1. Physiology & Psychology
Maternal physiological adaptations to pregnancy
The placenta
Psychology of pregnancy

2. Physiology of Pregnancy

3. Systematic Adjustments to Pregnancy
Cardiovascular
Respiratory
Urinary

4. Cardiac output during three stages of gestation, labor, and immediately postpartum compared with values of nonpregnant women. All values were determined with women in the lateral recumbent position.

5. TABLE 8-4. Ventilatory Function in Pregnant Women Compared with the Postpartum Period
During Pregnancy
Factor
10 Weeks
24 Weeks
36 Weeks
Postpartum 6-10 Weeks
Respiratory rate
15-16 16
16-17
Tidal volume (mL)
650
700
550a
Minute ventilation (L) —
10.5
7.5a
Vital capacity (L)
3.8
3.9
4.1
Inspiratory capacity (L)
2.6
2.7
2.9
2.5
Expiratory reserve volume (L)
1.2
1.3
Residual volume (L)
1.1
1.0
1.2a
a Significant increase or decrease compared with pregnant women.

6. Mean glomerular filtration rate in healthy women over a short period with infused inulin (solid line), simultaneously as creatinine clearance during the inulin infusion (broken line), and over 24 hours as endogenous creatinine clearance (dotted line).

7. King J. Physiology of pregnancy and nutrient metabolism
King J. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr 2000;71 (suppl):1218S-25S

8. Adjustments in Nutrient Metabolism
Goals
support changes in anatomy and physiology of mother
support fetal growth and development
maintain maternal homeostasis
prepare for lactation
Adjustments are complex and evolve throughout pregnancy

9. General Concepts 1. Alterations include: 2. Alterations are driven by:
increased intestinal absorption
reduced excretion by kidney or GI tract
2. Alterations are driven by:
hormonal changes
fetal demands
maternal nutrient supply

10. 3. There may be more than one adjustment for each nutrient.
4. Maternal behavioral changes augment physiologic adjustments
5. When adjustment limits are exceeded, fetal growth and development are impaired.

11. Birth weight of 11 children born to a poor woman in Montreal; 8 children were born before receiving nutritional counseling and food supplements from the Montreal Diet Dispensary and 3 children were born afterward.

12. 6. The first half of pregnancy is a time of preparation for the demands of rapid fetal growth in the second half

13. 7. Alterations in maternal physiology facilitate transfer of nutrients to the fetus.

14. Nitrogen Balance (g/day)

15. Hormonal Adjustments
Changes in over 30 different hormones have been detected in pregnancy
Estrogens: increase significantly in pregnancy, influence carbohydrate, lipid, and bone metabolism
Progesterone: relaxes smooth muscle and causes atony of GI and urinary tract
Human Placental Lactogen (hPL): stimulates maternal metabolism, increases insulin resistance, aids glucose transport across placenta, stimulates breast development

16. Late gestation is characterized by:
Anti-insulinogenic and lipolytic effects of Human chorionic somatomammotropin, prolactin, cortisol, glucagon)
Which Results in:
Glucose intolerance, insulin resistance, decreased hepatic glycogen, mobilization of adipose tissue

18. Maternal Nutrient Levels
Increased triglycerides
Increased cholesterol
Decreased plasma amino acids & albumin

20. Lipids Non pregnant Early pregnancy Late pregnancy Total triglycerides60
75 to 100
210
Total cholesterol
170
175 to 200
250
VLDL cholesterol 10 25
LDL cholesterol
105
100 to 125
150
HDL cholesterol 55
55 to 75 65

21. Maternal Albumin

22. Maternal Plasma volume increases ~ 40%
range 30-50%
nutrient concentration declines due to increased volume, but total amount of vitamins and minerals in circulation actually increases.

24. Mean hemoglobin concentrations (  —  ) and 5th and 95th (  —  ) percentiles for healthy pregnant women taking iron supplements

25. Embryonic Development
In early gestation Embryo is nourished by secretions of the oviduct and uterine endometrial glands
Uterine secretions include growth factors (e.g. TNFa, epidermal growth factor) that promote placental growth
Poorly nourished women and obese women at risk for aberrations in embryonic and placental development
Congenital anomalies
Adverse outcomes later in pregnancy (e.g. PIH)
Before implantation, blastocyst divides into embryonic cells and placental cells

26. Relationships of structures in the uterus at the end of the seventh week of pregnancy.

27. The Placenta 10-12 weeks is the period of placentation
Rapid early growth prepares way for fetal growth
Trophoblast cells use same molecular mechanisms as tumors, but are highly regulated and controlled

28. Placental Functions
Maintains immunological distance between mother and fetus
Special endocrine organ: “transient hypothalamo-pituitary-gonadal axis”
Responsible for exchange of nutrients, gases & metabolic waste products between maternal and fetal circulation

29. Placental Architecture
Maternal and fetal blood do not mix: “placental barrier”
Fetal blood flows through capillary networks within highly branched terminal chorionic villi
Maternal blood flows through intervillous space
Uterine arteriols bring blood in
Uterine venules drain blood

30. e-mail this to a colleague
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Placental vasculature                                                             
Reproduced with permission from: Vander, AJ, Sherman, JH, Luciano, DS. Human Physiology, 6th ed, McGraw-Hill, Inc p Original Figure Copyright © 2001 McGraw-Hill. ©2007 UpToDate® • Licensed to Univ Of Washington

31. Placental Capacity Increases During Gestation
Expression of transporters increases
The “brush border” microvilli develop to:
increase surface area
impede maternal blood flow
Flow through the placenta at term is 500 ml/minute

33. Mechanisms of Nutrient Transfer Across the Placenta

34. Maternal to Infant Nutrient Transportation Across The Placenta

35. Fetal to Maternal Transport
Carbon dioxide
Water & urea
Signaling Molecules: Hormones, cytokines, others

37. Factors Affecting Placental Transfer
Placental size
Diffusion distance –
diabetes and infection cause edema of the villi
distance decreases as pregnancy progresses and fetal needs increase
Maternal-placental blood flow
Blood saturation with gases and nutrients

38. Factors Affecting Placental Transfer (cont)
Maternal-placental metabolism of the substance
Disorders in expression or activity of nutrient transporters
Maternal use of tobacco, cocaine, alcohol

39. Metabolic Functions of the Placenta
Glycogen synthesis: from maternal glucose & stored
Cholesterol synthesis: placental cholesterol is precursor for placental progesterone and estrogens
Protein production: rises to 7.5 g per day at term
Lactate: produced in large quantities and needs to be removed

40. Endocrine Functions Placenta Produces Peptide hormones
Human Chorionic gonodotrophin (hCG) - secreted early and helps to maintain synthesis of progesterone
Human placental lactogen (hPL): increase supply of glucose to future by decreasing maternal stores of fatty acids by altering maternal secretion of insulin
Insulin-like growth factors (IGF): IGF signaling system is a major regulator of growth in fetus and infant

41. Endocrine Functions Steroid hormones
Progesterone: produced by placenta, needed to maintain non-contractile uterus
Estrogen: produced by placenta drives many processes in pregnancy
Glucocorticoids: placenta regulates fetal exposure

42. Emerging Understandings
Cytokines & Inflammatory molecules are produced by the placenta as well as adipocytes
Adverse outcomes in obese women may be associated with imbalances due to overproduction from both sources
“In pregnancy complicated with obesity or DM, continuous adverse stimulus is associated with dysregulation of metabolic, vasular and inflammatory pathways.”

43. The Known and Unknown of Leptin in Pregnancy (Hauguel-de-Mouzon, Am J Obstet Gynecology, 2006)
Maternal plasma leptin levels rise in pregnancy
Leptin is produced by placenta
Overproduction of placental leptin is seen with diabetes and htn in pregnancy
Umbilical leptin levels are biomarker of fetal adiposity
“Leptin may be sensitive to maternal energy status and coordinate metabolic response accordingly.” (King, Ann Rev Nutr, 2006)

44. Psychology of Pregnancy
Psychosocial tasks
Rubin
Leaderman’s tasks
Fathers
Stress and Depression

45. Developmental Tasks of Pregnancy (Rubin, 1984)
Seeking safe passage for herself and her child through pregnancy, labor, and delivery.
Ensuring the acceptance by significant persons in her family of the child she bears.
Binding-in to her unknown baby.
Learning to give of herself.

46. Maternal Focus I’m pregnant! Trimester 1 2 There’s a BABY….. 3
I’m going to be a MOM

47. Lederman, RP. Psychosocial Adaptation in Pregnancy, 2nd Ed. 1996
Developmental Tasks of Pregnancy
acceptance of pregnancy
identification with motherhood role
relationship to the mother
relationship to the husband/partner
preparation for labor
processing fear of loss of control & loss of self esteem in labor

48. Psychosocial adjustment during pregnancy: the experience of mature gravidas (Stark, JOGNN, 1997)
N=64 older gravidas (> 35), 46 younger gravidas (< 32) in third trimester
Lederman prenatal self evaluation questionnaire - examines conflicts for 7 steps
In general conflicts about maternal role were similar in both groups
Older gravidas had less concern about fear of helplessness and loss of control in labor - regardless of parity

49. Adolescents: PSYCHOSOCIAL FACTORS THAT INFLUENCE TRANSITION TO MOTHERHOOD (kaiser, 2004)
Gaining acceptance of the pregnancy in the family system
Awareness of the need to develop a sense of responsibility
Planning for a future that includes the baby
Viewing self as a mother

50. Laboring for Relevance: Expectant and New Fatherhood (Jordan, Nursing Research, 1990)
N=56 expectant fathers followed prospectively
Fathers reported:
grappling with the reality of the pregnancy and child
struggling for recognition as a parent from mother, coworkers, friends, family baby and society
plugging away at the role-making of involved fatherhood

51. Jordan, cont. Identified concerns:
Men not recognized as parents but as helpmates and breadwinners
Men felt excluded from childbearing experience by mates, health care providers, and society
Fathers felt that they had no role models for active and involved parenthood

52. Jordon’s Developmental Tasks of Fatherhood
Accepting the pregnancy
Identifying the role of father
Reordering relationships
Establishing relationship with his child
Preparing for the birth experience

53. What about Dad. Psychosocial and mental health issues for new fathers
What about Dad? Psychosocial and mental health issues for new fathers. (Condon, The Australian First Time Fathers Study)
Tasks:
Developing an attachment to the fetus
Adjusting to the dyad becoming a triad
Conceptualizing the self as “father”
What type of father?

54. Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)
Analysis of 1988 NMIHS (n=9122) and NSFG (n=2548) data.

55. Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)

56. Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)
“Knowing the planning status of a pregnancy can help identify women who may need support to engage in prenatal behaviors that are associated with healthy outcomes and appropriate infant care.”

57. Unintended Pregnancy

59. Post-Partum Depression – PRAMS

60. Washington State PRAMS

61. WA State PRAMS