בהצלחה בבחניה!!!!. Genitalia Skin Breasts Metabolic changes Hematological Cardiovascular Respiratory Urinary Gastrointestinal Endocrinology –Thyroid Hypermesis.

בהצלחה בבחניה!!!!

• Genitalia• Skin• Breasts• Metabolic changes• Hematological• Cardiovascular• Respiratory

• Urinary• Gastrointestinal• Endocrinology

– Thyroid

• Hypermesis• Musculoskeletal• Eyes• CNS

Genital tract – uterusGenital 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

Genital tract – uterusGenital tract – uterus contcont

• 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)

Genital tract – cervixGenital tract – cervix• Continuous softening

– Increased vascularity– Hypertrophy & hyperplasia of

cervical glands

• Mucus plague obstruction– (Bloody show)

• Squamous Metaplastic Cells– Size, shape, staining– PAP interpretation

Genital tract – vaginaGenital tract – vagina

• Increased vascularity– Violet color – Chadwick sign (1844-1905)

• Wall distention

• Increased thickness of mucosa

Genital tract – ovariesGenital tract – ovaries

• Ovulation ceases during pregnancy.

• Corpus luteum up to 7th week

Genital tract – ovariesGenital tract – ovaries contcont

• Luteoma of pregnancy– Solid ov tumor– Exaggeration of normal lutianization– May be up to 10 cm– Regresses after delivery

SkinSkin

• Pigmentation– Linea nigra

– Chloasma or melasma

– Around areola

– m/p increased MSH

Skin Skin contcont

• Striae gravidarum

• Vascular changes– Palmar erythema– Vascular spiders

BREASTBREAST

• Increased size

• Increased areola size

• Colostrum – 2nd trimester onwards

BREAST BREAST contcont• Increased areola size• Pigmentation• Montgomery

– Pimple like gland

– Secrete lubrication for areola

Metabolic changesMetabolic 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 20th week

0.5kg/w

Metabolic changesMetabolic changes

• Recommended daily dietary allowance– 2500 kcal

– 60 gr protein

– Vitamins

– Minerals• Fe, Ca, Mg, Zn, P, I

• Average 12.5 kg• From 20th week

0.5kg/w

Metabolic changes- Metabolic changes- contcont

• Water metabolism– Increased water retention– Fall in plasma osmolality 10mosm/kg– Induced by resetting of thirst and ADH

secretion

Metabolic changes- Metabolic changes- contcont

• Fat metabolism– Increased lipids– Increased lipoproteins– Increased apoliproteins

• Protein metabolism– 1000 gr of protein per total pregnancy

• Fetus, placenta• Uterus• breasts

Metabolic changes- Metabolic changes- contcont

Carbohydrate metabolism• Theology

– Ensure continuous glucose supply to fetus

• Pregnant woman state– Woman’s fuel switch

• Glu > Lipids

– Accelerated starvation

Metabolic changes- Metabolic changes- contcont

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

Hematological changesHematological changes

• Blood volume increase 45%– From 1st 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

Hematological changes – Hematological changes – contcont RBC & HbRBC & Hb

• Elevated erythropoietin – Shorter life span of RBC– Elevated reticulocytes

• “physiologic” anemia:– Normal Hb >11 g/dL– Severe anemia if <10 g/dL

Hematological changes – Hematological changes – contcont RBC & Hb - RBC & Hb - contcont

• Iron– Total iron requirement during pregnancy 1

gr– Daily Iron requirement 7 mg/day

Hematological changes – Hematological changes – contcont

WBC & PltWBC & 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

Hematological changes – Hematological changes – contcont

coagulation - coagulation - contcont

• Elevated fibrinogen & factor VIII• Acquired functional resistance to

activated protein C• Decrease in protein S • Antithrombin III levels unchanged

Hematological changes – Hematological changes – contcont

coagulation - coagulation - contcont

• Increased tendency to thrombosis:– Physiologic thrombophilia– Obstruction of venous return by uterus and

venous atonia by progesterone

Cardiovascular systemCardiovascular systemheartheart

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

Cardiovascular systemCardiovascular systemcirculationcirculation

• 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

Respiratory systemRespiratory system

• No change in respiratory rate

• Increase in :– Tidal volume

– Minute respiratory volume

– Minute oxygen uptake

Respiratory system- Respiratory system- contcont

• Diaphragm rises ~4 cm

• Unchanged Po2, slightly decreased Pco2

• Physiologic dyspnea (awareness of breathing)

– Tidal volume & lowered Pco2

Urinary systemUrinary system• Increased kidney size by 1.5 cm• Increased GFR & renal plasma flow

– By 50%

– 2nd trimester onwards

• Physiologic gucosuria – Increased GFR

– impaired tubular reabsorptive capacity for Glu

• Physiologic proteinuria– Increased GFR

– Up to 300 mg/24 h collection

Urinary systemUrinary system - -contcont

• 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

Gastrointestinal tractGastrointestinal tract

• Delayed gastric emptying– Mechanical & hormonal

• Pyrosis – Gastric reflux

• Gestational gingivitis• Constipation• Hemorrhoids

– constipation

Gastrointestinal tractGastrointestinal tractLiver & gallbladderLiver & gallbladder

• Liver– Increased alk phosphat

• Placental

– Other tests unchamged

• Gallbladder– Impaired contraction– Stasis– Increased prevalence of stones

Endocrine systemEndocrine systemthyroidthyroid

• 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

HHyperemesisyperemesis• Morning sicknessMorning sickness

– 80% up to 14 w80% up to 14 w– Unknown etiologyUnknown 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 Gastric electrical dysrhythmia – Elevated TSHElevated TSH

Musculoskeletal systemMusculoskeletal system

• Lordosis

• Muscular weakness

• Low back pain

EyesEyes

• Decreased intraocular pressure

• Corneal sensitivity

• Krukenberg spindles– Brownish-red pigmentation of posterior

surface of cornea

• Unaffected visual function

CNSCNS

• Problems with:– Concentration

– Attention

– Memory

• Most pregnant women report some memory disturbance

• Decline in :– Explicit memory– Implicit memory– Working memory

Underlying causesof memory impairment

in pregnancy

• Elevated progesterone • Glucocorticoids • Plasma neurotransmitters • Larger erythrocytes

– Lurie S, Piper I, Gordon Y, Reprod Sciences 2005

• Cultural stereotypes

CNS- CNS- contcont

• Mood disturbance– depression– stress – anxiety

• Sleep difficulty– Frequent awakenings– Reduced sleep efficiency