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The Pregnant Woman

The Pregnant Woman. Chapter 29. Structure and Function. Pregnancy and the endocrine placenta First day of menses is day 1 of menstrual cycle For first 14 days of cycle, one or more follicles in ovary develops and matures

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The Pregnant Woman

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  1. The Pregnant Woman Chapter 29

  2. Structure and Function • Pregnancy and the endocrine placenta • First day of menses is day 1 of menstrual cycle • For first 14 days of cycle, one or more follicles in ovary develops and matures • One follicle grows faster than others, and on day 14 of cycle this dominant follicle ruptures and ovulation occurs • If ovum meets viable sperm, fertilization occurs somewhere in oviduct (fallopian tube) • Remaining cells in follicle form corpus luteum, or “yellow body,” which makes important hormones • Chief among these is progesterone, which prevents sloughing of endometrial wall, ensuring a rich vascular network into which fertilized ovum will implant

  3. Structure and Function(cont.) • Pregnancy and the endocrine placenta (cont.) • Blastocyst, or fertilized ovum, continues to divide, differentiate, and grow rapidly • Specialized cells in blastocyst produce human chorionic gonadotropin (hCG), which stimulates corpus luteum to continue making progesterone • Between days 20 and 24, blastocyst implants into wall of uterus, and may cause small amount of vaginal bleeding • Specialized layer of cells around blastocyst becomes placenta • Placenta starts to produce progesterone to support pregnancy at 7 weeks and takes over this function completely from corpus luteum at about 10 weeks

  4. Structure and Function(cont.) • Pregnancy and the endocrine placenta (cont.) • Placenta functions as an endocrine organ and produces several hormones • These hormones help growth and maintenance of fetus, and direct changes in woman’s body to prepare for birth and lactation • The hCG stimulates rise in progesterone during pregnancy • Progesterone maintains endometrium around fetus, increases alveoli in breast, and keeps uterus in a quiescent state

  5. Structure and Function(cont.) • Pregnancy and the endocrine placenta (cont.) • Estrogen stimulates duct formation in breast • Also increases weight of uterus and increases certain receptors in uterus that are important at birth • Average length of pregnancy is 280 days from first day of last menstrual period (LMP), which is equal to: • 40 weeks • 10 lunar months • 9 calendar months • Note that this includes 2 weeks when follicle was maturing but before conception actually occurred

  6. Structure and Function(cont.) • Pregnancy and the endocrine placenta (cont.) • Pregnancy is divided into three trimesters • First trimester is the first 12 weeks • Second trimester is from 13 to 27 weeks • Third trimester is from 28 weeks to delivery • Woman pregnant for first time called primigravida • After she delivers, she is called a primipara • Multigravida: pregnant woman who has previously carried a fetus to the point of viability • Any pregnant woman might be called a gravida

  7. Structure and Function(cont.) • Pregnancy and the endocrine placenta (cont.) • Commonly used terminology is • G, gravida • P, para • T, term • PT, preterm deliveries • A, abortion—including missed, therapeutic, or voluntary • L, living children • It may be written as • G5 T3 PT0 A2 L3

  8. Structure and Function(cont.) • Changes during normal pregnancy • Pregnancy is diagnosed by three types of signs and symptoms • Presumptive signs are those woman experiences, such as amenorrhea, breast tenderness, nausea, fatigue, and increased urinary frequency • Probable signs are those detected by examiner, such as an enlarged uterus • Positive signs of pregnancy are those that are direct evidence of fetus, such as auscultation of fetal heart tones (FHTs) or positive cardiac activity on ultrasound (US)

  9. Structure and Function(cont.) • Changes during normal pregnancy: first trimester • Conception occurs on approximately 14th day of menstrual cycle • Blastocyst, which is the developing fertilized ovum, implants in uterus 6 to 10 days after conception, sometimes accompanied by small amount of painless bleeding • Serum hCG becomes positive after implantation when it is first detectable in maternal serum at approximately 8 to 11 days after conception • Following menstrual period is missed

  10. Structure and Function(cont.) • Changes during normal pregnancy: first trimester (cont.) • At time of missed menses, hCG can be detected in urine • Breast tingling and tenderness begin as rising estrogen levels promote mammary growth and development of ductal system; progesterone stimulates alveolar system as well as the mammary growth • Chorionic somatomammotropin (also called human placental lactogen or hPL), which is also produced by placenta, stimulates breast growth and exerts lactogenic properties

  11. Structure and Function(cont.) • Changes during normal pregnancy: first trimester (cont.) • More than half of all pregnant women have nausea and vomiting • Cause is unclear but may involve hormonal changes of pregnancy, low blood sugar, gastric overloading, slowed peristalsis, an enlarging uterus, and emotional factors • Fatigue is common and may be related to initial fall in metabolic rate that occurs in early pregnancy • Estrogen, and possibly progesterone, cause hypertrophy of uterine muscle cells and uterine blood vessels, and lymphatics enlarge

  12. Structure and Function(cont.) • Changes during normal pregnancy: first trimester (cont.) • Uterus becomes globular in shape, softens, and flexes easily over cervix (Hegar’s sign) • This causes compression of bladder, which results in urinary frequency • Increased vascularity, congestion, and edema cause cervix to soften (Goodell’s sign) and become bluish purple (Chadwick’s sign) • Early first-trimester blood pressures (BPs) reflect prepregnancy values

  13. Structure and Function(cont.) • Changes during normal pregnancy: first trimester (cont.) • In 7th gestational week • BP begins to drop until midpregnancy as a result of falling peripheral vascular resistance • Systemic vascular resistance decreases from vasodilatory effect of progesterone and prostaglandins • At end of 9 weeks, embryonic period ends and fetal period begins, at which time major structures are present • FHTs can be heard by Doppler US between 9 and 12 weeks • Uterus may be palpated at about 12 weeks

  14. Height of Fundus at Weeks of Gestation

  15. Structure and Function(cont.) • Changes during normal pregnancy: second trimester • By weeks 12 to 16 • Nausea, vomiting, fatigue, and urinary frequency of first trimester improve • 18 to 20 weeks woman recognizes fetal movement (“quickening”) • As breast enlargement continues, the veins of breast enlarge and are more visible through skin of lightly pigmented women • Colostrum, precursor of milk, may be expressed from nipples

  16. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • Colostrum • Yellow in color, contains more minerals and protein but less sugar and fat than mature milk • Also contains antibodies, which are protective for newborn during its first days of life until mature milk production begins • Areola and nipples darken, it is thought, because estrogen and progesterone have a melanocyte-stimulating effect, and melanocyte-stimulating hormone levels escalate from second month of pregnancy until delivery

  17. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • For same reason, midline of abdominal skin becomes pigmented, called lineanigra • You may note striaegravidarum (“stretch marks”) on breast, abdomen, and areas of weight gain • Systolic BP may be 2 to 8 mm Hg lower and diastolic BP 5 to 15 mm Hg lower than prepregnancy levels • Drop most pronounced at 20 weeks and may cause symptoms of dizziness and faintness, particularly after rising quickly

  18. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • Stomach displacement from enlarging uterus and altered esophageal sphincter and gastric tone as a result of progesterone predispose woman to heartburn • Intestines are also displaced by growing uterus, and tone and motility are decreased because of action of progesterone, often causing constipation • Gallbladder, possibly resulting from action of progesterone on its smooth muscle, empties sluggishly and may become distended

  19. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • Stasis of bile, together with increased cholesterol saturation of pregnancy, predisposes some women to gallstone formation • Progesterone and, to lesser degree, estrogen cause increased respiratory effort during pregnancy by increasing tidal volume • Hemoglobin, and therefore oxygen-carrying capacity, also increases • Increased tidal volume causes slight drop in partial pressure of arterial carbon dioxide (PaCO2), causing woman to occasionally have dyspnea

  20. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • Cutaneous blood flow augmented during pregnancy caused by decreased vascular resistance, presumably helping to dissipate heat generated by increased metabolism • Gums may hypertrophy and bleed easily; condition is called gingivitis or epulis of pregnancy • For same reason, nosebleeds may occur more frequently • Pregnant women with periodontal disease, a chronic local oral infection, are at risk for preterm delivery • Untreated, this may lead to systemic infection that affects maternal levels of prostaglandin E2 (PGE-2)

  21. Structure and Function(cont.) • Changes during normal pregnancy: second trimester (cont.) • 17 to 19 weeks • FHTs are audible by fetoscope, as opposed to Doppler imaging • Fetal outline palpable through abdominal wall at approximately 20 weeks

  22. Structure and Function(cont.) • Changes during normal pregnancy: third trimester • Blood volume, which increased rapidly during second trimester, peaks in middle of third trimester at approximately 45% greater than prepregnancy level and plateaus thereafter • This volume is greater in multiple gestations • Erythrocyte mass increases by 20% to 30%, caused by an increase in erythropoiesis, mediated by progesterone, estrogen, and placental chorionic somatomammotropin • However, plasma volume increases slightly more, causing slight hemodilution and small drop in hematocrit

  23. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • BP slowly rises again to approximately prepregnant level • Uterine enlargement causes diaphragm to rise and shape of rib cage to widen at base • Decreased space for lung expansion may cause a sense of shortness of breath • Rising diaphragm displaces heart up and to left • Cardiac output, stroke volume, and force of contraction are increased • Pulse rate rises 15 to 20 beats per minute

  24. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • Because of increase in blood volume, a functional systolic murmur, grade ii/iv or less, can be heard in more than 95% of pregnant women (Creasy and Resnick, 2004) • Edema of lower extremities may occur as result of enlarging fetus impeding venous return, and from lower colloid osmotic pressure; worsens with dependency, such as prolonged standing • Varicosities, which have a familial tendency, may form or enlarge from progesterone-induced vascular relaxation

  25. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • Also causing varicosities is engorgement caused by weight of full uterus compressing inferior vena cava and vessels of pelvic area, resulting in venous congestion in legs, vulva, and rectum • Hemorrhoids are varicosities of rectum that are worsened by constipation, which occurs from relaxation of large bowel by progesterone • Progressive lordosis, an inward curvature of lumbar spine, occurs to compensate for shifting center of balance caused by anteriorly enlarging uterus, predisposing woman to backaches

  26. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • Slumping of shoulders and anterior flexion of neck from increasing weight of breasts may cause aching and numbness of arms and hands as a result of compression of median and ulnar nerves in arm, commonly referred to as carpal tunnel syndrome • Approximately 2 weeks before going into labor, primigravida experiences engagement, also called “lightening” or “dropping,” when fetal head moves down into pelvis

  27. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • Symptoms include lower-appearing and smaller-measuring fundus, urinary frequency, increased vaginal secretions from increased pelvic congestion, and increased lung capacity • In multigravida, fetus may move down at any time in late pregnancy or often not until labor • Cervix, in preparation for labor, begins to thin (efface) and open (dilate) • Thick mucous plug, formed in cervix as a mechanical barrier during pregnancy, is expelled at variable times before or during labor

  28. Structure and Function(cont.) • Changes during normal pregnancy: third trimester (cont.) • Between 37 and 42 weeks • Pregnancy is considered term • After 42 weeks, pregnancy is considered postdated

  29. Structure and Function(cont.) • Determining weeks of gestation • Expected date of delivery, or EDD • 280 days from first day of LMP, may be calculated by using Nägele’s rule • Determine first day of last normal menstrual period • Using first day of LMP, add 7 days and subtract 3 months • This is the EDD that can then be used with a pregnancy wheel, on which EDD arrow is set, and then present date will be pointing to present week’s gestation

  30. Structure and Function(cont.) • Determining weeks of gestation(cont.) • Expected date of delivery, or EDD (cont.) • Number of weeks of gestation also can be estimated by • Physical examination (bimanual and pelvic exam) • Measurement of maternal serum hCG • Ultrasound • Signs such as first perceived fetal movement

  31. Structure and Function(cont.) • Weight gain in pregnancy • Amount of weight gained by term • Represents a baby, amniotic fluid, placenta, increased uterine size, increased blood volume, increased extravascular fluid, maternal fat stores, and increased breast size • Weight gain during pregnancy reflects both mother and fetus and is approximately 62% water gain, 30% fat gain, and 8% protein • Approximately 25% of the total gain is attributed to the fetus, 11% to placenta and amniotic fluid, and remainder to mother

  32. Structure and Function(cont.) • Weight gain in pregnancy (cont.) • The American College of Obstetricians and Gynecologists recommends following weight gain during pregnancy • 28 to 40 lb for underweight women • 25 to 35 lb for normal-weight women • 15 to 25 lb for overweight women • 35 to 45 lb for twin gestation • A healthy outcome may be expected within a great range of weight gain

  33. Structure and FunctionDevelopmental Competence • Each year in U.S., almost one million teenage women become pregnant • 78% are unplanned • Many pose serious medical risks for both mother and fetus, such as toxemia, anemia, prematurity, low birth weight infants, prolonged labor, and postpartum complications • Some teen pregnancies are planned and due in part to maladaptive attempts to solve social issues within home environment or manipulation of a boyfriend with promise of a prolonged relationship

  34. Structure and FunctionDevelopmental Competence(cont.) • Each year in the U.S., almost one million teenage women become pregnant (cont.) • Either attempt can bring bitterness from family and friends leading to cycle of poor reproductive and social choices • It is important for those teens wishing to continue a pregnancy to seek early prenatal care because they are at risk for maternal/fetal morbidity and mortality

  35. Structure and FunctionDevelopmental Competence(cont.) • Other risks for pregnant adolescents are largely psychosocial • This young woman is at risk for downward cycle of poverty beginning with an incomplete education, failure to limit family size, and continuing with failure to establish a vocation and become independent • She may be unprepared emotionally to be a mother • Her social situation may be stressful • She may not have the support of her family, her partner, or his family

  36. Structure and FunctionDevelopmental Competence(cont.) • Other risks for pregnant adolescent are largely psychosocial (cont.) • Medical risks for pregnant adolescent are generally related to poverty, inadequate nutrition, substance abuse, and sometimes sexually transmitted infections (STIs), poor health before pregnancy, and emotional and physical abuse from her partner • Adolescents, for social reasons, seek health care later when early prenatal care provides optimal management • In developing countries, maternal mortality for pregnant teenagers is major concern because of hypertension, embolism, ectopic pregnancy, and complications from pregnancy termination where abortion is illegal

  37. Structure and FunctionDevelopmental Competence(cont.) • Fertility • Declines with advancing maternal age • Due in part to a decrease in number and health of eggs to be ovulated, a decrease in ovulation, endometriosis, and early onset of menopause • According to the American Society for Reproductive Medicine there is an unrealistic expectation that medical science can undo effects of aging when women delay childbearing; therefore, more women of advanced maternal age are choosing to use donor eggs from younger women • The age of egg is important factor, not age of uterus

  38. Structure and FunctionDevelopmental Competence(cont.) • As we come to end of baby boomers’ fertility, many women of advanced maternal age (40s and 50s) are choosing to become pregnant with assisted fertility • With this comes concern not only for physical and emotional well-being of mother, but of psycho-logical challenges that child growing up with parents of advanced age will face • Women age 35 and older experience an increased risk of intrauterine fetal death, pregnancy induced hypertension, gestational diabetes, and delivery by cesarean

  39. Structure and FunctionDevelopmental Competence(cont.) • Risk of Down syndrome increases with maternal age • 1 in 1,250 at age 25 • 1 in 1,000 at age 30 • 1 in 400 at age 35 • 1 in 100 at age 40 • 1 in 30 at age 45

  40. Structure and FunctionDevelopmental Competence(cont.) • Women age 35 years or older or who have a history of a genetic abnormality are offered genetic counseling, and the options of both prenatal diagnostic screening tests • Two prenatal diagnostic options are: • Chorionic villi sampling (CVS) performed between gestational weeks 11 and 13 in which small sample of chorionic villi is removed to analyze genetic makeup • Amniocentesis, which is performed between gestational weeks 15 and 20 in which a small amount of amniotic fluid is removed to analyze genetic makeup • Both associated with small risk of complications and miscarriage

  41. Structure and FunctionDevelopmental Competence(cont.) • Prenatal screening involves a fetal anatomy ultrasound (US) scan and serum screening • There are two US scans used in genetic screening • Nuchal translucency (NT) done between gestational weeks 11 and 14, which measures a collection of fluid at nape of fetal neck • Detailed anatomy scan done between gestational weeks 18 and 20 • Some facilities continue to use Integrated Prenatal Risk Profile (IPRP), which uses a first trimester US between 10 and 12 weeks to measure NT and maternal serum analysis and a second maternal serum blood draw in the second trimester; results are only received after second maternal blood draw

  42. Structure and FunctionDevelopmental Competence(cont.) • There are two US scans used in genetic screening (cont.) • Because integrated screen requires a waiting period, the sequential screen was developed • Similar to IPRP, except that those whose risk for Down syndrome is increased after first blood draw are given an earlier option for prenatal diagnostic testing • Women of advanced maternal age (over 35 years old) experience increased risk of prenatal and neonatal deaths, pregnancy-induced hypertension, preterm delivery, small for gestational age (SGA), and large for gestational age (LGA) neonates, gestational diabetes, severe preeclampsia, anal sphincter tears, and cesarean deliveries

  43. Structure and FunctionCultural Competence • Over 30 million women worldwide have undergone female genital cutting, or female circumcision • Due to large racial demographic in U.S., more with this condition are seen in current clinical setting • These women are at an increased risk of perineal tears, wound infections, separation of episiotomies, postpartum hemorrhage and sepsis • Every minute, another woman dies in pregnancy or childbirth leaving children without a mother and families shattered struggling to care for those left behind

  44. Structure and FunctionCultural Competence(cont.) • Over 500,000 women die in childbirth each year • According to United Nations Populations Fund, this number remains globally high in an age where these deaths are preventable • 90% of these maternal deaths occur in Africa and Asia, and they occur from severe bleeding, sepsis, eclampsia, obstructed labor, and unsafe abortions • Many women who survive pregnancy and childbirth may suffer lifetime of physical and emotional complications such as vaginal or rectal fistula

  45. Structure and FunctionCultural Competence(cont.) • Hispanic population within U.S. between 1990 and 2000 grew by more than 40% • It is projected that between 2000 and 2010 that will increase by another 34% • Hispanics had highest birth rate in 2003 with 82.2 births per 1,000 teen females aged 15 to 19 • Still there are disparities in adequate access to preventative, prenatal, and dental care with these cultural groups along with Asian/Pacific islander, American Indian, and Alaskan Native populations

  46. Structure and FunctionCultural Competence(cont.) • Pregnancy is not only a medical event, but also one with profound psychological and social meaning for woman and for her family and community • All cultures recognize pregnancy as a unique period in a woman’s life that surrounds special customs and beliefs that have been developed throughout the ages • Spiritual practices and beliefs either provide her with or without support • Understanding what role these beliefs and practices play in woman’s pregnancy helps health care provider to acknowledge cultural differences

  47. Structure and FunctionCultural Competence(cont.) • Pregnancy is intensely personal and involves such charged issues as sexuality, relationships, contraception, nutritional practices, maternal weight gain, and abortion • You must be sensitive to these issues • You may begin by inquiring whether woman or her significant others have any special requests • This communicates your intention to respect cultural differences and preferences • Continuing rapport will help enable woman to bring up issues as they develop • A woman’s resistance to an action or a suggestion by clinician may represent a cultural issue

  48. Structure and FunctionCultural Competence(cont.) • Such issues may also be held differently by woman and one or more of her significant others, and such situations must be handled with care • Examples of culturally-charged issues are: • Dietary practices • Sexuality during and after pregnancy • Preference for gender of care provider • Preference for gender of infant • Contraceptive usage • Use your skill to understand such preferences within a cultural context and accept rather than judge the person • Whenever safe and possible, respect such wishes; this enhances success of birth in psychosocial dimensions

  49. Subjective Data • Menstrual history • Gynecologic history • Obstetric history • Current pregnancy • Medical history • Family history • Review of systems • Nutritional history • Environment/hazard

  50. Subjective Data(cont.) • Menstrual history • When was the first day of your last menstrual period that was normal in timing? Describe premenstrual symptoms, length, amount of flow, cramping. • Number of days in cycle? • Age at menarche? • Gynecologic history • Have you ever had surgery of the cervix or uterus? • Do you have any known history of or exposure to genital herpes?

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