Physiologic Change in Pregnancy

A. Cardio System

Heart Rate - increase 10 bpm (80-90)Elevation Blood/Plasma Volume - increases 4,000-5,250 mL; 2,600-3,600 mL- normal blood lossNSD: 300-400mLCS: 800-1000mLAnemia(pseudo anemia: false anemia)Hemoglobin: 11.5-14g/dL --- <11.5Hematocrit: 32-42% --- <30%RBC/WBC- RBC: 4.2-4.6 M- WBC: 20,000 cells (compensatory mechanism) The Fibrinogen- constituent of blood necessary for clotting- 50% increase (300-450mg/dL)- risk for blood clots

B. Respiratory System- the RR increases to about 18-20 bpm- nasal stuffiness (hormonal changes, avoid OTC medications; advice humidifiers)

C. Skeletal SystemLeg Cramps - alteration of calcium and phosphorous- dorsiflexionLeg Edema - management: elevationLordosis - wear low heeled shoes

D. GUTGreater Bladder Capacity - 1,500 mLUrinary Frequency- first and third trimester- kegels exerciseTraces of Glucose (urine)

E. GITGets Heart Burn (reflux)- elevation of head of bed - small frequent feedingsInactivity - constipation: increase oral fluid/increase fiber:0- decrease emptying of gallbladder: reabsorption of bilirubin -> subclinical jaundice -> generalized itchiness (regular bathing + lotion)The Morning Sickness- nausea and vomiting: 1st trimester (dry crackers)

F. Integumentary System1. Striae Gravidarum - stretch marks2. Linea Nigra 3. Palmar Erythema - redness and itchiness of palms4. Vascular Spiders - fiery veins or distended veins5. Diastasis - bluish groove as muscles of the abdomen are stretched 6. Melasma - brown pigmentation

G. Reproductive System7. Amenorrhea - suppression of your menstruation8. Breast Engorgement and Tenderness - breast tissue increases in size as milk is

formedSigns and Symptoms (must seen on both breasts)• Swelling• Hot Feeling• On Redness• Tenderness *if seen only on one breast: infection (mastitis)

Management:• Suck More• Apply Warm Packs• Continue Empty Breast• Keep Firm Fitting Bra - 2x larger during pregnancy

3. Cervical ChangesCoating of mucus: operculum (mucus coat)Color of cervix: pale pink - violet hueCervical softening: Goodelle's sign (6th week)4. Uterus Uterus is 1-2cm thick (early) --> 0.5cm thin (late)Tapping of lower uterine segment --> fetus bounces (Ballottement:20th week)Elevation --> Bartholomew's Rule (12-16-20-36)Regarding weight: 50g-1,000gUterine Contractions - Braxton Hicks

Felt on the abdomenA constant intensityLa effacement at dilatationStops when sedated/slows down when walkingErregular painless contraction

Softening of lower uterus: Hegar's sign (6th week)5. VaginaLeukorrhea - increase whitish vaginal dischargeBluish DiscolorationChadwick's Sign - bluish discoloration (6th week)

H. Endocrine System Changes1. Hormones

a. Estrogen - hormone of being a woman and female appearance• Nasal stuffiness

• Breast enlargement• Uterine Growth• Increase Vaginal Discharge• Vascular spider• Palmar erythema• Increase fibrinogen level

b. Progesterone• Slight increase of body temperature• Smooth muscle relaxation (prevents pre-term labor)• Maintains endometrial layerc. HCG - glycoprotein hormone produced initially by developing embryo later by placenta- role is to maintain corpus luteum of ovariesd. Prostaglandin- Initiates labor at TERM - smooth muscle contractione. Human Placental LactogenHelps Regulation (glucose, CHON, Fat) levelsPromotes mammary growthLaban sa insulin "antagonist" (insulin cannot, glucose can pass through placenta)To make glucose available for fetal development

2. Pituitary GlandAnterior: prolactive - production of milkPosterior: oxytocin - uterine contraction and milk/let down reflex

Psychological Changes

First Trimester• Acceptance of Pregnancy: ambivalence (interwoven feelings of wanting and not wanting

the baby)Second Trimester• Accepting the Baby (over protectiveness)Third Trimester• Preparing for Baby (nest building activities)

Emotional Responses9. Changes in sexual desire

1st TM: decrease sexual desire d/t N&V2nd TM: increase sexual desire d/t increase of blood to pelvic organs3rd TM: may be increase or decrease (discomforts/uncomfortable position, myths and fears)

2. Emotional Lability• Mood changes - extra sensitive d/t hormonal changes

Menstrual CycleHypothalamus• GnRH - secretion of FSH• LHrH - secretion of LHAnterior Pituitary Gland• FSH - maturation of ova (15-20 egg cells stimulated by ovaries)• LH - release of mature ova

Ovaries• Triggers LH - dominant Follicle to release Egg (Ovulation: occurs 14 days before onset

of next cycle)Uterus

Menstrual Phase(Day 1-5)Menstrual Flow: 30 to 80 mL (1/4 cup)Elevated Prostaglandin - contractility - dysmenorrheaNormal - 28 daysStart - 8 to 9 years old average 10 years(menarche) 50years(menopause)

Proliferative Phase(Day 6-14)FSH - ovary - increase estrogen - FSH decrease - LH - ovulationEstrogenic Phase

Secretory Phase(Day 15-21)LH - corpus luteum - increase progesterone - increases capillaries uterusInner lying will be corkscrew and twisted

Ischemic Phase(22-28)CL will regress - decrease estrogen and progesterone - rupture capillaries - sloughing off

Dysmenorrhea• Mild exercise• Analgesics (otc)• Iron • Warm compress

The Beginning of Lite:10.Fertilization11.Zygote - mitotic cell division - morula - blastocyst(structure that attaches to

endometrium) - form finger-like projections - chorionic villi sampling Risks if Chorionic Villi Sampling12.Bleeding 13. Infection14.Leaks of AF

Fetal Growth DevelopmentWeek 3: trachea and esophagus - single vessel TEFistulaWeek 4: trachea and esophagus begins to separate; spinal chordWeek 8: organogenesis/chromosomal analysis (sex)Fetal outline: ultrasoundWeek 10 - 12: fetal heart sounds - dopplerWeek 11: fetus movement - ultrasoundWeek 12: urine forms Week 16: fetal heart sound (stethoscope), lanugo/meconium, amniotic fluid (urine excreted) 800-1,200mL (<400 oligoH) (>2,000 polyH)Amniotic fluid - swallowed by fetus - esophagus block: e.atresia,

Sex- ultrasoundWeek 20: brown fat/vernix caseosa, quickeningWeek 24: surfactant (lungs)Week 28: alveoli, capillariesWeek 32: subq fat begins to form

Pre-Term• Pre 37 weeks• Premature lungs• Prone to infection• Poor muscle term• Prominent lanugo

Post-Term • Post 42 weeks• Parchment like skin• Produce long fingernails• Prominent scalp hair• Progressive placental insufficiency

Age of GestationNagele's Rule: EDC- 3 months + 7 days

Ex.LMP: March 13 - March 18Dec 20

Obstetric History

Gravida - # of pregnancyPara - # reached viability (alive or not)* twins as 1

T - > 37 weeksP - < 37 weeksA - miscarriagesL - iveM - ultiple (twins)

Pre-Natal VisitsStandardsq 4 weeks = 4-28 week gestationq 2 weeks = 28-36 weekWeekly = 36 to birth

Weight gain25-35 lbs1lb/month:1st trimester1lb/week: 2nd and3rd trimester

Signs and Symptoms

Presumptive Probable Positive

- subjective- amenorrhea- breast changes- nausea and vomiting- quickening

- objective- (+) by HCG laboratory test- abdominal changes- Hegar's sign- Goodel's- Ballotement- chadwick's sign- braxton hicks contraction

- fetal parts- ultrasound and xray- fetal heart rate

Laboratory Studies

Alpha Fetoprotein- a substance produced by the fetal liver that is present in amniotic fluid and maternal serum- done at 15 to 18 week gestation

MSAFP - elevated: neural tube defects - spina bifida; abdominal wall defects - decreased: chromosomal defect - down syndrome

Ultrasound• Age of gestation• Biophysical Profile

- Af volume- fetal movement- fetal breath- fetal tone- fetal reactivity

• Complications• Delivery Estimation• Establish position, sex of baby

15.Abdominal - full bladder- supine with pillow under right buttocks2. Transvaginal- empty bladder- dorsal lithotomy

Amniocentesis- aspiration of amniotic fluid- empty bladder- sonogram must be done first (determine location of fetus)

- color of amniotic fluid (green: meconium stain; yellow: increased bilirubin and Rh incompatibility - RHogam)- lung maturity: shake test (bubbles will appear - L:S ratio 2:1) done 35 weeks of gestation- chromosomal analysis: 14-16 weeks - complications

Amniotic Fluid Embolism - clot - pulmonary artery (DOB); CNS (alteration LOC)Bladder puncture - hematuriaCheck infections

Assessment of Fetal Well Being

• Fetal KicksFetal movements- increase: mother is eating/loud noise/increase activity of mother- decrease: intake of nicotine/placental insufficiencyCarefully sit/side lyingKick normally occurs twice every 10 mins. (10-12/hr)

Results:16.<10 -repeat17.<3 - notify doctor18.>12 - fetal distress

Non Stress Test- fetal heart rateIncreases: fetus moves (acceleration)Decreases: uterine contractions (deceleration)

Apply Fetal MonitorBy left side lyingCarefully press button (movements)

Reactive: normal result