Normal Pregnancy

1. Normal Pregnancy

2. Pregnancy is a normal physiologic process . . . . . . not a disease!

3. Is she pregnant?

4. Presumptive symptoms of pregnancy: • Cessation of menses • Nausea with or without vomiting • Frequent urination • Fatigue • Breast tenderness, fullness, tingling • Maternal perception of fetal movement (“Quickening”)

5. Presumptive signs of pregnancy: • Breast changes – enlargement, hyperpigmentation, Montgomery’s tubercles • Bluish or purplish coloration of the vaginal mucosa and cervix (Chadwick’s sign) • Increased skin pigmentation – chloasma, linea nigra • Appearance of striae on abdomen and breasts

6. Probable signs of pregnancy: • Enlargement of the abdomen • Changes in the size, shape, and consistency of the uterus • Changes in the cervix • Palpation of Braxton-Hicks contractions • Outlining the fetus manually • Endocrine tests of pregnancy

7. Positive signs of pregnancy: • Identification of the fetal heart beat separately and distinctly from that of the mother • Perception of fetal movements by the examiner • Visualization of pregnancy on ultrasound • Fetal recognition on X-ray

8. Assessment of Gestational Age • By LMP (last menstrual period) – the mean length of a normal pregnancy is 280 days from the first day of the last normal menstrual period • By physical exam • By ultrasound

9. Using the “Wheel” • Put the arrow marked FIRST DAY OF LMP on the appropriate date • The arrow marked APPROXIMATE DATE OF DELIVERY at the 40-week mark gives you the EDD • Today’s date gives you the EGA today

10. Naegele’s Rule • Add 7 days to the first day of the LMP, then subtract 3 months • EXAMPLE: LMP = October 15 + 7 days = October 22 - 3 months = July 22 = EDD

11. Uterine Sizing • 6 weeks – globular with softening of the isthmus, size of a tangerine • 8 weeks – globular, size of a baseball • 10 weeks – globular with irregularity around one cornua (Piskacek’s sign), size of a softball • 12 weeks – globular, size of a grapefruit

12. Uterine Sizing

13. Accuracy of Dating by Ultrasound

14. The Trimesters • The “trimesters” are three periods of 14 weeks each • 1st trimester = through completion of 14 weeks • 2nd trimester = through completion of 28 weeks • 3rd trimester = 29th through 42nd weeks

15. Gravida and Para • Gravida means a woman who has been, or currently is, pregnant • Para means a woman who has given birth • Nulligravida – never been pregnant • Primigravida – pregnant for the first time • Primipara – has delivered once • Multipara – has delivered more than once

16. G T P A L • G – GRAVIDA (how many pregnancies) • T – TERM (how many term deliveries) • P – PRETERM (how many preterm deliveries) • A – ABORTIONS (how many abortions, spontaneous or induced) • L – LIVING – how many children currently living

17. Term, Preterm, Abortion • TERM means delivery occurring in weeks 38-42 • PRETERM means delivery occurring in weeks 20-37 • ABORTION means delivery occurring before 20 weeks • POSTTERM means delivery occurring after week 42

18. Psychological Adaptation and Developmental Tasks of Pregnancy • 1st Trimester • Accepting reality of pregnancy • 2nd Trimester • Resolving feelings about her own mother; defining herself as a mother • 3rd Trimester • Active preparation for childbirth and baby

19. The First Prenatal Visit: History • Past medical history • Family medical history • Gynecologic history • Past OB history • Exposures to infections, teratogens, genetic problems • Social history • Nutritional status

20. HEENT Fundoscopic exam Teeth Thyroid Breasts Lungs Heart Abdomen Extremities Skin Lymph nodes The First Prenatal Visit: Exam

21. Vulva Vagina Cervix Uterine size Adnexae Rectum Labs: Pap GC & chlamydia Clinical pelvimetry: Diagonal conjugate Ischial spines Sacrum Subpubic arch Gynecoid pelvic type? The First Prenatal Visit: Pelvic Exam

22. Bones and Joints of the Pelvis

23. The Diagonal Conjugate • The obstetric conjugate extends from the middle of the sacral promontory to the posterior superior margin of the pubic symphysis. This is the most important diameter of the pelvic inlet. • The diagonal conjugate extends from the subpubic angle to the middle of the sacral promontory and can be measured clinically to estimate the obstetric conjugate.

24. The Ischial Spines • The transverse diameter, between the ischial spines, is a measurement of the dimensions of the pelvic cavity

25. The Pelvic Outlet • Subpubic arch • Bituberous (transverse) diameter • Inferior pubic rami

26. The First Prenatal Visit: Labs • ABO blood type • D (Rh) type • Antibody screen • CBC • Rubella • VDRL or RPR • HBsAg • HIV (optional) • Hemoglobin electrophoresis (as appropriate)

27. What to expect during the course of prenatal care Risk factors encountered Nutrition Exercise Work Sexual activity Travel, seat belts Smoking cessation Avoidance of drugs and alcohol Warning signs Where to go or call in case of problems Prenatal vitamins The First Prenatal Visit: Counseling

28. The Return Prenatal Visit • REVIEW THE CHART! • Calculate the EGA • Check the labs • Review weight gain • Review blood pressure • Review results of UA

29. Appropriate Weight Gain in Pregnancy

30. The Three “B’s” --- Baby, Belly, Bottom

31. Leopold’s Maneuvers • What is in the fundus?

32. Leopold’s Maneuvers • Where is the back and where are the small parts?

33. Leopold’s Maneuvers • What is the presenting part?

34. Measuring Fundal Height

35. Auscultating Fetal Heart Tones

36. The Routine OB Visit Schedule • Every 4 weeks until 28 weeks • Every 2 weeks from 28 until 36 weeks • Every week from 36 weeks until delivery • Six weeks postpartum

37. 15-20 weeks 24-28 weeks 35-37 weeks Quad Screen Diabetes Screen H&H Rhogam workup & injection Group B strep culture Other Routine OB Labs

38. Pregnancy is a normal physiologic process, not a disease . . . • however, pregnancy tends to be UNCOMFORTABLE. Your challenge is to differentiate common discomforts of pregnancy from pathology!

39. Nausea with or without Vomiting • Starts at 4-6 weeks, peaks at 8-12 weeks, resolves by 14-16 weeks • Causes: unknown; may be rapidly increasing and high levels of estrogen, hCG, thyroxine; may have a psychological component • Rule out: hyperemesis gravidarum

40. Ptyalism • Excessive salivation accompanied by nausea and inability to swallow saliva • Cause: unknown; may be related to increased acidity in the mouth

41. Fatigue • Causes: unknown; may be related to gradual increase in BMR • Rule out: anemia, thyroid disease

42. Upper Backache • Cause: increase in size and weight of the breasts • Relief: well-fitting, supportive bra

43. Low Backache • Cause: weight of the enlarging uterus causing exaggerated lumbar lordosis • Rule out: pyelonephritis (CVAT)

44. Leukorrhea • Definition: a profuse, thin or thick white vaginal discharge consisting of white blood cells, vaginal epithelial cells, and bacilli; acidic due to conversion of an increased amount of glycogen in vaginal epithelial cells into lactic acid by Doderlein’s bacilli • Rule out: vaginitis, STI, ruptured membranes

45. Urinary Frequency • 1st trimester: increased weight, softening of the isthmus, anteflexion of the uterus • 3rd trimester: pressure of the presenting part • Rule out: UTI

46. Heartburn • Relaxation of the cardiac sphincter due to progesterone • Decreased GI motility due to smooth muscle relaxation (progesterone) • Lack of functional room for the stomach because of its displacement and compression by the enlarging uterus • Rule out: GI disease

47. Constipation • Decreased peristalsis due to relaxation of the smooth muscle of the large bowel under the influence of progesterone • Displacement of the bowel by the enlarging uterus • Administration of iron supplements

48. Hemorrhoids • Relaxation of vein walls and smooth muscle of large bowel under influence of progesterone • Enlarging uterus causes increased pressure, impeding circulation and causing congestion in pelvic veins • Constipation

49. Leg Cramps • Cause: unknown. ? inadequate calcium, ? Imbalance in calcium-phosphorus ratio • Relief: straighten the leg and dorsiflex the foot:

50. Dependent Edema • Cause: impaired venous circulation and increased venous pressure in the lower extremities • Rule out: preeclampsia