Pregnancy: Conception,Fetal Development, & Maternal Adaptation

Function of Amniotic fluid

- Cushions the fetus from sudden maternal movements. - Prevents the developing human from adhering to the amniotic membranes. - Allows freedom of fetal movement, which aids in symmetrical musculoskeletal development. - Provides a consistent thermal environment.

Oogenesis

- Follicle-stimulating hormone (FSH): Secreted from the anterior pituitary gland, FSH stimulates growth of the ovarian follicles and stimulates the follicles to secrete estrogen. - Estrogen: Secreted from the follicle cells, estrogen promotes the maturation of the ovum. The process of oogenesis includes the following steps: - FSH stimulates the growth of the ovarian follicle, which contains an oogonium (stem cell). - Through mitosis, the oogonium within the ovary forms into two daughter cells: the primary oocyte and a new stem cell. Mitosis is the process by which a cell divides and forms two genetically identical cells (daughter cells), each containing the diploid number of chromosomes. - Through meiosis, the primary oocyte forms into the secondary oocyte and a polar body. The polar body forms into two polar bodies. The secondary oocyte forms into a polar body and a mature ovum. Meiosis is a process of two successive cell divisions that produce cells that contain half the number of chromosomes (haploid).

Spermatogenesis

- Follicle-stimulating hormone (FSH): Secreted from the anterior pituitary gland, FSH stimulates sperm production. - Luteinizing hormone (LH): Secreted from the anterior pituitary gland, LH stimulates testosterone production. - Testosterone: Secreted by the testes, testosterone promotes the maturation of the sperm. - Through mitosis, the spermatogonium (stem cell) within the seminiferous tubules of the testes forms into two daughter cells: a new spermatogonia and a spermatogonium. The latter differentiates and is referred to as the primary spermatocyte. Through meiosis, it forms two secondary spermatocytes, each of which forms two spermatids with the haploid number of chromosomes. Mature spermatids are called spermatozoa.

Abnormalities of Amniotic Fluid

- Polyhydramnios or hydramnios, which refers to excess amount of amniotic fluid (1,500-2,000 mL). Newborns of mothers who experience polyhydramnios have an increased incidence of chromosomal disorders and gastrointestinal, cardiac, and neural tube disorders. - Oligohydramnios, which refers to a decreased amount of amniotic fluid (less than 500 mL at term or 50% reduction of normal amount). This is generally related to a decrease in placental function. Newborns of mothers who experienced oligohydramnios have an increased incidence of congenital renal problems.

Nursing care during pregnancy

- Prenatal period: •Period of physical and psychologic preparation for birth and parenthood •Opportunity for nurses and members of health care team to influence family health •Healthy women seek care and guidance •Health promotion interventions can affect well-being of woman, child, and rest of family - Goal of prenatal care is to promote the health and well-being of the pregnant woman, the fetus, the newborn, and family - Emphasis on preventive care and optimal self-care - Prenatal care is sought routinely by women of middle or high socioeconomic status

Placenta Development

- placenta is formed from both fetal and maternal tissue - chorionic membrane that develops from the trophoblast, along with the chorionic villi, form the fetal side of the placenta. The chorionic villi are projections from the chorion that embed into the decidua basalis and later form the fetal blood vessels of the placenta. - endometrium is referred to as the decidua and consists of three layers: decidua basalis, decidua capsularis, and decidua vera. The decidua basalis, the portion directly beneath the blastocyst, forms the maternal portion of the placenta. - The maternal side of the placenta is divided into compartments or lobes known as cotyledons. - The placental membrane separates the maternal and fetal blood and prevents fetal blood from mixing with maternal blood, but it also allows for the exchange of gases, nutrients, and electrolytes.

Function of Placenta

1. Metabolic and gas exchange: In the placenta, fetal waste products and CO2 are transferred from the fetal blood into the maternal blood sinuses by diffusion. Nutrients such as glucose and amino acids and O2 are transferred from the maternal blood sinuses to the fetal blood through the mechanisms of diffuse and active transport. 2. Provides an immunologic barrier between the maternal and fetal systems. 3. Synthesizes glycogen and cholesterol 4. Hormone production: The major hormones the placenta produces are progesterone; estrogen; human chorionic gonadotropin (hCG); and human placental lactogen (hPL), also known as human chorionic somatomammotropin. - Progesterone facilitates implantation and decreases uterine contractility. - Estrogen stimulates the enlargement of the breasts and uterus. - hCG stimulates the corpus luteum so that it will continue to secrete estrogen and progesterone until the placenta is mature enough to do so. This is the hormone assessed in pregnancy tests. hCG rises rapidly during the first trimester and then rapidly declines. - hPL promotes fetal growth by regulating available glucose and stimulates breast development in preparation for lactation.

Fetal Circulation

High levels of oxygenated blood enter the fetal circulatory system from the placenta via the umbilical vein. ductus venosus connects the umbilical vein to the inferior vena cava. This allows the majority of the highly oxygenated blood to enter the right atrium. foramen ovale is an opening between the right and left atria. Blood high in oxygen is shunted to the left atrium via the foramen ovale. After delivery, the foramen ovale closes in response to increased blood returning to the left atrium. It may take up to 3 months for full closure. ductus arteriosus connects the pulmonary artery with the descending aorta. The majority of the oxygenated blood is shunted to the aorta via the ductus arteriosus with smaller amounts going to the lungs. After delivery, the ductus arteriosus constricts in response to the higher blood oxygen levels and prostaglandins FHR 110-160 bpm

Implantation

Implantation, the embedding of the blastocyst into the endometrium of the uterus, begins around day 5 or 6. To prepare for implantation, progesterone stimulates the endometrium to become thicker and more vascular while enzymes secreted by the trophoblast, now referred to as the chorion, digest the surface of the endometrium. Implantation normally occurs in the upper part of the posterior wall of the uterus.

Initial pregnancy visit

Interview: •Reason for seeking care •Health history (medical/surgical) •Nutrition history •Pre-pregnant weight; diet & exercise •History of drug use and herbal preparations •Medications & immunizations •Allergies •Family history •Social, experiential, and occupational history: DOB, race/ethnicity, contact information; Partner name (if involved) and race/ethnicity (if FOB); Social status: marital, housing, financial, educational level, living situation and support system •History of physical abuse/IPV Childbearing/Reproductive History: •Last Menstrual period, menstrual history •Abnormal paps/cervical procedures •STIs •DES exposure •Other gyn issues: fibroids •Obstetric history: GP (GTPAL), Prior pregnancies and complications, Labor/delivery/postpartum history

monozygotic twins

Monozygotic twins, also called identical twins, result from a fertilized ovum that splits during the early stages of cell division to form two identical embryos that are genetically the same.

Multiple gestation

Multiple gestation refers to more than one developing embryo, such as in the case of twins. Twins can be either monozygotic or dizygotic.

Cell Division

Single-cell zygote undergoes mitotic cell division known as cleavage. By the third day after fertilization, the zygote has morphed into a 16-cell, solid sphere called a morula. Mitosis continues; around day 5, the developing human enters the uterus and becomes a blastocyst. The blastocyst consists of an inner cell mass; the embryoblast, which will develop into the embryo; and an outer cell mass, the trophoblast, which assists in implantation and will become part of the placenta.

Follicular phase

The first phase begins the first day of menstruation and lasts 12 to 14 days. During this phase, the graafian follicle matures under the influence of two pituitary hormones: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). The maturing graafian follicle produces estrogen.

Secretory phase

The second phase begins after ovulation and ends with the onset of menstruation. During this phase, the endometrium continues to thicken. The primary hormone during this phase is progesterone secreted from the corpus luteum. If pregnancy occurs, the endometrium continues to develop and begins to secrete glycogen, the energy source for the blastocyst during implantation. If pregnancy does not occur, the corpus luteum begins to degrade and the endometrial tissue degenerates.

Ovulatory Phase

The second phase begins when estrogen levels peak and ends with the release of the oocyte (egg) from the mature graafian follicle. The release of the oocyte is referred to as ovulation. LH levels surge 12 to 36 hours before ovulation. Before this surge, estrogen levels decrease and progesterone levels increase.

Menstrual phase

The third phase occurs in response to hormonal changes and results in the sloughing off and expulsion of the endometrial tissue.

Proliferative phase

This first phase occurs following menstruation and ends with ovulation. During this phase, the endometrium prepares for implantation by becoming thicker and more vascular. These changes are in response to the increasing levels of estrogen produced by the graafian follicle.

presumptive signs of pregnancy

Those changes felt by the woman: Missed period, nausea/vomiting, breast tenderness, fatigue, fetal movement (late sign)

Probable signs of pregnancy

Those changes observed by an examiner:Chadwick's sign, Goodell sign, Hegar sign, uterine enlargement, pregnancy test

Positive signs of pregnancy

Those signs attributed only to the presence of the fetus: fetal heart tones, visualizing fetus on ultrasound, fetal movement

Endocrine changes in pregnancy

Thyroid: •TSH decrease 1st trimester, then increase and stabilize •T4 increases 1st trimester, then decreases Adrenal: •Physiologic hypercortisolism: Increases in adrenocortical function lead to increases in aldosterone, ACTH, cortisol, etc. Pituitary: •Enlargement (Increased risk infarction postpartum) Increased prolactin

Microbiome changes in pregnancy

Vaginal: •Increased lactobacilli over the course of pregnancy (L. johnsonii - can colonize lower GI tract in neonates; secretes antimicrobial bacteriocins which kill e. coli and thickens mucus) Gut: •Changes resembling proinflammatory and prodiabetogenic states - may promote energy storage & fetal growth Placental: •Resembles oral microbiome •Varies between women with preterm vs. term pregnancy

Nulligravida

a woman who has never been pregnant

Primigravida

a woman who is pregnant for the first time

Amniotic fluid

amniotic fluid is clear and is mainly composed of water. It also contains proteins, carbohydrates, lipids, electrolytes, fetal cells, lanugo, and vernix caseosa. During the first trimester, the amniotic membrane produces amniotic fluid; during the second and third trimesters, it is produced by the fetal kidneys. The amount of amniotic fluid peaks at 800-1,000 mL around 34 weeks' gestation and decreases to 500-600 mL at term.

Pregnancy Tests

based on recognition of hCG or β subunit of hCG •Enzyme-linked immunosorbent assay (ELISA)testing is most popular method of testing for pregnancy: - ELISA technology is the basis for most over-the-counter home pregnancy tests - Medication use, hormone based tumors, or improper collection may cause inaccurate results

Luteal Phase

begins after ovulation and lasts approximately 14 days. During this phase, the cells of the empty follicle morph to form the corpus luteum, which produces high levels of progesterone and low levels of estrogen. If pregnancy occurs, the corpus luteum releases progesterone and estrogen until the placenta matures enough to assume this function. If pregnancy does not occur, the corpus luteum degenerates, resulting in a decrease in progesterone and the beginning of menstruation.

Mesoderm

bones, teeth, muscles, dermis, connective tissue, CV system, spleen, urogential system

Counseling

can be in a group (centering pregnancy - support, community, shared experience) or solo

Endometrial cycle

changes in the endometrium of the uterus in response to the hormonal changes that occur during the ovarian cycle. This cycle consists of three phases: proliferative, secretory and menstrual

Chorion

chorionic villi, invade the endometrium and transfer nutrients from mother to the fetus

Umbilical Cord

consists of two umbilical arteries and one umbilical vein. The arteries carry deoxygenated blood while the vein carries oxygenated blood. These vessels are surrounded by Wharton's jelly, a collagenous substance that protects the vessels from compression. The umbilical cord is usually inserted in the center of the placenta and is about 55 cm long.

Embryo

embryo from the time of implantation through 8 weeks of gestation. Organogenesis, the formation and development of body organs, occurs during this critical time of human development. Primary germ layers known as the ectoderm, mesoderm, and endoderm form the organs, tissues, and body structures of the developing human. The ectoderm is the outer germ layer, the mesoderm is the middle layer, and the endoderm is the inner layer. These primary germ layers begin to develop around day 14.

Embryonic/Fetal membranes

embryonic sac, also called the bag of waters, is formed by the amniotic and chorionic membranes. The amniotic membrane (amnion) is the inner membrane and develops from the trophoblast, while the chorionic or outer membrane (chorion) develops from the embryoblast.

Ectoderm

epidermis, glands, nails, hair, CNS, PNS, eye lens, tooth enamel

Fetus

fetus from week 9 to birth. During this stage of development, organ systems grow and mature

Conception

Conception, also known as fertilization, occurs when a sperm nucleus enters the nucleus of the oocyte. Fertilization normally occurs in the outer third of the fallopian tube. The fertilized oocyte is called a zygote and contains the diploid number of chromosomes

Dizygotic twins

Dizygotic twins, also called fraternal twins, result from two separate ova fertilized by two separate sperm; they are not genetically identical.

Mamogenesis

happens in early pregnancy •Fourth stage of breast development: - Progesterone plays an important role - Maximum branching capability of the breast - Increased volume of breast tissue results from the development and proliferation of secretory tissue •Two distinct phases: - Ductular sprouting predominates in the first trimester - Lobular formation exceeds ductal sprouting in the second trimester

Menstrual cycle

influenced by the ovarian cycle and endometrial cycle

Endoderm

lining of respiratory and GI tracts, oropharynx, liver, pancreas, u

Ovarian Cycle

maturation of ova and consists of three phases: follicular, ovulatory, and luteal

Amnion

membranous sac which surrounds and protects the embryo

Parity

number of pregnancies in which fetus or fetuses have reached viability, not number of fetuses (e.g., twins) born. Whether fetus is born alive or is stillborn (fetus who shows no signs of life at birth) after viability is reached does not affect parity

Gravidity

pregnancy

Term

pregnancy from beginning of wee 38 to end of week 42

Postdate or postterm

pregnancy that goes beyond 42 weeks of gestation

Preterm

pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation

Lactogenesis (breast)

three stages

involution (breast)

weaning

Multigravida

woman who has been pregnant more than once

Primipara

woman who has completed one pregnancy with fetus or fetuses who have reached stage of fetal viability

Mutlipara

woman who has completed two or more pregnancies to stage of fetal viability

Nullipara

woman who has not completed a pregnancy with fetus or fetuses who have reached stage of fetal viability

Gravida

woman who is pregnant

Chorionic villus sampling (CVS)

•13-15 weeks pregnancy •Transcervical or transabdominal route •1/100 risk miscarriage •Earlier diagnosis and rapid results •Performed between 10 and 13 weeks of gestation •Removal of small tissue specimen from fetal portion of placenta: Chorionic villi originate in zygote, Tissue reflects genetic makeup of fetus

prenatal care visit schedule

•Appointments •Visits up to 28 weeks should be every 4 weeks •From 29-35 weeks, every 2 weeks •From 36-40 weeks, visits every 1 week •New schedule •Visits up to 28 weeks should be every 4-6 weeks •From 29-35 weeks, for 1st pregnancy visits every 2-3 weeks, 2nd and other pregnancies every 3-4 weeks •From 36-40 weeks, if no problems: visits every 1-2 weeks

Common third trimester discomforts

•Backache: Posture, footwear, body mechanics, exercise, heat/cold and massage, tylenol, maternity belt, 'pillow fortress' •Urinary frequency: Kegel's, empty bladder frequently, incontinence pads •Vaginal discharge: Cotton underwear, mini-pad, watch for signs of infection •Hemorrhoids: Sitz baths, avoid constipation, vaseline, ice packs, Tucks pads •Nosebleeds: Humidifier, saline spray, fluids •Varicose veins: Support hose, exercise, no crossed legs, elevate legs •Heartburn: Small meals, Tums, elevate HOB, avoid triggers •Bleeding gums: Soft toothbrush, flossing, keep up dental care •Constipation: Fiber, fluids, exercise, stool softeners •Leg cramps: Support hosiery, footwear, dorsiflexion, Tums •Swelling: Fluids, elevate feet, support hose, wrist splints

Initial visit - labs

•CBC, Blood type and screen, RPR/VDRL, Rubella antibody screen, HBV surface antigen, Gonorrhea and Chlamydia testing, PPD if high risk, Pap smear, Urinalysis and Culture, VZV titer in patients with no history of exposure/immunization, HIV testing Other: •Consider early GDM screen for women at higher risk: (+FH, PCOS, prior GDM, obesity) •Other timed pregnancy tests: survey ultrasound, gestational diabetes screening, Group B Strep •Genetic screening testing

Cell free fetal DNA

•Cell free fetal DNA (NIPT) (99% detection rate): Works by amplifying cell free DNA •DS, Trisomy 18 & 13 •Y chromosome •microdeletions •After 10 weeks •High risk pregnancies initially but now offered to all •consider insurance coverage

Uterus changes during pregnancy

•Changes in size, shape, and position: - Size: enlargement of muscle fibers & development of new muscle fibers - Shape: pear to globular to ovoid - Position: rotates slightly to right •Changes in contractility: Braxton-Hicks contractions •Uteroplacental blood flow: - Uterine blood flow increases twentyfold - Decreases due to contractions, maternal position, mean arterial pressure

Genetic testing

•Cystic fibrosis & SMA (spinal muscle atrophy) carrier screening •Hemoglobin electrophoresis •Ashkenazi Jewish Panel •Neural Tube Defect: AFP, fetal survey ultrasound

Sleep changes in pregnancy

•Decreased REM •Pregnancy discomforts •Sleep apnea Restless leg syndrome

Variations in nipples

•Everted •Pseudo-inverted •Retracted inverted •Dimpled inverted •Completely inverted •Anomalies: Supernumerary nipples and Bifurcated nipples

Factors affecting nutrition needs during pregnancy

•Factors that contribute to the increase in nutrient needs: - Development of uterine-placental-fetal unit - Increased maternal blood volume and constituents - Maternal mammary development - Increased metabolic rate •Energy needs: - Weight gain - Body mass index (BMI) = weight/height2 - Pattern of weight gain - Hazards of restricting adequate weight gain - Excessive weight gain

Third trimester visits

•Fetal assessment •Laboratory tests: Other blood tests (CBC, OBGCT), Repeat STI testing as appropriate •Immunizations: Influenza, Tdap, Rhogam •Group B Strep testing at 36 weeks

Trimesters

•First: weeks 1 through 13 •Second: weeks 14 through 26 •Third: weeks 27 through 40

Breast changes during pregnancy

•Fullness, heaviness •Heightened sensitivity from tingling to sharp pain •Areolae become more pigmented •Montgomery tubercles •Colostrum Striae

Obstetric History: GTPAL

•G: Gravidity •T: term births •P: preterm births •A: abortion (Miscarriage or elective termination) L: living children

Amniocentesis

•Genetic concerns •Women over 35 years old •Family history of chromosomal abnormalities •15 + weeks pregnancy •1/300 risk miscarriage •Fetal complications: - Death - Hemorrhage - Infection (amnionitis) - Injury from needle - Risks may be minimized by using ultrasound to direct the procedure

Establishing EDD (Estimated Date of Delivery)

•Gestational Age of fetus is the age in weeks and days measured from LMP •Nägele's rule for EDD is to subtract 3 months from LMP and add 7 days •EDD calculated as 280 days after LMP •Pregnancy dating should match first exam and LMP •EDD is not exact! Normal duration 280 days; range 266-294 days More like Estimated Month of Delivery

Gestational Landmarks

•Gestational sac: 4.5 to 5 weeks •Yolk sac: 5 weeks •Cardiac activity: 5.5 to 6 weeks •Measurable crown-rump length: 6 weeks

GI changes in pregnancy

•Gingival swelling, bleeding •Slowing of intestinal motility, relaxation of smooth muscle/sphincters •Decreased emptying of gall bladder •Increased alkaline phosphatase •Changes in appetite (Pica, Nausea/vomiting)

hCG

•Human chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy •Prevents degeneration of the corpus luteum •Promotes formation of syncytiotrophoblast •Aids spiral artery remodeling during the process of trophoblastic invasion •Promotes angiogenesis in uterine vasculature •Can be detected in serum or urine as early as 7 to 8 days after ovulation doubles every couple of hours

Ocular changes in pregnancy

•Increased corneal thickness & decreased intraocular pressure

Vulva changes during pregnancy

•Increased vasculature •Fat deposition •Edema & varicosities

Women in poverty or lacking health insurance may not have access to public or private care may have

•Lack of culturally sensitive care and communication interferes with access to care •Immigrant women may not seek prenatal care •Birth outcomes are less positive, with higher rates of maternal and newborn complications •Problems with low birth rate and infant mortality associated with inadequate prenatal care

Barriers to prenatal care

•Lack of motivation to seek care •Inadequate finances •Lack of transportation •Unpleasant clinic personnel •Unpleasant facilities or procedures •Inconvenient clinic hours •Problems with child care Personal and cultural attitudes

Nutrition needs during pregnancy

•Minerals and vitamins: - Iron - Calcium - Fat-soluble vitamins (Vitamins A, D, E, and K) •Other minerals and electrolytes: - Magnesium - Sodium - Potassium - Zinc - Fluoride •Water-soluble vitamins: - Folate or folic acid (Neural tube defects are more common in infants of women with poor folic acid intake) - Pyridoxine - Vitamin C - Vitamin B6 - Vitamin B12 - Protein - Omega 3 fatty acids - Fluids

Why nutrition matters?

•Nutrition assessment •Diagnosis of nutritional related problems or risk factors •Intervention based on an individual's dietary goals and plan for appropriate weight gain •Evaluation with referral to a nutritionist or dietitian as necessary •First trimester crucial for embryonic and fetal organ development •Healthful diet before conception ensures that adequate nutrients are available for developing fetus

Emotional changes in pregnancy

•Physical changes (anatomy, physiology, hormonal) •Sociocultural issues •Lifestyle changes: Heightened emotions & mood lability, increased risk for depression/anxiety

Integumentary changes in pregnancy

•Pigment changes: linea nigra, Chloasma (mask of pregnancy) •Striae gravidarum •Angiomas, telangectasias •Palmar erythema •brittle nails Increased hair growth

Neurological changes in pregnancy

•Reversible decrease in brain size •headaches

Prenatal education

•Sexual activity •Traveling •Environmental toxins (Mercury in fish, lead) •Infections: - Toxoplasmosis: no undercooked meat, avoid litter box - Listeria: no soft cheeses, no uncooked deli meats - TB Testing - Zika!! - COVID!!!!! •Warning signs: when/how to call - Bleeding - Pain - Fevers •Immunizations: - Flu vaccine - Tdap •Exercise: - Talk test for exercise intensity - Prenatal yoga

Hegar's sign

•Softening and compressibility of the lower segment of the uterus in early pregnancy (about the seventh week) •Palpated by the finger in the vagina as though the neck and body of the uterus were separated, or connected by only a thin band of tissue.

Cervical changes during pregnancy

•Softening of the cervical tip (Goodell sign) •Bluish discoloration of vagina and cervix (Chadwick Sign) •Glands proliferate •Increased friability Mucus plug (operculum)

Pregnancy:

•Spans 9 calendar months •10 lunar months of 28 days (280 days total)

Second trimester visits

•Subjective assessment •Maternal well-being: Weight, Blood pressure, Pregnancy discomforts, Fetal assessment: Fetal heart rate/movement (expect first fetal movement around 20 weeks in first pregnancy),cFundal height •Counseling: Genetic testing, Ultrasound, Classes

Vagina changes during pregnancy

•Thickened mucosa •Smooth muscle hypertrophies •Vaginal lengthening •Increased vascularity (Chadwick sign) •Increased discharge (leukorrhea)

Variations in breast shape types

•Type 1 - Round breasts, normal lower, medial and lateral quadrants •Type 2- Hypoplasia of lower medial quadrant •Type 3 - Hypoplasia of lower medial and lateral quadrants ("tubular") •Type 4- Severe constrictions, minimal breast tissue.

Renal changes in pregnancy

•Ureteral dilation & elongation, increased kidney size •Elevation in bladder trigone, hyperemia (microhematuria) • increased GFR and renal blood flow •Increased creatinine clearance: decrease in serum creatinine, BUN, uric acid •mild hyponatremia, glycosuria, calcium •increased protein excretion (upper normal protein = 300 mg/day) Increased urine volume, urinary stagnation

initial prenatal visit - physical exam

•Weight and height; BMI; Blood pressure •Complete physical exam •Pelvic: •Mons •Labia, clitoris, perineum •Urethra •Introitus, bartholins •Vagina •Cervix: Pap if indicated; Cervical cultures •Size of uterus Adnexa

Musculoskeletal changes in pregnancy

•exaggerated lordosis, forward neck flexion •anterior pelvic tilt •joint laxity •widening and increased mobility of SI joints and symphysis •nerve compression from fluid •High bone turnover/remodeling: reversible bone loss •Diastasis

initial prenatal visit - review of systems

•headache, dizziness •breast tenderness •nausea, vomiting, weight loss, heartburn, abdominal pain •change in elimination patterns, dysuria, constipation •vaginal bleeding, vaginal discharge with odor/itching •muscle or joint pain emotional concerns

Respiratory system changes in pregnancy

•increased nasal congestion due to hyperemia & edema •increased chest diameter (relaxation of ligaments of the rib cage) •increased tidal volume, reduced lung capacity, decreased functional residual capacity •exaggerated respiratory effort, chronic hyperventilation (O2 consumption is 20-40% higher) •Increased BMR due to increased O2 demands •PCO2 decreases, bicarb decreases, ph increases: respiratory alkalosis

cardiovascular system changes during pregnancy

•increased plasma volume •increased cardiac output (30-50% above preconception) & decreased SVR •Increased heart rate •BP decreases 2nd trimester & increases 3rd trimester •Heart displaces up and to left (Eccentric cardiac hypertrophy) •Increased venous pressure lower extremities

Hematological changes in pregnancy

•increased plasma volume (40-50%), RBC mass (20-30%): physiological anemia •mild thrombocytopenia •Neutrophilia •Increased lipids •increased procoagulant factors and diminished fibrinolysis: hypercoagulable state (five to sixfold increased risk thromboembolic disorders