1. IN THE NAME OF ALLAH

2. Maternal Physiology DR B. Khani

3. Maternal changes during pregnancy The maternal system may produce a series of changes in order to adapt to the needing of fetal growth and development influenced by placenta hormone and neuro-endocrine

4. Changes of reproductive system Uterus Body: become enlargement and soft from 7×5 ×3cm pre-pregnancy to 35×25 ×22cm at term. Volume of uterus cavity: become enlargement from 10ml pre-pregnancy to 5000ml at term.

5. Weight: be increased from 70g pre- pregnancy to 1000g at term. Blood supply: blood flow increased significantly. upto 500- 700ml/min,increased 4-6 times and most of blood flow is transported to the placenta(80-85%).

6. Isthmus: be dilated and become soft from 1cm pre-pregnancy a portion of the uterus after 12 gestational weeks Cervix: be soft and coloration or stain secrete amount of mucus avoiding the uterus cavity suffer from infection

7. Changes of ovary  Stop ovulation.  Corpus luteum formation and maintains for 7-10 weeks.  The function of corpus luteum is substituted by the placenta.  Corpus luteum atretic gradually after 3-4 months gestation.

9. Cardiovascular system 1. Heart: move upward and left. move upward and left. 2. Cardiac Output increase by 30%, reach to peak at 28 nd –32 th week increase by 30%, reach to peak at 28 nd –32 th week 3. Blood pressure early or mid pregnancy Bp↓.late pregnancy Bp↑.Supine hypotensive syndrome early or mid pregnancy Bp↓.late pregnancy Bp↑.Supine hypotensive syndrome

10. Cardiac Output

11. Maternal cardiac output is highest in which position? lateral recumbent lateral recumbentLowest? Standing Standing

12. Vascular Changes SVR decreases until mid-pregnancy, then rises slightly but remains 20% below non- pregnant values BP follows in parallel, especially DBP(10- 15 mmHg) SBP: 5-10 mmHg

13. SVR Changes

14. Respiratory Physiology Conformational changes in chest: –Transverse diameter increases 2 cm –Circumference increases 5-7 cm –Diaphragm rises 4 cm; excursion increases 1- 2 cm

15. The Respiratory system The Respiratory system Respiratory rate: no change Respiratory rate: no change vital capacity: no change vital capacity: no change Tidal volume: ↑ 40% Tidal volume: ↑ 40% Functional residual capacity:↓ Functional residual capacity:↓ O 2 consumption: ↑ 20% O 2 consumption: ↑ 20%

16. Respiratory Physiology

17. FEV1 is unchanged TV increases about 40%; since RR is unchanged, that increases minute ventilation 40% Increased MV leads to: –Increased alveolar oxygen –Slightly increased arterial oxygen (101-108) –Decreased alveolar and arterial CO2 (27-32)

19. Hematologic Changes Blood Volume increases by? 40-50% 40-50% Peaks at? 30-34 weeks 30-34 weeks RBC Mass increases? 20% without iron supplementation 20% without iron supplementation 30% with iron supplementation 30% with iron supplementation

20. Hematologic Changes

21. What are the total iron demands for a normal term pregnancy in a woman without preexisting iron depletion? 1000 mg : 1000 mg : –300 mg fetus and placenta –500 mg maternal red cell increase –200 mg compensate for normal daily losses Translates into required daily absorption of 3.5 mg.

22. Hematologic Changes Iron demands increase in later gestation (6-7 mg/day near term) About 10% of ingested iron is absorbed under conditions of normal iron demands; can increase when depleted Iron supplementation is needed to avoid iron depletion during pregnancy

23. Hematologic Changes Mild decrease in mean platelet count –Increased platelet destruction –Diluted Up to 8% will have gestational thrombocytopenia –Platelet count 70-150,000/mm 3 –No increased bleeding complications –Return to normal after delivery

24. Hematologic Changes Mean WBC count increases –1 st trimester 8000 (5100-9900) –2 nd and 3 rd trimester 8500 (5600-12200) –In labor may rise to 26,000-30,000 T helper 1 and natural killer cells decrease, T helper 2 increase (cell- mediated immunity  humoral immunity) Decreased concentrations of IgG, IgM, IgA

25. Coagulation System Procoagulant factors increased –(factors I, VII, VIII, IX, X). Natural inhibitors of coagulation decreased Decreased fibrinolysis –Reduced plasminogen activator Defense against puerperal hemorrhage Increased risk of thromboembolism

27. GI Physiology Common symptoms: heartburn, increased appetite Constipation may be increased Overall inhibition of GI motility Many physiologic changes attributed to progesterone

28. GI Physiology Esophagus –no change in motility –reduced LES resting pressure (decreases with gestational age)

29. GI Physiology Stomach –Conflicting data on acid production, gastric emptying –Davison (1970) showed a longer total emptying time but no difference in 30 minute volume; changes more pronounced in women with heartburn or in labor –Slowed emptying during labor due in part to analgesic and sedative use

30. GI Physiology Intestines –Increased transit time shown in multiple studies, probably progesterone-mediated –Theoretical changes in absorption related to slower transit time and longer exposure of intestinal contents to the mucosa could be beneficial - allow more time for absorption could be detrimental - allow bacterial overgrowth

31. Hepatic Physiology Increased protein synthesis (estrogen effect) –increased clotting factors, binding globulins –hemodilution decreases albumin concentration 50% of normal pregnancies have dilated esophageal veins (portal-systemic shunt) Hepatomegaly is abnormal; palmar erythema and spider veins common

32. Hepatic Physiology Normal values for AST, ALT, GGT, and bilirubin are lower in uncomplicated pregnancies than the normal non-pregnant laboratory reference range Normal values for AST, ALT, GGT, and bilirubin are lower in uncomplicated pregnancies than the normal non-pregnant laboratory reference range Abnormal LFT seen in 54% with preeclampsia and 14% with PIH Higher LFT: more proteinuria, lower platelets, more maternal complications

33. Hepatic Physiology NP 1 st 2 nd 3 rd AST (U/L) 7-4010-2811-2911-30 ALT (U/L) 0-406-326-326-32 Bili (μmol/L) 0-174-163-133-14 GGT (U/L) 11-505-375-433-41

34. The urinary system The urinary system Kidney Kidney 1) Renal plasma flow (RFP):↑35% 2) Glomerular filtration rate (GFR):↑ 50% Ureter : diluted Ureter : diluted Bladder : Frequent micturation Bladder : Frequent micturation Urine analyze Urine analyze

35. Endocrine Endocrine Pituitary (hypertrophy) Pituitary (hypertrophy) 1) LH/FSH: ↓ 2) PRL:↑ 3) TSH and ACTH:↑ Thyroid Thyroid 1) enlarged (TSH and HCG↑) 2) thyroxine↑ and TBG↑ → free T 3 T 4 unchanged