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Lifecycle Unit 2 Test > Endocrinology of pregnancy > Flashcards

Endocrinology of pregnancy Flashcards

1
Q

Background

A

a. Maternal physiology must meet enormous metabolic demands of the fetusb. Placenta as an endocrine organ unparalleled in quantity and diversity of hormones, growth factors i. super endocrine organc. Hormones regulate fetal metabolism and modify maternal physiology to ensure fetal growth; maternal health may decompensate

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2
Q

Functions of Placental and Maternal Hormones

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a. Maintain the corpus luteum during the first 7-10 wksb. Adjust maternal metabolism to provide nutrients to the fetusc. Stimulate the maternal circulatory system to transport gases and nutrients to and from the growing fetusd. Dampen uterine contractilitye. Prepare the maternal tissues for childbirthf. Prepare the breasts for lactationg. Hormones are intimately involved in the complex processes that lead to parturition

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3
Q

Hormonal Changes in Pregnancy- Endocrine System

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a. Insulin sensitivity early-resistance later (GDM) i. early pregnancy will have increased insulin sensitivity ii. major insulin resistance will develop later b. Earlier conversion to fatty acid metabolism due to decreased maternal glycogen stores from fetal-placental glucose demands–fasting ketones c. Changes in thyroid hormone levels (hCG)d. Increased iodine requirements (goiter, hypothyroid)e. Changes in autoimmunity (PPT)f. Estrogen induced pituitary growth (Sheehan’s a possible risk with growth and infarct)

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4
Q

Cardiovascular and Hematologic Changes(good review)

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a. 30-50% increase in C.O. (decompensation in CAD, CHF, Marfan’s, valvular stenosis)b. Decreased System Vascular Resistance–> decreased BP i. No change in pulm vasc resistance in pts with pulm htn c. Increase in HR d. 30-40% increase in blood volume (anemia of pregnancy) i. RBC increases, plasma increases even more

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5
Q

Respiratory/Acid Base Changes from Hormones(good review)

A

a. Increase in Tidal Volume, Minute Ventilation–> Resp Alkalosis b. Compensated Metabolic Acidosis leads to lower buffering capacity (earlier DKA) i. the body will excrete more HCO3-c. Increase in O2 consumptiond. Nasal mucosal edema (stuffy nose, sinusitis)

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6
Q

Renal Changes in Pregnancy

A

a. 40-60% increased GFR (clearance of iodine, drugs) — > BUN and Cr decreased b. Increased renal blood flowc. Altered tubular function (glucosuria)d. Decreased ureteral peristalsis (pyelo) e. Lowered osmostat for vasopressin release and thirst (hyponatremia)

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7
Q

GI Changes in Pregnancy

A

a. Decreased Lower Esophageal Sphincter (GERD, aspiration pneumonia)b. Decreased stomach emptying, peristalsis (gastroparesis, delayed absorption, constipation)c. Decreased GB emptying (cholestasis)

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8
Q

Polypeptide-Releasing Hormones from Placenta(dont need to know)

A
  1. CRH (20-fold increase at term)2. GnRH (stims hCG)3. GHRH4. TRH
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9
Q

Polypeptide Hormones from Placenta for DiscussionKnow these!

A

hCGhPL (hCS) —> Human placental lactogenhPGH (hGH-V)* –> Human placental grwoth hormone

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10
Q

Other Placental Peptide Hormones

A
  1. Leptin2. Neuropeptide Y3. Inhibini. Inhibits FSH, hCG, progesterone levels ii. Increase Down’s and molar pregnancies; decrease in ectopic and pregnancies at risk for abortion 4. Activin5. Chorionic ACTH—CRH systemInvolved in parturition6. Relaxin i. Potent stimulus in rats to Increase GFR and renal plasma flow and decrease SVR ii. Softens cervix, lengthens interpubic ligament7. PTH-rP i. Made by placenta, decidua, fetal parathyroids, mammary glands ii. Regulates calcium transport (fetal:maternal 2:1) iii. increases 1,25-OH Vit D 2-fold
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11
Q

Major Placental Peptide HormonesIntroducing the important ones

A

The highly varied temporal behavior reflects their function in pregnancy:1. hCG maintains the corpus luteum in early pregnancy2. hPL participates in the metabolic adjustments that deliver nutrients to the developing fetus 3. hPGH contributes to insulin resistance of pregnancy 4. CRH likely plays a role in parturition

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12
Q

Steroid Hormones from Placenta

A
  1. Progesterone2. Estrogen (up to 100-fold increase)3. 1,25-OH Vit D
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13
Q

Placental Anatomy

A

a. Day 4, embryo differentiated into inner cell mass (fetus) and trophectoderm (placenta)b. 6-7 days—endometrial attachment of trophoblast c. 2 types of trophoblastic cell phenotypes i. mononuclear Cytotrophoblast (early) ii. Syncytiotrophoblast (multinuclear layer on surface of villi; predominates later) Syncytiotrophoblast is the hormone generator!!

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14
Q

Syncytiotrophoblast

A

a. Major site of protein and steroid production b. Hemochorioendothelial placentation i. Directly bathed by maternal blood within intervillous space ii. Separated from fetal blood by several layers of tissue iii. Net transfer of steroids and polypeptide hormones to maternal blood is&raquo_space;> fetus

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15
Q

hCG and Sex Steroids through Pregnancy

A

a. hCG is highest in the early weeksb. Estrogen and progesterone continue to increase with pregnancyc. Placenta takes over about 12 weeks (the corpus luteum not needed at this point) i. hCG will maintain corpus luteum till 12 weeks ii. than the placenta can make enough progesteorne

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16
Q

Placental Transfer

A

a. More permeable to lipid soluble moleculesb. Hormones > 1200 Daltons have minimal accessc. Hormones actively metabolized by placenta i. T4 —> rT3 by Type III Monodeiodinase ii. Cortisol —> Cortisone by 11-B hydroxysteroid dehydrogenase

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17
Q

Human Chorionic Gonadotropin (hCG)

A

a. Glycoprotein (39 kD), like LH, FSH i. dont memorize this*b. Secreted by syncytiotrophoblastc. Alpha common to LH, FSH, TSH i. Beta similar to LH but unique C-terminal ii. hCG has similar function to all of thesed. Produced 8 days after ovulatione. Doubles q ~48 hrs for 1st 5-6 wksf. Peaks at ~10-12 wks (30-120,000 U/L)g. Nadirs at ~17 wks to ~20,000 U/L i. the hCH will start lowering h. T ½ 24-36 hrs

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18
Q

hCG Levels in Pregnancy

A

a. Peaks earlyb. Will come down by 16 weeks

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19
Q

Biologic Activity of hCG*Important

A

a. Maintains corpus luteum steroid (especially progesterone) synthesis until 8-10 wksb. Regulates differentiation i. cytotrophoblast—>syncytiotrophoblast; controls trophoblastic invasionc. Induces apoptosis of endometrial T-cells to promote immune survival of embryo d. TSH activity at high levels i. will help create thyroid hormonee. Stimulates fetal Leydig cells to produce fetal testosterone f. May cause hyperemesisg. Stimulates Relaxin–> increased GFR/Renal blood flow and decreased SVR in rats; studies ongoing in humans

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20
Q

hCG–Endocrine Clinical Correlates

A

a. hCG has TSH activity first trimesterb. hCG-induced hyperthyroidism with HGc. Lack of hCG doubling 1st trim—missed Abd. No gestational sac; hCG >1500 U/L-ectopic i. ectopic or miscarriage e. No cardiac activity; hCG>9000-missed Abf. Altered in placental insuff and trisomies: increased hCG in Down’s–decreased Trisomy 18

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21
Q

TSH and hCG in Pregnancy

A

a. hCG will raise, while maternal TSH will lowerb. hCH will take over the role of TSH, will see lower TSH levels during pregnancy i. normal to see lower TSH levels during pregnancyc. hCH will allow T4 to be released

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22
Q

Human Placental Lactogen (hPL) or Human Chorionic Somatomamotropin hCS) Important slide

A

a. 23 kD protein, like GH and PRL i. even stronger prolactin than growth hormone effectb. Secreted by syncytiotrophoblastc. Secretion rate parallels placental weight d. Detected at 5-10 days-peaks ~32 wks i. large amounts later in pregnancye. Made in massive quantities ~1-2 gm/day

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23
Q

hPL or hCS-Endocrine Clinical CorrelatesImportant slide

A

a. Originally thought to be insulin resistance hormone of pregnancy i. actually stimulates insulin secretionb. Facilitates mobilization and utilization of FFAs for energy by increased lipolysis c. Both insulin and anti-insulin effectsd. Stimulates insulin secretion *e. Weak GH activity and mainly a lactogen—Promotes growth of mammary tissue and stims prolactin

24
Q

hPGH(human placental growth hormone)

A

a. 22 kD protein b. Secreted by syncytiotrophoblastc. Differs from pit GH by 13 aa i. Not regulated by GHRH d. Same avidity for receptore. Secreted tonically; replaces pituitary GH ~20 wksf. Does not cross placenta but regulates IGF-1 g. hPGH decreased by glucose; increased by hypoglycemiah. Potent somatogen i. Lost during normal labor and 1 hr after placenta removal

25
Q

Changes in Hormones of Pregnancy During Gestation

A
  1. hPL will be the most massive in the later weeks of pregnancy2. hPGH was the 2nd highest i. saw a decrease in pituitary GH
26
Q

Of Mice and Women

A

a. Hypothesis: hPGH is a metabolically active hormone that can cause insulin resistance b. Aim: Study the metabolic effect of hPGH in transgenic mice that overexpress hPGH and insulin signaling changes in muscle

27
Q

Glucose and Insulin test with miceTesting hPGH

A

a. hPGH will lead to increased fat and lean mass of the miceb. Found out that the insulin levels were higher in the big mouse i. larger mouse was producing more hPGHc. Can lead to insulin resistance

28
Q

hPGH–Clinical Correlates

A

a. Maternal insulin resistance necessary to shunt glucose and amino acids to fetus to ensure adequate growth*b. hPGH appears to be the major insulin resistance hormone of pregnancyc. hPGH decreased in growth restricted fetusesd. Women with pre-existing insulin resistance develop GDM due to further insulin resistance from placental hormones and inadequate insulin secretion i. hPGH + previous D2M will lead to gestational diabetes

29
Q

Steroid Hormones Progesterone

A

a. Critical to maintain pregnancyb. Corpus luteum produces progesterone prior to 8-11 wksc. Progesterone biosynthesis dependent on number of LDL receptors on trophoblast plasma membraned. 30 ng/ml–>150 ng/ml; ~300 mg/daye. ~85% enters maternal circulation

30
Q

Stimulation of Progesterone Secretion

A

a. hCG will stimulate corpus lutreum to make progesteroneb. Placenta will eventually take over in production

31
Q

Functions of ProgesteroneImportant

A

a. Promotes decidua formation b. Substrate for synthesis of cortisol and aldosterone in the definitive zone of the fetal adrenal cortex c. Inhibits uterine contractionsd. Modulates immune system (promotes Th2 ab and suppresses Th1 cell mediated response) e. Stimulates minute ventilationf. Smooth muscle relaxant (GI, uterus; GU)g. Promotes lobular development in the breast; inhibits milk secretionh. May contribute to ↓ SVR

32
Q

Progesterone: Maternal-Placental-Fetal Axis

A

a. Some progesterone will cross the placentab. Will cause the placenta to make cortisol and aldosterone for the fetusc. will also make this unique compound called Estriol i. different than estradiol ii. only estriol only seen in pregnancy

33
Q

Progesterone Clinical Correlates

A

a. Progesterone given for luteal phase defectsb. Progesterone given to prevent preterm laborc. Misoprostone acts as abortifacentd. Autoimmune ds may improve; worsen PP (MS, PPT, Grave’s)e. Gastroparesis worsens; GERD, aspiration pneumoniaf. Ureteral relaxation results in urinary reflux, high risk of pyelonephritis

34
Q

Estrogen

A

a. Levels may increase ~100-fold during pregnancy i. very high risk of blood clotb. High levels of placental aromatase c. DHEAS—> estrogens by placentad. 20 mg/day estradiol; 80 mg/day of estriole. 90% estradiol secreted into maternal circ

35
Q

Estrogens–Function

A

a. Stimulates growth of myometriumb. Induces hypercoagulable state (increased clotting factors, fibrinogen) c. Induces protein synthesis (increased SHBG, TBG, CBG) d. Induces lactotrophs; Inibits Dopa–> increased PRL but antagonizes PRL at level of breaste. Peripheral vasodilation (decreased SVR, BP) i. Increases cardiac outputf. Inc mucosal edema (sinusitis, epistaxis)g. Increased uterine blood flow and decreased resistance i. Inc blood volume (anemia)h. Inc renal perfusion and GFR (increased proteinuria)i. Increased TG synthesis j. Increased Pituitary size and vasculature

36
Q

Estrogen Clinical Correlates

A

a. 5-10 X risk of thrombosis in pregnancy i. PE is leading cause of maternal mortalityb. Prolifative retinopathy worsens i. IncreasedCoag factors and anemia c. Pituitary size increases; prolactin macroadenomas may enlarge; pit at risk for ischemia (Sheehan’s) d. Est-containing OCPs may inhibit lactatione. ↑ Binding Proteins causes TT4, TT3, cortisolf. Estrogen induced hypertriglyceridemia can cause pancreatitis

37
Q

Thromboembolism in Pregnancy

A

a. Leading cause of maternal mortality in the U.S. and U.K. b. PE’s account for 15-20% of pregnancy-related deaths in US c. Relative risk of VTE 10X of non-pregnant state–1/1000 vs 1/10,000 (Lindquist 1999)

38
Q

Hypercoagulable State of Pregnancy

A

a. Stasis (venous flow decreased by 50% by 3rd trim) b. Vascular Damage (vaginal del or C-section)c. Hypercoagulabilityi. Increase factors V, VIII, vWF, fibrinogenii. Increase resistance APC (40%)iii. Increase PAI-1 and PAI-2iv. Increase Prot Sv. Increase in D-dimers and TAT complexesd. Risk back to baseline by 6 wks PP

39
Q

List and describe the hormonally mediated physiologic changes to the maternal endocrine system which occur during pregnancy.

A

a. Insulin resistance (gestational diabetes) → shunt nutrients (glucose) to fetusb. Early switching to fatty acid metabolism if fasting: ○ Normally non-pregnant women go 48 hours before inducing ketosis○ But pregnant only go 10 - 12 hours before inducing ketosis○ This happens because the baby gets all of the sugar synthesized by liver, Mom gets fatty acidsc. hCG-mediated hyperthyroidism → ↑ thyroid hormone levels d. ↑ in iodine requirements (maternal goiter, hypothyroidism) → huge demand increase by both mom and baby e. Changes in autoimmunity (postpartum thyroiditis)○ ↑ Th2 response, ↓ Th1 response○ Rheumatologic conditions improve during pregnancy, then post-partum have refractory worseningf. Pituitary growth (estrogen stimulated production of prolactin, Sheehan’s syndrome)g. Absorptive hypercalciuria → kidney stonesg. Placental vasopressinase → increase in risk of diabetes insipidus

40
Q

List and describe the hormonally mediated physiologic changes to the maternal cardiovascular which occur during pregnancy.

A

a. 30-50% ↑ in cardiac output (decompensation in heart disease)b. ↓ SVRc. ↓ in blood pressure before 20 weeks, ↑ back to normal by termd. ↑ in heart rate

41
Q

List and describe the hormonally mediated physiologic changes to the hematologic systems which occur during pregnancy.

A

a. 30-40% increase in blood volume (anemia)b. Gestational thrombocytopeniac. Hypercoagulation state caused by estrogen which induces ↑ in clotting cascade, ↓ protein S, ↑ fibrinogen

42
Q

List and describe the hormonally mediated physiologic changes to the maternal pulmonary (ENT) systems which occur during pregnancy.

A
  1. ↑ in oxygen consumption2. ↑ in tidal volume3. ↑ in minute ventilation → respiratory alkalosis4. Compensatory metabolic acidosis (↑ HCO3 urin secretion = ↓ serum HCO3) → ↓ buffering capacity.5. ↓ buffering capacity + faster switching to fatty acid metabolism → ↑ risk of DKA in pregnancy.6. Nasal mucosal edema (stuffy nose of pregnancy, sinusitis)
43
Q

List and describe the hormonally mediated physiologic changes to the maternal renal systems which occur during pregnancy.

A
  1. 40-60% ↑ in glomerular filtration rate → ↑clearance of hormones, drugs, and substrates2. Altered tubular function (glucosuria)3. ↑ plasma renal blood flow4. ↓ in ureteral peristalsis with mild hydronephrosis → ↑ in urinary tract infections and pyelonephritis5. Lowered osmostat for vasopressin release and thirst (hyponatremia)
44
Q

List and describe the hormonally mediated physiologic changes to the maternal gastrointestinal system which occur during pregnancy.

A
  1. ↓ in lower esophageal sphincter pressure (gastroesophageal reflux, aspiration pneumonia)2. ↓ in stomach emptying and peristalsis (gastroparesis, delayed absorption)3. ↓ in emptying of gall bladder (cholestasis)
45
Q

List the four major polypeptide releasing hormones produced by the placenta.

A

a. hCG / human chorionic gonadotropin → similar to LH and has TSH activity at high levelsb. hPL or hCS / human placental lactogen or chorionic somatomammotropinc. hPGH / human placental GHd. Relaxin → early rat models showing major role in ↑ GFR and ↓ SVR, softens cervix, ↓ uterine contractilitye. PTH-rP○ Helps transfer Ca2+ across placenta to help bone formation in growing fetus○ ↑ release of 1-α-hydroxylase release from placenta → ↑ active vitamin D

46
Q

Name the major steroid hormones produced by the placenta.

A

● Estrogen● Progesterone

47
Q

human chorionic gonadotropin (hCG)Function, Structure, Action

A
  1. Structure:α subunit is 92-aa polypeptide common to LH, FSH + TSH. β subunit is 145-aa and structurally similar to LH-β subunit (85% homology) but has a unique C-terminal extension. Stimulates TSH receptor at high levels → Hyperthyroidism of pregnancy → suppresses TSH = normal Stimulates the LH receptor, it can stimulate estradiol and 17-OH progesterone 2. Function:Maintains corpus luteum (CL) progesterone release until placenta can take over. Regulates differentiation from cytotrophoblast → synctiotrophoblastPromotes embryo survival by apoptosing endometrial T-cellsStimulates fetal leydig cells to make T↓ myometrial contractility ↑ relaxin release from trophoblast + CLCauses 1st trimester emesis3. Clinical Relevance: Elaborated even before implantation Monoclonal Ab specific to β-hCG used in home pregnancy testPeaks @ 10-12 weeks Can help sort out multiple gestations (↑), Down Syndrome (↑), missed abortions (failure to double or >9000 w/o heart beat)Major role is action on thyroid (↑ TH)
48
Q

human placental lactogen (hPL)Function, Structure, Action

A
  1. StructureNon-glycosylated 191-amino acid protein 67% homology with prolactin2. FunctionModest metabolic, growth, and lactogenic effects that end up delivering nutrients to babyStimulates insulin secretion and islet cell number in animals, along with lactogens such as prolactin.3. Clinical Relavance-↑ insulin secretion in pregnancy to maintain euglycemia-may play a role in insulin resistance in pregnancy-Mobilization and utilization of free fatty acids
49
Q

human placental growth hormone (hPGH)Function, Structure, Action

A
  1. Structure191 amino acids; differs from pituitary GH by 13 amino acids. Same avidity for GH recept2. FunctionStimulates gluconeogenesisContributes to insulin resistance in pregnancyPotent somatogen, weak lactogen.3. Clinical Relevance Likely to be the main insulin resistance hormone in pregnancy to ↑ nutrient availability to the fetus
50
Q

EstrogenFunction, Structure, Action

A
  1. FunctionSteroid HormoneEstrogen receptor in nucleus up regulates transcription2. ActionStimulates myometrium↑ hepatic protein synthesis → SHBG + TBG + CBG = binding proteinsInduces lactotrophsPeripheral vasodilationInhibits NE vasoconstrictionInhibits DA → ↑ PRLHypercoaguable state↓ Protein S↑ Clotting factors + fibrinogen↑ NO synth → ↓ SVR + ↓ BP↑ CO↑ mucosal edema, uterine blood flow↑ neovascularization↑ blood volume↑ renal BF, GFR↑ TG synthesis↑ Oxytocin receptors → ↑ Gap Jnc↑ Pituitary size3. Clinical↑ 100x during pregnancyHormonal effects due to changes in binding proteinsWorsens proliferative retinopathy (↑ neovasc)↑ thrombosis in pregnancy → only good for delivery, otherwise ↑ risk DVT/PEPRL macroadenomas enlarge → Sheehan’s*, visual field defects↑ TG → pancreatitis
51
Q

ProgesteroneFunction, Structure, Action

A

Structure- Steroid hormoneAction:Critical to maintain pregnancy by preventing uterine lining from being shed, inhibiting uterine contractions and promoting decidua formation. Substrate for aldosterone/cortisol synthesis in the fetal adrenal glandCompetes w aldosterone (maternal)Th1 → Th2 shiftStimulates minute ventilationSmooth muscle relaxant, ↓ SVR↑ GFRPromotes TDLU developmentInhibits milk secretion ↓ gastric motilityClinical Function:Give Progesterone if Luteal phase defects to prevent laborMifepristone (progesterone antagonist) → abortionAutoimmune Disease may improve → ↓ Th1, ↑ Th2, (MS, RA, PPT, Graves) → Refractory worsening postpartumUreter relaxation → ↑ of Pyelonephritis Gastroparesis worsens → GERD, constipation

52
Q

Summarize the amounts of estradiol, progesterone, prolactin, and human chorionic gonadotropin present in the maternal circulation and how they vary over the course of a normal pregnancy.

A

a. hCG → Greatest early then falls at 10 weeks when placenta takes overb. Estradiol → Rising throughout, greatest amount latec. Progesterone → Rising throughout until partuition.d. Prolactin → ↑ with estrogen via inhibition of dopamine

53
Q

Identify the trophoblastic cell type primarily responsible for hormone production.

A

a. Syncytiotrophoblast makes all steroid hormones and most peptide hormones. b. Cytotrophoblast can make a few peptide hormones. c. Other1) Syncytiotrophoblast:○ Majority of peptide hormones and all steroid hormones synthesized in placenta○ Syncytiotrophoblasts are bathed in Maternal blood○ Fetal blood is separated from maternal blood by many layers○ Location causes placental hormones to be secreted almost exclusively to maternal circulation○ Net transfer 10-fold greater to mom blood then fetal blood2) Cytotrophoblast → Inner Layer ○ Early synthesis of some peptide hormones in pregnancy○ No synthesis of steroid hormones ever!

54
Q

Describe the relative maternal / fetal distributions of placentally derived hormones and the physiologic bases for those distributions.

A

a. Hemochorioendothelial Placentation → word for anatomical structure of human placenta that puts syncytiotrophoblasts in direct contact with maternal blood supply. b. Location causes net transfer of steroids to maternal blood of ~10x compared to fetal blood. c. Large, lipid soluble molecules cannot cross placenta into fetus

55
Q

Describe the roles of the placenta, the fetal compartment, and the maternal compartment in the biosynthesis and metabolism of progesterone, the estrogens, and androgens.

A

Estriol is only synthesized in the Placenta and has been historically used to evaluate placental health in pregnancy.

Lifecycle Unit 2 Test (19 decks)

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