Pregnancy

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Pregnancy

  1. 1. Physiology of Pregnancy Santosh mohle BNYS SVYASASep 18, 2012 1
  2. 2. Sep 18, 2012 2
  3. 3. INTRODUCTION Pregnancy The course that the embryo and the fetus grow in the maternal body Stages of pregnancy 1.Early pregnancy: ≤12 weeks 2.Mid pregnancy: ≥13 weeks,≤27 weeks 3.Late pregnancy:≥28 weeks 4.Term pregnancy:≥37 weeks,<42 weeksSep 18, 2012 3
  4. 4. Normal pregnancy average duration is counting from first day of last menstrual period is about 280 days and 10 lunar months or 40 weeksSep 18, 2012 4
  5. 5. Formation of Embryo A. Fertilization Fusion of male & female gamates to form a zygote 1. Place: oviduct (ampulla) 2. Process capacitation → acrosome reaction→ penetrate the zona pellucida→ second meiosis →zygoteSep 18, 2012 5
  6. 6. Fertilization Fertilization in the ampulle of the FT.Prostaglandins• Oxytocin Sep 18, 2012 6
  7. 7. Contd… B. Implantation 1)Disappear of zona pellucida 2)Formation of syncytiotrophoblast 3)Synchronized development of blastocyst and endometrium 4)Adequate progesteroneSep 18, 2012 7
  8. 8. Contd… Process 1) morula (day 3) → enter uterine cavity (day 4) → early blastocyst→ late blastocyst (day 6-7) → implantation 2) location→ adherence→ penetrationSep 18, 2012 8
  9. 9. Fertilization Implantation 5-7 days after fertilization • Proteolytic enzymes of the trophoblast cellsSep 18, 2012 9
  10. 10. Development of embryo and fetus Definition 1.embryo: ≤ 8 weeks 2.Fetus: ≥ 9 weeks, human shapeSep 18, 2012 10
  11. 11. Development of embryo and fetus Physiology of fetus A.Circulation 1)fetus ←→placenta←→ mater 2)1 umbilical vein (full of oxygen), 2 umbilical artery (lack of oxygen) 3)Mixed blood (vein and artery)Sep 18, 2012 11
  12. 12. Development of embryo and fetus B. Hematology 1) Erythropoiesis From yolk sac: 3 weeks From liver: 10 weeks From bone marrow and spleen: term (90%)Sep 18, 2012 12
  13. 13. Development of embryo and fetus 2) Fetal hemoglobin Fetal hemoglobin: early pregnancy Adult hemoglobin: 32nd week Term: fetal type Hb 25% 3) White cells Leukocytes: 8 week Lymphocytes (antibody production): 12 week, thymus and spleenSep 18, 2012 13
  14. 14. Development of embryo and fetus C. Gastrointestinal tract 1) drink amniotic fluid: 4th month 2) no proteolytic activity 3) enzymatic deficiencies in liver: bilirubin is not easy to be clear.Sep 18, 2012 14
  15. 15. Development of embryo and fetus D. Kidney Its function begins at 11-14th week E. Endocrinology 1) Fetal thyroid: the first endocrine gland (6th week), synthesize thyroxine at 12th week 2) Fetal adrenal cortex: widen (20th week), a fetal zone. synthesize steroid hormones ( liver placenta mater)Sep 18, 2012 15
  16. 16. Placenta development Early nutrition of the embryo 10th weekSep 18, 2012 16
  17. 17. Placenta - oxygen transport • Similarities betwen placenta and lungs • Oxygen transport - simple difusionSep 18, 2012 17
  18. 18. Placenta • Structure 1. Primary villus syncytiotrophoblast cytotrophoblast 1. Secondary villus 2. third class vilus fetal capillary enter the stromaSep 18, 2012 18
  19. 19. Sep 18, 2012 19
  20. 20. Placenta Function 1.metabolism 1)Exchange of O2 and CO2 2)Exchange of nutritive factors and waste 1.Defensive Limited. IgG, virus, drugSep 18, 2012 20
  21. 21. Placenta Endocrine 1)Human chorionic gonadotrophic 2)Human placental lactogen 1)Oxytocinase 2)Cytokines and Growth Factors 1.Immunity toleranceSep 18, 2012 21
  22. 22. Fetal membranes Structure chorion and amnion Amnion A double-layered translucent membrane Become distended with fluidSep 18, 2012 22
  23. 23. Umbilical CordSep 18, 2012 23
  24. 24. Amniotic fluid Source 1.exudation of fetal membranes (early pregnancy) 2.Fetal urine 3.Fetal lung 4.Exudation of amnion and fetal skinSep 18, 2012 24
  25. 25. Cont • Absord 1. Fetal membrane 2. Umbilical cord 3. Fetal skin 4. Fetal drinking • Feature 1000-1500ml at 36th-38th weekSep 18, 2012 25
  26. 26. cont Function 1.Protect fetal move freely, warm 1.Protect mater prevent infectionSep 18, 2012 26
  27. 27. Fetal physiology - circulation Fetal heart rate (FHR) – beating at 5 weeks – 100 beats/min 8 weeks – 160 beats/min 15 weeks – 150 beats/min Birth – 130 beats/min Bradycardia – slow pulse rate – very dangerous to fetus Blood flow – 40% to head/upperbody 30% to placenta 30% to lower bodySep 18, 2012 27
  28. 28. Fetal circulationSep 18, 2012 28
  29. 29. Fetal Physiology - Respiration Gross breathing movements at 11 weeks Rapid and irregular – associated with REM (rapid eye movements) Isolated slow movements – gasps Function of fetal breathing: Stimulates growth of the lungs Conditioning of musclesSep 18, 2012 29
  30. 30. The First TrimesterLasts from conception to the twelfth week of pregnancy3periods during the first trimester: – The Germinal Period • Fertilized egg travels and implants in wall of uterus • Implantation occurs 10-14 days after conception – The Period of the Embryo • Lasts from third through 8th week of pregnancy • Major organs and anatomical structures begin to form – The Period of the Fetus • Lasts from ninth week of pregnancy until birth • All major organs continu Sep 18, 2012 30
  31. 31. The Second Trimester week 13-29Fetus assumes distinct human appearance• The nails harden and skin thickens, as well as the eye lashes, eye brows, and scalp hair appear during fifth and sixth months• Fetus’s visual and auditory senses are functional Sep 18, 2012 31
  32. 32. The Third Trimester week 29to 40All organ systems mature rapidly• Fetus prepares for birth• Fetus reaches ‘age of viability’, the point at which the fetus can survive outside of the uterus• Fetus shows better-organized gross motor activity, and sleepiness/ waking activity• Towards end of ninth month, fetus is positioned head- down with limbs curled up in ‘fetal position’ Sep 18, 2012 32
  33. 33. Physiologic changes in pregnant woman • Genital organs 1. Uterus 1) capacity: 5ml-5000ml.weight: 50g- 1000g 2) Hypertrophy of muscle cells 3) Endometrium→ decidua: basal decidua, capsular decidua, true decidua 4) Contraction: Braxton Hicks 5) Isthmus uteri: 1cm→ 7-10cmSep 18, 2012 33
  34. 34. Physiologic changes in pregnant woman 1) Cervix: colored 2) Ovary: placenta replaces ovary (10th week) 3) Vagina: dilated and soft, pH↓ (anti- bacteri bacteria) 4) Ligaments: relaxedSep 18, 2012 34
  35. 35. Changes in the shape of the uterus • Isthmus elongates during the 1st 10 weeks like a stalk • From 7mm to 2.5cms at 10 weeks • Later becomes the lower segment with the globular uterus sitting on topSep 18, 2012 35
  36. 36. Sep 18, 2012 36
  37. 37. BLOOD SUPPLY TO UTERUS • Blood supply pre pregnancy = 10mls/min • At 40weeks 800 – 900mls/min • 20% of cardiac output goes to uterusSep 18, 2012 37
  38. 38. 8th weekSep 18, 2012 38
  39. 39. 12th weekSep 18, 2012 39
  40. 40. 16th weekSep 18, 2012 40
  41. 41. 20th weekSep 18, 2012 41
  42. 42. 24th weekSep 18, 2012 42
  43. 43. 30th weekSep 18, 2012 43
  44. 44. 36th weekSep 18, 2012 44
  45. 45. Sep 18, 2012 45
  46. 46. Physiologic changes in pregnant woman The urinary system 1.Kidney 1)Renal plasma flow (RPF):↑ 35% 2)Glomerular filtration rate (GFR):↑ 50% 1.Ureter Dilated (↑ ) 1.Bladder Frequent micturationSep 18, 2012 46
  47. 47. Physiologic changes in pregnant woman Cardiovascular system 1.Heart: move upward, hypertrophy of cardiac muscle 1.Cardiac Output increase by 30%, reach to peak at 32nd –34th week 1.Blood pressure early or mid pregnancy Bp↓. late pregnancy Bp↑ .Supine hypotensive syndromeSep 18, 2012 47
  48. 48. Physiologic changes in pregnant woman Hematology 1. Blood volume 1) Increase by 30%-45% at 32nd –34th (peak) 2) Relatively diluted 1. Composition 1) Red cells Hb:130→ 110g/L, HCT:38%→ 31%. 1) White cells: slightly increase 2) Coagulating power of blood: ↑Sep 18, 2012 3) Albumin: ↓, 35 g/L 48
  49. 49. Hematologic changes •plasma volume increases (50%) •erythropoesis (RBC) increases (25%) • decreased Hb, hematocrite • Iron requirements increases significantly • Iron suplements neededSep 18, 2012 49
  50. 50. Physiologic changes in pregnant woman The Respiratory system 1. R rate: slightly ↑ 2. vital capacity: no change 3. Tidal volume: ↑ 40% 4. Functional residual capacity:↓ 5. O2 consumption: ↑ 20%Sep 18, 2012 50
  51. 51. Physiologic changes in pregnant woman • Gastrointestinal system 1) Gastric emptying time is prolonged→ nausea. 2) The motility of large bowel is diminished → constipation 3) Liver function: unchangedSep 18, 2012 51
  52. 52. Increases in body weightThe average weight gained by the body during pregnancy in about 12 kg the approximate weight of various structures which adds to the weigth gain fetus : 3.5kgAmniotic fluid : 2.0 kgPlacenta : 1.5 kgIncreases in matt. 5.0 kgSep 18, 2012 52
  53. 53. Hormonal changes Placenta mother aldosterone hypertension CRH ACTH cortisol edema insulin resistance HCG hyperthyroidismHC thyrotropin gestational diabetes ↑Calcium Hyperparathyroidism demands Sep 18, 2012 53
  54. 54. CHANGES ARE DUE TO • ALTERATIONS IN • HORMONAL PRODUCTION • CIRCULATION • METABOLISMSep 18, 2012 54
  55. 55. HORMONESOESTROGEN• Produced in corpus luteum• Produced by placenta after 12 weeks• Responsible for growth particularly of uterus and breasts Sep 18, 2012 55
  56. 56. progesterone • Produced in corpus luteum and then the placenta • Relaxes smooth muscle • Inhibits uterine contractions until uterus is prepared for labour • Regulates storage of body fatSep 18, 2012 56
  57. 57. Human chorionic gonadotrophic • Secreted from trophoblast of the developing embryo • Maintains corpus luteum until placenta takes over • Used in tests to confirm pregnancySep 18, 2012 57
  58. 58. Human placental lactogen • Alters maternal metabolism • Diverts glucose to fetus • Mobilises free fatty acids from maternal storesSep 18, 2012 58
  59. 59. RELAXIN • Released by corpus luteum then the Placenta • Softens pelvic ligaments • Reduces myometrial toneSep 18, 2012 59
  60. 60. Changes in the reproductive system: Uterus• endometrium ………….decidua• becomes more vascular and thicker due to oestrogen and progesterone• decidua provides glycogen rich enviroment to nourish fetus until trophoblastic cells develop into placenta• decidual cells produce prolactin and relaxinSep 18, 2012 60
  61. 61. MYOMETRIUM • Smooth muscle fibres embedded in a matrix of connective tissue • Grow 15 – 20 times normal sizeSep 18, 2012 61
  62. 62. PERIMETRIUM• Stretches with uterus upwards and outwards• Can cause discomfort• Spasm of broad ligament specially on right side due to right uterine obliquity Sep 18, 2012 62
  63. 63. 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 .Sep 18, 2012 63
  64. 64. After 20 weeks gestation • Uterine muscle tissue stretches to allow fetus to grow • Progesterone relaxes the smooth muscles enabling it to stretch Sep 18, 2012 64
  65. 65. Changes in the cervix • Length remains the same • Increase in width • Softening after third month due to oestrogen • Increased vascularity • Increased cervical mucosa • Increased glandular functionSep 18, 2012 65
  66. 66. BY 12 WEEKS • Uterus is upright and leans slightly to the right • No longer a pelvic organ • Uterus may be palpable above the pubic bone • Fetus now occupies most of the uterine cavity • Placenta now developedSep 18, 2012 66
  67. 67. BLOOD CHANGES • Increase in oestrogen: new blood vessels formed growth of existing ones • Therefore an increase in blood volume.Sep 18, 2012 67
  68. 68. • Blood volume: from 5 litres to 7.5 total volume up by 40-50%• Red cell mass: rises constantly throughout pregnancy Up by 20% by end of pregnancySep 18, 2012 68
  69. 69. 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 maintainedSep 18, 2012 69
  70. 70. Month nine• Lightening – Fetus descends to pelvic cavity• Cervix – Dilation, Effacement (softening,• thinning)• False Labor – Contractions initiate then• diminish• Labor:• Cervical effacement – dilation to 10 cm• Bloody Show – mucus plug of the cervix – blood-colored• Breaking Water Bag – rupturing of the amnion• Contractions – shorter intervals, longer, stronger Sep 18, 2012 70
  71. 71. Uterine Contraction• Uterine musculature becomes progressively more excitable• Estrogen/progesterone ratio changes increases excitability• Progesterone inhibits contraction• Estrogen increases gap junctional communication between• smooth muscle cells  increases contractility• Oxytocin (maternal posterior pituitary gland) increases excitability• Mechanically stretching uterine smooth muscle increases• contractility• Cervical stretching elicits uterine contractions• Fetal effects –glucocorticoids  placenta inhibits progesterone• Fetal oxytocin is also produced Sep 18, 2012 71
  72. 72. Labor and ParturitionParturition: Process by which the•baby is born•Labor: Strong uterine contractions,•Cervix stretching, Forcing the•fetus through the birth canal•Rhythmic strong uterine contractions expel the fetus•Positive-Feedback regulation of labor•Contractions push baby  stretch cervix•Stretched cervix Stronger uterine contraction•Cycles until parturition is complete Sep 18, 2012 72
  73. 73. contd• Contractions: 30 minutes  1-3 minutes• Contractions strongest at top of uterus – forcing baby• toward cervix (25 lbs/contraction)• Continuous contractions (tetanus) can stop blood flow and• lead to death of the baby• First stage of labor: cervical dilation (8-24 hours)• Second stage of labor: passage through birth canal (few minutes to half hour)• Third stage of labor: expulsion of the placenta Sep 18, 2012 73
  74. 74. After Birth• 10-45 minutes after parturition the placenta is• DeliveredSeparation and ExpulsionSeparation - Uterine cavity reduces in size • shearing the placenta from the uterine wallLimited bleeding – controlled by local production• of vasoconstrictors (prostaglandins)• Expulsion is by uterine contraction Sep 18, 2012 74
  75. 75. Conditions During Pregnancy • Constipation – Affects half of pregnant women – Causes: • increase in progesterone • the colon absorbing more water • worse in first 13-14 weeks – Treatment: • Drink plenty of fluids • Eat high fiber foods • Take fiber supplements – psylium husks, Metamucil, Ex-LaxSep 18, 2012 75
  76. 76. Cardiovascular change • Displaced to left and upward • Apex is move laterally • Apparent cardiomegarty on chest x- ray • Increase of left ventricular end diastolic dimension • increase of left ventricular wall mass c/w mild hypertrophy increase in preload increase capacitance of the systemic pulmonary vascular resistance pregnant rise to cvp or wedge pressureSep 18, 2012 76
  77. 77. Nausea and Vomiting duringPregnancy (NVP)(Morning Sickness)• Peaks during the first Trimester• Positive correlation with birth weight• Negative correlation with spontaneous abortions• Nausea – 50-70% of pregnant women• Vomiting – 40-50% of pregnant women• Less than 2% is solely in the morningSep 18, 2012 77
  78. 78. BreastDevelopmentPregnancyHormone-Dependent GrowthEstrogenGrowth HormoneProlactinAdrenal glucocorticoidInsulin• Growth and branching of the ductal systemFat Deposition• Progesterone: Final stages – synergistic with other hormones – growthof lobules, budding of alveoli, secretory characteristics, but not secretionSep 18, 2012 78
  79. 79. Lactation Prolactin: Promotes milk secretion Anterior pituitary Hypothalamus (inhibition)Steady rise week 5 – birth stimulates colostrum – low volume, no fat birth – sudden drop in Estrogen and Progesterone1-7 days prolactin induces high milk productionSep 18, 2012 79
  80. 80. Cont Other hormones are required: growth hormone, cortisol, parathyroid hormone Prolactin production is stimulated by signals from the nipple to hypothalamus(repression of prolactin- inhibiting hormone)  Anterior Pituitary  10-20x surge of prolactin Nursing can continue for years Once nursing stops - milk production declines within a weekSep 18, 2012 80
  81. 81. Milk Letdow Milk secreted into the alveoli of the breast, but must be ejected to the ductal system. Oxytocin (posterior pituitary) stimulates this reflex Oxytocin production controlled by hypothalamus (direct innervation of the posterior pituitary gland) Oxytocin induces contraction of myoepithelial cells around the alveoli Oxytocin induced by suckling and also cryingSep 18, 2012 81
  82. 82. BREAST FEEDING FEEDBACK LOOP – suckling of baby stimulates nerves in the areola of breast – this stimulates the pituitary to release prolactin and oxytocin – the prolactin initiates milk production and moves milk into ducts – oxytocin causes weak contractions in the breast to move the milk – oxytocin also causes weak contractions in the uterus to return the uterus to its normal size and shape, thus breast-feeding mothers regain uterine muscle control quickerSep 18, 2012 82
  83. 83. • Hear baby cry  release oxytocin  start to move milk "milk let down“• Stress à lowers milk release  lots of milk  no release  increased pressure pain (thus it is important to be relaxed and in a quiet area to feed)Sep 18, 2012 83
  84. 84. SFCC: Figure 14.14 84Sep 18, 2012 84
  85. 85. During Lactation Don’t:• Don’t drink alcohol• Don’t take medications unless OK by Medical Provider• Don’t take illegal drugs• Don’t smoke• Don’t get into environmental contaminants• Don’t have caffeine 85Sep 18, 2012 85
  86. 86. Yoga for pregnancy• Help with breathing and relaxation• Promote feelings of well-being• Energizing• Stress relief• Improve posture Sep 18, 2012 86
  87. 87. Yoga for pregnancy • Control of excess weight gain • Appearance Improved sleep • Decreased back pain • Decreased water retention • decrease in complications during labour • Shortened labourSep 18, 2012 87
  88. 88. Swimming • Uses large muscle groups of the legs and arms • No strain on ligaments • Feeling of weightlessness • Improved circulation • Water Temp 18-25 °CSep 18, 2012 88
  89. 89. Disadvantages of Not Yoga practice • Studies have shown that women who yoga practice do not experience an increase in: – Premature Rupture of Membranes (PROM) • When the membranes that hold the amniotic fluid break too early. – Congenital AbnormalitiesSep 18, 2012 89
  90. 90. Exercises to Avoid During Pregnancy• Ball sports• Contact sports: ultimate fighting, wrestling, football• Sports that involve bouncing, leaping, a sudden change of direction (increased joint laxity from hormones make joints susceptible to sprains)• Exercises that put you at risk for falls: rollerblading, horseback ridding, skiing• After 1st trimester avoid exercise in the supine position• Lying in the prone position• Lifting heavy free weights Sep 18, 2012 90
  91. 91. Contraindications to Exercise• Premature rupture of membranes• Preterm labor during the prior or current pregnancy• Persistent 2nd or 3rd trimester bleeding• conditions such as: – Cardiac disease, constrictive lung disease – Chronic hypertension – Severe anemia – Chronic bronchitis – Extreme obesity – Extreme underweight – History of an extremely sedentary lifestyle – Orthopedic limitations – Heavy smoker Sep 18, 2012 91
  92. 92. And Finally… THANK YOUSep 18, 2012 92

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