Physiologic Changes During Pregnancy

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Midterms # 1

paper through bimanual palpation

PHYSIOLOGIC CHANGES DURING PREGNANCY
Can be categorized as: • Local – reproductive organs only

 Ballottement – 16th-20th week,
fetus is small compared to amt of amniotic fluid present. Fetus bounce or rise on tapping sharply the lower uterine segment against the top examining hand



Systemic – the entire body is affected

LOCAL CHANGES
A. REPRODUCTIVE SYSTEM CHANGES a. Uterine Changes     Length: 6.5 – 32 cm Depth : 2.5 – 22 cm Width: 4 – 24 cm Weight: 50 – 1000g

 Braxton-Hicks contraction –

practice contractions, waves of hardness and tightening across her abdomen

b. Amenorrhea  Because of FSH suppression
by rising estrogen levels c. Cervical changes

 Vascular and edematous –
increased circulating estrogen  From pale pink to violet



Thickness: early in pregnancy 1cm-2cm, end of pregnancy 0.5 cm thick

 Volume: 2ml – more than 1000ml /4000g at term  End of twelfth week palpated at the symphysis pubis

 Operculum – mucous plug
in cervical canal that seals out bacteria during pregnancy preventing fetal and membrane infection

 20th or 22nd week reached
umbilicus

 Goodell’s Sign – softening
of the cervix from elasticity of earlobe to consistency of butter

 End of 36th week reached the
xiphoid process ( breathing is difficult)

d. Vaginal changes

 38th week, for a primigravida,
fetal head settles into the pelvis, the uterus returns to the height at 36th week

 Hypertrophic and enriched

with glycogen – because of increased estrogen light pink to a deep violet : increased vascularity

 Chadwick’s sign – normal

o

LIGHTENING – woman’s breathing becomes easier, lightening the load. *In multipara, it occurs at labor

 From pH >7 to pH 4 or 5

 Uterine blood flow: before 1520 ml/min, by the end of pregnancy 500-750 ml/min *75% goes to placenta

vaginal secretions because of Lactobacillus acidophilus (grows freely in increased glycogen envt) Candida albicans, itching and burning sensation with creamcheese-like discharge

 Candidiasis – caused by

 Hegar’s sign – extreme
softening of the lower uterine segment, felt as thin as tissue

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 Leukorrhea – excessive
discharge e. Ovarian changes

 Striae gravidarum – pink

 Ovulation stops because of

active feedback mechanism of E & P by corpus luteum/placenta

or reddish streaks on sides of abdomen and on thighs caused by rupture and atrophy of connective layer of skin *weeks after birth becomes striae albicantes or atrophicae (silvery-white)

 (-) prodn of FSH and LH

 Diastasis – separation of

 Corpus luteum – enlarges
until 16th week as placenta takes over as provider of E & P,

rectus muscles, appears after pregnancy as a bluish groove

 Umbilicus becomes obliterated and protruding

 Then becomes corpus
f. Changes in breasts

albicans – white and smaller

 Linea nigra – narrow
brown line in midline

 Melasma/chloasma –

 6th week. Changes are
noticeable

“mask of pregnancy”, dark pigmentations on cheeks and nose due to MSH spiders/Telangiectases – small, fiery-red, branching spot on thighs due to increasing estrogen

 Feeling of fullness, tingling
or tenderness – increased estrogen levels.

 Vascular

 Increased in size hyperplasia of mammary alveoli and fat deposits  Areola darkens and increases in diameter  Increased vascularity and prominent blue veins

 Activity of sweat glands increases

 Palmar erythema –
redness and itching on hands due to estrogen  Scalp hair growth increases

 Montgomery’s tubercles –
sebaceous glands enlarge and become protuberant - Keeps nipples supple, preventing drying and cracking during lactation

C. RESPIRATORY SYSTEM

 Marked congestion or stuffiness of
the nasopharynx – increased estrogen levels diaphragm

 Colostrum – thin watery

high-protein fluid that is precursor of breast milk, can be expelled at 16th week

 Shortness of breath – pressure on  Decreased PCO2 (blood CO2) of

SYSTEMIC CHANGES

32mmHg due to increased progesterone level – easier fetal CO2 transfer to maternal bloodstream

B. INTEGUMENTARY SYSTEM

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 Mild Hyperventilation – to

prevent maternal blood pH from becoming acidic bec of CO2 to help, add’l H2O and Na is lost

 Decreased iron absorption due to decreased gastric acidity  Excessive Fe: stomach irritation

 Polyuria – kidney excretes HCO3  Vital capacity: no change  Tidal volume: increased 30-40%
 RR: increased 1-2bpm  Residual volume: decreased by 20%

 Increased need of folic acid  Inadequate:
megalohemoglobinemia ( large, non-functioning RBC) : risk for fetal neural tube disorders c. Heart  Cardiac output increases by 25-50%  Heart rate increases by 10bpm

 Plasma PCO2: decreased 2730mmHg  Plasma pH: 7.40-7.45

 Plasma O2: Increased 104-108
mmHg  Respiratory minute volume: increased 40%  Expiratory reserve: decreased 20%

 More transverse

positioning due to diaphragm displacement pregnancy is due to SNS stimulation ; in later months due to increase thoracic pressure

 Palpitations: early in

D. TEMPERATURE

 Early: increases due to

d. Blood pressure

progesterone due to corpus luteum (same at ovulation) to placenta

 1st trimester: BP does not
rise

 16th week: decreases to normal due

 2nd trimester: BP decreases
due to decreased PR

E. CARDIOVASCULAR SYSTEM

 3rd trimester: BP goes up
same with 1st trimester e. Peripheral Blood flow

a. Blood volume – increases by 30%
 Blood loss during NSD: 300400 mL  Blood loss during CS: 8001000mL

 3rd trimester: blood flow in
lower extremities is impaired leading to edema, varicosities of the vulva, rectum, and legs f. Supine Hypotension Syndrome  Lying supine, the uterus presses vena cava against vertebrae: obstructing blood flow in lower extremities  Decrease venous return: decreased CO and BP

 Pseudoanemia - conc. of
hemoglobin and RBC decline in first trimester due to faster plasma volume increase than RBC prod’n b. Iron, Folic Acid & Vitamin Needs

 Total increased iron need of
800mg

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 Results to: o Maternal: Lightheadedness, faintness and palpitations Fetal: Hypoxia

 Heartburn – reflux of

stomach contents into esophagus because of: • upward displacement of the stomach relaxed cardioesophageal sphincter (due to relaxin, enzyme produced by ovaries)

o

 Corrected through turning the woman to her left side g. Blood Constitution  Fibrinogen: increases by 50% due to increased estrogen level



 Slow intestinal
peristalsis and the emptying time of stomach due to pressure caused by uterus displacing abdominal organs: leads to heartburn, constipation and flatulence

 Clotting Factors VII, VIII, IX,
& X and platelet count increases •

Safeguard against major bleeding

 Relaxin: decreases gastric
motility

 Total WBC count rises
slightly  Total Protein level of blood decreases due to fetal consumption

 Progesterone: makes GI
tract less active

 Subclinical Jaundice
(generalize itching) • Decreased emptying of bile from the gallbladder: reabsorption of bilirubin in maternal bloodstream

 Ankle & foot edema is

common due to lower total protein load and hypovolemia: equal osmotic and hydrostatic pressure 1/3*

 Blood lipids increases by  Cholesterol serum levels
increases by 90-100%* *for ready supply of available energy to the fetus

 Hypertrohy of gumlines

& bleeding of gingival tissue saliva prod’n due to increased estrogen lvls

 Hyperptyalism – increased

 Increased tooth decay:
lower than normal pH of saliva

F. GASTROINTESTINAL SYSTEM

 First trimester: “Morning
sickness” - nausea and vomiting early in the morning, increased HCG and progesterone levels/increased estrogen and decreased glucose

G. URINARY SYSTEM • Changes results from: o o Effects of high E & P levels Compression of bladder and ureters

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o o

Increased blood volume Postural influences

c. Bladder and ureter function

 Polyuria – increase urinary
frequency, during 1st trimester Until uterus rises out of pelvis and relieves pressure on bladder. This returns as lightening occurs.  Ureters increased in diameter & bladder capacity increases to 1500ml: due to increased progesterone

a. Fluid retention

 Total Body H2O increases to
7.5 L: increase Na reabsorption

 Increased Aldosterone

prod’n due to increased response Angiotensin-renin system to progesterone

o

Aldosterone aids in Na reabsorption

 Uterus rises on the right

 K levels remain adequate due to progesterone

side, pushed slightly by sigmoid colon: pressure on right ureter

 H2O is retained: aid the

increase in BV and serve as ready fluid supply of fetus

o

If not relieved, urinary stasis and pyelonephritis

b. Renal Function  Kidneys increased in size  Urine output increases 6080%  Sp. Gr. Decreases  GFR and renal plasma flow increases early in pregnancy At 2nd trimester, they increased by 30-50%  Lower BUN and creatinine lvls o 15mg/100ml or higher BUN is abnormal, as well as, Greater than 1mg/100ml creatinine

 Pressure on urethra: poor bladder emptying and bladder infection

o

Leads to kidney infection (mother) and UTI (fetus)

H. SKELETAL SYSTEM  Ca and P need is increased o Fetal skeleton must be build

 Gradual softening of pelvic ligaments and joints (relaxin and progesterone)  Excessive mobility of joints causes discomfort  3mm-4mm separation of symphysis pubis at 32 weeks o Difficulty walking

o

 Gestational DM due to:
o Accidental spilling of glucose in urine due to reabsorption of glucose Unused lactose is also spilled

 Lordosis/ “Pride of

o

Pregnancy” – forward curve of lumbar spine, may lead to backache

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I.

ENDOCRINE SYSTEM a. Placenta Produces large amts of E, P, HCG, HPL, relaxin & prostaglandins

Increased lvls of: protein-bound iodine, butanol-extractable iodine and thyroxine





 Emotional lability, tachycardia, palpitations, and diaphoresis

 ESTROGEN causes: breast and uterine enlargement, & palmar erythema  PROGESTERONE is involved in: maintenance of endometrium, inhibition of uterine contractility, & development of breasts for lactation  RELAXIN (corpus luteum): helps in inhibiting uterine activity, softening of the cervix (dilatation at birth) and collagen in joints (laxness in the lower spine & enlargement of birth canal) HCG (trophoblast): stimulates E and P synthesis HPL: insulin antagonist; more glucose for fetus PROSTAGLANDIN: affect smooth muscle contractility, initiates labor

 Parathyroid also increases in size, calcium prod’n

d. Adrenal glands Increased corticosteroids & aldosterone due to increased AG activity



 Decreased inflammatory reaction  Increased aldosterone lvls



e. Pancreas  Increased insulin prod’n due to increased glucocorticoid lvls  Maternal blood glucose level > fetal glucose level o To prevent hypoglycemia: Increase MBGL than normal  Low FBS of mother during first trimester  Less effective insulin due to insulin-antagonists (E, P & HPL)




b. Pituitary Gland  (-) prod’n of FSH and LH due to increased P and E  Increased prod’n of GH and MSH  Later: prod’n of oxytocin and prolactin J. IMMUNE SYSTEM

c. Thyroid and Parathyroid Glands
 Thyroid enlarges: BMR increases by 20%

 Immunocompetency decreases

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 IgG prod’n decreases: prone to infection  Increase WBC count

PCDN_N201_NCM101 07/31/2011 3:59pm

“LOVE is a strong word to say it too early, Yet, it is too wonderful to say it too late...”

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