Physical and Physiological Changes of Pregnancy Chap.8 PDF

Physical and Physiological Changes of Pregnancy Chap.8 12/07/2024 Dr eman awad tayyem 1  Anatomic and Physiologic Changes Pregnancy is divided into three trimesters, each approximately a 3-month period. Each trimester brings predictable chang...

Physical and Physiological Changes of Pregnancy Chap.8 12/07/2024 Dr eman awad tayyem 1  Anatomic and Physiologic Changes Pregnancy is divided into three trimesters, each approximately a 3-month period. Each trimester brings predictable changes for both the mother and the fetus 12/07/2024 Dr eman awad tayyem 2  Reproductive System Uterus: Increased amounts of estrogen and growing fetus – Enlargement in size &wt. (Before pregnancy the uterus is a small, almost solid, pear-shaped organ, weighing about 60 g , At the end of pregnancy weighs approximately 1100 g) – Increase in weight, strength, elasticity, and vascularity – By the end of pregnancy 1\6 of maternal blood volume is contained within the vascular system of the uterus – Braxton Hicks contraction , irregular ,painless, intermittent ,begin at about the fourth month. later months, may be confused with true labor contractions. 12/07/2024 Dr eman awad tayyem 3 Cervix: Increased estrogen levels – Hyperplasia – Endocervical glands secrete a thick, sticky mucus lead to formation of mucous plug – Mucous plug prevents organisms entering uterus and it is expelled when cervix is dilated/ at the onset of labor – Physiologic mucorrhea due to hyperactivity of glandular tissue----result in profuse discharge – Increase cervical vascularirty lead to::  Goodell's sign --- softening of cervix  Chadwich's sign ------bluish discolouration 12/07/2024 Dr eman awad tayyem 4  Chadwick sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy Goodell's sign It is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascularization is a result of hypertrophy and engorgement of the vessels below the growing uterus 12/07/2024 Dr eman awad tayyem 5  Ovaries:  stop ovulation  corpus luteum secret progesterone until the seventh week then placenta will take the task. Vagina: Increased estrogen levels – Increased thickness of mucosa – Increased vaginal secretions (leukorrhea))( thick , white, acidic (pH3.5-6) to prevent bacterial infections – Favor for growth of yeast( candida) – Connective tissue relaxes to permit passage of infant – Increase vascularity lead to blue purple color(Chadwich's sign) 12/07/2024 Dr eman awad tayyem 6  Breasts: Increased estrogen and progesterone levels – The breasts enlarge ,more nodular ,glands increase in size and number in preparation for lactation – Blood vessels more prominent – Nipples more erectile and areolas darken – Sebaceous glands enlarge,، – Striae may develop. – Colostrum produced during third trimester 12/07/2024 Dr eman awad tayyem 7 Respiratory system: – Increased volume of air 30%-40%per min. – Progesterone decreased airway resistance – Increase O2 consumption(15% to 20%) – Enlarged uterus presses and elevates diaphragm upward Increased antero-posterior diameter – Chest circumference / increase – Breathing changes from abdominal to thoracic as uterus enlarges – Nose stuffiness, epistaxis occur because of estrogen-induced edema 12/07/2024 Dr eman awad tayyem 8  Cardiovascular system:  Bld volume increase from first trimester ,increasing rapidly from 30-34 wks  Bld. volume increases(40%-50%)  Blood flow increases to organ systems with an increased workload e.g. breast ,uterus,placenta  Cardiac output increase early in pregnancy and peaks at 25 to 30 weeks ( 30% to 50% )  Pulse increase 10-15 b\min.  Bp. slightly decrease –lowest point second trimester(due to decrease in systematic vascular resistance) 12/07/2024 Dr eman awad tayyem 9  – Cardiovascular system : cont…  Enlarged uterus pressure on pelvic vessels dependent edema & varicose viens legs, vulva, rectum  Postural hypotension \increase bld.volume in lower extremities.  Supine hypotension syndrome\ pressure on vena cava ,pressure on aorta  corrected when woman lie on her left side or by placing a pillow or wedge under her right hip 12/07/2024 Dr eman awad tayyem 10  Cardiovascular system : cont…  Increase erythrocyte and plasma  plasma volume 50%  erythrocyte30%woman receive iron  and 18% with no , iron (to transport additional O2)  heamatocreate which measure concentration RBCs in plasma decrease ( physioloical anmia ) 12/07/2024 Dr eman awad tayyem 11   Cardiovascular system : cont…  Increased need for iron by the pregnant woman to 27 mg of iron daily.  WBCs / increases slightly to a range of 5600 to 12,200/mm  Fibrin and plasma fibrinogen levels increase Clotting factors increase (VII, VIII, IX, and X)/ pregnancy is a somewhat hypercoagulable state risk of developing venous thrombosis. 12/07/2024 Dr eman awad tayyem 12 GI system  Nausea, vomiting due to: :  elevated HCG  relaxation of smooth muscle of stomach  changes in carbohydrate metabolism).  Secretion of saliva may increase  Delayed gastric emptying and decreased peristalsis due to:  Increased progesterone l evels cause muscle relaxation  Enlarging uterus displaces the stomach upward and the intestines are moved laterally and posteriorly  heartburn (pyrosis)  Hemorrhoids / constipation & pressure on vessels  Spongy gum , bleed easily – The emptying time of the gallbladder is prolonged during pregnancy / progesterone 12/07/2024 Dr eman awad tayyem 13  Urinary Tract : ‫المسالك البولية‬ urinary frequency during first trimester, decrease in second trimester, reappears during the third trimester Glomerular filtration rate increases Renal tubular reabsorption increases Glucoseuria- kidneys’ inability to reabsorb all the glucose filtered by the glomeruli. 12/07/2024 Dr eman awad tayyem 14  Skin and Hair: Increased skin pigmentation caused by increased estrogen and progesterone Stria (stretch marks) appear on the abdomen, thighs, buttocks, and breasts Chloasma(mask of pregnancy) a darkening of the skin over the forehead and around the eyes/aggravated by exposure to the sun linea nigra pigmented line extends from the pubic area to the umbilicus or higher Spider nevi, bright-red elevations of the skin radiating from a central body (chest, neck, face, arms, and legs ) 12/07/2024 Dr eman awad tayyem 15 Musculoskeletal:  estrogen and progesterone relaxation of pelvic joints waddling gait.  lumbar spinal curve (lordosis),changes in posture  low backache.  Diastasis recti: separation of abd. muscle may occur / pressure of uterus on abd. Muscles Central Nervous System: Decreased attention, concentration and memory 12/07/2024 Dr eman awad tayyem 16  Metabolism: Increased during pregnancy to meet demands of the growing fetus and its support system Weight Gain: according to BMI Normal weight :(11.5 to 16.0 kg (25 to 35 lb) Overweight: 6.8 to 11.5 kg (15 to 25 lb) Obesity: 5 to 9 kg (11 to 20 lb) Underweight: 12.7 to 18.1 kg (28 to 40 lb) First trimester: 0.5 to 2.0 kg (1.1 to 4.4 lb) Second & third trimester 0.45 kg (1 lb) per week 12/07/2024 Dr eman awad tayyem 17  Water Metabolism Increased water retention / increased level of steroid sex hormones affects sodium and fluid retention Extra water is needed for the fetus, the placenta, amniotic fluid, and the mother’s increased blood volume, interstitial fluids, and enlarged organs. Nutrient Metabolism The fetus makes its greatest protein and fat demands during the second half of pregnancy, doubling in weight during the last 6 to 8 weeks Increase carbohydrate needs Fats are more completely absorbed during pregnancy 12/07/2024 Dr eman awad tayyem 18  Endocrine System – Thyroid : – Enlarged  Basal metabolic rate increase(20% to 25% )  Return to pre pregnant state within few weeks after birth. – Pituitary – anterior pituitary gland : FSH (stimulates ovum growth)+LH(brings about ovulation) posterior pituitary gland –Vasopressin (antiduiretic ) cause vaso- constriction (increase BP.) and regulate water balance 12/07/2024 Dr eman awad tayyem 19  Adrenals Glands : Cortisol: control carbohydrate and protein metabolism – return to normal within 1 to 6 weeks postpartum – aldosterone : the body’s protective response to the increased sodium excretion associated with progesterone Pancreas : – increase insulin needs – pancreatic cells will be stressed to meet this demand 12/07/2024 Dr eman awad tayyem 20  Hormones in Pregnancy HCG : secreted by trophoplast, stimulate progesterone and estrogen production by corpus luteum to maintain pregnancy hPL: insulin antagonist, decreases maternal metabolism of glucose Estrogen :  Secreted originally by the corpus.  produced primarily by the placenta as early as the seventh week  luteumstimulate uterine development  helps develop the ductal system of the breasts  Progesterone:  produced initially by the corpus luteum and then by the placenta.  plays the greatest role in maintaining pregnancy , maintain endometrium, decrease uterine contractility, prevent spontaneous abortion. 12/07/2024 Dr eman awad tayyem 21  Signs of Pregnancy 12/07/2024 Dr eman awad tayyem 22  Subjective (presumptive) changes : signs and symptoms that are usually experienced by the woman, cannot be considered proof of pregnancy ‫ال يمكن اعتبار العالمات واألعراض التي تعاني منها المرأة عادًة دليًال على الحمل‬ Amenorrhea( absence of menses) is one of the earliest symptom of pregnancy. Nausea and Vomiting (Morning Sickness).. Usually occurs occur frequently during the first trimester mostly occur in the morning ;morning sickness  Excessive fatigue may be noted within a few weeks after the first missed menstrual period and may persist throughout the first trimester  Urinary frequency is experienced during the first trimester as the enlarging uterus presses on the bladder. 12/07/2024 Dr eman awad tayyem 23  Breast Changes Tenderness and tingling sensations Increased pigmentation of the areola and nipple Changes in the Montgomery glands.. Veins also become more visible Quickening Mother’s perception of fetal movement Occurs about 18 to 20 weeks after the last menstrual period in a woman pregnant for the first time May occur as early as 16 weeks in a woman who has been pregnant before. Quickening is a fluttering sensation in the abdomen that gradually increases in intensity and frequency. 12/07/2024 Dr eman awad tayyem 24  Amenorrhea – Endocrine factors: early menopause; lactation; thyroid, pituitary, adrenal, ovarian dysfunction – Metabolic factors: malnutrition, anemia, climatic changes, diabetes mellitus, degenerative disorders, long-distance running – Psychologic factors: emotional shock, fear of pregnancy or sexually transmitted infection, intense desire for pregnancy (pseudocyesis), stress – Obliteration of endometrial cavity by infection or curettage – Systemic disease (acute or chronic), such as tuberculosis or malignancy  Nausea and vomiting – Gastrointestinal disorders‫ا‬ – Acute infections such as encephalitis – Emotional disorders such as pseudocyesis or anorexia nervosa 12/07/2024 Dr eman awad tayyem 25  Urinary frequency – Urinary tract infection – Cystocele – Pelvic tumors – Urethral diverticula – Emotional tension  Breast tenderness – Premenstrual tension – Chronic cystic mastitis – Pseudocyesis – Hyperestrogenism  Quickening – Increased peristalsis – Flatus (“gas”)) – Abdominal muscle contractions – Shifting of abdominal contents 12/07/2024 Dr eman awad tayyem 26  Objective (Probable) Changes Identified by an examiner during pregnancy. As they have other causes, they do not confirm pregnancy Changes in the pelvic organs physical changes detectable during the first 3 months of pregnancy caused by increased vascular congestion. These changes : 1. Goodell sign. a softening of the cervix 2. Chadwick sign is a bluish, purple, or deep-red discoloration of the mucous membranes of the cervix, vagina, and vulva 3. Hegar sign is a softening of the isthmus of the uterus, the area between the cervix and the body of the uterus. 12/07/2024 Dr eman awad tayyem 27  Enlargement and softening of the body of the uterus can be noted after the 8th wk of pregnancy. The fundus of the uterus is palpable just above the symphysis pubis at about 10 to 12 weeks’ gestation at the level of the umbilicus at 20 to 22 weeks’ gestation Enlargement of the abdomen during the childbearing years is usually regarded as evidence of pregnancy, especially if it is continuous and accompanied by amenorrhea 12/07/2024 Dr eman awad tayyem 28 12/07/2024 Dr eman awad tayyem 29 Braxton Hicks contractions :can be palpated after the 28th week. At the end of pregnancy, these contractions may become uncomfortable. They are often called false labor. Uterine souffle: may be heard when the examiner auscultates the abdomen over the uterus. It is a soft, blowing sound that occurs at the same rate as the maternal pulse and is caused by the increased uterine blood flow and blood pulsating through the placenta. ‫ إنه صوت رقيق‬.‫ يمكن سماعه عندما يسمع الفاحص البطن فوق الرحم‬:‫سوفلي الرحم‬ ‫ونفخ يحدث بنفس معدل نبض األم وينتج عن زيادة تدفق الدم في الرحم ونبض الدم عبر‬.‫المشيمة‬ Changes in pigmentation of the skin.. The nipples and areolae may darken linea nigra may develop. Facial melasma (chloasma) may become noticeable, striae may appear. 12/07/2024 Dr eman awad tayyem 30  The fetal outline may be identified by palpation in many pregnant women after 24 weeks’ gestation Ballottement is the passive fetal movement elicited when the examiner inserts two gloved fingers into the vagina and pushes against the cervix. This action pushes the fetal body up, and, as it falls back, the examiner feels a rebound. 12/07/2024 Dr eman awad tayyem 31 Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels Clinical Pregnancy Tests:  β-Subunit radioimmunoassay (RIA) :not only detect pregnancy but also detect an ectopic pregnancy or trophoblastic disease  Enzyme-linked immunosorbent assay (ELISA: may be done on urine or blood, is sensitive and quick. detect hCG levels as early as 7 to 9 days after ovulation and conception  Fluoroimmunoassay (FIA):takes about 2 to 3 hours to perform, is extremely sensitive  Over-the-Counter Pregnancy Tests: Home pregnancy tests, performed on urine , detect low levels of hCG, If the results are negative, the woman should repeat the test in 1 week if she has not started her period. 12/07/2024 Dr eman awad tayyem 32  Objective Changes Differential Diagnosis Changes in pelvic organs: Increased vascular congestion Goodell sign Estrogen-progestin oral contraceptives Chadwick sign Vulvar, vaginal, cervical hyperemia Excessively soft walls of nonpregnant uterus Hegar sign Uterine tumors Uterine enlargement Enlargement of abdomen Obesity, ascites, pelvic tumors Braxton Hicks contractions Hematometra, pedunculated, submucous, and soft myomas Large uterine myomas, large ovarian tumors, or any condition with greatly Uterine souffle increased uterine blood flow 12/07/2024 Dr eman awad tayyem 33  Estrogen-progestin oral contraceptives Pigmentation of skin: Melanocyte hormonal stimulation Chloasma (melasma) Linea nigra Nipples/areolae Abdominal striae Obesity, pelvic tumor Ballottement Uterine tumors/polyps, ascites Positive pregnancy test Increased pituitary gonadotropins at menopause, choriocarcinoma, hydatidiform mole Palpation for fetal outline Uterine myomas 12/07/2024 Dr eman awad tayyem 34  Diagnostic (Positive) Changes 1. Fetal heartbeat 2. detected with an electronic Doppler device as early as weeks 10 to 12 of pregnancy. 2. Fetal movement is actively palpable by a trained examiner after about the 20th week of pregnancy..2 3. Visualization of the fetus by ultrasound Gestational sac :4 to 5 weeks’ gestation (2 to 3 weeks after conception).  Fetal parts and fetal movement can be seen as early as 8 weeks’ gestation.  Transvaginal ultrasound has been used to detect a gestational sac as early as 10 days after implantation 12/07/2024 Dr eman awad tayyem 35 Psychologic Response of the Expectant Family to Pregnancy 12/07/2024 Dr eman awad tayyem 36  Pregnancy is a turning point in a family’s life Accompanied by stress and anxiety, whether the pregnancy is desired or not First child: expectant couple may be unaware of the physical, emotional, and cognitive changes of pregnancy May anticipate no problems from such a normal event For beginning families, pregnancy is the transition period from childlessness to parenthood Career goals and mobility may be affected After birth of a child, the couple enters a new, irreversible stage of their life together Subsequent pregnancy, routines and family dynamics are again altered Finances are an important consideration 12/07/2024 Dr eman awad tayyem 37  First-Trimester Mother’s Reactions – Informs father secretively or openly. – Feels ambivalent toward pregnancy, anxious about labor and responsibility of child – Is aware of physical changes, daydreams of possible miscarriage. – Develops special feelings for and renewed interest in her own mother, begins to form a personal identity as a mother.. Second-Trimester Mother’s Reactions – Remains regressive and introspective, pro- jects all preexisting perceives his lack of interest as a sign of weakness in him. – Continues to deal with feelings about motherhood; shops for nursery furniture as something concrete to do. – ‫تواصل التعامل مع مشاعر األمومة ؛ محالت ألثاث الحضانة كشيء ملموس للقيام به‬. – May experience anxiety or, alternately, may be very lackadaisical and wait until ninth month to look for furniture and clothes for baby. 12/07/2024 Dr eman awad tayyem 38  – Feels movement and is aware of fetus and incorporates it into herself. – May dream that partner will be killed, telephones him often for reassurance – Experiences more distinct physical changes; sexual desires may increase or decrease. Third-Trimester Mother’s Reactions – Experiences more anxiety and tension, with physical awkwardness.\ – Feels much discomfort and insomnia from physical condition. – Prepares for birth, assembles layette, picks out names. – Dreams often about misplacing baby or not being able to give birth, fears birth of deformed baby. – Feels ecstasy and excitement, has spurt of energy during last month. 12/07/2024 Dr eman awad tayyem 39  Psychologic Tasks of the Mother Rubin (1984) identified four major tasks that the pregnant woman undertakes to maintain her intactness ‫سليمة‬and that of her family and to incorporate her new child into the family system: ‫) أربع مهام رئيسية تقوم بها المرأة الحامل للحفاظ على سالمتها ومهام أسرتها ودمج طفلها الجديد‬1984( ‫حدد روبن‬ :‫في نظام األسرة‬ 1. Ensuring safe passage through pregnancy, labor, and birth 2. feels concern for both her unborn child and herself, looks for competent maternity care, seek information from literature, engages in self-care activities related to diet, exercise and becomes more aware of external threats in the environment— 2. Seeking acceptance of this child by others: Birth of a child alters a woman’s primary support group The woman slowly alters her network to meet the needs of her pregnancy partner’s support and acceptance help form a maternal identity other children :the mother also works to ensure their acceptance of the coming child 12/07/2024 Dr eman awad tayyem 40 3. Seeking commitment and acceptance of herself as mother to the baby (binding-in)..)‫ السعي لاللتزام وقبول نفسها كأم للطفل (ملزم‬.3 first trimester,:child remains abstract concept. ‫ يظل الطفل مفهوًما مجرًدا‬:‫الفصل األول‬. Quickening: child begins to become a real person, so mother begins to develop bonds of attachment ‫ لذلك تبدأ األم في تطوير روابط االرتباط‬، ‫ يبدأ الطفل في أن يصبح شخًصا حقيقًيا‬:‫التسريع‬ 4. Learning to give of oneself on behalf of one’s child. ‫تعلم أن يعطي المرء نفسه نيابة عن الطفل‬. Childbirth involves many acts of giving‫تنطوي الوالدة على العديد من أعمال العطاء‬ Baby showers and gifts are acts of giving that increase the mother’s self-esteem and help her recognize the separateness and needs of the coming baby. ‫هدايا استحمام األطفال والهدايا هي أعمال عطاء تزيد من تقدير األم لذاتها وتساعدها على التعرف على‬.‫انفصال واحتياجات الطفل القادم‬ 12/07/2024 Dr eman awad tayyem 41  Father’s Reactions – Differ according to age, parity, desire for child, economic stability. – Acceptance of pregnant woman’s attitude or complete rejection and lack of communication. – Is aware of his sexual feelings, may develop more or less sexual arousal. – Accepts, rejects, or resents mother-in-law. – May develop new hobby outside of family as sign of stress. 12/07/2024 Dr eman awad tayyem 42  Father’s Reactions – If he can cope, will give her extra attention she needs; if he cannot cope, will develop a new time-consuming interest outside of home. – May develop a creative feeling and a “closeness to nature.” – May become involved in pregnancy and buy or make furniture. – Feels for movement of baby, listens to heartbeat, or remains aloof, with no physical contact. – May have fears and fantasies about himself being pregnant, may become uneasy with this feminine aspect in himself. – May react negatively if partner is too demanding, may become jealous of physician and of physician’s importance to partner and her pregnancy. 12/07/2024 Dr eman awad tayyem 43  Father’s Reactions – Adapts to alternative methods of sexual contact. – Becomes concerned over financial responsibility. – Daydreams about child as if older and not newborn, dreams of losing partner. – Renewed sexual attraction to partner. – Feels he is ultimately responsible for whatever happens. 12/07/2024 Dr eman awad tayyem 44  Siblings‫إخوة‬ Siblings view the baby as a threat to the security of their relationships with their parents Parents who recognize this potential problem early in pregnancy and begin constructive actions can minimize the problem Preparation of the young child begins several weeks before the anticipated birth; let the child feel the baby moving in her uterus , help the parents put the baby clothes in drawers or prepare the baby’s room, 12/07/2024 Dr eman awad tayyem 45  Grandparents ‫الجد والجدة‬ Usually supportive of the couple Uncertain how deeply to become involved in the childrearing process. Clarifying the role of the helping grandparent ensures a comfortable situation for all Family cohesiveness is promoted by effective communication and discussion between young couples and interested grandparents 12/07/2024 Dr eman awad tayyem 46