, 1
NR602:MI
DTERM REVIEWWITHRESOURCES.
Si
gnso
fpr
egna
ncy(
pre
sumpt
ive
,pr
oba
ble
,po
sit
ive
)
• Presump ti
veSi g nsofPr eg na ncy:Symp tomst ha tares ugges t
iveofp regnancya re
consi
dered“p r
esump t
ivesi
gn s”wh ichme anst hattheya ret heleastob j
ect
iv
eo rsubj
ect
ive
si
g nswh ichc ana lsob ec a us edb yma nyo t
herc o ndi
t i
o nsothe rthanp r
egnancy.
•Ame no rr
he a:Hi ghlys ug gestiveofp regnan cyinahe a l
th yfemalewi t
hr e
g ular&
predi
ctablepe riods.Difficulttode te
rmin ei naf e malewh oh avei r
regul
arperi
odsori n
thosewh od on otk e
ept ra cko ftheirme ns t
ru a
lc y cle
s
•Na us ea&v omi t
i n g:Commons ymp tom( ~5 0%o fpreg
nanci
es)t
ypic
allyoccur
ri
ng
be t
we en2 -16we eksg es
ta t
ion
•Breaste ngorge ment&da r
ke ningoft hea reol as
:Oc cursa searl
ya s6-8we ek s
ges
ta
ti
on
•Breas ttende rness
•Fatigue
•Ur i
na ryFr eque ncy
•Sli
gh tincreasei nbo dytempe ra
ture:Ri seint e
mpe rat
urec oinci
deswi t
hlute
a l
ph a
sea ndi st her esul tofi n creasedpr oge s
te rone
•“Qu i
c kening ”:Mot he rf ee
lst hebab y’smo v eme ntsforthe1 s
tti
me ;sta
rtsat16
we eks.
• Probables i
g nsofp regnanc y:me a nthatt herei sah ig hlikeli
h oodo fpregnancyb utther
e
arestil
lo t
he rco nd i
tionst hatma yc auset hefn
id i ngs.
• Pr egna nc yt estsarec ons ide r
edpr oba blebe ca useβ- hCGa lsoprese
ntsi
nmo lar
pregna nciesa n dov ari
a nc ancer.
• Posit
i
veSignso fPregnancy:Themos treli
abl
ea ndmo s
to bj
ectivesi
gnso fposi
ti
ve
pregnancya rethos ewhe r et hep ro vi
derc a nc onfir
mt hep resenc eofaf et
us
•Palpa t
iono fthefet usb ythehe alt
hc arep r ovide r
•Ultrasou nda n dv i
s u ali
z at
io nofthef et
us
•FetalHe a rtTo nes( FHT)a us c
u l
tatedb yt h ehe a l
thc arep rov
ider
Pr
egna
ncya
ndf
unda
lhe
ightme
asur
eme
nt
• Funda
lheightcanpro
videval
uabl einfor
ma ti
ono nasse
ssi
n gtheg e
stat
ional
ag
eofthefetusaswel
lastomon i
t orfe
talgrowth.
o 1 2we eks
:Uteri
nefundusfir
strise
sa bovethesymph ysi
sp ubis
o 1 6we eks
:Uter
inefundu
si sbe t
we enthesymp hy
sisp ubi
sa ndumb il
ic
us
o 2 0we eks
:Uteri
nefundusi sattheleveloftheumbi l
icus
o 2 5-
35we eks:Measur
ethed i
stancebetweentheup peredgeo fpubicsymph
ysi
sand
t
hetopoftheut
eri
nefu
nduswi t
hatapeme as
ure.Fu
nda lhe
ighti
nc e
ntimet
ers
, 2
e
qual
sthenumberofge
sta
ti
ona
lweek
s(+/-2
cm).Fore
xample
,a28wee
k
g
est
at
ionfet
ussh
o ul
dhaveafu
nda
lheig
httha
tmeas
ure
sbet
ween2
6and30c
m.
*Bet
we en25 -
35we
ekst
hef
unda
lhe
ights
hou
ldme
asu
ree
qua
ll
ytot
henumbe
rof
g
est
at
iona
lwe
eks(
+/-2
cm).
Na
ege
le’
srul
e
• TheEDDi scalc
ulat
edbyaddingse
vend a
y st
othefr
is
tdayoft
helas
tme ns
tr
ualper
iod,
subtra
ctin
gt h
reemonthsanda dd
ingoney ear
.
*Forexampl
e,ift
hepat
ie
nt'
sla
stmens
tr
ualperi
od,LMP ,
wasonAugu
st10,20
19,t
he
EDDwou l
dbec al
cul
atedasfol
lo
ws.LMPe qual
sAu g
ust10
,2019plussev
en
days.August17,2
019,minusth
reemonths.May1 7,2019pl
usoneyea
randthate
quals
Ma y1 7,202 0.
He
mat
ologi
calc
hang
esdur
ingpr
egna
ncy
-Se
eTa
ble2
9.2p.7
77
• bloodvolumei nc rea
sesby3 0%to5 0%, or1,10
0to1,600mLa ndpeaksat3 0to34
weeks
’gest
ati
on.
• Thei ncreaseinb loodvolumeimpr o
v e
sb loo
dfo
lwtothevita
lorg
ansandp r
otect
sagai
nst
exces
siv
eb loodlossduri
ngbirt
h.
• Fetalgrowthd uringp r
egna
n c
ya ndnewbo r
nwe i
ghtar
ec or
rel
at
edwit
hthede g
reeof
bloodvo l
u mee xpansio
n.
• Oft hebloodv olumee xpansi
onoc cur
ringduringpreg
nancy,75
%i scons
ider
edtobe
plasma
• The reisa l
soas lightincr
easeinredb l
o odcel
lvolume(RBC).
• Thebl oodv olumec hangesresu
ltinhemo dil
uti
on,whic
hleadst
oastat
eofp hysi
olo
gic
anemi ad uri
n gp regnancy
.
• Ast heRBCv o l
u meincrease
s,iro
nde ma ndsals
oincrea
se.
, 3
• Leukocytosisoccursinpre
gnancy,withwh it
ebloodcellcountsincr
easin
gtoa smuchas
3
14,000t o1 7,000c ell
spermm ofbl ood(Ta bl
e2 9 -
3)
.
• Clott
ingfactorsincr
easeaswell
,creat
ingar i
skforclot
tingeventsdur
ingp r
egnancy.
• Syste
mi cvas cul
arresi
sta
nceisreducedd uetotheefec
tsofp rogest
erone,pr
ostag
landi
ns,
es
tr
o g
en,andp r
olac
ti
n.
• Thislowereds y
stemicvas
cula
rres
ista
nce, i
ncomb i
nat
ionwi t
hin f
eri
orvenacava
compressi
on, ispart
lyres
ponsi
bleforthede p
endentedemat hatoccur
sinp r
egnancy
.
• Epu l
isofp regnancy,orhypert
rophyo fthegumsa ccomp aniedbyb l
e e
d i
ng,maya l
so
oc
cura ndisd uetodecr
eas
edvascu
larres
ista
nceandincr
easeinthegrowt
hofc api
ll
ari
es
duringp re
g nanc y
Indic
ationsandcont
rai
ndi
cat
ionsforpr
esc
ribi
ngc
ombi
nede
str
oge
nvs
.pr
oge
ste
rone
-onl
y
bir
thcontro l
S
:eeAppendix11 -
Ap.2 48
• Mos tCOCf ormulat
ionsno wc ontainbe t
we en2 0to3 5mc gofe thinylest
radiolpl
usone
of8av ai
la
blep r
oges
ti
ns.
• Cons i derthe“ quickstart”me t
hodwhe ninit ia
tingo ra
lc ontracepti
ves.
▪ I flastme nst
rualpe ri
od(LMP)wa swi t hi
nt helast5d ays,theme th
o dcanbe
s
tar
tedi mmediat
ely.
▪ I nu n prot
ect
eds exwi thi
nl a s
t2we eks ,s
tarttheco ntr
acep t
iveme t
h odt
o da
yand
a
dvis epati
enttore t
urntot hec li
nicforap r
egna ncytestin3we e
k s
.
▪ I nst
ru ctwome nwh oa r
eus i
n gthep il
l,pa tch
,ring,inj
ecti
on, orimplan
ttouse
backu pcontracepti
o nfort hefr
ist7d a y s
.
▪ Re searchshowst hatther
ea renos ignifica
ntd i
fere
nc esinthen umbe rofblee
din
g-
s
po t
tingd aysora nyo t
he rb leedingp a rame t
e rbetwe enthei mme diat
eand
c
onventi
ona
lst
art
er
s.
• Indica ti
o ns:
▪ Wome nwi t
hd ysme norr
he aa ndme no rr
hagia
▪ Wo me nwh owa nttor e
gula teme nses
▪ Wome nwhowi lluseada ilyme thodc ons
istentl
y
• Bene ft
isofCOC
▪ De creasedb l
o o
dl ossanda nemi a
▪ De creasedme nstrualcra
mp sa ndpa inwi t
hmo rep re
d i
ctableme nses
▪ Ca nbeus edtoma ni
p u
latet hetimin go fme nses
▪ De cre ase
sriskofo vari
anc ancera nde ndome tri
alc ancer
▪ Re du cesri
skofe ctopi
cp reg nancy
▪ Efe ctivetotreatac ne,hi
rsut is
ma ndo t
hera ndrogene xcess/s
ensit
ivit
ys t
at
es
NR602:MI
DTERM REVIEWWITHRESOURCES.
Si
gnso
fpr
egna
ncy(
pre
sumpt
ive
,pr
oba
ble
,po
sit
ive
)
• Presump ti
veSi g nsofPr eg na ncy:Symp tomst ha tares ugges t
iveofp regnancya re
consi
dered“p r
esump t
ivesi
gn s”wh ichme anst hattheya ret heleastob j
ect
iv
eo rsubj
ect
ive
si
g nswh ichc ana lsob ec a us edb yma nyo t
herc o ndi
t i
o nsothe rthanp r
egnancy.
•Ame no rr
he a:Hi ghlys ug gestiveofp regnan cyinahe a l
th yfemalewi t
hr e
g ular&
predi
ctablepe riods.Difficulttode te
rmin ei naf e malewh oh avei r
regul
arperi
odsori n
thosewh od on otk e
ept ra cko ftheirme ns t
ru a
lc y cle
s
•Na us ea&v omi t
i n g:Commons ymp tom( ~5 0%o fpreg
nanci
es)t
ypic
allyoccur
ri
ng
be t
we en2 -16we eksg es
ta t
ion
•Breaste ngorge ment&da r
ke ningoft hea reol as
:Oc cursa searl
ya s6-8we ek s
ges
ta
ti
on
•Breas ttende rness
•Fatigue
•Ur i
na ryFr eque ncy
•Sli
gh tincreasei nbo dytempe ra
ture:Ri seint e
mpe rat
urec oinci
deswi t
hlute
a l
ph a
sea ndi st her esul tofi n creasedpr oge s
te rone
•“Qu i
c kening ”:Mot he rf ee
lst hebab y’smo v eme ntsforthe1 s
tti
me ;sta
rtsat16
we eks.
• Probables i
g nsofp regnanc y:me a nthatt herei sah ig hlikeli
h oodo fpregnancyb utther
e
arestil
lo t
he rco nd i
tionst hatma yc auset hefn
id i ngs.
• Pr egna nc yt estsarec ons ide r
edpr oba blebe ca useβ- hCGa lsoprese
ntsi
nmo lar
pregna nciesa n dov ari
a nc ancer.
• Posit
i
veSignso fPregnancy:Themos treli
abl
ea ndmo s
to bj
ectivesi
gnso fposi
ti
ve
pregnancya rethos ewhe r et hep ro vi
derc a nc onfir
mt hep resenc eofaf et
us
•Palpa t
iono fthefet usb ythehe alt
hc arep r ovide r
•Ultrasou nda n dv i
s u ali
z at
io nofthef et
us
•FetalHe a rtTo nes( FHT)a us c
u l
tatedb yt h ehe a l
thc arep rov
ider
Pr
egna
ncya
ndf
unda
lhe
ightme
asur
eme
nt
• Funda
lheightcanpro
videval
uabl einfor
ma ti
ono nasse
ssi
n gtheg e
stat
ional
ag
eofthefetusaswel
lastomon i
t orfe
talgrowth.
o 1 2we eks
:Uteri
nefundusfir
strise
sa bovethesymph ysi
sp ubis
o 1 6we eks
:Uter
inefundu
si sbe t
we enthesymp hy
sisp ubi
sa ndumb il
ic
us
o 2 0we eks
:Uteri
nefundusi sattheleveloftheumbi l
icus
o 2 5-
35we eks:Measur
ethed i
stancebetweentheup peredgeo fpubicsymph
ysi
sand
t
hetopoftheut
eri
nefu
nduswi t
hatapeme as
ure.Fu
nda lhe
ighti
nc e
ntimet
ers
, 2
e
qual
sthenumberofge
sta
ti
ona
lweek
s(+/-2
cm).Fore
xample
,a28wee
k
g
est
at
ionfet
ussh
o ul
dhaveafu
nda
lheig
httha
tmeas
ure
sbet
ween2
6and30c
m.
*Bet
we en25 -
35we
ekst
hef
unda
lhe
ights
hou
ldme
asu
ree
qua
ll
ytot
henumbe
rof
g
est
at
iona
lwe
eks(
+/-2
cm).
Na
ege
le’
srul
e
• TheEDDi scalc
ulat
edbyaddingse
vend a
y st
othefr
is
tdayoft
helas
tme ns
tr
ualper
iod,
subtra
ctin
gt h
reemonthsanda dd
ingoney ear
.
*Forexampl
e,ift
hepat
ie
nt'
sla
stmens
tr
ualperi
od,LMP ,
wasonAugu
st10,20
19,t
he
EDDwou l
dbec al
cul
atedasfol
lo
ws.LMPe qual
sAu g
ust10
,2019plussev
en
days.August17,2
019,minusth
reemonths.May1 7,2019pl
usoneyea
randthate
quals
Ma y1 7,202 0.
He
mat
ologi
calc
hang
esdur
ingpr
egna
ncy
-Se
eTa
ble2
9.2p.7
77
• bloodvolumei nc rea
sesby3 0%to5 0%, or1,10
0to1,600mLa ndpeaksat3 0to34
weeks
’gest
ati
on.
• Thei ncreaseinb loodvolumeimpr o
v e
sb loo
dfo
lwtothevita
lorg
ansandp r
otect
sagai
nst
exces
siv
eb loodlossduri
ngbirt
h.
• Fetalgrowthd uringp r
egna
n c
ya ndnewbo r
nwe i
ghtar
ec or
rel
at
edwit
hthede g
reeof
bloodvo l
u mee xpansio
n.
• Oft hebloodv olumee xpansi
onoc cur
ringduringpreg
nancy,75
%i scons
ider
edtobe
plasma
• The reisa l
soas lightincr
easeinredb l
o odcel
lvolume(RBC).
• Thebl oodv olumec hangesresu
ltinhemo dil
uti
on,whic
hleadst
oastat
eofp hysi
olo
gic
anemi ad uri
n gp regnancy
.
• Ast heRBCv o l
u meincrease
s,iro
nde ma ndsals
oincrea
se.
, 3
• Leukocytosisoccursinpre
gnancy,withwh it
ebloodcellcountsincr
easin
gtoa smuchas
3
14,000t o1 7,000c ell
spermm ofbl ood(Ta bl
e2 9 -
3)
.
• Clott
ingfactorsincr
easeaswell
,creat
ingar i
skforclot
tingeventsdur
ingp r
egnancy.
• Syste
mi cvas cul
arresi
sta
nceisreducedd uetotheefec
tsofp rogest
erone,pr
ostag
landi
ns,
es
tr
o g
en,andp r
olac
ti
n.
• Thislowereds y
stemicvas
cula
rres
ista
nce, i
ncomb i
nat
ionwi t
hin f
eri
orvenacava
compressi
on, ispart
lyres
ponsi
bleforthede p
endentedemat hatoccur
sinp r
egnancy
.
• Epu l
isofp regnancy,orhypert
rophyo fthegumsa ccomp aniedbyb l
e e
d i
ng,maya l
so
oc
cura ndisd uetodecr
eas
edvascu
larres
ista
nceandincr
easeinthegrowt
hofc api
ll
ari
es
duringp re
g nanc y
Indic
ationsandcont
rai
ndi
cat
ionsforpr
esc
ribi
ngc
ombi
nede
str
oge
nvs
.pr
oge
ste
rone
-onl
y
bir
thcontro l
S
:eeAppendix11 -
Ap.2 48
• Mos tCOCf ormulat
ionsno wc ontainbe t
we en2 0to3 5mc gofe thinylest
radiolpl
usone
of8av ai
la
blep r
oges
ti
ns.
• Cons i derthe“ quickstart”me t
hodwhe ninit ia
tingo ra
lc ontracepti
ves.
▪ I flastme nst
rualpe ri
od(LMP)wa swi t hi
nt helast5d ays,theme th
o dcanbe
s
tar
tedi mmediat
ely.
▪ I nu n prot
ect
eds exwi thi
nl a s
t2we eks ,s
tarttheco ntr
acep t
iveme t
h odt
o da
yand
a
dvis epati
enttore t
urntot hec li
nicforap r
egna ncytestin3we e
k s
.
▪ I nst
ru ctwome nwh oa r
eus i
n gthep il
l,pa tch
,ring,inj
ecti
on, orimplan
ttouse
backu pcontracepti
o nfort hefr
ist7d a y s
.
▪ Re searchshowst hatther
ea renos ignifica
ntd i
fere
nc esinthen umbe rofblee
din
g-
s
po t
tingd aysora nyo t
he rb leedingp a rame t
e rbetwe enthei mme diat
eand
c
onventi
ona
lst
art
er
s.
• Indica ti
o ns:
▪ Wome nwi t
hd ysme norr
he aa ndme no rr
hagia
▪ Wo me nwh owa nttor e
gula teme nses
▪ Wome nwhowi lluseada ilyme thodc ons
istentl
y
• Bene ft
isofCOC
▪ De creasedb l
o o
dl ossanda nemi a
▪ De creasedme nstrualcra
mp sa ndpa inwi t
hmo rep re
d i
ctableme nses
▪ Ca nbeus edtoma ni
p u
latet hetimin go fme nses
▪ De cre ase
sriskofo vari
anc ancera nde ndome tri
alc ancer
▪ Re du cesri
skofe ctopi
cp reg nancy
▪ Efe ctivetotreatac ne,hi
rsut is
ma ndo t
hera ndrogene xcess/s
ensit
ivit
ys t
at
es
