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Physiological changes in pregnancy

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Physiological changes in pregnancy Dr.Areefa Al Bahri Alimentary system changes the gums becomes spongy. the lower oesophageal sphincter is relaxed (hurt burn ... – PowerPoint PPT presentation

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Title: Physiological changes in pregnancy


1
Physiological changes in pregnancy
  • Dr.Areefa Al Bahri

2
The major maternal physiological adaptation to
pregnancy
  • 1-Systemic changes
  • -Blood volume homeostasis.
  • -cardio vascular system.
  • 2-Respiratory changes.
  • 3-urinary tract and renal function..
  • 4-Reproductive organs.
  • 6-endocrine changes.

3
systemic changes
  • volume homeostasis
  • fluid retention is the most fundamental systemic
    changes of normal pregnancy.
  • the total blood volume is increased during
    pregnancy by 30.
  • the most marked expansion occurs in extra
    cellular volume (ECV) with some increase in intra
    cellular water.

4
Changes in the cardiovascular system
  • These complex changes are necessary to
  • meet evolving maternal changes in physiological
    function
  • to promote the growth and development of the
    uteroplacental-fetal unit
  • to compensate for blood loss at the end of
    labour.
  • The key physiological changes that occur are

5
The key physiological changes that occur cardiac
system
INCREASE DECREASE
blood volume (WHY) systemic vascular resistance
cardiac output (30-50) blood pressure
stroke volume 10 Pulmonary vascular resistance
peripheral vasodilatation colloid osmotic pressure
6
  • Blood changes
  • The marked increase in plasma volume
    associated with normal pregnancy causes dilution
    of many circulating factors.
  • Hematological changes
  • Decrease in
  • red cell count.
  • hemoglobin concentration.
  • haematocrit.
  • Platelets

7
  • Increase in
  • Plasma volume
  • Red cell mass
  • Total blood volume
  • white cell count.
  • erythrocyte segmentation rate .
  • fibrogen concentration (cloating factor).
  • Plasma.

8
normal changes in heart sounds during pregnancy
  • increase loudness of both S1 S2.
  • gt95 develop systolic murmur which disappears
    after delivery.
  • 20 have a transient diastolic murmur.
  • 10 develop continues murmur due to increase
    mammary blood flow.
  • Relative tachycardia
  • collapsing pulse

9
Pregnancy problem due these changes
  • Physiological edema
  • Renin and aldosterone activity are increased by
    oestrogens, progesterone and prostaglandins,
    leading to increased fluid and electrolyte
    retention.
  • Physiological anemia
  • The total plasma volume is increase in higher
    percentage in comparison to RBC which result in
    hemodilution

10
  • Decrease blood pressure
  • Increase cardiac output is this lead to decrease
    arterial blood pressure by 10, therefore
    resistance to flow must be decreased. In addition
    this can be result in decrease in systemic
    vascular resistance, particularly in the
    peripheral vessels. The decrease begins at 5
    weeks' gestation, reaches a nadir in the second
    trimester (a 21 reduction) and then gradually
    rises as term approaches

11
supine hypotensive syndrome
  • The enlarging uterus compresses both the inferior
    vena cava and the lower aorta when the woman lies
    in supine position. This reduces venous return to
    the heart this condition happen in 10 of
    pregnant women.
  • Sign of supine hypotension
  • hypotension, bradycardia, dizziness,
    light-headedness.

12
Respiratory changes
  • Pregnancy is associated with marked changes in
    respiratory physiology mediated by biochemical
    and mechanical factors. These accommodate the
    progressive increase in oxygen consumption and
    the physical impact of the enlarging uterus.
    Normal oxygen consumption is 250mL/min at rest
    and increases by 20 in pregnancy in order to
    meet the 15 increase in the maternal metabolic
    rate

13
  • Changes in pregnancy result in an
    overcompensation to this respiratory demand. The
    resulting hyperventilation causes the arterial
    oxygen tension to increase and arterial carbon
    dioxide tension to fall, accompanied by a
    compensatory fall in serum bicarbonate. A mild
    respiratory alkalosis is therefore normal in
    pregnancy (Table 14.6).

14
  • Hyperventilation can be extremely uncomfortable
    and may lead to dyspnoea and dizziness. Although
    it is not usually associated with pathological
    processes, care must be taken not to dismiss it
    lightly and miss a warning sign of cardiac or
    pulmonary disease (Steinfeld Wax 2001) (Box
    14.2).

15
  • The shape of the chest changes as diameters
    increase, by about 2cm, resulting in a 57cm
    expansion of the chest circumference.
  • The flaring of the lower ribs, causes the
    diaphragm to rise by up to 4cm, its contribution
    to the respiratory effort increasing with no
    evidence of being impeded by the uterus.
  • These changes are thought to be mediated by the
    effect of progesterone, which together with
    relaxin, increases ribcage elasticity by relaxing
    ligaments. Progesterone also mediates

16
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17
Respiratory changes
  • increase O2 demand by 20 .
  • ?tidal volume with normal respiratory rate.
  • ?po2 and ?pco2 with compensatory ?HCO3(mild
    compensated respiratory alkalosis).
  • Breathlessness due to hyperventilation and
    elevation of diaphragm.
  • tissue and oxygen availability to placenta
    improves.

18
  • ventilatory changes
  • thoracic anatomy changes.
  • tidal volume increases.
  • vital capacity increase.
  • functional residual capacity decrease.

19
Central nervous system
  • The pituitary gland increases in size by 3050
    in pregnancy accounting for much of the increased
    pituitary activity.
  • Oestrogen and progesterone readily enter the
    brain acting on a multitude of nerve cells
    changing the balance between inhibition and
    stimulation.

20
Central nervous system
  • Oxytocin neurons are inhibited from releasing
    the stored oxytocin prematurely through several
    hormonal mechanisms involving progesterone,
    oestrogen and opioid peptides. At term,
    progesterone secretion falls and the inhibitory
    mechanism modified to allow gradual release of
    oxytocin in labour followed by a surge at the
    time of birth.

21
  • Sleep disturbances are a common complaint of
    pregnancy. Various hormonal and mechanical
    influences promote insomnia leading to disturbed
    sleep during pregnancy in most women (Santiago et
    al 2001).
  • This worsens toward the end of pregnancy and
    continues to some extent for 3 months postpartum
    (Hedman et al 2002).

22
  • Interventions include establishing sleep wake
    habits, avoiding caffeine, relaxation techniques,
    massage, heat and support for lower back pain,
    modifying sleep environment, limiting fluids in
    the evening and avoiding passive smoking. Sleep
    medications should be avoided. Some studies have
    shown that sleep loss in the last few weeks of
    pregnancy are associated with increased labour
    length and LSCS rates (Lee Gay 2004).

23
  • Pregnant women's sleep patterns are affected by
    both mechanical and hormonal influences. These
    include nocturia, dyspnoea, nasal congestion,
    stress and anxiety as well as muscular aches and
    pains, leg cramps and fetal activity (Box 14.3).
  •  

24
The urinary tract and renal function
  • blood flow increase (60-70).
  • glomerular filtration increased (50).
  • clearance of most substances is enhanced.
  • plasma creatinine ,urea,urate are reduced.
  • glycoseuria is normal.

25
Alimentary system changes
  • the gums becomes spongy.
  • the lower oesophageal sphincter is relaxed (hurt
    burn).
  • gastric secretion is reduced.
  • the intestinal musculature is relaxed
    (constipation).

26
Reproductive organs
  • the uterus
  • the adult uterus comprising three layers
  • inner layer thin circular MF.
  • outer layer thin long MF.
  • central layer thick inter locking fiber.
  • the ratio of muscle to connective tissue increase
    from the lower part of the uterus to the fundus.

27
  • in early pregnancy uterine growth result from
    both hyperplasia and hypertrophy while later
    hypertrophy accounts for most of increase.
  • it weight one kilo gram at term( in pre pregnancy
    50-60 grams
  • as the pregnancy advanced the uterus divided into
    upper and lower uterine segment the lower uterine
    segment composed of lower part of uterus and the
    upper cervix composed mainly from connective
    tissue because of this the lower uterine segment
    becomes stretched in late pregnancy.

28
  • the cervix
  • the cervix becomes softer and swollen in
    pregnancy
  • the mucus gland becomes distended and secrete
    mucus which forms a mucus plug that is expelled
    in labour as the show.
  • prostaglandins and collagenase especially in last
    weeks of pregnancy act on collagen fiber make
    cervix more softer.

29
  • the vagina
  • the vaginal mucosa becomes thicker during
    pregnancy.
  • the vaginal discharge during pregnancy increased
    due to increase desquamation of the superficial
    vaginal mucosal cells

30
  • D-breasts and lactation
  • the earliest changes is a swelling of the breast
    tissue.
  • oestrogen leads to increase in number of
    glandular ducts.
  • progesterone leads to proliferation of glandular
    epithelium of the alveoli.
  • prolactine leads to active secretion of milk
    after birth.

31
Endocrine changes
  • prolactine concentration increases markedly but
    act after delivery.
  • insulin resistance develop.
  • thyroid function changes little.
  • trans placental calcium transport is enhanced.
  • corticosteroid concentration increased.
  • aldesterone concentration increased.
  • angiotensin and renine increased

32
Hormones produced within uterus
  • human chorionic gonadotrophin (HCG)
  • it is secreted by trophoblast and can be detected
    in serum 10 days after conception (RIA).
  • there is high level of circulating HCG in early
    pregnancy (to provide a suitable environment for
    implantation and development).
  • to support corpus luteum secretion of oestrogen
    and progesterone in the first trimester until the
    placenta becomes able to produce these hormone.
  • the peak level normally occur in the 12th week .

33
  • constant level of HCG in late pregnancy is useful
    in
  • controlling placental secretion of Estrogen
    progesterone.
  • suppressing maternal immune system against fetus.
  • the human chorionic gonadotrophine normally
    disappear from urine 7-10 days after delivery of
    placenta.

34
Alimentary system changes
  • the gums becomes spongy.
  • the lower oesophageal sphincter is relaxed (hurt
    burn).
  • gastric secretion is reduced.
  • the intestinal musculature is relaxed
    (constipation).

35
Reproductive organs
  • the uterus
  • the adult uterus comprising three layers
  • inner layer thin circular
  • outer layer thin long
  • central layer thick inter locking fiber.
  • the ratio of muscle to connective tissue increase
    from the lower part of the uterus to the fundus.

36
  • in early pregnancy uterine growth result from
    both hyperplasia and hypertrophy while later
    hypertrophy accounts for most of increase.
  • it weight 1 kg at term( in pre pregnancy 50-60
    grams)
  • as the pregnancy advanced the uterus divided into
    upper and lower uterine segment the lower uterine
    segment composed of lower part of uterus and the
    upper cervix composed mainly from connective
    tissue because of this the lower uterine segment
    becomes stretched in late pregnancy.

37
  • the cervix
  • the cervix becomes softer and swollen in
    pregnancy with the result columnar epithelium
    lining cervical canal becomes exposed to vaginal
    secretion.
  • oestradiol stimulate growth of columnar
    epithelial of the cervical canal so it becomes
    violate in color
  • the mucus gland becomes distended and secrete
    mucus which forms a mucus plug that is expelled
    in labour as the show.
  • prostaglandins and collagenase especially in last
    weeks of pregnancy act on collagen fiber make
    cervix more softer.

38
  • the vagina
  • the vaginal mucosa becomes thicker during
    pregnancy.
  • the vaginal discharge during pregnancy increased
    due to increase desquamation of the superficial
    vaginal mucosal cells and action of pregnancy
    hormones

39
  • D-breasts and lactation
  • the earliest changes is a swelling of the breast
    tissue.
  • oestrogen leads to increase in number of
    glandular ducts.
  • prolactine leads to active secretion of milk
    after birth.

40
Endocrine changes
  • prolactine concentration increases markedly but
    act after delivery.
  • human growth hormone is suppressed .
  • insulin resistance develop.
  • thyroid function changes little.
  • trans placental calcium transport is enhanced.
  • corticosteroid concentration increased.
  • aldesterone concentration increased.
  • angiotensin and renine increased

41
Hormones produced within uterus
  • human chorionic gonadotrophin (HCG)
  • it is secreted by trophoblast and can be detected
    in serum 10 days after conception (RIA).
  • there is high level of circulating HCG in early
    pregnancy (to provide a suitable environment for
    implantation and development).
  • to support corpus luteum secretion of oestrogen
    and progesterone in the first trimester until the
    placenta becomes able to produce these hormone.
  • the peak level normally occur in the 12th week .

42
  • constant level of HCG in late pregnancy is useful
    in
  • controlling placental secretion of Estrogen
    progesterone.
  • suppressing maternal immune system against fetus.
  • the human chorionic gonadotrophine normally
    disappear from urine 7-10 days after delivery of
    placenta.

43
human placental lactogen
  • it is secreted by syncytotrophoblast.
  • It is level increase when the level of HCG start
    to drop .
  • HPL has no effect on fetus.
  • HPL effect on
  • 1-the breast
  • mammary growth during pregnancy.
  • produce of colostrums.
  • milk production lactation.

44
  • 2-protiens
  • HPL stimulate protein synthesis at cellular
    level.
  • 3-carbohydrate
  • 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.

45
Estrogen
  • it is produce by corpus luteum in early
    pregnancy.
  • it is produce by placenta in late pregnancy.
  • fetus (liver and adrenal ) provide certain enzyme
    which are lack in placenta.
  • role of estrogen
  • On connective tissue estrogen leads to
    polymerization of mucopoly saccarides of the
    ground substance leads to loose connective tissue
    mainly in the cervix.
  • On the protein estrogen stimulate directly RNA
    synthesis lead to protein synthesis.

46
progesterone
  • it is production same as estrogen.
  • it has effect on smooth muscle leads to decrease
    muscle excitability leads to muscle relaxation
    mainly in uterus.

47
Thyroid function
  • increase thyroid binding globulin.
  • increase bound form of T3,T4.
  • no change in free form of T3,T4.
  • So no evidence to support what previously thought
    to be physiological such as increase in size of
    thyroid gland , increase BMR, body temperature,
    heart rate.

48
Diagnosis of pregnancy
  • History symptoms.
  • Examination signs.
  • Investigation pregnancy test and ultrasound.

49
symptoms of pregnancy
  • 1-Amenorrhoea
  • abrupt cessation of menses in a woman with
    regular cycle is highly suggestive.
  • 2-breast symptoms
  • tenderness and fullness may be noticed .
  • 3-frequency of micturation
  • pressure on the urinary bladder by enlarging
    uterus.

50
  • 4-nausea with or without (morning sickness).
  • 5-abdominal enlargement.
  • 6-fetal movement
  • quickening is the first feels fetal movement PG
    at (18-20wks).
  • Multi para at (16-18wks).

51
signs of pregnancy
  • 1-breasts signs
  • enlargement and increase pigmentation of the
    nipple.
  • increased pigmentation in the areola (areola).
  • formation of secondary areola.
  • montgomery areola or tubercle
  • small tubercles 12-20 at the periphery of primary
    areola appear at 8th week due to active sebaceous
    gland.
  • prominent vein on the surface.
  • colostrum at 16th week is reliable in
    primigravida.

52
  • 2-skin signs
  • linear nigra.
  • stria gravidarum.
  • chloasma.

53
  • 3-genital tract signs
  • bluish discolouration of the vulva.
  • genital tract becomes more soft and warm.
  • Uterine changes
  • uterus becomes abdominal organs at 12th week.
  • uterus becomes rounded (globular) instead of
    flatten.
  • uterus becomes soft due to increase vascularity.

54
  • 4-signs due to presence of the fetus
  • fetal heart sounds
  • after 12 weeks fetal heart heard with fetal
    sonicaid.
  • after 24th week fetal heart heard with fetal
    stethoscope.
  • FHR 120-160 beats/minuts.
  • funic soufflé heard when fetal steatoscope lie
    directly over umbilical cord it is soft blowing
    murmur synchronous with fetal heart sounds.
  • palpitation of fetal parts from 24th weeks.
  • fetal movement may felt during palpation.
  • Braxton hicks sign irregular painless
    contraction palpable at 20th week.

55
investigation
  • 1-pregnancy tests
  • a pregnancy tests detects human chorionic
    gonadotrophine(HCG) in mother urine or serum.
  • urine tests agglutation inhibition (day 35 after
    LNMP).
  • anti serum (Ab) and some of patient urine is
    added.
  • if urine contains HCG it will combine with the
    antibody and thus prevents it from binding and
    agglutinating the particles.

56
  • blood tests (day 10 after implantation)
  • radio immune assay (RIA).
  • Enzyme-linked immuno assay (Elisa)
  • Can detect levels as low as 0.1-0.3 iu/l
  • Can detect pregnancy before the patient missed
    period.

57
Ultrasonography
  • 4 weeks pregnancy sac with decidual reaction .
  • 5 weeks yolk sac.
  • 6 weeks fetal part.
  • 6-7 weeks presence of fetal heart.
  • 9 weeks fetal morphology.

58
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