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John Dorsch, MD Director of Rural Health Programs University of Kansas School of Medicine – Wichita Family and Community Medicine And Family Practice Preceptor for Via Christi Regional Medical Center Wesley Medical Center These lecture notes are based on the CR-ROM by Dr. Dorsch and selected references from the course textbook (Swartz, Textbook of Physical Diagnosis, chapter 20) A Generally good Web Site for Women’s Health Issues: http://www.medscape.com SIGNIFICANCE OF MATERNAL MORTALITY IN THE UNITED STATES (FROM 1990-1995) • • • • • • • • • Embolism Hypertension Ectopic pregnancy Hemorrhage Stroke Anesthesia complications Abortion related Cardiomyopathy Infection 17% 12% 10% 9% 8% 7% 5% 4% 3.5%
GENERAL APPROACHES AND KEY ADJECTIVES FOR APPROACH TO THE PREGNANT PATIENT • • • • Use a gentle, steady approach Be thorough Be efficient Be systematic
INITIAL PRENATAL VISIT: Key Points • • • • • Provide time for a longer office visit, for example, 45 minutes Have patient come in early & complete paper work Help patient feel comfortable Begin interview with patient fully clothed Sit down & make eye contact
OTC & complimentary therapies • Allergies reactions • Emphasize need to communicate all medications considered during pregnancy • Social & home environment influences • Life-style issues: diet. as with any initial health care visit Attitudes can indicate future parent-child relationship risk factors: • How does the patient feel about the pregnancy? • Was the pregnancy planned Underlying medical problems need to be identified. exercise. with hCG present as early as 8 days after fertilization • Depending on the specific test used. progesterone & hCG (human chorionic gonadotropin) • Currently used pregnancy tests are based on amount of hCG in blood or urine. alcohol. deliveries • Birth control (methods used) • Fertility – infertility issues • Anesthesia issues or reactions • Pelvic injury • Medications: prescription. especially: • Diabetes • Hypertension • Renal disease • Hemoglobinopathy • Isoimmunization • STDs • Significant other infections All components of PMH are important.• First visit is preferred at 6 weeks gestation (6-8 weeks) THOROUGH MEDICAL HISTORY: Key points • • Important. miscarriages. abortions. sleep. especially • Age • Last pelvic exam and pap smear • Menstrual history • Previous pregnancies. drugs. smoking… • ROS: pre-pregnancy weights & baselines • • COMMON SYMPTOMS OF PREGNANCY TO CONSIDER: Key points • Amennorrhea: • Results from high levels of hormones: estrogen. concentrated urine improves pregnancy detection rate of urine to equal that of serum testing • Test may be positive as early as 3-4 days after implantation • 98% of test results are positive within 7 days after implantation Nausea or “morning sickness of pregnancy”: • Most common between 8-14 weeks gestation • Hypersensitivity to odors may develop • Severe vomiting may result in dehydration or ketosis • 2 .
brittleness or softening • Increased sweating • Hirsutism Urinary Changes: • Increased frequency due to uterine pressure in early & late pregnancy Vaginal Discharge: • Increased asymptomatic. due to decreases in gastric mobility & gastric acid Backache: • Increased hormone secretions (estrogen & progesterone) • Increased pelvic relaxation • Loss of abdominal muscle tone • Increased uterine weight • Abdominal Enlargement: • Uterus rises out of pelvis into abdomen by 12th week of gestation • Quickening: • Usually felt at 20 weeks in primigravida. milky cervical mucous & vaginal discharge • • • 3 . with increased pigmentation • Raised Montgomery’s tubercles on areola • Colostrum secreted by 16th week • Heartburn: • Relaxation of gastroesophageal sphincter • Upward displacement of stomach due to uterine enlargement • Digestions delays. but earlier in multipara Skin Changes: • Hyperpigmentation • Linea alba darkens to linea nigra • Chloasma pigmentation of face • “Stretch Marks” or striae gravidarum • Nail changes increased grooving.• Breast Changes: • Increased tenderness • Increased vascularity & sense of heaviness • Nipples more erectile. white.
• • • Fatigue: • Common in early pregnancy Headaches: • Common. especially around 16 – 20 weeks gestation Other symptoms: • Varicose veins • Leg cramps • Edema of legs & hands • Constipation • Bleeding gums • Insomnia • Dizziness THOROUGH PHYSICAL EXAMINATION • Objectives: • Evaluate health of mother & fetus • Determine gestational age of fetus • Initial plan of care Measurements & Vital Signs: • Height & Weight • Baseline vital signs & BP Skin changes: choasma of face • • • • • Teeth & Gums: check for hypertrophy of gums (increased vascularity) Thyroid: symmetrical enlargement (R/O goiter) Heart & Lungs: (In later stages of pregnancy): • PMI elevated & lateral in 3rd trimester • Non-pathological systolic flow murmurs develop Diastolic murmur is always pathological Breasts & Nipples: Note expected changes • Everted nipples indicate possible interference with breast feeding • Discrete masses are considered pathological Abdomen: • • • • • Contour Skin changes: linea nigra. from 11-13 weeks gestation • • 4 . striae gravidarum Fetal movement (felt by 24 weeks) Uterine size & fundal height Fetal Heart Rate (FHR): (120-160 per minute) Fetal Heart Tones audible with Doppler.
5 may be harmful to fetus Diet Prenatal appointment schedule: • Monthly: up to 32 weeks gestation • Every 2 weeks from 32 to 36 weeks • Every week from 36 to 40 weeks Expected changes of pregnancy & selected important things to know • • • • 5 . Vagina & vulva Gestational Age 4-6 weeks 6-8 weeks 7-8 weeks 8-12 weeks INITIAL DISCUSSIONS WITH PATIENT • Expected weight gain • Ideal: 25-30 pounds total • 2 pounds per month: 1st & 2nd trimester • 1 pound per week average: last trimester Exercise and activity levels • Varies with physical conditioning of patient • Contact sports not recommended • Core temperature elevations about 101.• Genitalia • • • • External genitalia & anus: lesions & varicosities Vaginal leukorrhea Adenexal areas: corpus luteum cyst-like enlargment Bimanual & pelvic measurements COMMON SIGNS OF EARLY PREGNANCY Sign Goodell Hegar McDonald Chadwick • Extremities: • Varicosities • Edema Finding softening of cervix softening of uterine isthmus fundus flexes easily on cervix bluish color or cervix.
mandatory: completed at first visit CBC: UA: ABO & Rh typing Rubella titer Pap smear HBsAg VDRL • detects anemia. Virus infects fetus. renal disease. infections baseline for protein. which infects fetus. hemoglobinopathies. heart & hearing abnormalities in fetus) Screens for cervical intraepithelial dysplasia or neoplasia Hepatitis B surface antigen. causing congenital anomalies Highly recommended lab screening (not mandatory) at first visit: STD smears/cultures Gonorrhea. glucose: r/o diabetes. hypertensive disease of pregnancy checks compatibility of maternal-fetal blood types & need for Rhogam determine presence or absence of maternal Antibodies (Rubella causes blindness.8 mg of Folic Acid per day reduces the occurrence of fetal neuronal tube defect • Most prenatal vitamins contain 1 mg of folic acid • Prenatal vitamins with folic acid are often recommended for non-pregnant women of child-bearing age who are planning pregnancy • Calculating the Due Date or Expected Date of Confinement (EDC) Last menstrual period (LMP) LMP less 3 months Add 1 year + 7 days = EDC Or Nagele’s Rule: LMP Add 9 months + 7 days = EDC • A Prenatal Flow Sheet for recording visits is through & efficient MILESTONE LABORATORY TESTS • Routine. Chlamydia.• Prenatal Vitamins: • Maternal ingestion of 0. 6 . may cause fetal anomalies or RPR: screens for syphilis.4 – 0. Herpes Generally cause eye infections & blindness.
and signed informed consent by patient MILESTONE LAB TESTS & PROCEDURES SCHEDULED LATER IN PREGNANCY • 16-18 Weeks: Ultrasound: most accurate for dating pregnancy Not mandatory. • UA for protein & glucose (dip stick UA). Lower renal threshold in pregnancy 2+ or greater UA protein could signal pregnancy induced hypertension (PIH) • Serum glucose screen • Fundal height: measured from top of pubic bone to top of uterine fundus Measurement is most accurate from 20-36 weeks gestation Each 1 cm increase indicates one additional week of gestation 7 . but most commonly done • 17-21 Weeks: (when standardized values for this test are most accurate) Alpha Fetal Protein (AFP) Medical-legal point: Important to offer this test. BP temp. and document that it was offered It is not mandatory in the sense that the patient can refuse High levels may indicate neuronal tube defects in the fetus Low values (not as predictive) may be indicative of trisomy 21 &other trisomy defects Triple Screen: may be used. and combines the following: AFP SerumEstriol HCG 24-28 Weeks: 50 Gram Glucose Tolerance Test (glucose challenge) H & H: may repeat at 28 weeks (especially with anemia) • 28-36 Weeks Beta Hemolytic Streptococcus Screen Collect culture swabs from vaginal introitus (not cervix) If positive.HIV repiratory infections & other infections of newborns. Active herpes near due date indicates need for C-section birth requires permission. mother must be treated before delivery to prevent fetal sepsis • EVERY OB VISIT Monitor: • weight.
about 18-19 weeks) • Multipara (sooner.• • • • • • Edema: dependent edema from pressure on inferior vena cava & iliac veins Nausea & vomiting: most prominent from 8-14 weeks gestation Pain & contractions Fetal movements Discuss this at 16 weeks & ask patient to record when fetal movements are felt (usually between 17-18 weeks) Bleeding or discharge Recent illness & concerns MEASURING UTERINE SIZE • • • • • • • • • • Nulliparous uterus: 8 weeks gestation (or if second baby): 10 weeks: 12 weeks: Palpable just above symphysis pubis 12-14 weeks: 16 weeks: 20 weeks: 28 weeks: 34 weeks: 38-40 weeks golf ball size hand ball size baseball size soft ball size uterus rises up into abdominal cavity fundus palpable halfway between symphysis & umbilicus fundus at umbilicus (lower border) fundus halfway between umbilicus & xiphoid fundus just below xiphoid fundus drops (“lightening”) : MILESTONES TO MONITOR ON SUBSEQUENT OB VISITS • Fetus: • FHT with Doppler: 12 weeks • Quickening: 16-19 weeks (ask patient to keep track of movements) • Primipara (later. about 16 weeks) 16-18 Weeks: • Ultrasound • Offer AFP or Triple Screen: 17-21 weeks • 24-28 Weeks: • 50 Gm Glucose Tolerance Test (glucose challenge) • May repeat H&H at 28 weeks (anemia vs hemodilution) • Rhogam given if Rh negative 32 Weeks: • Encourage to enroll in Lamaze classes 36 Weeks: • Talk about when to go to the hospital • • 8 .
• • • • • • • • • • • What to do if water breaks Mucous plug Analgesia.5 – 13 cm measurement from the inferior border of the symphysis pubis to sacral promontory • Obstetric conjugate • • Also measured the AP diameter of the pelvic inlet. epidural Conduct of labor Need to IV access Episiotomy Post natal contraception Tour of birth center Practitioner for infant medical care Circumcision Feeding: breast – bottle PELVIMETRY: Key Points • Initial considerations • Pelvic shape • Diagonal conjugate • Obstetrical conjugate • Angle of subpubic arch • Coccyx Pelvic shapes • • • • Gynecoid (50% of women): Pelvic outlet is round & pubic arch is wide Ancticipated delivery is vaginal.5 – 2 cms from the posterior board of The symphysis pubis to the sacral promontory • Angle of pubic arch or subpubic arch 9 . sponanteous • • Diagonal conjugate • • One of the most import measurements of AP diameter of pelvic inlet 12. possible forceps Platypelloid (3% of women): Pelvic outlet is transversely oval & pubic arch is wide Anticipated delivery is vaginal. more accurately obtained by x-ray Diagonal conjugate minus 1. spontaneous Android (25% of women): Pelvis outlet is heart shaped & pubic arch is narrow Anticipated delivery could be vaginal with forceps or cesarean Anthropoid (24% of women): Pelvic outlet is vertically oval & pubic arch is narrow Anticipated delivery is vaginal. anesthesia.
a prominent inward pointing coccyx could indicate possible problems with vaginal delivery COMMON CLINICAL URGENT PATHOLOGICAL CONDITIONS • First trimester bleeding: consider normal implantation of ovum. with use of forceps or suction. especially with abdominal pain) abruptio placenta or placenta previa blood loss over 500 ml during first 24 hours after delivery false pregnancy (psychiatric considerations) • • • Second semester bleeding: Postpartum hemmorage: Pseudocesis: 10 . threatened abortion (ectopic pregnancy. or a cesarean section When palpated during bimanual examination.• • • • Coccyx • Estimation of angle of subpubic arch is done by using both thumbs. vaginal varicosities. cervicitis. & examiner externally traces descending rami down to ischia tuberosities A wide pubic arch (105 degrees or more) accommodates spontaneous vaginal delivery A narrow pubic arch (less than 90 degrees) indicates a more difficult Delivery.
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