Maternal Physiology

Reproductive Tract
Uterus Cervix

Uterus
nonpregnant woman - 70 g , cavity of 10 mL or less pregnancy 1100 g, ave 5 or 20ml Arrangement of the Muscle Cells
An outer hoodlike layer A middle layer - main portion of the uterine wall An internal layer

Uterine Size, Shape, and Position

pear shape more globular formalmost spherical ovoid shape Position:
contacts the anterior abdominal wall intestines : laterally and superiorly rotation to the right (dextrorotation)caused by the rectosigmoid

Contractility
Beginning in early pregnancy ---irregular painless contractions 2nd Trimester braxton-hicks contraction ---unpredictably ,sporadically ,nonrhythmic. Late in pregnancy false labor

Uteroplacental Blood Flow

Placental perfusion is dependent on total uterine blood flow (uterine and ovarian arteries) Estimate blood flow 450 to 650 mL/min near term Regulation : blood flow = vasodilation
consequence of estrogen stimulation, progesterone, nitric oxide Insensitivity to angiotendin II

Cervix
major component is connective tissue Goodells sign softening of cervix cervical mucus changes
crystallization, or beading, as a result of progesterone arborization of the crystals, or ferning, is observed as a result of amnionic fluid leakage the Arias-Stella reaction - associated with both endocervical gland hyperplasia and hypersecretory appearance

 (+) pronounced softening & cyanosis of the cervix Cervical glands undergo marked proliferation Mucus plug ------resulting bloody show

Ovaries
a single corpus luteum can be found in pregnant women Maximal fxns first 6 to7 weeks of pregnancy

Skin
Blood flow:Increased Abdominal wall
striae gravidarum or stretch marks diastasis recti

Hyperpigmentation
linea alba linea nigra chloasma or melasma gravidarum (mask of pregnancy)

Vascular Changes
vascular spiders Palmar erythema

Breasts
Early weeks of pregnacy tenderness & tingling of the breast 2nd month increase in size & delicate veins become visible just beneath the skin Colostrum first few months can be expressed

Metabolic Changes
Weight Gain
Attributed to the uterus & its contents, the breast & increases in the blood volume & extrvascular extracellular fluid Maternal reserves metabolic alterations that result in an increase in cellular water & deposition of new fat & protein Aver wt gain : 12.5 kg

Table 5-1. Analysis of Weight Gain Based on Physiological Events during Pregnancy Cumulative Increase in Weight (g) Tissues and Fluids 10 20 30 40 Weeks Weeks Weeks Weeks Fetus 5 300 1500 3400 Placenta 20 170 430 650 Amnionic fluid 30 350 750 800 Uterus 140 320 600 970 Breasts 45 180 360 405 Blood 100 600 1300 1450 Extravascular fluid 0 30 80 1480 Maternal stores (fat) 310 2050 3480 3345

Water Metabolism
Increased water retention is a normal physiological alteration of pregnancy
Mediated by fall in plasma osmolality of approx 10 mOsm/kg

TBW increases average of 6.5L

At term, the fetus, placenta, and amnionic fluid approximates 3.5 L 3 L accumulates as a result of increases in the maternal blood volume & in the size of uterus & breast

Protein Metabolism
At term, the fetus and placenta together weigh about 4 kg and contain approx 500 g of protein remaining 500 g : uterus, breast & maternal blood

Carbohydrate Metabolism
Normal pregnancy is characterized by mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia

Hematological Changes Blood Volume

Pregnancy-induced hypervolemia has important functions: To meet the metabolic demands of the enlarged uterus with its greatly hypertrophied vascular system. To provide an abundance of nutrients and elements to support the rapidly growing placenta and fetus. To protect the mother and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. To safeguard the mother against the adverse effects of blood loss associated with parturition.

 Maternal blood volume begins to increase during the first trimester blood volume expands most rapidly during the second trimester rises at a much slower rate during the third trimester to plateau during the last several weeks of pregnancy.

 Hgb conc.--2.5 g/dL Iron Metabolism Total iron - 2.0 to 2.5 g approxi1000 mg of iron required for normal pregnancy The Puerperium 500 to 600 mL - blood loss during normal delivery 1000 mL - bllod loss (CS or twin del)

Immunological Functions
Leukocytes pregnancy, usually it ranges from 5000 to 12,000/L. During labor and the early puerperium
Aver.14,000 to 16,000/L 25,000/L or even more

Immunological Functions
Inflammatory Markers leukocyte alkaline phosphatase erythrocyte sedimentation rate (ESR) C-reactive protein factors C3 and C4 Spleen area enlarges by up to 50 percent compared with the first trimester

Immunological Functions
Coagulation and Fibrinolysis increased concentrations of all clotting factors, except factors XI and XIII, and increased levels of high-molecular-weight fibrinogen complexes Platelet average platelet count was decreased slightly during pregnancy to 213,000/L compared with 250,000/L in nonpregnant control women

Table 5-2. Changes in Measures of Hemostasis during Normal Pregnancy Parameter Activated PTT (sec) Thrombin time (sec) Fibrinogen (mg/dL) Factor VII (%) Factor X (%) Plasminogen (%) tPA (ng/mL) Nonpregnant 31.6 4.9 18.9 2.0 256 58 99.3 19.4 97.7 15.4 105.5 14.1 5.7 3.6 Pregnant (3540 weeks) 31.9 2.9 22.4 4.1a 473 72a 181.4 48.0a 144.5 20.1a 136.2 19.5a 5.0 1.5

Antithrombin III (%) 98.9 13.2 Protein C (%) 77.2 12.0

97.5 33.3 62.9 20.5a

Cardiovascular System
Cardiac output is increased as early as the fifth week and reflects a reduced systemic vascular resistance and an increased heart rate

Heart
displaced to the left and upward and rotated somewhat on its long axis. causing a larger cardiac silhouette on chest radiograph Resting PR increases about 10 beats/min normal cardiac sounds are altered during pregnancy. (1) an exaggerated splitting of the first heart sound with increased loudness of both components; ( (2) no definite changes in the aortic and pulmonary elements of the second sound; (3) a loud, easily heard third sound

Table 5-3. Central Hemodynamic Changes in 10 Normal Nulliparous Women Near Term and Postpartum
Pregnanta (3538 wks) Mean arterial pressure (mm Hg) Pulmonary capillary wedge pressure (mm Hg) 90 6 82 Postpartum (1113 wks) Changeb 86 8 62 NSC NSC

Central venous pressure (mm Hg)

Heart rate (beats/min) Cardiac output (L/min)

43
83 10 6.2 1.0

43
71 10 4.3 0.9

NSC
+17% +43%

Systemic vascular resistance (dyne/sec/cm5)

1210 266

1530 520
119 47 20.8 1.0 14.5 2.5

21%
34% 14% 28%

Pulmonary vascular resistance 78 22 (dyne/sec/cm5) Serum colloid osmotic pressure 18.0 1.5 (mm Hg) COP-PCWP gradient (mm Hg) 10.5 2.7

Circulation & Blood Pressure

Changes in posture affect arterial blood pressure
Arterial pressure usually decreases to a nadir at 24 to 26 weeks and rises thereafter. Diastolic pressure decreases more than systolic

supine hypotensive syndrome

supine compression of the great vessels by the uterus causes significant arterial hypotension

Respiratory Tract

 functional residual capacity and the residual volume are decreased Peak expiratory flow rates decline progressively as gestation compliance is unaffected by pregnancy, but airway conductance is increased total pulmonary resistance reduced, maximum breathing capacity forced or timed vital capacity are not altered appreciably.

Urinary System
Kidney Kidney size increases slightly glomerular filtration rate (GFR) and renal plasma flow increase early in pregnancy

Table 5-4. Renal Changes in Normal Pregnancy Alteration Kidney size Dilatation Approximately 1 cm longer on radiograph Clinical Relevance Size returns to normal postpartum

Resembles hydronephrosis on Can be confused with obstructive uropathy; sonogram or IVP (more marked on retained urine leads to collection errors; renal right) infections are more virulent; may be responsible for "distension syndrome"; elective pyelography should be deferred to at least 12 weeks postpartum Glomerular filtration rate and renal Serum creatinine decreases during normal plasma flow increase ~50% gestation; >0.8 mg/dL (>72 mol/L) creatinine already borderline; protein, amino acid, and glucose excretion all increase

Renal function

Maintenance of acid-base Decreased bicarbonate threshold; Serum bicarbonate decreased by 45 mEq/L; progesterone stimulates PCO2 decreased 10 mm Hg; a PCO2 of 40 mm respiratory center Hg already represents CO2 retention

Plasma osmolality

Osmoregulation altered: osmotic thresholds for AVP release and thirst decrease; hormonal disposal rates increase

Serum osmolality decreases 10 mOsm/L (serum Na ~5 mEq/L) during normal gestation; increased placental metabolism of AVP may cause transient diabetes insipidus during pregnancy

Gastrointestinal Tract
stomach and intestines are displaced by the enlarging uterus Gastric emptying time delayed because of hormonal or mechanical factors Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux of acidic secretions into the lower esophagus Hemorrhoids

Liver
no increase in liver size during human pregnancy Some laboratory test results of hepatic function are altered during normal pregnancy
alkaline phosphatase activity almost doubles AST, ALT, GGT & bilirubin slightly low

Gallbladder
During normal pregnancy, the contractility of the gallbladder is reduced, leading to an increased residual volume Increased prevalence of cholesterol stones

Endocrine System
Pituitary Gland
enlarges by approximately 135 percent

Growth Hormone
first trimester ---within nonpregnant values of 0.5 to 7.5 ng/mL 10 weeks ---3.5 ng/mL Plateu after 28 weeks at approx 14 ng/mL

Prolactin
ensure lactation present in amnionic fluid in high concentrations 20 to 26 weeks to 10,000 ng/mL. levels decrease and reach a nadir after 34 weeks

Thyroid Gland
undergoes moderate enlargement during pregnancy caused by glandular hyperplasia and increased vascularity

Parathyroid Glands
regulation of calcium concentration is closely interrelated to magnesium, phosphate, parathyroid hormone, vitamin D, and calcitonin physiology PTH plasma concentration
1st trimester decrease Increase progressively throughout the pregnancy

Physiological hyperthyroidism

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