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Summary Obstetrics
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Obstetrics notes detailing obstetric medicine, routine monitoring, foetal abnormalities and pregnancy related complications for medical school examinations. Notes made from multiple resources such as oxford handbook, question banks, university lectures and UK guidelines. Look at specialty sectio...

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  • September 5, 2022
  • 40
  • 2022/2023
  • Summary

Subjects

  • obstetrics
  • pregnancy
  • in utero
  • foetal medicine
  • medicine
  • medical notes
  • medical school
  • med notes

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  • Queens University Belfast (QUB)
  • Unknown
  • Medicine
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Obstetrics

Seán Keenan

2022

,Physiological Changes in Pregnancy


Hormonal
Physiological Changes
- Progesterone
o Corpus Luteum: Produces to 35 d post-conception
o Placenta: Produces progesterone past 35 d mark
o Effects: ↓ Smooth m. excitability; ↑ Body To
- Oestrogens (90 % Oestradiol)
o Effects: ↑ Breast growth; Water retention
o Thyroid: Often enlarges due to ↑ colloid
- Other Hormones
o Prolactin: Production in pituitary increased
o Cortisol: ↑ Output but ↔ unbound levels
o βHCG: ↑ Until 8 wks then plateaus and falls

Cardiovascular System
Physiological Changes
- Stroke Volume: SV ↑ 30 % - BP: SBP ↔; DBP ↓ in 1TM + 2TM; ↔ in 3TM
- Heart Rate: HR ↑ 15 % - Venous: Uterus may interfere with LL return
- Cardiac Output: CO ↑ 15 % - NB: Ankle oedema; Varicose veins; Supine ↓ BP

Respiratory System
Physiological Changes
- Ventilation: ↑ 40 %; Tidal volume ↑ 500-700 mL - Oxygen: Requirements ↑ 20 %
- NB: Caused by progesterone’s effect on resp. centre - BMR: Basal metabolic rate ↑ 15 % (thyroid/ACTH)

Circulatory System
Physiological Changes
- Blood: Blood volume ↑ 30 % (mostly in 2TM) - Fibrinolysis: ↓ Fibrinolytic activity (risks VTE)
- NB: Red cells ↑ 20 % but plasma ↑ 50 % (↓ Hb) - NB: Prevent excess bleeding in delivery
- COAGs: Slight ↑ in coagulants - Other: ↑ WCC; ↑ ESR; ↓ PTC
- NB: Fibrinogen; Factors VII, VIII, X

Urinary System
Physiological Changes
- Blood Flow: ↑ 30 % - Reabsorption: Salt + H2O ↑ by ↑ sex steroids
- GFR: ↑ 30-60 %; Leads to glycosuria + Proteinuria - Proteinuria: ↑ Urinary protein losses

Biochemical
Physiological Changes
- Calcium: ↑ Requirements during gestation (esp. 3TM) - Serum: ↓ Ca2+ (ionised Ca2+ stable); ↓ PO43-
- Placenta: Actively transported across placenta - Gut: Absorption increases to compensate

Liver
Physiological Changes
- Blood flow: Remains the same - Albumin: ↓ Levels
- ALP: ↑ 50 %

Uterus
Physiological Changes
- Mass: 100 g ➔ 1100 g (Hyperplasia ➔ hypertrophy) - Contractions: Braxton-Hicks occur at ~30 wks
- Cervix: ↑ Cervical ectropion and discharge - NB: Irregular; Occur every 20 mins; Progressive
- Position: Retroversion may cx urinary retention cervical changes are absent

, Plasma Chemistry in Pregnancy
Non-Pregnant Trimester 1 Trimester 2 Trimester 3
Centile / Analyte 2.5 97.5 2.5 97.5 2.5 97.5 2.5 97.5
+
Na mmol/L 138 146 135 141 132 140 133 141
2+
Ca mmol/L 2 2.6 2.3 2.5 2.2 2.2 2.2 2.5
Albumin Corrected Ca2+ 2.3 2.6 2.25 2.57 2.3 2.5 2.3 2.59
Albumin g/L 44 50 39 49 36 44 33 41
AST IU/L 7 40 10 28 11 29 11 30
AST IU/L 0 40 6 32 6 32 6 32
TSH 0 4 0 1.6 1 1.8 7 7.3
Analyte Non-Pregnant Pregnancy
ALP IU/L 3 300 ≤450*
Bicarcbonate mmol/L 24 30 20 25
Creatinine µmol/L 70 150 24 68
Urea mmol/L 2.5 6.7 2 4.2
Urate µmol/L 150 390 116 276
* ALP can be drastically raised in normal pregnancy

Normal Growth
Phases of Growth
- Phase I: 0-16 wks; Cellular hyperplasia - Phase III: 32 wks – Term; Hypertrophy
- Phase II: 16-32 wks; Hyperplasia + Hypertrophy

Production of Blood Products in Foetus
Hepatic Haematopoiesis Splenic Haematopoiesis
- Major: Major site of initial haematopoiesis - Minor: Minor site of haematopoiesis
- Begins: 6 wks gestation - Active: 12-25 wks gestation
- Peaks: 12-16 wks gestation Bone Marrow
- Declines: 36 wks gestation - Active: From 16 wks gestation ➔ Adulthood

, Prenatal Care

Description
The aim is to minimize the risks to the mother, neonate, or fetus by modifying pre-pregnancy conditions and risk
factors. This may involve advising against pregnancy or delaying conception until a safer time. Babies conceived 18–
23 months after a live birth have the lowest rate of perinatal problems. See paediatrics for Neural tube defects notes.


Basics of Prenatal Care
Weight Smoking
- Exercise: Encourage; Improves fitness + self-esteem - Mother: ↓ Fallopian tube fxn + ovulation
- Weight: Aim >18.5 and <30 - Father: Abnormal sperm production
- Avoid: Contact sports (abdominal trauma) - Miscarriage: Associated with 2-fold ↑ risk
Nutritional - Other: Preterm labour; ↓ Foetal growth; Placenta
- Folate: See below praevia; Abruption; Asthma RR 1.5
- Avoid: Liver; Vit A; Caffeine; Pâté; Soft cheese; Sushi Alcohol
- VitD: At risk ethnic groups; Obesity; Chronic disease - Mother: High levels risk foetal alcohol syndrome
- NB: VitD deficiency leads to ↑ risk of Pre-eclampsia; - Miscarriage: ↑ Risk of miscarriage
IUGR; T1DM; Asthma; Fractures; Rickets
Serology
- Rubella: Ensure immune to rubella

Folic Acid in Pregnancy
Functions Risk Factors for NTD
- THF: Necessary for FNA and RNA synthesis - FHx: NTD in either parent; Previous NTD pregnancy
Causes of Deficiency - Meds: Antiepileptic medication
- Drugs: Phenytoin; Methotrexate; Alcohol - Maternal: Coeliac disease; DM; Thalassaemia trait
- Physiological: Alcohol excess - Obesity: BMI >30 kg/m2
Consequences of Deficiency Prevention of Deficiency
- Haem: Macrocytic megaloblastic anaemia - ↔ Risk: 400 µg folate until 12 wks gestation
- Neuro: Neural tube defects (NTDs) - ↑ Risk: 5 mg folate 1 month preconception-12 wks



MORE Folate (B9) – Indications for 5 mg Antenatal Care Booking
- Metabolic Disorder (DM; Coeliac) - Blood (4): FBC; Rh; Group; Alloantibodies
- Obesity (BMI >30) - Virus (3): HBV; HIV; Syphilis
- Relative (FHx or Hx of NTDs) - Urine (2): Urine dipstick; Urine culture
- Epilepsy (on AEDs) - Exam (1): Full physical observations
- B(9)lood (SCA; Thalassemia)

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