GENERAL APPROACH TO THE PREGNANT WOMAN

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GENERAL APPROACH TO THE PREGNANT WOMAN
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Pregnancy

• Pregnancy (gestation) is the maternal
  condition of having a developing fetus in the
  body.
• The human conceptus from fertilization
  through the eighth week of pregnancy is termed an
  embryo from the eighth week until delivery, it
  is a fetus.

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Terminology

• Antepartum - before delivery
• Postpartum - after delivery
• Prenatal - occurring before the birth
• Gravida - number of pregnancies
• Para - number of pregnancies carried to full term
• Primigravida - woman who is pregnant for the
  first time
• Primipara - woman who has given birth to her
  first child
• Multiparous - woman who has given birth multiple
  times
• Gestation - period of time for intrauterine fetal
  development

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The diseases specific to pregnancy

• Hyperemesis gravidarum
•          Gestational diabetes
•          Preeclampsia (PIH)
•          Postpartum depression

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Common diseases that significantly affect
pregnancy include

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•          CVS diseases
•          Diabetes mellitus
•          Essential hypertension
•          Endocrine disorders
• Autoimmune diseases

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• Most pregnant women will have at least one of the
  following symptoms
• Backache
• Breathlessness
• Fatique
• Palpitations
• Ankle swelling
• Indigestion
• Nausea and vomiting
• Constipation
• Urinary frequency

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Early signs of pregnancy

• A woman may perceive early signs of pregnancy
  within a few days of the first missed menstrual
  period. Usually the earliest signs are
• Mastodynia (breast tenderness),
• fatique, and
• some abnormal reaction to food.

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ASSESSMENT
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TURKISH MINISTRY OF HEALTH RECOMMENDS

• 1. VISIT 0-14 WEEK
• 2. VISIT 18-24 WEEK
• 3. VISIT 30-32 WEEK
• 4. VISIT 36-38 WEEK

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• The first prenatal visit
• The first prenatal visit ideally should occur
  between 6 and 8 weeks of gestation. The purpose
  of the first visit is to identify all risk
  factors involving the mother and fetus. Once
  identified, high-risk pregnancies require
  individualized specialized care.

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 Certain specific prenatal care tasks for the
physician include the following  

•       Establish the diagnosis and estimated due
  date.
•     Diagnose and treat prenatal disease
• Promote a healthy pregnancy

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Establish the diagnosis and estimated due date

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• The date of the last menstrual period should be
  determined. If not known exactly, the date should
  be estimated. Information about the normal
  menstrual cycle should be obtained.
• Nägeles rule
• EDD estimated due date or estimated date
  of confinement
• EDD LMP ( Date of the first day of the last
  menstrual period ) 1 year and seven days
  three months

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• The length of human gestation is 280 days, or 40
  weeks, as counted from the first day of the LMP
  to the EDD.
• A term pregnancy may extend from 37 t0 42
  weeks gestation.
• If the patient is unsure of her LMP, an
  ultrasound examination can date the pregnancy
  with a first trimester accuracy of plus or minus
  4 days

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• An examiner may have difficulty determining the
  presence of pregnancy in the first 6 to 8 weeks
  of gestation.. Although the uterus is usually
  palpably enlarged and soft ( Hegars sign )
  within 6 weeks from the last menstrual period,
  the exact size often is not easy to determine.
  This is particularly true in obese women and in
  women who have had several children.

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• Chadwicks sign ( vaginal and cervical cyanosis
  ), -a purplish discoloration of the uterine
  cervix resulting from the increased blood
  supply-, is often present by 6 weeks from the
  LMP.

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• There are many components of prenatal care.
  Initially, confirmation of the diagnosis of
  pregnancy and the estimated gestational age must
  be established.
• Next is a full history and physical examination
  with laboratory evaluation.

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The physician questions the patient

• regarding her,
• past obstetrical experiences,
• past medical illnesses,
• surgical procedures,
• exposures to infection, and
• risk of genetic diseases.

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past obstetrical experiences

• The following information is necessary
• Length of gestation,
• Birth weight
• Fetal outcome
• Length of labor
• Fetal presentation
• Type of delivery ( vaginal, forceps or vacuum,
  cesarean section ),
• Complications
• A history of preterm labor is the most
  important risk factor for its development in
  subsequent pregnancies.

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past medical illnesses

• Some of the most important medical illnesses that
  cause problems in pregnancy include heart
  disease, particularly valvular diseases, worsen
  with the stress of pregnancy and diabetes
  mellitus, since altered glucose levels may result
  in congenital malformations or in a difficult
  birth because of a large baby.

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• Troublesome habits during pregnancy are
• use of cigarettes, which results in an increased
  incidence of intrauterine growth retardation,
• preterm labor, and abruptio placenta
• alcohol use, which may result in the fetal
  alcohol syndrome, and
• illicit drug use, with its potential for
  numoreous congenital defects and HIV infection.

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• Sexually transmitted diseases and other
  infectious diseases that put the fetus at risk
  for infection are
•         Herpes simplex type II,
•         Syphilis,
•         Gonorrhea,
•         Chlamydia,
•       HIV,
•        Hepatitis B,
• Tuberculosis
• Toxoplasmosis

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• A history of any genetic diseases among the
  patient, the father, or both extended families
  should be sought, particularly of the diseases
  that are diagnosable during pregnancy.

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• The risk of Down syndrome increases with maternal
  age, and patients of advanced maternal age
  (gt35 years) are advised of serum and amniotic
  fluid tests available for its prenatal diagnosis.

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The initial physical examination should include

• measurement of blood pressure and weight,
• breast exam and,
• pelvic exam for uterine sizing and
  abnormalities.
• The external genitalia, vagina, and cervix
  should be inspected carefully for abnormalities
  that may lead to difficulties in pregnancy,
  labor, or delivery.

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complete physical examination

• The physician performs a complete physical
  examination early in the pregnancy, paying
  special attention to the thyroid, in which
  abnormalities can create fetal hyperthyroidism or
  hypothyroidism result in decreased intellectual
  function
• the breasts, in which abnormal masses may grow
  quickly under the influence of gestational
  hormones and the heart, in which abnormal sounds
  may indicate a heart disease that causes
  difficulty during pregnancy.

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Laboratory data obtained routinely during
pregnancy include

• 1. A complete blood count ( CBC ), to
  determine the presence of anemia and to obtain a
  baseline platelet count
• 2. Blood type and Rh, to identify Rh-negative
  patients
• 3. Urine culture, to identify patients with
  asymptomatic bacteriuria, with its attendant
  risks of pyelonephritis and preterm labor

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• 4. Rubella screen, to determine the patients
  rubella status ( if no antibody is present, the
  patient is advised to avoid sick children during
  the pregnancy and to obtain the rubella
  immunization during the post partum period
• 5. Papanicolau smear, to identify patients
  with dysplasia, who need treatment during
  pregnancy
• 6. Gonorrhea cervical culture, and hepatitis B
  surface antigen, to identify patients whose
  infants are at risk for prenatal or perinatal
  transmission.

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•      A Papanicolau smear should be obtained for
  every patient at her first prenatal visit unless
  a negative exam has been obtained within the last
  6 months.
• A hematocrit and a urine culture should be
  obtained for all patients as well.
• Anemia is defined as a hemoglobin of less than
  11.0 gm / dL in the first and third trimester
  and less than 10.5 gm / dL in the second
  trimester, or, equivalently, a hematocrit of 33
  and 32 per cent, respectively.
• The most common cause of anemia in pregnancy is
  iron deficiency.

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Midtrimester screening tests
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• a. The couple should be counseled regarding
  maternal serum a-fetoprotein
• ( AFP ) testing for birth defects to be
  completed between the fifteenth and twentieth
  weeks of gestation ( best between the sixteenth
  and eightteenth ).
• Although there are numoreous causes for an
  abnormal AFP value, its primary purpose is to
  screen for neural tube defects.
• Abnormal results are further evaluated by
  ultrasonography and amniocentesis.

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• b. At 24 to 28 weeks, a one-hour glucola
• ( blood glucose measurement one hour after a 50
  mg oral glucose load ) is obtained to screen for
  gestational diabetes in all pregnant patients.
• Those with a particular risk ( e.g., previous
  gestational diabetes or fetal macrosomia ) may
  warrant earlier testing.
• Values greater than or equal 140 mg / dl are
  evaluated with a three-hour oral glucose
  tolerance test.

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•      Repeat hemoglobin and hematocrit are
  obtained at 26 to 30 weeks to determine the need
  for iron supplementation.
•       Repeat serologic testing for syphilis is
  recommended at 36 weeks for high risk groups.
•       At 28 to 30 weeks, an antibody screen is
  obtained in Rh-negative women.
•       Repeat third-trimester screening for
  gonorrhea and chlamydia is recommended in
  high-risk population.

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Promote a healthy pregnancy

• The physician emphasizes to the patient her
  responsibilities in providing as healthy an
  environment for the fetus as possible and often
  asks the patient to read further on the subject.

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Good nutrition during pregnancy

• Women should be encouraged to eat a balanced,
  nutritious diet, including whole grain cereals
  and breads , vegetables and fruit, protein-rich
  foods , and dairy products.
• A healthy diet is achievable from many cultural
  perspectives , and the starting point has to be
  with foods that are familiar and enjoyed by the
  patient.

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• Vitamin and mineral supplementation is not
  indicated by women who eat well-balanced diets,
  except for iron and folic acid ( Folic acid, 400
  micrograms daily should be begun at the first
  prenatal visit and continued through the first
  three months of pregnancy)
• It is not necessary to begin iron
  supplementation at the first prenatal visit.
• For most women it should be started in the second
  trimester and continued throughout pregnancy at a
  dose of 30 mg of elemental iron per day.

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• Calcium supplementation is recommended only in
  women who cannot eat diary products.
• The recommended daily allowance of calcium for
  the pregnant woman is the same as that for the
  nonpregnant woman, 1200 mg / day.

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Subsequent visits

• The standart schedule for prenatal office visits
• 0-32 weeks, once every 4 weeks
• 32-36 weeks,once every 2 weeks
• 36 weeks to delivery, once each week.

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Preparation for labor

• As term approaches, the patient should be
  instructed about the following danger signals
• Rupture of membranes
• Vaginal bleeding
• Evidence of preeclampsia (marked swelling of
  hands and face, blurring of vision, headache,
  epigastric pain, convulsions)
• Chills or fever
• Severe abdominal or back pain

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What are Leopold maneuvers?

• These are performed at each third trimester visit
  to assess the
• presentation,
• position,
• engagement of the fetus by using 4 different
  maneuvers.

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Leopold maneuver 1

• Palpate the fundus of the uterus to determine
  which fetal parts are in this portion of the
  uterus.
• It is used for outlining uterine contour and
  locating head

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Leopold maneuver 2

• Palpate either side of the abdomen to find the
  fetal back.
• It is used for locating the spine

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Leopold maneuver 3
Palpate just above the pubic symphysis for the
presenting part. It is used for determining the
engagement
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Leopold maneuver 4

• Palpate either side of the lower abdomen just
  above
• the pelvic inlet to determine if the head is
  flexed or extended
• It is used to determine the descent