OB Unit I StudyGuide

Obstetrics – Unit 1 Study Guide
Components of preconception care  activities that promote healthy mothers and babies must be initiated before period of critical fetal organ development  between 17 – 56 days after fertilization

Health Promotion
Risk Factor Assessment
Interventions
Nutrition  healthy diet (+ folic acid), optimum weight
Exercise and rest
Avoid substance abuse  tobacco, alcohol, “recreational” drugs
Use of risk-reducing sex practices
Attending to family and social needs
Medical history  immunities, family history, illnesses/infections, current use of medications, screenings for cancers
Reproductive history  contraceptive, obstetric, STDs
Psychosocial history  family situation, domestic violence, support systems, readiness for pregnancy
Financial resources
Environmental conditions  safety hazards, toxic chemicals, radiation
Anticipatory guidance/teaching
Treat medical conditions  medications, cessation or  in substance use/abuse, immunizations
Nutrition, diet, and weight management
Exercise
Genetic counseling
Family planning

Major goals of prenatal care  should be addressed in 1st visit
Define health status of mother and fetus
Determine gestational age of fetus and monitor fetal development
Identify woman at risk for complications and  risk
Provide appropriate education/preparation and psychosocial counseling
Cost benefit of prenatal care = most effective at ↓ perinatal mortality and morbidity
Menstruation  periodic uterine bleeding that begins approximately 14 days AFTER ovulation
Controlled by feedback system between endometrial, hypothalamic-pituitary, and ovarian cycles
Puberty = entire transitional stage between childhood and sexual maturity
Menarche = 1st menstruation
Initially menstrual periods are irregular, unpredictable, painless, and anovulatory (no ovum released)
After ≥ 1 years  hypothalamic-pituitary rhythm develops, and ovary produces adequate cyclic estrogen to make a mature ovum  periods become more regular, monitored by progesterone
Menstrual cycle  average length = 28 days (but variations are normal)
Purpose = prepares uterus for pregnancy  no pregnancy = period
1st day of bleeding = day 1 of the menstrual cycle (menses)
Average duration of menstrual flow = 5 days (with a range of 3 – 6 days)  average blood loss is 50 mLs

Menstrual blood clots within uterus  clot usually liquefies before being discharged
Uterine discharge = mucus + epithelial cells + blood
Endometrial cycle  4 phases = menstrual, proliferative, secretory, ischemic phases
Menstrual Phase
Proliferative Phase
Secretory Phase
Ischemic Phase
Day 1 – 5
Shedding of functional 2/3 of endometrium
From 5th day to ovulation (day 14)
Rapid growth and thickening
Estrogen  produced in ovarian follicles during first ½ of cycle and causes endometrium to thicken
From ovulation to 3 days before next menstrual period (day 25)
Large amounts of progesterone are produced
Progesterone  prepares endometrium for reception and development of fertilized ovum by  blood supply and glycogen
Day 25 – 28
Corpus luteum regresses  due to lack of fertilization and implantation
Causes blockage to blood supply of endometrium
Necrosis and separation of functional layer of endometrium
Menstrual bleeding begins

Hypothalamic-pituitary cycle  toward end of menstrual cycle, blood levels of estrogen and progesterone 
Stimulates hypothalamus to secrete gonadotropin-releasing hormone (GnRH)
GnRH  stimulates anterior pituitary secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH)  both target ovaries
FSH  stimulates development of ovarian graafian follicles  prepares ovary for ovulation
LH  brings final ripening of graafian follicle and ovulation  peaks about 13 – 14 days in cycle, after which ovum is released

Ovary produces ova, which then secretes estrogen and progesterone
No fertilization or implantation = regression of corpus luteum =  estrogen and progesterone = triggers hypothalamus to secrete GnRH
Normal feedback regulation of menstrual cycle depends on an intact hypothalamic-pituitary mechanism
Ovarian cycle  before ovulation, graafian follicles mature under influence of FSH and estrogen
LH surge affects a selected follicle  leads to ovulation of ovum
Mittelschmerz = localized lower abdominal pain that coincides with ovulation
Follicle emptys after ovulation and transforms into corpus luteum
Luteal phase = immediately after ovulation to start of menstruation = 14 days
Corpus luteum starts to secrete estrogen and progesterone 
 in basal body temperature due to  progesterone
Normally viscous vaginal mucus becomes thin, clear, and stretchy = spinnbarkeit
No fertilization or implantation = corpus luteum regresses =  estrogen and progesterone
Abnormalities of menstrual cycle  premenstrual syndrome (PMS) = set of physical and behavioral symptoms which recur with luteal phase and cease with menstruation  typical signs/symptoms:
Edema / weight gain (fluid)
Abdominal bloating
Breast tenderness
 creativity
Insomnia
Fatigue
Headache
Backache
Irritability

Cell division 
Mitosis  body cells replicate to yield 2 cells with same genetic makeup as parent cell  used for growth and development or cell replacement
Meiosis  germ cells divide and  their chromosome number by ½  produces gametes
Results in cells that contain 1 of each of 23 pairs of chromosomes = haploid
Female gamete (egg or ovum) + male gamete (spermatozoon) = zygote (with diploid number of human chromosomes, 46 or 23 pairs)

Oogenesis  process of egg (ovum) formation which begins during fetal life of female
By 30 weeks gestation a female baby has all ova she will ever produce for a lifetime  6 – 8 million in utero, 1 – 2 million at birth, 300,000 by puberty
Each month, 1 primary oocyte matures and completes meiotic division
Forms cells with 22 autosomes and 1 X sex chromosome
Spermatogenesis  process of sperm formation within testes when a male reaches puberty (↓ after age 40)
Spermatocytes go through 2 meiotic divisions to make diploid number of chromosomes (1st division) then into haploid gametes
Final cells formed contain 22 autosomes and 1 sex chromosome (some with X and some with Y)
Conception  union of a single egg and sperm = beginning of a pregnancy
Ovum  created through meiosis in ovarian follicles
Released during ovulation from ruptured ovarian follicle
 estrogen levels =  motility of uterine tubes to move ovum to uterine cavity
Ovum is fertile for only 24 hours after ovulation  if unfertilized by sperm, ovum degenerates
Sperm  swim toward ovum (average transit time = 4 – 6 hours)
Most are lost in vagina, within cervical mucus, in endometrium, or enter tube that contains no ovum
Sperm remain viable within woman's reproductive system for an average of 2 – 3 days
Fertilization  takes place in ampulla (outer 1/3) of uterine tube
Sperm successfully penetrates membrane surrounding ovum  membrane becomes impenetrable to other sperm = zona reaction
Nuclei from ovum and sperm fuse to combine chromosomes  restores diploid number = conception
Forms zygote = 1st cell of new individual
Cleavage  mitotic cellular replication begins as zygote travels length of uterine tube into uterus

Morula = 16 cell ball of cells produced within 3 days after fertilization  forms into blastocyst
Implantation  blastocyst embeds within endometrium 7 – 10 days after conception (“nidation”)
Blastocyst becomes embryo  2 – 5 weeks where organs and definite form develops
Endometrium of uterus becomes thick and vascular to store nutrients and vitamins = deciduas
Chorionic villi tap into maternal blood vessels from deciduas (lies under implantation) = decidua basalis  later forms placenta
Portion of endometrium covering blastocyst (surrounds ovum) = decidua capsularis
Portion lining rest of uterus (main uterine cavity) = decidua vera
Intrauterine development  divided into 3 stages
Ovum Stage
Embryo stage
Fetus stage
From conception until day 14
Cellular replication
Blastocyst formation
Initial development of embryonic membranes
Establishment of primary germ layers
Day 15 until approximately 8 weeks after conception
MOST critical time in development of organ systems and main external features
Fetus most susceptible to teratogens
At end of 8th week  all organ systems and external structures are present
From 9th week until pregnancy ends
Refinement of structure and function takes place
Fetus is LESS vulnerable to teratogens  except for those that affect CNS functioning
Viability of fetus to survive outside uterus  limited to CNS function and oxygenation capability of lungs
Can be as early as 22 weeks
Standard = 24 weeks
Lungs with surfactant = more viable fetus at 25 – 28 weeks

Primary germ layers  form all tissues and organs of embryo
Ectoderm = upper layer of embryonic disk  forms epidermis, glands, nails and hair, central and peripheral nervous systems, lens of eye, tooth enamel, and floor of amniotic cavity
Mesoderm = middle layer  forms bones and teeth, muscles (skeletal, smooth, and cardiac), dermis and connective tissue, cardiovascular system and spleen, and urogenital system
Endoderm = lower layer  forms epithelium lining respiratory and digestive tracts, including oropharynx, liver and pancreas, urethra, bladder, and vagina
2 fetal membranes form at time of implantation 
Chorion  outer membrane that contains chorionic villi on its surface
Villi burrow into decidua basalis and  in size and complexity
Becomes covering of fetal side of placenta
Contains major umbilical blood vessels that branch out over surface of placenta
Amnion  inner membrane which forms a fluid-filled sac around embryo
Becomes covering of umbilical cord
Covers chorion on fetal surface of placenta  eventually comes in contact with chorion surrounding fetus

Contains amniotic fluid  amount of fluid  weekly
Average volume at term = 800 mL
Volume changes constantly  fetus swallows fluid, fluid flows into and out of fetal lungs, and fetus urinates into fluid to  volume
Oligohydramnios = < 400 mL  linked to fetal renal abnormalities
Polyhydramnios = > 2000 mL  linked to GI & other malformations
Serves many functions 
Helps maintain a constant body temperature
Source of oral fluid and as a repository for waste
Cushions fetus from trauma by blunting and dispersing outside forces
Allows freedom of movement for musculoskeletal development and prevents tangling with membranes
Umbilical cord  blood vessels develop by 7th week to supply embryo with maternal nutrients and O2
2 arteries carry blood from embryo to chorionic villi; 1 vein returns blood to embryo  AVA
Wharton's jelly  connective tissue that prevents compression of blood vessels and ensures continued nourishment of embryo/fetus
Nuchal cord = cord wrapped around fetal neck
Placenta  begins to form at implantation
Maternal-placental-embryonic circulation in place by day 17
Same time as heartbeat begins (at 3 weeks)
Embryonic blood circulates between embryo and chorionic villi
Maternal blood supplies O2 and nutrients to embryonic capillaries in villi
Waste products and CO2 diffuse into maternal blood

Functions of placenta 
Hormone Production
Metabolic Functions
Maintains pregnancy and supports embryo
Human chorionic gonadotropin (hCG)  detected in maternal serum by 8 – 10 days after conception (shortly after implantation)
Preserves function of corpus luteum  supplies estrogen and progesterone to maintain pregnancy until placenta forms
Miscarriage occurs if corpus luteum stops functioning (abnormally slow  or a  in hCG) before placenta can produce sufficient estrogen and progesterone
Reaches max level at 50 – 70 days and then begins to 
 hCG = may indicate ectopic pregnancy, abnormal gestation, or multiple gestation
Human placental lactogen (hPL)  stimulates maternal metabolism to supply needed nutrients for fetal growth
Progesterone  maintains endometrium,  contractility of uterus, and stimulates  of breast alveoli and maternal metabolism
Estrogen (estriol)  stimulates uterine growth and uteroplacental blood flow
Causes a proliferation of breast glandular tissue
Stimulates myometrial contractility
Greatly  toward end of pregnancy
Respiration, nutrition, excretion, and storage
O2 diffuses from maternal blood across placental membrane into fetal blood, and CO2 diffuses in opposite direction
Placenta functions as a lung for fetus
Carbohydrates, proteins, Ca+, and iron  stored in placenta for ready access to meet fetal needs
H2O, inorganic salts, carbohydrates, proteins, fats, and vitamins pass from maternal blood supply across placental membrane into fetal blood for nutrition
Fetal concentration of glucose < glucose level in maternal blood
Due to rapid metabolism by fetus
Maternal immunoglobulins provide early passive immunity to fetus
Metabolic waste products of fetus cross placental membrane from fetal blood into maternal blood
Maternal kidneys then excrete them
Things that can cross placenta  viruses, some bacteria and protozoa, drugs, caffeine, alcohol, nicotine, CO, cigarette smoke

NO direct link exists between fetal blood in vessels of chorionic villi and maternal blood in intervillous spaces  1 cell layer separates them
Breaks can occur in placental membrane  causes fetal erythrocytes to leak into maternal circulation
Mother may develop antibodies to fetal RBCs  Rh(-) mother becomes sensitized to erythrocytes of her Rh(+) fetus
Placental function depends on maternal blood pressure supplying circulation
Vasoconstriction caused by hypertension or cocaine use =  uterine blood flow
 maternal blood pressure or  cardiac output =  uterine blood flow
When woman lies on her back  pressure of uterus compresses vena cava = ↓ blood return to right atrium
Optimal circulation (placental perfusion) = woman is lying at rest on her side
 uterine circulation may lead to intrauterine growth restriction of fetus and infants who are small for gestational age
Multifetal pregnancy 
Dizygotic twins  2 mature ova are produced in 1 ovarian cycle and are fertilized by separate sperm
Always 2 amnions, 2 chorions, and 2 placentas (that may be fused together)
Can be same sex or different sex
NOT genetically more alike than other siblings born at different times
Monozygotic twins  identical twins developed from 1 fertilized ovum which divides
Are same sex and have same genotype
Division occurs 4 – 8 days after fertilization  produces 2 embryos, 2 amnios, 1 chorion, 1 placenta
Late division can result in incomplete cleavage = conjoined twins

Pregnancy terms 
Gravidity
Pregnancy (gravida = woman who is pregnant)
Parity
Number of pregnancies that have REACHED 20 weeks of gestation
Nulligravida
Woman who has NEVER been pregnant
Nullipara
Woman who has NOT carried a pregnancy of ≥ 20 weeks of gestation
Primigravida
Woman who is pregnant for 1st time
Primipara
Woman who has had 1 pregnancy of ≥ 20 weeks of gestation
Multigravida
Woman who has had ≥ 2 pregnancies
Multipara
Woman who has had ≥ 2 pregnancies to 20+ weeks of gestation
Viability
Capacity to live outside uterus  about 22 – 25 weeks of gestation
Preterm
Pregnancy ≥ 20 weeks ≤ 37 weeks + 6 days of gestation
Term
Pregnancy ≥ 38 weeks ≤ 40 weeks of gestation
Postterm
Pregnancy > 40 weeks ≤ 42 weeks of gestation

Gravidity and parity  information obtained during history-taking interviews
GP  gravidity value will always be ≥ parity value
G = number of pregnancies woman has had, INCLUDING present one
P = number of pregnancies that have REACHED 20 weeks of gestation
Para refers to pregnancies, NOT fetuses
TPAL  full term, preterm, abortions, living children
Provides more information about woman's obstetric history
T (or F) = total number of term births
P = number of preterm births
A = number of abortions (miscarriage or elective termination of pregnancy)
L = number of children currently living

Signs of pregnancy  presumptive vs. probably vs. positive
Presumptive  changes felt by woman (subjective) = amenorrhea, fatigue, breast changes, nausea/vomiting
Probable  changes observed by an examiner (objective) = Hegar sign, ballottement, pregnancy tests
Positive  signs attributed only to presence of fetus = hearing fetal heart tones, visualizing fetus, palpating FMs
Assessment for risk factors 
Complete an obstetric history 
History of present illnessnes
Complications of prior pregnancies
Size of previous babies, course of previous deliveries
Family history  genetic diseases or abnormalities, hypertension, DM, OB complications, etc.
Social history  is pregnancy welcome, support system, teen pregnancy
Use of recreational drugs  alcohol, caffeine, nicotine, illicit drugs, etc.
Assess for intimate partner violence (IPV)  1:6 women are raped in their lifetime
5 forms  physical, sexual, psychological, emotional, economic
Can begin or escalate with pregnancy
Assess for abuse in private  NEVER in front of male partner
Nurse must know local resources and how to determine safety needs of client
Provide services and telephone numbers of a hotline and women's shelter or other safe haven
Should assess for abuse at each prenatal visit and on admission to labor
Risk factors are interrelated and cumulative in their effects
Genetic Factors
Demographic Factors
Behavioral Factors
May interfere with normal fetal or neonatal development, result in congenital anomalies, or create difficulties for mother
Defective genes
Transmittable inherited disorders
Chromosome anomalies
Multiple pregnancy
Large fetal size
ABO incompatibility
Maternal age < 20 or ≥ 35 yrs =  trisomies
Advanced paternal age = new autosomal dominant mutations
Previous pregnancy with birth defects
Geographic location  availability and quality of prenatal care, or environmental factors
Socioeconomic status
 educational attainment
Unmarried status
Racial and ethnic origins  African-American babies have highest rates of prematurity and low birth weight
Occupational hazards  chemical, physical, biologic, and psychologic hazards
Exposure to teratogens and infections  TORCH (toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes infections)
Substance abuse  smoking, alcohol, drugs
Lack of prenatal care
Nutritional status  adequate nutrition is one of most important determinants of pregnancy outcome
Dental hygiene  periodontal disease  risk for preterm birth and low birth weight
Psychosocial stressors  relationship between emotional distress and birth complications
Abuse and violence  infections from forced sex, abruptio placenta, preterm birth, and low-birth-weight

Specific pregnancy problems and related risk factors 
Preterm Labor
< 16 yrs old or ≥ 35 yrs old
Low socioeconomic status
Maternal weight < 50 kg (110 lb)
Poor nutrition, smoking
Previous preterm birth
Incompetent cervix
Uterine anomalies
Drug addiction and alcohol abuse
Pyelonephritis, pneumonia, infection
Multiple gestation
Anemia
Abnormal fetal presentation
Preterm rupture of membranes
Placental abnormalities
Polyhydramnios
Diabetes mellitus
Multiple gestation
Fetal congenital abnormalities
Isoimmunization (Rh or ABO)
Nonimmune hydrops
Abnormal fetal presentation
Oligohydramnios
Intrauterine growth restriction
Intrauterine fetal death
Intrauterine Growth Restriction (IUGR)
Multiple gestation
Poor nutrition, smoking
Prior pregnancy with IUGR
Hypertension (chronic or gestational)
Recurrent antepartum hemorrhage
Maternal diabetes with vascular problems
Fetal infections
Fetal cardiovascular anomalies
Drug addiction and alcohol abuse
Hemoglobinopathies
Postterm Pregnancy
Perinatal hypoxia, acidosis
Placental insufficiency
Chromosome Abnormalities
Maternal age ≥ 35 years at birth
Balanced translocation (maternal and paternal)

High risk pregnancy  life or health of mother or infant is jeopardized by a disorder dealth with or unique to pregnancy
Maternal health problems 
Leading causes = hypertensive disorders, infection, hemorrhage
Fetal and neonatal health problems 
Leading causes = congenital anomalies, preterm delivery,  birth weight, respiratory distress syndrome, effects of maternal complications, and SIDS
Receiving good prenatal care significantly  potential of developing fetal health problems
Antepartum testing  major expected outcome = detection of potential fetal compromise
Adolescent pregnancy  have  association with anemia, preeclampsia, CPD, STDs, IUGR, ineffective parenting
Things to assess:
Nutritional status
Attitude regarding pregnancy
Social support, peer activities
Financial status
Previous history of menstrual or OB complications
Education level
Access to prenatal care

Nursing interventions 
Avoid authority role
Encourage support person to attend prenatal visits
Encourage normal activities and promote childbirth education classes
Teach nutrition as well as dangers of alcohol, smoking, and drug use
Tests used to determine fetal well being and/or genetic screening 
Diagnostic testing  pap smear, serologic testing for syphilis, rubella titer, maternal blood type with Rh factor, gonococcus smear and Chlamydia, sickle cell prep, HIV, hepatitis, all STDs, GBS
Nursing assessment focus 
STDs and Infections
Cystitis/UTI
Pyelonephritis
HELLP syndrome
Preeclampsia
Abuse
Deep vein thrombosis (DVT)
Pregnancy induced hypertension (PIH)
Disseminated intravascular coagulation (DIC)

Diagnostic ultrasonography (ultrasound)  provides information regarding:
1st Trimester
Confirm pregnancy, viability, and presence of cardiac activity
Detect presence and location of IUD
Determine gestational age (more accurate during first 20 weeks of gestation)
Detect maternal abnormalities  bicornuate uterus, ovarian cysts, fibroids
Detect multiple gestation
Rule out ectopic pregnancy
Visualization during chorionic villus sampling
2nd Trimester
Establish or confirm dates
Confirm viability and placental placement
Detect congenital anomalies
Detect intrauterine growth restriction (IUGR)
Detect polyhydramnios, oligohydramnios
Visualization during amniocentesis
3rd Trimester
Confirm gestational age and viability
Detect macrosomia or IUGR
Detect congenital anomalies
Determine fetal position
Detect placental maturity
Detect placenta previa or abruptio placentae
Biophysical profile
Assess amniotic fluid volume
Doppler flow studies
Visualization during amniocentesis

Nonstress test (NST)  most widely applied technique to determine fetal well being
Normal fetus produces characteristic heart rate patterns in response to fetal movement
Fetus with an intact central nervous system = 90% of gross fetal body movements are associated with fetal heart rate accelerations (almost all accelerations accompanied by FMs)
Lack of acceleration  may be due to hypoxia, acidosis, drugs (analgesics, barbiturates, and β-blockers), fetal sleep, and some congenital anomalies
Noninvasive, relatively inexpensive, and has no known contraindications
Slightly less sensitive in detecting fetal compromise than are CST or BPP
Procedure  woman is seated in a reclining chair (or in a semi-Fowler position) with a slight left tilt to optimize uterine perfusion and avoid supine hypotension
FHR is recorded with a Doppler transducer
Tocodynamometer is applied to detect uterine contractions or fetal movements
If < 32 weeks gestation  look for 10 beats/min above baseline lasting for 10 seconds over a 30-minute strip
If ≥ 32 weeks gestation  look for ≥ 2 accelerations of 15 beats/min lasting for 15 seconds over a 20-minute period
If fetus is unreactive  apply vibroacoustic stimulation (“buzz”) for 3 seconds on maternal abdomen over fetal head
Repeated at 1-minute intervals up to 3x when there is no response
If test does NOT meet criteria for reactive test after 40 minutes = nonreactive  requires further assessments with a CST or BPP
NST should be performed 2x weekly (after 28 weeks of gestation) with patients who have diabetes or are at risk for fetal death

Contraction stress test (CST)  used to identify jeopardized fetus that was stable at rest but showed evidence of compromise after stress
Uterine contractions  uterine blood flow and placental perfusion
If sufficient to produce hypoxia in fetus  deceleration in FHR results = underlying uteroplacental insufficiency (usually uterine contractions usually do NOT produce late decelerations)
Reactive NSTs and negative CSTs = fetal well-being
Biophysical profile (BPP)  noninvasive dynamic assessment of a fetus based on assessment of acute and chronic markers of fetal disease
Includes fetal respirations, fetal movements, fetal tone, fetal heart rate (FHR) patterns via nonstress test (NST), and amniotic fluid volume
Typically performed if NST is non-reactive (so NST value would be 0)

Variable
Normal (Score = 2)
Abnormal (Score = 0)
Breathing Movements
At least 1 episode in 30 min, each lasting ≥ 30 sec
Episodes absent or no episode ≥30 sec in 30 min
Gross Body Movements
At least 3 trunk or limb movements in 30 min
< 3 episodes of body or limb movements in 30 min
Muscle Tone
At least 1 episode of active extension with return to flexion of fetal limb or trunk
Absence of movement or slow extension/flexion
Amniotic Fluid Volume
AFI >5 cm or at least one pocket >2 cm
AFI ≤5 cm and no single pocket >2 cm
Non-Stress Test (NST)
Reactive
Nonreactive

Central hypoxia causes fetus to alter movement, muscle tone, breathing, and heart rate patterns
Normal value = 8 – 10 (if amniotic fluid index is adequate)
Normal fetal biophysical activities = CNS is functional = fetus is NOT hypoxemic
Suspicious = 6  repeat testing next day
Abnormal = < 6
An abnormal score + oligohydramnios = labor should be induced
Reasons for performing BPP  hyperthyroidism, bleeding problems, lupus, kidney disease, diabetes mellitus, hypertension, pre-eclampsia, oligohyramnois, polyhyramnios, multiples, previous stillborn
Amniocentesis  performed to obtain amniotic fluid, which contains fetal cells
Possible AFTER week 14 of pregnancy  uterus becomes an abdominal organ and sufficient amniotic fluid is available for testing
Used for  prenatal diagnosis of genetic disorders or congenital anomalies (neural tube defects in particular, including spina bifida), assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease (isoimmunization from Rh disease)
Indicated for women > 35 years old for genetic testing
Results in 10 – 14 days for genetics, or within a few hours for fetal lung maturity results
Complications  fetomaternal hemorrhage, infection, abruption placentae, damage to intestines or bladder, amniotic fluid embolism, miscarriage, preterm labor, leakage of amniotic fluid
Standard practice to administer immune globulin D (RhoGAM) to Rh(-) woman
Chorionic villus sampling (CVS)  invasive procedure used to identify genetic disorders (EXCEPT spina bifida)
Typically performed between 10 – 12 weeks gestation
Receive results in 2 – 3 hours, up to 1 week
Involves removal of a small tissue specimen from fetal portion of placenta  reflects genetic makeup of fetus because chorionic villi originate in zygote
Complications  vaginal spotting or bleeding immediately afterward, miscarriage, rupture of membranes, chorioamnionitis, fetomaternal hemorrhage
Women who are Rh(-) should receive RhoGAM to avoid isoimmunization
Maternal serum alpha-fetoprotein (MSAFP)  used as a screening tool for genetic disorders in pregnancy
Screening is recommended for ALL pregnant women  identifies candidates for more definitive procedures of amniocentesis and ultrasound examination
Performed around 16 – 18 weeks gestation
AFP is secreted by fetal liver
Can be sampled in mom’s blood (maternal serum)
Used to screen for  neural tube defects (NTDs), Down Syndrome (associated with  MSAFP and  amniotic fluid AFP), renal defects, Turners Syndrome, esophageal/dudodenal atresia
 levels = associated with neural tube defects
 levels = associated with Down syndrome or other trisomies
Has a high false positive rate  can also be high with twins or when pregnancy is further along than previously thought
If positive result is given  repeat AFP or complete an amniocentesis
Coombs’ test  indirect Coombs’ test = screening test for Rh incompatibility
If fetus RBC mix with maternal RBC, Rh negative mom may make antibodies against fetal RBC
May cross placenta and attack fetus RBCs
May result in fetal anemia, O2 deficiency, heart failure or death
Direct Coombs = test on cord blood immediately after delivery
Indirect Coombs = test on maternal blood during pregnancy
Reproductive system and breast changes during pregnancy 
Uterus  changes in size, shape, and position
Fundus rises to height of symphysis pubis  uterine enlargement results from:
 vascularity and dilation of blood vessels
Hyperplasia  production of new muscle fibers and fibroelastic tissue
Hypertrophy  enlargement of preexisting muscle fibers and fibroelastic tissue
Development of deciduas
Mechanical pressure of growing fetus (after 3rd month)
At conception uterus is shaped like an upside-down pear  uterus becomes spherical or globular during 2nd trimester, then larger and more ovoid as it rises into abdominal cavity
Uterine enlargement determined by measuring fundal height  commonly used to estimate duration of pregnancy (measurement in cm ≈ weeks gestation from 16 – 38 weeks)
Measurement of fundal height may aid in identification of high risk factors 
Stable or  fundal height = intrauterine growth restriction (IUGR)
Excessive  fundal height = multifetal gestation (> 1 fetus) or hydramnios
Growing uterus eventually touches anterior abdominal wall and displaces intestines to either side of abdomen
Most of uterus rests against anterior abdominal wall  contributes to altering center of gravity
Softening and compressibility of lower uterine segment (uterine isthmus) occurs at around 6 weeks gestation = Hegar sign
Results in exaggerated uterine anteflexion during first 3 months of pregnancy
Uterine fundus presses on urinary bladder =  urinary frequency
Changes in contractility  after 4th month uterine contractions can be felt through abdominal wall = Braxton Hicks contractions
Irregular and painless  occur intermittently throughout pregnancy
Facilitates uterine blood flow and promotes O2 delivery to growing fetus
Cease with walking or exercise  do NOT  in intensity or duration or cause cervical dilation
Uteroplacental blood flow  rapidly  as uterus size 
O2 is extracted from uterine blood
3 factors that  uterine blood flow = low maternal arterial pressure, contractions of uterus, and maternal supine position
Factors that can  placental perfusion = hypertension, intrauterine growth restriction, diabetes mellitus, and multiple gestation
Quickening  recognition of fetal movements  typically around 16 – 18 weeks gestation
Commonly described as a flutter  difficult to distinguish from peristalsis
Fetal movements gradually  in intensity and frequency
Cervix  softening of cervical tip observed beginning of 6th week = Goodell sign (probable)
Passive movement of unengaged fetus = ballottement
Chadwick sign = violet-bluish color of cervix due to  vascularity around 6 – 8 weeks gestation
Vagina and vulva  pregnancy hormones prepare vagina for stretching during labor and birth
Causes vaginal mucosa to thicken, connective tissue to loosen, smooth muscle to hypertrophy, and vaginal vault to lengthen
Leukorrhea = white or slightly gray mucoid discharge with a faint musty odor  NORMAL!
Occurs in response to cervical stimulation by estrogen and progesterone pH of vaginal secretions more acidic  ranges from 3.5 – 6.0 (normal 4.0 – 7.0)
Due to  production of lactic acid
Provides more protection from some organisms  more vulnerable to other infections, especially yeast infections, because glycogen-rich environment of vagina is more susceptible to Candida albicans
Breasts  fullness, heightened sensitivity, tingling, and heaviness
Begins in early weeks of gestation  due to  levels of estrogen and progesterone
Nipples and areolae become more pigmented  secondary pinkish areolae develop, extending beyond primary areolae
Hypertrophy of sebaceous (oil) glands embedded in primary areolae (Montgomery tubercles)  keep nipples lubricated for breastfeeding
Development of mammary glands is functionally complete by midpregnancy
Lactation is inhibited until a  in estrogen level occurs after birth
Precolostrum = thin, clear, viscous secretory material  found in acini cells by 3rd month
Colostrum = creamy, white-to-yellowish-to-orange premilk fluid  may be expressed from nipples as early as 16 weeks of gestation

Normal physiologic adaptations to pregnancy 
Cardiovascular
Hematologic
↑ blood volume, hemodilution = physiologic anemia
↓ total peripheral resistance =  BP (both systolic and diastolic)
 SBP ≥ 30 mm Hg or  DBP ≥ 15 mm Hg over baseline pressure is significant finding = should be closely monitored
↑ cardiac output = slight  heart rate (10 – 15 beats/min above normal)
↑ O2 consumption = average respirations 16 – 24 breaths/min
↓ plasma colloid osmotic pressure + ↑ venous capillary hydrostatic pressure = physiologic edema
Diaphragm is displaced upward by enlarging uterus = shortness of breath
May experience sinus arrhythmia, premature atrial contractions, and premature ventricular systole
Compression of vena cava occurs in all women who lie on their backs during 2nd half of pregnancy
Supine hypotensive syndrome =  > 30 mm Hg in systolic pressure, then reflex bradycardia, cardiac output is  by half, and woman feels faint
Compression of iliac veins and inferior vena cava by uterus causes  venous pressure and  blood flow in legs = contributes to dependent edema, varicose veins in legs, and hemorrhoids
↑ clotting factors =  risk for clotting
 fibrinolytic activity (splitting up or dissolving of a clot) during pregnancy and postpartum period
↓ serum albumin =  colloid osmotic pressure =  risk for pulmonary edema
 normal Hgb values (11 – 16 g/dL) and Hct values (33% – 47%)
Anemia = Hgb ≤ 11 g/dL or Hct ≤ 32%
Total WBC count  during 2nd trimester and peaks during 3rd trimester
Platelets > 150,000
Renal
Endocrine
↑ renal plasma flow and GFR
↑ volume of urine held in pelvis and ureters =  urine flow rate
Stagnated urine +  glucose in urine +  urine pH =  susceptibility to UTIs
Bladder tone may  =  bladder capacity to 1500 mL
Compression of bladder by enlarging uterus results in urge to void even if bladder contains only a small amount of urine
Kidneys ability to excrete H2O less efficient later in pregnancy
Causes pooling of fluid in legs = physiologic or dependent edema
Causes  renal blood flow and GFR
Normal diuretic response starts when woman lies down, preferably on her side  fluid reenters
↑ estrogen = ↑ renin–angiotensin II–aldosterone secretion
↑ progesterone = block aldosterone effect (slight ↓ Na+)
↑ vasodilator prostaglandins = resists angiotensin II (slight ↓ BP)
Blood pH  slightly
Peripheral vasodilation and  sweat gland activity help dissipate excess heat resulting from  BMR
 basal temperature = average of 97 – 100o F
Gastrointestinal
Musculoskeletal
Nausea with or without vomiting  due to  levels of hCG and altered carbohydrate metabolism
Gums become hyperemic, spongy, and swollen  tend to bleed easily due to  levels of estrogen  Ca+ and phosphorus requirements during pregnancy  dietary devidiency may deplete mother’s bony stores, but does NOT draw Ca+ in her teeth
Iron absorbed more readily in small intestine to provide sufficient amounts for fetus to have a normal Hgb level (even if woman is anemic)
 progesterone production causes:
 smooth muscle tone and motility = esophageal regurgitation and reverse peristalsis = heartburn (pyrosis)
 GI motility =  H2O absorption from colon = constipation
Gallbladder distended due to  muscle tone during pregnancy =  emptying time and thickening of bile
Hypercholesterolemia =  risk for developing gallstones
Noticeable changes in posture  due to gradually changing body and  weight
Pelvis has a forward tilt,  abdominal muscle tone, and  weight bearing
Center of gravity shifts forward
 in normal lumbosacral curve (lordosis) + compensatory curvature in cervicodorsal region (↑ anterior flexion of head)
Waddling gait
Slight relaxation and  mobility of pelvic joints  from Relaxin
Integumentary
Neurologic
Alterations in hormone balance and mechanical stretching of skin
Hyperpigmentation  due to  melanotropin
Darkening of nipples, areolae, axillae, and vulva
Facial melasma (aka chloasma) = blotchy, brownish hyperpigmentation of skin over the cheeks, nose, and forehead, especially in pregnant women with dark complexions
Sun  this pigmentation in susceptible women
Usually fades after birth
Linea nigra = pigmented line extending from symphysis pubis to top of fundus in midline
Striae gravidarum (aka stretch marks)  caused by action of adrenocorticosteroids which cause separation within underlying connective skin tissue (collagen)
Occur over areas of maximum stretch  abdomen, thighs, and breasts
Usually fade after birth, although they never disappear completely
Angiomas (aka vascular spiders) = tiny, star-shaped or branched, slightly raised, and pulsating end-arterioles
Sensory changes in legs  due to compression of pelvic nerves or vascular stasis caused by enlargement of uterus
Pain from dorsolumbar lordosis
Carpal tunnel syndrome  from edema of peripheral nerves during 3rd trimester
Acroesthesia  numbness and tingling of hands caused by stoop-shouldered stance “Light-headedness,” faintness, and syncope (fainting)  due to vasomotor instability, postural hypotension, or hypoglycemia
Hypocalcemia  may cause muscle

Physical effects of hormones during pregnancy 
Follicle Stimulating Hormone (FSH)
Produced by anterior pituitary gland
Prepares ovary for ovulation
Luteinizing Hormone (LH)
Produced by anterior pituitary gland
Brings final ripening of graafian follicle in ovary for ovulation
Progesterone
Maintains pregnancy  especially in 1st trimester
Smooth muscle relaxant  stops uterus from contracting
Develops acini cells and lobules of breasts for lactation
Makes the GI system sluggish
Suppresses secretion of FSH and LH by anterior pituitary
Causes fat to deposit in subcutaneous tissues over maternal abdomen, back, and upper thighs
 mother's ability to use insulin (insulin demand  with 3rd trimester)
Estrogen
After conception  placenta produces estrogen in 7th week
Stimulates uterus to provide a suitable setting for fetus
Helps develop ductal system of breasts in preparation for lactation
Responsible for skin changes during pregnancy
Suppresses secretion of FSH and LH by anterior pituitary
Causes fat to deposit in subcutaneous tissues over maternal abdomen, back, and upper thighs
 mother's ability to use insulin (insulin demand  with 3rd trimester)
Promotes enlargement of genitals, uterus, and breasts
 vascularity, causes endometrium to thicken
Relaxes pelvic ligaments and joints
Interferes with folic acid metabolism
 level of total body proteins
Promotes retention of Na+ and H2O
 secretion of HCl and pepsin
Human chorionic gonadotropin (hCG)
Secreted by developing ovum and by placenta
Maintains corpus luteum production of estrogen and progesterone until placenta takes over function
Secreted in woman’s urine  gives positive pregnancy test
Human Placental Lactogen (HPL)
Acts as a growth hormone (stimulates breast development for lactation)
 maternal metabolism of glucose
 resistance to insulin = need more insulin
Facilitates glucose transport across placental membrane
 amount of fatty acids for metabolic needs
Relaxin
Ovarian hormone that assists in softening of connective and collagen tissue  true pregnancy hormone
Inhibits uterine activity,  strength of uterine contractions
Aids in softening cervix
Allows for loosening of pelvic ligaments  in preparation for childbirth
Prostaglandins (PGs)
Oxygenated fatty acids classified as hormones produced by most organs of body (including uterus)
Lipid substances that occur in high concentrations in female reproductive tract (menstrual blood is a potent source of PGs)
Metabolized quickly by most tissues  are biologically active in cardiovascular, GI, respiratory, urogenital, and nervous systems
Exert a marked effect on metabolism  particularly on glycolysis
PGs affect smooth muscle contractility and modulation of hormonal activity
Effect on ovulation, fertility, changes in cervix and cervical mucus, tubal and uterine motility, sloughing of endometrium (menstruation), onset of miscarriage and induced abortion
Thought to play role in onset of labor (term and preterm)

Pregnancy  lasts about 10 lunar months = 40 weeks = 280 days
Divided into three 3-month periods = trimesters
1st trimester = weeks 1 – 13
2nd trimester = weeks 14 – 26
3rd trimester = weeks 27 – term gestation (38 – 40 weeks)
Estimated date of birth  Nägele's rule is reasonably accurate
(1st day of LMP) - (3 months) + (7 days) + (1 year)
Most women give birth during period extending from 7 days before to 7 days after EDB

3 trimesters of pregnancy 
Health teachings regarding discomforts of pregnancy  dyspepsia, nausea/vomiting, constipation, flatus, varicosities, hemorrhoids, dependent edema, backache, leg cramps,  vaginal discharge, urinary frequency, dyspnea, pyrosis
Important things to teach during antepartal period  rest and sleep, exercise, travel issues, dental care, elimination, weight gain, sexual relationships, sibling preparation

1st Trimester
(Weeks 1 – 13)
2nd Trimester
(Weeks 14 – 27)
3rd Trimester
(Weeks 27 – 40)
Developmental Tasks
Establish and accept pregnancy
Tries on role  may wear maternity cloths before needed
Seek out other couples who are expecting
Adopt a pet
Works through old conflicts with siblings and parents
Loosening of defense mechanisms in preparation for role change
Perceive fetus as a separate individual
Pregnancy now becomes real
Continues to work through parent and sibling conflicts
Fantasizes about what it will be like to be a parent
Identifies parental role and “takes on” this role by selecting behaviors
Prepare for separation of baby
Establish a care-taking relationship
Needs to differentiate fetus from self
Prepares for physical separation and delivery
Takes on parenting role and gives up behaviors incompatible with parenting
Fantasizes about physical appearance and behavior of baby
Feelings
“Who, me pregnant?” “Now?”
Sense of unreality about pregnancy
Frequently feel ambivalence about pregnancy
Seeks confirmation of pregnancy by focusing on body changes
Starts to think about new role (finances, career choices?)
Uncertainty about reality of pregnancy disappears as fetal movement is felt
Changes in lifestyle
Fantasizes who baby will be like
Mood swings, irritability, ↑ sensitivity
Changes in sexual desire
Feels like pregnant forever
Sense of “realness” about baby
Vulnerable to loss, rejection, insults
Protective and focused on unborn baby and her body
Less active  turns inward, introverted
Anxiety about labor and delivery, loss of bodily control (fears death or may fear birth of defective infant)
Physical Manifestations
Menses cease
Basal body temperature ↑
Nausea and vomiting may occur
Enlargement, tenderness and tingling of breasts
Frequency of urination due to enlarged uterus
↑ vaginal secretions
Chadwick’s sign, Hegar’s sign, Goodell’s sign
Fundus rises to height of symphysis pubis
Mother gains 2 – 4 pounds
↓ sexual desire due to fatigue, nausea and vomiting
Abdomen enlarges
Quickening in 5th month
Heartburn, constipation
Fundus rises to point slightly above umbilicus at 20 weeks
May have leg cramps (↑ phosphorus levels prevent Ca+ absorption)
Fetal heart is audible
Fetal parts felt by doctor
Linea-nigra, chloasma, striae may develop
↑ flexibility in pelvis
Weight gain about 0.9 of a pound/week
Umbilicus protrudes
Fundus rises to height of xyphoid and then drops with lightening
Total weight gain is 25 – 30 pounds (average if pre-pregnancy weight is normal)
Shortness of breath
Varicosities (due to ↑ blood volume)
Backache and gait changes
Braxton-hicks contractions
Sexual intercourse uncomfortable in certain positions
Onset of labor
Teaching
Prevention for nausea  crackers before rising in AM, frequent small meals, avoid skipping meals
Need for childbirth education classes
Advise to avoid hot tubs (↑ risk neural tube defects and hypotension)
Provide anticipatory guidance about emotional and physical changes
Provide time for discussion of parenting behaviors
Provide anticipatory guidance regarding labor and delivery attachment and basic infant care
Provide opportunities for parents to discuss fears regarding parenting

Nutrition  nutrient needs are determined by stage of gestation
Nutrient
Dietary Purpose
Found In
Energy
PP = 1900 – 2200 kcal/day
Preg = + 300 kcal/day
Growth of fetal and maternal tissues
Carbohydrates, fats, and proteins
Protein
PP = 46 g
Preg = + 25 g
Synthesis of mammary glands, placenta
Rapid growth of fetus and uterus
Maintain colloidal osmotic pressure
Formation of amniotic fluid
Milk, meats, eggs, cheese (high biologic value)
Yogurt, legumes, nuts, grains
Fluid
PP = 2000 mL
Preg = 3000 mL
Exchange nutrients and waste products across cell membrane
Maintains body temperature
Promotes regular bowel function
Dehydration =  cramping, contractions, preterm labor
Caffeine  associated with  risk of miscarriage and giving birth to infants with IUGR
Limit intake to ≤ 300 mg/day (3 cups of coffee)
Water, milk, juices
Fruits, lettuce and other fresh vegetables
Fiber
PP = 25 g
Preg = 28 g
Promote regular bowel elimination
 long-term risk of heart disease, diverticulosis, and diabetes
Whole grains, bran
Vegetables, fruits, nuts and seeds
Calcium
PP = 1300 mg
Preg = 1300 mg
Maintains maternal bone mass
Fetal bone and tooth development
NO  needed during pregnancy
Milk, cheese, yogurt, tofu
Collards, kale, turnip greens
Baked beans, tortillas, sardines
Iron
PP = 15 mg
Preg = 30 mg
Allows transfer of adequate iron to fetus
Permits expansion of maternal RBC mass
Pregnant women should receive a supplement of 30 mg of ferrous iron daily, starting by 12 weeks of gestation
 iron absorption = vitamin C
 iron absorption = bran, tea, coffee, milk, egg yolk (avoid taking supplement within 2hrs of consuming)
Iron deficiency anemia =  risk of preterm birth
Liver, meats, eggs
Whole grain or enriched breads and cereals
Deep green leafy vegetables, legumes
Dried fruits, prune juice
Folate (folic acid)
PP = 400 mcg
Preg = 800 – 1000 mcg
Prevents neural tube defects (failure in closure of neural tube)
Women who have borne a child with a NTD are advised to consume 4000 mcg of folic acid daily
Ready-to-eat cereals, enriched grain products, whole grains
Green leafy vegetables, fruits, orange juice, cantaloupe
Chicken liver, legumes
Vitamin A
PP = 700 mcg
Preg = 770 mcg
Adequate intake is needed so that sufficient amounts of vitamin can be stored in fetus
Toxic if taken in high doses
Deep green leafy vegetables, dark yellow vegetables
Liver, fortified margarine and butter, milk
Vitamin D
PP = 5 mcg
Preg = 5 mcg
Plays an important role in absorption and metabolism of Ca+
Toxic if taken in high doses
Fortified milk and margarine, egg yolk, butter
Liver, seafood
Sunshine
Vitamin E
PP = 15 mg
Preg = 15 mg
Protects against oxidative stress that occurs during pregnancy
Toxic if taken in high doses
Vegetable oils, cheese, fish
Green leafy vegetables
Whole grains, liver, nuts, seeds
Vitamin K
PP = 90 mcg
Preg = 90 mcg
Involved in blood coagulation and bone metabolism
Toxic if taken in high doses
Vitamin K deficiency =  PT (prothrombin time)
Severe cases result in hemorrhage
Green leafy vegetables, plant oils, tomatoes
Dairy products, margarine, soybeans, lentils
Vitamin B6 (Pyridoxine)
PP = 1.3 mg
Preg = 1.9 mg
Protein metabolism
Animal proteins, meats, liver
Deep green vegetables, whole grains
Vitamin B12
PP = 2.4 mcg
Preg = 2.6 mcg
Production of nucleic acids and proteins
Formation of RBCs
Neural functioning
Eggs, meats, liver
Milk and milk products, fortified soy milk

1st trimester of pregnancy  crucial for embryonic and fetal organ development
Synthesis of fetal tissues places relatively few demands on maternal nutrition  needs are only slightly  over those before pregnancy
2nd and 3rd trimester  period of noticeable fetal growth when most of fetal stores of energy sources and minerals are deposited
 in nutrient needs for pregnant woman
Weight gain  amount of maternal weight gain and pattern of weight gain during pregnancy have an important bearing on course and outcome of pregnancy
Caloric intake should be adequate to support recommended weight gain
Associated with a  risk of giving birth to a small-for-gestational-age (SGA) or preterm infant
Weight gain during pregnancy is best way to determine whether kilocalorie intake is adequate
Very underweight or active women  require more than recommended  in kilocalories to sustain desired rate of weight gain
Primary factor = appropriateness of prepregnancy weight for woman's height (BMI)
Body Mass Index (BMI) ranges 
< 18.5 = underweight
18.5 – 24.9 = normal weight
25.0 – 29.9 = overweight
30.0 – 34.5 = obese
35.0 – 40 = very obese

Severely underweight women  more likely to have preterm labor, LBW infants, and infant with intrauterine growth restriction (IUGR)
Greater-than-expected weight gain  may occur for multiple gestation, edema, preeclampsia, and overeating
 likelihood of macrosomia and fetopelvic disproportion, operative birth, emergency cesarean birth, postpartum hemorrhage, infections, birth trauma, and late fetal death
Obese women are more likely than normal-weight women to have preeclampsia and gestational diabetes
Adolescents are encouraged to strive for weight gains at upper end of recommended range for their BMI because fetus and still-growing mother compete for nutrients
Heart diseases  pregnancy affects cardiovascular system by normal physiologic changes in blood volume,  peripheral resistance, and  arterial dilation
Major types  rheumatic heart disease with mitral stenosis, mitral or aortic regurgitation, congenital heart anomalies, blood pressure problems
Gestational diabetes mellitus  any degree of glucose intolerance with its onset or 1st recognition during pregnancy
Typically identified after 20th week of gestation  pregnancy unmasks diabetes
Caused by hPL hormone  insulin resistance =  blood sugar levels
Maternal glucose is transported across placenta  primary fuel for fetus
Glucose levels in fetus are directly proportional to maternal levels
Insulin does NOT cross placenta  by 10th week of gestation fetus secretes its own insulin at levels adequate to use glucose obtained from mother
 maternal glucose levels =  fetal glucose levels =  fetal insulin secretion
Maternal hyperglycemia = fetal hyperglycemia  can lead to fetal acidosis
After birth and separation from maternal source of glucose  newborn becomes hypoglycemic
1st trimester  rising levels of estrogen and progesterone stimulate  insulin production
Promotes  peripheral use of glucose and  blood glucose
Women with insulin-dependent diabetes are prone to hypoglycemia (low blood glucose)
Oral hypoglycemic agents  need to be discontinued in preconception period
Women are started on insulin before pregnancy when pregnancy is planned or as soon as pregnancy is diagnosed when it is unplanned
Can be used for Type 2 DM in 2nd and 3rd trimesters
2nd and 3rd trimesters  hormonal changes cause  tolerance to glucose and  insulin resistance
Ensures an abundant supply of glucose for fetus
Maternal insulin requirements gradually  to about 36 weeks of gestation
Women with GDM are at significant risk of developing glucose intolerance later in life
Risk factors for developing GDM 
Maternal age > 30
Obesity
Family history of type 2 diabetes
Obstetric history  infant weighing > 9 lb, hydramnios, unexplained stillbirth, > 2 miscarriages, or an infant with congenital anomalies
Hypertensive disorders
Recurrent monilial vaginitis
Glucosuria on 2 consecutive visits to clinic or office
Complications associated with DM during pregnancy 
Early pregnancy loss
Fetal macrosomia (birth weight > 4000 – 4500 g)  causes disproportionate shoulder and trunk size =  risk for shoulder dystocia =  likelihood of cesarean birth
Preeclampsia or eclampsia
Preterm labor/birth more likely to occur
Polyhydramnios (amniotic fluid > 2000 mL)  can cause supine hypotension, premature rupture of membranes, preterm labor, postpartum hemorrhage
 infections
Hyperglycemia can lead to ketoacidosis during 2nd and 3rd trimesters  especially if infection or other illness occurs  can lead to intrauterine fetal death
Fetal hypoglycemia, respiratory distress syndrome, polycythemia, hyperbilirubinemia, congenital anomalies, hypocalcemia
Insulin requirements  change as pregnancy progresses = need frequent adjustments in insulin dosage
1st trimester  little or no change occurs in prepregnancy insulin requirements
Dosage may need to be  because of hypoglycemia
2nd and 3rd trimesters  insulin resistance from hormones causes need for  insulin dosage to maintain target glucose levels
Insulin-dependent diabetes is managed in most women with 2 – 3 injections/day
Typically administer regular (short-acting) insulin before each meal and longer-acting (NPH or Lantus) insulin at bedtime

Type of Insulin
Onset
Peak
Duration
Lispro (rapid acting)
Within 15 min
2 – 3 hr
3 – 4 hr
Regular (short acting)
30 min
3 – 4 hr
6 – 8 hr
NPH (Intermediate acting)
2 – 4 hr
4 – 12 hr
12 – 24 hr
Lantus (long acting)
3 – 4 hr
14 – 24 hr
24 – 36 hr

Hyperglycemia will most likely be identified in 2-hour postprandial values  blood glucose levels peak about 2 hours after a meal
Target levels of blood glucose during pregnancy are  vs. nonpregnant values 
Fasting levels are generally between 60 – 90 mg/dL
2-hour postprandial levels should be < 120 mg/dL
Report episodes of hypoglycemia (< 60 mg/dL) and hyperglycemia (> 200 mg/dL)
Preterm labor  occurs after 20th week but before 37th week of pregnancy
Consists of uterine contractions (periodic tightening or hardening of uterus ) that can cause cervix to open earlier than normal (efface and dilate)
Labor contractions = regular, frequent, and hard  may be felt as tightening of abdomen or backache
Seek medical assistance  uterine contractions ≤ 10 minutes for 1 hour or bloody spotting or leaking of fluid comes from vagina
Pregnancy induced hypertension (PIH)  aka gestational hypertension  systolic BP > 140 mm Hg and diastolic BP > 90 mm Hg detected 1st time after midpregnancy without proteinuria
Preeclampsia  pregnancy-specific syndrome determined by PIH + proteinuria
Usually occurs AFTER 2nd trimester of pregnancy (earlier with hydatidiform mole and hydrops)
Symptoms  hyperreflexia, ankle clonus, severe headache that won’t go away, visual problems, irritability, epigastric RUQ pain,  serum creatinine, generalized edema
Deep tendon reflexes (DTRs) evaluated to detect any changes  especially important if woman is being treated with magnesium sulfate (absence of DTRs = impending magnesium toxicity)
Ankle clonus  rhythmic oscillations (jerks) of ≥ 1 beats felt when foot is in dorsiflexion and seen as foot drops to plantar-flexed position
Examiner supports leg with knee flexed
One hand sharply dorsiflexes foot, maintains position for a moment, then releases foot
Normal (negative clonus) = no oscillations seen
Women who demonstrate an  in systolic BP + 30 mm Hg or an  in diastolic BP + 15 mm Hg from normal warrant close observation if BP  occurs with proteinuria and hyperuricemia (uric acid ≥ 6 mg/dL)
Risk factors  nulliparity, family history of preeclampsia, multiple gestation, obesity, and chronic hypertension, renal disease, type 1 DM
Main pathogenic factor = poor perfusion as a result of vasospasm
Arteriolar vasospasm  blood vessel diameter  impedes blood flow to all organs and  BP
Complications  intrauterine fetal death, uteroplacental insufficiency, abruptio placentae, preterm birth, and low birth weight
Maternal complications of preeclampsia  renal and liver failure, HELLP syndrome, cerebral edema with seizures, hepatic rupture, abruptio placentae, and eclampsia
HELLP syndrome  characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LPs)

Eclampsia  characterized by seizures from preeclampsia
Mortality rates are highest when eclampsia is seen early in gestation (< 28 weeks), maternal age is < 25 years, woman is a multigravida, and chronic hypertension or renal disease is present
Fetus has  risk of complications from abruptio placentae, preterm birth, IUGR, and acute hypoxia
Nonstress testing (NST), contraction stress testing (CST), biophysical profile (BPP), and serial ultrasonography is used to assess fetal status
Fetal heart rate (FHR) is assessed for baseline rate, variability, and presence of accelerations  abnormal baseline rate,  or absent variability, or late decelerations are indications of fetal intolerance to intrauterine environment
Treatment  important goal of care with preeclampsia = prevention or control of convulsions
Magnesium sulfate  drug of choice in prevention and treatment of convulsions caused by preeclampsia or eclampsia
Administered as a secondary infusion (“piggyback”) to main intravenous (IV) line
Initial loading dose of 4 – 6 g diluted in at least 100 mL of IV fluid per protocol or physician's order  infused over 15 – 30 minutes
Followed by a maintenance dosage of magnesium sulfate diluted in an IV solution per physician's order (40 g of magnesium sulfate in 1000 mL of lactated Ringer's solution)
Therapeutic serum magnesium level = 4 – 7.5 mEq/L or 5 – 7 mg/dL
May cause  arterial BP secondary to relaxation of smooth muscle
Monitor maternal vital signs, FHR, urine output, DTRs, IV flow rate, and serum levels of magnesium sulfate
Assess for magnesium sulfate toxicity  depressed respirations, oliguria, sudden  in blood pressure, hyporeflexia, fetal distress
Calcium gluconate = antidote for magnesium sulfate toxicity
Diuresis within 24 – 48 hours is an excellent prognostic sign  evidence that perfusion of kidneys has improved as a result of relaxation of arteriolar spasm
Delivery of fetus = definitive cure for disease
Hyperemesis gravidarum  excessive vomiting that causes weight loss of ≥ 5% of prepregnancy weight + dehydration, electrolyte imbalance, ketosis, and acetonuria
Usually begins during first 10 weeks of pregnancy  can be < 20 weeks gestation
Risk factors  women who are nulliparous, have  body weight, have a history of migraines, or are pregnant with twins or hydatidiform mole
Related to  levels of estrogen or human chorionic gonadotropin (hCG) and associated with transient hyperthyroidism during pregnancy
Manifestations  significant weight loss, dehydration,  BP,  pulse rate, poor skin turgor, cannot keep even clear liquids down, electrolyte imbalances
Complications  ketonuria, acetonuria, metabolic acidosis
Treatment  NPO + IV therapy for correction of fluid and electrolyte imbalances
NPO until dehydration has been resolved and for at least 48 hours after vomiting has stopped
Daily weights  TPN may be needed for nutrition
Urine checks for presence of ketones  signifies malnutrition
Monitor electrolytes (Na+, K+, Cl-)
Fetal heart tone monitoring q8h minimum
Commonly used medications  pyridoxine (vitamin B6) alone or in combination with doxylamine (Unisom), promethazine (Phenergan), and metoclopramide (Reglan)
Hemorrhagic disorders  bleeding in pregnancy may jeopardize maternal and fetal well-being = medical emergencies
Maternal blood loss  O2 carrying capacity  adversely affects O2 delivery to fetus
Fetal risk = blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth
Predisposes woman to  risk for hypovolemia, anemia, infection, preterm labor, and preterm birth
Hemolytic disorders  occurs when blood groups of mother and newborn are different
Occur when maternal antibodies are present naturally or form in response to an antigen from fetal blood crossing placenta and entering maternal circulation
Maternal antibodies of IgG class cross placenta  causes hemolysis of fetal RBCs
Results in fetal anemia and often neonatal jaundice and hyperbilirubinemia
Rh Incompatibility  aka isoimmunization  occurs when an RhD(-) mother has an RhD(+) fetus who inherits dominant Rh(+) gene from father
Person with Rh(+) blood can receive blood from person with Rh(-) blood without any problems
Person with Rh(-) blood does NOT have Rh antibodies naturally in blood plasma
Rh(-) blood can develop Rh antibodies in blood plasma if given Rh(+) blood
Rh(-) fetus is in NO danger  has SAME Rh factor as Rh(-) mother
Rh(-) fetus with an Rh(+) mother = NO danger
Only Rh(+) fetus of an Rh(-) mother is at risk  require RhoGAM shot
Give RhoGAM injection with abortions or when question with bleeding

Pathogenesis of Rh incompatibility 
Hematopoiesis (forms RBCs) in fetus pass through placenta into maternal circulation
If fetus is Rh(+) and mother is Rh(-)  mother forms antibodies (maternal sensitization) against fetal blood cells
Can occur during pregnancy, birth, abortion, or amniocentesis
Usually women become sensitized in 1st pregnancy with an Rh(+) fetus  do NOT produce enough antibodies to cause lysis (destruction) of fetal blood cells
Subsequent pregnancies  antibodies form in response to repeated contact with antigen from fetal blood = lysis results
Multiple gestations, abruptio placentae, placenta previa, manual removal of placenta, and cesarean delivery  incidence of transplacental hemorrhage and isoimmunization
Severe Rh incompatibility = marked fetal hemolytic anemia and  bilirubin levels  fetal erythrocytes are destroyed by maternal Rh(+) antibodies
1st prenatal visit of Rh(-) woman with a fetus who MAY be Rh(+)  indirect Coombs’ test performed to determine whether she has antibodies to Rh antigen
Maternal blood serum is mixed with Rh(+) RBCs
If Rh(+) RBCs agglutinate or clump = maternal antibodies present or mother has been sensitized
Indirect Coombs’ test repeated at 28 weeks 
Woman given an IM injection of RhoGAM prophylatically (weeks 28 and 34)
If negative result = sensitization has NOT occurred
If positive result = sensitization HAS occurred = test is repeated at 4 – 6 week intervals to monitor maternal antibody titer (should be < 1:16)
At birth, neonate's cord blood is sent to laboratory to determine infant's blood type and Rh status
Mother is given another RhoGAM injection within 72 hours after birth to prevent sensitization in Rh(-) woman who has had a fetomaternal transfusion of Rh(+) fetal RBCs
Direct Coombs’ test performed on cord blood  determines whether maternal antibodies are present in fetal blood
ABO Incompatibility  disorder produced by incompatibility of ABO groups
More common than Rh incompatibility, but causes less severe problems in infant
Blood types 

Type A
Type B
Type AB
Type O
Antigens On Surface of RBCs
A
B
A and B
None
Antibodies In Blood Plasma
B
A
None
A and B
Can Give To
A and AB
B and AB
A and B
A, B, AB, and O
Can Receive From
A and O
B and O
A, B, AB, and O
O

Occurs if fetal blood type = A, B, or AB + maternal type = O
Incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across placenta to fetus
1st born infants may be affected  mothers with type O blood already have anti-A and anti-B antibodies in their blood
Erythroblastosis fetalis  hemolytic disease of fetus
Results from maternal sensitization or immunization against fetal antigen
Can cause hyperbilirubinemia = jaundice  post delivery, baby will be placed under bili lights to treat jaundice
Rarely precipitates significant anemia resulting from hemolysis of RBCs
Induced abortion  purposeful interruption of a pregnancy before 20 weeks of gestation
Elective abortion = performed at woman's request
Therapeutic abortion = performed for reasons of maternal or fetal health or disease
Nursing care  monitor vital signs, provid emotional support, administer analgesics, and postop monitoring
Most common complications  infection, retained products of conception, and excessive vaginal bleeding
1st trimester abortion 
Surgical (aspiration)
Medical
Most common procedure
Usually performed under local anesthesia in a physician's office, a clinic, or a hospital
Ideal time for performing this procedure = 8 – 12 weeks after last menstrual period
Bleeding afterwards equal to heavy menstrual period, cramps not severe
Prophylactic antibiotics to  risk of infection are commonly prescribed
Postabortion pain relieved with NSAIDs
Used for < 9 weeks after last menstrual period
Methotrexate  given IM or PO  cytotoxic drug that causes early abortion by blocking cellular division misoprostol (Cytotec)  given vaginally (usually)  prostaglandin analog that acts directly on cervix (soften and dilate) and on uterine muscle (stimulate contractions)
Mifepristone (fka RU 486)  given PO  binds to progesterone receptors to block action of progesterone, which is necessary for maintaining pregnancy
Side effects of medications  nausea, vomiting, diarrhea, headache, dizziness, fever, chills (mostly due to misoprostol)

2nd trimester abortion  associated with more complications and costs more than 1st trimester abortions
Dilation and Curettage (D&C)
Dilation and Evacuation (D&E)
Other Procedures
Can be performed at any point ≤ 20 weeks of gestation
Surgical procedure  cervix is dilated and a curette used to scrape uterine walls and remove uterine contents
Performed > 16 weeks of gestation
Wide cervical dilation followed by instrumental removal of uterine contents
Larger cannual used  can cause long term harmful effects on cervix
Saline injected into uterus to start contractions
Prostaglandins
Laminaria (type of seaweed) to soften and dilate cervix

Miscarriage (spontaneous abortion)  end of pregnancy without medical or surgical method before 20th week gestation
Causes of antepartum fetal death  uteroplacental insufficiency, fetal abnormalities, cord accidents, abruption placenta, hydrops fetalis, fetal infection, maternal infection, abuse (drug, domestic violence)
Early miscarriage  occurs < 12 weeks of gestation
Late miscarriage  occurs between 12 – 20 weeks of gestation
Nursing interventions 
ID type of abortion
Monitor vital signs, level of consciousness, and amount of bleeding
Place IV with 18 gauge  large enough for blood product infusion, if necessary
Woman who is Rh(-) and has NOT developed isoimmunization  given an IM injection of RhoGAM within 72 hours of miscarriage
Types  threatened, inevitable, incomplete, complete, and missed
All types but threatened miscarriage can lead to infection

Type of Miscarriage
Description
Amount of Bleeding
Uterine Cramping
Passage of Tissue
Cervical Dilation
Management
Threatened
May lead to inevitable
Slight, spotting
Mild
No
No
Bed rest, sedation, and avoidance of stress and orgasm
Inevitable
Membranes rupture
Moderate
Mild – severe
No
Yes
Prompt termination of pregnancy (via D&C)
Incomplete
Some products of conception are expelled
Heavy, profuse
Severe
Yes
Yes
Prompt termination of pregnancy (via D&C)
Complete
All products of conception are expelled
Slight
Mild
Yes
No
Sontaneous evacuation if no hemmorage and no infection
Missed
Fetus dies during first ½ of pregnancy, but retained in uterus
None, spotting
None
No
No
Spontaneous evacuation or pregnancy terminated

Recurrent premature dilation of cervix (aka incompetent cervix)  passive and painless dilation of cervical os without labor or contractions of uterus
May occur in 2nd trimester or early in 3rd trimester  miscarriage or preterm birth may result
Risk factors  history of cervical trauma, excessive cervical dilation for curettage or biopsy, ingestion of diethylstilbestrol (DES) by woman's mother while pregnant with woman, short cervix
Treatment  prophylactic cerclage keeps cervix closed
Strong suture inserted into and around cervix
Placed at 12 – 14 weeks of gestation and removed towards end of pregnancy when greatest risk of miscarriage has passed
Can lead to premature rupture of membranes (PROM), preterm labor, chorioamnionitis
Tocolytics can be given to prevent uterine contractions and further dilation of cervix
Activity and intercourse are restricted
Ectopic pregnancy  fertilized ovum is implanted outside uterine cavity (typically in fallopian tube)
Missed period, but early signs and symptoms of pregnancy are NOT present, pregnancy test = positive
Manifestations  missed menstrual period, adnexal fullness, tenderness (from dull to a colicky pain) may suggest an unruptured tubal pregnancy, dark red or brown abnormal vaginal bleeding, possible palpable mass
Ruptured ectopic pregnancy =  pain, typically generalized and unilateral, referred shoulder pain (from diaphragmatic irritation caused by blood in peritoneal cavity), signs of shock (hypotension, tachycardia), ecchymotic blueness around umbilicus (Cullen sign)
Any woman with complaints of abdominal pain, vaginal spotting or bleeding, and a positive pregnancy test should undergo screening for ectopic pregnancy
Treatment  vital signs STAT, assess bleeding, start IV, prep for ultrasound and possible laparotomy, type and cross match for 2 units of blood or packed RBCs
Removal of ectopic pregnancy by salpingostomy + dose of methotrexate after surgery to dissolve residual tissue
Hydatidiform mole (molar pregnancy)  type of gestational trophoblastic disease (GTD)  mole resembles a bunch of white grapes
Hydropic (fluid-filled) vesicles grow rapidly  causes uterus to be larger than expected during 1st trimester
Complete mole contains NO fetus, placenta, amniotic membranes, or fluid 
NO fetal heart tones present
Ultrasound shows grape like mass
Hemorrhage into uterine cavity and vaginal bleeding occur
Manifestations  vaginal bleeding, dark brown (coffee-ground) vaginal discharge, abnormally large uterus for gestation timeframe, anemia from blood loss, hyperemesis gravidarum, abdominal cramps, PIH < 20 weeks
Complications  hyperthyroidism, pulmonary embolization, uterine rupture, gestational trophoblastic neoplasia
Treatment  suction curettage (D&C), administration of RhoGAM shot to women who are Rh(-) is needed to prevent isoimmunization
Advise woman that subsequent pregnancies should be avoided for 1 year  to avoid confusing signs of choriocarcinoma with signs of pregnancy hCG levels are measured weekly until zero  then monthly for 1 year
Client is predisposed to choriocarcinoma and infection
Placenta previa  placenta is implanted in lower uterine segment near or over internal cervical os
Types of placenta previa 
Complete, total, or central = internal os is entirely covered by placenta when cervix is fully dilated
Partial = incomplete coverage of internal os
Marginal = only an edge of placenta extends to internal os, but it may extend onto os during dilation of cervix during labor
Low-lying placenta = placenta is implanted in lower uterine segment but does NOT reach os
Placental abruption (premature separation of placenta)  aka abruptio placentae  detachment of part or all of placenta from its implantation site

Abruptio Placentae
Placenta Previa
Definition
Detachment of part or all of placenta from its implantation site
Occurs in area of decidua basalis after 20 weeks of pregnancy and before birth of baby
Placenta is implanted in lower uterine segment near or over internal cervical os
Occurs in 2nd trimester
Risk Factors
Maternal hypertension, cocaine use, blunt abdominal trauma, smoking, polyhydramnios
Previous placenta previa, previous cesarean birth, suction curettage for miscarriage or induced abortion, multiple gestation, multiparity, maternal age > 35 years, African or Asian ethnicity, and smoking
Bleeding
Absent – moderate
Hemorrhage often concealed
Dark red blood (“port wine”)
Minimal – severe  life threatening
Hemorrhage always external
Bright red blood
Shock
Common, often sudden, profound
Uncommon
Uterine Tonicity
Persistent uterine contraction  hard, boardlike uterus
Normal – soft (except during contractions)
Tenderness (pain)
SEVERE abdominal pain
Painless
Location of Placenta
Normal  upper uterine segment
Placenta NOT palpable vaginally
Abnormal  lower uterine segment
Placenta palpable vaginally  NO VAGINAL EXAMS!
Hypertension
Common PIH
NOT usually associated with PIH
Fetal Effects
Nonreassuring fetal heart pattern
NO fetal movements
Normal fetal heart rate pattern
Fetal movements unchanged
Complications
Hemorrhage, hypovolemic shock, hypofibrinogenemia, thrombocytopenia
Fetal hypoxia, late decelerations
Uteral-placental insuffiency
Preterm birth, IUGR, fetal neurologic deficits
PROM, surgery-related trauma to structures adjacent to uterus, anesthesia complications, blood transfusion reactions, overinfusion of fluids
Abnormal placental attachments, vasa previa, postpartum hemorrhage, anemia, thrombophlebitis, and infection
Uteral-placental insuffiency, IUGR
Fetal late decelerations, preterm labor and birth
Treatment
Immediate birth considered a medical emergency
Rest and close observation (for < 36 weeks gestation and NOT in labor and NOT actively bleeding)
Always considered a potential emergency  massive blood loss with resulting hypovolemic shock can occur quickly if bleeding resumes
May require an emergency cesarean for birth

Vaginal infections  caused by candida albicans (most common) or bacterial vaginosis
Signs and symptoms  grayish white to yellow secretions, distinictive “odor”, pruritis, burning, soreness, dyspareunia, dysuris, etc.
Treatment  creams, vaginal tablets
Promotion of breastfeeding  infant should be put to breast within 1st hour after birth
Breastfeeding aids in contraction of uterus and prevention of maternal hemorrhage
Suppression of lactation  necessary when woman has decided NOT to breastfeed or in case of neonatal death
Wear a well-fitted support bra or breast binder continuously for at least first 72 hours after giving birth
Avoid breast stimulation  running warm water over breasts, newborn suckling, or pumping of breasts

Important medications 
Drugs
Actions
Contraindications
Nursing Implications
Antihypertensive
hydralazine (Apresoline)
Direct-acting peripheral arteriolar vasodilator
Patients with cardiovascular or cerebrovascular disease
Severe renal or hepatic disease
Has been safely used during pregnancy and lactation
Administer with meals
May cause drowsiness, peripheral neuritis, and edema
Sedative
phenobarbital (Luminal, Solfoton)
Inhibits transmission in nervous system and  seizure threshold
Produces all levels of CNS depression
Lactation  discontinue drug if breastfeeding or bottle feed
Can cause drug dependency in infant
Monitor respiratory status, pulse, BP frequently
May cause marked drowsiness
Avoid taking other CNS depressants
Monitor for unusual bleeding or bruising, nosebleeds, or petechiae
Uterine Relaxant (tocolytic) magnesium sulfate
Treatment of choice to suppress preterm labor
Prevention of seizures in pregnancy
Severe PIH, cardiac disease
Vaginal bleeding, intrauterine infection, dilation >6 cm
Acute fetal distress or fetal death
Have calcium gluconate (antidote for magnesium sulfate) available for emergency administration for respiratory complications
Monitor blood pressure, respiration, and I&O
Check deep tendon reflexes
Monitor for altered mental status, positive Homan’s sign
Continous monitoring of maternal vital signs and fetal heart rate
Hematinic
ferrous sulfate (Iron)
Replaces iron stores need for RBC development, energy and O2 transport, utilization
Hypersensitivity
Ulcerative colitis/regional enteritis
Hemolytic anemia, cirrhosis
Monitor Hct, Hgb, reticulocytes, bilirubin
Assess for toxicity  nausea, vomiting, diarrhea (black/dark green stools), pallor, hematemesis, , cyanosis, shock, coma
Monitor for constipation
Take on empty stomach
Beta2 Agonist terbutaline (Brethenine)
Bronchodilator
Relaxes uterine smooth muscle
Hypersensitivity to sympathomimetics
Narrow-angle glaucoma
Tachydysrhythmias
Continous monitoring of maternal vital signs and fetal heart rate
Assess for dyspnea and wheezing
Monitor for hypotension and tachycardia
Assess for hyperglycemia