4 Weeks

• Heart developing and starting to beat-does not have a regular beat yet
• Lung buds
• Midbrain

8 Weeks

• Heart beat detectable by ultrasound
• Differentiating brain sections
• Testes and Ovaries distinguishable
• External genitalia=sexless

12 Weeks

• Resemble a human
• Lungs have final shape
• Kidneys secrete urine
• Brain Complete
• Sucking Present
• Sex recognizable-BOY OR GIRL??

16 Weeks

• Wt. 100g=3.5 oz
• Meconium in bowel-1st stool
• Heart Well developed
• Elastic fibers in lungs

20 Weeks

• Wt 300 g=11 oz
• Fetal movements felt by the mother
• Primitive respiratory movements
• Vernix Caseosa (white, cheese-like substance for protection)
• Lanugo (fine hair)

24 Weeks

• Body Well proportioned
• Wt. 600 g=1.25 lbs
• Lecithin begins to appear in amniotic fluid
• Ability to hear

28 Weeks

• Lean body, nails appear
• Wt. 1110g = 2.5 lbs
• Alveolar surfaces contain lecithin
• Sleep-Wake Cycles

30 Weeks

• Starting to produce Subq Fat
• Can turn head
• L/S ratio 1:1
• Birth Position
• Aware of sounds outside
• Testes descending

36-40 Weeks

• Gaining 1 lb per week, becoming round
• Lanugo, Vernix Caseosa decrease
• Wt. 2900-3200g= 6-7 lbs
• Good Movement
• 36 Weeks= Spinal Cord at final level
• L/S Ratio: 2:1
• Cries, Strong Sucking Reflex
• Testes in scrotum, labia majora well developed

Viability

Gravida

Gravidity

Multigravida

Primigravida

Para

Multipara

Nullipara

Preterm

Term

Postdate or Postterm

Abortion

GTPAL

• Gravidity
• Term- # of fetus'born at term
• Preterm- # of preterm pregnancies
• Abortion/miscarriage- # of abortions or miscarriages
• Living- # of currently living children

Nagele's Rule

Presumptive Signs of Pregnancy

• Those felts by the woman, things she can pick up on

• Amenorrhea- missed menses
• Fatigue
• N/V
• Breast Changes
• Frequent Urination

Probable Signs of Pregnancy

• Observed by Examiner

• Positive Pregnancy test
• Hegar's Sign- Softening of lower uterine segment
• Goodell's Sign- Softening of cerival tip
• Chadwick's Sign-Violet, blue color to cervix/vagina
• Abdominal Enlargement
• Balloteement: Push on cervix during exam and feel fetus rebound, floating
• Braxton-Hicks: Contractions

FSH

Follicle-Stimulating Hormone

• Secreted anterior pituitary for ovarian follicle maturation,
• stimulates follicle in ovary to mature egg;
• stimulates development of ovarian graafian follicles and their production of estrogent

LH

Luteinizing Hormone

• Anterior pituitary for final maturation of follicle and lutenization of ruptured follicle
• Complete maturing of egg,
• Causes rupture of follicle to release egg

What happens at the end of the normal cycle?

Follicular Phase

(Ovarian Cycle)

• Hypothalmus initiates this phase by stimulating the pituitary gland to release FSH
• FSH stimulates the ovary to produce immature follicles which hold an immature oocyte
• Surge of LH from the anterior pituitary stimulates the final development and rupture of the mature follicle

Ovulation

(Ovarian Cycle)

• Surge of LH results in rupture of the mature follicle releasing the oocyte, day 14
• Drop in estrogen afterward
• Fallopian Tube: distal ends become active, cilia active to carry ovum to tubes
• Ovum dies after 24 hours unless fertilized
• Cervix mucous become thin, clear to help sperm travel through cervix to ovum

Luteal Phase

(Ovarian Cycle)

• Ovulation until menstrual phase- day 15-28
• After releasing the ovum the follicle closes and becomes the corpus luteum; peak function is 8 days after ovulation- secrete estrogen and progesterone
• Corpus luteum secretes progesterone to prepare the endometrium for implantation
• Increase in progesterone also causes an increase in temperature
• No fertilization=decrease in estrogen and progesterone resulting in endometrium involution
• If implantation does not occur, teh corpus luteum regresses, steroid levels decrease, functional layer of endometrium is shed.

Menstrual Phase

(Endometrial Cycle)

• Ischemia leads spiral arteries to rupture releasing blood into the uterus
• Sloughing/shedding of the functional 2/3s of the endometrium begins
• As estrogen and progesterone decrease the thickened lining sloughs off and passes through the vagina; 6-8 oz, 3-5 days
• Beginning of the menstrual flow marks the end of one cycle and the start of the next

Proliferative Phase: Day 5-Ovulation

(Endometrial Cycle)

• Increase in estrogen results in enlargement of endometrial glands
• Dilated vessels increase thickness of endometrium 8X
• Coincides with the follicular phase, dependent on estrogen which is determined by the follicle

Secretory Phase: Obulation-3 days before the next menstrual period

(Endometrial Cycle)

• Increase in progestoerone influences vascular changes in endometrium
• At the end of the secretory phase the fully matured secretory endometrium reaches the thickness of heavy, soft velvet
• It becomes luxuriant with blood and glandular secretions, a suitable protective nutritive bed for a fertilized ovum
• No ovulation=no secretory phase

Ischemic Phase: Sloughing off

(Endometrial Cycle)

• No fertilization results in dropping levels of estrogen and progesterone
• Implantation of the fertilized ovum generally occurs 7-10 days after ovulation
• If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses- with rapid decrease in these levels, the spiral arteries go into spasm.
• Spasm of the arteries results in ischemia, leading to shedding of the endometrium=menstrual flow, day 1 of next cycle.
• During the ischemic phase the lbood supply to the functional endometrium is blocked and necrosis develops

AFP

Alpha-Fetoprotein

• Blood test done on the mother, 15-18 weeks
• Many neural tube defects and abdominal wall defects are found using this procedure
• If findings are abnormal, follow-up procedures are required, genetic counseling.

Chorionic Villus Sampling

1st Trimester

• Placenta tissue sample, 10-12 weeks
• Can be transcervically or transabdominally
• Same indications as for Amniocentisis

• Exchanges oxygen, CO2, and carbon monoxide
• Supplies nutrients and electrolytes
• Excretory function from fetus to mother

• Production of hormones-progesterone to maintain pregnancy and relax smooth muscle, strogen to stiumulate uterine and mamary gland growth, hcG (human chorionic gonadotropin), HPL (human placental lactogen)
• Transfers maternal antibodies

• Ultrasound verification
• Fetal heart totnes
• Palpatation of fetus
• Movement of the fetus- Palpated or visulized

Reproductive Changes during Pregnancy

Uterus Changes

• Increase in capacity 10mL to 5000mL
•   Pelvic organ until 12 wks, then abdominal
• Level of umbilicus around 20 wks
• Lightening – fetus settles into pelvis 38-40 wks; allows mother to breathe easier
• Hegar’s sign – softening of lower segment
• Contractions – Braxton-Hicks – muscle exercising for labor
• Increase blood flow 20x, uterine soufflé (maternal HR), funic soufflé (fetal HR)

Reproductive Changes during Pregnancy

Cervial Changes

• Goodell’s sign (6-8 wks) – softening of cervix
• Chadwick’s sign – discoloration, violet, blue color to cervix
• Increase in mucous production – mucous plug to block bacterial invasion; for protection
•  Bloody show – small breakage in capillaries
• Ballottement – passive movement of the unengaged fetus

Vagina and Vulva Changes during Pregnancy

• Vaginal mucosa thickens, secretions increase
• Vaginal vault lengthens
• pH becomes acidic to protect against pathogenic organisms, increased chance of yeast infection; for protection
• vulva enlarge and thicken

• Increase in sensitivity, fullness, heaviness, tingling
• Nipples and areola darken
• Increase in size and number of glands
• Montgomery's tubercles (oil producing glands) hypertrophy- keep nipples lubricated for breastfeeding
• Colostrum produced as early as 16 weeks; different around the world due to climate differences

• Slight increase in cardiac size
• Increased blood volume and cardiac output
• Output increases 30-50%, increases pulse 10-15 bpm, systolic murmur
•   Volume increases 40-50%, peaks 34 wk, increase in plasma volume more than RBC’s resulting in physiologic anemia of pregnancy
•  Increase in clotting factors = increase risk for thrombosis (especially after C-section)
•  Vena cava syndrome – supine hypotension, uterus compresses vena cava resulting in decreased volume to R atrium = lower blood pressure
• Increase uterine size = dependent pressure = dependent edema, varicose veins, hemorrhoids
•  B/P 1^st trimester prepregnant levels, 2^nd trimester slightly decreases due to decreased pulmonary and peripheral vascular resistance, 3^rd trimester prepregnant levels

• Increased oxygen consumption 15-20%
•   Increase in thoracic cage permitting increased chest expansion
•   Volume of lung expansion remains the same but the feeling of dyspnea occurs during the 3^rd trimester
•   Increased incidence of respiratory infection and tract diseases

• 1st and 3rd trimester uterus compresses bladder decreasing capacity and increasing frequency
• Increased blood volume increases kidney size slightly, increased urinary stasis and UTI's, glycosuria, kidney unable to reabsorb all glucose
• Urine production increased 50%

• Increased estrogen=increased pigmentation:
• Cholasma-blotchy, brown facial area
• Linea nigra- dark line from symphysis pubis to top of fundus
• Striae gravidarum: stretch marks, permanent
• Palmar erythema: redness of palms

Increased sweat and sebaceous gland activity due to increased blood flow

• Appetite fluctuates, “morning sickness”
•  End 2^nd trimester appetite increases
•   Change in sense of taste = cravings
•   Pica – cravings (non-nutritional, try to avoid), ice, clay, starch
•   Swelling and bleeding of gums, estrogen
• Upward displacement of stomach = hiatal hernia
•  Increased progesterone = decreased tone of smooth muscle = heartburn
• Increased pressure from enlarging uterus = hemorrhoids, constipation
•   Stasis of bile, increased stone formation, results in gallbladder problems
•  Abdominal discomfort – ligament tension, GI disturbances

• 300 kcal daily

Danger sings of pregnancy

1st Trimester

• bleeding
• urinary infection
• N/V
• temp above 100
• abdominal pain

Danger sings of pregnancy

2nd Trimester

• Preterm labor
• pain in calf
• sudden gush/leak of fluid from vagina
• absense of fetal movement

Danger sings of pregnancy

3rd Trimester

• Sudden weight gain
• facial edema
• severe abdominal pain
• headache
• decrease or absence of fetal movements X24 hrs

• Slight vaginal bleeding, cervix closed, mild cramping, products of conception still in tact
• Diagnosis – ultrasound confirms intact pregnancy (hcG may be done)
•  Management – conservative: bed rest, pelvic rest, nutritious diet, adequate hydration

• Bleeding is greater than threatened abortion, ROM, cervix dilated, strong cramping, products of conception may or may not be passed
• Diagnosis – ultrasound (presence or absence of products of conception) and hcG levels
• Management – D&C prostaglandins to empty uterus

•  Some products of conception passed, severe cramping, heavy bleeding, cervix dilated
•  Diagnosis – ultrasound (products of conception in uterus)
• Management – D&C or prostaglandin

• All products of conception passed, slight bleeding, mild cramping, cervix closed, no treatment

• Dead fetus retained in uterus at least 6 weeks, irregular bleeding, + or – cramping, cervix closed
• Diagnosis – ultrasound reveals dead fetus in uterus
•  Management – D&C or induction

• 3 or more consecturive spontaneous abortions
• Identify cause and treat (cerclage in 2nd trimester)

• Color of bleeding and amount?
• Time period of soaking pad?
• Clots and fetal tissue passed?
• Backache, cramping, how strong?
• Save and bring all clots/tissues passed
• Prepare for surgery/procedure if indicated
• Bedrest, monitor bleeding,VS
• Evaluate for shock
• IV therapy
• Give Rhogam if indicated
• Provide emotional support

• Methotrexate by single injection can destroy ectopic cells and end the pregnancy without surgery (only if unruptured)
• Surgical management for the unruptured fallopian tube- linear salpingostomy to preserve the tube and salpingectory for ruptured tube.
• Follow up beta hcG level is monitored until it is undetectable to ensure no residual trophoblastic tissue left.
• RhoGam if Rh negative
• Contraceptives for at least 3 menstrual cycles to allow reproductive tract to heal