normal pregnancy and prenatal care

presumptive signs of pregnancy

amenorrhea, tender breasts, morning sickness

probable signs of pregnancy

piskacek sign, hegar sign, goodell sign, chadwick sign, braxton hicks, positive serum or urine pregnancy tests

piskacek sign

uterine bulge

hegar sign

softening of uterusc

goodell sign

softening of cervix

chadwick sign

blueish color of cervix, vagina, labia d/t increased blood flow and vessels near surface

positive signs of pregnancy

FHT - 10-12 weeks

visualization of fetus

positive fetal movement after 20 weeks

EDD tools

neageles tool, ultrasound

Neagele’s tool

first day of LMP, subtract 3 months, add seven days

only if indv has regular cycle

US for EDD

most reliable

8 weeks gestation

gestation period

first day LMP + 40 weeks complete weeks

first trimester

first day LMP until 13 weekss

second trimester

14 weeks until 27 weeks

third trimester

28 weeks until end of week 40+

first prenatal assessment

medical/surgical history, head to toe assess, pap smear if needed, STI screening, prenatal labs, reproductive history, intercourse/partners, onset of menses/flow/days, G and P, type of birth and year, LMP, genetic testing, vaginal US (transvaginal)

lifestyle questions: smoking/drinking, exercise, job, household role, IPV and depression screen

prenatal labs

syphilis, T+S, CBC, plt, hep, rubella, HIV

prenatal visit schedule

every 4 weeks until 32 weeks

every 2 weeks until 36 weeks

every week until birth

most appts are 15 min

8-10 weeks prenatal visit

collect history, US for EDD, meet w provider

12 week prenatal visit

complete chromosomal testing

18-20 weeks prenatal visit

full anatomy performed

24 weeks prenatal visit

one hour glucose tolerance test

28 weeks

rhogam for Rh neg pt

36-38 weeks

GBS testing, review labor instructions and discuss delivery

first trimester genetic testing

bw 10-13 weeks

blood test for autorecessive disorders, CF carrier screening, tay sachs disease,

US - nuchal translucency

nuchal test

looks at fluid in nuchal fold, 3.5 mm is normal

increased = increased risk heart issues, trisomy 18/21, turners syndrome, viral infection

second trimester screening

bw 15-22 weeks

maternal assays

US - anatomy scan (18-22)

diagnostic testing

chorionic villus sampling, amniocentesis

chorionic villus sampling

aspirate placental tissue to detect fetal abnormalities and genetic disorders

10-12 weeks

risk: miscarriage, hemorrhage

amniocentesis

15-18 weeks but can be done bw 11-14 weeks

take amniotic fluid to obtain fetal cells for genetic testing

risk: miscarriage, trauma to fetus/placenta, PTL, maternal infection

TORCH complications

transmitted from preg individual to fetus during pregnancy or at time of birth

significant cause of fetal/neonatal mortality and childhood morbidity

earlier infection = worse outcomes

TORCH

toxoplasmosis, other (syphilis, varicella, parvovirus b19), rubella, CMV, HSV/HIV

toxoplasmosis cx, transmission, sx

cx: toxoplasma gondii (parasite)

transmission: undercooked meat, contaminated water, cat feces

sx in infants: seizures, chorioretinitis, hydrocephalus

syphilis cx, sx

cx: treponema pallidum (bacteria)

sx: rash, osteochondritis, hepatosplenomegaly

varicella transmission, fetal risk

transmission: chickenpox

fetal risk: congenital varicella syndrome

parvovirus B19

transmission: resp droplets

fetal risks: hydrops fetalis, fetal anemia

rubella cx, transmission, sx

cx: rubella virus

transmission: respiratory droplets

sx: cataracts, congenital heart disease, hearing loss, blueberry muffin rash

CMV cx, transmission, sx

cx: CMV

transmission: body fluids

sx: hearing loss, IUGR, developmental delay, microcephaly, jaundice, blueberry muffin rash, thrombocytopenia

HSV/HIV cx, transmission, sx

cx: HSV

transmision: direct contact

sx: skin lesions, encephalitis, disseminated infection, CNS disease, multi-organ involvement

prevention/mgmt TORCH

prenatal screening and diagnosis, prophylactic measures, appropriate tx during pregnancy to reduce fetal transmission, monitor and intervene postnatally

every prenatal visit

wt, BP, urine dip, FHT, edema, fetal mvmts, fundal height

FM after 15 weeks

count mvmt beginning at 28 weeks gest or 26 for high risk

10 mvmts in an hour without eliciting response

if less than 10 mvmts, call provider

fundal height changes

12-14 weeks: right above pubic bone

16 wks: bw pubic bone and umbilicus

20-22 wk: right at umbilicus

24 wk: 1-2 fingerbreadths above umbilicus

40 weeks: 3-4 fingerbreadths below umbilicus

fetal non stress test (NST)

performed at 28+ wk

measures heartrate of fetus in response to its own mvmts

monitor for 20-30 mintues

reactive strip NST

normal baseline

2 acceleration: 10 beats above for 10 seconds 2 times in 10 minutes

at 32 wk: 15 beats above 15 sec twice in 10 minutes

reasons for NST

post dates, decreased fetal movement, HTN, DM/GDM, multiple gestation, comorbidities (lupus), trauma, bleeding, placental abnormalities

vibroacoustic stimulation

auditory stimulation to assess fetal well-being with EFM when NST is non-reactive

biophysical profile (BPP)

snapshot of a given moment, assess 5 fetal variable under US

BPP variables

BATMaN

breathing movement

amniotic fluid volume

tone of fetus

movmeent of fetus

NST

BPP scores

8-10 is reassuring

6 - may require repeat test, possible sign of fetal asphyxia

<4 - induction of labor

indication for BPP

increased risk of fetal hypoxia, placental insufficiencies, maternal DM, HTN

alcohol consumption

avoid, found in beverages

artificial sweetners

safe in moderationc

caffeine

200 mg per day, 12 oz cup of coffee

fish in pregnancy

fish is good for omega 3 fatty acids and mono-unsaturated fat and protein

avoid fish with high mercury/fish that eat other fish: swordfish, shark, albacore tuna, mackerel, sardines

choose: low-fat fish, small, white, flaky fish and shellfish, salmon is a healthy choiceu

unpasteurized foods

avoid d/t risk of listeria, e. coli, salmonella, hepatitis A

raw/undercooked eggs

avoid d/t risk of salmonella

diet and nutrition considerations

cultural considerations

caloric intake based on activity levels

increase 300 kcal a day

protein should be safe and well-prepped

half of body wt in water (2-3 liters daily)

dehydration complication

uterine irritability that can lead to PTL and contractions

PNV vitamins and supplements

cover nutritional gaps, decrease risk of birth defects, contain recommended daily folic acid/VB/iron, intake of 1200 mg of Ca, DHA associated w improved neurodevelopment, ferrous sulfate if needed (take w VC to help w absorption)

vitamins can make pt nauseous, encourage them to take it at night

iron considerations

can lead to constipation, discuss good bowel regimens

category A drugs

adequate and well controlled human studies demonstrate no risk

PNV

category B drugs

animal studies demonstrate no risk but no human studies

or

animal studies demonstrate a risk but humans have demonstrated no risk

amoxicillin, acetaminophen

category C drugs

animal studies demonstrate a risk but no human studies have been performed, potential benefits outweigh risks

SSRI, ASA

category D drug

human studies demonstrate a risk, potential benefits may outweigh risks

ACE-I, tetracycline

category X

animal or human studies demonstrate a risk, risks outweigh potential benefits

cytotec, thalidomide, oral contraceptives

OTC meds

can take any OTC med that does not contain ibuprofen or aspirin

ibuprofen - can cause early closure of DA and decrease amniotic fluid

aspirin - increase risk of bleeding, pt w risk of preeclampsia may take baby aspirin

weight gane during pregnancy

25-35 pounds

most women gain 7-10 in first 20 weeks

expect 0.5-1 lb per week

excess maternal weight gain linked to

T2 DM, increased risk c/s, fetal macrosomia, childhood obesity, maternal obesity after delivery

ETOH during preg

acamprosate and naltrexone to treat, NAS scoring

illicit drugs/opioids/prescription drugs

no marijuana during pregnancy or breastfeeding

tx: suboxone or methadone (NAS scoring)

anti-depressant

important to continue medication, may ned to increase dose or change meds

SSRIs require NAS scoring and newborn blood sugar protocol

estrogen

growth, breast tissue enlargement, uterine tissue enlargement, maintain uterine lining, trigger development of fetal organs, causes increased uterine contractility

progesterone

maintenance, thickens uterine lining, prevent body from ovulating, slows GI tract, relax uterus and smooth muscles, cause vasodilation for increased blood flow to uterus

hormone production

regulate by placenta at 8th week of pregnancy

cervix changes

changes shape, increased blood flow to allow for growthc

cervix changes

increased blood supply, chadwick sign, goodells sign, increase in cervical mucus for mucus plug, leukorrhea

vagina changes

increased blood supply, allows fro vaginal stretchingv

vulva changes

increased blood supply, allows for vaginal stretching

ovary changes

LH stimulates corpus luteum to produce progesterone until placenta takes over

breast changes

stretch marks, montgomery glands enlarge to provide lubrication for nipple tissue, development of colostrum

integumentary changes

linea nigra, palmer erythema, melasma, varicose veins, increased acne, pruritus

pruritus rule out

cholestasis with blood test

ursodiol lowers bile acids in blood and benadryl helps with itching

PUPPS

pruritic urticarial papules and plagues

rash spreading to arms and legs d/t overstretching of skin, causing a rash

neuro changes

carpal tunnel and syncope d/t decreased BP from vasodilation that tapers by 24 weeksc

cardiac changes

hypertrophy d/t volume overload and hormonal changes that increase CO

physiological leukocytosis of pregnancy and PP

iron changes

appears as an issue bc of hemodilution, may need t compensate

blood changes

WBC increases, 9-25K

supine hypotensive syndrome

in supine position, enlarged uterus compresses IVC, decreased blood flow to RA and decrease CO/BP, causing dizziness, diaphoresis, and pallor

respiratory changes

growing uterus elevates the diaphragm causing SOB

GI changes

slowing of GI tractu

urinary changes

increased renal sized, increased UTI risk, increased bladder and kidney volume, decreased bladder tone, urinary stasis and ureterovesical reflux

ureter changes

dilation of ureters and renal pelvis in week 6

common overall discomforts

N/V, fatigue, nasal congestion, upper/lower backache, leukorrhea, urinary frequency, dyspepsia, ptyalsim, flatulence, constipation, dental problems, leg cramps, dependent edema, nocturia, insomnia, round ligament pain, numbness/tingling in fingers, supine hypotensive syndrome, varicosities, dyspareunia

rule outs of common discomforts

dehydration, malnutrition, disrupted sleep, pyelonephritis, kidney stones, STI, BV, serious issues w hypotensive syndromes, leg cramp complications

first trimester complaints

tiredness, tender breasts, morning sickness, cravings, mood swings, constipation, need to pee more often, HA, heartburn, wt gain/loss

common complaints second trimester

body aches, stretch marks, darkening of skin around nipples, line on skin from belly to pubic hairline, patches of darker skin on face (masks of pregnancy), numb/tingling hands, itching, swelling

common complaints third trimester

SOB until lightening, heartburn, swelling of ankles/fingers/face, hemorrhoids, constipation, breast tenderness, belly button protrusion, insomnia, lightening, contractions

when to call provider

vaginal bleeding, severe abdominal pain, severe NV 24+ hr, sudden swelling/HA/vision changes/indigestion/heartburn not going away, leaking of fluid, decrease in fetal mvmt, fever >100.4, thoughts of self-harm/hurting someone else, DVT or PE signs, UTI signs, vaginal discharge changes

classic sign of preeclampsio

sudden swelling, headache, vision changes, indigestions, heartburn not going away