Maternal, Fetal, and Neonatal Flashcards
Name the three hormones important to pregnancy
- hCG (Human chorionic gonadotropin)
- Estrogen
- Progesterone
1st Trimester
Corpus Luteum: hCG (Human chorionic gonadotropin) increase
Ovarian: Estrogen and Progesterone increase
2nd Trimester
Corpus Luteum (regresses): hCG decreased
Placenta: takes over Estrogen and Progesteron production (and increase)
3rd Trimester
Placenta:
* hCG plateaus after decrease
* Decrease in Progesterone
* Continued increase in Estrogen
What do “take home” pregnancy tests check for?
hCG
Two physiological changes in mom
Blood Volume increases (1-2 L or 30%)
* Plasma increases more than RBC’s
Hypercoagulability
* Increased Fibrinogen in plasma
Why does moms blood volume increase?
Aldosterone = increase in RAAS
RAAS + Estrogen = increased ADH
Why does mom need more coagulation factors?
Body is preparing for blood loss during natural birth
Up to 25% loss
Moms CO increases by ~30%, Why?
SV increased due to more volume (RAAS)
slight HR increase
CO=HRxSV
Moms BP(MAP) decreases by 5-7%, why?
SVR decreases by 25%
release of Nitric Oxide vasodilates peripherals
Supine Hypotension Syndrome
in 5-10% of women
Instead of an increase in SVR to compensate there is a paradoxical parasympathetic response causing hypotension and fetal bradycardia
Treatment: Lay on her left side to decompress IVC
Increased Progesterone changes pulmonary function, how?
Increase in Tidal Volume
1. Progesterone= ⬆ CO2 sensitivity
2. ⬆ VO2 = ⬆ CO2 = ⬆ ventilation
3. (MV=RRxTV) no change in RR but ⬆ in TV = ⬆ PaO2 and ⬇ PaCO2
Uterine size changes pulmonary function, how?
Uterine size ⬆
Pushes up on diaphram (~4cm)
⬇ in RV and FRC
⬇ ERV and ⬆ in IC
Why does TLC and VC basically remain the same?
Increase in abdominal and thoracic dimensions compensate for larger lung expansion (⬆ TV)
⬆GFR in mom, why?
up to 40% and maintanence
- Nitric Oxide
- Relaxin
Both are vasodilators, ⬆ blood flow
Relaxin also does what?
Makes the pubic symphysis more compliant for birth
⬇RBF in 3rd trimester, why?
RBF: Renal Blood Flow
ANG II
vasoconstrictor
If RBF is ⬇ in the 3rd trimester how does GFR remain elevated?
ANG II vasoconstricts after the glomerulus, so bloodflow for filtration does not decrease
Creatinine in mom
0.5-0.6 mg/dL
* Normal levels 0.6-1.3
If you see a 1 it is likely pre-eclampsia
Placental hCS in mom
human chorionic somatomammotropin
makes mom IR
metabolizes glucose for baby
starts lipolysis (to form FFA) for mom
Gestational Diabetes
Increased Calcitriol and Calcitonin in mom
Lower PTH
⬆Ca2+ absorption
⬆PO4- absorption
Not through bone turnover
Thyroid in mom
bone turnover
neural development
At risk: cretinism (hypothyroidism)
What else can hCG bind to?
TSH receptors
Trophoblastic nutrition is also called what
Uterine milk
yuck
Main trophoblastic nutrition hormone?
Progesterone
Three phases to placental development
- Adhesion
- Invasion (two steps)
- Implantation
Adhesion Phase
Trophoblasts stick to endometrial tissue
Invasion Phase
Trophoblasts differentiate into two cell types
1. Cytotrophoblasts
2. Syncytiotrophoblasts
Sync cells form lacuna which digests moms blood vessels
Sync cells directly exposed to moms blood
Sync cells produce placental hormones (mostly hCG and some hCS)
hCG: Human chorionic gonadotropin and hCS: human chorionic somatomammotropin
Growth Factors
3
- IGF (Insulin like)
- TGF (transforming)
- EGF (epidermal)
Cytotrophoblasts
Inner layer of the trophoblast
This anchors the blastocyst to the uterine wall
Syncytiotrophoblast
- Fused cytotrophoblasts create this
- they extend outward to blood and glands
Implantation Phase
Cytotrophoblasts makeup the chorionic cilli
-Fetal capillary network
-serves as the border between maternal and fetal blood
What is Pre-eclampsia
usually in older / diabetic / and obese women
Trophoblasts can not invade deeply into tissues
-Growth restrictions
What is placenta accreta
Attachment extends into muscle layer (myometrium)
-results in continued placental bleeding after birth
What are the functions of the placenta
G-LIKE
Acts as the:
* Gut
* Lungs
* Immune modulator
* Kidneys
* Endocrine glands
Increased transfer of drugs across placenta are:
4 things
- Low molecular weight
- Lipid soluable
- Non-charged
- Non-protein binding
What drugs can cross the placenta?
MOVABLE-II
Most Anticholinergics (Atropine)
Opioids
Vasopressors
Antihypertensives
Benzos
Local anesthetics
Ethanol
Induction agents
Inhalation anesthetics
What drugs cross poorly?
Heparin (Large and charged)
Insulin (Large)
Muscle relaxants (Ionized and not lipid soluable)
1st & 2nd Trimester; which hormone is more important
Progesterone
3rd Trimester; which hormone is more important
Estrogen
Prostaglandins in the uterus?
These help create contractions
What does Progesterone do?
4 things
Decrease gap junctions
decrease oxytocin receptors
inhibits prostaglandins
creates a more negative resting membrane potential
Basically makes any contraction (aka labor) less likely to occur
What does Estrogen do?
4 things
Increases gap junctions
increases oxytocin receptors
increases prostoglandin receptors
creates a more positive resting membrane potential (enchancing contractions)
Braxton hicks contractions?
Flase Labor contractions
Does not increase in rate or strength
what two things trigger birth?
hormone factors: increase E2:P ratio, prostaglandins and oxytocin
mechanical factor: Ferguson reflex
what are the phases of birth?
0 - quiescence
1 - myometrial activation
2 - stimulation
3- involution
what happens in quiescence?
trimesters 1-2
progesterone and NO high
decrease in intracell calc = relax
what happens in myometrial activation?
last 6-8 wks
increases E:P ratio, PG, relaxin, oxy receptors, gap junc
braxton hicks
what happens in stimulation?
oxytocin, PG, stretch, uterine contraction
what happens in involution
ocytocin, PG
decrease post bleed
increase uterine repair
how much is full dilation?
10 cm
labor and delivery stages (stimulation phase)
dilation stage (6-12 hr) contrac to full dilation
expulsion stage (20m-2hr) full dilation to baby out
placental phase (15m) baby out to placenta out
describe ferguson reflex
baby head stretches cervix and positive feedback for oxy and increased contraction at fundus pushes baby down
what things would result in decreased contraction?
beta adrenergic, cAMP or NO, if you increase cAMP or cGMP that inhibits contraction
what things would result in increased contractions?
Prostaglandin (PGE2 & PF2a)
Oxytocin activation of IP3 and DAG
IP3 and DAG increase intercellular calc = more muscle contraction
what is the APGAR?
10 pt scale of baby
check at 1min and 5 min
<7 you need to be concerned
what does APGAR stand for?
appearance (blue?)
pulse (>100)
grimace (crys and pulls away)
activity (active mvmt)
respiration (strong cry)
2-1-0 pts
Less than 7 is bad
Twins can be?
2 types of twins
- Monozygotic: identical
- Dizygotic: fraternal
Dichorionic diamnionic
Own Sac
Own placenta
Twin with*
Monochorionic diamniotic
Own sac
One placenta
Twin with*
Monochorionic monoamniotic
One Sac
One Placenta
Twin with*
Monochorionic monoamniotic: conjoined twins
One Sac
One Placenta
the two fetus’ are joined
how does crying/suckling relay information to the CNS?
sensory afferents
regulation of lactation summary
stimulated by decrease in E2 and P after birth
sensory information inhibits PIH (dopamine)
stimulates oxytocin and Prolactin to be released
prolactin causes milk secretions
oxytocin causes muscle contraction in breast
lactational amenorrhea
prolactin inhibition of FSH and LH
Temporary infertility that accompanies breastfeeding and is marked by the absence of monthly periods
what is bilirubin?
yellow compound made when the liver is breaking down Hb
what do neonates do after birth with their Hb?
they try to replace HbF with HbAdult
what are the 4 shunts in fetal circulation?
placenta shunt: umbilical vein to liver
ductus venosus: umbilical vein to IVC
ductus arteriosus: PA to Aorta
foramen ovale: opening between LA and RA
what are the 6 circulatory changes with fetal vs neonate?
1- loss of placental BF (2x increase in SVR)
2- PVR decreases (lung expand and oxygen)
3- disintegration of umbilical cord (umb vein repaced with round ligament; umbilical artery is now iliac artery)
4- closure of ductus venosus (1-3 hr) blood flows to portal vein
5- ductus arteriosus closes at birth
6- foramen ovale closes at birth
what types of mothers/birth would you see low surfactant
premature
diabetic
fetus vs neonate lungs
fetus- amniotic fluid and movements of breaths
neonate- ENaC pump moves water out of lungs
transient tachypnea
abnormal fast breathing starts after 4-6 hr from birth
give oxygen and wait 1-2 days
respiratory distress syndrome
lack of surfactant
give surfactant and cpap/vent
what are the 3 neonatal respiratory triggers
sensory (being born)
mechanical (birth, squeezes lung)
chemical stimulation (cut umbilical = acidosis (increased CO2)
what are the 3 challenges a neonate faces at birth
hypoxia
hypoglycemia
hypothermia
what things in a neonate cause hypoxia
anesthestic depression
Hb phenotype
nasal breather
soft tissue obstruction
ETT may be difficult
why is hypoglycemia a problem in neonates?
limited gluconeogensis
glucose dependent brain
what are the threats for hypothermia for neonates?
radiation
conduction
convection
evaporation
