Diagnosis of pregnancy and physiologic change during(1)

Engidaw Ambelu

1. Diagnosis Of pregnancy and Physiologic Change during Pregnancy Ashete (MD) April 2018

2. Presentation Outline Definition of pregnancy How to diagnosis pregnancy Differential diagnosis of pregnancy Effect of pregnancy on specific organs(local) Effect of pregnancy on systems (Systemic)

3. Definition …….. Pregnancy ; is the maternal condition of having a developing fetus in maternal body. This is during reproductive period of women which is between menarche to menopause, usually 13-45 years of age. Gestational age Vs fertilization( ovulatory) age Gravidity, parity, grand multiparity, great grand multi.

4. Cont. Normal duration of gestation is 280 days ( 40 completed weeks) or 10 lunar months. Preterm: < 37 weeks Term : 37-42 weeks Post term: > 42 weeks Normal pregnancy is divided into three equal trimesters 1st Trimester: 1- 14 weeks 2nd Trimester: 14-28 weeks 3rd Trimester: 28- 42 weeks

5. Diagnosis Of Pregnancy Important because; assure couples prevent exposure to start ANC follow up Diagnosis of pregnancy usually begins when the women present with symptoms and/ or positive home urine pregnancy test Manifestation of pregnancy can be; presumptive, probable, and positive.

6. Presumptive Manifestation 1.1 Presumptive Symptoms Amenorrhea : is a fairly reliable sign of conception in women with regular menstrual cycles. In women with irregular cycles, it is not a reliable sign Nausea and Vomiting : occurs in approximately 50% of pregnancies and is most marked at 2–12 weeks' gestation. The nausea is probably related to rapidly rising serum levels of human chorionic gonadotropin (HCG), although the mechanism is not understood

7. Cont.. Extreme nausea and vomiting may be a sign of multiple gestation or molar pregnancy. Fatigue : Due to the soporific effects of progesterone Mastodynia ; may range from tingling to frank pain caused by hormonal responses of the mammary ducts and alveolar system. Circulatory increases result in breast engorgement and venous prominence. Similar tenderness may occur just before menses.

8. Cont … Montgomery's Tubercles ; enlargement of Circum lacteal Sebaceous Glands of the Areola Enlargement of these glands occurs at 6–8 weeks ' gestation and is a result of hormonal stimulation. Colostrum secretion; may begin after 16 weeks' gestation. Quickening: First perception of fetal kick by the mother Prim ; 18-20 weeks , Multi: 14-16 weeks Urinary frequency Because of increased bladder circulation and pressure from the enlarging uterus.

9. Cont.. 1.2 Presumptive Signs Increased Basal Body Temperature Persistent elevation over a 3-week period usually indicates pregnancy if temperatures have been carefully charted  Chloasma ; darkening of the skin over the forehead, nose bridge and cheekbones It usually occurs after 16 weeks' gestation and is intensified by exposure to sunlight. Linea Nigra ; is darkening of skin over the nipples and lower midline of the abdomen from the umbilicus to the pubis. It is due to stimulation of the melanophores by an increase in melanocyte-stimulating hormone .

10. Cont.. Stretch Marks or striae gravidarum are caused by separation of the underlying collagen tissue and appear as irregular scars. and usually occurs over abdomen, breast and thigh probably an adrenocorticosteroid response. These marks generally appear later in pregnancy when the skin is under greater tension. Spider Telangiectasias common skin lesions that result from high levels of circulating estrogen blanchable when compressed. Palmar erythema is often an associated sign.

11. 2. Probable Manifestation 2.1 Probable Symptoms ; these the same as presumptive manifestation 2.2 Probable Signs ; these are pelvic organ changes, like; Chadwick's Sign: Congestion of the pelvic vasculature causes bluish or purplish discoloration of the vagina and cervix. Hegar's Sign: is widening of the softened area of the isthmus, resulting in compressibility of the isthmus on bimanual examination. occurs by 6–8 weeks.

12. Cont.. Goodell’s sign: cyanosis and softening of the cervix is due to increased vascularity of cervical tissue. can occur as early as 4 weeks . Leukorrhea Relaxation of ligaments Abdominal enlargement Braxton- Hicks contraction

13. 3. Positive Evidence Fetal heart tones Fetoscope: 18-20 weeks Doppler: 10-12 weeks Perception of fetal movements & Outlining of the fetus Ultrasound demonstration of fetus Radiological demonstration of fetal skeleton Usually at 16 weeks as primary ossification centers appear at 12-14 weeks Replaced by ultrasound.

14. Cont.. Pregnancy Tests: Test accuracy ranges from 98.6-99%. Causes of false positive results: Proteinuria. Hematuria. At time of ovulation (cross reaction with LH). HCG injection for infertility treatment within the previous 30 days. Thyrotoxicosis (high TSH). Premature menopause (high LH & FSH). Early days after delivery or abortion. Trophoblastic diseases. hCG secreting tumours.

15. Cont … Causes of false negative results : Missed abortion. Ectopic pregnancy. Too early pregnancy. Urine stored too long in room temperature. Interfering medications. The pregnancy test becomes negative about: one week after labor, 2 weeks after abortion, and 4 weeks after evacuation of vesicular mole.

16. Differential Diagnosis of Pregnancy Uterine fibroids Ovarian cysts Hematometra Ascites Full baldder Pseudocyesis ; assuming as pregnant: amenorrhea, abd . distension, nausea and vomiting

17. Physiologic change during pregnancy Is a change that occur during pregnancy to support ongoing fetal growth Aim is to prepare and make ready for fetal expulsion and control the bleeding during delivery It is mainly on reproductive organs and systemic

18. Local Changes Uterus; one of unique features of the uterus is its remarkable capacity to increase in size in a few months and then to return essentially to its original state within a very few weeks. Capacity; from about 10ml almost solid organ to about 5L thin walled muscular container Size; from 7x5x3cm  35x25x22cm, about 5-6 times increase Weight: Undergoes a 20-fold : from 50-70 g  1-1.1kg Position; usually dextrorotation to the right caused by rectosigmoid on the left side of the pelvis

19. Local cont.. Uterine growth is through: almost entirely by hypertrophy of the muscle cells there is an increase in the amount of elastic connective tissue there is a remarkable increase in the size and number of blood vessels and lymphatics hypertrophy of the nerve supply of the uterus takes place

20. Cont.. Initially stimulated by hormone which latter on by pressure effect of expanding product of conception; usually after 12 weeks of gestation Braxton Hick contractions Uteroplacental blood flow ; delivery of most substances essential for the growth and metabolism of the fetus and placenta, as well as removal of most metabolic wastes, is dependent upon adequate perfusion of the placenta by maternal blood, which depends upon blood flow to the uterus through uterine and ovarian arteries Estimated to be 450 to 650mL/min near term.  50 ml/min in the nonpregnant state

21. Local cont … Cervix ; pronounced softening and cyanosis of the cervix occurs. These changes are apparent  5 th -6 th week due to increased vascularity and edema of the cervix hypertrophy and hyperplasia of the cervical glands mucus secretion is greatly increased Vagina ; It becomes deeply congested and cyanotic because of the greatly  vascularity ( characteristic violet color of the vagina). mucosa thickens connective tissue becomes less dense muscular coat hypertrophies in preparation for labour

22. Systemic Change Weight ; hormonal changes are responsible for a considerable  in weight during pregnancy. Women gain an average of approximately 12.5 kg, and it may be approximated as follows Fetus 3.5 kg Placenta 0.5 kg Amniotic fluid 0.8 kg Uterus 1.0 kg Increase in blood volume 1.5 kg Breasts 0.5 kg Extracellular fluid 1.5 kg Fat and protein storage 3.3 kg

23. Mucocutaneous Striae gravidarum (striae distensae or stretch marks) White in multi Red/brown in primi linea nigra : brownish-black color of the midline of the abdominal skin

24. Cont.. Chloasma/ melasma or mask of pregnancy : irregular pigmentation of the face and neck

25. Cont.. palmar erythema mild degrees of hirsutism alopecia skin tags (polypoid lesions) gingivitis

26. Breast Become enlarged by the 8 th week of pregnancy As they  in size, delicate veins become visible beneath the skin Nipples become considerably  ,deeply pigmented & erectile The primary areola deepens in color and lightly pigmented secondary areola develops at the periphery Montgomery’s tubercles appears ( hypertrophy sebaceous glands located in the primary areola) Colostrum ( a thick & yellowish fluid ) often can be expressed from the nipples >10 th week Until delivery and during puerperium there are histological and functional changes that permit synthesis and secretion of milk

27. Cont.. Rarely, breast enlargement may become So pathologically extensive and Referred to as gigantomastia

28. HEMATOLOGIC CHANGES 1.Change in Fluid Balance ; retention of sodium and water has important hemodynamic consequences: Total body water  steadily: 6-8 l accumulate in a normal pregnancy, most being located in the extracellular space Excess sodium retention reaches 500-900 mEq by the time of delivery Maternal blood volume   40–50% above nonpregnant levels (the main contribution to this expansion is plasma volume) .

29. Cont.. 2. Total red cell volume and Fe metabolism; - begins to rise at 10wks rises until term, average 450ml(increase by 33%) Compared with total red cell volume, plasma volume Increase greater  hemodilution with a  Hct termed “the physiologic anemia of pregnancy” .

30. Cont … IMPORTANCE OF INCREASED BLOOD VOLUME Protects the mother from the possibility of haemorrhage during pregnancy. Helps fill the expanded vascular system created by vasodilatation and large low -resistance vascular pool with in the uteroplacental unit. Protect the mother and fetus against the deleterious effects of impaired VR in the supine and erect positions.

31. Cont.. Iron requirements : In normal pregnancy  1 g ( 200 mg is excreted + 300 mg is transferred to fetus + 500 mg is needed for the mother ). Daily average requerment is 6-7 mg/ day

32. Coagulation and fibrinolysis Normal pregnancy is accompanied by major changes in the coagulation system:  in the level of all except Factors xi and xiii Particularly marked  of plasma fibrinogen(inc.50%).average 450mg late in pregnancy fibrinolytic activity is  during pregnancy Net effect = produce hypercoagulable state

33. Cont.. The alterations in the coagulation and fibrinolytic systems + blood volume + myometrial contraction  =>help to combat the hazard of hemorrhage during and after placental separation.

34. CIRCULATORY SYSTEM Heart; position and size: It is a little  and pushed by the elevation of the diaphragm and rotated forwards, so that the apex beat is moved upwards and laterally Heart rate : Its average  about 10-15 beats/min to  the cardiac output Heart sounds : The 1 st and 3 rd sounds become louder. The 2 nd sound is not notably affected Murmurs : Systolic ejection murmurs develop in most of the women; . In some women a diastolic murmur may occur

35. Cont.. Cardiac output ; it’s the most significant hemodynamic change during pregnancy Begins to  5 th week and  40%  20-24 weeks (the highest levels). The cardiac output fluctuates markedly with changes in body position Lowest in sitting or supine position=enlarged uterus compress IVC Highest in Rt and Lt lateral and knee chest position .

36. Cont..

37. Cont.. BLOOD PRESSURE; arterial BP:  during 2nd trimester &  thereafter. Venous pressure in the femoral venous: there is a tendency toward stagnation in the lower extremities SYSTEMIC VASCULAR RESISTANCE DECREASE; smooth muscle relaxing effect of progesterone presence of circulating substances exerting a vasodilatory effect on arterial and venous vasculature ( NO,PG,ANP ).

38. RESPIRATORY SYSTEM The major influence in the phenomenon of over breathing is a change in central respiratory control but alterations in the subdivision of lung volume are largely due to anatomical changes : the level of the diaphragm rises about 4 cm the subcostal angle widens the transverse diameter of the thoracic cage increases about 2 cm the circumference of the thoracic cage increases about 6 cm

39. Cont.. Respiratory functions: vital capacity= unchanged. FRC,RV,ERV decreased –due to elevated diaphragm tidal volume: increased (  40%) respiratory rate: no changes minute ventilation  from 7ml/min to  10,5 ml/min in late pregnancy.

40. Cont..

41. URINARY SYSTEM kidneys : size increase because vasculature & Interstitial volume, urinary dead space. ureters: dilatation of the calyces, renal pelvis and ureters, they are prominent on the right side & can be seen as early as the 1 st trimester and are present in 90% of women by the 3 rd trimester . Causes; hormonal effect–smooth Ms relaxation by progestrone

42. Causes of hydronephrosis and hydroureter obstruction-by the enlarged uterus pressure from a dilated ovarian venous plexus Hyperplasia of smooth MS in the distal 1/3 of the ureter – decrease in luminal size dilatation in upper 2/3 of the ureter Rt ureter dilated more than Lt . b/c greater compression of the Rt ureter due to dextrorotation of the uterus Rt ovarian vein complex, dilated more during pregnancy, lies obliquely over the Rt ureter

43. Cont.. Increase GFR(50%) and RPF(25%-50%). Plasma conc. of creatinine and urea decreased due to increased GFR. In early pregnancy, water excretion by the kidney is , that’s why frequency of micturition is often present The frequency of micturition in late pregnancy is due to the pressure of the uterus upon the bladder the dilation of ureters may led to urinary stasis and may consequently give rise to renal infection

44. ALIMENTARY SYSTEM  of appetite and  thirst. Gums are often swollen and bleed easily( epulis gravidarum ). Ptyalism can be found, almost always associated with nausea. Heartburn because of reflux esophagitis resulting from regurgitation of gastric acid.

45. Cont.. Gastric tone, secreting activity, and motility are ed . Besides, stomach and intestine are displaced. The colon may share in the general relaxation of smooth muscle structures and constipation is a common complaint Hemorrhoids are common Gallbladder is distended but hypotonic and bile is quite thick. Pregnancy predisposes to formation of gallstones

46. ENDOCRINE SYSTEM Pituitary gland Enlarges by 135% -proliferation of prolactin producing cells in the ant. pituitary. Makes it susceptible to alterations in blood supply – risk of postpartum infarction - sheehan’s syndrome.

47. Thyroid Gland Modification in the regulation of thyroid hormone Increase in circulating TBG-in response to high estrogen Thyroid stimulating factors of placental origin are produced e.g. hcG Decreased availability of iodide for maternal thyroid; increase renal loss of iodide transfer of iodide to the foetus Results in a relative iodine deficiency state Causes alteration in thyroid morphology ,histology, and lab indices

48. Cont.. Moderate enlargement of thyroid due to hyperplasia of glandular tissue and increased vascularity but doesn’t cause significant thyromegally Any goiter in pregnancy should be evaluated.

49. Carbohydrate Metabolism Normal pregnancy is x-zed by mild fasting hypoglycaemia, hyperinsulinemia, postprandial hyperglycaemia . Allows for the continuous transport of nutrients to the fetus and placenta To accommodate the increased demand for Insulin –hypertrophy and hyperplasia of the B-cells of the pancreas

50. Cont.. Conversion from predominantly CHO to predominantly fat utilization b/se of; earlier depletion of liver glycogen store during maternal fasting constant drain of maternal glucose by fetomaternal unit FBS is 10mg/dl less than non pregnant. Factors responsible for the diabetogenic effects of pregnancy; Human placenta lactogen Cortisol PRL Estrogen progestrone

51. Cont.. Progressivelordosis ;  ed mobility of the sacroiliac, sacrococcygeal & the pubic joints. During the last trimester: aching, numbness, and weakness in the upper extremities

52. References Williams Obstetrics 24 th edition Simplified Obstetrics

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