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Introduction to pregnancy and lactation

Michelle Jose

on 16 September 2012

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Transcript of Pregnancy

Pregnancy and Lactation Prepared by: Jose, Michelle Louise S. Pregnancy is the fertilization and development of one or more offspring, known as an embryo or fetus, in a woman's uterus. Childbirth usually occurs about 38 weeks after conception; in women who have a menstrual cycle length of four weeks, this is approximately 40 weeks from the start of the last normal menstrual period (LNMP). The Female Reproductive System Uterus part of the female reproductive tract that supports the developing baby
It is a hollow, pear shaped organ located in the pelvis between the bladder and rectum.
The uterus is capable of undergoing great changes in size and development during pregnancy.
In a female who has never had any children, the uterus weighs 30-40 g, measures 7.5cm wide and 2.5cm thick.
It is continuous with the fallopian tubes and the vagina. The uterus is divided into:
Body - upper part of uterus.
Cervix - narrow lower part of uterus which is continuous with the upper vagina.

The wall of the uterus is made of three layers:
Outside layer of serosa (perimetrium)
Middle layer of muscle (myometrium)
Inside layer of mucosa (endometrium) Fallopian Tubes These are fine tubes, leading from the ovaries to the uterus. They are important for transmitting eggs from the ovary to the uterus. This process is necessary for fertilization and initial development of the baby. The fallopian tubes are 10-12cm long FOUR MAIN AREAS:

Infundibulum: This is the funnel shaped part of tube next to the ovary. There are finger like extensions (fimbriae) which extend towards the ovary. These aid passage of the egg to uterus.

Ampulla: The segment where fertilization usually occurs.

Isthmus: Narrow segment of fallopian tubes, next to uterus.

Uterine segment: The part of the fallopian tube fixed into the uterine wall. Ovary Functions: produce eggs
secrete hormones
progesterone These hormones released help regulate maturation of eggs and help in producing bodily changes during puberty. As females develop within the womb, each ovary has a number of immature (young) eggs. Through puberty, the eggs mature and are released from the ovaries during ovulation. Vagina The vagina is a muscular tube 6-7.5cm long, which leads from the uterus to the outside of the body. The wetness and moisture of the vaginal surface is achieved by mucous from the cervix. The elastic fibres give the vaginal wall it's strength and elasticity. Functions: copulation (admitting the penis during sexual intercourse)
allowing menstrual blood to leave the body
giving birth. How am I developed? Pregnancy begins with implantation, the process leading to pregnancy occurs earlier as the result of the female gamete, or OOCYTE, merging with the male gamete, SPERMATOZOON, termed as fertilization. Cell division begins approximately 24 to 36 hours after the male and female cells unite. Cell division continues at a rapid rate and the cells then develop into what is known as a BLASTOCYTE. The blastocyst is made up of three layers:
the ECTODERM (which will become the skin and nervous system)
the ENDODERM (which will become the digestive and respiratory systems)
the MESODERM (which will become the muscle and skeletal systems).

Finally, the blastocyst arrives at the uterus and attaches to the uterine wall, a process known as implantation. EMBRYONIC STAGE a. Structures important to the support of the embryo develop, including the placenta and umbilical cord.

b. During this time, cells begin to differentiate into the various body systems. The basic outlines of the organ, body, and nervous systems are established.

c. By the end of the embryonic stage, the beginnings of features such as fingers, eyes, mouth, and ears become visible. 8
WEEKS Sex organs begin to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the last weeks of pregnancy. IMPORTANT DATES: 1.Gestational age

- the first day of the woman's last normal menstrual period, and the resulting fetal age 2.The date of conception
(about two weeks before her next expected menstrual period), with the age called fertilization age 3.The date of implantation

(about one week after conception). The mean pregnancy length has been generally assumed to be 280 days (or 40 weeks) of gestational age. There is a standard deviation of 8–9 days surrounding due dates calculated with even the most accurate methods.
This means that fewer than 5 percent of births occur on the day of being 40 weeks of gestational age;
50 percent of births are within a week of this duration, and
about 80 percent are within 2 weeks.

It is much more useful and accurate, therefore, to consider a range of due dates, rather than one specific day. PREGNANCY DURATION Naegele's rule LMP = 7 July 2009
+1 year = 7 July 2010
-3 months = 7 April 2010
+7 days = 12 April 2010 "at term" when gestation attains
37 complete weeks but is less than
42 (between 259 and 294 days since LMP). Events before completion of
37 weeks (259 days) are considered
preterm; from week 42 (294 days)
events are considered postterm. BIRTHS BEFORE 39 WEEKS: underdeveloped lungs,
infection due to underdeveloped immune system,
problems feeding due to underdeveloped brain,
and jaundice from underdeveloped liver Child Birth when she begins:
experiencing regular uterine contractions,
accompanied by changes of her cervix The postnatal period begins immediately after the birth of a child and then extends for about six weeks. During this period, the mother's body begins the return to pre-pregnancy conditions that includes changes in hormone levels and uterus size. Maternal Physiological Changes in Pregnancy Estrogen
human chorionic gonadotropin
Parathyroid hormone
aldosterone Musculoskeletal The pelvis tilts and the back arches to help keep balance. Poor posture occurs naturally from the stretching of the woman's abdominal muscles as the fetus grows. Physical One of the most noticeable alterations in pregnancy is the gain in weight. The enlarging uterus, the growing fetus, the placenta and liquor amnii, the acquisition of fat and water retention, all contribute to this increase in weight. Breast A woman's breasts grow during pregnancy, usually 1 to 2 cup sizes. Once lactation begins, the woman's breasts swell significantly and can feel achy, lumpy and heavy (which is referred to as engorgement). Cardiovascular The woman is the sole provider of nourishment for the embryo and later, the fetus, and so her plasma and blood volume slowly increase by 40-50% over the course of the pregnancy to accommodate the changes. Increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output.
Cardiac output increases by about 50%, mostly during the first trimester.
Increase in heart rate (15 beats/min more than usual) Hematology A pregnant woman will also become hypercoagulable, leading to increased risk for developing blood clots and embolisms, due to increased liver production of coagulation factors, mainly fibrinogen and factor VIII Metabolism During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and haemoglobin. PHYSIOLOGIC AND
PHARMACOKINETIC FACTORS •Drug absorption may be altered by delayed gastric emptying and vomiting
Higher estrogen and progesterone levels may alter liver enzyme activity and increase elimination of some drugs, but cause accumulation of others
glomerular filtration increase by 30% to 50% during pregnancy, possibly lowering the plasma concentration of renally cleared drugs
Body fat increases; thus volume of distribution of fat-soluble drugs may increase.
Plasma albumin concentrations decrease; thus volume of distribution of highly protein bound drugs may increase Select drugs that have been used safely or long periods of time
Prescribe doses at the lower end of the dosing range
Eliminate nonessential medication and discourage self-medication
Avoid medications known to be harmful
Adjust doses to optimize health of mother while minimizing risks to fetus. PREGNANCY-INFLUENCED ISSUES Gastrointestinal tract Constipation Constipation commonly occurs during pregnancy. Nondrug modalities such as education, physical exercise, biofeedback, and increased intake of dietary fiber and fluid should be instituted first.
If additional therapy is warranted, the use of supplemental fiber with or without a stool softener is appropriate. Lactulose, sorbitol, bisacodyl or senna can be used occasionally.
Castor oil and mineral oil should be avoided. Puberty Period When your body reaches a certain age, your brain releases a special hormone that starts the changes of puberty. It's called gonadotropin-releasing hormone gland releases into the bloodstream two more puberty hormones: luteinizing hormone and follicle-stimulating hormone . For guys, these hormones travel through the blood and give the testes the signal to begin the production of testosterone and sperm. Testosterone
hormone that causes most of the changes in a guy's body during puberty. In girls, FSH and LH target the ovaries, which contain eggs that have been there since birth. The hormones stimulate the ovaries to begin producing another hormone called estrogen. Estrogen, along with FSH and LH, causes a girl's body to mature and prepares her for pregnancy. Guys' shoulders will grow wider, and their bodies will become more muscular. Their voices will become deeper. For some guys, the breasts may grow a bit, but for most of them this growth goes away by the end of puberty. guys will notice other changes, too, like the lengthening and widening of the penis and the enlargement of the testes. All of these changes mean that their bodies are developing as expected during puberty. Girls' bodies usually become curvier. They gain weight on their hips, and their breasts develop, starting with just a little swelling under the nipple. menstrual period A period usually lasts from 5 to 7 days, and about 2 weeks after the start of the period a new egg is released, which marks the middle of each cycle. During the menstrual cycle, one of the eggs comes out of an ovary and begins a trip through the fallopian tube, ending up in the uterus. Before the egg is released from the ovary, the uterus has been building up its lining with extra blood and tissue. If the egg is fertilized by a sperm cell, it stays in the uterus and grows into a baby, using that extra blood and tissue to keep it healthy and protected as it's developing. When the egg doesn't get fertilized, the uterus no longer needs the extra blood and tissue, so it leaves the body through the vagina as a menstrual period. labour United States FDA Pharmaceutical Pregnancy Categories Pregnancy Category A

Adequate and well-controlled human studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters) Pregnancy Category B

Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Pregnancy Category C

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Pregnancy Category D

There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Pregnancy Category X

Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits. Principles for selecting medications for use during pregnancy include Gastroesophageal reflux disease Therapy includes lifestyle and dietary modifications such as small, frequent meals; alcohol, tobacco and caffeine avoidance; food avoidance 3 hours before bedtime; elevation of the head of the bed. Drug therapy, if necessary, may be initiated with aluminum, calcium or magnesium antacids; sucralfate; or cimetidine or ranitidine. Lansoprazole, omeprezole and metoclopramide are also options if the patient does not respond to H2-receptor blockers. Sodium bicarbonate and magnesium trisilicate should be avoided. Hemorrhoids Hemorrhoids during pregnancy are common Therapy includes high intake of dietary fiber, adequate oral fluid intake, use of sitz bath; topical anesthetics, skin protectants and astringents may also be used. Treatment for refractory hemorrhoids includes rubber band ligation, sclerotherapy and surgery. Nausea and vomiting Up to 80% of all pregnant women experience some degree of nausea and vomiting. Hyperemesis gravidarum occurs in only about 1% to 3% of pregnant women. Pharmacologic therapy may include the following:
antihistamines (e.g., doxylamine),
vitamins (e.g., pyridoxine, cyanocobalamine),
anticholinergics (e.g., diclyclomine, scopolamine),
dopamine antagonists (e.g., metoclopramide).
Ondansetron can Be used when other agents have failed and ginger is considered safe and effective.
Dexamethasone or prednisolone have been effective for hyperemesis gravidarum, but the risk of oral clefts is increased. Nonpharmacologic treatments:
eating small, frequent meals;
avoiding fatty foods;
acupressure and acustimulation. Endocrine Gestational diabetes mellitus Screening for gestational diabetes mellitus utilizes the oral glucose challenge test. nutritional and exercise interventions for all women, and caloric restrictions for obese women nutritional intervention fails to achieve fasting plasma glucose levels therapy with recombinant human insulin should be instituted; glyburide may be considered after 11 weeks of gestation. Goals for self-monitored blood glucose levels while on insulin therapy are a preprandial plasma glucose level between 80 and 110 mg/dL and a 2-hour postprandial plasma glucose level less than 155 mg/dL. Cardiovascular Hypertension Hypertension during pregnancy includes gestational hypertension, preeclampsia (hypertension with proteinuria), and chronic hypertension For women at high risk for preeclampsia low-dose aspirin
after 12 weeks gestation
reduces the risk for preeclampsia by 19%.
reduce the risk of preterm labor by 7% and fetal or neonatal death by 16%.
Calcium 1g/day
recommended for all pregnant women, as it may help prevent hypertension in pregnant women
reduce the risk of preeclampsia by 31 to 67%. hypertension in pregnancy Medications to prescribe:
calcium channel blockers.
Medications to avoid:
ACEIs should probably be avoided throughout pregnancy.
magnesium sulfate (except for eclampsia prevention),
high dose diazoxide,
chlorpromazine. Venous thromboembolism Risk factors for venous thromboembolism:
increasing age,
history of thromboembolism, hypercoagulable conditions,
operative vaginal delivery
cesarean section,
family history
thrombosis adjusted-dose low molecular weight heparin or unfractionated heparin treatment of acute thromboembolism AVOID WARFARIN Acute care issues Headache nonpharmacologic:
biofeedback and massage.
If drug therapy is needed,
acetaminophen is the first choice. tension headaches during pregnancy migraine headache rest reassurance and ice packs should be initially used.
If drug therapy is needed, acetaminophen is first-line therapy. NSAIDS are contraindicated after 37 weeks gestation refractory migraines
narcotics may be used. Nausea migraines
may be treated with metoclopramide. Urinary tract infection Causative Agent E. coli P.mirabilis
K. pneumonia Untreated bacteriuria:
preterm labor,
transient renal failure
low birth weight. Group B streptococcus bacteriuria
should be treated to reduce the rate of preterm delivery.
These women should also receive antibiotics at delivery to prevent infection in the newborn. Treatment of asymptomatic bacteriuria

A course of 7 to 10 days of treatment is common.

A repeat culture 10 days after completion of treatment is recommended. Cephalexin
Sulfa containing drugs
Folate anatagonists
tetracyclines hemolytic anemia in the newborn increase risk for kernicterus in the newborn cardiovascular malformations Chronic illnesses Allergic rhinitis, Asthma DOC: -acting B2-agonist (albuterol is preferred) mild persistent asthma Low-dose inhaled corticosteroids
Budesonide moderate persistent asthma low-dose inhaled corticosteroids with a long-acting B-agonist allergic rhinitis Intranasal corticosteroids
Beclomethasone and budesonide
Nasal cromolyn and first generation antihistamines Diabetes Insulin is the DOC for patients with either type 1 or type 2 diabetes during pregnancy;

glyburide can be used for type 2 diabetes after the 11th week gestation. Metformin is also an option.

Goal of therapy for self-monitoring of blood glucose are the same as for gestational diabetes. Depression the lowest possible dose of ANTIDEPRESSANTS About one to two babies per 1000 exposed to SSRIs in utero developed persistent pulmonary hypertension. When tricyclic antidepressants are withdrawn during pregnancy, they should be tapered gradually to avoid withdrawal symptoms. Drug tapering is usually begun 5 to 10 days before the estimated date of confinement. Labor and delivery Preterm labor occurs before 37 weeks of gestation •Tocolytic therapy Goal: to postpone delivery Drugs: magnesium sulfate, B-adrenergic agonists, NSAIDs and calcium channel blockers. terbutaline are 250 to 500 mcg subcutaneously every 3 to 4 hours. maternal side effects (e.g., hyperkalemia, arrhythmias, hyperglycemia, hypotension, and pulmonary edema) •Cervical ripening and labor induction Prostaglandin E2 analogs dinoprostone
oxytocin agent for cervical ripening Fetal heart rate monitoring associated with uterine rupture the labor induction after cervical ripening •Labor analgesia IV or IM administration of parenteral narcotics lower rates of oxytocin augmentation,
shorter stages of labor
fewer instrumental deliveries. Epidural analgesia administering an opioid and/or an anesthetic (e.g., fentanyl andor bupivacaine) through a catheter into the epidural space
associated with longer stages of labor
more instrumental deliveries Postpartum issues •Drug use during lactation Medications enter breast milk via passive diffusion of nonionized and non-protein-bound medications Drugs with longer half lives are more likely to maintain higher levels in breast milk. Strategies for reducing risk safe for use in the infant
are more protein-bound
medications with shorter half-lives
lower bioavailability have lower lipid solubility •Mastitis usually caused by staphylococcus aureus, e. coli and streptococcus 10 to 14 days of antibiotic (cloxacillin, dicloxacillin, oxacillin or cephalexin) bedrest,
adequate oral intake,
frequent evacuation of breast milk. •Postpartum depression emotional support from family and friends,
education about the condition and psychotherapy. tricyclic antidepressants and SSRIs Nortryptyline, amitrtiptyline, clomipramine, desipramine, fluvoxamine and bupropion Lactation Hormonal influences •Progesterone influences the growth in size of alveoli and lobes,
high levels of progesterone inhibit lactation before birth.
Progesterone levels drop after birth, this triggers the onset of copious milk production. Estrogen stimulates the milk duct system to grow and differentiate.
Like progesterone high levels of estrogen also inhibit lactation.
Estrogen levels also drop at delivery and remain low for the first several months of breastfeeding.
breastfeeding mothers avoid estrogen-based birth control methods, as a spike in estrogen levels may reduce a mother's milk supply. Prolactin increased growth and differentiation of the alveoli,
differentiation of ductal structures.
increase insulin resistance,
increase growth factor levels (IGF-1)
modify lipid metabolism in preparation for breastfeeding.
main factor maintaining tight junctions of the ductal epithelium
regulating milk production through osmotic balance. Growth hormone structurally very similar to prolactin and contributes to its galactopoietic function. ACTH structurally similar to prolactin. Glucocorticoids play a complex regulating role in the maintenance of tight junctions. TSH galactopoietic hormone, its levels are naturally increased during pregnancy. Oxytocin contracts the smooth muscle of the uterus during and after birth, and during orgasm(s).
contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly-produced milk into the duct system.
Oxytocin is necessary for the milk ejection reflex, or let-down to occur. Human placental lactogen (HPL) the placenta releases large amounts of HPL.
instrumental in breast, nipple, and areola growth before birth. Lactogenesis breasts make colostrum, a thick, sometimes yellowish fluid. At this stage, high levels of progesterone inhibit most milk production. Lactogenesis I Lactogenesis II abrupt withdrawal of progesterone in the presence of high prolactin levels stimulates the copious milk production The release of prolactin triggers the cells in the alveoli to make milk.

Prolactin also transfers to the breast milk. Some research indicates that prolactin in milk is greater at times of higher milk production,

highest levels tend to occur between 2 a.m. and 6 a.m. Lactogenesis III The hormonal endocrine control system drives milk production during pregnancy and the first few days after the birth. When the milk supply is more firmly established, autocrine (or local) control system begins. Ingestion of folic acid as it reduces the risk for neural tube defects in offspring.
Women at low risk should take 400mcg/day throughout the reproductive years. Women at high risk should take 4 mg/day
Assessment and reduction in the use of alcohol, tobacco and other substances
For smoking cessation, behavioral interventions are preferred. Preconception planning Patient's advice daily meals Fruits and vegetables. You can buy these fresh, frozen, canned, dried or juiced. Aim for at least five portions daily.
Starchy food. These include bread, pasta, rice and potatoes. Try to choose wholegrain options.
Foods rich in protein. These include lean meat and chicken, fish, eggs and pulses (such as beans and lentils). Try to aim for at least two portions of fish a week, including cccoily fish.
Dairy foods. These include milk, cheese and yoghurt which contain calcium.
Dairy products, along with sea fish and sea salt are all good sources of iodine. You need plenty of iodine in your diet to help your baby's development. 200 extra calories per day for the last three months:
otwo slices of wholemeal toast and margarine/butter
oa baked potato with an ounce of cheese
oone slice of cheese on toast
o2 ounces of canned tuna or chicken on three whole grain crackers take supplements o400 micrograms (mcg) folic acid a day for the first 12 weeks
o10 mcg of vitamin D a day throughout your pregnancy
oLater on in your pregnancy, you may need to take an iron supplement.
oCalcium is also important while you're pregnant, as you'll now need twice as much each day.
omultivitamin that contains folic acid, vitamin D, iron and calcium. Look for one that also contains Vitamin C, vitamin D, B vitamins such as B6 and B12, potassium, zinc, iodine and vitamin E.
oBig fish such as shark (as in shark fin soup), swordfish (espada), or marlin. These fish contain unsafe levels of naturally occurring mercury. Tuna contains some mercury too, so it's best you don't eat more than four medium-sized cans or two fresh tuna steaks per week.
oDon't eat liver and liver products (such as pate, liver sausage, or liver spread) because they may contain large amounts of the retinol form of vitamin A. Too much of this could be harmful to your developing baby.
oIt's best not to have more than 200mg caffeine, too. That's two mugs of instant coffee or four cups of tea or five cans of cola a day. Switch to decaffeinated drinks. unsafe for your baby: oCheeses with a white, moldy rind, such as brie and camembert, and blue-veined cheeses. All these cheeses could contain listeria, a bacteria that could harm your baby.
oRaw or undercooked meat, poultry, and eggs. All are possible sources of bacteria that can harm your unborn child. When cooking meat and eggs, make sure they are cooked properly.
oRaw seafood, such as oysters or sushi that has not been frozen before making.
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