MATERNAL ADAPTATIONS

TO PREGNANCY

Irene Maria Elena

Departemen Kebidanan dan Kandungan
FK UKRIDA
 UTERUS

HYPERTROPHY AND DILATION

Nonpregnant Term Pregnancy

-almostsolidstructure -volumeofcontents
average5L20L+
-weight70g -500-1000xgreater
capacity
-cavity10ml -weight1100g
-uterineenlargementstretchingand
markedhypertrophyofexistingmuscle
cells
-fibrousandelastictissueincrease
-sizeandnumberofbloodvesselsand
lymphaticsincrease
-uterinewallthinsasgestationprogresses
upto1.5cmattermwithlossof
firmnessandresistance
padapemberianoksitosinuntukmerangsangkontraksi
perlukehati-hatiankarenabisarupturakibattipisnya
dindingrahim.
Tandarupturuteri:ringbundlepatologist(perut
bergelombang)
-uterineenlargementisNOTsymmetrical

greatestatthefundus

- smoothmusclecelllayersarearrangedininterlacing
networkbetweenwhicharethebloodvessels
effectiveconstrictionofbloodvesselspostpartum
- Padapasienhidrosefalusumumnyasungsangkarena
kepalamengisifundusyanglebihbesar.PerluUSG
untukmengetahuiapaperluSCatautidak
 Changes in uterine size, shape and position
-pear-shapedglobular,
sphericalovoid
-becomesanabdominalorganbytheendof
12weeks
-undergoesdextrorotation

Changes in contractility
-Braxton-hickscontractionspainless,irregular,
andbecomesmorefrequenttowardsterm.

Pada 12 minggu, uterus sebesar telur bebek

yang sejajar dengan simfisi pubis
16 minggu,sebesar telur angsa yang terletak
antara dengan umbilikus dengan simfisis
20mgg ke bawah periksa pake
bimanual.kalau20mg> pake centimeter
diukur berapa dari pusat atau dari proc
xiphoid
 Uteroplacental blood flow
-progressivelyincreasesduringpregnancy
(450-650ml/minlateinpregnancy)

Control of Uteroplacental Blood Flow:

Estrogen and Progesterone
-decreasesresistancetobloodflow
Catecholamines (Norepinephrine,
Epinephrine)
-decreasesplacentalperfusiondueto
greatersensitivitytocatecholaminesofthe
uteroplacentalbeds
 Angiotension II
-vascularrefractorinesstopressoreffectsis
anormalpregnancyresponse
-decreaseinrefractorinessislikelyin
womendestinedtodeveloppreeclampsia
Nitric Oxide (Endothelium-derived
relaxing factor EDRF)
-apotentvasodilatorfromendothelialcells
thatinhibitplateletaggregationand
adhesiontovascularendothelialsurfaces
-decreasedinpreeclampticwomen
 Changes in the Cervix
- pronouncedsoftening
andcyanosis
increasein
vascularityandedema;
hypertrophyand
hyperplasiaofthe
cervicalglands.
-proliferationofglands
nearexternalorbeneath
thesratifiedsquamous
epitheliumoftheportio
vaginaliseversion

- Endocervicalcellsproduceamucoidplug,
richinimmunoglobulin&cytokines;actsas
abarrierwithinthecervicalcanalsoonafter
coception
- Attheonsetoflabor,thismucus plugis
expelled,resultinginabloody show.
-cervicalmucus-beadingpattern
(progesteroneeffect)inmajority
ferningpattern(estrogeneffectinsome)
 OVARIES AND
FALLOPIAN TUBES
Corpus luteum pregnancy
-maximumfunctionasat6-7weeksAOG
progesterone
-afterwhichcontributiontoprogesterone
productiondecreases

Relaxin
- aproteinhormonestructurallysimilarto
insulin
- secretedbythecorpusluteumof
pregnancy,placentaanddecidua
parietalis
-roleinpregnancynotessentialfor
pregnancymaintenance
-commercialpreparationsrolein
laborinduction,softeningand
effacementofthecervix

 Pregnancy Luteoma
- asolidovariantumorcausedby
exaggeratedluteinizationreactionofthe
ovaryinanormalpregnancy
- notatrueneoplasmandregressesafter
delivery
- mayrecurinsubsequentdeliveries
- maycausematernalvirilizationbutfemale
fetusisunaffected(placentalconversion
ofandrogens)

 Hyperreactio luteinalis

-anotherbenignlesionoftheovarythat
causesmaternalvirilizationduring
pregnancy
-acystictumor
-commonlyassociatedwithextremelyhigh
levelsofhCG
 Fallopian tubes

-somedecidualcellsdevelopbutno
continuousdecidualmembraneisformed,
-flattenedtubalmucosalepitheliumduring
pregnancy
 VAGINA AND PERINEUM
Increase in the vascularity and hyperemia
with softening in the connective tissue of
the vulva and perineum
- Chadwick sign bluish discoloration of
the vagina hyperemia. Vaginal wall
mucosa thickens, connective tissue loosens,
smooth muscle hypertrophy
may cause increase in length of the
vaginal canal especially in parous women
 Vaginal secretions
- increasesduringpregnancythick,
whitishdischarge
- acidicpH(3.5-6)duetoincreasein
lacticacidproductionfromglycogenin
vaginalepithelium(lactobacillus
acidophilus)
 Vaginal cytology
-twopatternsofresponseseenaspregnancy
progresses:
a.navicularcells
-smallintermediatecellsbecome
abundant
-ovoidcellswithvesicular,elongated
nucleus
b.nakednucleiandabundantlactobacilli
-vesicularnucleiwithoutcytoplasm
Skin
-increasedpigmentation
(neck,face,axilla,perineum)
Abdominalwalls
-lineanigraofpregnancy
-pigmentedskininthemidline
-Striaegravidarum
-characteristicwavy,reddishslightly
depressedstreaks.
-duetorapidandexcessivestretching
oftheskin
-Diastasisrecti
-separationoftherectusmuscles
 Breast
-enlargedduetohypertrophyand
hyperplasiaoftheglandsin
preparationforlactationandincrease
offattytissues.
-colostrummaybeexpressedafterfirst
fewmonthsofpregnancy.
Metabolic Changes
Weight gain
-attributabletotheuterusanditscontents
-thebreasts
-increasesinbloodvolumeand
extravascularextracellularfluid
-smallerfraction-increaseincellularwater
anddepositionofnewfatandprotein
 Analysis of weight gain based on physiological
events during pregnancy
Cumulative Increase in Weight (g) up to:
Tissues
and Fluids 10weeks 20weeks 30weeks 40weeks
Fetus 5 300 1500 3400
Placenta 20 170 430 650
Amnionic 30 350 750 800
fluid
Uterus 140 320 600 970
Breasts 45 180 360 405
Blood 100 600 1300 1450
Extravascular 0 30 80 1480
fluid
Maternal 310 2050 3480 3345
Stores(fat)
Total 650 4000 8500 12,500
 Water Metabolism

- water retained during pregnancy 6.5L

- water that taken up by the fetus, placenta and
amniotic fluid - 3.5L
- increase in plasma volume 1.5L
- increase in the size of the breast and uterus-
1.5L
Pitting edema of the ankles and legs
- increase in venous pressure below the level
of the uterus as a consequence of partial
occlusion of the vena cava.
-decreaseininterstitialcolloidosmotic
pressureinnormalpregnancy

*the amount of water to be mobilized

and excreted after delivery depends on:
-amountretainedduringpregnancy
-amountofbloodlossduringdelivery
-degreeofhydration/dehydrationduring
labor
 Protein Metabolism
- termfetusandplacentaweighs4kg.andcontain
about500gofprotein(50%oftotalincreaseduring
normalpregnancy)
-remaining50%uterus(contractileprotein)
breasts(glands)
maternalblood
(Hgb,plasmaproteins)
- ifcarbohydrateandfatingestionisinsufficient
catabolismofmaternalproteinstoresforenergy
needs
Carbohydrate Metabolism
-pregnancyispotentiallydiabetogenic:
DMmaybeaggravatedofclinicalDMmaybe
manifestsonlyduringpregnancy
-innormalpregnancy:
-mildhypocalcemia
-postprandialhyperglycemia
-hyperinsulinemia
-hyperinsulinemiamaybeduetoeffectsof
progesterone,estrogenandhumanplacental
lactogen
-prolongedhyperglycemia,hyperinsulinemia
(relativeinsulinresistance)andgreater
suppressionensuressustainedpostprandial
supplyofglucosetothefetus
-pregnancy-inducedperipheralresistanceto
insulin:(ensurescontinuousglucosesupply
fortransfertothefetus)
*increaseinsulinresponsetoglucose
*decreaseuptakeofglucose
*suppressedglucagonsresponse
- pregnantwomanrapidlychangesfrom
sustainedglucoseelevationpostprandially
toafastingstate(decreaseplasma,glucose,
aminoacids;increasefreefattyacids,
triglyceridesandcholesterol)pregnancy
includedswitchinfuels(glucosetofuels)
oracceleratedstarvations
Fat Metabolism
- increasedconcentrationsoflipids,
lipoproteinsandapolipoproteins.
-centralfatdeposition/storageoccursprimary
duringmidpregnancyandstoragedecreases
laterinpregnancyasfatalnutritionaldemands
increase.

Mineral Metabolism
-exceptforconsiderableincreased
requirementsforiron,metabolismofmost
mineralsremainessentiallyunchanged
duringpregnancy.
 Acid-Base Equilibrium
HYPERVENTILATIONINPREGNANCY
WOMENrespiratoryalkalosis
decreaseinPCO2decreaseinplasma
bicarbonate(partialcompensation)
minimalincreaseinbloodpHshiftintheO2
dissociationcurveoftheleftincrease
affinityofmaternalhgbforO2(BohrEffect)

offsetbyincreasein2,3diphosphoglycerate
inmaternalRBCsshiftinO2dissociation
curvetotherightfacilitatesO2releasetothe
fetus.
 HEMATOLOGIC
CHANGES
Blood Volume
- near term: average of 45% increase in blood
volume
- degree of blood volume expansion is
considerably variable
- result from:
increase plasma
increase erythrocytes (accelerated
production)
 -moderateerythroidhyperplasiaand
slightincreaseofreticulocytecount
2-3foldincreaseinmaternal
plasmaerythropoietinlevels(after20
wksAOG)
Atrial Natriuretic Peptides
-bioactivepeptidessecretedbyatrial
myocytes
-producessignificantnatriuresisand
diuresis
-increaseinrenalflowandGFRwith
inhibitionanddecreaseinreninsecretion
-bluntscorticotrophin(ACTH)andangiotensin
II-stimulatedreleaseofaldosterone
- directvasorelaxantactiononvascular
smoothmusckes
-maybeinvolvedinpostpartumdiuresis
 Hemoglobin and Hematocrit
-decreasesslightlyslightdecreasein
wholebloodviscosity
-hbg<11g/dLduringpregnancyis
abnormalandduetoiron
definitelynothypervolemia

Iron Metabolism
-totalironrequirement
1000mg;6-7mg/day
300mg-fetusandplacenta-obligatory
- increasedemandsinpregnancymustbe
metbysupplementation
sincedietaryironandstoredironareusually
insufficient
- notallironintheformofhgbaddedto
maternalcirculationislost
~50%islostduringnormaldelivery
(placentalimplantationsite,placenta,
episiotomyandlacerations,lochia)
-bloodloss(NSD)~500-600ml
-bloodloss(twinsorCS)~1000ml

 Immunologic and Leukocyte Function

-decreaseinhumoralantibodies(dueto
hemodilution)
-depressedPMNleukocytechemotaxisand
adherence
-increaseinleukocytecountsof1.4000-
16000ml
ormoreesp.duringlaborandtheearly
puerperium
-increaseinCreactiveprotein
-increaseactivityofleukocytealkaline
phosphatase.
 Blood Coagulation

-increase levels of:

factor I-fibrinogen increase ESR
factor VII - proconvertin
factor VIII - antihemophilic globulin
factor IX - christmas factor , plasma
thromboplastin complement
factor X- stuart factor
factor II- prothrombin only minimal
increase
-decreasedlevelsof:
factorXI-plasmathromboplastin
antecedent
factorXIII-fibrinstabilizingfactor
-moderatedecreaseinplateletconcentration
duetoriseinplateletconsumptionduring
normalpregnancy
CARDIOVASCULAR
SYSTEM
Heart
-restingpulserateincreasesby10-15
beats/min.
-duetoelevationofdiaphragmheartis
displacedtotheleftandupwards,slightly
rotatedaboutitsownaxis

-increaseincardiacsilhoutte
-increaseleftventricularwallmassandend
diastolicdimensions
-increasecalculatedstrokevolumeindirect
proportiontoEDV
-increasecardiacoutputespeciallyinthe
lateralrecumbentposition:
predominantlyduetoincrease
inotropicstate
 EventswhichaffectCO:
decreaseinarterialBPandvascular
resistance
increaseinbloodvolume,maternal
weightand
BMR
Cardiac Sounds in Normal Pregnancy
-exaggeratedsplittingoffirstheartsound
-systolicmurmurin90%
-softdiastolicmurmur,transient,in20%
-continuousmurmurfromincreasebreast
vasculaturein10%

 Vascular Reactivity
ControllingFactors:
a.renin,angiotensionIIandplasma
volume
-increaseinplasmarenin,renin
activity,reninsubstrate,angiotensinII
andaldosterone
-bluntedpressorresponseto
angiotensinIIinfusionfrom
individualvesselrefractoriness
 b.prostaglandins
-potentmediatorsofvascularreactivity
inseveralorgans
-progesterone-relatedsubstancesmaybe
mediatorsofrefractorinessto
angiotensinIIinnormalpregnancy
c.progesterone
-progestininducedmechanismmay modulate
prostaglandin-mediated vascular
responsivenesstopressor effectsof
angiotensin.

 d.cyclicAMP
-theophyllinemayrestorevascular
refractionessbyinhibiting
phosphodiesteraseincreasein
cAMPwithinvascularsmooth
muscles

e.endothelinI
-themostpotentvasoconstrictor
butunknownpreciserolein
pregnancy
 Circulation
-occlusionofpelvicveinsandtheIVCby
graviduterusstagnationofbloodin
thelowerextremitiesincrease
lower extremityvenouspressure
dependentedema/varicoseveins/
hemorrhoids.
 -supinehypotensivesyndrome
compressionofvenoussystemby
graviduterusreductionofvenous
returndecreasecardiacfilling and
outputhypotension
-increasecutaneousbloodflowdissipates
heatfromincreasedmetabolism
RESPIRATORY SYSTEM
AnatomicalChanges

-diaphragmrises4cmandsubcostal
anglewidens
-transversediameterofthoraciccage
increasesby2cm
-thoraciccircumferenceincreasesby6cm
butdoesnotpreventreductionofresidual
volumecausedbydiaphragmelevation
-increaseddiaphragmaticexcursion.
 Pulmonary Function
-increase:tidalvolume,minuteventilatory
volume,minuteO2uptake,airway
conductance
-decrease:functionalresidualcapacityand
residualvolume,totalpulmonary resistance
-constant:maximumbreathingcapacity, vital
capacityandlungcompliance

-Physiologic Dyspnea
-increasedawarenessofdesiretobreath
maybeduetoincreaseintidalvolume
whichcausesslightfallinbloodpO2
-inducedbyprogesteroneandtoalesser
extentestrogen
-diseasesoftherespiratorytractmaybe
moresevereduringpregnancy

 URINARY SYSTEM
Kidneys
-sizeincreasesslightlywithriseinGFR
andRPF
Loss of Nutrients
-greateramountsofvariousaminoacids
andwatersolublevitaminsandother
nutrientsarelostinurine
 Tests of Renal Function
-decreaseinplasmaconcentrationof
creatinineandureaduetoincreaseinGFR
-creatinineclearanceisausefultestto
estimaterenalfunctionduringpregnancy
-urineconcentrationtestsaremisleading.

 Urinalysis
-glucosuriainpregnancyisnotnecessarily

abnormalbutmaybeduetoriseinGFR
andimpairedtubularreabsorption(when
glucosuriaisrecurrenthowever,DMmust
beconsidered)
 -proteinuriaisnotusualinnormal
pregnancyexceptonoccasionduringand
aftervigorouslabororactivity

-hematuriaifnotduetocontamination
duringcollection,signifiesurinarytract
disease;itmaybeduetotraumatolower
urinarytractfromdifficultlaborand
delivery

 Hydronephrosis and hydroureter (w/

ureteral elongation and lateral
displacement)
Causes:
Graviduteruscompressesureters
ureteraldilatationespontheright
(dextrorotationofuterus,leftureteris
cushionedbysigmoid,markedlydilatedright
ovarianveincomplexwhichliesobliquely
overtherightureter.

EffectofProgesterone
 Bladder
-from4thmonthAOG:increasesizeof
uterus,pelvicorganhyperemia,muscle and
connectivetissuehyperplasia
elevationofbladdertrigone/thickening of
posterior,intrauretericmargin/ marked
deepeningandwideningof trigone.

-reducedbladdercapacitywith
compensatoryincreaseinabsoluteand
functionalurethrallength
 -pregnancyordelivery-inducedweakness

ofurethralsphinctermechanismmayhave
aroleinurinarystressincontinence
GASTROINTERSTINAL
TRACT/LIVER/GALL
BLADDER
Stomach and Intestines
-displacedbygraviduterusmayalter
P.E.findingsincertaindiseasestates
e.g.appendix
-delayedgastricemptyingtimeand
intestinaltransittime(hormonaland
mechanicalfactors)
 -pyrosisorheartburnesophagealreflux
fromalteredpositionofstomachanda
decreaseinesophagealsphinctertone
Gums
-hyperemia
-epulisofpregnancylocalizedarea
ofvascularswelling
-estrogeninduced

 Rectum
-hemorrhoidsconstipationandhigh

venouspressurebelowlevelofgravid
uterus
 Liver
-somehepaticfunctiontestresultswill be
affectedduringpregnancyand maybe
misinterpretedashepatic disease:
*totalalkalinephosphatasealmost
doubles
* plasmaalbuminconcentration
decreasesalthoughtotalalbumin
increasesduetogreater
volumeofdistribution

 Gallbladder
-sluggishimpairedcontraction,high residual
volumebilestasis
increasecholesterolsaturationof
pregnancyincreaseprevalenceof
cholesterolstones.
-progesteroneinhibitscholecystokinin
mediatedsmoothmusclestimulation
-estrogeninhibitsintraductal transportofbile
acidscholestasis

 ENDOCRINE SYSTEM
Pituitary gland
-enlarges~135%buthasnoeffects
-nonessentialforpregnancymaintenance

*GrowthHormones
-onlymin.increasefrom10wksand
plateausafter28wksintheserum
-inAF,peaksat14-15wksthenslowly drops
toreachbaselineafter36weeks.

*remainselevatedforsometimepostpartumbut
atalowerlevelthanduringpregnancywhile
placentallactogenrapidlydiminishes
relativelackofthesehormoneslossoftheir
diabetogeniceffectsdecreasesinsulin
requirementsinwomenwithDMduringthe
earlypuerperium
 Prolactin
-increasesmarkedlyinmaternalserum
(10fold)andafterdelivery
-principalfunctionisforlactation:
promotesDNAsynthesisandmitosisof
glandularepithelialcellsand
presecretoryalveolarcellsofthebreast.
-promotesmammaryalveolarcellRNA
synthesis,galactopoiesis,productionof
caseinandlactalbumin,lactoseandlipids

lipotrophin
-givesrisetoylipotrophinand
endorphins-potentendogenousopioidthatis
elevatedinstressfulsituationssuchaslabor
Thyroid Gland
-markedincreaseincirculatinglevelsof
majorthyroxinetransportprotein:thyroid
bindingglobulinduetomarkedincreasein
estrogen

 -excessproductionfromplacentaofseveral
thyroidstimulatinghormones
-decreasedavailabilityofiodidefor
maternalthyroidduetoincreaseinrenal
clearanceandlossestothefetoplacental
unitinlategestation(relativeiodine-
deficiencystate)
-moderateenlargementofthyroidgland
(hyperplasiaandincreasedvascularity)
-hcg:thyrotropin-likeeffects.

 Parathyroid Glands
-hypertrophyandhyperplasia enlargement
andincreasedcellular activity
-parathyroidhormoneinplasma
decreasesduringthefirsttrimesterthen
risesthroughout
-increased:parathryroidhormone,GFR
andfetaltransferofcalciumchronic
suppressionofcalciumconcentrations
inthepregnantwoman
 -estrogenblocksparathyroidhormone
actiononboneresorptioncalcium
supplytothefetus
Adrenals
-littlemorphologicalchangesduring
pregnancybutseveralsecretionsmay
beaffected:
 Cortisol
-circulatingcortisolrisesbutmost are
transcortin-bound
-circulatingACTHisreduced
strikinglybutlevelsofACTH
(corticotrophin)andfree
cortisolrisesaspregnancy
progresses.
Aldosterone, renin and angiotensin II
-increaseespeciallyinthelatterhalfof
pregnancy

Deoxycorticosterone
-increases(maternalextraadrenal
hydroxylationofplasmaprogesterone)
Androstenedione and testosterone
-increasesinmaternalplasmaplacental
conversiontoestrogen
MUSKULOSKELETAL
SYSTEM

- progressivelordosis-shiftincenterof
gravityoverthelowerextremities

-jointsincreasemobilityofsacroiliac,
sacroccygealandpubicjoints
(hormonalchanges)
 EYES
intraoccularpressure
-decreasesduetoincreaseinvitreous
outflow
cornea
-decreaseincornealsensitivity
-slightincreaseincornealthickness
(edema)difficultyinwearingcontact
lensescomfortably

 -Krukenbergspindles-brownishred
opacitiesontheposteriorsurfaceof
thecornea(hormonaleffect)
accomodation
-transientloss
 CATATAN

Mucoid plug agar ga jadi multiple pregnancy.

Tapi kalau ada gen kembar atau sperma kuat
bisa terjadi kehamilan kembar
6-7mgg fs korpus lutheum diganti plasenta.
Pada 6-7mgg ada acute abdomen
kemungkinan itu ruptur korpus
lutheum(sakit+pendarahan endometrium)
Pada pendarahan endomterium, tidak perlu
dibuang seluruhnya, bisa dengan open
wide resection tapi ada resiko abortus
karena kemungkinan placenta belum
mensuport progesteron untuk kehamilan
Pregnancy lutheoma bisa balik lagi pada
kehamilan berikutnya walau tidak ganas.
Ini bisa keluar di ujian.
Bakterial vaginosis membuat vagina menjadi
basa karena bakteri doderlin digantikan
dengan bakteri patologis
Pada kehamilan perlu diet seimbang pada
umumnya kecuali pada DM dan hipertensi
yang perlu diet khusus
Pada anemia def besi kehamilan, pemberian
malam sebelum tidur untuk mengurangi efek
mual dari preparat besi
Kalau obstipasi akibat preparat besi, dianjurkan makan
banyak serat. Obat tidak dianjurkan untuk obstipasi
karena kehamilan
Pada wanita hamil bisa didengar murmur grade 1-2.
kalau 3-4 itu ada kardiomyopathi sehingga perlu dirujuk.
Wanita hamil dengan penyakit jantung ga boleh sakit
karena bisa heart attack
Pada penyakit jantung yang hamil, ketika placenta lepas
maka blood flow akan meningkat sehingga bisa
meninggal juga.
Pada ibu hamil, ada glukosuria bisa
curiga DM walau dia normal juga
biasanya ada sedikit.
Pada ibu yang partus lama, dia bisa
terjadi gangguan buang air kecil sehingga
perlu di toilet training lalu rujuk ke urologi.
Apendisitis pada kehamilan nyeri berada
di agak medial dan keatas.