Physiologic Changes in Pregnancy

Hematologic
Hypercoagulable state
o clotting factors
o result of venous stasis secondary to uterine pressure on great veins of lower
extremity
Anemia
o plasma volume by 50%
o RBC mass only by 30%
o Result is a dilutional gap of 15-20%
Leukocytosis
o result of granulocyte demargination
no absolute increase in WBC number
Slight thrombocytopenia (still wnl)
Cardiac
Cardiac output by 50%
o result of heart rate and stroke volume
recall that CO = HR x SV
o flow changes
S2 split with inspiration
distended neck veins
systolic ejection murmor
diastolic murmor is NOT a normal finding during pregnancy
S3 gallop
BP in first 24 weeks with gradual return to normal
o peripheral vascular resistance due to progesterone mediated smooth muscle
relaxation
Dramatic shifts in cardiac physiology result in high pregnancy mortality in mothers
with cyanotic heart disease
o can result in Eisenmenger's syndrome
Pulmonary
Mucosal hyperemia
o nasal stuffiness
o increased nasal secretions
Respiratory rate
o driven by progesterone stimulation of respiratory drive centers
o results in chronic respiratory alkalosis with renal compensation
Vital capacity, inspiratory reserve do not change
PFTs that
o total lung capacity (TLC)
result of diaphragm elevation by expanding uterus
o functional residual capacity (FRC)
o residual volume (RV)
PFTs that
 o tidal volume
o minute ventilation
leads to respiratory alkalosis
PO2, CO2
allows fetal PCO2 to remain near 40 mmHg
GI
Progesterone leads to
o GI motility
o lower esophageal tone, leading to GERD
Risk of cholelithiasis
GI tract motility
Hemorrhoids due to
o constipation
o increased venous pressure
uterus compressing inferior vena cava
Renal
Progesterone leads to
o bladder tone
o urinary stasis predisposes to UTI / pyelonephritis
GFR
o glucose excretion
thus urine dipstick positive and NOT useful in managing diabetes
o NO significant in protein loss
o serum creatinine and BUN
Endocrine
Pituitary gland size and vascularity
o susceptibility to Sheehan's syndrome
Fasting glucose
Post-prandial glucose
o fetus produces own insulin at weeks 9-12
Thyroid binding globulin (TBG)
o due to estrogen
o leading to total T3 and T4
o free T3 and T4 remain same (pregnant women are euthyroid)
Cortisol and cortisol binding protein
Skin
Normal skin changes during pregnancy mimic liver disease
o due to estrogen
o can see spider angiomas
o can see palmar erythema
Hyperpigmentation due to
o melanocyte stimulating hormone
affects umbilicus
perineum
face
 linea nigra

Prenatal Care

Diagnosis
Symptoms of pregnancy
o amenorrhea
o urine frequency
o breast engorgement
o nausea
o bluish discoloration of vagina, vulva, and cervix due to vascular
congestion (Chadwick's sign)
o softening of cervix
Urine Pregnancy Test (UPT)
o detects hCG or B subunit
sensitive to 1-2 weeks
Ultrasound
o most accurate method to detect fetal size
gestational Sac - 5 weeks
fetal image detected at 6-7 weeks
cardiac activity at 8 weeks
Initial Workup-First visit
Estimated date of confinement (EDC)
o Nageles's Rule: LMP + 7 days - 3 mos + 1 yr
Ex.) LMP 4/19/12, EDC = 1/26/13
calculation based on regular 28 day cycle (only 20-25%)
o sonogram estimation
crown-rump length (CRL)
biparietal diameter (BPD)
of note, sonogram estimation of EDC is more accurate earlier in
pregnancy than later
Complete pelvic exam
o estimate uterine size
o PAP smear
o cultures for gonorrhea and chlamydia
Labs
o CBC
o blood type with Rh status
o urinalysis and culture
o RPR test for syphilis
o Rubella titer
 if not already immune DO NOT VACCINATE
recall MMR is a live virus vaccine
o TB skin testing
o offer HIV/HBV antibody test
o sickle cell prep
o TSH
hypothyroid women should have their dose of levothyroxine
increased if found to be pregnant. During pregnancy, increased
circulating levels of thyroxine-binding globulin (TBG) and
increased plasma volume increase demand for T4
Genetic counseling indicated by history
Recommend 25-35 lb weight gain during pregnancy
Consider folate, iron & multivitamins
First Trimester
Visit every 4 weeks
Evaluate
o weight gain / loss
o BP
o pedal edema
o fundal height
o urine dip for glucosuria and proteinuria
trace glucose is normal due to GFR
trace protein is not normal and should be evaluated
Estimate Gestational Age by Uterine Size
12 At pubic symphysis
weeks
16 Midway from symphysis to umbilicus
weeks
20 At umbilicus
weeks
20-36 Height (in cm) above pubic symphysis correlates with weeks of gestation
weeks

Second Trimester
Continue visits every 4 weeks
15-18 weeks
o offer triple marker screen (hCG, estriol, AFP)
used to detect neural tube defects or trisomies
17 weeks
o document movement
o amniocentesis if > 35 years old or history indicates
24 weeks
o glucose screening
25 -28 weeks
 o repeat Hct
Third Trimester
Every 4 weeks until week 28, then every two weeks, then every week after 36.
Routine third trimester tests
o urine analysis
o blood glucose
Inquire about preterm labor symptoms
o vaginal bleeding
o contractions
o rupture of membranes
28-30 weeks
o give RhoGAM if indicated
28-32 weeks
o mothers with pre-gestational diabetes should undergo twice weekly nonstress
testing until delivery
35-37 weeks
o screen for Streptococcus agalactiae (Group B Strep)
36-40 weeks
o cervical chlamydia and gonorrhea cultures if indicated

Alpha-fetoprotein (AFP)
Snap Shot
On a routine screening a 35-year-old pregnant female has low serum serum AFP
levels.
Introduction
Measured in routine screening around 15-18 weeks (second trimester)
AFP and amniocentesis can help detect
o neural tube defects
o trisomies
AFP is synthesized in the fetal liver, GI tract, and yolk sac
Elevated Maternal Serum AFP
Elevated MSAFP
o neural tube defects
anacephaly
meningomyelocele
encephalocele
o twin gestations
If the MSAFP measures twice the median value then evaluate by
o ultrasound
o amniocentesis
Decreased MSAFP
Decreased MSAFP
o Trisomy 21 (Downs Syndrome)
o Trisomy 18 (Edwards Syndrome)
Intrapartum Fetal Assessment
Biophysical Profile (BPP)
5 measurements of fetal well being, each rated on scale of 1-2
Scoring
o 8-10 is normal
o 6 is equivocal
delivery if > 36 weeks
repeat BPP in 24 hours if < 36 weeks
o 4 or less is abnormal
requires immediate intervention
Measure
o fetal breathing
o gross body movements
o fetal tone
extremity extension and flexion
o qualitative amniotic fluid volume
o reactive fetal heart rate
Fetal Heart Rate
Normal FHR 120-160
Tachycardia is FHR > 160 for more than 10 minutes
o causes include
maternal fever
fetal hypoxia
immaturity
anemia
infection
maternal thyrotoxicosis
Bradycardia is FHR < 110 for more than 10 minutes
o causes include
congenital heart block
fetal anoxia
maternal beta blockers
FHR variability
o reliable indicator of fetal well being
o suggest CNS oxygenation
o decreased variability associated with anomalies
Electronic Fetal Heart Rate Monitoring (EFM) Tracing Interpretation
Accelerations
o FHR at least 15 bpm above baseline for 15-20 secs
o suggests fetal well being
Early decelerations
o FHR (not below 100) that coincide with uterine contraction
o results from pressure on fetus head resulting in vagus nerve stimulation and
reflex bradycardia
 o physiologic and not harmful to fetus
Variable decelerations
does not coincide with uterine contractions
rapid in FHR (often < 100) with rapid return to baseline
relfex mechanism due to umbilical cord compression
correct by shifting maternal position or amnioinfusion if membranes ruptured
Late decelerations
begins after contraction has started
associated with uteroplacental insufficiency and viewed as potentially
dangerous
causes include
o placental abruption
o PIH
o maternal diabetes
o maternal anemia
o maternal sepsis
o postterm pregnancy
o hyperstimulated uterus
repetitive late develerations require intervention

Genetic Testing
Introduction
Chromosomal abnormalities account for
o 50-60% of spontaneous abortions
o 5% of stillbirths
o 3% of multiple miscarriages
Indications for genetic testing
o advanced maternal age (>35 years)
o prior child with chromosome or single gene abnormality
o known chromosomal abnormality
o abnormal results from prenatal screening test such as triple marker screen
Chorionic Villous Sampling
Introduction
o sampling of placental villi as a means of prenatal genetic testing
based on assumption that the placenta has the same genetic makeup
as the developing fetus
o can be performed at 10-12 weeks
can follow up an abnormal first trimester screen following
confirmatory ultrasound
Complications
o transverse limb abnormality
risk greatest when performed < 10 weeks
o rupture of membranes
o chorioamnionitis
Amniocentesis
 Introduction
o sampling of amniotic fluid as a means of prenatal genetic testing
based on capture of free-floating fetal cells in the amniotic fluid
also used to drain amniotic fluid in setting of polyhydramnios and
sample fluid when chorioamnionitis suspected
o can be preformed > 15 weeks
used to follow-up an abnormal quad screen
can only be considered after an ultrasound confirms gestational age,
single and viable intrauterine pregnancy, and the absence of fetal
abnormalities that might explain the abnormal quad screen
Complications
o rupture of membranes
o chorioamnionitis

Fetal Parameters
Ultrasound
Ultrasound most reliable method for assessing fetal growth
o earlier ultrasounds are almost always more accurate than late ultrasounds
never change the estimated gestational age based on an ultrasound
obtained late in the pregnancy
ultrasound is the next best step in management in
patient's with abnormal AFP, -hCG, inhibin, unconjugated
estriol levels
cases where you are unsure of fetal presentation
cases of painless vaginal bleeding and fetal bradycardia (vasa
previa)
any case where you suspect placenta previa (painless vaginal
bleeding, no fetal bradycardia)
Fundal Height
Least invasive
If 2 cm deviation from normal during weeks 18-36, repeat measurement and/or
ultrasound

Early Pregnancy Fetal Parameters

Useful in early pregnancy
o gestational sac
o crown-rump length
Late Pregnancy Fetal Parameters
Four measurement requirement due to wide deviation in normal for each
One of the most effective ways of evaluating gestational age
Includes
o cerebellar diameter (HC)
o biparietal diameter of skull (BPD)
o abdominal circumference (AC)
o femur length (FL)
 Presentation of Labor
Introduction
Progressive effacement and dilation of uterine cervix resulting from contractions of
uterus
Braxton Hicks contraction (false labor)
o uterine contractions without effacement & dilation of cervix
85% undergo spontaneous labor and delivery between 37 to 42 weeks
Presentation of Labor
Patients told to come to hospital when
o regular contractions q 5 min for at least 1 hr
o rupture of membranes
o significant bleeding
o decrease in fetal movement
On arrival to hospital
o auscultation of fetal heart sounds
o determine fetal position (Leopold maneuvers)
o vaginal exam to check
rupture of membrane (ROM)
cervical effacement and dilation
fetal station (level of fetus relative to ischial spine)
zero station is at the level of the ischial spine
APGAR SCORE
One Minute designed to assess the neonates need for resuscitation
Five Minute designed to assess the neonates response to resuscitative efforts
Score 0 1 2
1. Skin color blue body pink body but blue pink on body and all
(Apearance) extremities. extremities.
2. Heart rate absent HR < 100 beats/min > 100 beats/min
(Pulse)
3. Respirations absent breathing slow and irregular breathing good breathing and
crying
5. Irritability no response to nasal grimace response to nasal coughs, sneezes, pulls
(Grimace) suction suction away to nasal suction
4. Muscle tone flaccid weak muscle tone but some moving 4 limbs with
(Activity) movement good tone
Overview
Week 1-3
o "all-or-none": the embryo either dies or survives without any complications
Week 3-8 (embryonic period)
o most vulnerable time period due to organogenesis
Week 8-38
 o growth and function of organ/embryo is affected
o decreased susceptibility due to organs already formed
Teratogens

Examples Effects on Fetus

ACE inhibitors Renal damage
o renal dysplasia
Alcohol Fetal Alcohol Syndrome (see below)
Alkylating agents Absence of digits
Cleft palate
Renal agenesis
Aminoglycosides CN VIII toxicity
Anticonvulsants Cleft lip and palate
Cocaine Abnormal fetal development
Fetal addiction
Low-birth weight
Placental abruption
Diethylstilbestrol Vaginal clear cell adenocarcinoma
(DES) Other cervical, ovarian, and uterine abnormalities
Folate antagonists Neural tube defects (REVIEW)
o myelomeningocele
Lithium Ebstein's anomaly
o atrialized right ventricle
Maternal diabetes Caudal regression syndrome
o sirenomelia
o renal dysplasia or aplasia
o imperforate anus
Phenytoin Cleft lip and palate
Congenital heart defects
Potassium iodide Congenital goiter or hypothyroidism
Cretinism
Nicotine Premature delivery
Low birth weight
Intrauterine growth retardation
ADHD
Tetracyclines Discolored/stained teeth
Thalidomide Gastrointestinal atresia
Absence or malformation of external ear
Phocomelia
o "seal" limbs
 Valproate Inhibits intestinal folate absorption leading to neural tube
defects
Cleft lip
Renal defects
Vitamin Spontaneous abortions
A/isotretinoin Cleft palate
Cardiac abormalities
Eye and external abnormalities
Warfarin Bone deformities
o femur, vertebral, and calcaneus show stippled
appearance on X-ray
Fetal hemorrhage
Abortion
Spasticity and seizures

Fetal Alcohol Syndrome

Fetal alcohol syndrome (FAS)
o pregnant mothers who consume alcohol increase their risk of delivering a
child with FAS:
mental retardation
limb dislocation
cardiovascular defects such as ventricular septal defects
microcephaly
holoprosencephaly
facial abnormalities: hypertelorism, short palepebral fissures, long
philtrum
heart and lung fistulas
o alcohol is leading cause of mental retardation

Spontaneous Abortion
Snapshot
A 35-year-old G3P2 presents with vaginal bleeding and cramping pain at 12 weeks.
An ultrasound was performed. (Threatened abortion)

Introduction
Defined as non-elective termination of pregnancy at < 20 weeks gestation
Epidemiology
o occurs spontaneously in 15% of all pregnancies
Causes
o chromosome abnormalities
cause 50% of spontaneous abortions
o endocrine disease
o fibroids
 o incompetent cervix
o infection
Listeria, Mycoplasma, ToRCHeS
o chronic disease
DM, SLE
o environmental factors
toxins, radiation, smoking, ETOH
Risk factors
o increased parity
o advanced maternal age
o advanced paternal age
o conception within three months of live birth
o single pregnancy loss does not significantly increase risk of further abortion
Classification
Threatened
o normal US with minimal bleeding and NO cervical dilation
Missed
o abnormal US with NO bleeding or cervical dilation
Inevitable
o abnormal US with bleeding and cervical dilation but no loss of products of
conception
Incomplete
o abnormal US with bleeding and cervical dilation and loss of some but not all
products of conception
Completed
o abnormal US with bleeding and cervical dilation and loss of all products of
conception
Presentation
Symptoms
o vaginal bleeding and pain
Evaluation
Diagnosis
o vaginal bleeding and pain in first half of pregnancy is presumed to be
threatened abortion unless another diagnosis can be made, including
ectopic pregnancy
cervical polyps
cervicitis
molar pregnancy
Labs
o serum progesterone
> 25 ng/mL corresponds to a normal intrauterine pregnancy
< 5 ng/mL corresponds to a nonviable gestation
o b-hCG
rate of increase used to measure the viability of a pregnancy in the 1st
trimester
 threatened abortion should continue to have levels increase by >66%
every 48 hours while a non-viable (e.g. inevitable abortion)
Ultrasound
o presence of fetal heart rate can differentiate threatened from all other non-
viable abortion types
Hysterosalpingoram
Treatment
Observation alone
o indications
threatened spontaneous abortion
completed spontaneous abortion
Scheduled surgical evacuation
o indications
missed spontaneous abortion
Emergency surgical evacuation
o indications
inevitable spontaneous abortion
incomplete spontaneous abortion
o technique
suction curettage in 1st trimester
dilation and evacuation (D&E) in 2nd trimester
RhoGAM
o indicated when mother is Rh- and father is either Rh+ or unknown
o funtions to prevent isoimmunization from fetal-maternal blood contact as a
result of the failed pregnancy
see Rh disease topic