Female Reproductive system

Adaptations to pregnancy, Physiology of Parturition and Lactation

Learning objectives To discuss ~

Physiological adaptations of Cardiovascular, respiratory, renal and gastrointestinal during the course of normal pregnancy Uterine changes during pregnancy Physiology of Parturition Physiology of lactation including Role of hormones in functioning of mammary glands

Learning Outcomes
At the end of the lecture student should be able to;

Describe physiological adaptations during the course of normal pregnancy Describe the cardiovascular, respiratory, renal and gastrointestinal changes during normal pregnancy Describe the uterine changes during pregnancy Describe the physiology of Parturition Describe the role of hormones in functioning of mammary glands Describe the physiology of lactation

MATERNAL CHANGES IN PREGNANCY

MATERNAL CHANGES DURING PREGNANCY

Weight Gain

About 24 lb increase in weight especially during last two trimesters Weight gain attributes to
7 pounds is fetus 4 pounds is amniotic fluid, placenta, and fetal membranes. 2 pounds due to increase in the uterus 2 pounds due to increase in breasts 6 pounds of this is extra fluid in the blood and extracellular fluid 3 pounds is generally fat accumulation.

Increased desire for food during pregnancy partly as a result of removal of food substrates from the mothers blood by the fetus. partly because of hormonal factors

Mothers weight gain can be as great as 75 pounds instead of the usual 24 pounds

Increase Basal Metabolic Rate

During the latter half of pregnancy. 15 per cent Increase in BMR consequent to: Increased secretion of many hormones such as thyroxine, adrenocortical hormones, and the sex hormones, Frequent sensation of becoming over-heated, owing expenditure of more energy for muscle activity for carrying extra load that she is carrying, greater amounts of energy than normal.

Increased absorption of Nutrients

Mother stores sufficient protein, calcium, phosphates, and iron from her diet in advance in placenta as well as in normal store depots to meet the anticipated extra requirement of these nutrients for greatest growth of the fetus occurs during the last trimester of pregnancy.

Maternal deficiencies of calcium, phosphates, iron, and the vitamins can occur during pregnancy if appropriate care to provide additional nutritional elements are not present in a pregnant womans diet.

Increased absorption of Nutrients

Iron requirement during pregnancy is about 975 mg against normal store of 100 mg, maximum reaches upto 700 mg. Iron requirement is met by : by the fetus (375 mg) by the mother (600 mg) form her own extra blood. Hence iron supplements must during pregnancy. Increase demand for vitamin D, for calcium absorption (normally poorly absorbed by the mothers gastrointestinal tract without vitamin D). Supplementation with vitamin K to the mothers diet to provide sufficient prothrombin to prevent hemorrhage, particularly brain hemorrhage, caused by the birth process.

Mammary Glands

Breasts grow larger, Skin appears thinner, Diameter of the areola increases, Veins become more prominent. As the nipples become more erect, Pigmentation of the areola increases and the mammary glands enlarge.

Cardiovascular Adaptations
30 to 40 per cent increase in cardiac output above normal at end of II Trimester and beginning of third trimester, falls to little above normal during the last 8 weeks of pregnancy. Blood Pressure also varies. Systolic remains same There is fall in diastolic pressure Vasodilation (Kinin,Nitric oxide,EDF)

Blood Volume During Pregnancy

1 to 2 liters of extra blood in circulatory system of mother at the time of birth of the baby . 30 per cent increase in Maternal blood volume shortly before term, Partly due to
Increased in aldosterone and estrogens during pregnancy, Increased fluid retention by the kidneys. Increase activity of bone marrow to produce extra red blood cells to go with the excess fluid volume. Only about one fourth of this amount is normally lost through bleeding during delivery of the baby,

Respiration During Pregnancy

Consumption of oxygen increases Because of

Increased basal metabolic rate of a pregnant woman greater size , the total amount of oxygen used by the mother is about 20 per cent above normal, and a commensurate amount of carbon dioxide is formed.

Increase minute ventilation of mother ~ believed that the high levels of progesterone increases the respiratory centers sensitivity to carbon dioxide Respiratory rate increased to maintain the extra ventilation due to pressure exerted by the growing uterus against the abdominal contents, press upward against the diaphragm.

Maternal Urinary System

About 6 pounds of extra water and salt accumulates during pregnancy Rate of urine formation increased because of increased fluid intake and increased load or excretory products. Increased reabsorptive capacity of renal tubules for sodium, chloride, and water 50 per cent consequent of increased production of steroid hormones by the placenta and adrenal cortex. Increased GFR as much as 50 per cent Increase the rate of water and electrolyte excretion in the urine due to increase GFR.

Amniotic Fluid

It is the fluid inside fluid present in uterus in which the fetus floats Normal volume is between 0.5 -1 L, increased few ml to several L Increased turnover of the amniotic fluid due to additional formation and absorption through the amniotic membranes

Changes in the gastrointestinal system

Increases absorption of nutrients and water Increase chances for constipation due to decrease intestinal mobility. Decrease Peristalsis together with tone and mobility because of the production of the progesterone Slows the rate of secretion of hydrochloric acid and pepsin. Increase nausea and heartburn (pyrosis) due to reduced gastric emptying. Relaxation of the cardiac sphincter may increase regurgitation and chance for heartburn. Growth of uterus pushes the abdominal Organs such as Stomach , intestines, and other adjacent organs

Changes in endocrine system activity

Increases secretion of Parathyroid Gland to meets the increased requirements for calcium needed for fetal growth. Large amounts of estrogen and progesterone secretion by placenta by 10 to 12 weeks of pregnancy. It serves to
Maintain the growth of the uterus, helps to control uterine activity,

Cause many of the maternal changes in the body.

Changes of the skeletal system

Realignment of the spinal curvatures during pregnancy to maintain balance due to the increase in size of the uterus and pressure on the abdominal wall
Slight relaxation and increased mobility of the pelvic joints, which allows stretching at the time of delivery of the infant. "waddling" gait ; walks with head and shoulders thrust backward and chest protruding outward to compensate.

Uterine Changes

Uterus gains weight from 50g to 1000g Increases in width and length approximately five times its normal size. Uterus rises above the symphysis pubis by the 12th week, reach the xiphoid process by the 36th week of pregnancy Abdominal Changes corresponding to changes that occur in the uterus. Increase in connective tissue and elastic tissue.

Physiology of Parturition

Parturition:

Duration of pregnancy is 280 days or 40 weeks from the first day of last menstrual period. Defined as act or process of giving birth;

Labor

Physiologic process~ refers to expulsion of products of conception (i.e. the fetus, membranes, umbilical cord, and placenta) by the uterus.

Parturition

Sudden change of slow, weak rhythmicity of uterus transform in to strong tonic contraction~ positive feedback theory Labor contractions follow principles of positive feedback Two types of positive feedback:
Stretching of cervix Release of Oxytocin

Parturition
Progressive hormonal changes Uterine Excitability Mechanical changes

Uterine Contractions

Highly excited and contractile Uterus with progress in pregnancy at term Expulsion of Child giving birth

Hormonal Factors of Parturition E/P Ratio increases

Hormonal Secretions from fetal glands

Increased Secretion of Oxytocin

Mechanical Factors of Parturition

Stretch of uterine musculature Myogenic transmission of signals from cervix to uterine wall

Gradual increase and frequent fetal movement in uterus

Stretch & irritation of cervix ~ rupture of membrane

Positive feedback theory

Uterine contractions

Stretch of cervix and distention of vagina

Afferents from cervix and vagina

positive feedback to the hypothalmus

Oxytocin from posterior pituitary Formation of Prostaglandins in the decidua

Parturition

STAGES: 1. DIALATATION OF CERVIX 2. EXPULSION OF FETUS 3.EXPULSION OF PLACENTA

Parturition has not yet begun

Dilatation of Cervix; 1st Stage

10-12 hrs in primigravidas, 6-8 hrs in multigravidas Retraction of lower uterus & cervix, so a continuous birth canal formed Head of fetus pressing cervix initiation of neuroendocrine reflex

The cervix is dilating

Expulsion:

nd 2

stage

Last for 40 min in primi and 15-30 min in multi Once full dilatation achieved Fetal membrane ruptures Fetus head move suddenly to birth canal and move continuously till delivery effected.

The cervix is completely dilated, and the fetuss head is entering the cervical canal; the amniotic sac has ruptured and the amniotic fluid escapes.

The fetus is moving through the vagina.

Separation & Expulsion of placenta

15-30 Min Further continued uterine contractions~ size decreases gradually. Separation of placenta from uterine layer associated. Uterus involutes after 4 to 5 wks weight decreases and attain normal size.

The placenta is coming loose from the uterine wall preparatory to its expulsion.

MECHANISM

1.PRESSURE ON CERVIX BY FETAL HEAD 2. DIALATATION OF CERVIX & STRECHING OF NERVE ENDINGS 3. OXYTOCIN & PROSTAGLANDINS 4.STRONG CONTRACTIONS OF UTERUS 5. FURTHER INCREASE IN WIDTH OF CERVIX & SHORTENING OF ENDOCERVICAL CANAL 6. HEAD GOES FURTHER DOWN 7. POSITIVE FEED BACK SET IN

Two types of positive feedback mechanisms increase uterine contractions during labor: of the cervix causes the entire

1. Stretching

body of the uterus to contract

2. Cervical

stretching also causes the pituitary

gland to secrete oxytocin

Physiology of Lactation

Physiology of Lactation
Divided into three phases Mammogenesis (the growth of the mammary glands) Lactogenesis (the initiation of milk production), Galactopoiesis (the maintenance of the milk supply).

Mammogenesis

Mammary gland development during childhood is limited to general growth.

Mammary gland development begins during the 78 week of gestation when primary and secondary ducts develop. At puberty, estrogen exerts major influence on breast growth in a girl, when primary and secondary ducts grow. Complete development of mammary function occurs only in pregnancy.

Hormonal Effects

Breast growth continue to occur during each menstrual cycle in response to the changes in hormones. Several hormones control breast development during pregnancy;
estrogen, progesterone, Adrenocorticotropic hormone (ACTH), prolactin, and growth hormone.

Estrogen causes the ductal system to proliferate and differentiate, Progesterone promotes an increase in the size of the lobes, lobules, and alveoli. ACTH and growth hormone combine with prolactin and progesterone to promote mammary growth.

Lactogenesis

Lactogenesis is the onset of milk secretion. During the second half of pregnancy, secretory activity accelerates and colostrum is produced.

Comprises of two phase: Stage I: capacity of the breast to secrete milk during later pregnancy Stage II; onset of copious milk secretion occurs after birth (days two or three to eight postpartum)

Hormonal control

Lactogenesis is triggered by a fall in progesterone and estrogen levels and continued presence of prolactin. Decrease progesterone and estrogen levels Causes~ Releases very large amounts of prolactin. Prolactin levels rise and fall in proportion to the frequency, intensity, and duration of nipple stimulation and the suckling stimulus.

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Milk Ejection Reflex

The milk ejection reflex (MER), causes the alveoli to release the milk. Suckling of the nipple of breast ~ stimulates the nipple~ signals sent up the nerve pathways to the paraventricular and supraoptic nuclei in the hypothalamus causing the production of oxytocin. Oxytocin released from the posterior pituitary gland. and causes the muscles around the alveoli (myoepithelia) to contract and push the stored milk down the ducts through the collecting sinuses and out the nipple pores. The MER has a strong psychological base. Emotional upsets, stress, embarrassment, severe cold, certain drugs, anxiety, pain, discomfort, excessive nicotine, caffeine, or alcohol intake, or inadequate rest may inhibit the MER.

Ejection of Milk: Oxytocin

Milk

let down reflex or Suckling reflex Neuroendocrine reflex

spinal cord

Suckling of breast

Afferent conduction of APs

Contraction of the myoepithelial cells Oxytocin secretion hypothalamus

Ejection of milk

Increase [milk] in the alveoli of the breast

Prolactin secretion

Galactopoiesis

Galactopoiesis, or the maintenance of a milk supply, requires removal of milk from the breast. It is the quantity and quality of infant suckling or milk removals that controls breast milk synthesis. Milk production reflects the infants appetite rather than the womans ability to produce milk. As long as milk is regularly removed, the alveolar cells will continue to secrete milk. This phenomenon, called the supply-demand response, is a feedback control that regulates the production of milk to match the infant of the infant.

Effect of Estrogen on the Breast

Causes: Development of stromal tissue Growth of an extensive ductal system Deposition of fat in the breasts Inhibits the actual secretion of milk Development of alveoli and lobules brought about by estrogens is slight. Progesterone and prolactin causes the determinative growth and function of these structures. Therefore, estrogens initiate growth and is responsible for the characteristic external appearance of the mature female breast, but they do not complete the job of converting the breasts into milk producing organs.

Effect of Progesterone on the Breast

Promotes development of lobules and alveoli Causes alveolar cells to proliferate, enlarge and become secretory in nature Does not cause alveoli to secrete milk (actually inhibits the secretion of milk), milk is secreted only after the prepared breast is further stimulated by prolactin.

Effect of Prolactin 1. Major function of prolactin is milk production oxytocin stimulates ejection 2.Release is inhibited by PIH (dopamine) 3.Suckling response inhibits PIH release