June 16, 2014

MATERNAL PHYSIOLOGY

MATERNAL PHYSIOLOGY
1.04
o increase elastic tissue which adds strength to
TOPIC OUTLINE uterine wall
I. Maternal Physiology  Early gestation
II. Reproductive Tract o hypertrophy is stimulated by estrogen, perhaps by
A. Uterus progesterone not in response to mechanical
B. Cervix distention (1st 3 months)
C. Ovaries  After 12 weeks
D. Fallopian Tube o increase in uterine size is predominantly related to
E. Vagina And Perineum pressure exerted by product of
III. Skin conception(mechanical distention)
A. Abdominal Wall  Uterine enlargement – most marked in the fundus
B. Pigmentation  Early gestation
C. Vascular Changes o fallopian tube, ovarian and round ligament
IV. Breast o Attach only slightly below apex of fundus
V. Metabolic Changes o In later months, located slightly above the middle of
A. Weight Gain the uterus
B. Water Metabolism
C. Protein Metabolism
D. Carbohydrate Metabolism ARRANGEMENT OF MUSCLE CELLS
E. Fat Metabolism  Outer hoodlike layer
VI. Electrolyte And Mineral Metabolism o arches from fundus and extends to various ligaments
VII. Hematologic Changes  Middle Layer (most important layer)
A. Blood Volume o dense network of muscle fiber perforated in all
B. Hemoglobin Changes And Hematocrit directions by blood vessel
C. Iron Metabolism o each has double curve-interface in figure of 8
D. Immunological And Leukocyte Function o has blood vessels in between which prevent bleeding
E. Coagulation especially during delivery
VIII. Cardiovascular System  Internal layer
A. Heart o sphincter like fiber around office of fallopian tube and
IX. Respiratory Tract internal os
X. Urinary System
XI. Gastrointestinal Tract
A. Liver UTERINE SHAPE, SIZE, & POSITION
B. Gall Bladder
XII. Endocrine System  HEGAR’S SIGN
A. Pituitary Gland o Softening of isthmus; lower uterine segment
B. Prolactin o 6th-8th week
C. Thyroid
D. Parathyroid Hormone AOG IN
UTERINE CHANGES
E. Calcitonin And Calcium WEEKS
XIII. Muscuoskeletal 1st few weeks  Originally pear-shaped
XIV.Eyes  globular, spherical or ovoid (increase
XV. CNS length > width)
 (beyond this week it is already
12th week
noticeable)
I. MATERNAL PHYSIOLOGY  rises to pelvic brim (it already becomes
 anatomical, physiological, and biochemical adaptations to an abdominal organ)
pregnancy are profound  at the level of the umbilicus
 these remarkable changes begin soon after fertilization  in contact with anterior abdominal wall
and continue throughout gestation, and most occur in  displace intestine laterally and
response to physiological stimuli provided by the fetus superiorly
and placenta. 20 weeks
 undergoes rotation to the right as it
 Anatomical and physiologic changes in various systems enlarges dextrorotation due to
during pregnancy rectosigmoid on the left
 appendix moves upward and lateral
II. REPRODUCTIVE TRACT Bet. 18-32  FUNDIC HEIGHT (upper border of
A. UTERUS weeks symphysis pubis to fundus)
 Non pregnant *20-34 weeks – measurement of fundic height = AOG in
o almost solid structure weeks
o weighs: ~70 g
o cavity: 10 ml or <
 At term:
o weight = 1100 g
o volume = 5-20 L
o thickness =1.5 cm or <
o (Thickness)  readily indentable wall (easily
palpable fetus)
o Uterine enlargement involves:
o stretching and marked hypertrophy of muscle
cells tissue

Transcribers: Angala, MH. Javier KA. Page 1 of 5

 MATERNAL PHYSIOLOGY

o regress after delivery

o ultrasonographic charac: solid complex appearing
unilateral or bilateral mass with cystic feature that
correspond to areas of haemorrhage
 THECA LUTEIN CYST
o benign ovarian lesion that results from exaggerated
physiological follicle stimulation (hyper reaction) –
stimulation termed as hyperreactio luteinalis
o associated with marked elevated hCG
o regress after delivery
o frequently with gestational trophoblastic disease.
They are more likely in pregnancies associated with a
large placenta, for example, diabetes, D-
isoimmunization, and multiple fetuses.
BRAXTON HICKS CONTRACTION

 Painless uterine contraction without cervical dilatation D. FALLOPIAN TUBE

 little hypertrophy during pregnancy
 epithelium of the tubal mucosa becomes flattened
UTEROPLACENTAL BLOOD FLOW Decidual cells may develop in the stroma of the
endosalpinx, but a continuous decidual membrane is not
 placental perfusion: dependent on total uterine blood formed
flow from uterine and ovarian artery  Fallopian torsion: very rarely happens especially in the
 uterine blood flow, 450-650 ml/min near term presence of paratubal or ovarian cysts, may result in
 fetal placental blood flow by continuing growth of fallopian tube torsion
placental vessel
 maternal placental blood flow increase by vasodilation
because of estrogen E. VAGINA AND PERINEUM
 nitric oxide (Endometrium Derived Relaxing Factor) –  CHADWICK’S SIGN
potent vasodilator released by endothelial cell o due to increased vascularity vagina becomes
 normal pregnancy has refractoriness to pressor effects of violaceous (bluish to purple)
angiotensin II  Vaginal wall undergoes striking changes
1.  mucosal thickness
*Note: During normal pregnancy Angiotensin have no 2. loosening of connective tissue
vasoconstrictor effect; but this is not applicable if the mother 3. hypertrophy of smooth muscles – in preparation for
is pre-eclamptic. distension during labor
 volume of cervical secretion in the vagina (thick and
white discharge)
B. CERVIX  Acidic pH 3.5-6.0
 undergo pronounced softening and cyanosis due to o due to increase in production of lactic acid from
increased vascularity and edema of entire cervix, glycogen in vaginal epithelium by action of
hypertrophy and hyperplasia of cervical gland Lactobacillus acidophilus
 GOODELL’S SIGN
o softening of cervix
o 6th & 8th week III. SKIN
 CERVICAL EVERSION: A. ABDOMINAL WALL
o proliferating columnar endocervical glands  red,  STRIAE GRAVIDARUM
velvety and bleed easily (normal in pregnancy) o reddish
 endocervical mucosal cells produce copious amount of o slightly depressed streaks in the skin of abdomen
tenacious mucus that obstruct the cervical canal rich in Ig o “stretch marks”
and cytokines → mucus plug (bloody show) o In multi-glistening silvery lines
o dried cervical mucus (crystallization / beading) due to  DIASTASIS RECTI
progesterone o rectus muscle separation
o arborization of crystal / ferning due to amniotic fluid o abdominal muscle wall cannot hold tension (weak)
leakage

B. PIGMENTATION
C. OVARIES  Linea alba Linea Nigra
 ovulation ceases during pregnancy  CHLOASMA/ MELASMA GRAVIDARUM/MASK OF
 maturation of new follicles is suspended PREGNANCY
 Corpus Luteum of Pregnancy o dark discoloration of the face and neck
o function maximally during the first 6th-7th week o Melanocyte-stimulating hormone
(progesterone production) o elevated at 2nd month term
o after 7th week, progesterone is produced by the o estrogen and progesterone has melanocyte
placenta stimulating effect
 Clinical implication *These two mechanisms are still questionable.
o Safe surgical removal of corpus luteum after seven
weeks of gestation, and will not produce spontaneous
abortion.
 Decidual reaction beneath the surface of ovaries – C. VASCULAR CHANGES
endometrial glands (red in ovaries)  angioma/ vascular spiders and palmar erythema (may be
 LUTEOMA OF PREGNANCY confused with liver disease)
o represents exaggerated luteinization recation of  no clinical significance due to hyperestrogenemia
normal ovary
o size: microscopic to 20 cm
Transcribers: Angala, MH. Javier KA. Page 2 of 5
 MATERNAL PHYSIOLOGY

IV. BREAST D. CARBOHYDRATE METABOLISM

 breast tenderness and tingling sensation
 breast size
 prominent veins
 larger and more deeply pigmented and erectile nipples
 broader and pigmented areola
 prominent gland of Montgomery (hypertrophic
sebaceous glands – small elevation surrounding the
areola)
 nipples become considerably larger, more deeply
pigmented, and more erectile.
 After the first few months, a thick, yellowish fluid—
colostrum—can often be expressed from the nipples by
gentle massage
 rarely excessively large GIGANTOMASTIA

V. METABOLIC CHANGES
A. WEIGHT GAIN
 Due to uterus and its content, breasts increase in blood
volume, extravascular extracellular fluid increase in
cellular water and deposition of new fat and
proteinmaternal reserve
 27.5 lbs (Hytten, 1991) or 12.5 kg
o weight gain if BMI before pregnancy is normal
 before 2 lbs 1st trimester, 11 lbs 2nd trimester and 11 lbs
3rd trimester (2-11-11)
 1990’s, recommended between 25-35 lbs (11.5-16 kg)
provided that pre-pregnant weight is normal
 normal pregnancy is characterized by:
o mild fasting hypoglycaemia: plasma level of insulin
observed in pregnancy
o postprandial hyperglycemia and hyperinsulinemia
o hyperinsulinemia: consistent with pregnancy →
induced state of peripheral resistance to insulin to
ensure postprandial supply of glucose to fetus
o mechanism/s for insulin resistance
 Estrogen and progesterone
  human placental lactogen
 lipolysis
 liberation of free fatty acids facilitate increased
tissue resistance to insulin
E. FAT METABOLISM
 concentration of lipid, lipoprotein and apolipoprotein
during pregnancy, lactation speeds the rate of decrease
 Fat deposition is mostly central than peripheral
 LEPTIN
o increased progressively
o peak on 2nd trimester
o plateau at term (3-4x higher than non-preg)
o peptide hormone
o primarily secreted by adipose tissue
o also produced by placenta
o plays a key role in the regulation of body fat and
energy expenditure

B. WATER METABOLISM
VI. ELECTROLYTE AND MINERAL METABOLISM
 ↑in water retention
 total accumulation of Na and K
o ↓ in plasma osmolality of approximately 10 mOsm/kg
o but slightly  serum concentration due to expanded
induced by resetting of osmotic threshold for thirst
plasma volume
and vasopressin secretion
 Serum calcium level
 At term:
o 3rd trimester
o 3.5 L due to:
o 200 mg/day calcium deposited in fetal skeleton-
o Fetus
dietary intake important
o Placenta
 Serum Mg level
o Amniotic fluid
o 3.0 L due to:
VII. HEMATOLOGIC CHANGES
o increase blood volume
A. BLOOD VOLUME
o uterus
o breast  maternal blood volume ↑ markedly during pregnancy
o 6.5 L minimum amount of extra water (40-45% at term)
 blood volume expansion results from increase of both
 PITTING EDEMA of ankles and legs plasma & electrolyte → physiologic anemia of
o due to ↑venous pressure below the level of uterus pregnancy→ supplementary iron
o due to partial occlusion of vena cava by gravid uterus,  blood volume: plasma > erythrocyte
especially during the night  important function of pregnancy induced hypervolemia:
 Pressure of enlarging uterus on pelvic veins, varicose 1. To meet the demands of enlarged uterus with its
veins, edema greatly hypertrophied vascular system
2. To protect the mother & in turn fetus against
deleterious effect of impaired venous return in
C. PROTEIN METABOLISM supine and erect position
 fetus, the uterus, and maternal blood 3. To safeguard the mother against the adverse
o are relatively rich in protein rather than fat or effects of blood loss associated with parturition
carbohydrate
 At term:
B. HEMOGLOBIN CONCENTRATION AND HEMATOCRIT
o the fetus and placenta together weigh about 4 kg and
contain approximately 500 g of protein, or about half  in spite of augmented erythropoesis- slight ↓ in
of the total pregnancy increase hemoglobin and hematocrit
 remaining 500 g is added to the uterus as contractile
protein, to the breasts primarily in the glands, and to the
C. IRON METABOLISM
maternal blood as hemoglobin and plasma proteins
IRON STORES
 Amino acid concentrations are higher in the fetal than in
the maternal compartment
 total iron stores (2-2.5 g total iron content of normal
 concentration is largely regulated by the placenta
adult women)
o which not only concentrates amino acids into the fetal
 300 mgiron store of normal young women
circulation, but also is involved in protein synthesis,
oxidation, and transamination of some nonessential
amino acids
IRON REQUIREMENT

 1,000 mg: total iron requirement in normal pregnancy

Transcribers: Angala, MH. Javier KA. Page 3 of 5

 MATERNAL PHYSIOLOGY

o 300mg: actively transferred to the placenta and fetus  thoracic circumference, increase about 6cm
o 200 mg: lost via excretion (GIT)  Pulmonary Function
o 500 mg: 1 ml normal erythrocyte contains 1 mg iron
→ 450 ml of erythrocyte in pregnancy
 6-7 mg/day iron requirement in 2nd half of pregnancy
 Supplemental iron
o required because amount of iron absorbed from the
diet together with that mobilized from store is usually
insufficient to meet the maternal demand imposed by
pregnancy
o Absence would decrease the hemoglobin
concentration

D. IMMUNOLOGICAL AND LEUKOCYTE FUNCTION

 suppression of variety of humoral and cell-mediated
immunological function in order to accommodate foreign
semi-allogenic fetal graft
 ESR: due to elevated plasma globulin and fibrinogen
 C3 & C4: during 2ND and 3RD trimester
 WBC count: average 14,000-16,000/μl o Tidal volume, minute ventilatory volume and minute
o During labor puerperium: WBC≥25,000 /μl O2 uptake increased
o Maximum breathing capacity and forced or time lung
compliance  not altered
E. COAGULATION o Functional residual capacity and residual volume is
 concentration of all clotting factors decreased
o except Factor XI and Factor XIII o Airway conductance is increased; total pulmonary
resistance reduced due to progesterone
 platelet concentration due to hemodilution

*Note: During pregnancy elevation of the diaphragm causes

VIII. CARDIOVASCULAR SYSTEM
these respiratory changes.
A. HEART
 resting pulse rate ↑10 beats/minute
 heart is displaced to the left and upward
o due to ↑ in size of thoracic cavityapex moved X. URINARY SYSTEM
laterally ↑ in size of cardiac silhouette in x-ray  slightly Kidney size
 CO (peak increase- after delivery)  slightly GFR and renal plasma flow 50% by 2nd
 BP: at mid-pregnancy and rises thereafter trimester
 Diastolic pressure more than systolic  Serum creatine and urea nitrogen (BUN)
 Cardiac Natriuretic Peptide- Atrial Natriuretic Peptipe  Creatinine clearance
(ANP) and B type Natriuretic Peptide (BNP)  Glucosuria
o produced and secreted by cardiomyocytes o not necessarily abnormal  due to ↑GFR and
o to regulate blood volume by producing significant impaired tubular reabsorptive capacity for filtered
natriuresis and diuresis glucose
o promote vascular smooth muscle relaxation o glucose challenged test – can be done to determine if
varicosities and haemorrhoids - venous stasis there is gestational diabetes
o Supine hypotensive syndrome enlarges uterus  Hydroureter and Hydronephrosis due to progesterone
compresses vena cava, arterial hypotension (advise effect → more marked on the right due to cushioning
the mother to lateral (preferably left) side lying) provided of the left ureter by sigmoid colon and greater
compression of right ureter

XI. GASTROINTESTINAL TRACT

 appendix is displaced upward and lateral by enlarging
uterus
 ↓gastric motility
 prolonged gastric emptying due to progesterone
 Anesthesia during labor (NPO)
 PYROSIS (heartburn)
o caused by reflux of acidic secretion into the lower
esophagus
o due to altered position of stomach
o lower esophageal sphincter tone is decreased
Figure : Change in cardiac outline that occurs in pregnancy.
o high intragastric pressure
The light lines represent the relations between the heart and
thorax in the nonpregnant woman, and the heavy lines  EPULIS
o focal, highly vascular swelling of gums
represent the conditions existing in pregnancy. These
findings are based on x-ray findings in 33 women.  HEMORRHOIDS
o due to elevated pressure in veins below the level of
enlarged uterus

IX. RESPIRATORY TRACT

 diaphragm rises by 4 cm A. LIVER
 subcostal angle widens as transverse diameter of thoracic  Total alkaline phosphatase activity
cage increase by 2 cm  slightly :

Transcribers: Angala, MH. Javier KA. Page 4 of 5

 MATERNAL PHYSIOLOGY

o Serum aspartate transferase (AST) XIV. EYES

o alanine transferase (ALT) serum  ↓Intraocular pressure due to vitreous flow
o glutamyl transferase  Corneal sensitivity
o bilirubin o greatest during late gestation
 Slight  in corneal thickness due to edema
 KRUNKENBERG SPINDLES → brownish-red opacities on
B. GALLBLADDER posterior surface of cornea
 Progesterone impaired gallbladder contraction → stasis +  transient loss of accommodation in pregnant and
↑ saturated cholesterol →↑ stone formation lactating women
 Intrahepatic cholestasis linked to circulating level of  visual function unaffected
estrogen with inhibition of intraductal transport of bile
acid
 PRURITUS GRAVIDARUM XV. CNS
o due to retained bile salt  problems with attention, concentration, memory limited
studies and often anecdotal
 12 weeks AOG first 2 months postpartum difficulty
XII. ENDOCRINE SYSTEM going to sleep, reduced sleep efficiency, frequent
A. PITUITARY GLAND awakenings, fewer hours of night sleep
 enlarged approximately 135% postpartum depression
 compress optic chiasma and reduce visual field →
minimal changes in vision
Questions:

B. PROLACTIN 1. Painless uterine contractions during the latter part

 10x at term 150 ng/ml of pregnancy
 Ensue lactation (principal function) 2. Diaphragm rises by how many centimeters
3. Mask of pregnancy
4. Discoloration of the vagina
C. THYROID 5. Softening of the cervix
 Moderate enlargement d/t glandular hyperplasia and
6. Increased concentration of all clotting factors
increase vascularity
except
 TBG, total T4, BMR 7. Rectus muscle separation
 Free T4: rise slightly then returns to normal 8. Softening of isthmus; lower uterine segment
 T3: pronounced to 18th week then plateaus 9. At term, the weight of the uterus is
 TRH unchanged 10. Total iron requirement in normal pregnancy

Answers:
D. PARATHYROID HORMONE
 Hypercalcemic Vit D 1. Braxton hick’s contraction
 plasma Ca and Mg → stimulate release PTH 2. 4 cm
 Ca & Mg: suppress PTH 3. Melanoma gravidarum
 during 1st trimester, increase progressively throughout 4. Chadwick’s sign
pregnancy 5. Goodell’s sign
 PTH due to decrease Ca concentration, due plasma 6. Factor XI and Factor XIII
volume, GFR and maternal fetal transfer of Ca → 7. Diastasis recti
PHYSIOLOGIC HYPERPARATHYROIDISM OF PREGNANCY 8. Hegar’s sign
9. 1100g
10. 1,000 mg
E. CALCITONIN AND CALCIUM
 secretes C-cells which are located in parafollicular areas
of thyroid gland  Ca+2 and Mg+2 ↑ biosynthesis →
secretion of calcitonin

F. ADRENAL GLAND
 ↑ in:
o Cortisol
o Aldosterone
o Deoxycorticosterone
o Androstenedione
o testosterone
 in:
o Dehydroepiandrosterone (DHEAS)

XIII. MUSCULOSKELETAL
 Progressive lordosis (characteristic feature)
 ↑ motility of Sacroiliac, sacrococcygeal and pubic joints
during pregnancy
o not brought about by increase in estrogen,
progesterone

Transcribers: Angala, MH. Javier KA. Page 5 of 5