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jess repro > 6.2: Physiological adaptations in pregnancy > Flashcards

6.2: Physiological adaptations in pregnancy Flashcards

1
Q

What ‘red flags’ would you be looking for in a history and examination during antenatal screening and what will it help you determine?

A
  1. Baby’s risk of acquiring genetic diseases (FH)
  2. Maternal lifestyle; smoking and alcohol
  3. Mother’s medical conditions/system disorder
  4. Risk factors for gestational diabetes, preeclampsia, etc.
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2
Q

What are you looking for in an antenatal blood test?

A
  1. Blood group and antibody (e.g; Rh factor)
  2. Hb - looking for anemia, hemoglobinopathies; SC disease, thalessemias, CF, etc
  3. Infections; syphilis, HIV, Hep B, rubella; *only ones that can be treated, managed
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3
Q

What would you check for in an antenatal urinalysis?

A
  1. Proteins; the ratio of protein:creatinine can help diagnose preeclampsia
  2. Nitrates
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4
Q

Other than taking urinalysis, blood test and history what else would you do during antenatal screening?

A

Ultrasound to check fetal viability

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5
Q

How is the maternal CVS and blood affected during pregnancy?

A

Increased blood volume: since CO = SV X HR they all increase

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6
Q

What happens to the systemic vascular resistance and the BP?

A

Systemic vascular resistance decreases:
Progesterone causes vasodilation -> reduced afterload -> decreased BP/hypotension

But BP should return to normal during third trimester

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7
Q

How is the preload and afterload affected during pregnancy?

A

Preload increases, afterload decreases (due to reduced systemic vascular resistance)

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8
Q

What happens to the diaphragm during pregnancy? Which other structure does this affect?

A

Moves up due to the increased pressure from the uterus, this displaces the heart

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9
Q

When and why can aortocaval compression occur? What advice can be given to prevent consequences of this?

A

In the third trimester: Compression of the abdominal aorta and IVC due to the gravid uterus when a pregnant women lies on her back

-> lie on her L side since IVC is on the R side (so baby’s weight can’t put pressure on it and vessel remains open)

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10
Q

How do endothelia change in pregnancy?

A
  1. More permeable (hormones)

2. Progesterone causes vasodilation

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11
Q

Name six factors that put some women at risk for preeclampsia. When will signs of it begin to show?

A

Signs show after 20-21 weeks, but milder case = later diagnosis

  1. FH
  2. High BMI and first pregnancy
  3. Older women having their first pregnancy
  4. Multiple pregnancies
  5. Chronic hypertension
  6. Any autoimmune condition
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12
Q

What is preeclampsia, how is it caused and how is it managed?

*Also what is it characterized by?

A

Pregnancy complication as a result of widespread endothelial damage caused by an imbalance between androgenic and antiandrogenic factors. The trophoblast cells fail to invade into the spiral arteries; so the vessels remain thick and muscular and their is a reduction of blood flow reaching the baby, hindering the baby’s growth

Characterized by high blood pressure (rises when there is endothelial damage) and signs of damage to another organ system (e.g; kidneys, liver)

Only treatment option is to treat the BP, monitor the kidney/liver function and try to extend the pregnancy as long as you can until the mother begins to deteriorate (e.g; can’t control her BP) or there is risk of damage to fetal growth (latest 34 weeks)

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13
Q

How are the kidneys affected during pregnancy? (4 things)?

How does the volume that the urinary system has to deal with change?

A

Volume increases by 30%

  1. The GFR increases by 40-65%
  2. Renal plasma flow increases by 50-80%
  3. Filtration capacity remains intact
  4. Functional renal reserve (ability to increase the renal plasma flow and GFR) decreases because the GFR increases
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14
Q

What happens to the blood creatinine as GFR increases in pregnancy and what are the normal serum creatinine ranges in pregnancy? What does it mean if this value is abnormal?

A

Decreases, normal pregnancy ranges are between 25-75mmol/L, if this is abnormal can be a sign of preeclampsia or other renal pathologies that have been aggravated during pregnancy

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15
Q

What happens to the bladder and the ureters during pregnancy and why? What is one complication that can arise as a result

A

Due to the influence of progesterone…

  1. Bladder doubles its capacity (10000 mL) (relaxing influence of progesterone)
  2. Ureters dilate - this also predisposes to an ascending bacterial infection
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16
Q

What are some consequences that can happen in the urinary system as a result of pregnancy

A

Urinary stasis (progesterone effect): can lead to hydronephrosis (kidney swells due to urine failing to properly drain from kidney to bladder) and cause hydroureter.

Can also lead to obstruction and a UTI; which can causes pyelonephritis (inflammation of the kidney typically due to a bacterial infection) which can irritate the uterus putting women at risk of going into pre-term labor

17
Q

When would you want to investigate a pregnant woman for a UTI? How would you diagnose an asymptomatic pregnant woman with one?

A

Investigate/offer renal scan when the woman experiences backache or flank pain and has dysuria

Many pregnant women with bacterial infections in the urine are asymptomatic so have to check nitrites in a urinalysis

18
Q

What happens to the chest wall in pregnancy and why? What happens as a consequence of this?

A

The following increase; subcostal angle, chest wall circumference, chest wall anterior-posterior and transverse diameters

These changes compensate for the 4cm elevation of the diaphragm (due to the expanding uterus) so that the total lung capacity isn’t significantly reduced - however, there is still a reduction in the functional residual capacity

19
Q 
Define the following and describe how they change in pregnancy
A) Vital capacity 
B) Total lung capacity 
C) Minute and alveolar ventilation 
D) Tidal volume 
E) Respiratory rate
A

A) Max exhalation after max inhalation; unchanged
B) Vital capacity + residual volume; unchanged
C) Amount of air expelled from alveoli/min; Increased
D) Volume of air moved in-out of lungs with each ventilation cycle; increased
E) Amount of breaths/min; unchanged

20
Q

Name two physiological respiration issues pregnant women experience and why they occur.

A

Physiological hyperventilation occurs due to

  1. increased metabolic CO2 production
  2. progesterone also stimulates a respiratory drive causing the woman to hyperventilate

Physiological dyspnea; due to progesterone driven hyperventilation

21
Q

What is a consequence of physiological hyperventilation and how is it compensated for?

A

This causes respiratory alkalosis which is compensated for by increased renal bicarbonate excretion

22
Q

What happens to the PaO2, PaCO2 and FEV1 in pregnant women?

A

PaO2; increases
PaCO2; decreases
FEV1; unchanged

23
Q

Why does the vital capacity remain the same in pregnancy?

A

The expiratory reserve volume reduces in pregnancy but to compensate the tidal volume and the inspiratory reserve volume increase

24
Q

What happens to the mothers insulin resistance as the pregnancy progresses and why?

A

Maternal peripheral insulin resistance increases and her body switches to gluconeogenesis and alternative fuels (so more glucose goes to the baby)

This is achieved by anti-insulin hormones that are increased in pregnancy; hPL, prolactin, estrogen/progesterone, and cortisol

25
Q

Why is pregnancy associated with an increased risk of keto acidosis?

A

Since pregnant women undergoing gluconeogenesis may use fatty acids - so their fasting free fatty acid concentration will increase, and the substrate of lipolysis is ketones

26
Q

What happens to the fasting plasma glucose and post-prandial blood glucose when pregnant?

A

Fasting plasma glucose decreases

Post-prandial blood glucose increases

27
Q

Name 6 risk factors for developing gestational diabetes and what would you offer to screen this group of women? (and when would you offer it?)

A
  1. Immediate FH
  2. High BMI>30
  3. Previous gestational diabetes
  4. Ethnicity; asians and Afro-Caribbeans
  5. Delivery of a baby>4.5 kilo in the past
  6. Women with history of polycystic ovarian syndrome

Offer a glucose tolerance test at 26 weeks to screen for gestational diabetes

28
Q

Name three risks to the fetus associated with poor control of gestational diabetes and one risk for the mother. What is provided for mothers with this risk?

A
  1. Macrosomic fetus
  2. Stillbirth
  3. Increased rate of congenital defects

Mother has a high risk of developing type 2 diabetes down the line (must have annual blood glucose testing by the GP)

29
Q

Why are fetuses born to a mother with gestational diabetes so large but born hypoglycemic? What are they at risk of?

A

They are macrosomic due to the hyperglycaemic environment in the mother, their pancreases adapted and overly stimulated the production of insulin which is an anabolic hormone (increases production of glycogen and adipose). When the babies are born the glucose available to them is much less than what their bodies have become accustomed to and so they’re born hypoglycaemic

Respiratory distress syndrome, infections, etc (also stillbirth and other congenital defects)

30
Q

What happens to the amount of thyroid hormones during pregnancy and why? Does this change the amount of free T4?

A

Since hCG and TSH are structurally similar (on the alpha subunit) when women get pregnant hCG mimics TSH and the amount of T3 and T4 increases.

However, the amount of free T4 remains unchanged as although levels have risen the amount of thyroid binding globulin (which carries it) also increases

31
Q

What happens to the appendix during pregnancy?

A

Moves to the RUQ as the uterus enlargens

32
Q

Describe 4 physiological changes in the GI system during pregnancy

A
  1. Smooth muscle relaxation by progesterone
  2. GI; gut is relaxed, delaying the transit time/emptying means women may feel constipated, vomit, full quickly
  3. Biliary tract; stasis
  4. Pancreas; increased risk of pancreatitis
33
Q

Why are pregnant women more at risk of having a DVT?

A

Pregnancy is a pro-thrombotic state and more fibrin is deposited at the sight of implantation - there is more fibrinogen and clotting factors and reduced fibrinolysis

In addition, there is more blood stasis due to the vasodilation from progesterone (which is further aided by compression of the AA and IVC from the gravid uterus)

34
Q

How does thromboembolic disease commonly present in pregnancy? What can you offer? Warfarin?

A

A tender swollen calf most commonly, but can also be SOB and chest pain

Can give low molecular weight heparin but NOT warfarin as it crosses the placenta and is teratogenic. However, it can be given after birth and the mother will still be able to breastfeed

35
Q

Name 8 signs and symptoms for a pulmonary embolism in pregnancy and two additional ones for a massive PE

The 8: DPPTTHHC

A
  1. Dyspnea
  2. Palpitations
  3. Pleuritic chest pain
  4. Tachycardia
  5. Tachypnea
  6. Hypotension
  7. Collapse
  8. Hemoptysis
    +cyanosis/hypoxia in a massive PE
36
Q

Name 6 signs and symptoms for a DVT in pregnancy, is it usually proximal or distal?

A

Usually proximal

  1. Unilateral leg pain/tenderness
  2. Swelling in an extremity
  3. Increased calf/thigh circumference
  4. Increased temp
  5. Prominent superficial veins
  6. Pitting edema
37
Q

Why do pregnant women sometimes experience anemia? (both physiologically and pathologically)

A

Can occur physiologically as the plasma volume has increased but the # of RBCs hasn’t as much.

Can also be due to an iron and folate deficiency or other hemoglobinopathies; sickle cell, thalassemias, etc

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