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Physiologic changes of pregnancy lect 2.ppt
- 1. Physiologic changes of pregnancy Prof. Aziza Tosson
- 2. AIMS īŽ TO GAIN AN UNDERSTANDING OF THE PHYSIOLOGICAL CHANGES THAT OCCUR DURING PREGNANCY
- 3. LEARNING OUTCOMES īŽ IDENTIFY THE CHANGES THAT TAKE PLACE WITHIN THE UTERUS AND BODY SYSTEMS DURING PREGNANCY īŽ CONSIDER THE EFFECT THESE CHANGES HAVE ON THE WOMAN īŽ EXPLORE THE ROLE OF THE MIDWIFE WHEN GIVING ADVISE TO THESE WOMEN
- 4. Objectives īŽ Symptoms and physical findings of each organ system īŽ Physiologic versus pathologic changes īŽ Diagnostic tests and interpretations during physiological changes
- 5. UNDERSTANDING NEEDED īŽ TO EXPLAIN THE PHYSIOLOGICAL CHANGES THAT TAKE PLACE TO THE WOMAN īŽ TO UNDERSTAND THE MINOR DISORDERS OF PREGNANCY īŽ RECOGNISE PATHOLOGICAL CHANGES IN ORDER TO REFER APPROPRIATELY
- 7. Anatomical Changes Anatomical Changes īŧ īŧ Pelvis Pelvis īŧ īŧ Pelvic Floor Muscles Pelvic Floor Muscles īŧ īŧ Uterus Uterus īŧ īŧ Uterine Ligaments Uterine Ligaments īŧ īŧ Cervix Cervix īŧ īŧ Placenta Placenta īŧ īŧ Amniotic Fluid Amniotic Fluid
- 9. Pelvic Floor Muscles Pelvic Floor Muscles
- 11. Physiological Changes īŽ Circulatory īŽ Thermoregulation īŽ Metabolic īŽ Respiratory īŽ Digestive īŽ Urinary īŽ Skin īŽ Breasts īŽ Biomechanical
- 12. DEFINITION THE CHANGES THAT TAKE PLACE IN THE MATERNAL ORGAN SYSTEM IN RESPONSE TO PREGNANCY. TO ACCOMADATE THE PREGNANCY AND TO PREPARE THE WOMAN FOR LABOUR
- 13. Organ systems īŽ Cardiovascular system īŽ Pulmonary system īŽ Genital tract īŽ Urinary system īŽ Endocrine system īŽ Gastrointestinal Tract īŽ Skin
- 14. CHANGES ARE DUE TO īŽ ALTERATIONS IN īŽ HORMONAL PRODUCTION īŽ CIRCULATION īŽ METABOLISM
- 15. HORMONES OESTROGEN īŽ Produced in corpus luteum īŽ Produced by placenta after 12 weeks īŽ Responsible for growth particularly of uterus and breasts
- 16. progesterone īŽ Produced in corpus luteum and then the placenta īŽ Relaxes smooth muscle īŽ Inhibits uterine contractions until uterus is prepared for labour īŽ Regulates storage of body fat
- 17. Human chorionic gonadotrophic īŽ Secreted from trophoblast of the developing embryo īŽ Maintains corpus luteum until placenta takes over īŽ Used in tests to confirm pregnancy
- 18. Human placental lactogen īŽ Alters maternal metabolism īŽ Diverts glucose to fetus īŽ Mobilises free fatty acids from maternal stores
- 19. RELAXIN īŽ Released by corpus luteum then the Placenta īŽ Softens pelvic ligaments īŽ Reduces myometrial tone
- 20. Changes to Body System Changes to Body System īŧ īŧ First Trimester First Trimester ī ī Baby begins to grow Baby begins to grow ī ī Increased urination Increased urination ī ī Changes with skin and Changes with skin and hair hair ī ī Thickening waistline Thickening waistline ī ī Nausea/fatigue Nausea/fatigue īŧ īŧ Second Trimester Second Trimester ī ī Baby Babyâ âs weight increases s weight increases ī ī Energy level improves Energy level improves ī ī Heartburn Heartburn ī ī Leg cramps Leg cramps ī ī Pelvis relaxes causing SI Pelvis relaxes causing SI discomfort discomfort īŧ īŧ Third Trimester Third Trimester ī ī Baby has more rapid Baby has more rapid growth & weight gain growth & weight gain ī ī Backaches Backaches ī ī Swelling of the hands, Swelling of the hands, legs, and feet legs, and feet ī ī Breathlessness Breathlessness ī ī More frequent More frequent urination urination
- 21. Maternal changes - anatomical and physiological īŽ Cardiovascular changes īŽ increase in SV īŽ increase in cardiac output īŽ increase in HR at given work load īŽ increase in blood volume (mostly during latter half of pregnancy) īŽ Uterus may compress large blood vessels reducing venous return īŽ Total Body water
- 23. Cardiovascular Changes īŽ Blood volume īŽ Cardiac (heart) output īŽ Stroke volume īŽ End diastolic volume īŽ Resting pulse īŽ % of blood plasma īŽ Hematocrit īŽ Blood pressure īŽ Blood supply to uterus īŽ Cardiac reserve īŽ Vascular resistance DECREASE INCREASE
- 24. Wajed Hatamleh RN, MSN, PhD. Cardiovascular System īŽ Heart shifts up and to the left īŽ Hemoglobin stays the same (12-16 g/dL) initially īŽ May drop down to 10 g/dL and still be normal physiologic anemia. īŽ Normal pregnancy Hgb is 10-14 g/dL later in pregnancy īŽ Decreased Hct (38-47%) īŽ Normal pregnancy Hct is 32-42 later in pregnancy īŽ Pulse rate may increase 10-15 beats. īŽ Weight of uterus can cause supine hypotensive syndrome.
- 25. Supine hypotension related to Venal cava syndrome This leads to dizziness, air hunger, nausea
- 26. Total body water īŽ Increases 6-8 L īŽ Increases by 40 % īŽ Normal body water īŽ 2/3 intracellular īŽ 1/3 extracellular īŽ ž interstitial īŽ Âŧ intravasular īŽ 2/3 increase is extravascular
- 27. Physiologic anemia of pregnancy īŽ Physiologic intravascular change īŽ Plasma volume increases 50-70 % īŽ Beginning by the 6th wk īŽ RBC mass increases 20-35 % īŽ Beginning by the 12th wk īŽ Disproportionate increase in plasma volume over RBC volume----Hemodilution īŽ Despite erythrocyte production there is a physiologic fall in the hemoglobin and hematocrit readings
- 28. Iron deficiency anemia īŽ With erythropoiesis of pregnancy, iron requirements increase. īŽ Because large amounts of iron may not be available from body stores and may not be in the diet īŽ Supplementation is recommended to prevent iron deficiency anemia īŽ At term, Hemoglobin less than 10.0 is usually due to iron deficiency anemia rather than the hemodilution of pregnancy
- 29. Normal Iron Requirements īŽ Total body iron content average in normal adult females is 2gm īŽ Iron requirement for normal pregnancy is 1 gm īŽ 200 mg is excreted īŽ 300 mg is transferred to fetus īŽ 500 mg is need for mom īŽ Total volume of RBC inc is 450 ml īŽ 1 ml of RBCs contains 1.1 mg of iron īŽ 450 ml X 1.1 mg/ml = 500 mg īŽ Daily average is 6-7 mg/day īŽ Small intervals between pregnancies are most concerning
- 30. Respiratory system īŽ Mechanical īŽ diaphragm īŽ Consumption īŽ Increase in needed oxygen īŽ Stimulation īŽ Progesterone stimulation
- 31. Respiratory Changes Respiratory Changes īŧ īŧ Respiratory capacity Respiratory capacity increases increases īŧ īŧ Shortness of breath Shortness of breath īŧ īŧ Pulmonary reserve Pulmonary reserve decreases decreases īŧ īŧ Increased risk of Increased risk of muscle soreness muscle soreness īŧ īŧ Tendency to Tendency to hyperventilate hyperventilate RESULT RESULT adjust the intensity level and duration of exercise adjust the intensity level and duration of exercise
- 32. Physiologic changes - īŽ RESPIRATORY SYSTEM īŽincrease respiratory rate īŽincreased oxygen consumption īŽcommon are nasal stuffiness, nosebleeds due to Increased vascular swelling to nose
- 33. Respiratory īŽ Consumption īŽ O2 consumption Increases 15-20 % īŽ 50 % of this increase is required by the uterus īŽ Despite increase in oxygen requirements, with the increase in Cardiac Output and increase in alveolar ventilation oxygen consumption exceeds the requirements. īŽ Therefore, arteriovenous oxygen difference falls and arterial PCO2 falls.
- 34. Physiologic changes - īŽ GASTROINTESTINAL īŽ Digestive system slow due to progesterone īŽ Nausea and vomiting īŽ Ptyalism: increase salivation īŽ Heartburn īŽ Hemorrhoids īŽ Prolonged gallbladder emptying time may lead to gall stones īŽ Bile salt buildup may lead to itching.
- 35. Gastrointestinal Tract īŽ Displacement of the stomach and intestines īŽ Appendix can be displaced to reach the right flank īŽ Gastric emptying and intestinal transit times are delayed secondary to hormonal and mechanical factors īŽ Pyrosis is common due to the reflux of secretions īŽ Vascular swelling of the gums īŽ Hemorrhoids due to elevated pressure in veins
- 36. Digestive Changes Digestive Changes īŧ īŧ Digestive system slows Digestive system slows īŧ īŧ Intestines are pushed up Intestines are pushed up and to the sides and to the sides īŧ īŧ Smooth muscle of the Smooth muscle of the stomach relaxes and can stomach relaxes and can cause heartburn cause heartburn īŧ īŧ Constipation and hemorrhoids are Constipation and hemorrhoids are common during pregnancy common during pregnancy īŧ īŧ Morning sickness Morning sickness
- 37. Physiologic changes - īŽ METABOLISM īŽBMR increases by 20-25 % during pregnancy īŽRecommended weight gain â 25-35 lb īŽOverweight â 15-25 lb īŽUnderweight â 25-35 lb īŽNeed for increased iron, calcium,
- 38. Metabolic Changes īŽ Insulin level īŽ Carbohydrate utilization during exercise as weight increases īŽ Estrogen īŽ Progesterone īŽ Relaxin īŽ Caloric requirements by ~ 300 calories/day īŽ Protein and fluid requirements INCREASES IN:
- 39. Genital Tract īŽ Increased vascularity and hyperemia īŽ Vagina īŽ Perineum īŽ Vulva īŽ Increased secretions īŽ Characteristic violet color of the vagina īŽ Chadwickâs sign īŽ Increased length to the vaginal wall īŽ Hypertrophy of the papillae of the vaginal mucosa
- 40. Physiologic changes in pregnancy - Reproductive system īŽ Uterus â īŽ Enlarges : esp fundal area thickens, then thins later in preg īŽ Umbilicus by 20 weeks īŽ Xyphoid by 36 weeks fundus, Braxton-Hicks irregular contractions after 4 months īŽ Cervix â mucous plug, Goodellâs sign, Chadwickâs sign īŽ Ovaries âafter 11 weeks, the plac prod progesterone and estrogen
- 41. Changes in the cervix īŽ Length remains the same īŽ Increase in width īŽ Softening after third month due to oestrogen īŽ Increased vascularity īŽ Increased cervical mucosa īŽ Increased glandular function
- 42. changes in size uterus grows to 30x23x20 at term weight increases to 900gms hypertrophy.. Oestrogen causes cells to increase until 20 weeks gestation Hyperplasia:- number of cells increase under the influence of oestrogen .
- 43. After 20 weeks gestation īŽ Uterine muscle tissue stretches to allow fetus to grow īŽ Progesterone relaxes the smooth muscles enabling it to stretch
- 44. Relative Uterus Size During Pregnancy Figure 28.15
- 45. Changes in the shape of the uterus īŽ Isthmus elongates during the 1st 10 weeks like a stalk īŽ From 7mm to 2.5cms at 10 weeks īŽ Later becomes the lower segment with the globular uterus sitting on top
- 46. īŽ ORGANISATION OF MUSCLE FIBRES īŽ Inner circular layer īŽ Surrounds cornua, lower uterine segment and cervix īŽ Middle layer īŽ Oblique, crisscross arrangement involved in contractions to expel fetus īŽ Outer longitudinal layer īŽ Contracts and retracts thickening the upper segment
- 47. BY 12 WEEKS īŽ Uterus is upright and leans slightly to the right īŽ No longer a pelvic organ īŽ Uterus may be palpable above the pubic bone īŽ Fetus now occupies most of the uterine cavity īŽ Placenta now developed
- 48. 2ND TRIMESTA īŽ Development of the upper and lower uterine segment īŽ Upper segment, thicker containing oblique muscles īŽ Lower segment formed from the isthmus contains circular and longitudinal muscles īŽ Uterus is pear shaped again īŽ Braxton Hicks contractions
- 49. 3rd TRIMESTA īŽ Lower segment formed from isthmus and contains longitudinal fibres īŽ Upper segment thick and contains oblique muscle fibres īŽ By 36 weeks lower segment measures 8-10cms īŽ Engagement īŽ By 38 weeks the cervix is taken up into the lower segment
- 50. BLOOD CHANGES īŽ Increase in oestrogen: new blood vessels formed growth of existing ones īŽ Therefore an increase in blood volume.
- 51. BLOOD SUPPLY TO UTERUS īŽ Blood supply pre pregnancy = 10mls/min īŽ At 40weeks 800 â 900mls/min īŽ 20% of cardiac output goes to uterus
- 52. īŽ Blood volume: from 5 litres to 7.5 total volume up by 40-50% īŽ Red cell mass: rises constantly throughout pregancy Up by 20% by end of pregnancy
- 53. PLASMA VOLUME Increases from 10th week of pregnancy variable related to parity, fetal weight and number Reaches maximum level approx 50% above non-pregnant levels at 32-34 weeks then maintained
- 54. īŽ 50% rise in plasma volume īŽ 20% rise in red cell mass īŽ Heamodilution: Physiological anaemia īŽ Most apparent at 32-34 weeks
- 55. RENAL SYSTEM īŽ DILATION OF THE RENAL VESSELS īŽ DUE THE EFFECTS OF PROGESTERONE īŽ INCREASED RENAL BLOOD FLOW īŽ GFR INCREASES BY 60% IN EARLY PREGNANCY īŽ SIZE OF PORES INCREASED
- 56. Urinary Changes īŽ Kidneys grow and filter more blood as the blood volume increases īŽ Become more susceptible to bladder and kidney infections īŽ Bladder becomes compressed causing frequent urination and incontinence
- 57. Wajed Hatamleh RN, MSN, PhD. Physiologic changes - īŽURINARY TRACT īŽIncreased glomerular filtration rate īŽFrequency īŽInfection : Smooth muscle of bladder relaxes/stasis
- 58. Endocrine īŽ Normal pregnancy physiology shows īŽ âlower lows and higher highsâ īŽ Postprandial hyperglycemia īŽ To ensure sustained glucose levels for fetus īŽ Accelerated starvation īŽ Early switch from glucose to lipids for fuels īŽ Insulin resistance promotes hyperglycemia īŽ Resistance-Reduced peripheral uptake of glucose for a given dose of insulin īŽ Mild fasting hypoglycemia occurs with elevated FFA, triglycerides,and cholesterol
- 60. WATER, WATER, WATER īŽ Provide a ready source of water īŽ Encourage frequent water breaks Hydration is a major concern during maternal exercise.
- 61. Insulin resistance īŽ Anti-insulin environment is aided by: īŽ placental lactogen īŽ Like growth hormone īŽ Increases lipolysis and FFA īŽ Increases tissue resistance to insulin īŽ Increased unbound cortisol īŽ Estrogen and Progesterone may also exert some anti-insulin effects
- 62. Thyroid īŽ Estrogen stimulates Increase in TBG īŽ Total T3 and T4 are increased īŽ However the active hormones remains unchanged īŽ hCG stimulates thyroid īŽ TSH is reduced īŽ Iodine deficient state īŽ Due to Increased renal clearance īŽ To rule out pathologic changes īŽ Early in pregnancy TSH can be used īŽ Later free T4 is needed
- 63. Liver īŽ Liver morphology unchanged īŽ Lab Tests similar to liver disease īŽ Alkaline phosphatase doubles īŽ AST, ALT, GGT and bilirubin are slightly lower īŽ Decreased plasma albumin
- 64. Gallbladder īŽ Impaired contraction īŽ High residual volumes īŽ Promotion of stasis īŽ Stasis associated with increased cholesterol saturation of pregnancy, supports predisposition of stones īŽ Intrahepatic cholestasis īŽ Retained bile salts-pruritus gravidarum
- 65. Wajed Hatamleh RN, MSN, PhD. Physiologic changes - īŽINTEGUMENTARY SYSTEM These result from stretching of the skin and hormonal changes īŽ Linea nigra: pigmentation down middle line of abd īŽ Chloasma â âmask of pregnancyâ īŽ Straie: stretch marks of abd, breasts, thighs and buttocks īŽ Sweating
- 66. Skin changes īŽ Chloasma or melasma gravidarum īŽ Striae īŽ Linea nigra
- 67. Skin Changes īŽ Stretch marks īŽ Dark pigmented line on there abdomen which is called Linea Nigra īŽ Pigment changes on their face and neck īŽ Small blood vessels in the face, neck and upper chest īŽ MOST OF THESE RESOLVE AFTER PREGNANCY
- 68. Melasma
- 69. Melasma
- 70. Melasma īŽ Also known as the mask of pregnancy īŽ More common in dark skin people īŽ More pronounced in the summer īŽ Fades a few months after delivery īŽ Repeated pregnancy can intensify īŽ Can occur in normal non-pregnant women with harmless hormonal imbalances or women on OCPs or depo
- 71. Striae
- 72. Striae īŽ Reddish slightly depressed īŽ Breasts, thighs, and abdomen īŽ In future pregnancies they appear as glistening, silver lines
- 73. Linea nigra
- 74. Hyperpigmentation īŽ Melasma and linea nigra īŽ Estrogen and progesterone īŽ Some melanocyte stimulating effect
- 75. Breast Changes īŽ Nipples become larger and darker īŽ A thick yellowish fluid can be expressed from the nipple īŧ Early in pregnancy, tenderness and tightness is common īŧ After 8 weeks, breasts grow and blood vessels often are visible
- 76. Wajed Hatamleh RN, MSN, PhD. MS system īŽ Joint relaxation īŽ Posture changes -lordosis/center of gravity Back ache īŽ Diastasis recti: separation of rectus abdominous īŽ Leg cramp due to calcium, and stretching
- 77. Pelvic Floor Muscle Functions īŽ Maintain alignment and support of internal organs īŽ Control of urine flow īŽ Sexual enhancement īŽ Eliminate waste from rectum īŽ Improve recovery from episiotomy
- 78. Uterus & Uterine Ligaments Uterus Broad ligament Round ligament
- 79. Biomechanical Changes īŽ Weight distribution shifts īŽ Joint movement īŽ Balance of muscle strength īŽ Spinal curves increase īŽ Joint laxity becomes greater īŽ More structural discomfort īŽ Increased potential for nerve compression
- 80. Potential for Injury īŽ Nerve compression syndromes īŽ Low back discomforts or pelvic pain īŽ Upper back fatigue īŽ Lower extremity īŽ Pelvic floor function
- 81. Postural Dynamics īŽ Increased curve of the waist īŽ Top of pelvis tilts forward īŽ More flexion in the hip joint īŽ Increased hunching in the upper back and neck īŽ Tailbone is pushed back
- 82. Muscles Affected īŽ Overstretching & weakening of gluteal muscles & hamstrings īŽ Overstretching & weakening of abdominal muscles & pelvic floor īŽ Overstretching & weakening of upper back muscles īŽ Shortening and tightening of low back & hip flexors muscles īŽ Shortening of upper back flexors & pectoral muscles
- 83. Wajed Hatamleh RN, MSN, PhD. Neurological and sensory īŽ Decreased intraoccular pressure īŽ Corneal thickening īŽ Altered sense of smell īŽ Decreased attention span īŽ Problems with memory īŽ Altered CNS physiology leading to mood disturbance.
- 84. Combat Effects of Gravity/ Hormones īŽ Do pelvic tilts īŽ Alter the stance īŽ Shorten the jog stride īŽ Lower or eliminate the step in aerobics īŽ Avoid rapid leg abduction īŽ Avoid breast stroke kick in swimming īŽ Recognize tolerance for activities will vary īŽ Do pelvic floor exercises to prevent trauma īŽ Emphasize strengthening & stretching exercises īŽ Wear abdominal support/ sports bra when exercising for support
- 85. Changes to Body System īŽ First Trimester īŽ Baby begins to grow īŽ Increased urination īŽ Changes with skin and hair īŽ Thickening waistline īŽ Nausea/fatigue īŽ Second Trimester īŽ Babyâs weight increases īŽ Energy level improves īŽ Heartburn īŽ Leg cramps īŽ Pelvis relaxes causing SI discomfort īŽ Third Trimester īŽ Baby has more rapid growth & weight gain īŽ Backaches īŽ Swelling of the hands, legs, and feet īŽ Breathlessness īŽ More frequent urination