Uncomplicated pregnancy L2 Flashcards
what basic changes occur in the uterus during pregnancy?
1) uterine vascularity increases; BVs dilate
2) hyperplasia
3) hypertrophy
4) development of decidua
hyperplasia
new muscle fibers/tissue
hypertrophy
enlargement of existing muscle fibers
decidua
thick layer of mucus membrane that lines the uterus during pregnancy and is shed after birth
what is the fundus?
the top of the uterus
describe changes in fundal height that occur throughout pregnancy
12 weeks: @ symphysis pubis
16 weeks: between symphysis pubis and umbilicus
20 weeks: @ umbillicus
36 weeks: @ xiphoid process
what is nullipara?
a woman who has never given birth
what is multipara?
a woman who has given birth before
when does the uterus drop down into the pelvis?
nullipara - 2 weeks before the onset of labor
multipara - @ the start of labor
ballottement
a technique of palpating a floating structure (fetus and amniotic sac) by bouncing it gently and feeling it rebound.
* can be done at between 16 and 18 weeks
what happens to the center of gravity of the uterus during pregnancy?
center of gravity is altered: uterus enlarges and tilts against the anterior abdominal wall
what are Braxton Hicks contractions?
“practice contractions” that facilitate an increase in blood flow to the uterus
* they can be felt at about 16 weeks and will last until real labor begins
how does a fetus get O2?
O2 is extracted from maternal blood to oxygenate fetus and increases as pregnancy progresses
endovascular trophoblasts
cells that invade and modify uterine spiral arteries
* increase blood flow to placenta
how do endovascular trophoblasts increase blood flow to placenta?
they dilate and uncurl uterine spiral arteries reducing resistance and increasing blood flow
what does additional blood flow to the placenta do?
increases gas exchange and the amount of nutrients to the placenta and fetus
what are changes that occur with the cervix during pregnancy?
1) Hegar’s sign
2) Chadwick’s sign
3) friability
4) operculum “mucus plug”
Hegar’s sign
softening of the lower uterine segment that occurs at about 6 weeks of pregnancy
Chadwick’s sign
bluish color to cervix, vagina, and labia that occurs at about 8 weeks and results from increased blood flow
describe friability of the cervix during pregnancy
tissue easily damaged and can lead to bleeding after intercourse
describe operculum “mucus plug” that forms during pregnancy
forms to protect the intrauterine environment
what changes occur with the vagina during pregnancy?
1) increased vaginal discharge - leukorrhea
2) changes in vaginal pH
3) increased vascularity
what can changes in the pH of vaginal secretions that occur due to pregnancy increase the risk of?
lower, acidic pH can increase the risk of yeast infections
leukorrhea
thick white vaginal discharge
what can increased vascularity of the vagina cause?
- changes in arousal
- edema to area
- varicosities later in pregnancy
what changes to the breasts does increased estrogen and progesterone cause?
- increased sensitivity of breasts and nipples
- feeling of firmness, heaviness, and nipples become erect
- nipples and areola become more pigmented
describe the changes that increased blood flow to the breasts causes
- vessels below skin dilate
- lactogenesis stage 1 completes @ about 16 weeks
describe what occurs in lactogenesis stage 1
- may leak colostrum
- lactation is inhibited by high levels of progesterone
TAB
therapeutic abortion
SAB
spontaneous abortion
pregnancy causes these changes associated with the CV system:
1) heart itself
2) CO
3) pulse rate
4) blood volume
5) blood composition
6) BP
what happens to the heart itself during pregnancy?
1) slight hypertrophy due to increased blood flow
2) position changes due to changes in diaphragm position
3) transient murmurs may be auscultated
changes in CO related to pregnancy:
CO increased by 30-50% by week 32 due to increased SV and heart rate
changes in BV related to pregnancy:
- plasma volume increases 40-50% (1500mL)
plasma - 1000mL
RBC - 450mL
physiologic anemia - hemodilution of cells
blood plasma increases at a faster rate than RBCs which causes a dilution of blood and reduced ability for blood to carry gasses
changes in blood composition due to pregnancy
- circulation time decreases by week 32
- increase in WBCs
- Virchow’s triangle: increased venous stasis, increased coagulability factors, and increased endothelial damage
- increased risk for thrombosis
what lab values indicate anemia?
- Hgb under 10g/dl
- Hct under 35%
changes in BP throughout pregnancy:
- 1st trimester: no change
- 2nd trimester: is decreased 5-10mmHg
- 3rd trimester: returns to 1st trimester values
- supine hypotensive syndrome can occur
supine hypotensive syndrome
when the uterus restricts blood flow in the inferior vena cava causing a drop in BP
* can occur at about 24+ weeks
* CO is reduced 25-30%
* a drop in SBP can be 30mmHg or more and cause reflex bradycardia cutting CO 50%
* pregnant person feels faint and it can cause fetal heart rate decels
what position change often causes supine hypotensive syndrome?
when a patient is moved from left lateral to supine
changes in the respiratory system related to pregnancy:
1) physiologic changes in rib position
2) respiratory changes
3) O2 requirement
4) upper airway vascularity
5) basal metabolic rate (BMR)
6) acid-base balance
what happens to the ribs during pregnancy?
ribs flare out
what changes in respiration occur during pregnancy?
- pregnant women switch from abdominal to thoracic breathing
- deeper breathing as a result of progesterone causes increased tidal volume
what happens to O2 requirements during pregnancy?
increased oxygen demand
describe changes in upper airway vascularity during pregnancy:
- can cause nasal and sinus stuffiness due to estrogen
- epistaxis (nose bleeds)
- changes in voice
what happens to BMR during pregnancy?
increases by 15-20% at term due to increased O2 demand from increased tissue mass of the uterus and fetal needs
describe the changes in acid-base balance in a pregnant woman:
respiratory alkalosis is compensated by metabolic acidosis
* this facilitates maternal-fetal O2-CO2 transfer
how much is respiration rate increased during pregnancy?
RR increases 2 breaths per minute and there is an increased awareness to breath
why is there a heat intolerance in pregnancy?
increased BMR produces excess heat
what causes changes in the renal system?
1) increased estrogen and progesterone
2) increased uterus size
3) increased blood volume
what anatomical changes occur in the kidneys during pregnancy?
1) dilation of ureters, pelvises, and renal calyces
2) urine flow rate decreases and leads to stasis/stagnation
3) urethra lengthens
4) bladder is pushed above pelvic brim
what functional changes occur in the kidneys during pregnancy?
1) renal plasma flow is increased
2) increased GFR (~50%) (increased creatinine clearance and decreased serum creatinine)
3) reabsorption system easily overstressed by which leads to pooling of fluids
4) protein leakage ~+1
5) tubular reabsorption of sodium is increased
6) tubular reabsorption of glucose is decreased (increased glucose in urine)
what can stasis/stagnation in the kidneys cause?
infection. pooled urine can be a medium for bacteria to grow
what happens to urinary frequency during pregnancy?
what causes it?
urinary frequency is increased because:
* the enlarged uterus puts pressure on bladder
* bladder sensitivity increases
where does the bladder move during pregnancy and when does this occur?
bladder is pulled up into the abdomen in the 2nd trimester
what happens to a urethra during pregnancy and what procedure does this affect?
it lengthens due to the repositioning of the bladder.
* need to account for the added length of the urethra while inserting a urinary catheter after epidural placement
what position increases perfusion to kidneys and facilitates better electrolyte balance?
left lateral position
what happens when a pregnant woman consumes too much sodium?
tubular sodium reabsorption increases to maintain sodium levels. too much sodium can cause the system to become overstressed which leads to edema in legs
what effect does pooling fluids in the legs have on the kidneys?
how do you treat it?
- causes less blood flow to the kidneys.
- elevating the legs is preferable over diuretics
how much protein leakage into the urine is acceptable during pregnancy?
a slight protein leakage of +1 is acceptable
what changes occur to the integumentary system due to pregnancy?
1) hyperpigmentation due to melanotropin release from anterior pituitary
2) stretching
3) vascular changes
4) changes to the hair and nails
what occurs due to pregnancy related hyperpigmentation?
1) linea nigra
2) melasma
3) darkening of the nipples, areolas, vulva, and thighs
linea nigra
a dark vertical line from the symphysis pubis to the fundus
* starts as linea alba (before pigmentation)
* not present in all pregnant women
linea alba
less pigmented vertical line that runs from the symphysis pubis to the fundus (becomes more visible when it becomes pigmented)
melasma/chloasma
brownish facial pigmentation that is exacerbated by the sun
* usually fades after pregnancy
striae gravidarum
stretch marks
* occur on the abdomen, breasts, and thighs
* occurs due to separation of collagen
* 50-90% of women will have these stretch marks
does the mother or the fetus grow the placenta?
the fetus
what does the woman’s body see the placenta as?
a foreign invader due to fathers genetic material
how does the placenta protect itself from the mothers immune system?
before the mothers immune system has a chance to attack, the outer layer of the placenta hides it from the mothers body
HCG
a hormone produced by the placenta that causes the lining of the uterus to produce a protein/milk as a snack for the placenta/embryo until a blood supply is obtained
* this is the hormone detected in pregnancy tests
how is a blood supply obtained for the placenta?
- the placenta invades the uterine wall with tentacles that absorb blood.
- the uterus toughens to keep them from traveling all the way through
whos DNA does the placenta contain?
the offspring its housing
when the placenta cant break through the uterus and cant get enough blood what does it do?
the placenta produces a protein that serves as a distraction in another area of the uterus causing immune cells to relocate giving it an opportunity for the placenta to break through to a blood supply
human placental lactogen
a hormone secreted by the placenta that causes the nutrients in the mothers blood to remain in the blood giving the placenta the opportunity to absorb nutrients
preeclampsia
high BP caused by the placenta forcing the mothers heart to pump more blood
* emergency*
what does pregnancy do to the hair and nails?
- excessive hair growth
- accelerated nail growth (hirsutism)
- scalp hair loss is decreased
hirsutism
accelerated nail growth
what are the vascular changes to the integumentary system associated with pregnancy?
1) spider angiomas
2) palmar erythema
3) increase in perspiration related to increased blood supply
spider angiomas
vascular spiders
palmar erythema
blotches on hands
changes to the musculoskeletal system associated with pregnancy:
1) increased body weight
2) lordosis
3) increased mobility of pelvic joints
4) separation of abdominal muscles
lordosis
center of gravity is more forward
what causes changes to the mobility of pelvic joints?
what do these changes do to gait?
the ovarian hormone relaxin causes relaxation and increased mobility of pelvic joints
* causes mother to have a waddling gait
diastasis recti abdominis
persistent separation of the muscles of the abdominal wall
NSAIDs and pregnancy
no NSAIDs are allowed during pregnancy because it can cause renal anomolies and premature closure of ductus arteriosis
ductus arteriosis
temporary blood vessels that connect the aorta and pulmonary artery to a fetus
what are treatments for diastasis recti abdominis?
1) rest
2) ice
3) heat
4) massage/PT
5) tylenol
6) CAM
7) yoga/exercise
what are some neurologic system changes that occur in pregnancy?
1) sciatica
2) carpal tunnel syndrome
3) headaches
4) syncope, lightheadedness, faintness
5) muscle cramps
sciatica
compression of pelvic nerves
what causes carpal tunnel in pregnancy?
edema around peripheral nerves
what are Sx of carpal tunnel syndrome?
burning, paresthesia, and pain from hand to elbow
what sort of headaches are associated with pregnancy?
migraines and tension headaches
describe headaches associated with pregnancy
- migraines - may increase or decrease
- tension headaches - may increase or decrease
EDD
estimated delivery date
LMP
last menstrual period
what phase of pregnancy is syncope common in?
in early stages of pregnancy
what are common causes of syncope, lightheadedness, and faintness during pregnancy?
1) hypoglycemia
2) postural hypotension
3) vasomotor instability
what are pregnancy related muscle cramps often due to?
hypocalcemia
changes in appetite related to pregnancy:
- hunger and cravings
- nausea and vomiting (morning sickness or hyperemesis gravidarum)
- pica
pica
craving for non-food material
when does morning sickness usually end?
the beginning of the 2nd trimester
changes with the mouth related to pregnancy:
1) ptyalism
2) gum hypertrophy–>bleeding gums
is dental care covered under Medi-Cal?
yes
ptyalism
excessive salivation
changes with the esophagus, stomach, & intestines related to pregnancy:
1) regurgitation/heartburn
2) hiatal hernia
how many pregnant women experience hiatal hernia?
up to 20%
changes to the gallbladder & liver related to pregnancy:
1) cholelithiasis
2) cholecystitis
3) cholestasis
4) increased gallbladder emptying time and thickening of bile
cholelithiasis
gallstones
cholecystitis
inflammation of the gallbladder
why do pregnant women get heartburn?
delayed stomach emptying related to increased hormones
what causes changes in pregnant women’s mouths?
increased estrogen
what is a common cause of abdominal discomfort in pregnant women?
constipation
purpose of prolactin in pregnant women?
prepares breasts for milk production
purpose of oxytocin in pregnant women?
- stimulates uterine contractions
- stimulates milk ejection (let down)
source of prolactin and oxytocin?
pituitary gland
purpose of parathyroid hormone in pregnant women?
Ca and Mg regulation
purpose of cortisol in pregnant women?
- stimulates production of insulin
- increases peripheral resistance to insulin
purpose of aldosterone in pregnant women?
- stimulates reabsorption of excess sodium from the renal tubules
source of cortisol and aldosterone?
adrenal glands
purpose of additional insulin secretion from pancreas?
production of insulin increased to compensate for insulin antagonism caused by placental hormones
what hormones are secreted by the placenta?
progesterone and estrogen
what hormones are secreted by the corpus luteum?
progesterone and estrogen
gravidity
person who is pregnant
nulligravida
never been pregnant
primigravida
first time pregnant
multigravida
2 or more pregnancies
parity
number of births after 20 weeks of gestation
nullipara
has never completed a pregnancy past 20 weeks
primipara
completed 1 birth at later than 20 weeks
multipara
2 or more births at later than 20 weeks
do fetal/neonatal deaths count for parity?
yes
what is G P?
gravidity & parity
pre-term
neonate born before 37 weeks (up to 36+6)
term
child born 37+0 - 41+6
post-date
child born 40+0 - 41+6
post-term
child born after 42 weeks of gestation
G
T
P
A
L
G - gravida
T - term
P - preterm
A - abortion (can be therapeutic abortion or spontaneous abortion(miscarriage))
L - living children
Chances of survival @
21 weeks or less
22 weeks
23 weeks
24 weeks
25 weeks
26 weeks
27 weeks
30 weeks
34 weeks
are infants born between 22-25 weeks viable?
they are on the cusp of viability and are at increased risk of neurological injury if they survive
viability
ability to live outside the womb; begins at about 22 weeks
hCG
early biological marker of pregnancy
when does hCG production begin?
at implantation
when is hCG detectable in maternal serum or urine?
7-8 days before expected menstrual period
difference between qualitative and quantitative pregnancy tests (hCG tests):
qualitative: +/-
quantitative:
* measures hCG levels
how do hCG levels rise and fall
rises until peak at50-70 days of pregnancy and then decreases
quickening
being able to feel the fetus move in belly
what are presumptive signs of pregnancy?
1) breast changes
2) amenorrhea
3) nausea & vomiting
4) urinary frequency
5) fatigue
6) quickening
what are probable signs of pregnancy?
1) positive preg test
2) Goodell, Chadwick, Hegar signs
3) Braxton hicks contractions
4) ballottement
what are positive signs of pregnancy?
1) ultrasound
2) fetal heart tones via doppler
3) fetal movements
look over slide 27 PP2 for other causes that can cause signs of pregnancy
EDD
estimated delivery date
LMP
last menstrual period
how do you calculate EDD?
LMP - 3 months + 7 days (adjust year as needed)
when is the initial prenatal visit typically?
in the first trimester (0-13 weeks)
time frame of the first trimester
0-13 weeks
what is involved with prenatal history taking in the initial visit?
1) ob/gyn hx
2) nutritional hx
3) meds (include OTC)
4) supplements
5) family hx
6) social/environmental factors
7) occupational hx
what is done at initial visit for pregnancy?
1) prenatal history taking
2) medical history
3) reason for seeking care
4) other health concerns
5) review S/Sx
6) coping
7) labs
what are screenings for fetal chromosomal abnormalities?
- nuchal translucency check via ultrasound @ around 12 weeks
- labs for free beta hCG and PAPP-A
**increased NT, increased free beta hCG, and decreased PAPP-A can suggest aneuploidy
NT
nuchal translucency
hCG
human chorionic gonadotropin (hormone)
PAPP-A
pregnancy associated plasma protein A
what lab tests are involved in the initial prenatal visit?
1) CBC
2) blood type and Rh factor
3) rubella titer
4) HIV screen
5) HbsAG screen
6) RPR/VDRL
7) Tay-Sachs
8) sickle cell
9) cystic fibrosis
10) glucose tolerance test HgbA1c
11) pelvic
12) pap smear
13) culture for STIs
14) TB skin test
first trimester priority education:
1) schedule for prenatal visits
2) anticipatory guidance for discomforts of pregnancy
3) S/Sx to report immediately
4) Kegal exercises
5) nutritional needs
S/Sx that pregnant women should report immediately
1) vaginal bleeding/cramping
2) syncope
3) intractable nausea/vomiting
what is included with nutritional needs education for pregnant women?
1) adequate but not accessive weight gain
2) begin prenatal vitamins (especially Folic acid)
3) things to avoid consuming
what should pregnant women avoid consuming?
1) raw foods (sushi, shellfish, beef, tartare, soft cheeses
2) deli meats and salads (egg/potato salad)
3) high-mercury containing fish
4) limit caffeine
5) alcohol (no safe amount)
6) medications/herbs/supplements (unless reviewed with MD/CNM)
what is the time frame of the 2nd trimester?
14-26 weeks
what is included in a second trimester prenatal visit?
1) VS
2) physical exam
3) auscultate FHT
4) discuss birth plans
5) labs
how much weight should a pregnant woman gain during pregnancy?
about 1lb/week (25-35lbs total)
what is an especially important VS to watch out for in second trimester prenatal visits?
BP: elevated BP could be an indication of developing gHTN or preeclampsia
what blood pressures would be alarming in a second trimester prenatal visit?
- above 140/90
- an increase in systolic higher than 30 over baseline
- an increase in diastolic higher than 15 over baseline
when we do a urine dip in a second trimester prenatal visit, what are we looking for?
protein or glucose higher than specs
what is involved with a physical exam at a 2nd trimester prenatal visit?
1) assess breasts and nipples and ask about their feeding preferences
2) ask about quickening (starts at approx 20 weeks)
what lab tests are involved with a 2nd trimester prenatal visit?
1) urine dip ( for protein and glucose)
2) quad screen (15-20 weeks)
3) amniocentesis (prn)
what is quad screen used to detect?
- down syndrome
- neural tube defects such as spina bifida and anencephaly
- other chromosomal defects
what is measured in a quad screen?
- MSAFP
- hCG
- UE
- Inhibin A
priority education topics in the second trimester:
1) ongoing care needs
2) S/Sx of potential complications
S/Sx of potential complications in pregnancy (2nd trimester)
1) bleeding
2) decreased fetal activity
3) preeclampsia S/Sx
4) PPROM
5) infections
S/Sx of preeclampsia
1) headache
2) blurred vision/visual disturbance
3) epigastric pain
4) swelling in face/fingers
5) muscular irritability
PPROM
PROM - prelabor rupture of membrane
PPROM - preterm PROM
S/Sx of PPROM
amniotic fluid discharge
S/Sx of infections
- chills
- fever
- burning with urination
how to measure fundal height between weeks 24-36
- measured from symphysis pubis to top of uterus in CM
- should be equal to weeks of gestation between weeks 24-36
what can decreased fundal height indicate?
- IUGR- intrauterine growth restriction
- SGA - small for gestational age
- fetal death
what can increased fundal height indicate?
- macrosomia - big baby
- multifetal gestation - twins or more
- polyhydramnios - too much amniotic fluid
interventions for common discomforts (headaches)
- rest
- hydration
- acetaminophen
interventions for common discomforts (constipation)
- hydration
- exercise
- prune juice
interventions for common discomforts (varicose veins)
- elevate legs
- support stockings
interventions for common discomforts (food cravings)
- small meals help keep blood sugar steady
interventions for common discomforts (heartburn)
- small meals
- sit up after eating
- no spicy foods
- antacids (tums)
interventions for common discomforts (joint/ligament pain)
- support garments
- abdominal binder
- prenatal yoga and/or massage
what is involved in a third trimester prenatal visit?
1) VS
2) fundal height measurement
3) physical exam (may include vaginal/cervical exam toward end of pregnancy)
4) labs
5) Rhogam
when is Group beta strep culture done?
35-37 weeks
Rhogam injection
given between 26-28 weeks for Rh - moms
what is included in third trimester labs?
1) GBS ~35-27 weeks
2) GTT (26-28 weeks)
3) STI screen
4) urine dip for protein/glucose
GTT
glucose tolerance test
what time frame is the 3rd trimester?
27-40 weeks
what education is involved with a 3rd trimester prenatal visit?
1) interventions for discomforts (same as 2nd trimester)
2) discuss S/Sx of onset of labor & when do call OB triage/head to hospital
3) how to manage mood swings
4) parenting role
5) planning for birth and newborn (C/S vs vaginal)
S/Sx that indicate a need to call or head to the hospital
1) regular, strong contractions
2) ROM
3) loss of mucus plug
4) bloody show
5) high kick counts (10/2)
6) S/Sx of preeclampsia
what are the three phases of psychological development when a woman is pregnant?
1) accepts biological fact - “I am pregnant”
2) accepts need to nurture fetus - “I am going to have a baby”
3) prepares for role of parent - “I am going to be a mother”
state of mood in the 3rd trimester?
1) may be dealing with rapid mood changes
2) may have feelings of ambivalence (mixed feelings)
Couvades syndrome
sympathetic pregnancy - father feels some of the same (psychosomatic) symptoms as pregnant partner
fathers may begin to identify with their new role as a father. what can affect this?
may be influenced by how their own father was
grandparent responses:
1) if only in 30s or 40s may lack interest; may be non-supportive
2) may see pregnancy as a renewal of their youth
3) pregnancy may help bridge a previous estrangement
sibling adjustment
1) may feel replaced (first crisis for child)
2) consistancy in their life helps them accept the new arrival
3) they need to be prepared to be big brother or sister
what are some special considerations related to immunization for the pregnant women?
- no live, or live attenuated viral vaccines
- flu, TDAP, and covid vaccines recommended
what are some special considerations related to traveling during pregnancy?
1) air travel may be restricted toward end of pregnancy due to increased risk of DVT (avoid after 7 months)
2) if traveling via car for long periods of time make sure to stop frequently and walk around to avoid venous stasis
hot tubs and saunas while pregnant?
avoid hot tubs and saunas for long periods of time
what areas should pregnant women avoid?
areas with zika virus or covid hotspots
seat-belt use while pregnant
should be worn under belly, not over
what are some maternal concerns related to multifetal pregnancies?
1) increased BV–> increased strain on CV system
2) increased anemia
3) increased uterine distension–> increased separation of abdominal muscles
4) increased risk for placenta previa
5) increased risk for separation of placenta
6) lack of preparation (financial, emotional, educational, space)
7) possible need for selective reduction
8) risk of prematurity
9) PROM
selective reduction
when one or more fetuses are aborted in a multifetal pregnancy to increase the chances the other fetuses will survive
dizygotic twins
originates from 2 fertilized ova and 2 sperms (will see 2 corpus luteum)
monozygotic twins
originates from 1 ovum
* increased risk of congenital malformations
dichorionic twins
wont know if they’re identical or fraternal until delivery
monochorionic twins
if the egg divides before day 5 = diamniotic
if the egg divides between day 7 -13 = monoamniotic
