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what drives many preg-related endocrine &metabolic changes
Increasing levels of estradiol & progesterone & the placental hormones- esp humanchorionic gonadotropin (HCG)
Stimulate lactotrophs in the anterior lobe of the pituitary gland
Stores oxytocin and antidiuretic hormone (ADH)
HCG resets receptors for thirst & ADH release- leading to ↓ in serum Na  and sometimes polyuria
Posterior pituitary gland
Effects of estrogen on thyroxine-binding globulin & the stimulation of thethyrotropin (TSH) receptor by HCG lead to
fluctuations in free T4 and T3 levels & TSH (normal ranges)
describe the glucose levels during preg
- ↑ insulin resistance in later preg
- Linked to transient hyperglycemia after meals
- Btwn meals fasting glucose levels fall bc of demands of fetal growth & ↑ peripheral use of glucose
- Shift from carb to fat metabolism
what are the hormone changes towards the end of preg?
- ↑ in placental corticotrophin-releasing hormone & adrenal adrenocorticotrophic hormone (ACTH) produce a “state of relative hypercortisolism” that may be a trigger for labor
- Production of CRH suggest that a placental clock determines the timing of birth
what does rising progesterone do?
- RR does NOT change
- Tidal vol & min ventilation ↑ (C/O’s dyspnea
- Progesterone and estradiol lower esophageal sphincter tone (Contribute to symptoms of reflux and heartburn)
- Relaxes tone and contraction in the ureters- causing hydronephrosis, and ↑ risk of bacteriuria in the bladder
what are the CV changes?
- Erythrocyte mass & plasma vol ↑ = more blood (plas vol ↑ more – causing relative hemodilution & physiologic anemia, which can protect against blood loss during childbirth)
- CO ↑
- Systemic vascular resistance & BP ↓
what are the musculoskeletal changes?
- Ensues from wt gain and relaxin (hormone secreted in the corpus luteum & placenta
- Lumbar lordosis as the gravid uterus enlarges
- Contributing to mechanical low back discomfort
- Ligamentous laxity in sacroiliac joints & the pubic symphysis (To ease passage of baby)
when do breast become nodular?
by 3rd mo gestation
↑vascularity, vagina a bluish/ violet color
why does vaginal pH become more acidic?
- from Lactobacillus acidophilus on the ↑ levels of glycogen stored in the vag epithelium
- Helps protect against vag infections
- ↑ glycogen may ↑vag candidiasis
- Palpable softening at the isthmus
- early dx sign of preg
when does the uterus rise out of the pelvic cavity?
by 12 wks
uterine wt increases from 50-70 g to:
purpose of mucus plug:
to prevent fetus from infection
brownish-black pigmented line along the midline, may be visible
Rectus abd muscle may separate at the midline
Common concerns during 1st trimester preg
N, c/ or s/ V, breast tenderness, tingling, wt loss, fatigue
Common concerns during 2nd trimester preg
Groin/lower abd paino Abd striae (late 2nd or third)
Common concerns during 3rd trimester preg
Fatigue, contractions, loss of mucous plug, edema
Common concerns during all trimesters preg
- No menses (amenorrhea)
- Urinary freq
what appears on the cervix during preg?
- red velvety mucosa, (cervical erosion or eversion)
- considered nml
concerns to address during prenatal visits:
- symptoms of preg
- maternal attitudes of preg
- Current health: smoking, alcohol, use of illicit drugs, domestic violence
- past ob hx; Prior complications of preg
- past med hx
how do you Determine week of gestation by date
- Count in wks from menstrual age (MC) (LMP) or conception age
- Compare estimate c/ palpable size of uterus if still in pelvic cavity, or by ht of fundus if above symphysis pubis
how do you determine expected date of delivery?
- Naegele’s rule: add 7 days to LMP, subtract 3 mo, add 1 yr
- Do US to confirm it
- Accurate and improves descision making if delays in fetal growth, preterm labor, or preg beyond 42 wks
- If pt can’t remember LMP, has irregular menses, or dating is uncertain, vaginal probe US can confirm date in 1st trimester
goals of initial prenatal visit
- Confirming the preg
- Assessing health status of the mother & any risks for complications
- Counseling to ensure birth of a healthy baby
what diet should you recommend?
- 300 cal, 5-10 g of protein, 15 mg of iron, 250 mg of Ca, 400-800 micrograms of folic acid
- Prescribe a multivitamin c/ at least 400 micrograms of folic acid
- Caution against ingesting unpasteurized dairy products, undercooked meats, & excess vit A—can be toxic
- Seafood is controversial
ideal wt gain per BMI:
Low -- BMI <19.8
Normal – BMI 19.8-26.0
High – BMI 26.0-29.0
Obese – BMI >29.0
avg wt gain:
- Low: 28-40lbs
- normal: 25-35
- Obese: ~15
Avg: 28 lbs
ideal wt gain per trimester:
- Very little ↑1st trimester
- Rapid ↑ 2nd trimester
- Mild slowing of the ↑ 3rd trimester
when should preg women avoid supine positions? and why?
- after 1st trimester
- Can compress the IVC and abd aorta- ↓ blood flow for u and baby
what are immunizations safe to give during preg? what should preg women be up to date on?
- All preg XX should be up to date on tetanus & influenza vaccs
- Can be administered in any trimester
- Pneumococcal, meningococcal, & hepatitis B vacc’s are safe in preg
blood pressure is elevated >140/>90 BEFORE 20 weeks’ gestation
blood pressure becomes elevated >140/>90 AFTER 20 weeks’ gestation
what could you hear when listening to the heart? is this nml or abnml?
- venous hums
- common in preg
- bc of increased blood vol
- should go away after baby is born
when can Fetal movement be felt by examiner
at 24 wks
rule when measuring fundal height
- From 20 weeks to 32 weeks, the fundal height in centimeters should approximate the number of weeks of gestation
- Measure the fundal height from the superior portion of the pubis symphysis to the top of the fundus
How and when do you auscultate fetal HR?
what is normal fetal HR?
- Auscultate the fetal heart rate with the Doptone (from 10 weeks) or the fetoscope (from 18 weeks)
- The fetal heart rate will be in the 150s to 160s during the first weeks of pregnancy and in the 120s to 140s by term
what initial lab work should be done?
what should be done every consequent visit? what are you looking for?
- Initial lab work: CBC, blood typing, hepatitis panel, HIV testing, syphilis testing, UA and cx, PAP smear, chlamydia and gonorrhea cx
- Every consequent visit tests urine for glucose (looking for gestational diabetes), protein (looking for preeclampsia), and WBC (looking for infection)
what are the special techniques?
- First Maneuver (Upper Pole)
- Second Maneuver (sides of the abd)
- Third Maneuver (Lower pole)
- Fourth Maneuver
sequence of future office visits:
- one visit is needed during the first trimester for a full H&P with the lab work·
- During the 2nd trimester and in the 3rd trimester until 32wks, the patient is seen monthly.
- From 32-36 weeks, the patient is seen every two weeks.
- From 36wks- delivery, the patient is seen weekly.