1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Normal Pregnancy CAPT Mike Hughey, MC, USNR

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2 Symptoms of Pregnancy Nausea (1st TM) Breast and nipple tenderness (1st TM) Marked fatigue (1st & 3rd TM) Urinary frequency (1st & 3rd TM) Patient thinks she’s pregnant

3. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 Pregnancy Tests are Very Reliable Turn positive at about the first missed period (4 weeks after the LMP or 14 days after conception. Detect ~30 units of HCG Double the sensitivity by doubling the amount of urine.

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 Serum can be Used May use serum if urine is unavailable Tape red-top tube to the wall After 10 minutes, draw off enough serum to match, drop for drop, the urine required for the test. Sludging of proteins, albumin can be a problem Different forms of HCG in urine and serum Will work well enough for most purposes.

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Routine Visits Q4 weeks until 28 weeks Q2 weeks, 28-36 weeks Q week, 36-delivery

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Routine Visits At each visit:

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Urine Test for Protein and Glucose Protein may indicate pre- eclampsia Glucose may indicate gestational diabetes

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 Estimating Gestational Age LMP plus 280 days Add 7 days, subtract 3 months MacDonald's Rule (cm = weeks)

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 Fetal heart beat You may never hear it with a stethoscope 16-20 weeks with DeLee Stethoscope 12-14 weeks with Doppler 5-6 weeks with ultrasound

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 Take a Prenatal Vitamin Each Day Folic Acid 400 mg/day before pregnancy 600-800 mg/day during pregnancy Those with a normal balanced diet probably don’t need extra vitamins No one has a normal balanced diet.

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 Initial Prenatal Laboratory Tests Hgb/Hct WBC U/A Blood type & rH Atypical antibody screen Rubella titer RPR or VDRL Hep B HIV GC/Chlamydia Pap

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 Subsequent Laboratory Tests Amniocentesis at 11-17 weeks for women >35 Serum AFP at 15-18 weeks Targeted (Level II) ultrasound for women at high risk at 16- 20 weeks Hgb/Hct at 28 weeks OB Glucose at 28 weeks (1- hour post 50 g oral load) Rhogam to all rH negative women at 28 weeks

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13 Skin Changes Chloasma (darkening of face) Spider telangectasias (red, star- shaped marks) Stretch marks Linea nigra Darkening of nipples

14. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14 Exercise During Pregnancy Balance Joint changes Heat Increased cardiac output

15. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Nausea & Vomiting Common up to 16 weeks If she can’t keep anything down, or has ketones in urine, give IV fluids Avoid antiemetics Benadryl, Scopolomine, Compazine, Phenergan, Reglan have all been used with good results

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Heartburn Reflux esophagitis Antacids are OK Suck on them rather than chewing them

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Sciatica 30% of pregnancies Avoid standing for long periods Sit with knees slightly higher than the hips

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 Sciatica Sleep in semi-fetal position with a pillow between the knees

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19 Carpal Tunnel Syndrome 30% of pregnancies Numbness of the distal median nerve due to compression from edema Worse in the morning No treatment necessary so long as lesion is sensory only Rest, wrist splint may be helpful Injections, surgery almost never necessary

20. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20 Upper Respiratory Infection Acetaminaphen - OK Guaifenisin - OK Pseudoephedrine - OK in 2nd TM Triprolidine - OK Penicillins - OK Cephalosporins - OK Erythromycin - OK

21. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21 Medications During Pregnancy Antibiotics - some OK, some not Local anesthetics - OK Local with epinephrine - not OK Aspirin - not OK Immunizations - some are OK, some are not Antimalarial - some OK, some are not Narcotics - OK except for addiction issue

22. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22 Thermal Stress During Pregnancy Avoid elevation of core temperature Mess decks Engine room spaces Laundry

23. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23 Acoustic Stress During Pregnancy Fetus receives about 15 dBA less than the mother. Avoid exposure in which ear protection is needed. Brief transit is OK (less than 5 minutes) If double ear protection required, pregnant woman should avoid the area completely.

24. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24 Low Frequency Whole Body Vibration Avoid it if possible

25. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 25 Chemical Exposure During Pregnancy Organic solvents Fuel oils Paint thinners Mercury Lead Cadmium Avoid:

26. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 26 Radiation Exposure During Pregnancy Avoid radiation exposure If it's important, then go ahead but shield the abdomen to the extent possible.

27. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27 Diving During Pregnancy Don't do it Pregnant are women predisposed to decompression sickness and embolism. Fetal circulation bypasses the lungs...any bubble goes directly to the brain or coronary arteries. Prolonged low hyperbaric pressures may be safe, but fetal effects include narrowing of foramen ovale and ductus arteriosus

28. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28 Aircrew Status G forces Noise Heat Balance Fumes Rules vary by service, type of aircraft, job, and mission

29. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29