, Fetal Femur Length.

Fundal height: in cm. with tape Fundal height: in cm. with tape measure measure

More Precise Method:More Precise Method: McDonald’s Method - determines McDonald’s Method - determines

duration of preg. in lunar months or duration of preg. in lunar months or weeks. weeks.

Fundus [cm] x 2/7 = lunar months.Fundus [cm] x 2/7 = lunar months. Fundus [cm] x 8/7 = weeks. *More Fundus [cm] x 8/7 = weeks. *More

common common

Ex. 12 cm x 8/7 = 96/7 = 13 wks. & 5 Ex. 12 cm x 8/7 = 96/7 = 13 wks. & 5 daysdays

Stated: 13 & 5/7 wks. Stated: 13 & 5/7 wks.

Counseling on: Counseling on: Childbirth education [Lamaze]Childbirth education [Lamaze] Dental care Dental care Immunizations [up to date]Immunizations [up to date] Clothing [loose fitting]Clothing [loose fitting] Substance use Substance use Alcohol abuse in pregnancy leading Alcohol abuse in pregnancy leading

cause of mental retardation in US. cause of mental retardation in US. Related to ^ developmental problems Related to ^ developmental problems & fetal growth restriction.& fetal growth restriction.

Medications: OTC [caution; get MD Medications: OTC [caution; get MD advice 1advice 1stst] ]

Physical AbusePhysical Abuse – Domestic Violence – Domestic Violence ^ stress in couples with poor coping ^ stress in couples with poor coping skills; woman more vulnerable; skills; woman more vulnerable; male ^ male ^ control. control.

Assess for abuse @ every visit.Assess for abuse @ every visit. Refer client to local/national abuse Refer client to local/national abuse

hotlineshotlines sex OK if not hi risk - PT labor, sex OK if not hi risk - PT labor,

bleeding, etc.bleeding, etc. Physical Activity [notify MD - Physical Activity [notify MD -

contx/bleeding]contx/bleeding] Travel- frequent BR/walking stops.Travel- frequent BR/walking stops. Safety helmets, seatbelts, smoke Safety helmets, seatbelts, smoke

alarms, sunscreen. alarms, sunscreen.