Unit 4

Chapter 14 Physical and psychologic changes of pregnancy

Diagnosis
feelings can be good or bad confirmation early diagnosis important

Presumptive Signs
can be caused by other problems
amenorrhea nausea and vomiting fatigue urinary frequency breast tenderness quickening

Probable Signs
Changes in the pelvic organs Goodells Sign- softening of the cervical tip Chadwicks Sign- deepened violet-bluish color of vaginal mucosa s/t increased vascularity of the area Hegars Sign- softening & compressibility of lower uterus Increase in size of uterus Ballottement- rebound of unengaged fetus Braxton-Hicks contractions Serum lab tests (positive pregnancy test)
Serum & urine test= accurate assessment for presence of hCG (production begins w/ implantation). hCG- hormone produced by placenta

Positive Signs
FHR/ fetal heart sounds Fetal movement felt by examiner
Visualization by ultrasound

Physiological Changes
local- reproductive systemic- major body organs

Local
Uterus
pre-pregnancy small semisolid pear shaped weight increases from 50Gm to 1000Gm enlargement primarily a result of hypertrophy of pre-existing myometrial cells

Uterine changes
Uterus: Increased amounts of estrogen and growing fetus Cervix: Increase estrogen levels
Hyperplasia Formation of mucous plug Mucous plug prevents organisms entering uterus

Uterine changes
Thickening of the walls Enlargement due to hypertrophy Increase in vascular and lymphatic system

Uterine
development of new fibro-elastic tissue between bands of muscles cells increase as result of estrogen measure lightening

Uterine
blood flow 15-20ml/min pre-pregnancy at term 500-700ml/min by end of pregnancy 1/6 total maternal blood volume is circulating through the uterus bleeding- serious problem

Uterus
Braxton Hicks
painless contractions estrogen distention of the uterus felt by 4th month practicing no cervical changes occur

amenorrhea

Early signs of pregnancy may include:

Blue discoloration of the cervix and vagina (Chadwick's sign) Chadwick's sign is a bluish discoloration of the cervix, vagina, and labia caused by the hormone estrogen which results in venous congestion Softening of the cervix (Goodell's sign) significant softening of the vaginal portion of the cervix

Cervix
mucosa of cervix undergoes marked changes
endocervical cells secrete thick, tenacious mucus which accumulates and forms mucus plug. Seals cervical canal to prevent infection Expelled at start of labor

Cervix
increased mucus leads to increased discharge increased vascularity and increased discoloration

Early signs of pregnancy may include:

Softening of the uterus (Ladin's sign and Hegar's sign)
Ladin's sign is a clinical sign of pregnancy in which there is softening in the midline of the uterus anteriorly at the junction of the uterus and cervix. It occurs at about 6 weeks gestation Hegar's sign is an indication of pregnancy in a woman, specifically the compressibility and softening of the cervical isthmus (the portion of the cervix between the uterus and the vaginal portion of the cervix) and the uterine cervix appearing bluish and engorged

Darkening of the nipples Unexplained pelvic or abdominal mass

Vaginal changes
Hypertrophy, increased vascularization, hyperplasia (enlargement) d/t estrogen Increased secretions, loosening of connective tissue

Breast changes
Glandular hyperplasia and hypertrophy Areolae darken, superficial veins prominent Breast size increases around 20 weeks Striae may develop
Breasts: Increased estrogen and progesterone levels Increase in size and number of mammary glands Nipples more erectile and areolas darken Colostrum produced during third trimester

Breasts
changes are noted soon after first missed period increase in size and nodularity preparing for lactation 2nd month superficial veins are prominent nipples are more erect

Breasts
pigmentationof areola is more prominent sebacious glands enlarge (Montgomery Tubercles) 16th week colostrum

Respiratory system:
Increasing levels of progesterone causes:
Increased volume of air/increase tidal volume Oxygen consumption increases Decreased airway resistance Increased anteroposterior diameter Breathing changes from abdominal to thoracic, occurs as uterus enlarges Vascular congestion nasal mucosa

Respiratory
tidal volume (normal breathing) increases 40% respiratory rate increases
small degree of hyperventilation

oxygen consumption increases by 20% diaphragm is displaced >SOB no change in vital capacity

Respiratory
Progesterone levels signal hypothalmus to reset acceptable PCO2 levels
low CO2 levels allows for CO2 to cross the placenta maintain pH with load of CO2 from fetusmother hyperventilates to blow off excess

Respiratory
cumulative effect
SOB nasal stuffiness epistaxsis

Cardiovascular system:
Increased levels of estrogen and progesterone Cardiac output and blood volume increases Blood volume increases 40%-45% Decrease in systemic and pulmonary vascular resistance Increased size of uterus interferes with blood return from lower extremities Increased level of red cells to increase oxygen delivery to cells Clotting factors increase

Cardiovascular
pressure on diaphragm displaces the heart blood volume increases 30-50%
occurs gradually and peaks at 28-32 weeks adequate exchange of nutrients compensate for blood loss

CV
rise in cardiac output 25-50%
pulse rate increases BP remains relatively unchanged

concentration of Hgb and erythrocytes may initially decline

CV
femoral venous pressure slowly rises
stasis dependent edema varicosities

fibrinogen levels increase 50%

clotting factors platelets

wbc, protein

GI system:
Action of increasing levels of progesterone Delayed gastric emptying Decreased peristalsis Nausea and vomiting Hyperemia, softening and bleeding of gums Constipation Heartburn hemorrhoids

GU system:
Increased blood volume Glomerular filtration rate increases Renal tubular reabsorption increases Pressure on bladder causes frequency

Urinary
alterations
fluid retention,renal, ureter, and bladder function

result of:
estrogen and progesterone activity compression increased blood volume postural influences

Urinary
total body H2O content increases must increase Na reabsorption retained to assist:
increased blood volume source of nutrients for the fetus

Urinary
excrete waste from mother and fetus breakdown protein compensate for blood volume UOP increases 60-80% specific gravity decreases

Urinary
GFR increases
decrease BUN increase filtration of glucose

ureters increase in diameter bladder capacity increases frequency increases (10-12X/day)

Skin changes
Hyperpigmentation Striae Chloasma Vascular spider nevi Decreased hair growth Hyperactive sweat and sebaceous glands Linea nigra

Vascular spider nevi

Chloasma

Linea nigra

Musculoskeletal changes
Relaxation of joints caused by increased estrogen and progesterone Center of gravity changes Separation of rectus abdominus

Eyes, cognitive and metabolic changes

Decreased intraocular pressure Thickening of cornea Reports of decreased attention, concentration, and memory Extra water, fat, and protein are stored Fats are more completely absorbed

Endocrine changes
T4 and BMR increase, TSH decreases Concentration of parathyroid hormone increases Thyrotropin (known also as thyroid stimulating hormone (TSH) and adrenotropion (adrenal hormone) alter maternal metabolism Prolactin is responsible for lactation secretion of oxytocin and vasopressin Increased aldosterone

Endocrine
placenta produces:
estrogen progesterone HCG HPL (human placental lactogen) relaxin prostaglandins

Endocrine
thyroid
increased vascularity hyperplasia increased BMR increased oxygen consumption

Endocrine
pituitary
decreased FSH and LH Prolactin increases secretes oxytocin

results in:
anovulation lactation increased pigmentation

Endocrine
pancreas- early pregnancy
there is a decrease in insulin production r/t increased fetal demands

after 1st trimester

increase in insulin production r/t insulin antagonist properties of estrogen, progesterone, and HPL

Vena cava syndrome

is a result of obstruction of the inferior vena cava. It can be caused by invasion or compression by a pathological process or by thrombosis in the vein itself. This is quite common during the third trimester of pregnancy when the uterus compresses the vein in the right side position.

Psychological
attitudes depends on:
environment social cultural family individuals

gamut of emotions
need time to adjust

First Trimester
Developmental Task
acceptance of pregnancy 50% are surprises concerns center on self partners response

Second trimester
Acceptance of Baby
quickening start to make plans educate fantasize

Third Trimester
Preparing for Parenthood
nesting must complete specific tasks reworking developmental tasks role playing fantasizing

Emotional Responses
ambivalence grief narcissism introversion vs. extroversion body image and boundary stress couvade syndrome

Responses
emotional lability change in sexual desire change in expectant family