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Normal Pregnancy CAPT Mike Hughey, MC, USNR Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 Routine Visits • Q4 weeks until 28 weeks • Q2 weeks, 28-36 weeks • Q week, 36-delivery Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Routine Visits • At each visit: Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Urine Test for Protein and Glucose • Protein may indicate preeclampsia • Glucose may indicate gestational diabetes Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Estimating Gestational Age • LMP plus 280 days • Add 7 days, subtract 3 months • MacDonald's Rule (cm = weeks) Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 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 1620 weeks Hgb/Hct at 28 weeks OB Glucose at 28 weeks (1hour post 50 g oral load) Rhogam to all rH negative women at 28 weeks Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 Skin Changes • Chloasma (darkening of face) • Spider telangectasias (red, starshaped marks) • Stretch marks • Linea nigra • Darkening of nipples Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13 Exercise During Pregnancy • Balance • Joint changes • Heat • Increased cardiac output Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Heartburn • Reflux esophagitis • Antacids are OK • Suck on them rather than chewing them Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Sciatica • 30% of pregnancies • Avoid standing for long periods • Sit with knees slightly higher than the hips Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Sciatica • Sleep in semi-fetal position with a pillow between the knees Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19 Upper Respiratory Infection • Acetaminaphen - OK • Guaifenisin - OK • Pseudoephedrine - OK in 2nd TM • Triprolidine - OK • Penicillins - OK • Cephalosporins - OK • Erythromycin - OK Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21 Thermal Stress During Pregnancy • Avoid elevation of core temperature • Mess decks • Engine room spaces • Laundry Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23 Low Frequency Whole Body Vibration • Avoid it if possible Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24 Chemical Exposure During Pregnancy Avoid: • Organic solvents • Fuel oils • Paint thinners • Mercury • Lead • Cadmium Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 25 Radiation Exposure During Pregnancy • Avoid radiation exposure • If it's important, then go ahead but shield the abdomen to the extent possible. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 26 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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27 Aircrew Status • • • • • • G forces Noise Heat Balance Fumes Rules vary by service, type of aircraft, job, and mission Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29