normal preg prenatal care

presumptive signs

subjective, what patient reports.

could be preg or other cause

examples

- amenorrhea

- tender breasts

- morning sickness

- fatigue

- urinary frequency, nocturia

- perception of fetal movement (quickening)

probable signs

objective

Enlargement of abd/uterus

Color/consistency diff in vagina, cervix, & uterus

Palpation of fetal outline, fetal movements, uterine contractions

Ballottment of fetus (cervix exam)

Positive pregnancy test

positive signs

audible FHT

visualization of fetus on ultrasound

EDB (due date)

by LMP using neageles rule

neageles rule

first day of last period

-3 months

+7 days

+1year

We can use Naegele's Rule to calculate the estimated date of birth if the person:

has know LMP

regular cycles

didnt conceive on hormonal contraception or breast feeding

by US (reliable before 15weeks)

first trimester

- first day of LMP through end of 13wks

second trimester

14 through end of 27wks

third trimester

28 through end of week 40+

abortion = miscarriage = early pregnancy loss

same meaning

Chemical = biochemical = anembryonic = blighted ovum.

preg progressed to + hCG

but not enough for a yolk sac or embryo.

diagnosis can be difficult bc it could be just too early or if its anembryonic

This is a situation in which the diagnostic time lag comes into play

threatened abortion

bleeding, catch all term

bleeding in early pregnancy.

often used as a dx of exclusion or a catch-all term when we can't attribute the bleeding to anything specific (yet).

cervix closed and a heart beat present

Inevitable and incomplete abortion

means bleeding + pain + an open cervix, when there is clinical certainty that the pregnancy loss is in progress.

happens at home

Missed abortion.

no bleeding or pain AND no cardiac activity,

even though pregnancy is advanced enough that there should be cardiac activity.

A way to remember

"The pregnancy has ended but the person's body 'missed' initiating a miscarriage

induce a abortion because fetus isn't alive anymore

Complete abortion.

when all pregnancy products have been expelled. A way to remember complete abortion is: "The miscarriage has been completed."

28 week testing

STIs like HIV, RPR, HBV

For a low-risk pregnancy, prenatal visits will be every

4 weeks until 32 weeks (8 months).

Then every 2 weeks. Starting at 36 weeks visits will be weekly until birth.

At 1 hour if bs is over 135 they will need a

3 hour test, 100g of sugar of some drink ,

3 values are taken and if 2 are elevated then they have gestational diabetes.

Need 2 doses of penicillin

28 weeks

3 hour glucose tolerance test

Administered following a 3 day high carb diet and 8 hour overnight fast, baseline fasting glucose level drawn, patient drinks 100g oral glucose, blood glucose drawn at 1, 2, and 3 hours. If two or more values are elevated then diagnosis of GD happens.

first prenatal appointment

head to toe physical assessment

- pap smear, STI, prenatal labs

medical history

gynecologial/reproductive history

- intercoursre

- pap

- type of birth

- LMP

when do they do the first prenatal appointment

8-12 weeks

in the first trimester

first prenatal appointment testing?

carrier testing (CF, tay-sachs, sickle cell, spinal muscular atrophy)

Fetuses cannot make their own

thyroid hormone until mid-pregnancy, so they are dependent on the mother's thyroid hormone

Prenatal Labs

◦CBC with platelets

◦NL HGB (1st tri:

Alpha-fetoprotein (AFP)

components of triple, quad, penta, integrated, and sequential screens can detect neural tube defects. It can be added to any test.

diagnosit testing?

chronionic villus sampling

amniocentesis

nuchal translucency ultrasound looks at the amount of

fluid in the fetal neck (nuchal fold). Normal NT is 3.5 millimeters- ultrasound is done between 11- and 14-weeks gestation.

Increase in fluid could indicate increased risk of cardiac anomalies, trisomy (18 & 21), Turners syndrome, or viral infection.

first trimester screening

chronic villus sampling

nuchal translucney ultrasound

NIPs/NIPt/Cell-free DNA (cfDNA)

NIPS (non-invasive prenatal screening)

As early as 9-10 weeks; Tests fetal DNA in mother's blood for trisomies

can id sex

chorionic villus sampling

can id sex, chromo dx,

amniocentesis

dx chromo, can help eval neural tube defect.

TORCH Infections in Pregnancy

Toxoplasmosis

other infections

rubella

cytomegalovirus

herpes simplex virus

Toxoplasmosis

- cause

- transmission

- signs/symp in infants

toxoplasma gondil

water, meat, cat feces

seizures, chorioretinitis (eye inflam), hydrocephalus

Other infections

- includes syphilis, varicella-Zoster, Parvovirus B19

syphilis

- cause

- signs

treponema pallidum

rash, osteochondritis, hepatospenomegaly

varicella zoster

- cause

chickenpox-during pregnancy

parovirus B19

- cause

- signs

resp droplets

hydrops fetalis, fetal anemia

rubella

- cause

- transmission

- signs

rebella virus

resp drop

cataracts, CHD, hearing loss, "blueberry muffin" rash

Cytomegalovirus

- cause

- transmission

- signs

CMV (herpes virus family)

body fluids

hearing loss, IUGR, dev delay, microcephaly, jaundice, bludeberry muffin rash, thrombocytopenia

herpes simplex virus

- cause

- transmission

- signs

HSV1/2

direct contact (during delivery)

skin lesions, encephalitis, disseminated infection, CNS disease, mult organ involvement

prevention and management of TORCH

screening

prophylactic measures

monitoring interventions postnattally

every prenatal visit

•Weight

•Blood pressure- 120/80 or less is normal

•FHT- 110-160

•Edema

•+ FM (fetal movement/quickening) after 15wks

•Count fetal movement beginning at 28 weeks gestation (or 26 weeks for high-risk) until birth Count The Kicks!

•10 movements in an hour without trying to elicit a response (e.g., drinking something cold, eating something sweet, etc.)

•If less than 10 movements patient should call the provider

•Fundal height

•20- Umbilicus +/- 1 or 2 fingerbreadths= palpation

•22 weeks- (22cm from the symphysis to the fundus- +/- 2 cm of gestational age = 20 - 24 cm using tape measure

•40weeks 3-4 finger breaths below the umbilicus

all or nothing period

Until 4 weeks, exposures will either cause miscarraige or have no effect

embryonic period

the period from 2 to 8 weeks after fertilization, during which the major organs and structures of the organism develop

Fetal Non-Stress Test (NST)

- when is it preformed

measures HR in response to fetus's own movement.

>28 weeks gestation

usually 20-30mins

Reactive strip (NST)

normal baseline

2 accelerations

reasons for NST

Post dates,

decreased fetal movement,

HTN of any kind,

DM/GDM,

multiple gestation.

Biophysical Profile (BPP)

BATMaN

breathing movements of fetus

amniotic fluid volume

tone of fetus

movement of fetus

non stress test

8-10 normal

4 or less - abnormal

alcohol

artificial sweetener

what to do?

avoid alcohol

artificial sweetener safe to use in moderation

fish what to do?

choose low fat fish, white, flaky fish, shellfish

unpasteurized foods what to do?

avoid, in cheese, mold

•In most cases it is safe and recommended to eat fish through your pregnancy to maximize

Omega-3 fatty acids, mono-unsaturated fats, and protein.

most fresh water fish are safe, salmon is healthy, no albacore tuna

prenatal vitamins and supplements

can decrease neural tube defects

calcium 1200mg,

folic acid400mcg, vit B, iron

DHA sup good for neruo dev

ferrous sulfate (with Vit C)

under 50 is anemic

FDA Pharmaceutical Pregnancy Categories for OTC Medications~

- What is safe

- What is not safe

category A

adequate and well controlled human studies demonstrate no risk.

- vitamins

category B

animal studies demonstrate no risk, but no human studies have been preformed

OR

animal studies dem a risk, but human studies demonstrated no risk

category C

animal studies dem a risk but no human studies, benefits may outweigh risks

ibuprofen

category D

human studies demonstrate a risk. potential ben may outweigh risks

category X

both dem a risk, risk outweigh potential benefits

•As a rule, you may safely take any over the counter medication that does not contain

ibuprofen or aspirin.

hemorrhoids meds

insomnia meds

preparation H, cortaid

unisom, tylenol PM

Ibuprofen can cause premature

premature closure of the ductus arteriosus and decreased amniotic fluid.

vaccines recommened for preg patients

Tdap

influenza inactivated

COVID19

RSV

recommeneded for certain preg vac

hep A, B, meingococcal

vacc contraindicated in preg

influenza live

MMR

Varicella (VAR)

human papillomavirus (HPV)

ETOH

ethyl alcohol

•Treatment for alcohol use disorder-

acamprosate and naltrexone- NAS scoring

•Treatment for opioid use disorder-

Suboxone or Methadone- NAS scoring

estrogen in pregnancy

growth

breast tissue enlargement,

uterine tissue enlargement,

maintains the uterine line,

triggers the dev of fetal organ ,

causes increased uterine contractions

progesterone in pregnancy

thickens the uterine lining,

prevents the body from ovulating while pregnant

slows GI

relaxes uterus and smooth muscle

vasodilation to increase blood flow to uterus

both E and P are produced around

8th week of pregnancy

reproductive system changes during pregnancy

- uterus

shape

increased blood flow for growth

reproductive system changes during pregnancy

- cervix

chadwicks sign - increased blueish blood, purple hue

goodells sign - soften cervix

increase in cervical mucus for mucus plug

leukorrhea (whitish vaginal discharge)

reproductive system changes during pregnancy

- vulva

increase blood

vaginal stretching

reproductive system changes during pregnancy

- ovaries

LH stims the corpus luteum it makes progesterone for 6-7wks

then placenta takes over

reproductive system changes during pregnancy

- breast

stretch marks

montgomery glands enlarge for lubrication for nipple tissue

colostrum

integumentary changes

linea nigra

palmer erytheme

melasma

varicose veins

increased acne

pruritus

rule out cholestasis

slowing or stoppage of bile flow from gallbladder

common in 2 to 3 trimester, goes away after 1-2wks after birth

rule out pruritic urticarial papules and plagues (PUPPs)

rash spreads to arms and legs

linea nigra

dark pigment line

palmer erythema

red, itchy palms,

an increase in estrogen and blood volume,

malasma

mask or pregnancy

varicose veins

on legs, even labia during preg,

fade after birth

increase in acne is because

increase hormones

dry itchy skin can be because?

- treatment?

skin being stretched tight

could be a sign of cholestasis

if it spreads to arms and legs it could be prutritic urticarial papules and plagues (PUPP)

ursodiol - lowers bile acid in blood

what lowers bile acid in blood

ursodiol

neuro and cardiac changes

neuro - carpel tunnel and syncope

cardiac - hypertrophy and increase blood volume = + CO

needs iron because hemodilution

blood changes in WBCs

supine hypotensive syndrome

supine hypotensive syndrome

pressure from uterus on vena cava decreases amount of venous return from the lower extremities and caused - BP

causing dizziness, diaphoresis, and pallor

•Dizziness and syncope are often caused by a

drop in blood pressure.

Most pregnant people experience low blood pressure during early pregnancy that tappers off by 24 weeks. This low blood pressure occurs as a result of vasodilation (Estrogen, Progesterone, & Relaxin) and more blood being rerouted to the fetus. This is usually benign and transient condition.

•Cardiac hypertrophy occurs during pregnancy as a consequence of both

volume overload and hormonal changes.

Both pregnancy- and exercise-induced cardiac hypertrophy are generally thought to be similar and physiological

resp changes

•Growing uterus elevates the diaphragm, causing SOB

•GI changes

•Slowing of the GI tract

•Urinary changes

•Pregnancy affects both the kidney and the remainder of the urinary tract

•Increased renal size

•Kidney volume increases by up to 30 percent, primarily due to an increase in renal vascularity and interstitial volume.

•Ureters:

•Dilatation of the ureters and renal pelvis

can be visualized on ultrasound examination by the second trimester, and may not resolve until 6 to 12 weeks postpartum

Pregnant women are at increased risk for UTIs. Beginning in week 6 and peaking during weeks 22 to 24, approximately 90 percent of pregnant women develop

ureteral dilatation,

which will remain until delivery (hydronephrosis of pregnancy).

Increased bladder volume and decreased bladder tone, along with decreased ureteral tone, contribute to increased urinary stasis and ureterovesical reflux.

Common Discomforts

n/v - increasing hormones

fatigue

nasal congestion - E&P increase blood

upper lower backache - progesterone relaxes cartilages

leukorrhea - high E stims vascularity, important to let area breath

urinary frequency - pressure and P

dyspepsia - P relaxes sphincter and enlarges uterus

ptyalsim - + salivation

other common discomforts

Flatulence- decreased GI motility, pressure uterus on abdominal contents

Constipation-progesterone relaxes

Dental Problems- hormones make gums more edematous and friable

Leg Cramps-Calcium and phosphorus, more pressure on major blood vessels, r/o serious conditions

§Dependent Edema- vascular relaxation

Nocturia-at night blood flow to the kidneys is better

Insomnia

Round Ligament pain-can be scary-nothing all the way to PTL

Numbness and tingling in the fingers-carpel tunnel

Supine Hypotensive Syndrome

Varicosities-vascular relaxation

Dyspareunia-pelvic congestion, position, psychological

common first trimester complaints

Extreme tiredness Tender,

swollen breasts.

Upset stomach with or without throwing up (morning sickness)

Cravings or distaste for certain foods

Mood swings

Constipation

Need to pass urine more often

Headache

Heartburn Weight gain or loss

common second trimester complaints

Body aches

Stretch marks

Darkening of the skin

A line on the skin running from belly button to pubic hairline

mask of pregnancy.

carpal tunnel syndrome

Itching on the abdomen, palms, and soles of the feet. (Call doctor if nausea, loss of appetite, vomiting, jaundice or fatigue combined with itching. These can be signs of a serious liver problem.)

Swelling

common thrid trimester complaints

SOB until lightening occurs

Heartburn

Swelling

Hemorrhoids

Constipation

may leak colostrum

Belly button may stick out Insomnia

Lightening (2-4 weeks before birth)

Contractions