Anatomy and Physiology of Pregnancy Lectures 1 N. Petrenko, MD, PhD AND-2 Nursing Care of Childbearing Family

Anatomy and Physiology Anatomy and Physiology of Pregnancyof Pregnancy

Lectures Lectures 11

N. Petrenko, MD, PhDN. Petrenko, MD, PhD

AND-2AND-2

Nursing Care of Childbearing FamilyNursing Care of Childbearing Family

The Start of It AllThe Start of It All

In either case, the process will In either case, the process will inevitably involve a sperm and an inevitably involve a sperm and an

eggegg

Or….for those women who get tired Or….for those women who get tired of waiting for the “right man”of waiting for the “right man”

Pregnancy is a Pregnancy is a normal physiologic normal physiologic

process . . . process . . . . . . not a disease!. . . not a disease!

Signs of pregnancySigns of pregnancy

Presumptive (generally subjective)Presumptive (generally subjective) Probable (objective)Probable (objective) Positive (diagnostic)Positive (diagnostic)

Presumptive symptoms of Presumptive symptoms of pregnancy pregnancy ((felt by womanfelt by woman):):Cessation of mensesCessation of menses

Nausea with or without vomitingNausea with or without vomiting““Morning sickness”Morning sickness”Frequent urinationFrequent urinationFatigueFatigueBreast tenderness, fullness, tinglingBreast tenderness, fullness, tinglingMaternal perception of fetal Maternal perception of fetal

movement (“Quickening”) 18-20w, movement (“Quickening”) 18-20w, 16 w16 w

Probable signs of pregnancy Probable signs of pregnancy ((observedobserved by examinerby examiner):):

Changes in the size, shape, and Changes in the size, shape, and consistency of the uterus (Hegar sign-consistency of the uterus (Hegar sign-softening of the cervix softening of the cervix ))

Enlargement of the abdomen Enlargement of the abdomen Changes in the cervix (Goodell sign-Changes in the cervix (Goodell sign-

softening of the cervix softening of the cervix ))

Probable signs of pregnancy Probable signs of pregnancy ((observedobserved by examinerby examiner):):

Bluish or purplish coloration of the Bluish or purplish coloration of the vaginal mucosa and cervix vaginal mucosa and cervix (Chadwick’s sign-(Chadwick’s sign-a dark blue to a dark blue to purplish-red congested appearance of purplish-red congested appearance of the vaginal mucosa the vaginal mucosa ))

Palpation of Braxton-Hicks Palpation of Braxton-Hicks contractionscontractions

Outlining the fetus manuallyOutlining the fetus manuallyEndocrine tests of pregnancyEndocrine tests of pregnancy

Positive signs of pregnancyPositive signs of pregnancy((noted by examiner, confirm pregnancynoted by examiner, confirm pregnancy))

Identification of the fetal heart beat Identification of the fetal heart beat separately and distinctly from that separately and distinctly from that of the mother (10-12 w)of the mother (10-12 w)

Perception of fetal movements by Perception of fetal movements by the examiner (18-20 w)the examiner (18-20 w)

Visualization of pregnancy on Visualization of pregnancy on ultrasoundultrasound

Fetal recognition on X-rayFetal recognition on X-ray

Presumptive signs of Presumptive signs of pregnancy pregnancy

Increased skin pigmentation – Increased skin pigmentation – chloasma, linea nigrachloasma, linea nigra

Appearance of striae on abdomen Appearance of striae on abdomen and breastsand breasts

Adaptation to pregnancyAdaptation to pregnancy

Reproductive system & Reproductive system & BreastBreast

Uterus: increase size, shape and Uterus: increase size, shape and position, softness of cervix, position, softness of cervix, discoloration of cervical mucosa, discoloration of cervical mucosa, leukorrhea)leukorrhea)

Breast: tenderness, fullness, tingling Breast: tenderness, fullness, tingling enlargement, nipple and areola enlargement, nipple and areola hyperpigmentation, Montgomery’s hyperpigmentation, Montgomery’s tubercles, colostrum (16 w)tubercles, colostrum (16 w)

CardiovascularCardiovascular System System Stroke Volume: Stroke Volume: 50% 50% Cardiac Output: Cardiac Output: 30-50% (6.2 30-50% (6.2±1.0 L/min)±1.0 L/min)

Nonpregnant is 4.3Nonpregnant is 4.30.9 L/min0.9 L/min Elevated upward and rotated forward to the Elevated upward and rotated forward to the

leftleft More auddible splitting of S1,S2,S3 after More auddible splitting of S1,S2,S3 after

20w20w Heart Rate: Heart Rate: 15% ( 15% ( 10-20 bpm) (14-20 w) 10-20 bpm) (14-20 w) Sinus arrhytmia, premature atrial Sinus arrhytmia, premature atrial

contraction, premature ventricular systolecontraction, premature ventricular systole

CardiovascularCardiovascular System System

Blood Pressure: Blood Pressure: I trim: same as prepregnancyI trim: same as prepregnancy II trim till 20 w: II trim till 20 w: 3-5 mmHg systolic and 5-10 3-5 mmHg systolic and 5-10

mmHg diastolic mmHg diastolic III trim: returns to the patient’s prepregnant III trim: returns to the patient’s prepregnant

level level Supine hypotensionSupine hypotension

Hematologic ChangesHematologic Changes

Blood Volume: Blood Volume: 45% ( 45% ( 1450-1750 ml) 1450-1750 ml) Protects the mother from devastating Protects the mother from devastating

hemorrhage at deliveryhemorrhage at delivery Plasma Volume: Plasma Volume: 45-50% ( 45-50% ( 1200-1300 ml) 1200-1300 ml)

Serves to dissipate fetal heat productionServes to dissipate fetal heat production Red Cell Mass: Red Cell Mass: 18-30% ( 18-30% ( 250-450 ml) 250-450 ml)

Necessary to Necessary to O O22 transport to meet fetal needs transport to meet fetal needs

Based on the above, pregnancy normally Based on the above, pregnancy normally results in a “physiologic anemia”results in a “physiologic anemia” Hgb: 10-12 g/dL (nonpregnant = 12-15 g/dL)Hgb: 10-12 g/dL (nonpregnant = 12-15 g/dL) Hct: 32-40% (nonpregnant = 35-47%)Hct: 32-40% (nonpregnant = 35-47%)


WBC: WBC: 11stst Trimester: 3,000-15,000/mm Trimester: 3,000-15,000/mm33

(mean 9500/ mm(mean 9500/ mm33))22ndnd & 3 & 3rdrd Trimesters: 6,000-16,000/mm Trimesters: 6,000-16,000/mm33

(mean 10,500/ mm(mean 10,500/ mm33))Labor: 20,000-30,000/mmLabor: 20,000-30,000/mm33


Fibrin: Fibrin: 40% at term 40% at term Plasma Fibrinogen (Factor I): Plasma Fibrinogen (Factor I): 50% 50% Clotting time: UnchangedClotting time: Unchanged Coagulation Factors V, VII, VIII, IX, X, XII all Coagulation Factors V, VII, VIII, IX, X, XII all Coagulation Factors XI, XIII both Coagulation Factors XI, XIII both slightly slightly Prothrombin time: Unchanged or Prothrombin time: Unchanged or slightly slightly Platelets: Unchanged Platelets: Unchanged Fibrinolitic activity ↓Fibrinolitic activity ↓

Respiratory System Respiratory System Respiratory rate unchanged or sligly Respiratory rate unchanged or sligly

increaseincrease Tidal volume Tidal volume ↑ 30-40%↑ 30-40% Vital capacity Vital capacity unchanged unchanged Inspiratory capacity Inspiratory capacity ↑↑ Exspiratory capacity Exspiratory capacity ↓↓ Total lung capacity unchanged or sligly Total lung capacity unchanged or sligly

decreasedecrease Oxygen consumption Oxygen consumption ↑15-25 %↑15-25 %

Respiratory Changes During PregnancyRespiratory Changes During PregnancypH: slight pH: slight to 7.40-7.45 to 7.40-7.45

Remains roughly at nonpregnant level Remains roughly at nonpregnant level because the because the PaCO PaCO22 is compensated is compensated for by for by renal excretion of bicarbonate renal excretion of bicarbonate (HCO(HCO33))

Serum HCOSerum HCO33: : (18-31 mEq/L) (18-31 mEq/L)

Renal SystemRenal System

Kidneys enlarge with a length Kidneys enlarge with a length of ~1 cm as of ~1 cm as measured by intravenous pyelographymeasured by intravenous pyelography

Renal pelves & urether dilateRenal pelves & urether dilate Renal Plasma Blood FlowRenal Plasma Blood Flow

30-50% by the end of the first trimester30-50% by the end of the first trimester GFRGFR

30-50% by the end of the first trimester30-50% by the end of the first trimester The The in Renal Plasma Flow and GFR are in Renal Plasma Flow and GFR are

responsible for decreases in the following:responsible for decreases in the following: Uric acid (serum) 4.5 mg/dLUric acid (serum) 4.5 mg/dL BUN (serum) 12 mg/dLBUN (serum) 12 mg/dL Creatinine (serum) 0.5-0.6 mg/dLCreatinine (serum) 0.5-0.6 mg/dL

Creatinine Clearance 150-200 mL/min Creatinine Clearance 150-200 mL/min

GI SystemGI System AppetiteAppetite

I trim I trim II trim II trim because because metabolic needs metabolic needs Pica (Nonfood craving)Pica (Nonfood craving)

Mouth Mouth Gums hyperemic, spongy, swollen, bleeding, nonspecific Gums hyperemic, spongy, swollen, bleeding, nonspecific

gingivitis, ptyalismgingivitis, ptyalism Esophagus, Stomac, intestinesEsophagus, Stomac, intestines

Hiatal hernia (7-8 month)Hiatal hernia (7-8 month) Gastric emptying become slowerGastric emptying become slower hypochloric acidhypochloric acid Acid indigestion or hearburn (pyrosis)Acid indigestion or hearburn (pyrosis)

ConstipationConstipation HemorrhoidsHemorrhoids

GI SystemGI System Gallbladder Gallbladder

decreased tonedecreased tone development of stonesdevelopment of stones

Liver Liver intrahepatic holestasisintrahepatic holestasis Pruritus gravidarum (severe itching) with or Pruritus gravidarum (severe itching) with or

without jandicewithout jandice Abdominal discomfortAbdominal discomfort

Pelvic heavinessPelvic heaviness Displacement of appendixDisplacement of appendix

Integumentary SystemIntegumentary System

Darcening of nipples, areola, axillae, vulvaDarcening of nipples, areola, axillae, vulva Facial melasma=chloasmaFacial melasma=chloasma Linea NigraLinea Nigra Striae gravidarumStriae gravidarum Palmar erythema (Caucasian, African-American)Palmar erythema (Caucasian, African-American)

Musculoskeletal SystemMusculoskeletal System

Change in postureChange in postureWaddling walkWaddling walkBack PainBack PainSlight relaxation and increased Slight relaxation and increased

mobility of the pelvic joints mobility of the pelvic joints Diastasis recti abdominisDiastasis recti abdominis

Neurological ChangesNeurological Changes Compression of pelvic nerves or vascular stasis caused by Compression of pelvic nerves or vascular stasis caused by

enlargement of the uterus may result in sensory changes in the enlargement of the uterus may result in sensory changes in the legs.legs.

Dorsolumbar lordosis may cause pain because of traction on Dorsolumbar lordosis may cause pain because of traction on nerves or compression of nerve roots.nerves or compression of nerve roots.

Edema involving the peripheral nerves may result in Edema involving the peripheral nerves may result in carpal carpal tunnel syndrome tunnel syndrome during the last trimester. The syndrome is during the last trimester. The syndrome is characterized by paresthesia (abnormal sensation such as burning characterized by paresthesia (abnormal sensation such as burning or tingling) and pain in the hand, radiating to the elbow. The or tingling) and pain in the hand, radiating to the elbow. The sensations are caused by edema that compresses the median sensations are caused by edema that compresses the median nerve beneath the carpal ligament of the wrist. nerve beneath the carpal ligament of the wrist.

Acroesthesia (numbness and tingling of the hands) is caused by Acroesthesia (numbness and tingling of the hands) is caused by the stoop-shouldered stance.the stoop-shouldered stance.

Tension headache is common when anxiety or uncertainty Tension headache is common when anxiety or uncertainty complicates pregnancy. However, vision problems, sinusitis, or complicates pregnancy. However, vision problems, sinusitis, or migraine may also be responsible for headaches.migraine may also be responsible for headaches.

Light-headedness, faintness, and even syncope (fainting) are Light-headedness, faintness, and even syncope (fainting) are common during early pregnancy. Vasomotor instability, postural common during early pregnancy. Vasomotor instability, postural hypotension, or hypoglycemia may be responsible.hypotension, or hypoglycemia may be responsible.

• • Hypocalcemia may cause neuromuscular problems such as Hypocalcemia may cause neuromuscular problems such as muscle cramps or tetany.muscle cramps or tetany.

Endocrine SystemEndocrine System Pituitary and placental hormones. Pituitary and placental hormones.

estrogen and progesteroneestrogen and progesterone suppress secretion of FSH & LHsuppress secretion of FSH & LH amenorrhea After implantation, the fertilized ovum and the chorionic villi produce hCG, which amenorrhea After implantation, the fertilized ovum and the chorionic villi produce hCG, which

maintains the corpus luteum's production of estrogen and progesterone until the placenta maintains the corpus luteum's production of estrogen and progesterone until the placenta takes over their production (Creasy & Resnik, 1999).takes over their production (Creasy & Resnik, 1999).

Progesterone & EstrogenProgesterone & Estrogen maintaining pregnancy (relaxing smooth muscles, decrease uterine contractility) maintaining pregnancy (relaxing smooth muscles, decrease uterine contractility) Deposition of the fat in subcutaneous tissues over the maternal abdomen, back, and upper Deposition of the fat in subcutaneous tissues over the maternal abdomen, back, and upper

thighs. thighs. promote the enlargement of the genitals, uterus, and breasts and increases vascularity, promote the enlargement of the genitals, uterus, and breasts and increases vascularity,

causing vasodilation.causing vasodilation. relaxation of pelvic ligaments and joints.relaxation of pelvic ligaments and joints. decrease secretion of hydrochloric acid and pepsin, which may be responsible for digestive decrease secretion of hydrochloric acid and pepsin, which may be responsible for digestive

upsets such as nausea.upsets such as nausea. Prolactin Prolactin

Initiation of lactation; however, the high levels of estrogen and progesterone inhibit lactation Initiation of lactation; however, the high levels of estrogen and progesterone inhibit lactation by blocking the binding of prolactin to breast tissue until after birth.by blocking the binding of prolactin to breast tissue until after birth.

Oxytocin Oxytocin as the fetus matures as the fetus matures stimulate uterine contractions during pregnancy, but high levels of progesterone prevent stimulate uterine contractions during pregnancy, but high levels of progesterone prevent

contractions until near termcontractions until near term stimulates the let-down or milk-ejection reflex after birth in response to the infant sucking at stimulates the let-down or milk-ejection reflex after birth in response to the infant sucking at

the mother's breast.the mother's breast. Human chorionic somatomammotropin (hCS) = human placental lactogen (hPL)Human chorionic somatomammotropin (hCS) = human placental lactogen (hPL)

acts as a growth hormone, and contributes to breast development.acts as a growth hormone, and contributes to breast development.

Endocrine SystemEndocrine System Thyroid gland.Thyroid gland.

gland activity and hormone production. gland activity and hormone production. moderate enlargement of the thyroid gland caused by hyperplasia of the moderate enlargement of the thyroid gland caused by hyperplasia of the

glandular tissue and increased vascularity glandular tissue and increased vascularity Thyroxine-binding globulin increases as a result of increased estrogen levels (20 Thyroxine-binding globulin increases as a result of increased estrogen levels (20

weeks).weeks). Total (free and bound) thyroxine (T4) Total (free and bound) thyroxine (T4) between 6 and 9 weeks of gestation and between 6 and 9 weeks of gestation and

plateaus at 18 weeks of gestation. Free T4 and free triiodothyronine (T3) return plateaus at 18 weeks of gestation. Free T4 and free triiodothyronine (T3) return to nonpregnant levels after the first trimester. Despite these changes in hormone to nonpregnant levels after the first trimester. Despite these changes in hormone production, the pregnant woman usually does not develop hyperthyroidism .production, the pregnant woman usually does not develop hyperthyroidism .

Parathyroid gland.Parathyroid gland. slight hyperparathyroidism, a reflection of increased fetal requirements for slight hyperparathyroidism, a reflection of increased fetal requirements for

calcium and vitamin D. The peak level of parathyroid hormone occurs between calcium and vitamin D. The peak level of parathyroid hormone occurs between 15 and 35 weeks of gestation when the needs for growth of the fetal skeleton are 15 and 35 weeks of gestation when the needs for growth of the fetal skeleton are greatest. Levels return to normal after birth.greatest. Levels return to normal after birth.

Pancreas. Pancreas. Maternal insulin does not cross the placenta to the fetus. As a result, in early Maternal insulin does not cross the placenta to the fetus. As a result, in early

pregnancy, the pancreas decreases its production of insulin. pregnancy, the pancreas decreases its production of insulin. Placental hormones (hCS, estrogen, and progesterone). Placental hormones (hCS, estrogen, and progesterone). Adrenal glands. Adrenal glands.

aldosterone aldosterone , resulting in reabsorption of excess sodium from the renal tubules. , resulting in reabsorption of excess sodium from the renal tubules. Cortisol Cortisol

Gravida and ParaGravida and Para

GravidaGravida means a woman who has been, means a woman who has been, or currently is, pregnantor currently is, pregnant

ParaPara means a woman who has given birth means a woman who has given birth

Nulligravida – Nulligravida – never been pregnantnever been pregnant PrimigravidaPrimigravida – pregnant for the first time – pregnant for the first time Primipara – Primipara – has delivered oncehas delivered once Multipara –Multipara – has delivered more than once has delivered more than once

G T P A LG T P A L

G – GRAVIDA (how many pregnancies)G – GRAVIDA (how many pregnancies)T – TERM (how many term deliveries)T – TERM (how many term deliveries)P – PRETERM (how many preterm P – PRETERM (how many preterm

deliveries)deliveries)A – ABORTIONS (how many abortions, A – ABORTIONS (how many abortions,

spontaneous or induced)spontaneous or induced)L – LIVING – how many children L – LIVING – how many children

currently currently livingliving

Term, Preterm, AbortionTerm, Preterm, Abortion

TERM means delivery occurring in TERM means delivery occurring in weeks 38-42weeks 38-42

PRETERM means delivery occurring PRETERM means delivery occurring in weeks 20-37in weeks 20-37

ABORTION means delivery occurring ABORTION means delivery occurring before 20 weeksbefore 20 weeks

POSTTERM means delivery occurring POSTTERM means delivery occurring after week 42after week 42

Duration 280 days =40 weeks= 10 Duration 280 days =40 weeks= 10 lunar months = 9 calendar monthlunar months = 9 calendar month

1st Trimester 1-13 weeks1st Trimester 1-13 weeksAccepting reality of pregnancyAccepting reality of pregnancy

2nd Trimester 14-26 weeks2nd Trimester 14-26 weeksResolving feelings about her own mother; Resolving feelings about her own mother;

defining herself as a motherdefining herself as a mother

3rd Trimester 27-40 weeks3rd Trimester 27-40 weeksActive preparation for childbirth and babyActive preparation for childbirth and baby

Assessment of Gestational Assessment of Gestational AgeAge

By LMPBy LMP

By physical examBy physical exam

By ultrasoundBy ultrasound

Nagele’s RuleNagele’s Rule

Subtract 3 months from that date then Subtract 3 months from that date then add 7 daysadd 7 days

1st day of LNMP (last normal menstrual 1st day of LNMP (last normal menstrual period) period)

ExampleExample: : LNMP: September 10, 2006LNMP: September 10, 2006

Expected Due Date (EDD): June 17, 2007Expected Due Date (EDD): June 17, 2007

Uterine SizingUterine Sizing6 weeks – globular with softening of 6 weeks – globular with softening of

the isthmus, size of a tangerinethe isthmus, size of a tangerine

8 weeks – globular, size of a baseball8 weeks – globular, size of a baseball

10 weeks – globular with irregularity 10 weeks – globular with irregularity around one cornua (Piskacek’s sign), around one cornua (Piskacek’s sign), size of a softballsize of a softball

12 weeks – globular, size of a 12 weeks – globular, size of a grapefruitgrapefruit

Uterine SizingUterine SizingUterine enlargement 12 weeks – At Symphysis 16 weeks – Midway between

symphysis and umbilicus 20 weeks – At the umbilicus 36 weeks - Near xyphoid process

Uterine SizingUterine Sizing

Accuracy of Dating by Accuracy of Dating by UltrasoundUltrasound

Gestational Gestational Age weeks)Age weeks)

Ultrasound Ultrasound MeasurementsMeasurements

Range of Range of AccuracyAccuracy

< 8< 8 Sac sizeSac size ++ 10 days 10 days

8-128-12 CRLCRL ++ 7 days 7 days

12-1512-15 CRL, BPDCRL, BPD ++ 14 days 14 days

15-2015-20 BPD, HC, FL, ACBPD, HC, FL, AC ++ 10 days 10 days

20-2820-28 BPD, HC, FL, ACBPD, HC, FL, AC ++ 2 weeks 2 weeks

> 28> 28 BPD, HC, FL, ACBPD, HC, FL, AC ++ 3 weeks 3 weeks

Review of Systems – 1Review of Systems – 1stst TrimesterTrimester

NauseaNausea VomitingVomiting HeadachesHeadaches DizzinessDizziness CrampingCramping Urinary frequencyUrinary frequency

Pain with urinationPain with urination Changes in Changes in

discharge (amount, discharge (amount, color, odor)color, odor)

PruritisPruritis BleedingBleeding

Review of System – 2Review of System – 2ndnd TrimesterTrimester

Gums bleedingGums bleeding Nose bleedingNose bleeding ConstipationConstipation Fetal movementFetal movement

CrampingCramping BleedingBleeding DysuriaDysuria Abnormal Abnormal

dischargedischarge pruritispruritis

Review of Systems – 3rd Review of Systems – 3rd TrimesterTrimester

IndigestionIndigestion SwellingSwelling Leg crampsLeg cramps Fetal movementFetal movement Difficulty sleepingDifficulty sleeping

ContractionsContractions BleedingBleeding Calf painCalf pain HeadachesHeadaches Epigastric painEpigastric pain Visual changesVisual changes

History - MenstrualHistory - Menstrual

MenarcheMenarcheIntervalIntervalLengthLengthRecent birth Recent birth

control or control or lactation lactation

LMPLMPSure of date?Sure of date?Normal in length Normal in length

& flow& flowOther helpful Other helpful

tidbitstidbitsDate of Date of

conceptionconceptionER sonogramER sonogram

Obstetric HistoryObstetric History

Dates of all pregnancies (include Dates of all pregnancies (include previous miscarriage or termination)previous miscarriage or termination)

GAGAGender, weightGender, weightLength of laborLength of laborCoping techniquesCoping techniquesRoute of deliveryRoute of deliverySpecial events AP, IP, PP, NeoSpecial events AP, IP, PP, Neo

Gynecologic HistoryGynecologic History

Last PapLast PapAbnormal papAbnormal papGyn surgery or problems (e.g. Gyn surgery or problems (e.g.

infertility)infertility)Family planning methodsFamily planning methodsSexually transmitted infectionsSexually transmitted infections

Medical/Surgical HistoryMedical/Surgical History

Serious illnessesSerious illnessesHospitalizationsHospitalizationsSurgerySurgeryDrug allergies or unusual reactionsDrug allergies or unusual reactionsMeds since LMPMeds since LMP

Family HistoryFamily History

MaternalMaternal DiabetesDiabetes CADCAD Pre-eclampsiaPre-eclampsia Preterm deliveryPreterm delivery Cancers (breast, Cancers (breast,

ovarian, colon)ovarian, colon) Depression, Depression,

bipolaritybipolarity TwinsTwins Anesthesia reactionsAnesthesia reactions

Maternal or Maternal or PaternalPaternal Birth defectsBirth defects Mental retardationMental retardation Bleeding disordersBleeding disorders Chromosomal Chromosomal

abnormalities (e.g. abnormalities (e.g. Dpwn Syndrome)Dpwn Syndrome)

Vital SignsVital Signs

TemperatureTemperature Blood Blood

pressurepressure RespirationsRespirations Radial pulseRadial pulse

Elevated BP suggests the presence of pre-Elevated BP suggests the presence of pre-eclampsia. eclampsia.

Elevated BP may be defined as a Elevated BP may be defined as a persistently greater than 140 systolic or persistently greater than 140 systolic or 90 diastolic. Usually, if one is elevated, 90 diastolic. Usually, if one is elevated, both are elevated. both are elevated.

Elevated temperature suggests the Elevated temperature suggests the possible presence of infection. possible presence of infection.

Many pregnant women normally have oral Many pregnant women normally have oral temperatures of as much as 99+. These temperatures of as much as 99+. These mild elevations can also be an early sign mild elevations can also be an early sign of infection. of infection.

While a pregnant pulse of up to 100 BPM While a pregnant pulse of up to 100 BPM or greater may be normal, rapid pulse or greater may be normal, rapid pulse may also indicate hypovolemia. may also indicate hypovolemia.

Additional MeasurementsAdditional Measurements

HeightHeightWeightWeightBMI (BMI (Body mass index Body mass index ))

BMI Categories: BMI Categories: Underweight = <18.5 Underweight = <18.5 Normal weight = 18.5-24.9 Normal weight = 18.5-24.9 Overweight = 25-29.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater Obesity = BMI of 30 or greater

The First Prenatal Visit: The First Prenatal Visit: HistoryHistory

Past medical historyPast medical historyFamily medical historyFamily medical historyGynecologic historyGynecologic historyPast OB historyPast OB historyExposures to infections, teratogens, Exposures to infections, teratogens,

genetic problemsgenetic problemsSocial historySocial historyNutritional statusNutritional status

The First Prenatal Visit: ExamThe First Prenatal Visit: Exam

HEENTHEENT Fundoscopic examFundoscopic exam TeethTeeth ThyroidThyroid BreastsBreasts LungsLungs HeartHeart AbdomenAbdomen ExtremitiesExtremities

SkinSkin Lymph nodesLymph nodes

The First Prenatal Visit: Pelvic The First Prenatal Visit: Pelvic ExamExam

VulvaVulva VaginaVagina CervixCervix Uterine sizeUterine size AdnexaeAdnexae RectumRectum

Labs:Labs: PapPap GC & chlamydiaGC & chlamydia

Clinical pelvimetry:Clinical pelvimetry: Diagonal conjugateDiagonal conjugate Ischial spinesIschial spines SacrumSacrum Subpubic archSubpubic arch Gynecoid pelvic Gynecoid pelvic

type?type?

Bones and Joints of the Bones and Joints of the PelvisPelvis

The Diagonal ConjugateThe Diagonal Conjugate The The obstetric conjugate obstetric conjugate

extends from the middle of extends from the middle of the sacral promontory to the the sacral promontory to the posterior superior margin of posterior superior margin of the pubic symphysis. This is the pubic symphysis. This is the most important the most important diameter of the pelvic inlet.diameter of the pelvic inlet.

The The diagonal conjugatediagonal conjugate extends from the subpubic extends from the subpubic angle to the middle of the angle to the middle of the sacral promontory and can sacral promontory and can be measured clinically to be measured clinically to estimate the obstetric estimate the obstetric conjugate.conjugate.

The Ischial SpinesThe Ischial Spines The transverse The transverse

diameter, between diameter, between the ischial spines, the ischial spines, is a measurement is a measurement of the dimensions of the dimensions of the pelvic cavity of the pelvic cavity

The Pelvic OutletThe Pelvic Outlet Subpubic archSubpubic arch

Bituberous Bituberous (transverse) (transverse) diameterdiameter

Inferior pubic rami Inferior pubic rami

The First Prenatal Visit: LabsThe First Prenatal Visit: LabsABO blood typeABO blood typeD (Rh) typeD (Rh) typeAntibody screenAntibody screenCBCCBCRubellaRubellaVDRL or RPRVDRL or RPRHBsAgHBsAgHIV (optional)HIV (optional)Hemoglobin electrophoresis (as Hemoglobin electrophoresis (as

appropriate)appropriate)

The First Prenatal Visit: The First Prenatal Visit: CounselingCounseling

What to expect What to expect during the course during the course of prenatal careof prenatal care

Risk factors Risk factors encounteredencountered

NutritionNutrition ExerciseExercise WorkWork Sexual activitySexual activity

Travel, seat beltsTravel, seat belts Smoking cessationSmoking cessation Avoidance of drugs Avoidance of drugs

and alcoholand alcohol Warning signsWarning signs Where to go or call Where to go or call

in case of problemsin case of problems

Prenatal vitaminsPrenatal vitamins

The Return Prenatal VisitThe Return Prenatal Visit

REVIEW THE CHART!REVIEW THE CHART!Calculate the EGACalculate the EGACheck the labsCheck the labsReview weight gainReview weight gainReview blood pressureReview blood pressureReview results of UAReview results of UA

Leopold's ManeuversLeopold's Maneuvers - - are used to determine are used to determine the orientation of the fetus through the orientation of the fetus through

abdominal palpation.abdominal palpation. 1. Using two 1. Using two

hands and hands and compressincompressing the g the maternal maternal abdomen, a abdomen, a sense of sense of fetal fetal direction is direction is obtained obtained (vertical or (vertical or transverse).transverse).

..

2. The sides of the uterus are palpated to 2. The sides of the uterus are palpated to determine the position of the fetal back and small determine the position of the fetal back and small

parts.parts.

3. The presenting part (head or butt) is palpated 3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement above the symphysis and degree of engagement

determineddetermined

4. The fetal occipital prominence 4. The fetal occipital prominence is determined.is determined.

Measuring Fundal HeightMeasuring Fundal Height

Auscultating Fetal Heart Auscultating Fetal Heart TonesTones

The Routine OB Visit The Routine OB Visit ScheduleSchedule

Every 4 weeks until 28 weeksEvery 4 weeks until 28 weeks

Every 2 weeks from 28 until 36 weeksEvery 2 weeks from 28 until 36 weeks

Every week from 36 weeks until Every week from 36 weeks until deliverydelivery

Six weeks postpartumSix weeks postpartum

Other Routine OB LabsOther Routine OB Labs 15-20 weeks15-20 weeks

24-28 weeks24-28 weeks

35-37 weeks35-37 weeks

Quad ScreenQuad Screen

Diabetes ScreenDiabetes Screen H&HH&H Rhogam workup & Rhogam workup &

injectioninjection

Group B strep Group B strep cultureculture

Pregnancy is a normal Pregnancy is a normal physiologic process, not a physiologic process, not a

disease . . . disease . . . however, pregnancy tends to be however, pregnancy tends to be

UNCOMFORTABLEUNCOMFORTABLE..

Your challenge is to differentiate common Your challenge is to differentiate common discomforts of pregnancy from pathology!discomforts of pregnancy from pathology!

Дякую за Увагу!Дякую за Увагу!

Nausea with or without Nausea with or without VomitingVomiting

Starts at 4-6 weeks, peaks at 8-12 Starts at 4-6 weeks, peaks at 8-12 weeks, resolves by 14-16 weeksweeks, resolves by 14-16 weeks

Causes: unknown; may be rapidly Causes: unknown; may be rapidly increasing and high levels of increasing and high levels of estrogen, hCG, thyroxine; may have estrogen, hCG, thyroxine; may have a psychological componenta psychological component

Rule out: hyperemesis gravidarumRule out: hyperemesis gravidarum

Most cases of nausea and Most cases of nausea and vomiting in pregnancy will resolve vomiting in pregnancy will resolve spontaneously within 16 to 20 spontaneously within 16 to 20 weeks of gestation.weeks of gestation.

Nausea and vomiting are not Nausea and vomiting are not usually associated with a poor usually associated with a poor pregnancy outcome. pregnancy outcome.

Nausea and vomiting Nausea and vomiting in early pregnancy in early pregnancy

A

Nausea and vomiting in early Nausea and vomiting in early pregnancypregnancy

If a woman requests or would like to If a woman requests or would like to consider treatment, the following consider treatment, the following interventions appear to be effective in interventions appear to be effective in reducing symptoms:reducing symptoms:

non-pharmacologicalnon-pharmacological

– – gingerginger – – P6 acupressureP6 acupressure

pharmacologicalpharmacological

– – antihistamines.antihistamines. A

PtyalismPtyalism Excessive salivation Excessive salivation

accompanied by accompanied by nausea and inability nausea and inability to swallow salivato swallow saliva

Cause: unknown; Cause: unknown; may be related to may be related to increased acidity in increased acidity in the mouththe mouth

FatigueFatigue

Causes: unknown; Causes: unknown; may be related to may be related to gradual increase in gradual increase in BMRBMR

Rule out: anemia, Rule out: anemia, thyroid diseasethyroid disease

BackacheBackacheWomen should be informed Women should be informed

that exercising in water, that exercising in water, massage therapy massage therapy might might help to ease backachehelp to ease backache

during pregnancy.during pregnancy. A

Upper BackacheUpper Backache

Cause: increase in size and weight of Cause: increase in size and weight of the breaststhe breasts

Relief: well-fitting, supportive braRelief: well-fitting, supportive bra

Low BackacheLow Backache

Cause: weight of the Cause: weight of the enlarging uterus enlarging uterus causing exaggerated causing exaggerated lumbar lordosislumbar lordosis

Rule out: Rule out: pyelonephritis pyelonephritis (CVAT)(CVAT)

LeukorrheaLeukorrhea

Definition: a profuse, thin or thick white Definition: a profuse, thin or thick white vaginal discharge consisting of white vaginal discharge consisting of white blood cells, vaginal epithelial cells, and blood cells, vaginal epithelial cells, and bacilli; acidic due to conversion of an bacilli; acidic due to conversion of an increased amount of glycogen in vaginal increased amount of glycogen in vaginal epithelial cells into lactic acid by epithelial cells into lactic acid by Doderlein’s bacilliDoderlein’s bacilli

Rule out: vaginitis, STI, ruptured Rule out: vaginitis, STI, ruptured membranesmembranes

Urinary FrequencyUrinary Frequency 1st trimester: 1st trimester:

increased weight, increased weight, softening of the softening of the isthmus, anteflexion of isthmus, anteflexion of the uterusthe uterus

3rd trimester: 3rd trimester: pressure of the pressure of the presenting partpresenting part

Rule out: UTIRule out: UTI

HeartburnHeartburn Relaxation of the cardiac Relaxation of the cardiac

sphincter due to progesteronesphincter due to progesterone Decreased GI motility due to Decreased GI motility due to

smooth muscle relaxation smooth muscle relaxation (progesterone)(progesterone)

Lack of functional room for the Lack of functional room for the stomach because of its stomach because of its displacement and compression displacement and compression by the enlarging uterusby the enlarging uterus

Rule out: GI diseaseRule out: GI disease

HeartburnHeartburnWomen who present with symptoms Women who present with symptoms

of heartburn in pregnancy should of heartburn in pregnancy should be offered information regarding be offered information regarding lifestyle and diet modification.lifestyle and diet modification.

Antacids may be offered to women Antacids may be offered to women whose heartburn remains whose heartburn remains troublesometroublesome

GPP

A

ConstipationConstipation Decreased peristalsis Decreased peristalsis

due to relaxation of the due to relaxation of the smooth muscle of the smooth muscle of the large bowel under the large bowel under the influence of progesteroneinfluence of progesterone

Displacement of the Displacement of the bowel by the enlarging bowel by the enlarging uterusuterus

Administration of iron Administration of iron supplementssupplements

ConstipationConstipation

Women who present with Women who present with constipation in pregnancy constipation in pregnancy

should be offered information should be offered information regarding diet modification, regarding diet modification, such as bran or wheat fibre such as bran or wheat fibre

supplementation.supplementation. A

HemorrhoidsHemorrhoids Relaxation of vein walls Relaxation of vein walls

and smooth muscle of and smooth muscle of large bowel under large bowel under influence of progesteroneinfluence of progesterone

Enlarging uterus causes Enlarging uterus causes increased pressure, increased pressure, impeding circulation and impeding circulation and causing congestion in causing congestion in pelvic veinspelvic veins

ConstipationConstipation

HemorrhoidsHemorrhoidsWomen should be offered Women should be offered

information concerning diet information concerning diet modification. modification.

If clinical symptoms remain If clinical symptoms remain troublesome, standard troublesome, standard hemorrhoids creamshemorrhoids creams should be should be considered.considered. GPP

Leg CrampsLeg Cramps Cause: unknown. ? inadequate calcium, ? Cause: unknown. ? inadequate calcium, ?

Imbalance in calcium-phosphorus ratioImbalance in calcium-phosphorus ratio

Relief: straighten the leg and dorsiflex the foot:Relief: straighten the leg and dorsiflex the foot:

Dependent EdemaDependent Edema Cause: impaired Cause: impaired

venous circulation venous circulation and increased and increased venous pressure in venous pressure in the lower the lower extremitiesextremities

Rule out: preeclampsiaRule out: preeclampsia

VaricositiesVaricosities Impaired venous circulation and increased Impaired venous circulation and increased

venous pressure in lower extremitiesvenous pressure in lower extremities Relaxation of vein walls and surrounding Relaxation of vein walls and surrounding

smooth muscle under the influence of smooth muscle under the influence of progesteroneprogesterone

Increased blood volumeIncreased blood volume Familial predispositionFamilial predisposition

Varicose veinsVaricose veinsVaricose veins are a common Varicose veins are a common

symptom of pregnancy that will symptom of pregnancy that will not cause harm andnot cause harm and

Compression stockingsCompression stockings can can improve the symptoms but will not improve the symptoms but will not prevent varicose veins from prevent varicose veins from emerging.emerging. A

Vaginal dischargeVaginal discharge

Women should be informed Women should be informed that an increase in vaginal that an increase in vaginal

discharge is a discharge is a common common physiological changephysiological change that that occurs during pregnancy. occurs during pregnancy.

GPP

If If vaginal dischargevaginal discharge is associated is associated withwith itching, soreness, offensive itching, soreness, offensive smell or pain on passing urinesmell or pain on passing urine there may be an infective cause there may be an infective cause

and investigation should be and investigation should be considered.considered.


GPP

A A 1-week course of a topical 1-week course of a topical imidazoleimidazole is an effective is an effective treatment and should be treatment and should be considered for vaginal considered for vaginal

candidiasis infections in candidiasis infections in pregnant women.pregnant women.


A

The effectiveness and safety The effectiveness and safety of of oral treatments for oral treatments for vaginal candidiasisvaginal candidiasis in in

pregnancy is uncertain and pregnancy is uncertain and these should not be offered.these should not be offered.


GPP

InsomniaInsomnia

Discomfort of the enlarged uterusDiscomfort of the enlarged uterus Any of the common discomforts of pregnancyAny of the common discomforts of pregnancy Fetal activityFetal activity Psychological causesPsychological causes

Round Ligament PainRound Ligament Pain Round ligaments attach Round ligaments attach

on either side of the on either side of the uterus just below and in uterus just below and in front of insertion of front of insertion of fallopian tubes, cross fallopian tubes, cross the broad ligament in a the broad ligament in a fold of peritoneum, fold of peritoneum, pass through the pass through the inguinal canal, insert in inguinal canal, insert in the anterior portion of the anterior portion of the labia majorathe labia majora

When stretched, they When stretched, they hurt!hurt!

Hyperventilation Hyperventilation and Shortness of Breathand Shortness of Breath

Causes: Causes: Increase in the BMRIncrease in the BMR Pressure of the uterus Pressure of the uterus

on the diaphragmon the diaphragm Changes in the oxygen-Changes in the oxygen-

carbon dioxide balancecarbon dioxide balance Exertion of carrying Exertion of carrying

extra weightextra weight

Rule out: asthma, Rule out: asthma, pneumonia, TB, pneumonia, TB, anxietyanxiety

Supine Hypotensive Supine Hypotensive SyndromeSyndrome

Screening for Screening for hematological hematological

conditionsconditions

AnemiaAnemiaPregnant women should be Pregnant women should be

offered screening for anaemia. offered screening for anaemia. Screening should take place early Screening should take place early

in pregnancy in pregnancy (at the first (at the first appointment) and at 28 weeksappointment) and at 28 weeks. .

This allows enough time for This allows enough time for treatment if anaemia is detected.treatment if anaemia is detected.B

Hemoglobin levels outside the Hemoglobin levels outside the normal range for pregnancy normal range for pregnancy

(that is, 11 g/dl at first contact and (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks)10.5 g/dl at 28 weeks) should be investigated and should be investigated and

iron supplementationiron supplementation considered considered if indicated.if indicated.

AnemiaAnemia

A

Blood grouping and Blood grouping and red cell red cell

alloantibodiesalloantibodies

Women should be offered Women should be offered testing for testing for blood group blood group and RhD statusand RhD status in early in early

pregnancy. pregnancy. BB

If a pregnant woman is RhD-If a pregnant woman is RhD-negative, offer negative, offer partner testingpartner testing

to determine whether the to determine whether the administration of anti-D administration of anti-D prophylaxis is necessary.prophylaxis is necessary.

BB



It is recommended that It is recommended that routine antenatal anti-D routine antenatal anti-D prophylaxis is offered to prophylaxis is offered to

all non-sensitized all non-sensitized pregnant women who are pregnant women who are

RhD negative.RhD negative.



NICE 2002

Women should be screened for Women should be screened for atypical red cell alloantibodies atypical red cell alloantibodies in early pregnancy and again in early pregnancy and again at 28 weeks regardless of their at 28 weeks regardless of their

RhD status.RhD status.



D

Pregnant women with clinically Pregnant women with clinically significant atypical red cell significant atypical red cell

alloantibodies should be offered alloantibodies should be offered referral to a referral to a specialist centrespecialist centre for for

further investigation and advice on further investigation and advice on subsequent antenatal management.subsequent antenatal management.



GPP

Screening for Screening for fetal anomaliesfetal anomalies

Screening for Screening for structural anomaliesstructural anomalies

Pregnant women should be offered an Pregnant women should be offered an ultrasound scanultrasound scan to screen for structural anomalies, to screen for structural anomalies, ideally between 18 and 20 weeks’ ideally between 18 and 20 weeks’

gestationgestation, by an appropriately trained , by an appropriately trained sonographer and with equipment of sonographer and with equipment of

an appropriate standard.an appropriate standard. A

Screening for Down’s Screening for Down’s syndromesyndrome

Pregnant women should be Pregnant women should be offered screening for Down’s offered screening for Down’s syndrome with a test which syndrome with a test which

provides the current standard provides the current standard of a of a detection rate above 60% detection rate above 60% and a false-positive rate of less and a false-positive rate of less

than 5%. than 5%. B

The following tests meet this standard:The following tests meet this standard:from 11 to 14 weeksfrom 11 to 14 weeks– – nuchal translucency nuchal translucency (NT)(NT)– – the combined test the combined test (NT, hCG and PAPP-A)(NT, hCG and PAPP-A)from 14 to 20 weeksfrom 14 to 20 weeks– – the triple test the triple test (hCG, AFP and uE3)(hCG, AFP and uE3)– – the quadruple test the quadruple test (hCG, AFP, uE3, (hCG, AFP, uE3,

inhibin A)inhibin A) B

Screening for Screening for infectionsinfections

Asymptomatic Asymptomatic bacteriuriabacteriuria

Pregnant women Pregnant women should be offeredshould be offered routine screeningroutine screening for asymptomatic for asymptomatic bacteriuria by midstream urine bacteriuria by midstream urine culture early in pregnancy. culture early in pregnancy.

Identification and treatment of Identification and treatment of asymptomatic bacteriuria asymptomatic bacteriuria reduces the reduces the risk of preterm birth.risk of preterm birth. A

Asymptomatic Asymptomatic bacterial vaginosisbacterial vaginosis

Pregnant women should Pregnant women should not be offerednot be offered routine screening for bacterial routine screening for bacterial vaginosis because the evidence vaginosis because the evidence

suggests that the identification and suggests that the identification and treatment of treatment of asymptomatic bacterial asymptomatic bacterial vaginosisvaginosis does not lower the risk for does not lower the risk for

preterm birth and other adverse preterm birth and other adverse reproductive outcomes.reproductive outcomes. A

Chlamydia Chlamydia trachomatistrachomatis

Pregnant women should Pregnant women should not be offered routine screeningnot be offered routine screening

for asymptomatic chlamydia for asymptomatic chlamydia because there is insufficient because there is insufficient

evidence on its effectiveness and evidence on its effectiveness and cost effectiveness. cost effectiveness.

C

CytomegalovCytomegalovirusirus

The available evidence does The available evidence does not support routine not support routine

cytomegalovirus screeningcytomegalovirus screening in pregnant women and it in pregnant women and it

should not be offered.should not be offered.B

Hepatitis B Hepatitis B virusvirus

Serological screening for hepatitis Serological screening for hepatitis B virus B virus should be offeredshould be offered to to pregnant women pregnant women

So that effective postnatal So that effective postnatal intervention can be offered to intervention can be offered to infected women to decrease the risk infected women to decrease the risk of mother-to-child-transmission.of mother-to-child-transmission. A

Hepatitis C Hepatitis C virusvirus

Pregnant women should Pregnant women should not be offered routine screeningnot be offered routine screening

for hepatitis C virus because for hepatitis C virus because there is there is insufficient evidenceinsufficient evidence on on

its effectiveness and cost its effectiveness and cost effectiveness.effectiveness. C

HIV infectionHIV infectionPregnant women Pregnant women should be offered should be offered

screening for HIV infection earlyscreening for HIV infection early in antenatal care because in antenatal care because

appropriate antenatal appropriate antenatal interventions can reduce interventions can reduce

mother-to-child transmission of mother-to-child transmission of HIV infection.HIV infection. D

RubellaRubellaRubella-susceptibility screening Rubella-susceptibility screening should should

be offered early in antenatal carebe offered early in antenatal care to to identify women at risk of contracting identify women at risk of contracting

rubella infection and to enable rubella infection and to enable vaccination in the postnatal period for vaccination in the postnatal period for the protection of future pregnancies.the protection of future pregnancies.

B

Streptococcus group Streptococcus group BB

Pregnant women Pregnant women should not be should not be offered routine antenatal offered routine antenatal

screeningscreening for group B for group B streptococcus (GBS) streptococcus (GBS)

because evidence of its clinical because evidence of its clinical effectiveness and cost effectiveness effectiveness and cost effectiveness

remains uncertain.remains uncertain. C

SyphilisSyphilisScreening for syphilis Screening for syphilis should be should be offered to all pregnant women at offered to all pregnant women at an early stage in antenatal carean early stage in antenatal care because treatment of because treatment of

syphilis is beneficial to the syphilis is beneficial to the mother and fetus.mother and fetus. B

ToxoplasmosisToxoplasmosisRoutineRoutine antenatal serological antenatal serological

screening for toxoplasmosis screening for toxoplasmosis should not be offeredshould not be offered because because the harms of screening may the harms of screening may

outweigh the potential outweigh the potential benefits.benefits. B

Pregnant women should be informed of primary Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis prevention measures to avoid toxoplasmosis

infection, such as:infection, such as:1.1. Washing hands before handling foodWashing hands before handling food2.2. Thoroughly washing all fruit and Thoroughly washing all fruit and

vegetables, before eatingvegetables, before eating3.3. Thoroughly cooking raw meats Thoroughly cooking raw meats 4.4. Wearing gloves and thoroughly washing Wearing gloves and thoroughly washing

hands after handling soil and gardeninghands after handling soil and gardening5.5. Avoiding cat faeces in cat litter or in soil.Avoiding cat faeces in cat litter or in soil.

ToxoplasmosisToxoplasmosis

C

Documents

Anatomy and Physiology of Pregnancy Lectures 1 N. Petrenko, MD, PhD AND-2 Nursing Care of Childbearing Family