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Reproductive systems > Maternal physiology > Flashcards

Maternal physiology Flashcards

1
Q

What does the body need to adapt to pregnancy?

A
  • Volume support (volume expansion and vasodilation)
  • Nutrition (increased respiration, insulin resistance, increased absorption)
  • Waste clearance (increased GFR and hepatocellular stimulation)
  • Pregnancy maintenance (uterine quiescence and immunologic sequestration)
  • Childbirth (MSK and clotting)
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2
Q

What drives the adaptations of the human body during pregnancy?

A
  • Hormones e.g.
  • hCG
  • oestrogen
  • progesterone
  • relaxin
  • hPL
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3
Q

Why does immunity change in pregnancy?

A
  • Baby is a foreign object in mother’s body
  • Need to avoid body rejecting baby
  • Allows baby to thrive but as a parasite
  • Allows mother to be a good host
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4
Q

What is meant by the statement: the foetus is a hemi-allograft?

A
  • Recognised by maternal immune system
  • Half of foetus is foreign to mother (1/2 mum’s genes and 1/2 dad’s
  • SO incited allo-response is not cytotoxic
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5
Q

What happens to immunity in pregnancy?

A
  • Immunosuppressed state
  • Higher attack rate and severity of certain viral pathogens i.e. varicella
  • May improve certain autoimmune conditions
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6
Q

What does mum need from respiration in pregnancy?

A
  • Continued O2 delivery to her organs and periphery
  • Increased O2 supply to meet metabolic demand
  • Increased CO2 clearance
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7
Q

What does baby need from respiration in pregnancy?

A
  • Oxygen delivery
  • Carbon dioxide removal
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8
Q

How are the respiratory needs of mum and baby met during pregnancy?

A
  • Increased ventilation
  • Tidal volume increases by ~30-40%
  • Minute ventilation increases by ~40-50%
  • Increase PaO2, decrease PCO2
  • pH change (respiratory alkalosis, compensated by renal bicarb excretion)
  • Expiratory reserve volume decreases by ~20%
  • Total lung capacity decreases by ~5%
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9
Q

What is the clinical consequence of respiratory changes that occur in mum during pregnancy?

A
  • Dyspnoea of pregnancy occurs in 60-70% of patients
  • Multifactorial
  • Most likely due to hyperventilation and decreased PaCO2
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10
Q

What else could cause dyspnoea in a pregnant woman?

A
  • Cardiac pathology
  • Anaemia
  • DVT/PE
  • Asthma
  • Pneumonia/ARDS
  • Pulmonary oedema
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11
Q

What does baby need from the cardiovascular system and the blood?

A
  • Delivery of nutrients
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12
Q

What does a pregnant mum need from the cardiovascular system and the blood?

A
  • Needs to fill utero-placental-foetal circulation
  • Oxygenate growing uterus - very vascular and high demand
  • Protect from impaired venous return
  • Prepare for potential blood loss during delivery
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13
Q

How are the changes to the cardiovascular system and the blood achieved during pregnancy?

A
  • Volume expansion
  • Clotting mechanisms
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14
Q

How is volume expansion of the cardiovascular system during pregnancy achieved?

A
  • In early pregnancy volume increases
  • In late pregnancy heart rate increases
  • Progesterone causes smooth muscle relaxation
  • Decreased systemic vascular resistance
  • Drop in BP (but then returns to pre-pregnancy level)
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15
Q

How is increased clotting of the cardiovascular system during pregnancy achieved?

A
  • Increased procoagulants (fibrinogen, factor VIII, vWF)
  • Decreased anticoagulants (e.g. Protein S)
  • Reduced fibrinolysis
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16
Q

How is stroke volume increased in pregnancy?

A
  • Oestrogen and progesterone activates RAAS
  • Oestrogen also activates release of angiotensin from liver
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17
Q

What are the consequences of pregnancy on the cardiovascular system?

A
  • Increased RAAS leads to peripheral oedema
  • Change in plasma volume leads to change in RBC volume
  • Dilutional oedema
  • Clotting leads to hypercoagulable state - increased number of thromboembolic events
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18
Q

What are the values that define anaemia in pregnancy?

A
  • 1st trimester Hb <110 g/l
  • 2nd and 3rd trimester: <105 g/l
  • Postpartum <100 g/l
  • Normal Hb: 115-165 g/l
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19
Q

Why does anaemia of pregnancy occur?

A
  • Red cell mass increases by 25-30%
  • Not enough to counter dilutional increase in plasma volume
  • Iron deficiency is a problem despite relative macrocytosis
  • Most common cause of anaemia in pregnancy is iron deficiency
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20
Q

What are the complications of anaemia of pregnancy?

A
  • Increased morbidity for mum and baby
  • Preterm delivery
  • Maternal fatigue
  • Infant iron deficiency anaemia
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21
Q

What does the baby need from the renal system during pregnancy?

A
  • Remove waste
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22
Q

What does the mum need from the renal system during pregnancy?

A
  • Increase clearance of waste at the kidneys
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23
Q

What changes occur to the renal system during pregnancy?

A
  • Increased glomerular filtration rate
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24
Q

How do renal haemodynamics change in pregnancy?

A
  • Systemic vasodilation leads to increased renal blood flow
  • This increases GFR by 50%
  • Afferent and efferent arteriole vasodilation
  • Decreases serum urea and creatinine
25
Q

How does tubular function change in pregnancy?

A
  • PCT absorption decreases
  • Leads to increased glycosuria
  • Increased Ca2+ excretion
  • Increased glycosaminoglycans
  • Decreased reabsorption of uric acid
26
Q

What systemic changes occur to the kidney in pregnancy?

A
  • Decreased sensitivity to RAAS
  • Increased water retention (hypothalamus has a lower threshold for vasopressin)
  • Decreased plasma osmolality
26
Q

What systemic changes occur to the kidney in pregnancy?

A
  • Decreased sensitivity to RAAS
  • Increased water retention (hypothalamus has a lower threshold for vasopressin)
  • Decreased plasma osmolality
27
Q

What structural changes occur to the kidney during pregnancy?

A
  • Increased size of kidneys and ureters
  • Right > left
  • Decreased speed of urine passage
  • Hydronephrosis
28
Q

What does baby need from the GI system during pregnancy?

A
  • Nutrients
29
Q

What does mum need from the GI system during pregnancy?

A
  • Feed herself and her baby
  • Increase absorption of minerals and vitamins
30
Q

What adaptations occur in the GI system during pregnancy?

A
  • Slow transit time
31
Q

What are the effects of progesterone on the GI system?

A
  • Decreased lower oesophageal sphincter tone - leads to GORD and aspiration
  • Decreased gallbladder contractility - leads to gallstones
  • Decreased large and small bowel motility - leads to increased mineral absorption, constipation and increased water absorption
32
Q

What structural changes occur to the GI system in pregnancy?

A
  • Gravid uterus displaces bowel
  • Can cause mechanical obstruction
33
Q

How do LFT values change during pregnancy?

A
  • ALP levels increased due to placental synthesis
34
Q

What does baby need from the endocrine system during pregnancy?

A
  • Nutrients
  • A good environment
35
Q

What does mum need from the endocrine system during pregnancy?

A
  • A way to give glucose to baby
  • A lot of calcium
  • Keep metabolism under control
36
Q

How does the endocrine system change during pregnancy?

A
  • Thyroid regulation
  • Parathyroid activation
  • Insulin resistance
37
Q

How does the thyroid gland adapt to pregnancy?

A
  • Pregnancy is considered a euthyroid state
  • Imbalanced levels can affect foetal development
  • Oestrogen stimulates liver to produce Thyroid Binding Globulin
  • Need to increase thyroxine production
  • hCG has a similar alpha subunit to TSH
  • So it has a weak stimulating effect on thyroid
38
Q

How do PTH and calcium levels change in pregnancy?

A
  • Increased PTH leads to increased active vitamin D
  • Increases Ca2+ and phosphorus absorption from gut during pregnancy
  • Bones do not resorb Ca2+ and phosphorus
  • Decreased PO4 excretion by kidneys and increased Ca2+ absorption at kidneys
  • Due to increased 1 alpha-hydroxylase
39
Q

What are the pre-pregnancy determinants of insulin resistance?

A
  • Ethnicity
  • Physical inactivity
  • Obesity
  • Dietary composition
  • Polycystic ovarian syndrome
  • Hypertension
40
Q

What causes insulin resistance in pregnancy?

A
  • Tumour necrosis factor a
  • Placental lactogen
  • Placental growth hormone
  • Oestrogen
  • Progesterone
  • Cortisol
41
Q

What are the risk factors for gestational diabetes mellitus?

A
  • BMI above 30 kg/m2
  • Previous macrosomic baby weighing 4.5kg+
  • Previous gestational diabetes
  • Family history of diabetes
  • Ethnicity with high prevalence of diabetes
42
Q

What are the investigations/diagnosis of gestational diabetes mellitus?

A
  • Oral glucose tolerance test to test for gestational diabetes in women with risk factors
  • Blood glucose or OGTT if previous gestational diabetes mellitus
  • Diagnose if plasma glucose 5.6 mmol/l or above
  • A 2 hour plasma glucose level of 7.8 mmol/l or above
43
Q

What are the potential complications of gestational diabetes for the mother?

A
  • Increased risk of pre-eclampsia, polyhydramnios, premature labour
  • Shoulder dystocia
  • Failure for labour to progress
  • Increased risk of developing Type 2 diabetes mellitus
44
Q

What are the potential complications of gestational diabetes for the baby?

A
  • Macrosomia
  • Congenital abnormalities (cardiac, renal, neural tube defects)
  • Hypoxia and sudden intrauterine death after 36 weeks gestation
  • Hypoglycaemia
  • Respiratory distress
  • Jaundice
45
Q

What changes occur in MSK and skin during pregnancy to help the baby?

A
  • Room to grow
  • A way out
46
Q

What changes occur in MSK and skin during pregnancy to help the mum?

A
  • Cope with additional weight
  • Cope with change in centre of gravity
  • Prepare body for childbirth
47
Q

How does MSK and skin change during pregnancy?

A
  • Everything becomes loose and stretchy
48
Q

What MSK-related symptoms does a woman experience during pregnancy?

A
  • Back pain
  • Shoulder pain
  • Tension headaches
  • Pelvic pain
49
Q

What adaptations occur to the MSK system during pregnancy?

A
  • Change in centre of gravity due to increased lordosis and kyphosis and forward flexion of neck
  • Stretching of abdominal muscles impede posture and strain paraspinal muscles
  • Increased motility of sacroiliac joints and pubic symphysis causes anterior tilt of pelvis
50
Q

What changes can be seen in the skin during pregnancy?

A
  • Chloasma
  • Palmar erythema
  • Vascular spiders
  • Linea nigra
50
Q

What changes can be seen in the skin during pregnancy?

A
  • Chloasma
  • Palmar erythema
  • Vascular spiders
  • Linea nigra
51
Q

What is pre-eclampsia?

A
  • Pregnancy-induced hypertension with proteinuria +/- maternal organ dysfunction after 20 weeks
52
Q

What is the NICE definition of pre-eclampsia?

A
  • New onset of hypertension (>140/90) after 20 weeks
  • And the co-existence of 1 or more of the following new-onset conditions:
  • Proteinuria
  • Other maternal organ dysfunction
  • Uteroplacental dysfunction
53
Q

What is severe pre-eclampsia?

A
  • Pre-eclampsia with severe hypertension that does not respond to treatment
54
Q

What is the pathogenesis of pre-eclampsia?

A
  • Impaired invasion of trophoblast leading to shallow invasion of spiral arteries
  • Remain small calibre and of high resistance
  • Leads to hypoperfusion and ischaemia
  • Systemic endothelial dysfunction
55
Q

What are the symptoms of pre-eclampsia?

A
  • Headache
  • Vision disturbance (blurring/flashing)
  • Epigastric pain
  • Swelling of hands, feet, face
  • Vomiting
  • SOB
56
Q

What are the maternal complications of pre-eclampsia?

A
  • Seizure
  • Cerebral haemorrhage
  • Renal failure
  • Pulmonary oedema
  • HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)
  • DIC
57
Q

What are the foetal complications of pre-eclampsia?

A
  • Growth restriction
  • Oligohydramnios
  • Placental infarct
  • Foetal distress
  • Premature delivery
  • Stillbirth

Reproductive systems (20 decks)

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