Fisiologi kehamilan

Shofwal Widad
Bagian Obstetri & Ginekologi FK UGM/RS Dr Sardjito Yogyakarta

Transport Spermatozoa

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Perkembangan embryo

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Implantasi
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Pertumbuhan & perkembangan embryo & struktur penunjangnya

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Plasenta

Widad Obgyn UGM

Fungsi plasenta
Plasenta:
Pertukaran gas Transport nutrisi Ekskresi zat-zat sampah Produksi hormon Proteksi

Widad Obgyn UGM

Anatomi/Fisiologi
Tali pusat
Penghubung plasenta-janin 2 arteri 1 vena

Selaput amnion
Membran yang melingkupi janin Cairan amnion berasal dari beberapa sumber 500 - 1000 cc (setelah 20 minggu) Pecah KPD
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Diagnosis kehamilan
Anamnesis Pemeriksaan fisik Pemeriksaan laboratorium Pemeriksaan penunjang

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Anamnesis -- Possible sign

Amenorrhea Mual - muntah Mastodinia Quickening Frekuensi kencing Konstipasi

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Pemeriksaan fisik -- Possible signs

Suhu badan basal Penambahan berat badan Pigmentasi Perubahan payudara Pembesaran abdomen Perubahan genital Kontraksi uterus Ballotement
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Linea nigra

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Striae rubra

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Perubahan payudara

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Hegar sign

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Ballotement

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Positive sign
Palpasi Pemeriksaan laboratorium test hCG Denyut jantung janin Stetoskop Laenec : 18 weeks Doppler : 12 weeks Ultrasound : 6- 7 weeks Rontgenography : 12-14 weeks TERATOGENIK

Widad Obgyn UGM

Menentukan usia kehamilan Rumus Naegele

HPM/HPHT harus teratur, 28 hari HPL = (Tanggal + 7), (Bulan -3) (Tahun +1) 11-8-03 18-5-04 05-1-03 12-10-03 Durasi: 280 hari (40 minggu) 37 - 41 : kehamilan aterm 28 - 37 : kehamilan preterm 42 atau lebih : kehamilan postterm Kurang dari 28 : Periode abortus
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Menentukan usia kehamilan Tinggi Fundus uteri

Widad Obgyn UGM

Menentukan usia kehamilan

Quickening : 16-18 minggu pada multigravida : 18-20 minggu pada primigravida Test kehamilan positif: 5 minggu Ultrasonografi:
Gestational sac (GS) Crown-lump length (CRL) Biparietal diameter (BPD) Denyut jantung janin

Widad Obgyn UGM

Positive Signs
Ultrasonografi: 5.5 minggu 6 minggu 6-7 minggu 8 minggu 10 minggu 12 minggu
: Gestational sac : Embryonic pole : FHR : Gerakan janin : Plasenta : BPD
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5,5 minggu

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7 minggu

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12 minggu, CRL 46.9 mm

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6 weeks, dizygotic twin

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Perubahan fisiologis
TD menurun pada trimester-1
sistolik 2-4 mmHg diastolik 5-15mmHg

Denyut jantung (hingga 10-15 x/menit) Volume darah 48-58% Cardiac output 40% Faktor pembekuan darah Konsumsi O2 hingga 15% Motilitas usus Produksi asam lambung

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Perubahan anatomi
Diafragma naik 4 cm rusuk terangkat Ukuran uterus Kandung kencing bergeser naik Pergeseran usus Distraksi simfisis Dilatasi ureter Respons spinchter gastro-esophagus supine hypotensive syndrome Aliran darah ke uterus 10x Tekanan venosa perifer
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Sistem Sirkulasi Janin

Tekanan vaskuler kebalikan dari dewasa
Venosa > arterial

Konstriksi vaskuler pulmonal

PaO2 rendah, paru-paru kolaps

Resistensi rendah di plasenta Fetal shunts

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Sistem Sirkulasi Janin

Fetal shunts
Ductus arteriosus Foramen ovale Ductus venosus

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SIRKULASI DEWASA
Vena cavae Right ATRIUM Lef t ATRIUM

Pulmonary veins

LUNGS

Right VENTRICLE

SYSTEMIC CAPILLARIES

Left VENTRICLE

Pulmonary

arteries

Right ventricle pumps to the lungs

Septa/partitions separate heart into Aorta left and right chambers

Left ventricle serves rest of body

de-oxygenated blood
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semilunar valves AV valves

SIRKULASI MATERNAL

Vena cava

JANTUNG
ATRIUM kanan

Vena Pulmonalis

ATRIUM kiri

PARU

KAPILER SISTEMIK
ARTERI UTERINA

VENTRIKEL VENTRIKEL kanan kiri

Pulmonary arteries

Aorta
PLASENTA
ARTERI UTERINA VENA UTERINA

PLACENTA
UTERUS Pembuluh darah janin
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PLASENTA

Pembuluh darah TALI PUSAT

HUGE EXCHANGE SURFACE

from branching processes - chorionic villi - containing fetal capillaries

Maternal blood
Disuplai oleh arteri uterina Keluar melalui vena uterina

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Jantung memompa darah ke seluruh tubuh

SIRKULASI JANIN

Jantung menerima darah bekas dari seluruh tubuh

Paru-paru

Heart

aorta

Restriksi aliran darah menuju dari dari paru-paru

Janin mendapatkan darah yg kaya oksigen dari plasenta

VENA CAVA

masuk ke janin melalui sistem vena & melalui jalan pintas di jantung
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FETAL CIRCULATION I
Pembuluh darah berasal dari plasenta masuk janin melalui vena umbilicalis, tetapi membawa darah kaya O2 Fetal capillaries in placental villi

TALI PUSAT dengan

2 ARTERI UMBILICALIS 1 VENA UMBILICALIS

UTERINE WALL
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PLACENTA
UMBILICAL VEIN

FETAL CIRCULATION
Menggunakan ductus venosus utk masuk ke vena cava inferior jantung

HEART
Vena cava IVC
Right VENTRICLE Left VENTRICLE

Right ATRIUM

OLef t
ATRIUM

Pulmonary veins

LUNGS

DUCTUS VENOSUS to get past the liver SYSTEMIC

CAPILLARIES

Pulmonary arteries

Aorta
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PLACENTA

FETAL CIRCULATION

UMBILICAL VEIN
HEART Vena cava IVC
Right VENTRICLE Left VENTRICLE

Right ATRIUM

OLef t
ATRIUM

Pulmonary veins

LUNGS

DUCTUS VENOSUS

SYSTEMIC CAPILLARIES

Pulmonary arteries

Umbilical arteries
Aorta
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FETAL CIRCULATION IV

PLACENTA
UMBILICAL VEIN

Since oxygenated blood is coming in where normally systemic venous blood arrives, & the lungs have no access to air, the flow through the heart is special & the lungs are bypassed
Pulmonary veins

HEART Vena cava IVC

Right VENTRICLE Left VENTRICLE

Right ATRIUM

OLef t
ATRIUM

LUNGS

DUCTUS VENOSUS to get past the liver SYSTEMIC

Umbilical arteries

CAPILLARIES

Pulmonary arteries

Aorta
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FETAL CIRCULATION V

PLACENTA
UMBILICAL VEIN

Karena darah kaya O2 datang dari tempat yg normalnya merupakan muara vena sistemik, dan karena paru-paru tidak punya akses thd udara, maka aliran menuju paruparu dilewatkan (bypasseed)

O
HEART Vena cava
Right ATRIUM

OLef t
ATRIUM
Left VENTRICLE

Pulmonary veins

LUNGS

DUCTUS VENOSUS to get past the liver

IVC
Right VENTRICLE

SYSTEMIC CAPILLARIES

Pulmonary arteries

Aorta
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FETAL CIRCULATION VI
Oxygenated blood comes in where normally systemic venous blood arrives

Lungs are bypassed 1

Foramen ovale between atria

lets red blood pass into the left atrium for distribution, via left ventricle & aorta, around the fetus

HEART Vena cava

DUCTUS VENOSUS
Right ATRIUM

OLef t
ATRIUM
Left VENTRICLE

Pulmonary veins

LUNGS

IVC
Right VENTRICLE

SYSTEMIC CAPILLARIES
Umbilical arteries

Pulmonary arteries

Aorta
Lungs are bypassed 2

Another bypass is the Ductus arteriosus

allowing blood to pass from Widad Obgynpulmonary UGM trunk to the aorta

FETAL CIRCULATION VII: Conversion to post-natal

Critical steps are closure of Foramen ovale
Umbilical arteries DUCTUS VENOSUS &

Ductus arteriosus

Foramen ovale Pulmonary HEART

Vena cava
DUCTUS VENOSUS

Right ATRIUM

OLef t
ATRIUM
Left VENTRICLE

veins

LUNGS

IVC
Right VENTRICLE

SYSTEMIC CAPILLARIES
Umbilical arteries

Pulmonary arteries

Ductus arteriosus AortaWidad Obgyn UGM

FETAL CIRCULATION VIII: Conversion to post-natal

Closure of Foramen ovale Forces venous blood (now all deoxygenated) into the right ventricle for expulsion to the lungs Closure of DUCTUS VENOSUS Stops use of umbilical vessels, & converts all Vena cava vena cava blood to deoxygenated IVC SYSTEMIC CAPILLARIES Closure of
Umbilical arteries Stops use of umbilical vessels

HEART
Right ATRIUM

OLef t
ATRIUM
Left VENTRICLE

Pulmonary veins

LUNGS

Right VENTRICLE

Pulmonary arteries

Aorta

Closure of
Ductus arteriosus

means that blood expelled from the right Widad Obgyn UGM has to go to the lungs ventricle

FETAL CIRCULATION IX: Conversion to post-natal

Closure of Foramen ovale Pressure-rise in left atrium resists the blood trying to come through the Foramen ovale, and pushes its flap back onto the septum for later fusion Closure of
DUCTUS VENOSUS

First inspirations of the lungs cause lung vessels to greatly reduce their resistance. Blood flows more freely through, so raising the pressure in the left atrium

Vena cava IVC

Right ATRIUM

OLef t
ATRIUM
Left VENTRICLE

Pulmonary veins

LUNGS

Initial closure is by muscular contraction, lumen is obliterated by fibrosis only later

Right VENTRICLE

HEART
Pulmonary arteries

SYSTEMIC CAPILLARIES

Umbilical arteries

Aorta
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Closure of
Ductus arteriosus

FETAL CIRCULATION Vena cava

DUCTUS VENOSUS

Foramen ovale
Right ATRIUM

OLef t

HEART
ATRIUM

Pulmonary veins

LUNGS

FETAL CIRCULATION X: Conversion to post-natal The foramen ovale can just seal shut, but the ductus venosus & d. arteriosus (&umbilical arteries) have to shrivel to become just connective tissue ligaments

IVC

Right VENTRICLE Left VENTRICLE

SYSTEMIC CAPILLARIES
Umbilical arteries

Pulmonary arteries

Aorta

Ductus arteriosus

Vena cava
Ligamentum venosum

HEART
Right ATRIUM Lef t ATRIUM

Pulmonary veins

LUNGS

Note distinction between venous deoxygenated blood in Right chambers & oxygenated blood from lungs in Left chambers of postnatal baby
Medial umbilical ligaments

Right VENTRICLE

SYSTEMIC CAPILLARIES

Left VENTRICLE

Pulmonary arteries

Aorta
Widad Obgyn UGM Ligamentum arteriosum

POST-NATAL CIRCULATION

The Uterine Cycle

Series of cyclic phases of the endometrium Phases coordinate with the ovarian cycle Endometrial phases directed by FSH and LH Phases of uterine cycle
Menstrual phase days 1-5
Stratum functionalis is shed

Proliferative phase days 6-14 Secretory phase days 15-28

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hypothalamus

GnRH

Cycle Overview
GnRH secretion affects LH and FSH secretion by pituitary LH and FSH affect follicle maturation
Estrogen and progesterone from ovary affect uterus
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anterior pituitary

FSH

LH

FSH

LH

FSH

LH
ovulation

LH

estrogens estrogens progesterone estrogens

menstruation

FOLLICULAR PHASE

LUTEAL PHASE

The Menstrual Cycle

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