FOUNDATION OF MIDWIFERY

ANATOMY AND PHYSIOLOGYCAL CHANGES DURING PREGNANCY IN OTHER RELATED SYSTEM

GROUP 1

ANASTASIA WILLIAM ANNIE ANAK JADAM ASBIH BINTI JITAL BIBIANA IVY @ IVY AMIN BOKIAH BINTI JAINAL PUDDIN CHAIRIN OSIIN DAINE CHRISTY LEBA ANAK UJAI DAYANA GEORGE TIMIN

LEARNING OBJECTIVE

At the end of this session, student should be able to

1. Described the gross structure of related system in reproductive system.

2. Described the macroscopic and microscopic of system

3. Explained the function of related system to pregnancy

4. Explain the changes of related system during pregnancy, labour, and puerperium

5. Explained the contribution of the reproductive system

INTRODUCTION

The changes that occur in the pregnant mother’s body are caused by a several factors.

Many of these changes are caused by the growth of the fetus inside the uterus.

CARDIOVASCULAR ( CVS ) CHANGES DURING PREGNANCY

GROSS SRUCTURE CVS

LOCATION

Heart enlarged by chamber dilation

and hyperthropy. Upward

displacement of the diapgram causes

the heart shifted to the left and

upwards..

Displacement diapgram and shifted of the heart during

pregnancy

FUNCTION

1. Meet the increase metabolic demands of the mother and

foetus

2. Promote growth and development of uteroplacenta-foetal unit.

3. Compensated for blood loss at the end of labour.

RELATIONSHP WITH OTHER ORGAN

To promote blood circulation to other organ ( pulmonary and

systemic )

Utero placenta – fetal circulation is supply oxygen and

nutrient to fetus.

BLOOD SUPPLY

Coronary artery is the blood supply to

heart. Its divided to left coronary artery

and right coronary artery.

NERVES SUPPLY

The cardiac nerve are autonomic nerves which supply to the

heart. They are superior cardiac nerve, middle cardiac nerve

and inferior cardiac nerve.

SUPPORT

Supported by thoracic cavity where the diaphgram separating

the thorax from the abdomen.

CHANGES CVS DURING PREGNANCY CHANGES CVS DURING LABOUR

CHANGES CVS DURING PUERPERIUM

Blood volume increase 30-40% at 6 – 8 week

-Cardiac output increase 30 – 50 at first

trimester.

-Blood pressure normal lowering in early

pregnancy and back to normal during term

-Heart rate modest increase

-Anemia due toincrease plasma volume

followed small increase in RBC 20 – 30%

-Varicose vein develop because of enlarged

uterus puts pressure to the inferior vena cava

and pressure to the leg veins

-Aortacaval compression in mid pregnancy

Oxygen consumption increased

-Intravascular volume increased

300 – 500 ml blood from the

contracting uterus to the

venouse system

-Cardiac output increased

during contracting due to

response of cathecolamine

secretion.

-Heart rate increased

-Blood pressure increased

Stroke volume increased

despite blood loss secondary

to increased venouse returned

Cardiac output not changes

after 2 weeks delivery

- Heart rate back to normal

CHANGES IN GASTROINTESTINAL DURING PREGNANCY

GROSS STRUCTURE

FUNCTION

Digestive system is unique and specialized function of turning

food into the energy you need to survive and packaging the

residue for waste disposal.

Changes during pregnancy Changes during labour Changes during puerperium

Mouth-Become highly vascularised, oedematous, have less resistance to infection and easily irritate ( progesterone and oestrogen)-Increase thirsty and appetiteOesophagus-Heartburn and burning sensation affecting 30 -70% - lower tone of the oesophagus spintcer caused impaired and regurgitation of gastric acids.( progesterone and oestrogen)Stomach-Decreased of acid gastric secretion and motility delayed the gastric empty-Delayed chymes increase heartburn and nauseatedIntestine and colon-Constipation due to reduced gastrointestinal muscle tone and motility

-Mendelson’s syndrome

Only during LSCS

-chemical pneumonitis

cased by reflux of acid

gastric

-caused of pressure of

gravid uterus

-progesterone relaxant

smooth and cardiac

muscle

-Increase gas distension due

to relaxed of abdomen

-Haemorrhoid will be more

painful if there is presence of

haemorrhoid and will

disappear within a few

weeks.

BLOOD & NERVES SUPPLY

The organs of the GIT receive arterial blood supply from three arteries: -Coeliac trunk for foregut -Superior mesenteric artery for mid gut -Inferior mesenteric artery for hindgut -The veins drain into the portal vein and from thence to the liver and ultimately inferior

vena cava. -The vagus nerve supplies parasympathetic innervation up to the proximal 2/3rd of the

transverse colon where it hands over to the sacral outflow. Sympathetic innervation is derived from the greater, lesser and least splanchnic nerves (T6-T12). Sensory fibres run with the sympathetic.

RESPIRATORY SYSTEM CHANGES DURING PREGNANCY

GROSS STRUCTURE

FUNCTION

Deliver oxygenated blood and nutrition to the mother

and fetus.

CHANGES DURING PREGNANCY, LABOUR AND PUERPERIUM

ANATOMIC CHANGES

Upper airway

Hyperemia, friability, mucosal oedema, hypersecretion of the airway mucosa.

Nasal obstruction, epistaxis, sneezing episodes and vocal changes may

occur, and worsen when lies down.

Preferential mouth breathing and intolerant of nasal canula delivery of O₂.

CONT….

Lower airway

Mucosal changes occur in larynx and trachea.

Nonspecifec complaints of airway irritinat ( irritant cough or sputum

production)

Estrogen increse tisu hydration and edema,also cause capillary

congestion and hyperplastic and hypersecretory mucous glands.

Subcostal angle 68

Thoracic cage upwards by

5 -7 circumference

Displacement of the ribcage in pregnancy and non pregnancy showing elevated diaphragm, the increase tranverse and circumference, flaring out of ribs and the subcostal angle

Displacement of the ribcage,diaphragm and the heart during pregnancy

CHANGES DURING PREGNANCY CHANGES DURING LABOUR CHANGES DURING PUERPERIUM

- RR ↑ in pregnancy.

- Breath more deeply event at rest.

-Anterior posterior and transverse -diameter ↑ about 2cm resulting in a 5-7 expansion of the chest circumference.

- Progressively increase the subscostal angle from 68ᵒ to 103ᵒ at term.

- Changes mediated by progesterone and relaxin which ↑ ribcage elasticity by relaxing ligaments.

-By 8/52 gestation: Expansion of the ribcage cause the Tidal Volume (TV)↑ by 30-40%.

-Respiratory responses are

greatly affected by stage of labour

and the respond to pain and

anxiety.

- TV ( tidal volume ) range from

350 to 2250ml and minute

ventilations from 7 to 90 L/min

Back to normal

Summary of changes in respiratory function

Blood Gases

Aterial O₂ partial pressure (PₐO₂) is slightly ↑:

Non pregnant (98-100mmHg)

Pregnant (101-104mmHg)

Hyperventilation of pregnancy cause a 15-20% ↓ in martenal arterial Carbon Dioxide

artial Pressure (PₐCO₂) = 35 - 40mmHg → 30mmHg or ↓ in late pregnancy.

ENDOCRINE SYSTEM CHANGES DURING PREGNANCY

The Endocrine system

-the collection of glands of an organism that secrete

hormones directly into the circulatory system to be carried

towards a distant target organ.

- The major endocrine glands in female include the pineal

gland, pituitary gland, pancreas, ovaries, thyroid gland,

parathyroid gland, hypothalamus, and adrenal glands

Figure 1: The endocrine system in non pregnant female

What changes in the Endocrine system during pregnancy?

The major changes in endocrine system during

pregnancy is the placenta where it acting as a

temporary endocrine gland called Endocrine

placenta.

synthesizes a huge and diverse number of hormones

and cytokines that have major influences on ovarian,

uterine, mammary and fetal physiology

Figure 2: The placenta as temporary endocrine gland

placenta

Foetus

Placental hormones

Hormones Changes Roles

1. hCG (human chorionic gonadotrophin)

Peaks: 8-10 weeks and then declines by week 20th remains stable until labour

1. produced by the placental syncytiotrophoblast and cytootrophoblast cells following implantation

2. stimulates the production of oestrogen and progesterone within the ovary

2. diminishes once the placenta is mature enough to take over oestrogen and progesterone production.

- rescue the corpus luteum from involution so that it can continue to produce progesterone to maintain the decidua

Table 1: hCG hormones and its contribution

Placental hormones

hormones changes Role

2. Progesterone

Peaks :increases around 8-10 weeks

- produced by the corpus luteum during the first 9 weeks of pregnancy before shift to placenta

# decreases or disruption of the progesterone production promotes the cervical re-modelling and initiates labour (Mesiano at el 2011)

1. promotes decidualization 2. prevent menstruation and rejection of the

trophoblast3. inhibits smooth muscles contractility4. maintains myometrial quiescent5. prevent onset of uterine contraction (Feldt-

Rasmussen and Mathiessen 2011)

Table 2: Progesterone hormones and its contribution

Placental hormones

hormones Changes Roles

3. Oestrogen -- Primarily produced by the corpus luteum and follicles

- 3-8 times higher during pregnancy , it is within 6-7 weeksWhere the secretion had taken over by the placenta.

- increases uterine blood flow

– facilitates the placental oxygenation and nutrition to fetus

– prepares the breast for lactation

– simulates the production of hormone-binding globulin in liver ( Myatt and Powell 2010)

- During last trimester, increasing the excitability of the myometrium and prostaglandins synsthesis.

Table 3: Oestrogen hormones and its contribution

Placental hormones

hormones changes Role

4. Human

placental

Lactogen (hPL)

--Produced by the

syncytiotrophoblast

- increases up to 30

folds throughout

pregnancy

1. regulated the maternal carbohydrate, lipid, protein

metabolism and fetal growth.

2. promote the growth of the breast tissues in

preparation for lactation (Braun at el 2013)

3. It can also decrease maternal tissue sensitivity to

insulin, resulting in gestational diabetes

Table 4: hPL hormones and its contribution

Placental hormones

hormones Changes Roles

5. Relaxin -produced by corpus luteum in both pregnant and non pregnant female

-levels rise during 1st trimester and additional relaxin is produced by the decidua.

- peak is reached during the 14 weeks and at delivery

1. increased cardiac output2. increased renal blood flow3. and increased arterial compliance.4. It also relaxes other pelvic ligaments. It is believed to

soften the pubic symphysis.

Table 5 : Relaxin hormones and it contribution

Figure 3 : schematic level of progesterone, oestrogen and HCG throughout the pregnancy

Other Endocrine changesTHE PITUITARY GLANDThe pituitary gland are increasing in size 2- 3 folds from it normal size during pregnancy

Figure 4: The pituitary gland is a pea-sized structure located at the base of the brain, just below the hypothalamus and attached to it by nerve fibers

Pituitary Glands hormonesAnterior Pituitary

- Prolactin Hormone

Changes:

- hypertrophy and hyperplasia of the lactotrophs ( prolactin secreting cells) by the anterior lobe of the

pituitary gland under the influence of oestrogen hormone as a result prolactin level increases- by term, the levels are about 10 times in preparation of milk production

Roles:

1. prepares the mother’s breasts for lactation and also aids in the final stages of lung maturation for the

baby

2. infant sucking at the breast can cause the prolactin secrection released

Table 6 : prolactin hormones and it contribution

Pituitary Glands hormonesPosterior pituitary- Oxytocin hormoneChanges: - Low throughout pregnancy but increase in labour (Feldt-Rasmussen and Mathiessen 2011)Roles: 1. act on the myometrium to increase the length, strength and frequency of contraction during

labour2. keeping the uterine contractions going continues after the baby is born and begin to shrink

the uterus back to its original size3. the high levels of oxytocin in both mother and baby at this time promote affection,

attachment and a desire in the mother to protect and guard the baby4. promotes the let-down reflex, too, which enables the breasts to produce milk

Table 7 : oxytocin hormones and it contribution

Other Endocrine changes

Thyroid Gland Changes in size:

moderately enlarged during pregnancy due to hormone-induced glandular hyperplasia and increased vascularity.

Fetal thyroxine wholly obtained from maternal sources in early pregnancy since the fetal thyroid gland only becomes functional in the 2nd trimester of gestation.

Figure 5: showing situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath

Thyroid Gland Hormones

hormones changes Roles

(TBG) Thyroxine binding globulin

- rise almost 2-3 folds because estrogen increases TBG production

1. required for metabolic changes as well as transfer the thyroxine to fetal brain cells for normal brain development

2. Maintaining it supply for both mother and fetal requirement

thyroxine (T4) and triiodothyronine (T3)

- levels rise from about 6–12 weeks and plateauing at approximately 20 weeks of gestation

Parathyroid hormone Parathyroid gland Increase in size slightly

1. To meet up the increases of the requirement for the calcium needed in fetal growth

Thyroid Hormones

Figure 6: Changes in thyroid function indices throughout gestation. The shaded area represents the normal range of the TBG, total T4, TSH, free T4 and hCG.

Leve

l con

cent

ratio

n

Weeks of gestation

Adrenal gland

Figure 6: The adrenal glands are located bilaterally in the retroperitoneum superior and slightly medial to the kidneys

•the outer cortex is under the control of ACTH from the anterior pituitary. It secretes steroid hormones (corticosteroids).

•the inner medulla is controlled by the sympathetic nervous system. It secretes adrenaline.

Changes during Pregnancy Size: does not cause much change in the size of the adrenal glands

Hormone Changes RolesCortisol or glucocorticoid

Marked increase 1. particularly helpful in times of long and short term stress.

2. have anti-insulin, anti-inflammatory, and anti-allergic actions

3. needed to make the precursors of adrenaline, which the inner medulla will produce and secrete

Aldosterone increased amounts by the adrenal glands as early as 15 weeks of pregnancy

1. regulates absorption of sodium from the distal tubules of the kidney

CONCLUSION

This system plays an important role in growth and development of the

foetus in pregnancy. It is important for the midwives trained staff to know

the changes during pregnancy and to deliver good care and reduces

complication.

Reference

Jayne Marshall, Maureen Raynor ( 2014 ) Myles Textbook for Midwives sixteen edition, Churcill Livingstone

Jane Coad, Melvyn Dunstall ( 2007 ) Anatomy and Physiology for Midwives second edition, Churcill Livingstone

Janet Medforth et.al ( 2010 ) Oxford Handbook of Midwives South Asian Eition, oxford

Quick Doctor, physiological changes of pregnancy. Retrieved from www.doctor.com/docs/476537/physiologic_changes_of_pregnancy.

Elizabeth Eden ,MD understanding pregnancy symptoms. Retrieved from

http:www.pregnancy_and_parenting/pregnancy/issue/understanding_pregnancy_symptoms.

Mother & child glossary ( 2002 ) Health on The Net Foundation. Retrieved from www.hon.ch/Dossier/motherchild/preg_changes/circulation.html

Mother& child glossary ( 2002 ) Health on The Net foundation. Retrieved from www.hon.ch/Dossier/motherchild/preg_changes/lungs.html.

Alexandra house, Oldham terrace ( 2013 ) The UK’s for parents. Hormone in pregnancy. Retrived at http://www.nct.org.uk/birth/hormones-labour.