[13.2] OB Part II (Maternal Physiologic Changes in Pregnancy)

From Ms. Haydee Bacani's Lecture Last August 20, 2025

1. Presumptive Signs

2. Probable Signs

3. Positive Signs

What are the categories of the signs of pregnancy?

a. Presumptive signs

Subjective

a. Presumptive signs
b. Probable signs
c. Positive signs

b. Probable signs

Objective

a. Presumptive signs
b. Probable signs
c. Positive signs

c. Positive Signs

Confirmatory

a. Presumptive signs
b. Probable signs
c. Positive signs

PRESUMMMPTIVE

• Pain

• Respiratory Changes

• Enlarged Breasts

• Skin Changes

• Urinary Frequency

• Movements

• Morning Sickness

• Menses Cessation

• Palmar

• Tiredness

• Increased Salivation

• Vaginal Discharges

• Enlarged Uterus/Abdomen

What are the Presumptive Signs of pregnancy?

PROBaBBLE

• Positive Serum Pregnancy Tests

• Reported

• Outline Felt by Examiner

• Ballotement

• Braxton Hicks

• Bluish Vagina

• Lower Uterine Softening

• Embryonic Sac

What are the Probable Signs of Pregnancy?

HOMES

• Heartbeat of Fetus

• Outline seen in Ultrasound

• Movement felt by

• Examiner

• Skeleton in Xray

What are the Positive Signs of Pregnancy?

1. Headache

2. Chest

3. Back

4. Leg

Presumptive Sign of Pregnancy: What kinds of pain are usually complained in pregnancy?

Mild, occassional

Presumptive Sign of Pregnancy (Pain): Describe the normal headache in pregnancy

Severe, continuous, unrelieved

Presumptive Sign of Pregnancy (Pain): Describe the abnormal headache in pregnancy

Increased blood volume by 40 to 50%

Presumptive Sign of Pregnancy (Pain): What is the normal cause of headache in pregnancy?

Increased Blood pressure

Presumptive Sign of Pregnancy (Pain): What is the abnormal cause of headache in pregnancy?

• Icepacks on the forehead

• Paracetamol (not NSAID → with bad effects to the baby)

Presumptive Sign of Pregnancy (Pain): How do you manage normal headache in pregnancy?

Visual Changes (Nadamay na optic nerve)

Presumptive Sign of Pregnancy (Pain): What are the complications of abnormal headaches in pregnancy?

Burning → Heartburn/Pyrosis

Presumptive Sign of Pregnancy (Pain): What is the normal chest pain in pregnancy?

GIT (Reflux Regurgitated)

SS

• Sphincter Relaxed

• Stomach pushed upward (enlarged uterus)

Presumptive Sign of Pregnancy (Pain): What are the causes of normal chest pain in pregnancy?

Flatulence

Presumptive Sign of Pregnancy (Pain): When there is increased HCL acid in the stomach, what could be the effect aside from pyrosis?

Decreased GIT motility

• Constipation

Presumptive Sign of Pregnancy (Pain): In pregnancy, what happens to the GIT motility? What results from that?

5Ss

1. SFF

2. Slow chewing (to avoid overeating)

3. Should wait 2-3 hours before lying down

4. Side: Left

5. Support pillow #2

Presumptive Sign of Pregnancy (Pain): What should you advice for pregnant patients with heartburn? (SSSSS)

ABTFC

• Alka-Seltzer (Antacid; Alkaline)

• Baking Soda (Alkaline)

• Tomatoes

• Fatty

• Citrus / Caffeinated Bev. / Cola / Cabbage

Presumptive Sign of Pregnancy (Pain): What should a pregnant patient with chest pain (pyrosis) avoid? (ABTFC)

Lower Back ONLY

• If umabot na sa harap → Labor

Presumptive Sign of Pregnancy (Pain): Describe the normal back pain in pregnancy

2Ps

• Posture: Pride of Pregnancy (Lordosis)

• Progesterone + Relaxin (Soften pelvic joints)

Presumptive Sign of Pregnancy (Pain): What are the causes of lower back pain in pregnancy? (PP)

HASSSSS

• Hot pads

• Acupuncture

• Stand Straight

• Support pillow (when sitting)

• Squatting (when picking something up) [NO BENDING]

• Shoes: Low-mod heeled [NO HIGH HEELS]

• Strengthen lumbar spine

  • Decreased Lower Back Pain, Easier Labor and Delivery

Presumptive Sign of Pregnancy (Pain): What should you encourage the pregnant patient with lower back pain to do? (HASSSSS)

Pelvic Rock

• Hollow Back for 1 minute then relax. Do it for 15 to 20 minutes

Presumptive Sign of Pregnancy (Pain): What exercise should you teach a pregnant patient with lower back pain?

Cramps

Presumptive Sign of Pregnancy (Pain): Describe the normal leg pain in pregnancy

Decreased calcium and increased phosphorus; Blood stasis from increased uterine pressure

Presumptive Sign of Pregnancy (Pain): What is the usual cause of leg cramps among pregnant women?

• Take Calcium 1g/day and Magnesium Ctrate/Lactate BID (Phosphorus Binder)

• Ambulate

• Elevate

Presumptive Sign of Pregnancy (Pain): How do you prevent leg cramps in pregnancy?

Dorsiflex foot towards her and extend the knee

Presumptive Sign of Pregnancy (Pain): How do you manage leg cramps?

Clot

• Venous thrombosis → Increased risk for embolism

Presumptive Sign of Pregnancy (Pain): What is the abnormal leg pain in pregnancy?

SHE

• Stasis: Uterine Pressure

• Head of Fetus: Venous Damage

• Estrogen: Thrombocytic

Presumptive Sign of Pregnancy (Pain): What are the causes of leg clots in pregnancy? (SHE)

1. Ambulate

2. Elevate

3. Hydrate

4. Elastic Stockings

   1. Before Arising

   2. Pantyhose

Presumptive Sign of Pregnancy (Pain): How do you prevent leg clots in pregnancy?

Homan’s Sign

• There is POSSIBLY a clot at the leg

Presumptive Sign of Pregnancy (Pain): What should you assess for leg clots? What does the positive sign mean?

Thrombophlebitis

Presumptive Sign of Pregnancy (Pain): What does it mean when there is pain, red, warmth, swelling, fever/chills at the leg?

ABCDE

• AVOID HAM

  • Hot compress (Can dislodge; Moist heat only)

  • Ambulation (Prevention only)

  • Massage (Prevention only)\

• Bed Rest: No CBR (Temporary)

• Call MD

• Doppler Ultrasound (Confirmatory) / Drug: Anticoagulants

  • Heparin ONLY (HEP ✋🚫 you cannot cross the placenta)

  • Warfarin NO NO (WAG → War with fetus; Teratogenic)

• Embolectomy (Surgery)

Presumptive Sign of Pregnancy (Pain): How do you manage leg clots? (ABCDE)

3Ss

• Shortness of breath in 3rd trimester

  • Cause: Enlarged Uterus

• Speedy breaths (Tachypnea)

  • Cause: Enlarged breaths

• Stuffiness of nose

  • Cause: Estrogen (Increased Vascularity)

Presumptive Sign of Pregnancy (Respiratory Changes): What are the respiratory changes in pregnancy, together with their cause? (SSS)

Relieved: Engagement

Effect: Lightening (gumaan ang pakiramdam)

Presumptive Sign of Pregnancy (Respiratory Changes): When does the shortness of breath be relieved and what is the effect called?

BREAST

• Blue Veins (increased vascularity from estrogen)

• Ready for Lactation (Estrogen + Progesterone + Human Placental Lactogen)

• Enlarged (Estrogen)

• Areola Darkens (Estrogen)

• Secretes Colostrum: 16 weeks

• Tender/Tingling (Esp in cold air; Estrogen)

Presumptive Sign of Pregnancy (Enlarged Breasts): What should you remember in relation to the enlarged breasts in pregnancy? (BREAST)

SKIN

• Striae Gravidarum / Spider Teleangiectasis

• Kloasma/Chloasma/Melasma

• Increased Pigments (Estrogen)

• Nigra (Linea)

Presumptive Sign of Pregnancy (Skin Changes): What should you remember about the skin changes in pregnancy? (SKIN)

Chloasma

Presumptive Sign of Pregnancy (Enlarged Breasts): Mask of pregnancy

Linea Nigra

Presumptive Sign of Pregnancy (Enlarged Breasts): Dark thin line mid abdomen

IHI

• Increased Bladder Pressure

• Hormones (HCG and Increased Aldosterone → Increased BV)

• Increased GFR and dilated ureters

Presumptive Sign of Pregnancy (Urinary Frequency): What should you remember about the urinary frequency in pregnancy? (IHI)

a. Mild

Presumptive Sign of Pregnancy (Urinary Frequency):

1st Trimester

a. Mild
b. Fades
c. Stronger

b. Fades

Presumptive Sign of Pregnancy (Urinary Frequency):

2nd Trimester

a. Mild
b. Fades
c. Stronger

c. Stronger

Presumptive Sign of Pregnancy (Urinary Frequency):

3rd Trimester

a. Mild
b. Fades
c. Stronger

Yes

• d/t increased eGFR and dilated ureters

Presumptive Sign of Pregnancy (Urinary Frequency): Is it normal for pregnant patients to urinate with glucose?

1. 20 weeks

2. 18-20 weeks

3. 16 weeks (mas maaga, mas sensitive na sila)

Presumptive Sign of Pregnancy (Movements): Identify the onset of quickening in the following:

1. Average

2. Primipara

3. Multipara

Kick Count

Presumptive Sign of Pregnancy (Movements): Fetal well-being assessment

1. OD

2. One hour / Post Meal (baka hindi gumalaw si baby kasi gutom)

3. Left recumbent

4. 10-12/hr (if less than 10, baka tulog si baby)

   1. Ambulate → repeat → if kulang pa rin → Report

Presumptive Sign of Pregnancy (Movements): Identify what is being described in the following in relation to kick count:

1. Frequency

2. Time

3. Position

4. Rate

   1. If below, what to do

Anytime, especially upon waking up

• 1st Trimester (Increased HCG due to presence of chorion)

Presumptive Sign of Pregnancy (Morning Sickness): When does this happen during the day? What trimester?

Increased

• Progesterone

• HCG

• Estrogen

Presumptive Sign of Pregnancy (Morning Sickness): What are the causes? (PHEG)

1. NO - Snack before bed

2. NO - SFF

3. NO - Sour

4. NO - Sips

5. YES

6. YES

7. NO - AVOID 4S

8. YES

9. NO - Delay breakfast (10-11 AM)

Presumptive Sign of Pregnancy (Morning Sickness): Identify if the following are included in the management (YES or NO):

• Snack after going to bed

• Large meals

• Bitter candy

• Gulps of carbonated beverage

• Acupressure wrist band

• Acupuncture

• Eat 4S to stimulate peristalsis: Spicy, seasoned, sebo, sudden movements

• Dry toast/crackers

• Early Breakfast (6-7 AM)

Hyperemesis Gravidarum

• Above 1-2x a day vomiting

• Above 12 to 14 weeks (dapat mababa na HCG by now)

• Signs of dehydration

  • May stimulate posterior pituitary gland which releases both ADH and oxytocin → Premature Uterine Contractions

Presumptive Sign of Pregnancy (Morning Sickness): When should you notify the physician?

Increased Estrogen and Progesterone

Presumptive Sign of Pregnancy (Menses Cessation): What is the cause?

1. 6 to 10 weeks (mas maaga)

2. 3 to 4 months and more [LACTATIONAL AMENORRHEA]

Presumptive Sign of Pregnancy (Morning Sickness): When should menses return in the following:

1. Non-breastfeeding

2. Breastfeeding

1. Red, itchy

2. Increased Estrogen (Inc. Vascularity)

3. Calamine Lotion

Presumptive Sign of Pregnancy (Palmar Erythema): Identify the following:

1. Assessment findings

2. Cause

3. Management

a. Striae Gravidarum

Cocoa Butter Lotion

a. Striae Gravidarum
b. Palmar Erythema
c. Hemorrhoids

b. Palmar Erythema

Calamine Lotion

a. Striae Gravidarum
b. Palmar Erythema
c. Hemorrhoids

c. Hemorrhoids

Witch Hazel

a. Striae Gravidarum
b. Palmar Erythema
c. Hemorrhoids

Decreased glucose due to organogenesis

Presumptive Sign of Pregnancy (Tiredness): What is the cause during the 1st trimester?

Peak increased blood volume by 40-50%

Presumptive Sign of Pregnancy (Tiredness): What is the cause during the 2nd trimester?

Inc BV → Diluted blood → Seems like RBC is low → Pseudoanemia

• Kidney senses → Release erythropoietin

Presumptive Sign of Pregnancy (Tiredness): Why is there pseudoanemia in 2nd trimester?

1. Heaviest Pregnancy

2. Sleep deprivation d/t

   1. Movements

   2. SOB

   3. Urinary Frequency

Presumptive Sign of Pregnancy (Tiredness): What are the causes in 3rd trimester?

+300 cal/day

• +500 cal/day

Presumptive Sign of Pregnancy (Tiredness): What is the recommended dietary allowance?

• How about for those breastfeeding?

Add pillows to avoid SOB, basta comfortable

Have short AM naps (not PM → lalong magkakadifficulty)

Presumptive Sign of Pregnancy (Tiredness): How do you assist a pregnant client in having enough sleep?

25 to 35 lbs in normal BMI

Presumptive Sign of Pregnancy (Tiredness): What is the average weight gain of pregnant patients with normal BMI?

1. 1lb/month

2. 1lb/week (or +2lb → siya lang pwede umextra)

3. 1lb/week

Presumptive Sign of Pregnancy (Tiredness): What should be the weight gain in the following

1. 1st Trimester

2. 2nd Trimester

3. 3rd Trimester

1. Monthly (if confirmed)

2. Every 2 weeks

3. Weekly

Presumptive Sign of Pregnancy (Tiredness): What is the schedule of visits of a pregnant patient, in relation to the following?

1. Suspected pregnancy to 28 weeks (0 to 7 mos)

2. 28 weeks to 36 weeks (7 to 9 mos; 3rd tri)

3. 36 weeks to delivery (9 to 10 mos)

FeFA

• Iron

• Folic Acid (Vitamin B9)

Presumptive Sign of Pregnancy (Tiredness): What supplements should a pregnant patient take to prevent true anemia?

800 mg

Presumptive Sign of Pregnancy (Tiredness): Requirement for Fe

15-30 mg/day

Presumptive Sign of Pregnancy (Tiredness): Supplement dose of Fe

400 mg

Presumptive Sign of Pregnancy (Tiredness): Requirement for FA

400 mcg

Presumptive Sign of Pregnancy (Tiredness): Supplement dose for FA

Mother = 500 mg

Fetus = 300 mg

Presumptive Sign of Pregnancy (Tiredness): In 800 mg Fe, how much is for the mother and how much is for the fetus?

Green, Animal Products, Nuts/Grains

Presumptive Sign of Pregnancy (Tiredness): What foods are rich in iron?

Pernicious Anemia (Vitamin B12 deficiency)

Presumptive Sign of Pregnancy (Tiredness): If patient is vegetarian, what type of anemia is she at risk for?

1. GI Upset

2. Constipation

3. Stool Color

Presumptive Sign of Pregnancy (Tiredness): What are the side effects of Fe?

Take with food AND vitamin C

Presumptive Sign of Pregnancy (Tiredness): How should the patient take Fe to avoid GI upset?

2 hours gap

Presumptive Sign of Pregnancy (Tiredness): When the patient is taking Fe, when should she take Ca and Mg supplements?

FALSE

• Laxative = GI Irritant (MD Only)

• Enema = GI Stimulant (Preterm Labor)

• Mineral Oils = Decreased ADEK Absorption

Presumptive Sign of Pregnancy (Tiredness):

TRUE or FALSE: If the patient is taking Fe, she should take laxatives, enema, and mineral oils to ease constipation

Stool Softener (Docusate sodium or Colace)

Suppository

Presumptive Sign of Pregnancy (Tiredness): What meds are safe for preggy pts with constipation r/t Fe supplementation?

Dark, black, greenish

Presumptive Sign of Pregnancy (Tiredness): What is the expected stool color in patients taking Fe supplementation?

Folate, Vitamin B9

Presumptive Sign of Pregnancy (Tiredness): What are other terms for Folic Acid?

a. Acid

Folic Acid

a. Acid
b. Alkaline

b. Alkaline

Folate

a. Acid
b. Alkaline

To prevent:

1. Megaloblastic anemia

2. Neural Tube Defects

Presumptive Sign of Pregnancy (Tiredness): Why is folic acid supplementation needed for pregnant women?

b. Vitamin B9

Megaloblastic anemia

a. Vitamin B12
b. Vitamin B9

a. Vitamin B12

Pernicious Anemia

a. Vitamin B12
b. Vitamin B9

• Milk (Anmum Materna)

• Eggs

• Salmon

Presumptive Sign of Pregnancy (Tiredness): To fulfill the folic acid requirement of pregnant patients, what foods should they eat?

Ptyalism

Presumptive Sign of Pregnancy (Increased Salivation): What is increased salivation also called as?

Increased estrogen

Presumptive Sign of Pregnancy (Increased Salivation): What is the cause?

Pica

Presumptive Sign of Pregnancy (Increased Salivation): What do you call non-food cravings?

Chipped paint

Presumptive Sign of Pregnancy (Increased Salivation): What is the common material being craved for by those with pica?

It contains lead → Brain damage

Presumptive Sign of Pregnancy (Increased Salivation): What is the dangerous chemical in paint? What is its not wanted effect?

1. Nutrition (busog but has no nutritional value)

2. Fetus (fetal harm)

Presumptive Sign of Pregnancy (Increased Salivation): What are the two main concerns in patients with pica?

• First, consider their lifestyle, budget, religion, etc.

• The food should contain the following;

  • 50% Fruits and Vegetables

  • 30% Grains

  • 20% Protein

  • Dairy

Presumptive Sign of Pregnancy (Increased Salivation): What should you answer the patient if they say “Nurse, what should I eat?”

Leukorrhea

Presumptive Sign of Pregnancy (Vaginal Discharges): What is vaginal discharges also called as?

Estrogen

Presumptive Sign of Pregnancy (Vaginal Discharges): What is the cause?

Lactobacillus acidophilus

Presumptive Sign of Pregnancy (Vaginal Discharges): What is the organism normally in vaginal discharge?

a. Acidic

Presumptive Sign of Pregnancy (Vaginal Discharges): Normal pH of women’s (not pregnant) vaginal discharge

a. Acidic
b. Alkaline

b. Alkaline

Presumptive Sign of Pregnancy (Vaginal Discharges): pH of a pregnant patient’s vaginal discharge

a. Acidic
b. Alkaline