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Pregnancy: genetics, conception, fetal development Conception union of single egg and sperm, marks the beginning of the pregnancy not at as isolated event but as a part of sequential process: – gamete formation (egg and sperm) – ovulation (release of the egg) – fertilization (union of the gametes) – implantation in the uterus Cell Division. Mitosis the body cells replicate to yield two cells with the same genetic makeup as the parent cell. First the cell makes a copy of its DNA; then it divides, and each daughter cell receives one copy of the genetic material. The purpose of mitotic division is for growth and development or cell replacement. Cell Division. Meiosis The process by which germ cells divide and decrease their chromosomal number by half and produces gametes: – sperm in males – eggs in females Human body cells contain 46 chromosomes (diploid) Gametes contain 23 chromosomes (haploid) Cell Division. Mitosis vs Meiosis Gametogenesis: Spermatogenesis Begins at puberty (400 million/day) Mitotic division of 1 diploid spermatogonium (primitive sperm cell): – produces 2 daughter cells Primary spermatocyte – contains diploid number of chromosomes – The cell has already copied its DNA before devision, so four alleles for each gene are present. The cell is still considered diploid because the copies are bound together (one allele plus its copy on each chromosomes) I mitotic division – Secondary spermatocytes – contains 23 chromosomes one contains the X chromosome (plus its copy) and the other the Y chromosome (plus its copy). Gametogenesis: Spermatogenesis II mitotic division –Spermatids (haploid) –two gametes with an X chromosome – two gametes with a Y chromosome all of which will –develop into viable sperm Each primary spermatocyte: – produces 4 spermatozoa Gametogenesis Spermatogenesis primary spermatocytes (46) 2 haploid secondary spermatocyte(22X+22Y) 4 Spermatids Gametogenesis: Oogenesis Begins during fetal life in the female All cells contained in the ovaries at birth The majority of the estimated 2 million primary oocytes (the cells that undergo the first meiotic division) degenerate spontaneously. Only 400 to 500 ova will mature during the approximately 35 years of a woman's reproductive life. Gametogenesis: Oogenesis Oogonia (stem cells of females) complete mitotic divisions between third and seventh months gestation: – primary oocytes replicate their DNA but remain suspended at this stage until puberty Maturation of primary oocyte and completes the I Meiosis Division – producing 1 secondary oocyte (with original cytoplasm) – and 1 polar body (that disintegrates) – 22 autosomes and 1 X sex chromosome II Meiosis Division (at ovulation) – Ovum an & 3rd polar body are formed – The first polar also divides to form 2 additional polar bodies Result: 1 ovum+3 polar body Gametogenesis Oogenesis Primary oocyte Secondary oocyte+polar body mature ovum+3 polar body Gametogenesis: Spermatogenesis vs Oogenesis Ovum Meiosis occurs in the female in the ovarian follicles and produces an egg, or ovum. Each month, one ovum matures with a host of surrounding supportive cells. At ovulation the ovum is released from the ruptured ovarian follicle. High estrogen levels increase the motility of the uterine tubes so their cilia are able to capture the ovum and propel it through the tube toward the uterine cavity. An ovum cannot move by itself. Ovum Two protective layers surround the ovum. The inner layer is a thick, acellular layer, the zona pelluada. The outer layer, the corona radiata, is composed of elongated cells. Ova are considered fertile for approximately 24 hours after ovulation. If unfertilized by a sperm, the ovum degenerates and is reabsorbed. Sperm Ejaculation during sexual intercourse normally propels almost a teaspoon of semen containing as many as 200 million to 500 million sperm into the vagina. The sperm swim with the flagellar movement of their tails. Some sperm can reach the site of fertilization within 5 minutes, but average transit time is 4 to 6 hours. Sperm remain viable within the woman's reproductive system for an average of 2 to 3 days. Most sperm are lost in the vagina, within the cervical mucus, or in the endometrium, or they enter the tube that contains no ovum. As sperm travel through the female reproductive tract, enzymes are produced to aid in their capacitation. Capacitation is a physiologic change that removes the protective coating from the heads of the sperm. Small perforations then form in the acrosome (a cap on the sperm) and allow enzymes (e.g., hyaluronidase) to escape. These enzymes are necessary for the sperm to penetrate the protective layers of the ovum before fertilization. Fertilization Takes place in the ampulla of uterine tube When a sperm successfully penetrates the membrane surrounding the ovum, both sperm and ovum are enclosed within the membrane, and the membrane becomes impenetrable to other sperm; this is termed the zona reaction. The second meiotic division of the oocyte is then completed, and the ovum nucleus becomes the female pronucleus. The head of the sperm enlarges to become the male pronucleus, and the tail degenerates. The nuclei fuse and the chromosomes combine, restoring the diploid number (46). Conception, the formation of the zygote, is now complete. Fertilization Fertilization Mitotic cellular replication, called cleavage, begins as the zygote travels the length of the uterine tube into the uterus. This voyage takes 3 to 4 days. Because the fertilized egg divides rapidly with no increase in size, successively smaller cells, blastomeres, are formed with each division. A 16-cell morula, a solid ball of cells, is produced within 3 days, and is still surrounded by the protective zona pellucida. Further development occurs as the morula floats freely within the uterus. Fluid passes through the zona pellucida into the intercellular spaces between the blastomeres, separating them into two parts: the trophoblast (which gives rise to the placenta) and the embryoblast (which gives rise to the embryo). A cavity forms within the cell mass as the spaces come together, forming a structure termed the blastocyst cavity. When the cavity becomes recognizable, the whole structure of the developing embryo is known as the blastocyst. The outer layer of cells surrounding the cavity is the trophoblast Fertilization Implantation The zona pellucida degenerates, and the trophoblast attaches itself to the uterine endometrium, usually in the anterior or posterior fundal region. Between 6 and 10 days after conception, the trophoblast secretes enzymes that enable it to burrow into the endometrium until the entire blastocyst is covered. This is termed implantation. Endometrial blood vessels erode, and some women experience implantation bleeding (slight spotting and bleeding during the time of the first missed menstrual period). Implantation Chorionic villi, or fingerlike projections, develop out of the trophoblast and extend into the blood-filled spaces of the endometrium. These villi are vascular processes that obtain oxygen and nutrients from the maternal bloodstream and dispose of carbon dioxide and waste products into the maternal blood After implantation, the endometrium is termed the decidua. The portion directly under the blastocyst, where the chorionic villi tap the maternal blood vessels, is the decidua basalis. The portion covering the blastocyst is the decidua capsularis, and the portion lining the rest of the uterus is the decidua vera EMBRIO AND FETUS EMBRIO AND FETUS Pregnancy lasts approximately 10 lunar months (9 calendar months, 40 weeks, or 280 days). Length of pregnancy is computed from the first day of the last menstrual period (LMP) until the day of birth. However, conception occurs approximately 2 weeks after the first day of the LMP. Thus the postconception age of the fetus is 2 weeks less, for a total of 266 days, or 38 weeks. Postconception age is used in the discussion of fetal development. Intrauterine development is divided into three stages: – preembryonic (from conception until day14. This period covers cellular replication, blastocyst formation, initial development of the embryonic membranes, and establishment of the primary germ layers) – Embryo (2nd week after fertilization until the end of the 2nd month. Development of organs and systems) – Fetus (the 3rd through the 9th months of development) Early Developmental Stages Primary Germ Layers Ectoderm, Mesoderm and Endoderm During gastrulation, three major cell lineages are being established. They are the Ectoderm (shown in the diagram as blue), Mesoderm (red) and Endoderm (yellow). Following gastrulation, various cell lineages are derrived from these three primary cell types. For example, the Ectoderm gives rise to the epidermis and its derrivatives such as nails, hair and teeth. On the other hand, the Ectoderm also gives rise to the Central Nervous System. Development of the embrio Membranes At the time of implantation, two fetal membranes that will surround the developing embryo begin to form. The chorion develops from the trophoblast and contains the chorionic villi on its surface. The villi burrow into the decidua basalis and increase in size and complexity as the vascular processes develop into the placenta. The chorion becomes the covering of the fetal side of the placenta. It contains the major umbilical blood vessels that branch out over the surface of the placenta. As the embryo grows, the decidua capsularis stretches. The chorionic villi on this side atrophy and degenerate, leaving a smooth chorionic membrane. The inner cell membrane, the amnion, develops from the interior cells of the blastocyst. The cavity that develops between this inner cell mass and the outer layer of cells (trophoblast) is the amniotic cavity. As it grows larger, the amnion forms on the side opposite to the developing blastocyst. The developing embryo draws the amnion around itself to form a fluid-filled sac. The amnion becomes the covering of the umbilical cord and covers the chorion on the fetal surface of the placenta. As the embryo grows larger, the amnion enlarges to accommodate the embryo/fetus and the surrounding amniotic fluid. The amnion eventually comes in contact with the chorion surrounding the fetus. AMNIOTIC FLUID At first the amniotic cavity derives its fluid by diffusion from the maternal blood. The amount of fluid increases weekly, and 800 to 1200 ml of transparent liquid is normally present at term. The amniotic fluid volume changes constantly. – – – Volume – – Oligohydramnios - less than 300 ml of amniotic fluid is associated with fetal renal abnormalities Hydramnios - more than 2 L of amniotic fluid is associated with gastrointestinal and other malformations Function – – – – – the fetus swallows fluid fluid flows into and out of the fetal lungs the fetus urinates into the fluid, greatly increasing its volume helps maintain a constant body temperature a source of oral fluid and as a repository for waste protect the fetus from trauma by blunting and dispersing outside forces allows freedom of movement for musculoskeletal development keeps the embryo from tangling with the membranes Amniotic fluid contains albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fructose, fat, leukocytes, proteins, epithelial cells, enzymes, and lanugo hair. Study of fetal cells in amniotic fluid through amniocentesis yields much information about the fetus. Genetic studies (karyotyping) provide knowledge about the sex and the number and structure of chromosomes. Other studies, such as the lecithin/sphingomyelin ratio, determine the health or maturity of the fetus. Yolk Sac At the same time the amniotic cavity and amnion are forming, another blastocyst cavity forms on the other side of the developing embryonic disk. This cavity becomes surrounded by a membrane, forming the yolk sac. The yolk sac aids in transferring maternal nutrients and oxygen, which have diffused through the chorion, to the embryo. Blood vessels form to aid transport. Blood cells and plasma are manufactured in the yolk sac during the second and third weeks. At the end of the third week, the primitive heart begins to beat and circulate the blood through the embryo, connecting stalk, chorion, and yolk sac. The folding in of the embryo during the fourth week results in incorporation of part of the yolk sac into the embryo's body as the primitive digestive system. Primordial germ cells arise in the yolk sac and move into the embryo. The shrinking remains of the yolk sac degenerate. By the fifth or sixth week, the remnant has separated from the embryo. Umbilical cord By day 14 after conception the embryonic disk, amniotic sac, and yolk sac are attached to the chorionic villi by the connecting stalk. During the third week the blood vessels develop to supply the embryo with maternal nutrients and oxygen. During the fifth week, after the embryo has curved inward on itself from both ends (bringing the connecting stalk to the ventral side of the embryo), the connecting stalk becomes compressed from both sides by the amnion, forming the narrower umbilical cord. Two arteries carry blood to the chorionic villi from the embryo, and one vein returns blood to the embryo. The cord rapidly increases in length. At term the cord is 2 cm in diameter and ranges from 30 to 90 cm in length (with an average of 55 cm). It twists spirally on itself and loops around the embryo/fetus. A true knot is rare, but false knots occur as folds or kinks in the cord and may jeopardize circulation to the fetus. Connective tissue called Wharton's jelly prevents compression of the blood vessels and ensures continued nourishment of the embryo/fetus. Compression can occur if the cord lies between the fetal head and the pelvis or if it is twisted around the fetal body. When the cord is wrapped around the fetal neck, it is termed a nuchal cord. Because the placenta develops from the chorionic villi, the umbilical cord is usually located centrally. A peripheral location is less common and is termed battledore placenta. The blood vessels are arrayed out from the center to all parts of the placenta. Placenta. Structure The placenta begins to form at implantation. During the third week after conception, the trophoblast cells of the chorionic villi continue to invade the decidua basalis. As the uterine capillaries are tapped, the endometrial spiral arteries fill with maternal blood. The chorionic villi grow into the spaces with two layers of cells: the outer syncytium and the inner cytotrophoblast. A third layer develops into anchoring septa, dividing the projecting decidua into separate areas called cotyledons. In each of the 15 to 20 cotyledons, the chorionic villi branch out, and a complex system of fetal blood vessels forms. Each cotyledon is a functional unit. The whole structure is the placenta. The maternal-placental-embryonic circulation is in place by day 17, when the embryonic heart starts beating. By the end of the third week, embryonic blood is circulating between the embryo and the chorionic villi. In the intervillous spaces, maternal blood supplies oxygen and nutrients to the embryonic capillaries in the villi. Waste products and carbon dioxide diffuse into the maternal blood. Functions of the placenta: 1. Transfer gasses 2. Transport nutrients 3. Excretion of wastes 4. Hormone production – temporary endocrine organ – estrogen and progesterone 5. Formation of a barrier – incomplete, nonselective – alcohol, steroids, narcotics, anesthetics, some antibiotics and some organisms can cross Hormones of Placenta human chorionic gonadotropin (hCG) – detected 8-10 days after conception or shortly after implantation, basis of pregnancy test, preserves the function of the ovarian corpus luteum, ensuring a continued supply of estrogen and progesterone needed to maintain the pregnancy. Miscarriage occurs if the corpus luteum stops functioning before the placenta is producing sufficient estrogen and progesterone. The hCG reaches its maximum level at 50 to 70 days, then begins to decrease human placental lactogen (hPL) or human chorionic somatomammotropin - similar to a growth hormone and stimulates maternal metabolism to supply needed nutrients for fetal growth. This hormone increases the resistance to insulin, facilitates glucose transport across the placental membrane, and stimulates breast development to prepare for lactation. placental prolactin - Helps convert mammary glands to active status Relaxin- Increases flexibility of pubic symphysis, permitting pelvis to expand during delivery Progesterone – maintains the endometrium, decreases the contractility of the uterus, and stimulates development of breast alveoli and maternal metabolism Estrogens – stimulates uterine growth and uteroplacental blood flow, causes a proliferation of the breast glandular tissue and stimulates myometrial contractility. Placental estrogen production increases greatly toward the end of pregnancy. Extraembryonic Membranes & Placenta Formation Figure 29–5 (1 of 3) G. Fetus at 2-3weeks 1/10 of an inch long nervous system is developing blood cells are developed H. Fetus at 4 weeks May float freely for 48 hours before implanting Arm buds start to be evident gets more of a curved appearance eyes start to develop implantation of to the uterus and placenta is taking place I. The Fetus at 5 weeks •The nose starts to form •Placental blood vessels form •endocardial(muscle) cells begins to form the two heart tubes J. The Fetus at 6 weeks •1/2 inch long (floating in amniotic fluid) •leg buds present •spine is visible •ears are forming •at 6 weeks heart muscle starts to beat •has rapid growth at this stage •head/mouth/liver/intestines start to take shape K. The Fetus at 7 weeks • 3/4 inches long • Hand/fingers are formed and moving •eye lens form •skull bones are visible and growing •sexual organs are forming •brain waves have started •muscles develop and get stronger L. Fetus at 8-9 weeks old Heart Development Ends The brain can move muscles Sexual organs are forming Feet become more defined Digits are separating on hands/feet Toe/Finger joints are visible As you can see the fetus is in its own sac of amniotic fluid attached to the mother by an umbilical cord to the placenta where it gets all it’s nourishment from. (Above are two twin boy fetuses in separate sacs) M. 10 Week Old Fetus (2 1/2 months old) Now considered a fetus • 1-2 inches long •Has a stump for a tail’ • Is now very active • Facial features developed • Fingers/ Toes/ Hands/ Feet developed •Internal Organs are functioning • Nervous System is responsive: He/She can feel! N. 11 Weeks old: Now is 2 1/2 inches long 12 WEEKS(3 months) •3 inches long •umbilical cord intact and is fully functional 14 WEEKS (3 1/2 months) •3- 31/2 inches •weight is 1 ounce •muscles are developing •sex organs form •eyelids form •fingernails and toenails •spontaneous movement is observed 15-18 WEEKS ( 4-4 1/2 months) •Sensory Organs form at (15) •(16) is turning inside of MOM •(18) 5 1/2 inches •blinks, grasps, moves mouth, hair on head and body is present •all systems are developed •fetal respiration's are occurring •Must be at least 24 weeks to survive outside of womb WEEK 22 (2 1/2 months) •1/2 pound •10 inches long •sweat glands •external skin is turning from transparent to opaque WEEK 26 (6 1/2 Months •Inhales and exhales •cries •eyes are completely formed •has tongue and taste buds •has a 50% chance of survival outside of the womb with intensive Medical care WEEK 30 (7 1/2 months) (7 1/2 mo.) •Is premature if born •But most do well if born at this time •Girls fair better than boys because their lungs are more developed. FULL TERM (36 -40 weeks) This is the end of normal gestation…. Baby is now able to live outside of the mother’s womb. Normal pregnancy 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” Pregnancy is a normal physiologic process . . . . . . not a disease! Signs of pregnancy Presumptive (generally subjective) Probable (objective) Positive (diagnostic) Presumptive symptoms of pregnancy: Cessation of menses Nausea with or without vomiting Frequent urination Fatigue Breast tenderness, fullness, tingling Maternal perception of fetal movement (“Quickening”) Presumptive signs of pregnancy: Breast changes – enlargement, hyperpigmentation, Montgomery’s tubercles Bluish or purplish coloration of the vaginal mucosa and cervix (Chadwick’s sign) Increased skin pigmentation – chloasma, linea nigra Appearance of striae on abdomen and breasts Probable signs of pregnancy: Enlargement of the abdomen Changes in the size, shape, and consistency of the uterus Changes in the cervix Palpation of Braxton-Hicks contractions Outlining the fetus manually Endocrine tests of pregnancy Positive signs of pregnancy: Identification of the fetal heart beat separately and distinctly from that of the mother Perception of fetal movements by the examiner Visualization of pregnancy on ultrasound Fetal recognition on X-ray Expected Physical Changes Cardiovascular Blood volume increase Physiological anemia Vital signs stable Increased clotting factors Edema Cardiovascular Changes During Pregnancy Heart Rate: 15% ( 10-20 bpm) Stroke Volume: 50% Cardiac Output: 30-50% (6.2±1.0 L/min) – Nonpregnant is 4.30.9 L/min Blood Pressure: 3-5 mmHg systolic and 5-10 mmHg diastolic in the first trimester and returns to the patient’s prepregnant level by term Systemic Vascular Resistance: 21% (1210 dyne·cm·sec-5 versus 1530 dyne·cm·sec-5 ) Colloid Oncotic Pressure: 20% (18.0 ±1.5 mmHg) – Nonpregnant is 20.8 ±1.0 mmHg Hematologic Changes During Pregnancy 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 During Pregnancy— cont. 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 Expected Physical ChangesRespiratory Oxygen consumption increases with decrease airway resistance Deeper respirations and upward pressure on diaphragm Respiratory Changes During Pregnancy Respiratory Rate: Unchanged or slight Tidal Volume (Vt): 30-40% – This occurs at the expense of the expiratory reserve volume (ERV) which 20% – Vital capacity (VC) & inspiratory reserve volume (IRV) remain relatively stable 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) Oxygen consumption: 15-29% PaO2: 104-108 mmHg PaCO2: 27-32 mmHg – ~40 mmHg in nonpregnant women – The above change in PaO2 and PaCO2 is very important b/c it the CO2 gradient between the fetus and mother, therefore, facilitating the transfer of CO2 from the fetus to the mother Expected Physical Changes Gastrointestinal and Urinary Systems Nausea, vomiting, constipation, slowed peristalsis Bladder capacity increases and tone decreases; risk of UTIs increases GI Changes Appetite Gastric emptying Absorption Bowel sounds Blood flow to the pelvis Morning sickness Pyrosis Constipation Gallbladder and Liver Gallbladder with decreased tone Renal Function Changes During Pregnancy Kidneys enlarge with a length of ~1 cm as measured by intravenous pyelography Renal Plasma Blood Flow – 30-50% by the end of the first trimester GFR – 30-50% by the end of the first trimester 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 Clotting Factor Changes During Pregnancy 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 Expected physical changes Integumentary System Hyperpigmentation Linea Nigra Melasma Skin Changes Increased subdermal fat Hyperpigmentation Striae Linea nigra Chloasma Angiomas Pruritis Palmar erythema Increased perspiration Endocrine Changes Amenorrhea Progesterone Estrogen Ant pituitary suppresses the FSH and LH causing to rise Post pituitary produces oxytocin Neurological Changes Carpal Tunnel Syndrome Numbness/Tingling Lightheadedness Muscle Cramps Musculoskeletal Changes Change in posture Waddling Back Pain Assessment of Gestational Age By LMP (last menstrual period) – the mean length of a normal pregnancy is 280 days from the first day of the last normal menstrual period By physical exam By ultrasound Using the “Wheel” Put the arrow marked FIRST DAY OF LMP on the appropriate date The arrow marked APPROXIMATE DATE OF DELIVERY at the 40-week mark gives you the EDD Today’s date gives you the EGA today 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 Expected Physical Changes Reproductive System 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 + 10 days 20-28 BPD, HC, FL, AC + 2 weeks > 28 BPD, HC, FL, AC + 3 weeks The Trimesters The “trimesters” are three periods of 14 weeks each 1st trimester = through completion of 14 weeks 2nd trimester = through completion of 28 weeks 3rd trimester = 29th through 42nd weeks 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 GTPAL 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 Psychological Adaptation and Developmental Tasks of Pregnancy 1st Trimester – Accepting reality of pregnancy 2nd Trimester – Resolving feelings about her own mother; defining herself as a mother 3rd Trimester – Active preparation for childbirth and baby 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 Recent birth control or lactation LMP – Sure of date? – Normal in length & flow Other helpful tidbits – Date of conception – ER sonogram Obstetric History Dates of all pregnancies (include previous miscarriage or termination) GA Gender, weight Length of labor Coping techniques Route of delivery 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 – – – – Diabetes 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. Down Syndrome) Vital Signs Temperature Blood pressure Respirations Radial pulse Elevated BP suggests the presence of preeclampsia. 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. 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 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 Quad Screen 24-28 weeks Diabetes Screen Rhogam workup & injection Group B strep culture 35-37 weeks 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! 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 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. GPP Antacids may be offered to women whose heartburn remains troublesome 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 oxygencarbon 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 RhDnegative, 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 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 D status. 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