1.0 Diagnosis of Pregnancy & Physiologic Changes.ppt

Diagnosis of Pregnancy & Physiologic Changes of pregnancy is described in detail here

1. Diagnosis of Pregnancy &
Physiological Changes in Pregnancy
Dr Kenneth Chanda
BScHB, MBChB, MMed (MMOG)-[UNZA]
First version: 18-10-17
Latest version: 18-10-17

2. Diagnosis of Pregnancy
•Duration by Naegle`s rule is 9 calendar
months and 7 days or 280 days or 40 weeks
from LMP (menstrual or gestational age)
•However, fertilization occurs 14 days prior to
the expected missed period and in a normal
cycle of 28/7 it is 14/7after LNMP
•Therefore, the true GA is 280-14 =266/7.This
is called fertilisation or ovulatory age

3. Diagnosis of Pregnancy (Cont’d)
Subjective
•Amenorrhea
•Morning sickness –rarely beyond 12/52
•Frequency of micturition due to
•Pressure of gravid uterus on bladder
•Congestion of bladder mucosa
•Stretching of bladder base due to backward
displacement of the cervix
All these irritate the bladder but stop after 12/40 due to
straightening of uterus

4. Diagnosis of Pregnancy (Cont’d)
Subjective (Cont’d)
•Breast discomfort-feeling full
•Fatigue
Objective signs
•Breast changes –only valuable in primigravida-enlarge
and get engorged. Montgomery`s tubercle are
prominent. Colostrum as early as 12/40
•Per abdomen –remains pelvic until 12/40

5. Diagnosis of Pregnancy (Cont’d)
•Immunological test (Gravindex or pregnancy
test)
–Measures HCG in urine or serum
•Sonography (Ultrasound): detects pregnancy
as early as 5/52

6. Physiological Changes: Definition
•Changes that are a positive adaptation of the
mother to accommodate and support the fetus
as it grows and develops through out the
pregnancy
•Are temporal and produce no permanent
deleterious effect on the mother

7. Physiological Changes:
Introduction
•The anatomical, physiological and biochemical
adaptation to pregnancy are profound
•Most occur in response to physiological stimuli
provided by the fetus
•It is important to know what ‘normal’
parameters of the changes are in order to
diagnose and manage common medical
problems in pregnancy

8. Organ Systems
•Skin
•Breast
•Genital tract
•Cardiovascular system
•Respiratory
•Urinary
•Gastrointestinal tract
•Endocrine

9. Skin Changes
•Chloasma or Melasma gravidarum
•Striae
•Linea nigra
•Angiomas (vascular spiders)
•Palmar Erythma
•Increased pigmentation of breast nipples

10. Skin Changes (Cont’d)
Chloasma or melasma gravidarum
•Also called mask of
pregnancy
•Irregular brownish
patches of varying sizes
that appear on the face
and neck
•Fades a few months
after delivery
•Repeated pregnancy can
intensify them

11. Skin Changes (Cont’d)
Striae Gravidarum
•Stretch marks
•Seen on the skin of the
abdomen, breasts and
sometimes the thighs
•Results from rapid and
excessive stretching of
the skin accompanied
by breaking of
underlying connective
tissue

12. Skin Changes (Cont’d)
Linea Nigra
•Caused my
hyperpigmentation
•Aetiology same for
melasma
•Possibly increased
malanocyte stimulating
effect
•Oestrogen and
progesterone also
implicated

13. Skin Changes (Cont’d)
Angiomas (Vascular spiders)
•Mostly a consequence
of hyperestrogenemia
•Are of no clinical
significance and
disappear shortly after
delivery
•2/3 of whites & 10% of
black women
•Common on neck, face,
upper chest and arms

14. Skin Changes (Cont’d)
Palmar Erythma
•2/3 white & 1/3 black
pregnant women are
prone to experiencing
primary palmar
erythema
•Increased estrogens
may act as the trigger
•May be linked to the
changes in the functions
of the vasculature and
skin

16. Breast Changes (Cont’d)

17. Breast Changes (Cont’d)

18. Genital Changes
Vulva
•Oedematous and hyperemic with viscosities
Vagina
•↑ vascularity → violet color (Chadwick’s sign)
•Vagina with supporting structures becomes
progressively distensible
•Ruggae disappear
•pH is 3.5-6 (Action of Doderlen’s Bacilli)

19. Genital Changes (Cont’d)
Chadwick’s sign

20. Genital Changes (Cont’d)
Cervix
•As early as 1 month after conception the
cervix begins to undergo pronounced
softening (Goodwell’s sign)
•Results from ↑ vasularity and oedema
together with hypertrophy and hyperplasia of
cervical glands
•Endocervical glands produce copious amounts
of mucus that obstruct cervical canal
•Expelled as blood show at onset of labour

21. Genital Changes (Cont’d)
Uterus
•Non pregnant uterus weighs 50g and measures
7.5X5X2.5 with capacity of 4mls
•At term weighs 1000g and measures 28 X24 X
21cm with capacity of 5L
•Enlargement due to hypertrophy stimulated by
oestrogen and probably progesterone
•Uterine musculature arranged in 3 strata; inner
circular, intermediate cris-crossed and outer
longitudinal

22. Genital Changes
Uterus (Cont’d)

23. Genital Changes
Uterus (Cont’d)

24. Genital Changes (Cont’d)
ovaries
•Ovulation ceases and maturation of new
follicles suspended
•Only single corpus luteum of pregnancy can
be identified
•A decidual reaction beneath the surface of the
ovaries occurs
•Diameter of ovarian pedicle increases from
0.9cm to 2.6cm

25. Cardiovascular changes
•Changes first seen at 8 weeks of pregnancy
•Cardiac output increased by 40 % with peak at
30 to 32 wks
•Peripheral resistance decreased
•Resting pulse rate increased by about 10 bpm
•Apex beat moves to the 4
th
intercoastal space
•First heart sound is amplified
•But 2
nd
heart sound remains unchanged

26. Cardiovascular changes(cont’d)
•Systolic murmur in 90 %

27. Haematological changes
•These occur by the 8
th
week
•Blood volume increases by about 40-45% with
maximum at 30 -32wks
•Benefits of increased volume are:
a)Meets the demands of the enlarged uterus
b)Protects mother from effects of impaired
venous return
c)Safe guards against effects of blood loss
d)↓viscosity ensure optimal gaseous exchange

28. Haematological changes (cont’d)
•Plasma volume increases by 40%
•Red cell volume increase by 18-20%
•White cell count varies from 7000 to 15000/uL
•In pueperium the WBC may rise up to 25000
•Platelets fall from an average of 250000 to
213000
•Blood coagulation factors all go up except
factor XI and XIII (Greatest increase in
Fibrinogen

29. Heamatological changes (cont’d)
•Fibrinolytic activity is depressed until 15
minutes after delivery
•Protein C levels remain unchanged
•Resistance to activated protein C increases

30. Respiratory changes
•The diaphragm rises to about 4cm
•Subcoastal angle widens
•Breathing becomes diaphragmatic
•The physiological dead space decreases
•Respiratory rate is slightly changed
•Functional residual capacity decreases

31. Urinary system
•Kidney size increases slightly by about 1cm
•GFR and renal plasma flow increase early in
pregnancy
•24 hrs urine creatinine clearance increases by
40 to 50%
•Glycosuria is not necessarily abnormal

32. Gastrointestinal changes
•Decreased motility due to progesterone
•Increases appetite and thirst from growth of
conceptus
•Late in pregnancy, pressure of a large uterus
reduces capacity for large meals

33. GIT changes (cont’d)
•Gastric emptying time is unchanged except in
labour
•Heartburn is common
•Appendix displaced upwards

34. Metabolic changes
•Average weight gain of about 12.5kg from
Uterus and its contents
Breast increase with fat deposition
Blood volume and extravascular volume
increase
•Woman gains about 6.5L of water
3.5 in featus,placenta and amniotic fluid
3.0 in the mother

35. Metabolic changes (cont’d)
Protein metabolism
•is that of positive nitrogen balance
•Peak values are reached at 28wks
•500g retained by term
•At term featus and placenta weigh 4kg,500g
of which is protein

36. Metabolic changes (cont’d)
Carbohydrate metabolism
• Characterised by mild fasting hypoglycaemia
and post prandial hyperglycaemia
•Increased basal level of plasma insulin
associated with state of peripheral resistance
•Ensure sustained post prandial supply to fetus
•Insulin action is 50-70 % 0f normal health
•Probably due to placental lactogen

37. Metabolic changes (cont’d)
Fat metabolism
•Shows increases in the concentrations of
lipids, liproteins, apoproteins in plasma
•Fat is mainly stored in abdominal wall, back,
thighs and retroperitoneally

38. Endocrine Changes
Pituitary gland
•Enlarges by approximately 135 %
•Changes in vision from compression of optic
chiasma are minimal
•Growth hormone secreted predominantly
from maternal pituitary gland during 1
st

trimester (placenta starts secreting at 8 weeks
•Prolactin levels increase (10 fold by term)

39. Endocrine Changes
Thyroid gland
•3 modifications in regulation of thyroid
Marked increase in circulating levels of major
thyroxine transport proteins
Several thyroid stimulating factors of placental
origin are produced
Decreased availability of iodine for maternal
thyroid

40. Endocrine Changes (Cont’d)
Thyroid gland (Cont’d)
•Thyroxine binding globulin increases early in
pregnancy, peaks at 20wks and stabilises after
•Total T4 ↑btn 6-9wks, plateaus at 18wks
•Rise in T3 pronounced at 18 weeks then
plateaus
•TRH are not increased

41. Endocrine Changes (Cont’d)
Adrenal glands
•Undergoes little or no morphologic change
•Serum cortisol increased but much is bound to
cortisol binding globulin
•Increase is due to lower cortisol clearance
•Aldosterone secretion increased from 16 wks
•This protects against natriurect effects of
progesterone and natrieretic peptide