Anatomy and Physiology of Pregnancy

1. Anatomy and Physiology of Pregnancy Lecture IrynaKuziv, MD, PhD Pregnancy is a normal physiologic process . . . . . . not a disease!

2. Probable signs of pregnancy (observedby examiner): • Bluish or purplish coloration of the vaginal mucosa and cervix (Chadwick’s sign-a dark blue to purplish-red congested appearance of the vaginal mucosa ) • Palpation of Braxton-Hicks contractions • Outlining the fetus manually • Endocrine tests of pregnancy

3. Positive signs of pregnancy(noted by examiner, confirm pregnancy) • Identification of the fetal heart beat separately and distinctly from that of the mother (10-12 w) • Perception of fetal movements by the examiner (18-20 w) • Visualization of pregnancy on ultrasound • Fetal recognition on X-ray

4. Uterus

5. Mechanism Of Uterine Enlargement Considerable increase in elastic tissue Stretching & marked hypertrophy of muscle cells. Accumulation of fibrous tissue, particularly in the external muscle layer.

6. Uterine size, shape & position • First few weeks, original peer shaped organ • As pregnancy advances, corpus & fundus assumes a more globular form. • By 12 weeks, the uterus becomes almost spherical . • Subsequently, uterus increases rapidly in length than in width & assumes an ovoid shape. • With ascent of uterus from pelvis, it usually undergoes Dextrorotation (caused by the rectosigmoid colon on the left side)

7. Breast changes

8. Breast • Breast: tenderness, fullness, tingling enlargement, nipple and areola hyperpigmentation, Montgomery’s tubercles, colostrum (16 w)

9. Integumentary System • Darcening of nipples, areola, axillae, vulva • Facial melasma=chloasma • Linea Nigra • Striae gravidarum • Palmar erythema (Caucasian, African-American)

10. Striagravidarum

11. Butterfly pigmentation

12. Pigmentation: It is due to suprarenal changes, it usually begins to appear after the 4th month. The pigmentation may appear anywhere but the commonest sites are: 1. Linea nigra: which is a line of pigmentation between the umbilicus and the symphysis pubis. 2. Increased pigmentation of the nipple as primary areola and appearance of the secondary areola.

13. Vascular • Vascular spider Minute, red elevations on the skin common on the face, neck, upper chest, and arms, with radicles branching out from a central lesion. The condition is often designated as nevus, angioma, or telangiectasia. • Palmar erythema . The two conditions are of no clinical significance and disappear in most women shortly after pregnancy (estrogen)

14. Musculoskeletal System • Change in posture • Waddling walk • Back Pain • Slight relaxation and increased mobility of the pelvic joints • Diastasis recti abdominis

15. Uterine Sizing • Uterine enlargement • 12 weeks – At Symphysis • 16 weeks – Midway between symphysis and umbilicus • 20 weeks – At the umbilicus • 36 weeks - Near xyphoid process

16. Uterine Sizing

17. Accuracy of Dating by Ultrasound

18. Medical/Surgical History • Serious illnesses • Hospitalizations • Surgery • Drug allergies or unusual reactions • Meds since LMP

19. Family History • Maternal • Diabetes • CAD • Pre-eclampsia • Preterm delivery • Cancers (breast, ovarian, colon) • Depression, bipolarity • Twins • Anesthesia reactions • Maternal or Paternal • Birth defects • Mental retardation • Bleeding disorders • Chromosomal abnormalities (e.g. Down Syndrome)

20. Vital Signs • Temperature • Blood pressure • Respirations • Radial pulse • Elevated BP suggeststhepresenceofpreeclampsia. • Elevated BP maybedefinedas a persistentlygreaterthan 140 systolicor 90 diastolic. Usually, ifoneiselevated, bothareelevated. • Elevatedtemperaturesuggeststhepossiblepresenceofinfection. • Manypregnantwomennormallyhaveoraltemperaturesofasmuchas 99+. Thesemildelevationscanalsobeanearlysignofinfection. • While a pregnantpulseofupto 100 BPM orgreatermaybenormal, rapidpulsemayalsoindicatehypovolemia.

21. Additional Measurements • Height • Weight • BMI (Body mass index ) • BMI Categories: • Underweight = <18.5 • Normal weight = 18.5-24.9 • Overweight = 25-29.9 • Obesity = BMI of 30 or greater

22. Bones and Joints of the Pelvis

23. The Diagonal Conjugate • The obstetric conjugate extends from the middle of the sacral promontory to the posterior superior margin of the pubic symphysis. This is the most important diameter of the pelvic inlet. • The diagonal conjugate extends from the subpubic angle to the middle of the sacral promontory and can be measured clinically to estimate the obstetric conjugate.

24. The Ischial Spines • The transverse diameter, between the ischial spines, is a measurement of the dimensions of the pelvic cavity

25. The Pelvic Outlet • Subpubic arch • Bituberous (transverse) diameter • Inferior pubic rami

26. The First Prenatal Visit: Counseling • What to expect during the course of prenatal care • Risk factors encountered • Nutrition • Exercise • Work • Sexual activity • Travel, seat belts • Smoking cessation • Avoidance of drugs and alcohol • Warning signs • Where to go or call in case of problems • Prenatal vitamins

27. Leopold's Maneuvers - are used to determine the orientation of the fetus through abdominal palpation. • 1. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). • .

28. 2. The sides of the uterus are palpated to determine the position of the fetal back and small parts.

29. 3. The presenting part (head or butt) is palpated above the symphysis and degree of engagement determined

30. 4. Thefetaloccipitalprominenceisdetermined.

31. Measuring Fundal Height

32. Auscultating Fetal Heart Tones