1. בהצלחה בבחניה!!!!

2. Genitalia Skin Breasts Metabolic changes Hematological Cardiovascular Respiratory Urinary Gastrointestinal Endocrinology –Thyroid Hypermesis Musculoskeletal Eyes CNS

3. Genital tract – uterus From 70 gr/10 ml to 1100 gr/5000 ml –Growth 500-1000 times Patterns of growth: –Hypertrophy –Fibrous tissue –Vessels, lymphatics –Asymmetrical Fundus>other parts Placental site>other parts

4. Genital tract – uterus cont Contractility –1 trimester onwards –Braxton-Hicks (Hicks JB 1823-1899) Blood flow –450-650 ml/min (40W) –Regulation Estrogen/Progesterone Catecholamines/Angiotensin II Nitric oxide (vasodilator)

5. Genital tract – cervix Continuous softening –Increased vascularity –Hypertrophy & hyperplasia of cervical glands Mucus plague obstruction –(Bloody show) Squamous Metaplastic Cells –Size, shape, staining –PAP interpretation

6. Genital tract – vagina Increased vascularity –Violet color –Chadwick sign (1844-1905) Wall distention Increased thickness of mucosa

7. Genital tract – ovaries Ovulation ceases during pregnancy. Corpus luteum up to 7th week

8. Genital tract – ovaries cont Luteoma of pregnancy –Solid ov tumor –Exaggeration of normal lutianization –May be up to 10 cm –Regresses after delivery

9. Skin Pigmentation –Linea nigra –Chloasma or melasma –Around areola –m/p increased MSH

10. Skin cont Striae gravidarum Vascular changes –Palmar erythema –Vascular spiders

11. BREAST Increased size Increased areola size Colostrum –2 nd trimester onwards

12. BREAST cont Increased areola size Pigmentation Montgomery –Pimple like gland –Secrete lubrication for areola

13. Metabolic changes Weight gain –Fetus, placenta 4.2 –Amniotic fluid 0.8 –Uterus 1.0 –Breasts 0.4 –Blood volume 1.5 –3rd space 1.5 –Fat 3.4 Average 12.5 kg From 20 th week 0.5kg/w

14. Metabolic changes Recommended daily dietary allowance –2500 kcal –60 gr protein –Vitamins –Minerals Fe, Ca, Mg, Zn, P, I Average 12.5 kg From 20 th week 0.5kg/w

15. Metabolic changes- cont Water metabolism –Increased water retention –Fall in plasma osmolality 10mosm/kg –Induced by resetting of thirst and ADH secretion

16. Metabolic changes- cont Fat metabolism –Increased lipids –Increased lipoproteins –Increased apoliproteins Protein metabolism –1000 gr of protein per total pregnancy Fetus, placenta Uterus breasts

17. Metabolic changes- cont Metabolic changes- cont Carbohydrate metabolism Theology –Ensure continuous glucose supply to fetus Pregnant woman state –Woman’s fuel switch Glu > Lipids –Accelerated starvation

18. Metabolic changes- cont Metabolic changes- cont Carbohydrate metabolism - cont Alterations –Fasting hypoglycemia –Postprandial hyperglycemia –Hyper-insulinemia Causes –Increased insulin response to Glu –Reduced peripheral uptake of Glu –Suppressed glucagon response Theology –Ensure continuous glucose supply to fetus

19. Hematological changes Blood volume increase 45% –From 1 st tr onwards –Plasma increase 50% –RBC increase 30% –Result in “physiologic” anemia Why? –To meet demands of enlarged uterus –To protect mother from impaired venous return –To safeguard from blood loss due to parturition

20. Hematological changes – cont RBC & Hb Elevated erythropoietin –Shorter life span of RBC –Elevated reticulocytes “physiologic” anemia: –Normal Hb >11 g/dL –Severe anemia if <10 g/dL

21. Hematological changes – cont RBC & Hb - cont Iron –Total iron requirement during pregnancy 1 gr –Daily Iron requirement 7 mg/day

22. Hematological changes – cont WBC & Plt WBC –Increase up to 16,000-20,000 –Mainly because of neutrophyls Platelets –Plt count decrease, but stay in normal range 7% gestational thrombocytopenia –Constant MPV –Constant reticulated plt –Decreased plt activation during pregnancy –Increased plt activation towards delivery

23. Hematological changes – cont coagulation - cont Elevated fibrinogen & factor VIII Acquired functional resistance to activated protein C Decrease in protein S Antithrombin III levels unchanged

24. Hematological changes – cont coagulation - cont Increased tendency to thrombosis: –Physiologic thrombophilia –Obstruction of venous return by uterus and venous atonia by progesterone

25. Cardiovascular system heart 5th week onward, max 32 nd week –Increased cardiac output –Increased heart rate 10 b/min –No change in inotropic effect –Left & upward displacement of apex (ECG) –Increased stroke volume

26. Cardiovascular system circulation 5th week onward, max 32nd week –Decreased systemic & pulmonary resistance –Decrease in blood pressure S>D –Supine hypotension syndrome Influenced by: –Renin, Angiotensin –PG –Endothgelin

27. Respiratory system No change in respiratory rate Increase in : –Tidal volume –Minute respiratory volume –Minute oxygen uptake

28. Respiratory system- cont Diaphragm rises ~4 cm Unchanged Po 2, slightly decreased Pco 2 Physiologic dyspnea (awareness of breathing) –Tidal volume & lowered Pco 2

29. Urinary system Increased kidney size by 1.5 cm Increased GFR & renal plasma flow –By 50% –2 nd trimester onwards Physiologic gucosuria –Increased GFR –impaired tubular reabsorptive capacity for Glu Physiologic proteinuria –Increased GFR –Up to 300 mg/24 h collection

30. Urinary system - cont Hydronehprosis & hydroureter –Rt > lt in 90% of pregnant women –Cushioning of lt urter by sigmoid colon –Compression of rt ureter by dextrorotated uterus –Progesterone action Bladder –Increase in urinary incontinence Progesterone Uterine pressure

31. Gastrointestinal tract Delayed gastric emptying –Mechanical & hormonal Pyrosis –Gastric reflux Gestational gingivitis Constipation Hemorrhoids –constipation

32. Gastrointestinal tract Liver & gallbladder Liver –Increased alk phosphat Placental –Other tests unchamged Gallbladder –Impaired contraction –Stasis –Increased prevalence of stones

33. Endocrine system thyroid Enlargement of thyroid –Due to increased vascularity Increased thyroxin binding globulin –Decreased clearance Due to Estrogen Total T4 & T3 rise up to 20 w % plateaus but within normal range Free T4 & T3 unchanged Normal TSH within normal range

34. H yperemesis Morning sicknessMorning sickness –80% up to 14 w –Unknown etiology m/p hormonalm/p hormonal HyperemesisHyperemesis persistent vomiting,persistent vomiting, dehydration, ketosis, dehydration, ketosis, electrolyte disturbances, electrolyte disturbances, weight loss (> 5%) weight loss (> 5%) –Gastric electrical dysrhythmia –Elevated TSH

35. Musculoskeletal system Lordosis Muscular weakness Low back pain

36. Eyes Decreased intraocular pressure Corneal sensitivity Krukenberg spindles –Brownish-red pigmentation of posterior surface of cornea Unaffected visual function

37. CNS Problems with: –Concentration –Attention –Memory Most pregnant women report some memory disturbance Decline in : –Explicit memory –Implicit memory –Working memory

38. Underlying causes of memory impairment in pregnancy Elevated progesterone Glucocorticoids Plasma neurotransmitters Larger erythrocytes –Lurie S, Piper I, Gordon Y, Reprod Sciences 2005 Cultural stereotypes

39. CNS- cont Mood disturbance –depression –stress –anxiety Sleep difficulty –Frequent awakenings –Reduced sleep efficiency