Pregnancy
Content
Pregnancy
Debbie McGregor, EdD
Pregnancy
The Menstrual Cycle
Cyclic uterine bleeding in response to cyclic hormonal changes. Menstruation occurs when the ovum is not fertilized Occurs every 28 days plus or minus 5 10 days. Lasts average of 3-6 days
Phases of The Menstrual Cycle
Menstrual Phase (1-6). Low estrogen. Endometrium sheds. Proliferative Phase (7 14) Endometrium and myometrium thicken. Estrogen level peaks just before ovulation. Secretory Phase (15-26) Estrogen drops. Progesterone increases. Ischemic Phase (27-28) Estrogen and progesterone levels fall.
The Menstrual Cycle
Conception
Fertilization Implantation- 3-4 days after th day after Preembryonic period- Up to 14 fertilization. Rapid cell division Embryonic period From day 15th up to 8wks. Rapid growth, tissue differentiation, organ formation High susceptibility to drugs, alcohol, radiation, tobacco, environmental factors
Conception
One sperm burrows inside the egg to fertilize it. Fertilization unites the mother s and father s genes.
Fetal Growth
Embryo referred to as a fetus after the eighth week of gestation Weeks 1-13 All organ systems are formed and continue to develop. Weeks 13- 26 Infant viable by the end of this period. Weeks 27 38 Fat deposited and refinement of organ development.
The First Two Months
Once fertilized by day eight the ball of cells attaches to the uterine wall. Now an embryo the placenta and umbilical cord develop by week eight.
Fetal Growth
Month Three
A complete set of internal organs are formed. Now a fetus the baby has transparent skin. Tiny buds for ears and eyelids form.
Month Four
External genitalia is distinctly formed. Facial features are more detailed. The senses begin to awaken hearing and seeing.
Month Five
Fetal movement begins. Muscles and limbs are becoming stronger. Sucking reflex is developed.
Month Six
Fetus is covered with lanugo and vernix. Hearing is now well developed. Heart sounds are strong. Lungs can now breathe on their own.
Month Seven
Fetus has limited space so now may remain in fetal position. Lanugo begins to disappear. Eyelids open.
Months Eight & Nine
Fetus gains almost half his weight in the last weeks. Nervous system and lungs are maturing. Fetus assumes position for birth.
Genetics
Homologous chromosomes: A matched pair of chromosomes, one from each parent
inherited
There are 23 pairs of homologous chromosomes Autosomes nonsex chromosomes
22 of the 23 pairs are autosomes. One pair is the sex chromosomes, X or Y.
Autosomal Dominant Disorders
Abnormal gene overshadows the normal gene of the pair to produce the trait Affected individual has an affected parent, i.e., parent passes the gene to the child Affected individual has a 50% chance of passing down the abnormal gene to each of his/her children.
Autosomal Recessive Disorders
Affected individual has clinically normal parents, but both parents are carriers of the same abnormal recessive gene There is a 25% chance of carrier parents passing the abnormal gene on to any of their children, i.e., each pregnancy has a 25% chance of resulting in an affected child
Genetics
Autosomal Dominant Disorders
50% risk of the disorder with each pregnancy. Affected parent passes the gene to the child e.g. Huntington Chorea, Polycystic kidneys. 25% risk of the disorder with each pregnancy. If both parents carry the same recessive gene there is 50% chance of the child carrying the gene e.g. sickle cell, PKU, cystic fibrosis.
Autosomal Recessive Disorders
Sex Chromosome Abnormalities
X- linked or sex- linked disorders
The abnormal gene is carried on the X chromosome X-linked disorder is manifested in a male who carries the abnormal gene on his X chromosome
His mother is a carrier when the normal gene on one X chromosome overshadows the abnormal gene on the other X chromosome
Genetics Cont d
X-Linked Dominant Disorders
Affected father may have affected daughter but no affected son e.g. Duchenne s muscular dystrophy, hemophilia With each pregnancy the risk for infants of carrier females is 50% for a male to affected and 50% for females to be carriers.
X-Linked Recessive Disorders
Key Words
Gestation Trimester Term Preterm Postterm
Antepartum Intrapartum Postpartum Gravida Parity
More Key Words
Nulligravida Primigravida Multigravida Abortion Stillbirth
Nutrition
Basic Four Food Group
Protein Carbohydrate Dairy Fruit & Vegetable
Weight Gain in Pregnancy
Normal weight gain based on BMI is 25-35 lbs
This is based on the distribution of pounds through the breasts, blood volume, fluid volume, placenta, uterus, fat reserves and the infant.
Daily Requirements
A pregnant woman needs an additional 300 cal/day. Protein = 3 servings/day
Daily Requirements
Carbohydrate/Grain = 6 servings/day
Daily Requirements
Dairy Products = 4 servings/day
Daily Requirements
Fruits = 2 servings/day Vegetables = 3 servings/day
Hormones in Pregnancy
Estrogen Stimulates uterine development to provide environment for fetal growth. It also helps prepare breast for lactation.
Hormones in Pregnancy
HCG - human chorionic gonadotropin Secreted by trophoblast. Stimulates progesterone and estrogen to maintain the pregnancy until the placenta takes over that function.
Hormones in Pregnancy
HPL - human placental lactogen Otherwise known as human chorionic somatomammotropin. Antagonist of insulin. Decreases the maternal metabolism of glucose to allow fetal growth.
Hormones in Pregnancy
Progesterone Maintains the endometrium and inhibits uterine contractions thus preventing abortion. Also aids in preparation for lactation.
Prostaglandins Lipid substance produced by body tissue. Exact purpose unknown. High concentrations found in pregnancy. Associated with onset of labor. Decreased levels contribute to pregnancy induced hypertension.
Hormones in Pregnancy
Relaxin Found in maternal serum from time of first missed period. Inhibits uterine activity, aids in softening the cervix.
Physiologic Changes
CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM RENAL SYSTEM
INTEGUMENTARY SYSTEM MUSCULOSKELETAL SYSTEM ENDOCRINE SYSTEM REPRODUCTIVE SYTEM
GASTROINTESTINAL SYSTEM
Physiologic Changes
Cardiovascular System
Pseudoanemia- increased blood volume leads to increased plasma over red blood cells. Supine hypotension/venocaval syndrome increase cardiac load - may cause palpitation blood pressure decreases in second trimester due to lowered peripheral resistance decreased regional blood flow causes edema and varicosities.
Physiologic Changes
Respiratory System - can be described as chronic respiratory alkalosis compensated by chronic metabolic acidosis hyperventilation shortness of breath nasal stuffiness- due to increased estrogen levels
Physiologic Changes
Renal System Glomerular filtration rate increases sometimes resulting in glycosuria ( greater than a trace or 1+ is suspicious) Pressure of the uterus on the ureter causes urinary stasis and pyelonephritis Pressure on the urethra results in poor emptying which can cause infection leading to kidney problems or preterm labor
Physiologic Changes
Gastrointestinal system
heartburn, constipation, flatulence- due to displacement of the stomach and slowed intestinal peristalsis nausea and vomiting/morning sickness- caused by increased human chorionic gonadotropin(HCG) and progesterone levels hyperptyalism- caused by increased estrogen levels
Physiologic Changes
Integumentary System - striae gravidarum - diastasis - chloasma/melasma - linea negra
Physiologic Changes
Musculoskeletal
Softening of pelvic ligaments and joints due to increased relaxin - this aids the birth process Lordosis due to pregnant posture and gait causes backache. Pelvic tilt exercises help to ease the discomfort.
Physiologic Changes
Endocrine Thyroid - enlargement causes increased basal metabolic rate Parathyroid - slight enlargement allows for better use of calcium and vitamin D Pancreas - in the first trimester decreased insulin production allows for more glucose availability for fetal growth
Physiologic Changes
Endocrine Continued
Pituitary - increased secretion of prolactin prepares breast for lactation. Increased skin pigmentation caused by melanocyte stimulating hormone Adrenals - Increased glandular activity results in elevated corticosteriod and aldosterone level which suppresses inflammatory action and promotes sodium reabsorption
Physiologic Changes
Uterus increase in size- palpable by the end of the 12th week above the symphysis pubis lightening- descension of the fetal head into the pelvis Hegar s sign- softening of the uterine segment Braxton Hicks contractions- false labor
Physiologic Changes
Cervical Goodell s sign- softening of the cervix operculum/mucus plug- acts as a barrier Vaginal Chadwick s sign - purplish color of the vaginal wall
Physiologic Changes
Breasts changes are due to the effects of estrogen and progesterone production. fullness, tingling or tenderness darkened areola prominent blue veins maybe seen th week secretion of colostrum by the 16
Psychological Tasks
Acceptance of the Pregnancy
often accompanied by feelings of ambivalence feelings such as narcissism, introversion, daydreaming and fantasizing emotionally labile couvade syndrome
Acceptance of Baby
Preparation for baby- End of Pregnancy
Birth Smarts
Question: Does pregnancy cause hemorrhoids?
Birth Smarts
Answer: Pregnancy causes anything you want to blame it for.
Signs of Pregnancy
Presumptive - Subjective
.
Amenorrhea- missing one or more period Nausea/ Vomiting Fatigue Breast changes Quickening
Signs of Pregnancy
Probable- Objective
Pelvic Organ Changes:
Goodell s sign, Hegar s sign, Chadwicks s sign
Enlarged abdomen Uterine soufflé Changes in pigmentation Ballottement Pregnancy tests
Signs of Pregnancy
Positive - Diagnostic
Fetal heart tones - audible with a stethoscope at 18 - 20 weeks, using a Doppler audible at 10 - 12 weeks Ultrasound - per vagina gestational sac seen at 6 weeks Fetal movement - felt by examiner at 20 -24 wks, felt by mother at 16 - 20 weeks
Birth Smarts
Question: What is the most reliable method to determine a baby s sex?
Birth Smarts
Answer: Childbirth
First Trimester Discomforts
Nausea/ Vomiting(morning sickness) Fatigue Urinary frequency Breast tenderness Salivation/Ptyalism
Second &Third Trimester Discomforts Backache
Shortness of breath Edema Braxton Hicks contractions Headaches Insomnia Carpel Tunnel syndrome Leukorrhea/ Vaginal discharge Constipation Varicosities and hemorrhoids Muscle cramps Hypotension Palpitations
Pregnancy Warning Signs
Vaginal bleeding Increased or decreased fetal movement Headaches or blurred vision Swelling of hands and/or feet Burning on urination Abdominal or chest pains Chills or fever Persistent vomiting Increase in fluid from the vagina
The Obstetrical History
Current Pregnancy
Nagels Rule 1st day of LMP - (-3mths+7days) Fundal height measurement Discomforts and attitude Gravida/Parity - FPAL Pregnancy history Perinatal status - Apgar score, growth & development
Past Obstetrical History
OB History Cont d
Gynecology History
Last pap - normal/abnormal Prior infections - STDs Previous surgery Menarche - regularity,duration, dysmenorrhea Contraception Sexual history
OB History Cont d
Current & Past Medical History Personal History - age, income, smoker Family Medical History Partner s Medical & Personal History
Maternal Screening
Blood Studies
Blood type, CBC, VDRL, MSAFP HIV, Hepatitis, Rubella, Sickle Cell, TORCH Glucose testing
Urinalysis, Pap smear & Cultures- GBS Tuberculosis - PPD/Chest Xray Ultrasound- BPD, FL, AFV, Placenta
TORCH
T = Toxoplasmosis O = Hepatitis B R = Rubella C = Cytomegalovirus (CMV) H = Herpes Simplex Virus (HSV)
TORCH
Toxoplasmosis - protozoan infection caused by eating improperly cooked meat or contact with cat feces or litter. Infection causes fetal brain damage or increased incidence of abortion in first trimester Other Infections - e.g. HIV, Hepatitis, GBS, Syphillis, varicella causes fetal damage
Toxoplasmosis
Treatment:
Sulfadiazine 1gram QID x 28 days Childbearing women should avoid outside cats Should not clean litter box Do not eat uncooked meat Wash hands before and after touching uncooked meats Wash area with bleach water where meat was prepared
Patient Education:
Group Beta Streptococcus (GBS)
Most common cause of neonatal sepsis in the USA Predisposing Factors that increase maternal risk:
< 20 years of age White race Low socioeconomic status Mutiple sex partners Sex partners that are positive carriers of GBS Prolong PROM Amnionitis Endometritis
GBS Cont d
Can be transmitted to the fetus during labor and delivery Fetal complications:
Sepsis Pneumonia Meningitis
GBS Cont d
Maternal symptoms include: Fever Uterine tenderness Dysuria Diagnosis:
Culture
Urine Cervix Rectal area
GBS Cont d
Treatment:
Prenatal - ampicillin L&D
Ampicillin 2 gms q 6 hr IV if ROM 18 hrs or greater Culture of maternal and fetal placental site Cultures on the newborn
TORCH Cont d
Rubella - causes fetal infection abortion, hearing impairment, psychomotor retardation, IUGR, congenital heart disease Cytomegalovirus - causes mental retardation, auditory impairments Herpes Simplex - Can be contracted during vaginal delivery process. Causes SAB, IUGR
Rubella
Incubation: 2-3 weeks Transmitted via:
Nasopharyngeal secretion Transplacental
Diagnostics:-serology, throat culture normal titer 1:8 Symptoms:
Maternal:
Slight fever, headache Pink maculopapular rash on face, neck arms X 3 days
Cytomegalovirus (CMV)
Sexually transmitted Transmission:
Transplacental Cervical route during birth Breast milk Saliva Semen Urine
CMV Cont d
Maternal Symptoms in 5%
Low grade fever Malaise Enlarged liver IUGR SGA Microcephaly Deafness, blindness Mental retardation Enlarged liver & spleen 95% are asymptomatic
Neonatal Symptoms
Hepatitis
Incubation period: 20-180 days Transmission: Infected blood and body fluids
Sexually Sharing needles, razors Transplacental
Diagnostics: HbsAG blood test Clinical Manifestations:
Maternal Fever, jaundice,enlarged liver, PTL Newborn stillborn, + HBV (95% chronic carrier Mother rest, high protein/ low fat diet, adequate hydration, Ampicillin is drug of choice Infant Hep B immunoglobin (HBIG) - Hep B Vaccine within 12 hrs of birth
Treatment:
Herpes Simplex Virus (1 & 2)
Incubation Period:
2
10 days
Transmission:
Sexual exposure Active lesion
Ascending infection through birth canal
Diagnostics:
Blood test (HSV-1 and HSV-2) Culture of lesion
Herpes Simplex Virus Cont d
Symptoms Prodromal Phase - Occurs before
lesions appear
Numbness Tingling Burning, itching
More symptoms
Burning with urination Fever, headache, malaise (with primary
occurrence of infection) Painful vesicular lesions (with primary occurrence and recurrence)
Blisters break and leave moist ulcerations Then drying and crusting of ulcers
Herpes Simplex Virus Cont d
Newborn effects: 50-60% mortality if primary infection Neurological Opthalmic Respiratory CNS Treatment:
Good genital hygine
Acyclovir/Zovirax Valacyclovir / Valtrex
HSV Education
Condoms every single time one engages in I/C Abstain from I/C from beginning of prodromal phase to after lesions have healed. Male condoms only cover the penis
If there are lesions on the scrotum, the virus can be transmitted to the partner. Remember: skin to skin contact.
HIV and Pregnancy
Transmission:
Blood, body secretions Genital & rectal Breast milk Increased PROM Increased pre-term labor Full immune system compromised
Maternal effects:
HIV and Pregnancy Cont d
Neonatal effects:
IUGR Microcephaly Failure to thrive Neurological abnormalities Incubation period < 1 year
Treatment for HIV
Pre and post testing counseling Prenatal (mother): ZDV/AZT 300mg BID PO L & D : ZDV loading 2mg/kg IV Continuous infusion 1mg/kg/hr IV Postpartum (infant) for 6 weeks ZDV 2mg/kg PO QID
Fetal Screening
Chorionic Villi Sampling Amniocentesis Percutaneous Umbilical Blood Sampling Alpha-fetoprotein Analysis Ultrasound - BPP Fetal MonitoringNST,AST,CST,NSST,OCT
Debbie McGregor, EdD
Pregnancy
The Menstrual Cycle
Cyclic uterine bleeding in response to cyclic hormonal changes. Menstruation occurs when the ovum is not fertilized Occurs every 28 days plus or minus 5 10 days. Lasts average of 3-6 days
Phases of The Menstrual Cycle
Menstrual Phase (1-6). Low estrogen. Endometrium sheds. Proliferative Phase (7 14) Endometrium and myometrium thicken. Estrogen level peaks just before ovulation. Secretory Phase (15-26) Estrogen drops. Progesterone increases. Ischemic Phase (27-28) Estrogen and progesterone levels fall.
The Menstrual Cycle
Conception
Fertilization Implantation- 3-4 days after th day after Preembryonic period- Up to 14 fertilization. Rapid cell division Embryonic period From day 15th up to 8wks. Rapid growth, tissue differentiation, organ formation High susceptibility to drugs, alcohol, radiation, tobacco, environmental factors
Conception
One sperm burrows inside the egg to fertilize it. Fertilization unites the mother s and father s genes.
Fetal Growth
Embryo referred to as a fetus after the eighth week of gestation Weeks 1-13 All organ systems are formed and continue to develop. Weeks 13- 26 Infant viable by the end of this period. Weeks 27 38 Fat deposited and refinement of organ development.
The First Two Months
Once fertilized by day eight the ball of cells attaches to the uterine wall. Now an embryo the placenta and umbilical cord develop by week eight.
Fetal Growth
Month Three
A complete set of internal organs are formed. Now a fetus the baby has transparent skin. Tiny buds for ears and eyelids form.
Month Four
External genitalia is distinctly formed. Facial features are more detailed. The senses begin to awaken hearing and seeing.
Month Five
Fetal movement begins. Muscles and limbs are becoming stronger. Sucking reflex is developed.
Month Six
Fetus is covered with lanugo and vernix. Hearing is now well developed. Heart sounds are strong. Lungs can now breathe on their own.
Month Seven
Fetus has limited space so now may remain in fetal position. Lanugo begins to disappear. Eyelids open.
Months Eight & Nine
Fetus gains almost half his weight in the last weeks. Nervous system and lungs are maturing. Fetus assumes position for birth.
Genetics
Homologous chromosomes: A matched pair of chromosomes, one from each parent
inherited
There are 23 pairs of homologous chromosomes Autosomes nonsex chromosomes
22 of the 23 pairs are autosomes. One pair is the sex chromosomes, X or Y.
Autosomal Dominant Disorders
Abnormal gene overshadows the normal gene of the pair to produce the trait Affected individual has an affected parent, i.e., parent passes the gene to the child Affected individual has a 50% chance of passing down the abnormal gene to each of his/her children.
Autosomal Recessive Disorders
Affected individual has clinically normal parents, but both parents are carriers of the same abnormal recessive gene There is a 25% chance of carrier parents passing the abnormal gene on to any of their children, i.e., each pregnancy has a 25% chance of resulting in an affected child
Genetics
Autosomal Dominant Disorders
50% risk of the disorder with each pregnancy. Affected parent passes the gene to the child e.g. Huntington Chorea, Polycystic kidneys. 25% risk of the disorder with each pregnancy. If both parents carry the same recessive gene there is 50% chance of the child carrying the gene e.g. sickle cell, PKU, cystic fibrosis.
Autosomal Recessive Disorders
Sex Chromosome Abnormalities
X- linked or sex- linked disorders
The abnormal gene is carried on the X chromosome X-linked disorder is manifested in a male who carries the abnormal gene on his X chromosome
His mother is a carrier when the normal gene on one X chromosome overshadows the abnormal gene on the other X chromosome
Genetics Cont d
X-Linked Dominant Disorders
Affected father may have affected daughter but no affected son e.g. Duchenne s muscular dystrophy, hemophilia With each pregnancy the risk for infants of carrier females is 50% for a male to affected and 50% for females to be carriers.
X-Linked Recessive Disorders
Key Words
Gestation Trimester Term Preterm Postterm
Antepartum Intrapartum Postpartum Gravida Parity
More Key Words
Nulligravida Primigravida Multigravida Abortion Stillbirth
Nutrition
Basic Four Food Group
Protein Carbohydrate Dairy Fruit & Vegetable
Weight Gain in Pregnancy
Normal weight gain based on BMI is 25-35 lbs
This is based on the distribution of pounds through the breasts, blood volume, fluid volume, placenta, uterus, fat reserves and the infant.
Daily Requirements
A pregnant woman needs an additional 300 cal/day. Protein = 3 servings/day
Daily Requirements
Carbohydrate/Grain = 6 servings/day
Daily Requirements
Dairy Products = 4 servings/day
Daily Requirements
Fruits = 2 servings/day Vegetables = 3 servings/day
Hormones in Pregnancy
Estrogen Stimulates uterine development to provide environment for fetal growth. It also helps prepare breast for lactation.
Hormones in Pregnancy
HCG - human chorionic gonadotropin Secreted by trophoblast. Stimulates progesterone and estrogen to maintain the pregnancy until the placenta takes over that function.
Hormones in Pregnancy
HPL - human placental lactogen Otherwise known as human chorionic somatomammotropin. Antagonist of insulin. Decreases the maternal metabolism of glucose to allow fetal growth.
Hormones in Pregnancy
Progesterone Maintains the endometrium and inhibits uterine contractions thus preventing abortion. Also aids in preparation for lactation.
Prostaglandins Lipid substance produced by body tissue. Exact purpose unknown. High concentrations found in pregnancy. Associated with onset of labor. Decreased levels contribute to pregnancy induced hypertension.
Hormones in Pregnancy
Relaxin Found in maternal serum from time of first missed period. Inhibits uterine activity, aids in softening the cervix.
Physiologic Changes
CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM RENAL SYSTEM
INTEGUMENTARY SYSTEM MUSCULOSKELETAL SYSTEM ENDOCRINE SYSTEM REPRODUCTIVE SYTEM
GASTROINTESTINAL SYSTEM
Physiologic Changes
Cardiovascular System
Pseudoanemia- increased blood volume leads to increased plasma over red blood cells. Supine hypotension/venocaval syndrome increase cardiac load - may cause palpitation blood pressure decreases in second trimester due to lowered peripheral resistance decreased regional blood flow causes edema and varicosities.
Physiologic Changes
Respiratory System - can be described as chronic respiratory alkalosis compensated by chronic metabolic acidosis hyperventilation shortness of breath nasal stuffiness- due to increased estrogen levels
Physiologic Changes
Renal System Glomerular filtration rate increases sometimes resulting in glycosuria ( greater than a trace or 1+ is suspicious) Pressure of the uterus on the ureter causes urinary stasis and pyelonephritis Pressure on the urethra results in poor emptying which can cause infection leading to kidney problems or preterm labor
Physiologic Changes
Gastrointestinal system
heartburn, constipation, flatulence- due to displacement of the stomach and slowed intestinal peristalsis nausea and vomiting/morning sickness- caused by increased human chorionic gonadotropin(HCG) and progesterone levels hyperptyalism- caused by increased estrogen levels
Physiologic Changes
Integumentary System - striae gravidarum - diastasis - chloasma/melasma - linea negra
Physiologic Changes
Musculoskeletal
Softening of pelvic ligaments and joints due to increased relaxin - this aids the birth process Lordosis due to pregnant posture and gait causes backache. Pelvic tilt exercises help to ease the discomfort.
Physiologic Changes
Endocrine Thyroid - enlargement causes increased basal metabolic rate Parathyroid - slight enlargement allows for better use of calcium and vitamin D Pancreas - in the first trimester decreased insulin production allows for more glucose availability for fetal growth
Physiologic Changes
Endocrine Continued
Pituitary - increased secretion of prolactin prepares breast for lactation. Increased skin pigmentation caused by melanocyte stimulating hormone Adrenals - Increased glandular activity results in elevated corticosteriod and aldosterone level which suppresses inflammatory action and promotes sodium reabsorption
Physiologic Changes
Uterus increase in size- palpable by the end of the 12th week above the symphysis pubis lightening- descension of the fetal head into the pelvis Hegar s sign- softening of the uterine segment Braxton Hicks contractions- false labor
Physiologic Changes
Cervical Goodell s sign- softening of the cervix operculum/mucus plug- acts as a barrier Vaginal Chadwick s sign - purplish color of the vaginal wall
Physiologic Changes
Breasts changes are due to the effects of estrogen and progesterone production. fullness, tingling or tenderness darkened areola prominent blue veins maybe seen th week secretion of colostrum by the 16
Psychological Tasks
Acceptance of the Pregnancy
often accompanied by feelings of ambivalence feelings such as narcissism, introversion, daydreaming and fantasizing emotionally labile couvade syndrome
Acceptance of Baby
Preparation for baby- End of Pregnancy
Birth Smarts
Question: Does pregnancy cause hemorrhoids?
Birth Smarts
Answer: Pregnancy causes anything you want to blame it for.
Signs of Pregnancy
Presumptive - Subjective
.
Amenorrhea- missing one or more period Nausea/ Vomiting Fatigue Breast changes Quickening
Signs of Pregnancy
Probable- Objective
Pelvic Organ Changes:
Goodell s sign, Hegar s sign, Chadwicks s sign
Enlarged abdomen Uterine soufflé Changes in pigmentation Ballottement Pregnancy tests
Signs of Pregnancy
Positive - Diagnostic
Fetal heart tones - audible with a stethoscope at 18 - 20 weeks, using a Doppler audible at 10 - 12 weeks Ultrasound - per vagina gestational sac seen at 6 weeks Fetal movement - felt by examiner at 20 -24 wks, felt by mother at 16 - 20 weeks
Birth Smarts
Question: What is the most reliable method to determine a baby s sex?
Birth Smarts
Answer: Childbirth
First Trimester Discomforts
Nausea/ Vomiting(morning sickness) Fatigue Urinary frequency Breast tenderness Salivation/Ptyalism
Second &Third Trimester Discomforts Backache
Shortness of breath Edema Braxton Hicks contractions Headaches Insomnia Carpel Tunnel syndrome Leukorrhea/ Vaginal discharge Constipation Varicosities and hemorrhoids Muscle cramps Hypotension Palpitations
Pregnancy Warning Signs
Vaginal bleeding Increased or decreased fetal movement Headaches or blurred vision Swelling of hands and/or feet Burning on urination Abdominal or chest pains Chills or fever Persistent vomiting Increase in fluid from the vagina
The Obstetrical History
Current Pregnancy
Nagels Rule 1st day of LMP - (-3mths+7days) Fundal height measurement Discomforts and attitude Gravida/Parity - FPAL Pregnancy history Perinatal status - Apgar score, growth & development
Past Obstetrical History
OB History Cont d
Gynecology History
Last pap - normal/abnormal Prior infections - STDs Previous surgery Menarche - regularity,duration, dysmenorrhea Contraception Sexual history
OB History Cont d
Current & Past Medical History Personal History - age, income, smoker Family Medical History Partner s Medical & Personal History
Maternal Screening
Blood Studies
Blood type, CBC, VDRL, MSAFP HIV, Hepatitis, Rubella, Sickle Cell, TORCH Glucose testing
Urinalysis, Pap smear & Cultures- GBS Tuberculosis - PPD/Chest Xray Ultrasound- BPD, FL, AFV, Placenta
TORCH
T = Toxoplasmosis O = Hepatitis B R = Rubella C = Cytomegalovirus (CMV) H = Herpes Simplex Virus (HSV)
TORCH
Toxoplasmosis - protozoan infection caused by eating improperly cooked meat or contact with cat feces or litter. Infection causes fetal brain damage or increased incidence of abortion in first trimester Other Infections - e.g. HIV, Hepatitis, GBS, Syphillis, varicella causes fetal damage
Toxoplasmosis
Treatment:
Sulfadiazine 1gram QID x 28 days Childbearing women should avoid outside cats Should not clean litter box Do not eat uncooked meat Wash hands before and after touching uncooked meats Wash area with bleach water where meat was prepared
Patient Education:
Group Beta Streptococcus (GBS)
Most common cause of neonatal sepsis in the USA Predisposing Factors that increase maternal risk:
< 20 years of age White race Low socioeconomic status Mutiple sex partners Sex partners that are positive carriers of GBS Prolong PROM Amnionitis Endometritis
GBS Cont d
Can be transmitted to the fetus during labor and delivery Fetal complications:
Sepsis Pneumonia Meningitis
GBS Cont d
Maternal symptoms include: Fever Uterine tenderness Dysuria Diagnosis:
Culture
Urine Cervix Rectal area
GBS Cont d
Treatment:
Prenatal - ampicillin L&D
Ampicillin 2 gms q 6 hr IV if ROM 18 hrs or greater Culture of maternal and fetal placental site Cultures on the newborn
TORCH Cont d
Rubella - causes fetal infection abortion, hearing impairment, psychomotor retardation, IUGR, congenital heart disease Cytomegalovirus - causes mental retardation, auditory impairments Herpes Simplex - Can be contracted during vaginal delivery process. Causes SAB, IUGR
Rubella
Incubation: 2-3 weeks Transmitted via:
Nasopharyngeal secretion Transplacental
Diagnostics:-serology, throat culture normal titer 1:8 Symptoms:
Maternal:
Slight fever, headache Pink maculopapular rash on face, neck arms X 3 days
Cytomegalovirus (CMV)
Sexually transmitted Transmission:
Transplacental Cervical route during birth Breast milk Saliva Semen Urine
CMV Cont d
Maternal Symptoms in 5%
Low grade fever Malaise Enlarged liver IUGR SGA Microcephaly Deafness, blindness Mental retardation Enlarged liver & spleen 95% are asymptomatic
Neonatal Symptoms
Hepatitis
Incubation period: 20-180 days Transmission: Infected blood and body fluids
Sexually Sharing needles, razors Transplacental
Diagnostics: HbsAG blood test Clinical Manifestations:
Maternal Fever, jaundice,enlarged liver, PTL Newborn stillborn, + HBV (95% chronic carrier Mother rest, high protein/ low fat diet, adequate hydration, Ampicillin is drug of choice Infant Hep B immunoglobin (HBIG) - Hep B Vaccine within 12 hrs of birth
Treatment:
Herpes Simplex Virus (1 & 2)
Incubation Period:
2
10 days
Transmission:
Sexual exposure Active lesion
Ascending infection through birth canal
Diagnostics:
Blood test (HSV-1 and HSV-2) Culture of lesion
Herpes Simplex Virus Cont d
Symptoms Prodromal Phase - Occurs before
lesions appear
Numbness Tingling Burning, itching
More symptoms
Burning with urination Fever, headache, malaise (with primary
occurrence of infection) Painful vesicular lesions (with primary occurrence and recurrence)
Blisters break and leave moist ulcerations Then drying and crusting of ulcers
Herpes Simplex Virus Cont d
Newborn effects: 50-60% mortality if primary infection Neurological Opthalmic Respiratory CNS Treatment:
Good genital hygine
Acyclovir/Zovirax Valacyclovir / Valtrex
HSV Education
Condoms every single time one engages in I/C Abstain from I/C from beginning of prodromal phase to after lesions have healed. Male condoms only cover the penis
If there are lesions on the scrotum, the virus can be transmitted to the partner. Remember: skin to skin contact.
HIV and Pregnancy
Transmission:
Blood, body secretions Genital & rectal Breast milk Increased PROM Increased pre-term labor Full immune system compromised
Maternal effects:
HIV and Pregnancy Cont d
Neonatal effects:
IUGR Microcephaly Failure to thrive Neurological abnormalities Incubation period < 1 year
Treatment for HIV
Pre and post testing counseling Prenatal (mother): ZDV/AZT 300mg BID PO L & D : ZDV loading 2mg/kg IV Continuous infusion 1mg/kg/hr IV Postpartum (infant) for 6 weeks ZDV 2mg/kg PO QID
Fetal Screening
Chorionic Villi Sampling Amniocentesis Percutaneous Umbilical Blood Sampling Alpha-fetoprotein Analysis Ultrasound - BPP Fetal MonitoringNST,AST,CST,NSST,OCT
