Physiologic Changes in Pregnancy 2
Dr.Huda AdnanChanges in the Filter
Renin – stimulated by progesteroneAlso made by placentaAngiotensinogen Angiotensin I Angiotensin II Aldosterone Distal tubuleNet absorption of Na+Excretion of K+Water retention: 6-8 litersglycosuriaIncreased renal blood flow50-75% increaseGFR – 50% increaseDecreased Albumin = lower colloid oncotic pressureOther urinary tract changes
Ureteral dilation / hydroureter Smooth muscle relaxation Later exacerbation by uterine obstruction Urinary stasis* Dilation of pelves and calyces Increased kidney sizeGastrointestinal
Slowed GI motility Constipation, early satiety Relaxation of LES GERD Nausea / vomiting Often proportional to HCG level Liver / gallbladder Biliary stasis, cholesterol saturation More stones Increased Coagulation factors Increased binding proteins (thyroid, steroid, vitamin D)Other “Adaptations” “I can’t see my feet!!!”Altered center of gravityAltered gaitGreater joint laxityWidening of symphysis pubisAffects other jointsThorax; widened costovertebral angleFatigue / somnolence
Integumentary Changes
Spider angiomata and palmar erythema Hair growth (abdomen and face) Mucosal hyperemia Striae gravidarum Hyperpigmentation (esp. linea nigra) Rashes and acne relatively commonEndocrine Changes
Pancreas Carbohydrate metabolism -Insulin resistance Due to increased Human placental lactogen, cortisol Thyroid Function Increased TBIG (via liver) Increased total T4 and T3 free levels unchanged HCG suppresses TSH Adrenal function Free plasma cortisol is elevated CRH from placenta stimulates ACTHImmunology
Must adapt to accept ‘allograft’Immune response altered, but not deficientModulates away from cell-mediated cytotoxic effectsProgesterone effectNK cells decrease by 30%Enhanced humoral / innate immunityImmunoglobulins still activeIgG crosses placentaMore susceptible to CMV, HSV, Varicella, MalariaDecrease in symptoms of some autoimmune disordersCase history
Case 136 y.o. female presents to ERCC: Fatigue, dyspnea, chest painHPI:Progressive SOB and dyspnea over several weeks. Poor exercise tolerance and easy fatigability‘get winded after 1 flight of stairs’Substernal chest pain, peaks in morning and nightNocturnal cough, semi-productive – clearLeg swellingpolyuria
PMHMild obesityOb/gyn – menses at age 12; irregular menses; no pregnanciesMedsOral contraceptivesmultivitaminsSocialMarried for 2 years. No exposures
Skin warm, calmmy. Mild facial acne and increased hair – medium coarsenessENT . Nasal mucosa slightly hyperemic. Mild non-nodular thyromegalyCVTachycardia (HR 107)+ JVP systolic murmurs over pulmonic and aortic v.
ChestClear bilaterally. Diaphragm elevated.Ext pretibial pitting edemaAbdSkin – spider angiomata and striae. Medium course hair, infraumbilical.Distended, firm, non-tender.