Advanced Practice Education Associates

Pregnancy
Pregnancy

OVERVIEW

• Routine Prenatal Care

 First Trimester
 Second Trimester
 Third Trimester
• Physiologic Changes
• Common Discomforts
• Common Complications

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FIRST TRIMESTER – CONCEPTION TO 14 WEEKS

• Preconception (update immunizations, start folic acid)
• Symptoms of pregnancy
• Pregnancy testing, due date
• Diagnostic testing, immunizations
• History: genetic history, domestic violence, etc.
• Exam
• Patient teaching: weight gain, nutrition, exercise
• AVOID: alcohol, drugs, infections, skydiving!
• Problems: bleeding, cramping, ECTOPIC, etc.
• Schedule of visits

Question
What statements about folic acid are correct? Select all that apply.
1. ALL pregnant WOMEN should take 1 mg (1,000 mcg) daily
2. Before becoming pregnant, women should take 0.4 mg (400 mcg) daily
3. Prevents cleft palate
4. Prevents neural tube defects!!!!

Preconception: per CDC, FOLIC ACID

• ALL WOMEN of reproductive age:
 Necessary to prevent neural tube defects!!!
 Prepregnancy: 0.4 mg (400 mcg)
 Pregnancy confirmed: 1 mg (1,000 mcg)
 How much for "risk takers"?

Symptoms of Pregnancy
• Variable presentation:
 Late (light) or missed menses
 Frequent urination
 Fatigue
 Nausea and/or vomiting (morning sickness)
 Breast tenderness

Nausea in Pregnancy
• Avoid ondansetron (Zofran), not first line
• Ginger
• Saltines/ginger ale
• Diclegis (FDA approved)
 Doxylamine succinate 10 mg (antihistamine)
 Pyridoxine 10 mg (B6)
 Sig: 2 tabs HS
 If symptoms persist, add 1 tab in am

Diagnosis of Pregnancy
• Urine versus blood pregnancy hCG* tests? Which is best?
 Urine: sensitive 9-12 days after conception
 Serum: sensitive 8-11 days after conception (best test - most sensitive and specific)
* Human chorionic gonadotrophin

Additional Notes:

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“When am I due?”
• Naegele’s Rule*:
 Subtract 3 months from LMP
 Add 7 days
 Add 1 year
 Pregnancy = 281-282 days
*Manual due date calculation

Patient History: At first visit, or prior to

• Current pregnancy history
• Past OB history
• Menstrual, gynecologic history
• Personal, family medical history
• Past surgical history
• Genetic history
• Psychosocial information

Domestic Violence and Depression Screening

• ACOG, AMA recommend ‟routine assessment of ALL pregnant women for domestic violence
and depression”
• Often begins or worsens during pregnancy and postpartum
• 7-20% of pregnant women are physically abused
• 3x higher rate if pregnancy unintended!!!
• More medical problems during pregnancy and delivery than nonabused women

Risk Factors
• Age <35 years
• Single, divorced, separated
• Alcohol or drugs: or partners who do
• Smoker
• Childhood: physical or sexual abuse

Question
What are domestic violence clues? Select all that apply.
1. Missed prenatal visits
2. Overly supportive partner
3. Bipolar disorder
4. History of childhood abuse
5. Improbable injury

Domestic Violence Clues

• Bruising
• Improbable injury
• Depression, anxiety
• Late prenatal care (after first trimester)
• Missed prenatal visits
• Cancellation of appointment (short notice)
• Overprotective partner
 If female this might be a clue re “human trafficking”
Additional Notes:

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Physical Exam
• Baseline BP, and weight
• Complete physical exam
• Cervical screening (per ASCCP)
 Gentle sampling: broom, spatula; AVOID cytobrush

Standard Diagnostic Studies: at first prenatal visit

First things FIRST!
• Pregnancy test:
 hCG identified
• If normal pregnancy
 hCG doubles every 24-72 hours in first trimester
• Qualitative (Yes or No) vs quantitative (amount of hCG)

Question
What statements are true about pregnancy testing? Select ALL that apply.
1. In a normal pregnancy, urine and blood tests are about equally accurate.
2. If an ectopic pregnancy is suspected, a “qualitative” HCG serum test should be ordered.
3. If a home urine test is positive, an in-office test is not needed.
4. Urine testing can be done as soon as a missed period occurs.

Standard Diagnostic Studies: at first prenatal visit

• Pregnancy test if NOT previously done
• CBC (anemia) or H&H plus MCV
• Note:
 MCV helps screen for thalassemia
 MCV <80 fL in the absence of Fe deficiency anemia suggests thalassemia
• Urinalysis: for bacteria, protein and glucose
• Urine culture:
 If at high risk of pyelonephritis
 Especially if asymptomatic bacteriuria
• Blood type and Rh: antibody screening
• Rubella immunity: AVOID IN PREGNANCY
 If immune, NOT needed
 If NOT immune, immunize AFTER delivery and avoid infected people!!!
• TSH:
 If symptoms, personal or family history, or other risk factors
 If hypothyroidism: needs increase in pregnancy
 If untreated: may delay neurologic development

Pregnancy: STI Screening — CDC 2015 Guidelines

• HIV: first, third trimester
• Chlamydia: ages <25 years
• GC: If high risk, especially if <25 years old
• Syphilis
• Hepatitis A, B, C (per risk)
• BV, Trich: consider screening
• HSV Type 2: if at high risk or symptomatic
Additional Notes:

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Question
Which of the following vaccines are safe to administer to a pregnant patient? Select all that apply.
1. Tetanus and diphtheria
2. MMR
3. 9vHPV
4. Influenza
5. Pneumococcal

Diagnostic Studies for “At-Risk” Patients

• Tuberculosis
• Sickle cell anemia (SCA): with Hgb electrophoresis

Ultrasound: Indications
• First Trimester:
 Confirm due date, assess fetal development, identify abnormalities
• Second Trimester:
 Confirm date/size, abnormalities, if bleeding, etc.
• Third Trimester:
 Date/size, complications, bleeding, baby position (especially if breech suspected)

A Day In Clinical Practice

A 32-year-old woman presents to your office with LMP 45 days ago and lower right quadrant
pain. What should be in your differential diagnosis? Select all that apply.
1. Cholecystitis
2. Urinary tract infection
3. Ectopic pregnancy
4. Appendicitis
5. Ovarian cyst

Ectopic Pregnancy: Symptoms

• Lower abdominal pain (unilateral), vaginal bleeding, missed menses
• Symptoms 6-8 weeks after LMP
• Low-grade fever
• HCG: Quantitative
 DOES NOT DOUBLE within 24-72 hours

Risk Factors: Ectopic Pregnancy

• Previous ectopic pregnancy
• Tubal pathology, tubal surgery
• Current IUD use Image Copyright Life Under The Lights

• Previous cervicitis (GC)

http://www.lifeunderthelights.com/2012/11/29/on-
the-topic-of-ectopics-ectopic-pregnancy-for-
• History of PID ems/#sthash.enhWE9qS.dpbs

• Others

Medications in Pregnancy Recent Warnings:

Medication Concern
Acetaminophen (Tylenol)* ADD/ADHD
Fluconazole (Diflucan)* Miscarriage (single dose may be OK)
Nitrofurantoin (Macrobid)* Congenital abnormalities (2019 ACOG-Avoid in 1st trimester)
Ondansetron (Zofran)* Heart/ Cleft Palate? (FDA warning, NOT first line for nausea)
*May use if benefits outweigh risks

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Medications in Pregnancy
• Avoid if possible; negative effect on pregnancy
• Pregnancy Categories
 OTC still using A-X
 Prescription: Eliminated A-X

FDA System to Rank Drugs

• SAFE (old A): safe in pregnancy
 Example: folic acid, B6, levothyroxine
• Probably SAFE (old B): appear safe in pregnancy after years of prescribing
 Examples: PCN, cephalosporins, prednisone, insulin
• May NOT be Safe (old C): OK if benefits outweigh risks or safety studies incomplete
 Examples: pseudoephedrine, fexofenadine, quinolones, triptans, ondansetron (Zofran),
lamotrigine (Lamictal; cleft palate?); fluconazole (Diflucan), nitrofurantoin (Macrobid),
acetaminophen (Tylenol), sertraline (Zoloft; safer), paroxetine (Paxil; less safe)
• NOT Safe (old D): Clear risks for the fetus;
 Examples: chemo drugs, phenytoin, tetracyclines
 NEW – fluoxetine (Prozac)
• Boxed Warning DO NOT USE: cause birth defects; NEVER USE IN PREGNANCY!
 Examples: misoprostol, thalidomide

A Day In Clinical Practice

A pregnant patient (first trimester) is taking fluoxetine (Prozac) for depression. What should be
done with this medication during pregnancy? Select the correct answer.
1. Discontinue and consider sertraline (Zoloft).
2. Discontinue and start TCAs.
3. Continue at the same dose.
4. Continue but reduce the dose.
Which antibiotic(s) are contraindicated in pregnancy? Select all that apply.
1. Amoxicillin
2. Levofloxacin
3. Trimethoprim sulfamethoxazole
4. Doxycycline
5. Keflex

Single Pregnancy
• BMI <18.5: weight gain 28-40 pounds
• BMI 18.5-24.9: weight gain 25-35 pounds!!!
• BMI 25.0-29.9: weight gain 15-25 pounds
• BMI >30: weight gain 11-20 pounds
 Mother's birth weight influences neonatal morbidity and mortality
 Mother's birth weight may influence child’s future risk of DM, HTN, CVD

Exercise
• At least 30 minutes of moderate exercise most days (150 minutes weekly)
• Avoid risky activities (falls, abdominal trauma): NO scuba diving
• NO AIR TRAVEL after 36 weeks (ACOG); earlier if history of preterm labor, or risks
Additional Notes:

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Alcohol (Teratogen), Cigarettes, Illicit Drugs

• 6.7% of pregnant women consume EtOH
• Total avoidance is recommended to prevent:
 Fetal alcohol syndrome (FAS)
 Fetal alcohol effects (FAE)
 Miscarriages
• Screen all pregnant women!!!
 Counseling is an effective intervention!!!

Cramping During Pregnancy

• Due to hormonal changes or growing uterus: usually normal
• Encourage rest (left side) and fluids
• Worsening cramps (preterm labor)
• Unilateral pain, or associated bleeding, may indicate ectopic pregnancy or threatened
abortion: REFER to ER
• Most ectopics end in miscarriage

Infection Precautions During Pregnancy

• AVOID febrile illnesses/contagious diseases: influenza, toxoplasmosis, CMV, varicella, Parvo
B19 (avoid cleaning cat box), Listeria, Measles!!!
• Zika: NEW Nov 2019 per CDC:
 If male partner exposed, condoms x3 months
 Women: if exposed, wait 8 weeks before conceiving
 Microcephaly, cleft palate, etc.
 Highest risk in first trimester
 CDC.gov for latest info

Immunizations in Pregnancy
• Every Pregnancy: (to protect the newborn)
 Influenza: give any time in pregnancy
 Tdap: give between 27-36 weeks’ gestation
• Live attenuated vaccinations: AVOID in pregnancy!
 MMR
 Varicella

Teaching Plan
• Report to HCP:
 Vaginal bleeding
 Leakage of fluid from vagina
 Decreased fetal activity!!!
 Signs of preterm labor

When should our patient return?

• Traditional schedule of visits in uncomplicated pregnancy:
 Every 4 weeks until 28 weeks’ gestation
 Every 2 weeks from 29 weeks’ to 36 weeks’ gestation
 Every week after 36 weeks’ gestation
Additional Notes:

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SECOND TRIMESTER – 14 TO 28 WEEKS

Routine visits: Key points
• Fundal height
• Gestational diabetes
• Quickening
• Genetic screening/ultrasound
• Rhogam
• Preterm labor

Assessment
• Blood pressure, weight, fundal height, fetal heart auscultation
• CBC for anemia
• Urinalysis as indicated (glucosuria, proteinuria, ketonuria)
• Dysuria (asymptomatic bacteriuria → pyelonephritis)

Gestational Diabetes Screening

• Who: all pregnant women
• When: 24-28 weeks’ gestation
• How: no consensus
• Up to 18% of pregnant women will have gestational diabetes

Gestational Diabetes Significance

• Preeclampsia
• Hydramnios
• Macrosomia
• Fetal organomegaly
• Maternal/infant trauma
• Perinatal mortality
• Others

Gestational Diabetes Screening

• Diabetes diagnosed at initial visit is overt diabetes
• Diabetes diagnosed during pregnancy is gestational diabetes

Screens for Overt Diabetes

• Identified at first prenatal visit:
 Fasting glucose >126 mg/dL, or
 A1C >6.5%, or
 Random >200 mg/dL (and confirmed by another means)
• Increased risk for congenital anomalies, nephropathy, retinopathy, etc.

Screening for Gestational DM

• Two-Step: Screen. If positive, diagnostic testing (ACOG recommends)
• One-Step: Screen/test with 2-hour, 75 g 2-hour GTT; more convenient, but expensive

If a Positive Screen:
• 3-hour, 100-g OGTT
• If 2 of the following are met → diagnose w/gestational diabetes:
 Fasting glucose: >95 mg/dL
 1-hour glucose: >180 mg/dL
 2-hour glucose: >155 mg/dL
 3-hour glucose: >140 mg/dL

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Question
Which statements are true about gestational diabetes (GD)? Select ALL that apply.
1. Screening should be conducted in the second trimester.
2. One abnormal reading on the 3-hour OGTT = gestational diabetes.
3. GD affects about 18% of pregnant women.
4. GD is associated with maternal and fetal abnormalities.

If DM Diagnosed…
• Referral to registered dietitian (RD)
• 3 meals (moderate sized) plus 2-4 PROTEIN-focused snacks, but needs individual
adjustment by RD
• Insulin (safety studies for NPH, Novolog, Humalog, Levemir)
• Oral metformin (ACOG but not ADA)
 Safe throughout pregnancy

Fundal Height — "McDonald's Rule"

• Uterus: uterine fundal height measured in cm from symphysis pubis to top of uterus
• Between 18-34 weeks’ gestation, there is good correlation between fundal height (cm) and
gestational age of the fetus (in weeks)
• 2 cm wiggle room; if under/over, REFER
• Bladder must be empty!

Integrated Screen: Advanced Maternal Age and/or High Risk

• Refer to maternal-fetal medicine:
 15-22 weeks’ gestation for blood testing
▪ AFP: alpha fetoprotein
▪ Estriol (uE3): unconjugated estriol
▪ Beta-hCG: human chorionic gonadotropin
▪ Inhibin A (inhA)
 If abnormal, follow-up with: ultrasound and/or amniocentesis!!!

Chromosomal Abnormalities
• Down Syndrome (trisomy 21): most common chromosomal abnormality in live births
• Turner Syndrome:
 Most common sex-chromosome abnormality in girls
 Loss of part or all of an X chromosome
 Short in stature, square chests, others
Turner Syndrome

Image Copyright DNAdirect

http://services.dnadirect.com/grc/patient- Image Copyright 2016 Zedna Brickick Website
site/chromosome-analysis-infertility/how-chromosome- http://sicknessfinder.com/klinefelter-and-turner-
analysis- syndrome/
works.html?8D3A4A4F60D3E475E71CDDF63034F493

Fetal Movement “Quickening”

• Primipara: 17-20 weeks’ gestation
• Subsequent pregnancies: 15-16 weeks’ gestation
Why? ___________________________________________________________

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A Day In Clinical Practice

A pregnant mother is Rh negative. When should she receive RhoGam (anti D immune globulin)?
Select all that apply.
1. At diagnosis of pregnancy
2. At 12-14 weeks’ gestation
3. At about 28 weeks’ gestation
4. During each trimester
5. Within 72 hours of delivery
A pregnant mother who is Rh-negative has had a suspected miscarriage early this morning. LMP
8 weeks ago. How should this be handled?
1. She does not need RhoGam.
2. She should receive RhoGam now.
3. She needs RhoGam only if miscarriage occurs in the second trimester.
4. She needs RhoGam only if miscarriage occurs in third trimester.

Education
• Reinforce at second and third trimesters:
 Vaginal bleeding
 Leakage of fluid per vagina
 Uterine contractions
 Decreased fetal activity
• Signs of preterm labor:
 Low/dull backache
 Increased uterine activity
 Menstrual-like cramps
 Diarrhea
 Spotting/bleeding
• Educate regarding signs and symptoms of labor:
 Low back pain
 Passage of “bloody show”
 Regular contractions
 Rupture of membranes
• Route of delivery
• Breastfeeding
• Neonatal circumcision
• Car seat

THIRD TRIMESTER – 28 TO 40 WEEKS

Assessment
• Ask about: pain, contractions, bleeding?
• Vital signs: blood pressure, weight
• Urinalysis as indicated: glucosuria, proteinuria, ketonuria?
• Dysuria: asymptomatic bacteriuria → pyelonephritis
• Review of symptoms: indicating danger signs of pregnancy, contractions?
• Screen for STIs: vaginal discharge?
• Fundal height measurement
• Fetal heart tones/fetal activity
• Later in pregnancy: DO NOT PERFORM!
 Vaginal examination to determine cervical dilatation, effacement, station of presenting
part
 Presenting fetal part
• Assess: parental-fetal attachment

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Maternal Assessment of Fetal Activity (kick counts)

• Procedure: start at about 28 weeks’ gestation
 Patient lies on her left side for 30 minutes after eating
 She records the time she starts the test and notes each time the baby moves or kicks
• Findings
 A healthy fetus should move 3-5 times within 1 hour!!!
 Most move a lot more than this!

Diagnostic Studies
• 35-37 weeks’ gestation
 Group B Strep (Strep agalactiae) screening
 Vaginal and rectal swabs performed
 Common cause of neonatal sepsis AND associated morbidity, mortality

COMMON COMPLICATIONS ASSOCIATED WITH PREGNANCY

Preterm Premature Rupture of Membranes (PPROM) Image Copyright 2018 The
• Nitrazine testing: Hearst Corporation All rights
reserved.
 pH of amniotic fluid = 7.0-7.7 https://blog.timesunion.com/
mdtobe/answer-to-medical-
 Normal vaginal pH = 3.8-4.2 mystery-monday-99/2573/

Preterm Premature Rupture of Membranes (PPROM): Image Copyright © 2018

Fern Test Memorang, Inc.
https://www.memorangapp.com/fla
• Fern Test: fluid from posterior vaginal fornix swabbed shcards/3089/Labor+and+delivery/

on a slide, allowed to dry ≥10 minutes

• Amniotic fluid: has a delicate ferning pattern, like frost
on a window
Image Copyright ADAM, Charlene
Placenta Previa S. Dezzutti, PhD; University of
Pittsburgh; Magee-Womens
• Improper implantation of the placenta into the lower Research Institute; Use of
Mucosal Assays in Microbicide
uterine segment Trials August 26, 2015
https://mtnstopshiv.org/sites/defaul
t/files/attachments/Dezzutti%20Ge
Assessment Findings nital%20tract%20PD%2026%20A
ugust%202015.pdf
• Painless vaginal bleeding, usually beginning at the end
of the second trimester
• A vaginal examination should NOT be performed if placenta previa is suspected

Management
• Cesarean section is required:
 If frequent, recurrent, or profuse bleeding persists OR
 If fetal well-being jeopardized
• Refer:
 For placenta previa OR
 Abruptio placenta

Question
Which of the following are true about placenta previa? Select all that apply.
1. Causes painless vaginal bleeding
2. Usually occurs in the second trimester
3. No referral is needed unless it worsens
4. May progress to placenta abruptio

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Pre-Eclampsia
• Hypertensive condition that occurs during pregnancy and resolves after pregnancy
• Can occur anytime:
 After the 20th week
 Usually occurs in third trimester

Diagnostic Criteria
• Definition lacks consensus!!!
• ACOG, 2013 definition:
 “New development of HTN and either proteinuria or end organ dysfunction after 20
weeks’ gestation is usually due to preeclampsia”
• Proteinuria: removed as essential criterion
• Edema: is no longer a criterion
• BUT: edema of the face and hands, AND edema associated with more than a 2-kg weight
gain in 1 week … WORRY!!!!
• End organ: heart failure, pulmonary edema, decreased GFR, thrombocytopenia

Management
• Delivery of infant by 40 weeks’ gestation or earlier
• Bed rest in left lateral recumbent position to decrease pressure on vena cava
• Well-balanced diet with moderate protein intake
• Excessive salt intake should be avoided, but sodium restriction not recommended
• Hospitalization recommended if BP 160/110 mm Hg consistently with bed rest
• Diuretics/ACE inhibitors NOT recommended for treatment
• Antihypertensives (Labetalol cat B)
 Methyldopa (Aldomet) is drug of choice
 Hydralazine (Apresoline)
 CCBs (nifedipine, verapamil, diltiazem)
• Educate re: signs and symptoms of worsening preeclampsia
• Delivery of infant is definitive treatment

Peripartum Depression/Postpartum Depression

• Depressive episode within 4 weeks of delivery
• Most postpartum mood changes resolve by day 10
• Affects about 13% of pregnant women
• Edinburgh Postnatal Depression Scale for screening
Additional Notes:

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CHECK YOUR KNOWLEDGE

According to CDC, what is the recommended dose of folic acid for pregnant women?
1. 0.5 mcg (500 mg) per day
2. 1 mg (1,000 mcg) per day
3. 0.4 mcg (400 mg) per day
4. 2 mg (2,000 mcg) per day

Which statement is NOT true about ectopic pregnancy?

1. Fallopian tube rupture may occur shortly after onset of symptoms.
2. Symptoms typically occur about 6-8 weeks after LMP.
3. Serum HCG levels double every 24-72 hours.
4. Lower abdominal pain may occur on right or left side.

Folic acid is recommended prior to and during the first 3 months of pregnancy to prevent neural
tube defects. Select the examples of neural tube defects.
1. Cleft palate
2. Spina bifida
3. Anencephaly
4. Encephalocele

A patient has a fundal height measurement of 32 cm. She is probably about (select all that apply):
1. 14-18 weeks pregnant.
2. 18-22 weeks pregnant.
3. 32 weeks pregnant.
4. ready to deliver.

The uterine fundus should be palpable at 20 weeks’ gestation:

1. at the level of the umbilicus.
2. just above the level of the symphysis pubis.
3. midway between the symphysis and umbilicus.
4. below the symphysis pubis.

Uterine Size
• 6-8 weeks: small pear
• 8-10 weeks: orange
• 10-12 weeks: grapefruit
• At 12 weeks: palpable just above symphysis
• At 16 weeks: midway between symphysis and umbilicus
• 20 weeks: at level of umbilicus

A 14-day postpartum patient has a positive screen for

depression. What is this patient’s most likely diagnosis?
1. Postpartum blues
2. Postpartum depression
3. Major depressive disorder
4. Postpartum psychosis
Additional Notes:

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Thank you!
• Mimi@MimiSecor.com
• For my App, Text "DrMimi" to 36260

Resources for Pregnancy

• Carcio, H.A., Secor, R. M. (2018). Advanced Health Assessment of Women, 3rd ed. New
York, NY: Springer Publishing.
• Secor, R. M., Fantasia, H. C. (2017). Fast Facts About the Gynecologic Exam For Nurse
Practitioners, 2nd ed. New York, NY: Springer Publishing.
• Advanced Practice Education Associates. CareOnPoint. www.careonpoint.com
• Hollier, A. Clinical Guidelines in Primary Care (2018). 3rd ed. Lafayette, LA: APEA.
• To view this lecture again, visit the APEA CE Library and purchase the Fundamentals of
Pregnancy on video: https://www.apea.com/ce-library
Additional Notes:

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Additional Notes:

210 Copyright 2020 Advanced Practice Education Associates