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Physiology & Psychology. Maternal physiological adaptations to pregnancy The placenta Psychology of pregnancy. Physiology of Pregnancy. Systematic Adjustments to Pregnancy. Cardiovascular Respiratory Urinary.

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Physiology & Psychology

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Physiology psychology l.jpg

Physiology & Psychology

  • Maternal physiological adaptations to pregnancy

  • The placenta

  • Psychology of pregnancy


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Physiology of Pregnancy


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Systematic Adjustments to Pregnancy

  • Cardiovascular

  • Respiratory

  • Urinary


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Cardiac output during three stages of gestation, labor, and immediately postpartum compared with values of nonpregnant women. All values were determined with women in the lateral recumbent position.


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Mean glomerular filtration rate in healthy women over a short period with infused inulin (solid line), simultaneously as creatinine clearance during the inulin infusion (broken line), and over 24 hours as endogenous creatinine clearance (dotted line).


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King J. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr 2000;71 (suppl):1218S-25S


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Adjustments in Nutrient Metabolism

  • Goals

    • support changes in anatomy and physiology of mother

    • support fetal growth and development

    • maintain maternal homeostasis

    • prepare for lactation

  • Adjustments are complex and evolve throughout pregnancy


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General Concepts

1. Alterations include:

  • increased intestinal absorption

  • reduced excretion by kidney or GI tract

    2. Alterations are driven by:

  • hormonal changes

  • fetal demands

  • maternal nutrient supply


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3. There may be more than one adjustment for each nutrient.

4. Maternal behavioral changes augment physiologic adjustments

5. When adjustment limits are exceeded, fetal growth and development are impaired.


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Birth weight of 11 children born to a poor woman in Montreal; 8 children were born before receiving nutritional counseling and food supplements from the Montreal Diet Dispensary and 3 children were born afterward.


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6. The first half of pregnancy is a time of preparation for the demands of rapid fetal growth in the second half


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7. Alterations in maternal physiology facilitate transfer of nutrients to the fetus.


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Nitrogen Balance (g/day)


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Hormonal Adjustments

  • Changes in over 30 different hormones have been detected in pregnancy

  • Estrogens: increase significantly in pregnancy, influence carbohydrate, lipid, and bone metabolism

  • Progesterone: relaxes smooth muscle and causes atony of GI and urinary tract

  • Human Placental Lactogen (hPL): stimulates maternal metabolism, increases insulin resistance, aids glucose transport across placenta, stimulates breast development


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Late gestation is characterized by:

  • Anti-insulinogenic and lipolytic effects of Human chorionic somatomammotropin, prolactin, cortisol, glucagon)

    Which Results in:

  • Glucose intolerance, insulin resistance, decreased hepatic glycogen, mobilization of adipose tissue


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Maternal Nutrient Levels

  • Increased triglycerides

  • Increased cholesterol

  • Decreased plasma amino acids & albumin


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Lipids


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Maternal Albumin


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Maternal Plasma volume increases ~ 40%

  • range 30-50%

  • nutrient concentration declines due to increased volume, but total amount of vitamins and minerals in circulation actually increases.


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Mean hemoglobin concentrations (  —  ) and 5th and 95th (  —  ) percentiles for healthy pregnant women taking iron supplements


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Embryonic Development

  • In early gestation Embryo is nourished by secretions of the oviduct and uterine endometrial glands

  • Uterine secretions include growth factors (e.g. TNFa, epidermal growth factor) that promote placental growth

  • Poorly nourished women and obese women at risk for aberrations in embryonic and placental development

    • Congenital anomalies

    • Adverse outcomes later in pregnancy (e.g. PIH)

  • Before implantation, blastocyst divides into embryonic cells and placental cells


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Relationships of structures in the uterus at the end of the seventh week of pregnancy.


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The Placenta

  • 10-12 weeks is the period of placentation

  • Rapid early growth prepares way for fetal growth

  • Trophoblast cells use same molecular mechanisms as tumors, but are highly regulated and controlled


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Placental Functions

  • Maintains immunological distance between mother and fetus

  • Special endocrine organ: “transient hypothalamo-pituitary-gonadal axis”

  • Responsible for exchange of nutrients, gases & metabolic waste products between maternal and fetal circulation


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Placental Architecture

  • Maternal and fetal blood do not mix: “placental barrier”

    • Fetal blood flows through capillary networks within highly branched terminal chorionic villi

    • Maternal blood flows through intervillous space

      • Uterine arteriols bring blood in

      • Uterine venules drain blood


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Placental Capacity Increases During Gestation

  • Expression of transporters increases

  • The “brush border” microvilli develop to:

    • increase surface area

    • impede maternal blood flow

  • Flow through the placenta at term is 500 ml/minute


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Mechanisms of Nutrient Transfer Across the Placenta


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Maternal to Infant Nutrient Transportation Across The Placenta


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Fetal to Maternal Transport

  • Carbon dioxide

  • Water & urea

  • Signaling Molecules: Hormones, cytokines, others


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Factors Affecting Placental Transfer

  • Placental size

  • Diffusion distance –

    • diabetes and infection cause edema of the villi

    • distance decreases as pregnancy progresses and fetal needs increase

  • Maternal-placental blood flow

  • Blood saturation with gases and nutrients


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Factors Affecting Placental Transfer (cont)

  • Maternal-placental metabolism of the substance

  • Disorders in expression or activity of nutrient transporters

  • Maternal use of tobacco, cocaine, alcohol


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Metabolic Functions of the Placenta

  • Glycogen synthesis: from maternal glucose & stored

  • Cholesterol synthesis: placental cholesterol is precursor for placental progesterone and estrogens

  • Protein production: rises to 7.5 g per day at term

  • Lactate: produced in large quantities and needs to be removed


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Endocrine Functions

  • Placenta Produces Peptide hormones

    • Human Chorionic gonodotrophin (hCG) - secreted early and helps to maintain synthesis of progesterone

    • Human placental lactogen (hPL): increase supply of glucose to future by decreasing maternal stores of fatty acids by altering maternal secretion of insulin

    • Insulin-like growth factors (IGF): IGF signaling system is a major regulator of growth in fetus and infant


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Endocrine Functions

  • Steroid hormones

    • Progesterone: produced by placenta, needed to maintain non-contractile uterus

    • Estrogen: produced by placenta drives many processes in pregnancy

  • Glucocorticoids: placenta regulates fetal exposure


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Emerging Understandings

  • Cytokines & Inflammatory molecules are produced by the placenta as well as adipocytes

  • Adverse outcomes in obese women may be associated with imbalances due to overproduction from both sources

  • “In pregnancy complicated with obesity or DM, continuous adverse stimulus is associated with dysregulation of metabolic, vasular and inflammatory pathways.”


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The Known and Unknown of Leptin in Pregnancy (Hauguel-de-Mouzon, Am J Obstet Gynecology, 2006)

  • Maternal plasma leptin levels rise in pregnancy

  • Leptin is produced by placenta

  • Overproduction of placental leptin is seen with diabetes and htn in pregnancy

  • Umbilical leptin levels are biomarker of fetal adiposity

  • “Leptin may be sensitive to maternal energy status and coordinate metabolic response accordingly.” (King, Ann Rev Nutr, 2006)


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Psychology of Pregnancy

  • Psychosocial tasks

    • Rubin

    • Leaderman’s tasks

  • Fathers

  • Stress and Depression


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Developmental Tasks of Pregnancy (Rubin, 1984)

  • Seeking safe passage for herself and her child through pregnancy, labor, and delivery.

  • Ensuring the acceptance by significant persons in her family of the child she bears.

  • Binding-in to her unknown baby.

  • Learning to give of herself.


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Maternal Focus


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Lederman, RP. Psychosocial Adaptation in Pregnancy, 2nd Ed. 1996

  • Developmental Tasks of Pregnancy

    • acceptance of pregnancy

    • identification with motherhood role

    • relationship to the mother

    • relationship to the husband/partner

    • preparation for labor

    • processing fear of loss of control & loss of self esteem in labor


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Psychosocial adjustment during pregnancy: the experience of mature gravidas(Stark, JOGNN, 1997)

  • N=64 older gravidas (> 35), 46 younger gravidas (< 32) in third trimester

  • Lederman prenatal self evaluation questionnaire - examines conflicts for 7 steps

  • In general conflicts about maternal role were similar in both groups

  • Older gravidas had less concern about fear of helplessness and loss of control in labor - regardless of parity


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Adolescents: PSYCHOSOCIAL FACTORS THAT INFLUENCE TRANSITION TO MOTHERHOOD (kaiser, 2004)

  • Gaining acceptance of the pregnancy in the family system

  • Awareness of the need to develop a sense of responsibility

  • Planning for a future that includes the baby

  • Viewing self as a mother


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Laboring for Relevance: Expectant and New Fatherhood(Jordan, Nursing Research, 1990)

  • N=56 expectant fathers followed prospectively

  • Fathers reported:

    • grappling with the reality of the pregnancy and child

    • struggling for recognition as a parent from mother, coworkers, friends, family baby and society

    • plugging away at the role-making of involved fatherhood


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Jordan, cont.

  • Identified concerns:

    • Men not recognized as parents but as helpmates and breadwinners

    • Men felt excluded from childbearing experience by mates, health care providers, and society

    • Fathers felt that they had no role models for active and involved parenthood


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Jordon’s Developmental Tasks of Fatherhood

  • Accepting the pregnancy

  • Identifying the role of father

  • Reordering relationships

  • Establishing relationship with his child

  • Preparing for the birth experience


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What about Dad? Psychosocial and mental health issues for new fathers. (Condon, 2006. The Australian First Time Fathers Study)

Tasks:

  • Developing an attachment to the fetus

  • Adjusting to the dyad becoming a triad

  • Conceptualizing the self as “father”

  • What type of father?


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Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)

  • Analysis of 1988 NMIHS (n=9122) and NSFG (n=2548) data.


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Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)


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Effects of pregnancy planning status on birth outcomes and infant care (Kost et al. Family Planning Perspectives, 1998)

  • “Knowing the planning status of a pregnancy can help identify women who may need support to engage in prenatal behaviors that are associated with healthy outcomes and appropriate infant care.”


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Unintended Pregnancy


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Post-Partum Depression – PRAMS


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Washington State PRAMS


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WA State PRAMS


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