Physiology of Pregnancy

Содержание

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Normal Pregnancy Pregnancy The course that the embryo and the fetus

Normal Pregnancy

Pregnancy
The course that the embryo and the fetus grow

in the maternal body
Stages of pregnancy
Early pregnancy: ≤12 weeks
Mid pregnancy: ≥13 weeks,≤27 weeks
Late pregnancy:≥28 weeks
Term pregnancy:≥37 weeks,<42 weeks
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Formation of Embryo Fertilization Place: oviduct (ampulla) Process capacitation → acrosome

Formation of Embryo

Fertilization
Place: oviduct (ampulla)
Process
capacitation → acrosome reaction→ penetrate

the zona pellucida→ second meiosis →zygote
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Formation of Embryo Implantation requirement Disappear of zona pellucida Formation of

Formation of Embryo

Implantation
requirement
Disappear of zona pellucida
Formation of syncytiotrophoblast
Synchronized development of blastocyst

and endometrium
Adequate progesterone
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Formation of Embryo Process morula (day 3) → enter uterine cavity

Formation of Embryo

Process
morula (day 3) → enter uterine cavity (day 4)

→ early blastocyst→ late blastocyst (day 6-7) → implantation
location→ adherence→ penetration
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Development of embryo and fetus Definition embryo: ≤ 8 weeks Fetus: ≥ 9 weeks, human shape

Development of embryo and fetus

Definition
embryo: ≤ 8 weeks
Fetus: ≥ 9 weeks,

human shape
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Development of embryo and fetus Physiology of fetus Circulation fetus ←→placenta←→

Development of embryo and fetus

Physiology of fetus
Circulation
fetus ←→placenta←→ mater
1 umbilical vein

(full of oxygen), 2 umbilical artery (lack of oxygen)
Mixed blood (vein and artery)
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Development of embryo and fetus

Development of embryo and fetus

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Development of embryo and fetus Hematology Erythropoiesis From yolk sac: 3

Development of embryo and fetus

Hematology
Erythropoiesis
From yolk sac: 3 weeks
From liver: 10

weeks
From bone marrow and spleen: term (90%)
EPO production: 32nd week
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Development of embryo and fetus Fetal hemoglobin Fetal hemoglobin: early pregnancy

Development of embryo and fetus

Fetal hemoglobin
Fetal hemoglobin: early pregnancy
Adult hemoglobin: 32nd

week
Term: fetal type Hb 25%
White cells
Leukocytes: 8 week
Lymphocytes (antibody production): 12 week, thymus and spleen
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Development of embryo and fetus Gastrointestinal tract drink amniotic fluid: 4th

Development of embryo and fetus

Gastrointestinal tract
drink amniotic fluid: 4th month
no proteolytic

activity
enzymatic deficiencies in liver:
bilirubin is not easy to be clear.
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Development of embryo and fetus Kidney Its function begins at 11-14th

Development of embryo and fetus

Kidney
Its function begins at 11-14th week
Endocrinology
Fetal

thyroid: the first endocrine gland (6th week), synthesize thyroxine at 12th week
Fetal adrenal cortex: widen (20th week), a fetal zone. synthesize steroid hormones (E3, liver placenta mater)
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Placenta Structure Primary villus syncytiotrophoblast cytotrophoblast Secondary villus third class vilus fetal capillary enter the stroma

Placenta

Structure
Primary villus
syncytiotrophoblast cytotrophoblast
Secondary villus
third class vilus
fetal capillary enter the stroma

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Placenta: Villi a. These structures, the functioning units of the placenta,

Placenta: Villi

a. These structures, the functioning units of the placenta,

are formed by invading placental tissue (trophoblast) and contain the terminal fetal capillaries of the umbilical arteries.
b. The villi are surrounded by the intervillous space into which maternal blood from the decidual (uterine) arteries is forced by maternal arterial pressure.
c. Gases and nutrients pass from the maternal blood in the intervillous space, across the membrane of the trophoblast to the basement membrane of the fetal capillary, and then through the single endothelial cell layer of the fetal capillary to the fetal blood.
The fetal capillaries drain into the fetal veins that join to form the umbilical vein.
Maternal blood drains from the intervillous space into the maternal veins.
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Placenta: cotyledons Placental cotyledons (lobes) are formed from the branching villi

Placenta: cotyledons

Placental cotyledons (lobes) are formed from the branching villi supplied

by one terminal arterial branch and its partner venous branch of the fetal umbilical vessels.
On average, about 20 cotyledons make up the fetal side of the placenta.
The maternal side of the placenta is divided by
septa into lobes.
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Placenta: structure 1 – umbilical arteries, 2 – stem villus, 3

Placenta: structure

1 – umbilical arteries,
2 – stem villus,
3 –

decidual septa,
4 – decidual layer,
5 –myometrium,
6 – veins,
7 – spiral arteries,
8 – chorion,
9 – amnion,
10 – intervillous space, 11 – umbilical vein,
12 – cotyledon.
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Scheme of placental circulation.

Scheme of placental circulation.

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Feto-placental circulation 1- uterine artery 2- arcade arteries 3- spiral arteries

Feto-placental circulation

1- uterine artery
2- arcade arteries
3- spiral arteries
4- intervillous space
5-

placental vessels
6- vessels of the umbilical cord
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Placenta Function Exchange of nutritive factors and waste Exchange of O2

Placenta

Function
Exchange of nutritive factors and waste
Exchange of O2 and CO2
Secretion of

proteins and steroid hormones
Immunology
metabolism
Defensive - Limited. IgG, virus, drug
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Placenta: functions The placenta transfers nutrition and oxygen from the mother

Placenta: functions

The placenta transfers nutrition and oxygen from the mother to

the fetus, removes metabolic waste products from the fetus to be eliminated by the mother, and synthesizes proteins and hormones that support fetal development and important maternal physiologic changes.
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1. Mother-to-fetus transfer of nutrients a. The essential substances for growth

1. Mother-to-fetus transfer of nutrients

a. The essential substances for growth and

development move from the mother to the fetus in four ways:
(1) Active transport: amino acids, calcium
(2) Facilitated transport: glucose
(3) Endocytosis: cholesterol, insulin, iron, immunoglobulin G (IgG)
(4) Sodium pumps and chloride channels: ions
b. Solute size and lipid solubility are also important factors that influence transport.
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2. Gas exchange This process involves supplying oxygen to the fetus

2. Gas exchange

This process involves supplying oxygen to the fetus and

removing carbon dioxide
from the fetus.
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3. Secretion of proteins and steroid hormones a. Progesterone is produced

3. Secretion of proteins and steroid hormones

a. Progesterone is produced by

the placenta from maternal cholesterol, is secreted into the maternal circulation, and is important for maintaining pregnancy.
b. Estrogen is converted from circulating fetal androgens (dehydroepiandrosterone sulfate [DHEAS] produced in the fetal adrenal glands. Estrogen plays an important role in maternal physiologic changes in pregnancy, labor, and lactation.
c. Numerous proteins, peptides, and growth factors are produced in the placenta. They are important for placental growth, fetal growth and development, and the maternal physiologic changes necessary to ensure adequate nutrition to the fetus.
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4. Immunology. Invading placental cells express a unique antigen, HLA-G, which

4. Immunology.

Invading placental cells express a unique antigen, HLA-G, which is

not recognized as a "foreign" antigen by the mother.
Other unique antigens and local immune suppression contribute to the prevention of rejection of the fetal-placental unit.
5. Metabolism. Glucose is the primary substrate for placental aerobic metabolism.
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Fetal membranes Structure chorion and amnion Amnion A double-layered translucent membrane Become distended with fluid

Fetal membranes

Structure
chorion and amnion
Amnion
A double-layered translucent membrane
Become distended

with fluid
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Umbilical cord

Umbilical cord

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Umbilical cord A. Umbilical arteries. Two umbilical arteries originate from the

Umbilical cord

A. Umbilical arteries. Two umbilical arteries originate from the fetal

aorta. They supply fetal blood to all portions of the placenta for gas and solute exchange. A single umbilical artery is associated with low birth weight and chromosomal anomalies in about 10 to 15% of infants.
B. Umbilical vein. One umbilical vein returns nutrient-rich, oxygen-rich blood to the fetus.
Wharton jelly
Umbilical cord Length - 30-70cm
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Umbilical cord In most cases, the cord is about 20 inches

Umbilical cord

In most cases, the cord is about 20 inches long

and almost 1 inch in diameter. It usually appears loosely coiled. Inside the cord are two arteries and one vein. The vein supplies the baby with oxygenated, nutrient-rich blood, and the arteries carry de-oxygenated, nutrient-depleted blood back to the placenta. On occasion, the umbilical cord will only have two vessels; one artery and one vein.
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Here is a normal three vessel umbilical cord. Note that there

Here is a normal three vessel umbilical cord. Note that there

are two arteries toward the right and a single vein at the left. Most of the parenchyma of the cord consists of a loose mesenchyme with intercellular ground substance (Wharton's jelly).
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Amniotic fluid

Amniotic fluid

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Amniotic fluid Amniotic fluid ( AF ) - the habitat of

Amniotic fluid

Amniotic fluid ( AF ) - the habitat of the

fetus, performs several functions simultaneously : the creation of spaces for free movement of the growing fetus , protection from mechanical injury , maintaining temperature balance , preventing compression of the umbilical cord at birth , the implementation of the transport function and participation in metabolism .
AF is yellowish in early pregnancy, then lighter and transparent, and - cloudy , opalescent at the end of pregnancy ; pH - 6,98-7,23, specific gravity- 1007-1080 g / l , the protein content - 0.18-0.2 % glucose - 22 mg% urea - 23 mg%. AF may contain embryonic hair (lanugo), cells of the epidermis , sebaceous gland cells (vernix caseosa).
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Amniotic fluid AF volume depends on the term of pregnancy. Increase

Amniotic fluid

AF volume depends on the term of pregnancy. Increase in

volume is uneven. The peak of AF volume fixed at 33.8 weeks and is 931 ml. AF volume in the range 22-39 weeks does not change significantly (630 ml and 817 ml, respectively) and averaged 777 ml .
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Amniotic Fliud Towards the end pregnancy (term of labor) the volume

Amniotic Fliud

Towards the end pregnancy (term of labor) the volume of

amniotic fluid comes up to 1-1.5 liters, and every three hours it is completely updated, with one-third recycled by fetus.
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Amniotic Fluid Index (AFI) An ultrasound procedure used to asses the

Amniotic Fluid Index (AFI)

An ultrasound procedure used to asses the amount

of amniotic fluid. The amniotic fluid index is measured by dividing the uterus into four imaginary quadrants . The linea nigra is used to divide the uterus into right and left halves.The umbilicus serves as the dividing point for the upper and lower halves.
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Amniotic fluid index The transducer is kept parallel to the patient’s

Amniotic fluid index

The transducer is kept parallel to the patient’s longitudinal

axis and perpendicular to the floor. The deepest, unobstructed, vertical pocket of fluid is measured in each quadrant in centimeters.
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AFI at different terms of pregnancy (Amniotic Fluid Index Percentile Values)

AFI at different terms of pregnancy (Amniotic Fluid Index Percentile Values)

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Amniotic Fluid Index Percentile Values (mm) Wks 2.5th 5th 50th 95th 97th

Amniotic Fluid Index Percentile Values (mm)

Wks 2.5th 5th 50th 95th

97th
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US - amniotic fluid

US - amniotic fluid

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Amniotic Fliud Function Protect fetal move freely, warm Protect mater prevent infection

Amniotic Fliud

Function
Protect fetal
move freely, warm
Protect mater
prevent infection

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Amniotic fliud Source exudation of fetal membranes (early pregnancy) Fetal urine

Amniotic fliud

Source
exudation of fetal membranes (early pregnancy)
Fetal urine
Fetal lung
Exudation of amnion

and fetal skin
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Amniotic fliud Absord Fetal membrane Umbilical cord Fetal skin Fetal drinking

Amniotic fliud

Absord
Fetal membrane
Umbilical cord
Fetal skin
Fetal drinking
Feature
1000-1500ml at 36th-38th week (peak), transparent

→ slightly turbid
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Critical periods of development: 1 - progenez - a meiosis (step

Critical periods of development:

1 - progenez - a meiosis (step

maturation of gametes) and fertilization process.
2 - in the prenatal ontogenesis to critical periods include implantation (6-8 days), placentation and development of axial organ rudiments (3-8 week) during embryogenesis {};
3 - Fetal: the period of intensive development of the brain (15-20-th week), during the formation of the main functional systems of the body (20-24 week)
4 - the birth process.
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Physiologic changes in pregnant woman Genital organs Uterus capacity: 5ml-5000ml.weight: 50g-1000g

Physiologic changes in pregnant woman

Genital organs
Uterus
capacity: 5ml-5000ml.weight: 50g-1000g
Hypertrophy of muscle cells
Endometrium→decidua:

basal decidua, capsular decidua, true decidua
Contraction: Braxton Hicks
Isthmus uteri: 1cm→ 7-10cm
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Physiologic changes in pregnant woman Cervix: colored Ovary: placenta replaces ovary

Physiologic changes in pregnant woman

Cervix: colored
Ovary: placenta replaces ovary (10th week)
Vagina:

dilated and soft, pH↓(anti-bacteri bacteria)
Ligaments: relaxed
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Physiologic changes in pregnant woman Cardiovascular system Heart: move upward, hypertrophy

Physiologic changes in pregnant woman

Cardiovascular system
Heart:
move upward, hypertrophy of cardiac

muscle
Cardiac Output
increase by 30%, reach to peak at 32nd –34th week
Blood pressure
early or mid pregnancy Bp↓.late pregnancy Bp↑ .Supine hypotensive syndrome
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Physiologic changes in pregnant woman Hematology Blood volume Increase by 30%-45%

Physiologic changes in pregnant woman

Hematology
Blood volume
Increase by 30%-45% at 32nd –34th

(peak)
Relatively diluted
Composition
Red cells
Hb:130→110g/L, HCT:38%→ 31%.
White cells: slightly increase
Coagulating power of blood: ↑
Albumin: ↓,35 g/L
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Physiologic changes in pregnant woman The Respiratory system R rate: slightly

Physiologic changes in pregnant woman

The Respiratory system
R rate: slightly ↑
vital capacity:

no change
Tidal volume: ↑ 40%
Functional residual capacity:↓
O2 consumption: ↑ 20%
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Physiologic changes in pregnant woman The urinary system Kidney Renal plasma

Physiologic changes in pregnant woman

The urinary system
Kidney
Renal plasma flow (RFP):↑35%
Glomerular filtration

rate (GFR):↑ 50%
Ureter
Dilated (P↑)
Bladder
Frequent micturation
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Physiologic changes in pregnant woman Gastrointestinal system Gastric emptying time is

Physiologic changes in pregnant woman

Gastrointestinal system
Gastric emptying time is prolonged→ nausea.


The motility of large bowel is diminished → constipation
Liver function: unchanged
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Physiologic changes in pregnant woman Endocrine Pituitary (hypertrophy) LH/FSH: ↓ PRL:↑

Physiologic changes in pregnant woman

Endocrine
Pituitary (hypertrophy)
LH/FSH: ↓
PRL:↑
TSH and ACTH:↑
Thyroid
enlarged (TSH and

HCG↑)
thyroxine↑ and TBG↑ → free T3 T4 unchanged
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Diagnosis of pregnancy Questionable signs of pregnancy Probable signs True signs

Diagnosis of pregnancy

Questionable signs of pregnancy
Probable signs
True signs
Laboratory tests : β-HCG,

ptrogesterone
Additional methods : US
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Questionable signs of pregnancy Change of appetite. Changes of smell (aversion

Questionable signs of pregnancy
Change of appetite.
Changes of smell (aversion to

perfume, tobacco, any other smells).
Changes of the nervous system: quick fatigability, sleepiness, irritability, quick change of mood (instability of mood).
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Questionable signs Morning sickness. Pigmentation of the skin ( nipple and

Questionable signs

Morning sickness.
Pigmentation of the skin ( nipple and areolae,

linea alba, forehead and cheeks).
Increase of fatty tissue, enlargement of abdomen.
Frequency of micturition- due to: 1) pressure of the bulky uterus on the fundus of the bladder because of excessive anteverted position of the uterus; 2) congestion of the bladder mucous membrane, 3) stretching of the bladder base due to backward displacement of the cervix.
Breast discomfort.
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Probable signs Cessation of menses (or amenorrhea). Breast changes - enlargement

Probable signs

Cessation of menses (or amenorrhea).
Breast changes - enlargement of

breasts with vascular engorgement evidenced by the delicate veins visible under the skin. The nipple and areola become more pigmented and prominent. Thick yellowish secret (foremilk) usually appears.
Discolouration of the vestibule and anterior vaginal wall - cyanotic due to local vascular congestion.
Changes of size, shape and consistence of the uterus.
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Pregnancy’ sign in VE: Piskacek’s sign. It is an asymmetrical enlargement

Pregnancy’ sign in VE:

Piskacek’s sign.
It is an asymmetrical
enlargement of

the
uterus due to the
lateral implantation
of fertilized ovum.
In such cases one
half of the uterus is
larger than another.
As pregnancy advances,
symmetry is restored.
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Hegar’s sign. It is present in two-thirds of cases. It can

Hegar’s sign.

It is present in two-thirds of cases. It can be

manifested at term of 6-10 weeks, or a little earlier in multiparae. This sign is based on the fact that:
the upper part of the body of the uterus is enlarged by the growing ovum;
the lower part of the body is empty and extremely soft, and
the cervix is comparatively dense. Because of variation in consistency, on bimanual examination the abdominal and vaginal fingers seem to appose below the body of the uterus.

Pregnancy’ sign in VE:

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Pregnancy’ sign in VE: Early as 4-8 weeks Henter’s sign is

Pregnancy’ sign in VE:

Early as 4-8 weeks Henter’s sign is appear:

expressed anteflexion of uterus due to softening of isthmus, and at the same time the crest on the anterior wall of the uterus are palpable.
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Pregnancy’ sign in VE: Haus-Gubarev’s sign - the cervix of the

Pregnancy’ sign in VE:

Haus-Gubarev’s sign - the cervix of the uterus

becomes very mobile, due to softening of the isthmus of the uterus.
Snegiryov’s sign – Increased irritability of the uterus body presented with appearance of hypertonicity of the uterus under palpating fingers during bimanual examination.
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Uterus sizes Week 6: Plum or golf ball size (hen’s egg)

Uterus sizes

Week 6: Plum or golf ball size (hen’s egg)
Week 8:

Tennis ball size
Week 10: Large orange size
Week 12: Grapefruit size (palpable at suprapubic area)
Week 14: Cantaloupe size
Week 16 : between the symphysis pubis and the navel
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Uterus sizes Week 20: at the 2 cross fingers (4 cm)

Uterus sizes

Week 20: at the 2 cross fingers (4 cm) below

the navel
Week 24: uterus reaches the navel
Week 28: 2-3 cross fingers higher the navel
Week 32: midway between the umbilicus and xiphoid process of sternum
Week 36- 38: uterus reaches the xiphoid and costal arches
Week 40 : fundus of the uterus drops to the middle of the distance between the navel and the xiphoid process. At the end of pregnancy belly button sticks out.
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Uterus sizes at different terms of pregnancy

Uterus sizes at different terms of pregnancy

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Uterus size at different term of gestation

Uterus size at different term of gestation

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True (authentic) signs of pregnancy Palpation of the fetal parts. Evidently

True (authentic) signs of pregnancy

Palpation of the fetal parts.
Evidently audible fetal

heart sounds.
Active movements of the fetus felt by examiner.
Cardiography of the fetus.
The US examination of the fetus, which evidently shows fetal parts, or fertilized ovum in the uterus.
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Laboratory diagnosis - HCG Immunological test of pregnancy - increased Beta-human

Laboratory diagnosis - HCG

Immunological test of pregnancy - increased Beta-human chorionic

gonadotropin level in blood serum and in urine. Detection in maternal serum and urine is evident only after implantation and vascular communication has been established with the decidua by the syncytiotrophoblast 8-10 days after conception.
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hCG levels in weeks from the last normal menstrual period: 3

hCG levels in weeks from the last normal menstrual period:

3 weeks

LMP 5 – 50 mIU/ml
4 weeks LMP 5 – 426 mIU/ml
5 weeks LMP 18 – 7,340 mIU/ml
6 weeks LMP 1,080 – 56,500 mIU/ml
7-8 weeks LMP 7, 650 – 229,000 mIU/ml
9-12 weeks LMP 25,700 – 288,000 mIU/ml
13-16 weeks LMP 13,300 – 254,000 mIU/ml
17-24 weeks LMP 4,060 – 165,400 mIU/ml
25-40 weeks LMP 3,640 – 117,000 mIU/ml
Women who are not pregnant <5.0 mIU/ml
Women after menopause 9.5 mIU/ml
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Laboratory diagnosis - Progesterone Viable intrauterine pregnancy can be diagnosed if

Laboratory diagnosis - Progesterone

Viable intrauterine pregnancy can be diagnosed if the

serum progesterone levels are greater than 25 ng/mL (>79.5 nmol/L).
Conversely, finding serum progesterone levels of less than 5 ng/mL (< 15.9 nmol/L) can aid in the diagnosis of a nonviable pregnancy.
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Pregnancy diagnosis: Sonography Transvaginal ultrasonography (TVUS), and transabdominal ultrasonography (TAUS) are

Pregnancy diagnosis: Sonography

Transvaginal ultrasonography (TVUS), and transabdominal ultrasonography (TAUS) are used

to determine:
the fertiliezed ovum in the uterinbe cavity,
the size of the uterus (term of gestation),
cardiac motion can sometimes be identified in a 2- to 3-mm embryo but is almost always present when the embryo grows to 5 mm or longer. At 5-6 weeks' gestation, the fetal heart rate ranges from 100-115 beats per minute. At 9 week of gestation the heart rate ranges from 140 bpm.
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Laboratory diagnosis - Progesterone Viable intrauterine pregnancy can be diagnosed if

Laboratory diagnosis - Progesterone

Viable intrauterine pregnancy can be diagnosed if the

serum progesterone levels are greater than 25 ng/mL (>79.5 nmol/L).
Conversely, finding serum progesterone levels of less than 5 ng/mL (< 15.9 nmol/L) can aid in the diagnosis of a nonviable pregnancy.
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US exam The yolk sac can be recognized by 4-5 weeks'

US exam

The yolk sac can be recognized by 4-5 weeks' gestation

and is seen until approximately 10 weeks' gestation. The yolk sac is a small sphere with a hypoechoic center and is located within the GS
- Предыдущая
Фёдор Александрович Абрамов 1920-1983
Следующая -
История возникновения спички

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