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Ivano-Frankivsk National Medical University Obstetrics and Gynecological Department

Physiology of pregnancy. Prenatal care. Physical examination of pregnant.

Obstetrics (from the Latin obstare, "to stand


by") is the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (the period shortly after birth).

Pregnancy is the state of heaving products of


conception implanted normally or abnormally in the uterus or occasionally elsewhere. Pregnancy is terminated by spontaneous or elective abortion or delivery.

TERMS AND DEFINITIONS


Pregnancy is divided into trimesters: first trimester - up to 14 weeks of gestation second trimester - 14 to 28 weeks of gestation third trimester - 28 weeks to delivery viability - minimum age for fetus survival, ca. third trimester previable infant - delivered prior to 22 weeks preterm infant - delivered between 22-37 weeks term infant - delivered between 37- 42 weeks

embryo - conceptus between time of fertilization to 10 weeks of gestation fetus - from 10 weeks of gestation to time of birth infant - time of birth to 1 year of age A pregnancy carried beyond 42 weeks is considered postterm

PHYSIOLOGY OF PREGNANCY
During pregnancy, many physiological changes occur in a pregnant woman, which are entirely normal, including cardiovascular, hematologic, metabolic, renal and respiratory changes that become very important in the event of complications.

Musculoskeleton and dermatology:


lower back pain due to a shift in gravity. increased estrogen can cause spider angiomata and palmar erythema - from increased skin vascularity. increase melanocyte-stimulating hormone (MSH) can cause hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), perineum and face. edema, or swelling, of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs.

Cardiovascular:
plasma and blood volume slowly increase by 40-50% over the course of the pregnancy. heart rate - 15 beats/min more than usual. cardiac output increases by 30% to 50%, mostly during the first trimester, with the maximum being reached between 20 to 24 weeks' gestation and maintained until delivery. systemic vascular resistance decreases due to the smooth muscle relaxation caused by elevated progesterone, leading to a fall in blood pressure. diastolic blood pressure consequently decreases between 12-26 weeks, and increases again to prepregnancy levels by 36 weeks. If the blood pressure remains abnormal beyond 36 weeks, the woman should be investigated for preeclampsia, a condition that precedes eclampsia

Hematology:
the plasma volume increases by 40-50% and the red blood cell volume increases only by 2030%, which leads to a decrease the hematocrit. white blood cell count increases and may peak at over 20 mil/mL in stressful conditions. decrease in platelet concentration to a minimal normal values of 100-150 mil/mL. the pregnant woman also becomes hypercoagulable due to increased liver production of coagulation factors, mainly fibrinogen and factors VII-X. However, the actual clotting and bleeding times do not change.

Metabolism and Nutrition:


During pregnancy, both protein and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and hemoglobin. increased caloric requirement by 300 kcal/day. most patients should gain between 10 and 15 kg during pregnancy. increased protein requirement from 60 g/day to 70 or 75 g/day. increased folate requirement from 0.4 to 0.8 mg/day (important in preventing neural tube defects). All patients are advised to take prenatal vitamins to compensate for the increased nutritional requirements. Any patient whose hematocrit and hemoglobin fall during pregnancy is advised to increase iron intake with oral supplementation.

Gastrointestinal:
nausea and vomiting (morming sickness") may be due to elevated estrogen, progesterone and hCG, which should resolve by 14 to 16 weeks, and may also be due to hypoglycemia. prolonged gastric empty time. decreased gastroesophageal sphincter tone, which both can lead to acid reflux and possibly combine with decreased esophageal one to cause ptyalism, or spitting, during pregnancy. decreased colonic motility, which leads to increased water absorption and constipation.

Renal:
increase the kidneys in size and dilate the ureters, which may lead to increased rates of pyelonephritis. increased glomerular filtration rate (GFR) by 50%. decreased blood urea nitrogen and creatinine, and glucosuria (due to saturated tubular reabsorption). persistent glucosuria can suggest gestational diabetes. increased renin-angiotensin system, causing increased aldosterone levels which results in increased sodium resorption.

Pulmonary:
increased tidal volume (30-40%). decreased total lung capacity by 5% due to elevation of diaphragm from uteral compression. decreased exiratory reserve volume about 20%. increased minute ventilation (30-40%) which causes a decrease in PaCO2 and a compensated respiratory alkalosis. All of these changes can contribute to the dyspnea (shortness of breath) that a pregnant woman may experience.

Endocrine:
increased estrogen, which is mainly produced in the placenta. Low estrogen levels is associated with fetal death and anencephaly. the placenta produced human chorionic gonadotropin (hCG), which acts to maintain progesterone production by the corpus luteum. Levels of hCG double approximately every 48 hours during early pregnancy, reaching a peak at approximately 10 to 12 weeks. human placental lactogen (hPL) is produced by the placenta and ensures nutrient supply to the fetus. hPL, also known as human chorionic somatomammotropin, causes lipolysis with a concominant increase in circulation free fatty acids. It is also acts as an insulin antagonist, which has a diabetogenic effect. This leads to increased levels of insulin and protein synthesis.

increased

progesterone production, first by corpus luteum and later by the placenta. It couses relaxation of smooth muscle, which has multiple effects on the gastrointestinal, cardiovascular, and genitourinary systems. high estrogen levels cause an increase in thyroid bilding globulin (TBG). Placental hormones such as hCG may also have thyroidstimulating properties that lead to an elevation in total T3 and T4 and a suppression of thyroidstimulating hormone (TSH). Together, these changes lead to a euthyroid state. levels of prolactin are markedly increased during pregnancy, and after delivery in response

PRENATAL CARE
Prenatal care is important in screening for various complications of pregnancy and to educate the patient. They include a series of outpatient office visits that involve routine physical examinations and various screening tests. Important issues of prenatal care include initial patient evaluation, routine patient evaluation, nutrition, disease states during the pregnancy, and preparing for the delivery.

INITIAL VISIT is often the longest of the prenatal visits because it involves obtaining a complete history and performing laboratory tests. It should occur early in the first trimester, between 6 and 12 weeks.

Initial visit or the first prenatal visit includes: 1. Confirm pregnancy. 2. Take history. 3. Perform physical examination. 4. Order laboratory tests. 5. Ultrasound examination - in 9-11 weeks of pregnancy. 6. Consultation by therapeutist, dentist, ophthalmologist, dermatologist, and otorinolaryngologist. 7. Organizing the specific high-risk patients groups. Risk factors should be identify during the initial visit, and should be discuss with the patient. 8. Organizing patient education about pregnancy. 9. Determine pregnancy plan.

DIAGNOSIS OF PREGNANCY

There are three groups of signs of pregnancy: presumptive, probable and positive. Presumptive signs of pregnancy are: slight fatigue vomiting nausea appetite changes disturbances of taste and sense of smell sleepiness hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), perineum and face, palmar erythema, spider angiomata

Probable signs of pregnancy are: uterus asymmetry secretion of colostrum or milk enlargement of the breasts positive immunological reactions - elevated hCG amenorrea Snegirov's sign - by bimanual examination the uterus contracts and becomes more firm. Hubarevs and Haus - by bimanual examination a doctor determines fundus and eagles of uterus have wrong form. The eagle with implantation of the egg has more sizes than another one. The uterus has asymmetric form.

Horvits-Hegars - by bimanual examination a doctor determines softening of isthmus of uterus, fingers of external and internal hand can meet easy. Cervix is recognizes as firm organ than uterus. Heanters - by bimanual examination in early pregnancy a doctor determines comb-shap form on the anterior wall of uterus in media line which doesnt spread on fundus or posterior wall of uterus or cervix. Positive signs of pregnancy are: palpation of fetal parts auscultation of fetal heart beating perception of active fetal movements by the examiner.

The Patients History includes:


I. COMPLAINTS. II. THE MEDICAL HYSTORY is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, illnesses, operations. It includes several subsets. * Life history (anamnesis vitae) It includes child's behavior (such as timing of talking, walking, etc) as it compares to other children of the same age and child's diseases and during the life, medical allergies. The surgical history is a chronicle of operations. * Family history It lists the health status of immediate family members as well as their causes of death (if known), hereditary diseases.

* Social history The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. There are many professional factors, that have negative effect on womans health. Various habits which impact health, such as tobacco use, alcohol intake, drugs use, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits.

* Obstetric history menstrual history reflects the patients age at first menstruation (menarche), the menstrual cycle (the duration of menstruation, the interval from the first day of one menstrual period to the first day of the next menstrual period, the estimated amount of bleeding, and pain present. The last menstrual period. sexual history reflects the first sexual contact, patients contraceptive history. generative history lists prior pregnancies including date, outcome (spontaneous and therapeutic abortion, ectopic pregnancy, term delivery) mode of delivery, length of time in labor and second stage, birth weight, and any complications. secretory history reflects amount, smell, appearance of vaginan secrets.

The obstetric history also includes any complications and symptoms during the present pregnancy.

DATING OF PREGNANCY The gestational age (GA) of a fetus is the time in weeks and days from last menstrual period (LMP) up to present. Developmental age or conceptional age is the number of weeks and days since fertilization. The Naegeles rule is used to calculate the Expected Date of Delivery (EDD) or Estimated Date of Delivery (EDD). It is:
To subtract 3 month from the LMP and add 7 days.

Traditionally a human pregnancy is considered to last approximately 40 weeks (280 days) from the LMP, or 38 weeks (266 days) from the date of fertilization. Ultrasound is often used to determine the EDD. The dating done with crown-rump length in the 9-11 weeks of gestation is probably even more accurate, to within 3 to 5 days. Other measures used to estimated gestational age include auscultation of the fetal heart at 10 weeks by Doppler ultrasound, and maternal awareness of fetal movement or quickening, which occurs between 16 and 20 weeks.

III. GENERAL ORGAN SYSTEM EXAMINATION


General state. Basic biometrics: height, weight. Temperature. Skin: check of the hair to see how the hair is growth (male, female type), check of the skin will tell if there are marks or changes to the skin. Cardiovascular system: blood pressure, pulse rate and rhythm, peripheral edema, cardiac exam. Abdomenal examination: notes in particular any tenderness, bloating, organ enlargement. Renal. Musculorskeletal system. Nervous system, including mental status. Breast examination.

IV. EXTERNAL OBSTETRICS EXAMINATION


1. Fundal height is a measure of the size of the uterus used to assess fetal growth and development. It is measured from the top of the pubic bone to the fundus (in cm). 2. The circumference of abdomen (in cm). Both are properly recorded by doctor on every prenatal visit. 3. Leopold's Maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. The maneuvers consist of four actions, which help to determine the lie, position, variety, and presentation of the fetus, and can indicate whether the delivery is going to be complicated, or whether a Cesarean section is necessary. It is important to note that all findings are not truly diagnostic, and actual position can only be determined by ultrasound.

While performing the maneuvers the woman should lay on her back and her knees are bend a little.

First maneuver
While facing the woman, palpate the woman's fundus with both hands. A professional can determine the size, consistency, shape, and mobility of the fetal part which is present in the fundus. The fetal head is hard, firm, round, and moves independently of the trunk while the buttocks feels softer, is symmetric, unlike the head, it moves with the trunk. A professional can also determine the measurement of the uterine fundal height (on the levels: on the level of nawel (umbilicus), ribs, xiphoid process).

Second maneuver
Still facing the woman, the health care provider attempts to determine the location of the fetal back. He palpates the abdomen using the palms of the hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back is felt firm and smooth while fetal extremities (arms, legs) are felt like small irregularities and protrusions. So, a professional can determine the lie of the fetus, position, and variety of fetus.

Third maneuver
The professional attempts to determine what fetal part is lying above the inlet, or lower abdomen. The examinator puts the thumb and fingers of the right hand above the symphysis pubis. A professional can determine the presenting part of the fetus and its level above pelvic inlet.

Fourth maneuver
The examinator turns the face to the woman's feet. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. A professional can determine the relationship between the leading fetal part and the pelvic inlet. (The head/buttocks may be above the pelvic inlet, or fixed to the pelvic inlet, or in the midpelvis).

Fetal relationship: The lie is the relationship between the longitudinal


axis of fetus and mother: longitudinal, oblique, and transverse. Presentation is the relationship between the leading fetal part and the pelvic inlet: cephalic (occiput), or breech. The presenting part may be the fetal heard or the breech. Position is the relationship between definite back of the fetus to the right or left side of maternal pelvis. With each presentation there may be two position: left (I) or right (II).

Variety is the relation of the back of fetus to the anterior and or posterior side of the mother's pelvis (posterior or anterior). Engagement - the fetal is engaged if the widest leading part (typically the widest circumference of the head) is negotiating the inlet.

Station - relationship of the leading bony part of


the fetus to the maternal ischial spines. If at the level of the spines it is at 0 station, if it passed it by 2 cm it is at +2 station.

Attitude - relationship of fetal head to spine:


flexed, neutral, or extended attitudes are possible.
After the all Leopold's Maneuvers the conclusion must be formulated.

4. Auscultation - determination of fetal heart rate can be done by auscultation with a stethoscope. The normal range for the fetal heart rate is between 110 and 170 beats per minute. Hearing the heartbeat under the mother's umbilicus suggests a cephalic presentation, above the mother's umbilicus - a breech presentation. In labor also electronic fetal monitoring (exernal tocometer) is using.

V. GYNECOLOGIC EXAMINATION: Pelvic exam begins with the inspection of external genital organs. Attention should be paid to pubic hair type (masculinizing, feminizing), presence or absence of hair on the internal thigh surfaces. Any pigmentations, discoloration, edema, ulcers condilomatous nodes and varicose veins should be exam. For vaginal speculum exam single-blade Sims speculum with vaginal retractor or bivalve Cuskoes speculum are used. Bivalve speculum is introduced into the vagina with close values, turned on 90 and than is opened. Uterine cervix and vaginal walls must be inspected. The vagina should be inspected for lesions, discharge. The cervix, masses, vesicles, or other lesions should be described.

Bimanual exam: initially, the index and middle fingers of one gloved hand should be inserted into the patient`s vagina underneath the cervix, while the clinician`s other hand is placed on the abdomen at the uterine fundus. With the uterus trapped between the two hands, the examiner should identify whether there is cervical motion tenderness and evaluate the size, shape, and directional axis of the uterus. The adnexa should then be assessed with the vaginal hand in the vaginal fornices. Then the posterior fornices and the lateral pelvic is examinated.

VI. ADDITIONAL METHODS OF EXAMINATION Bacterioscopy exam (CVU smear) gives possibility to determine bacterial flora, epithelium cells, leucocyte number, and reaction of vaginal discharge. The Papanikolaou test (also called Pap smear) is a medical screening method to detect premalignant and malignant processes in the ectocervix. The following changes of vagina are physiological during pregnancy: increase of blood circulation, loosening of vagina walls, hypertrophy and hyperplasia of muscular layer, alkaline reaction of vagina.

The panel of lab tests in the first trimester includes:


complete blood count (CBC) coagulation studies, hematocrit biochemical exam (liver function, liver enzymes, uric acid, electrolytes, serum albumin, urea, creatinine) blood type and Rh-factor (Rh D negative antenatal patients should receive anti-D immunoglogbulin (Rh IgG) at 28 weeks to prevent Rh disease) Rapid plasma reagent (RPR) which screens for syphilis (Wasserman's Reaction) Rubella antibody screen

CVU smear and Pap smear urinalysis and culture HIV (human immunodeficiency virus) screen Group B Streptococcus screen Ultrasound (10-12 weeks) Double screen (PAAP, h-CG) - elevation correlated with neural tube defects and decrease correlated with Down's syndrome

On each ROUTINE PRENATAL CARE VISIT blood pressure, weight, measurement of the uterus, and auscultation of the fetal heart are performed and assessed. Maternal weight is followed throughout the pregnancy. After 14 weeks Doppler ultrasound is used to auscultate the fetal heart rate. Urine is routinely dipped for protein, glucose, blood, and leukocyte esterase.

The panel of lab tests in the second trimester includes:


triple screen (maternal serum alpha-fetoprotein, -hCG and estriol) - 15-18 weeks HIV (human immunodeficiency virus) screen - 23-24weeks amniocentesis in older patients and high-risk patients ultrasound - 18-20 weeks

At each visit, the patient is asked about symptoms that indicate complications of pregnancy: vaginal bleeding, vaginal discharge or leaking of fluid, and urinary symptoms. After 20 weeks patients are asked about contractions and fetal movement. During the third trimester the fetus is viable. Prenatal visits increase to every 2 to 3 weeks from 28 to 36 weeks and than to every week after 36 weeks.

The panel of lab tests in the third trimester includes:


complete blood count coagulation studies, hematocrit biochemical exam Rapid plasma reagent (Wasserman's Reaction) Ultrasound (32-34 weeks), Doppler ultrasound (Blood flow velocity in umbilical cord) after 30 weeks Biophysical profiles (BPP) - after 30 weeks

Thanks to prenatal care visit the most potentially serious problems can be prevented and treated effectively. However, problems sometimes develop suddenly and unexpectedly.

Thank you for attention

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