Normal Pregnancy

Pregnancy is a normal physiologic process . . .

. . . not a disease!

Is she pregnant?

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

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

Naegele’s Rule

• Add 7 days to the first day of the LMP, then subtract 3 months

• EXAMPLE: LMP = October 15

+ 7 days = October 22

- 3 months = July 22 = EDD

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

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

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

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

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

Appropriate Weight Gain in Pregnancy

Kg. Lb.

Thin

(BMI < 19.8)

12.5-18 28-40

Average

(BMI 19.8-26.0)

11.5-16 25-35

Heavy

(BMI 26.1-29.0)

6.0-11.5 15-25

Obese

(BMI > 29.0)

6.0 15

The Three “B’s” --- Baby, Belly, Bottom

Leopold’s Maneuvers

• What is in the fundus?

Leopold’s Maneuvers

• Where is the back and where are the small parts?

Leopold’s Maneuvers

• What is the presenting part?

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!

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

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

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

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

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

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

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

Remember:

Pregnancy is normal!