Normal pregnancy and prenatal care

Who is most at risk of pre-eclampsia?

- women that are having their first pregnancy - multiple gestations - mothers > 35 years - having hypertension - diabetes - obesity - family history

First we want to take an obstetric history in the initial visit. What do we record here?

- Discuss current symptoms - Discuss any perceptions regarding childbearing (including potential birth plans) and the effect of the pregnancy on the patient's life Outcomes of all previous pregnancies - length of gestation - birth weight - length of labor - type of delivery - fetal/neonatal outcome - anesthesia - complications - if C section was performed

What is maternal weight gain during pregnancy due to?

- Fetus - Placenta - Amniotic fluid - Breast enlargement - Uterus - Increased interstitial fluid and blood volume A woman who is 15% or more below ideal body weight or of short stature has a risk for a small for gestational age infant and preterm delivery - may reflect poor nutrition, inadequate nutrition absorption, maternal illness which can predispose the mother to an inadequate volume expansion and the fetus to growth restriction - recommended weight gain of 11.5 - 16 kg during a singleton pregnancy and underweight can gain more but overweight may gain less

What are some laboratory tests we run initially for pregnancy?

- complete blood count (hemoglobin, hematocrit, platelets - blood group and RH typing (ABO/Rh) - screen for antibodies against blood group antigens - VDRL (venereal disease research lab) or RPR (rapid plasma reagent) for syphyllis, hepatitis B surface antigen - serology to detect antibodies against rubella and HIV - Women with a history of gestational diabetes are given a glucose challenge test (GCT) with oral ingestion of a solution containing 50 g of glcuose

What are the indications for ultrasound?

- dating - aneuploidy assessment - anatomical survey - cervical length assessment - fetal well-being can be monitored by ultrasound using the biophysical profile

What are the negative effects of nicotine and cigarette smoking?

- increased risk of low birth weight infants with cigarette smoking - risk of intrauterine growth restriction - placenta previa - placenta abruption - preterm birth - low birth weight - perinatal mortality

What are some endocrine functions of the placenta?

- progesterone - placenta takes over production from corpus luteum around 10 weeks - oestrogen - placenta lacks enzymes to make directly but cooperates with foetus to make oestrogens - hCG --> rescue Corpus Luteum from luteolysis - placental lactogen (chorionic sommatotropin, hCS) is growth promoting, low lactogenic activity, stimulates maternal metabolism (lipolysis and insulin antagonism)

What are some common complaints of pregnancy?

1) Ptyalism - excessive salivation --> cause unknown 2) Pica - ingestion of substances with no nutritive value 3) Urinary frequency and renal function - enlarging uterus and fetus decrease bladder capacity leading to frequency - glomerular filtration rate increases 50% during pregnancy - dysuria or hematuria may be a sign of infection - 2-12% of women may have a UTI without symptoms 4) Varicose veins - pressure by the enlarging uterus, which reduces venous return, as well as the relaxation of vascular smooth muscle by progesterone may result in enlargement of the peripheral veins in the lower extremities and development of varicosities 5) Joint and back pain - relaxation may result in a small degree of separation or mobility at the pubic symphysis and sacroiliac articulations so they may experience an unstable pelvis which results in pain - lordosis occurs b/c of the protuberant abdomen 6) Leg cramps/numbness 7) Breast soreness 8) Discomfort in hands

What is Chadwick's sign?

Congestion of the pelvic vasculature causes blueish discoloration of the vagina and cervix. This a presumptive sign of pregnancy

When does fetal movement begin?

Initial perception of fetal movement occurs at 18-20 weeks gestation in primiparous patients and as as 14 weeks gestation in multiparous patients. Maternal perception of movement is called quickening, but this is not a dependable sign of pregnancy

What is a teratogen? When do these have the greatest effect on a fetus?

A teratogen is a toxin, drug, or a biologic agent that causes a harmful effect on a fetus. The greatest effect of a drug is normally during the period of organogenesis (weeks 2-10 after LNMP). Drugs with the potential for addiction such as heroin, methadone, and benzodiazepines can cause major problems for the neonate, including withdrawal.

What is pre-eclampsia?

Affects pregnant women after 20 weeks gestation and up to 6 weeks after delivery - causes new onset hypertension - proteinuria (marker of kidney damage) Symptoms can be mild to life threatening

What is the fetal age?

Age of the conception calculated from the time of implantation, which is 4-6 days after ovulation is completed

What are spider telangiectasia?

Also known as spider angioma/spider nevus. It is a type of telangiectasis (swollen blood vessels) found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider's web. Spider angiomas are found only in the distribution of the superior vena cava, and are thus commonly found on the face, neck, upper part of the trunk, and arms. Common skin lesions of pregnancy that result from elevated plasma estrogen. Estrogen has an endothelial vasodilation effect. Both the vascular stellate skin lesions as well as palmar erythema may be seen in pregnancy and also occur in patients with liver failure

What are some clinical findings (symptoms and signs) about someone who is pregnant?

Amenorrheao Nausea and vomiting Breast changes - mastodynia - breast engorgement - colostrum secretion - development of secondary breast tissue Fetal movemement Elevated basal body temperature Skin changes - chloasma - linea nigra - striae - spider telangiectasia Pelvic organ changes - Chadwick's sign - Hegar's sign - Leukorrhea - Pelvic ligaments - abdominal enlargement - uterine contractions

How do we use uterine size as a clinical parameter?

An early first-trimester examination usually correlates well with the estimated gestational age. The uterus is palpable just at the pubic symphysis at 8 weeks. At 12 weeks, the uterus becomes an abdominal organ, and at 16 weeks, it is usually at the midpoint between the pubic symphysis and the umbilicus. Between 18 and 34 weeks' gestation, the uterus size or fundal height is measured in centimeters from the pubic symphysis to the upper edge of the uterine corpus, and the measurement correlates well with the gestational age in weeks (Fig. 6-1). The uterus is palpable at 20 weeks at the umbilicus. After 36 weeks, the fundal height may decrease as the fetal head descends into the pelvis.

Can pregnant women have sex?

No adverse outcome can be directly attributed to sexual intercourse during pregnancy. If cramping, spotting, or bright red bleeding follows coitus, sexual activity should not occur until the patient is evaluated by her clinician. A patient with preterm labor or vaginal bleeding should not have coitus until evaluated by her clinician.

In terms of edema for pregnant women what do we look for?

Are there transient episoes of general edema or swelling - Lower extremity edema in late pregnancy is a natural consequence of hydrostatic changes in lower body circulation. - Edema of the upper body (eg, face and hands), especially in association with relative or absolute increases in blood pressure, may be the first sign of preeclampsia, although edema is not part of the current diagnostic criteria. - A moderate rise in blood pressure without excessive fluid retention may suggest a predisposition to chronic hypertension.

What must we instruct the patient in preparation for labor?

As term approaches, the patient must be instructed on the physiologic changes associated with labor. She is usually admitted to the hospital when contractions occur at 5- to 10-minute intervals. She should be told to seek medical advice for any of the following danger signals: (1) rupture of membranes, (2) vaginal bleeding, (3) decreased fetal movement, (4) evidence of preeclampsia (eg, marked swelling of the hands and face, blurring of vision, headache, epigastric pain, convulsions), (5) chills or fever, (6) severe or unusual abdominal or back pain, or (7) any other severe medical problems.

What happens to maternal blood pressure during pregnancy?

Blood pressure tends to decrease 5-7 mm (both systolic and diastolic components) early in the second trimester but return to normal in the 3rd - elevation of blood pressure may preceded an increase in proteinuria seen with hypertension in pregnancy

What are risk factors for placental abruption?

Blunt trauma Drugs Multiparity Maternal age > 35 Previous abruption (strongest risk factor)

What do we do in the physical examination of pregnancy during the 1st visit?

Bony pelvis - pelvic inlet - midpelvis - pelvic outlet Uterus - The uterus can be used to confirm gestational age in the first half of pregnancy. As the uterus enlarges, it becomes globular and often rotates to the right. Cervical length - A nulliparous woman who has not undergone a vaginal delivery will have a closed external cervical os. A multiparous patient may have a greater opening or dilation of the external os. Adnexal exam - During the pelvic exam, a bimanual examination is performed, and the cervical length and evaluation of both ovaries (the adnexa) can be performed.

What is a postterm infant?

Born after 42 weeks gestation - may result in excessive size infant with diminished placental capacity - usually offer induction of labor after week 41 b/c prenatal mortality rates increase after the due date

Why do we do cystic fibrosis screening?

CF is inherited in an autosomal recessive manner. It is caused by the presence of mutations in both copies of the gene for the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Those with a single working copy are carriers and otherwise mostly normal. CFTR is involved in production of sweat, digestive fluids, and mucus. When CFTR is not functional, secretions which are usually thin instead become thick. The condition is diagnosed by a sweat test and genetic testing. Screening of infants at birth takes place in some areas of the world.

What do we look for in the fetal heart tones?

Can be auscultated by 10-12 weeks gestation using a handheld doppler device. Look at: - rate - rhythmn - presence of any irregulatory of heart rate - accelerations/decelerations

What is amenorrhea?

Cessation of menses is caused by hormones (estrogen and progesterone) produced by the corpus luteum. The abrupt cessatino of menses in a healthy reproductive-aged female with predictable cycles is highly suggestive of pregnancy

What is Chloasma?

Chloasma - mask of pregnancy is skin darkening of the forehead, bridge of the nose, or cheek bones. This pregnancy-associated change is linked to genetic predisposition and usually occurs after 16 weeks gestation. Chloasma is exacerbated by sunlight - caused by steep rise in estrogen levels b/c they stimulate melanin production (also known as hyperpigmentation)

What is contained within the colostrum?

Colostrum is known to contain immune cells (as lymphocytes) and many antibodies such as IgA, IgG, and IgM. Other immune components of colostrum include the major components of the innate immune system, such as lactoferrin, lysozyme, lactoperoxidase, complement, and proline-rich polypeptides (PRP).

Why do pregnant women get nausea and vomiting?

Common symptom (50% of pregnancies) that begins as early as 2 weeks gestational age and customarily resolves at between 13-16 weeks gestation - can lead to hyperemesis gravidarum which is an extreme form of nausea and vomiting and is characterized by dehydration, weight loss and ketonuria. - uncomplicated nausea and vomiting is treated with frequent small meals, a dry diet, and emotional support - one reason for nausea is progesterone is being secreted alot and that relaxes smooth muscle which makes it so food may not make it's way down as well as usual and that stasis of food can lead to vomiting.

What are the lab findings of DIC? Treatment?

Decreased platelets and fibrinogen Prolonged prothrombin time Increased D-Dimer Treast underlying cause --> may give supplementary clotting factors or fibrinogen depending on situation

What is a live birth?

Delivery of any infant (regardless of gestational age) that demonstrates evidence of life independent of whether the umbilical cord has been cut or the placenta detached

How is diagnosis of pregnancy usually made? Why is it crucial to diagnose as soon as possible?

Diagnosis is made on the basis of amenorrhea and a positive pregnancy test - it is crucial to diagnose pregnancy as soon as possible in order to initiate appropriate prenatal care, avoid teratogen (an agent that can cause a deleterious fetal effect), exposure, and diagnose nonviable or ectopic pregnancies

What is disseminated intravascular coagulopathy?

Disseminated intravascular coagulopathy is a rare sequelae occurring after an intrauterine fetal demise (IUFD). Coagulation studies may be started 2 weeks after the demise of one twin, and delivery can be undertaken if serial serum fibrinogen levels fall below 200 mg/dL. In a singleton IUFD, coagulation studies including fibrinogen are done immediately after the diagnosis is made, and delivery is initiated promptly.

What happens with Pre-eclampsia when the endothelium gets damaged?

Endothelial damage increases vascular permeability. This means fluid can get into the tissues and since you already have protein loss from proteinuria even more fluid moves into tissues from the blood vessels and this causes generalized edema often seen in legs, face, hands - can cause pulmonary edema --> causes cough and shortness of breath - cerebral edema which can cause headaches, confusion, and seizures --> now you can get Eclampsia

What happens if you drink alcohol while you are pregnant?

FAS which includes - pre-post natal growth restriction - cranial-facial dysmorphology (including microcephalus and microphthalmia) - mental retardation - cardiac defects - behavioral abnormalities

What can we use to diagnose pregnancy?

Fetal heart tones --> detectable by handheld Doppler (after 10 weeks gestation) or by fetoscoep (after 18-20 weeks gestation) - normal heart rate is 110-160 beats per minute, with a higher fetal heart rate observed early in pregnancy Uterine size/fetal palpatation - can be used to diagnose pregnancy secondary to uterine enlargement Imaging studies - Sonography is one of the most useful technical aids in diagnosing and monitoring pregnancy. Cardiac activity is discernible at 5-6 weeks via transvaginal sonogram, limb buds at 7-8 weeks, and finger and limb movements at 9-10 weeks. At the end of the embryonic period (10 weeks by LNMP), the embryo has a human appearance. Pregnancy tests (home) - Sensitive, early pregnancy tests measure changes in the level of human chorionic gonadotropin (hCG). Urine Pregnancy Test - An antibody assay recognizing the β-hCG subunit is the initial lab test performed in the office to diagnose pregnancy. The test is reliable, rapid (1-5 minutes), and inexpensive, with a positive test threshold between 5 and 50 mIU/mL, characterized by a color change. This is the most common method to confirm pregnancy.

What are some late signs and symptoms of pregnancy failure?

First sign of fetal demise is usually the absence of fetal movement as noted by the mother if FHT cannot be appreciated, real-time ultrasonography is virtually 100% accurate in describing the absence of fetal heart motion

What are some genetic screening and testing we do initially?

First trimester screening using a combination of a fetal nuchal translucency measurement and maternal serum analysis of pregnancy-associated plasma protein A (PAPP-A) and free or total B-hCG us used to screen for trisomy (21, 18, and 13) - great detection rates between 85-87% and false positive less than 5% With the use of first-trimester screening, maternal serum a fetoprotein (AFP) should be drawn at 15-18 weeks gestation to screen for open neural tube defects Analytes studied include - serum b-hCG - unconjugated estriol - AFP - inhibin - hemoglobin electrophoresis for hemoglobinopathies (sickle cell disease risk) - cystic fibrosis screening

What is gestational diabetes?

Gestational diabetes also known as gestational diabetes mellitus (GDM), is when a woman without diabetes, develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it does increase the risk of pre-eclampsia, depression, and requiring a Caesarean section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of being too large, having low blood sugar after birth, and jaundice. If untreated, it can also result in a stillbirth. Long term, children are at higher risk of being overweight and developing type 2 diabetes.

What are some laboratory evaluations during the 3rd trimester?

Gestational diabetes screening Complete blood count --> for anemia Group B streptococcus

What are some ways to diagnose early pregnancy failure?

Gold standard is ultrasound. Definitive diagnosis requires recognition of a fetus in the absence of cardiac activity. In cases where ultrasound findings are equivocal, serial measurements of serum B-hCG levels with a failure to demonstrate an appropriate increase are helpful

What is the difference between gravid and parity?

Gravid means pregnant and gravida is the total number of pregnancies that a woman has had, regardless of outcome Parity is the number of births both before and after 20 weeks' gestation, and comprises 4 components 1. Full-term births 2. Preterm births (having given birth to an infant (alive or deceased) weighing 500 g or more, or at or beyond 20 completed weeks 3. Abortions: pregnancies ending before 20 weeks, either induced or spontaneous 4. Living children

Severe preeclampsia (Systolic > 160 and Diastolic > 110) can lead to?

Hemorrhagic stroke Placental abruption (placenta detaches from the uterine wall prematurely)

What is Eclampsia?

If a woman develops preeclampsia + seizures

What can occur due to Pre-eclampsia in severe disease?

In severe disease there may be: - red blood cell breakdown - a low blood platelet count With local areas of vasospams you can get: - impaired liver function --> and this leads to injury and swelling and elevation of liver enzymes and stretches of the capsule. Then you get right upper quadrant pain (epigastric pain --> cardinal symptom of pre-eclampsia) - kidney dysfunction --> oliguria (low urine) and proteinuria which are signs of glomerular damage - swelling - shortness of breath due to fluid in the lungs, or - visual disturbances --> decreased retinal flow and get blurred vision, flashing lights or scotoma (blurry spot on vision) Pre-eclampsia increases the risk of poor outcomes for both the mother and the baby. If left untreated, it may result in seizures at which point it is known as eclampsia

What is Leukorrhea?

Increase in vaginal discharge, containing epithelial cells and cervical mucous, secondary to hormonal changes

The spiral arteries undergo a transformation for pregnancy to be successful. What is it?

It is done to ensure delivery of high volume, low resistance maternal blood flow to the placental IVS - involves dilation of the artery lumen, trophoblast invasion of the vessel wall, replacement of the muscular and elastic tissue of the arterial wall (media) by a thick layer of fibrinoid material - In normal early embryonic development, the outer epithelial layer contains cytotrophoblast cells, a stem cell type found in the trophoblast that later differentiates into the fetal placenta. These cells differentiate into many placental cells types, including extravillous trophoblast cells. Extravillous trophoblast cells are an invasive cell type which remodel the maternal spiral arteries by replacing the maternal epithelium and smooth muscle lining the spiral arteries causing artery dilation. This prevents maternal vasoconstriction in the spiral arteries and allows for continued blood and nutrient supply to the growing fetus with low resistance and high blood flow.

What is the role of lactoferrin in the colostrum?

Lactoferrin's primary role is to sequester free iron, and in doing so remove essential substrate required for bacterial growth. Antibacterial action of lactoferrin is also explained by the presence of specific receptors on the cell surface of microorganisms. Lactoferrin binds to lipopolysaccharide of bacterial walls, and the oxidized iron part of the lactoferrin oxidizes bacteria via formation of peroxides. This affects the membrane permeability and results in the cell breakdown (lysis)

What is Linea nigra?

Linea nigra - melanocyte-stimulating hormone increases which is made by the placenta, causing darkening of the nipples and the lower midline from the umbilicus to the pubs.

What is an infant?

Live born human from the moment of birth until the completion of 1 year of life

What constitutes a large for gestational age fetus? (macrosomic infant). What about a low birth weight infant?

Macrosomic infant/large for gestational age --> estimated fetal weight at or beyond the 90th % and that can be 4000g or above - suspected in women with previous macrosomic fetus or those with diabetes mellitus Low birth weight infant --> live birth for which the infant's weight is less than or equal to 2500 g

Explain the breast changes that occur during pregnancy

Mastodynia - breast tenderness may range from tingling to pain caused by hormonal changes affecting the mammary duct and alveolar system Breast engorgement - breast engorgement and periareolar venous prominences are also seen early in pregnancy, especially in primiparous patients - Montgomery's tubercles are the portion of the areolar glands visible on the skin surface. These tubercles can be more pronounced during pregnancy secondary to hormonal changes occurring as early as 6-8 weeks gestation Colostrum secretion - is a form of milk produced by the mammary glands of mammals (including humans) in late pregnancy. Development of secondary breast tissue - development of secondary breast tissue may occur across the nipple line. Hypertrophy of secondary breast tissue may occur in the axilla and cause a symptomatic mass

What are complications of placental abruption?

Maternal - hypovolemic shock - sheehan syndrome (perinatal pituitary necrosis) - renal failure - DIC ~ from release of thromboplastin Fetal - intrauterine hypoxia and asphyxia - premature birth

In the initial visit what do we take down in terms of medical/surgical/family/social history?

Medical - want to take a full past medical as pregnancy may influence a number of maternal organ systems and preexisting conditions may be exacerbated during pregnancy - prior blood transfusion may increase risk of hemolytic disease b/c of maternal antibodies produced secondary to minor blood group mismatch - diabetes, other endocrine diseases, hypertension, epilepsy, autoimmune diseases Surgical - previous gynecologic, abdominal, or uterine surgery may necessitate a C section - In addition, a history of cervical surgery, multiple induced abortions, or recurrent fetal losses may suggest cervical incompetence. Family history - A family history of diabetes mellitus should alert the clinician about an increased risk of gestational diabetes, especially if the patient has a history of a large infant or a previous birth defect, or an unexplained fetal demise. Glucose testing should be performed at the initial prenatal visit if there is a strong suspicion of undiagnosed pregestational diabetes rather than waiting until 24-28 weeks' gestation. Awareness of familial disorders is also important in pregnancy management. Thus a brief, 3-generation pedigree is useful. Antenatal screening tests are available for many hereditary diseases Social history - The prenatal history should include documentation of tobacco and alcohol use, any contact with intravenous drugs or drug users, or other drug use. Exposures (workplace and otherwise) should be evaluated.

Who is offered invasive genetic testing?

Must be offered to all women, especially those who will be 35 years of age or older at the time of delivery or who have a history of an abnormal pedigree or risk factors for inherited diseases

What is the neonatal period?

Neonatal period is defined as birth until 28 days of life; during this interval, the infant is designated as a newborn or neonate

What is the pregnancy calendar or calculator?

Normally, human pregnancy lasts 280 days or 40 weeks (9 calendar months or 10 lunar months) from the LNMP. This may also be calculated as 266 days or 38 weeks from the last ovulation in a normal 28-day cycle. The easiest method of determining gestational age is with a pregnancy calendar or calculator. The EDD can be determined mathematically using Naegele's rule: subtract 3 months from the month of the LNMP and add 7 to the first day of the LNMP. Example: With an LNMP of July 14, the EDD is April 21.

What is Oligospermia? What is Asthenospermia?

Oligispermia - less than 20 million/ml and is considered low Asthenospermia - problems with sperm mobility, movement is slow, not in a straight line. This is when less than 40% of sperm have normal motility

What is a preterm infant?

One born between 20 weeks and 37 completed weeks of gestation

What are placental abruption signs/symptoms?

Pain in the abrupted area Uterus might tense up/become rigid - b/c muscle layer contracts to reduce bleeding

What is a sign/symptom of placenta previa?

Painless abrupt onset of bright, red bleeding

What happens to the uterus in terms of contractions during pregnancy?

Painless uterine contractions (Braxton Hick's contractions) are felt as tightening or pressure. They usually begin at approximately 28 weeks gestation and increase in regulatory with advancing gestational age. These contractions usually disappear with walking or exercise whereas true labor contractions become more intense

Placental abruption can be classified into?

Partial/Complete Apparent/Concealed If the rupture occurs near the margin you can get vaginal bleeding and apparent blood loss but if it occurs in a central area it could just be a pocket of blood and lead to concealed blood loss

What happens to the pelvic ligaments and abdomen during pregnancy?

Pelvic ligaments --> There is relaxation of the sacroiliac and pubic symphysis during pregnancy. Relaxation is pronounced at the pelvic symphysis. Abdominal enlargement occurs during pregnancy, duh

What is placenta accreta?

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall). Three grades of abnormal placental attachment are defined according to the depth of invasion: Accreta - chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis. - The placenta attaches strongly to the myometrium, but does not penetrate it. Increta - chorionic villi invade into the myometrium. - Occurs when the placenta penetrates the myometrium. Percreta - chorionic villi invade through the myometrium. - Occurs when the placenta penetrates the myometrium. Because of abnormal attachment to the myometrium, placenta accreta is associated with an increased risk of heavy bleeding at the time of attempted vaginal delivery. The need for transfusion of blood products is frequent, and hysterectomy is sometimes required to control life-threatening hemorrhage.

What is Placental abruption?

Premature separation of all or part of the placenta resulting in haemorrhage or bleeding - after 20 weeks of gestation - happens when separation of uterine wall and the decidua basalis - caused by degeneration of decidua arteries that supply blood to the placenta (usually due to hypertension, smoking) - these diseased vessels rupture causing hemorrhage and separation of placenta

How is AFP related to neural tube defects?

Presence of open neural tube defects (NTDs) can be detected with the measurement of AFP in the amniotic fluid or maternal bloodstream. AFP is the major serum protein in early embryonic life and is 90% of the total serum globulin in a fetus. It is believed to be involved in preventing fetal immune rejection and is first made in the yolk sac and then later in the GI system and liver of the fetus. It goes from the fetal blood stream to the fetal urinary tract, where it is excreted into the maternal amniotic fluid. The AFP can also leak into the amniotic fluid from open neural tube defects such as anencephaly and myelomeningocele, in which the fetal blood stream is in direct contact with the amniotic fluid.

What happens to the basal body temperature of pregnant women?

Progesterone produces 0.5 degrees farenheit increase in the basal body temperature, which persists after the missed menses. The rise in temperature occurs within the luteal phase of the menstrual cycle

What vaccines should be given to the pregnant woman?

The flushot is safe any trimester. Diphtheria and tetanus toxoid, hepatitis B vaccine series, and killed polio vaccine may be administered during pregnancy to women at risk. Live attenuated vaccines (varicella, measles, mumps, polio, and rubella) should be given 3 months before pregnancy or postpartum. Live virus vaccines are contraindicated in pregnancy secondary to the potential risk of fetal infection.

Why do babies have a higher heart rate?

Smaller heart means the more work it has to do to maintain homeostasis in the body b/c that leads to smaller stroke volume per beat cycle. The muscles are smaller which also means less distance to contract so a beat can also happen faster. Neonates cannot adapt their stroke volume to meet metabolic demands, just the heart rate and their parasympathetic tone increases with age thereby slowing down their heart rate

In terms of male fertility what are some important factors?

Sperm quality - male infertility can be due to low sperm counts, poor sperm quality/morphology or both

What is striae?

Striae - can be on breast or abdomen and appear as irregular scars. Caused by collagen separation due to mechanical distension and rapidly developing areas of the body during pregnancy

What sexually transmitted diseases do we test for in pregnant women?

Syphilis Chlamydia Gonorrhea Herpes simplex virus HIV Other infections: - trichomonas - candidiasis - bacterial vaginosis

What is an abortion?

The expulsion or extraction of part (incomplete) or all (complete) of the placenta or membranes without an identified fetus or with a fetus (alive or deceased) weighing less than 500 g or with an estimated gestational age of less than 20 completed weeks or 139 days from the last menstrual period, if fetal weight is unknown.

What are the nutritional requirements for pregnant women?

The mother's nutrition from the moment of conception is an important factor in the development of the infant's metabolic pathways and future well-being. The pregnant woman should be encouraged to eat a balanced diet and should be made aware of special needs for iron, folic acid, calcium, and zinc. The average woman weighing 58 kg (127 lb) has a normal dietary intake of 2300 kcal/d. An additional 300 kcal/d is needed during pregnancy, and an additional 500 kcal/d is needed during breastfeeding. Consumption of fewer calories could result in inadequate intake of essential nutrients. Protein - 1 g per kg + 20 g per day in the 2nd half of pregnancy Calcium - 1200 mg per day Iron - need adequate iron intake for the increased red blood cell production Vitamines/Minerals - folic acid reduces the risk of neural tube defects

Background. Describe the placenta

The placenta is basically like a flat cake (literally what it means). It has a materal and fetal layer. The maternal layer which is called the decidua basalis has uterine arteries bringing blood in and uterine veins taking stuff out. The fetal part called the chorion has chorionic villi. It has little blood vessels and these go into the decidia basalis. This decidua however is a huge pool of blood. Gases and nutrients go in/out through the small chorionic tissues

What is the purpose of prenatal care?

The purpose of prenatal care is to ensure a successful pregnancy outcome when possible, including the delivery of a live, healthy fetus. It's proven that mothers receiving prenatal care have a lower risk of complications, and one of the principal aims of prenatal care is the identification and special treatment of the high-risk patient—the one whose pregnancy, because of some factor in her medical history or an issue that develops during pregnancy, is likely to have a poor outcome.

What is the purpose of the initial office visit during pregnancy or conception?

The purpose of the first office visit is to identify any risk factors influencing the mother and/or fetus. A plan of care for a high-risk pregnancy may be established at the first prenatal visit, including pertinent consultations of subspecialists.

For obstetric purposes, the gestational age or menstrual age is?

Time elapsed since the first day of the last normal menstrual period (LNMP), which actually precedes the time of oocyte fertilization

What is the perinatal period?

Time from 28 weeks gestation to the first 7 days of life; this also includes the late fetal and early neonatal period

How is biparietal diameter measurement taken?

To back up for a moment, every human has two parietal bones—one on the left side of the skull and one on the right side of the skull. Each parietal bone looks like a curved plate that has two surfaces and four sides. So, the BPD measurement is the diameter across your developing baby's skull, from one parietal bone to the other. To picture it, imagine taking a string and placing one end of it at the top of your right ear and the other end of it at the top of your left ear, letting it rest on the top of your head. The length of that string would give you a very rough idea of your biparietal diameter. When your baby is inside your uterus, an ultrasound technician takes this measurement, while looking at your developing baby on a computer screen and using digital measuring tools.

What are the functions of the placenta?

Transport/exchange of gases, nutrients, and waste products between M-F circulations - oxygen, carbon dioxide, steroids, water all by simple diffusion - nutritional substances - glucose and amino acids are actively transported across placenta - electrolytes exchanged in significant quantities - maternal antibodies - confer some passive immunity to foetus as immune system immature - transcytosis

What are the 4 clinical parameters we use for pregnancy?

Ultrasound Uterine size Quickening Fetal heart tones

What is the pathophysiology of pre-eclampsia?

Unknown but key pathophysiological feature is the development of an abnormal placenta. The placenta of women with pre-eclampsia is abnormal and characterized by poor trophoblastic invasion. After the first trimester trophoblasts enter the spiral arteries of the mother to alter the spiral arteries and thereby gain more access to maternal nutrients. Normally spiral arteries dilate to 5-10x their size which can deliver lots of blood to the developing fetus but in pre-eclampsia these utero-placental arteries become fibrous causing them to narrow which means less blood gets to the placenta. A poorly perfused placenta can lead to intrauterine growth restriction (IUGR) or even fetal death. - hypoperfused placenta starts to release pro-inflammatory proteins which then get into the mothers circulation and cause her endothelial cells to become dysfunctional and when that happens the response is to vasoconstriction - kidneys also start retaining more salt - both of these things result in hypertension

What do we test in the urine during the initial visit?

Urinalysis and culture is performed b/c 2-12% of pregnant women have an asymptomatic urinary tract infection Test for protein, glucose and ketones Proteinuria of greater than or equal to 2+ on a standard dipstick (which correlates to greater than 300 mg/24 hours on a time urine collection) may indicate renal disease or the onset of preeclampsia. Presence of glucosuria signifies that glucose transport to the kidney exceeds the transport capacity of the kidneys - no clinical significance unless carb intolerance or gestational diabetes present

What do we use the ultrasound for?

Used routinely to determine viability, estimate gestational age, screen for aneuploidy (abnormal # of chromosomes), and evaluate fetal anatomy and well-being. Done at week 12 for dating. Do nuchal translucency.

What is the treatment of (Pre)Eclampsia?

Usually have the baby if available

Is exercise recommended for pregnant women?

Yes. 30 minutes or more of moderate intensity physical activity but avoid risky exercises

What is placenta previa?

When the placenta implants in the lower uterus and covers the internal cervical os. This can easily bleed which happens 20 weeks after gestation. Normally the placenta implants in the upper uterus and no idea why it might go into the lower uterus. Thought to occur when upper uterus is not well vascularized this is why the risk factors are: - previous cesarean - abortion - uterine surgery - multiparity - since these all can result in damage to that area they are risk factors for this Other risk factors: - having multiple placentas - placenta larger than normal surface area - maternal age > 35 - intrauterine fibroids - maternal smoking

What is the HELLP syndrome?

When you have pre-eclampsia and you get all these formation of thrombi which uses up platelets your blood cells can bump into them causing hemolysis. H-hemolysis E-elevated L-liver enzymes L-low P-platelets Occurs in 10-20% of women with severe (pre)eclampsia

What is Hegar's sign?

Widening and softening of the body or isthmus of the uterus. Occurs at 6-8 weeks menstrual age or gestational age. Estrogen and progesterone cause increased cervical softening and dilation of the external os

What is the pathophysiology of DIC?

Your coagulation cascade is going out of control which leads to the formation of lots of clots --> leads to organ ischemia - you now also start consuming all your platelets and clotting factors which means other blood vessels around do not have these so the slightest damage will lead to bleeding so you essentially get too much clotting and too little elsewhere. - a serious medical condition like Sepsis, malignancy, trauma, obstetric complications or intravascular hemolysis can release procoagulants which tip formation of new clots over fibrinolysis - WIth the widespread clot formation you can get ischemia, necrosis and organ damage (especially the kidneys, liver, lungs and brain) and you get depletion of platelets and clotting factors - You also get fibrin degradation products in the circulation and these interfere with clot formation --> makes everything worse - so on one side you get thrombosis and one side you get bleeding Background: with damage to endothelium you get vasoconstriction to limit blood flow then platelets go to the damaged site and recruit more platelets and form a plug (primary hemostasis). Then clotting factors that are in the blood (usually synthesized by the liver) get activated and in turn also activate fibrinogen to fibrin to create a hard clot --> after you do fibrinolysis to break down the clot so it doesn't get bigger than it needs to be.