Maternal Physiology

Reproductive Tract
• Uterus • Cervix

Uterus
• nonpregnant woman - 70 g , cavity of 10 mL or less • pregnancy – 1100 g, ave 5 or ≥ 20ml • Arrangement of the Muscle Cells
– An outer hoodlike layer – A middle layer - main portion of the uterine wall – An internal layer

and Position • pear shape→ more globular form→almost spherical →ovoid shape • Position: – contacts the anterior abdominal wall – intestines : laterally and superiorly – rotation to the right (dextrorotation)caused by the rectosigmoid . Shape.Uterine Size.

Contractility • Beginning in early pregnancy ---irregular painless contractions • 2nd Trimester – braxton-hicks contraction ---unpredictably . • Late in pregnancy – false labor .nonrhythmic.sporadically .

nitric oxide – Insensitivity to angiotendin II . progesterone.Uteroplacental Blood Flow • Placental perfusion is dependent on total uterine blood flow (uterine and ovarian arteries) • Estimate blood flow 450 to 650 mL/min near term • Regulation : ↑ blood flow = vasodilation – consequence of estrogen stimulation.

as a result of progesterone – arborization of the crystals. or ferning.Cervix • major component is connective tissue • Goodell’s sign – softening of cervix • cervical mucus changes – crystallization. is observed as a result of amnionic fluid leakage the Arias-Stella reaction .associated with both endocervical gland hyperplasia and hypersecretory appearance . or beading.

• (+) pronounced softening & cyanosis of the cervix • Cervical glands undergo marked proliferation • Mucus plug ------resulting bloody show .

Ovaries • a single corpus luteum can be found in pregnant women • Maximal fxns – first 6 to7 weeks of pregnancy .

Skin • Blood flow:Increased • Abdominal wall – striae gravidarum or stretch marks – diastasis recti • Hyperpigmentation – linea alba – linea nigra – chloasma or melasma gravidarum (mask of pregnancy) • Vascular Changes – vascular spiders – Palmar erythema .

Breasts • Early weeks of pregnacy – tenderness & tingling of the breast • 2nd month increase in size & delicate veins become visible just beneath the skin • Colostrum – first few months can be expressed .

Metabolic Changes • Weight Gain – Attributed to the uterus & its contents. the breast & increases in the blood volume & extrvascular extracellular fluid – Maternal reserves – metabolic alterations that result in an increase in cellular water & deposition of new fat & protein – Aver wt gain : 12.5 kg .

Table 5-1. Analysis of Weight Gain Based on Physiological Events during Pregnancy Cumulative Increase in Weight (g) Tissues and Fluids 10 20 30 40 Weeks Weeks Weeks Weeks Fetus 5 300 1500 3400 Placenta 20 170 430 650 Amnionic fluid 30 350 750 800 Uterus 140 320 600 970 Breasts 45 180 360 405 Blood 100 600 1300 1450 Extravascular fluid 0 30 80 1480 Maternal stores (fat) 310 2050 3480 3345 .

placenta. the fetus.5L – At term.5 L – 3 L accumulates as a result of increases in the maternal blood volume & in the size of uterus & breast .Water Metabolism • Increased water retention is a normal physiological alteration of pregnancy – Mediated by fall in plasma osmolality of approx 10 mOsm/kg • TBW increases average of 6. and amnionic fluid approximates 3.

the fetus and placenta together weigh about 4 kg and contain approx 500 g of protein • remaining 500 g : uterus.Protein Metabolism • At term. breast & maternal blood .

postprandial hyperglycemia.Carbohydrate Metabolism • Normal pregnancy is characterized by mild fasting hypoglycemia. and hyperinsulinemia .

against the deleterious effects of impaired venous return in the supine and erect positions. . • To provide an abundance of nutrients and elements to support the rapidly growing placenta and fetus. • To safeguard the mother against the adverse effects of blood loss associated with parturition.Hematological Changes Blood Volume Pregnancy-induced hypervolemia has important functions: • To meet the metabolic demands of the enlarged uterus with its greatly hypertrophied vascular system. • To protect the mother and in turn the fetus.

.• Maternal blood volume begins to increase during the first trimester • blood volume expands most rapidly during the second trimester • rises at a much slower rate during the third trimester to plateau during the last several weeks of pregnancy.

5 g • approxi1000 mg of iron required for normal pregnancy The Puerperium • 500 to 600 mL .• Hgb conc.--2.bllod loss (CS or twin del) .5 g/dL Iron Metabolism • Total iron .blood loss during normal delivery • 1000 mL .0 to 2.2.

14.000/L – 25.000 to 16.000/L.Immunological Functions • Leukocytes • pregnancy.000/L or even more . • During labor and the early puerperium – Aver. usually it ranges from 5000 to 12.

Immunological Functions Inflammatory Markers • leukocyte alkaline phosphatase • erythrocyte sedimentation rate (ESR) • C-reactive protein • factors C3 and C4 Spleen • area enlarges by up to 50 percent compared with the first trimester .

Immunological Functions Coagulation and Fibrinolysis • increased concentrations of all clotting factors. and increased levels of high-molecular-weight fibrinogen complexes Platelet • average platelet count was decreased slightly during pregnancy to 213.000/L in nonpregnant control women .000/L compared with 250. except factors XI and XIII.

6 Pregnant (35–40 weeks) 31.1a 136.9 22.1a 473 ± 72a 181.5 ± 20.2 Protein C (%) 77.9 ± 2.4 97.7 ± 15.4 ± 4.4 ± 48.5 ± 14.5a 5.9 ± 2.5 ± 33.0 ± 1.9 18.0 97.0a 144.5 Antithrombin III (%) 98. Changes in Measures of Hemostasis during Normal Pregnancy Parameter Activated PTT (sec) Thrombin time (sec) Fibrinogen (mg/dL) Factor VII (%) Factor X (%) Plasminogen (%) tPA (ng/mL) Nonpregnant 31.6 ± 4.0 256 ± 58 99.3 ± 19.2 ± 12.1 5.Table 5-2.5a .4 105.7 ± 3.9 ± 20.3 62.9 ± 13.2 ± 19.

Cardiovascular System • Cardiac output is increased as early as the fifth week and reflects a reduced systemic vascular resistance and an increased heart rate .

• causing a larger cardiac silhouette on chest radiograph • Resting PR increases about 10 beats/min • normal cardiac sounds are altered during pregnancy. easily heard third sound .Heart • displaced to the left and upward and rotated somewhat on its long axis. (3) a loud. ( (2) no definite changes in the aortic and pulmonary elements of the second sound. (1) an exaggerated splitting of the first heart sound with increased loudness of both components.

5 (mm Hg) COP-PCWP gradient (mm Hg) 10.9 NSC +17% +43% Systemic vascular resistance (dyne/sec/cm–5) 1210 ± 266 1530 ± 520 119 ± 47 20.2 ± 1.7 .3 ± 0.5 –21% –34% –14% –28% Pulmonary vascular resistance 78 ± 22 (dyne/sec/cm–5) Serum colloid osmotic pressure 18. Central Hemodynamic Changes in 10 Normal Nulliparous Women Near Term and Postpartum Pregnanta (35–38 wks) Mean arterial pressure (mm Hg) Pulmonary capillary wedge pressure (mm Hg) 90 ± 6 8±2 Postpartum (11–13 wks) Changeb 86 ± 8 6±2 NSC NSC Central venous pressure (mm Hg) Heart rate (beats/min) Cardiac output (L/min) 4±3 83 ± 10 6.0 ± 1.5 ± 2.5 ± 2.Table 5-3.0 4±3 71 ± 10 4.0 14.8 ± 1.

Circulation & Blood Pressure • Changes in posture affect arterial blood pressure – Arterial pressure usually decreases to a nadir at 24 to 26 weeks and rises thereafter. – Diastolic pressure decreases more than systolic • supine hypotensive syndrome – supine compression of the great vessels by the uterus causes significant arterial hypotension .

Respiratory Tract .

. but airway conductance is increased • total pulmonary resistance reduced.• functional residual capacity and the residual volume are decreased • Peak expiratory flow rates decline progressively as gestation • compliance is unaffected by pregnancy. maximum breathing capacity • forced or timed vital capacity are not altered appreciably.

Urinary System Kidney • Kidney size increases slightly • glomerular filtration rate (GFR) and renal plasma flow increase early in pregnancy .

elective pyelography should be deferred to at least 12 weeks postpartum Glomerular filtration rate and renal Serum creatinine decreases during normal plasma flow increase ~50% gestation. progesterone stimulates PCO2 decreased 10 mm Hg. Serum bicarbonate decreased by 4–5 mEq/L. hormonal disposal rates increase Serum osmolality decreases 10 mOsm/L (serum Na ~5 mEq/L) during normal gestation. sonogram or IVP (more marked on retained urine leads to collection errors. renal right) infections are more virulent.8 mg/dL (>72 mol/L) creatinine already borderline. increased placental metabolism of AVP may cause transient diabetes insipidus during pregnancy . >0. and glucose excretion all increase Renal function Maintenance of acid-base Decreased bicarbonate threshold.Table 5-4. amino acid. may be responsible for "distension syndrome". a PCO2 of 40 mm respiratory center Hg already represents CO2 retention Plasma osmolality Osmoregulation altered: osmotic thresholds for AVP release and thirst decrease. Renal Changes in Normal Pregnancy Alteration Kidney size Dilatation Approximately 1 cm longer on radiograph Clinical Relevance Size returns to normal postpartum Resembles hydronephrosis on Can be confused with obstructive uropathy. protein.

Gastrointestinal Tract • stomach and intestines are displaced by the enlarging uterus • Gastric emptying time – delayed because of hormonal or mechanical factors • Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux of acidic secretions into the lower esophagus • Hemorrhoids .

GGT & bilirubin slightly low . ALT.Liver • no increase in liver size during human pregnancy • Some laboratory test results of hepatic function are altered during normal pregnancy – alkaline phosphatase activity almost doubles – AST.

leading to an increased residual volume • Increased prevalence of cholesterol stones . the contractility of the gallbladder is reduced.Gallbladder • During normal pregnancy.

5 ng/mL – 10 weeks ---3.5 ng/mL – Plateu after 28 weeks at approx 14 ng/mL • Prolactin – – – – ensure lactation present in amnionic fluid in high concentrations 20 to 26 weeks to 10. levels decrease and reach a nadir after 34 weeks .000 ng/mL.5 to 7.Endocrine System Pituitary Gland – enlarges by approximately 135 percent • Growth Hormone – first trimester ---within nonpregnant values of 0.

Thyroid Gland • undergoes moderate enlargement during pregnancy caused by glandular hyperplasia and increased vascularity .

Parathyroid Glands • regulation of calcium concentration is closely interrelated to magnesium. vitamin D. and calcitonin physiology • PTH plasma concentration – 1st trimester decrease – Increase progressively throughout the pregnancy • Physiological hyperthyroidism . phosphate. parathyroid hormone.

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