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MATERNAL PHYSIOLOGY

Maternal Changes During Pregnancy, Labor,


and Birth
Learning Objectives

 Explain how estrogen, progesterone, and hCG are


involved in maintaining pregnancy
 List the contributors to weight gain during pregnancy
 Describe the major changes to the maternal digestive,
circulatory, and integumentary systems during
pregnancy
 Summarize the events leading to labor
 Identify and describe each of the three stages of
childbirth
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV. Changes in Organ Systems During Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Urinary system
e) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV. Changes in Organ Systems During Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Urinary system
e) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
I. Introduction
• Pregnancy lasts 280 days (40 weeks)
• Divided in three trimesters – 14/28/40

• Important changes in all systems TO:


– Regulate metabolism
– Sustain fetal growth
– Prepare the body for
labor/birth/postpartum

• ALL changes related to placental


hormones
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV. Changes in Organ Systems During Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
II. Effects of Hormones

Roles of Hormones

1. Maintain pregnancy

2. Prepare for delivery

3. Prepare mother for afterbirth & breastfeeding


II. Effects of Hormones

• Estrogen/Progesterone/hCG

• 7-12w → corpus luteum


• 14w+ → placenta

• Placenta converts androgens to estrogen


*Estrogen levels increase 30 fold by childbirth
II. Effects of Hormones
II. Effects of Hormones

Estrogen Actions:
• Suppresses FSH/LH

• Induces growth of fetal tissues

• Regulates Progesterone, cortisol


• Stimulates uterine and mammary tissue growth &
Prepare for delivery
II. Effects of Hormones

Relaxin Actions:
• Increases elasticity of the symphysis pubis and ligaments

• Helps dilate the cervix during labor


II. Effects of Hormones

Progesterone Actions:
• Suppresses FSH/LH

• Inhibits prolactin secretion from anterior pituitary

• Inhibits uterine contractions (decreases late in


pregnancy, allowing progression to labor) = SMOOTH
MUSCLE RELAXANT
– Given as treatment for threatened abortion & prevention of
preterm birth!
II. Effects of Hormones

hCG Actions:
• Secreted by throphoblast – from day 8 of fertilization
(positive pregnancy test)
• Survival of corpus luteum

• Stimulates male gonads to secrete testosterone


• Similar fraction to TSH
II. Effects of Hormones

Human Placental Lactogen


• Counters the effects of maternal insulin to
support the fetal needs
II. Effects of Hormones
Other hormones:
Anterior pituitary gland -> hypertrophy

Thyrotropin - ↑thyroid hormone = ↑ metabolic rate,


augment appetite, hot flashes

Prolactin – augment mammary gland & milk


production

ACTH - ↑ cortisol secretion which leads to fetal protein


synthesis

MSH – melanocyte stimulating hormone


Anatomical Changes
Breast development

• Progesterone – ↑ Breast Lobules


• Estrogen – ↑ Breast Ducts

Breast Cancer!!
Breast development
Summary

I. Introduction
II. Effects of Hormones
III.Weight Gain
IV. Changes in Organ Systems During Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
III.Weight Gain

• 2nd and 3rd trimesters – dramatic changes in maternal


anatomy
• 1st trimester – no need for additional calories
• 2nd and 3rd trimester – additional 300 calories/day
– Normal weight gain aprox 0.45 kg/week
III.Weight Gain
Institute of Medicine (IOM) recommendations:

Singleton pregnancy
• BMI <18.5 kg/m2 (underweight) – Weight gain 28 to 40 lb (12.5 to 18.0 kg)
• BMI 18.5 to 24.9 kg/m2 (normal weight) – Weight gain 25 to 35 lb
(11.5 to 16.0 kg)
• BMI 25.0 to 29.9 kg/m2 (overweight) – Weight gain 15 to 25 lb (7.0 to 11.5 kg)
• BMI ≥30.0 kg/m2 (obese) – Weight gain 11 to 20 lb (5 to 9.0 kg)

Twin pregnancy
• BMI <18.5 kg/m2 (underweight) – No recommendation due to insufficient data
• BMI 18.5 to 24.9 kg/m2 (normal weight) – Weight gain 37 to 54 lb
(16.8 to 24.5 kg)
• BMI 25.0 to 29.9 kg/m2 (overweight) – Weight gain 31 to 50 lb (14.1 to 22.7 kg)
• BMI ≥30.0 kg/m2 (obese) – Weight gain 25 to 42 lb (11.4 to 19.1 kg)
III.Weight Gain
Contributors to Weight Gain During Pregnancy

Component Weight (kg) Weight (lb)

Fetus 3.2–3.6 7–8


Placenta and fetal
0.9–1.8 2–4
membranes
Amniotic fluid 0.9–1.4 2–3

Breast tissue 0.9–1.4 2–3

Blood 1.4 4

Fat 0.9–4.1 3–9

Uterus 0.9–2.3 2–5

Total 10–16.3 22–36


III.Weight Gain
Summary
I. Introduction
II. Effects of Hormones
III. Weight Gain
IV.Changes in Organ Systems During
Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Urinary system
e) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
IV. Changes in Organ Systems During Pregnancy
a. Digestive and Urinary System Changes

• Nausea and vomiting/ morning sickness


• Gastric reflux/heartburn

• Constipation

• Urinary frequency (↑ GFR, maternal and fetal


wastes, compression from enlarged uterus)
IV. Changes in Organ Systems During Pregnancy
a. Digestive and Urinary System Changes
IV. Changes in Organ Systems During Pregnancy
a. Digestive and Urinary System Changes

• Uterine compression = mild/fiziologic


uretero-hydronephrosis (more on right side)
• Stasis (Progesterone)
• HIGHER RISK of UTI
• Frequent asymptomatic bacteriuria (<105
CFU)
• Renal artery blood flow ↑ -> GFR ↑ (aprox
40%) - urinary output ↑ ->urinary frequency
– > glycosuria, proteinuria (<300mg/24h)
IV. Changes in Organ Systems During Pregnancy
a. Digestive and Urinary System Changes
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV.Changes in Organ Systems During
Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
Changes in Organ Systems During Pregnancy
b. Circulatory System Changes

• Anatomical changes:
– Heart displaced left and upward and rotated on
its long axis

• Physiological changes
– Systemic vascular resistance is decreased
– Mean arterial pressure is decreased
– Heart rate is increased
– Cardiac output is increased
Changes in Organ Systems During Pregnancy
b. Circulatory System Changes

• Blood volume increases by 30-50%


(approx. 2L) – physiological anemia,
physiological edema
• Increased erythropoiesis
• Leukocytosis
• Thrombocytopenia (>150.000!)
Changes in Organ Systems During Pregnancy
b. Circulatory System Changes
Changes in Organ Systems During Pregnancy
b. Circulatory System Changes

• ↑ Cardiac output = (↑ Heart rate x ↑ Stroke


volume)
• Lower peripheral resistance =

• Blood pressure – drops in the 1st trim and rises in


the 3rd
• ‘Vena cava syndrome’ – lipothymia

• Varicose veins / hemorrhoidal veins


Changes in Organ Systems During Pregnancy
b. Circulatory System Changes
Changes in Organ Systems During Pregnancy
b. Circulatory System Changes

Coagulation:

Hypercoagulability!
• ↑ factor I, II, III, VII, IX, XII

• ↓ fibrinolysis

• ↓ protein C and protein S = ↑


thrombo-embolic risk – DVT!!
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV.Changes in Organ Systems During
Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
Changes in Organ Systems During Pregnancy
c. Respiratory system changes

JP is a 25 y.o G1P0 intrauterine pregnancy 34 w


gestation.
She reports increasing difficulty in taking
deep breaths.
She denies shortness of breath on exertion and no
chest pain. Her pregnancy has been uncomplicated
and she has no medical problems.

What is the most likely cause of her difficulty


in breathing?
Changes in Organ Systems During Pregnancy
c. Respiratory system changes

• ↑ metabolism & ↑ maternal and fetal necessities (O2 and


CO2)
• Ascension of diaphragm + intraabdominal pressure =
thoracic respiration (inferior costal)

• Estrogens - ↑ vascularization -> edema, hyperemia in nose,


pharynx, esophagus, tracheae, bronchia.
• ↑ current respiratory volume, ↑ respiratory frequency
• Progesterone
– hyperventilation
– Relaxes ligaments (↑ tidal volume & minute volume)
– ↓CO2 = mild respiratory alkalosis
Changes in Organ Systems During Pregnancy
c. Respiratory system changes
Changes in Organ Systems During Pregnancy
c. Respiratory system changes
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV.Changes in Organ Systems During
Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Integumentary System Changes
V. Physiology of Labor
VI. Stages of Childbirth
Changes in Organ Systems During Pregnancy
e. Integumentary System Changes

• Estrogen, ACTH, Glucocorticoids


• Dermis stretches extensively (↑uterus,
breast, fat deposits)
• Torn connective tissue = stiae (stretch
marks) – red/purple ->silvery white
• Darkened areola, white line, chloasma
Changes in Organ Systems During Pregnancy
e. Integumentary System Changes
Changes in Organ Systems During Pregnancy
e. Integumentary System Changes
Mood changes
Summary

I. Introduction
II. Effects of Hormones
III. Weight Gain
IV. Changes in Organ Systems During Pregnancy
a) Digestive and Urinary System Changes
b) Circulatory System Changes
c) Respiratory system changes
d) Urinary system
e) Integumentary System Changes

V. Physiology of Labor
VI. Stages of Childbirth
V. Physiology of Labor
Childbirth typically occurs within a week of a woman’s due
date (39/40weeks – 42 weeks)

1. After 7th month Progesterone levels plateau then drop


2. Estrogen levels continue to rise.
3. E/P ratio ↑ = myometrium more sensitive to uterine
contractions (P no longer inhibits them)
4. After 8th month ↑ fetal Cortisol levels - ↑ estrogen
secretion by the placenta = fetal-hypothalamic-
pituitary adrenal axis
– Braxton-Hicks contractions = FALSE LABOR
• Relieved with rest and hydration
5. +/- bloody show or mucus plug = common sign 1-2 days
prior to labor
V. Physiology of Labor

5. Posterior pituitary OXITOCIN – stimulates uterine


contractions
6. Myometrium increases sensitivity to oxytocin -
↑Receptors
7. As labor nears oxytocin begins to stimulate stronger,
painful uterine contractions which in a positive feed
back loop stimulate secretion of prostaglandins
from the fetal membranes
8. Stretching the myometrium and cervix initiate regular
contractions = TRUE LABOR
– Pain in labor is attributed to myometrial hypoxia during uterine
contractions
V. Physiology of Labor

No matter what seems to initiate labor it involves


regular uterine contractions, mediated through ATP-
dependent binding of myosin to actin. Unlike vascular
smooth muscle, myometrium has sparse innervation, thus
regulation of contractions is hormonal.
PHASES OF LABOR
V. Physiology of Labor

Phase 3 of labor ends with CHILDBIRTH

STAGES OF CHILDBIRTH:
I. Cervical Dilation
II. Expulsion
III. Delivery of placenta
IV. Postpartum/Afterbirth
V. Ph
ysi
olo
gy
of
La
bo
r
V. Physiology of Labor
Stage I of childbirth

I. Cervical Dilation
• For birth to occur the cervix must fully dilate to
10 cm wide
• Longest stage of labor (6-12 hours) – varies
widely
• Typically they rupture at the end of dilation stage
in response to excessive pressure;
– Amniotic membranes rupture before onset of labor in
12% of patients;
V. Physiology of Labor
Stage II of childbirth

II. Expulsion stage


• Begins when the fetal head enters the birth canal
• Ends with the birth of the newborn
• Takes up to 2 hours
• +/- episiotomy
• Umbilical cord double clamped and cut
V. Physiology of Labor
Stage III of childbirth

III. Delivery of the placenta


• Contractions shreads the placenta from the back of the
uterine wall
• No more than 30 minutes!
• >30 minutes = retained placenta – manual/instrumental
removal; even SURGICAL
• Examination of the placenta
V. Physiology of Labor
Stage IV of childbirth

IV. Afterbirth
• Starts immediately after delivery of the placenta
• Uterine contractions continue for several hours after
birth
• Uterus returns to its pre-pregnancy size = INVOLUTION
• Breastfeeding starts
• Uterine contractions limit blood loss during
delivery of the placenta and immediately
afterbirth
• Postpartum discharge for up to 1-2 weeks – LOCHIA =
endometrial lining, erythrocytes, debris