Obstetric Pearls for the Primary Care Practitioner Objectives

Objectives
Obstetric Pearls for the Primary
Care Practitioner
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Pamela Schmagel, MD
Rushmore OB/GYN
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Body Water Metabolism
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Chronic volume overload – active sodium
and water retention
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Total body water increases 6-8 liters
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changes in osmoregulation
renin-angiotensin system
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Osmoregulation
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increased maternal weight
hemodilution of pregnancy
elevation of maternal cardiac output
Significant physiologic changes occur in the
cardiovascular system during pregnancy.
These are usually well tolerated in healthy
young women however certain cardiac
disorders increase concerns for morbidity
and mortality.
Shortly after conception plasma volume
expands
Osmotic threshold is reset for antidiuretic
hormone and thirst
Increase water intake and urinary volume
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Blood volume increases by about 1.5 liters
Cardiovascular System
Understand normal physiologic changes of
pregnancy
Recognize the diagnosis and treatment of
common medical conditions of pregnancy
Discuss obstetrical emergencies requiring
intervention
Understand pharmaceutical classifications of
medications used in pregnancy
Transient polydipsia and polyuria during weeks 5
to 8
Increase in sodium retention but less than
increase in total body water
Heart
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Displaced to left and
upward due to
anatomical changes of
pregnancy
May increase size of
cardiac silhouette on
chest x-ray
Mild myocardial
hypertrophy due to
expanded blood volume
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Cardiac Output
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Cardiac output increases by 30-50%
The initial increase occurs by 5 weeks
gestation
40% increase by 12 weeks
Peak is between 25-30 weeks
Increased cardiac output mostly directed to
uterus, placenta and breasts
Stroke volume and heart rate increase to
contribute to increased cardiac output
Supine Hypotension Syndrome
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Pallor
Sweating
Nausea
Vomiting
Lightheaded/dizzy
Fetal heart rate
changes
Supine Hypotension Syndrome
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Blood Pressure
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Normal Changes that Mimic Heart Disease
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BP = Cardiac Output x systemic vascular
resistence
BP decreased in pregnancy due to decrease
in SVR
Increase in BP greater than pre-pregnancy
values is not normal
Nadir occurs during second trimester
Normal Changes that Mimic Heart Disease
Dyspnea
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Supine position
Enlarged uterus compresses the inferior
vena cava
Reduces venous return to the heart and
therefore reduces cardiac ouput
IVC can be completely occluded in late
pregnancy
Not a concern prior to 24 weeks
Most prior to 20 weeks
Usually does not worsen
Does not occur at rest
Does not preclude normal activities
Decreased exercise tolerance
Fatigue
Syncope
Chest discomfort
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Peripheral edema
Mild tachycardia
JVD after 20 weeks
Systolic ejection murmur
Third heart sound
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Findings Not Associated with Normal
Pregnancy
Respiratory System
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Hemoptysis
Syncope or chest pain with exertion
Progressive orthopnea
Paroxysmal nocturnal dyspnea
Lung Changes
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Elevation of diaphragm
decreases lung volume
Functional residual capacity
( expiratory reserve volume
and residual volume)
decrease
Inspiratory capacity
increases
No change in vital capacity
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Spirometry and peak
flowmeters are unchanged
and can be used in
managing respiratory
illnesses
Chronic hyperventilation due
to increase in tidal volume
and minute ventilation
Respiratory rate does not
change
Mild respiratory alkalosis
Urinary System
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Hematocrit decreases during gestation
Usually not less than 30%
Hypercoagulable state
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Increase in levels of procoagulant factors
Decrease in fibrinolytic system
Gastrointestinal System
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Urinary frequency and urgency
Increased GFR (decrease in BUN and
Creatinine)
Treat UTI for 10 days. Send culture
Maternal plasma volume increases 50%
RBC volume increases 18-30%
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Right ureteral dilation greater than right
Mild h
hydronephrosis
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h i iis normall
May cause flank pain if significant
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Kidneys and ureters increase in size
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Hematologic Changes
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Increased nasal stuffiness due to hyperemic
and edematous changes in mucosa of
nasopharynx and increased secretion of
mucus
Epistaxis
Chronic cold symptoms but try to avoid
chronic use of nasal decongestants
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Increase in appetite
Decrease lower
esophageal sphincter
Decreased tone and
motility of GI tract
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Need additional 300
kcal/day
Heartburn
Constipation
Nausea/Vomiting
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Breasts
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Tenderness and heavy feeling by 4 weeks
after LMP
Rapidly enlarge during the first 8 weeks of
pregnancy due to vascular engorgement
Progressive change due to ductal growth and
alveolar hypertrophy
Nipples enlarge and areolae enlarge and
darken
Skin Changes
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Increased hirsutism
Normal increase in
scalp
p hair loss 2-4
months after delivery
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Reassure resolution after
6-12 months
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Most are treated as the non-pregnant patient
Special attention to certain medications that
may affect fetus
Avoid surgical interventions if condition is
expected to resolved after delivery
Hyperpigmentation
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Melasma or chloasma
Linea nigra
Increase in size and
number of nevi
The Eye
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Increased thickness of
cornea
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Decreased intraocular
pressure
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Due to edema
Noted by 10 weeks
gestation
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Stretch marks
Creams of no benefit
Color fades but mark
remains
Common Medical Conditons of Pregnancy
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Striae Gravidarum
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Skin Changes
Improvement in
preexisting glaucoma
Avoid expensive
changes in eye glass or
contact lens
prescriptions
No change to visual
fields
Consider elevated
blood pressure with
complaints of
scotomata
Headaches
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Increased in first and third trimester
Increase in hormones and blood volume
C ff i withdrawal
Caffeine
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Hypoglycemia
Fatigue and lack of sleep
Sinus congestion and allergies
Prepregnancy migraines usually decrease
Consider preeclampsia
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Headaches
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Decrease stress
Improve posture
Check vision
Increase hydration and sleep
Avoid
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ASA, NSAID, ergotamine, Triptans
Short course of narcotics
Morning Sickness
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Usually resolves by 16th
week
Small frequent meals
Dry crackers prior to getting
out of bed
Avoid triggers
Acupressure wristbands
Vitamin B6
Phenergan, Compazine,
Reglan, Zofran
Low Back Pain
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Due to shift in gravity and lordosis of
pregnancy
Hormonal changes causing relaxation in
joints
Improve posture and support
Appropriate shoes
Tylenol, heating pad massage
Chiropractic care and physical therapy
Heartburn
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Worse in second and
third trimesters
Small frequent
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meals
Avoid lying down after
eating
Avoid certain foods
Antacids
H2 blockers
Proton pump inhibitors
Carpal Tunnel
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Pain, numbness, tingling of
wrist and fingers
Pressure on median nerve
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Overuse
Increased edema
Decrease use
Elevate arms when lying
down
Wrist Splints
Avoid surgery unless doesn’t
resolve
Constipation and Hemorrhoids
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Increase fluids
Dietary changes to increase fiber
Regular bowel habits
Exercise
Stool softeners
Avoid straining
Analgesic and steroid ointments
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Yeast Infection
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Increased estrogen and glucose in vaginal
discharge
White, cottage-cheese discharge
Pruritis
Antifungal vaginal cream
Fluconazole
Pruritic Urticarial Papules and Plaques of
Pregnancy
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Terms of Pregnancy
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Gravida – pregnant woman
Gravida 1/primagravida - 1st pregnancy
Para – birth past age of viability or 20 wks
Para 0 or nullipara – no pregnancies past 20
weeks
Para 1 or primipara – one pregnancy past 20
weeks
Multipara – 2 or more births past 20 weeks
Benign dermatosis
Late 3rd trimester or
postpartum
Usually 1st pregnancy
Severe itching
Unknown cause
Self limited
Antipruritics, emollients,
steroids
Terms of Pregnancy
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Multiple births count as
only one para
Stillbirths past 20
weeks count as one
para
TPAL
Obstetrical Emergencies
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--------------------Term
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P---------------------Preterm
Preterm
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All female patients of
reproductive age are
pregnant until proven
otherwise
All pregnant patients
have an ectopic
pregnancy until proven
otherwise
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First Trimester Bleeding
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Threatened abortion
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Spontaneous ab
Inevitable ab
Incomplete ab
Complete ab
Ectopic pregnancy
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Serum hCG positive 5 days
after conception
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Normal pregnancy DOUBLES
Q 48 hours, therefore draw
serially
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5-6wks = 1000 = gestational
sac on TVUS
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Max: 100,000 at 10
10--12 wks
Third Trimester Bleeding
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Placental abruption
Ectopic Pregnancy
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Preeclampsia
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Placenta Previa
Work up for ectopic
pregnancy
Urine hCG
If positive obtain TVUS
and quantitative hCG
Tubal mass or no IUP
with quant >1000-2000
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Systolic BP greater than 140
Diastolic BP greater than 90
Proteinuria
(Edema)
Severe BP >160/110
HELLP syndrome
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Classification of Medications
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Almost all medications cross placenta
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Exceptions Heparin and Insulin
Usually prescribe as you would for the non
nonpregnant patient with some exceptions
Risk factors assigned based on risk to fetus
Definitions based on FDA
Do not refer to breast feeding risk
Hemolysis (LDH >600), Elevated Liver enzymes
(AST >70), Low Platelets (<100K)
Risk Factor Categories
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A – Controlled studies show no risk
B – No evidence of risk in humans
C – Risk cannot be ruled out
D – Positive evidence of risk
X – Contraindicated in pregnancy
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Drugs Contraindicated
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Isotretinoin
Misoprostol
Methotrexate
Warfarin
Ergotamines
ACE inhibitors
Nitroprusside
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Quinolones
Tetracyclines
NSAIDS
Antiepileptic drugs
Streptomycin,
Kanamycin
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