Anatomy and Physiology of Pregnancy Nursing Care of Childbearing Family Anatomy and Physiology of Pregnancy Lectures 1 N. Petrenko, MD, PhD

The Start of It All

In either case, the process will inevitably involve a sperm and an egg

Or….for those women who get tired of waiting for the “right man” In vitro fertilization, etc.

Pregnancy is a normal physiologic process . . . . . . not a disease!

Signs of pregnancy Presumptive (generally subjective) Probable (objective) Positive (diagnostic)

Presumptive symptoms of pregnancy (felt by woman): Cessation of menses Nausea with or without vomiting “Morning sickness” Frequent urination Fatigue Breast tenderness, fullness, tingling Maternal perception of fetal movement (“Quickening”) 18-20w, 16 w

Probable signs of pregnancy (observed by examiner): Changes in the size, shape, and consistency of the uterus (Hegar sign-softening of the cervix ) Enlargement of the abdomen Changes in the cervix (Goodell sign-softening of the cervix )

Probable signs of pregnancy (observed by examiner): Bluish or purplish coloration of the vaginal mucosa and cervix (Chadwick’s sign-a dark blue to purplish-red congested appearance of the vaginal mucosa ) Palpation of Braxton-Hicks contractions Outlining the fetus manually Endocrine tests of pregnancy

Positive signs of pregnancy (noted by examiner, confirm pregnancy) Identification of the fetal heart beat separately and distinctly from that of the mother (10-12 w) Perception of fetal movements by the examiner (18-20 w) Visualization of pregnancy on ultrasound Fetal recognition on X-ray

Presumptive signs of pregnancy Increased skin pigmentation – chloasma, linea nigra Appearance of striae on abdomen and breasts

Adaptation to pregnancy

Reproductive system & Breast Uterus: increase size, shape and position, softness of cervix, discoloration of cervical mucosa, leukorrhea) Breast: tenderness, fullness, tingling enlargement, nipple and areola hyperpigmentation, Montgomery’s tubercles, colostrum (16 w)

Cardiovascular System Stroke Volume:  50% Cardiac Output:  30-50% (6.2±1.0 L/min) Nonpregnant is 4.30.9 L/min Elevated upward and rotated forward to the left More auddible splitting of S1,S2,S3 after 20w Heart Rate:  15% ( 10-20 bpm) (14-20 w) Sinus arrhytmia, premature atrial contraction, premature ventricular systole

Cardiovascular System Blood Pressure: I trim: same as prepregnancy II trim till 20 w:  3-5 mmHg systolic and 5-10 mmHg diastolic III trim: returns to the patient’s prepregnant level Supine hypotension

Hematologic Changes Blood Volume:  45% ( 1450-1750 ml) Protects the mother from devastating hemorrhage at delivery Plasma Volume:  45-50% ( 1200-1300 ml) Serves to dissipate fetal heat production Red Cell Mass:  18-30% ( 250-450 ml) Necessary to  O2 transport to meet fetal needs Based on the above, pregnancy normally results in a “physiologic anemia” Hgb: 10-12 g/dL (nonpregnant = 12-15 g/dL) Hct: 32-40% (nonpregnant = 35-47%)

Hematologic Changes WBC:  1st Trimester: 3,000-15,000/mm3 (mean 9500/ mm3) 2nd & 3rd Trimesters: 6,000-16,000/mm3 (mean 10,500/ mm3) Labor: 20,000-30,000/mm3

Hematologic Changes Fibrin:  40% at term Plasma Fibrinogen (Factor I):  50% Clotting time: Unchanged Coagulation Factors V, VII, VIII, IX, X, XII all  Coagulation Factors XI, XIII both  slightly Prothrombin time: Unchanged or  slightly Platelets: Unchanged Fibrinolitic activity ↓

Respiratory System Vital capacity unchanged Respiratory rate unchanged or sligly increase Tidal volume ↑ 30-40% Vital capacity unchanged Inspiratory capacity ↑ Exspiratory capacity ↓ Total lung capacity unchanged or sligly decrease Oxygen consumption ↑15-25 %

Respiratory Changes During Pregnancy pH: slight  to 7.40-7.45 Remains roughly at nonpregnant level because the  PaCO2 is compensated for by  renal excretion of bicarbonate (HCO3) Serum HCO3:  (18-31 mEq/L)

Renal System Kidneys enlarge with a length  of ~1 cm as measured by intravenous pyelography Renal pelves & urether dilate Renal Plasma Blood Flow  30-50% by the end of the first trimester GFR The  in Renal Plasma Flow and GFR are responsible for decreases in the following: Uric acid (serum) 4.5 mg/dL BUN (serum) 12 mg/dL Creatinine (serum) 0.5-0.6 mg/dL Creatinine Clearance 150-200 mL/min

GI System Appetite Mouth Esophagus, Stomac, intestines Constipation I trim  II trim  because  metabolic needs Pica (Nonfood craving) Mouth Gums hyperemic, spongy, swollen, bleeding, nonspecific gingivitis, ptyalism Esophagus, Stomac, intestines Hiatal hernia (7-8 month) Gastric emptying become slower  hypochloric acid Acid indigestion or hearburn (pyrosis) Constipation Hemorrhoids

GI System Gallbladder Liver Abdominal discomfort decreased tone development of stones Liver intrahepatic holestasis Pruritus gravidarum (severe itching) with or without jandice Abdominal discomfort Pelvic heaviness Displacement of appendix

Integumentary System Darcening of nipples, areola, axillae, vulva Facial melasma=chloasma Linea Nigra Striae gravidarum Palmar erythema (Caucasian, African-American)

Musculoskeletal System Change in posture Waddling walk Back Pain Slight relaxation and increased mobility of the pelvic joints Diastasis recti abdominis

Neurological Changes Compression of pelvic nerves or vascular stasis caused by enlargement of the uterus may result in sensory changes in the legs. Dorsolumbar lordosis may cause pain because of traction on nerves or compression of nerve roots. Edema involving the peripheral nerves may result in carpal tunnel syndrome during the last trimester. The syndrome is characterized by paresthesia (abnormal sensation such as burning or tingling) and pain in the hand, radiating to the elbow. The sensations are caused by edema that compresses the median nerve beneath the carpal ligament of the wrist. Acroesthesia (numbness and tingling of the hands) is caused by the stoop-shouldered stance. Tension headache is common when anxiety or uncertainty complicates pregnancy. However, vision problems, sinusitis, or migraine may also be responsible for headaches. Light-headedness, faintness, and even syncope (fainting) are common during early pregnancy. Vasomotor instability, postural hypotension, or hypoglycemia may be responsible. • Hypocalcemia may cause neuromuscular problems such as muscle cramps or tetany.

Endocrine System Pituitary and placental hormones.  estrogen and progesterone suppress secretion of FSH & LH amenorrhea After implantation, the fertilized ovum and the chorionic villi produce hCG, which maintains the corpus luteum's production of estrogen and progesterone until the placenta takes over their production (Creasy & Resnik, 1999). Progesterone & Estrogen maintaining pregnancy (relaxing smooth muscles, decrease uterine contractility) Deposition of the fat in subcutaneous tissues over the maternal abdomen, back, and upper thighs. promote the enlargement of the genitals, uterus, and breasts and increases vascularity, causing vasodilation. relaxation of pelvic ligaments and joints. decrease secretion of hydrochloric acid and pepsin, which may be responsible for digestive upsets such as nausea. Prolactin  Initiation of lactation; however, the high levels of estrogen and progesterone inhibit lactation by blocking the binding of prolactin to breast tissue until after birth. Oxytocin  as the fetus matures stimulate uterine contractions during pregnancy, but high levels of progesterone prevent contractions until near term stimulates the let-down or milk-ejection reflex after birth in response to the infant sucking at the mother's breast. Human chorionic somatomammotropin (hCS) = human placental lactogen (hPL) acts as a growth hormone, and contributes to breast development.

Endocrine System Thyroid gland. Parathyroid gland. Pancreas.  gland activity and hormone production. moderate enlargement of the thyroid gland caused by hyperplasia of the glandular tissue and increased vascularity Thyroxine-binding globulin increases as a result of increased estrogen levels (20 weeks). Total (free and bound) thyroxine (T4)  between 6 and 9 weeks of gestation and plateaus at 18 weeks of gestation. Free T4 and free triiodothyronine (T3) return to nonpregnant levels after the first trimester. Despite these changes in hormone production, the pregnant woman usually does not develop hyperthyroidism . Parathyroid gland. slight hyperparathyroidism, a reflection of increased fetal requirements for calcium and vitamin D. The peak level of parathyroid hormone occurs between 15 and 35 weeks of gestation when the needs for growth of the fetal skeleton are greatest. Levels return to normal after birth. Pancreas. Maternal insulin does not cross the placenta to the fetus. As a result, in early pregnancy, the pancreas decreases its production of insulin. Placental hormones (hCS, estrogen, and progesterone). Adrenal glands. aldosterone , resulting in reabsorption of excess sodium from the renal tubules. Cortisol 

Gravida and Para Gravida means a woman who has been, or currently is, pregnant Para means a woman who has given birth Nulligravida – never been pregnant Primigravida – pregnant for the first time Primipara – has delivered once Multipara – has delivered more than once

G T P A L G – GRAVIDA (how many pregnancies) T – TERM (how many term deliveries) P – PRETERM (how many preterm deliveries) A – ABORTIONS (how many abortions, spontaneous or induced) L – LIVING – how many children currently living

Term, Preterm, Abortion TERM means delivery occurring in weeks 38-42 PRETERM means delivery occurring in weeks 20-37 ABORTION means delivery occurring before 20 weeks POSTTERM means delivery occurring after week 42

Duration 280 days =40 weeks= 10 lunar months = 9 calendar month 1st Trimester 1-13 weeks Accepting reality of pregnancy 2nd Trimester 14-26 weeks Resolving feelings about her own mother; defining herself as a mother 3rd Trimester 27-40 weeks Active preparation for childbirth and baby

Assessment of Gestational Age By LMP By physical exam By ultrasound

Nagele’s Rule Subtract 3 months from that date then add 7 days 1st day of LNMP (last normal menstrual period) Example: LNMP: September 10, 2006 Expected Due Date (EDD): June 17, 2007

Uterine Sizing 6 weeks – globular with softening of the isthmus, size of a tangerine 8 weeks – globular, size of a baseball 10 weeks – globular with irregularity around one cornua (Piskacek’s sign), size of a softball 12 weeks – globular, size of a grapefruit

Uterine Sizing Uterine enlargement 12 weeks – At Symphysis 16 weeks – Midway between symphysis and umbilicus 20 weeks – At the umbilicus 36 weeks - Near xyphoid process

Uterine Sizing

Accuracy of Dating by Ultrasound Gestational Age weeks) Ultrasound Measurements Range of Accuracy < 8 Sac size + 10 days 8-12 CRL + 7 days 12-15 CRL, BPD + 14 days 15-20 BPD, HC, FL, AC 20-28 + 2 weeks > 28 + 3 weeks

Review of Systems – 1st Trimester Nausea Vomiting Headaches Dizziness Cramping Urinary frequency Pain with urination Changes in discharge (amount, color, odor) Pruritis Bleeding

Review of System – 2nd Trimester Gums bleeding Nose bleeding Constipation Fetal movement Cramping Bleeding Dysuria Abnormal discharge pruritis

Review of Systems – 3rd Trimester Indigestion Swelling Leg cramps Fetal movement Difficulty sleeping Contractions Bleeding Calf pain Headaches Epigastric pain Visual changes

History - Menstrual Menarche Interval Length LMP Sure of date? Normal in length & flow Other helpful tidbits Date of conception ER sonogram Menarche Interval Length Recent birth control or lactation

Obstetric History Dates of all pregnancies (include previous miscarriage or termination) GA Gender, weight Length of labor Coping techniques Route of delivery Special events AP, IP, PP, Neo

Gynecologic History Last Pap Abnormal pap Gyn surgery or problems (e.g. infertility) Family planning methods Sexually transmitted infections

Medical/Surgical History Serious illnesses Hospitalizations Surgery Drug allergies or unusual reactions Meds since LMP

Family History Maternal Maternal or Paternal Diabetes CAD Pre-eclampsia Preterm delivery Cancers (breast, ovarian, colon) Depression, bipolarity Twins Anesthesia reactions Maternal or Paternal Birth defects Mental retardation Bleeding disorders Chromosomal abnormalities (e.g. Dpwn Syndrome)

Vital Signs Elevated BP suggests the presence of pre-eclampsia. Elevated BP may be defined as a persistently greater than 140 systolic or 90 diastolic. Usually, if one is elevated, both are elevated. Elevated temperature suggests the possible presence of infection. Many pregnant women normally have oral temperatures of as much as 99+. These mild elevations can also be an early sign of infection. While a pregnant pulse of up to 100 BPM or greater may be normal, rapid pulse may also indicate hypovolemia. Temperature Blood pressure Respirations Radial pulse

Additional Measurements Height Weight BMI (Body mass index ) BMI Categories: Underweight = <18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater

The First Prenatal Visit: History Past medical history Family medical history Gynecologic history Past OB history Exposures to infections, teratogens, genetic problems Social history Nutritional status

The First Prenatal Visit: Exam HEENT Fundoscopic exam Teeth Thyroid Breasts Lungs Heart Abdomen Extremities Skin Lymph nodes

The First Prenatal Visit: Pelvic Exam Vulva Vagina Cervix Uterine size Adnexae Rectum Labs: Pap GC & chlamydia Clinical pelvimetry: Diagonal conjugate Ischial spines Sacrum Subpubic arch Gynecoid pelvic type?

Bones and Joints of the Pelvis

The Diagonal Conjugate The obstetric conjugate extends from the middle of the sacral promontory to the posterior superior margin of the pubic symphysis. This is the most important diameter of the pelvic inlet. The diagonal conjugate extends from the subpubic angle to the middle of the sacral promontory and can be measured clinically to estimate the obstetric conjugate.

The Ischial Spines The transverse diameter, between the ischial spines, is a measurement of the dimensions of the pelvic cavity

The Pelvic Outlet Subpubic arch Bituberous (transverse) diameter Inferior pubic rami

The First Prenatal Visit: Labs ABO blood type D (Rh) type Antibody screen CBC Rubella VDRL or RPR HBsAg HIV (optional) Hemoglobin electrophoresis (as appropriate)

The First Prenatal Visit: Counseling What to expect during the course of prenatal care Risk factors encountered Nutrition Exercise Work Sexual activity Travel, seat belts Smoking cessation Avoidance of drugs and alcohol Warning signs Where to go or call in case of problems Prenatal vitamins

The Return Prenatal Visit REVIEW THE CHART! Calculate the EGA Check the labs Review weight gain Review blood pressure Review results of UA

Leopold's Maneuvers - are used to determine the orientation of the fetus through abdominal palpation. . 1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse).

2. The sides of the uterus are palpated to determine the position of the fetal back and small parts.

3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement determined

4. The fetal occipital prominence is determined.

Measuring Fundal Height

Auscultating Fetal Heart Tones

The Routine OB Visit Schedule Every 4 weeks until 28 weeks Every 2 weeks from 28 until 36 weeks Every week from 36 weeks until delivery Six weeks postpartum

Other Routine OB Labs 15-20 weeks 24-28 weeks 35-37 weeks Quad Screen Diabetes Screen H&H Rhogam workup & injection Group B strep culture

Pregnancy is a normal physiologic process, not a disease . . . however, pregnancy tends to be UNCOMFORTABLE. Your challenge is to differentiate common discomforts of pregnancy from pathology!

Дякую за Увагу!

Nausea with or without Vomiting Starts at 4-6 weeks, peaks at 8-12 weeks, resolves by 14-16 weeks Causes: unknown; may be rapidly increasing and high levels of estrogen, hCG, thyroxine; may have a psychological component Rule out: hyperemesis gravidarum

Nausea and vomiting in early pregnancy Most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation. Nausea and vomiting are not usually associated with a poor pregnancy outcome. A

Nausea and vomiting in early pregnancy If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms: non-pharmacological – ginger – P6 acupressure pharmacological – antihistamines. A

Ptyalism Excessive salivation accompanied by nausea and inability to swallow saliva Cause: unknown; may be related to increased acidity in the mouth

Fatigue Causes: unknown; may be related to gradual increase in BMR Rule out: anemia, thyroid disease

Backache Women should be informed that exercising in water, massage therapy might help to ease backache during pregnancy. A

Upper Backache Cause: increase in size and weight of the breasts Relief: well-fitting, supportive bra

Low Backache Cause: weight of the enlarging uterus causing exaggerated lumbar lordosis Rule out: pyelonephritis (CVAT)

Leukorrhea Definition: a profuse, thin or thick white vaginal discharge consisting of white blood cells, vaginal epithelial cells, and bacilli; acidic due to conversion of an increased amount of glycogen in vaginal epithelial cells into lactic acid by Doderlein’s bacilli Rule out: vaginitis, STI, ruptured membranes

Urinary Frequency 1st trimester: increased weight, softening of the isthmus, anteflexion of the uterus 3rd trimester: pressure of the presenting part Rule out: UTI

Heartburn Relaxation of the cardiac sphincter due to progesterone Decreased GI motility due to smooth muscle relaxation (progesterone) Lack of functional room for the stomach because of its displacement and compression by the enlarging uterus Rule out: GI disease

Heartburn Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification. Antacids may be offered to women whose heartburn remains troublesome GPP A

Constipation Decreased peristalsis due to relaxation of the smooth muscle of the large bowel under the influence of progesterone Displacement of the bowel by the enlarging uterus Administration of iron supplements

Constipation Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation. A

Hemorrhoids Relaxation of vein walls and smooth muscle of large bowel under influence of progesterone Enlarging uterus causes increased pressure, impeding circulation and causing congestion in pelvic veins Constipation

Hemorrhoids Women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard hemorrhoids creams should be considered. GPP

Leg Cramps Cause: unknown. ? inadequate calcium, ? Imbalance in calcium-phosphorus ratio Relief: straighten the leg and dorsiflex the foot:

Dependent Edema Cause: impaired venous circulation and increased venous pressure in the lower extremities Rule out: preeclampsia

Varicosities Impaired venous circulation and increased venous pressure in lower extremities Relaxation of vein walls and surrounding smooth muscle under the influence of progesterone Increased blood volume Familial predisposition

Varicose veins Varicose veins are a common symptom of pregnancy that will not cause harm and Compression stockings can improve the symptoms but will not prevent varicose veins from emerging. A

Vaginal discharge Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. GPP

Vaginal discharge If vaginal discharge is associated with itching, soreness, offensive smell or pain on passing urine there may be an infective cause and investigation should be considered. GPP

Vaginal discharge A 1-week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis infections in pregnant women. A

Vaginal discharge The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is uncertain and these should not be offered. GPP

Insomnia Discomfort of the enlarged uterus Any of the common discomforts of pregnancy Fetal activity Psychological causes

Round Ligament Pain Round ligaments attach on either side of the uterus just below and in front of insertion of fallopian tubes, cross the broad ligament in a fold of peritoneum, pass through the inguinal canal, insert in the anterior portion of the labia majora When stretched, they hurt!

Hyperventilation and Shortness of Breath Causes: Increase in the BMR Pressure of the uterus on the diaphragm Changes in the oxygen-carbon dioxide balance Exertion of carrying extra weight Rule out: asthma, pneumonia, TB, anxiety

Supine Hypotensive Syndrome

Screening for hematological conditions

Anemia Pregnant women should be offered screening for anaemia. Screening should take place early in pregnancy (at the first appointment) and at 28 weeks. This allows enough time for treatment if anaemia is detected. B

Anemia Hemoglobin levels outside the normal range for pregnancy (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks) should be investigated and iron supplementation considered if indicated. A

Blood grouping and red cell alloantibodies Women should be offered testing for blood group and RhD status in early pregnancy. B

Blood grouping and red cell alloantibodies If a pregnant woman is RhD-negative, offer partner testing to determine whether the administration of anti-D prophylaxis is necessary. B

Blood grouping and red cell alloantibodies It is recommended that routine antenatal anti-D prophylaxis is offered to all non-sensitized pregnant women who are RhD negative. NICE 2002

Blood grouping and red cell alloantibodies Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 weeks regardless of their RhD status. D

Blood grouping and red cell alloantibodies Pregnant women with clinically significant atypical red cell alloantibodies should be offered referral to a specialist centre for further investigation and advice on subsequent antenatal management. GPP

Screening for fetal anomalies

Screening for structural anomalies Pregnant women should be offered an ultrasound scan to screen for structural anomalies, ideally between 18 and 20 weeks’ gestation, by an appropriately trained sonographer and with equipment of an appropriate standard. A

Screening for Down’s syndrome Pregnant women should be offered screening for Down’s syndrome with a test which provides the current standard of a detection rate above 60% and a false-positive rate of less than 5%. B

The following tests meet this standard: from 11 to 14 weeks – nuchal translucency (NT) – the combined test (NT, hCG and PAPP-A) from 14 to 20 weeks – the triple test (hCG, AFP and uE3) – the quadruple test (hCG, AFP, uE3, inhibin A) B

Screening for infections

Asymptomatic bacteriuria Pregnant women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth. A

Asymptomatic bacterial vaginosis Pregnant women should not be offered routine screening for bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes. A

Chlamydia trachomatis Pregnant women should not be offered routine screening for asymptomatic chlamydia because there is insufficient evidence on its effectiveness and cost effectiveness. C

Cytomegalovirus The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered. B

Hepatitis B virus Serological screening for hepatitis B virus should be offered to pregnant women So that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child-transmission. A

Hepatitis C virus Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence on its effectiveness and cost effectiveness. C

HIV infection Pregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection. D

Rubella Rubella-susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies. B

Streptococcus group B Pregnant women should not be offered routine antenatal screening for group B streptococcus (GBS) because evidence of its clinical effectiveness and cost effectiveness remains uncertain. C

Syphilis Screening for syphilis should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and fetus. B

Toxoplasmosis Routine antenatal serological screening for toxoplasmosis should not be offered because the harms of screening may outweigh the potential benefits. B

Toxoplasmosis C Washing hands before handling food Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection, such as: Washing hands before handling food Thoroughly washing all fruit and vegetables, before eating Thoroughly cooking raw meats Wearing gloves and thoroughly washing hands after handling soil and gardening Avoiding cat faeces in cat litter or in soil. C