1. Anatomy and Physiology of Pregnancy
Lecture
Iryna Kuziv, MD, PhD
Pregnancy is a normal physiologic process . . .
. . . not a disease!

2. Probable signs of pregnancy (observed by examiner):
Bluish or purplish coloration of the vaginal mucosa and cervix (Chadwick’s sign-a dark blue to purplish-red congested appearance of the vaginal mucosa )
Palpation of Braxton-Hicks contractions
Outlining the fetus manually
Endocrine tests of pregnancy

3. Positive signs of pregnancy (noted by examiner, confirm pregnancy)
Identification of the fetal heart beat separately and distinctly from that of the mother (10-12 w)
Perception of fetal movements by the examiner (18-20 w)
Visualization of pregnancy on ultrasound
Fetal recognition on X-ray

4. Uterus Non Pregnant Uterus Pregnant Uterus Muscular Structure
Almost Solid
Relatively thin – walled (≤ 1.5 cm)
Weight
≈ 70 gm
Approx gm by the end of pregnancy
Volume
≤ 10 ml
≈ 5 L by the end of pregnancy

5. Mechanism Of Uterine Enlargement
Stretching & marked hypertrophy of muscle cells.
Considerable increase in elastic tissue
Accumulation of fibrous tissue, particularly in the external muscle layer.

6. Uterine size, shape & position
First few weeks, original peer shaped organ
As pregnancy advances, corpus & fundus assumes a more globular form.
By 12 weeks, the uterus becomes almost spherical .
Subsequently, uterus increases rapidly in length than in width & assumes an ovoid shape.
With ascent of uterus from pelvis, it usually undergoes Dextrorotation (caused by the rectosigmoid colon on the left side)

7. Breast changes

8. Breast
Breast: tenderness, fullness, tingling enlargement, nipple and areola hyperpigmentation, Montgomery’s tubercles, colostrum (16 w)

9. Integumentary System Darcening of nipples, areola, axillae, vulva
Facial melasma=chloasma
Linea Nigra
Striae gravidarum
Palmar erythema (Caucasian, African-American)

10. Stria gravidarum

11. Butterfly pigmentation

12. Pigmentation: It is due to suprarenal changes, it usually begins to appear after the 4th month. The pigmentation may appear anywhere but the commonest sites are: 1. Linea nigra: which is a line of pigmentation between the umbilicus and the symphysis pubis. 2. Increased pigmentation of the nipple as primary areola and appearance of the secondary areola.

13. Vascular Vascular spider Minute, red elevations on the skin
common on the face, neck, upper chest,
and arms, with radicles branching out
from a central lesion. The condition is often
designated as nevus, angioma, or telangiectasia.
Palmar erythema .
The two conditions are of no clinical significance and disappear in most women shortly after pregnancy (estrogen)

14. Musculoskeletal System
Change in posture
Waddling walk
Back Pain
Slight relaxation and increased mobility of the pelvic joints
Diastasis recti abdominis

15. Uterine Sizing Uterine enlargement 12 weeks – At Symphysis
16 weeks – Midway between symphysis and umbilicus
20 weeks – At the umbilicus
36 weeks - Near xyphoid process

16. Uterine Sizing

17. Accuracy of Dating by Ultrasound
Gestational Age weeks)
Ultrasound Measurements
Range of Accuracy
< 8
Sac size
+ 10 days
8-12
CRL
+ 7 days
12-15
CRL, BPD
+ 14 days
15-20
BPD, HC, FL, AC
20-28
+ 2 weeks
> 28
+ 3 weeks

18. Medical/Surgical History
Serious illnesses
Hospitalizations
Surgery
Drug allergies or unusual reactions
Meds since LMP

19. Family History Maternal Maternal or Paternal Diabetes CAD
Pre-eclampsia
Preterm delivery
Cancers (breast, ovarian, colon)
Depression, bipolarity
Twins
Anesthesia reactions
Maternal or Paternal
Birth defects
Mental retardation
Bleeding disorders
Chromosomal abnormalities (e.g. Down Syndrome)

20. Vital Signs Elevated BP suggests the presence of preeclampsia.
Elevated BP may be defined as a persistently greater than 140 systolic or 90 diastolic. Usually, if one is elevated, both are elevated.
Elevated temperature suggests the possible presence of infection.
Many pregnant women normally have oral temperatures of as much as 99+. These mild elevations can also be an early sign of infection.
While a pregnant pulse of up to 100 BPM or greater may be normal, rapid pulse may also indicate hypovolemia.
Temperature
Blood pressure
Respirations
Radial pulse

21. Additional Measurements
Height
Weight
BMI (Body mass index )
BMI Categories:
Underweight = <18.5
Normal weight =
Overweight =
Obesity = BMI of 30 or greater

22. Bones and Joints of the Pelvis

23. The Diagonal Conjugate
The obstetric conjugate extends from the middle of the sacral promontory to the posterior superior margin of the pubic symphysis. This is the most important diameter of the pelvic inlet.
The diagonal conjugate extends from the subpubic angle to the middle of the sacral promontory and can be measured clinically to estimate the obstetric conjugate.

24. The Ischial Spines
The transverse diameter, between the ischial spines, is a measurement of the dimensions of the pelvic cavity

25. The Pelvic Outlet Subpubic arch Bituberous (transverse) diameter
Inferior pubic rami

26. The First Prenatal Visit: Counseling
What to expect during the course of prenatal care
Risk factors encountered
Nutrition
Exercise
Work
Sexual activity
Travel, seat belts
Smoking cessation
Avoidance of drugs and alcohol
Warning signs
Where to go or call in case of problems
Prenatal vitamins

27. Leopold's Maneuvers - are used to determine the orientation of the fetus through abdominal palpation.
1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). .

28. 2. The sides of the uterus are palpated to determine the position of the fetal back and small parts.

29. 3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement determined

30. 4. The fetal occipital prominence is determined.

31. Measuring Fundal Height

32. Auscultating Fetal Heart Tones