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Presumptive Signs of Pregnancy

Woman notices/experiences, indicates to her that she’s pregnant

Maternal physiologic changes

Missed menses
Breast tenderness
Ptyalism ( excessive secrition of saliva) 
Skin pigmentation changes


Probable Signs of Pregnancy
Maternal anatomic & physiologic changes, detected and documented by examiner

Enlargement of uterus ( pregnant vs fibroid tumor)
Chadwick’s sign - blue cervix, vagina and labia                ( pregnant vs cancer) 
? Fetal movement


Positive Signs of Pregnancy
Detected & documented by an examiner, but can only be attributed to fetus

2. X-ray
3. Fetal heart tones
4. ? Fetal movement


Pregnancy Tests
Always used with Hx & PE

BhCG (Beta sub-unit of Human Chorionic Gonadotropin)
Blood or urine
Low cost
Readily available
BhCG only during pregnancy
Low levels after fertilization; increase with implantation
Predictable rise, peaking at 60-70 days


Qualitative BhCG

“quality” of being pregnant
Urine test
Readily available
Serum test
Rarely needed


Quantitative BhCG

Amount or “quantity”
Serum tests
Generally, high-risk only
Predictable rise of hCG


Pregnancy Tests = Probable Signs

False positives

1. Cross-reaction with LH
2. Misread
3. Protein or blood in urine (UTI)
4. Marijuana use
5. Aldomet use ( antihypertensive) 
6. Antidepressant use
7. Tumors (ovary, breast, melanoma)


Pregnancy Tests = Probable Signs

False negatives

1. Impending abortion
2. Misread
3. Medications
4. Ectopic pregnancy
5. Too early/late in pregnancy
6. Urine stored improperly
7. Urine too dilute


Antepartal Care ( 14 prenatal visits ) 

Every 4 weeks until 28 weeks
Every 2 weeks until 36 weeks
Weekly until delivery
Modify prn



type of polysomy in which there are three instances of a particular chromosome, instead of the normal two.

E: trisomy 21 - Down syndrome 


History-Taking & Assessment

All pertinent areas: past, present, potential
Consider physical appearance; verbal & non-verbal communication
“Why are you here today?” 

(abortion ?) 



History: Personal Characteristics

1. Name, address, phone number - track down and find out why she never came back ;
2. D.O.B. - Risk factors !!!
~ PIH ( pregnncy induced hypertension) , C/S, STDs, preemies, LBW ( starve themselves - hiding pregnancy) , anemia (unhealthy diet) , domestic violence
Mature gravidas (35+) * turns 35 on the date of delivery 
~ PIH, C/S, trisomies ( Offer genetic caunseling !!! lawsuit for Wrongful Life), chronic health conditions
3.Marital status
family support, sexual practices, stress factors
4. Race/ethnicity/religion -  African-American; Mediterranean sea countries - cickle cell anemia testing 
5. Education
6. Occupation


History: FOB (Father of Baby)

1. Age
2. Height/weight
3. Race/ethnicity/religion
4. Education
5. Occupation
6. Current health status
7. Significant medical history - Self & family - as far as grandparents 
8. Use of licit or illicit substances
9. Blood type & Rh ( M -) + (D+) = (B +)
10. Response to pregnancy


History: Current Pregnancy

1. LMP
Any bleeding since?
2. Presumptive signs?
3. Pregnancy test done?
4. Response/adaptation to pregnancy


Establish EDC by LMP

1. EDC wheel ( first day of your last menstrual period) 
2. Nagele’s Rule:
LMP -3 months + 7 days
Example: April 20
Minus 3 mo. = January
Add 7 days = 27
EDC January 27


Establish EDC by Ultrasound (US)

- CR length (crown-rump)
Most accurate method
7 – 13 weeks’ only


Establish EDC by US

BPD (biparietal diameter)
After 13 weeks’ gestation
Earlier is better
16-18 weeks’: +/- 7 days
End of preg.: +/- 4 weeks
Femur length comparison


History: Past Obstetric Data

Year of each previous pregnancy
Gestational age at outcome
Abortion, preterm, term, stillborn
Length of labor
Type of delivery
Gender, weight
Neonate’s health status
AP, IP, PP complications?


Parity: TPAL

1. Term: 38 weeks’ gestation +
2. Preterm: 20-37 completed weeks’
3. Abortion: any pregnancy that ended prior to 20 weeks’ gestation
4. Living: alive today (not just born alive)


History: Current Medical Data

Perception of current health status
Height, weight, vital signs
Blood type & Rh?
Current acute or chronic conditions
Allergies ( anesthetic agents)
Exposure to communicable disease or colds/flu since pregnant
Exposure to teratogens - N1: Alcohol  since pregnant
Eating patterns ( Anorexia nervosa & Bulimia nervosa)
Exercise routines
Use of licit or illicit substances


History: Past Medical Data

Childhood diseases
Blood transfusions
Onset/treatment: anemia, asthma, blood dyscrasias, Ca, CVD, DM, endocrine disorders,
HPN, psychiatric disorders ( take meds) , renal or UT diseases ( UTI - pyelonephritis - preterm delivery) , TB ( cannot take TB drugs) 


History: Family Medical Data

Both sides; back to grandparents
If deceased, note cause of death
Ca, cardiopulmonary diseases, pregnancy complications, congenital anomalies, DM, HPN,
psychiatric disorders, renal disease, TB, vascular disease
Operative deliveries - forceps delivery


History: Gynecologic Data

1. Menstrual history
- Menarche ( first time period)
- Typical cycle
- Dysmenorrhea: Primary ( cramps, headache) - gets better after pregnancy; Secondary - severe pain endometriosis (scaring, stenosis) - doesnt get better after pregnancy
2. Sexual history & practices 
3. Contraceptive history & practices - IUD + pregnant - remove!!! sepsis 
4. Injuries to pelvic structures/organs


Physical Assessment

1. Empty bladder - pelvic exam; urinalysis; urine per culture and sensitivity !!! asymptomatic UTI - pyelonephritis - preterm delivery 
2. Private, comfortable room; respect modesty
3. Weight & VS, then PE
4. Review changes/danger signs every visit
Vaginal bleeding, loss of fluid, pelvic pain, back pain, abdominal pain, edema, HA, blurred
vision, contractions, no fetal movement ( fetus stops moving 8-12 hours before heart stops beating) 


Cardiovascular System

1. Heart rate increases 10-15 BPM
2. Blood volume increases 30-50%  ( when give birth bleed - 500 vaginal; 1000 C-section)

Estrogen (placenta) - STIMULATION  
3. Cardiac stroke volume increases ( more blood with each systole ) - cardiac output increases 40 % !!! to supply uterus and placenta to get that blood to fetus 

4. Cardiac output increases  - healthy women can handle ; pre existing  cardiac disease - HF during pregnancy

6. Slight decrease arterial BP ( 12-14 weeks gestation) 


Progesterone (placenta) - RELAXATION

7.Systolic heart murmurs common - heart shifts position - Grade 2 murmur ( stethoscope) - common, innocent 


Cardiovascular System

1. Vena cava syndrome AKA supine hypotensive syndrome ( 3 trimester)
- Position of woman
Compression of inferior vena cava or pelvic veins
Low BP, sweaty, dizzy

TX: get them off their back; turn to the side; sits or stands all day - walk around - skeletal muscles bring blood back up to the heart 


Cardiovascular System

1. Blood flow increased: some skin, GI, breasts, uterus
2. Blood flow unchanged: liver, brain
3. WBC rises: up to 12,000/ml normal
4. Blood hypercoagulable: fibrin, fibrinogen, clotting factors rise ( walk around)
5. Increased cholesterol, triglycerides, lipoproteins, fatty acids ( intact nervous system) 


Pseudoanemia (Physiologic Anemia of Pregnancy)

Blood volume rises - Plasma rises faster than RBC - hematocrit drops 7 %


Respiratory System

1. Progesterone causes respiratory center in brain to become more sensitive to CO2
2. Need more O2 for fetus, placenta, cardiac & respiratory effort, maternal tissues (uterus,
3. Kidney compensates; no changes in acid-base balance
4. Respiratory rate unchanged
-  Amount of air breathed/minute increases 40%
-  Breathing more efficient; less air in lungs after expiration
5. Mechanical changes
- Progressive flaring rib margins
- Breathing more diaphragmatic than costal


Gastrointestinal System

N/V common 1st TM
hCG & carbohydrate metabolism
“morning sickness”
Remedies: avoiding overly warm places, avoiding smell triggers, moving slowly in the
morning, dry crackers, avoiding greasy or spicy foods, eating small amounts frequently,
high protein foods, salty foods before meals, avoiding fluids with meals, peppermint tea
Take prenatal vitamins later in day, B6 50 mg/day, ginger capsules 250 mg 3x/day
Sea bands, acupressure, Reliefband
Need to differentiate normal “morning sickness” from hyperemesis gravidarum ( persistent; dehydration)