Anatomy and Physiology

Pregnancy

Pregnancy (the period from conception to the birth of her baby) can be a difficult time for

the mother. Not only are there obvious anatomical changes, but striking changes occur

in her physiology as well.

Anatomical Changes

The ability of the uterus to enlarge during pregnancy is nothing less than remarkable.

Starting as a fist-sized organ, the uterus grows to occupy most of the pelvic cavity by 16

weeks. As pregnancy continues, the uterus pushes higher and higher into abdominal

cavity. As birth nears, the uterus reaches the level of the xiphoid process and occupies

the bulk of the abdominal cavity. The crowded abdominal organs press superiorly

against the diaphragm, which intrudes on the thoracic cavity. As a result, the ribs flare,

causing the thorax to widen.

The increasing bulkiness of the abdomen changes the woman’s center of gravity, and

many woman develop an accentuated lumbar curvature (lordosis), often accompanied

by backaches, during the last few months of pregnancy. Placental production of the

hormone relaxin causes pelvic ligaments and the pubis symphysis to relax, widen, and

become more flexible. This increased motility eases birth passage, but it may also result

in a waddling gait during pregnancy.

Obviously, good maternal nutrition is necessary throughout the pregnancy if the

developing fetus is to have all the building materials (proteins, calcium, iron, and the
like) it needs to form its tissues and organs. The old expression “A pregnant woman is

eating for two” has encouraged many women to eat twice the amount of food actually

needed during pregnancy, which of course, leads to excessive weight gain. Actually, a

pregnant woman needs only about 300 additional calories daily to sustain proper fetal

growth. The emphasis should be on high-quality food, not just more food.

Physiological Changes

Gastrointestinal System

Many women suffer nausea, commonly called morning sickness, during the first few

months of pregnancy, until their system adjusts to the elevated levels of progesterone

and estrogens. Heartburn is common because the esophagus is displaced and the

stomach is crowded by the growing uterus, which favors reflux of stomach acid into the

esophagus. Another problem is constipation, because motility of the digestive tract

declines during pregnancy.

Urinary System

The kidneys have the additional burden of disposing of fetal metabolic wastes, and they

produce more urine during pregnancy. Because the uterus compresses the bladder,

urination becomes more frequent, more urgent, and sometimes uncontrollable.

Respiratory System

The nasal mucosa responds to estrogen by becoming swollen and congested; thus,

nasal stuffiness and occasional nosebleeds may occur. Vital capacity and respiratory
rate increase during pregnancy, but residual volume declines, and many women exhibit

dyspnea (difficult breathing) during the later stages of pregnancy

Cardiovascular System

Perhaps the most dramatic physiological changes occur in the cardiovascular system.

Total body water rises and blood volume increases by 25-40% to accommodate the

additional needs of the fetus. The rise in blood volume also acts as a safeguard against

blood loss during birth. Blood pressure and pulse typically rise and increase cardiac

output by 20-40%; this helps propel the greater blood volume around the body. Because

the uterus presses on the pelvic blood vessels, venous return from the lower limbs may

be impaired somewhat, resulting in varicose veins.

Events of Embryonic and Fetal Development

As the zygote journeys down the uterine tube (propelled by peristalsis and cilia), it

begins to undergo rapid mitotic cell divisions–forming first two cells, then four, and so

on. This early stage of embryonic development is called cleavage. Since there is not

much time for cell growth between divisions, the daughter cells become smaller and

smaller. Cleavage provides a large number of cells to serve as building blocks for

constructing the embryo (developmental stage until the 9th week). By the time the

developing embryo reaches the uterus (about 3 days after ovulation, or on day 17 of the

woman’s cycle), it is morula, a tiny ball of 16 cells that looks like a microscopic

raspberry. The uterine endometrium is still not fully prepared to receive the embryo at

this point, so the embryo floats free in the uterine cavity, temporarily using the uterine

secretion for nutrition. While still unattached, the embryo still continues to develop until
it has about 100 cells, and then it hollows out to form a ball-like structure, a blastocyst or

chorionic vesicle. At the same time, it secretes an LH-like hormone called human

chorionic gonadotropic (hCG), which prods the corpus luteum of the ovary to continue

producing its hormones. (If this were not the case, the functional layer of the

endometrium would be sloughing off shortly in menses.) it is hCG that many home

pregnancy test assay for in a woman’s urine.

The blastocyst has two important functional areas: the trophoblast, which forms the

large fluid-filled sphere, and the inner cell mass, a small cluster of cells displaced to one

side. By day 7 after ovulation, the blastocyst has attached to the endometrium and has

eroded away the lining in a small area, embedding itself in the thick velvety mucosa. All

of this is occurring even while development is continuing and the three primary germ

layers are being formed from the inner cell mass. The primary germ layers are the

ectoderm (which gives rise to the nervous system and the epidermis of the skin), the

endoderm (which forms mucosae and associated glands), and the mesoderm (which

give rise to virtually everything else). Implantation has usually been completed and the

uterine mucosa has grown over the burrowed-in embryo by day 14 after ovulation–the

day the woman would ordinarily be expecting to start menses. After it is securely

implanted, the trophoblast part of the blastocyst develops elaborate projections, called

chorionic villi, which cooperate with the tissues of the mother’s uterus to form the

placenta. Once the placenta has formed, the platelike embryonic body, now surrounded

by a fluid-filled sac called amnion, is attached to the placenta by a blood vessel–

containing stalk of tissue, the umbilical cord. Generally by the 3rd week, the placenta is

functioning to deliver nutrients and oxygen to and remove wastes from the embryonic
blood. All exchanges are made through the placental barrier. By end of the 2nd month

of pregnancy, the placenta has also become an endocrine organ and is producing

estrogen, progesterone, and other hormones that help to maintain thepregnancy. At

this time, the corpus luteum of the ovary becomes inactive.

By the 8th week of embryonic development, all the groundwork has been laid down, at

least in rudimentary form, and the embryo looks distinctly human. Beginning in the

9th week of development, the embryo is referred to as a fetus. From this point on, the

major activities are growth and organ specialization, accompanied by changes in body

proportions. During the fetal period, the developing fetus grows from a crown-to-rump

length of about 3 cm (slightly more than 1 inch) and a weight approximately 1 g (0.03

ounce) to about 36 cm (14 in) and 2.7 to 4.1 kg (6-10 lbs) or more. (Total body length at

birth is about 55 cm, or 22 in.) As you might expect with such tremendous growth, the

changes in fetal appearance are quite dramatic. By approximately 270 days after

fertilization (the end of the 10th lunar month), the fetus is said to be “full-term” and is

ready to be born.
The Biliary System

The Gallbladder

The gallbladder, a pear-shaped, hollow, saclike organ, 7.5 to 10 cm (3 to 4 in) long, lies

in a shallow depression on the inferior surface of the liver, to which it is attached by

loose connective tissue. The capacity of the gallbladder is 30 to 50 ml of bile. Its wall is

composed largely of smooth muscle. The gallbladder is connected to the common bile

duct by cystic duct.

The gallbladder functions as a storage depot for bile. Between meals, when the

sphincter of Oddi is closed, bile produced by the hepatocytes enters the gallbladder.

During storage, a large position of the water in bile is absorbed through the walls of the

gallbladder, so that gallbladder bile is five to ten times more concentrated than that
originally secreted by the liver. When food enters the duodenum the gallbladder

contracts and the sphincter of Oddi (located at the junction of the common bile duct with

the duodenum) relaxes. Relaxation of the sphincter of Oddi allows the bile to enter the

intestine. This response is mediated by secretion of the hormone cholecystokinin-

pancreozymin(CCK-PZ) from the intestinal wall. Bile is composed of water and

electrolytes (sodium, potassium, calcium, chloride and bicarbonate) along with

significant amounts of lecithin, fatty acids, cholesterol, bilirubin and bile salts. The bile

salts, together with cholesterol, assist in emulsification of fats in the distal ileum. They

are then reabsorbed into the portal blood for return to the liver, after which they are

once again excreted into the bile. This pathway from hepatocytes to bile to intestine and

back to the hepatocytes is called the enterhepatic circulation. Because of the

enterohepatic circulation, only a small fraction of the bile salts that enter the intestine

are excreted in the feces. This decreases the need for active synthesis of bile salts by

the liver cells.

Approximately half of the bilirubin, a pigment derived from the breakdown of red blood

cells, is converted by the intestinal flora into urobilinogen, a highly soluble substance.

Urobilinogen is either excreted in the feces or returned to the portal circulation, where it

is re-excreted into the bile. About 5% is normally absorbed into the general circulation

and then excreted y the kidneys.(Porth,2005)

If the flow of the bile is impeded (e.g., by gallstones in the bile ducts), bilirubin does not

enter the intestine. As a result, blood levels of bilirubin increase. This cause increased

renal excretion of urobilinogen, which results from conversion of bilirubin in the small
intestine, and decreased excretion in the stool. These changes produce many of the

signs and symptoms seen in gallbladder disorders.

The Pancreas

The pancreas, located in the upper abdomen, has endocrine as well as exocrine

functions. The exocrine functions include secretion of pancreas enzymes into the

gastrointestinal tract through the pancreatic duct. The endocrine functions include

secretion of insulin, gucagon, and somatostatin directly into the bloodstream.

The Exocrine Pancreas

The secretions of the exocrine portion of the pancreas are collected in the pancreatic

duct, which joins the common bile duct and enters the duodenum at the ampulla of

Vater. Surrounding the ampulla is the sphincter of Oddi, which partially controls the rate

at which secretions from the pancreas and the gallbladder enter the duodenum.

The secretions of the exocrine pancreas are digestive enzymes high in protein content

and electrolyte-rich fluid. The secretions, which are very alkaline because of their high

concentration of sodium bicarbonate, are capable of neutralizing the highly acid gastric

juice that enters the duodenum. The enzyme secretions include amylase, which aids in

digestion of carbohydrates; trypsin, which aids in the digestion of protein; and lipase,

which aids in the digestion of fats. Other enzymes that promote the breakdown of more

complex foodstuffs are also secreted.

Hormones originating in the gastrointestinal tract stimulate the secretion of these

exocrine pancreatic juices. The hormone secretin is the major stimulus for increased
bicarbonate secretion from the pancreas, and the najor stimulus for digestive enzyme

secretion is the CCK-PZ. The vagus nerve also influences exocrine pancreatic

secretion.

The Endocrine Pancreas

The islets of Langerhans, the endocrine part of the pancreas, are collections of cells

embedded in the pancreatic tissue. They are composed of alpha, beta and delta cells.

The hormone produced by the beta cells is called insulin; the alpha cells secrete

glucagon and the delta cells secrete somastatin.

Insulin

A major action of insulin is to lower glucose by permitting entry of glucose into the cells

of the liver, muscle and other tissues, where it is either stored as glycogen or used for

energy. Insulin also promotes the storage of fat in adipose tissue and the synthesis of

proteins in various body tissues. In the absence of insulin, glucose cannot enter the

cells and is excreted in the urine. This condition, called diabetes mellitus, can be

diagnosed by high levels of glucose in the blood. In diabetes mellitus, stored fats and

protein are used for energy instead of glucose, causing loss of body mass. The level of

glucose in the blood normally regulates the rate of insulin secretion from the pancreas.

Glucagon

The effect of glucagon (opposite to that of insulin) is chiefly to raise the blood glucose

by converting glycogen to glucose in the liver. Glucagon is secreted by the pancreas I

response to a decrease in the level of blood glucose.

Somastatin

Somastatin exerts a hypoglycemic effect by interfering with release of growth hormone

from the pituitary and gucagon from the pancreas, both of which tend to raise blood

glucose levels.

Endocrine Control of Carbohydrate Metabolism

Glucose required for energy is derived by metabolism of ingested carbohydrates and

also from proteins by the process of gluconeogenesis. Glucose can be stored

temporarily in the liver, muscles, and other tissues in the form of glycogen. The

endocrine system controls the level of blood glucose by regulating the rate at which

glucose is synthesized, stored, and moved to and from the bloodstream. Through the

action of hormones, blood glucose is normally maintained at about 100 mg/dL

(5.5mmol/L). Insulin is the primary hormone that lowers the blood glucose level.

Hormones that raise the blood glucose level are glucagon, epinephrine,

adrenocorticosteroids, growth hormone, and thyroid hormone.

The endocrine and exocrine functions of the pancreas are interrelated. The major

exocrine function is to facilitate digestion through secretion of enzymes into the proximal

duodenum. Secretin and CCK-PZ are hormones from gastrointestinal tract that aid in

the digestion of food substances by controlling the secretions of the pancreas. Neural

factors also influence pancreatic enzyme secretion. Considerable dysfunction of the

pancreas must occur before enzyme secretion decreases and protein and fat digestion

becomes impaired. Pancreatic enzyme secretion is normally 1500 to 2500 mL/day.