(Williams) CHAPTER 4: Maternal Physiology

REPRODUCTIVE TRACT
UTERUS
 Uterine Hypertrophy – d/t Estrogen and Progesterone, less of Position of the placenta;
predominantly in the FUNDUS.
 Uterine wall – formed most by the MIDDLE Layer
 Piriform/pear-shaped  more Globular/Spherical (by 12 weeks)
 Displaces abdomen LATERALLY & SUPERIORLY (Mc: Dextrorotation)
 2nd Trimester – detected by BiManual Exam
 Braxton Hicks – unpredictable, sporadic, nonrhythmic (5-25 mmHg)
 Placental perfusion = Total Urine Blood flow
o Androstenedione & Xenon-133
 450-650 mL/min (term)
 Reduced ELASTIN & ADRENERGIC NERVE DENSITY  increased Venous Caliber/distensibility
 Increased Maternal-placental blood flow – VASODILATION (d/t ESTROGEN) & REDUCED
VASCLUAR RESISTANCE (d/t NITRIC OXIDE, ESTRADIOL, PRORGESTERONE, RELAXIN)
o Arterial Diameter – x2 by 20 weeks
o Increased Nitric Oxide production – d/t Estrogen, PlGF, VEGF
o soluble FMS-like tyrosine kinase 1 (sFlt-1) INC – inactivate/decrease PlGF & VEGF –
Preeclampsia
 Uterine blood flow & placental perfusion decline with NICOTINE and CATECHOLAMINE

CERVIX
 1st month – softening (edema) & cyanosis (increased vascularity
 Connective Tissue – major component
 Remodeling: Decreased Collagen and Proteoglycans; Increased water content (Estrogen &
Progesterone Metabolism
 EXTENSION/EVERSION – normal in pregnancy (d/t proliferating endocervical glands)
 Mucus: rich in Immunoglobulins and Cytokines (effective against infections)
 Mucus plug expelled = “Bloody Show”
 Most pregnants: PROGESTERONE – poor crystallization/beading
 Some pregnants: AMNIOTIC FLUID LEAKAGE – arborization of crystals/ferning
 Arias-Stella Reaction – endocervical gland hyperplasia and hypersecretory appearance
 APICAL PROLAPSE: If uterus persists in Prolapsed position  Incarceration (10-14 weeks)

Ovaries
 Corpus luteum: Maximally – first 6-7 weeks pregnancy; 4-5 weeks postovulation
 Excision and Bil. Oophorectomy at 16 weeks – does not cause abortion/pregnancy loss
 Decidual reaction – observed at CS delivery; resemble freshly torn adhesions
o Rise from subcoelomic mesenchyme
o Due to PROGESTERONE stimulation
 Increased Ovarian vein diameter during pregnancy

Relaxin
 Secreted by CORPUS LUTEUM
 Key role in maternal physiological adaptations
  Augmented renal hemodynamics, decreased serum osmolality, and increased uterine artery
compliance

Theca-Lutein Cysts
 Benign
 Due to exaggerated physiological follicle stimulation (Hyperreactio luteinalis)

Fallopian Tubes
 Little hypertrophy during pregnancy
 Epithelium flattens

Vagina and Perineum

 Bartholin gland duct cysts (1cm)
 Chadwick sign – bluish color of vagina d/t INCREASED VASCULARITY
 Increase in Mucosal Thickness, Loosening of the connective tissue, and smooth muscle
hypertrophy.
 Hobnailed appearance – due to papillae of Vaginal hypertrophy; absence = vaginal wall prolapse
 Secretions: Thick, white discharge, acidic; due to Increased prod. of LACTIC ACID thru
Lactobacillus acidophilus.
 10-20x risk for Candidiasis

BREASTS
 Colostrum – thick, yellowish fluid thru gentle massage
 Glands of Montgomery – hypertrophic sebaceous glands; small elevations around areola
 Gigantomastia – pathological; requires postpartum surgery

SKIN
 Striae gravidarum/stretch marks – reddish striae
 diastasis recti - rectus muscles separate in the midline
 Linea alba – midline dark brown-black pigmentation to form Linea nigra
 Chloasma/melasma gravidarum – mask of pregnancy
 ESTROGEN and PROGESTERONE – have melanocyte-stimulating effect
 NEVUS/ANGIOMA/TELANGIECTASIS – minute, red skin elevations with radicles branching out
from a central lesion.
 Hyperestrogenemia – Palmar erythema and Angioma

METABOLIC CHANGES
 Total Pregnancy Energy demand – 77,000 kcal
o 1st Tri: 85 kcal/day
o 2nd Tri: 285 kcal/day
o 3rd Tri: 475 kcal/day

Weight Gain
 Uterus
 Breasts
 Maternal Reserves:
o Water, Fat, Protein
Water Metabolism
 Inc water retention
 3.5 L (fetus, placenta, and amniotic fluid)
 + 3.0 L (maternal BV, Uterus, Breasts)
 Total Ave: 6.5 L
 Pitting Edema Ankles and Legs
 Increased venous pressure through partial VENA CAVA OCCLUSION

Protein Metabolism
 AA higher in FETAL
o Regulated by PLACENTA

Carbo Metabolism
 Mild Fasting HYPOGLYCEMIA
 Postprandial HYPERGLYCEMIA
 HYPERINSULINEMIA
 Accelerated starvation – switch fuels from GLUCOSE to LIPIDS

Fat Metab
 HYPERLIPIDEMIA:
o Inc insulin resistance
o Estrogen

LEPTIN
 Produced significantly by the PLACENTA
 Together with ADENOPECTIN – energy homeostasis and lipid metabolism
 Asso with Preeclampsia and Gestational Diabetes

Electrolyte & Mineral Metab

 Increased Filtration of Na & K, retained:
o 1000 mEq – Na
o 300 mEq – K
 Ca & Mg declines
 Phosphate – within non pregnant level
 T4 increases
_______________________________________________
HEMATOLOGIC

BLOOD VOLUME
1. Meets metabolic demands
2. Provides nutrients to the fetus
3. Safeguards mothers against parturition-asso blood loss
HYPERVOLEMIA: 40 – 45%
Expands RAPIDLY – during 2nd TM
 Increased in:
o Plasma (more)
o Erythrocytes (inc. of 450 mL) – peaks at 3rd TM
 Hgb and Hct Decreases
o Hgb levels:
o 12.5 g/dL
o <11.0 g/dL – abnormal (d/t IDA)