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Physiological changes in : Blood CVS Respiratory system Renal system Endocrine Metabolism Skin Reproductive organs Physiological changes in the pregnancy are aimed to ↙ To maximize nutrition and oxygen to developing fetus ↘ Help maternal system adjust to the extra stress Increase to max 40% above non pregnant level ↘ ↙ ↑↑Plasma volume ↑Erythrocytes mass Factors contributing to fluid retention •Sodium retention. • Resetting of osmostat. • ↓ Thirst threshold. • ↓ Plasma oncotic pressure. Consequence of blood volume expanding ↓ ↓ ↓ ↑ Stoke volume ↑ Renal blood flow ↑Placental blood flow ↑↑Plasma volume>↑Erythrocyte volume (Heamodilution) ↓Heamoglobuline ↓heamatocrite ↓ RBC count ↓ Albumine concntration 1. ↓RBC count 2. ↑WBC 3. Platelets count unchanged , reactivity increase, their survival is reduced in pregnancy. thrombotic ↓ All clotting factors increased antithrombotic ↓ fibrinolytic ↓ 1-Plasminogen levels are increased during pregnancy 2- plasma D-dimer concentration increases progressively -Antithrombin III levels remain unchanged - protein S activity decreases - activated protein C resistance increase. antifibrinolytic ↓ -α2-antiplasmin decreased -plsminogen activator inhibitor increased Iron requirement during pregnancy is increased pregnancy without iron supplementation leads to depletion of iron stores. plasma folate concentration decreased due to increase renal clearance of folat red cell folate concentrations do not decrease • ↑ Heart rate (10–20 per cent). • ↑ Stroke volume (10 per cent). • ↑ Cardiac output (30–50 per cent). • ↓ Peripheral resistance (35 per cent) • ↓ Mean arterial pressure (10 per cent). • ↓ Pulse pressure. 1-The first heart sound is loud and sometimes split 2- a third heart sound is audible in 84 per cent of pregnant women by 20 weeks gestation. 3- An ejection systolic murmur can be heard in 96 per cent of apparently normal pregnant women. 4-diastolic murmur occurs transiently in only 20 percent of pregnant women 5- 10 per cent develop continuous murmurs due to increased mammary blood flow. the heart is displaced to the left and upward and rotated somewhat on its long axis du to progressive elevation of diaphragm ,as result: 1. the apex is moved somewhat laterally from its usual position 2. causing a larger cardiac silhouette on chest radiograph . 3. Normal pregnancy induces slight left-axis deviation Respiratory system 2- the diaphragm is elevated 4 cm by the enlarging uterus. 3-the lower ribcage circumference expands by 5 cm. 4- increasing the ribcage subcostal angle. Ventilation •↑ Minute ventilation. • ↑ Tidal volume. •↓ERV •↓RV •↓FRC •FEV1&PEV (unchang) hyperventilation ↓ ↑↑Carbonic anhydrase ↓ ↓↓CO2+H2O↔H2CO3↔HCO3 ↓ renal excretion hyperventilation ↓ ↑ po2 ← +H ↓ 2,3-DPG ↓ right shift of oxyheamoglobulin dissociation curve • ↓ pCO2(30-50)%. • ↑ pO2. • pH alters little. • ↑ Bicarbonate excretion. • ↑ Oxygen availability to tissues and placenta. ↑ Kidney size (1 cm). • Dilatation of renal pelvis and ureters. IVP of normal 35 weeks pregnancy • ↑Renal Blood flow (60–75 per cent). • ↑ Glomerular filtration (50 per cent). • ↑ Clearance of most substances. • ↓ Plasma creatinine, urea and urate. • Glycosuria is normal Gastrointestinal system Pregnancy gingivitis Decrease in the PH& increase in protein conc. of saliva. Reduction of lower esophageal sphincter tone . Increasing gastric acidity -Delayed gastric emptying -Prolonged gastrointestinal transit time may lead to constipation -Physical findings such as telangiectasia and palmar erythema appear in up to 60 per cent of normal pregnancies -hepatic protein production increased - an increase in serum alkaline phosphatase secondary to fetal and placental production is observed in pregnancy. -s. alanine transaminase &s.aspartate transaminase shown to be lower during pregnancy, -LDH unchanged -the increased production and plasma levels of fibrinogen and the clotting factors VII, VIII,X and XII. - plasma cholesterol levels rise by around 50 per cent in the third trimester and triglycerides may rise to two or three times normal levels. Pitutery hypertrophy Increase prolactine (15 folds higher than non pregnant) Suppression of gonadotrophines Increase in the production of thyroid binding globulin. Increase in the total thyroid hormones. There is a fall in TSH and arise in the fT4 in the 1st trimester. it is followed by a fall in fT4 with advanced gestations. Relative deficiency in the iodide. -↑ total cortisol -↑Free cortisol -Loss of diurnal variation of cortisol ↓ - Production of placental ACTH -↑CBG ↓ 1- 10 fold increase in aldosterone & deoxycocorticosterone ↓ ↓ minrelocorticoides - Increase placental production - Increase activiy of renin &angiotonsine Increase the level of ACTH&CRH ↓ Glucocorticoides Placental production of ATH&CRH Pregnancy specific ↓ -HCG -HPL hypothalmas pituitary ↓ CRH -GnRH - ↓ -HGH -ACTH -PRolactin steroids ↓ ostriol progesterone Is produced by trophoblast cells. The B-subunit is pregnancy specific and used as a sensitive pregnancy test maintaining the function of the corpus luteum circulating hCG values reach peak by 10 weeks & fall off after 12 weeks Pregnancy is hypermetabolic state ↙ BMR increased by (10-20)% ↘ Additional total energy requirement is about 300 kcal/day Is consist of : 1- products of conceptions 2- increase of various maternal tissue 3- increase maternal fat stores Ranges of weight gain recommended during pregnancy for women with : Low BMI (< 20) is 12.5 kg -18 kg Normal BMI is 11.5 – 16kg In the first half of pregnancy: 1- fasting plasma glucose concentrations are reduced 2- little change in insulin levels. In the 2nd half of pregnancy: 1- an increase in glucose values 2- significant increases in plasma insulin concentrations This suggests relative insuline resistance caused by diabetogenic hormones of pregnancy After 8th week pregnancy, there is increase in circulating concentrations of: triacylglycerols, fatty acids, cholesterol phospholipids all In early pregnancy: oestrogen, progesterone and insulin promote the accumulation of maternal fat stores in early pregnancy and inhibit lipolysis. In late pregnancy: fat mobilization is enhanced to allow pregnant women: - to use stored lipid for energy needs - Minimize protein catabolism - preserving glucose and amino acids for the fetus. total plasma calcium concentrations is decrease There is little change in the circulating concentration of unbound calcium The fetal demand for calcium is about6.5 mmol per day There are three methods of maternal adaptation to provide calcium in favour of developing fetus: 1- increasing gut absorption 2- mobilizing skeletal calcium reserves 3-`restricting renal losses. • Hyperpigmentation. • Striae gravidarum. • Hirsuitism. • ↑ Sebaceous gland activity Linea nigra Thank you