BLOCK XI: ALTERATIONS IN SEXUAL FUNCTION AND REPRODUCTION

AMENORRHEA (Maternal Physiology)

Dr. E. Aquitania

LEGEND
MATERNAL PHYSIOLOGY
BLACK (BOLD)-Important terms/terms emphasize by tutors
BLUE - Audio Addendums
PURPLE - Mnemonics/Transcriber’s Notes
 40 weeks: term pregnancy
 hCG gives a (=) pregnancy test
 Fetilization – implantation --- production of hCG by the
MATERNAL PHYSIOLOGY
syncytiotrophoblast
I. REPRODUCTIVE TRACT
a. Uterus
 Peak levels: 8-12 week gestation
b. Cervix
c. Ovaries and Fallopian Tubes I. REPRODUCTIVE TRACT
d. Vagina and Perineum a. Uterus
II. ABDOMINAL WALL AND SKIN  In non-pregnant state uterus weigh approx. 70g and
a. Skin almost solid
b. Breast  During pregnancy uterus becomes thin walled
III. METABOLIC muscular organ sufficient to accommodates fetus,
a. Weight Gain placenta, and amniotic fluid
IV. BODY WATER  Total volume of content at term average 5L but may
V. PROTEIN METABOLISM be 20L or more
VI. CARBOHYDRATE METABOLISM  Term weighs 1100g
VII. FAT METABOLISM  Uterine enlargement involves stretching and marked
VIII. HEMATOLOGY hypertrophy of muscles cells due to estrogen and
a. Blood Volume progesterone
b. RBC Mass  Most marked in fundus
c. Iron  Due to accumulation of fibrous tissue
d. Leukocytes
 Wall thins out as gestation progresses (1.5 cm or less)
e. PMN’s
 Originally a pear shape (6th weeks) as pregnancy
f. Platelets
advances corpus and fundus becomes globular (end of
g. Coagulation Factors
2nd month) and almost spherical (end of 20th week)
IX. CARDIOVASCULAR SYSTEM
a. Position and Size of the Heart
 Located at the midline but as it grows it ascends to true
b. Cardiac Output
pelvic cavity and tends to rotate to the right
c. Peripheral Resistance (dextrorotation) because of the descending colon and
d. Blood Pressure rectum (Pregnant Uterus is in DEXTROROTATION)
e. Labor  Contractility
f. Effects of Labor in CVS o 1st trimester: irregular (uterine contraction)
g. Postpartum o 2nd trimester: feel palpable contractions
X. RESPIRATORY SYSTEM o 3rd trimester: BRAXTON HICKS contraction
a. Lung Volume (normal and painless contraction), false labor
b. Pulmonary Function  Utero placental blood flow
c. Dyspnea of Pregnancy o Perfuses placenta-depending on uterine flow from
d. Effects of Labor on Pulmonary System uterine to ovarian arteries
XI. RENAL SYSTEM o Increase progressively about 500 ml/min near
a. Anatomy term
b. Renal hemodynamics  Control of uterine blood flow
c. Urinary System o Maternal-placental: vasodilation
d. Metabolites o Fetal-placental: increase by continuing growth of
e. Salt and Water Metabolism placental vessels
f. Glucosuria
b. Cervix
g. Bladder
 The one being palpated during IE
XII. GI SYSTEM
 1 month AOG: softening and cyanosis
a. Appetite
o From increased vascularity and edema
b. Mouth
o Hypertrophy and hyperplasia of cervical glands
c. Stomach
d. Small and Large bowel and Appendix
o Hegar’s sign – softening of the cervix
e. Colon  Mucus plug
f. Gallbladder o Copious amounts of tenacious mucus obstruct
g. Liver cervical canal
XIII. THYROID o Expelled at term as bloody show at the start of
XIV. MUSCULOSKELETAL SYSTEM labor
XV. EYE o Immunological barrier that protects the uterine
contents against infection from the vagina

August 11, 2019

 BLOCK XI │AMENORRHEA (Maternal Physiology)

c. Ovaries and Fallopian Tubes a. Skin

 Ovulation cease during pregancy  Pigmentation
o Maturation of new follicles is suspended o Linea nigra
o Cycle of ovulation stops, secretions of FSH and LH  Marked pigmentation of linea alba (midline of
stops (ovulation-LH surge) the abdomen)
 Corpus Luteum o CHLOASMA or MELASMA GRAVIDARUM
o Function maximally 6-7 weeks and thereafter  “mask of pregnancy”
progesterone production is minimal (because  Irregular brownish patches of varying size on
Progesterone now is secreted by the Placenta) face/neck
o Corpus luteum comes from the graafian follicle  Disappear or regress after delivery
after the ovum has been released
 Decidual reaction
o Pink, reddish, elevated patches of tissues on
surface of uterus
o Bleeds easily
 Pregnancy luteoma
o Solid ovarian tumor develops during pregnancy
made up of large acidophilic leutenized cells
 Vascular Changes – VASCULAR SPIDERS (spider
o Spontaneously Regress after delivery
angioma)
 Theca Lutein Cysts
 Nevus, telangiectasias
o Benign, bilateral ovarian lesions
 Angiomas, minute red elevations with
o Result from exaggerated physiologic follicles
branching radicles from a central lesions
stimulation (hyperreactio luteinalis)
o Palmar eruthema due to Consequence of
o Associated with marked elevated levels of hCG
hyperestrogemia
o Usually self-limited and resolve following a
 No clinical significance
delivery
b. Breast
 Fallopian tubes
 Early breast tenderness and tingling (mastodynia)
o Musculature – little hypertrophy
 2nd month:
d. Vagina and Perineum
o Increase in size; veins visible
 Chadwick’s sign
o Nipple bigger, deeply pigmented; more erectile
o Violet discoloration of vagina
 Colostrum (7-8 months)
o Increased vascularity and hyperemia
o Thick yellow fluid-colostrum can be expressed
o Softening of CT (connective tissue)
 Glands of Montgomery
 Mucosa thicken, loose CT, hypertrophy of smooth
o Hypertrophic sebaceous glands
muscle cells
o In preparation for the distension that accompanies
labor and delivery
o pH: acidic (as low as 3.50)
o increased volume of cervical secretions in the
vagina
 physiologic leucorrhea

II. ABDOMINAL WALL AND SKIN

 Stria Gravidarum – “stretch marks” Becomes darker as the pregnancy goes on.
o Reddish, slighty depressed steaks in abdomen,
breast and thigh III. METABOLIC
o Multiparous – silvery, glistening streaks – ols striae a. Weight Gain
o From over distension of CT of skin  Weight gain is due to:
 Diastasis Recti o Uterus and its contents
o Separation of rectus abdominis muscles in the o Increased breast tissue
midline because of overstreching (skin – o Blood and water volume (extravascular and
attenuated fascia – peritoneum) extracellular fluid)
o Hernia may develop o Deposition of fat and protein, increased cellular
o Maybe normal unless too severe water
 “maternal reserve”
o Average weight gain is 12.5 kg (consider built and
nutrition of patient)

2

 Weight gain
o 1st trimester: 1-2 kg
o 2nd trimester: 1-2 kg
o 3rd trimester: most of the weight gain
IV. BODY WATER
 Increased water retention due to fall in plasma
osmolality (patient develops edema)
 TBW (Total Body Weight) increases from 6.5L to 8.5L
o At term water content of fetus, placenta and AF is
3.5L
 Pitting edema of legs and ankles usually at end of the
day
 Due to increase in venous pressure below the level of
uterus resulting from partial occlusion of vena cava
V. PROTEIN METABOLISM
 About 1000g of weight gain is attributable to protein
o Half – found in fetus and placenta
o The rest – distribute as uterine contractile protein,
breast glandular tissue, plasma protein, and
hemoglobin
 Plasma albumin levels are decreased
 Increased fibrinogen levels (hyper coagulatory state –
protect mother from blood loss during delivery)
In the physiology of pregnancy, it is important to know what
increases or decreases during pregnancy.
VI. CARBOHYDRATE METABOLISM
 Mild fasting hypoglycemia
o Result of increased plasma insulin
 Post prandial hyperglycemia and hyperinsulinemia
o Pregnancy induced peripheral resistance to insulin
to ensure a sustained post prandial supply of
glucose
o Accelerated starvation – pregnancy induced rapid
switch from postprandial state of elevated and
sustained glucose level to a fasting state of
decreased plasma glucose and amino acid
VII. FAT METABOLISM
 Total body fat increases during pregnancy
 2nd half of pregnancy
o Plasma lipids increase
o Fat storage occurs primarily then decrease later in
pregnancy
 After delivery
o Triglyceride, cholesterol and lipoproteins decrease
VIII. HEMATOLOGY
a. Blood Volume
 Increase – varies according to:
o Height and weight
o The number of pregnancies and deliveries
o Singleton or multiple fetuses
 Increase progressively from 6 to 8 weeks’ gestation
 Maximum volume at 32-34 weeks
BLOCK XI │AMENORRHEA (Maternal Physiology)
 Needed to: %
o Facilitates maternal and fetal exchanges of
respiratory gases, nutrient and metabolites
o Increase perfusion of other organs (kidneys)
o Extra blood volume reduces the impact of
maternal blood loss at delivery
o The blood volume returns to normal 10-14 days
postpartum
 Plasma volume increases by 45%
o Mediated by progesterone and estrogen acting on
the kidneys initiating renin-angiotensin and
aldosterone pathway
b. RBC Mass
 RBC mass increases by 250-450cc by term
o Renal erythropoietin increases red cell mass by 20-
30% which is a smaller rise that the plasma
volume
o Plasma volume increases faster than RBC volume
until the end of 2nd trimester, when the increase
in RBC is synchronized with the plasma increase
 Physiological anemia of pregnancy (hemodilution)
o Supplemental intake of iron and folic acid help to
restore hemoglobin levels
c. Iron
 Maternal requirement: 5-6mg/d
o Iron demand is increase (due to increase in RBC)
o Iron deficiency anemia
 If supplemental iron is not added to the diet
d. Leukocytes
 Total WBC count – increases up to 5,000-12,000/ml
o Some 16,000/ml
 During labor – 25,000-30,000/ml
e. PMN’s contribute to the increase
 Lymphocyte and monocytes essentially the same
f. Platelets
 Platelets experience a progressive decline but should
remain within normal range
 Likely due to increased destruction
g. Coagulation Factors
 Increased levels
o Fibrinogen (Factor I), factor VIII
o Factors VII, IX, X and XII
 Depressed fibrinolytic activity
 Increased coagulant capacity + reduced fibrinolytic =
protect against hemostatic challenge of placental
separation
 Vwd factor 8 = bleeding
IX. CARDIOVASCULAR SYSTEM
a. Position and Size of the Heart
 Displacement of heart upward and to the left
o Due to uterine enlargement leading to elevation of
diaphragm
o Rotation on its long axis = apex beat is moved
laterally
o ECG: left axis deviation, depressed ST segments
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 Cardiac capacity increase by 70-80ml
o Due to ventricular hypertrophy and dilatation of
cardiac muscles
 Size of the heart appears to increase (12%)
b. Cardiac Output
 Increase by 40%
o 1.5L/min increase over the non-pregnant level
 Reaching its MAX at 20-24 weeks AOG to term
 Cardiac output – very sensitive to changes in body and
position
o Increase with gestation
o Due to the uterus impinge upon the IVC thereby
decreasing blood return to the heart (put patient
to left lying position)
 Arterial BP and vascular resistance decrease
 Blood volume, maternal weight and BMR increase
 Increase in CO, stroke volume due to increase blood
volume
 Estrogen and progesterone causes vasodilation and fall
in PVR
 Heart rate increases by 15-20% (compensatory)
 CO (Cardiac output) is position dependent
o Lower when supine
 IVC compression by the uterus reduces
venous return to the heart
o At 38-40 weeks, there is a 25-30% fall in CO when
turning from the side to the back
o Fall in CO is compensated by a rise in peripheral
vascular resistance
 Supine hypotensive syndrome (1-10%
patients)
c. Peripheral Resistance
 Peripheral resistance = BP divided by CO
o BP either decrease or remain the same during
pregnancy and CO increases appreciably
o PR declines markedly
 Blood flow in skin
o Increased cutaneous blood flow serves to
dissipate excess heat from increased metabolism
d. Blood Pressure
 Arterial BP decreases to a nadir in mid pregnancy and
rises thereafter(so you notice on some pts. a high bp
on the 3rd trimester)
 Diastolic BP decreases more than systolic BP
 SUPINE HYPOTENSION (aka Aortocaval compression)
o Mid pregnancy, when the patient lie supine
enlarging uterus compresses both IVC and lower
aorta
o Reduction in uteroplacental flow and renal blood
flow
(This compression is enough to cause the
pregnant mother to loose consciousness;
managementleft lateral side lying position)
o Reduces venous return to the heart leading to a
fall in preload and cardiac output, fall in BP (advice
mother not to change position abruptly)
BLOCK XI │AMENORRHEA (Maternal Physiology)
e. Effects of Labor in CVS
 Supine position: uterine contraction will cause
o A 25% increase in CO
o A 15 % decrease in heart rate
o A result at 33% increase in stroke volume
 Left lateral recumbent position
o The hemodynamic parameters stabilize
o Only 7.6% increase in CO
o 0.7% decrease in heart rate
o A 7.7% increase in stroke volume
* are attributable to IVC occlusion caused by gravid uterus
f. Labor
 First stage of labor: 12-31% rise on CO due to an
increase in SV
 Second stage of labor: 34% increase in CO
o Not only pain-related
o Uterine contractions result in the transfer of 300-
500cc of blood from the uterus to the general
circulation
 Enhanced venous return to the heart
 Increase in CO by 10-15%
g. Postpartum
 Immediate pp period: 10-20% rise in CO
o Rise of obstruction of venous return
o Extracellular fluid mobilization
 Rise in CO associated with reflex bradycardia
o SV increases → this may persist for one to two
weeks after delivery
X. RESPIRATORY SYSTEM
 Early in pregnancy
o Capillary dilatation occurs through RT – leading to
engorgement of nasopharynx, larynx, trachea and
bronchi
o Makes breathing thru the nose difficult
o Respiratory infection and preeclampsia aggravate
these symptoms
 Upper Respiratory Tract
o Hyperemic mucosa of nasopharynx
 Estrogen-mediated
 Nasal stuffiness and epitaxis
o Polyposis of the nose and sinuses may occur and
regress after delivery
o “chronic cold”
 Mechanical Changes
o Configuration of thoracic cage changes early in
pregnancy
 Increase in subcostal angle, transverse
diameter and circumference of chest
(increase in throracic diameter – 2cm,
throracic circumference – 6cm)
o With advancing gestation, the level of diaphragm
is pushed up (4cm); displaced upward and widens
 Tidal Volume (VT) – amount of air a person breathes
in and out during quiet normal breathing
 Vital Capacity (VC) – total amount of the person can
breathe in and out
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 BLOCK XI │AMENORRHEA (Maternal Physiology)

 Functional Residual Capacity (FRC) – total amount XI. RENAL SYSTEM

of air left in the lungs at the end of normal exhalation a. Anatomy
 Inspiratory Reserve Volume (IRV) – additional  Kidney enlargement
amount a person could inhale o Increased renal vascular and interstitial volume,
 Expiratory Reserve Volume (ERV) R>L
 Residual Volume (RV)  Ureteral and renal pelvis dilatation by 8 weeks
a. Lung Volume (Yung results na makukuha niyo; REFER to o Right > Left
Pulmo)  Mechanical compression by uterus and ovarian
 Total lung capacity (TLC) – total amount of air the venous plexus smooth muscle relaxation by
lungs can contain progesterone; dextrorotation of the uterus
 TLC = RV+ERV+VT+IRV  Right ureter is more dilated than the left
 VC = ERV+VT+IR because of hyperplasia of smooth muscle in
 FRC = RV+ERV distal one-third of the ureter may cause
 The amount of air inside our lungs is reduction of the luminal site
compartmentalized and are called volumes  Implications
 Volumes that come together are called capacities o Increased incidence of pyelonephritis
Lung volume and pulmonary function (so ito na lang o Difficulty in interpreting radiographs
imememorize niyo) o Interference with studies
 RR – slight increase b. Renal hemodynamics
 Increased in:  Increased in:
o Vt – gradually o GFR (50%)(amount of blood that passes through
o Minute m\ventilator volume your glumeroli) but volume of urine passed is not
o Minute O2 uptake increased
 Not changed o Renal plasma flow rate
o Max breathing capacity o Urinary flow and sodium excretion in late
o Timed vital capacilty pregnancy altered by posture
b. Pulmonary Function  Endogenous creatinine clearance increases
 Decreased: o Begins by 5 weeks
o FRC o Conc of crea in serum is reduced (in proportion
o RV, ERV, IRV to increase in GFR) and conc of BUN is reduced
o TLC renal pelvis dilates
 Larger Vt and smaller RV cause increased alveolar c. Urinary System
ventilation (65%) during pregnancy  Renin
 Increased respiratory tidal volume associated with o Levels of the enzyme renin increase early in the 1 st
normal RR trimester, the rise until term
o (increased respiratory minute volume --- o It Act on angiotensinogen A1, A2 (vasoconstrictor)
hyperventilation of pregnancy occurs --- causing a  Normal pregnancy – resistant to the pressor
decrease in alveolar CO2 --- lowers the maternal effect of elevated levels of angiotensin 2
blood CO2 tension)  Pregnancy induced hypertension (PIH) –
o Maternal hyperventilation is considered a susceptible to the A2pre-
protective measure to prevent the fetus from the eclampsia/eclampsia
exposure to excessive levels of CO2 d. Metabolites
c. Dyspnea of Pregnancy  Increased GFR → decline in serum urea and creatinine
 Common complaint  BUN – 8-9 mg/dl by end 1st trimester
o 60-70% of patients  Decline in serum creatinine
o Late first or early second trimester o 0.7 mg/dl by end 1st trimester
 Likely due to various factors o 0.5-0.6 mg/dl by term
o Reduced PaCO2 levels  Early decline in serum uric acid levels
o Awareness of increased tidal volume of pregnancy o Nadir at 24 weeks
d. Effects of Labor on Pulmonary System o Same as non-pregnant level at end of pregnancy
 There is further decrease in functional residual capacity due to increased reabsorption of urate
(FRC) during the early phase of each uterine e. Salt and Water Metabolism
contraction  Plasma osmolality begins to decline by 2 weeks after
o Resulting from the redistribution of blood from the conception
uterus to the central venous pool o Reduction in serum sodium and other anions

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 Sodium loss during pregnancy
o 50% rise in GFR
o Progesterone: natriuresis
 Renal tubular reabsorption of Na+ increases
(aldosterone, estrogen and deoxycorticosterone)
 Sodium homeostasis
f. Glucosuria
Nutrient excretion
 Increase in glucose excretion
o 1-10 g glucose excretion per day
 Due to 50% increase in GFR
o Implications
 Impairment of tubular reabsorption capacity
for filtered glucose
 Increase levels of urinary glucose
 Susceptibility of pregnant women to UTI
 Increase in amino acid excretion during gestation
o No increased protein loss (100-300 mg/24 hr)
 Increased urinary loss of folate and vitamin B12
g. Bladder
 Will not increase in size, it will be just displaced
 As uterus enlarges – displaced upward and flattened in
the AP diameter, increased on urinary frequency –
pressure from the uterus
 Bladder vascularity increases
 Muscle tone decreases – increase in capacity up to
1,500ml
XII. GI SYSTEM
 Increase in
o Nutritional requirement
 Vitamins and minerals
o Nausea and vomiting
 Related to relative levels of hCG
 Nausea and Vomiting
o Morning sickness complicates 70% of pregnancies
o Onset 4-8 weeks up to 14-16 weeks
o Cause?
 Relaxation of smooth muscle of stomach,
elevated levels of steroids and hCG
 Rx – supportive: reassurance, support, and
avoiding triggers
o HEG(Hyperemesis Gravidarum)
 Weight loss, ketonemia, electrolyte imbalance
(most common is low level of K n/v, muscle
weakness, can’t walk) and dehydration
 Possible renal or hepatic damage
 IVF, antiemetics
 NPO continue IV
*Hyperemesis Gravidarum
a. Appetite
 Increase early 1st trimester
 Increase intake 200kcal by end 1st trimester
o RDA: 300 kcal/day during pregnancy
 Sense of taste may be blunted
BLOCK XI │AMENORRHEA (Maternal Physiology)
 Pica (eating things w/ no nutritional value; not food)
o Check for poor weight gain and refractory anemia
 South – clay or starch (laundry or cornstarch)
 UK – cool
 Also soap, toothpaste and ice pica
b. Mouth
 Unchanged pH or production of saliva
o Saliva production is unaltered
o Ptyalism – usually in women with HEG
 Due to inability to swallow
 Can lose up to 1-2 L of saliva per day
 Decreasing starchy foods might help
 Gums – become hypertrophic, hyperemic and friable
o May bleed after brushing
o Estrogen effect increase vascularity
 Epulis gravidarum
o Regress 1-2 months after delivery
o Excise if persistent or excessive bleeding
c. Stomach
 Decreased tone and motility
o Progesterone
o Possibly due to decreased levels of motilin
(peptide that stimulate GIT smooth muscles)
 Transmit time of food-slower, longer
 Reduced tone of the gastroesophageal junction
sphincter
o Increased intraabdominal pressure leads to acid
reflux
o Slower emptying time
o Dilatation or relaxation of the cardiac sphincter
o More prevalent in later pregnancy due to elevation
of the stomach by the enlarge uterus
o Manifest as heart burn
 More commonly, gastric acidity is reduced
 Gastrin production
o Increase significantly
o Result to:
 Increased stomach volume
 Decreased stomach pH
o Gastrin production of mucus maybe increased
 Lower incidence of PUD
o May be due to decreased gastric acid secretion
delayed emptying, increase in gastric mucus, and
protection of mucosa by prostaglandins
d. Small and Large bowel and Appendix
 Displaces upward and laterally
 The appendix is displaced superiorly in the right flank
area
 Reduced motility of small bowel
o Increased transit time in the third trimester and
postpartum
 Enhanced iron absorption
o As a response to increase iron needs
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 BLOCK XI │AMENORRHEA (Maternal Physiology)

e. Colon XIV. MUSCULOSKELETAL SYSTEM

 Constipation  Increased hormone levels
o Mechanical obstruction by the uterus o Result in softening and relaxation in the joints
o Reduced motility (more mobility)
o Increased water absorption
 Portal venous pressure is increased  Center of gravity shifts
o Dilation of gastroesophageal vessels o Increased curvature in the lower back and anterior
 Issue in those with preexisting esophageal flexion in the neck (LORDOSIS-common in
varices pregnancy)
o Dilation of hemorrhoidal veins  Edema of leg
 hemorrhoids o Decreased venous return in late pregnancy
f. Gallbladder
 Gall bladder function altered XV. EYE
o Hypotonia of the smooth muscle wall  Decreased intraocular pressure
o Emptying time is slowed and incomplete  Corneal sensitivity
 Biliary cholesterol saturation increases and  Krukenberg spindles
chenodeoxycholic decreases o Brownish-red pigmentation of posterior surface of
o Bile can become thick, and bile stasis cornea
o Increased risk gallstone formation  Unaffected visual function
g. Liver  Increased thickness of cornea due to fluid retention
 Liver does not enlarge IN SHORT, IT IS VERY DIFFICULT TO BE PREAGNANT,
 Hepatic blood flow remains unchanged ESPECIALLY IN THE FIRST TRIMESTER BECAUSE OF N/V!
o CO to the liver decreases by ~35%
 Spider angiomata and palmar erythema
o Elevated estrogen levels
 Lab data
o Drop in serumalbumin
o Rise in serum alkaline phosphatase
 Placental production and some hepatic
production
o Rise in serum cholesterol, fibrinogen,
ceruloplasmin, binding proteins for corticosteroids,
sex steroids, thyroid hormones, and vitamin D
o No change in serum bilirubin, AST, ALT, protime,
and 5’ nucleotidase
o Rise in (GGT) GammaGlutamylTransferase is
controversial

XIII. THYROID
 The normal pregnant woman is euthyroid
 Changes in thyroid morphology and lab indices
o Estrogen-induced increase in TBG
o Decreased circulating extra thyroidal iodide
o Thyroid enlargement usually not detected by exam
o Normal thyroidal uptake of iodide
 Serum TSH decreases early in gestation
o Rises to pre-pregnancy levels by end of 1st
trimester
o T4 increases early in gestation
 Role of hCG stimulating the thyroid Transcribed by : GROUP 1
o Rise in TBG leads to rise in total T4 and total T#
 Active hormones free T4 and free T3 are MADAYAG, Djamafe
unchanged PUSAYEN, Teresito
o Free T4 is the most reliable method of evaluating QUEMI, Juan Paulo
thyroid function in pregnancy RABAGO, Khristine Andrea
REPOYO, Berlanne