PHYSIOLOGY OF PREGNANCYISKANDAR ZULQARNAINA. ABADI*

IT Obstetri 1 : Obstetri Fisiologi

Fertilisasi , inplantasi dan nidasi .Hormon-hormon plasenta.Perubahan morfologi janin dan fisiologi janin.Perubahan anatomik dan Fisiologi ibu hamil.Asuhan antenatal.*

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ENDOMETRIUM & DECIDUAMaternal tissues of fetal-maternal communication systemDirect cell to cell contact (blastocyst-maternal endometrium) since 6th days after fertilization (blastocyst apposition)Then occurred immunological acceptance of the conceptus, maternal recognition of pregnancy, placental development, pregnancy maintenance, & fetal nutrition

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Endometrial / decidual functionThe hormonal responsiveness and phenotypic changes of the endometrial / decidual cells facilitates apposition and implantation of the blastocyst.

The decidua serves as an immunologically specialized tissue.

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Endometrial / decidual function

The endometrium/decidua and the spiral arteries accept trophoblast invasion, providing for embryo-fetal nutrition.

The decidua contributes cytokines and growth factors that promote placental growth, function, and the inhibition of (trophoblast) apoptosis.

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Hormonal regulation of the endometriumEstrogenestradiol-17b & other bioactive estrogens in vivo cause replication of the epithelium indirectly (probably through actions on the stromal cells)estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial epithelial cell growth factor, which functions in a paracrine manner to cause replication of the adjacent epithelial cells.*

Hormonal regulation of the endometriumProgesteroneprogesterone receptors is dependent on previous estrogen actionProgesterone actions a decreases in the synthesis of estrogen receptor molecules progesterone acts to increase the rate of enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol dehydrogenase. *

FERTILIZATION & NIDATION*

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EMBRIOLOGICAL DEVELOPMENT*

PLACENTA & FETAL MEMBRANES the fetus is dependent upon the placenta as its lung, liver, and kidneys. The organ serves these purposes until sufficient maturation of the fetus allows it to survive ex utero as an air-breathing organism*

PLACENTAL DEVELOPMENTThe blastocyst + its surrounding tropho-blasts grow and expandextends endometrial cavity buried in the endometrium/decidua. The innermost pole enters into the formation of the placenta the anchoring cytotrophoblasts and the villous trophoblasts.

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PLACENTAL DEVELOPMENT

The trophoblasts of the villus are the outer layer of syncytium and an inner layer of cytotrophoblasts. The pole developing toward the endometrial cavity is covered by the chorion frondosum, at this time by decidua (capsularis). decidua capsularis + decidua parietalis decidua vera.

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TROPHOBLASTIC BIOLOGYSyncytiotrophoblastThe cytotrophoblast the syncytium

Chorionic villi Villi can first be distinguished easily in the human placenta the 12th day after fertilizationCytotrophoblasts mesenchymal cord, invades the solid trophoblast column secondary villi

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TROPHOBLASTIC BIOLOGY

Placental cotyledonsthe short, thick, early stem villi branch repeatedly, forming progressively finer subdivisions & >> increasingly small villi the main stem (truncal) villi & their ramifications (rami) placental cotyledon (lobe)each cotyledon is supplied with a branch (truncal) of the chorionic artery; and for each cotyledon, there is a vein, constituting a 1:1:1 ratio of artery to vein to cotyledon.

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PLACENTAL AGINGplacentas of early pregnancy, the branching connective tissue cells are separated by an abundant loose intercellular matrix

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PLACENTAL AGING

histological changes decrease in thickness of the syncytiumpartial reduction of cytotrophoblastic cellsdecrease in the stromaincrease in the number of capillaries the approximation of these vessels to the syncytial surface

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PLACENTAL AGING

Other changesthickening of the basement membranes of the trophoblast capillariesobliteration of certain fetal vesselsfibrin deposition on the surface of the villi in the basal and chorionic plates & intervillous space.

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PLACENTAL AT TERMBoyd and Hamilton (1970)the placenta at term + 185 mm & 23 mm (thickness)Volume +497 ml & weight 508gsFrom the maternal surface, the number of slightly elevated convex areas (lobes or if small, lobules) varies from 10 to 38The lobes are also referred to as cotyledons.

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BLOOD CIRCULATION IN THE MATURE PLACENTAFetal circulationFetal deoxygenated, or "venous-like," blood 2 umbilical arteriesBlood, with oxygen content placenta fetus through 1 umbilical vein.

Maternal circulationMaternal blood the basal plate driven high up the chorionic plate by the head of maternal arterial pressure After bathing the external microvillus surface of chorionic villi, the maternal blood drains back venous orifices in the basal plate the uterine veins.*

AMNIONStructureBourne (1962) 5 layers of amnion tissueThe inner surface single layer of cuboidal epithelial cells, derived from embryonic ectodermdistinct basement membrane

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AMNIONStructure the acellular compact layerfibroblast-like mesenchymal cells (widely dispersed at term), derived from mesoderm the relatively acellular zona spongiosa contiguous with the chorion laeve.

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AMNIONDevelopmentamniogenic cells, line this inner surface of trophoblasts the precursors of the amnionic epitheliumthe human amnion is 1st identifiable +7th or 8th day of embryo development.The amnion a small sac that covers the dorsal surface of the embryo

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AMNIONDevelopment

as the amnion enlarges , it gradually engulfs the growing embryothe amnion and chorion laeve, though slightly adherent, are never intimately connected, and usually can be separated easily, even at term.

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AMNIONAmnion cell histogenesisthe epithelial cells of the amnion are derived from fetal ectodermthe epithelial cells line the innermost (amnionic fluid) side of the amniona layer of fibroblast-like (mesenchymal) cells, derived from embryonic mesoderm.

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AMNIONAmnion cell histogenesisearly in pregnancy, the epithelial cells of the amnion replicate faster than the mesenchymal cellsAt term, the epithelial cells form a continuous uninterrupted epithelium on the fetal surface of the amnion. *

AMNIONIC FLUIDaverage volume +1000 mL is found at termmay vary widely from a few milliliters to many litersabnormal conditions oligohydramnios polyhydramnios or hydramnios*

UMBILICAL CORDDevelopmentAt first, the embryo is a flattened disc interposed between amnion and yolk sacthe embryo bulges into the amnionic sac and the dorsal part of the yolk sac is incorporated into the body of the embryo to form the gut.

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UMBILICAL CORDDevelopment

The allantois projects into the base of the body stalk from the caudal wall of the yolk sac or, later, from the anterior wall of the hindgut. The cord at term normally has 2 arteries and 1 vein

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UMBILICAL CORDStructure & functionBlood flows from the umbilical vein by two routesthe ductus venosus empties directly into the inferior vena cavanumerous smaller openings the fetal hepatic circulation the hepatic vein the inferior vena cava *

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PLACENTAL HORMONESHuman placental lactogen (hPL1) human chorionic gonadotropin (hCG)chorionic adrenocorticotropin (ACTH2)

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PLACENTAL HORMONES

proopiomelanocortin, chorionic thyrotropin, growth hormone variant, parathyroid hormone-related protein (PTH-rP), calcitonin, and relaxinhypothalamic-like releasing and inhibiting hormones thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), corticotropin-releasing hormone (CRH), somatostatin & growth hormone-releasing hormone (GHRH)*

MATERNAL ADAPTATION TO PREGNANCYUterus During pregnancy, uterine enlargement involves stretching and marked hypertrophy of muscle cells

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MATERNAL ADAPTATION TO PREGNANCY

Cervix softening and cyanosis of the cervixvascularity and edema of the entire cervixhypertrophy and hyperplasia of the cervical glands.

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MATERNAL ADAPTATION TO PREGNANCYOvariumOvulation ceases during pregnancy and the maturation of new follicles is suspended only a single corpus luteum of pregnancy can be found functions maximally during the first 6-7 wks of pregnancy (4-5 wks postovulation)

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MATERNAL ADAPTATIONSFallopian tubesThe musculature of the fallopian tubes little hypertrophy The epithelium of the tubal mucosa flattened Decidual cells may develop in the stroma of the endosalpinx, but a continuous decidual membrane is not formed.

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MATERNAL ADAPTATIONS

Vagina & perineumincreased vascularity and hyperemia develop in the skin and muscles of the perineum and vulvasoftening of the normally abundant connective tissue of these structuresIncreased vascularity prominently affects the vaginaThe copious secretion and the characteristic violet color of the vagina during pregnancy (Chadwick sign) hypertrophy of the smooth-muscle cells The papillae of the vaginal mucosa hypertrophy, creating a fine, hobnailed appearance*

SKIN CHANGESIn the later months of pregnancy, reddish, slightly depressed streaks ----- develop in the skin of the abdomen,the breasts and thighsthe reddish striae of the present pregnancy, glistening, silvery lines that represent the cicatrices of previous striae

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SKIN CHANGES

the midline of the abdominal skin becomes markedly pigmented, assuming a brownish-black color to form the linea nigra irregular brownish patches of varying size appear on the face and neck, giving rise to chloasma or melasma gravidarum (mask of pregnancy) accentuation of pigment of the areolae and genital skin*

BREAST CHANGES1st month breast tenderness and tingling2nd month the breasts increase in size the nipples larger, more deeply pigmented, and more erectile

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BREAST CHANGES

Then a thick, yellowish fluid, colostrum, can often be expressed from the nipples by gentle massagethe areolae broader and more deeply pigmentedScattered through the areolae glands of Montgomery, (hypertrophic sebaceous glands)*

METABOLIC CHANGESWater metabolism

At term, the water content of the fetus, placenta, and amnionic fluid amounts to about 3.5 L.

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METABOLIC CHANGESWater metabolismIncreased water retention is a normal physiological alteration of pregnancy.

This is mediated by a fall in plasma osmolality of approximately 10 mOsm/kg induced by a resetting of osmotic thresholds for thirst and vasopressin secretion

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METABOLIC CHANGESWater metabolismAnother 3.0 L accumulates as a result of increases in the maternal blood volume and in the size of the uterus and the breasts. Thus, the minimum amount of extra water that the average women retains during normal pregnancy is about 6.5 L.*

PROTEIN METABOLISMAt term, the fetus + placenta 4 kg & contain approximately 500 g of protein, or about half of the total pregnancy increase .

The remaining 500 g is added to the uterus as contractile protein, to the breasts primarily in the glands, and to the maternal blood as hemoglobin and plasma proteins.

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PROTEIN METABOLISM

Amino acids used for energy are not available for synthesis of maternal protein. With increasing intake of fat and carbohydrates as energy sources, less dietary protein is required to maintain positive nitrogen balance.*

CARBOHYDRATE METABOLISMNormal pregnancy is characterized by mild fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemiapregnancy-induced state of peripheral resistance to insulin1. Increased insulin response to glucose. 2. Reduced peripheral uptake of glucose. 3. Suppressed glucagon response.

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FAT METABOLISM

The concentrations of lipids, lipoproteins, and apolipoproteins in plasma increase.

Low-density lipoprotein cholesterol (LDL-C) levels peak week 36 the hepatic effects of estradiol and progesterone

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FAT METABOLISM

High-density lipoprotein cholesterol (HDL-C) peaks at week 25, decreases until week 32, and remains constant for the remainder of pregnancy.

High-density lipoprotein-2 and -3 cholesterol levels peak at approximately 28 weeks and remain unchanged throughout the remainder of pregnancy*

HAEMATOLOGICAL CHANGESthe blood volumes at or very near term averaged about 40 to 45 percent above their nonpregnant levels

hemoglobin concentration and the hematocrit decrease slightly during normal pregnancy

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HAEMATOLOGICAL CHANGES

The total iron content of normal adult women ranges from 2.0 to 2.5 g The leukocyte ranges 5000 - 12,000/Ulfibrinogen concentration increases about 50 percent to average about 450 mg/dL late in pregnancy, with a range from 300 to 600*

CARDIOVASCULAR SYSTEM CHANGESThe most important changes in cardiac function the first 8 weeks of pregnancy Cardiac output is increased the 5th week of pregnancyBetween weeks 10 - 20, plasma volume ,preload *

RESPIRATORY SYSTEM CHANGESThe diaphragm rises + 4 cm during pregnancy .The subcostal angle widens transverse diameter of the thoracic cage +2 cmThe thoracic circumference increases + 6 cm

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RESPIRATORY SYSTEM CHANGES

The amount of oxygen needs The respiratory rate is little changed during pregnancythe tidal volume, minute ventilatory volume, and minute oxygen uptake increase appreciably as pregnancy advances*

GI TRACT CHANGESGastric emptying and intestinal transit times are delayed in pregnancy because of hormonal or mechanical factors.Pyrosis (heartburn) is common during pregnancy and is most likely caused by reflux of acidic secretions into the lower esophagus*

GESTATIONAL AGEThe Ngele rule estimated date of confinement (EDC). Using last menstrual period minus 3 months, plus 1 week and 1 yearthe assumptions a normal gestation is 280 days & 28-day menstrual cyclesPhysical examination Ultrasound confirmation*

ANTE NATAL CARESuatu program berkesinambungan selama kehamilan, persalinan, kelahiran dan nifas yang terdiri atas edukasi, skreening, deteksi dini, pencegahan, pengobatan, rehabilitasi yang bertujuan untuk memberikan rasa aman dan nyaman kepada ibu dan janinnya sehingga kehamilan menjadi suatu pengalaman yang menyenangkan.

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ANTE NATAL CARE*TUJUANSetiap ibu hamil dan menyusui agar dapat memelihara kesehatannya sebaik mungkin.Setiap ibu hamil dapat melahirkan bayi sehat tanpa gangguan apapun dengan cara yang terpilih dan kemudian hari dapat merawat bayinya dengan baik.

ANTE NATAL CARE*TUJUANSetiap ibu hamil dan menyusui agar dapat memelihara kesehatannya sebaik mungkin.Setiap ibu hamil melahirkan bayi sehat tanpa gangguan apapun dengan cara yang terpilih dan kemudian hari dapat merawat bayinya dengan baik.

ANTE NATAL CARE*TUJUAN3. Menjaring kehamilan risiko tinggi dan mengupayakan pengelolaan selanjutnya sehingga ibu hamil tidak akan jatuh pada keadaan penyulit / komplikasi yang berat atau sampai meninggal (kematian ibu).

ANTENATAL CARE* Tabulasi faktor risiko Skreening dan deteksi dini Evaluasi dan penilaian maternal dan pertumbuhan janin. Evaluasi dan penilaian rute persalinan dan kelahiran. Evaluasi dan penilaian nifas. Konseling Nutrisi, Gerak Badan (Exercise), Medis, Genetik

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EMBRIOLOGICAL DEVELOPMENT*

ANTENATAL CARE* Minimum antenatal care 1x 1st trimester 1x 2nd trimester 2x 3rd trimester

Effective normal antenatal care every month early pregnancy 28 wks GA every 2 wks 28 36 wks GA every wks 37 wks GA - delivery