1. Maternal physiology during pregnancy Major Nabila Amin Assistant Professor CMH Rawalpindi

2. Reproductive tract (1) Uterus: from 50g-1100g Uterus: from 50g-1100g from <10ml – 5L from <10ml – 5L <2%- 15-20% of cardiac output <2%- 15-20% of cardiac output Isthmus uteri —— lower segment of the uterus Isthmus uteri —— lower segment of the uterus

3. Braxton Hicks contraction: sporadic, irregular, asymmetrical, and painless, low pressure, lasting < 30 sec Braxton Hicks contraction: sporadic, irregular, asymmetrical, and painless, low pressure, lasting < 30 sec Reproductive tract (2)

4. Characteristics of True and False Labor Regular Contractions Regular Contractions Stronger, longer, closer together Stronger, longer, closer together Bloody show often present Bloody show often present Cervix effaced and dilated Cervix effaced and dilated Head is fixed between contractions Head is fixed between contractions Sedation does not stop true labor Sedation does not stop true labor Irregular Irregular No change in contraction characteristics No change in contraction characteristics No show No show No cervical change No cervical change Head may be ballotable Head may be ballotable Sedation stops false labor Sedation stops false labor

5. Cervix and vulva —— Chadwick’s sign Cervix and vulva —— Chadwick’s sign congestion of the pelvic vasculature, cause bluish or purplish discoloration of the cervix and vulva congestion of the pelvic vasculature, cause bluish or purplish discoloration of the cervix and vulva Leukorrhea: increase in vaginal discharge, rich in glucose, lactic acid, low vaginal pH Leukorrhea: increase in vaginal discharge, rich in glucose, lactic acid, low vaginal pH Ovary: slightly enlarged, corpus luteum regresses after 10 weeks’ gestation Ovary: slightly enlarged, corpus luteum regresses after 10 weeks’ gestation Reproductive tract (2)

6. Breasts: increase in circulation Engorgement and venous prominence Engorgement and venous prominence Mastodynia (breast ternderness): tingling to frank pain caused by hormonal responses of the mammary ducts and alveolar system Mastodynia (breast ternderness): tingling to frank pain caused by hormonal responses of the mammary ducts and alveolar system Montgomery’s tubercles: enlargement of circumlacteal sebaceous glands of the areola Montgomery’s tubercles: enlargement of circumlacteal sebaceous glands of the areola Colostrum secretion: Colostrum secretion:

7. Cardiovascular changes (1) Position and size of heart Position and size of heart ECG changes ECG changes Increased heart rate (+15%) Increased heart rate (+15%) 15-degree left axis deviation 15-degree left axis deviation Inverted T-waves in lead III Inverted T-waves in lead III Q in lead III and AVF Q in lead III and AVF Unspecific ST changes Unspecific ST changes Appear larger on roentgenogram Appear larger on roentgenogram

8. Cardiovascular changes (2)  Heart rhythms and murmurs: soft, transient Caution: How to interpret these murmurs Caution: How to interpret these murmurs  Inferior vena cava syndrome: In the supine position, the inferior vena cava is compressed by the enlarged uterus, resulting in decreased cardiac output. Some women may have symptoms that include dizziness, light-headedness, and syncope.

9. Cardiovascular changes (3) Stroke volume +30% Stroke volume +30% Heart rate +15% Heart rate +15% Cardiac output +40% Cardiac output +40% Oxygen consumption +20% Oxygen consumption +20% SVR (systemic vascular resistance) -5% SVR (systemic vascular resistance) -5% Systolic BP -10mmHg Systolic BP -10mmHg Diastolic BP -15mmHg Diastolic BP -15mmHg Mean BP -15mmHg Mean BP -15mmHg

10. Blood volume +30% Blood volume +30% Plasma volume +40% Plasma volume +40% Red blood cell volume +20% Red blood cell volume +20% Dilutional anemia Dilutional anemia Increase cardiac output Increase cardiac output Decrease blood viscosity Decrease blood viscosity Vasodilatation Vasodilatation Right shift oxyhemoglobin dissociation curve Right shift oxyhemoglobin dissociation curve Cardiovascular changes (4)

11. Venous pressure: Venous pressure: 1. unchanged in the upper body 2. Significantly increases in the lower extremities, esp. during supine, sitting or standing position, returns to near normal in lateral recumbent position Cardiovascular changes(5)

12. Hematologic system (1) Blood volume (polymorphonuclear) +40% Blood volume (polymorphonuclear) +40% Dilutional anemia Hb 110 g/L Dilutional anemia Hb 110 g/L Leukocytosis 15,000/  l Leukocytosis 15,000/  l Platelet not change Platelet not change Sedimentation rate increase, 100m/h Sedimentation rate increase, 100m/h

13. Hematologic system (2) Clotting factors: hypercoagulable, throboembolism Clotting factors: hypercoagulable, throboembolism Fibrinogen (factor I) +50% (4.5 vs 3 g/L) Factor VIII increase Factors VII, IX, X and XII increase Prothrombin time, PT shortened ATPP activated partial thromoplastin time shortened Fibrinolytic activity decrease

14. Hematologic system (3) Iron : active transplacental transfer Iron : active transplacental transfer Requirement 1000mg Requirement 1000mg increase maternal red cell mass 500mg increase maternal red cell mass 500mg fetal development 300mg fetal development 300mg compensate for normal iron loss 200mg compensate for normal iron loss 200mg To supply, 300 mg of ferrous sulfate is needed, and twice the dose for anemic patients.

15. Renal changes (1) Kidney slightly enlarged Kidney slightly enlarged Renal plasma flow +35% Renal plasma flow +35% Glomerular filtration rate +50% Glomerular filtration rate +50% Serum creatinine, uric acid Serum creatinine, uric acid and urea nitrogen Renin, angiotensin I and II Renin, angiotensin I and II Renin substrate Glucosuria (50%) + Glucosuria (50%) +

16. Renal changes (2) renal pelves dilated renal pelves dilated Ureters (esp. right side) dilated Ureters (esp. right side) dilated Bladder tone reduced Bladder tone reduced Bladder capacity reduced Bladder capacity reduced Residual volume increased Residual volume increased Chance of pyelonephritis increaased Chance of pyelonephritis increaased

17. Pulmonary changes Mucosal hyperemia Mucosal hyperemia Subcostal angle Subcostal angle Chest circumference and diameter Chest circumference and diameter Diaphragmatic excursion Diaphragmatic excursion Tidal volume +30-40% Tidal volume +30-40% PO 2 is increased, PCO 2 is decreased. PO 2 is increased, PCO 2 is decreased. Total lung capacity decrease -15% Total lung capacity decrease -15% Minute ventilation +30-40% Minute ventilation +30-40% Mild respiratory alkalosis Mild respiratory alkalosis

18. Gastrointestinal change Morning sickness Morning sickness hyperremesis gravidarum (weight loss, ketonemia and electrolyte imbalance) hyperremesis gravidarum (weight loss, ketonemia and electrolyte imbalance) Dietary craving: pica Dietary craving: pica Decreased gastrointestinal motility: reflux and heartburn Decreased gastrointestinal motility: reflux and heartburn Gallbladder function, cholestasis Gallbladder function, cholestasis Hyperemia and softening of the gums (epulis) Hyperemia and softening of the gums (epulis) Hemorrhoid Hemorrhoid Appendix displaced Appendix displaced

19. Skin changes Vascular spiders Vascular spiders Striae gravidarum Striae gravidarum Hyperpigmentation (estrogen and melanocyte- stimulating hormone) Hyperpigmentation (estrogen and melanocyte- stimulating hormone) Linea alba——linea nigra Linea alba——linea nigra Chloasma Chloasma Skin nevi Skin nevi

20. Metabolism Basal metabolism rate, BMR +15-20% Basal metabolism rate, BMR +15-20% Weight gain 12.5 Weight gain 12.5 Fetus 3400g Fetus 3400g Placenta 650 Placenta 650 Amniotic 800 Amniotic 800 Uterus 960 Uterus 960 Plasma, red cells 1450 Plasma, red cells 1450 Mammary glands 405 Mammary glands 405 Extracellular, extravascular water 1480 Extracellular, extravascular water 1480 Deposition of fat and protein 3345 Deposition of fat and protein 3345 Insulin resistance Insulin resistance

21. A quiz Definitions Definitions 1. fetus 2. hyperemesis gravidarus 3. Morula 4. Inferior vena cava syndrome 5. Chadwick’s sign 6. Capacitation 7. Lower segment of uterus

22. 1. Fetal membrane is composed of ______and______. 2. The prerequisites for successful implantation are________, _______ and ___________. 3. Placenta is composed of _______, _________and ___________. 4. Maternal-fetal-placenta unit is a concept usually used to describe the production of ________and can be used to evaluate the placental function.

23. True or false 1. Supplement of iron during pregnancy is primarily to prevent fetal anemia. 2. Because of the frequent incidence of glucosuria among pregnant patients, quantitative urine glucose measurements are not clinically useful in managing patients with diabetes, because they do not reflect blood glucose levels. 3. The left pyelonephritis has a higher incidence in pregnant women.

24. 4.On chest x-ray, the heart appears to demonstrate cardiomegaly during pregnancy. 5. In the fetus, the blood circulating in the IVC enters the right atrium and mix well with the deoxygenated blood from SVC and then goes to the left atrium and supplies the head, etc.

25. 1. In a normal singleton pregnancy, maternal blood volume A. increases by 10-15% B. increases by 45% C. decreases by 10-15% D. decreases by 45%

26. 2. Which of the following is not characteristic of a normal pregnancy? A. cardiac volume increases by 10% B. the ECG shows deviation to the left C. the rest pulse rate increases by approximately 10- 15% beats per min D. arterial blood pressure and vascular resistance increases E. The heart is displaced upward and to the left

27. 3. Epulis is a pregnancy-related vascular swelling of the A. Gums B. Nailbed C. Larynx D. Nares E. Epiglottis

28. THANK YOU