Midterms # 1
PHYSIOLOGIC CHANGES DURING PREGNANCY
paper through bimanual palpation
Ballottement – 16th-20th week, fetus is small compared to amt of amniotic fluid present. Fetus bounce or rise on tapping sharply the lower uterine segment against the top examining hand
Braxton-Hicks contraction – practice contractions, waves of hardness and tightening across her abdomen
Can be categorized as: Local – reproductive organs only • •
Systemic – the entire body is affected
LOCAL CHANGES A. REPROD REPRODUCT UCTIVE IVE SYSTE SYSTEM M CHANGES CHANGES a. Uter Uterin ine e Cha Chang nges es
Length: 6.5 – 32 cm
Depth : 2.5 – 22 cm
Width: 4 – 24 cm
Weight: 50 – 1000g
b. Amenorrhea
c. Ce Cerv rvic ical al chan change ges s
Vascular and edematous – increased circulating estrogen
From pale pink to violet
Operculum – mucous plug in cervical canal that seals out bacteria during pregnancy preventing fetal and membrane infection
Goodell’s Sign – softening of the cervix from elasticity of earlobe to consistency of butter
Thickness: early in pregnancy 1cm-2cm, end of pregnancy 0.5 cm thick Volume: 2ml – more than 1000ml /4000g at term
End of twelfth week palpated at the symphysis pubis
20th or 22nd week reached umbilicus
End of 36th week reached the xiphoid process ( breathing is difficult)
38th week, for a primigravida, fetal head settles into the pelvis, the uterus returns to the height at 36th week o
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LIGHTENING – woman’s breathing becomes easier, lightening the load. *In multipara, it occurs at labor
Uterine blood flow: before 1520 ml/min, by the end of pregnancy 500-750 ml/min *75% goes to placenta Hegar’s sign – extreme softening of the lower uterine segment, felt as thin as tissue
Because of FSH suppression by rising estrogen levels
d. Vagi Vagina nall chan change ges s
Hypertrophic and enriched with glycogen – because of increased estrogen
Chadwick’s sign – normal light pink to a deep violet : increased vascularity
From pH >7 to pH 4 or 5 vaginal secretions because of Lactobacillus acidophilus (grows freely in increased glycogen envt)
Candidiasis – caused by Candida albicans , itching and burning sensation with creamcheese-like creamcheese-like discharge
Leukorrhea – excessive discharge
e. Ovarian changes
Ovulation stops because of active feedback mechanism of
*weeks after birth becomes striae albicantes or atrophicae (silvery-white)
E & P by corpus luteum/placenta
(-) prodn of FSH and LH
Corpus luteum – enlarges until 16th week as placenta takes over as provider of E & P,
f.
Striae gravidarum – pink or reddish streaks on sides of abdomen and on thighs caused by rupture and atrophy of connective layer of skin
Then becomes corpus albicans – white and smaller
Changes in breasts
Diastasis – separation of rectus muscles, appears after pregnancy as a bluish groove
Umbilicus becomes obliterated and protruding
Linea nigra – narrow brown line in midline
Melasma/chloasma – “mask of pregnancy”, dark pigmentations on cheeks and nose due to MSH
Vascular spiders/Telangiectases – small, fiery-red, branching spot on thighs due to increasing estrogen
6th week. Changes are noticeable
Feeling of fullness, tingling or tenderness – increased estrogen levels.
Increased in size hyperplasia of mammary alveoli and fat deposits
Areola darkens and increases in diameter
Activity of sweat glands increases
Palmar erythema – redness and itching on hands due to estrogen
Scalp hair growth increases
Increased vascularity and prominent blue veins
Montgomery’s tubercles – sebaceous glands enlarge and become protuberant
C. RESPIRATORY SYSTEM - Keeps nipples supple, preventing drying and cracking during lactation
Colostrum – thin watery high-protein fluid that is precursor of breast milk, can be expelled at 16 th week
SYSTEMIC CHANGES
B. INTEGUMENTARY SYSTEM
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Marked congestion or stuffiness of the nasopharynx – increased estrogen levels
Shortness of breath – pressure on diaphragm
Decreased PCO 2 (blood CO2) of 32mmHg due to increased progesterone level – easier fetal CO2 transfer to maternal bloodstream
Mild Hyperventilation – to prevent maternal blood pH from becoming acidic bec of CO 2
Decreased iron absorption due to decreased gastric acidity
Polyuria – kidney excretes HCO 3 to help, add’l H2O and Na is lost
Excessive Fe: stomach irritation
Vital capacity: no change
Increased need of folic acid
Inadequate: megalohemoglobinemia ( large, non-functioning RBC) : risk for fetal neural tube disorders
Tidal volume: increased 30-40%
RR: increased 1-2bpm
Residual volume: decreased by 20%
Plasma PCO2: decreased 2730mmHg
Plasma pH: 7.40-7.45
Plasma O2: Increased 104-108 mmHg
Respiratory minute volume: increased 40%
Expiratory reserve: decreased 20%
c. Heart
Cardiac output increases by 25-50%
Heart rate increases by 10bpm
More transverse positioning due to diaphragm displacement
Palpitations: early in pregnancy is due to SNS stimulation ; in later months due to increase thoracic pressure
D. TEMPERATURE
Early: increases due to progesterone due to corpus luteum (same at ovulation)
d. Blood pressure
16th week: decreases to normal due to placenta
E. CARDIOVASCULAR SYSTEM
a. Blood volume – increases by 30%
Blood loss during NSD: 300400 mL
Blood loss during CS: 8001000mL
Pseudoanemia - conc. of hemoglobin and RBC decline in first trimester due to faster plasma volume increase than RBC prod’n
1st trimester: BP does not rise
2nd trimester: BP decreases due to decreased PR
3rd trimester: BP goes up same with 1 st trimester
e. Peripheral Blood flow
f.
Supine Hypotension Syndrome
Lying supine, the uterus presses vena cava against vertebrae: obstructing blood flow in lower extremities
Decrease venous return: decreased CO and BP
b. Iron, Folic Acid & Vitamin Needs
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Total increased iron need of 800mg
3rd trimester: blood flow in lower extremities is impaired leading to edema, varicosities of the vulva, rectum, and legs
Results to: o
o
Maternal: Lightheadedness, faintness and palpitations
Heartburn – reflux of stomach contents into esophagus because of: •
Fetal: Hypoxia •
Corrected through turning the woman to her left side
g. Blood Constitution
Fibrinogen: increases by 50% due to increased estrogen level
Clotting Factors VII, VIII, IX, & X and platelet count increases •
Safeguard against major bleeding
upward displacement of the stomach relaxed cardioesophageal sphincter (due to relaxin, enzyme produced by ovaries)
Slow intestinal peristalsis and the emptying time of stomach due to pressure caused by uterus displacing abdominal organs: leads to heartburn, constipation and flatulence
Relaxin: decreases gastric motility
Total WBC count rises slightly
Progesterone: makes GI tract less active
Total Protein level of blood decreases due to fetal consumption
Subclinical Jaundice (generalize itching) •
Decreased emptying of bile from the gallbladder: reabsorption of bilirubin in maternal bloodstream
Ankle & foot edema is common due to lower total protein load and hypovolemia: equal osmotic and hydrostatic pressure
Blood lipids increases by 1/3*
Hypertrohy of gumlines & bleeding of gingival tissue
Cholesterol serum levels increases by 90-100%*
Hyperptyalism – increased saliva prod’n due to increased estrogen lvls
Increased tooth decay: lower than normal pH of saliva
*for ready supply of available energy to the fetus
F. GASTROINTESTINAL SYSTEM
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First trimester: “Morning sickness” - nausea and vomiting early in the morning, increased HCG and progesterone levels/increased estrogen and decreased glucose
G. URINARY SYSTEM •
Changes results from: o
o
Effects of high E & P levels Compression of bladder and ureters
o
o
Increased blood volume Postural influences
c. Bladder and ureter function
a. Fluid retention
Until uterus rises out of pelvis and relieves pressure on bladder.
Total Body H 2O increases to 7.5 L: increase Na reabsorption Increased Aldosterone prod’n due to increased response Angiotensin-renin system to progesterone o
Aldosterone aids in Na reabsorption
K levels remain adequate due to progesterone
H2O is retained: aid the increase in BV and serve as ready fluid supply of fetus
Polyuria – increase urinary frequency, during 1st trimester
This returns as lightening occurs.
Ureters increased in diameter & bladder capacity increases to 1500ml: due to increased progesterone
Uterus rises on the right side, pushed slightly by sigmoid colon: pressure on right ureter o
If not relieved, urinary stasis and pyelonephritis
b. Renal Function
Kidneys increased in size
Urine output increases 6080%
Sp. Gr. Decreases
GFR and renal plasma flow increases early in pregnancy At 2nd trimester, they increased by 30-50%
Pressure on urethra: poor bladder emptying and bladder infection o
H. SKELETAL SYSTEM
Ca and P need is increased o
Lower BUN and creatinine lvls o
o
o
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Gradual softening of pelvic ligaments and joints (relaxin and progesterone)
Excessive mobility of joints causes discomfort
3mm-4mm separation of symphysis pubis at 32 weeks
Gestational DM due to: o
Accidental spilling of glucose in urine due to reabsorption of glucose Unused lactose is also spilled
Fetal skeleton must be build
15mg/100ml or higher BUN is abnormal, as well as, Greater than 1mg/100ml creatinine
Leads to kidney infection (mother) and UTI (fetus)
o
Difficulty walking
Lordosis/ “Pride of Pregnancy” – forward curve of lumbar spine, may lead to backache
Increased lvls of: protein-bound iodine, butanol-extractable iodine and thyroxine
I. ENDOCRINE SYSTEM a. Placenta
Emotional lability, tachycardia, palpitations, and diaphoresis
Produces large amts of E, P, HCG, HPL, relaxin & prostaglandins ESTROGEN causes: breast and uterine enlargement, & palmar erythema
Parathyroid also increases in size, calcium prod’n
PROGESTERONE is involved in: maintenance of endometrium, inhibition of uterine contractility, & development of breasts for lactation
d. Adrenal glands
Increased corticosteroids & aldosterone due to increased AG activity
RELAXIN (corpus luteum): helps in inhibiting uterine activity, softening of the cervix (dilatation at birth) and collagen in joints (laxness in the lower spine & enlargement of birth canal)
Decreased inflammatory reaction
Increased aldosterone lvls
HCG (trophoblast): stimulates E and P synthesis
e. Pancreas Increased insulin prod’n due to increased glucocorticoid lvls
HPL: insulin antagonist; more glucose for fetus
Maternal blood glucose level > fetal glucose level
PROSTAGLANDIN: affect smooth muscle contractility, initiates labor
To prevent hypoglycemia: Increase MBGL than normal o
b. Pituitary Gland
Low FBS of mother during first trimester
(-) prod’n of FSH and LH due to increased P and E
Increased prod’n of GH and MSH
Less effective insulin due to insulin-antagonists (E, P & HPL)
Later: prod’n of oxytocin and prolactin
J.
c. Thyroid and Parathyroid Glands Thyroid enlarges: BMR increases by 20%
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IMMUNE SYSTEM Immunocompetency decreases
IgG prod’n decreases: prone to infection
Increase WBC count
PCDN_N201_NCM101 07/31/2011 3:59pm
“LOVE is a strong word to say it too early, Yet, it is too wonderful to say it too late...”
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