Pregnancy (not a disease)

Overview

Physiological Changes in Pregnancy

Uterus, Vagina and Breast Physiology changes

Uterus (Cervix + Isthmus + Body of uterus)

• Muscle hypertrophy til 20weeks then stretching till term.
• Uterine and ovarian arteries undergo hypertrophy
• Cervix
  • Reduced collagen → allows dilatation
  • Hypertrophy of cervical glands → thick mucus plug
• Uterine body
  • ↑size, shape, shape and consitency
  • Increases 10-fold

Vagina

• ↑Oestrogen → stimulates glycogen synthesis and deposition in the vagina → lactobacilli proliferation → lactic acid production → decreases pH in the vagina preventing pathogenic bacterial growth

Breast

• ↑Oestrogen → Fat tissue, lactiferous ducts
• ↑Progesterone → Breast lobule

Endocrine Physiology changes

Pituitary Gland 

• Enlarges because of ↑anterior lob hormone secretion

Thyroid hormones

• Thyroid gland hypertrophy because of increase demand during pregnancy

Endocrine changes

• ↑Progesterone
• ↑Oestrogen (mainly oestradiol)
• ↑Human placental lactogen

Progesterone

• Causes smooth muscle relaxation
  • Reflux
  • ↑Tidal volume of lungs
• Prevents preterm labour (because it relaxes the uterus)

Oestrogen

• Promotes breast and nipple growth
• Increases uterine blood flow, myometrial growth and cervical softening
• Increases sensitivity of myometrial oxytocin receptors

Human placentala lactogen

• Modifies maternal metabolism → ↑energy supply to the featus
• ↑Insulin secretion but ↓insulin peripheral effect, promoting glucose supply to the infant.

Haemtological Physiology Changes

• ↑Plasma volume (~40%) - acute weight gain is commonly due to oedema
• ↑Red cell volume
• ↑WBC - neutophilia specifically
• Slight ↓platelets
• ↑Clotting factors → hypercoagulable state

Respiratory Physiology Changes

• Uterus grows → diaphragm rises → breathing becomes diaphragmatic
• ↑Tidal volume (~40%)

Cardiovascular Physiology Changes

• ↑Cardiac output
  • ↑Heart Rate (15bmp) × ↑Stroke Volume (~10%)
• ↓Peripheral resistance
• Blood pressure (most noticeable diastolic) drop by ~15mmhg by mid-term and return back to normal full term.

Urinary Physiology Changes

• ↑Kidney size by 1cm
• ↑ Renal blood flow (~40%) a result of increase cardiac output.
• ↑ Renal blood flow means ↑ GFR

Digestive Physiology changes

• ↑Progestrone → Oesophageal sphincter relaxation → oesophageal reflux
• ↑Progestrone → reduced bowel motility → constipation
• Uterine enlargement → Increase intra-abdominal pressure → worsens reflux + heart burn

Signs and Symptoms

Early Pregnancy

• Amenorrhoea
• Nausea/vomiting - 2/3 of women (morning sickness)
• Breast tenderness and enlargement
• Increased urinary frequency
• Pigmentation of areola
• Dyspnea
• Fatigue
• Light headedness

Late Pregnancy

Hormonal changes 

• Nausea and Vomiting
• Gastro-oesophageal reflux (Progesterone)
• Constipation (Progesterone)
• Breast enlargement
• Vaginal discharge

Uterine Enlargement 

• Pelvic discomfort
• Backache
• Siatica
• Stress incontinence (3rd trimester)
• Haemorrhoids (3rd trimester)

Other

• Carpal tunnel syndrome
• Polyuria
• Itching and rash
• Headaches
• Dyspnea
• Fatigue
• Insomnia
• Stretch marks
• Calf cramps
• Braxton Hicks contractions

Diagnosis

Any of the following:

• Beta-hcG in urine or blood (most common)
• Positive ultrasound examination of abdomen
• Fetal cardiac activity on Doppler ultrasound

Supported by:

• Amenorrhoea
• Clinical evidence

Antenatal Check

Antenatal check refers to the health care provided to a pregnancy woman throughout pregnancy until labour. Basically a screening program intended to detect complications early, provide health education and implement effective health promotive and preventative interventions.

TIMING (4:2:1)

• 4 weekly till 28 weeks
• 2 weekly from 28 – 34 weeks
• Weekly from 36 till delivery

Normal, uncomplicated pregnancy

• First visit (discussed in detail in next section)
• First ultrasound

First Visit to Doctor

Introduction

Confirmation of pregnancy and discussion of models of care

• Establish if planned pregnancy - Affects potential decision for abortion and how the woman will deal/approach pregnancy
• Demographics (age, ethnicity)
• Date of the first day of LMP and thus expected date of delivery
  • Use Naegele’s rule, based on 280-day average for each pregnancy i.e. add 9 months and 7 days.
  • Importance of dating: antenatal schedule is evidence based and involves tests done at particular times so gestational age should be as accurate as possible.
  • Ultrasound sounds also do dating
  • Important to keep in mind that Indian or Afro-Caribbean women have shorter gestational times than Caucasians

• Current antenatal history - common symptoms of early pregnancy
• Obstetric history
  • Important since previous problems increase the chance of reccurence (e.g. gestational diabetes, pre-eclampsia, miscarriage etc.)
  • To establish: previous antenatal/intrapartum/post-partum problems: miscarriages, ectopics, stillbirths, live births, mode of delivery, induction or spontaneous, gestation
  • Gravidity and parity (G.P.)
  • Breast feeding history - Benefits: better nutrition, GI function, immunological protection, psychological well-being for mother, long term benefits for child
• Gynaecological history
  • Date of last pap smear and result
  • Previous contraception use
  • Gynaecological problems - endometriosis, PID, ovarian cysts, fibroids
• Medical history
  • Surgeries
  • Medications (inc. vitamins, folate, iodine supplementation)
  • Medical conditions (e.g. hyperlipidemia, epilepsy, Graves etc.)
  • Allergies
  • Immunisation status
• Social History
  • Psychosocial support (grandparents will be around? Partner? Financial situation?)
  • Smoking
  • Alcohol
  • Nutrition
  • Physical exercise (recommended, but not excessive)

• Family history - E.g. congenital conditions (heart defects), syndromes (e.g. Down syndrome), cystic fibrosis etc.

Examination

• General Observations
• BMI
• Vital signs
• Cardiovascular exam
• Thyroid exam
• Breast exam
• Abdominal exam
• Vaginal Exam
• Urinalysis

Investigations

• ABO
• Rhesus
• FBC
• Rubella
• TPHA
• Hep B and Hep C
• HIV
• Syphilus
• Urine M/C/S
• Ultrasound

Medical Complications During Pregnancy

• Hyperemesis Gravidarum
• Gestational Diabetes
• Thromboembolic disorder
• Anaemia
• Hypertension
• Pre-eclampsia
• PV Bleeding
• Ante-partum haemorrhage

More info Medical Complication During Pregnancy

Unplanned Pregnancy

• Contraception