ch 11

Signs and Symptoms of Pregnancy

Presumptive Signs

• subjective; signs that only the pregnant person can perceive

• most obvious: absence of menstruation

  • bonus if accompanied by consistent nausea, fatigue, breast tenderness, and urinary frequency

• these symptoms (above) can be caused by conditions other than pregnancy

• fetal movements are also known as_________

  • quickening

Probable Signs

Physical Signs

• objective; can be detected on physical examination by HCP

• these symptoms can be caused by conditions other than pregnancy, including elevated hCG levels

  • elevated hCG levels can be caused by ovarian cancer, choriocarcinoma, hydatidiform mole

Common signs:

• Goodell sign: softening of the cervix (5 weeks)

• Chadwick sign: bluish-purple coloration of the vaginal mucosa and cervix (6-8 weeks)

• Hegar sign: softening of the lower uterine segment or isthmus (~16 weeks)

Other signs:

• Positive pregnancy test (4–12 weeks)

• changes in the size & shape of the uterus; increased abdominal girth from uterine enlargement (14 weeks)

• Hyperpigmentation of the skin (16 weeks)

• Ballottement: HCP pushes against the patient’s cervix during a pelvic exam and feels a rebound from the floating fetus (16–28 weeks)

• Braxton Hicks contractions (16-28 weeks)

• Palpable fetal outline

Pregnancy tests

• Serum and urine tests measure the presence of human chorionic gonadotropin (hCG)

  • a glycoprotein

  • earliest biochemical marker for pregnancy

  • hCG <5 mIU/mL = negative

  • hCG >25 mIU/mL = positive

  • levels should double every 29-53 hours during the first 30 days after implantation and peak ~8-10 weeks gestation

    • this has been used by HCP’s to differentiate normal from abnormal gestations

      • low levels = ectopic pregnancy

      • higher-than-normal levels = multiple-gestation pregnancy

        • corresponds with morning sickness period (6-12 weeks)

• At-home tests:

  • highly accurate but a + result should be confirmed with Doppler fetal heart sounds, ultrasound, physical examination, or a serum pregnancy test

  • major concern = possibility of false negatives if performed too early (hCG hasnt reached detectable levels)

  • recommendation: if absence of menses continues, retest in 1 week

Positive Signs

• these confirm that a fetus is growing in the uterus

• Common signs:

  • Ultrasound verification (4-6 weeks)

  • FHR seen on ultrasound (5–6 weeks)

  • Auscultation of fetal heart tones via Doppler (10 to 12 weeks)

  • Palpation of fetal movement felt by experienced clinician (20 weeks)

• if pregnancy is confirmed, the HCP should:

  • include an estimated gestational age

  • give pts info about normal s&s and instruct them to report concerns

  • set up a schedule of prenatal visits to assess mom and baby throughout the entire pregnancy

Physiologic Adaptations During Pregnancy

Reproductive System Adaptations

Uterus

• decreased uterine vascularity and muscle tone

• increase in blood flow

• uterine growth:

  • stimulated by estrogen

  • occurs as a result of both hyperplasia and hypertrophy of the myometrial cells

    • Hyperplasia: increase in # of cells

    • Hypertrophy: increase in size of existing cells

• uterine walls thin

• Blood vessels elongate, enlarge, dilate, and sprout new branches

• the diameter of the main uterine artery doubles in size to accommodate the increased blood volume needed to supply the placenta

• Increased strength and elasticity allow uterus to contract and expel fetus during birth

• Braxton Hicks contractions: spontaneous, irregular, and painless contractions beginning in the 1st trimester

  • continue throughout pregnancy

  • more noticeable in the last month as they thin/efface the cervix before birth

• the isthmus (lower portion of the uterus) progressively thins as pregnancy progresses, thereby forming the lower uterine segment

• positive Hegar sign (softening and compressibility of the lower uterine segment) results in exaggerated uterine anteflexion (tilting or curving of the uterus tilts toward the bladder) during early months of pregnancy

• uterus remains in pelvic cavity for the first 3 months of pregnancy, after which it progressively ascends into the abdomen

• growing uterus presses on the bladder → increased urinary frequency

• supine hypotensive syndrome: uterus falls backwards against the inferior vena cava when lying down → vena cava compression → reduced venous return and decreased CO & BP → orthostatic stress

  • occurs from lying to sitting to standing

  • symptoms experienced: weakness, lightheadedness, nausea, dizziness, or syncope

  • solution: side-lying position which displaces the uterus to the left and off the vena cava

• Fundal height best correlates with gestational age between 18-32 weeks

  • Obesity, hydramnios, and uterine fibroids may interfere with accuracy

  • 20 weeks : at the level of the umbilicus and measures 20 cm

  • 36 weeks: at the xiphoid process (its highest level)

  • 38-40 weeks: drops due to lightening (see next bullet)

• lightening: when the fundal height drops as the fetus begins to descend and engage into the pelvis

  • first pregnancy: usually occurs ~2 weeks before onset of labor

  • multigravida (second or subsequent pregnancy): usually occurs at the onset of labor

Cervix

• 6-8 weeks of pregnancy: vasocongestion (tissues swell due to increased blood flow) and the influence of estrogen → Goodell sign (softening of cervix)

• endocervical glands: increase in size and number & produce more cervical mucus

• progesterone forms a thick mucus plug that blocks the cervical os and protects the opening from bacterial invasion

• increased cervical vascularization → Chadwick sign (cyanosis or bluish-purple discoloration of cervix and vaginal mucosa)

• increased estrogen and changes in the solubility of collagen → Cervical ripening (softening, effacement, increased distensibility)

  • begins ~4 weeks before birth

• cervical connective tissues change elasticity and strength

• Increases in mass, water content, and vascularization

• Changes from a relatively rigid to a soft, distensible structure that allows the fetus to be expelled

Vagina

• estrogen increases vaginal vascularity → pelvic congestion (tissues swell due to increased blood flow) and vaginal hypertrophy (size increase) in preparation for the distention needed for birth

• vaginal mucosa thickens

• connective tissue begins to loosen

• smooth muscle begins to hypertrophy (size increase)

• vaginal vault (upper part of the vagina) begins to stretch and lengthen in preparation for expansion during birth

• leukorrhea (whitish/yellowish vaginal discharge) increases during the second trimester

  • helps prevent bacterial infections

• Vaginal pH increases → increased risk for candidiasis

  • can be transmitted at birth

  • neonates develop thrush

  • treated with local antifungal agents

Ovaries

• the increased blood supply enlarges them until ~12-14 weeks gestation

• elevated estrogen and progesterone levels cease ovulation and block secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary

• weeks 6-7: the ovaries stop producing hormones (the corpus luteum regresses) and the placenta takes over the major production of progesterone

Breasts

• increase in fullness (size), become tender, and grow larger due to estrogen and progesterone

• become highly vascular; veins become visible under the skin

• nipples become larger and more erect

• nipples and areola become deeply pigmented

• tubercles of Montgomery (sebaceous glands) enlarge and become prominent and keep the nipples lubricated for breastfeeding

• breast growth and thinning of the skin → striae (stretch marks)

  • begin as pink to purple color, then eventually fade to a silver color, but never completely disappear

• colostrum (creamy, yellowish breast fluid) can be expressed from the breast, if squeezed, by the 3rd trimester

General Body System Adaptations

GI System

• motility specifically is most effected, not secretory nor absorptive functions

• intra-abdominal portion of the esophagus may be displaced into the thorax

• increased progesterone → relaxation of the lower esophageal sphincter and a decrease in gastric tone → dyspepsia

• increased estrogen and proliferation of blood vessels and circulation to the mouth → gums become hyperemic (increased blood flow), swollen, and fragile and tend to bleed easily

• Taste perception often changes

• saliva produced in the mouth becomes more acidic

• decreased unconscious swallowing when nauseated → excessive salivation (ptyalism or sialorrhea)

  • typically resolves spontaneously during the 2nd trimester, although it sometimes endures throughout the pregnancy

  • relief interventions: gum chewing, frequent sips of water, sucking on hard candies, or antiemetics

• increased dental plaque, calculus, and debris deposits → periodontal disease (gingivitis and periodontitis)

  • Increased hormone production boosts vascular permeability and tissue edema, promoting the development of gingivitis and periodontitis

• Elevated progesterone levels → smooth muscle relaxation → delayed gastric emptying and decreased peristalsis → more water than normal is reabsorbed → bloating and constipation

  • Constipation can also result from low-fiber food choices, reduced fluid intake, iron supplements, decreased activity levels, and intestinal displacement secondary to a growing uterus

  • Constipation, increased venous pressure, and the pressure of the uterus contribute to the formation of hemorrhoids.

  • slowed gastric emptying + relaxation of the cardiac sphincter → reflux → heartburn (pyrosis)

    • relieved with OYTC antacids

• Cholelithiasis (gallstone disease) is more likely to occur

  • The emptying time of the gallbladder is prolonged secondary to the smooth muscle relaxation from progesterone

  • Hypercholesterolemia can increase the risk of gallstone formation

  • Other risk factors: high BMI, multiparity (more than 1 previous viable pregnancy)

  • N/V symptoms usually last from 6-20 weeks but may continue

    • usually occurs in the morning but can last all day

    • highest incidence is 6-12 weeks

    • linked to high levels of hCG and circulating estrogen and progesterone, gastric acidity, GERD, genetic factors, and lowered tone and motility of the digestive tract

CV system

• increased: HR, CO, plasma volume & blood volume (the most striking cardiac alteration)

• decreased: total peripheral resistance, systemic vascular resistance, BP

Blood volume:

• increases beginning at the 10-12th week, peaks at the 30-34th week, and decreases slightly by the 40th week

  • this rise correlates directly with fetal weight

• the increase is mostly made up of plasma (75%) with an increasing but small amount of RBCs (refer to purple text under “blood components” within this heading)

  • leads to “physiologic anemia of pregnancy”

    • lower h&h

    • normal adaptation of pregnancy

• increase is needed to provide:

  • adequate hydration to fetal and maternal tissues

  • blood flow to perfuse the uterus

  • a reserve to compensate for blood loss at birth and during the postpartum period

  • increased perfusion to other organs, especially mom’s kidneys since they are excreting waste products for herself and baby

CO and HR:

• peaks at 20-24 weeks and declines slightly thereafter

• CO increases with greater venous return, increased HR, and right heart output (to the lungs), especially when lying on the left side after 20 weeks

• HR increases by 10-30bpm until term

• slight hypertrophy (size increase) of the heart

  • accommodates the increase in blood volume and CO

• when blood volume peaks, someone with preexisting heart disease may have worsened symptoms as the heart begins to decompensate (cant keep up anymore)

  • Close monitoring is warranted at 28-35 weeks

BP:

• 1st trimester = remains at prepregnancy level

• 2nd trimester = BP decreases 5-10 mmHg

  • progesterone → peripheral vasodilation → decreased BP, especially diastolic pressure

• 3rd trimester = returns to 1st trimester levels

• high BMI = high BP

Blood components:

• RBC count increases, depending on amount of iron available

  • necessary to transport the additional oxygen required during pregnancy.

  • RBC count increases, but plasma volume rises even more due to hormones and sodium & water retention (refer to purple text under “blood volume” within this heading)

  • mainly due to increased circulating erythropoietin

• demands of growing fetus + increase in maternal blood volume = increased iron requirements

  • fetal tissues prevail over mom’s tissues with respect to use of iron stores

• fibrin and plasma fibrinogen levels increase, plus various blood clotting factors which make pregnancy a hypercoagulable state

  • contribute to slowed venous return, pooling, and dependent edema which increase the risk for venous thrombosis

Respiratory System

• oxygen consumption increases due to the increased oxygen requirements of the developing fetus, placenta, and maternal organs

  • causes faster, deeper breathing

• decreased space for lungs as the diaphragm shifts upward due to pressure from the uterus

• increased: diaphragmatic excursion, chest circumference, transverse diameter

  • increases tidal volume (volume of air inhaled) causing deeper, diaphragmatic breathing

  • causes hyperventilation and hypocapnia (low co2 blood levels)

  • can cause dyspnea in later pregnancy

• thoracic muscles & cartilage relax → chest broadens, thoracic breathing → increased air volume per minute

• increased estrogen → increased blood flow in the respiratory tract → congestion (more blood flow = swelling of tissues)

• increased sex hormones & heightened allergy sensitivity → possible epistaxis and rhinitis

Renal/Urinary System

• increased CO and relaxin → decreases efferent and afferent resistance (carries blood to and from the kidneys) → increases blood volume and blood flow to kidneys → increases GFR → increases urine flow and volume, substances delivered to the kidneys, and perfusion, filtration (hyperfiltration) & excretion of protein, amino acids, and glucose

  • drugs cleared by the kidneys may need higher and more frequent doses for therapeutic blood levels

• kidneys must adapt to increased maternal and fetal waste

• renal changes result from hormonal influences of estrogen and progesterone, pressure from the enlarging uterus, and increased maternal blood volume

• Kidney and ureter dilation raises the risk of urinary stasis and infection

  • ureters elongate, widen, and become more curved above the pelvic rim by the 2nd trimester due to progesterone

• Hormones (progesterone) cause the kidneys to enlarge by increasing firmness and slowing smooth muscle movement

• progesterone causes renal pelvis to dilate

• kidney activity normally increases when lying down and decreases upon standing

  • possibly why a pregnant person may need to urinate frequently while trying to sleep

  • late in the pregnancy, increased kidney activity is even greater when the person lies on their side rather than their back

Musculoskeletal System

• characterized by posture and walking changes

  • increased lordosis (inward curve of lower back) & cervicodorsal (neck & upper back) extension to compensate for enlarging abdomen

  • caused by: center of gravity shifting forward, progesterone & relaxin on pelvic joints, and the increasing weight and position of the growing fetus

• progesterone and relaxin cause ligaments around the sacroiliac joints and pubic symphysis to soften and stretch (relaxation), making the joints wider and more flexible

  • peaks by beginning of 3rd trimester

  • increases pelvic cavity size and makes delivery easier

  • causes the characteristic “waddle” gait

• postural changes (see 1st bullet) plus with the loosening of the sacroiliac joints (see 2nd bullet) may result in lower back pain

• common issues: low back pain, disk disease, pelvic girdle & hip pain, leg & foot pain/cramps, and hand & wrist pain

  • pelvic girdle: bones that form the base of the spine and connect the spine to the legs

Integumentary System

• changes in pigment, vascular supply, connective skin tissue, hair growth, nail structure, and gland functions

  • many disappear but not all, some only fade

• common: hyperpigmentation (blotchy, brownish), typically localized & mild

  • due to elevated estrogen, progesterone, and melanocyte-stimulating hormone levels

  • mainly seen on the nipples, areola, umbilicus, perineum, and axilla, and the forehead and cheeks of dark-haired people

  • may develop on the face, aka facial melasma or “mask of pregnancy”

  • exacerbated by sun exposure

  • tends to recur in subsequent pregnancies

  • linea nigra: pigmented line down the middle of the abdomen, extending from the umbilicus to the pubic area

• Striae gravidarum (stretch marks): irregular reddish streaks appearing most often on the abdomen, breasts, and thighs, but also on the lower back, buttocks, and upper arm

  • most prominent by 6-7 months

  • caused by: genetics, hormone changes, high BMI, reduced connective tissue strength resulting from elevated adrenal steroid levels, tension on the skin, and stretching of the structures secondary from fetal growth

    • more common in younger people & those carrying larger infants

Vascular-related skin changes:

• Varicose veins: form due to long periods of sitting or standing (causing distention, instability, and poor circulation), and pressure from the growing uterus which slows blood flow

  • preventative measures:

    • elevate legs when sitting or lying down

    • Avoiding prolonged standing or sitting

    • Resting in left lateral position

    • walk daily for exercise

    • Avoid tight clothing or knee-high hosiery

    • Wear compression socks if this is a preexisting condition before pregnancy

• vascular spiders: small blood vessels caused by vascular changes and high estrogen levels

  • may appear on the neck, thorax, face, and arms

  • typically disappears after childbirth

• Palmar erythema: a well-defined pinkish area on the palms of the hands

  • related to elevated estrogen levels and other factors that cause vascular changes (vascular distention, instability, proliferation of blood vessels)

Hair and nails:

• hair growth may decrease

  • After delivery, the body catches up with subsequent hair loss for several months

• Nails typically grow faster

  • may experience increased brittleness, distal separation of the nail bed, whitish discoloration, and transverse grooves on the nails

    • most of these conditions resolve postpartum

Endocrine System

Thyroid Gland:

• enlarges slightly

• becomes more active during pregnancy due to increased vascularity and hyperplasia (increased number of cells)

• maternal thyroid hormone:

  • secretion increases

    • causes BMR (the amount of oxygen consumed by the body) to progressively increase

  • transferred to the fetus beginning soon after conception

  • critical for fetal brain development, neurogenesis, and organizational processes

    • especially important prior to 20 weeks as fetal production becomes more functional at 20 weeks

      • after 20 weeks, much of the thyroxin (T4) needed for development continues to be provided by mom

  • Low maternal thyroid levels places the fetus at higher risk of fetal hypothyroidism

Pituitary Gland:

• enlarges and grows in size due to an increase in blood supply

• when hormones from target glands rise, the anterior pituitary ceases its own hormones

• FSH and LH:

  • secreted by anterior pituitary

  • secretion is inhibited as a result of hCG produced by the placenta and corpus luteum, plus increased secretion of prolactin by the anterior pituitary gland

  • hormone levels remain decreased until after delivery

• TSH levels: reduced during the 1st trimester but return to normal for the remainder of the pregnancy

  • secreted by anterior pituitary

• GH levels:

  • secreted by anterior pituitary

  • decreased

  • the action of human chorionic somatomammotropin (hCS), aka human placental lactogen (hPL), likely decreases the need and use of GH

• Prolactin:

  • secreted by anterior pituitary

  • secreted in pulses and increases 10-fold to promote breast development and the lactation process

  • high progesterone levels secreted by the placenta → inhibition of prolactin on the breast → suppresses lactation

    • placenta is expelled at birth, progesterone levels drop → lactogenesis begins

• Melanocyte-stimulating hormone (MSH):

  • secreted by anterior pituitary

  • levels increase

    • causes skin changes along with estrogen and possibly progesterone

• Oxytocin:

  • made in the hypothalamus, secreted by posterior pituitary

  • gradually increases as fetus matures

  • responsible for uterine contractions, both before and after delivery

  • muscle layers of the uterus (myometrium) become more sensitive to oxytocin near term

  • at the end of a term pregnancy, levels of progesterone levels decline → contractions occur more frequently and intensely (previously suppressed by progesterone)

    • believed to be one of the initiators of labor

  • After delivery, oxytocin secretion continues → myometrium contracts → constriction of uterine blood vessels → decreases amount of vaginal bleeding after delivery

  • responsible for milk ejection during breastfeeding

    • Stimulation of the breasts through sucking or touching stimulates the secretion of oxytocin

  • can increase the severity of after pains since oxytocin stimulates uterine contractions

• ADH, aka vasopressin:

  • made in the hypothalamus, secreted by posterior pituitary

  • its release is unchanged in pregnancy

  • helps the body conserve water by reducing urine formation and causes vasoconstriction, which raises BP and hypervolemia

Pancreas:

• increased demand to meet needs of pregnancy → increased secretion of insulin

• Maternal insulin does not cross the placenta, so the fetus must produce its own supply to maintain glucose control

• In early pregnancy, maternal glucose goes to the fetus, so the mother's levels are low.

  • fetus is also drawing amino acids and lipids from mom, decreasing her ability to synthesize glucose.

• Hormonal antagonists rise in late pregnancy, so more insulin is needed to overcome their effects.

  • examples of hormonal antagonists: hCS, steroids (cortisol), placental GH, glucocorticoids, prolactin, estrogen, and progesterone

  • results in glucose being less likely to enter mom’s cells and is more likely to cross over the placenta to the fetus

• mom becomes slightly insulin resistance to make sure the growing fetus gets enough glucose

• if mom doesn’t have enough beta cells (of the islets of Langerhans) → mom cant make enough insulin → blood sugar levels rise

• in early pregnancy, maternal insulin production and insulin level decreases

Adrenal Glands:

• hormone production increases

• increased cortisol levels helps in times of stress

  • regulates carb and protein metabolism

  • secretion doesnt increase, the rate of clearance decreases

  • Levels rise in the 2nd and 3rd trimesters due to higher estrogen and placental release of corticotropin-releasing hormone (CRH)

    • most cortisol is deactivated to cortisone by a placental enzyme to protect the fetus

• aldosterone increases

  • normally regulates absorption of sodium from within the kidney (at the distal tubules)

  • During pregnancy, progesterone promotes salt loss in urine, while aldosterone helps regulate electrolytes, water balance, and blood pressure

Prostaglandin Secretion:

• theorized: increased prostaglandins production → facilitates uterine contractions, promotes cervical ripening, and increases myometrial sensitivity to oxytocin needed for labor

Placental Secretion:

• placenta can make enzymes, proteins, fats, and carbs for energy storage

• placenta functions as an endocrine gland, manufacturing and secreting hormones (protein and steroid hormones)

  • the placenta begins to produce these hormones:

    • hCG (protein hormone): maintains the maternal corpus luteum, which secretes progesterone and estrogens

    • hPL/hCS (protein hormone):

      • prepares mammary glands for lactation

      • involved in the process of making glucose available for fetal growth by altering maternal carb, fat, and protein metabolism

      • Antagonist of insulin because it decreases tissue sensitivity or alters the ability to use insulin

    • relaxin (protein hormone):

      • secreted by the placenta and corpus luteum

      • act synergistically with progesterone

      • increases flexibility of the pubic symphysis, permitting the pelvis to expand during delivery

      • cervical dilation

      • suppresses the release of oxytocin by the hypothalamus, thus delaying the onset of labor contractions

    • progesterone (steroid hormone):

      • Produced by the corpus luteum during the first few weeks of pregnancy and then by the placenta until term

      • supports and maintains the uterine endometrium

      • inhibits uterine contractility, maternal immune response

      • assists in the development of the breasts for lactation (the milk-producing glands)

    • estrogen (steroid hormone):

      • Promotes enlargement of the genitals, uterus, and breasts and increases vascularity, causing vasodilatation

      • Relaxation of pelvic ligaments and joints

      • Associated with hyperpigmentation, vascular changes in the skin, increased activity of the salivary glands, and hyperemia of the gums and nasal mucous membranes

      • Aids in developing the ductal system of the breasts in preparation for lactation

Changing Nutritional Needs of Pregnancy

• *DRI = daily recommended intake*

• Iron and folic acid: needed to make more blood cells (since maternal blood volume increases), and must be supplemented since diet alone usually can't meet the increased demand

• Iron: essential for fetal growth & brain development and in the prevention of maternal anemia

  • DRI during pregnancy: 27 mg/day of ferrous iron

    • lactating = 9-10 mg/day

• folic acid: should be increased before and early in pregnancy is key to preventing fetal neural tube defects

  • DRI during pregnancy: 400-800 mcg/day of folic acid, possibly higher if there is previous history of fetuses with neural tube defects

    • lactating = 500 mcg/day (within same range as during pregnancy)

  • food sources: dark green vegetables (broccoli, romaine lettuce, and spinach), baked beans, black-eyed peas, citrus fruits, peanuts, liver

• Eat at least 8-12 oz of lower methylmercury fish weekly, with one of them being an oily fish

Nutritional Requirements During Pregnancy

• Protein DRI during pregnancy: 71 g/day during 2nd & 3rd trimesters

  • same if lactating

• Calorie DRI during pregnancy: 2,200–2,400 (2nd trimester), 2,400–2,600 (3rd trimester) daily

  • lactating = 2,200–2,400 daily

Food Concerns During Pregnancy

Fish, Shellfish, and levels of Mercury:

• Most fish and shellfish contain some mercury

• high levels of mercury can harm a fetus’s CNS if eaten in large amounts

  • also associated with pregnancy complications

• mercury exposure is likely to arise from predatory fish consumption

• before becoming pregnant, when pregnant, and if breastfeeding:

  • avoid fish with moderate to high mercury levels for 6–12 months before conception and during pregnancy

    • shark, swordfish, king mackerel, marlin, orange roughy, bigeye tuna, tilefish

  • eat 8-12 oz (two average meals) weekly of low mercury fish

    • shrimp, white albacore tuna (limit to 6 oz/week), salmon, lobster, sole, tilapia, cod, haddock, pollock, catfish

  • check local advisories about the safety of fish caught in local lakes, rivers, and coastal areas

Maternal Weight Gain

• amount of weight gain is not as important as what they eat

  • extra weight can be lost after pregnancy, but poor nutrition during pregnancy cant be reversed

• Dieting during pregnancy is never recommended, even for people with higher weight

  • Severe calorie restrictions are associated with low birth weight

• If pt is gaining weight in a steady, gradual manner, then they are taking in enough calories

  • adequate calories doesn’t always mean sufficient nutrient intake

  • quantity and quality of foods must be evaluated

• recommended weight gain in 1st trimester based on prepregnancy BMI:

  • underweight (<18.5) = 5 lb

  • healthy (18.5 to 24.9) = 3.5-5 lb

  • high BMI (25 or higher) = 2 lb

  • much of the weight gain here is due to uterine growth and blood volume expansion

• recommended weight gain in 2nd & 3rd trimester based on prepregnancy BMI:

  • underweight (<18.5) = slightly more than 1 lb/week

  • healthy (18.5 to 24.9) = 1 lb/week

  • high BMI (25 or higher) = 0.5-0.6 lb/week

• recommended total weight gain throughout pregnancy based on prepregnancy BMI:

  • underweight (<18.5) = 28-40 lb

  • healthy (18.5 to 24.9) = 25-35 lb

  • overweight (25 to 29.9) = 15-25 lb

  • obese (>30) =11-20 lb

Nutrition Promotion

Teaching to Promote Optimal Nutrition During Pregnancy:

• Follow a healthy dietary pattern and select a variety of foods from each food group

• Gain weight in a gradual and steady manner depending on prepregnancy BMI

  • refer to red text under previous heading

• Avoid weight reduction diets during pregnancy

• Do not skip meals

• Do not restrict salt use unless instructed by your HCP

• Engage in reasonable physical activity for 150 min/week

Special Nutritional Considerations

Lactose intolerance:

• Additional or substitute sources of calcium and vitamin D may be necessary

• Encourage the pt to drink and eat lactose-free dairy products or calcium-enriched orange juice or soy milk

Vegetarians:

• choose not to eat meat, poultry, and fish; plant-based foods only

• Lacto-ovo-vegetarians:

  • no: red meat, fish, and poultry

  • yes: eggs, milk, dairy products, plant-based foods

• Lacto vegetarians:

  • no: eggs, meat, fish, and poultry

  • yes: milk, dairy products, plant-based foods

• Vegans:

  • no: foods originating from animals (eggs, milk, milk products)

  • yes: plant-based foods ONLY

• must pay special attention to their intake of protein, iron, calcium, vitamin D, and vitamin B12

  • Suggestions include:

    • For protein: Substitute soy foods, beans, lentils, nuts, grains, and seeds.

    • For iron: Eat a variety of meat alternatives along with vitamin C–rich foods.

    • For calcium: Substitute soy, calcium-fortified orange juice, kale, broccoli, and tofu.

    • For vitamin D: Consume fortified milk, fish, cereal, and take prenatal vitamins

    • For vitamin B12: Eat fortified soy foods and cereals, and take a B12 supplement.

Pica

• intense craving for and eating of nonfood items over at least 1 month

• Common cravings:

  • geophagia = dirt, clay, soil

  • amylophagia = raw starch (cornstarch, laundry starch, flour)

  • pagophagia = ice, freezer frost

• Other possible cravings: paper, toilet paper, charcoal, baby powder, chalk, coffee grounds, paint chips, ashes

• Nutritional and clinical implications include the following:

  • geophagia: replaces nutritive sources and can contain toxic substances

    • causes iron-deficiency anemia, low gestational weight gain, constipation, hypokalemia, parasitic infection

  • pagophagia: can cause iron-deficiency anemia, low gestational weight gain, tooth fractures, jaw pain, freezer burn injuries

  • amylophagia: replaces iron-rich foods → iron deficiencies, and also leads to abdominal discomfort, poor glucose control, and excessive weight gain

Psychosocial Adaptations During Pregnancy

Maternal Emotional Responses

Ambivalence

• having conflicting feelings at the same time; a normal, universal feeling

  • the person may feel proud and excited, while simultaneously fearful and anxious

• mom commonly experiences this during the 1st trimester

  • evolves into acceptance by 2nd trimester, when fetal movement is felt

• reactions are influenced by several factors: the way they were raised, their current family situation, the quality of the relationship with their partner, their hopes for the future, their personality, and their ability to adapt to changing circumstances

Introversion

• focusing on oneself

• common during the early part of pregnancy

  • heightening in the 1st and 3rd trimesters when their focus is on behaviors that will ensure a safe and health pregnancy outcome

• normal psychological adaptation

• person may withdraw and become increasingly preoccupied with themselves and their fetus

• may participate less with the outside world, may appear passive to their family and friends

Acceptance

• happens during the 2nd trimester

• the physical changes of the growing fetus bring a sense of reality and validity to the pregnancy

• many tangible signs that someone separate from themselves is present; they conceptualize the fetus as a person

  • enlarging abdomen, fetal movement, hearing the heartbeat, seeing the fetal image on an ultrasound, feeling distinct parts, recognizing independent sleep and wake patterns

• may verbalize positive feelings about the pregnancy

• may accept their new body image and talk about the new life within

Mood Swings

• Emotional lability: having rapid, intense mood swings, where emotions can change quickly and feel hard to control

• mom may start to cry without any apparent cause

• Some people feel as though they are riding an “emotional roller coaster”

• common throughout pregnancy

Change in Body Image

• normal but can be stressful

• Some people feel beautiful, while others feel uncomfortable with their appearance

• some people may view pregnancy as a from worrying about weight, while others worry about weight gain

Becoming a Parent (Maternal Tasks)

• maternal tasks must be accomplished to incorporate the maternal role into her personality

• Accomplishing these tasks helps mom develop her self-concept as a parent and build a strong mutual bond with the baby

• Primary focus: ensuring safe passage throughout pregnancy and birth by participating in positive self-care activities

  • 1st trimester: person focuses on themselves, not on the fetus

  • 2nd trimester: person develops a great attachment to the fetus

  • 3rd trimester: person has concern for themselves and the fetus as one

• Seeking acceptance of infant by others

  • 1st trimester: acceptance of pregnancy by themselves and others

  • 2nd trimester: family needs to relate to the fetus as member

  • 3rd trimester: unconditional support by others

• Seeking acceptance of self in maternal role to infant (“binding in”)

  • 1st trimester: pregnant person accepts idea of pregnancy, but not of an infant

  • 2nd trimester: sensation of fetal movement (quickening) causes mom to acknowledges fetus as a separate entity within them

  • 3rd trimester: person longs to hold infant and becomes tired of being pregnant

• Learning to give of oneself

  • 1st trimester: identifies what must be given up to assume new role

  • 2nd trimester: identifies with infant and learns how to delay own desires

  • 3rd trimester: questions their ability to become a good parent

Pregnancy and Sexuality

• discomforts of pregnancy can produce stress on the sexual relationship between mom and her partner

• mom’s sexual desire may change throughout the pregnancy

  • 1st trimester: may be less interested in sex because of fatigue, nausea, and fear of disturbing the early embryonic development

  • 2nd trimester: interest may increase because of the stability of the pregnancy

  • 3rd trimester: enlarging physical size may produce discomfort during sexual activity

• Abstinence recommended for people with pregnancy complications [vaginal bleeding, preterm cervical dilation, preterm labor risk, risk of antepartum (during labor, before birth) hemorrhage because of placenta previa]

Pregnancy and the Partner

• 2nd trimester: dad accepts role as caregiver and support person, accepts the reality of the fetus when movement is felt, and experiences confusion when dealing with their pregnant partner’s mood swings and introspection

• 3rd trimester: dad prepares for the reality of this new role and negotiates what the role will be during the labor and birthing process

  • dad’s response depends on the state of the relationship

  • a struggling relationship may push the partner away near the end of pregnancy when responsibilities grow

    • may manifest as working late, staying out late with friends, or beginning new or superficial relationships

  • in a stable relationship, the partner now finds concrete tasks to do (painting the nursery, assembling the car seat, attending childbirth classes)

• Expectant partners share many of the same anxieties as their pregnant partners

Pregnancy and Siblings

• sibling’s reaction to pregnancy is age dependent

  • young toddler’s may regress in toilet training or ask to drink from a bottle again

  • older school-aged child may ignore the new addition to the family and engage in outside activities to avoid the new member

  • Preparing siblings for a new baby should match their age and life experiences at home

• child may fear changes in their bond with their parents or worry about being replaced by the new family member → beginning of sibling rivalry

  • reduce this by constant reinforcement of love and caring