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Hormone regulation in pregnancy
- 1. Hormonal regulation system of Pregnancy Dr Bhaskar J Paul Associate professor Obstetrics and Gynaecology
- 2. Rational Maternal changes in pregnancy Hormones responsible for those changes
- 3. Learning objectives 8. Endocrine change in mother 10. Changes in maternal circulation 12.Consequences of pregnancy on respiration • Physiological symptoms (13) • How pregnancy is detected (14)
- 4. A trigger ! A 26 years old G1P0 at 35 weeks of pregnancy came to Antenatal clinic with the complaint of sudden blackout while getting up from the couch she has noticed increasing spell of breathing difficulty and feels her heart moves faster for no obvious reason . she feels burning sensation below the ribs and she has bowel motion every two days . A clinical scenario Her pulse is 90 /m BP : 100/70 Respiration rate : 24/m Mild pedal edema Cardiac sound : S1, S2 normal Chest : normal to auscultation How do you plan to manage advise this lady ? Your response ?
- 5. Outliner Hormones of the placenta fetal adrenal gland Changes in the various systems Hormones of the labor and lactation
- 6. Section 1. • Hormones of the placenta . • Fetal adrenal gland . • Diagnosis of pregnancy
- 7. • Hormones : Graffian follicle & ovulation • Maintenance : Corpus luteum • Hormones of placenta : Luteo-placental shift
- 8. Maturation of graffian follicle and ovulation
- 9. Maintenance of corpus luteum after fertilization
- 10. Placenta as main endocrine organ Luteo- placental shift • Corpus luteum • Placenta New power house !
- 11. EM view of the placenta
- 13. Hormones of the placenta Peptides Steroids Growth factors
- 14. Protein hormones • Human chorionic gonadotropin • Human placental lactogen • Growth Factors • Early pregnancy factor (EPF) • Pregnancy specific B 1 Glycoprotein • Pregnancy associated plasma protein (PAPPA)
- 15. Human Chorionic Gonadotropin • Glycoprotein • Molecular weight : 36K-40K Dalton • Hormone Nonspecific unit : alpha (92amino A) • Hormone specific unit : Beta (145 amino A)
- 16. HCG : Function Stimulus for • Corpus luteum • Leydig cells • Immuno suppression • Adrenal / placental steroidogenesis • Maternal thyroid • Relaxin from CL
- 17. HCG level at different periods of pregnancy
- 18. Human Placental Lactogen • HC somato mammotropin • Syn cytiotrophoblast • similar to GH , Prolactin • 3rd week • 5 to 25 micg/ml ( 36 wks) • Plasma conc placental mass
- 20. Function of HPL • Antagonize insulin • Maternal lipolysis • Angiogesis : fetal vasculature • growth of breast lactation
- 22. Progesteron • Corpus luteum • trophoblast • cholesterol pregnenolone • Pregnolone progesterone 3 B- OH dehydrogenase • 250 mg
- 23. Plasma level of steroids
- 24. Estrogen • Estriol (E3) Estradiol (E2) • syncytiotrophoblast • Precursor: fetal maternal • Diczfalusy : maternal feto placental unit
- 26. Estrogen What placenta does not have ? 17,20-lyase (CYP17) C21 C19 • helped fetal adrenal gland . What placenta has ?
- 27. Function Progesterone • Maintenance of pregnancy • uterine growth • • endometrim decidua • myometrial contraction • Development of breast • Lobulo alveolar system Estrogen • Maintenance of pregnancy • Hypertrophy hyperplasia • accomodation blood flow Development of breast • Hypertrophy proliferation of duct
- 28. Function Progesteron • quiescence • lysosomal membranes • prostaglandin synthesis • Immuno modulatory Estrogen • Sensitize myometrium to oxytocin and prostaglandin • Ripens the cervix
- 29. Both • adaptation of the maternal organs increasing demand growing fetus • activity of gonadotropin –gonadal axis
- 30. Fetal adrenal Gland • largest • unique fetal zone. (85%) 100 to 200 mg/d 30 to 40 mg/day (A)
- 31. Conversion of lipo protein to cholesterol
- 32. Diagnostic value of the placental hormone • Diagnosis of pregnancy : HCG • trophoblastic tumors : HCG • Feto- placental unit : HPL Estradiol
- 33. Section 2 Regulatory activity • Metabolism • System • Gland
- 34. Carbohydrate Metabolism • E3 accumulation of glycogen • hPL insulin reistance • maternal glucose Feto-placental unit
- 35. Protein/ NA metabolism Protein and nucleic acid metabolism • E3 :synthesis • P : catabolism • 1 kg • 50 % :fetus /placenta • uterus, breast, maternal hemoglobin , plasma protein
- 36. Lipid Metabolism • Lipoprotein, apo lipoproteins • Early pregnancy : fat storage • Later pregnancy: FFA Triglyseride cholesterol
- 39. Cardiac out put • Blood volume • SVR Stroke volume • Progesterone • Vasodilatory (NO, ANP) Systemic vascular resistance
- 41. Progesteron Increase the sensitivity of chemoreceptor to CO2 Increased ventilation and fall in arterial pH Respiratory alkalosis
- 42. Renal system • Renal calyces , pelvis, ureters dilate • Mech. compression • Progesteron :relaxation
- 43. Gastrointestinal system lowered • Sphincter tone decreased • Gastrointestinal molity decreased • Gall bladder contractility • Progesteron
- 44. • Morning sickness • NVP • Constipation • Bleeding gums • Epulis gravidarum • Hemorrhoids • HCG, progesterone • relaxed smooth muscle • Mechanical obstruction of colon • • venous pressure
- 45. Skin changes • Vascular spiders • Palmar erythema • Hyper pigmentation • Mask of pregnacy • Circulating estrogen • Estrogen and MSH
- 46. Breast changes • enlarges 25 % -50 % • Nipple larger • Mobile • Areola larger , pigmented • Blood flow • Estrogen :Ductal growth • Progesteron : alveolar hypertrophy
- 47. •Changes in the individual glands
- 48. Thyroid gland • Enlarges • HCG : rise in T4 • E2 :TBG • Total T4 and T3 • Free T3 and T4
- 49. Adrenal Gland • Estrogen : CBG • serum cortisol • plasma cortisol • ACTH • aldosterone • deoxycorticosterone • maternal DHEA increases
- 50. Pituitary gland • 30 % wt • GH • Prolactin • ACTH , CRH • ADH • FSH, LH
- 51. Others • PTH normal • Does not cross the placenta • Calcitonin Parathyroid • Hyperinsulinemia • Anti-insulin factors • HPL , leptinPancreas
- 52. Uterine contractility • Estrogen • Progesteron
- 53. Section 3 •Hormones of labour & lactation
- 54. Initiation of labour Activation of fetal HPA ACTH cortisol Estrogen Oxytocin from maternal pituitary
- 55. Hormones of the lactation • ejection •oxytocin • maintenance •Prolactin • synthesis and secretion •prolactin •preparation •Estrogen : duct formation Mammogenesis lactogenesis galactokinesisgalactopoiesis
- 56. Answer to our case The reason for sudden black out The reason for breathing difficulty The reason for heart burn and constipation
- 57. Summary • Hormones liberated after conception are responsible for establishment and maintenance of a successful pregnancy and lactation. • These hormones regulate and help in adaptations of various maternal systems . • It may produce certain vexing symptoms of pregnancy, which is physiological and disappears immediately after the delivery .
- 58. A teaser for the day ! What is the reason for increasing cardiac output in later half of the pregnancy ? Circulatory volume Decreased PRMaternal heart rate Stroke volume
- 59. Reference Chapter 5, 207th edition Charles Beckmann Obstetrics and Gynecology Dr Fehmida lecture
- 60. . Thank you
Notas del editor
- Ovulation : LH surge Preovulatory rise of 17 alpha OH progesterone Positive feed back of estrogen Combined FSH rise and LH surge Completion of reduction division of oocyte Lutenisation of granulosa cell Synthesis of progesteron and prostaglandin
- CL Secretes about 40 mg of progesterone per day Syncytiotrophoblast after implantation secretes HCG and HPL Maintains the growth and function of CL
- Chemically and functionally similar to LH A subunit is similar to LH , FSH and TSH B subunit is unique to HCG Placental GnRH has a control over HCG
- Peak levels reach about 100,000 mIU/mL (D60-80 ) beginning of 10 to 12 wks GA, hCG begins to decline nadir is reached by about 20 weeks
- Lower level in ectopic pregnancy / abortion Higher level in hydratidiform mole , Rh isoimmunisation Following delivery , not detectable after 24 hours
- Dehydroepiandrosterone sulfate (DHEA-S), secreted in fetal adrenal glands, is converted to 16 -hydroxydehydroepiandrosterone sulfate (16 OH DHEA-S) in the fetal liver. These steroids, DHEA-S and 16 OHDHEA-S, are converted in the placenta to estrogens, viz., 17 -estradiol (E2) and estriol (E3). Near term, half of E2 is derived from fetal adrenal DHEA-S and half from maternal DHEA-S. 90 percent of E3 in the placenta arises from fetal 16 OHDHEA-S and only 10 percent from all other sources
- can synthesize cholesterol from two-carbon fragments, All enzymes involved in cholesterol biosynthesis are elevated lipoproteins are used as a source of cholesterol