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Case 1: Maternal Physiology

A.C., 26 year old 12 weeks pregnant consulted CERVIX


because of the following symptom: nausea, gets tired easily, The cervix softens and marked cyanosis can be noted.
frequency in urination and breast heaviness. Pertinent PE: Increased vascularity, edema of the entire cervix,
Weight - 115lbs, BP - 110/70, PR - 90/min, RR 24/min, Temp hypertrophy and hyperplasia of the glands.
37.3 C. Diffuse enlargement of anterior neck area which 12-fold reduction in the mechanical strength of the
moves on deglutition. Heart and Lungs Normal on Speculum: connective tissue fibers by term.
cervix is violaceous, smooth with whitish, mucoid discharge IE The septa separating the glandular spaces become thinner
revealed a cervix which is soft, long, close. Uterus is soft, presenting a honeycomb appearance.
symmetrically enlarged to 12 weeks size. Extension or eversion of the proliferating columnar
On her 28th week AOG, she noticed that she has a
endocervical glands. Tissue tends to bleed even with minor
black line on her abdomen and experiences backaches. She
trauma.
was likewise concerned that she was gaining too much weight
and might develop diabetes.
Changes in the cervical mucous
Fragmentary crystallization/beading as an effect of
Maternal Adaption to Pregnancy
progesterone.
Systemic changes occur soon after fertilization and goes on
Ferning/arborization of the crystals
throughout gestation and even until the puerperium.
The stimulus for these adaptive changes is the growing
b. Ovaries
fetus.
Suspension of both follicular phases of menstruation and
ovulation.
GENITAL TRACT
The CORPUS LUTEUM is still found in the ovaries ,
a) Uterus
In the non-pregnant state the uterus weighs about 70 g. with producing progesterone as its main function for about 6-7
weeks AOG.
a cavity of >/= 10mL.
By term the uterus can be distended and thinning of the
The corpus luteum of pregnancy releases RELAXIN, that
walls occurs to accommodate the fetus. The volume of the
functions to remodel the connective tissue of the reproductive
contents ranges from 5L. 20L. and can weigh up to 1100 g.
tract. This will allow successful pregnancy and parturition.
Involves stretching and marked HYPERTROPHY of the
It is also secreted by the placenta and decidua parietalis.
muscles. Stimulated by high levels of ESTROGEN and
PROGESTERONE.
PREGNANCY LUTEOMA
Collagen fibrils
Characterized by an over exaggeration of the luteinization
Great increase in size, number of blood vessels and
reaction of normal pregnancy.
lymphatics. Hypertrophy of the nerves (increase size of the
They are not true malignancies but are quite large
Frankenhauser ganglion)
abdominal masses.
Enlargement is asymmetrical, it is more pronounced at the
fundus.
HYPERREATIO LUTEINALIS
Dependent also on the location of the placenta.
Second benign lesion that causes virilization during
Enlargement more pronounced at the area of the placental
pregnancy.
apposition.
A cystic tumor that is related to increased serum hCG.
* The muscles of the uterus are arranged in three layers:
c. Fallopian Tubes
1. External hoodlike layer
The musculature of the FT undergoes hypertrophy during
2. Internal layer consisting of sphincter like fibers around the
orifice. pregnancy.
3. An in-between of dense muscular fibers perforated by the The epithelium flattens out.
blood vessels. (Main bulk; contraction act as ligatures during
birth as the blood vessels are constricted) d. Vagina and Perineum
Increased vascularity and hyperemia develop in the skin of
As pregnancy proceeds, the uterus gains a more globular the perineum and vulva.
shape and spherical by the end of the 12th week. This Softening of the normally firm connective tissue.
adaptation pushes the uterus out of the pelvic cavity. CHADWICKs SIGN: violet color of the vagina during
Tension on the round and broad ligaments. pregnancy resulting from hyperemia.
With ascent of the uterus, it rotates to the RIGHT Undergoes adaptive changes to prepare the vaginal
(Dextrorotation) caused by the rectosigmoid colon on the left passage for labor.
side of the pelvis. Undergoes hypertrophy to nearly at the same extent as the
uterus.
First trimester: experience normally painless irregular
contractions. Increased cervical and vaginal secretions. Thick, whitish
Second trimester: contractions are detectable by bimanual discharge aith an acidic pH produced by Lactobacillus
examination. acidophilus from the glycogen of the vaginal epithelium.
Contractions are non rhythmic and appear sporadically. The
intensities vary from 5-25 mmHg. SKIN
Rhythmicity may increase with fetal age, and can go on for a. Abdominal Wall
a series of 10-20 minutes. Irritation can be often surmised as Reddish, slightly depressed streaks develop, and can reach
false labor pains. up to the area of the breasts and thighs.
In multiparous women, aside from the red striae, white
Increase in uteroplacental blood flow ranging from 450 glistening streaks develop as evidence of previous striations.
650 mL/min ----- this is a consequence of growing placental The rectus muscle separate from the midline, creating a
size and increasing blood vessels. diastasis recti.
Before pregnancy the flow of blood is equally divided among
the myometrium, endometrium and the site of future placental b. Pigmentation
implantation. Discoloration of the abdominal skin + appearance of the
End of first trimester: 50% blood flow to the endometrium linea nigra.
At term: 90% distributed to the placental cotyledons. Chloasma/Metasma gravidarum are irregular brownish
patches that develop over the skin of the face and neck.
NITRIC OXIDE Effect of estrogen and progesterone to the melanocyte
Potent vasodilator released by the endothelium that also stimulating hormone.
inhibits platelet aggregation.
Sensitivity of the smooth muscle to NO decreases as c. Vascular Changes
gestation advances.
Angiomas/Vascular Spiders: minute red elevations on the A minimal increase in the pH shifts the oxygen dissociation
skin common in the face, neck and the upper extremities. curve to the left. This adaptation increases the affinity of
Palmar erythrema maternal hemoglobin for oxygen (Bohr effect).
Hyperventilation that results in a reduced maternal pCO2
facilitates the transfer of CO2 from the fetus to the mother but
BREASTS appears to impair release of oxygen from maternal blood to the
In the early weeks, the woman may experience swelling and fetus.
tingling sensations.
Increase in the size and the delicate veins of the breast d. Electrolytes
become more prominent. Large accumulations of sodium and potassium that
Enlargement of the nipples making it more erectile, and a decreases in the plasma.
more pigmented areola. Increase in their glomerular filtration, but the excretion of
Extrusion of a yellowish fluid the colostrums with gentle these electrolytes are unchanged.
massage. Progesterone counters aldosterones effect on natriuesis
Around the areola which has become even more deeply and kaliuresis.
pigmented, are slight elevations of the Glands of Montgomery
(hypertrophied sebaceous glands) HEMATOLOGIC CHANGES
a. Blood Volume
METABOLIC CHANGES Maternal blood volume increases during pregnancy (to
a. Weight Gain about 40-45% more than the usual). Increase in both
Most of the weight is contributed by the uterus and its A fetus is not essential in the production of hypervolemia, a
contents plus hypervolemia and extravascular fluid increase. hyadatidiform cyst also produces increased ECV.
Increase in cellular water and deposition of new fat and Functions:
protein (maternal reserves) Meet the demands of the enlarged uterus.
Protect both mother and fetus from the deleterious effects of
b. Metabolism changes impaired venous return.
WATER Safegaurd the mother against adverse effects of parturition.
There is increased water retention, mostly attributed to a fall Slightly elevated reticulocyte count during pregnancy.
in plasma osmolality induced by resetting threshold for thirst Followed by increased levels of erythropoietin.
and vasopressin action.
Water content (of the fetus) at term: 3.5 L. + 3.0 L more as a ANP
result of increased maternal blood volume. Secreted by the atrial myocytes that produces significant
The minimum amount of extra water the woman can hold: 6.5 natriuesis. It also increases renal blood flow and GFR and
L. decrease secretion of renin.
Increase of venous pressure below the level of the uterus as Have a direct vasorelaxant effect
a consequence of partial occlusion of the vena cava produces Reduce basal release of aldosterone from the adrenals.
accumulation of fluid in the ankles and legs. Hypothesized that atrial stretch receptors are activated by
the expanded blood volume
PROTEINS
The fetus and placenta have a protein content of 500 g. HEMOGLOBIN AND HEMATOCRIT
Another 500 g. is added to the uterus as contractile Decreases slightly during pregnancy.
proteins, to the breasts as found in the glands, and to the Whole blood viscosity also goes down with it.
maternal blood as hemoglobin and plasma proteins. Hgb average: 12.5 mg/dL; can go as low as 11.0 mg/dL
Daily supplement of protein is needed.
IRON METABOLISM
CARBOHYDRATES Total iron content in women: 2-2.5 g.
Normal pregnancy is characterized by mild fasting The iron requirement for normal pregnancy is 1000 mg.
hypoglycemia, postprandial hyperglycemia and 300 mg.: actively transferred to the fetus and placenta
hyperinsulinemia. 200 mg.: lost through various routes
Increased insulin response to glucose. As blood erythrocyte volume expand, more iron is needed,
Increased peripheral uptake of glucose. Thus another 500 mg. is required, because 1 mL. RBC
Suppressed glucagons contains 1.1 mg at an expanded volume of 450 mL.
Increased concentration of free fatty acids from lipolysis The requirement becomes increased, expecially during the
(enhanced by hPL) facilitate increased tissue resistance to second half. It now become about 6-7 g. a day from
insulin. exogenous sources.
The amount of iron absorbed through the food plus those
FATS mobilized from the body stores are insufficient to meet the
Concentrations of all lipids are usually increased in demands.
pregnancy (includes lipoproteins and apolipoproteins) Increased TIBC and ferritin levels.
LDL-C peaks at about 36 weeks (consequence of hepatic
effects of estradiol) BLOOD LOSS
HDL-C peaks at 25 weeks but decreases by the 32nd week. Bleeding after birth: Originating from the placental
Storage of fat occurs during mid pregnancy. Later in the implantation site, the placenta itself, the laceration/episiostomy,
pregnancy, the fat stores may be depleted due to increased and in the lochia.
fetal demands. About 500-600 mL. of blood can be lost in a single
pregnancy. About 1000 mL. in a caesarian section or in
MINERALS multiple deliveries (twins)
IRON: pregnancy induces minimal change in iron
metabolism. b. Immunological/Leukocyte
CALCIUM and MAGNESIUM: plasma levels decline. Pregnancy reduces the effects of a variety of cellular and
Lowered plasma proteins cause little of the minerals that are humoral mediated immune responses in order to
bound. accommodate the foreign semiallogenic fetal graft.
PHOSPHATE: within non pregnant range. The renal Humoral antibody titers are also decreased, which makes
threshold for inorganic phosphates excretion is elevated in the mother susceptible to infections.
pregnancy due to increased calcitonin. Depressed leukocyte chemotaxis and adherence.
NORMAL: 5,000-12,000/L.
c. Acid Base Balance LABOR AND PUERPERIUM: 25,000 /L.
Minute ventilation increases during pregnancy causing At average: 14,000-16,000/L.
respiratory alkalosis. LAP is increased beginning quite early in pregnancy.
A moderate decrease in plasma bicarbonate from 26 mmol 1000-fold increased response of C-reactive protein.
to 22 mmol partially compensates for this.
Elevated ESR due to increased globulins and fibrinogen. Prostacyclin is the principal prostaglandin of the
C3 and C4 are also increased. endothelium that is increased in late pregnancy. The purpose
of which is to regulate BP and coagulation. It is also implicated
COAGULATION in angiotensin resistance.
The coagulation cascade is activated during normal
pregnancy. PROGESTERONE AND METABOLITES
Increased concentrations of all clotting factors except XI and Normally, the blood vessel walls of the pregnant woman,
XIII with increased levels of high-molecular weight fibrinogen. after delivery of the placenta, lose the refractoriness to
The increase in high-molecular weight fibrinogen contributes angiotensin II.
greatly to the increased ESR. Progesterone regulates this effect.
D-dimers may also be increasing with gestational age.
Fibrinolytic systems are weakened during pregnancy, ENDOTHELINS
because plasminogen-activator inhibitors are increased during Endothelin-1 is produced in the endothelial cells and
pregnancy. vascular smooth muscle to regulate vasomotor tone by
inducing vasoconstriction.
CARDIOVASCULAR SYSTEM It has been identified in the amnion, amniotic fluid, deciduas
The most important changes in the CVS is apparent during and placental tissue.
the first 8 weeks of pregnancy. It acts on a paracrine fashion, and is the MOST potent
5th week: Increase in the cardiac output as a function of vasoconstrictor identified.
reduced systemic resistance and increased HR. It is stimulated by angiotensin II, Arg-vassopressin, and
Ventricular performance during pregnancy is influenced by thrombin.
the decrease in the systemic vascular resistance and changes It can stimulate secretion of ANP, aldosterone and
in pulsatile arterial flow. catecholamines.
Vascular capacity increases due to increased compliance. Functions:
Regulate CO
a. Heart Reduce RBF
The resting pulse rate during pregnancy is 10 bpm. Reduce GFR
The heart is displaced to the left and upward as a result of Activate PLC
Increase ICF Calcium
diaphragmatic enlargement. It is also somewhat rotated on its
long axis.
b. Circulation
Extent of these changes are a function of
Blood pressure of a pregnant woman varies depending on
Size and position of the uterus
her position.
Toughness of the abdominal wall
Arterial BP usually decreases to a nadir at about
Configurations of the abdomen and thorax
Some degree of pericardial effusion. midpregnancy and rises thereafter.
The antecubital venous pressure remains unchanged during
Increase of left ventricular mass and end-diastolic
pregnancy. However, in the SUPINE position, the venous
dimensions. This corresponds to an increase in HR, CO, and
pressure rises steadily from 8 cmH2O to 24 cmH2O at term.
SV.
** The elevated venous pressure returns to normal when the
In multifetal pregnancies, there is also increase in CO
woman lies on her side or after delivery.
predominantly controlled by increased ionotropic effect.
This adaptive change can form the so-called varicosed
Alterations in cardiac sounds:
veins, because there is retarded blood flow with increased
Exaggerated splitting of the first heart sound; no change in 2nd;
venous pressures at the lower extremities.
and a loud easily heard 3rd sound.
Changes in the Supine Position:
Systolic murmur (90%) intensified at inspiration; disappears
At the supine position, the uterus causes the greatest
shortly after delivery.
compression to the venous system. Cardiac filling and output
Slight deviation of electrical axis to the left (ECG) may be reduced at this point.
The uterus can also compress on the large aorta to
CARDIAC OUTPUT sufficiently lower the arterial pressure below the level of
Arterial blood pressure and vascular resistance are compression.
Increased cutaneous blood flow in the skin serves to
decreased, while ECV, maternal weight and metabolic rates
increase. dissipate heat generated by increased metabolism.
CO is HIGHER in the RECUMBENT position; because in
RESPIRATORY TRACT
the supine position, the uterus impedes cardiac venous return
Facts:
from the IVC.
The diaphragm rises about 4 cm. during pregnancy
CO becomes appreciably greater at the 2nd stage of labor
Transverse diameter of the thoracic cage widens by + 2 cm.
with forceful expulsion.
+ 6 cm. to the thoracic circumference. But this adaptation does
not affect residual volume (think elevated diaphragm!)
LATE IN PREGNANCY
Increases in HR, SV, and CO.
a. Pulmonary Function
Decrease in Systemic vascular and Pulmonary vascular Amount of oxygen actually delivered into the lungs (by
resistance. increased TV) is GREATER than what is required during
Decrease Colloid Osmotic pressure pregnancy.
No change in pulmonary capillary wedge pressure, and Maternal hemoglobin (in increased pH) has greater affinity
central venous pressure. for oxygen thus increasing total oxygen-carrying capacity.
Maternal atriovenous oxygen difference is decreased.
RENIN, ANGIOTENSIN II and BV Although the CO is increased, the lowered Hgb content of
RAA axis controls salt and water volume. All components of
blood accounts for poor oxygen delivery = PHYSIOLOGIC
the system are increased during pregnancy. ANEMIA OF PREGNANCY (lowered atrial oxygen tension)
Renin substrate is produced in the maternal liver. Actual Facts:
hormones are secreted by the maternal kidney and the Tidal volume, Minute ventilatory volume, and minute oxygen
uteroplacental unit. uptake INCREASES
Increase in angiotensin precursor (angiotensinogen) is MBC, FVC, are not altered
attributed to increased estrogen secretion. Functional residual capacity, RV of air is DECREASED as a
Sensitivity to angiotensin II is not stimulated by ECV consequence of elevated diaphragm
increase, it is increased because of vessel wall refractoriness. Lung compliance is not affected.
Airway conductance is INCREASED
PROSTAGLANDIN Total Pulmonary Resistance (TPulR) is DECREASED probably
Increase production of prostaglandin play a central role in due to Progesterone action.
regulating vascular tone, BP and sodium balance.
Increased awareness to breathe is a feature of pregnancy,
evident in early weeks of gestation. ENDOCRINE SYSTEM
Physiological dyspnea = thought to be increased TV that
lowers the PCO2 a. Pituitary glands - Enlarges during pregnancy but is not
This phenomenon is influenced largely by required during pregnancy.
PROGESTERONE and to a lesser degree Estrogen.
GROWTH HORMONE
URINARY SYSTEM At the 1st trimester, GH in the serum and AF are at non-
a. Kidneys pregnant values. Serum values of GH increase by the 10th
The size of the kidney increases slightly during pregnancy. week and plateau after 28 weeks.
(About 1.5 cm. longer than normal) GH in the AF peaks by the 14th 15th week, and reach
GFR and RBF is INCREASED. Where GFR can rise up to baseline by the 36th week.
50% by the beginning of the 2nd trimester.
Late in pregnancy, urinary flow and sodium excretion PROLACTIN
average less than half the excretion rate in the supine position Prolactin has a 10-fold increase in the maternal blood.
than in the recumbent position. After delivery, there is a paradoxical decrease even in
There is also theory of increased excretion of nutrients via breastfeeding women.
the urine. Such nutrients include amino acids and water- Pulsatile burst of prolactin in response to sucking.
soluble vitamins. Estrogen can increase the activation of the lactotrophs in
the pituitary.
TESTS FOR RENAL FUNCTION Serotonin also increases prolactin secretion.
The PLASMA concentration of both urea and creatinine Its principal function is LACTATION
often decrease in pregnancy attributed to the increased GFR. The amniotic fluid also contains appreciable amounts of
Much is lost in the urine. prolactin, probably secreted by the fetus or by the decidua.
Creatinine Clearance: a very useful test to estimate renal
function. b. Thyroid
During the day, women tend to accumulate the water in the Marked increase of thyroxine transport proteins and binding
form of dependent edema. Water is then excreted in the globulins in response to ESTROGEN.
recumbent position (at night = nocturia) Thyroidal activating substances are also made in the
URINE IS DILUTE placenta.
The thyroid is controlled by both thyrotrophin and hCG
URINALYSIS during normal and abnormal pregnancies
Glucosuria in pregnancy is not immediately abnormal; Increase clearance of iodide and losses to the fetus during
increased GFR + low reabsorptive capacity of the tubules gestation, may result to a iodine deficiency state.
account for glucose in the urine. Hyperplasia of the glandular tissue + vascuarity.
Proteinuria is not always evident. Increased hCG production indeed causes activation of the
Urine should not contain blood. Hematuria during pregnancy thyroid.
can be a sign of UTI. Difficult labor and trauma to the minimal transfer of thyroxine from mother to child
passages can cause hematuria in subsequent urinalysis. somewhere in advanced age.

HYDRONEPHROSIS / HYDROURETER c. Parathyroid gland


With the uterus rising above the pelvic inlet, the ureters may The goal of its secretion is the maintain high calcium and
be compressed. low phosphates in the blood.
There is unequal degree of dilatation. LEFT: Sigmoid colon The values of PTH decrease during the 1st trimester, and
RIGHT: Greater compression by dextrorotation of the uterus. increases progressively throughout the remainder of the
Can also be caused by elevated Progesterone levels. pregnancy.
Intensified levels are attributed to the fact that maternal
b. Bladder calcium stores are low.
Pregnancy was found to also cause urinary incontinence. PTH is blocked by estrogen.
Urinary frequency and output increases during pregnancy. Physiological hyperparathyroidism of pregnancy.
Elevation of the bladder trigone and the thickening of its Calcium and magnesium increase the biosynthesis of
posterior, intraureteric margin is caused by hyperplasia and calcitonin.
hyperemia of the uterus. Opposes the action of PTH by lowering plasma calcium.
Sphicnter weakness = pathogenesis of urinary stress Since pregnancy causes calcium stress, levels of calcitonin
incontinence. are generally higher.
Little residual urine.
d. Adrenals
GIT CORTISOL
Organs of the GIT particularly the stomach and intestines Considerable increase in cortisol.
are displaced by the growing uterus. Clearance of cortisol is decreased in pregnancy.
Gastric emptying and intestinal transit times are delayed in In early pregnancy, levels of ACTH are depressed. Thus a
pregnancy, because of hormonal and mechanical factors. paradox is established between the two.
Ex. Progesterone decreases motilin ALDOSTERONE
Pyrosis or regurgitation of acid contents is common, this is Considerable increase in secretion in order to protect the
due to the altered position of the stomach. mother from the natriuretic effect of preogesterone and ANP.
Epulis of Pregnanacy or swelling of the gums develop
occasionally and regresses after delivery. MUSCULO-SKELETAL
Hemorrhoids Progressive lordosis is a characteristic feature of pregnancy.
The body is compensating for the anterior position of the
a. Liver enlarging uterus. The lordosis shifts the weight back over the
Does not enlarge, total ALP activity can double during lower extremes.
pregnancy, the increase is contributed by the placental ALP Increased mobility in the following joints as a result of
isoenzyme. hormonal changes: Sacroiliac, Sacrococcygeal, Pubic joints
AST, ALT and GGT are usually lower in pregnancy. Marked lordosis is already characterized by anterior neck
flexion and slumping of the shoulder girdle which may produce
b. Gallbladder traction to the median and ulnar nerves ---- causes pain and
Impaired gallbladder contractions lead to stasis. This is discomfort + numbness
associated with increased cholesterol saturation during
pregnancy.
Cholesterol stones
EYES
Even with pituitary hypertrophy, the optic tracts are
compressed, but no significant change in vision is observed.
Decrease in intraocular pressure due to increased vitreous
outflow.
Decreased corneal sensitivity. Thickness may also change
as a consequence of edema.
Krukenberg spindles are brownish red opacities on the
posterior surface of the cornea. Hormonal effects are causing
this phenomenon.
Transient but reversible loss of accommodation reflex.

CNS
Problems with attention, concentration and memory
Difficulty in sleeping, frequent awakenings, reduce sleep
efficiency and fewer hours of sleep.