IN THE NAME OF ALLAH

1. IN THE NAME OF ALLAH

2. Maternal Physiology DR. E. ZAREAN

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

10. Cardiac Output

11. Cardiac Output • Maternal cardiac output is highest in which position? lateral recumbent • Lowest? 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 • Respiratory rate: no change • vital capacity: no change • Tidal volume: ↑ 40% • Functional residual capacity:↓ • O2 consumption: ↑ 20%

16. Respiratory Physiology

17. Respiratory Physiology • 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% • Peaks at? 30-34 weeks • RBC Mass increases? 20% without iron supplementation 30% with iron supplementation

20. Hematologic Changes

21. Hematologic Changes • What are the total iron demands for a normal term pregnancy in a woman without preexisting iron depletion? 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/mm3 • No increased bleeding complications • Return to normal after delivery

24. Hematologic Changes • Mean WBC count increases • 1st trimester 8000 (5100-9900) • 2nd and 3rd 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 • Abnormal LFT seen in 54% with preeclampsia and 14% with PIH • Higher LFT: more proteinuria, lower platelets, more maternal complications

33. Hepatic Physiology

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

35. Endocrine Pituitary (hypertrophy) • LH/FSH: ↓ • PRL:↑ • TSH and ACTH:↑ Thyroid • enlarged (TSH and HCG↑) • thyroxine↑ and TBG↑→ free T3 T4 unchanged