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Signs of pregnancy presumptive (subjective signs) Amenorrhea, nausea, vomiting, increased urinary frequency, excessive fatigue, breast tenderness, quickening at 18–20 weeks probable (objective signs) Goodell sign (softening of cervix) Chadwick sign (cervix is blue/purple) Hegar’s sign (softening of lower uterine segment) Uterine enlargement Braxton Hicks contractions (may be palpated by 28 weeks) Uterine soufflé (soft blowing sound due to blood pulsating through the placenta) Integumentary pigment changes Ballottement, fetal outline definable, positive pregnancy test (could be hydatidiform mole, choriocarcinoma, increased pituitary gonadotropins at menopause) positive (diagnostic signs) Fetal heart rate auscultated by fetoscope at 17–20 weeks or by Doppler at 10–12 weeks Palpable fetal outline and fetal movement after 20 weeks Visualization of fetus with cardiac activity by ultrasound (fetal parts visible by 8 weeks) Pregnancy and fundal height measurement Signs of pregnancy (presumptive, probable, positive) Pregnancy and fundal height measurement As pregnancy progresses, the fundus rises out of the pelvis ( Figure 29-1 ). At 12 weeks’ gestation, the fundus is located at the level of the symphysis pubis. By week 16, it rises to midway between symphysis pubis and the umbilicus. By 20 weeks’ gestation, the fundus is typically at the same height as the umbilicus. Until term, the fundus enlarges approximately 1 cm per week. As the time for birth approaches, the fundal height drops slightly. This process, which is commonly called lightening, occurs for a woman who is a primigravida around 38 weeks’ gestation but may not occur for the woman who is a multigravida until she goes into labor
Naegele’s rule Add seven days to the first day of your LMP and then subtract three months. For example, if your LMP was November 1, 2017: Add seven days (November 8, 2017). Subtract three months (August 8, 2017). The EDD is calculated by adding seven days to the first day of the last menstrual period, subtracting three months and adding one year. This formula is known as Naegele's Rule. For example, if the patient's last menstrual period, LMP, was on August 10, 2019, the EDD would be calculated as follows. LMP equals August 10, 2019 plus seven days. August 17, 2019, minus three months. May 17, 2019 plus one year and that equals May 17, 2020. Hematological changes during pregnancy During pregnancy, the heart is displaced upward and to the left within the chest cavity by the gravid uterus’s pressure on the diaphragm. As pregnancy progresses, the risk for inferior vena cava and aortic compression leading to supine hypotension increases when the woman lies in a supine position. To avoid hypotension and potential syncope, the woman should be advised to lie in a left lateral position. Hemodynamic changes and anatomic changes also may alter vital signs in the pregnant woman ( Table 29-2 ).
newborn weight are correlated with the degree of blood volume expansion. Of the blood volume expansion occurring during pregnancy, 75% is considered to be plasma ( King et al., 2015 ). There is also a slight increase in red blood cell volume
(RBC). The blood volume changes result in hemodilution, which leads to a state of physiologic anemia during pregnancy. As the RBC volume increases, iron demands also increase. Leukocytosis occurs in pregnancy, with white blood cell counts increasing to as much as 14 , 000 to 17 ,000 cells per mm 3 of blood ( Table 29-3 ). Clotting factors increase as well, creating a risk for clotting events during pregnancy. Systemic vascular resistance is reduced due to the effects of progesterone, prostaglandins, estrogen, and prolactin. This lowered systemic vascular resistance, in combination with inferior vena cava compression, is partly responsible for the dependent edema that occurs in pregnancy. Epulis of pregnancy, or hypertrophy of the gums accompanied by bleeding, may also occur and is due to decreased vascular resistance and increase in the growth of capillaries during pregnancy ( Jarvis, 2016 ). Indications and contraindications for prescribing combined estrogen vs. progesterone-only birth control Progestin-only contraceptives are used continuously; there is no hormone-free interval, as occurs with combined methods. These contraceptive methods have minimal effects on coagulation factors, blood pressure, or lipid levels and are generally considered safer for women who have contraindications to estrogen, such as cardiovascular risk factors, migraine with aura, or a history of VTE. In spite of this belief, the product labeling for some progestin-only products mimics the labeling for products containing estrogen. The U.S. Medical Eligibility Criteria for Contraceptive Use ( CDC, 2010 ; see Appendix 11-A ) can be used to identify appropriate candidates for progestin- only contraception. Progestin-only contraceptives do not provide the same cycle control as methods containing estrogen, and unscheduled bleeding is common with all progestin-only methods. Typically, unscheduled bleeding occurs most frequently during the first 6 months of method use, with a substantial number of users becoming amenorrheic by 12 months of use ( Hubacher, Lopez, Steiner, & Dorflinger, 2009 ). Overall blood loss decreases over time, making progestin-only methods protective against iron- deficiency anemia. With appropriate counseling, many women see amenorrhea as a benefit of these methods. All progestin-only methods are likely to improve menstrual symptoms, including dysmenorrhea, menorrhagia, premenstrual syndrome, and anemia ( Burke, 2011 ). The thickening of cervical mucus seen with progestin methods is protective against PID. Progestin-only contraceptives include the progestin-only pill (POP), an injection, an implant, and three progestin-containing intrauterine devices. The implant and devices are covered in the section on long-acting reversible contraception.
- Category 1 : a condition for which there is no restriction for the use of the contraceptive method
- Category 2 : a condition where the advantages of using the method generally outweigh the theoretical or proven risks
- Category 3 : a condition where the theoretical or proven risks usually outweigh the advantages of using the method
- Category 4 : a condition that represents an unacceptable health risk if the contraceptive method is used Menstrual cycle physiology The initiation of menstruation, called menarche, usually happens between the ages of 12 and 15. Menstrual cycles typically continue to age 45 to 55, when menopause occurs. Many women find themselves reluctant to discuss the existence and normality of menstruation. The word menstruation has been replaced by a variety of euphemisms, such as the curse , my period , my monthly , my friend , the red flag , or on the rag. Most women experience deviations from the average menstrual cycle during their reproductive years. As a result, it is not uncommon for women to display certain preoccupations regarding their menstrual bleeding, not only in relation to the regularity of its occurrence, but also in regard to the characteristics of the flow, such as volume, duration, and associated signs and symptoms. Unfortunately, society has encouraged the notion that a woman’s normalcy is based on her ability to bear children. This misperception has understandably forced women to worry over the most miniscule changes in their menstrual cycles. Indeed, changes in menstruation are one of the most frequent reasons why women visit their clinician. Numerous patterns in the secretion of estrogens and progesterone are possible; in fact, it is difficult to find two cycles that are exactly the same. Studies that include women of different ethnicities, occupations, genetics, nutritional status, and age have demonstrated that the length and duration of the menstrual cycle vary widely ( Assadi, 2013 ; Johnson et al., 2013 ; Karapanou & Papadimitriou, 2010 ). Menarche is the most readily evident external event that indicates the end of one developmental stage and the beginning of a new one. It is now believed that body composition is critically important in determining the onset of puberty and menstruation in young women ( Ferin & Lobo, 2012 ). The ratio of total body weight to lean body weight is probably the most relevant factor, and individuals who are moderately obese (i.e., 20–30% above their ideal body weight) tend to have an earlier onset of menarche ( Johnson et al., 2013 ). Widely accepted standards for distinguishing what are regular versus irregular menses, or
normal versus abnormal menses, are generally based on what is considered average and not necessarily typical for every woman. According to these standards, the normal menstrual cycle is 21 to 35 days with a menstrual flow lasting 4 to 6 days, although a flow for as few as 2 days or as many as 8 days is still considered normal ( Ferin & Lobo, 2012 ). The amount of menstrual flow varies, with the average being 50 mL; nevertheless, this volume may be as little as 20 mL or as much as 80 mL. Generally, women are not aware that anovulatory cycles and abnormal uterine bleeding (changes in bleeding
Influenza (flu) a Women who are pregnant are at Any increased risk for flu-related gestation complications. when the injection is available Tetanus, diphtheria, pertussis (Tdap) After maternal vaccination, antibodies cross the placenta and decrease the risk of pertussis infection in the newborn. Third trimester (ideally 27– 36 weeks’ gestation) Advised If at Risk Rationale Timing Hepatitis B If the woman is at risk for acquiring HBV, she should be vaccinated. Indications include risk of occupational exposure to blood, treatment for a sexually transmitted infection, more than 1 sex partner in the past 6 months, recent intravenous drug use, and HBsAg– positive sex partner. 3 injections beginning at any point in gestation Contraindicated Rationale Measles, mumps, rubella This live virus vaccine has a (theoretical) risk to the fetus. Varicella This live virus vaccine has a (theoretical) risk to the fetus. Abbreviations: HBsAg, HBV surface antigen; HBV, hepatitis B virus. a Live attenuated influenza vaccine (LAIV [FluMist]) should not be given to pregnant women. Emergency contraception Sperm can live for up to 5 days in the female reproductive tract, and pregnancy can occur with intercourse 5 days prior to ovulation. The highest risk of pregnancy is in the 48 hours immediately preceding ovulation ( Wilcox, Dunson, & Baird, 2000 ). However, due to the uncertainty of ovulation timing, emergency contraception is offered if unprotected intercourse (UPI) occurs at any time in the menstrual cycle. The Yuzpe, levonorgestrel, and ulipristal acetate emergency contraceptive pill (ECP) regimens as well as the copper IUD may all be used within 120 hours of UPI. The Yuzpe and levonorgestrel methods have a dramatic decline in their effectiveness with time and should be used as soon as possible after an event of
UPI.
The Yuzpe regimen consists of combined ECPs that The Yuzpe regimen consists of combined ECPs that must contain at least 100 mcg of ethinyl estradiol and 0.50 mg of levonorgestrel, repeated in 12 hours. A dedicated combined ECP product is not available in the United States, but numerous COCs can be used as combined ECPs (see Table 11-1 , footnote i). COCs containing norgestrel
not have further intercourse within the same cycle.
The copper IUD is by far the most effective of emergency contraception methods, with a pregnancy rate of approximately 1 in 1,000 cases in which it is used for this purpose ( Cheng, Che, & Gulmezoglu, 2012 ). Safety and Side Effects Levonorgestrel ECPs, combined ECPs, and ulipristal acetate should not be given to women with a known or suspected pregnancy; there are no other contraindications to their use. The long history of use of levonorgestrel indicates little risk exists if it is inadvertently taken in early pregnancy. There is less experience with ulipristal acetate, although no reasons for concern were raised in the clinical trials. The usual contraindications and precautions for ongoing COC and POP use do not apply to ECPs ( CDC, 2010 ), but the usual contraindications and precautions to copper IUD use do apply when using this method for emergency contraception (see Appendix 11-A ). Neither the copper IUD nor oral emergency contraception methods are considered abortifacients ( American College of Obstetricians and Gynecologists, 2014b ). Combined ECPs frequently cause nausea and vomiting, which can be reduced by giving an antiemetic, such as promethazine, prior to treatment. Spotting, changes in next menses, headache, breast tenderness, and mood changes can also occur. These same side effects are sometimes noted with levonorgestrel ECPs but are much less frequent and less severe with this option ( Zieman et al., 2015 ). Headache, dysmenorrhea, nausea, and abdominal pain are the most frequently observed side effects with ulipristal acetate ( F i n e e t a l. , 2010 ; Glasier et al., 2010 ). The copper IUD can cause the side effects discussed in the section on intrauterine contraception. Advantages and Disadvantages Emergency contraception is the only contraceptive method that can be used after intercourse. It cannot be used as an ongoing method of contraception, however, and it provides no STI protection. Access to emergency contraception remains limited because only one method— levonorgestrel ECPs—is available without prescription—and even then it is available only to women 17 and older. Clinicians can increase access to emergency contraception by providing advance prescriptions to all women of reproductive age for ulipristal acetate. Studies have shown that having ECPs at home increases the likelihood that they will be used when needed and does not promote sexual risk taking ( Glasier & Baird, 1998 ; R a i n e , H a r p e r , L e o n , & Darney, 2000 ). Providing emergency contraception prescriptions over the phone as needed is another way to increase access. Tier 1, 2 & 3 methods of contraception and efficacy Tier 1
Intrauterine Devices (IUD)
- Paragard® and T380A® are copper bearing IUDs (Cu-IUD) and are effective up to 10 years
Depot Medroxyprogesterone Acetate (DMPA)
- Depo-Provera® (progestin only); given via injection; lasts 3 months
- Prevent LH surge which inhibits ovulation, thickens cervical mucus and causes the endometrium to atrophy which reduces the likelihood of implantation; minimal effects on coagulation, blood pressure and lipid levels
- Benefits: Highly effective; reduces menstrual flow and within a year most women have amenorrhea
- Contraindications: Suspected or confirmed pregnancy, known or suspected malignancy of the breast, significant liver disease undiagnosed vaginal bleeding, history of anorexia, active thrombophlebitis, or current or past history of thromboembolic disorders or cerebrovascular disease
- Risks: Loss of bone mineral density (black box warning: avoid use for more than 2 years), delayed return of fertility
- Side Effects: Headache, depression, breakthrough bleeding and weight gain
- Educate woman calcium with vitamin D and weight bearing exercise to
prevent bone mineral loss
- Benefits: Safe for breastfeeding women, considered safer for women who have contraindications to estrogens
- Risks: Procedural associated risks are very low; insertion site bruising possible
- Disadvantages: Requires provider training for insertion, high initial cost
- Side Effects: Similar to other progestin-only methods (breakthrough bleeding, amenorrhea, breast tenderness, weight gain)
Sterilization (Tubal ligation or Vasectomy)
- Tubal ligation: Surgical procedure to block the fallopian tubes; various methods of mechanical occlusion which are generally effective immediately; Essure® is the only transcervical method that can be performed in an office setting by hysteroscopy; Essure ® requires a hysterosalpingogram (HSG) to be done 3 months after the procedure to confirm tubal occlusion; decreased risk of ovarian cancer
- Vasectomy: Surgical procedure to occlude the vas deferens; various methods of occlusion; vasectomy is less invasive than female sterilization; not immediately effective - the man must wait 3 months before relying on sterilization; usually advised to perform a sperm count before stopping other contraceptive methods Tier 2 methods essentially include hormonal contraception other than LNG-IUSs and implanted devices. These include:
- Combined oral contraceptive (COC) pills- estrogen and progesterone
- Oral contraceptive pill- progestin only "Minipill"
- Emergency contraception
