• Genitalia• Skin• Breasts• Metabolic changes• Hematological• Cardiovascular• Respiratory
• Urinary• Gastrointestinal• Endocrinology
– Thyroid
• Hypermesis• Musculoskeletal• Eyes• CNS
Genital tract – uterusGenital tract – uterus
• From 70 gr/10 ml to 1100 gr/5000 ml– Growth 500-1000 times
• Patterns of growth:– Hypertrophy – Fibrous tissue– Vessels, lymphatics– Asymmetrical
• Fundus>other parts• Placental site>other parts
Genital tract – uterusGenital tract – uterus contcont
• Contractility– 1 trimester onwards– Braxton-Hicks (Hicks JB 1823-1899)
• Blood flow– 450-650 ml/min (40W)
– Regulation• Estrogen/Progesterone
• Catecholamines/Angiotensin II
• Nitric oxide (vasodilator)
Genital tract – cervixGenital tract – cervix• Continuous softening
– Increased vascularity– Hypertrophy & hyperplasia of
cervical glands
• Mucus plague obstruction– (Bloody show)
• Squamous Metaplastic Cells– Size, shape, staining– PAP interpretation
Genital tract – vaginaGenital tract – vagina
• Increased vascularity– Violet color – Chadwick sign (1844-1905)
• Wall distention
• Increased thickness of mucosa
Genital tract – ovariesGenital tract – ovaries
• Ovulation ceases during pregnancy.
• Corpus luteum up to 7th week
Genital tract – ovariesGenital tract – ovaries contcont
• Luteoma of pregnancy– Solid ov tumor– Exaggeration of normal lutianization– May be up to 10 cm– Regresses after delivery
BREAST BREAST contcont• Increased areola size• Pigmentation• Montgomery
– Pimple like gland
– Secrete lubrication for areola
Metabolic changesMetabolic changes
• Weight gain– Fetus, placenta 4.2– Amniotic fluid 0.8– Uterus 1.0– Breasts 0.4– Blood volume 1.5– 3rd space 1.5– Fat 3.4
• Average 12.5 kg• From 20th week
0.5kg/w
Metabolic changesMetabolic changes
• Recommended daily dietary allowance– 2500 kcal
– 60 gr protein
– Vitamins
– Minerals• Fe, Ca, Mg, Zn, P, I
• Average 12.5 kg• From 20th week
0.5kg/w
Metabolic changes- Metabolic changes- contcont
• Water metabolism– Increased water retention– Fall in plasma osmolality 10mosm/kg– Induced by resetting of thirst and ADH
secretion
Metabolic changes- Metabolic changes- contcont
• Fat metabolism– Increased lipids– Increased lipoproteins– Increased apoliproteins
• Protein metabolism– 1000 gr of protein per total pregnancy
• Fetus, placenta• Uterus• breasts
Metabolic changes- Metabolic changes- contcont
Carbohydrate metabolism• Theology
– Ensure continuous glucose supply to fetus
• Pregnant woman state– Woman’s fuel switch
• Glu > Lipids
– Accelerated starvation
Metabolic changes- Metabolic changes- contcont
Carbohydrate metabolism - cont• Alterations
– Fasting hypoglycemia– Postprandial hyperglycemia– Hyper-insulinemia
• Causes– Increased insulin response to Glu– Reduced peripheral uptake of Glu– Suppressed glucagon response
• Theology– Ensure continuous
glucose supply to fetus
Hematological changesHematological changes
• Blood volume increase 45%– From 1st tr onwards
– Plasma increase 50%
– RBC increase 30%
– Result in “physiologic” anemia
• Why?– To meet demands of enlarged uterus
– To protect mother from impaired venous return
– To safeguard from blood loss due to parturition
Hematological changes – Hematological changes – contcont RBC & HbRBC & Hb
• Elevated erythropoietin – Shorter life span of RBC– Elevated reticulocytes
• “physiologic” anemia:– Normal Hb >11 g/dL– Severe anemia if <10 g/dL
Hematological changes – Hematological changes – contcont RBC & Hb - RBC & Hb - contcont
• Iron– Total iron requirement during pregnancy 1
gr– Daily Iron requirement 7 mg/day
Hematological changes – Hematological changes – contcont
WBC & PltWBC & Plt• WBC
– Increase up to 16,000-20,000– Mainly because of neutrophyls
• Platelets– Plt count decrease, but stay in normal range
• 7% gestational thrombocytopenia– Constant MPV– Constant reticulated plt – Decreased plt activation during pregnancy– Increased plt activation towards delivery
Hematological changes – Hematological changes – contcont
coagulation - coagulation - contcont
• Elevated fibrinogen & factor VIII• Acquired functional resistance to
activated protein C• Decrease in protein S • Antithrombin III levels unchanged
Hematological changes – Hematological changes – contcont
coagulation - coagulation - contcont
• Increased tendency to thrombosis:– Physiologic thrombophilia– Obstruction of venous return by uterus and
venous atonia by progesterone
Cardiovascular systemCardiovascular systemheartheart
• 5th week onward, max 32nd week– Increased cardiac output– Increased heart rate 10 b/min– No change in inotropic effect– Left & upward displacement of apex (ECG)– Increased stroke volume
Cardiovascular systemCardiovascular systemcirculationcirculation
• 5th week onward, max 32nd week– Decreased systemic & pulmonary resistance– Decrease in blood pressure S>D– Supine hypotension syndrome
• Influenced by:– Renin, Angiotensin– PG– Endothgelin
Respiratory systemRespiratory system
• No change in respiratory rate
• Increase in :– Tidal volume
– Minute respiratory volume
– Minute oxygen uptake
Respiratory system- Respiratory system- contcont
• Diaphragm rises ~4 cm
• Unchanged Po2, slightly decreased Pco2
• Physiologic dyspnea (awareness of breathing)
– Tidal volume & lowered Pco2
Urinary systemUrinary system• Increased kidney size by 1.5 cm• Increased GFR & renal plasma flow
– By 50%
– 2nd trimester onwards
• Physiologic gucosuria – Increased GFR
– impaired tubular reabsorptive capacity for Glu
• Physiologic proteinuria– Increased GFR
– Up to 300 mg/24 h collection
Urinary systemUrinary system - -contcont
• Hydronehprosis & hydroureter– Rt > lt in 90% of pregnant women– Cushioning of lt urter by sigmoid colon– Compression of rt ureter by dextrorotated
uterus– Progesterone action
• Bladder– Increase in urinary incontinence
• Progesterone• Uterine pressure
Gastrointestinal tractGastrointestinal tract
• Delayed gastric emptying– Mechanical & hormonal
• Pyrosis – Gastric reflux
• Gestational gingivitis• Constipation• Hemorrhoids
– constipation
Gastrointestinal tractGastrointestinal tractLiver & gallbladderLiver & gallbladder
• Liver– Increased alk phosphat
• Placental
– Other tests unchamged
• Gallbladder– Impaired contraction– Stasis– Increased prevalence of stones
Endocrine systemEndocrine systemthyroidthyroid
• Enlargement of thyroid– Due to increased vascularity
• Increased thyroxin binding globulin– Decreased clearance
• Due to Estrogen
• Total T4 & T3 rise up to 20 w % plateaus but within normal range
• Free T4 & T3 unchanged• Normal TSH within normal range
HHyperemesisyperemesis• Morning sicknessMorning sickness
– 80% up to 14 w80% up to 14 w– Unknown etiologyUnknown etiology
• m/p hormonalm/p hormonal
• HyperemesisHyperemesis• persistent vomiting,persistent vomiting,• dehydration, ketosis,dehydration, ketosis,• electrolyte disturbances,electrolyte disturbances,• weight loss (> 5%)weight loss (> 5%)
– Gastric electrical dysrhythmia Gastric electrical dysrhythmia – Elevated TSHElevated TSH
EyesEyes
• Decreased intraocular pressure
• Corneal sensitivity
• Krukenberg spindles– Brownish-red pigmentation of posterior
surface of cornea
• Unaffected visual function
CNSCNS
• Problems with:– Concentration
– Attention
– Memory
• Most pregnant women report some memory disturbance
• Decline in :– Explicit memory– Implicit memory– Working memory
Underlying causesof memory impairment
in pregnancy
• Elevated progesterone • Glucocorticoids • Plasma neurotransmitters • Larger erythrocytes
– Lurie S, Piper I, Gordon Y, Reprod Sciences 2005
• Cultural stereotypes
CNS- CNS- contcont
• Mood disturbance– depression– stress – anxiety
• Sleep difficulty– Frequent awakenings– Reduced sleep efficiency
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