Maternal Physio - Hema and Immuno

Question 1

Pregnancy is a state of ____ [hypo/hypervolemia]

Answer 1

Hypervolemia

Question 2

Hypervolemia averages ___ percent above the nonpregnant blood volume after ___ weeks

Answer 2

• 40 to 45 percent
• 32 to 34

Note:

• This begins in the 1^st trimester
• Most rapid increase on 2^nd trimester

Summary:

• 12 weeks – 15%
• 32 weeks – 40 to 45%

Question 3

When does increase in blood volume begin? When is it fastest?

Answer 3

• Begins in the 1^st trimester
• Most rapid increase on 2^nd trimester

Question 4

The rationale of hypervolemia

Answer 4

1. To meet the metabolic demands of the enlarged uterus with its greatly hypertrophied vascular system
2. To provide an abundance of nutrients and elements to support the rapidly growing placenta and fetus
3. To protect the mother and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions
4. To safeguard the mother against the adverse effects of blood loss associated with parturition

Question 5

In hypervolemia, what blood components increase?

Answer 5

Plasma and erythrocytes but proportionately more plasma

Question 6

Reflects ↑ erythrocyte production

Answer 6

↑ Reticulocyte count

• Note:*
• As such, there is moderate erythroid hyperplasia in the bone marrow

Question 7

What happens to hgb concentration and hct during pregnancy? What is mechanism?

Answer 7

They decrease; because of great plasma augmentation

Question 8

Normal hemoglobin level during pregnancy

Answer 8

12.5 g/dL

Question 9

Abnormal levels of hgb per trimester

Answer 9

• First
  
  • < 10 g/dl
• Second
  
  • < 10.5 g/dl
• Third
  
  • < 11 g/dl
• Note:*
• Anemia in pregnancy is defined as hgb < 11 g/dl

Question 10

Define anemia of pregnancy

Answer 10

Levels below 11.0 g/dL

Question 11

When does physiologic anemia of pregnancy occur?

Answer 11

T2

• Note:*
• This makes sense as hypervolemia happens fastest during the second trimester

Question 12

What change happens to whole blood viscosity?

Answer 12

Decreased

• Note:*
• Makes sense because although both RBC and plasma increases, plasma increases more so the hgb, hct and viscosity is decreased

Question 13

Iron requirements in normal pregnancy is about how much? Describe the appropriation.

Answer 13

• 1000 mg/day
  
  • 300 mg are actively transferred to the fetus and placenta
  • 200 mg are lost (primarily in GIT)
  • 500 mg due to increase in circulating erythrocytes

Summary:

• Most of the iron (50%) is used for hematopoiesis, especially in the last half of pregnancy
• 300 for the 3aby

Question 14

Normal estimated blood loss in:

• Single NSD
• Twin NSD
• CS

Answer 14

• Single NSD
  
  • 500 to 600 cc
• Twin NSD
  
  • 1,000 cc
• CS
  
  • 1,000 cc

Question 15

T/F. Maternal blood volume ↑ more if having twins or higher order gestations as compared to singleton

Answer 15

True

Question 16

Why is there a need for iron supplementation?

Answer 16

The amount of iron from the diet is insufficient to meet the needs of the pregnancy, so patients must take supplemental iron

Question 17

Suppression of ____ is requisite for pregnancy continuation

Answer 17

Th1 response

Question 18

Immunologic function during pregnancy (in general)

Answer 18

• Suppression of humoral and cell-mediated immunological functions
  
  • Suppression of Th1 response is requisite for pregnancy continuation

Question 19

Suppressed and upregulated immunologic activities

Answer 19

• Suppressed activity
  
  • Decreased secretion of IL-2, interferon, and TNF-β due to Th1 and Tc1 suppression
• Upregulated activity
  
  • ↑ secretion of IL-4, IL-6, IL-13 d/t Th2 upregulation
  • IgA and IgG in cervical mucus
  • IL-1B in cervical and vaginal mucus

Question 20

Clinical implication of TH1 suppression in pregnancy

Answer 20

Results in remission of some autoimmune disorders such as RA, MS and Hashimoto thyroiditis

Question 21

Failure of Th1 suppression may be related to development of ____

Answer 21

Pre-eclampsia

Question 22

Normal leukocyte count during normal pregnancy and labor

Answer 22

• 5,000 to 12,000/μL (upper value up to 15,000/μL)
• During labor and early puerperium > 25,000/μL

Question 23

If WBC is elevated 24 hours after delivery, entertain what possible diagnosis?

Answer 23

Endometriosis

Question 24

Markers of inflammatory states, when and how

Answer 24

• ↑ CRP throughout pregnancy
• ↑ ESR d/t elevated plasma globulins and fibrinogen
• ↑ C3 and C4 during the 2^nd and 3^rd trimester

Question 25

Coagulation and fibrinolysis factors that increase during pregnancy

Answer 25

• Fibrinogen
• Factor VII
• Factor X
• Plasminogen

Note:

• 1, 7, 10, plasminogen
• Oen, seven, ten, plasminogen

Question 26

Hormone that causes an ↑ in clotting factors

Answer 26

Estrogen

Memory aid:

• Oen, seven, ten, plasgminogen
• Estroge

Question 27

Coagulation and fibrinolysis factors that decrease during pregnancy

Answer 27

• aPTT
• tPA
• Antithrombin III
• Protein C
• Protein S
• Platelet

Memory aid:

• a_P_TT
• t_P_A
• Antithrombin III
• _P_rotein C
• _P_rotein S
• _P_latelet

Question 28

What happens to the platelet level during pregnancy? What is the mechanism?

Answer 28

• Decreased (213,000/µL [non-pregnant 250,000])
• Mechanism
  
  • Physiologic
    
    • possibly due to hemodilution
    • increased platelet consumption
    • production of thromboxane A2, which induces platelet aggregation

Question 29

Platelet level returns to normal level when?

Answer 29

2 to 4 weeks postpartum

Question 30

Thrombocytopenia platelet level

Answer 30

116,000/mL