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test format sounds like little cases, short answer

IMPLANTATION TIMELINE
--implantation takes about a week after fertilization
remember, fertilization can be somewhat delayed after intercourse
sperm live a while depending on conditions, eggs pop out when they want
--estimate implantation at 4-5 weeks after LMP
if cycle is "normal" 28 days with ovulation on day 14-16 and fertilization within a few days of that, I don't get how this works. Because then implantation would be around day 21-26, and 4-5 weeks is more like 28-35 days
anybody care to explain why 4-5 weeks is correct?

GRACE PERIOD
before placenta is formed at 15 days gestation
fetal tissue isn't differentiated, no blood supply from mom to baby
can drink, smoke, enjoy teratogens and baby doesn't get poisoned
new moms that didn't know they were pregnant are often happy to hear this

SENSITIVE TIME PERIOD: 1ST TRIMESTER
susceptibility to teratogens, infx is higher
greatest effects are in the beginning of the trimester
organogenesis happens weeks 5-10
mom who has an exposure at 6 weeks will abort
the same exposure at 24 weeks won't budget the pregnancy
fetal BBB not formed until 6 months
OTHER SENSITIVE TIMES: neonate, adolescent, woman in luteal phase
(in the second half of cycle, breast tissue is more susceptible, also girls given vaccines in this time of the month are more likely to develop autoimmune dz)
women after full term pregnancy has different breast tissue vs early termination
early termination causes high breast susceptibility

CIGARETTE SMOKING
-->VASOCONSTRICTION of the placenta-->deprives fetus of O2
lasts ~15-20mins per cig
-->toxic chemicals in mom's blood: CO (carbon monoxide binds fetal hemoglobin), NH4, acetone, formaldehyde, hydrogen cyanide, pyrene (affects prot transport-->learning disorders), vinyl chloride
-->Nicotene causes release of acetylcholine, epinephrine, norepinephrine, and antidiuretic hormone, causing tachycardia-->incr cardiac ouotput, peripheral vasoconstriction, incr BP, changes in fat and carbohydrate metabolism
-->MATERNAL COMPLICATIONS: placental abruption (bleeding), mineralization of placenta makes it friable and less effective at gas and nutrient transport, lung probs, risk of SAB, placenta previa, premature rupture of membranes (PROM), low birth weight, premature labor, fetal and neonatal death
-->TROUBLE FOR THE KIDDO: less developed vasculature, learning disabilities, poor reading and math scores, lowers IQ by about 10 points, ADD, ADHD, babies less responsive to sound and harder to comfort, more SIDS, more respiratory dz incl pneumo, asthma, higher cancer risk esp non-Hodgkin's lymphoma, ALL, Wilm's tumor, also strabismus

MORNING SICKNESS
--physiology behind nausea of preg
--bHCG (beta human chorionic gonadotropin, the hormone that you measure to track a pregnancy)-->less stomach acid
--progesterone (from the corpus luteum)-->decr smooth muscle contraction, less peristalsis
--blood glucose imbalances can also cause N/V??? at what extreme and by what mech?
--begins early in preg when B-HCG is doubling why??? what organs???
--resolves when: corpus luteum and placenta take over hormone manufacture
placenta makes estrogen and B-HCG stops doubling so body can acclimate
--two herbs to stop nausea: ginger (not if hot or constipated), wild yam (incr prog and anti-spasmodic)
--two supplements: B6, K, C
--other tx: eat small meals, complex CHO, popcorn, almonds??

HCG
--made by embryo soon after conception
--made later by syncytiotrophoblast (part of placenta)
--prevents disintegration of the corpus luteum of the ovary
--corpus luteum maintains progesterone production critical for preg
--may affect immune tolerance of the pregnancy
--early pregnancy testing (drugstore pee kits) detect HCG at time of missed period
--serum test for B-HCG accurate 9 days after ovulation (qualitative only)
--also by some kinds of tumor

BLOOD NORMALS AND ANEMIA
HCT 36-48% (if 30-32% hemorrhage is more risky)
Wiggin: over 33% normal in 1st trimester
normal ratios: the 1:3:9 rule = RBC:HGB:HCT
HGB normal: 12-16 g/dL, get seriously worried if it's 9 or lower
(expect transient HGB decrease in 1st trim as blood volume incr)
SUPPS for IDA: Iron supplements, 30mg/day normal, 60-90mg/day if IDA
(take with vitamin C to incr absorption)
(better bound to citrate or gluconate, sulfates cause stomach upset)
(avoid vitamin E with iron, it oxidizes)
Floradix is a liquid Fe supplement, or start cooking in cast iron
HERBS: Urtica, Rumex (esp if constipated)

HUMAN GESTATION
--40 weeks from LMP
--266 days from exact day of conception
--EDD = estimated due date
--hard to know EDD if menses were irregular, untracked, ovulation early/late
--other changes by which you can guess the stage incl: fundal height, size of uterus, dates of 1st positive preg test, 1st fetal heart tones (FHT), quickening, femur measurements by US best at 20-24 weeks
--EDD important to know if infant is pre or post maturity: CI for OOH
--can deliver out of hospital 37-42 weeks up to 43 weeks for multips
--you can't deliver OOH if you don't know due date
--EDD key if considering TAB, amniocentesis, alpha fetal prot test for Down's and neural tube defects
--can check fetal maturity by amniocentesis: lung surfactant ratio
--know if there's intrauterine growth retardation: is the preg viable?
--fetal heart tones can be heard by week 8-10 using doppler
--fetal heart can be seen beating on US at 8 weeks: viable
--fetoscope can detect heartbeat at 16-20 weeks

NUTRITION FOR PREGNANCY
PROTEIN RDA: 60-90 g/day
CALORIES needed in preg: 2,500-3,000/day, 500-1000 extra when lactating
CALCIUM: 600-1200 mg/day supp
VITAMIN A: not more than 10,000 IU/day dt teratogenicity, use beta carotene or carotenoid blends instead (ask if acne or infertility has been txed w/ vit a)
*FOLATE: 800-1000 mcg/day absolute MUST (green leafies don't provide enough, prevent neural tube defects)(deficiency assoc w/ smoking, birth control pills)
VEGANS: supplement B12, folate, protein
ZINC: 15-30 mg/day
B VITS: 50mg/day, 25% of females B deficient, B6 need 15x higher in preg, give right amount not too much or fetus will become dependent, good for PIH and nausea
VIT C: 500-1000 mg, in early preg 10g dose may cause miscarriage, decreases SIDS if taken during PG and continued during breast feeding
VIT D: teacher says 400 IU/day but I'm thinking she'll change her mind when she reads some of the new research, esp for us in cloudy parts of Oregon
PRENATAL VITAMINS: if woman wants to get preg then start her on these before she conceives to be sure she is not toxic with too much A or too little folate, also make sure she is getting good omega 3 EFAs pre-pregnancy

WEIGHT GAIN
no weight loss during pregnancy!!
weight gain should be according to BMI, average is 27.5 lbs
if underweight, gain 28-40 lbs, midwt gain 15-35, overwt gain 15-25
different rates of gain in 1st trim, all close to 1lb/week in 2nd & 3rd
if wt gain insufficient late-->much more likely to be premature

DIURETICS
NO pharmaceutical diuretics in pregnancy
the preferred herbal is taraxicum, it's potassium sparing and mild
you could also use what Stansbury calls nourishing diuretics in teas:
equisetum, urtica

HYPERTENSION
is it PIH or regular HTN?
moderate use of mild diuretics as mentioned above
don't restrict salt!! needs electrolytes even in preg unless renal issue
?????

HEMORRHOIDS, VARICOSITIES: TX
soften stool: magnesium (no irritant laxatives)
sitz baths
Hammamelis virginiana topical
Collinsonia canadensis local and tincture PO
Symphytum poultice local
potato wedge suppository
avoid straining, sitting too long
kegel exercises, walking, swimming
for varicose veins in legs: elevate legs often, avoid standing too long
end showers with cold to tone legs/feet
SUPPS: vit E 400 IU, bioflavonoids 1000mg, Rutin 500mg qd, lecithin 2000mg tid stop at 36th week dt anticoag effect, pycnogenol min 1mg/lb body wt
(quercetin is CI, mb teratogenic!!)

ALCOHOL
--reduces mom's fertility
--causes thiamine and other vitamin deficiencies
DRINKING IN PREGNANCY-->complications
3x more bleeding in 1st and 2nd trimester
more infection, placental abruption, spontaneous abortion
if a woman has spontaneously aborted before the risk is doubled if they drink
10% incr in risk of defects with over 1oz/day or 5+ drinks at a time
20% incr risk at moderate drinking: 2oz/day
FETAL COMPLICATIONS
FAS = fetal alcohol syndrome, must have at least one feature from each of the following 3 categories:
1. Prenatal or postnatal delay in weight or head circumference (small kid)
2. Distinct physical characteristics, min 2 of these: small head, small eyes or short eye openings, narrow lip without center groove, short upturned nose or flattened mid-facial area. Males may have abnormal testes.
3. Abnormalities of CNS: signs of brain dysfunction, delays in behavioral development and/or cognitive impairment
FAE = ? less severe than FAS but includes eye, heart, kidney, lung, other organ probs, slow growth, musculoskeletal defects, ADD, ADHD, irritability, mental retardation

CONTRA-INDICATIONS FOR OUT OF HOSPITAL BIRTH (CI for OOH)
multiple gestation, non-vertex presentation, DM, HIV/AIDS, bleeding disorder, chem addiction or abuse, placenta previa: placenta over os-->C-section
CI IF NOT CONTROLLED: gestational DM, PIH = preg induced HTN, IUGR = intrauterine growth retardation, vaginal bleeding (mb CI), anemia (HCT under 30), thyroid dz
HTN, renal dz, pancreatitis
CI IF SEVERE: FHT abn, heart dz, resp dz, asthma, gall bladder dz, neurological probs, paralysis, anatomical abn, fetus or mother, teratogenic exposures
hepatitis
QUESTIONABLE: smoker, VBAC (after cesarian), mom in late 30's or older, or early teen, grand multip, obesity, poor nutrition, serious emot or psych probs, not committed to OOH

PICA
is the craving to eat nonfoods: chalk, dirt, ice, charcoal
usually caused by a nutritional deficiency
low protein or calcium

CONSTIPATION
TX: taraxicum, rumex crispus, avoid straining, increase fluids, increase fiber (oatmeal, celery psyllium, etc), warm prune juice, dried fruit (not banana), incr exercise, decr stress

BRAXTON-HIX CONTRACTIONS
uterine tightening to prepare for labor
not pathological, not rhythmic, not painful
may occur as early as week 20

BACK PAIN
ligamentous laxity dt relaxin
may relax pelvis enough to cause sciatica, cause hypermobility of jts
low back also taxed by change in posture dt growth in uterus, incr lordosis
TX for lax ligs, one physical medicine, one herbal
heat, muscle work
blocking pelvis, or SI adjustment, pubic symphysis adjustment
adjust right up to birth but go easy because relaxin keeps her loose
OTHER TX: calcium, cell salts
EXERCISES: knee to chest on waking, pelvic rocking, cat & cow, walking, swimming, no new sports, good posture
check tailbone for alignment in exam, needs to move for birth
rest, firm mattress, belt or truss
CALCIUM 1500-2000 MG QD
HERBS: symphytum and hypericum ointment locally

CARPAL TUNNEL
may occur due to swelling in extremities
physical medicine tx, lunate bone adjustment
fingers tingling mbdt cervicals or brachial plexus syndrome
B6, bromelain, stop eating steaks (lower inflam)

EARLY BLEEDING
brown spotting no cramping at 8 weeks-->no US, do bedrest, pelvic rest
not increased spotting, cx long and firm,
24 hours pass, no cramping-->not likely to abort
22 weeks spotting-->still prob no miscarriage
12 weeks spotting, no prenatal care, nausea at 6 weeks, no heart beat-->poss miscarriage, go home and wait or refer to gyn for D&C
if bleed more than 2 maxis/hour then go to hospital
if bleeding too much give what? methergine = pharmaceutical
herb, cinnamon erigerone
WHAT CAUSES EARLY BLEEDING?
romantic evening night before, friable cx, SAB

WHAT FRACTION OF PREGNANCIES MISCARRY?
1/5-6 pregs miscarry

LABS
what lab test must order on all preg?
blood type, ABO, Rh
might need rogam even if miscarries

HOW MANY CALORIES AND WEIGHT GAIN NEEDED IN PREG?
2500-3000 calories per day, average 27.5 pounds weight gain

WHEN CAN FETOSCOPE HEAR fetal hEART BEAT?
16-20 weeks

What causes neural tube defects?
folic acid deficiency

Why might you not find heart tones in week 15 with doppler?
non-viable pregnancy, SAB
posterior baby: rear location of uterus & fetal attachment inside uterus
wrong dates

What does calcium do in preg, what it's good for?
PTH increases-->more Ca+ is released from bones and less is lost by kidneys
absorption in GI is increased, usu no bone loss in pregnancy
USE CA TO TX:
HTN (PIH) and toxemia, prevent bone loss during nursing
ease leg cramps and other muscle pain, spasm, aches
bleeding gums, headache, always give with Mg

What are the important exams to perform on a woman who has had many partners?
gonorrhea/chlamydia DNA probe
hepatitis B

How much vit A is safe in preg?
no more than 10,000 IU's/day
better to use beta carotene which can be converted to Vit A by the body if needed
better than that: mixed carotenoids, absorbed best with fat

How to manage blood sugar in pregnancy?
encourage regular gentle exercise, avoid simple sugars in diet
SUPPS: chromium picolinate
HERBS: Gymnema, devil's club, fenugreek

NOTES FROM GEORGIANA


• When does implantation occur?
◦ 1 wk after fertilization
◦ 4-5 wks after LMP
• Why need to know when implantation occurs/grace period?
◦ Before 15 days gestation, there’s no differentiation of fetal tissue, no blood supply from mom to baby so if the women drank, smoked, was exposed to teratogen it won’t have an impact. This can be reassuring to mom.
• When normally hear FHT?
FHT 120-160bpm
◦ With 2 mHz Doppler will hear at 12 wks
◦ With 3 mHz Doppler will hear at 10 wks
◦ With fetiscope will hear at 16-19 wks
• Why is it important to note FHT?
◦ So can make assessment as to why not hearing FHT
• List 2 conditions smoking can cause (probably will see more moms who smoke than take meth; also, affects last up to 20 minutes after smoking-causing prolonged vasoconstriction)
◦ Placenta abruption
◦ Learning disabilities, ADD/ADHD
◦ Low birth wt
◦ Lung Problems
• Mechanism of nausea of PG & constipation (heartburn/gas)
◦ β-HCG ↓ stomach acid & decr appetite, so no food in the stomach & not digesting the food that is in there.
*blood glucose imbalances also cause N/V
• When should Nausea should resolve?
◦ End of 1st trimester (12-16 wks)
◦ Nausea often ends all at once
• Nausea resolves because
◦ When placenta starts making hormones (ESTROGEN), more efficient/smoother than corpus luteum
◦ β -HCG stops doubling, body can acclimate to it
• Remedies to stop nausea, know 2 each
◦ Herbs (remember dandelion for just about everything)
▪ Ginger (not if hot or avoid constipated)
▪ Wild yam (↑ progesterone levels and is an anti-spasmodic)
◦ Homeopathy
▪ Sepia (can’t stand smell of food)
▪ Tabacum (intractable N/V)
◦ Supplements
▪ Vit B6
▪ Vit K, C
◦ Eat small meals, protein, complex CHO, popcorn, almonds
• Lab values for PG
◦ Normal Hb: 12-16 g/dL (Dr. Wiggin: Hb in 1st trimester will be ↓ d/t ↑ in blood volume, this is nonpathological)
◦ Normal Hct: 36-48% (if ↓ 30-32% risk of hemorrhage per Dr. Zieman’s notes) (Dr. Wiggin: ↑ 33% is normal in PG in 1st trimester, remember 1:3:9 rule, RBC#:Hb:Hct)
◦ Herbs that help if anemic & why
▪ Fe phos cell salts (well absorbed)
▪ Fe citrate or gluconate (doesn’t cause constipation & better absorbed) rather than Fe sulfate
▪ Floradex-all plant sources
▪ Nettles & yellowdock (esp if constipated)

Iron in-take for Pregnancy is what? What if she is anemic, then how much iron?
30mg/d
60-90mg/d

You must take iron seperate from what? What other supplement will incr absorption of iron?
▪ Vit E cuz it oxidizes the Fe
▪ Vit C
• How long is human gestation
◦ 40 wks from LMP
• When most vulnerable to damage from toxins
◦ Gestation
◦ Neonate
◦ Puberty
◦ 2nd half of menstrual cycle when there are breast changes (risk of breast CA)
• RDA
◦ Protein: 60-90 g/day
◦ Calories: 2500-3000 calories/day
◦ Ca2+: 600-1200 mg/day supplement plus dietary intake
◦ Vit A: ↓ 10,000 IU/day (m/b on vit A for infertility or acne so discontinue)
◦ Folate: 800-1000 mcg/day (green leafy veggies, associated w/ neural tube defects)
◦ Vegans, make sure getting enough
▪ B12, folate
▪ Protein (PG biggest adrenal drain of all)
• Salt
◦ Even if have high BP because need electrolytes since have double the am’t of blood volume than non-PG women
◦ Decr electrolytes=Dehydration, BV will contrict, incr BP
◦ Vegetarians develop more pre eclampsia because
▪ Don’t have enough protein/albumin in blood
▪ BV have to constrict because fluid leaking out of tissues
◦ Herbal tx
▪ Taraxicum leaf

• Big, cranky PG women with hemorrhoids & varicose veins (know 2 remedies each)
◦ Homeopathic
▪ Sepia
▪ Nux-v
◦ Herbs
▪ Hammamelis
▪ Taraxicum
▪ Valerian (for irritability)

• Fetal EtOH syndrome (esp from adopted kids from Russia, etc.)
◦ Difference w/ & w/o FAS
▪ Shape of face (look like elves); small, flattened
▪ Eyes (small, short eye openings), nose (short, upturned), chin, lip (narrow w/o center groove)
▪ Learning/behavioral disabilities
◦ Fetal EtOH effect-less severe than FAS
• What is pica, why do people get it? (given a case that’s not culturally learned)
◦ Eating clay, coal, dirt, chalk, refrig ice
◦ Physiological signal of protein or Ca2+ deficiency or glucose intolerance
• Constipation
◦ Tx
▪ Give Rumex (for Fe & won’t get constipated)
▪ Taraxacum

• Braxton Hicks contractions in 2nd trimester-normal? Referral?
◦ Little tightenings all around uterus in discrete spots
◦ Normal, not rhythmatic, don’t hurt
◦ Rest if they are strong

• Give 2 reasons for accurate due date.
◦ know if baby premature/overdue
◦ Monitoring Health of Baby
▪ Low fundal height (need lots of U/S)-may suspect intrauterine growth retardation (IUGR)
▪ testing for FAS
• Complaints-physical medicine

◦ What happens to pelvic girdle at end of pregnancy?
▪ SI joints relax ( dt relaxin hormone)
▪ Tx
• SI block (assess leg length, Low block goes under Long leg)
• herbal, nutritional support
◦ symphytum/hypericum, Ca2+, calc phos cell salts
• have pt do squats, knee to chest, pelvic rock, walking, swimming

◦ Carpal Tunnel Syndrome, more edematous during PG
▪ Could be more about the neck & shoulder (thoracic outlet syndrome),
▪ Adjust Lunate bone
▪ Supplements: Bromelain, Vit B6
▪ Decr inflammation causing foods (meat, chs)
• Know when need U/S in 1st trimester
8weeks

◦ Bleeding
▪ Brown, light, no cramping
▪ Red, no cramping
• bed rest-no housework
• pelvic rest-nothing into vagina, no intercourse, no tampons, etc.
◦ later in pregnancy
▪ examine cervix find
• long, firm, closed
◦ good prognosis
• soft, little open, red blood on hand
◦ bad prognosis, miscarriage likely
◦ if only 9 wks PG, check for viability
▪ can’t use doppler yet, not even 3 mHz one
▪ hormone levels won’t tell viability (predictive but not specific)
▪ *can only do U/S*
• need to see heart beat
◦ abdominal U/S at 8 wks
◦ vaginally probe 10 days earlier
◦ seeing gestational sac or organs doesn’t help
◦ if see yolk sac on U/S but not baby yet
▪ not confirmation of miscarriage yet
▪ come back 2 wks later to see if can date
◦ Sac low in uterus on U/S?
▪ Bad sign
◦ Sac smaller than normal?
▪ Bad sign
▪ Come back, m/b dates are wrong

◦ What if hadn’t seen pt before, she’s PG, spotting at 12 wks, pregnancy had been okay, not nauseous anymore, can’t find heartbeat using 3 mHz Doppler, gestational sac only looks 4 wks old
▪ Not good
▪ Options
• come back in a wk
• wait to have miscarriage
• do a D&C
• if don’t want a D&C, monitor for
◦ Hemorrhage
▪ no more than 2 pads in ½ to 1 hrs
▪ TX
• herbal: cinnamon, hammamelis
• pharmaceutical: Methergine

◦ Lab: Do ABO Rh
• give Rhogam w/in 72 hrs if Rh (-)
Why?

◦ If don’t get rid of all contents of miscarriage, risk:
▪ DIC
▪ Calcification
▪ Infxn

• Know how common miscarriages are so can talk to pt w/ a lot of grief
◦ 1 out of every 5-6 pregnancies

• Know how many calories need/weight gain, diet generally
◦ PG Calories 2500-3000 (lacatation xtra 500-1000/day)
◦ Weight 27.5 lbs put on depends on food choices
▪ Calories from chicken, kale, quinoa different from choices at McDonalds

• When woman feels quickening?
◦ Primiparous 18-20 wks
◦ Multiparous 16-19 wks

• Neural tube defects
• if fam hx: dose 4g/day & hx of smoking & B/C use consider Incr dose
◦ Folate-need 800 to 1000 mcg/day minimum

• Why not get FHT early? Know 2 reasons
◦ Non-viable fetus
◦ Wrong dates
◦ posterior position of the fetus
◦ thick abdominal wall-overweight
◦ mb retroflexed uterus

• Nutrients good for bleeding gums?
◦ Vit C
◦ Bioflavonoids
◦ Ca2+

• If have had a lot of pregnancies w/ lots of different partners what labs would you do?
◦ STDs
▪ Pelvic exam: GC, CT, wet mount
▪ Blood Tests: Hep B, HIV,

• Know what to do for blood sugar imbalances
◦ PG is a hyper (natural state of insulin resistance)/hypo (using up nutrition so quickly) glycemic state
▪ GTF Chromimum Picolinate
▪ Devil’s Club
▪ Gymnema
▪ Fenugreek
▪ Decr refined carb and simple sugars

• Sx of Preg
◦ Breast swelling
◦ N/V
◦ Fatigue
◦ When PG test was (+)
◦ Leucorrhea

What does calcium do in pregnancy?
PTH incr, more Ca+ release from bones, decr Ca+ loss from KD, incr absp in GI tract
No net bone loss in pregnacy, but will have bone loss during nursing if inadequate Ca+ inatke

What is the term used for severe VOMITING leading to dehydration which happens in 1/1000 hospital births?
Hyperemesis Graviderium

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