{"id":374,"date":"2020-08-13T20:18:29","date_gmt":"2020-08-13T20:18:29","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=374"},"modified":"2020-10-20T17:02:23","modified_gmt":"2020-10-20T17:02:23","slug":"maternal-and-fetal-physiology","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/maternal-and-fetal-physiology\/","title":{"rendered":"Maternal and Fetal Physiology"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/ajTzJhYtOpg\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration 12:52<\/p>\n<input type='hidden' bg_collapse_expand='69e9c84b1b1cf9052481210' value='69e9c84b1b1cf9052481210'><input type='hidden' id='bg-show-more-text-69e9c84b1b1cf9052481210' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c84b1b1cf9052481210' value='Hide Transcript'><button id='bg-showmore-action-69e9c84b1b1cf9052481210' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfcfc;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c84b1b1cf9052481210' ><\/p>\n<p>00:00<br \/>\nhello and welcome to this app go basic<br \/>\n00:02<br \/>\nscience objective video about maternal<br \/>\n00:05<br \/>\nfetal physiology after watching this<br \/>\n00:08<br \/>\nvideo you should be able to describe the<br \/>\n00:11<br \/>\nmaternal endocrine changes that provide<br \/>\n00:13<br \/>\nan adaptive environment for the<br \/>\n00:15<br \/>\ndeveloping fetus identify the<br \/>\n00:17<br \/>\nphysiologic changes of pregnancy that<br \/>\n00:19<br \/>\nallow the mother to tolerate a symbiotic<br \/>\n00:21<br \/>\nrelationship and explain how the<br \/>\n00:24<br \/>\nphysiologic adaptation of the fetus<br \/>\n00:26<br \/>\nand placenta allow the fetus to thrive<br \/>\n00:29<br \/>\nhey Jamie how are you doing<br \/>\n00:31<br \/>\nisn&#8217;t your duty coming up soon oh I&#8217;m<br \/>\n00:35<br \/>\nexhausted this baby is taken over every<br \/>\n00:37<br \/>\nsingle organ system in my body I don&#8217;t<br \/>\n00:41<br \/>\nthink it&#8217;s taking over every single<br \/>\n00:42<br \/>\norgan system are you kidding me were you<br \/>\n00:45<br \/>\nnot listening to any of the ob gene<br \/>\n00:47<br \/>\nlectures the fetus is a master parasite<br \/>\n00:50<br \/>\nit&#8217;s able to use its influence to<br \/>\n00:52<br \/>\nmanipulate every organ system and<br \/>\n00:54<br \/>\nendocrine pathway okay fine<br \/>\n00:57<br \/>\nbut I bet I can find one organ system<br \/>\n00:59<br \/>\nthat is not manipulated I know that<br \/>\n01:02<br \/>\novarian hormones are affected but it&#8217;s<br \/>\n01:04<br \/>\nnot like the entire endocrine system is<br \/>\n01:06<br \/>\nbeing manipulated what about the<br \/>\n01:08<br \/>\npancreas or the tiny parathyroids<br \/>\n01:11<br \/>\nnice try Sam<br \/>\n01:13<br \/>\nalmost every endocrine hormones is<br \/>\n01:15<br \/>\naltered in pregnancy some due to true<br \/>\n01:17<br \/>\nphysiologic changes and others due to<br \/>\n01:19<br \/>\nincreased liver production of finding<br \/>\n01:21<br \/>\nglobulin or decreased serum albumin due<br \/>\n01:23<br \/>\nto the delusional effects of volume<br \/>\n01:25<br \/>\nexpansion maternal endocrine changes are<br \/>\n01:28<br \/>\nalso mediated by increased renal<br \/>\n01:29<br \/>\nlamellar filtration decreased hepatic<br \/>\n01:32<br \/>\nclearance for metabolic clearance of<br \/>\n01:34<br \/>\nhormones by the placenta there is not a<br \/>\n01:36<br \/>\ngland that is spared the pituitary gland<br \/>\n01:38<br \/>\nincreases in size mainly due to lactate<br \/>\n01:41<br \/>\nRauf hyperplasia stimulated by high<br \/>\n01:42<br \/>\nestrogen levels prolactin progressively<br \/>\n01:45<br \/>\nincreases during gestation in<br \/>\n01:46<br \/>\npreparation for lactation while FSH LH<br \/>\n01:49<br \/>\nare almost undetectable the thyroid<br \/>\n01:51<br \/>\ngland enlarges in the first trimester<br \/>\n01:52<br \/>\nthe HCG and TSH alpha subunits are very<br \/>\n01:56<br \/>\nsimilar<br \/>\n01:56<br \/>\nthus elevated HCG has spiro trophic<br \/>\n01:59<br \/>\neffect total serum thyroxine increases<br \/>\n02:02<br \/>\ndue to increased production of thyroid<br \/>\n02:04<br \/>\nbinding globulin however free t3 and t4<br \/>\n02:07<br \/>\nremain unchanged and those darling tiny<br \/>\n02:11<br \/>\nparathyroid glands undergo hyperplasia<br \/>\n02:13<br \/>\nto increase hormone production and meet<br \/>\n02:15<br \/>\nthe calcium needs a fetal bone formation<br \/>\n02:17<br \/>\nthe pancreas yeah that too it undergoes<br \/>\n02:20<br \/>\nhyperplasia of insulin-secreting beta<br \/>\n02:22<br \/>\ncells insulin is responsible for<br \/>\n02:24<br \/>\nintracellular transport of nutrients but<br \/>\n02:26<br \/>\ndoes not itself cross the placenta<br \/>\n02:28<br \/>\ninsulin regulates the availability of<br \/>\n02:30<br \/>\nmetabolites for placental transport even<br \/>\n02:32<br \/>\nthe adrenal cortex is not spared from<br \/>\n02:35<br \/>\nfetal influence the total serum cortisol<br \/>\n02:37<br \/>\nis increased mostly due to an estrogen<br \/>\n02:39<br \/>\nstimulated increase in cortisol binding<br \/>\n02:41<br \/>\nglobulin or CBG increased cortisol may<br \/>\n02:44<br \/>\nalso contribute to insulin resistance<br \/>\n02:45<br \/>\nand development of striae my least<br \/>\n02:48<br \/>\nfavorite<br \/>\n02:48<br \/>\nthose darn stretch marks okay Jamie you<br \/>\n02:53<br \/>\nwin this time<br \/>\n02:55<br \/>\nlet&#8217;s pause think and apply when<br \/>\n02:57<br \/>\nevaluating a pregnant patient what<br \/>\n03:00<br \/>\nhappens if a physician fails to<br \/>\n03:01<br \/>\nrecognize normal pregnancy related<br \/>\n03:04<br \/>\nchanges in endocrine function tests this<br \/>\n03:08<br \/>\nmay lead to unnecessary testing and<br \/>\n03:10<br \/>\ntherapies that are potentially harmful<br \/>\n03:12<br \/>\nto the fetus and the mother oh my feet<br \/>\n03:18<br \/>\nfeel so swollen this state of chronic<br \/>\n03:20<br \/>\nvolume overload with active sodium and<br \/>\n03:22<br \/>\nwater retention is getting old quick huh<br \/>\n03:25<br \/>\nI guess the changes in the<br \/>\n03:26<br \/>\nrenin-angiotensin system and ozma<br \/>\n03:28<br \/>\nregulation will come to an end soon<br \/>\n03:30<br \/>\nenough Jamie what about the<br \/>\n03:33<br \/>\ncardiovascular system what yeah the<br \/>\n03:38<br \/>\ncardiovascular system is minimally<br \/>\n03:40<br \/>\naffected by the fetus are you kidding me<br \/>\n03:43<br \/>\nmy cardiovascular system is so tightly<br \/>\n03:45<br \/>\ninfluenced by my fetus first my ribcage<br \/>\n03:47<br \/>\nchanges and my elevated diaphragm has<br \/>\n03:50<br \/>\nrotated my heart slightly there&#8217;s an<br \/>\n03:51<br \/>\neccentric hypertrophy of the heart<br \/>\n03:53<br \/>\nresulting from expanded blood volume and<br \/>\n03:55<br \/>\nincreased afterload the cardiac output<br \/>\n03:57<br \/>\nincreased in early gestation with a peak<br \/>\n03:59<br \/>\nincrease of 30 to 50 percent this is a<br \/>\n04:02<br \/>\nresult of increased blood volume heart<br \/>\n04:04<br \/>\nrate and stroke volume blood pressure<br \/>\n04:06<br \/>\nand systemic vascular resistance<br \/>\n04:07<br \/>\ndecreased with mid pregnancy nadir due<br \/>\n04:10<br \/>\nto progesterone mediated smooth muscle<br \/>\n04:12<br \/>\nrelaxation and relative unresponsiveness<br \/>\n04:14<br \/>\nto angiotensin ii and norepinephrine in<br \/>\n04:17<br \/>\npregnancy<br \/>\n04:18<br \/>\nthere is also an increased risk of<br \/>\n04:20<br \/>\npulmonary edema due to the combined<br \/>\n04:22<br \/>\neffects of falling systemic and<br \/>\n04:23<br \/>\npulmonary vascular resistance and<br \/>\n04:25<br \/>\ndecreased colloid osmotic pressure and<br \/>\n04:27<br \/>\npregnancy cardiac function crescendos in<br \/>\n04:30<br \/>\nlabor and immediately postpartum and<br \/>\n04:32<br \/>\nmust manage the auto transfusion that<br \/>\n04:34<br \/>\noccurs after delivery of the baby in<br \/>\n04:35<br \/>\nplacenta as the uterus rapidly in<br \/>\n04:38<br \/>\nvolutes you&#8217;re okay fine I guess you&#8217;re<br \/>\n04:41<br \/>\nright aha see are you scared me what are<br \/>\n04:47<br \/>\nyou doing back there<br \/>\n04:48<br \/>\na hematologic system i win Oh Sam I<br \/>\n04:53<br \/>\ncan&#8217;t believe how much you forgot from<br \/>\n04:54<br \/>\nyear one the hematologic system is 100%<br \/>\n04:57<br \/>\ninfluenced by the fetus in fact all<br \/>\n04:59<br \/>\ncomponents of blood plasma platelets<br \/>\n05:01<br \/>\nwhite blood cells and red blood cells<br \/>\n05:03<br \/>\nare altered in pregnancy these changes<br \/>\n05:06<br \/>\nare considered protective against<br \/>\n05:07<br \/>\npossible hemorrhage the total blood<br \/>\n05:09<br \/>\nvolume increases by 40 to 50 percent in<br \/>\n05:11<br \/>\npregnancy one there&#8217;s an increase in<br \/>\n05:14<br \/>\nplasma volume at 6 weeks with a mismatch<br \/>\n05:16<br \/>\nin red cell volume that leads to a<br \/>\n05:18<br \/>\nphysiologic and anemia nattering at 28<br \/>\n05:21<br \/>\nto 34 weeks to a three-fold increase in<br \/>\n05:24<br \/>\nerythropoietin causes a wreath Royd<br \/>\n05:26<br \/>\nhyperplasia in bone marrow to help<br \/>\n05:29<br \/>\nincrease red blood cell mass 3 platelet<br \/>\n05:32<br \/>\ncounts decrease partly due to chemo<br \/>\n05:35<br \/>\ndelusion and partly due to an increased<br \/>\n05:37<br \/>\ndestruction and aggregate II for white<br \/>\n05:40<br \/>\nblood cells particularly neutrophils and<br \/>\n05:43<br \/>\ngranulocytes increase due to elevated<br \/>\n05:45<br \/>\nestrogen and cortisol levels in<br \/>\n05:47<br \/>\npregnancy<br \/>\n05:47<br \/>\nfinally a most concerning there&#8217;s a<br \/>\n05:50<br \/>\nfive-fold increase risk for<br \/>\n05:52<br \/>\nthromboembolism due to estrogen<br \/>\n05:54<br \/>\nstimulation of the liver to produce pro<br \/>\n05:56<br \/>\ncoagulants and there is a decrease of<br \/>\n05:58<br \/>\nnatural coagulation inhibitors and<br \/>\n06:00<br \/>\nfibrinolytic activity so nice try Sam<br \/>\n06:03<br \/>\nbut you&#8217;re gonna have to work harder to<br \/>\n06:05<br \/>\nfind something this baby is not trying<br \/>\n06:06<br \/>\nto manipulate ah this is getting so hard<br \/>\n06:09<br \/>\nnow surprise from your spidey friend<br \/>\n06:12<br \/>\npulmonary there is no way that kiddo can<br \/>\n06:16<br \/>\nget near your lungs are you kidding me<br \/>\n06:19<br \/>\ndo you hear me right now my elevated<br \/>\n06:21<br \/>\ndiaphragm from the baby pushing up<br \/>\n06:22<br \/>\ndecreases my total lung capacity and<br \/>\n06:24<br \/>\nfunctional residual capacity increased<br \/>\n06:27<br \/>\nprogesterone drives an increase in<br \/>\n06:29<br \/>\nnew ventilation and chronic<br \/>\n06:30<br \/>\nhyperventilation resulting in an<br \/>\n06:32<br \/>\nincreased pao2 and decreased paco2<br \/>\n06:36<br \/>\nconsequently I have a chronic<br \/>\n06:38<br \/>\nrespiratory alkalosis that is partially<br \/>\n06:42<br \/>\ncompensated for by an increased renal<br \/>\n06:44<br \/>\nexcretion of bicarbonate although this<br \/>\n06:46<br \/>\nmild dyspnea is compatible with daily<br \/>\n06:49<br \/>\nactivities it does increase inspiratory<br \/>\n06:51<br \/>\nmuscle effort so no Sam I still win this<br \/>\n06:55<br \/>\nbaby is manipulating everything now if<br \/>\n06:58<br \/>\nyou will excuse me I have to find a<br \/>\n07:00<br \/>\nbathroom and before you even try the<br \/>\n07:02<br \/>\nrenal system is definitely under siege<br \/>\n07:04<br \/>\nprogesterone causes smooth muscle<br \/>\n07:06<br \/>\nrelaxation which dilates the ureters in<br \/>\n07:09<br \/>\nrenal pelvis as they empty more slowly<br \/>\n07:11<br \/>\nrenal plasma flow and glomerular<br \/>\n07:13<br \/>\nfiltration rate increase leading to<br \/>\n07:15<br \/>\nincreased clearance of creatinine<br \/>\n07:16<br \/>\nglucose urinary protein and albumin and<br \/>\n07:19<br \/>\nmy favorite is a decreased bladder<br \/>\n07:22<br \/>\ncapacity due to an enlarged uterus okay<br \/>\n07:26<br \/>\non that note Spidy we&#8217;ll see you soon Oh<br \/>\n07:29<br \/>\nin the bathroom is at the top of the<br \/>\n07:30<br \/>\nstairs on the left hey Sam thanks for<br \/>\n07:35<br \/>\ninviting me to join you for dinner I am<br \/>\n07:37<br \/>\nstarving Jamie are you able to eat all<br \/>\n07:41<br \/>\nthat at once I just assumed with the<br \/>\n07:43<br \/>\nincrease in progesterone you have a<br \/>\n07:45<br \/>\nrelaxed gastro esophageal sphincter and<br \/>\n07:47<br \/>\na wicked reflux especially with the<br \/>\n07:50<br \/>\nuterus causing gastric compression<br \/>\n07:52<br \/>\nthanks Sam you are right sometimes I do<br \/>\n07:55<br \/>\nget reflux but that&#8217;s not even the half<br \/>\n07:58<br \/>\nof it<br \/>\n07:58<br \/>\nprogesterone decreases intestinal<br \/>\n08:00<br \/>\nmotility and gastric emptying<br \/>\n08:02<br \/>\nprogesterone also slows gall bladder<br \/>\n08:05<br \/>\nemptying which leads to increased<br \/>\n08:06<br \/>\nbiliary cholesterol saturation and<br \/>\n08:08<br \/>\nincreased risk for gallstone production<br \/>\n08:10<br \/>\nbut the worst is the increase in port of<br \/>\n08:13<br \/>\nvenous pressure that leads to terrible<br \/>\n08:15<br \/>\nhemorrhoids well at least I have a<br \/>\n08:17<br \/>\nreduced risk for peptic ulcer disease<br \/>\n08:19<br \/>\nthankfully an increase in placental<br \/>\n08:22<br \/>\nhistamines leads to increase maternal<br \/>\n08:24<br \/>\ngastric mucin production which in turn<br \/>\n08:26<br \/>\nprotects my gastric mucosa immune<br \/>\n08:28<br \/>\nchanges also help increase tolerance of<br \/>\n08:30<br \/>\nh pylori you&#8217;re right Jamie the baby has<br \/>\n08:33<br \/>\ninfluenced almost every body system but<br \/>\n08:36<br \/>\nremember the baby has to make lots of<br \/>\n08:38<br \/>\nadaptations to successfully live with<br \/>\n08:40<br \/>\nyou two<br \/>\n08:41<br \/>\nthe first and most important is dealing<br \/>\n08:43<br \/>\nwith your immune system the fetus and<br \/>\n08:46<br \/>\nthe placenta produce estrogen<br \/>\n08:47<br \/>\nprogesterone human chorionic<br \/>\n08:49<br \/>\ngonadotropin and human placental lacta<br \/>\n08:52<br \/>\nj&#8217;en which may allow for maternal<br \/>\n08:54<br \/>\ntolerance of the antigenically different<br \/>\n08:56<br \/>\nfetus progesterone also acts<br \/>\n08:59<br \/>\nsynergistically with relaxin to promote<br \/>\n09:01<br \/>\nuterine quiescence and inhibits t-cell<br \/>\n09:04<br \/>\nmediated allograft rejection this may<br \/>\n09:06<br \/>\naid in uterine tolerance of the<br \/>\n09:08<br \/>\ntrophoblastic tissue the interference of<br \/>\n09:11<br \/>\nmaternal and fetal vasculature in the<br \/>\n09:13<br \/>\nplacental bed also blocks or masks<br \/>\n09:15<br \/>\nantibodies and as such only IgG can<br \/>\n09:19<br \/>\ncross the placenta the benefit of<br \/>\n09:22<br \/>\nallowing for passage of IgG is to<br \/>\n09:24<br \/>\nprovide passive immunity to the fetus<br \/>\n09:26<br \/>\nand early neonate this baby is certainly<br \/>\n09:30<br \/>\nwell protected and well fed growing<br \/>\n09:32<br \/>\nbigger and bigger every day well I hope<br \/>\n09:35<br \/>\nso all that food and oxygen you&#8217;re<br \/>\n09:37<br \/>\nconsuming is doing its job glucose<br \/>\n09:40<br \/>\nderived from the placenta is the main<br \/>\n09:42<br \/>\nsubstrate for fetal oxidative metabolism<br \/>\n09:44<br \/>\nespecially in the fetal brain to produce<br \/>\n09:46<br \/>\nenergy and tissue growth other<br \/>\n09:49<br \/>\nsubstrates also include lactate and<br \/>\n09:50<br \/>\namino acids fat tissue growth is a<br \/>\n09:53<br \/>\nresult of conversion of carbohydrates to<br \/>\n09:55<br \/>\nlipids and placental fatty acid uptake<br \/>\n09:58<br \/>\nand uses about 20% of fetal oxygen<br \/>\n10:02<br \/>\nconsumption higher fetal insulin levels<br \/>\n10:05<br \/>\nincreased fetal body heart and liver<br \/>\n10:07<br \/>\nweights this is exacerbated in diabetic<br \/>\n10:09<br \/>\nmothers with poorly controlled glucose<br \/>\n10:11<br \/>\nlevels corticosteroids too are important<br \/>\n10:14<br \/>\nto fetal growth in organ maturation with<br \/>\n10:17<br \/>\nfetal levels increased at par tradition<br \/>\n10:19<br \/>\nhowever fetal growth actually slows near<br \/>\n10:22<br \/>\nparturition perhaps through suppression<br \/>\n10:24<br \/>\nof fetal igf-1 binding proteins for<br \/>\n10:27<br \/>\nigf-1 increased near-term and high<br \/>\n10:30<br \/>\nlevels also correlate with utero<br \/>\n10:32<br \/>\nplacental insufficiency finally let&#8217;s<br \/>\n10:35<br \/>\nnot forget all those cardiovascular<br \/>\n10:36<br \/>\nchanges the fetus must undertake you<br \/>\n10:39<br \/>\nremember that aapko educational video<br \/>\n10:41<br \/>\nnumber 8 that we saw during first year<br \/>\n10:43<br \/>\nright<br \/>\n10:44<br \/>\nlet&#8217;s pause thinking apply why does it<br \/>\n10:48<br \/>\nfeed a seemly tolerate significant<br \/>\n10:49<br \/>\nmaternal hypoxemia as a result of<br \/>\n10:51<br \/>\nmaternal pneumonia or pulmonary edema<br \/>\n10:54<br \/>\nthe fetus does not experience problems<br \/>\n10:57<br \/>\nas readily because of compensatory<br \/>\n10:59<br \/>\nmechanisms including increased cardiac<br \/>\n11:02<br \/>\noutput increase fh are increased oxygen<br \/>\n11:06<br \/>\ncarrying capacity of fetal hemoglobin<br \/>\n11:08<br \/>\nincreased RBC and anatomical shunts yeah<br \/>\n11:13<br \/>\nI remember that video it is amazing how<br \/>\n11:15<br \/>\nthere&#8217;s almost a total rerouting of the<br \/>\n11:17<br \/>\ncirculation with the first breath and<br \/>\n11:19<br \/>\nthese compensatory mechanisms are able<br \/>\n11:22<br \/>\nto maintain a state of fetal aerobic<br \/>\n11:24<br \/>\nmetabolism even though I swear like I am<br \/>\n11:26<br \/>\nconstantly sucking win these days see<br \/>\n11:29<br \/>\neven though you feel like the baby is<br \/>\n11:31<br \/>\ntrying to manipulate all of your system<br \/>\n11:33<br \/>\nfor its benefit the fetus has to make<br \/>\n11:35<br \/>\nseveral adaptations to survive the<br \/>\n11:37<br \/>\nintrauterine environment maybe it&#8217;s more<br \/>\n11:40<br \/>\nof a symbiotic relationship rather than<br \/>\n11:42<br \/>\na parasitic one yeah okay you&#8217;re right<br \/>\n11:46<br \/>\nit is a pretty amazing system that<br \/>\n11:48<br \/>\nallows the fetus to grow and develop<br \/>\n11:49<br \/>\nthanks for reminding me<br \/>\n11:51<br \/>\nsometimes it is easy to get caught up in<br \/>\n11:53<br \/>\nall the discomfort<br \/>\n11:55<br \/>\nthis concludes this aapko basic science<br \/>\n11:57<br \/>\nobjective video about maternal fetal<br \/>\n11:59<br \/>\nphysiology you should be able to<br \/>\n12:02<br \/>\ndescribe the maternal endocrine changes<br \/>\n12:04<br \/>\nthat provide an adaptive environment for<br \/>\n12:07<br \/>\nthe developing fetus identify the<br \/>\n12:09<br \/>\nphysiologic changes of pregnancy that<br \/>\n12:11<br \/>\nallow the mother to tolerate a symbiotic<br \/>\n12:13<br \/>\nrelationship and explain how the<br \/>\n12:16<br \/>\nphysiologic adaptation of the fetus and<br \/>\n12:18<br \/>\nplacenta allow the fetus to thrive<br \/>\n12:21<br \/>\nthanks for watching<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" width=\"560\" height=\"315\" src=\"https:\/\/www.youtube.com\/embed\/LludDq5ZzOc\" frameborder=\"0\" allow=\"accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture\" allowfullscreen><\/iframe><\/p>\n<p>Duration 7:39<\/p>\n<input type='hidden' bg_collapse_expand='69e9c84b1c11a2073468393' value='69e9c84b1c11a2073468393'><input type='hidden' id='bg-show-more-text-69e9c84b1c11a2073468393' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c84b1c11a2073468393' value='Hide Transcript'><button id='bg-showmore-action-69e9c84b1c11a2073468393' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c84b1c11a2073468393' ><\/p>\n<p>00:00<br \/>\nWelcome to this talk<br \/>\n00:01<br \/>\non the physiological changes<br \/>\n00:03<br \/>\nin pregnancy.<br \/>\n00:05<br \/>\nPregnancy is associated<br \/>\n00:06<br \/>\nwith a number<br \/>\n00:07<br \/>\nof profound physiological and<br \/>\n00:09<br \/>\nanatomical changes<br \/>\n00:10<br \/>\nthat both assist<br \/>\n00:11<br \/>\nin fetal survival as well as<br \/>\n00:13<br \/>\nprepare the mother for delivery.<br \/>\n00:15<br \/>\nAnd it&#8217;s important to know what<br \/>\n00:16<br \/>\nthe parameters<br \/>\n00:17<br \/>\nof these normal changes<br \/>\n00:18<br \/>\nare in order to diagnose<br \/>\n00:20<br \/>\nand manage<br \/>\n00:21<br \/>\nother medical problems that may<br \/>\n00:22<br \/>\noccur in pregnancy.<br \/>\n00:23<\/p>\n<p>00:26<br \/>\nBy the end of this lecture,<br \/>\n00:28<br \/>\nyou&#8217;ll be able to describe<br \/>\n00:29<br \/>\nthe physiological changes<br \/>\n00:31<br \/>\nin pregnancy<br \/>\n00:31<br \/>\nin terms<br \/>\n00:32<br \/>\nof the cardiovascular,<br \/>\n00:34<br \/>\nrespiratory, hematological,<br \/>\n00:36<br \/>\nand gastrointestinal systems.<br \/>\n00:38<br \/>\nYou&#8217;ll also understand<br \/>\n00:39<br \/>\nthe impact of these changes<br \/>\n00:41<br \/>\non the management<br \/>\n00:41<br \/>\nof the pregnant patient.<br \/>\n00:42<\/p>\n<p>00:46<br \/>\nPregnancy induces<br \/>\n00:47<br \/>\nprofound changes in the woman&#8217;s<br \/>\n00:48<br \/>\nanatomy and physiology.<br \/>\n00:50<br \/>\nThe female body begins to adapt<br \/>\n00:52<br \/>\nto the growing demands<br \/>\n00:53<br \/>\nof the fetus<br \/>\n00:54<br \/>\neven before pregnancy may be<br \/>\n00:55<br \/>\nclinically detected.<br \/>\n00:57<br \/>\nThese complex areas<br \/>\n00:59<br \/>\nof physiological an<br \/>\n01:00<br \/>\nanatomical changes are primarily<br \/>\n01:02<br \/>\nhormonally mediated<br \/>\n01:03<br \/>\nand affect every system<br \/>\n01:04<br \/>\nof the body.<br \/>\n01:06<br \/>\nThe primary goals are<br \/>\n01:07<br \/>\nto optimize maternal conditions<br \/>\n01:09<br \/>\nfor fetal growth,<br \/>\n01:10<br \/>\nprepare for delivery,<br \/>\n01:12<br \/>\nand to develop the mother&#8217;s<br \/>\n01:13<br \/>\nbreast for the production<br \/>\n01:14<br \/>\nof milk.<br \/>\n01:14<\/p>\n<p>01:17<br \/>\nFirst, let&#8217;s take a look<br \/>\n01:18<br \/>\nat the cardiovascular changes<br \/>\n01:20<br \/>\nin pregnancy.<br \/>\n01:22<br \/>\nThe cardiac output increases<br \/>\n01:23<br \/>\nas a function of two changes<br \/>\n01:25<br \/>\nin how the heart works.<br \/>\n01:27<br \/>\nOne, there&#8217;s an increase<br \/>\n01:28<br \/>\nin stroke volume,<br \/>\n01:29<br \/>\nor the blood of volume<br \/>\n01:30<br \/>\npumped out of the heart<br \/>\n01:31<br \/>\nper beat.<br \/>\n01:33<br \/>\nThis is predominantly<br \/>\n01:34<br \/>\nas a result of increased blood<br \/>\n01:35<br \/>\nvolume.<br \/>\n01:37<br \/>\nTwo, there&#8217;s an increase<br \/>\n01:38<br \/>\nin the resting heart rate.<br \/>\n01:40<br \/>\nThe heart rate is about 15 beats<br \/>\n01:41<br \/>\nper minute<br \/>\n01:42<br \/>\nhigher<br \/>\n01:42<br \/>\nthan in non-pregnant women.<br \/>\n01:44<br \/>\nAs you remember,<br \/>\n01:45<br \/>\nthe cardiac output<br \/>\n01:46<br \/>\nis the product of the stroke<br \/>\n01:47<br \/>\nvolume and the heart rate.<br \/>\n01:49<br \/>\nThus, this results<br \/>\n01:50<br \/>\nin the steady rise<br \/>\n01:51<br \/>\nin cardiac output, which rises<br \/>\n01:53<br \/>\nabout 50%<br \/>\n01:54<br \/>\nabove the pre-pregnancy cardiac<br \/>\n01:56<br \/>\noutput.<br \/>\n01:57<br \/>\nThe blood pressure, however,<br \/>\n01:59<br \/>\nas you can see from the graph,<br \/>\n02:00<br \/>\ntakes a slight dip<br \/>\n02:01<br \/>\nat the beginning,<br \/>\n02:02<br \/>\nand then slowly rises.<br \/>\n02:04<br \/>\nThus, it&#8217;s relatively stable.<br \/>\n02:06<br \/>\nThus, with a stable BP<br \/>\n02:08<br \/>\nand an increase<br \/>\n02:09<br \/>\nin cardiac output, there must be<br \/>\n02:10<br \/>\na decrease in systemic vascular<br \/>\n02:12<br \/>\nresistance.<br \/>\n02:13<\/p>\n<p>02:16<br \/>\nAnother change you may see<br \/>\n02:17<br \/>\nduring the later stages<br \/>\n02:18<br \/>\nof pregnancy<br \/>\n02:19<br \/>\nis aortocaval compression,<br \/>\n02:21<br \/>\nor compression of both<br \/>\n02:23<br \/>\nthe inferior vena cava<br \/>\n02:24<br \/>\nand the lower aorta<br \/>\n02:26<br \/>\nwhen the patient is supine.<br \/>\n02:28<br \/>\nThis leads to a reduction<br \/>\n02:29<br \/>\nin venous return,<br \/>\n02:30<br \/>\nand thus, a fall<br \/>\n02:31<br \/>\nin cardiac pre-load The fall<br \/>\n02:33<br \/>\nin cardiac pre-load<br \/>\n02:34<br \/>\nmay reduce cardiac output, which<br \/>\n02:37<br \/>\nmay threaten perfusion.<br \/>\n02:40<br \/>\nFurthermore, compression<br \/>\n02:41<br \/>\nof the aorta<br \/>\n02:41<br \/>\nmay lead to reduced perfusion<br \/>\n02:43<br \/>\nto the uterus and placenta, as<br \/>\n02:45<br \/>\nwell as the kidneys.<br \/>\n02:46<br \/>\nIt&#8217;s been shown<br \/>\n02:47<br \/>\nthat during the last trimester,<br \/>\n02:49<br \/>\nmaternal kidney function is<br \/>\n02:50<br \/>\nlower in the supine position<br \/>\n02:52<br \/>\nthan when sitting or standing.<br \/>\n02:54<br \/>\nFetal transplacental gas<br \/>\n02:56<br \/>\nexchange may also be affected,<br \/>\n02:58<br \/>\ndue to decreased perfusion<br \/>\n02:59<br \/>\nto the placenta.<br \/>\n03:01<br \/>\nAs a result, one should advise<br \/>\n03:03<br \/>\nwomen not to lie supine<br \/>\n03:05<br \/>\nduring the later stages<br \/>\n03:06<br \/>\nof pregnancy.<br \/>\n03:06<\/p>\n<p>03:10<br \/>\nThe respiratory tract also<br \/>\n03:11<br \/>\nundergoes changes in response<br \/>\n03:12<br \/>\nto the maternal adaptation<br \/>\n03:14<br \/>\nto pregnancy.<br \/>\n03:15<br \/>\nStarting at the upper airways,<br \/>\n03:17<br \/>\nhormone-induced changes<br \/>\n03:18<br \/>\nto the mucosa vasculature<br \/>\n03:20<br \/>\nof the upper airways<br \/>\n03:21<br \/>\nleads to capillary engorgement,<br \/>\n03:23<br \/>\ncongestion, and edema.<br \/>\n03:25<br \/>\nThis may lead to nasal<br \/>\n03:26<br \/>\nstuffiness, and more<br \/>\n03:27<br \/>\nimportantly,<br \/>\n03:28<br \/>\ndifficulties with intubation<br \/>\n03:30<br \/>\nin the case<br \/>\n03:31<br \/>\nthat emergent Cesarean sections<br \/>\n03:33<br \/>\nbecome necessary.<br \/>\n03:35<br \/>\nMinute ventilation rises 150%<br \/>\n03:36<br \/>\nat term, as you can see<br \/>\n03:38<br \/>\nin the graph on the right.<br \/>\n03:40<br \/>\nProgesterone, a known stimulant<br \/>\n03:41<br \/>\nof the respiratory drive,<br \/>\n03:43<br \/>\ngradually rises<br \/>\n03:44<br \/>\nthroughout pregnancy.<br \/>\n03:45<br \/>\nAnd as such, it increases<br \/>\n03:46<br \/>\nsensitivity to carbon dioxide<br \/>\n03:49<br \/>\nsuch that increased CO2 elicits<br \/>\n03:51<br \/>\nan exaggerated respiratory<br \/>\n03:52<br \/>\neffort.<br \/>\n03:54<br \/>\nProgesterone is also known<br \/>\n03:55<br \/>\nto reduce airway resistance<br \/>\n03:56<br \/>\nby bronchial and tracheal<br \/>\n03:58<br \/>\nsmooth muscle relaxation.<br \/>\n04:01<br \/>\nThe functional<br \/>\n04:01<br \/>\nresidual capacity, or FRC,<br \/>\n04:04<br \/>\nor the apnoeic reserve<br \/>\n04:06<br \/>\nof oxygen, decreases by 20%,<br \/>\n04:09<br \/>\nwhile the inspiratory capacity<br \/>\n04:11<br \/>\nremains the same.<br \/>\n04:12<br \/>\nThis is partly<br \/>\n04:13<br \/>\ndue to the mechanical effect<br \/>\n04:14<br \/>\nas the gravid uterus<br \/>\n04:15<br \/>\ncausing elevation<br \/>\n04:16<br \/>\nof the diaphragm,<br \/>\n04:18<br \/>\nas well as the hormonal changes<br \/>\n04:19<br \/>\nassociated with pregnancy.<br \/>\n04:21<br \/>\nAs a result,<br \/>\n04:23<br \/>\nthe pregnant patient<br \/>\n04:24<br \/>\nhas a decreased ability<br \/>\n04:25<br \/>\nto tolerate periods of apnea.<br \/>\n04:29<br \/>\nPregnant women also have<br \/>\n04:30<br \/>\na marked increase<br \/>\n04:31<br \/>\nin their oxygen consumption<br \/>\n04:32<br \/>\nby up to 40% to 50%<br \/>\n04:34<br \/>\nover non-pregnancy levels.<br \/>\n04:36<br \/>\nThis decreases<br \/>\n04:37<br \/>\nthe partial pressure of carbon<br \/>\n04:39<br \/>\ndioxide and gives rise<br \/>\n04:40<br \/>\nto the chronic respiratory<br \/>\n04:41<br \/>\nalkalosis of pregnancy.<br \/>\n04:42<\/p>\n<p>04:46<br \/>\nNow, let&#8217;s review some<br \/>\n04:47<br \/>\nof the hematological changes<br \/>\n04:48<br \/>\nin pregnancy.<br \/>\n04:49<br \/>\nAs you can see from the graph,<br \/>\n04:51<br \/>\nblood volume increases by 50%<br \/>\n04:53<br \/>\nto 100%.<br \/>\n04:55<br \/>\nAt the same time, red blood cell<br \/>\n04:56<br \/>\ncounts only increase by 25%<br \/>\n04:58<br \/>\nto 40%.<br \/>\n05:00<br \/>\nThis is why the hematocrit dips<br \/>\n05:02<br \/>\ndown in this graph<br \/>\n05:03<br \/>\nbecause we have what&#8217;s<br \/>\n05:04<br \/>\ncalled physiological anemia<br \/>\n05:06<br \/>\npregnancy, or dilutional anemia.<br \/>\n05:09<br \/>\nElevated erythropoietin levels<br \/>\n05:10<br \/>\nincrease total red blood cell<br \/>\n05:12<br \/>\nmass.<br \/>\n05:13<br \/>\nBut hemoglobin concentrations<br \/>\n05:14<br \/>\nnever reach pre-pregnancy levels<br \/>\n05:16<br \/>\nbecause you&#8217;re also having<br \/>\n05:18<br \/>\nan increase<br \/>\n05:18<br \/>\nin the overall plasma volume.<br \/>\n05:21<br \/>\nAt the same time, the increased<br \/>\n05:23<br \/>\nred blood cell production also<br \/>\n05:24<br \/>\ncreates a fall in serum iron,<br \/>\n05:26<br \/>\nwhile increasing the transferrin<br \/>\n05:28<br \/>\nand total iron-binding capacity.<br \/>\n05:31<br \/>\nAs you can also see<br \/>\n05:32<br \/>\nfrom the graph, there&#8217;s also<br \/>\n05:34<br \/>\na rise in the total white blood<br \/>\n05:35<br \/>\ncells during pregnancy.<br \/>\n05:38<br \/>\nLevels of some clotting factors,<br \/>\n05:40<br \/>\nincluding seven, eight, nine,<br \/>\n05:42<br \/>\nand 10, as well as fibrinogen,<br \/>\n05:45<br \/>\nincrease during pregnancy,<br \/>\n05:47<br \/>\nwhile fibrinolytic activity<br \/>\n05:48<br \/>\ndecreases.<br \/>\n05:50<br \/>\nThis increases the risk<br \/>\n05:52<br \/>\nof thromboembolic disease.<br \/>\n05:54<br \/>\nThe whole point<br \/>\n05:55<br \/>\nof this increased coagulability<br \/>\n05:56<br \/>\nthough is to protect<br \/>\n05:57<br \/>\nfrom hemorrhage at delivery.<br \/>\n05:59<br \/>\nBut it also puts the mother<br \/>\n06:01<br \/>\nat risk for getting DVTs<br \/>\n06:03<br \/>\nduring pregnancy.<br \/>\n06:04<\/p>\n<p>06:07<br \/>\nFinally, let&#8217;s complete<br \/>\n06:08<br \/>\nour overview<br \/>\n06:09<br \/>\nof the physiological changes<br \/>\n06:10<br \/>\nin pregnancy<br \/>\n06:11<br \/>\nby discussing briefly<br \/>\n06:12<br \/>\nthe musculoskeletal, endocrine,<br \/>\n06:14<br \/>\nand renal changes in pregnancy.<br \/>\n06:17<br \/>\nIn terms<br \/>\n06:17<br \/>\nof the musculoskeletal system,<br \/>\n06:19<br \/>\nthere are elevated levels<br \/>\n06:20<br \/>\nof relaxin, which helps prepare<br \/>\n06:22<br \/>\nfor delivery by softening<br \/>\n06:23<br \/>\nthe cervix,<br \/>\n06:24<br \/>\ninhibiting uterine contractions,<br \/>\n06:26<br \/>\nand relaxing<br \/>\n06:27<br \/>\nthe pubic symphysis.<br \/>\n06:29<br \/>\nThis increased ligamentous<br \/>\n06:30<br \/>\nlaxity, however, leads<br \/>\n06:31<br \/>\nto an increased risk<br \/>\n06:32<br \/>\nfor back injury<br \/>\n06:33<br \/>\nand pubic symphysis dysfunction.<br \/>\n06:36<br \/>\nIn terms<br \/>\n06:36<br \/>\nof the endocrine changes,<br \/>\n06:37<br \/>\nthere are increased levels<br \/>\n06:38<br \/>\nof prolactin to prepare<br \/>\n06:40<br \/>\nfor breastfeeding,<br \/>\n06:41<br \/>\nlinearly increasing levels<br \/>\n06:43<br \/>\nof corticotropin releasing<br \/>\n06:44<br \/>\nhormone,<br \/>\n06:45<br \/>\nwhich is thought to be<br \/>\n06:46<br \/>\na possible stimulant for labor,<br \/>\n06:48<br \/>\nand increased insulin production<br \/>\n06:50<br \/>\nin order to maintain blood sugar<br \/>\n06:51<br \/>\nlevels.<br \/>\n06:52<br \/>\nPregnancy is also associated<br \/>\n06:54<br \/>\nwith increased insulin<br \/>\n06:55<br \/>\nresistance due to the secretion<br \/>\n06:57<br \/>\nof human placental oxygen.<br \/>\n06:59<br \/>\nThus, the risk<br \/>\n06:59<br \/>\nfor gestational diabetes<br \/>\n07:01<br \/>\nmellitus.<br \/>\n07:03<br \/>\nRenal changes include increase<br \/>\n07:04<br \/>\nurinary stasis.<br \/>\n07:06<br \/>\nThis is due to smooth muscle<br \/>\n07:08<br \/>\nrelaxation of the renal pelvis,<br \/>\n07:10<br \/>\nureters, and bladder,<br \/>\n07:11<br \/>\nwith an increase in bladder<br \/>\n07:12<br \/>\ncapacity and residual urine<br \/>\n07:14<br \/>\nvolume.<br \/>\n07:15<br \/>\nThis urinary stasis leads<br \/>\n07:17<br \/>\nto an increased risk for UTIs.<br \/>\n07:20<br \/>\nThere&#8217;s also increased<br \/>\n07:21<br \/>\nactivation reno-angiontensin<br \/>\n07:23<br \/>\nsystem, which leads to increased<br \/>\n07:25<br \/>\nsodium retention and edema.<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration 12:52 Duration 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