N431 Lifespan OB Preconception and Prenatal Care

Progesterone

initially produced by corpus luteum and later placenta takes over. Its greatest role is to maintain pregnancy - thus the hormone of pregnancy. Maintains endometrium and inhibits uterine contractility, thus preventing early spontaneous adoptions. Also plays a role in breast development in preparation for lactation

Tetanus toxoid, reduced diptheria toxoid and acellular pertussis (Tdap)

Indicated During Every Pregnancy. Can Be Initiated Postpartum or When Breastfeeding or Both

Inactivated influenza

Indicated During Every Pregnancy. Can Be Initiated Postpartum or When Breastfeeding or Both

Pneumococcal vaccines

May Be Given During Pregnancy in Certain Populations. Can Be Initiated Postpartum or When Breastfeeding or Both

Meningococcal conjugate (MenACWY) and Meningococcal serogroup B

May Be Given During Pregnancy in Certain Populations. Can Be Initiated Postpartum or When Breastfeeding or Both

Hep A

May Be Given During Pregnancy in Certain Populations. Can Be Initiated Postpartum or When Breastfeeding or Both

Hep B

May Be Given During Pregnancy in Certain Populations. Can Be Initiated Postpartum or When Breastfeeding or Both

HPV

no information

Measles, mumps, and rubella

Contraindicated During Pregnancy. Can Be Initiated Postpartum or When Breastfeeding or Both

Varicella

Contraindicated During Pregnancy.Can Be Initiated Postpartum or When Breastfeeding or Both

Normal BMI

18.5 to 24.9

recommendation 11.5 to 16 kg or 25-35 Ibs weight gain

Underweight

(BMI less than 18). <18kg

recommended 28-40 Ibs or 12.5 to 18 kg

Obese

(BMI 30 or greater). At least 5-9 kg or 11-20Ib

Overweight

recommended 7-11.5 kg or 15-25 Ibs

Weight gain recommendations 1st trimester

0.5-2 kg (1-4.5 lbs)

Weight gain recommendations 2nd and 3rd trimesters

~ 0.5kg (1-2 lbs) / week

Braxton Hicks contractions

perceived after 20 weeks, irregular, painless, change with activity. term we use to describe late pregnancy contractions that are not labor (they are not dilating the cervix). These contractions are a normal result of increased blood flow to the uterus and help to efface and soften the cervix in preparation for labor and birth.

Uterus changes

Since the uterus houses the fetus, it needs to stretch and grow to accommodate the fetus. We measure the height of the uterus (called the "fundal height" whenever we assess the patient during pregnancy. The uterus is a pelvic organ until after 12 weeks of pregnancy when it becomes palpable in the maternal abdomen

uterus 8-10 weeks

size of a large orange (2x non-pregnant)

uterus 12 weeks

size of a large grapefruit - leaves pelvis - top edge may be felt at pubic symphysis

uterus 20 weeks

fundus at umbilicus

uterus 36-38 weeks

xiphoid

Lightening

fundus may decrease as fetus moves down and engages into the pelvis ("baby dropped")

Vagina changes

▪Estrogen causes thickening of vaginal mucosa, loosening of connective tissue, and an increased vaginal secretion (leukorrhea). Secretions are thick, white, and acidic (pH 3.5 - 6.0) that help prevent bacterial infection but favors yeast multiplication. By end of pregnancy the vagina will be sufficiently relaxed to permit passage

▪Chadwick's sign = bluish-purple color of the cervix and vaginal wall (8-12 weeks) from the increased blood flow

Cervix changes

Increased vascularity (hormonal) causes both softening (Goodell's sign = 4-6 weeks) and bluish discoloration (Chadwick's sign)

Endocervical glands secrete a thick, sticky mucus, that accumulates and form a mucous plug (operculum-prevents infection getting into uterus)

blood volume

Increases rapidly until 30-34 weeks and then plateaus until birth at about 40-50% above non-pregnant state

cardiac output

Begins to increase early in pregnancy and peaks at 25-30weeks gestation at 30-50% above non-pregnant state

resting pulse rate

↑ 10-15 beats per minute

BP

Decreases slightly reaching is lowest point in second trimester and gradually increases in third trimester.

RBC volume

Increases by 30% in women who take iron supplementation and only 18% in women who do not.

Physiologic anemia-

Plasma volume ↑ by 50% more than RBCs =↓hematocrit

Leukocyte production

Increases slightly to a range of 5600 to 12,200/mm3 or higher

coagulation

Fibrin and plasma fibrinogen increases and clotting factors VII, VIII, IX, and X increases creating a hypercoagulable state - risk for DVT

extremities changes

Dependent edema and varicosity of legs, vulva, and rectum (hemorrhoids) in late pregnancy: From pressure of enlarging uterus on pelvic and femoral vessels interferes with returning blood flow causing stasis.

Striae gravidarum

Stretch marks - pink, silver, purple (50 - 90%)

Vascular spiders

Angiomas as a result of elevated estrogen levels - red spots on chest, arms, legs (10-65%)

Palmar erythema

related to estrogen - red palms (increased estrogen), 35=60%. Common in Caucasian women

PUPPS

Pruritic urticarial papules of pregnancy - (1%) hives, itching

Nulligravida

never been pregnant before

Primigravida

first conception person has

Multigravida

had more than 1 pregnancy

Gravida

# of pregnancies

Para

# of births

Nullipara

never given birth before, could be pregnant but non beyond 20 weeks gestation

Primipara

1 birth more than 20 weeks gestation

Multipara

more than 1 pregnancy that has gone beyond 20 weeks gestation

Presumptive Sigresumptive Signsns

Amenorrhea

Nausea and vomiting

Urinary frequency

Quickening -perception of fetal movements

Breast tenderness

Fatigue

Insomnia

Backpain

Food cravings

Constipation

Skin changes: pigmentation of nipple and areola, linea nigra, and chloasma (face mask - facial melasma) - this may appear as probable sign in other literature

Probable Signs

Abdominal enlargement

Braxton Hicks contractions

Uterine Souffle

Palpation of fetal parts or movement

Changes in pelvic organs Goodell's Sign Chadwick's sign Hegar's sign

Pregnancy test positive (hCG

Fetal outline palpable at 24 weeks and Ballotment

Positive signs

proof of pregnancy detected by examiner and can only be caused by pregnancy. Fetal heart beat: detected as early as 10-12 weeks through doppler

Fetal movement: actively palpable by a trained examiner after about 20 weeks

Visualization of fetus through USS

Naegele's rule

Method to estimate EDC Add 7 to first day of LNMP Subtract 3 to the month Add 1 to the year

G Parity (G-T-P-A-L)

G (pregnancy)

P (T-P-A-L). Full term (37 week or <) Preterm (>20-36 6/7 weeks) Abortions- either therapeutic or spontaneous (<20 weeks) Living Children (total living)

Fundal height

Before she gets on the blood let her urinate first.

The fundus is the top of the uterus and is a good place to assess for fetal growth. As the fetus grows, the fundus rises. The chart above shows where the top of the fundus should be at specific weeks gestation in a normal fetus.

The fundal height should be at the umbilicus (20 cm) at 20 weeks (mid-pregnancy).

We measure the fundal height with a tape measure (in cm) from the symphysis pubis to the top of the fundal edge with our hands and fingers. The number of cm should correlate with the weeks gestation with a single fetus.

Abdominal Palpation - Leopold's maneuver

First maneuver, the fundal grip - fundal palpation

Second maneuver, the umbilical grip - lateral palpation to identify the fetal back

Third maneuver, the Pawlick grip - with finger and thumb feel the presenting part (confirms the fundal grip findings

Fourth Maneuver - pelvic grip - locate the fetus brow to check if head is well flexed - check for engagement

labs in early pregnancy

Complete blood count (CBC)

Blood type

Urinalysis

Urine culture

Rubella

Hepatitis B and hepatitis C

Sexually transmitted infections (STIs)

Human immunodeficiency virus (HIV)

Tuberculosis (TB)

Lead - routine in Wisconsin

Later in Pregnancy

A repeat CBC

Rh antibody test

Glucose screening test - Glucose Tolerance Test (24-28 weeks)

Group B streptococci (GBS) - accurate if done within 5 weeks of delivery