ANATOMY AND PHYSIOLOGY

Physiological Changes of Pregnancy

During pregnancy, there is an increase happened in the blood supply to the

vagina, that is why there’s changes of color from pink to purple, and it becomes more

elastic during second trimester until the end of trimester. In addition, Once the mother

given a birth, typically the color and the size will return as blood flow goes back to normal.

According to Hickman (2021), the hormonal and physical changes that happen during

pregnancy and childbirth it can cause the vagina and labia to change. Moreover, it is

recommended to have a Kegel’s exercise before and after birth it can help your labor and

delivery go smoother and prevent pelvic floor problems.

Vagina changes during the pregnancy:

a. Swelling- The labia majora and minora may increase slightly in size and look

puffy or swollen for the duration of the pregnancy.

b. Discoloration- The color of the skin on both inner and outer labia may
temporarily

darken to a bluish or purplish color due to increased blood flow.

c. Labia shape- Sometimes the outer lips may slightly retract, which can make the

inner lips look bigger or expose them for the first time.

d. Varicose veins. -Varicose veins are common during pregnancy, including the

vulva (or external genitalia).

e. Infections- Hormonal changes can increase the risk of yeast infections during

pregnancy and the corresponding itchiness and discomfort.

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 f. Increased discharge- Extra discharge during pregnancy helps to maintain a

healthy balance of bacteria in the vagina. Discharge should be thin, milky and

mild- smelling. If it’s lumpy, thick or accompanied by other symptoms (like

itchiness or a fishy odor), let your doctor know.

g. Spotting- Light spotting during pregnancy is relatively common and usually

benign.

Vaginal changes due to childbirth:

a. Stretches and Tears-You may experience tears to the vagina during labor and

delivery, and the labia minora (but not majora) can sometimes slightly stretch or

tear. Tears to your vagina and labia will usually heal within seven to 10 days.

b. Soreness- The amount of postpartum perineal pain you’ll experience depends on

how you delivered and whether you had any tears. Vaginal and labial soreness

should resolve within a few weeks.

Anatomical Changes of Uterus & Fetal Changes

Women that are pregnant undergo serious anatomical and physiological changes.

It helps their body to cope with the increased physical and metabolic demands of their

pregnancies. The body systems such as, cardiovascular, respiratory, hematological, renal,

gastrointestinal and endocrine, all undergo important physiological alterations and

adaptations. It is a need so that to allow development of the fetus and to allow the mother

and fetus to survive the demands of childbirth (Tan & Tan, 2018).

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Uterus

Uterus, is also known as womb, an inverted pear-shaped muscular organ of the

female reproductive system, that located between the bladder and the rectum. Typically,

uterus has a multiple role which is to nourish the fetus and house a fertilized egg until

the fetus, is ready to be delivered and after the pregnancy, the uterus shrinks down to

almost its normal size. Furthermore, the shaped that formed like an inverted pear, the

uterus sits behind the bladder and in front of the rectum. It has four main section

discussed below in accordance to the study that conducted (Whitlock, 2020).

a. Fundus- The broad curved area at the top and widest portion of the organ that

connects to the fallopian tubes.(Whitlock,2020) • .

b. Corpus-The main part of uterus that starts directly below the level of fallopian

tubes and continues downward, becoming increasingly narrower.

c. Isthmus-The lower narrow part of the uterus.

d. Cervix-The lowest two inches of the uterus. Tubular in shape, the cervix opens

into the vagina and dilates (widens) to allow

Three distinct layers of tissue these are the following:

a. Perimetrium- It is the outer layer of the tissue that was made of epithelial cells.

b. Myometrium –It is the middle layer of smooth muscle tissue.

c. Endometrium –It is the the inner lining that builds up. over the course of month

and shed if pregnancy does not occur.

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 Figure 1. Anatomy of Uterus

According to Patil et. al (2020), after conception the uterus immediately provides

a nutritive and protective environment after conception that helps the fetus to grow and

develops. In non-pregnant state it increases from the size of a small pear to accommodate

a full-term baby at 40 weeks gestation. The tissues from which the uterus is produced

continue to develop for the first 20 weeks, and it increases in weight from about 50 to

1,000 gm (grams) does not get any heavier after this time, but extends to accommodate

the growing baby, placenta, and amniotic fluid. The uterus will have grown to about five

times its normal size. The time pregnancy is complete, the uterus has approximately

height from

7.5 to 30 cm (top to bottom), width from 5 to 23 cm (side to side) and 2.5 to 20 cm in

depth (front to back).

Figure 2. Uterus changes of size

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Fetus

Pregnancy has three trimesters, each of which is marked by specific fetal

developments. A pregnancy is considered full-term at 40 weeks; infants delivered before

the end of week 37 are considered premature.

First Trimester

A baby is conceived when the sperm cell penetrates the egg. This happens around

the end of week 2 of the pregnancy. Then, at this moment that the baby’s sex is

determined. This depends on whether the sperm cell was carrying an X chromosome (a

baby girl) or a Y chromosome (a baby boy).

Figure 3. Fertilization

The fertilized egg cell begins to divide soon after conception. The egg is made

up of hundreds of cells by week 3. It has now moved down the fallopian tube and

implanted itself into the lining of the uterus. The baby continues to grow and it becomes

an embryo. Embryo

An embryo undergoes gastrulation process to form the 3 tissue layers. The inner

layer (endoderm) will be the baby’s lungs, liver, and digestive system. The middle layer

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(mesoderm) will become the baby’s bones, kidneys, sex organs, and heart. The outer layer

(ectoderm) will make up the baby’s skin, hair, eyes, and nervous system. (Rye et.al,

2015).

Figure 4. Gastrulation is the process wherein the cells in the blastula

rearrange themselves to form the germ layers

The spinal cord, brain, heart, and lungs grow and develop rapidly during the first

trimester. In addition, the mouth, nose, eyes, ears, toes, and fingers begin to form. The

baby’s heart will begin to beat around week 6. It sometimes cannot be heard until around

week 10-12. The umbilical cord, which serves to nourish the baby and dispose of the

wastes throughout the pregnancy, is formed during the first trimester. The digestive

system and reproductive system develop during the first trimester. The muscles continue

to form in week nine, the baby may begin to move, but cannot feel these movements yet.

By the end of the first trimester, baby will be about three inches long and weigh ½ an

ounce.

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Figure 5. Nine (9) Week Old Fetus in Utero

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Second Trimester

In the second trimester, the baby’s hair, including eyebrows and eyelashes, begins

to grow. Muscles and bones continue to develop, allowing more movement. If the baby

is a girl, her eggs will develop in her ovaries early in the second trimester. By about

week 18, the baby can hear the heartbeat of the mother and may even be startled by loud

noises. The baby will grow quickly in the second trimester. The mother may begin to feel

the baby move during the fifth month. As a result of the development of taste buds and

sensory neurons, the baby will be able to taste and touch during the second trimester.

Figure 6. Sixteen (16) Week Old Fetus in Utero

By the end of week 23, the baby probably weighs about a pound. Babies born this

early may be able to survive with the help of expert medical care, but they usually have

mental and physical disabilities. The baby’s eyes are sealed shut until the end of the

second trimester when the baby starts to blink. By the end of the second trimester, the

baby will weigh almost 2 pounds and will be about 1-foot long. By now, all of the

essential organs have formed.

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 Figure 7. Twenty-four (24) Week Old Fetus in Utero

Third Trimester

In early third trimester, the baby may begin to recognize the sound of both

parent’s voice. The baby will frequently move during this period. The mother may feel

the patter movements like 10 actions per hour. Babies begin “practicing” breathing

during the third trimester by moving their diaphragm. The mother may find that the baby

gets the hiccups from time to time. During the final few weeks before birth, the baby will

gain a good deal of weight. By week 33, the baby is in position for delivery, ideally with

the head resting on mother’s cervix. The bones harden and the skin becomes thicker.

Figure 8. Twenty-Eight (28) Week Old Fetus in Utero

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 By 34 weeks, the baby would be able to survive outside of your womb without

extensive medical intervention, although oxygen therapy may be needed. Beginning at

week 35, the baby will grow rapidly, gaining 1/2 -3/4 pound per week. Babies are

considered to have grown to “full-term” by week 37. But, the baby will continue to grow

and gain weight, and will most often be delivered between weeks 38 and 42. The baby

will weigh an average of 7.5 pounds at birth and measure about 20-22 inches long. A

pregnancy that goes beyond 42 weeks is considered past the due date. At this time, the

doctor may induce labor.

Anatomical Changes & Physiology of Placenta

Placenta

The placenta is a unique fetal organ that performs a number of physiologic

functions. Paramount is the placenta's interrelationship between the mother and fetus in

the delivery of oxygen and nutrients and in the removal of waste. The health and growth

of the fetus are dependent on this complex interaction (Mcnanley, 2008).

Chorion

The chorion forms the placenta and consists of the syncytiotrophoblast,

cytotrophoblast, and extraembryonic mesoderm. The cytotrophoblast grows into the

syncytiotrophoblast as finger-like projections, which are called the primary chorionic

villi (Guttmacher, 2014).

Amniotic sac

Commonly called the bag of waters, sometimes the membranes, is the sac in

which the fetus develops in amniotes. It is a thin but tough transparent pair of

membranes that hold a developing embryo (and later fetus) until shortly before birth

(Guttmacher, 2014).
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Villus

The villus is composed of a single layer of trophoblast (monochorial) separating

maternal blood from fetal vessels (Woods,2008).

Maturation of the villous structure

Maturation of the villous structure occurs during gestation. The villous structure

in the first (A), second (B), and third (C) trimester, respectively. Notice decreases in

branching of vessels and stroma thickness. Vessels are located more peripherally, and

dilatation occurs at the venous aspect (Mcnanley,2008).

Figure 9. Maturation of villous structure

Syncytiotrophoblast

The syncytiotrophoblast, which later grows as part of the placenta, facilitates

implantation by directly invading the wall of the endometrium in the uterus (Woods,

2008). Terminal villi

Terminal villi are the functional unit at which maternal-fetal exchange of

nutrients and gases occur. Mother's blood provides oxygen, water with electrolytes,

hormones, and other nutrients. In exchange, the fetus excretes carbon dioxide, water,

urea, hormones, and other waste products. The maternal and fetal circulation do not mix.

Instead, blood flow moderates the passive or active transport of nutrients and gases

between vasculature (McConkey, 2016).

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Macrophage

Macrophage in the stroma of the chorionic villi and syncytiotrophoblast play a

critical role in the protection of the fetus. Additionally, many leukocytes reside in the

decidua of the endometrium to support a successful pregnancy (McConkey, 2016).

Human chorionic gonadotropin

Human chorionic gonadotropin (hCG) is synthesized and released from the

syncytiotrophoblast to stimulate luteal progesterone production to maintain the

pregnancy. Without hCG production, the absence of progesterone would trigger menses

and, therefore, the sloughing of the endometrium with the implanted zygote (McConkey,

2016).

Human chorionic somatomammotropin (HCS)

Human chorionic somatomammotropin (HCS), also known as human placental

lactogen (HPL) promotes breast development and alters the metabolism of the mother. It

decreases maternal insulin sensitivity so that more glucose is available for the fetus

(Cole, 2013).

Physiology of the Urinary Bladder During Pregnancy

During pregnancy, your growing baby can place a lot of pressure on your

bladder. This can lead to urine leakage (incontinence). Bladder control problems can

happen both during pregnancy and after childbirth. Causes of bladder control issues can

include pelvic organ prolapse, weakened pelvic floor muscles and damaged pelvic

nerves. Kegel exercises are often recommended to help strengthen your pelvic muscles

and regain bladder control (Cleveland clinic,2020).

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Apex

Located superiorly, pointing towards the pubic symphysis. It is connected to the

umbilicus by the median umbilical ligament (a remnant of the urachus) (Andersson,

2004). Body

Main part of the bladder, located between the apex and the fundus (Andersson,

2004).

Fundus (or base)

Located posteriorly. It is triangular-shaped, with the tip of the triangle pointing

backwards (Petkov,2014).

Neck

Formed by the convergence of the fundus and the two inferolateral surfaces. It is

continuous with the urethra (Petkov,2014).

Musculature

The musculature of the bladder plays a key role in the storage and emptying of

urine. In order to contract during micturition, the bladder wall contains specialized

smooth muscle known as detrusor muscle. Its fibers are orientated in multiple directions,

thus retaining structural integrity when stretched. It receives innervation from both the

sympathetic and parasympathetic nervous systems (Cleveland Clinic,2020).

Internal urethral sphincter

a. Male – consists of circular smooth fibers, which are under autonomic control. It

is thought to prevent seminal regurgitation during ejaculation.

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 b. Females – thought to be a functional sphincter (i.e., no sphincteric muscle
present).

It is formed by the anatomy of the bladder neck and proximal urethra.

External urethral sphincter

It has the same structure in both sexes. It is skeletal muscle, and under voluntary

control. However, in males the external sphincteric mechanism is more complex, as it

correlates with fibers of the rectourethral is muscle and the legator ani muscle (Cleveland

Clinic, 2020).

Vasculature

The vasculature of the bladder is primarily derived from the internal iliac vessels.

(Andersson, 2004).

Lymphatics

The superolateral aspect of the bladder drains into the external iliac lymph nodes.

The neck and fundus drain into the internal iliac, sacral and common iliac nodes

(Andersson, 2004).

Uterus

The uterus lies over the bladder and presses upon it during early pregnancy. Later

the uterus rises out of the pelvis. As the uterus grows larger and moves upward, the

bladder is pushed forward and pulled upward (Wijma et al., 2001).

Urethra

The urethra, the tube through which urine is discharged from the bladder, is

stretched and distorted. As these distortions take place, the wall of the bladder becomes

thickened, the blood vessels become enlarged, and fluid collects in the tissues forming

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the

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wall of the bladder. The results are swelling, stasis of blood in the blood vessels, and some

mechanical inflammation of the bladder wall (Wijma et al., 2001).

Kidney pelvis

The funnel like part of the kidney, called the kidney pelvis, also becomes dilated.

With this dilation of the kidney pelvis and the ureters there is also a loss of tonicity or

contractility in the pelvis of the kidney and the ureters (Wijma et al., 2001).

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 PATHOPHYSIOLOGY

Placenta Previa with Percreta of the Urinary Bladder

Risk Factors

 Placenta Previa
 Previous Childbirth
 Prior Cesarean
 Placenta Position
Section
 Maternal Age
 Previous Uterine
Surgeries
Placenta abnormally
penetrates entirely through
the myometrium and into
the uterine serosa

Attaches to another organ

that may invade urinary
bladder (anterior) rectum

Vaginal Bleeding

02 reaches to bloodstream

Premature Birth

Placenta previa is a problem of pregnancy in which the placenta grows in the

lowest part of the womb (uterus) and covers all or part of the opening to the cervix

(Bagga, Francis & Sze, 2019). Most cases are diagnosed early on in pregnancy via

sonography and others may present to the emergency room with painless vaginal

bleeding in the second or third trimester of pregnancy. If the edge of the placenta is less

than 2mm from the cervix, it is

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known as a low-lying placenta (Tommy's, 2020). While if the placenta completely covers

the cervix, it is called placenta previa. It is a major risk factor for postpartum hemorrhage

and can lead to morbidity and mortality of the mother and neonate (Ryu, Choi & Bae,

2019). Nearly all women with placenta previa need a C-section (Icahn School of

Medicine at Mount Sinai, 2021). If the placenta covers all or part of the cervix, vaginal

delivery can cause severe bleeding.

Figure 10. Types of Placenta Previa

Bagga, Francis, and Sze (2019) also added that the presence of placenta previa can also

increase a woman's risk for placenta accreta spectrum (PAS). This spectrum of

conditions includes placenta accreta, increta, and percreta. Joy, Lyon, and Levine (2001)

stated that when an absence of the decidua basalis exists and incomplete development of

the fibrinoid layer occurs, the placenta can be attached directly to the myometrium

(accreta), invade the myometrium (increta), or penetrate the myometrium (percreta).

Also, the placenta accreta is placenta attaches itself too deeply and too firmly into the

uterus (March of Dimes, 2021). The placenta increta is the placenta that attaches itself

even more deeply into the muscle

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wall of the uterus. Lastly, placenta percreta refers to the placenta that grows through the

uterus, sometimes extending to nearby organs, such as the bladder.

Figure 11. Placenta Accreta Spectrum (PAS)

Although the etiology of adherent placenta remains uncertain, the most widely

accepted theory is that this pathology arises due to one or more of the following

conditions such as defective decidua, maternal vascular remodeling, or excessive

trophoblastic invasion (Tantbirojn, Crum and Parast, 2008). Additionally, excessive

trophoblastic growth may lead to uncontrolled invasion towards the myometrium

resulting in placenta accreta, while dehiscence of a scar allows chorionic villi greater

access to invade past the superficial myometrium resulting in placenta increta or placenta

percreta. Tantbirojn, Crum and Parast further discussed that placenta increta and percreta

are not due to a further invasion of extravillous trophoblast in the uterine wall, rather they

likely arise secondary

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to dehiscence of a scar, leading to the presence of chorionic villi deep within the uterine

wall, and thus give extravillous trophoblast greater access to the deep myometrium.

Figure 12. Urological Manifestations of Placenta Percreta

According to Jauniaux et al., as cited by Lu (2019), placenta percreta is the most

invasive, with the villi reaching or penetrating through the uterine serosa reaching the

surrounding pelvic tissues and organs. It is thought to occur due to a defect of the

endometrial-myometrial interface in the area of a uterine scar, which allows trophoblastic

infiltration beyond the superficial myometrium as well as villous development inside the

myometrium. It has been shown that there is an increased likelihood of placenta previa

with an increased number of previous cesarean section deliveries (Gilliam, Rosenberg

and Davis, 2002). Maternal age of 33 or greater, and multiple cesarean deliveries

increase the risk for adherent placenta disorders, therefore a detailed past medical history

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is essential to

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determine the overall risk and to anticipate complicated placental implantation disorders

(Ibrahim et al., 2014). Other risk factors for placenta percreta are submucous myoma,

previous curettage, Asherman’s syndrome, advanced maternal age, gandmultiparity,

smoking, chronic hypertension as well as a previous history with adherent placenta

disorders. Furthermore, an early diagnosis allows adequate preparation for delivery, thus

optimizing patient safety and outcomes.

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