Arrangement of the Muscle Cells

The uterine musculature during pregnancy is arranged in three strata:

1. An outer hoodlike layer - arches over the fundus and extends into the various ligaments.
2. A middle layer- composed of a dense network of muscle fibers perforated in all directions by
blood vessels.
- Forms The main portion of the uterine wall.
- has a double curve that forms figure 8 when interlaced
3. An internal layer- with sphincter-like fibers around the fallopian tube orifices and internal os
of the cervix
Uterine Size, Shape, and Position
first few weeks -pear shape,
12 weeks - becoming almost spherical, then when it increases in length it assumes ovoid shape.
end of 12 weeks - uterus has become too large to remain entirely within the pelvis.
As the uterus continues to enlarge, it contacts the anterior abdominal wall, then ultimately reaching
almost to the liver.
dextrorotation rotation of the uterus to the right.
- caused by the rectosigmoid on the left side of the pelvis.
- As the uterus rises, tension is exerted on the broad and round ligaments.
With the pregnant woman standing, the longitudinal axis of the uterus corresponds to an extension of
the axis of the pelvic inlet.
When the pregnant woman is supine, the uterus falls back to rest on the vertebral column and the
adjacent great vessels, especially the inferior vena cava and aorta.
Contractility
Beginning in early pregnancy, the uterus undergoes irregular contractions that are normally painless.
During the second trimester, these contractions may be detected by bimanual examination.
Braxton Hicks- contractions
- contractions appear unpredictably and sporadically and are usually nonrhythmic.
- Their intensity varies between 5 and 25 mm Hg.
- Until the last several weeks of pregnancy, these Braxton Hicks contractions are
infrequent, but they increase during the last week or two. At this time, the contractions
may occur as often as every 10 to 20 minutes and also may assume some degree of
rhythmicity.
- Late in pregnancy, these contractions may cause some discomfort and account for so-
called false labor
- 75 percent of women with 12 or more contractions per hour were diagnosed with
active labor within 24 hours

Uteroplacental Blood Flow
Placental perfusion- dependent on total uterine blood flow, (from the uterine and ovarian arteries.)
Uteroplacental blood flow increases progressively during pregnancy,
- 450 to 650 mL/min near term
Uterine vein remodeling due to reduced elastin content and adrenergic nerve density, which results
in increased venous caliber and distensibility.
- such changes are necessary to accommodate massively increased uteroplacental blood
flow.
uterine contractions, either spontaneous or induced, caused a decrease in uterine blood flow that was
approximately proportional to the intensity of the contraction.
tetanic contraction caused a precipitous fall in uterine blood flow.
Uterine contractions appear to affect fetal circulation much less

Regulation of Uteroplacental Blood Flow
maternal-placental blood flow- the increase is due occurs principally by means of vasodilation
fetal-placental blood flow - is increased by a continuing growth of placental vessels
estradiol and progesterone contributed to the downstream fall in vascular resistance in women with
advancing gestational age
nicotine and catecholamine - significant decreases in uterine blood flow and placental perfusion
normal pregnancy is characterized by vascular refractoriness to the pressor effects of infused
angiotensin II. This insensitivity serves to increase uteroplacental blood flow.
large-conductance potassium channels - also contribute to uteroplacental blood flow regulation
through several mediators, including estrogen and nitric oxide.

Cervix
- undergo pronounced softening and cyanosis As early as 1 month after conception
=These changes result from increased vascularity and edema of the entire
cervix, together with hypertrophy and hyperplasia of the cervical glands.
- small amount of smooth muscle, its major component is connective tissue.
- Rearrangement of this collagen-rich connective tissue (cervix)
= is necessary for maintenance of a pregnancy to term
= dilatation to aid delivery
= repair following parturition so that a successful pregnancy can be repeated
- the cervical glands undergo such marked proliferation that by the end of pregnancy
they occupy approximately half of the entire cervical mass, rather than a small fraction
as in the nonpregnant state. These normal pregnancy-induced changes represent an
extension, or eversion, of the proliferating columnar endocervical glands.
- This tissue tends to be red and velvety and bleeds even with minor trauma, such as
with Pap smear sampling.
- The endocervical mucosal cells produce copious amounts of a tenacious mucus that
obstruct the cervical canal soon after conception.
= this mucus is rich in immunoglobulins and cytokines and may act to protect
the uterine contents against infection from the vagina
= At the onset of labor, if not before, this mucus plug is expelled, resulting in a
bloody show. Moreover, the consistency of the cervical mucus changes
= beading - characterized by crystallization occurs when cervical mucus is
spread and dried on a glass slide
-a result of progesterone
= ferning - arborization of the crystals as a result of amnionic fluid leakage
- During pregnancy, basal cells near the squamocolumnar junction are likely to be
prominent in size, shape, and staining qualities. These changes are considered to be
estrogen induced.
- Arias-Stella reaction - endocervical gland hyperplasia and hypersecretory appearance
-which makes the identification of atypical glandular cells on
Pap smear particularly difficult

Ovaries
- Ovulation ceases during pregnancy, and the maturation of new follicles is suspended.
- only a single corpus luteum can be found in pregnant women.
- corpus luteum removal ordinarily does not cause abortion.
- bilateral oophorectomy at 16 weeks has been reported to result in an otherwise
uneventful pregnancy.
- FSH levels do not reach perimenopausal levels until approximately 5 weeks
postpartum.
- decidual reaction - common in pregnancy and is usually observed at cesarean delivery.
=These elevated patches of tissue bleed easily.
=are seen on the uterine serosa and other pelvic, or even extrapelvic,
abdominal organs.

Poiseuille's law -flow in a tubular structure is dependent on the product of its radius to the fourth
power!

Relaxin
- protein hormone
- secreted by
corpus luteum
decidua
placenta
- secretion is similar to that of human chorionic gonadotropin (hCG).
- an important factor in the initiation of augmented renal hemodynamics and decreased
osmolality associated with pregnancy.
- serum relaxin levels do not correlate with increasing peripheral joint laxity during
pregnancy

Pregnancy Luteoma
- a solid ovarian tumor that developed during pregnancy
- composed of large acidophilic luteinized cells, which represented an exaggerated
luteinization reaction of the normal ovary.
- are variable in size, ranging from microscopic to over 20 cm in diameter.
- Typical sonographic characteristics include a solid, complex-appearing unilateral or
bilateral mass with cystic features that correspond to areas of hemorrhage.
- It is usually not possible to differentiate luteomas from other solid ovarian neoplasms,
- Pregnancy luteomas may result in maternal virilization, but usually the female fetus is not
affected.
-This is presumably because of the protective role of the trophoblast with its high
capacity to convert androgens and androgen-like steroids to estrogens
- Occasionally, a female fetus can become virilized.
- regress after delivery, they may recur in subsequent pregnancies

Theca-Lutein Cysts
- benign ovarian lesions
- resulted from exaggerated physiological follicle stimulationtermed hyperreactio
luteinalis.
- markedly elevated serum levels of hCG
- found frequently with gestational trophoblastic disease
- They are also more likely to be found with a large placenta such as with diabetes, D-
isoimmunization, and multiple fetuses.
- Theca-lutein cysts have also been reported in chronic renal failure as a result of
reduced hCG clearance, and in hyperthyroidism as a result of the structural homology
between hCG and thyroid-stimulating hormone
- they also are encountered in women with otherwise uncomplicated pregnancies and
are thought to result from an exaggerated response of the ovaries to normal levels of
circulating hCG
- usually asymptomatic,
- hemorrhage into the cysts may cause abdominal pain.
- Maternal virilization may be seen in up to 25 percent of women.
- Changes including temporal balding, hirsutism, and clitoromegaly are associated with
massively elevated levels of androstenedione and testosterone.
- diagnosis typically is based on sonographic findings of bilateral enlarged ovaries
containing multiple cysts in the appropriate clinical settings.
- The condition is self-limited, and resolution follows delivery.


Fallopian Tubes
- The musculature of the fallopian tubes undergoes little hypertrophy during pregnancy.
- The epithelium of the tubal mucosa, however, becomes somewhat flattened.
- Decidual cells may develop in the stroma of the endosalpinx, but a continuous
decidual membrane is not formed.
- the increasing size of the gravid uterus, (with paratubal or ovarian cysts) may result in
fallopian tube torsion

Vagina and Perineum
- During pregnancy, increased vascularity and hyperemia develop in the skin and
muscles of the perineum and vulva, with softening of the underlying abundant
connective tissue.
- Chadwick sign violet vagina due to Increased vascularity prominently
- changes include:
=increase in mucosal thickness
=loosening of the connective tissue
=hypertrophy of smooth muscle cells
- cervical secretions within the vagina during pregnancy is increased ad consists of a
thick, white discharge.
=The pH is acidic, varying from 3.5 to 6.
=This results from increased production of lactic acid from glycogen in the
vaginal epithelium by the action of Lactobacillus acidophilus.