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Alterations of cardivascular function
basic pathophy based on chapter notes
194
Pathology
Undergraduate 1
11/12/2010

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Cards

Term

Causes of HTN

Definition

Sleep apnea

Renovascular disease

Coarctation of the aorta

Drug induced

chronic kidney disease

pheochromocytoma

thyroid or parathyroid disease

primary aldosteronism

Term

Stage II HTN parameters

Definition
≥160/≥100
Term

Stage 1 HTN parameters

Definition
140-159/90-99
Term

Prehypertension parameters

Definition
120-139/80-89
Term

What is the formula to determine MAP?

Definition

MAP = CO x TPR

Term

Chronic high BP is associated with ­ed risk of:

Definition

         left ventricular hypertrophy

         left-sided heart failure

         atherosclerosis

Term

Mediators that cause VD and ¯\ BP

Definition

  histamine

   some PGs

        prostacyclin

         nitric oxide

Term

 

Mediators that cause VC and increase BP
Definition

angiotensin II

vasopressin

endothelin

thromboxane A

Serotonin

Term
What is the major determinant of DP?
Definition
Systemic vascular resistance (SVR)
Term

Passive elastic recoil of the aorta ejects blood into peripheral arteries during diastole so that DP never falls to zero  is characterized by?

Definition
Windkessel effect
Term

SP is a function of ?

Definition
volume ejected & the compliance of the aorta
Term

Pathologic venous conditions are the result of?

Definition

Obstruction to flow (deep vein thrombosis)

Structural alterations (valvular incompetence)

Term

a specific term that identifies the arterial inflammatory process as autoimmune in nature is?

Definition
Arteritis
Term

Inflammation of the intima of a vein is known as?

Definition
Phlebitis
Term

Inflammation of the intima of an artery is known as?

Definition
Vasculitis
Term

What is angina pectoris of a variant form that is characterized by chest pain during rest and by an elevated ST segment during pain.

Definition
Prinzmetal angina
Term

An embolus is an abnormal particle circulating in the blood what types are there?

Definition

fat

air

amniotic fluid

bacteria

cancer cells

Term
Eventually the thrombus may break free from the vessel wall and become an
Definition

embolus.

Term

A detached thrombus is a?

Definition

Thromboembolus

Term

A thrombus is a _________ blood clot formed within a vessel or heart chamber.

Definition
Stationary
Term

In the venous system, obstruction manifests as

Definition

edema.

Term
In the arterial system, obstruction manifests as
Definition
distal ischemia
Term
Obstruction causes
Definition

­­­­­­­pressure upstream­

¯ed flow downstream

Term

Secondary lymphedema

Definition
Most frequently due to the surgical removal of lymph nodes or radiation damage to lymphatic vessels during cancer treatment
Term

Primary lymphedema

Definition
Related to a congenital decrease in lymphatics or an obstruction of the thoracic duct.
Term

Blood flow through a particular vascular bed is regulated ?

Definition
centrally by the ANS and locally by the organ or tissue
Term
Main factors affecting resistance to flow
Definition

Radius of vessel  (most imp determinant in healthy ind.

Length of vessel

  Blood viscosity
  Turbulence

Term

Resistance

Definition

R = DP/F

Term
Blood pressure
Definition
DP = F x R
Term

Flow

Definition
F = DP/R
Term

3 Causes of Edema

Definition

increased HPC

increased venous pressure

increased ECF as a result of fluid retention

¯ed pC

increased capillary permeability

¯ed plasma protein [  ]

Primary lymphatic blockage

Term
Thromboangiitis obliterans
Definition

 

a chronic, recurring, inflammatory, vascular occlusive disease, chiefly of the peripheral arteries and veins of the extremities.
Term

 

Raynaud disease
Definition
primary vasospastic disease of small arteries and arterioles The cause is unknown. There is an exaggerated response of vasomotor controls to cold or emotion.
Term

 

Intermittent Claudication is the hallmark of
Definition
chronic, stable limb ischemia
Term

 

Intermittent claudication
Definition

is leg pain that occurs during exercise.

It is a cramping pain and weakness in the legs (especially the calves) on walking that disappears after rest.
Term

 

six P’s herald acute limb ischemia
Definition

 

1.Pulselessness
2.Pain
3.Pallor
4.Polar (cold)
5.Paresthesia
6.Paralysis
Term

 

Arteriosclerosis
Definition

 

a chronic disease of the arterial system characterized by abnormal thickening and hardening of the vessel walls.
Term

 

Atherosclerosis
Definition

 

a form of arteriosclerosis in which the thickening and hardening of the vessel walls are caused by soft deposits of intra-arterial fat and fibrin that harden over time
Term

 

Hardening leads to decreased _____?______
Thickening leads to increased _____?______
Definition

Compliance

Resistance

Term

 

Progression of Atherosclerosis
Definition

 

Damaged endothelium
 
fatty streak
 
fibrous plaque
 
complicated lesion
Term

 

Pathogenesis of Atherosclerosis
Definition

 

A.1. Endothelial injury
B.2. Influx of lipids
C.3. Accumulation of lipids in vessel wall, proliferation of smooth muscle cells, and accumulation of macrophages
D.4. Atheromas consist of a lipid-rich soft part and a firm fibrous cap
Term

 

Clinical Manifestations of Atherosclerosis
Definition

 

­increased TPR and ¯ed compliance ® hypertension
Term

 

Modifiable risk factors associated with atherosclerosis
(SEE GOD In Weeks)
Definition

1.Smoking

2.
Elevated cholesterol and LDLs
Elevated blood pressure
3.
Glucose intolerance pressure
Obesity
Decreased physical activity
4.
Ineffective stress management
6.7.Weight fluctuations
8.
5.
Term

 

Coronary heart disease (CHD) is
caused by atherosclerotic obstructions of the vessels and
characterized by
Definition

 

insufficient delivery of oxygenated blood to the myocardium because of atherosclerotic coronary arteries. 
Term

Modifiable Risk Factors for CAD

CHHOP D SALT
Definition

 

Cigarette smoking
Hypertension
Hyperhomocysteinemia
Obesity
Psychosocial factors (stress)
Dyslipidemia
Sedentary life style  
Atherogenic diet
Lipoprotein a 
Type 2 diabetes mellitus
Term

 

Pathogenesis of Atherosclerosis
Definition
  1. Injury to vessel wall
  2. Lipids accumulate in vascular wall
  3. Macrophages infiltrate and oxidize lipids
  4. Inflammation and release of local growth factors (Angiotensin II)
  5. plaque formation on intimal wall
  6. Mini thrombi incorporated into plaque ruptures

 

 

Term

 

Plaque formation & progression in a coronary artery
Definition

 

Type IV, V, and VI lesions predispose to the ischemic syndromes.
Term

 

5 Clinical syndromes of CHD based on severity and onset of clinical symptoms
(MUSIC)
Definition

Myocardial infarction (ACS)

Unstable angina (ACS)

Stable angina pectoris (chronic)

Ischemic cardiomyopathy (chronic)

Cardiac death (sudden)

Term

 

Factors that ¯ myocardial O2 supply
Definition

 

Hemodynamic factors
­increased coronary vessel resistance
Hypotension
¯ed blood volume
Cardiac factors
¯ed diastolic filling time
­increased HR
Valvular incompetence
Hematologic factors
¯ed O2 content of blood
Systemic disorders that ¯ blood supply/O2 availability
Shock
Term

 

Stable angina
Definition

 

-Stable angina is generally relieved by rest and nitroglycerin
-Nitroglycerin is a drug that causes coronary & peripheral vasodilation. 
chronic coronary obstruction that results in recurrent, predictable chest pain (also called classic or typical angina) Stenosed arterioles dilate poorly in response to ­ed myocardial O2 demands
Term

 

Prinzmetal angina
Definition

 

occurs unpredictably, & usually at rest. 
Probable mechanism is vasospasm which explains the responsiveness to treatment with Ca++-channel blocking drugs.
Term

 

In the treatment of myocardial ischemia,
the factors most amenable to pharmacologic manipulation are:
Definition

 

Blood pressure
Heart rate
Contractility
LV volume
Term
Effects of anti-anginal medications on myoccardial o2 supply and demand
Definition
[image]
Term

 

With stable angina, plaque progression is______and collateral circulation has time to develop.
Definition
 gradual
Term

 

Acute coronary syndromes are associated with _______ disruption of a vulnerable plaque.
Definition
acute
Term

 

A sudden coronary obstruction due to thrombus formation over an atherosclerotic plaque produces an _____ ______ _____.
Definition
acute coronary syndrome
Term
What acute coronary syndrome causes reversible myocardial ischemia?
Definition

 

Unstable angina
Term

 

What acute coronary syndrome 

Causes 
Death of myocardial cells?
Definition
Myocardial infarction
Term

 

Pathogenesis of Acute Coronary Syndromes
Definition

 

  1. Plaque disruption or breakdown
  2. Tissue thromboplastin exposed
  3. Platelet aggregation and clotting cascade activated
  4. Thrombus formation
  5. Acute ischemia
Term

 

Classification of Acute Coronary Syndromes
Definition
[image]
Term

 

Characteristics of 3 ischemic syndromes
Definition
[image]
Term

 

2 major types of MI
Definition

 Subendocardial  

 1.Transmural
Infarct involves the entire wall thickness
More common type of infarct
Symptoms are more severe
Infarct does not affect the entire ventricular wall thickness Less common Less severe symptoms
Term

 

ECG and ischemia
Definition
[image]
Term

 

Heart Failure
Definition

 

an inability of the heart to maintain sufficient cardiac output to optimally meet metabolic demands of tissues and organs. 
HF results in inadequate perfusion of body tissues. 
Term

 

Myocardial ischemia
Definition

 

(CAD) is the most common cause of heart failure
Remember, myocardial ischemia occurs when the heart’s demand for O2 exceeds the ability to supply O2
Term

 

Hypertension is the 2nd most common cause of ?
Definition

 

left ventricular dysfunction which leads to heart failure
Term

 

Dilated cardiomyopathy 
Definition

is the 3rd most common cause of left ventricular dysfunction

Dilated cardiomyopathy is a condition in which the heart becomes weakened and enlarged, and cannot pump blood efficiently
Term

 

Factors that increase­ myocardial O2 demand
Definition

 

High systolic blood pressure
 ­increased ventricular volume
 ­increased thickness of the myocardium (LV hypertrophy)
 ­ed HR resulting from:
Exercise
Stress
Hyperthyroidism
Anemia
Hyperviscosity of blood
 Conditions that increase­ contractility
i.e. exercise
Term

 

Left heart failure categorieds based on myocardial fiber impairment
Definition

 

Systolic heart failure
Impaired ability of fibers to contract
Low ejection fraction (EF)
Higher EDV
Diastolic heart failure
Impaired ability of fibers to relax
EF is normal
Lower EDV
Due to ineffective ventricular filling
Term

 

Insufficient cardiac pumping is manifested by:
Definition

 

¯ed cardiac output,called forward failure
 
1.congestion of blood behind the pump, called backward failure
Term

 

1.
causes of heart failure include? (short answer potential)
(More Heartfailure Clients)
Definition

 

1.
myocardial ischemia (leading cause)
hypertension (second leading cause)
Cardiomyopathy (3rd leading cause)
Term

 

Left-sided Heart Failure
Backward/forward effects
Definition

BACKWARD:

Dyspnea and Paroxysmal nocturnal dyspnea

Orthopnea

Cough

Cyanosis

Basilar crackles

FORWARD:

Fatigue/Anxiety/Restlessness/Confusion

Oliguria

increased HR

faint pulses

 

Term
Right-sided Heart Failure
Backward/forward effects
Definition

BACKWARD:

Hepatomegaly, Ascites, Splenomegaly

Subcutaneous edema

Anorexia

Jugular vein distention

FORWARD:

Increased HR with faint pulses

Oliguria

Fatigue/anxiety/confusion/restlessness

 

 

 

Term

 

Effect of digoxin on the Na+/K+ pump
Definition
  1. Digoxin inhibits the Na+/K+ pump, resulting in accumulation of intracellular Na+ and less efficient Ca++ extrusion.
  2. The increased IC Ca++  strengthens myocardial contraction.
  3. Digitalis competes with K+ for the K+ binding site on the Na+/K+ pump.  Low serum K+ \ potentiates the effect of digitalis.

 

Term

PRELOAD-REDUCING DRUGS

Definition

DIURETICS: (most generic drug names end in "ide")

B-type natriuretic peptide

Loop diuretics

Thiazide and thiazide like

VENODILATORS: (just the two are listed)

Nitroglycerine

Morphine

Term

AFTERLOAD-REDUCING DRUGS

Definition

Ca++ channel blockers

Centrally acting anti-adrenergics

Peripherally acting anti-adrenergics

Direct vasodilators

 

Term

INOTROPIC DRUGS

(Increase contractility)

Definition

Cardiac glycosides

Beta adrenergics

Phosphodiesterase inhibitors

 

(digoxin, dopamine and isoproterinol are common)

Term

NEUROHORMONAL MODULATORS

(think of lol-il-an)

Definition

Beta blockers

Angiotensin-converting enzyme inhibitors

Angiotensin receptor blockers

 

(many beta blockers end in "lol")

(many ACE inhibitors end in "il")

(many ARBs end in "an")

Term

 

Shock is a life-threatening condition characterized by hypotension and insufficient delivery of oxygenated blood to cells and tissues.
WHAT ARE THE CAUSES?
Definition

 

Infections
Heart disease
Trauma
Blood loss
Anaphylactic reactions
Term

 

Causes of circulatory shock can be divided into 4 main types:
Definition

 

Cardiogenic
Results from heart disease that has progressed to decompensated heart failure
 Hypovolemic
Associated with loss of blood volume or excessive loss of EC fluids
 Obstructive
A circulatory blockage disrupts cardiac output
 Distributive
Characterized by a greatly expanded vascular space because of inappropriate vasodilation
Term

 

Excess production of ___ ___ is an important mechanism of vascular failure in shock. 
Definition
nitric oxide
Term

 

Cardiogenic Shock
Definition

 

¯ed myocardial contractility causes
1.¯ed tissue perfusion
2.pulmonary edema
Term

 

Differentiation of the acute coronary sydromes
Definition
[image]
Term
Stroke volume formula
Definition

EDV-ESV=SV

Term
Cardiac Output Formula
Definition

SV x HR = CO

(normal= 5-6L/min resting)

(25-30 L/min exercising)

CRAZY!!

Term
Ejection Fraction Formula
Definition

EF=SV/EDV

(70-80ml- should be 60-75%)

Term
Pressure, flow, resistence formula
Definition

Flow (Q)= change in pressure (P)/ Resistence (R)

Also... QxR=change in P

Term
Compliance formula
Definition

Compliance (C)= change in volume (V)/change in pressure (P)

 

C=V/P

Term
MAP formula
Definition

MAP=DP+PP/3

MAP is upstream pressure

Term
Venous Return Formula
Definition

VR=(Pms-RAP)/RvR


VR (venous return)

Pms (mean systemic pressure)

RAP (right atrial pressure)

RvR (resistence to venous return)

 

 

Term

 

F = CO
What parameters do A-E represent?
A=HR
B=SV
C=AL
D=Contractility
E=PL
Definition
[image]
Term
general pathophys of hypertension is due to what?
Definition

Increased TPR

Increase in circulating blood volume (BV)

Increase in both TPR and BV

Term
Current theories that explain pathogenesis of HTN
Definition
  1. overactivity of SNS which causes VasoConstrict. and Increased CO
  2. Overactivity of RAA system
  3. Salt and water retention by kidneys
  4. Hormonal inhibition of Na/K transport across cell membranes increased IC Ca+ therefore VC and increased TPR=HTN
  5. Insulin resistence and endothelial function interaction

 

Term
complicated hypertension
Definition
sustained, primary hypertension that has pathologic effects beyond hemodynamic alterations and fluid and electrolyte imbalances, compromising structure and function of vessels
Term
2 major mechanisms of hypertension induced tissue damage
Definition

ischemia

edema

Term
orthostatic hypertension
Definition

drop in systolic of 20mmHg or drop of diastolic by 10 mmHg within 3 minutes of standing

This decreases CO

Term
what is the treatment of raynaud DISEASE?
Definition
Ca++ channel blockers which cause VD by interfering with Ca++ influx into smooth muscle cells
Term
Raynaud phenomenon versus raynaud disease
Definition
  • Raynaud phenomenon- vasospastic attacks secondary to systemic diseases
  • Raynaud disease- vasospastic attacks triggered by cold or stress
Term
What happens when myocardial demand exceeds supply?
Definition
Ischemia in tissue and pain perception in peripheral nerves
Term
decreased compliance and increased TPR lead to?
Definition
hypertension
Term

Put the following in order:

___Foam cells release cytokines that encourage atherosclerosis development

___Monocytes differentiate into macrophages

___LDL is oxidized

___LDL causes adhesion and entry of moncytes and T Lymphocytes into endothelium

___Macrophages ingest LDL "clean up" and become foam cells creating fatty streak

___LDL enters intima via endothelium

Definition
  1. LDL enters intima via endothelium
  2. LDL is oxidized
  3. LDL causes adhesion and entry of moncytes and T Lymphocytes into endothelium
  4. Monocytes differentiate into macrophages
  5. Macrophages ingest LDL "clean up" and become foam cells creating fatty streak
  6. Foam cells release cytokines that encourage atherosclerosis development
Term

Diagnosis of ACS is based on 3 primary indicators

(SEE)

Definition

Symptoms

ECG changes

Elevation of cardiac markers in blood

Term

1. Patients with chest pain, evidence of acute ischemia and ST elevation ECG changes are cadidates for?

 

2. Patients with symptoms of unstable angina (no biomarkers) and no ST segment elevation on the ECG may not benefit from the same treatment but rather from this primary choice of treatment

Definition

1. acute reperfusion therapy

2. Antiplatelet drugs

Term
WHat are the cardiac isoenzymes that are biomarkers of an MI?
Definition

CK-MB

troponin-I

troponin-T

Term

Subendocardial MI has an ECG finding of?

 

Transmural MI ECG finding is?

Definition

Subendocardial- ST segment depression, T wave inversion

Transmural- ST segment elevation and Q waves

Term

Angiotensin II is released systemically and locally. What are the local effects?

What are the systemic effects?

Definition

Local: coronary artery alterations that affect myocardial O2 supply and coronary arterial spasm leasing to decreased myocardial O2 supply

 

Systemic: (increased PL and increased AL) systemic artery alterations increase O2 demand increased AL= increased myocardial work and therefore, increased myocardial demand

Term
Mortality from an MI is related to
Definition
decreased SV
Term
A drop in CO from an MI triggers a number of compensatory responses mediated by the SNS. Name them...
Definition

Increased HR

Increased Contractility

Increased vasoconstriction

 

(these increase blood pressure)

Term
cardiac tamponade
Definition

external compression on the heart from fluid accumulation in the pericardial sack leading to decreased SV.

this manifests as distended neck veins, and pulsus paradoxus= arterial BP during expiration exceeds arterial BP during inspiration by >10mmHg

Term
Acute pericarditis
Definition
sticking and rubbing of visceral and parietal pericardial layers. Diagnosable by presence of a friction rub
Term
Myocarditis
Definition
Inflammatory disorder typically with viral cause characterized by scattered, necrotic and dead heart muscles. Major complication is dilation of the 4 heart chambers with reduced contractility.
Term
Cardiomyopathy
Definition

3 major functional classes:

  1. Dialted=enlargement of all 4 chambers and decreased contractility
  2. Hypertrophic=primarily affects LV and septum. Conditions that increase contractility such as exhertion cause obstructed ventricular flow and decreased CO
  3. Restrictive (constrictive)= stiff, fibrotic left ventricle leading to left HF and decreased CO

 

Term
2 types of valve disorders
Definition
  1. stenosis=failure of complete valve opening which increases the pressure work of the heart
  2. Regurgitation=inability of the valve to completely close, allowing backflow and increased volume work for the heart
Term
Systolic versus diastolic heart failure
Definition

systolic= impaired contractility causing low

diastolic=impaired myocardial fiber relaxation causing increased LVEDP."heart failure with a normal EF" *pulmonary congestion/edema

Term
3 Main compensations for heart failure
Definition
  1. SNS activation (increased HR, contractility, arterial vasoconstriction and RAA activation)
  2. Increased PL (kidney output reduces increasing volume)
  3. Myocardial hypertrophy (increased muscle mass) growth promotion by neurohormones such as angiotensin II and norepinephrine.
Term
Cor Pulmonale
Definition
Right ventricle hypertropy and dialtion secondary to diseas of lungs or lung blood vessels
Term
Conception:
Definition
The union of a single egg and sperm. (Gamete formation, ovulation, fertilization, implantation)
Term
Fertilization:
Definition
Penetration of the ovum by the sperm (with accompanying union of genetic material)
Term
Implantation:
Definition
(nidation) trophoblast secretes enzymes that burrow into the endometrium and bury the blastocyst. (6-10 days after conception)
Term
Chorionic Villi:
Definition
finger-like projections that develop out of the trophoblast to effect exchange of nutrients and O2.
Term
Chorion
Definition
covers the fetal side of placenta and has all the big vessels in it bring fetal blood to the placenta for exchange of nutrients and O2.
Term
Amnion
Definition
eventually surrounds embryo and forms a sac and covers the umbilical cord
Term
Amniotic fluid:
Definition
* initially a filtrate of maternal blood
* serves as cushion
* protects the cord
* maintains body temp
* helps fetus grow symmetrically
* provides testing material for fetal studies
Term
Umbilical cord
Definition
initially the stalk which attaches early embryonic cell mass to the chorionic villi,
has 2 arteries and 1 vein, with an average length of 22 inches at birth.
Wharton’s jelly surrounds vessels.
Term
Placenta
Definition
Organ of metabolic exchange (respiration, nutrition, excretion, storage) and hormone production
Semi-permeable barrier able to keep out many compounds, proteins, bacteria, etc that are of large molecular weight but not many of the deleterious enemies of the fetus fit this description.
Term
The placenta functions by
Definition
simple diffusion
active transport
pinocytosis
Term
Functioning is directly related to maternal circulation. With maternal circulation dependent on
maternal blood pressure
condition of her vessels
maternal position
uterine contractions
Definition
Placenta
Term
Placenta functions as:
Definition
A means of metabolic exchange
Respiration
Nutrition
Excretion
Storage

Endocrine gland producing four hormones to maintain pregnancy
Human chorionic gonadotropin (hCG)
Human chorionic somatomammotropin (hCS) or hPL
Progesterone
Estrogen
Term
Embryo:
Definition
day 15-week 8 after conception
Term
Embryo:
Definition
day 15-week 8 after conception
Term
Embryonic stage
Definition
(day 15 – week 8):
Critical period of development
structures/systems
Stage most susceptible to
teratogens
Term
Fetal stage
Definition
(week 9 – end of pregnancy):
Refinement and maturation
of structures/systems.
Critical period continues for
neurologic development
Cephalocaudal development
Term
Gestation:
Definition
period of intra-uterine development from conception through birth (pregnancy)
Term
Gravida:
Definition
a pregnant woman
Term
Primigravida:
Definition
pregnant for the first time
Term
Multigravida:
Definition
pregnant more than once
Term
Parity:
Definition
the number of pregnancies in which the fetus or fetuses have reached viability ( ~20 weeks)
Term
Nullipara:
Definition
a woman who has not completed a pregnancy to viability
Term
Primipara:
Definition
a woman who has completed one pregnancy to an age of viability
Term
Multipara:
Definition
a woman who has completed more than one pregnancy to viability
Term
Abortion:
Definition
loss of pregnancy prior to the age of viability
Term
Stillbirth:
Definition
fetal loss greater than the age of viability
Term
Term pregnancy:
Definition
38 – 42 weeks gestation
Term
Preterm:
Definition
20 weeks-prior to 37 weeks gestation
Term
Postdate or Postterm:
Definition
after 42 weeks gestation
Term
hCG
Definition
Earliest biochemical marker for pregnancy
Basis of test
Detected 7-10 days after conception
Term
Radioimmunoassay (RIA)
Definition
Blood or urine
Use radioactively labeled marker
Tests for beta subunit of hCG
Term
Radioreceptor (RRA)
Definition
serum
Measures ability to inhibit binding of radio-labeled hCG to receptors
Term
Enzyme-linked immunosorbent assay (ELISA)
Definition
Urine
Most popular
Uses anti-hCG with enzymes to bond with hCG in urine
Term
Changes to reproductive system during pregnancy
Definition
Uterus
• Increases in both numbers and size of cells, increased vascularity, and development of decidua

• Process of enlargement is hormonal in first trimester and mechanical after that.

• Shape of the uterus changes as it rises out of abdomen

• There is a correlation between uterine size and weeks gestation
• Increased uterine blood flow and pelvic congestion produce Chadwick's sign; bluish color to the cervix

• Capacity of the uterus grows 500, even 1000 times

• The round ligaments that help to hold the uterus in place, enlarge and stretch, eventually the intestines are pushed to the side.

• Non-expulsive contractions called Braxton Hicks contractions begin to facilitate blood flow.
Term
Changes to cervix
Definition
• Chadwick's sign.

• Glandular tissue becomes hyperactive and produces a thick tenacious mucous which plugs the cervix.

• Appearance of the cervical os changes with parity.

• In pregnancy there is increased friability
Term
Changes to the vagina
Definition
• Hormones thicken the mucosa, loosen the connective tissue and prepare the vaginal for birth

• Estrogen causes exfoliation of the vaginal mucosa, this rapid shedding of cells coupled with the increased secretion due to the high vascularity create an increase in vaginal discharged called leukorrhea

The pH changes, becoming more acidic
Term
Changes to breasts
Definition
• Can be one of the first things a woman notices when she is pregnant. Fullness, tingling, nipples become very sensitive.

• Increased pigmentation of the nipples and areola

• Increased vascularity is noted by the visibility of blood vessels that create a network visible beneath the skin.

• Montgomery's tubercles, small sebaceous glands in the areolar tissue enlarge produce a natural lubricant
• Striae may appear.

• If a pregnancy ends after 16 weeks the milk will come in

• High levels of estrogen inhibit the milk producing hormone prolactin from being secreted however colostrum is present in the third trimester.
Term
Changes to cardiovascular system
Definition
• Adaptation to meet increased metabolic needs created by pregnancy.

• Mild cardiac hypertrophy secondary to increased blood volume.

• Auscultatory changes: More audible split s1-s2 after 20 weeks and common to have systolic ejection murmurs but not over grade II

• Pulse increases to 10-15 BPM over her norm

• Arterial blood pressure decreases slightly in the first trimester, with a low point in the second trimester and returns to normal by the third trimester.
• Orthostatic hypotension is common as are varicosities and edema.

• Blood volume increases 30 -50% starting around ten weeks.

• Physiologic anemia.

• RBC production is accelerated.

• WBC levels increase then remain stable.

• Cardiac output is greatly increased.

• Function can significantly affected by maternal position and activity

• Coagulation tendencies are increased.
Term
Changes to respiratory System
Definition
• Structural changes occur: rib cage relaxes, there is an increase in the diameter of thoracic cage

• Small degree of pregnancy induced hyperventilation due to progesterones effect on the CNS

• Increase vascularity leads to congestion of upper airways and nasal and sinus stuffiness, epitaxsis and even voice changes.
Term
Metabolic Regulation in pregnancy
Definition
• BMR is increased related to the increased oxygen demands and increased cardiac work. Dissipation of excess heat from this increased BMR is why pregnant women feel so warm and sweat a lot.

• Thyroid function increases in response to higher BMR
Term
Renal system changes in pregnancy
Definition
• Ureters, renal pelvis dilate, smooth muscles like the linings of bladder, uterus and urethra have relaxed tone

• Relaxed tone makes women more susceptible to stagnant urine and infection, especially since the threshold for glucose is lower in pregnancy and glycosuria may be present creating an even more favorable environment for bacteria.
Renal System


• Ureters, renal pelvis dilate, smooth muscles like the linings of bladder, uterus and urethra have relaxed tone

• Relaxed tone makes women more susceptible to stagnant urine and infection, especially since the threshold for glucose is lower in pregnancy and glycosuria may be present creating an even more favorable environment for bacteria.
Renal System


• Ureters, renal pelvis dilate, smooth muscles like the linings of bladder, uterus and urethra have relaxed tone

• Relaxed tone makes women more susceptible to stagnant urine and infection, especially since the threshold for glucose is lower in pregnancy and glycosuria may be present creating an even more favorable environment for bacteria.
• Decreased bladder tone may make the bladder hold far more urine then normal...if the mechanical pressures don't make her void every half-hour.

• GFR is increased due to blood volume and demands for waste excretion are increased with fetal waste present.

• To maintain the blood volume needed, the kidneys increase their ability to retain Na.

• Protein in urine in measurable amounts is abnormal and a sign of renal disease

• The best maternal position for renal function is the left lateral recumbent.
Term
Chloasma
Definition
mask of pregnancy,
fades after pregnancy
Term
Human Chorionic Gonadotropin (HCG):
Definition
Secreted by trophobast in
early pregnancy to stimulate corpus
lutem to continue estrogen and
progesterone production in order
to maintain the pregnancy until
the placenta can assume that function.
Term
Human Placental Lactogen (hPL):
Definition
also called Human Chorionic
Somatomammotropin is an antagonist
of insulin creating increased circulating
free fatty acids and glucose for metabolic
needs.
Term
Estrogen:
Definition
Secreted first from
the corpus luteum by the seventh
week of pregnancy it is mostly a
placental hormone.
It stimulates uterine development
to provide an appropriate
environment for the fetus
It helps to develop the ductal system
of the breast. (tissue building and
increased vascularity)
Term
Progesterone:
Definition
Produced first by the
corpus luteum and then by the placenta
It plays the greatest role in maintenance
of the pregnancy.
It maintains the endometrium and inhibits uterine contractility. (smooth muscle relaxation; uterus, G-I ,vessels)
Term
Relaxin:
Definition
The primary source
is the corpus luteum but some
may come from the placenta or
decidua.
Acts to inhibit uterine contractions
Softens cervix and "remodel collegen"
Term
Prostaglandins:
Definition
Lipid substances
arising from most tissues but
greater concentrations in the female
reproductive tract.
Involved in initiation
of labor. Mechanism unclear.
Term
Presumptive signs of pregnancy
Definition
1. Breast Changes
2. Amenorrhea
3. Nausea, Vomiting
4. Urinary Frequency
5. Fatigue
6. Quickening
Term
Probable signs of pregnancy
Definition
1. Goodell’s sign
2. Chadwick’s sign
3. Hegar’s sign
4. Positive pregnancy test
5. Braxton Hick’s contractions
6. Ballotment
Term
Positive signs of pregnancy
Definition
1. Visualization of fetus
2. FHT’s
3. Fetal movement palpated
Term
Pregnancy assessment
Definition
History: Demographics
Gyn history
Family history
Medical history
OB history (previous pregnancies)
Present pregnancy
LMP vs. LNMP
EDC: Nagele’s Rule
Pregnancy tests
Planned pregnancy and is father supportive?
Problems or events of this pregnancy
Signs and symptoms of pregnancy
Patient preferences: Support persons, birth plans, planned medications, early DC
Term
EDC or EDD:
Definition
expected date of confinement or delivery
266 days from conception
280 days from first day of LMP assuming a 28 day cycle
9 calendar months
10 lunar months (4 week months)
Term
Nagele's rule
Definition
Based on 28 day regular cycle
Add one year
Subtract 3 months and add 7 days to the
first day of the last menstrual cycle.
Term
Physical Exam (initial)
Definition
a complete physical, focusing on the reproductive system.

assessment of the nipples related to breastfeeding

assessment of the fundal height, or assessment of uterine size by bimanual exam.
FHTs

DTRs, edema and varicosities

Measurement of the adequacy of the bony pelvis
Term
Lab work (initial)
Definition
Blood work
type and Rh, antibody screen for Rh
or other blood related antibodies
serology RPR or VDRL
HBsAg
Rubella screen
CBC
Maternal serum AFP/prenatal risk screen between 14-18 weeks. Or earlier if “sequential screening” indicated or requested

HIV screen by inclusion
Cultures:
GC, Chlamydia, Herpes only with lesions or to check for cervical shedding

Urinalysis and culture is necessary

Pap smear

Others as history indicates: Sickle prep, PPD
Term
The return OB visit
Definition
Typically see clients
1x/month till 28 weeks
2x/month 28-36 weeks
1x/week 36-40 weeks
more frequently if go past 40 weeks, at least 2x/week.

client weighs self and checks her urine looking for glycosuria or proteinuria

Midwife or nurse does BP

Chart to compare to norms and observe pattern

Encourage and answer questions.
Anticipatory Guidance
Term
Ongoing lab work
Definition
28, 36 weeks Hct

28 weeks 1 hour post 50gm glucola

28 weeks Rhogam if Rh neg

Cultures as history deems necessary
Term
Continued assessment
Definition
Fundal Height Measurements

Fetal Heart tones: Doptone, Fetascope

Fetal Movement: Quickening, Monitoring

Fetal Position: Leopold maneuvers

Discuss progress of pregnancy
share patterns of growth: weight, fundal height
how new developments such as quickening compare to norms
refer to fetus as a person
Term
1st trimester anticipatory guidance
Definition
Hazards
Radiation
Drugs
Hyperthermia
Infections – viral/bacterial

Danger signals
Severe vomiting [ hyperemesis gravidarum
Chills, fever, burning on urination, diarrhea [ infection
Abdominal cramping; vaginal bleeding [ miscarriage, ectopic pregnancy

Discomforts/relief measures
Nausea and Vomiting
Urinary frequency
Breast tenderness
Increased vaginal discharge (leukorrhea)
Nasal stuffiness and epitaxis
Ptyalism
Mood swings/ambivalence
Term
2nd trimester anticipatory guidance
Definition
Discomforts and Relief Measures:
Pigmentation deepens; acne, oily skin
Spider nevi
Pruritus
Palpitations
Supine hypotension and bradycardia
Faintness
Food cravings
Heartburn
Constipation
Flatulence with bloating/belching
Varicose veins
Headaches
Carpal tunnel syndrome
Periodic numbness, tingling of fingers
Round ligament pain
Join pain, backache, pelvic pressure
Teaching related to Danger Signs For:
Preterm labor
Hypertensive conditions
Term
Third trimester anticipatory guidance
Definition
L&D material
Discomforts / Relief measures
Heartburn
Dependent edema
Varicosities, hemorrhoids
Constipation
Backache
Leg cramps
Faintness
Shortness of breath
Insomnia
Mood swings, ambivalence, increased anxiety
Urinary frequency and urgency
Braxton Hicks uterine contractions
Danger Signals: Decreased Fetal Movements
Term
Preterm Labor
Incidence: 10%
Morbidity and Mortality
83% morbidity
Causes: 50% unknown
Risk factors and Causes
Signs and symptoms:
Definition
Uterine contractions q 10min or more frequent with or without other signs
Menstrual-like cramps felt in lower abdomen constant or intermittent
Low dull backache felt below the waistline either constant or intermittent
Pelvic pressure that feels like the baby is pushing down either constant or intermittent
Abdominal cramping with or without diarrhea
Increase or change in vaginal discharge
Term
Maternal Weight Gain
Definition
Expected pattern is 2-5lbs in the first trimester and about a pound (450g) a week in the second and third trimesters

Poor weight gain is defined as less then 2.2lbs or 1kg per month in the second and third trimesters.
Term
Wt gain in pregnancy
Definition
Baby 7 -8.5 pounds
Amniotic fluid 2
Placenta 2-2.5
Uterus 2
Breasts 1-4
Increased Blood Volume 4-5
Increased Fluid 3-5
Maternal stores 4-6
Term
Energy needs:
Definition
variable but we use 300 calories as the average. For increased BMR, energy needs
Term
Protein:
Definition
60 gms is needed for just about everything...fetal and placental growth, maternal blood volume and constituents, maternal tissues, to maintain colloidal osmotic pressure and store reserves.
Term
Iron:
Definition
30 mg above norm of 15 mg needed. Needed to make RBCs and for fetal stores.
Term
Folic Acid:
Definition
recommended 0.4- 0.8 mg multiple pregnancy. RX prenatal vitamins usually have .08. Needed in DNA synthesis and maternal erythropoiesis.
Term
Calcium:
Definition
1000 -1200mg
Term
Every pregnant women should be on a multivitamin with
Definition
minerals (iron, mag, zinc, cal/pho) and folic acid.
Term
Avoid excess in
Definition
fat soluble vitamins
Term
The Psychological Trimesters of Pregnancy
FIRST TRIMESTER:
Definition
Focus is on self, begins to do "cost Analysis” the benefits vs. the worries...may be unsure and scared...moody. Watches and analyzes every physical change. (Body Image)

Ambivalence is a common trait of early pregnancy even in the most planned pregnancy. Not accepting pregnancy does not mean not accepting the child.
Term
The Psychological Trimesters of Pregnancy
SECOND TRIMESTER:
Definition
Mother feels movement...fetus says "I am!"
Mother is interested in producing a healthy baby and looks to ways to do so...proper eating etc.
This is the time when she feels best. Develops a narcissism love of self...baby and she are one.
May become involved in traditional feminine activities; cooking, crafts.
Tends to seek out other pregnant women or recent mothers.
May increase or renew contact with her own mother.
Begins to question what the baby will be like, sex etc
Increasing feelings of protectiveness towards infant and increasing sense of vulnerability about herself.
Term
The Psychological Trimesters of Pregnancy

THIRD TRIMESTER:
Definition
Increasing intensity in feelings of vulnerability...sees world as hostile, doesn't want to be alone.
Sees herself as alone …no one really cares or understands...may seek additional support
Sees the baby as simultaneously one with her but separate from her
Focus is on labor and delivery
process...fears, unsure.
Wants to hear birth stories.
Childbirth classes to increase
knowledge base.
Increasing discomfort helps
to separate fetus from mother
"I want out of this" tired of pregnancy.
Term
PSYCHOLOGICAL TASKS
Definition
Acceptance of pregnancy
Reordering of relationships
Acceptance of fetus as a separate individual
Acceptance of the mother/father role
Resolution of fears about childbirth
Attachment
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