Midwifery Flashcards
Describe photos - month of pregnancy + anatomical changes
- a) non pregnant
- b) 5th month
- c) 9th month
- d) prior to birth
many organs compressed (bladder, lungs, etc) - not always externally visible, but felt by pregnant women.
how is corpus luteum maintained?
production of hcg by trophoblasts. CL continues to produce progesterone, which maintains the uterine lining for implantation. AFter 6-10w post fertilization, placenta takes over.
Placenta produces estrogen and hcg and hpl, which stimulates breast development
Blackburn (2013) Maternal, Fetal, & Neonatal Physiology
How is pregnancy dated?
first day of LMP + 7 - 3mths +1year
40 weeks from first date of LMP
hcg, estrogen, progesterone levels
hcg peaks at 11-12 w, whereas estrogen and progesterone continue to rise until term and birth
Hematologic & Hemostatic changes - blood volume
- Hypervolemia: BV ↑ 30-45%
- Plasma volume
- ↑ starts 6-8 wks
- Peaks 28-32 wk
- 75% of total BV ↑ due to plasma
- RBCs
- ↑ 20-30%
- Lags behind plasma
- Hemodilution, physiologic anemia
Hematologic & Hemostatic changes: WBCs
- WBC volume ↑ 8%, up to 15,000/mm3
Hematologic & Hemostatic changes: PLTs
- Platelets largely unchanged
- Mild-moderate thrombocytopenia
Hematologic & Hemostatic changes: coagulation
- Hypercoagulable state
- Starts 11-15 weeks
- Clotting Factors
- Increase: I, VII, VIII (increase then decrease), IX, XII, von willebrand.
- decrease: XI, and VIII later in pregnancy (to about 50% of nonpregnant)
normal labs in pregnancy
different from nonpregnant and may change throughout pregnancy
normal labs in pregnancy 2
same idea - may be different from nonpregnant
Anemia in pregnancy - risks
- Yes - blood loss in birth, etc
- Lab values differ from non-pregnant
- Risk for iron-deficiency anemia
- ↑ Risk for thromboembolic disorders
- Increases further with age, parity, C/S
- Increase in coagulopathies (PIH - disrupts clotting)
*iron supplements w/vit c. Warn about dark stool & constipation
Cardiovascular changes : position of <3
- starts at 3-4w, plateaus 2nd or early 3rd T
- Diaphragm elevates –> Heart displaced to left, rotated (apex displaced laterally)
- most women tolerate changes unless CV dz
Cardiovascular changes: CO & systemic vascular resistance
Cardiac Output
◦↑ 30-50%
◦50% of that ↑ by 8 weeks GA
◦↑ HR 10-20 BPM
↓ Systemic vascular resistance (–> inc BF to uterus)
most women tolerate well
Cardiovascular changes: skin
↑ Skin perfusion (d/t vasodilitation)
CV changes: RAAS
- Renin-angiotensin-aldosterone (all components increase)
- ◦Enhanced sodium and water retention
- help maintain BP
CV changes: vessels
- ↑ Vascular distensibility
- Aorto-caval compression (increases venous pressure in lower extremities - leakage from vasculature)
- Decreased baroreflex (impaired BP regulation - difficulty responding to OH and blood loss)
- BP decreases
Cardiac exam on pregnant women: what might you see?
- Jugular venous distension
- Split S1, sometimes split S2
- 3rd sound audible at times
- SEM along LSB (92-95% of women) >grade 2 or thrill must be evaluated
- Soft, transient diastolic (20% of women)
- ↑ Mammary blood flow, veins dilate
- Mammary souffle (14% of women)
- MVP common – may ↓ murmur
BP in pregnancy: worried about low or high?
both
BP in pregnancy - normal changes
- Lowest second trimester: lowest 24-32 weeks, returns to nonpregnant values near term
- Measurement changes
BP in pregnancy - what compounds effects?
physiologic but can be compounded by other pregnancy changes
- Positional effects
- Supine hypotensive syndrome (uterus compress great vessels)
- Orthostatic hypotension (perhaps d/t decreased baroreflex sensitivity)
- Other hypotensive effects (heat, long hot showers, etc.)
- Hypertensive disorders of pregnancy
aortocaval compression relief, image
Clinical implications of CV changes in pregnancy: multiple pregnancies
even greater increase in CO, stroke volume
increase in HR, anemia, PIH, MVP (tend to be asymptomatic)
Clinical implications to increased skin perfusion
- Vascular spiders, palmar erythema
- Nasal hyperemia: congestion
*
Exercise in pregnancy
- shorter labors, fewer perinatal complications, inhibits clot formation, varicosities, weight gain
- ◦30” daily 2-3x/wk
- ◦Aerobic walking, stretching, biking, weights
- ◦Benefits swimming
- ◦Cautions:
- no lifting >25lbs,
- balance (biking in 3rd T),
- redistributes blood to skin and muscles, so may cause dizziness;
- high heat (hyperthermia can be teratogenic, so also stay away from saunas & hottubs),
- avoid jumping, deep flexion of joints, blunt abdominal trauma, aortocaval compression (supine)
Respiratory: anatomical changes
- ◦Position of diaphragm shifts
- ◦↑ Subcostal angle
- ◦↑ Chest diameter & circumferences
- ◦ Hyperemia oro- & nasopharynx
probably due to relaxation of ligaments btwn rib cage and sternum
Respiratory: physiologic changes
- ◦Progesterone respiratory stimulant
- ◦Chronic mild hyperventilation (increased alveolar O2, drop in arterial CO2)
- ◦Favors transfer CO2 fetus → mom
- ◦Chronic mild hyperventilation (increased alveolar O2, drop in arterial CO2)
Progesterone & PGs in respiration
- prog: decrease airway resistance up to 50%
- both relax smooth muscles of resp tract - reduced WOB
O2 consumption in pregnancy
O2 consumption increases d/t metabolic demands of mother, placenta, fetus, and lung capacity changes
Which of the following increase during pregnancy?
Respiratory rate (RR)
Vital capacity (VC)
Inspiratory capacity (IC)
Tidal volume (TV)
Inspiratory reserve volume (IRV)
Functional residual capacity (FRC)
Expiratory reserve volume (ERV)
Residual volume (RV)
Total lung capacity (TLC)
Inspiratory capacity, tidal volume,
Which of the following decrease during pregnancy?
Respiratory rate (RR)
Vital capacity (VC)
Inspiratory capacity (IC)
Tidal volume (TV)
Inspiratory reserve volume (IRV)
Functional residual capacity (FRC)
Expiratory reserve volume (ERV)
Residual volume (RV)
Total lung capacity (TLC)
FRC, ERV, RV, TLC
Which of the following stay the same during pregnancy?
Respiratory rate (RR)
Vital capacity (VC)
Inspiratory capacity (IC)
Tidal volume (TV)
Inspiratory reserve volume (IRV)
Functional residual capacity (FRC)
Expiratory reserve volume (ERV)
Residual volume (RV)
Total lung capacity (TLC)
RR, VC, IRV
Physiologic dyspnea
Result of anatomic & physiologic changes
(60-70% women)
◦1st trimester start, max 28-31 weeks
◦At rest or with mild exertion
r/o pathology then reassure
URIs & rhinitis
- d/t capillary engorgement and hyperperfusion, hyperemia of oro and nasopharynx, along w/smooth muscle relaxation
- ◦Immune system changes
- ◦↑ susceptibility to pneumonia - if they do get URI
- tolerate coughs longer, but if febrile & productive cough, recognize may be more serious*
Asthma in pregnancy
(8% women)
better, worse, or unchanged
inhaled steroids first line
Kidney size in pregnancy
Kidneys enlarge about 1 cm
growth d/t increased renal vasculature, IS volume, dilation of pelvis, renal calyces, and ureters
Effect of progesterone & PGs on kidneys
- Progesterone leads to:
- ↓ Bladder tone, ↑ capacity (maybe - but compression decreases later
- Hypomotility, ↓ peristalsis ureters (PG mediated)
Changes to ureters in pregnancy
- Ureters longer, tortuous, displaced (leads to stasis, interferes w/glomerular filtration)
- *also *↑ Hydronephrosis and hydroureter
Physiologic Renal and Fluid homeostasis changes
- Na+ retention
- ↑ Extracellular volume
- GFR↑ 40-60%
- ◦Starts 4-6 wk, peaks 9-16 wk
- ◦Maintained until term
- ↑ Reabsorption, secretion solutes (glc, AAs, protein)
- Renin-angiotensin-aldosterone altered (maintain homeostasis, may play role in PIH)
Clinical implications of kidney changes
- ↑ Frequency (60% of women)
- Nocturia
- Incontinence (30-50% of women) (24% of these have continued sx 1yr post-partum)
- Dependent edema (more in obese, large babies)
- ↑ UTIs, pyelonephritis
- Urine testing
- Renal testing
Maternal GI & hepatic changes
- Mouth; gum tissue friable w/bleeding, saliva more acidic, more plaque, etc –> more gingivitis. No evidence for >caries
- Esophagus↓ sphincter tone, motility, pressure
- Stomach ↓ tone, motility, emptying (may help w/nutrient absorption). Increased risk GERD. N/V etiology unknown.
- Intestines ↓ tone, motility, ↑H2O absorption
- Liver enzymes altered
- estrogen appetite suppressant, prog - appetite stimulant*
Clinical implications of GI and hepatic changes
- Gingivitis (30-80% women), ptyalism, caries
- increased preterm, SGA
- Heartburn - pyrosis (80% of women) (H2 antagonists if necessary Class B, PPIs if more severe - class C)
- NVP
- ◦Nausea (70-90% of women)
- ◦Vomiting (30-45% of women with nausea)
- hcg levels may be involved
- assoc w/better pregnancy outcomes
- ◦Hyperemesis (<1% of women)
- ◦Nausea (70-90% of women)
- Food cravings/aversion (esp meat, poultry, eggs)
- Pica -consumption of nonnutritive substances. Starch, ice, dirt (cultural). Concerns over whether safe
Constipation, bloating, flatulence in pregnancy
Acute abdomen differential dx
- ◦Obstetrical causes - enlarged uterus (pressure), contractions, ligament pain, prone to pulling abdominal muscles
- ◦Non-obstetrical causes, including appendicitis, UTI
appendix in pregnancy
displaced upward and laterally to right. 2nd trimester - above iliac crest
weight gain recommendations
how many calories per day
extra 350-450 kcal, depends on weight
Mortality rates & weight gain
Skin in pregnancy
- Hemangiomas, varicosities
- Pruritis (abdomen or generalized. Can be sign of intrahepatic cholestasis, but probably not)
- Vasomotor instability
- Hair growth mild hirsutism
- Hyper-pigmentation (91% of women) (estrogen, prog)
- ◦Areolar, genitalia, axillae, linea nigra
- ◦Freckles, nevi, scars
- ◦Melasma (chloasma)
- Striae gravidarum
- hair loss postpartally*
melasma/chloasma
mask of pregnancy.
Recommendation: avoid sun, use sunscreen. usually fades significantly to completely
Striae Gravidarum
stretch marks. 50 - 80% of women. Probably secondary to estrogen, relaxin, adrenocorticoids; irregular pink or purple and become silvery white
more frequent in younger, obese, larger babies. Tends to be familial. Can itch. can be on breasts.
Musculoskeletal changes
- Joint mobility increased
- Progressive lordosis
- Stretching ligaments
- Stretching abdominal muscles
- Diastasis recti - separation of abdominal muscles. PP ab exercises
- Flexion neck & slumping shoulders (can lead to nerve compression)
- Balance
Clinical implications of MS changes
- Joint laxity, SP separation
- Low back pain (45-50% of women): combo of hormonal and mechanical factors
- Lumbar lordosis: shifts center of gravity antiororly - strain. Teach pelvic tilt.
- sciatica d/t nerve compression
- Abdominal pain
- Carpal tunnel: pressure on median and ulnar nerves d/t anterior neck flexion, edema, etc
- Leg cramps: *pressure or electrolytes *
- Falls
- Headaches
Immune system & pregnancy
- Suppression - may help to not reject fetus, but can have implications for maternal health
- Activation - can lead to spontaneous abortion
Eyes and pregnancy
increased Intraocular pressure - don’t get new contact lenses
Sleep
difficult to fall asleep by 12w. Less efficient sleep.
CNS effects
reduced attention/memory, continues postpartum
perhaps d/t sleep?
Emotional lability & pregnancy
sleep deprivation, discomforts, hormonal changes, role changes, financial & social changes
significance of facial edema after 20w gestation
investigate preeclampsia
preeclampsia
SBP >140 or DBP >90 after 20w, w/proteinuria
significant thyroid enlargement: normal or abnormal
abnormal
(some enlargement is physiologic)
When does mom feel fetal movement
18-24 w
