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Questions and Answers
Which of the following is NOT a change related to estrogen during pregnancy?
Which of the following is NOT a change related to estrogen during pregnancy?
What is a significant consequence of the decrease in estrogen levels after delivery?
What is a significant consequence of the decrease in estrogen levels after delivery?
What is a characteristic feature of physiological edema during pregnancy?
What is a characteristic feature of physiological edema during pregnancy?
Which statement accurately describes the metabolic state during pregnancy?
Which statement accurately describes the metabolic state during pregnancy?
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Which factor contributes to the physiological edema seen during pregnancy?
Which factor contributes to the physiological edema seen during pregnancy?
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What causes the increased pigmentation seen in pregnancy, such as the linea nigra?
What causes the increased pigmentation seen in pregnancy, such as the linea nigra?
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Which change is associated with the skin during pregnancy?
Which change is associated with the skin during pregnancy?
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What is the primary cause of uterine weight increase during pregnancy?
What is the primary cause of uterine weight increase during pregnancy?
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What is the typical increased utero-placental blood flow during pregnancy?
What is the typical increased utero-placental blood flow during pregnancy?
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Which of the following changes occurs in the uterus during pregnancy?
Which of the following changes occurs in the uterus during pregnancy?
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What anatomical change occurs in the transverse diameter of the chest during respiratory system changes?
What anatomical change occurs in the transverse diameter of the chest during respiratory system changes?
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What is the role of the mucus plug during pregnancy?
What is the role of the mucus plug during pregnancy?
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Which of the following features remains constant during respiratory system changes?
Which of the following features remains constant during respiratory system changes?
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Which hormone primarily supports the decidua during pregnancy?
Which hormone primarily supports the decidua during pregnancy?
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What happens to the total lung capacity during respiratory system changes?
What happens to the total lung capacity during respiratory system changes?
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What is the most common form of vaginitis during pregnancy?
What is the most common form of vaginitis during pregnancy?
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Which statement correctly describes the changes in O₂ binding capacity during respiratory changes?
Which statement correctly describes the changes in O₂ binding capacity during respiratory changes?
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What is the primary reason for respiratory alkalosis during respiratory system changes?
What is the primary reason for respiratory alkalosis during respiratory system changes?
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What does the Chadwick/Jacquemier sign indicate?
What does the Chadwick/Jacquemier sign indicate?
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What change occurs to LH and FSH levels during pregnancy?
What change occurs to LH and FSH levels during pregnancy?
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What is a common cause of low birth weight in infants?
What is a common cause of low birth weight in infants?
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Which condition is characterized by a common cardiovascular issue during the immediate postpartum period?
Which condition is characterized by a common cardiovascular issue during the immediate postpartum period?
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What symptom may indicate a need to rule out heart disease during history taking?
What symptom may indicate a need to rule out heart disease during history taking?
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Which complication is associated with poor wound healing postnatally?
Which complication is associated with poor wound healing postnatally?
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What condition results from maternal fatigue and likely affects blood flow during pregnancy?
What condition results from maternal fatigue and likely affects blood flow during pregnancy?
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What is the recommended IFA tablet dosage for non-pregnant females aged 20-49 years?
What is the recommended IFA tablet dosage for non-pregnant females aged 20-49 years?
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Which of the following is NOT a guideline for the consumption of IFA tablets?
Which of the following is NOT a guideline for the consumption of IFA tablets?
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During the first three months of pregnancy, which supplement should a pregnant female take?
During the first three months of pregnancy, which supplement should a pregnant female take?
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Which characteristic distinguishes pathological anemia from physiological anemia?
Which characteristic distinguishes pathological anemia from physiological anemia?
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What is the main feature of physiological anemia during pregnancy?
What is the main feature of physiological anemia during pregnancy?
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What is the most common physiological cause of anemia during pregnancy?
What is the most common physiological cause of anemia during pregnancy?
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Which type of anemia is frequently encountered as a pathological cause in pregnant women?
Which type of anemia is frequently encountered as a pathological cause in pregnant women?
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According to WHO, what is the definition of severe anemia in terms of hemoglobin levels?
According to WHO, what is the definition of severe anemia in terms of hemoglobin levels?
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Which of the following maternal effects is associated with severe anemia?
Which of the following maternal effects is associated with severe anemia?
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What is a potential antenatal effect of anemia due to placentomegaly?
What is a potential antenatal effect of anemia due to placentomegaly?
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What is the total iron requirement for a pregnant woman?
What is the total iron requirement for a pregnant woman?
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What is the approximate daily iron requirement during the first trimester of pregnancy?
What is the approximate daily iron requirement during the first trimester of pregnancy?
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Which of the following is NOT an intervention of the Anemia Mukt Bharat Programme?
Which of the following is NOT an intervention of the Anemia Mukt Bharat Programme?
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How much elemental iron is contained in each tablet provided in the I-NIPI programme?
How much elemental iron is contained in each tablet provided in the I-NIPI programme?
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What percentage of dietary iron is typically absorbed by the body?
What percentage of dietary iron is typically absorbed by the body?
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What is the primary effect of increased plasma volume during pregnancy on blood viscosity?
What is the primary effect of increased plasma volume during pregnancy on blood viscosity?
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Which of the following hematological parameters increases during pregnancy?
Which of the following hematological parameters increases during pregnancy?
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What change occurs in kidney size during pregnancy?
What change occurs in kidney size during pregnancy?
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What does the term 'benign gestational thrombocytopenia' refer to?
What does the term 'benign gestational thrombocytopenia' refer to?
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Which of the following parameters remains unchanged during pregnancy?
Which of the following parameters remains unchanged during pregnancy?
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What change occurs to glomerular filtration rate (GFR) during pregnancy?
What change occurs to glomerular filtration rate (GFR) during pregnancy?
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Which factor is associated with an increased risk of asymptomatic bacteriuria (ASB) during pregnancy?
Which factor is associated with an increased risk of asymptomatic bacteriuria (ASB) during pregnancy?
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What is the likely management for a pregnant woman diagnosed with asymptomatic bacteriuria?
What is the likely management for a pregnant woman diagnosed with asymptomatic bacteriuria?
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What effect does increased progesterone have on gastrointestinal motility during pregnancy?
What effect does increased progesterone have on gastrointestinal motility during pregnancy?
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Which of the following is a potential complication of untreated asymptomatic bacteriuria during pregnancy?
Which of the following is a potential complication of untreated asymptomatic bacteriuria during pregnancy?
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Study Notes
Estrogen in Pregnancy
- Estrogen influences multiple changes during pregnancy:
- Cutaneous changes like linea nigra, stretch marks, chloasma gravidarum, palmar erythema, and spider naevae
- Increased thyroid binding globulin
- Obstetric cholestasis
- Fluid retention
- Onset of labor
Prolactin in Pregnancy
- Prolactin levels rise during pregnancy and lactation
- Estrogen inhibits prolactin's actions during pregnancy, suppressing milk production
- Postpartum, placental delivery reduces estrogen levels, removing the inhibitory effect, leading to milk production
General Changes in Pregnancy
- Basal metabolic rate (BMR) increases by 10-20%
- Pregnancy is an anabolic state
- Physiological edema is common due to:
- Fluid retention (6.5L)
- Sodium and potassium retention, leading to dilution
- Decreased plasma osmolality and viscosity due to fluid retention
- Uterine pressure on the inferior vena cava
- Hypoproteinemia
Physiological vs Pathological Edema
- Physiological edema subsides on rest, while pathological edema persists
- Physiological edema is characterized by pitting, occurring in dependent areas like feet and sacrum
- Pathological edema lacks pitting and is found in non-dependent areas, often indicating preeclampsia (PIH)
Cutaneous Changes in Pregnancy
- Increased estrogen stimulates melanocyte-stimulating hormone (MSH) production, causing skin pigmentation changes
- Linea nigra: A darkly pigmented line on the abdomen
- Stretch marks: Pink striae gravidarum (current pregnancy) and silvery-gray striae albicans (previous pregnancies)
- Pregnancy mask/chloasma gravidarum: Pigmentation on the face
- Palmar erythema: Redness on the palms
- Spider naevae: Dilated veins below the skin
Changes in Reproductive Organs
-
Uterus:
- Weight increases from 1 to 1100g
- Hypertrophy is the primary cause of uterine growth, sometimes accompanied by hyperplasia
- Progesterone is the responsible hormone
- Uterine and utero-placental blood flow significantly increase
- Uterine position becomes dextrorotated (rotated to the right) to accommodate the sigmoid colon
Respiratory System Changes
-
Anatomical Changes:
- Transverse diameter of the chest increases by a cm
- Diaphragm is pushed up 4 cm
- Chest circumference increases by 6 cm
- The subcostal angle widens
-
Functional Changes:
- Increased inspiratory capacity, tidal volume, and minute ventilation
- Reduced CO₂ washout, leading to respiratory alkalosis, compensated by increased renal bicarbonate excretion
- Increased oxygen carrying capacity
- Decreased oxygen binding capacity
- Increased oxygen demand
- Inspiratory reserve volume remains constant
- Respiratory rate remains constant
- Vital capacity remains constant
- Total lung capacity and residual volume decrease
- Expiratory reserve volume decreases
Other Changes During Pregnancy
-
Iron Metabolism:
- Decreased iron levels except for serum transferrin and total iron binding capacity
-
Calcium Metabolism:
- Fetal calcium requirement: 30mg for skeleton formation
- RDA in pregnancy: Calcium 1000mg/day, Vitamin D 400IU/day
- Increased GI absorption of calcium
- Increased active form of Vitamin D production
- Increased bound calcium due to decreased albumin
- Increased total calcium due to fetal uptake
- Normal unionized serum calcium levels
-
Pituitary Gland:
- Size increases by 125% (mainly anterior pituitary) with increased blood flow
- Decreased blood flow due to postpartum hemorrhage (PPH) can lead to Sheehan syndrome (necrosis of anterior pituitary)
-
Spleen:
- Size increases by 50%
Breast Changes
-
Growth:
- Ductal growth due to estrogen
- Alveolar growth due to estrogen and progesterone
- Fat deposition due to insulin
-
Colostrum:
- Yellow discharge expressed from 12 weeks of pregnancy
-
Montgomery tubercles:
- Sebaceous glands around areola
Cervix Changes
-
Chadwick/Jacquemier sign:
- Bluish discoloration of the cervix due to increased vascularity
-
Mucus plug:
- Seals the mouth of the cervix, preventing infections
-
Release of show:
- Expulsion of blood and mucus in true labor pain
-
Hypertrophy and hyperplasia:
- Length of the cervix increases to 4-5 cm
- Ectropion/Eversion of the cervix: Columnar epithelium of endocervix grows over the squamous epithelium of exocervix, leading to post-coital bleeding but not pre-malignant
Vagina Changes
-
Increased Lactobacilli/Doderlein bacilli:
- Leads to a more acidic vaginal pH (3.5)
-
Decreased pathogenic bacteria:
- Reduced risk of vaginal infections
-
Candidiasis:
- Most common vaginitis d/t Candida thriving in acidic pH
-
Bluish discoloration:
- Chadwick/Jacquemier sign
Endocrine Changes
- Pregnancy is a progesterone-dependent state
- Progesterone suspends ovulation, increases estrogen and progesterone levels
- LH and FSH are decreased, leading to amenorrhea
- Ovulation remains suspended
IFA Tablets
- Non-pregnant females (20-49 years): 1 pill/week
- If pregnancy is planned, start folic acid supplementation 1 month prior to conception
- Pregnant females:
- First 3 months: Folic acid
- Fourth month onwards: Iron + folic acid/Red pill (Prevention)
- Dose: 1 tablet/day
- Duration: Throughout pregnancy + 180 days after delivery
- Correct consumption method: 2 hours after meals, at least 2 hours apart from calcium tablets, not with tea/milk
Types, Definitions & Adverse Effects of Anemia in Pregnancy
-
Physiological vs Pathological Anemia:
- Physiological anemia is caused by hemodilution. Hb > 11 gm%
- Pathological anemia arise from underlying conditions. Hb < 11 gm%
-
Intranatal Complications:
- Uterine inertia
- Maternal exhaustion
-
Postnatal Complications:
- Postpartum hemorrhage (PPH)
- Subinvolution of uterus
- Sepsis
- Venous thromboembolism
- Postpartum depression
- Poor wound healing
- Congestive heart failure (CHF)
Fetal Effects of Anemia
- Fetal anemia can occur due to maternal iron deficiency
- Maternal anemia increases risk of prematurity and low birth weight
Clinical Aspects of Anemia in Pregnancy
-
History Taking:
- Fatigue, lethargy, lightheadedness
- Progressive dyspnea (rule out heart disease)
- Palpitations
- Orthopnea
- Edema (physiological: relieved by rest; pathological: protein deficiency)
- Loss of appetite
- Passage of worms in stool
- Bleeding tendencies (hematuria, hematemesis)
- Past history of:
- Chronic diseases like rheumatoid arthritis, CKD, CLD
- Pica
- Tuberculosis (TB)
- Hyperemesis gravidarum
- Menstrual history: menorrhagia
- Assess amount of blood loss (based on sanitary pad usage)
Causes of Anemia in Pregnancy
- Physiological: Hemodilution
-
Pathological:
- Acquired:
- Nutritional deficiencies (most common)
- Hemolytic anemia
- Anemia of chronic disease
- Aplastic anemia
- Inherited:
- Thalassemia
- Sickle cell anemia
- Inherited hemolytic anemia
- Other hemoglobinopathies
- Acquired:
- Note:* Physiological anemia is most common, and iron deficiency anemia is the most frequent pathological cause.
Definitions of Anemia in Pregnancy
-
WHO:
- Anemia: < 11 g/dL
- Mild: 10-10.9 g/dL
- Moderate: 7-9.9 g/dL
- Severe: < 7 g/dL
- Very severe: Hb < 4 g/dL
-
CDC Guidelines:
- Trimester 1: < 11 g/dL
- Trimester 2: < 10.5 g/dL
- Trimester 3: < 11 g/dL
Maternal Effects of Anemia
-
Antenatal:
- Placentomegaly to compensate for poor fetal oxygenation
- Preterm labor/PROM due to maternal stress
- Increased risk of infections
- Congestive heart failure (CHF)
- Pregnancy-induced hypertension (PIH)/APH due to placentomegaly or folic acid deficiency
Iron Requirements During Pregnancy & I-NIPI
-
Total iron requirement: 1000mg
- RBCs: 500mg
- Fetus: 300mg
- Excreted: 250mg
- Iron transport from mother to fetus: Via active transport
-
Iron supplementation: Mandatory during pregnancy
- Approximate daily requirement: 4-6mg/day
- 1st Trimester: 0.8mg/day
- 3rd Trimester: 7.5mg/day
-
Note:
- 50% of females in India are anemic
- Anemia is responsible for half of global deaths
- Most common indirect cause of maternal mortality
- Daily dose: 40-60mg/day (only 10% of dietary iron is absorbed)
-
ANEMIA MUKT BHARAT PROGRAMME (I-NIPI): Launched in 2018
- Free iron and folic acid tablets provided to all women
- Each tablet contains 60mg of elemental iron and 500mcg of folic acid
-
Programme: 6 x 6 x 6
- 6 beneficiaries: Pregnant and non-pregnant females of reproductive age
- 6 interventions: Digital hemoglobinometer screening, IFA tablets, deworming, delayed cord clamping, food fortification, addressing other causes of anemia
- 6 institutional methods: Implementing the programme
Hematological Changes in Pregnancy
-
Parameters that increase:
- Blood volume (plasma volume by 40-50%)
- RBC volume (by 20-30%)
- Hemoglobin mass (in g)
- O₂ carrying capacity of blood
- Erythropoietin
- Reticulocyte count (d/t erythropoiesis)
- MCV
- WBC count:
- ≥ 15,000: Pregnancy
- ≥ 25,000: In labor
- Inflammatory proteins (CRP, ESR)
- Clotting factors (excluding 11 and 13): Hypercoagulable state
- Plasma protein mass (in g) (globulin ↑, sex hormone binding globulin ↑, thyroid binding globulin ↑)
-
Parameters that decrease:
- Blood viscosity (d/t hemodilution)
- Hematocrit
- Hb concentration (does not fall below 11g/dL)
- RBC life span
- Platelet count (stays within normal range; called 'Benign gestational thrombocytopenia')
- Clotting factors 11 and 13
- Fibrinolytic activity
- Protein C, protein S, and anti-thrombin levels
- Plasma protein concentration (albumin ↓, A:G ratio = 1:1)
-
Compensatory mechanisms for hemodilution:
- Increased cardiac output
- Increased 2,3-BPG production
- Right shift of Hb-O₂ dissociation curve
- Increased SpO₂
- Decreased blood viscosity
-
Parameters that remain unchanged:
- Bleeding time (BT)
- Clotting time (CT)
- APTT
- MCHC
- Blood pH
-
Note: Isolated increased APTT along with a history of thrombosis may indicate Antiphospholipid syndrome (APLA).
Renal Changes in Pregnancy
- Increased kidney size: By 1 cm
- Bilateral hydroureter: Decreased peristalsis in the ureters due to progesterone (smooth muscle relaxant), leading to urinary stasis
- Increased risk of urinary tract infections (UTIs)
- Right side is more affected due to the dextrorotation of the uterus, increasing pressure on the right side
Renal System Changes in Pregnancy
- Increased renal blood flow: By 80%
- Increased urinary frequency: More frequent urination in the 1st and 2nd trimesters due to irritation of the bladder by the growing uterus (relieved in the 3rd trimester due to the descent of the fetal head)
- Increased glomerular filtration rate (GFR): By 50%
- Decreased: Serum urea, serum uric acid, and serum creatinine
Bladder Pressure in Pregnancy
- Increased bladder pressure increases the risk of stress urinary incontinence.
Urine Routine/Microscopy Changes in Pregnancy
-
Done at the first antenatal visit:
- Glycosuria: Possibly indicates diabetes
- Proteinuria: Not physiological and often seen in preeclampsia (PIH)
- Asymptomatic bacteriuria (ASB): Presence of ≥ 10⁵ bacteria/mL in a midstream clean-catch urine sample without UTI symptoms
Urine Routine/Microscopy Management in Pregnancy
-
Repeated every trimester to monitor for ASB:
- Microorganism: E.coli
- Complications: Pre-term labor and acute pyelonephritis (25% of cases)
- Risk factors: Diabetes, sickle cell anemia
- Management: Nitrofurantoin (DOC)
- Recurrence rate: 30%
Gastrointestinal System Changes in Pregnancy
- Motility Changes:
- Increased progesterone levels cause smooth muscle relaxation, leading to:
- Increased risk of gastroesophageal reflux
- Increased risk of constipation
- Gall bladder contractility:
- Decreased gall bladder contractility increases the risk of gall stones
- Gastric emptying time: Increased
-
Hepatic enzymes:
- ALP: Increased due to placental (heat-stable) ALP release
- SGOT & SGPT: Normal (Elevation is always pathological, e.g., HELLP syndrome)
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Description
Explore the critical hormonal changes during pregnancy, focusing on the roles of estrogen and prolactin. This quiz covers various physiological adaptations, including metabolic rate alterations and fluid retention. Test your understanding of how these hormones influence pregnancy and lactation.
