Presumptive signs (subjective)

Probable signs (objective)

Positive signs (100% diagnostic)

Subjective Date (stated data by the woman)

-Amenorrhea (missed period, most common)

-Nausea

-Fatigue

-Swollen, tender breasts

-Frequent urination

Data collected by a trained examiner

-Chadwicks Signs 

-Hegar's Sign

Goodell's Sign

Enlarging Uterus & ballottement

Braxton-Hick's Contractions & positive pregnancy test

Probable sign

Blueish/purplish color of the cervix, vagina, and perineum.

Probable sign

Softening of the uterine isthmus (lowest portion of the uterus)

Probable Sign

Softening of the cervix

Probable Sign

Examination where fetus bounces back in/rebounds after examiner pushes on uterus.

Can cause elevated HCg which cn cause you a false positive on a pregnancy test.

Choriocarcinoma - cancer of the lining of the uterus.

Diagnostic of pregnancy because nothign else can cause these signs.

Ultrasound visualization of the gestational or fetus (100%)

Fetal heart beat with doppler/ultrasound

Palpation of fetal movement after the 20th week.

Cells increase in size, uterus expands.

Cellular hypertrophy and growth and dilation of maternal vessels.

Fetus & placenta push uterus up into abdominal cavity.

by the 20th week fundus should be able to be palpated at the umbillicus.

Growth and vasodilation in maternal blood supply and uterine artery doubles in size.

Increase in vascularity and glandularity and formation of mucous plug.

responsible for probable signs b/c of increase vascularity.

Mucuous plug protects bacteria from going into uterus.

Ceasing of ovulation, follicles stop maturing

corpus luteum secretion of progesterone for 6-7 weeks if it falls off spontaneous abortion will occur.

Increased vascularity (chadwick's sign)

Leukorrhea (increased WBC) to protect uterus from bacteria

become tender & tingly

Increase in size

darkening of areola

Prominence of Montgomery's tubercles

visible veins, striae (stretch marks)

colostrum production (very first breast milk)

Prolaction

(endocrine changes)

Oxytocin

(Endocrine changes)

responsible for uterine contractions

also good after birth to help prevent hemmorrhage

helps stimulate letdown reflex-milk leaks from breasts at the sound/scent of baby.

Increased blood volume & hemodilution

(hematologic changes)

Increases by 40-45%.

RBCs and plasma icnrease in volume. Plasma increases at a higher rate than RBCs.

This causes hemodilution. the blood becomes more diluted.

CBC might have H&H appearing low, but it's really not.

Hypercoagulability

(hematologic changes)

Increase in fibrinogen (blood clotting factor)

Clotting and bleeding times shoudl be within normal limit still.

Venous Stasis

(hypercoagulability)

Blood is not returning as easily.

This puts them at risk for DVTs.

The increase in exchange of nutrients and gases helps protect against decrease blood return in lower extremities.

Also prepares her for blood loss during labor.

Cardiovascular

(hematologic changes)

Increased workload due to expanded blood volume.

Heart is pushed up and to the left due to uterus it cna cause systolic heart murmur.

Decrease in BP, Increase HR, Increase Cardiac Output

Uterus is pressing down on aorta and vena cava (Supine Hypotensive Syndrome) if in supine position/laying flat it can cause BP to fall. Puts pressure on vessels.

TX: resposition to lateral side.

uterus is pressing down on aorta and vena cava.

If in supine position/laying flat it can cause BP to fall. 

It puts pressure on the vessels.

TX: repostion to lateral side (left)

Lordosis-increased curvature of spine to compensate for shifting center of gravity

diastasis recti abdominis-abdominal muscles separate as uterus expand. ligaments become stretched. often have abdominal pain.

Vasocongestion occurs.

Lining of respiratory tract becomes congested and causes cold like symptoms. Nasal lining becomes fragile which can cause norse bleeds (caused by estrogen).

TX: humidifiers, saline sprays

dyspnea-encourage frequent rest b/c the baby pushes on the diaphragm making it hard to breath.

N&V-caused by rising levels of HCG

ptyalism-increase in saliva production

pyrosis & cholestasis

constipation-progesterone slows the intestines and gastric emptying.

hemorrhoids-increase pressure below uterus & from constipation

Stomach is pushed upwards and hormone causes the lower esophageal sphincter to relax.

Causes acid reflux and heartburn

Decrease in gallbladder contraction.

Hormones relax, leads to bile stasis.

Increase risk for gall stones.

pyelonephritis-uterus puts pressure on bladder causes urinary stasis. Increased risk for bladder infection.

incrreased GFR-due to increased cardiac output

glycosuria-may find glucose in urine. kidneys cannot absord it fast enough. additional testing needed to rule out gestational diabetes.

Cholasma-hyperpigmentation. Brown spots on forehead, cheeks. can resolves, but sometimes doesn't completely. "pregnancy mask"

linea nigra-darkened line down middle of abdomen

striae- s t r e t c h  marks.

1st trimester-accept the pregnancy; feelings of ambivilance (even when planned), usually become introverted.

2nd trimester-accept the baby; enhanced by fetal heart beat or fetal movement, start to be more extroverted.

Couvade Syndrome

3rd trimester-prepare for parenthood;nesting instinct sets in. many discomforts are in full effect. aches & pains.

sympathetic pregnancy seen in fathers.

Abdomen gets bigger.

Fatigue.

1st trimester-total wt gain 3-4lbs

Poor wt gain-less than 16lbs is associated with risk for low birth weight baby.

300 extra calories required each day in 2nd & 3rd trimesters.

400mcg of folic acid recommended (typically in prenatal vitamins)

Pica

Eating of non food items.

D/t cravings developed during pregnancy associated with iron defeciency.

medical & OB hx-get baseline info

physical/pelvic exam, vitals, breast exam

Labs (CBS, blood type & antibody screen, hep B, rubella, RPR, HIV, UA, C&S)

EDD/EDC-calculate due date, estimated date of confinement

bimanual vaginal exam

calculate due date by last menstrual period.

Formula for determining due date from last menstrual period.

Add 7 to LMP then subtract 3 months.

Pregnancy Landmarks

Validation of Gestational Age

HR doppled at 10-12 weeks

Quicking at 16-20 weeks (first feeling of movement. For first pregnancy later, for second/multiples earlier)

Ultrasound allows verification of EDD based on size of fetal structures. The earlier the more accurate the EDD b/c every fetus in the beginning grows at the same rate.

Every month until 32 weeks

Twice per month 32-36 weeks

Weekly 36-birth

Weight

BP

Urine protein & glucose dip

fetal HR

Fundal height (should be equivalent to weeks gestation from 18-32 weeks)

balanced diet: prenatal vitamins & food pyramid

Hygiene: dental, build up of plaque can cause preterm labor. Cannot take hot baths/saunas should be avoided.

Exercise:As long as there's no contraindications.

Breast Care: supportive bra, avoid harsh chemicals & detergents and expose nipples to air & sunlight for healing.

Sexual Activity:unless hx of preterm labor or contraindication or rupture of membranes or vaginal bleeding.

No ETOH, tobacco, avoid caffiene.

MSAFP-maternal serum alpha-feto protein (15-20 weeks)

Glucose tolerance test- for gestational diabtes (24-28)

Antibody screen & RhoGam if Rh(-)(28 weeks)

Group B Beta strep-vaginal/rectal culture some women have this in their normal flora (not harmful), but can affect the baby. They need to be treated with antibiotics before delivery. (35-37 weeks)

Kick counts

Ultrasound

MSAFP markers

Quad check

Amniocentesis

Chorionic villius sampling

NST (nonstress testing)

BPP(biophysical profile)

CST(contraction stress testing)

Daily assessment of fetal movement

10/2hours is good

If levels decreased it shows down syndrome.

If levels are elevated pregnancy may be further along or neural tube defects. It can also indicate multiples or fetal death. Or gastioschisis (abdominal contents growing out of abdomen)

Determine abnormal defects at 16-20 weeks.

Also determine gestational age.

Go in through cervix and take chunk of placenta out.

Look for chromosomal abnormalities.

Done up 12-13 weeks.

After 28 weeks

Monitor put on abdomen and another traces uterine activity.

It's a way to see if baby is well and look at fetal HR.

Can indicate birth defects.

Often will follow up with amniocentesis to look at chromosomes.

5 variables.

Ultrasound

breathing, movement, fetal tone, measure amniotic fluid volume, nonstress test

Get up to two points for each variable.

Pregnancy related complication.

Severe N/V

Can result in dehydration, wt loss, hypokalemia, acid base imbalance, electrolyte imbalance.

TX: hospitlization, IV therapy, antiemetic (zofran pump), TPN usually b/c they can't hold down food

Fertilized egg implants egg outside of uterus.

Usually in fallopian tube, but can be in ovary or cervix (rare)

Normal S/SX of pregnancy, 4-8wks after last period.

Most common sign severe abd pain, stabbing lower pelvic pain

Shoulder pain & signs of shock

S/sx of shock: low BP, pallor, weak, rapid pulse, increased respirations, cold, clammy skin.

Those are signs that tube is rupturing. Need prompt diagnosis to prevent hemmorrhage and hypovolemic shock.

Give methotrexate to disrupt cell production and dissolve embroyo and save tube.

Or surgical removal or ruptured tube and possible transfusion.

Loss of pregnancy before viability (20 weeks).

Miscarriage/spontaneous-due to natural causes before 20 weeks.

Induced-deliberately caused by chemical/mechanical manipulation.

Therapeutic-medically recommened if mother/fetus life is in danger or possible chromosomal abnormality that puts them in danger.

Benign growth of placental tissue

Can cause positive pregnancy test.

During fertilization there's an error that happens. It results in a nonviable, rapidly growing mass of cells, like a cluster of grapes.

Brown to bright red vaginal bleeding

Increased HCG reading more than normal.

No fetal HR

Looking at ultrasound looks like grape like vesicles.

DNC-evacuation of uterus or hysterectomy

Watch for choricarcinoma, they'll be at high risk!

Afterwards they need HCG drawn for 1-2 weeks.

Also advised not to get pregnant for a full year.

Pt needs LOTS of emotional support!

Abnormal implantation of the placenta in lower portion of uterus.

Complete Previa-completely covers cervical opening

Partial Previa-Partially covers cervical opening

Marginal/low lying-near cervical opening. Sometimes starts out low and migrates up.

painless bright red bleeding d/t rupture of blood vessels.

Danger is when placenta is separating/compressed before birth

Amt of bleeding and gestation of pregnancy determines treatment.

If bleeding is slight and stops spontaneously and fetus is immature they'll be hospitilized on bedrest.

If bleeding is severe they'll do immediate c section (no vaginal birth!)

With low lying previa they can do vaginal birth.

Post partem they're at risk for hemmorhage and infection!

A digital vaginal exam should not be done if there's bleeding. Could be a placenta previa.

Ultrasound must be done first to determine source!

Premature separation of a normally implanted placenta.

It can be partially separated or completely separated.

It can also be conceled or apparent.

Usually happens later in pregnancy or in labor.

Cause: unknown

Associated with HTN, women over 35, multipara

Trauma to uterus, smoking, cocaine use

Premature rupture of membranes

Can be complete or partial.

Usually if complete it's apparent.

But if it's concealed it means blood is not coming out of the vagina.

Can be partial or complete

Blood is coming out of the vagina.

Separation can be mild and show no symptoms or severe and cause complications.

Uterus can rupture, renal failure, hemmorhagic shock, fetal hypoxia, fetal anemia, growth retardation, and even maternal and fetal death :(

Sudden constant abdominal pain with dark red vaginal bleeding

Tender rigid abdomen & hypertonic contrations.

If amniotic fluid ruptures it'll be bloody.

Might show s/sx of maternal shock and will show signs of fetal distress.

If abruption is mild may induce labor if the pregnancy is far along enough.

If abruption is severe EMERGENCY c section is performed and possible hyterectomy.

They're at risk for hemmorhage and atony (muslce that's lost it's strength)

Also at risk for DIC (disseminated intravascular coagulation)

DIC (disseminated intravascular coagulation)

Primary goal is to maintain safety of pregnant woman and fetus!

Maintain placental perfusion and blood volume. Observe bleeding closely. Weigh pads.

Freq vital and monitoring of baby. Evaluate pain. IV access. Have oxygen and blood products available.

Encourage to lie on side to increase placenta perfusion. Watch for s/sx of shock. Provide emotional support.

Pregnancy induced HTN (PIH)

Above 140/90. Happens for first time during pregnancy.

No prescence of protein in urine.

Monitor for preeclampsia.

Check urine frequent & BP. Give them antihypertensives.

Bp above 140/90 and protein in the urine.

Early detection is important!

7 times more likely to die without prenatal care!

Cause: unknown. sensitivity or reaction to foreign bodies.

Spasms of the arteries.

Generalized vasoconstriction.

Decreased bloodflow and oxygen to organs including CNS, kidneys, liver, and placenta.

This leads to increased BP, generalized edema, and organ edema.

160/110 and 2 plus protein in urine.

S/SX: related to edema in body organs and decrease blood flow in tissues and nervous system irritability.

Deep tendon reflexes, clonus, severe h/a, and visual changes d/t edema around brain. Seeing spots (meaning seizures can occur)

Epigastric pain, increased liver enzymes, decreased platlet count

Maternal & fetal death.

Also can cause seizures, pulmonary edema, cerebral edema and stroke, decreased blood flow to liver, HELLP syndrome (hemolysis elevated liver enzymes low platlets), thrombocytopenia, DIC (blood clots)

reduced blood flow to placenta can cause abruption and can cause intrauterine growth restriction (IUGR) affects mom, fetus, and baby after birth. Lungs may not full be developed.

Watch labs.

No cure other than delivery. Incude labor after 37 weeks.

Preterm- depends on severity of preeclampsia/eclampsia and lung maturity.

activity restriction and decreased stimulation.

Freq BP monitoring, 24hr urine to see how much protein is in urine. If at certain level they need to deliver.

Report sudden h/a & epigastric pain (organ edema & visual disturbances.

Monitor baby, do kick counts, nonstress test.

Freq biophysical profiles, anmiocentesis for lung maturity.

Betamethasone (steroid) if fetus is at risk for early delivery to help for fetal lung maturity.

Bedrest, keep room dark

No loud noises, limit visitors.

Magnesium sulfate (skeletal muscle relaxant)

Antihypertensives

Careful and freq monitoring of mom and fetus.

Freq fetal monitoring.

Enforce quiet environment.

Seizure precautions. I&Os.

Listen to lungs. Assess DTR (deep tendon reflexes) & clonus

Daily wt (for edema) Labs (urine dip for protein)

CBC-platlets and metabolic profile for liver enzymes.

T - toxoplasmosis

O - other (Hep B, suphillis, varicella, herpes)

R - rubella

C - cytomegalovirus

H - herpes simplex virus

Trasmitted through undercooked meat and cat feces (yummy)

Caused by protazoan.

Doesn't produce symptoms until it crosses placenta.

Particularly harmful 10-24 weeks gestation.

Complications: choriretinitis, intracranial calcification, hydrocephallis.

Prevention: don't clean litter box, wear gloves, good handwashing, eat fully cooked meals

Transmitted sexually (blood/body fluids)

Risk for developing liver disorders. Transmitted to fetus through delivery.

If they're positive or unknown they'll give them HBIg immune globulin and hepatitis vaccine within first 12 hrs of birth and subsequent vaccinations after that.

Transmitted sexually or through broken skin.

Red pustule.

Infeciton of fetus may fesult in fetal demise, spontaneous abortion or premature birth.

If survival there's a high chance of baby being infected. And possible complications of syphillis are blindness & deafness.

Transmitted through respiratory droplet.

Recurrent form lies dormant.

Complications are low birth wt babies, skin lesions, limb hyperplasia, contractures, damage to eyes and ears and CNS mental retardation, paralysis and seizures.

13-20 weeks highest gestation risk.

Viral infection. Highest risk is in the first trimester.

There may be no symptoms or they're generally mild. 

Such as low grade fever, rash, malaise, conjuctivitis, lymphadenopathy.

can cause still birth, hearing impairment, and congenital abnormalities.

Congential viral infection. Transmitted through droplet.

Highest risk is first 20 weeks.

Contact with infected bodily fluids (saliva, blood, breast milk, urine semen)

Known as the silent menace. No symptoms.

Common source : young children are carriers.

Prevention: handwashing, no sharing utensils!

Infant complications: neurologic abnormalities, eye and brain damage, liver disease

Sexually transmitted by direct contact.

Highest risk is when contracting disease for first time during last trimester!

Can't deliver vaginally if disease is active. Have to deliver by c section.

No vaginal exams/internal fetal monitoring during flare ups.

Diabetes Mellitus

(Gestational Diabetes)

Just like type 2 diabetes. Insulin resistant.

Develops during pregnancy and woman has an increase risk for developing type 2 later in life.

Goes away after birth. No known cause, but believe it's due to hormones.

HX of delivery LARGE baby

HX of gestational diabetes

Previous unexplained fetal demise

Pregnant while 35 and up

Family hx of type 2/gestational

Obesity, noncausian ethnicity.

24-28 weeks oral glucose tolerance test

watch diet, monitor glycemic control

May put on insulin, exercise, monitor fetus

nonstress test, biophysical profile, fetal kick count

*oral hypoglycemic meds contraindicated!

Time delivery, c section if baby is too large