Key Terminology

Gravida/Para System

gravidity: number of total pregnancies including the current one

pregnancy with twins: gravidity = 1
parity: pregnancy outcomes written is "x + y", where
x: number of births beyond the age of viability (24 weeks of gestation) including terminations/miscarriages and living
children (term and preterm)
y: number of births prior to the age of viability (also referred to as miscarriage)
twin birth: parity = 2

TPAL System

t - term births (delivery > 37 weeks gestation)

p - pre-term births (delivery 20  36 weeks gestation)
a - abortions / miscarriages (< 20 weeks)
l - living children

Clinical

symptoms
amenorrhea (secondary. a common presenting complain.)
nausea & vomiting (associated with a rise in beta-hCG levels)
general fatigue
breast enlargement
mild uterine cramping
exam findings (due to fluctuating hormone levels)
telangiectasias, palmar erythema, linea nigra
softening of the cervix (goodell sign)
softening of the uterus (ladin sign)
blue discoloration of vagina/cervix (chadwick sign)

Pregnancy Diagnosis
syncytiotrophoblast produces a hormone called human chorionic gonadotropin (hCG) which has alpha & beta subunits
beta-hCG is used in the antibody testing to confirm pregnancy (alpha subunit is the same as the one in LH, FSH, and
TSH, thus has no diagnostic value)
serum test
threshold: as low as 12 mIU/mL of beta-hCG
positive within 1 week of conception
urine test
threshold: at least 2050 mIU/mL of beta-hCG
positive after 2 weeks of conception

Human Chorionic Gonadotropin (hCG)

physiology
syncytiotrophoblast secretes hCG which binds to the LH receptors on corpus luterum to maintain it (alpha subunits of LH
& hCG are the same)
corpus luteum secretes progesterone (preventing menstruation) to maintain the pregnancy for the first 10 weeks
at 10 weeks, syncytiotrophoblast starts secreting progesterone itself to maintain the pregnancy
levels
double every 48 hours initially after conception
normally rise by at least 60% after 48 hours (if it doesn't, indicates nonviable pregnancy)
peak at 100,000 mIU by ~810 weeks (after which placenta secretes progesterone)
decline to 12,000 mIU by ~20 weeks
high levels in
 multiple gestation
hydatidiform moles
choriocarcinomas
down syndrome
low levels in
ectopic/failing pregnancy
edwards syndrome
patau syndrome

Pregnancy Dating
fetal movements (quickeing) felt at
1820 weeks in nulligravida
1618 weeks in multigravida
fetal heart tones using a stethoscope can be felt at ~10 weeks

Dating

embryonic age: age dated to fertilization

gestational age: age dated to LMP (embryonic age + 2 weeks)

Expected Delivery Date (EDD

neagle's rule: (9 months + 7 days) + 1st day of LMP

in vitro fertilization
exact implantation date is known
date of conception + 266 days = EDD

fundal height

height of the uterine fundus relative to the pubic symphysis correlates to gestational age: 1 cm - 1 week (gestation
age)

if fundal height doesn't correspond to the gestational age: size-date discrepancy

incorrect gestational age dating
larger than expected
multiple gestation
macrosomia
polyhydroamnios
molar pregnancy
smaller than expected
fetal growth restriction
oligohydroamnios
intrauterine fetal demise
uterus becomes an abdominal organ at ~12 weeks

Ultrasound Scans

1. dating scan (1st trimester)

used after confirming the pregnancy via a positive b-hCG test

helps confirm intrauterine pregnancy (exclude ectopic pregnancy)
helps date the pregnancy in the first trimester, via
gestational landmarks:
gestational sac: 4.55 weeks
yolk sac: 56 weeks
fetal pole: 5.56 weeks
crown-rump length (in mm) - correlates with the gestational age
as accurate as +/ 5 days < 9 weeks
 as accurate as +/ 7 days at 913 weeks

2. growth scan (2nd trimester)

used to estimate fetal weight using 4 parameters

biparietal diameter
head circumference
abdominal circumference
femur length
helps assess fetal growth in terms of percentiles for gestational age (normal, restricted, accelerated)

Physiological Changes in Pregnancy

Cardiovascular

maternal heart rate increases slightly (to aid placental & uterine perfusion)
fall in systemic vascular resistance, as
placenta is a low resistance system
there is maternal vasodilation
decreased systemic vascular resistance > decrease in
afterload in the left ventricle
blood pressure
rise in the blood volume > increase in preload
increased preload + decreased afterload > rise in cardiac output

blood pressure

in the later stages of pregnancy, when the baby gets larger it can compress the IVC when the mother is supine > decrease in
venous return (to the right atrium) & pre-load (to the left ventricle) > fall in cardiac output > supine hypotension (can cause
dizziness & fainting when lying flat) > reflex tachycardia (can cause palpitations)

cases of valvular heart disease

regurgitation (mitral / aortic) is well-tolerated

fall in left ventricular afterload > decreased blood regurgitated
stenosis (mitral / aortic) is very poorly tolerated
rise in blood volume during pregnancy > increased preload > higher volume of blood that can't pass through the stenotic
valve > can be life-threatening

Pulmonary
 minute ventilation increases
(increased metabolism as the baby grows) > more CO2 to exhale
rise in progesterone levels > rise in ventilation
minute ventilation = tidal volume x respiratory rate
tidal volume increases substantially
respiratory rate increases minimally (no tachypnea)
since more CO2 is exhaled > pCO2 falls from ~40 mm Hg to ~30 mm Hg > respiratory alkalosis > kidneys compensate by
decreasing the HCO3  p: normal / slightly high

Renal

blood diverted from the maternal circulation to placenta > kidneys sense this > high renin levels > salt & water retention >
increase in total plasma volume & mild peripheral edema > increased GFR > more plasma flow > slight decrease in BUN &
creatinine

Hematological

RBC mass

increased maternal erythropoetin during pregnancy > increased RBCs

dilutional anemia (physiological)
rise in plasma volume is greater than the rise in RBCs > decreased hematocrit (keeps decreasing as the pregnancy
progresses)

coagulation

increased incidence of DVTs & pulmonary emboli in pregnant women as

 pregnancy is a hypercoagulable state
may have evolved to be like so to protect against blood loss at delivery
coagulation factors levels change e.g. increased fibrinogen, decreased protein S
 fetus obstructs venous return > sluggish blood flow in lower extremities

Endocrine

thyroid gland

estrogen > rise in thyroid binding globulins (TBGs)

TBGs bind to thyroid hormone > rise in total T3/4 (not free T3/4
hCG can stimulate the thyroid gland
hCG has the same alpha unit as TSH
increase in free T4 & subsequent decline in TSH (via negative feedback)
these effects are noted in early pregnancy when hCG is high

Weight

weight gain

normal weight gain: ~1012.5 kg (2226 lb)

excess weight gain associated with

fetal macrosomia
gestational diabetes mellitus (GDM
gestational hypertension
less weight gain associated with
low birth weight
baby small for gestational age (SGA
preterm delivery

BMI

BMI is more predictive of pregnancy outcomes compared to gestational weight gain

 underweight (BMI  18.5 kg/m2 & overweight (BMI  30 kg/m2  greater risk of adverse outcomes therefore greater weight
gain recommended for women with low BMI & vice versa

exercise

associated with low risk of GDM, pre-eclampsia, and cesarean delivery

contraindicated in high-risk patients like
cervical insufficiency (risk of pregnancy loss in 2nd trimester)
placenta previa
gestational HTN (and pre-eclampsia, eclampsia)
multiple gestation
amniotic fluid leak

Common problems in Pregnancy

problem cause management

back pain enlarged uterus > lordosis & change in center of gravity supportive: stretching. acetaminophen.

constipation increased fluid intake. laxatives.

edema lower extremity edema from IVC compression positional change.

GERD increased relaxation of sphincters antacids (gaviscon, esso)

hemorrhoids venous congestion. IVC compression. sitz bath. steroids. avoid constipation.

round ligament pain stretched uterus/ligament attachments > adnexal pain. self-limited.

urinary frequency increased circulating plasma volume. (rule out UTI.