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Physiological changes during pregnancy
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Pregnancy Physiology.ppt

Pregnancy Physiology.ppt

  1. 1. MATERNAL PHYSIOLOGY IN PREGNANCY
  2. 2. OBJECTIVE <ul><li>Pregnancy causes physiologic changes in all maternal organ systems; most return to normal after delivery. </li></ul><ul><li>In general, the changes are more dramatic in multifetal than in single pregnancies. </li></ul><ul><li>Major adaptations in maternal anatomy, physiology, and metabolism are required for successful pregnancy. </li></ul><ul><li>Nearly every organ system is affected. </li></ul><ul><li>Understanding these changes helps to distinguish normal physiology from pathological disease states. </li></ul>
  3. 3. BODY WATER METABOLISM <ul><li>Condition of chronic water overload </li></ul><ul><li>Active Na and water retention </li></ul><ul><li>1. Changes in osmoregulation </li></ul><ul><li>2. Renin-angiotensin system </li></ul><ul><li>Body water increase 6.5L  8.5L </li></ul><ul><li>1. 1500 cc increase in blood vol </li></ul><ul><li>2. RBC increase ~400cc </li></ul><ul><li>Elevation of maternal CO </li></ul>
  4. 4. OSMOREGULATION <ul><li>Na retention increases 900 mEq but serum Na decreases 3-4 mmol/l </li></ul><ul><li>Plasma osmolality decreases 10 mOsm/kg </li></ul><ul><li>Enhanced tubular reabsorption of Na secondary to aldosterone,estrogen and deoxycorticosterone. </li></ul><ul><li>Increased GFR and Atrial Natriuretic Peptide favor Na excretion </li></ul>
  5. 5. CARDIOVASCULAR CHANGES <ul><li>Heart </li></ul><ul><li>Displaced to the left and upward </li></ul><ul><li>Apex is moved laterally </li></ul><ul><li>Apparent cardiomegaly on chest x-ray </li></ul><ul><li>Increase in left ventricular end- diastolic dimension </li></ul><ul><li>Increase in left ventricular wall mass c/w mild hypertrophy Increase in preload with increase capacitance of the systemic and pulmonary vascular resistances to prevent rise in CVP or wedge pressure. </li></ul><ul><li>Grade II-III systolic flow murmurs at left lower sternal border </li></ul>
  6. 6. RESPIRATORY CHANGES <ul><li>Upper Respiratory Tract </li></ul><ul><li>Hyperemia and edema induced by estrogen </li></ul><ul><li>Nasal stuffiness and epistaxis </li></ul><ul><li>Mechanical changes (earlier than mechanical pressure of rising uterus </li></ul><ul><li>Chest circumference expands 5-7 cm </li></ul><ul><li>Subcostal angle increases from 68 to 103 degrees </li></ul><ul><li>Transverse diameter increases 2cm </li></ul><ul><li>Level of diaphragm rises 4cm but excursion is not impeded </li></ul><ul><li>Respiratory muscle function is not affected by pregnancy </li></ul>
  7. 7. LUNG VOLUME AND PULMONARY FUNCTION <ul><li>Elevation of the diaphragm decreases the volume of the lungs in the resting state, reducing TLC by 5% and </li></ul><ul><li>FRC by 20% FRC mainly dcreased by RV </li></ul><ul><li>Vital capacity does not change </li></ul><ul><li>Spirometry is not changed in pregnancy </li></ul><ul><li>FEV1 is unchanged </li></ul><ul><li>Peak flow is unchanged </li></ul>
  8. 8. RESPIRATORY CHANGES <ul><li>Chronic hyperventilation </li></ul><ul><li>Progesterone induced </li></ul><ul><li>Minute volume is increased </li></ul><ul><li>Tidal volume is increased </li></ul><ul><li>Respiratory rate is unchanged </li></ul><ul><li>Increased early in the first trimester </li></ul>
  9. 9. HEMATOLOGIC CHANGES <ul><li>40-50% increase in blood volume beginning at 6 weeks and plateaus at 30 weeks </li></ul><ul><li>Both plasma volume and cell mass increase </li></ul><ul><li>Physiologic anemia of pregnancy nadiring at 30 weeks </li></ul><ul><li>Increase in erythropoietin and reticulocyte count </li></ul>
  10. 10. IRON METABOLISM <ul><li>Absorption in the duodenum in the divalent state </li></ul><ul><li>Trivalent food source must be converted by ferric reductase to divalent form </li></ul><ul><li>Fe  enterocytes  bound transferrin  transported to liver, spleen, muscle and bone marrow  incorporated into hemoglobin, myoglobin, ferritin or hemosiderin </li></ul><ul><li>1000mg iron requirement, about 3.5 mg/d of Fe </li></ul><ul><li>Requirements increase in third trimester </li></ul><ul><li>Fetus receives Fe through active transport </li></ul>
  11. 11. FE SUPPLEMENTATION <ul><li>Fe supplementation usually not needed before 20 weeks </li></ul><ul><li>30mg of elemental FE  325 mg ferrous gluconate </li></ul><ul><li>Fe supplements </li></ul><ul><li>Ferrous sulfate ( 65mg elemental Fe) </li></ul><ul><li>Ferrous gluconate (35mg of elemental Fe) </li></ul>
  12. 12. PLATELETS <ul><li>Progressive decline in count from 1 st -3 rd tri </li></ul><ul><li>Increased platelet destruction </li></ul><ul><li>Gestational thrombocytopenia of pregnancy </li></ul><ul><li>Burrows @Kelton reported an 8% prevalence </li></ul><ul><li>Plts range between 70-150,000. </li></ul><ul><li>Diagnosis of exclusion </li></ul><ul><li>?PET/HELLP, ITP, viral disease, HIV, autoimmune disease, ie lupus </li></ul>
  13. 13. OTHER HEMATOLOGIC CHANGES <ul><li>Leukocytosis secondary to neutophils </li></ul><ul><li>Estrogen induced </li></ul><ul><li>Cortisol induced </li></ul><ul><li>Altered immune status </li></ul><ul><li>Modulation away from cellular immunity towards humoral immunity </li></ul><ul><li>Paradoxical decline of immunoglobins A,G,M </li></ul><ul><li>Only IgG crosses the placenta </li></ul>
  14. 14. URINARY SYSTEM <ul><li>Anatomic Changes </li></ul><ul><li>Renal hypertrophy </li></ul><ul><li>Dilation of renal pelvis/calyces </li></ul><ul><li>15mm on the right in 3 rd trimester </li></ul><ul><li>5mm on the left </li></ul><ul><li>Predisposition to pyelonephritis in the presence of assymptomatic bacteriuria </li></ul><ul><li>Dilation of ureters to 2 cm </li></ul><ul><li>Mechanical compression </li></ul><ul><li>Progesterone-induced smooth muscle relaxation </li></ul>
  15. 15. BLADDER CHANGES <ul><li>Bladder trigone elevation occurs with increased vascular tortuousity throughout the bladder leading to microhematuira </li></ul><ul><li>Decrease bladder capacity </li></ul><ul><li>Increased frequency of urinary incontinence </li></ul>
  16. 16. RENAL HEMODYNAMICS <ul><li>Renal blood flow increases 50% </li></ul><ul><li>GFR increases 50% (120cc/min  180cc/m) </li></ul><ul><li>Serum Creatinine and BUN levels decrease </li></ul><ul><li>Glycosuria occurs due to exceding of maximum tubular reabsorptive capacity </li></ul><ul><li>No increase in proteinuria </li></ul><ul><li>UTI </li></ul><ul><li>Pre-existing renal disease </li></ul><ul><li>PET </li></ul>
  17. 17. DIGESTIVE TRACT CHANGES <ul><li>Addition of 300 kcal/day </li></ul><ul><li>Gingivitis of pregnancy </li></ul><ul><li>Violaceous pedunculated lesion </li></ul><ul><li>Epulis gravidarum </li></ul><ul><li>Stomach </li></ul><ul><li>Delayed emptying during labor </li></ul><ul><li>Gastroesophageal reflux disease (GERD) </li></ul><ul><li>Esophageal dysmotility </li></ul><ul><li>Gastric compression due to enlarging uterus </li></ul><ul><li>Decrease sphincter tone </li></ul>
  18. 18. <ul><li>Small bowel </li></ul><ul><li>Motility is reduced due to progesterone allowing for more efficient absorption </li></ul><ul><li>Large bowel </li></ul><ul><li>Decreased transit times allows for both water and sodium absorption </li></ul><ul><li>Increased portal hypertension leading to dilation wherever there are portosystemic venous anastomoses </li></ul>
  19. 19. <ul><li>Gallbladder </li></ul><ul><li>Decreased rate of emptying due to progesterone </li></ul><ul><li>Cholesterol saturation is increased while chenodeoxycholic acid is decreased in bile favoring stone formation </li></ul>
  20. 20. <ul><li>Liver </li></ul><ul><li>Size and histology are unchanged </li></ul><ul><li>Clinical and laboratory changes mimic disease states </li></ul><ul><li>Spider angiomas and palmar erythema </li></ul><ul><li>Serum albumin and total protein decrease </li></ul><ul><li>Serum alkaline phosphatase activity </li></ul><ul><li>Other LFT’s are unchanged </li></ul>
  21. 21. SKELETAL AND POSTURAL CHANGES <ul><li>Lordosis of pregnancy~ progressive increase in anterior convexity of the lumbar spine </li></ul><ul><li>Preserves center of gravity </li></ul><ul><li>Ligaments of the symphysis and sacroiliac joints loosen during pregnancy due to relaxin </li></ul>
  22. 22. ENDOCRINE CHANGES <ul><li>Thyroid Physiology </li></ul><ul><li>Euthyroid state </li></ul><ul><li>Increase in thyroxine-binding globulin </li></ul><ul><li>Decrease in circulating pool of extra-thyroidal iodide </li></ul><ul><li>Slight thyromegaly </li></ul><ul><li>Free T4 and T3 remain normal </li></ul><ul><li>Small amounts of </li></ul><ul><li>TRH @T4 cross the placenta </li></ul><ul><li>Fetal thyroid active by 12 weeks gestation </li></ul>
  23. 23. <ul><li>Adrenal function </li></ul><ul><li>Increases in corticosteroid-binding globulin </li></ul><ul><li>Increases in free cortisol </li></ul><ul><li>Zona fasciculata is increased </li></ul><ul><li>Marked increase in CRH from placental sources </li></ul><ul><li>Delayed plasma clearance of cortisol due to renal changes </li></ul><ul><li>Resetting of hypothalamic-pituitary sensitivity to cortisol feedback on ACTH production </li></ul>
  24. 24. <ul><li>Pituitary gland </li></ul><ul><li>Enlarges due to proliferation of prolactin-secreting cells </li></ul><ul><li>Enlargement makes it more susceptible to alterations in blood flow, ie PPH </li></ul><ul><li>Prolactin levels are increased (ten times higher at term) to prepare breasts for lactation </li></ul>
  25. 25. <ul><li>Pancreas and Fuel Metabolism </li></ul><ul><li>Physiologic glucose intolerance to insure continuous transport of nutrients from mother to fetus </li></ul><ul><li>Fasting hypoglycemia </li></ul><ul><li>Postprandial hyperglycremia </li></ul><ul><li>Hyperinsulinemia </li></ul>
  26. 26. FUEL METABOLISM <ul><li>Pregnant prolonged fasting </li></ul><ul><li>Increased utilization of fat stores </li></ul><ul><li>Lipolysis generates glycerol, fatty acids and ketones for gluconeogenesis and fuel </li></ul><ul><li>More HPL, less insulin results in increased utilization of fat stores </li></ul><ul><li>Maternal response to starvation </li></ul><ul><li>Hypoglycemia, hypoinsulinemia </li></ul><ul><li>Hyperlipidemia, hyperketonemia </li></ul>
  27. 27. <ul><li>Maternal response to feeding </li></ul><ul><li>Hyperglycemia, </li></ul><ul><li>Hyperinsulinemia, </li></ul><ul><li>Hyperlipidemia, </li></ul><ul><li>Resistance to insulin </li></ul><ul><li>Insulin secretion increases throughout </li></ul><ul><li>Insulin resistance increases to 50-80% in third trimester </li></ul><ul><li>Borderline pancreas function leads to GDM </li></ul>
  28. 28. ENDOCRINE CHANGES <ul><li>Diabetogenic effects of pregnancy </li></ul><ul><li>HPL  lipolytic and anti-insulin </li></ul><ul><li>Cortisol </li></ul><ul><li>Prolactin </li></ul><ul><li>Estrogen and progesterone </li></ul><ul><li>Fetal glucose levels are 20 mg/dl less than maternal values </li></ul><ul><li>Placental glucose transport is carrier mediated facilitated transport that is energy independent </li></ul>
  29. 29. FUEL AND METABOLISM <ul><li>Lipids and lipoproteins increase in pregnancy </li></ul><ul><li>Total cholesterol, LDL, HDL and triglycerides all increase </li></ul><ul><li>Necessary as precursors for steroidgenesis </li></ul><ul><li>Does not appear to lead to atheroslerosis unless pre-existing hyperlipidemia </li></ul>
  30. 30. PLACENTAL TRANSPORT OF NUTRIENTS
  31. 31. INTEGUMENTAL CHANGES <ul><li>Hyperpigmentation </li></ul><ul><li>90% of pregnancies </li></ul><ul><li>Localized to areas of increased melanocytes </li></ul><ul><li>Choasma of pregnancy </li></ul><ul><li>70% of women </li></ul><ul><li>All races </li></ul><ul><li>Up to 30% of changes can persist </li></ul>
  32. 32. <ul><li>Hair Changes </li></ul><ul><li>Mild hirsutism is common </li></ul><ul><li>Excessive virilization should prompt investigation for androgen-secreting tumors </li></ul><ul><li>Normal preganncy increases amount of hair in anagen phase(growth) </li></ul><ul><li>Postpartum, telogen effluvium may occur with increased amount of hair in resting phase which leads to loss </li></ul>
  33. 33. OCULAR CHANGES <ul><li>Increased thickness of the cornea </li></ul><ul><li>Edema induces a 3% increase </li></ul><ul><li>Affects contacts </li></ul><ul><li>Decreased intraocular pressure </li></ul><ul><li>Glaucoma improves </li></ul><ul><li>Minimally decreases visual fields </li></ul>
  34. 34. YOGA PRACTICES <ul><li>YOGA IS BALANCE (SAMATVAM) </li></ul><ul><li>I A Y T CORRECTS IMBALANCES </li></ul><ul><li>AIMS : </li></ul><ul><li>STRESS REDUCTION </li></ul><ul><li>RELIEF OF PAIN </li></ul><ul><li>MEDICATION REDUCTION </li></ul>
  35. 35. Ánandamaya Kôùa Vijòanánmaya Kôùa PERFECT HEALTH Manômaya Kôùa Annamaya Kosa Pranamaya Kosa ÁDHIJA VYÁDHIS YOGA Panchakosa concept
  36. 37. Thank You
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