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الشريحة 1


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الشريحة 1

  1. 1. Maternal ChangesMaternal Changes with Pregnancywith Pregnancy Dr. Ashraf fouda Ob/Gyn. SpecialistOb/Gyn. Specialist Egypt – Domiatt General HospitalEgypt – Domiatt General Hospital
  2. 2. Pregnancy is a period ofPregnancy is a period of adaptation for :adaptation for : • The needs of the fetusThe needs of the fetus • Meeting the stress ofMeeting the stress of pregnancy and labourpregnancy and labour
  4. 4. (A) The whole(A) The whole uterusuterus
  5. 5. increase fromincrease from 7.5 x 5 x 2.57.5 x 5 x 2.5 cmcm in nonpregnant statesin nonpregnant states toto 35 x 25 x 20 cm35 x 25 x 20 cm at termat term i.e. the volume increasei.e. the volume increase 1000 time1000 time 11--SizeSize
  6. 6. increases fromincreases from 50 gm50 gm in nonpregnant statein nonpregnant state toto 1000 gm1000 gm at termat term 22--WeightWeight
  7. 7. pyriform in the nonpregnant state , becomes globular at 8th week , then pyriform by 16th week till term . 33--ShapeShape
  8. 8. with ascent from the pelvis , the uterus usually undergoes rotation with tilting to the right (dextrorotation) due to the presence of the rectosegmoid colon on the left side. 44--PositionPosition
  9. 9. 5 - Consistency :5 - Consistency : becomes progressivelybecomes progressively softersofter due to :due to : i - Increased vascularityi - Increased vascularity ii - Presence of amniotic fluidii - Presence of amniotic fluid
  10. 10. from the firstfrom the first trimestertrimester onwards , theonwards , the uterus undergoesuterus undergoes irregular painlessirregular painless contractionscontractions (Braxton Hicks(Braxton Hicks contractions)contractions) .. They may causeThey may cause some discomfortsome discomfort late in pregnancylate in pregnancy 66--ContractilityContractility
  11. 11. 7- Capacity7- Capacity increases fromincreases from 4 ml4 ml in non-pregnantin non-pregnant state tostate to 4000 ml4000 ml at termat term
  12. 12. (B) Myometrial(B) Myometrial changeschanges
  13. 13. 1 -1 - HypertrophyHypertrophy (estrogen(estrogen effect)effect) rather thanrather than hyperplasiahyperplasia (progesterone(progesterone effect)effect) till 14th weektill 14th week, then, then the fetus exerts a directthe fetus exerts a direct stretchstretch
  14. 14. of theof the lowerlower uterineuterine segmentsegment (L.U.S.) from(L.U.S.) from the isthmusthe isthmus and lowerand lower
  15. 15. Formation of lowerFormation of lower uterine segmentuterine segment After 12 weeks,After 12 weeks, the isthmusthe isthmus (0.5cm)(0.5cm) starts to expandstarts to expand gradually to form the lowergradually to form the lower uterine segment whichuterine segment which measuresmeasures 10 cm10 cm in length atin length at termterm
  16. 16. Upper Uterine SegmentUpper Uterine Segment • PeritoneumPeritoneum:: Firmly-attachedFirmly-attached • Myometrium:Myometrium: 3 layers; outer3 layers; outer longitudinal, middle oblique andlongitudinal, middle oblique and inner circular.inner circular. • The middle layer forms 8-shaped fibersThe middle layer forms 8-shaped fibers around the blood vessels to controlaround the blood vessels to control postpartum hemorrhagepostpartum hemorrhage
  17. 17. Upper Uterine SegmentUpper Uterine Segment • Decidua:Decidua: Well-developedWell-developed • Membranes:Membranes: Firmly-attachedFirmly-attached • Activity:Activity: Active, contracts,Active, contracts, retracts and becomes thickerretracts and becomes thicker during labour.during labour.
  18. 18. Lower Uterine SegmentLower Uterine Segment • PeritoneumPeritoneum:: Loosely-Loosely- attachedattached • MyometriumMyometrium :: 2 layers;2 layers; outer longitudinal and innerouter longitudinal and inner circular.circular.
  19. 19. Lower Uterine SegmentLower Uterine Segment • DeciduaDecidua:: Poorly-developedPoorly-developed • MembranesMembranes:: Loosely-Loosely- attached.attached. • ActivityActivity:: Passive, dilates,Passive, dilates, stretches and becomes thinnerstretches and becomes thinner during labourduring labour
  20. 20. The junction between theThe junction between the upper uterine segmentupper uterine segment (U.U.S.) which is thick and the(U.U.S.) which is thick and the lower uterine segment whichlower uterine segment which is thin is called theis thin is called the physiologic contraction ringphysiologic contraction ring at the level of the symphysisat the level of the symphysis pubispubis (not seen or felt)(not seen or felt)
  21. 21. (C) Uterine(C) Uterine blood vesselsblood vessels
  22. 22. 11 -- Uterine artery lumen:Uterine artery lumen: is doubled and its blood flowis doubled and its blood flow increases 5 timesincreases 5 times 2 -2 - Myometrial and decidualMyometrial and decidual arteriesarteries (spiral arteries) undergo(spiral arteries) undergo fibrinoid degeneration due to 2fibrinoid degeneration due to 2 waves of trophoblastic migration ,waves of trophoblastic migration , so they become dilated to be theso they become dilated to be the uteroplacentaluteroplacental arteriesarteries
  23. 23. •Uterine blood flowUterine blood flow increasesincreases progressively andprogressively and reaches aboutreaches about 500500 ml / minute at termml / minute at term
  24. 24. (D) Changes in the cervix :(D) Changes in the cervix : 1 -1 - It becomesIt becomes hypertrophied , soft andhypertrophied , soft and bluishbluish in colour due toin colour due to oedema and increasedoedema and increased vascularity.vascularity.
  25. 25. 2 - Soon after conception , a thick2 - Soon after conception , a thick cervical secretion obstructs thecervical secretion obstructs the cervical canal forming acervical canal forming a mucous plugmucous plug .. 3 - The endocervical epithelium3 - The endocervical epithelium proliferates and or evertedproliferates and or everted forming cervical ectopyforming cervical ectopy (previously called erosion)(previously called erosion)
  26. 26. (E) Changes in fallopian tubes(E) Changes in fallopian tubes and ligaments (round and broad):and ligaments (round and broad): InactiveInactive ,, elongatedelongated ,, marked increase inmarked increase in vascularityvascularity There may be broadThere may be broad ligamentligament varicose veinsvaricose veins
  27. 27. (F) Changes in the vagina :(F) Changes in the vagina : The vagina becomesThe vagina becomes softsoft ,, warmwarm ,, moistmoist withwith increased secretion andincreased secretion and violetviolet in colourin colour (Chadwick's sign)(Chadwick's sign) due todue to increased vascularityincreased vascularity
  28. 28. (G) Changes in the vulva :(G) Changes in the vulva : •It becomes soft, violet in colour • Oedema and varicosities may develop
  29. 29. (H) Changes in the ovaries(H) Changes in the ovaries 1 - Both ovaries are1 - Both ovaries are enlarged due to increasedenlarged due to increased vascularity and oedemavascularity and oedema particularly the ovaryparticularly the ovary which conatins the corpuswhich conatins the corpus luteum .luteum .
  30. 30. (H) Changes in the ovaries(H) Changes in the ovaries 2 - Corpus luteum continues to2 - Corpus luteum continues to grow tillgrow till 7 - 8 weeks7 - 8 weeks , then it, then it stops growingstops growing , It becomes, It becomes inactive and startsinactive and starts degeneration at 12 weeksdegeneration at 12 weeks (degeneration is completed(degeneration is completed after labour)after labour)
  31. 31. Corpus luteum secretesCorpus luteum secretes 1.estrogen ,1.estrogen , 2.progesterone,2.progesterone, 3.relaxin3.relaxin hormoneshormones
  32. 32. (H) Changes in the ovaries(H) Changes in the ovaries 3 -3 - Ovulation ceases duringOvulation ceases during pregnancy due topregnancy due to pituitary inhibition by thepituitary inhibition by the high levels of oestrogenhigh levels of oestrogen and progesteroneand progesterone
  33. 33. • RelaxinRelaxin is a proteinis a protein hormone.hormone. • Its exact role in pregnancyIts exact role in pregnancy is unknown. • It may induceIt may induce softness andsoftness and effacementeffacement of the cervix.of the cervix.
  34. 34. II - HaematologicalII - Haematological ChangesChanges
  35. 35. (A) Blood volume(A) Blood volume The total blood volumeThe total blood volume increases steadily fromincreases steadily from early pregnancy to reachearly pregnancy to reach a maximum ofa maximum of 35-45 %35-45 % above the non-pregnantabove the non-pregnant levellevel at 32 weekat 32 week ..
  36. 36. - Plasma volume :Plasma volume : Increases fromIncreases from 26002600 ml byml by ±± 45 %45 % ((12501250 in the 1stin the 1st pregnancy) andpregnancy) and 15001500 mlml in subsequent pregnanciesin subsequent pregnancies
  37. 37. - Red blood cell massRed blood cell mass : • Increases fromIncreases from 1400 ml1400 ml (nonpregnant) by(nonpregnant) by 33 %33 % (± 450(± 450 ml) due to increased productionml) due to increased production resulting fromresulting from erythropoeitin orerythropoeitin or action of hCG or HPL .action of hCG or HPL . • The increase is steady till fullThe increase is steady till full term.term.
  38. 38. The increase in plasmaThe increase in plasma volume is more than thevolume is more than the increase in red blood cellincrease in red blood cell mass (Hb mass) resultingmass (Hb mass) resulting in haemodilutionin haemodilution (physiologic anemia)(physiologic anemia)
  39. 39. However, theHowever, the minimal Hb.minimal Hb. accepted isaccepted is 10-11 gm%10-11 gm%
  40. 40. Values of increased blood volumeValues of increased blood volume 1 - Meets increased demands1 - Meets increased demands for uterus , baby .... etc .for uterus , baby .... etc . 2 - Protects against supine2 - Protects against supine hypotension syndrome .hypotension syndrome . 3 - Protects against fluid loss3 - Protects against fluid loss in labour .in labour .
  41. 41. Increased blood volumeIncreased blood volume more than the increasemore than the increase in red cell mass , leadsin red cell mass , leads toto decreased blooddecreased blood viscosityviscosity which leadswhich leads toto decrease indecrease in peripheral resistanceperipheral resistance
  42. 42. (B) Blood(B) Blood indicesindices
  43. 43. 1 - Decreased Hb % and RBCs % : • Erythrocytes decrease fromErythrocytes decrease from 4.5 million / mm3 to 3.74.5 million / mm3 to 3.7 million / mm3million / mm3 (due to the(due to the relative increase in plasmarelative increase in plasma volume more than red cellvolume more than red cell mass) .mass) .
  44. 44. ErythrocytesErythrocytes contentscontents fromfrom 2,3- DPG2,3- DPG increasesincreases which competes for 02which competes for 02 binding sites in the Hbbinding sites in the Hb molecule , thus releasingmolecule , thus releasing more 02 to the fetusmore 02 to the fetus ..
  45. 45. Hb concentrationsHb concentrations fallsfalls fromfrom 14 gm / dl14 gm / dl ToTo 12 gm / dl.12 gm / dl.
  46. 46. 2 -2 - M.C.H.CM.C.H.C : no change: no change 3 -3 - M.C.V.M.C.V. ::  ,,  oror nono changechange (depending on(depending on the availability of Fe).the availability of Fe). 4-4- FragilityFragility of R.B.Cs:of R.B.Cs: ..
  47. 47. 5 -5 - ReticulocytesReticulocytes : mild: mild  6 -6 - E.S.RE.S.R :: from 12 tofrom 12 to 50 mm / hour50 mm / hour 7 –7 – FibrinogenFibrinogen::  fromfrom 200 - 400 mg / dl to 400 -200 - 400 mg / dl to 400 - 600 mg / dl.600 mg / dl.
  48. 48. 8 -8 - White blood cells:White blood cells: (from 7.000 / mm3 to 10.500 /(from 7.000 / mm3 to 10.500 / mm3 during pregnancy and upmm3 during pregnancy and up to 16.000 / mm3 during labour :to 16.000 / mm3 during labour : --  PNL & its enzymes .PNL & its enzymes . - Lymphocytes : no change .- Lymphocytes : no change .
  49. 49. 9 -9 - Platelets:  or  10-Total plasma proteins : slightly  (mainly  albumin) resulting in  osmotic pressure.
  50. 50. (C) Coagulation(C) Coagulation systemsystem
  51. 51. • PlateletsPlatelets  oror . (controversial).. (controversial). • FibrinogenFibrinogen doubled to 600 mg %doubled to 600 mg % • Factor VIIIFactor VIII tripled .tripled . • Factor VII & factor XFactor VII & factor X areare doubleddoubled • Factor XI & factor XIIIFactor XI & factor XIII slightslight  • Fibrinolytic activityFibrinolytic activity ..
  52. 52. • Therefore pregnancy is aTherefore pregnancy is a hypercoagulative statehypercoagulative state .. • All these changes areAll these changes are reversed after labour withreversed after labour with  RBCs production (notRBCs production (not  destruction)& the excess Fedestruction)& the excess Fe is stored .is stored .
  53. 53. Ill - CardiovascularIll - Cardiovascular system changessystem changes
  54. 54. (A) Changes in the heart(A) Changes in the heart
  55. 55. As the diaphragm is elevatedAs the diaphragm is elevated progressively during pregnancyprogressively during pregnancy the apex isthe apex is displaced upwardsdisplaced upwards and to the leftand to the left so that it lies in theso that it lies in the 4th intercostal space outside the4th intercostal space outside the midclavicular line.midclavicular line. Position:Position:
  56. 56. Pulse rate :Pulse rate : - The resting pulse rateThe resting pulse rate increases byincreases by 8 beats / min.8 beats / min. (8 weeks) and(8 weeks) and 16 beats / min16 beats / min.. (full term).(full term). -Some episodes of-Some episodes of ectopic beatsectopic beats - Water hummer pulse .- Water hummer pulse .
  57. 57. Heart soundsHeart sounds • The first heart soundThe first heart sound becomebecome louder before midpregnancylouder before midpregnancy and splitting of this sound mayand splitting of this sound may occur due to earlier closer of theoccur due to earlier closer of the mitral than the tricuspid valvemitral than the tricuspid valve • The intensity of theThe intensity of the secondsecond heart soundheart sound may increase.may increase.
  58. 58. Heart soundsHeart sounds •The third soundThe third sound becomesbecomes louder before mid-louder before mid- pregnancy and persistspregnancy and persists as such till one week postas such till one week post partum.partum. •The fourth soundThe fourth sound maymay be detectable bybe detectable by phonocardiography.phonocardiography.
  59. 59. MurmursMurmurs Systolic functional murmursSystolic functional murmurs develop in most of women, usuallydevelop in most of women, usually early systolicearly systolic, but, but mid systolicmid systolic murmursmurmurs may occur and heard overmay occur and heard over the left sternal edge,the left sternal edge, they are thought to be due tothey are thought to be due to functional tricuspid regurgitationfunctional tricuspid regurgitation
  60. 60. ECG CHANGESECG CHANGES • The main features of ECG may beThe main features of ECG may be attributed to the changes in theattributed to the changes in the position of the heart.position of the heart. • The axisThe axis undergoesundergoes left shift by 15 -left shift by 15 - 28°.28°. • TheThe QRSQRS complexes become ofcomplexes become of lowlow voltagevoltage, and, and T waveT wave becomesbecomes flattenedflattened..
  61. 61. (B) Haemodynamic(B) Haemodynamic changeschanges
  62. 62. 1 - Cardiac output1 - Cardiac output (C.O.P.)(C.O.P.)
  63. 63. Cardiac output:Cardiac output: increases mainly by increasedincreases mainly by increased stroke volume rather thanstroke volume rather than increased heart rate reaching aincreased heart rate reaching a maximum of 40%maximum of 40% above theabove the non-pregnant levelnon-pregnant level at 20 weeksat 20 weeks to be maintained till termto be maintained till term..
  64. 64. Cardiac outputCardiac output Distribution :Distribution : • 400 ml400 ml to theto the uterusuterus ,, • 300300 mlml to theto the kidneyskidneys ,, • 300 ml300 ml toto skinskin ,, • 300 ml300 ml toto GITGIT ,, breastbreast && heartheart
  65. 65. • Values : Distributes extra 02 •During labour : C.O.P. increases moreC.O.P. increases more particularly during theparticularly during the second stage due tosecond stage due to pain ,pain , uterine contractions , anduterine contractions , and expulsive effortsexpulsive efforts pushingpushing the blood into the generalthe blood into the general circulationcirculation
  66. 66. • Postpartum : the increasedthe increased C.O.P. isC.O.P. is maintained for upmaintained for up toto 4 days4 days and thenand then declines rapidlydeclines rapidly
  67. 67. 2 - Arterial blood2 - Arterial blood pressurepressure
  68. 68. Although C.O.P.Although C.O.P. incease , yet A.B.P.incease , yet A.B.P. isis decreaseddecreased inin midtrimestermidtrimester toto increase again inincrease again in 3rd trimester3rd trimester
  69. 69. This is due to: i -- Decreased PeripheralDecreased Peripheral resistanceresistance :: (mainly affect diastolic B.P.)(mainly affect diastolic B.P.) due to :due to : vasodilatation +vasodilatation + increase metabolism +increase metabolism + arteriovenous shunt atarteriovenous shunt at placenta .placenta .
  70. 70. ii -ii - Supine hypotensionSupine hypotension :: may develop in some women inmay develop in some women in late pregnancy while lying supinelate pregnancy while lying supine due to compression on the I.V.C.due to compression on the I.V.C. by the large pregnant uterus ,by the large pregnant uterus , resulting in decreased venousresulting in decreased venous returnreturn  C.O.P. and low B.P.C.O.P. and low B.P. to the extent thatto the extent that faintingfainting maymay occuroccur
  71. 71. iii -iii - DecreasedDecreased sensitivity of bloodsensitivity of blood vesselsvessels toto angiotensin IIangiotensin II which is vasoconstrictorwhich is vasoconstrictor
  72. 72. Vena Cava SyndromeVena Cava Syndrome
  73. 73. • The posture of the pregnantThe posture of the pregnant woman affects arterial bloodwoman affects arterial blood pressure.pressure. • Typically, it isTypically, it is highest whenhighest when she is sittingshe is sitting,, lowest when lyinglowest when lying in the lateral recumbent positionin the lateral recumbent position and intermediate when supine.and intermediate when supine.
  74. 74. PeripheralPeripheral VasodilatationVasodilatation
  75. 75. blood flow to the skin,blood flow to the skin, particularly in the handsparticularly in the hands and feet generally givingand feet generally giving the pregnant women athe pregnant women a feeling of warmthfeeling of warmth Peripheral VasodilatationPeripheral Vasodilatation
  76. 76. Peripheral VasodilatationPeripheral Vasodilatation Increases the congestion ofIncreases the congestion of nasal mucosa leading tonasal mucosa leading to a common complaint ofa common complaint of nasal obstruction andnasal obstruction and bleedingbleeding (epistaxis).(epistaxis).
  77. 77. 3 - Venous pressure3 - Venous pressure
  78. 78. Increased venous pressureIncreased venous pressure in the lower limbs due to :in the lower limbs due to : 1.1. Back pressure from the compressedBack pressure from the compressed I.V.C. by the pregnant uterus .I.V.C. by the pregnant uterus . 2.Mechanical pressure of the uterus2.Mechanical pressure of the uterus on pelvic veins .on pelvic veins . 3.Increased venous return from3.Increased venous return from internal iliac veins --> increaseinternal iliac veins --> increase pressure in external iliac veins .pressure in external iliac veins .
  79. 79. Increased venous pressureIncreased venous pressure in the lower limbsin the lower limbs Predisposes to :Predisposes to : Oedema ,Oedema , varicose veinsvaricose veins and pilesand piles
  80. 80. Oedema and varicose veins in theOedema and varicose veins in the lower limbs & vulva are due tolower limbs & vulva are due to i -i -  Venous pressure .Venous pressure . ii - Relaxation of the smooth muscles inii - Relaxation of the smooth muscles in the wall of the veins by progesteronethe wall of the veins by progesterone iii -iii -  Osmotic pressure in blood .Osmotic pressure in blood . iv -iv -  Capillary permeability (due toCapillary permeability (due to progesterone and aldosterone).progesterone and aldosterone). v -v -  Interstitial pressure (Na retention).Interstitial pressure (Na retention).
  81. 81. Varicose Veins treatmentsVaricose Veins treatments 1.1. avoid longavoid long periods ofperiods of standingstanding and encourageand encourage active exercise. 2. avoid2. avoid constricting clothesconstricting clothes.. 3. keep the3. keep the legs elevatedlegs elevated whilewhile sitting and during sleep.sitting and during sleep.
  82. 82. 4. use of elastic stockings. These should be removed at night and applied with leg elevated before getting out of bed in the morning (empty veins). 5. stretch panties may be necessary for vulval varicosities.
  83. 83. IV - RespiratoryIV - Respiratory systemsystem
  84. 84. (A) Anatomically:(A) Anatomically: The enlargedThe enlarged uterus displacesuterus displaces the diaphragmthe diaphragm upup to ± 4 cm .to ± 4 cm .
  85. 85. This result in :This result in : 1.1. The diaphragmatic mobilityThe diaphragmatic mobility is reduced andis reduced and respirationrespiration becomes mainly thoracicbecomes mainly thoracic .. 2.2. Widen the subcostal angleWiden the subcostal angle and increases the transverseand increases the transverse diameter of the chest.diameter of the chest.
  86. 86. Respiratory functionsRespiratory functions The respiratory rateThe respiratory rate does not increase duringdoes not increase during pregnancy from itspregnancy from its normal rate ofnormal rate of 14 - 15 /14 - 15 / minute.minute.
  87. 87. Overbreathing (deep respiration) occurs due to the effect of excess progesterone
  88. 88. Shortness of breathShortness of breath (the need to breath becomes a(the need to breath becomes a conscious one)conscious one) andand dyspneadyspnea are commonare common complaint of the pregnantcomplaint of the pregnant women which may be due towomen which may be due to unfamiliarity with low C02unfamiliarity with low C02 tension in the alveolartension in the alveolar capillariescapillaries..
  89. 89. The vital capacityThe vital capacity 1.The inspiratory capacity1.The inspiratory capacity (Tidal volume +(Tidal volume + inspiratory volume)inspiratory volume) isis decreaseddecreased in latein late pregnancypregnancy
  90. 90. 2.The expiratory reserve2.The expiratory reserve volumevolume (maximum amount of air(maximum amount of air which can be expired afterwhich can be expired after normal expiration) isnormal expiration) is reducedreduced 3.The residual volume3.The residual volume is reduced .is reduced .
  91. 91. The reduction in:The reduction in: 1.The inspiratory capacity1.The inspiratory capacity 2.The expiratory reserve2.The expiratory reserve volumevolume 3.The residual volume3.The residual volume is not significantis not significant..
  92. 92. 4.4.The tidal volumeThe tidal volume :: (amount of gas inspired(amount of gas inspired or expired in eachor expired in each respiration)respiration) risesrises through-out pregnancythrough-out pregnancy by about 40 % .by about 40 % .
  93. 93. HyperventilationHyperventilation is due tois due to increased tidalincreased tidal volume notvolume not respiratory raterespiratory rate
  94. 94. V - Urinary systemV - Urinary system
  95. 95. (A) Kidney and kidney(A) Kidney and kidney function testsfunction tests •Renal blood flow and glomerular filtration rate increases by 50 % . This leads to increased excretion
  96. 96. • Therefore:Therefore: 1.1. There isThere is  serum creatinineserum creatinine (due to(due to  creatinine cleareance) ,the samecreatinine cleareance) ,the same forfor uric aciduric acid.. 2.2.  blood ureablood urea .. 3.3.  kidney excretion of glucose duekidney excretion of glucose due toto  filtration load andfiltration load and  renalrenal threshold leading tothreshold leading to renalrenal glucosuriaglucosuria
  97. 97. Therefore , in interpretatingTherefore , in interpretating the results of kidneythe results of kidney function test you should takefunction test you should take into consideration thatinto consideration that the highest normal values inthe highest normal values in pregnancy = the lowestpregnancy = the lowest normal values in non-normal values in non- pregnant statepregnant state
  98. 98. (B) Ureters(B) Ureters Dilatation of the uretersDilatation of the ureters and renal pelvis due to :and renal pelvis due to : i - Relaxation of thei - Relaxation of the ureters by the effect ofureters by the effect of progesterone .progesterone .
  99. 99. ii - Pressure against theii - Pressure against the pelvic brim by the uteruspelvic brim by the uterus particularly on the rightparticularly on the right side due to dextroposedside due to dextroposed uterus and dilatation ofuterus and dilatation of the right ovarian vesselsthe right ovarian vessels
  100. 100. (C) Bladder and urethra(C) Bladder and urethra • Frequency of micturitionFrequency of micturition in early pregnancy due to :in early pregnancy due to : i - Pressure on the bladderi - Pressure on the bladder by the enlarged uterus .by the enlarged uterus . ii - Congestion of theii - Congestion of the bladder muscosa .bladder muscosa .
  101. 101. • Urinary stress incontinence may develop for the first time during pregnancy (due to decreased intraurethral pressure and decreased length of the urethra) and spontaneously relieved later on
  102. 102. VI - GastrointestinalVI - Gastrointestinal tracttract & liver& liver
  103. 103. 1 - Gingivitis :1 - Gingivitis : There is increased vascularity and tendency for bleeding as well as hypertrophy of the interdental papillae
  104. 104. • The gums may becomeThe gums may become hyperemic and soft and mayhyperemic and soft and may bleedbleed when mildly traumatized,when mildly traumatized, as with a tooth with a tooth brush. • Epulis of pregnancyEpulis of pregnancy may develop.may develop. Treated by dental hygiene andTreated by dental hygiene and cryosurgery for severe casescryosurgery for severe cases.
  105. 105. 2 - Ptyalism:2 - Ptyalism: • It is excessive salivation which isIt is excessive salivation which is more common in association withmore common in association with oral sepsis .oral sepsis . • It is due toIt is due to failure to swallowfailure to swallow salivasaliva and not due to increase in amount.and not due to increase in amount. • Smoking is stopped andSmoking is stopped and anticholinergic drugs may helpanticholinergic drugs may help..
  106. 106. 3 - Nausea and vomiting3 - Nausea and vomiting Nausea (morning sickness)Nausea (morning sickness) and vomitingand vomiting (emesis gravidarum)(emesis gravidarum) occur in early monthsoccur in early months
  107. 107. 4 - Appetite changes4 - Appetite changes (longing or craving)(longing or craving)
  108. 108. • The pregnant woman dislikesThe pregnant woman dislikes some foods and odours whilesome foods and odours while desires othersdesires others • Reduced sensitivity of theReduced sensitivity of the taste budstaste buds during pregnancyduring pregnancy creates the desire forcreates the desire for markedly sweet, sour , or saltmarkedly sweet, sour , or salt foods .foods .
  109. 109. (pica)(pica) Deviation may be soDeviation may be so extreme to the extentextreme to the extent of eating blackboardof eating blackboard chalk , coal or mudchalk , coal or mud
  110. 110. 5 - Indigestion5 - Indigestion and flatulenceand flatulence
  111. 111. This is probably due to :This is probably due to : i - Decreased gastric acidityi - Decreased gastric acidity caused by regurgitation ofcaused by regurgitation of alkaline secretion from thealkaline secretion from the intestine to the stomach .intestine to the stomach . ii - Decreased gastric motilityii - Decreased gastric motility (progesterone effect).(progesterone effect).
  112. 112. 6 - Heart burn6 - Heart burn Due to reflux of acidicDue to reflux of acidic gastric contents to thegastric contents to the oesophagusoesophagus
  113. 113. The treatment includes :The treatment includes : (a)(a) small frequent mealssmall frequent meals toto prevent overdistension ofprevent overdistension of the stomach ,The eveningthe stomach ,The evening meal should be taken atmeal should be taken at least 3 hours before goingleast 3 hours before going to bedto bed
  114. 114. (b)(b) avoidavoid fatty foods,fatty foods, chocolate, and smoking, aschocolate, and smoking, as these relax the lowerthese relax the lower esophageal sphincter.esophageal sphincter. (c) the(c) the bed should be raisedbed should be raised at the head (15-20 cm), andat the head (15-20 cm), and an extra pillow is extra pillow is used.
  115. 115. (d)(d) AntacidAntacid PreparationsPreparations containing aluminiumcontaining aluminium hydroxide arehydroxide are favoured.favoured.
  116. 116. 7 - Constipation7 - Constipation due to : i - Reduced motility of largei - Reduced motility of large intestineintestine (progesterone effect).(progesterone effect). ii - Increased water reabsorptionii - Increased water reabsorption from large intestinefrom large intestine (aldosterone effect).(aldosterone effect).
  117. 117. 7 - Constipation7 - Constipation iii - Pressure on the pelvic colon by the pregnant uterus. iv - Sedentary life during pregnancy .
  118. 118. It is treated byIt is treated by (a) evacuation of the(a) evacuation of the bowel at the samebowel at the same time each daytime each day (bowel training)(bowel training)
  119. 119. (b)(b) diet rich in fiberdiet rich in fiber inin the form of vegetables,the form of vegetables, fruits, and branfruits, and bran (c)(c) milkmilk and avoidand avoid dehydration bydehydration by increasing fluid intake.increasing fluid intake.
  120. 120. (d)(d) minimize coffee andminimize coffee and teatea as they are diureticsas they are diuretics and cause dehydration.and cause dehydration. (e)(e) increase physicalincrease physical activityactivity and avoidand avoid sedentary life.sedentary life.
  121. 121. (f) a(f) a mild laxativemild laxative maymay be needed. Liquidbe needed. Liquid paraffin is betterparaffin is better avoided as it preventsavoided as it prevents absorption of fatabsorption of fat soluble vitamins.soluble vitamins.
  122. 122. In some womenIn some women ironiron supplementationsupplementation may be the causemay be the cause
  123. 123. 8 - Gall stones8 - Gall stones More tendency to stoneMore tendency to stone formation due to atonyformation due to atony and delayed emptyingand delayed emptying of the gall bladderof the gall bladder
  124. 124. 9 - Haemorroids9 - Haemorroids
  125. 125. due to :due to : i - Mechanical pressure on the pelvic veins. ii - Laxity of the walls of the veins by progesterone iii - Constipation.
  126. 126. 10 - Appendix10 - Appendix Is displaced upwards and laterally (pain and tenderness due to appendicitis is higher than in nonpregnant state)
  127. 127. AppendixAppendix
  128. 128. LiverLiver i - Decreased albumin andDecreased albumin and increased globulin resultingincreased globulin resulting inin decreased A/G ratiodecreased A/G ratio ii - Increased heat labile serumii - Increased heat labile serum alkaline phosphatase .alkaline phosphatase .
  129. 129. Therefore bothTherefore both A/GA/G ratioratio andand heat labileheat labile alkaline phosphatasealkaline phosphatase are not reliable as liverare not reliable as liver function tests duringfunction tests during pregnancypregnancy
  130. 130. VII - MetabolicVII - Metabolic changeschanges
  131. 131. (A) Weight gain The averageThe average weight gain inweight gain in pregnancy ispregnancy is 10 - 12 kg10 - 12 kg
  132. 132. The increaseThe increase occurs mainly inoccurs mainly in the second andthe second and third trimester at athird trimester at a rate ofrate of 350 - 400350 - 400 gm/ weekgm/ week
  133. 133. Out of the 11 kg weight gainOut of the 11 kg weight gain 6 kg is6 kg is composed ofcomposed of maternal tissuesmaternal tissues (breast,(breast, fat, blood and uterinefat, blood and uterine tissues), andtissues), and 5 kg of fetal tissue , placenta5 kg of fetal tissue , placenta and amniotic fluidand amniotic fluid
  134. 134. Maternal TissuesMaternal Tissues Increases during weeks of Pregnancy 0 200 400 600 800 1000 1200 1400 1600 10 wk 20 wk 30 wk 40 wk Uterus Mammary Gland Plasma Volume King JC. Am J Clin Nutr 71 (5(S));2000.
  135. 135. Products of ConceptionProducts of Conception Increases during weeks of PregnancyIncreases during weeks of Pregnancy 0 500 1000 1500 2000 2500 3000 3500 10 wk 20 wk 30 wk 40 wk Fetus Placenta Amniotic Fluid King JC. Am J Clin Nutr 71 (5(S));2000.
  136. 136. Out of the 11 kgOut of the 11 kg weight gainweight gain:: 77kg are waterkg are water,, 33kg fat andkg fat and 11kg proteinkg protein
  137. 137. )B) Water metabolismB) Water metabolism There is tendency toThere is tendency to water retentionwater retention secondary tosecondary to sodium retentionsodium retention
  138. 138. (C) Protein metabolism(C) Protein metabolism There is tendency forThere is tendency for nitrogen retentionnitrogen retention (+ ve nitrogen balance)(+ ve nitrogen balance) for fetal and maternalfor fetal and maternal tissue formationtissue formation
  139. 139. (D) Carbohydrate metabolism(D) Carbohydrate metabolism Pregnancy is potentiallyPregnancy is potentially diabetogenicdiabetogenic -- Alimentary glucosuriaAlimentary glucosuria maymay occur inoccur in earlyearly pregnancy .pregnancy . -- Renal glucosuriaRenal glucosuria may occur inmay occur in thethe middlemiddle of pregnancy .of pregnancy .
  140. 140. (E) Fat metabolism(E) Fat metabolism There is increase of plasma lipids with tendency to acidosis (HPL action)
  141. 141. (F) Mineral metabolism There isThere is increasedincreased demanddemand for iron ,for iron , calcium ,calcium ,
  142. 142. VIII - MusculoskeletalVIII - Musculoskeletal changeschanges
  143. 143. (a)(a) Increased mobility ofIncreased mobility of pelvic jointspelvic joints due todue to softening of the joints andsoftening of the joints and ligaments caused byligaments caused by progesteroneprogesterone andand relaxinrelaxin (b)(b) Flattening of feetsFlattening of feets ..
  144. 144. (c)(c) Progressive lordosisProgressive lordosis leading to lordotic gait &leading to lordotic gait & backache (backache ( by highby high heals).heals). (d)(d) Pendulous abdomenPendulous abdomen inin multigravida resulting inmultigravida resulting in many complicationsmany complications
  145. 145. BackacheBackache
  146. 146. • The majority of pregnantThe majority of pregnant women complain of lowwomen complain of low backache which increasesbackache which increases as pregnancy pregnancy advances. • It is due toIt is due to increasedincreased lumbar lordosislumbar lordosis to counter-to counter- balance the forwardbalance the forward growth of the uterusgrowth of the uterus
  147. 147. •This puts strain on ligaments and muscles leading to pain. • Strain of sacroiliac joint is relatively common. •Progesterone causes softening and relaxation of ligaments.
  148. 148. Backache is treated by: (a) more periods of rest. (b) use of maternity corset. (c) local heat in the form of hot water bag or infrared lamp
  149. 149. (d) analgesics given systemically or as local creams,local creams, Paracetamol is the drug ofParacetamol is the drug of choice, Non-steroidal anti-choice, Non-steroidal anti- inflammatory drugs asinflammatory drugs as indomethacin may be givenindomethacin may be given (e)(e) physiotherapyphysiotherapy may bemay be needed.needed.
  150. 150. OrthopaedicOrthopaedic consultationconsultation isis indicated if pain isindicated if pain is severe, or radiates tosevere, or radiates to the legs, and in thethe legs, and in the presence ofpresence of neurological signsneurological signs
  151. 151. Leg crampsLeg cramps •These are common inThese are common in thethe second halfsecond half ofof pregnancy particularlypregnancy particularly at nightat night.. •The exact cause isThe exact cause is unknown.unknown.
  152. 152. It may be related to shift ofIt may be related to shift of blood away from theblood away from the muscle, i.e.,muscle, i.e., ischaemicischaemic cramp, or it may becramp, or it may be tetanictetanic cramp caused by lack ofcramp caused by lack of calcium, or increasedcalcium, or increased phosphorous, or bothphosphorous, or both
  153. 153. • Treated byTreated by takingtaking calciumcalcium tabletstablets, and, and reducing the intakereducing the intake of phosphorous-containingof phosphorous-containing substancessubstances as milk, meat, andas milk, meat, and cheese.cheese. • Vitamin B complexVitamin B complex may be tried.may be tried. • Leg massageLeg massage andand hyperextension of foot helphyperextension of foot help during the attackduring the attack.
  154. 154. Round ligament strainRound ligament strain • Pain is felt along the roundPain is felt along the round ligament and in the groin.ligament and in the groin. • Pain unilateral and left-sided,Pain unilateral and left-sided, (dextroflexion ).(dextroflexion ). • It is due to stretching of theIt is due to stretching of the nerve fibres in the roundnerve fibres in the round ligaments.ligaments.
  155. 155. IX - EndocrineIX - Endocrine systemsystem
  156. 156. 1 - Anterior pituitary1 - Anterior pituitary
  157. 157. i - Increase in sizei - Increase in size more than increase inmore than increase in vascularityvascularity This renders anteriorThis renders anterior pituitary liable forpituitary liable for ischaemiaischaemia
  158. 158. ii -ii - Pregnancy cellPregnancy cell (modified(modified chromophobe) appears duechromophobe) appears due to increased hCG .to increased hCG . iii -iii - Prolactin levelProlactin level increasesincreases up to 150 ng /ml at term toup to 150 ng /ml at term to ensure lactation .ensure lactation .
  159. 159. 2 - Posterior pituitary2 - Posterior pituitary Does not hypertrophy ,Does not hypertrophy , but increase itsbut increase its oxytocin secretionoxytocin secretion near termnear term
  160. 160. 3 - Thyroid gland3 - Thyroid gland There is diffuseThere is diffuse slightslight enlargementenlargement of the glandof the gland
  161. 161. Gland activity isGland activity is  asas evidenced by normal free T4evidenced by normal free T4 (although total T4(although total T4 ) due to) due to  thyroid binding globulinthyroid binding globulin (TBG) ,(TBG) , BMR 20 % ,BMR 20 % ,  total T3total T3 ,, protein bound iodine andprotein bound iodine and TSHTSH
  162. 162. 4 - Parathyroid gland4 - Parathyroid gland Hypertrophy due toHypertrophy due to increased demandincreased demand for Calciumfor Calcium
  163. 163. 5 - Suprarenal gland5 - Suprarenal gland HypertrophyHypertrophy particularly theparticularly the cortexcortex resulting in increasedresulting in increased glucocorticoidsglucocorticoids (cortisone)(cortisone) and increasedand increased mineralocorticoidsmineralocorticoids (aldosterone)(aldosterone)
  164. 164. 6 - Insulin6 - Insulin increased mainlyincreased mainly due to HPLdue to HPL (anti -(anti - insulin hormone)insulin hormone)
  165. 165. 7 -Ovaries7 -Ovaries corpus luteum ofcorpus luteum of pregnancypregnancy functions till 8-12 wks.functions till 8-12 wks. when its function is takenwhen its function is taken by the placentaby the placenta
  166. 166. XI - Skin changesXI - Skin changes
  167. 167. 1 - Persistance of basalPersistance of basal body temperaturebody temperature (BBT) elevation(BBT) elevation beyondbeyond the expected day ofthe expected day of menstruationmenstruation (due to increased(due to increased progesterone).progesterone).
  168. 168. 2 - Spider telangiectasisSpider telangiectasis & palmar erythema& palmar erythema due todue to increased estrogenincreased estrogen oror cutaneous vasodilatationcutaneous vasodilatation
  169. 169. 3 -3 - CutaneousCutaneous vasodilatationvasodilatation (hyperaemia)(hyperaemia)
  170. 170. leads to :leads to : ii -- Masks pallorMasks pallor due todue to anaemia with or withoutanaemia with or without palmar erythema .palmar erythema . ii -ii -  Glandular activitiesGlandular activities (sweat & sebaceous(sweat & sebaceous glands).glands). iii -iii - Sensation of heat andSensation of heat and nasal congestionnasal congestion
  171. 171. 44 - Pigmentation- Pigmentation due to increased estrogendue to increased estrogen oror melanocyte stimulating hormonemelanocyte stimulating hormone oror ACTHACTH
  172. 172. •In the faceIn the face == chloasmachloasma graviderom = mask ofgraviderom = mask of pregnancypregnancy a butterfly pigmentationa butterfly pigmentation on the cheeks and nose .on the cheeks and nose . It usually disappears fewIt usually disappears few months after labourmonths after labour ..
  173. 173. •In abdomenIn abdomen:: Linea Nigra=Linea Nigra= pigmentation inpigmentation in midline below themidline below the umbilicusumbilicus
  174. 174. Linea nigraLinea nigra
  175. 175. Stria gravidarumStria gravidarum pigmentation in the lowerpigmentation in the lower abdomen ,abdomen , flanks , inner thighs ,flanks , inner thighs , buttocks & breast andbuttocks & breast and increase as pregnancyincrease as pregnancy advancesadvances
  176. 176. It starts bluishIt starts bluish (stria rubra)(stria rubra) ,, then becomes pale to becomethen becomes pale to become whitewhite (stria albicans)(stria albicans) afterafter delivery , which persistsdelivery , which persists (primigravida has stria rubra(primigravida has stria rubra only ,while multigravida hasonly ,while multigravida has bothboth S.RS.R and S.A)and S.A)
  177. 177. It It may be due toIt It may be due to mechanicalmechanical stretching or increasedstretching or increased glucocorticoidsglucocorticoids which resultswhich results in rupture of the elasticin rupture of the elastic fibres in the dermis andfibres in the dermis and exposure of the vascularexposure of the vascular subcutaneous tissuessubcutaneous tissues
  178. 178. 5 - Secretions5 - Secretions increase in sweatincrease in sweat and sebaceousand sebaceous glands activityglands activity
  179. 179. (B) Breast signs(B) Breast signs
  180. 180. • Diagnostic in primigravidaDiagnostic in primigravida andand may persist after delivery .may persist after delivery . • In multigravida it may be dueIn multigravida it may be due to the previous pregnancies .to the previous pregnancies . • TheyThey may occur with anymay occur with any hyperestrogenhyperestrogen , so they are, so they are not diagnostic for pregnancynot diagnostic for pregnancy
  181. 181. i - First month :i - First month : increased size & vascularityincreased size & vascularity (dilated veins)(dilated veins) , mastodynia, mastodynia may be present which rangesmay be present which ranges from tingling to frank painfrom tingling to frank pain due to hormonal responses ofdue to hormonal responses of the mammary ducts andthe mammary ducts and alveolar systemalveolar system
  182. 182. ii - Second month :ii - Second month : increased pigmentation ofincreased pigmentation of the nipple & areola andthe nipple & areola and prominence ofprominence of Montgomery tuberclesMontgomery tubercles (nonpigmented nodules(nonpigmented nodules around thearound the primaryprimary areola (12 - 20)areola (12 - 20)
  183. 183. Montgomery tuberclesMontgomery tubercles They were thought to beThey were thought to be enlarged sebaceousenlarged sebaceous glands, but recently theyglands, but recently they are found to be the lips ofare found to be the lips of orifices of peripheralorifices of peripheral active lacteal ductsactive lacteal ducts
  184. 184. Breast changesBreast changes
  185. 185. iii -iii - Third month :Third month : secretion ofsecretion of colostrumcolostrum (thick yellowish(thick yellowish fluid) which can befluid) which can be expressed from theexpressed from the nipplenipple
  186. 186. iv -iv - Fourth month :Fourth month : a pigmented areaa pigmented area appears around theappears around the primary areola calledprimary areola called thethe secondary areolasecondary areola
  187. 187. Lower limbs signsLower limbs signs i -i - EdemaEdema :: bilateral and pittingbilateral and pitting ii -ii - Varicose veinsVaricose veins
  188. 188. XII. NeurologicXII. Neurologic SystemSystem
  189. 189. • Sensory changes fromSensory changes from compression of nervescompression of nerves • Tension headachesTension headaches • Carpal tunnel syndrome dueCarpal tunnel syndrome due to edemato edema • Numbness and tinglingNumbness and tingling related to postural changesrelated to postural changes
  190. 190. 1.1. HeadacheHeadache It is relatively common, andIt is relatively common, and attributed to intracranialattributed to intracranial vasodilatation caused byvasodilatation caused by oestrogen andoestrogen and progesteroneprogesterone
  191. 191. 1.1. HeadacheHeadache • It is most troublesome in theIt is most troublesome in the second trimester, but maysecond trimester, but may persist throughout pregnancy.persist throughout pregnancy. • However, headache may be dueHowever, headache may be due to lack of sleep, or lack of sleep, or overwork. • An analgesic is prescribedAn analgesic is prescribed.
  192. 192. 2.2. FaintingFainting It results from loweringIt results from lowering of blood pressure due toof blood pressure due to vasodilatation whichvasodilatation which occur in pregnancyoccur in pregnancy
  193. 193. 3.3. InsomniaInsomnia During pregnancy someDuring pregnancy some women are sleepy andwomen are sleepy and depressed, others may bedepressed, others may be irritable and sufferirritable and suffer insomniainsomnia
  194. 194. 4.Carpal tunnel syndrome4.Carpal tunnel syndrome Caused byCaused by compressioncompression ofof thethe median nervemedian nerve as itas it passes through its fibrouspasses through its fibrous tunnel at the wrist, as atunnel at the wrist, as a result of fluid retentionresult of fluid retention and oedema in pregnancyand oedema in pregnancy
  195. 195. There is tingling,There is tingling, numbness andnumbness and burning sensationburning sensation affecting the radialaffecting the radial side of the handside of the hand
  196. 196. •Treatment:Treatment: includes reassurance, use of aincludes reassurance, use of a wrist splint, diuretics, nonwrist splint, diuretics, non steroidal anti-inflammatorysteroidal anti-inflammatory drugs, and local injection ofdrugs, and local injection of hydrocortisone in the tunnelhydrocortisone in the tunnel below the fibrous roofbelow the fibrous roof (retinaculum)(retinaculum)
  197. 197. Operation is rarelyOperation is rarely needed duringneeded during pregnancy by incisingpregnancy by incising the retinaculum tothe retinaculum to relieve compressionrelieve compression
  198. 198. Other compressionOther compression neuropathies affectneuropathies affect the lateral cutaneousthe lateral cutaneous nerve of the thigh ,nerve of the thigh , obturator andobturator and peroneal nervesperoneal nerves
  199. 199. LEUCORRHOEALEUCORRHOEA The normal vaginalThe normal vaginal discharge increasesdischarge increases during pregnancy becauseduring pregnancy because of excess oestrogen andof excess oestrogen and may form a complaintmay form a complaint
  200. 200. However, a pathologicalHowever, a pathological discharge, e.g.,discharge, e.g., monilial infectionsmonilial infections which is common inwhich is common in pregnancy must bepregnancy must be excluded.excluded.