normal pregnancy chapter 104 tintinalli presented by dr. kelley december 6, 2005
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Normal Pregnancy
Chapter 104 TintinalliPresented by Dr. KelleyDecember 6, 2005
Normal Pregnancy
THE POSSIBILITY OF PREGNANCY MUST BE CONSIDERED IN EVERY WOMAN OF REPRODUCTIVE AGE REGARDLESS OF CHIEF COMPLAINT!!!!
Normal Pregnancy
A study showed that 7% of women who stated there was no chance of pregnancy and had normal on-time last menstrual periods were pregnant.Barrier method use, contraceptives, and tubal sterilization does not guarantee pregnancy prevention!!
Terminology
Gravidity Total # of
pregnancies regardless of duration or outcome.
Parity # of pregnancies
completed to delivery during viable period.
G#P# (Full term-Preterm-Aborted-Living)G3P2 (2-0-1-2)
Terminology
Duration= 40 weeks (calculated from first day of last menstrual period)3 Trimesters of Equal Length- 1st- Conception to 14 weeks 2nd- 14-28 weeks 3rd- 28-42 weeks
Term pregnancy requires completion of at least 37 weeks.
Physiology
Cardiovascular 40-45% circulating blood volume 43% in CO 17% in resting HR 20% in SVR BP of diaphragm displaces heart and to the
leftlarger cardiac silhouette on CXRleft axis deviation on EKG (Also, small benign pericardial effusioncardiac silhouette)
Physiology Cont.
Respiratory Dyspnea common complaint Hormone-induced 40% in tidal
volume pCO (nl. Pregnancy value 30mmHg) Functional residual capacity b/c of
of diaphragm
Physiology Cont.
GI Gastric reflux 2º to delayed gastric
emptying, intestinal motility, and lower esophageal sphincter tone.
Gallbladder emptying delayed and less efficient risk of cholesterol stone formation.
Physiology Cont.
GU renal blood flow kidney size GFR (up to 50% by 2nd trimester)
results in BUN/Creat.
Physiology Cont.
Hematopoietic 40-45% circulating
blood volume 2º to plasma volume and # of erythrocytes
HgB conc. 2º to dilutional intravascular volume but should not below 11g/dL
High Fe requirements Reticulocyte count 2nd
half of preg. Leukocyte counts
range 5000-12000 cells/µL
Leukocyte function 2nd trimester so susceptibility to infection.
coagulation factors ESR Slight platelets
Physiology Cont.
Endocrine Hyperinsulinemia and fasting
hypoglycemia 2º to changes in carbohydrate metabolism
Postprandial hyperglycemia 2º to altered response to glucose ingestion.
Thyroid with vascularity and mild hyperplasia but clinically detectable goiter is not normal. (Free thyroxine and TSH to assess thyroid function during pregnancy)
Physiology Cont.
Uterus uterine weight (701100g) intrauterine volume (105000mL) 12 weeks uterus expands into
abdominal cavity
Physiology Cont.
Breasts Breast tenderness and tingling
starting in 1st trimester Breasts enlarge Nipple size pigmentation
History and Physical
HistoryOb/gyn history including menstrual status and contraceptive use on every women of reproductive ageHints of pregnancy-nausea, vomiting, fatigue, cessation of menses, urinary frequencyLMP datePrenatal care and course of current and past pregnancies
History and Physical Cont.
Quickening (1st maternal perception of fetal movement)- 18-20 weeks primigravida- 2 weeks earlier in subsequent pregnancies.
Physical ExaminationRoutine assessment of motherFetal Heart Tones- auscultated by fetal stethoscope by 16-19 weeks (nl. 120-160 beats/minute)
History and Physical Cont.
A pelvic exam must be performed whenever pregnancy part of differential diagnosis. Key components: Appearance of cervix Presence of discharge or blood Wet prep. & culture for Neisseria
gonorrhoeae & Chlamydia trachomatis Bimanual exam to determine size &
tenderness of uterus and adnexa.
History and Physical Cont.
Palpation of fundus of uterus- 12 weeks- Symphysis pubis 16 weeks- Midway between
symphysis pubis and umbilicus 20 weeks- Umbilicus 20-32 weeks- 1 cm above umbilicus
for every 1 week
Making the Diagnosis
Serum and/or Urine HCG HCG is a glycoprotein produced by
trophoblast after implantation. Composed of alpha and beta subunits with
beta subunit unique to HCG. ELISAs detect beta-HCG in urine as low as
10-20mIU/mL approx. 1 week after conception
<1% false negative rate on nondilute urine.
Making the Diagnosis Cont.
+ pregnancy test does not confirm a normal intrauterine pregnancy!!!!+ beta-HCG can be found in ectopic, recent spontaneous or induced abortion, and HCG secreting tumors (molar pregnancies).Pelvic ultrasonography after 4-5 weeks gestation for definitive diagnosisSerial beta-HCG levels useful- level doubles every 1.4-2.0 days following implantation in early pregnancy if not ectopic or nonviable pregnancy.
Making the Diagnosis Cont.
Pelvic UltrasonographyGestational Sac- 5.5-6 weeks gestation-
transabdominal 4-5 weeks gestation- transvaginal
Cardiac Activity- 6 weeks gestation
Abdominal Discomfort-Differential Diagnosis
Must include all possiblities for nonpregnant and pregnant women!!!1st trimester-
Ectopic and threat. Abortion
Late 2nd/3rd trimester- Premature labor,
abruption, uterine rupture
Early pregnancy- Vascular cong. Of pelvic
tissue, round ligament tension
Late pregnancy- Braxton-Hicks (irregular,
palpable contractions)
Appendicitis- location of pain upward and rightwardCholelithiasis- may cause cholecystits or pancreatitis
Syncope-Differential Diagnosis
Anemia Electrolyte imbalanceDehydrationPulmonary embolismCardiac arrythmias Sometimes unclear etiology but pregnant
women with PVCs and PACs May occur in patients with and without
heart disease.
Medication Use in Pregnancy
Gestational age and stage of development, dose, duration of exposure and individual susceptibility influence the potential effects of drug exposure during pregnancy.
Fetus is most vulnerable to teratogenic effects at 4-12 weeks gest. (period of organogenesis)Table 104-1- FDA Categorization of Drug Risk in Pregnancy.
Medication Use in Pregnancy-Antimicrobial Agents
All enter fetal circulation to some extent.Info on safety of newer extended-spectrum or late-generation agents limited.Table 105-1PCN and Cephalosporins generally are regarded as safe for use in any trimester!!!!
Medication Use in Pregnancy-Analgesic Agents
Acetaminophen is the analgesic agent of choice!ASA- 1st trimester- congenital defects. Later- Coagulation abnormalities with hemorrhagic
complications in neonate and mother and premature patent ductus arteriosus closure
ASA and NSAIDs- May prolong gestation and labor thru inhibition of
cylooxygenase. Also assoc. with oligohydramnios, intestinal perforation, hydrops fetalis, and renal failure (especially Indomethacin).
Medication Use in Pregnancy-GI Agents
Nausea and Vomiting- Antiemetics safety has not been studied in
prospective human trials, but benefit of improved metabolic conditions and maternal well being should be considered.
Promethazine (category C), prochlorperazine (C), metoclopramide (B) (5-10mg PO, IV,IM q 8 º), ondansetron (B) (8mg PO q 8 º)
Dyspepsia- Most OTC antacid preps, cimetidine, and
ranitidine are regarded as safe.
Medication Use in Pregnancy-Cold Preparations
OTC cold preps are usually combinations with sympathomimetic agents vasoconstrictive properties vascular-mediated congenital defects.When absolutely necessary consider each agent of combined prep.1st trimester exposure to dextromethorphan or guaifenesin has not been assoc. with adverse fetal effects.
Medication Use in Pregnancy-Anesthetics
Lidocaine- Not associated
with detrimental fetal effects.
Combination Tetracaine, Adrenaline-Epinephrine, & Cocaine (TAC) and Lidocaine, Adrenaline, & Tetracaine (LAT) should not be used b/c risks of absorbed cocaine and adrenaline-epinephrine.
Medication Use in Pregnancy-Contraceptives
Should be d/c’d ASAP!!!!However, no demonstrated risk of fetal malformation in early pregnancy.
Immunizations During Pregnancy
YESInactivated (killed-virus) vaccines including: Influenza Tetanus toxoid with
or without diptheria toxid
Immunoglobins including tetanus, hepatitis, rabies, & varicella
NOLive-virus vaccines including: Measles Mumps Rubella Poliomyelitis Varicella
Preventive Medicine & Counseling
Nutrition & Nutritional Supplements Average total weight gain- 12.5 kg (28 lbs.) Folic Acid before and during pregnancy to
prevent neural tube defects (1mg/day-no history of neural tube defects, 4mg/day- + h/o previous pregnancy with neural tube defects)
Vitamins A, D, C, and B6 in excess may lead to congenial defects.
Fe supplementation recommended Zinc deficiencyneural tube
defects15mg/day recommended
Preventive Medicine & Counseling Cont.
Caffeine Studies show an increased risk of
miscarriage in 1st and 2nd trimesters with consumption of >150mg/day.
Aspartame Metabolized to phenylalanine crosses into
fetal circulation high concentration can lead to mental retard. (Fetal toxicity unlikely unless excessive maternal intake or maternal heterozygous carrier of PKU)
Preventive Medicine & Counseling Cont.
Substance AbuseCocaine- risk of abruptio placenta, growth-restricted infants, preterm labor, developmental delayOpiates- no known teratogenic effects. danger with withdrawal.Amphetamines- congenital abnorm.
Hallucinogens & “Designer Drugs”- inconclusiveNicotine- rates of spontaneous Ab., abruption, preterm labor, low birth weight, risk of SIDS (effects if cessation by 16 weeks)—Nicotine gum (Category C), Nicotine patch (D)
Preventive Medicine & Counseling Cont.
Substance Abuse Cont.Alcohol-
Fetal Alcohol Syndrome- microcephaly, mental retardation, & behavioral d/o
Greatest risk 1st trimester
No established safe quantity of consumption.
Travel No restraints in
normal pregnancy.
Frequent ambulation during long duration.
Protective restraint devices at all times!
Preventive Medicine & Counseling Cont.
Exercise-OK for moderate physical exerciseACOG recommends: Non-weight bearing (minimize chance
of abdominal trauma) No scuba diving No exercise in supine position Individual based programs
Disposition
Normal Uncomplicated Pregnancy Recommend f/u for prenatal care &
Obstetrics evaluation by 6-8 weeks gestation. F/u for specific signs & symptoms- Table 104-
3 Recommendations on activities, lifestyle, and
appropriate use of prescription and OTC meds given.
Ob consult when needed for management options.
Questions
1. If a 35 yoa female tells you that she has had a tubal ligation, you should not be concerned about the possibility of pregnancy. A. True B. False
2. Pregnancy causes a decrease in cardiac output. A. True B. False
3. During pregnancy, which of the following is false? A. Increased renal blood flow B. Increased kidney size C. Increased GFR D. Increased BUN/Creat.
4. At 20 weeks gestation the uterine fundus should be palpated where? A. Umbilicus B. Pubic symphysis C. Between umbilicus and nipple line D. Is not able to be palpated at this
time
5. The differential diagnosis for syncope in pregnancy includes all of the following except: A. Anemia B. Electrolyte imbalance C. Dehydration D. Pulmonary Embolus E. Cardiac Arrythmia F. All of the above are true
Answers
1. False2. False (increase in CO)3. D4. A5. F
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