Chapter3 Normal pregnancy

Wang Fu-ling
 一、 Pregnancy physiology
 Pregnancy is the maternal condition of

having a developing fetus( 胎儿 ) in the

body.
 What is pregnancy?
Pregnancy is defined as the course of
embryo （胚胎） and fetal growth
and development in uterine
It begain at the fertilization and end the
delivery of the fetal and it’s attachment
 （一） The fetus
1 Fetus growth and development
 2 Fetal physiology
1 、 Fetus growth and development

Fertilization is defined as the course of

combination of the oocyte and sperm
It onset 12h after ovulation usually in
ampulla of the oviduct(fallopian tube)
1 、 Fetus growth and development
 The human conceptus from fertilization
through the eighth week of pregnancy is
termed an embryo from the eighth week
until delivery ， it is a fetus.
 The estimated age of the fetus calculated
from the frist day of the last menstrual
period ,assuming a 28-day cycle.
1 、 Fetus growth and development
 During the frist 8 weeks,the term embryo is
used to denote( 表示 ) the developing
organism because it is during this time that
all the major organs are formed .
1 、 Fetus growth and development
 Afterthe eighth week, the word fetus is
proper, the growth of the fetus may be
described in units of 4 weeks’ gestational
age, beginning with the first day of the
LMP
（ last menstrual period ）
1 、 Fetus growth and development
 8weeks: the organs are beginning to form
 12weeks: the fingers and toes have nails,and the
external genitalia may be recognizable
 16weeks :the sex is discernible as male or female
 20weeks :heart tones may often be detected by
stethoscope( 听诊器 ),movements have been
perceives by mother,the uterine fundus is near the
level of the umbilicus （脐）
1 、 Fetus growth and development
 24weeks ： some fat is beginning to be deposited
beneath the wrinkled skin,viability is reached by
the 24th week,but survival at this stage is still
relatively rare
 28weeks ： the lungs are now capable of
breathing,but the surfactant content is low;survival
is possible in level II or level III neonatal centers
1 、 Fetus growth and development
 32weeks ： if born at this stsge,about 5 of 6
infants survivie
 36weeks ： the skin has lost its wrinkled
appearance,the chances for survival are good
 40weeks ： the head has a maximal transverse
diameter of 9.5cm. The average fetus
,therefore,requires cervical dilatation of almost
10cm before it can descend into the vagina
 2 、 Fetal physiology
Contents:
 Circulatory function
 Hematology( 血液学 )
 Respiratory function
 Gastrointestinal function
 Renal function
 Endocrinology( 内分泌学 )
2 、 Fetal physiology
（ 1 ） Circulatory function
2) fetus ←→placenta←→ mother
3) Umbilical cord: 1 umbilical vein (full of
oxygen), 2 umbilical artery (lack of
oxygen)
4) Mixed blood (vein and artery)
Development of embryo and fetus
 2 、 Fetal physiology
（ 2 ） Hematology （血液学）
Erythropoiesis （红细胞生成）
From yolk sac （卵黄囊） : 3 weeks
From liver: 10 weeks
From bone marrow and spleen ： after 10 weeks

*By10weeks the liver assumes the major role in

erythropoiesis,but the spleen and bone marrow
gradually take over this function
 2 、 Fetal physiology
(3) Respiratory function
gas exchange in the fetus occurs in the
placenta
(4) Gastrointestinal tract
No truly function until after birth
(5) Kidney
Its function begins at 9-12th week
 2 、 Fetal physiology
(6)Endocrinology
• Fetal thyroid: the first endocrine gland (6th
week), synthesize thyroxine at 12th week

• Fetal adrenal cortex consists mainly of a fetal

zone that disappears about 6months after birth.
3 、 The placenta ， umbilical cord
and amniotic fluid
 The placenta
 The umbilical cord
 The amniotic fluid （羊水）
 （ 1 ） The placenta
 Development of the placenta
 Functions of the maternal placental-fetal
unit
 （ 1 ） The placenta
 Structure
2. Primary villus （绒毛）
3. Secondary villus
4. third class villus
fetal capillary( 胎儿毛细血管 ) enter the
stroma
*1 、 Development of the placenta
 Fertilization

3. Place: oviduct (ampulla)

4. Process
capacitation → acrosome reaction→
penetrate the zona pellucida→ second
meiosis →zygote( 受精卵 )
Implantation
2. requirement
• Disappear of zona pellucida
• Formation of syncytiotrophoblast
• Synchronized development of blastocyst
and endometrium
• Adequate progesterone
1. Process
• morula (day 3) → enter uterine cavity
(day 4) → early blastocyst→ late
blastocyst (day 6-7) → implantation
• location→ adherence→ penetration
 （ 2 ） Functions of the maternal
placental-fetal unit
 Endocrine function
Human chorionic
gonadotropin （ HCG ）
Human chorionic somatomammotropin
Placental proteins （胎盘蛋白）
Estrogen
 Metabolitic function
 Protective function
 Endocrine function
Human chorionic gonadotropin(HCG)
 Itis a glycoprotein that has biologic and
immunologic similarities to luteinizing hormone
from the pituitary
 H CG is produced by the syncytiotrophoblast of
the placenta
 This measurement is useful because it can detect
pregnancy in all patients on day 11 after
fertilization
 Endocrine function

Human chorionic somatomammotropin(hGS)

 hGS is a protein hormone with
immunologic and biologic similarities to
pituitary growth hormone
 It has been suggested that hGS is the
“growth hormone”of pregnancy
Endocrine function

Placental proteins
 PAPP-A,PAPP-B,PAPP-C,PAPP-D
 PAPP-D is the hormone hCS
Endocrine function

Estrogen
 Estrogen production by the placenta is
dependent upon precursors reaching it from
both the fetal and maternal compartments
 Metabolitic function
 The primary function of the placenta is the
transport of oxygen and nutrients to the fetus and
the reverse transfer of CO2(carbon dioxide), urea,
and other catabolites back to the mother.
 These compounds are required for the synthsis of
new tissues,eg,amino acids 、 vitamins and so on.
 Substances such as certain maternal hormones,
which may modify fetal growth.
 Protective function
 The placental membranes are often referred
to as a “barrier” to fetal transfer, but there
are few substances(eg, drugs) that will not
cross the membranes at all.
 （ 2 ） The umbilical cord
 In the early stages, the embryo has a thick
embryonic stalk containing 2 umbilical
arteries,one large umbilical vein,the allantois （尿
囊） ,and primary mesoderm( 原中胚层 ).
 At birth ， the mature cord : long 50-60cm
diameter 12mm
 A long cord is defined as more than 100cm and a
short cord as less than 30cm.
 （ 3 ） The amniotic fluid
 Inthe first of pregnancy,amniotic fluid
volume appears to increase in association
with growth of the fetus
 Average volume 800ml
Amniotic fluid
Source: early from serum dialysis( 透析 )
late from fetal urine
Absorb: by fetal membrane, fetal
swallowing(400-500ml/day)
Umbilical cord
Fetal skin
Amniotic exchange: between maternal
and fetal 400ml/h
Volume of amniotic fluid
 8 weeks:5-10ml

 10 weeks:30ml

 20 weeks:400ml

 38 weeks:1000ml

Note: After 38weeks, both amniotic fluid

and maternal plasma volume decrease.
Status of amniotic fluid
 pH:7.20

 Density:1.007-1.025

 Contained: water(98-99%)

inorganic substance( 无机
物)
organic substance(1-2%)
 The functions of amniotic fluid
 Cushions the fetus against severe injury
 Provides a medium in which the fetus can move
easily
 Warm
 May be a source of fetal nutrients
 In early pregnancy,is essential for fetal lung
development
 Protect mother
 Prevent infection
 4 、 Maternal physiology during
pregnancy
 The physiologic,biochemical,and anatomic
changes that occur during pregnancy are
extensive and may be systemic or local.
 Those maternal adaptation maintain a
healthy environment for the fetus.
Content:
 Genital tract
 Breasts
 Cardiovascular system
 Hematologic system
 Pulmonary system
 Gastrointestinal tract
 （ 1 ）、 Genital tract

 Uterus
 Ovaries
 Vagina and perineum
Changes of uterus
Body: become enlargement and soft
from 7×5 ×3cm pre-pregnancy to
35×25 ×22cm at term
Volume of uterus cavity:
become enlargement from 5ml pre-pregnancy to
5000ml.at term
Weight: be increased from 50g pre-
pregnancy to 1100g at term
Blood supply:blood flow increased significantly

up to 450-650ml/min,increased 4-6
times and most of blood flow is
transported to the placenta(80-85%)
Isthmus: be prolonged and become soft from
1cm pre-pregnancy a portion of the
uterus after 12 gestational weeks

Cervix: be soft and coloration or stain

secrete amount of mucus avoiding the
uterus cavity suffer from infection
Changes of ovary
 Stop ovulation

 Corpus luteum formation and maintains for

10 weeks
 And the function of corpus luteum is

substituted by the placenta

 Corpus luteum atretic gradually after 3-4

months gestation.
 Vagina and perineum
 During pregnancy,increased vascularity and
hyperemia develop in the skin and muscles
of the perineum and vulva,and there is
softening of the normally aboundant
connective tissue( 结缔组织 ) of these
structure.
 （ 2 ）、 Breasts
 In the early weeks,the pregnant woman often
experiences tenderness and tingling.
 After the second month,the breasts increase in size
and delicate veins become visible just beneath the
skin.
 After the first few months,a thick,yellowish
fluid,colostrum,can often by expressed from the
nipples （乳头） by gentle massage( 按摩 )
（ 3 ）、 Cardiovascular system
 Heart
 Cardiac output
 Blood pressure
Heart
Heart border: become enlargement
Heart rate: increased 10-15 beat per min at the
late pregnancy
Heart volume: increased 10% at the late
pregnancy
Cardiac output
Very important for fetal growth and development

Increased begin 10 weeks and upto the peak

at 32-34 weeks and continuing at this level
until term
Cardiac output increase approximately 40%
during pregnancy
Blood pressure changes due to
pregnancy
 No obvious change in Systolic pressure
 Mild decreased in diastolic pressure

Vein pressure
 No significantly changes in Upper limb vein

pressure
 Lower limb vein pressure increased because of

the disturbance of vein reflux （返流 ）

 4 、 Hematologic system
 Blood volume
 Blood components
 Red blood cells
 White blood cells
 Clotting factors
Changes of blood system
Volume: the average increase in volume at
term is 45-50%. Hypervolemia begins in the frist
trimester,increses rapidly in the second
trimester,and the peak at about the 30th week.
Changes of blood components
Red cell: the increase in red blood cell mass is about
33%,or approximately 450ml of erythrocytes( 红细
胞 ).Since plasma volume increases earlier in pregnancy
and faster than red blood cell volume,after the end of
second trimester( 妊娠期的 3 个月 ) :
red cell decreased 3.6×1012(4.2×1012)
Hb （ hemoglobin ） decreased
110g/L(130g/L)
 WBC(white blood cell):the total blood
leukocyte count increases during normal
pregnancy from a pregnancy level of
4300-4500/uL to 5000-12000/uL in the
last trimester.
Clotting factors:

During pregnancy , level of several essential

coagulation factors increase.There are marked
increases in factorI 、 VII 、 VIII 、 IX 、 Xand
XII .
 (5) 、 Pulmonary system
 Pregnacy produces anatomic and
physiologic changes that affect respiratory
performance
 Total lung capacity is reduced(4-5%)by the
elevation of the diaphragm （膈肌）
 (6) 、 Gastrointestinal tract
 During pregnancy,nutritional requirements
are increased,and several maternal
alterations occur to meet this demand
 二、 Diagnosis of pregnancy
 The diagnosis of pregnancy is usually made
on the basis of a history amenorrhea （闭
经） ,an enlarging uterus,and a positive
pregnancy test
1 、 Diagnosis of the first-trimester
pregnancy （早期妊娠）
 History and symptoms
 Signs
 Assistant examination
 （ 1 ） History and symptoms
①Amenorrhea ：
It is a fairly reliable sign of conception in
women with regular menstrual cycles.
In women with irregular cycles,it is not a
reliable sign. Delayed menses may also be
caused by other factors such as emotional
tension,chronic disease,endocrine
disorders,and so on.
②Morning sickness （ nausea and
vomiting ） :
This common symptom occurs in approximately
50% of pregnancies.
It begins at about 6 weeks’ gestation and disappears
at about 12 weeks’ gestation in most patients.
It is usually most severe in the morning but can
occur at any time.
The cause is probably rising serum levels of HCG.
③Bladder frequency （尿频） :
It occurs because of increased bladder circulation
and pressure from the enlarging uterus.
It usually disappears after 12 weeks’ gestation when
the uterus enlarges so much that it’s no longer a
pelvic organ.
 (2)Signs
 Changes in the genital organs
 Changes in breasts

A. Mastodynia( 乳房痛 )
B. Enlargement
C. Linea nigra （色素沉着）
 (3) Assistant examination
 Pregnancy test : urine testing
 Ultrasound examination
 Increased basal body temperature
①Pregnancy test
 Sensitive early pregnancy tests measure
changes in levels of HCG.
 If maternal renal function is normal, urine
values are usually proportionate to serum
values.
 Radioimmunoassay for HCG is a sensitive
and specific test for early pregnancy.
②Ultrasound examination
 It is one of the most useful technical aids in
diagnosing and monitoring pregnancy.
 Cardiac activity is dicernible at 5-6weeks
 Limb buds at 7-8weeks
 Finger and limb movements at 9-10weeks
 At the end of the embryonic period(10week by
LMP), the embryo has a human appearance
③Increased basal body temperature
 Persistent elevation of basal body
temperature over a 3-week period usually
indicates pregnancy if temperatures have
been carefully charted.
 2 、 Diagnosis of the second and
third-trimester pregnancy

 Symptoms and signs

 Assistant examination
 (1)Symptoms and signs
 ①Uterine enlargement
 ②Quickening( 胎动 )
 ③Fetal heart tones
 ④Palpation( 触诊 ) of fetus
①Uterine enlargement
 At 16 weeks, the uterus is usually at the midpoint
between the pubic and the umbilicus.
 At 20 weeks ,the uterus is palpable at the
umbilicus.
 At 26-34 weeks, fundal height correlates roughly
with the estimated gestational age.
 But after 36 weeks, the fundal height may
decrease as the fetal head descends into the pelvis.
②Quickening( 胎动 )
 The first fetal movement is usually
appreciated at 17 weeks in the average
multipara （经产妇） and at 18 weeks in
the average primipara( 初产妇 ).
③Fetal heart tones
 It may be heard at 20weeks.
 The normal fetal heart rate is 120-160beats
per minute.
 It is best to palpate the maternal pulse for
comparison.
④Palpation( 触诊 ) of fetus
 After20 weeks, the fetal outline can be
palpated through the maternal abdominal
wall.
 (2)Assistant examination
 Ultrasoundexamination----ultrasound is
used to measure fetal growth parameters, to
estimate fetal weight, to access fetal
anatomy, and to measure amniotic fluid
volume.
 3 、 Pregnancy monitoring
 The perinatal interval is the span of fetal
and neonatal life.
 The perinatal interval of life may be divided
into 2 periods:
Perinatal period I :28weeks of completed
gestation to the frist 7days of life
Perinatal period II: 20weeks of gestation
through 27days of life
Prenatal care( 产前保健
)
 The purpose of prenatal care is to ensure,as
much as possible, an uncomplicated
pregnancy and the delivery of a live healthy
infant.
 Mothers and offspring who receive prenatal
care have a lower risk of complications.
 4 、 Initial office visit( 初诊 )
（ 1 ） History
 （ 2 ） Physical examination
 （ 3 ） Laboratory tests
 （ 1 ） History
 Present pregnancy ： The interview should begin
with a full discussion of the symptoms; to
determine the duration of pregnancy, the patient
with regular menses may be able to accurately
calculate the estimated date of confinement(EDC),
using the first day of the LMP(LMP-3months+7
days)
 Previous pregnancy :eg: events of prior
pregnancies provide inportant clues to potential
problems in the current one.
 Medical history:eg: a history of
cardiovascular 、 gastrointestinal , and
endocrine disorders.
 Surgical history ： eg ： a history of
previous gynecologic surgery
 Family history : eg ： history of diabetes
mellitus
 (2)Physical examination
 General examination( 一般检查 )
 Pelvic examination （骨盆检查）
General examination( 一般检查 )
A complete physical examination must be
performed on every new patient.
Pelvic examination
 Pelvicsoft tissue ： any pelvic mass should
be described accurately and evaluated by
Ultasound examination.
 Bony pelvis :①pelvic
inlet②midpelvis③pelvic outlet
 Cervical length: average cervical length is
3-4cm
 Laboratory tests
The following laboratory assessments should
be performed as early as possible in
pregnancg and some of these repeated at
least once between 24 and 36 weeks’
gestation:
 Blood screening
 Genetics testing
 Urine testing
 5 、 Subsequent visits
The standard schedule for prenatal office
visits is:
 0-32week:once every 4weeks;
 32-36weeks:once 2weeks;
 36weeks to delivery:once each week
 Weight, gain blood pressure, fundal height,
findings on abdominal examination by
Leopold’s maneuvers
 6 、 nutrition in pregnancy
 The pregnant woman should be encouraged
to eat a balanced diet and should be made
aware of special needs for iron, folic acid,
and zinc.
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