The Placenta, Umbilical Cord, & Amniotic Cavity, changes of pregnancy Flashcards

1
Q

The Placenta

general

A

Temporary fetal organ that begins developing shortly after implantation

Roles of the placenta:
Facilitating nutrient, and gas and waste exchange between maternal and fetal circulations
Serves as an endocrine organ producing hormones that regulate both maternal and fetal physiology during pregnancy

Placental cells (trophoblasts) invade and start to remodel the uterine vasculature within a few hours after implantation → starts to produce hCG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Placental Structure

A

Flat, discoid organ measuring 20-25 cm in diameter and 3 cm in thickness

Membranes (fuses into a single membrane by delivery):
Amnion
Chorion

2 sides:
Basal plate (maternal side):
Divided into lobes
Separated by septa

Chorionic plate (fetal side):
Contains branching chorionic villi, providing a massive surface for exchange
Umbilical cord emerges from the fetal side of the placenta

Umbilical cord:
2arteries
1 vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Placental Circulation

A

Chorionic villi provide a large surface area for maternal–fetal exchange

Spiralarteries(maternal) fill the intervillous spaces in the decidua basalis layer of the endometrium:
-Bring in oxygenated blood for fetus
-Spiralarteries“rupture” and become large spaces called lacunae

2 umbilical arteries bring deoxygenated blood from fetus to placental chorionic villi

Gas and molecule exchange occurs between the fetal blood in the chorionic villi and the maternal blood in the lacunae, across the placental barrier

1umbilical veintransports oxygenated blood back to the fetus

Maternalveinstake deoxygenated blood back to the maternalcirculation

Maternal and fetal blood never come into direct contact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Functions of the Placenta

A

Gas exchange
O2-CO2exchange
Occurs via simplediffusion
Fetal hemoglobin has ↑ affinity for oxygen compared to maternal hemoglobin

Nutrient exchange
Provides materials needed for fetal development and growth
Mechanisms of exchange:
Water andsodiumby simplediffusion
Glucoseby facilitateddiffusion
Large molecules (LDLs, peptides,antibodies) by receptor-mediatedendocytosis
Amino acidsby secondaryactive transport

Metabolic functions
Glycogen synthesis
Cholesterolsynthesis
Protein metabolism

Waste product removal
Waste products (urea and CO2) are transported back to the mother
Occurs via simplediffusion

Hormonal secretion
Human chorionic gonadotropin(hCG): Maintains the activity of the corpus luteum required for continuation ofpregnancy
Human growth hormone(hGH)
Human placental lactogen: Stimulates maternal insulin production to ↑ glucose available to the fetus
Chorionic thyrotropin
Chorioniccorticotropin-releasing hormone(CRH)
Progesterone: Maintainspregnancy, preventsmenstruation
Estrogens
Glucocorticoids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Placenta previa

general, Dx, Tx

A

Abnormal attachment of the placenta in the lower uterine segment

Can obstruct (partially or completely) the internal cervical os
Maternal and fetal hemorrhage can result fromcervical dilation

Classically presents as painless bright red vaginal bleeding

Diagnosed by ultrasound

Treatment:
Pelvic rest (avoiding digital exams and intercourse)
Delivery via C-section prior to the onset oflabor(or emergently if there is clinical bleeding)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Abnormal implantation of the placenta into the uterine wall

dx, tx

A

Placenta accreta
Chorionic villi invade to the myometrium

Placenta increta
Chorionic villi penetrate deeper into the myometrium

Placenta percreta
Chorionic villi reach the uterine serosa and/or invade other organs

Diagnosed by ultrasound

Treatment:
Delivery via planned C-section, sometimes with concurrent hysterectomy (especially in cases of placenta increta and placenta percreta)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Placental abruption

general, dx, tx

A

Premature separation of the normally implanted placenta from the uterus

Clinical diagnosis based on a presentation with painful contractions with or without bleeding
Large abruptions may be seen on ultrasound

Treatment
Depends on thegestational ageand size of abruption
Significant abruptions require immediate delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

The Umbilical Cord

general and length

A

Connects the fetus to the placenta
Extends from the fetal umbilicus to the fetal surface of the placenta

Cord length:
Depends on amniotic fluid volume and fetal mobility
Average length: 55 cm
≤ 40 cm is considered a short cord

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Umbilical cord

structure

A

Vessels
Contains 2arteriesand 1 vein
Vessels are surrounded by a protective substance called Wharton’s jelly
Counted by sonographic evaluation, with the 3 vessels seen in the 1st trimester
Coiling: the vein andarteriesspiral around each other

Bloodflow
Umbilical vein supplies oxygenated blood to the fetus
Umbilicalarteriestake deoxygenated blood away from the fetus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Umbilical cord structure

Insertion into the placenta:

A

Normal: central insertion

Variants:
Eccentric: off center

Marginal: the cord inserts on the edge of the placenta

Velamentous: last portion of the umbilical cord lacks the protective Wharton’s jelly, leaving the umbilical vessels exposed

Abnormal insertion
Increases the risk of complications duringlaborand/or delivery
Umbilical cord rupture and/or prenatal hemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Amniotic Cavity

functions and amnioin

A

Fluid-filled cavity that encases the developingembryo/fetus

Functions of the amniotic cavity
Protects fetus against trauma
Protects umbilical cord against compression
Nutrientreservoirfor the fetus
Provides space for normal fetal growth and development

Amnion:
An avascular, tough but pliable membrane
1 of the 2 primary fetal membranes
Ultimately fuses with the chorion
Functions of the amnion:
Involved in solute and water transport required for amniotic fluidhomeostasis
Produces bioactive compounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Amniotic cavity

Amniotic fluid
Normal fluid index/oligo/poly

A

Amniotic fluid:
Liquid that surrounds theembryoand fetus during its development
As the fetus grows, it “creates” amniotic fluid via urination, and continually “recycles” the fluid byswallowingit
Congenital defects inswallowingand/or the renal/urinary system can lead to abnormalities in amniotic fluid volume

Normal amniotic fluid index: 5-25 cm of fluid
Oligohydramnios: less than 5 cm
Polyhydramnios: greater than 25 cm is considered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Β-hCG

A

Peaks around week 9
Produced by the placenta
Maintains to activity of the corpus luteum until ~12 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Estrogen (estriol)

A

Produced by the corpus luteum → placenta
Increases throughout pregnancy; drops drastically just before birth
Prepares the maternal body for delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Progesterone

A

Produced by the corpus luteum → placenta
Increases throughout pregnancy; drops drastically just before birth
Maintains the uterine lining
Smooth muscle relaxant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

changes during pregnancy

Uterus

A

Increased uterine size
Hypertrophy of the uterine wall - ↑ fibrous and elastic tissue
Growth is initiated by ↑estrogenlevels
By term, the uterus is 5x its normal size
By 28 weeks, uterine growth slows and theuteruscontinues to stretch and become thinner
Fundal height measurements

Increase blood flow

Muscle contraction
Uterus is maintained by ↑ levels ofprogesterone
Braxton-Hicks contractions
Irregular contractions that donotcause cervical change
More noticeable as the pregnancy progresses

Uterine involution
Return of theuterusto its pre-pregnant state in the 1st several weeks postpartum

16
Q

changes during pregnancy

Cervix

A

Cervix softens (Goodell’s sign)

and can becomebluish (Chadwick sign)due to:
Increased vascularization
Hypertrophy and hyperplasia of the cervical glands

May undergo eversion:
Glandular cells normally lining the cervical canal become visible on the surface of the cervix
Can cause benign bleeding
All bleeding in pregnancy should be fully evaluated
Endocervical mucosal cells produce amucus plug (operculum), an immunological barrier for uterine contents

17
Q

changes during pregnancy

Ovaries

A

Follicle-stimulating hormone (FSH) ceases its activity due to the increased levels of estrogen and progesterone secreted by the corpus luteum → placenta

Corpus luteum
Enlarges during early pregnancy
May even form a cyst on the ovary
Suppliesprogesteroneduring the 1st part of pregnancy to help maintain the lining of the endometrium
10-12 weeks of pregnancy, the placentais developed enough to take over production of progesterone

18
Q

changes during pregnancy

breasts

A

Changes result form estrogen and progesterone production

Breast fullness that continues throughout pregnancy

Increased size
Hyperplasia of mammary alveoli and fat deposits

Hyperpigmentation and enlargement of the areola

Enlargement of the Montgomery glands
Sebaceous glands of the areola
Secrete an antibacterial oil that moistens and protects the nipple during breastfeeding

Surface vessels may become prominent due to ↑ circulation
Bluish tint to the breasts

Colostrum production
Occurs by week 16
Precursor of breast milk
Thin, watery, yellowish secretion with high protein content
Thickens as pregnancy progresses

19
Q

changes during pregnancy

integumentary system

A

Alterations in hormonal balance and mechanical stretching are responsible for several changes in the integumentary system

Hyperpigmentation:
Face (melasma or “mask of pregnancy”)
Brownish hyperpigmentation of the skin over centrofacial-malar area due to ↑ melanocyte-stimulating hormone, estrogen, and progesterone
Begins at ~16 weeks of pregnancy and gradually increases
Exacerbated by sun exposure
Usually fades after delivery
Umbilicus
Areola of the nipples
Perineum
Linea nigra
Dark line that runs from the umbilicus to the symphysis pubis and may extend as high as the sternum
After delivery, the line begins to fade, but may never completely disappear

Stretch marks (Striae gravidarum)
Separation within underlying connective tissue of the skin
Occurs over areas of maximal stretch…the abdomen, buttocks, thighs, and breasts
Fade after delivery, but never completely disappear

Sweat Glands
↑ activity throughout the body leading to profuse perspiration during pregnancy
Other common cutaneous changes:
Spider angiomas
Palmar erythema
Worsening of varicosities

Nail changes:
Brittle nails
Beau’s lines
Arrest ofnail growth at the area under the cuticle and will present as indentations in the nails

20
Q

changes during pregnancy

heme/anemia

A

Blood volume:
Increased plasma volume gradually by 30-50% (1500 ml to 3 units)
↑ estrogen → stimulation of the renin-angiotensin system → ↑ levels of circulating aldosterone; aldosterone promotes renal Na+ reabsorption and water retention

Results in decrease concentration of red blood cells and hemoglobin
Dilutional anemia = fatigue, shortness of breath
Diagnosis of anemia if the hemoglobin falls below 10.5 g/dL and the hematocrit drops below 30%

Hypervolemia of pregnancy compensates for material blood loss at delivery
Average loss:
400-500 cc for vaginal delivery
1000 cc caesarean delivery

RBC mass:
Human placental lactogen (human chorionic somatomammotropin) produced by the placenta promotes erythropoiesis by enhancing the effects of erythropoietin → RBC production
↑ utilization of iron
Reason women need iron in pregnancy!
Placenta actively transports iron from the mother to the fetus, so the fetus is generally not anemic

Hypercoagulability:
50% ↑ in blood coagulation factors
I, II, VII, VIII, X, and XII

21
Q

changes during pregnancy

cardio

A

Heart displacement:
Heart rotates in response to uterine enlargement and diaphragmatic elevation
Left-upward displacement (15-20 degree shift to the left on electrical axis)
Apical beat (point of maximum intensity) shifts laterally

Cardiac output:
CO = SV x HR
↑ CO of 30-50% in the 1st & 2nd trimester to accommodate hypervolemia
SV ↑ and reaches maximum at 12-24 weeks gestation
Position dependent: supine ↓ SV
HR ↑ after 20 weeks…average increase of ~10 beats/min

Venous return:
↓ venous return because of vena caval obstruction by the enlarging gravid uterus → CO ↓
Supine hypotensive syndrome:
10% of patients (3rd trimester)
Sensitive to caval compression
Hypotension, bradycardia, syncope
Encourage lateral positioning

Peripheral vascular resistance:
↓ in the first trimester due to smooth muscle-relaxing effects of progesterone and ↑ production of vasodilators (prostaglandins, nitric oxide, etc.)
At the time of delivery ~40% decrease

Blood pressure:
Arterial pressure
↓ in systolic (4-6 mm Hg) and diastolic (8-15 mm Hg) pressure with a maximum by 20-24 weeks
Most often returns to normal by term
↑ BP may be an indicator of preeclampsia

Venous pressure
Progressive ↑ in the lower extremities due to compression of the vena cava by the gravid uterus → edema and varicosities
↓ in the lower extremities immediately after delivery

Blood flow distribution:
Increased flow
Uterus
↑ in a gestational age-dependent manner
Kidneys
Skin
Particularly the hands and feet to help dissipate heat produced by metabolism
Breasts

Strenuous exercise:
Diverts blood flow to large muscles → ↓ uretoplacental perfusion
Exercise plans should be discussed providing physician

22
Q

changes during pregnancy

murmurs, heart sounds, rhythm

A

Murmurs:
Low-grade systolic ejection murmurs detected in up to 90% of patients
Diastolic murmurs should NOT be considered normal in pregnancy

Heart Sounds:
Normal findings
Second heart sound splitwith inspiration
S3gallop (third heart sound) after mid-pregnancy

Rhythm:
↓ threshold for reentry supraventricular tachycardia
Normal findings
Sinus tachycardia
Sinus bradycardia
Isolated atrial and ventricular premature contractions

23
Q

changes during pregnancy

pulmonary system

A

Changes occur due to increased oxygen demand of the mother and fetus
Primarily mediated by progesterone

Thorax enlargement:
Changes due to uterine enlargement
Diaphragm is elevated ~4-5 cm
Rib cage is displaced upward creating a ~2 cm diameter and 6 cm circumference increase in the lower thorax

Lung Volume & Capacities:
↓ total lung capacity and functional residual capacity due to elevation of the diaphragm
Relaxation of the musculature of the conducting airways (pregnancy-induced bronchodilation)
Slight ↑ tidal volume and inspiratory capacity
Respiratory rate:
↑ to 18-20/minute resulting from ↑ maternal oxygen consumption…demands from the uterus, placenta, and fetus
Hyperventilation
Progesterone creates an increased sensitivity to CO2
↓ arterial PCO2 = what acid-base disturbance?
Compensation by ↑ renal excretion of bicarbonate

24
Q

changes during pregnancy

bladder and kidney

A

Bladder:
Displaced upward and is flattened by the enlarging uterus
Urinary frequency
↓ bladder tone as a result of smooth muscle relaxation by progesterone (poor contraction for emptying)
↑ bladder capacity and ↑ residual volume…risk for urinary tract infection

Increased functional activity to maintain fluid, solute, and acid–base balance in response to the marked activity of the cardiorespiratory systems

Enlargement of the kidneys
Dilation of the urinary collecting system
Predisposing the patient to ascending urinary tract infections

Displacement of the enlarging uterus slightly to the right by the sigmoid colon → pressure on the right ureter
Potential for urine stasis, hydronephrosis, and pyelonephritis

25
Q

changes during pregnancy

renal function

A

Renal function:
Functional changes are the result of an increase in renal perfusion → ↑ glomerular filtration rate (GFR)

Various solutes presented to the renal system
↑ excretion of urinary glucose
Trace of glucose on routine “dipstick” evaluation is normal
↑ excretion of amino acids and water-soluble vitamins (B12 and folate)

Slight increase in protein loss
Proteinuria during pregnancy could indicate underlying pathology (renal disorder)
>300 mg per dayis considered high

>
↑ creatinine clearance → ↓ serum creatinine and ↓ blood urea nitrogen (BUN)

All components of the renin–angiotensin–aldosterone system increase during pregnancy

~80% of the glomerular filtrate is reabsorbed by the proximal tubules
Aldosterone – sodium reabsorption in the distal tubules
Vasopressin – free water regulation → determines urine concentration
Decreased specific gravity = dilute urine

26
Q

changes during pregnancy

gastrointestinal system

A

Displacement of the stomach and intestines due to the enlarging uterus
Portal vein enlargement due to increased blood flow

Smooth muscle relaxation by progesterone
Lower esophageal sphincter tone
↓ GI motility
Impaired gallbladder contractility

Gastroesophageal reflux
Results from imbalance between the lower intraesophageal pressures and increased intragastric pressures, combined with the lower esophageal sphincter tone

Gallstones and cholestasis of bile salts
Reduced gallbladder contractility
Estrogen-mediated inhibition of intraductal transportation of bile acids

Constipation
Mechanical obstruction of the colon due to the increasing size of the uterus
Reduced GI motility
Increased water absorption during pregnancy

27
Q

changes during pregnancy

metabolism

A

Increases in nutritional requirements
↑ rest to conserve energy and enhance fetal nutrition

Appetite and food intake increases
Food cravings…Picais an especially intense craving for substances such as ice, starch, and clay

Weight gain and altered body shape
Average weight gain: 12.5 kg (27.5 lbs)
Uterus and contents, breast tissue, blood volume, water volume (extravascular and extracellular) fluid, deposition of fat and protein

Weight loss (early pregnancy)
Nausea and vomiting or “morning sickness”
4-8 weeks gestation → resolves by 14-16 weeks
Severe form is known as hyperemesis gravidarum…weight loss, electrolyte imbalance, and ketosis

Lack of proper nutrition may be an indication of intrauterine growth retardation (IUGR) of the infant