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Repro > Maternal physiology > Flashcards

Maternal physiology Flashcards

1
Q

Why does the body need to adapt during pregnancy? and how does it do each one

A

Volume support - expansion and vasodilation

Nutrition - increased respiration and absorption, insulin resistance

Waste clearance - increased GFR, hepatocellular stimulation

Pregnancy maintenance - uterine quiescence, immunological sequestration

Childbirth - MSK and clotting changes

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2
Q

What drives the adaptations of pregnancy?

A

Hormoens - hCG, oestrogen, progesterone, relaxin and hPL

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3
Q

Why do changes in immunity occur? how does this occur

A

Mum needs to be good host
Baby needs to thrive as ‘parasite’ but foreign

= Immune regulation needed

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4
Q

What is the fetus genitically?

A

Hemi-allograft - half genetic material is foreign, half is maternal

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5
Q

What does immune regulation mean for pregnant women?

A

The response to foetus is not cytotoxic when recognised by maternal immune system

Pregnancy is therefore an immunosupressed state - higher attack rate and severity of certain viral pathogens (eg varicella zoster)

BUT autoimmune conditions could improve during pregnancy

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6
Q

What two things are balanced in pregnancy immune wise?

A

Rejection and tolerance - less rejection and more tolerance in pregnancy so more vulnerable

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7
Q

Why do changes in respiration occur and how does this happen?

A

Baby needs CO2 removal and O2 delivery and mum also needs to meet her demands

= Increased ventilation needed

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8
Q

What are some of the respiratory system adaptations in pregnancy and what does this mean for body?

A

Increase tidal volume
Increased minute ventilation - 50%
= increase paO2, decrease pCO2 - means that slight respiratory alkalosis in pregnancy (kidneys compensate by excreting more bicarbonate)

Expiratory reserve volume and total lung capacity decrease - compression from foetus

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9
Q

What can happen to mum due to these changes to respiratory system?

A

Can sometimes feel short of breath even though respiratory rate does not change much - probably due to hyperventilation and decreased pCO2

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10
Q

What could be other causes of dyspnoea in pregnancy?

A

Cardiac - MI? Angina?
Anaemia
DVT/PE
Asthma
Pneumonia
Pulmonary oedema

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11
Q

Why do changes in CVS occur in pregnancy? How does this happen?

A

Baby needs delivery of nutrients

Mum needs to fill utero-placental circulation, oxygenate growing foetus, protection from impaired venous return, prepare for blood loss during delivery

= Volume expansion and clotting changes needed

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12
Q

How does mum increase her cardiac output in pregnancy?

A

Initially - increased volume (increase stroke volume)

Later - increased heart rate

Overall - LV hypertrophy, can sometimes hear regurge murmurs due to increased volume

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13
Q

Effect of progesterone on CVS

A

Smooth muscle relaxation = decreased systemic vascular resistance
= drop in BP

(but then returns to pre-pregnancy level as increased volume and decreased SVR balance eachother out)

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14
Q

Normal BP in pregnancy

A

Less than 140/90

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15
Q

What happens to clotting in pregnancy?

A

Increase procoagulants - fibrinogen, factor VIII, vWF

Decreased anticoagulants - protein S

Reduced fibrinolysis

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16
Q

Why is clotting altered in pregnancy?

A

To prevent bleeding post-partum/during birth

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17
Q

How does the body increase stroke volume by increasing volume?

A

Activates RAAS - oestrogen and progesterone cause drop in BP

Renin released from kidney –> angiotensinogen to angiotensin I

ACE in lungs activates angiotensin I to II

Angiotensin II = aldosterone release (increase ENac and RomK - more water retention), vasoconstriction too

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18
Q

Potential problems pregnancy can cause do due changes within CVS

A

Increased RAAS and fluid retention can cause peripheral oedema (swollen ankles)

Increases in plasma volume are not mirrored by changes in RBC numbers - can cause DILUTIONAL ANAEMIA

Altered clotting causes hypercoagulable state - increased chance of DVT/PE
BE AWARE OF DYSPNOEA presentation

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19
Q

Another cause of anaemia in pregnancy

A

Iron deficiency anaemia - foetus needs it too and can use mums

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20
Q

Hb and anaemia in pregnancy level

A

1st trimester 110g/L
2nd and 3rd - 105g/L
Post partum - 100g/L

(normal is 115-165g/L)

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21
Q

Complications caused by anaemia in pregnancy

A

Increase morbidity for mum and baby
Preterm delivery
Maternal fatigue
Infant Iron deficiency anaemia

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22
Q

Why can iron deficiency be difficult to diagnose in pregnancy with blood film?

A

Iron deficiency anaemia is Microcytic anaemia usually
In pregnancy, RBC mass increases and become macrocytic - can be confusing on blood film as IDA can maifest in macrocytic cells

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23
Q

Why do we need to change the renal system in pregnancy?

A

Baby needs to remove waste and mum needs to increase the clearance of waste

= increased GFR needed - by 55%

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24
Q

What changes occur within the renal system

A

Systemic vasodilation (from progesterone) means there is increased renal blood flow
= increase GFR and decreased serum urea and creatinine - 20%

Decreased PCT absorption = glucosuria

Smooth muscle relaxation and obstruction = increase size of kidneys and ureters (R larger than left), decreased speed of urine (not as high pressure)

Increases renin release and EPO production

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25
Q

Consequence of decreased speed of urine

A

Urine stasis can occur increasing risk of UTI
Or hydronephrosis

26
Q

Changes to hypothalamus affecting kidney

A

Decreased threshold for ADH release (released more easily)

27
Q

How are changes in GI system achieved?

A

Slower transit time - absorb more nutrients for mother and baby

28
Q

Structural changes to GI system

A

Uterus enlarged can displace bowel and cause mechanical obstruction

29
Q

What happesn to LFT’s in pregnancy?

A

ALP levels increase due placenta synthesising it

30
Q

What does progesterone cause to happen to GI system and the consequences?

A

Decreased lower oesophageal sphincter tone - GORD, aspiration

Decreased small bowel motility - Mineral absorption good

Decreased large bowel motility - water absorption good BUT can get constipation

Decreased gall bladder contractility - Gallstones

31
Q

Why and HOW do changes in endocrine system occur?

A

Baby needs nutrients
Mum needs to give glucose to baby, lots of calcium and keep metabolism controlled

= Thyroid regulation, PTH activation and insulin resistance is needed

32
Q

What happens to thyroid in pregnancy?

A

Considered euthyroid state overall (normal levels)
BUT oestrogen stimulates thyroid binding globulin hepatic production
This causes decrease in free plasma thyroid hormone (as it binds to TBG)
This causes increased thyroxine production
= overall normal levels

33
Q

hCG effects on thyroid?

A

Has similar alpha subunit to TSH
Has a weak stimulating effect

34
Q

Consequences of increase thyroid activity in pregnancy (but overall normal levels)

A

Goitre of pregnancy can sometimes occur

35
Q

What happens to PTH in pregnancy?

A

Increases

Increases 25 OH D production from liver (via 25 hydroxylase, inactive Vit D, Calcifediol)

Increased activity of alpha 1 hydroxylase (forms active Vit D Calcitriol)

Increase in active vitamin D formed

increased Ca2+ absorbed from gut (but levels remain normal overall)

36
Q

What are all preganant women recommended to take due to increase demand for Ca2+?

A

Vitamin D supplements

37
Q

What happens to glucose metabolism in pregnancy?

A

Diabetogenic - insulin resistance and increased insulin secretion

Plasma glucose levels raise due to resistance allowing foetus to gain glucose

38
Q

Pre-pregnancy determinants of insulin resistance - what can cause gestational diabetes to be more likely

A

Ethnicity
Physical inactivity
Obesity - central specifically
Diet
PCOS
Hypertension

39
Q

What is gestational diabetes?

A

Onset of elevated blood sugar levels during pregnancy - hyperglycaemia in pregnancy

40
Q

How common is GDM?

A

One of the most common
84% of 1 in 6 births

41
Q

Problems with GDM

A

Materal mortality leading cause
Increase maternal morbidity
Perinatal and neonatal morbidity
Later long term consequences

42
Q

Risk factors for GDM

A

BMI above 30 kg/m2
Previous macrosomic baby 4.5 kg or more
Previous gestational diabetes
Family history diabetes (first degree)
Ethnicity

43
Q

Investigations for gestational diabetes

A

Oral glucose tolerance test
Blood glucose or OGTT if previous GDM

44
Q

Diagnosis criteria for gestational diabetes

A

If fasting plasma glucose is 5.6 mmol/L or higher
OR
if 2 hr plasma glucose is 7.8mmol/L or higher

(normal fasting diagnosis needs to be greater than 7 and OGTT needs to be higher than 11.1, SO THESE PREGNANCY VALUES ARE A LOT LOWER than normal)

45
Q

Mothers risk of gestational diabetes

A

Increase risk of:
- pre-eclampsia
- polyhydramnios (lots of amniotic fluid)
- premature labour

Complications:
- shoulder dystocia
- Failure to progress

+ Increased risk of developing T2DM post pregnancy

46
Q

Baby risks for GDM

A

Macrosomia
Congenital abnormalities - cardiac, renal, neural tube
Hypoxia and sudden intrauterine death after 36 weeks

Neonate after birth:
Hypoglycaemia (used to lots of glucose in womb and high insulin release in response to this)
Respiratory distress
Jaundice

47
Q

Why do changes in MSK and skin occur in pregnancy?

A

Baby needs room to grow and a way out
Mum needs to cope with additional weight, change in centre of gravity and prepare for childbirth

= loose and stretchiness needed

48
Q

What happens to body MSK in pregnancy?

A

Change in centre of gravity:
- increased lordosis and kyphosis
- Forward flexion of neck

Stretching abdominal muscles:
- Impedes posture
- Strains paraspinal muscles

Increased motility of sacroiliac joints and pubic symphysis = anterior tilt of pelvis

Ligament laxity increased

49
Q

What can change in centre of gravity and stretching of abdo muscles result in?

A

Back/shoulder pain
Tension headaches

50
Q

What cab anterior tilt of pelvis result in?

A

Pelvic pain

51
Q

What are some consequences of fluid retention/oedema on MSK?

A

Can compress structures eg carpal tunnel syndrome compression of median nerve

52
Q

Skin changes in pregnancy

A

Chloasma/Melasma - tanned rash on face
Palmar erythema
Vascular spiders
Linea nigra (through midline)

all caused by increased melanin from oestrogen

53
Q

What is pre-eclampsia?

A

Pregnancy induced hypertension with proteinuria +/- maternal organ dysfunction after 20 weeks

54
Q

NICE definition of pre-eclampsia?

A

New onset of hypertension >140/90 after 20 weeks
+ coexistence of one of these: proteinuria, organ dysfunction, uteroplacental dysfunction

55
Q

What does NICE define as severe pre-eclampsia?

A

Pre-eclampsia with severe hypertension that does not respond to treatment

56
Q

Risk factors for pre-eclampsia

A

Age 40+
Nulliparity - first pregnancy
Pregnancy interval 10 years+
Family history
Previous history
BMI 30+
Pre-existing vascular disease eg hypertension
Pre-existing renal disease
Multiple pregnancy - eg twins

57
Q

Cause/pathogenesis of pre-eclampsia

A

Impaired invasion of trophoblast leading to shallow invasion of spiral arteries (not deep enough into wall, arteries remain small and high resistance)

This leads to hypoperfusion and ischaemia to placenta and foetus = systemic and endothelial dysfunction

58
Q

Symptoms of pre-eclampsia

A

Headache
Vision disturbance - blurring/flashing
Epigastric pain
Swelling of hands, feet, face
Vomiting
SOB

59
Q

Complications of pre-eclampsia - maternal

A

Seizures (eclampsia)
Cerebral haemorrhage
Renal failure
Pulmonary oedema

60
Q

Syndrome complication for mother in pre-eclampsia

A

HELLP syndrome:
Haemolysis
Elevated Liver enzymes
Low Platelets

–> Disseminated intravascular coagulation

61
Q

Fetal complications of pre-eclampsia

A

Growth restriction
Oligohydramnios
Placental infarct/abruption
Fetal distress
Premature delivery
Stillbirth

62
Q

Examinations for pre-eclampsia

A

Check reflexes - CNS involved?
Auscultate and percuss lungs - oedema?
Clonus?
right upper quadrant tenderness from hepatic swelling

Repro (22 decks)

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