Doc750
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1. Normal Pregnancy Physiology
Day 1: Fertilization; repetitive cell division begins
Day 3: Blastocyst enters uteine cavity
Day 6: Implantation of embryo; early placenta begins to form from trophoblastic cells and produces B-hCG
Day 9: Early lacunae form in placenta
Day 17: Beginning of maternal-fetal circulation; CNS begins to develop
Week 3: Heart begins to form
Week 4: GIT begins to form
Week 5: Early lungs begin to form
Week 6: Reproductive system begins to differentiate; limbs began to develop
Week 9: Kidneys began to function
Week 12: Easy to distinguish fetal sex; biliary system begins to form
Week 17: Early detectable fetal movement
Week 20: Pancreas begins to function
Week 24: Surfactant production begins; Finger nails present, earliest chance of survival with premature birth.
Week 28: Eyes open; Hair develops
Week 30: Chubby body appearance resembling mature form
Week 32: Fetus usually survives if born prematurely
Week 35: Firm grasp
Week 37: CNS matures
Week 38: Fetus considered full term
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| Doc750
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Normal Changes in Maternal Physiology during Pregnancy
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CVS:
-CO increases 40% with assoc. increase in SV (10-30%) and HR (12-18 bpm)
-Systolic murmur may be heard b/c of increased CO
- Myocardial O2 demands increase
-Systolic and diastolic BP decrease slightly
- Uterus displaces heart slightly superiorly
Respiratory:
- Uterus displaces diaphragm superiorly and causes decrease of residual volume,
functional residual capacity, and ERV.
- Total body O2 consumption increases 20%
- TV increases 40 % with associated increase in minute ventilation b/c of stim by
progesterone.
- pCO2 decreases to ~30 mm Hg; Dyspnea is frequent complaint despite increased
minute ventilation and normal rate.
Renal:
-RPF and GFR increase 40%
-Decrease BUN & Crea
-Increased renal loss of bicarbonate to compensate for respiratory alkalosis
- Blood and interstitial fluid volume increase
Endocrine:
-Nondiabetic hyperinsulinemia with associated wild glucose intolerance
-Production oh HPL contributes to glucose intolerance by interfering with insulin
activity.
-Fasting triglycerides increase
-Cortisol increases
Hematologic:
-Increase RBC production
-Hematocrit decreases b/c of increased blood volume
-Hypercoagulable state
GIT:
-Increased salivation
-Decreased gastric mobility
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| Doc750
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Important Nutritional Demands during Pregnancy
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Calcium
Increased Need: 1000-1300 mg/day (50% increase)
Reason for Need: Lactation reserves; Increased utilization by fetus
Effects of Insufficiency: Impaired maternal bone mineralization; HTN; Premature birth; LBW
Fluids
Increased Need: Adequate hydration important
Reason for Need: Increased total-fetal fluid volume
Effects of Insufficiency: Relative dehydration
Folate:
Increased Need: .8-1 mg/day (start 4 wks before attempted conception)
Reason for Need: Normal fetal neural tube development
Effects of Insufficiency: Neural tube defects
Iron:
Increased Need: 30 mg/day (100% increase)
Reason for Need: RBC production
Effects of Insufficiency: Maternal anemia, premature birth, LBW, maternal cardiac complications
Protein:
Increased Need: 60g/day (30% increase)
Reason for Need: Additional needs of maternal, fetal, and placental tissue
Effects of Insufficiency: Impaired fetal and placental growth
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| Doc750
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- Teratogens will either kill the fetus or have no effect within the initial 2 wk gestation. They can cause abnormal organ development b/w 2 and 12 weeks.
- Daily caloric intake during pregnancy should be 2,500 kcal
- airline travel permitted up to 36 weeks
- sexual intercourse continued during pregnancy unless the mother is considered high risk for spontaneous abortion, premature labor or placenta previa
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| Doc750
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II. Prenatal Care
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Ideal weight gain
a. 28-40 lbs in a woman with BMI <19.8
b. 25-35 lb for BMI 19.8-26 (~ 2 lb in 1st trimester, .75 lb/wk in second and third trimester)
c. 15-25 lb for BMI > 26
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| Doc750
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Common Screening Labs Performed during Pregnancy
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Initial Visit: CBC, Blood antibody & Rh typing, Pap smear, Gonorrhea/Chlamydia screening, UA, RPR/VDRL, Rubella antibody titer, Hepatitis B surface antigen, HIV screening (consent)
16-18 weeks: Quadruple scren (maternal serum alpha-fetoprotein, hCG, unconjugated estradiol, maternal serum inhibin A) to look for trisomy 21, and 18, and neuraltube defects
18-20 weeks: US dating of pregnancy and assessment for gross fetal abnormalities
24-28 weeks: 1 hr glucose challenge to screen for gestational DM
32-37 weeks: Cervical culture for N. gonorrhea and C. trachomatis; GBS screening
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| Doc750
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- Low maternal pregnancy associated plasma protein A (PAPP-A) levels are associated with an increased risk of trisomies 21 and 18.
- Maternal serum AFP levels: This screen is only valid if performed during the correct gestational window (16-18 weeks)
* High levels are assoc with an increase risk of neural tube defects or multiple gestation
* Low levels are assoc with increased risk of trisomy 18 and 21.
- In trisomy 18 all quadruple-screen markers are low except inhibin A.
- In trisomy 21 maternal serum AFP and unconjugated estradiol are low, whereas hCG, and inhibin A are high
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| Doc750
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Prenatal Assessment for congenital Diseases in High Risk Pregnancies
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Quadruple Screen
Description: Maternal serum AFP, Estradiol, hCG and maternal serum inhibin A levels measured to assess risk for neural tube defects and trisomies.
Indications: Performed in all pregnant woman at 16-18 weeks gestation; Frequently initial marker for fetal complications
Full Integrated Test:
Description: US measurement of nuchal translucency and serum measurement of PAPP-A in 1st trimester and quadruple screen in 2nd trimester; lowest false positive rate for noninvasive tests.
Indications: Woman who present in 1st trimester who desire noninvasive testing with the lowest false positive risk.
Amniocentesis:
Description: Transabdominal needle aspiration of amniotic fluid from amniotic sac after 16 wk gestation to meaure amniotic AFP and determine cerotype (detects neural tube and Ch disorders with greater sensitivity than triple screen alone)
Inidications: Abnormal quadruple scrren, age>35, risk of Rh sensitization; carries anexcess 1% risk of spontaneous abortion over normal risks for abortion
Chorionic villi sampling:
Description: Transabdominal or Tran cervical aspiration of chorionic villus tissue at 9-12 wk gestation to detect chromosomal abnormalities.
Indications: Early detection of chromosomal abnormalities in higher risk patients (advanced age, hx of children with genetic defects)
Percutaneous Umbilical blood sampling:
Description: Blood collection from umbilical vein after 18 weeks of gestation to identify Ch defects, fetal infection, Rh sensitization.
Indications: Late detection of genetic disorders, pregnancies, with high risk for Rh sensitization.
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| Doc750
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III. Medical Complications of Pregnancy
A. Gestational DM
1. New onset glucose intolerance that begins during pregnancy
2. Risk factors: family history of DM, >25 of age, obesity, prior polyhydramnios, recurrent abortions, prior still birth, prior macrosomia, HTN, African American, corticosteroid use, PCOS
3. History and Physical: usually asymptomatic
4. Labs: Fasting glucose >126 mg/dL or abnormal glucose tolerance test performed at 24-28 wk gestation.
5. Treatment:
A. Strict glucose control through diet and exercise
1. 40kcal/kg/day in woman with BMI <22
2. 20 kcal/kg/day in woman with BMI 22-27
3. 24 kcal/kg/day in woman with BMI 27-29
4. 12-15 kcal/kg/day in woman with BMI >29
5. Self monitoring of glucose performed to determine therapy efficacy
B. Insulin should be used in pts failing nonpharmocological therapy to keep fasting glucose <90 mg/dL
and 1 hr postprandial glucose <120 mg/dL
C. Periodic fetal US and nonstress tests performed to assess fetal well being
D. C-section may be indicated for macrosomic babies
6. Complications:
A. Maternal: maternal polyhydramnios, preeclampsia, renal insufficiency, diabetic ketoacidosis,
hyperosmolar hyperglycemic nonketotic coma, retinopathy.
B. Fetal: hypoglycemia (secondary to therapy; can also occur after delivery), hypocalcaemia, fetal
macrosomia (ie baby of abnormally large size), IUGR, neural tube defects, cardiac defects,
intrauterine fetal demise.
C. Perinatal or postnatal : traumatic delivery, delayed Neurologic maturity, fetal RDS.
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| Doc750
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| Doc750
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Pregestational Diabetes Mellitus
1. DM that exists before pregnancy; patient may or may not be aware of disease
2. H/P: Consistent with typical presentation of DM; patients more likely to have
significant hyperglycemia, postpartum hyperglycemia, and low BMI
3. Labs: Increased serum glucose (prior to and during pregnancy), increased Hemoglobin
A1c with poor control; Detection of anti-insulin and anti-islet cell antibodies is
diagnostic for DM type 1.
4. Treatment: Try to control glucose with diet and exercise
-Insulin used for glucose control in type I and in type II DM not adequately
controlled with lifestyle modifications.
- Fetal US and echo (esp. in 3rd trimester) used to identify cardiac,
Neurologic and growth abnormalities.
- Early delivery after fetal lung assessment and corticosteroid admin
recommended for poor glucose control or maternal complications.
** Gestational DM occurs most frequently in the 2nd and 3rd trimester. If mother presents with signs and symptoms earlier in pregnancy suspect nongestatinal DM.
** Continue glucose assessment after birth b/c maternal glucose needs will change suddenly for pts with gestational DM and b/c the mother has a low risk of remaining diabetic after pregnancy.
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| Doc750
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Preeclampsia:
1. Pregnancy induced HTN with Proteinuria and edema that develops after 20 weeks of gestationin 5% of pregnancies owing to unknown cause
2. Risk Factors: HTN, nulliparity, prior hx of preeclampsia, <15 or >35 yr of age, multiple gestation ( eg twins), vascular disease, chronic HTN or renal disease, DM, obesity, African American
3. H/P:
a. Asymptomatic in mild cases
b. Edema in hands and feet, rapid weight gain, headache, epigastric abdominal pain, visual
disturbances, hyperreflexia.
C. BP >140/90 mm Hg during pregnancy in a patient who was formerly normotensive.
4. Labs:
a. UA shows 2+ Proteinuria on dipstick or >4 g protein/24 hr
b. Decreased platelets, normal or mildly increased crea, increased ALT, and AST, decreased GFR
c. fetal nonstress test and amniocentesis ca be useful to assess fetal well being.
5. Treatment:
A. If near term, induce delivery
B. If mild and far from term, prescribe restricted activity, frequent maternal examinations for worsening
symptoms, protein assessments and fetal nonstress tests twice per week.
C. If severe, and far from term, closely monitor in inpatient setting and maintain BP <155/105 with
diastolic >90 using anti-HTN medications (freq. Labetalol). Give IV MgSO4 for seizure
prophylaxis, closely monitor maternal and fetal health, and induce delivery as soon as fetus is viable.
6. Complications:
A. Eclampsia, seizures, stroke, IUGR, pulmonary edema, maternal organ dysfuncion, oligohydramnios,
preterm delivery; hemolytic, Elevated LFT, and low platelet count (HELLP) syndrome can cause
abruptio placenta, renal insufficiency, encephalopathy, and DIC
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| Doc750
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Eclampsia
1. Progression of preeclampsia leading to maternal seizures that can be severe and fatal for both mother and child if left untreated.
2. H/P: headaches, visual disturbances, and upper abdominal pain frequently precede onset of seizures.
3. Labs: Findings similar to preeclampsia.
4. Treatment: Treatment is similar to preeclampsia, with delivery being the definitive solution; labor should be induced as soon as stable.
- Use MgSO4 and IV diazepam to control seizures.
- Stabilize patient with sufficient 02 and BP control (Labetalol or hydrolyzing)
- Continue MgSO4 and anti-HTN meds for 48 hours following delivery b/c 25 % of seizures occur within 24 hr postpartum
5. Complications: Risk of maternal (<2%) and fetal (6-12%) death; 65% risk of preeclampsia and 2 % risk of eclampsia in subsequent pregnancy.
** Anticonvulsant use in pregnancy: Pt with epilepsy should be kept on their regular anticonvulsant medication (unless valproic acid) during pregnancy, but should be given supplemental vitamin K and folate.
** Valproic acid should never be used for epileptic seizure prophylaxis b/c of significant teratogenic risk.
** Diazepam can be used to break active seizures (80% effective)
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| Doc750
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Maternal Asthma (preexisting)
1. Severe maternal asthma is associated with preeclampsia, spontaneous abortion, IUGR, and fetal demise
2. H/P: Course of disease frequently does not change during pregnancy from prior severity, but exacerbations may be less tolerated by the mother b/c of normal physiologic respiratory changes in pregnancy.
3. Treatment:
-Mild intermittent asthma treat with short acting B-agonist as needed
-Mild persistent asthma treat with short acting B-agonist and low dose inhaled corticosteroid
-Moderate persistent asthma treat with medium dose inhaled corticosteroid or a low dose inhaled corticosteroid plus a long acting B-agonist (salmeterol)
- Severe persistent asthma treat with a high dose inhaled corticosteroid and a long acting B-agonist
4. Complications: Increased risk of preeclampsia, spontaneous abortion, IUGR, fetal death; Oral corticosteroid use may be associated with IUGR and cleft palate.
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| Doc750
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Maternal Nausea and vomiting
1. Most woman experience N/V in the 1st trimester of pregnancy; Most cases improve by the second trimester.
2. Most likely caused by increases in chorionic gonadotropins or imbalance of progesterone and estrogen.
3. H/P: N/V that occurs frequently and may be daily; typically occurs in 1st trimester and improves after 16 weeks gestation
4. Treatment: Maintenance of hydration status, avoidance of large meals, elevating head in bed; antacids following meals may be helpful in worse cases.
Hyperemesis Gravidarum: is severe n/v that affects 1% of pregnant woman. It may be complicated by electrolyte abnormalities and treated with avoidance of large meals, adequate hydration, and pyridoxine and doxylamine.
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| Doc750
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Maternal DVT
1. Risk of DVT increases during pregnancy b/c of venous stasis and relative increase in circulating clotting factors.
2. H/P: Similar presentation to that in no pregnant patients; clinical diagnosis may be more difficult in pregnant patients b/c edema is also common in absence of DVT.
3. Radiology: US and Doppler studies are safe means of finding thrombosis
4. Treatment:
-IV heparin dosed to maintain PTT at two times normal or LMWH (enoxaprin)
dosed to achieve consistent anti-factor Xa levels 0.5-1.2 U/mL at 4 hr after
injection.
- Patients should be switched to subQ unfractioned heparin 2 weeks before
delivery.
- Anticoagulation should be continued following delivery for 6 weeks (warfarin or
enoxaprin can be used postpartum)
5. Complications: Pulmonary embolus; heparin therapy can be complicated by
hemorrhage or thrombocytopenia.
** Warfarin is teratogenic, do not use during pregnancy
** Stop all anticoagulation during active labor until 6 hours after delivery to prevent severe hemorhage
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| dermatology
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good job doc750
thanx
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