Maternal-fetal Adaptation & Physiological Changes In Pregnancy

MATERNAL-FETAL ADAPTATION & PHYSIOLOGICAL CHANGES IN PREGNANCY

Dr. Abarham Martadiansyah, SpOG (K) Maternal Fetal Medicine Division Obstetric & Gynecology Departement RSMH/ Med Fac UNSRI

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REPRODUCTIVE TRACT SKIN BREASTS METABOLIC CHANGES HEMATOLOGICAL CHANGES

CARDIOVASCULAR SYSTEM RESPIRATORY TRACT URINARY SYSTEM GASTROINTESTINAL TRACT ENDOCRINE SYSTEM

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REPRODUCTIVE TRACT

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The uterine musculature during pregnancy is arranged in three strata: 1. An outer hoodlike layer, which 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. 3. An internal layer, with sphincter-like fibers around the fallopian tube orifices and internal os of the cervix. AB/B22/2019

• Height and weight (hyperplasia) the height increases from 7.5 cm to 35cm the weight increases from 50g to 1000g at term • Uterine ligaments show hypertrophy • Dextro-rotation the uterus is tilted and twisted to the right in 80% of cases • Lower uterine segment (LUS) the LUS is formed from the isthmus formed from the 4 th month to reach 10 cm at full term

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• First few weeks ~ original pear shape  a more globular form  spherical by 12 weeks. • The organ increases more rapidly in length than in width and assumes an ovoid shape

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Cervix • Contains a small amount of smooth muscle, its major component is connective tissue • Goodell sign • Chadwick sign • Hegar sign • increased volume of cervical secretions consists of a somewhat thick, white discharge

• The endocervical mucosal cells produce copious amounts of a tenacious mucus

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Ovaries • Ovulation ceases during pregnancy, and the maturation of new follicles is suspended. • Only a single corpus luteum can be found in pregnant women

Vagina & Perineum • Chadwick sign : violet color and with softening of connective tissue • The pH is acidic, varying from 3.5 to 6 AB/B22/2019

Fallopian tubes • Musculature hypertrophy • The epithelium flattened

SKIN Hyperpigmentation

Blood Flow in Skin • Increased cutaneous blood flow in pregnancy serves to dissipate excess heat generated by increased metabolism

Abdominal Wall • Striae gravidarum or stretch marks

• The midline of the abdominal skin • linea alba transfom into linea nigra • Irregular brownish patches on face and neck • chloasma or melasma gravidarum—the so-called mask of pregnancy. • Pigmentation of the areolae and genital skin may also be accentuated

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Peripheral Vascular Changes • Angiomas, called vascular spiders, develop in about two thirds of white women and approximately 10 percent of black women. • Palmar erythema is encountered during pregnancy in about two thirds of white women and one third of black women. AB/B22/2019

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Musculoskeletal System

• Progressive lordosis is a characteristic feature of normal pregnancy. • The sacroiliac, sacrococcygeal, and pubic joints have increased mobility during pregnancy • The bones and ligaments of the pelvis undergo remarkable adaptation during pregnancy

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Central Nervous System

• Women often report problems with attention, concentration, and memory throughout pregnancy and the early postpartum period Sleep • Beginning as early as about 12 weeks and extending through the first 2 months postpartum, women have difficulty going to sleep, frequent awakenings, fewer hours of night sleep, and reduced sleep efficiency AB/B22/2019

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METABOLIC CHANGES • The third trimester, maternal basal metabolic rate is increased by 10 - 20 % compared with that of the nonpregnant state. total pregnancy • Energy demands are estimated to be as high as 80,000 kcal or about 300 kcal/day

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Weight Gain • A smaller fraction of the increased weight result in an increase in cellular water and deposition of new fat and protein—so-called maternal reserves

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Water Metabolism

• At term, the water content of the fetus, placenta, and amnionic fluid approximates 3.5 L.

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Protein Metabolism • At term, the fetus and placenta together weigh about 4 kg and contain approximately 500 g of protein, or about half of the total pregnancy increase Carbohydrate Metabolism

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

• The concentrations of lipids, lipoproteins, and apolipoproteinsin plasma increase appreciably during pregnancy AB/B22/2019

Leptin • Primarily secreted by adipose tissue • Regulation of body fat and energy expenditure • Increase and peak during the second trimester and plateau until term • 2-4x higher than nonpregnant Ghrelin • Secreted by adipose tissue • Role in fetal growth and cell proliferation AB/B22/2019

Electrolyte and Mineral • 1000 mEq of sodium and 300 mEq of potassium are retained • GFR of sodium and potassium is increased, the excretion of these electrolytes is unchanged

HEMATOLOGICAL CHANGES Blood Volume

• Hypervolemia associated with normal pregnancy averages 40 – 45 % above the nonpregnant blood volume after 32 to 34 weeks

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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.

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Iron Metabolism Storage Iron • The total iron content of normal adult women ranges from 2.0 to 2.5 g Iron Requirements • 1000 mg of iron required for normal pregnancy, about 300 mg are actively transferred to the fetus and placenta, and another 200 mg are lost through various normal routes of excretion

Puerperium • Not all the maternal iron added in the form of hemoglobin is lost with normal delivery • These normal losses are from the placental implantation site, episiotomy or lacerations, and lochia

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Immunological Function • Not all aspects of immunological function are depressed Leukocytes • The leukocyte count varies considerably during pregnancy, it ranges from 5000-12,000/L • During labor and the early puerperium, it become elevated, attaining levels of 25,000/L or even more, it averages 14,000 to 16,000/L Inflammatory Markers • Many tests performed to diagnose inflammation cannot be used reliably during pregnancy AB/B22/2019

Coagulation & Fibrinolysis

• During normal pregnancy, both coagulation and fibrinolysis are augmented but remain balanced to maintain hemostasis.

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Platelets • Average platelet count was decreased slightly during pregnancy • Decreased platelet concentrations are partially due to the effects of hemodilution Regulatory Proteins • natural inhibitors of coagulation proteins C, S, and Z and antithrombin. • Inherited or acquired deficiencies of these and other natural regulatory proteins collectively referred to as thrombophilias— account for many thromboembolic episodes during pregnancy Spleen • By the end of normal pregnancy, the splenic area enlarges by up to 50 percent compared with the first trimester AB/B22/2019

CARDIOVASCULAR SYSTEM Heart

Change in cardiac outline that occurs in pregnancy. The blue lines represent the relations between the heart and thorax in the nonpregnant woman, and the black lines represent the conditions existing in pregnancy. These findings are based on radiographic findings in 33 women AB/B22/2019

Cardiac Output • Normal pregnancy  MAP and vascular resistance decrease, while blood volume and basal metabolic rate increase

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RESPIRATORY TRACT Respiratory rate is essentially unchanged, but tidal volume and resting minute ventilation increase significantly as pregnancy advances

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Oxygen Delivery • The amount of oxygen delivered into the lungs by the increased tidal volume clearly exceeds oxygen requirements imposed by pregnancy

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URINARY SYSTEM Kidney • Kidney size increases slightly. • GFR and renal plasma flow increase early in pregnancy

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Ureters

Bladder

• After the uterus rises – The ureters laterally displacing and compressing at the pelvic brim. – The intraureteral tonus increased

• Increased uterine size • The hyperemia and the hyperplasia of the bladder’s muscle and connective tissues elevates the bladder trigone and causes thickening

The drainage of blood and lymph from the bladder base impairs, easily traumatized, and probably more susceptible to infection.

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GASTROINTESTINAL TRACT • Pyrosis (heartburn) is caused by reflux of acidic secretions into the lower esophagus • The gums may become hyperemic and softened during pregnancy and may bleed when mildly traumatized • Hemorrhoids are common during pregnancy AB/B22/2019

Liver • There is no increase in liver size during pregnancy • The concentration of serum albumin decreases during pregnancy

Gallbladder • The contractility of the gallbladder is reduced, because progesterone impairs gallbladder contraction by inhibiting cholecystokinin

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ENDOCRINE SYSTEM Pituitary Gland

• The pituitary gland enlarges by approximately 135 % • The increase may be sufficient to compress the optic chiasma and reduce visual fields, impaired vision due to physiological pituitary enlargement during normal pregnancy is rare

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Growth Hormone • During first trimester  GH is secreted predominantly from the maternal pituitary gland, and concentrations in serum and amnionic fluid are within nonpregnant values of 0.5 to 7.5 ng/mL Prolactin • Maternal plasma levels of prolactin increase markedly during normal pregnancy and conc entrations are usually 10-fold greater at term—about 150 ng/mL AB/B22/2019

Thyroid Gland • Physiological changes of pregnancy cause the thyroid gland to increase production of thyroid hormones by 40 to 100 percent to meet maternal and fetal needs

Parathyroid Glands The regulation of calcium concentration is closely interrelated to magnesium, phosphate, parathyroid hormone, vitamin D, and calcitonin physiology. AB/B22/2019

Relative changes in maternal thyroid function during pregnancy. Maternal changes include a marked and early increase in hepatic production of thyroxine-binding globulin (TBG) and placental production of chorionic gonadotropin (hCG). Increased thyroxine-binding globulin increases serum thyroxine (T4) concentrations, and chorionic onadotropin has thyrotropinlike activity and stimulates maternal T4 secretion. The transient hCG-induced increase in serum T4 levels inhibits maternal secretion of thyrotropin. Except for minimally increased free T4 levels when hCG peaks, these levels are essentially unchanged. (T3 triiodothyronine.) AB/B22/2019

FETAL GROWTH

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Prenatal Stages • Zygote – After sperm & ovum unites – Lasts about two weeks

• Embryo – Last about the time of implantation (week 4) until week 8 – Muscle, bone, organs & other body parts of the body form – Almost all internal organs begin to form AB/B22/2019

st 1

Trimester

0 Weeks – 13/6 Weeks

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First Month

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Four weeks

• Genetic pattern established since conception • Heart, eyes, nervous system formed AB/B22/2019

Two Months

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Two Months • Week 5: baby – growing fast – Size – orange seed – Heart taking shape

• Week 6: – Crown (head) to rump (bottom) measurements – Jaws, cheeks & chin – beginning to develop – 80 beats per minute

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Six weeks • Arms and legs formed • Skeleton complete, reflexes active • Brain waves present

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Two Months • Week 7: – 10,000 times bigger than at conception – Size blueberry – Brain – 250,000 cells per minute generated – Mouth, tongue forming – Arm, legs buds – begging to sprout segment

• Week 8:

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– Baby (embryo) is about 1/2 inch long (size of a grape) and has distinct, slightly webbed fingers. Face, eyes, ears, and limb have developed. Veins are clearly visible. The heart has divided into right and left chambers. – Looks more human – Spontaneous movements – you cannot feel

Seven weeks • Brain activity present • Appearance complete

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Eight weeks • Now officially a fetus • All systems in place • Just need to develop and increase size

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Eight weeks

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Beginning at the

rd 3

month/Week 9

• Fetus – Growth – process of growth and maturation – Last about 7 months

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Three Months • Week 9: – At the beginning baby (fetus) is about 1 inch long by the end, 3 inches!!! Weighing in at 1 ounce – Bones forming, elbows can now bend – Muscles & tissues start to develop – Covered by very thin skin (see through)

• Week 10:

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– 1 ½ in” long – Bones forming, elbows can now bend – Buds of baby teeth are forming under gums – Eye lids begin to close to protect developing eyes

Three Months • Week 11/12 : – Just over 2 in @, 2 ½ @ 12” – 1/3 oz @ 11, ½ oz @ 12 – Body – straightening out – Fingers & toes nails forming

– Gender is evident (though cannot tell with ultrasound) – More Human characteristics – Most systems formed, though immature

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Eleven weeks

• Arms and legs move, sucks thumb • Inhales and exhales amniotic fluid AB/B22/2019

Twelve weeks

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Twelve weeks

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Three Months • Week 13: – 3 in” – Size – peach – Head – about half the size of baby

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2nd Trimester 14 Weeks – 27/6 Weeks

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4 months

Four Months

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• Baby is covered with a layer of thick, downy hair called lanugo. His heartbeat can be heard clearly. This is when you may feel your baby's first kick. Size about 3 inches long. • Facial feature becomes clearer

Four Months • Baby becomes sensitive to touch

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Sixteen weeks

• Grasps, swims, kicks, turns somersaults AB/B22/2019

Five Months • A protective coating called vernix caseosa begins to form on baby's skin • End of the month – baby weighs one pound and is nearly 8 inches long

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Five Months • Hair, eyelashes & eyebrows appear • Teeth continue to develop • Organs are maturing • Hands able to grip • Baby more active

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Eighteen weeks • Vocal cords work; fetus can cry

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Five Months Previous Plus:

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– More energy! – Fetal movements @ end – Achiness in lower abdomen & along sides (stretching of ligaments supporting the uterus) – Backache – Leg cramps – Skin color changes – A protruding naval

Twenty weeks

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Six Months • Eyebrows and eyelids are visible. The baby's lungs are filled with amniotic fluid, and he/she has started breathing motions. If the mother talks or sings, the baby can hear. • Grows to about two pounds • Fat deposits begin to appear beneath wrinkly skin AB/B22/2019

Twenty-four weeks

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6 Months

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3rd Trimester • 28-40 Weeks • Getting enough Omega-3 is more important than ever in the 3rd trimester when your baby’s brain development is being fast tracked. • Time to think about signing up for child birth classes.

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Seven Months • At the beginning of the seventh month, the baby weighs about 2 ½ pounds and is about 14-16 inches long.

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Seven Months • His body is wellformed. Fingernails cover his fingertips • Nervous, circulatory & other systems mature • Periods of fetal activities are followed by periods of rest & quiet. AB/B22/2019

Eight Months • Baby is gaining about half a pound per week, and layers of fat are piling on. He/she has probably turned headdown in preparation for birth. • End of the month, baby weighs in at 5 ½ pounds

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Nine Months

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• Baby is a hefty 6-9 pounds at the end of the month and measures between 19 and 20 inches. • Fetal movement decreases with less room to move • Increase fat under the skin makes baby looks less wrinkled

Nine Months • Baby gains diseasefighting antibodies from the mommy’s blood • Baby descends lower into the pelvis, ready for birth (breath easier)

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After Birth

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