physiologic changes in pregnancy a systems review
TRANSCRIPT
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Physiologic Changes in Pregnancy
A Systems Review
Physiologic Changes in Pregnancy
A Systems Review
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Adaptations Adaptations
• Protect maternal functioning
• Prepare for childbirth & lactation
• Provide nurturing environment
• Meet maternal metabolic needs
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Anatomical/Mechanical Adaptations
Anatomical/Mechanical Adaptations
• Uterus enlarges, moves out of pelvis, and affects surrounding organs
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Endocrine/Hormonal SystemEndocrine/Hormonal System
• Pregnancy-specific endocrine system controls the integrity & duration of pregnancy
• Many of the physiologic changes during pregnancy are mediated by hormones
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PlacentaPlacenta
• Serves as an endocrine gland during pregnancy
• Secretes many hormones, growth factors, and other substances
• Major hormones produced by placenta:– Human chorionic gonadotropin (hCG)– Human placental lactogen (HPL)– Estrogen– Progesterone
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hCGhCG
• Major function is to maintain estrogen & progesterone production by corpus luteum until placental function adequate (~ 10 wks)
• hCG levels elevated in multiple pregnancies and low with ectopic pregnancy or abnormal placentation
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hPL Human placental lactogen hPL Human placental lactogen
• Principal action of hPL is to increase the supply of glucose to the fetus by decreasing maternal stores of fatty acids
• Alters maternal secretion of insulin
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EstrogensEstrogens
• Steroid hormones secreted by ovaries in early pregnancy and the placenta for most of pregnancy
• Prevent further ovarian follicular development during pregnancy
• ↑ blood flow to uterus and stimulates growth of uterine muscle mass
• Prepares breasts for lactation• May initiate onset of labor
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ProgesteroneProgesterone
• Acts on uterine muscle to inhibit prostaglandin production
• Acts in other areas of body as well– Relaxes venous walls – Alters respiratory center sensitivity to CO2– Aids in development of lobules of breasts
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RelaxinRelaxin
• Inhibits uterine activity, maintaining uterine quiescence during pregnancy; ↓ strength of UCs
• Plays a role in cervical ripening; may help suppress oxytocin release during pregnancy
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Prostaglandins (PGs)Prostaglandins (PGs)
• Affect smooth muscle contractility • Causes onset of labor, myometrial
contractility, & cervical ripening
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ProlactinProlactin
• Released from anterior pituitary• Matures mammary ducts and glands• Initiation of lactation after birth• Increased levels in pregnancy– Lactation inhibited due to high estrogen
levels– Levels decrease after delivery of
placenta which then allows lactation.
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Hematologic SystemHematologic System• Anatomic Changes– Heart Position• shifts upward and to the left
– Heart Size• increased due to blood volume & cardiac
output
– Auscultatory – change in heart sounds• Systolic murmur (90%-95% of women)-only
during last 2 trimesters
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Hematologic ChangesHematologic Changes
• Normal pregnancy is associated with 30-50% increase in plasma volume between 6 and 24 weeks.
• Normal pregnancies at the same time only have an increase of RBCs of 15-30% causing a normal reduction in hemoglobin levels.
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Hematologic ChangesHematologic Changes
• WBC’s– starts to during 2nd trimester, and peaks
in 3rd trimester– Peaks at 9,000-15,000 prior to labor– 10,000-16,000 during labor, may reach as
high as 29,000
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Hematologic Changes Hematologic Changes
• Platelets– unchanged or slightly
• Coagulation factors– Fibrinogen – Factors V, VII, VIII, IX, X, XII – Prothrombin slightly or unchanged– Bleeding & clotting times unchanged
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Hemodynamic ChangesHemodynamic Changes
• Cardiac Output – High Flow State 30-50% over pre-pregnant– Begins early, ~ 50% of occurring by 8 wks
gestation, peaks in 2nd trimester, and plateaus until term
– Positional changes (most dramatic at term)- Optimized in lateral position
– Somewhat decreased in sitting position–Markedly decreased in supine
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Cardiac Output ChangesCardiac Output Changes
• UCs ( approx. 300-500 ml)• Progressive rise in CO during labor– Latent phase 15%– Active phase 30%– 2nd Stage 45%– Immediate PP 65%
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Hemodynamic ChangesHemodynamic Changes
• Heart rate ↑15% or 15-20 bpm– Heart rate increases when sitting or
supine positions up to 40% with multiple gestation
• Sinus Arrhythmias– PAC, PVC, skipped beats–Momentary pressure in neck or chest
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Hemodynamic Changes Hemodynamic Changes• Blood Pressure–SBP & DBP in 1st trimester,
lowest in 2nd trimester, gradually toward pre- pregnancy levels by term
–Caused by progesterone & vasodilation
–BP varies with age, activity, anxiety, position, health problems
–Cuff size
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BP Considerations BP Considerations
• A difference of 5-10 mmHg between arms is common
• SBP in lower extremities is usually 10mmHg higher than reading in upper extremities
• Obtaining an orthostatic BP can cause the SBP to fall 10-15 mmHg and the diastolic to rise slightly by ~ 5 mmHg– Always obtain pulse rate with orthostatic
BP’s
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BP Considerations BP Considerations
• Establish baseline BP early• Consistent arm, arm position,
posture• BP’s with UC’s, pain, and anxiety
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CV System: Clinical SignificanceCV System: Clinical Significance
• Arrhythmias– Conversion techniques
• Supine Hypotension Syndrome– 2nd half of pregnancy, uterus compresses
vena cava causing SBP ( up to 30 mmHg), CO by half
–Weakness, lightheaded, dizziness, nausea, syncope
– Interventions• Hypervolemia– To accommodate uterine vasculature, provide
hydration, fluid reserves for birth/PP
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Clinical SignificanceClinical Significance
–Anemia • True anemia < 11mg/dL or hct < 33%• RBC mass with iron supplementation
–Hypercoagulation in Pregnancy• Risk of thromboembolic disease• DVT prophylaxis• Anticoagulation therapy
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Factor V Leiden MutationFactor V Leiden Mutation
• Also known as Activated Protein C Resistance
• Most common cause of inherited thrombophilia in caucasions
• 3-10x ↑ risk clotting when pt. has 1 copy of the gene, and 30-140x greater if 2 copies of gene
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DVT ProphylaxisDVT Prophylaxis• Coumadin
– Inhibits Vitamin K coagulation– Crosses placenta– Risks: abortion, fetal anomalies (face, bones, eyes, CNS)
• Heparin/Lovenox– Inhibits formation new clots– Does not cross placenta or into breast milk– Costs more than Coumadin, more difficult to regulate– SQ administration– Maternal risks: Bruising, tissue irritation, transient
thrombocytopenia, bleeding– Fetal risks: premature, stillbirth
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Cardiovascular System - PPCardiovascular System - PP
• HR & atrial size return to pre-preg. values in 1st 10 days PP
• Left ventricular size normalizes at 4-6 mo.
• Plasma volume returns to normal by 6-8 wks, and may be as early as 2-3 wks
• CO ↑ 24-48 hrs after birth, then progressively over 6-12 wks PP
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Respiratory System Respiratory System• Anatomic Changes–Diaphragm • Upward shift 4-7 cm.
–Chest/Ribs• Chest circumference 5-7 cm.• Ribs flare
–Abdomen• Abdominal muscle tone • Diaphragmatic/thoracic breathing
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Respiratory System Respiratory System
• Lung Volumes –Respiratory Rate (slight
or no change)
–Tidal Volume (Vt) 30-40%
–Functional Residual Capacity (FRC) 20-25%–Minute Ventilation 30-40%
(almost 50% by term)
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Gas ExchangeGas Exchange
• Arterial Blood Gases
Pregnant Non-pregnant
• pH 7.40 - 7.45 7.35 - 7.45• pO2 104 - 108 mmHg 90 - 100 mmHg• pCO2 27 - 32 mmHg 35 - 45 mmHg• HCO3 18 -22 mmHg 22 - 26 mmHg
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Gas ExchangeGas Exchange
• O2 consumption increases by almost 20% during pregnancy to meet the increased metabolic demands of the placenta, fetus and maternal organs
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Respiratory – Clinical SignificanceRespiratory – Clinical Significance
• Pregnancy is a state of relative hyperventilation, which may be centrally mediated through progesterone. The respiratory rate does not change while tidal volume increases, resulting in an approximately 50% increase in minute ventilation
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Respiratory – Clinical SignificanceRespiratory – Clinical Significance
• Increased blood flow to the nasopharynx may cause pregnant women to complain of congestion
• Pregnant women may develop a benign growth increasing this congestion
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Respiratory System Respiratory System
• Postpartum–Return to Normal Within 1 to 3
Weeks, Except for Rib Cage Flaring
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Renal System Renal System• Anatomic Changes– Kidneys• Slight in weight & size
– Urinary Collecting System• Ureters dilated & elongated, tortuous,
motility and tone • Urethra lengthens
– Bladder• Displaced forward & upward in late
pregnancy; convex to concave shape• Urine output • Urine frequency in 60% of pregnant women;
incidence in stress & urge incontinence
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Renal Function ChangesRenal Function Changes
• Renal Plasma Flow (RPF) 60-80% by mid-second trimester,
then 50% above pre-pregnancy by 3rd trimester
• Glomerular Filtration Rate (GFR) 40-50% by early 2nd trimester clearance of creatinine, BUN, &
uric acid
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Renal Function ChangesRenal Function Changes
• Sodium & Water Metabolism– 2 to 6 mEq of Na are reabsorbed daily to
meet fetal/maternal needs, causing an increase in body water weight
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Nutrient Excretion Nutrient Excretion
–Glucose (due to 50% in GFR)
–Amino acid
–Urinary protein loss
–Folate & Vitamin B12
–Bicarbonate excretion
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Clinical Significance - RenalClinical Significance - Renal
• Hydronephrosis/Hydroureter (80%) risk UTI’s– Difficulty diagnosing urinary tract
obstructions, radiology & renal tests
• Bladder– Stress incontinence– Edema risk trauma during labor/birth– Potential for infection
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PostpartumPostpartum
• Hemodynamic changes– Renal volume RTN within first week– Creatinine clearance values return to
non-preg. by 6th day postpartum
• Anatomic changes– Hydronephrosis & hydroureter may last
as long as 6-12 weeks after delivery
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Gastrointestinal SystemGastrointestinal System• Anatomic/Physiologic Changes–Mouth and Pharynx• Hyperemia, edema of tissue & gums in saliva production
– Esophagus and Stomach• Lower esophagus sphincter
pressure• Pyloric incompetence (bile reflux)• Tone & motility • Acidity
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GI System GI System
• Intestines and Colon– Displaced upward and laterally– Tone & motility
• Gallbladder– Size – Position more horizontal– Hypotonic & distended
• Appendix– Displaced from gravid uterus,
higher and more to the right
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Liver Function Liver Function
• Pushed superior & posterior
• Function altered in pregnancy– Alkaline phosphatase 2-4x– Cholesterol levels double – Plasma albumin to 3.0 g/dl– Fibrinogen 50%– Serum levels of bilirubin, AST/SGOT,
ALT/SGPT unchanged
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Metabolic ChangesMetabolic Changes• Hypoglycemia–Pancreas stimulated to insulin secretion–Glycogen storage & peripheral
glucose utilization –Hepatic glucose production & FBS
levels –Glucose & amino acids used for
fetal growth and development
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Metabolic ChangesMetabolic Changes
• Hyperinsulinemia – Glucose levels as pregnancy progresses free fatty acids & ketones mobilized for
maternal energy (so glucose available for fetal needs)
• Insulin resistance during later half of pregnancy insulin production – Effects of rising levels of prolactin and
maternal cortisol and glucagon
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Clinical Significance - GI SystemClinical Significance - GI System
• Diagnosis of Appendicitis– Displacement of appendix by gravid uterus
• Aspiration LES competence, delayed stomach emptying
time, gastric acid secretion, tone/gastric motility
• Peptic Ulcers– Acid secretion in 1st/2nd trimesters, delayed
gastric emptying, gastric mucous secretion, protective effect of prostaglandins on gastric mucosa
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Nausea In PregnancyNausea In Pregnancy
• High levels of hormones progesterone and b-HCG slow digestion and promote formation of intestinal gas
• Low blood sugar
• Fatigue and lack of exercise
• Deficiency in B vitamins
• Increase in T4, results in smooth muscle relaxation in the stomach
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Nausea in PregnancyNausea in Pregnancy
• Symptoms begin between 4-6 weeks of pregnancy.
• Usually improve by the 15-20 weeks
• Aggravated by ptyalism (excessive salivation)
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Hyperemesis GravidariumHyperemesis Gravidarium
• Associated with weight loss, ketonemia, electrolyte imbalance, possible liver and renal damage
• Treatment– IV replacement, fluids, electrolytes– Antiemetics (po, IV, suppository, Zofran
SQ pump)– Vitamin B6 50 mg, Unisom– Psychological support
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Dietary ChangesDietary Changes
• Small frequent meals• Avoid oily or spicy foods• Protein snack before sleeping• Eating before arising (crackers, etc.)• Drink liquids separate from meals• Well-balanced, varied, whole foods diet
with little or no processed foods• Minimize odors in room (remove tray cover
before taking meal tray into room, etc.)
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Herbal SupplementsHerbal Supplements
• Ginger root (Zingiber officinalis)– Powdered, 250 mg capsules 4x daily
• Fresh ginger root as a tea, steeped in boiling water x 15 min. and sipped slowly throughout day; sweeten with honey
• Chamomile tea (Maricara recutita) sipped throughout day, especially at bedtime
• Peppermint tea (Menthe piperata), dried or fresh leaves (not the essential oil)
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Herbal SupplementsHerbal Supplements
• Cinnamon or peppermint candies
• Raspberry leaf tea (Rubus idaeus), 1-2 cups per day, steeped 5 min. or less; use 1 tsp of dried herb for 1 cup of boiling water
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PrecautionsPrecautions
• Do not use high dose of vitamin B6 in the 3rd trimester (may decrease breast milk and/or cause rebound B6 deficiency in baby)
• Do not use essential oil of peppermint internally
• Do not use herbal tinctures because of alcohol content
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Herbal CautionsHerbal Cautions• FDA has no regulatory mechanism to
ensure either the quality of raw materials or manufacturing process for herbs.
• Be careful in the selection of the type of herb as well as the company that manufactures it.
• List of FDA dietary supplement recalls available online at www.fda.gov
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Herbal CautionsHerbal Cautions
• The United States Pharmacopoeia (USP) recently began the Dietary Supplement Verification Program (DSVP) – a voluntary program to certify dietary supplements for quality (www.usp.org)
• Products that meet the USP’s standards for purity, accuracy of ingredient labeling, and manufacturing practices are granted the right to add a USP certification mark to the labeling
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GI SystemGI System
• Constipation motility, H2O absorption from colon,
uterine pressure, iron in PNV– Interventions
• Hemorrhoids– Hyperemia of pelvic organs, pressure
gravid uterus, straining from constipation– Relief measures
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Intrahepatic Cholestasis of Preg. (IHCP)
Intrahepatic Cholestasis of Preg. (IHCP)
• Results from retention and accumulation of bile in the liver
• Pruritis gravidarium: itching, anorexia, malaise, epigastric pain, dark urine, jaundice
• Management– Reassurance, corn starch baths, soothing
ointments, avoid perfumed soaps/toiletries, Ursodeoxycholic acid
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CholecystitisCholecystitis
• Gallstone formation from incomplete emptying & residual volume of cholesterol crystals in gallbladder–S/S: RUQ pain, N/V, weight loss,
intolerance to fatty foods, fever–Management: BR, IV’s, NPO,
antibiotics, possible surgical intervention after r/o other problems
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GI SystemGI System
• Weight Gain– 1st half – maternal stores– 2nd half – fetal growth & development– Need to gain 20 pounds to ensure
adequate growth & development• Low BMI (underwt) 28 to 40 pounds• Average BMI (ave. wt) 25 to 35 pounds• High BMI (overweight) 15 to 25 pounds
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Weight DistributionWeight Distribution
Pounds
• Fetus, placenta, amniotic fluid 11
• Uterus, breasts 2
• Blood volume 4
• Maternal stores 5
• Tissue, fluid 3
Total 25
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Gastrointestinal SystemGastrointestinal System
• Postpartum–Weight Loss 12 pounds in 3 mo.– Lower Esophageal Sphincter (LES)
Competence – returns ~ 6 wks– IHCP (intrahepatic cholestasis of
pregnancy) – disappears shortly after delivery (within days)
– Liver Function – returns to normal about 3 weeks PP
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Musculoskeletal SystemMusculoskeletal System
• Anatomic/Physiologic Changes– Ligaments• Ligaments soften early in pregnancy; affected
most - sacroiliac, sacrococcygeal, pubic joints
– Lumbar Lordosis• Spinal curve progressively , keeps center of
gravity over legs, accommodates wt. of uterus
– Diastasis Recti – rectus abdominis muscle seperates due to pressure from gravid uterus.
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MusculoskeletalMusculoskeletal
• Anatomic/Physiologic Changes– Skin changes
diaphoresis• Mask of pregnancy
– Calcium Metabolism GI reabsorption & renal excretion• Maternal total serum Ca until 34-36
wks, then slightly . No loss of bone density in pregancy
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Musculoskeletal System Musculoskeletal System
• Clinical Significance–Joint/Ligament Softening• Facilitates vag birth, pelvic
discomfort late in preg., gait unsteadiness (falls), “waddle”
–Lumbar Lordosis – low back pain
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MusculoskeletalMusculoskeletal
• Postpartum–Most Changes Resolve Within Six
Weeks
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Neuromuscular SystemNeuromuscular System
• Physiologic Changes
–Eye• Corneal thickness • Intraocular pressure
• No other nervous system changes, but several discomforts
in DTRs not normal in pregnancy
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Clinical Significance - Neuromuscular
Clinical Significance - Neuromuscular
• Ocular changes– Contact lens intolerance, blurred vision,
spontaneous subconjunctival hemorrhages
• Headaches– Mild, frontal 1st/2nd trimesters– Severe – assess for PIH, esp. > 20 wks
• Dizziness/Syncope– Vasomotor instability, postural
hypotension, hypoglycemia
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Clinical Significance - Neuromuscular
Clinical Significance - Neuromuscular
• Hypotension• Paresthesias/Tingling– Pressure from gravid uterus interfering with
circulation– Tingling of hands/fingers (hyperventilation,
lumbodorsal lordosis, flexion of neck/shoulder slumping)
• Transient Neuropathies– Bell’s Palsy, carpal tunnel
syndrome, foot drop
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NeuromuscularNeuromuscular
• Postpartum–Most Changes Regress by Six
Weeks Postpartum
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Reproductive ChangesReproductive Changes
• Uterus– Size , capacity
• Uterine vasculature blood flow from 15-20
ml/min. to 500 ml/min.–Myometrial stretching/thinning beginning
at 5 months
• Cervix vascularity, softening, dilation– Endocervical gland hyperactivity• Mucus plug, mucus production
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Reproductive ChangesReproductive Changes• Vagina– Hypertrophy, vascularization, hyperplasia• Connective tissue loosens, mucosa thickens
– Endocervical gland hyperactivity leukorrhea• Vulvar and vaginal varicosities can occur
• Breasts size, nodularity, vascularity– Growth of ducts and secretory glands–Montgomery glands hypertrophy– Colostrum production
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Reproductive - PostpartumReproductive - Postpartum
• Involution continues over six to ten weeks postpartum
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The End…..The End…..
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ReferencesReferencesRoberts, V. Myatt L.(2013) Placental Development and Physiology. UpToDate.Bauer, K. (2014) Factor V Leiden and Activated Protein C Resistance: Clinical Manifestations and Diagnosis. UpToDate.Funai, E., Gillen-Goldstein, J., Roque, H., & Abdel-Razeq, S. (2014) Respiratory Tract Changes During Pregnancy. UpToDate.Bauer, K. (2014) Hematologic Changes in Pregnancy. UpToDateThadhani, R., & Maynard, S. (2014) Renal and Urinary Tract Physiology in Normal Pregnancy. UpToDate.