FOUNDATION OF MIDWIFERY ANATOMY AND PHYSIOLOGYCAL CHANGES DURING PREGNANCY IN OTHER RELATED SYSTEM GROUP 1 ANASTASIA WILLIAM ANNIE ANAK JADAM ASBIH BINTI JITAL BIBIANA IVY AMIN BOKIAH BINTI JAINAL PUDDIN CHAIRIN OSIIN DAINE CHRISTY LEBA ANAK UJAI DAYANA GEORGE TIMIN LEARNING OBJECTIVE At the end of this session, student should be able to 1. Described the gross structure of related system in reproductive system. 2. Described the macroscopic and microscopic of system 3. Explained the function of related system to pregnancy 4. Explain the changes of related system during pregnancy, labour, and puerperium 5. Explained the contribution of the reproductive system INTRODUCTION The changes that occur in the pregnant mothers body are caused by a several factors. Many of these changes are caused by the growth of the fetus inside the uterus. CARDIOVASCULAR ( CVS ) CHANGES DURING PREGNANCY GROSS SRUCTURE CVS LOCATION Heart enlarged by chamber dilation and hyperthropy. Upward displacement of the diapgram causes the heart shifted to the left and upwards.. Displacement diapgram and shifted of the heart during pregnancy FUNCTION 1. Meet the increase metabolic demands of the mother and foetus 2. Promote growth and development of uteroplacenta-foetal unit. 3. Compensated for blood loss at the end of labour. RELATIONSHP WITH OTHER ORGAN To promote blood circulation to other organ ( pulmonary and systemic ) Utero placenta fetal circulation is supply oxygen and nutrient to fetus. BLOOD SUPPLY Coronary artery is the blood supply to heart. Its divided to left coronary artery and right coronary artery. NERVES SUPPLY The cardiac nerve are autonomic nerves which supply to the heart. They are superior cardiac nerve, middle cardiac nerve and inferior cardiac nerve. SUPPORT Supported by thoracic cavity where the diaphgram separating the thorax from the abdomen. CHANGES CVS DURING PREGNANCY CHANGES CVS DURING LABOUR CHANGES CVS DURING PUERPERIUM Blood volume increase 30-40% at 6 8 week -Cardiac output increase 30 50 at first trimester. -Blood pressure normal lowering in early pregnancy and back to normal during term -Heart rate modest increase -Anemia due toincrease plasma volume followed small increase in RBC 20 30% -Varicose vein develop because of enlarged uterus puts pressure to the inferior vena cava and pressure to the leg veins -Aortacaval compression in mid pregnancy Oxygen consumption increased -Intravascular volume increased 300 500 ml blood from the contracting uterus to the venouse system -Cardiac output increased during contracting due to response of cathecolamine secretion. -Heart rate increased -Blood pressure increased Stroke volume increased despite blood loss secondary to increased venouse returned Cardiac output not changes after 2 weeks delivery - Heart rate back to normal CHANGES IN GASTROINTESTINAL DURING PREGNANCY GROSS STRUCTURE FUNCTION Digestive system is unique and specialized function of turning food into the energy you need to survive and packaging the residue for waste disposal. Changes during pregnancy Changes during labour Changes during puerperium Mouth -Become highly vascularised, oedematous, have less resistance to infection and easily irritate ( progesterone and oestrogen) -Increase thirsty and appetite Oesophagus -Heartburn and burning sensation affecting % - lower tone of the oesophagus spintcer caused impaired and regurgitation of gastric acids.( progesterone and oestrogen) Stomach -Decreased of acid gastric secretion and motility delayed the gastric empty -Delayed chymes increase heartburn and nauseated Intestine and colon -Constipation due to reduced gastrointestinal muscle tone and motility -Mendelsons syndrome Only during LSCS -chemical pneumonitis cased by reflux of acid gastric -caused of pressure of gravid uterus -progesterone relaxant smooth and cardiac muscle -Increase gas distension due to relaxed of abdomen -Haemorrhoid will be more painful if there is presence of haemorrhoid and will disappear within a few weeks. BLOOD & NERVES SUPPLY The organs of the GIT receive arterial blood supply from three arteries: -Coeliac trunk for foregut -Superior mesenteric artery for mid gut -Inferior mesenteric artery for hindgut -The veins drain into the portal vein and from thence to the liver and ultimately inferior vena cava. -The vagus nerve supplies parasympathetic innervation up to the proximal 2/3rd of the transverse colon where it hands over to the sacral outflow. Sympathetic innervation is derived from the greater, lesser and least splanchnic nerves (T6-T12). Sensory fibres run with the sympathetic. RESPIRATORY SYSTEM CHANGES DURING PREGNANCY GROSS STRUCTURE FUNCTION Deliver oxygenated blood and nutrition to the mother and fetus. CHANGES DURING PREGNANCY, LABOUR AND PUERPERIUM ANATOMIC CHANGES Upper airway Hyperemia, friability, mucosal oedema, hypersecretion of the airway mucosa. Nasal obstruction, epistaxis, sneezing episodes and vocal changes may occur, and worsen when lies down. Preferential mouth breathing and intolerant of nasal canula delivery of O . CONT. Lower airway Mucosal changes occur in larynx and trachea. Nonspecifec complaints of airway irritinat ( irritant cough or sputum production) Estrogen increse tisu hydration and edema,also cause capillary congestion and hyperplastic and hypersecretory mucous glands. Thoracic cage upwards by 5 -7 circumference Displacement of the ribcage in pregnancy and non pregnancy showing elevated diaphragm, the increase tranverse and circumference, flaring out of ribs and the subcostal angle Displacement of the ribcage,diaphragm and the heart during pregnancy CHANGES DURING PREGNANCYCHANGES DURING LABOURCHANGES DURING PUERPERIUM -RR in pregnancy. -Breath more deeply event at rest. -Anterior posterior and transverse - diameter about 2cm resulting in a 5-7 expansion of the chest circumference. -Progressively increase the subscostal angle from 68 to 103 at term. -Changes mediated by progesterone and relaxin which ribcage elasticity by relaxing ligaments. -By 8/52 gestation: Expansion of the ribcage cause the Tidal Volume (TV) by 30-40%. -Respiratory responses are greatly affected by stage of labour and the respond to pain and anxiety. - TV ( tidal volume ) range from 350 to 2250ml and minute ventilations from 7 to 90 L/min Back to normal Summary of changes in respiratory function Blood Gases Aterial O partial pressure (PO ) is slightly : Non pregnant (98-100mmHg) Pregnant ( mmHg) Hyperventilation of pregnancy cause a 15-20% in martenal arterial Carbon Dioxide artial Pressure (PCO ) = mmHg 30mmHg or in late pregnancy. ENDOCRINE SYSTEM CHANGES DURING PREGNANCY The Endocrine system -the collection of glands of an organism that secrete hormones directly into the circulatory system to be carried towards a distant target organ. - The major endocrine glands in female include the pineal gland, pituitary gland, pancreas, ovaries, thyroid gland, parathyroid gland, hypothalamus, and adrenal glands Figure 1: The endocrine system in non pregnant female What changes in the Endocrine system during pregnancy? The major changes in endocrine system during pregnancy is the placenta where it acting as a temporary endocrine gland called Endocrine placenta. synthesizes a huge and diverse number of hormones and cytokines that have major influences on ovarian, uterine, mammary and fetal physiology Figure 2: The placenta as temporary endocrine gland placenta Foetus Placental hormones HormonesChangesRoles 1. hCG (human chorionic gonadotrophin) Peaks: 8-10 weeks and then declines by week 20th remains stable until labour 1.produced by the placental syncytiotrophoblast and cytootrophoblast cells following implantation 2.stimulates the production of oestrogen and progesterone within the ovary 2.diminishes once the placenta is mature enough to take over oestrogen and progesterone production. - rescue the corpus luteum from involution so that it can continue to produce progesterone to maintain the decidua Table 1: hCG hormones and its contribution Placental hormones hormoneschangesRole 2. Progesterone Peaks : increases around 8-10 weeks -produced by the corpus luteum during the first 9 weeks of pregnancy before shift to placenta # decreases or disruption of the progesterone production promotes the cervical re- modelling and initiates labour (Mesiano at el 2011) 1.promotes decidualization 2. prevent menstruation and rejection of the trophoblast 3. inhibits smooth muscles contractility 4.maintains myometrial quiescent 5.prevent onset of uterine contraction (Feldt- Rasmussen and Mathiessen 2011) Table 2: Progesterone hormones and its contribution Placental hormones hormonesChangesRoles 3. Oestrogen--Primarily produced by the corpus luteum and follicles times higher during pregnancy, it is within 6-7 weeks Where the secretion had taken over by the placenta. - increases uterine blood flow facilitates the placental oxygenation and nutrition to fetus prepares the breast for lactation simulates the production of hormone-binding globulin in liver ( Myatt and Powell 2010) - During last trimester, increasing the excitability of the myometrium and prostaglandins synsthesis. Table 3: Oestrogen hormones and its contribution Placental hormones hormoneschangesRole 4. Human placental Lactogen (hPL) --Produced by the syncytiotrophoblast - increases up to 30 folds throughout pregnancy 1. regulated the maternal carbohydrate, lipid, protein metabolism and fetal growth. 2. promote the growth of the breast tissues in preparation for lactation (Braun at el 2013) 3. It can also decrease maternal tissue sensitivity to insulin, resulting in gestational diabetes Table 4: hPL hormones and its contribution Placental hormones hormonesChangesRoles 5. Relaxin-produced by corpus luteum in both pregnant and non pregnant female -levels rise during 1 st trimester and additional relaxin is produced by the decidua. - peak is reached during the 14 weeks and at delivery 1.increased cardiac output 2. increased renal blood flow 3.and increased arterial compliance. 4.It also relaxes other pelvic ligaments. It is believed to soften the pubic symphysis. Table 5 : Relaxin hormones and it contribution Figure 3 : schematic level of progesterone, oestrogen and HCG throughout the pregnancy Other Endocrine changes THE PITUITARY GLAND The pituitary gland are increasing in size 2- 3 folds from it normal size during pregnancy Figure 4: The pituitary gland is a pea-sized structure located at the base of the brain, just below the hypothalamus and attached to it by nerve fibers Pituitary Glands hormones Anterior Pituitary - Prolactin Hormone Changes: -hypertrophy and hyperplasia of the lactotrophs ( prolactin secreting cells) by the anterior lobe of the pituitary gland under the influence of oestrogen hormone as a result prolactin level increases -by term, the levels are about 10 times in preparation of milk production Roles: 1.prepares the mothers breasts for lactation and also aids in the final stages of lung maturation for the baby 2.infant sucking at the breast can cause the prolactin secrection released Table 6 : prolactin hormones and it contribution Pituitary Glands hormones Posterior pituitary - Oxytocin hormone Changes: - Low throughout pregnancy but increase in labour (Feldt-Rasmussen and Mathiessen 2011) Roles: 1.act on the myometrium to increase the length, strength and frequency of contraction during labour 2.keeping the uterine contractions going continues after the baby is born and begin to shrink the uterus back to its original size 3.the high levels of oxytocin in both mother and baby at this time promote affection, attachment and a desire in the mother to protect and guard the baby 4.promotes the let-down reflex, too, which enables the breasts to produce milk Table 7 : oxytocin hormones and it contribution Other Endocrine changes Thyroid Gland Changes in size: moderately enlarged during pregnancy due to hormone-induced glandular hyperplasia and increased vascularity. Fetal thyroxine wholly obtained from maternal sources in early pregnancy since the fetal thyroid gland only becomes functional in the 2 nd trimester of gestation. Figure 5: showing situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the oesophagus and carotid sheath Thyroid Gland Hormones hormoneschangesRoles (TBG) Thyroxine binding globulin - rise almost 2-3 folds because estrogen increases TBG production 1.required for metabolic changes as well as transfer the thyroxine to fetal brain cells for normal brain development 2.Maintaining it supply for both mother and fetal requirement thyroxine (T4) and triiodothyronine (T3) - levels rise from about 612 weeks and plateauing at approximately 20 weeks of gestation Parathyroid hormoneParathyroid gland Increase in size slightly 1.To meet up the increases of the requirement for the calcium needed in fetal growth Thyroid Hormones Figure 6: Changes in thyroid function indices throughout gestation. The shaded area represents the normal range of the TBG, total T4, TSH, free T4 and hCG. Level concentration Weeks of gestation Adrenal gland Figure 6: The adrenal glands are located bilaterally in the retroperitoneum superior and slightly medial to the kidneys the outer cortex is under the control of ACTH from the anterior pituitary. It secretes steroid hormones (corticosteroids). the inner medulla is controlled by the sympathetic nervous system. It secretes adrenaline. Changes during Pregnancy Size : does not cause much change in the size of the adrenal glands HormoneChanges Roles Cortisol or glucocorticoid Marked increase1.particularly helpful in times of long and short term stress. 2.have anti-insulin, anti-inflammatory, and anti-allergic actions 3.needed to make the precursors of adrenaline, which the inner medulla will produce and secrete Aldosteroneincreased amounts by the adrenal glands as early as 15 weeks of pregnancy 1.regulates absorption of sodium from the distal tubules of the kidney CONCLUSION This system plays an important role in growth and development of the foetus in pregnancy. It is important for the midwives trained staff to know the changes during pregnancy and to deliver good care and reduces complication. 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