Prenatal care

explain the fluctuation of human chorionic gonadotropin hormone (HCG) during pregnancy

increases 66% every 48 hours during early pregnancy then peak, peaks at 10 weeks, then decreases throughout second trimester and then levels off

how do we confirm pregnany?

ultrasound

what are some common breast changes with pregnancy?

breast enlargement and tender nipples larger and more erectile with darkening of areola and prominence of the Montgomery glands

explain the cause behind morning sickness

elevated levels of progesterone, estrogen, HPL, and HCG

what do we have to see to diagnose hyperemesis gravidarum that sets it apart from morning sickness

persistent vomiting, acute starvation, weight loss at least 5%, and electrolyte, thyroid, and/or liver abnormalities

explain the documentation of pregnancies, children, and if they are alive or not

GPTPAL

G: number of pregnancies including current

P: broken up into the TPAL

• T: term pregnancies (37+ weeks)

• P: preterm: 20-36 weeks

• A: abortions (ectopic pregnancies, abortions, miscarriages, etc.)

• L: living children

if the uterine size does not match the estimated date of delivery (Naegele’s rule), then what do we use?

ultrasound

what is Naegele’s rule for estimating the EDD (estimated delivery date)?

FDLMP - 3mo + 7 days + 1 year

note: leap year subtract 1 day

physiology changes a lot during pregnancy. What is the outcome of increased estrogen?

hypercoagulable state and stimulates prolactin

physiology changes a lot during pregnancy. What is the outcome of increased progesterone?

SOB; GERD; hydronephrosis

physiology changes a lot during pregnancy. What is the outcome of increased HCG?

supports the corpus luteum (the corpus luteum and HCG both decrease as pregnancy continues)

physiology changes a lot during pregnancy. What is the outcome of increased HPL?

gestational diabetes

physiology changes a lot during pregnancy. What is the outcome of TSH?

hypo or hyperthyroidism

physiology changes a lot during pregnancy. What is the outcome of increased relaxin?

ligament laxity; pubic symphysis mobility

How do we set up the patient for a physical exam when pregnant?

semi-seated position with head of bed elevated at least 30 degrees

hips and knees slightly flexed and avoid extended periods in supine position after 20 weeks

what might we see on PE for a pregnant pt? (5)

rash or hyperpigmentation (melasma), swollen gums (epulis), prominent Montgomery glands (on breasts), nipple discharge and nipple inversion

when listening to the heart of a pregnant pt, you may notice mammary souffle. What does this reflect?

increased blood flow in normal vessels (heard at 2nd or 3rd intercostal space at sternal border)

briefly describe linea nigra, melasma, and striae gravidarum (tings you may see on PE of a pregnant pt)

line nigra: brownish black line along midline of abdomen

melasma: face discoloration (“mask of pregnancy”)

striae gravidarum: stretch marks on abdomen that appear purplish

How do we measure fundal height?

less than 20 weeks: finger breadth approximation

20+ weeks: tape measure from top of pubic symphysis to top of uterine fundus

when can you start to hear the fetal heartbeat? what is the rate? what instrument do we use?

after 10-12 weeks

use doppler (handheld doptone)

early: 150-160 then slows to 120-140 near term

what weeks are the 1st, 2nd, and 3rd trimester?

1st: 13 weeks and 6 days

2nd: 14 weeks - 27 weeks ans 6 days

3rd: after 28 weeks until delivery

what do we use Leopold’s maneuver for?

to determine the fetal lie (how the baby is positioned) within the maternal abdomen

start in 2nd trimester, most accurate after 36 weeks

what is this?

a dark blue to purplish-red congested appearance of the vaginal mucosa

Chadwick’s sign

what is this?

occurs during 1st trimester; softening of uterus at junction with cervix

Hegar’s sign

what is this?

softening and cyanosis of the cervix after 4 weeks

Goodell’s sign

what is this?

softening of the uterus after 6 weeks

Ladin’s sign

what are the 4 recommended vaccines during pregnancy, what are the 3 that are unsafe?

recommended: Tdap, influenza, RSV, and Covid

unsafe (live): MMR, polio, varicella

what is the window to give the Tdap vaccine to a pregnant pt?

27 - 36 weeks GA

explain exercise and pregnancy

it is important to stay active during pregnancy

what are two screening questionnaires we need to make sure to go over with our pregnant pts?

Edinburgh postnatal depression scale and domestic/intimate partner violence questionnaire

what are 4 main reasons for the pregnant pt to contact the physician?

vaginal bleeding, leakage of fluid form vagina, uterine contractions, and decreased fetal activity

what are the increments for follow up visits for a pregnant pt?

0-28 weeks: 1 visit every 4 weeks

28-36 weeks: 1 visit every 2 weeks

36+ weeks: 1 visit per week

40+: 2 visits per week

what are 4 screenings we do at the 3rd trimester

gestational diabetes screening, Rh factor (this is repeated from first visit if negative blood type), CBC, and RPR (high risk populations)