IDENTIFICATION OF RISK FACTORS
Obstetrical history—number of pregnancies, pregnancy duration, complications, mode ofdelivery, perinatal outcome
Medical and surgical history—diabetes mellitus, hypertension, cardiac, thyroid, seizure disor-der, anemia
Social history—educational level, marital status, social support, abusive relationships
Family history—inherited diseases, mental retardation, birth defects, perinatal deaths
Sexual history—age of first intercourse, current partners, lifetime sexual partners, previoussexual abuse
Lifestyle—alcohol, tobacco, recreational drugs, poor nutrition, eating disorders
Teratogenic exposure—x-radiation, toxins, chemicals, prescription medications
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USMLE Step 2 l Obstetrics
NORMAL PREGNANCY EVENTS
First Trimester
Assuming a 40 menstrual week pregnancy, the first trimester is assumed to extend from concep-tion through to 13 weeks.
• Normal symptoms seen in the majority of pregnancies include nausea, vomiting, fatigue, breast tenderness, and frequent urination.
• Spotting and bleeding occur in 20% of pregnancies, 50% of which will continuesuccessfully.
• Average weight gain is 5–8 pounds.
• Complications—spontaneous abortion.
Second Trimester
Assuming a 40 menstrual week pregnancy, the second trimester is assumed to extend from 13 to
26 weeks.
• Normal symptoms are an improved feeling of general well-being.
• Round ligament pain is common.
• Braxton-Hicks contractions are painless, low-intensity, long-duration contractionsthat can be palpated as early as 14 weeks.
• Quickening (maternal awareness of fetal movement) is detected at 18–20 weeks by
primigravidas and 16–20 weeks by multigravidas.
• Average weight gain is 1 pound per week after 20 weeks.
• Complications include incompetent cervix (painless cervical dilation leading to delivery of a nonviable fetus); premature membrane rupture, and premature labor.
Third Trimester
Assuming a 40 menstrual week pregnancy, the third trimester is assumed to extend from 26 to
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40 weeks.
• Normal symptoms include decreased libido, lower back and leg pain, urinary frequency, and Braxton-Hicks contractions.
• Lightening describes descent of the fetal head into the pelvis resulting in easier mater-nal breathing, pelvic pressure.
• Bloody show describes vaginal passage of bloody endocervical mucus, the result ofcervical dilation before labor.
• Average weight gain is 1 pound per week after 20 weeks.
• Complications include premature membrane rupture, premature labor, preeclampsia, urinary tract infection, anemia, and gestational diabetes.
NORMAL PREGNANCY COMPLAINTS
Backache is very common, especially in the latter part of pregnancy because of the change incenter of gravity with the enlarging uterus. Muscles and ligaments are now used that otherwise would not be. Management is encouragement of correct posture.
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Chapter 4 l Prenatal Management of the Normal Pregnancy
Bleeding gums is caused by the increase of blood flow to the gums with pregnancy. If it is asso-ciated with clinical swelling, it is known as epulis. Management is conservative.
Breast enlargement. Each breast increases in size by 400 grams and may result in an increaseof one to two cup sizes. Management is a support bra.
Carpal tunnel. As many as 50% of pregnant women will experience numbness, tingling, burn-ing, or pain in at least two of the three digits supplied by the median nerve. Management is fitting with a wrist splint (most cases will spontaneously resolve after delivery).
Complexion changes. Some women develop brownish or yellowish patches called chloasma, orthe “mask of pregnancy,” on their faces. Others may develop a linea nigra on the lower abdomi-nal midline, as well as hyperpigmentation of the nipples and external genitalia. Management is conservative.
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Dizziness. Blood pressure normally decreases in pregnancy, which may lead to postural hypo-tension. Management is avoiding rapid postural changes, such as standing up quickly.
Fatigue is very common in pregnancy, probably because of rapid hormonal changes.
Management is adequate resting and the avoidance of excessive activity.
Fluid retention. Increased circulating steroid levels and decreased serum albumin results inedema in over half of pregnant women. Edema is not a criterion for preeclampsia. Management is elevating legs and using support hose.
Hair and nails. Hair shedding decreases in pregnancy. Telogen effluvium is the excessive shed-ding of hair occurring 1−5 months after pregnancy. Telogen effluvium occurs in 40−50% of women. Nails may become more brittle. Management is conservative.
Headaches. Muscle contraction and migraine headaches are more common in pregnancyprobably because of increased estrogen levels. Management is physical therapy (e.g., ice packs, massage) with medication only as a last resort.
Leg cramps. Lower extremity muscle cramps are frequent in pregnancy. Management is hydra-tion, stretching exercises, and calcium supplementation.
Morning sickness. Nausea and vomiting are common in early pregnancy and are probablymediated by elevated hCG levels. Management is eating small meals emphasizing crackers and carbohydrates.
Nosebleeds. Vasodilation and increased vascular supply results in more frequent nosebleeds.
Management is saline drops and the avoidance of nasal sprays.
Stretch marks. Genetic predisposition and pregnancy can result in striae gravidarum. Womenwith stretch marks have increased risk of delivery lacerations. Management is conservative.
Stress incontinence. Pressure on the bladder with an enlarging uterus frequently results inan involuntary loss of urine. Management is strengthening the pelvic diaphragm with Kegel exercises.
Varicose veins. Increased blood volume, the relaxing effect of progesterone on smooth muscle,and an increased lower-extremity venous pressure often result in lower-extremity varicosities. Management is discouraging prolonged standing and sitting.
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USMLE Step 2 l Obstetrics
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