Maternal changes during pregnancy for undergraduate

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  • There are many physiologic changes in pregnancy. Some mimic the signs, symptoms, or laboratory finding of disease in the nonpregnant woman yet are normal in pregnancy. Therefore , knowledge of normal maternal physiologic changes helps avoid unnecessary diagnostic or therapeutic interventions.
  • The uterus undegoes an enormous increase in weight from the 70g nonpregnant size to approximately 1100g at term, primarily through hypertrophy of existing myometrial cells. Also, the uterine cavity, which in the nongravid state has a volume of less than 10 ml, increases up to as much as 5 liters. Cardiac output to the uterus is less than 2% in the nongravid state, but increases to 15%-20% at term.
  • The increase of vaginal discharge consists of epithelial cells and cervical mucus due to hormonal stimulation. Cervical mucus that has been spread on a glass slide and allowed to dry no longer forms a fernlike pattern but has a granular appearance.
  • Circulatory increases result in breast engorgement and venous prominence. Similar tenderness may occur just before menses.
    Montgomery’s tubercles: sometimes called montgomery’s follicles, the small elevations surrounding the areolae, enlarge and become more prominent. enlargement of these glands occurs at 6-8 weeks and is due to hormonal stimulation.
    Colostrum: during the latter portion of pregnancy, a thick yellow fluid can be expressed from the nipples. Ultimately, lactation depends on synergistic actions of estrogen, progesterone, prolactin, hPL , cortisol and insulin.
  • As the uterus enlarges and the diaphragm becomes elevated, the heart is displaced upward and somewhat to the left with rotation on its long axis, so that the apex beat is moved laterally to the left.
    With the anatomical changes in the heart, there may also be alterations in heart rhythm and electrocardiographic finding, and non pathologic murmurs may occur. ECG changes are probably due to the change in position of the heart and may include a 15-20 degree shift to the left in the electrical axis. There may be reversible ST, T and Q waves changes.
    In order to detect pathologic changes in the ECG, one has to know about physiologic changes during pregnancy. Diaphragmatic elevation causes leftward deviation of the heart. The result is a 15 degree left axis deviation. Q wave may be present in leads III and AVF. Inverted T waves may be seen in lead III. Unspecific ST changes may occur. Caused by the leftward deviation, the heart may appear enlarged in the chest roentgenogram.
  • The first heart sound may be split, with increased loudness of both portions. As many as 90% gravid women may have a late systolic or ejection murmur attributable to the increase in the stroke volume and the decrease in blood viscosity. The murmur disappear soon after birth.
    Caution is needed in interpreting murmurs during pregnancy, particularly systolic murmurs, because such physiologic alterations do not necessarily indicate heart disease and must be differentiated from pathologic changes.
    During pregnancy, cardiac output is very sensitive to positional alterations. In the supine position, the inferior vena cava is compressed by the enlarged uterus, resulting in decreased cardiac output. Although most women do not become overtly hypotensive when lying supine, some may have symptoms that include dizziness, light-headedness, and syncope. This is termed the inferior vena cava syndrome.
  • Increases in stoke volume and heart rate are responsible for the changes in cardiac output. Increased metabolic demands of mother and fetus are the cause for this rise in cardiac output. The resting oxygen consumption of the parturient increases approximately 20% compared to non-pregnant levels. Increased hormonal levels, estrogen and prostaglandins cause a vasodilatation and therefore a decrease in systemic vascular resistance and pulmonary vascular resistance. Decreased peripheral resistance causes a small decrease in systolic blood pressure and a more marked decrease in diastolic blood pressure.
  • Maternal blood volume increases during pregnancy, reaching a maximum of 30% at approximately 28-32 weeks of gestation. Plasma volume increases from 40-70 ml/kg which represents a rise of 40%. The different rate of increase in blood and plasma volume accounts for the relative anemia of pregnancy. The dilutional anemia of the parturient decreases the oxygen carrying capacity of the blood. Several mechanism compensate for this disadvantage: increased cardiac output, decreased blood viscosity, vasodilatation and right shift of the oxyhemoglobin dissociation curve provide increased flow and better oxygen extraction in the tissue.
    Cardiac out put begins a progressive rise in the first trimester and peaks by 22-28 weeks of gestation. The rise represents the increased metabolic demands of the mother and fetus as pregnacy progresses.
  • The compression of the inferior vena cava by the uterus and the pressure of the fetal presenting part on the common iliac veins can result in decreased blood return to the heart. This decreases cardiac output, leads to a fall in blood pressure, and causes edema in the lower extremities.
  • Normal pregnant patients are relatively resistant to the hypertensive effects of the increased levels of renin-angiotensin-aldosterone, whereas patients with hypertensive disease of pregnancy are not.
    Glucosuria during pregnancy is not necessarily abnormal. Glucose is excreted in the urine at some point during pregnancy in more than 50% of women. Glucosuria may be explained by the increase in GFR with impairment of tubular resorption capacity for filtered glucose. Glucosuria can also predispose pregnant women to urinary tract infection.
  • Increased residual volume and with the dilated collecting system, urinary stasis results, predispose to an increased incidence of pyelonephritis in patients with asymptomatic bacteriuria.
  • Pregnancy related changes of the respiratory system are the result of both anatomic and functional changes.
  • The exact etiology of this nausea is unknown, the morning sickness appears related to elevated levels of pregesterone, human chorionic gonadotropin, and relaxation of the smooth muscle of the stomach.
    In general, there is decreased gastrointestinal motility during pregnancy because of increasing levels of progesterone. As a result, gastric emptying time is prolonged and there is decreased eophageal tone and imcompetence of the esophageal tone and incompetence of the esophageal-stomach sphincter, leading to gastric reflux and heart burn, common complaints in pregnancy.
  • Maternal changes during pregnancy for undergraduate

    1. 1. Maternal cahnges during pregnancy DR Manal Behery Professor Ob&Gyne Zagazig University 2014
    2. 2. Reproductive tract (1)  Uterus : from 50g-1100g from <10ml – 5L from pyriform to globular Fundl level From 7.5cm -35cm
    3. 3. Lower uterine segment
    4. 4. Reproductive tract (2)  Braxton Hicks contraction: sporadic, irregular, asymmetrical, and painless, low pressure, lasting < 30 sec
    5. 5. Reproductive tract (2)  Cervix and vulva —— Chadwick’s sign 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 Ovary: slightly enlarged, corpus luteum regresses after 10 weeks’ gestation
    6. 6. Breasts: increase in circulation     Engorgement and venous prominence 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 Colostrum secretion:
    7. 7. Breast changes
    8. 8. Montgomery tubercles non pigmented nodules (12-20) around the areola in 2nd month (enlarged sebaceous glands or rudimentary lactiferous ducts).
    9. 9. (2) Cardiovascular system changes
    10. 10. Cardiovascular changes (2 )  Position and size of heart  ECG changes Increased heart rate (+15%) 15-degree left axis deviation
    11. 11. Cardiovascular changes (2)  Inferior vena cava syndrome:
    12. 12. Cardiovascular changes (cont)         Stroke volume +30% Heart rate +15% Cardiac output +40% Oxygen consumption +20% SVR (systemic vascular resistance) -5% Systolic BP -10mmHg Diastolic BP -15mmHg Mean BP -15mmHg
    13. 13. Cardiovascular changes (4)  Blood volume +30%  Plasma volume +40%  Red blood cell volume +20%  Delusional anemia Increase cardiac output Decrease blood viscosity Vasodilatation
    14. 14. Venous pressure : Venous blood flow  unchanged in the upper body  Significantly increases in the lower extremities, esp. during supine, sitting or standing position, returns to near normal in lateral recumbent position
    15. 15. ( 3) Urinary system changes
    16. 16. Increased frequency of micturation
    17. 17. Kidney slightly enlarged  Renal plasma flow +35%  Glomerular filtration rate +50%  Serum creatinine, uric acid and urea nitrogen  Renin, angiotensin I and II Renin substrate  Glucosuria (50%) + 
    18. 18. Renal changes       renal pelves dilated Ureters (esp. right side) dilated Bladder tone reduced Bladder capacity reduced Residual volume increased Chance of pyelonephritis increaased
    19. 19. Pulmonary changes  Mucosal hyperemia  Subcostal angle  Chest circumference and diameter  Diaphragmatic excursion  Tidal volume  PO2 is increased, PCO2 is decreased.  Total lung capacity decrease  Minute ventilation  Mild respiratory alkalosis +30-40% -15% +30-40%
    20. 20. Gastrointestinal change
    21. 21. Skin changes  Chloasma  Striae gravidarum  Linea alba——linea nigra   Vascular spiders Skin nevi
    22. 22. Nervous system disorders
    23. 23. Muscloskeletal system
    24. 24. Metabolism    Basal metabolism rate, BMR +15-20% Weight gain 12.5 Fetus 3400g Placenta 650 Amniotic 800 Uterus 960 Plasma, red cells 1450 Mammary glands 405 Extracellular, extravascular water 1480 Deposition of fat and protein 3345 Insulin resistance
    25. 25. A quiz
    26. 26. 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%
    27. 27. 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 1015% beats per min D. arterial blood pressure and vascular resistance increases E. The heart is displaced upward and to the left
    28. 28. 3 . Epulis is a pregnancy-related vascular swelling of the A. Gums B. Nailbed C. Larynx D. Nares E. Epiglottis
    29. 29. THANK YOU
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