A. PRENATAL CARE.

1. Assess the physiologic changes during pregnancy.

• Remembering: 1 test items
• Applying: 1 test items

PHYSIOLOGIC ADAPTATIONS IN PREGNANCY

A REPRODUCTIVE SYSTEM CHANGES

1. Uterus
a. Uterine size is increased due to hypertrophy of existing muscles and
connective tissues (No formation of new muscle fibers in pregnancy).
 Weight increases from 60 g (non- pregnant) to 1000 g (fullterm).
 Length increases from 7.5 cm to 32 cm; width from 4 cm to 24 cm and
depth from 2.5 cm to 22 cm.

B. Uterine shape changes from globular to OVAL

c. New fibroelastic tissues are formed; this makes up stronger uterine

walls.

d. Fundic height changes

 12th week: level of symphysis pubis
 13th week: rising from pelvic cavity; may be palpable just above the
symphysis pubis
 14th week: an abdominal content 20th to 22nd week: at umbilical level
 36th week: at xiphoid process level

e. Increased vascularity to the pelvic region (estrogen effect)

results:
 Hegar's sign: softening of lowering uterine segment called the isthmus
easy compressibility of the uterus
 Goodell's sign: softening of the cervix
 Consistency of the tip of the nose: non-pregnant cervix
 Consistency of ear lobe: pregnant cervix (Goodell's sign)
 Consistency of whipped butter cervix ripe for labor
 Chadwick's sign: bluish or purplish discoloration of the vaginal mucosa
and cervix

f. Braxton-Hicks Contractions: Intermittent irregular, painless, abdominal,

and false labor contractions felt as abdominal muscle tightening by about 4
months; more pronounced at 8 months.

G. Ballottement: Rebounding of fetal head against examining fingers by 4

to 5 months
h. Secondary amenorrhea: due to the persistence of the corpus luteum

2. Cervix
a. Shorter, thicker, more elastic
b. With edema and hyperplasia there is increased mucus production which
makes up the protective mucus plug (week. As it seals the cervis, it abo abo
prevents bacterial contamination of the uterine cavity
c. Increased vascularity causes cervix to be soft: Goodell's sign

3. Vagina
a. Hypertrophy and hyperplasu→ thickened vaginal mucosa
b. Leukorrhea: whitish, mucoid, non-foul, non-pruritic vaginal secretions
increases as estrogen level increases, provides increased vaginal acidity, an
added protection from bacterial invasion
c. Increased vascularity results to bluish discoloration: Chadwick's sign

4. Perineum
a. Hypertrophy, edema and relaxation, there is an increase in size
B. Increased vascularization; changes into deeper color

5. Ovaries
A. Ovum production ceases
b. Corpus luteum persists and takes over hormonal production task in carly
pregnancy
c Placenta: Major endocrine organ in pregnancy

6. Breasts
a. Increased size and firmness
b. There is tingling sensation in the nipples in 4 weeks and there is also
breast tenderness
c. Enlargement of areola, alveoli duct and alveoli system
d. Darkening of arcola and skin around it
E. Enlargement and prominence of superficial veins
F. Enlargement of Montgomery's glands
G. Colostrum (4 to 5 months): thin, watery, light yellow, high protein
secretion

B. ENDOCRINE SYSTEM CHANGES

1. Placenta
A. Chorion of placenta secretes HCG which functions to:
 Maintain the corpus luteum (most important function)
 Aid in diagnosing pregnancy by its detection in maternal serum and
urine
 Serum/blood: As carly as 8 to 10 day or at the time of implantation
 Unier: As early as 10 to 14 days after the missed menstruation
  Found elevated in excessive vomiting

c. Mature placenta at 10 to 12 weeks, increased placental hormones

estrogen progesterone, HCG and HPL/HCS (human placental lactogen/human
chorionte somatomammotropin).
 HPL is the major diabetogenic hormone or insulin antagonist in pregnancy
gestational DM or difficulty to control pre-existing DM.

2. Anterior Pituitary Gland (APG)

A. No ovulation from increased follicle stimulating hormone
b. Breast is prepared for lactation with increased prolactin

3. Posterior Pituitary Gland (PPG)

a. Oxytocin is produced by hypothalamus, stored and secreted by the PPG.

b. Fetal head pressure on the cervix stimulates PPG to secrete oxytocin

stimulates uterine myometrium uterine contractions labor onset (aided by
the drop in progesterone in late pregnancy).

4. Thyroid Gland
a. Changes in thyroid activity resulting to elevated BMR are due to
(Cunningham et al., 2001):
 elevated serum estrogen
 placental effects on thyroid function
 increased renal clearance of iodide or decreased available iodide
b. Increased thyroid activity increased BMR; any extraordinary growth must
be assessed (Littleton & Engebretson, 2006)
 increased pulse rate
 elevated cardiac output
 heat intolerance
c. The 25% increased in metabolic rate activity by 25% returns to normal
levels at 6th week postpartum.

5. Parathyroid Gland
 a. Enhanced calcium and phosphorus metabolism to meet fetal needs
for increased calcium
 b. The leading cause of cramps in pregnancy is calcium-phosphorus
imbalance.

6. Pancreas
 a. Increased insulin secretion in response to increase metabolism in
pregnancy.
  b. Insulin secreted by pancreas is rendered ineffective by insulin
antagonists of pregnancy most importantly human placental lactogen
or human chorionic somatomammotropin (HCS).

7. Adrenal Cortex
a. Increased cortisol works at multiple sites promoting metabolism of
macronutrients carbohydrates, protein, and fat. When the gravida needs
more energy, cortisol activates gluconeogenesis, converting stored protein
to glucose.

b. Increased aldosterone promotes sodium retention, and thereby water

reabsorpotion; enhances the water-retaining effect of progesterone resulting
in the cushingoid feature in pregnancy.

C. RESPIRATORY SYSTEM CHANGES

1. Nose: Increased vacularity (estrogen effect) → common epistaxis, nasal

stuffiness, hoarseness, Eustachean tube blockage causing temporary
deafness or difficulty in hearing

2. Respiratory Rate
a. Not much change; rate increase can be constant at 6/min. and deeper
b. Maximum increase under normal conditions: 24/min. at rest
c. Lung volume changes due to mechanical, hormonal, or biochemical
influences

3. Diaphragm rises by as much as 1 inch at 36 to 38 weeks resulting in

dyspnea which is relieved by lightening.

4. Lungs
A. Slight increase in vital capacity
b. Increase in oxygen consumption by 15% ar 6 to 40 weeks
c. Tendency to hyperventilate due to
1) mother's need to blow off carbondioxide transferred to her from fetus;
and
2) direct effect of progesterone on respiratory center

d. Signs of Hyperventilation
 dizziness/lighth headedness
 Pallor
 tingling sensation on fingertips/lips
c. Management: Encourage the woman to breathe into a paper bag or her
cupped hands to prevent complication respiratory alkalosis. In normal
pregnancy, lung volume changes and progesterone cause
a state of compensated respiratory alkalosis.

D. CIRCULATORY SYSTEM
1. Cardiac rate increases by 10 to 15 bpm/min. in the second to third
trimesters.

2. Palpitation in early and late pregnancy due to

a. Sympathetic nervous system disturbances (carly)

b. Increased intraabdominal pressure (late)

3. Transient murmurs and slight cardiomegaly, systolic murmurs due to

increased viscosity of the blood and upward displacement of the heart

4. Blood pressure changes:

a. Remains constant, but may drop slightly in the second trimester.
b. Supine position --inferior vena caval compression-- decreased
venous return decreased cardiac output---hypotension. Prevention and
management: left lateral recumbent (L.LR)

5. Circulating volume increases from the end of 5. the first trimester (30%)
up to the period just
before labor (50%). Physiologic Anemia of pregnancy results from the
disproportionate increase between the circulating blood volume and the red
blood cells.

6. Cardiac output increases by 20 to 30% in the first and second trimesters

to meet increased tissue demands.

7. Vascularity increases (estrogen effect):

a. Dilation of pelvic veins or/resulting in deep pelvic veins varicosities
b. Leg varicosities

8.Fibrinogen level increases by 50% due to progesterone effect (Normal

fibrinogen, non-pregnant state: 200-400 mg/dL):
a. Increased tendency to clotting high risk for thrombophlebitis
b. Positive Homan's sign is a danger sign of deep vein thrombosis (DVT).
c. Non-pathologic increased in sedimentation rate (Normal value, non-
pregnant state: 20-30 mm/hr.).
9. Edema of lower extremities is common in the last 6 weeks of pregnancy
because of the pressure on the pelvic girdle.

10. Hematologic Changes

a. Red Blood Cells: increased by 30% but usually drops
b. Hemoglobin: 12 to 15 g/dL. (average: 13 to 14 g/dL)
C. Hematocrit: 37% to 42%
d. Hgb and Het may drop by 10% in the second and thind trimesters
pseudoanemia/ physiologic anemia
e. WBC: 5,500 to 11,500/mm (in pregnancy) 20,000/mm (in labor)
25,000/mm (in post-partum). Levencytosis is pregnancy is not usually a sign
of infection.

E. GASTROINTESTINAL SYSTEM CHANGES

1. Mouth: Increased estrogen level

a. Increased acidity of saliva
b. Ptyalism: increase saliva in women with nausea, appears 2 to 3 weeks and
disappears after delivery (Gabbe et al., 2002).
c. Increased vascularity soft and swollen. gums/gingivitis difficulty in chewing
and gum bleeding Prevention of gum bleeding: dental hygiene
d. d. NO tooth loss in pregnancy.
e. May have benign mouth rumors due to vascular proliferation secondary to
hormonal changes; may not resolve after delivery.

2. Stomach
a. Displaced backward: appendix palpated as high as right flank, bowel
sounds may not be auscultated in 4 abdominal quadrants.
b. Displaced upward and compressed resulting in difficult digestion
c. Cardiac sphincter relaxed esophageal reflux heartburn or pyrosis, a
common discomfort felt as burning sensation behind the sternum
d. Motility and slow digestion (progesterone effect)
e. Emptying time delayed
f. Decreased free hydrochloric acid plus decreased motility and digestion
contribute to morning sickness and heartburn/pyrosis

3. GI Tract relaxation (progesterone effect)→ discomforts:

a. morning sickness (nausea and vomiting)
b. flatulence
c. constipation and hemorrhoids
4. Gall Bladder
Progesterone relaxes gallbladder wall poor tone delayed emptying time
cholesterol in the bile likely to crystalize (→)tendency to gallstones formation
5. Liver: displaced by uterus; blood flow to it not markedly changed;
expected liver laboratory findings mimic liver disease (Gabbe et al., 1996):
 Serum albumin concentration decreased by 30% (Normal value, non-
pregnant state 3.5-5g/dl)
 Serum alkaline phosphatase level increased to 2 to 3 times normal levels
(Normal value non-pregnant state: 30-115 mU/ml)
 Serum cholesterol 2 times nonpregnant level (Normal value, non-
pregnant state: 150. 200 mg/dL).

P. URINARY SYSTEM CHANGES

1. Renal Plasma Volume: increased by 25% tro 50% in the first and
second trimesters; normal by the end of third trimester

2. Globular filtration rate (GFR): increased by 50% in the second and third
trimesters increased urinary output with decreased specific gravity

3. Increased renal tubular reabsorption rate

4. Increased renal urea and creatinine clearance

5. Frequency of Voiding: increased in the first and third trimesters

because of uterine pressure on the bladder, usually not in the second
trimester when the uterus has risen into the abdominal cavity.

6. Bladder Capacity: 1,500 mL in the second trimester

7. Glycosuria: the presence of glucose in the urine due to lowered renal

threshold for glucose

7. Relaxed Smooth Muscles of Bladder, Ureters (persists up to 4 to 6

weeks after delivery) results we
a. Dilation of ureters (May also result from uterine pressure.)
b. Decreased bladder tone
c. Increased potential for stasis and urinary infection (UTI)

9. Renal function is compromised in both sitting and standing positions due

to the effects of vena caval syndrome. The best position that enhances
renal perfusion is the lateral (LLR) or the left side-lying position.

G. INTEGUMENTARY SYSTEM CHANGES: present in the second

trimester onwards
1. Chloasma: dark patches on the cheeks, nose and neck; 'mask' of
pregnancy due to increasedmelanocyte-stimulating hormones of pregnancy

2. Linea Nigra: dark line from symphysis pubis upward to xyphoid process
due to increased estrogen

2. Striae Gravidarum: stretch marks, silvery streaks on the abdomen,

upper thighs and lower breasts due to adrenal hypertrophy 4 Palmar
Erythema (reddened palms) and vascular spider nevi (facial) from increased
vascularity due to elevated estrogen
3.
4. 5. Diaphoresis: due to increased activity of the sweat and selbsaceous
glands from pregnancy's increased metabolic rate

H. MUSCULO-SKELETAL SYSTEM CHANGES

1. Increased estrogen, progesterone and relaxin; relaxed ligaments and
joints
a. Softening and relaxation of symphysis pubis and sacroiliac joints increase
the birth canal
b. Pelvic looseness results in duck-waddle/waddling gait
C. Difficulty maintaining balance predisposes to slips and falls

2. The number one reason why tub bathing in pregnancy is not encouraged
is the change in the musculo-skeletal system that results in poor balance
predisposing to slips and other injuries.

3. Stress on ligaments and muscles of the mid-and lower spine results in

backache.

4. Lordosis from shift in the center of gravity during pregnancy results in

backache and fatigue.

5. Cramps from calcium and phosphorous imbalance, and pressure of the

gravid uterus on nerves supplying the lower extremities

V. EMOTIONAL/PSYCHOSOCIAL ADAPTATIONS IN PREGNANCY

A. FIRST TRIMESTER

1. Normal denial to confirmation of pregnancy

2. Ambivalence about pregnancy, child, and parenting

3. Mood swings or emotional lability

5. Focusing on the self

B. SECOND TRIMESTER
1. Acceptance of the baby as distinct from self; enhanced by quickening
which is "my baby is alive" to the layman

2. With fantasy and daydreaming

3. Introspective, evaluates marriage, career, in-laws

4. Most comfortable stage

C. THIRD TRIMESTER
1. Fear/anxiety/dreams about labor, pain, mutilation, and death

2. Anxiety related to responsibilities

3. Preparation for birth: nesting behavior, role playing

D. PSYCHOLOGIC TASKS OF PREGNANCY:

Related to the psychosocial adaptations in pregnancy are the psychologie
tasks of pregnancy

1. Acceptance of pregnancy as a reality and incorporation of the fetus into

the body image

2. Preparation for physical separation from fetus (birth)

3. Attainment of maternal role