1. MATERNAL CHANGES DUE TO PREGNANCY DR.CHIPPY

2. INTRODUCTION During pregnancy many demands are made on the mother consequent upon the rapid growth of the fertilized ovum. Maternal system undergo certain changes to meet the requirement of the growing fetus. They are only temporary adaptations without any deleterious effect on the mother in a normal pregnancy.

3. THE VARIOUS CHANGES ARE IN THE: GENITAL TRACT HEMATOLOGICAL SYSTEM WEIGHT CHANGES METABOLIC CHANGES SYSTEMIC CHANGES HORMONAL CHANGES HCG ESTROGEN PROGESTERONE ANDROGENS HPL PROSTAGLANDIN PITUITARY HORMONE ADRENAL HORMONE THYROID HORMONE

4. CHANGES IN THE GENITAL TRACT THE UTERUS In a nullipara uterus is pear shaped 6.5cm,70gm.pelvic organ. In pregnancy-oval.32 cmlong,24cmwide 22cmdeep.1kg.fills the abdomen. Hypertrophy. mainly by estrogen. Uterine CT ↑,softens. isthmus soften first. HEGAR’S sign. Fundus dilates. cervix sphincteric. (neural) Abdominal by 12 weeks

5. GENITAL CHANGES CONTD…. UTERINE ARTERY Arteries hypertrophy, veins dilate, lymphatics multiply and enlarge Increased placental blood flow, spiral arterioles  dilated sinuses. Invasion of trophoblast -destroy muscle wall/elastic layer of sp.art.----3 stages pre-invasive (up to 12 weeks) intraluminal(12-20 weeks) wall replacement. Uterine blood flow ↑ -- 500-700ml at term.

6. GENITAL CHANGES CONTD… Braxton – Hicks contractions Starts in first TM. Palpable from 2 nd TM onwards. Irregular/sporadic/infrequent/non rhythmic,painless contractions until the last few weeks of preg. Last week- become rhythmic and may lead to false labor pains.

7. CERVICAL CHANGES Cervix becomes soft and blue in the first tm. ↑vascularity,edema,hyperplasia,hypertro phy of cervical glands/ ↑ secretion. Eversion of ec gland epithelium Basal cell changes Stromal changes

8. VAGINAL CHANGES ↑ vascularity,violet discoloration ↑ secretion FALLOPIAN TUBES/ROUND LIGAMENT/OVARIES FT- ↑ vascularity /stretched out RL-thickened and hypertrophied Ovaries-enlarged/CL

9. BREAST CHANGES > in primi 2 nd month: ↑ size, bluish streaks Nipple -erectile, areola-more pigmented Montgomery’s follicles. 5 th month: secondary tubercle secondary Mf Colostrum

10. HEMATOLOGICAL CHANGES Blood volume Total blood vol.↑ by 30% Plasma ↑by 50%. ↑total cell vol. 20%--1400ml  1650ml(↑ production) Erythrocyte count ↓4.5mill/cu.mm  3.7mill/cu.mm(upto 30weeks) Hemoglobin ↓(13 to 11 gm/dl)

11. Hematological changes (Contd..) Hematocrit ↓(40% to 33%)—last 10weeks No change in Hb conc. in the RBC Marked ↑ in leukocyte count (7000 to 12000/cu.mm)20000-25000 in labour peurperium. Clotting factors also show increase. ↑7,8,9,10. ↓13. 2&11↔ Platelets ↑

12. Serum proteins Serum proteins ↓(hydremia,last trimester) A/G ratio ↓ Non- pregna nt pregna nt Tot protein 7.196.46 Albumin 3.782.44 globulin 3.414.02

13. Alpha fetoprotein ↑ during pregnancy(53-55g/l) Total serum lipids ↑ Cholesterol ↑ -3.4g/l Phospholipids ↑ Fibrinogen ↑ (260  388mg%)upto 600mg% Plasminogen activity ↑ FDP ↑

14. WEIGHT CHANGES DURING PREGNANCY Average total weight gain =12.5kg Weight before pregnancy tend to exert an influence on the net weight gain. Influence baby's weight.(300-400gm) Weight gain (gm) Fetus3400 Placenta 650 Amniotic fluid 800 Uterus 970 Breast 405 Blood1450 Extra vascular fluid 1480 Maternal fat stores 3345 total12,500

15. METABOLIC CHANGES Water metabolism Water retention…6.5litres(3+3.5) Uterine compression of venacava  partial occlusion  pitting edema. Fat metabolism fat storage ↑ (max in 2 nd tm/↓in 3 rd tm) Ketonuria and ketonemia develop faster in pathologic states bcz of accelerated starvation.

16. METABOLISM..contd Carbohydrate metabolism ↓ FBS ↑plasma free fatty acid (placental lactogen promotes lipolysis and antagonizes insulin in the periphery) ‘state of accelerated starvation’. ↑endogenous insulin secretion. ↑insulin response to glucose load.

17. Metabolism contd… Protein metabolism protein content ↑ Fetus and protein-500gm of protein Uterine contractile protein +Hb +plasma proteins=500gm of proteins

18. Metabolism contd.. MINERAL METABOLISM Cu and ceruloplasmin ↑ Ca,Mg↓ Ca ↑(free) late pregnancy Zn (total) ↑ Iron metabolism :↓serum Fe and ↑TIBC (after 24 th week) s.Folate,vit B12,vit B6 and vit C↓

19. METABOLISM Contd.. SERUM ELECTROLYTES ↓Na(2-3 mEq/l) K,Ca(10%)↓ HCO3 ↓ Cl ↔

20. SYSTEMIC CHANGES CARDIOVASCULAR SYSTEM Heart is displaced upwards and rotated in the anterioposterior axis. Apex beat shifted ↑cardiac volume of 75ml. ↑left ventricular mass and end diastolic pressure

21. CVS—Contd.. Heart sounds altered—s1 loud and split. s2 same.s3 heard in 75% of normal pregnancy.(rapid ventricular filling during early diastole) Systolic ejection murmurs. ECG changes

22. CVS contd….. Cardiac output 4.5l  5.5l(by 12- 16weeks)  6l(mid pregnancy up to 32 weeks and then decline to 5-5.5l at term. ↑pulse rate up to 15beats/mnt Blood pressure-110-120/75-85mmHg.

23. Peripheral circulation: Varicose veins: 1. ↑intra abdominal pressure 2. dilated vessels 3. vasomotor changes 4. Occlusion of CI vein due to excess flow from pelvic veins 5. heredity Supine hypotension syndrome

24. THE RESPIRATORY SYSTEM Flaring of lower ribs. Sub costal angle ↑68° to 103° Diaphragm raised by 4cm Transverse diameter of chest ↑ by 2cm. More diaphragmatic type of respiration No change in the respiratory rate. VC no change TV ↑ by 200ml.RV↓200ml.

25. RS contd… Physiological dyspnea of pregnancy ↑tidal volume and fall in Pco2  dyspnea Progesterone direct action on respiratory centre Pulmonary artery pressure remains the same/vasodilatation occurs  ↑vascular markings on x-ray

26. THE GASTROINTESTINAL SYSTEM Stomach and intestine displaced /appendix displaced upwards and laterally. Heartburn--↓lower esophageal sphincter tone Gastric emptying time is delayed, due to effect of progesterone./aspiration. Piles/hemorrhoids Gall stones (↓GB contractions) Impaired GI function.

27. THE URINARY SYSTEM Dilatation of renal pelvis/elongation and dilatation of ureters above pelvic brim.>on rt.side. (progesterone/compression) GFR/RPF ↑ Altered RFT Greater loss of AA and water soluble vit Conc. of urea and creat ↓(↑ GFR)

28. US---contd Renal glycosuria – common.r/o pathologic cause  ↑GFR /Tubular reabsorbtion of glucose same. Normally no proteinuria. Bladder hyperplasia(4 th month). bladder trigone is elevated.

29. NERVOUS SYSTEM Excitable nervous system Melancholy Depression Frequent awakenings/lack of sleep Postpartum blues

30. THE ENDOCRINE SYSTEM-THE HORMONES SPECIFIC ROLE IN PREGNANCY SECRETION ALTERED BY PREGNANCY HCGTHYROID HORMONE PROGESTERONEOTHER PITUITARY HORMONES ESTROGENADRENAL ANDROGENPANCREATIC PALCENTAL HORMONES-HPLPROSTAGLANDINS SOME PITUITARY HORMONES

31. HORMONES hCG Glycoprotein-2 subunits- ᾳ and beta(92 &145)/galactose. FSH,LH,TSH. Beta unique to hCG. Source-STB of placenta. Detected in blood soon after implantation.

32. HORMONES contd.. hCG International units 1 IU/ml at 6 weeks  100 IU/ml (peak) b/w 60 th and 80 th day  then decreases to a nadir by 20 th week. ↑ in Twins/ chorio Ca/ vesicular mole/Down Luteotrophic till 68 th day.

33. HORMONES contd.. ESTROGEN Steroid hormone-C18 Main types are estrone, estriol and 17 beta estradiol Source from placenta-requires a normal feto - placental unit. 90% estriol precursor from fetus/10% from placental estradiol and estrone. ↓ placental estrogen in iud /anencephaly

34. HORMONES contd.. PROGESTERONE From STB of placenta. Hormone which sustains pregnancy Precursors-cholesterol and pregnanelone Highest levels found in the umbilical vein Excreted in urine as pregnanediol

35. HORMONES contd… ACTIONS OF PROGESTERONE ACTIONS OF ESTROGEN Secretory changes In Endometrium /prepares for implantation Breast duct system proliferation, pigmentation of nipples and areola Sustain the viability of fetus/reduce uterine excitability Hypertrophy and hyperplasia of uterine muscles SM relaxation Stimulates respiratory centre lowers Pco2 Development of breast alveoli and lobules

36. HORMONES contd… ANDROGENS Free circulating androgens in the pregnant are less as compared to non pregnant women No correlation b/w this level and the sex of the fetus.

37. HORMONES contd… HPL Human chorionic somatomammotropin Polypeptide hormone similar to GH/human prolactin Lipolysis and inhibit gluconeogenesis Anti- insulin action-anabolic action on mother and fetus. STB Correlation with placental weight. Peak of 5-15 g/ml at term.

38. HORMONES contd.. PROSTAGLANDINS C20.PGA,E,F Wide distribution-decidua, endometrium,amniotic fluid In labor PARATHYROID GLAND ↑PTH

39. HORMONES contd.. PITUITARY HORMONES Gonadotrophins :FSH and LH suppressed. ACTH increased levels. MSH polypeptide similar to ACTH pigmentation-nipple/areola/ chloasma /linea alba

40. HORMONES contd… POSTERIOR PITUITARY HORMONES Oxytocin – uterine contractions, milk ejection Vasopressin- Antidiuresis ADRENAL HORMONES Corticosteroid –maternal adrenal cortex/fetus produces urinary excretion ↑

41. HORMONES contd… ALDOSTERONE Progesterone  Na losing effect  combated by rise in aldosterone. Renin -angiotensin system-causes rise in aldosterone due to reduced mean BP in kidney during pregnancy.

42. HORMONES contd… THYROID HORMONE ↑the rate of oxygenation of the cells Rising BMR ↑ protein bound iodine INSULIN Rise in plasma insulin in late pregnancy without a corresponding fall in blood glucose—insulin resistance RENIN Activity raised in pregnancy Extra renin by maternal kidneys

43. PELVIS AND SKELETAL SYSTEM ↑vascularity/ligaments lax/mobility at the joints ↑ Compensatory lordosis & rotation of pelvis on the femur Leads to anterior neck flexion and slumping of shoulder joint-traction on the ulnar and median nerve

44. THE SKIN Diastasis recti Striate gravidarum – linea gravidarum Chloasma/Melasma gravidarum Linea nigra Spider naevi Palmar erythema