the pregnant woman Flashcards
what does estrogen do? (3)
- Endometrial growth supports early pregnancy
- Stimulates prolactin from anterior pituitary: readies breast tissue for lactation
- Contributes to a hypercoagulable state that increases risk of thromboembolic events
which hormone dominates the beginning of the menstrual cycle?
estrogen
what does progesterone do? (3)
- Increase tidal volume and alveolar minute ventilation; leads to resp. alkalosis and SOB sensation
- Esophageal sphincter tone decreases: gastroesophageal reflux— ( works with estradiol)
- Relaxes tone in ureters and bladder: hydronephrosis and risk of bacteruria
what does HCG do?
Produced by the placenta supports progesterone synthesis in corpus luteum preventing the early embryo being lost to menstruation
- (AKA supports pregnancy until the pregnancy can support itself- keeps placental supported by progesterone)
***what hormone is implicated in the insulin resistance and hyperglycemia associated with gestational diabetes?
human placental lactogen
***___ of all women with GDM will go on to have _____ ______ _____ in their lifetime
half
type 2 DM
if a woman has GDM in first pregnancy? will she likely have it in her second? what are the babies like?
yes!
babies are big
how do thyroid hormones (T3, T4, TSH) levels change in pregnancy?
fluctuate, usually normal ranges, due to HCG’s stimulation of TSH receptor
what secretes relaxin? what does it do?
Secreted by corpus luteum and placenta
- Promotes ligamentous laxity in the SI joints and pubic symphysis in preparation for passage of the fetus
when does erythropoeitin levels increase? what does this do?
Increases during pregnancy raising erythrocyte mass
- Plasma volume increases causing relative hemodilution and physiologic anemia
- CO increases but systemic vascular resistance decreases: net decrease in BP
what anatomic changes happen to the breast in pregnancy? (4)
- Moderate enlargement due to hormonal stimulation increased vascularity and glandular hyperplasia
- Nipples larger and more erectile, darker areola and pronounced Montgomery glands
- Increased venous pattern
- 2nd and 3rd trimester colostrum secretion; a nutrient rich precursor to milk
what anatomic changes happen to the uterus in pregnancy? (3)
- increases in size: Muscle cell hypertrophy
- Increase in fibrous and elastic tissue
- Development of blood vessels and lymphatic
in the ___ trimester, Uterus confined to pelvis
and Retains prior position
first
what happens to the uterus/ b/c of the uterus in the second trimester ? (4)
- 12-14 weeks uterus becomes externally palpable above pelvic brim
- Starts to invade space for bladder
- Intestines are displaced laterally
- Stretching of round ligaments- mostly on the right side
___ wks the uterus is at the umbilicus level (to of the fundus palpable here)
20
___ wks the uterus is just above the pelvic brim (tops of fundus palpable here)
12 - 14
what are the breakdown of wks between first, second, and third trimester?
first: 0-12 wks
second: 13-28 wks
third: 29-40 wks
what anatomic changes happen to the vagina in pregnancy? (3)
- Chadwick’s sign
- Vaginal walls become more deeply rugated due to thickening of mucosa and loosening of connective tissue and hypertrophy of muscle cells
- Increase in glycogen stores in epithelium = proliferation of Lactobacillus acidophilus –> decrease vaginal pH
***what is chadwick’s sign ?
- increased vascularity leads to a bluish color of vaginal walls and cervix
what happens to the cervix in pregnancy?
- Chadwick’s sign- appears cyanotic
- Hegar’s sign
- Mucus plug fills the cervical canal to protect from
outside influence (protect from bacteria)
***what is hegar’s sign?
palpable softening of the cervical isthmus
what is the first thing “to go” in delivery?
mucus plug of the cervical canal
might be able to feel ______ ______ as a small nodule that then disappears by _________
Might be able to feel corpus luteum as a small nodule then disappears by mid-pregnancy
(changes in the adnexae in pregnancy)
what happens to the external abdomen in pregnancy?
- Stria gravidarum (stretch marks)
- Linea nigra- a brownish black line along the midline
- Diastasis recti- rectus abdominis muscles may separate
what is the cervical isthmus? (kinda weeds)
the uterine isthmus is the inferior-posterior part of uterus, on its cervical end — here the uterine muscle (myometrium) is narrower and thinner. It connects superiorly-anteriorly to the complementary parts of the uterus: the body and the fundus
what is the adnexae?
The appendages to the uterus are known as the adnexa uteri. The parts of the adnexa uteri are the fallopian tubes, ovaries, and ligaments
looking at a quantitative HCG: know where they should be (baseline) based on what?
dates of last menstrual cycle
if HCG higher than what you expect, what does this mean?
they have twins or they further along in the pregnancy than they thought they were (a month or so earlier)
if pregnancy is viable, what number do we want to go up?
HCG hormone levels
what test do we do to confirm pregnancy?
urine HCG (maybe blood HCG but not really necessary)
health history for pregnancy (6)
- Current state of health
- Past obstetric history
- Past medical history
- Family history
- Expected weeks of gestation (first day of LMP- last menstrual period)
- Expected date of delivery (Naegele’s rule)
acute/chronic issues that effect pregnancy (weeds)
Abdominal surgeries Hypertension Diabetes Cardiac conditions Asthma Hypercoagulability states Mental health disorders HIV/STIs Abnormal Pap smear
how do you ask for the expected weeks of gestation?
first day of LMP (last menstrual period)
what is “ G” (gravida)?
how many prior pregnancies you have had
what is the “P” (para/ parity) ?
how many labors you have had. includes term deliveries, preterm, spontaneous/therapeutic abortions
what are pregnancy complications that you may ask history about? (4)
DM, HTN, preeclampsia, preterm labor
what are labor or delivery complications that you may ask history about? (3)
Large babies, fetal distress, emergency interventions
what are risks to maternal and fetal health? (weeds)
Tobacco, alcohol, illicit drugs
Medications, OTC medications, Herbal
Toxic exposures at home or work? (Cat litter)
Nutritional intake
Adequate social support and financial support
Stress at home or work
Physical abuse or domestic violence
what does “TPAL” stand for?
T- term (to 20 wks)
P- preterm
A- abortion (spontaneous or therapeutics)
L- living
***what is naegele’s rule?
Estimated Date of Delivery (EDD): Add seven (7) days to first day of LMP Subtract three (3) months Add one (1) year
for family history, how far along in the family tree do you ask about?
2 generations up and 2 generations down
if there is a congenital problem/anomaly in the first child is it more likely that their second will have it?
yes
what do babies get from breastmilk that they can’t with formula?
Passive immunity from certain infectious diseases until their own immunity is functional at 3-4 months
gestational age is used to establish timeframe of the pregnancy. what information is this useful for? (5)
- For normal progress
- Establishing paternity
- Timing screening tests
- Tracking fetal growth
- Effective preterm and postdates labor
breastfeeding may suppress _______, but don’t rely on it for ________
ovulation, birth control !
if baby has a fever… what do you need to do?
COMPLETE and THOROUGH workup !
limitation to naegele’s rule for determining EDD?
Shorter or longer than 28 day cycles ( Irregular menstrual cycles)
EDD, you use Naegele’s rule OR add ____ wks to first day of LMP. but most of the time a _____ _____ is done to confirm.
40
-dating US
how frequent are checkups during pregnancy? (3 parts)
- Usually once a month until 30 weeks gestation
- Then every two weeks until 36 weeks
- Then every week until delivery
***what is important to document with each checkup for a pregnant woman? (6)
- History
- fetal movement felt by patient
- contractions
- leakage of fluid
- vaginal bleeding
- PE- Vital signs (BP and weight), fundal height, verification of fetal HR, determination of fetal position and activity
***what is important to document from the PE of pregnant checkup? (4)
- Vital signs (BP and weight)
- fundal height
- verification of fetal HR
- determination of fetal position and activity
health promotion and counseling (7parts)
Nutrition Weight gain Exercise Substance abuse Domestic violence Prenatal laboratory screening Immunizations
nutrition for pregnancy, what multivitamin should she take?
Multivitamin
With 0.4 to 0.8 mg of folic acid and 30 mg or iron
nutrition: what to avoid in pregnancy? (4)
Excess amounts of Vitamin A (can become toxic)
Fish with mercury (shark, swordfish, some canned tuna
Unpasteurized dairy products
Undercooked meats
nutrition: only increase by _____ calories a day if pregnant
Should only increase by 300 calories a day
______ and _________ are associated with poor birth outcomes
Excessive and inadequate weight gain
rules for exercise in pregnancy? specifically after the 1st trimester? what about in the 3rd trimester? what to do if fatigued/uncomfortable?
- mild to moderate exercise, short periods (30min+), 3 or more times a week
- After 1st trimester avoid exercise in supine position (compress inferior vena cava decreasing blood flow to placenta)
- 3rd trimester no exercise that might cause loss of balance
- STOP if fatigued/uncomfortable
_______ ______ _______is the leading cause of preventable mental retardation in the U.S.
Fetal alcohol syndrome is the leading cause of preventable mental retardation in the U.S.
what amount of alcohol is safe to drink when pregnant?
There is no known “safe dose” so abstinence is best
__________ Accounts for about 1/3rd of low-birth-weight babies and many other poor pregnancy outcomes like placental abruption, and preterm labor
tobacco
what two vaccines should pregnant women get?
Tetanus (Tdap) and flu
what three vaccines are safe for pregnant women?
Pneumococcal
Meningococcal
Hepatitis B
what three vaccines are unsafe in pregnancy?
measles/mumps/rubella
Polio
Varicella
what do you give a woman who is Rh negative woman? (if dad might be Rh positive?.. ) how often does she get this?
Rho (D) immunoglobulin or RhoGam should be given to all Rh-negative women at 28 weeks gestation and again within 3 days of delivery to prevent sensitization to an Rh-positive infant
what are included in initial screenings ? (weeds)
Blood type and Rh Antibody screen CBC- especially hematocrit and platelet count Rubella titer Syphilis test Hepatitis B surface antigen HIV test STI screening for GC and Chlamydia UA with culture
what are two “timed screenings” for prenatal visit?
- Oral glucose tolerance test for Gestational diabetes around 24 weeks
- Vaginal swab for group B strep between 35-37 weeks
what do you need to check for each prenatal visit? (maybe weeds)
Evaluate blood pressure Weight Urine protein and glucose Uterine size for progressive growth Fetal heart rate
After patient reports __________ she should be asked about it at every visit
After patient reports “quickening” (fetal movement) she should be asked about it at every visit
Between ___ -____ weeks patient should be taught warning signs of preterm labor
24-34 weeks
4 signs of preterm labor
Uterine contractions
Leakage of fluid
Vaginal bleeding
Low pelvic pressure low back pain
Beginning in the _______patient should be taught to recognize the warning signs of preeclampsia
2nd trimester
what are the 4 warning signs of preclampsia?
Headache
Visual changes
Hand or facial swelling
Epigastric or RUQ pain
At 28 weeks systemic examination of the abdomen is carried out to identify what 3 things?
- The lie (eg., longitudinal, transverse, oblique)
- The presentation (eg., vertex, breech, shoulder)
- The position (eg., flexion, extension, or rotation of the occiput)
how many maneuvers of leopold are there?
4 (upper pole, sides abd, lower pole, flexion of fetal head )
1st maneuver of leopold
UPPER POLE
Women’s side facing her head
Fingers together palpate gently to determine what part is in the upper pole (usually buttocks feel firm but irregular. Head feels firm round, smooth)
2nd maneuver of leopold
SIDES OF MATERNAL ABD
Facing patients head, one hand each side of abdomen trying to capture body of fetus
One hand steadies, the other palpates for the position of the back vs. the extremities
The hand on back feels smooth, firm surface length of hand; hand on arms and legs feels irregular bumps, and maybe kicking
3rd maneuver of leopold
LOWER POLE
Face patient’s feet, fingertips touching together, palpate just above symphysis pubis
Palpate to see if head (smooth, firm, rounded) or buttocks (firm but irregular
Judge the descent or engagement of the presenting part into the maternal pelvis
4th maneuver of leopold
FLEXION OF FETAL HEAD
This assumes the head is the presenting part in the pelvis
Face the patient’s feet, place hands on either side of the uterus and determine the fetal front and back side.
Using one hand at a time run it down each side of the fetal body until you run into the “cephalic prominence”.
If the prominence is on the back of the body the head is extended and the face is presenting
If it is on the front side of the body the head is flexed and the top of its head is presenting
Most comfortable positions for patient will be ______ or _________
Most comfortable positions for patient will be sitting or left-side-lying position
hyperreflexive on genital exam may be a sign of what?
preclampsia
what do you check in the supine part of the exam?
Uterine palpation, fetal heart tones, pelvic exam
- As quickly/efficiently as possible
- Semi-sitting with knees bent
what is expected of the thyroid on exam?
Thyroid – modest symmetric enlargement expected
Wt loss greater than ___% during first trimester may be due to ______
5%
hyperemesis
what constitutes preclampsia?
SBP > 140 and DBP > 90 after week 20 and proteinuria
what is chloasma?
on HENT of pregnant woman: chloasma (mask of pregnancy, irregular brownish patches around forehead, cheeks, nose, or jaw)
how can the hair present on a pregnant woman?
- dry or oily
- sometimes generalized hair loss or mild hirsutism
why would you check the eyes of a pregnant woman?
look at conjunctiva- check for anemia sign
nose exam for pregnant woman, what are some common things?
nasal congestion and nose bleeds are both common
in the mouth of a pregnant woman, it is common to see ____ enlargement
gingival
thorax and lung exam of a pregnant woman may show what two things? why might they have respiratory alkalosis ?
elevated diaphragm & increased chest diameter
* May have resp. alkalosis – TV and Alveolar minute ventilation increase but resp rate constant
heart exam of pregnant woman: ____ elevated in late pregnancy. what might you also hear? why?
PMI elevated late in pregnancy (4th ICS).
- Venous hum and systolic or continuous mammary souffle (pronounced soo-fl)
souffle (soo-fl) ? when and where do you find this?
when: late pregnancy or during lactation
where: heard 2nd or 3rd ICS. systolic > diastolic
what is souffle (soo-fl)? where does it come from? (maybe weeds)
murmur with blowing quality: due to increased blood flow in normal vessels.
breast of pregnant woman may present how?
venous pattern noticeable, nipples and areolae dark, prominent Montgomery glands; more tender and nodular; colostrum expression from nipples
when are fetal movements felt by mother? by others?
18-20wks (mom)
24wks (someone touching her stomach)
**regular contractions before ___wks with or without pain or bleeding = ABNORMAL
37
when do you assess fundal height? from where to where do you measure?
20 wks
Measure top of symphysis pubis to uterine fundus in the midline. measure in cm
fundal height: should roughly equal weeks of gestation from wk ___ - ____. deviation from expected: if its >4cm or <4cm; what is the significance?
wk 20-32
if fundal height is >4cm from the expected value, what might that mean?
> 4cm = mult. Gestation, large fetus, extra amniotic fluid, uterine leiomyoma
if the fundal height is <4cm than the expected value, what might that mean?
<4cm = missed abortion, transverse lie, growth retardation, false pregnancy
avg fetal HR is around what?
160 but slows to 140-120 near end of term
when and where can you find fetal HR? (weeds)
Doppler ~ 10 weeks
12-18 weeks heard midline lower abdomen
Fetoscope – 18 wks
>28 weeks heard over fetal back or chest
genitalia and rectal exam (weeds)
Labia and clitoris enlargement is normal
Note scars, perineal incisions and introitus relaxation in multiparous women
Palpate Bartholin’s and Skene’s gland for tenderness
Check for cystocele or rectocele
Note hemorrhoids
Speculum exam – cervix color, shape, healed lacs
If PAP is done use wooden spatula or cotton tip applicator
bimanual exam of cervix, os, uterus and adnexa (weeds)
Usually easier in pregnancy due to relaxation
Cervix softer
Cervical os – nulliparous vs multiparous
Cervical length – cervical tip to lateral fornix (1.5-2 cm before 34-36 wks)
Palpate adnexae
Assess pelvic muscle strength
extremity exam (3) -( weeds)
Note varicose veins
Note edema
Check knee and ankle reflexes
common symptoms- 1st trimester
N/V, breast tenderness, fatigue
common symptoms- 2nd trimester
lower abdominal pain and abdominal striae (stretch marks)
common symptoms- 3rd trimester
fatigue, stretch marks, contractions, loss of mucus plug, edema
common symptoms- all trimesters
amenorrhea, heartburn, urinary frequency, vaginal discharge, constipation, hemorrhoids, backache
vaginal discharge in pregnancy
leukorrhea is normal - from increased secretions (vasocongestion and hormonal changes)
- anything foul smelling or with pruritis should be investigated
