Phys and Pathophys - part 2 - Exam 1 Flashcards
During pregnancy, PMI shifts ____ and heart size increases _____
PMI shifts laterally and heart size increases by 12%
What is supine hypotensive syndrome due to?
compression of the inferior vena cava that causes hypotension, bradycardia and syncope when the pregnant pt lies supine
What cardiovascular changes will all INCREASE when pregnanct?
-stroke volume
-heart rate
-cardiac output
-blood flow distribution to the uterus, kidneys, breast and skin
- LE venous pressure increases
What heart rate increase in normal for a preg pt?
~ 15 bpm more at term than nonpregnant rate
progressively increases as the preg progresses and can be increased more for multiple gestations
What 2 cardiovascular changes DECREASE in preg?
-BP decreases slightly
-peripheral vascular resistance
What does increased LE venous pressure result in?
edema and varicosities
Why does peripheral vascular resistance decrease in preg?
due to enhanced vasodilators
Where are systolic murmurs the most common in preg? Why? How common are they?
Murmurs or bruits at left sternal edge
internal thoracic (mammary) artery
up to 90%! very common
What are some EKG changes that may be seen in pregnancy?
May see left axis shift, ST depression, T-wave flattening
What are 2 respiratory anatomic changes seen in preg?
Capillary dilation
rib cage is increasingly displaced upward and thoracic circumference is increased
What is the net effect of respiratory changes due to preg? Often can result in _______
less overall lung space, but less “dead space” and increased tidal volume
aka respiratory rate is constance but gas exchange efficiency is better
mild respiratory alkalosis due to more CO2 being expelled
What renal changes are seen with pregnancy?
Increased renal size
Dilated renal calyces and pelves
Dilated and tortuous ureters
Bladder - displaced upward,
flattened, decreased tone
What 3 renal functions increase with pregnancy?
plasma flow
GFR
Creatinine clearance resulting in LOWER serium CR and BUN
_____ activity increases when pregnancy and is very resistant to _____ effect
renin
pressor effects
Why would renin increase if not to cause vasopressor effects?
renin causes increased Na and water absorption which helps maintain the higher blood volume needed when pregnant
What are 2 noteworthy GI system effects due to preg?
increased salivation
decreased intestinal transit times in the 2nd and 3rd trimester
______ is an extremely common GI complaint due to preg? What are the 3 reasons behind it?
Reflux/heartburn in 30-80% of gravidas
Greater production of gastrin
Decreased esophageal peristalsis
Hormone-mediated relaxation of LES
what 2 liver changes are seen during preg?
Mild decrease in protein, esp. albumin
Increased serum alkaline phosphatase: due to alk phos isoenzymes from placenta
What electrolyte is especially affected by albumin?
calcium, because it is protein bound
During preg the blood volume increases by ______. Describe the process that leads to this.
50%
increased estrogen → stimulates RAAS → increased aldosterone → Na+ reabsorption → water retention
Why do you think we see a physiologic anemia in pregnancy?
due to disproportional amount of increase of blood volume (50%) to increase in RBC (33%)
Why are preg pts more likely to clot? give 3 reasons
Increase in several clotting factors
Decrease in protein S, fibrinolytic activity
Platelet count decreases due to hemodilution
Does immune function increase or decrease with preg? Do AI diseases tend to get better or worse with preg?
slightly decrease
AI diseases tend to get better
What effect does preg have on the pituitary gland?
Enlarges by 135% during normal pregnancy
growth hormone is increased
prolactin is 10X greater than normal
does prolactin increase or decrease after delivery? When is prolactin levels the highest?
decrease after delivery even in breastfeeding women
highest during pregnancy
hCG structurally similar to _____. ____ naturally drops during pregnancy. Can be mistaken for ______. Low ______ can mask ______ in preg
TSH
TSH
hyperthyroidism (need to check free T4 levels)
TSH, hypothyroidism
PTH is ____ in first trimester and _____ in 2nd/3rd trimester
decreased in first and increased in 2nd/3rd
Is calcium increased or decreased in pregnancy? Why?
calcium is decreased
Due to ↑ plasma volume, ↑ GFR, fetal transfer, lower albumin
Is vit D increased or decreased?
increased
Are ACTH and free cortisol increased or decreased? Aldosterine? why?
increased
increased- RAAS activity, can help protect against natriuresis
What is a common eye complaint for preg pts? is IOP increased or decreased?
contacts due not fit as well but visual function is normal
IOP decreases
during preg, cornea ______. What are Krukenberg spindles?
cornea thickens
brownish-red opacity on posterior cornea
What is the dark line on the abdomen called? What is melasma?
linea nigra
uneven darkening on the face that is exacerbated by sun exposure
also common in women who are on OCP
What is the technical term for stretch marks? what are they caused by?
Striae gravidarum
Thick, hyperemic skin caused by decreased collagen adhesiveness and increased ground substance formation
What is Cutis marmorata?
mottled appearance of skin
secondary to vasomotor instability
What are Beau’s lines?
Nails - brittle; horizontal grooves
What is this?
spider angioma
What is the average weight gain recommended for a preg pt?
25-35 lbs
What change to carb metabolism is common in preg?
Hyperinsulinemia and insulin resistance
because your body wants to keep glucose in the blood to help maintain fetal development
What 4 electrolyte metabolism are decreased?
sodium, potassium, calcium, magnesium
little change in phosphate
_______ is decreased in preg and needs to be supplemented in a NORMAL preg. Is fetal RBC production impaired if it is NOT supplemented?
IRON
fetal RBC production is NOT impaired, only harms the mother
What 4 specials “things” need to be supplemented in a preg pt’s diet?
iron, folic acid, calcium and zinc
these 3 especially
how many additional calories are needed during a preg females diet? during lactation?
pregnancy: 300 calories
lactation: 500 calories
What is the protein requirement for a preg female?
1 g/kg/day, plus 20 g/d in 2nd half of pregnancy
60-80 g/d in the average woman
What is the calcium requirement for a preg female? At what level does the maternal skeleton demineralize?
1200 mg during pregnancy and lactation
< 600 mg/d - maternal skeleton demineralization
How much iron is recommended per day for a preg pt?
60-120 mg/day
________ reduces the risk of neural tube defects. _____is needed 1 month prior to conception and through the first 3 months of pregnancy
folic acid
0.4mg/day
what is the recommended folic acid supplementation if the pt is insulin-dependent DM or taking valproic
acid or carbamazepine? _____ is recommendation if hx of neural tube defects
1mg/day
4mg/day
__________ may help with N/V of pregnancy
B6 + doxylamine
What is the recommended dietary intake for Vit C? How does it compare to a non-preg pt?
80-85mg/day
20% more than nonpregnant
What macronutrient is crucial for embryonic development?
protein
What are the 3 functions of the placenta? Is the placenta fetal or maternal in orgin?
Release hormones and enzymes to maternal bloodstream
Transport of all fetal nutrients and metabolic products
Exchange of O2 and CO2 for fetal circulation
placenta is fetal in origin
How is arterial bleeding controlled in the placenta?
bleeding is controlled by uterine contraction
What do placental secretions help with?
Help control intrauterine growth, maturation of vital organs, and childbirth
including hCG, placental proteins, steroids
T/F: Very few drugs/substances will cross the placenta
FALSE!! most substances WILL CROSS the placenta
large molecular size or charge will have a HARDER time crossing: heparin, insulin
If a drug is bound to albumin will it be less likely or more likely to cross the placenta?
MORE likely to cross the placenta
______ from uterine spiral arteries drains freely into sinuses around placental villi. _______ helps control the amount of blood flow.
Maternal blood
The degree of uterine wall contraction
What antibody is small enough to cross the placental barrier?
maternal IgG
What is a zygote? Once it divides it forms a ball of cells known as the ______
a single sperm enters the egg cell
morula
When does the morula enter the uterus?
3-5 days after fertilization
What causes a blastocyst to form?
Gradual accumulation of fluid between cells of morula
a blastocyst inner cell group becomes the _______. The outer cell group becomes ________
inner: embryo
outer: supportive tissues
Day______: blastocyst implants and invades the endometrium and myometrium
**Day ______ : blastocyst is totally encased in endometrium
6-7
**10 aka fully buried in the uterus
During weeks 1-4 of gestation, the outer cell group will form _______ and the inner cell group will form _____
Outer cell group - chorionic villi → becomes placenta
Inner cell group → becomes major cell lines that eventually give rise to distinct tissues
What are the 3 layers of embryonic tissue? What give rise to each?
Endoderm - innermost layer: Epithelial lining of multiple systems
Mesoderm - middle layer: connective tissue
Ectoderm - outermost layer: pidermis, sweat glands, hair, nails, tooth enamel, “outer epithelium: lining of mouth, nostrils and anus, nervous system
What 4 things begin developing at week 5?
brain, spinal cord, heart and GI tract
What is important to remember about week 6-7 of gestation?
development of eyes, ears and some bones
limb bud and some cranial nerves
heart begins to beat
What is important to note about week 8?
lungs begin to develop
what is important to note about week 9?
all essential organs have begun to form
What is important to note about week 10?
fetal heart tones are audible by doppler US
marks the END of embryonic period
What is important to note about weeks 11-14?
RBC are produced in the liver
urine is produced and put into amniotic fluid
center of ossification in most fetal bones
What is important to note about weeks 15-18?
fine hair called lanugo develops
sucking movement starts
meconium is produced in the intestinal tract
What is important to note about weeks 19-21?
fetus is capable of hearing
mother may begin to feel “fluttering” fetal movement
What is considered midpoint of pregnancy?
week 20
What is important to note about week 23-25?
bone marrow begins to make blood cells
fingerprints and footprints form
fetus may respond to sounds
**What week does the fetus have up to 90% of survivability? Why?
Week 26
alveoli form in the lungs
What is important to note about week 26?
fetus has hand and startle reflex
alveoli form in lungs
**What is super important to note about weeks 27-30?
**surfactant begins to be produced
What is important to note about weeks 31-42?
fetus begins storing iron, calcium and phosphorus (weeks 31-34)
increase in body fat
During what months of pregnancy is there the greatest risk of major fetal malformations?
first 2 months
specifically weeks 3-8
_______ is one of the highest embryologic malformations in the entire body system. 20% are due from _______
Malformations of GU tract
Genetic/inheritance
_______ is needed for a male GU tract. When does formation of GU structures begin?
Functional Y chromosome
Weeks 4-8
What is the embryological reproductive development order?
genetic → gonadal → ductal → genital
What does genetic reproductive embryologic development determine by?
determined at fertilization by sex chromosomes
How does the gonadal part of embryologic development work?
genetic sex is expressed on developing gonadal tissue
Sex-determining region of Y chromosome encodes for testis-determining factor (TDF)
What is the purpose of testis-determining factor (TDF)? Where is it found? When does it begin?
gonad differentiates into a testis with production of antimüllerian hormone and testosterone
Sex-determining region of Y chromosome
begins about week 8
What are the 2 different names for “male” ducts?
Wolffian ducts
mesonephric ducts
What are the 2 different names for female ducts?
Müllerian ducts
paramesonephric ducts
What is the responsibility of antimullerian hormone?
suppresses “female” Müllerian (paramesonephric) ducts
until ductal differentiation, the embryo has both female and male ducts
what is the role of testosterone in embryologic development?
persistence and differentiation of “male” Wolffian (mesonephric) ducts
What is the difference between agenesis and agonadism?
agenesis - gonad did not form at all
agonadism - gonads formed initially and later degenerated
What are streak gonads? What are the possibly caused by?
primordial gonadal formation, no differentiation due to lack of germ cells
May have release of antimüllerian hormone without any production of testosterone - suppresses both ducts
What is the cloaca? At what point does the urorectal septum form?
precursor of urogenital structures
weeks 5-7
What does the urorectal septum divide?
divides cloaca into the urogenital sinus and the anorectal canal
What does the cloaca become in a male? female?
male: urinary bladder, urethra, and penis
female: urinary bladder, urethra and vagina
What is vaginal atresia?
the lower portion of the vagina is only fibrous tissue
as a male develops the Wolffian ducts become _______, _______ and _______
Epididymis, ductus deferens, ejaculatory ducts
In males, what is the vestigial remnant of the Wolffian ducts? mullerian duct?
Wolffian: appendix epididymis
Mullerian: appendix testis
at the _____ week the testes descend through the inguinal canal. _____ week the testes is in the scrotum
28th week: descend through inguinal canal
32nd week: testes in scrotum
In females, what happens to the Wolffian ducts?
mostly regress and becomes trigone of bladder
in females, what happens to the mullerian ducts? Do they require ovaries to differentiate?
Midline fusion → uterus
Distal ducts → oviducts
do NOT require ovaries to differentiate, unlike in males that DO NEED testes (to provide testosterone) to differentiate
What does a bifid/double clitoris indicate? what does a hypertrophic clitoris indicate?
failure of fusion of the embryonic clitoris
intersex disorder
Quiz yourself over this slide deck before you take the test. View in presentation mode!!. DO IT!!!
https://docs.google.com/presentation/d/1HCpaf8zHsf9ziAQlaOrPGC8LPGP27ybT7t_sG5TZ3wo/edit#slide=id.gee8a4675b_0_100
In order to normally develop has a male what 3 things must be true
- Need functional XY chromosomes
- Need antimullerian hormone to “get rid” of mullerian ducts
- Need Testosterone to be present to encourage the growth of Wolffian ducts
