Professional Documents
Culture Documents
LESSON #14
John Dorsch, MD
Director of Rural Health Programs
University of Kansas School of Medicine – Wichita
Family and Community Medicine
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)
• Embolism 17%
• Hypertension 12%
• Ectopic pregnancy 10%
• Hemorrhage 9%
• Stroke 8%
• Anesthesia complications 7%
• Abortion related 5%
• Cardiomyopathy 4%
• Infection 3.5%
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• Important, 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, especially:
• Diabetes
• Hypertension
• Renal disease
• Hemoglobinopathy
• Isoimmunization
• STDs
• Significant other infections
• All components of PMH are important, especially
• Age
• Last pelvic exam and pap smear
• Menstrual history
• Previous pregnancies, abortions, miscarriages, deliveries
• Birth control (methods used)
• Fertility – infertility issues
• Anesthesia issues or reactions
• Pelvic injury
• Medications: prescription, OTC & complimentary therapies
• Allergies reactions
• Emphasize need to communicate all
medications considered during pregnancy
• Social & home environment influences
• Life-style issues: diet, exercise, sleep, drugs, alcohol, smoking…
• ROS: pre-pregnancy weights & baselines
• Amennorrhea:
• Results from high levels of hormones:
estrogen, progesterone & hCG (human chorionic gonadotropin)
• Currently used pregnancy tests are based on amount of hCG in
blood or urine, with hCG present as early as 8 days after fertilization
• Depending on the specific test used, 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
• Breast Changes:
• Increased tenderness
• Increased vascularity & sense of heaviness
• Nipples more erectile, with increased pigmentation
• Raised Montgomery’s tubercles on areola
• Colostrum secreted by 16th week
2
• Heartburn:
• Relaxation of gastroesophageal sphincter
• Upward displacement of stomach due to uterine enlargement
• Digestions delays, 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, 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, brittleness or softening
• Increased sweating
• Hirsutism
• Urinary Changes:
• Increased frequency due to uterine pressure in early & late pregnancy
• Vaginal Discharge:
• Increased asymptomatic, white, milky cervical mucous & vaginal discharge
• 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
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THOROUGH PHYSICAL EXAMINATION
• Objectives:
• Evaluate health of mother & fetus
• Determine gestational age of fetus
• Initial plan of care
• Abdomen:
• Contour
• Skin changes: linea nigra, 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, from 11-13 weeks gestation
• Genitalia
• External genitalia & anus: lesions & varicosities
• Vaginal leukorrhea
• Adenexal areas: corpus luteum cyst-like enlargment
• Bimanual & pelvic measurements
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• Extremities:
• Varicosities
• Edema
• Diet
• Prenatal Vitamins:
• Maternal ingestion of 0.4 – 0.8 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
Or
Nagele’s Rule:
LMP
Add 9 months + 7 days = EDC
5
MILESTONE LABORATORY TESTS
• 16-18 Weeks:
• 17-21 Weeks: (when standardized values for this test are most accurate)
Alpha Fetal Protein (AFP)
Medical-legal point: Important to offer this test, 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:
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H & H: may repeat at 28 weeks (especially with anemia)
• 28-36 Weeks
EVERY OB VISIT
Monitor:
• weight, BP temp,
• 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
• 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
• Fetus:
• FHT with Doppler: 12 weeks
• Quickening: 16-19 weeks
(ask patient to keep track of movements)
• Primipara (later, about 18-19 weeks)
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• Multipara (sooner, 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
• What to do if water breaks
• Mucous plug
• Analgesia, anesthesia, 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
• Initial considerations
• Pelvic shape
• Diagonal conjugate
• Obstetrical conjugate
• Angle of subpubic arch
• Coccyx
• Pelvic shapes
• Diagonal conjugate
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pubis to sacral promontory
• Obstetric conjugate
• Coccyx