Pregnancy

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Pregnancy is usually an exciting and special time in a woman’s life. The duration of
human pregnancy is 9 calendar months, 10 lunar months, 40 weeks, or 280 days.
The length of pregnancy is divided into three trimesters, or 3-month periods. Each
trimester is characterized by its own unique and predictable developments for the
mother and her baby. To accommodate the changes taking place throughout the
gestational period, the pregnant woman’s body undergoes changes in size and
shape, and all of her organ systems modify their various functions to create an
environment that is protective and nurturing for the growing fetus.
The female body undergoes many physiological and anatomic changes during
pregnancy. Several factors are responsible for the woman’s adaptation to
pregnancy.
Hormonal influences, mechanical pressure arising from growth of the fetus inside
the uterus, and the mother’s physical adaptation to her changing body all account
for the changes that take place during pregnancy. The majority of these changes are
brought about by the hormones of pregnancy, primarily estrogen and progesterone.
Although the most dramatic changes occur in the reproductive system, every other
body system is also affected by pregnancy.
Although pregnancy is a normal event, problems can occur. Therefore, you need an
understanding of normal maternal physiology so that you can recognize potential or
actual problems that warrant attention. Also, your understanding of the normal
physiological and psychological events that take place during pregnancy will assist
you in teaching your patient and her family about changes that are normal and
expected and how to identify signs and symptoms that should be reported to her
healthcare provider.
SYSTEM/STRUCTURE/CHANGES
Integumentary
Skin
 Changes result from hormones and
mechanical stretching. Increased skin
thickness and hyperpigmentation are
caused by increased secretion of
melanotropin, an anterior pituitary
hormone.

SYSTEM/STRUCTURE/CHANGES

 Chloasma, the “mask of pregnancy,”
is a brownish hyperpigmentation of the
skin over the cheeks, nose, and
forehead. It appears in 50 to 70 percent
of pregnant women and occurs most
often in those with dark complexions,
usually after the 16th week. Sunlight
enhances the heightened pigmentation,
which generally fades after delivery.
 Darkening of the nipples, areolae,
axillae, and vulva also occur, and scars
and moles may darken.

 Increased action of
adrenocorticosteroids occurs in 50 to 90
percent of pregnant women, causing
cutaneous elastic tissue to become more
fragile.

 Increased estrogen results in color and
vascular changes.

 The linea alba may become pigmented
(linea nigra) and extends from the
symphysis pubis to the umbilicus.
 Stretch marks (striae gravidarum)—
pinkish-red streaks with slight
depressions in the skin—may appear
over the abdomen, thighs, breasts, and
buttocks, fading to silvery or white after
pregnancy.
 Angiomas, or vascular spiders, are
tiny, branched, pulsating end-arterioles

on the neck, chest, face, and arms.
These skin lesions are bluish, do not
blanch with pressure, and usually
disappear after the baby’s birth.

 Increased sebaceous gland secretions.
 Increased blood supply to skin,
increased basal metabolic rate (BMR),
and progesterone-induced increased
body temperature.
Hair
 Increased hair growth during pregnancy
as a result of hormonal influences.

Nails
 Changes in nail growth and texture as a
result of hormonal influences.
HEENT
Ear
 Increased vascularity of upper
respiratory tract may cause swelling of
the tympanic membrane and eustachian
tube.
Nose
 Estrogen-induced edema and vascular
congestion of the nasal mucosa and
sinuses.
Mouth/Throat
 Edema of the larynx.
 Higher estrogen levels increase
vascularity and connective tissue
proliferation.

Respiratory
 Estrogen promotes relaxation of the
ligaments and joints of ribs.

 Increase in oxygen consumption by 15
to 20 percent.

 Palmar erythema is characterized by
a pinkish-red, diffuse mottling over the
palms of the hands.

 The skin develops increased oiliness
and acne or takes on a “healthy glow.”
 Increased perspiration and feeling
“hotter.”
 Some women may have excessive hair
growth in unusual places (hirsutism).
Increase in fine body hair growth also
occurs but disappears after delivery.
Increase in brittle hair growth usually
does not.
Excessive scalp oiliness or dryness may
also occur.
 Nails may grow longer, soften, or thin.

 Decreased hearing, a sense of fullness
in the ears, or earaches.

 Nasal stuffiness and epistaxis
(nosebleed).

 Some women may experience vocal
changes.
 Gum hypertrophy and bleeding of gums
while brushing teeth is common. Epulis
—raised, red nodules on gums that bleed
easily—may develop but generally
regress after delivery.
 Increase in transverse diameter by 2
cm with a total circumference increase
of 6 cm. Increase in the costal angle >
90 degrees.
 Thoracic breathing as pregnancy
progresses.
 The diaphragm becomes displaced as
pregnancy progresses.

 Higher levels of progesterone increase
sensitivity of respiratory receptors,
increasing tidal volume, which results in
respiratory alkalosis with compensated
mild metabolic acidosis.
Cardiovascular
 Increase in cardiac output and maternal
blood volume by approximately 40 to 50
percent. Because the heart must pump
harder, it actually increases in size. The
body adapts to increase in blood volume
with peripheral dilation to maintain BP.
Hormones cause peripheral dilation.

 Compression of vena cava impairs
venous return and results in decreased
cardiac output when woman is supine
during second half of pregnancy.

 Compression of iliac veins and inferior
vena cava increases venous pressure
and decreases blood flow to extremities.
Breasts
 Increase in estrogen and progesterone
soon after conception causes many
changes in mammary glands.
 Increased blood supply to breasts.
 Increased growth of mammary glands.
 Increase in luteal and placental
hormones leads to increase in lactiferous
ducts and lobule-alveolar tissue.
Gastrointestinal
 Increased levels of hCG and altered
carbohydrate metabolism.
 Change in senses of taste and smell.

 Slight increase in respiratory rate.
 30 to 40 percent increase in tidal
volume.
 Increase in inspiratory capacity.
 Decrease in expiratory volume.
 Total lung capacity slightly decreased.
 Decrease in PCO2 (27 to 32 mm Hg)
leads to increase in pH (more alkaline)
and decrease in bicarbonate (18 to 21
mEq/L).

 Heart rate may increase by 10 to 15
beats per minute, and systolic murmurs
may be heard. Increase in blood volume
may cause physiological or “pseudo”
anemia because the plasma increase
exceeds red blood cell production. Sinus
arrhythmias and premature atrial or
ventricular contractions may occur. BP is
normal in first
and third trimesters; systolic and
diastolic BP drops 5 to 10 mm Hg during
second trimester.
 Orthostatic hypotension can occur as a
result of decreased venous return and
decreased cardiac output.
 Dependent edema, varicose veins in
legs and vulva, hemorrhoids.

 Breasts may feel full, with increased
sensitivity, tingling, and heaviness.
Increased nipple erectility and
hypertrophy of Montgomery’s tubercles
(glands).
 Blood vessels become more visible.
 Increase in breast size.
 Striae gravidarum (stretch marks) on
breasts.
 Breasts become softer, looser, and
nodular. Colostrum produced by 16th
week.

 Morning sickness during first trimester.
 Decreased swallowing and increased
stimulation of salivary glands by starch
ingestion.
 After the 7th month of pregnancy, the
upper portion of the stomach may

 May result in decreased appetite or
unusual nonfood cravings (pica).
 Nausea.
 Some women develop ptyalism, or
excessive salivation.

herniate.
 Increased progesterone decreases tone
and motility of smooth muscles.
 Increased estrogen leads to decrease in
hydrochloric acid.
 Increased progesterone decreases
muscle tone and peristalsis.

 Gallbladder becomes increasingly
distended because of decreased muscle
tone. Emptying time is prolonged and
bile thickens.

 Hiatal hernia is more likely to occur in
older, obese, or multiparous women.
 Esophageal regurgitation, reverse
peristalsis, and delayed stomach
emptying result in heartburn (pyrosis).
 Peptic ulcers rarely occur.
 Constipation can be caused by
hypoperistalsis, increased water
absorption from large intestines,
decreased physical activity,
displacement of intestines, abdominal
distension, and iron supplements.
 Increased risk for gallstones.

 Displacement of intestines by uterus.

Genitourinary
 Changes caused by increased estrogen
and progesterone. By 10th week of
pregnancy, renal pelvis and ureters have
already begun to dilate. As pregnancy
progresses, smooth muscle walls of
ureters undergo hypertrophy and
hyperplasia and muscle tone relaxes.
Ureters become elongated and tortuous,
resulting in larger volume of urine held
in pelvis and ureters, slower urine flow
rate, and urinary stasis.
 Increased vascularity in pelvic area.
 Decreased bladder tone.
 Increased pressure on bladder by
uterus.
 Increase in renal blood flow.
 Decrease in renal blood flow in latter
part of pregnancy
Reproductive
 Increased pelvic congestion.

 Increased levels of estrogen and

 Abdominal changes include round
ligament tension, flatulence, distension,
cramping, pelvic heaviness, and
contractions.
 Increased risk for urinary tract
infections (UTIs).

 Hyperemia of bladder and urethra.
 Increased bladder capacity to 1500 mL.
 Increased urge to void.
 Increased glomerular filtration rate.
 Physiological/dependent edema.

 Softening of cervix (Goodell’s sign).
Bluish coloration of cervix and vaginal
mucosa (Chadwick’s sign).
 Hypertrophy of glands in cervical canal.
Softening and compressibility of lower
end of uterus (Hegar’s sign).
 Vaginal smooth muscle and connective
tissue loosen up and expand to
accommodate passage of fetus through
birth canal.
 Uterus undergoes cell hypertrophy and
hyperplasia and grows to a capacity of

progesterone.

approximately 1000 g. Once conception
occurs, ovulation ceases, uterine
endometrium thickens, and number and
size of uterine blood vessels increase. As
fetus grows, uterus continues to enlarge
throughout pregnancy.

Musculoskeletal
 Increase in abdominal size with
decreased muscle tone and increased
weight-bearing capacity.

 Causes forward tilting of pelvis and
changes in posture and walking style. To
maintain balance, the lumbosacral curve
becomes more exaggerated, and woman
develops exaggerated anterior flexion of
head.

 Increased mobility of pelvic joints.
 Abdominal musculature stretches as
uterus enlarges.

 Facilitates labor and birth process.
 Rectus abdominis muscles may stretch
to the extent that a permanent
separation occurs (diastasis recti
abdominis).

Neurologic
 Hypoglycemia, postural hypotension, or
vasomotor instability.
 Anxiety.
 Hormonal changes.
 Edema compresses median nerve
beneath carpal ligament of wrist,
producing paresthesia and pain radiating
to thumb, index, middle, and part of ring
fingers, especially in dominant hand.
 Inadequate calcium intake.
 Enlarged uterus may compress pelvic
nerves.
 Accentuated lumbar curve (lordosis)
compresses or pulls lumbar nerve roots.
 Stoop-shouldered posture puts pressure
on brachial plexus.
 Change in body’s center of gravity
during pregnancy.
Endocrine
Pituitary and Placental Hormones
 Decreased follicle-stimulating hormone.

 Syncope and lightheadedness, often
seen in early pregnancy.
 Tension headaches may be related to
anxiety.
 Emotional lability.
 Carpal tunnel syndrome.

 Leg cramps or tetany.
 Sensory changes in lower extremities.
 Low back pain.
 Numbness and tingling in hands
(acroesthesia).
 Body’s base of support widens.
 Amenorrhea.
 Fat deposits in subcutaneous tissue
over abdomen, back, and thighs.

 Increased progesterone relaxes smooth
muscles, which results in decreased
uterine contractions and prevents
spontaneous abortion.
 Increased estrogen.

 Maintains pregnancy.

 Increased prolactin.

 Causes uterine contractions at time of
delivery and letdown milk reflex.
 Contributes to breast development.

 Increased oxytocin.
 Human placental lactogen or hCG acts

 Enlarges uterus, breasts, and genitals;
increases vascularity.
 Causes lactation.

as a growth hormone and decreases
glucose metabolism and increases fatty
acids.
Thyroid
 BMR gradually increases throughout
pregnancy.
 Hyperplasia and increased vascularity
of thyroid gland.
Parathyroid
 Increased parathyroid hormone peaks
between 15 and 35 weeks’ gestation to
meet increased requirements for calcium
and vitamin D for fetal skeletal growth.
Pancreas
 As fetus grows, it requires increasing
amounts of glucose.
Adrenals
 Increase in cortisol.

 May cause heat intolerance, fatigue,
and lassitude.
 Enlargement of thyroid gland.

 Slight hyperparathyroidism develops.

 As mother’s glucose stores are
depleted, she experiences decreasing
blood glucose levels.
 Increases production of insulin and
mother’s resistance to insulin.
 Increased risk for thrombus formation.

Immunologic/Hematologic
 Increased coagulability results from
increases in clotting factors VII, VIII, IX,
X, and fibrinogen. Fibrinolytic activity is
depressed to minimize risk of bleeding.
 Increase in blood volume 40 to 50
percent > nonpregnant state, about
1500 mL; 1000 mL is plasma, 500 red
blood cells.
 Increase in white blood cells during
second and third trimesters.

 Hemodilution causes physiological
anemia.
 Increase is seen in granulocytes.

Performing the assessment
Your patient’s prenatal workup includes a health history and physical assessment. A
complete health history is essential to providing optimal care for the pregnant
woman. If there is no recent complete health history available, you should perform
one before proceeding with the specific pregnancy-related questions.
After the health history comes the physical examination. Keep the key history
findings in mind as you perform it. Taken together, the history and physical
examination form a complete picture of your patient’s prenatal health.
Health History
This section focuses specifically on the current pregnancy. The first prenatal visit
involves collection of baseline information about your patient and her partner and
identification of risk factors.
Key points to remember when obtaining a prenatal history:
 Focus on the current pregnancy and the presenting presumptive symptoms. Take a
detailed obstetric/ gynecologic history.
 Use the past medical history to identify anything that would affect or be affected
by pregnancy.
 Pay special attention to the nutritional history.

 Pay special attention to the use of prescribed,over-thecounter (OTC), and illegal
drugs; it may have a major impact on the developing fetus.
 Determine the patient’s reaction to pregnancy—was it planned?
 Identify major supports—family, spouse, significant other.
 Assess for history or risk of physical abuse.
 After you have completed your questions, ask the patient if she has any problems
or concerns that have not been covered, and give her an opportunity to discuss
them.
Biographical Data
A careful review of the biographical data will be helpful in identifying actual or
potential problems. Collecting this data also allows your patient to answer
uncomplicated questions comfortably and sets the tone for the remainder of the
interview.
First, clarify your patient’s name, address, and date of birth. Geographic location
may have a bearing on pregnancy outcome because women residing in the
southern and western regions of the United States have a higher incidence of
preeclampsia. Women who will be age 35 or older at the time of delivery should be
offered genetic counseling and testing. Determine what effect the patient’s
occupation may have on her pregnancy. Also identify the patient’s religious
preference and cultural/ ethnic group and incorporate them into her care, if
appropriate. Biographical data will also be helpful in identifying your patient’s
supports.
Current Health Status
The current health status includes verifying the patient’s pregnancy, performing a
symptom assessment, and calculating the estimated date of birth (EDB) or “due
date.”
Documenting Pregnancy
It is useful to document the patient’s pregnancy before proceeding with the initial
comprehensive prenatal evaluation. Both urine and serum pregnancy tests are
based on levels of human chorionic gonadotropin (hCG), which are secreted into the
mother’s bloodstream and then excreted into the urine.
Urine pregnancy tests are 95 to 98 percent accurate and are sensitive within 7 days
after implantation.
The test is inexpensive and widely available without prescription, so many women
test themselves at home.
The first voided specimen of the morning is best to use for testing because
concentrated urine improves the pregnancy detection rate. Serum pregnancy tests
do not indicate pregnancy until levels rise above baseline values— usually around
25 to 30 metric International Units (mIU)/ mL. The hCG is detectable in serum as
early as 7 to 9 days after ovulation, or just after implantation. During the first 3 to 4
weeks after implantation, the hCG level doubles every 2 days, then peaks at 60 to
70 days.
The diagnosis of pregnancy is based on the following indicators:
 Presumptive signs (experienced by the patient).
 Probable signs (observed by the examiner).
 Positive signs (attributed only to the presence of the fetus).
Symptom Assessment
The presenting symptoms usually relate to the presumptive signs of pregnancy. Your
patient may present with multiple symptoms and vague complaints, all related to
the pregnancy. Because pregnancy affects every system of the body, the review of
systems (ROS) will address every presenting sign and symptom. Remember to
perform a symptom analysis (PQRST) for all presenting symptoms.
Calculating the Estimated Date of Birth
Once the pregnancy has been confirmed, the EDB, also termed the estimated date
of confinement (EDC), is calculated.

Establishing the baby’s due date involves obtaining accurate information regarding
the mother’s menstrual history, including the last menstrual period (LMP). To
calculate the EDB, apply Naegele’s rule:Add 7 days to the first day of the LMP, and
then subtract 3 months from that date. Considerations in calculating the EDB
include:
 Find out the first day of the LMP. Make sure that the patient is sure of the date
because the EDC is based on the LMP. Conception usually occurs around 2 weeks
after the LMP in a 28-day cycle.
 Review the patient’s menstrual history, including frequency of menses,length of
flow,normalcy of the LMP, and contraceptive use.
 Ultrasound studies may also be used to estimate the gestational age.
Past Health History
The purpose of the past health history is to uncover diseases or other risk factors
that could affect the woman’s health or the fetus’s well-being during pregnancy.
Allergies to food, drugs, or environmental factors need to be noted because they
can be exacerbated during pregnancy. Ask about exposure to toxins (e.g., radiation
or chemicals) in the environment or at work, because this can affect fetal health. Is
your patient on any medications? Identify all prescribed and OTC drugs (including
alcohol and tobacco) your patient took before and during her pregnancy for their
potential effects on the developing fetus.
Also take an obstetric history. Has your patient had previous pregnancies? If so, ask
how many and if complications occurred during pregnancy or labor. Also ask about
neonatal complications, such as birth defects, jaundice, infection, or death. Be sure
to follow up on unclear or vague answers, and remember that sometimes rewording
the question may help the patient find a relevant response.
Ask your patient if she has any of the diseases listed in the following
paragraphs,which pose a particular risk to the expectant mother and/or fetus.
Diabetes
If your patient has diabetes, ask about the age of onset. If she is insulin dependent,
ask what type and amount of insulin she takes. If her diabetes is diet controlled, ask
about use of oral hypoglycemics. If she has had other pregnancies, did she have
gestational diabetes?
Uncontrolled diabetes in pregnancy can cause congenital anomalies, fetal
overgrowth (macrosomia), intrauterine fetal death, delayed fetal lung maturation,
and neonatal death. Oral hypoglycemics may cause fetal damage and are
contraindicated. Women with a history of gestational diabetes are more likely to
develop it again with subsequent pregnancies.
Hypertension
If your patient has chronic HTN, ask how she controls it. Does she take
antihypertensive medication? If so, explain that these drugs may be contraindicated
in pregnancy.
HTN may result in decreased placental perfusion and intrauterine fetal growth
restriction. PIH may recur.
Cardiac Disease
Patients with mitral valve prolapse (MVP) may need prophylactic antibiotics during
labor to prevent streptococcal infections and subsequent bacterial endocarditis and
valve disease.
Liver Disease
If your patient has hepatitis B, the infant may require treatment (hepatitis B
immunoglobulin and hepatitis vaccine) after birth.
Cancer
Patients with cervical cancer who were treated with cone biopsy (cone-shaped
section of the cervix is removed for examination) are at risk for preterm labor.
Infectious Diseases
Rubella,mononucleosis, and other viral infections in the first trimester can cause
fetal abnormalities.
Pulmonary Disease
Medications and inhalers used for asthma may be harmful to the fetus or may affect
anesthesia used during labor. Inhalants and general anesthesia may be
contraindicated for patients with asthma.

Gastrointestinal Disease
Ask about previous abdominal surgery and note the type of scarring;this may
influence the type of delivery. Colitis and other bowel problems may be exacerbated
in pregnancy.
Other Medical Problems
Varicosities and renal, gallbladder, genitourinary, autoimmune, neurological, and
psychiatric conditions may be exacerbated in pregnancy.
Gynecologic Diseases and Sexually Transmitted Diseases
Vaginitis should be identified and treated early to prevent intrauterine
complications. Untreated sexually transmitted diseases (STDs), such as genital
herpes and gonorrhea, can be transmitted to the fetus during passage through the
birth canal. The transmission rate for babies born to human immunodeficiency virus
(HIV)–infected mothers is 20 to 35 percent.
Family History
The purpose of the family history is to identify potential physical and emotional
complications of pregnancy and familial patterns of health or illness. Ask specific
questions to pinpoint inherited diseases. Some questions to ask include:
 “Was anyone in your family diagnosed with heart disease before age 50?”
(Cardiovascular disease or heart defects may be inherited.)
 “Does anyone in your family have lung disease, tuberculosis, or asthma?”
(Pulmonary disorders may be familial; tuberculosis is contagious.)
 “Do any family members have diabetes?” (Endocrine problems are genetically
linked.)
 “Does anyone in your family have cancer?” (There is a genetic component with
certain types of cancer.)
 “Is there a history of birth defects, inherited genetic disorders, blood disorders, or
mental retardation in your family?” (There is a genetic risk for Down syndrome,
spina bifida, brain defects, anencephaly, heart defects, muscular dystrophy, cystic
fibrosis, hemophilia, thalassemia, and other disorders.)
 “Did your mother or sisters have complications during pregnancy or labor?”
(Daughters and sisters of
preeclamptic women have a higher tendency toward preeclampsia.)
Be sure to consider your patient’s race/ethnic background when taking a family
history. For example, children of African American women are at risk for sickle cell
disease. Identification of sickle cell disease will prevent a crisis; testing the motherto-be is appropriate if status is
uncertain.
Review of Systems
Normal changes that occur during pregnancy have an impact on every body
system.The ROS will help you to identify normal physiological changes as well as
alert you to abnormal findings.
Psychosocial Profile
The psychosocial profile is an important component of the assessment because it
lays the groundwork for a trusting nurse-patient relationship. The profile provides an
opportunity to explore the patient’s reactions to the pregnancy and to identify
lifestyle patterns that may pose a threat to her or her baby’s well-being.
Start by asking your patient about her health practices and beliefs. Is she proactive
(getting regular preventive healthcare) or reactive (seeking healthcare only when
ill)? Also inquire about self-care, such as breast self examinations (BSEs). Determine
the patient’s acceptance
Review of Systems
AREA/QUESTIONS TO ASK
General Health Survey
 How have you been feeling?

RATIONALE/SIGNIFICANCE
 Feelings of fatigue and ambivalence are
normal during the first trimester.
 During the second trimester, mothers-

Body Weight
 What is your normal weight (before
pregnancy)?
 Have you lost or gained weight since a
year ago? How much?

Integumentary
 Have you noticed any changes in your
skin, hair, or nails?
HEENT
Eyes
 Do you have any vision problems?

Ears
 Do you have any hearing problems?

Nose
 Do you have nasal stuffiness?
 Nosebleeds?
Neck
 Have you noticed any masses in your
neck?
Mouth/Throat
 Do you have any trouble with your
throat?
 Since your LMP, have you had a fever
or chills without a cold?
 Do you have a cough that doesn’t go
away or frequent chest infections?

 Do your gums bleed? When was your

to-be are introspective and energetic.
 The third trimester is characterized by
restlessness, mood swings, and interest
in preparing for the baby.
Denial of the pregnancy, withdrawal,
depression, or psychosis signal
psychological problems that warrant
referral.
 Optimal weight gain during pregnancy
depends on patient’s heightand normal
weight. Recommended weight gain in
pregnancy is:
 Underweight patient: 28 to 40 lb.
 Normal weight patient: 25 to 35 lb.
 Overweight patient: 15 to 25 lb.
 Twin gestation: 35 to 45 lb.
Low pregnancy weight and inadequate
weight gain during pregnancy contribute
to fetal growth restriction and low birth
weight.
 Hormonal changes cause
hyperpigmentation of skin (chloasma,
linea nigra), thin nails, oily hair.
 Excessive tearing may be associated
with allergies; blurred vision or spots
before the eyes may indicate
preeclampsia.
 Decreased hearing, earaches, or sense
of fullness in ears occurs because
tympanic membranes swell as a result of
increased
vascularity.
 Increased vascularity from increased
estrogen causes nasal edema.
 Slight thyroid enlargement is normal;
marked enlargement may indicate
hyperthyroidism.
 Prolonged nasal congestion with sore
throat, fever, and chills may be an upper
respiratory infection.
 Fetal exposure to viral illnesses is
associated with fetal growth restriction,
developmental delays, hearing
impairment, and mentalretardation.
 Persistent cough and frequent chest
infections may indicate pneumonia or
tuberculosis.
 Gum hypertrophy is common; bleeding

last dental exam?

 Do you have increased saliva?

Respiratory
 Do you have shortness of breath?
Dyspnea? Other breathing problems?

Cardiovascular
 Do you have a history of cardiovascular
disease? Palpitations? Dizziness?

 Do your ankles swell?

Breasts
 Have you noticed pain, lumps, or fluid
leaking from your breasts?

Gastrointestinal
 Do you have nausea and vomiting that
do not go away?

 Are you more thirsty than usual?

during tooth brushing may be associated
with gum disease and warrants further
dental evaluation.
 Ptyalism (excessive saliva) often occurs
within 2 to 3 weeks after the first missed
period and is not associated with
pathology.
 Thoracic breathing, slight
hyperventilation, and shortness of
breath occur in late pregnancy.
 Dyspnea may be associated with
respiratory distress; dyspnea with
markedly decreased activity tolerance
may indicate cardiovascular disease.
 Pregnant women with pre-existing
cardiovascular disease, such as MVP, can
decompensate as a result of increased
workload of the heart. Be alert for
cardiovascular changes associated with
PIH and eclampsia.
 Supine hypotension can occur from
vena caval compression.
Lying supine compresses vena cava and
aorta, decreasing cardiac output. Advise
patient to lie on left side to increase
renal perfusion and output and reduce
edema.
 Dependent edema and varicose veins
in legs frequently occur in pregnancy,
but may also be associated with PIH and
eclampsia.

 Fullness, increased sensitivity, tingling,
and heaviness are common early in
pregnancy; however, lumps and pain
may also indicate breast disease.
 Colostrum secretion from breasts is
normal during pregnancy and varies in
color.
 Excessive nausea and vomiting may be
associated with hyperemesis
gravidarum; sudden, excessive weight
gain could indicate a multifetal gestation
or fluid retention associated with PIH.
 Abdominal pain or cramping may be
related to round ligament pain or may
signal impending miscarriage.
 Hydration must be maintained because
the patient may be at risk for
hypovolemia, cholecystitis, or

 Do you ever notice black or bloody
stools?
 Do you have diarrhea or trouble
passing stools?
Genitourinary
 Do you ever have burning or pain when
you urinate?

 Do you have to urinate more often than
normal?

Reproductive
 When was your LMP?
 Do you have increased vaginal
discharge?

 Have you experienced any vaginal
bleeding, leakage of fluid, or unusual
vaginal discharge?

Musculoskeletal
 Do you have leg cramps?
 Do you have back pain?

Neurologic
 Do you have a history of depression,
difficulty sleeping, loss of appetite?

 Have you experienced light-

cholelithiasis.
Appendicitis during pregnancy may be
difficult to diagnose because the
appendix is displaced upward and
laterally.
 Blood in the stools or a change in bowel
habits may indicate constipation or
hemorrhoids.

 Urinary urgency and frequency are
common during pregnancy and are not
cause for concern unless accompanied
by pain or burning, which may signal a
UTI.
 During pregnancy, women may have
asymptomatic bacteriuria.
UTIs must be promptly diagnosed and
treated because untreated
UTIs predispose patient to complications
such as preterm labor,
pyelonephritis, and sepsis.
 Needed to determine EDC.
 Increased white vaginal discharge
(leukorrhea) is normal during pregnancy.
Discharge accompanied by a foul odor,
itching, or burning may indicate
infection.
 Vaginal bleeding, fluid leakage, or
vaginal discharge may indicate placenta
previa, rupture of membranes, or vaginal
infection.
Untreated vaginal infections predispose
patient to preterm labor or fetal
infections.
 Leg cramps may indicate calcium
deficiency.
 Curvature of the lumbar spine may be
accentuated during pregnancy, resulting
in backache.
 Severe back pain may be associated
with disc disease.
 Emotional lability can occur during
pregnancy; however, these symptoms
also may indicate psychological
disorders.
Patients with a history of psychological
disorders must be continually monitored
for signs and symptoms and referred
when appropriate.
 Fainting may indicate anemia.

headedness, dizziness, or fainting?
 Do you have wrist pain, numbness, or
tingling?
Endocrine
 Do you have increased fatigue or heat
intolerance?
 Do you have a history of diabetes or
gestational diabetes?
Immunological/Hematological
 Do you have a history of anemia?
 History of thrombophlebitis?

 Wrist pain, especially in the dominant
hand, may indicate carpal tunnel
syndrome.
 Common symptoms associated with
increase in BMR and hormonal changes.
 Positive history of diabetes calls for
close monitoring.
 Physiological anemia may occur during
pregnancy. As a result, preexisting
anemia may worsen.
 Increase of clotting factors increases
risk of thrombus formation.

Complications can occur during each trimester of pregnancy. The following is a list
of signs and symptoms of complications and their causes.
First Trimester
 Severe vomiting: Hyperemesis gravidarum.
 Chills, fever: Infection.
 Burning on urination: Infection.
 Abdominal cramping, bloating, vaginal bleeding: Spontaneous abortion,
miscarriage.
Second and Third Trimesters
 Severe vomiting: Hyperemesis gravidarum.
 Leakage of amniotic fluid from vagina before labor begins: Premature rupture of
membranes.
 Vaginal bleeding, severe abdominal pain: Miscarriage, placental separation.
 Chills, fever, diarrhea, burning on urination: Infection.
 Change in fetal activity: Fetal distress, intrauterine fetal demise.
 Uterine contractions before due date: Preterm labor.
 Visual disturbances (blurring, double vision, spots): Hypertensive disorders (PIH).
 Swelling of face, fingers, eye orbits, sacral area: PIH.
 Severe, frequent, or continuous headaches: PIH.
 Muscular irritability or convulsions (seizures): PIH.
 Severe stomachache (epigastric pain): PIH.
 Glucosuria, positive glucose tolerance test result: Gestational diabetes mellitus.

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