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MATERNAL-FETAL

ADAPTATION & PHYSIOLOGICAL CHANGES


IN PREGNANCY

Dr. Abarham Martadiansyah, SpOG (K)


Maternal Fetal Medicine Division
Obstetric & Gynecology Departement
RSMH/ Med Fac UNSRI
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REPRODUCTIVE TRACT

SKIN

BREASTS

METABOLIC CHANGES

HEMATOLOGICAL CHANGES

CARDIOVASCULAR SYSTEM

RESPIRATORY TRACT

URINARY SYSTEM

GASTROINTESTINAL TRACT

ENDOCRINE SYSTEM
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REPRODUCTIVE TRACT

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The uterine musculature
during pregnancy is arranged
in three strata:
1. An outer hoodlike layer,
which arches over the
fundus and extends into
the various ligaments.
2. A middle layer, composed
of a dense network of
muscle fibers perforated in
all directions by blood
vessels.
3. An internal layer, with
sphincter-like fibers
around the fallopian tube
orifices and internal os of
the cervix.
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• Height and weight (hyperplasia)
the height increases from 7.5
cm to 35cm the weight
increases from 50g to 1000g at
term
• Uterine ligaments show
hypertrophy
• Dextro-rotation the uterus is
tilted and twisted to the right in
80% of cases
• Lower uterine segment (LUS)
the LUS is formed from the
isthmus formed from the 4 th
month to reach 10 cm at full
term

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• First few weeks ~ original pear shape  a more globular form
 spherical by 12 weeks.
• The organ increases more rapidly in length than in width and
assumes an ovoid shape

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Cervix • The endocervical mucosal
cells produce copious
• Contains a small amount of
amounts of a tenacious
smooth muscle, its major
mucus
component is connective
tissue
• Goodell sign
• Chadwick sign
• Hegar sign
• increased volume of
cervical secretions consists
of a somewhat thick, white
discharge

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Ovaries
• Ovulation ceases during
pregnancy, and the
maturation of new
follicles is suspended.
• Only a single corpus
luteum can be found in
pregnant women

Vagina & Perineum


Fallopian
• Chadwick sign : violet color and
with softening of connective
tubes
tissue
• The pH is acidic, varying from • Musculature hypertrophy
3.5 to 6 • The epithelium flattened
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SKIN
Blood Flow in Skin Hyperpigmentation
• Increased cutaneous blood • The midline of the abdominal skin
flow in pregnancy serves to • linea alba transfom into linea
dissipate excess heat nigra
generated by increased • Irregular brownish patches on
metabolism face and neck
• chloasma or melasma
gravidarum—the so-called
mask of pregnancy.
Abdominal Wall • Pigmentation of the areolae and
genital skin may also be
• Striae gravidarum or accentuated
stretch marks
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Peripheral
Vascular Changes

• Angiomas, called
vascular spiders, develop
in about two thirds of
white women and
approximately 10
percent of black women.
• Palmar erythema is
encountered during
pregnancy in about two
thirds of white women
and one third of black
women.
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Musculoskeletal System

• Progressive lordosis is a characteristic feature of


normal pregnancy.
• The sacroiliac, sacrococcygeal, and pubic joints have
increased mobility during pregnancy
• The bones and ligaments of the pelvis undergo
remarkable adaptation during pregnancy

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Central Nervous System

• Women often report problems with attention,


concentration, and memory throughout pregnancy
and the early postpartum period

Sleep
• Beginning as early as about 12 weeks and extending
through the first 2 months postpartum, women have
difficulty going to sleep, frequent awakenings, fewer
hours of night sleep, and reduced sleep efficiency

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METABOLIC CHANGES

• The third trimester, maternal basal metabolic


rate is increased by 10 - 20 % compared with
that of the nonpregnant state. total pregnancy
• Energy demands are estimated to be as high as
80,000 kcal or about 300 kcal/day

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Weight Gain

• A smaller fraction of the increased weight result in an


increase in cellular water and deposition of new fat
and protein—so-called maternal reserves

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Water Metabolism

• At term, the water content of the fetus, placenta, and


amnionic fluid approximates 3.5 L.

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Protein
Metabolism
• At term, the fetus and placenta together weigh about
4 kg and contain approximately 500 g of protein, or
about half of the total pregnancy increase
Carbohydrate
Metabolism
• Normal pregnancy is characterized by mild fasting
hypoglycemia, postprandial hyperglycemia, and
hyperinsulinemia
Fat Metabolism
• The concentrations of lipids, lipoproteins, and
apolipoproteinsin plasma increase appreciably during
pregnancy
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Leptin
• Primarily secreted by adipose
tissue
• Regulation of body fat and Electrolyte and Mineral
energy expenditure • 1000 mEq of sodium and
• Increase and peak during the 300 mEq of potassium
second trimester and plateau are retained
until term • GFR of sodium and
• 2-4x higher than nonpregnant potassium is increased,
the excretion of these
electrolytes is
Ghrelin unchanged
• Secreted by adipose tissue
• Role in fetal growth and cell
proliferation

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HEMATOLOGICAL CHANGES
Blood Volume
• Hypervolemia associated with normal pregnancy
averages 40 – 45 % above the nonpregnant blood
volume after 32 to 34 weeks

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Pregnancy-induced hypervolemia has important functions:

• To meet the metabolic demands of the enlarged uterus with


its greatly hypertrophied vascular system.
• To provide an abundance of nutrients and elements to
support the rapidly growing placenta and fetus.
• To protect the mother and in turn the fetus, against the
deleterious effects of impaired venous return in the supine
and erect positions.
• To safeguard the mother against the adverse effects of
blood loss associated with parturition.

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Iron Metabolism

Storage Iron
• The total iron content of
normal adult women
Puerperium
ranges from 2.0 to 2.5 g • Not all the maternal iron added in
Iron Requirements the form of hemoglobin is lost with
• 1000 mg of iron required for normal delivery
normal pregnancy, about • These normal losses are from the
300 mg are actively placental implantation site,
transferred to the fetus and episiotomy or lacerations, and
placenta, and another 200 lochia
mg are lost through various
normal routes of excretion

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Immunological
Function

• Not all aspects of immunological function are depressed


Leukocytes
• The leukocyte count varies considerably during pregnancy, it
ranges from 5000-12,000/L
• During labor and the early puerperium, it become elevated,
attaining levels of 25,000/L or even more, it averages 14,000
to 16,000/L
Inflammatory Markers
• Many tests performed to diagnose inflammation cannot be
used reliably during pregnancy

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Coagulation & Fibrinolysis

• During normal pregnancy, both coagulation


and fibrinolysis are augmented but remain
balanced to maintain hemostasis.

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Platelets
• Average platelet count was decreased slightly during pregnancy
• Decreased platelet concentrations are partially due to the effects of
hemodilution

Regulatory Proteins
• natural inhibitors of coagulation proteins C, S, and Z and
antithrombin.
• Inherited or acquired deficiencies of these and other natural
regulatory proteins collectively referred to as thrombophilias—
account for many thromboembolic episodes during pregnancy

Spleen
• By the end of normal pregnancy, the splenic area enlarges by up to
50 percent compared with the first trimester

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CARDIOVASCULAR SYSTEM
Heart

Change in cardiac outline that occurs in pregnancy. The


blue lines represent the relations between the heart and
thorax in the nonpregnant woman, and the black lines
represent the conditions existing in pregnancy. These
findings are based on radiographic findings in 33 women
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Cardiac Output
• Normal pregnancy  MAP and vascular
resistance decrease, while blood volume and
basal metabolic rate increase

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RESPIRATORY TRACT

Respiratory rate is essentially unchanged, but tidal volume and


resting minute ventilation increase significantly as pregnancy
advances

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Oxygen Delivery
• The amount of oxygen delivered into the lungs
by the increased tidal volume clearly exceeds
oxygen requirements imposed by pregnancy

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URINARY SYSTEM
Kidney
• Kidney size increases slightly.
• GFR and renal plasma flow increase early in pregnancy

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Ureters Bladder
• After the uterus rises • Increased uterine size
– The ureters laterally • The hyperemia and the
displacing and hyperplasia of the
compressing at the pelvic bladder’s muscle and
brim. connective tissues
– The intraureteral tonus elevates the bladder
increased trigone and causes
thickening

The drainage of blood and lymph from the bladder base impairs,
easily traumatized, and probably more susceptible to infection.

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GASTROINTESTINAL TRACT
• Pyrosis (heartburn)
is caused by reflux
of acidic secretions
into the lower
esophagus
• The gums may
become hyperemic
and softened
during pregnancy
and may bleed
when mildly
traumatized
• Hemorrhoids are
common during
pregnancy

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Liver
• There is no increase in liver size during pregnancy
• The concentration of serum albumin decreases during pregnancy

Gallbladder

• The contractility of the gallbladder is reduced, because


progesterone impairs gallbladder contraction by inhibiting
cholecystokinin

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ENDOCRINE SYSTEM
Pituitary Gland

• The pituitary gland enlarges by approximately 135 %


• The increase may be sufficient to compress the optic
chiasma and reduce visual fields, impaired vision due
to physiological pituitary enlargement during normal
pregnancy is rare

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Growth Hormone
• During first trimester  GH is secreted
predominantly from the maternal pituitary
gland, and concentrations in serum and
amnionic fluid are within nonpregnant values
of 0.5 to 7.5 ng/mL
Prolactin
• Maternal plasma levels of prolactin increase
markedly during normal pregnancy and conc
entrations are usually 10-fold greater at
term—about 150 ng/mL
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Thyroid Gland

• Physiological changes of pregnancy cause the thyroid gland to


increase production of thyroid hormones by 40 to 100 percent
to meet maternal and fetal needs

Parathyroid
Glands

The regulation of calcium concentration is closely interrelated to


magnesium, phosphate, parathyroid hormone, vitamin D, and
calcitonin physiology.

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Relative changes in maternal thyroid function during pregnancy. Maternal changes include a
marked and early increase in hepatic production of thyroxine-binding globulin (TBG) and placental
production of chorionic gonadotropin (hCG). Increased thyroxine-binding globulin increases serum
thyroxine (T4) concentrations, and chorionic onadotropin has thyrotropinlike activity and
stimulates maternal T4 secretion. The transient hCG-induced increase in serum T4 levels inhibits
maternal secretion of thyrotropin. Except for minimally increased free T4 levels when hCG peaks,
these levels are essentially unchanged. (T3 triiodothyronine.)
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FETAL GROWTH

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Prenatal Stages
• Zygote
– After sperm & ovum unites
– Lasts about two weeks
• Embryo
– Last about the time of implantation (week 4) until
week 8
– Muscle, bone, organs & other body parts of the
body form
– Almost all internal organs begin to form
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1 st Trimester
0 Weeks – 13/6 Weeks

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First Month

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Four weeks

• Genetic pattern established since conception


• Heart, eyes, nervous system formed
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Two Months

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Two Months
• Week 5: baby – growing
fast
– Size – orange seed
– Heart taking shape
• Week 6:
– Crown (head) to rump
(bottom) measurements
– Jaws, cheeks & chin –
beginning to develop
– 80 beats per minute

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Six weeks
• Arms and legs formed
• Skeleton complete, reflexes active
• Brain waves present

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Two Months
• Week 7:
– 10,000 times bigger than at
conception
– Size blueberry
– Brain – 250,000 cells per minute
generated
– Mouth, tongue forming
– Arm, legs buds – begging to sprout
segment
• Week 8:
– Baby (embryo) is about 1/2 inch
long (size of a grape) and has
distinct, slightly webbed fingers.
Face, eyes, ears, and limb have
developed. Veins are clearly
visible. The heart has divided into
right and left chambers.
– Looks more human
– Spontaneous movements – you
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cannot feel
Seven weeks

• Brain activity present


• Appearance complete

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Eight weeks
• Now officially a fetus
• All systems in place
• Just need to develop and increase size

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Eight weeks

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Beginning at the 3 rd month/Week 9
• Fetus
– Growth – process of growth and maturation
– Last about 7 months

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Three Months
• Week 9:
– At the beginning baby (fetus) is about
1 inch long by the end, 3 inches!!!
Weighing in at 1 ounce
– Bones forming, elbows can now bend
– Muscles & tissues start to develop
– Covered by very thin skin (see
through)
• Week 10:
– 1 ½ in” long
– Bones forming, elbows can now
bend
– Buds of baby teeth are forming
under gums
– Eye lids begin to close to protect
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Three Months
• Week 11/12 :
– Just over 2 in @, 2 ½ @ 12”
– 1/3 oz @ 11, ½ oz @ 12
– Body – straightening out
– Fingers & toes nails forming
– Gender is evident (though
cannot tell with ultrasound)
– More Human characteristics
– Most systems formed,
though immature

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Eleven weeks

• Arms and legs move, sucks thumb


• Inhales and exhales amniotic fluid
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Twelve weeks

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Twelve weeks

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Three Months
• Week 13:
– 3 in”
– Size – peach
– Head – about half the size of
baby

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2nd Trimester
14 Weeks – 27/6 Weeks

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4 months
Four Months
• Baby is covered with
a layer of thick,
downy hair called
lanugo. His
heartbeat can be
heard clearly. This is
when you may feel
your baby's first
kick. Size about 3
inches long.
• Facial feature
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becomes clearer
Four Months
• Baby becomes
sensitive to touch

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Sixteen weeks

• Grasps, swims, kicks, turns somersaults


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Five Months

• A protective coating
called vernix
caseosa begins to
form on baby's skin
• End of the month –
baby weighs one
pound and is nearly
8 inches long

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Five Months

• Hair, eyelashes &


eyebrows appear
• Teeth continue to
develop
• Organs are maturing
• Hands able to grip
• Baby more active

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Eighteen weeks
• Vocal cords work; fetus can cry

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Five Months
Previous Plus:
– More energy!
– Fetal movements @
end
– Achiness in lower
abdomen & along
sides (stretching of
ligaments supporting
the uterus)
– Backache
– Leg cramps
– Skin color changes
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– A protruding naval
Twenty weeks

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Six Months
• Eyebrows and eyelids
are visible. The baby's
lungs are filled with
amniotic fluid, and
he/she has started
breathing motions. If the
mother talks or sings,
the baby can hear.
• Grows to about two
pounds
• Fat deposits begin to
appear beneath wrinkly
skin
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Twenty-four weeks

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6 Months

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3rd Trimester
• 28-40 Weeks
• Getting enough Omega-3 is more important
than ever in the 3rd trimester when your baby’s
brain development is being fast tracked.
• Time to think about signing up for child birth
classes.

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Seven Months
• At the beginning of
the seventh month,
the baby weighs
about 2 ½ pounds
and is about 14-16
inches long.

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Seven Months
• His body is well-
formed. Fingernails
cover his fingertips
• Nervous, circulatory
& other systems
mature
• Periods of fetal
activities are followed
by periods of rest &
quiet.
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Eight Months
• Baby is gaining about
half a pound per week,
and layers of fat are
piling on. He/she has
probably turned head-
down in preparation for
birth.
• End of the month, baby
weighs in at 5 ½
pounds

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Nine Months
• Baby is a hefty 6-9
pounds at the end of
the month and
measures between
19 and 20 inches.
• Fetal movement
decreases with less
room to move
• Increase fat under
the skin makes baby
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Nine Months
• Baby gains disease-
fighting antibodies
from the mommy’s
blood
• Baby descends
lower into the pelvis,
ready for birth
(breath easier)

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After Birth

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