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Life Cycle > LC Exam 2: Maternal Physiology and Pregnancy > Flashcards

LC Exam 2: Maternal Physiology and Pregnancy Flashcards

1
Q

Total body water and pregnancy

A

Increased from 6.5 to 8L (2kg)
Includes expanded plasma, RBC, extra/intracellular
Preg= chronic overload state

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2
Q

Normal weight gain in pregnancy

A

1lb/wk for under/nml BMI

.5lb/wk for overweight/obese

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3
Q

Osmoregulation

A

AVP secretion increased, but inactivated by placenta
Water retention>Na retention
Net sodium loss (some from RAAS activation)

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4
Q

Cardio markers

A 
RAAS elevated (5x)
ANP, BNP also elevated
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5
Q

CV changes to blood volume

A

Plasma volume increased 50%
RBC mass increased 30%
Therefore dilutional anemia (Hct 32-36%)

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6
Q

CV changes in BP

A

Decline until 22 weeks, then normalization
Progesterone effect on smooth muscles and increased NO
Effect of decreased vascular resistance
HTN = >140/90

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7
Q

CV heart physiology changes

A

Increased CO (mostly SV, some HR in 3rd tri, 10 bpm)
Hypertrophy of ventricle
Increased preload, decreased afterload
Decreased CO? IVC compression by uterus -> roll

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8
Q

Reorganization of blood flow

A

No change in brain, liver, kidney
Increased perfusion to breast, skin, uterus
Uterus 2% to 15%
IVC compression can lead to edema, hemorrhoids, DVT risk

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9
Q

Cardio physical exam

A

Normal sinus
PMI is displaced left (uterus size) (left axis deviation)
Systolic ejection murmurs (LSB)
Diastolic murmur is abnormal
S3 common
Increased PVCs, some ST segment changes
Arrhythmias common (also heart closer to chest wall, easier to notice)

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10
Q

CXR changes

A

Heart size ratio unchanged
Left heart border more straight
Heart is more horizontal
Prominent pulmonary vasculature

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11
Q

Pulmonary edema hypothesis

A

Increased colloid oncotic pressure
No change in wedge pressure
More tendency to develop edema

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12
Q

Cardiac changes in labor and postpartum

A

Straining: valsalva decreases return, reflex brady, sympt discharge, maintained CO
Relax: increased return, increased MAP, reflex brady
HR relax

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13
Q

Valve disease in pregnancy

A

Regurg better tolerated then stenosis
Decrease in heart fxn (progression to HF and CHF possible)
Aortic stenosis: fixed CO, can’t increase with preg (orthostatic with increased HR)

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14
Q

Pulmonary changes

A 
Rate unchanged, VC unchanged
TV increases (prog effect on CO2 sensors)
Decreased RV, decreased TLC
FEV1 and FVC unchanged (as does ratio)
PaCO2 decreases (27-32mmHg, nml 40- too high in preg)
PaO2 increases
pH unchanged/increases - bicarb loss
HCO3 decreases
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15
Q

Mechanical pulmonary changes

A

Chest size increases

Breathing becomes more diaphragmatic (pushed up but excursion increases)

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16
Q

Pregnancy gas exchange

A

Primary respiratory alkalosis with compensatory metabolic acidosis
Less buffer available -> DKA faster with GDM

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17
Q

Asthma in pregnancy

A

May improve with increased cortisol
Keep pO2 WNL
The common therapies are still safe (beta agonists and steroids)

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18
Q

Kidneys during pregnancy

A

Enlarged organ
Hydronephrosis - right side more than left
Due to both mechanical compression and progesterone relaxation
Resolves by 6 weeks post partum
Increased pyelo risk -> more stasis (progesterone)

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19
Q

Kidney physiology

A

Increased GFR
Increased renal plasma flow (more then GFR)
Via NO increase (progesterone)
Relative hyponatremia

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20
Q

Chronic renal insufficency

A

Associated with adverse outcomes
Try and plan and get off dialysis prior to preg
Transplant if possible

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21
Q

Platelets

A

Also diluted

15% 100-150k (116k suggested as cutoff)

22
Q

Immune system

A

WBC increases over course
1st tri: 8000
2/3rd tri: 8500 (up to 12,000)

23
Q

Coagulation

A 
Increase in most factors (decrease hemorrhage)
Increased risk DVT/PE (5-6x), L>R
XI and XIII decline
Protein C = constant, ATIII constant
Protein S = shrinks
24
Q

DVT/PE treatment/prophylaxis

A 
LMW is gold standard (switch to unfrac at 36 wks)
Avoid coumadin (contraindicated)
Postpartum: coumadin vs. heparin
25
Q

GI changes

A

Increased saliva production (no change in carries)
Decreased tone/motility (progesterone)
Decreased risk of PUD
Increased GE reflux (prog relaxation)
Early saiety in 3rd
Appendix rises
Increased portal venous pressure (hemorrhoids)

26
Q

Increased caloric intake during preg

A

1st: 200cal/day

2/3rd: 300 cal/day

27
Q

Gallbladder changes

A

Increased residual volume
Decreased motility
Increased risk of stone
Tx: low fat diet and elective ectomy (if mid-trimester, better outcomes)

28
Q

Liver changes

A

Spider angioma, palmar erythemia all normal (increased E2, “glow”)
Decreased albumin/protein (hemodilution)
Elevated alk phos (placental production)
Cholestasis (most common, jaundice, can lead to malabsorbtion of fat -> vit K def)

29
Q

Skin changes

A

Hyperpigmentation (hCG stimluation of MSH)
Increased blood flow to skin
Gum hyperemia

30
Q

5 important pregnancy hormones

A 
hCG
hPL
hPGH
Progesterone
Estrogen
31
Q

Iodine requirements in pregnancy

A

Increase

32
Q

PTH-rp and pregnancy

A

Produced by placenta, decidua, fetal parathyroids, and mammary glands
Regulates Ca2+ transport
Increased 1,25OH x2

33
Q

3 steroid hormones from placents

A

Progesterone
Estrogen
1,25OH Vit D

Levels: maternal»»fetal
Maternal system sees effect more than fetus

34
Q

Progesterone secretion maintained by:

Main, important action

A

Corpus luteum up to ~8-10weeks
Placenta takes over after

Prevent preterm labor
(progesterone antagonists given as abortive tx)

35
Q

a subunit of ßhCG is same as

ß subunit is similar to

A

FSH
LH
TSH (increased T4, decrease TSH early in preg)

ß is most similar to LH (more LH activity)

36
Q

ßhCG levels

A

Produced 8 days after ovulation
Doubles q 48 hours for first 5-6 weeks
Peaks at 10-12 weeks (peak of n/v, maintains CL)
t1/2 = 24-36 hours

37
Q

Human placental lactogen (hPL)

A

Secreted by synctioTB
Similar to GH and PRL (more PRL)
Made increasing amounts in pregnancy, very high at end of pregnancy
Increases insulin resistance, change to FFA metabolism
Also stimulates insulin secretion

38
Q

Human placental growth hormone (hPGH)

A

Secreted by synctioTB
Similar to GH (not regulated by GHRH)
Causes insulin resistance
Causes decrease in pit GH secretion

39
Q

Insulin resistance in pregnancy mediated by

A

hPL
hPGH
TNF-a (increases with preg)
Adiponectin (decreases with preg)

40
Q

Progesterone

A 
LDL receptors on placenta
LDL required for progesterone synth.
Promotes deciuda formation
Inhibits uterine contraction
Promotes Th2 response and suppress Th1 response
Can actually improve autoimmunity d/o
Lobular development in breast
Lots of relaxant effects
41
Q

Estriol

A

Only seen in pregnancy
Maternal cholesterol, placental progesterone, fetal DHEAS (adrenal), fetal 16-OH DHEAS (liver), placental estriol to maternal circulation

42
Q

Aromatase in placenta

A

DHEA to E2 plus Estrone

Even in PCOS, CAH etc -> low low chance of excess virulization of fetus

43
Q

Estrogen

A

Increased production
Produced by placenta due to aromatase (DHEAS)
Hypercoaguable state
Induces lactrotrophs (PRL, don’t give E2 with trouble feeding)
Increases blood flow, volume
Increased TG synth. (acute pan risk)
Increased pit size (Sheehan’s risk)

44
Q

Insulin changes of normal pregnancy/GDM

A

Can reveal LADA (thin women with GDM, think LADA)
Insulin sensitivity in 1st tri, risk for night hypogly
Insulin resistance in 2nd/3rd with hPL, hPGH, TNF-a and adiponectin
GDM is risk factor for T2DM later on

45
Q

OGTT in pregnancy

A

Normal pregnancy have normal BG but slightly higher post-prandial (due to resistance)
GDM have much higher BG levels

46
Q

Why do obese women give birth to larger babies?

A

BG are on average higher than normal, but not GDM high
Trigly also high early and late in preg
Late -> more E2 -> more acute pan risk

47
Q

Postpartum management of GDM

A

50% risk T2DM in 20 yrs
OGTT 6-12 weeks PP to dx or stratify risk
Contraception to prevent future preg
Breast feeding decreases T2DM risk

48
Q

Neonatal GDM risk after birth

A 
LGA, shoulder dystocia
Infant RDS
Hypoglycemia (mom sugar cross, high baby insulin, mom sugar gone after delivery, baby insulin still high)
Hyperbili
Polycythemic (outgrow own blood supply)

OGTT doesn’t help predict infant mortality (only maternal T2DM risk)

49
Q

Risk factors for childhood obesity

A 
Maternal glucose status is big but also:
Maternal BMI
LGA
Lipids, dietary fat
Rate of weight gain 0-6 months
Feeding most (breast feeding is protective)
50
Q

Thyroid function in pregnancy

A

ßhCG has TSH activity: increases T4
E2 increases binding globulin (TBG -> increases T4)
Higher T4 suppresses normal TSH

51
Q

Thyroid stuff that crosses placenta

A

Anti-thyroid drugs cross well (make sure REAL)
TSH receptor ab (Grave’s) cross well
T4 crosses okay

52
Q

Postpartum thyroiditis

A 
Destruction of gland
Histologically looks like Hashimoto's
Transient increase in T4 (from cell breakdown)
Risk of recurrence in future pregnancies
Monitor for chronic hypothyroid
Tx. transient increase with ß-blocker
Tx. hypothyroid and re-evaluate in year

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