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what drives many preg-related endocrine &metabolic changes
Increasing levels of estradiol & progesterone & the placental hormones- esp humanchorionic gonadotropin (HCG)
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Stimulate lactotrophs in the anterior lobe of the pituitary gland
Estradiol
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Stores oxytocin and antidiuretic hormone (ADH)
HCG resets receptors for thirst & ADH release- leading to ↓ in serum Na [] and sometimes polyuria
Posterior pituitary gland
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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)
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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
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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
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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
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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 ↓
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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)
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when do breast become nodular?
by 3rd mo gestation
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Chadwick’s sign
↑vascularity, vagina a bluish/ violet color
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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
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Hegar’s sign
- Palpable softening at the isthmus
- early dx sign of preg
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when does the uterus rise out of the pelvic cavity?
by 12 wks
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uterine wt increases from 50-70 g to:
800-1200 g
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purpose of mucus plug:
to prevent fetus from infection
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brownish-black pigmented line along the midline, may be visible
linea nigra
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Rectus abd muscle may separate at the midline
diastasis recti
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Common concerns during 1st trimester preg
N, c/ or s/ V, breast tenderness, tingling, wt loss, fatigue
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Common concerns during 2nd trimester preg
Groin/lower abd paino Abd striae (late 2nd or third)
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Common concerns during 3rd trimester preg
Fatigue, contractions, loss of mucous plug, edema
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Common concerns during all trimesters preg
- No menses (amenorrhea)
- Heartburn
- constipation
- Backache
- Urinary freq
- Leucorrhea
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what appears on the cervix during preg?
- red velvety mucosa, (cervical erosion or eversion)
- considered nml
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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
- FH
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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
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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
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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
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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
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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
- high:15-25
- Obese: ~15
Avg: 28 lbs
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ideal wt gain per trimester:
- Very little ↑1st trimester
- Rapid ↑ 2nd trimester
- Mild slowing of the ↑ 3rd trimester
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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
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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
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Chronic hypertension
blood pressure is elevated >140/>90 BEFORE 20 weeks’ gestation
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Gestational hypertension
blood pressure becomes elevated >140/>90 AFTER 20 weeks’ gestation
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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
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when can Fetal movement be felt by examiner
at 24 wks
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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
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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
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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)
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what are the special techniques?
- First Maneuver (Upper Pole)
- Second Maneuver (sides of the abd)
- Third Maneuver (Lower pole)
- Fourth Maneuver
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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.
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