Maternity Exam 1

Week 1 & 2

Menstrual Cycle Terms

Menarche = first period

Frequency = 21-36 days, average 28 days

40 year reproductive lifespan

…………………..

Ovarian Cycle = Ovaries

-Follicular Phase = Day 1 to Ovulation

—mature follicles into mature egg

-Ovulation = Day 14 usually

—follicle ruptures into mature egg, goes to fallopian

—basal body temp increases 0.4deg

—sperm live 3-5days in vag

-Luteal Phase = Day 15 to day 28

—ruptured follicle becomes corpus luteum

…………………..

Endometrial Cycle = Uterus

-Proliferative Phase

—thicken endometrium due to high estrogen

-Secretory Phase

—continue to thicken, corpus luteum supports

-Ischemic Phase

—cut off perfusion to encourage shedding

-Menstrual Phase

—shedding endometrium

………………………………..

Luteal + Secretory

Follicular + other Endometrial

Menstrual Hormones

Gonadotropin-releasing Hormone, GnRH

-pulsed from hypothalamus throughout cycle

—make pituitary release FSH & LH to support ovulation

……………………….

Follicle-stimulating Hormone, FSH

-secreted by anterior pituitary

—highest during first week of follicular phase

-release & mature ovarian follicles

………………………

Luteinizing Hormone, LH

-secreted by anterior pituitary

—surges 10-12hr before ovulation

-final maturation of preovulatory follicles & luteinization of ruptured follicle

-stimulate ovulation & corpus luteum

—decrease estrogen, increase progesterone

Corpus Luteum

Temporary endocrine gland

—produces progesterone = thicken lining for pregnancy

Produced after ovulation, second half of menstrual

………….

Pregnancy: produce progesterone until placenta takes over

—12 weeks

No Pregnancy: dissolve, decrease progesterone, initiate menstruation

Other Hormones

Estrogen

-responsible for female sexual characteristics

-secreted by ovaries

—develop & mature follicle

—increase size & weight of uterus

—expand blood supply

…………………………….

Progesterone

-secreted by corpus luteum

—induce swelling, increase endometrial secretion

—reduce uterine contractions, maintain pregnancy

…………………………..

Prostaglandins

-primary mediators of inflammatory process

—key for ovulation: free ovum from follicle

-VERY present in menstrual blood

Perimenopause

2-8 years before menopause

………………

Most common vasomotor: hot flashes, night sweats

-due to loss of estrogen

—Hormone Replacement Therapy, HRT

…..

Irritability/mood issues

Vaginal dryness/dyspareunia

—dyspareunia = pain during/after sexual intercourse

Irregular periods

Brain fog

Low libido

Menopause

12 consecutive months without a period

-Average age: 51-52 years old

…………….

Perimenopausal symptoms persist but decrease

…………….

Treatment

-DEXA Scan

-Vitamin C & D

-Weight-bearing exercises

-Reduce alcohol & caffeine = reduce vasomotor symptoms

-stop smoking

-vaginal moisturizers & hormonal creams

-HRT not over 65yo

Amenorrhea

Absence of menses

-Dysfunction in hypothalamus-pituitary-ovary axis

…………………………..

Primary = failure to reach menarche

-congenital abnormalities

—mullerian agenesis = no vagina

—Turner syndrome = defective gonads

—transverse vaginal septum

—imperforate hymen

-GnRH deficiency, PCOS, hypothyroidism

-stress, excessive exercise, weight loss, anorexia & eating disorders

-chronic illness = diabetes, thyroid disease, depression, pregnancy, ovarian/adrenal tumors

…………………………….

Secondary =absence of menses for 3 cycles OR irregular menses for 6 months

—previously menstruated regularly, not due to pregnancy, breastfeeding, or menopause

-Asherman syndrome = pregnancy intrauterine adhesions

-Sheehan Syndrome = postpartum pituitary necrosis

-Functional hypothalamus amenorrhea

—GnRH deficiency related to eating disorders, stress, excessive exercise

-Systemic diseases: diabetes, celiac

-pituitary, ovarian, adrenal tumors

-hyperprolactinemia, thyroid conditions, PCOS

-primary ovarian insufficiency

………………………………………………………..

Diagnostics

-Pelvic/vaginal ultrasound

-human chorionic gonadotropin hCG = pregnancy?

-thyroid panel, prolactin, FSH, LH

-17 hydroxyprogesterone = adrenal tumor?

-karyotype = turner syndrome?

Dysmenorrhea

Primary = painful menstrual bleeding

-absence of underlying pelvic pathology

—increased prostaglandin production in ovulatory cycle causes uterine contractions

-Risk Factors: younger age, smoking, stress

……………………..

Secondary = painful menstrual bleeding due to pelvic/uterine pathology

—endometriosis, pelvic adhesions, adenomyosis, fibroids, PID, IUS, cervical stenosis, congenital abnormalities

……………………

Treatment

-First line = NSAIDS, hormonal contraceptives

-Tranexamic acid TXA

-massage therapy

-acupuncture

Abnormal Uterine Bleeding AUB

Umbrella term = changes to normal menstruation pattern

-heavy bleeding, increased length of menses

……………………

Diagnostics

-Pelvic Ultrasound US

-thyroid panel, CBC, protein C&S, Von Willebrand, HcG

-endometrial biopsy

…………..

Treatment

-combined oral contraceptives, IUD

-Depo provera

-Tranexamic acid TXA = antifibrinolytic

-iron infusion if anemic

Premenstrual Disorders

Premenstrual Syndrome PMS

-luteal phase physical/emotional/behavioral symptoms

—resolves with menstruation

-peaks 5-7days prior to menses

………………………

Premenstrual Dysphoric Disorder PMDD

-more severe variant of PMS

—more chronic, occurs most days

…………………………………………………………

Nursing Management

-stress reduction techniques

-no smoking, alcohol

-SSRIs

Polyps

Mucous membrane growths

-typically benign

…

Most common in multiparous, premenopausal women

…

Manifestations

-sometimes no symptoms

-bleeding after sex, intermenstrual bleeding

….

Diagnostics & Treatment

-pelvic ultrasound, hysteroscopy

-excise tissue, send to pathology to check malignancy

Uterine Fibroids

AKA myomas, leiomyomas

…..

Benign tumors in uterus

-smooth muscle, fibrous connective tissue

…..

Estrogen dependent = risk shrinks with menopause

-highest incidence during reproductive years

Most common reason for hysterectomy

More prevalent in black women

……………….

Treatment

-OCP, IUD

-GnRH antagonists

—elagolix, Orlissa

-GnRH agonists

—leuprolide, Lupron

-UAE, myomectomy, hysterectomy

…………………………

Types

-Sub-serousal = underneath outermost peritoneal layer of uterus

—grow outside uterus

-Intramural = grow within uterine wall

—most common

-Sub-mucosal = grow below endometrium into uterine cavity

-Cervical

Polycystic Ovarian Syndrome PCOS

Most common endocrine condition in women at reproductive age

Most common reason for infertility

Higher risk of pregnancy & birth complications

……..

Follicles have cyst-like appearance

-eggs never mature, ovulation doesn’t occur

………

Causes

-metabolic syndrome, insulin resistance, obesity, diabetes, liver disease, dyslipidemia

-obstructive sleep apnea, cardiovascular risk

-infertility, endometrial cancer

…………………

Symptoms

—Big 3: polycystic ovaries, irregular periods, excessive androgen

-irregular menses, oligomenorrhea

-hirsutism

…………………

Treatment

-OCPs

-metformin

Endometriosis

Estrogen-dominant chronic inflammatory process

-endometrium-like tissue implants outside uterus

—called lesions

—throughout abdominal cavity = bowel, bladder, ovary, uterosacral ligaments, diaphragm, pleural cavity

…………………..

Pelvic pain throughout the month

-lesions swell & respond to hormones

……………………

UNKNOWN causes

-correlations = 1st degree relative, low BMI, tall height, shorter menstrual cycle under 17 days

…………………….

Treatments

-OCs, Progestins

-Long-acting GnRH analogs = create pseudo-menopause

…………………….

Surgery

-lysis of adhesions, laparoscopic surgery

-hysterectomy may not relieve pain if lesions remain

Infertility

In Women

-overweight or underweight, eating disorders

-scarred fallopian tubes, uterine fibroids, endometriosis, ectopic pregnancy, PID

-oligo-ovulation or anovulation

-older age, exposure to chemo agents

…………………………………………………..

In Men

-exposure to toxins = mercury, chemo, X-rays

-smoking, diabetes, STIs

-frequent bike-riding, anabolic steroids, low sperm

……………………………………………………

Assessment

-semen analysis

-hysterosalpingogram

…………………

Options

-IUI = intrauterine insemination

-IVF = in-vitro fertilization

-Medications: Clomid = induce ovulation

………….

…………..

Pre-Contraception Assessment

Bleeding pattern during cycle

Current meds

Adherence to meds

….

Do you ever want to be pregnant?

Contraception uses

Prevent pregnancy

……..

Functional ovarian cyst

AUB, dysmenorrhea, menorrhagia, amenorrhea, PMS, PMDD, Endometriosis

Acne

Migraines

Breast conditions

Contraception Hormoens

Estrogen = Ethinyl

-inhibit ovulation through FSH suppression

-stabilize endometrium to prevent bleedings

-Side Effects: tenderness, nausea, headache

—Contraindicated = Blood clot

……………………..

Progestin = Norethindrone, levonorgestrel, noregestimate, drospirenone

-most effective contraceptive effect

—inhibits ovulation through LH suppression

—inhibits sperm penetration via cervical mucous thickening

-Side Effects: bloating, mood issues, weight gain

Combined Contraception COC

Pill, Patch, Ring

…..

Contraindications

-smoking over 35yo

-blood clot, stroke

-migraine with aura

-current breast cancer

-severe hypertension

-childbirth under 45 days ago

Oral Contraceptive Pills

Monophasic = consistent hormones throughout cycle

Multiphasic = vary hormones throughout cycle

……………

Pattern of Use

-monthly cycling = typical use

—break fr a week for withdrawal bleed

-extended/continuous use

—2+ cycles, fewer periods

………………

Missed pill?

-24-28hr window: take pill immediately

-Over 48hr: take 2 pills, use back up method for 7day

……………….

Barriers

-adherence to med, timing

Contraceptive patch

continuous daily systemic dose

….

New patch weekly for 3 weeks

1 patch-free week

……………………………………

Rotate application sites

-never on breast

-commonly causes skin irritation

Vaginal Ring

Plastic ring, continuous dosing system

…

3 weeks in, 1 week out

…………

Keep in during sex

Wash hands before insertion

…………

Vaginal irritation

Gotta be comfortable putting in independently

Birth Control RED FLAGS

ACHES

-Abdominal pain

-Chest pain

-Headache

-Eye problems

-Severe leg pain/Swelling of legs/feet

Hormone Side Effects

Estrogen

-Nausea

-breast tenderness

-Increased BP, trigs

-Arterial thrombosis

-VTE, DVT, PE

……………………………

Progestin

-fatigue

-breast tenderness

-depression

-increased insulin resistance

-weight gain

-menstrual irregularities

Progestin-Only Contraception Methods

Progestin-only Pill

Injectable

Implant

IUD

Progestin-Only Pills POP

lower dose than in COCs

safe for breastfeeding & when can’t have estrogen

…….

must take the same time every day

-miss a pill, take & use back up method for 48hr

……..

Common Side Effect: menstrual irregularities

Progestin-Only Injectable DEPO

Administered ever 12-15 weeks

-SubQ, IM

-Not immediately reversible for ovulation

—at least 12 months

………………………..

Lack of period in 50% of patients

Weight gain, irregular bleeding

Decrease in BMD

Increase LDL, lower HDL

Implant, Nexplanon

Implanted under skin

-Lasts 5 years

………..

Reduce dysmenorrhea & endometriosis pain

Irregular bleeding, amenorrhea

Levonorgestrel IUD

Slows ovum transport, increase cervical mucous, inhibit sperm motility

-reversible & resume ovulation quickly

……

Mirena Liletta = 8 years

Kyleena = 5 years

Skyla = 3 years

………..

Irregular bleeding & cramping first few months after insertion

Check strings monthly at home

Copper IUD

Non-hormonal

-copper hostile to sperm

-can be used as emergency contraception

……………

ParaGard = up to 10 years

Emergency Contraception

Inhibit or delays ovulation

-doesn’t stop already existing pregnancy

………………….

Levonorgestrel = Plan B pill

-pills taken within 72hr after unprotected intercourse

UPA Ella

-within 120hours of unprotected sex

—more effective than Plan B

Copper IUD

Other Contraception Methods

Abstinence, Withdrawal Method

Breastfeeding/Lactation

Sterilization

Fertility Awareness = basal body temp for ovulation

…..

Vaginal Spermicides = Phexxi

-change vaginal pH

Cervical diaphragm

-prevent semen form entering cervix

Sponge

-use for 24hr, leave in place 6hr after intercourse

………….

……………….

Cervical Cancer

caused by HPV

-vaginal intercourse, anal/oral sex, intimate skin-skin contact

…………………

Pap smears

-start age 21

-q3 years until 30yo

-q5 years 30+ & if paps normal

……………….

Colposcopy & LEEP to remove abnormal tissue

Endometrial Cancer

AKA uterine cancer

Most common GYN cancer

…………..

Change in bleeding pattern, increase in heaviness

BTB

bleeding after menopause!!

………..

Pelvic ultrasound US

endometrial biopsy

Ovarian Cancer

Often deadliest GYN cancer due to late diagnosis

………..

Older women, 63+

White women

BRCA genetic mutation

……………………….

Vague Symptoms

-bloating

-weight loss over time

-pelvic pain

………………………………

Serous = most common

-originates at distal end of fallopian tube

Vaginal Cancer

Rare

Largely caused by HPV

90% are SCCs that began in vaginal epithelium

……….

Older women, 67 average age

…………

If localized: radiation, local incision, laser surgery

If metastasized: hysterectomy, remove lymph nodes, may also need radiation

Vulvar Cancer

Rare but aggressive

Usually SCCs

…………

Post-menopausal: 60s-70s

………………

Precancerous changes = Vulvar intraepithelial neoplasia VIN

…………..

First Type = HPV infection, occurs in younger women

Second Type = older women

………

………

STIs

Women more susceptible than men

-due to anatomy

………..

Can cause cervical cancer, infertility, ectopic pregnancy, chronic pelvic pain, death

…………

46% occur in 15-24yo

-risky sexual behavior

-unwillingness to disclose sexual activity

-delay medical treatment due to fear/shame

—untreated infections can lead to PID/inferility in women

Infections Affecting Vaginal Discharge

Vaginitis = inflammation, infection

………………..

Candidiasis = yeast infection, VVC

-itching

-white, thick, curd-like discharge

-History: pregnancy, diabetes, recent antibiotics abx, obesity, tight clothes

-Treatment: Monistat, fluconazole/Diflucan

………………..

Trichomoniasis = protozoan

-itching

-foamy, foul-smelling discharge

-strawberry cervix

-Treatment: metronidazole 500mg BID for 5-7day

………………..

Bacterial Vaginosis BV = gram neg Bacillus

-fishy odor

-lactobacilli replaced with higher concentration of anaerobic bacteria

—vaginal pH higher than 4.5

-Treatment:

—oral metronidazole 500mg BID for 7day

—vag metronidazole 0.75% nightly for 5nights

—clindamycin intravaginally for 7nights

Infections Causing Cervicitis

Chlamydia = bacterial parasite

-highest risk age 14-24yo

-can be asymptomatic

—mucopurulent vaginal discharge

—abnormal bleeding

—infection/inflammation of urethra, endometrium, tubes

-In Pregnancy: chorioamnionitis, PROM, SAB, low birth weight

—transferred during vaginal birth causing ophthalmia neonatorum = blindness in baby

-Treatment:

—doxycycline 100mg oral PID for 7day

—azithromycin 1g oral once

…………………………….

Gonorrhea = aerobic gram neg bacteria

-mucopurulent vaginal discharge

-dysuria

-AUB

-In Pregnancy: chorioamnionitis, PROM, SAB, low birth weight

—transfer during vaginal birth to cause blindness

-Treatment: ceftriaxone 500mg IM AND azithromycin 1g oral once

—treat both chlamydia & gonorrhea because co-infection is common

Infections Causing Genital Lesions

Genital Herpes Simplex HSV

-spread through sexual contact, vaginal birth, kissing

-may be asymptomatic

—painful vesicular lesions

—mucopurulent discharge

—tingling, itching, pain = prodromal phase of virus

—fever, chills, malaise, headache

-Treatment: antivirals

—Valacyclovir, Acyclovir

……………………………………

Syphilis = spirochete

-spread through sexual contact or congenital

-painless ulcers

-4 stages: primary, secondary, tertiary, latent

-In Pregnancy: SAB, low birth weight, PROM, stillbirth

—check labs early & at 28 weeks

-Treatment: penicillin G 2.4 million units IM

—when latent: need 3 doses at weekly intervals

-Check again 6, 1, 18 months

Non-Curable STIs

Hepatitis B

-transmitted via saliva, blood, semen, vaginal secretions

-flu-like symptoms:

—malaise, rashes, fatigue, anorexia, nausea, pruritus, fever, RUQ pain

……………

HIV

-deplete CD4 T-cells = opportunistic infections

-transmitted via vaginal, oral, anal secretions & IV drug use

-asymptomatic at first, symptoms than depend on viral load

—flu-like symptoms

………….

Human Papilloma Virus HPV

-most common STI

-painless, flesh colored genital warts

-can cause cervical, vaginal, anal, penile, & oropharyngeal cancer

Pelvic Inflammatory Disease PID

Inflammatory disorders caused by an ascending infection of genital tract

—usually chlamydia or gonorrhea

………

Risk Factors:

-25yo

-multiple sex partners

-IUD within 3 weeks, lack of condoms

-history of STI and PID

…………….

Can scar fallopian tubes, increasing infertility risk

…………..

Treatment:

-Ceftriaxone 500mg IM single dose

-AND doxycycline 100mg oral BID for 14 days

-AND metronidazole 500mg oral BID for 14 days

Intimate Partner Violence

Risk Factors:

-depression

-heavy drinking & drugs

-young age

-low income, unemployment, financial stress

-marital conflict, dysfunctional stress

……………….

Children can develop psychiatric disorders & low self-esteem

Lasts longer if women have children

Breast Disorders

Any non-cancerous breast abnormality

…….

Non-proliferative epithelial lesions

-breast cysts = most common

-fibrocystic changes = lumpy/tender before menses

—overgrowth of fibrous tissue in connective tissues supporting breast

—wear supportive bra, oral contraceptives, low-fat diet, vitamin E & D supplements, hot/cold packs, diuretics, reduce salt, NSAIDs, surgical removal

Fibroadenoma

proliferative lesions in breast without atypia

—atypia = cell abnormalities

fibrous & glandular tissue

—round, oval, firm, rubbery, smooth

—mobile, may be tender

—usually unilateral

…..

most common benign tumor type in breast

most common 15-35yo

…..

stimulated by hormones AKA estrogen

-grow during pregnancy, smaller with menopause

………

Can be surgically removed

Breast Cancer

Risk Factors:

-older women, white, BRCA genes

-delayed childbearing, nulliparity, never breastfed

-history of radiation to chest-especially during puberty, family cancer history

-high breast density, postmenopausal obesity

-alcohol

………………..

Diagnosis

-mammogram, MRI ultrasound

-fine needle aspiration, sentinel lymph node biopsy

-hormone receptor status

……………….

Treatment

-surgery = mastectomy

-radiation, chemotherapy

-hormone/endocrine therapy, immunotherapy

………

………..

Fertilization

start of pregnancy

takes place in outer third of fallopian tube

….

sequential process

—gamete formation, ovulation, fertilization, uterine implantation

Multiples

identical = monozygotic twins

-fertilized egg splits into 2 fetuses

-share 1 placenta

-typically look alike & same gender

……………………

Fraternal = dizygotic twins

-2 separate eggs, 2 different sperm

-separate placenta

-share 50% of genes, can be different sexes

Stages of Fetal Development

Pre-embryonic = Preconception to Day 14

Embryonic = Day 15 to Week 8

Fetal = Week 9 to Birth

Pre-embryonic Stage

Conception to Day 14

………………………….

Zygote = ovum fertilized by sperm

Zona Pellucida = clear protein layer blocking other sperm

Cleavage = mitosis, as zygote transports to uterus

..

Morula = 16 cells, look like solid ball

..

Blastocyst = cells divide, fluid filled space appears

-hollow ball of cells, eventually forms embryo & amnion

Trophoblast = outer layer of cells

-develops into embryonic membranes, chorion, & placenta

………………..

Chorion = outermost embryo layer, villi on surface

Amnion = thin protective membrane containing amniotic fluid

Yolk sac = second cavity develops 8-9 days after conception

-transfers maternal nutrients/oxygen to embryo for weeks 2-3 until placenta takes over

………………………..

Phases:

-ovum, fertilization, zygote, morula, blastocyst, implantation

Embryonic Stage

Day 15-Week 8

Basic structures of all major organs form

Most vulnerable to teratogens

………………………

Embryonic Layers

-Ectoderm = CNS, special senses, skin, glands

-Mesoderm = skeletal, urinary, circulatory, reproductive

-Endoderm = respiratory, liver, pancreas, digestive

Teratogens

Risks vary by timing & dosing

-most risky during embryonic stage

………………

Physical = ionizing radiation

Infections = rubella, CMV, toxoplasma, syphilis, varicella, herpes

Maternal conditions = diabetes, obesity, thyroid disorders, PKU

Drugs/chemicals = anti-epileptics, high-dose vitamin A, anti-coagulants, tetracyclines

..

Alcohol, tobacco, unprescribed drugs

Fetal Stage

Week 9 until Birth

……………………

All major systems present in basic form

-growing & refining

-lungs last to mature

…

Determine fetal sex by week 12

Gestational Age = Fertilization age + 2 weeks

Full term = 38 weeks

……………………………………………………..

Weeks 16-20

-quickening = first fetal movement

-vernix = white wax protecting skin

-lanugo = soft hair protecting skin/keep warm

-can hear fetal heart tones

-kidneys secrete urine into amniotic fluid

…………………….

Weeks 21-24

-alveoli & lung surfactant formation

-able to survive outside uterus

-translucent & red skin

…………………….

Weeks 29-32

-rhythmic breathing movements, lungs not fully mature

-store iron, calcium, & phosphorus

………………….

Weeks 33-38

-lanugo disappears

-increase body fat, filling uterus

-mom gives antibodies

Fetal Circulation Shunts

Close after birth

Direct oxygen-rich blood into systemic circulation while bypassing underdeveloped pulmonary

………….

Ductus venosus = umbilical vein to inferior vena cava

Ductus arteriosus = main pulmonary artery to aorta

Foramen ovale = anatomic opening between right & left atria

Placenta

Makes hormones

Protects fetus from maternal immune response

Remove waste from fetus

Provide nutrients & oxygen from mother to fetus

…………

3 vessel chord = 1 vein, 2 arteries

Wharton’s Jelly = surrounds BV of umbilical cord to prevent compression

…………………………..

Hormones

-chorionic gonadotropin = preserve & help progesterone production

-prolactin = lactation, regulated insulin production

-human placental lactogen hPL = develop breasts for lactation, decrease maternal insulin sensitivity to increase fetal nutrition

-estrogen = uterine contractility, enlarge breast & uterus

-progesterone = decrease uterine contractility, maintain endometrium

-relaxin = relax pelvic ligaments, soften cervix

Amniotic Fluid

Maintain constant body temp for fetus

Permits symmetric growth & development

Cushions fetus from trauma

Keeps umbilical cord largely free of compression

Promote fetal movement for MSK development

…

40 weeks = 1000mL fluid

…………………

Polyhydramnios = more than 2000mL

-fetal GI abnormalities, neural tube defects, higher risk of surgical births due to fetal intolerance

……

Oligohydramnios = less than 500mL

-uteroplacental insufficiency, fetal renal abnormalities, higher risk of surgical births & low birth weight

…..

…….

Pregnancy

3 trimesters of 13 weeks

………….

Presumptive/Subjective Signs

-amenorrhea, breast tenderness = 3-4 weeks

-breast enlargement = 6 weeks

-N/V = 4-14 weeks

-fatigue = 12 weeks

..

-urinary frequency, hyperpigmentation of skin, fetal movements, uterine enlargement

……………

Probable/Objective Signs

-positive pregnancy test = 4-12 weeks

-abdominal enlargement

-Ballottement = 16-28 weeks

—feel fetus move with finger

-Braxton Hicks contractions = 16-28 weeks

-Goodell sign = 5 weeks

—cervix softens

-Chadwick sign = 6-8 weeks

—increase blood, vagina/cervix/vulva look bluish/purple

-Hegar sign = 6-12 weeks

—enlarged upper uterine body, lower uterus is soft

Positive Pregnancy Signs

Ultrasound verification = 4-6 weeks

Auscultation of fetal HR via doppler 10-12 weeks

Fetal movement felt by provider = 20 weeks

Reproductive Changes with Pregnancy

Uterus

-increase size, weight, length, width, depth, volume, overall capacity

-increased uterine contractility

-ascends into abdomen after first 3month

-fundal height by 20 weeks’ should be at umbilicus

-Vena cava syndrome = don’t lay on back

……………….

Cervix

-mucus plug formation

-increase vascularization = Chadwick sign

-ripens 4 weeks before birth

……………….

Vagina

-increased vascularity with thickening

-lengthening of vaginal vault

-secretions = more acidic, white, thick

—leukorrhea

………………

Ovaries

-enlarge until 12-14 weeks

-cessation of ovulation

…………….

Breasts

-increase in size & nodularity for lactation

-increased nipple size, more erect & pigmented

-production of colostrum after 12 weeks

—antibody-rich yellow fluid

—converts to mature milk after delivery

Other Body Changes with Pregnancy

GI/GU:

-gums = hyperemic, swollen, friable

-ptyalism = excess saliva

-gingivitis

-decreased peristalsis & smooth muscle relaxation

—constipation

-hemorrhoids

—constipation + increased venous pressure from uterus

-slowed gastric emptying

—heartburn

-prolonged gallbladder emptying

-N/V

-dilation of renal pelvis, elongation/widening/curving of ureters

-increased GFR, increased urine output

-increased kidney activity laying down

……………………….

Cardio/Respiratory:

-increased BV = 50% more

-increased CO, venous return, & HR

-slight decline in BP until midpregnancy

-increased RBC, though less than BV causing anemia

-increased iron demands

-increased fibrin, fibrinogen, clotting factors

—hypercoagulable state

-increased diaphragmatic excursion, chest circumference, tidal volume

—diaphragmatic breathing

-increased oxygen consumption

-congestion due to increased vascularity

……………………..

MSK/Integumentary:

-softened/stretched ligaments of sacroiliac joints & symphysis pubis

-postural changes: swayback, upper spine extension

-forward shift in center of gravity

-Lordosis = lumbosacral curve

-waddle gait

-hyperpigmentation, mask of pregnancy = facial melasma

-linea nigra on belly

-striae gravidarum = stretch marks

-varicose veins, vascular spiders

-palmar erythema

-decline in hair growth, increased nail growth

………………………..

Endocrine/Immune:

-thyroid enlarges, increased activity, increased BMR

-pituitary enlarges, decreased TSH, inhibit FSH/LH, increase prolactin/MSH, gradual increase in oxytocin

-pancreas: insulin resistance due to hPL in second half of pregnancy

-adrenal glands: increased cortisol & aldosterone

-prostaglandin

-Placenta: hCG, hPL, relaxin, progesterone, estrogen

-enhance innate immunity, suppress adaptive immunity

—increased infection risk, impact autoimmune chronic disease

Nutrition in Pregnancy

protein = 60-80 g/day

iron increases to 27g/day

calcium = 1000-1300mg/day

folic acid = 400-800 mcg/day

….

only increase in 300cal/day

—1800-2200 cal/day is nonpreg recommended

…….

potential nutritional issues:

vegetarianism, cultural diet, gluten-free, lactose intolerance

PICA = graving dirt & concrete & brick

—your body is craving minerals

bariatric surgery

-first 12-18 month after causes malabsorption restriction

—can compromise fetal growth IUGR

………

Sketchy foods

-artificial sweeteners

-fish & shellfish,

-processed/prepared foods, raw/unpasteurized milk

Pregnancy BMI & Weight Gain

Healthy BMI = 18.5-25

-gain 25-35lb

—first tri = 3..5-5lb

—second & third tri = 1 lb/week

……………………

Underweight BMI = under 18.5

-gain 40lb

—first tri = 5lb

-second & third tri = 1+ lb/week

…………………..

Overweight BMI = 25-30

-gain 15-25lb

—first tri = 2lb

—second & third tri = 2/3 lb/week

..

Obese = over 30

-gain 11-20lb

…..

……..

First Visit after missing period

AKA amenorrhea visit

………………

preconception counseling, patient feelings

urine pregnancy test

schedule ultrasound for confirmation

Naegele’s rule to approximate due date EDD/EDC

—=LMP -3months + 7 days then adjust for year?

First prenatal visit

establish trust, determine family support

..

OBGYN history

-first day of last menstrual period LMP

-gravidity = # pregnancies

-parity = outcomes of pregnancies

—T = term = 37-42week

—P = preterm = 20-37week

—A = abortion = early loss prior to 20 weeks

—L = living children

..

Current Preg

-EDC or EDD

..

Med History

-allergies, immunization, STIs

…

Physical assessment

-BMI

Pregnancy Slang

Gravida I, primigravida

—first pregnancy

Gravida II, secundigravida

—second pregnancy

……………………….

Para = had at least 1 child last beyond 20week gestation

Primipara, primip

—1 birth

Multipara, multip

—2+ births

Nullipara, para 0

—no viable offspring

Pregnancy Diagnostics

Pelvic Exam, Pap smear

-Cervical smear if abnormal pap smear

—Intervene after delivery: GC/CT

..

Ultrasound = first trimester, 18-20week anatomy scan

………………………………….

Labs

-urinalysis = each visit

..

Rubella titer, Hep B antigen

HIV, VDRL, RPR testing = treat first visit & 37week

GBS from cervical sample at 36week

..

-CBC = first visit, 24-28weeks

-blood typing

-Rh factor

—need rhogam at 28weeks, up to 72hr after delivery

..

HBAIC = 24-28week, 6week postpartum

—also first week if have risk factors

Pregnancy & Immunizations

Yes:

Hep B

Inactivated flu

Tdap

Rabies

…………………….

No:

live/activated flu

MMR

Varicella

BCG aka tuberculosis

typhoid

Frequency of Pregnancy Visits

Up to 28weeks = every 4weeks

29-36weeks = every 2weeks

37week-birth = every week

…………………..

Weight, BP,

fundal height, fetal quickening

—Major growth benchmarks: 12, 20, 36, 38

FHR = 110-160bpm

urine testing = protein, glucose, ketones, nitrites

Pregnancy RED FLAGS

First Trimester

-bleeding, painful urination

-lower abdominal pain

-severe/persistent vomiting

-dizziness with shoulder pain

………………….

Second Trimester

-uterine contractions, sudden gush of fluid

-calf pain

-no fetal movement for more than 12hr after 29+ weeks

………………

Third Trimester

-sudden weight gain, periorbital/facial edema

-severe upper abdominal pain

-headache with visual changes

-decreased fetal daily movement for 24+ hr

Genetic Testing & Fetal Well-Being

Maternal Serum Tests:

Alpha fetoprotein analysis = 15-20week

—defect = higher level AFP in amniotic fluid

..

Marker screening tests = quad screen, PAPP-A

-noninvasive method, first trimester

—low maternal PAPP-A at 11-13 week = placenta not working = stillbirth, preterm, preeclampsia, chromosomal issues

-fetal aneuploidy = trisomy 13, 18 21

-neural tube defects

……………………………………….

Nuchal Translucency Screening = 11-14 week

—increased translucency = chromosomal abnormalities as they have higher collagen/connective tissue

..

Chorionic villus sampling CVS = 10-13 weeks

-biopsy placental tissue for prenatal genetic testing

..

Amniocentesis = 15-20week

-transabdominal puncture of amniotic sac for sample

—invasive procedure

..

Doppler Flow studies = 28 week

..

Percutaneous umbilical blood sampling PUBS

Non-stress test

Contraction stress test

biophysical profile

Non-Stress Test NST

Fetal Heart Rate Reactivity test

..

Performed after 28week if maternal risk factors

..

EFM in semi-fowlers or on side

-press button when feel fetal movement

Takes 20-30 min

……

Goal Outcomes = REACTIVE NST

Normal FHR baseline

Average Variability

2+ accelerations over 20min period

Contraction Stress Test CST

Fetal response to uterine contractions

—early warning of fetal compromise = hypoxia, asphyxia

………….

Performed at full term if maternal risk factors OR non-reactive NST

Fetal monitor for 20-30min

-elicit uterine activity of 3 contractions/10min through nipple stimulation or IV oxytocin/pitocin

………..

Goal Outcomes = NEGATIVE CST

-no late decelerations with contractions in the 10-15min period

Biophysical Profile BPP

Fetal Well-being via 5 markers

-fetal tone, gross fetal movements, fetal breathing movements, & amniotic fluid volume

—via ultrasound

-fetal heart reactivity

—via NST

-present = 2 points, not present = 0 points

—8-10 is good, 6 is sus, 4 is bad

Trimester Discomforts

First Trimester

-urinary frequency/incontinence

-fatigue

-N/V, constipation

-breast tenderness

-nasal stuffiness, bleeding gums, epistaxis

-cravings

-leukorrhea

………………………

Second Trimester

-backache

-varicosities of vulva & legs

-hemorrhoids

-flatulence with bloating

…………………..

Third Trimester

-return of first trimester discomforts

-SOB, dyspnea

-heartburn, indigestion

-dependent edema

-Braxton Hicks contractions

Preparing for Birth

Education

-perinatal

-childbirth

—lamaze = breathing & relaxation techniques

—bradley = exercises, slow/controlled abdominal breathing, partner-coached

—dick-read, natural, fear reduction, abdominal breathing techniques

…………………..

Hospital, home birth, birth centers

Obstetrician, midwife, doula

breastfed, bottle-feed

…..

No saunas or hot tubs, overheating with exercise