PHYSIOLOGY OF

PREGNANCY
ISKANDAR ZULQARNAIN
A. ABADI

IT Obstetri 1
1. Fertilisasi

: Obstetri Fisiologi

, inplantasi dan nidasi .

2. Hormon-hormon plasenta.
3. Perubahan morfologi janin dan fisiologi
janin.
4. Perubahan anatomik dan Fisiologi ibu
hamil.
5. Asuhan antenatal.

ENDOMETRIUM & DECIDUA

Maternal

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

Endometrial / decidual function

The

hormonal responsiveness and

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

The

decidua serves as an immunologically

specialized tissue.

Endometrial / decidual function

The

endometrium/decidua and the spiral

arteries accept trophoblast invasion,
providing for embryo-fetal nutrition.

The

decidua contributes cytokines and

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

Hormonal regulation of the

endometrium
Estrogen
estradiol-17b

& other bioactive estrogens in

vivo cause replication of the epithelium
indirectly (probably through actions on the
stromal cells)
estrogen acts on the endometrial stromal cells
to promote the synthesis of an endometrial
epithelial cell growth factor, which functions in
a paracrine manner to cause replication of the
adjacent epithelial cells.

Hormonal regulation of the

endometrium

Progesterone

progesterone

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

FERTILIZATION & NIDATION

EMBRIOLOGICAL

PLACENTA & FETAL MEMBRANES

the

fetus is dependent upon the placenta

as its lung, liver, and kidneys.
The organ serves these purposes until
sufficient maturation of the fetus allows it
to survive ex utero as an air-breathing
organism

PLACENTAL DEVELOPMENT
The

blastocyst + its surrounding trophoblasts grow and expand

extends

endometrial cavity
buried in the endometrium/decidua.
The

innermost pole enters into the

formation of the placenta the
anchoring cytotrophoblasts and the
villous trophoblasts.

PLACENTAL DEVELOPMENT
The

trophoblasts of the villus are the outer

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

TROPHOBLASTIC BIOLOGY
Syncytiotrophoblast
The

cytotrophoblast the syncytium

Chorionic
Villi

villi

can first be distinguished easily in the human

placenta the 12th day after fertilization
Cytotrophoblasts mesenchymal cord, invades
the solid trophoblast column secondary villi

TROPHOBLASTIC BIOLOGY
Placental
the

cotyledons

short, thick, early stem villi branch repeatedly,

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

PLACENTAL AGING

placentas

of early pregnancy, the

branching connective tissue cells are
separated by an abundant loose
intercellular matrix

PLACENTAL AGING
histological
decrease

changes

in thickness of the syncytium

partial reduction of cytotrophoblastic cells
decrease in the stroma
increase in the number of capillaries
the approximation of these vessels to the
syncytial surface

PLACENTAL AGING
Other

changes

thickening

of the basement membranes of the

trophoblast capillaries
obliteration of certain fetal vessels
fibrin deposition on the surface of the villi in
the basal and chorionic plates & intervillous
space.

PLACENTAL AT TERM
Boyd

and Hamilton (1970)

the

placenta at term + 185 mm & 23 mm

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

the maternal surface, the number of

slightly elevated convex areas (lobes or if
small, lobules) varies from 10 to 38
The lobes are also referred to as
cotyledons.

BLOOD CIRCULATION IN THE

MATURE PLACENTA

Fetal circulation

Fetal deoxygenated, or "venous-like," blood 2 umbilical arteries

Blood, with oxygen content placenta fetus
through
1 umbilical vein.

Maternal circulation

Maternal blood the basal plate

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

AMNION
Structure

Bourne (1962) 5 layers of amnion tissue

The inner surface single layer of
cuboidal epithelial cells, derived from
embryonic ectoderm
distinct basement membrane

AMNION
Structure
the

acellular compact layer

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

AMNION
Development
amniogenic

cells, line this inner surface

of trophoblasts the precursors of the
amnionic epithelium
the human amnion is 1st identifiable +7th
or 8th day of embryo development.
The amnion a small sac that covers
the dorsal surface of the embryo

AMNION
Development
as

the amnion enlarges , it gradually

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

AMNION
Amnion
the

cell histogenesis

epithelial cells of the amnion are

derived from fetal ectoderm
the epithelial cells line the innermost
(amnionic fluid) side of the amnion
a layer of fibroblast-like (mesenchymal)
cells, derived from embryonic
mesoderm.

AMNION
Amnion
early

cell histogenesis

in pregnancy, the epithelial cells of

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

AMNIONIC FLUID
average

volume +1000 mL is found at

term
may vary widely from a few milliliters
to many liters
abnormal conditions
oligohydramnios
polyhydramnios

or hydramnios

UMBILICAL CORD
Development
At

first, the embryo is a flattened disc

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

UMBILICAL CORD
Development
The

allantois projects into the base of

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

UMBILICAL CORD
Structure

& function

Blood flows from the umbilical vein by two

routes
the ductus venosus empties directly into
the inferior vena cava
numerous smaller openings the fetal
hepatic circulation the hepatic vein
the inferior vena cava

PLACENTAL HORMONES

Human

placental lactogen (hPL1)

human chorionic gonadotropin (hCG)
chorionic adrenocorticotropin (ACTH2)

PLACENTAL HORMONES
proopiomelanocortin,

chorionic thyrotropin,
growth hormone variant, parathyroid hormonerelated protein (PTH-rP), calcitonin, and relaxin
hypothalamic-like releasing and inhibiting
hormones thyrotropin-releasing hormone
(TRH), gonadotropin-releasing hormone
(GnRH), corticotropin-releasing hormone (CRH),
somatostatin & growth hormone-releasing
hormone (GHRH)

MATERNAL ADAPTATION TO
PREGNANCY

Uterus
During

pregnancy, uterine enlargement

involves stretching and marked
hypertrophy of muscle cells

MATERNAL ADAPTATION TO
PREGNANCY
Cervix
softening

and cyanosis of the cervix

vascularity and edema of the entire
cervix
hypertrophy and hyperplasia of the
cervical glands.

MATERNAL ADAPTATION TO
PREGNANCY
Ovarium
Ovulation

ceases during pregnancy and

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

MATERNAL ADAPTATIONS
Fallopian
The

tubes

musculature of the fallopian tubes

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

MATERNAL ADAPTATIONS
Vagina

& perineum

increased

vascularity and hyperemia develop in the skin and

muscles of the perineum and vulva
softening of the normally abundant connective tissue of these
structures
Increased vascularity prominently affects the vagina
The copious secretion and the characteristic violet color of the
vagina during pregnancy (Chadwick sign)
hypertrophy of the smooth-muscle cells
The papillae of the vaginal mucosa hypertrophy, creating a fine,
hobnailed appearance

SKIN CHANGES
In

the later months of pregnancy, reddish,

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

SKIN CHANGES
the

midline of the abdominal skin becomes

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

BREAST CHANGES
1st

month breast tenderness and

tingling
2nd month the breasts increase in size
the nipples larger, more deeply
pigmented, and more erectile

BREAST CHANGES
Then

a thick, yellowish fluid, colostrum,

can often be expressed from the nipples by
gentle massage
the areolae broader and more deeply
pigmented
Scattered through the areolae glands of
Montgomery, (hypertrophic sebaceous
glands)

METABOLIC CHANGES
Water
At

metabolism

term, the water content of the fetus,

placenta, and amnionic fluid amounts to
about 3.5 L.

METABOLIC CHANGES
Water

metabolism
Increased water retention is a normal
physiological alteration of pregnancy.
This

is mediated by a fall in plasma

osmolality of approximately 10 mOsm/kg
induced by a resetting of osmotic
thresholds for thirst and vasopressin
secretion

METABOLIC CHANGES
Water

metabolism

Another

3.0 L accumulates as a result of

increases in the maternal blood volume
and in the size of the uterus and the
breasts.
Thus, the minimum amount of extra water
that the average women retains during
normal pregnancy is about 6.5 L.

PROTEIN METABOLISM
At

term, the fetus + placenta 4 kg &

contain approximately 500 g of protein, or
about half of the total pregnancy increase .

The

remaining 500 g is added to the

uterus as contractile protein, to the breasts
primarily in the glands, and to the maternal
blood as hemoglobin and plasma proteins.

PROTEIN METABOLISM
Amino

acids used for energy are not

available for synthesis of maternal protein.

With

increasing intake of fat and

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

CARBOHYDRATE METABOLISM
Normal

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

FAT METABOLISM
The

concentrations of lipids, lipoproteins,

and apolipoproteins in plasma increase.

Low-density

lipoprotein cholesterol (LDLC) levels peak week 36 the hepatic

effects of estradiol and progesterone

FAT METABOLISM
High-density

lipoprotein cholesterol (HDLC) peaks at week 25, decreases until week

32, and remains constant for the remainder
of pregnancy.

High-density

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

HAEMATOLOGICAL CHANGES
the

blood volumes at or very near term

averaged about 40 to 45 percent above
their nonpregnant levels

hemoglobin

concentration and the

hematocrit decrease slightly during normal
pregnancy

HAEMATOLOGICAL CHANGES
The

total iron content of normal adult

women ranges from 2.0 to 2.5 g
The leukocyte ranges 5000 - 12,000/Ul
fibrinogen concentration increases about
50 percent to average about 450 mg/dL
late in pregnancy, with a range from 300 to
600

CARDIOVASCULAR SYSTEM
CHANGES
The

most important changes in cardiac

function the first 8 weeks of pregnancy
Cardiac output is increased the 5th
week of pregnancy
Between weeks 10 - 20, plasma volume
,preload

RESPIRATORY SYSTEM CHANGES

The

diaphragm rises + 4 cm during

pregnancy .
The subcostal angle widens transverse
diameter of the thoracic cage +2 cm
The thoracic circumference increases + 6
cm

RESPIRATORY SYSTEM CHANGES

The

amount of oxygen needs

The respiratory rate is little changed
during pregnancy
the tidal volume, minute ventilatory
volume, and minute oxygen uptake
increase appreciably as pregnancy
advances

GI TRACT CHANGES
Gastric

emptying and intestinal transit

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

GESTATIONAL AGE
The

Ngele rule estimated date of

confinement (EDC).
Using

last menstrual period minus 3 months,

plus 1 week and 1 year
the assumptions a normal gestation is 280
days & 28-day menstrual cycles
Physical

examination
Ultrasound confirmation

ANTE NATAL CARE

Suatu

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

ANTE 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 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 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 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

ANTENATAL CARE
Minimum antenatal care
1x 1st trimester
1x 2nd trimester
2x 3rd trimester
Effective normal antenatal care
every month early pregnancy 28 wks GA
every 2 wks 28 36 wks GA
every wks
37 wks GA - delivery