Midterms # 1

paper through bimanual palpation

PHYSIOLOGIC CHANGES DURING PREGNANCY

Can be categorized as: Local reproductive organs only

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

Systemic the entire body is affected

LOCAL CHANGES
A. REPRODUCTIVE SYSTEM CHANGES a. Uterine Changes Length: 6.5 32 cm Depth : 2.5 22 cm Width: 4 24 cm Weight: 50 1000g

Braxton-Hicks contraction

practice contractions, waves of hardness and tightening across her abdomen

b. Amenorrhea Because of FSH suppression

by rising estrogen levels c. Cervical changes

Vascular and edematous

increased circulating estrogen From pale pink to violet

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

Operculum mucous plug

in cervical canal that seals out bacteria during pregnancy preventing fetal and membrane infection

20th or 22nd week reached

umbilicus

Goodells Sign softening

of the cervix from elasticity of earlobe to consistency of butter

End of 36th week reached the

xiphoid process ( breathing is difficult)

d. Vaginal changes

38th week, for a primigravida,

fetal head settles into the pelvis, the uterus returns to the height at 36th week

Hypertrophic and enriched

with glycogen because of increased estrogen light pink to a deep violet : increased vascularity

Chadwicks sign normal

LIGHTENING womans breathing becomes easier, lightening the load. *In multipara, it occurs at labor

From pH >7 to pH 4 or 5

Uterine blood flow: before 1520 ml/min, by the end of pregnancy 500-750 ml/min *75% goes to placenta

vaginal secretions because of Lactobacillus acidophilus (grows freely in increased glycogen envt) Candida albicans, itching and burning sensation with creamcheese-like discharge

Candidiasis caused by

Hegars sign extreme

softening of the lower uterine segment, felt as thin as tissue

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 Leukorrhea excessive
discharge e. Ovarian changes

Striae gravidarum pink

Ovulation stops because of

active feedback mechanism of E & P by corpus luteum/placenta

or reddish streaks on sides of abdomen and on thighs caused by rupture and atrophy of connective layer of skin *weeks after birth becomes striae albicantes or atrophicae (silvery-white)

(-) prodn of FSH and LH

Diastasis separation of

Corpus luteum enlarges

until 16th week as placenta takes over as provider of E & P,

rectus muscles, appears after pregnancy as a bluish groove

Umbilicus becomes obliterated and protruding

Then becomes corpus

f. Changes in breasts

albicans white and smaller

Linea nigra narrow

brown line in midline

Melasma/chloasma

6th week. Changes are

noticeable

mask of pregnancy, dark pigmentations on cheeks and nose due to MSH spiders/Telangiectases small, fiery-red, branching spot on thighs due to increasing estrogen

Feeling of fullness, tingling

or tenderness increased estrogen levels.

Vascular

Increased in size hyperplasia of mammary alveoli and fat deposits Areola darkens and increases in diameter Increased vascularity and prominent blue veins

Activity of sweat glands increases

Palmar erythema
redness and itching on hands due to estrogen Scalp hair growth increases

Montgomerys tubercles
sebaceous glands enlarge and become protuberant - Keeps nipples supple, preventing drying and cracking during lactation

C. RESPIRATORY SYSTEM

Marked congestion or stuffiness of

the nasopharynx increased estrogen levels diaphragm

Colostrum thin watery

high-protein fluid that is precursor of breast milk, can be expelled at 16th week

Shortness of breath pressure on Decreased PCO2 (blood CO2) of

SYSTEMIC CHANGES

32mmHg due to increased progesterone level easier fetal CO2 transfer to maternal bloodstream

B. INTEGUMENTARY SYSTEM

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 Mild Hyperventilation to

prevent maternal blood pH from becoming acidic bec of CO2 to help, addl H2O and Na is lost

Decreased iron absorption due to decreased gastric acidity Excessive Fe: stomach irritation

Polyuria kidney excretes HCO3 Vital capacity: no change Tidal volume: increased 30-40%
RR: increased 1-2bpm Residual volume: decreased by 20%

Increased need of folic acid Inadequate:

megalohemoglobinemia ( large, non-functioning RBC) : risk for fetal neural tube disorders c. Heart Cardiac output increases by 25-50% Heart rate increases by 10bpm

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%

More transverse

positioning due to diaphragm displacement pregnancy is due to SNS stimulation ; in later months due to increase thoracic pressure

Palpitations: early in

D. TEMPERATURE

Early: increases due to

d. Blood pressure

progesterone due to corpus luteum (same at ovulation) to placenta

1st trimester: BP does not

rise

16th week: decreases to normal due

2nd trimester: BP decreases

due to decreased PR

E. CARDIOVASCULAR SYSTEM

3rd trimester: BP goes up

same with 1st trimester e. Peripheral Blood flow

a. Blood volume increases by 30%

Blood loss during NSD: 300400 mL Blood loss during CS: 8001000mL

3rd trimester: blood flow in

lower extremities is impaired leading to edema, varicosities of the vulva, rectum, and legs 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

Pseudoanemia - conc. of
hemoglobin and RBC decline in first trimester due to faster plasma volume increase than RBC prodn b. Iron, Folic Acid & Vitamin Needs

Total increased iron need of

800mg

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 Results to: o Maternal: Lightheadedness, faintness and palpitations Fetal: Hypoxia

Heartburn reflux of

stomach contents into esophagus because of: upward displacement of the stomach relaxed cardioesophageal sphincter (due to relaxin, enzyme produced by ovaries)

Corrected through turning the woman to her left side g. Blood Constitution Fibrinogen: increases by 50% due to increased estrogen level

Slow intestinal
peristalsis and the emptying time of stomach due to pressure caused by uterus displacing abdominal organs: leads to heartburn, constipation and flatulence

Clotting Factors VII, VIII, IX,

& X and platelet count increases

Safeguard against major bleeding

Relaxin: decreases gastric

motility

Total WBC count rises

slightly Total Protein level of blood decreases due to fetal consumption

Progesterone: makes GI
tract less active

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 1/3*

Blood lipids increases by Cholesterol serum levels

increases by 90-100%* *for ready supply of available energy to the fetus

Hypertrohy of gumlines

& bleeding of gingival tissue saliva prodn due to increased estrogen lvls

Hyperptyalism increased

Increased tooth decay:

lower than normal pH of saliva

F. GASTROINTESTINAL SYSTEM

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

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o o

Increased blood volume Postural influences

c. Bladder and ureter function

Polyuria increase urinary

frequency, during 1st trimester Until uterus rises out of pelvis and relieves pressure on bladder. This returns as lightening occurs. Ureters increased in diameter & bladder capacity increases to 1500ml: due to increased progesterone

a. Fluid retention

Total Body H2O increases to

7.5 L: increase Na reabsorption

Increased Aldosterone

prodn due to increased response Angiotensin-renin system to progesterone

Aldosterone aids in Na reabsorption

Uterus rises on the right

K levels remain adequate due to progesterone

side, pushed slightly by sigmoid colon: pressure on right ureter

H2O is retained: aid the

increase in BV and serve as ready fluid supply of fetus

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% Lower BUN and creatinine lvls o 15mg/100ml or higher BUN is abnormal, as well as, Greater than 1mg/100ml creatinine

Pressure on urethra: poor bladder emptying and bladder infection

Leads to kidney infection (mother) and UTI (fetus)

H. SKELETAL SYSTEM Ca and P need is increased o Fetal skeleton must be build

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 o Difficulty walking

Gestational DM due to:

o Accidental spilling of glucose in urine due to reabsorption of glucose Unused lactose is also spilled

Lordosis/ Pride of

Pregnancy forward curve of lumbar spine, may lead to backache

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I.

ENDOCRINE SYSTEM a. Placenta Produces large amts of E, P, HCG, HPL, relaxin & prostaglandins

Increased lvls of: protein-bound iodine, butanol-extractable iodine and thyroxine

Emotional lability, tachycardia, palpitations, and diaphoresis

ESTROGEN causes: breast and uterine enlargement, & palmar erythema PROGESTERONE is involved in: maintenance of endometrium, inhibition of uterine contractility, & development of breasts for lactation 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) HCG (trophoblast): stimulates E and P synthesis HPL: insulin antagonist; more glucose for fetus PROSTAGLANDIN: affect smooth muscle contractility, initiates labor

Parathyroid also increases in size, calcium prodn

d. Adrenal glands Increased corticosteroids & aldosterone due to increased AG activity

Decreased inflammatory reaction Increased aldosterone lvls

e. Pancreas Increased insulin prodn due to increased glucocorticoid lvls Maternal blood glucose level > fetal glucose level o To prevent hypoglycemia: Increase MBGL than normal Low FBS of mother during first trimester Less effective insulin due to insulin-antagonists (E, P & HPL)

b. Pituitary Gland (-) prodn of FSH and LH due to increased P and E Increased prodn of GH and MSH Later: prodn of oxytocin and prolactin J. IMMUNE SYSTEM

c. Thyroid and Parathyroid Glands

Thyroid enlarges: BMR increases by 20%

Immunocompetency decreases

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 IgG prodn 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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