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CFB > WCS15 Physiology Of Pregnancy & Minor Ailments > Flashcards

WCS15 Physiology Of Pregnancy & Minor Ailments Flashcards

1
Q

Physiological changes in pregnancy

A
  1. Respiratory system
  2. Cardiovascular system
  3. Haematological system
  4. Endocrine system
  5. Renal system
  6. GI system
  7. Hepatobiliary system
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2
Q

Physiological adaptation of pregnancy

A
  • Proactive (rather than reactive)
  • Maintain safe environment for fetus
  • Provide extra energy, nutrition, oxygen needed to support fetal growth
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3
Q
  1. Respiratory system
A

Mechanical effects
- enlarging uterus
- hormonal changes + increasing laxity of thoracic ligaments
—> affect anatomy of thoracic cage

Biochemical: ↑ Progesterone —> ↑ O2 consumption + ↑ Tidal volume
Mechanical: Enlarging uterus —> Elevate resting diaphragm position + ↑ Abdomen size + ↑ Ribcage size

  1. Lifting of rib cage with upward flaring of ribs
    - ↑ AP + Transverse diameter
    - ↑ Lower chest wall circumference
    - ↑ Costal angle
  2. Elevation of diaphragm
    - Uterus displaces diaphragm superiorly at term
    - function remains normal, excursion not reduced
  3. ↑ Oxygen consumption
    - by 20% (30-40 ml/min) from baseline level of 220 ml/min to support:
    —> Extra cardiac, renal, respiratory work of mother
    —> Uterine, breast development of mother
    —> Metabolism of feto-placenta unit
  4. ↑ Ventilation
    - by 40%
  5. ↑ Tidal volume
    - by 40%: 500 —> 700 ml
  6. ***No change in respiratory rate
  7. ↓ Maternal pCO2
    —> to allow more efficient placental transfer of CO2 from the fetus
    - maternal pCO2: 4.8 kPa —> 3.7 kPa
    - fetal pCO2: 7.3 kPa
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4
Q

Clinical relevance of Respiratory system

A

Dyspnea during normal pregnancy is common (even in early pregnancy when uterus is still small), mechanism not clear
—> Progesterone-induced hyperventilation
—> Dyspnea during pregnancy correlated with low pCO2

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5
Q
  1. Cardiovascular system
A
  1. ↓ Systemic vascular resistance —> ↓ Afterload
    - ↓ 35-40% baseline
  2. ↑ Plasma volume —> ↑ Preload
  3. ↑ HR
    - progressively throughout pregnancy by 10-20 bpm, max in 3rd trimester
  4. ↑ SV
  5. ↑ CO
    - 30-50%, sharpest rise in CO occurs by beginning of 1st trimester, continued increase into 2nd trimester, further ↑ during labour
  6. ↓ SBP, DBP
    - ∵ ↓ PVR
    - to lowest point during 2nd trimester (5-10 mmHg below baseline)
    - gradually ***↑ during 3rd trimester to near pre-pregnant level at term
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6
Q

Clinical relevance of Cardiovascular system

A
  1. Ejection systolic murmur may be detected from mid-trimester (flow murmur) due to hyperkinetic state of CVS system
    —> check if murmur changes with position (not change with position)
  2. More common for Gestational hypertension / Pre-eclampsia to be diagnosed in 3rd trimester
  3. Unusual if BP starts to rise during mid-trimester even though it is still below 140/90 mmHg
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7
Q
  1. Haematological system
A
  1. ↑ Plasma volume
    - starting at 6-8 weeks
    - ↑ progressively until 30-34 weeks
  2. ↑ RBC mass
    - by 20%
    - ***↑ erythropoiesis (provided that mother has normal nutrition + sufficient Fe / vitamin supplement)
  3. Plasma volume ↑ > RBC mass ↑
    - physiological anaemia from haemodilution —> ***↓ Hb, Hct, RBC count
  4. ↓ Hb, Hct, RBC count
  5. ↑ WBC (↑ Neutrophil)
  6. ↓ Platelet count
    - Haemodilution effect
    - Increased fibrinolysis physiologically within uteroplacental circulation to maintain blood flow
  7. ↑ Procoagulatory factors
    - Factor 7, 8, 10, fibrinogen
  8. ↓ Antithrombin III, Protein S
    - inhibitor of coagulation
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8
Q

Benefits of Hypervolaemia + Anaemia

A
  1. ↓ Blood viscosity
    —> ↓ resistance to flow
    —> ↑ placental perfusion + ↓ Cardiac work
  2. ↑ Blood volume
    - provide reasonable reserve against blood loss during delivery / post-partum haemorrhage
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9
Q

Clinical relevance of Haematological system

A
  1. Note Hb level at booking visit + Repeat Hb later in pregnancy (28-32 weeks)
    - woman may become ***anaemic in later part of pregnancy
  2. Watch out for ***Venous Thromboembolism (∵ Pregnancy pro-coagulatory)
    - esp. if other risk factors e.g. prolonged bed rest
  3. Expansion in plasma volume is relatively less in women with pre-eclampsia
    - watch out if woman has ***static / increasing Hct
  4. Thrombocytopenia due to pregnancy
    - 8-10% of normal pregnancy
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10
Q
  1. Endocrine system
A

Increased metabolic needs during pregnancy
1. ↑ Thyroxine-binding globulin

  1. ↑ Total T4, T3
    - by 50% during 1st half of pregnancy
    - plateauing at ~20 weeks of gestation
  2. No change in free T4, T3
  3. hCG has weak thyroid-stimulating activity
    - peaks at ~12 weeks
    —> ↓ TSH / ↑ free T4, T3
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11
Q

Clinical relevance of Endocrine system

A
  1. Transient (usually Subclinical) hyperthyroidism should be considered normal
  2. Use Trimester-specific reference range during pregnancy
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12
Q
  1. Renal system
A
  1. ↑ Kidney size
    - 1 cm in length
    - volume ↑ up to 30%
    - marked dilatation of calyces, renal pelvis + ureters in most pregnant women due to ***hormonal factors (just like enlarging uterus in later pregnancy)
  2. ↑ Renal plasma flow
    - by 60-80%
  3. ↑ GFR
    - by 50% over non-pregnant women by the end of 1st trimester
  4. ↓ Serum Cr, Ur level
  5. ↓ Reabsorption of glucose
  6. ↑ Excretion of glucose across glomerulus
    - by 10x
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13
Q

Clinical relevance of Renal system

A
  1. Physiological hydronephrosis + hydroureter during pregnancy
    - usually more over right side
  2. Glycosuria by dipstick testing is common in pregnancy
    - may be present in the absence of hyperglycaemia / renal disease
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14
Q
  1. GI system
A

Relaxation of smooth muscle:

  1. ↑ Intragastric pressure
  2. ↓ Lower esophageal sphincter pressure
  3. ↓ Gastric peristalsis
  4. ↓ Gastric emptying
  5. ↑ Small + Large bowel transit time (↑ H2O absorption from gut)
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15
Q

Clinical relevance of GI system

A
  • Gastro-esophageal reflux
  • N+V
  • Constipation
    —> Normal in pregnancy
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16
Q
  1. Hepatobiliary system
A

↑ Liver metabolism in pregnancy

  1. ↑ ALP
    - ↑ with gestation (∵ placental production)
    - 2-4 fold by term, max 400 U/L in 3rd trimester
    - therefore may not be reliable when look at total ALP
  2. ↓ GGT
  3. ↓ Albumin
    - by 20-40%
    - partially dilutional by ↑ blood volume (contribute to most of fall in total serum protein)
  4. ↓ Bilirubin
  5. ***No change in bile acid, ALT, AST
17
Q

Clinical relevance of Hepatobiliary system

A

Caution with interpretation of lab results
- e.g. ALP in pregnancy may not be reliable
—> need specific tests (isoenzymes to distinguish ALP from placenta from other source) to exclude liver / bone cause

18
Q

Minor ailments of pregnancy

A
  • not life-threatening
  • discomfort + distress
  • due to adaptation of maternal body
  • many caused by ***Progesterone on smooth muscles / CT of body
  1. N+V
  2. Heartburn
  3. Constipation
  4. Fainting / Dizziness
  5. Varicosities (varicose veins, haemorrhoids, vulval varicosities)
  6. Backache
  7. Leg cramps
  8. Carpal tunnel syndrome
  9. Subluxation of pubic symphysis
  10. Urinary frequency
19
Q
  1. N+V (Morning sickness)
A
  • Onset always in 1st trimester
  • usually till 12 weeks
  • 70% of pregnant woman
  • Severe: Hyperemesis gravidarum

Etiology:

  • Unknown
  • Various contributory factors proposed
  • Associated with ↑ hCG

Prevention / Treatment:
- Dietary / Lifestyle change
- Avoid trigger
- **Light snacks instead of large meal
- **Avoid Fe supplements
- Seek medical advice if severe —> need to correct electrolyte + fluid imbalance
- ***Anti-emetics
—> Dimenhydrinate, Promethazine (H1 receptor antagonist)
—> Metoclopramide (Dopamine antagonist + UGI motility stimulants)

20
Q
  1. Heartburn
A

50% of pregnant women

Related to:

  1. Relaxing effect of ***progesterone on cardiac sphincter
  2. ↑ intragastric pressure due to growing uterus
  3. Flattening of diaphragm distorts the shape of stomach + ↓ angle at the gastroesophageal junction

Prevention / Treatment:

  • Dietary modification: **small, frequent meals, low in spices, avoid food that lower sphincter pressure e.g. **chocolate, coffee, alcohol
  • Elevate head of bed: sleep in ***upright position by additional pillows
  • ***Antacids: taken after meals + at bedtime
21
Q
  1. Constipation
A

May lead to haemorrhoids —> further increase constipation due to fear of pain

Etiology:

  • ↓ Gut motility by progesterone
  • ↑ H2O absorption from gut due to ↑ gut transit time
  • Oral Fe supplement

Prevention / Treatment:

  • ↑ Dietary fibre
  • Adequate fluid intake
  • Moderate exercise
  • Maintain regular bowel habit
  • Stool softener / Laxative
22
Q
  1. Fainting / Dizziness
A

Insufficient blood / O2 to the brain

Etiology:

  • ↑ Vasodilatation due to ***progesterone on smooth muscle
  • Standing ***erect for long time
  • **Supine hypotension:
  • ↓ CO due to ***↓ venous return caused by pressure of gravid uterus on vena cava when supine

Prevention / Treatment:

  • Get up slowly after sitting / lying down
  • If feel faint —> find a seat
  • ***Avoid total supine position, turn to lie on side if starts to feel faint
23
Q
  1. Varicosities (varicose veins, haemorrhoids, vulval varicosities)
A

Etiology:

  • Relaxing effect of progesterone of smooth muscles of venous wall
  • Aggravated by growing uterus —> **Pelvic congestion + **Poor venous return
  • Constipation

Prevention / Treatment:

  1. Haemorrhoids
    - prevention / treatment of constipation
    - topical medication e.g. Anusol suppositories
    - surgery NOT performed
  2. Varicose veins
    - avoid prolonged standing
    - exercising leg muscles
    - ***elevation of legs
    - support stockings
  3. Vulval varicosities
    - sanitary pad / panty girdle for support
    - caution when ***cutting the episiotomy
24
Q
  1. Backache
A

50% of pregnant women

Etiology:
- ↑ Lumbar lordosis causing strain on back muscles
- Ligamentous laxity due to hormone
—> ***Progesterone
—> ***Relaxin

Prevention / Treatment:

  • sit on comfortable chair who support both back + thighs
  • stand tall with abdomen + buttocks tucked in
  • wear flat shoes for even weight distribution
  • sleep on good mattress to ensure equal pressure on all parts of body
  • care taken when changing from lying down to avoid straining the back muscles —> arms should be used to pushed up into sitting position
  • avoid lifting heavy objects
25
Q
  1. Leg cramps
A
  • Often at night
  • can be very painful
  • more common during 3rd trimester

Etiology:
- Unknown

Prevention / Treatment:

  • Regular gentle exercise, esp. ankle / leg movements to improve circulation
  • Mg, Ca, non-pharmacological treatment options can be used for relief of leg cramps in pregnancy, based on woman’s preferences / available options
26
Q
  1. Carpal tunnel syndrome
A
  • numbness / tingling in fingers / hands
  • worse at night
  • common in 2nd, 3rd trimester

Etiology:
- **Fluid retention + **Swelling of CT which compresses median nerve in wrist

Prevention / Treatment:

  • Elevate hand
  • Noctural wrist ***splinting
  • Physiotherapy
27
Q
  1. Subluxation of pubic symphysis
A
  • Suprapubic pain, Tenderness, Swelling, Edema
  • worse upon weight-bearing, walking, climbing stairs, turning in bed, changing posture

Etiology:

  • Pubic symphysis widens due to ***Relaxin —> ↑ mobility
  • Mechanical strain

Prevention / Treatment:

  • Rest
  • Pelvic support
  • Analgesia
28
Q
  1. Urinary frequency
A
  • Affect most during 1st (growing uterus pressing on bladder), 3rd trimester

Etiology:

  • Pressure from growing uterus on the bladder
  • ↑ reabsorption of Na, H2O —> ↑ need to pass urine esp. at night (i.e. Nocturia)

Prevention / Treatment:

  • ***Fluid restriction in the evening with ↑ fluid intake earlier in the day
  • Limited intake of natural diuretics e.g. Caffeine

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