Chapter3 Normal pregnancy

Wang Fuling
 一、 Pregnancy physiology
 Pregnancy is the maternal condition of

having a developing fetus( 胎儿 ) in the

body.
 What is pregnancy?
Pregnancy is defined as the course of
embryo （胚胎） and fetal growth
and development in uterine
It begain at the fertilization and end the
delivery of the fetal and it’s attachment
 （一） The fetus
1 Fetus growth and development
 2 Fetal physiology
1 、 Fetus growth and development

Fertilization is defined as the course of

combination of the oocyte and sperm
It onset 12h after ovulation usually in
ampulla of the oviduct(fallopian tube)
1 、 Fetus growth and development
 The human conceptus from fertilization
through the eighth week of pregnancy is
termed an embryo from the eighth week
until delivery ， it is a fetus.
 The estimated age of the fetus calculated
from the frist day of the last menstrual
period ,assuming a 28-day cycle.
1 、 Fetus growth and development
 During the frist 8 weeks,the term embryo is
used to denote( 表示 ) the developing
organism because it is during this time that
all the major organs are formed .
1 、 Fetus growth and development
 Afterthe eighth week, the word fetus is
proper, the growth of the fetus may be
described in units of 4 weeks’ gestational
age, beginning with the first day of the
LMP
（ last menstrual period ）
1 、 Fetus growth and development
 8weeks: the organs are beginning to form
 12weeks: the fingers and toes have nails, and the
external genitalia may be recognizable
 16weeks :the sex is discernible as male or female
 20weeks :heart tones may often be detected by
stethoscope( 听诊器 ),movements have been
perceives by mother, the uterine fundus is near the
level of the umbilicus （脐）
1 、 Fetus growth and development
 24weeks ： some fat is beginning to be
deposited beneath the wrinkled skin,
viability is reached by the 24th week, but
survival at this stage is still relatively rare
 28weeks ： the lungs are now capable of
breathing, but the surfactant content is low;
survival is possible in level II or level III
neonatal centers
1 、 Fetus growth and development
 32weeks ： if born at this stage, about 5 of 6
infants survive
 36weeks ： the skin has lost its wrinkled
appearance, the chances for survival are good
 40weeks ： the head has a maximal transverse
diameter of 9.5cm. The average fetus ,therefore,
requires cervical dilatation of almost 10cm before
it can descend into the vagina
 2 、 Fetal physiology
Contents:
 Circulatory function
 Hematology( 血液学 )
 Respiratory function
 Gastrointestinal function
 Renal function
 Endocrinology( 内分泌学 )
2 、 Fetal physiology
（ 1 ） Circulatory function
2) fetus ←→placenta←→ mother
3) Umbilical cord: 1 umbilical vein (full of
oxygen), 2 umbilical artery (lack of
oxygen)
4) Mixed blood (vein and artery)
Development of embryo and fetus
 2 、 Fetal physiology
（ 2 ） Hematology （血液学）
Erythropoiesis （红细胞生成）
From yolk sac （卵黄囊） : 3 weeks
From liver: 10 weeks
From bone marrow and spleen ： after 10 weeks

*By10weeks the liver assumes the major role in

erythropoiesis, but the spleen and bone marrow
gradually take over this function
 2 、 Fetal physiology
(3) Respiratory function
gas exchange in the fetus occurs in the
placenta
(4) Gastrointestinal tract
No truly function until after birth
(5) Kidney
Its function begins at 9-12th week
 2 、 Fetal physiology
(6)Endocrinology
• Fetal thyroid: the first endocrine gland (6th
week), synthesize thyroxine at 12th week

• Fetal adrenal cortex consists mainly of a fetal

zone that disappears about 6months after birth.
3 、 The placenta ， umbilical cord
and amniotic fluid
 The placenta
 The umbilical cord
 The amniotic fluid （羊水）
 （ 1 ） The placenta
 Development of the placenta
 Functions of the maternal placental-fetal
unit
 （ 1 ） The placenta
 Structure
2. Primary villus （绒毛）
3. Secondary villus
4. third class villus
fetal capillary( 胎儿毛细血管 ) enter the
stroma
*1 、 Development of the placenta
 Fertilization

3. Place: oviduct (ampulla)

4. Process
capacitation → acrosome reaction→
penetrate the zona pellucida→ second
meiosis →zygote( 受精卵 )
Implantation
2. requirement
• Disappear of zona pellucida
• Formation of syncytiotrophoblast
• Synchronized development of blastocyst
and endometrium
• Adequate progesterone
1. Process
• morula (day 3) → enter uterine cavity
(day 4) → early blastocyst→ late
blastocyst (day 6-7) → implantation
• location→ adherence→ penetration
 （ 2 ） Functions of the maternal
placental-fetal unit
 Endocrine function
Human chorionic
gonadotropin （ HCG ）
Human chorionic somatomammotropin
Placental proteins （胎盘蛋白）
Estrogen
 Metabolitic function
 Protective function
 Endocrine function
Human chorionic gonadotropin(HCG)
 Itis a glycoprotein that has biologic and
immunologic similarities to luteinizing hormone
from the pituitary
 H CG is produced by the syncytiotrophoblast of
the placenta
 This measurement is useful because it can detect
pregnancy in all patients on day 11 after
fertilization
 Endocrine function

Human chorionic somatomammotropin(hGS)

 hGS is a protein hormone with
immunologic and biologic similarities to
pituitary growth hormone
 It has been suggested that hGS is the
“growth hormone”of pregnancy
Endocrine function

Placental proteins
 PAPP-A,PAPP-B,PAPP-C,PAPP-D
 PAPP-D is the hormone hCS
Endocrine function

Estrogen
 Estrogen production by the placenta is
dependent upon precursors reaching it from
both the fetal and maternal compartments
Metabolitic function
Protective function
The functions of placenta
 Gas exchange

 Suply of nutrition

 Depletion of fetal product of metabolisn

 Defense function
Hormone synthesis
Human chorionic gonadotropin(HCG)
Human placental lactogen(HPL)
Pregnancy specific β -glycoprotein(PS β 1G)
Human chorionic thyrotropin(HCT)
Estrogen, P, Oxytocinase, heat stable alkaline
phosphatase(HSAP)
 The umbilical cord
 The embryo has a thick embryonic stalk
containing 2 umbilical arteries,one large
umbilicak vein,the allantois,and primary
mesoderm.
 At birth long 50-60cm diameter 12cm
 The amniotic fluid
 Inthe first of pregnancy,amniotic fluid
volume appears to increase in association
with growth of the fetus
 Serum osmolality sodium urea creatinine
 Average volume 800ml
 Gravity 比重 1.008
 pH7.2
Amniotic fluid
Source: early from serum dialysis

late fron fetal urine

Absorse: by fetal membrane, fetal
swallowing(500ml/day)
Amniotic exchange: between maternal
and fetal 400ml/h
Volume of amniotic fluid
 8 weeks:5-10ml

 10 weeks:30ml

 20 weeks:400ml

 38 weeks:1000ml
Status of amniotic fluid
 pH:7.20

 Density:1.007-1.025

 Contained: water(98-99%)

inorganic substance
organic substance(1-2%)
 The amniotic fluid
 Cushions the fetus against severe injury
 Provides a medium in which the fetus can
move easily
 May be a source of fetul nutrients
 In esrly pregnancy,is essential for fetal lung
development
 Amniotic fliud
 Absord
2. Fetal membrane
3. Umbilical cord
4. Fetal skin
5. Fetal drinking
 Feature

1000-1500ml at 36th-38th week (peak), transparent →

slightly turbid
 Amniotic Fliud
 Function
2. Protect fetal
move freely, warm
4. Protect mater
prevent infection
 The amniotic fluid
 34-36 weeks determination of amniotic
fluid volume becomes even more
complicated because the larger fetus
swallows more fluid,upsetting the
relationship between fetal size and fluid
volume.
 38weeks both amniotic fluid and maternal
plasma volume decrease.
 Maternal physiology during
pregnancy
 Genital tract
 Breasts
 Cardiovascular system
 Hematologic system
 Pulmonary system
 Gastrointestinal tract
 Genital tract
 Uterus
 Ovaries
 Vagina and perineum
Uterus
Changes of reproductive system
Uterus
Body: become enlargement and soft
from 7×5 ×3cm pre-pregnancy to
35×25 ×22cm at term
Volume of uterus cavity:
become enlargement from 5ml pre-pregnancy to
5000ml.at term
Weight: be increased from from 50g pre-
pregnancy to 1000g at term
Wall: become thickness and the thickist at mid-
period from 1 cm pre-pregnancy to 2-2.5

cm at term
Blood suply:blood flow increased significantly
upto 500- 700ml/min,increased 4-6
times and most of blood flow is
transported to the placenta(80-85%)
Isthmus: be dialated and become soft from 1cm
pre-pregnancy a portion of the uterus

after 12 gestational weeks

Cervix: be soft and coloration or stain

secrete amount of mucus avoiding the
uterus cavity suffer from infection
Changes of ovary
 Stop ovulation

 Corpus luteum formation and maintains for

10 weeks
 And the function of corpus luteum is

substituted by the placenta

 Corpus luteum atretic gradually after 3-4

months gestation.
 Vagina and perineum
 During pregnancy,increased vascularity and
hyperemia develop in the skin and muscles
of the perineum and vulva,and there is
softening of the normally aboundant
connective tissue of these structure.
 Breasts

 In the early weeks,the pregnant woman often

experiences tenderness and tingling.
 After the second month,the breasts increase in size
and delicate veins become considerably
larger,more deeply pigmented,and more erectile.
 After the first few months,a thick,yellowish
fluid,colostrum,can often by expressed from the
nipples by gentle massage
 Cardiovascular system
 Heart
 Cardiac output
 Blood pressure
Heart
Changes of the circulation
Heart border: become enlargement
Heart rate: increased 10-15 beat per min at the
late pregnancy
Heart volume: increased 10% at the late
pregnancy
Cardiac output
Very important for fetal growth and development

Incrased begain 10 weeks and upto the peak

at 32 weeks
80ml/bp and keeps the level to the term
pregancy
Blood pressure changes due to pregnancy
 No obvious change in Systolic pressure
 Mild decreased in diastolic pressure

Vein pressure
 No significantly changes in Upper limb vein

pressure
 Lower limb vein pressure increased because of

the disturbance of vein reflux

 Hematologic system
 Blood volume
 Blood components
 Red blood cells
 White blood cells
 Clotting factors
Changes of blood system
Volume: increased (30-45% ) begain 6- 8 weeks
and up to the peak at 32-34 weeks
increased about 1500ml including
plasma 1000ml and red cell 500ml
Changes of blood component
Red cell: reticulocyte increased
red cell decreased 3.6×1012(4.2×1012)
Hb decreased 110g/L(130g/L)
WBC: neutrophilic granulocyte increased
lymphocyte mild increased
no change in orther blood cells
Coagulation
Hypercoagulability
Factor ⅱⅴⅶ ⅷ Ⅸ ⅹ increased
ESR increased significantly upto 100mm/h

Plasma protein
albumin decreased
 Pulmonary system
 Pregnacy produces anatomic and
physiologic changes that affect respiratory
performance
 Total lung capacity is reduced(4-5%)by the
elevation of the diaphragm
 Gastrointestinal tract
 During pregnancy,nutritional requirements
are increased,and several ,aternal alterations
occur to meet this demand
 Diagnosis of pregnancy
 The diagnosis of pregnancy is usually made
on the basis of a history amenorrhea,an
enlarging uterus,and a positive pregnancy
test
 Diagnosis of the first-trimester
pregnancy
 History and symptoms
 Signs
 Assistant examination
 History and symptoms

 Amenorrhea
 Morning sickness
 Bladder frequency
 Signs

 Changes in the genital organs

 Changes in breasts
 Mastodynia
 Enlargement
 Linea nigra
 Assistant examination
 Pregnancy test
 Ultrasound examination
 Increased basal body temperature
 Diagnosis of the second and
third-trimester pregnancy
 Symptoms and signs
 Assostant examination
 Symptoms and signs
 Uterine enlargement
 Quickening
 Fetal heart tones
 Palpation of fetus
 Assostant examination
 20-30weeks measurement of fetal biparietal
diameter is used
 After 30 weeks the accuracy of
measurement by ultrasound is much less
 Pregnancy monitoring
 Perinatal period I 28weeks of completed
gestation to the frist 7days of life
 Perinatal period II 20weeks of gestation
through 27days of life
 Prenatal care
 Initialoffice visit
 Subsequent visits
 Untrition in pregnancy
 Initial office visit
 History
 Physicalexamination
 Laboratory tests
 History
 Present pregnancy
 Previous pregnancy
 Medical history
 Surgical history
 Family history
 Physical examination
 General examination
 Pelvic examination
 Pelvic examination
 Pelvicsoft tissue
 Bony pelvic
 Cervical pelvic
 Bony pelvic
 Pelvic inlet
 Midpelvis
 Pelvic outlet
 Laboratory tests

 Blood screening
 Genetics testing
 Urine testing
 Subsequent visits
 The standard schedule for prenatal office
visits is 0-32week:once every 4weeks;
 32-36weeks:once 2weeks;
 36weeks to delivery:once each week
 Weight, gain blood pressure, fundal height,
findings on abdominal examination by
Leopold’s maneuvers
 Fetul heart tones
 Untrition in pregnancy

A balanced diet
 Iron,folic acid,calcuim,zinc
 Fetal assessment
 Assessment of prenatal diagnosis
 Assessment of fetal well-being
 Fetal maturity tests
 Fetal distress
 Assessment of prenatal
diagnosis
 Ultrasound
 Amniocentsis
 Chorionic villus sampling
 Fetal blood sampling
 Assessment of fetal well-being

 Fetul monitoring techniques

 Fetul heart rate interpretation
 Fetal maturity tests

 Lecithin:sphingomyelin ratio
 Phosphatidylglycerol
 Foam stability index
 Fetal distress
 Undulating baseline-alternating tachycardia and
bradycardia with wide swings,often with reduced varibility
in between
 Severe bradycardia-fetual heart rate below 100bpm for a
prolonged period of time of at least 10minutes
 Tachycardia with diminished variability unrelated to drugs
 Tachycardia associated with additional nonreassuring
periodic patterns such as late decelerations or variable
decelerations with late recovery-with careful
interpretation,FHRpatterns can be a useful screening test
for acidemia and hypoxemia
 Disorders of amnionic fluid
volume
 Normally,amnionic fluid volume increases
to about 1L,or somewhat more by 36
weeks,but decreases thereafter
 Postterm,there may be only 100 to 200ml or
less