Maternal Anatomy And Physiology

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Maternal anatomy and physiology

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Maternal Anatomy And Physiology

  1. 1. Maternal Anatomy andMaternal Anatomy and PhysiologyPhysiology http://crisbertcualteros.page.tlhttp://crisbertcualteros.page.tl
  2. 2. Definition of Terms 1. Perinatal period - period after birth of an infant weighing 500 g or more and ending at 28 completed days after birth 2. Birth Rate – number of live births per 1000 population 3. Fertility Rate – number of live births per 1000 females aged 15 to 44 yrs.
  3. 3. 4. Live Birth – birth whenever the newborn at or sometime after birth breaths spontaneously or shows any other signs of life 5. Stillbirth or Fetal Death – absence of signs of life at or after birth 6. Neonatal Death – - early – death of the liveborn during the first 7 days after birth - late – death after 7 days but before 29 days
  4. 4. 7. Stillbirth Rate – number of stillborn neonates per 1000 neonates born, including livebirths and stillbirths 8. Neonatal Mortality Rate – number of neonatal deaths per 1000 live births
  5. 5. 9. Perinatal Mortality Rate – number of stillbirths plus neonatal deaths per 1000 total births 10. Infant death – all deaths of liveborn infants from birth through 12 months of age 11. Infant Mortality Rate – number of infant deaths per 1000 live births
  6. 6. 12.Low-birthweight – newborn whose weight is less than 2500 gms 13.Very-Low-Birthweight – newborn whose weight is less than 1500 gms 14.Term Neonate- a neonate born anytime after 37 completed weeks
  7. 7. 15. Preterm Neonate – neonate born before 37 completed weeks 16. Postterm Neonate – neonate born anytime after completion of the 42nd week 17. Abortus – fetus or embryo removed or expelled from the uterus during the first half of gestation (20 wks or less and weighing less than 500 gms.)
  8. 8. 18.Direct Maternal Death – death of the mother resulting from obstetrical complications of pregnancy, labor, or the puerperium, and from interventions, omissions, or incorrect treatment Ex. Exsanguination after uterine rupture
  9. 9. 19. Indirect Maternal Death – maternal death not directly due to an obstetrical cause, but resulting from previously existing disease or a disease that developed during pregnancy, labor, or the puerperium, but which was aggravated by maternal physiological adaptation to pregnancy Ex. Complications of Mitral Valve Prolapse
  10. 10. 20.Nonmaternal Death – death of the mother resulting from accidental or incidental causes not related to pregnancy Ex. Vehicular accident
  11. 11. Maternal AnatomyMaternal Anatomy
  12. 12. External Generative Organs
  13. 13. Mons pubisMons pubis - Fat filled cushion that lies over the symphysis pubis - After puberty, covered by curly hair called the escutcheon - Women– triangular - Men – not well circumscribed
  14. 14. Labia MajoraLabia Majora - Homologous with the male scrotum - Round ligament terminates at the upper border - Merge posteriorly to form the posterior commissure - Puberty covered with hair - Richly supplied with sebaceous glands and plexus of veins
  15. 15. Labia MinoraLabia Minora - Supplied with a variety of nerve endings and are very sensitive - Merge anteriorly into 2 lamellae: - lower- frenulum - upper – prepuce - Posteriorly fuse to form fourchette
  16. 16. ClitorisClitoris - Principal female erogenous organ - Homologue of the penis - Composed of glans, corpus, and 2 crura - Vessels are connected with the vestibular bulbs
  17. 17. VestibuleVestibule - Almond shaped area enclosed by labia minora laterally and extends from the clitoris to fourchette - Peforated by 6 openings
  18. 18. VestibuleVestibule Vestibular Bulbs - Correspond to the anlage of the corpus spongiosum of the penis - Almond-shaped aggregations of veins that lie beneath the mucous membrane on either side of the vestiblue
  19. 19. PerineumPerineum - Support: - pelvic diaphragm consists of levator ani M and coccygeus M posteriorly - urogenital diaphragm made up of deep transverse perineal M, constrictor of urethra, int. & ext. fascial coverings
  20. 20. Internal Generative OrgansInternal Generative Organs
  21. 21. UterusUterus - Posterior wall covered by serosa - Forms the Pouch of Douglas - Upper ant. Wall covered by seosa, lower united with post. Wall of bladder by loose connective tissue - Resembles a flattened pear
  22. 22. UterusUterus - 2 parts; - upper triangular- corpus or body - lower cylindrical- cervix - isthmus- portion between internal os and endometrial cavity
  23. 23. UterusUterus 1. Cornua- portion were oviduct emerges 2. Fundus – convex upper segment above cornua 3. Round ligament – insert below the tubes 4. Broad ligament – fold of peritoneum extending to pekvic side walls 5. Uterosacral ligament – posterior to the uterus
  24. 24. UterusUterus Cervix - Internal os- level at which peritoneum reflects upos the bladder - Portio vaginalis- lower vaginal portion - Nabothian cysts- occluded cervical glands
  25. 25. UterusUterus Endometrium - Epithelium made up of single layer high columnar ciliated cells - Invaginations form the tubular uterine glands
  26. 26. UterusUterus Blood Supply - Internal iliac A  uterine A & ovarian A(aorta) arcuate A  radial A coiled or spiral A (endometrium) - supply midportion & superficial third of the endometrium
  27. 27. UterusUterus Blood Supply - Lateral to cervix, uterine A crosses over the ureter - of significance during hysterectomy
  28. 28. UterusUterus Myometrium - Makes up the major portion of the uterus - Smooth M - Thicker in the inner layers
  29. 29. UterusUterus Ligaments 1. Broad ligament- wing- like structure - mesosalpinx- inner 2/3 where fallopian tubes are attached - infundibulopelvic ligamentor suspensory ligament of the ovary- ovarian vessels traverse
  30. 30. UterusUterus 2. Cardinal Ligament – transverse cervical ligament, Mackenrodt ligament - thick base of the broad ligament united with the supravaginal portion of the cervix
  31. 31. UterusUterus 3. Round Ligament - terminates in the upper portion of the labia majora - corresponds with the gubernaculum testis
  32. 32. UterusUterus 4. Uterosacral Ligament - from the supravaginal portion of the uterus and attaches to the fascia over the sacrum - form the lateral boundaries of the Pouch of Douglas
  33. 33. OviductsOviducts - Fallopian tubes - 4 portions: 1. Interstitial-within the muscular wall of uterus 2. Isthmus- narrow portion 3. Ampulla- wide lateral portion 4. Infundibulum- fimbriated end, funnel-shaped opening
  34. 34. OviductOviduct - Lined by a single layer of columnar cells some ciliated, others secretory - Musculature- inner circular , outer longitudinal - Major innervation is sympathetic
  35. 35. OvariesOvaries - Size in the childbearing years: - length: 2.5-5 cm. - width: 1.5-3 cm. - thickness: 0.6-1.5 cm. - Ovarian fossa of waldeyer- slight depression on the lateral wall of pelvis for ovaries
  36. 36. OvariesOvaries - Attached to broad ligament by mesovarium - Utero-ovarian ligament- just below interstitium to ovary - Infundibulopelvic or suspensory ligament of the ovary- to the pelvic wall; through it course the vessels and nerves
  37. 37. OvariesOvaries - 2 portions: 1. Cortex- outer layer - connective tissue cells where primodial and graafian follicles are scattered - outer portion- tunica albuginea lined by a single layer of cuboidal epithelium, germinal epithelium of Waldeyer
  38. 38. OvariesOvaries 2. Medulla – central portion - composed of loose connective tissue continuous with the mesovarium - with arteries and veins, with small amount of M fibers
  39. 39. The Bony PelvisThe Bony Pelvis
  40. 40. The Bony PelvisThe Bony Pelvis - Composed of the sacrum, coccyx, and 2 innominate bones - Innominate bone formed by the fusion of the ilium, ischium, and pubis - Joined to the sacrum by sacroiliac synchondrosis and to one another at the symphysis pubis
  41. 41. Pelvic anatomyPelvic anatomy - False pelvis lies above the linea terminalis - True pelvis below this boundary - important in childbearing - ishial spines- its distance represents the shortest pelvic diameter - landmark for assessing level of presenting part
  42. 42. Planes and Diameters of the PelvisPlanes and Diameters of the Pelvis Four Imaginary Planes: 1. Plane of the Pelvic inlet – superior strait 2. Plane of the Pelvic Outlet – inferior strait 3. Plane of the Midpelvis – least pelvic dimensions 4. Plane of the Greatest Pelvic Dimension – no obstetrical significance
  43. 43. Pelvic InletPelvic Inlet Pelvic Inlet - 50% of women with a gynecoid pelvic inlet - 4 diameters:
  44. 44. Pelvic InletPelvic Inlet 1. Anteroposterior diameter: - shortest distance between the promontory and the symphysis pubis - obstetrical conjugate - normally measures 10 cm. or more - clinical measurement of the obstetrical conjugate s done by subtracting 1.5-2 cm. from the diagonal conjugate
  45. 45. Pelvic InletPelvic Inlet 2. Transverse diameter - at right angles to the obstetrical conjugate - greatest distance between the linea terminalis on either side :13.5 cm. 3. 2 Oblique diameters - from the sacroiliac synchondrosis to the ileopectineal eminence: 13 cm.
  46. 46. MidpelvisMidpelvis - Measured at the level of the ischial spine - Interspinous diameter : 10 cm. or more, smallest diameter of the pelvis
  47. 47. Pelvic OutletPelvic Outlet - Three diameters: - anteroposterior - transverse: between the ischial tuberosities : 11cm. - posterior sagittal
  48. 48. Pelvic ShapesPelvic Shapes
  49. 49. Pelvic ShapesPelvic Shapes 1. Android : anterior portion is narrow and triangular 2. Platypelloid : flattened gynecoid pelvis - short anteroposterior, wide transverse
  50. 50. Pelvic ShapesPelvic Shapes 3. Gynecoid - found in 50% of women - most suitable for delivery of the fetus 4. Anthropoid - anteroposterior diameter is greater than the transverse - found in 1/3 of women
  51. 51. Menstrual CycleMenstrual Cycle PhysiologyPhysiology
  52. 52. Normal Menstrual CycleNormal Menstrual Cycle Two Segments: 1. Ovarian Cycle a. follicular phase b. luteal phase 2. Uterine Cycle a. proliferative phase b. secretory phase
  53. 53. Normal Menstrual CycleNormal Menstrual Cycle lasts from 21 – 35 days  duration of 2 – 6 days of flow  average blood loss of 20 – 60 ml  changes in weight gain – 1 – 3 lbs. - due to fluid retention
  54. 54. Definition of Menstrual Cycle IrregularitiesDefinition of Menstrual Cycle Irregularities 1. Oligomenorrhea – infrequent, irregularly timed episodes of bleeding usually occurring at intervals of more than 35 days 2. Polymenorrhea – Frequent but regularly timed episodes of bleeding usually occurring at intervals of 21 days or less 3. Menorrhagia – Regularly timed episodes of bleeding that are excessive in amount (>80 ml) and duration of flow (> 5 days)
  55. 55. 4.4. Metrorrhagia – irregularly timed bleeding 5. Menometrorrhagia – excessive prolonged bleeding that occurs at irregularly timed, frequent intervals 6. Hypomenorrhea – regularly timed bleeding that is decreased in amount 7. Intermenstrual Bleeding – (usually not of excessive amount) that occurs between bleeding otherwise normal menstrual cycle
  56. 56. Endometrial CycleEndometrial Cycle Main Stages of the Endometrial Cycle: 1. Early Proliferative Phase - 2/3 shed off during menstruation - reepithilialization starts even before menstraution ceases - 5th day epithelial surface is restored, revascularization of endometrium - endometrial thickness - < 2mm
  57. 57. -- glands narrow, tubular structures follow almost a straight parallel course - glandular epithelium – low columnar, nuclei round, more vesicular, larger - stroma: - deep layer – packed densely, nuclei deep staining, small - superficial layer – packed loosely, nuclei round, more vesicular larger - mitotic figures – present by fifth day until 2 – 3 days after ovulation - blood vessels numerous but no extravasated blood or lymphatic infiltrarion
  58. 58. 2. Late Proliferative Phase - endometrium thicker due to glandular hyperplasia and increased steomal ground substance - stroma: - superficial layer – loose stroma with glands widely separated - deep layer – dense stroma with glands crowded and tortuous - glandular epithelium – taller and pseudostratified
  59. 59. Proliferative PhaseProliferative Phase • Day by day dating is not possible • Vary in length from 7-21 days
  60. 60. 3. Early Secretory Phase - 3 zones become well-defined: a. basal zone – adjacent to myometrium, undergoes little changes b. compact zone – beneath endometrial surface, glands are straight and narrower with secretions c. spongy zone – in between both layers, glands are tortuous, serrated, little stroma - stroma edematous
  61. 61. 4. Mid to Late Secretory Phase - extremely vascular, succulent, rich in glycogen - suited for implantation and growth of blastocyst - decidualization – stromal cells around blood vessels undergo hypertrophic changes - intimate relationship of arteries and aterioles - formation of pericellular basement membrane around stromal cells
  62. 62. 5. Premenstrual Phase - 2 – 5 days prior to menstruation - regression of the corpus luteum - decrease progesterone and estrogen - changes: a. regression in endometrial growth - decrease thickness, glands collapse - spiral arterioles more coiled  inc. resistance to arterial blood flow  hypoxia b. infiltration of stroma by polymorphonuclears and mononuclear leukocytes - pseudoinflammatory appearance
  63. 63. 6. Menstrual Phase - arterial and venous bleeding, more arterial - leakage from vessels and hematoma formation * Secretory Phase of constant duration - 12 - 14 days
  64. 64. Accurate Dating by HistologicAccurate Dating by Histologic CriteriaCriteria • 14 – 16 : (assuming ovulation occurs at day 14) subnuclear glycogen with vacuoles in glandular epithelium • 17 -18 : vacuoles displace nuclei toward middle of cells, mitosis rare • 18 : mitosis cease • 20 : near maximum secretion into lumen, few vacuoles left
  65. 65. • 20 – 21 : interstitial edema, abundant ground substance • 23 – 24 : predecidualization - increase cytoplasm of stromal cells around arterioles then throughout stroma • 24 – 28 : marked decrease in endometrial thickness - extravasation of blood - disintegration of stromal cells
  66. 66. Ovarian CycleOvarian Cycle • At birth 1-2 million oocytes remain in the ovary • At puberty, 300,000 only available for ovulation • Only 400 – 500 will ultimately be released • Oocytes persist at diplotene resting stage of meiosis until ovulation • Mitotic stasis- due to oocyte maturation inhibitor (OMI) from granulosa cells • Midcycle LH surge disrupts the gap junction allowing meiosis to resume
  67. 67. Follicular PhaseFollicular Phase 1. Primordial follicles - initial recruitment and growth gonadotropin independent - FSH resumes control of follicular differentiation - changes: oocyte growth expansion of a single layer of follicular granulosa cells to a multilayer of cuboidal cells
  68. 68. 2. Preantral Follicle - breakdown of corpus luteum, follicular growth stimulated by FSH - formation of zona pellucida – glycogen- rich - mitotic proliferation of granulosa cells - theca cells proliferate - production of estrogen – released to systemic circulation - dominant follicle determined
  69. 69. 3. Preovulatory follicle - fluid-filled antrum – plasma with granulosa cell secretions - oocyte connected to follicle by a stalk of specialized granulosa cells (cumulus oophorus) - high levels of estrogen > 48 hrs. enhaces LH release  LH surge  luteinization of granulosa cells  progesterone production  ovulation
  70. 70. Granulosa cell-derived peptides: 1. Inhibin – inhibits FSH release a. Inhibin A – mainly active in luteal phase b. Inhibin B – secreted in follicular phase - stimulated by FSH 2. Activin – stimulates release of FSH from pituitary gland and potentiates its action in the ovary
  71. 71. 4. Ovulation - midcycle LH surge responsible for increase in prostaglandins and proteolytic enzymes in follicular wall - weakens wall and allow perforation
  72. 72. Luteal PhaseLuteal Phase Corpus LuteumCorpus Luteum -- remaining follicular shell - primary regulator of luteal phase - produce progesterone which support endrometrium - if pregnancy does not occur- regression - estradiol and progesterone provide negative feedback  decrease FSH and LH
  73. 73. Corpus LuteumCorpus Luteum -- function depends on continued LH production - in absence of stimulation – regress in 12 – 16 days  corpora albicans - pregnancy : hCG mimics LH action stimulates corpus luteum to continually produce progesterone - luteal-placental shift – 5 wks. AOG
  74. 74. Decidua of the EndometriumDecidua of the Endometrium - Decidua – highly specialized endomerium of pregnancy - Trophoblast invasion occurs
  75. 75. Decidual StructureDecidual Structure Three portions: Decidua basalis- directly beneath blastocyst implantation Decidua Capsularis – overlies the enlarging blastocyst separating it from the rest of the uterine cavity - in contact internally with the avascular extraembryonic fetal membrane, chorion laeve 3. Decidua Parietalis/Decidua Vera – lines the remainder of the uterus
  76. 76. Placental CirculationPlacental Circulation Maternal blood->basal plate >maternal arterial pressure > chorionic plate > bath external microvillous surface of chorionic villi > venous orifices > uterine V = spiral A perpendicular to ; veins parallel to uterine wall
  77. 77. AmnionAmnion - Innermost fetal membrane contiguous with the amniotic fluid - Avascular structure - Provides almost all of the tensile strength of fetal membranes - Its integrity is important to successful fetal outcome - Metabolic function: involved in solute and water transport to maintain amniotic fluid homeostasis
  78. 78. Umbilical cordUmbilical cord - Funis - Has two arteries and one vein - A component of fetal membranes - Wharton jelly- extracellular matrix of specialized connective tissue
  79. 79. Fetal CirculationFetal Circulation
  80. 80. Maternal PhysiologyMaternal Physiology
  81. 81. Reproductive Tract
  82. 82. UterusUterus - During pregnancy, it is transformed into a thin- walled organ sufficient to accommodate the fetus, placenta, and amniotic fluid - Non-pregnant Pregnant Volume: 10 ml cavity 5- 20 L Weight: 70 g 1100 g - Uterine enlargement involves stretching and marked hypertrophy of muscle cells - stimulated by estrogen and some progesterone influence
  83. 83. UterusUterus - Arrangement of Muscle cells: 1. Outer hoodlike layer- arches over the fundus and extends into the ligaments 2. Middle layer – dense network of M fibers perforated in all direction by blood vessels 3. Internal layer – sphincter-like fibers around the orifice of the fallopian tubes and the internal os of the cervix
  84. 84. UterusUterus - Braxton Hicks contraction – painless uterine contraction in a normal pregnancy - Uteroplacental Blood Flow- delivers most substances essential for growth and metabolism
  85. 85. CervixCervix - During pregnancy, the cervix undergoes softening and cyanosis due to increased vascularity and edema - Mucus plug – copious amount of mucus produced to obstruct the cervical canal - Bloody show- expulsion of the mucus plug - cervical mucus beading in pregnancy due to progesterone - Ferning- amniotic fluid leakage
  86. 86. OvariesOvaries - Ovulation ceases and maturation of new follicles is suspended in pregnancy - Corpus luteum- maximally functions in progesterone production in the 1st 6-7 wks. of pregnancy - Luteoma of pregnancy – solid ovarian tumors produced due to exaggerated luteinization reaction
  87. 87. OvariesOvaries - Theca-lutein Cysts – benign ovarian lesions resulting from exaggerated physiological follicle stimulation - associated with markedly elevated serum hCG levels
  88. 88. Fallopian TubesFallopian Tubes - Musculature undergoes hypertrophy - Epithelium of tubal mucosa becomes flattened
  89. 89. Vagina and PerineumVagina and Perineum -- Chadwick sign- violet discoloration due to increased vascularity - Changes in preparation for distention: 1. increase thickness of mucosa 2. Loosening of connective tissue 3. Hypertrophy of smooth M cells
  90. 90. SkinSkin
  91. 91. Abdominal wallAbdominal wall - Striae gravidarum- “stretch marks” - reddish, slightly depressed streaks - Diastasis recti- rectus M separated at midline
  92. 92. PigmentationPigmentation - Linea nigra –– markedly pigmented midline of linea alba - Chloasma/melasma gravidarum – irregular brownish patches on the face and neck
  93. 93. Vascular ChangesVascular Changes - Vascular spiders – minute red elevations on the skin, face, neck upper chest and arms - Palmar erythema- no clinical significance and disappear shortly after pregnancy
  94. 94. BreastBreast
  95. 95. BreastsBreasts - Early weeks – breast tingling and tenderness - Second month- increase in size, veins become visible, nipple become larger, darker and more erectile - Colostrum – thick yellowish fluid - Glands of Montgomery – small elevations on the broader and darker areols
  96. 96. Metabolic ChangesMetabolic Changes
  97. 97. Weight gainWeight gain - Attributed to the uterus and its contents, breasts, increase in blood volume and extracellular fluid - Average wt. gain: 12.5 kg. or 27.5 lbs.
  98. 98. Water MetabolismWater Metabolism - Increased water retentionIncreased water retention - At term, water content of fetus, placenta, and amniotic fluid : 3.5 l - Increased blood volume and size of uterus and breasts : 3.0 l - The total amount 6.5 ml
  99. 99. Protein MetabolismProtein Metabolism - At term, fetus and placenta weigh 4 kg. with 500 g of protein - Nitrogen balance increases with gestation
  100. 100. Carbohydrate MetabolismCarbohydrate Metabolism - Mild fasting hypoglycemia, postprandial hyperglycemia, hyperinsulinemia - Increased basal level of plasma insulin
  101. 101. Fat MetabolismFat Metabolism -- Concentration of lipids, lipoprotein, apolipoproteis in plasma increase - LDL increases may be attributed to estrogen - Fat usually deposited in the central rather than peripheral sites
  102. 102. Electrolyte and Mineral MetabolismElectrolyte and Mineral Metabolism - 1000 meq of Na and 300 meq of K are retained in pregnancy - Total Ca and Magnesium levels decrease
  103. 103. Hematological changesHematological changes
  104. 104. Blood VolumeBlood Volume - Increases to 40-45% above non-pregnant levels - Functions of prenancy-induced hypervolemia: 1. Meet demans of enlarged uterus 2. Protect mother and fetus against deliterious effects of impaired venous effects in the supine and erect position 3. Safeguard the mother against the adverse effects of blood loss associated with parturition
  105. 105. Iron MetabolismIron Metabolism - Total iron requirement: 1000 mg - Amount of iron absorbed from the diet and that mobilized from stores is insufficient to meet maternal demands - Supplemental iron is necessary - Blood loss: Normal delivery: 500 ml - cesarean delivery: 1000 ml
  106. 106. Cardiovascular SystemCardiovascular System
  107. 107. HeartHeart - Resting pulse rate increases by 10 beats/min. - Cardiac sounds: exaggerated splitting of the 1st heart sound, increased loudness of both sounds - Systolic murmur noted in 90% of pregnant women
  108. 108. HeartHeart - Cardiac Output: increased in early pregnancy - much greater in the 2nd stage of labor - Increase is lost immediately after delivery
  109. 109. Circulation and Blood PressureCirculation and Blood Pressure - Arterial BP decreases to a nadir at midpregnancy and rises thereafter - In late pregnancy, blood flow at the lower extremities is retarded due to occlusion of the pelvic veins and inferior vena cava - Supine hypotensive syndrome- due to compression of venous system from enlarging uterus
  110. 110. Respiratory TractRespiratory Tract
  111. 111. Pulmonary FunctionPulmonary Function - Respiratory rate is not changed - Increased functions: - tidal volume - minute ventilatory volume - minute oxygen uptake - Decreased functions: - functional residual capacity - residual volume
  112. 112. Acid-Base EquilibriumAcid-Base Equilibrium - Increased tidal volume lowers blood PCO2 - Induced by progesterone mainly - Respiratory alkalosis stimulated the increased affinity of maternal hemoglobin for oxygen (Bohr effect)
  113. 113. Uirnary SystemUirnary System
  114. 114. KidneyKidney Renal Changes: 1. Kidney size increases 2. Glomerular filtration rate and renal plasma flow increases early 3. Dilatation of pelves, calyces, ureter 4. Renal bicarbonate threshold decreases 5. Osmoregulation is altered
  115. 115. UretersUreters - More ureteral dilatation on the R due to: - cushioning on the L by sigmoid - dextrorotaiton of he uterus - Progesterone may contribute to ureteral dilatation
  116. 116. BladderBladder - Some women develop stress urinary incontinence - Few anatomic changes noted- deepening and widening of trigone
  117. 117. Gastrointestinal TractGastrointestinal Tract
  118. 118. - Stomach and intestines are displaced by the enlarging uterus - Pyrosis (heartburn)- common during pregnancy, caused by reflux of acidic secretions - Epulis - hyperemic and softened gums - Hemorrhoids – due to constipation and elevated pressure in veins
  119. 119. Liver - Concentration of serum albumin decreases - Leucine aminopeptidase activity is elevated – has oxytocinase activity Gallbladder - Decreased contractility due to progesterone
  120. 120. Please visit:Please visit: http://crisbertcualteros.page.tlhttp://crisbertcualteros.page.tl

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