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physiological changes in pregnancy
Terms in this set (45)
Anatomical changes during pregnancy - uterus
- body: height 7.5cm to 35cm / weight 50g to 1000g at term
- lig - hypertrophy
- dextrortatation: telted and twisted to the right in 80% of cases
lower uterine segment (LUS)
the LUS is formed from the isthmus
LUS is the part of the uterus and the upper cervix which lies between the attachment of the peritoneum of the uterovesical pouch superiorly & the internal cervical os inferiorly.* The isthmus of the uterus, the lower extremity of which joins with the cervical canal
anatomical changes- cervix
- edema and congestion, and becomes soft
- mucus plug (operculum): cervical mucus closing the cervical canal
- increased secretion from its glands
anatomical changes- vulva
shows increased vascularity and varicosity
anatomical changes- vagina
- shows increased vascularity soft, moist and bluish
- distention of vagina at birth
anatomical changes- ovary
- shows increased vascularity and size
- one ovary contains the corpus luteum [support the baby until the formation of the placenta]
anatomical changes - pelvic lig
- relaxation of the ligaments
- relaxation of the pelvic joints
- the pelvis become more mobile and increases in capacity
Breast changes during pregnancy
• Increased size and vascularity warm, tense and tender
• Increased pigmentation of the nipple and areola
• Secondary areola appear (light pigmentation around the 1ry areola)
• Montgomery tubercules appear on the areola (dilated sebaceous glands)
• Colostrum like fluid is expressed at the end of the 3rd month
• Pigmentation due to increased melanocyte stimulating hormone:
- linea nigra: pigmentation of the linea alba, more marked below the umbilicus
- chloasma gravidarum: Butterfly pigmentation of the face (mask of pregnancy)
• Striae gravidarum
stretch of the abdominal wall rupture of the subcutaneous elastic fibers pink lines in flanks - become white after labor
high levels in ?
peak level occur in ?
- secreted by trophoblast and can be detected in serum 10 days after conception.
- there is high level of circulating HCG in early pregnancy (to provide a suitable environment for implantation and development).
- Function to support corpus luteum secretion of estrogen and progesterone in the 1st trimester until the placenta becomes able to produce these hormone.
-the peak level normally occur in the 12th week .
- normally disappear from urine 7-10 days after delivery of placenta.
levels inc ?
effect on ?
peak level occur in ?
it is secreted by syncytotrophoblast.
It is level increase when the level of HCG start to drop .
has minimal effect on fetus.
HPL effect on :
mammary growth during pregnancy.
production of colostrum.
2-protiens 🡪 HPL stimulate protein synthesis at cellular level.
stimulate insulin secretion .
inhibit insulin action.
4-fat 🡪 HPL mobilize fat from body store (lypolysis) lead to increase maternal blood glucose and maternal tissue can not utilize the glucose so the glucose will be available for fetus.
produced by? 2
++produced by corpus luteum in early pregnancy.
and by placenta (estrone and estradiol) and fetal adrenals (estriol) in late pregnancy.
+Levels continue to increase till term
+Estriol accounts for 85%
+role of estrogen:
-On connective tissue: leads to loose and pliable connective tissue mainly in the cervix.
-On the protein: estrogen stimulate directly RNA synthesis lead to protein synthesis.
-On the uterus: induces its growth and controls its function.
produced by? 2
it is production same as estrogen.
Levels increases steadily during pregnancy.
it has effect on smooth muscle leads to muscle relaxation mainly in uterus.
Accounts for smooth muscle relaxation leading to:
- Constipation, delayed gastric emptying
- Reduced bladder and ureteric tone.
- Venous dilation.
- Reduced diastolic pressure.
Endocrine changes- thyroid gland
mesure of the thyroid fxn?
production and secretion?
Production of thyroid hormone increases by 40% to 100% to meet maternal and fetal demands
Thyroid gland> moderate enlargement during pregnancy
TBG is increased during pregnancy because the high estrogen levels induce increased hepatic synthesis the free, biologically active concentration of each hormone is unchanged.
TSH levels > decreased slightly in the 1st trimester ( when HCG levels are at their highest) >> increase again at the end of the 1st trimester, and the upper limit in pregnancy is raised to 5.5 μmol/l compared with the level of 4.0 μmol/l in the non-pregnant state.
Only minimal amounts of thyroid hormone cross the placenta. However, the fetus is reliant on maternal thyroxine to maintain normal fetal thyroid function.
The production and secretion of fetal thyroid hormone starts at around the 20th week of gestation.
Endocrine changes- pituitary gland
- FSH/LH levels
- Serum prolactin levels increase in the first trimester and are 10 times higher at term.
- (FSH) and (LH) levels are almost undetectable during pregnancy.
- Pituitary growth hormone production is decreased but serum growth hormone levels are increased due to growth hormone production from the placenta.
- oxytocin levels increase in pregnancy and peak at term.
Gastrointestinal tract changes
- Nausea and vomiting
- Increased salivation (ptyalism)
- Alteration in sense of taste.
- Increased appetite and thirst.
About 0.5-3% of pregnant women develop hyperemesis gravidum, a severe form of nausea and excessive vomiting, often resulting in
- electrolyte imbalance,
- weight loss and
- vitamin or mineral deficiencies.
hormones involved in the etiology of NV
(hCG), estrogen, progesterone, and thyroid hormones
The nausea symptoms usually resolve by __________________ but about 10-20% of the patients experience symptoms beyond ___________________ and some until the end of the pregnancy.
- week 20
Becomes hypermic and soft
More prone to bleeding from minor trauma.
Causes of heartburn?
- Reduced tone of the lower esophageal sphincter leading to reduced intraesophageal pressure.
- Esophageal peristalsis has a lower amplitude and lower speed.
- stomach is increasingly displaced upwards by the gravid uterus leading to an altered axis and increased intragastric pressure.
Reduced motility of small bowel
increased transit time in the third trimester and postpartum
Enhanced iron absorption
Mechanical obstruction by the uterus
Increased water absorption
Biliary cholesterol saturation increases and chenodeoxycholic acid decreases
increased risk gallstone formation
- Exaggerated lordosis of the lower back
Joint laxity in the anterior and longitudinal ligaments of the lumbar spine
Widening and increased mobility of the sacroiliac joints and pubic symphysis.
Although pregnancy and lactation are associated with
reversible bone loss
, studies do not support an association between parity and osteoporosis in later life.
Bone turnover is low in the
and increases in the
when fetal calcium needs are increased.
By the third trimester, maternal basal metabolic rate is increased by 10% to 20% compared with that of the non-pregnant state
Weight Gain in Pregnancy
The average weight gain in pregnancy uncomplicated by generalized edema is 12.5 kg (28 lb).
The products of conception constitute only about 40% of the total maternal weight gain.
INSULIN EFFECTS AND GLUCOSE METABOLISM
- insulin secretion
- insulin sensitivity
- Glycogen synthesis and storage by the liver
- increased insulin secretion
- increased insulin sensitivity in early pregnancy, followed by progressive insulin resistance.
- the insulin response to glucose stimulation is augmented.
- Glycogen synthesis and storage by the liver increases and gluconeogenesis is inhibited. Thus, during the first half of pregnancy, the anabolic actions of insulin are potentiated due to growing fetus and inc tissue.
Insulin levels are increased in both the fasting and postprandial states in pregnancy. Fasting glucose levels are however decreased due to:
- increased storage of tissue glycogen
- increased peripheral glucose use
- decrease in glucose production by the liver
- uptake of glucose by the foetus
If a woman's endocrine pancreatic function is impaired, and she is unable to overcome the insulin resistance associated with pregnancy then
gestational diabetes develops.
gestational diabetes develops.
in 2nd half if happened in the 1st half this is undetected DM
Normal pregnancy is characterized by mild fasting ______________, postprandial _______________________ and _____________________.
Pregnant women require an increased intake of protein during pregnancy.
Amino acids are
transported across the placenta to fulfill the needs of the developing fetus.
During pregnancy, protein catabolism is decreased as fat stores are used to provide for energy metabolism.
Positive nitrogen balance throughput pregnancy.
Increased calcium absorption is associated with an increase in calcium excretion in the urine and these changes begin from 12 weeks.
During periods of fasting, urinary calcium values are low or normal, confirming that hypercalciuria is the consequence of increased absorption.
Pregnancy is therefore a risk factor for kidney stones.
Placental Transfer of Nutrients
The transfer of substances across the placenta occurs by several mechanisms, including simple diffusion, facilitated diffusion, and active transport.
Low molecular size and lipid solubility promote simple diffusion.
Amino acids are actively transported across the placenta, making fetal levels higher than maternal levels.
Glucose is transported by facilitated diffusion, leading to rapid equilibrium with only a small maternal-fetal gradient.
Glucose is the main energy substrate of the fetus.
Hematological changes - Blood volume
Increases progressively from 6 to 8 weeks' gestation
maximum volume at 32-34 weeks 🡪 45% increase
estrogen stimulation of renin-angiotensin-aldosterone system.
Increase in plasma and erythrocytes volume.
Hematological changes - RBC mass
Red blood cell mass increases by ( 20-30% increase) by term
Moderate erythroid hyperplasia in the bone marrow is present
Reticulocyte count is elevated.
Result mostly from elevated plasma erythropoietin levels.
production of erythrocyte peaks during the third trimester
Hematological changes - body water
TBW increases up to (6.5L -8.5L)
At term water content of fetus, placenta and amniotic fluid is 3.5L
Another 3L accumulates from increased blood volume, plasma volume, RBC, extravascular and intracellular.
Also caused by decreased plasma osmolality of approximately 10 mOsm/kg:
Water retention exceeds Na retention.
Resetting of osmotic thresholds for thirst and vasopressin
Pregnancy is a condition of chronic volume overload
physiologic anemia of pregnancy
may function to decrease blood viscosity
may improve intervillous perfusion?
However, any hemoglobin level below 11 mg/dl during pregnancy should be considered abnormal, and is mainly due to iron deficiency rather than hypervolemia
Peripheral WBC count rises progressively during pregnancy
1st trimester - mean 9500/mm3 (3000-15,000)
2nd and 3rd trimester - mean 10,500 (6000-16,000)
Labor - may rise up to 25,000
These changes may account for the improvement of some autoimmune diseases during pregnancy.
Hematological changes-platelets-d- and coagulation factors.
Platelets experience a progressive decline but should remain within normal range ( minmal value of 100,000-150,000)
Likely due to increased destruction.
Partially due to dilutional effect.
Increased levels of (Fibrinogen (Factor I), Factors VII through X)
No change in prothrombin (Factor II), Factors V and XII
Decline in platelet count, Factors XI and XIII and protein S levels
Increase resistance to protein C
CO in pregnancy
-increases in first half of preg d/t increase in SV and increase in BV
- second half of preg will increase d/t HR
Compression by gravid uterus:
on IVC it causes:
- Supine Hypotension Syndrome
- ↑ in pelvic and L.L. venous pressure 🡪
a. varicose veins in L.L. and vulva
c. edema of pregnancy (contributed also by delutional hypo-albuminemia).
d. ↑ risk of thrombosis (Ex.: DVT) by blood stasis.
- Elevated diaphragm position 🡪 ↓ negative intra-thoracic pressure 🡪 ↓ Resting lung volumes (RV, and FRC [ due to lowered RV and ERV; FRC=RV+ERV])
- This will NOT impair diaphragmatic or thoracic muscle movement 🡪 NO change in Vital capacity
Minute ventilation= RR*TV 🡪 RR does NOT change,
TV increase by 40% at term.
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