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OBgyn Week 7

Normal Pregnancy

Conception• Traditionally, involves a fertile woman and a

fertile man. (These days can involve egg donors, sperm donors, surrogates, fertility hormones, artificial implantation, and other techniques which will not be covered in this lecture)

• Possible during fertile window of woman’s cycle (around ovulation)

• Sperm must travel through cervix, uterus, fallopian tubes to reach and fertilize egg

Conception• Sperm undergo enzymatic reactions

(while traveling through cervical mucus and fallopian tubes) to help penetrate the protective layers around the ovum

• Sperm chemically attracted to ovum– Progesterone– Follicular fluid from ovum

Conception

Conception• Fertilization occurs in Fallopian tube,

zygote (fertilized egg) continues to divide as it travels to uterus and implants

• Takes 3-4 days for embryo to reach uterus

• Implantation generally occurs ~3-4 days after embryo enters the uterus

Fertilization to Implantation

Fertile Days of CycleFactors to consider:• Ovulation occurs ~day 14 (anytime of day)• Ovum can survive up to 24 hours after ovulation • Sperm can survive in the vagina up to 48 hours

after ejaculation• So fertile window is ~days 11-16 of cycle

(if trying to conceive, these are best days; expand to ~days 8-19 if trying NOT to conceive)– strict day correlation depends on cycle regularity– remember - follicular phase can vary in length

Fertility Symptoms• Charting of menses

– Helps determine fertile days, esp if regular cycles• Cervical mucus

– Will be thicker, stretchy when most fertile• Cervical position and feel

– Cervix softens, moves further from introitus when fertile• Basal body temp

– Increases just after ovulation• Hormone levels

– LH surges prior to ovulation (must draw blood to test)• Salivary crystallization

– At-home test kits available

Cycle charts

Multiples• Most commonly twins or triplets• May arise from:

– Release and fertilization of multiple ova(fraternal twins)

– Division of zygote into two embryos(identical twins)Division during stage when cells are totipotent

– Combination of these– Identical triplets or quadruplets also possible

• High risk of pre-term delivery, low birth weight

Early Pregnancy SxAll of these are due to hormone level changes:• Nausea / vomiting (esp in AM)

• Commonly lasts until ~week 12-15, when placenta takes over roll of hormone production from corpus luteum

• Swollen / tender breasts• Mood changes / irritability• Fatigue• Leucorrhea: white, thicker vaginal discharge• Lack of menstrual period

• Will have been pregnant ~2 weeks by this point• May have light spotting lasting ~1 day (more may be sign of

spontaneous abortion or of ectopic pregnancy)

Abnormal SxSymptoms of ectopic pregnancy or spontaneous abortion may include:

Cramps

Severe abdominal pain

Bleeding

Spotting > 1 days

Fainting or Dizziness

Pregnancy Diagnosis• Urine b-HCG - accurate at time of missed period

(home test kits available OTC)• Serum b-HCG - quantitative tests most sensitive• Ultrasound (abdominal)

– 5-6 weeks can see gestational sac– 8 weeks can see heart beat to assess viability

Vaginal Ultrasound can determine heart beat, gestational sac at 5 weeks

Later Signs of Pregnancy– Softening and bluing of cervix– Enlargement of uterus (may be palpated by 15 wks)– Fetal heart tones (Doppler or fetascope)

• 120-160bpm, so easy to tell apart from mother’s• May be detected as early as 10 wks• Lack of FHT by 12-14 weeks is concerning, may be due to:

– Wrong date determination

– Non-viable fetus

– Posterior position of fetus

– Thick abdominal wall

– Retroflexed uterus

Later Signs of Pregnancy• Quickening: first fetal mvmt felt by the mother

– Primiparous: 18-20 weeks– Multiparous: 16-19 weeks

• Braxton Hicks contractions: localized uterine contractions that may start at 20 weeks; very irregular and variable

• At 20 weeks, ballotment: moveable baby

Length of Pregnancy

• Estimated Due Date = 40 weeks (280 days) after first day of last menstrual period

• Naegle’s rule: subtract 3 months from LMP, add 7 days, add 1 year

• Add 266 days from exact day of conception• 85% of women deliver around EDD; 10% early, 5% late

• “Normal” can vary from 37-42 weeks• LMP used to estimate gestational age• And remember, fertilization usually occurs ~2

weeks after first day of LMP• Conception age refers to date of probable conception• ~2 weeks less than gestational age

Establishing EDD• Difficulties with establishment of Due Date

– Irregular or abnormal menses• Miscarriage• Lactation (annovulatory for 6-12 months)• Gynecological problems (e.g. polycystic ovaries)

– Other interfering factors• Low dose OCPs• Early or late ovulation• Poor recording of menstrual history

Establishing EDD• Importance of establishing correct EDD

– Determine pre or post maturity• Important if home birth (safe to deliver weeks 37-42; if

premature or postdate, need to refer to hospital)

– Determine IUGR (Intrauterine growth retardation)– Determine multiple pregnancy or abnormal levels

of amniotic fluid– Determine paternity– Gestational age important in considering TAB,

amniocentesis, alpha fetal protein

Maternal Changes

• Weight gain

• Loosening of joints

• Hormonal changes

• Increase in blood volume

• Enlargement of uterus, crowding of abdominal and pelvic organs

• Enlargement of breasts

Weight Gain• Normal weight gain

~30 lbs if healthy weight at start of pregnancy~9 of these lbs are weight of fetus, placenta, amniotic fluid,

uterine hypertrophy, increased blood volume, breast enlargement, maternal intra/extracellular volume

• Variables to weight gain:– Age, parity, income, maternal education, etc.– Large weight gain associated with LGA (large for

gestational age) babies• Contributes to maternal obesity, gestational diabetes,

increased risk for CV dz and diabetes later in life

– Low weight gain associated with SGA babies • Greater risk for preterm labor

Maternal Weight Gain• National Academy of Science

recommendations according to BMI– 28-40# for underweight women

• 5# in first trimester; >1# week thereafter

– 15-35# for women at normal weight• 2-4# in first trimester; 1# week thereafter

– 15-25# for overweight women• 2# in first trimester; <1# week thereafter

Maternal Changes

Physiologic Changes– Cervical changes: effacement and dilation

• Thick clot of mucus in cervical os: mucous plug• Cervix softens and becomes cyanotic (increased vascularity)• Change in consistency in cervical mucus

– Uterine changes:• Displaces intestines laterally and superiorly• Increases tension on on broad and round ligaments• Uterus also undergoes irregular contractions

– Unpredictable, nonrhythmic, aka Braxton-Hicks

– Vaginal changes: • Softening of tissues• Increased cervical mucus• Decreased pH (3.5 to 6) (antibacterial function?)

Phys Changes– Ovaries

• Ovarian function ceases, maturation of new follicles suspended

• Corpus luteum produces progesterone (until ~week 12, when placenta takes over this function)

• Corpus luteum also secretes relaxin hormone

– Changes in breasts:• Increased tenderness in first weeks• Increase in size• Nipples become enlarged and more deeply pigmented• Colostrum secreted pre or post-natally

Phys Changes– Musculoskeletal changes

• Softening of ligaments (esp. sacro-illiac and pubic symphisis) due to relaxin hormone

• Lumbar lordosis• Loosening of all joints

– Often noticed as increase of foot length / shoe size

– Skin changes: • chloasma (“mask” of pregnancy)• linea nigra on abdomen• striae • increased hair growth, increased perspiration

Phys Changes - CV– Cardiovascular changes

• Increased cardiac outflow by 30-40%• Increase in blood volume by >35%

– Increase in body mass (enlarged uterus)– Facilitates blood flow/ gas exchange to placenta– Protects mother against excessive blood loss during labor– Greater increase in plasma than erythrocytes

• Benign ejection systolic heart murmurs• Increased pulse rate 10-15bpm

(How would you expect her pulse to feel?)– Edema of pregnancy

• Increased capillary pressure and permeability• Fetal pressure in pelvis decreases venous return of lower half of

body

More Physiologic Changes– Increase in cellular respiration for fetus/placenta

and mom– Shortness of breath dt restriction on diaphragm– Kidneys about 1 cm larger during pregnancy– Increase in dental caries– Decreased secretion of HCL and pepsin– Decreased gastric emptying and intestinal motility– Increased metabolic rate by 20%

Endocrine Changes

– Increased thyroid function (free, active thyroid hormone T3 remains the same)

– Incrased prolactin, cortisol, aldosterone– Decreased GH, FSH, LH– Difficulty balancing blood glucose

• Glucose as energy source favored by fetus

– Estrogen increases 1000x (ovaries and adrenals)

– Progesterone increases 10x

Estrogen Effects– Influences growth and fxn of uterus, breasts, labia– Increases pliability of CT, joint relaxation– Increases adipose tissue (fat stores)– Increases skin pigmentation– Increases Na+ and volume retention– Stimulates 3rd trimester prostaglandin production– Associated with mood swings– Increases insulin production/ secretion as well as

tissue sensitivity to insulin– Increases uterine receptivity to progesterone and

oxytocin

Progesterone Effects– Produced by corpus luteum, then by

placenta– Increases the blood supply of endometrium– Suppresses maternal immunological

response to fetus– Inhibits contraction of uterus– Relaxes smooth muscle (bladder tone,

slows GI motility)– Radically decreases at labor onset

More Endocrine Changes– Prolactin

• Produced by maternal and fetal pituitary glands, uterus• Sustains milk production and regulates milk composition

– Prostaglandins• Produced by mother, fetus, placenta• Soften cervix, prime maternal body for labor

– Oxytocin• Produced by hypothalamus, released by pituitary• Stimulates uterine contractions, milk let down/ ejection• Distension of cervix and vagina stimulates release of

oxytocin and prostaglandins during labor

Endocrine Changes - HCG– bHCG (beta human chorionic gonadotrophin)

• Secreted by fetus starting day 6-8• Prevents degeneration of corpus luteum so that E and P

continue to be secreted• Maximum levels at 7-16 weeks• At 8-12 weeks, promotes testosterone synthesis and

secretion for male sexual differentiation• Used in diagnosis for quantitative pregnancy tests/

ectopic pregnancy

Endocrine Changes - HPL– HPL (human placental lactogen)

• aka HCS (Human Chorionic Somatomammotropin)• Produced by placenta• Decreases maternal insulin sensitivity

– Elevates maternal blood glucose levels with decreased maternal glucose usage = more available for fetus

• Elevated during hypogycemia to mobilize free fatty acids for energy for maternal metabolism

• Increases lipolysis– Glucose preferentially used as fuel by fetus, maternal energy

increasingly comes from fat stores

• Decreases hunger sensation and diverts maternal CHO metabolism to fat metabolism in 3rd trimester

• Plateaus in 3rd trimester

Trimesters• Pregnancy divided into trimesters, each

~3 months (13-14 weeks)– 1st : weeks 0-13– 2nd : weeks 14-28– 3rd : weeks 29-40

Week-by-Week Developments

• First Trimester (embryonic development)*Highly sensitive to teratogens during this stage*– Weeks 1 and 2: remember, this is preconception:

mother’s body prepares for ovulation, fertilization– Wk 3: fertilization occurs, cell division begins– Wk 4: CNS begins to develop, angiogenesis, primitive

cardiovascular system– Wk 5: neurogenesis, brain activity, heart beat

HCG levels detectable via home test kits

– Wk 6: embryo size of a bean, face developing– Wk 7-8: Eyes, hair, all essential organs, movement– Wk 8: Embryonic stage over, fetal stage begins

First trimester continued– Wk 9-12: dvpmt of fetal muscle, cartilage, genitals,

Fetal Heart Tones detectable– Wk 13: fetus is about the size of a peach

– Common maternal symptoms:• Morning sickness, breast tenderness/swelling, fatigue, weight

gain, constipation, heartburn, food cravings, frequent urination

– Recommendations:• Focus on good nutrition: nutrient-dense and fiber-rich foods,

avoid refined carbs, eat small, frequent meals• Ginger, acupuncture to relieve nausea• Gentle exercise to aid circulation, bowel mvmts, fatigue• Kegel exercises now to help prevent incontinence later

Fetal development2nd trimester (wk 14-28)

Further organ development and functionFetus swallows fluid, urinates, sleeps and wakes– Week 16: toes, fingers, eyelashes– Wk 17: fetus can hear outside noises; mom may start to be

visibly pregnant, may feel “quickening”– Wk 20: gender identification possible with ultrasound– Wk 21: mom SOB, fetus presses against diaphragm– Wk 24: Check baby’s position; if born at this time, there is a

chance of survival of infantLack of lung dvpmt, low body weight are greatest risk factors

– Wk 25: all organs formed, now mainly growth; risk for pre-eclampsia begins

2nd trimester• Common maternal symptoms:

– Striae, linea nigra, hemorrhoids and other varicosities, increased allergen sensitivity, swollen feet/ankles, shortness of breath

– Increased incidence of dental caries (cavities)

• Recommendations:– Continue to focus on good nutrition– Rest, nap, put feet up periodically– Good oral hygiene especially important

Fetal development3rd trimester (wk 29-40+)

Fetal weight gain ~1 ounce/dayBrain develops rapidly: Maternal nutrition - omega 3s

– Wk 33: fetus moves downward, head down– Wk 34: testes descend (in male fetus)– Wk 37: lung surfactant produced– Wk 38-40: ready for delivery!– Wk 41-42: still within normal, low-risk range

U.S. averages for infants at term birth:Female wt: 7 lbs, male wt: 7.5 lbs, length: 20”

Placenta• New organ (!) develops for pregnancy only• Develops from embryonic cells (outer layer of

blastocyst)• Allows gas exchange (oxygen, CO2) without

mixing of maternal and fetal circulation• Also permeable to vitamins, glucose, free

fatty acids and electrolytes, and antibodies

Placental Circulation• Mother’s circulation

connects through uterine wall

• Fetal circ from placenta via umbilical cord

• Placental circulation reverse of convention– Arteries carry

deoxygenated blood– Veins carry oxygenated

blood

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Placenta in Multiples• Depends on:

– Dizygotic twins v. monozygotic twins– Time at which cleavage of monozygote occurred

• A= dizygotic twins (two sperm fertilized two eggs)• B= monozygotic twins, cleavage of zygote 4-8d post fertilization• C= monozygotic twins, cleavage of zygote 8-12d post fert.

Nutrition - general

• Early fetal development– Folate: needed for proper brain and CNS development -

must have good levels at very start of pregnancy to prevent defects

– B12: also needed for proper fetal CNS dvpmt– Vitamin A: overdoses can cause defects, so important not to

megadose during pregnancy– Prenatal vitamins

• Maintenance of pregnancy– Extra calories (~100-300 more/day)– Quality fats (including omega 3s), oils, and protein– Nutrient-dense, fiber-rich foods– Avoid refined carbs and “empty” calories!

Nutrition• Do not restrict salt during pregnancy!

• Electrolytes needed to balance increased blood volume• Low sodium diet can lead to elevated BP (drop in blood volume

makes kidneys react as if hemorrhage occurred and release renin, which constricts blood vessels)

• No weight-loss diets during pregnancy!• If pt overweight, focus on healthy food choices

• Protein needs increase (60-100g/day)• Increased risk for Pregnancy-induced hypertension with

malnutrition, low protein, low calories and low salt• Can monitor protein status by checking serum albumin

Nutrition - minerals• Iron

• 30mg/day (60-90mg/d if mom anemic)• Better taken with vitamin C, away from tannins

• Calcium• 600-1200mg/ day supplemental to dietary intake• Increased PTH stimulates calcium release from bones• No net bone loss during pregnancy, but bone loss can occur

during lactation with inadequate calcium intake • Deficiency: muscle spasm, bleeding gums, headache

• Zinc• 15-30mg/day; >30mg may be teratogenic• Important for protein synthesis• Deficiency associated with: infertility, chronic SAB, PIH,

dysfunctional labor, infections

Nutrition - folate• Folic acid

* Start taking before pregnancy*• 800-1000mcg/day• Needed for DNA synthesis, protein metabolism,

neurological development• Deficiency assoc with neural tube defects (spina bifida)• Deficiency common in vegan diets, smoking, OCP use• Should always supplement with Vitamin B12, as it can

mask symptoms of B12 deficiency

Nutrition - vitamins• B vitamins

• 25% women in US are deficient in B vitamins• 50mg/day B6• Helps with nausea/ vomiting• B12 deficiency results in CNS defects in baby• Esp. important for vegans to supplement B12

• Vitamin C• 500-1000mg/d• Megadoses (10g) may cause miscarriage in early weeks• May also interfere with pregnancy test results• Decreased incidence of SIDS if taken during pregnancy

and continued while breast feeding

Nutrition - vitamins• Vitamin A

• Use beta-carotene in pregnancy as high doses of vit A may be teratogenic (>10,000IU)

• Be aware of patients using vitamin A as skin treatment (acne, wrinkles)

• Vitamin D• Recent research: deficiencies increase risk for C-section• Sunshine is best source• Supplement doses determined by serum vitamin D levels

Nutrition - prenatal vitamins• Take before and throughout pregnancy

• Most necessary vitamins and minerals are included in prenatal formulas

• May need extra iron if anemic

• Need omega 3 fatty acids (not included)

• And, of course, still need a good diet

Nutrition - multiplesNutrition for multiple gestation (twins, etc.)

• Each fetus requires additional increase in mother’s total blood volume

• Each fetus requires ~30g protein and 200 calories daily

• Higher dose prenatal vitamins

• Frequent meals

Maternal Malnutrition• Malnutrition increases risk of:

– Prolonged, difficult labors– Pre-eclampsia and eclampsia (part of PIH)

• Stroke, seizures, death

– Placental abruption– Low birth weight infants

Exercise During Pregnancy• Healthy, fit women can often continue their

regular exercise programs• Ensure good hydration • May fatigue much faster• Don’t increase intensity beyond pre-pregnancy levels

• Yoga and walking are recommended for women who are not used to exercising

• Bicycle riding is not recommended, as center of gravity changes - increase risk of falls

Exercise - contraindicationsPre-eclampsia Severe heart disease

Multiple gestation Preterm labor (now or prior pregnancy)

Incompetent cervix Premature rupture of membranes

Placenta previa after 26w Lung disease

Persistent 2nd or 3rd trimester bleeding

Intrauterine growth retardation

Discontinue Exercise if:

Amniotic fluid leakage

Dyspnea before exertion

Calf pain/ swelling Headache

Chest pain Muscle weakness

Decreased fetal movement

Preterm labor

Dizziness Vaginal bleeding

Conventional Prenatal Care• First visit usually ~week 6-10

– Medical history and full physical exam– Ultrasound– Labwork: CBC, UA, vaginal culture, STI tests, blood

type, Rh factor, metabolic panel

• Routine care - monthly visits until wk 28– Lab results, vital signs, fetal heart rate– Later: fundal height measurement

• Visits every 2 weeks until week 36– Stay current with any changes in vital signs– Check for group B strep with vaginal culture

• Weekly visits until delivery

Ultrasound• Often done at:

• 10 wks: determine if fetus is living and due date• 20 wks: check anatomy and for structural defects• Week 32-34: assess fetal size, position and well-

being

High Risk Pregnancy• Defined as any of the following:

– Maternal age <15 or >35– Maternal weight <100lbs pre-preg or obese– Maternal height <5’– History of complications with previous pregnancies

(including stillbirth, fetal loss, preterm labor and/or delivery, small-for-gestational age baby, large baby, pre-eclampsia or eclampsia)

– More than 5 previous pregnancies, even if normal– Bleeding during the third trimester– Abnormalities of the reproductive tract, including uterine

fibroids

High Risk Pregnancy continued

• Defined as any of the following:– Rh incompatibility– Pre or post-term delivery (<37 or >42 wks)– Multiples – Hypertension– Gestational diabetes– Infection of vagina, cervix, or kidneys– Fever– Acute surgical emergency (appendicitis, etc.)– Chronic illness (sickle cell anemia, AIDS, etc.)

• High-Risk status necessitates delivery care from highly trained specialists

Rh Incompatibility• In women with Rh neg blood types• Occurs only if baby in womb has Rh positive

blood type (father must have Rh pos blood for this to be genetically possible)

• Danger lies in exposure to second Rh pos fetus - mother’s immune system may develop antibodies to fetal blood with first exposure and attack blood of second fetus

• Treatment is Rh immune globulin injection (Rhogam shot) in 7th month of gestation and within 72 hours of delivery

Avoid During PregnancyTeratogens - some medications, alcohol, solvents, chemicals

• Alcohol• Androgens and testosterone • ACE inhibitors• Coumarin• Carbamazepine• Anti-folates (methotrexate)• Cocaine• DES (no longer available in U.S.)

Avoid During Pregnancycontinued

• Lead, Lithium, Mercury• Phenytoin• Streptomycin, kanamycin• Tetracyline• Thalidomide• Trimethadione, paramethadione• Valproic acid• Vitamin A in high doses

Teratogen Classification• Weigh risk vs benefit case-by-case

– CATEGORY A:• Controlled studies in humans have demonstrated no fetal

risks. There are few category A drugs. Examples include prenatal vitamins, but not massive dosages of vitamins.

– CATEGORY B: • Animal studies indicate no fetal risks, but there are no

human studies; or adverse effects have been demonstrated in animals, but not in well-controlled human studies.

Teratogen Classification continued

– CATEGORY C: • There are either no adequate studies, either animal or

human, or there are adverse fetal effects in animal studies but no available human data. Many medications pregnant women use fall into this category.

– CATEGORY D: • There is evidence of fetal risk, but benefits are thought to

outweigh the risks.

– CATEGORY X: • Proven fetal risks clearly outweigh any benefit.

– Accutane

Common Complaints During Pregnancy

(The following slides list common symptoms experienced during pregnancy, along with conditions that must be ruled out, and recommendations for treatment and prevention)

Common Complaints During Pregnancy

• Fatigue: need to rule out anemia– TCM ddx?

• Drowsiness– Due to increase in progesterone, worst in 1st

trimester– Be careful driving!– Take naps (also helps nausea)– Remind her it is not forever– Make sure diet and iron levels ok, if so, don’t fight

urge to rest

Common Complaints• Mask of pregnancy: chloasma

– Temporary increased pigmentation due to hormone changes– Most common in women with poor diet, liver not processing

hormones well– More common in multips

Common Complaints• Rashes

– Increased metabolism, sweating, flesh leads to increased skin/skin contact

– Increased sensitivity to allergens

• Pruritis– Hormones or increased vascularization– Can be early sign of PIH (dt decreased Kd

function)– Skin stretching– Oatmeal bath, adequate dietary oils and fats

Common Complaints• Blood sugar imbalance

– Aggravated by fetal competition for blood glucose, hormone fluctuation

– Frequent small meals, increase protein (60-90g/d)– Avoid sugar (max 1 glass of juice or one fruit/ day)

• Insomnia– Can’t get comfortable– Increased frequency of urination– Worry/ anxiety– Usually worse in 1st and 3rd trimesters– Counseling, warm baths, pillows behind back, between

knees, under belly, wet sock treatment, exercise, decrease caffeine

Common Complaints - Nausea

• Nausea/ vomiting– b-Hcg decreases stomach acid and appetite;

blood sugar imbalance also contributes– Usually n/v decrease after 12-16 weeks– Nausea is a good sign: lower likelihood of SAB

• No nausea mb sx not enough b-hcg being produced

– Hyperemesis graviderum: severe n/v, need to be hospitalized for dehydration

Common Complaints - Nausea

• Suggestions: – eat small, frequent meals (every 3-4h), especially

protein, even if not hungry– Protein snack before bed or during the night– Increase complex carbohydrates; have dry

crackers at bedside, eat first thing in the morning– Consider eliminating food intolerances– Precede meals with 1Tbsp. Apple cider vinegar– Visualizations, acceptance of pregnancy,

grounding, roots pulling down to earth

Common Complaints• Heartburn

– Reflex from pressure on stomach; usually late in pregnancy but may be early on

– Avoid lying down for 2h after eating; eat small, frequent meals slowly

– Avoid fats, spicy foods, carbonated drinks– Chew gum to increase saliva, digestive enzymes– Warm teas but avoid mint (relaxes sphincter)

• Pytalism (excess salivation)– Hormones of pregnancy, CHO deficiency

• Eat CHO at every meal

Common Complaints• Pica

– Desire for non-foods such as dirt, paint chips– Generally a sign of protein or calcium deficiency– need

to improve diet

• Constipation – Progesterone relaxes smooth muscle, decreases gut

motility; later in pregnancy uterine size crowds bowels– Avoid straining (hemorrhoids)– Increase fluids, fiber, prune juice (better if heated),

exercise, decrease stress

Common Complaints• Diarrhea

– Common; may alternate with constipation– Increase fiber

• Flatulence – Due to decrease in gut motility, pressure on

bowels– Chew food well, avoid offending foods,

carbonation– Digestive enzymes, probiotics

Common Complaints• Nosebleeds/ bleeding gums

– Increased vascularity, calcium deficiency– Ensure bleeding stops within normal time; if any doubts,

check platelets, pro-thrombin time

• Abdominal Pain– Need to rule out: placental abruption, uterine infection,

ectopic PG, Kd infection, premature labor, ruptured ovarian cyst

– Round ligament pains, braxton-hicks contractions, baby kicking

• Shortness of breath– Anemia, mechanical pressure

Common Complaints• Heart palpitations

– Increased blood volume and pressure increases work load on heart

– Aggravated by increased weight, pressure of uterus on diaphragm

– Anemia– Rule out thyroid (esp. hyperthyroid)– Consider referral to cardiologist

• Breast tenderness– Well-fitting bra, avoid underwire (blocks milk ducts)– Proper vitamin E intake

Common Complaints• Hemorrhoids

– Increased laxity of veins, increased pressure on pelvic venous system and lymphatics

– Constipation causing straining, increasing pressure

• Varicose veins– Same etiology as hemorrhoids; often a genetic

component, more common in multiparous women– Common locations along leg, behind knee– Need to monitor for thrombophlebitis– Keep legs elevated above heart 15min of every 4h– Decrease length of time spent standing

Common Complaints• Edema

– Increased uterine size leads to slow venous return– Increased permeability and blood volume pushes

fluid out into interstitial space– Need to rule out PIH, esp. with facial edema

• Swelling in ankles at end of day, esp. after standing; may want to remove rings on fingers (normal)

– Rest at least 15min/4hours– Check nutrition: proper protein, salt, water intake

Common Complaints• Low back pain

– Relaxin softens SI joints, pulls on lumbar musculature, puts pressure on nerves; causes joints to be hyper-mobile

– Change in body weight and its distribution changes posture

– Larger uterus increases lumbar lordosis– Wear sensible shoes, avoid heavy lifting (>25#)– Prenatal exercises: pelvic rocks, knee to chest on

waking, walking, swimming, check posture– Don’t start new sports during pregnancy

Common Complaints• Leg cramps

– Relative buildup of lactic acid, Relative calcium deficiency, Decreased circulation in legs

– Stretch legs, massage during cramping– Calcium, magnesium

• Headache– In addition to all non-PG related etiologies, increase

in b-hcg, blood volume changes, anemia, hypogycemia, calcium deficiency, PIH

– Avoid aspirin, ibuprofen (decrease platelets)– Hot foot back with cold compress on neck

Common Complaints• Syncope/dizziness

– Increase vagal response to position change, increased demand on heart, anemia, increased blood volume, hypoglycemia

– Get up slowly, careful with hot baths, treat cause

• Stretch marks– Approx. half genetic, other half due to excess weight,

poor tissue support– 50% women get them; of these 50% go away

postpartum– Exercise to improve muscle tone– Vitamin E, shea butter

Common Complaints• Hydrorrhea gravidarium:

• Normal, profuse watery discharge, white or clear, no itch• Can be confused with water breaking (but won’t be alkaline

like amniotic fluid)

• Yeast infection• Increase in estrogen, change in pH• Cotton underwear, good hygiene, low sugar

• Trichomonas vaginal infection• Should not be treated until postpartum • Flagyl contraindicated during pregnancy

• Bacterial vaginosis• Cleocin antibiotic cream vaginally ok during PG

Key Concepts• Fertile window is days 11-16 of cycle• Gestational age begins at LMP• Normal pregnancy length is 40 weeks• Proper folate levels nec before conception• Focus on good nutrition, not weight gain• What is Rh incompatibility? Who is at risk?

• There are MANY changes during pregnancyKnow which are normal, which need investigation