PHYSIOLOGY OF PHYSIOLOGY OF PREGNANCYPREGNANCY

ISKANDAR ZULQARNAINISKANDAR ZULQARNAIN

A. ABADIA. ABADI

IT Obstetri 1 IT Obstetri 1 : Obstetri Fisiologi: Obstetri Fisiologi

1.1. Fertilisasi , inplantasi dan nidasi .Fertilisasi , inplantasi dan nidasi .

2.2. Hormon-hormon plasenta.Hormon-hormon plasenta.

3.3. Perubahan morfologi janin dan fisiologi Perubahan morfologi janin dan fisiologi janin.janin.

4.4. Perubahan anatomik dan Fisiologi ibu Perubahan anatomik dan Fisiologi ibu hamil.hamil.

5.5. Asuhan antenatal.Asuhan antenatal.

ENDOMETRIUM & DECIDUAENDOMETRIUM & DECIDUA

Maternal tissues of fetal-maternal Maternal tissues of fetal-maternal communication systemcommunication systemDirect cell to cell contact (blastocyst-Direct cell to cell contact (blastocyst-

maternal endometrium) maternal endometrium) since 6 since 6thth days days after fertilization (“blastocyst apposition”)after fertilization (“blastocyst apposition”)

Then occurred immunological acceptance Then occurred immunological acceptance of the conceptus, maternal recognition of of the conceptus, maternal recognition of pregnancy, placental development, pregnancy, placental development, pregnancy maintenance, & fetal nutritionpregnancy maintenance, & fetal nutrition

Endometrial / decidual Endometrial / decidual functionfunction

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

The decidua serves as an immunologically The decidua serves as an immunologically specialized tissue. specialized tissue.

Endometrial / Endometrial / decidualdecidual function function

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

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

Hormonal regulation of the Hormonal regulation of the endometriumendometrium

EstrogenEstrogenestradiol-17b & other bioactive estrogens in estradiol-17b & other bioactive estrogens in

vivo cause replication of the epithelium vivo cause replication of the epithelium indirectly (probably through actions on the indirectly (probably through actions on the stromal cells)stromal cells)

estrogen acts on the endometrial stromal cells estrogen acts on the endometrial stromal cells to promote the synthesis of an endometrial to promote the synthesis of an endometrial epithelial cell growth factor, which functions in epithelial cell growth factor, which functions in a paracrine manner to cause replication of the a paracrine manner to cause replication of the adjacent epithelial cells.adjacent epithelial cells.

Hormonal regulation of the Hormonal regulation of the endometriumendometrium

ProgesteroneProgesteroneprogesterone receptors is dependent on progesterone receptors is dependent on

previous estrogen actionprevious estrogen actionProgesterone actions Progesterone actions a decreases in the a decreases in the

synthesis of estrogen receptor molecules synthesis of estrogen receptor molecules progesterone acts to increase the rate of progesterone acts to increase the rate of

enzymatic inactivation of estradiol-17b enzymatic inactivation of estradiol-17b through an increase in the activity of estradiol through an increase in the activity of estradiol dehydrogenase. dehydrogenase.

FERTILIZATION & NIDATIONFERTILIZATION & NIDATION

EMBRIOLOGICAL EMBRIOLOGICAL DEVELOPMENTDEVELOPMENT

PLACENTA & FETAL MEMBRANES PLACENTA & FETAL MEMBRANES

the fetus is dependent upon the placenta the fetus is dependent upon the placenta as its lung, liver, and kidneys. as its lung, liver, and kidneys.

The organ serves these purposes until The organ serves these purposes until sufficient maturation of the fetus allows it sufficient maturation of the fetus allows it to survive ex utero as an air-breathing to survive ex utero as an air-breathing organismorganism

PLACENTAL DEVELOPMENTPLACENTAL DEVELOPMENTThe blastocyst + its surrounding tropho-The blastocyst + its surrounding tropho-

blasts grow and expandblasts grow and expandextends extends endometrial cavity endometrial cavity buried in the endometrium/decidua. buried in the endometrium/decidua.

The innermost pole enters into the The innermost pole enters into the formation of the placenta formation of the placenta the the anchoring cytotrophoblasts and the anchoring cytotrophoblasts and the villous trophoblasts. villous trophoblasts.

PLACENTAL DEVELOPMENTPLACENTAL DEVELOPMENT

The trophoblasts of the villus are the outer The trophoblasts of the villus are the outer layer of syncytium and an inner layer of layer of syncytium and an inner layer of cytotrophoblasts. cytotrophoblasts.

The pole developing toward the The pole developing toward the endometrial cavity is covered by the endometrial cavity is covered by the chorion frondosum, chorion frondosum, at this time by at this time by decidua (capsularis). decidua (capsularis).

decidua capsularis + decidua parietalisdecidua capsularis + decidua parietalis decidua vera. decidua vera.

TROPHOBLASTIC BIOLOGYTROPHOBLASTIC BIOLOGYSyncytiotrophoblastSyncytiotrophoblast

The cytotrophoblast The cytotrophoblast the syncytium the syncytium

Chorionic villi Chorionic villi Villi can first be distinguished easily in the human Villi can first be distinguished easily in the human

placenta placenta the 12th day after fertilization the 12th day after fertilizationCytotrophoblasts Cytotrophoblasts mesenchymal cord, invades mesenchymal cord, invades

the solid trophoblast column the solid trophoblast column secondary villi secondary villi

TROPHOBLASTIC BIOLOGYTROPHOBLASTIC BIOLOGYPlacental cotyledonsPlacental cotyledons

the short, thick, early stem villi branch repeatedly, the short, thick, early stem villi branch repeatedly, forming progressively finer subdivisions & >> forming progressively finer subdivisions & >> increasingly small villi increasingly small villi

the main stem (truncal) villi & their ramifications the main stem (truncal) villi & their ramifications (rami) (rami) placental cotyledon (lobe)placental cotyledon (lobe)

each cotyledon is supplied with a branch (truncal) each cotyledon is supplied with a branch (truncal) of the chorionic artery; and for each cotyledon, of the chorionic artery; and for each cotyledon, there is a vein, constituting a 1:1:1 ratio of artery there is a vein, constituting a 1:1:1 ratio of artery to vein to cotyledon. to vein to cotyledon.

PLACENTAL AGINGPLACENTAL AGING

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

PLACENTAL AGINGPLACENTAL AGING

histological changes histological changes decrease in thickness of the syncytiumdecrease in thickness of the syncytiumpartial reduction of cytotrophoblastic cellspartial reduction of cytotrophoblastic cellsdecrease in the stromadecrease in the stroma increase in the number of capillaries increase in the number of capillaries the approximation of these vessels to the the approximation of these vessels to the

syncytial surfacesyncytial surface

PLACENTAL AGINGPLACENTAL AGING

Other changesOther changes thickening of the basement membranes of the thickening of the basement membranes of the

trophoblast capillariestrophoblast capillariesobliteration of certain fetal vesselsobliteration of certain fetal vessels fibrin deposition on the surface of the villi in fibrin deposition on the surface of the villi in

the basal and chorionic plates & intervillous the basal and chorionic plates & intervillous space. space.

PLACENTAL AT TERMPLACENTAL AT TERM

Boyd and Hamilton (1970)Boyd and Hamilton (1970) the placenta at term the placenta at term ++ Ǿ185 mm & 23 mm Ǿ185 mm & 23 mm

(thickness)(thickness)Volume Volume ++497 ml & weight 508gs497 ml & weight 508gs

From the maternal surface, the number of From the maternal surface, the number of slightly elevated convex areas (lobes or if slightly elevated convex areas (lobes or if small, lobules) varies from 10 to 38small, lobules) varies from 10 to 38

The lobes are also referred to as The lobes are also referred to as cotyledons. cotyledons.

BLOOD CIRCULATION IN THE BLOOD CIRCULATION IN THE MATURE PLACENTAMATURE PLACENTA

Fetal circulationFetal circulation Fetal deoxygenated, or "venous-like," blood Fetal deoxygenated, or "venous-like," blood 2 umbilical 2 umbilical

arteriesarteries Blood, with Blood, with ↑↑↑↑ oxygen content ∞ placenta oxygen content ∞ placenta fetus fetus through through

1 umbilical vein. 1 umbilical vein.

Maternal circulationMaternal circulation Maternal blood Maternal blood the basal plate the basal plate driven high up driven high up the chorionic plate the chorionic plate by the head of maternal arterial pressure by the head of maternal arterial pressure After bathing the external microvillus surface of chorionic villi, the After bathing the external microvillus surface of chorionic villi, the

maternal blood drains back maternal blood drains back venous orifices in the basal plate venous orifices in the basal plate the uterine veins. the uterine veins.

AMNIONAMNION

StructureStructureBourne (1962) Bourne (1962) 5 layers of amnion tissue 5 layers of amnion tissueThe inner surface The inner surface single layer of single layer of

cuboidal epithelial cells, derived from cuboidal epithelial cells, derived from embryonic ectodermembryonic ectoderm

distinct basement membrane distinct basement membrane

AMNIONAMNION

Structure Structure the acellular compact layerthe acellular compact layerfibroblast-like mesenchymal cells (widely fibroblast-like mesenchymal cells (widely

dispersed at term), derived from dispersed at term), derived from mesoderm mesoderm

the relatively acellular zona spongiosa the relatively acellular zona spongiosa contiguous with the chorion laeve.contiguous with the chorion laeve.

AMNIONAMNION

DevelopmentDevelopmentamniogenic cells, line this inner surface amniogenic cells, line this inner surface

of trophoblasts of trophoblasts the precursors of the the precursors of the amnionic epitheliumamnionic epithelium

the human amnion is 1the human amnion is 1stst identifiable identifiable ++77thth or 8 or 8thth day of embryo development. day of embryo development.

The amnion The amnion a small sac that covers a small sac that covers the dorsal surface of the embryothe dorsal surface of the embryo

AMNIONAMNION

DevelopmentDevelopment

as the amnion enlarges , it gradually as the amnion enlarges , it gradually engulfs the growing embryoengulfs the growing embryo

the amnion and chorion laeve, though the amnion and chorion laeve, though slightly adherent, are never intimately slightly adherent, are never intimately connected, and usually can be connected, and usually can be separated easily, even at term. separated easily, even at term.

AMNIONAMNION

Amnion cell histogenesisAmnion cell histogenesisthe epithelial cells of the amnion are the epithelial cells of the amnion are

derived from fetal ectodermderived from fetal ectodermthe epithelial cells line the innermost the epithelial cells line the innermost

(amnionic fluid) side of the amnion(amnionic fluid) side of the amniona layer of fibroblast-like (mesenchymal) a layer of fibroblast-like (mesenchymal)

cells, derived from embryonic cells, derived from embryonic mesoderm.mesoderm.

AMNIONAMNION

Amnion cell histogenesisAmnion cell histogenesisearly in pregnancy, the epithelial cells of early in pregnancy, the epithelial cells of

the amnion replicate faster than the the amnion replicate faster than the mesenchymal cellsmesenchymal cells

At term, the epithelial cells form a At term, the epithelial cells form a continuous uninterrupted epithelium on continuous uninterrupted epithelium on the fetal surface of the amnion. the fetal surface of the amnion.

AMNIONIC FLUIDAMNIONIC FLUID

average volume average volume ++1000 mL is found at 1000 mL is found at termterm

may vary widely from a few milliliters may vary widely from a few milliliters to many litersto many liters

abnormal conditions abnormal conditions oligohydramnios oligohydramnios polyhydramnios or hydramniospolyhydramnios or hydramnios

UMBILICAL CORDUMBILICAL CORD

DevelopmentDevelopmentAt first, the embryo is a flattened disc At first, the embryo is a flattened disc

interposed between amnion and yolk interposed between amnion and yolk sacsac

the embryo bulges into the amnionic sac the embryo bulges into the amnionic sac and the dorsal part of the yolk sac is and the dorsal part of the yolk sac is incorporated into the body of the embryo incorporated into the body of the embryo to form the gut.to form the gut.

UMBILICAL CORDUMBILICAL CORD

DevelopmentDevelopment

The allantois projects into the base of The allantois projects into the base of the body stalk from the caudal wall of the body stalk from the caudal wall of the yolk sac or, later, from the anterior the yolk sac or, later, from the anterior wall of the hindgut. wall of the hindgut.

The cord at term normally has 2 arteries The cord at term normally has 2 arteries and 1 veinand 1 vein

UMBILICAL CORDUMBILICAL CORD

Structure & functionStructure & functionBlood flows from the umbilical vein by two Blood flows from the umbilical vein by two

routesroutesthe ductus venosus empties directly into the ductus venosus empties directly into

the inferior vena cavathe inferior vena cavanumerous smaller openings numerous smaller openings the fetal the fetal

hepatic circulation hepatic circulation the hepatic vein the hepatic vein the inferior vena cava the inferior vena cava

PLACENTAL HORMONESPLACENTAL HORMONES

Human placental lactogen (hPL1) Human placental lactogen (hPL1) human chorionic gonadotropin (hCG)human chorionic gonadotropin (hCG)chorionic adrenocorticotropin (ACTH2) chorionic adrenocorticotropin (ACTH2)

PLACENTAL HORMONESPLACENTAL HORMONES

proopiomelanocortin, chorionic thyrotropin, proopiomelanocortin, chorionic thyrotropin, growth hormone variant, parathyroid hormone-growth hormone variant, parathyroid hormone-related protein (PTH-rP), calcitonin, and relaxinrelated protein (PTH-rP), calcitonin, and relaxin

hypothalamic-like releasing and inhibiting hypothalamic-like releasing and inhibiting hormones hormones thyrotropin-releasing hormone thyrotropin-releasing hormone (TRH), gonadotropin-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), corticotropin-releasing hormone (CRH), (GnRH), corticotropin-releasing hormone (CRH), somatostatin & growth hormone-releasing somatostatin & growth hormone-releasing hormone (GHRH)hormone (GHRH)

MATERNAL ADAPTATION TO MATERNAL ADAPTATION TO PREGNANCYPREGNANCY

Uterus Uterus During pregnancy, uterine enlargement During pregnancy, uterine enlargement

involves stretching and marked involves stretching and marked hypertrophy of muscle cellhypertrophy of muscle cellss

MATERNAL ADAPTATION TO MATERNAL ADAPTATION TO PREGNANCYPREGNANCY

Cervix Cervix softening and cyanosis of the cervixsoftening and cyanosis of the cervixvascularity and edema of the entire vascularity and edema of the entire

cervixcervixhypertrophy and hyperplasia of the hypertrophy and hyperplasia of the

cervical glands. cervical glands.

MATERNAL ADAPTATION TO MATERNAL ADAPTATION TO PREGNANCYPREGNANCY

OvariumOvariumOvulation ceases during pregnancy and Ovulation ceases during pregnancy and

the maturation of new follicles is the maturation of new follicles is suspended suspended

only a single corpus luteum of only a single corpus luteum of pregnancy can be found pregnancy can be found

functions maximally during the first 6-7 functions maximally during the first 6-7 wks of pregnancy (4-5 wks wks of pregnancy (4-5 wks postovulation)postovulation)

MATERNAL ADAPTATIONSMATERNAL ADAPTATIONS

Fallopian tubesFallopian tubesThe musculature of the fallopian tubes The musculature of the fallopian tubes

little hypertrophy little hypertrophy The epithelium of the tubal mucosa The epithelium of the tubal mucosa

flattened flattened Decidual cells may develop in the stroma Decidual cells may develop in the stroma

of the endosalpinx, but a continuous of the endosalpinx, but a continuous decidual membrane is not formed.decidual membrane is not formed.

MATERNAL ADAPTATIONSMATERNAL ADAPTATIONS

Vagina & perineumVagina & perineum increased vascularity and hyperemia develop in the skin and increased vascularity and hyperemia develop in the skin and

muscles of the perineum and vulvamuscles of the perineum and vulva softening of the normally abundant connective tissue of these softening of the normally abundant connective tissue of these

structuresstructures Increased vascularity prominently affects the vaginaIncreased vascularity prominently affects the vagina The copious secretion and the characteristic violet color of the The copious secretion and the characteristic violet color of the

vagina during pregnancy (Chadwick sign) vagina during pregnancy (Chadwick sign) hypertrophy of the smooth-muscle cells hypertrophy of the smooth-muscle cells The papillae of the vaginal mucosa The papillae of the vaginal mucosa hypertrophy, creating a hypertrophy, creating a

fine, hobnailed appearancefine, hobnailed appearance

SKIN CHANGESSKIN CHANGES

In the later months of pregnancy, reddish, In the later months of pregnancy, reddish, slightly depressed streaks -----slightly depressed streaks ----- develop in develop in the skin of the abdomen,the breasts and the skin of the abdomen,the breasts and thighsthighs

the reddish striae of the present pregnancy, the reddish striae of the present pregnancy, glistening, silvery lines that represent the glistening, silvery lines that represent the cicatrices of previous striae cicatrices of previous striae

SKIN CHANGESSKIN CHANGES

the midline of the abdominal skin becomes the midline of the abdominal skin becomes markedly pigmented, assuming a brownish-markedly pigmented, assuming a brownish-black color to form the linea nigra black color to form the linea nigra

irregular brownish patches of varying size irregular brownish patches of varying size appear on the face and neck, giving rise to appear on the face and neck, giving rise to chloasma or melasma gravidarum (mask of chloasma or melasma gravidarum (mask of pregnancy) pregnancy)

accentuation of pigment of the areolae and accentuation of pigment of the areolae and genital skingenital skin

BREAST CHANGESBREAST CHANGES

11stst month month breast tenderness and breast tenderness and tinglingtingling

22ndnd month month the breasts increase in size the breasts increase in size the nipples the nipples larger, more deeply larger, more deeply

pigmented, and more erectilepigmented, and more erectile

BREAST CHANGESBREAST CHANGES

Then Then a thick, yellowish fluid, colostrum, a thick, yellowish fluid, colostrum, can often be expressed from the nipples can often be expressed from the nipples by gentle massageby gentle massage

the areolae the areolae broader and more deeply broader and more deeply pigmentedpigmented

Scattered through the areolae Scattered through the areolae glands of glands of Montgomery, (hypertrophic sebaceous Montgomery, (hypertrophic sebaceous glands)glands)

METABOLIC CHANGESMETABOLIC CHANGESWater metabolismWater metabolism

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

METABOLIC CHANGESMETABOLIC CHANGES

Water metabolismWater metabolismIncreased water retention is a normal Increased water retention is a normal

physiological alteration of pregnancy. physiological alteration of pregnancy.

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

METABOLIC CHANGESMETABOLIC CHANGES

Water metabolismWater metabolismAnother 3.0 L accumulates as a result of Another 3.0 L accumulates as a result of

increases in the maternal blood volume increases in the maternal blood volume and in the size of the uterus and the and in the size of the uterus and the breasts. breasts.

Thus, the minimum amount of extra water Thus, the minimum amount of extra water that the average women retains during that the average women retains during normal pregnancy is about 6.5 L.normal pregnancy is about 6.5 L.

PROTEIN METABOLISMPROTEIN METABOLISM

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

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

PROTEIN METABOLISMPROTEIN METABOLISM

Amino acids used for energy are not Amino acids used for energy are not available for synthesis of maternal protein.available for synthesis of maternal protein.

With increasing intake of fat and With increasing intake of fat and

carbohydrates as energy sources, less carbohydrates as energy sources, less dietary protein is required to maintain dietary protein is required to maintain positive nitrogen balance.positive nitrogen balance.

CARBOHYDRATE METABOLISMCARBOHYDRATE METABOLISM

Normal pregnancy is characterized by mild Normal pregnancy is characterized by mild fasting hypoglycemia, postprandial fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemiahyperglycemia, and hyperinsulinemia

pregnancy-induced state of peripheral pregnancy-induced state of peripheral resistance to insulinresistance to insulin

1. Increased insulin response to glucose. 1. Increased insulin response to glucose.

2. Reduced peripheral uptake of glucose. 2. Reduced peripheral uptake of glucose.

3. Suppressed glucagon response. 3. Suppressed glucagon response.

FAT METABOLISMFAT METABOLISM

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

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

FAT METABOLISMFAT METABOLISM

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

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

HAEMATOLOGICAL CHANGESHAEMATOLOGICAL CHANGES

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

hemoglobin concentration and the hemoglobin concentration and the hematocrit decrease slightly during normal hematocrit decrease slightly during normal pregnancypregnancy

HAEMATOLOGICAL CHANGESHAEMATOLOGICAL CHANGES

The total iron content of normal adult The total iron content of normal adult women ranges from 2.0 to 2.5 g women ranges from 2.0 to 2.5 g

The leukocyte ranges 5000 - 12,000/UlThe leukocyte ranges 5000 - 12,000/Ul fibrinogen concentration increases about fibrinogen concentration increases about

50 percent to average about 450 mg/dL 50 percent to average about 450 mg/dL late in pregnancy, with a range from 300 to late in pregnancy, with a range from 300 to 600600

CARDIOVASCULAR SYSTEM CARDIOVASCULAR SYSTEM CHANGESCHANGES

The most important changes in cardiac The most important changes in cardiac function function the first 8 weeks of pregnancy the first 8 weeks of pregnancy

Cardiac output is increased Cardiac output is increased the 5 the 5thth week of pregnancyweek of pregnancy

Between weeks 10 - 20, plasma volume Between weeks 10 - 20, plasma volume ↑↑,preload ,preload ↑↑

RESPIRATORY SYSTEM CHANGESRESPIRATORY SYSTEM CHANGES

The diaphragm rises The diaphragm rises ++ 4 cm during 4 cm during pregnancy .pregnancy .

The subcostal angle widens ∞ transverse The subcostal angle widens ∞ transverse diameter of the thoracic cage diameter of the thoracic cage ↑↑ ++2 cm2 cm

The thoracic circumference increases The thoracic circumference increases ++ 6 6 cmcm

RESPIRATORY SYSTEM CHANGESRESPIRATORY SYSTEM CHANGES

The amount of oxygen needs The amount of oxygen needs ↑↑The respiratory rate is little changed during The respiratory rate is little changed during

pregnancypregnancy the tidal volume, minute ventilatory the tidal volume, minute ventilatory

volume, and minute oxygen uptake volume, and minute oxygen uptake increase appreciably as pregnancy increase appreciably as pregnancy advancesadvances

GI TRACT CHANGESGI TRACT CHANGES

Gastric emptying and intestinal transit Gastric emptying and intestinal transit times are delayed in pregnancy because times are delayed in pregnancy because of hormonal or mechanical factors.of hormonal or mechanical factors.

Pyrosis (heartburn) is common during Pyrosis (heartburn) is common during pregnancy and is most likely caused by pregnancy and is most likely caused by reflux of acidic secretions into the lower reflux of acidic secretions into the lower esophagusesophagus

GESTATIONAL AGEGESTATIONAL AGE

The Nägele rule ∞ estimated date of The Nägele rule ∞ estimated date of confinement (EDC). confinement (EDC). Using last menstrual period minus 3 months, Using last menstrual period minus 3 months,

plus 1 week and 1 yearplus 1 week and 1 year the assumptions the assumptions a normal gestation is 280 a normal gestation is 280

days & 28-day menstrual cyclesdays & 28-day menstrual cyclesPhysical examination Physical examination Ultrasound confirmationUltrasound confirmation

ANTE NATAL CAREANTE NATAL CARE

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

ANTE NATAL CAREANTE NATAL CARE

TUJUAN

1. Setiap ibu hamil dan menyusui agar dapat memelihara kesehatannya sebaik mungkin.

2. Setiap ibu hamil dapat melahirkan bayi sehat tanpa gangguan apapun dengan cara yang terpilih dan kemudian hari dapat merawat bayinya dengan baik.

ANTE NATAL CAREANTE NATAL CARE

TUJUAN

1. Setiap ibu hamil dan menyusui agar dapat memelihara kesehatannya sebaik mungkin.

2. Setiap ibu hamil melahirkan bayi sehat tanpa gangguan apapun dengan cara yang terpilih dan kemudian hari dapat merawat bayinya dengan baik.

ANTE NATAL CAREANTE NATAL CARE

TUJUAN

3. 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 CAREANTENATAL 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

EMBRIOLOGICAL EMBRIOLOGICAL DEVELOPMENTDEVELOPMENT

ANTENATAL CAREANTENATAL 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