Week 6 pt 1: pregnancy

Question 1

Pregnancy induces profound changes in a woman’s anatomy and __________

Answer 1

physiology

Question 2

Maternal and fetal metabolic requirements increase as pregnancy progresses; a change in __________ output occurs to meet these demands.

Answer 2

cardiac

Question 3

What 2 parts of CO are increased in pregnancy?

Answer 3

1) Cardiac output (SV x HR)
2) Heart rate to compensate for extra volume
Approx. 10-20 bpm over baseline

Question 4

What 2 parts of CO are decreased in pregnancy? Explain

Answer 4

1) System vascular resistance (SVR)
-Hormones progesterone, relaxin are vasodilators and cause decrease in SVR
2) Systemic blood pressure, beginning around week 7 until around week 26, then gradually returns near baseline levels (so overall is relatively stable)
BP falls approx. 10 mmHg

Question 5

Aortocaval compression/IVC compression: When should you consider that this may be happening?

Answer 5

If BP is low during pregnancy and patient is experiencing symptoms, consider IVC compression:
-> 20 weeks gestation; supine position

Question 6

Growing uterus is compressing on IVC and/or aorta can threaten perfusion to body and/or placenta. What Sx does this lead to?

Answer 6

Less venous return > less cardiac output > BP falls > dizziness, lightheadedness, headache, presyncope > syncope

(This is why “pregnancy pillows” were created)

Question 7

More fluid in the body leads to what? Why?

Answer 7

1) Leads to daytime pedal edema
Nocturia/frequent nighttime urination
2) Increased venous return > increased preload > increased cardiac output > increased renal perfusion pressure > increased GFR > increase in urine output

Question 8

Describe the Hematological system’s expansion in volume in pregnancy

Answer 8

1) Expansion of the plasma volume and increase in red blood cell mass begin early (4th week of pregnancy)
2) Peaks at 28-34 weeks (third trimester) then plateaus

Question 9

Describe Physiological anemia of pregnancy

Answer 9

1) Plasma volume increases more quickly than red blood cell mass (dilutional anemia)
2) Prenatal vitamins contain iron to make more blood, carry more oxygen, combat anemia

Question 10

Describe the course of Anemia during pregnancy

(in a patient with Normal amount of hemoglobin and normal volume (12.1 – 15.1)
Normal hemoglobin on lab pre-pregnancy)

Answer 10

1) Early pregnancy until ~ week 26
-Same amount of hemoglobin, but increased blood volume
-Hemoglobin concentration falls = “anemia”
2) Pregnancy at ~ week 26
-Hemoglobin production has increased but still can’t keep up with blood volume.
-Hemoglobin concentration reaches lowest point.
3) Pregnancy after week 26
-RBC production begins catching up to blood volume
-Toward the end of term, hemoglobin returns to normal

Question 11

Hemoglobin concentration falls and anemia typically begins when?

Answer 11

Early pregnancy until wk 26

Question 12

Describe how Coagulability increases

Answer 12

1) Increase in clotting factors (7, 8, 9, 10) and fibrinogen
2) Meanwhile, fibrinolytic activity decreases

Question 13

Pregnant women may also experience less blood flow to _______ later during pregnancy because blood vessels within pelvis are compressed by growing uterus

Answer 13

legs

Question 14

What lifestyle change during pregnancy may predispose to blood clots?

Answer 14

Less active than normal (bed rest, etc.)

Question 15

What musculoskeletal occur in pregnancy? Why?

Answer 15

1) Increase in joint laxity, increased risk of sprain
2) Elevated levels of relaxin, help for delivery by softening the cervix and relaxing pubic symphysis14

Question 16

1) Why does PRL increase?
2) What does the increase in cortisol cause?

Answer 16

1) Breastfeeding; “pro-lactation”
2) Contributes to insulin resistance
-Causes striae “stretch marks”

Question 17

Hormonal changes during pregnancy allow for increased blood flow to kidneys and altered autoregulation, such that GFR ______________ approx. 50%

Answer 17

increases

Question 17

1) Why is there an Increase in corticotropin releasing hormone (CRH)?
2) Does insulin increase or decrease? Why?

Answer 17

1) Stimulant for labor
2) Maintain blood sugar levels (risk of gestational DM)

Question 18

Describe the effects of pregnancy on renal function

Answer 18

1) Increased urinary stasis due to smooth muscle relaxation of the renal pelvis, ureters, and bladder
This urinary stasis leads to increased risk of UTI
2) Uterus grows, pressing on bladder
Decreased bladder capacity due to uterine enlargement
3) Also, an increase in activation of RAAS system (renin-angiotensin-aldosterone system)

Question 19

Increased cardiac output leads to what chain reaction? Explain

Answer 19

1) Increased cardiac output > increased renal perfusion > increased GFR > low creatinine
2) Normally, 0.5 – 1.0
-During pregnancy, creatinine = 0.4 – 0.8

Question 20

Explain why pregnant women are at higher risk for a UTI

Answer 20

Dilation of urinary tract secondary to increased blood volume = greater risk of ascending infection

Question 21

Describe n/v in pregnancy and how to Tx

Answer 21

1) Nausea and vomiting (morning sickness)
2) Hyperemesis gravidarum: Diclegis: only FDA approved med for N/V in pregnancy
-Phenergan, Zofran, Reglan commonly used

Question 22

Why may constipation occur in pregnancy? Explain the physiology

Answer 22

1) Progesterone = vasodilator
2) Decrease transmit time in intestines > colonic relaxation > hard stools > constipation

Question 23

Why may hemorrhoids occur in pregnancy?

Answer 23

Increased fluid in veins, some of which are in rectum

Question 24

Why does GERD (heartburn) occur in pregnancy? How do you Tx?

Answer 24

1) LES (lower esophageal sphincter) relaxation plus compression of stomach by gravid uterus > reflux 2) Lifestyle changes, avoid caffeine, spicy foods, nicotine TUMS are safe during pregnancy

Question 25

True or false: Pregnancy increases risk of gallbladder disease

Answer 25

True

Question 26

Describe Breast enlargement in pregnancy

Answer 26

1) Mammary glands Proliferate in 1st trimester Differentiate in 2nd trimester Produce milk in 3rd trimester 3) Hormones involved: prolactin, oxytocin

Question 27

Describe 4 forms of hyperpigmentation in pregnancy

Answer 27

1) Melasma: “Mask of pregnancy” 2) Linea nigra: Darkening of the skin over linea alba 3) Linea alba – band of white, fibrous tissue running down from sternum to pelvis Latin – alba “white”; nigra “black” 4) Palmar erythema 5) Spider angioma: aka spider telangiectasia

Question 28

“How much weight gain in pregnancy is normal?”

Answer 28

1) If underweight to begin with, gain more -Build up adipose stores 2) If overweight to begin with, gain less -Adipose stores are adequate, weight gain should be due to placenta, fluid, fetus 3) More weight if having twins, but avg is 25-35lbs

Question 29

Weight gain in pregnancy should be due to what?

Answer 29

Amniotic fluid, placenta, fetus, maternal adipose stores

Question 30

High levels of progesterone and estrogen hormones during pregnancy can temporarily loosen the tissues and bones that keep teeth in place. What can this predispose to?

Answer 30

Gingivitis and/or periodontal disease if left untreated

Question 31

What is the placenta? What does it do?

Answer 31

1) Temporary organ that forms during pregnancy - attaching to lining of uterus 2) Deliver oxygen and nutrients to the baby through the umbilical cord

Question 32

Placenta fulfills several critical roles as the interface between mother and fetus; list 3

Answer 32

1) Transfers oxygen, nutrients from maternal to fetal circulation 2) Removes carbon dioxide and waste from fetal to maternal circulation 3) Secretes hormones to regulate metabolism and fetal growth and development

Question 33

1) What occurs days 1-3 post-fertilization? 2) What abt days 4-5?

Answer 33

1) Zygote (fertilized ovum) develops within fallopian tubes 2) Blastocyst forms after fertilization -Evolves trophoblast, hypoblast, epiblast, extraembryonic mesoderm

Question 34

What occurs days 5-11 after fertilization?

Answer 34

-Implantation: Trophoblast-cytotrophoblast-synciotrophoblast “Eats” its way into endometrium, embeds in endometrium, and gets covered with epithelium -Can sometimes lead to “implantation bleeding”

Question 35

Early Development Days 12-13 after fertilization: What becomes the yolk sac and continues to develop?

Answer 35

Hypoblast

Question 36

Early Development Days 12-13 after fertilization: 1) What will become amniotic cavity, amnion, embryo? 2) What happens with the Extraembryonic mesoderm?

Answer 36

1) Epiblast; continues to develop 2) Continues to proliferate Fluid-filled cavity forms as cavities converge, forming “chorionic cavity” or “gestational sac” which can be identified on ultrasound

Question 37

Describe Early Development Days 13-21 after fertilization

Answer 37

1) As each segment continues to develop, you see the chorion form circulatory structures 2) Chorionic cavity expands 3) Embryo and yolk sac are both present and are connected to chorion by ‘yolk stalk/connecting stalk’ which eventually becomes umbilical cord

Question 38

Describe early development after day 21

Answer 38

1) Structures continue to develop 2) Chorion and chorionic villi -Chorionic villi will give off circulation of placenta -Act as barrier between placenta and chorionic cavity -Provide circulation between placenta and baby -Communicating with ‘connecting stalk’ -Baby grows larger -Umbilical cord develops -Placenta grows into uterine wall -Amniotic fluid is produced

Question 39

What makes up the umbilical cord?

Answer 39

2 umbilical arteries; 1 umbilical vein

Question 40

Describe how fetal circulation works

Answer 40

1) Placenta accepts blood w/o oxygen from fetus through umbilical cord 2) Blood picks up oxygen in the placenta 3) Oxygen-rich blood returns to fetus, via umbilical vein 4) Oxygen-rich blood goes through one of two ‘extra’ connections in fetal heart that will close after birth

Question 41

1) Foramen ovale (can lead to a PFO if not closed) does what? 2) Ductus arteriosus (can lead to a PDA if not closed) does what?

Answer 41

1) Blood goes from right atrium to left atrium to left ventricle and out of aorta, blood with most oxygen goes to brain 2) Short vessel connecting pulmonary artery to aorta; allows oxygen-rich blood to bypass pulmonary circulation into systemic circulation

Question 42

List all the steps of fetal circulation

Answer 42

1) Oxygenated blood comes from placenta 2) Enters baby through umbilical vein 3) Tracks to the vena cava 4) Enters right atrium 5) Passes through foramen ovale (closes after birth, normally) -Enters left atrium -Passes mitral valve -Enters left ventricle -Pumps to aorta and systemic circulation 6) Passes tricuspid valve -Enters right ventricle -Pumps to pulmonary artery -Passes ductus arteriosus (closes after birth, normally) -Enters aorta -Enters systemic circulation 7) Deoxygenated blood returns to placenta via umbilical arteries

Question 43

Describe Preconception and Antepartum Care (commonly known as Prenatal Care

Answer 43

1) Do you plan to get pregnant in the next 12 months?” 50% of all pregnancies are unplanned 2) Want to lower risks of low birth weight, premature birth, and neonatal death 3) Promote mother’s health as well 4) Identify and manage complications early on 5) Lots of counseling

Question 44

List some prenatal counseling points

Answer 44

Diet Exercise Prenatal vitamins Smoking and alcohol cessation Medications Travel

Question 45

1) List some safe vaccines in pregnancy 2) List some vaccines that you should sometimes give depending on risk

Answer 45

1) Flu, pertussis, COVID-19, RSV, 2) Hepatitis, pneumonia and meningitis

Question 46

What should you test for prenatally?

Answer 46

1) Hepatitis B, Hepatitis C 2) Syphilis, HIV 3) Varicella titers, Rubella titers

Question 47

What prenatal bloodwork should you get?

Answer 47

1) ABO type 2) Rh antigen -If negative, consider alloimmunization (RhoGAM) 3) CBC: baseline Hgb/Hct 4) CMP: electrolytes, renal, liver, glucose 5) Pap smear

Question 48

Describe urine testing in pregnancy

Answer 48

1) Check protein and glucose: both can be elevated physiologically -Protein: monitor for kidney disease, pre-eclampsia -Glucose: watch for gestational diabetes 2) Gonorrhea/Chlamydia: Screen and treat if + 3) Urinalysis: Gram stain and culture if bacteria is found -Asymptomatic bacteriuria IS treated in pregnancy 4) Optional screening for aneuploidy: Chromosomal abnormalities