OB/GYN Blueprints Ch.

1 Pregnancy and Prenatal Care

Pregnancy o B-hCG will rise 100.000 mIU/mL by 10 weeks gestation Levels off to 30,000-20,000 mIU/mL in 3rd trimester o May see gestational sac on US at 5 wks gestation B-hCG of 1,500-2000 mIU/mL o May see heart beat at 6 wks B-hCG of 5000-6000 mIU/mL o Terms and Definitions: Embryo- conception to 8 wks gestation Fetus- 8 wks til birth Infant- delivery to 1 yr First trimester- until 12 wks Second trimester- 12-24 wks Third trimester- 24 wks until delivery Previable- delivered prior to 24 wks Preterm- delivered from 24-37 wks Term- delivered from 37-42 wks Post term- delivered after 42 wks Gravidity (G)- # of times a women has been pregnant Parity (P)- # of pregnancies that led to birth at or beyond 20 wks (>500 g) o Dating Pregnancy Gestational age (GA)- measured from last menstrual period (LMP) Usually 2 weeks more than DA Developmental age (DA)/conceptional age/embryonic age- # of days and weeks since fertilization Nageles rule- subtract 3 mo from LMP and add 7 days Gives you estimated delivery date (EDD) With uncertain LMP, US is used to determine EDD Crown-rump length done in 1st trimester is most accurate

Physiology of Pregnancy o Cardiovascular CO increases 30-50% During 1st trimester, and 20-24 wks

Due to an increase in SV and then maintained by increase in HR SVR decreases decreased arterial BP Elevated progesterone leads to smooth muscle relaxation BP will decrease 5-10mmHg/10-15mmHg It should never exceed prepregnancy levels Pulmonary Increase tidal volume 30-40% Decreases ERV by 20% Total lung capacity is decreased by 5% Due to elevated diaphragm Increased minute ventilation by 30-40% Increase in PAO2 and PaO2 Decrease in PACO2 and PaCO2 Increased removal of CO2 from fetus and increased delivery of O2 to fetus Dyspnea of pregnancy can occur in 60-70% of pts Gastrointestinal Nausea and vomiting occur in 70% (morning sickness) Elevated estrogen, progesterone, and B-hCG Hypoglycemia may cause it Tx with snacking Typically resolves 14-16 wks Hyperemesis gravidarum Severe form in which women lose >5% of weight and go into ketosis Prolonged gastric emptying time + Decreased GES tone = reflux Constipation is common Renal Increase in size Ureters dilate Increased rate of pyelonephritis GFR increases 50% BUN and creatinine decrease 25% Increased renin-angiotensin system -> increased aldosterone > increased Na resorption Plasma Na does not change due to increased GFR Hematology Plasma volume increases 50% but RBC count increases only 20-30% Leads to decrease in hematocrit (dilutional anemia) WBC count increases Hypercoagulable state

o Endocrine Hyperestrogenic state- from placenta mostly Produced from adrenal precursors Low estrogen associated w/ fetal death and anencephaly hCG has similar alpha unit to LH, FSH, and TSH placenta produces hCG maintains corpus lutem which produces progesterone that maintains endothelium Progesterone eventually produced by placenta Relaxes smooth muscle in CV, GI and GU systems Human placental lactogen (hPL) Aka. Human chorionic somatomammotropin Produced by placenta Ensures constant nutrient supply to fetus Causes lipolysis and increased FFA Insulin antagonist (diabetogenic) Thyroid hormone Estrogen stimulates TBG -> increased total T3 & T4 but free T3/T4 remains constant hCG is weak stimulant to thyroid pregnancy is considered euthyroid o Musculoskeletal and Dermatologic Posture changes Spider angiomata and palmar erythema secondary to increased estrogen Hyperpigmentation of nipple, umbilicus, abdominal midline (linea nigra), perineum, face (melasma or chloasma) Increased level of MSH and steroid hormones o Nutrition Average women needs 2000-2500 kcal/day Increased by 300 kcal/day while pregnant and 500kcal/day while breastfeeding Should gain 20- 30 lbs Overweight women are advised to gain only 15-25 lbs Underweight women are advised to gain 28-40 lbs Increase protein intake from 60 to 70-75 g/day Ca intake 1.5 g/day Supplement Iron Folate should be 0.8 mg/day

Elevated fibrinogen, and factors VII-X Increase in venous stasis, and vessel endothelial damage (Virchow triad)

Prenatal Care o Initial Visit b/w 6-10 wks do full Hx and PE LMP is crucial for proper dating US may be needed for dating All other evaluations are based on the dating obtained Diagnostic Tests: CBC, blood type, antibody screen, RPR, VDRL, rubella, Hep BsAg, UA, and urine culture Test for aneuploidy with Nuchal translucency w/US and serum markers See Table 1-3 and 1-4 for battery of tests o Routine Prenatal Visit BP, wt, urine dipstick, measurement of uterus, and fetal heart sounds Ask about symptoms that may show complications o First Trimester Visits Familiarize pt with pregnancy Let them know the changes that will occur Assess nutrition US for NT Culture for any infxns to see if tx is needed o Second Trimester Visits MSAFP is usually done 15-18 wks Increased risk of NTD if elevated Increased risk of Down Syndrome (aneuplodies) if decreased Triple Screen- B-hCG, estriol, and MSAFP Quad Screen- Inhibin A, B-hCG, estriol, and MSAFP 18-20 wks most pts given screening US checks for anomalies, amniotic fluid volume, and placental location o Third Trimester Visits Occasional Braxton Hicks contractions (irregular) Visits increase to every 2-3 wks from 28-36 wks and once wk after 36 wks Rh(-) should receive RhoGAM at 28 wks Beyond 32-34 wks Leopold maneuvers are performed to determine fetal presentation Sweeping or stripping the cervix at each visit reduces incidence of post term labor Labs:

27-29 wks hematocrit, RPR/VDRL, glucose loading test (GLT) GLT= 50 g oral glucose loading dose and check serum glucose 1 hr later >140 mg/dL do a Glucose tolerance test (GTT) o fasting serum glucose level and then give 100 g oral glucose and measure serum at 1, 2, and 3 hrs o normal values: fasting=95, 1 hr=180, 2 hr=155, 3 hr=140 GBS swap at 36 wks o Tx w/ IV penicillin

Routine Problems of Pregnancy o Back Pain Low back pain is common in third trimester Mild exercise -> release of endorphins and reduce pain Gentle massage, heat pads, and Tylenol for mild pain Muscle relaxants or sparse narcotics for severe pain o Constipation increased progesterone decreases bowel motility Tx: increase PO fluids stool softeners, bulk agents o Contractions Braxton Hicks are normal (irregular contractions in third trimester) Dehydration may increase contrxn 10-14 glasses of water a day o Dehydration Increased intravascular space and third spacing make it hard to stay hydrated o Edema Compression of IVC and pelvic veins can increase hydrostatic pressure in LE Elevate LE above the heart May be preeclampsia o GE Reflux Tx: antacids, eat several small meals, avoid lying down after meal o Hemorrhoids Increased venous stasis, IVC compression -> congestion of venous system Tx: topical anesthetics and steroids for pain and swelling

 Increase fluids, and fiber o PICA Craving for inedible foods o Round Ligament Pain Pain in adnexa or low abdomen Rapid expansion of uterus Tx: warm compression or acetaminophen o Urinary Frequency Increased IV volumes and GFR Compression of bladder by uterus UTI o Varicose Veins Elevation of LE and pressure stockings help

Prenatal Assessment of Fetus o See Ch 3 for prenatal screeings