Detailed account of the various changes that occur in maternal anatomy, physiology, and metabolism of pregnant women. These physiological changes are often very precise, and deviations of physiological responses can be a prelude to possible disease/infectious states. In this second part of Labor, we will examine the various systems of the human body,its altered states during pregnancy, and how those changes affect the woman preparing for delivery. Special care is imperative in properly determining the needs of an expecting mother, so developing an intimate, trusting relationship between the mother and fully understanding her physiological output will lead to the best chances of a successful delivery.
physiology of labor includes the contraction and retraction of the muscles of uterus. I hope this presentation will help the persons of concerned subject.
Maternal physiological changes in pregnancy are the adaptations during pregnancy that a woman's body undergoes to accommodate the growing embryo or fetus. ... The pregnant woman and the placenta also produce many other hormones that have a broad range of effects during the pregnancy.
physiology of labor includes the contraction and retraction of the muscles of uterus. I hope this presentation will help the persons of concerned subject.
Maternal physiological changes in pregnancy are the adaptations during pregnancy that a woman's body undergoes to accommodate the growing embryo or fetus. ... The pregnant woman and the placenta also produce many other hormones that have a broad range of effects during the pregnancy.
obstetric and gyneacology; Changes in pregnancy, cardiovascular changes, respiratory changes, endocrine changes, gastrointestinal changes, related organ changes in pregnancy. hormonal changes during pregnancy.
Antenatal care & changes during pregnancy1302011987
antenatal care with including all the changes during pregnancy with signs & symptoms of pregnancy. in this presentation i had cover all the topics related to pregnancy unit.
Physiological changes during pregnancyDeepa Mishra
PHYSIOLOGICAL CHANGES DURING PREGNANCY
Deepa Mishra
Assistant Professor (OBG)
Pregnancy
Pregnancy usually occurs during 15-44 yrs of a woman.
Duration of pregnancy from LMP is 280 days or 40 weeks or 9 months and 7 days
Three trimester-
1st Trimester -0 -12 weeks
2nd trimester – 13-28 weeks
3rd trimester -29-40 weeks s
Physiological changes
Reproductive system
Hematological and Cardiovascular changes
Respiratory, Acid base balance, electrolyte changes
Urinary changes
GI changes
Metabolic changes
Skeletal and neurological changes
Skin changes
Endocrinal changes
Psychological changes
With the use of fertility enhancing medications, advance maternal age pregnancies and just the natural order od twinning, this pregnancy presentation has become more common among providers. Here we explore the etiology, presentation and management of twin pregnancies.
A normal pregnancy results in a number of important reversible physiological and hormonal changes that alter thyroid structure and more importantly function.
Understanding these change are important to interpreting, identifying and managing of thyroid disease in pregnancy.
An inspirational, self-help book designed to assist women in improving their lifestyle, physically, mentally, spiritually and emotionally. Through small but successful changes, women can find untapped roadways that lead to happier lifestyles. This book will make you laugh, cry, explore, investigate and scrutinize, but ultimately understand that it only takes simple steps to get to a better you.
The book is also designed as a journal, where you can interact with the information and maintain a personal memoir of your success. After completing this unique adventure, you will have a treasured keepsake and reference to always stay on that positive road...to a better you.
Parvovirus B-19 in Pregnancy Parvovirus is a member of the family Parvoviridae. The virus contains a single-stranded DNA. It can only infect humans. 50% of all adults have been infected sometime during childhood or adolescence.
Parvovirus B-19 in Pregnancy Epidemiology Congenital infection rates vary depending on the prevalence in the community. Approximately 50 to 75% of adult women are immune. 20% to 30% of susceptible adults in school settings will become infected. Day-care workers have a 20% to 50% risk of seroconversion. The risk of infection among susceptible adults following household exposure to an infected person is approximately 50%.
Obstetrical Ultrasound• Introduced in the late 1950’s ultrasonography is a safe, non- invasive, accurate and cost-effective means to investigate the fetus• Computer generated system that uses sound waves integrated through real time scanners placed in contact with a gel medium to the maternal abdomen• The information from different reflections are reconstructed to provide a continuous picture of the moving fetus on the monitor screen
In-depth explanation of labor divided into two extensive parts. A thorough examination of proper procedure, care, and health for expecting mothers. Delicate consideration must be taken to insure the safety of the baby and promote the best chances for a healthy delivery. Topics such as biochemical messengers, hormonal balance, preterm conditions, fetal position, and cardinal movements.
In-depth explanation of labor divided into two extensive parts. A thorough examination of proper procedure, care, and health for expecting mothers. Delicate consideration must be taken to insure the safety of the baby and promote the best chances for a healthy delivery. Topics such as biochemical messengers, hormonal balance, preterm conditions, fetal position, and cardinal movements.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Maternal Physiology in Pregnancy Major adaptations in maternal anatomy, physiology, and metabolism are required for successful pregnancy. Nearly every organ system is affected. Understanding these changes helps to distinguish the normal physiology of pregnancy from pathological disease states.
3. Maternal Physiology in Pregnancy These changes create a myriad of pregnancy symptoms that include Nausea/Emesis (morning sickness) Headaches Backaches Urinary frequency Hemorrhoids/Constipation Leg Cramps Edema more common lower extremity Breast tenderness Paresthesis Varicose veins
4. Maternal Physiology in Pregnancy Due to the pregnancy effect on major organ systems including: Nutritional Digestive Tract Changes Urinary System Cardiovascular System Respiratory System Metabolism Skeletal Endocrine Integument Ocular
5. Maternal Physiology in Pregnancy: Nutritional During pregnancy, nutritional requirements, including those for vitamins and minerals, are increased, and several maternal alterations occur to meet this demand. Addition of 300 kcal/day. The mother`s appetite usually increases, so that food intake is greater, although some women have a decreased appetite or experience nausea and vomiting. These symptoms may be related relaxation of smooth muscle, increasing levels of human chorionic gonadotrophin (hCG) and estrogen.
6. Maternal Physiology in Pregnancy Complicates 70% of pregnancies normally from 4-16 weeks True Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids, “that may requiring hospitalization, IV fluids, anti-emetics even protonics or TPN Pica: craving for substances that are not food Etiology unknown Check for poor weight gain and refractory anemia South - clay or starch (laundry or cornstarch) UK – coal Also soap, toothpaste and ice
7. Maternal Physiology in Pregnancy: Digestive Tract Changes If the pH of the oral cavity decreases, tooth decay may occur linked to pre-term deliveries. Tooth decay during pregnancy, however, is not due to lack of calcium in the teeth, dental calcium is stable and not mobilized during pregnancy as is bone calcium. The gums may become hypertrophic, hyperemic and friable; this maybe due to increased systemic estrogen. Vitamin C deficiency also can cause tenderness and bleeding of the gums.
8. Maternal Physiology in Pregnancy: Digestive Tract Changes Gingivitis of pregnancy: vascular swelling of the gums can lead to the development of pyogenic granulomas : Epulis gravidarum: regress 1-2 mos after delivery excise if persistent or excessive bleeding
9. Maternal Physiology in Pregnancy: Digestive Tract Changes Gastrointestinal Motility Reduced during pregnancy due to increased levels of progesterone, which decrease the production of motilin, a hormonal peptide that is known to stimulate smooth muscle in the gut. Transit time of food throughout the gastrointestinal tract much slower, more water than normal is reabsorbed, leading to constipation.
10. Maternal Physiology in Pregnancy: Digestive Tract Changes Decreased tone and motility secondary to progesterone Esophagus :dysmotility Esophageal peristalses is deceased, accompanied by gastric reflux because of the slower emptying time and dilatation or relaxation of the cardiac sphincter. Stomach Reduced tone of the gastroesophageal junction sphincter Production of the hormone gastin increases significantly, resulting in increased stomach volume and decreased stomach pH.
11. Maternal Physiology in Pregnancy Gastric compression due to enlarging uterus with decrease sphincter tone increasing incidence GERD This reflux is more prevalent in later pregnancy owing to elevation of the stomach by the enlarged uterus, making the use of anesthesia, especially general anesthesia more hazardous because of the increased possibility of regurgitation and aspiration. Lower incidence of PUD (peptic ulcer disease) may be due to decreased gastric acid secretion delayed emptying, increase in gastric mucus, and protection of mucosa by prostaglandins
12. Maternal Physiology in Pregnancy: Digestive Tract Changes Small bowel : Reduced motility and tone are allow for more efficient absorption, especially iron Large Bowel: Decreased transit times allows for both water and sodium absorption. Increased portal hypertension with dilation wherever there are porto-systemic venous anastamoses (varices) affecting esophagus, vulva and increase varicose veins and hemorrhoids may lead to ovarian vein thrombosis
13. Maternal Physiology in Pregnancy: Gastrointestinal Changes Gallbladder Decreased rate of emptying and hypotonia of the smooth muscle wall Emptying time is slowed and often incomplete Bile can become thick, and bile stasis Cholesterol saturation is increased while chenodeoxycholic acid is decreased in bile These changes favor the development of gallstones
14. Maternal Physiology in Pregnancy: Gastrointestinal Changes Liver Liver size and histology are unchanged Serum albumin and total protein decrease so there is a decrease in the albumin/globulin ratio Serum alkaline phosphatase increases due to placental and some hepatic production No change in serum bilirubin, AST, ALT Clinical and laboratory changes mimic disease states Spider angiomas and palmar erythema
15. Maternal Physiology in Pregnancy: Urinary System Anatomic Changes Renal hypertrophy Dilatation renal pelvis/calyces 15mm on the right in 3rd trimester 5mm on the left. Each kidney increases in length by 1-1.5cm, with a concomitant increase in weight. The ureters are dilated to 2 cm resulting in hydroureter from: progesterone-induced smooth muscle relaxation causing hypotonia mechanical compression above the brim of the bony pelvis by the ovarian vein complex in the suspensory ligament of the ovary dextorotation of the uterus during pregnancy, may explain why the right ureter is usually more dilated than the left.
16. Maternal Physiology in Pregnancy: Urinary System Hyperplasia of smooth muscle in distal one-third of the ureter may cause reduction in the luminal size The ureters also elongate, widen, and become more curved: there is an increase in urinary stasis This may lead to infection and predispose to pyelonephritis in the presence of asymptomatic bacteriuria (30%)
17. Maternal Physiology in Pregnancy: Urinary System Bladder As the uterus enlarges, the urinary bladder is displaced upward and flattened in the anterior-posterior diameter Bladder vascularity increases and muscle tone decreases, increasing capacity up to 1500ml. Trigone elevation occurs with increased vascular tortuousity throughout the bladder leading to microhematuira Decrease bladder capacity Increased frequency of urinary incontinence
18. Maternal Physiology in Pregnancy: Urinary System Renal Hemodynamic Renal blood flow increases 50% . GFR increases 50% (120cc/min180cc/m.) The renal plasma flow rate increases by as much as 25-50%.. Serum Creatinine and BUN levels decrease. Urinary flow and sodium excretion rates in late pregnancy can be altered by posture, being twice as great in the lateral recumbent position as in the supine position. Even thought the GFR increased dramatically during pregnancy, the volume of the urine passed each day is not increased.
19. Maternal Physiology in Pregnancy: Urinary System With the increase in GFR, there is an increase in endogenous clearance of creatinine. The concentration of creatinine in serum is reduced in proportion to increase in GFR, and concentration of blood urea nitrogen is similarly reduced. Glucosuria during pregnancy is not necessarily abnormal, may be explained by the increase in GFR with impairment or exceeding tubular reabsortion capacity for filtered glucose. Increased levels of urinary glucose also contribute to increased susceptibility of pregnant women to urinary tract infection. Proteinuria changes little during pregnancy and if more than 300mg/24h is lost, a disease process should be suspected.
20. Maternal Physiology in Pregnancy: Urinary System Levels of the enzyme renin, which is produced in kidney, increase early in the first trimester, and continue to rise until term This enzyme acts on its substrate angiotensinogen, to first form angiotensin1 and then angiotensin2, which acts as a vasoconstrictor Normal pregnant women are resistant to the pressor effect of elevated levels of angiotensin2 but those suffering from preeclampsia are not resistant, this is one of the some theories to explain this disease.
21. Maternal Physiology in Pregnancy: Cardiovascular System 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. (apparent cardiomegaly on chest x-ray) Cardiac capacity increases by 70-80mL. This may be due to increased volume or hypertrophy of cardiac muscle. The size of the heart appears to increase by about 12%. Increase in left ventricular end- diastolic dimension. Increase in left ventricular wall mass c/w mild hypertrophy. Increase in preload with increase capacitance of the systemic and pulmonary vascular resistances prevenst rise in CVP or wedge pressure. Grade II-III systolic flow murmurs at left lower sternal border.
22. Maternal Physiology in Pregnancy: Cardiovascular System 30-35% in CO (CO= SV x HR), reaching its maximum at 20-24 weeks gestation and continuing at this level until term The increase in output can be as much as1.5L/min over the non pregnant level HR increases as early as 5 weeks GA Peaks at 32 weeks at 15-20 beats above baseline(20% increase) Stroke volume increases as early as 8 weeks GA, peaks at 20 weeks with a 20-30% increase Cardiac output is very sensitive to changes in body position.
23. Maternal Physiology in Pregnancy: Cardiovascular System This sensitivity increases with gestational age, presumably because the uterus impinges upon the inferior vena cava, thereby decreasing blood return to the heart Because blood pressure either decreases or remain the same during pregnancy and cardiac output increases appreciably, there is good evidence that peripheral resistance( Peripheral resistance equals blood pressure divided by cardiac output) declines markedly. The elevated venous pressure returns toward normal if the woman lies in the lateral recumbent position.
25. Maternal Physiology in Pregnancy: Cardiovascular System Effects of the Labor on the Cardiovascular System When a patient is the supine position, uterine contractions can cause a 25% increase in maternal cardiac output, a 15% decrease in heart rate, and a resultant 33% increase in stroke volume. However when the laboring patient is in the recumbent position, the hemodynamic parameters stabilize , with only a 7.6% increase in cardiac output, a 7% decrease in heart rate, and a 7.7% increase in stroke volume These significant differences are attributable to inferior vena caval occlusion caused by the gravid uterus
26. Maternal Physiology in Pregnancy: Cardiovascular System During contractions, pulse pressure increases 26% in the supine position but only 6% in the lateral recumbent position. Important to have laboring patients in the left lateral recumbent position
27. Maternal Physiology in Pregnancy: Cardiovascular System BP= CO x SVR SVR decreases to a minimum at midpregnancy with a gradual rise towards term but still 20% lower than non-pregnancy Decrease SVR secondary to hormonal vasodilatation (progesterone), NO, prostaglandins, ANP BP changes nadir by midpregancy Diastolic and mean pressure decrease more than the systolic Increases to baseline in third trimester
28. Maternal Physiology in Pregnancy: Cardiovascular System Other cardiovascular changes: Increases in CO, HR Decreases in SVR, PVR No change in MAP, PCWP, CVP,
29. Maternal Physiology in Pregnancy: Cardiovascular System Blood Volume ` Increase in the blood volume beginning at 6 weeks and plateaus at 30 weeks The magnitude of the increases varies according to the size of woman, the number of pregnancies she has had, the number of infants she has delivered, and whether there is one or multiple fetuses Both plasma volume (50%)and cell mass (30%) increase Physiologic anemia of pregnancy nadiring at 30 weeks
30. Maternal Physiology in Pregnancy: Cardiovascular System By term, the average increase in volume 45-50% The increase is needed for extra blood flow to the uterus, extra metabolic needs of fetus, and increased perfusion of others organs, especially kidneys Extra volume also compensate for maternal blood loss delivery The average blood loss with vaginal delivery is 500ml, cesarean section is 1000ml and C/Hyst 1500 ml 10% drop HCT can be considered post-partum hemorrhage
32. Maternal Physiology in Pregnancy: Cardiovascular System Blood Volume Singleton (n=50) 3rd trim. non-preg. % increase Blood volume 4820 3250 48 RBC volume 1790 1355 32 Hct (%) 37.0 41.7 Pritchard, JA. Changes in blood volume during pregnancy 5th percentile for hemoglobin was 11.0 g/L in the 1st trimester; in the 2nd trimester it was 10.5 g/L and 10.3 g/L in the third trimester Acta Obstet Gynecol Scand. 2000 Feb;79(2):89-98
33. Maternal Physiology in Pregnancy: Cardiovascular System Iron Metabolism Absorption in the duodenum in the divalent state Trivalent food source must be converted by ferric reductase to divalent form Febound transferrintransported to liver, spleen, muscle and bone marrow incorporated into hemoglobin, myoglobin, ferritin or hemosiderin 1000mg iron requirement, (about 3.5 mg/d) Requirements increase in third trimester Fetus receives Fe through active transport
34. Maternal Physiology in Pregnancy: Cardiovascular System With the increase in red blood cells, the need for iron for the production of hemoglobin increases, but Fe supplementation usually not needed before 20 weeks Fe supplementation Ferrous sulfate 20% ( 65mg elemental Fe) Ferrous gluconate 12% (35mg of elemental Fe) and ferrous fumarate 33%(108mg of elemental Fe) ; fumerate and gluconate better absorbed(organic Fe) For severe anemia: Preparations Iron Dextran (Imferon, Dexferrum) High rate of serious reaction (requires test dose) Intramuscular or Intravenous Dose based on estimated iron deficits
35. Maternal Physiology in Pregnancy: Cardiovascular System (Test dose)[25 mg] [100 ml] [5 min][Prescribed dose] [250 to 1000mg](Usually 500 ml NS) Total dose infusion: infuse over 2 to 6 hours.
36. Maternal Physiology in Pregnancy: Cardiovascular System Sodium ferric gluconate (Ferrlecit) Dosing: 125 mg/weekly IV for 8 weeks (total: 1 gram) Much safer than Iron Dextran (no test dose needed) Iron sucrose (Venofer) Much safer than Iron Dextran (no test dose needed) Dosing: 200 mg IV for 5 doses over 2 week period Precautions Intravenous iron must be started very slowly Adverse affects: fever, pain, headaches, Myalgias and arthralgias Anaphylaxis Occurs in 0.61% of patients given Iron Dextran Occurs in 0.04% of patients given ferric gluconate
37. Maternal Physiology in Pregnancy: Cardiovascular System Maternal requirements can reach 5-6mg/d in the latter half of pregnancy If supplemental iron is not added to the diet, iron deficiency anemia will result If iron is not readily available, the fetus, uses iron from maternal stores. Thus, the production of fetal hemoglobin is usually adequate even if the mother is severely iron deficient and anemia in the newborn is rarely a problem Maternal iron deficiency more commonly may cause preterm labor and late spontaneous abortion,
38. Maternal Physiology in Pregnancy: Cardiovascular System White Blood Cells The total blood leukocyte count increases during pregnancy from a pre-pregnancy level of 4300-4500/mL to 5000-12000/mL in the last trimester, although counts as high as 16000/mL have been observed in the last trimester Counts as high as 25000-30000/mL have been noted in a normal patient during labor Lymphocyte and monocyte numbers stay the same throughout pregnancy; polymorphonuclear leucocytes are the primary contributors to the increase.
39. Maternal Physiology in Pregnancy: Cardiovascular System Platelets Progressive decline in count from 1st-3rd trimester. Increased platelet destruction. Plts range between 70-150,000, gestational thrombocytopenia of pregnancy Burrows @Kelton reported an 8% prevalence. Diagnosis of exclusion: PIH/HELLP, ITP, viral disease, HIV, autoimmune disease, ie lupus.
40. Maternal Physiology in Pregnancy: Cardiovascular System Other Hematologic Changes Leukocytosis secondary to increase neutophils estrogen and cortisol induced Altered immune status, immunocompromised Paradoxical decline of immunoglobins A,G,M Only IgG crosses the placenta
41. Maternal Physiology in Pregnancy: Cardiovascular System Coagulation System Hypercoaguable state Increased venous stasis lead to vessel wall injury Changes in the coagulation cascade Increases in factors I,VII,VIII, IX and X Unchanged or mildly increasedfactors II, V, XII Decrease in factors XI, XIII Decrease in fibrinolysis with decreased plasminogen activator Increase in factor I (fibrinogen) causes elevated sed rate Decrease in protein S but no change in protein C and antithrombin III. Activated protein C decreases
42. Maternal Physiology in Pregnancy: Cardiovascular System Fibrinolytic activity is depressed during pregnancy and labor, although the precise mechanism is unknown The placenta may be partially responsible for this alteration in fibrinolytic status Plasminogen levels increase concomitantly with fibrinogens levels, causing an equilibration of clotting and lysing activity
43. Maternal Physiology in Pregnancy:Respiratory System Anatomic and Physiologic Changes Pregnancy produces changes that affect respiratory performance Early in pregnancy, capillary dilatations occurs throughout the respiratory tract, leading to engorgement of the nasopharnyx, larnyx, trachea, and bronchi This causes the voice to change and makes breathing though the nose difficult. Upper respiratory tract hyperemia and edema induced by estrogen leading to nasal stuffiness and epistaxis Chest X-rays reveal increased vascular makings in the lungs.
44. Maternal Physiology in Pregnancy:Respiratory System As the uterus enlarges, the diaphragm is elevated as much as 4cm, but elevation of the diaphragm does not impede its movement. The rib cage is displaced upward and widens, increasing the lower thoracic diameter by 2cm and the thoracic circumference by up to 6cm. Chest circumference expands 5-7 cm Subcostal angle increases from 68 to 103 degrees Respiratory muscle function is not affected by pregnancy Abdominal muscles have less tone and are less active during the pregnancy, causing respiration to be more rather than less diaphragmatic.
45. Maternal Physiology in Pregnancy:Respiratory System Elevation of the diaphragm decreases the volume of the lungs in the resting state, reducing TLC by 5% and FRC by 20% FRC mainly decreased by RV Vital capacity does not change Chronic hyperventilation progesterone induced Minute volume is increased Tidal volume is increased Respiratory rate is unchanged( Increased early in the first trimester)
46. Maternal Physiology in Pregnancy:Respiratory System Dead volumes increase owing to relaxation of the musculature of conducting airways. Tidal volumes increases gradually(35-50%)as pregnancy progresses. Total lung capacity is reduced (4-5%) by the elevation of the diaphragm. Functional residual capacity, residual volume, and respiratory reserve volume all decrease by about 20%. Larger tidal volume and smaller residual volume cause increased alveolar ventilation (about 65%) during pregnancy. Inspiratory capacity increases 5-10%.
47. Maternal Physiology in Pregnancy:Respiratory System Functional respiratory changes include a slight increase in respiratory rate, a 50% increase in minute ventilation, a 40% increase in tidal volume A progressive increase in oxygen consumption of up to 15-20% above non-pregnant levels by term. With the increase in respiratory tidal volume associated with a normal respiratory rate, there is an increase in respiratory minute volume of approximately 26% . As the respiratory minute volume increases, hyperventilation of pregnancy occurs, causing a decrease in alveolar CO2
48. Maternal Physiology in Pregnancy:Respiratory System This decrease lowers the maternal blood CO2 tension; however alveolar oxygen tension is maintained within normal limits. Maternal hyperventilation is considered a protective measure that prevents the fetus from the exposure to excessive levels of CO2. Because this decrease in FRC occurs without a concomitant change in dead space, there is little residual dilution and, therefore, presumably more efficient gas exchange.
49. Maternal Physiology in Pregnancy:Respiratory System Spirometry: the most common of the Pulmonary Function Tests(PFTs), measuring lung function, specifically the measurement of the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. FEV1 (forced expiratory pressure in 1 second), 80-100% of average values are considered normal and is unchanged Peak Expiratory Flow: is the maximal flow (or speed) achieved during the maximally forced expiration initiated at full inspiration, measured in liters per minute, also unchanged
52. Maternal Physiology in Pregnancy:Respiratory System: Gas Exchange Hyperventilation leads to deceased PCO2 Increases CO2 gradient between fetus and mother Chronic respiratory alkalosis Compensatory metabolic acidosis 20-40% increase in maternal oxygen consumption Normal arterial blood gas values Ph= 7.4-7.45 PCO2= 28-32 PO2= 101-106 HCO3= 18-21
53. Maternal Physiology in Pregnancy Metabolism As the fetus and placenta grow and place increasing demands on the mother, phenomenal alterations in metabolism occur The most obvious physical changes are weight gain and altered body shape Weight gain is due not only to the uterus and its contents but also to increase breast tissue, blood and water volume in the form of extravascular and extracellular fluid Deposition of fat and protein and increased cellular water are added to the maternal stores The average weight gain during pregnancy is 12.5Kg. (23-25 lbs)
54. Maternal Physiology in Pregnancy During normal pregnancy, approximately 1000g of weight gain is attributable to protein Half of this is found in the fetus and the placenta, with the rest being distributed as uterine contractile protein, breast glandular tissue, plasma protein, and hemoglobin Total body fat increases during pregnancy, but the amount varies with total weight gain During the second half of pregnancy, plasma lipids increase , but triglycerides, cholesterol and lipoproteins decrease soon after delivery The ratio of low density lipoproteins to high density lipoproteins increases during pregnancy
55. Maternal Physiology in Pregnancy Body Water Metabolism Condition of chronic water overload Active Na+ and water retention 1. Changes in osmoregulation 2. Renin-angiotensin system Body water increase 6.5L 8.5L 1. 1500 cc increase in blood volume 2. RBC increase ~400cc Elevation of maternal CO
56. Maternal Physiology in Pregnancy Osmoregulation Na+ retention increases 900 mEq but serum Na+ decreases 3-4 mmol/l Plasma osmolality decreases 10 mOsm/kg Enhanced tubular reabsorption of Na+ secondary to aldosterone, estrogen and deoxycorticosterone Increased GFR and Atrial Natriuretic Peptide favor Na+ excretion
57. Maternal Physiology in Pregnancy Skeletal Changes: Calcium metabolism Maternal total calcium levels decline due to decreased albumin bound concentration Serum ionized level remains unchanged Increased intestinal absorption occurs in first trimester, actively transported across the placenta Maternal serum phosphate levels are unchanged PTH levels remain unchanged Elevated levels of vitamin D allow for increase Ca++ absorption Calcitonin levels rise to preserve maternal skeleton
58. Maternal Physiology in Pregnancy Skeletal and Postural Changes Lordosis of pregnancy~ progressive increase in anterior convexity of the lumbar spine, preserves center of gravity Ligaments of the symphysis and sacroiliac joints loosen during pregnancy due to relaxin
59. Maternal Physiology in Pregnancy Endocrine Changes Thyroid Physiology Euthyroid state Increase in thyroxine-binding globulin Decrease in circulating pool of extra-thyroidal iodide Slight thyromegaly Free T4 and Free T3 remain normal Small amounts of TRH /T4 cross the placenta Fetal thyroid active by 12 weeks gestation
60. Maternal Physiology in Pregnancy Endocrine Changes Adrenal function Increases in corticosteroid-binding globulin Increases in free cortisol Zona fasciculata is increased Marked increase in CRH from placental sources Delayed plasma clearance of cortisol due to renal changes Resetting of hypothalamic-pituitary sensitivity to cortisol feedback on ACTH production
61. Maternal Physiology in Pregnancy Endocrine Changes Pituitary gland enlarges due to proliferation of prolactin-secreting cells Enlargement makes it more susceptible to alterations in blood flow Prolactin levels are increased (ten times higher at term) to prepare breasts for lactation
62. Maternal Physiology in Pregnancy Endocrine Changes Pancreas and Fuel Metabolism Physiologic glucose intolerance to insure continuous transport of nutrients from mother to fetus Fasting hypoglycemia Postprandial hyperglycemia Hyperinsulinemia
65. Maternal Physiology in Pregnancy Fuel Metabolism Pregnant prolonged fasting Increased utilization of fat stores Lipolysis generates glycerol, fatty acids and ketones for gluconeogenesis and fuel More HPL, less insulin results in increased utilization of fat stores Maternal response to starvation hypoglycemia, hypoinsulinemia , hyperlipidemia, hyperketonemia
66. Maternal Physiology in Pregnancy Fuel Metabolism Maternal response to feeding Hyperglycemia Hyperinsulinemia Hyperlipidemia Resistance to insulin Insulin secretion increases throughout Insulin resistance increases to 50-80% in third trimester Borderline pancreas function leads to GDM
67. Maternal Physiology in Pregnancy Endocrine Changes Diabetogenic effects of pregnancy HPLlipolytic and anti-insulin( Cortisol Prolactin Estrogen and Progesterone Fetal glucose levels are 20 mg/dl less than maternal values Placental glucose transport is carrier mediated facilitated transport that is energy independent
68. Maternal Physiology in Pregnancy Fuel and Metabolism Lipids and lipoproteins increase in pregnancy Total cholesterol, LDL, HDL and triglycerides all increase Necessary as precursors for steroiodgenesis Does not appear to lead to atherosclerosis unless pre-existing hyperlipidemia
70. Maternal Physiology in Pregnancy Integumental Changes Hyperpigmentation 90% of pregnancies Localized to areas of increased melanocytes Choasma of pregnancy 70% of women in all races Linea alba…Linea nigra Up to 30% of changes can persist
71. Maternal Physiology in Pregnancy Integumental Changes Hair Changes Mild hirsutism is common Excessive virilization should prompt investigation for androgen-secreting tumors Normal pregnancy increases amount of hair in anagen phase(growth) Postpartum, telogen effluvium may occur with increased amount of hair in resting phase which leads to loss
72. Maternal Physiology in Pregnancy Ocular Changes Increased thickness of the cornea secondary to fluid retention, this edema induces causing a 3% increase Affects contacts Decreased intraocular pressure Glaucoma improves Minimally decreases visual fields
73. Maternal Physiology in Pregnancy So you see there are extensive changes in maternal physiology that occur in pregnancy Be careful in interpretations of what are normal pregnancy changes, especially when parameters like lab values represent the non-pregnant state Visit our website @ secondopinion2.com or contact us at info@secondopinion2.com “CHANGE THAT’S WORTH IT”